I don’t like that you do abortions, but if you didn’t, I would probably be dead

I was paged by labor and delivery three times during the 10 minute drive from my house. I headed straight from the parking lot to the labor ward expecting a patient of mine to be close to delivery. I was wrong.

The chief resident and attending obstetrician were waiting. They looked tired and worried.

A woman had arrived on Friday with ruptured membranes. She was 21 weeks along in her pregnancy and now there was no amniotic fluid left at all. She and her husband wanted everything done. Despite the dismal prognosis for her baby, in respect for the patient’s autonomy, antibiotics were started. Within 24 hours it was clear she had an infection.

Delivery was recommended as these infections are potentially deadly. The parents refused. “The antibiotics might work,” they said. And no amount of discussion about the overwhelming medical evidence that supported delivery could sway their decision. Inducing labor at 21 weeks while their baby was still alive was abortion.

The infection worsened despite the antibiotics. The patient, who was  rapidly deteriorating, and her husband reluctantly consented to an induction of labor.

And now it was clear why I was needed. Infected uteruses don’t contract very well. Prostaglandins and oxytocin both failed to produce even a cramp.

“They are very pro-life,” the resident warned. “It took several hours of convincing just to get them to agree to talk with you.” Considering I practiced in the bible belt this was not an unfamiliar scenario. I shrugged and walked into the room.

My patient was clearly very ill. Flushed, sweating, and drifting in and out of consciousness. The smell of anaerobes unmistakeable.

I reviewed what had transpired to date. The infection. The prognosis. And what I could offer. A dilation and evacuation.

They had two concerns. The first, their baby was still alive in spite of the infection. The second problem was that I was an abortionist. Couldn’t a doctor who didn’t perform abortions do the procedure?

“I understand your baby is still alive, but he or she cannot live. It is sad and it is unfair, but the pregnancy is now killing you. It is not a matter of if you die, but when.” I paused. “You have other children at home and they will be without a mother. If it is any consolation, at 21 weeks babies do not feel pain.”

The husband’s body language said it all. “How did you learn to do these procedures,” he  asked.

“By doing abortions. Lots of them. I have done more late term abortions than most doctors of my generation. That makes me very skilled. But the privilege of helping women end their pregnancies safely also gave me the skill to help women like your wife. There is no other way. You have to do a lot of these procedures to become proficient. Even more to do them safely for a women at 21 weeks who has an infection.”

There was no response, so I continued. “This is a very precarious situation. An infected uterus is easy to damage. I could make a hole and injure other organs. Even if the procedure goes well, the bleeding might not stop. A hysterectomy could still be needed. The infection in the blood stream might still get worse. But without the procedure, your wife will die.”

My patient spoke. “I don’t want to die.”

Within the hour we were in the operating room. The procedure went well. The bleeding, though profuse, was controlled without a blood transfusion. Within 24 hours she looked like a completely different woman.

Several months later I was surprised to find her name on my schedule. Especially given the reason was a first prenatal visit. After the appointment was over, I expressed my pleasure to have her in my practice, but also my surprise.

She looked at me and said, “I don’t like that you do abortions, but if you didn’t, I would probably be dead and not celebrating this new life. My husband isn’t thrilled that I am seeing you. He just can’t wrap his head around the fact that women sometimes really need someone who can do what you do. But I don’t see how I could go to anyone else. You saved my life.”

I think of the many times I have been in this exact situation over the years and it makes me wonder what happens now to the women who rupture their membranes at 21 weeks in Idaho, Nebraska, North Carolina, and Ohio. These women can’t choose to have a dilation and evacuation or even an induction of labor. They must wait until their baby succumbs in utero or for a spontaneous delivery, almost always a grim prognosis for their baby. Unless of course an infection develops and her life and health are in danger. Only then, when it is more dangerous, can a woman terminate her pregnancy at 21 weeks with ruptured membranes.

And if the induction of labor fails, as they often do, will these women be able to find a provider in one of those states skilled enough to safely perform a dilation and evacuation at 21 weeks in the presence of an infection?

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  • http://www.livewellthy.org Stewart Segal, MD

    This article needs to go viral, circulate over the internet and help others through a very hard time! Keep up the good work!!

    • miolly Ciliberti RN

      Agree. Thank you for meeting your patients needs no matter what they are.

  • http://www.thepreemieexperiment.blogspot.com Stacy

    Anonymous Physician wrote: “and it makes me wonder what happens now to the women who rupture their membranes at 21 weeks in Idaho, Nebraska, North Carolina, and Ohio. These women can’t choose to have a dilation and evacuation or even an induction of labor.”

    I’ll tell you what they do. The NICU would be alerted and a team of medical staff would descend upon the delivery room where a 21 week old fetus would be delivered via c-section. Obviously that baby will not survive and the doctors would use the “born alive protection act” to justify their decision. Very sad.

