I meet her in an ultrasound room. The doctor in charge today told me a little bit of my patient’s back story.
She is 36 years old, and 27 weeks pregnant, which makes her a “high-risk pregnancy” because of “advanced maternal age.” You get this tag when you’re 35 or older. We’re the same age. I’ve thought about another child, about trying again for that little girl, a feeling strengthened over the past month of studying obstetrics as new and perfect lives pass through my hands. So it’s this I’m thinking about as I get ready to watch another mom prepare for her new arrival.
Ultrasounds are mostly fun. This late, you get to see so many details and pictures are part of the journey. They end up in albums, in frames, on Facebook walls. This time, the ultrasound is happening because when she went to her OB appointment this morning, the baby’s heart rate was slower than it should have been.
The first view is of limbs, feet. Perfect. Beautiful.
The tech adjusts the probe, bringing the chest into view. I can see the heart suddenly. The probe is set to capture heart rate, the pulsations appearing as little waveforms along the bottom of the screen.
Two things strike me at once: The rate is much too slow, worryingly slow, and the heart itself is all wrong.
I’m just a fourth-year medical student. I have so little training and experience at this point, and even I can see a problem. The heart is too big, taking up too much space, with too many parts. As she scans up, I can see an enormous growth, distorting the heart’s shape, taking up spaces where the lungs belong. I force myself to hold still, to be silent. I force myself not to cry. I clamp down my jaw hard because this is not my tragedy. This is someone else’s, and she doesn’t even know yet.
The ultrasound tech keeps chatting, a superhuman feat, I think. She takes pictures. Then she goes to get the doctor, the maternal fetal medicine specialist who deals in high-risk pregnancies. Dr. Smith sees it all, carries this weight of knowing. Of having to say the unsayable.
She sits down, smiles, says she’s going to take another look. More pictures. More examination. A measurement of the heart rate for the official chart. It is getting worse.
The doctor cleans up the patient’s belly, wiping away the gel with the towel. She helps her patient sit up, and tells her to finish dressing and come across the hall to her office.
The couple come into the room slowly, almost clumsily in their hesitation. They know they are going to hear something bad. They don’t want to hear it; they want to get it over with.
Dr. Smith invites them to sit. She asks what they know right now. This is a typical way to start with bad news. Find out what the patient knows, clear up any misunderstandings, move on with clarifying information.
They met “late” they say, but they want babies together. They want this baby. The day the pregnancy test showed two pink lines was the happiest day of their lives.
Dr. Smith starts with the heart rate. She explains it is too slow, that if this continues it would cause problems with the baby’s growth. She picks up one of the ultrasound pictures and points to the heart, to the lungs, and she names them. But here, she says, and uses her pencil to sketch out the outline, this isn’t supposed to be here, this is a tumor.
The shock on their faces is clear. Mom’s eyes widen as she looks at the circled area. “It is so big …” she trails off.
The doctor pulls another picture out and places it beside the first one. “Here,” she draws another circle, “this is where lung should be, but instead the tumor is taking up that space.” She stops. They continue to stare at the pictures.
The dad pulls up courage first. “Can this be removed? I mean, I know they do heart surgery on babies when they’re born …”
Dr. Smith explains that the damage is so profound it would be hard to reconstruct the heart, even if the lungs were OK. But they aren’t. They are barely there. There is not enough of them to sustain life, even if the baby made it another 14 weeks.
“But I don’t think he will live that long” she says. “His heart is already failing, that is why it is so slow. And it is slower now than it was at your appointment a couple hours ago.”
There is a long silence. The mom speaks this time. “What are my options?”
So here we are, with the question that men in suits want to answer for her with a surety that they understand every situation in which this question could be asked.
The first option is to do nothing. To wait. To let nature take its course. It will probably only be a couple of days, but it is hard to be absolute about these things.
Women in this situation can opt for a surgical abortion, if they can find a hospital to perform it, or labor can be induced, which will amount to the same thing.
They talk about the risks of all the options. In the end, she chooses induction. She is lucky in some ways, because this hospital is in a state where this is allowed. Many states prohibit abortion this far along. Some women travel many states away for procedures in this situation, procedures which can cost tens of thousands of dollars. She is lucky because in many countries this is not allowed at all. Women die waiting for miracles that don’t happen.
She is shown to the maternity ward and given medication to soften her cervix and allow dilation, a necessary step because labor is something her cervix would not be preparing to do for another three months. Early the next morning, the heartbeat is slower, skipping some beats, clearly failing. An IV placed in her arm administers the pitocin drip to make her contractions start.
During these hours, I come in and out of the room, checking on her between other patients, offering something to drink, encouragement, conversation. I hold her hand when she cries. Her husband stays by her side, mostly silent, dabbing at his eyes with an increasingly soggy tissue. The tissue box empties. I bring another. I step into the bathroom to wipe my own eyes. Dr. Smith comes by, and leaves crying as well.
The fetal heart stops shortly before she delivers. When he is born, he is wrapped up in a blanket, fitted with a doll’s hat. They spend time together as a family. A photographer is offered for pictures.
This is one of the ways a “late-term” abortion happens. A fairly common way, and for the most common reason, because the developing fetus would not have survived outside of the womb. “Late term” appears to confuse people, and lead to the erroneous assertion that viable fetuses, those who can survive outside the womb, are being killed.
This is not the case. Only 1.3 percent of abortions are performed after 20 weeks (halfway through a pregnancy). Far fewer, 0.08 percent, happen after 24 weeks, the age of viability where the fetus might survive outside the womb. Extremely rarely this may be as late as 36 weeks in the cases of anencephaly (where the fetus develops without a head) or other severe and fatal defects.
Sometimes a woman may terminate a pregnancy after 20 weeks when her life is in danger. Pre-eclampsia is an often deadly condition that forces a premature end to pregnancy. Delivering the baby is the only way to resolve the condition. If the fetus can be saved, it will be. There is never a point where this isn’t considered.
A cancer diagnosis is another situation that can force this heart-wrenching decision. Many chemotherapies are toxic to a developing fetus, so early deliveries are planned. Eight weeks into a pregnancy, the prospect of waiting until the fetus is viable may present a death sentence for the mother. In these cases, an early abortion is the safest choice.
There are many details for each unique situation, and I have glossed over only a few examples, which brings us to my point. These are complicated choices.
Abortion has become an ugly word hurled between people at opposite ends of a spectrum of belief. Some feel abortion is a sin and should never exist. Some feel it is a right and should be freely accessible.
Here’s something that gets talked about less. Nobody loves abortion. Many people feel intensely uncomfortable with the idea, and most of us are deeply sad at the loss. Nobody thinks it should be the way we control our reproductive potential. Even the most staunch supporters of the right to choose, and I am one of them, wish and work for alternatives.
There are proven ways to decrease the number of abortions that are performed. Shaming women doesn’t work. Cutting access doesn’t work. Preventing unwanted pregnancy through comprehensive sex education and readily available contraception works. Offering support and resources to women who need them works.
I cry when I remember the story I just related. I recall the tight clench of the woman’s hand during her contractions, the tears streaming down her face. I remember escaping to the bathroom because I needed a break from bearing witness.
In today’s political climate, parents like those in this story live with memories they cannot share without fear of judgement. Not only do they lose something precious, they are silenced by fear and shame. Instead of the support they deserve through a time of terrible loss, they will receive condemnation for doing the best they could in an unspeakable situation.
Dr. Tobin Moon Carson is a family medicine-trained doctor of osteopathic medicine practicing in New York. She is a Farmington native and graduate of the University of Maine at Farmington and University of New England. This essay is memory of an experience from her medical training.