ASSIGNMENT ON

DILATATION AND
EVACUATION

SUBMITTED TO: SUB,ITTED BY:

INTRODUCTION:
Obstetric operations are surgical procedures and as such irrespective of the nature of operation (major or
minor), asepsis and antiseptic precautions are to be taken

Even an internal examination during late pregnancy and labor requires utmost asepsis. The proximity of
the bladder and rectum to the operative field should deserve attention prior to any operative procedure.
Before proceeding to vaginal operative or manipulative obstetrics, some protocols are to be maintained.
While a uniform guideline is difficult to formulate, the following preliminaries are to be followed with a
few additions or alterations as and when required.

These are: 1. Anesthesia—either general or local is used. In some cases, the operation may be performed
with intravenous diazepam sedation. 2. Te patient is to be placed in lithotomy position. 3. Full surgical
asepsis is to be taken: (a) Surgical team is to wear sterile cap, mask, thorough hand wash and to wear
gown and gloves (b) Vulva and vagina are to be swabbed with antiseptic solution (c) Cervix is cleaned
with povidone-iodine solution (d) Te perineum is to be draped by sterile towel and the legs with leggings.
4. To empty the bladder—If the patient is ambulant, she is asked to empty the bladder before she is placed
on the table; otherwise catheterization is to be done. 5. Vaginal examination is done.

DILATATION AND EVACUATION (D&E)

The operation consists of dilatation of the cervix and evacuation of the products of conception from the
uterine cavity. The operation may be performed: ‹

One stage: Dilatation of the cervix and evacuation of the uterus are done in the same sitting. ‹

Two stages: (a) First phase includes slow dilatation of the cervix (b) Second phase includes rapid
dilatation of the cervix and evacuation.

ONE STAGE OPERATION

INDICATIONS: (1) Incomplete abortion (most common) (2) inevitable abortion (3) medical
termination of pregnancy (6–8 weeks) and (4) hydatidiform mole in the process of expulsion

PROCEDURES:

Preliminaries: The steps to be followed are those mentioned earlier. The patient is put under general
anesthesia. Internal examination is done to note the size and position of the uterus and state of dilatation
of the cervix.

Steps: (Incomplete abortion – recent)

(1) If the cervix is not sufficiently dilated to admit the index finger (usually it does), it should be dilated.
(2) Sim’s posterior vaginal speculum is introduced and an assistant is asked to hold it. The anterior lip of
the cervix is grasped by an Allis forceps to steady the cervix. Uterine sound is not to be introduced.
Sounding provides no information but risks perforation and bleeding.

(3) The cervical canal is gradually dilated up to the desired extent by the graduated metal dilators

(4) The products are removed by ovum forceps. The uterine cavity is finally curetted gently by a flushing
(blunt) curette. Injection methergine 0.2 mg is to be administered intravenously during the procedure
(5) The speculum and the Allis forceps are to be removed. The uterus is to be massaged bimanually with
the help of the external hand and the internal fingers, placed inside the vagina.

(6) After being satisfied that the uterus is firm and the bleeding is minimal, the vagina and perineum are
toileted; a sterile vulval pad is placed and the patient is sent back to her bed. Postabortion care includes:
(a) emergency treatment of complications of any abortion spontaneous or induced (b) family planning
counseling and referral services and (c) linkages to other reproductive health services (comprehensive
services). Male partner should be involved.

TWO STAGE OPERATION

INDICATIONS: (1) Induction of first trimester abortion (most common) (2) missed abortion (uterus 8–
10 weeks) and (3) hydatidiform mole with unfavorable cervix (long, firm and closed os). To prevent
damage to the cervix during rapid dilatation, a two-stage operation is, however, preferred in such cases.

PROCEDURES

(A) FIRST PHASE: It consists of introduction of laminaria tents or lamicel (MgSO4 sponge) into the
cervical canal to effect its slow dilatation. The same may be effective by intravaginal insertion of
misoprostol (PGE1 ), 400 µg 3 hours before surgery. It has less side effects.

Steps of introduction of tents:

The preliminaries to be followed are those mentioned earlier. (a) The patient should empty her bladder
beforehand (b) no anesthesia is required and (c) the appropriate size and number of the tent required are
selected.The threads attached to one end are tied to the roller gauze

Steps:

(1) Internal examination is done to note the size and position of the uterus and state of the cervix.

(2) Sim’s posterior vaginal speculum is introduced and an assistant is asked to hold it. Te anterior lip of
the cervix is grasped by an Allis forceps to steady the cervix.

(3) The cervical canal may have to be dilated, especially in primigravidae by one or two smaller metal
dilators (Hawkin Ambler: size 3/6 or 4/7) to facilitate the introduction of the tents.

(4) The tents are introduced one after the other, holding it by tent introducing forceps The tents should be
introduced for at least 4 cm (1.5"), so that the tips are placed beyond the internal os. Te tents can also be
introduced manually.
(5) The roller gauze is used to pack the upper vagina so as to prevent the displacement of the tents.

(6) The patient is returned to her bed.