  • LTC

    So, you’re telling me that with a doctor who is not well-skilled and practiced in late term abortions, the outcome for this patient would have been worse with certainty? I am not arguing that your skill in the dilation and evacuation procedure not only spared her life, but avoided unnecessary bleeding and other complications. However, is it absolutely true that with a provider that didn’t do late term abortions, her outcome would have been worse? I don’t believe that your practice of doing many late term abortions was necessary to help this woman have a good outcome in this situation.

    • An ob doc with some grey hair

      “So, you’re telling me that with a doctor who is not well-skilled and practiced in late term abortions, the outcome for this patient would have been worse with certainty?”

      Yes.

      This is one of the most difficult procedures in ob-gyn. Nothing beats experience for these procedures. This patient and her husband are very fortunate that skilled doctor was available, and in the next generation of ob-gyn doctors these skills will cease to exist.

    • doctor1991

      As an OBG myself, I would have to disagree. I would not feel comfortable doing this procedure, especially with the patient septic and the uterus very susceptible to perforation.

      • ninguem

        Doctor1991 – Faced with this scenario, if not comfortable with the D+E described, how would you approach the problem as described?

  • http://medschool.ucsf.edu/academy/ Molly Cooke

    Thank you very much for this wonderful story and for your work.

  • http://notevena.blogspot.com Kylie Hodges (@kykaree)

    I had severe pre eclampsia at 27 weeks. I, and my unborn child, were extremely fortunate and I give thanks every day that my symptoms had become severe enough for action after the “magic 24″

    If I had been under 24 weeks I would have considered termination. In my opinion a human ending of a pregnancy pre 24 weeks is far superior than Stacy’s scenario of giving parents false hope, submitting a non viable fetus to hours or days of futile medical treatment.

    It’s just wrong. I don’t like abortion, but I don’t like that in the 21st century women still die in pregnancy.

  • DrDutch

    PPROM at 21 weeks, even if the mom is “well” will likely result in a poor outcome, even if pregnancy manages to continue for many more weeks. Presuming the baby (once delivered) does NOT have profound pulmonary hypoplasia (which is essentially guaranteed), the mortality risk will still be high, as will the long-term morbidity. These will also be impacted by when the baby is delivered (24 weeks is much different than 28 and 32 and so on).

    This case is difficult- just as all cases of pre-viable babies. To the family, they have seen the ultrasounds. They have felt the baby kick. They have heard the heart tones. To those of us who do NICU for a living, we know that the outcomes for less than 24 weekers are very poor, and it is uncommon to entertain resuscitation at less than 24 weeks, almost never at less than 23, and never less than 22. The 22-24 week range is a great debate, and while some centers report “survival until discharge” outcomes, what we have limited data on in this group is long-term outcomes (meaning functionality once in grade school). The collective world experience to date is unfavorable in this 2 week range.

    It is very hard to be the NICU doctor with this situation – explaining that *nothing* can be done- for the aforementioned reasons. Combine that with the sensationalism of a drive-by news media which jumps on the *miracle* stories, and the job is even more difficult.

    OBs would do the world a favor by taking time during the early 2nd trimester to discuss the concept of *viability* with their patients so as to set a framework of expectations for when these emergencies occur.

    This case was difficult, and it seems it was managed as best as possible.

  • Cat

    to LTC: I am not the physician who wrote this, but as a physician I can assure you that unlike first-trimester suction abortions, dilation and evacuation at 21 weeks is not a simple procedure. It is not to be attempted by someone who does not do them regularly, because of the unacceptably high risk of uterine perforation, retained fetal parts, cervical laceration, etc. Only abortion providers develop skills sufficient to be truly competent in D&E; most ob-gyns only learn how to induce labour, which would have been a more dangerous option for this woman given her infected, atonic uterus.

    In medicine one cannot say much “with certainty”; another physician might have had a lucky break and managed to empty the uterus successfully, but if it were me on the table, or a patient of mine, I would consider it an unacceptable risk to get a D&E from anyone but a regular abortion provider. Indeed, I would even transfer a patient to another center for such specialist care, rather than “take my chances” with another ob-gyn.

  • David

    A very sad story. I am glad that the mother’s life was spared and that this skilled physician was able to save a life, however a human life was taken during this procedure and that should not be minimized. Like @LTC, I take issue with the implication that the frequent practice of late-term abortions somehow made the outcome better. This type of procedure should only be an option in the gravest of situtations and performed with a heavy heart. I find it difficult to believe that a 21 week old baby does not feel pain, even extraordinary pain during an abortion. See Dr. Ranalli’s comments below.

    “Medical facts of fetal pain

    Anatomical studies have documented that the body’s pain network—the spino-thalamic pathway—is established by 20 weeks gestation.

