The vast majority of abortions in the United States –nearly 92% — take place during the first trimester of pregnancy. For women who have a later abortion, the most common method is dilation and evacuation (D&E), which involves removing the fetal and placental tissue with a combination of suction and instruments. A small number of second-trimester abortions are done by inducing labor with drugs, a procedure called induction abortion.
Many women prefer D&E to induction, because it is quicker and does not require hospitalization or going through the physical and emotional stresses of labor. Some women, however, desire an induction abortion for many of the same reasons women choose medication abortion in the first trimester.
Occasionally, women ending wanted pregnancies due to unexpected problems decide to go into labor with an induction procedure in order to hold the fetus and say good-bye. This may also be possible after some D&E procedures (called intact D&Es).
What to Expect
Having a dilation and evacuation (D&E) abortion is similar in many ways to having a vacuum aspiration procedure. Because the pregnancy is further along, however, the cervix needs to be opened wider to allow the larger pregnancy tissue to pass, which requires the clinician to soften and dilate the cervix ahead of time. This process of cervical preparation can take anywhere from a few hours in the early second trimester to a day or two for later procedures.
There are two main methods of cervical preparation: osmotic dilators and misoprostol, one of the drugs used in medication abortion.
Osmotic dilators are short, thin rods made of seaweed (laminaria) or synthetic material (Dilapan). After inserting a speculum, the clinician places one or more osmotic dilators in the cervical opening. The placement only takes a few minutes. The dilators absorb moisture and expand over the next several hours, gradually stretching the cervix open. You will likely feel pressure or intermittent cramping as your cervix dilates. If you are having a later second-trimester abortion, you may have more osmotic dilators placed on the following day.
Once osmotic dilators are inserted, you should not touch or put fingers into your vagina, rub your belly, or get a massage. The osmotic dilators are removed at the time of the abortion. It’s important to keep your appointment to complete the abortion; if you miss your appointment and the osmotic dilators are left in the cervix, you are at increased risk of infection, bleeding and miscarriage.
The second way of preparing the cervix uses the medication misoprostol, which is a prostaglandin that softens the cervix. The small misoprostol tablets may be placed between your cheeks and gums, under your tongue, or in the vagina a few hours before your abortion. Side effects with the doses used for cervical preparation are uncommon but may include cramping, nausea, mild diarrhea, or chills and/or a fever.
Sometimes osmotic dilators and misoprostol are used together, particularly for later abortions or intact D&Es. For later abortions (after about 20 weeks LMP), an injection into the abdomen may be given to ensure fetal demise before the procedure is started.
Your provider may recommend stronger pain medication or sedatives for a D&E than would be necessary for vacuum aspiration, in addition to local anesthesia in the cervix. If necessary, the provider may use dilator instruments to enlarge the cervical opening further. Then the clinician removes the pregnancy (fetal and placental tissue) with vacuum aspiration, forceps, and a curette (a small, spoon-like instrument). This takes a few minutes, and you may feel a tugging sensation and some strong cramping as the uterus empties.
For more information on later abortions, including additional links to resources, visit the Later Abortion section developed by Advancing New Standards in Reproductive Health Care, University of California, San Francisco. The site includes resources for women, clinicians, researchers and policymakers.