Anesthesia or Analgesia Related Deaths of Women From Legal Abortion: The Need for Increased Regulation

Association for Interdisciplinary Research in Values and Social Change
Vol. 12, No. 1 November/December 1997
Thomas W. Strahan, J.D.
Reproduced with Permission

According to the Centers for Disease Control, since 1983 anesthesia-related complications have become the most frequent cause of death of U.S. women from legal abortion. The vast majority of these anesthesia-related deaths appear to occur during first-trimester abortion under general anesthesia. (Lawson, 1994) Despite the known dangers from the use of general anesthesia, compared to local anesthesia, it remains in widespread use. A 1993 survey by the Alan Guttmacher Institute found that 33% of freestanding abortion-facilities and 17% of hospitals, which perform abortions, offer general anesthesia. (Henshaw, 1995) A 1981 survey of National Abortion Federation members found that only 58% exclusively used local anesthesia. (Landy and Lewit, 1982) Another survey by the Alan Guttmacher Institute found that 21.8% of the induced abortions in the U.S. during 1982 were under general anesthesia. (Joseph, 1987)

This article reviews some of the various methods and kinds of anesthesia and/or analgesia used in connection with induced abortion and the risk factors with respect to the various methods. In addition, some of the accumulated evidence of compliance or non-compliance of abortion-facilities with general standards developed for the administration of anesthesia will be reviewed.

Types of Anesthesia or Analgesia

The various types of anesthesia procedures are: general anesthesia, conscious sedation, monitored anesthesia, and local or regional block. General anesthesia includes the loss of consciousness as well as the loss of feeling or sensation. It thus results in the loss of the patient's protective reflexes. Regional block administers anesthesia, frequently by injection with a syringe, to a limited region. In the abortion context, this is usually called a para-cervical block. Conscious sedation reduces or eliminates feeling or sensation. Analgesia relieves pain without loss of consciousness. The lowest effective concentration of analgesic agents should be used. (ACOG Technical Bulletin No.112)

In the abortion context, analgesics or sedatives are used frequently in combination with para-cervical block. If heavy sedation is used it may closely approximate general anesthesia. The analgesics or sedatives may be given orally, by injection, or intravenously. Since the protocol for use of anesthesia or analgesics in the context of induced abortion is controversial, a wide range of various drugs and techniques have been employed.

Fast-acting barbiturates are frequently employed for induced abortion under general anesthesia. Once administered, the drugs rapidly enter the bloodstream. However, although efficient, they tend to compromise safety because of the risk of respiratory depression. The various types include: methohexital (Brevital), thiopental (Pentothal), and thiamylal (Surital). Other drugs known to have been used to induce general anesthesia prior to induced abortion include droperidol (Inapsine), halothane, nitrous oxide and ether. All of these drugs have been implicated in the deaths of women from legal abortion.

The anesthetic, which appears to be most likely to be used for local or para-cervical block, is lidocaine (Xylocaine). Lidocaine may be epinephrine-free or may contain epinephrine (adrenaline). Chloroprocaine (Carbocaine) is also in current use and possibly Marcaine as well. Hydrochloride, bupivacaine, and mepivacine also have been used.

A wide range of analgesics or sedatives has been employed in connection with induced abortion. These may be administered prior to, during or after the abortion. These include: Librium, diazepam (Valium), merperidine (Demerol), Sublimaze, ibuprofen, lorazepam, Althesin, alfathesin, alfentanil, Nubain, morphine-scopolamine, pethidine, midazolam, flumazenil, fentanyl, droperidol (Inapsine), ketamine, enflurane, thiamyal (Surital), halothane (Fluothane), Synalogos DC, and nitrous oxide/oxygen. Some of these drugs have also been experimentally used for para-cervical block, and apparently, depending on the dosage, may be used for general anesthesia as well.

