Sometimes a pregnancy half fails. The membranes rupture before viability and an infection sets up shop in the uterus. Medically, the pregnancy has to end; whether the fetus is still alive or not does not matter. If an infected uterus is left unevacuated, the bacteria will eventually spread to the blood stream and it will be fatal. This is fact.
At times the body offers a consolation and goes into labor. It doesn’t seem like it at the time but it is more than a small mercy. When the uterus does not start contracting the patient has to choose: drugs to induce labor or a surgical procedure called dilation and evacuation (D&E). It is like starring in a horror movie where you choose the weapon.
Labor is labor. It hurts and can take days. A premature uterus, especially an infected one, often does not cooperate. Days of both grieving and waiting to grieve break even the strongest. No one has assigned fault, in fact everyone has said the opposite, but the pathways of sadness and self-doubt and blame cut deeper and deeper with each taunting contraction. A brain fuddled by lack of sleep, medication side effects, days without fresh air, and the stench of sweat from the bed sheets cannot possibly reframe this experience. When women tell me they “can’t even get this right” I want to cry.
At the end of the labor there is a baby. Often bruised and macerated. Many find that visual very hard as technically those injuries were caused by their own body. As a doctor you can try to explain it away as predicted medical consequences, which they are, but your words are repelled by a force field of despair. Sometimes the baby survives the infection and the traumatic labor and delivery and then the patient has to decide if she is able to hold her baby until death comes or if she is not. These things shatter people.
The other medical option is a D&E, a surgical procedure to remove the pregnancy through the cervix. It requires more skill, medically speaking, than the labor. You only come by this skill if you have done a lot of second trimester abortions because that is exactly what it is, but harder because an infected uterus has the consistency of soft butter. Your instruments are like a hot knife. You are using a hot knife to remove sharp fragments from a bed of soft butter. Do it incorrectly and you damage the uterus, puncture the bowel, or cause catastrophic blood loss. The fact that your patient is already ill with infection makes every potential sequelae worse.
A D&E bypasses all of the emotional trauma of the labor and the decisions that come afterward about holding the body. The patient gets an anesthetic and afterward the physical part of the nightmare is over. Sometimes, if the infection is advanced, the medical team may recommend a D&E up front. The risks of a D&E performed by a well-trained individual are very low.
Some women chose labor but after a day or so it is clear their body has a different idea. An infected uterus can’t always be whipped into shape with oxytocin and prostaglandins. A few even refuse a D&E even when they are very ill if there is still a fetal heartbeat. As they wait for the uterus to labor correctly they get sicker and sicker. Bacteria is showering the blood stream. Their heart rate is unbelievably fast. Their blood work is ominous. The staff all look at each other in that way medical people do when we know we are on the precipice of something very bad. Eventually, the patient agrees to the D&E and the relief is palpable.
When you are the person who will do the D&E the patient is always relieved to see you. She either knows she doesn’t want to labor, can’t handle any more labor, or she knows she is very sick. Sepsis makes you feel as if you are dying, which you are.
Sometimes her partner glares. “There is still a heartbeat,” he might say or if there is not, “How come we need someone special for this?” He knows the answer, but he wants me to say it. If I don’t, I can’t save the life of the person dying in the bed, so I tell him that you can’t do a D&E’s without abortions. This irritates many because their narrative is that abortions are never needed and yet here they are needing one or needing help from someone who can only help because of abortion training.
Without abortion training there will soon be no one with the skill to do a D&E and the option will be induction of labor or a hysterectomy or a hysterotomy (a C-section, but this early it often wrecks the uterus for future childbearing). Both a hysterectomy and a hysterotomy are major surgeries and much more likely to have serious and even fatal consequences than a D&E, especially for pregnant women with infections.
D&E’s are now illegal in Texas (because of Senate Bill 8, passed last week) unless the pregnant person is very ill. How ill? I’m a gynecologist and I don’t know.
Sec. 171.102. PARTIAL-BIRTH ABORTIONS PROHIBITED.
(a) A physician or other person may not knowingly perform a partial-birth abortion.
(b) Subsection (a) does not apply to a physician who performs a partial-birth abortion that is necessary to save the life of a mother whose life is endangered by a physical disorder, physical illness, or physical injury, including a life-endangering physical condition caused by or arising from the pregnancy.
Sec. 171.103. CRIMINAL PENALTY.
A person who violates Section 171.102 commits an offense. An offense under this section is a state jail felony.
No one knows how sick is sick enough. Is it ruptured membranes? Is it a fever of 101 F or 103 F? Low blood pressure? How low? Tachycardia? How fast? Positive blood cultures? Malpractice insurance doesn’t cover the criminal action the State of Texas might take against you for saving a woman’s life with a D&E so it is almost certain that doctors will wait too long. This is how Savita Halappanavar died in Ireland.
Banning D&Es unless Death himself is in your room unhooking your intravenous is also cruel. Every choice about this pregnancy has been taken away because of ruptured membranes and infection and now the Texas government has taken away the only power that a pregnant woman has over her body. Every single person I have ever counseled has known almost immediately what feels best. Pregnant women can visualize the sequence of medical events with labor and with a D&E. You can see it in their faces. They know what is the least traumatic landing for them. Now in Texas they have no say.
The cruelty and emotional trauma imposed by SB8 aside some women who fail to respond to labor inducing drugs will get D&Es too late and some will die. As the hospitals lose providers by attrition who are skilled to do D&Es there will be more and more hysterotomies and hysterectomies. The lucky women will be the ones who go home with a big scar on their belly to remind them of their pregnancy that wasn’t to be and how much their government hates women.