Abortion Methods: Dilation & Extraction (D&E Abortion)

What is a Dilation and Evacuation Abortion?

Dilation and Evacuation (D&E, also sometimes called Dilatation and Evacuation) is the most common type of surgical abortion during the second trimester in the United States. [1] A dilation and evacuation abortion implies two parts. The cervix must first be “prepared”, meaning dilated wide enough for the fetal parts to fit through. The second part is to dismember and remove or “evacuate” the fetus piece by piece.

History of D&E Abortion

Dilation and evacuation abortions were first performed in the United States in the 1970s. Dr. David Grimes, a late-term (including the second half of the second trimester and into the third trimester) abortion doctor published a research study on D&Es in 1977. [2] The biggest challenge in performing D&Es has always been getting the cervix to dilate, since its natural tendency at that point in the pregnancy is to remain closed. Japanese and European abortion doctors first developed a way to dilate the cervix gradually over several days with sterilized seaweed, called laminaria. Later on, synthetic dilators such as Dilapan and Lamicel allowed for even more dilation. Once greater dilation could be achieved, larger instruments could be used to reach through the cervix into the uterus to remove fetal body parts. Dr Warren Hern, another currently-practicing abortion doctor, developed instruments to rotate fetal body parts before removing them from the uterus. [3]

What percentage of Abortions are D&E Abortions?

The Centers for Disease Control (CDC) collect abortion data each year, and the results of their data collection are available online through the year 2014. [4] Abortion data since 2014 have not yet been published. States and several large cities like Washington D.C. and New York City have the option to report their data to the CDC each year or not. For 2014, California, Maryland, and New Hampshire abortion numbers were not reported. In the CDC report, abortion methods are classified as surgical or medical (medication). They report 652,639 abortions total, and almost 47,000 abortions in the second trimester.[5]

The second trimester typically refers to between 12 and 26 weeks after the last menstrual period. Some estimates say that up to 96% of abortions between 14 and 20 weeks along are D&Es. This statistic may not be accurate, though, because it comes from Centers for Disease Control and Prevention (CDC) data that also include other abortion methods. [6]

What happens during a D&E Abortion?

Cervical Preparation

“Cervical preparation” is recommended for all pregnancies over 12-14 weeks to reduce the risk of complications. [7] Dilating the cervix adequately is especially important for four groups of women. These include: teenagers, women with abnormal cervical anatomy, women who have had medical procedures done to their cervix before such as a colposcopy or cervical biopsy or LEEP (loop electrosurgical excision procedure), and women past 20 weeks gestation. [8] All of these groups have a higher likelihood of injury to the cervix and perforation or puncture of the uterus.

Different combinations of medicines and sometimes sterilized seaweed called laminaria or long, thin, synthetic rods called Dilapan-S or medicated sponges called Lamicel may be used to dilate or open the cervix so that the abortion tools and fetal body parts can fit through. [9]  The sponges and laminaria swell to absorb the amniotic fluid, forcing the cervix open. The medications chemically cause contractions and cervical softening and opening. One combination of medicines includes the same two medications, Misoprostol and Mifepristone, which are used for medical abortion in the first trimester.

Dilation of the cervix varies from one abortion doctor to another. Some of them start the process two days before the abortion, some the day before the abortion, and some just four hours before the abortion is performed. [10] Often, antibiotics will be given when the laminaria or other synthetic materials are placed to prevent infection. [11] More laminaria or Dilapan-S or Lamicel may be added to the cervix every few hours, or what’s currently in place may be removed and new materials may be placed.

Procedure Day

The day of the abortion, a brief history and physical are performed, blood samples are taken to check for sexually transmitted infections, an antibiotic pill will be given, and an ultrasound will be done. After the cervix has been dilated, the dismemberment and removal process only takes about 30 minutes. [12] The woman may be given pain medication such as Ibuprofen, anti-anxiety medication such as Valium, and some type of local anesthesia shot or shots to numb the cervix. Sometimes intravenous (IV) sedation medicine or general anesthesia are given since D&E is associated with significant pain, but general anesthesia also has higher complication rates than local anesthesia.