Anesthesia Standards

Somewhat different standards apply depending upon whether local, regional block, conscious sedation or general anesthesia is administered. The American College of Obstetricians and Gynecologists (ACOG) and the Joint Commission for Accreditation of Health Care Organizations have established standards for the use of anesthesia in doctor's offices, outpatient clinics, ambulatory surgical centers, and hospitals. All require record keeping, patient screening and testing, qualified personnel, patient monitoring, and provision for emergency care. ACOG standards state that: "abortion may be performed in a physician's office, an outpatient clinic, a freestanding ambulatory surgical center or a hospital." For second-trimester abortions, instillation abortions, or for patients with other risk factors, an ambulatory surgical facility is preferred and in some States required. ACOG standards only describe local anesthesia or conscious intravenous sedation for physicians' offices or outpatient facilities. Ambulatory surgical centers are specifically authorized to use local, general or regional block anesthesia. They further state that ambulatory surgical facilities, whether freestanding or hospital based, should apply the same standards as hospitals for anesthesia. (ACOG Guidelines, 1996)

According to the Joint Commission for Accreditation of Health Care Organizations, the same standards for general anesthesia also apply to sedation, with or without analgesia, which in the manner used, may be reasonably expected to result in the loss of protective reflexes. Loss of protective reflexes is defined as an inability to handle secretions without aspiration or to maintain a patent (open) airway independently. (JCAHCO, 1996)

Also, some local governments and /or states have statutes or regulations for anesthesia, which would need to be taken into account. Manufacturers' recommendations regarding the use of specific drugs also represent potentially important standards or guidelines.

Local vs. General Anesthesia

According to the Centers for Disease Control (CDC), deaths of women undergoing legal abortion, attributable to general anesthesia complications, represented 29.4% of the total number of legal abortion-related deaths in the U.S. during 1980-1985. It was further reported that at least 23 of the 27 deaths from general anesthesia complications were due to hypoventilation and/or loss of airway resulting in hypoxia (decreased oxygen) of which 24 occurred during the first trimester. The proportion of deaths of women from legal abortion, caused by general anesthesia complications, was 30% in freestanding clinics and 28.5% in hospitals. The type of anesthetic was known in 23 of the 27 cases, including 21 women who received short-acting barbiturates. The women who received short-acting barbiturates included 15 who received methohexital (Brevital), 3 who received thiopental (Pentothal), 2 who received thiamylal (Surital), and one who received an unspecified short-acting barbiturate. In addition, one woman received droperidol (Inapsine) and one woman was given nitrous oxide and ether. (Abash, 1988)

The results of another investigation were published in a recent book entitled Victims of Choice (1996), written by Kevin Sherlock. This investigation used newspaper reports, coroner reports, malpractice suits and other investigative information, to identify 135 clearly established or suspected deaths of U.S. women from legal abortion during 1973-1994. Of these, at least 36 (26.6%) were anesthesia- or analgesia-related, of which at least twenty-two (22) involved reports of coroners or medical examiners. Of the 36 anesthesia-related deaths, at least 23 resulted in malpractice claims against the abortion-facility by the next of kin of the deceased woman. Some of the deaths resulted in investigations by State health-departments, district attorney's offices or medical licensing boards.

32 of the deaths occurred following induced abortions in freestanding facilities, while 4 occurred after abortions in facilities, which were described as hospitals. Of the four hospitals, one was found to be seriously deficient in emergency care, while another was a place where several women had died from legal abortion for various other reasons.