    • “At 20 weeks, the fetal brain has the full complement of brain cells present in adulthood, ready and waiting to receive pain signals from the body, and their electrical activity can be recorded by standard electroencephalography (EEG).”
    — Dr. Paul Ranalli, neurologist, University of Toronto

    • An unborn baby at 20 weeks gestation “is fully capable of experiencing pain. … Without question, [abortion] is a dreadfully painful experience for any infant subjected to such a surgical procedure.”
    — Robert J. White, M.D., PhD., professor of neurosurgery, Case Western University

    Unborn babies have heightened sensitivities

    Unborn babies at 20 weeks development actually feel pain more intensely than adults. This is a “uniquely vulnerable time, since the pain system is fully established, yet the higher level pain-modifying system has barely begun to develop,” according to Dr. Ranalli.

    “Having administered anesthesia for fetal surgery, I know that on occasion we need to administer anesthesia directly to the fetus, because even at these early gestational ages the fetus moves away from the pain of the stimulation,” stated David Birnbach, M.D., president of the Society for Obstetric Anesthesia and Perinatology and self-described as “pro-choice,” in testimony before the U.S. Congress.

    Given the medical evidence that unborn babies experience pain, compassionate people are viewing abortion more and more as an inhumane and intolerable brutality against defenseless human beings.

    The unborn baby at 20 weeks

    Fetal development is already quite advanced at 20 weeks gestation:

    • The skeleton is complete and reflexes are present at 42 days.

    • Electrical brain wave patterns can be recorded at 43 days. This is usually ample evidence that “thinking” is taking place in the brain.

    • The fetus has the appearance of a miniature baby, with complete fingers, toes and ears at 49 days.

    • All organs are functioning—stomach, liver, kidney, brain—and all systems are intact at 56 days.

    • By 20 weeks, the unborn child has hair and working vocal cords, sucks her thumb, grasps with her hands and kicks. She measures 12 inches.”

    Source: http://www.mccl.org/page.aspx?pid=298

    • miolly Ciliberti RN

      David, if you are against abortions than don’t have one. But leave women alone to decide for themselves what they want to do with their bodies.

      • David

        Molly,
        If it was only the woman’s body in question, then I would I agree with you.

        • ninguem

          How about abortion past the gestational age of viability?

          How about abortion for sex selection?

          Woman is 37-weeks pregnant, perfectly normal, father leaves her, she wants to abort the pregnancy?

          No regulation at all? None?

  • http://drpullen.com Health Blog

    It is sad that people against elective abortion cannot distinguish life saving terminations from elective abortions.

    • ninguem

      Uh…..yes they can, Dr. Pullen. See my post below, sorry it’s long, but I cited the legislation. The legislation in question made provision for life-saving terminations.

      Assuming there’s a competent practitioner available, and assuming there is a medical need for a life-saving mid-trimester abortion (I’d say the sepsis described here would count as life-saving), the woman in question would be able to get that life-saving mid-trimester abortion in Omaha or Boise or Cincinnati…..or anywhere ense in the country, as far as I can tell.

      The pro-life organizations seem to be OK with that, I cited one link from National Right to Life to that effect.

      If I’m misinterpreting the law, I’d like to hear about it………seems quite explicit to me. Aborting the pregnancy described in this thread, would be quite legal everywhere in the Union.

      • http://twitter.com/DrEdPullen Edward Pullen

        My comment was not directed at your comment, rather at the vocal minority who make providers who offer even this life saving (no viable baby to be saved here) procedure the object of their wrath.  

  • An OB

    David is mistaken.

    Medical experts in the field of pain and cognition agree that a functioning cerebral cortex is required to translate nocioception into pain.

    A fetus at 21 weeks does not have the neuoanatomy capable of pain. Primitive reflexes do not imply perception of pain, they are just that, primitive reflexes.

    There is no medical evidence to support the contrary.

  • Emma B

    Why should abortion be different from any other surgery, where experience makes expertise? If I need a c-section, I’m not going to go to the family practitioner who did a handful of them in residency 20 years ago. I’m going to go to someone who does them on a frequent basis. If I need cancer surgery, I’m going to go to a doctor who deals with cancer every day. I would never dream of trusting my life, health, or fertility to someone who has never done a certain operation before.

    Doctors forget unused skills over time, just like everyone else, and improve with practice. This is true even when you personally disapprove of the skill in question.

  • DrDutch

    There is an extensive body of literature examining the issue of pain in the NICU. There are pain assessment tools which our nurses utilize. These are based on observation, and observation is subjective. And to be fair, assessing “pain” in adults is subjective- my “pain” tolerance is different than another person’s. While efforts can be made to investigate the pain experienced by the unborn child, these will be faced with similar limitations. To make the issue even more difficult, the immaturity of the nervous system at these early gestational ages will muddy that water even further.

