Elizabeth Petrucelli

Author, Blogger, Educator

Category: second trimester miscarriage

The D&E for Miscarriage

When a baby dies in the second trimester of pregnancy, their death is either a miscarriage or a stillbirth. Stillbirth in the U.S. is defined as when a baby dies after 20 weeks gestation. A death before 20 weeks gestation is called a miscarriage. A second trimester miscarriage is a miscarriage between 12 completed weeks and 20 weeks. How a second trimester miscarriage is managed differs greatly between care providers. This post is the information I give my clients when they are told the unfortunate news that they are experiencing a second trimester miscarriage.

There are multiple factors when it comes to options for delivering a baby who has died or will die before 20 weeks gestation. Many care providers immediately state that the patient needs a surgical procedure called a D&C; although beyond 12 weeks gestation (in the second trimester), the surgical procedure is a D&E; which is different and I will explain those differences.

First; however, let me state that if the woman is experiencing a missed miscarriage, a D&C may be performed instead of a D&E. For example, if the woman goes to her 16 week appointment only to discover her baby died at 11 weeks gestation, the doctor will likely recommend a D&C. But, if the woman goes to her 16 week appointment and the baby has recently died, then a D&E would be recommended (even if the doctor calls the procedure a D&C).

When a doctor recommends surgery for the miscarriage, a woman usually schedules the procedure either for that day or within a week but rarely is the woman given any other options.

There are other options for second trimester miscarriage.

Just like with first trimester miscarriage, a woman has three options for miscarriage.

  1. Expectant Management (wait and see approach).
  2. Medical Management (using a medication to induce the miscarriage/delivery)
  3. Surgical Management (D&C or D&E)

When it comes to second trimester miscarriage, the number one cited reason for surgical management of miscarriage is risk of infection from leaving the baby or “pregnancy tissue” in the uterus. Yet, in the several hours of research on this particular topic, I could not find any substantial data to prove that a woman was at a higher risk of infection with expectant management of miscarriage versus surgical management of miscarriage.

This Cochrane Review explained that the risk for infection with expectant management of miscarriage was similar to surgical management; although I did find information here that suggests there is a 1% risk of infection with expectant management and this site suggests 0% to 10% chance of infection with expectant management. This leads me to believe it’s not well studied, especially in the second trimester since second trimester miscarriage and pregnancy loss is less common.

Nearly ALL the websites I explored stated that the woman’s preference should be utilized. But here lies the conundrum because care providers are only presenting one option for second trimester miscarriage; the D&E.

The D&E (dilatation and evacuation) is generally performed for miscarriages over 12 weeks gestation. The difference between a D&C and D&E procedure is that during a D&E, the surgeon dilates the cervix and then uses a grasping instrument (forceps) to remove the baby (sometimes in parts) and then uses a vacuum or curettage to suction and scrape the remaining tissue in the uterus.

In essence, because the uterus is not dilated big enough to remove the entire baby all at once, the baby must be removed in pieces and once removed, a curettage procedure is performed. While this is a very effective and viable option, some women and their partners would like to see and hold their baby, possibly take pictures of and with their baby, receive handprints/footprints from their baby, wash their baby, dress their baby, provide dignified services such as baptisms or blessings, and bury or cremate their baby. Some of these options might be available with a D&E but not all of them.

If I were your bereavement doula, I would personally walk you through these options and discuss them at length so you can make the best decision for your family. Hiring a bereavement doula is highly recommended for miscarriage and stillbirth. It is nearly impossible to explain in such detail here all a bereavement doula would present and help you with in this scenario. Please reach out if you would like to know more, I can help from afar as well.

There is no definitive amount of time on when labor will begin with expectant management. I use the term labor, because it is labor. It is NOT a heavy period, especially in the second trimester. Your cervix still has to soften (efface) and dilate (open) in order for the uterus to contract and push out the baby (“contents”).

