obs and gynae- detail of manual vacuum aspirator

1. UTERINE EVACUATION METHODS
- DR. NIDHI SINGH
1

2. Objectives
At the end of this session, participants will be able to:
1. Describe how each method of uterine evacuation works
2. List main advantages/disadvantages of each method
3. Identify the instruments (or parts) used in each method
4. Describe any indications, contraindications and precautions as
applicable for each method
5. Identify the parts of the MVA equipment and select correct
syringe/cannula size
6. Demonstrate ability to check, assemble and prepare equipment
7. Perform the VA procedure according to the steps outlined
8. Demonstrate appropriate counseling before, during and after
the VA procedure
9. Recognize and solve technical or procedural problems during
VA
2

3. Uterine Evacuation
• Because most complications result from retained products of
conception (POC), removal of the contents of the uterus (uterine
evacuation) is one of the primary components of emergency
treatment.
3

4. Uterine Evacuation Methods
• The main methods for treatment of first and second trimester
incomplete abortion are vacuum aspiration (VA), sharp
curettage (SC) and pharmacological methods.
• Vacuum aspiration is generally preferred to sharp curettage (or
D&C) due to lower minor complications rate and reduced need
for surgical facilities (WHO, 1994).
4

5. Vacuum Aspiration (VA)
• Safe and effective method that works by applying suction to
remove uterine contents
• Used in industrialized countries for more than 20 years
• Suction is produced by a manual syringe, foot pump or electric
pump, via a cannula (tube) placed into the cervix
5

6. Manual Vacuum Aspiration (MVA)
• A safe, effective and low-cost method of uterine evacuation
• A hand-held vacuum syringe is used to empty the uterus
• Syringes come as no-valve, single-valve, double-valve and MVA
Plus:
– No-valve syringes not recommended:
• Do not create a vacuum until cannula is inserted,
increasing risk of uterine perforation
6

7. Single-Valve Syringe with Cannulae
7

8. Double-Valve Syringe with Cannulae
8

9. MVA Plus
9

10. Foot Pump Suction Evacuation (FSE)
• An alternative device for uterine evacuation.
• Uses flexible cannulae and is operated by the provider
performing the uterine evacuation procedure. Vacuum can be
easily obtained.
• The provider controls the vacuum by digitally occluding with the
thumb a small venting port at the point of attachment of the
cannulae to the suction tubing.
10

11. Foot Pump Suction Evacuator
11

12. Comparison of MVA and Foot Pump Suction
Evacuation
• A study published in the South Africa Medical Journal compared
the foot pump suction evacuator with the manual vacuum
aspirator for uterine evacuation.
• Findings showed that the FSE and MVA were similar in
effectiveness and outcomes. The time to perform the FSE was
not significantly different in operative blood loss estimation or
the time needed to perform the procedure.
• There were no cases of uterine perforation, cervical injuries or
blood transfusions. Both techniques were easy to use.
Adapted from: Gaertner et al.,1998.
12

13. Electric Vacuum Aspiration (EVA)
• Uses an electric pump and cannulae to evacuate the uterus by
providing either intermittent or continuous suctioning.
• Most devices provide a continuous level of suction. However,
newer models may also provide intermittent suction.
13

14. Electric Vacuum Aspiration (EVA) (2)
• The EVA method has about the same effectiveness as the
manual device:
– No evidence showing a significant difference in the rate of
complications between the two methods. Patient satisfaction
is also comparable, aside from the noise level.
• Due to the electricity requirements and the initial high cost
of the machine, EVA may not be the most suitable method
where resources are limited.
14

15. Electric Vacuum Aspiration Machine
15

16. Vacuum Aspiration: Advantages
• MVA and FSE do not require electricity and can be used in
remote settings, extending a woman’s access to emergency
treatment.
• EVA, MVA and FSE have the same effectiveness rate. There is
no evidence showing a significant difference in the rate of
complications.
• Patient satisfaction for EVA and MVA is also comparable.
• Flexible cannula (MVA, FSE):
– Can reach deep into the uterus even when it is anteverted or
retroverted
– Rounded tip and narrow width requires little dilatation
16

17. Vacuum Aspiration: Advantages
• Though VA and sharp curettage (SC) are equally effective for
treatment of incomplete abortion, women undergoing VA
procedures experience less blood loss and less incidence of
uterine perforation than those undergoing SC.
17

