Uterine Evacuation with Manual Vacuum Aspiration (MVA) A Training Manual for Conducting Short Courses

Transcription

1 Uterine Evacuation with Manual Vacuum Aspiration (MVA) A Training Manual for Conducting Short Courses

2 ISBN: Ipas. Produced in the United States of America. Suggested Citation: Ipas Uterine Evacuation with Manual Vacuum Aspiration (MVA): A Training Manual for Conducting Short Courses. Chapel Hill, NC: Ipas. Ipas is a nonprofit organization that works globally to increase women s ability to exercise their sexual and reproductive rights and to reduce abortion-related deaths and injuries. We seek to expand the availability, quality and sustainability of abortion and related reproductive health services, as well as to improve the enabling environment. Ipas believes that no woman should have to risk her life or health because she lacks safe reproductive health choices. WomanCare Global LLC is an exclusive distributor of Ipas instruments. For information regarding availability or to report an adverse event contact WomanCare Global at [email protected] or Ipas PO Box 5027 Chapel Hill, North Carolina 27514, USA Web site: [email protected] Graphic Design: Jamie McLendon Editor: Jennifer Daw Holloway Printed on recycled paper An Ipas international publication

3 Manual Vacuum Aspiration (MVA) Each year, nearly 67,000 women die from unsafe abortion and about 5 million more are injured, often permanently (WHO 2007). Many of these women could be saved and their injuries prevented if clinicians in their communities were trained and equipped to use a simple, inexpensive medical device the manual vacuum aspiration (MVA) instrument. MVA involves the use of a plastic aspirator to evacuate the uterus for miscarriage management (incomplete, missed or inevitable abortion), first-trimester abortion (also called menstrual regulation), and endometrial biopsy. The manual vacuum aspirator consists of a cylinder, plunger and valve. To evacuate the uterus, the aspirator is attached to a cannula which is inserted through the cervix to aspirate the contents of the uterus. The MVA device is handheld and portable. The procedure is quiet, fast and inexpensive (Dalton 2006) and can be performed in a wide variety of clinical settings because it does not rely on electricity. Unlike traditional dilatation and curettage with a sharp curette, an MVA procedure does not typically require general anesthesia. In a small percentage of cases (<2%), one or more of the following can occur during or after the procedure: uterine or cervical injury, pelvic infection, vagal reaction, incomplete evacuation or acute hematometra. The benefits of MVA for uterine evacuation are: MVA is safe; it increases women s access to medical care by making it possible to offer services at lower level facilities and by midlevel providers; and it reduces health-care costs (WHO 2003). The World Health Organization (WHO) recommends MVA as a preferred technique for uterine evacuation (WHO 2003), including for treatment of miscarriage, postabortion care (PAC), induced abortion in early pregnancy or for incomplete abortion, such as in cases of failed medical abortion. UTERINE EVACUATION WITH MANUAL VACUUM ASPIRATION (MVA): A TRAINING MANUAL FOR CONDUCTING SHORT COURSES 1

4 Because of its importance to obstetric care, WHO and the United Nations Population Fund (UNFPA) have included MVA instruments on their proposed list of essential drugs and other commodities for reproductive health care (WHO and UNFPA 2003) and in technical guidance for uterine evacuation (WHO 2003). This Resource Historically, Ipas and other international nongovernmental organizations have supported training events of five days or more with the goal of health-care facilities adopting a model of more comprehensive care for women (either postabortion care or abortion care, including MVA for treatment, as well as contraceptive services, counseling for other health needs, provision of other reproductive health services and community partnerships for prevention of unsafe abortion). Though many health-care professionals are eager to gain the knowledge and skills necessary to provide obstetric care with MVA, they cannot take significant time away from clinical responsibilities to take part in lengthy training events. Ipas recognizes that every clinician does not need a comprehensive course designed to help a team adopt a new model of care and notes that professionals come to training events with existing ranges of knowledge and skills and varying learning needs. Clinicians can avail themselves of a broad continuum of educational options to gain the knowledge and skills they need at a particular point in their professional careers and practices. The courses outlined in this manual are designed to meet the middle range of training needs in MVA use. For example, attending these courses requires more effort/time and results in more knowledge/skill-building than simply reading MVA product inserts or studying a wallchart, but not as much as performing several procedures one-on-one with an experienced clinical trainer supervising or attending a multi-day clinical course. This manual, which is specific to MVA (excluding the other elements of comprehensive models), will serve as a guide for MVA training facilitators to provide three standard courses each with different objectives, prerequisites and course lengths, based on the participants level of familiarity with MVA and experience with transvaginal procedures. The courses include up-to-date content and are based on principles of adult learning. Participants who successfully complete the courses will gain the specified knowledge and skills offered in each of the courses. Variations of these standard courses have been delivered around the world. 2 UTERINE EVACUATION WITH MANUAL VACUUM ASPIRATION (MVA): A TRAINING MANUAL FOR CONDUCTING SHORT COURSES

5 The Courses The three courses vary in length and scope and can be offered separately or in a series so that participants can attend more than one course in a convenient timeframe. The basic course themes are: MVA and its clinical applications; How to perform MVA on a pelvic model and all local instrument processing options (where regulatory conditions approve re-use); The above topics plus supervised clinical practice, management of complications and guidance on monitoring of services. Training facilitators should select course materials based on the environmental context in which the learners will put their new knowledge and skills to use. The two key issues of environmental context to identify for course content selection are: 1. Clinical applications for use of MVA In every country of the world, there are at least two clinical applications for MVA: treatment of incomplete or missed abortion (miscarriage) and endometrial biopsy. Additionally, in most countries, therapeutic abortion is legally permitted to save the woman s life or preserve her health and/or for other indications. Most women live in countries where induced abortion is permitted, with or without restrictions (CRLP 2007). Materials on the CD-ROM included with this manual are labeled Uterine Evacuation for either INCOMPLETE/MISSED ABORTION: for use in contexts that focus on treatment of incomplete/missed abortion, whether miscarriage management or treatment of complications of an induced procedure, and endometrial biopsy Or, ALL INDICATIONS: for contexts that include treatment of incomplete/missed abortion, first-trimester induced abortion and endometrial biopsy 2. Regulatory Context: Are cannulae labeled for single or multiple use? The use and re-use of cannulae varies among countries and clinical practices. In the United States and some other countries, Ipas EasyGrip cannulae are labeled for single use and should be discarded after use. Where local regulations permit, these cannulae can be reused after high-level disinfection or sterilization. Please note that flexible Karman cannulae and 3mm cannulae for endometrial biopsy are labeled for single use in all countries and should be discarded after use. Trainers should plan to follow country-specific labeling regarding single-use or processing of instruments for reuse. Materials on the CD-ROM included with this manual are labeled either SINGLE USE: for settings where cannulae are used once and discarded Or, MULTIPLE USE: for settings where cannulae are processed for reuse UTERINE EVACUATION WITH MANUAL VACUUM ASPIRATION (MVA): A TRAINING MANUAL FOR CONDUCTING SHORT COURSES 3