The investigation identified at least 10 deaths related to general anesthesia, 4 deaths related to local anesthesia, and 3 deaths related to analgesia. The type of anesthesia related to the remaining deaths was unspecified. The identified drugs used for general anesthesia were: Brevital (3), fast-acting barbiturate (1), intravenous anesthesia (1), halothane (1), and nitrous oxide (1). The drugs associated with deaths from local anesthesia were: lidocaine with epinephrine and Librium (1), and lidocaine (Xylocaine, Zylocaine) (3). The analgesic drugs related to deaths from legal abortion were: a suspected Demerol overdose, a Sublimaze reaction with Thorazine, and an unspecified painkiller, which caused vomiting and the abortionist failed to clear the airway. Again, the majority of deaths appeared to be related to general anesthesia. (Sherlock, 1996)

An earlier study using data from the CDC and the Alan Guttmacher Institute from 1972-77, also concluded that the use of general anesthesia was associated with a twofold to fourfold increased risk of death from abortion, compared to local anesthesia for abortions at twelve gestational weeks or less. (Peterson, 1981) Local anesthesia has also been found to be safer than general anesthesia for second-trimester abortion. (Mackay, 1985)

The use of general anesthesia also appears to be a contributing cause of abortion-related deaths of women from other causes. A CDC study of women during 1971-1975 who were undergoing first- trimester abortion, found that the incidence of uterine hemorrhage, uterine perforation, intra-abdominal hemorrhage, and cervical injury were all significantly higher for general anesthesia compared to local anesthesia. (Grimes, 1978)

According to the CDC, 20% of the abortion-related deaths of women in the U.S. during 1972-1987 resulted from severe hemorrhaging. (Lawson, 1994) And it has been reported by the CDC that uterine trauma (perforation or rupture) increases by 1000-fold the risk of death of women from legal abortion. (Grimes, 1983)

Loss of Protective Reflex

In addition to the loss of protective reflexes preventing independent breathing or aspiration, a woman undergoing abortion under general anesthesia may lose the ability to feel pain or other sensations. There is an increased likelihood of general anesthesia increasing the risk of cervical laceration, perforation and hemorrhage. This is thought to be due to the protective effects of a conscious patient who reacts when the person performing the abortion pushes too hard with an instrument, thus helping to prevent injury.

Warren Hern, in his book on Abortion Practice, compares local versus general anesthesia, and states: "It is preferable to have a patient who is uncomfortable but able to tell me what she is feeling, and if she feels a strange new abdominal pain, than to have a patient who is quite comfortable because she is dead." He also has observed that the woman is "alert, responsive and communicative both during and after an abortion procedure under local anesthesia. She is able to report important symptoms that may signal the onset of serious complications, in time to prevent them from becoming more serious or even fatal." He also states that the gag reflex is not diminished under local anesthesia, whereas it is suppressed under general anesthesia. (Hern, 1990)

Another abortionist who used local anesthesia for second-trimester D & E abortion instructed the woman as follows: "If, during the procedure, you feel tightness in your chest, the urge to cough, or feel any unusual sensations, please communicate with the nurse, counselor or doctor immediately while the procedure is going on."(emphasis in original). (Hanson, 1985) A review article similarly stated, "Use of general anesthesia increases the risk of cervical laceration, perforation and hemorrhage with D & E. We think this is because the conscious patient reacts when the surgeon pushes too hard with an instrument, thereby causing injury. (Stubblefield, 1986)

Local or Para-cervical Blocks

The use of local anesthesia, although considered safer than general anesthesia, also carries a risk of death. In one death, a toxic level of lidocaine was found, when 25 ml. of 2% lidocaine, without epinephrine (500 mg.) was administered to produce both a para-cervical and pudential block. In another case, a woman died after receiving 20 ml. of 1% mepivacaine (200 mg.).(Grimes and Cates, 1976) In two other cases, it appeared that the women died from an overdose of epinephrine-free lidocaine, which exceeded the manufacturer's recommendations for their body weight. (Berger, 1974) After these deaths, a study was undertaken to determine the minimum dosage of lidocaine to eliminate toxicity in the blood. It concluded that 90-100 mg. of lidocaine was associated with safe blood levels. (Blanco, 1982)

