Choosing between D&C and Natural Miscarriage

When you have a choice between surgery and natural miscarriage or labor

Usually you will be offered a choice between surgery and either waiting for a natural miscarriage or having induced labor. The two types of surgery are D&C (dilate and curettage) or a D&E (dilate and evacuation–for bigger babies between 14 and 20 weeks).

Some doctors prefer you wait for it to happen naturally due to the small risks of dilating the cervix for a D&C. Waiting it out is typically only for those less than 10 weeks along due to the risk of blood clots and hemorrhage, but this depends on your doctor. On rare occasions, you may be offered a methotrexate shot and a suppository to bring on a natural miscarriage. As for the choosing between a D&E and actual labor, state laws vary about the age of viability, and you may fall in the gray area, which will be discussed later.

Things to think about when choosing between natural labor and D&C surgery:

Do I want to wait for a natural miscarriage?

Advantages: If you wait, you can feel certain that there was no mistake made. When the baby comes you will know that nature has run its course. You can go home instead of going immediately to a hospital or office procedure. You can take a little time to say goodbye and gather loved ones around you.

Disadvantages: For some women, this process is not much worse than a bad period, for for many, it can take several days and be extremely painful and scary. You may have to have a D&C anyway if everything does not come out (called an incomplete abortion). It may be distressing to think of walking around with your baby who is no longer living. Having tissue come at home may be frightening and you may feel awkward, not sure if you save it, or bury it, or what to do.

Do I want a D&C?

Advantages: This is mostly painless and will get you back on track to start trying again much sooner. The physical part of the ordeal will end.

Disadvantages: There is some risk of damaging the cervix during dilation, although that has mostly been taken care of by using laminaria, or seaweed sticks to dilate you gently overnight. Some doctors now use a cream to begin dilation. (If this will not be done, ask if you are going to be dilated (very early pregnancies may not need it, and your cervix may already be opening), and how. Mechanical dilation is riskier. Some women also worry about punctures or perforations of the uterus. While this is a possibility, the risk is small. Even if this should this happen, the uterus will usually heal without complications or harm to your next pregnancy. The main disadvantage to this procedure is that you will not get to see the baby, ever. Most clinics and hospitals will have the baby’s remains cremated. If you are pretty far along, holding the baby may be very important to you.

If your doctor does not agree with your decision to either wait or to have a D&C, GET A SECOND OPINION. This is your baby and your life. If you need a second opinion, a good place to go is a women’s hospital or clinic, where they usually focus on you, not the procedure, and help you make the best decision based on all the information available.

The Gray Area

The death of your baby becomes a legal issue somewhere between 20-28 weeks gestation. Some countries, or regions within a country, require labor and delivery at 24 weeks; some allow the doctor some discretion. Naturally, if you have already begun early labor, you may not have a choice. If your labor could be stopped, then the miscarriage might not happen at all. Otherwise, the cause of the miscarriage is usually Fetal Demise, and if the baby died well before the exam that showed no heartbeat, then it may measure out smaller than the pregnancy would indicate.

There will be a viability point, usually at 24 weeks, where you have no choice but to deliver the baby. To find out more about this, and whether or nor you want or will be able to have your baby’s remains, you may want to read about the politics of fetal death.

If you are more than 20 weeks:

Things to think about when choosing between a D&E and induced labor:

Do I want a D&E (if eligible)?

Advantages: This is mostly painless and will get you back on track to start trying again much sooner. The physical part of the ordeal will end.

Disadvantages: You will never see your baby, and if you are like me, where the baby was too small to see its sex and the chromosome tests do not come out, you will never even know if your baby was a boy or a girl.

Do I want to deliver the baby through labor?

Advantages: You will get to hold your baby, take a picture if you want, and say goodbye. It will be very, very hard and sad, but it will make you feel better later.

Disadvantages: Although this is not always the case, the drugs they give you to dilate your cervix and induce labor might make you very sick—throwing up, diarrhea, some women have mentioned hallucinations and terrible fear. It can take many hours or even days to get dilated enough to get the baby out. And the result is the same: you have done all this labor to see a baby that is not alive.

Different doctors will push different options. Weigh them the best you can and make sure you get what you want. Even if you regret your decision later (as I did for many years), remember that there simply is no good way to deliver a baby who has died. It’s a terrible thing no matter what.

Natural Miscarriage

If you choose to wait it out for a natural miscarriage, you will most likely have a difficult wait. It may not seem real; you will harbor hope that it will never happen. Eventually the cramping and bleeding will begin, and you may react with severe grief and panic. You may feel ridiculous or morbid trying to catch tissue in a jar or plastic bag for testing. All these things are fine. Do the best you can. If all goes well, the cramps will subside and a regular blood flow will resume. Keep in mind that you may not pass all the tissue and will have to have a D&C to empty your uterus.

During the next few days you will likely experience the following:

• Cramps and bleeding, sometimes quite painful and heavy.
• Passage of tissue, resembling large blood clots in the earliest weeks up to pinkish/grayish material, possibly even in a discernible sack. Try not to traumatize yourself by searching for the baby. Most of what you see will be bits of the placenta. Believe me, I understand the impulse. Not seeing my baby was traumatizing in itself. And mine was fully formed at 20 weeks. Just do the best you can.
• If you collect the tissue, it may be refrigerated until you take it for testing. If this is your first miscarriage, it is not necessary to keep the tissue. It is rarely tested in this case. Any tissue that falls into the toilet is not testable, so you do not need to retrieve it.

Call your doctor if you experience the following:

• Any sort of abdominal pain that lasts beyond the cramping stage. You could be developing an infection. Don’t panic though, just call and you will get an antibiotic and a check up.
• A fever that starts to approach 100 degrees. Again, infection is a possibility.
• Cramps beyond endurance. You may need a pain medication or a D&C.
• Bleeding that comes heavy and fast, soaking a pad every few hours, for more than three days. If the bleeding does not slow down after that, you may have tissue that is causing hemorrhaging, and you will need a D&C.
• Bleeding that lasts longer than two weeks. A D&C may be necessary.
• Bleeding that starts and stops and starts and stops for weeks. Some tissue is still causing hormones to be created, and you will need intervention.

You will feel some of the following as the days and weeks wear on:

• A mild start and stop bleeding pattern up to two weeks. You should have a new cycle, unrelated to the first bleeding, between 4 and 7 weeks after the miscarriage. I didn’t get a fresh cycle until the last day of the 7th week, so don’t panic if you are still waiting. A few women need a Provera shot to jump start their cycle, but this is not terribly unusual. Call your doctor if you go much longer than 7 weeks, just for your peace of mind. You may want to start charting your temperatures after the bleeding stops to see where you are. Remember that you can get pregnant that first cycle, so use contraceptive. For more information, see the section on trying again.
• Snappy, unhappy, angry feelings. Wanting to be left alone or wanting to talk about what happened with everyone you know.\
• A sense that it isn’t real, that it never happened.
• Hypersensitivity to sad TV or reading materials, being revolted or angry about happy scenes of families, seeing symbols in everything you do, from gardening to dreams to what you eat.
• Anger at the baby, wishing you never knew about the pregnancy, wanting to throw out all the baby reminders, or clinging to the little angel you lost, thinking about him/her nonstop, wanting everyone to recognize that the baby was real.
• Anger and/or jealousy of other pregnant women, even friends and family, to the point you don’t want to even talk with them. This is okay. I felt this way for several months.