Draft: Shortened Walsh Report now online

Draft Report on Symphysiotomy in Ireland from 1944 to 1984

 

Please note: This report is disputed by SOS Ireland and is provided as an aide to researchers and those studying the subject. The report is in no way endorsed by Survivors of Symphysiotomy. For a commentary on SOS’s position please click here

For a PDF version of the report please use this link

About the Draft Report

 

This document is a shorter version of the Draft Report on Symphysiotomy in Ireland

1944 to 1984. (Symphysiotomy is pronounced sim-fizzy-ot-o-me).

 

The draft report is the first stage of a two-stage process. This first stage sets out the

history of the practice of symphysiotomy in Ireland from 1944 to 1984. The second

stage will include a consultation process on the draft report.

 

Symphysiotomy is an operation to widen a woman’s pelvis during difficult childbirth.

It was usually carried out under local anaesthetic and involved cutting fibres around

the pelvic bones to separate the bones and allow the baby to pass through.

Symphysiotomy was used in cases where caesarean sections were not suitable, for

example, if the mother was too ill or there wasn’t enough time.

 

Concerns about symphysiotomy and its long-term effects on women who underwent

the operation emerged in 2001. Since then, there have been calls for an inquiry into

the practice. Several Ministers for Health ruled out a full-scale inquiry. Finally,

Minister for Health Mary Harney agreed to commission a report on the practice.

 

This report is the third attempt to examine the practice of symphysiotomy in 20th

century Ireland. Unfortunately, the first two attempts fell through for various reasons.

Now, it is hoped that this report will serve the women who underwent this procedure

and who deserve an investigation that establishes the facts and acknowledges the

anxiety and pain that they have carried for many years.

 

The report focuses on the period 1944 to 1984 although symphysiotomy was used

mostly from the late 1940s right through to the 1960s. After that time, caesarean

sections were used more in difficult births.

 

 

 

 

 

Information was gathered from maternity hospitals all over the country but the most

complete information comes from the Dublin area. Also, information from Our Lady

of Lourdes Hospital in Drogheda was examined because there is particular concern

that the practice of symphysiotomy continued there for longer than at any other

hospital. The Dublin hospitals produced annual reports giving details about the use

of symphysiotomy. Information for other parts of the country is scarce as the level of

record-keeping and reporting varied from one region to another.

 

What this report covers (Terms of Reference)

 

The following are the Terms of Reference agreed with the Department of Health and

Children for this report:

 

Report on the rates of symphysiotomy and maternal mortality (the number of

women who died in childbirth) in Ireland from 1944 to 1984 by referring to

available information including annual reports and other reports.

Examine symphysiotomy rates against maternal mortality rates over the time

in question.

Examine international reviews of symphysiotomy practice and associated

rates in other countries and compare to Ireland.

Review any guidelines and protocols that applied to symphysiotomy in Ireland

during the time in question.

Write a report based on the findings, providing an accurate picture of the

extent of the use of symphysiotomy in Ireland and an examination of the Irish

experience compared to other countries.

Objectives added by the author

 

The practice of symphysiotomy is controversial and has left survivors of the

procedure with suspicions and anxieties. In Ireland, survivors are concerned about

the influence of the Catholic Church. The Catholic Church’s opposition to

 

 

 

 

 

contraception and sterilisation meant that caesarean sections – which might limit the

number of children a woman might have – would not be in keeping with the Church’s

teachings. Therefore, in addition to the terms of reference agreed with the

Department of Health and Children, the author of this report tried to review

information that might help to answer two key questions:

 

Why was symphysiotomy used in Ireland at a time when other countries had

stopped using it?

Was the decision to perform a symphysiotomy sometimes based on religious

beliefs rather than good clinical judgement where a caesarean section might

have been better for the mother?

How the report was done (Methodology)

 

Information for the report was gathered in the following ways:

 

Databases relating to maternal care in Britain, Spain, Germany, France and

Italy were accessed and searched. Also, worldwide information held by the

Organisation for Economic Co-operation and Development (OECD) was

reviewed.

Requests for information were made to libraries and national records systems

in each of the countries named above.

Paper records in Ireland were checked, including Department of Health files in

the National Archives and annual reports of hospitals held in the National

Library.

All the Irish public maternity hospitals were asked to provide records of

statistics relating to symphysiotomy rates, if these existed.

Data from the Central Statistics Office on health and maternity care were

examined.

 

 

 

A literature review was completed using searches of the online medical

journals PubMed and Medline as well as hard copy searches of mid-20th

century medical journals held at University College Cork and the National

Library, Dublin.

Limitations of available sources

 

Maternity hospitals were not required to produce annual reports in the 1940s, 1950s

or 1960s so no firm statistics are available.

 

Findings in relation to the Terms of Reference

 

Symphysiotomy rates, mortality rates and so on

 

This short version of the Draft Report gives a small sample of the findings. They

relate to the Rotunda Hospital, Dublin, in 1952. You can read the detailed findings for

all the maternity hospitals in the full version of the report where much of the

information is laid out in tables.

 

Rotunda Hospital

Year of most symphysiotomies: 1952

Total number of deliveries: 5,874

Number of symphysiotomies: 7

Number of maternal deaths related to symphysiotomies: 0

Number of infant deaths related to symphysiotomies: 0

Number of caesarean sections: 201

Number of maternal deaths related to caesarean sections: 1

Number of infant deaths related to caesarean sections: 34

 

The tables in the full version of the report present findings for the Rotunda Hospital,

the National Maternity Hospital (Holles Street), the Coombe Hospital and Our Lady

of Lourdes Hospital in Drogheda. The detail is greater in the full report and the tables

cover about 15-20 years. There is some additional information from these records in

 

 

 

 

 

the report. For example, in some cases information about the health of the woman

after a symphysiotomy was performed or the reason why it was performed is

included.

 

Examine international reviews of the practice of symphysiotomy

 

The practice of symphysiotomy was at its peak in Ireland at a time when the practice

had declined in the rest of Europe but before it became common in the developing

world.

 

Guidelines and protocols regarding symphysiotomy in Ireland

 

There were no regulations or protocols for symphysiotomy in mid-20th century

Ireland. Medical professionals discussed symphysiotomy and their opinions and

experience guided the practice. This lack of regulation meant that some women

underwent symphysiotomy without giving their consent and some women were

unaware that a symphysiotomy had been performed on them.

 

Summary of findings

 

Symphysiotomy, which had been practised in the early 20th century, was reintroduced

into certain Irish hospitals in the 1940s to help women who had

difficulty giving birth due to narrow or obstructed birth passages. It was

considered to be the most suitable thing to do in order to obey the laws of the

time. The law between 1944 and 1984 was very much influenced by the

teachings of the Catholic Church which meant that contraception and

sterilisation to prevent pregnancy were illegal and unacceptable.

Symphysiotomy was favoured over caesarean sections as, in the 1940s and

1950s, the safety of repeat caesarean sections was unproven.

Symphysiotomy was used mostly in emergencies when labour became

difficult and the mother couldn’t deliver her baby safely without help. It was

considered to be an appropriate procedure in these circumstances.

Symphysiotomy was never proposed as an alternative to caesarean section.

The rates of caesarean sections rose steadily in the 1950s and 1960s.

 

 

 

Symphysiotomy was a safer way of dealing with difficult births than caesarean

section in the 1940s and 1950s. Fewer mothers and babies died as a result of

symphysiotomy compared to the death rates associated with caesarean

sections. Overall, symphysiotomy was not used very often. Between 1950 and

1955 for example, it was used on average in one in every 200 deliveries

(0.47%) in the Coombe and National Maternity Hospital (Holles Street).

Between 1960 and 1965, it was used in one in a 100 deliveries (0.98%) at Our

Lady of Lourdes Hospital, Drogheda.

The use of symphysiotomy was continually reviewed and discussed by the

medical profession and the practice was used less often as women’s general

health improved and the safety rates of caesarean sections improved.

Symphysiotomy was wrongly used in a number of cases. There were cases of

‘symphysiotomy on the way out’. This means that the procedure was

performed after the woman had already given birth by caesarean section.

Before the woman’s abdomen was closed after the section, the

symphysiotomy was performed to increase the chances of the woman having

a normal delivery on her next baby.

Symphysiotomy was used at Our Lady of Lourdes Hospital, Drogheda until

1984 which is not in keeping with the rest of the country. The practice

declined everywhere else from the mid-1960s.

Recommendations

 

Recommendations will be made when the second stage of the two-stage process –

the consultation stage – is completed.

 

 

 

 

 

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Index

 

Overview p. 2

Note on Focus of the Draft Report p. 2

Methodology p. 3

Limitations of Available Sources p. 4

Terms of Reference p. 8

Additional Objectives p. 9

Definition of Symphysiotomy p. 14

Religion and Irish Obstetrics p. 16

Rates of Symphysiotomy and CS in the Dublin Hospitals p. 21

Guidelines and Protocols for Symphysiotomy in Ireland p. 24

Alternatives to Symphysiotomy or CS for Disproportion p. 32

Maternal Health and Symphysiotomy p. 32

Context for Reintroduction of Symphysiotomy p. 38

Relative risks of Symphysiotomy and Caesarean Section p. 40

Long-term Effects of Symphysiotomy p. 44

The Decline in Symphysiotomy p. 49

Our Lady of Lourdes Hospital, Drogheda p. 52

Symphysiotomy ‘On the Way Out’ p. 57

Issues of Consent p. 65

Findings and Recommendations p. 70

Select Bibliography of Secondary Medical Literature p. 72

 

 

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Dr Oonagh Walsh,

 

University College Cork

 

Draft Report on Symphysiotomy in Ireland, 1944-1984

 

Overview:

 

This draft report is the first stage of a two-stage process aimed at fulfilling the

request of the previous Minister for Health and Children (Mary Harney) in relation to

the practice of symphysiotomy in Ireland. This first phase is an independent

academic research report. The second phase will involve consultation with relevant

stakeholders to provide comment on the report. The final report will not be

concluded until this process has been completed. This draft report has been

compiled with reference to printed sources, and analysis of medical reports and

research, and this first stage has not involved interviews with individuals directly

involved in symphysiotomies (mothers, practitioners and midwives in particular). This

approach is central to the production of an independent report, compiled without

influence or input from vested interests. Once the independent baseline has been

established, the researcher will seek both feedback from the stakeholders, and

further input from those with direct experience in the procedure. From the

announcement of this project, the author had unsolicited contact from various

individuals with experience of the procedure, offering their perspectives. None of

these offers of assistance were followed up, in order to ensure that this report

remained free from influence from either proponents of the procedure, or opponents

of it. Now that the draft report is complete, the author will seek additional input in

order to ensure that the final report, which will be placed in the public domain,

reflects as accurately as possible the history of symphysiotomy in Ireland.

 

Note on Focus of the Draft Report:

 

The report focuses on the years 1944 to 1984, the period in which symphysiotomy

was employed in some Irish hospitals. The years of most significant use were from

the late 1940s to the 1960s, when the operation was largely superseded by Lower

Segment Caesarean Section as a response to obstructed labour. The draft report

 

 

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draws heavily on the position in Dublin, and in Our Lady of Lourdes Hospital in

Drogheda, given the particular concerns expressed regarding practice there. These

hospitals produced periodic annual reports, with specific detail regarding

symphysiotomy and its uses. The national picture is far less clear.1 Most maternity

hospitals did not produce annual reports, and the survival of individual maternity

registers, and indeed patient medical charts varies from region to region. At this

stage it is important to identify the prevalence of the procedure from the 1940s to the

1980s on the basis of available figures. A figure of 1,500 symphysiotomies has been

suggested for this period 1944-19922. Preliminary figures from regional maternity

hospitals suggest the usage was a good deal lower than in the capital, and the

procedure does not appear to have been used at all in some centres. 1,500

symphysiotomies between 1944 and 1992 gives a rate of 0.05 as a percentage of

total deliveries, or a symphysiotomy rate of 0.03 per 100,000 births.3 Thus it was a

rare intervention in comparison with caesarean section, for example, which rose

steadily in the same period from a rate of just under 2% of deliveries in 1944 to over

4% nationally in 1984. This is not in any way to minimise the suffering of the women

who underwent the operation, but it does indicate its exceptionalism in Ireland as a

whole.

 

Methodology:

 

The study sets out to establish accurate rates of usage of symphysiotomy in Ireland

as a whole, and to compare its use in other European countries in the second half of

the twentieth century. Searches were undertaken of databases relating to maternal

care in Britain, Spain, Germany, France, and Italy, as well as OECD world-wide

material. Requests for information were also made to repositories and national

records systems in each of these countries. Printed primary sources in Ireland were

checked, including Department of Health files in the National Archives, and Annual

Reports in the National Library. All of the Irish public maternity hospitals were

 

 

 

 

1 Although individual hospitals have been helpful with regard to gathering statistics there are

significant problems. Not least of these is the fact that few hospitals compiled annual reports in the

mid-twentieth century, and recovering detail on specific operations requires hand searches of data on

operations undertaken, and the consultation of case notes, which is outside the terms of reference of

this report.

2 Marie O’Connor, Bodily Harm: Symphysiotomy and Pubiotomy in Ireland, 1944-92, ‘Executive

summary’, p. 12.

3 There were 2,527,896 births in the Republic of Ireland between 1944 and 1992 inclusive. Central

Statistics Office, Vital Statistics, Births by State, Year and Statistic, 1944-1992.

 

 

 

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contacted to determine the availability of statistics relating to rates of the procedure.4

The Central Statistics Data on Health and on maternity care was examined. A

comprehensive secondary literature review was undertaken using searches of

PubMed and Medline, as well as hard copy searches of mid-twentieth century

medical journals held at University College Cork and the National Library, Dublin.

 

Limitations of Available Sources:

 

In Ireland and abroad it has proved very difficult to secure accurate figures regarding

the use of symphysiotomy. From the early twentieth century, when the technique

was adapted by Zarate to prevent the complete division of the pubic symphysis, the

procedure was employed throughout Europe, albeit in small numbers relative to

overall deliveries. However, as maternity hospitals were not required to produce

annual reports, evidence of usage is often anecdotal, and no firm statistics are

available. There has never been a randomised trial of symphysiotomy (one of the

standards for the evaluation of a medical procedure) in any country, although there is

a substantial body of medical literature on its use in specific hospitals and regions

worldwide (see bibliography). Britain was originally chosen as a comparator in this

study, and searches of the National Health Service Health and Social Care

Information Centre database, and the British Department of Health Hospital Episode

Statistics were undertaken. No results for symphysiotomy were found,5 although the

procedure was in fact employed sporadically throughout the UK after 1945,6 and

periodic discussions took place in the medical journals regarding a possible revival of

the procedure in the face of a rising caesarean section rate.7 Staff in the NHS

records departments also undertook searches, without success. The material

compiled by the Royal College of Obstetricians and Gynaecologists in London is too

 

 

 

 

4 Cork University Maternity Hospital; Kerry General Hospital, Tralee; South Tipperary General

Hospital; St Luke’s General Hospital Kilkenny; Waterford Regional Hospital; Wexford General

Hospital; Galway University Hospitals; Letterkenny General Hospital; Mayo General Hospital,

Castlebar; Portiuncula Hospital, Ballinasloe; Sligo General Hospital; Mid Western Regional Maternity

Hospital Limerick; Cavan/Monaghan Hospital Group ; Midland Regional Hospital Mullingar and

Midland Regional Hospital Portlaoise.

5 In common with other European countries, including Ireland, Britain’s searchable statistics cover the

relatively recent past. The Hospital Episode Statistics (HES) begin in 1989, and do not cover all

procedures.

6 Statements by British obstetricians in the Reports of the Dublin maternity hospitals confirm that the

operation was occasionally performed in Britain in the late 1940s, but it is impossible to determine the

extent of its use without hand-searches of archival material, where it survives.

7 Donald A.M. Gebbie, ‘Vacuum Extraction and Symphysiotomy’ in the British Medical Journal

(February 4, 1967), Vol. 1, p. 301.

 

 

 

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recent to include symphysiotomy, and searches of their historic statistics have shown

no mention of the procedure.8 However, a 2003 article in the British Journal of

Obstetrics and Gynaecology describes three recent British cases, and argues for the

use of the procedure in certain carefully selected deliveries.9 As there is a strong

connection between the use of symphysiotomy and an acceptance of Catholic

precepts regarding contraception and sterilisation, data from Spain and Southern

Germany was examined for rates. There are no available figures for use in the

second half of the twentieth century in the health statistics of the Instituto Nacional

de Estadística, although the procedure was the subject of an article in Spain,

published in 1955, which described its use in 27 deliveries.10 It appears to have been

used in Spain as late as 1953, when an article describing its use in emergency

breech deliveries in 259 cases (between 1927 and 1953) was published.11

Symphysiotomy was employed in deliveries in the predominantly Catholic Southern

Germany in the first half of the century, but there are no available statistics for its use

after 1945 in the Statistisches Bundesamt Deutschland, or in the databases available

through the German Federal Health Monitoring System. Searches by federal health

staff in Germany also failed to establish rates.12 Although international comparative

statistics relating to maternal and infant mortality and morbidity are available from

1960 through the Organisation for Economic Co-Operation and Development

Statistical Extracts, there are no figures for symphysiotomy.13 The key databases for

France, including those of the Institut National d’Etudes Démographiques (INED)

and the National Institute of Statistics and Economic Studies (INSEE) were

searched, and although some historic data on maternity care is available, there is no

 

 

 

 

8 Statistics of the Royal College of Obstetricians and Gynaecologists, on labour and delivery, and

maternal and perinatal mortality.

9 Wykes, C.B., Johnston, T.A., Paterson-Brown, S. and Johanson, R.B. 2003. ‘Symphysiotomy: a

lifesaving procedure’ in British Journal of Obstetrics and Gynaecology: An International Journal of

Obstetrics & Gynaecology, No. 110, pp. 219–221.

10 E.L. García-Triviño, La sinfisiotomı´a y su posicion en la actual obstetrician, Acta Ginecol 1955, Vol.

6, pp. 143– 149, cited in Kenneth Bjorklund, ‘Minimally invasive surgery for obstructed labour: a

review of symphysiotomy during the twentieth century (including 5000 cases)’ in British Journal of

Obstetrics and Gynaecology, March 2002, Vol. 109, pp. 236–248.

11 S. Dexus & N. Salarich, ‘Supplementary symphysiotomy of recourse and in emergencies in fetal

extraction by natural route’ (De la sinfisiotomaa complementaria de recurso o de emergencia en el

curso de la extraccion fetal por las vaas naturales) in Rev Esp Obstet Ginecol 1954;13:358– 366,

cited in Bjorklund.

12 In common with most European states, Germany is retrospectively compiling health data. However,

the searchable material is too recent for this study. Staff conducted searches of historic health data

and found no results.

13 OECD Statistics datasets on maternal and infant mortality, and morbidity, 1960-2010.

 

 

 

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mention of symphysiotomy. The procedure was used in France, but the available

material relates primarily to the first half of the twentieth century.14 Thus

symphysiotomy does not appear in the accessible data for western Europe, despite

its limited use in Spain, nor does it feature in European medical research literature,

despite its occasional use in mid-century.15

 

There is a good deal of discussion as to the potential role of symphysiotomy in

reducing the rising caesarean section rate in the developed world. One obstetrician

has used a small number of symphysiotomies (6) in Canada to deal with emergency

deliveries in which caesarean was refused, or inappropriate, and his interventions

are provoking a reappraisal, and discussion of, a possible reintroduction of the

procedure in Western obstetrics.16

 

Rates in Ireland:

 

Despite the use of symphysiotomy in several Irish hospitals, it does not feature in the

historic vital statistics published by the Central Statistics Office, and there is no

relevant data at the Economic and Social Research Institute (ERSI). Symphysiotomy

pre-dates the modern Hospital Inpatient Examination (HIPE) database, and checks

by staff in all of the maternity hospitals reveal no figures on the procedure since its

commencement. Annual reports and maternity registers were collated for certain

hospitals over this time period and these, where available, provide the data on rates

for this draft report. Although the Dublin maternity hospitals and Our Lady of Lourdes

Hospital provide figures for the procedure in their published annual reports, the other

hospitals do not, and securing precise detail on the procedure will require hand

searches of maternity patient medical charts: this requires patient permission, and is

outside the terms of reference of this draft report, which is to look at published

reports. The survival rates of primary maternity records in individual hospitals varies

widely. In some hospitals, only birth registers survive, in others, there are complete

patient medical charts.

