(17 to 22 weeks)
Second trimester patients receive
a preoperative evaluation similar to first trimester patients.
However, due to the greater length of pregnancy, second trimester
patients receive a more extensive ultrasound screening exam
at the beginning of their appointment at Orlando Women's Center.
Those features of the pregnancy that are evaluated at this
time include the diagnosis of fetal age, which is made by taking
measurement of the fetus; such as head size, femur length
and abdominal circumference. These measurements provide a
precise determination of fetal age. Other evaluations include
position of the placenta, the presence, absence, or unusual
quantity of amniotic fluid; the presence of visible fetal
anomalies, pathology such as fibroids in the uterine wall,
and whether or not the fetus is viable.
Aside from variations in informed
consent materials, the second trimester patient experiences
the same preoperative procedures as the first trimester patient.
The main difference is that the second trimester patient remains
overnight at Orlando Women's Center. The purpose of overnight
observation is to assure maximum safety for the patient. The
possibility of placental abruption (separation of the placenta)
and severe vaginal bleeding are life threatening situations
which can occur following a second trimester procedure. These,
and any other potential complications must be diagnosed and
treated by the physician and staff in an expeditious manner.
Misoprostol and Laminaria, if indicated,
are inserted on the first day. After several hours the patient
is reevaluated to determine if additional Misoprostol is required,
and to establish if Laminaria is needed, must be added or
can be removed. If there has been no significant change in
the cervix, the amniotic sac (membranes) are ruptured with
instruments under direct ultrasound vision. The primary purpose
of this maneuver is to increase the natural Prostaglandins
near and around the cervix which creates stronger uterine
contractions and initiates labor. The second purpose of releasing
all the amniotic fluid from within the intrauterine cavity
is to decrease the incidence of an amniotic fluid embolism,
whereby the amniotic fluid could enter the patient's bloodstream
and cause severe shortness of breath, lack of oxygen circulating
throughout the body, Disseminated Intravascular Coagulation
(DIC), and other serious complications, including death.
A high dose oxytocin regimen may
be started after initiating an intravenous (IV) infusion.
Medication is given for discomfort throughout the entire procedure.
(22.5 to 24 weeks)
At 22.5 menstrual weeks and later, the first step in the abortion
procedure on day one is an injection of digoxin and potassium
chloride into the fetal heart to cease fetal heart activity.
The patient is given IV sedation for comfort prior to beginning
the procedure. This procedure is performed under direct ultrasound
vision. The patient does not usually feel any pain or discomfort,
and most do not even recall having this part of the procedure
performed. The patient does not observe the fetus on the ultrasound
screen unless she chooses to do so. The injection is administered
with strict attention to sterile technique, and takes approximately
3 minutes.
Following the injection into the
fetus, Misoprostol and Laminaria are placed into the posterior
vaginal route, and in the cervix respectively. The remainder
of the procedure is similar to that of one for 17 to 22 weeks.
If the fetus that is between
17 to 24 weeks does not deliver spontaneously after given
a trial of multiple insertions of Misoprostol & Laminaria,
rupturing of the membranes, and a high dose oxytocin protocol,
it may require that the physician perform a surgical evacuation
of the uterus (dilation and evacuation i.e. D&E) using
instruments such as forceps to remove the fetus and placenta.
All the other steps taken up to this point serve to enhance
the safety of the late second trimester abortion procedure.
The choice of procedural technique is dictated by the patient's
health and safety.
In order to provide services
to you we require that your personal doctor, genetic counselor,
or Perinatologist, provide documentation of the diagnosis
for your child indicating that continuing the pregnancy will
be a threat to your life, or your health. In the past 10 years
we have had experience with pregnancy terminations for fetal
abnormalities such as 1) Central Nervous System that include:
holoprosencephaly, encephalocele, encephalomyelocele, hydrocephalus,
Spina Bifida, holorachischisis, Dandy Walker, anencephaly,
holoanencephaly, absence of corpus callosum; 2) Cardiac abnormalities
that include: Primary Pulmonary Hypertension, Hypolastic left
and right ventricle, holoacardius, tetraloy of Fallot, Eisenmenger's
complex, transposition of great vessels; 3) Chromosomal abnormalities
that includes a) Common: trisomy 13, 18, 21, b) less common:
trisomy 16, short arm and long arm deletions; 4) Skeletal
abnormalities: Polydactyly, Achondroplasia, Osteogenesis imperfecta,
lethal dwarfism, 5) Kidney abnormalities: Adult and Infantile
Polycystic Kidney diseases, Potter's Syndrome; 6) GI abnormalities:
gastroschisis, omphalocele.
Why do these fetal and other
abnormalities occur?
- They are mistakes of nature.
- Only 97% of babies born in the US are healthy.
- 3% of babies have a severe congenital/chromosomal abnormality.
Orlando Women's Center's Approach
to Obstetrical Care
- Women's bodies were designed
to have 6 to 9 pound babies.
