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Medical Procedures |
First Trimester On the first day of the first trimester procedure, each patient is given a preoperative examination with ultrasonography to determine the length of pregnancy as precisely as possible. This examination also provides the opportunity to identify any unusual or pathologic aspects of the pregnancy or pelvic structures that could affect safety. The ultrasonographic screening exam is included in the patient fee. Routine laboratory examinations include a hematocrit (test for anemia), blood Rh type, and a basic urine test. These tests are also included in the fee. Following a session to provide routine information necessary to giving informed consent, the patient meets with the physician (Dr. Hern) so that the doctor can answer any remaining questions, to review follow-up plans, and to review birth control methods to be used after the abortion. The patient then receives a routine physical examination and pelvic examination by the physician. At that point, one laminaria is inserted into the cervix (opening of the uterus). The laminaria is a naturally occurring seaweed about the size of a kitchen matchstick that has the property of absorbing moisture from the body and slowly becoming larger. It has been medically prepared so as to prevent infection. After it has been placed in the cervix, the laminaria expands overnight and dilates the cervix in a gentle, natural manner that reduces pain during the procedure and reduces the risk of uterine perforation. In addition to Dr. Hern's own experience with 30,000 first trimester abortion patients, the medical literature strongly supports the evidence that the use of laminaria reduces the trauma to the cervix and the risk of uterine perforation. On the second day, the patient returns to the clinic for her abortion. A preoperative narcotic analgesia is provided to make the patient as comfortable as possible. The laminaria is removed, and local anesthesia is placed in the cervix in order to minimize pain. The suction cannula is then inserted into the cervix and the uterine contents removed by vacuum aspiration. When this phase is completed (about 2 minutes), the uterus is explored with other instruments that permit the physician to remove all tissue, thereby reducing the risk of complications. The patient is observed in the recovery room for a period of up to an hour in order to observe for evidence of any complications. The patient is then given a follow-up exam appointment unless she plans to visit her own physician or another facility for her follow-up care. MEDICAL
PROCEDURES
- Second Trimester Second trimester patients also receive an ultrasound screening exam at the very beginning of their appointment at Boulder Abortion Clinic. In this case, a more extensive examination is necessary. Among those features of the pregnancy evaluated at this time include the diagnosis of fetal age, which is made by measuring various parts of the fetus, such as head size and femur length, that give a precise knowledge of fetal age. Other evaluations include position of the placenta, the presence of, absence of, or unusual quantity of amniotic fluid, the presence of visible fetal anomalies, pathology such as fibroids in the uterine wall, and whether the fetus is alive or not. Aside from variations in the content of educational and informed consent materials appropriate for the length of gestation, the second trimester patient experiences the same preoperative procedures as the first trimester patient. The main difference is that the second trimester patient experiences an extra day of laminaria dilation of the cervix. The second trimester patient returns on the second or third day (depending on her exact length of gestation) for replacement of the original laminaria with several new laminaria in order to continue and enhance the process of cervical dilation. This procedure, done under local anesthesia, usually takes only a few minutes, but it is an essential step in the process to assure maximum safety. 15 To 19 Weeks From 15 through 19 menstrual weeks, the patient comes in at her appointed time for her abortion and is given a preoperative analgesic and sedative medication. In the operating room, the laminaria are removed and the cervix checked for adequate dilation. The amniotic sac is then ruptured with instruments under direct ultrasound vision. The purpose of this maneuver is to release all the amniotic fluid to the extent possible. This prevents the patient from experiencing an amniotic fluid embolism, in which the amniotic fluid can enter the bloodstream and cause death or serious complications. Because amniotic fluid embolism (AFE) is one of the most dangerous possible complications of pregnancy and abortion, Dr. Hern developed the technique of preventing this complication from happening. After that, the uterine contents are evacuated surgically by using forceps and other instruments placed into the uterus through the vagina and cervix. An intravenous infusion (IV) is in place at this time so that the physician can give medication quickly for pain and to give medication that causes the uterus to contract as the abortion is completed. 20 to 26 Weeks Late second trimester patients receive all of their preoperative evaluation and consultation on the first day of their appointment, and return on the second day for the initial steps of the abortion procedure. At 20 menstrual weeks and later, the first step in the abortion procedure on the second day of her appointment is an injection of medication into the fetus that will stop the fetal heart instantly. The patient is awake during this procedure, which is done under local anesthesia and with the use of direct ultrasound vision. The woman does not observe the fetus on the ultrasound screen in this process. The injection, done with strict attention to sterile technique, usually takes about ten minutes, although the appointment may take longer because of preparations that must be made. Following the injection into the fetus, the first laminaria is placed in the cervix. The patient may leave at that time and must stay in Boulder unless arrangements are made for the patient to stay in a neighboring town. On the third day, the late second trimester patient returns for a brief appointment, at which time the first laminaria is removed and more are placed under local anesthesia. This process permits maximum gentle dilation of the cervix over a two-day period. On the fourth day, the patient returns for her
abortion. Following observation of vital signs (blood
pressure, temperature, and pulse), the laminaria are
removed and a long-acting local anesthesia is again
placed in the cervix. Under direct ultrasound vision, the
amniotic membrane is ruptured so as to permit free flow
of the amniotic fluid from the uterus. The amniotic fluid
is drained as completely as possible. Dr. Hern developed this technique
for the following reasons:
As with the earlier second trimester procedures (15-19 weeks), the later second trimester procedure (20-26 weeks) may require that the physician perform a surgical evacuation of the uterus ("dilation and evacuation" or "D & C") using instuments such as forceps to remove the fetus and placenta. All the other steps taken up to that point, such as use of laminaria, induced fetal demise, and medical induction, serve to enhance the safety of the late second trimester abortion procedure. The choice of procedures is dictated by the woman's safety needs at the time. *Fewer than 1 in 2000 patients has needed a blood transfusion in second trimester and later abortions at Boulder Abortion Clinic - a remarkable record of safety, considering the fact that up to 5% of all second trimester patients have required transfusion in other clinic settings in the United States. MEDICAL
PROCEDURES
- Third Trimester Patients coming in for very late abortion - over 26 menstrual weeks' gestation - are almost always seeking services for termination of a desired pregnancy that has developed serious complications. This usually means the discovery of a catastrophic fetal anomaly or genetic disorder that guarantees death, suffering, or serious disability for the baby that would be delivered if the pregnancy were to continue to term. Occasionally a woman presents at this stage for pregnancy termination because of her own severe medical illness or a psychiatric indication. (See "A Special Note About Fetal Anomaly") At this point, termination of pregnancy is considered a far more dangerous procedure and carries with it serious risks of complication. That is why pregnancy termination at this stage requires more experience and skill in the operating physician. It also requires scrupulous attention to procedures that reduce the risk of complication. The first step for third trimester patients is the same as for second trimester patients at 20 weeks or more. The main difference here is that more precautions are taken to reduce the special risks for more advanced pregnancy termination. Instead of changing the laminaria once on the third day, for example, the laminaria may be changed twice. An additional day of laminaria treatment is rarely, but possibly, necessary. One of the main differences for third trimester patients having a pregnancy terminated for fetal anomaly is that they may wish to have an intact fetus that they can examine and hold as part of the grief process. For many of these patients, it is not a fetus - it's a baby. The woman and her family may request special procedures such as special religious ceremonies, genetic studies, formal autopsy, private cremation, or private burial. We can arrange for any or all of these special procedures upon request. While these procedures or ceremonies can be arranged upon request, we do not expect or require any patients or families to go through any special rituals, ceremonies, or grief process at Boulder Abortion Clinic. Dr. Hern believes that the patient's own family, physician, and religious counselors are better prepared to provide these kinds of support at home in most cases. All third trimester patients are carefully observed in the recovery room for a period of up to two hours before being discharged to the care of a family physician, unless a patient desires return to Boulder Abortion Clinic for her follow-up examination. |
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1130 Alpine Avenue |