6 The Courses at a Glance Title Course 101 Introduction to MVA Course 201 Pelvic Model Practice with MVA Course 301 Supervised Clinical Practice with MVA Description Introduction to MVA Practice MVA on a Pelvic Model Processing MVA instruments for reuse, where allowed Supervised Clinical Practice with MVA Monitoring of Services Management of Complications Program Length ~ three hours ~ four hours ~ One six to eight hour day Prerequisites None Course 101 or equivalent IpasUniversity course completions, which are: MVA Facts and Features Uterine Evacuation with Ipas MVA Plus Stocking Facilities with MVA Course 101 or equivalent IpasUniversity course completions, which are: MVA Facts and Features Uterine Evacuation with Ipas MVA Plus Stocking Facilities with MVA AND Course 201 Topics Covered Uterine evacuation methods MVA facts and features: Clinical application and product features Supervised practice on pelvic model Processing instruments for reuse, where allowed Perform a supervised MVA procedure in a clinical facility* Monitoring of services Overview of MVA procedure Management of complications MVA stocking and resupply Learning Objectives Upon completion participants will: Be familiar with the Ipas MVA instruments and know how and when to resupply Be able to simulate MVA on a pelvic model Be able to process MVA instruments in accordance with local regulations and with locally available products/systems Have performed a supervised MVA procedure in a local clinical facility* Be familiar with key tools for monitoring services with a goal toward quality improvement Be able to manage potential complications Recommended Trainers/ Presenters 1 clinical trainer 1 representative from local MVA distributor who can facilitate stocking and resupply of instruments 1 clinical trainer 1 representative from local MVA distributor who can facilitate stocking and resupply of instruments 1 clinical trainer and 2 additional clinical trainers for part of the workshop 1 representative from local MVA distributor who can facilitate stocking and resupply of instruments Recommended Participants Up to 20 participants Up to 10 participants per clinical trainer Up to 5 participants per clinical trainer Please note that while endometrial biopsy is an indication for MVA, specific training on endometrial biopsy is not a part of these course models. 4 UTERINE EVACUATION WITH MANUAL VACUUM ASPIRATION (MVA): A TRAINING MANUAL FOR CONDUCTING SHORT COURSES

7 Ipas policy/guidelines on clinical training with live patients Promoting quality care for women is a top Ipas priority. To that end, participants in course 301 (Supervised Clinical Practice of MVA) must have completed course 201. Clinical trainers and participants in course 301 must meet all professional requirements of the facility where supervised clinical practice is offered. Options for Delivering Courses These short courses offer training facilitators and participants great flexibility in finding the course and schedule that best meets participants needs and available time. For example: Courses offered separately First day of the month Course 101 Monthly, or occasionally to meet demand Course 201 Monthly, or occasionally to meet demand Course 301 Or, courses offered as a series Example 1: Courses offered on closely-scheduled days Tuesday Evening Course 101 Thursday Evening Course 201 Saturday all day Course 301 Example 2: Courses offered on two successive days Friday Morning Course 101 Friday Afternoon Course 201 Saturday all day Course 301 UTERINE EVACUATION WITH MANUAL VACUUM ASPIRATION (MVA): A TRAINING MANUAL FOR CONDUCTING SHORT COURSES 5

8 The Trainers/Presenters The trainers/presenters for these courses should be clinicians skilled in uterine evacuation with MVA and capable of training on all elements in the courses. Ideally, clinical trainers will be a member of Ipas s Global Trainers Network (GTN), a network for clinical trainers and organizations that provide sexual and reproductive health training. Ipas ensures that GTN trainers are able to: Follow current clinical guidelines Utilize Ipas clinical training curricula Employ effective teaching methodologies based on adult learning principles Serve as effective presenters and facilitators For information on how to find an Ipas GTN trainer in your area, please send an to [email protected]. For Course 301, depending on the number of participants and clinical practice volume, there may be concurrent sessions that require additional clinical trainers or local monitoring experts during a one-hour period. Ipas recommends that a representative from a local MVA distributor also serve as a trainer/presenter at these courses. It is important that participants know where they can procure a sustainable supply of instruments following completion of a course. The Materials This manual and accompanying CD-ROM includes all the information and tools necessary to plan and implement Course 101, Course 201 and Course 301, including: Course overviews for instructors Participant agendas Materials checklists with links to learning and instructional aids Planning checklists Learning assessments with answer keys Evaluation forms Certificates for course completion Information on MVA instruments and local availability Please note that the CD-ROM also contains all of the PowerPoint course slide sets. The slides are not reproduced in this manual. The detailed course overviews include the number of PowerPoint slides per topic and all suggested supporting materials and activities. For ease of presenter use, the entire course is in one slide deck. However, it is not all PowerPoint-based. Place-holder slides for interactive and hands-on activities are included with instructions. There are also test your knowledge question slides at the end of certain topics. Please note that correct answers for all test your knowledge slides are in the Speaker s Notes. All trainers/presenters should plan to review the correct answers before presenting the test questions to audiences. Should 6 UTERINE EVACUATION WITH MANUAL VACUUM ASPIRATION (MVA): A TRAINING MANUAL FOR CONDUCTING SHORT COURSES

9 the trainer/presenter not wish to include the test your knowledge slides in the educational session, the slides can be hidden or deleted. All slides can be re-ordered, and the interactive slides can be interspersed throughout the presentation, rather than reviewing them at the end of a topic. Ipas wants to ensure maximum flexibility for each individual presenter s preferred style and comfort level, while maintaining standard content. Additional resources that can be used in a blended learning approach With the goal of maximizing the time of learners and trainers, Ipas recommends the following tools that can be used as distance learning, job aids or supplemental learning for participants and trainers. Specifically, documented completion of selected courses from IpasUniversity can serve as a prerequisite to Course 201. IpasUniversity ( IpasU is a self-paced Internet learning site for reproductive health-care providers with a focus on safe abortion care and postabortion care. IpasU offers free courses for both clinicians (already in practice and those still in-training) as well as those who work with developing world clinicians. At present, IpasU courses are available in English only. Other Ipas curricula (online and in print) Ipas is a global leader in reproductive health training. Our performance-based Woman-Centered Abortion Care and Woman- Centered Postabortion Care courses are known for their participatory, experiential learning methods, based on principles of adult learning and empowerment education. These courses are normally offered as part of a larger in-service training program. Trainers and reference manuals are available on (use search term womancentered ). Access to the Global Trainers Network (GTN) Participants who successfully complete any of the three courses outlined in this manual may be interested in working with an experienced Ipas trainer from the Global Trainers Network to build and strengthen their skills in providing MVA care, or expand their knowledge of the Woman- Centered approach. For more information please send an to: [email protected] MVA Calculator ( Use the free online MVA Calculator to estimate facility supply needs for MVA at UTERINE EVACUATION WITH MANUAL VACUUM ASPIRATION (MVA): A TRAINING MANUAL FOR CONDUCTING SHORT COURSES 7

10 References Center for Reproductive Policy and Law The World s Abortion Laws. New York: CRR.( Dalton, Vanessa, Lisa Harris, Carol Weisman, Ken Guire, Laura Castleman, Dan Lebovic Patient Preferences, Satisfaction, and Resource Use in Office Evacuation of Early Pregnancy Failure. Obstetric Gynecology 108(1): World Health Organization Unsafe abortion: Global and regional estimates of the incidence of unsafe abortion and associated mortality in Geneva: WHO. World Health Organization and UNFPA Essential drugs and other commodities for reproductive health services. Draft discussion document. Geneva: WHO. World Health Organization Safe abortion: technical and policy guidance for health systems. Geneva: WHO. Tools Course 101: Introduction to MVA 1. Course overview for trainers/presenters 2. Sample participant agenda 3. Recommended materials checklist (with pdfs or links to all materials) 4. Sample planning checklist 5. Sample course evaluation tool 6. Sample certificate for course completion 7. Information on MVA instruments and local availability (sample template) Course 201: Pelvic Model Practice with MVA 1. Course overview for trainers/presenters 2. Sample participant agenda 3. Recommended materials checklist (with pdfs or links to all materials) 4. Sample planning checklist 5. Guidance on set up and training with pelvic models 6. MVA Procedures Checklist 7. Sample learning assessment tool (tests & answer keys) 8. Sample course evaluation tool 9. Sample certificate for course completion 10. Information on MVA instruments and local availability (sample template) 8 UTERINE EVACUATION WITH MANUAL VACUUM ASPIRATION (MVA): A TRAINING MANUAL FOR CONDUCTING SHORT COURSES

