· Web view Explain: The figure on this slide includes a list of contraceptive methods, arranged from the most effective method at the top to the least effective

The Training Resource Package for Family Planning Vasectomy Module

Vasectomy (Male Sterilization): Session Plan

Notes to Facilitator:

The slides and session plan provide presentation support for conveying technical information and for conducting the interactive learning activities. Case studies and role plays help reinforce the learning process.

To use this presentation most effectively, please: Read the Vasectomy (Male Sterilization) Facilitator’s Guide, on the Using the Training Resource

Package tab, for guidance on selecting and adapting TRP materials for the learning needs of your audience.

Next, read this session plan, which includes detailed learning objectives for this module and describes how to use this presentation and other materials required to prepare for and conduct the learning activities.

Training Process ResourcesSession I: Characteristics of Vasectomy (Male Sterilization)Session Objectives:

Introduce participants to the course and have them complete the knowledge assessment By the end of the session, participants will be able to describe the characteristics of vasectomy in

a manner so that the client can understand the following:

Welcome and Introduction (5 min.)• Greet participants and introduce yourself.• See the Conducting Training tab in the TRP website (available at:

http://www.fptraining.org/content/conducting-training) for ice breaker options.

Discussion (10 min.)

• Ask participants to briefly state their expectations from the course and have one of the cotrainers list these on a flipchart.

• State that during this course, the participants will learn how to counsel clients, evaluate clients for eligibility, and perform vasectomy and provide necessary follow-up support. The training will include working in groups, discussing case studies, role plays, demonstrations, model practice, and clinical practice in the clinical area. Throughout the learning process, their knowledge and skills will be evaluated.

• Present the training objectives and discuss these with reference to the listed expectations.

• Present the training schedule and review the training materials that participants will receive or have received.

• Discuss workshop norms and list them on a flipchart (to be hung somewhere clearly visible for the period of the workshop).

• Discuss administrative and logistics issues related to the training.

Basic Slide Set Session I: Slides 2-4

Conducting Training Tool: Icebreaker Options

Conducting Training Tool: Illustrative Training Schedule

Last revised: 15 August 2018 Page 1 of 78

http://www.fptraining.org/content/conducting-training

The Training Resource Package for Family Planning Vasectomy ModulePretest Questionnaire(30 min.)

Distribute the questionnaires and review the instructions.

Inform participants that they are not supposed to write their names on the prestest, but numbers that will be distributed, and they should remember those numbers and use the same in the posttest.

At the end, collect the questionnaires and score or mark them, then prepare a summary for presentation at an appropriate time during the training.

Evaluation Tool: The Vasectomy (Male Sterilization) Pretest (including the answer key for scoring or marking)

Session ObjectivesPresentation (5 min.)<Display Slide 5>

Present the objective of Session I.

Ask if there are questions, and answer these, as needed.

Basic Slide Set Session I: Slide 5

What Is Vasectomy? Key Points for Providers and ClientsPresentation and Discussion (5 min.)<Display Slide 6>

Ask the participants: “What is vasectomy?” Allow 2–4 participants to answer.

Explain:

Vasectomy is a permanent method of contraception for men who do not want to have any more children. The method involves a safe, simple, and short surgical procedure performed on the scrotum. Through a puncture on the scrotum, the provider locates each of the tubes that carry the sperm (also called the vas deferens) and divides and blocks them by tying them closed. The blockage may also be achieved by applying heat or an electric current (also known as cautery).

Because the procedure is permanent, vasectomy cannot be reversed.

The procedure requires a trained provider and should be performed in the right settings—within a health facility or clinic, or in other settings with the necessary equipment and supplies to ensure quality of care.

Two types of approaches have been described, the conventional or incisional surgical approach to vasectomy and no-scalpel vasectomy (known as NSV). Both approaches are quick, effective, and safe. Conventional vasectomy requires the use of a scalpel to access the vas; the incision is therefore wider when compared with NSV, in which the surgeon uses two special instruments to access the vas. There is also less risk of hemorrhage and other related complications than with conventional vasectomy. Conventional vasectomy is no longer the recommended technique.

The key points for providers and clients to remember about vasectomy include:

o The method is intended to be permanent, and therefore reversal is not usually possible. It is a method for men or couples who will not

Basic Slide Set Session I: Slides 6-7: What Is Vasectomy? and Key Points for Providers and Clients



want any more children in the future.

o Vasectomy is one of the most effective contraceptive methods.

o Vasectomy requires a trained provider with the necessary skills to safely perform this simple procedure.

o The contraceptive effects are delayed, however, and the client or couple must use another contraceptive for a period of three months after the vasectomy.

o Vasectomy does not affect the man’s sex drive or sexual performance. It is not castration. The man also still ejaculates in the same way as he did before the procedure, and vasectomy does not make the man feminine.

o Vasectomy does not protect the man against STIs, including HIV. For protection against HIV and other STIs, a man should use condoms.

Effectiveness of VasectomyPresentation and Discussion (5 min.)<Display Slide 8>

Explain:

The figure on this slide includes a list of contraceptive methods, arranged from the most effective method at the top to the least effective method at the bottom.

In this list, spermicides are the least effective method, while the most effective methods are female sterilization, implants, and intrauterine devices (IUDs).

Ask the participants: “Where would you put vasectomy on this list?” After participants respond, click the mouse to reveal the answer.

Conclude by emphasizing that vasectomy is in the top tier of methods, as it is a very effective method of contraception, but like other methods of contraception, it carries a small risk of failure.

Basic Slide Set Session I: Slide 8: Effectiveness of Vasectomy

Handout # 1: Comparing Effectiveness of Family Planning Methods

Handout # 2: If 100 Women Use a Method for One Year, How Many will Become Pregnant?

Relative EffectivenessPresentation (5 min.)<Display Slide 9>

Explain: There is another way to look at effectiveness. In this slide, we look at

how effective family planning (FP) methods are as they are commonly used.

The slide shows the number of women who would get pregnant if 1,000 women used a method for one year. So, if 1,000 fertile women were having sex but not using any protection from pregnancy, 850 of them would become pregnant within one year.

Vasectomy is not fully effective for three months after the procedure.

Basic Slide Set Session I: Slide 9: Relative Effectiveness of FP Methods



Where men cannot have semen examined three months after the procedure to see if it still contains sperm, pregnancy rates are about 2–3 per 1,000 women over the first year after their partners have had a vasectomy. Where men are able to have their semen examined after vasectomy, the pregnancy rate is less than one pregnancy per 100 women over the first year after their partners have had vasectomy (approximately two per 1,000).

On this slide, if the same 1,000 women were using male sterilization, 1.5 would become pregnant.

As part of good counseling, it is important to inform clients about how effective each method is.

Ask the participants: “What if these same women were using a female condom? How many would become pregnant?” Answer: 210 women would become pregnant.

Explaining How the Vasectomy WorksPresentation and Discussion (5 min.)<Display Slide 10>

Explain:

Male sterilization works by closing off each vas deferens, thus blocking the flow of sperm into the semen. The semen continues to be ejaculated, but it cannot cause pregnancy because it contains no sperm.

The onset of the contraceptive effect is not immediate, however. It takes up to three months for the sperm that are within the vas deferens above the blocked section to be ejaculated.

Ask: “How would you explain to a client how vasectomy works without using medical terms?” Allow a few responses.

Explain:

Vasectomy works by keeping sperm out of semen. This is achieved by cutting and closing off the tubes that carry the sperm. Semen is ejaculated as usual, but it cannot cause pregnancy.

Ask if there are any questions and respond to these as needed.

Basic Slide Set Session I: Slide 10: Vasectomy: Method of Action

Characteristics of Vasectomy (Male Sterilization)Presentation and Discussion (5 min.)<Display Slide 11>

Ask: “What are some of the characteristics of male sterilization?” Allow a few responses, then advance the slide to display the characteristics.

Explain:

The characteristics of the vasectomy (male sterilization) method include the following:

1. The method must be offered by a trained health care provider and involves a simple surgical procedure.

Basic Slide Set Session I: Slide 11: Characteristics of Vasectomy (Male Sterilization)



2. The procedure is much simpler than female sterilization.

3. No user action is required after the procedure takes effect.

4. The procedure can be performed at any time the man makes an informed and voluntary decision to have the procedure.

5. During the procedure, the man remains awake; after the procedure, he may experience some discomfort or pain during recovery.

6. The client may be required to do serial semen analysis to verify the lack of spermatozoa in the semen after the procedure.

7. Vasectomy is not generally reversible. In developed countries, vasectomy reversal is available; however, such services are costly, and success is not guaranteed.

Other characteristics are:

1. Male sterilization is one of the most effective FP methods. The method carries a small risk of failure. This risk of failure remains the same beyond the first year after vasectomy.

2. The method is also not effective in the first three months after the procedure. Men should use the condom or have their spouse use another effective FP method to avoid pregnancy during this period.

3. Some of the reasons for failure include not following instructions to use another method in the first three months, a mistake made by the provider, or the cut ends of the vas growing back together.

4. Male sterilization is safe and convenient, and it has fewer side effects and complications than many of the methods used by women.

5. This method does not offer any protection against STIs or HIV.

Allow some time for questions or comments from participants.

Health Benefits, Non-Health Benefits, and Risks of VasectomyPresentation and Discussion (5 min.)<Display Slide 12>

Explain:

Some of the non-health benefits of male sterilization are that it is cost-effective, as having the procedure is a one-off event, and there is no need to go back to the clinic for resupply.

The method does not interfere with sex.

This method allows the man to play a significant role in FP.

The method may enhance enjoyment and frequency of sex

The method is very safe, but it carries a small risk of failure.

As a surgical procedure that is done under some form of anesthesia to manage pain, vasectomy carries a small risk associated with pain management drugs and the surgical procedure.

Basic Slide Set Session I: Slide 12: Health Benefits, Non-Health Benefits, and Risks of Vasectomy


The Training Resource Package for Family Planning Vasectomy ModulePossible Side Effects and Complications of VasectomyPresentation and Discussion (10 min.)<Display Slide 13>

Ask: “What are some of the side effects and complications of vasectomy?” Allow as many responses as possible.

Advance to Slide 14 to reveal the list of possible side effects and complications.

Explain:

Male sterilization per se does not have side effects, but the pain management drugs and the surgical procedure may cause:

o Headaches and mild dizziness

o Nausea

o Fever

o Pain

Complications are also uncommon or very rare and may include:

o Injury to other structures of the spermatic cord

o Hemorrhage and formation of a hematoma

o Wound infection, which may lead to formation of a localized abscess

o In the long term, development of sperm granulomas

o Development of antisperm antibodies

o Regret, if the client’s decision was not well-considered

Vasectomy carries a small risk of failure.

Ask if the participants have any comments or questions and respond accordingly.

Basic Slide Set Session I: Slides 13 and 14: Possible Side Effects and Complications of Vasectomy

Vasectomy Fact SheetDiscussion (10 min.)

Have one of the cotrainers to distribute Handout #3: Vasectomy Fact Sheet to all participants.

Refer participants to the fact sheet and explain that they will have a chance to review some of the characteristics of male sterilization again, as these are also covered in the handout.

Introduce the fact sheet as an aid specifically designed to enable the provider to make quick reference to the important characteristics of vasectomy (male sterilization).

Review the content by asking participants to take turns in reading aloud

Handout #3: Vasectomy Fact Sheet



sections of the fact sheet.

Ask if anyone has comments or questions about the characteristics of vasectomy.

Respond to any questions by providing additional explanations and clarifications, as needed. Link the discussions to what you presented earlier in this session.

Inform the participants that some facts in the handout will be discussed later during the course. (You can give examples of these.)

Ask the participants to consider how they might use the fact sheet in their work.

Allow some responses and discuss briefly each response.

Remind the participants that the fact sheet is not intended to be distributed to clients as a source of information on vasectomy.

Wrap up the session by asking participants to find some free time to go through the fact sheet again.

Ask if anyone has comments or questions about the session or related topics and respond to these accordingly.

Session II: Anatomy and Physiology of the Male Reproductive SystemSession ObjectivesBy the end of the session, participants should be able to:

• Describe the male genitourinary anatomy and physiology

• Describe the anatomy of the spermatic cord and its internal structures

• Explain the effects of vasectomy on male reproductive anatomy and physiology

Note to the trainer:

1. Prepare a flipchart with a diagram of the male reproductive system and label the male reproductive organs numerically. Do not write the actual name of each organ. Place the flipchart diagram in the front of the room, where all can see it clearly.

Presentation and Discussion (2 min.)<Display slides 1 and 2>

Present the objectives of the session.

Allow some time for any clarification, if needed.

Basic Slide Set II: Slides 1 and 2: Introduction and Session Objectives

Anatomy of Male Reproductive OrgansPresentation, Exercises, and Discussion (5 minutes)

The purpose of the exercise is to review the functions of the organs of the male reproductive system and their relevance to vasectomy.<Display Slide 3>

Ask the participants to identify all of the parts on this diagram of the male internal and external reproductive system and state one aspect of the identified organ that is relevant to vasectomy, where applicable.

Basic Slide Set II: Slide 3: Anatomy of the Male Reproductive Organs



Inform them that they have four minutes to complete the exercise.

They may use their notebooks to write down their responses.

At the end of four minutes, call all participants together and ask for responses from volunteers.

o Possible responses should include the following:

a. The ureter is an internal organ with no direct anatomical significance for or relevance to vasectomy.

b. The bladder is an internal organ with no anatomical significance for or relevance to vasectomy.

c. The seminal vesicles are structures that continue to produce seminal fluids, which form the bulk of ejaculate after vasectomy.

d. The prostate gland is an internal structure that continues to function normally after vasectomy, producing prostatic fluids that contribute to ejaculatory fluids but that otherwise has no direct relationship to vasectomy.

e. The vas deferentia are internal structures within the scrotum that must be identified, isolated, and excised and ligated during vasectomy, thereby interrupting the flow of sperm and this is what makes vasectomy effective, by three month after the procedure.

f. The epididymis is an internal organ important in the development of the sperm. The surgeon must make the incision in the right place to avoid injury to the epididymis. After vasectomy, these tubules may become engorged with sperm and may rupture.

g. The scrotal sac contains the vas deferens, testis, and spermatic cord, among others, all structures relevant to vasectomy; any scars or deformities, swelling, masses, anomalies of the blood vessels (e.g., varices), or accumulation of fluid are significant and have implications for the planning of the procedure.

h. Both testes must be identified before vasectomy, as the absence of one or both, the locations of these structures, any deformities or swelling, and their mobility will all have implications for the vasectomy procedure.

i. The urethra is the conduit for passing both semen and urine out of the body (during ejaculation and urination, respectively). However, it has no direct relation to the vasectomy procedure. Nevertheless, the surgeon must examine this structure to ensure that there is no evidence of infection or bleeding, etc., as part of the client evaluation.

As the participants share their responses, correct these, as appropriate.

Wrap up the session by stating that during the next session, you will



review some of these anatomical structures in detail.

Male External Reproductive OrgansPresentation and Discussion (3 min.)<Display Slide 4>

Explain:

The two principal external organs of the male reproductive system are the penis and the scrotum.

The penis contains the urethra and specialized, highly vascularized tissue to achieve an erection.

The scrotum is divided into two scrotal sacs, each containing a testis and an epididymis.

Emphasize the following: During vasectomy, a puncture is made in the scrotum to allow the surgeon access to the vasa (ductus) deferentia. The opening is made midway between the base of the penis and the top of the testis, on the median raphe. This puncture site is chosen because (1) it allows easy access to the vasa through the scrotal sac, and (2) it avoids risk of injury to the epididymis and the testicles.

Ask if there are any questions or comments, and provide answers, if necessary.

Basic Slide Set II: Slide 4: Male External Reproductive Organs

Male Internal Reproductive OrgansPresentation and Discussion (5 min.)<Display Slide 5>

Explain:

The male internal reproductive organs consist of three groups—namely, the testis, the ducts, and the accessory glands.

The testes (also called testicles or male gonads) produce sperm and the male sex hormone testosterone. Emphasize that after vasectomy, the testes continue to produce both sperm and hormones.

The ducts group consist of the epididymides, the vasa deferentia, the ejaculatory ducts, and the urethra. The two epididymides (which begin at the testes) are each connected to one of the vasa deferentia. Each vas ends at the base of the prostate, where it is joined by ducts from the seminal vesicle. Together, each vas and duct from a seminal vesicle forms an ejaculatory duct (not pictured). The two ejaculatory ducts open into the urethra to allow the passage of sperm and seminal fluid during ejaculation. You will learn how to palpate the cord to identify and secure the vas using the three-finger technique; with this technique, you can easily feel the vas as a firm cord-like structure by rolling the spermatic cord between your thumb and third finger.

The accessory glands include the seminal vesicles, the prostate, and the bulbourethral glands (not pictured). These glands empty their secretions, which contribute to the seminal fluid, into the urethra. The seminal fluid carries sperm through the urethra during ejaculation. The

Basic Slide Set II: Slides 5, 6, and 7: Male Internal Reproductive Organs



urethra also carries urine.

Use slides 6 and 7 to summarize the male internal and external reproductive organs.

