{{Short description|Gynecological procedure}} {{Infobox abortion method | name = Dilation and evacuation | AKA/Abbreviation= D&E | Abortion_type = Surgical | Date_first_use = 1970s | Date_last_use = | Gestational_age = 13–24 weeks | Usage_notes = | Use_AU% = <!-- Australia --> | Use_AU_date = | Use_CA% = <!-- Canada--> | Use_CA_date = | Use_NZ% = | Use_NZ_date = | Use_SE% = | Use_SE_date = | Use_EW% = | Use_EW_date = | Use_US% = | Use_US_date = | Use_ZA% = <!-- South Africa --> | Use_ZA_date = | Medical_notes = }} '''Dilation and evacuation''' ('''D&E''') or '''dilatation and evacuation''' (British English) is the dilation of the [[cervix]] and surgical evacuation of the [[uterus]] (potentially including the fetus, placenta and other tissue) after the first trimester of [[pregnancy]]. It is the most common method and procedure for [[Abortion|abortions]] in the second trimester of pregnancy.<ref>{{Cite web |last=Johnson |first=Traci |title=Abortion Types and Costs |url=https://www.webmd.com/women/abortion-procedures |access-date=2024-10-27 |website=WebMD |language=en |quote="While doctors can do vacuum aspirations until about 14 weeks, the most common type of second-trimester abortion is called dilation and evacuation, or D&E."}}</ref> The procedure can also be used to remove a [[Miscarriage|miscarried]] fetus from the womb.<ref name="ebsco2">{{cite web |date=January 2007 |title=Miscarriage |url=http://healthgate.partners.org/browsing/browseContent.asp?fileName=11672.xml&title=Miscarriage |archive-url=https://web.archive.org/web/20070927011336/http://healthgate.partners.org/browsing/browseContent.asp?fileName=11672.xml&title=Miscarriage |archive-date=2007-09-27 |access-date=2007-04-07 |work=EBSCO Publishing Health Library |publisher=Brigham and Women's Hospital}}</ref><ref name="webmd2">{{cite web |date=2004-10-07 |title=Dilation and evacuation (D&E) for abortion |url=http://www.webmd.com/a-to-z-guides/Dilation-and-evacuation-DE-for-abortion |archive-url=https://web.archive.org/web/20070502000343/http://www.webmd.com/a-to-z-guides/Dilation-and-evacuation-DE-for-abortion |archive-date=2007-05-02 |access-date=2007-04-07 |work=Healthwise |publisher=WebMD}}</ref>
In various health care centers it may be called by different names: * D&E (dilation and evacuation) * ERPOC (evacuation of retained [[products of conception]]) * TOP or STOP ((surgical) termination of pregnancy)
D&E normally refers to a specific second trimester procedure.<ref name="webmd">{{cite web |date=2004-10-07 |title=Dilation and evacuation (D&E) for abortion |url=http://www.webmd.com/a-to-z-guides/Dilation-and-evacuation-DE-for-abortion |archive-url=https://web.archive.org/web/20070502000343/http://www.webmd.com/a-to-z-guides/Dilation-and-evacuation-DE-for-abortion |archive-date=2007-05-02 |access-date=2007-04-07 |work=Healthwise |publisher=WebMD}}</ref> However, some sources use the term D&E to refer more generally to any procedure that involves the processes of dilation and evacuation, which includes the first trimester procedures of manual and electric [[vacuum aspiration]].<ref name="ebsco">{{cite web |date=January 2007 |title=Miscarriage |url=http://healthgate.partners.org/browsing/browseContent.asp?fileName=11672.xml&title=Miscarriage |archive-url=https://web.archive.org/web/20070927011336/http://healthgate.partners.org/browsing/browseContent.asp?fileName=11672.xml&title=Miscarriage |archive-date=2007-09-27 |access-date=2007-04-07 |work=EBSCO Publishing Health Library |publisher=Brigham and Women's Hospital}}</ref> [[Intact dilation and extraction]] (D&X) is a different procedural variation on D&E.<ref name="presentation">{{cite conference|last=Haskell|first=Martin|date=1992-09-13|title=Dilation and Extraction for Late Second Trimester Abortion|url=http://www.vanderbilt.edu/SFL/partial-birth_abortion.htm|location=Dallas, Texas|archive-url=https://web.archive.org/web/20060916154715/http://www.vanderbilt.edu/SFL/partial-birth_abortion.htm|archive-date=September 16, 2006|access-date=2007-05-05|book-title=National Abortion Federation Risk Management Seminar}}</ref>
