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Instruments and Procedures
in
Obstetrics and Gynecology
 Instruments and Procedures
in
Obstetrics and Gynecology

Kiran Agarwal MD FICOG

Associate Professor, Rohilkhand Medical College and Hospital
Pilibhit Bypass Road, Bareilly

Vice President, Rohilkhand Medical College and Hospital

Institute of Dental Sciences
Rohilkhand College of Nursing
Bareilly-243001 (UP) INDIA

Foreword
Narendra Malhotra

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

New Delhi • London • Philadelphia • Panama
 ®

Jaypee Brothers Medical Publishers (P) Ltd

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Jaypee Brothers Medical Publishers (P) Ltd
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Email: info@[Link] Email: cservice@[Link]
Jaypee Medical Inc Jaypee Brothers Medical Publishers (P) Ltd
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Jaypee Brothers Medical Publishers (P) Ltd
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Phone: +977-9741283608
Email: Kathmandu@[Link]

Website: [Link]
Website: [Link]

© 2014, Jaypee Brothers Medical Publishers

The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do
not necessarily represent those of editor(s) of the book.
All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any
means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing
of the publishers.
All brand names and product names used in this book are trade names, service marks, trademarks or
registered trademarks of their respective owners. The publisher is not associated with any product or vendor
mentioned in this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative
information about the subject matter in question. However, readers are advised to check the most current
information available on procedures included and check information from the manufacturer of each product
to be administered, to verify the recommended dose, formula, method and duration of administration,
adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety
precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage
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copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the
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Inquiries for bulk sales may be solicited at: jaypee@[Link]

Instruments and Procedures in Obstetrics and Gynecology

First Edition: 2014
ISBN 978-93-5152-137-2
 Dedicated to
My father (Late) Dr Rajendra Gupta
DMRE, DMRT, MD (Radiology)
who is a source of inspiration for me.
 FOREWORD

Obstetrics and gynecology today has

become a fast expanding branch and
everyday new procedures and equipments
and instruments in this field are added. We
are also over flooded with literature, books,
online internet articles and guidelines, etc.
There are many books on medical
surgical instruments and equipments and
procedures, but this lovely manual is
different. The approach in this manual/
book is very practical. To a medical student, intern, resident fresh
out of theory teaching this manual offers a very clear and simple
way of describing an instrument and its uses.
This manual has different sections and each section contin­
ing photographs, description and their uses which are clearly
explained in simple words.
I congratulate Associate Professor Kiran Agarwal for this
wonderful manual and recommend this as a standard teaching
manual for undergraduates, postgraduates, residents and also
for the practicing gynecologist.

Prof Narendra Malhotra

DIU Croatia
Past President FOGSI
FOGSI Rep To FIGO
MD Rainbow Hospitals
Consultant and Director
MNMH(P) Ltd
 PREFACE

I always felt in my practising career, that there is a lack of simple

yet concise and handy book for students and residents on
instruments and procedures in obstetrics and gynecology. In this
endeavor I consulted several textbooks and aimed at presenting
a book with clinical experience in a manner that would be
understood by all.
This book will be practically useful not only for junior doctors
but also for consultants and busy practitioners who are unable to
refer to larger textbooks and journals. The book includes general
instruments, specialized instruments and diagnostic tools in
its different sections. Some instruments are of historical value
only but focus has been made on what is basic, practical and
important to know and learn in art and science of obstetrics and
gynecology.

Kiran Agarwal
 ACKNOWLEDGMENTS

I salute my institution Rohilkhand Medical College and Hospital

which has given me opportunity to write this book.
I humbly acknowledge and sincerely thank the affectionate
and caring attitude of all the people throughout my work and all
praises to Almighty God who enlightened me to carry out this
work successfully.
I would take this opportunity to thank my husband, Dr Ashok
for his constructive suggestions, encouragement, his companion­­-
ship, understanding and moral support.
With supreme sincerity and deep sense of appreciation I thank­
fully acknowledge Dr Abhaya and my children Dr Kanupriya and
Dr Mohit, Dr Arjun and Dr Cheena for giving valuable suggestions
in various sections.
I must accord and express thanks to Dr Prity and Dr Pallavi
for helping me from time to time for successfully completing this
project.
I am grateful to M/s Jaypee Brothers Medical Publishers (P)
Ltd for accepting this book for publication.
I would welcome any valuable suggestions and feedback or
queries for further improvement at ashokkiran_bly@[Link]
 CONTENTS

Section – 1 1–16
Instruments for Examination in Obstetrics and Gynecology
• Sims Speculum 1
• Cusco’s Speculum 4
• Auvard Speculum 6
• Sims Anterior Vaginal Wall Retractor 7
• Vulsellum 8
• Tenaculum 10
• Uterine Sound 12
• Bladder Sound 13
• Pinard’s Stethoscope 14
• Stethoscope and Digital Fetal Doppler 15
Section – 2 17–37
Instruments for Dilatation, Curettage and Evacuation
• Hegar’s Dilators 17
• Uterine Curette 20
• Endometrial Biopsy Curette 24
• Pipelle 26
• Ovum Forceps 27
• Karman Double Whistle Cannula, Karman Menstrual
Regulation Syringe and Manual Vacuum Aspiration
Syringe 29
• Laminaria Tent 36
Section – 3 38–44
Instruments for Tubal Patency Test
• Instruments for Tubal Patency Tests 38
Section – 4 45–62
Instruments for Operative Vaginal Delivery
• Obstetrical Forceps 45
• Ventouse or Vacuum Extractor 57
xiv Instruments and Procedures in Obstetrics and Gynecology

Section – 5 63–69
Instruments for Destructive Operations
• Instruments for Destructive Operations 63
Section – 6 70–74
Catheters
• Catheters 70
Section – 7 75–105
General Instruments in Obstetrics and Gynecology
• Cheatle Forceps 75
• Towel Clips 76
• Sponge Holding Forceps 77
• Bard Parker’s Knife 78
• Retractors 80
• Needle Holder 87
• Dissecting Forceps 89
• Artery Forceps 91
• Pessary 95
• Tissue Holding Forceps 96
• Scissors 99
• Umbilical Cord Clamp 105
Section – 8 106–135
Special Instruments in Obstetrics and Gynecology
• Green Armytage Forceps 106
• Doyen’s Myoma Screw 107
• Bonney’s Myomectomy Clamp 107
• IUCD Removing Hook 109
• Uterine Packing Forceps 110
• Uterus Holding Forceps 112
• Mersilene Tape 113
• Shirodkar Cervical Encerclage Needles 115
• Intrauterine Insemination Cannula 117
• Electrosurgical Loop 120
 Contents xv

• Cervical Punch Biopsy Forceps 122

• Cryomachine 123
• Suture Materials 126
Section – 9 136–148
Instruments for Cervical Screening
• Ayre’s Spatula and Cytobrush 136
• Colposcope 144
Section – 10 149–173
Diagnostic Tools
• Cardiotocograph 149
• Hysteroscope 160
• Laparoscope 164
• Ultrasound 168

Further Reading 175

Index 177
Section
1Instruments for Examination in
Obstetrics and Gynecology
SIMS SPECULUM

Designed by Marion Sims

It is a nonself-retaining vaginal speculum used in vaginal
examination and operations to retract posterior vaginal wall
(sometimes lateral or anterior wall) and view vagina and cer-
vix.

Types
• Metallic speculum: It needs external light source
• Plastic speculum: It may be equipped with a light source.

Sizes
• Small for nulliparous, virgins and adolescents
• Large for parous woman
Used according to vaginal length and cavity.

Parts
Blades
At an angle to shaft and point towards same side. Different sizes
are used for different sizes of vagina. Each valve (blade) is round-
ed at the end so the instrument is atraumatic (Fig. 1.1).
Lubricant: Water-based jelly is preferred.

Groove
For drainage of secretions by slightly tilting the instrument and
collection of specimen from vagina.
2 Instruments and Procedures in Obstetrics and Gynecology

Figure 1.1: Sims bivalved vaginal speculum

Technique
Position
Lithotomy by edge of table /Sims position.

Method
Wear gloves. Appropriate size of the speculum is taken.
Lubricate speculum (except in Pap smear). Labia minora are
gently separated and urethra is identified prior to insertion.
Speculum is inserted well below the meatus because of urethral
sensitivity. To improve comfort with speculum examination the
woman is asked to relax posterior wall muscles. Sims speculum
should not be inserted with blades in line with cleft of the vulva
and then rotated in vagina because it is designed for “direct” ap-
plication. In any case vagina is wider from side to side than from
front to back, so Sims speculum is introduced directly posteri-
orly to its full length for inspection of cervix.

Uses
To retract vaginal wall and speculate vagina and cervix.

