THE QUINACRINE METHOD PROCEDURE MANUAL
CHAPTER 3 The Procedure
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 Learning ObjectivesAt the end of this lesson, you will be able to:
PrerequisitesBefore being trained to perform Quinacrine sterilizations, a provider must have:
In case of the accidental insertion of quinacrine or a cannula or sound into a pregnant uterus, it is also recommended that the provider be able to perform menstrual regulation or have ready access to a facility which can. Equipment needed to perform a QSUnlike surgical sterilization, QS can be performed in a number of settings. To provide a quinacrine sterilization in your clinic, you need the following pieces of equipment. Other similar equipment can be substituted, depending on what is available.1. A vaginal speculum. A bivalve, Graves or Pederson model, is recommended so that you can have both hands free. You will need three sizes: small, medium and large. If these are unavailable, other types can be used. However, other types of specula may require the assistance of a second person. 2. A tenaculum 3. A pair of gloves 4. Betadine (or any other locally available antiseptic) 5. A sponge stick or gauze 6. Lubricant - to make insertion of the speculum easier and more comfortable. (This is recommended, though not absolutely necessary.) 7. A 4 mm Karman cannula, or flexible sound, with easy-to-read measurement markings to measure the length of the uterus. 8. A Quinacrine inserter with 7 pellets (252 mg of quinacrine hydrochloride). In some places, quinacrine pellets are sold separately from the inserter. If this is the case in your clinic and you intend to use the inserter more than once, you must make sure that the inserter is high level disinfected and dry. You will also need to wear sterilized gloves while loading the inserter. To load the inserter, first remove the plunger, then with gloved hands, place the quinacrine pellets into the end. Then push the plunger back in position until the first pellet is at the tip of the sheath. 9. Ibuprofen tablets. Recommendations vary. Most recommend that the client be given 800 mg of ibuprofen orally 2 hours before the procedure to reduce abdominal cramping and prevent tubal spasm. Others recommend that an antiprostaglandin be given for the days following the procedure as needed for pain.  The Quinacrine InserterA Copper-T IUD inserter can be modified into a quinacrine inserter. It is best that this modification be commercially prepared because it requires technical support and training. Complete specifications for the modification can be obtained from Center for Research on Population and Security (CRPS), P.O. Box 13067, Research Triangle Park, NC 27709 USA.The prepared inserter must be cold sterilized and dried. Drying is usually accomplished with an alcohol rinse and air drying. Then it must be stored in a sterile container. It must be used within one week. (Packaged loaded inserters are sterilized with ethylene oxide gas or gamma radiation.) Taking a Client HistoryWhen the client arrives at the clinic for a QS, greet her, review her record, make sure that she has been properly counseled and that you have received her informed consent. Each clinic usually has some sort of patient record which they use to collect the following information, if it has not already been done.(1) Demographic information. This includes: her age; education; the number of living children she has and the age of her youngest child. (2) Medical history. This would include the following medical conditions:
(3) A brief physical exam, unless performed within the last week. This would include a brief check of the heart, lungs, abdomen, pulse and blood pressure. ContraindicationsThere are eight conditions that should prevent or delay a quinacrine sterilization. These are:
Quinacrine should never be inserted in a pregnant uterus because of the risk of incomplete abortion or congenital malformations of the fetus. See Appendix D for information on how to be reasonably sure that your client is not pregnant. In the case of severe cervicitis, pelvic inflammatory disease, purulent discharge or other severe infections in the genital tract, the woman should be treated, given a temporary method of contraception and counseled to return to the clinic at a later date, depending on the severity of the infection. In the case of active vaginal bleeding, insertion should not be done and a diagnosis of the cause of bleeding should be made. If a tumor is found in the reproductive tract, rule out malignancy. Then evaluate whether it is causing harm or would interfere with a QS. In the case of a severe uterine distortion, it may be difficult or impossible to insert the quinacrine at the top of the fundus, and consequently, the liquid quinacrine may not flow into the fallopian tubes. If this is the case, the woman should be counseled on other more appropriate contraceptive methods. If the woman is postpartum, she must wait at least six weeks after delivery for her uterus to return to its normal size and shape. The same is true for a woman who is postabortion, if the abortion occurred in the second or third trimester. If it occurred in the first trimester and without complications, she may have a QS after her next menstrual period. To prepare for the procedure, ask the client:
When it is time to begin, ask the client to lie on her back on a clean, comfortable table with legs bent and apart, and buttocks at the end of the table. Always inform your client about what you intend to do, before you do it. The Bimanual Pelvic ExamBefore performing a quinacrine sterilization, you will first do a bimanual pelvic exam. Because one prerequisite for performing a QS is having done 100 bimanual exams, we will not discuss this at length here.There are three primary pieces of information you need from the bimanual exam in order to perform a QS. Without this information, you run a much higher risk of misplacing the quinacrine, and subsequently, resulting in method failure. 1) Contraindications which are not readily apparent or of which the client is unaware. These include pregnancy, severe cervicitis, purulent discharge, and distortion of the uterine cavity. These will be discussed further in the next section. 2) Position of the uterus. Is the uterus anteverted? midposition? or retroverted? This will tell you which direction to guide the inserter. In previous clinical trials, incorrect insertion of either a quinacrine or an IUD inserter has sometimes resulted in perforation of the uterus and bleeding - because the provider guided the inserter in without regard for the direction in which the uterus was positioned. If the uterus is ante- or retroverted, you will need to use the tenaculum to draw the anterior lip of the cervix down in order to align the uterus for the insertion. If an ante- or retroverted uterus is not detected before the insertion, the provider may incorrectly assume that they are placing the pellets at the top of the uterus, when in fact, they are placing them in the lower uterine segment or in the cervical canal.  3) The approximate length of the uterus. With this information, you will be able to assess the location of the fundus (the top of the uterus) where the pellets must be placed. Incorrect placement of the quinacrine pellets (in other words, placement of the pellets too low) is probably the single greatest cause of method failure. The ProcedureOnce contraindications that may be found during the bimanual have been ruled out, you can move on to the procedure.The quinacrine nonsurgical sterilization procedure involves 10 steps, and is very similar to an IUD insertion. As mentioned before, a complete QS requires two visits to the clinic, one month apart, to receive an insertion of 252 mg of quinacrine hydrochloride per visit. Each step should be performed carefully, gently and slowly. Studies suggest that if the endometrium tears and bleeds, then the blood prevents the action of the quinacrine on the fallopian tubes. At any sign of fainting, stop the insertion and place a cool, wet cloth on the client's forehead. Allow the client to rest and remain lying down to ensure adequate blood flow. STEP 1 Select a speculum of the appropriate size and warm it with clean warm water. Then gently guide the clean speculum into the vagina. Open the blades after full insertion and maneuver the speculum so that the cervix comes into full view. Secure the speculum with the blades open by tightening the thumb screw. STEP 2 Inspect the cervix and note the color of the cervix, its position, any ulcerations, nodules, masses, bleeding, cervicitis or purulent (yellow, foul-smelling) discharge. If you notice any contraindications for quinacrine sterilization which were not noted earlier, discontinue the procedure, and follow the management suggestions recommended under "Contraindications". Some women may exhibit symptoms of a moderate infection (for example, a rose-colored cervix, discharge, or the appearance of erosion), however this is quite common in women who have had a number of children. STEP 3 Using a sponge stick, clean the cervix and vagina with an antiseptic. STEP 4 Gently apply the tenaculum to the anterior lip of the cervix. This instrument is used to stabilize the cervix. In the case of an anteverted or retroverted uterus, the tenaculum is used to apply traction so that the cervical canal is aligned with the uterine cavity. This makes it easier to pass the inserter to the uterine fundus. Your client may feel slight discomfort. Ask her if she is all right, and assure her that this will be the most uncomfortable