1 Paracervical block (see Chapter 173, Paracervical Block, for additional information) is a simple, safe, and effective means of providing local anesthesia for abortion in the office setting (Fig. 127-5). The technique can vary, including the site of injection, type of anesthetic, and quantity of solution injected. Most clinicians limit the total amount of 1% lidocaine injected to 20 mL (or 0.5% lidocaine to 40 mL) to avoid lidocaine toxicity.

Figure 127-5 Paracervical block technique. “X” marks the locations where submucosal injections can be made. Ten milliliters of local anesthetic (1% lidocaine or 2% chloroprocaine) are injected with a 22-gauge needle into four sites at the 3, 5, 7, and 9 o’clock positions. (Some clinicians prefer to inject in the 4 and 8 o’clock positions only.) Ideally, the injection should be given submucosally, near the junction of the cervix and vagina. The injection should be superficial enough to raise a bleb or wheal under the mucosa. Because the area is vascular, care must be taken not to inject the anesthetic directly into a vessel. The tenaculum may be used to elevate the cervix and hold it to either side for better exposure of the injection sites.

Cervical Preparation

The cervix may be dilated mechanically with plastic or metal dilators, or with the assistance of preprocedural prostaglandins such as misoprostol. Prostaglandins cause softening and dilation of the cervix as well as some uterine cramping. Misoprostol is the prostaglandin of choice because it is inexpensive, stable at room temperature, and effective in a variety of dosing routes, and has been shown to be effective in first-trimester abortion. Several studies show that misoprostol, given vaginally, is more effective than given orally; buccal and sublingual dosing have also been documented as effective, but they both have more unwanted side effects than the vaginal route. Studies examining various doses found that 400 µg (vaginal or sublingual) is most effective and that higher doses were not necessary. Although not well studied, 400 µg by the buccal route is a commonly used alternative. Optimal dosing occurs when misoprostol is given 2 to 4 hours before the procedure; however, administration as late as 1 hour before the procedure can be helpful with cervical softening. Patients commonly experience some cramping and bleeding before the actual surgical procedure with this drug.

Laminaria is an option for dilation but it is less popular because it requires two visits to the office (Fig. 127-6). Some clinicians routinely use misoprostol for all women undergoing uterine aspiration in the outpatient setting regardless of gestational age. Other providers prefer laminaria for primiparous women over 10 to 12 weeks and multiparous women with an estimated gestational age of 12 weeks or greater. The Society of Family Planning guidelines for first-trimester abortion state that cervical ripening be considered for all adolescents and is recommended for any women at 12 to 14 weeks or if an initial attempt at dilation has been unsuccessful.