Katharine O'Connell

(WOMENSENEWS)–It is often in the second trimester of a pregnancy–when most fetal tests are first able to identify problems–that women, their partners and their doctors learn something has gone seriously wrong and the fetus will die during pregnancy or not long after birth.

Most women are given an ultrasound at 16 to 18 weeks of pregnancy, when fetal organs have developed enough to detect such abnormalities.(Chorionic villous sampling, an earlier testthat brings its own risks of limb abnormalities and miscarriage, is reserved for use with women at high risk of genetic defects.)

After that, the women and their families face the shock and grief of a fatal fetal diagnosis, such as anencephaly, skeletal dysplasia, trisomy 18 or 13. (Trisomy defects combine gastrointestinal, nervous system and cardiac abnormalities.) They also face the tough choice of whether to end the pregnancy.

When a woman decides to end her second-trimester pregnancy, she and her doctor choose methods that either pull or push the fetus out. Pulling procedures are called “dilation and evacuation” and “intact dilation and extraction.” The pushing procedure is induced labor.

In the first two, the fetus is pulled out through a dilated cervix. In the third, medications cause a labor process which eventually propels the fetus out. A woman may also wait until the fetus dies (and must be removed) or, in some cases, until the pregnancy comes to term and she then endures labor.

The two pulling procedures will apparently be outlawed by the Partial-Birth Abortion Ban Act undergoing final revisions in Congress to reconcile the versions approved by the House and Senate. (Many obstetricians say that because the ban’s broad language does not name a known medical procedure it will outlaw all second-trimester abortions; other doctors, chiefly those opposing abortion, say the ban describes only intact dilation and extraction, though it doesn’t name the procedure.)

If the ban becomes law, the remaining choices for women in this predicament are likely to be limited. They may induce a delivery shortly after receiving the diagnosis, wait until the fetus dies in utero and is then delivered, or–if the fetus survives until the onset of labor–to give birth to an infant fated to die soon thereafter.

Ban Limits Options

Doctors who oppose the ban argue against it on both clinical and humanitarian grounds. “If the defect is diagnosed early, to wait the months knowing what the inevitable outcome will be is much more upsetting and detrimental,” says obstetrician Dr. Katharine O’Connell of New York’s Columbia-Presbyterian Hospital. “This is one of the worst things a woman can go through. We want to provide her with as many options as possible.”

O’Connell said that inducing labor is an option, and one that would not be affected by the ban. While it can be done as early as 16 weeks, it is normally not done until 19 or 20 weeks of pregnancy, she said, and puts the woman under particular stress.

In the second trimester, she said, induced labor requires medication doses much higher than those used at the normal end of pregnancy. Induced labor “takes two-to-three days compared to less than half an hour in an operating room.”

“Overall, abortion is very safe no matter how you do it,” she said. She emphasizes that a significant difference exists between methods using dilation and the induction of labor at any point. “Many studies,” she said, “have shown the ‘D and E’ or ‘D and X’ is preferable.”

In the early second trimester, from about the 13th to 19th weeks, O’Connell said, the fetus isn’t developed enough to “hold together” when the physician grasps it during either of the dilation procedures and comes out, unavoidably, in more than one piece. After the 19th week, the fetus holds together during intact dilation and extraction, but the largest part, the head, must be compressed or slightly crushed to exit even a dilated cervix.

Anti-choice doctors such as Minneapolis obstetrician Dr. Steve Calvin object to these procedures as “gruesome” and say bringing the fetus out fully intact is the only appropriate option, one that requires inducing labor and most often a wait.

Calvin said that the two procedures using dilation are not clinically necessary and are, in fact, less humanitarian than induction.

“Induced labor leads to the fetus dying on its own, often in the arms of its parents,” says Calvin, a member of the American Association of Pro-Life Obstetricians and Gynecologists. Calvin has long offered his patients with fatal fetal defects only the options of induced labor or carrying the fetus until a natural labor occurs. So the ban would not affect his practice.

He said that after a fetus is delivered–either dead or soon to die–medical staff support the family in an important viewing and grieving process.

He recounted how a patient with a fetus with anencephaly–a fatal absence of part of the skull and brain–had labor induced, delivered the dead fetus and then held it and grieved over it. The parents included their children, age 5 and 7, in saying goodbye to the dead infant.

Patients are grateful for this emotional closure, Calvin said. “We probably do it a couple dozen times a year. We do a high-risk (pregnancy) practice.”

O’Connell, a member of the New York-based advocacy group Physicians for Reproductive Choice and Health, said that a similar grieving and closure experience is also possible with intact dilation and extraction.

She described a patient diagnosed at 20 weeks with a fatal abnormality called “twin-twin transfusion,” in which, despite one twin taking all the nutrients and blood, both are so harmed neither can survive.

The woman chose the dilation and extraction procedure and was able to hold both twin girls afterwards. “She said it made all the difference to say goodbye to her daughters,” O’Connell said. “You can remove the fetus basically whole and wrap in a blanket; it doesn’t always happen this way, but it can.” The larger fetal head had to be “minimally crushed,” she says and that staff covered the injury with a small hat.

Training Limited for Abortion Procedures

Calvin said he had not performed an intact dilation and extraction procedure in 23 years of obstetric practice and believes it is only used because it is much quicker than induced labor.

O’Connell, however, argued that intact dilatation and extraction procedure is not often used because fewer obstetricians are being trained in it or other abortion procedures. Routine training in second-trimester abortion techniques, according to O’Connell, fell to 7 percent in 1992 from 23 percent of all programs in 1976. She added that obstetricians tend to use those procedures they trained in as medical residents because they feel confident in carrying them out successfully.

Suzanne Batchelor has written on health and medicine for Medscape, CBS Healthwatch and the Texas Medical Association’s “Healthline Texas,” and for the national science series “Earth and Sky.”

For more information:

Women’s eNews–“‘Partial-Birth’ Abortion Term Puzzles Many Doctors”:

Physicians for Reproductive Choice and Health–

American Association of Pro Life Obstetricians and Gynecologists–