Intact dilation and extraction - Definition and Overview

Intact dilation and extraction is an abortion technique in which the patient's cervix is dilated and fetus extracted in substantially one piece. The term "dilation and extraction" or "D&X" was coined in 1992 by Dr. Martin Haskell, who developed the procedure as an alternative to dilation and evacuation or D&E (see below). Slightly later, the term "intact dilation and evacuation" was proposed by Dr. James McMahon. The term "intact D&X" was later settled upon by combining elements of both proposals.

Surgical Process

Although the images are almost always sensationalized or emotionally manipulated, the actual procedure of the minor surgery is relatively simple.

After preliminary procedures and administering appropriate hormones to induce the process of labor, the doctor uses an ultrasound and forceps to take hold of the fetus' leg. The fetus is turned, if necessary, and pulls the leg out of the canal. At this point, pro-life advocates say, the baby is 'partially birthed' - thus the controversial name for the procedure. The doctor subsequently births the rest of the baby, usually without the aid of forceps, leaving only the head still inside the birth canal. With sufficient force, the doctor inserts scissors into the base of the back of the skull. The doctor spreads the scissors to widen the opening, and then inserts a suction catheter. The brain tissue is removed, allowing the rest of the fetus to pass easily.

The collapsing of the brain is the major reason why physical deformities of the fetus' head prompt pro-choice advocates to defend the procedure as medically necessary, saying it's the only way to birth the fetus. The pro-life opponents say that caesarean section can birth the fetus.

Since the procedure is so widely disputed, here is how both a pro-choice and pro-life group describes it. This is to ensure that bias is given to neither political side, only to the scientific process involved. Neither description is untrue in what it says, only manipulative in how it is said.

Planned Parenthood Description

Dilation and Evacuation

Dilation and evacuation (D&E) is performed in two steps.

The first step of a D&E involves cervical preparation (softening and dilation).

The vagina is washed with an antiseptic.

Absorbent dilators may be put into the cervix, where they remain for several hours, sometimes overnight. Misoprostol may also be used to facilitate dilation of the cervix.

During the second step of a D&E

The woman may be given medication to ease pain and/or prevent infection.

A local anesthetic is injected into or near the cervix. General anesthesia can also be used.

The dilators are removed from the cervix.

The fetus and other products of conception are removed from the uterus with surgical instruments and suction curettage. This procedure takes about 10-20 minutes.

National Right to Life Description

Partial-Birth Abortion

Abortionists sometimes refer to these or similar types of abortions using obscure, clinical-sounding euphemisms such as "Dilation and Extraction" (D&X), or "intact D&E" (IDE) which mask the realities of how the abortions are actually performed.

This procedure is used to abort women who are 20 to 32 weeks pregnant -- or even later into pregnancy.* Guided by ultrasound, the abortionist reaches into the uterus, grabs the unborn baby’s leg with forceps, and pulls the baby into the birth canal, except for the head, which is deliberately kept just inside the womb. (At this point in a partial-birth abortion, the baby is alive.) Then the abortionist jams scissors into the back of the baby’s skull and spreads the tips of the scissors apart to enlarge the wound. After removing the scissors, a suction catheter is inserted into the skull and the baby’s brains are sucked out. The collapsed head is then removed from the uterus.

Circumstances in which the procedure is performed

Intact D&X procedures are extremely rare, carried out in roughly 0.2% (two-tenths of one percent) of all abortions in the USA. According to the Alan Guttmacher Institute there were 1,310,000 abortions (2000) which would put the figure of Intact D&X somewhere between 2500 and 3000. They are performed during the third trimester of pregnancy for various reasons, such as:

• The fetus is dead.
• The fetus is so malformed that it can never gain consciousness and will die shortly after birth.
• The fetus is alive, but continued pregnancy would place the woman's life in severe danger.
• The fetus is alive, but continued pregnancy would grievously damage the woman's physical health and/or disable her.
• The fetus is alive, but the woman wishes to end her pregnancy for mental health reasons.

