Hi, I'm Jen Russo. I am Senior Medical Advisor for Planned Parenthood of the Pacific Southwest, and also Media Editor for the journal Contraception. Today I'm going to be talking about an instrument primer for DNA procedures. The purpose of the talk is to identify instruments routinely used in dilation and evacuation procedures and talk about the purpose of each instrument and reasons for variation. This talk came about because we were struggling to identify instruments in our health center and I realized that we had different definitions of instruments ranging from medical assistants to physicians. Even my definition that I may go over in this lecture might be disputed. I think there's some need to all be sharing common language and to be correctly identifying instruments to improve quality and safety when we do procedures. Then I also think that this talk could be used with medical students and trainees to improve their understanding of the instruments we use and why during these procedures. My main reference was the MedKine catalog. You all may be familiar with this catalog. I strongly suggest looking at it for our gynecology instruments. There are many other instruments that are included in that catalog that may be used in dilation and evacuation procedures that I won't go over in this talk. It would be a great reference for you as well. I'm including pictures from the catalog and you'll see that the pictures are very two-dimensional. I will also show you some instruments that I think are pertinent. I'm going to talk about specula, tenacula, forceps, and suction cannulae. There's some cross over to first trimester aspiration procedures in this talk, and I'm going to talk about suction and other instruments that we use for both. Which specula do we use in D&E procedures? Here's the range of what I've seen used in the past. There are many other specula as well, but I'm going to go through these because they're the ones that I've most commonly used. I also want to give a disclaimer that in the MedGyn catalog, they use the term blade, which I think is not particularly trauma-informed or really particularly descriptive of the bills of the speculum or the sides of the speculum. I think are better descriptions of those parts of the speculum. The grave speculum is what's called in our clinics a medium speculum, and it has a certain width to the bills. It's like a medium width, and you can see the sizes here. It's hard to define exactly what the width is because there's so many different sizes of the instrument. But basically, it ranges from three-quarters of an inch to what appears to be one and a half inches. Just FYI, that is the general width of a grave speculum. Then there's a more graves, which is the same width, which is one and a quarter in this case. If you look back, it is basically in between the sizes of the small, medium, and large. But it's three and a half inch long. This is a shorter speculum. It has a shorter bill, and this can be very useful in first trimester procedures and bringing down the cervix into view, especially when using a manual vacuum aspirator because it leaves you more room to pass the cannula so that you don't end up hitting into the speculum with the hub of the syringe. Then there's the Wiseman graves, which is also known as an open-sided speculum. Some people call this a bivalve speculum, and it has an opening on the side. If you're using instruments, you can pull this out and keep your instruments in. It also allows you to open forceps a little bit more wide because it doesn't bang into the speculum. You can see that this is a graves in every other way. Then there's the clover, which is similar to the more graves, but it has a wider opening, a four centimeter opening, and it has these shorter bills, and they're also more rounded. Maybe you can see here on the end, it's a little bit challenging, but there's sort of a cup here, so it's a little bit curved right on this end here more than the more graves is, and it has a wider opening here. Then there's the Peterson, and the Peterson has a narrower bill design. It's sort of like the small speculum that some people say, and you can see the widths are a lot smaller. They're all smaller than one inch, and so it's narrower and maybe better for use in a patient who hasn't had a pelvic exam before. I don't think I've ever used one for a D&E procedure, but it is sometimes available. Okay, so the tenaculum is used to hold the cervix stable during the procedure, and I think probably most of you are familiar with the single tooth tenaculum. Trying to move this around so that you can see. So this is the single tooth tenaculum, and I don't typically use that in a D&E procedure, but some people do. So you can see here the Jacobson double tooth tenaculum, and it has two teeth, and it has sort of large rings. It comes in straight or curved, whereas the Jacobs has smaller rings and also the two by two teeth, which are a little bit different if you look between the two, and can come in straight and curved as well. I just want to show you that the curve can be angled up because you can see, probably in this picture best, you can see there's like a little notch there in the speculum. Can't see it there. So you can see that little notch, and some people find that it's helpful to take the angle of this and actually flip this the other way and have the angle. So