Posted in Procedures

Endometrial Biopsy

Consent Forms

Ensure Patient is Not Pregnant

Equipment List

  1. Sponge forceps (1)
  2. Nitrile exam gloves (2 pair each)
  3. Exam-room sheet (1 sheet)
  4. Chux pads (4)
  5. Speculum (3 total: 1 white, 1 green, 1 blue)
  6. Lubricant gel packet (5)
  7. Pipelle (1)
  8. Os finder (1)
  9. Formalin cup (1 cup)
  10. Foxtail swabs (at least 5 or more)
  11. Sanitary pad (1)
  12. Iodine swab sticks (3)

Procedure Note

ENDOMETRIAL BIOPSY:

Procedure was discussed with the patient including indications, risks, benefits, and alternatives. The patient opted to go forward with procedure. Timeout completed and documented on paper chart.

After visualization of the cervix with a clean speculum the cervix was prepped with iodine swab sticks, a single tooth tenaculum was used to stabilize the cervix, then an endometrial biopsy pipelle was inserted through the cervical os. Uterus measured _ cm on the pipelle markings. Tenaculum removed. Pipelle plunger was withdrawn completely and a spiral motion of the pipelle was performed to sample the endometrial lining. A total of _ passes were performed until adequate sampling obtained. Pipelle removed. Tenaculum site was hemostatic. Minimal bleeding noted from cervical os. Patient tolerated procedure well. Return precautions given.

Followup per pathology results.

Posted in Procedures

IUD Removal

Consent Form

Equipment List

  1. Chux pads (3)
  2. Exam-room sheet (1 sheet)
  3. Sanitary pad (1)
  4. Speculum (1 each size)
  5. Speculum light (1)
  6. Sponge forceps (1)
  7. Cytobrush (1)
  8. Foxtail swabs (10)
  9. Surgical lubricant (2)

Procedure Note

IUD REMOVAL

Pre-procedure counseling and consent completed, all questions answered. A timeout was performed and time documented on paper consent form.

The speculum was inserted and the cervix was identified. The IUD strings were identified and grasped with a sponge forceps and the IUD was removed without difficulty. The patient tolerated the procedure well. No complications. IUD inspected by myself and patient, complete IUD and attached strings present. IUD disposed of appropriately. Standby present throughout exam: _.

Posted in Procedures

IUD Replacement

Consent Form:

Equipment List

  1. IUD device
  2. Sterile gloves (2 pair)
  3. Chux pads (3)
  4. Exam-room sheet (1 sheet)
  5. Sanitary pad (1)
  6. Pipelle (1)
  7. Os finder (1)
  8. Speculum (1 each size)
  9. Speculum light (1)
  10. Sponge forceps (1)
  11. Cytobrush (1)
  12. Curved scissors (1)
  13. Tenaculum (1)
  14. Iodine swabs (5)
  15. Foxtail swabs (10)
  16. Surgical lubricant (2)

Procedure Note

IUD REMOVAL AND INSERTION

Before the procedure began the risks and benefits were discussed, including the risk of bleeding, device failure or expulsion, device migration, uterine perforation or insertion in the uterine wall, and infection. Patient voiced understanding and desire to proceed. Timeout performed (time documented on paper timeout form).

The speculum was inserted and the cervix was identified. The IUD strings were visualized and grasped with sponge forceps. The IUD was removed without difficulty.

IUD inspected by myself and patient, complete IUD and attached strings present. IUD disposed of appropriately.

Betadine was used to clean the cervix. After cleansing, tenaculum was applied to anterior/superior cervix. Os Finder was inserted to gently dilate the cervix, and pipelle was used to sound the depth of the uterus. Depth measured at _ centimeters. The intrauterine device was inserted and deployed per manufacturer instructions. The string was cut to 3 centimeters length and a sample of the remaining string was given to the patient for later comparison. The patient tolerated the procedure well, without significant signs or symptoms of vasovagal responses. EBL less than _ ml. Standby present throughout the procedure including any pre-procedure examinations: _.