Uses in gynecology
1. P/S (per speculum examination) in gynecology
• Inspect cervix for growth, erosion, discharge
• Inspect vagina for vaginitis, cystocele, rectocele, enterocele,
VVF.
2. Perform minor procedures on the cervix
 Instruments for Examination in Obstetrics and Gynecology 3

• Cervical biopsy, conization of cervix

• Cervical tear stitching
• Polypectomy
• Dilatation of cervix.
3. Perform procedures on the uterus
• Dilatation and curettage (D and C)
• Endometrial biopsy (EB)
• Intrauterine contraceptive device (IUCD) insertion.
4. Major gynecological operations
• Vaginal hysterectomy
• Fothergill’s repair
• Anterior colporrhaphy and posterior colpoperineorrhaphy
• VVF (vesicovaginal fistula) repair.
5. Diagnostic procedures
• Hysteroscopy
• Hysterosalpingography, sonosalpingography
• Tubal insufflation
6. Collection from vagina
• Cytology, staining, culture
• Three swab test.

Uses in obstetrics
1. P/S (per speculum examination) in obstetrics
• Discharge
• Leaking
• Bleeding in APH (antepartum hemorrhage), abortions,
PPH (postpartum hemorrhage) to diagnose traumatic
PPH and repair tears.
2. Performing procedures
• Medical termination of pregnancy (MTP)
• Dilatation and evacuation (D and E).
3. McDonald stitch, Shirodkar stitch.

Advantage
Good view.

Disadvantages
• Assistant is required to hold the speculum
• Cannot visualize the cervix without anterior vaginal wall
retraction.
4 Instruments and Procedures in Obstetrics and Gynecology

CUSCO’S SPECULUM

Devised by Cusco Edward Gabrial.

It is a self-retaining vaginal speculum.

Types
• Metallic
• Plastic.

Sizes
• Small
• Large.

Parts
Blades
• Two blades are shaped like the beak of a duck
• Blades can be opened up and fixed at the required angle by an
adjustable arrangement (Fig. 1.2).

Handle
• It is at right angle to the blades. When handle is closed blades
will open
• Screw mechanism on handle makes it self-retaining.

Figure 1.2: Cusco’s bivalved self-retaining speculum

 Instruments for Examination in Obstetrics and Gynecology 5

Technique
Position
Dorsal / Lithotomy.

Method
It is same as in Sims speculum. Wear gloves. Appropriate size of
speculum is taken. Lubricate speculum (except in Pap smear).
Prior to insertion, labia minora are gently separated and urethra
is identified and it is inserted with closed blades in vagina. When
speculum is inserted completely it is angled approximately 30°
downward to reach the cervix. Uterus lies in anteverted position
commonly and ectocervix lies apposed against posterior vaginal
wall. As speculum is opened ectocervix is visualized. The fixation
screw is tightened depending on the amount of exposure needed,
then it is unscrewed and blades closed when speculum is taken
out (if the cervix is pointing forwards, the uterus is retroverted
and if it pointed backwards it is anteverted).

Uses in gynecology and obstetrics

1. P/S examination: An important examination in obstetrics
and gynecology
• To visualize the cervix for erosion, discharge and growth
• To visualize vaginal fornices.
2. Perform minor operations on the cervix
• Biopsy
• Cautery
• Polypectomy.
3. Collect vaginal pool material and scraping for cytological study
4. IUCD follow-up and removal
5. Colposcopy.

Advantages
• Ideal for visualization and operations on cervix
• Self-retaining, so no assistant is required
• It can be used in patients who cannot be put in lithotomy position.

Disadvantage
• Limited view of vagina as anterior and posterior walls cannot
be visualized.
6 Instruments and Procedures in Obstetrics and Gynecology

AUVARD SPECULUM
It is self-retaining vaginal speculum.
It is a heavy instrument with a heavy metal ball.

Parts
• Blade
• Groove: A channel is provided on the handle to collect the
blood and drain (Fig. 1.3).
• Heavy metal ball: Which makes it self-retaining.

Figure 1.3: Auvard vaginal speculum

Technique
• Position: Lithotomy
• Method: Same as in Sims speculum.

Uses
It is used to retract posterior vaginal wall in
1. Operations on vagina, cervix and uterus, e.g. vaginal hysterectomy.
2. Anterior colporrhaphy, VVF repair.
 Instruments for Examination in Obstetrics and Gynecology 7

Advantages
Advantages of Sims and Cusco’s speculum combined.
• Good view of vagina
• Self-retaining.

