Opinion ID: 4538315
Heading Depth: 4
Heading Rank: 3

Heading: Umbilical Cord Transection

Text: Finally, the Secretary suggests that abortion providers may induce fetal demise through umbilical cord transection. To administer this procedure, the physician first dilates a patient’s cervix and then—using an ultrasound for guidance—ruptures the amniotic membrane in order to allow access inside the amniotic sac, where the umbilical cord is located. This causes the amniotic fluid to drain from the uterus, shrinking its size and making it more difficult to visualize and grasp the umbilical cord. The physician then inserts an instrument through the cervix and locates the umbilical cord, which at this stage is approximately the width of a piece of yarn. Grasping the umbilical cord, the physician inserts another instrument through the cervix and cuts No. 19-5516 EMW Women’s Surgical Center, et al. v. Friedlander, et al. Page 23 the cord. Once the cord is cut, the physician waits for the fetal heartbeat to stop, which can take up to ten minutes. The physician may then administer a standard D&E. The district court found that this, too, was not a workable method for inducing fetal demise. It provided three reasons for that finding. First, umbilical cord transection is technically challenging because of the difficulty of visualizing the uterus and locating and grasping the umbilical cord. Meier, 373 F. Supp. 3d at 821 (citing Tr. Vol. I, R. 106 at PageID ##4434–36; Tr. Vol. II, R. 107 at PageID ##4669–70, 4672). Second, it is essentially experimental because there has only been one study focused on the procedure. Id. (citing Tr. Vol. I, R. 106 at PageID ##4438–41; Tr. Vol. III-B, R. 102 at PageID ##3808–09). Finally, umbilical cord transection carries serious health risks, including blood loss, infection, and uterine injury. Id. at 821–22 (citing Tr. Vol. I, R. 106 at PageID ##4436–37; Tr. Vol. II, R. 107 at PageID ##4669, 4673). The Secretary does not meaningfully challenge any of these findings, which again are more than adequately supported by the record. He argues only that the one study of umbilical cord transection suggests the procedure is feasible, safe, and effective, as does the fact that an EMW expert and an EMW doctor had performed umbilical cord transections in the past. But on clear error review, we will not override the district court’s decision not to credit a single medical study after finding that it “does not provide the type or quality of evidence that warrants reaching generalized conclusions about the feasibility or reliability of umbilical cord transection.” Id. at 821. And the simple fact that umbilical cord transections have been performed at some point does not suggest that they are safe in every instance or that they pose no additional, significant risks to those who would be compelled to undergo them. The Secretary also takes issue with the district court’s statement that umbilical cord transections “pose[] another hurdle for the provider because if they cut fetal tissue instead of, or in addition to the cord” while searching for it in the uterus, “they have arguably violated the Act.” Id. (citing Tr. Vol. I., R. 106 at PageID ##4435–36; Tr. Vol. II, R. 107 at PageID ##4669– 70). The Secretary responds that, because of H.B. 454’s intent requirement, it does not apply when a physician accidentally dismembers a fetus prior to demise, and so it would not be enforced against a physician in this circumstance. But, as the Eleventh Circuit has explained in a similar case, “[m]id-litigation assurances are all too easy to make and all too hard to enforce, No. 19-5516 EMW Women’s Surgical Center, et al. v. Friedlander, et al. Page 24 which probably explains why the Supreme Court has refused to accept them.” Williamson, 900 F.3d at 1328 (citing Stenberg, 530 U.S. at 940–41); accord Stenberg, 530 U.S. at 945–46; Yost, 375 F. Supp. 3d at 868. Nor does this argument disturb the court’s conclusion that the technical difficulty of umbilical cord transection makes it an infeasible workaround to H.B. 454. Taken together, these findings demonstrate that should patients be required to undergo an umbilical cord transection prior to receiving a D&E, they would be subjected to a medically risky and experimental procedure that, given its technical challenges, fewer providers may be equipped to administer. These findings inevitably lead to the conclusion that umbilical cord transection—like digoxin and potassium chloride injections—is not a feasible workaround to H.B. 454.