 

 

 

 

14 M. Dumont, ‘The Long and Difficult Birth of Symphysiotomy, or, From Severin Pineau to Jean-Rene

Sigault’ in Journal de Gynécologie, Obstétrique et Biologie de la Reproduction (Paris) 1989; No. 18,

Vol 1, pp. 11-21.

15 Establishing accurate figures for usage in western Europe will require hand-searches of individual

maternity hospital registers.

16 S. Menticoglou, ‘Is there a Role for Symphysiotomy in Developed Countries?’ in Journal of

Obstetrics and Gynaecology, May 2009, Vol. 29, No. 4, pp. 272-277

 

 

 

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The compilation of rates from the Irish public maternity hospitals has been

complicated by the merger of several hospitals in recent years. This has resulted in

original records being placed in storage, access to which is dependent upon patient

permission. The use of the procedure varied considerably across the country, with

the largest numbers in Dublin, Drogheda and Cork:

 

Letterkenny General Hospital: Search of records confirmed no symphysiotomies.

Sligo General Hospital: Search of records confirmed no symphysiotomies.

Portiuncula Hospital, Ballinasloe: Fewer than 5 confirmed symphysiotomies.

Galway University Hospital: Search of records confirmed no symphysiotomies.

Mid-Western Regional Maternity Hospital, Limerick: Fewer than 5 confirmed

 

 

symphysiotomies.

 

 

Midland Regional Hospital, Mullingar: Search of records confirmed no

symphysiotomies.

Midland Regional Hospital, Portlaoise: Search of records confirmed no

 

 

symphysiotomies.

 

 

Waterford Regional Hospital (Airmount Hospital): Fewer than 5 symphysiotomies (to

be confirmed).

Rotunda Hospital Dublin: 24 confirmed symphysiotomies.

National Maternity Hospital Dublin: 281 symphysiotomies (to be confirmed; likely to

 

 

be slightly higher).

Coombe Hospital Dublin: 242 symphysiotomies (to be confirmed).

Our Lady of Lourdes Hospital: 378 confirmed symphysiotomies.17

Louth County Hospital: search of records confirmed no symphysiotomies.

Cork University Maternity Hospital (created from the merger of the Bon Secours, St

 

 

Finbarr’s and Erinville Maternity Hospitals): 51 confirmed symphysiotomies.

 

 

 

 

 

17 For the period 1944-1984. The returns in the table for Our Lady of Lourdes Hospital on p. 48 are

based on the published reports, which cover the period 1958-1984.

 

 

 

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Terms of Reference:

 

The following are the Terms of Reference agreed with the Department of Health for

this Report:

 

Document the rates of symphysiotomy and maternal mortality in Ireland from 1940 to

date by reference to available data (including annual reports and other reports)

 

Assess symphysiotomy rates against maternal mortality rates over the period

Critically appraise international reviews of symphysiotomy practice and

associated rates in a number of comparable countries in the world and in

Ireland

Review any guidelines and protocols that applied in Ireland on

symphysiotomy over the time period

Write a report based on the findings of the above analysis providing an

accurate picture of the extent of use of symphysiotomy in Ireland, and an

examination of the Irish experience relative to other countries.

Assess symphysiotomy rates against maternal mortality rates over the period:

 

See pp. 19-23; 30-32; 37, and passim.

 

Critically appraise international reviews of symphysiotomy practice and

associated rates in a number of comparable countries in the world and in

Ireland:

 

European reviews of symphysiotomy relate principally to the early twentieth century,

when the procedure was little used in Ireland. When symphysiotomy was most

extensively used in Ireland, in the 1950s, it was rare in Europe, and in the developing

world. It began to be employed in the developing world more extensively from the

late 1960s and the 1970s onwards. Thus Ireland has a unique usage profile, with the

procedure at its peak in the 1950s when it was no longer used in western Europe,

but before it became a more common procedure in the developing world in the

1960s and ’70s. The critical appraisal of the procedure in this report is based upon

three bodies of work: 1. Medical evaluations of the procedure from early twentieth

 

 

 

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century Europe; 2. Assessments of the usage and outcomes in mid-twentieth century

Ireland, in the specific context of Irish medical, religious, legal and social

circumstances, and 3. The most recent medical literature on the procedure, which

comes for the most part from experiences in the developing world, where caesarean

sections are often not available or are rejected by patients.

 

A Cochrane Review of symphysiotomy was published in 2010.18 It noted that there

has never been a randomised trial of symphysiotomy, and that results from the

procedure are based upon a substantial body of observational evidence. It

concluded that the procedure has a potentially life-saving role to play in the

developing world, and with proper training and aftercare, offers a clinically

acceptable response to obstructed labour in environments where caesarean section

is unavailable or unacceptable. The high mortality and morbidity rate associated with

childbirth in the developing world, where over 530,000 women die in childbirth each

year, an estimated 50,000 because of obstructed labour, has intensified the

discussion over the potential of the procedure.

 

Review any guidelines and protocols that applied in Ireland on symphysiotomy

over the time period:

 

There were no guidelines or protocols in Ireland on symphysiotomy in the mid-

twentieth century (see p. 24 onwards).

 

Additional Objectives, added by the author:

 

The practice of symphysiotomy is controversial. Throughout the twentieth century, it

was a procedure that provoked intense discussion in the medical profession, and the

reluctance of many obstetricians to employ it in delivery stemmed from anxiety

regarding the long-term effects of interference with the mother’s skeletal structure.

As medical interventions became more sophisticated in the mid-twentieth century,

and maternal and foetal outcomes improved, symphysiotomy declined. Suspicions

 

 

 

 

18 ‘Cochrane Reviews are systematic reviews of primary research in human health care and health

policy, and are internationally recognised as the highest standard in evidence-based health care.

They investigate the effects of interventions for prevention, treatment and rehabilitation.’ J.G. Hofmeyr

& M.P. Shweni, ‘Symphysiotomy for feto-pelvic disproportion (Review)’ in The Cochrane Library 2010,

Issue 10, p. 2.

 

 

 

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were therefore raised as to why the procedure was used in Ireland when it had

 

largely disappeared from other European countries. Although the Department of

 

Health commissioned a report within the terms of reference above, this author

 

increasingly felt that it needed to address the survivors’ central question: why was

 

symphysiotomy used in Ireland? Moreover, why was it used in their particular cases?

 

The second question cannot be answered without an examination of individual case

 

notes, which is not possible in terms of a general report, but the author felt it

 

imperative to engage with the use of the procedure in Ireland within its highly specific

 

social, religious, and political circumstances. Thus two additional objectives arise.

 

The first is to assess, on the basis of medical practice from the 1940s to the 1980s,

 

the suitability of the procedure in Ireland. It is not the purpose of this report to

 

evaluate symphysiotomy as a medical procedure per se. As will be seen, there is an

 

international unanimity of opinion amongst obstetricians and midwives as to the

 

value, and indeed the life-saving potential of symphysiotomy in specific clinical

 

situations.19 This opinion is offered in environments with high levels of infant and

 

maternal mortality20 and morbidity21, where caesarean sections may not be safe or

 

indeed even available, and where cases of neglected labour are relatively common.

 

These incidents arise most commonly in the developing world, and it is therefore

 

 

 

 

19 The practice has come under particular scrutiny in the last decade, for two principal reasons. The

first is the appalling rate of maternal mortality in the developing world, despite a series of targets for

reduction. Over half a million women die in childbirth annually, and it is estimated that between 8 and

10% are as a result of obstructed labour, a major indication for symphysiotomy. The second is a

growing concern regarding the rise in Caesarean Section in the western world, standing at over 30%

of all births in the United States, 26% in Ireland, and almost 25% in Britain. Symphysiotomy is now

being discussed in western medicine in the context of reducing the CS rate, especially in North

America. See E. Declercq, F. Menacker & M. MacDorman, ‘Maternal risk profiles and the primary

caesarean rate in the United States, 1991-2002’ in American Journal of Public Health 2006b, Vol. 96,

pp. 867-72; C. McCourt, J. Weaver, H. Statham, S. Beake, J. Gamble & D. K. Creedy, ‘Elective

caesarean section and decision making: A critical review of the literature’ in Birth 2007, vol. 34, pp.6579;

Healthy Baby Directory for the West of Ireland, Association for the Improvement of Maternity

Services in Ireland, 2011; J.P. Rooks, N.L. Weatherby, E.K. Ernst, S. Stapleton, D. Rosen & A.,

Rosenfield, ‘Outcomes of care in birth centers: The National Birth Center Study’ in New England

Journal of Medicine, 1989, Vol. 321, pp. 1804-11; F. Althabe & J.F. Belizan, ‘Caesarean section: The

paradox’ in The Lancet 2006, Vol. 368, pp. 1472-3; K.C. Johnson & B.A. Daviss, ‘Outcomes of

planned home births with certified professional midwives: Large prospective study in North America’

in British Medical Journal 2005, vol. 220, p. 1416; S.M. Taffel, P.J. Placek & T. Liss, ‘Trends in the

United States caesarean section rate and reasons for the 1980-85 rise’ in American Journal of

Public Health 1987, Vol. 77, pp. 955-9, U.S. Department of Health and Human Services. Maternal,

infant and child health. Healthy People 2010, 2nd ed. Washington DC: U.S. Government Printing

Office, November 2000, pp. 16-30-31, and international citations throughout this report.

20The number of deaths per 100,000 (or, occasionally, 10,000) live births. Maternal mortality is one of

the standard measures of the quality of a health care system.

21 In this context, morbidity refers to the frequency of the appearance of complications following

symphysiotomy, as opposed to the prevalence of disease.

 

 

 

11

 

 

 

 

 

from those regions, and especially Africa, that the widest range of research has

come in recent years. This has had the effect of consolidating a suspicion amongst

observers that symphysiotomy is an inferior procedure, and has made an impartial

evaluation difficult. Few western practitioners have personal experience of its

application, or its effects. Symphysiotomy is included in the Managing Obstetric

Emergencies and Trauma – the MOET Course Manual,22 a core training text in

British obstetrics, and there is agreement regarding the necessity for its inclusion in

the training of European obstetricians and midwives for those emergencies where its

use is indicated. However, the application of symphysiotomy in the developed world

is rare, as caesarean section is routinely used before extreme difficulties arise: ‘Not

only are the indications for symphysiotomy rare in developed countries, but the

cases that might benefit from symphysiotomy – mainly obstructed after-coming-head

and failed instrumental delivery in a woman unfit for an urgent CS – are such dire

emergencies, that it is hardly a suitable opportunity to teach the procedure or even

for an obstetrician to maintain a rarely used skill.’23

 

The second additional objective is an evaluation of whether symphysiotomy was

used inappropriately in Ireland. It has been contended that the procedure was

employed in cases where a caesarean section would normally have been indicated,

and that as a result mothers were subject to a clinically inferior form of treatment.

Moreover, there exists a suspicion that the decision to perform a symphysiotomy

instead of a caesarean section was influenced by a Catholic commitment to

unrestricted pregnancy and childbirth, and that the obstetrical concern regarding the

dangers of repeat caesareans might lead to demands for sterilisation or

contraception, both anathema to practising Catholics in the period under review.

Women who underwent the procedure have emphasised the importance of

understanding why it was used in their cases, and if non-medical factors influenced

an obstetrician’s decision to perform symphysiotomy over caesarean section. Thus it

is important to determine, as far as possible from this historic distance, whether an

 

 

 

 

22 Charlotte Howell, Kate Grady and Charles Cox (eds), Managing Obstetric Emergencies and

Trauma – the MOET Course Manual Royal College of Obstetricians and Gynaecologists, 2007,

Section 4: ‘Obstetric Emergencies’.

23Douwe Arie Anne Verkuyl, ‘Think Globally, Act Locally: the case for symphysiotomy’ in PLoS

Medicine, March 2007, Vol. 4, Issue 3, pp. 401-406.

 

 

 

12

 

 

 

 

 

inappropriate decision was made for religious as opposed to clinical reasons.24 The

Hippocratic Oath requires that a physician ‘does no harm’: an inappropriate use of a

procedure for reasons other than clinical would violate this basic principle, and is

therefore an integral element in this draft report.

 

Concerns regarding symphysiotomy and the long-term effects of the procedure

emerged in 2001. Since then, there have been calls for an inquiry into the practice,

originally to Micheál Martin, then Mary Harney, and finally James Reilly, the current

Minister for Health. The former Ministers ruled out an inquiry, but sought to have a

report on the practice commissioned. This report represents the third such attempt to

evaluate the practice of symphysiotomy in twentieth-century Ireland. The first was to

have been undertaken by a Swedish obstetrician, who had already conducted a

comparative evaluation of the international incidence of symphysiotomy in the

twentieth century. Following considerable public discussion, and inaccurate and

unsubstantiated allegations of partiality, the obstetrician withdrew from the process.

The second proposed team of investigators (based in Northern Ireland, Scotland and

England) comprised an obstetrician, a clinical psychologist, and a team of

researchers at the Liverpool School of Tropical Medicine: this team also withdrew as

a result of disagreements over the extent and scope of the project. It is certainly a

matter of regret that neither of the original reviews proceeded. Either would have

provided the data required to assess Ireland’s use of symphysiotomy, and advanced

the investigation by some years. The women who underwent this procedure are no

longer young, and deserve the satisfaction of an investigation that seeks to establish

facts, and acknowledge the anxiety and pain that they have carried for a good many

years.

 

This topic is a difficult and often painful one, a fact underlined by the divisions

between elements of the survivors’ groups, which has resulted in two separate

organisations representing women who experienced symphysiotomy. This is not a

story of heroes and villains. It is a complex interaction of medical, socio-religious and

cultural factors that makes a definitive statement as to the appropriateness of the

 

 

 

 

24 The published annual reports from the Dublin maternity hospitals provide detailed summaries of

symphysiotomy cases in certain years, including obstetric histories, detail on the progress of labour,

and information on follow-up (when the patient returned for after-care) that gives clear indications of

the circumstances under which the procedure was used. Similarly, summary case notes for

caesarean section patients are also provided, allowing for a comparison of cases. See Clinical

Reports of the Dublin Maternity Hospitals in Irish Journal of Medical Science 1940-1968.

 

 

 

13

 

 

 

 

 

procedure in the mid-twentieth century no easy matter. Historical distance should not

be used as a means of excusing unacceptable behaviour: interventions must be

evaluated on an accepted standard of good practice at the time, and if a physician

knowingly imposes an inferior standard of care for ideological reasons he is guilty of

poor treatment, even if motivated by mistaken good intention. Equally, however,

historical context is vital to a proper evaluation of practice. Medical care advances

through trial and error, and it is only in the application of new techniques, some of

which will inevitably produce disappointing results, that a firm empirical basis for

adoption emerges. The extensive use of x-ray to diagnose pelvic disproportion, for

example, which occurs as part of the development of obstetric care in the last

century, and is an integral part of the symphysiotomy story, would be regarded with

great alarm by modern practitioners. But it was an application of a modern

technology done with the intention of improving maternity care, and abandoned

when a safer and more reliable means (ultrasound) was developed. Thus the

practice of symphysiotomy must be evaluated in terms of good obstetric standards

that prevailed from the 1940s to the 1980s. Medical history, including the history of

obstetrics, includes many instances of interventions that were initially heralded as

major advances, and relegated once the consequences were realised. Irving Loudon

recounts two extraordinary developments that attracted supporters in the United

States and Britain respectively:

 

Maternal mortality rates were also high when maximum surgical

interference in normal or potentially normal labours was

encouraged or advocated. A leading American obstetrician in the

1920s, Joseph Bolivar DeLee, wrote a paper entitled ‘The

prophylactic forceps operation’ in which he advocated that

procedures for ordinary deliveries be changed to include

anaesthetizing every patient in the second stage of labour,

delivering the baby with forceps, and manually removing the

placenta using the ‘shoehorn manoeuvre’. His advice was heeded

by many obstetricians and horrendous examples of iatrogenic25

mortality resulted. Another example, from Britain, was the

widespread use of chloroform and forceps by general practitioners

 

 

25 The result of intervention by a physician.

 

 

 

14

 

 

 

 

 

in uncomplicated deliveries between 1870 and the 1940s. This was

described by one observer as a tendency a ‘little short of murder’

and accounted for many unnecessary deaths.26

 

Definition of Symphysiotomy:

 

Symphysiotomy is an operation, usually carried out under local anaesthetic, to

enlarge the size of the mother’s pelvis and facilitate delivery in cases of relatively

minor obstruction or disproportion. Where major obstruction is present, caesarean

section is the appropriate procedure. It was believed that symphysiotomy resulted in

a permanent enlargement of the mother’s pelvis, although modern research has

questioned whether this is indeed the case.27

 

This ‘plain language’ summary describes the procedure:

 

Symphysiotomy is an operation to enlarge the capacity of the

mother’s pelvis by partially cutting the fibres joining the pubic

bones at the front of the pelvis. Usually, when the baby is too big

to pass through the pelvis, a caesarean section is performed. If

caesarean section is not available, or the mother is too ill for, or

refuses, caesarean section or if there is insufficient time to perform

caesarean section (for example when the baby’s body has been

born feet first, and the head is stuck), symphysiotomy may be

performed. Local anaesthetic solution is injected to numb the area,

then a small cut is made in the skin with a scalpel, and most of the

fibres of the symphysis are cut. As the baby is born, the symphysis

separates just enough to allow the baby through. Large

observational studies have shown that symphysiotomy is

extremely safe with respect to life-threatening complications, but

rarely may result in pelvic instability. For this reason, and because

the operation is viewed as a ‘second-class’ operation, it is seldom

performed today. Health professionals fear censure should they

 

 

 

 

26 Irvine Loudon, ‘Maternal Mortality in the Past and its Relevance to the Developing World Today’ in

The American Journal of Clinical Nutrition Vol 72, No. 1, July 2000, p. 2425.

27J. Van Roosmalen, ‘Symphysiotomy as an alternative to caesarean section’ in International Journal

of Gyneacology and Obstetrics No. 25, 1987, pp 451-458. See the same author’s 1990 article on

symphysiotomy in ‘Safe Motherhood: caesarean section or symphysiotomy?’ in American Journal of

Obstetrics and Gynaecology July 1990, Vol 1, Part 1, No. 163, pp. 1-4.

 

 

 

15

 

 

 

 

 

perform a symphysiotomy which leads to complications.

Proponents argue that many deaths of mothers and babies from

obstructed labour in parts of the world without caesarean section

facilities could be prevented if symphysiotomy was used. 28

 

Although symphysiotomy is most often a medical intervention, performed to facilitate

delivery, it may also happen spontaneously during labour. An allied procedure which

severs the pubic bone lateral to the symphsis is known as pubiotomy and is rarely

used. There is reference to a similar practice in Ireland in the fifteenth century29 that

appears to have been used prophylactically30:

 

The earliest successful symphysiotomy was performed in Paris in 1777 on a woman

with dwarfism who had lost her three previous children. Although mother and child

survived the operation, the mother suffered significant after-effects, including severe

difficulty in walking, and urinary incontinence. The operation was utilised throughout

the nineteenth century in relatively small numbers, but there was a revival of interest

in the procedure at the end of the century as improved aseptic techniques greatly

improved the maternal mortality and morbidity rate. The technique was modified in

the 1920s by an Argentinian obstetrician named Enrique Zarate so that the symphsis

fibres were partially and not completely severed: this was to reduce the chance of

long-term pelvic instability, as the pelvic girdle did not divide in the manner of earlier

symphysiotomies.31 Local anaesthetic now also replaced general anaesthetic for the

procedure, and this is the technique that was used in Ireland in the mid-twentieth

century. The operation is now associated exclusively with childbirth, but has

occasionally been used on men.32 During the Vietnam War, an American surgeon

used symphysiotomy to control massive haemorrhage and facilitate reconstruction

 

 

 

 

28 G. Justus Hofmeyr and P. Mike Shweni, ‘Symphysiotomy for feto-pelvic disproportion (Review)’ in

The Cochrane Library 2010, Issue 10, p. 2.