Disadvantages
• Prolonged use causes postoperative perineal pain.
• Used when operation is done under anesthesia.

SIMS ANTERIOR VAGINAL WALL RETRACTOR

This instrument is used along with Sims speculum to retract the

anterior vaginal wall.

Parts
• A long instrument with shaft and oval fenestrated ends.
• Two loops are set at an angle of 15° with the shaft which face
in opposite directions (Fig. 1.4).

Figure 1.4: Sims anterior vaginal wall retractor

8 Instruments and Procedures in Obstetrics and Gynecology

• Transverse serrations on loop prevent slipping of instrument

and fits into rugosities of vagina.
It is differentiated from uterine curette by following points:
n It is larger in size.
n Oval loops have transverse serrations.

Technique
• Used along with Sims speculum.
• Instrument is used to retract anterior vaginal wall with the
angle at oval end facing upwards.
• Can be used to retract sagging vaginal wall for good exposure
of the cervix.

Uses
• To visualize the cervix in obstetrical and gynecological
operations.
• In postpartum hemorrhage just after delivery as blunt curette
to remove products of conception and membranes.

VULSELLUM
Designed by Teals
It is a long instrument which can be applied to the anterior lip or
the posterior lip of cervix. Usually it is 20 cm in length.

Parts
Teeth
Interlocking sharp teeth which ensure a firm grip on cervix when
it is locked (Fig. 1.5).
 Instruments for Examination in Obstetrics and Gynecology 9

Blades
Blades have a curve so that field of vision is not blocked during
the procedure. Distance in between blades prevent crushing of
tissues held in between them. The instrument gives a firm grip
on the cervix and pulling cervix straightens uterocervical canal
so that chances of perforation are reduced.

Figure 1.5: Teals vulsellum

Technique
Vaginal exposure is done by retracting vaginal walls using Sims
speculum and Sims anterior vaginal wall retractor.
Anterior lip of the cervix is grasped with the teeth of
vulsellum and the instrument is locked. The curve should
face upwards.

Uses
Uses in gynecology
1. To catch the anterior lip of cervix for surgical procedures
• Operations of cervix, e.g. biopsy and cautery
• Cryosurgery
• D and C (dilatation and curettage)
• IUCD insertion
• Drainage of hematometra and pyometra
• Fothergill’s operation to hold the new cervical stump after
amputation
• Vaginal hysterectomy
• To test degree of descent of uterus by giving traction with
vulsellum in case of prolapse.
10 Instruments and Procedures in Obstetrics and Gynecology

2. To catch the posterior lip of cervix

• Aspirating pus in pelvic abscess, i.e. posterior colpotomy
• Aspirating blood in ectopic pregnancy, i.e. culdocentesis
• Fothergill’s operation
• Vaginal hysterectomy
• If growth on the anterior lip of the cervix then catch the
posterior lip of cervix.
3. To hold uterine fundus during abdominal hysterectomy.
4. To give gentle traction on fetal head after craniotomy or the
collapsed head in IUD baby.
5. To remove polyps by twisting.

Use in obstetrics
• To catch the cervix in pregnant patient, e.g. MTP, S and E, D
and E.

Disadvantages
Cervical trauma and bleeding. The cervix is soft in pregnancy
so sponge holding forceps is used to hold cervix instead of
vulsellum.

TENACULUM

It is used in the nulliparous cervix in place of vulsellum.

Parts
It can be differentiated from vulsellum by following points:
• Straight instrument and not curved as vulsellum
• Single tooth is present
 Instruments for Examination in Obstetrics and Gynecology 11

• Grip is more secure than vulsellum because its bite is deeper.

Two blades have gap in between to prevent crushing of
structure.

Figure 1.6: Jarcho’s tenaculum

Technique
• Retract anterior and posterior vaginal walls for exposure of
the cervix
• Anterior lip of the cervix is held with a tenaculum (Fig. 1.6).

Uses
• To hold the anterior lip of the cervix / posterior lip of cervix in
place of vulsellum
• In nulliparous, to hold the cervix in sonosalpingography
(SSG), hysterosalpingography (HSG) and chromopertubation
during laparoscopy.
• To hold cervix in cryosurgery or cautery of cervix.

Advantage
Better for nulliparous cervix because it occupies less space.

Disadvantages
• Cervical tears are greater than in vulsellum as the bite is
deeper
• Discomfort or pain.
12 Instruments and Procedures in Obstetrics and Gynecology

UTERINE SOUND

Designed by Simpson.

