“You Can’t Just Tell Someone to Go Home and Pass an 18-Week Fetus. That’s Not Safe.”

BY MEGAN CARPENTIER

Amanda’s case highlights a key problem about being pregnant in an anti-abortion state in post-Roe America. Vague laws that prioritize the “life” of even a non-viable fetus above the health or life of the person carrying it prevents doctors from providing crucial care in dangerous and life-threatening situations. 

That’s because, until September 2021, there was one red line in the law that even the most anti-abortion state legislators could not cross: There had to be exceptions to any and every abortion restriction, even after fetal viability, “for the preservation of the life or health of the mother.”

But last year, when the U.S. Supreme Court allowed the state of Texas to implement its ban on abortions after six weeks—10 months before it overturned Roe v. Wade—it allowed the state to set a new standard. 

Under Texas’ S.B. 8, the only time an abortion might be allowed after cardiac activity is detected would be in the case of a “medical emergency”…which the statute does not define. (Another section of the state’s abortion law does define a medical emergency as a condition that “places the woman in danger of death or a serious risk of substantial impairment of a major bodily function,” though medical providers and lawyers say it’s unclear whether it applies to S.B. 8 and notes that a woman’s health is a better standard.) But because S.B. 8 created a private right of action, even a doctor who can absolutely prove there was a medical emergency would still have to go to court to make their case if sued.

These legal burdens made the situation for Amanda’s doctors untenable. Her condition was likely to cause a “medical emergency,” but they couldn’t treat it as one until it became much more dangerous for her.

Drs. Jenn Conti, Heather Irobunda, and Jennifer Lincoln of Obstetricians for Reproductive Justice have spent time with Amanda and her husband. They sat down with The Meteor to explain the medical facts, and what patients are facing.

Tell us more about Amanda’s diagnosis. What is an “incompetent cervix” and how common is it?

Dr. Heather Irobunda: Cervical insufficiency (or incompetency) happens in about 1% of all pregnancies. However, it happens in about 20% of people who end up having miscarriages [in the second trimester]. 

Dr. Jennifer Lincoln: By definition, this is a painless cervical dilation, as opposed to typical preterm labor or labor, where you have contractions and it hurts. With cervical insufficiency, you don’t know, or there might just be these vague symptoms like Amanda had, where she’s like, “Something just doesn’t feel right.”

Dr. Irobunda: Sometimes a patient will come in for a routine ultrasound around 20 weeks, and then we may notice that their cervix is shortened or is dilated. 

Dr. Lincoln: Sometimes what we’ll see is a cervix that is so completely shortened that it’s non-existent anymore, and it’s also dilated. Or, when we look in the vagina with the speculum, all we see is the amniotic sac because it’s basically prolapsed down past where the cervix is. That was the case for Amanda when she went in.

Dr. Irobunda: It can happen so quickly: You can evaluate a patient a week or a few days before and everything looks fine. And then all of a sudden, your patient comes back in and is like, “I feel, like, a lot of pressure. Things feel weird. Can you check me out?” And then their cervix can be completely dilated and there’s no real reason. 

Dr. Lincoln: But, as you can imagine, the term “cervical incompetence,” like many obstetric terms we have, is a really terribly guilt-producing word.

What is the normal course of treatment?

Dr. Irobunda: What we can do depends on how long the cervix is. If the cervix is just shortened and not open, we can do something called a rescue cerclage, which is a stitch we basically put in the cervix to try to keep the cervix closed until term. But if there’s pretty much nothing left and it’s dilated, unfortunately, there’s not much that we can do to close the cervix back up or prevent it from dilating more.

Dr. Lincoln: Sometimes part of the fetus is even in the vagina. Or it’s not possible to treat with cerclage because they’re showing other signs of infection, and if we were then to put a stitch in their cervix and basically sew in an infected bag of water and placenta and fetus, they would be at a much higher risk of having complications and going on to be septic.

Dr. Irobunda: In these cases, this is going to, unfortunately, end up with a baby that will not be alive. Depending on when, there may be the option of waiting and seeing how long it takes for your body to kind of kick the rest of this into gear and deliver the fetus that had passed on (which is called “expectant management” and is more common in earlier miscarriages).

Dr. Lincoln: But you can’t just tell somebody to go home and expectantly wait to pass an 18-week size fetus. That’s not going to be safe for anybody. The risk of infection is so high, especially with an exposed membrane and bag of water in the vagina. And then Amanda’s ruptured.

Dr. Irobunda: In my state, New York, there’s also the option that we can help induce this miscarriage by giving you medications in the hospital while we are monitoring you. Then it would come out of the vagina and we can give you as much pain medication as you need to get through that. And then the other option is to do a procedure called a dilation and evacuation, in which we would sedate you and then we use various instruments to remove what’s left of the pregnancy.

Dr. Lincoln: What should have been done without all these laws is not a difficult question. In a case where you’ve got somebody who has no cervix left, their bag of water was exposed in the vagina for days, now their bag of water is broken, every OB-GYN is trained to know that all of our patients look very stable until the moment they fall off that cliff and they’re not.

You’re talking about sepsis?

Dr. Lincoln: Yes. Patients can go from being healthy and fine to being septic in a matter of an hour. If you walked in like she did, we would say, “We need to move forward with delivery. You are stable now, this could very much change, and so we need to get the infection out of you, which unfortunately means the placenta and the fetus.” And it’s hard because these are people who want the baby. Sometimes you just wish you could leave people alone or say, “Let me give you a few days to decide.” In this particular situation for Amanda, I don’t think any OB-GYN would have felt comfortable doing that.

Dr. Irobunda: The longer that person remains pregnant, number one, it increases the risk of bad outcomes in terms of things like infection, sepsis, bleeding, and hemorrhage. But it also does a lot mentally to that patient and the family, just knowing that this pregnancy is a miscarriage and that it is not going to end well. We need to minimize the suffering of those involved. It’s not right.

What do you see as the long-term effects of these laws that prohibit or inhibit doctors from performing abortions?

Dr. Lincoln: These laws are tying our hands and, eventually, will end up killing patients. When these people say, “Well, there’s an exception so that’s OK,” well, actually, there’s not. The bottom line is that when somebody can go from being healthy to dead in 30 minutes, how are we supposed to wade through all of that with lawyers who have no clue? I guarantee you they are not awake at 2:00 AM. 

Dr.  Irobunda: It’s really hard to make sweeping laws about things like abortion because all these cases are different. The medicine is not black and white, [and] these laws don’t give anybody any wiggle room. We’re putting people in danger.

Dr. Jenn Conti: These laws affect every aspect of how women’s healthcare is handled from here on out. Once you start criminalizing doctors for doing their jobs, no one is safe—because there’s this paralyzing fear amongst healthcare providers that, if anything goes wrong involving pregnancy, someone somewhere could accuse them of illegal activity. And that’s all that matters in states like Texas: an accusation of guilt.   

What would your advice be for other women in these circumstances? 

Dr. Conti: If you’ve experienced post-Roe harm, I first want to offer my sympathy to you, because you didn’t deserve that. 

If you want to share your story as a way of giving yourself a voice and fighting back, you can head to our website and use the contact form at the bottom of the page to either share anonymously or indicate that you are interested in becoming part of future ORJ storytelling projects.

You can read Amanda’s full story, in her own words, here. Stay tuned for more United States of Abortion stories. 

For abortion access resources and to create a voting plan for the 2022 midterm elections, visit iwillharness.com/abortion.

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Megan Carpentier is currently an editor at Oxygen.com and a columnist at Dame Magazine. Her work has been published in Rolling Stone, Glamour, The New Republic, the Washington Post, and many more.