11 MVA Course 301: Supervised Clinical Practice with MVA 1. Course overviews for trainers/presenters 2. Sample participant agenda 3. Recommended materials checklist (with pdfs or links to all materials) 4. Sample planning checklist 5. Guidance on setting up and running clinical practicum 6. MVA Procedures Checklist 7. Sample learning assessment tool 8. Sample course evaluation tool 9. Sample certificate for course completion 10. Information on MVA instruments and local availability (sample template) UTERINE EVACUATION WITH MANUAL VACUUM ASPIRATION (MVA): A TRAINING MANUAL FOR CONDUCTING SHORT COURSES 9

12 10 UTERINE EVACUATION WITH MANUAL VACUUM ASPIRATION (MVA): A TRAINING MANUAL FOR CONDUCTING SHORT COURSES

13 Tools

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15 Tools 1) The materials printed in this manual are for the uterine evacuation practice environment of incomplete and/ or missed abortion. The accompanying CD-ROM contains the materials for all indications and both regulatory settings (single use and multiple use of cannulae). 2) These tools and accompanying PowerPoint slides may be adapted for specific training circumstances, only to the extent that the content is NOT altered. For example, if the same group of participants takes all three courses, certain review sections and accompanying slides in MVA 201 and MVA 301 can be deleted to avoid redundancy, and the timeframes on the agenda can be altered, as necessary. Additional location-specific information may be inserted, as well. A) MVA Course Course overview for trainers/presenters 2. Sample participant agenda 3. Recommended materials checklist (with pdfs or links to all materials) 4. Sample planning checklist 5. Sample course evaluation tool 6. Sample certificate for course completion 7. Information on MVA instruments and local availability (sample template) B) MVA Course Course overview for trainers/presenters 2. Sample participant agenda 3. Recommended materials checklist (with pdfs or links to all materials) 4. Sample planning checklist 5. Guidance on set up and training with pelvic models 6. MVA Procedures Checklist 7. Sample learning assessment tool (tests & answer keys) 8. Sample course evaluation tool 9. Sample certificate for course completion 10. Information on MVA instruments and local availability (sample template) C) MVA Course Course overviews for trainers/presenters 2. Sample participant agenda 3. Recommended materials checklist (with pdfs or links to all materials) 4. Sample planning checklist 5. Guidance on setting up and running clinical practicum 6. MVA Procedures Checklist 7. Sample learning assessment tool (tests & answer keys) 8. Sample course evaluation tool 9. Sample certificate for course completion 10. Information on MVA instruments and local availability (sample template) UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 1

16 Tool A-1: MVA 101 Course Overview (Context: Incomplete/Missed Abortion) -- Approximately Three Hours INSTRUCTIONS: Use this Course Overview tool to study the topics, suggested timeframes and supporting slides/materials/activities for the course. Plan and adjust the agenda (separate tool) accordingly. Presentation Topic ~ # Slides Suggested Materials Suggested Length Welcome & Introductions 8 slides Informational Flyers (Ipas MVA 10 minutes Plus, Ipas EasyGrip, 3mm cannula, Ipas mission) Statistics 5 slides 10 minutes UE Methodologies Review and Comparison INCOMPLETE/MISSED: 17 slides 30 minutes Ipas Product Overview 9 slides 30 minutes 10 slides with test questions MVA Procedure 44 slides 6 slides with test questions to use interactively with course participants (correct answers are in speaker notes). MVA steps wall chart Performing MVA + Processing Bifold Performing UE spiral notebook CD-ROMS: 6 min MVA technique using the Ipas MVA Plus or Performing UE with MVA Plus 45 minutes Stocking and Resupply of Instruments 18 slides mvacalculator.org JSI Table Local Distributor contact information Course Close 1 slide Course Evaluation Certificates 15 minutes 15 minutes UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 2

17 Tool A-2: MVA 101 Sample Agenda for Participants INSTRUCTIONS: Adjust this Agenda accordingly and provide one for each participant at beginning of course. Time (adapt as necessary for local setting) (10 minutes) 9:00 am 9:10 am Topic Introduction Lead Presenter (include names, rather than roles, once presenters confirmed) Representative from Local Distributor & Clinical Trainer (10 minutes) 9:10 am 9:20 am Global and local context for MVA Clinical Trainer (30 minutes 9:20 am 9:50 am) (30 minutes) 9:50 am 10:20 am (15 minutes) 10:20 am 10:35 am (45 minutes) 10:35 am 11:20 am Review and comparison of uterine evacuation technologies Overview of MVA instrument Coffee/tea break MVA procedure overview Clinical Trainer Clinical Trainer Clinical Trainer (15 minutes) 11:20 am 11:35 am MVA stocking and resupply Local Distributor (15 minutes) 11:35 am 11:50 am Course close and evaluation Clinical Trainer & Local distributor UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 3

18 Tool A-3: MVA 101 Recommended Materials Checklist with Link to PDF: Course Context: Incomplete/Missed Abortion INSTRUCTIONS: Use this Materials Checklist as guidance to ensure all audiovisual equipment and printed materials are in place for training event. Recommended Quantity Quantity Ordered Status Item Link to pdf, where applicable 1 Computer and LCD projector for powerpoint presentations Participant Agenda Informational flyers (MVA Plus, EasyGrip, 3mm, mission) Contact information from local supplier/vendor of MVA, including JSI Table and link to Peforming Uterine Evacuation with the Ipas MVA Plus Aspirator and Ipas EasyGrip Cannulae: Instructional booklet Performing Uterine Evacuation with Ipas MVA Plus and Ipas EasyGrip Cannulae: Instructional CD-ROM OR CD-Rom of 6 minute video MVA steps wall chart Performing MVA + Processing Bifold List of on-line resources Certificates of participation and completion Plus Flyer 2007 Easy Grip Flyer 3 mm Flyer 2007 Performing UE with Ipas MVA Plus MVA Procedure Steps Wallchart PAC MVA Steps and Processing Tool A-9 Course evaluation tool Tool A-8 Ipas MVA Plus aspirators and Ipas EasyGrip cannulae UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 4

19 Tool A-4: MVA 101 Sample Planning Checklist INSTRUCTIONS: Use this Planning Checklist as guidance to ensure all necessary steps and planning details for setting up the training event are followed with enough time for completion. Target date Action Person responsible 5-6 weeks prior to Secure venue for course course (training room with space for the number of participants and adequate seating arrangements for participatory learning and appropriate viewing of audiovisual materials) Status Ensure computer, projector, screen, audio will be available at venue Contract appropriate clinical trainer and product representative for course For full series of three courses: Ensure trainer has required credentials for clinical training/patient care Ensure participants will have MVA instruments for use during and after course and ensure resupply mechanism Ensure required learning aids and printed materials are ordered in appropriate numbers (see materials list for items and quantities) 5 weeks prior Advertise, invite participants 4 weeks prior Make any necessary travel arrangements and ensure travelers are aware of all details (including potential airport pick-up and hotel) and requirements for reimbursement for any expenses Monitoring plan: Plan for follow-up with each course participant 2 weeks prior Finalize slidesets, have file and back-up file for projection; print any handouts for participants; check ordered learning aids and printed materials Reconfirm venue arrangements Reconfirm arrangements with clinical trainer and product representative (Local Distributor) UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 5