part of the procedure. STEP 5 Measure the length of the uterus. This is the most important step. Correct placement of the quinacrine is crucial to the success of this procedure. Carefully guide the 4 mm Karman cannula or flexible sound into the cervical canal. You may feel some resistance when the cannula reaches the internal os. Look at the cannula marks, and judge, from the bimanual, whether you are indeed up to the fundus (the top of the uterus) or only at the internal os. If you believe the cannula is at the internal os, continue to gently maneuver the cannula further. The uterus is approximately 7 to 7.5 cm long in its nonpregnant state. STEP 6 Examine the markings on the cannula or sound and note this compared to the uterine length - as estimated during the bimanual pelvic exam. Once you believe that the end of the cannula has reached the top of the uterus (or fundus) note the measurement to the external cervical os. If the uterus and cervix measure more than 8 cm long, then you should suspect pregnancy or a pathologic condition (e.g. fibroids), and discontinue the procedure until pregnancy is ruled out. A normal uterine cavity is around 4 cm long. The cervix can measure 3 cm or more, if the woman has had many children. If at any time you suspect you have perforated the uterus, withdraw the cannula or inserter and discontinue the procedure. Follow the guidelines for perforation listed under "Management of side effects or complications" in Chapter 5. STEP 7 Remove the cannula or sound and measure it against your loaded quinacrine inserter. Set the stop of the quinacrine inserter 1/2 cm less than the combined length of the uterus and cervix. In other words, the quinacrine inserter will reach 1/2 cm from the top of the uterus. STEP 8 Guide the inserter gently through the cervical canal until the preset stop is at the external cervical os. Holding the outer sheath of the inserter steady, gently advance the plunger until all the pellets are deposited at the top of the uterus. DO NOT withdraw the sheath while pushing in the plunger (as you would during an IUD insertion.) This may result in some Quinacrine pellets being placed low in the uterus and will not be effective. STEP 9 Once all the pellets are expelled, gradually withdraw the inserter with the plunger in place. STEP 10 Gently detach the tenaculum. There may be bleeding at the site of application of the tenaculum to the cervix. Reassure the woman that this blood is not coming from the uterus. If available, apply a silver nitrate stick to the bleeding site or maintain some pressure on it with a clean gauze or cotton ball. Immediate Post-procedureAdvise the client to lie down for 1 hour following the insertion. You can provide an analgesic to ease the cramping and pain associated with the procedure.Important. The administration of any immunization or medication, including the insertion of quinacrine, may cause an anaphylactic reaction, though rarely. Two cases of severe allergic reaction have been reported following the second insertion of quinacrine among the more than 125,000 users of QS. Both patients had a full recovery and left the clinic healthy because their clinicians were prepared to deal with this reaction. All clinicians who administer quinacrine should be trained in responding to acute anaphylaxis. A review of the symptoms and treatment appear in Appendix E. Common Insertion MistakeIn its first experimental stages, the Quinacrine sterilization technique was based on the Copper-T IUD insertion procedure. This insertion technique was soon found, however, to be significantly less effective. In the IUD insertion technique, the inserter is introduced up to the fundus of the uterus. Then, rather than holding the outer sheath steady and depositing all the pellets at the fundus of the uterus, the sheath is slowly pulled back.As seen in the diagrams below, this deposits the pellets in a line down the uterus. Consequently, the majority of the pellets are not near the openings of the fallopian tubes and the chance of occlusion of the tubes is reduced. | ||
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Case Study IVProvider X performs a QS in the following way:She picks the cleanest speculum and begins to open the blades as she inserts it into her client's vagina. After she notices a little bleeding coming from the cervix, she attaches the tenaculum. She then inserts the quinacrine inserter until she feels the fundus. Holding the plunger steady, she gently pulls the outer sheath down to release the pellets. She withdraws the inserter, detaches the tenaculum and ask the client to lie down for 15 minutes. Has she performed the QS procedure in an incorrect way? List some of the mistakes she has made and rewrite the steps of a QS according to the correct method/technique. | ||