The patient was given the patient handout and card for the specific device and lot number of inserted device. The patient agrees to return for fever, severe lower abdominal cramping, heavy bleeding, or purulent discharge. The patient was counseled on how to check the strings herself to ensure the IUD has not been displaced, and instructed to return for a post-placement exam if desired.

Posted in Procedures

Nexplanon Replacement

Consent

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Sterile gloves (1 pair)
  3. Nexplanon
  4. 1% lidocaine with epinephrine (1 vial)
  5. Mosquito curved ridged hemostat (1)
  6. 11 Blade disposable scalpel (1)
  7. Chux pads (2)
  8. Alcohol swabs (6)
  9. 18 gauge 1.5 inch needle (1)
  10. 27 gauge 1.5 inch needle (1)
  11. 5 ml syringe (1)
  12. ChloraPrep 3mL stick (1)
  13. Steri strips (1)
  14. Sterile 2×2 gauze (6)
  15. Coban roll (1)

Procedure Note

NEXPLANON REPLACEMENT

The Nexplanon rod in place was palpated in the patient’s _ arm in the appropriate position. After informed consent was obtained, and time-out completed, the patient’s left arm was prepped in a sterile fashion with a ChloraPrep swab. Approximately 5 cc of 1% lidocaine with epinephrine was infused along the planned incision site, and below and along the palpated rod. An incision was made, the device brought to the level of the incision. The rod was removed intact and verified by patient and physician. Patient tolerated procedure well. Minimal bleeding throughout procedure. Steri-Strips were placed over incision, and covered by sterile gauze and pressure dressing. Minimal (<1 ml) blood loss during procedure. Post procedure instructions & precautions were given, including: keep top compression dressing in place for 24 hours, then dressing can be removed but allow Steri-strips to remain in place for 3-5 days. Keep the area clean and dry until fully healed. Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills. Patient informed that effective immediately she must use another form of birth control if pregnancy is not desired.

The needle of the Nexplanon insertion device was inserted into the skin through the newly created incision site. Upon insertion the needle was brought horizontal and using a tenting – advance motion the needle was advanced to its entire length. The applicator button was depressed and Nexplanon rod remained in place after the device was removed. The rod was palpated in place subdermally by both the physician and the patient. Minimal bleeding. The patient tolerated the procedure well. A Steri-strip and gauze dressing was applied over the insertion site and a pressure dressing was applied over the area. Post procedure instructions & precautions were given, including: keep compression dressing in place for 24 hours, then keep area clean and covered (with Band-Aid or gauze dressing) until healed, usually 3-5 days. Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills, the implant comes out or you have concerns about its location, or you have a positive pregnancy test or suspect you might be pregnant. Wallet card given.

Patient informed replacement date: _.

Posted in Procedures

Nexplanon Removal

Consent

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Sterile gloves (1 pair)
  3. 1% lidocaine with epinephrine (1 vial)
  4. Mosquito curved ridged hemostat (1)
  5. 11 Blade disposable scalpel (1)
  6. Chux Pads (2)
  7. Alcohol swabs (6)
  8. 18 gauge 1.5 inch needle (1)
  9. 27 gauge 1.5 inch needle (1)
  10. 5 ml syringe (1)
  11. ChloraPrep 3mL stick (1)
  12. Steri strips (1)
  13. Sterile 2×2 gauze (6)
  14. Coban roll (1)

Procedure Note

NEXPLANON REMOVAL

The Nexplanon rod in place was palpated in the patient’s _ arm in the appropriate position. After informed consent was obtained, and time-out completed, the patient’s left arm was prepped in a sterile fashion with a ChloraPrep swab. Approximately 3 cc of 1% lidocaine with epinephrine was infused along the planned incision site, and below the palpated rod. An incision was made, the device brought to the level of the incision. The rod was removed intact and verified by patient and physician. Patient tolerated procedure well. Minimal bleeding throughout procedure. Steri-Strips were placed over incision, and covered by sterile gauze and pressure dressing. Minimal (<1 ml) blood loss during procedure. Post procedure instructions & precautions were given, including: keep top compression dressing in place for 24 hours, then dressing can be removed but allow Steri-strips to remain in place for 3-5 days. Keep the area clean and dry until fully healed. Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills. Patient informed that effective immediately she must use another form of birth control if pregnancy is not desired.

