Opinion ID: 3036015
Heading Depth: 3
Heading Rank: 1

Heading: Post-First Trimester Abortion Methods

Text: The vast majority of abortions in the United States are performed during the first trimester.1 Approximately ten percent 1 The first trimester lasts until the thirteenth or fourteenth week of pregnancy, measured from the woman’s last menstrual period (“lmp”). Planned Parenthood Fed’n of Am. v. Ashcroft, 320 F. Supp. 2d 957, 960 1306 PLANNED PARENTHOOD v. GONZALES of abortions are performed during the second trimester. Only about one percent are performed after the twentieth week from the woman’s last menstrual period (“lmp”) and only a small portion of those after the twenty-fourth week, the earliest time at which viability begins. In short, only a tiny percentage of abortions are performed after viability may have commenced. Women seek abortions after the first trimester for various reasons, including newly discovered fetal anomalies and maternal health problems that are created or exacerbated by the pregnancy. This is primarily because ultrasound and amniocentesis — procedures that often detect these medical conditions — generally are not available until the second trimester. Because abortions are rarely performed after the twenty-fourth week lmp and even more rarely after the second trimester (in both cases almost always for medical reasons), the Act essentially regulates previability second trimester abortions. Nearly all post-first trimester abortions are performed using one of two methods: dilation and evacuation (“D&E”) or induction.2 D&E accounts for 85 to 95 percent of such abortions. (N.D. Cal. 2004); see also Stenberg v. Carhart, 530 U.S. 914, 923 (2000) (measuring the first trimester at twelve weeks gestational age, which equals fourteen weeks lmp after adding the approximately two weeks between menstruation and conception). The second trimester lasts until approximately the twenty-seventh week lmp (twenty-four weeks gestational age), with the third culminating in birth (typically at forty weeks lmp). Planned Parenthood, 320 F. Supp. 2d at 960. A fetus is generally understood to have achieved viability—meaning that there exists a realistic potential for long-term survival outside the uterus—at twenty-four weeks lmp or later. Id. 2 Two additional methods are available but are used exceedingly rarely, usually only in an emergency: hysterotomy, which resembles a caesarean delivery through the abdomen; and hysterectomy, which involves complete removal of the woman’s uterus with the fetus inside. Stenberg, 530 U.S. at 987 n.7. PLANNED PARENTHOOD v. GONZALES 1307 Unlike induction, which is a form of “medical” abortion, D&E is a surgical procedure involving two steps: dilation of the cervix and surgical removal (evacuation) of the fetus. There are two forms of D&E, intact and non-intact.3 The first step of the procedure, cervical dilation, is the same for both forms of D&E. It is achieved primarily through the use of osmotic dilators, which are sponge-like devices that expand the cervix, typically over a period of twenty-four to forty-eight hours. Some doctors also use medications known as prostaglandins in conjunction with the osmotic dilators, though these drugs sometimes induce labor spontaneously, which results in partial or complete expulsion. The dilation process is necessary so that the doctor may insert an instrument, generally a type of forceps, through the cervix and into the uterus in order to remove the fetus. The second step of the procedure, the evacuation phase, is when the two forms of D&E become different.4 When performing a non-intact D&E, the doctor, under ultrasound guid- 3 Some doctors reject the characterization of intact and non-intact D&E as two separate forms of the D&E procedure. Rather, they believe that there is only a single form which is sometimes performed in a manner that differs from other implementations, but in a way that is of no medical consequence. Other doctors choose not to label the intact and non-intact procedures as forms of D&E for a different linguistic reason. These doctors reserve the term D&E for the non-intact procedure and call intact removals “dilation and extractions” (“D&X”). D&X is the nomenclature used in Stenberg. 530 U.S. at 927. The labeling of the procedure is of no consequence to our analysis; however, for simplicity’s sake we prefer intact and non-intact D&E. What is relevant, however, is that one could substitute D&X for intact D&E wherever the latter term appears in our opinion and nothing would change in any respect. 4 In either form of D&E, the removal procedure usually lasts ten to fifteen minutes, during which the woman receives either conscious sedation or general anesthesia. 