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 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 afterwards about holding the body. The patient gets an anesthetic and afterwards 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 heart beat. As they wait for the uterus to labor correctly they get sicker and sicker. Bacteria is showering the blood stream. Their heart rate is unbelievable 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 heart beat,” 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.

D & E’s are now illegal in Texas (SB 8) unless the pregnant person is very ill. How ill? I’m a gynecologist and I don’t know.

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.

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 & E’s 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 & E’s 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.

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  1. What we need is not anti abortion laws that tie doctor’s hands. That’s barbaric. What lawmakers should be focused on is (1) more and better education for women who may not have access to it, and (2) encouraging research into better and safer birth control options. Those two aspects would go a long way to avoid accidental unwanted pregnancies and thus reduce the number of “elective” abortions. No one wants to have an abortion. No one ever wants to be in a situation where the subject of abortion has to appear. Whether by “choice” or medical tragedy. It’s ridiculously ignorant for anyone to think so and horribly ignorant to put all abortions into the same category. And punishing people for not holding the same belief system is exactly what drove people to this continent in the first place. For the record, I am not pro abortion, and I am not against abortion when deemed necessary and appropriate, but it doesn’t matter because it’s not my place to dictate to anyone else what they should or should not do or believe. We should help and support each other, even in hard times, not condemn and persecute.

    1. The other thing that consistently reduces abortions is help for the poorest families. Some women have abortions because a third child would mean the two they already have would go hungry. Of course that’s also unpopular with most people who call themselves “pro-life”.

  2. When men set themselves up as gods, and I mean “men” and “gods” here, no equivocation intended, bad things happen. Your analysis is spot on. Dealing with the potential for death should give anyone pause. It’s tough, and should never be trivialized or marginalized. Docs are on the front lines here, not to mention the person suffering. Legislators forget that or likely have never been in a position to make such hard choices. I needed to read your analysis. Thanks.

  3. Another issue with these laws involves hospitals owned by religious orders. As more and more hospitals are consolidated and owned by Catholic groups, and other religious groups there will be no where for women to receive life saving reproductive care.

    Another sad consequence in the USA.

  4. I suppose this will help solve the problem of women being unable to obtain affordable birth control in TX…just make sure they die, or end up infertile. Bigger issue is that this won’t stop in TX, it will spread across the country like a giant fungus.

  5. Serious question , asked with greatest respect ; Do any of the people that have made this situation law have an MD after their names or are they just being ( pardon my French ) bloody minded ?

    1. I’ll answer your question. The author of this bill, which is now law was Charles Schwertner who is an orthopedic surgeon. A primary sponsor is Donna Campbell who is both an emergency physician and an ophthalmologist.

      Here’s a link to the sponsors:

      As a resident of Texas and a retired nurse with over 40 years of practice, I’m disgusted by these people. Sadly, this law will wend it’s way through the courts just as the former TRAP laws that were finally overturned by the SCOTUS. The waste of taxpayers money is ludicrous.

      I can only hope that the day the SCOTUS makes their decision that Justice Kennedy: a. Is still a member and b. he’s in the correct frame of mind to rule with the 4 sane members.

  6. If all doctors were like you, Jen, this law would have no teeth. They could act when needed and all testify that the doctor on the scene is the only one who can say if the patient was ‘sick enough’. What really terrifies me is that there are doctors that will not only refuse appropriate care for there patients but are prepared to police other doctors to ensure they do the same.

    To put it in religious terms, (I am not religious but I know my bible), doctors need to be like Jacob – prepared to wrestle with God himself for the life of their patients.

  7. I’m honestly surprised that it’s taken them this long. Once D&X was off the table, and stopped rx’ing medical abortions via telemedicine, I assumed D&E would be targeted. Texas is on a speeding train heading straight for mediaeval times.

    A couple of years ago, when Texas essentially banned abortion by using TRAP laws to close down the majority of clinics, people were talking about how to perform manual suction aspirations, just like the Jane collective used to. Others are stockpiling Cytotec, because they can’t afford to make a sixteen hour round trip to a clinic.

    This ever-present lie, the fiction that anti-abortion legislation is to “protect babies”, cannot disguise the truth, that these laws are about hating and punishing anyone with a uterus. The forced-birthing foetus fetishists are a plague upon half of the population.

    Why not just bring back the old septic wards and be done with it? It seems like Texas is desperate to return to the bad old days of women bleeding out on someone’s kitchen table, or of men taking advantage of women in desperate situations, and making rape the price of the illicit procedure, along with a thick wad of cash, of course. That was incredibly common, stil! Is in places without legal abortion.

    This is a sick, sad turn of events. Gilead approaches.

  8. As an L&D nurse this is horrifying to me. I graduated from high school the year Roe passed and have watched us go backward ever since. When you have been in a position to watch a woman hoping against hope to carry her fetus to viability after PPROM (preterm ruptured membranes) at 17 weeks, knowing how unlikely such an outcome will be. Then watching as she quickly becomes septic and dies with her devastated family at her bedside. At that point you understand how important this skill remains. Every time I hear a congress person (man!) say, “We have come to a time when an abortion is NEVER necessary to save the life of a woman.” I want to scream. Until congress/lawmakers live in my world, they should not make medical decisions or laws. A choice between women and their physicians. Period.

  9. Of course you can’t figure out what the actual medical requirements are! That way they have a life-of-the-mother exception to pass Constitutional muster but since you can’t figure it out you can’t actually use it and it is in reality a total ban.

  10. It’s absolutely appalling. 20 years ago when my daughter was due I suddenly had to confront that my friends and I, with our beautiful burgeoning bellies, were doing something that decades earlier had been extremely risky. We all got through, one way or another and today our facebook feeds are full of gorgeous kids embracing their adulthood.

    The thought that my daughter might live somewhere that didn’t provide the same maternity care as I received is shattering. That my son might meet the woman of his dreams but lose her in this way, it’s unthinkable. We expect things to get better, not worse. Losing a baby is horrific, but being forced to be critically ill before appropriate care is given is archaic – and in a “first world country” it is criminal.

    In NZ we fight hard for new generation oncology medicine like Keytruda to be available.
    In Texas, they’re fighting to keep maternity care to the 1970s standards
    F’ing unbelievable.

  11. I’ve assisted on many d&e’s as a student alone, including women like the ones you have just described. This is horrifying. This is sickening. Not to mention women who get second trimester abortions in general who aren’t sick. Can we please stop torturing and stigmatizing these women?

  12. This post is particularly poignant and educational. If more people understood the stark reality that so many women in this situation face, it would be hard to pass such heartless legislation. Thank you, as always, for sharing your experiences in such a relatable, eloquent way.

  13. Amazing! I didn’t know any of this! How awfully terrifying it must be for a woman to be in that situation! And now, she can’t even choose the torture for which she’s been given? Thank you, Dr. Jen, for the education you give. We cannot allow this to happen in another State.

  14. How can we be so backward?!
    My first thought was that poor woman in Ireland. If she had received proper treatment, she would have a family now, instead of being dead.

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