Parts
• It is 30cm long angulated instrument with handle at one end
and a rounded blunt tip at the other end.
• It has graduations in inches or centimeters (Fig. 1.7).
• The angle accommodates for flexion of uterus and prevents
perforation as it fits into the anteverted or retroverted uterus.
• Angulated at 7cm from the tip (which is the normal uterocer-
vical length).
• Blunt tip does not cause injury when introduced.

Figure 1.7: Simpson uterine sound

Technique
Uterine sounding
• Bimanual examination.
• Retract anterior and posterior vaginal walls for exposure of
the cervix.
• Anterior lip of the cervix is grasped with vulsellum.
• Uterine sound is held as a “Pencil” with thumb and two
fingers.
• Sound is guided slowly through cervical os into the uterine
cavity and to fundus.
• The distance from the fundus to external os is measured by
score marks (graduations) along the length of sound.

Uses
• It confirms the direction of uterus, i.e. anteverted or retroverted.
• It measures uterine cavity and cervical length, i.e. uterocervical
length.
 Instruments for Examination in Obstetrics and Gynecology 13

• It is used to diagnose cervical stenosis and congenital

malformations, e.g. bicornuate uterus.
• Used as first dilator prior to operations on uterus and cervix,
i.e. D and C, S and E.
• It is used to sound a polyp, IUCD, uterine septum called
sounding of the uterus.
• It helps to break the adhesions in Asherman’s syndrome
(therapeutic use).
• It differentiates between chronic inversion and fibroid polyp.
• In a misplaced IUCD, uterine sound can be inserted and X-
ray of pelvis is taken in AP and lateral view. Position of IUCD
in relation to sound shows that IUCD has perforated uterus.

Disadvantage
Perforation: If direction or size of the uterus is misjudged,
perforation is suspected when instrument travels deeper than
the measured uterine length.

Contraindications
• Pregnancy
• Infection.

BLADDER SOUND

It is a long instrument similar to uterine sound.

Parts
It is differentiated from uterine sound by following points:
• Shorter in length
14 Instruments and Procedures in Obstetrics and Gynecology

• No graduations are present (Fig. 1.8)

• The tip is more blunt and so it is atraumatic.
• The angle is at a lesser distance from the blunt tip.
It is an obsolete instrument used for exploring the interior of
a bladder to detect stones by sounding because now noninva-
sive procedures are available like radiography and ultrasonog-
raphy.

Figure 1.8: Bladder sound

Uses
• To define the limits of bladder in vaginal surgeries
• Used as a urethral dilator in urethral stenosis
• To diagnose bladder injury in gynecological operations.

PINARD’S STETHOSCOPE

(Fetoscope)
• Invented by Adolphe Pinard.
• Instrument to hear fetal heart sound.

Parts
• Simple hollow tube with one broad end and another narrow
end (Fig. 1.9).
 Instruments for Examination in Obstetrics and Gynecology 15

Figure 1.9: Pinard’s stethoscope

• Narrow end has a wide rim which is used as an earpiece.

• Broad end is placed over the patient’s abdomen.

Technique
• The instrument is kept at right angle on patient’s abdomen.
• The instrument should not be touched with hand while lis-
tening to FHS.
It is rarely used now since use of stethoscope and digital fetal
Doppler.

STETHOSCOPE AND DIGITAL FETAL DOPPLER

These instruments are to hear FHS with high acoustic sensitivity.
Stethoscope has ear tips with ear tubes set to accommodate
the anatomy of the ear (Fig. 1.10).
Digital fetal Doppler has display to give read out of fetal heart
rate (FHR) in beats per minute (bpm) (Fig. 1.11).
16 Instruments and Procedures in Obstetrics and Gynecology

Figure 1.10: Stethoscope

Figure 1.11: Digital fetal Doppler

Auscultation
The fetal heart is auscultated for one minute (normal 110–160
bpm)NICE guidelines. During labor fetal heart rate should be
auscultated during and immediately after uterine contraction to
detect late deceleration.
n Low-risk pregnancy
Auscultation in—1st stage labor: 30 minutes interval
2nd stage labor: 15 minutes interval.
n High-risk pregnancy
Auscultation in—1st stage labor: 15 minutes interval
2nd stage labor: 5 minutes interval.
Section
2 Instruments for Dilatation,
Curettage and Evacuation
HEGAR’S DILATORS
These are curved double ended dilators with conical tips used to
dilate endocervical canal and internal os rapidly.

Types
• Metallic
• Plastic.

