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Intact dilation and extraction is a surgical technique which can be used for partial-birth abortion or the removal of a dead fetus after a late-term miscarriage, in which the patient's cervix is dilated and fetus extracted in substantially one piece. The term "dilation and extraction" or "D&X" was coined in 1992 by Dr. Martin Haskell, who developed the procedure as an alternative to dilation and evacuation or D&E (see below). Slightly later, the term "intact dilation and evacuation" was proposed by Dr. James McMahon. The term "intact D&X" was later settled upon by combining elements of both proposals.

Surgical Process

After preliminary procedures over a period of 2-3 days, to gradually dilate the cervix, and sometimes the administering of hormones to induce the process of labor, the doctor uses an ultrasound and forceps to take hold of the fetus' leg. The fetus is turned to a breech position, if necessary, and the doctor pulls one or both legs out of the birth canal, causing what is commonly known as the 'partial-birth' of the fetus. The doctor subsequently births the rest of the baby, usually without the aid of forceps, leaving only the head still inside the birth canal. With sufficient force, the doctor inserts scissors into the base of the back of the skull. The doctor spreads the scissors to widen the opening, and then inserts a suction catheter. The brain tissue is removed, killing the fetus, and allowing the rest of the fetus to pass easily.

The collapsing of the brain is the major reason cited by pro-choice advocates who say that physical deformities of the fetus' head, such as hydrocephalus, may make the procedure medically necessary for the safety of the mother. The pro-life opponents say that caesarean section or draining the fetus' excess cerebrospinal fluid before birth can permit a safe live birth even in such cases.

Since the procedure is so widely disputed, here is how both a pro-choice and pro-life group describes it. Readers should consider both authors' biases and intents when reading the passages below.

Planned Parenthood Description

Dilation and Evacuation

Dilation and evacuation (D&E) is performed in two steps.

The first step of a D&E involves cervical preparation (softening and dilation).

The vagina is washed with an antiseptic.

Absorbent dilators may be put into the cervix, where they remain for several hours, sometimes overnight. Misoprostol may also be used to facilitate dilation of the cervix.

During the second step of a D&E

The woman may be given medication to ease pain and/or prevent infection.

A local anesthetic is injected into or near the cervix. General anesthesia can also be used.

The dilators are removed from the cervix.

The fetus and other products of conception are removed from the uterus with surgical instruments and suction curettage. This procedure takes about 10-20 minutes.

National Right to Life Description

Partial-Birth Abortion

Abortionists sometimes refer to these or similar types of abortions using obscure, clinical-sounding euphemisms such as "Dilation and Extraction" (D&X), or "intact D&E" (IDE) which mask the realities of how the abortions are actually performed.

This procedure is used to abort women who are 20 to 32 weeks pregnant -- or even later into pregnancy.* Guided by ultrasound, the abortionist reaches into the uterus, grabs the unborn baby’s leg with forceps, and pulls the baby into the birth canal, except for the head, which is deliberately kept just inside the womb. (At this point in a partial-birth abortion, the baby is alive.) Then the abortionist jams scissors into the back of the baby’s skull and spreads the tips of the scissors apart to enlarge the wound. After removing the scissors, a suction catheter is inserted into the skull and the baby’s brains are sucked out. The collapsed head is then removed from the uterus.

Circumstances in which the procedure is performed

Intact D&X procedures are rare, carried out in roughly 0.2% (two-tenths of one percent) of all abortions in the USA. According to the Alan Guttmacher Institute there were 1,310,000 abortions (2000) which would put the figure of Intact D&X somewhere between 2500 and 3000. They are performed during the last half of a pregnancy for various reasons, such as:

• The mother and baby are healthy, but the mother wishes to terminate her pregnancy. This is by far the most common reason.
• The fetus is dead (in which case the procedure is not an abortion).
• Fetal abnormality or other medical complications to pregnancy.