you would be holding onto the cervix here, and then the angle would go up and get your instrument out of the way. Hopefully that makes sense. My drawing isn't fabulous, but I hope you get the idea. This would be flipped over and be pulled out of your view. And the bearer is curved even more, same reason. It has some teeth at the functional part of the instrument. And so those teeth can be used to grasp the cervix. The shaw is very similar, but it has a smooth end and no teeth. And then the ring, which happens to be my favorite thing to hold the cervix during a D&E procedure because the cervix is often pretty dilated and sort of patchless. And so the ring holds onto it very well and gets sort of a better surface area of tissue that it's compressing so that there's less risk that it'll pull off. Okay, moving on to dilators. So first I'm gonna talk about the Pratt, which is probably the most common dilator that you've seen. It has a flat midsection, and then the ends are tapered but blunted. And these are measured in French. So French is a circumference, as many of you are aware. And some of the dilators are measured in French and some are measured in millimeters. Millimeters is the metric that we use for suction cannulae. So you have to do a conversion from diameter to circumference to be able to convert where you should be dilating to. And then I'm bringing up the Pratt Extra Large because I'm gonna compare it with another dilator in a moment, but you can see that this is large. Same shape and blunted end. So Hank. Hank dilators have, the mnemonic is Hank has a shank. It has these guide rings that sit at about four centimeters. So it helps you to know if you're through the internal ass or how far you are in through the cervix into the uterus. It also may be potentially a little bit of a stopper, but not really. And these are measured in terms of French as well. And they tend to be a little bit on the smaller side. And then there's the Hagar, which looks like a cigar. That's the mnemonic for Hagar. So Hagar looks very similar to that extra large dilator, but as you can see, it's curved in this area. So it's curved, whereas this is straight in this area. And so that's how you can tell those two apart. But Hagar looks like a cigar. It also is a little bit more tapered at the end. And these are measured in terms of millimeters. So these are the diameter. And then there's the plastic Pratt's, which are also known as the Deniston's. And these are very similar to a Pratt. However, they're measured in terms of diameter and not circumference. So it's millimeters. And these are really great for packing. Like if you have a first trimester set, then this is a lot lighter than a first trimester metal set. And so a lot of places choose the plastic for that reason, easier to sterilize. I'm sure there are a bunch of other reasons. The metal may be more helpful when you're having a challenging dilation. However, because the weight, in my experience, of the metal makes it easier to dilate. Okay, now let's talk about types of forceps, which was really the reason that I constructed this talk, because I was finding that staff were finding it challenging to know the names of all of the different forceps. We've done a lot to try to help with that by tracing them and allowing staff to like hold up the jaws to different tracings. But even still, it can be really challenging and it's challenging even amongst physicians to agree on what the names are of all of these forceps. So first is the SOFR forceps, which is not the smallest, but tends to be the smallest in some of the kits that we have. And I am going to stop share because I want to show you these. So this is a SOFR. And you can see that the end is kind of rectangular. It's not as triangular as the others. It's not a rectangle, but it's rounded on the edges. But you can see that the jaws are parallel here. And in these, you can see the serrations are kind of fine serrations. And it has a closed end if you look on end at it, essentially. This one also has a screw as a hinge, which I think is a little bit more flimsy than an actual screw. I think it's a little bit more flimsy than another option that we have. So these are SOFRs. Again, SOFRs. Okay. So let's go back to the presentation. And I'm going to move on to beerers. This is usually the larger forceps that at least I have been familiar with using. And these are a little bit more triangular in shape. So you can see here in the image, these are coarse serrated jaws. And coming back so that you can see it. So when you're comparing it to a SOFR, it's a little bit more triangular in shape. The jaws have a coarse serration on them. And on the ends, they close. Okay. So they're not open-ended. And I'm going to explain why that's important in just a moment. And then you can see the hinge of this is a little bit more of an angled hinge. It's not, it doesn't have that screw. These happen to have a ratchet so that you can close on tissue. For me personally, I don't really love using one with a ratchet. I like it to be open so that I can open and close easily. But those are some just differences. And all forceps can have these variations of the ratchet and the different hinge. Okay. So this is a beerer. And then I don't have an example of the HERN, but you can see that it has sort of this also shortened triangular jaw with coarse teeth. And this, from my