18. Vacuum Aspiration: Contraindications (MVA,
FSE)
Contraindicated for use in clients with:
• A uterine size over 12 weeks LMP (MVA)
• Acute cervicitis or pelvic infection, except in an emergency
• Large fibroids unless emergency back-up is available
18

19. Vacuum Aspiration: Precautions
• In the following cases, VA should be used with caution, and only
in facilities with full emergency backup.
• Clients with:
– History of bleeding disorders
• Risk of excessive bleeding or hemorrhage
– History or suspicion of prior uterine perforation:
• Risk of injuring the bowel
– Severe anemia:
• Risk of severe shock and death
19

20. Vacuum Aspiration: Precautions (2)
• Hemodynamic instability (hemorrhage/shock, cardiac disease):
– Risk of severe shock and death
• Uterine fibroids:
– Risk of perforation
• In the presence of infection, proceed only with antibiotic
coverage (initiate antibiotics before starting procedure
20

21. Dilatation and Curettage (D&C) Sharp Curettage
(SC)
• WHO recommends that this method be used only when vacuum
aspiration is not available.
• Uses a curette or a similar metal surgical instrument to empty
the uterus.
• Usually performed under general or regional anesthesia, or
heavy sedation.
• Recent studies show that it can be performed as an outpatient
procedure in hospitals/some health centers.
21

22. Comparison of Vacuum Aspiration and
Dilatation and Curettage
Characteristics Vacuum Aspiration
(EVA)
Dilatation and
Curettage (D&C)
Effectiveness Rate 98% 99%
Pain Less pain Increased pain
Complications Fewer minor
complications than
D&C
Increased bleeding
(may be due to use
of anesthesia)
22

23. Comparison of VA and SC
MVA:
• Vacuum suction with plastic
cannula, lowering the risk of
uterine perforation
• Minimal cervical dilatation
required
• Analgesia, light sedation and/or
local anesthesia can be used
• Outpatient procedure, reducing
the need for hospital stay
D&C:
• Scraping with sharp, metal
curette, increasing the risk of
uterine perforation
• Mechanical dilatation often
23
required
• Heavy sedation, analgesia
and/or general anesthesia
often used
• Operating theater procedure,
often requiring hospital stay

24. D&C Instruments
24
Source: www.HealthAtoZ.com 2004.

25. Indications for Sharp Curettage (SC)
• Sharp curettage has been effectively used for many conditions.
Some of the indications include:
– Excessive vaginal bleeding
– Abnormal vaginal bleeding
– Polyps
– Incomplete abortion:
• When VA not available
– Molar pregnancy:
• Risk of uterine perforation is high with SC; VA may be
safer and associated with less blood loss
– Diagnostic:
• Endometrial cancer
• Determine cause of vaginal bleeding
25

26. Pharmacological Methods of Uterine
Evacuation: Misoprostol
• A prostaglandin initially developed to treat gastrointestinal
problems:
– Prostaglandins are a group of chemicals made by nearly all
of the body's cell membranes.
• Different prostaglandins have different effects on the body:
– They can help treat inflammation and pain, raise or lower
blood pressure, affect the immune system and stimulate
uterine contractions and labor.
26

27. Pharmacological Methods of Uterine
Evacuation: Misoprostol (2)
• Research indicates that 600 ug of misoprostol (oral) is an
effective dosage for use in postabortion care.
• Studies for sublingual dosage amounts for use in postabortion
care are ongoing.
• WHO has included misoprostol on its list of essential medicines
for miscarriage and incomplete abortion.
27

28. Expectant Management
• Spontaneous abortion with partial expulsion of POC sometimes
resolves itself as part of the natural process.
• Over time, the remaining uterine contents will be expelled
without any intervention. Expectant management is allowing this
process to take place.
• During this time, the provider must monitor the client for signs of
complications and make sure the complete evacuation of uterine
contents has occurred.
28

29. Indications for Expectant Management
• Expectant management should be carried out only under the
following circumstances:
– Clients with uncomplicated spontaneous abortions
– Availability of skilled care and emergency services in case of
complications
– If possible, ultrasound and hCG monitoring capability should
be available
29

