Insertion techniques

Most clinicians can easily learn how to insert osmotic dilators, and techniques and protocols for use are quite varied. Experienced providers graduafiy acquire dexterity and acumen in tailoring the use of osmotic diiating devices to the great variety of cervicai responses they encounter. A general technique of insertion is described here:

•  After inserting a specuium into the vagina and optionally cleansing the cervix, grasp the cervix with a singie-tooth or vulsellum tenaculum, long Allis clamp, or similar device. This maneuver permits stabilization of the cervix during insertion. Some providers prefer to inject focal anesthetic into the cervical lip before grasping it; others prefer to administer full cervical anesthesia prior to osmotic dilator placement. Patient anxiety and sensitivity to pain may govern these choices;

•  Before placing the first set of osmotic devices, many providers like to "test" the cervix by passing one or a series of small-caliber rigid plastic or metal dilators past the internal os. This maneuver defines the angle and length of the cervical canal while permitting initial assessment of tissue resistance at the internal os. Modest dilation with rigid mechanical dilators prior to insertion of osmotic devices also permits placement of more osmotic dilators, thereby increasing the width of dilation eventually achieved;

•  Grasp the end of the osmotic device with a ring or packing-style forceps and insert it into the endocervical canal such that the tip extends just beyond the internal os (Fig. 11.1). Coating the osmotic dilator with lubricant jelly often eases insertion. Some providers also bathe the devices in a disinfectant such as iodine-povidone solution, although this step is of unproven value as a safety or performance-enhancing technique;

•  Osmotic dilators are usually placed in "sets" by sequentially inserting one device after the other until several

Devices fit snuggly, but not tightly, within the cervix. Ideally, the distal end of laminaria should extend a few millimeters beyond the external os in order to faciUtate removal (Fig. 11.1). Lamicel® are inserted full length up to the flared knob. Similarly, the provider should see the end or knob of the Dilapan-S™ device protruding from the external os;

Digital examination after insertion of osmotic dilators confirms that the devices have not slipped out of the cervix and are not packed too tightly;

Most providers place one or more gauze sponges in the vagina following osmotic device insertion to absorb blood and vaginal fluid. The sponges also may help prevent dilators from sliding out prior to swelling. The clinician can hold the sponge(s) in place with packing forceps while removing the vaginal speculum;

Document in the patient's record the number, size, and type of osmotic dilators placed. These devices are packaged as single units, so counting the wrappers before discarding them or attaching the wrappers to the chart helps assure an accurate account of placed devices.

Women whose osmotic dilators will remain in place overnight can be discharged after receiving appropriate instructions. Patients can resume normal activity following placement. Many wiU experience mild to moderate cramping, especially in the first few hours postinsertion, but the pain usually responds to low dose nonsteroidal analgesics. Many providers begin antibiotic prophylaxis at the time of osmotic dilator placement. Forewarn patients about the rare possibiUty that the gauze sponge(s), as weU as some of the dilators, might dislodge prior to surgery. Asking patients to track the number of devices expelled or to bring them to the facility helps to account for aU devices. Occasionally, patients wiU experience spontaneous rupture of membranes during or after osmotic dilator insertion. This event is not an emergency and rarely requires additional therapy prior to surgical evacuation of the uterus. However, these patients should be monitored closely for fever, especially if multiple-day cervical preparation is planned. If fever should ensue, some clinicians add parenteral antibiotics or a second antibiotic orally. Finally, clinicians should stress the importance of returning as scheduled for the D&E procedure

Figure 11.1 Osmotic dilator insertion. (A) Laminaria placed appropriately through the internal os. (B) Laminaria does not pass through the internal os. Swelling results in tunneling of the endocervical canal and inadequate dilation of the internal os. (C) Laminaria inserted too far into the endocervical canal. This placement may result in rupture of the membranes and difficult removal.

To avoid the risk of infection from profonged retention of the difators.

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Literature: Management of Unintended and Abnormal Pregnancy.