Dilation & Extraction

Once the pain and anxiety medications are given, the abortion doctor inserts a speculum, the same cold, metal gripping tool used during Pap smears in OB/GYN offices. The speculum may be weighted if the woman is past 16 weeks along. The speculum widens the vagina and makes the cervix more visible so that the abortion doctor can see what he or she is doing. A tenaculum is a gripping instrument with long handles and a clamp at the end that moves the cervix closer to the vaginal opening. Tenaculum may have sharp metal teeth to help hold the cervix in place. Ultrasound is often used to guide the abortion doctor. Dilators such as Dilapan-S or Lamicel or laminaria are removed. [13]

If the woman is less than 16 weeks along, the abortion doctor may be able to suction out the fetal parts like in a vacuum abortion. Once the fetus is older than 16 weeks, though, forceps are required. Forceps are grasping instruments used to grasp, crush, twist, and pull fetal body parts such as arms and legs or pieces of arms and leg out. The fetal head and spinal column often have to be crushed before they can be removed, especially the farther along the woman is. After the body parts are removed, the placenta is suctioned or scraped out, usually with the abortion doctor placing his hand on the woman’s stomach to help feel for it in the uterus.

After this, the abortion doctor or other staff have to reassemble all of the body parts to make sure that no fetal bone or other tissue remains.

At what point does the fetus die during the Abortion?

The World Health Organization suggests inducing fetal demise, making sure that the fetus is dead before the abortion, for women 20 weeks or more pregnant. This is because the fetus is easier to dismember if it is not moving. The two medications used together for first trimester medication abortion do not technically cause fetal death. In those abortions, the fetus typically dies during the violent contractions they cause. Similarly, and because the fetus is bigger, when one or both of those medicines are used to dilate the cervix before a second trimester abortion like a D&E, they are not expected to cause fetal death.

Fetal death is typically achieved through injection of a medication such as Potassium Chloride or Digoxin into the amniotic sac that holds the fetus. Potassium Chloride is very effective but requires a highly skilled doctor because accidentally injecting it into the mother’s bloodstream could kill her instead of the fetus. Potassium Chloride kills the fetus almost immediately, and the abortion doctor uses ultrasound to watch for the heart to stop beating. Digoxin, on the other hand, takes more time to stop the fetal heartbeat, but is safer for the woman, especially in cases of accidental injection into her bloodstream. It is less effective than Potassium Chloride in killing the fetus, and because it takes longer to act is often given one day before the abortion. This means an additional office visit for the woman seeking an abortion.

When fetal death is not induced before the D&E, the fetus dies when the abortion doctor crushes its skull with large forceps.

What are the Side Effects or Complications of a D&E Abortion?

Expected side effects include:

  • Pain, may be severe, especially if general anesthesia is not used[14]
  • Cramping
  • Bleeding

Serious complications include:

  • Cervical injury
  • Uterine perforation
  • Infection
  • Life-threatening hemorrhage (bleeding)
  • Uterine rupture
  • Incomplete abortion due to body parts or placenta or other tissue left inside the uterus
  • Disseminated intravascular coagulopathy (life-threatening blood clotting and bleeding)
  • Anesthesia-complications such as respiratory depression[15]

Both cervical injury and uterine perforation can lead to life-threatening hemorrhage or bleeding. [16] A weakened or damaged cervix may lead to preterm labor or preterm premature rupture of membranes (bag of waters breaking) in future pregnancies. Either one of these conditions can end in miscarriage or in the baby being born before 37 weeks and having brain, lung, heart, and other problems. [17]

How often do Complications occur?

While only about 10–15% of all abortions are done in the second trimester, they are responsible for roughly two-thirds or 66% of all major complications. [18][19] Risk of death from second trimester abortion is over 20 times higher than from first trimester abortion. [20] Risk of death from abortion increases by 38% each week starting in the second trimester. [21] Generally, serious complications occur in about 1 in every 100 women who undergoes D&E abortion. [22] [23] [24]

Citations:

[3] Cassing Hammond MD, and Stephen Chasen MD, “Dilation and Evacuation,” Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009), 158.

[6] Jatlaoui, T. C., A. Ewing, M. G. Mandel, K. B. Simmons, D. B. Suchdev, D. J. Jamieson, and K. Pazol. 2016. Abortion surveillance—United States, 2013. MMWR Surveillance Summaries 65(12):1–44.