(7) Prophylactic antibiotic (doxycycline 100 mg PO BID for 3 days and metronidazole PO 400 mg BID
for 5 days) is usually administered.

(B) SECOND PHASE: It consists of further dilatation of the cervix by graduated metal dilators followed
by evacuation of the uterus

Procedures „ The patient is brought back to the operation theater usually after 12 hours. The patient
should empty her bladder beforehand. „

Preliminaries: The steps to be followed are those previously mentioned. The operation may be
conducted under intravenous diazepam sedation, local paracervical block or under general anesthesia

Steps: (MTP – 8 weeks)

(1) The posterior vaginal speculum is introduced after removing the roller gauze. The tents are removed
with the help of sponge forceps. The vagina and the cervix are swabbed with antiseptic (povidone-iodine)
solution. The posterior vaginal speculum is removed.

(2) Vaginal examination is done to note the size of the uterus, position of the uterus and state of dilatation
of the cervix.

(3) Posterior vaginal speculum is reintroduced and is to be held by an assistant. The anterior lip of the
cervix is to be grasped by the Allis forceps to steady the cervix.

(4) The cervix is dilated with the graduated metal dilators up to the desired extent (10/13 to 12/15) to
facilitate introduction of the ovum forceps.

(5) The products are removed by introducing the ovum forceps. Intravenous methergine 0.2 mg is to be
given during this stage to minimize blood loss. Firm and well contracted uterus facilitates curettage

(6) The uterine cavity is thoroughly curetted by a flushing curette.

(7) The posterior vaginal speculum and the Allis forceps are removed. The uterus is massaged bimanually
and after being satisfied that the uterus is empty (evidenced by a well contracted uterus with minimal
bleeding), the patient is sent to her bed after placing a sterile vulval pad.

(8) Oxytocic agents:Injection methergine 0.2 mg IM is given. Alternatively oxytocin 20 units in 500 mL
of normal saline IV is given intraoperatively and continued after the operation for 30 minutes.

(9) Prophylactic antibiotics (doxycycline and metronidazole) are prescribed.

DANGERS OF D&E OPERATION

Immediate:(1) Excessive hemorrhage—may be due to (a) incomplete evacuation or (b) atonic uterus. (2)
injury—(a) cervical lacerations of varying degree which may lead to formation of a broad ligament
hematoma and (b) uterine perforation. (3) Shock due to: (a) local anesthesia—convulsions,
cardiorespiratory arrest, death due to intravascular injection or over dose. (b) Excessive blood loss. (c)
Cervical shock—vasovagal syncope due to cervical stimulation. (4) Perforation—injury to major blood
vessels, bowel or bladder. Risk is more with advanced gestation. (5) Sepsis—endometritis, myometritis
and pelvic peritonitis. (6) Hematometra may cause pain. (7) Increased morbidity and (8) Continuation of
pregnancy (failure) – 1%.

Late: (1) Pelvic inflammation (2) infertility (3) cervical incompetence (4) uterine synechiae and in
subsequent pregnancy risks are: (5) preterm labor and (6) ectopic pregnancy

MANAGEMENT PROTOCOL OF UTERINE PERFORATION

 The management depends on the location, size and nature of the instrument causing the
perforation. 
 The procedure is stopped. 
 Perforation made by small instruments such as sound or smaller size dilator – Expectant
treatment with observation of pulse and blood pressure. Antibiotic is to be given. 
 Perforation caused by bigger size dilator or ovum or ring forceps or suction cannula: Diagnostic
laparoscopy is helpful to assess the size and site of perforation and the amount of hemorrhage.
Operative laparoscopy or laparotomy may be needed to tackle the situation. One should not forget
to inspect the intestine or omentum for evidence of injury. 
 Lateral cervical tearwith broad ligament hematoma or laceration of uterine artery: Laparotomy
followed by repair (conservative surgery) or hysterectomy.
  Perforation prior to complete evacuation: Any of the following may be followed—(a) to stop
evacuation, vaginal evacuation can be done under laparoscopic visualization; (b) if laparotomy is
decided: (i) complete the evacuation either through the rent or anterior hysterotomy, if
preservation of the uterus is necessary and (ii) hysterectomy, if family is completed. Along with
the definitive surgery, simultaneous resuscitative procedure and administration of antibiotics are
mandatory.

BIBLIOGRAPHY:

BOOK REFERENCE:

 Cunningham, Leveno, Bloom. William’s obstetrics. 23rd edition. United states of America;
Mcgraw Hill companies: 2010

 Dutta D.C. Textbook of obstetrics. Sixth edition. Calcutta, India; New Central Book agency (P)
Ltd: 2004.

 Fraser DM, Cooper MA. Myles Textbook of Midwives. Fourteenth edition. Edinburgh; Churchill
Livingstone: 2003.

 Jacob A. A comprehensive textbook of midwifery. Second edition. India; Jaypee Brothers

Medical publishers (P) ltd.

 Pillitteri A. Maternal and child health nursing. Care of the childbearing and childrearing family.
Sixth edition. Philadelphia; Lippincott Williams & wilkins: 2010
NETREFERENCE: https://www.ncbi.nlm.nih.gov/pmc/articlesss