teaching, and Dr. HERN could probably verify this for us, is to use for internal version so that we're able to grasp the lower extremity and turn to a breach position. I usually do that with the, with no amniotomy so that there's plenty of fluid and that enables, and this has a curve that enables you to go through the curve of the uterus to grasp tissue. There are several different HERN forceps. There's also HERN Patterson, which has a little bit of a smaller and smaller jaws to it, coarse teeth. And this one in particular has a ratchet. And then there's Blumenthals. And I do have an example of those. And that's why I was talking about the open and closed end. So I'm going to compare them to beerer. This is the beerer. This is the Blumenthal. You can see that the Blumenthal is slightly larger in this case. But as you can see from my slides, there's many different sizes of these. Okay. But overall, they typically are larger than a beerer. And they too have a coarse serration. But at the end, they are open. And hopefully you can see that, that there's an open end there, right here. And that's different from the beerer, which is, I need to ratchet it down, but it's closed. Okay. So closed versus open. And the open enables you to avoid grasping the fundus and pulling it down, which can cause, obviously, a perforation. So there's a, or that's my understanding. And Dr. Blumenthal can also weigh in on this, is that this is designed to not grasp myometrium. Okay. And then there's finks, which I also don't have an example of, but these are a little bit smaller than a sofer. Although sofers also come in 13. Let's look at the different sizes. So, sofer can come in a 12, 14 millimeter jaw. Beerer is 16 to 19. Hearn is 12 to 19. Hearn-Patterson is 17. Blumenthal is 20. So again, larger than the rest. And then finks come in 13, which is, there are some smaller sofers that are a little smaller than this. But these are fairly similar but these are fairly similar. They are very small and then they're slightly curved and they have the concave tip as well. And some people really like these for earlier second trimester procedures. And then there's stubble fields, which are slightly curved, very long forceps with oval jaws. They have 14 millimeter jaws and they're a bit longer. And I have not used these before, but you can see that they have a finer serration and a bit of a more triangular jaw. Okay, moving on to suction. So even in D&E procedures, it's possible to use manual vacuum aspirator. And you can see one example here. They come in different, slightly different shapes, but roughly the same idea. And these can be used for uterine aspiration at the conclusion or beginning of a procedure. And then I wanted to talk about suction handles because I've worked in a few different places and we've had different equipment in each place that I've worked. And you can see here that there's the plastic suction handle on the right side. And then this is me showing actually a suction extender, but the suction handle is metal. And there's a big difference between these in that with the metal, the ring to close the suction needs to be pushed down or pulled down. And with the plastic, it's actually pushed up. Okay, so they're the opposite movement when you want to apply the suction. And then I'm not, I don't think an extender exists for plastic, but if there is, I'm not aware of it. But this extender can be very helpful if we're dealing with a patient where we're having trouble reaching the fundus. And like in that situation, where you feel like your hand is inside of the speculum, this prevents that. So that's an extra extender. And then we've had a recent change that our 14 cannula, the rigid curve 14 has been changed so that actually it fits onto small tubing. There's small tubing, small diameter tubing and larger diameter tubing. Typically 14 and above, or now for us 15 and above is large tubing. And then I just wanted to show different kinds of cannulae. So this is a flexible cannula. You can see here, this is a six flex and it's flexible. And the tip has two openings on it. So some people like that because they can sort of twist and you're covering more surface area as you suction. There's also rigid and straight cannulae. Rigid, curved and straight cannulae. Both of these are rigid. I prefer the curved personally because it curves with the uterus. This is an eight and a seven. So these are all different sizes. But these are the three types of cannulae. This only has one hole, whereas the flex has two. And those are just our core cannulae. I'm not aware of any other kind. There are some different manufacturers that have like colored endings and things like that, but they're all flex and rigid, straight and curved. So that is all I have for you today. Please feel free to forward me questions or suggestions for this talk. I know that it could have encompassed a lot more information and many more instruments, but I think these are our core. And I would really love to hear from you, to hear if you have different thoughts and suggestions, and hope this opens a dialogue about preferred instruments and also helps us in clinic to make sure that we're labeling correctly and sharing the same language about the instruments we're using. Thank you so much for joining me for this talk.

DNA procedures

instrument primer

gynecology instruments

specula

forceps