Saturday, February 25, 2006

Surgical Abortion 101

I mentioned before that "partial-birth" abortion is nothing but a political concoction.

Although Scott Lemieux was nice enough to explain that the Court has the authority to evaluate the constitutionality of any enactment by the legislature, I still can't get over the enormity of this idiocy.

I don't know what to do about incompetent politicians power tripping all over the place. What I do know is that I didn't do a very good job explaining to you why "partial-birth" abortion is a made up procedure. I simply declared the definition nonsense and moved on. That's not good enough. You need to judge for yourselves. I think the best way to accomplish that is for us to go over the surgical techniques for abortion. Although what follows is just an overview*, it will allow you to compare and contrast, and it would help me highlight the gulf between reality and political propaganda.

This is how our overlords you know who define "partial-birth" abortion:

`(b) As used in this section--

`(1) the term `partial -birth abortion' means an abortion in which--

`(A) the person performing the abortion deliberately and intentionally vaginally delivers a living fetus until, in the case of a head-first presentation, the entire fetal head is outside the body of the mother, or, in the case of breech presentation, any part of the fetal trunk past the navel is outside the body of the mother for the purpose of performing an overt act that the person knows will kill the partially delivered living fetus; and

`(B) performs the overt act, other than completion of delivery, that kills the partially delivered living fetus;

And here is how surgical abortions are actually performed in real life.

First, a brief introduction. A pregnancy can be terminated either medically or surgically.

We've already reviewed the drugs used for medical abortions. Briefly:

-- There are many drugs and regimens used for medical terminations. Only three drugs are routinely used for early terminations [pregnancies up to 9 weeks (63 days)]: misoprostol, mifepristone (RU-486), and methotrexate.

-- There have been reports of women self-administering misoprostol--multiple doses, taken at 24-hour intervals.

-- While early pregnancy termination drugs are easy to use and to self-administer, these drugs act on an already established pregnancy. Terminating a pregnancy, even an early one, can be associated with potentially deadly complications, like an ectopic, or retained products of conception.

The technique used for medical abortions is labor induction. From TL (p328):

Labor induction includes administration of abortifacients either systemically (vaginal or intramuscular prostaglandins) or directly into the uterus (eg, hypertonic saline or hyperosmolar urea).

Second, let's review surgical abortion techniques.

Surgical abortion techniques include:

-- Cervical dilatation/uterine evacuation

*Early suction curettage (menstrual aspiration)
*Sharp curettage
*Suction curettage (vacuum aspiration)
*Dilatation and Evacuation (D&E)
*Dilatation and Extraction (D&X)

-- Laparotomy

*Hysterotomy (incision of the uterus)
*Hysterectomy (removal of the uterus)

Early suction curettage (menstrual aspiration)

First, a bit of history (G, p1308):

Initially viewed as an alternative to true abortion because it could be performed even before pregnancy was diagnosed with certainty, the procedure was described as 'menstrual regulation" and performed without confirmation of pregnancy. Properly done, the minisuction procedure has many advantages, but the experience of several years has shown that, when abortion is legal [ah, the good ol' times], the procedure should be delayed until pregnancy is diagnosed. With the sensitive pregnancy tests now available, many women are able to obtain this early abortion within 1 or 2 weeks after the menstrual period is missed. The minisuction procedure is readily accomplished in the physician's office. The only instruments required in addition to a speculum and a tenaculum are the Karman cannula and a modified 50-ml syringe.

So, menstrual aspiration is performed 1 to 3 weeks after a missed period (W, p873) [upper gestational-age limit for this procedure ranges from 42 to 50 days from the last menstrual period (TL, p328] and the following instruments are used:



Karman cannula

self-locking syringe with pinch valve

One thing to keep in mind (TL, p328):

Menstrual regulation [aspiration] differs from suction curettage in several ways. First, anesthesia is not usually required, although analgesia may ease the cramping that occurs towards the end of the evacuation. Second, dilatation [of the cervix] is often not required for menstrual regulation. If a given cannula cannot be introduced into the uterus, then smaller flexible cannulae in the set can be used as dilators.

The technique is pretty simple (G p1308, TL p328, and W p874; remix/links mine):

After pelvic examination to determine the shape and position of the uterus and to ensure that pregnancy is 7 weeks size or less, the cervix is exposed with a speculum, infiltrated with local anesthetic, and grasped with a tenaculum placed vertically at 12 o'clock. A 4- and then 5-mm-diameter cannula is passed through the cervical canal as dilators. (The 4- and 5-mm cannulas are not large enough to evacuate the uterus dependably in pregnancy but are useful atraumatic dilators...) A 6-mm cannula [or one of appropriate size] is next inserted, the syringe is attached and the pinch valve released to establish suction. Blood and tissue flow into the syringe. The 6-mm cannula is rotated and pushed in and out with gentle strokes, taking care to rotate the cannula only on the out stroke so as to avoid twisting off the flexible tip by rotating it when it is pressed against the uterine fundus [the back wall of the uterus]. The cannula should not be removed while a vacuum exists in the syringe; likewise, the plunger of the syringe must never be advanced while the cannula is connected and within the uterus, because air embolism can result. When no more tissue comes through, the cannula is withdrawn and its tip cleared in a sterile fashion. The cannula is reinserted and vacuum reestablished for a final check curettage to prove the uterus is empty [gritty feel of the endometrium]. The operator must then carefully examine the aspirated tissue to identify the gestational sac to prevent failed abortion, to diagnose molar pregnancy, and to detect ectopic pregnancy. [To identify placenta in the aspirate] the syringe contents are placed in a clear plastic container and examined with back lighting. Tap water is used to wash the tissue held in a strainer. The tissue is immersed in clear water. Placenta is [to the naked eye] soft, fluffy, feathery, and villous [fingerlike].

[Sorry I went on a bit, but I had fun putting this together. And, yes, I do realize how dorky that sounds.]

One more thing about menstrual aspiration. Problems include: the procedure being performed on a nonpregnant patient, incomplete abortion, failure to recognize an ectopic, and rarely (W p873), uterine perforation.

OK, enough for today [not sure what made me think I could cover all the techniques in one post]. Next up will be sharp and suction curettage.


After reading this post by Dr. B, let me make one thing very clear: This is not a "how-to perform a surgical abortion" guide. The post is just an overview; the information is more than incomplete from a clinical/practical perspective.

*Here are the main sources for this post (I did try to integrate the page reference in the post):

Obstetrics: Normal and Problem Pregnancies, Gabbe (G)

Te Linde's Operative Gynecology (TL)

Williams Obstetrics (W)


At 4:51 AM, Blogger David Toub said...

Very nice description. Leroy Carhart once told me a few years ago that he calls it "partial truth abortion," and he's quite correct there. The fact is that no abortion is pretty, and any could be misrepresented to the general population as something unpleasant and horrible. But intact D&E was intended as a safer alternative to midtrimester D&E, which is essentially a blind procedure and can risk retained products of conception and uterine perforation. Somehow, that gets lost in the PR by the right wing. When I was still in practice, my medical assistant, who was a lovely person, was reading a pamphlet on "partial birth abortion" and confronted me as to whether this was real. I tried to present her with the facts, but doubt anything could counter the emotionally charged propaganda that was being put out at the time.

BTW, I'm being hit by comments from one right-wing reader of my blog on all my political-oriented posts, including one on EC (this guy apparently feels that hospitals should practice based on their own moral codes, and if EC is considered immoral to a hospital, then so be it). Feel free to respond---reinforcements are always welcome 8-)

At 4:06 PM, Blogger Dark Daughta said...

This post was so thorough and informative. Thank you. In light of what's happening in South Dakota, and the fact that banning abortion could be a trend that spreads, your information at least offers some sources where wimmin can do some research and make some connections that will lead to more information about these procedures.

At 4:01 AM, Blogger Scott Lemieux said...

Thanks for the link! I agree completely about the ridiculous, trumped up nature of the "partial-birth" tactic. Stevens and Ginsburg actually did a good job of pointing this out in Carhart, but it's amazing how many nominal pro-chiocers treat the issue as if it were serious.

At 6:59 PM, Anonymous Anonymous said...

Hmmm. Here's what I see here (paraphrasing):

They have outlawed a ficticious medical proceedure.

(legal description of outlawed proceedure)

But out here in the real world, this is what we really do.

(medical descriptions of several legal proceedures)

OK, so what's the problem? What you are saying is, basically, that the government has outlawed something that *never* happens. So how does this affect you? And why would you waste so much time complaining about it?


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