Dilation and evacuation procedures have been increasingly banned in US states since the ''[[Dobbs v. Jackson Women's Health Organization]]'' decision overruled the right to an abortion.<ref name=":5" />
==Indications for D&E== Dilation and evacuation (D&E) is one of the methods available to completely remove the fetus and all of the placental tissue in the uterus after the first trimester of pregnancy.<ref>{{Cite journal|last1=Stubblefield|first1=Phillip G.|last2=Carr-Ellis|first2=Sacheen|last3=Borgatta|first3=Lynn|date=July 2004|title=Methods for Induced Abortion|journal=Obstetrics & Gynecology|volume=104|issue=1|pages=174–185|doi=10.1097/01.aog.0000130842.21897.53|pmid=15229018|issn=0029-7844}}</ref> A D&E may be performed for a surgical abortion, or for surgical management of a miscarriage.<ref name="bulletin 102"/>
=== Abortion === Induced abortion after the first trimester of pregnancy is rare. Approximately 930,000 abortions were documented in the US in 2020. Of these, 492,000 were medication abortions.<ref>{{Cite journal |last1=Jones |first1=Rachel K. |last2=Kirstein |first2=Marielle |last3=Philbin |first3=Jesse |date=2022-11-20 |title=Abortion incidence and service availability in the United States, 2020 |url=https://www.guttmacher.org/article/2022/11/abortion-incidence-and-service-availability-united-states-2020 |journal=Perspectives on Sexual and Reproductive Health |volume=54 |issue=4 |pages=128–141 |doi=10.1363/psrh.12215 |pmid=36404279 |s2cid=203813573 |language=en|doi-access=free |pmc=10099841 }}</ref> Fewer than 10% of all abortions in the United States are performed after 13 weeks of gestation, and just over 1% are performed after 21 weeks of gestation.<ref name=":0">{{Cite journal|last1=Jatlaoui|first1=Tara C.|last2=Boutot|first2=Maegan E.|last3=Mandel|first3=Michele G.|last4=Whiteman|first4=Maura K.|last5=Ti|first5=Angeline|last6=Petersen|first6=Emily|last7=Pazol|first7=Karen|date=2018-11-23|title=Abortion Surveillance – United States, 2015|journal=MMWR. Surveillance Summaries|volume=67|issue=13|pages=1–45|doi=10.15585/mmwr.ss6713a1|issn=1546-0738|pmc=6289084|pmid=30462632}}</ref> In the United States, 95–99% of abortions after the first trimester of pregnancy are performed by surgical abortion via dilation and evacuation.<ref name=":0" />
People who do not have access to affordable abortion care in their area or who face legal restrictions to obtaining a wanted abortion may wait longer to get an abortion after they make the decision to terminate their pregnancy. When an abortion is delayed, a D&E may be necessary.<ref>{{Cite web|url=https://www.guttmacher.org/evidence-you-can-use/later-abortion|title=Later Abortion|date=2016-10-13|website=Guttmacher Institute|access-date=2019-07-29}}</ref> Other factors that often lead to an abortion in the second trimester are late testing for pregnancy, insurance or funding barriers, or delayed provider referral.<ref name=":032" />
Abortion can be considered in the case of congenital anomalies, including genetic aneuploidies and anatomic anomalies, especially since they may not be identified until the second trimester.<ref>{{Cite web |title=Screening for Fetal Chromosomal Abnormalities |url=https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/screening-for-fetal-chromosomal-abnormalities |access-date=2023-10-30 |website=www.acog.org |language=en}}</ref><ref name=":032" /> Other medical indications for an abortion in the second trimester include preeclampsia with severe features or preterm premature rupture of membranes prior to a viable fetal age.<ref name=":032" />