Spermatic CordPresentation and Discussion (5 min.)<Display Slide 8>

Explain:

One of the first steps in vasectomy is to identify the vas deferens, so that it can be anesthetized and occluded. During the injection of local anesthetic and during NSV, care should be taken to avoid the testicular artery and veins located within the internal spermatic fascia.

The vas deferens is located within the spermatic cord. It can be easily palpated and differentiated from other structures in the cord (the spermatic fascia, arteries, and veins), as it is a firm, thick structure within the spermatic cord.

The internal spermatic fascia forms a sheath around the vas and has important structures, such as the blood supply to the vas, which are commonly severed during vasectomy, leading to hematoma formation. The internal spermatic fascia is the sheath or structure that is used to separate the testicular and prostatic ends of the vas by a technique referred to as fascial interposition. You will learn how to perform the fascial interposition later in the course.

The vas is approximately 35 cm long and 2–3 mm in diameter. The small diameter of the lumen of the vas presents the main challenge to vasectomy reversal. Without microsurgical techniques, the success of vasectomy reversal is low (pregnancy rates range from 35% to 57%). Even when microsurgical techniques are used, success is often limited (the success rate of microsurgical techniques is between 38% and 82%).

Basic Slide Set II: Slide 8: Spermatic Cord

Anatomical Conditions of SignificancePresentation and Discussion (5 min.)<Display Slide 9>

Explain:

Anatomical variations are characteristic of the following conditions; if they are diagnosed, the provider may need to take certain precautions or refer the client for specialized care by a highly skilled surgeon. Such conditions therefore, tend to influence where and when the client can have a vasectomy. These conditions include:

o Undescended testis. Ask participants to explain what an undescended testis is. Allow a few responses, then explain that this is a condition where one testis or both testes are located in the inguinal region or in the abdomen, instead of in the scrotum. This occurs when there are problems with the descent of the testis from

Basic Slide Set II: Slide 9: Anatomical Conditions of Significance



the abdomen to the scrotum. Problems during the development process early in life may contribute to the failure of complete descent into the scrotum. If this problem is diagnosed during the client evaluation, the provider should refer the client to a highly skilled surgeon for care.

o Hydrocele. This literally means fluid in the scrotal sac. The condition may be congenital or may be caused by parasitic infestation, among others. If diagnosed with hydrocele, the client must be managed by a skilled surgeon or referred to a facility where he can receive appropriate care and have the vasectomy.

o Inguinal hernia. In this condition, there is a defect in the integrity of the abdominal wall in the inguinal region, leading to partial or complete protrusion of some of the abdominal viscera through the defect. If this problem is identified, it is recommended that the vasectomy procedure and surgery for herniorraphy be planned and performed at the same time.

o Aberrant vas deferens. Although extremely rare, an aberrant vas (or a third vas that is as a result of a congenital anomaly) if not diagnosed during vasectomy may present as a case vasectomy failure.

Physiological Changes after VasectomyPresentation and Discussion (5 min.)<Display Slide 10>

Explain:

• After vasectomy, the male sexual and reproductive physiology remains unaffected, aside from the desired change in fertility.

• Erection and ejaculation are not affected, because the nerves involved in erection are not disrupted during vasectomy. Neither are the seminal vesicle ducts affected, so they continue to function normally. Seminal fluid, which forms the largest part of ejaculatory fluid, continues to be produced. As a result, the client will not notice any reduction in the amount of ejaculatory fluid.

• Emphasize that sperm production continues, even though the sperm’s passage through the reproductive system has been blocked. These sperm are absorbed into the tissue and tubes of the epididymis. You may add that sometimes sperm blockage causes pressure to build up in the epididymis and its tubes, causing these structures to distend and, in time, rupture. Such ruptures are usually asymptomatic and not problematic. The sperm granulomas that can form at the site of the rupture do not usually require treatment. These may be palpable as small nodules.

• Sex drive, which is a physiological process, also is not affected by vasectomy.

• Inform the participants that vasectomy causes a breakdown in the

Basic Slide Set II: Slide 10: Physiological Changes after Vasectomy



blood-testes barrier, which leads to increased levels of sperm antigen and antisperm antibodies in the serum of most men who have had a vasectomy. Factors influencing the development of the antisperm antibodies in vasectomized men are unknown. Studies have shown no association of these antibodies with problems in humans.

Conclude by stating that over the years, some concerns have been raised about possible negative health consequences of vasectomy. However, large, well-designed studies have consistently shown no adverse effects of vasectomy on the risks of heart disease, testicular or prostate cancer, immune system disorders, and a host of other conditions. Men requesting the procedure can thus be reassured that no substantial long-term health risks are associated with the procedure.

Session III: Who Can Have a Vasectomy?

Session ObjectivesBy the end of this session, participants will be able to:

1. State who can have a vasectomy

2. Define the medical eligibility criteria (MEC)

3. List the MEC classification used for permanent methods such as vasectomy

4. Demonstrate an ability to screen a client for eligibility for vasectomy

Notes for facilitator: Secure adequate copies of the national guidelines on FP services for

providers and go through the sections on male sterilization

Review the WHO MEC chapters for permanent methods, particularly male sterilization

Make enough copies of the MEC checklist for vasectomy

Review the case studies

IntroductionPresentation and Discussion (5 min.)<Display slides 1 and 2>

Introduce Session III and explain the overall purpose of this session.

Review the objectives, which are displayed in Slide 2.

Basic Slide Set III: Slide 2: Session III Objectives

Who Can Have a Vasectomy (Male Sterilization)?Presentation and Discussion (10 min.)<Display Slide 3>

Explain:

• Vasectomy is a safe procedure; with proper counseling and informed consent, any man can have vasectomy safely.

• This includes men who

Basic Slide Set III: Slide 3: Who Can Have a Vasectomy?



o Have no children or few children

o Are not married

o Are young

o Do not have permission from their wife or have spousal consent,

o Are at risk of contracting an STI

o Are infected with HIV, regardless of whether they are receiving antiretroviral drugs

• No medical condition would be an absolute contraindication for vasectomy.

• In some situations, men opting to have a vasectomy may need to wait if they have problems in the genital area—for example, ulcers in the genital region, infections, injuries, or swellings or lumps in the penis or scrotum. Men with other systemic health conditions, such as diarrhea, may also need to wait until the condition has resolved following treatment.

• In all instances, careful counseling is important to ensure that the man will not regret his decision to have the vasectomy.

Allow a few minutes for comments and questions, and respond as needed.

Medical Eligibility CriteriaDiscussion and Presentation (5 min.)<Display Slide 4>

Ask: What are the Medical Eligibility Criteria? Allow some responses from the participants.

Explain:

The MEC are one of the World Health Organization (WHO) evidence-based guidelines on contraceptive use. The MEC inform the FP provider if a client with a certain medical or physical condition can use a contraceptive method effectively and safely.

The 5th edition of the WHO Medical Eligibility Criteria was recently launched for use.

At the national level, FP programs develop national guidelines on contraceptive use for service providers.

This national guideline development process is informed by evidence-based publications and resources, such as the latest version of the WHO MEC for contraceptive use.

Ask the participants to: State the MEC categories used for permanent methods of

contraception.

Allow some responses, then explain:

Basic Slide Set III: Slides 4 to 6: Medical Eligibility Criteria

Handout #4: Sections of the WHO Medical Eligibility Criteria (5th ed.) Relevant to Male Sterilization



According to the WHO medical eligibility criteria, male sterilization is classified into four distinct categories:

A = Accept

C = Caution

D = Delay

S = Special


<Display Slide 5>

Explain:

As stated earlier, there are some conditions or circumstances when certain precautions need to be addressed or when the provider needs to delay a procedure to allow time for further evaluation of the condition or treatment of the client.

In a few instances, the client’s health condition may necessitate that the procedure be performed by a highly skilled surgeon and in other clinical settings with additional equipment and supplies (to support use of general anesthesia or other kinds of support that the client may need because of his condition).

The four categories listed earlier are meant to assist the provider in determining when and where the client can have the vasectomy procedure performed safely, depending on the outcomes of an evaluation of his health condition.

The rationale for assigning different conditions to specific categories is based on evidence where theoretical and proven risks are compared to advantages and benefits to the client if sterilization is performed as the contraceptive method of choice.

The procedure should, however, be performed in the right setting, to ensure infection prevention and the availability of all necessary equipment and supplies, as recommended by national and institutional service provision guidelines.

For Category A (Accept), the advantages and benefits of vasectomy outweigh the theoretical and proven risks associated with the vasectomy procedure on the client with the particular condition. There is therefore no reason to restrict the client’s eligibility for vasectomy. The method can thus be provided to all clients who have been counseled and who have opted for vasectomy.

In Category C (Caution), the conditions classified here have elevated theoretical or proven risks, although the advantages and benefits of the vasectomy still outweigh such risks. Certain precautionary measures or extra preparations and precautions are recommended to minimize any such risk. Client with such conditions can have the procedure performed in routine settings, but with extra precautions and



preparations.

In Category D (Delay), the conditions may elevate theoretical or proven risks to the client if the vasectomy procedure is performed. It is therefore recommended that the procedure be delayed to allow for time for the condition to be further evaluated and corrected. At this point, the client can then have the vasectomy, since the advantages and benefits of vasectomy far outweigh the risks after the condition is resolved.

The few conditions that fall in Category S (Special) pose an increased theoretical or proven risk if the vasectomy procedure is performed in routine settings. The risks of complications are minimized if the procedure is performed by an experienced surgeon and staff in clinical settings with the required equipment for anesthesia and other back-up support.

It is important to note that under most circumstances, female sterilization procedures carry higher risks than vasectomy, which is simpler procedure.

We shall now review some of the conditions that are classified in these categories

<Display Slide 6>

Explain:

Category A includes conditions such as sickle cell disease, other chronic ailments (such as mild hypertension), and clients who are at risk of HIV or other STIs.

Category C includes young men who are unmarried or who have no or few living children, clients with mental disorders (including those with depressive disorders); all of these clients require careful counseling, so they understand the permanence of vasectomy. Other conditions in this category include clients with a varicocele or hydrocele (unilateral or bilateral) and clients with diabetes.

Ask if all participants understand what a varicocele or hydrocele is.

Allow a few responses from participants. Possible responses are:

o Varicocele is the abnormal engorgement of the veins/ blood vessels from the spermatic cord and structures within the scrotum.

o Hydrocele is an abnormal accumulation of fluid in a sac within the scrotum.

Category D conditions include any systemic infections, including diarrhea, local infections of the penis and scrotum such as balanitis (an inflammation commonly caused by infection of parts of the penis), scrotal skin infections or ulcers, and STIs—all of which are likely to increase the risks of wound infection and therefore compromise postoperative recovery. Other conditions or chronic infections that may need delays include elephantiasis and intrascrotal mass(es) that may


The Training Resource Package for Family Planning Vasectomy Modulerequire further evaluation.

Category S includes conditions, such as coagulation disorders, which may necessitate special preparation of the client before surgery to ensure that the procedure does not put him at risk. Inguinal hernia is another condition that may be managed by skilled surgeons when they perform a vasectomy, since the vas is also accessible through the inguinal incision. However, unless the hernia is bilateral, the other vas will still need to be accessed and ligated. In cryptorchidism or undescended testis, again the skills of an experienced surgeon may be required to access the vas and, where appropriate, manage the undescended testis.

Distribute copies of WHO MEC for contraceptive use on male sterilization and take some time to orient participants on the listed conditions under each category.

If you had prepared adequate numbers of copies of the National Guidelines on Family Planning for service providers, you should also distribute these and refer participants to the relevant sections, to give them an idea of how different conditions are categorized in the national guidelines.

MEC Checklist for VasectomyPresentation/Discussion (10 minutes)<Display Slide 7>

Begin by introducing the WHO MEC checklist.

Have the one of the cotrainers distribute Handout #5: Medical Eligibility Criteria Checklist for Vasectomy

Refer the participants to the handout, and…

Explain:

The WHO MEC for vasectomy checklist is a simple, easy-to-apply tool developed by WHO to aid the provider in determining a client’s eligibility for vasectomy. This is done by asking the client if he has any of the conditions listed in the MEC. The two-page tool contains a set of questions relating to different medical conditions that are relevant to the procedure. As a health care provider, one should use the aid to ask each client these questions. If the answer to all questions is “no,” then the client can be classified as Category A, and he can have the procedure at any time in routine settings.

Review the content of the tool: The first part is the introductory section, with instructions on how to use the tool and an explanation of all of the MEC categories for vasectomy. Then go through the second part of the tool, which features the actual questions.

If a client responds “yes” to any of the questions, follow the instructions on the tool. These recommend caution, delay, or special arrangements and possible action(s). Elaborate by giving examples

Basic Slide Set III: Slide 7: Understanding the MEC Checklist for Vasectomy

Handout #5: Medical Eligibility Criteria Checklist for Vasectomy



using the tools.

Remind the participants that the client evaluation, which includes a physical examination, is an important complement to the use of the checklist.

Ask if there are any questions or comments, and respond to these as needed.


The Training Resource Package for Family Planning Vasectomy ModuleVasectomy Use by Men with HIVPresentation/Discussion (10 minutes)<Display Slide 8>

Explain:

According the 5th Edition of WHO’s Medical Eligibility Criteria for Contraceptive Use, clients who are asymptomatic or who have a mild form of HIV clinical disease, according to WHO’s classification of HIV/AIDS disease (whether they are on antiretroviral drugs or not) can have the vasectomy procedure in routine settings. WHO’s classification of mild forms of AIDS (also known as clinical stage 2) includes patients confirmed with HIV infection with symptoms such as weight loss of more than 10%, recurrent infections of the respiratory system, recurrent oral lesions, fungal infections of the nails, herpes zoster infections, and skin lesions.

Patients should however be counseled that vasectomy does not protect them against HIV or other STIs and that they should continue consistent use of the male or female condom to prevent infections.

Patients with advanced or severe forms of HIV clinical disease who are on antiretroviral drugs can also safely have a vasectomy, but special arrangements should be in place for this category of clients.

Emphasize that clients with HIV clinical disease, as with all other seronegative male clients, should not be coerced or pressured to accept vasectomy.

Basic Slide Set III: Slide 8: Vasectomy Use by Men with HIV

Client Assessment/EvaluationPresentation/Discussion (10 minutes)<Display Slide 9>

Explain:

A client opting for vasectomy should be further assessed for any health condition to determine his clinical eligibility for the procedure; the outcomes of the assessment also help the provider to determine and discuss with the client when and where the vasectomy will be performed and the type of provider to do so. Emphasize that such an evaluation should be done in a location that ensures that the rights of the client are sustained.

This assessment is conducted through a client-provider interaction in which the health care provider takes a medical history and a family and reproductive history and asks about past medical conditions (including surgery, particularly to the genitalia, for any condition.) Other relevant information about the client gathered in this assessment includes current ailments or acute conditions, such as any systemic infections (e.g., diarrhea) chronic conditions such as diabetes, hypertension, allergies to specific types of medication, coagulation disorders, current or past treatment for mental or depressive illness, and any other conditions.

Basic Slide Set III: Slide 9: Client Assessment/Evaluation



The provider should also inquire about the client’s family history, including his marital status, number of children, future fertility intentions, relations with his spouse, and sexual history, including experience of symptoms indicative of STIs.

Extremely anxious clients may need additional preparations for vasectomy. Those who are young and have no living children may require careful counseling to ensure that they understand that vasectomy is permanent, thus avoiding subsequent dissatisfaction and regret.

A physical examination also forms part of the client assessment or evaluation. The physical examination should be guided by the outcomes of the medical history; however, at minimum, it should include a quick general examination of the client, followed by an essential and mandatory examination of the lower abdomen and the genitalia. The provider should assess the penis and scrotum to determine the ease of palpation of the vas and other structures, such as the testis in the two sides of the scrotal sac; the provider should also inspect for evidence of previous scrotal surgery, injuries to the genitalia, presence of ulcerative conditions or tumor growths, balanitis, scrotal swelling, and presence of varicocele or hydrocele. Providers should also look for signs suggestive of an inguinal hernia and unilateral undescended testis.

Any evidence of active infections, such as diarrhea, balanitis, urethritis, and scrotal skin infections, will require the surgery to be delayed, to avoid wound sepsis and related complications. Difficulties in palpating the vas may necessitate extra preparations for adequate anesthesia and the services of a skilled surgeon. Similarly, clients with inguinal hernia and cryptorchidism or undescended testis may require special attention.

Routine laboratory examination prior to the procedure is not necessary unless the client has a medical condition that requires investigation, such as diabetes, liver or renal disease, or a coagulation disorder.

It is also not necessary to request the client to have a semen analysis prior to surgery. Vasectomy can also be performed even if there is no provision for post procedure semen analysis (e.g., during outreaches or at a mobile clinic, etc.).

The provider-client interaction should also include a discussion of the findings from the assessment and their implications on how to proceed with the selected contraceptive option.

Ask if there are any questions and/or comments, and respond to these, as appropriate.


The Training Resource Package for Family Planning Vasectomy ModuleCase Studies<Display Slide 10>

Group Exercises/Discussions (25 minutes)The purpose of these exercises is to enable participants to learn and demonstrate how to use the MEC to determine clients’ eligibility for vasectomy.

Distribute Handout #5: Medical Eligibility Criteria Case Studies to all participants and inform them that they will now work in pairs, with each pair working on two case studies in the handout.