20 Tool A-5: MVA 101 Course Evaluation INSTRUCTIONS: Insert date and location at top of evaluation and delete instructions. Provide Course Evaluation to all participants at the end of the course and ask them to complete and turn in before leaving. Study the responses after the course, with the goal of using responses to improve and adapt the course for future offerings. MVA 101: Introduction to MVA Course Evaluation DATE: LOCATION: Course Objective: Be familiar with the Ipas MVA product line and know how to re-supply 4 = strongly agree 3 = agree 2 = disagree 1 = strongly disagree Rating 1. The course fulfilled its goal and objective (see above). Comments: 2. The trainers were responsive to participants needs. Comments: 3. Because of this course, I have a better understanding of the importance of MVA and how to use it. Comments: 4. Now that I have completed this course, I feel (please circle the appropriate response): a. Ready to take the next two courses before offering care with MVA to women b. That this procedure is not one I would choose to provide c. Prepared to promote (but not provide) MVA services d. Other [please describe] UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 6

21 5. What suggestions can you offer to improve this course in the future? 6. I came to this course with (please circle the appropriate response): a. No experience providing transvaginal procedures b. Less than three years clinical experience including transvaginal procedures c. Between three and five years of clinical experience including transvaginal procedures d. More than five years of clinical experience including transvaginal procedures 7. My clinical background is: a. Professional midwife or nurse-midwife b. Other advance practice or midlevel clinician (physician s assistant, clinical officer, professional nurse, etc) c. Medical doctor (non specialist) d. Ob-Gyn specialist e. Public Health (non practicing clinician) f. Other (please describe) UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 7

22 Tool A-6: MVA 101 Certificate Template (full page version on CD-ROM) INSTRUCTIONS: Add logos of sponsoring organizations, include names of trainers and date and print one copy of Certificate Template for each participant, customized with each individual participant name, and distribute to participants at the close of course. Insert logo of sponsor/host organization Introduction to Manual Vacuum Aspiration Course 101 Add Logo of sponsoring Organization CERTIFICATE OF COMPLETION Awarded to NAME PLACE DATE Insert name of Clinical Trainer Insert name of Course Sponsor UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 8

23 Tool A-7: Information on Instruments and Availability INSTRUCTIONS: Insert specific contact information of local MVA instruments supplier in template, delete instructions and print one copy for each course participant. [Name and contact information for MVA instruments supplier(s):] For information on planning and calculating instruments supply, see and/or use the following table: UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 9

24 B) MVA Course 201 The materials printed in this manual are for the uterine evacuation practice environment of incomplete and/ or missed abortion. The accompanying CD-ROM contains the materials for all indications and both regulatory settings (single use and multiple use of cannulae). Tool B-1: MVA 201 Course Overview (Contexts for samples for course 201: Incomplete/Missed Abortion; Multiple use) Approximately Four Hours INSTRUCTIONS: Use this Course Overview tool to study the topics, suggested timeframes and supporting slides/materials/activities for the course. Plan and adjust the agenda (separate tool) accordingly. This Overview can be adapted depending on whether this course is offered immediately after course 101 or offered on its own without 101 as an immediate precursor. Presentation Topic ~ # Slides Suggested Materials/Activities Suggested Length Welcome & Introductions Review of Content from MVA slides Informational flyers (Ipas MVA Plus, Ipas EasyGrip, 3mm cannula, Ipas mission 30 minutes Hands-on Practice 18 slides 44 slides MVA Procedures Checklist Practice with instrument disassembly and re-assembly Procedure demonstration and practice with pelvic model 2-4 hours Instruments Processing 33 slides Processing wall chart 30 minutes 16 slides with test questions Resupply of Instruments 39 slides mvacalculator.org JSI Table Local Distributor contact information 30 minutes Learning Assessment 1 slide Administer learning assessment 15 minutes Course close (same as above) Administer course evaluation Give out certificates 15 minutes UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 10

25 Tool B-2: MVA 201 Sample Agenda for Participants: INSTRUCTIONS: Adjust this agenda accordingly and provide one for each participant at beginning of course. This Agenda can be adapted depending on whether this course is offered immediately after course 101 or offered on its own without 101 as an immediate precursor. Time (adapt as necessary for local setting) (30 minutes) 1:00 1:30 (120 minutes) 1:30 pm 3:30 pm (15 minutes) 3:30 pm 3:45 pm Topic Welcome, introductions, review of content from 101 (or IpasU equivalent) Demonstration and practice on pelvic model (Use skills assessment from procedure checklist) Coffee/Tea break Lead Presenter (include names, rather than roles, once presenters confirmed) Clinical Trainer and Representative from Local Product Distributor Clinical Trainer (30 minutes) 3:45 pm 4:15 pm MVA instruments processing Representative from Local Product Distributor (30 minutes) 4:15 pm 4:45 pm MVA stocking and resupply Representative from Local Product Distributor (15 minutes) 4:45pm 5:00 pm Learning assessment Clinical Trainer & Representative from Local Product Distributor (15 minutes) 5:00 pm 5:15 pm Course close Clinical Trainer & Representative from Local Product Distributor UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 11

26 Tool B-3: MVA 201 Sample Materials Checklist with Link to PDF INSTRUCTIONS: Use this Materials Checklist as guidance to ensure all audiovisual equipment, training aids, medical supplies and printed materials are in place for training event. This checklist should be adjusted, depending on whether this course is offered immediately after MVA 101 or offered on its own without 101 beforehand (participants who just took MVA 101 will already have most of these materials). Recommended Quantity Quantity Ordered Status Item (Link to pdf) 1 Computer and LCD projector for powerpoint presentations 1 TRAINER TIPS FOR USE OF PELVIC MODELS FOR MVA CLINICAL TRAINING Participant agenda Pelvic Model Informational flyers (Ipas MVA Plus, Ipas EasyGrip, 3mm cannula, Ipas mission) Contact information from local supplier/vendor of MVA, including JSI Table and link to Peforming Uterine Evacuation with the Ipas MVA Plus Aspirator and Ipas EasyGrip Cannulae: Instructional booklet Performing Uterine Evacuation with Ipas MVA Plus and Ipas EasyGrip Cannulae: Instructional CD-ROM OR CD-Rom of 6 minute video MVA steps wall chart Plus Flyer 2007 Easy Grip Flyer 3 mm Flyer 2007 Performing UE with Ipas MVA Plus MVA Procedure Steps Wallchart UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 12

27 Performing MVA + Processing Bifold Processing wall chart UE for incomplete and missed abortion : PAC MVA Steps and Processing MVA Processing Wallchart List of online resources: Procedure checklists Tool B-6 Certificates of participation and completion Tool B-9 1 for every 2 participants Learning assessment tool Tool B-7 Course evaluation tool Tool B-8 Pelvic models 1 for each participant or for each pelvic model 1 for each pelvic model Ipas MVA Plus aspirators and Ipas EasyGrip cannulae (for each participant or for each pelvic model) One speculum, tenaculum and injection syringe per pelvic model Drape for each pelvic model (when not in use) 1 for each pelvic model Buckets and supplies for demonstrating instrument processing (include solution for decontamination soak, locally available products for high-level disinfection (HLD) or sterilization, including wrappers for autoclave.) 1 set Samples of locally available contraceptives and pain medications (optional) UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 13

28 Tool B-4 MVA 201 Sample Planning Checklist INSTRUCTIONS: Use this Planning Checklist as guidance to ensure all necessary steps and planning details for setting up training event are followed with enough time for completion. Target date Action Person responsible 5-6 weeks prior to Secure venue for course course (training room with space for the number of participants and adequate seating arrangements for participatory learning and appropriate viewing of audiovisual materials) Status Ensure computer, projector, screen, audio will be available at venue Contract appropriate clinical trainer and product representative for course Ensure participants will have MVA instruments for use during and after course and ensure resupply mechanism Ensure required learning aids and printed materials are ordered in appropriate numbers (see materials checklist for items and quantities) NOTE: Be sure to include pelvic models, procedural supplies and instruments processing supplies, as shown on materials checklist 5 weeks prior Advertise, invite participants 4 weeks prior Make any necessary travel arrangements and ensure travelers are aware of all details (including potential airport pick-up and hotel) and requirements for reimbursement for any expenses Monitoring plan: Plan for follow-up with each course participant 2 weeks prior Finalize slidesets, have file and back-up file for projection; print any handouts for participants; check ordered learning aids and printed materials Reconfirm venue arrangements Reconfirm arrangements with clinical trainer and product representative UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 14

