What is Surgical Abortion?

Surgical abortion refers to abortion done using surgical instruments. Procedures vary due to the stage of the pregnancy and size of the baby at the time of the abortion. 

  • Suction Aspiration (surgical aspiration, vacuum abortion, suction dilation and curettage (D&C))

  • Menstrual Aspiration (menstrual extraction, manual aspiration)

  • Dilation and Evacuation

  • Dilation and Extraction (D&X) (intact D&E, partial birth abortion)

  • Surgical Dilation and Curettage (D&C)

  • Hysterotomy and Hysterectomy Suction Aspiration (surgical aspiration, vacuum abortion, suction dilation and curettage (D&C))

  • Partial Birth Abortion (D&X)

Suction Aspiration
The Suction Aspiration method is the most common method of abortion used in Canadian abortion clinics and hospitals. Used generally between six and 14 weeks of pregnancy, the cervical muscle is stretched open. A hollow plastic tube with a knife like edge is inserted into the uterus. The suction machine then tears the baby’s body into pieces. These pieces are sucked through the tube and collected into a bottle. Often a sharp loop-shaped knife called a curette is then inserted into the uterus to loosen any remaining tissue so that it can be suctioned out. When the suctioning is finished, the abortionist must examine the baby parts and tissue to see if the abortion is complete.

Menstrual Aspiration
– Also known as menstrual extraction or manual aspiration.
In 2004, less than 1% of abortions reported in Canada used this method. 5 Before abortion was legalized, the term ‘menstrual extraction’ was used to disguise the performance of an early suction abortion up to seven weeks’ gestation, sometimes even before a pregnancy was confirmed. The term is misleading, since either the embryo (if the woman is pregnant), or the uterine lining (if she is not pregnant) is suctioned out. Currently, menstrual aspiration refers to an early abortion from three to 10 weeks’ gestation, using a syringe for suction. A thin hollow tube is inserted into the slightly dilated cervix. The tube is attached to a large syringe and the embryo is suctioned out.

Dilation and Evacuation (D&E)
Statistics are not clear on how many D&E abortions occur in Canada each year. In 2004, at least 11% of abortions in Canada occurred after 13 weeks’ gestation. In the US, the majority of abortions that occur after 13 weeks are performed using a variation of this method.

The D&E method refers to an abortion done using forceps to dismember and extract the baby instead of, or together with, suction. In reality, a combination of methods is generally used in abortion after 13 weeks. As the baby grows larger and its bones become harder, the baby becomes more difficult to extract. The cervix must be opened wider, and the head of the baby is large and must be crushed before it can be removed. Bone fragments are sharp and must be carefully removed to avoid damage to the uterus and cervix. The baby parts removed must be identified to make sure the abortion is complete and no parts are left in the uterus. Suction is used for a final clean out of any bits of baby or placental tissue that may remain. Sometimes medications such as digoxin or potassium chloride are injected into the baby through the woman’s abdomen, to kill it before the D&E procedure.

After 19 to 20 weeks, a solution of urea or saline is sometimes injected into the amniotic sac before the abortion. This kills the baby and stimulates contractions. Urea also begins the breakdown of bones and other tissue to make removal of the parts easier for the abortionist .Oxytocin may be used to stimulate contractions and bring about delivery of the baby.

Prostaglandin method
Prostaglandin is a hormone that induces labor. The baby usually dies from the trauma of delivery.

Saline
This method is done after the 16th week of pregnancy. A large needle is inserted into the abdominal wall of the mother and into the baby’s amniotic sac. A concentrated salt solution is injected into the the amniotic fluid. The baby breathes and swallows it, is poisoned, struggles, and sometimes convulses. It takes over an hour to kill the baby. When successful, the mother goes into labour and about a day later delivers a dead baby.

Dilation and Evacuation
– Also known as dilation and Evacuation (D&X)
(intact D&E, partial birth abortion)
There are no laws in Canada restricting abortion. Since abortion reporting and recording is inconsistent and incomplete across Canada, it is not known if, or how many, abortions occur by this method in Canada each year. D&X abortion is a variation of the D&E method, and is used after the first 20 weeks of pregnancy. The Canadian Medical Association considers a child viable after 20 weeks gestation. Laminaria treatment over several days causes wide cervical dilation. The abortionist, guided by ultrasound, uses forceps to grasp the baby and position it face down and feet first. The baby, intact and often still alive at this point, is delivered up to the head. The head is too big to pass through the cervix. After puncturing the base of the skull, the brain is suctioned out, the skull collapses, and the dead baby is delivered. Digoxin, potassium chloride, saline or urea are sometimes used to kill the baby before delivery.

Surgical Dilatation and Curettage (D&C)
Local or general anesthetic is given to the mother before her cervix is dilated. The cervix is dilated with laminaria or rigid dilators; sometimes, the prostaglandin Misoprostol is also given to soften and dilate the cervix. A loop-shaped knife called a curette is inserted through the cervix. The curette cuts the baby and its placenta from the uterine wall and breaks it up. Then the baby parts and the placenta are scraped out of the uterus through the cervix and discarded.

Hysterotomy and Hysterectomy
Hysterotomy refers to a caesarean delivery as an abortion method. The woman’s abdomen and uterus are opened surgically. The baby is lifted out, the placenta is delivered and the umbilical cord is clamped. If no chemical has been injected to kill the baby prior to this point, the baby is often still alive. Hysterotomy is sometimes used in situations where there is a uterine abnormality, which would make the more common abortion methods difficult or impossible. Hysterectomy is the removal of the uterus. When used as abortion methods, these procedures have a higher risk of major complications and death than any other method.What is Medical Abortion?