29 ‘The wild Irish women do break the pubic bones of the female infant, so soon as it is borne. And I

have heard some wandering Irish women affirm the same to be true, and that they have ways to keep

these bones from uniting. It is for certain that they be easily and soon delivered. And I have observed

that many wanderers of that nation have a waddling and lamish gesture in their going.’ Percival

Willughby, Observations in Midwifery (ca. 1672)

30 A medicine or treatment to prevent disease.

31 D. Maharaj and J. Moodley, ‘Symphysiotomy and Fetal Destructive Operations’ in Best Practice and

Research in Clinical Obstetrics and Gynaecology, 2002, Vol. 16, No. 1, pp. 117-131.

32 John N. Wettlaufer & John W. Weigel, Urology in the Vietnam War: Casualty Management and

Lessons Learned Washington: Borden Institute, 2005, chapter 7.

 

 

 

16

 

 

 

 

 

following deep tissue injury by high velocity weaponry.33 It was also utilised in

surgery for the removal of tumours of the pelvis,34 and more recently in the treatment

of urethral injuries in children.35

 

Religion and Irish Obstetrics:

 

Irish obstetrical practice was heavily influenced by, and constrained within, a widely

accepted religious framework. This influence was not merely ideological, but also

shaped legislation in order to ensure conformity to certain religious principles. The

dominance of the church in almost all areas of Irish life was also felt within medicine,

and in the period of this study the pernicious influence of the Catholic Archbishop of

Dublin, Charles John McQuaid, spread far beyond the capital. His interference to

their detriment in the broader realm of women’s general health reflected a

preoccupation with largely illusory battles regarding morals, ensuring that

malnourished and exhausted mothers produced children whom they could not afford

to feed, clean, or clothe. McQuaid, in common with the rest of the Church hierarchy,

did indeed believe that ‘the issue of maternity care was a religious one.’36 An

unyielding belief system that would not countenance artificial contraception or

sterilisation for the prevention of pregnancy also placed legal restrictions upon

medical practitioners, and put them into a very different position from their European

peers. Many found the position intolerable. The testimony of obstetricians, and the

memoirs of other practitioners, indicate how many medics struggled to provide the

care their patients needed, while constrained by a conservative medical and social

structure.37 It is within this context that the revival of symphysiotomy must be

 

 

 

 

33 Stuart M. Selikowitz, ‘The Symphysiotomy Approach to High Velocity Missile Trauma’ in Annals of

Surgical Oncology, Vol 178, No. 5, pp. 616-20.

34 T.M. Holder & L.F. Peltier, ‘Symphysiotomy for Exposure in Resection of Pelvic Tumors’ Surgery,

60:819,

1966.

35 Basiri, A, Shadpour, P, Moradi, MR, Ahmandnia H, & Madaen, K., ‘Symphysiotomy: a viable

approach for delayed management of posterior urethral injuries in children’ in Journal of Urology, Nov.

2002; No. 168, Vol. 5, pp. 2166-2169.

36 Amongst the several disgraceful outcomes of McQuaid’s interference in family life was the loss of

free maternity care and meals offered by multi and non-denominational organisations such as the St

John’s Ambulance Brigade to Dublin mothers. Lindsey Earner-Byrne, Mother and Child: maternity and

child welfare in Dublin, 1922-60 (Manchester: Manchester University Press, 2007), p. 107.

37 For discussion of the limits on medical practice in a variety of specialisms mid-century, and the

general state of the nation’s health, see for example Ivor Browne, Music and Madness (Cork: Cork

University Press, 2008); J.B. Lyons JB. A Pride of Professors; the lives of the professors of medicine

at the Royal College of Surgeons in Ireland (Dublin: A & A Farmar, 1999); Robert Collis, To Be a

Pilgrim (London: Secker & Warburg, 1975); James Deeny, To cure and to care: memoirs of a chief

 

 

17

 

 

 

 

 

considered: in which multiple births were the norm, artificial contraception and

sterilisation to prevent pregnancy were illegal as well as ethically unacceptable, and

repeat caesarean sections carried grave dangers. A procedure that appeared to offer

the possibility of safe repeat deliveries for a very specific group of mothers was

therefore actively explored.

 

It has been repeatedly claimed that symphysiotomy was promoted by Irish

obstetricians, Alexander Spain and Arthur Barry (respective Masters of the National

Maternity Hospital) in particular, for religious and not clinical reasons.38 The first

element of this claim is partly true. Spain and Barry were both devout Catholics,

serving a predominantly Catholic patient population, and they made no secret of their

willing conformity to religious precepts in the treatment of patients.39 However, they

operated within an environment in which considerable restrictions were placed upon

medical practitioners. Whatever their personal inclinations or beliefs, doctors

practising in Ireland were confined by key legislative limits in relation to family

planning and advice. The Censorship of Publications Act of 1929 eliminated

published material that offered information on the avoidance of pregnancy by

banning any material that was deemed to ‘advocate the unnatural prevention of

contraception or the procurement of abortion or miscarriage.’ Indeed, much of the

emphasis of the Act, and the evidence presented to the ‘Committee on Evil

Literature’ that shaped its parameters, concerned birth control and the prevention of

conception.40 The sale of artificial contraceptives were banned under the 1935

Criminal Law Amendment Act: any doctor offering such material, and even

information on it, was liable to prosecution.41

 

 

 

 

medical officer (Dun Laoghaire: Glendale Press, 1989); Noel Browne, Against the Tide (Dublin: Gill

and Macmillan, 1986).

38 Marie O’Connor, Bodily Harm (Dublin: Johnswood Press, 2011), p. 82 and passim.

39 Sterilisation and caesarean hysterectomies were undertaken in the Dublin hospitals, often in

response to haemorrhage after delivery. There was strong opposition to sterilisation for contraceptive

purposes on the part of Catholic obstetricians such as Spain, who described such intervention, even

at the request of the mother, as ‘mutilation’. Alexander Spain, ‘Symphysiotomy and Pubiotomy: An

Apologia based on the study of 41 cases’ in Journal of Obstetrics and Gynaecology of the British

Empire, 1949, Vol. 56, pp. 576-85.

40 Although the Catholic church vigorously advanced the Act, the Church of Ireland took an active part

in shaping its provision through the Anglican Committee member. For a discussion of the records

relating to the Committee, see Tom Quinlan, ‘Ferreting Out Evil: the records of the Committee on Evil

Literature’ in Journal of the Irish Society of Archives, Autumn 1995, Vol. 2, No. 2, pp. 49-56.

41 Section 17 of the Act stated: ‘Any person who acts in contravention of the foregoing sub-section of

this section shall be guilty of an offence under this section and shall be liable on summary conviction

thereof to a fine not exceeding fifty pounds or, at the discretion of the court, to imprisonment for any

 

 

18

 

 

 

 

 

Regardless of the physical and psychological stress associated with repeated

pregnancy and birth, Irish family size was exceptionally large by European

standards, over twice that of England. There was moreover a unique reproductive

profile: marriage rates were relatively low, but fertility rates were very high, meaning

that large numbers of Irish men and women never married, but those that did had

very large families: ‘It is in connection with the structure of childbearing in this period,

rather than overall fertility rates, that Irish exceptionalism can again be

unambiguously asserted. In Ireland, the uniqueness of the structure of childbearing

lay in the degree to which marriages were few but families were large, a combination

which had been a feature of Irish reproductive patterns since the late nineteenth

century.’42 Any young woman starting a family in this period could conservatively

expect to bear five live children,43 without the benefit of pauses through

contraception. But this statistic provides only a partial picture of individual

reproductive profiles. Ireland was unique in the post-war western world in terms of

numbers of individual pregnancies, and in home deliveries. In the 1950s, medical

students from the UK attended the Dublin hospitals in order to experience both the

domiciliary delivery system44, which had disappeared in Britain when hospital

delivery became the norm under the National Health Service, and to treat the ‘Grand

Multipara’: a woman who has had six or more children. Hospital records provide

general detail on family size, and mothers on their eighth pregnancy were so

common that they did not excite particular comment. In addition to the live births,

women could furthermore expect to suffer miscarriage, stillbirth, and post-partum

difficulties including incontinence, uterine prolapse, diabetes insipidus, and perineal

problems.45

 

 

 

 

term not exceeding six months or to both such fine and such imprisonment and, in any case to

forfeiture of any contraceptive in respect of which such offence was committed.’

42 Tony Fahy, ‘Trends in Irish Fertility Rates in Comparative Perspective’, in The Economic and Social

Review, Vol. 32, No. 2, July, 2001, p. 159.

43 ‘In 1946 Irish couples who had been married for thirty to thirty-four years (married 1912-16) had on

average 4.94 children.’ Mary Daly, The Slow Failure: population decline and independent Ireland,

1922-1973 (Wisconson: University of Wisconson Press, 2006), p. 122.

44 Deliveries in the home, as opposed to hospital.

45 Maternity hospitals spent a good deal of time addressing underlying pregnancy-associated

problems in mothers, and attempting to establish a basic level of health. It was widely acknowledged

that larger families contributed significantly to ill-health amongst mothers and children, as scant

resources were stretched ever further, and debilitated women gave birth in turn to malnourished

infants.

 

 

 

19

 

 

 

 

 

Many Irish women were indeed ‘slaves to fertility’ in this era. Although the

 

acceptance of strictures upon family size and family life may seem incomprehensible

 

from the perspective of the early twenty-first century, with modern open access to

 

contraception, the reality was that all agents operated in an environment of general

 

acceptance of a startling level of interference in private matters. It is necessary to

 

understand the depth and unquestioning acceptance of such strictures upon

 

personal autonomy, and the importance of religious observance in all aspects of Irish

 

life. It was only as recently as 1979 that the Family Planning Act was passed, and

 

even then contraception was legally limited to married couples, and only available on

 

prescription.46 In the 1940s, women who had problematic deliveries were a pressing

 

concern: where in Britain sterilisation or limited contraception47 were options in some

 

cases, there was no such choice in Ireland (even in Britain, contraception was legally

 

limited in the post-war years to married men and women, and only on prescription48).

 

It was the lack of options in the control of fertility that was one of the key factors

 

behind a return to symphysiotomy.

 

This is the explicit theme of successive ‘Transactions’ of the Royal Academy of

 

Medicine, the published accounts of discussions of the three Dublin maternity

 

hospital annual reports, and the subject of several separate publications by the

 

Dublin Masters. In the course of the discussions, the standards of obstetric care in

 

Ireland in relation to Britain were the source of frequent comment. Symphysiotomy

 

 

46 Diarmaid Ferriter, The Transformation of Ireland 1900-2000 (London: Profile books, 2004), p. 666.

47 Although condoms were relatively available after 1918, it was not until 1961, and the introduction of

the pill, that a reliable form of artificial contraception was taken up in the UK in large numbers. Illegal

(or ‘criminal’) abortion was common in Britain until 1968, when abortion was legalised under the 1967

Abortion Act.

48 ‘In circulars issued by the [British] Ministry of Health the authorities have been advised that (1) they

have no general power to establish birth control clinics as such; (2) advice on contraceptive methods

should be given only to:

 

(a) Married women who, being expectant or nursing mothers, are attending welfare centres and

for whom further pregnancy would be detrimental to health; and

(b) Married women attending clinics for women suffering from gynaecological conditions for

whom pregnancy would be detrimental to health, either because of some gynaecological

condition or because of some other form of sickness, physical or mental, such as

tuberculosis, heart disease, diabetes, chronic nephritis, etc.’

The establishment of the NHS was regarded as key in reforming this patchy provision: ‘we

recommend that restrictions be removed and that the giving of advice on contraception to married

persons who want it should be accepted as a duty of the national health service…Some doctors would

also object, on religious or other grounds, to giving advice on contraception, but this is unlikely to be a

serious impediment to national policy if patients are given the right to seek advice, if they want it, from

other doctors within the National Health service.’ Royal Commission on Population Report, (London:

His Majesty’s Stationary Office, June 1949), p. 194.

 

 

 

20

 

 

 

 

 

was regularly raised as a specific difference in practice between the two states (see

comments below), and variations in other approaches were also noted. The visiting

British obstetricians observed that Irish maternity care in general was more

conservative, meaning that there was a policy of non-intervention as far as

possible49, and a desire to permit the mother to deliver naturally. Although

Caesarean Section rates were comparable with those in Britain, mothers were

permitted to labour for longer periods of time before surgery, and this attracted some

comment. Over the years of this study, prolonged labour was frequently mentioned,

and the respective Masters initiated a policy of earlier intervention as a result.

Symphysiotomy in Ireland has been associated with younger mothers,50 and this is

borne out by experience in the developing world, where symphysiotomies are

indicated in cases where very young and physically undeveloped women face

problems of pelvic disproportion in greater numbers than older mothers.

 

Symphysiotomy was a statistically exceptional intervention in Irish obstetrics. At the

height of its use in Dublin, from the mid 1940s to the mid 1950s, when it went into

decline, it accounted for 0.34% of the total deliveries at the National Maternity

Hospital, and 0.4% at the Coombe.51 The caesarean section rate increased from

1.1% to 4.6% in the same period, and remained on a steady upward trajectory.52

From the outset, symphysiotomy was viewed as a means of coping with a very

specific cohort, and was never proposed as an alternative to caesarean section. The

circumstances under which the procedure was to be performed did not vary

significantly over the course of thirty years, despite optimistic predictions by both

Spain and Barry that it would find additional applications. The indications for

symphysiotomy both remained generally constant over the period under review, and

conformed to those recommendations outlined by recent literature, with one

important exception (see ‘symphysiotomy on the way out’ below). The tables below

compiled from the Dublin maternity hospital annual reports provide figures for the

 

 

 

 

49 This term includes assistance at all levels, including induction, forceps, vacuum, episiotomy,

symphysiotomy and caesarean section.

50 Jacqueline K. Morrisey, An Examination of the Relationship between the Catholic Church and the

Medical Profession in Ireland in the period 1922-1992, with particular emphasis on the Impact of this

Relationship in the Field of Reproductive Medicine (Unpublished PhD thesis, University College

Dublin, 2004), p. 188.

51 Calculated from the Annual Clinical Reports, 1945-1965 inclusive. The Rotunda has been excluded

as symphysiotomy was rarely used, and its inclusion would artificially lower the overall rate.

52 The national rate is now 26.2%, well above the target of 10-15% set by the World Health

Organisation. Perinatal Statistics Report (Dublin, 2009), p. 19.

 

 

 

21

 

 

 

 

 

rise and fall in the use of symphysiotomy, and selected comments from the Masters

as to the use and consequences of the procedure – see footnotes for critical

evaluations of individual cases, as well as indications of use in non-emergency

situations. A note on terms: the Dublin reports use a variety of terms to describe

non-emergency symphysiotomies, including ‘on the way out’, ‘in combination with

caesarean section’, ‘elective pre-labour symphysiotomy’ and ‘symphysiotomy at

section’. Their use is dependent upon the specific circumstances of each delivery,

and are cited in this report’s footnotes as they appeared in the original documents.

Please also note that the footnoted comments on individual deliveries are a selection

from a much larger number, chosen to illustrate the differing circumstances under

which symphysiotomy was used. The annual reports contain much additional

comment and information.

 

Rates of Symphysiotomy53 and Caesarean Section in the Dublin Hospitals:54

 

Rotunda Hospital:

 

YEAR No. Of

Symphs

Symphs

as % of

births

Mat

Deaths

Symph

Foetal

Deaths

Symph

No.

Of

CS

CS

as %

of

births

Mat

Deaths

CS

Foetal

Deaths

CS

Total

Deliveries

1948 0 0 0 0 95 1.9 4 5 4,788

1949 0 0 0 0 113 1.9 1 4 5,740

1950 0 0 0 0 131 2.3 2 13 5,509

1951 1 0.01 0 0 135 2.3 3 24 5,718

1952 755 0.16 0 0 201 3.4 1 34 5,874

1953 356 0.07 0 0 152 2.8 0 6 5,286

195457 2 0.04 0 0 166 3.8 2 16 5,623

 

 

 

 

53 These tables are for the years of highest usage of the procedure: figures showing usage for all

years (checked where available against the maternity registers) will be included in the final report.

54 The annual reports were published by the three hospitals until 1968. These tables reflect the years

of highest usage of symphysiotomy in Dublin.

55 These symphysiotomies were performed ‘at Caesarean Section to facilitate vaginal delivery in

future pregnancies’.

56 These three were ‘Symphysiotomy at Section’.

57 Prof. A.S. Duncan of Cardiff noted: ‘The pride of place given in the Rotunda Report to the Social

Service Department emphasises to us the ever-increasing realisation of the importance of socioeconomic

factors in the aetiology of obstetrical abnormalities’ p. 527. Commenting on the issue of

possible incontinence following symphysiotomy, he stated: ‘One cannot very well come to Dublin and

not comment on the operation of symphysiotomy. I am impressed, and convinced of its value in the

failed forceps type of case, but I must confess that I am still unhappy about the prophylactic operation

 

 

22

 

 

 

 

 

1955 258 0.03 0 0 167 2.9 0 10 5,731

1956 159 0.01 0 0 148 2.5 0 10 5,845

1957 1 0.01 0 0 211 3.9 2 25 5,366

1958 0 0 0 0 171 3.0 0 7 5,554

1959 0 0 0 0 189 3.8 2 6 6,120

1960 0 0 0 0 196 3.0 0 15 5,840

1961 1 0.01 0 0 224 4.1 2 18 5,356

1962 360 0.05 0 0 243 4.3 0 26 5,648

1963 3 0.05 061 0 270 4.7 2 15 5,727

1964

1965 0 0 0 0 335 5.1 2 30 6,472

 

Coombe Hospital:

 

YEAR No. Of

Symphs

Symphs

as % of

births

Mat

Deaths

Symph

Foetal

Deaths

Symph

No.

Of

CS

CS

as %

of

births

Mat

Deaths

CS

Foetal

Deaths

CS

Total

Deliveries

1950 11 0.3 0 1 31 0.9 0 2 3,548

1951 16 0.4 0 1 82 2.2 0 12 3,666

 

 

 

 

or the symphysiotomy combined with Caesarean Section. The sequelae [long term ill consequences]

in your experienced hands certainly seem to be minimal. There has been considerable criticism in

relation to the incidence of subsequent stress incontinence of urine, but I think we must remember

that stress incontinence of minor degree is very common in women, and that this becomes more clear

if patients are asked specifically about the symptom. In this connection you may be interested in the

results of a questionnaire study which I recently carried out amongst young nulliparous [women who

have never given birth to a live infant] hospital nurses. Of 134 nurses who replied to the

questionnaire, 87 or nearly two-thirds stated that they had at one time or another experienced stress

incontinence. Of these, 17 had experienced it frequently, and 18 at times when the bladder was not

even full. In 58 the causative stress was as simple an action as laughing. If we consider that these

were young nulliparae I think that we must not criticise too strongly the minor degrees of incontinence

displayed for example by some of Dr. Feeney’s followed-up series.’p . 528.