Help participants form the groups by pairing each up with the participant seated next to him/her.

Allocate each group two case studies and give the following instructions for working on the case studies:

“Each group should read the case study they have been assigned and then discuss the questions that follow. Once they are through with the two questions, they should familiarize themselves with the other case studies. They will have 10 minutes to discuss the case studies; at the end of the group discussions, they will be asked to present their answers to the questions in plenary.”

Allow the groups 10 minutes for the exercise.

At the end of 10 minutes, call the participants to plenary and ask each group to present the case study, first by reading the case and then by giving the answers to the questions. Allow a few minutes of discussion after each presentation. Provide the correct answers and any explanation, as needed. An answer key can be found in Annex D of the facilitator’s guide.

Conclude the session by informing the participants that in most instances, a client may have only one condition that is also clearly classified in MEC, but there will also be instances where a client may have multiple conditions that fit in different categories. In such a case, it is up to the provider to assess the client and determine the course of action. Inform them that they will have an opportunity to observe and practice how to evaluate clients for eligibility during the demonstrations and model and clinical practice sessions later in the training.

Basic Slide Set III: Slide 10: Case Studies

Handout #6: Medical Eligibility Criteria Case Studies

Training Process ResourcesSession IV: Providing Vasectomy

Objective: Demonstrate how to provide no-scalpel vasectomy

Specific ObjectivesBy the end of this session, participants will be able to:

1. State when the client can have the vasectomy procedure


The Training Resource Package for Family Planning Vasectomy ModuleTraining Process Resources

2. Counsel a client for the vasectomy procedure

3. Effectively counter or correct misunderstandings or misconceptions and rumors about vasectomy in the local setting

4. List the side effects and the intraoperative, immediate postoperative, and long-term complications associated with vasectomy

5. Counsel the client about the side effects of vasectomy

6. Describe the management of complications and side effects

Notes to the facilitator:

Collect a sample of the most current written consent forms for permanent methods of contraception and make an adequate number of copies for use during this session.

Review the role play scripts and case studies and discuss with the cotrainers the most appropriate group divisions and how to conduct the role plays and case study sessions.

IntroductionPresentation, Discussion (5 minutes)<Display slides 1 and 2>

Present the objectives as displayed on Slide 2.


Basic Slide Set IV: Slide 1 and Slide 2: Session IV Objectives

Timing of the Vasectomy ProcedurePresentation, Exercises, Discussion (5 minutes)<Display Slide 3>

Ask: “When can a client have a vasectomy?” Allow a few responses, then advance the slide presentation to reveal the answers.

Explain:

The vasectomy procedure can be performed at any time if:

o The client has made the request and is prepared for the procedure.

o No medical condition(s) would require referral, delay, or special precautions.

o There is evidence that the client has made an informed and voluntary decision, including a written informed consent.

o The skilled provider is ready to provide quality vasectomy services.

Clients may need to wait if:

o They have problems with their genitals, such as infection, swelling, an injury, lumps, or ulcers in the penis or scrotum.

o They have systemic infections such as diarrhea, a chest infection, etc.

Basic Slide Set IV: Slide 3: Timing of Vasectomy Procedure



Clients with serious conditions—such as coagulation disorders, inguinal hernia, unilateral undescended testis, large varicocele, or hydrocele—should be referred for further evaluation and management by experienced surgeons at facilities with equipment and supplies for general anesthesia and other support.

Ask if there are any questions or comments and clarify or respond to these as needed.Key Counseling Topics for VasectomyPresentation, Brainstorming, Discussions (5 minutes)<Display Slide 4>

Ask: “What are counseling topics that a provider should discuss with a potential vasectomy user?” Have your co-trainer list them on a sheet of flipchart paper as they are mentioned by participants.

Allow adequate time for the listing of topics. When participants have no more responses, inform them that you will now display what you have prepared.<Advance to Slide 5>

Explain:The following are some of the key counseling topics that the provider needs to cover during a counseling session.

• What the client already knows about this method. This information will assist the provider to tailor the discussions appropriately and, where needed, provide correct and complete information about vasectomy, if the client’s knowledge is incomplete and/or incorrect.

• What vasectomy is and how it works. The provider needs to inform the client what vasectomy is (i.e., that it is a permanent method of contraception for men, that it is a safe, simple, and short surgical procedure, and that it involves cutting and blocking the tubes that carry the sperm to the penis), and how the method works.

• The permanence of the method. The client needs to fully understand the implications of having a vasectomy on his ability to father children in the future. The decision to have a vasectomy should therefore be made after careful consideration.

• Safety and efficacy of the method. The provider should also explain to the client that the procedure is safe and simple and that the client remains awake during the procedure. The method is also one of the most effective methods of contraception; however, the client must understand that the contraceptive action only takes effect after a period of about three months. The client must therefore use other temporary methods, such as condoms, to avoid making his spouse pregnant.

• Health and other benefits. The provider should also explain to the client the health and nonhealth benefits of vasectomy.

Basic Slide Set IV: Slides 4–5: Key Counseling Topics for Vasectomy



• Availability of other FP methods. The provider must explain that the facility offers a full range of contraceptive methods and should describe all of the different methods that are available for the client and his spouse.

Explain:The key counseling topics on vasectomy are

Vasectomy procedure: The provider should discuss the vasectomy procedure with any client who is interested in this method. The discussion should include the following: what the procedure entails; the pain management regimen that will be used; where, how, and by whom the procedure will be performed; what attire the provider and the client will be instructed to wear prior to the procedure; who else may be in the procedure area/room and their roles; what the client may feel during the entire procedure and how he should respond to any pain or discomfort; the time it will take for the provider to complete the procedure; what the client will feel after the procedure; and what will happen in the immediate postoperative period before he is discharged.

Side effects and complications: The provider should also discuss the possible side effects and complications. The client should be informed that while vasectomy has no side effects and that complications are uncommon-to-rare when a skilled provider performs the procedure, in a few instances some complications may occur. Such complications or problems include bleeding during surgery or immediately after the procedure, formation of a hematoma, and pain. Other complications include infections, formation of granulomas, and, in rare instances, failure of the procedure. If the client makes a hasty decision, the client may later regret the vasectomy and seek reversal of the procedure.

Protection against STIs and HIV: The provider should be sure to confirm the client understands that the vasectomy procedure does not protect him from any STIs, including HIV, and that for protection, he will need to use a barrier method such as the male or female condom. The provider will need to help the client assess his risk of contracting any of these infections and advise him accordingly.

Preprocedure and postprocedure instructions: The provider should discuss with the client when and where he will have the procedure, as well as what he needs to do on the day before and on the day of the procedure. Additionally, the provider should discuss with the client when he should expect to be discharged after the procedure and should give instructions on what the client should do during the immediate postoperative period.

Informed consent As a surgical procedure, vasectomy can only be performed if the client voluntarily provides written informed consent for the procedure. The client provides informed consent during counseling. The provider should ensure that all of the client’s concerns and questions about vasectomy have been fully addressed and that the



client is satisfied with the information about the method of his choice before he gives written informed consent.

Ask if there are any questions or comments and respond to these as needed.

Correcting Rumors and Misunderstandings about VasectomyPresentation, Exercise, Discussion (20 minutes)

Notes for the Facilitator:In preparation for the exercise on Slide 6, identify and secure gifts that you want to share with the participants who answer all responses correctly. These gifts should be simple; examples include pens, stickers with a star or other wording as a mark of recognition, sweets, etc.<Display Slide 6>

Ask: “What are rumors and misconceptions or misunderstandings?” Allow a few responses from the participants.

Explain:

A rumor is an unconfirmed story that is normally transferred from one person to another, by word of mouth or by any other means of communication, such as mobile phones or, in some instances, social media.

ExerciseInform the participants that they will now do an exercise by working individually to answer a few questions on rumors. Instruct them to remove a sheet of paper from their notebooks on which to record their responses; at the end of the exercise, they will hand the sheet to their immediate neighbor to be scored. The questions will actually be statements, and it will be up to the participants to decide whether the statement is true or not. The responses should be true/false. Inform the participants that the person who answers all questions correctly will receive a small gift as recognition of their performance.

Make sure that all of the participants are ready before you advance the slide to display the questions.

Reveal the questions one by one and give the participants three minutes to respond.

The statements are:

1. In rare instances, vasectomy may cause testicular cancer.

2. The volume of ejaculate from vasectomized men is always significantly lower than that of nonvasectomized men.

3. Vasectomy causes vascular problems for men, especially those who have chronic hypertension.

Basic Slide Set IV: Slides 6–8: Correcting Rumors and Misunderstandings about Vasectomy

Basic Slide Set IV: Slide 9: Role Play on Correcting Rumors and Misconceptions

Handout #7: Correcting Rumors and Misunderstandings—Role Play Scripts



4. Vasectomy is not castration.

5. Vasectomy does not interfere with manhood or sexuality in any way.

6. It is easier to perform female sterilization on a female client than to perform a vasectomy on a man.

7. Vasectomy makes men obese and weak.

At the end of three minutes, ask the participants to share their sheets of paper with a neighbor to be scored. Advance to Slide 7 to reveal the correct responses. Allow time for scoring, then ask which respondents answered all questions correctly and give prizes to the winners.<Advance to Slide 8>

Explain:In general, rumors arise when:

• An issue or piece of information is of importance to people, but it has not been clearly explained.

• There is nobody available who can clarify or correct the incorrect information by providing facts.

• The original source of the rumors is perceived to be credible.

• Clients have not been given enough information about contraceptive options.

• People are motivated to spread rumors for political reasons.

A misconception or misunderstanding is a mistaken interpretation of ideas or information. If a misconception is imbued with elaborate details and becomes a fanciful story, then it acquires the characteristics of a rumor.

<Allow some time for questions or comments, and respond to these as appropriate.>

State that some misconceptions and rumors include that vasectomy:

• Is castration.

• Makes the man weak.

• Makes the man obese.

• Prevents the man from ejaculating during intercourse.

• Interferes with manhood and sexuality.

• May cause testicular cancer

Ask: “How would you as a provider respond to rumors or misunderstandings during a counseling session?” Allow a few responses, and if they mention all of the steps in the correct order, reinforce by quickly reviewing them again.

Explain:Last revised: 15 August 2018 Page 25 of 78

The Training Resource Package for Family Planning Vasectomy ModuleTraining Process ResourcesThese are the recommended steps for dealing with rumors and misunderstandings:

• Listen carefully and politely. Do not laugh or interrupt the client to give the correct information.

• Define to the client what a rumor or misunderstanding is.

• Find out where the rumor came from, and talk to the people who started it or repeated it. Check whether there is some basis for the rumor.

• Explain the facts.

• Use strong scientific facts about FP methods to counter misinformation.

• Always tell the truth. Never try to hide information about side effects or problems that might occur with various methods.

• Clarify information with the use of demonstrations and visual aids.

• Give examples of people who are satisfied users of vasectomy (only if they are willing to have their names used). This kind of personal testimony is most convincing.

• Reassure the client by examining him and informing him about his current physical condition.

• Counsel the client about all FP methods.

Ask the participants if they have any questions or comments and respond to these as needed.<Advance to Slide 9>

Explain:

Participants will now do a role play on correcting misconceptions and rumors and misconceptions.

Divide the participants into three groups. Separate the three role-play scripts in Handout #6: Correcting Rumors and Misunderstandings—Role Play Scripts and give each group their script for the providers and the clients.

Ask them to decide in their groups who will play the roles of a client and a provider. They should then read through the scripts and practice the role play session so that they are ready to perform it in plenary.

Allow five minutes for the discussions and the practice in groups.

Call all participants back together and ask each group to perform the role play. Allow time for a feedback session after each role play.

Ask if there are any questions, and respond to these as needed.

Points of Informed ConsentPresentation, Discussion (5 minutes)<Display Slide 10>

Basic Slide Set IV: Slide 10: Points of Informed Consent



Ask: “What is informed consent?” Allow a few responses.

Explain:

Informed consent is “a medical, legal, and rights-based construct whereby a client agrees to receive medical treatment, such as surgery for a permanent method of contraception, or to take part in a study, based on knowledge of all appropriate and available options, information about these options, and an understanding of the relevant medical facts and potential risks associated with the methods/treatment options”

The provider should ensure that the client makes a voluntary decision and is not rushed or coerced into giving the written consent.

An informed consent form should be used to secure the signature. Only the man can give written informed consent for vasectomy; spousal consent is not mandatory.

Clients who cannot read or write must initial the informed consent forms after the contents have been explained to them and all of their concerns and questions addressed. In such instances, a witness may also be required to append their signature on the form. The provider who has obtained written informed consent is also expected to sign the form.

Advance the slide and explain that:The information that a client should know about vasectomy before giving informed consent includes the following:

1. Temporary, reversible methods of contraception that they as a couple can use are available.

2. Vasectomy is a surgical procedure.

3. Vasectomy is a permanent method of contraception and therefore irreversible.

4. If the procedure is performed and is successful, the client will not be able to have any more children.

5. Though simple and safe and having some benefits, the procedure carries some risks associated with the anesthesia and surgery.

6. The client is free to change his mind about having the procedure done at any time before the surgery.

7. The procedure will not protect him from STIs, including HIV infection.

Distribute copies of Handout #7 and review the content. Allow time for questions and comments, and respond to these as needed.

Inform the participants that they will have a chance to practice using the form during the practical sessions.

Handout #8: Sample Informed Consent Form

Verifying Informed and Voluntary Decision Making Just before Surgery Basic Slide Set IV: Slide Last revised: 15 August 2018 Page 27 of 78

The Training Resource Package for Family Planning Vasectomy ModuleTraining Process ResourcesPresentation, Discussion (5 minutes)<Display Slide 11>

Explain:

In many settings, counseling of the client may take place several days or weeks before the date of the actual procedure; moreover, the client may be counseled by a different provider who may be stationed at the community level or at a static facility away from where the actual procedure is to be performed. It is therefore the responsibility of the surgeon to verify that the client made an informed and voluntary decision, irrespective of whether he signed the written consent form. This is to ensure that the client did not sign the form under any duress or any form of coercion.

The verification is ideally done by the surgeon just before surgery.

This slide shows a simple job aid that can be used by the surgeon to check the client’s readiness for the vasectomy. It should be used just before starting any part of the surgery.

This tool has a series of questions that the surgeon asks the client; from his responses, the surgeon can decide whether to proceed with the surgery or not. It is also recommended that the surgeon carefully observe the client’s behavior during this interaction—for example, an extremely nervous client who seems to be interested in the possibilities of reversal of the procedure in the future may not be the right candidate for the procedure.

Distribute copies of Handout #9: Job Aid for Verifying Informed and Voluntary Decision Making and review it, explaining how it should be used.Inform participants they will have a chance to practice using the tool during model and clinical practice sessions.

Ask if there are any questions, and respond to these, as needed.

11: Verifying Informed and Voluntary Decision Making Just before Surgery

Handout #9: Job Aid for Verifying Informed and Voluntary Decision Making

Counseling about Possible Side Effects and Intraoperative, Immediate Postoperative, and Long-Term ComplicationsPresentation, Discussion (5 minutes)<Display Slide 12>

Explain:During counseling, prior to giving informed consent, the client should fully understand the side effects and possible complications of vasectomy.

The provider should therefore explain to the client that vasectomy has very few side effects, if any, and that most of these are transient and subside after a short period of time.

• Some of these side effects include discomfort, bruising, and slight pain over the wound, which normally subsides with analgesics and bed rest.

• The client may also notice a few streaks of blood in his ejaculate

Basic Slide Set IV: Slide 12: Counseling about Possible Side Effects and Intraoperative, Immediate Postoperative, and Long-Term Complications



immediately after the procedure.

• In rare instances, the client may experience persistent dull pain in the scrotal area for several months after the procedure.

Clients should also be informed that the procedure carries some risks that are associated with the drugs used for pain management and the surgical procedure and complications that may arise, although these are rare. These risks include the following:

• Bleeding may increase during and after the procedure, and blood clots may accumulate.

• The wound may become infected, which can lead to formation of an abscess. Such an infection may manifest itself as a painful swelling, oozing of fluid or pus from the wound, or general malaise, with or without fever.

• Lastly, in very rare instances, the method may fail. In some cases, this may result in pregnancy in the man’s spouse. In other instances, where semen analysis is routinely performed, there will be evidence of high numbers of sperm and high sperm motility several months or years after the procedure.

• After the procedure, clients should be counseled as they receive the postoperative instructions about side effects or any complication that may arise and how to prevent these.

Allow time for comments and questions and respond to these as needed.Explaining the Vasectomy ProcedurePresentation, Discussion (5 minutes)<Display Slide 13.>

Explain:

• A client who selects vasectomy as his method of choice needs to know what will happen during the NSV procedure. The provider should explain the procedure at a level of detail that will enable the client to understand what to expect. The provider should use simple language and avoid medical jargon.