Sizes
• Size increases gradually ranging from diameter of few millim-
eters to more than 2 cm. Number of dilators are according to
diameter of the shaft. Each double ended dilator has two sizes
with a difference of 0.5 mm (Fig. 2.1).

Parts
• Solid rod which is curved near the tip.

Figure 2.1: Hegar’s dilators

18 Instruments and Procedures in Obstetrics and Gynecology

• Tip is tapered. The dilating portion is within terminal 1.5 cm

of dilator.

Technique
• Consent
• Patient preparation. Empty bladder.

Steps
1. Anesthesia and patient positioning
• GA or paracervical block
• Dorsal lithotomy position
Bimanual examination.
2. Uterine sounding is done after retraction with speculum and
holding cervix with vulsellum. Sounding confirms size and
direction of the uterus.
3. Uterine dilatation: Hegar’s dilator is held as in pen holding
manner in right hand by thumb and first two fingers, while
fourth and fifth fingers and heel of hand (ulnar border) rests
on perineum and buttock. This prevents injury from sudden
and excessive dilatation (Fig. 2.2).

Figure 2.2: Method of cervical dilatation

 Instruments for Dilatation, Curettage and Evacuation 19

• The right and left hand provide traction and counter trac-
tion so that the amount of pressure is controlled while di-
lating the cervical os.
• Each dilator is gently and gradually advanced through the
internal os.
• Serial dilatation continues until cervix admits the selected
curette.
• Tip is directed anteriorly or posteriorly according to
direction of the uterus whether it is anteverted or
retroverted.
• For MTP the dilatation required depends on size of
pregnancy in weeks, i.e. for 6 weeks pregnancy the size of
dilator required is no. 6.

Uses
Uses in gynecology
• Prior to curettage (commonest), D and C and polypectomy.
• Prior to hysteroscopy.
• Acquired or congenital cervical stenosis. To prevent cervical
stenosis following Manchester operation for prolapse of
uterus and following conization.
• To drain hematometra, pyometra.
• Smaller sizes can be used as urethral dilator in stricture.
• Prior to removal of embedded intrauterine contraceptive
device dilator no. 4 / no. 5 is used.
• Prior to breaking uterine adhesions in Asherman’s syndrome.
• To diagnose incompetent os, if no. 8 dilator goes easily in the
internal os of the cervix in nonpregnant patient.
• Prior to insertion of radium into the uterine cavity in cancer
cervix and endometrial cancer.
• Dysmenorrhea.

Uses in obstetrics
• D and E, MTP, incomplete abortion, missed abortion, vesicular
mole.
• Drain lochiometra.
• Retrograde dilatation in elective cesarean section.
20 Instruments and Procedures in Obstetrics and Gynecology

Advantages
• The angle makes the instrument less traumatic.
• The increasing sizes of dilators make cervical canal patulous
by gradually stretching the muscle and fibrous tissue of the
cervix.

Disadvantages
Complications are few and rare
• Vasovagal shock due to forceful dilatation.
• Injury: Cervical tear and laceration, false passage.
• Uterine perforation occurs mainly in soft uterus, i.e. pregnant
uterus, in atrophic postmenopausal or scarred uterus and can
also occur in malignant uterus. In acute anteflexion the di-
lator can perforate posteriorly and when retrodisplacement
exists, the perforation usually occurs anteriorly. When dilator
goes further in without resistance beyond measured length
of uterine cavity then perforation is suspected.
• Hemorrhage.
• Infection.
• Injury to bladder and intestine.
• Late: Cervical incompetence (due to excessive dilatation) and
cervical stenosis.

UTERINE CURETTE
It is a long double ended instrument.

Sizes
Different sizes of loops from a few millimeters to few centimeters
are available.
 Instruments for Dilatation, Curettage and Evacuation 21

Parts
The terminal ends are oval loops. They are angled to the shaft.
It is differentiated from anterior vaginal wall retractor by
following points:
• It is smaller
• Oval loops are sharp and blunt without transverse serrations.
n Sharp end has smaller loop and is used in gynecological
conditions.
n Blunt end has larger loop and is used in obstetrics (Fig. 2.3).

Figure 2.3: Blakes blunt and sharp uterine curette

Technique
• Consent
• Patient preparation. Empty bladder
• Injection atropine is given to prevent vasovagal attack.