Expectant management of second trimester miscarriage could take days, weeks, or even months to complete. Waiting is not always an option for women both physically and emotionally. Preparing to deliver a baby at home would also need to be considered as many women are sent home to give birth to their deceased baby. I do not recommend having such a large baby at home on your own and always recommend to my clients that they are admitted to the hospital for induction. Too many women have gone home to either wait for the baby or utilize medical management (taking medication to induce a miscarriage) and ended up in the emergency room bleeding severely and requiring a blood transfusion.

In my blog post, How to Prepare for Your Miscarriage, I explain in depth the materials needed in order to have a miscarriage at home. If you are considering this option, please read the information and prepare accordingly. If you are uncomfortable with the risks or seeing such an early baby, a hospital induction is an option. Care providers may give some push-back on this option and of course, there may be higher medical costs associated with this option but if you want to deliver your baby in a hospital with all the medical equipment needed for the risks, you can and should have this option.

I want to end this post with the risks of D&E. I have not linked to any specific website on this procedure as it may be too traumatic because the websites that list the risks are for abortion, not second trimester miscarriage. However, should you want to confirm the risks I list, you may conduct an internet search “Risks of D&E” which will provide the information.

The risks of the D&E are very similar to the risks of a D&C.

  • Injury to the cervix and/or uterine lining.
  • Uterine perforation (the provider punctures a hole in the uterus)
  • Infection
  • Bleeding/hemorrhaging
  • Retained products of conception, fetal tissue, or other tissue (requiring a second surgery)
  • Uterine rupture (from medications frequently used before the procedure to prepare the cervix)
  • Blood clots

It is also important to note that with a second trimester miscarriage, you may go through baby blues and/or depression just like a woman who has a full term, live birth and you may lactate and/or have engorged breasts. These are more likely to occur after 16 weeks gestation although I have had a few clients with 14 week losses who lactated (breastmilk).

I highly recommend you purchase the book, It’s Not ‘Just’ a Heavy Period; The Miscarriage Handbook to help you through this process. It explains miscarriage more in depth.

How to Prepare for Your Miscarriage

miscarriage in ultrasound roomYou’ve just been told that your baby/pregnancy isn’t viable, that there is no longer a heartbeat, or that you will be miscarrying; so what do you do now? Chances are, you were sent home with medication to induce the miscarriage or told to just go home and wait it out but do you really know all that you need to prepare for? Probably not.

Here is some practical information on how to prepare for your miscarriage. This is information you would likely never hear from your care provider.

Step 1. Before you leave the doctors office, ask for the following (if you have already left, you can call them or send someone back to their office).

  • A list of warning signs.
  • Induction medication instructions, warning signs, and how long it may take to work.
  • A miscarriage kit (strainer, gloves, saline solution, container for remains/baby).
  • Pain medication (prescription in hand or actual pills).
  • A sleep aid (if you feel you will need it).

Step 2. Prepare your home by setting up the bathroom for the delivery process. Purchase a miscarriage kit. If you don’t have time to purchase a kit, use the information below to prepare.

  • Have the strainer in the toilet (for every use)
  • A container to place the baby/remains.
  • Saline solution (for preserving and viewing the baby).
  • Gloves on hand in case you feel like you need them (it’s okay to touch the baby/remains without gloves).
  • Towels/wash clothes for cleaning up.

Step 3. Prepare emotionally.

  • Talk with others who may have miscarried.
  • Share your feelings with your partner and ask him how he is feeling/doing.
  • Books are an excellent way to learn what others have felt and they can help validate your own feelings. It’s Not ‘Just’ a Heavy Period; The Miscarriage Handbook or The Miscarriage App, can be very helpful.
  • Join an online support group and ask others about their experiences.

Step 4. Have someone with you. You should not miscarry or deliver your baby at home alone.

  • Your partner or husband should be with you. If they are not available, a friend or other family member should be with you.
  • Hire a professional such as a bereavement doula, loss doula, or perinatal loss specialist who can mentor you through this process.
  • Ask if you can be induced and deliver in the hospital. For miscarriages beyond 10 weeks, this can be a very viable option. I recommend that all my clients deliver in a hospital when they are between 14 – 20 weeks.