58 Combined with Caesarean Section.

59 Combined with Caesarean Section.

60 Although the babies were safely delivered, the mothers suffered injury: ‘Two of the patients

however, have had considerable disability from stress incontinence, and this coupled with the rather

prolonged convalescence necessary following the operation make it difficult for me to accept it for use

in any but occasionally selected cases where a funnel-shaped pelvis leads to obstructed labour at the

plane of least pelvic dimensions.’ Annual Report, p. 33

61‘Case No. 59973 was disastrous due to extraction of the head from brim level immediately following

symphysiotomy. This sequence of events (symphysiotomy immediately followed by forceps) is

reported by experts on symphysiotomy to be the worst possible procedure and the one most likely to

be followed by severe stress incontinence. Caesarean section should have been performed in this

case, and the subsequent career of this patient has been quite disastrous.’ Annual Report, p. 35

 

 

 

23

 

 

 

 

 

1952 19 0.4 0 3 100 2.3 1 4,301

1953 25 0.7 0 1 115 3.0 1 6 3,749

1954 1962 0.5 0 2 116 3.0 0 9 3,860

1955 15 0.4 0 2 94 2.5 2 6 3,685

1956 32 1.0 0 4 89 2.8 1 8 3,187

1957 6 0.2 0 0 104 3.3 0 11 3,103

1958 8 0.3 0 0 134 4.6 0 10 2,883

1959 1363 0.4 0 0 124 4.0 1 13 3,072

196064 1765 0.5 0 1 131 3.9 0 17 3,387

196166 1267 0.3 0 0 96 2.8 1 4 3,420

196268 4 0.1 0 0 135 3.8 0 6 3,522

196369 5 0.1 0 1 140 4.1 1 7 3,401

1964

1965 0 0 0 0 170 5.5 1 15 3,106

 

National Maternity Hospital:

 

YEAR No. Of

Symphs

Symphs

as % of

births

Mat

Deaths

Symph

Foetal

Deaths

Symph

No.

Of

CS

CS

as %

of

births

Mat

Deaths

CS

Foetal

Deaths

CS

Total

Deliveries

1950 20 0.4 0 5 58 1.3 1 20 4,555

1951 18 0.4 0 2 44 1.0 3 5 4,486

1952 28 0.5 0 5 67 1.2 5,715

1953 18 0.3 0 2 58 1.2 0 7 5,392

1954 33 0.6 0 4 53 1.0 0 9 5,298

1955 33 0.6 0 0 51 0.9 0 2 5,432

1956 21 0.4 0 2 93 1.8 1 7 5,093

1957 9 0.2 0 0 87 1.8 0 2 4,717

 

 

62 Two were combined with Caesarean Section.

63 Nine of these were ‘prophylactic’.

64 There were 24 vaginal deliveries after symphysiotomy this year.

65 Four of these were prophylactic.

66 20 had vaginal deliveries following symphysiotomy. ‘None of these women on careful questioning

showed any of the disabilities so commonly attributed to this operation. None of them had any

abnormality of gait or stress incontinence.’ p. 40

67 Of the 12 symphysiotomies, eight were in labour and four prophylactic

68 13 patients delivered vaginally following symphysiotomy.

69 16 patients delivered vaginally following symphysiotomy.

 

 

 

24

 

 

 

 

 

1958 6 0.1 0 0 88 1.8 0 5 4,752

1959

19607071 16 0.3 0 0 100 1.8 0 9 5,492

196172 1273 0.2 0 1 140 2.5 2 15 5,500

196274 1975 0.3 0 0 133 2.4 1 9 5,607

196376 12 0.2 0 0 168 0 6

1964

1965 5 0.09 0 1 211 3.7 1 18 5,747

 

The pattern of use of symphysiotomy in the Dublin public hospitals was therefore as

follows: the procedure was rarely used at the Rotunda, although the hospital was

unique in employing it most often after caesarean section, in anticipation of the next

obstructed pregnancy. This did not follow good clinical practice, in which

symphysiotomy was and is regarded as appropriate only during labour (see below).

Symphysiotomy was statistically a far safer procedure than caesarean section, with

no maternal deaths as opposed to an average of two annually with section, and a far

lower foetal mortality rate (although still a distressingly high one). The operation was

most prevalent in the early to mid 1950s, when it began to decline, and was relatively

rare in the 1960s. This pattern reflects the changes in maternal health and maternal

care in Ireland. The health of mothers improved steadily in the late 1940s and 1950s,

with a decline in women with contracted pelvis presenting for delivery. This reduced

the numbers of mothers regarded as suitable cases for symphysiotomy. From the

early 1950s, it also became clear that with improvements in health, and in surgical

technique (especially the widespread adoption of the Lower Segment Section in

caesarean section), that repeat caesarean section was safer than had previously

been thought, and numbers rose accordingly. This largely eliminated the need for

symphysiotomy.

 

 

 

 

70 Six patients had a symphysiotomy this year as an elective procedure before the onset of labour:

Five delivered vaginally, one by caesarean section because of rupture of a previous section scar.

71 There were 28 vaginal deliveries following previous symphysiotomy this year, 24 spontaneous, 4

with forceps.

72 22 delivered vaginally after symphysiotomy, 19 spontaneous, three with forceps.

73 Three were elective pre-labour symphysiotomies; four were ‘on the way out’.

74 25 delivered vaginally after a previous symphysiotomy, 19 spontaneous, five forceps, one vacuum.

75 10 symphysiotomies in labour, six elective pre-labour, three ‘on way out’.

76 22 vaginal deliveries after symphysiotomy. ‘[There was]…no case of orthopaedic problems this

year, but one of severe incontinence.’

 

 

 

25

 

 

 

 

 

Guidelines and Protocols for Symphysiotomy in Ireland:

 

There were no guidelines or protocols for symphysiotomy in mid-twentieth century

Ireland. This was not unusual: protocols did not exist for many aspects of medical

care in the twentieth century as a whole, which evolved through practical application,

and were revised on the basis of discussion in professional forums such as those

reported in the ‘Transactions’ of the Dublin Hospitals (below), in the training of

students, and on the basis of published papers in medical journals. There was

however a general acceptance of the indications for symphysiotomy, which were

‘mild to moderate disproportion’: a greater degree indicated caesarean section.

When Arthur Barry proposed symphysiotomy as a response to obstructed labour, he

did so on the basis of recent results reported by obstetricians in Britain and

continental Europe, including the seminal work of Chassar Moir, the British

obstetrician with whom Barry was to vigorously debate in Dublin in 1951 (below).77

 

In the absence of formal guidelines, the appropriate use of symphysiotomy (or

indeed any obstetrical intervention) depended upon peer-review, and the audit of

practice. The Inquiry of Judge Maureen Harding Clark into peripartum hysterectomy

at Our Lady of Lourdes Hospital provides a valuable context for this report, in

suggesting a model for investigation (albeit on a much more limited scale), as well as

analysis of the influence of religious belief on medical practice.78 It has an especial

significance with regard to the use of symphysiotomy at Lourdes, and the role of

audit in ensuring patient safety and maintaining clinical standards. Harding Clark

found that the major factors in permitting the extraordinarily high levels of caesarean

hysterectomies at Lourdes were an atmosphere in which the actions of obstetricians

were accepted unquestioningly by other staff, and ‘the prevailing insular atmosphere

of the unit which never questioned, reviewed or audited outcomes, [and] allowed

hysterectomies for perceived haemorrhage to continue at unacceptable rates

 

 

 

 

77 In Barry’s 1952 article ‘Symphysiotomy or Pubiotomy: Why? When? And How’, he depends heavily

upon Moir and Kerr’s 1949 work Operative Obstetrics, which indicated the appropriate use of

symphysiotomy. Moir’s disagreement with Barry was less the question of symphysiotomy’s

usefulness, and more the extent to which it was utilised in Dublin in comparison with the UK. Moir

argued for the use of contraception and caesarean section to regulate fertility, and criticised the

religious ideology that led to continual pregnancy. Barry also cited research published in Spanish

(Zarate [1931]; Vautrin [1947]; Bazan and Rossi Escala [1948]; Salarich Tarrents [1949]).

78 Judge Maureen Harding Clark, S.C., The Lourdes Hospital Inquiry: An Inquiry into Peripartum

Hyserectomy at Our Lady of Lourdes Hospital, Drogheda. (Dublin: The Stationary Office, January

2006).

 

 

 

26

 

 

 

 

 

throughout the last 10 years of Dr. Neary’s practice.’79 Another problem lay in the

lack of training in modern obstetric approaches at Lourdes, and a lack of awareness

regarding up-to-date approaches to problems such as post-operative haemorrhage

in caesarean section. However, the situation with regard to symphysiotomy is

somewhat different. In the period under review, there were no clinical guidelines for

symphysiotomy. This was a period of transition in obstetric care, when maternal

mortality was in decline, hospital deliveries were increasing, and medical intervention

in delivery more frequent. Good practice was in a process of evolution, and the role

of the published reports, and discussion of practice between hospitals, as well as by

invited observers, was crucial in shaping the delivery of maternity care.

 

Audit is an integral element in the maintenance of clinical standards, and an

essential safeguard against malpractice.80 In Ireland, in common with Britain in the

period under review, there was no formal system of audit of practice for

obstetricians. The Institute of Obstetricians and Gynaecologists of the Royal College

of Physicians of Ireland was founded in 1976, and acts as an advisory body for

professional training and practice. It does not have any formal power of audit or

independent investigation into obstetric practice. Prior to its establishment, the Royal

College of Obstetricians and Gynaecologists in London fulfilled this role, and most

senior obstetricians in Ireland held Membership of the Royal College (MRCOG),

although this was not a prerequisite for practice. Membership was (and is) through

examination, and implies a high standard of expertise, as it is a postgraduate

qualification.81 Many Irish obstetricians attended training courses at the RCOG, and

the Royal College played a key role in approving Irish maternity hospitals as training

centres for Irish doctors. Representatives from the RCOG visited Irish maternity

hospitals and inspected facilities throughout the twentieth century; they then made

recommendations for improvement if necessary. Although both bodies received

annual reports from some of the Irish maternity hospitals from the 1940s, there is no

consistency in submission, and no obligation on individual centres to submit reports,

apart from the three Dublin public maternity hospitals. When the reports were sent to

 

 

79 Lourdes Hospital Inquiry, p. 249.

80 Richard A. Greene of the National Perinatal Epidemiology Centre in Cork has identified the

necessity for audit in obstetric care, and the difficulties associated with gathering the information

necessary to identify trends. Perinatal Epidemiology Centre, Annual Report 2007, p. 4.

81 The process is a two-part examination, with the second element part of the RGOG’s ‘advanced

training’. It is a lengthy and rigorous process. See Royal College of Obstetricians and Gynaecologists

Tips for Trainees in Obstetrics and Gynaecology, February 2009.

 

 

 

27

 

 

 

 

 

the two institutions, there was no requirement to review them, compare practice

between hospitals, or note areas of concern.82 Thus although Irish obstetrics was

overseen by two professional bodies, there was no regulatory input from them, and

interventions in hospital practice occurred only for the purpose of evaluating facilities

for training.83 However, there was an annual review of practice at the Dublin

Hospitals that constituted a process of audit.

 

Indeed, the relationship between the ROCG and Irish obstetricians is best seen in

the Dublin maternity hospitals. In the period under review there was regular contact

between Dublin and London, with British obstetricians travelling annually to Ireland to

review and discuss developments in Irish maternity care. There were three public

maternity hospitals in Dublin: the Rotunda, the Coombe, and the National Maternity

Hospital at Holles Street. They are unique in operating under a system of

Mastership, first established at the Rotunda Hospital in the 1750s. The Master is

responsible for all aspects of care in the institution, and has been described as a

chief executive as much as a clinician. The seven-year term appointments both carry

a high responsibility, and offer an exceptional degree of authority. The Masters

traditionally shaped the delivery of care, and in an earlier period exercised an

unparalleled control over their hospitals. Practice therefore reflected the ethos of the

Master, and at the National Maternity Hospital in particular in the 1940s and ‘50s this

meant conformity to Catholic beliefs.84 Thus there was no use of sterilisation for

contraceptive purposes, and no advice on artificial methods of contraception.85 This

system prevailed for many years. Even in a period when the cultural context had

altered and the general population accepted artificial contraception, some few staff at

the Coombe were still reluctant to prescribe it themselves: however, they raised no

objections to colleagues doing so.86

 

 

 

 

82 Harding Clark identified this lack of a requirement to review as a significant failing in relation to

standards at Drogheda. passim

83 The system of inspection is detailed in Harding Clark, Inquiry.

84 It would not be accurate to describe the Rotunda as a ‘Protestant’ hospital, although it was

perceived to be largely independent of Catholic influence in the mid twentieth century. For the most

part, it followed the prevailing medical ethos in not offering contraceptive advice.

85 Both the Coombe and Holles Street began family planning clinics in the late 1950s, but offered

advice only on natural methods of avoiding pregnancy.

86‘I had no compunctions about prescribing the pill and one of my functions was prescribing it for

patients who came to me specifically for this purpose. I cannot recall that my aberrant intervention in

this matter caused any concern to my obstetrical colleagues. They never spoke to me about the

 

 

28

 

 

 

 

 

The three hospitals published annual reports, which provided detailed information on

maternity care. Although based on the reports published by the RCOG, and using

clinical standards set in Britain,87 the Irish reports were far more discursive and

detailed, going beyond the largely statistical model prevailing in the UK. The reports

were originally initiated in fact as a process of audit: ‘Medical Audit, initiated by

Master George Johnston in 1869, remained active through the debates on the

annual Clinical Reports of the Dublin maternity hospitals at the Royal Academy of

Medicine in Ireland, as maternal mortality declined through the late 1940s and

1950s.’88 The reports were published to 1968, providing a unique insight into

changing obstetric practice in Ireland.89 From the early 1940s until the practice

largely ceased in the l960s90, symphysiotomy was extensively discussed, both by the

British obstetricians who were invited to review the annual reports, and by the

Masters of the hospitals, and clinicians who attended the meetings. In sharp contrast

to the situation uncovered by the Harding Clark Inquiry into the Lourdes Hospital,

where obstetric practice was not assessed or overseen,91 symphysiotomy was

exhaustively debated, and a wide variety of opinion expressed as to its suitability and

efficacy. Thus the use of symphysiotomy in mid twentieth-century Ireland was a

widely discussed approach, robustly attacked and defended over the course of

twenty years.

 

The earliest discussions, and amongst the most intense, occurred in the early 1950s

when the procedure was reintroduced. The ‘Transactions’ for 1951 are particularly

important, as that year saw a detailed debate regarding the potential as well as

limitations of the operation, and a discussion of the conservative obstetrical

 

 

 

 

matter, nor did the master ever intervene despite his and his colleagues’ reluctance to prescribe the

pill.’Risteárd Mulcahy, Memoirs of a Medical Maverick Dublin: Liberties Press, 2010, pp. 102-3.

87 The reports applied the so-called RCOG standard as a measure for Irish results in areas such as

maternal and foetal mortality. The Rotunda also produced statistics under the ‘Rotunda Standard’

which differed from the RCOG standard, and was based upon the specific conditions prevailing in

Dublin – the respective Rotunda Masters believed that this gave a more accurate picture of Irish

obstetrics.

88 Alan Browne, ‘Mastership in Action at the Rotunda, 1945-95’ in Alan Browne (ed) Masters,

Midwives and Ladies-in-Waiting: the Rotunda Hospital, 1745-1995 Dublin: A & A Farmar, 1995, p. 24.

89 There was no obligation on the part of maternity hospitals outside of the three Dublin Lying-in

institutions to compile reports. They were merely required to present statistics to the RCOG in the first

instance, and after 1976 to the IOG. These bodies were not required to review or respond to the

reports.

90 With the exception of Our Lady of Lourdes in Drogheda, where the practice continued, albeit in

diminishing numbers, until 1984.

91 The culture of deference to senior medical staff, and an unwillingness to question practice, allowed

the anomalous situation to continue at Lourdes. Harding Clark, passim.

 

 

 

29

 

 

 

 

 

environment in Dublin, explicitly linked to religious belief. Obstetricians quoted

biblical text at each other, and a robust attack and defence took pace, involving

comments from a large number of physicians. It is clear that at this stage the

potential of the operation was still being explored, especially in relation to ‘curing’

disproportion. This was a pressing problem in international obstetrics, known to

cause problems at delivery, but very difficult to diagnose with any certainty. Prof. C.

Scott Russell of Sheffield noted that ‘In the Industrial North of England where I have

worked for nearly five years, contraction of the pelvis is still quite common, and from

my experience I can say without hesitation that the clinical methods of assessing

disproportion, especially in the ante-natal period, are not precise enough in doubtful

and difficult cases.’92 He then discussed at length the differing approaches to cope

with disproportion, from methods of diagnoses (radiological pelvimetry and

cephalometry; early induction of labour before the baby reaches full size; trial labour,

caesarean section, and symphysiotomy: ‘Though I have performed it two or three

times with benefit, I have in recent years preferred the lower segment Caesarean

section’) through to results, which were mixed. Prof. Chassar Moir spoke next, and

focused specifically on the imperative for vaginal deliveries in Dublin, which he

viewed with some anxiety. From his perspective, it was unethical to approach

obstetrics with the intention of securing limitless pregnancies and deliveries, simply

because of religious belief. The debate was less about the virtues or otherwise of

symphysiotomy (‘Let me make my position quite clear. I believe there is a place for

symphysiotomy. I myself have used this operation in the past and am prepared to

use it again in the future.’), and more about an obstetrician’s role in protecting the

health of mothers and children, regardless of religious belief. Indeed, the discussion

produced a general unanimity regarding the positive potential of symphysiotomy in

cases of disproportion, but disagreement over what the visiting obstetricians saw as

a reckless commitment to successive pregnancies at all costs. There was an

explicitly expressed fear that Ireland’s prohibition of contraception and sterilisation to

limit family size would result in the operation being inappropriately used.

 

In the ‘Transactions’ in each subsequent year, symphysiotomy was specifically

discussed, until the numbers undertaken fell naturally in the late 1950s. Indeed, it is

the most extensively evaluated procedure in the professional debates, and also

 

 

92 p. 1023.

 

 

 

30

 

 

 

 

 

features in each of the individual hospital reports, with summary case studies,

outcomes (immediate and long-term), and detail on deliveries subsequent to

symphysiotomy. Despite the optimism expressed by Barry and Spain in particular,

the procedure never superseded caesarean section, which became more common

with each successive year. The role of the Transactions is vital in shaping obstetric

practice: it provided a forum not merely for discussion, and placed Irish practice

under external observation, but in the presentation of statistics and case studies of

procedures, it provided an empirical base from which evaluation could take place,

and that is where its real value lay. The recognition that LSS caesareans were safer

than originally thought, and that the circumstances of mothers had improved steadily,

came about because of the availability of hard data from the hospitals.

 

It has been alleged that symphysiotomy was chosen over caesarean section in

Ireland not for clinical but ideological reasons, and that CS was a safe procedure

from the 1940s. This was not the case. Ireland had a good record of successful

caesarean section delivery, although a higher maternal mortality rate than that in

Britain.93 From the mid 1940s, almost all sections were the Lower Uterine Segment

Section (LSS), a much safer operation than the so-called ‘Classical Section’ that

involved a midline longitudinal incision providing a larger space to deliver the baby,

but a higher mortality rate and greater long-term complications.94 But even the LSS

carried significant immediate as well as long-term health risks, which increased with

repeat sections.95 In 1948, J. K. Feeney, Master of the Coombe Hospital, published a

review of Caesarean Sections in Dublin in 1946, indicating that poor maternal health,

combined with multiple repeat sections as a result of high fertility, led to a

substantially increased mortality rate:

 

 

 

 

93 Maternal mortality following caesarean section was between 0.5-1.1% nationally in Britain, and 2%

in Ireland.

94 The classical section was occasionally used in Dublin in specific emergency deliveries, including

nuchal cord (where the umbilical cord is around the baby’s neck), but was rare in the late 1950s and

‘60s.

95 One of the major complications of caesarean section was ‘adhesions’: fibrous bands of scar tissue

that form between internal organs and tissues, joining them together abnormally. They form

commonly after surgery, especially abdominal surgery, as a normal part of the healing process.

Repeat caesareans created a risk of large numbers of adhesions, which caused major problems in

recovery, and left many patients in a great deal of pain. The Rotunda noted cases throughout the

1950s where difficulties in closing the abdominal wound after caesarean delivery occurred because of

the number of adhesions.

