1. the pregnancy is further along (late 1st, 2nd and 3rd trimesters)
2. there are maternal medical complications
3. it is performed during hospitalization

How is each Surgical Techniques Performed?
There are several surgical techniques used in performing abortion. The following section discusses the techniques according to the gestational age of the developing baby and trimester of pregnancy. Some surgical techniques may be used in combination with each other, or with medical techniques (e.g., complications related to a medical abortion).

First trimester - procedures performed up to 14 weeks (3 months, 2 weeks)

Suction Aspiration
Dilation and Curettage (D&C)

Second trimester - procedures performed between 12 and 24 weeks (3-6 months)

Dilation and Evacuation (D&E)
Saline Injection or Salt Poisoning

Third trimester - procedures performed from 20 weeks (5 months) up to full term

Partial Birth Abortion (D&X)

Suction or Vacuum Aspiration Technique

When Used?
Suction Aspiration is the most common 1st trimester technique. It is used to terminate a pregnancy up to 14 weeks old.

Procedure Description

1. The woman lies on her back with her feet in stirrups.
2. The cervix is cleaned.
3. Local cervical pain killer may be given.
4. A clamp (tenaculum) is placed on part of the cervix.
5. A dilator is used to open the cervix wide enough for the suction tube to fit inside.
6. The doctor guides the tube inside the uterus and turns on the suction machine.
7. The placenta as well as the baby's head, limbs and organs are removed in pieces small enough to fit through the suction tubing and into a container.
8. The nurse (or assistant) reassembles the baby making certain that all of it has been suctioned from the uterus.

Infection

• Retained pregnancy components or an undiagnosed STD may cause an infection requiring outpatient PID treatment, or hospitalization for intravenous antibiotics. If pregnancy components are retained, the woman will need another aspiration procedure.

Persistent or excessive bleeding

• Abnormal bleeding may result from uterine muscles not contracting or blood vessels not constricting to stop the bleeding. Also, blood clots may develop inside the uterus after the procedure. The women will need repeat suction and medication to stop bleeding.

• The uterus and/or intestine may have been perforated (a wall punched through with the suction tube or other instrument inserted within the uterus). On occasion with hemorrhaging, a woman may require abdominal surgery and/or a blood transfusion to replace large blood losses.

• The cervix may be lacerated (cut or torn) requiring suture repair in order to stop significant bleeding.

Failed Abortion

• Sometimes, when this procedure is performed during the earliest stages of human development, the suction device may miss the baby. In such cases, the pregnancy continues; a sonogram is performed to locate the baby for repeat suction if there is no ectopic pregnancy.

Dilation and Curettage (D&C) Technique

When Used?
Dilation and Curettage abortion technique is used up to 14 weeks gestational age, or when there are complications resulting from other procedures (such as, an incomplete abortion, a failed abortion or retained components of the pregnancy after suction). This technique is also used following a miscarriage.

Procedure Description

1. The woman lies on her back with feet in stirrups.
2. The cervix may be dilated mechanically or with medication before the procedure (if the pregnancy is greater than 12 weeks gestational age). Otherwise, it is dilated during the procedure.
3. The cervix is cleaned and a local pain killer may be given.
4. A clamp (tenaculum) is attached to part of the cervix.
5. If the cervix is dilated, a curette (a steel loop-shaped surgical knife) is used to scrape out the placenta and the baby. This scraping process is called curettage.

Infection

• Retained pregnancy components or an undiagnosed STD may cause an infection requiring outpatient PID treatment, or hospitalization for intravenous antibiotics. If pregnancy components are retained after an aspiration procedure, the woman may need another aspiration procedure in addition to repeat curettage.

Persistent or excessive bleeding

• Abnormal bleeding may result from uterine muscles not contracting or blood vessels not constricting to stop the bleeding. Also, blood clots may develop inside the uterus after the procedure. The women will need repeat suction and medication to stop bleeding.

• The uterus and/or intestine may have been perforated (a wall punched through by the instrument inserted within the uterus). On occasion with hemorrhaging, a woman may require a blood transfusion to replace large blood losses and/or additional abdominal surgery to repair the damage.

• The cervix may be lacerated (cut or torn) requiring suture repair in order to stop significant bleeding.

Failed Abortion

• Sometimes, when this procedure is performed during the earliest stages of human development, the suction device may miss the baby. In such cases, the pregnancy continues; a sonogram is performed to locate the baby for repeat suction and D&C (if there is no ectopic pregnancy).

Dilation and Evacuation (D&E) Technique

When Used?
Dilation and Evacuation is the most common surgical technique used in the 2nd trimester. Generally, it is performed when the pregnancy is between 12 - 24 weeks gestational age.

NOTE: Because the developing baby is bigger at this stage and bone calcification has occurred, forceps are used to empty the uterus. The cervix must be opened wider (than that required in a D&C or Suction Aspiration) to allow entry of forceps. Forceps refers to the surgical instrument resembling pliers with sharp teeth used to grab and pull out body parts/tissue. Intravenous sedation or general anesthesia may be required.

Procedure Description
Method 1 (May require a minimum of 2 visits)

1. While at the clinic, laminaria (a seaweed-based substance) is inserted into the cervix causing dilation.
2. The woman goes home and returns the next day.
3. After returning to the clinic, she lies on her back with feet in stirrups.
4. The laminaria is removed and the size of the cervical opening is evaluated.
5. The cervix is cleaned; a clamp is attached to part of it.
6. If the cervical opening is wide enough for forceps to enter, the process of grabbing, crushing and tearing away the baby's body parts begins.
7. After the procedure, the baby's parts are reassembled to insure that all pieces have been removed.
8. A final curettage may be performed.

1. Laminaria is inserted inside the cervix to cause it to dilate.
2. If after a given period of time the cervix is not open wide enough, it is stretched to allow forceps inside the uterus.
3. The procedure continues according to protocol until all the baby's body parts are removed from the uterus.
4. A final curettage may be performed.

Complications may include:

Infection

• Retained pregnancy components or an undiagnosed STD may cause an infection requiring outpatient PID treatment, or hospitalization for intravenous antibiotics. If pregnancy components are retained, the woman will need another curettage procedure.

Persistent or excessive bleeding

• Abnormal bleeding may result from uterine muscles not contracting or blood vessels not constricting to stop the bleeding. Also, blood clots may develop inside the uterus after the procedure. The woman will need medication to stop bleeding.

• The uterus and/or intestine may have been perforated (a hole punched through the wall by instruments inserted within the uterus). The walls of the uterus are much thinner in 2nd trimester. On occasion, the hemorrhaging is severe enough to require a blood transfusion and abdominal surgery.

• The cervix may be lacerated (cut or torn) requiring suture repair in order to stop significant bleeding.

Cervical Incompetence

• A woman may not be able to carry a future pregnancy to term as a result of injuries to the cervix during a 2nd trimester abortion.

Injection or Poisoning Technique
When Used?
Saline (or other toxic level chemical) injection is performed when a pregnancy is 16 weeks and beyond (when enough amniotic fluid is present to surround the baby.)

Saline Injection

Note: This procedure may require hospitalization.

1. A long needle is inserted through the mother's abdomen (belly) into the amniotic sac.
2. Amniotic fluid is removed from the sac and is replaced by a very strong salt solution meant to kill the baby. By the 4th month of pregnancy, the baby has been drinking and breathing in amniotic fluid to help the organs develop properly. However, when the salt solution is substituted for the normal amniotic fluid, it causes severe burning of the baby's skin, eyes, mouth and lungs.
3. Labor may begin within 24 hours of the saline injection resulting in the delivery of a badly burned, shriveled, dead baby.

Future Infertility Problems
The woman may have future infertility problems if the uterus has been badly scarred during this procedure.

Partial Birth Abortion (D&X) Technique

When Used?
This technique is approved for use in women with pregnancies 20 weeks gestational age and beyond.

Procedure Description

General anesthesia may be required to complete this procedure.

Day 1 and 2

1. Laminaria (a seaweed-based substance) is inserted into the cervix and left in place for up to a 2-day period.

1. An ultrasound is used to locate the baby's legs.
2. The doctor takes large forceps to grab each leg and pull them through the cervix and down into the vagina.
3. The remainder of the body, except the head, is pulled through the cervical opening.
4. The head remains inside the uterus.
5. The doctor makes an incision (cut) at the base of the skull and inserts a catheter (tube) to suck out the brain, causing the skull to collapse.
6. The dead body is then removed completely from the uterus.
   

Any Complications or Side Effects?
When this procedure is used on full term sized infants, it is in effect, intentionally rearranging the baby's in utero position from head down to feet and legs down for a breech delivery.

Infection

• Retained pregnancy components or an undiagnosed STD may cause an infection, as well as or other post-procedure complications that require treatment including intravenous antibiotics. If pregnancy components are retained, the woman will need another procedure to remove fragments.

Persistent or excessive bleeding

• Abnormal bleeding may result from uterine muscles not contracting or blood vessels not constricting to stop the bleeding. Also, blood clots may develop inside the uterus after the procedure. The woman may need another procedure and/or medication to stop bleeding.

• The uterus and/or intestine may have been lacerated or perforated (a hole punched through the wall by instruments inserted within the uterus). The walls of the uterus are at its thinnest in 3rd trimester. On occasion, the hemorrhaging is severe enough to require a blood transfusion.

• The cervix may be lacerated (cut or torn) requiring suture repair in order to stop significant bleeding.

Cervical Incompetence

• A woman may not be able to carry a future pregnancy to full term as a result of injuries to the cervix (excessive stretching and tearing) following this procedure.