30. Manual Vacuum Aspiration
Manual vacuum aspiration (MVA) uses a specially designed, hand-held
vacuum syringe with a flexible plastic cannula to apply suction
in order to remove the products of conception from the uterus. This
method does not require electricity.
Note: MVA is not the ideal procedure for evacuating the uterus
in molar pregnancies:
• The amount of tissue in such cases is often copious.
30

31. Indications for MVA
• Uterine evacuation first trimester
– Induced abortion
– Spontaneous abortion or early pregnancy failure
(EPF)
• Complications management
– Incomplete medical abortion
– Post-abortal hematometra
• Uterine sampling
– Endometrial biopsy

32. MVA vs EVA
EVA
• Electric pump
• Costly but longer life
• Variable noise level
• Not easily portable
• Capacity: 350-1,200 cc
• Constant suction
• Fragmentation of POCs
MVA
• Manual aspirator
• Inexpensive
• Quiet
• Portable
• Capacity: 60 cc
• Suction decreases as
aspirator fills
• POCs likely intact

33. Complications with MVA
• Rare
• Same as for EVA
– Incomplete evacuation
– Uterine or cervical injury
– Infection
– Hemorrhage
– Vaso-vagal reaction

34. MVA Instruments

35. MVA: Key Benefits
• Safety & efficacy equivalent
to EVA
•Portable
•Low tech
•Low-cost
•Small and quiet
 Significant implications for
incorporating services into the office
setting

36. Other Clinical Benefits of MVA
POCS are easier to visualize & inspect
– Often more intact
– Easier detection of early EGA
• Fewer re-aspirations in MVA vs EVA group
(Goldberg 2004)
– Can still send to pathology for genetics

37. MVA POC Check: Benefits for EPL
Creinin and Edwards 1997
Electric Suction Machine MVA Aspirator
What
is
that?
Ther
e it
is!

38. Preparing VA Instruments
• Select cannulae:
– Inspect cannulae for cracks or other defects; discard if there
are any visible signs of weakness or wear.
– Select cannulae according to the assessment of uterine size
(weeks LMP).
– Prepare several cannulae of different sizes. The cannula
needs to be large enough to allow passage of tissue
expected (according to gestation) and fit snugly through the
cervix.
38

39. 39

40. 40

41. 41

42. • Performing the MVA Procedure
• Step One: Prepare and Check Instruments
• Position the plunger all the way inside the cylinder.
• Have collar stop in place with tabs in the cylinder
holes.
• Push valve buttons down and forward until they lock
• Pull plunger back until arms snap outward and catch
on cylinder base . This “charges”the instrument.
• Check vacuum by leaving the instrument in the
“charged” position for two to three minutes, then
release the buttons. A rush of air indicates that the
aspirator maintained a vacuum
42

43. 43

44. • Step Two: Prepare the Patient
• Ask the woman to empty her bladder.
• Conduct a bimanual exam to confirm uterine size and
position.
• Insert speculum.
• Step Three: Perform Cervical Antiseptic Prep
• Clean cervical os with antiseptic.
• Follow No-Touch Technique: no instrument that
enters the uterus can contact contaminated surfaces
before being inserted through the cervix
44

45. • Step Four: Perform Paracervical Block
• Paracervical block is recommended.
• Using local protocols, administer paracervical block
and place tenaculum.
• Use lowest anesthetic dose possible to avoid toxicity.
• Step Five: Dilate Cervix
• Use mechanical dilators or progressively larger
cannulae to dilate the cervix.
• Dilate the cervix to allow a cannula approximate to
the uterine size to fit snugly through the os
45

46. Paracervical Block

47. • Step Six: Insert Cannula
• While applying traction to the tenaculum, insert the
cannula through the cervix, just past the os and into
the uterine cavity until it touches the fundus, and then
withdraw it slightly.
• Do not insert the cannula forcefully.
• * For endometrial biopsy, use the Ipas 3mm cannula
with an adapter.
47

48. 48

49. • Step Seven: Suction Uterine Contents
• Attach the cannula to the prepared aspirator.
• Release the vacuum by pressing the buttons.
• Evacuate the contents of the uterus by gently and slowly
rotating the cannula and using a gentle in-and-out motion.
• * For endometrial biopsy, aspirate tissue by moving the
cannula gently back and forth along the uterine wall,
taking the appropriate sample.
• When finished, depress the buttons and withdraw the
instruments.
• * For endometrial biopsy, withdraw instruments when an
adequate amount of tissue is obtained
49