 

 

 

31

 

 

 

 

 

One of the aims of the conscientious obstetrician is to keep his

Caesarian section rate as low as is compatible with intelligent and

conservative obstetrical practice. Whilst a very low rate is not

necessarily an indication of obstetrics of a high standard, it should be

constantly borne in mind that a Caesarian section is a major

abdominal operation accompanied by maternal mortality and

morbidity rates which are considerably higher than those of vaginal

delivery. It has been estimated that Caesarian section performed

under ideal conditions should carry with it a maternal mortality rate of

only 0.5% to 1%, but this figure has not yet been attained in the mass

obstetrics of hospital practice. Until all pregnant women receive the

full advantages of efficient antenatal care and social service, patients

suffering from serious disease and in poor condition will continue to

be admitted to our maternity hospitals. In addition to the risks of

operation, the remote chronic obstetrical invalidity associated with

repeat Caesarian sections is an important consideration in a

community in which birth control and sterilisation are not practiced.96

 

In fact, the combined maternal mortality rate in Dublin following section was 2%, a

figure that exceeded the prevailing rate in Britain. This varied from year to year, and

between hospitals, from a high of 4.2% in the Rotunda in 1947-48 (an unusually high

number, caused by women with heart disease), to 0 in 1962.97 It was Irish women’s

larger family size that contributed to this higher rate, with greater numbers of

pregnancies and deliveries resulting in a concomitant raised mortality and morbidity

rate. But it was the babies that bore the brunt of mortality and morbidity in Ireland:

‘Foetal loss is of course higher in this city (Dublin) than in London, but the

circumstances are so different. Foetal loss is improving steadily every year under the

influence of the maternity hospitals, but childbirth being what it is the loss in a

community having four or more children per family must of necessity be greater than

in communities having one and a half to two children per family…The risks to mother

 

 

 

 

96 J.K. Feeney, ‘Caesarean Section in Dublin’ in Irish Journal of Medical Science, Sixth Series, No.

276, December 1948, p. 777.

97 The adjusted annual average in the 1940s and 1950s at the Rotunda was 2 deaths following

 

section each year.

 

 

 

32

 

 

 

 

 

and child increase with increasing parity.’98 Foetal loss was generally higher in

Ireland than in Britain, at an average of 7% of all deliveries, compared with just over

4% nationally in the UK.99 The difference was claimed to lie in emergency, unbooked

cases in Ireland: the adjusted rate for booked cases was 4.6%.100

 

Alternatives to Symphysiotomy or Caesarean Section for Disproportion:

 

There were few safe alternatives until the mid 1950s. The Rotunda deviated from the

NMH and the Coombe in avoiding symphysiotomy in the late 1940s, and successive

Masters explored other possibilities for safe delivery. In the 1940s, the hospital had

initiated a policy of early induction of labour, hoping to avoid the problem of

disproportion by delivering the baby before it reached its full size and weight. Babies

were induced at 37 weeks, with variable results: ‘Our policy has been to induce

labour to avoid excessive disproportion by puncture of the membranes rather than

bougies, and to combine this with medicinal induction unless there appears to be

established disproportion, but we do not attempt induction before the 37th week. If

moderate disproportion is already present we prefer to allow trial labour at term, and,

if in doubt of the final outcome, to perform Caesarean section.’101 There were many

problems associated with the delivery of pre-term babies, and respiratory difficulties

in particular were common. Moreover, it was still an unreliable means of avoiding the

problems of disproportion, which often did not become clear until the second stage of

labour. The personal preferences of the Masters determined delivery policy, and

 

E.W.L. Thompson of the Rotunda explored other possibilities because of his own

dislike of symphysiotomy. Section rates were higher there than the other two

hospitals for this reason: ‘Some of the less severe cases (of disproportion) could

certainly have been treated by symphysiotomy, and probably very successfully. I

cannot however, get away from my dislike for the general use of this procedure.’102

Across the hospitals, there was a tendency to allow women to continue in labour for

longer periods than in Britain, a policy that attracted critical comment in the 1940s.

98 A.P. Barry, ‘Transactions’, Irish Journal of Medical Science 1955, p. 531.

99 ‘Transactions’, Irish Journal of Medical Science 1951, p. 1030.

100100 Booked cases had a better outlook for the simple reason that they represented mothers who

attended the hospitals for prenatal care. Any problems could therefore be identified and treated before

they reached a critical point. The unbooked cases formed the majority of the emergency admissions,

often with no accompanying medical history.

101 Rotunda Hospital Report for 1948.

102 Rotunda Hospital Report for 1957.

 

 

 

33

 

 

 

 

 

Maternal Health and Symphysiotomy:

 

Symphysiotomy is associated with poor maternal health, for two principal reasons.

The first relates to the main indication for the procedure: disproportion and/or

contracted pelvis. Contracted pelvis was relatively common in nutritionally deprived

mothers, who had not achieved full growth before pregnancy. It was frequently

described in Britain in the pre and immediate post-war years, and was specifically

associated with inner-city populations.103 In Ireland, it was common amongst inner

city mothers in Dublin, Belfast, Cork and Limerick, but also throughout rural areas.

The economic situation of many Irish families was dire: the 2009 Commission to

Inquire into Child Abuse provides shocking detail regarding the deprivation faced by

many Irish families because of poor wages and unemployment104. Mothers and

children felt the full impact of poor diet, with women in particular suffering from

chronic illness associated with inadequate nutrition. They also presented in labour

with complications that made them poor candidates for general anaesthetic

(anaemic, with heart disease, tubercular), and ensured that symphysiotomy was

considered a safer alternative to caesarean section in the 1940s and 1950s.

 

The Dublin maternity hospitals served areas of significant deprivation. The health of

mothers in particular was often poor: it was common in working-class families for

mothers to prioritise the health of husbands (as breadwinners) and children over

themselves, leading to high degrees of malnourishment and chronic illness. This was

a feature of working-class life in Britain in the same period, with a similar impact

upon maternal and child health.105 When added to frequent pregnancy and nursing,

mothers were often physically debilitated when they arrived for delivery at hospital.

 

 

 

 

103 ‘I am personally convinced that nutritional and environmental factors are still responsible for the

high incidence of the milder forms of pelvic contraction which exist in this region to-day.’ Hector R.

MacLennan, ‘The Management of Labour in Contracted Pelvis’ in the British Medical Journal, October

9, 1954, pp. 837-40. MacLennan was a consultant surgeon at the Royal Maternity and Women’s

Hospital, Glasgow.

104 David Gwynn Morgan, Commission to Inquire into Child Abuse, Chapter 3, ‘Society and the

Schools’, part 1, ‘Social, economic and family background: Child Poverty in Independent Ireland’ 3.013.18,

May, 2009.

105 A seminal study of the impact of poverty on child health was conducted by Maud Pember Reeves

of the Fabian Society in Lambeth, a working-class district of London in 1913. The study found

conditions of deprivation identical to those prevailing in areas of inner-city Dublin almost thirty years

later, with large family size, poor nutrition, and a heavy infant mortality rate linked to malnutrition and

disease (there was a new-born mortality rate in Lambeth of 9%, but a total death rate amongst the

children of the study families of a staggering 29%). Round About a Pound a Week (London: The

Fabian Society, 1913).

 

 

 

34

 

 

 

 

 

Women presented with a wide range of chronic illnesses as well as poor physical

 

condition, and this was a source of concern throughout their pregnancies, and had

 

major implications for delivery and for the early health of their children. They were

 

dangerously anaemic (in 1950, 75% of expectant mothers attending the Coombe

 

were anaemic106), malnourished, and presented with a number of life-threatening

 

illnesses that made pregnancy a dangerous process. Rates of rheumatic heart

 

disease and pulmonary tuberculosis were high107, and it became necessary to

 

establish anaemia clinics for expectant mothers in the 1950s. Each of the hospitals

 

also had an Almoners Department, whose purpose was to interview patients in order

 

to determine their ability or otherwise to pay for medical treatment. The almoners

 

however found themselves in the position of proto-social workers, finding that the

 

economic, social and health problems faced by Dublin mothers required direct

 

emergency relief. In the early years, the principal problem was malnutrition, and of

 

the average 3,000 women assisted each year across the three hospitals, over two

 

thirds required extra nutrition.108 A major problem in addressing the issue was the

 

fact that mothers, if given additional food to take home, invariably gave it to their

 

children and spouses, and continued in the same state of ill-health.109

 

Malnourishment caused specific obstetric problems, seen in Dublin in unusually high

 

numbers. Placenta previa, a condition in which the placenta attaches in the lower

 

part of the uterus rather than the more muscular upper section, occurs commonly in

 

 

 

 

106 ‘During the year, 30 per cent of our obstetrical patients had a haemoglobin content of less than 50

per cent, whilst 75 per cent of them had less than 70 per cent Hb. These women are ill-fitted to

withstand the stress and strain of pregnancy and labour, they cannot afford blood loss and their

resistance to infection is poor. Malnutrition is the most important single aetiological factor. This state

of ill health occurs as a result of poverty; the diet of bread and tea; lack of cooking facilities; anorexia,

nausea and vomiting and focal sepsis.’ Coombe Hospital Report for 1950, p. 703.

107 In the early 1950s Dr Risteárd Mulcahy was invited by Dr Feeney, Master of the Coombe, to

establish a weekly clinic to treat mothers with heart disease: ‘Rheumatic heart disease was still a

particular scourge among the poorer classes in Ireland and particularly in women….The social

conditions of many of them were poor, particularly in terms of malnutrition, iron deficiency anaemia

and chronic respiratory infections. These were major complicating factors in the heart patients and so

often helped to precipitate heart failure. There is little doubt that when the patients received optimum

medical treatment, combined later with much improved social circumstances, their prognoses were

greatly improved, even without surgery.’ Medical Maverick, p. 101.

108 The hospitals were unable to help all the women in need, so had to prioritise those in the direst

situations. In the Rotunda in 1957 for example it was found that ‘2,009 mothers needed help or

advice. In the Maternity Department, many patients, more particularly attending the anaemia clinic,

needed material aid in procuring extra nourishing foods over and above that which could be obtained

from statutory sources. Voluntary agencies frequently gave this extra assistance, and our own

Samaritan Fund was used to help until such outside aid could be procured. It was observed that

numerous patients did not know what constituted a well-balanced diet, and very many had not

sufficient knowledge to cook plain and essentially nourishing meals.’ ‘Clinical Report’ 1957.

109 Earner-Byrne, Mother and Child; Almoner’s Report, Coombe Hospital (1950), p. 825.

 

 

 

35

 

 

 

 

 

normal pregnancies but usually corrects itself before delivery. In about 10% of cases

the placenta covers the cervix and a caesarean section is required, often relatively

early to avoid the risk of haemorrhage. The condition is more frequent in

malnourished women, those with a history of multiple births, and in mothers with

uterine scarring from caesarean section or routine pregnancy. It can cause anaemia

in mother and child, and is an indication for early, often caesarean, delivery. There

were rarely fewer than 50 full-term or near-term cases in each of the three hospitals

each year, and while maternal mortality with the condition was very low, it took a

heavy toll on babies, with a combined average foetal loss of over a third.

 

Malnourishment and deprivation produced additional complicating factors, the most

important of which was contracted pelvis, resulting in disproportion at delivery, and

seen in large numbers in British as well as Irish maternity hospitals.110 Prof. T.N.A.

Jeffcoate noted high caesarean section rates in industrial cities in the UK, and

attributed it to pelvic disproportion: ‘In 5 large maternity units in Liverpool not less

than 350 Caesarean sections for disproportion are performed each year. I had

always imagined that the high incidence of contracted pelvis in Liverpool, and

probably in Glasgow as well, was accounted for in large part by Irish immigrants

living in very poor circumstances.’111 Malnourishment was associated with pelvic

contraction, but was also implicated in a series of additional ailments that led to

problems in pregnancy and delivery in Ireland, including an increasing caesarean

section rate: ‘…considering the prevalence of contracted pelvis amongst the poor

patients of this city and the large number of abnormal cases of all kinds admitted

from the city and country, the present Caesarian rate of about 3.5 indicates a

reasonably conservative outlook, as compared to other centres.’112

 

The Dublin hospitals faced additional difficulties with regard to their patients. Until the

1960s, it was common for women to only present for a hospital delivery once

complications set in. This meant that throughout the 1940s and 1950s, one-third of

 

 

 

 

110 Pelvic Disproportion was the major indication for both symphysiotomy and caesarean section in

the mid-twentieth century. As general maternal health improved, the numbers of cases dropped

significantly, and as more accurate diagnoses of the condition occurred it was realised that it had

been over-diagnosed in both Britain and Ireland.

111 Prof. T.N.A. Jeffcoate, ‘Disproportion’ in ‘Transactions of the Royal Academy of Medicine in

Ireland’ in The Irish Journal of Medical Science Report of Meeting of October 20th, 1950, p. 857.

112 J.K. Feeney, ‘Caesarian Section in Dublin’ in Irish Journal of Medical Science, Sixth Series, No.

 

276, December 1948, p. 757.

 

 

 

36

 

 

 

 

 

the cases were ‘unbooked’, and presented in varying stages of difficulty. The

National Maternity Hospital as a result dealt with ‘a very high percentage of

abnormalities’ each year that could not be identified or treated in advance, increasing

the likelihood of interventions such as symphysiotomy and caesarean section. This

was confirmed across the Dublin hospitals, which dealt with not only unbooked

cases, but emergency admissions from rural areas, amounting to 30% of their cases

each year: ‘Our maternal and foetal mortality is influenced by this circumstance and

cannot be fairly compared to those institutions which deal with circumscribed

geographical areas.’113 The rural cases were a particular problem in that many

patients had already been in labour for extraordinarily long periods of time before

admission to hospital: 50 hours was high in the early years, but not exceptional.

Many of these patients had already undergone failed attempts at forceps delivery

and other interventions, and in many cases the foetus was in distress and

sometimes already dead. Thus the Dublin hospitals faced particular problems in

terms of its patient profile, which made obstetric care challenging, to say the least.

 

In addition (or perhaps as a contributing factor to) the poor health of mothers was an

exceptionally high birth rate for married women: ‘Fertility in the Republic was

considerably higher than in any other western European country from the 1950s up

to 2000, a period in history when control gradually became the norm. Even in the

1960s, thirty per cent of all births in the Republic were fifth births or higher. This

figure had reduced to fifteen per cent by 1980, and to five per cent by 1990.’114 When

the Advisory Body on Voluntary Health Insurance reported in 1956, it noted that

premiums for maternity care would be higher than for other covers, given the high

fertility rates for married Irishwomen: ‘The rate of fertility among married women in

this country is high. During the period 1950-1952, the average annual number of

births per 1,000 women of childbearing age was 254, compared with 111 in Britain.

In the USA the figure for 1949-51 was 150, and in Denmark it was 136 for the same

period.’115

 

 

 

 

113 J.K. Feeney, Coombe Hospital Report, in ‘Transactions’, Irish Journal of Medical Science, 1955, p.

528.

114 Ann Rossiter, Ireland’s Hidden Diaspora: the ‘abortion trail’ and the making of a London-Irish

underground, 1980-2000 London: IASC Publishing, 2009, p. 91.

115 Advisory Body on Voluntary Health Insurance Scheme Report Dublin: Government Publications,

Stationary Office, 1956, p. 17.

 

 

 

37

 

 

 

 

 

 

The high birth rate, and poor health, contributed to a considerably higher than

average maternal mortality rate in Ireland in comparison with other countries,

although the gap closed steadily as the century advanced.

 

Maternal Mortality Rates116:

 

Maternal Mortality Rates in Ireland117, the USA, England & Wales, and the

Netherlands from 1920 to 1960:118

IRELAND USA ENG &

WALES

N’LANDS

1920 62.8 68.9 43.3 24.0

1930 50.4 63.6 44.0 33.3

1940 40.2 37.6 26.1 23.5

 

 

116 Rate expressed as maternal deaths per 10,000 births.

117 Central Statistics Office, Vital Statistics, chapter 4 Infant Mortality, Stillbirths and Maternal

Mortality, p. 156.

118 Figures for the USA, England & Wales and the Netherlands taken from Irvine S.L. Loudon,

‘Childbirth’ in Companion Encyclopaedia of the History of Medicine, Volume 2 London: Routledge,

1993, p. 1067.

 

 

 

38

 

 

 

 

 

1950 15.5 8.3 8.7 10.5

1960 5.7 3.7 3.9 3.7

 

There is another important issue with regard to the prevalence of symphysiotomy in

Dublin and Drogheda in particular, and its relative absence in the regional hospitals.

The Dublin Masters consistently cited poor maternal health as a explanation for

symphysiotomy. Their annual reports confirm that significant numbers of mothers

often presented with problematic labours, and underlying, often chronic, medical

conditions that made them difficult obstetrical cases. The obstetricians were both

prepared for unusual cases, and were experienced in less common procedures such

as symphysiotomy, making it a viable intervention. In other maternity hospitals

throughout the country, however, the procedure may well have been avoided

because of a lack of training and experience in its use. This factor remains a central

element in discussions regarding symphysiotomy’s use in the modern world: as

noted earlier, even when an obstetrician is aware of the appropriate indications for

symphysiotomy, there may be a reluctance to employ it because of a lack of

experience.119 Such caution seems a sensible approach to such a major medical

intervention. But the role of the individual practitioner is also important. As is evident

from the Dublin ‘Transactions’, some obstetricians had a greater faith in the

procedure than others, and were instrumental in its use. This is also the case with

Gerard Connolly in Our Lady of Lourdes Hospital in Drogheda, where the operation

was much more extensively used than in any other regional hospital (see below).

The fact that symphysiotomy largely ceased in Drogheda on Connolly’s retirement

underlines the association between an individual belief in the value of the procedure,

and the experience to undertake it.

 

Context for Reintroduction of Symphysiotomy:

 

The procedure of symphysiotomy was reintroduced in Ireland in the mid 1940s. The

principal contexts for its use were:

 

 

 

 

119 ‘Not only are the indications for symphysiotomy rare in developed countries, but the cases that

might benefit from symphysiotomy – mainly obstructed after-coming-head and failed instrumental

delivery in a woman unfit for an urgent CS – are such dire emergencies, that it is hardly a suitable

opportunity to teach the procedure or even for an obstetrician to maintain a rarely used skill.’ Douwe

Arie Anne Verkuyl, ‘Think Globally, Act Locally: the case for symphysiotomy’ in PLoS Medicine,

March 2007, Vol. 4, Issue 3, pp. 401-406.

 

 

 

39

 

 

 

 

 

It helped to achieve a predominant goal in obstetrics of a vaginal delivery.

It offered a means of avoiding caesarean section in cases of minor to

moderate obstruction

From the 1940s, there was a continuing rise in hospital deliveries, and a

concurrent rise in major interventions including caesarean section, forceps

delivery, and episiotomies

The maternal mortality rate was much lower with symphysiotomy than

caesarean section

Advances in technology, especially x-ray, encouraged consideration of the

prevalence of pelvic disproportion

There was a growing concern regarding the rise in caesarean section, and the

risks associated with multiple sections

Sterilisation for contraceptive purposes and contraception were illegal,

ensuring an exceptionally high birth rate.

The poor health of many mothers presenting for delivery necessitated an

increasingly interventionist obstetric policy

Obstetric care was utterly transformed following the Second World War. Up until the

mid 1930s, maternal mortality rates had remained largely unchanged in Britain and

Ireland from the 1860s. One of the most dangerous places to deliver a baby prior to

1930 was in hospital, where mothers contracted puerperal fever in huge numbers.

Despite the establishment of the British College of Obstetricians and Gynaecologists

in 1929 (later the Royal College of Obstetricians and Gynaecologists), and an

increasing emphasis upon education and training, standards across Britain and

Ireland were very varied and mortality rates high. The introduction of sulphonamide

drugs120 however had a dramatic effect on survival rates, and combined with

penicillin (available from 1945), significantly reduced maternal mortality. The

introduction of the Irish Hospital Sweepstakes directed considerable sums of money

towards the improvement of the three Dublin maternity hospitals, which received

£318,483 between them from 1931-5.121 Thus by 1945 medical standards had risen,

and a more interventionist obstetric policy developed in both countries. In Britain,

 

 

 

 

120 The first effective drug treatments against bacterial infection developed in Germany in the early

1930s.

121 Joseph Robins, ‘Public Policy and the Maternity Services’ in Masters, Midwives and Ladies-In-

Waiting: The Rotunda Hospital 1745-1995, Dublin: A&A Farmar, 1995, p. 287.

