The Horn of Africa

Dilation and Curettage

It's 9pm and dark outside. We're in a tiled exam room with bright yellow curtains. A row of gynecological tables are all empty. The nurse is assembling the tools we'll need. Two trays, sterile gloves, sterile gauze, a bowl of antiseptic solution, lidocaine for local anesthesia, a speculum, forceps, dilators of various sizes, curettes of various sizes, a large bowl at the foot of the table.

Our concerns are infection, Asherman's syndrome (intrauterine adhesions), perforation of the uterus (and perhaps subsequently the bowel, etc), lesions on the cervix, etc. But these are only the things that can go wrong.

What we're doing tonight is a D&C -- dilation and curettage. An incomplete miscarriage is the reason. Our patient miscarried and has had heavy vaginal bleeding for days. She's been receiving blood, but this will be a definitive fix. We used an ancient ultrasound machine to look at the uterus earlier and, sure enough, there is a small sac inside that needs cleared out. Once it's gone, the bleeding will stop.

The technique is this: Wipe the area clean with antiseptic solution, soak up the blood in the vagina. Insert the speculum and lock it on the open position, visualizing the cervix. Inject the cervix with lidocaine to provide local anesthesia. Use the dilators, starting with the smallest, to gradually dilate the cervix, giving access to the uterus. Insert a dilator into the uterus and note the depth, as if checking an oil dipstick. Insert a curette into the uterus and gently scrape the uterine wall, careful not go too deep (the dipstick), and then slide it out, along the speculum, until it drops into the basin at the foot of the bed, between your legs, below her legs.

As needed, use sterile gauze to sop up blood pooling in the vagina. As pieces of tissue are removed, give them a very cursory inspection. In the States, I think the tissue would be sent to a lab. Here, it is dropped into the basin. Be gentle with the patient but be diligent to get all of the tissue out of the uterus. Inevitably, the paper beneath the buttocks of the patient will become soaked with blood and bits of tissue, like a great crimson waterfall dripping down into the basin below.

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I observed my first D&C last night. I was uncomfortable and surprised and had to remind myself that any violence we were doing was in the patients best interest: without this procedure, she might eventually bleed out and die.

When the procedure was finished, I went to the library and read up on exactly what it was. The knowledge of what we'd been doing, why, what the salient considerations were, etc, was reassuring. As one might guess from the technique used, D&C used to be a rather common method of abortion. These days, there're much safer and easier medical abortions, but surgical abortions utilzing D&C, D&E (evacuation), etc, are still sometimes performed. The textbook here claims 2.6% in the US in 1996, down from 24.7% in 1970.

After a once-through with the gynecology textbook, I went and had dinner. Goat meat again, with rice. After dinner, Dr. Derrick and I went back down to the clinic.

I assisted in my first D&C last night. This one was messier, as the pregnancy had advanced further, but I felt immesurably more comfortable. This time, I helped prepare the tools needed and then put on sterile gloves to assist. I probed the cervix with a dilator, under the doctors guidance, noting and discussing the resistance felt in the uterus. This kind of experience is invaluable, I think. It will make the didactic portion of PA school immesurably more personal and visceral.

posted by daviduri @ 12:25 AM