L&D or D&E? | Counseling | Therapy

L&D or D&E?

Dr. Erica , LCSW, DSW — Therapist

There are so many painful decisions involved from the moment you learn your baby is facing a life-limiting illness, or serious anomaly. With very little time to spare, parents are forced to determine if they want to continue the pregnancy to term or end it prematurely through a termination or abortion. It’s important to note that not everyone is comfortable using the term “abortion” when describing ending a wanted pregnancy. Unfortunately, language has become weaponized and used to attack and stigmatize women who make the choice to end pregnancies for a variety of reasons. For some women, having an abortion refers to ending an unwanted pregnancy, while a termination feels more procedural and medical, as an action resulting from testing and diagnosis. In the babyloss community, the procedure is often called EWP, or ending a wanted pregnancy, as well as TFMR, or termination for medical reasons. Most medical and research literature refers to it as TOPFA: termination of pregnancy due to fetal anomaly, or TOP for short. For the purpose of consistency, these entries will call the procedure a termination, but any language you choose to use to describe the experience is what is right for you.

First Trimester: Dilation and Curettage (D&C)

For women who terminate their pregnancies in the first trimester, the most common option is a D&C, or dilation and curettage. This option is not only reserved for women who have been diagnosed with a fetal anomaly; rather, women who tragically miscarry or choose abortion earlier in pregnancy also receive a D&C. Prior to 11 weeks’ gestation—and usually before the time an anomaly can be diagnosed, unless a patient has a history that warrants and allows for genetic testing—pregnancies can be safely ended with medication at home. A D&C, however, is an outpatient procedure that involves the removal of uterine tissue through first dilating or opening the cervix and then using surgical instruments to complete the procedure. Medication is also commonly used to begin to open the cervix prior to the procedure. Some women receive general anesthesia and are completely unconscious for the procedure. Others may receive sedation and have some awareness. A D&C is usually performed prior to 13 weeks’ gestation, in the first trimester. A common medical reason for having a D&C at this time may be the detection of Trisomy 13, 18, or 21 during prenatal sequential screening or non-invasive prenatal testing (NIPT).

Second Trimester: Dilation and Evacuation (D&E) or Labor and Delivery (L&D)

As mentioned in earlier entries, many birth defects are not detected until the second trimester of pregnancy. It is an unfortunate and painful reality that women may head excitedly into their 20-week anatomy scan excited to learn about the sex of their baby, only to learn that the baby has not developed normally. Due to many legal restrictions across the United States, some women may only have two to four weeks to gather information about their baby’s prognosis and make a decision about termination. While there are clinics in the United States that perform later terminations, traveling and paying up front for the procedure can be costly and may not be an option for everyone. While this article does not discuss the legal and political climate in which abortion is restricted and time-limited, it is important to acknowledge that these restrictions can cause an additional pain and burden on women and families who are already grieving as they attempt to decide what path is best for them.

It is also important to note that not every hospital or clinic offers both options of D&E and L&D, which is further troublesome as families report feeling more peaceful with their decision if they have a choice regarding how to end the pregnancy.

What is a D&E and Who is it For?

Similar to a D&C, a dilation and evacuation (D&E) is a surgical procedure that consists of first dilating the cervix and then emptying the uterus. Statistically, most women choose this option. Prior to the procedure, women are given medication to open the cervix, as usually in the second trimester it is high and closed. Different types of dilators may be used depending on what your physician determines is best for you, and the process may last from a few hours to a few days, depending on your stage of pregnancy. Many women report that this is the most painful component of the D&E. If you are considering this route, be sure to talk to your provider about pain management strategies, as physical pain can also make emotional pain all the more intense.

Once the cervix is dilated, a D&E is performed as an outpatient surgery under sedation or anesthesia, in which the surgeon removes your pregnancy through your vagina. Research indicates that this procedure is safe (and safer than an L&D) and women experience few post-operative complications, though there can be the risk of scar tissue that might affect a woman’s ability to conceive in the future. If this happens, or there are pieces of tissue retained, an additional surgery can address this. After a D&E, bleeding is common, but it should taper off over a few weeks. There may also be pain and cramping, in addition to the emotional pain of losing your baby.

Women opting for a D&E may feel it is too painful to go through a delivery where they meet and hold their baby. They may feel that psychologically it is best for them to be anesthetized and go home the next day instead of experience a longer hospital inpatient admission. Choosing a D&E also means making arrangements for your fetus’ remains to be sent to pathology for analysis if you would like to explore the diagnosis you received, and learn about whether future pregnancies may be affected. You will also be given options for burial according to your hospital’s resources, but you can choose to also have your fetus’ remains sent to a crematorium or returned to you for burial. Your physician will be able to provide you with the resources to do this.

If you choose a surgical abortion like a D&E, you are not a bad mother. What is most important is that choosing this method feels best, emotionally and physically, for you and your partner, if one is involved.

What is an L&D and Who is it For?

L&D stands for “Labor and Delivery”, and, just as the name implies, this procedure involves laboring and delivering your baby. Prior to the procedure, your doctor may inject medication through a syringe into your fetus or amniotic sac to stop the heart. The next step is admission to a hospital labor and delivery unit, in which medication is given to dilate your cervix, usually as a small pill administered through the vagina. Sometimes, medication like Pitocin, a synthetic version of the hormone Oxytocin, is given to stimulate contractions. If you experience labor pains, you may be offered relief through oral medications or an epidural. You will then deliver your baby and hold them for as long as you like. Your care team will not provide any intervention to continue your baby’s life, so if you have not received an injection, your baby may breathe for a few moments, then stop. During this time, some parents opt to take pictures to memorialize the birth. Organizations like Now I Lay Me Down to Sleep offer this service free of charge. Research indicates that an L&D may come with slightly more complications than a D&E due to vaginal delivery and the chance of greater bleeding or infection. However, an L&D is also common and not unsafe. After the procedure, you can expect bleeding and cramping as your uterus shrinks to return to normal size and extra tissue is passed through your vagina.

This procedure may be for you if you want a chance to meet your baby and leave their body intact. Your options may then be limited in terms of sending your baby’s remains to pathology for genetic studies, unless you are comfortable with the body no longer being intact. The hospital social worker will also have the resources available for you about options for the remains. Some parents follow religious or spiritual practices that dictate the need for them to say goodbye to their pregnancy face to face, or to keep the body whole. However, it is important to note that some parents find this process triggering as they are admitted to a unit where unaffected births are happening, and they have to leave the hospital without a living child.

If you choose an L&D, you are not a bad mother. What is most important is that choosing this method feels best, emotionally, and physically, for you and your partner, if one is involved.

Summing Up

Whether D&E or L&D, every step of your procedure should feel supported and as though you feel empowered in the choices you are making, as difficult as they are. No procedure comes without emotional and psychological consequences. Sometimes, anxiety and stress can be heightened if you have to travel out of state for your procedure. And some parents may develop intrusive memories and anxiety in the early weeks after the procedure, though time should slowly start to cause these memories to feel less acute. However, some parents report experiencing post-traumatic stress disorder (PTSD)-like symptoms. This can only be diagnosed by a licensed mental health provider, and there are validated and evidence-based techniques for coping with these as well. It is so important to seek help from a professional, as early as possible, who can help you walk this path and choose what is best for you. Please consider reaching out, as nobody should have to go through this alone.

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