Intact dilation and extraction (D&X, IDX, or intact D&E) is a surgical procedure that terminates and removes an intact fetus from the uterus. The procedure is used both after miscarriages and for abortions in the second and third trimesters of pregnancy. When used to perform an abortion, an intact D&E can occur after feticide or on a live fetus.
In the United States, where federal law describes an intact D&E on a live fetus as a partial-birth abortion,Gonzales v. Carhart550 U.S. ____ (2007). Findlaw.com. Retrieved 2007-04-30. the procedure is uncommon. The 2003 federal Partial-Birth Abortion Ban Act, which was upheld by the Supreme Court of the United States in the case of Gonzales v. Carhart, outlaws an intact D&E of a fetus with a heartbeat under most, though not all, circumstances.
Indications As with non-intact D&E or labor induction in the second trimester, the purpose of D&E is to end a pregnancy by removing the fetus and placenta. Patients who have a fetus diagnosed with severe congenital anomalies may prefer an intact procedure to allow for viewing of the remains, grieving, and achieving closure. In cases where an autopsy has been requested, an intact procedure allows for a more complete examination of the body.
An intact D&E is also used in abortions to minimize the passage of instruments into the uterus, reducing the risk of trauma. It also reduces the risk of cervical lacerations that may be caused by the removal of bony parts from the uterus and the risk of retention of fetal parts in the uterus such as brain matter and tissue.
Procedure As with non-intact D&E, intact D&E may be performed in freestanding clinics, ambulatory surgical centers, and in hospitals. Intra-operative pain control is usually dependent on the setting and patient characteristics but commonly involves local analgesia with either IV sedation or general anesthesia. Preoperative antibiotics are administered to reduce the risk of infection. In cases where the woman is Rh-negative, Rho(D) immunoglobulin (RhoGam) is administered to prevent the risk of developing erythroblastosis fetalis (hemolytic disease of the newborn) in subsequent pregnancies. Intact D&E is more feasible among women with higher parity, at higher gestational ages, and when cervical dilation is greater. There are no absolute contraindications.
Cervical preparation The surgery is preceded by cervical preparation, which may take several days. Osmotic dilators, natural or synthetic rods that absorb moisture from the cervix, are placed in the cervix and mechanically dilate the cervix over the course of hours to days. Misoprostol can be used to soften the cervix further. Intact D&E can only be performed with 2–5 centimeters of cervical dilation.
Fetal termination Fetal injection of digoxin or potassium chloride may be administered at the beginning of the procedure to allow for softening of the fetal bones or to comply with relevant laws in the physician's jurisdiction and the U.S. federal Partial-Birth Abortion Ban Act. Umbilical cord transection can also be used to induce fetal demise prior to removal.
Removal of fetus and placenta During the surgery, the fetus is removed from the uterus in the breech position. If the fetal presentation is not breech, forceps or manual manipulation can be used to turn it to a breech presentation while in the uterus (internal version). The fetal skull is usually the largest part of the fetal body and its removal may require mechanical collapse if it is too large to fit through the cervical canal. Decompression of the skull can be accomplished by incision and suction of the brain or by using forceps to collapse the skull.
Recovery Recovery from an intact D&E is similar to recovery from a non-intact D&E. Postoperative pain is usually minimal and managed with NSAIDs. In cases of uterine atony and corresponding blood loss, methergine or misoprostol can be given to encourage uterine contraction and achieve hemostasis. Patients who have recently undergone an intact D&E are monitored for signs of coagulopathy, uterine perforation, uterine atony, retained tissue, or hemorrhage.
Complications The risks of intact D&E are similar to the risks of non-intact D&E and include postoperative infection, hemorrhage, or uterine injury. Overall, the complication rate is low, with rates of serious complications (those requiring blood transfusion, surgery, or hospital treatment) ranging from 0 per 1,000 cases to 2.94 per 1,000 cases. The rate of minor complications is approximately 50 in 1,000 (5%), the same as the minor complication rate for non-intact D&E; the rate of serious complications is higher in non-intact D&E.
Data directly comparing the safety of non-intact to intact D&E are limited. There is no difference in postoperative blood loss or major complications when compared to non-intact D&E. There is no difference in risk of subsequent preterm delivery. The risk of retained tissue is lower since the fetus is removed intact.
In some cases, the physician may not be able to remove the fetus intact due to anatomical limitations. This may present a psychological problem for the patient who wishes to view the remains, or make a comprehensive autopsy impossible, precluding an accurate postmortem diagnosis of fetal anomalies.