29 Tool B-5: MVA 201: Guidance for Setting Up and Training with Pelvic Models INSTRUCTIONS: The enclosed CD-ROM includes a 4-page guide on preparing for and training with pelvic models. Facilitators should use the guide to ensure that all components of pelvic model training are in place prior to a course. Trainers and presenters should review it in advance of course for specific suggestions on pelvic model training. UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 15

30 Tool B-6: MVA Procedure Checklist: Incomplete/Missed Abortion INSTRUCTIONS: Provide a copy to each participant for use during training on pelvic models. Skills Yes No Comments Creates pain management plan Tailors pain management plan with woman according to her needs Discusses sources of pain, options, potential side effects Includes combination of support and pharmacological measures Takes into account woman s medical and psychological status, dilatation necessary, staff skill, nature of procedure and availability of supplies Prepares the instruments Checks vacuum retention of aspirator Has more than one instrument available Prepares the woman Administers pain medication in timely fashion Asks woman to empty her bladder Asks what supportive measures she would like and provides them Asks for permission to start Puts on barriers and washes hands Performs pelvic exam to confirm assessment findings Warms and inserts speculum gently Removes foreign bodies in os; refers if bowel present Performs cervical antiseptic prep Follows No-Touch Technique Uses antiseptic sponges to clean os and, if desired, vagina Administers paracervical block Uses less than 200mg lidocaine Aspirates before injecting 1 2mL at tenaculum site Places tenaculum Applies slight traction to expose tissue transition Slowly injects 2 5mL lidocaine to inches at 3,5,7 and 9 o clock Dilates cervix if needed Inserts cannula Applies gentle traction to cervix Rotates cannula while gently applying pressure Inserts cannula to just past internal os OR to fundus and pulls back Suctions uterine contents Holds tenaculum and end of cannula in one hand UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 16

31 Attaches charged aspirator Releases buttons to start vacuum Rotates cannula 180 degrees each direction Uses an in and out motion Does not withdraw aperture beyond os Uses gentle operative technique Uses positive, respectful, supportive reassurance Stops when pink foam without tissue passes, gritty sensation is felt, uterus contracts around cannula and uterine cramping increases Removes the instrument Is ready to evacuate again after inspecting tissue if needed Inspects tissue Empties aspirator into container Looks for products of conception (POC) Evaluates amount based on estimated gestation Determines all POC have been removed Completes remaining steps: Wipes cervix to assess bleeding Considers if pelvic exam is advisable Reassures woman that procedure is finished Performs post-procedure care Processes instruments Removes barriers and washes hands Ensures woman is escorted to recovery area Resolves technical problems that arise UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 17

32 Tool B-7: MVA 201 Sample Learning Assessment Tool (test & answer key) (Note that the CD-ROM contains a version for participants, that does not indicate correct answers) INSTRUCTIONS: Select the appropriate learning assessment and make one copy for each participant and administer at end of course to all participants. Review answers with all participants after they have completed test. This test is appropriate for all four course versions (with answer on #10 different for Multiple Use versus Re-Use) Learning Assessment: MVA 201 (Pelvic Model Practice with MVA) Name: Date: 1. The steps of processing include which of the following? a) Decontamination soak b) Cleaning c) High-level disinfection (HLD) or sterilization d) Storage e) All of the above [correct] 2. Following an MVA procedure, all instruments that will be reused should be a) Kept wet until they can be cleaned [correct] b) Kept dry until they can be cleaned c) Kept in an air-tight storage device d) Immediately sterilized 3. Which of the following methods is NOT acceptable for processing Ipas MVA Plus aspirators? b) Sterrad Processor c) HLD with chemicals d) Dry heat [correct] e) Steam Sterilization 4. Active Stock of MVA is a. New devices, in original packaging, in the facility store room b. The devices kept in the procedure room to serve women needing MVA in any given day or shift [correct] c. The devices in the central warehouse to send to facilities when requisitioned d. The devices the chief health practicioner keeps at her private practice to serve her patients 5. The primary goal of forecasting MVA needs for health-care facilities is: a) To reduce the length of time between ordering and receiving new MVA aspirators b) To reduce the number of women whose health and lives are at risk when providers lack MVA when needed [correct] c) To increase the number of providers trained and equipped to offer care with MVA d) To help provide program information for potential donors 6. When a clinic storeroom reaches the reorder point quantity for MVA devices, how many should be reordered? a. The Total Initial Stock b. The Reserve Maximum minus the reorder point quantity [correct] c. The Active Stock plus the Reserve Stock quantities d. The Reserve Maximum UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 18

33 7. You are planning MVA needs for a small hospital, open 24 hours per day. Based on your facility s past experience, you project that you will provide MVA care to an average of 70 women each month. Use the MVA Initial Supply and Resupply table to determine how many aspirators should be available in the active inventory: a) 2 b) 4 c) 6 [correct] d) 8 8. For that same facility that serves 70 women per month with MVA, what is the maximum number of aspirators that should be held in reserve, unused in the facility storeroom? a) 2 b) 7 [correct] c) 13 d) The steps for preparing the instrument and checking vacuum retention are out of order below. Please order the steps correctly by numbering them 1-5. a) Pull the plunger straight back until the plunger arms snap outward and catch on the cylinder base [2] b) Let the aspirator sit for several minutes [3] c) Push the valve buttons to release the vacuum [4] d) Listen for a rush of air into the vacuum, indicating that the vacuum has been retained [5] e) Push both valve buttons down and forward at the same time until they lock into place [1] 10. Ipas EasyGrip cannulae (select all that apply) [ANSWER CHANGES DEPENDING ON REGULATORY CONTEXT: C FOR REUSE, C and D FOR SINGLE USE] a) Can be used after cleaning b) Cannot be autoclaved or boiled c) Must be HLD or sterile before entering the sterile uterus [correct] d) Cannot be reused [correct for SINGLE USE regulatory context) 11. Put the 10 steps of the procedure in order : a) Process instruments [10] b) Aspirate tissue [7] c) Prepare instruments [1] d) Prepare the woman [2] e) Prepare the cervix [3] f) Insert Cannula [6] g) Dilate cervix [5] h) Perform any concurrent procedures [9] i) Perform paracervical block [4] j) Inspect tissue [8] 12. The recommended cannula sizes for a woman seeking uterine evacuation for an 8 week LMP procedure, with a closed cervix is a) 4 mm-5mm b) 6 mm-8mm c) 7mm 9 mm [correct] d) 10mm or 12 mm e) TBD UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 19

34 13. Paracervical block by itself is necessary and sufficient pain management for most women undergoing MVA: a) True b) False [correct] 14. Pain management for an MVA procedure can include a) Conscious sedation b) Paracervical block c) Anxiolitics d) Analgesics e) Any one or more of the above [correct] UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 20

35 Tool B-8: MVA 201 Course Evaluation INSTRUCTIONS: Insert date and location at top of evaluation and delete these instructions. Provide Course Evaluation for each participant at the end of the course and ask them to complete and turn in before leaving. Study the responses after the course, with the goal of using responses to improve and adapt the course for future offerings. MVA 201 Course Evaluation DATE: LOCATION: Course Objectives: Be able to simulate procedure on a pelvic model. Be able to process MVA instruments in accordance with local regulations and with locally available products/systems 4 = strongly agree 3 = agree 2 = disagree 1 = strongly disagree Rating 1. The course fulfilled its goal and objectives (see above). Comments: 2. The trainers were responsive to participants needs. Comments: 3. Because of this course, I have a better understanding of how to use MVA. Comments: UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 21