There has been very limited study of the overall risk of life-threatening convulsions in connection with induced abortion under local anesthesia. In the Joint Program for the Study of Abortion (JPSA), which took place in the early 1970's, an incidence of 7 convulsions was reported among 19,792 suction-curettage abortions, performed under local anesthesia, for a rate of 3.5 per 10,000 abortions. (Berger, 1974) Another later study reported three significant lidocaine reactions in 11,747 second-trimester dilatation and evacuation abortions. (Peterson, 1983)

Because of the risk of toxicity from para-cervical anesthesia, the CDC stated in 1976 that, "... physicians should administer para-cervical anesthesia only in settings in which resuscitative drugs and equipment, as well as personnel skilled in their use, are immediately available. If toxicity is suspected, the injection should be stopped immediately. The patient should be given high concentrations of oxygen by mask, to raise her oxygen reserve in case convulsions ensue. If tremor, twitching or convulsions occur, the patient should be treated with intravenous diazepam or a rapid-acting barbiturate... If cardiovascular arrest occurs, the patient should be treated in the usual manner with oxygen-ventilation, cardiac massage, bicarbonate and inotropic agents." (Grimes and Cates, 1976)

A later study at Planned Parenthood abortion-facilities reported 5 convulsive seizures among 22,000 women, obtaining first-trimester abortions under para-cervical block. This represents a rate of 2.3 per 10,000 abortions. After the occurrence of these seizures, a protocol was introduced, which limited the injection of 1% lidocaine to no more than 16 ml. and usually only 12 ml. This was done because it was concluded that the early anesthetic complications occurred because an excessive amount of anesthesia was given in fewer sites, without withdrawal of the syringe plunger to assure that the anesthetic had not entered a blood vessel. Because it was clearly shown that seizures can occur during abortion under local anesthesia, it was concluded that it is necessary to have resuscitative drugs, an airway, oxygen, and trained personnel immediately available to the procedure room. It was also concluded that personnel should include those who are certified in cardiopulmonary resuscitation (CPR). Also, if patients had a suspicious history of idiosyncratic reaction to local anesthetic agents, they were not given local anesthetic agents. After the introduction of these changes, no further convulsive seizures were reported. (Hakim-Elahi, 1990)

Pre-Existing Risk Factors in Women

Some women are allergic to, or have a sensitivity to drugs used as anesthetics for induced abortion. This may occur with both local and general anesthesia. Allergic reactions to lidocaine, as well as general anesthetics, which resulted in the death of women, have been reported. However, despite this fact, a medical history form used by an abortion-facility may only ask a single general question as to whether or not the woman has any allergies. Another abortion-facility, in a form entitled Facts about Early Abortion, merely stated: " Some women may be allergic to novocaine derivatives. If this is known, it is important to tell the doctor." Nothing was stated about the potential risk factors of allergic reactions.

A leading article on abortion-practice states that induced abortion under general anesthesia is contra-indicated if the woman has a history of cardiac failure or cyanotic heart disease. In that case, it states that the abortion ought to be done in a hospital under local anesthetic, intravenous sedation, cardiac monitoring, and with an anesthesiologist present. (Stubblefield, 1986) Despite this risk factor, some facilities may not examine the woman or be made aware in advance of administering general anesthesia.

One study found that obesity, previous thrombophlebitis, use of oral contraceptives, type A blood, or concurrent sterilization were risk factors for death of women, caused by pulmonary thromboembolism after legal abortion under general anesthesia. (Kimball, 1978)

A CDC study of women, who had died during 1972-1985 from general anesthesia complications of induced abortion, identified 9 out of 27 women to have pre-existing medical conditions. These were asthma (1), hypertension and obesity (1), multiple sclerosis (1), fever and diarrhea (1), cervical cone biopsy (1), and obesity (4). The book, Victims of Choice, identified: bronchial asthma (1), bronchial asthma and contact sensitivity (1), chronic asthmatic (1) and pre-existing unspecified lung problems (1), as risk factors in anesthesia-related deaths from legal abortion. (Atrash, 1988)