Posted in Procedures

Nexplanon Insertion

Consent

Ensure Patient is Not Pregnant

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Nexplanon device (1 package)
  3. 1% Lidocaine with epinephrine (1 vial)
  4. Chux pads (2)
  5. Alcohol swabs (6)
  6. 18 Gauge 1.5 inch needle (1)
  7. 27 Gauge 1.5 inch needle (1)
  8. 5 ml Syringe (1)
  9. ChloraPrep 3 ml stick (1)
  10. Steri strips (1)
  11. Sterile 2×2 gauze (6)
  12. Coban roll (1)

Procedure Note

NEXPLANON INSERTION

After informed consent was obtained and pregnancy reasonably excluded, a time-out was completed. The patient’s _ arm was then prepped in a sterile fashion with a ChloraPrep swab. A subdermal wheal was created at the entry point, then approximately 5 cc of 1% lidocaine with epinephrine was infused along the planned insertion path. The needle of the Nexplanon insertion device was inserted into the skin. Upon insertion the needle was brought horizontal and using a tenting – advance motion the needle was advanced to its entire length. The applicator button was depressed and Nexplanon rod remained in place after the device was removed. The rod was palpated in place subdermally by both the physician and the patient. Minimal bleeding. The patient tolerated the procedure well. A Steri-strip and gauze dressing was applied over the insertion site and a pressure dressing was applied over the area. Post procedure instructions & precautions were given, including: keep compression dressing in place for 24 hours, then keep area clean and covered (with Band-Aid or gauze dressing) until healed, usually 3-5 days. Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills, the implant comes out or you have concerns about its location, or you have a positive pregnancy test or suspect you might be pregnant. Patient instructed to use a back-up form of birth control for 7 days past insertion date. Wallet card given.

Patient informed replacement date is three years from today.

Posted in Procedures

IUD Insertion

Consent Form:

Patient Handouts

Ensure Patient is Not Pregnant

Equipment List

  1. IUD device
  2. Sterile gloves (2 pair)
  3. Chux Pads (3)
  4. Exam-room sheet (1 sheet)
  5. Sanitary Pad (1)
  6. Pipelle (1)
  7. Os Finder (1)
  8. Speculum (1 each size)
  9. Speculum Light (1)
  10. Sponge Forceps (1)
  11. Curved Scissors (1)
  12. Tenaculum (1)
  13. Iodine swabs (5)
  14. Foxtail Swabs (10)
  15. Surgical Lubricant (2)

Procedure Note

IUD INSERTION

Before the procedure the risks and benefits were discussed, including the risk of bleeding, expulsion or migration of IUD, uterine perforation or embedding in the uterine wall, and infection. Patient voiced understanding and desire to proceed. Timeout performed (time documented on paper timeout form).

The speculum was inserted and the cervix was identified. Betadine was applied to the cervix and cervical os. Tenaculum was applied to anterior/superior cervix. Os Finder was inserted to gently dilate the cervix, and pipelle was used to sound the depth of the uterus. Depth measured at _ centimeters. The intrauterine device was inserted and deployed per manufacturer instructions. The string was cut to 3 centimeters length and a sample of the remaining string was given to the patient for later comparison. The patient tolerated the procedure well, without significant signs or symptoms of vasovagal responses. EBL less than _ ml. Standby present throughout the procedure including any pre-procedure examinations: _.

The patient was given the patient handout and card for the specific device and lot number of inserted device. The patient agrees to return for fever, severe lower abdominal cramping, heavy bleeding, or purulent discharge. The patient was counseled on how to check the strings herself to ensure the IUD has not been displaced, ind instructed to return for a post-placement exam if desired.