36 4. Now that I have completed this course, I feel a. Ready to offer care to women with MVA b. Ready to take the next course, before offering care with MVA to women c. That this procedure is not one I would choose to provide d. Prepared to promote (but not provide) MVA services e. Other [please describe] 5. What suggestions can you offer to improve this course in the future? 6. I came to this course with a. No experience providing transvaginal procedures b. Less than three years clinical experience including transvaginal procedures c. Between three and five years of clinical experience including transvaginal procedures d. More than five years of clinical experience including transvaginal procedures 7. My clinical background is as: a. Professional midwife or nurse-midwife b. Other advance practice or midlevel clinician (physician s assistant, clinical officer, professional nurse, etc) c. Medical doctor (non specialist) d. Ob-Gyn specialists e. Public Health (non practicing clinician) f. Other (please describe) 8. As a pre-requisite for this course, I took: a) MVA 101 b) Equivalent IpasUniversity courses UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 22

37 Tool B-9: MVA 201 Certificate Template (full page version on CD-ROM) INSTRUCTIONS: Insert logos and names of trainer and sponsor. Print one copy of Certificate Template for each participant, customized with each individual participant name, and distribute at the close of course. Insert logo of sponsor/host organization Pelvic Model Practice with Manual Vacuum Aspiration Course 201 Add Logo of sponsoring Organization CERTIFICATE OF COMPLETION Awarded to NAME PLACE DATE Insert name of Clinical Trainer Insert name of Course Sponsor UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 23

38 Tool B-10: Information on Instruments and Availability INSTRUCTIONS: Insert specific contact information of local MVA instruments supplier in template, delete instructions and print one copy for each participant in course. There is only one version of this template. Contact information for MVA instruments supplier(s): For information on planning and calculating instruments supply, see and/or use the following table: UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 24

39 MVA Course 301 Tool C-1: MVA 301 Course Overview Approximately six to eight hours (context: incomplete/missed abortion; reuse) INSTRUCTIONS: Use this Course Overview tool to study the topics, suggested timeframes and supporting slides/materials/activities for the course. Plan and adjust the agenda (separate tool) accordingly. This Overview can be adapted depending on whether this course is offered immediately after MVA 101 and 201 or offered separately. Presentation Topic ~ # Slides Suggested Materials/Activities Suggested Length Welcome & Introduction Review MVA content 20 slides Highlight procedure, including pain management and postprocedure care 30 minutes Follow-Up Care 9 slides 10 minutes Orientation to clinical practicum and other rotations 1 slide Discussion and orientation to practicum and rotation to other topics 20 minutes Clinical practicum rotation Monitoring to Improve Services rotation Management of Complications rotation Procedure checklist Clinical skill evaluation checklist minutes (concurrent with two other rotations) 15 slides minutes (concurrent with practicum) 38 slides minutes (concurrent with practicum) Resupply of Instruments 18 slides Mvacalculator.org JSI Table Local Distributor contact information Learning assessment 1 slide Administer learning assessment Review clinical skill evaluation with individual participants (if not completed during clinical practicum) Course Close (same as above) Administer course evaluation Distribute certificates 15 minutes 30 minutes 15 minutes UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 25

40 Tool C-2: MVA 301 Sample Agenda for Participants INSTRUCTIONS: Adjust this Agenda and provide one for each participant at beginning of course. This agenda can be adapted depending on whether this course is offered immediately after MVA 101 and 201 or offered separately. Time (adapt as necessary for local setting) (30 minutes) 8:30 9:00 (10 minutes) 9:00 9:10 (20 minutes) 9:10 9:30 ( minutes) 9:30 1:00 Topic Welcome, introductions, review of content from MVA 101 and 201 Follow-up care Orientation to clinical practicum and rotations through classroom topics Three Concurrent Sessions, with rotations through each: Lead Presenter (include names, rather than roles) Clinical Trainer & Representative local Distributor Clinical Trainer Clinical Trainer 1. Clinical practicum Clinical Trainer 2. Monitoring of services Clinical Trainer B 3. Management of complications Clinical Trainer C (60 minutes) 1:00 2:00 (15 minutes) 2:00 2:15 (30 minutes) 2:15 2:45 (15 minutes) 2:45 3:00 Meal break MVA stocking and resupply Learning assessment Course close Representative from Local Distributor & Clinical Trainer Clinical Trainer Clinical Trainer & Representative from Local Distributor UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 26

41 Tool C-3: MVA 301 Recommended Materials Checklist with Link to PDF INSTRUCTIONS: Use this Materials Checklist as guidance to ensure all audiovisual equipment, training aids, medical supplies and printed materials are in place for training event. The Materials Checklist should be adjusted, depending on whether this course is offered immediately after MVA 101 and 201 (participants who just took 101 and 102 will already have most of these materials). Recommended Quantity Quantity Ordered Status Item (link to pdf) 2 Computer and LCD projector for powerpoint presentations (need two for concurrent rotation modules) Participant agenda Informational flyers (Ipas MVA Plus, Ipas EasyGrip, 3mm cannula, mission) Contact information from local supplier/vendor of MVA, including JSI Table and link to Peforming Uterine Evacuation with the Ipas MVA Plus Aspirator and Ipas EasyGrip Cannulae: Instructional booklet Performing Uterine Evacuation with Ipas MVA Plus and Ipas EasyGrip Cannulae: Instructional CD-ROM OR CD-Rom of 6 minute video MVA steps wall chart Performing MVA + Processing Bifold Processing wall chart Article: Manual vacuum aspiration for uterine evacuation: Pain management List of on-line resources Plus Flyer 2007 EasyGrip Flyer 3mm Flyer 2007 Performing UE with Ipas MVA Plus MVA Procedure Steps Wallchart PAC MVA Steps and Processing MVA Processing Wallchart Pain Management MVA UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 27

42 Procedure Checklists Tool C-6 Learning assessment tool (includes clinical skill evaluation) Tool C-7 Course evaluation tool Tool C-8 1 for each participant Certificates of participation and completion Ipas MVA Plus aspirators and Ipas EasyGrip cannulae Tool C-9 1 set Samples of locally available contraceptives and pain medications (optional) UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 28

43 Tool C-4 MVA 301 Sample Planning Checklist INSTRUCTIONS: Use this Planning Checklist as guidance to ensure all necessary steps and planning details for setting up training event are followed with enough time for completion. Target date Action Person responsible 5-6 weeks prior to Secure venue for course course (Training room with space for the number of participants and adequate seating arrangements for participatory learning and appropriate viewing of audiovisual materials.) NOTE: During course rotations, two training rooms are required for concurrent sessions, in addition to the separate clinical training venue. Status Ensure computers, projectors, screens, audio will be available at venue Secure venue for clinical training where: Trainer can provide clinical care, and Participants from outside the facility are able to provide patient care in training context. Coordinate with facility staff to ensure that both: Women are cared for in a timely way Clinical training needs for participants are met. (Course participants should demonstrate knowledge and skills on pelvic model before offering clinical care.) Contract appropriate clinical trainers and representative from Local Distributor for course There is a 3-to-4 hour block of time with concurrent sessions that requires three clinical trainers: Supervised Clinical Practicum Management of Complications Monitoring Services (could be a monitoring expert who is very familiar with MVA services, but not a clinician) Ensure clinical trainer has all required credentials for clinical training/patient care at the facility where clinical practicum will take place. Ensure participants will have MVA instruments for use during and after course and ensure resupply mechanism Ensure required learning aids and printed materials are ordered in appropriate numbers (see materials checklist for items and quantities) UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 29

