D&C and D&E - Nishmat Yoatzot Halacha

Medical Background

Two fairly common gynecological procedures in which instruments enter the uterus are a D&C (dilation and curettage) and D&E (dilation and evacuation).

Dilation refers to dilation of the cervical opening to allow a small instrument to pass into the uterus.

Curettage is the removal of some tissue from inside the uterus using a spoon-shaped instrument called a curette. Sometimes a suction or vacuum is used instead of or in addition to a curette.

Evacuation refers more broadly to the removal of the uterine contents, most commonly using a vacuum aspirator, though other instruments or techniques may also be used.

A D&C might be needed for a number of reasons: to remove fetal tissue following miscarriage; to remove placental remnants from the uterus after childbirth; to diagnose or treat abnormal uterine bleeding (often accompanied by hysteroscopy); to remove a uterine cyst, polyp, fibroid, infected tissue, or tumor; or to terminate a pregnancy in the first trimester.

A D&E procedure may be performed to remove tissue from a miscarriage in the second trimester, or for a second trimester abortion, typically between weeks 14-24 of pregnancy.

We discuss the halachic implications of these procedures below.

Preparing the Cervix

Medications such as misoprostol, a prostaglandin which can be administered orally or vaginally, may be used to soften the cervix and make it easier to dilate. Various factors may influence the decision to use such a medication, including whether a woman is or was recently pregnant, and if pregnant, how far along. In some cases, laminaria, a rod made of synthetic or natural material that expands as it absorbs fluid, is placed in the cervix in advance of the procedure to assist with dilation.

Where the cervix needs to be more widely dilated, misoprostol or laminaria may be used some time in advance of the procedure itself, ranging from a few minutes to a whole day. This may be the case for certain pregnancy terminations or for some types of hysteroscopy.

Pain Management

Usually, a D&C is performed with pain control measures, such as general anesthesia, sedation, or local anesthesia. A D&E is typically performed under general anesthesia or sedation. The type of pain control used depends on the details of the planned procedure and a woman’s medical history.

A woman should be sure to ask her care team about pain control measures in advance of the procedure and to advocate for the level of pain control that she believes will be best for her well-being.

Niddah Status

In most cases, a woman will become niddah following a D&C or D&E, depending on the following factors:

Uterine Bleeding

Bleeding following these procedures is usually considered uterine bleeding that makes a woman niddah.

However, there is halachic debate regarding whether bleeding from a D&C or D&E could sometimes be considered dam makkah, bleeding from a wound, which does not cause niddah. This can be relevant in situations in which we can more readily presume that the bleeding is dam makkah, as with a postmenopausal woman. A woman should not hesitate to ask a halachic authority how her procedure affects her niddah status.

Pregnancy Loss

In the case of a miscarriage or abortion more than forty days from conception (usually calculated from mikveh immersion), the removal of fetal tissue during the procedure causes a woman to have the status of a yoledet (a woman who has given birth). The laws that apply to a yoledet are almost identical to those for a woman in niddah. A woman in this type of situation would follow the usual guidelines for becoming tehorah after pregnancy loss. Learn more here.

Cervical Dilation

Even when a woman does not have bleeding that makes her niddah, and the procedure does not involve pregnancy loss, dilating the cervix more than 19 mm can itself cause niddah (learn more here). Devices used for a D&C or D&E procedure usually have a diameter of 19 mm or less, in which case the dilation alone does not make a woman niddah.

However, some procedures that involve removal of larger amounts of tissue may require wider dilation of the cervix. A woman can verify with her medical provider how dilated her cervix was at the time of her procedure and follow up with a halachic authority.

Recovery & Becoming Tehorah

Following a D&C or D&E a woman may have mild pain, which may feel somewhat like menstrual cramps, for a day or two after a D&C, and sometimes for a few days longer after a D&E. Spotting or bleeding may continue for several weeks following a D&C or D&E.

MInimum Wait

The minimum wait is observed according to a woman’s usual custom.

If she usually counts from the day she became niddah, and was not in niddah prior to the procedure, then the first day of the minimum wait is the halachic day on which the procedure was performed. If she was in niddah prior to the procedure, the minimum wait is counted from when she first became niddah, rather than from the day of the procedure.

If she usually counts from the most recent episode of intercourse, she does so here as well.

Hefsek Taharah & Bedikot

To avoid the risk of infection when the cervix is open, a woman should not introduce anything into the vagina following the procedure until it is cleared by her medical provider, commonly around a week or two after the procedure. This would include using a tampon, having sexual intercourse, or performing bedikot.

Bedikot are often approved earlier, however, provided they are gentle and shallow. A woman should ask her medical provider how long she should wait before attempting a hefsek taharah and performing bedikot in the clean days. In case of medical need, it is sufficient to insert the finger just until the first knuckle and rotate it gently. A woman counting seven clean days in this situation would generally perform only the hefsek taharah (omitting the moch dachuk), one bedikah on day one, one bedikah on day seven, and preferably one other bedikah on one of the intermediate days.

Mikveh Immersion

Some healthcare providers recommend avoiding bathing or swimming for 1-2 weeks after the procedure, although showers are typically acceptable. Most women will be cleared for mikveh immersion by the end of the seven clean days. If a woman has particular concern or is unsure, she should ask her medical provider.

If a woman is not physically or emotionally ready for relations, mikveh immersion is still encouraged so that the couple can stop keeping the harchakot and resume other types of physical affection.

Vesatot

A woman’s next period may come early or late depending on how long it takes for her uterine lining to regenerate. After a procedure performed for a pregnancy of over forty days, a woman begins calculating vesatot only from her first period after the procedure. Otherwise, she should continue to calculate her vesatot based on her last period before the procedure. Bleeding from the procedure itself does not affect her veset calendar.

Contraception

There may be a time period during which it is medically inadvisable for a woman to become pregnant following a D&C or D&E. Women who hope to try to conceive as soon as medically safe after the procedure might be interested in halachically permissible short-term birth control options (learn more here). Learn more about choosing a contraceptive method here. Couples who need more personalized halachic guidance should not hesitate to reach out to us or to their halachic authority.

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