• Clients should know the following:

o The provider will assist in positioning the client on the procedure table, before exposing the operation site.

o The provider will use proper infection prevention procedures at all times. (This includes cleansing the operation site with antiseptics, covering the operation site, and wearing gloves, gowns, etc.) He will receive instructions from the provider on what to do during the procedure.

o The client will receive an injection of local anesthetic in the scrotal

Basic Slide Set IV: Slide 13: Explaining the Vasectomy Procedure



area to prevent pain. He stays awake throughout the procedure.

o The provider feels the skin of the scrotum to find the vas deferens—the two tubes in the scrotum that carry the sperm.

o Using a specially designed instrument, the provider grasps one of the tubes and makes a puncture in the skin over the tube.

o The first tube is then lifted through the puncture site, cut, and tied. In some instances, the cut tubes are closed with heat or electricity. The other tube is also secured and tied through the same puncture site.

o The puncture site is then covered with an adhesive bandage.

o After the procedure, the client will be expected to rest for at least half an hour.

o If all is well, he will receive instructions at discharge.

In most instances, this explanation about the procedure should be adequate; however, the provider should allow the client to seek clarification about the procedure and provide additional information as needed.

Allow time for comments and questions from the participants, and answer these, as appropriate.

Supporting the Vasectomy UserPresentation, Brainstorming, Discussion (5 minutes)<Display Slide 14>

Ask: “How can a provider support the client who opts to use vasectomy?” Allow a few responses and have a co-trainer list them on a sheet of flipchart paper.

<Advance the slide and explain:>

• Supporting the vasectomy user includes explaining self-care for vasectomy before coming for the procedure and after the procedure.

o How to prepare himself for the procedure

o What he should do after the procedure

o When to return to the clinic/facility

• To support the user, the provider should discuss the instructions verbally and give the client written or pictorial instructions. Alternatively, if the client has come with his spouse or with a caretaker, the provider should also explain the instructions to the spouse or caretaker, if the client consents.

<Advance to Slide 15>

Explain:

Basic Slide Set IV: Slides 14–15: Supporting the Vasectomy User



These are the preprocedure and post-procedure instructions.

Before the procedure, the client should have a bath and ensure that he cleans his external genitalia before coming to the facility.

The client should wear clean, loose-fitting clothing to the health facility.

He does not need to shave the operation area.

After the procedure, the client should do the following:

o Rest for two days.

o If possible, put cold compresses on the scrotum for four hours, to decrease pain and bleeding.

o Wear snug underwear or pants for 2–3 days to help support the scrotum (point out image on slide). This will lessen swelling, bleeding, and pain.

o Keep the puncture site clean and dry for 2–3 days. The client can use a towel to wipe his body clean, but he should not soak in water.

o Avoid having sex for 2–3 days.

o For three months after the procedure, use condoms or another effective FP method.

o Take the pain-relieving medicine provided when he is in pain.

o Return to the facility on the specified date. (In settings where semen analysis is routinely performed, the client should be advised when to come for semen analysis to verify if the vasectomy was successful and if there is a need for repeat visits. In limited-resource settings, routine semen analysis to confirm the success of vasectomy is not mandatory. A nonmotile sperm count of less than100,000/ml is a confirmation that the vasectomy was successful.

Share a sample of written and pictorial preprocedure and postprocedure instructions and review them.


Postoperative CarePresentation, Brain Storming, Discussion (5 minutes)<Display Slide 16>

Explain:

1. NSV is a short, simple, and safe procedure. The postoperative period is not normally eventful.

2. The client should be observed for at least 30 minutes after the procedure before discharge.

Basic Slide Set IV: Slide 16: Postoperative Care



3. Before discharge, the provider should ensure that the client has no complaint, is in stable condition, and is experiencing no bleeding from the operation site.

4. For pain management, the client should be given analgesics for the first few days.

5. The client should also receive postoperative instructions.

Ask: “What are some useful postoperative instructions?” Have one of the co-trainers list the participants’ responses on a sheet of flipchart paper. Allow some time for these, until it is evident that no new points will be coming from the participants.

The responses should include

• Care for the wound

• Bed rest

• When to resume light, normal duties,

• When to resume sex

• How to use the pain-relieving drugs

• How to protect against pregnancy in the first three months after vasectomy

• The follow-up schedule

• What to do if:

o He experiences any problems or complications or has any questions

o They suspect that the spouse has conceived

• When to return for semen analysis

Review the list of responses and discuss each response, as needed.

Ask if there are any questions or comments, and respond to these, as needed.

Medical Reasons to Return to the Clinic after VasectomyPresentation, Discussion (5 minutes)<Display Slide 17>

Explain:All client should understand that they are welcome to visit the clinic at any time after the procedure, particularly when they have:

• Problems or questions/concerns about the procedure

• Swelling at the operation site that seems to be getting worse

• Fever

Basic Slide Set IV: Slide 17: Medical Reasons to Return to the Clinic after Vasectomy



• Pus, serous fluid, or bleeding from the operation site

• Worsening pain, heat, and redness of the wound

• Contraceptive failure.

Inform the participants that you will discuss what to do when the client presents with such complaints in detail later in the session.

Helping the Vasectomy UserPresentation, Discussion (5 minutes)<Display Slide 18>

Explain:

• Vasectomy users who come to the facility or call in for assistance in the immediate postoperative period, or several months or years later, need prompt assistance from the provider.

• The provider should welcome the client and take time to explore the nature of his concerns or problems.

• This process may involve taking a history and examining the client to make a definitive diagnosis of the problem before deciding on the appropriate treatment.

• Problems or complications and side effects that may affect the man’s satisfaction with vasectomy include:-

o Bleeding or accumulation of blood clots after the procedure

o Wound infection

o Abscess formation

o Persistent pain lasting for months after the procedure,

o Method failure

o Other illnesses or medical conditions that may not be related to vasectomy

In instances where the provider can confirm after history and examination of the operation site that the condition or illness is unrelated to the procedure, the client needs reassurance that he is recovering well from the procedure and that the condition or problem he is experiencing does not result from the procedure.

The provider should also explain to the client what condition he thinks the client has and what form of assistance or treatment is required, including what can be done at that facility and whether he needs more specialized care, which may only be available at different facility. If needed, the client should be referred to the appropriate section within the same facility or to a different facility.

Basic Slide Set IV: Slide 18: Helping the Vasectomy User

Managing Side Effects and Intraoperative, Immediate Postoperative, and Long-Term Complications of Vasectomy

Basic Slide Set IV: Slides 19–21: Intraoperative,


The Training Resource Package for Family Planning Vasectomy ModuleTraining Process ResourcesPresentation, Discussion (10 minutes)<Display Slide 19>

Explain:

State that you will now discuss how to manage problems that may affect clients who have had a vasectomy.

<Advance the slide and state that you will begin by looking at the side effects.>

Ask: “What is the most important thing that you can do for a man who complains of problems that in your judgement are transient side effects associated with the vasectomy procedure?” Accept responses from the participants, then inform them that you will now compare their responses with answers you have prepared on the slide.

<Advance the slide to reveal the table summarizing management or actions needed to address side effects and complications>.

Explain:

• A client who complains of discomfort, pain, or swelling needs follow-up counseling and reassurance. The provider should provide detailed information about the side effects and also provide analgesics for symptomatic relief of pain. Clients should also be advised on the importance of rest and, where applicable, use of scrotal support. If possible, he can apply cold compresses for the first four hours after the procedure, which may decrease pain and bleeding. Good counseling and explanation of possible side effects before the client has the vasectomy are important in reducing anxiety and enabling the client to tolerate the method’s transient side effects. It is also an important factor influencing client satisfaction.

• If the client’s complaint is about the appearance of streaks of blood in his first ejaculate, he needs to be reassured that this is temporary and should subside with subsequent ejaculations.

• Once again, the provider should revisit the postoperative instructions with the client, as appropriate.

• Remind the client that he is welcome to call in or visit if he has any concerns or if he experiences problems.


Explain the following points to the training participants:

Hemorrhage

Hemorrhage is a complication that may occur either during the procedure or after it. The provider can prevent hemorrhage during the procedure by ensuring that he/she is gentle and avoids severing small vessels around the vas when striping the sheath and inspecting the

Immediate Postoperative, and Long-Term Complications of Vasectomy



wound to identify and ligate or cauterize bleeder(s), before dressing the wound.

At the end of the procedure, the provider should verify if there is any evidence of active bleeding. In most instances, the bleeding may be controlled with compression. However, if blood clots accumulate, the provider should prepare the client for evacuation of the clots and arrest of the bleeders. Clients with such problems also need counseling and reassurance.

Injury to other structures of the spermatic cord

Such injuries are very rare, and in most instances the surgeon can avoid them by following the recommended steps and avoiding rushed movements when using dissecting forceps. (Note: In most instances, this will be an injury to the vessels within the cord.)

Infection

If a client reports back to the facility a few days after the procedure complaining of pain or persistent swelling, redness, and oozing of pus or fluid from the operation site, it is highly likely that the wound is infected. In some instances, these symptoms may also be associated with fever and general malaise. The provider should explain to the client the nature of the problem and institute treatment. Such treatment includes cleaning the infected operation site and applying a dressing. The client should also receive a full course of antibiotics. A follow-up visit may be required if the infection does not resolve after the course of antibiotics. The provider can prevent postoperative sepsis by ensuring that there is no break in aseptic practice during the procedure, detecting symptoms such as fever and pain at an early stage, and managing them with antibiotics, as needed. Additionally, the provider should ensure that the client understands the postprocedure instructions related to wound care.

In very rare instances, when there is evidence of abscess formation, the client should be counseled and advised on the recommended management of the condition. Treatment of an abscess requires drainage. If this is possible at the facility, arrangements should be made for the abscess to be drained; otherwise, the client may need to be referred to facilities where this can be done and the client can be discharged on a full course of antibiotics. A follow-up visit will be required to assess progress.

<Display Slide 21>

Explain the following points to the training participants:

Sperm granuloma formation

Clients may present with persistent relatively painless swelling or “nodules” in the scrotum several months after vasectomy. If granuloma formation is suspected, the client should be counseled and referred to a



specialist for care.

Chronic testicular pain or pain lasting for manths

Clients presenting with persistent pain after the procedure should be counseled and advised to use scrotal support to see if this provides lasting relief, and/or to soak in warm water. Analgesics should also be provided. Providers should also offer antibiotics if infection is suspected. If pain persists for several months and the client cannot tolerate it any further or seems depressed, he should be referred for further care.

Pregnancy

Pregnancy of the spouse following a vasectomy procedure may be an indication of method failure—if the vas recanalized, or if the surgeon did not ligate and excise both vas, or in extremely rare instances if there is an aberrant vas. Additionally, if the client does not follow instructions and has unprotected sex with his spouse in the first three months postprocedure, the spouse is likely to conceive. To prevent method failure, the provider should follow the recommended steps for identifying, isolating, and occluding the vas. Techniques such as fascial interposition, in addition to thermal or electrical cauterization, have been reported to have persistently lower failure rates. Postprocedure semen analysis to confirm successful occlusion of the vas may be helpful to some extent.

All clients opting for vasectomy must be informed of the very small risk of failure before undergoing the vasectomy.

The client and the spouse should receive counseling and be told of the options for managing the problem. The spouse should be referred for antenatal care. A repeat vasectomy may also be arranged for the client. The couple may also consider other contraceptive options soon after the current pregnancy.

Regret and dissatisfaction with the method

Clients who made a hasty decision to have a vasectomy or who were not adequately counseled may experience regret several years after the procedure. Good counseling and screening of clients for eligibility may avoid such regret. Vasectomy should be considered permanent. Clients presenting with regret should be counseled and told about the options at their disposal, such as assisted reproduction, adoption, and in some instances reversal. Clients should however be informed that vasectomy reversal is expensive and not always successful.

NOTE:Explain that other complications and side effects, though rare, may be associated with the pain medication used during the procedure. These include allergies and related drug reactions that may be associated with lidocaine and any analgesic or sedatives used. Such conditions should be



managed symptomatically. Drug allergies can be avoided if the provider takes good history from clients who have experienced similar incidents in the past.

Role Plays<Display Slide 22>

Role Play (10 minutes)

Follow the step-by-step instructions in the Facilitator’s Guide section on facilitating role plays, to prepare for and conduct this activity

1. Discuss the learning objectives of the role-play activity.

2. Review the instructions for the client, the provider, and the observer roles and the other learning resources developed for the activity.

3. View a demonstration role play and clarify any questions.

4. Conduct role plays in small groups, based on the scenarios provided, and discuss the reactions.

5. Discuss the activity in a large group (plenary) session.

Review Handout #10, #11, and #12 with the participants. These include:

1. Five different role play scenarios, each with a client information sheet and observer information sheet (Handout #12)

2. The instruction sheet that describes the roles of providers, clients, and observers (Handout #11)

3. The Role Play Observation Checklist for Clinicians (Handout #12)

Use the following questions to help the small groups structure the feedback that they will provide to each other after each role play. (Prepare a flipchart to display these discussion questions where they can be easily seen by all small-group participants.)

What was going on between the provider and the client?

What did the provider do that was effective in this situation?

What might the provider consider doing differently if this situation were to happen again?

How did the provider attend to the items on the counseling observation checklist and the case-specific observation included in the role play description?

After the small groups conduct each role play, encourage the groups to talk about what happened during the role play from the persepective of the provider (self assessment), the client (personal satisfaction with the interraction), and the observer (objective assessment using the role-play observation checklist, including case-specific observations that are included in the role-play description).

Basic Slide Set IV: Slide 22: Role Plays and Case Studies

Handout #10: Role Play Scenarios

Handout #11: Role Play Instructions for the Provider, Observer, and Client

Handout #12: Role Play Observation Checklist

Case StudiesExercises (20 minutes)

Handout #13: Case Studies: Managing Complications and Side Effects of



Divide the participants into 2–4 groups.

Distribute Handout # 13 and assign each group a different case study. Ask the group to review the case studies and answer questions to present their answers to the rest of the group,

Allow 15 minutes for discussion of the cases and for the groups prepare their answers, and then use five minutes to present their answers to the rest of the group.

Vasectomy

Session V: Practicing No-Scalpel VasectomyThis session will focus on practicing no-scalpel vasectomy as the recommended technique, rather than the conventional or incisional vasectomy technique. The overall purpose of the session is to demonstrate the NSV procedure.

By the end of this session, participants will be able to:

• Describe how to prepare a client for no-scalpel vasectomy (NSV)

• List the steps of the NSV procedure in the correct sequence

• Demonstrate the NSV procedure on the model

• Demonstrate the NSV procedure on a client

Notes to the Trainer

In preparation for this session, the trainers/cotrainers should go through the training materials to thoroughly understand the content and be comfortable to lead discussions.

Prepare work stations for the demonstration and model practice sessions.

IntroductionPresentation, Discussion (5 minutes)<Display slides 1 and 2>

Present the objective shown on Slide 2


Basic Slide Set V: Slides 1–2: Introduction and Session Objectives

Client Preparation for NSVPresentation, Brainstorming, Discussion (5 minutes)<Display Slide 3>

Ask: “What are the key steps or activities that a provider needs to follow when preparing a client for NSV?” Ask one of the cotrainers to list the participants’ responses on a sheet of flipchart paper.

Allow some time for responses. Once the list is completed, explain:

• The provider should screen the client interested in vasectomy for his

Basic Slide Set V: Slide 3: Client Preparation for NSV



eligibility.

• The client should be helped to make an informed and voluntary decision and should have signed the informed consent form.

• The provider should also perform an examination of the client to assess his general health status and, more specifically, to examine his external genitalia. The provider should then inform the client of his findings and plan on where and when the client can have the procedure.

• The provider should also explain the procedure in detail and review with the client what he needs to do prepare for the procedure in the form of preoperative instructions.

• During the preparation, the provider should also explain the postoperative instructions and, if possible, should provide the client with written materials on all instructions (if the client is literate).

NSV Instruments and SuppliesPresentation, Discussion (5 minutes)<Display Slide 4>

Notes to the Facilitator:Review the list of instruments, equipment, and supplies in advance of this session and ensure that you have adequate number of the unique instruments to pass around to participants, so they can get a feel for the instruments as you discuss them, even before the actual demonstration and practice session.

Explain:

• NSV is performed without the use of a scalpel.

• The two unique instruments that are used to perform the procedure are the ringed clamp forceps and the dissecting forceps.

• Both instruments were developed by Prof. Li Shunqiang in China.

• The ringed clamp comes in various sizes; the right size for NSV is 3–4 mm.

• Like other forceps, once in place, the ringed clamp can be locked to secure what has been held with the clamp.

<At this point, show the participants the ringed clamp and the different parts of the instrument. Inform them that at a later stage, they will learn how to use this instrument.>

• The dissecting forceps is another unique instrument used in NSV. It is designed for use in several ways; it has curved and sharp pointed blades, which can be used to make a small opening in the skin by puncturing the skin or other tissues. By opening the blades, the forceps can be used to spread tissues or widen the puncture site. It can also be used to hold tissues or to suture.

• Refer participants to the list of instruments, equipment, and basic

Basic Slide Set V: Slide 4: NSV Instruments and Supplies

NSV’s unique instruments (sample ringed clamp and dissecting forceps)

Handout #14: Basic Furniture, Equipment, Instruments, and Expendable Supplies for NSV



furniture and supplies and review the list slowly, allowing time for questions or comments.

• Note that vasectomy can be performed in a relatively simpler setting when compared with other sterilization procedures, such as female sterilization. The basic infrastructure set-up should include a waiting area for clients, a private room for counseling and examination of the client, a preprocedure area, and the operation area. The procedure area should meet the minimum requirements for maintenance of infection prevention, good lighting, etc.