    The extremely preterm baby will exhibit reflexive movements. It may gasp. It may move the arms and legs. And that little heart….any of us who took a physiology lab likely did the experiment where we opened an amphibian chest, dissected out the heart, and watched that little thing beat on the table. Yes, The Temple of Doom did have some truth to it. Those little non-Big Macified hearts will have an inheirent automaticity that will result in activity for minutes to hours after delivery. This makes the *death* experience (unfortunately death is when the heart stops) that much harder. And this is why we will admit the extremely preterm baby who is not going to be resuscitated to the NICU- for comfort care. If the parents make the request.

  • LTC

    I heard of a situation where an extremely preterm baby was delivered and taken from the mom to the NICU, “according to protocol.” That baby was going to die soon. Why not let the parents hold the baby and say goodbye with the most comfort possible: the loving arms of her/his parents? In this situation, the mother, although traumatized, wanted to hold her baby. The midwife got int a huge fight with the ob/gyn resident and “protocol” won out. Very, very sad.

    • DrDutch

      I would doubt that you have the whole story here…..don’t know of any place where “protocol” supercedes human decency. So either some details are missing, or their was a serious misunderstanding.
      Most places have something in writing to manage the case of a non-resuscitable, but live infant. This could extend from the extermely preterm, to later gestations with “life-incompatible” conditions where the family chooses comfort care. This will include some supervision from the NICU (or Pediatrics, whomever is the first responder for OB). Even with a “protocol” in place, the protocol provides a guideline. And guidelines are not absolutes.

      And if this tale is true with what you are sharing, then the family should have written a letter of complaint, and sent it to the nurse manager of the NICU, the L/D floor, the chairs of Peds and OB/GYN, and the CEO of the hospital in question, and included a line such as “….not only will we never choose the services of your hospital for Obstetric purposes, we will encourage every single person we know the NOT choose your hospital.”

  • gerridoc

    This article spells out a scenario illustrating a difficult and complicated decision that obstetricians and their patients could possibly face regarding mid trimester pre-term labor. Policy regarding termination of pregnancies must reflect reality based upon medical evidence and cannot be boiled down into a stringent set of restrictions based upon religious beliefs of a segment of the populace.

  • ninguem

    “I think of the many times I have been in this exact situation over the years and it makes me wonder what happens now to the women who rupture their membranes at 21 weeks in Idaho, Nebraska, North Carolina, and Ohio. These women can’t choose to have a dilation and evacuation or even an induction of labor. They must wait until their baby succumbs in utero or for a spontaneous delivery, almost always a grim prognosis for their baby. Unless of course an infection develops and her life and health are in danger. Only then, when it is more dangerous, can a woman terminate her pregnancy at 21 weeks with ruptured membranes.”

    What would the doctors do in those states, and actually a few more that have passed the “Pain-Capable Unborn Child Protection Act”

    Actually, what they would do is abort the pregnancy, same as the anonymous physician in this story. At least that’s my read of the law. Here’s the original Nebraska legislation:

    http://nebraskalegislature.gov/FloorDocs/101/PDF/Slip/LB1103.pdf
    Sec. 5. No person shall perform or induce or attempt to perform or induce an abortion upon a woman when it has been determined, by the physician performing or inducing the abortion or by another physician upon whose determination that physician relies, that the probable postfertilization age of the woman’s unborn child is twenty or more weeks unless, in reasonable medical judgment (1) she has a condition which so complicates her medical condition as to necessitate the abortion of her pregnancy to avert her death or to avert serious risk of substantial and irreversible physical impairment of a major bodily function or (2) it is necessary to preserve the life of an unborn child. No such condition shall be deemed to exist if it is based on a claim or diagnosis that the woman will engage in conduct which would result in her death or in substantial and irreversible physical impairment of a major bodily function. In such a case, the physician shall terminate the pregnancy in the manner which, in reasonable medical judgment, provides the best opportunity for the unborn child to survive, unless, in reasonable medical judgment, termination of the pregnancy in that manner would pose a greater risk either of the death of the pregnant woman or of the substantial and irreversible physical impairment of a major bodily function of the woman than would another available method. No such greater risk shall be deemed to exist if it is based on a claim or diagnosis that the woman will engage in conduct which would result in her death or in substantial and irreversible physical impairment of a major bodily function.

    I’d say the woman described, “…..has a condition which so complicates her medical condition as to necessitate the abortion of her pregnancy to avert her death or to avert serious risk of substantial and irreversible physical impairment of a major bodily function….”

    I find this page from a pro-life site revealing:

    ……50 Alabama legislators co-sponsored the model Pain-Capable Unborn Child Protection Act which, as drafted by the National Right to Life Committee’s state legislation department, protects the life of the unborn child at the point that they are capable of feeling pain, except when the mother “has a condition which so complicates her medical condition as to necessitate the abortion of her pregnancy to avert death or to avert serious risk of substantial or irreversible physical impairment of a major bodily function or…it is necessary to preserve the life of an unborn child.”

    http://nrlcomm.wordpress.com/2011/06/16/pain-capable-unborn-child-protection-act-becomes-law-in-alabama/

    I cited this from a pro-life site, so of course, they’re celebrating this. They don’t seem to have a problem with the clause.

    Hey, I’m not a lawyer, maybe there’s a subtlety I’m missing. The way I read the law, the woman described would legally be able to get a mid-trimester abortion anywhere in the Union.

    Whether there is a practitioner capable of doing the prodcedure, experienced enough to do it, is another matter, but I doubt that would change regardless of the law. No different from finding a neurosurgeon or any other subspecialty procedure in a low-population state.

    There’s so much rhetoric around abortion, it can be hard to get the facts.

    BOTH SIDES try to obscure the facts to suit their position.

  • Amanda

    Perhaps the physician was referring to states that have banned public funding of abortion training? Some states have actually enacted legislation which forbids public universities from teaching med students how to perform abortion. While late term abortions may be legal when the mother’s life or health (although the “health” provision has been severely limited in recent years) is at risk, there will be fewer doctors capable of performing the procedures due to these laws prohibiting training.

    • ninguem

      No, Amanda, not by any plain English reading of the post.

      “……These women can’t choose to have a dilation and evacuation or even an induction of labor. They must wait until their baby succumbs in utero or for a spontaneous delivery, almost always a grim prognosis for their baby……”

      The author did not say “these women can’t find a doctor trained to do a mid-trimester D+E” (though that may well be true in small states). A plain English reading, the author says women do not have a mode of medical treatment available to them (a mid-term abortion), they have to wait for the fetus to die, adding to the risk in a case like the one described.

      Thing is, what the author writes is just not true. If I’m missing something here, I’d like to know about it. Am I misreading the law. The “life and health” exception is right there in the statute, and sure seems to apply to the case described.

    • ninguem

      There’s also a line that seems silly to me……”almost always a grim prognosis for their baby”.

      I’ll stick my neck out and say that the prognosis is equally grim for the baby. A medical or surgical abortion, or an intrauterine fetal demise, the fetus is just as dead, I daresay an equally grim prognosis.

  • Penny

    Sad story. The husband might have felt differently if he himself were the one carrying the baby. My guess is that most women under the same circumstances would’ve considered themselves extremely lucky to have such a good physician.

    Some time ago I heard a former judge speaking on the radio. He said that one thing he always taught upcoming lawyers was that too often people go too much “by the book.” Everything they do and say is learned from books, but the one thing that they should always remember is that “common sense” should always prevail over any reading material or teaching by another.

    Unfortunately, it generally doesn’t in our court rooms, which is justice system is a failure.

    For those who would argue this on religious grounds, I often feel that that was exactly what the story of Adam and Eve was about. God became very angry when they ate from the tree of knowledge instead of going by their own God-given sense. He knew that now that they were on that track, things would never go back or be the same. They would continue to do that from that day on and would in a sense be “thrown out of the Garden of Paradise.”

    There is never black or white in law or in many medical situations. Under any grey area, no loving God would penalize people for trying their hardest to make what they believed was the most “common sense” and truly caring decision. Jesus forgave many sinners during his time because he knew of their difficult personal situations. He also didn’t care for those who judged others negatively when they were trying their very hardest under very difficult circumstances to do what they believed was right. Bravo to that intelligent and obviously extremely loving and caring physician!

  • Penny

    Sorry if I skip the odd word in my articles some times. I’ve had that problem for many years — don’t know if it’s caused by mini seizures or just poor attention.

  • Dave Mittman, PA

    Great blog. Great physician. He did not throw politics into the discussion, only medicine.
    This shows the FACT that medicine is not the black and white profession many people think it is. There is much grey to be practiced, people to be considered and the text books do not tell us all we need to know.
    Dave

    • ninguem

      I’d say that misrepresenting the abortion statute in “Idaho, Nebraska, North Carolina, and Ohio” constitutes throwing politics into the discussion. In fact, I’m coming to wonder if this story is a fiction.

      The FACT (to use your caps) is that a midtrimester abortion under the circumstances described here, is legal anywhere in the USA.

      If anyone can point out something to the contrary, I’d like to see the citation. So far, no takers.

      I’m not approaching this from a “pro-life” or “pro-choice” point of view (to use the inaccurate euphemisms).

      I’m “pro-facts”. And I’d like to see some.

  • ninguem

    Actually, the story just seems a little too perfect.

    The deliberate misunderstanding or (I suspect) misrepresentation of the statute.

    The glib remark about the natural course of disease being bad for the baby……..but aborting the baby is not?

    I’m coming to wonder if maybe this story is a work of fiction.

