Abortion

Dilation and evacuation

Performed during the second 12 weeks of pregnancy—that is, between 14 and 20 weeks since the start of your last menstrual period—dilation and evacuation usually involves a combination of vacuum aspiration, dilation and curettage, and the use of surgical instruments such as forceps. It is safe and is also the most common procedure used for abortion in the second trimester.

Vacuum aspiration (also called suction aspiration) is used to clear the contents of the uterus. The cervix is first dilated and antibiotics are given to prevent infection. A hollow tube attached to a pump is then passed into the uterus. When the pump is turned on, suction from the device removes pregnancy tissue from the uterus.

Dilation and curettage involves the use of instruments inserted through the vagina to scrape and suction tissue from the endometrium (lining of the uterus).

Before your dilation and evacuation, your doctor will want to perform an ultrasound to determine the size of your uterus and the date of conception.

The day before your D&E, a cervical dilator is inserted into your cervix to slowly dilate it. This device (called an osmotic dilator), when placed in a closed cervix, absorbs moisture from the tissues surrounding the cervix. This causes the device to swell and to open the cervix slowly, with little discomfort. Dilation of the cervix reduces the risk of injury to the cervix during the abortion procedure.

Usually performed in a hospital or abortion clinic, dilation and evacuation typically lasts 30 minutes but does not require an overnight stay.

What will happen?

During your D&E procedure, your doctor will give you antibiotics to prevent infection. You'll then be positioned on the table in the same position as for a pelvic exam: lying on your back with your feet in stirrups. The doctor will then use a speculum to open your vagina. Once your vagina and cervix are cleaned with an antiseptic solution, you'll be given an injection of paracervical block (a pain medication) in the cervical area as well as a sedative.

If your procedure is performed in a hospital operating room, you could receive an injection of anesthesia into your spine. Injection of anesthetic into the fluid surrounding your spinal cord numbs the area between your legs. Alternatively, you could be put under a general anesthetic, which means you will be asleep throughout the dilation and evacuation procedure.

The doctor will then grasp your cervix with an instrument designed to hold the uterus in place. Your cervix will then be dilated using probes of increasing size. An abortion performed during the second 12 weeks of pregnancy requires the cervix to be dilated more than is needed for a vacuum aspiration.

Once the cervix is sufficiently dilated, a thin, hollow tube called a cannula is passed into the uterus. The cannula is attached to a bottle and a pump. The pump provides gentle suction used to remove the pregnancy from the uterus.

A loop-shaped instrument called a curette is then used to gently scrape the endometrium (lining of the uterus) and remove tissue from the uterus.

Forceps are passed into the uterus to grasp larger pieces of tissue. The use of forceps is more likely in pregnancies of 16 weeks of more; this is done before the uterine lining is scraped with a curette.

Suction may be used as a final step to ensure all pregnancy contents are removed from the uterus. Tissue removed during a dilation and evacuation procedure is examined to ensure all pregnancy tissue was removed and that the abortion is complete. Your doctor may also perform an ultrasound during the procedure to confirm that all tissue was removed and that the pregnancy is ended.

A medication such as Vasopressin may be administered to reduce the amount of bleeding from the procedure.

What can I expect after surgery?

Immediately following your surgery, you'll be taken to a recovery area where nurses will observe you and care for you. You will stay in the recovery room from 1 to 4 hours. Before you are discharged, your doctor or nurse will give you special instructions and information to help you in your recovery. You will likely be given a sheet with these instructions and the names and numbers of whom to contact if a problem arises.

Once you return home following your abortion, rest quietly. You may feel tired. You may also experience pain, cramping, and light vaginal bleeding. You may also experience other side effects such as nausea, diarrhea, headache, constipation, or gas. In order to feel better and recover quickly, it's important to limit your activity and to increase it slowly. Rest when you need to, and be sure to get enough sleep.

Depending how you feel the following day, you should be able to resume normal activities. You may experience pain: medications such as Ibuprofen (Advil) or Acetominophen (Tylenol) can help relieve cramping pain.

