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 can’t 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:
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 don’t 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 it’s 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
don’t know where this...all the controversy about rotating the fetus comes
from. I don’t 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 what’s the next step you do?
Carhart:
I didn’t 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 don’t think anyone
really knows.
Question:
Are there situations where you don’t divide the cord?
Carhart:
There are
situations when I can’t.
Question:
What are those?
Carhart:
I just can’t get to the cord. It’s
either high above the fetus and structures where you can’t reach up that
far. The instruments are only 11 inches long.
Question:
Let’s take the situation where you haven’t divided the cord because you
couldn’t, 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 that’s 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 the feet or legs and the crushing of the skull, or I’m
sorry, the decompressing of the skull?
Carhart:
Well, you know, again, this is where I’m
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 don’t think it
has any brain function, so it’s 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 don’t 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.