possible malignancy, investigation of abnormal bleeding, and abortion. The World Health Organization recommends sharp curettage only when suction aspiration is unavailable. Dilation and evacuation (D&E), used after 12 to 16 weeks, consists of opening the cervix and emptying the uterus using surgical instruments and suction. D&E is performed vaginally and does not require an incision. Intact dilation and extraction (D&X) refers to a variant of D&E sometimes used after 18 to 20 weeks when removal of an intact fetus improves surgical safety or for other reasons. Abortion may also be performed surgically by hysterotomy or gravid hysterectomy. Hysterotomy abortion is a procedure similar to a caesarean section and is performed under general anesthesia. It requires a smaller incision than a caesarean section and can be used during later stages of pregnancy. Gravid hysterectomy refers to removal of the whole uterus while still containing the pregnancy. Hysterotomy and hysterectomy are associated with much higher rates of maternal morbidity and mortality than D&E or induction abortion. First trimester procedures can generally be performed using local anesthesia, while second trimester methods may require deep sedation or general anesthesia. Labor induction abortion In places lacking the necessary medical skill for dilation and extraction, or when preferred by practitioners, an abortion can be induced by first inducing labor and then inducing fetal demise if necessary. This is sometimes called "induced miscarriage". This procedure may be performed from 13 weeks gestation to the third trimester. Although it is very uncommon in the United States, more than 80% of induced abortions throughout the second trimester are labor-induced abortions in Sweden and other nearby countries. Only limited data are available comparing this method with dilation and extraction. Unlike D&E, labor-induced abortions after 18 weeks may be complicated by the occurrence of brief fetal survival, which may be legally characterized as live birth. For this reason, labor-induced abortion is legally risky in the United States. Other methods Historically, a number of herbs reputed to possess abortifacient properties have been used in folk medicine. Among these are: tansy, pennyroyal, black cohosh, and the now-extinct silphium. In 1978, one woman in Colorado died and another developed organ damage when they attempted to terminate their pregnancies by taking pennyroyal oil. Because the indiscriminant use of herbs as abortifacients can cause serious—even lethal—side effects, such as multiple organ failure, such use is not recommended by physicians. Abortion is sometimes attempted by causing trauma