In Canada in 2004, approximately 3% of reported abortions were done using pharmaceutical drugs. Medical abortion is considered successful if complete expulsion of the embryo and placenta occurs without the need for surgery to complete the abortion.

Medical abortion is not commonly recommended in pregnancies past the first 49-63 days because of the increase in incomplete abortion, heavy and prolonged uterine bleeding and ongoing pregnancy past this stage. When severe bleeding or pain is present, surgical techniques are used to complete the abortion.

Medical abortion takes longer than surgical abortion, is less effective, and requires more clinic visits. Medical abortion results in heavier, more prolonged bleeding, and more pain, nausea and vomiting than surgical abortion. Medical abortion has a 10 fold greater risk of serious infection and death than surgical (suction curettage) abortion.

Medical abortion is preferred over surgical abortion by some women because of its effectiveness in early pregnancy, or because it does not require anesthetics or use of surgical instruments. Other women prefer it because it is more private and possibly more accessible, and because it may more closely resemble natural miscarriage.

Most medical abortions involve the use of a combination of drugs that work together to bring about the abortion over a period of a number of days or weeks.

Medical Abortion Methods

  • Methotrexate and Vaginal or Oral Misoprostol

  • Misoprostol

  • Mifepristone and Misoprostol

  • Labor Induction Methods (instillation methods)

  • Saline Abortion

  • Urea

  • Prostaglandins

In Canada, methotrexate and misoprostol are used together for medical abortion up to 49 days of pregnancy.

Methotrexate breaks down the cell layer that attaches the embryo to the wall of the uterus, depriving the embryo of essential nutrients and resulting in its death.

Misoprostol is a synthetic prostaglandin that causes the cervix to soften and dilate, and the uterus to contract and expel the embryo or fetus.

Abortion with methotrexate and misoprostol requires several clinic visits. During the first visit, methotrexate is injected, followed at 2-7 days with misoprostol pills at home or at a clinic, either inserted into the vagina or taken by mouth. A follow-up visit is required after 1 to 3 weeks to determine if the abortion has occurred.

The methotrexate and misoprostol abortion regimen causes complete abortion in 70-97% of cases. While most of the abortions occur within the first hours or days after taking the misoprostol, 20 to 35% will take up to several weeks. A surgical abortion is scheduled to complete the abortion if it has not occurred by that point because the drugs used can cause birth defects.

Side effects of medical abortion using methotrexate and misoprostol include: significant cramping pain and heavy bleeding during the abortion, along with nausea, vomiting, diarrhea, headache, fever, and chills; prolonged bleeding for one to seven weeks afterwards, and infection; birth defects if the pregnancy is ongoing and the baby survives.

Misoprostol
Misoprostol is a synthetic prostaglandin that causes the cervix to soften and dilate, and the uterus to contract and expel the baby.

Misoprostol is used vaginally in abortions up to 56 days since the first day of the last menstrual period. When used alone, Misoprostol causes complete abortion in 22-94% of cases.

Early side effects are worse with this method than with other methods of medical abortion, and include pain, dizziness, nausea, vomiting, diarrhea, chills and rashes.34 Heavy and prolonged bleeding and infection are associated with medical abortion in general. Misoprostol is generally used with another drug because of the higher incidence of side effects and lower rate of effectiveness when it is used alone.

Misoprostol is commonly used in surgical abortions as well, to soften and dilate the cervix, and to reduce bleeding.

Mifepristone and Misoprostol
Mifepristone, also known as RU-486 or the ‘abortion pill’, used together with misoprostol is the most commonly used medical abortion combination worldwide.

Mifepristone is not approved for abortion in Canada. In 2001, the only Canadian trial of Mifepristone was stopped after the death of a woman from toxic shock brought on by a bacterial infection related to her abortion;42 similar deaths were recorded elsewhere.

Mifepristone causes abortion by blocking the action of progesterone. Progesterone prepares the uterine lining for implantation and is essential for maintenance of the pregnancy. Progesterone also suppresses uterine contractions.

Mifepristone causes the uterine lining to break down, resulting in detachment of the embryo from its source of nutrition. It causes the cervix to soften and dilate. It also makes the body release prostaglandins and increases the effects of these prostaglandins in causing the uterus to contract.

Mifepristone/Misoprostol abortions are quicker than methotrexate/misoprostol abortions. Both regimens have similar rates of complete abortion, side effects and complications. Serious infection and heavy, prolonged bleeding are the most notable side effects, along with nausea, vomiting, diarrhea and headache.

Labor induction methods (instillation methods)
In Canada in 2004, less than 1% of reported abortions used labor induction methods, such as instillation of saline, urea or prostaglandin solutions into the amniotic sac.

Saline abortion
Saline abortion refers to the injection of a concentrated salt solution into the amniotic sac through the mother’s abdomen. The solution burns and kills the baby, stops placental functioning, and stimulates labor.

Saline abortions are rare in Canada, due to maternal deaths and a high level of side effects.

Urea
No urea abortions were reported in Canada for 2004. Although urea instillation abortions are safer than saline abortions, the abortion takes a long time to occur. Urea is sometimes used in D&E abortions to kill the baby and soften its bones to make it easier to remove.

Prostaglandins
Less than 1% of reported abortions in Canada in 2004 were listed as prostaglandin abortions. Prostaglandins can be injected into the amniotic sac or taken by the mother to induce abortion. However, due to a high rate of side effects, as well as cases of temporary baby survival, this is not a common abortion method. Sometimes saline or urea are injected into the amniotic sac to ensure the baby will be dead when it is delivered, or the baby is killed by an injection of potassium chloride or digoxin into the heart or amniotic sac.

Other reported methods
In addition to the methods listed above, there are other methods of abortion infrequently used in Canada. Combinations of the above methods may also be listed under “Other” in statistical reports.