44 5 weeks prior Advertise, invite participants 4 weeks prior Make any necessary travel arrangements and ensure travelers are aware of all details (including potential airport pick-up and hotel) and requirements for reimbursement for any expenses Monitoring plan: Plan for follow-up with each course participant 2 weeks prior Finalize slidesets, have file and back-up file for projection; print any handouts for participants; check ordered learning aids and printed materials Reconfirm venue arrangements, including reconfirmation with clinical facility Reconfirm arrangements with clinical trainers and representative from Local Distributor UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 30

45 Tool C-5: MVA 301: Guidance on Setting Up and Running Clinical Practicum INSTRUCTIONS: Use this guide for facilitators to ensure that all components of running a clinical practicum are in place and for trainers/presenters to study in advance of practicum for specific guidance and suggestions on planning and conducting a clinical practicum. There is only one version of this guidance tool. Advance Preparation Ensure that all learners have reached competency in simulated skills practice prior to partaking in the clinical practicum. Obtain approval for site(s) used for training. Plan the design of the practicum. Organize trainers and discuss their roles, emphasizing teamwork. Determine how to involve practicum-site staff in the practicum. Clinical Practicum Note to trainer: This document may need to be adapted for your setting. Consider the length of time needed and available for practice, the order of topics, the need for additional trainers, the amount of review required at the start of each topic and other logistics when adapting the module. Determine what each learners role will be during the practicum. Determine how to configure teams of learners and trainers. Arrange for learners to observe or assist with care for women with complications. Prepare and duplicate materials (flipcharts, checklists, evaluation forms). Ensure readiness of equipment and supplies needed for the practicum. Have alternative activities ready for learners to do when client caseload is slow. Review the Clinical Training Approaches and Coaching Skills session of the Effective Training in Reproductive Health: Course Design and Delivery Trainer s Manual. Review Conducting This Clinical Practicum (below). Conducting This Clinical Practicum Time required The time required for this clinical practicum can vary significantly depending on the practicum design, the needs and skills of learners, the amount of time available, and many other factors. Format This practicum module is divided into practicum sessions by skill set. The content of each session reflects the module of the same name in the didactic part of this training. Each session of the practicum should begin with a short content review a mini-lecture using flipcharts and a review of the checklist(s) for that skill. After completing the content and checklist review, brief learners on the details of the session and then release them to their assignments. At the end of each practice session, have learners regroup to debrief and discuss. Designing the Practicum The design of the practicum depends on the needs of the learners and realities of the practicum site. Determine whether the practicum can be held with several learners and several trainers at one time at the same site or at several sites at the same time. A modular or other adapted approach can be used, staggering place, times, learners, trainers and/or skills. Consider designing the practicum so that learners practice skills that logically go together during clinical care. Utilize the time well. UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 31

46 If the learners will be divided into groups or will practice at different sites, arrange for additional trainers, because each learner must be directly supervised by a trainer. Employ principles of adult learning and maintain a positive learning environment. Before the Practicum Identify when caseload at the practicum site is highest. To build caseload, consider asking local facilities to refer women coming for abortion services to the practicum site during the training period. Alternatively, schedule women for endometrial biopsy during the practicum and allow learners to perform the procedure, as the skill is similar to uterine evacuation. Ensure that practicum-site protocols, equipment and supplies are consistent with skills to be taught; decide how to handle any noted discrepancies. If necessary, adapt training activities to more closely reflect practicum-site practices, or create additional activities. Determine where review and debrief discussions can take place before and after practice. This may be a private room on- or off-site. Determine how to keep track of learners who have successfully achieved competency and those who need more practice, as well as how the latter will receive that additional practice. During the Practicum Refer to the Reference Manual frequently during review, debriefing and other discussions with learners. Assign learners to practice procedures according to their skill level. Assign a few learners and a trainer to work together in practice groups. Pair strong learners with weaker ones and ask them to help each other. Once some learners have reached competency, they can help those who have not. Ensure learners understand what their roles are, what the other learners roles are and how to assist other learners. Limit the number of learners and observers for each procedure. Obtain the client s permission for learners to perform the procedure, ensuring she understands that the trainer will be present and that she has the right to refuse without being denied care. Always respect the woman s right to confidentiality and privacy, not only in direct care but also when discussing her care with learners. Only give corrective feedback to learners in the presence of a client when the mistake could endanger her or cause her discomfort, in order to limit the anxiety of the client as well as the learner. Carefully monitor the practicum to ensure that other trainers are following agreed-upon protocols and using the checklists; to problem-solve issues that arise; to ensure that practice groups are working well; and to make certain that every learner is getting opportunities to participate. In addition to leading a debrief discussion, consider seeking feedback from learners after each session. Use the Clinical Skills Evaluation form in this module for evaluating learners to determine if they can be considered competent in abortion-care skills. After the Practicum Provide the evaluation for learners to complete Debrief with site staff and other trainers about what worked well and how the clinical practicum could be improved, and thank everyone for their participation. Provide each learner with specific recommendations for implementing and improving their skills when they return to their sites. Provide feedback on each learner s skills to their site supervisor, if appropriate. Provide opportunities for refresher courses and site-visit exchanges between learners. Ask the learners what they see as their most important next steps and how you might assist them. UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 32

47 Tool C-6: MVA Procedure Checklist: Incomplete/Missed Abortion INSTRUCTIONS: Provide a copy to each participant for use during training on pelvic models. Only one version of this tool is printed below, but the CD-ROM contains both versions. MVA Procedure Checklist: Incomplete/Missed Abortion Skills Yes No Comments Creates pain management plan Tailors pain management plan with woman according to her needs Discusses sources of pain, options, potential side effects Includes combination of support and pharmacological measures Takes into account woman s medical and psychological status, dilatation necessary, staff skill, nature of procedure and availability of supplies Prepares the instruments Checks vacuum retention of aspirator Has more than one instrument available Prepares the woman Administers pain medication in timely fashion Asks woman to empty her bladder Asks what supportive measures she would like and provides them Asks for permission to start Puts on barriers and washes hands Performs pelvic exam to confirm assessment findings Warms and inserts speculum gently Removes foreign bodies in os; refers if bowel present Performs cervical antiseptic prep Follows No-Touch Technique Uses antiseptic sponges to clean os and, if desired, vagina Administers paracervical block Uses less than 200mg lidocaine Aspirates before injecting 1 2mL at tenaculum site Places tenaculum Applies slight traction to expose tissue transition Slowly injects 2 5mL lidocaine to inches at 3,5,7 and 9 o clock Dilates cervix if needed Inserts cannula Applies gentle traction to cervix Rotates cannula while gently applying pressure Inserts cannula to just past internal os OR to fundus and pulls back Suctions uterine contents UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 33

48 Holds tenaculum and end of cannula in one hand Attaches charged aspirator Releases buttons to start vacuum Rotates cannula 180 degrees each direction Uses an in and out motion Does not withdraw aperture beyond os Uses gentle operative technique Uses positive, respectful, supportive reassurance Stops when pink foam without tissue passes, gritty sensation is felt, uterus contracts around cannula and uterine cramping increases Removes the instrument Is ready to evacuate again after inspecting tissue if needed Inspects tissue Empties aspirator into container Looks for products of conception (POC) Evaluates amount based on estimated gestation Determines all POC have been removed Completes remaining steps: Wipes cervix to assess bleeding Considers if pelvic exam is advisable Reassures woman that procedure is finished Performs post-procedure care Processes instruments Removes barriers and washes hands Ensures woman is escorted to recovery area Resolves technical problems that arise UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 34