Another pre-existing risk factor for death from anesthesia-reactions may be the color of the woman's skin. The CDC has observed that if the woman's skin is a color other than white and she exhibits hypoxia, it may make it more difficult to recognize if she has cyanosis (a dark blue or purple color), compared to a white-skinned woman. (Atrash, 1988) There is some evidence for this. In the study of 36 women with clearly established or suspected anesthesia-related deaths from induced abortion, reported in Victims of Choice, among the 18 women whose race was identified, only 4 were identified as white, while 9 were identified as black. 5 appeared to be other women of color, who were Japanese (1), Spanish (1), Mexican (1), Asian/Japanese (1), or Haitian (1). (Sherlock, 1996)

The pre-existing use of drugs may also constitute a risk factor for death, when interacting with analgesic or anesthetic drugs used in induced-abortion procedures. In 1981 a Missouri woman died who was taking the anti-psychotic drug Thorazine. She was given Valium and Sublimaze in the process of obtaining an induced abortion and subsequently died. The abortion-facility was accused of not having heart-monitoring equipment, general-anesthetic equipment or adequate resuscitation equipment or procedures. In another instance, a Maryland woman died in 1989 after receiving a fast-acting barbiturate prior to the abortion. She went into cardiac arrest and was deprived of oxygen for 12 minutes, before paramedics arrived on the scene. Medical examiners later found a trace of heroin in her blood. (Sherlock, 1996)

Failure to take an adequate medical history may result in women with asthma or other lung problems to be at risk, particularly for abortion under general anesthesia. In one instance a woman died following general anesthesia, administered by a nurse anesthetist in preparation for an induced abortion. The decedent had a history of asthma. She was one of four women who died at the same facility from anesthesia-related causes during 1986-1988. Her death-certificate listed bronchial asthma, and contact-sensitivity as a contributing cause of her death from the sequelae of anoxia due to respiratory arrest. Bronchial asthma was the contributing factor in the death of another woman at the same facility, from anesthesia-related complications, in connection with induced abortion. Later the abortionist at the facility lost his license to practice medicine, because of failure to take adequate medical histories of women, among other reasons. (Sherlock, 1996)

Risk Factors related to the Abortion Process

There are several risk factors for anesthesia-related death from legal abortion, which can occur in connection with the abortion or following the abortion. For example, the CDC found that at least 23 of the 27 deaths of U.S. women during 1980-1985 from anesthesia-complications were due to hypoventilation (underventilation, increased levels of carbon dioxide) and/or loss of airway resulting in hypoxia (low Ievels of oxygen). (Atrash, 1988) Lack of oxygen or loss of airway implies that the personnel involved may have been negligent by not clearing the airway or providing necessary oxygen.

This was confirmed in Victims of Choice. This investigation reported on 135 U.S. women, who died from legal abortion from 1973-1994, and found that there were 36 anesthesia-related deaths, related to legal abortion. In at least 11 cases there was evidence of failure or incompetent intubation or attempt to resuscitate. In addition, there was evidence of lack of emergency-equipment in 8 cases, negligent or unqualified personnel in 12 cases, and failure to monitor women in 8 cases.

In at least 6 of the cases the paramedics were called. However, in one instance there was a 40- minute delay before they arrived; in another case they arrived 20 minutes after the woman stopped breathing; in still another case they arrived after the woman had been without oxygen for at least 12 minutes, and another where the paramedics arrived 1 to 1_ hours after the initial onset of difficulty. In another instance the woman was blue and in cardiac arrest when the paramedics arrived. They also reported that the abortion staffers had put an oxygen mask upside down on her face. Thus, it appears that a substantial number of the women would not have died if the abortion-facility had competent personnel and adequate equipment, along with a pre-established plan to put into operation to handle an emergency situation. (Sherlock, 1996)