Step 5. Consider testing. Doctors speculate that miscarriages are caused by genetic abnormalities but with so few women testing (only 13% of stillborn babies receive an autopsy), we just don’t know for sure if there is something you can do to prevent a miscarriage.

  • Ask your doctor about the Anora Miscarriage test kit by Natera. This is a test on your baby’s remains and may give you some answers such as sex of the baby and the baby’s condition/chromosomes. For baby’s between 16-20 weeks an autopsy may also be performed.
  • Ask your doctor to run blood tests on you which may reveal conditions like MTHFR and other antibody/antigen issues which could cause miscarriage.
  • In a future pregnancy, consider progesterone testing to ensure your progesterone is at the optimal level for carrying a baby. This test should be done as soon as you become pregnant and monitored during the first trimester.

Step 6. Decide the final resting place for the baby/remains. You have many options available to you.

  • Flushing (accidental or purposeful) is one option. If you feel guilt over flushing or would like to honor your baby, you can perform a water ceremony for miscarriage which can help to release some of the guilt and/or honor your baby.
  • Burial (at home, at a cemetery, or other location). Be sure to check the local laws on home burial or burial at any other location other than a cemetery, you do not want to break local ordinances and laws. Burial at home is not usually recommended in the event that you might move. Some families choose to bury a tiny baby in a pot and plant a tree which is portable in the event of moving. Many cemetery’s offer communal burial or plots for miscarried babies and many are free. Be sure to inquire.
  • Cremation. You will need to work with a mortuary or crematory for cremation if you are not utilizing the hospital cremation process. Please note that most hospitals cremate all biohazard together and that includes the baby/remains. You will also not receive any ashes back with hospital cremation/disposal. Many mortuaries and crematories will conduct the cremation free of charge. You might even be able to include special blankets or notes during that process. Be sure to inquire. With very early babies (13 weeks and earlier), you may not receive any ashes back.

Step 7. Create memories. Yes, there are ways to create memories, even for early miscarriages.

Memory Box for Miscarriage - Erika Zane Photography

  • Pictures can be taken of your very tiny baby either professionally or with your phone.
  • Smells and scents can help you remember. Lavender is a very common scent used to help relax but it can also be used to help you remember. You may not think you will want to remember this experience but many women do.
  • Name your baby. This can be very beneficial in validating your baby’s existence. It’s not something everyone does but many women enjoy naming their baby, even if they call their baby “peanut” or Baby (insert last name).
  • Miscarriage AnnouncementMementos don’t have to be elaborate. If you have a larger baby, you can try capturing handprints/footprints but with smaller babies, you will need be a bit more creative. Examples of mementos are sympathy cards, hospital admission bracelet (from you), remembrance jewelry, breastmilk pendant (if your milk came in), cord keepsake, blanket (with or without baby’s name on it), plant a tree, plant flowers, make a donation to a charity,  etc.
  • Create a miscarriage announcement.
  • Attend annual events such as a candlelight vigil or remembrance walk. You can find local vigils and events here.

Step 8. Move forward.

  • Understand that moving forward is not moving on. It will take time for you to feel like you can move, let alone move forward. Take your time moving forward.
  • Seek a support group or one-on-one mentoring/counseling.
  • You will likely never return to “normal” but will learn a new normal.
  • There is no timeline on grief. Some people move through grief quickly and some move through grief more slowly. There is no right or wrong.
  • Purchase a recovery kit.
  • Grief is not depression.
Photo Credit: Dravas Photography

Photo Credit: Dravas Photography

Having a miscarriage is not easy, even if you might not have wanted the baby. It is emotionally and physically draining yet we are led to believe that this is an easy experience and it’s “no big deal.” Many women are confused when they are hurting yet are not treated as if this is a hurtful event. With the information above, women will understand how to prepare for your miscarriage. They will feel empowered and validated and will know they have options.

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