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Friday, October 15, 2010

For the women of South Dakota: an abortion manual (2006)

I understand that you're probably really angry right now. Maybe you're reading a blog expressing that anger -- the anger that your state thinks it knows better than you what to do with your body. Maybe you're anxiously wondering where the nearest abortion clinic is, now that you will have to leave the state to get to one. If you have a serious medical condition, you might be doubling up on birth control methods, leading to a lot of worry and possibly negative side effects.

But what you need right now isn't the righteous anger the rest of the blogosphere will give you. You need more.

In the 1960s and early 1970s, when abortions were illegal in many places and expensive to get, an organization called Jane stepped up to the plate in the Chicago area. Jane initially hired an abortion doctor, but later they did the abortions themselves. They lost only one patient in 13,000 -- a lower death rate than that of giving live birth. The biggest obstacle they had, though, was the fact that until years into the operation, they thought of abortion as something only a doctor could do, something only the most trained specialist could perform without endangering the life of the woman.

They were deceived -- much like you have probably been deceived. An abortion, especially for an early pregnancy, is a relatively easy procedure to perform. And while I know, women of South Dakota, that you never asked for this, now is the time to learn how it is done. There is no reason you should be beholden to doctors -- especially in a state where doctors have been refusing to perform them, forcing the state's only abortion clinic to fly doctors in from elsewhere.

No textbooks or guides existed at that time to help them, and the equipment was hard to find. This is no longer true. For under $2000, any person with the inclination to learn could create a fully functioning abortion setup allowing for both vacuum aspiration and dilation/curettage abortions. If you are careful and diligent, and have a good grasp of a woman's anatomy you will not put anyone's health or life in danger, even if you have not seen one of these procedures performed.

Today, I will discuss dilation and curettage -- what used to be the most common abortion procedure before vacuum aspiration took its place. Vacuum aspiration is an easier method, but sometimes remaining fetal/placental material necessitates doing a "cleanup" D&C anyway, so you should know how to do this procedure first.

DISCLAIMER: I am posting this as information only. Whether anyone chooses to act upon this information is their own concern. I believe in the free exchange of information and ideas. I believe this information has been kept from women for too long, and there is no reason they should not know about a procedure being performed on their own body, and no reason women should be kept in the dark about how to perform it -- especially if someone they know is having their health jeopardized by this law.

Instruments needed and their uses

You will need:

One set of uterine dilators (any equipment may be purchased from numerous websites. If you need assistance in finding this equipment, do not hesitate to email me at molly.blythe@gmail.com)
Vaginal speculum
Pregnancy test
One set of uterine curettes
One pair of uterine forceps
One pair of regular forceps
Sterile bags for medical instruments and medical waste
A course of antibiotics
Sedative medication
Pressure cooker
Container of bleach solution: one part chlorine bleach to 10 parts water
Strong soap
Sterile latex gloves
Water-based lubricant
Maxi pads
Clean plastic sheeting and towels
Exam table
Wet wipes

First, let's talk instruments, before we talk implementation:

Cervical dilators come in many forms. Some hydroscopic dilators work by absorbing moisture from the vagina into the dilator, gradually increasing its diameter until it is workable. However, the "old-fashioned" way is with a set of dilators -- metal instruments of varying sizes. It would probably be best for an illegal practitioner to use these, as they are essentially infinitely reusable as long as they are sterilized between uses. Essentially, the practitioner begins with the smallest instrument and inserts it into the cervix. Then, he or she moves on to the next smallest, and so forth, until the cervix is sufficiently dilated to allow the uterine forceps to be used. This is the easiest part of the abortion, and one that requires very little knowledge other than the placement of the cervix.

Uterine forceps look like a hybrid of a scissor handle and a bird of prey's talon. Their use, once the cervix is dilated enough to allow access to the uterus, is simple: they remove the fetal material from the uterus -- as much as can be removed in this manner.

