The resident took me aside before the procedure. She asked me if I have ever seen a D&E, or dilation and evacuation. I shook my head, it was my first day on the gynecologic surgery service and this D&E would be my second procedure.
“When we remove the fetus, it is going to come out in parts. If you feel yourself getting light-headed or faint, just take care of yourself and sit down or leave.”
I thanked her for the escape hatch.
A Dilation & Evacuation is performed when a pregnancy has resulted in a miscarriage and the gestational products have not been expelled on their own. The procedure is conducted under general anesthesia and the patient in stirrups. The OB/GYN dilates the cervix with a series of curved rods with increasing thickness to allow access to the uterine cavity, where the placenta, yolk sac, and fetal remains are located.
Then, with the cervix dilated, the physician inserts a tube hooked up to suction and evacuates the uterus. There is a mesh inside the suction container to collect any solid materials.
I wasn’t sure if the resident tells that to all the students, or just thought it prudent to tell me. I mentioned briefly in the previous procedure that my partner is pregnant. Maybe that’s why she gave me that out. Maybe not.
The attending and the resident set themselves between the patient’s legs. Resident in the hot seat and the attending looking over the shoulder. They needed me to the patient’s left, to operate the ultrasound probe and to provide visualization of the uterus and the contained materials.
The last time I had seen an ultrasound, I was sitting in an OB/GYN office with Mackenzi, witnessing the heartbeat of my child. I jellied up the probe and searched for the uterus. A few nervous seconds of pressing the electric-razor-like object into the plump belly got me to the target: a hazy bubble surrounded by black, surrounded by more haze. The fetus, without a heartbeat, sat in the center of the screen surrounded by the gestational sac inside the uterus.
“There. You have it. Don’t move,” the resident instructed.
And so I locked into place, mesmerized by the blob that looks so much like my blob, the one on my refrigerator door. I saw our blob at eight weeks, now about thirteen weeks along. Her blob died at sixteen weeks and four days.
The resident asked the circulating nurse to turn on the suction as she dilated the cervix with the curved stainless steel rods. She asked me to turn the probe 90deg to allow for a longitudinal, or lengthwise, view of the uterus. Then, she inserted the suction tube.
I saw the tube on the ultrasound screen. Contact with the little blob. Then I heard the vacuum container fill. I looked down at the floor and saw the red flowing from the suction tube down into the container.
The resident operated quickly and assertively. Less like a tender removal and more like someone scrubbing a particularly troublesome frying pan. The blob and their surrounding fluids disappeared as the suction tube advanced. Soon, I only saw uterus with no space between.
The attending disconnected the vacuum container and removed the mesh bag which held the filtered solid materials. She laid the contents onto a towel and used her gloved hands to sift through the remains. We needed to ensure that all of the products of conception, meaning the fetus, placenta, and yolk sac, were all removed successfully or else there is a risk of infection as the retained materials rotted inside the uterus.
Most of the bloody, lumpy pile was placenta and lining from the uterus. She quickly fished out a leg. Then an arm. The head. The other arm with the shoulder attached.
As she found pieces of the fetus, she arranged them together like a puzzle. The reassembled baby reminded me of balut, a Southeast Asian dish of mostly gestated chicken egg. The ribs were visible, soft and flexible. The face had the characteristics of eyes, nose, and ears.
I couldn’t help my fascination, and I think the attending picked up on it. I had studied embryology, or the alien-like development of a fetilized egg to a ready-to-poop baby. I hated it, because it didn’t make any sense to me. Now, looking at this 16 wk and 4day old fetus, I could see the sequential aspects of growth.
The attending pulled out an arm and a leg to send for chromosomal analysis. This was the patient’s second miscarriage and they wanted to understand if there was an underlying genetic defect that caused them. The rest of the body would go to the morgue.
“Sixteen weeks is the cutoff,” the attending told me. “Before sixteen weeks, they go to pathology. After sixteen weeks, the morgue.”
Most people wait until the second trimester, or after 12 weeks, to announce the pregnancy. Ourselves included. The baby gets to go to the morgue after sixteen. Before twenty weeks, the death of the fetus is called a spontaneous abortion. After twenty weeks, an intrauterine fetal demise or stillbirth.
So many landmarks and thresholds to cross.
Soon after, we wrapped up the D&E, removed the drapes, and waited for the anesthesia to loosen its hold on the patient. She was a larger woman. I remember meeting her and her partner before the procedure. She seemed nervous and anxious. I did not blame her.
As she began to rouse, the anesthetist suctioned out a large amount of sputum from her airway. The ventilator removed from her windpipe, we heard the first noise. A cry.
No, more like a wail. Something deep and primal. The sequence reminded me of eliciting a cry from a newborn: suction the airway, stimulate until they cry and open their lungs.
“Honey, are you in pain or are you sad?” the anesthetist asked. Did she need pain meds? Or just comfort?
No response. Those nearby touched her. Those further away looked wistful. I squeezed her foot as she continued to cry.
A death for her baby. A birth for her.