The surgery is preceded by cervical preparation which may take several days. Laminaria sticks, natural or synthetic rods that absorb moisture from the cervix, mechanically dilate the cervix. Misoprostol can be used to soften the cervix further; an intact D&E can only be performed with 2-5 centimeters of cervical dilation. Feticidal 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 federal Partial-Birth Abortion Ban Act . During the surgery, the fetus is removed from the uterus in the breech position, with mechanical collapse (crushing) of the fetal skull if it is too large to fit through the cervical canal. Decompression of the skull can be accomplished by incision and suction of the contents, or by using forceps. If the fetus is in a vertex presentation, forceps can be used to turn it to a breech presentation while in the uterus (internal version).
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