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the Body Politic
Vol. 7, No. 1 - January 1997, Page 21
Copyright © 1997 by the Body Politic Inc.
ACOG Answers Questions on
Third Trimester Termination Procedures
In response to questions about the proposed ban on so-called "partial birth abortions" in New York State, the American College of Obstetricians and Gynecologists has released the following statement.
Legal Note: Generally, an abortion is legal in New York if done within the first 24 weeks of pregnancy. After that (third trimester) the Penal Law only allows a termination of pregnancy to save the woman's life. But Supreme Court rulings have added two additional grounds: (1) the fetus would be incapable of sustaining life outside the womb, or (2) to preserve the woman's health. Any other third trimester termination is a crime in New York. The law does not specify what medical procedures are used.
Q: How frequently are third trimester terminations of pregnancy performed in New York State?
Third trimester terminations are so rare that the New York State Department of Health does not keep statistics on frequency. One large upstate medical center, which averages approximately 4,000 births per year, reports that in the last 8 years, only one third-trimester pregnancy termination was performed at its facility and it involved a fetus which had already died in utero. 95.5% of abortions take place before 15 weeks. Only a little more than one-half of one percent take place at or after 20 weeks. A woman in her third trimester in New York undergoing a legal interruption of pregnancy does so only under extreme circumstances. If there is a viable fetus, the fetus is delivered with full medical support for the mother and infant.
Q: For what fetal conditions could a third trimester termination be medically indicated?
Cases in which major organs fail to develop so abnormally that they cannot be corrected by surgery and therefore the fetus cannot survive. If a fetus dies in utero, this situation can present serious health risks to the woman, e.g. the risk of hemorrhage.
Q: What medical problems could the woman develop that might require interruption of a pregnancy?
Rare maternal problems could threaten the life and/or health of the pregnant woman if the pregnancy continued, for example, severe heart disease, kidney failure or severe toxemia. In every instance efforts would be made to bring the pregnancy to a satisfactory conclusion for the benefit of the fetus and the mother. However, there may be a rare emergency where continuation of the pregnancy may be incompatible with the woman's ability to live. No matter how wanted the pregnancy, a woman may find herself carrying a pregnancy which threatens her life or health. In those extremely rare circumstances when a termination is done to save the life of the mother, the fetus will not survive if the mother dies. Full life support and neonatal intensive care services are provided to any fetus delivered close enough to term to have any possibility of life.
Q: Why can't severe fetal abnormalities always be detected in the first 24 weeks of pregnancy?
Medical science has made tremendous advances in technology. Ultrasound and amniocentesis are some of the tools that can assist in monitoring a pregnancy. However, it is not possible for technology to predict all problems, nor is it reasonable to expect that to be the case. No test is infallible nor can all hospital or physician's offices afford the most sophisticated equipment.
Also, in some cases, the level of experience and the sophistication of the diagnostician can lead to inconclusive results. Some abnormalities may be nearly undetectable, given the small size of the fetus earlier in pregnancy and become apparent when the fetus is larger. Other abnormalities may not manifest themselves until later in a pregnancy. Amniocentesis is an invasive procedure with health risks and is not performed routinely. Furthermore, this procedure does not diagnose or indicate all problems.
Good obstetrical care is important to maximize the chance of detecting problems early in pregnancy. Unfortunately, state health statistics indicate that there are many women in New York State who, for a variety of reasons, do not receive prenatal care until later in the pregnancy -- if at all. In addition, trends in managed care indicate that there may be even more restrictions placed on routine testing.
Q: How are prospective patients screened?
When a pregnancy is found to have severe fetal problems the patient will almost always be transferred to a large tertiary hospital for a second opinion by physicians with knowledge about special medical conditions and genetic problems. If the abnormalities are found to be so severe that the fetus will not survive outside the womb, then options are explained to the woman, including ending the pregnancy if she desires. Even though a woman and her consulting physician decide to interrupt a pregnancy during the third trimester, such a decision must be approved by the hospital ethics committee, the hospital lawyers, and other physicians, including perinatologists and geneticists. In New York state, such approval is very rarely given.
Q: What medical procedures can be used to interrupt a pregnancy after the first trimester?
There are three basic procedures that can be used. It is important to remember that all invasive medical procedures carry risks and not every patient is a good candidate for certain procedures. The condition of the patient, as well as the nature of the problems that lead to the decision to interrupt the pregnancy, must be carefully assessed so that the procedure that is best suited to each situation can be used.
Induction of labor
- Induction of labor prior to term can be a lengthy process with serious discomfort and pain which may take several days. This is because the cervix, which holds the uterus closed during the pregnancy, is resistant to cervical opening (dilation) until about 36 weeks. Inductions require hospitalization and strict medical supervision. In addition, dilation is often incomplete and there is a constant risk of infection.
- At any stage of pregnancy, a cesarean section is a major surgical procedure which may result in significant blood loss, possible infection in rare cases may result in maternal death. Prior to 30 weeks of gestations, the lower uterine segment is usually too thick to use the standard transverse (horizontal) incision. Therefore a vertical incision is necessary. This incision may not heal well. As a result, the uterus may rupture during future pregnancies which is life threatening to the mother and fetus. Also, after a vertical incision in the uterus, all future births will require a cesarean.
Intact dilation and extraction
- Intact D&E is an alternate method to induction or labor or cesarean section. It is done by medical providers with special training in hospitals while the patient is under general anesthesia. This procedure is primarily done when the abnormalities of the fetus are so extreme that independent life is not possible or when the fetus has died in utero. The procedure consists of a breech extraction. Since the cervix is often incompletely open, it may be impossible to deliver the head. Therefore, a needle or other surgical instrument can be introduced to drain cerebral fluids similar to a spinal tap which makes it possible to deliver the head through the cervix without damage to the mother. During this procedure the medications which are often used to anesthetize the mother cross the placenta and anesthetize the fetus. This procedure is not done in the third trimester if the fetus is viable.
Q: What is an elective procedure in medicine?
Statements have been made that third trimester terminations are being done on an elective basis. There is a great deal of confusion about the term "elective" when applied to a medical procedure. It is not equivalent to an elective course in school. In medicine, an elective procedure means a procedure that does not have to be done on an emergency basis. The term does not imply that the procedure is not "medically necessary." It means that it is safe to schedule the procedure when appropriate physicians are available or when the patient is in a stable condition. The operation can be necessary to save a patient's life and still be classified as elective.
Q: Is there such a procedure as a "partial birth abortion?"
NO. There is no medical procedure call a "partial birth abortion." The term is not found in any medical dictionaries, textbooks or coding manuals. The language in federal and state legislation is incorrect.
Editor's Note: In 1997, laws to ban the D&X procedure will be proposed in many state legislatures and resurrected in the Congress. The laws referred to in this release apply specifically to New York State, but the information about the D&X procedure is applicable across the nation.
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