Curettes are perhaps the most foreign-looking of the implements used. Essentially, they look like small spoons with sharp edges. These are used after the uterine forceps, to make sure the rest of the fetal material and placenta is scraped from the sides of the uterus.

A course of antibiotics is CRUCIAL. The most common cause of death post-illegal abortion is due to infection. When your uterus has been opened up, it is more prone to infection. Do not fool around with this: antibiotics are absolutely necessary post-abortion. Antibiotics can be purchased from Mexican pharmaceutical supply houses for less than $2 per course.

Now that we've discussed the more uncommon instruments, let's move on to discussing the procedure itself.

Procedure

Sterilizing instruments is absolutely critical. The most professional way to sterilize instruments would be with an autoclave -- but this is something to get only if you have an extra few hundred dollars to spend in the name of efficiency. Sterilization is no joke, and nothing to be skimped on, but you can sterilize instruments very well with a household pressure cooker. Ordinary boiling water does not kill all pathogens; while boiling water was the best people could do 100 years ago, it is not the best we can do now. Check your pressure cooker's manual carefully and figure out how much water needs to be placed in it to stay at 250-260 degrees for 30 minutes. Be sure to refer carefully to the manual, or injury and damage to the cooker could result. Place the water and instruments into the pressure cooker and allow it to "cook" them for 30 minutes at the 250-260 temperature. This will steam-sterilize your instruments. If you have an autoclave, lucky you! Follow its operating instructions.

Assuming you have no autoclave, follow the instructions for opening your pressure cooker, then remove the instruments with an already-sterilized pair of ordinary forceps. set them in the sterile bags. Now your instruments are prepared. From now on, be sure to only touch the instruments on the handle side, rather than on the side coming into contact with the cervix and uterus. Wipe down your table with bleach solution, allow it to dry, and then place clean plastic sheeting over it.

Your patient should be naked from the waist down and should have her pubic area shaved. Request that the patient does so the night before. Administer a sedative to the patient long enough before the procedure begins that it will be fully effective during the D&C procedure. Prior to the procedure, conduct an ordinary pregnancy test on the woman. This may seem like a silly step, but pregnancy tests are never 100% accurate, and women have been known to come to abortion clinics and test negative. Ask your patient how long it has been since her last period. If it has been eight weeks or less, the procedure itself will take less than 15 minutes after dilation begins. The length grows, however, until at about 13-14 weeks (the limit for a D&C procedure because of the limited dilation ability of dilators) it will last up to 45 minutes. Honesty is IMPERATIVE, because dishonesty could endanger the woman's health.

Once the patient has "assumed the position" in the stirrups, wipe the vulva and anal areas with separate wet wipes, including the labia majora and minora. Once the patient is clean, lubricate the vagina with water-based lubricant and use the vaginal speculum to open the vagina and examine the cervix (information on how to use a speculum properly is widely available online and in print and does not need to be reprinted here, but please be sure you understand how to use the speculum prior to conducting this procedure).

The cervix is a small, round, smooth-looking muscle at the top of the vaginal canal. Please be sure to familiarize yourself with the female reproductive system prior to performing any procedure such as this. The cervix is the entrance to the uterus. A non-pregnant uterus is only as big as a small pear, but it grows bigger even in the earliest months of pregnancy -- at 8 weeks, it is the size of a peach, and at 14 weeks, the size of a grapefruit. I didn't make up all these fruit-sizing terms, other people did, and I apologize for making anyone uncomfortable whilst eating fruit salad from now on.

It is important to know the approximate size of the uterus because that's where you're headed. Get out your smallest dilator and insert it slowly and gently into the cervix. This hurts -- it's part of why your patient is sedated. Novocaine is sometimes injected to numb the cervix, but when you are just starting, it is probably preferable to stay away from needles entirely. Insert each dilator in turn. Even the largest dilator, as you will notice, doesn't give you very much room -- less than an inch of opening. There's no way you can see into the uterus. From here on out -- this is the scary part -- you will have to operate on feel alone. Don't feel too afraid. Each element in the uterus feels different from the others, and as long as you are careful and understand exactly what the procedure involves at each step, it will not be too difficult.

