Years ago, I supported a dear friend of mine through her abortion. She was carrying a 6-week (8.5 wk gestation, development arrested at 6) surrogate pregnancy that was conceived at a fertility clinic. At six weeks, the baby had a heartbeat of about 60bpm, and we all knew the pregnancy was not viable. She could expect a miscarriage at some point in the coming weeks. This was not her baby. She had agreed to carry a child to term and deliver another family’s baby, she hadn’t signed up to have their miscarriage. After considering her options, she asked for management to end the pregnancy ASAP, preferably using a vacuum aspiration (due to its expediency). The fertility clinic wouldn’t help her. While they could assist her with miscarriage management, they could only do so when there was no heartbeat. They were not an abortion clinic, so could not help her end this pregnancy, even though her doctors agreed this pregnancy would only eventually miscarry. They advised her to stay on her fertility medications until there was no heartbeat. Something she, and the intended parents, didn't feel was necessary.
Irate at the lack of support and respect to help her manage this loss, we turned to our local abortion clinics. Our city had seven clinics, but the one we strongly preferred was fully booked. Reluctantly, we booked in the next day at another abortion clinic in town. My friend is a highly informed midwife, full spectrum doula, and advocate. She knew exactly what she wanted, and we had called ahead to ensure they offered vacuum aspiration, her preferred management plan. Upon signing in with reception, she met with a counselor who handed her a set of consent forms to sign for a D&C procedure. She challenged the documentation to the counselor, to let them know there must have been a mistake, as she was not consenting to a D&C, she was consenting to a vacuum aspiration. The counselor said they were the same thing. When my friend insisted that they are in fact quite different procedures, the counselor left to speak with the doctor. The doctor then took my friend aside. Clearly annoyed and bothered, the doctor explained that while she would indeed be receiving a vacuum aspiration, like everyone else in the clinic that day, everyone just understands the terminology associated with “D&C” and they used that as colloquial terminology on their forms to simply mean “ending the pregnancy with instruments rather than medication”. Also, if there were complications with the vacuum aspiration, they might need to resort to a D&C.
We were pissed. Was she really being asked to consent in writing to a particular procedure she was not receiving, while never actually consenting to the procedure she was receiving? We considered walking right out of that clinic, on ethics alone. But she was desperate for this pregnancy to be over. We couldn’t reschedule. Shaking, pissed, nauseous, she slowly crossed out every instance on the form where it said “D&C” and hand wrote above “vacuum aspiration” and handed it back to the counselor.
At first, I took this to be a shitty experience at an abortion clinic I definitely wouldn’t be recommending to anyone else. But over time in supporting miscarriage and abortion management, it’s become clear that the term “D&C” is thrown around carelessly, even when it’s not an accurate description of the care on offer. It leaves vulnerable people with narratives of their experience that are not accurate, perpetuates concern and misinformation in the reproductive health world, and is just bad medical practice.
Okay, what is a true D&C?
Curettes of various sizes to be used for uterine D&C
A D&C is a medical gynecology procedure to remove the contents of a uterus, most commonly for miscarriage management and abortion procedures. It refers specifically to dilation and curettage (“D&C”): two separate steps. First, the cervix is dilated in order to permit the curette instrument. Second, the uterine lining is scraped away and extracted using a curette (a metal instrument with an open-spoon-like end). D&Cs are an “old-school” procedure, with a mixed history of safety. These days, they are often complemented by the use of vacuum aspiration (see below) to ensure complete contents are removed. D&Cs are recommended by the World Health Organization only when vacuum aspiration is not available, as the safety profile of vacuum aspiration is more favourable.
depiction of a dilation & curettage procedure
These days, true D&Cs are performed primarily in emergency rooms, hospitals, and other places that do not specialize in managing pregnancy loss. Emergency room doctors, or gynecologists working shift at a hospital may or may not be trained in vacuum aspiration techniques or have the proper equipment on site. Rather, sets of D&C instruments are often readily available and will be performed on site. Places that specialize in pregnancy loss management (such as abortion clinics, early pregnancy loss clinics, etc.) will rarely turn to a D&C unless absolutely necessary: rather, those places favour vacuum aspiration.
D&Cs, when properly performed, are unlikely to cause immediate or long-term complications. However, they do carry risks of uterine perforation, uterine scarring or adhesions, and resulting conditions like Asherman’s syndrome. They’re more risky than vacuum aspiration, and they should NOT be the default procedure.
Okay, so then what is a vacuum aspiration?
plastic cannulas and tubing used in electric vacuum aspiration procedures.
Vacuum aspiration uses suction to remove the contents of the uterus rather than a metal instrument. A flexible blunt plastic cannula is inserted into the uterus, and attached to a suction device which pulls tissue from the uterus. Suction is strong enough not to need scraping of the uterine walls, rather it pulls tissue away as the cannula moves inside the uterus (by direction of the practitioner). There are different kinds of vacuum aspiration, including manual vacuum aspiration (MVA) and electric vacuum aspiration (EVA). With MVA, the flexible plastic cannula is attached directly to a MVA kit, similar to a very large syringe with specialized mechanisms. MVA is self-contained and does not require electricity, so it is silent. It can be performed in specialized clinics, but also in offices, homes, and other outpatient locations. With EVA, the plastic cannula is attached to tubing and a suction machine. EVA tends to have stronger suction settings, and can be used later in a pregnancy. It also has a distinct noise that is often memorable to people having the EVA procedure.
cannulas are attached directly to an MVA kit, similar to a very large syringe with specialized mechanisms, for a manual vacuum aspiration procedure. Manual vacuum aspiration does not involve electricity, so it is silent.
plastic cannulas and tubing are attached to a suction machine for electric vacuum aspiration
In general, all vacuum aspiration procedures are preferred management methods when appropriate, as they carry fewer complications and risks than a D&C. They also do not require anesthesia and have quicker recovery.
So how can I figure out what kind of procedure I’m having, then?
Ask your care providers! Ask them to carefully describe the procedure, and the instruments used. If you have a preference between D&C and vacuum aspiration, make sure you speak up and clarify which procedure you are expecting. Don’t take “they’re the same thing” for an answer, and try not to be bullied into accepting a procedure you don’t want. Insist on accurate disclosure and consent paperwork. Don’t permit the medical-industrial-complex to default to laziness or belief that patients can’t understand or care about the difference in procedures. We care. And we insist on transparency.
I’ve decided I want vacuum aspiration, but they’re saying D&C is the only option…
You’re in the wrong place! This situation happens most often when people present at the emergency department of their local hospital for miscarriage management or abnormal bleeding. Many emergency departments and hospitals only offer D&C. If you’re looking for a vacuum aspiration, consider a specialized clinic, like an “early pregnancy loss clinic” or an abortion clinic or other community provider who may be able to offer this in their office or in your home. It can sometimes take more than a day to coordinate a specialized appointment, and in an emergency you may not have this time. However, most pregnancy losses and abortions are not an emergency and can wait for your preferred management plan.
It’s common that hospitals, emergency departments, gynecologists, or doctors refer to the emergency room as the only place for pregnancy loss management. It’s common that they wouldn’t think to refer to an abortion clinic for anything other than an “elective” abortion. But abortion clinics are specialized clinics! Their specialists do these procedures day-in and day-out (unlike emergency room docs!). If someone is looking for management options they should be afforded all options, including vacuum aspiration, and the best specialists for it, including abortion clinics.
The term “D&C” describes a specific medical procedure. It is not an appropriate catch-all for any procedure that empties a uterus!
It is important to use accurate medical terminology when describing the procedures people are going to receive in their body, especially with the intimacy and vulnerability of abortion care & miscarriage management. Respect people enough to trust them to hold new, nuanced information and understand their bodies best. It is patronizing to talk down to people as if they couldn’t possibly understand accurate terminology and it is unethical to ask people to consent to procedures they are not actually receiving (while giving them different procedures they did not consent to).