  • Jo

    Abortion under any circumstances should never be reason to pat oneself on the back. So you saved the life of a mother, yet a life has been lost, maybe a great life.

    My sister was in simular situation, first they stated baby would not survive then they said she would not survive. She chose not to terminate, they told her he had mainline brain damage. Today her son is genius, 5.0 GPA finished law college in 3 years, law school early with honors and just graduated post graduate studies with honors. Only residual from is he is blind in one eye.

    With new advances in technology every day, Live Birth should be tried whenever possible and advances in such technology researched in order to save these little ones earlier. Tearing the unborn child apart to save the mother when there are other possible, (in the future probable) alternatives, always giving life a chance is a good thing, not a bad thing.

    • http://foreverinhell.com Personal Failure

      A great life? You mean the dead fetus that was killing its mother? There was no way to save the fetus in that situation, the only question was whether the mother was going to die, too.

      • DrDutch

        “With new advances in technology every day, Live Birth should be tried whenever possible and advances in such technology researched in order to save these little ones earlier. Tearing the unborn child apart to save the mother when there are other possible, (in the future probable) alternatives, always giving life a chance is a good thing, not a bad thing.”

        Over-reaching, generalized statement.
        A few things:
        It is about 20+ years since the administration of post-natal surfactant and antenatal steroids became commonplace. Since then, our ability to provide care for the tiniest of babies has become better. My senior partners lived in an era where most babies born less than 27-28 weeks were not resuscitated – these were considered miscarriages, similar to the less than 22-23 weekers of today. With that increase in the “n” of babies between 23-26 weeks has come the consequences of preterm delivery- chronic lung disease of prematurity, retinopathy of prematurity, intraventricular hemorrahges….and long-term disability. For every one *miracle* child that survives the NICU (mortality for 23-24 weekers remains 40-50%, and long-term morbidity for the 23-26 week club remains high), come many more than have long-term problems. Yes, they are cute as little babies— then they grow up, and need someone to look after them.

        Consider the concept of *Number needed to treat* – the principle in intervention research where we consider how many patients will need an intervention to prevent one case of disease. Because of the limitation of long-term follow-up in clinical research, we don’t have a huge data-set. But after years of doing this job, I can say that the number of very tiny babies who escape with few to no potentially life-altering consequences is small. And as the number of babies we *try* to save that are of extreme prematurity, the more of those problems we will see.

        This does not mean we throw in the proverbial towel and not try to do our job better. But what people have to try to understand is that medicine has a costm and it is not just financial. And those costs are difficult to envision for patients, parents, families, and yes, the medical team.

        Unfortunately the mainstream news medias do not paint a true picture of the life of an extremely preterm infant. 3-4 months in the hospital. Multiple IVs. Multiple *pokes* for blood. Constant stimulation from the environment, which, relative to the protection of the womb is cold, bright, and loud. Prolonged periods of receiving only IV nutrition. Lumbar punctures. Ultrasounds. Nights where the medical team tells the family “I’m not sure if you will survive the night”. And the unknown- how will this work out at age 18.

        Our job is to give your baby the best chance at a meaningful life. To me, that means NOT making you smile because you get to change a diaper. It means growing up, going to school, maybe college, and becoming a productive member of society. If we fail at that task most of the time, we need to ask if we are doing that job well. I can say, at least in 2011, that we cannot do that job well at less than 24 weeks. And the outcomes between 24 and 26 weeks are not terrific. Placing expectations that we continue moving backwards in gestational age is absurd. We can keep “trying”, but the public also needs to have a reasonable expectation on what is likely to happen.

        And for the record, I’d be a lot happier knowing that a patient whom we thought was going to do poorly actually did well. The reverse is a much more bitter pill to swallow.

    • bostonfan

      Yes, maybe that 21 week fetus would’ve survived and gone on to law school. Great idea, let’s try a live birth for every single pregnancy, even if there’s no live mother.

  • Amy

    To a hammer everything looks like a nail.

  • An OB

    In states with a 20 week law RIGHT NOW doctors are not doing inductions of labor for ROM at 20 weeks because they are afraid they will be prosecuted. Their hospitals are telling them they are “on their own.” A patient with ruptured membranes is not in danger until she gets the infection, so having ruptured membranes at 21 weeks does not meet the “health of the mother” proviso. Only when the infection takes place does maternal health become the immediate issue.

    ninguem, there have been stories in the press similar to this case. I refer you to a recent article in the New York Times (See below). Do you think the couple featured in the NYT is lying?

    How is this case too perfect? I see this scenario, ruptured membranes pre-viability a couple of times a month and I am one doctor at one hospital. This is my reality as an OB at a tertiary care facility. Ninguem, are you an OB? How many times have you sat on the edge of the bed and discussed the sad realities of no amniotic fluid at 21 weeks? Many women want to wait and see and many do not. That is their choice. Or should be.

    http://www.nytimes.com/2011/06/27/us/27abortion.html

    The authro is right in his assertion about the laws in the states mentioned. Check out the Guttmacher Institute

    http://www.guttmacher.org/statecenter/spibs/spib_OAL.pdf

    • ninguem

      Ah this is called the shout-down question.