=== Miscarriage === Dilation and evacuation can be offered for the management of second trimester miscarriage if skilled providers are available.<ref name="bulletin 102">{{Cite journal|date=March 2009|title=ACOG Practice Bulletin No. 102: Management of Stillbirth|journal=Obstetrics & Gynecology|volume=113|issue=3|pages=748–761|doi=10.1097/aog.0b013e31819e9ee2|pmid=19300347|issn=0029-7844|doi-access=free}}</ref> Some women choose D&E over labor induction for a second trimester loss because it can be a scheduled surgical procedure, offering predictability over labor induction, or because they find it emotionally easier than undergoing labor and delivery. The risks of maternal morbidity during an induction of labor are higher compared to dilation and evacuation.<ref name=":6">{{Cite journal |date=March 2020 |title=Management of Stillbirth: Obstetric Care Consensus No, 10 |url=https://journals.lww.com/10.1097/AOG.0000000000003719 |journal=Obstetrics & Gynecology |language=en |volume=135 |issue=3 |pages=e110–e132 |doi=10.1097/AOG.0000000000003719 |pmid=32080052 |s2cid=211230954 |issn=0029-7844|url-access=subscription }}</ref> Additionally, a subsequent [[dilation and curettage]] procedure for retained placental products may be required after an induction of labor for a miscarriage.<ref name=":6" /> Both a labor induction and dilation and evacuation offer the option of fetal and placental testing. Although pregnancy loss is emotionally distressing, there are rarely medical complications associated with a short (<1 week) delay to management.<ref name="bulletin 1022">{{Cite journal|date=March 2009|title=ACOG Practice Bulletin No. 102: Management of Stillbirth|journal=Obstetrics & Gynecology|volume=113|issue=3|pages=748–761|doi=10.1097/aog.0b013e31819e9ee2|issn=0029-7844|pmid=19300347|doi-access=free}}</ref>
=== Molar pregnancy === Dilation and evacuation is also a treatment option for a [[molar pregnancy]], especially for those who wish to maintain fertility. The procedure is typically done under sonographic guidance as soon as a hydatidiform mole is suspected.<ref>{{Cite journal |last=Soper |first=John T. |date=February 2021 |title=Gestational Trophoblastic Disease: Current Evaluation and Management |journal=Obstetrics & Gynecology |language=en |volume=137 |issue=2 |pages=355–370 |doi=10.1097/AOG.0000000000004240 |issn=0029-7844 |pmc=7813445 |pmid=33416290}}</ref><ref>{{Citation |last1=Bruce |first1=Shaina |title=Gestational Trophoblastic Disease |date=2023 |url=https://www.ncbi.nlm.nih.gov/books/NBK470267/ |work=StatPearls |access-date=2023-11-15 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29261918 |last2=Sorosky |first2=Joel}}</ref>
==Description of procedure==
=== Cervical preparation === Prior to the procedure, cervical preparation with osmotic dilators or medications is recommended in order to reduce the risk of complications such as cervical laceration and to facilitate cervical dilation during the procedure.<ref name=":02">{{Cite book|title=Clinical practice handbook for safe abortion.|others=World Health Organization. Reproductive Health and Research|year=2014|isbn=978-92-4-154871-7|location=Geneva, Switzerland|page=37|oclc=879416856|last1 = Organization|first1 = World Health}}</ref><ref name=":2">{{Cite journal|last1=Fox|first1=Michelle C.|last2=Krajewski|first2=Colleen M.|date=February 2014|title=Cervical preparation for second-trimester surgical abortion prior to 20 weeks' gestation: SFP Guideline #2013–4|journal=Contraception|volume=89|issue=2|pages=75–84|doi=10.1016/j.contraception.2013.11.001|issn=1879-0518|pmid=24331860|doi-access=free}}</ref><ref name=":032">{{Cite web|url=https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Second-Trimester-Abortion|title=Second-Trimester Abortion – ACOG|website=www.acog.org|access-date=2019-07-09}}</ref> Although there is no consensus as to which method of cervical preparation is superior in terms of safety and technical ease of the procedure, one particular concern is reducing the risk of [[preterm birth]]. Concerns within the medical community have advised against or at least asked for further research concerning the safety of performing the dilation of the cervix on the same day as the surgery for some or all second trimester pregnancies. The concern is that performing the dilation too soon before the surgery could increase the risk of preterm birth should the woman ever carry a subsequent pregnancy to term.