Q. DOCTOR, GOING BACK TO THE CASES IN WHICH YOU ARE DOING A

11 D&E AND IT PROCEEDS WITH A PARTIALLY INTACT DELIVERY SO THE

12 CALVARIUM IS STUCK IN THE CERVIX, I THINK YOU TESTIFIED THAT

13 YOU SLIDE, YOU USE THE FORCEPS TO CRUSH THE CALVARIUM, RIGHT?

14 A. YES.

15 Q. IS IT FAIR THAT YOU GENERALLY SLIDE THE BIERER FORCEPS, IF

16 YOU ARE USING THOSE, OR ANY FORM OF FORCEPS, UNDER THE CERVIX

17 BETWEEN THE FETUS AND THE UTERINE CAVITY; IS THAT CORRECT?

18 A. I AM SORRY, CAN YOU REPEAT THAT PART?

19 Q. LET ME JUST ASK YOU.

20 CAN YOU DESCRIBE FOR US HOW YOU GET THE FORCEPS

21 AROUND THE CALVARIUM BEFORE CRUSHING IT?

22 A. IN A SITUATION WHERE THE FETUS IS DELIVERED UP UNTIL THE

23 CALVARIUM?

24 Q. THAT'S RIGHT.

25 A. AGAIN, AS I TESTIFIED, I WOULD SEPARATE THE CALVARIUM FROM

1 THE FETUS, SO --

2 Q. LET ME STOP YOU RIGHT THERE.

3 HOW WOULD YOU SEPARATE THE CALVARIUM FROM THE FETUS?

4 A. UNDER DIRECT VISUALIZATION, I WOULD USE, SEEING OUTSIDE OF

5 THE CERVIX WITHIN THE VAGINA THAT I CAN SEE DIRECTLY, I WOULD

6 USE SCISSORS TO CUT THE NECK AND SEPARATE THE -- I AM NOT IN

7 THE UTERUS, I AM IN THE VAGINA, SEPARATING THE FETAL CALVARIUM

8 FROM THE FETAL BODY.

9 Q. AND AFTER YOU'VE DONE THAT, THE CALVARIUM IS STILL IN THE

10 CERVIX?

11 A. OR IN THE LOWER UTERINE SEGMENT.

12 Q. OKAY.

13 THEN WHAT IS THE NEXT STEP THAT YOU DO?

14 A. THE NEXT STEP I WOULD USE IS TO PUT THE BIERER FORCEPS --

15 IS WHAT I MOST LIKELY WOULD BE USING IN THE SITUATION -- INTO

16 THE UTERUS, GET AROUND, OPEN THEM WIDE, GET AROUND THE

17 CALVARIUM, AND CRUSH THE CALVARIUM. JUST AS IF IT WERE HIGHER

18 UP AND NOT STUCK IN THE CERVIX, I WOULD BE DOING IT JUST THE

19 SAME WAY.
-----
HOWEVER, SOMETIMES THE CERVIX IS NOT DILATED ENOUGH

20 TO ALLOW THE CALVARIUM TO PASS.

21 Q. AND WHAT DO YOU THEN DO?

22 A. I WOULD SEPARATE THE CALVARIUM FROM THE BODY.

23 Q. WHEN YOU PERFORM THE EVACUATION IN THE TYPICAL D&E, DO YOU

24 EVER NEED TO CONVERT THE LIE OF THE FETUS OR THE DIRECTION OF

25 THE FETUS?

1 A. SOMETIMES. SOMETIMES THE FETUS IS, AGAIN, WHAT WE WOULD

2 CALL VERTEX OR CEPHALIC. AND THAT IS WHEN THE HEAD IS

3 PRESENTING AT THE CERVIX.

4 THE HEAD IS THE DIFFICULT -- THE MOST DIFFICULT

5 PORTION TO DELIVER IN THESE PROCEDURES, AND OCCASIONALLY I WILL

6 SEE IF I CAN DELIVER THE CRANIUM INITIALLY. OFTEN THAT DOESN'T

7 WORK, AND I WOULD NEED TO REACH IN A LITTLE BIT HIGHER UP WITH

8 THE FORCEPS, GRASP THE LOWER EXTREMITY AND PULL DOWN, AND THAT

9 KIND OF CONVERTS THE PRESENTATION TO A BREECH PRESENTATION.

10 Q. WHEN YOU ARE DOING YOUR REGULAR PROCEDURE, DOES IT EVER

11 HAPPEN THAT YOU BRING OUT THE FETUS INTACT OR PARTIALLY INTACT

12 UP TO THE HEAD?

13 A. YES, SOMETIMES IT DOES.

14 Q. APPROXIMATELY HOW MANY TIMES DOES IT HAPPEN IN YOUR

15 PROCEDURES?

16 A. MAYBE 15 TO 20 PERCENT.

17 Q. AND WHEN THIS HAPPENS, DO YOU CONSIDER IT TO BE A DIFFERENT

18 PROCEDURE FROM AN ABORTION THAN ONE WHICH IS DISARTICULATED

19 BEFORE THAT POINT?

20 A. I DON'T THINK IT IS DIFFERENT, AND I FEEL FORTUNATE WHEN IT

21 HAPPENS IN SOME WAYS, BECAUSE I THINK THAT I WILL THEN HAVE

22 LESS PASSES INTO THE UTERUS, AND I THINK LESS CHANCE FOR INJURY

23 OR INFECTION.