      No I’m not an obstetrician.

      Nor am I a woman, to address another shout-down question.

      But I can read English.

      The case described is in a plain-English reading, consistent with the law. Mother’s life and health are clearly endangered. I stand by what I wrote.

      The New York Times contradicts itself. Not that this is unusual. Nice eye-catching headline “Several States Forbid Abortion After 20 Weeks”

      Except when they don’t forbid it. The example cited at the head of this thread, is one such case. I quote: “….They [the 20-week laws] permit abortions after 20 weeks only to avert the death or “serious physical impairment of a major bodily function” of the mother…..”

      Are you saying that the case cited is not an example of a threat of “serious physical impairment” of the mother, that could be cured by a mid-trimester abortion? I’m not anti-abortion, I say the abortion is indicated.

      But as you say in your shout-down question, I’m not an obstetrician.

      And you contradict yourself when you say the author is right about the laws, then you cite the Guttmacher Institute. there’s a whole column of “Prohibited EXCEPT IN CASES OF LIFE OR HEALTH ENDANGERMENT”. Specifically looking at “Idaho, Nebraska, North Carolina, and Ohio”, in a clear case of maternal endangerment as cited at the head of this thread, by your Guttmacher citation, the abortion would be allowed. Ohio has a special mark, as the law was enjoined. So we don’t know ehere they stand.

      You bring up new issues. Premature rupture of membranes, where the mother is not yet endangered, but likely will become endangered. Doesn’t look like fetal anomaly is considered, where a late-discovered fetal anomaly will be life-compromising or lethal after birth, but the fetus is fine in utero. If any of these matters are dealt with in the 20 week laws, I’m not aware of it.

      As such, I agree, looks like there are aspects of the law that do need to be addressed. It doesn’t help matters to represent that the woman described here would not be able to get a legal abortion. That’s just not true, from a plain reading of your own citations.

      • Anonymous

        I agree with you that too many doctors play God with their experience card…nullify others, etc., yet…let’s go one step further…I am using a broad brush…..stop using that same shout down question on your patients. Educate them patiently….patients can read English too…..I know that’s shocking:)…but we seek clarity…not arrogance of position or power.

  • ninguem

    “The Dutch Policy,” BBC News, 22 September 2004, …

    http://news.bbc.co.uk/2/hi/programmes/panorama/3677278.stm

    To use this as one example. In Holland, this would be regarded as a stillbirth. Resuscitation would not be offered.

    I’m not saying that’s right or wrong. Maybe we’re too aggressive in the USA, for a baby with no chance of survival.

  • Dr Adjoa

    I applaud you for writing this telling piece especially since family planning cases are not common on this blog. You demonstrate the need for providers trained in abortion care which is a part of comprehensive women’s health care. Sadly American society has demonized and politicized abortion and the onslaught of GOP legislation restricting abortion access is disturbing. I myself
    received training in abortion care as a fellow and I’m proud to advocate for women to have the right to safe abortions! And wonderful that she later returned to you as a prenatal patient after you saved her life.

  • Dr Adjoa

    I applaud you for writing this telling piece especially since family planning cases are not common on this blog. You demonstrate the need for providers trained in abortion care which is a part of comprehensive women’s health care. Sadly American society has demonized and politicized abortion and the onslaught of GOP legislation restricting abortion access is disturbing. I myself
    received training in abortion care as a fellow and I’m proud to advocate for women to have the right to safe abortions! And wonderful that she later returned to you as a prenatal patient after you saved her life.

  • Tpyoung99

    My daughter just had a D&E performed by an OB-GYN who does not perform abortions. Her baby died in utero and as a well trained physician in patient care, he performed the necessary proceedure. Performing abortions to end the life of babies is not a political issue with me or my daughter (or to the millions of others opposed to it). It is simply a question as to when life begins. My comments are not meant as a personal attack directed at the author of this piece. But, to say that it was necessary to perform countless abortions on helpless babies and their healthy mothers in order to provide medical and surgical treatment to an ill mother and her baby is wrought with too many philosphical and ethical problems to discuss in this limited forum. I do feel for this family that had to endure such a terrible outcome of the pregnancy listed above and I rejoice in their subsequent pregnancy.

