Explanation of the Procedures

Once your pregnancy has been confirmed, and the doctor knows how many weeks along the pregnancy is, and you have decided to end the pregnancy, the procedure offered typically reflects your stage of gestation. Early abortions can be accomplished medically or surgically, but most facilities do not have the protocols established or personnel with the technical ability to offer medical abortions (with pills). Therefore, most abortions are performed surgically.

• Women often travel far for their abortion procedure and feel comfortable completing the preoperative preparation in a short office visit. In states where laws require waiting periods, this can be done in stages.
  
  
• The assessment process involves only a targeted history, physical examination, laboratory work, and ultrasound (including dating of the pregnancy, if indicated) followed by a counseling session.
  
  
• Second-trimester abortion preparation is more difficult. Preparing the cervix in less than 24 hours is almost impossible, but the basic assessment process is identical.
  
  
• Ultrasound examinations may be used to look specifically for obvious problems with the fetus.
  
  
• Some centers also offer an intra-amniotic injection of the drug digoxin, which stop heart activity in the fetus before a second-trimester abortion.

Medical abortion

• First- and second-trimester medical abortion
  
  
  • First-trimester (first three months of a pregnancy) terminations are accomplished medically with misoprostol alone, methotrexate-misoprostol combination regimens, or Mifeprex (RU-486) with or without misoprostol. Other prostaglandins are used in other countries.
    
    
  • Medical abortions are indicated for women who consent to a medical abortion but are also willing to undergo a surgical abortion if the medical abortion fails. Gestational age is usually less than 42-49 days, but many protocols can be used, including for gestations up to 63 days from the last menstrual period.
    
    
  • The Mifeprex/misoprostol drugs are given as follows:
    
    
    • On day one, Mifeprex (200mg or 600mg) as pills are taken by mouth in the doctor's office.
      
      
    • On day two or three, misoprostol (800mcg is taken as pilsl or inserted vaginally) or in an office setting with four hours of observation.
      
      
    • Between days 7 and 10, you return to the office to determine if the abortion has been completed.
      
      
    • If it has not, a repeat dose of misoprostol is given or you may undergo a surgical abortion.
      
      
    • About 50% will abort in the first three days, about 80% of patients by the next day, and only about 5% of patients will need a surgical abortion.

• The methotrexate/misoprostol regimen is similar, as follows:
  
  
  • Methotrexate is injected on day one.
    
    
  • On days six to seven, misoprostol is taken at home vaginally, and you return to the office on day eight to determine if the abortion has taken place. Misoprostol can be repeated with monitoring, or surgical abortion may be completed.

• Prostaglandin-induced second-trimester abortion: Medication can be given vaginally, orally, or injected into the fetus. The most typical regimen is usually 200mcg vaginally every four hours until the process is complete.
  

• Saline-induced abortion: A long process that was used 20 years ago is not often performed but is safe.
  

Surgical abortion

• Cervical dilatation and preparation
  
  
  • For a first-trimester termination, particularly at less than 10 weeks' gestation, rarely do you need to have your cervix dilated (enlarged so the contents of the uterus can pass through and out of your body). If you are in the latter part of the first trimester (first three months), you may have a small sterilized stick called a laminaria japonica (or more than one) placed in your cervix to open it. These laminaria take about four hours to be useful and may be placed overnight.
    
    
  • Before inserting the stick, your cervix may be swabbed with Betadine, a cleaning solution. You may be given an injection of numbing solution into the cervix. This is the beginning of the abortion procedure. Please understand your risks, and they should have been explained in the counseling process, before you start the dilatation process.

• Sedation during abortion
  
  
  • Most women are coached through an abortion as the health care provider explains each step. Some women prefer to have some numbing in their cervix. Most do not require IV sedation.
    
    
  • If heavy sedation is selected, then IV fluids will be used.

• First-trimester surgical abortion
  
  
  • Early terminations are performed with little cervical dilatation and using a hand-held syringe or a small-bore cannula (a tube) attached to a suction machine. Abortions performed with a syringe are referred to as manual aspirations (or menstrual extractions). Those performed with the suction generated by a vacuum aspirator are referred to as a vacuum aspiration. Both procedures take only a few minutes.
    
    
  • Tools are used to grasp the cervix after it has been prepared with Betadine and possibly numbed. The cannula is carefully inserted through the cervix into your uterus. The actual evacuation is performed by applying suction to the syringe or via the machine. The procedure takes a few minutes to complete. There is a small amount of blood loss.
    
    
  • The doctor will check the tissue to make sure it has all been taken out.

• Dilatation and curettage (D&C)
  
  
  • This specifically is a term that is usually applied to a diagnostic procedure or the treatment of an incomplete abortion.
    
    
  • The procedure is usually accomplished with similar dilatation procedures, but the uterus is emptied with a sharp metal curette. These curettes are more dangerous than the flexible or rigid plastic devices, which are used in the suction procedures, and are not recommended for abortion procedures.

• Second-trimester dilatation and evacuation
  
  
  • Dilatation and evacuation is the safest and most common method of second-trimester termination used by experienced health care professionals. Dilation takes place over hours and possibly days with the sticks to enlarge the cervix.
    
    
  • Once the cervix is enlarged enough, the procedure is accomplished using a combination of suction curettage and manual evacuation of the fetus and placenta.  Ultrasound may be used to guide the tools.
    
    
  • The procedure is longer and more uncomfortable than a first-trimester procedure, but many women can comfortably go through the procedure with local anesthesia.

• Dilatation and extraction
  
  
  • This procedure is accomplished by cervical preparation similar to cases of dilatation and evacuation, but the fetus is removed in a mostly intact condition. The fetal head s able to be collapsed after the contents are evacuated so that it may pass through the cervix.
    
    
  • Very few providers perform the procedure. It is usually reserved for cases of maternal medical complications or serious medical problems with the fetus.
    
    
  • The procedure, referred to as intact dilatation and extraction, called partial-birth abortion, has now been banned by a 2007 Supreme Court ruling.
    
    
  • To avoid performing a partial birth abortion while performing a legal dilatation and extraction, digitalis or potassium chloride may be injected onto the fetus to induce preoperative fetal death. Fetal cord cutting may accomplish this as well.
    
    
  • Research has not firmly established at what age a healthy fetus can feel pain, but generally it is thought that this occurs around 24-28 weeks.

• Induction of labor
  
  
  • Most doctors have experience with the standard drugs used to induce labor for birth. These can be used in the second trimester of pregnancy.
    
    
  • Premature rupture of membranes is one indication for this method.
    
    
  • o Cervical ripening agents are typically necessary with either laminaria or misoprostal.