 

 

 

40

 

 

 

 

 

with the creation of the National Health Service, births increasingly took place in

hospital, with the domiciliary system of delivery falling rapidly out of favour.122 In

Ireland, the numbers of women delivering at home also decreased, but more slowly

than in Britain, and the ‘extern’ service of the three Dublin hospitals, and to a lesser

extent outside the major cities, remained a feature until the early 1970s.

 

Relative risks of Symphysiotomy and Caesarean Section:

 

One of the principal reasons for employing symphysiotomy was the dangers

associated with Caesarean Section, which were very real in the 1950s and ‘60s.

Although the operation had a high rate of success, it also had a far greater maternal

mortality rate than symphysiotomy, and a higher total foetal loss rate. In the NMH in

1952 for example, 18 symphysiotomies were performed with no maternal deaths and

two stillbirths, while 56 sections were undertaken, with 4 maternal deaths and 5

foetal deaths (2 stillbirths and 3 neonatal deaths).123 The relative death rates for the

two procedures remained relatively consistent. The maternal mortality rate for

sections declined slowly but steadily, as the general health of mothers improved, but

was always significantly higher than for symphysiotomy, where maternal deaths

were very rare. It is important at this point to emphasise that in discussing relative

mortality rates, it is understood that in very many cases deaths occurred not as a

direct result of the procedure, whether symphysiotomy or CS, but because of an

underlying health problem that was exacerbated by pregnancy and delivery. In the

1950s and ‘60s, section was performed under general anaesthetic, which carried a

much higher degree of risk than the local anaesthetic required for symphysiotomy:

this risk applied equally in other operations requiring general anaesthetic. Moreover,

CS is often utilised because of a health risk to the mother in particular, meaning that

even before the operation the patient is in a disadvantaged state.

 

The maternal health outcomes for symphysiotomy and section have been

extensively studied elsewhere, and the findings broadly confirm the Irish experience:

 

Maternal and perinatal mortality, comparing the outcomes of

symphysiotomy and caesarean section, were analysed in ten

 

 

 

 

 

122 Martin Gorsky, ‘The British National Health Service 1948-2008: A Review of the Historiography,’

Social History of Medicine, Dec 2008, Vol. 21 Issue 3, pp 437-460

123 Report of the National Maternity Hospital for 1952.

 

 

 

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studies conducted between 1908 and 1995 comprising about 800

symphysiotomies and 1200 caesarean sections. Maternal mortality

was four times higher with caesarean section than with

symphysiotomy during the first half of the century and six times

higher in the second half of the century. Perinatal mortality was the

same for symphysiotomy and caesarean section.124

 

Perinatal outcomes were rather better in Ireland in the later years of use. In the

Dublin hospitals, perinatal deaths were on average 15% for symphysiotomy in the

1940s, dropping to 8% in the early to mid-1950s.125 Caesarean section perinatal

death rates were higher, and varied year to year, but saw a similar drop from a high

of 25% to 12% in the period under review. There were of course remarkable

exceptions to the accepted rules, which were specifically commented upon. One

mother’s spectacular reproductive career ended with a caesarean hysterectomy in

1951: ‘Case 4 must present a world’s record in Caesarean sections: 3 classical, 6

lower segment and 1 Caesarean hysterectomy (10). This woman had a scarred but

adequate abdominal wall. During her obstetrical life of 18 years, she had enjoyed

good health. She experienced the ministrations of no less than four successive

Masters of the Hospital (Healy, Corbet, Keelan, Feeney). Microscopial examination

of the scarred uterus showed excessive tissue with, in places, absence of muscle.’126

 

Vaginal delivery remains a key goal within obstetrics today, and is described as a

‘normal’ birth in contrast to delivery by caesarean, forceps or other medical

intervention. The National Health Service in Britain is committed to lowering the

section rate in its hospitals, which currently stands at 24.6%127, and there are

widespread concerns regarding a general misconception regarding the absolute

safety of caesarean section: given its prevalence, there is a tendency to

underestimate the risks associated with what is major abdominal surgery.128 The

 

 

 

 

124 Kenneth Bjorklund, ‘Minimally invasive surgery for obstructed labour: a review of

symphysiotomy during the twentieth century (including 5000 cases)’ in British Journal of Obstetrics

and Gynaecology, March 2002, Vol. 109, pp. 236–248.

125 Clinical Reports for the Dublin Maternity Hospitals, 1944-1984.

126 Clinical Report of the Coombe Lying-In Hospital for 1951, p. 29.

127 ‘Focus on Caesarean Section’, National Health Service Institute, 2007

128 In addition to concerns regarding patient safety, there are also anxieties over the financial

implications in increasingly straightened times for the NHS. Costs for a CS patient are over 25%

 

 

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National Institute for Health and Clinical Excellence in the UK has recently

recommended that women in Britain should be offered CS if they wish it, and not

primarily, as at present, on medical grounds. Their November 2011 guidelines offer a

detailed analysis, and series of recommendations, regarding the increase in

caesarean deliveries in Britain, and an acknowledgement of the importance of

maternal choice in ensuring a safe and satisfactory delivery.129 In the United States,

where the CS rate has increased substantially, there are similarly intense debates

over vaginal versus CS deliveries.130 A recent study of the Irish case has revealed

substantial differences in section rates across maternity units, from the lowest at

22% of births at the National Maternity Hospital Dublin to a high of 43% at St. Lukes

Hospital, Kilkenny.131 Nationally, the Irish rate is 26.2% of births, a steadily

increasing number. What is little realised is that Caesarean Section still carries a

higher maternal mortality rate in the western world than vaginal delivery, and is

associated with significant long-term health problems. A recent study in France

indicates that: ‘After adjustment for potential confounders, the risk of postpartum

death was 3.6 times higher after caesarean than after vaginal delivery…Both

prepartum132 and intrapartum133 caesarean delivery were associated with a

significantly increased risk. Caesarean delivery was associated with a significantly

increased risk of maternal death from complications of anaesthesia, puerperal

infection, and venous thromboembolism.’134 Similarly, in Britain caesarean section is

the highest single cause of mortality in hospital deliveries at 61%135 of all hospital

 

 

 

 

higher than a normal delivery, with mothers having a hospital stay of 3-4 days, as opposed to just 1, in

addition to theatre costs.

129 NICE Clinical Guideline, ‘Caeserean Section’, November 2011, pp. 1-282.

130 Fay Menacker & Brady E. Hamilton, ‘Recent Trends in Caesarean Delivery in the United States’

National Center for Health Statistics Data Brief, No. 35, March 2010, pp 1-2.

131 A recent study by Cuidiú, The Consumer’s Guide to Maternity Services in Ireland, provides

detailed information on relative rates of CS section for first-time mothers as well as sections in

subsequent pregnancies. See http://www.bump2babe.ie/column/P/statistics/ for both the statistics,

and analysis for the trends relating to delivery choices.

132 The period before delivery.

133 Pertaining to the period during labour and birth.

134 Catherine Deneux-Tharaux, Elodie Carmona, Marie-Heléne Bouvier-Colle, & Gérard Bréart,

‘Postpartum Maternal Mortality and Caesarean Delivery’ in Obstetrics and Gynaecology, September

2006, Vol. 108, No. 3, Part 1, pp. 541-8.

135 G. Lewis, ‘Saving Mother’s Lives: reviewing maternity deaths to make motherhood safer, 20032005’

The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom

London: CEMACH, 2007, P. 13

 

 

 

43

 

 

 

 

 

maternal deaths.136 A large-scale international study of the topic published in 2007

confirmed the relative risks of section delivery, which were higher for elective

sections than emergency. Examining a total of 106,546 births over a three month

period in eight Latin American countries, the researchers found that:

 

Caesarean delivery independently reduces overall risk in breech137

presentations…[however]…the increase in rates of caesarean

delivery at an institutional level is not associated with any clear

overall benefit for the baby or mother but is linked with increased

morbidity for both…In the crude analysis, the maternal mortality and

morbidity index in women in the elective caesarean delivery group

(5.5%) was higher than that in the intrapartum caesarean group

(4.9%) and vaginal delivery groups (1.8%).138

 

In Ireland in the mid-twentieth century, the maternal mortality rate for caesarean

section was much higher, and was a constant source of discussion. Symphysiotomy

was therefore regarded by some obstetricians as a means of reducing the number of

deaths. In the ‘Transactions’ for 1961, Dr Gallagher proposed a more extensive

study of the possibilities of symphysiotomies: ‘I think if we are going to state a policy

with regard to CS in Dublin it should be to keep down the number of sections as far

as possible. One way of achieving that would be for the three Masters to select 30

cases a year each and do elective symphysiotomies on them.’139 The suggestion

was not implemented, not least because the actual numbers (as opposed to the

proportionate use in total deliveries) of symphysiotomies had plateaued, and repeat

caesarean sections were becoming increasingly common, as well as safer. The

numbers of sections for conditions other than dire emergency in labour were rising,

with good results: ‘Falkiner [of the Rotunda] was innovative in extending the use of

 

 

 

 

136 Again it is important to emphasise that the section does not necessarily cause the death. In many

cases, an underlying medical condition may make a section necessary, but factors such as heart

disease, high blood pressure, or pre-eclampsia makes the outlook poor.

137 A baby born with feet or buttocks first. Complications in labour are more common with breech

deliveries.

138 Jose Villar, Guillermo Carrdi, Nelly Zavaleki, Allan Donner, Daniel Wojdyla, Anibal Faundes,

Alejandro Velazco, Vicente Bataglia, Ana Langer, Alberto Narváez, Eliette Valladareo, Arichana Shah,

Liana Campodónico, Mariana Romero, Sofia Reynoso, Karla Simônia de Pádua, Daniel Giordano,

Maricus Kublickas and Arnaldo Acosta, ‘Maternal and Neonatal Individual Risks and Benefits

Associated with Caesarean Delivery: multicentre prospective study’ in British Medical Journal, 2007,

November 17; 335 (7628) 1025.

139 ‘Transactions’ in Irish Journal of Medical Science, 1961, p. 536.

 

 

 

44

 

 

 

 

 

caesarean section for conditions other than disproportion and ante-partum

haemorrhage from placenta praevia. He used it more liberally than ever before in the

management of severe cases of pre-eclamptic toxaemia140 of pregnancy, and was

criticised for doing so by the Academy. However, as time went by the results fully

justified the policy.’141 By the early 1960s, it was becoming increasingly clear that

with improved maternal health, and better surgical and anaesthetic techniques,

repeat caesareans no longer held the dangers they once had. A short study

conducted at the Rotunda confirmed this trend: ‘A preliminary study of Multiple

Repeat Caesarean Sections from Rounda Hospital Records by Dr Terence Hynes

suggests that multiple repeat section in fact constitutes a very small degree of

danger to the patient. Out of 115 cases who had already undergone at least three

previous Caeseaean Sections there was no rupture of the uterus, no maternal

mortality and minimal foetal loss.’142

 

Long-term Effects of Symphysiotomy:

 

The nature of the procedure, and the potential danger of introducing pelvic instability,

was at the forefront of obstetricians’ minds from the 1940s. It proved a constant

source of discussion at the Royal Academy of Medicine, when Obstetricians of the

Royal College travelled to Dublin to discuss the maternity hospital reports, but also

between the Masters of the three Dublin hospitals. Many of the reports include detail

regarding the short-term impact of the procedure, and present individual case notes

up to discharge. Some patients returned for follow-up, but it was more common for

mothers to come to hospital only when they were about to deliver their next baby.

The Dublin hospital reports provide some detail on the figures (recovery, ambulation,

incontinence, pain), follow-up in some cases,143 and commentary on subsequent

vaginal deliveries.

 

 

 

 

140 A potentially fatal condition of pregnancy characterized by high blood pressure, protein in the urine,

abnormal weight gain, and oedema [excessive swelling].

141 Browne, p. 30.

142 Rotunda Hospital Annual Report for 1961, p. 29.

143 Reporting is not consistent. Many patients failed to attend hospital for follow-up, and in some

reports note is taken of women who subsequently underwent a spontaneous vaginal delivery, but

does not comment on general health.

 

 

 

45

 

 

 

 

 

In 1955, the Master of the Coombe Hospital published a review of symphysiotomy

 

patients144 who had undergone the procedure between January 1950 and December

 

1953, and reported these results145:

 

Difficulty in Walking

 

44 experienced no difficulty whatever

 

2 had difficulty after a long walk, of about one mile

 

2 had difficulty “if already tired”

 

1 had a tired feeling in the right leg after a long walk

 

1 complained of difficulty, but this was not substantiated by observation

 

Difficulty in lifting heavy articles, such as a bucket of water

 

39 experienced no difficulty

 

4 “could not manage” a bucket of water

 

3 felt “uncomfortable” in the pelvis, when lifting such a weighty article

 

2 had difficulty from the 7th month of a succeeding pregnancy

 

1 had “occasional” difficulty in lifting weights

 

Pain in the back

 

35 had no backache

 

8 had “occasional” backache

 

4 had “fairly constant” backache

 

 

 

 

144There were periodic reports of symphysiotomy outcomes throughout the annual reports. The

Coombe listed the following results in 1947 from the total of nine women who had undergone the

procedure that year:

No 23: ‘…patient up on 9th day – discharged on 16th day. Follow up: three months later – no disability.’

No. 24:’…discharge on 17th day – no disability. Returned 4 weeks later with frequency of micturition –

cystitis, which yielded quickly to Sulphonamides. Two months later – quite well.’

No. 25: ‘…Patient discharged well on 17th day. Attended the Academy of Medicine walking perfectly

on 16th day. Follow up not possible.’

No. 26: ‘…Patient discharged on 16th day walking well. Came back 3 days later complaining of some

pain in region of wound. There was local sepsis, wound was incised, and sepsis cleared up perfectly

in 4 days. Left hospital without x-ray. Follow up impossible.’

No. 27: ‘Patient up on 9th day. Discharged free of all disability on 16th day. Returned 2 months later

complaining of slight stress incontinence. On examination with bladder full this could not be

demonstrated when lying down, but was evident in the erect position. Still under observation.’

No. 28: ‘…Patient up on 10th day, discharged, walking well and without disability on 16th day. Two

months later – no disability.’

No. 29: Discharged on 19th day.

No. 30: ‘…Patient up on 10th day, discharged walking perfectly on 14th day.

No. 31: ‘no comment on condition after operation.’

145 Report of the Coombe Maternity Hospital for 1954, pp. 55-6.

 

 

 

46

 

 

 

 

 

2 had backache “during the period”

1 had backache in the late weeks of a succeeding pregnancy

 

 

Incontinence of urine

 

38 had normal control over micturition

2 had poor control with “bad cough”

2 had defective control, but only in last two months of a succeeding pregnancy

1 had defective control in bad weather

1 had defective control for 3 months after symphysiotomy, but then regained

continence

1 had defective control when pregnant next time, in cold weather and just before

menstruation

1 had slight incontinence on sneezing

1 had to “run” when she “felt the impulse”

1 had poor control “at intervals”

1 had poor control

And in 1, stress incontinence had preceded symphysiotomy and has since been

cured by sub-urethral repair

 

Other complaints which might be connected with the operation

 

1 complained of “deadness” in one leg on long standing

1 complained of “coldness” and “pain” in one leg

1 complained of “coldness” in one leg during period and when pregnant next time

1 complained of “occasional weakness” in legs

1 complained of “a feeling of strain” in the pelvis

 

Pregnancy following symphysiotomy

 

21 patients each had one spontaneous vertex146 delivery of a living infant

1 patient had an easy assisted breech delivery of a living 9lb foetus

4 women had each 2 spontaneous vertex deliveries

3 women each had 3 spontaneous vertex deliveries

 

 

146 Baby delivered head first.

 

 

 

47

 

 

 

 

 

1 patient had, to follow the symphysiotomy, one Caesarean Section and then 2 easy

vaginal deliveries

1 patient had, to follow the symphysiotomy, one Caesarean Section

(spondylolisthesis),147 not suitable for symphysiotomy in the first instance

1 had a spontaneous delivery of a large postmature macerated148 foetus

1 patient had an abortion

1 patient had a miscarriage

16 patients have not become pregnant so far

 

As is well established, reported pain following any injury or medical intervention is

highly individual, and assessments are likely to be effected by the expectation of

both the patient and the physician. Patients undergoing identical procedures will

report a wide variety of responses, good and bad, that offer very different

perspectives on treatment. Moreover, the questions asked of a patient will have a

significant effect upon their response, and the manner in which it is recorded. The

relationship between patient and practitioner will also effect, if not predetermine, the

outcome. This is noted in the results above: the Master somewhat paternalistically

notes that he did not himself interview the patients at follow-up, in order to avoid the

personal relationship from influencing the women’s responses: ‘In case the answers

of the patients to specific questions might be coloured by any gratitude which they

might feel, the interviews were not carried out by me.’

 

The early conclusions appear to be supported by follow-up reports from the modern

developing world. A number of studies of long-term effects have been conducted,149

which concur broadly with the Dublin reports. A study of a small cohort of 34 women

after symphysiotomy in Zimbabwe in 2008 for example found the following results:

‘None reported serious soft tissue injuries in the birth canal e.g. laceration, fistulae,

and haemorrhage, or post-operative infection. One suffered stress incontinence,

eight reported pain on walking, seven of them after 10-20 kilometres. One woman

 

 

 

 

147 Forward displacement of one of the lower lumbar vertebrae over the vertebra below it or on the

sacrum.

148 A stillborn infant with skin and tissue softening.

149 There are methodological problems with these reports, which are acknowledged by authors, in that

patient return for follow-up is even more erratic than in the mid-twentieth century Irish case. The

criteria for inclusion are however clearly laid out, and the results, although relatively small-scale, are

verifiable.

 

 

 

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(stress incontinence above) who delivered a baby with hydrocephalus150 had pain in

symphysis pubis and a feeling of instability in pelvis when walking any distance…the

results from the present study and previous follow-up studies indicate that

symphysiotomy confers an acceptable level of complaints in the long run.’151 A

follow-up study of 100 South African patients in 1963 specifically addressed the

issue of pain, examining the symphysis pubis, groin, hip, thigh, sacro-iliac joint and

evaluating stress incontinence. It was found that there were some long-term effects,

but negative reports were slightly higher amongst the control group of women who

had had a normal vaginal delivery. 60% of this group reported some or all of the

symptoms during the follow-up period or in a subsequent pregnancy, compared with

58% of the symphysiotomy patients. Tests included walking, running, jumping and

carrying weights.152 In 1975, the results of a Nigerian study comparing outcomes of

symphysiotomy with caesarean section were published. It found that long-term

effects were similar with both procedures, with the two cohorts reporting sub-fertility

(7%), stress incontinence (3%) and backache (25%).153 A comparative study of

symphysiotomy (86 patients) and caesarean section (920) in New Guinea showed

better outcomes for the symphysiotomy patients in terms of maternal mortality and

morbidity154, and so on.

 

There is no doubt that some women have suffered adverse effects from the

procedure, and in the case of patients who went on to have subsequent children,

there may well have been an exacerbation of operative injuries. Part of the problem

in assessing long term problems after symphysiotomy is that other factors, including

subsequent pregnancies, may themselves contribute to chronic ill health.

Incontinence occurs in approximately 10% of women as a result of normal

 

 

 

 

150 A condition in which fluid accumulates in the brain, typically in young children, enlarging the head

and sometimes causing brain damage. Babies with hydrocephalus were difficult to deliver, and the

condition accounted for a number of symphysiotomies in Dublin in the 1940s and ‘50s in particular.

151 Henge Langi Ersdal, Douwe A.A. Verkuyl, Kenneth Bjorklund & Staffan Bergström,

‘Symphysiotomy in Zimbabwe; Postoperative Outcome, Width of the Symphysis Joint, and

Knowledge, Attitudes and Practice among Doctors and Midwives’ in PLoS One, 2008, Vol. 3(10),

e3317. See also Staffan Bergström, H. Lublin, & A. Molin, ‘Value of symphysiotomy in obstructed

labour management and follow-up of 31 cases’ in Gynecologic and Obstetric Investigation 1994, No.