The first step is to break the membrane holding the fetus inside. You can feel around with the forceps for it. To get an idea of what each part looks like -- and to see the texture so that you understand better how it will feel -- I recommend looking at books with photographs of first trimester fetuses (personal recommendation for its astonishing photographs: A Child is Born), The membrane should be easily broken with the forceps. Depending on how far along the pregnancy is, varying quantities of clear or pinkish fluid may come from the vagina. As you grasp the sac with your forceps, twist it away so that it detaches. You will now need to remove small pieces of fetal material and membrane from the uterus with the forceps. Some of these pieces will be distinctly identifiable as fetal material. Save the material until the end of the procedure on a piece of plastic, so that you can be sure the entire fetus has been removed. If doing this sounds too ethically challenging, remember that fetuses do not have the capacity to feel actual pain until the third trimester. You are not "hurting" it, and it has no awareness, nor the capacity for awareness, that you are extracting it.

This portion of the abortion procedure should not be particularly painful for the patient.

While you are removing fetal material, you will also be removing pieces of placenta. However, because the placenta is attached to the uterine wall -- and because it is the blood source for the baby -- bleeding may begin at this time. It is imperative that if bleeding begins at this point in the procedure, you do NOT stop. Stopping the procedure and attempting to stanch the bleeding will not work. The bleeding will stop on its own once the placenta is totally removed from the uterus. It may be scary, but keep going.

Once you have removed most of the material that is removable, you must move on to curettage. By now you will have felt the walls of the uterus with the forceps, and you must move on to using the spoon-shaped curettes. Find the spot on the uterine wall where placenta still clings -- the curette will make a sound much like metal on metal on a clean uterine wall, but will not make the same scraping sound on a place that still needs material removed. Scrape from the uterine walls, scraping material toward the cervix. Use the same general form of stroke you would use to scoop ice cream, and don't be afraid to scrape fairly hard. Scraping softly could leave tissue behind, and if there's anything you don't want, it's that. The other cue that will inform you the uterus is clean is that the patient will generally report feeling a cramp when the clean uterus is scraped, whereas a scrape of placenta will not feel as painful. Listen to your patient and listen to your curettes.

Once the material is removed from the uterine wall, any excess bleeding will generally slow or stop and it's uterine forceps time again. Take the remaining material out with the forceps. Most pieces of fetal material will come out with a simple tug on the forceps (again, don't be too afraid to use force and put a bit of muscle into it). However, at 13-14 weeks the fetal head may be slightly big to bring out. Pinch it with the forceps and take it out in pieces, as well. Make absolutely sure all bone fragments are removed from the uterus, as well as all other material. If necessary, use the curette again to remove remaining material and repeat the procedure with forceps.

By this point, bleeding should be no more than in a normal period, and likely quite a bit less. If the patient is still bleeding heavily at this point, get her to a hospital -- it means you likely did not curette completely, and the hospital will generally complete the procedure as her life is assuredly in danger.

When you feel the curettage and removal is complete, make sure you examine the fetal material you have already extracted. If you're missing anything obvious -- for instance, a head -- make sure to find and remove it.

Allow your patient to rest comfortably on the table if she wishes, or to get dressed. She will likely have some residual bleeding, so make sure you have maxi pads on hand (I would not risk infection from tampons so soon after the procedure). Give her the course of antibiotics and stress to her how imperative it is that she use them as directed. Make sure that she understands any bleeding or problems means she needs to call 911 immediately. When she is ready, allow her to leave -- if sedated, do not allow her to drive home herself. Follow up in a few days and make sure she is not experiencing much bleeding or pain.

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I will be following up this article with directions for performing vacuum aspiration for first-trimester pregnancies and inducing miscarriages for later ones. I hope this can prove educational for the next generation of women, who may have to start a second Jane program. I am sorry we live in times where it is necessary to publish this material, but if women work together, an abortion ban doesn't mean that women and girls are left with no choices.

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