Following surgery, you can expect to have irregular bleeding or spotting during the first 2 weeks. During the first week, avoid tampons and use only pads. You'll also want to avoid rinsing your vagina with douche or other fluids.

You may be given medication to help your uterus contract and return to its pre-pregnancy state. As this happens, you'll experience cramps similar to menstrual cramps. They may be present for several hours or possibly a few days. Some women experience cramps for up to 6 weeks after their abortion.

You'll want to avoid sexual intercourse until you are fully recovered and the bleeding has stopped—usually 2 to 3 weeks. You can begin birth control pills immediately following the procedure, but be sure to use a condom during the first weeks of intercourse to prevent infection.

You can also expect emotional reactions for 2 to 3 weeks.

What are the advantages of dilation and evacuation?

• This is the only procedure available for abortions performed during the second trimester

What are the disadvantages and risks?

• This procedure is riskier than the others described in this section.
• Because of the instruments used to suction and scrape the uterus, injury to the cervix or uterus is possible. Although rare, perforation of the uterus (hole in the uterus) is also possible and occurs most commonly during cervical dilation. Bleeding is usually minimal, and no repair is necessary.
• Because bacteria can enter the uterus during the procedure, infection is possible. This is more likely in the case of an untreated disease or sexually transmitted infection. Symptoms, which usually occur within 2 to 3 days of the procedure, include nausea, fever, pain, or abdominal tenderness. In order to reduce the risk of infection, be sure to finish all of your prescribed antibiotic medications.
• Hemorrhage (moderate to severe bleeding) sometimes caused by injury to the uterus or cervix, perforation of the cervix, or uterine rupture. Although rare, the scar from an upper uterine incision may tear open when medication is used to induce labor.
• Risks increase with surgical abortions performed during the second trimester of pregnancy, particularly if performed after the sixteenth week of pregnancy.

Although rare, other complications include:

• Tissue remaining in the uterus. This can lead to recurrent cramping, abdominal pain, and bleeding within a week of the procedure. Prolonged bleeding, however, may not develop until some weeks later.
• If the uterus doesn't contract to push out all pregnancy tissue, the opening to the cervix may become blocked, thereby preventing blood from leaving the uterus. When this occurs, the uterus becomes enlarged and tender, resulting in abdominal pain, cramping, nausea, and blood clots.

Where blood clots occur or some pregnancy tissue remains in the uterus, a repeat vacuum aspiration is performed and medication to stop bleeding is administered.

What about my fertility?

An abortion rarely affects a woman's ability to become pregnant in the future. Because it is possible to become pregnant in the weeks right after an abortion, you should consider the various methods of birth control available to you and your partner to prevent another unplanned pregnancy. You should also avoid sexual intercourse until your body has fully recovered—usually at least 1 week or as advised by your doctor. Use birth control in the first weeks following your abortion, and be sure to use condoms as well—to prevent infection.

How will I feel?

Some women find it very emotionally difficulty to cope with having had an abortion. In fact, between 5 and 30 percent report feelings of anxiety, guilt, or mild depression. It's normal to experience a broad range of emotions after an abortion—from relief and happiness to sadness, shame, regret, guilt, grief, and loss. There are as many reactions as there are women and each woman is unique.

Most women feel they have made the right decision; it's rare for them to become clinically depressed following an abortion. However, if your feelings are overwhelming and persistent, or if you have a previous history of depression, you should consult a professional therapist. (Refer to Finding and Evaluating a Therapist for more information.) Depression is a very serious illness.

Consider counseling even if you feel "OK"—abortion is a weighty issue and there is no "right" or "normal" way to feel about it: every woman is different.

Understanding your emotions and taking care of yourself are important: doing so can help you let go of pain and start to heal. Talk to your partner, friends, or family to let them know what you're feeling. You may also want to consider professional counseling. If you're not sure where to go for counseling, talk to your abortion provider: most providers can refer you to counseling services to assist you in dealing with your feelings.