• The examination room and operation area should be of the right temperature (20–25° C), including the antiseptic solution to be used in skin preparation to ensure relaxation of the dartos muscles of the scrotum and therefore ease of mobility and manipulation of the contents of the scrotum.

NSV Procedure: TasksPresentation, Discussion (5 minutes)<Display Side 5>

Explain:

The NSV procedure can be broken down into a number of key tasks that are performed by the provider.

These tasks cover what is done immediately before the procedure, during the procedure, and immediately after the procedure, before the client’s discharge.

The listed tasks do not include any of the tasks that take place when the client returns to the facility for scheduled or unscheduled follow-ups.

Each task can be further broken down into a number of discreet steps.

The NSV procedural tasks include the following

Preprocedure tasks—the steps performed in the preprocedure area/room

Preoperative tasks—the steps undertaken in the procedure area immediately before surgery begins

Infiltration with local anesthetic—the steps undertaken to eliminate pain and minimize client discomfort during the procedure (including steps for infiltration of the operation site with local anesthetics to block pain)

Delivery and occlusion of the vas—the series of steps for occlusion of the vas

Postprocedure tasks—all steps that should be taken immediately after the procedure, to the moment when the client is discharged

<Explain to the participants that we shall look at each of these tasks and specific steps in detail later.>

Basic Slide Set V: Slide 5: NSV Procedure: Tasks

Handout #15: Competency-Based Skills Learning Guide for NSV



Inform the participants that these steps capture not only the skills but also the attitudinal aspects needed to effectively perform the NSV procedure (for example, greeting the client in a friendly manner, ensuring that the client is comfortable, communicating with the client, etc.).

Ask one of the cotrainers to distribute Handout #15, the competency-based checklist for NSV (learning guide), and review this tool, covering its purpose, how it is designed, and how they will use it to follow the presentation, as well as when learning the actual skill.

Preprocedure Steps in the Preprocedure AreaPresentation, Discussion (5 minutes)<Display Slide 6>

Explain:The following are the 11 steps that constitute the preprocedure tasks, which are to be performed in the preprocedure area when the team receives a client for vasectomy:

1. Greeting the client in a culturally appropriate and friendly manner, welcome him to the clinic and offer him a seat, introduce yourself, find out how you can help the client, and ensure privacy for an examination.

2. Ask the client whether he still wants a vasectomy.

3. Review with the client the information in his medical record and review his reproductive health and pertinent medical history. One should verify that the client is not suffering from any acute illness (malaria, diarrhea, flu, chest infection, etc.) or a local scrotal infection; the provider should also review the findings of any physical examination done prior to this appointment.

4. Ensure that the client has no history of allergies to common substances used during vasectomy, such as antiseptics, analgesics, and lidocaine.

5. For clients referred with an appointment for their vasectomy from other facilities or from the community, review if they received and adhered to the preoperative instructions in preparation for the vasectomy.

6. The provider must ensure that the client has been appropriately counseled for vasectomy by verifying informed consent and asking the client if he has any questions about vasectomy. The client should also sign a written informed consent form.

7. If all is well and the client can have the procedure, ask him to void his bladder.

8. At this point, the client should be given a gown to wear, but in resource-limited settings, he may use his own clothing, provided it is clean.

9. The surgeon and his assistant should prepare for the procedure by changing into the appropriate surgical attire (masks, cap, jumps/scrubs,

Basic Slide Set V: Slide 6: Preprocedure Steps



boots/shoes).

10. The assistant should also ensure that the procedure area or room is well-prepared, clean, and ready to receive a client for vasectomy.

11. Once the client is ready, the assistant should escort him into the procedure area.

Ask the participants if they have any questions or comments and respond appropriately. You may also ask the participants to share the set-up at their work stations and how the steps can be adapted or implemented in such settings.

Preprocedure Steps in the Procedure AreaPresentation, Discussion (5 minutes)<Display Slide 7>

Explain:

1. It important to ensure that the room is warm enough, to ensure relaxation of the scrotal muscles. If the room is too cold, then alternative arrangements may be needed, such as wrapping the scrotum in a warm cloth for a short period of time. The ideal and comfortable room temperature ranges between 20o and 25o C.

2. Once the client is in the procedure area, direct him to the examination couch or operation table and help him to get onto the couch/table and lie in the supine position. Ensure that he is comfortable. Provided him with a small pillow for his head, if necessary.

3. The surgeon and his assistant should continue communicating with the client. At this point, they should tell him what they are about to do, what he should expect to feel, and what he is expected to do. The client should be asked to inform the surgeon and his assistant if he experiences pain or discomfort, while at the same time taking a deep breath.

4. Instruments, supplies, and equipment, including an emergency tray or kit, should be available in the procedure room.

5. The next step is to examine the external genitalia, with a focus on the scrotum and its contents. Before doing this, the provider should wash his hands and/or apply alcohol-based handrub and rub them gently until they are dry.

6. The provider then puts on examination gloves and examines the client’s genitalia, focusing on operation site. During the examination, the provider verifies that both testes are in the scrotum, that there are no swellings or ulcerations on the scrotum or penis, and most important that the spermatic cords are mobile.

7. The provider should also ensure that the client followed the preoperative instructions and that the scrotum and the immediate surrounding skin/structures are clean; if the client is very hairy, the

Basic Slide Set V: Slide 7: Preprocedure Steps in the Procedure Area



provider can clip the hair at the operative site. In the event that the operation area is visibly dirty/soiled, it is important to ensure that this area is cleaned before any procedure can continue. This is an important precautionary measure to minimize the risk of infection, since the majority of postoperative infections are caused by invasion of the surgical site with bacteria/organisms from the skin.

8. The provider then disposes of the examination gloves and explains to the client his findings and the next course of action.

9. The surgeon should then perform a surgical scrub using ordinary or medicated soap and water, dry the hands with a sterile hand towel, and then apply an alcohol-based handrub.

10. Allow time for the hands to dry, or use a sterile hand towel, before putting on a sterile surgical gown and sterile gloves. (Briefly explain to the participants the importance of putting on the sterile surgical gloves correctly, to avoid contamination of the gloves before surgery.)

11. The surgeon then arranges the instruments on the tray. If there is a sterilized NSV set, have the assistant open this pack without touching the inner side, which is sterile. Set up the tray in such a way that you have easy access to the instruments you will need. Always have the instruments and supplies that you will need to use first closer to you and those to be used last toward the furthest end of the tray. This helps avoid any contamination/soiling of instruments that you have yet to use, and it is also more organized, thus minimizing the chances of injuries and of difficulty in locating an instrument when you need it.

12. The next step is to withdraw 5 cc of 2% lidocaine in a syringe or 10 cc of 1% lidocaine solution. The surgeon and his team should follow infection prevention precautions when withdrawing the local anesthetic. Ensure that you also have some sterile gauze and antiseptic solution on the tray, for cleaning the operation site. Once all has been set, proceed to prepare the operation site.

13. The assistant then ensures that the operation site is well-exposed.

14. The surgeon then moves to the right side of the client (if he is right-handed). This is the position from where he will perform the procedure, from the start to the end.

Preparation of the Operation SitePresentation, Discussion (5 minutes)<Display Slide 8>

Explain:

1. Preparation of the operation site entails establishing a sterile field at and around the operation site. To do this, one should first secure the penis away from the operation site (which is in the midline and is midway between the base of the penis and the end of the scrotum). This can be done by loosely making a knot around the penis with gauze, which is

Basic Slide Set V: Slide 8: Preparation of the Operation Site



then strapped to the mid-abdominal area or is held to the client’s gown with a towel clip. (State that these will all be covered with the sterile gown.)

2. The surgeon then uses the sponge forceps to grasp sterile gauze, which is dipped in antiseptic (preferably, iodine solution) and used to clean the operation site.

3. Clean a wide area, starting from the operation site and then scrubbing and working the skin outward to cover a wider area, including the underside of the scrotum, the upper thighs, and suprapubic area. Allow 2–3 minutes for the antiseptic to take effect before you begin the procedure.

4. Next, drape the client. If applicable, open the sterile surgical drapes and use them to drape the client.

5. Isolate the scrotum with the fenestrated drape by pulling the scrotum through the small opening.

6. At all times, the surgical assistant and the surgeon should maintain communication with the client.

7. Although vasectomy is a minor and short procedure, it is essential to take the client’s vital signs before the start of the procedure.

8. Communicate to the client that you will start the procedure by giving him an injection to anesthetize the operation site, and that he will feel a pinch and a short-lived stinging sensation.

Pain Management during and Immediately after NSVPresentation, Discussion (5 minutes)<Display Slide 9>

Explain:

1. For pain management during NSV, use of local anesthetic is sufficient and provides adequate anesthesia. The recommended drug is lidocaine (also known as xylocaine or lignocaine), which is commonly available and is not costly. (However, newer, more potent local anesthetics can also be used.) Concentrations of 1% or 2% may be used. If the client is extremely anxious, the provider should reassure him and can provide a small dose of an anxiolytic, such as diazepam or its derivatives.

2. The lidocaine solution used should not contain epinephrine. The recommended dosage of lidocaine is 5 ml/cc of 2% solution or 10 ml of 1% solution, which translates to 100 mg of lidocaine. The dosage may be increased if the anesthetic effect is not sufficient, but it should not exceed the maximum recommended dosage for lidocaine, which is 4.5 mg per kg of body weight. (This translates to 300 mg of lidocaine.)

3. Side effects to lidocaine are rare. They are mostly allergic reactions; the more severe and life-threatening reactions are neurologic. Drug toxicity also has serious cardiovascular effects; these are also rare. Such serious

Basic Slide Set V: Slide 9: Pain Management during and Immediately after NSV



complications are more likely to occur when the recommended dosage is exceeded and/or the drug is injected directly into a blood vessel.

4. The drug usually is administered using a syringe and needle; however, with recent advances in this field, local anesthetic can also be administered with a device that releases the anesthetic under high pressure, thus eliminating the need to use a needle to deliver the drug into the underlying tissues. The device also uses a much lower dosage of the anesthetic. Other advantages are that the infiltration is painless and is therefore very acceptable to the client. The surgeon requires some level of training to ensure that the sprayed jet is directed correctly.

5. Once the anesthetic has been infiltrated, the surgeon should wait for at least two minutes for good anesthetic effect.

6. During the procedure, the surgeon and assistant should communicate with the client to try to comfort him, reassure him that all is well, and distract him from any discomfort.

7. The effects of lidocaine last for just less than an hour before they begin to wear off. This is ample time for the surgeon to perform the procedure and observe the client for a short period of time.

8. For postoperative pain, the client should be discharged with analgesics such as paracetamol or ibuprofen.

9. Other effective nonpharmacological actions that can provide relief for pain and/or can minimize discomfort include providing scrotal support and recommending bed rest immediately after the procedure.

Infiltration with Local Anesthetic: StepsPresentation, Discussion (5 minutes)<Display Slide 10>

Explain:To correctly infiltrate the local anesthetic, follow these six steps:

1. Continue communicating with the client.

2. Use the recommended dosage of either 5 ml of 2% lidocaine solution or 10 ml of 1% lidocaine.

3. Use the three-finger technique to isolate and fix the vas at the operation site.

4. Use the needle with the syringe to raise a small skin wheal at the operation site. This is done by injecting 0.5–1.0 ml of lidocaine just under the skin.

5. Infiltrate the right vas, then isolate, fix, and infiltrate the left vas through the skin wheal.

6. Finally, wait for two minutes to allow for optimum anesthetic effect before puncturing the skin.

Basic Slide Set V: Slide 10: Infiltration with Local Anesthetic: Steps



Each of these steps will now be described in some detail.

Three-Finger TechniquePresentation, Discussion (5 minutes)<Display Slide 11>

Explain

1. The three-finger technique, which was developed by Prof. S. Li, is used to identify, isolate, and fix the vas. The vas can easily be identified as a firm, cord-like structure that easily slips between the fingers on palpation. The technique involves use of the first three fingers (thumb, index, and middle fingers) of the left hand.

2. Start as follows:

• Place or position the left thumb over the operation site (in the midline and midway between the base of the penis and the end of the scrotum).

• Position or place the middle finger of the same hand underneath the scrotum (below the operation site).

• Move the middle finger on either side laterally underneath the scrotum, to palpate and identify the vas as a cordlike structure between the thumb and the middle finger.

• Use the index finger to fix the vas at the operation site by placing it above the operation site, away from the thumb.

• To make the vas more prominent under the skin at the operation site, push the middle finger upward.

• Take some time to describe and demonstrate how this technique is performed, if needed.

• Allow time for questions and comments.

• Inform the participants that they will have a chance later in the course to observe the technique on the NSV video and during the NSV demonstrations, and to practice the technique during model and clinical practice sessions.

3. To infiltrate the vas with the local anesthetic, stand on the right side of the client if you are right-handed(or on the left side of the client if you are left-handed), face the client’s head, and, using the left hand, identify, isolate, and fix the right vas under the median raphe, midway between the base of the penis and the top of the testes. Trap the vas under the skin firmly using the three-finger technique. Isolating and trapping the right vas is difficult for the left-handed surgeon and requires a lot of practice to master the steps.

Slide 11: Three-Finger Technique

Raising a Small Wheal at the Operation SitePresentation, Discussion (3 minutes)

Basic Slide Set V: Slide 12: Raising a Small Wheal at


The Training Resource Package for Family Planning Vasectomy ModuleTraining Process Resources<Display Slide 12.>

Explain:

Once the right vas has been identified, isolated, and fixed, using the three-finger technique:

1. Inform the client that you will now infiltrate the operation site with anesthetic and that he will feel a prick and a stinging sensation as you insert the needle and administer the drug.

2. Insert the needle just deep enough to penetrate the skin above the vas.

3. Slowly inject about 0.5 ml (and no more than 1 ml) of lidocaine solution.

the Operation Site

Infiltration of the Right Vas with Local AnestheticPresentation, Discussion (5 minutes)<Display Slide 13.>

Explain:

1. Advance the needle parallel to the right vas within the external spermatic fascial sheath, toward the inguinal ring.

2. Once the needle is fully inserted (about 4 cm), aspirate to ascertain that the needle is not in a blood vessel.

3. Without withdrawing the syringe, and keeping the vas fixed, infiltrate about 2 ml of 2% lidocaine or 4 ml of 1% lidocaine.

4. Slowly withdraw the needle completely.

Basic Slide Set V: Slide 13: Infiltration of the Right Vas with Local Anesthetic

Infiltration of the Left Vas with Local AnestheticPresentation, Discussion (5 minutes)<Display Slide 14>

Explain:

The left vas should also be anesthetized. The approach involves identifying, isolating, and fixing the left vas, using three-finger technique, followed by the administration of anesthesia to the vas.

The detailed steps are as follows:

1. Standing on the right side of the client, change your position to face the client’s feet.

2. Use your left hand to identify, isolate, and fix the left vas underneath the injection puncture site.

3. Reinsert the needle through the needle puncture.

4. Advance the needle in the left external spermatic fascial sheath

Basic Slide Set V: Slide 14: Infiltration of the Left Vas with Local Anesthetic



toward the inguinal ring.

5. Advance the full length of the needle (approximately 4 cm).

6. Aspirate the syringe to ensure that the needle is not in a blood vessel.

7. Without withdrawing the needle, slowly inject about 2 ml of anesthetic solution.

8. Completely withdraw the needle.

Wait for Two MinutesPresentation, Discussion (2 minutes)<Display Slide 15>

Explain:

1. After infiltration with the anesthetic, use a piece of sterile gauze to pinch the skin wheal between the thumb and forefinger, to reduce edema.

2. Wait for about two minutes for the anesthesia to take effect.

3. Continue communicating with the client.

4. If there is evidence that the client is feeling pain immediately before or after starting the procedure, give a repeat injection following the same steps, but this time without raising the wheal. The maximum allowable dose of 2% lidocaine is 15 cc.

Basic Slide Set V: Slide 15: Wait for Two Minutes

Delivering and Occluding the VasPresentation, Discussion (3 minutes)<Display Slide 16.>

Explain:

The next task is delivering and occluding the right vas.

The following are the recommended seven steps for achieving this task:

1. Fix the right vas under the skin wheal with the left hand, using the three-finger technique.

2. Grasp the vas using the ringed clamp forceps.

3. Puncture the skin using the dissecting forceps.

4. Deliver the right vas.

5. Strip the sheath from the right vas.

6. Occlude the right vas by ligation and excision or by thermal or electrocautery.

7. Continue communicating with the client throughout the procedure.

Inform the participants that you will now review what each of these steps

Basic Slide Set V: Slide 16: Delivering and Occluding the Vas


The Training Resource Package for Family Planning Vasectomy ModuleTraining Process Resourcesentails.

Securing the Right VasPresentation, Discussion (5 minutes)<Display Slide 17>

Explain:

1. To fix the right vas under the small skin wheal with the left hand, once again use the three-finger technique.

2. Review again the steps of the three-finger technique:

• Place or position the left thumb over the operation site (in the midline and midway between the base of the penis and the end of the scrotum).

• Position or place the middle finger of the same hand underneath the scrotum (below the operation site).

• Move the middle finger on either side laterally underneath the scrotum, to palpate and identify the vas as cordlike structure between the thumb and the middle finger.

• Use the index finger to fix the vas at the operation site by placing it above the operation site, away from the thumb.

• To make the vas more prominent under the skin at the operation site, push the middle finger upward. The thumb should be slightly below the operation site.

Basic Slide Set V: Slide 17: Securing the Right Vas

Grasping the Right VasPresentation, Discussion (5 minutes)<Display Slide 18>

Explain:

1. To grasp the vas, use the ringed clamp forceps. The surgeon must hold the ringed clamp correctly.

2. For greater accuracy and control, it is important to remember to hold and apply the forceps correctly.

a. The forceps is best held with the palm facing up and the wrist extended, as shown in this slide.

b. When using it to grasp the vas, it is important to apply it at perpendicular to the vas (i.e., at 90o).

c. The axis of the forceps should be parallel to the longitudinal axis of the vas.

d. Adequate upward pressure on the middle finger must be applied to make the vas more prominent under the skin.

3. Open the forceps and apply the clamp directly over the vas at a 90o angle at the puncture site.

Basic Slide Set V: Slide 18: Grasping the Right Vas



4. Slowly close the forceps to the first click-stop, to grasp the vas.

5. When grasping the vas, avoid holding more of the skin and ensure that the vas is not partially held with the clamp.

6. Once the vas is held, stop applying the three-finger technique and transfer the ringed clamp forceps to the left hand.

7. With the left hand, slowly lower the handles of the ringed clamp along the axis of the vas. This maneuver results in the folding and elevation of the vas at the puncture site.

8. Press the index finger of the left hand lightly downward over the vas to tighten the scrotal skin just ahead of the tips of the ringed clamp and over the anesthetized area.

Puncture of the SkinPresentation, Discussion (5 minutes)<Display Slide 19>

Explain:

1. The next step is to puncture the skin over the vas. This is done with the dissecting forceps.

2. The forceps should also be held and used correctly. It is held with the right hand, with the curved pointed blades facing downward. To puncture the skin over vas at the anesthetized area, use the medial blade of the forceps.

3. Open the blades of the forceps slightly and, while holding it along the longitudinal axis of the vas and at an angle of 45°, use a quick, sharp, single movement of the medial blade to puncture the skin down to the vas.

4. Next, withdraw the medial blade of forceps from the puncture site and close the blades.

5. The ringed forceps should be held in the same position after the skin puncture.

<Display Slide 20>

The next step is to widen the skin puncture, with the aim of having a small operation site that is wide enough to deliver the vas.This is done as follows

6. With the closed blades of the dissecting forceps facing downward and along the longitudinal axis of the vas, insert both blades of the forceps into the same puncture hole to the same depth down to the vas.

7. Gently open the blades of the dissecting forceps to spread the tissues, including the skin, over the vas transversely, to create an opening that is twice the diameter of the vas.

Basic Slide Set V: Slides 19–20: Puncturing the Skin



8. Withdraw both blades of the dissecting forceps.

Delivering the VasPresentation, Discussion (5 minutes)<Display Slide 21>

Explain:

To deliver the vas through the skin opening:

1. Still holding the dissecting forceps with the right hand and the ringed clamp forceps in position (with the left hand), open the blades of the dissecting forceps slightly, while it is still facing downward and along the longitudinal axis of the vas, and pierce the wall of the vas with the tip of the lateral blade of the forceps. Alternatively, one can hold the bare vas directly with the tips of the forceps.

2. Rotate the handles of the dissecting forceps clockwise (along the same longitudinal axis) slowly through 180°, so that the pointed tips of the blades face upward.

3. To deliver the vas, while still holding it with the dissecting forceps, slowly release the ringed clamp with the left hand. This will allow the rotated dissecting forceps to elevate the vas through the puncture site as the rest of the scrotum drops back.

4. Gently close the blades of the dissecting forceps on the vas to prevent it from slipping back into the scrotum while the ringed clamp forceps is removed. Do not lock the dissecting forceps to hold the vas.

Basic Slide Set V: Slide 21: Delivering the Vas

Stripping the Sheath from the VasPresentation, Discussion (5 minutes)<Display Slide 22>

Explain:

To strip the internal spermatic fascia off the vas:

1. Use the ringed clamp to gently grasp the partial thickness of the vas.

2. Gently release the vas by opening the blades of the dissecting forceps.

3. With the dissecting forceps still in the right hand, slightly open the blades and align it to the horizontal plane with the blades facing upward.

4. Use one blade of the forceps to puncture the sheath just below the vas.

5. Withdraw the blade. Ensure that the vas artery has not been severed. If this happens, clamp or cauterize all bleeders, to avoid bleeding and formation of a hematoma.

6. Close the blades, while still holding the dissecting forceps in the right hand horizontally with the tips of the blade closed and facing up.

7. Reinsert the tips of the dissecting forceps into the puncture site.

Basic Slide Set V: Slide 22: Stripping the Sheath from the Vas



8. Rotate the dissecting forceps 90o clockwise, so the blades face sideways and are in the vertical plane.

9. Open the blades gently to bluntly strip the sheath from the vas.

10. Continue stripping the sheath and its contents until at least 1 cm of the vas has been stripped.

Occluding the Right Vas by Ligation and ExcisionPresentation, Discussion (5 minutes)<Display Slide 23>

Explain:

The next step is to ligate the vas. We begin by ligating the prostatic end of the vas, then the testicular end, and then excise the vas between the ligatures. Ligatures used are either chromic catgut or silk or cotton.

The detailed steps are as follows:

1. Hold the vas vertically with the ringed clamp forceps.

2. Pass the suture through the looped vas.

3. Ligate the prostatic end of the vas using a square knot. Avoid tying the sheath and the vessels as you ligate the vas.

<Display Slide 24.>

4. Cut one end of the suture 2–3 mm from the knot, leaving about 5–7 cm of the other end of the suture.

The next step is to ligate the testicular end of the vas.

1. Use a separate ligature. Place the second ligature at least 1.5 cm away from the first knot. Avoid tying the sheath and the vessels as you ligate the vas.

2. Excise up to 1 cm of the vas between the two ligatures.

3. Ensure hemostasis.

4. Cut both ends of the testicular suture, leaving about 2–3 mm of suture from the knot.

Basic Slide Set V: Slides 23–24: Occluding the Right Vas by Ligation and Excision

Occluding the Vas by Thermal Cautery or ElectrocoagulationPresentation, Discussion (5 minutes)<Display Slide 25>

Explain:

1. Once isolated, the vas can be occluded using thermal cautery or electrocoagulation of the mucosa.

2. Evidence from recent studies has shown consistently lower failure rates following extensive cauterization of the mucosa (up to 1 cm).)

3. Cauterization of the vasal mucosa is done after the sheath has been

Basic Slide Set V: Slide 25: Occluding the Vas by Thermal Cautery or Electrocoagulation



stripped from the vas.

4. The vas is partially opened if a blunt probe is being used, and the probe is inserted in one end of the vas. Then the current is switched on. It is recommended that the current be switched off after blanching of the vas or with the appearance of smoke.

5. The probe is then withdrawn and allowed to cool down before it is inserted to the other end of the vas (about 1 cm). Cauterization. Is then repeated.

6. Divide the end, if performing fascial interposition.

7. Handheld, battery-operated thermal cautery devices are now on the market and have been successfully used for NSV in low-resource settings.

Fascial Interposition (Right Vas)Presentation, Discussion (5 minutes)<Display Slide 26>

Explain:

The next step is fascial interposition. The aim of this interposition is to improve the success rates for vasectomy by creating a barrier between the ligated and excised testicular end and the prostatic end of the vas. To do this, we interpose the internal spermatic fascia or sheath between the two stumps, with the testicular stump being buried below the sheath.

The steps are as follows:

1. Gently pinch and pull up on the scrotum with the thumb and index finger to allow both ends of the vas to drop back into their original positions in the scrotum.

2. Gently grasp and pull the long suture of the prostatic end of the vas to reexpose the cut end of the vas, which will be partly covered with fascia. (If both stumps reappear, drop them back into the scrotum and repeat until only the prostatic end of the vas comes out of the puncture site.)

Ask if there are any questions or comments and respond to these, as appropriate.

<Display Slide 27>

3. Gently grasp and hold the sheath with the tip of the dissecting forceps.

4. Ensure that the other stump is within the sheath.

5. Tie (using a square knot) the fascial membrane at about 2–3 mm below the tie at the prostatic end.

6. Cut the suture used to secure the fascia 2–3 mm from the knot.

Basic Slide Set V: Slides 26–27: Fascial Interposition (Right Vas)



7. Gently pull and cut the suture at the prostatic end of the vas to allow the stump to drop back into its original position in the scrotum.

8. Allow time for questions and comments, and respond to these as needed.

Occluding the Left Vas by Ligation and Excision and Fascial InterpositionPresentation, Discussion (5 minutes)<Display Slide 28.>

Explain:

After fascial interposition of the right vas, the left vas should be occluded by ligation and excision and fascial interposition. The steps are similar to those just described for the right vas. The steps for occluding the vas using cautery are similar to those described earlier for the occlusion of the right vas.


1. Isolate and fix the left vas using the three-finger technique.

2. Grasp the left vas at the lower end of the puncture site, using the ringed clamp forceps.

3. Use the dissecting forceps to puncture through the skin and fascia.

4. Isolate the left vas and deliver the vas from the scrotum through the same opening.

5. Strip the sheath from the vas.


7. Ligate the prostatic end and leave one end of the suture 5–7 cm long.

8. Ligate the testicular end of the vas about 1.5 cm from prostatic end knot, and cut strings 2–3 mm below the stump.

9. Excise no more than 1 cm of the vas between the two ligatures.


11. Perform fascial interposition, as described earlier.

Allow time for questions and comments and respond to these as needed.

Basic Slide Set V: Slide 28: Occluding the Left Vas by Ligation and Excision and Fascial Interposition

Wound DressingPresentation, Discussion (2 minutes)<Display Slide 29.>

Explain:

Before the wound is dressed, ensure that hemostasis has been achieved.


1. Pinch the puncture site tightly for one minute.

Basic Slide Set V: Slide 29: Wound Dressing



2. Inspect for bleeding.

3. Apply adhesive tape divided at both ends for better four-point holding, to cover the small wound.

4. Tell the client that you have finished with the procedure and comfort him.

5. Allow the client to rest for a few minutes as you perform some of the postprocedure tasks.

Postprocedural TasksPresentation, Discussion (3 minutes)<Display Slide 30.>

Explain:

After the procedure, the provider must complete a number of steps, including the following:

1. Dispose of waste materials such as cotton balls or gauze by placing them in a leakproof container or plastic bag.

2. Sections or segments of the excised vas should be disposed of like any other hazardous waste. (Sending them as specimens to the lab is not recommended.)

3. Clean all instruments with soap and water and allow them to dry before inspection, packaging, and sterilization. Use of chlorine solution for reprocessing is no longer recommended.

4. Remove your gloves by turning them inside out and dispose of them in a leakproof container.

5. Wash your hands thoroughly with soap and water and dry them with a clean, dry cloth, or allow them to air dry.

6. Apply an alcohol-based handrub and gently rub your hands together or allow them to air dry.

7. Observe the client for at least 30 minutes.

8. Provide postoperative instructions and verify that the client fully understands them.

9. Discharge the client after a period of at least 30 minutes of observation after the procedure.

10. Record the procedure in the client chart and registers, as appropriate.

Basic Slide Set V: Slide 30: Postprocedural Tasks

Roles and Responsibilities of the NSV Team MembersPresentation, Discussion (5 minutes)<Display Slide 31>

Explain:

To perform NSV, the surgeon requires the services of at least one assistant.

Basic Slide Set V: Slide 31: Roles and Responsibilities of the NSV Team Members



The roles and responsibilities of the surgeon include the following:

• Reviewing the client history and evaluation

• Verifying informed consent

• Explaining to the client what will happen and what to do if he experiences pain or discomfort

• Performing the NSV procedure

• Continuously communicating with the client throughout the procedure, or as needed

• Being responsible for the surgery and its outcome

• Leading emergency treatment of the client, in the event of a complication requiring urgent attention

• Giving postoperative instructions

• Discharging the client

• Writing up client notes

The assistant, on the other hand, is responsible for:

• Helping the client prepare for the procedure

• Preparing the procedure area for NSV

• Assisting during surgery (e.g. ligating the vas when the surgeon is holding the forceps in the appropriate position)

• Assisting the surgeon with the resuscitation of the client, in the event of an emergency

• Communicating with the client throughout the procedure

• Observing the client, as needed

• Performing some of the postprocedure tasks (instrument processing, waste disposal, maintenance of the operating area, etc.)

• Discharging the client

• Giving postoperative instructions

• Writing up client notes

The NSV Procedure VideoPresentation, Discussion (15 minutes)<Display Slide 32>

Explain:

The NSV video is a WHO educational material that was produced in China. It features Prof. Li Shunqiang, the originator of the NSV technique, performing the NSV procedure.

The purpose of the video is to demonstrate how to perform NSV. It is designed for training health care providers who are allowed by national

Basic Slide Set V: Slide 32: The NSV Procedure Video and related audiovisual equipment,




guidelines to perform such procedures. The video is about eight and one-half minutes long.

Providers should not attempt to perform a vasectomy after simply watching the video.

The video shows how to perform the NSV procedure in an ideal setting. It is in English. (If your local language is not English, consider arranging to have one of the co-trainers narrate the video, after becoming familiar with its content.

The video can be watched as many times as needed, during and after the training.

The video is limited to the NSV technique and does not include other preprocedure and postprocedure tasks reflected on the learning guide for NSV (such as waste disposable, instrument processing, and isolation and ligation of the left vas).

After watching the video, discuss what was similar to the tasks/steps outlined in this training and what was done differently.

Demonstration of the NSV ProcedurePresentation, Demonstrations, Discussion (45 minutes)

Notes to the TrainerUse the handout on demonstrations and return demonstrations in the facilitator’s guide to prepare and conduct this session.

<Display Slide 33>

Explain:

1. The trainers will conduct a demonstration of the NSV procedure. This will be done both on the scrotal model and on an improvised model. The improvised model is added because of the limitations of the scrotal model, particularly when practicing the three-finger technique.

2. Inform the participants that they should observe all the steps, while at the same time referring to their learning guides as appropriate, and that they should note their questions or comments for discussion at the end of the demonstration.

3. The demonstration should include all preprocedure and postprocedure steps.

4. When demonstrating the procedure for the first time, provide a running commentary on what you are doing, including explaining what the instruments are and how to use them. At this time, you should also pass around the instruments, so the participants can get a feel for the instruments.

5. Start the demonstration by showing the participants how to set up the procedure area in readiness for the procedure. This includes ensuring that sterile packs of instruments are available, as well as infection

Basic Slide Set V: Slide 33: Demonstration of the NSV Procedure


Evaluation Tool: Competency-Based Checklist for NSV—Observation Checklist

NSV Facilitator’s Guide

One workstation set up



prevention equipment and supplies, an emergency tray, etc.

6. At the end of the demonstration, allow time for questions, comments, and answers. For the feedback and discussions to be systematic, go through each task in the sequence in which it was demonstrated. Respond to questions as needed.

7. Inform the participants that you will now do another demonstration, but this time you will not give a running commentary. They should again write any questions or comments on paper and share them during the discussion at the end of the demonstration.

Model Practice SessionsPresentation, Discussions, Demonstration, Coaching, Skills PracticeTime: 2 hours

<Display Slide 34>

Explain:

1. Divide the participants into small groups and explain that the groups will now practice on the models.

2. While in their groups, they should assign each team member a role (client, surgeon, and assistant). If the groups have more than three members, the additional participant(s) should assume the role of an observer(s). If, however, each team is less than three participants, the trainer may play the role of the assistant. The other participant plays the role of the client and an observer.

3. Switch roles as many times as is needed to ensure that all participants have had adequate time to practice and master the skills.

4. Review the learning guide so that participants know all the steps well, in the correct sequence.

5. Emphasize that during the practice session, the participants must follow the steps as they are in the guide and should avoid the temptation to introduce any “shortcuts.”

6. Remind the participants to use their guides to learn and practice each step.

7. At the start of the model practice, one of the co-trainers will take the role of the surgeon and will demonstrate the procedure again at a workstation. The trainer will then coach each participant through all the steps and eventually will allow the team to practice on their own.

8. After each practice session, you must have a feedback session, during which the surgeon, the client, the assistant, and the observer all will give comments—first highlighting what was done well, followed by steps that need to be improved, and finally agreeing on what the surgeon must do to master steps that were omitted or not done correctly. The trainers will also participate in the feedback sessions,

Basic Slide Set V: Slides 34–35: Model Practice



Handout #14: List of Basic Furniture, Equipment, Instruments, and Expendable Supplies for NSV

Workstations set up for the practice sessions



until they feel that the participants have mastered the process.

9. Allow the participants to continue with the practice sessions but spend time at the workstations to assist the training participants, as needed.

10. Be sure that the participants have access to the NSV video, so that they can watch it at any time before and after a demonstration.

11. Ensure that each workstation has a set of the instruments, supplies, models, and equipment needed for the practice session, and that more of the instruments and supplies are at a separate table and available to participants as needed.

12. Remind the participants to take care of the models: Treat them with respect, as if they were part of a client; do not use or add water or any other solution or fluid; do not cut them; do not suture them; cover them with drapes after use.

13. Tell the participants that they can puncture the improvised model (i.e., the glove that represents the scrotal skin).

14. Tell the participants that two hours have been allotted to the practice session.

15. As they practice, the groups should use the observation checklist to assess their progress in mastering the skills.

16. At any time that a team feels they have mastered all the NSV skills, they should alert the trainers for an evaluation.

<Display Slide 35>

Explain:

• This slide shows a picture of an improvised model to use for NSV. There is a commercially designed scrotal model for practicing the NSV procedure during training. However, the model is rigid, and this makes practicing the three-finger technique challenging.

• Professor Kaza Ram and his colleagues at the Maulana Azad Medical College in New Delhi developed this simple model for use in training. It consists of a glove placed on a plastic water bottle, with a small amount of tubing or IV catheter within the glove to be used as the vas. This model has a better feel, and the glove can be punctured several times or even replaced completely with another glove during model practice sessions.

Evaluation of Skills on ModelsPresentation, Discussions, Evaluation of Skills (30 minutes)<Display Slide 36>

Explain:

1. The trainer or a team of trainers will evaluate the NSV skills of each participant using the observation checklist. At the end of the

Basic Slide Set V: Slide 36: Evaluation of Skills on Models




observation, the trainer will provide feedback to the participant; this is the time when the participant will be informed of his performance.

2. As indicated in the observation tool, all steps must be done correctly and in the proper sequence for the participant to be assessed as competent or proficient to perform the procedure (i.e., 100%).

3. If a participant still has missed some steps or not performed them correctly, the participant should practice those steps and then evaluated again when they consider themselves ready.

4. The trainers are there to assess the participants and provide them with the coaching they need to master the skills before another round of evaluation and feedback.

5. Once a participant has been declared competent, arrangements will be made for them to proceed to supervised clinical practice with clients.

Workstations set up

Supervised Clinical Practice on Clients and Evaluation of Skills

Presentation, Discussion, Demonstration and Return Demonstration, Coaching, Skills Practice, Evaluation of Skills (6–8 hours)

<Display Slide 37>

Explain:

1. Explain to the participants the logistical arrangements and schedule for supervised practice on clients in the clinical area.

2. In the clinical area, participants will be expected to observe all etiquette, just as they would at their workplace.

3. Emphasize that clients’ right should always be respected. Before the participants or trainers can observe a procedure, they should seek consent from the client and respect whatever decision he makes.

4. Participants and providers should ensure that clients’ rights to both visual and auditory privacy are always upheld .

5. The client should also be made aware that this is a training session, and if he consents, his care will be managed by participant, supervised by a qualified and experienced provider.

6. Participants will be expected to counsel clients before the procedure.

7. The first activity in the clinical area will be a courtesy call to the relevant authorities, in line with facility protocols.

8. Once they have been introduced to the facility, participants may proceed to the clinical area and be introduced to the staff and oriented on the set-up of the facility.

9. The trainer will arrange and perform a demonstration of the NSV procedure on a client. This first demonstration should include a running commentary on what the trainer is doing.

Basic Slide Set V: Slide 37: Supervised Clinical Practice on Clients and Evaluation of Skills



10. A feedback session should also take place at a separate location, one that allows for privacy and confidentiality.

11. For the following clients, the trainer will coach a participant on the NSV procedure. In the first case, the participant will scrub up and assist the trainer.

12. Depending on the client load, the participant will then be coached to perform specific tasks, such as using the three-finger technique, anesthetizing the vas, then isolating and occluding the vas, and handling postprocedure tasks, all under supervision and coaching, as needed.

13. Once the participant has mastered the steps, they will continue to practice under supervision.

14. Participants should not begin a procedure without a trainer being present in the procedure area.

15. Once a participant is ready for evaluation, the trainers will evaluate the participant as he/she performs the procedure on a client, using the observation checklist; at the end of the evaluation, the trainers will provide the necessary feedback.

Session VI: Emergency PreparednessSession ObjectivesBy the end of this session, participants will be able to:

1. Describe emergency preparedness requirements for vasectomy and related services

2. List components of emergency preparedness

Describe management of rare emergency situationsIntroductionPresentation, Discussion (5 minutes)<Display Slide 2>

Present the objectives as listed on the slide.


Basic Slide Set VI: Slides 1–2: Session Objectives

Emergency PreparednessPresentation, Discussion (10 minutes)<Display Slide 3>

Explain:

All facilities that provide vasectomy services or that perform other major or minor surgical procedure must have an emergency management and preparedness plan in place. Although prevention of such unlikely events is key, such facilities should have all relevant equipment, supplies, and skilled staff to manage an emergency situation—or at least have the capability to stabilize the client before referral to a facility that has the capacity to handle such cases.

Basic Slide Set VI: Slide 3: Emergency Preparedness



Because of the administration of pain management drugs and or as a result of the presence of coexisting medical conditions, some clients may (although rarely) develop complications, even when undergoing a simple and safe surgical procedure such as vasectomy.

In most instances, the problem begins as a minor complication, but if it is not addressed promptly, the condition may progress to be life-threatening. The surgical team should always be prepared to prevent, detect, and manage such emergency situations.

Emergency Preparedness Involves…Presentation, Brainstorming, Discussion (5 minutes)<Display Slide 4>

Ask: “What does emergency preparedness involve?” Allow the participants to respond to the question and have one of the co-trainers write all of the responses on a sheet of flipchart paper.

<Advance the slide once there is evidence that there are no more responses from the participants.>

Explain:

Let us now look at this list of what emergency preparedness involves:

• Proper client assessment and preparation for the procedure

• Prevention of intraoperative and postoperative complications

• Routine, regular monitoring of the client’s condition

• Availability of emergency drugs and equipment in the procedure and recovery area or rooms

o All emergency equipment must be immediately available, prepared for use, and in good functioning condition.

o A battery-operated light source should always be available for back-up or focused illumination of the operative site.

• Availability of providers skilled at recognizing early signs of complications that may be life-threatening and able to call for assistance and at the same time initiate emergency action

• A surgical team with the ability to initiate cardiopulmonary resuscitation and stabilize the client before transfer for specialized care

• Mechanisms for routinely assessing the emergency kit or equipment, drugs, and supplies

<Display Slide 5>

• A supervisory system that conducts regular emergency drills with surgical teams to determine providers’ responsiveness to different emergency situations (Limitations or weaknesses identified must be promptly addressed through trainings or replacement/purchase of

Basic Slide Set VI: Slides 4–5 Emergency Preparedness Involves…



required resources.)

• Staff (the surgical team) who are highly knowledgeable about the drugs used for vasectomy and for any emergency situation and who periodically refresh their knowledge on these drugs

• Establishment of an effective referral system for transferring emergency cases that cannot be managed on-site

• For mobile or outreach vasectomy and related services, highly skilled providers, fully equipped with emergency supplies and equipment and with established referral links to selected local back-up facilities (Those facilities must have the relevant equipment, instruments, supplies, and trained staff required to handle complications following vasectomy.)

Emergency TrolleyPresentation, Discussion (5 minutes)<Display Slide 6>

Explain:

• This slide shows an emergency trolley assembled for use in the procedure area or in the recovery area/room.

• Emphasize that even in routine settings, it is important to have the emergency tray in place.

• Refer participants to Handout # 16 and review the list of emergency equipment, drugs, and other supplies and when or in which emergency situation they should be used, as presented in the handout.

• Inform the participants that such emergency equipment and supplies are now commercially available as kits that can be easily carried around, especially for outreach services, but that also can find application at static facilities.

• Ask the participants to share their experiences on how their workstations are prepared to manage emergencies, particularly when performing minor surgical procedures such as vasectomy.

Allow some time for questions and comments and respond to these as needed.

Basic Slide Set VI: Slide 6: Emergency Trolley,

Handout #16: List of Emergency Equipment, Drugs, and Supplies

Emergency SituationsPresentation, Discussion (5 minutes)<Display Slide 7>

Explain:

Vasectomy is a simple procedure, and emergencies are very rare. However, if in unskilled hands, a client may experience significant bleeding. In most instances, this will not be life threatening, but if it is not promptly managed, the client’s condition may deteriorate. Excessive bleeding may also occur among clients with a history of coagulation disorders.

Signs of excessive bleeding include restlessness, rapid respiration,

Basic Slide Set VI: Slides 7–8: Rare Emergencies



tachycardia, falling blood pressure, etc.

Depending on the cause of the hemorrhage, it is important to identify the bleeders and ligate or cauterize them. If the bleeding is excessive, start intravenous fluids and take blood for cross-matching. Monitor vital signs.

Such situations may be prevented by doing proper client evaluation to identify conditions such as coagulation disorders and refer clients for specialized care, and by using gentle surgical techniques, especially when stripping the fascia to avoid severing the testicular artery.

<Display Slide 8>

Explain:

• Lidocaine toxicity is rare. It may occur if the recommended dosage of 4–5 mg/kg is exceeded or if the anesthetic (5 ml of 2%) is rapidly injected into the vessel. The signs of toxicity include tinnitus, restlessness, confusion, slurred speech, twitching, convulsions, and cardiac arrhythmias; in severe cases, respiration is depressed, and if it is not attended, it may lead to mortality.

• There is no antidote for lidocaine. Lidocaine toxicity is an emergency. Steps include controlling convulsions, ensuring that the client is breathing, and initiating cardiorespiratory resuscitation if there is evidence of respiratory depression or cardiac arrest. The patient may need referral to sites with high-dependency and intensive care facilities to manage such complications.

• To prevent such emergencies, when infiltrating the local anesthetic, always ensure that the needle is not in a vessel, by aspirating it before injecting the local anesthesia. Use of the newer devices that infiltrate anesthesia under high pressure eliminates the risk of lidocaine toxicity. However, such drugs are not readily available and may be costly when compared to lidocaine solution.

• Ask participants if they have any questions and respond to these as needed.


The Training Resource Package for Family Planning Vasectomy ModuleSession VII Infection Prevention

By the end of the session, participants will be able to:

• Describe infection prevention practices important to vasectomy

• Explain health workers’ responsibilities in infection prevention

• Demonstrate the appropriate infection prevention procedures to follow before, during, and after vasectomy

Demonstrate appropriate waste disposal procedures for the different kinds of waste during supervised practice on models and on clientsIntroduction and Session ObjectivesPresentation, Discussion (5 minutes)

<Show Slide 2>

Present the objective of the session as listed on Slide 2.

Ask if there are any questions and respond to these as appropriate.

Basic Slide Set VII: Slides 1–2 Session Objectives

Infection Prevention Practices Important to VasectomyPresentation, Brainstorming, Discussion (5 minutes)

<Show Slide 3>

Ask: “What are some of the activities that the vasectomy surgical team should follow as part of infection prevention?” Have one of the cotrainers write participants’ suggestions on a sheet of flipchart paper; allow some time for participants to respond.

The list should include the following

• Correct hand hygiene

• Consistent use of appropriate gloves

• Proper aseptic technique

• Correct use of and disposal of sharps

• Correct processing of instruments

• Maintenance of the operating area and waste disposal

Advance the slide to display content of the list and take time to go through the participants’ list.

Discuss commonalities and any discrepancies between what the participants mentioned and the list on the slide.

Tell the participants that they will review the implementation of key infection prevention practices as they relate to NSV services.

Basic Slide Set VII: Slide 3: Infection Prevention Practices Important to Vasectomy

Hand Hygiene Basic Slide Set VII: Slides


The Training Resource Package for Family Planning Vasectomy ModulePresentation, Brainstorming, Discussion (5 minutes)<Show Slide 4>

Ask: “Can any you define hand hygiene and also state when hand hygiene should be carried out?” Have one of the cotrainers capture the participants’ responses on a sheet of flipchart paper.

After responses from participants, explain:

Hand hygiene is a general term referring to any action of hand cleansing that includes:

• Washing hands with the use of water and soap or a soap solution, either nonantimicrobial or antimicrobial, OR

• Applying a waterless antimicrobial handrub to the surface of the hands (e.g., an alcohol-based handrub)

Ask: “When should hand hygiene be carried out?” Have one of the cotrainers capture the participants’ responses on a sheet of flipchart paper.

Advance the slide and compare the participants’ responses with the list in slides 4 and 5.

The list should include the following:

Immediately after arriving at work

Before examining a client

After examining each client

After touching anything including instruments or objects that might be/not be visibly contaminated by blood or other body fluids, or after touching mucous membranes (e.g., eyes, nose, mouth)


• Before putting on gloves for clinical procedures

• After removing gloves (Hands can become contaminated if gloves have invisible holes or tears.)

• After using the toilet or latrine

• Before leaving work at the end of the day (Explain that hand hygiene is performed at the end of the day before leaving work to reduce the risk spreading pathogens from the health facility to the community, including one’s family and relatives.)

Allow time for questions and comments and respond to these as appropriate.

4–5: Hand Hygiene

Kinds of Hand HygienePresentation, Discussion (3 minutes)<Display Slide 6>

Ask: “Can you name types of hand hygiene, and when it is appropriate to carry out each?” Allow time for the participants to respond. After a few responses, advance the slide to reveal the two kinds of handwashing, and

Basic Slide Set VII: Slide 6: Kinds of Hand Hygiene


The Training Resource Package for Family Planning Vasectomy Modulebriefly discuss when it is appropriate to carry out each.

Explain:

There are two kinds of hand hygiene—use of alcohol-based handrub and handwashing with soap and running water.

Use of an alcohol-based handrub is the preferred hand hygiene method when hands are not visibly soiled. It is also the WHO-recommended hand hygiene method.

It is a quicker and simpler way to improve hand hygiene among health care workers than handwashing with soap and running water.

Use of handrub kills or inhibits the growth of both transient and resident microorganisms, but it does not remove soil.

The handrub should be prepared at the facility using readily available supplies. Alcohol is the active ingredient, but because using alcohol alone tends to dry the skin, it is best to make an alcohol-based handrub solution by adding together 2 ml of glycerine, propylene glycol, or sorbitol and 100 ml of 60–80% alcohol.

Handwashing with soap (plain or antimicrobial) and running water (routine handwashing) is recommended when the hands are visibly dirty or soiled with blood or other body fluids (e.g., urine, feces) or when they are contaminated with proteinaceous material (e.g., mucous).

Handwashing with soap and running water should also be used for hand hygiene if alcohol-based handrub is unavailable.

(Note: Distinguish between hand hygiene and surgical scrub and tell the participants that surgical scrub will be discussed separately.)

Hand Hygiene Steps with Alcohol-Based HandrubPresentation, Demonstration, Discussion (2 minutes)<Display Slide 7>

Explain:

An alcohol-based handrub should take 20–30 seconds.

The following are the recommended steps of alcohol-based handrubs:

1. Apply a palmful of the product in a cupped hand, covering all surfaces.

2. Rub hands palm to palm.

3. Rub the right palm over the back of the left hand with interlaced fingers, and vice versa.

4. Rub palm to palm with the fingers interlaced.

5. Rub the backs of the fingers against the opposing palms, with fingers interlocked.

<Advance to Slide 8.>

6. Rotating, rub the left thumb clasped in the right palm, and vice

Basic Slide Set VII: Slides 7–8: Hand Hygiene with Alcohol-Based Handrub



versa.

7. Rotating, rub backward and forward with the clasped fingers of the right hand in the left palm, and vice versa.

8. Once dry, your hands are safe.

Ask if there are any questions and respond as needed

Proceed to demonstrate the use of alcohol-based handrub for hand hygiene.

Tell the participants that they will do a return demonstration of hand hygiene during simulation/clinical practice.

Aseptic TechniquePresentation, Discussion (5 minutes)<Display Slide 9>

Ask: “What do you understand by the term ‘aseptic technique’?” Take a few responses from the participants, then explain:• The term “aseptic technique” refers to the practices performed just

before or during a clinical or surgical procedure to reduce the client’s risk of infection by lessening the likelihood that microorganisms will enter areas of the body where they can cause infection.

<Advance the slide to reveal the various practices that constitute aseptic technique.>

• Such practices include:

o Surgical hand preparation and gloving

o Use of barriers to infection (i.e., surgical attire)

o Client preparation for clinical or surgical procedures

o Establishment and maintenance of a sterile field

o Use of good surgical technique

o Creation of a safer surgical area

Explain to the participants that you will shortly discuss each of these steps in detail.

Basic Slide Set VII: Slide 9: Aseptic Technique

Surgical Hand PreparationPresentation, Discussion (5 minutes)<Display Slide 10>

Explain:

• Surgical hand preparation, also referred to as surgical hand antisepsis or presurgical hand preparation, is defined by WHO as antiseptic handwash or antiseptic handrub performed preoperatively by the surgical team to eliminate transient flora and reduce residential skin flora.

Basic Slide Set VII: Slide 10: Surgical Hand Preparation


The Training Resource Package for Family Planning Vasectomy Module< Click to advance slide to each point.>

• The total aerobic bacterial count on the hands of a health worker ranges from 3.9 x 104 to 4.6 x 104 colony-forming units per square centimeter (CFU/cm2). Alcohol-based handrub and antiseptic soap have been shown to reduce the release of bacteria from hands that have been contaminated in a research setting. The extent of this reduction depends on several factors, including the duration of exposure to the antisepsis agent. We will revisit this issue as we discuss the different types of surgical hand preparation.