<ref name=Lyus>{{Cite journal|last=Lyus|first=Richard|date=December 22, 2016|title=Cervical preparation prior to second-trimester surgical abortion and risk of subsequent preterm birth|journal=Journal of Family Planning and Reproductive Health Care |volume=43 |issue=1 |pages=70–71|doi=10.1136/jfprhc-2016-101695|pmid=28007822 |doi-access=free}}</ref><ref name=":1">{{Cite journal|last1=Newmann|first1=Sara J.|last2=Dalve-Endres|first2=Andrea|last3=Diedrich|first3=Justin T.|last4=Steinauer|first4=Jody E. |last5=Meckstroth|first5=Karen|last6=Drey|first6=Eleanor A.|date=2010-08-04|title=Cervical preparation for second trimester dilation and evacuation|journal=The Cochrane Database of Systematic Reviews |issue=8|article-number=CD007310|doi=10.1002/14651858.CD007310.pub2|issn=1469-493X|pmid=20687085}}</ref> However, for dilation and evacuation at greater than 20 weeks gestation, at least one day of cervical preparation is recommended, with the option of serial dilation for more than one day.<ref name=":4">{{Cite journal |last1=Newmann |first1=Sara |last2=Dalve-Endres |first2=Andrea |last3=Drey |first3=Eleanor A. |date=April 2008 |title=Cervical preparation for surgical abortion from 20 to 24 weeks' gestation |journal=Contraception |language=en |volume=77 |issue=4 |pages=308–314 |doi=10.1016/j.contraception.2008.01.004|pmid=18342657 |doi-access=free }}</ref> Dilation can be achieved with either osmotic dilation or [[misoprostol]], although osmotic dilation with either [[laminaria]] or Dilapan is recommended.<ref name=":4" />
=== Anesthesia options === Most patients will be provided NSAIDs for pain management. Local anesthetics, such as lidocaine, are frequently injected by the cervix to reduce pain during the procedure.<ref name=":42">{{Cite book|title=Management of Unintended and Abnormal Pregnancy Comprehensive Abortion Care|last=Paul, Maureen, Hrsg. Lichtenberg, Steve, Hrsg. Borgatta, Lynn, Hrsg. Grimes, David A., Hrsg. Stubblefield, Phillip G., Hrsg. Creinin, Mitchell D., Hrsg.|date=2011|publisher=John Wiley & Sons|isbn=978-1-4443-5847-6|oclc=899157428}}</ref><ref name=":032"/><ref>{{Cite journal|last1=Allen|first1=Rebecca H.|last2=Singh|first2=Rameet|date=June 2018|title=Society of Family Planning clinical guidelines pain control in surgical abortion part 1 – local anesthesia and minimal sedation|journal=Contraception|volume=97|issue=6|pages=471–477|doi=10.1016/j.contraception.2018.01.014|pmid=29407363|issn=0010-7824|doi-access=free}}</ref> IV sedation may also be used.<ref>{{Cite journal|last1=Cansino|first1=Catherine|last2=Denny|first2=Colleen|last3=Carlisle|first3=A. Sue|last4=Stubblefield|first4=Phillip|date=2021-12-01|title=Society of Family Planning clinical recommendations: Pain control in surgical abortion part 2 – Moderate sedation, deep sedation, and general anesthesia|url=https://www.contraceptionjournal.org/article/S0010-7824(21)00351-6/abstract|journal=Contraception|language=English|volume=104|issue=6|pages=583–592|doi=10.1016/j.contraception.2021.08.007|issn=0010-7824|pmid=34425082|doi-access=free|url-access=subscription}}</ref> General anesthesia may be used depending on individual circumstances, however it is not preferred as it adds significant anesthesia risks to the procedure.<ref name=":42" />{{Rp|90–100}}
=== Infection prophylaxis === Immediately prior to the procedure, antibiotics of either doxycycline or azithromycin are usually administered to prevent infection.<ref name=":032"/>
=== Thromboprophylaxis === Prophylaxis for venous thromboembolism is not typically required for this procedure.<ref name=":8" />
