Beyond the First Trimester

Pictured: Misoprostol tablets


Correct me if I'm wrong, but I feel like most people who know what's up know the gist of a first trimester abortion procedure. The cervix is minimally dilated, the doctor inserts a small plastic tube through the cervix and into the uterus, the tube is connected to the aspirator, which creates gentle suction to remove the pregnancy tissue, it takes five minutes, all is well, some cramping and bleeding are normal as the uterus return to a non-pregnant state. Everyone get that?

But the second trimester abortion is more shrouded in secrecy, maybe because it's less socially acceptable or because fewer clinics offer it or because it's less common (most abortions take place in the first trimester). I'm not going to get into why women do have second trimester abortions because it doesn't matter. Jezebel offered a pretty comprehensive explanation a few months ago about the ins and outs of the second tri procedure, so I wanted to offer an overview of the process and technicalities. Again, this is based on my own experiences and my clinic's protocols. Your mileage may vary.

A second trimester abortion is known as a D&E, or a dilation and evacuation procedure, and it takes place over the course of two to three days--that's the dilation process. The evacuation part is only about 10 to 15 minutes. There's still no cutting involved--everything is removed through the cervix, and it's still a minimally-invasive and safe procedure. But since the fetus is more developed, the cervix needs to dilate more to accommodate the instruments and the removal.

There are a few options for opening the cervix, including the use of Misoprostol, a medication that softens and opens the cervix or a clinician inserts small, sterile seaweed sticks called laminaria into the cervix. Sometimes, the client takes an anti-anxiety medication beforehand, and some clinicians use local anesthetic on the cervix before inserting dilators. The insertion is quick and the woman can't feel the laminaria once it's in place. It remains snug in the cervix overnight and it absorbs moisture which gently dilates the cervix to the appropriate amount. A dilating cervix causes cramping, but it's manageable, especially with pain medication and heating pads.

If the woman is measuring later in the second trimester, the doctor might also inject Digoxin, a common heart medication, through her abdomen and into the uterus in order to stop the fetal heart. This usually happens on the first day of the procedure, after the laminaria is inserted. Because the cervix is opening overnight, there's a small risk for miscarriage, so this injection is a preventative and humane measure.

The client usually spends the night near the clinic. Clinics are not equipped with overnight facilities, so the client stays in a hotel or with a friend or with someone like Vegan Vagina. And women leave with lengthy instructions and lists of phone numbers in case of emergency. If all goes well, the client returns to the clinic early in the morning for the procedure, itself. It's performed under general anesthesia or with some type of sedation. The doctor removes the laminaria if it was in place and then removes the fetus using suction and instruments similar to those that are used for a first trimester abortion. the process still doesn't cause any problems with fertility, health, etc. (I cannot say that enough.) It's normal to have more cramping and bleeding than after first trimester procedures because the uterus kind of has further to go back to normal, and the woman is more likely to have increased breast tenderness. But it's safe, it's do-able, and most importantly, it's completely necessary for the freedom and well-being of women. And because we, as providers, spend a few days with women going through the D&E process, women and their families who have entrusted us with their freedom and well-being, it's also special for us. Thank you, women.

What are you doing here? Go read this Nation article!

In the past year-and-a-half-ish, there's been a lot of noise (well, relative to the usual silence, at least) about women self-medicating with misoprostol to induce an abortion. The first piece, the New York Times article "For Privacy’s Sake, Taking Risks to End Pregnancy," was short on data (which is unfortunately bound to be the case with reports of activity that is both rare and hidden) and long on extrapolation (which is unfortunately bound to be the case with NYT trend pieces). It implied that lots of Dominican women in New York are endangering themselves via illegal abortion despite easy access to cheap legal procedures. (Lots of broad brushstrokes in there, don't you think? Technically a self-induced abortion isn't even "illegal" in NYC!) The letters to the editor included some thoughtful additional information (most of it anecdotal), by the way. More to the point, there were substantive critiques (like "Side Effects: Complications at The New York Times from DIY Abortions" at RH Reality Check) of how the paper was written and that extrapolation I mentioned, including objections from the researchers involved in the study cited.