Posted in Procedures

Reasonable certainty a woman is not pregnant

For the purpose of starting birth control

  1. No symptoms or signs of pregnancy, and
  2. Any one of the following:
    1. ≤7 days after the start of normal menses.
    2. No had sexual intercourse since the start of last normal menses.
    3. Been correctly and consistently using a reliable method of contraception.
    4. ≤7 days after spontaneous or induced abortion
    5. Within 4 weeks postpartum.
    6. Fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority ≥85% of feeds are breastfeeds), amenorrheic, and <6 months postpartum.

Should you wait to start birth control?

In situations in which the health-care provider is uncertain whether the woman might be pregnant, the benefits of starting the implant, depot medroxyprogesterone acetate (DMPA), combined hormonal contraceptives and progestin-only pills likely exceed any risk; therefore, starting the method should be considered at any time, with a follow-up pregnancy test in 2-4 weeks. For IUD insertion, in situations in which the health-care provider is not reasonably certain that the woman is not pregnant, the woman should be provided with another contraceptive method to use until the health-care provider can be reasonably certain that she is not pregnant and can insert the IUD.

When starting a new form of birth control, if >5 days after menses started, use back-up method or abstain for 7 days. Exception: Copper-containing IUDs are immediately effective.

Documentation

Pregnancy was reasonably excluded based on the patient having no symptoms or signs of pregnancy and:

  • [_] ≤7 days after the start of normal menses.
  • [_] no sexual intercourse since the start of last normal menses.
  • [_] been correctly and consistently using a reliable method of contraception.
  • [_] ≤7 days after spontaneous or induced abortion
  • [_] within 4 weeks postpartum.
  • [_] fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority ≥85% of feeds are breastfeeds), amenorrheic, and <6 months postpartum.

Reference:

Posted in Procedures

Colposcopy

Reference

Link: IARC Atlas of visual inspection of the cervix with acetic acid for screening, triage, and assessment for treatment.

Patient Information

Documentation

Colposcopy Biopsy Equipment List

  1. Colposcope (1)
  2. Colposcopy Biopsy Punch (3, preferably of different sizes)
  3. Kevorkian Endocervical Curette (1)
  4. Endocervical Speculum (1)
  5. Sponge Forceps (1)
  6. Labels with patient information (10)
  7. Nitrile Exam Gloves (2 pair each)
  8. Exam-room sheet (1 sheet)
  9. Chux Pads (4)
  10. Speculum (3 total: 1 white, 1 green, 1 blue)
  11. Lubricant Gel Packet (5)
  12. Pipelle (1)
  13. Formalin cups, in a row (4 cups)
  14. Foxtail Swabs (at least 15 or more)
  15. Sterile CTA (6 packages with 2 swabs each)
  16. Monsel’s solution (1 bottle)
  17. Acetic acid (1 bottle)
  18. Normal saline (1 bottle)
  19. Sterile urine cups (4 cups)
  20. Sanitary Pad (1)
  21. Iodine, either:
    • Lugol’s iodine (1 bottle), preferred Lugol’s is a solution of elemental iodine (5%) and potassium iodide (KI, 10%) together with distilled water.
    • Povidone iodine sticks (10) Povidone-iodine is a chemical complex of povidone, hydrogen iodide, and elemental iodine.

Procedure Note

COLPOSCOPY

Pre-procedure counseling and consent: Possible limitations and risks include pain, bleeding, infection, complications from anesthesia, partial success requiring repetition of procedure. Procedure-specific risks discussed. Peri-operative risks, benefits, and limitations discussed and understood – Patient wished to proceed. Patient was awake throughout the entire procedure. TIME OUT: performed, time is documented on consent form. Patient was identified using full name plus any suffix and DOB. Patient was evaluated and medical record reviewed to include medical history and laboratory findings, if ordered. Radiographs are not applicable to this procedure. Procedure and site/side matches the consent form. Patient/Legal Guardian awake throughout the procedure and was involved in the site/side marking. Final time out: Physician paused to verify that this is the correct patient, procedure and site/side when applicable. Physician verified the patient is positioned correctly for the procedure, and all necessary equipment is available.