49 Tool C-7: MVA 301 Sample Learning Assessment Tools (Contexts: incomplete/missed abortion; multiple use for cannulae) INSTRUCTIONS: There are two parts of Learning Assessments for MVA 301: (1) Clinical Skills Evaluation, and (2) Learning Assessment for Managing Complications and Monitoring. For Clinical Skills Evaluation: Provide one copy per participant for the Clinical Trainer who is conducting the Clinical Practicum portion of this course. The Clinical Trainer will complete an evaluation for each participant and review it with personally with the participant, either immediately after the practicum (if time allows) or during the Learning Assessment module of the course. For the Learning Assessment for Managing Complications and Monitoring, keep one copy of test with highlighted answers for presenter/trainer. Select the participant version from the CD-ROM (correct answers not noted) make one copy for each participant and administer at end of course to all participants. Review answers with all participants after they have completed test. UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 35

50 Clinical Skills Evaluation UTERINE EVACUATION FOR INCOMPLETE/MISSED ABORTION: Instructions: The trainer should use one form to evaluate the ability of each learner based on direct observation of the learner s management of an incomplete abortion case, including performance of manual vacuum aspiration (MVA). Proficiency in MVA service delivery requires demonstrating competency on all items in Part I. If a learner does not demonstrate competency or cannot be observed, refer to Part II where recommendations can be made as to how performance might be improved to achieve competency. After completing the form, the trainer should discuss the results with the learner. Mark an X in the box next to each step that is competently demonstrated by the learner. I. Clinical Skills 1. Establishes rapport with the woman, helping her feel comfortable 2. Assesses the woman s status: medical history, presenting conditions, date of LMP, emotional state 3. Provides or confirms that the woman received counseling: privately explores her decisions 4. Discusses the procedure with the woman and obtains consent 5. Evaluates need for and administers pain management based on the woman s condition and her desires 6. Uses infection-prevention practices: handwashing, gloves 7. Assesses uterus: size, position, trauma 8. Identifies cervical laceration or trauma 9. Identifies possible reproductive tract infection 10. Ensures that the cannulae are HLD or sterile and rinsed of caustic solutions 11. Prepares aspirator and checks vacuum 12. Selects cannula based on uterine size and dilatation; inspects cannula and aspirator for wear 13. Swabs cervix, and vagina if desired, with antiseptic solution 14. Administers paracervical block and any other medications; allows time for medications to take effect 15. Dilates the cervix, if needed 16. Inserts cannula and attaches aspirator 17. Uses no-touch technique; does not contaminate the cannula 18. Moves cannula effectively to empty the uterus 19. Stops evacuation when signs of completion are present 20. Examines the aspirate to assure it is consistent with the woman s condition 21. Assures post-procedure care is provided to monitor and discuss her recovery 22. Assures contraceptive counseling and a method are provided if the woman desires 23. Assures follow-up care is scheduled with referrals made where needed II. Recommendations. For skills that were not performed to competency or were not observed, suggest recommendations to be followed, for example: needs to continue practice under supervision or repeat clinical training. Item Recommendation UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 36

51 III. Comments Please add any comments you may have about the learner s ability to perform MVA. PLEASE PRINT Evaluator Learner Name Name UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 37

52 Sample Learning Assessment Tool for Managing Complications and Monitoring (test & answer key) (Trainer version) Circle the correct response 1. MVA procedures result in immediate and long-term complications when performed by trained providers: a. Rarely, but complications can include infection and/or retained POC [correct] b. Quite often c. Such as breast cancer and infertility d. b & c 2. Managing complications does not entail: a. Staff knowing how to recognize a complication b. Staff knowing how to treat a complication c. Referral for conditions that cannot be fully treated onsite [correct] d. Fully treating onsite all complications that occur 3. Retained products of conception (POC): a. Is indicated by vaginal bleeding and pain b. Can lead to infection c. Is treatable by vacuum aspiration d. All of the above [correct] 4. Continuing pregnancy: a. Is the same as failed abortion b. Requires uterine evacuation c. Both a & b [correct] d. Is caused by dilatation and curettage (D&C) 5. A condition that occurs when the uterus cannot contract to stop bleeding is: a. Disseminated intravascular coagulopathy (DIC) b. Ashermans Syndrome c. Uterine atony [correct] d. Hematometra 6. The causes of medication-related complications can include: a. Overdosage b. Incorrect injection into a vessel c. Hypersensitivity d. All of the above [correct] 7. Medical-abortion complications include: a. Severe and prolonged bleeding, continuing pregnancy [correct] b. Severe headaches, dizziness c. Brief fainting spells d. a & c 8. A vasovagal reaction: a. Is the same as physiological shock b. Usually resolves itself and is not life-threatening [correct] c. Indicates uterine perforation d. Must be treated surgically UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 38

53 9. Sites should refer women with complications to another facility if: a. They cannot fully treat her onsite [correct] b. She cannot pay at the current site c. She has a high fever d. She has injury to the uterus, vagina or bowel 10. After-care for women with complications includes providing: a. Close monitoring b. Information about follow-up c. Counseling on medical and emotional consequences d. All of the above [correct] 11. Circle True or False: 1. True or False Monitoring is a random tracking of services conducted once in a while. [false] 2. True or False Monitoring does not need to be expensive or complex.[true] 3. True or False It is possible to use existing sources of information for monitoring.[true] 4. True or False To measure changes in one type of service, different information should be collected each time. [false] 5. True or False An example of an indicator is the number and type of complications. [true] 12. Put the steps of monitoring in correct order: [b,a,d,c] a. Information gathering b. Planning c. Developing an action plan d. Analysis UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 39

54 Tool C-8: MVA 301 Course Evaluation INSTRUCTIONS: Insert date and location of course at top of evaluation. Provide Course Evaluation for each participant at the end of the course and ask them to complete and turn in before leaving. Study the responses after the course, with the goal of using responses to improve and adapt the course for future offerings. MVA 301 Course Evaluation DATE: LOCATION: Course Objectives: Perform a supervised MVA procedure in a local clinical facility Be familiar with key tools for monitoring services with a goal toward quality improvement Be able to manage potential complications 4 = strongly agree 3 = agree 2 = disagree 1 = strongly disagree Rating 1. The course fulfilled its goal and objectives (see above). Comments: 2. The trainers were responsive to participants needs. Comments: 3. Because of this course, I have a better understanding of how to use MVA. Comments: UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 40

55 4. Now that I have completed this course, I feel a. Ready to offer care to women with MVA b. That I need more training before offering care with MVA to women c. That this procedure is not one I would choose to provide d. Prepared to promote (but not provide) MVA services e. Other [please describe] 5. What suggestions can you offer to improve this course in the future? 6. I came to this course with a) No experience providing transvaginal procedures b) Less than three years clinical experience including transvaginal procedures c) Between three and five years of clinical experience including transvaginal procedures d) More than five years of clinical experience including transvaginal procedures 7. My clinical background is as: a) Professional midwife or nurse-midwife b) Other advance practice or midlevel clinician (physician s assistant, clinical officer, professional nurse, etc) c) Medical doctor (non specialist) d) Ob-Gyn specialists e) Public Health (non practicing clinician) f) Other (please describe) UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 41

56 Tool C-9: MVA 301 Certificate Template (full page version on CD-ROM) INSTRUCTIONS: Print one copy of Certificate Template for each participant, customized with each individual participant name, and distribute at the close of course. Insert logo of sponsor/host organization SUPERVISED CLINICAL PRACTICE WITH Manual Vacuum Aspiration Course 301 Add Logo of sponsoring Organization CERTIFICATE OF COMPLETION Awarded to NAME PLACE DATE Insert name of Clinical Trainer Insert name of Course Sponsor UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 42

57 Tool C-10: Information on Instruments and Availability INSTRUCTIONS: Insert specific contact information of local MVA instruments supplier in template, delete instructions and print one copy for each participant in course. Contact information for MVA instruments supplier(s): For information on planning and calculating instruments supply, see and/or use the following table: UTERINE EVACUATION WITH MVA: A TRAINING MANUAL FOR CONDUCTING SHORT COURSES Page 43

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60 E-09-MVA-008 Rev. 0 12/2009 MVASRTC-E09