Our Bodies, Ourselves (72 page)

The cost of abortion rises throughout the second trimester. In addition, these abortions require more time off from work or school and may require longer travel distances to find a provider. Although the health risks of abortion increase with gestational age of the pregnancy, the complication rates are still very low.
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The most common method of second-trimester abortion in the United States 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 (because unexpected problems arise) decide to 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).

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 takes only 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 (for more information about misoprostol, see
“Medication Abortion,”
). 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. Follow the recommendations of your clinician. 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 twenty 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 uses 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, spoonlike instrument). This takes a few minutes, and you may feel a tugging sensation and some strong cramping as the uterus empties.

As the name implies, induction abortion involves medications that cause the uterus to contract
and expel the pregnancy. After a certain point in pregnancy (usually around twenty-four weeks), a D&E can no longer be performed and the only option is an induction abortion. The experience is similar to labor, although as the fetus is smaller than a full-term baby the process may last a shorter time. Painful contractions can last for several hours or even a day or so. The procedure usually takes place in specialized facilities or hospitals, where the quality of care and degree of personal attention vary. Although a few specialized clinics have dedicated space for induction abortion, most general hospitals don't. Therefore, you may find yourself on a ward with women who are delivering babies. If possible, bring a partner or friend to support you and to help ensure that you get the compassionate treatment you deserve.

Preparation for an induction abortion is much the same as for D&E, except that you may need to plan for an overnight stay in the hospital or hotel located near the clinic. You will have blood tests and an ultrasound exam, and the clinician may use osmotic dilators to
prepare your cervix
.

Medications to induce abortion can be given in a number of ways. Most commonly, prostaglandin suppositories or misoprostol tablets are inserted into your vagina every few hours. Oxytocin (Pitocin) may be given through an IV line. For later abortions, an injection into the abdomen may be given to ensure fetal demise. Although this may sound scary, the abdomen is numbed before the injection, and you will probably feel only a slight cramp when the needle enters your uterus.

Each woman's experience is different. The contractions will probably feel like mild cramps at first and then become more intense. When the amniotic sac breaks, you will feel a gushing of warm liquid from the vagina. Later, you may experience a lot of pressure in the rectal area as the fetus is expelled. If the placenta does not come out within a few hours, your provider may use suction or a curette to remove it.

For pain, you may be given strong medications, sedatives, or epidural anesthesia (regional anesthesia commonly used in childbirth). Relaxation exercises, deep breathing, and the support of a friend can help make the contractions easier to tolerate. Medications are also available to control common side effects such as nausea, vomiting, and fever. You should be as comfortable as possible during the abortion process, so be sure to ask for more pain medication or support if you need it.

For more information on abortion after the first trimester, see ansirh.org/research/late-abortion.php.

After a vacuum aspiration or D&E abortion, you will go to a recovery area to rest. The staff will periodically check your vital signs and bleeding. It is normal to bleed moderately or even to pass small clots; the intensity of the cramping usually lessens during the first half hour. Depending on the procedure, the type of anesthesia you had, and how you are feeling, you may stay in the recovery area from twenty minutes to an hour or more. If you had IV sedation or general anesthesia, you will need someone to drive or accompany you home.

Before you leave, the staff will provide information about what to expect over the next few days and what signs to look for that might indicate a complication (see “Symptoms to Watch for
After an Abortion,”
). Be sure you know the emergency number to call in case problems arise. You may also receive antibiotics to prevent infection and a medication to help minimize the bleeding (avoid alcohol, as it can increase bleeding). Avoid putting anything into your vagina (no tampons, no sexual intercourse,
and no douching) for five days after the abortion, as the cervix is open and there is a greater chance of an infection during this time.

You may also be advised to rest and to avoid heavy lifting and strenuous exercise. Self-care is important, but work, school, and family circumstances may make some of these recommendations unrealistic. In addition, no studies have shown that these activities actually increase the risk of complications after abortion. The best guide is to listen to your body and use common sense.

Because you can get pregnant again shortly after an abortion, even before your first period, it's important to use reliable birth control if you don't want another pregnancy. For more information, see “Starting Birth Control
After an Abortion.”

You may be given a follow-up appointment for two to three weeks after the abortion. At this visit, the clinician will check how you are doing emotionally and physically. Most women feel fine and do not have any problems after an abortion, but it's also normal to feel tired or to have cramps for several days. Bleeding ranges from none at all to a light or moderate flow, which may stop and then start again. Some signs of pregnancy (such as nausea) usually get better in a day or two, while others (such as breast tenderness) may take a week or two.

Emotionally, most women report feeling relief after an abortion, but it is also perfectly normal to have mixed or even negative feelings. The decision to terminate a pregnancy can be sad or stressful. It may be made more upsetting by the stigma against abortion fueled by those who are opposed to abortion rights.

One woman describes such an experience when she became pregnant at age 19:

I knew from the moment I found out that I didn't want to carry the pregnancy to term, but I was overwhelmed by images everywhere telling me that it was “wrong” to consider abortion… .
When I searched for information on the Internet, I was bombarded by religious websites with brutal pictures of aborted fetuses. When I tried to go to my friends for help, I was told they were “so excited” and couldn't wait for me to have a baby. My boyfriend kept saying how much he wanted a son. No one asked me what I wanted. I felt robbed of choice, like my body was being controlled by everyone but me
.

My dreams of going to college and moving out were over because of one mistake. Finally, some kind of switch went off in my head. I couldn't afford to care what other people thought. I wanted my life back. If that is selfish, then I was willing to be selfish. What kind of mother would I be, anyway? The next day I made an appointment, but it was hard. I cried a lot. But that was two years ago, and I will be graduating from college in a few months. Most importantly, I tell myself every day that I made the right choice, and I know in my heart that I did
.

Your abortion provider is usually the best source of information or care if problems arise. If you require medical attention and cannot return to your abortion provider for care, ask for the best place to go in your area. You may not have a choice in emergency situations, but try to stay away from Catholic-owned hospitals or practitioners, as they oppose abortion and may not give you the most compassionate and appropriate care. If possible, bring a support person with you. When you receive care at another location, be sure to let the abortion provider know. This helps the clinics track their abortion complications and improve the quality of their services.

Abortion-related complications are rare in the United States, but they do happen. Below is a list of symptoms that may indicate a problem. If you have any of these symptoms or other concerns, get help immediately.

All women bleed during an abortion. In rare cases, some women bleed more than is safe. The best way to tell if you are bleeding too much after an abortion is to keep track of the number of pads you are using and the number and size of any clots. Call your provider if you soak two maxi pads an hour for two hours in a row, if you pass large clots, or if you begin to feel light-headed.

The main way that your uterus controls bleeding after an abortion is to contract, squeezing the blood vessels shut. Heavy bleeding can occur if your uterus relaxes too much (uterine atony) or if some fetal or placental tissue is left in the uterus (retained tissue or incomplete abortion). Very rarely, excessive bleeding can be due to a uterine injury that occurred during the abortion.

Uterine cramping is normal after any kind of abortion, but persistent or severe pelvic pain may indicate a problem. Contact your provider if intense pain persists after you've used a heating pad and taken pain relievers.

The most common cause of severe pain is an infection. Most infections are mild and can be treated at home with antibiotics prescribed by your provider. Postprocedure pain may also be caused by retained fetal or placental tissue (incomplete abortion) or clots (hematometra). If the tissue or clots don't pass on their own, you may need medication or a vacuum aspiration to empty the uterus.