38, pp. 31–5.

152 A.H. Lasbrey, ‘The Symptomatic Sequelae of Symphysiotomy: a follow-up study of 100 patients

subjected to symphysiotomy’ in South African Medical Journal 1963; vol. 37, pp. 231-234.

153 V.J. Hartfield, ‘Late Effects of symphysiotomy’ in Tropical Doctor 1975, Vol. 5, pp. 76-78.

154 G. Mola, M. Lamang, ad I. Mcgoldrick, ‘A retrospective study of matched symphysiotomies and

caesarean sections at Port Moresby General Hospital’ in Papua New Guinea Medical Journal 1981;

 

24: 103-112.

 

49

 

 

 

 

 

pregnancy and delivery,155 and incontinence may set in long after delivery: women

with temporary loss of urinary control immediately after delivery which resolves itself

are in fact three times more likely to suffer incontinence in the five years following

delivery than women without children.156 There are also well established links with

long-term pelvic girdle pain and pregnancy (http://www.pelvicgirdlepain.com/ ). When

the media first began to cover the story of symphysiotomy in Ireland, many women

approached the hospitals where they had delivered, as they had suffered long-term

health problems after births including incontinence and chronic back pain. They now

feared that they had had symphysiotomies, and as many patients had not been

aware that they had undergone the procedure, this was an understandable reaction.

In one hospital for example, nine women came forward, of whom two had actually

undergone the procedure. ‘Normal’ pregnancy and delivery can carry a significant

morbidity rate, an element that needs to be addressed as part of any review of

symphysiotomy.

 

The Decline in Symphysiotomy:

 

The procedure went into increasing decline from the early 1960s. There are several

key reasons:

 

Improvements in maternal health, that significantly reduced the risks of

pregnancy and delivery. These included better nutrition and housing, and

improved medical provision under the Health Act of 1953157

Increasing use of repeat Lower Section Caesarean Section, as evidence

indicated that the established ‘Three Caesarian Rule’ pertaining to the

‘Classical Section’ was outmoded

 

 

155 E. Eason E et al. ‘Effects of carrying a pregnancy and of method of delivery on urinary

incontinence: A prospective cohort study.’ Bio Medical Central Pregnancy and Childbirth 2004, 4:4.

See also Thom D et al. ‘Evaluation of parturition and other reproductive variables as risk factors for

urinary incontinence in later life’ in Obstetrics and Gynaecology 1997, Vol. 90 (6), pp. 983-9.

156 S. Stanton , R. Kerr-Wilson & V. Grant Harris, ‘The incidence of urological symptoms in normal

pregnancy’ in British Journal of Obstetrics and Gynaecology, 1980, Vol. 87, pp. 897-900.

157 Under this act, women were entitled to a full maternity service, and could choose their own doctor

or midwife. They also had the option of private care for a fee in nursing homes. ‘Comprehensive

medical and nursing care for their infants was also provided for. Maternity cash grants of £4 for each

birth were introduced for women in what became known as the lower income group. A requirement on

health authorities to provide child welfare clinic services was substituted for the permission to do so.’

Brendan Hensey, The Health Services of Ireland (2nd revised edition, Dublin: Institute of Public

Administration, 1972), p. 25

 

 

 

50

 

 

 

 

 

Increasing use of drugs such as oxytocin to shorten labour, reducing the need

for symphysiotomy

A growing realisation, shared with obstetricians in Britain, that pelvic

disproportion had been over-diagnosed

Maternity care in Ireland, in common with the rest of the western world, improved

steadily throughout the twentieth century. The World Health Organisation’s report on

Maternal Mortality in 2005 confirms an exceptionally low rate of maternal mortality in

twenty-first century Ireland, the lowest in the world. Maternal mortality is now grossly

unevenly distributed, with an astonishing 99% of pregnancy and labour-related

deaths occurring in the developing world, where an estimated 536,000 women die

each year.158 Ireland’s preeminent position makes the condition of women in the

developing world truly devastating to contemplate. WHO defines the risk of maternal

mortality as the likelihood that a ‘15-year-old female will die eventually from a

maternal cause…Of all 171 countries and territories for which estimates were made

in 2005, Niger had the highest estimated lifetime risk of 1 in 7, in stark contrast to

Ireland, which had the lowest lifetime risk of 1 in 48 000.’

 

The early 1960s marked a turning point in terms of the use of symphysiotomy in

Ireland. Post-war improvements in housing, nutrition, and hospital care had made a

dramatic impact upon maternal health, and legislative change such as the Health Act

of 1954, which established a public health care system, now offered a basic level of

care to the impoverished. TB had been brought under control, rates of chronic illness

such as rheumatic heart disease were lowered, and there was direct intervention in

public health to control infectious disease.159 Public housing schemes began, and

 

 

 

 

158 ‘Of the estimated total of 536 000 maternal deaths worldwide in 2005, developing countries

accounted for 99% (533 000) of these deaths… By the broad MDG [Millennium Development Goals –

the WHO’s stated targets for improvements in maternal health care] regions, MMR [Maternal Mortality

Rate] in 2005 was highest in developing regions (at 450 maternal deaths per 100 000 live births), in

stark contrast to developed regions (at 9) and countries of the commonwealth of independent states

(at 51). These countries are (listed in descending order): Sierra Leone (2100), Niger (1800),

Afghanistan (1800), Chad (1500), Somalia (1400), Angola (1400), Rwanda (1300), Liberia (1200),

Guinea Bissau (1100), Burundi (1100), the Democratic Republic of the Congo (1100), Nigeria (1100),

Malawi (1100), and Cameroon (1000). By contrast, Ireland had an MMR of 1.’ World Health

Organisation, Maternal Mortality in 2005: Estimates Developed by WHO, UNICEF, UNFPA and the

World Bank (WHO Press, 2007), p. 1.

159 The recent TV3 documentary series ‘The Tenements’ gives an idea of the conditions under which

large families lived, and an indication of how the new suburban developments were heralded as a

great advance.

 

 

 

51

 

 

 

 

 

moved families from one-room tenements to flats on the outskirts of the city.160

Moreover, there had been advances in medical care that led to symphysiotomy’s

decline. Obstetricians found that quickening the pace of labour eliminated the need

for such intervention, and new drugs such as oxytocin which accelerated labour,

produced vaginal deliveries without the need for symphysiotomy. One of the

indicators for symphysiotomy was inertia during labour. This had been overcome by

symphysiotomy, which in allowing the baby’s head to descend, had advanced the

process. Although modern practice questions excessively rapid labour, in the 1960s

it was heralded as a safe and positive advance, effectively eliminating the

horrendous marathon labours of 50 and 60 hours that had occurred in the 1940s.

The impact of wider changes in Ireland were noted by the British obstetricians. In the

discussions for 1965, Ian Donald of Glasgow commented: ‘There are details in

looking back over 10 years but the general picture is one of clearly increased social

wellbeing with less of the diseases that go with bad social conditions.’161 At the same

meeting he made specific comment on symphysiotomy, with a prescient indication of

its future application: ‘After the last meeting in 1955 I came away from Dublin more

impressed with symphysiotomy than I would be today. It seems to be dying a natural

death. I could find none mentioned in the Coombe record, only 5 at the National as

compared with 33 cases ten years ago, and 4 at the Rotunda, one of whom still had

to be delivered by CS. In one of the cases the uterus was ruptured. I can’t help

feeling that this is attempting to secure delivery per vaginam at too high a price. I am

still, however, convinced of the value of symphysiotomy in underdeveloped

communities such as in East Africa where patients disappear into the bush for their

next baby after a Caesarean section and where at Makerere, which I visited last

summer, 25 per cent of uterine ruptures are in previous Caesarean section scars.’162

Only a year later, the further decline in symphysiotomy excited notice. Prof Geoffrey

Dixon of Bristol recorded: ‘The low incidence of symphysiotomy in all units has

tempted me into venturing into a prophecy of what your invited speaker will have to

show for symphysiotomy in 10 years time i.e. 0.0%. There seem to me two possible

explanations for this falling incidence, either you are adopting a UK policy in

 

 

 

 

160 This was to prove a mixed blessing. Although living conditions vastly improved in the new

accommodation, some families found themselves isolated in the new estates, and mothers often

found it difficult to afford the bus fare to travel to the city hospitals for check-ups.

161 ‘Transactions’ in Irish Journal of Medical Science 1965, p. 55.

162 Ibid, pp. 58-9.

 

 

 

52

 

 

 

 

 

relationship to Caesarean Section and symphysiotomy, or improved nutrition in

Dublin is bringing your patients’ pelvis into line with their UK sisters. The figures from

the Rotunda and the comments from the Coombe and the National suggest that the

latter is the true explanation.’163

 

Continual evaluation of caesarean section, especially repeat sections, were a feature

of the Dublin annual reports, and the findings were shared between the three

hospitals. The Rotunda was particularly interested in the safety of repeat operations,

as symphysiotomy was used there far less than in the NMH and the Coombe. In

1961, the Master reported: ‘A preliminary study of Multiple Repeat Caesarean

Sections from Rounda Hospital Records by Dr Terence Hynes suggests that multiple

repeat section in fact constitutes a very small degree of danger to the patient. Out of

115 cases who had already undergone at least three previous Caeseaean Sections

there was no rupture of the uterus, no maternal mortality and minimal foetal loss.’164

 

Despite the decline in symphysiotomy use in Dublin, however, the practice was not

yet out of favour in other hospitals:

 

Our Lady of Lourdes Hospital, Drogheda:

 

As concern has been expressed regarding rates of symphysiotomy at Our Lady’s, it

is appropriate that this draft report specifically examines the practice here; figures

from other national maternity centres suggest a lower usage. Although rates of

symphysiotomy in Our Lady’s appears to reflect the proportionate usage elsewhere,

the preliminary figures indicate that the practice continued at the hospital far later

than at any other institution. Symphysiotomy was still in use in the hospital as late as

1984, albeit in very small numbers. Published reports for Our Lady of Lourdes

Hospital are not available for the entire period of this study. There are clinical reports

from 1959 to 1984, which provide statistical detail on deliveries, and the relative

rates of symphysiotomy and caesarean section.

 

 

163 Transactions, Irish Journal of Medical Science, 1966, p. 551.

164 Clinical Report of the Rotunda Hospital for 1961, p. 29.

 

 

 

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Our Lady of Lourdes Hospital, Drogheda: comparative symphysiotomy and

caesarean section rates:165

YEAR No. Of

Symphs

Symphs

as % of

births

Mat

Deaths

Symph

Foetal

Deaths

Symph

No.

Of

CS

CS

as %

of

births

Mat

Deaths

CS

Foetal

Deaths

CS

Total

Deliveries

1958 21 44 0 2

1959 14 0.9 0 0 44 2.9 0 7 1,495

196061

48 1.5 0 5 89 2.8 0 6 3,203

196263

40 1.1 0 87 2.5 0 5 3,500

196465

22 0.5 0 2 127 2.9 0 5 4,411

196667

31166 0.6 0 0 152 3.0 1 11 5,014

196869167

19168 0.3 0 2 183 3.4 5,435

197071

26 0.5 0 1 199 3.4 1 22 5,771

197273

15 0.3 0 0 186 3.3 0 11 5,702

197475

8 0.1 0 0 203 3.5 0 8 5,725

197677

9 0.1 0 0 222 3.6 0 12 6,088

19784

0.06 0 0 281 4.4 0 8 6,348

 

 

 

 

165 The hospital produced a combination of annual and biannual reports as indicated, therefore in

some years the figures address a 12 month period rather than a 24.

166 7 of these symphysiotomies were ‘performed after delivery, and during closure of abdominal

wound [often referred to as “symphysiotomy on the way out”].

167 The 1968-69 Report contained a summary of cases of symphysiotomy. ‘There has been a steady

decrease in the use of symphysiotomy throughout the sixties. The operation was performed on a total

of 160 cases [1960-69] with these results:

Vaginal Delivery: 135

Caesarean Section 11

Symphysiotomy on “way out” after CS 14

There were 9 foetal deaths: 5 of congenital malformation, 3 asphyxial death, and 1 traumatic I.C.H.

[intracranial haemorrhage]’

168 3 “on way out”.

 

 

 

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79

1980 3 0.09 0 0 178 5.5 0 5 3,235

1981 1 0.03 0 0 169 5.6 0 2,998

1982 3 0.1 0 0 170 6.3 2,708

1983 1 0.03 0 0 184 7.0 2,628

1984 3 0.1 0 0 243 10.1 0 8 2,399

 

The patterns at Our Lady’s suggests a broadly equivalent use of the procedure in

relation to the Dublin hospitals (0.4 of the total deliveries at Lourdes, as opposed to

an aggregate of 0.36 for the NMH and the Coombe169). However, this is not an

accurate picture as it excludes the period in which it was at its height in Dublin, the

late 1940s and early 1950s. The procedure had a far lower maternal and foetal

mortality rate than caesarean section, with no maternal deaths and 10 foetal for

symphysiotomy, against 2 maternal and 110 foetal deaths for section.

 

Judge Maureen Harding Clark’s report into peripartum hysterectomy at Our Lady’s

investigated not merely the use of the procedure, but the broader culture that existed

at the hospital. That report found a unique situation: one in which consultants,

Gerard Connolly (the founding obstetrician) in particular, were obeyed by the nursing

and management staff without question. The ethos was unswervingly Catholic, with

an absolute ban on artificial contraception even when it was both legal, and broadly

accepted, in other maternity hospitals and indeed in the country at large.170 Connolly

cast a long shadow over obstetric practice at Our Lady’s. The persistence of

symphysiotomy at the hospital twenty years after it had largely ceased elsewhere in

Ireland appears to be specifically linked with Connolly’s tenure. Michael Neary

reported that Connolly ‘was a firm believer in carrying out symphysiotomies in the

hopes of avoiding caesarean section and in this was influenced by Dr.Arthur Barry,

the former Master of Holles Street Maternity Hospital.’171 However, the context in

which symphysiotomy took place at Our Lady’s in the 1970s and ‘80s is very

different from that of the 1950s, when Barry advocated the procedure.

 

 

 

 

169 The Rotunda figures are excluded from this calculation as they were so low in relation to births that

inclusion would produce an artificially low overall figure for the three hospitals.

170 Astoundingly, Connolly was prepared to undertake caesarean hysterectomies and render a women

permanently infertile, rather than permit artificial contraception, which could easily be reversed.

Harding Clark, p. 233.

171 Harding Clark, p. 233.

 

 

 

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The investigation into general obstetric practices at Our Lady’s revealed a centre

dominated by one consultant, with a narrow range of experience and training, whose

dedication to the hospital and its patients apparently precluded criticism. Connolly

continued practices that were increasingly outmoded in the 1970s and early 1980s:

his occasional use of the ‘Classical Section’ (also utilised by Neary) for caesarean

delivery rather than the widely accepted and less traumatic Lower Segment Section

was heavily criticised. Connolly’s continued use of symphysiotomy at a much later

period than other obstetricians also appears to be part of this autocratic, old-

fashioned system. Harding Clark noted that the lack of ongoing training for

practitioners at Our Lady’s contributed to inadequate standards, and this may well be

an element in the hospital’s continued use of symphysiotomy. The procedure was

used in the same clinical situations as in Dublin (mild to moderate disproportion), and

at similar proportionate rates, but its persistence when it had largely disappeared

elsewhere puts it outside accepted practice. All of the factors that saw

symphysiotomy’s national decline were also present at Drogheda (safer LSS

deliveries, better maternal health, use of oxytocin in labour), therefore one would

expect to see Our Lady’s follow the same pattern.

 

The production of annual clinical reports at Our Lady’s was specifically investigated

by Harding Clark. It had originally been intended by Our Lady’s that the Drogheda

reports be published at the same time as the Dublin maternity hospital reports, in

order to compare practice, but this was generally not achieved until the 1980s.172 If

that original intention had indeed been fulfilled, and if either the Royal College of

Obstetricians and Gynaecologists in London or the Institute of Obstetricians and

Gynaecologists in Dublin (after 1976) had been formally required to review the

reports, Our Lady’s continued use of symphysiotomy would have been noticed.

Connolly appeared to view maternity care in the 1970s and ’80s as if it were still the

1950s, and his refusal to countenance contraception, and to approach deliveries in

the belief that caesarean section was still potentially dangerous, ensured that he

retained a faith in symphysiotomy as a solution to obstructed labour.

 

There is another unusual element in the Drogheda hospital. The symphysiotomies

performed at Our Lady’s include a high number of elective procedures, which would

 

 

172 Harding Clark, Inquiry, p. 286.

 

 

 

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have been carried out with patient consent: there were nine elective

symphysiotomies out of 40 in 1962-3 for example, amounting to almost a quarter of

the total. This is a different pattern from other centres, where the procedure was

used in the majority of cases during labour, and in a smaller number ‘on the way out’.

Despite the major deficiencies in Connolly’s obstetrical record, the Harding Clark

Inquiry found that many patients as well as colleagues spoke highly of his skill and

dedication to his work, 173 and it is not improbable that some patients who underwent

symphysiotomy did so willingly on his professional advice.174 Connolly’s own

evaluation of symphysiotomy does not suggest a commitment to the procedure at all

costs, and he appeared to welcome its gradual decline.175 However, the fact that it

persisted for so long at Our Lady’s when alternative methods for dealing with difficult

deliveries were available is unacceptable.

 

Allegations have been made that symphysiotomy at Our Lady’s was employed for

training purposes, to improve techniques for use in the Medical Missionaries of Mary

hospitals in Africa, and the use of procedure at a later stage than other maternity

hospitals has been described as ‘experimental’176 This is a serious allegation,

implying that some symphysiotomies were carried out unnecessarily to facilitate

training, and must be a cause of enormous distress for women who underwent the

procedure. There appears however to be no evidence to support the assertion. Our

Lady’s was an approved training centre by the Royal College of Obstetricians and

Gynaecologists. Moreover, the observation of procedures is a long established, and

 

 

173 ibid, pp. 162-4.

174 This can be verified only through an examination of individual patient case notes.

175 His comments in the annual reports indicate his changing attitude towards the

procedure:

‘[one case in 40 symphysiotomies developed stress incontinence which]…was

successfully treated by suburethral repair. The more frequent use of oxytocin drip and the

vacuum extractor will, undoubtedly, help to reduce the need for symphysiotomy (Clinical

Report for 1962 & 1963).’

‘The oxytocic drip was used much more frequently in the two years under review, than in

previous years. There is no doubt that it is a great asset in shortening labour, and it has

reduced the number of patients requiring symphysiotomy for borderline disproportion

(Clinical Report for 1964 & 1965).’

‘[Commenting on changing indication for the procedure] The 26 cases were all delivered

vaginally of living infants, except for one neonatal death due to hydrocephalus. All cases

were done in labour, 25 being performed in the second stage of labour. There were 10

breech deliveries and one face presentation. The incidence of this operation has been

unchanged over the last 8 years. However, the operation now is nearly always done in

the second stage of labour and never electively or during closure of the abdominal wound

after a caesarean section (Clinical Report for 1970 & 1971).’

176 Marie O’Connor, Bodily Harm (Dublin: Johnswood Press, 2011), pp 117-18.

 

 

 

57

 

 

 

 

 

indeed central element in medical and nursing training, and has been part of Irish

medical training from the eighteenth century.177 The presence of trainee or junior

doctors in theatre was common, and the practice of securing permission from the

patient a relatively recent development. 178 The assertion does not appear to be

supported by the patterns of delivery at Our Lady’s. Symphysiotomy declined

steadily from the mid 1960s, and the caesarean section rate rose at an equally

steady rate: one would expect the operation to be employed to a greater extent, and

a lower CS rate lower as a consequence, to support its inappropriate use as a

training tool.

 

Symphysiotomy ‘On the Way Out’:

 

The context for the reintroduction and eventual decline in symphysiotomy in Ireland

has been examined. When the procedure was first discussed by obstetricians in the

1940s it was regarded as an appropriate response to specific situations, namely mild

to moderate disproportion at delivery. As such, it was an acceptable medical

response to a serious condition, as it remains in parts of the modern world. However,

there is an additional element in its application in certain hospitals in Ireland that

does not conform to standard practice, and that is its use as a prophylactic

procedure, in advance of labour and delayed delivery, and indeed in advance of

pregnancy. Often referred to as symphysiotomy ‘on the way out’, this is a deviation

from good practice.