1308 PLANNED PARENTHOOD v. GONZALES ance, grasps a fetal extremity with forceps and attempts to bring the fetus through the cervix. At this point, the fetus will ordinarily disarticulate, or break apart, because of traction from the cervix, and the doctor must return the instrument to make multiple passes into the uterus to remove the remaining parts of the fetus, causing further disarticulation. To complete the removal process, the doctor evacuates the placenta and any remaining material using a suction tube, or cannula, and a spoon-like instrument called a curette. In an intact D&E, the doctor, rather than using multiple passes of the forceps to disarticulate and remove the fetus, removes the fetus in one pass, without any disarticulation occurring (i.e., the fetus is “intact”). An intact D&E proceeds in one of two ways, depending on the position of the fetus in the uterus. If the fetus presents head first (a vertex presentation), the doctor first collapses the head, either by compressing the skull with forceps or by inserting surgical scissors into the base of the skull and draining its contents. The doctor then uses forceps to grasp the fetus and extracts it through the cervix.5 If the fetus presents feet first (a breech presentation), the doctor begins by grasping a lower extremity and pulling it through the cervix, at which point the head typically becomes lodged in the cervix. When that occurs, the doctor can either collapse the head and then remove the fetus or continue pulling to disarticulate at the neck. (If the doctor uses the latter option, he will have to use at least one more pass of the forceps to remove the part of the fetus that remains, and the procedure is not considered an intact D&E.) As the district court found, some doctors prefer to use the intact form of D&E, whenever possible, because they believe it offers numerous safety advantages over non-intact D&E. As the district court also found, intact D&E may be significantly safer than other D&E procedures because it involves fewer 5 In some cases, doctors will convert a fetus that presents head first into the breech position before beginning the evacuation. PLANNED PARENTHOOD v. GONZALES 1309 instrument passes, a shorter operating time and consequently less bleeding and discomfort for the patient, less likelihood of retained fetal or placental parts that can cause infection or hemorrhage, and little or no risk of laceration from bony fetal parts. Finally, as the district court found, intact D&E is in fact the safest medical option for some women in some circumstances. For example, women with specific health conditions and women who are carrying fetuses with certain abnormalities benefit particularly from the availability of the intact D&E procedure. According to the American College of Obstetricians and Gynecologists (“ACOG”), the safety advantages offered by intact D&E mean that in certain circumstances it “may be the best or most appropriate procedure . . . to save the life or preserve the health of a woman.”6 Doctors typically decide whether to attempt an intact D&E based primarily on the amount of cervical dilation, but they can never predict beforehand whether they will be able ultimately to remove the fetus intact. In most cases, intact D&E is not an option from the outset; in others, although the procedure may start out as an intact removal, during the course of the procedure it turns into a non-intact D&E. As explained further below, the government construes the Act as prohibiting intact D&Es but permitting non-intact 6 The primary alternative to the D&E procedures is induction, which comprises approximately 5 percent of abortions performed between weeks fourteen and twenty and 15 percent of abortions performed after the twentieth week. Many doctors consider inductions less safe than D&Es. When employing this procedure, the doctor starts an IV and uses a prostaglandin suppository (or a saline injection) to induce uterine contractions and labor. The entire process takes between eight and seventy-two hours, with most inductions concluding within twenty-four hours. Some inductions will not completely expel the fetus, requiring the doctor to perform a D&E to finish the procedure. Although a D&E may be performed in an outpatient setting, a woman choosing to undergo induction must be admitted to a hospital. 1310 PLANNED PARENTHOOD v. GONZALES D&Es, whereas the plaintiffs assert that it covers both forms of the procedure, as well as induction. The plaintiffs also contend that even if the Act banned only intact D&Es, it would still be unconstitutional.