Women may select general anesthesia without being made aware of the risks. For example, general anesthesia may be promoted by abortion-facility "counselors'' for economic reasons, because there is frequently an additional charge by the abortion-facility for general anesthesia. According to press reports, one abortion-clinic attempted to do so by offering "counselors" additional cash bonuses, if general anesthesia was used. In this instance, the abortion-facility paid "counselors " a $2 bonus for general anesthesia, while Demerol and Valium bonuses were 75 cents, and local anesthesia was only a 25-cent bonus. (Crutcher, 1996)

An examination of various forms of abortion-facilities also indicates that a description of risks from anesthesia may be inaccurate or incomplete. For example, a form, entitled Facts about Early Abortion, which is provided to women seeking induced-abortion, contains this statement: "A local anesthetic is usually injected into the cervix (lower part of the uterus). In some cases a tranquilizing medicine is administered. A general anesthetic may also be used." In a later section on the same page, under Local Anesthetic Reaction, it states: "Some women may be allergic to novicaine derivatives. If this is known, it is important to tell the doctor." Other than warning about possible narcotic allergic reactions, no information whatsoever was provided on the risks of local anesthetic, tranquilizers, or general anesthetic.

Vomiting during an abortion is a risk factor for death. If the woman is under local anesthesia her "gag reflex" would still be functioning. However, if she is under general anesthesia it would be impaired and increase the risk of death as a result. Vomiting may occur because the woman has recently had food prior to her undergoing abortion, despite a possible warning not to do so. Vomiting can also occur because of anesthetic or analgesic drug reactions. In one case death resulted when a woman went rigid from an apparent seizure and then started vomiting. She had been given an analgesic known to cause vomiting, and the abortionist had failed to determine whether or not she had recently eaten. He continued with the abortion and made no attempt to clear her airway. She later died in a hospital. (Sherlock, 1996, p.30)

Movement of the woman during the abortion procedure may also increase the risk of an anesthesia overdose. In one study, which used either alfentanil and nitrous oxide or fentanyl and nitrous oxide as an anesthetic during induced abortion, approximately two thirds of the women were reported to have moved during the abortion procedure. In 23-30% of the cases the movement was vigorous. This necessitated repeated additional doses of narcotics, and in about 20% of the cases required one or two incremental doses of thiopentone. (Enright and Parker, 1988)

Use of Anesthesia for Distressed or Exploited Women

Fear, anxiety or discomfort prior to or during the abortion-procedure may influence the type or kind of anesthesia. One study of 101 women, undergoing abortion under local anesthesia and various analgesia, reported that 52 felt calm, 20 were sense, 19 were worried, and 9 felt horrified, and 22 had severe or very severe pain. (Jakobbson, 1990) This pain and anxiety, or lack of patient-cooperation (a phrase coined by an abortionist) can lead to a number of possible abuses with anesthesia. Some abortionists will resort to heavy sedation or general anesthesia to make certain the abortion occurs. One Wisconsin abortionist required women to sign a statement in advance, authorizing him to administer Twilight Sleep, Valium and Demerol l.V., if necessary in his judgment, in order to complete the abortion procedure.

Another article, describing abortion-procedures, stated, "Unless lack of patient-cooperation indicate otherwise, (abortion) is carried out under cervical block" (emphasis added). (Castadot, 1986) One Swedish study of patient-discomfort among 101 women, using local anesthesia and pre-medication, reported that 6 women, who were perceived by the doctors as not cooperating, received additional anesthesia. (Jakobbson, 1990)

General anesthesia may be used on special populations who undergo induced abortion. For example, an abortion-facility may, as a matter of policy, administer general anesthesia to all teenagers undergoing abortion, apparently because of their frequent fear and anxiety. (Donati, 1996) General anesthesia also appears to be routinely used if fetal tissue or organs are to be obtained, apparently to protect against distress of the woman. (Lindvall, 1989) (Gustavii, 1989) (Peterson, CM et al., 1988)

Analgesic or anesthetic drugs may be used as a form of manipulation to induce a woman to obtain an abortion. At a Missouri abortion-facility women were administered the sedatives Anaprox DS and Hydroxyzine, to reduce anxiety and which also cause drowsiness, thus altering their state of consciousness, before they completed the consent process. (Sloan vs. Women's Community Health Center). In another instance, a woman, who was fearful and ambivalent and still resisting undergoing an abortion, was administered an anesthetic intravenously without her knowledge or consent, which resulted in her having no recollection of the procedure. She subsequently suffered both physical and emotional injury.

