What is dilation and curettage (D&C)?

Dilation and curettage (D&C) is a procedure in which the cervix of the uterus is expanded (dilated) so that the uterine lining (endometrium) can be removed with a spoon-shaped instrument called a curet or curette. The procedure is performed for a variety of reasons. Most commonly, this surgery is done in order to help determine the cause of abnormal uterine bleeding. It can also be done to help determine the degree of abnormality of the endometrium in cases of cancer or pre-cancerous cells that are detected by an in-office biopsy. D&C is also sometimes necessary to remove tissue after a miscarriage.

Why is a D&C done?

In general, a D&C is used to help determine the health of the uterine lining or to remove abnormal tissue. Occasionally, the procedure can correct some of the problems in the uterus such as polyps, scar tissue, or tissue overgrowth.

What are reasons not to perform a D&C?

There are very few contraindications to D&C. Generally if a patient is too ill to undergo surgery, then she should probably not have this procedure. Furthermore, if the patient is unable to move her legs apart, such as with severe arthritis in the hips, the surgeon may not be able to perform the procedure since it requires enough movement of the legs to accommodate a speculum and the surgeon. If the patient is pregnant or thinks that she could be pregnant, she should not have the operation unless the D&C is for the purpose of an abortion.

Pre-op: What happens before surgery?

Before a D&C, the same general recommendations as for other outpatient procedures apply. It is recommended that the patient take nothing by mouth (food, water, etc.) for at least 7 hours before the scheduled operation. Often, the doctor will see the patient the day before surgery to discuss the procedure and the potential complications in greater detail.

What type of anesthesia is used for a D&C?

Most D&Cs are done under general anesthesia. The procedure is typically very short, and the general anesthetic can be quickly reversed, with the patient going home later the same day. Some patients prefer or require spinal or epidural blocks, but these forms of anesthesia take more time for the anesthesiologist to perform and require more recovery time for the patient. Occasionally, in a very motivated patient, the procedure can be done under a local anesthetic with or without intravenous pain medication or twilight sleep. Overall, the choice of anesthetic is a generally determined by the anesthesiologist and the patient. The surgeon performing the procedure only requires that the patient not move during the surgery.

How is a D&C performed?

The actual procedure is done in an operating room, either in a hospital, surgery center, or a specially designated room in a physician's office. After adequate anesthesia has been administered, and with the patient in position (similar to that for a Pap smear), the vagina and cervix are cleansed with an antibacterial scrub (usually Betadine). An instrument is used to grasp the upper portion of the cervix, and then the opening to the uterus is gradually widened with metal dilators to about the size of a large pencil. Once the dilation has been completed, the curette, which is an instrument with a flat metal loop at the end, is inserted into the uterine cavity and is used to gently scrape the lining of the uterus. When the surgeon feels the gritty layer of cells just above the muscle of the uterus, then he/she knows that the scraping has gone deep enough to sample the tissue adequately. This scraping is done throughout the uterus, and the tissue that is removed is then sent to a pathologist for microscopic examination. After the surgeon feels that enough tissue has been obtained, that the entire uterine cavity has been sampled, or that any abnormal growths that were seen on ultrasound were removed, then the procedure is stopped. Often, the doctor uses a viewing instrument to examine the uterus visually (hysteroscopy) prior to the D&C to make the procedure more complete. This is not, however, always necessary. Dilation and Curettage Preparation
Depending on the type of anesthesia used, the doctor's instructions before a D&C will most likely include the following: Avoid unnecessary drugs: A few days before your D&C, stop taking drugs such as aspirin, which can cause increased risk of bleeding, and any over-the-counter medications, such as cold medication and laxatives. Avoid alcohol and tobacco use. Many surgeons now recommend the patient stop taking any herbal supplements at least two weeks before surgery. Talk with the doctor about all medications you take. Chronic conditions: The doctor will most likely want the patient's other medical problems stabilized prior to the surgery. For example, if the patient has uncontrolledhigh blood pressure, she may be put on a strict treatment plan in or out of the hospital to improve blood pressure. This is important to avoid any unnecessary complications during the D&C procedure. Eating and drinking: The doctor will also instruct the patient not to eat or drink for 12 hours before your D&C if it is done under general anesthesia (the patient is completely asleep), or for 8 hours before a local or regional (for example, spinal anesthesia, just the lower portion of your body is numbed and you have no feeling) is used. Preliminary tests: On the day before or day of the procedure, the doctor may want to obtain certain routine blood, urine, and other tests to be sure no medical problems have been missed.