Some of the babies which fall into this later category have developed hydrocephalus, a treatable condition since 1952, the treatment of which has made good progress in recent years. Approximately 1 in 2,000 babies develop hydrocephalus while in the womb; this is about 5,000 a year in the United States. The defect is not usually discovered until late in the second trimester of pregnancy. If a baby develops hydrocephalus, the head may expand to a size of up to 250% of the radius of a normal newborn skull, making it impossible for it to pass through the cervix. In such a case, the physician may drain the excess fluid in utero using a syringe, thereby enabling a normal, vaginal live birth. Alternately, a caesarian section can be used for the safe delivery of a hydrocephalic baby, but with a larger than usual incision. Or the fetus can be aborted by an intact D&X procedure in which suction is used to extract both the brain and the fluid, before collapsing the fetal skull and withdrawing the dead fetus.

In an Intact D&X, the cervix is first gradually dilated over a 2 to 3 day period. The fetus is delivered feet-first (breech). The surgeon inserts a sharp object into the back of the fetus' head, and inserts a vacuum tube through which the brains and its fluids are extracted. The head of the fetus contracts at this point and allows the fetus to be more easily removed from the uterus. The technique was pioneered by Dr. Martin Haskell in 1992.

Intact D&X procedures are not performed during the first trimester, because there are better ways to perform abortions. There is no need to follow such a procedure because the fetus' head is quite small at this stage of gestation and can be quite easily removed from the woman's uterus.

The concensus of the medical community (as stated in the Findings section of the Partial-Birth Abortion Ban of 2003) is that partial-birth abortion, i.e., intact D&X of a live fetus, is never medically necessary.

Legal and political situation in the United States

It has been suggested that this article be merged with Partial-birth abortion. (Discuss)

About the terminology

When used to abort a live fetus, this procedure is referred to as "partial-birth abortion" in the media and among pro-life groups. In the medical field intact dilation and extraction is sometimes referred to as a D&X procedure (not to be confused with the D&E procedure dilation and evacuation, in which the fetus is dismembered before being removed from the womb).

Efforts to ban the procedure

Since 1995, led by Congressional Republicans, the United States House of Representatives and U.S. Senate have moved several times to pass measures banning the procedure. After several long and emotional debates on the issue, such measures passed twice by wide margins, but President Bill Clinton vetoed those bills in April 1996 and October 1997 on the grounds that they did not include health exceptions. Subsequent Congressional attempts at overriding the veto were unsuccessful.

On October 2, 2003, with a vote of 281-142, the House again approved a measure banning the procedure. Through this legislation, a doctor could face up to two years in prison and face civil lawsuits for performing such an abortion. A woman who undergoes the procedure cannot be prosecuted under the measure. On October 21, 2003, the United States Senate passed the same bill by a vote of 64-34. The measure does not contain health exemptions but does contain an exemption to save a woman's life. On November 5, 2003, President George W. Bush signed the Partial-Birth Abortion Ban Act (HR 760, S 3), which defined partial-birth abortions as:

. . . an abortion in which -- (A) the person performing the abortion deliberately and intentionally vaginally delivers a living fetus until, in the case of a head-first presentation, the entire fetal head is outside the body of the mother, or, in the case of breech presentation, any part of the fetal trunk past the navel is outside the body of the mother for the purpose of performing an overt act that the person knows will kill the partially delivered living fetus; and (B) performs the overt act, other than completion of delivery, that kills the partially delivered living fetus.

Note that this definition of "partial-birth abortion" is not equivalent to "intact dilation & extraction," and covers a different range of procedures. The bill does not ban intact D&X when the fetus is already dead, making it clear that it is not a medical technique that is the issue, but the purposeful death of the "partially born" infant that is unacceptable, as it is perceived to be only inches away from classic infanticide. This infanticide protection enhancement was also addressed in the Born-Alive Infants Protection Act which protects babies who are born as the results of botched abortions.

On November 6, through efforts of the American Civil Liberties Union and the National Abortion Federation, three United States district court judges issued temporary restraining orders against enforcement of the ban.

Legal and political situation in the United Kingdom

Questioned about UK government policy on the issue in Parliament, Baroness Andrews stated that "We are not aware of the procedure referred to as 'partial-birth abortion' being used in Great Britain. It is the Royal College of Obstetricians and Gynaecologist's (RCOG) belief that this method of abortion is never used as a primary or pro-active technique and is only ever likely to be performed in unforeseen circumstances in order to reduce maternal mortality or severe morbidity."