[11] Cassing Hammond MD, and Stephen Chasen MD, “Dilation and Evacuation,” Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009), 171.

[13] Cassing Hammond MD, and Stephen Chasen MD, “Dilation and Evacuation,” Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009), 172.

[19] Cassing Hammond MD, and Stephen Chasen MD, “Dilation and Evacuation,” Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009), 179

[22]  Grimes DA et al: Mifepristone and misoprostol versus dilation and evacuation for midtrimester abortion: a pilot randomised controlled trial. BJOG 2004 Feb;111(2):148-53;

[23] Kelly T et al: Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomized controlled trial. BJOG 2010 Nov;117(12):1512-20

[24] Turok DK et al: Second trimester termination of pregnancy: a review by site and procedure type. Contraception 2008 Mar;77(3):155-61

Abortion Methods: D&X Abortion (Partial-Birth Abortion)

Dilation & Extraction (D&X), also known as Partial-Birth Abortion or Intact D&E or Intact D&X

What is a Dilation & Extraction Abortion?

From the law banning dilation & extraction abortions in 2003,  the legal definition of a D&X abortion is: “the person performing the abortion deliberately and intentionally vaginally delivers a living fetus until, in the case of a head-first presentation, the entire fetal head is outside the body of the mother, or, in the case of breech presentation, any part of the fetal trunk past the navel is outside the body of the mother or, in the case of breech presentation, any part of the fetal trunk past the navel is outside the [mother’s] body . . . , for the purpose of performing an overt act that the person knows will kill the partially delivered living fetus; and performs the overt act, other than completion of delivery, that kills the fetus.” [1]

History of D&X Abortion

Independently of each other, Dr Martin Haskell, an abortion doctor from Ohio, and another abortion doctor in California started performing intact D&Xs on some women more than 16 weeks pregnant in the early 1990s. In 1992, Dr Martin Haskell presented a paper on intact D&Xs at a medical conference of the National Abortion Federation. Intact D&X abortions theoretically would have decreased complication rates because an intact delivery of the dead fetus would mean less likelihood of retained fetal body parts and tissue. Also, delivering the dead fetus aborted because of a medical anomaly (something wrong with the fetus potentially preventing it from living long or at all outside the womb) whole as opposed to in parts could potentially make for a better autopsy. Finally, delivering the dead baby whole could give his or her parents the opportunity to hold him/her and grieve his/her death. [2]

Court Cases

In 1997, Nebraska banned intact D&X abortions, which Supreme Court Justice Anthony Kennedy later called “a procedure many decent and civilized people find so abhorrent as to be among the most serious of crimes against human life.”[3]

In 2000, Stenberg vs Carhart, the Supreme Court struck down Nebraska’s ban on intact D&X abortions. Stenberg vs Carhart said that the ban was invalid because, among other reasons, it did not include an exception to allow for the life of the mother.  Partial birth abortion was later made illegal throughout the entire United States by a Supreme Court decision in 2003. In that ruling, the Supreme Court determined that an intact D&X abortion “is a gruesome and inhumane procedure that is never medically necessary and should be prohibited.” [4]

Two court cases, Carhart vs Ashcroft in 2003 and Planned Parenthood Federation of America vs Ashcroft in 2004, challenged this court ruling. In 2007, Gonzalez vs Carhart, the Supreme Court upheld the 2003 ban on intact D&X. [5] 

What percentage of Abortions are D&X Abortions?

Less than 0.5& of all abortions were estimated by Alan Guttmacher Institute (in 2006) to be D&X abortions. Now that this type of abortion is illegal, numbers are no longer tracked. However, video footage obtained during an undercover investigation by the Center for Medical Progress suggests that at least some Planned Parenthood affiliates may still be doing D&X abortions. The purpose of doing these D&X abortions would be to get intact fetal specimens for body part harvesting and sale. In the video, Dr Suzie Prabhakaran, an abortion doctor and Planned Parenthood medical director, described “checking a box” on abortion documentation to say that the doctor intended to use dismemberment, also known as the D&E (dilation & evacuation) method. If the fetus were actually aborted by D&X, the law would not technically be broken because the documented intent was to abort by dismemberment. [6]

Previously, another abortion doctor and Planned Parenthood executive named Dr Deborah Nucatola was recorded speaking about D&X abortions happening in Planned Parenthood clinics. She stated: “The Federal [Partial-Birth] Abortion Ban is a law, and laws are up to interpretation. So there are some people who interpret it as it’s intent. So if I say on Day 1 I do not intend to do this, what ultimately happens doesn’t matter.” [7]

What happens during a D&X Abortion?