=== Surgical procedure === A [[Speculum (medical)|speculum]] is placed in the vagina to allow visualization of the cervix. If [[osmotic dilators]] were placed prior to the procedure, these are removed.<ref name=":05"/>
The cervix may be further dilated with rigid dilator instruments such as [[Hegar dilators|Hegar]] and Pratt dilators (as opposed to osmotic dilators).<ref name=":032" /> Sufficient cervical dilation decreases the risk of morbidity, including cervical injury and uterine perforation.<ref name=":1"/><ref name=":032"/> Uterine contents are removed using a cannula to apply aspiration, followed by forceps to remove fetal parts.<ref name=":04">{{Cite book|title=Clinical practice handbook for safe abortion.|others=World Health Organization. Reproductive Health and Research|year=2014|isbn=978-92-4-154871-7|location=Geneva|page=52|oclc=879416856|last1 = Organization|first1 = World Health}}</ref> Tissue inspection ensures removal of the fetus in its entirety. The procedure may be performed under ultrasound guidance to aid in visualizing uterine anatomy and to assess if all tissue has been removed at the completion of the procedure.<ref name=":42"/> Operative ultrasonography is beneficial because it can reduce the risk of uterine perforation.<ref>{{Cite journal |last1=Stubblefield |first1=Phillip G. |last2=Carr-Ellis |first2=Sacheen |last3=Borgatta |first3=Lynn |date=July 2004 |title=Methods for Induced Abortion |url=http://journals.lww.com/00006250-200407000-00027 |journal=Obstetrics & Gynecology |language=en |volume=104 |issue=1 |pages=174–185 |doi=10.1097/01.AOG.0000130842.21897.53 |pmid=15229018 |issn=0029-7844|url-access=subscription }}</ref>
The procedure usually takes less than half an hour.<ref name=":3" />
=== Uterotonics === There is no consensus on the routine use of perioperative or postoperative [[uterotonic]] medications. While many providers use these agents, there is no definitive evidence to support a decreased risk for bleeding under 20 weeks gestation.<ref name=":032" />
=== Recovery === D&E is usually performed in the outpatient setting, and the patient can be safely sent home the same day after a period of observed recovery, ranging from 45 minutes to several hours. Generally, the woman may return to work the following day.<ref name=":3">{{Cite journal|last=Hammond|first=C.|date=2009|title=Recent advances in second-trimester abortion: an evidence-based review|journal=Am J Obstet Gynecol|volume=200|issue=4|pages=347–356|doi=10.1016/j.ajog.2008.11.016|pmid=19318143}}</ref> The type of anesthesia given also influences the appropriate amount of recovery time before discharge. There is rarely a need for narcotic pain medications afterwards, and [[Nonsteroidal anti-inflammatory drug|NSAIDs]] are recommended for home pain management. Recovery from the procedure is typically fast and uncomplicated.<ref name=":05">{{Cite book|title=Management of unintended and abnormal pregnancy: comprehensive abortion care|date=2009|publisher=Wiley-Blackwell|others=Paul, Maureen.|isbn=978-1-4443-1293-5|location=Chichester, UK|oclc=424554827}}</ref>{{Rp|174}}
Some women may experience lactation after a second-trimester loss or termination of pregnancy. Limited data exists for the efficacy of medications to suppress lactation. However, one randomized control trial found [[cabergoline]] to be effective in preventing breast symptoms of engorgement, leakage, and tenderness after a second-trimester loss or termination of pregnancy.<ref>{{Cite journal |last1=Henkel |first1=Andrea |last2=Johnson |first2=Sarah A. |last3=Reeves |first3=Matthew F. |last4=Cahill |first4=Erica P. |last5=Blumenthal |first5=Paul D. |last6=Shaw |first6=Kate A. |date=June 2023 |title=Cabergoline for Lactation Inhibition After Second-Trimester Abortion or Pregnancy Loss: A Randomized Controlled Trial |url=https://journals.lww.com/10.1097/AOG.0000000000005190 |journal=Obstetrics & Gynecology |language=en |volume=141 |issue=6 |pages=1115–1123 |doi=10.1097/AOG.0000000000005190 |pmid=37486652 |s2cid=258767994 |issn=0029-7844|url-access=subscription }}</ref>
