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. Fetal 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. Umbilical cord transection can also be used to induce fetal demise prior to removal. 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). 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. Decompression of the skull can be accomplished by incision and suction of the brain or by using forceps to collapse the skull. Recovery Recovery from an intact D&E is similar to recovery from a non-intact D&E. Postoperative pain is usually minimal and managed with NSAIDs. In cases of uterine atony and corresponding blood loss, methergine or misoprostol can be given to encourage uterine contraction and achieve hemostasis. Patients who have recently undergone an intact D&E are monitored for signs of coagulopathy, uterine perforation, uterine atony, retained tissue, or hemorrhage. Complications The risks of intact D&E are similar to the risks of non-intact D&E and include postoperative infection, hemorrhage, or uterine injury. Overall, the complication rate is low, with rates of serious complications (those requiring blood transfusion, surgery, or hospital treatment) ranging from 0 per 1,000 cases to 2.94 per 1,000 cases. The rate of minor complications is approximately 50 in 1,000 (5%), the same as the minor complication rate for non-intact D&E; the rate of serious complications is higher in non-intact D&E. Data directly comparing the safety of non-intact to intact D&E are limited. There is no difference in postoperative blood loss or major complications when compared to non-intact D&E. There is no difference in risk of subsequent preterm delivery. The risk of retained tissue is lower