50. • Signs that indicate the uterus is empty:
• Red or pink foam without tissue is seen passing
through the cannula
• A gritty sensation is felt as the cannula passes over
the surface of the evacuated uterus
• The uterus contracts around or grips the cannula
• The patient complains of cramping or pain, indicating
that the uterus is contracting
50

51. 51

52. • NOTE: If more than one aspirator is required to empty the
uterus:
• (1) Detach the cannula from the aspirator, leaving the cannula in
place. Empty the aspirator,recharge it and carefully reattach it to
the cannula. Resume evacuation.
• (2) Remove both the aspirator and the cannula. Use strict No-
Touch Technique, never allowing the tip of the cannula to
contact a contaminated surface. Detach the cannula. Empty the
aspirator.Recharge the aspirator and carefully reattach it to the
cannula, ensuring that the cannula remains sterile. Reinsert the
cannula, and resume aspiration.
• OR(3) Have a second aspirator readily available if more than
one aspirator is needed.
52

53. • Step Eight: Inspect Tissue
• The MVA procedure is not complete until products of
conception have been inspected and confirmed.
• Empty the contents of the aspirator into a container.
• Inspect tissue for products of conception by straining material or
floating material in water or vinegar and viewing with a light from
beneath.
• If inspection is inconclusive, reaspiration may be necessary. If
indicated, follow clinic protocols to rule out ectopic pregnancy.
• * Endometrial biopsy samples should be handled according to
laboratory protocols
53

54. • Step Nine: Perform Any Concurrent Procedures
• When the procedure is complete, proceed with any
contraception or other concurrent procedures, such
as IUD insertion.
• Step Ten: Process Instruments
• As soon as the procedure is complete, immediately
discard cannulae and soak the aspirator and
adapters (if used) to ease cleaning.
54

55. 55

56. The VA Procedure
*Absence of POC in a woman with symptoms of pregnancy
may strongly indicate the possibility of ectopic pregnancy.
56

57. Post-Procedure Care-
Monitor recovery of the client:
• Take vital signs before moving the client from the procedure
area.
• Continue with pain management as needed.
• Encourage the woman to eat, drink and walk as she wishes.
• Explore the client’s feelings and concerns and provide
explanation and support as needed.
57

58. Post-Procedure Care—
• Check bleeding at least once before discharge and check to see
that cramping has reduced. Prolonged cramping is not normal.
• Client may be discharged as soon as she is stable, can walk
without assistance and has received post-procedure counseling
and family planning information and services.
• In most instances, uncomplicated cases can be discharged in
1–2 hours.
58

59. Post-Procedure Care—
• complete FP counseling and assist client in deciding on a
method before she is discharged.
• Provide other health services as needed (if available) such as
tetanus prophylaxis or Rh immune globulin if client Rh-negative.
• Advise the client of signs that need immediate attention:
– Prolonged cramping (more than a few days)
– Prolonged bleeding
– Bleeding more than a normal menstrual period
– Severe or increased pain
– Fever, chills
– Fainting
59

60. Management of Problems during the VA Procedure
• The key to recognizing and managing problems during VA is to
know that they can occur even under the best circumstances.
• Most problems are not serious and if recognized immediately
and corrected or treated, the client’s recovery will not be
affected.
60

61. Technical Problems—VA Procedure
1. Syringe is full (MVA):
– Keep a second prepared syringe on hand during the
aspiration and switch syringes if one becomes full.
2. Cannula is withdrawn prematurely (MVA, EVA, FSE):
– If the opening of the cannula is pulled into the vaginal canal
with the valve still open, the vacuum will be lost.
3. Cannula is clogged (MVA, EVA, FSE):
– Never try to unclog the cannula by pushing the plunger back
into the barrel with the cannula tip still in the uterus.
4. Syringe does not hold vacuum (MVA):
– Try lubricating the plunger and barrel with a drop of silicone.
If this does not work, replace the O-ring. If the syringe still
does not hold a vacuum, discard it and use another syringe.
61

62. Procedural Problems—MVA, EVA, FSE
1. Less than expected tissue/No POC:
– Consider possible ectopic pregnancy.
– Consider complete abortion or misdiagnosis.
2. Incomplete evacuation:
– Use correct size cannula.
– May need to repeat evacuation.
3. Uterine perforation:
– This is rare.
– Signs include severe pain, abdominal distention, cervical
motion tenderness, shoulder pain and rigid abdomen.
62

