Sunday, December 21, 2014

"After Tiller" Hero's 35-Week Fiasco

HT: Operation Rescue

Source: New Mexico Medical Board document regarding late-term abortion practitioner Shelley Sella, former colleague of late-term abortion practitioner George Tiller.

The New Mexico Medical board was called on to determine if Shelley Sella's care of Patient M.L. (I will refer to her as "Madison" to avoid the dehumanizing use of initials.) constituted negligence.

Sella's Practice

Sella's abortion clinic, Southwest Women's Options, provides outpatient abortions only. For serious complications, the protocol is to call 911 and have an ambulance take the patient to the University of New Mexico Hospital. Sella's treatment of the injured patient was standard protocol for third trimester abortions at her clinic.

Madison's Abortion

The Pregnancy

Madison had traveled to New Mexico from New York specifically for the purpose of a late abortion. This was an elective abortion of a viable fetus.

At the time she made the appointment, Madison informed clinic staff that she had a history of a previous c-section. Of all the patients Sella had seen with a previous c-section, Madison, at an estimated 35 weeks at the time of the appointment, would be the most advanced in pregnancy.
As was the routine for late abortions, Madison was to stay at a nearby hotel during the abortion process.

During Madison's first visit to Sella's clinic on May 2, 2011, an ultrasound was performed. One measurement of the fetal head was consistent with a fetal age of 39 weeks 2 days, and the other measurement was consistent with a fetal age of 40 weeks 4 days. This, Madison was full term in her pregnancy.

Day One

Madison was first seen by Sella at her abortion clinic on May 10, 2011. That day, Sella administered two drugs vaginally: misoprostal to soften and shorten the cervix in preparation for delivery, and digoxin to cause fetal demise. Sella also inserted laminaria into Madison's cervix. These are matchstick-sized pieces of sterilized and dried seaweed which absorb fluid and expand, thus dilating the cervix.

Day Two

Madison returned on May 11. Sella administered a second dose of misoprostal and changed the expanded laminaria with fresh ones. A second ultrasound was performed to verify that the fetus was dead. Madison was sent back to her hotel with a third dose of misoprostal which she was to self-administer. Madison followed instructions and late in the evening she went into labor. She returned to the clinic. Sella started an IV and began administering pitocin, a drug to induce and speed labor.

Shortly after midnight on the morning of May 12, Sella administered additional misoprostal.

At around 7:00 a.m. on May 12, Sella increased the dose of pitocin and administered more misoprostal.

Catastrophic Consequences

At around 1:17 p.m., Sella stopped the pitocin drip because she suspected that Madison's uterus had ruptured. Approximately 45 minutes later, Madison was taken to the hospital. Her uterus had indeed ruptured due to the strength of the contractions.

Standards of care

The typical measure for standards of care in medical treatment is the "local community standard," meaning what is typical among other physicians in the area. For specialists, however, whose local communities have no similar practitioners, a "community standard" could refer to the "community" of other experts in the same specialty. However, the medical board in the Sella late-abortion case determined that there is no standard of care for late abortions. They opted, therefore, to use a standard of care for obstetric care since the abortion method Sella used is a labor-induction method and thus comparable to inducing labor in obstetric patients.

Sella's Care of Madison

The abortion performed on Madison would be analogous to induction of labor of a full-term infant after a previous c-section. Use of misoprostol and pitocin to induce labor in a term-pregnancy after c-section is specifically proscribed by the American College of Obstetrics and Gynecology due to the risk of uterine rupture, which can cause catastrophic hemorrhage.

The amount of misoprostal administered to Madison was double the amount appropriate for induction of labor at that state of pregnancy. Again, inducing labor with misoprostal and pitocin would only be appropriate if the patient did not have a previous c-section.

An expert obstetrician testified that he would  never induce labor with misoprostal on an outpatient basis, or on a patient with a previous c-section, because "the contraction patter of misoprostol is unpredictable and quite often very powerful." Though he did sometimes perform third-trimester abortions, he only did so in a hospital. He did not leave patients in a hotel without medical supervision.

A previous c-section is a known risk factor for uterine rupture in future vaginal deliveries. The larger the fetus, the higher the risk. The full-term size of the fetus Madison was aborting would make the risk of uterine rupture equal to that of a full-term delivery.

The fact that the fetus had been dead for some time prior to labor would reduce the risk of rupture because decomposition of the fetal tissue would cause it to soften. The use of instruments to reduce the size of the fetal head prior to delivery would also reduce the risk of rupture; however, Sella did not use any means to reduce the size of the fetal head. [N.B. those methods could involve crushing of the skull or use of suction to remove the brain, thus allowing the skull to collapse without use of external pressure from instruments.]

Sella could not be unaware that her protocol was subjecting Madison to a high risk of catastrophic uterine rupture.


Why is Dr. Shelley Sella, who played Russian roulette with her patient's lives, considered a hero by the abortion-rights movement?

The Medical Board noted that Madison's abortion, be it at 35 or 40 weeks, was an elective abortion but nevertheless legal under New Mexico law. Roe vs. Wade gives states the option to permit or ban elective third-trimester abortions. Should we view New Mexico as a forward-thinking state with a high dedication to reproductive choice, or as a barbaric state that allows term infants to be aborted when they could just as easily be delivered alive?

During the brouhaha over the "Partial Birth Abortion" ban, Ron Fitzsimmons of the National Coalition of Abortion Providers admitted,  and independent journalists verified, that the bulk of abortions past 20 weeks are elective, performed on healthy women to abort healthy fetuses. Should the abortion-rights movement be held accountable for dogged efforts to mislead the public about the real reasons late abortions are being performed?

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