When there is no one skilled enough to do a D & E

“Dr. Gunter, I think, uh, there’s a fetal skull in the abdomen,” my resident said with that hesitancy that says I want you to tell me I’m wrong. The first time you diagnose something that is very bad you actually hope you are mistaken and want someone more senior to reassure you that you are over reacting and tell you that this is just an odd presentation of something benign.

“I’ll be right down,” I said and turned to my medical assistant. “Cancel the rest of my clinic.”

Our patient had that beige-grey skin tone that accompanies the beginning of the end. It’s a color that announces the window of opportunity to save a life is closing. She was damp from her own sweat. The combination of her pallor and the beads of water made her look like a wax figure that had been in the heat for too long and was just starting to melt.

She had arrived by ambulance and she was having trouble telling us what had happened. What we did know was that she had been pregnant and now wasn’t. Whether she’d had a second trimester elective termination (what the public calls an abortion), a fetal demise, very preterm premature rupture of membranes, or a septic abortion didn’t really matter. There was now an infection, either due to the retained parts or a bowel injury. Or both. I glanced at the frozen image on the ultrasound monitor. How my resident managed to do a scan when the patient had such a rigid belly was beyond me, but when you are very junior and you don’t yet have the knowledge that something is actually technically difficult you just assume it is your own inexperience and ineptitude and soldier on. If you don’t know what you don’t know then sometimes you don’t even recognize that it is hard.

A second trimester D&E requires training. Even a skilled provider can push a sharp fragment through the uterus, that’s why skilled providers count at the end to make sure nothing is missing. Leaving something in the uterus leads to local infection and bleeding, but even worse is when something is inadvertently pushed through the uterus along with vaginal bacteria, potentially making contact with bowel or blood vessels. That needs to be fixed right away. Surgical complications happen, even with the most skilled provider. Failure to recognize them and act is the real problem.

“Have you called general surgery?” code for I-am-very-worried-we-have-a-bowel-perforation. He nodded.

Apparently there was no one to call. I wanted to hug and comfort her, but there was a time when what I thought was proper doctor conduct got in the way. Now that I have been very ill myself going into surgery I understand many patients need more comfort than the promise of technically proficient surgery.

The fragments were behind the uterus in the center of an abscess. There was no bowel injury. We were astounded. After we cleaned out the belly and carefully rechecked the bowel I gingerly emptied the uterus while the general surgeon watched from above.“That’s, uh, thin” he said.

After it was all done the general surgeon pulled me aside. “What the Hell was that?”

I understood his complete disorientation on how we got from A to B because a general surgeon doesn’t work with residents who have never seen a colectomy.

A general surgeon hasn’t taken a patient to the operating room to repair the devastation of a back alley cholecystectomy.

A general surgeon doesn’t have to conference call a state senator with a hospital attorney to ask if his patient in the ICU meets the legal definition of “life threatening” to get an incarcerated hernia repaired.

A general surgeon doesn’t have his appendectomy training limited by medically asinine legislation.

A general surgeon doesn’t have to deal with colleagues who refuse to perform mastectomies based on their personal religion.

I could have told my colleague that our patient may have had ruptured membranes or a fetal demise and chose a D & E or maybe even failed an induction so there was no other option and her OB/GYN misjudged his or her skill set. I could have told him this may have been the end result of someone taking advantage of the medically naive, disenfranchised, and desperate.

Instead I turned to him and said, “This is what happens when a women needs a D & E and she can’t get a doctor who is skilled enough to do it.”

Join the Conversation


  1. I fear we are all going to be seeing more problems like this. And septic uteri. It looks like the pendulum is going to swing all the way back to the days before Roe. So, so sad.

  2. I was an RN on a gyn floor in Texas during the time before Roe. We saw too many girls/women with life-threatening sepsis after their back alley procedures. Also had a couple requiring hysterectomies after being butchered by incompetents. Yes, we, too, saw fetal parts in the abdomen on xray. So sad, I actually thought we were past all that. No matter what they say about saving the fetus, it’s all about punishing the woman.

  3. Yes, and yes. We are trained to do second trimester D&Es during internship here in South Africa because there are so many doctors who refuse to do them. Our OBGYN professor where I work told us that when he was training, they lost at least a patient a week to septic abortions. Now we hardly ever see it anymore. But your story is especially interesting to me because we had a very similar case at our hospital not so long ago: a patient who had a backstreet abortion and became septic. Despite numerous interventions she did not improve, until an ultrasound of the abdomen revealed a foetal skull high up in the abdomen. Her case resulted in a lifesaving hysterectomy which was so sad.

    Side-note: I loved what you said here, “when you are very junior and you don’t yet have the knowledge that something is actually technically difficult you just assume it is your own inexperience and ineptitude and soldier on”.
    I definitely experience that all the time these days.

  4. Have you seen this?

    New abortion bill extends waiting period, prohibits procedures at UNC hospitals

    The bill would “prohibit two of the finest medical schools in the the country from providing doctors with the training necessary to provide safe abortion care,” said Melissa Reed, a vice president for public policy for Planned Parenthood, a women’s health care nonprofit known for its advocacy for abortion rights.
    Read more at http://www.wral.com/new-abortion-bill-extends-waiting-period-prohibits-procedures-at-unc-hospitals/14554102/#YiitzLGRDq2d94sT.99

Leave a comment

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: