Abortion After 20 Weeks

A few days ago, I received an email from one of the many pro-choice organizations I follow. The email was in panic mode:

“URGENT! Your signature needed! Our reproductive rights are being threatened again!”

Two days ago, Congress passed a bill banning elective abortion after 20 weeks gestation. “Elective,” meaning not due to conditions dangerous to the mother (such as preeclampsia or eclampsia), or fetal demise, or fetal malformations that are incompatible with life. Those are still possible. Just not, “I don’t want to have this baby.” I haven’t read the full text of the bill, so I don’t know what other exceptions there are. Stay tuned.

I took a deep breath and wrote a letter, but not the kind they wanted or were expecting.

You see, I have a lot of personal history surrounding both abortion and fetuses, and from where I stand, it’s not so simple. Truth be told, it’s never simple to curtail any life, no matter how tiny or how tenuous.

When I was a 16 year old virgin, in 1970, I was drugged, dragged into a dark basement, and raped so violently that after two reconstructive surgeries my nether parts are still not normal. I ran away, partially because the much older man who did the rapes was then sharing me with his friends and as a young person with Asperger Syndrome I didn’t know what to do, and partially because my mother’s abuse escalated around that time, probably due to my increased vulnerability. I fled from Massachusetts to California, where instead of peace and love I found more rape.

I missed a couple of periods. My breasts were swollen. I had no idea what was going on, since there was no such thing as sex education in the schools at that time, and my parents were phobic about anything having to do with sex. I went to a mobile street clinic and discovered I was pregnant.

Being California, there were choices. I could have the baby and keep it; I could have the baby and give it away; or I could have an abortion. I couldn’t fathom either of the first, so I settled upon the latter.

My pregnancy was past 11 weeks by the time I discovered it. California law required that pregnancies over 12 weeks be terminated in the hospital rather than the clinic because of the different technique necessary and the increased danger of perforation of the uterus. The soonest they could schedule me was in two weeks, at almost 14 weeks of pregnancy.

I’m glad they did it in the hospital, because they knocked me out. All I remember is the OB resident coming to see me afterward in tears, ranting at me about “people thinking they can use abortion as birth control.” I had no idea what he was talking about, or why he was so upset.

Fast forward to 1988.

I was a second year resident in Pediatrics at a big city hospital. My Neonatology rotation included participation on the Perinatal Ethics Committee, which deliberated on matters concerning difficult pregnancies and how to handle them.

There was a woman in her fifth month of pregnancy on the inpatient Obstetrics ward. She was 38 years old and had been pregnant already many times, and had miscarried every time. Her underlying problem was high blood pressure, which prevented proper blood flow to the placenta. She routinely miscarried between 18 and 24 weeks. At that time, and mostly until this day, for specific reasons, 24 weeks was considered the lower limit of fetal viability. Efforts to work around those limits are ongoing, but for the most part not practicable.

But she desperately wanted her baby. The perinatal team knew her well and liked her in spite of her challenges. They felt that if it were technically possible to save her baby, then we had a mandate to do all we could to deliver her a living child.

Now, this lady was no married, upper class, healthy white person. She was black, intellectually disabled, and chronically ill with severe hypertension due to lupus. She was unmarried, lived in a rough part of town, and had a criminal record for theft. In other words, a high-risk prospective parent under any circumstances, and especially for a very premature delivery. What was the prognosis, really, for her to safely and effectively parent a tiny preemie who would, if she survived, need intensive care in the hospital for months and intense home care for years afterward? Not so good. We debated the issue for hours and hours. The lady really desperately wanted her baby, but we were literally not certain we could deliver a viable baby for her, and certainly not a healthy one.

What should we do?

One thing in favor was stress. Normally we think of all kinds of stress as undesirable. We’re always thinking up new ways to combat stress in our lives. But stress is the premature baby’s friend. Stress in utero leads to increased stress hormone production by both mother and fetus, and this speeds the maturation of the fetal lungs. That was one good thing. After the lungs, the greatest challenges are the kidneys, and the skin. In utero, the placenta takes care of fetal waste, but undeveloped kidneys are something we have not learned to adequately deal with on the outside. Likewise, no need for skin inside, but here in the big world, without skin we quickly dehydrate and without its protective barrier, bacteria get in and wreak havoc.

These things don’t finish their development until the middle of the 23rd week. Our job was to keep this lady pregnant until the end of that week, if possible.

The plan was to do thrice-daily ultrasounds of the maternal-fetal circulation. Her problem had historically been that because of her hypertension, her placenta would become calcified, leading to a net reversal of blood flow so that instead of her blood going to the fetus, the blood flow became reversed, so the fetus became starved of oxygen and died. We put her on complete bed rest with high levels of supplemental oxygen, to keep the pregnancy going until that precious 24th week, at least.

In our cutting-edge neonatal ICU we boasted well over 90% survival at 26 weeks, unheard of at that time. That’s because our hospital pioneered the use of pig surfactant, a substance that, when blown into the stiff lungs of a tiny preemie, caused those lungs to become suddenly functional. It was nothing less than miraculous.

(Part of that miracle is that it was discovered by an Orthodox Jewish postdoctoral fellow, who would come into the hospital at all hours to blow a tube of pig lung secretions down a baby’s tube.)

This almost entirely eliminated the biggest barrier to survival of premature babies, the lungs, unmasking the next big challenges, which were and still remain, skin and kidneys. (We don’t have artificial substitutes for either kidneys or skin, but believe me, they’re working on it.) So we knew that if we could get this little girl past that 23rd week, between the stress and the surfactant we’d stand a pretty good chance for having her grow up.

The neonatal team was on call for the moment the blood flow in her placenta reversed. If she made it to 24 weeks, we’d deliver by Cesarian section and then, if she breathed spontaneously or with minimal intervention, we’d go all out. If she did not breathe, we would not intubate her. That was the compromise we worked out.

As it turns out, she never made it to 24 weeks. At 23 1/2, placental blood flow reversed. We had a quick conference and reconvened in the delivery room, where the fetus was removed by Cesarian section and handed off to the attending neonatologist, who happened to be me.

Squirming in the surgical towel they handed me was the tiniest human I have ever seen. I placed her on the scale: 325 grams, about a third of a pound. I’ve had burgers bigger than that! Her eyes were open, and she had all her fingers and toes. She was perfect.

As I laid her very carefully on the cold scale, a hole opened in her tiny face and a huge wail came out! She cried lustily, and I shrugged as I handed her to the NICU nurse.

“She wants to live,” I observed.

“Damn right she does,” said the nurse protectively, placing her in the warm incubator. “Let’s roll!” And they took her to the NICU, where she endured many challenges but never gave up.

I followed her until she was nearly 3 years old, then lost track. She didn’t have it easy. Her mother predictably dropped out of the picture, but her aunt took over and did a great job with her. She never had any of the really disastrous preemie problems (brain bleeds, oxygen toxicity, gut problems, sepsis.) We figured the stress she endured prenatally might have helped. Or maybe, as in the Jewish way of thinking, her soul really, really needed this particular vehicle in order to accomplish its mission.

No matter. After holding that little tiny life in my hand, watching her hang onto that life for all she was worth and actually grow up, there’s no way I’m going to say that a 20+ week fetus does not feel, or is not alive.

The Agony Of Pregnancy Loss

This is going to be another heavy hitter, Dear Readers.  Please consider whether this is good for you to read before proceeding.  It contains graphic descriptions of a miscarriage, surgery, and references to abortion.

I’ve given myself away, but then this is not fiction.

My medical school had an agreement with a VA (Veterans Administration) hospital, where third- and fourth-year medical students could rotate through and get some up-close-and-personal experience being on the front lines.  Rather than standing on a stool (if you were short like me) holding retractors in the operating room, we were taught to actually operate.

And in the medical wing, we learned by doing, and by working closely with the attending physician.  This was much better than standing at the back of a crowd of students, interns, and residents on ward rounds in the private hospital.

I had lots of harrowing adventures at the VA.  I loved it.  Everything was edgy and often dicey.  The patients were high morbidity.  The doctors were all foreign medical graduates, some of whom were the best docs I’ve ever worked with, and some of whom…well, I sure wouldn’t want them working on me.  You just never knew, from day to day, what you would end up in the middle of.

I loved surgery.  Part of that was Dr. Duy, a brilliant Vietnamese surgeon who taught me how to tie one-handed knots down in a hole (in those days, gall bladder surgery was done through an open incision, and you were literally working in a hole up to your wrist).  He taught me how to amputate a gangrenous leg–we had to do that a lot because of the diabetic veterans who were “drinking men” and didn’t take care of themselves.  (That was one of the intake questions:  “Are you a drinking man?”  It was crucial to know, because if he was, if deprived of his alcohol he might go into DT’s and die on us.  For “drinking men,” part of the admission orders were two beers or two shots of rye whiskey per day, more if indicated.)

I dreaded operating with Dr. Chung, a Korean doc who didn’t speak much English and was a clumsy brute compared to Dr. Duy. He did a lot of abdominal surgeries looking for metastatic cancer.  In those days the way you did that was by opening somebody up from top to bottom, and taking biopsies from all the major organs, to send to Pathology.  Then you would stand around in the freezing OR, hugging yourself and jumping up and down until the frozen section came back.  After that you either did or did not take out more stuff, and finally you closed the abdomen and took an x-ray to make sure you hadn’t left anything in there.

My job was to close the abdomen.  There weren’t surgical staples back then, or any of a million conveniences we have now–just a bunch of different sizes of suture material, either dissolving or non-dissolving.

Dr. Chung would walk away, stripping off his gloves, and I knew that I was going to close.  It was no easy task for a small person, especially if the patient was large, pulling the wound together and tying the knots, with nobody to put their finger on it to keep it from slipping.  Yes, it was that simple.

Dr. Chung used to tell me to hurry up and just to make sure I did, he would tell the anesthesiologist to wake the patient up while I was still working!

The reason I’ve gone into all this is: One day I walked into the operating suite and smelled the distinctive odor of halothane gas.  That is what we used in those days as the anesthetic.  I’m sure some or even most of you have smelled that smell.  There is nothing like it.  It triggers my PTSD just thinking about it.

I walked into the OR and asked the scrub nurse, who was scurrying around setting up for the next case, what the deal was with the gas.

“Oh, the anesthesia machine is leaking,” she said in mid-scurry.  “We have a requisition in.”

Uh-oh.  That meant it might get fixed today, or next week, or next month…

So we operated with the doors open.  I tell you, we were all half-anesthetized.  I hope those patients did all right, because I don’t remember a thing.  I spent two weeks half-gassed to death, and then my rotation ended and I could breathe again.

But not the baby I was carrying.  I was married, and this was my first planned pregnancy.  I was 16 weeks along, and I loved the little flutter in my tummy with all my heart.

Then one day, at the end of my surgery rotation, the fluttering stopped.  The bleeding began.

I called my OB doc.  He put me on strict bed rest.  I was torn between being panicked at the prospect of losing my baby, and being panicked because my own OB rotation was supposed to start in a few days.  But the bleeding got heavier, and finally waves of pain had me curled into the fetal position, panting.  Then something warm and wet came out in a gush of blood.

I sat up and looked.  It was a little alien, wrapped in its delicate capsule.  All of it was there.  I could see the tiny limbs, and the beginnings of a face….I wrapped it up in plastic wrap and took it to my OB.  I don’t know what they did with it.

I can’t begin to describe the grief.  I think losing this pregnancy unleashed all the grieving I hadn’t been able to do for the abortion I had suffered 13 years before.  I was overcome, and could do nothing but sob for two weeks.  Then I picked myself up, put on my whites and went to my OB-GYN rotation.

I knocked gingerly on the attending’s office door.  She was the daughter of an OB with whom I had done a rotation as a 3rd year student, and we mutually hated each other.  The daughter was worse than her father.

“Yes, come in,” she said to my knock.  I entered.  She did not offer me a chair.  In fact, she did not even look up from her charting.

“I heard what happened.  It won’t affect your grade,” was all she said.  Then, awkwardly waiting for some other utterance, I perceived that there wasn’t going to be any, so I left her office.

I was met by a nurse in scrubs, who said “Come with me.”  I followed her into a room where a woman was lying on a table, her feet up in stirrups, a stainless steel bucket on the floor between her legs, and what looked like a large suction hose…..

“Go ahead, sit down,” commanded a senior student.  “You’re going to do this one.”  I looked from the apparatus at the bottom of the table to the ashen face of the Hispanic woman at the top…

“Is this what I think it is?” I whispered.  The senior student nodded.  I threw up in the bucket and ran out.  I ran all the way home and collapsed on the bed, hysterical.  My husband came home and found me that way.  It was the only time I ever saw him in a fury.  I know that he went to the dean, because on another occasion when I was stuck holding retractors for the OB father and daughter combo (I had to repeat OB after that episode), they skewered me about my husband going to the dean.

All these years later, I just can’t, in my wildest nightmares, imagine expecting a woman who had just lost a wanted pregnancy, to go on abortion detail.  I know there are many things more cruel than that in this world, but for me, at that moment, I would rather have suffered a horrible death than to perform an abortion.

All the while I was thinking of that woman.  I found out her history, why she was there to get an abortion: she was a Mexican migrant worker, she already had six children, and her husband had threatened to punch her in the stomach if she didn’t abort, because six children was enough for him.  Birth control pills were beyond her reach financially, and her husband refused to use condoms.  So it was she who bore the consequences.

I firmly believe in a woman’s right to control over her own body.  If that includes abortion, who am I to judge?  When Rebecca, who was childless at the time, said “Give me children or I will die!”  Isaac replied, “Am I instead of G-d, that I can give life?  Go and pray!”  I too feel that way:  Am I instead of G-d, who gives life and brings death?  I am just a mortal human, trying to feel my way as best I can.

As it says in Ethics of the Fathers (a Jewish text), “Judge not, lest you also be judged.”

Compassion, Not Judgement, For Girls Like Me

I have been unwillingly sucked into a Facebook conversation with the wife of an old and dear friend.  She loudly condemns abortion, and calls everyone who has had one a “murderer.”

In that case, I guess I am a murderer in her eyes.

At age 16 I was drugged, dragged into a dark, damp basement, and brutally raped.  Then the same rapist started “sharing” me with his friends.  I finally escaped, onto the streets, where I traded my body for food, shelter, and sometimes a five dollar bill.  I was in a state of dissociation that has followed me down the years–45 years, to be exact–as of this coming April 22.

This righteous lady crows that she was also raped, and managed to have her baby, with the help of my friend.

Lucky lady.  I had no friends at the time, nor anywhere to turn.  I was homeless, and knew that my baby would be taken from me by the state if I had her.  I’m sure it was a “her.”

So I took the only path that I could see, and I had an abortion.

It was horrible.  It turned out to be on the the last day of the third month.  It traumatized everyone, including the doctor who did it.  On my follow-up visit to the hospital, he accused me of “having sex irresponsibly and then getting rid of it.”

I could not reply to him.  His judgmental attitude triggered feelings of my mother’s constant judgment and criticism, and it rendered me speechless.  I took his verbal thrashing and went away feeling like a kicked dog, along with the terrible sadness of pregnancy loss.  I had already felt the little flutter of life, I knew I had killed my baby, and I was being castigated for taking the only path open to me.

A few days postoperatively my breasts swelled up and started leaking fluid.  I made a panicked call to the medical resident who had performed the abortion.

“You’re lactating,” he said coldly.  “Buy a tight bra.”

“Lactating.”  I had to look that one up.  “Producing milk.”  Oh no.  More grief, fueled by the physical evidence of no baby.  And I bled profusely, because of the lateness of the abortion.  Money for pads there was none, so I relied on rags ripped from cloth things I found in the dumpsters, that I washed by hand without soap, because there was usually no soap in the public restrooms where I washed my hair in cold water, and rinsed out my underwear when they got too stiff to be comfortable.

“Tight bra?”  I didn’t have money for a 25 cent hamburger, let alone any kind of bra.  So I leaked and ached for a couple of weeks till it went away.

Oh God, those were horrible times.  And yet, they were nothing compared to the abuse that drove me from the parental “home.”

Sure, I could have gone to one of the “homes for unwed mothers.”  One or two of my classmates had suddenly disappeared, only to return several months later, depressed and bereft, stigmatized and avoided.  Our mothers strictly forbade us to socialize with them.  One of them whom I knew well suicided.  I could not bring myself to go that route.

Yes, I had an abortion.  I don’t regret it.  I’m sad about it, always will be, and wonder what would have happened if I had had my baby.  She would have been almost 45 now–what would she be doing?  She would not have had much of an upbringing, if I had kept her the way this lady did.  I had no resources myself.

Nowadays there are many options for girls who get pregnant: open adoptions, where the girl can participate in her child’s life, and in the adoptive parents’ lives, almost like another child in their family.  There is foster care, which can help a girl grow up while her baby is in a safe place (usually!).  There are many programs that support pregnant teens with educational and job skills while they complete their pregnancy, so that they can support themselves and their baby and not be dependent on their own families or the state for sustenance.  And of course there are the many grandparents–more grandparents than birth parents are willing to help their grandchildren through an accidental pregnancy and with helping to raise the child, for multiple reasons.

So I ask, don’t judge me for the decision I made as a child.  What I need is compassion.  Even if you are vehemently against abortion for your own reasons, and would never have an abortion in your own life–please be kind to those who are in desperate straits, and choose abortion because that is the only avenue they can see at the time.

Labels and Identities, Part Three (and then some)

I loved medical school so much that I was never even aware of the fact of “being a medical student.” I was too busy being it it, doing it, loving it, being in love with it.

Nevertheless, I had a sense of solidity that I had never experienced before. With my dual degree program came huge financial commitments, and great opportunities. I applied for and got many kinds of grants and fellowships, some as large as $10,000 and some as small as $300. They all added up, and each one was a feather in my cap.

There were jobs, too. The first years were a patchwork of lab jobs, hospital grunt work, general go-fer gigs for the administration. Then I settled into my niche of tutoring and educational program development. I helped design and implement a model of teaching medical communication skills to new doctors, and a testing tool to evaluate its effectiveness. Faced with an embarrassingly inadequate human sexuality module in our med school, I complained, and was given the green light to develop the ideal one. Med school was “heaven on a stick,” to borrow a phrase.

My marriage surpassed any expectations I could have had, if I was the type to have expectations, and I’m not. I could never have imagined the satisfaction that bloomed from the cultivation of cooperation and intimacy between two people in love with each other and with their respective and mutual work, for we shared certain teaching and administrative duties in the school. We were a team. We were even asked to write an article for the medical school journal on the art of cooperation and compromise.

I got pregnant during the fourth year of my six year program. It was not overtly planned. But since we were using the Cooperative Method of Fertility Awareness Family Planning (another of my hats, since I was a certified teacher and taught in the Student Gynecology Clinic) which required both partners to be clearly aware of where the woman is in her fertility cycle, we KNEW I was fertile and the predictable outcome did in fact result. It took us both a few minutes to get used to the idea, and then we were elated.

I was in the midst of a long subinternship in surgery at that time. A subinternship is just like an internship, except you don’t get paid. You work the same long hours, take the same night call, have the same responsibilities as an intern. Our med school supplied students to a chronically understaffed VA hospital, and there were many excellent subinternship opportunities there. It really was a great thing to do as a student in surgery. At the private hospitals, the best a medical student could hope to do in surgery was stand on a stool at the back of a crowd hoping to get a look at the surgeon working. If you were really lucky, you might get a turn holding retractors, which meant you could actually see the operation in progress.

As a subintern at the VA, I worked one on one with each of two foreign doctors. Dr. Duy was a marvelously skilled Vietnamese surgeon, French trained, with nimble fingers and a gift for teaching. The first day, he taught me how to tie surgical knots one-handed with both my right and my left hand. I still use some of the skills he gave me, even though I haven’t done surgery in more than ten years.

The other surgeon was a North Korean. He was a coarse brute who caused unutterable pain and suffering. I don’t remember his name, thank G@d

My jobs included assisting the surgeon in the evaluation of the patient, preparing the operative site, and if it was an abdominal surgery, opening the abdomen and preparing the operative field. After the surgeon had finished in the abdomen, my job was to close the layers of the abdominal cavity and finally the skin. We had a grumpy old anesthetist: if he thought I was taking too long sewing the patient up, he would “lighten up” the anesthesia so that the patient would start to cough. The old bastard.

One morning I went into the operating room and found the doors propped open. “What’s this?” I asked the nurse. “Why are the doors propped open?”

“We’ve got a leak in the anesthesia machine,” she told me. “Until they get it fixed we’re gonna have to operate with the doors open.” Oh, I though, this way we’ll only be half as anesthetized as the patients.

I inhaled Halothane along with everyone else for the next four weeks. And then, one week after I finished that rotation and went on to the next one, I miscarried. I was ten weeks along.

I had no idea how attached I had grown to that little nubbin of life that was growing inside me. I absolutely fell apart. I couldn’t function. The clinical rotation I had just started was, of all things, Obstetrics and Gynecology. I couldn’t set foot on the ward for a week after the miscarriage. I just lay in the bed and cried.

The dean ran interference for me and spoke to the OB/GYN director, who was a woman. She was the daughter of the senior OB/GYN in that town, and had joined her father’s practice. She had a strong academic background, loved power, and used it freely.

When I finally got my feet back under me I made an appointment to speak with her, for I had already missed the whole first week of my eight week rotation. I knocked on her door.

“Come in,” she called. I entered the sleek wood office. She sat writing at an expansive desk. “I heard what happened,” she said, not bothering to raise her head and look at me. “It won’t affect your grade.”

I waited for whatever came next, but it never came, so I waited some more, not knowing what she expected of me.

“You can go now,” she said to her desk, still scribbling, “The nurse will give you your assignment.”

I wandered back out into the hall, feeling very unsure of myself, and was greeted by a large and cheerful nurse who ushered me down a hall and into a clean green room whose only features were a GYN exam table, an exam light, a wheeled stool, a kick bucket (the kind on wheels that you position with your feet, that’s why it’s called a “kick bucket”), and a room divider screen, with whatever was behind it.

Not too long afterwards, the door opened again and the same nurse brought in a gowned woman, and asked her to make herself comfortable on the table. The nurse positioned the woman and left her alone with me. There was an awkward silence, since we had not been introduced.

Five minutes later the door opened again, and this time it was Dr. S. and an entourage: an intern, a resident, and another medical student. Dr. S. began to talk to the woman on the table, and intermittently explaining a thing or two to the entourage. I felt like a ghost, since no one had acknowledged my existence since the nurse had put me in there to begin with.

Next thing I knew, objects were being retrieved from behind the room divider. A tray with sterilized instruments on it. And a machine that looked like….a vacuum. It was a vacuum. For performing abortions. My stomach contorted. I begged pardon, and stumbled from the room, under the searing glare of Dr. S……