During the Dilation and Curettage Procedure

Anesthesia

 Local anesthesia: If the patient has a local anesthetic, she will lie on your back in the standard pelvic examination position: legs apart and the knees drawn up. The doctor will insert an instrument called a speculum into the vagina to hold the vagina wall apart. The doctor or assistant will then clean the inner and outer vagina, including the cervix, with a cleaning solution. The doctor will then steady the cervix with a clamp and inject a local anesthetic into the cervix on either side. This is called a paracervical block and relieves pain from the dilating of the cervix. It does not numb any of the rest of the body. Spinal anesthesia: A needle is placed in the lower back, usually while the patient is sitting up. Anesthetic is injected through this needle into the spinal fluid that surrounds the spinal cord. This causes numbness usually from the level of the belly button on down. The anesthesia wears off in 1-3 hours. General anesthesia: If general anesthesia is given, the patient will not be aware of anything including the cleaning step, after the patient loses consciousness. The patient will lie on the table with an anesthesiologist or nurse anesthetist at the head. The paitent may be given an injection of medication to assist in relaxing the patient and to dry up any oral secretions. The patient will then receive an intravenous fast-acting anesthetic and immediately fall asleep for the procedure and the patient's breathing will be monitored. Dilation (the first step): While grasping the cervix with a clamp, the doctor will pass a thin, flexible piece of metal called a sound to determine the depth and angle of the uterus. These measurements allow the doctor to know how far into the uterus the curette can be safely inserted. The usual method of dilation is to insert a thin, smooth metal rod gently along the vaginal canal and up into the tiny cervical opening. The rod is left in place for a moment, then withdrawn and replaced by a slightly larger rod. This process is repeated until the cervix has expanded to about the width of a finger. This method takes about 10 minutes. If the patient is under local anesthesia, she may experience crampy discomfort caused by stretching of the cervical muscles to accommodate the rods. Another method being used with increasing frequency is to insert laminaria tents (cigarette-shaped pieces of a special dried seaweed) into the cervix 8-20 hours before the procedure. The laminaria absorb water from the tissues and swell up, slowly distending and dilating the cervical canal. This is less traumatic than using the metal dilators. Hysteroscopy and curettage (the second step): After dilation, the doctor holds the vagina open again with the speculum. The doctor may also reach into the cervix with a tiny spoon to obtain a specimen of the cervical lining. At this point, the hysteroscope is usually inserted into the uterus so that the doctor may look at the inside of the uterus. The doctor may see fibroids, polyps, or overgrowths of the endometrium. At that time, instruments may be inserted through the hysteroscope and biopsy, or removal, of the fibroids, polyps, or endometrial overgrowths may be accomplished. The doctor will now place a slightly longer and larger curette through the dilated cervix and up into the uterus. This is a metal loop on the end of a long, thin handle. With steady, gentle strokes, the doctor will scrape or suction the uterine wall. This tissue is sent to the lab for analysis. When the curettage is completed, the instruments are removed. If under local anesthesia, the patient will probably experience a tugging sensation deep in the abdomen as the curetting is performed. If this is too painful, the patient should tell the doctor, who may then order pain medicine. The entire procedure, including curettage takes about 20 minutes. At the end, the patient may have cramps that may last about 30 minutes; however, some women experience cramps for a much longer period of time.

After the Dilation and Curettage Procedure

 The recovery time is generally short following a D&C. Cramps, similar to menstrual cramps, will probably be the patient's strongest sensation immediately after a D&C. Although most women experience cramps for less than an hour, some women may have cramps for a day or more. The patient may also have some light bleeding for several days. The patient will most likely be placed in the recovery room immediately after the procedure. Most hospitals and outpatient clinics will keep the patient for an hour or until she is fully awake. The patient will need to arrange for a ride home. It is suggested that the patient not drive for at least 24 hours after anesthesia. This is recommended even after a sedative/local anesthesia because side effects of these drugs can temporarily impair the coordination and response time. Naproxen or ibuprofen are usually given for relief from cramping. Narcotics are seldom, if ever, needed for the pain following the D&C.