===Variations=== If the fetus is removed intact, the procedure is referred to as [[intact dilation and extraction]] by the [[American Medical Association]],<ref>[http://www.ama-assn.org/apps/pf_new/pf_online?f_n=resultLink&doc=policyfiles/HnE/H-5.982.HTM&s_t=abortion&catg=AMA/HnE&&nth=1&&st_p=0&nth=2& Health and Ethics Policies of the AMA] {{Webarchive|url=https://web.archive.org/web/20200426024756/https://www.ama-assn.org/apps/pf_new/pf_online?f_n=resultLink&doc=policyfiles%2FHnE%2FH-5.982.HTM&s_t=abortion&catg=AMA%2FHnE&&nth=1&&st_p=0&nth=2& |date=2020-04-26 }} ''American Medical Association''. H-5.982 Retrieved April 24, 2007.</ref> and referred to as "intact dilation and evacuation" by the [[American Congress of Obstetricians and Gynecologists]] (ACOG).<ref>[http://www.acog.org/from_home/publications/press_releases/nr04-18-07.cfm ACOG Statement on the US Supreme Court Decision Upholding the Partial-Birth Abortion Ban Act of 2003] {{webarchive|url=https://web.archive.org/web/20070611003520/http://www.acog.org/from_home/publications/press_releases/nr04-18-07.cfm |date=2007-06-11 }} (April 18, 2007). Retrieved 2007-04-22.</ref>
== Risks == D&E is a safe procedure when performed by experienced practitioners.<ref name=":42"/> The rate of mortality for all types of legal abortion procedures in the US (not specifically D&E) is 0.43 abortion-related deaths per 100,000 reported legal abortions.<ref name=":7">{{Cite journal |last=Kortsmit |first=Katherine |date=2022 |title=Abortion Surveillance — United States, 2020 |url=https://www.cdc.gov/mmwr/volumes/71/ss/ss7110a1.htm |journal=MMWR. Surveillance Summaries |language=en-us |volume=71 |issue=10 |pages=1–27 |doi=10.15585/mmwr.ss7110a1 |issn=1546-0738 |pmc=9707346 |pmid=36417304}}</ref> There were four identified deaths related to abortion in the US during 2019, out of 625,000 abortions.<ref name=":7" /> The strongest risk factor for mortality following abortion is increasing gestational age.<ref>{{Cite journal|last1=Jatlaoui|first1=Tara C.|last2=Boutot|first2=Maegan E.|last3=Mandel|first3=Michele G.|last4=Whiteman|first4=Maura K.|last5=Ti|first5=Angeline|last6=Petersen|first6=Emily|last7=Pazol|first7=Karen|date=2018-11-23|title=Abortion Surveillance – United States, 2015|journal=MMWR. Surveillance Summaries|volume=67|issue=13|pages=1–45|doi=10.15585/mmwr.ss6713a1|pmid=30462632|pmc=6289084|issn=1546-0738}}</ref>
Risks of D&E include bleeding, infection, uterine perforation, retained products of conception, and cervical laceration.<ref name=":2" /> Hemorrhage occurs following less than 1% of all surgical abortions.<ref name=":032"/> Infection rates following second trimester abortion have been reported to be 0.1–4%. The risk of infection is decreased by the use of antibiotics.<ref name=":032"/> The risk of retained products of conception and uterine perforation are both under 1%.<ref name=":8">{{Cite web |last1=Hammond |first1=Casey |last2=Steinauer |first2=Jody |last3=Chakrabarti |first3=Alana |date=June 6, 2023 |title=Second-trimester pregnancy termination: Dilation and evacuation |url=https://www.uptodate.com/contents/second-trimester-pregnancy-termination-dilation-and-evacuation |access-date=November 14, 2023 |website=UpToDate}}</ref> The risk of cervical laceration is up to 3%.<ref name=":8" /> Even rarer, a hysterectomy or damage to surrounding organs or tissues (i.e. bowel or omentum) can occur during a D&E.<ref name=":42" /><ref name=":2" />
There is no evidence that surgical abortion causes an increase in infertility or adverse outcomes in subsequent pregnancies.<ref name=":42" />{{Rp|252–254}}
== Alternatives==
Alternatives to D&E include [[labor induction]] abortion and [[medical abortion]].
Complication rates after D&E are lower than those of labor induction (medical abortion) after 13 weeks, as has been established through multiple studies.<ref name=":3" /> Additionally, in certain clinical scenarios—severe anemia, for example—D&E may be preferred over labor induction.<ref name=":12">{{Cite journal |last1=Borgatta |first1=Lynn |last2=Kapp |first2=Nathalie |date=2011 |title=Labor induction abortion in the second trimester |journal=Contraception |language=en |volume=84 |issue=1 |pages=4–18 |doi=10.1016/j.contraception.2011.02.005 |pmid=21664506|doi-access=free }}</ref>
==Law== The laws in the United States surrounding dilation and evacuation have been rapidly evolving since the ''[[Dobbs v. Jackson Women's Health Organization]]'' decision in 2022. Proposals to limit abortion access sometimes target specific procedures such as D&E, though this also restricts access for non-abortion patients, such as those with pregnancy loss.<ref name=":5" /> Kansas was the first state to ban D&E in 2015; later it was struck down in 2016. Currently, D&E is specifically banned in thirty-four states, except when deemed necessary for the preservation of the patient's life.<ref name=":5">{{Cite web|date=2016-08-16|title=Bans on Specific Abortion Methods Used After the First Trimester|url=https://www.guttmacher.org/state-policy/explore/bans-specific-abortion-methods-used-after-first-trimester|url-status=live|access-date=2021-03-02|website=Guttmacher Institute|language=en|archive-url=https://web.archive.org/web/20170112063525/https://www.guttmacher.org/state-policy/explore/bans-specific-abortion-methods-used-after-first-trimester |archive-date=2017-01-12 }}</ref> Twenty-one states have banned a "partial-birth" abortion, referring to an intact dilation and extraction.<ref name=":5" /> Three of the twenty-one states have a health exception, and seventeen states allow an exception for life endangerment.<ref name=":5" />
[[Abortion in Europe#National abortion laws|Abortion laws in Europe]], including dilation and evacuation, vary by country.
== Physician training == A national survey of 190 US obstetrics and gynecology residency program directors in 2018 found that 22% considered their graduates to have had enough training in dilation and evacuation to be competent. After Dobbs v. Jackson, almost half of the US obstetrics and gynecology programs are located in states that have implemented abortion restrictions, which will further limit training in dilation and evacuation.<ref>{{Cite web |date=2023-06-14 |title=The State Abortion Policy Landscape One Year Post-Roe |url=https://www.guttmacher.org/2023/06/state-abortion-policy-landscape-one-year-post-roe |access-date=2023-11-13 |website=Guttmacher Institute |language=en}}</ref><ref>{{Cite journal |last1=Vinekar |first1=Kavita |last2=Karlapudi |first2=Aishwarya |last3=Nathan |first3=Lauren |last4=Turk |first4=Jema K. |last5=Rible |first5=Radhika |last6=Steinauer |first6=Jody |date=August 2022 |title=Projected Implications of Overturning Roe v Wade on Abortion Training in U.S. Obstetrics and Gynecology Residency Programs |journal=Obstetrics & Gynecology |language=en |volume=140 |issue=2 |pages=146–149 |doi=10.1097/AOG.0000000000004832 |pmid=35852261 |s2cid=250627945 |issn=0029-7844|doi-access=free }}</ref> The Accreditation Council for Graduate Medical Education states that these programs must either adapt by sending residents to legal jurisdictions where they are able to obtain this training or include uterine evacuation simulations in the educational curriculum.<ref>{{Cite web |date=June 24, 2022 |title=ACGME Program Requirements for Graduate Medical Education in Obstetrics and Gynecology Summary and Impact of Interim Requirement Revisions |url=https://www.acgme.org/globalassets/pfassets/reviewandcomment/220_obstetricsandgynecology_2022-06-24_impact.pdf |website=Accreditation Council for Graduate Medical Education}}</ref>
==See also== *[[Abortion]] *[[Late-term abortion]] *[[Intact dilation and extraction]]
==References== {{reflist}}
{{Abortion}} [[Category:Methods of abortion]]