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First of all, one can’t be partially born. In obstetrics, you are pregnant or you aren’t, and you are delivered or you are not. For example, there is an obstetrical emergency called shoulder dystocia where the fetal head delivers but the shoulders get stuck. It’s an emergency and if you don’t act appropriately and promptly, the outcome can be horrendous. Even in this situation, the pregnancy is not delivered until every part is delivered. Using the term “partial birth abortion” is like saying “cutting out half the guts” when you really mean a hemicolectomy. The former is a very imprecise and poor descriptor for the latter.
The American Congress of OB/GYNs (ACOG) has taken this term “partial birth abortion” to mean an intact dilation and evacuation without fetal demise before the procedure. Some also call this procedure a dilation and extraction or D & X. It involves delivering the smallest fetal part through the cervix and decompressing the cranium with suction if needed. That may be hard for some to read, but this is surgery.
Are images of this procedure graphic? Yes, but all surgical images are graphic. Before you judge the procedure, please read this article in its entirety. If you want to understand more about the procedure as doctors understand it. you can read this article and this Committee Opinion from ACOG.
A D & X can be performed safety up to 36 weeks by a trained provider, but procedures after 27-28 weeks are incredibly rare. Remember, only 1.3 percent of abortions happen after 20 weeks and most of these happen by 24 weeks.
Why do women need an intact dilation and extraction or D & X?
The more advanced the gestational age, the greater the risk of maternal trauma with a standard D & E (dilation and evacuation), so a D & X reduces this risk. The complication rate, even including pregnancies up to 36 weeks, is 0.5-5 percent. Before you judge the later procedures, please read the entire article. The complication rate for a c-section is 27 percent, and 10 percent have serious complications. So obviously, if a later pregnancy needs to be delivered, the D & X is the safest.
Inducing labor for a second or third trimester abortion is also an option for some women, but it actually has a higher complication rate than a surgical abortion (D & E or D & X). According to ACOG, “Compared with D&E, termination by induction with misoprostol is less cost-effective, is associated with a greater risk of complications, such as incomplete abortion, and may be prolonged.”
Some women may choose an induction of labor as they may be personally more comfortable with that technique and an induction may sometimes be more helpful if an autopsy is needed to help understand the birth defects for future pregnancy planning. However, many women end up with inductions because their doctors aren’t skilled to do a D & X, and so the legal system has foisted a less safe medical procedure on them.
When might a later term abortion and specifically D & X be indicated?
Anytime a woman after 20 weeks needs to be delivered. Remember: with D & X the complication rate 0.5-5 percent, and a c-section has a complication rate of 27 percent (but complication rates with c-sections rise the more premature the delivery and with maternal health problems, like infection or high blood pressure).
Consider a woman at 35 weeks and her fetus has Potter syndrome. This is typically not compatible with life (basically no kidneys or lungs). She did not want to have a termination and elects to go through with the pregnancy and deliver at term. She is now 35 weeks and her fetus is a transverse lie (meaning it’s laying sideways not head down or bottom down) and so can’t come out vaginally with a normal labor. The doctors can’t even attempt to turn it head down with a procedure called an external cephalic version because with Potter syndrome there is no fluid and without fluid you can’t turn a fetus. Her choices are a c-section or a D & X.
Consider a woman at 29 weeks and her fetus has trisomy 13. She would have terminated earlier before 23 weeks had she known, however, her doctor is very anti-choice (she was unaware of this) and so her genetic ultrasound occurred late at 21 weeks. By the time she had the amniocentesis and got the results she was 23 weeks. She met with several local OB/GYNs and non had the skill set to do a D & E at 23 weeks as none had abortion training in residency. Emotionally she does not feel she can carry the pregnancy to term. Her local options are a hysterotomy at 23 weeks, basically a very premature c-section which often damages the uterus, or wait until she delivers at term. By the time she locates a provider for a D & X and has raised the cash she is 29 weeks.
Consider a woman with mirror syndrome at 28 weeks. Her fetus has severe birth defects including a massive tumor on the lower back. This can only fit vaginally with some kind of instrumentation. The birth defects appear incompatible with life and she had previously met with a neonatal intensive care specialist at 25 weeks and the plan was no resuscitation after delivery. She is now getting sicker by the minute. Her options are a c-section or a D & X.
Consider a woman with a very wanted twin pregnancy from IVF. At 23 1/2 weeks she gets what she thought was the worst imaginable news, one of her twins has died. But then it gets worse. She develops severe preeclampia and needs to be delivered as soon as possible as her remaining wanted pregnancy is killing her. Her choice is a c-section or a D & E/D & X.
Consider a woman with ruptured membranes at 22 weeks in her first pregnancy. She has an infection and is rapidly getting sicker. She needs to be delivered as soon as possible. Drugs to induce labor have failed as an infected uterus often cannot be flogged chemically into contracting. Her option is a hysterotomy (the early, uterus-damaging c-section) with an infected uterus (her risk of a hysterectomy are high) or a D & E/D & X, which is more likely to save her uterus.
Pregnancy can lead to medically unbelievable scenarios.
It is not possible to explain all the permutations and combinations of obstetrical tragedies. The collision of fetal chromosomes and the crazy adaptations that a pregnant woman goes through can lead to some truly medically bizarre and scary situations.
Just think about the immune system. Pregnancy is like an organ transplant, except the genetic match is only 50 percent. To stop the body from attacking or rejecting the fetus the maternal immune system undergoes major changes. It’s not a perfect work around, but evolutionarily speaking it works most of the time. If you are not in the most group then things can go really, really wrong. Like catastrophically wrong. It’s even hard for doctor’s to understand what can happen. When I explained mirror syndrome to a general surgeon, all he could say was “That’s just messed up.”
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