This summer, Nicholas Kristof wrote a surprisingly nice column ("Another Pill That Could Cause A Revolution") about misoprostol's revolutionary power to save women's lives in multiple ways. Considering that he's been reluctant in the past to even mention abortion, even when writing about pregnancy-related mortality, and considering that his writing tends toward simplistic reduction of complicated problems and even toward cavalier moralizing about the decision-making of the poor, well, that was a pretty nice column, considering.

And this week, Laura Tillman at the Nation brings us "Crossing the Line," which explores in a bit more depth the reasons that in many situations -- even among US residents, even among speakers of English, even among US-born women -- it might be entirely logical to obtain medication under the table and induce an abortion at home. I'll just post an excerpt here to give you an idea, but you should read the whole piece.

A single mother of two boys, Diana was unemployed and in the hospital when she began to suspect she was pregnant. It was December 2006, and she had missed her period for two months. Her doctor conducted a urine test, which came back negative, but when Diana still hadn't gotten her period in January, she started to panic. She knew it wasn't the right time for another baby. She wasn't working and had been suffering severe symptoms of brittle diabetes, a rare form of diabetes that requires frequent hospital visits and brings bouts of depression. She felt unstable and wasn't able to afford her medications. "I thought, If I am pregnant, I want to take something to not be pregnant," she says.

For most women in the United States, this would mean a trip to a doctor or abortion clinic. But where Diana lives, in Brownsville, Texas, just north of the border, Mexican pharmacies are only a few miles away. Items said to be abortifacients—including pills, teas and shots—are well-known to be cheap and accessible just across the bridge. Misoprostol, a pill that makes up half of the two-drug combination prescribed for medical abortions in the United States, is easy to purchase over the counter in Mexico because of its effectiveness in treating ulcers. When used alone and taken correctly, it will produce a miscarriage between 80 and 85 percent of the time. ...

Go read the rest! And have a good week!


PS: Lots of very interesting research has been done on misoprostol (and mifepristone too) in the past year or few -- on both clinical and psychosocial aspects of medication abortion -- and I hope to talk more about all that in a few upcoming posts. Hope that sounds good to you :)

Happy pills

The other day when I answered the phone at the clinic, a Spanish-speaker was on the other end of the line asking about "the pill that brings on your period." I've gotten used to breaking it down on the phone after chatting with clients who ask for a Pap smear, then end up incensed that the Pap didn't test for HIV because that's really what they wanted to check out, and what do you mean that "Pap smear" doesn't translate into "all things vaguely gynecological"? (But that might be another post for another day.) I asked her a series of questions about "Did you take a pregnancy test?" and "Is this the first period you've missed?" because maybe she really DID want to start birth control that would regulate her period. But no, she definitely was referring to the series of pills that would cause an early miscarriage and soothe the conscience into believing it's only a late period, not an abortion.

Women of all demographics are drawn to the RU486/Mifeprex & Misoprostol regimen because it's kind of like Abortion Lite, but women from conservative, Catholic countries where abortion is illegal and money is scarce especially like this route. And when they end up here, in a country where they don't speak the language and they don't have the time to navigate the laws of choice, they often do the familiar thing and buy the pills (usually only one type of pill--the cheaper one that doesn't really cause an entire abortion) on the street. Of course this is dangerous for a variety of reasons, and it ends up being pricey when they have to come to the clinic for a D&C, anyway. So, on the one hand, I appreciated this woman on the phone calling a clinic so that she could get the medication from a medical provider and be overseen by a doctor.

On the other hand, though, I struggled with the desire to give her accurate information and be straight with her with the lingo of "abortion," not "inducing a period" and also respecting her need for coping with this unintended and unwanted pregnancy in a way that she knew how, and especially, not scaring her off an into the streets where she would acquire the tablets from someone who would fully go along with her "bring on the period" plan. Women aren't dumb, and they know full well that a period of this type comes along with a fetus, but where does that leave as as providers and as advocates for women? Readers or co-bloggers, have you ever been faced with this situation? Do you fully disabuse the woman of this notion of the innocuous pill since eventually, they will end up having an ultrasound that clearly diagnoses a presence in the uterus? (That's what I ended up doing.) Or do you go along with the plan a little bit, allowing the woman to see the experience as she wants to see it?