HOWTO: Perform the Dilation & Curettage Surgical Procedure

The procedure may be performed under general anaesthesia, spinal (level of L3-L4 spine, inject 10-15 cc. of 0.25% Marcaine carefully), paracervical block (0.25% Marcaine injected just inside the vaginal mucosa, next to the cervix on each side, 5 cc.) or 50-75 mg. Demerol IV slow drip while monitoring the patient's vital signs carefully. Required Equipment: Sterile surgical-grade gloves 0.25% Marcaine, [or equiv.] solution and hypodermic needle kit or 50-75 mg. Demerol and accompanying IV hardware. Lubricating jelly Speculum Antiseptic sponges Transfer forceps Tenaculum forceps Set of Hegar dilators [various sizes] 4-6 small, sharp Curettes Uterine polyp forceps Continuous sterile roller gauze Antibiotics [as needed] Perform the Dilation & Curettage Procedure: Insert a comfortably warm, sterile speculum into the vagina. Ask the patient, if conscious, to relax and bear down. While carefully spreading the labia with a gloved hand, insert the speculum blades slowly downward and inward, watching the insertion closely. As the cervix is approached, slowly open the blades and allow the blades to straddle the cervix between them. Lock the screw lock of the speculum. Wipe the entire cervical stump three times, in a circular fashion outward, with antiseptic sponges on transfer forceps. Discard the swabs and forceps. Bend the uterine sound to the estimated angle of the uterine position. Grasp the cervix with a tenaculum forcep at the six o' clock position and gently insert the sound until resistance is met. Here, you will again try to note any lesions or

growths, as you insert the sound. Read the depth of the uterine cavity by noting the level of the mucous or blood on the sound, as you would the oil level on a dipstick. Make a mental note of the depth of the uterine cavity. Starting with the smallest Hegar dilator, insert the dilator into the cervix, to the dilator lip. Proceed to the next larger size, until the cervix is at least as open as the loop of the largest curette, probably a #8 Hegar. Start with a small, sharp curette by scraping the entire diameter of the cervical canal with an in and out motion. Repeat the four-quadrant scraping of the uterus by going to the depth of the uterus and scraping outward all along the uterine walls, in deep, even strokes, so as to obtain long strips of endometrium. Ensure that all endometrial tissue is removed from the inner surface of the uterus. Curette the top of the uterus in an up-and-down fashion and remove all endometrial tissue. Insert a dry, sterile sponge on a uterine forcep and swab the uterine cavity, using a twisting motion as you withdraw the forceps. Re-insert uterine polyp forceps and grasp for masses. Withdraw the forceps and observe for bleeding. Post-Operative Care:

Replace the uterus, by removing the tenaculum and speculum and using both hands, push the uterus gently, but firmly, upward. Place patient on bed rest for 3 days and limit the patient's activity for at least 7 days. Excessive bleeding may require packing the uterine cavity with long, continuous sterile roller gauze and observing for shock, until the patient is out of danger and hemostasis is achieved. Monitor patient for any signs of infection during the recovery period. Tend to patient's emotional needs and concerns during the recovery period.

Dilation and curettage (D&C) is a brief surgical procedure in which the cervix is dilated and a special instrument is used to scrape the uterine lining. Knowing what to expect before, during, and after a D&C may help ease your worries and make the process go more smoothly for you. Here's what you need to know. Reasons for Dilation and Curettage You may need a D&C for one of several reasons. A D&C is done to: Remove tissue in the uterus during or after a miscarriage or abortion or to remove small pieces of placenta after childbirth. This helps prevent infection or heavy bleeding. Diagnose or treat abnormal uterine bleeding. A D&C may help diagnose or treat growths such as fibroids, polyps or endometriosis, hormonal imbalances, oruterine cancer. A sample of uterine tissue is viewed under a microscope to check for abnormal cells.

Dilation and Curettage Procedure: What to Expect You can have a D&C in your doctor's office, an outpatient clinic, or the hospital. It usually takes only 10 to 15 minutes, but you may stay in the office, clinic, or hospital for up to five hours.

Before a D&C, you will have a complete history taken and sign a consent form. Ask your doctor any questions you have about the D&C. Be sure to tell your doctor if: You suspect you are pregnant. You are sensitive or allergic to any medications, iodine, or latex. You have a history of bleeding disorders or are taking any blood-thinning drugs.

You will receive anesthesia, which your doctor will discuss with you. The type you have depends upon the procedure you need. If you have general anesthesia, you will not be awake during the procedure. If you have spinal or epidural (regional) anesthesia, you will not have feeling from the waist down. If you have local anesthesia, you will be awake and the area around you cervix will be numbed.