  • Tpyoung99

    My daughter just had a D&E performed by an OB-GYN who does not perform abortions. Her baby died in utero and as a well trained physician in patient care, he performed the necessary proceedure. Performing abortions to end the life of babies is not a political issue with me or my daughter (or to the millions of others opposed to it). It is simply a question as to when life begins. My comments are not meant as a personal attack directed at the author of this piece. But, to say that it was necessary to perform countless abortions on helpless babies and their healthy mothers in order to provide medical and surgical treatment to an ill mother and her baby is wrought with too many philosphical and ethical problems to discuss in this limited forum. I do feel for this family that had to endure such a terrible outcome of the pregnancy listed above and I rejoice in their subsequent pregnancy.

  • Kim Menier

    Thank you for your candid comments, and your bravery in performing a service that puts you in the line of fire, literally.
    I am pro-choice, although when I faced the same ordeal you have described in your article, I found it very difficult to make the decision for myself. I was fortunate to have a knowledgeable and empathetic doctor, perhaps even a colleague of yours, help me through this very difficult time.  I wanted to say “thank you” for having the courage to do what few people would be willing to do for others.

  • Kim Menier

    Thank you for your candid comments, and your bravery in performing a service that puts you in the line of fire, literally.
    I am pro-choice, although when I faced the same ordeal you have described in your article, I found it very difficult to make the decision for myself. I was fortunate to have a knowledgeable and empathetic doctor, perhaps even a colleague of yours, help me through this very difficult time.  I wanted to say “thank you” for having the courage to do what few people would be willing to do for others.

  • Anonymous

    It’s my understanding that they no longer teach abortion in medical schools.  The very fact that this physician has to post anonymously is terrifying.  Our “convictions” have played politics with women’s lives.  It’s as bad now, as it was when I had an abortion before they were legal.  I was lucky, I had a real doctor.  But I saw a lot of women who took their chances on pills that didn’t work, or trips to Mexico where they were at the mercy of a medical system they didn’t know how to navigate.  The fact that this country refuses to acknowledge is that if a woman wants an abortion, she will get one.  Period.  The transmogrification of the issue from one of women’s rights, to murder of unborn children, is what discourages me about the future of this country.  Our bodies, our consciences.  It’s hard enough to make the decision to get an abortion, let alone having the added angst of what goes on in this country in an effort to stop us.  But we will not be stopped.  It’s not a boast, it’s a fact.

  • ejj1939

    It’s my understanding that they no longer teach abortion in medical schools.  The very fact that this physician has to post anonymously is terrifying.  Our “convictions” have played politics with women’s lives.  It’s as bad now, as it was when I had an abortion before they were legal.  I was lucky, I had a real doctor.  But I saw a lot of women who took their chances on pills that didn’t work, or trips to Mexico where they were at the mercy of a medical system they didn’t know how to navigate.  The fact that this country refuses to acknowledge is that if a woman wants an abortion, she will get one.  Period.  The transmogrification of the issue from one of women’s rights, to murder of unborn children, is what discourages me about the future of this country.  Our bodies, our consciences.  It’s hard enough to make the decision to get an abortion, let alone having the added angst of what goes on in this country in an effort to stop us.  But we will not be stopped.  It’s not a boast, it’s a fact.

  • Catherine Megill

    Was your daughter at 21 weeks, with an infected, atonic uterus? Was she close to sepsis? Are you sure that he did a D&E and not simply a dilation and extraction? (if there was an intact fetus at the end, then it was not a D&E…) If he actually did a D&E without doing them routinely, then he put your daughter at undue risk and if something had gone wrong you would have a valid malpractice suit on your hands. ANY surgical procedure requires a certain practice to remain safe to perform (“countless” is inaccurate – remember that 90% of abortions are done before 12 weeks and 99% are done before 20 weeks, so there are simply not that many elective later cases to go around -from what I have learned, a provider should be doing 50-100 midtrimester D&Es a year if they want to call themselves competent.

  • Anonymous

    Why did the author use their credentials as an abortionist to prove anything beyond the fact they do not value life? Maybe the baby wasn’t viable…it was still a human the parents had grown to love. I only had pro life OB’s and one of my best friends is a pro life OB. How thankful her patients are to her….gosh…wonder how thankful we should be Dr. Anon here who wants to blur the lines of two completely different issues. Being an abortionist does not make one an expert of children in the womb…if anything…..I will get flagged if I say a
    Much more because we are supposed to show tolerance while being extended little.

    Just so odd to me when doctors who are supposed to save lives have no problem killing one because mom proclaims her legal right above her child…then we act horrified when Casey Anthony kills her own child. A child is a chikd whether the Supreme Court extends a chikd in the womb is relative…lawful…yeah…moral….no.

    I guess I tend to think this doctor wants to justify abortion by showing how pro lifers find it hard to give up on life….too bad Anon doesn’t feel that way. Sigh….

  • Anonymous

    Sorry…talking to my child and not typing well (I have six). I live in Ohio….the new Governor has done marvelous things and one of them is viewing children in and out of the womb as precious. Surely it is unethical to use hard cases in one area to justify your experience in killing?