• The warm, moist conditions inside surgical gloves provide an ideal environment for the growth of microorganisms. Scrubbing with antiseptics before beginning surgical procedures will help prevent the growth of microorganisms for a period of time and will reduce the risk of infection to the client if a glove develops holes, tears, or nicks during the procedure. It is important that the antiseptic used is broad-spectrum and will maintain the bacterial release from the hands below the minimum baseline throughout the procedure. Most commercially available antiseptics in soap and waterless handrub preparations are required to meet such standards.

• Ideally, surgical hand preparation should be carried out before every procedure.

• Two types of surgical hand preparations are recommended

o Water-based surgical scrubbing, also referred to as surgical handscrub or presurgical scrub

o Alcohol-based surgical handscrub, also referred to as surgical handrub

• Ask if there are any questions and respond to these accordingly.

Steps for Handscrub with Alcohol-Based HandrubPresentation, Brainstorming, Discussion (5 minutes)<Display Slide 11>

Explain:

We shall now review each step for surgical handscrub with alcohol-based products, as recommended by WHO.

<Inform the participants that they are free to ask questions and make comments at any time as you present the steps.>

There are 17 steps to the surgical handscrub.

The technique must be performed on perfectly clean, dry hands.

Upon arrival in the operating theater or procedure area, and after having donned theater clothing or attire, the health care provider must wash his/her hands with soap and water.

After the operation, when removing gloves, the health care provider

Basic Slide Set VII: Slides 11–13: Steps for Handscrub with Alcohol-Based Handrub



must rub his/her hands with alcohol-based handrub or wash them with soap and water, if any residual talc or biological fluids are present.

The procedural steps for surgical handscrub are presented in correct sequence and must be carried out as shown in these slides.

Step 1: Put approximately 5 ml of alcohol-based solution into the palm of your left hand, using the elbow of your other arm to operate the dispenser.

Step 2: Dip the fingertips of your right hand into the solution to decontaminate under the nails (5 seconds).

Step 3: Smear the solution on the right forearm up to the elbow.

Steps 4–7: To ensure that the whole skin area is covered, use circular movements around the forearm until the solution has fully evaporated (10–15 seconds).

Respond to any questions or points of clarification, as needed.


Step 8: Put approximately 5 ml of alcohol-based solution into the palm of your right hand, using the elbow of your other arm to operate the dispenser.

Step 9: Dip the fingertips of your left hand into the solution to decontaminate under the nails (5 seconds).

Step 10: Smear the solution on the left forearm up to the elbow. To ensure that the whole skin area is covered, use circular movements around the forearm until the handrub has fully evaporated (10–15 seconds).

Step 11: Put approximately 5 ml of alcohol-based product in the palm of your left hand, using the elbow of your other arm to operate the dispenser. Rub both hands at the same time up to the wrists, and ensure that all steps represented in steps 12–17 are followed (20–30 seconds).

Allow time for questions, clarification, or comments, and respond to these as needed.

<Advance to Slide 13.>

Step 12: Cover the whole surface of the hands up to the wrist with alcohol-based solution, rubbing palm against palm with a rotating movement.

Step 13: Rub the back of the left hand, including the wrist, moving the right palm back and forth, and vice versa.

Step 14: Rub palm against palm back and forth with fingers interlinked.

Step 15: Rub the back of the fingers by holding them in the palm of the other hand, with a sideways back-and-forth movement.

Step 16: Rub the thumb of the left hand by rotating it in the clasped Last revised: 15 August 2018 Page 70 of 78


palm of the right hand, and vice versa.

Step 17: When the hands are dry, don sterile surgical clothing and gloves.

Note: Repeat the described sequence (average duration, 60 seconds) as many times as it takes to correspond to the total duration recommended by the manufacturer for surgical hand preparation with alcohol-based handrub. For example, if the manufacturer recommends that the handrub formulation is to be applied for three minutes, then this translates to repeating the sequence three times.

Allow some time for additional questions and comments.

Steps for Surgical Handscrub with Water and Bactericidal SoapPresentation, Discussion (5 minutes)<Display Slide 14>

Explain:

Water-based surgical scrub (simply known as surgical handscrub) is defined as the systematic washing of the fingernails, hands, and forearms with a bactericidal soap or solution in a prescribed manner for a period of 3–5 minutes before a surgical procedure. Not all medicated soaps are antimicrobial or antiseptic.

Some soaps are labeled antimicrobial or antiseptic but are not always appropriate for use in surgical hand scrub. Explain that there are standards to which health facilities need to adhere when supplies are being secured.

Water-based surgical handscrub:

o Is highly effective

o Is recommended when hands are soiled or visible dirty

o Requires clean running water.

o Should ideally be performed before every procedure

Ask: “Can anyone describe how water-based handscrubbing is done?” Allow one or two responses, then proceed.

Explain:

The WHO’s recommended protocol for surgical handscrub with medicated soap includes the following procedural steps:

1. Start timing. Scrub each side of each finger, between fingers, and the back and front of the hand for two minutes.

2. Proceed to scrub the arms, keeping the hands higher than the arms at all times. This helps to avoid recontamination of the hands by water from the elbows and prevents bacteria-laden soap and water from contaminating the hands.

3. Rinse hands and arms by passing them through the water in one

Basic Slide Set VII: Slide 14: Steps for Surgical Handscrub with Water and Bactericidal Soap



direction only, from the fingertips to the elbow. Do not move the arm back and forth through the water.

4. Proceed to the operating theater holding hands above elbows.

5. At all times during the scrub procedure, care must be taken not to splash water onto the surgical attire.

6. Once in the operating theater, dry hands and arms using a sterile towel and aseptic technique before donning gown and gloves.

7. To prevent skin irritation from too-frequent handscrubbing in high-volume settings, use 3–5 ml of an alcohol-based handrub solution between clients, rubbing hands together until the alcohol dries. Then scrub every hour or after every four clients (whichever comes first).

8. While washing with warm water is recommended because it makes the antiseptic and soap work more effectively, use of hot water should be avoided, as it removes more of the protective fatty acids from the skin.

Inform the participants that they will have time to practice handscrubbing during the practical sessions.


Use of Appropriate BarriersPresentation, Brainstorming, Discussion (5 minutes)<Display Slide 15>

Ask: “Can you list some of the protective barriers worn for infection prevention during surgical procedures such as vasectomy?” Have one of the cotrainers write all responses mentioned by participants on a sheet of flipchart paper, and allow some time for the participants to respond, until they have exhausted their ideas of the kinds of barriers used.

Explain that the role of these barriers is to break the disease transmission cycle.

Ask: “Can anyone quickly remind us of the disease transmission cycle?” Allow one or two responses, then advance the slide.

Explain briefly the transmission of infection using the diagram on the slide.

Refer the participants to the list of responses and click the mouse and confirm that the participants mentioned all of the barriers.

1. Emphasize that sterile gloves should be used for all vasectomy procedures and must be changed between clients.

2. Tell the participants that you will demonstrate the appropriate use of barriers when preparing for client examination and when demonstrating surgery.

Basic Slide Set VII: Slide 15: Use of Appropriate Barriers

Client PreparationPresentation, Brainstorming, Discussion (5 minutes)

Basic Slide Set VII: Slides 16–18: Client Preparation



<Display Slide 16>

Explain:

1. Infection prevention begins well before the preparation of the client for surgery. At the time of client evaluation for eligibility, it is important to examine the surgical site to ensure that there is no evidence of infection on the skin. In addition, the provider must also verify that the client does not have an acute infective illness such as diarrhea. If such conditions are present, the procedure should be delayed until the condition has been resolved.

2. Other precautions and client preparation actions to prevent infections include giving instructions to the client on relevant personal hygiene, such as cleaning the surgical site (external genitalia) well on the day of the surgery, wearing clean clothing, and not shaving the operation area. The client should also receive instructions on what to do in the postoperative period, to avoid contamination of the wound after surgery.

3. Prior to entering the procedure area, the client should also change into a surgical gown.

4. If upon examination before surgery the surgical site (scrotum and surrounding area) is visibly dirty, the provider should clean the operative site before surgery.

5. If the client has excessive hair at the surgical site, the hair can be trimmed. Avoid shaving the client, as this increases the risk of postoperative infection.

<Display Slide 17>

Ask: “Which antiseptics are used in your facilities for surgical skin preparation?” Allow a few responses, then click the mouse to reveal the preferred antiseptics.

Explain:

1. Preferred antiseptics include non–alcohol-based iodine compounds such as povidone iodine (Betadine) and chlorhexidine gluconate (Hibiclens, Hibitane, or Hibiscrub).

2. Alcohol or alcohol-based products should not be used to cleanse the genitalia, because they irritate the mucous membranes.

3. Hexachlorophene should never be used as an antiseptic, because it is potentially toxic to the nervous system.

4. Iodine, including tincture of iodine (which is alcohol-based), should not be used, because it irritates mucous membranes.

<Display Slide 18>

Explain:Last revised: 15 August 2018 Page 73 of 78


To prepare the surgical site, use a sterile sponge forceps to hold antiseptic-soaked gauze. The antiseptic should be at room temperature.

Apply the solution in a circular motion, starting from the surgical site and working outward. (Do not permit excess antiseptic to pool underneath the client.)

After preparing the surgical site, cover the area with a sterile surgical drape. The appropriate drape for vasectomy is the fenestrated drape, with a small enough opening that allows the surgeon to expose only the scrotum by pulling it through the opening.

Ask if there are any questions or comments and respond to these as needed.

Establishing a Sterile Surgical FieldPresentation, Discussion (5 minutes)

<Display Slide 19>

Ask: “How does one establish a sterile surgical field?” After a few responses, click the mouse to advance the slide.

Explain:

1. The sterile field includes all sterile drapes, the front of the sterile gowns worn by the surgical team (from waist to neck, and from fingertips to elbow), and the instrument tray.

2. To establish a sterile field, the surgical team must do the following

• Complete a surgical handscrub

• Don a sterile gown and surgical gloves

• Prepare the surgical site with antiseptics

• Drape the client with sterile drapes

• Set up a sterile surgical instrument tray

Ask of there are any questions and respond to these as needed.

Basic Slide Set VII: Slide 19: Establishing a Sterile Surgical Field

Maintaining a Sterile FieldPresentation, Discussion (5 minutes)<Display Slide 20>

Ask: “What should you as a member of the surgical team do to maintain a sterile field?” After a few responses, click the mouse and review the content of the slide.

Explain:

The surgical team can maintain a sterile field by doing the following:

• Allow only sterile items and personnel within the sterile field

• Always be conscious of where you are and move within or around the

Basic Slide Set VII: Slides 20–21: Maintaining a Sterile Field



sterile field

• Place only sterile items within the sterile field

• Do not contaminate items when opening, dispensing, or transferring them

• Consider any sterile item that has been penetrated (cut, made wet, or torn) to be contaminated


• Consider items located below the level of the draped client to be nonsterile

• Recognize that the edges of a package containing sterile items are nonsterile

• When in doubt as to whether an item is still sterile, consider it contaminated

• Never set up a sterile field near a door or open window

Allow time for comments and questions, and respond to these, as needed.

Infection Prevention Practices during the Vasectomy ProcedurePresentation Discussion (5 minutes)<Display Slide 22>

Explain:

To reduce the risk of infection during the NSV procedure:

1. The surgeon and team should observe safe injection practices (when withdrawing the local anesthetic with a syringe and needle and using it to anesthetize the operation area).

2. The surgeon must exercise good surgical techniques, as recommended in the learning guide.

3. The surgeon must pay meticulous attention to avoiding blood vessels, such as the vas artery, and in the event it is severed, to arrest the bleeding so as to avoid hematoma formation.

4. Gentle handling of tissue during surgery will reduce the risk of infection. Postprocedure infections are most likely to occur when tissues have been damaged through rough handling or excessive manipulation during surgery or when there is excessive bleeding.

5. At the end of the procedure, the wound should be appropriately dressed, to ensure that it does not become contaminated.

Basic Slide Set VII: Slide 22: Infection Prevention Practices during the Vasectomy Procedure

Infection Prevention Practices after the Vasectomy ProcedurePresentation, Brainstorming, Discussion (5 minutes)<Display Slide 23>

Ask: “What are some of the tasks performed to prevent the spread of infection immediately after the vasectomy procedure?” After a few responses from the participants, click the mouse to advance the slide.

Basic Slide Set VII: Slide 23: Infection Prevention Practices after the Vasectomy Procedure



Explain:

Tasks performed immediately after the vasectomy procedure to prevent the spread of infection include:

Hand hygiene

Instrument processing

Processing of linens for reuse

Waste disposal

Maintenance of the operating area

Instrument ProcessingPresentation, Discussion (15 minutes)<Display Slide 24>

Ask: “How are reusable surgical instruments processed at your facilities? Allow a few participants to share their experiences.

Refer the participants to Handout #17, on processing reusable instruments.

Explain:

The 2016 WHO guideline on decontamination and reprocessing of medical devices for health care facilities recommended the policy for local decontamination should follow the Spaulding classification.

That is:

o Devices that are involved with broken skin or mucous membranes or sterile body cavities (such as NSV instruments) should be decontaminated using sterilization.

o Devices in contact with mucous membranes or body fluids, such as bedpans, urine bottles, and respiratory equipment, should be decontaminated using high-level disinfection.

o Devices in contact with intact skin, such as stethoscopes and blood pressure machine cuffs, only require cleaning.

It is important to emphasize that WHO no longer recommends decontaminating instruments by soaking them in 0.5% chlorine solution for no more than 10 minutes as the first step in instrument processing. Instead, it recommends that instruments be thoroughly cleaned.

Instrument processing includes the following steps:

Step 1—Cleaning. It is now recommended that all used instruments be prepared for decontamination at the point of use. Point-of-use instrument processing begins with removal of gross soiling from instruments, by wiping them with a damp, clean cloth. Soaking or spraying before cleaning prevents soil from drying on the devices, making them easier to clean. If applicable, instruments such as the

Basic Slide Set VII: Slide 24: Instrument Processing

Handout #17: Processing Instruments for Reuse



Graves speculum should be disassembled during cleaning. Other hinged instruments must be opened to ensure access to all surfaces. Scrubbing with a brush, detergent, or enzymes (recommended by the manufacturer) and water removes blood, other body fluids, organic material, tissue, and dirt. Items should then be rinsed with clean running water. Cleaning greatly reduces the number of microorganisms. If cleaning has not been done, sterilization may not be effective. Staff should always wear utility gloves when cleaning instruments; all sharps should be disposed of correctly in puncture-proof containers, to guard against injury from sharp objects.

Step 2: Inspection and Function-Testing of Instruments, and Assembly and Packaging. All instruments in the vasectomy set should be inspected after cleaning. Joints of forceps and serrations should be inspected for cleanliness. Hinged devices such as scissors and forceps should be checked for ease of movement and alignment of jaws and teeth, and they should be tested whether they are functioning correctly. Any defective or malfunctioning instruments should be replaced. The next step is to assemble all vasectomy instruments on the tray before packaging/wrapping and labeling them. Instruments should be assembled in the tray to ensure ease of use by the surgical team. Double-wrapping is recommended. Material for wrapping instruments should be permeable to steam and gaseous sterilants, but resistant to penetration by microorganisms following sterilization. Use of metal sterilization drums with fenestrations that can be opened manually is no longer recommended.

Step 3: Sterilization. Sterilization destroys all microorganisms, including bacterial endospores. It is recommended for instruments and other items that come into contact with the bloodstream or with tissues under the skin. Sterilization can be performed using steam (autoclave), dry heat (electric oven), or chemicals. Note that high-level disinfection is not recommended as an acceptable alternative to sterilization for reprocessing vasectomy instruments.

Step 4: Storage: The final step in instrument processing is proper storage to prevent instruments from becoming contaminated. It is as important as decontamination, cleaning, and sterilization.

Allow questions and comments and clarify these as needed.

Inform the participants that they will have a chance to demonstrate their instrument processing skills during the practice sessions in the clinical area.

Waste Disposal and Maintenance of the Operating AreaPresentation, Discussion (5 min.)<Display Slide 25>

Show the slide and draw out the experiences of the participants concerning their waste management and operating-area maintenance practices by asking the following questions:

Basic Slide Set VII: Slide 25: Waste Disposal and Maintenance of the Operating Area



• What are some of the wastes that you generate at your facility?

• How do you treat these different kinds of waste?

• Which types of color-coded bins do you have?

• Which wastes do you put in each color-coded bin?

• Do you have heavy-duty gloves at your facility? Are they used when handling wastes?

After receiving responses from the participants, explain:

Management of waste from a vasectomy procedure is no different from what should be done routinely.

• Surgical wastes should be segregated at the point of generation and held in appropriate color-coded bins, as per guidelines.

• Sharps should be disposed of in puncture-proof sharps containers.

• Operating tables, counters, and instrument carts should be cleaned between clients.

• The procedure area or operating theater should be cleaned on a daily basis, preferably before beginning procedures, and at the end of the day, after the last procedure.

• Any bodily fluids spilled on the floor should first be decontaminated with 0.5% chlorine solution before being wiped up.



· Web view Explain: The figure on this slide includes a list of contraceptive methods, arranged from the most effective method at the top to the least effective

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