Before the D&C, you may need to remove your clothing, put on a gown, and empty your bladder. During a D&C, you lie on your back and place your legs in stirrups like during a pelvic exam. Then the doctor inserts a speculum into your vagina and holds the cervix in place with a clamp. Although the D&C involves no stitches or cuts, the doctor cleanses your cervix with an antiseptic solution. A D&C involves two main steps: Dilation involves widening the opening of the lower part of the uterus (the cervix) to allow insertion of an instrument. The doctor may insert a slender rod (laminaria) into the opening to gradually cause it to widen. Or medication may soften the cervix to help it widen. Curettage involves scraping the lining and removing uterine contents with a long, spoon-shaped instrument (a curette). The doctor may also use a cannula to suction any remaining contents from the uterus. This can cause some cramping. In many cases, a tissue sample goes to a lab for examination.

Sometimes other procedures are performed along with a D&C. For example, your doctor may insert a slender device to view the inside of the uterus (called hysteroscopy). After a D&C, there are possible side effects and risks. Common side effects include: Cramping Spotting or light bleeding

Complications such as a damaged cervix and perforated uterus or bowel are rare. But be sure to contact your doctor if you have any of the following symptoms after a D&C: Heavy or prolonged bleeding or blood clots Fever Pain Abdominal tenderness Foul-smelling discharge from the vagina

In very rare cases, scar tissue (adhesions) may form inside the uterus. Called Asherman's syndrome, this may cause infertility and changes in menstrual flow. Surgery can repair this problem, so be sure to report any menstrual flow changes after a D&C. Dilation and Curettage Recovery: What to Expect

After a D&C, you will need someone to take you home. If you had general anesthesia, you may feel groggy for a while and have some brief nausea and vomiting. You can return to regular activities within one or two days. In the meantime, ask your doctor about any needed restrictions. You may also have mild cramping and light spotting for a few days. This is normal. You may want to wear a sanitary pad for spotting and take pain relievers for pain. You can expect a change in the timing of your next menstrual period. It may come either early or late. To prevent bacteria from entering your uterus, delay sex and use of tampons until your doctor says it's OK. See your doctor for a follow-up visit and schedule any further treatment that's needed. If any tissue was sent for a biopsy, ask your doctor when to expect results. They are usually available within several days.

How is a D&C procedure done?

A D&C procedure may be done as an outpatient or inpatient procedure in a hospital or other type of surgical center. A sedative is usually given first to help you relax. Most often, general anesthesia is used, but IV anesthesia or paracervical anesthesia may also be used. You should be prepared to have someone drive you home after the procedure if general or IV anesthesia is used. 1) You may receive antibiotics intravenously or orally to help prevent infection. 2) The cervix is examined to evaluate if it is open or not. If the cervix is closed, dilators (narrow instruments in varying sizes) will be inserted to open the cervix to allow the surgical instruments to pass through. A speculum will be placed to keep the cervix open. 3) The vacuum aspiration (also called suction curettage) procedure uses a plastic cannula (a flexible tube) attached to a suction device to remove the contents of the uterus. The cannula is approximately the diameter in millimeters as the number of weeks gestation the pregnancy is. For example, a 7mm cannula would be used for a pregnancy that is 7 weeks gestation. The use of a curette (sharp edged loop) to scrape the lining of the uterus may also be used, but is often not necessary. 4) The tissue removed during the procedure may be sent off to the pathology lab for testing. 5) Once the health care provider has seen that the uterus has firmed up and that the bleeding has stopped or is minimal, the speculum will be removed and you will be sent to recovery.

What are the possible risks and complications of a D&C procedure?

Risks associated with anesthesia such as adverse reaction to medication and breathing

problems
Hemorrhage or heavy bleeding Infection in the uterus or other pelvic organs Perforation or puncture to the uterus

 Laceration or weakening of the cervix Scarring of the uterus or cervix, which may require further treatment Incomplete procedure which requires another procedure to be performed

Hanks Cervical Dilators (sizes 9 thru 20)

Goudell Dilator

Polyp Forceps (straight/curved)

Thomas Dull Uterine Curette

Sims Sharp Uterine Curette

Heaney Serrated Uterine Curette

Gaylor Cervical Biopsy Forcep

Metal Catheter

Jacobs Single Tooth Uterine Tenaculum N/A

Uterine Sound

Bozeman Uterine Packing Forceps N/A

Eastman Vaginal Retractor

Sims Vaginal Retractor

Auvard Weighted Speculum

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Last updated 09/05/06. A SCC Library production.