On my OB Gyn rotation, an optional component is being able to observe during terminations of pregnancies. Because this is such a controversial topic, I thought others might be interested in reading about my experiences. I wrote these thoughts down several years ago, and I recently found them again:
First, to give some background, one thing that I learned is that most abortions in the US are to women who already have kids. That was my experience in the outpatient OB Gyn clinic as well, when women came in after just finding out they were pregnant, the only ones who asked about termination were older women who already had children. In some cases, women were older and with some health problems of their own and taking medication when they got pregnant. The first trimester is often the most sensitive time to toxic exposures, and women often do not know they are pregnant early on in the pregnancy, particularly if they have irregular menses at baseline. Lots of medications, such as some of the common medications used to treat hypertension (e.g. lisinopril) increase the chance of fetal defects; advanced maternal age also increases the risks for lots of pregnancy complications and fetal abnormalities on it’s own, and I think a lot of the concern these woman had was both about not being healthy to take care of a baby, particularly one with potential health issues of its own. The statistic might also arise from unmarried women who are already taking care of a child, and are already struggling. In any event, you can read about the demographics here:
From what I understand, abortions are also an optional part of OB Gyn residency; some residents learn how to do abortions, some do not; it is their individual choice. The same is true of other medical staff, they can choose to not participate. In the hospital where I was observing, that meant that there were sometimes issues with staffing the procedures, independent of the doctors. Termination of pregnancy is usually done in the outpatient (clinic) setting, but for some more complicated cases (such as in a pregnant woman with serious health issues), it is done in the OR. Many of the scrub techs, circulating nurses, etc. did not want to participate, and there seemed to be a little bit of tension about this. I’m not sure if it is also a problem when the patients go to post-op recovery, but from what I observed, everyone was taking care of the patients once their procedure was done. The medical students just stand in the background watching.
One thing I also learned during my rotation as a whole is that abortions are sort of on a spectrum. There are various kinds of pregnancy which are definitely non-viable, such as an ectopic pregnancy, molar pregnancy, an “inevitable abortion” (kind of miscarriage), etc. In many cases, there is some sort of fetal-like material that needs to be removed using a dilation and curettage or other procedure. Some women actually have very strong feelings about not having treatment to end their ectopic pregnancies or molar pregnancies, which actually can be quite dangerous to the woman’s health, as they are more like a quick growing cancer than a “pregnancy”. However, it is also sometimes not so straightforward what is healthy and viable, and there is sometimes no bright line.
If you have strong anti-abortion feelings, and someone tells you they want to give you a drug to end your ectopic pregnancy (sometimes called a tubal pregnancy), you might react strongly to this. We actually had a woman with an ectopic pregnancy identified in the emergency department leave for a little while, but she eventually came back.
As mentioned, many terminations of pregnancy can be done in the outpatient clinic, and I saw this being done once as well. However, I also observed some done in the hospital OR. These were done in the OR because the patient had particular health concerns or the fetus was of advanced gestational age. In that way, my experience was probably biased, but most of the patients I saw had serious health problems, which is why they needed to have the procedure done in the controlled setting of the OR. These same health concerns in many cases actually made being pregnant risky itself:
For example, for a woman with pulmonary hypertension trying to bring a baby to full term, maternal mortality statistics range from 30-50%. Medical science is improving all the time, and hopefully these numbers will go down steadily, but trying to counsel a pregnant patient about these risks and options is a very hard thing to do, certainly emotionally, but also intellectually because these numbers are very “soft” without great studies behind them.
It is also worth spending a moment to mention the attending physician I was observing in the OR. He was a man, and he was absolutely amazing when it comes to patient interaction. Many of his patients were, perhaps unsurprisingly, quite nervous and stressed out. He had an incredibly calm and empathic demeanor. He also put a lot of effort into describing the procedure and what was going to happen to the medical students. Talking to him a little bit at the end of the day, he gave some of his personal background. As a young man, he was doing some medical work in Kenya as a volunteer, and he saw many women who had botched “back alley” type abortions, and it so horrified him that it became a very important part of his life’s work to help women get access to medical abortions. It is also worth mentioning that in terms of demeanor and warmth to patients (and medical students) he was probably the best doctor I’ve observed in all of my clinical rotations (certainly one of the best); he himself noted that he actively cultivated gentleness in both his physical procedures and interactions because he thought the standards on a man in his profession were much higher. To one patient in the post op area, he said, with the utmost sincerity: “Thank you for the privilege of your trust”, I had never heard a surgeon come out of the OR and say something like that to a patient, and certainly not with that much earnestness. I hope to cultivate such an attitude and warmth toward all my patient interactions.
The early gestational age terminations were very straightforward, a sort of suction like device removes some gloppy red, indistinct material (called the POC, products of conception), and then it’s over. Very quick, gentle, and smooth. For some of the patients, the issues were around things like how they were tolerating anesthesia with their other health problems, and the termination of pregnancy seemed like an incidental part of the process.
However, I also saw the termination of a 20 week pregnancy, and that was a completely different story. This was in a very young teenage (nearly a tween) girl, and there was a fairly complicated and dark back story of how she ended up pregnant and why she was getting the termination done so late in gestation; I didn’t learn the details, and I was not going to quiz her or her family about it.
The medical students had been told a few times in advance that many people find these terminations from later in gestation unsettling, and that was definitely the case for me. It was a “Dilate and Evacuation”, which is a more involved procedure:
In this case, the fetus is quite recognizable and basically has to be taken apart before it is removed in pieces. Seeing it happen, it made me feel a bit sick to my stomach, and a sort of generalized feeling of melancholy swept over me. This was the last procedure of the day, which was good because I didn’t feel like being there any more.
So that was my medical school experience with abortions. I am grateful to the patients who let me observe. I think it was definitely important to learn about, as I now have specific knowledge about what is involved if a patient asks me.
Overall, it has really inspired me to make sure I am able to give my patients good quality advice on contraception; although the women seemed grateful to have access to the abortions, clearly they didn’t want to be in that situation. As there is usually a computer in clinic, now I try to show my patients this helpful infographic from the NY Times when they ask about contraception. It shows different anticipated pregnancy rates with different forms of birth control: