Surgical Abortion: Clinic + OR + Procedure Steps

Pre-procedure (clinic):

• •Give miso 400 mcg 2 hours prior to procedure for >10 weeks.
• •Order set: Surgical abortion.

Consents:

• •.OBGYNCONSENT for the e-consent (SIGN BEFORE MEDS).
• •Consents + purple sheet + abortion form + telehealth f/u in 2 weeks.

Intra-op orders:

• •Bedside ultrasound for >10 weeks during procedure.
• •Order zofran 4 mg IV, toradol 15 mg IV, azithromycin 500 mg PO.
• •Lidocaine: 10 cc + 10 cc injected at 4 and 8 o’clock (nurses order lido).

Notes required (clinic):

• •Pre-sedation note (sign before procedure).
• •Procedure note.
• •Progress note.

OR workflow:

• •Offer Ativan and TXA.
• •Pre-op H&P → place in Prep for surgery tab → orders.
• •Consent for lams and D+E.
• •Plan for genetics.
• •Disposition of fetus.
• •Cabergoline (offered in any second trimester) — 1 mg dose in PACU. Side effect: increased nausea.
• •Footprints.
• •22–24 weeks → KCl injection with MFM.
• •>20 weeks: can offer digoxin injection (70% efficacy if injected intrafetal; still effective if intraamniotic).
• •Pre-op orders: DNA extract and hold, karyotype, SNP chromosome microarray.

17-step procedure walkthrough:

• •Bimanual exam.
• •Insert speculum.
• •Do swabs if indicated (GC/CT under 25).
• •Inject lidocaine (1–2 mL) into anterior lip.
• •Place tenaculum — wrist up!
• •Inject at 2 o’clock and 10 o’clock (or 4 and 8 if you can see) with 20 mL lidocaine. Go in 3 cm, pull back first, inject as you come out.
• •Put on sterile gloves.
• •Dilate — first thing is 5 and goes up by one after. Go past cervix; should be fast/smooth. Dilate to # of weeks for abortion (or EPL dx if EPL). Round to completed weeks.
• •Prep suction — click shut, pull back, put top on.
• •Insert into cervix and go to fundus, then click open suction. First motion is twisting — then up and down and twisting.
• •Come out, remove tip, expel syringe.
• •RELOAD — click shut, pull out, put tip on.
• •Repeat until you feel rough uterine “cry”, then draw out.
• •Look for bleeding from os.
• •Remove tenaculum, apply pressure if site is bleeding — may use silver nitrate.
• •Remove speculum.
• •Grab POC to look at them.