Author: Bryantla

Salisbury Hospital Foundation Trust

Manual Vacuum Aspiration Proforma
Date…………………… Time……………….
Indication………………………………………
Parity…………………………………………..
Ultrasound findings……………………………
Gestation size………………………………….

Patient label

Relevant details:
POGHx
PMH
Allergies
Medications

Anti D given Y/N/NA
Consent Y/N
Misoprostol 400mcg PV Y/N
Analgesia given
Paracetamol 1g Y/N
Dihydrocodeinre 30mg 60mg Y/N
Ibuprofen 200mg 400mg Y/N

Operation details:
Surgeon…………………………………………………………………(Nurse/SHO/Reg/Cons)
Assistant………………………………………………………(Student/HCA/Nurse/SHO/Reg/Cons)
Second assistant………………………………………………(Student/HCA/Nurse/SHO/Reg/Cons)
Findings during procedure:
Uterine Size………..…………………………………………………………………………………….
Cervix………………….………………………...……………………………………………………….
Dilation…………………………………………………………………………………………………...
Adnexae..………………………………………………………………………………………………..

Procedure:
Has pt passed urine? Y/N
IV access Y/N
Cervical block with citinest Y/N
Cervical dilatation to catheter size 6/7/8/9/10
Cavity empty Y/N
Volume aspirated……………………………………mls
Products of conception confirmed Y/N
Bimanual compression Y/N
Oxytocin 5IU Y/N/NA

Comfortable throughout Y/N
Haemostasis achieved Y/N
Needles disposed of Y/N
Products sent to histology Y/N/NA

Details of any complications……………………………………………………………………………..……………………………………………………………………………………………………………
Post procedure transabdominal scan findings...………………………………………………………….
Any follow up arrangements……………………………………………………………………………..
Print name……………………………. Signature……………………………………………………
Nurse/SHO/Reg/Consultant/Other (please specify)……………………..

Pre procedure / recordings
Date and time
Blood pressure
Pulse rate
Temperature
Respiratory rate
Oxygen saturations
Pain score

Post procedure
Date and time
Blood pressure
Pulse rate
Temperature
Respiratory rate
Oxygen saturations
Pain score

30 mins post / procedure
Date and time
Blood pressure
Pulse rate
Temperature
Respiratory rate
Oxygen saturations
Pain score

1 hour post / procedure
Date and time
Blood pressure
Pulse rate
Temperature
Respiratory rate
Oxygen saturations
Pain score

Check list:
Adequate pain relief Y/N/NA
Antiemetic given Y/N/NA
Patient passed urine Y/N
Appropriate advice and contact numbers given Y/N
Doctor informed of discharge Y/N
Discharge letter written Y/N
Print name……………………………………. Signature……………………………………………
Nurse/SHO/Reg/Consultant/Other (please specify)……………………..