Dilation

The “d” in D&X stands for “dilation,” and this starts one or more days before the abortion. The cervix typically has to be dilated more than with suction or D&C abortions because the baby is bigger. Oftentimes osmotic cervical dilators called laminaria start the process. Laminaria are long, thin rods of sterilized seaweed, and they soak up the amniotic fluid. This stretches and opens the cervix. Sometimes synthetic osmotic cervical dilators like Dilapan-S may be used instead. On the day of the abortion, Misoprostol, the early abortion pill, is often given to increase the dilation. If needed, surgical instruments may be used to manually stretch and open the cervix.

Extraction

After the cervix is adequately dilated, the abortion doctor pulls the baby feet first (this is called a breech presentation) until only its head remained inside. Then, the doctor punctures the head or back of the neck with sharp surgical scissors or a trochar, a hard, pointed metal tool. Then, they suction the fetus’ brain tissue out into a catheter which collapses the skull. The fetus is then delivered the rest of the way. [8]

Testimony

From testimony by a nurse for abortion provider Dr Martin Haskell, given during 2007 court case:

“Dr. Haskell went in with forceps and grabbed the baby’s legs and pulled them down into the birth canal. Then he delivered the baby’s body and the arms, everything but the head. The doctor kept the head right inside the uterus. . . . The baby’s little fingers were clasping and unclasping, and his little feet were kicking. Then the doctor stuck the scissors in the back of his head, and the baby’s arms jerked out, like a startle reaction, like a flinch, like a baby does when he thinks he is going to fall. The doctor opened up the scissors, stuck a high powered suction tube into the opening, and sucked the baby’s brains out. Now the baby went completely limp. . . . He cut the umbilical cord and delivered the placenta. He threw the baby in a pan, along with the placenta and the instruments he had just used. [9]

Variations on this procedure include: crushing the fetal skull with forceps, squeezing the fetal skull until the brain tissue oozes out and the skull collapses, or twisting the fetal head until it comes off of the rest of the body (decapitating it). [10]

At what point does the fetus die during the Abortion?

Typically, the fetus dies when the skull is pierced and the brain tissue is suctioned out.

What are the side effects of a D&X Abortion?

D&X abortion has the same general risks as any other surgical method of second trimester abortion. These include:

  • Non-white women undergoing surgical abortion are more than twice as likely as white women to die from the procedure
  • Obese women undergoing surgical abortions are more likely to have greater blood loss and increased procedure time
  • Retained fetal tissue, placenta, or amniotic sac can lead to life-threatening infection
  • Hematometra (abnormal collection of blood in the uterine cavity)
  • Bleeding severe enough to require a blood transfusion
  • Uterine atony (failure of the uterus to contract after abortion, causing uncontrolled bleeding)
  • Disseminated intravascular coagulopathy (life-threatening blood clotting and bleeding disorder)
  • Infection (may require hospitalization)
  • Cervical injury
  • Uterine perforation (hole punctured in the uterine wall)
  • Asherman syndrome (scarring of the uterine lining or in the cervical canal potentially causing infertility, miscarriage, or preterm delivery in future pregnancies)
  • Deep vein thrombosis (potentially life-threatening blood clot, usually in legs)
  • Pulmonary embolism (life-threatening blood clot in one or both lungs)
  • Amniotic fluid embolism (amniotic fluid from fetal amniotic sac enters the mother’s blood stream)[11]

How often do Complications occur?

Between 1 and 2 of every 100 women who have a second trimester intact D&X abortion could expect to experience one or more of the serious complications listed above. [12]

Citations:

[2]Cassing Hammond MD, and Stephen Chasen MD, “Dilation and Evacuation,” Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009) 193.

[11] Cassing Hammond MD, and Stephen Chasen MD, “Dilation and Evacuation,” Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009), 244-264.

[12] Ibid.