Society and culture
United States politics The term "partial-birth abortion" is primarily used in political discourse—chiefly regarding the legality of abortion in the United States.. religioustolerance.org. Accessed April 14, 2006. The term is not recognized as a medical term by the American Medical AssociationHealth and Ethics Policies of the AMA American Medical Association. H-5.982 Retrieved April 24, 2007. nor the American College of Obstetricians and Gynecologists.ACOG Files Amicus Brief in Gonzales v. Carhart and Gonzales v. PPFA September 22, 2006 The American College of Obstetricians and Gynecologists. Retrieved April 25, 2007. This term was first suggested in 1995 by Congressman Charles T. Canady, while developing the original proposed Partial-Birth Abortion Ban.Alex Gordon. "The Partial-Birth Abortion Ban Act of 2003". Harvard Journal on Legislation. Volume 41, Number 2, Summer 2004. (see footnote 15)H.R.1833. To amend title 18, United States Code, to ban partial-birth abortions . According to Keri Folmar, the lawyer responsible for the bill's language, the term was developed in early 1995 in a meeting among herself, Charles T. Canady, and National Right to Life Committee lobbyist Douglas Johnson.Gorney, Cynthia. Gambling With Abortion. Harper's Magazine, November 2004. Canady could not find this particular abortion practice named in any medical textbook, and therefore he and his aides named it.Adam Simon, “Elite Discourse, Programming and Survey Response in the Partial Birth Abortion Debate ” (March 2003). "Partial-birth abortion" was first used in the media on June 4, 1995, in a Washington Times article covering the bill.
In the U.S., a federal statute defines "partial-birth abortion" as any abortion in which the life of the fetus is terminated after having been extracted from the mother's body to a point "past the navel [of the fetus]" or "in the case of head-first presentation, the entire fetal head is outside the body of the mother" at the time the life is terminated. The U.S. Supreme Court has held that the terms "partial-birth abortion" and "intact dilation and extraction" are basically synonymous.Gonzales v. Carhart, 550 U.S. ____ (2007). Findlaw.com. Retrieved 2007-04-19. However, there are cases where these overlapping terms do not coincide. For example, the intact D&E procedure may be used to remove a deceased fetus (e.g., due to a miscarriage or feticide) that is developed enough to require dilation of the cervix for its extraction.Gonzales v. Carhart, 550 U.S. ____ (2007). Findlaw.com. Retrieved 2007-04-30. ("If the intact D&E procedure is truly necessary in some circumstances, it appears likely an injection that kills the fetus is an alternative under the Act that allows the doctor to perform the procedure.") Removing a dead fetus does not meet the federal legal definition of "partial-birth abortion," which specifies that partial live delivery must precede "the overt act, other than completion of delivery, that kills the partially delivered, living fetus."U.S. Code, Title 18, Part I, Chapter 74, Section 1531, "Partial-birth abortions prohibited."
In addition to the federal ban, there have also been a number of state partial-birth abortion bans. There, courts have found that state legislation (rather than federal legislation) intended to ban "partial-birth abortions" could be interpreted to apply to some non-intact dilation and evacuation (D&E) procedures. Non-intact D&E, though performed at similar gestational ages, is a fundamentally different procedure.
Controversy Some people believe the D&E procedure illustrates that abortion, and especially late-term abortion, is the taking of a human life and therefore ought to be illegal. People who believe this consider the procedure to be infanticide,Koukl, Gregory. Partial-Birth Abortion Is Not About Abortion . Stand to Reason. Accessed April 25, 2006.White, Deborah. Pros & Cons of Partial Birth Abortions About.com. Accessed April 25, 2006. a position that many in the anti-abortion movement extend to cover all abortions.The Official Point of View of the Romanian Orthodox Church on Abortion (summary) . The Romanian Patriarchate. Accessed April 25, 2006.Achacoso, Jaime B. A Sin and a Crime Catholic.com. Accessed April 25, 2006.Gonzalez, Ramon. Pro-life teens challenged Western Catholic Reporter. October 23, 2000. Accessed April 25, 2006. Some advocates, both for and against abortion rights, see the intact D&E issue as a central battleground in the wider abortion debate, attempting to set a legal precedent so as to either gradually reduce or gradually increase access to all abortion methods.Slippery Slope: Democratic Wavering in the Battle for Reproductive Rights . PERRspectives.com. February 25, 2004. Accessed April 25, 2006.Strategic Initiatives The Rockridge Institute. Accessed April 25, 2006.
Dr. Martin Haskell has called the intact D&E procedure "a quick, surgical outpatient method" for late second-trimester and early third-trimester abortions.Haskell, Martin. Dilation and Extraction for Late Second Trimester Abortion . Presented at the National Abortion Federation Risk Management Seminar, September 13, 1992. The Partial-Birth Abortion Ban Act of 2003 describes it as "a gruesome and inhumane procedure that is never medically necessary."108th Congress, 1st Session, S.3. Partial Birth Abortion Ban Act of 2003.
According to a BBC report about the U.S. Supreme Court's decision in Gonzales v. Carhart, "government lawyers and others who favour the ban, have said there are alternative and more widely used procedures that are still legal - which involves dismembering the fetus in the uterus." An article in Harper's magazine stated that, "Defending the Partial-Birth Abortion Ban... requires arguing to judges that pulling a fetus from a woman's body in dismembered pieces is legal, medically acceptable, and safe; but that pulling a fetus out intact, so that if the woman wishes the fetus can be wrapped in a blanket and handed to her, is appropriately punishable by a fine, or up to two years' imprisonment, or both." Alternately, opponents of abortion rights frame the issue as one in which a partially-born infant's life is disposable, whereas pulling the infant only a few more inches down the birth canal automatically transforms it into "a living person, possessing rights and deserving of protection." The U.S. Supreme Court has stated that intact D&E remains legal as long as there is first a feticidal injection while the fetus is still completely inside of the mother's body.