Fifteen years after Roe vs. Wade, second trimester abortions were still considered pariah, yet performed daily at the University Hospital of Somewhere Else. After about 12 weeks gestation, a “simple” vacuum suction procedure to end an unwanted pregnancy became too dangerous-the softening, enlarging walls of the uterus could be accidentally gored all too easily by the suction cannula, with serious or possibly even fatal results to the pregnant woman.
The procedure for pregnancies beyond this time frame and up to the no-man’s-land of about 20 weeks gestation was to soften the mouth of the womb with hormonal gel, and induce labor with Pitocin, in order to deliver a pre-viable fetus. The procedure began in the afternoon and took many hours. Most patients delivered in the wee hours of the night, and the women, devoid of the fruit of their troublesome fertility, were usually ready to be discharged to home in the morning.
So distasteful was this procedure to most of the medical staff that it fell to the most junior, least-likely-to-protest medical doctors to perform. Namely, these were the six first year OB-GYN residents, the interns, who were also in charge of caring for and delivering the at-term laboring mothers in Labor and Delivery, one floor above the ward where the abortions were performed. Four of the new OB-GYN residents (two of whom were previously known to be secular in outlook) claimed religious objections. Despite suspicions that for at least for two of those residents, concerns about extra work and lack of sleep played as big a role as moral qualms, the task fell to the remaining two interns, of which I was one. My one barely-willing coworker and I were on duty for all the scheduled “terminations” on each of our every-third-night “calls” (36 hour shifts).
The procedures were onerous beyond the obvious. The hormone gel and labor caused pain and vomiting, and these patients needed anti-emetics, narcotics, and periodic checks. Once the fetus had emerged, the immature placenta tended to stick to the inner wall of the womb, unlike the “afterbirth” at term deliveries. Every bit of this clinging organ had to be removed, manually if necessary, as any leftover tissue could cause delayed infection or serious bleeding. More pain, more distress for patient and doctor. Finally, it was the intern’s job to collect the pre-viable fetus and placenta and package them for the pathologist in what looked like a Kentucky Fried Chicken bucket and lid. Add to this the fact that there were usually three to seven abortions performed per “call” to be juggled along with the nightly circus of the Labor and Delivery ward-the latter being the intern’s main responsibility-and you can understand why we hated this duty.
Despite the physical awfulness of the procedure for the patient, we were amazed to find that some women requested this service multiple times; a few of these merry-go-round women seemed to regard the procedure both as “birth control” and a physically-painful but necessary inconvenience, like a root canal. Nothing indicating that the abortion was more significant than this was apparent in their demeanor.
That attitude, though incredibly disquieting, was not the norm. The rest of the patients were a mixed bag: Many were teenagers, either unaware of their missed periods or denying their absence. Most were women on state-supported Medicaid, who often applied for an abortion at 8-10 weeks, but due to administrative delays, did not receive approval for payment of the procedure until they were farther along than the “safe” 12-week cut-off for a first trimester abortion. A tragic last category, the only women in my experience to come accompanied by mate and/or family, were those that were aborting a fetus with some serious birth defect detected by prenatal testing. These families were much harder on the staff than even the “merry-go-round root-canal” women, as we couldn’t distance ourselves with dark humor from a grieving family’s plight and sorrow.
On the afternoon of one long “call” day, I admitted a woman from category number three- A Medicaid-delayed abortion. Her name was Maya Miller. She was 15 weeks as assessed by a minimal-quality out of hospital ultrasound. She had discovered her contraceptive failure relatively early, and filled out the requisite paperwork in good time, but approval had just now come through.
Maya had her first child at 17, and her second at 19. Now, at 24, she had just about managed to dig herself and her small family (2 boys, aged 7 and 5 plus her widowed mother) out of the hole that her early fertility had plunged them into. First, she achieved a GED, then completed cosmetology school on the back of her part-time waitressing while Grandmom watched the boys. After several years of Hair Flattery, (“That’s where you learn the real skills, doc, they just give you the basics in beauty school,”) she was noted by the owners to have a real flair for hair and given encouragement. Just before she became pregnant, she had interviewed for and landed a job in an upscale salon in Fells Point. This was the break she’d been working towards. More hours, better tips, health insurance. She could get off Medicaid on the first of this upcoming January. This pregnancy was ill-timed. Her current boyfriend was not interested in becoming a father of one child, much less three.
“He just hasn’t got the stones for it. Now he’s history, my boys deserve better. You know, doc, as much as I love my boys to death, I always wanted a girl, dreamed of doing her hair, little dresses…When the approval ran so late, I thought hard about having this baby too…but I ran the numbers again and again. There’s just no way. There’s not enough money. I can’t give up this job and wind up on welfare forever. My mom isn’t that healthy, she has diabetes. I just can’t ask her to watch three, and the cost of daycare… One more child would sink us all.”