External genitalia examined, Bartholin’s and Skene’s glands examined. Visual peri-rectal exam performed.

Bimanual exam performed, uterus palpated for position, size, and tenderness. Ovaries palpated for position, size, tenderness, symmetry.

Speculum inserted, vagina visually examined with attention for color, discharge, tone, and on vaginal mucosa for lesions, evidence of genital warts, or other abnormalities.

The cervix was identified. The entire transformation zone and squamocolumnar junction were visualized. Initial observation of the cervix was performed, with attention for abnormal vessels and annotation of visible lesions. Observation of cervix with acetic acid solution, with attention to visualization of entire squamocolumnar junction, and any visible lesions. Observation of cervix with Lugol’s iodine solution to clearly demarcate the squamocolumnar junction.

MODIFIED RCI: _
Color: _
Lesion margin and surface configuration: _
Vessels: _
Iodine staining: _

Pap smear _ performed.
Endocervical curettage was _ performed.
Endometrial biopsy was _ performed.

At conclusion of the procedure no further bleeding was noted. EBL _ mL. No complications.

Modified Reid Colposcopy Index (RCI)

Colour

0

  • Low-intensity acetowhitening (not completely opaque).
  • Indistinct acetowhitening.
  • Transparent or translucent acetowhitening.
  • Acetowhitening beyond the margin of the transformation zone
  • Pure snow-white color with intense surface shine.

1

  • Intermediate shade – grey/white color and shiny surface (most lesions should be scored in this category).

2

  • Dull, opaque, oyster white or grey.

Lesion margin and surface configuration

0

  • Microcondylomatous or micropapillary contour.
  • Flat lesions with indistinct margins.
  • Feathered or finely scalloped margins.
  • Angular, jagged lesions. Score zero even if part of the peripheral margin does have a straight course.
  • Satellite lesions beyond the margin of the transformation zone.

1

  • Regular-shaped, symmetrical lesions with smooth, straight outlines.

2

  • Rolled, peeling edges. Epithelial edges tend to detach from underlying stroma and curl back on themselves. Note: Prominent low-grade lesions often are over-interpreted, while subtle avascular patches of HSIL can easily be overlooked.
  • Internal demarcations between areas of differing colposcopic appearance. For instance a central area of high-grade change and peripheral area of low-grade change.

Vessels

0

  • Fine/uniform-calibre vessels closely and uniformly placed. At times, mosaic patterns containing central vessels are characteristic of low-grade histological abnormalities. These low-grade-lesion capillary patterns can be quite pronounced. Until the physician can differentiate fine vascular patterns from coarse, over-diagnosis is the rule.
  • Poorly formed patterns of fine punctation and/or mosaic.
  • Vessels beyond the margin of the transformation zone.
  • Fine vessels within microcondylomatous (tiny warts) or micropapillary lesions. Generally, the more microcondylomatous the lesion, the lower the score. However, cancer also can present as a condyloma, although this is a rare occurrence.

1

  • Absent vessels.

2

  • Well defined coarse punctation or mosaic, sharply demarcated and randomly and widely placed. Branching atypical vessels indicative of colposcopically overt cancer are not included in this scheme.

Iodine staining

0

  • Positive iodine uptake giving mahogany-brown color.
  • Negative uptake of insignificant lesion, i.e., yellow staining by a lesion scoring three points or less on the first three criteria.
  • Areas beyond the margin of the transformation zone, conspicuous on colposcopy, evident as iodine-negative areas (such areas are frequently due to parakeratosis – a superficial zone of cornified cells with retained nuclei.)

1

  • Partial iodine uptake – variegated, speckled appearance.

2

  • Negative iodine uptake of significant lesion, i.e., yellow staining by a lesion already scoring four points or more on the first three criteria.

Final Score: Colposcopic prediction of histologic diagnosis using the Reid Colposcopic Index (RCI)

0 – 2: Likely to be CIN 1

3 – 4: Overlapping lesion: likely to be CIN 1 or CIN 2

5 – 8: Likely to be CIN 2-3