Deep breath. This is going to be a tough blog post to write.
I am not going to get political about abortion. No way, no how — that’s not what this blog is about. But since I happen to fall into the <1% of women who have experienced second trimester pregnancy loss (in my case not an abortion, but rather a fetal demise or a “missed” late miscarriage), I was deeply shocked and appalled to read this week that Kansas has become the first state in the US to ban the D&E procedure in the second trimester. I feel that I need to help make sure that medically correct information is out there about the risks of D&E compared to its alternative, medically induced labor, and speak about my experience with medically induced labor in the second trimester.
A depressingly large number of women have experience with miscarriage in the first trimester, but odds are that you don’t personally know anyone who has experienced a second trimester loss (and by “know anyone,” I mean, “know anyone well enough that you’ve discussed it with them”). Maybe that’s not true of people reading my blog — we’re sort of a biased sample, alas. But with that in mind, I’d like to share a bit about what a second trimester termination is like, from the mother’s point of view.
After the midwife couldn’t find my daughter’s heartbeat, and her death had been confirmed by ultrasound, the doctor discussed with me what would happen next. I asked if I had options for how to deliver my daughter; she said I didn’t. I now know that to be false: the two options that are typically available to women in the second trimester for ending a pregnancy (either voluntarily or after fetal demise) are D&E (which stands for “Dilation and Evacuation” — a souped-up cousin of the far more common D&C, or “Dilation and Curettage”) and induced labor. The clinical evidence is clear: D&Es are safer and have lower rates of complication than medically induced labor. I later found out that D&Es require a very well-trained and experienced practitioner, which can be hard to find largely because the procedure is so rare. My doctor was not trained to carry out this procedure, nor was anyone at my local hospital, but it would have been available to me if I had chosen to travel to an abortion clinic in a city half an hour from where I live. In hindsight, I wish I’d known the relative risks and had availed myself of the option of having a D&E performed rather than blindly following my doctor’s recommendation of going through with medically induced labor, because I did wind up being one of the 29% of women who have complications from medically induced labor — whereas my risk of complications with a D&E would have been 4%.
In a medically induced birth, labor induction is started 1-3 days before delivery with the use of oral and/or vaginal medications. We found out that my daughter died at 4pm on a Thursday. My doctor had me take oral doses of cytotec every four hours between Thursday afternoon and Friday morning. Thursday night was the worst of my life, physically and emotionally (well, Friday night would be worse, but I didn’t know that yet). I was still reeling from the news that my daughter had died, and it was impossible to sleep while my abdomen was racked with increasingly intense, clenching contractions. I came back to the office Friday morning so my doctor could check on my progress; at that time she tried to insert laminaria to speed cervical dilation, but I was already too dilated and she wound up breaking my water instead. Once your water has broken, it starts you on a clock, since you’re then susceptible to infection (especially since in a mid-trimester fetal demise, infection is one of the likely culprits in the first place), so you need to deliver in the next 24 hours or so. She upped my dose of cytotec, sent me home again, and told me to come to the hospital when I needed pain medication. She said that she wouldn’t hold back on the pain medication, since there was no need for me to suffer through labor unmedicated (because my baby was already dead, although she didn’t put it so bluntly).
After more than 24 hours of labor induction, when the painful contractions radiated through my midsection like strange hula hoops (at the time, bemusedly, I compared them to electron orbitals) and I could no longer keep walking or talking through a contraction, I finally decided to go to the hospital. I apparently waited a little too long, though. When we got to the hospital they knew I was coming and led me to a room at the end of the hallway, somewhat isolated from the sounds of living babies being born. However, they had no standing orders for pain medication, so they couldn’t give it to me until my doctor or midwife arrived. I got changed and managed to get myself arranged in the bed, all the while experiencing by far the most intense pain of my life. The nurses kept assuring me that the midwife was on the way. I don’t know how long it took — perhaps no more than half an hour, but when you’re in labor, half an hour is eternity. Finally I felt something shift inside me. I told the nurse. She told me it was probably the baby. The midwife walked in as my baby entered the birth canal. There was no time for pain medication, and I delivered a very small, very beautiful, but very dead baby girl without any pain medication whatsoever. She was small compared to a full-term baby, but larger than I’d imagined — about the length of my hand from the bottom of my palm to the top of my fingertips. There was a lull after she was born, but little did I know that the worst was yet to come.
The placenta. It’s common to have problems with delivery of the placenta during the second trimester. In fact, retained products of conception are the single most common complication of medically induced labor in the second trimester, accounting for the large majority of the 29% of women who experience complications with this procedure. It happened to me. For four hours, the midwife tried to get the placenta to come out. First by tugging on the severed end of the umbilical cord, then with an injection that induced monstrously painful contractions — even worse than the pain I’d experienced while delivering my daughter. Periodically she’d also “massage” my uterus (scare quotes because no massage has ever felt more like sadistic torture). The longer it takes to deliver the placenta, the higher your risk of hemorrhage, so after four hours of agony she called in the backup doctor on duty. They could not bring me in for a D&C at that point, since I had snacked in the afternoon before coming to the hospital (my doctor had told me to eat and drink normally, so my husband and mom had tried to convince me to eat something). The backup doctor, whom I’d never met before he walked into my hospital room that day, was the kindest and most compassionate person I encountered throughout all of this horrific experience. At that point, I was all but begging for them to make me unconscious. I found myself clawing up the side of the hospital bed to get away from the pain, before I realized how illogical that was. He immediately increased my dose of pain medication by a factor of five (I’d been telling the midwife I wasn’t feeling any relief, but she didn’t listen to me), and finally I was able to handle the pain. He then removed the placenta manually, using instruments to reach through my already-dilated cervix from the end of the bed. Once the placenta came out I was immediately relieved of pain, and as soon as the nurses finished cleaning me up I slept like I have never slept before. (I’d be back two weeks later for surgery for retained products, which would leave me with scarring of the uterus that now threatens my fertility, but I didn’t know that at the time.)
THAT is the alternative to D&E. If I’d had a D&E, I would have been under general anesthesia and would not have experienced any pain until after I woke up and started healing. I would almost certainly not have experienced retained products of conception, nor the scarring of my uterus that followed.
Banning the D&E procedure does not mean banning abortion — Kansas can’t do that, because for now, at least, it’s unconstitutional. So the only thing the Kansas law accomplishes is to unnecessarily subject women to the nightmare of a second-trimester induced labor, to increase their risk of complication and possible infertility. And even though there are exceptions to the law (saving the life of the mother, for example), as my experience shows, it is already difficult to find an experienced practitioner to carry out a D&E, and if it is made illegal in all but the rarest of cases, good luck finding a practitioner who can carry it out for that one-in-a-million woman. I know abortion is a hot-button topic in this country, but I hope we can all agree that while it would be far better for there to be no pregnancies ending in the second trimester, if pregnancies must end, they should be ended in the safest and most humane way possible. What happened to me was both less safe and less humane than a D&E, and it scares me, truly scares me, to think that women in Kansas will now be forced to endure the same thing.