Steps
1. Anesthesia and patient positioning
• GA or sedation with a paracervical block with 1% ligno-
caine, 5 to 10ml at 3 and 9 O’ clock position.
• Lithotomy position
Bimanual examination.
2. Uterine sounding
• After retracting vagina with speculum and holding cervix
with vulsellum confirm the size and direction of the
uterus.
3. Uterine dilatation
• Done with dilators depending on size of curette to be
inserted and indication of operation starting from no. 3 to
no. 10.
22 Instruments and Procedures in Obstetrics and Gynecology

4. Uterine curettage
• Uterine curette is introduced with tip facing anteriorly if
uterus is anteverted and posteriorly if uterus is retroverted
to avoid perforation. Curette is advanced to fundus following
the long axis of corpus. Pressure is exerted gently but firmly
against endometrium as curette is pulled towards internal
cervical os lengthwise. Posterior surface is curetted followed
by anterior and then left and right lateral surface and finally
fundus. Action of curette is gentle one with curette lightly
held in first three fingers and thumb of right hand.
• Curetted endometrial sample is collected on swab placed
just under posterior lip of cervix in posterior fornix. Tissue
is sent for HPE in 10% formalin and AFB culture in saline
as required. The angulation between loop and shaft helps
in easy removal of uterine contents without causing injury
to uterus.
Normal endometrium is pink and healthy.
Profuse, pale looking friable tissue suggests malignancy.

Hysteroscopy directed biopsy and curettage is a more accurate

procedure.
Uses in gynecology
Sharp end of curette is used.
1. Dysfunctional uterine bleeding (DUB) for hormonal pattern.
2. Secondary amenorrhea: To detect tubercular endometritis.
Optimum results are obtained from endometrial samples
curetted from cornua of the uterus as tuberculosis is a de-
scending infection and cornual end is the first part of the
uterine cavity to be affected.
3. Postmenopausal bleeding: To rule out endometrial cancer.
4. Endometrial cancer: To study the endocervical tissue and the
extent of spread. This helps in staging and deciding treatment.
For fractional curettage three specimens are taken and
sent in labelled vials.
• Undilated cervical canal: Endocervical curettage(ECC).
• Dilated cervix just above the internal os from isthmic
region.
 Instruments for Dilatation, Curettage and Evacuation 23

• From uterine cavity (4 walls, i.e. anterior, lateral, posterior

and fundus).
Involvement of endocervical lining places malignancy
in stage II of the disease.
5. Infertility: Till now D and C was performed premenstrually
to detect if ovulation has occurred or not. Proliferative endo-
metrium indicates nonovulation and secretory endometrium
indicates ovulation. Now D and C is replaced by ultrasound
for monitoring ovulation except in tubercular endometritis
where endometrial tissue is sent in saline for AFB culture and
PCR.
The corpus luteal phase defect is diagnosed if endometrial
histology lags behind by 2 days of menstrual date.
6. A menopausal woman on hormonal replacement therapy for
endometrial hyperplasia and cancer.
7. A woman on tamoxifen therapy for breast cancer must
have curettage 6-monthly for the diagnosis of endometrial
hyperplasia and cancer.
8. Diagnosis of choriocarcinoma.
9. Treatment of Asherman’s syndrome to break adhesions.
10. After removal of polyp and prior to myomectomy.

Uses in obstetrics
Blunt end of the instrument is used for (check curettage)
1. Incomplete abortion, missed abortion
2. Evacuation of hydatidiform mole
3. MTP (medical termination of pregnancy)
4. PPH for retained products of conception

Disadvantages
Complications are less than 1%
• Infection
• Perforation
• Cervical injuries
• Hemorrhage
• Asherman’s syndrome leading to amenorrhea and placenta
praevia with over enthusiastic curettage as it damages the
decidua basalis layer
24 Instruments and Procedures in Obstetrics and Gynecology

• Infertility
• Ectopic pregnancy due to PID
• Rupture uterus during subsequent pregnancy or labor.

Contraindications
• Suspected pregnancy
• Genital tract infection
• In acute endometritis and salpingitis curettage should be
avoided
• Removal of the infected placental tissue is preceded by
parenteral antibiotics
• Pyometra.

ENDOMETRIAL BIOPSY CURETTE

It is a long tubular instrument used for endometrial biopsy.

Parts
• Hollow and blunt tipped instrument
• The tip has a whistle subterminally which is notched and has
cutting edge
• The instrument is angulated about 5cm from tip for easier
introduction in the uterine cavity (Fig. 2.4)
• Stilette is for removing biopsy tissue.