A woman may seek out general anesthesia in repeat abortions, if she has had severe pain from an earlier abortion under local anesthesia. Women having first or repeat abortions may also select general anesthesia, in an attempt to repress the abortion experience and attempt to alleviate psychological distress. (Polk-Walker, 1993) However, women who fail to take emotional considerations into account, engage in denial, or let others decide for them have not received proper counseling (Landy, 1986), and may end up regretting their decision later. (Reardon, 1987)

Anesthesia Record-Keeping

The medical history and operating report of a significant number of abortion-facilities is frequently very sketchy, particularly with medical records, reviewed in connection with possible malpractice litigation. For example, one operating report of a woman with post-abortion complications did record vital signs and the analgesic used, but did not record at all the type or amount of anesthesia administered, nor was there any record of a consent of the woman undergoing the abortion. In addition, the medical history was reported to be "minimal" and the physical exam "cursory" as described by a medical expert.

In another instance, the operative report provided the name of the anesthesiologist, recorded that general anesthesia had been administered for a three-minute period, which coincided with the time of the abortion operation. But, there was no mention of the type or amount or method used. Although the woman aspirated gastric or mouth contents into her lungs while under general anesthesia, there was no mention of it on the operative report. Instead, it merely stated that the patient tolerated the procedure well and was taken to the recovery room in satisfactory condition. The aspiration resulted in a lung infection shortly after leaving the facility, with a high fever approaching 105 degrees C. Subsequently, she died after negligent treatment for her bronchial infection at another hospital. (Jeffies vs. Memorial Hospital of Gardena).

In a third instance, a woman was admitted for a first-trimester abortion under local anesthesia. The type and amount of local anesthesia was 40 cc of 1% carbocaine (400 mg.). It was not stated whether or not the carbocaine contained epinephrine or was epinephrine-free. Nor was there any reference to the woman's body weight. In the expert medical review of the case no mention was made of the dosage of local anesthesia. This may be due to the fact that the minimum dosage of carbocaine for induced-abortion under local anesthesia had not yet been determined. However, other references indicate that a much lower amount should be used. Thus, a potentially toxic dosage may have been administered.


It appears that a substantial number of anesthesia-related deaths from legal abortion are preventable. There is evidence of an over-use of general anesthesia by abortion-facilities, possibly because it permits greater efficiency of operation, and possible increased-revenues for those who use it. General anesthesia or heavy sedation also is a potentially effective tool of control over women to assure that abortion occurs even among those who are anxious, nervous or fearful of obtaining an abortion. General anesthesia appears to be particularly attractive to women who are attempting to repress the abortion-experience or who are suffering psychological distress. Thus, it appears that there is a particular moral aspect to abortion, that is a factor in the use of general anesthesia for induced abortion.

The evidence is clear and convincing that general anesthesia has a greater risk of death or serious injury than local anesthesia. Part of the greater risk occurs because of inadequate screening, testing and evaluation of women seeking abortion. Another important reason for increased risk appears to be due to inadequately trained or negligent personnel, involved in the administration of anesthesia. When anesthesia-related deaths have occurred, there is frequently poor or non-existent monitoring of patients, and an appalling lack of adequate provision for emergency care and treatment. However, there appear to be adequate standards or guidelines in place, which could be applied in a more systematic manner with respect to abortion-facilities, to prevent deaths from occurring. In some situations, additional legislation may be necessary. But it appears that all that is necessary is to require abortion-facilities to only meet the same anesthesia standards required of other medical facilities.

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