She seemed forthright, smart, and sure. I felt less despair about this woman’s situation and her likely life outcome than I often did. I examined her, counselled her on what to expect, and started the procedure.
When I checked on her at nightfall, she was beginning to become uncomfortable. I asked the nurses to administer some Demerol and I checked her progress. As I was advising her to try to get some sleep while the medicine was in effect, I noticed she’d put a pocket-sized picture of her two boys, clad in peewee soccer uniforms, next to her emesis basin on the chipped bedside stand.
That night turned out to be a busy one for me- five second trimester terminations, eight women in labor “on the board” in Labor and Delivery. I lost count of how many times I bolted up or ran down the stairs. By 3 a.m I was exhausted .
When I got the call from the nursing station on the 15th floor: “Bed 1505 delivered,” I wasn’t even sure which abortion patient I would be seeing. I entered the quiet, darkened room. The only light came from behind the half-ajar bathroom door from a bare bulb over the tiny sink. As I approached the bed, I made out a half-sitting figure, knees bent and slightly parted, with a still, doll-like form prone on its stomach on the blanket in between the woman’s legs. The fetus look large to me, likely 17 or even 18 weeks. Had I admitted an 18-weeker this afternoon? I hadn’t thought so, but the outside ultrasounds weren’t always so accurate. I sat on the bedside, gently laid a sterile towel over the disturbingly well-formed fetus and visually followed the umbilical cord up to where it disappeared into the women’s introitus.
“Ok, I said, “It’s almost over. Are you ok?”
“I’m bleeding.”
“Yes, but not too much, you are okay. I need to get the afterbirth out. This may hurt some, so I’m going to have the nurse come in and give you some more pain medicine.”
It was painful, but I was by now expert, and it was quickly over. The nurse exited the room. As I gathered up the lifeless fetus and the afterbirth my patient asked sleepily, “Can you tell what it is?”
Without thinking, I flipped the tiny form over in my palm, where it lay supine. “It’s a girl.”
Instantly, my nearly-dozing patient was alert and sobbing, rising up in the bed.
“Oh, no, oh God no! A girl? My girl, it was my girl! My God, what have I done?” The patient was Maya Miller.
My heart felt like a fist in my chest. I cursed myself for my stupidity and inadvertent cruelty. I had forgotten. I hadn’t registered that this was Maya Miller’s room, and I had let slip from my mind what she had said during her intake exam.
What could I do? I held her, despite my bloody gloves, and whispered the best things I could think of.
“You are making sure your boys are okay, right? They need you, you did this for them, right? You must think of the children you already have. You have to be brave for your sons. You are doing right by them.”
She slowly calmed, sniffled, wiped her eyes. She showed me the picture on the institutional nightstand. I admired their boyish faces out loud and at length. Finally, I left. At 4:30 a.m. I stopped by her doorway to make sure she was asleep.
At 6:30a.m., she was already up, washed, and halfway dressed when I came to round on her. I asked her to wait while I briefly examined her, gave her the post-procedure instructions, prescriptions, paperwork. Her eyes were dry, and her mouth was set.
“How are you?” I asked, dropping the “doctor” tone, and looking her in the eye.
“I just don’t know,” she replied, looking down at her hands, “I was sure this was what I had to do, but now…”
“You are thinking of your boys, and your Mom, and the life you want for all four of you. That’s the right thing to be thinking of now. And you need to think of yourself, of course. In your papers are the names of some good people you can talk to about this, if you need to or want to. And for what it’s worth, I think you are incredibly brave.”
“Brave?” She shook her head, laughed shortly, “I don’t feel brave, I feel…like someone I love has died.”
Maya Miller gathered her things and left the room, head up, eyes front.
I don’t know what happened to Maya Miller, but I know what happened to me. I left my residency five months into my internship year. I cannot say that performing second trimester abortions harmed me nor that they were the main factor that led me to leave the field of OB-GYN forever.
However, I do know that throughout medical school and during my aborted internship I spent too much time, with too little sleep, in my own kind of no-man’s-land. I saw things, did things, felt things that had me wondering who I was, who I was becoming. Somewhere amid my travails in the abortion ward, Labor and Delivery, the ICU, the Emergency Room, the Operating Room and the hospital parking lot, boundary conditions claimed me. As sometimes happens to medical folk, I became lost in a shadowy neverland between wrong and right, immoral and moral, death and life, culpability and blamelessness, decision and regret.
So, I feel a kinship with Maya Miller, and wish her well, no matter what she chose, or how she chose to live with it. I too have made impossible decisions and wrestled in the aftermath with incalculable regret.
Paula Lyons, MD
8/13/2018