Abstract

PIP:

With the advent of legalized abortion in the US in 1973, the innovation, adoption and dissemination of new and improved medical procedures for the voluntary termination of pregnancy became an important objective. 3 principal techniques were introduced: suction curettage, instillation procedures using saline solution or prostaglandin, and dilatation and evacuation (D and E). Suction curettage in the 1st trimester was readily adopted because the procedure was less traumatic than the traditional dilatation and curettage. Instillation procedures for abortions in the 2nd trimester were also readily adopted. Physicians preferred them to surgical procedures, were familiar with the delivery simulation, and were comfortable with the hospital setting in which the procedure was performed. D and E, an extension of the suction procedure to abortions in the 2nd trimester has lower complication rates than instillation procedures and can be performed early in the midtrimester. A 1981 membership survey conducted by the National Abortion Federation found that about 1/3 of the members performed D and E midtrimester abortions, a wider acceptance than was expected. In 1978, of the 2nd trimester abortions, 85% of the early midtrimester and 25% of the 16 weeks gestation or later abortions were done by D and E. Acceptance in some other countries is also increasing. A study of the relationship of a history of 2nd trimester abortions and subsequent adverse pregnancy outcomes was unable to identify any statistically significant relationship with the possible exception of low birth weight infants. According to a 1976 survey of teaching hospitals, less than 1/4 require their residents to perform midtrimester abortions. Very few medical schools include D and E procedures in their residency training programs. Residents should use the D and E technique only under supervision and after becoming experienced in 1st trimester suction curettage. A survey reported that D and E techniques can be learned by all gynecologists, can be safer than instillation procedures and can be safely performed in nonhospital settings. Ultrasound can be helpful during the procedure to diagnose pelvic pathology, guide instruments and manipulate fetal and placental tissue with more precision. Local anesthesia is associated with fewer complications than general anesthesia. An increasing number of physicians are using laminaria tents to dilate the cervix which reduces the risk of perforation and cervical injury, and the cervix returns to normal within a shorter period of time than with metal dilators. Laminaria have been successfully used on a outpatient basis. A questionnaire survey found both positive and negative staff reactions in facilities which had instituted 2nd trimester D and E procedures. Training for staff before initiating the new procedure and at periodic intervals thereafter is essential and should include factual information on the procedure, sonography, laminaria, fetal development, as well as the opportunity to share reactions, reassess attitudes and resensitize staff to patient needs. D and E procedures shift the psychological burden from nurses and patients to the physicians.