Some of the fetuses which fall into this category have developed hydrocephalus, a treatable condition since 1952 that has made good progress in recent years. Approximately 1 in 2,000 fetuses develop hydrocephalus while in the womb; this is about 5,000 a year in the United States. The defect is not usually discovered until late in the second trimester of pregnancy. If a fetus develops hydrocephalus, the head may expand to a size of up to 250% of the radius of a normal newborn skull, making it impossible for it to pass through the cervix. In such a case, the physician may elect to perform an intact D&X procedure by draining off the fluid from the brain area, collapsing the fetal skull and withdrawing the dead fetus. A caesarian section delivery would allow the safe delivery of a hydrocephalic fetus, but with increased risks to the mother, in comparison to an intact D&X procedure. The risk to the viable, treatable, hydrocephalic fetus of intact D&X is essentially 100%.

In the 2 to 3 day procedure, the cervix is dilated. The fetus is delivered feet-first. The surgeon inserts a sharp object into the back of the fetus' head, and inserts a vacuum tube through which the brains and its fluids are extracted. The head of the fetus contracts at this point and allows the fetus to be more easily removed from the uterus. The fetus can then be removed with less damage to the woman. The technique was pioneered by Dr. Martin Haskell in 1992.

Intact D&X procedures are not performed during the first trimester, because there are better ways to perform abortions. There is no need to follow such a procedure because the fetus' head is quite small at this stage of gestation and can be quite easily removed from the woman's uterus.

Legal and political situation in the United States

About the terminology

This procedure is referred to as "partial-birth abortion" in the media and among pro-life groups. In the medical field intact dilation and extraction is sometimes referred to as a D&X procedure (not to be confused with D&E procedure dilation and evacuation.)

Efforts to ban the procedure

Since 1995, led by Congressional Republicans, the United States House of Representatives and U.S. Senate have moved several times to pass measures banning the procedure. After several long and emotional debates on the issue, such measures passed twice by wide margins, but President Bill Clinton vetoed those bills in April 1996 and October 1997 on the grounds that they did not include health exceptions. Subsequent Congressional attempts at overriding the veto were unsuccessful.

On October 2, 2003, with a vote of 281-142, the House again approved a measure banning the procedure. Through this legislation, a doctor could face up to two years in prison and face civil lawsuits for performing such an abortion. A woman who undergoes the procedure cannot be prosecuted under the measure. On October 21, 2003, the United States Senate passed the same bill by a vote of 64-34. The measure does not contain health exemptions but does contain an exemption to save a woman's life. On November 5, 2003, President George W. Bush signed the Partial-Birth Abortion Ban Act (HR 760, S 3), which defined partial-birth abortions as:

. . . [A]n abortion in which the person performing the abortion partially vaginally delivers a living fetus before killing the fetus and completing the delivery.

Note that this definition of "partial-birth abortion" is not equivalent to "intact dilation & extraction," and covers a different range of procedures. The bill does not ban intact D&X when the fetus is already dead, making it clear that it is not a medical technique that is the issue, but the purposeful death of the partially born that is unacceptable, as it is only inches away from classic infanticide. This infanticide protection enhancement was also addressed in the Born-Alive Infants Protection Act which protects babies who are born as the results of botched abortions.

On November 6, through efforts of the American Civil Liberties Union and the National Abortion Federation, three United States district court judges issued temporary restraining orders against enforcement of the ban.

Legal and political situation in the United Kingdom

Questioned about UK government policy on the issue in Parliament, Baroness Andrews stated that "We are not aware of the procedure referred to as 'partial-birth abortion' being used in Great Britain. It is the Royal College of Obstetricians and Gynaecologist's (RCOG) belief that this method of abortion is never used as a primary or pro-active technique and is only ever likely to be performed in unforeseen circumstances in order to reduce maternal mortality or severe morbidity."