63. Other Problems
1. Vaginal bleeding not due to pregnancy:
– Break-through bleeding (hormonal contraceptive use)
– Uterine fibroids
2. Ectopic pregnancy:
– Delay in treatment of an ectopic is dangerous.
– Risk is higher in women with:
• Previous ectopic pregnancy
• Pelvic infection
• IUD or progestin-only contraceptive use
63

64. Processing the Ipas MVA Plus Aspirator
• Basics of Infection Prevention
• Wash hands immediately before and after every patient contact.
• Consider all blood and body fluids from all patients to be
potentially infectious.
• Use personal protective barriers (gloves, gowns, face protection,
shoes) when contact with blood or other body fluids is
• expected.
• Avoid skin punctures, especially when handling needles.
• Use No-Touch Technique: the tip of the cannula, or the tip of
any other instrument that enters the uterus, shouldnever touch
non sterile surfaces (including the vaginal walls) prior to
insertion.
64

65. • Step 1: Soak Instruments Immediately After Use
• Following the procedure, all aspirators and adapters
that will be reused should be kept wet until cleaning.
Using a 0.5% chlorine solution is an option.
65

66. • Step 2: Clean all aspirators and adapters thoroughly in
warm water and detergent, not soap. Wear gloves and face
protection.
• Disassemble the aspirator by pulling the cylinder out of the valve
• Wash all surfaces of the instrument in warm water and detergent
• Use soft brush
• Clean until no blood or tissue is visible
• Rinse
66

67. Step 3: Processing Options
• Sterilize
• Steam autoclave in linen or paper for 30 minutes at 250ºF
(121ºC) with a pressure of 15 lbs/in2 (106 kPa).
• DO NOT USE HIGHER TEMPERATURES AS DAMAGE MAY
OCCUR. This device cannot withstand temperatures higher
than 250ºF.
• High-Level Disinfect (HLD)
• Soak immersed in a 2% glutaraldehyde solution (Cidex) for
20 minutes. Rinse aspirators as appropriate.
• Boiling water for 20 minutes
• Step 4: Store or Use Immediately
• Store: Aspirators should be stored in dry, covered
containers or packages, protected from dust and other
contaminants.
67

68. CASES

69. Case 1
You see a 18-year old woman, G2P1001, whose last period
was 8 weeks ago. She had a positive home pregnancy test 3
weeks ago. She has not had an ultrasound during this
pregnancy.
Three days ago, she began to spot. Today, her bleeding has
increased, like a very heavy period with some clots. She
began cramping last night and now reports that the cramping
is severe. She comes to your clinic today for assessment and
treatment if required.

70. Case 1
Her medical history includes a spontaneous
vaginal delivery 2012. She is otherwise healthy.
On exam, she appears comfortable and is able to
walk around the room and talk easily. Her vital
signs:
BP 110/70, Pulse 90, Temp 97.8
At this point, how would you proceed with
evaluation?

71. Case 1
The examination reveals the following
– Abdomen: soft, non tender
– Vaginal vault: scant amount of blood, consistent with a
menses
– Cervix: os open, tissue at os noted
– Bimanual exam: uterus enlarged, approx. 8 weeks size,
non tender
• Her hemoglobin is 12.2.
• Urine pregnancy test: positive
What tests do you think you should order now?

72. Case 1
The ultrasound reveals an intrauterine
gestational sac, and thickened
endometrial stripe.
What is the diagnosis?
What are the treatment options available
for this patient?

73. Case 1 continued
The same 18 yro G2P1001, experiencing mild-moderate
cramping with mild-moderate bleeding in
your clinic, and an ultrasound evidence of an
incomplete abortion elects an MVA procedure as
she wants to take care of this as soon as possible.
You are performing the MVA-all seems to be going
well. However, the aspirator is only about one-quarter
full and you remember from this course
that at this gestational age, you would expect more
tissue than this. You are not sure whether or not
you are done.

74. Case 1 continued
How can you tell if you are done? List 4 signs
suggesting completion.
What do you do?

75. MVA Key Concepts
• MVA safe & effective for early pregnancy loss in first
trimester
• Allows for care that day, in the office, with their
primary provider
• Any uterine evacuation’s efficacy is improved by
systematically checking for completion

76. Case 2
41 yr G1P1 presents to the Clinic for her first
prenatal visit in a very desired pregnancy. Her LMP
was 10 weeks ago and she is certain of her dates.
The pregnancy has been uncomplicated except for
a small amount a bleeding she had about 1 week
ago. You evaluate the patient and finds that her BM
exam is consistent with a 7 wk IUP, os is closed.
What other information might you be interested in
knowing about?
What might you order to get a diagnosis?

77. Case 2
Fortunately, your Clinic has a portable
ultrasound, and you are able to supervise the
resident with a vaginal probe ultrasound. You
see a well-circumscribed, though empty
gestational sac.
What are your differential diagnoses? What do
you tell the patient?

78. Case 2
The patient returns 5 days later with further
spotting and cramping. A 2nd serum β-hCG is
done, as well as a repeat ultrasound. The
ultrasound now shows a large irregular shaped
gestational sac. The serum β-hCG level has
dropped.
What is your assessment?

79. Case 2 Anembryonic Pregnancy
• Consider the emotional aspects of miscarriage
• Element of choice in patient satisfaction
• Effectiveness of medication methods as well as
surgical methods

80. Case 2 continued
The patient decided to opt for medical treatment.
She took both mifepristone and misoprostol and is
now seeing you for her routine follow-up visit,
scheduled 2 weeks after she took mifepristone.
She has been having persistent spotting, and says
that she is really “sick of it.” Vaginal ultrasound
reveals a non-viable, persistent gestational sac.
Specifically, there is no evidence of growth but the
sac is still present.

81. Case 2 continued
You counsel her about options, including
observation, repeating misoprostol, and
surgical completion. The woman has
significant childcare problems and wants
to minimize the number of visits she must
make to your clinic. Therefore, she
requests surgical completion.

82. Case 2 continued
You perform MVA and are partway through the
aspiration when you note that the cannula seems to
be sliding back and forth over the uterine lining too
easily; it feels like nothing is happening.
What could be going on?
What do you do to test your answer to question #1?
How might MVA on this patient be different from that
performed on surgical abortion patients who have
not received mifepristone or misoprostol?

83. Case 3
26 yo G2P2002 LMP uncertain because of
irregular periods well known to you presents to
your office with spotting x 4 days. She denies
any pain. Her urine pregnancy test is positive,
her cervical os closed. Her uterus is retroverted.
She has a remote history of Chlamydia infection
about 10 years ago.
What is your differential diagnosis?
What tests would you order now?

84. Case 3
You perform an ultrasound and you see small
echolucent area, which could be a small
gestational sac or a pseudosac.
What should you do now?
What is your diagnosis? What are you options for
treatment?

85. Case 3 Key Concepts
Ectopic Pregnancy
• Ectopic vs early pregnancy may be hard to
differentiate
• Methotrexate an option for early & stable patients
• MVA can help evaluate POC in clinic, guiding
diagnosis & referral decision

86. Case 3 continued
26 yo G2P2002 LMP uncertain because of
irregular periods is at your office for
pregnancy termination with either early
intrauterine versus ectopic pregnancy in
the differential. She would like to deal with
it today and with you if possible. You want
to make sure it is not an ectopic
pregnancy….

87. Case 3 continued
Initially, dilitation of the cervix seems slightly
more difficult than usual. However, after the first
two dilator passes, it then progresses
uneventfully. A 6 mm cannula is placed in the os,
the aspirator is connected, and only scant blood
is obtained. Dilitation for correct placement is
attempted again. Again, only scant blood is
obtained.
What do you think is happening?
What do you do now?

88. MVA Key Concepts
• Helpful to trouble shoot & know how to solve common MVA
problems
• Lack of suction can caused by
– Device not assembled or working properly
– Clogged cannula
• Can never go wrong by stopping & reassessing

89. MVA Key Concepts
• Checking device & placement helpful when not
getting scant or no products back
• Ultrasound helps assess placement of cannula
• MVA can be help diagnose ectopic pregnancy
• Floating products of conception very helpful in
assessing uterine contents (and is easy to do)

90. Conclusions
Evidence demonstrates
• Uterine evacuation can be managed safely in an out-patient
clinic setting
• Moving out of the operating room
– Saves both time, money, resources
– Offers significant both choice & advantages to
both women & clinicians

91. “Never, ever, think outside the box.”