Editing Intact dilation and extraction (section)

==Procedure==
As with non-intact D&E, intact D&E may be performed in freestanding clinics, ambulatory surgical centers, and in hospitals. Intra-operative pain control is usually dependent on the setting and patient characteristics but commonly involves local analgesia with either IV sedation or general anesthesia. Preoperative antibiotics are administered to reduce the risk of infection.<ref name="naf4">{{cite book|title=Management of Unintended and Abnormal Pregnancy|last1=Paul|first1=Maureen|last2=Lichtenberg|first2=Steve|last3=Borgatta|first3=Lynn|last4=Grimes|first4=David A.|last5=Stubblefield|first5=Phillip G.|last6=Creinin|first6=Mitchell D.|publisher=John Wiley and Sons|year=2011}}</ref> In cases where the woman is Rh-negative, [[Rho(D) immune globulin|Rho(D) immunoglobulin]] (RhoGam) is administered to prevent the risk of developing [[Hemolytic disease of the newborn|erythroblastosis fetalis]] (hemolytic disease of the newborn) in subsequent pregnancies.<ref name=":02"/> Intact D&E is more feasible among women with higher [[Gravidity and parity|parity]], at higher gestational ages, and when cervical dilation is greater.<ref name="naf" /> There are no absolute contraindications.

=== Cervical preparation ===
The surgery is preceded by cervical preparation, which may take several days. [[Laminaria stick|Osmotic dilators]], natural or synthetic rods that absorb moisture from the [[cervix]], are placed in the cervix and mechanically dilate the cervix over the course of hours to days. [[Misoprostol]] can be used to soften the cervix further. Intact D&E can only be performed with 2–5 centimeters of [[cervical dilation]].<ref name=":02"/>

=== Fetal termination ===
Fetal injection of [[digoxin]] or [[potassium chloride]] may be administered at the beginning of the procedure to allow for softening of the fetal bones or to comply with relevant laws in the physician's jurisdiction and the U.S. federal Partial-Birth Abortion Ban Act.<ref name="naf" /> Umbilical cord transection can also be used to induce fetal demise prior to removal.<ref>{{Cite journal|last1=Tocce|first1=Kristina|last2=Leach|first2=Kara K.|last3=Sheeder|first3=Jeanelle L.|last4=Nielson|first4=Kandice|last5=Teal|first5=Stephanie B.|date=2013-08-08|title=Umbilical cord transection to induce fetal demise prior to second-trimester D&E abortion|url=https://pubmed.ncbi.nlm.nih.gov/24034582/|journal=Contraception|volume=88|issue=6|pages=712–716|doi=10.1016/j.contraception.2013.08.001|issn=1879-0518|pmid=24034582}}</ref>

=== Removal of fetus and placenta ===
During the surgery, the fetus is removed from the uterus in the [[breech position]]. If the fetal presentation is not breech, forceps or manual manipulation can be used to turn it to a breech presentation while in the uterus (internal version).<ref name="naf4"/> The fetal skull is usually the largest part of the fetal body and its removal may require mechanical collapse if it is too large to fit through the cervical canal.<ref name=":02"/> Decompression of the skull can be accomplished by incision and suction of the brain or by using forceps to collapse the skull.<ref name="naf" />