- Orlando Women's Center's approach is for the patient
to have a miscarriage which is 1/5 to 1/2 the size in weight
of a normal pregnancy.
- At Orlando Women's Center, our Fetal Indications for
Termination of Pregnancy Program involves managing the pregnancy
by a premature stillborn delivery. During this process we
try to duplicate the natural, safe and reliable course intended
by nature. The cervix will be dilated with Misoprostol and
Laminaria. When the cervix is opened adequately, labor will
be induced by naturally occurring hormones, and the delivery
will be experienced under "twilight" sedation. With the
use of twilight anesthesia for the labor and delivery most
patients do not feel or remember very much of the process.
Generous amounts of medication are administered during the
labor to relieve discomfort. On the first day of the process
an injection of medications called digoxin and potassium
chloride is administered into the fetal heart to assure
stillborn birth which will not experience discomfort during
the procedure. The actual labor and delivery will take place
in our center. Patients are usually able to travel comfortably
within 45 minutes to an hour after delivery.
- Fetal Demise: This is initiated
by injection of the combination of Digoxin and
Potassium Chloride (most commonly) into the fetal heart to assure
the following:
- No further fetal pain or discomfort
- No live birth
- Helps to prepare the fetus for a normal, safe miscarriage
- Cervical Preparation: Prostaglandin,
normally found in the body at low doses, and increased during
initiation of labor, causes uterine contractions and cervical
softening. Types of Prostaglandin:
- Prostaglandin E2 - High incidence of side effects such as fever, nausea, vomiting,
diarrhea, elevated blood pressure, stroke and heart attack
- Prostaglandin F2 - High incidence of live births, cervical tears and retained
tissue
- Prostaglandin E1 (Misoprostol) -
- Naturally found in the stomach and determined to decrease the incidence of gastric ulcers
- Less incidence of side effects
- Laminaria -
A naturally occurring seaweed the size of a match stick, which swell
within several hours of being inserted into the cervix and slowly
become larger. They can be removed and be reinserted several hours
later on the same or next day. Laminaria help widely dilate (open) the
cervix so that it will be less dangerous to perform the premature
delivery. Less pain, incidence of uterine perforation, damage to the
bowel or other organs.
- Oxytocin
- A hormone that is secreted
in the brain, which in high doses is used to initiate labor
in women at full term.
- Several studies around the world have been done to show
that Oxytocin can also be used to help prepare the cervix
for premature delivery by causing softening and dilation
of the cervix.
- Intrauterine Instillation Agents
- Concentrated Normal Saline(20%)
- Causes initiation of labor within 24 to 36 hours (faster initiation of labor and delivery with use of oxytocin)
- High incidence of side effects
- DIC
- Infection
- Blood transfusion
- Concentrated Urea (40 gms)
- Side effects include
- Infection
- Blood Transfusion
- Premature Delivery
- Time from initiation of Cervical Maturation until delivery is from 4 to 36 hours. The average time is 18 hours.
- Pain medication is administered as needed for discomfort.
- Stillborn Activity
- Program is designed to be socially, culturally, spiritually, and emotionally in harmony with the variety of situations that
our patients bring to us.
- Some women want to bond with their baby once the premature delivery occurs. This is an important step for the patient and her
family to help in bringing closure to this devastating crisis. Some couples initially find this a very frightening thought, but we
have found that couples who wish to view or hold their child are able to work through the grieving process more effectively. When
couples elect not to see their child they may later regret omitting this option. We encourage you to take pictures of the baby alone
and with family members. We can arrange for your baby to have an autopsy or other confirmatory studies that must be arranged prior to
your arrival with your doctor or geneticist. Cremation or a funeral with burial can be arranged.
- The difficult part after making the decision to have a premature delivery is saying goodbye to the relationship you have had with
your baby. We understand that the vast majority of our Fetal Indications patients are experiencing the most difficult situation of
their lives. We recognize your decision to come to our center has been both distressing and difficult. You will have a private
consultation with our Medical Director, Dr. James Pendergraft. All patients and their partners or significant others are encouraged
to ask questions and to help support other members that will be in our facility going through a similar crisis.
- Support and Healing Group
You will also be in contact with women that have chosen to have a premature delivery that may be under similar
circumstances and reasons why you have chosen this path. There have been patients that exchange phone numbers and
talk with each other for months and years later.
How does this premature delivery process work?
- Arrive midday
- Meet with business office
- Lab and counseling
- Perform ultrasound
- Digoxin/Potassium Chloride fetal intra-cardiac injection
- Begin cervical preparation process
- Bond with other patients, families, and staff
Counseling
Women seeking termination of pregnancy at Orlando Women's Center have highly individual needs. These needs vary widely;
the pregnancy may be highly desired by the woman, and her partner, but cannot be continued because of abnormal development.
The pregnancy may be desired, but comes at the wrong time in the woman's life or in her relationship with her partner. She
may not have a satisfactory, or even any relationship with the man by whom she became pregnant. Some women do not ever want to
have children; many become pregnant when they are not prepared to become a mother or to have another child.
When we use the term counseling at Orlando Women's Center, it does not mean that we engage in
psychotherapy or intervention. Our first concern is to provide support for the woman seeking our services. In addition, we
wish to provide support for her family to the fullest extent possible and appropriate.
A counseling session has several objectives:
To give the woman an opportunity to express and understand her feelings about her pregnancy and her decision to have or not to
have an abortion. We want to determine that this is really her decision and that she is not being pressured in any way to end
the pregnancy.
To provide the woman with accurate information about the procedure she is requesting; it is important
that she know and understand important facts and details in order to give informed consent.
To make sure the woman understands her own reproductive anatomy and physiology. Most women do;
however, even highly educated women sometimes have misunderstandings or questions.
To help each woman understand the methods of contraception available to her and her partner following
the abortion. As a part of this, we want to make sure each woman has a plan for follow-up care in order to assure she does not
experience complications, and that she receives appropriated treatment should they develop. We encourage each patient to see her
own physician or other qualified physician in her community for follow-up care; however, we will provide this care if the woman
desires.
For couples who come to us with a desired pregnancy which must be terminated for reasons of fetal
malformation or genetic disorder, we are prepared to give total support. However, we feel that their most satisfactory, permanent
support is likely to be found with their own physician or counselor in their home community.
The individuals who provide counseling and information sessions for patients at Orlando Women's Center
are experienced nurses and counselors who are thoroughly familiar with all aspects of abortion. They are fully supportive of
women who wish to terminate a pregnancy, and are able to answer most of their questions.
After the patient reviews informational material and meets with her counselor, she will meet with Dr.
Pendergraft. If she has questions that have not been answered by her counselor, she may have them answered at this time. She
then signs the consent form indicating that she understands and requests the procedure to terminate her pregnancy. She may bring
her partner or other family members with her during this session.
The patient's partner, friends, or family may accompany her during her counseling session, the meeting
with Dr. Pendergraft, and they may even be in the recovery room when appropriate; however, these persons are not permitted in the
operating room.
Postoperative Care
Because pregnancy is not a benign condition, and terminating a pregnancy is a surgical procedure, each patient must have excellent
postoperative and follow-up care. This is absolutely necessary to prevent complications. No matter how well an abortion is
performed, complications can occur. The difference between a safe result with a full return to good health and an undesirable result
is often good postoperative care and prompt treatment of complications.
Each patient who has an abortion at Orlando Women's Center is taken from the operating room into a recovery
room where she can lie down, relax, and receive the attention of the recovery room nurses as well as her family members and friends.
During this time, her blood pressure and pulse as well as other aspects of physical evaluation will be monitored by expert recovery
room nurses. She will receive information concerning aftercare and her follow-up examination. If she has chosen a method of birth
control, she may receive information or, in the case of oral contraceptives, a starting supply. Her vital signs (blood pressure,
pulse) will be observed on several occasions after the abortion, before leaving the operating room, upon arriving to the recovery
room, and before being discharged. The nurse makes numerous other observations of each patient such as general status, presence or
absence of abdominal pain, amount of bleeding, and state of recovery from pain medications. Follow-up exams at Orlando Women's Center
are included in the fee for those who can and wish to return to see Dr. Pendergraft and his staff for the follow-up exam.
Our purpose is to ensure that every woman who comes to Dr. Pendergraft's office for a termination of
pregnancy receives the safest possible care and the most compassion and support for the patient and her family. When she leaves,
we want her to feel confident that she is returning to good health and is able to live her life as she chooses.
Orlando Women's Center is a professional organization dedicated to providing expert, confidential, and
respectful health care services. We maintain a national and international reputation for providing the highest quality abortion
services in a safe and caring environment. Kindness, courtesy, and respect are the cornerstones of our patient-provider relationships.
Women and families are intellectually, emotionally, spiritually, and ethically competent to struggle with
complex health issues-including abortion-and come to decisions that are appropriate for themselves.
REFERRAL AREAS
Patients have come to us from all parts of the world
| 1) South America |
|
8) Japan |
| 2) Puerto Rico |
9) Korea |
| 3) Iran |
10) Kuwait |
| 4) India |
11) Dominican Republic |
| 5) Pakistan |
12) Virgin Islands |
| 6) Egypt |
13) United States |
| 7) Germany |
14) Australia |
MATERNAL MORBIDITY AND MORTALITY
- Over 1000 procedures done with our technical procedure
- No deaths
- No Hospital Admissions
- No blood transfusions
- No C-Sections
- No Hysterotomies
- Less than 1% incidence of infections
- Extensive review of literature and reports from the facilities that perform induction procedures show that
Orlando Women's Center is one the safest places worldwide to have a premature delivery for Fetal Indication for
termination of pregnancy performed
- Patient safety and comfort are our number one priority
- Staff is Caring, and Compassionate
- Major hospital is located 0.2 miles from our office. Back up coverage with OB/GYN service is available at all times.
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