Question: Are
there times when you dont remove the fetus intact?
Carhart: Yes,
sir.
Question: Can
you tell me about that, when that occurs?
Carhart: That
occurs when the tissue fragments, or frequently when you rupture the membranes,
an arm will spontaneously prolapse through the oz. I think most...statistically
the most common presentation, we talk about the forehead or the skull being
first. We talked about the feet being first, but I think in probably the great
majority of terminations, its what they would call a transverse lie, so
really youre looking at a side profile of a curved fetus. When the
patient...the uterus is already starting to contract and they are starting to
miscarry, when you rupture the waters, usually something prolapses through the
uterine, through the cervical os, not always, but very often an extremity
will.
Question: What
do you do then?
Carhart: My
normal course would be to dismember that extremity and then go back and try to
take the fetus out either foot or skull first, whatever end I can get to
first.
Question: How do
you go about dismembering that extremity?
Carhart: Just
traction and rotation, grasping the portion that you can get a hold of which
would be usually somewhere up the shaft of the exposed portion of the fetus,
pulling down on it through the os, using the internal os as your
counter-traction and rotating to dismember the shoulder or the hip or whatever
it would be. Sometimes you will get one leg and you cant get the other
leg out.
Question: In
that situation, are you, when you pull on the arm and remove it, is the fetus
still alive?
Carhart:
Yes.
Question: Do you
consider an arm, for example, to be a substantial portion of the
fetus?
Carhart: In the
way I read it, I think if I lost my arm, that would be a substantial loss to
me. I think I would have to interpret it that way.
Question: And
then what happens next after you remove the arm? You then try to remove the
rest of the fetus?
Carhart: Then I
would go back and attempt to either bring the feet down or bring the skull
down, or even sometimes you bring the other arm down and remove that also and
then get the feet down.
Question: At
what point is the fetus...does the fetus die during that process?
Carhart: I
dont really know. I know that the fetus is alive during the process most
of the time because I can see fetal heartbeat on the ultrasound.
The Court:
Counsel, for what its worth, it still is unclear to me with regard to the
intact D&E when fetal demise occurs.
Question: Okay,
I will try to clarify that. In the procedure of an intact D&E where you
would start foot first, with the situation where the fetus is presented feet
first, tell me how you are able to get the feet out first.
Carhart: Under
ultrasound, you can see the extremities. You know what is what. You know what
the foot is, you know what the arm is, you know what the skull is. By grabbing
the feet and pulling down on it or by grabbing a knee and pulling down on it,
usually you can get one leg out, get the other leg out and bring the fetus out.
I dont know where this...all the controversy about rotating the fetus
comes from. I dont attempt to do that. I just attempt to bring out
whatever is the proximal portion of the fetus.
Question: At the
time that you bring out the feet in this example, is the fetus still
alive?
Carhart:
Yes.
Question: Then
whats the next step you do?
Carhart: I
didnt mention it. I should. I usually attempt to grasp the cord first and
divide the cord, if I can do that.
Question: What
is the cord?
Carhart: The
cord is the structure that transports the blood, both arterial and venous, from
the fetus to the back to the fetus, and it gives the fetus its only source of
oxygen, so that if you can divide the cord, the fetus will eventually die, but
whether this takes five minutes or fifteen minutes and when that occurs, I
dont think anyone really knows.
Question: Are
there situations where you dont divide the cord?
Carhart: There
are situations when I cant.
Question: What
are those
Carhart: I just
cant get to the cord. Its either high above the fetus and
structures where you cant reach up that far. The instruments are only 11
inches long.
Question:
Lets take the situation where you havent divided the cord because
you couldnt, and you have begun to remove a living fetus feet first. What
happens next after you have gotten the feet removed?
Carhart: We
remove the feet and continue with traction on the feet until the abdomen and
the thorax came through the cavity. At that point, I would try...you have to
bring the shoulders down, but you can get enough of them outside, you can do
this with your finger outside of the uterus, and then at that point the
fetal...the base of the fetal skull is usually in the cervical
canal.
Question: What
do you do next?
Carhart: And you
can reach that, and thats where you would rupture the fetal skull to some
extent and aspirate the contents out.
Question: At
what point in that process does fetal demise occur between initial
remove...removal of of the feet or legs and the crushing of the skull, or
Im sorry, the decompressing of the skull?
Carhart: Well,
you know, again, this is where Im not sure what fetal demise is. I mean,
I honestly have to share your concern, your Honor. You can remove the cranial
contents and the fetus will still have a heartbeat for several seconds or
several minutes, so is the fetus alive? I would have to say probably, although
I dont think it has any brain function, so its brain dead at that
point.
Question: So the
brain death might occur when you begin suctioning out of the
cranium?
Carhart: I think
brain death would occur because the suctioning to remove contents is only two
or three seconds, so somewhere in that period of time, obviously not when you
penetrate the skull, because people get shot in the head and the dont die
immediately from that, if they are going to die at all, so that probably is not
sufficient to kill the fetus, but I think removing the brain contents
eventually will .