Technique
1. OPD procedure
• Consent
• Patient preparation. Empty bladder.
 Instruments for Dilatation, Curettage and Evacuation 25

Figure 2.4: Randall’s endometrial biopsy curette

Steps
1. Anesthesia is not required.
• Bimanual examination
• Sedation is given.
2. Uterine sounding:
• After retracting vagina with speculum and holding the
cervix with vulsellum, confirm the size and direction of
the uterus.
• The cervix is not dilated.
3. Uterine curettage
• Endometrial biopsy curette is inserted according to position
of the uterus whether anteverted or retroverted.
• Uterine wall is curetted and 10ml syringe is attached to create
negative pressure to suck out endometrial tissue. During
withdrawal of instrument pressing against the uterine wall a
strip of endometrium is removed.
• The tissue is sent for HPE and AFB culture.

Uses
• Diagnosis of DUB
• Diagnosis of corpus luteum insufficiency: Biopsy is taken on
D21–24
• Diagnosis of anovulation: Biopsy is taken on D21–28 and if cy-
cles are irregular biopsy on D1.
Endometrial biopsy for diagnosis of tuberculosis is done in
late premenstrual phase as tubercles are present in superficial
layers and are shed during menstruation.

Disadvantages
• Perforation
26 Instruments and Procedures in Obstetrics and Gynecology

• Infection.
Endometrial biopsy is not adequate for diagnosis of endo-
metrial cancer or endometrial tuberculosis because the strip of
endometrium taken does not reveal entire endometrium.

PIPELLE

It is a flexible plastic endometrial sampling device.

Parts
• Outer tube measures 3.1 mm in diameter.
• Inside tube is closely fitted rod which when withdrawn creates
a vacuum which sucks endometrium sufficient enough to
give a histological report (Fig. 2.5).

Figure 2.5: Pipelle

Technique
• OPD procedure.
• Anesthesia is not required.
• Office endometrial biopsy can be taken.
• There is no need of syringe to develop a negative pressure.
• There are markings on the device to allow measurement of
uterine depth.
 Instruments for Dilatation, Curettage and Evacuation 27

• Pipelle stilette is retracted so that suction pressure is created

and now the hollow tube is withdrawn to internal cervical os
and then advanced back to fundus several times.
• Slow withdrawal from the uterine cavity causes sufficient
suction to obtain an adequate endometrial specimen.

Use
Used for pipelle sampling of endometrium.

Advantages
• Easy
• No admission / no anesthesia required.

Disadvantages
• Difficulty in introducing in the postmenopausal female
• Inadequate specimen as endometrial surface area sampled is
small and can miss polyps and endometrial carcinoma.

OVUM FORCEPS

Designed by Haywood Smiths.

Parts

Blades (Fig. 2.6)

• Blades are spoon-shaped, fenestrated and have blunt ends
• Longitudinal fenestrations can hold good amount of tissue.
28 Instruments and Procedures in Obstetrics and Gynecology

Lock
1. It is absent.
2. Anything held in blades is firmly caught but not nipped and
so no crushing.
Ovum forceps is differentiated from sponge holding forceps
by following points:
• It has no lock
• It has no serrations
Catch lock is absent so less chances of injury to intra-
abdominal structures.

Figure 2.6: Haywood smiths ovum forceps

Technique
• Consent
• Patient preparation. Empty bladder
• Anesthesia LA / GA.

Method
• Retract posterior and anterior vaginal wall and catch cervix
by vulsellum.
• Os is dilated with Hegar’s dilators.
• Ovum forceps is introduced with closed blades.
• Once in uterine cavity blades are opened and products of
conception are grasped and removed by rotatory movements.
 Instruments for Dilatation, Curettage and Evacuation 29

Uses
• Evacuation of products of conception in abortion and vesicular
mole.
• Evacuation of products of conception in secondary PPH.

Advantage
• No catch ratchet so no crushing action.

Disadvantages
• Perforation
• Infection
• Injury to intra-abdominal structure.

KARMAN DOUBLE WHISTLE CANNULA, KARMAN MEN-

STRUAL REGULATION SYRINGE AND MANUAL
VACUUM ASPIRATION SYRINGE

Karman cannula
A long tubular structure made of plastic or metal.
n Types:
Rigid or flexible
n Sizes:
4–12mm
n Parts
• Distal end: Double whistle at the terminal end.
• Proximal end: Fixes into syringe.
• Superior overhanging edge acts as a curette (Fig. 2.7).
The number of cannula corresponds to diameter of cannula
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