 

Symphysiotomy ‘on the way out’ referred to the practice of performing the procedure

immediately after a caesarean section. It occurred when a woman had already

delivered her baby by section, and her abdominal wound was being stitched: the

obstetrician then partially cut the symphysis pubis. It was done in cases where the

obstetrician believed that the patient was suffering from a relatively mild degree of

disproportion, and would be able to deliver her next baby vaginally. Because the

procedure was performed without labour, the degree of pelvic widening was less

than in the usual symphysiotomy: this, it was argued, would avoid the danger of

 

 

 

 

177 Toby Barnard, ‘The Wider Cultures of Eighteenth-Century Irish Doctors’ in James Kelly and Fiona

Clark (eds) Ireland and Medicine in the Seventeenth and Eighteenth Centuries (Surrey: Ashgate

Press, 2010), p. 185

178 There is international agreement regarding the necessity for informed patient consent to

observation and a very high rate of agreement from patients, especially in teaching hospitals – see

‘Informed Consent Process important to Surgery Patients in Teaching Hospital’ in ScienceDaily,

September 19, 2011.

 

 

 

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pelvic instability, but still produce the fractional expansion needed to deliver the next

baby naturally (the scar tissue laid down during healing marginally widened the

pelvic diameter). Also referred to as ‘Prophylactic Symphysiotomy’ (prophylactic

meaning a measure taken to prevent a disease or condition), it is a use of the

procedure that appears to have little clinical justification.179 There are several

important issues:

 

Symphysiotomy was and is appropriate only during labour, when the degree

of disproportion can be evaluated (see attached bibliography for reviews on

appropriate use of the procedure)

A woman diagnosed with disproportion in one pregnancy may have a normal

delivery in the next, and require neither symphysiotomy or caesarean section

A decision to undertake a symphysiotomy in an emergency situation may be

clinically justified for the safety of the mother and child, but a non-emergency

application, while the mother is under general anaesthetic, appears

indefensible

The potential benefit of symphysiotomy before labour, and indeed before

pregnancy, was speculative, and flew in the face of acceptable practice (see

below)

Some obstetricians argued that symphysiotomy ‘on the way out’ was appropriate in

certain cases of moderate disproportion, and that a subsequent pregnancy would be

successfully delivered vaginally once the pelvis was enlarged. But this application of

symphysiotomy violates several principles of good practice that prevailed both in the

1950s and ’60s, and today. From the earliest consistent use of symphysiotomy, there

was general agreement that it was appropriate only in very specific circumstances.

Archibald Donald180 identified its use in emergency deliveries in 1896, and E.

 

 

 

 

179 It differed from elective symphysiotomy in that the latter was employed in the advanced stages of

pregnancy, often days before labour (very occasionally more than a week). It was advised in cases of

diagnosed disproportion, in order to avoid the dangers of a trial labour that was likely to fail to

proceed. It appears to have been undertaken in consultation with the mothers, and, as such, was a

‘negotiated’ medical decision.

180 Pioneer of the Manchester-Fothergill operation to repair prolapse in young women subsequent to

delivery.

 

 

 

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Hastings Tweedy181 reviewed its use in 1910. He described five degrees of

contraction, and recommended symphysiotomy only in degree three:

 

with a conjugate measuring between 3••• in and 2•••

in. With such

measurements, normal delivery is neither to be looked for nor

expected….If the woman is long in labour, with the membranes

ruptured, symphysiotomy or pubiotomy should be proferred….Much

has recently been heard of the operations of symphysiotomy,

pubiotomy, and hysterectomy, and many think they are simply rivals

to classical Caesarean Section. Were this so, I should not be

concerned in recommending them to your consideration. They

neither compete with Caesarean Section nor even with each other;

they are complementary operations, each with its own field of

usefulness. Until this is clearly realised it will be impossible to stay

the present sacrifice of life which has resulted, and must result,

from such obsolete procedures as induction of premature labour,

prophylactic turning, high forceps, and perforation. It is only a

matter of a few years before all these methods will be viewed with

the utmost abhorrence. Not only will it be considered criminal to

perforate the head of a living child, but to permit one to die because

of delay in delivery or from obsolete methods will rightly be

condemned. Symphysiotomy or pubiotomy is to be highly

recommended.182

 

Irish obstetricians from the 1940s similarly emphasised the limitations of

symphysiotomy, and identified its best usage. Although there were no agreed clinical

guidelines, it was repeatedly stated that its principal use was as an emergency

intervention in very specific cases of disproportion that emerged, for the most part,

during delivery: in effect, the indications for symphysiotomy could only truly be

determined during labour. Even Arthur Barry, who was an active proponent of the

procedure, proposed its use only in labour:

 

 

181 Master of the Rotunda Hospital.

182 ‘Modern Methods of Delivery in Contracted Pelvis’ in Proceedings of the Royal Society of

Medicine, 1910: 3 (Obstetrics and Gynaecology Section).

 

 

 

60

 

 

 

 

 

When should the operation be performed? The answer to this is

comparatively simple. The operation should be carried out: (a) in all

young primigravidae183 with pelvic contraction undergoing trial

labour when the natural powers are failing to overcome the

obstruction; (b) in all multigravidae184 with disproportion sufficient to

cause obstruction; (c) in all cases of failed forceps due to

contracted outlet if the child is alive; (d) in face presentation with the

chin posterior and in brow presentation, where efforts at correction

have failed; (e) in all young primigravidae with contracted pelvis

selected for trial labour in whom early rupture of the membranes or

inertia occurs. In such cases it is better to do the operation too early

than too late, as delay may result in loss of the baby. The operation

should not be employed unless the true conjugate185 is at least 8.5

centimetres. Size and moulding of the foetal head may occasionally

alter this rule.186

 

Predicting likely difficulties in labour is, and always has been, an inexact science. As

Prof. C. Scott Russell of Sheffield noted in 1951 when discussing diagnoses of

disproportion ‘…most of us I suppose use the term to describe a state of affairs in

which the normal course of labour is likely to be, or is, disturbed because of

insufficient room in the birth canal for the passage of the foetus. Such a definition

draws immediate attention to the fact that we cannot always tell if labour is to be

upset because of supposed disproportion until after the labour is over. We can be

wise after the event: in our speciality this is not very helpful.’187 Many women with

histories of uncomplicated deliveries suffer complications in later labours, and vice

versa. Thus undertaking an operation that interfered with the skeletal structure was a

serious decision, a fact underpinned by its use in Ireland in relatively small numbers

 

 

183 A woman who is pregnant for the first time.

184 A woman who is pregnant and has been pregnant at least twice before.

185 In obstetrics this is defined as ‘the shortest pelvic diameter through which the foetal head must

pass during birth, measured from the promontory of the sacrum to a point a few millimeters from the

top of the pubic symphysis’ (The American Heritage Medical Dictionary, 2007). An accurate

measurement is crucial in cases of symphysiotomy, as this is the single most important factor in

determining its employment. A smaller conjugate would indicate a caesarean section rather than a

symphysiotomy.

186 Arthur P. Barry, ‘Symphysiotomy or Pubiotomy: Why? When? And How?’ in The Irish Journal of

Medical Science Sixth Series, No. 314, February 1952, pp 50-51.

187 ‘Transactions’ in Irish Journal of Medical Science, 9th October, 1951, p. 1022.

 

 

 

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of mothers. In the review of modern literature undertaken for this report, only material

 

published in international scientific journals, with verifiable statistics and clear

 

methodologies, was used to assess the procedure. Thus the publications represent

 

peer-reviewed, scientifically credible research, and not speculative reviews. No

 

author in these papers proposes prophylactic symphysiotomy, nor any equivalent to

 

symphysiotomy ‘on the way out’.188 All deal with its value in emergency deliveries,

 

especially in cases of cephalopelvic disproportion. There are additional specific

 

circumstances under which the procedure offers the best chance of saving the

 

baby’s life, and the rapid delivery of a breech baby, whose head is trapped at the last

 

moment, is one strong indication.189 This is described as the ‘most dreaded

 

complication of the breech vaginal delivery’, because of the lack of time to save the

 

baby, and occurs in approximately one in every five hundred breech deliveries.190 A

 

similar emergency indication is in cases of shoulder dystocia,191 where problems

 

arise after the head has been delivered.192 These cases, in addition to the well-

 

established application in disproportion, justify a clinical decision to use

 

symphysiotomy. As a recent Indian study emphatically states: ‘Symphysiotomy

 

should only be done in an established case of obstructed labour but not in

 

anticipation of obstructed labour.’193 Mid-century obstetricians were aware of the

 

appropriate conditions for the use of symphysiotomy. In successive Royal Academy

 

of Medicine Transactions, and severally in the Dublin hospital reports, there was

 

 

 

 

188 Belgian obstetricians had reported on prophylactic symphysiotomy in the 1930s. See Bjorklund,

Minimally Invasive surgery, p. 241.

189 A discussion of the possible role of symphysiotomy in breech deliveries in Canada indicates the

relatively rare, but potentially fatal, case of ‘entrapment of the aftercoming head.’ ‘In more than 30

years of obstetric practice, I am unaware of a symphysiotomy ever having been carried out in a

hospital or region where I have served. At the same time, I am aware of only two instances of

entrapment of the aftercoming head during vaginal breech delivery in those same centres, and the

newborn outcomes were tragic.’ The article considers the possible use of symphysiotomy in these

exceptional circumstances in Canada, where a sophisticated medical system should eliminate long-

term health risks to the mother. David Young, ‘Why Vaginal Breech Delivery Should Still Be Offered’

in Journal of Obstetrics and Gynaecology Canada, 2006, Vol 28, No. 5, pp. 386-89.

190 Savas Menticoglou, ‘Symphysiotomy for the Trapped Aftercoming Parts of the Breech: a review

of the literature and a plea for its use’ in The Australian & New Zealand Journal of Obstetrics &

Gynaecology, Vol. 30 No. 1, pp. 1-9.

191 An obstetrical emergency that occurs when the anterior (the front) shoulder of the baby becomes

lodged behind the superior symphysis pubis, preventing further delivery. Shoulder dystocia is not

always preventable, and is usually not recognized until after the head has been delivered, and gentle

downward traction of the fetal head fails to accomplish delivery. It is believed to occur in

approximately 2% of deliveries.

192 T.Murphy Goodwin, Erika Banks, Lynnae K. Millar & Jeffrey P. Phelan, ‘Catastrophic Shoulder

Dystocia and Emergency Symphysiotomy’ in American Journal of Obstetetrics and Gynaecology,

1997, Vol. 177, pp. 463–4.

193 A.P. Choudhury, B. Bhadra & A. Roy, ‘Practical Symphysiotomy: an overview’ in Journal of the

Indian Medical Association August 2010, vol. 108, No. 8, pp. 503-4.

 

 

 

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agreement regarding the limited conditions under which it should be performed: it

was a response to an emergency situation. Although disproportion might be

suspected, the generally accepted policy, expressed through the ‘Transactions’, was

to ‘wait and see’. If labour failed to advance, then it would be clearer as to whether

symphysiotomy or caesarean section was indicated.

 

The Rotunda performed very few symphysiotomies. Although not under the control

of avowedly Catholic Masters in this period, the patients were predominantly

Catholic, and the broad medical philosophy similar to that of the Coome and the

NMH. The problems of disproportion and obstructed labour facing the other two

hospitals were shared by the Rotunda, and were a constant source of anxious

discussion. While successive Masters expressed more overt concern regarding

symphysiotomy, it was the Rotunda that explored the procedure ‘on the way out’

before the other Dublin hospitals, and employed it to a greater extent, albeit in tiny

proportionate numbers. In 1952 for example there were seven symphysiotomies at

the Rotunda, all ‘performed at Caesarean section to facilitate vaginal delivery in

future pregnancies.’194 One of the hospital’s obstetricians, Hugo McVey, published a

paper in 1955 entitled ‘The Treatment of Disproportion by Combined Lower Segment

Section with Symphysiotomy’.195 In his opening summary of the procedure in Ireland

and elsewhere, he notes the key concern regarding caesarean section for

disproportion (‘This decision, while overcoming the difficulty of the present

pregnancy, makes no provision for any future pregnancy. The patient still has a

contracted pelvis, and, further, a uterine scar’), and then identifies Ireland’s unique

obstetrical situation:

 

In this country we have the special circumstances of treating a

 

population in which sterilisation and contraception are not practiced.

 

Thus a young primigravida delivered by Caesarean section for

 

disproportion faces a lifetime of repeat operations with all the

 

hazards of uterine rupture, adhesions and bladder injury. In gross

 

disproportion Caesarean section is unquestionably correct, but in

 

minor or medium degrees of disproportion if symphysiotomy allows

 

 

194 ‘Clinical Report of the Rotunda Hospital for 1952’, p. 27.

195 Irish Journal of Medical Science, 1955, pp. 299-307.

 

 

 

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of vaginal delivery on this and all other subsequent pregnancies, it

 

is surely the operation of choice.

 

The paper went on to describe a series of eight ‘combined’ operations at the

Rotunda. Because it was performed after the section and the delivery of the

baby there was no measurable increase in the diameter of the pelvis, as labour

had not caused the symphysis to stretch. ‘No ambulatory or gynaecological

difficulty was encountered’ in any of the cases, and four of the women went on to

have normal vaginal deliveries (the other four had not had a subsequent

pregnancy by the time the paper was published). McVey proposed the combined

procedure as a means of avoiding a traumatic, possibly failed, vaginal delivery in

the present pregnancy (by delivering through caesarean section at an early

stage), and facilitating delivery in any future pregnancy. The article is important

in that it is an attempt to face the reality of successive pregnancies, and the

problems of repeat sections. In one of the cases, McVey notes that the patient

subsequently delivered a larger baby without difficulty, owing to the fact that the

symphysis separated ‘to about two fingers’ breadth’, and ‘closed again after the

child was born. No gynaecological or ambulatory disturbance occurred after

delivery.’

 

But there is an inherent difficulty in his approach. He criticises prophylactic

symphysiotomy on the grounds that disproportion cannot be determined without

labour: ‘It is easy to diagnose a minor degree of disproportion at 38 weeks,

perform an immediate symphysiotomy and await a vaginal delivery two weeks

later. If the patient then has a vaginal delivery, what has been proved? Precisely

nothing. The question will still be asked: “How do you know she couldn’t have

had a vaginal delivery without symphysiotomy?” A question to which there is no

answer, because there has been no trial of labour before symphysiotomy.’ But

the combined operation is in part a prophylactic procedure, as although the

present delivery indicated disproportion, the next might not.196 A symphysiotomy

performed during labour, when moderate disproportion is proven, may be

justified as a means of saving mother and child and avoiding the risk of section,

 

 

 

 

196 The chances of disproportion in subsequent deliveries was high, as the numbers of repeat

caesarean sections for the condition indicated.

 

 

 

64

 

 

 

 

 

but undertaken after delivery, almost certainly without consultation or consent,

cannot.

 

In the same year, J.K. Feeney, Master of the Coombe Hospital, published a lengthy

review of symphysiotomy, and laid down the following recommendations and

conclusions:

 

It is said that symphysiotomy has its best application in those

centres in which sterilization is not practiced after 3 or more

Caesarean sections. This may be so, but the field of application

should be far wider and determined by the fact that, in the well

chosen case, the operation overcomes dystocia and leaves a

permanently enlarged pelvis for the future; that it is safe and easy

to perform and that there are no unpleasant after-effects in

locomotion, pelvic instability, urinary control, etc. Let me make it

clear initially that the case for symphysiotomy should be carefully

selected and that the employment of the operation should not be

overdone. The general indication is provided by the case of minor

or moderate disproportion…Symphysiotomy has no place in the

treatment of major disproportion…the most satisfactory and

satisfying indication is disproportion with larger foetus in the

multipara…the course of labour is on these lines: the patient

advances until the cervix is as dilated as it can become under the

circumstances i.e. it admits the hand or half-hand with a palpable

rim all around. The presenting head is unengaged with the vertex,

bearing caput, projecting into the brim. The patient is bearing

down and the attendant believes that the uterus may rupture if the

obstruction is not relieved. The foetus appears to be larger than

previous ones. In such a case, symphysiotomy results in easy

spontaneous delivery. The baby is often born within a few minutes,

as the patient is recovering from the anaesthetic…I have on a few

occasions rapidly performed symphysiotomy when I encountered

difficulty in extracting the aftercoming head [in breech deliveries]

but I do not recommend this procedure because in one’s haste the

 

 

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bladder might be injured. Symphysiotomy is an operation which

should be performed deliberately and methodically…My

experience of prophylactic symphysiotomy is limited to 7 cases

which worked out satisfactorily, but I do not ordinarily recommend

it. The average patient should have the benefit of a carefully

supervised trial of labour…I do not present symphysiotomy mainly

as an alternative to Caesarean Section. In point of fact, the

indications for and scope of section have been extended in this

hospital during my scope in office…At least 60 patients have

returned for easy vaginal delivery after previous

symphysiotomy.’197

 

Although no clinical guidelines existed for the use of symphysiotomy, there was a

general consensus of opinion as to best practice, both in mid-century, and today,

which exclude its use in combination with caesarean section. Our Lady of Lourdes

Hospital also used symphysiotomy ‘on the way out’. Of a total of 160 cases of the

procedure between 1960 and 1969, 14 were symphysiotomies combined with

caesarean section (‘on the way out’ was not used at Our Lady’s after 1969, according

to a statement by Connolly in the annual report for 1970-71).198

 

Issues of Consent:

 

The question of patient consent to symphysiotomy in Ireland has been raised.

Determining consent to symphysiotomy, or any other medical intervention, is highly

problematic. It is only in recent years that written consent to elective procedures has

become commonplace in Western medicine, and every responsible hospital

recognises that circumstances may arise during treatment that makes the securing

of consent impossible. If a patient is unconscious, in a life-threatening situation, or

labouring under significant mental distress that makes consent impossible, then

medical and nursing staff are placed in a position of significant responsibility with

regard to the most appropriate treatment for the patient. Guidelines governing

informed consent (best articulated in the case of intellectually disabled patients)

 

 

 

 

197 J.K. Feeney, ‘Clinical Report of the Coombe Lying-In Hospital for 1955’ in Irish Journal of Medical

Science

 

pp. 61-65.

198 Our Lady of Lourdes Maternity Hospital, Clinical Reports, 1960-1984.

 

 

 

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pertain largely to non-emergency, elective procedures, and are of comparatively

recent date. Surprisingly, there is still no legal requirement in Ireland to obtain written

consent to medical procedures,199 and outside of mental health, no clear standards

for securing medical consent: ‘In general, valid consent must be informed consent.

The law is not clear on exactly how much information a doctor must give a patient.

Consent is now legally defined for the purposes of psychiatric treatment but not for

other treatment.’200

 

During the period under review, consent for obstetric procedures was not sought in

any coherent manner: consent was implied, and the obstetrician presumed to be

working in the best interests of the patient. It is impossible to determine from this

historic distance whether patients were informed when a symphysiotomy was about

to be performed201, or if they were made aware of potential long-term health risks.

Given both the emergency conditions under which the procedure was normally

conducted, as well as the hierarchial nature of medical practice in the 1950s and

‘60s, it is unlikely that patients were consulted to any significant degree. In this

period, there were no guidelines in Britain or Ireland for obtaining consent to medical

procedures, although consent was implied on voluntary admission to hospital. This

situation continued well into the late twentieth century, as the controversy over the

standards in paediatric care in Britain, which resulted in the Bristol Inquiry,

indicated.202 This far-reaching and lengthy Inquiry investigated the care and

treatment of children with cardiac illness at Bristol Royal Infirmary between 1984 and

1995. The final report was published in 2001, and represents one of the most

thorough and far-reaching investigations into modern medical practice, across a wide

range of issues including consent, communication, patient-doctor relationships, and

responsibility. It found that even in the late 1990s, there was no formal method, or

 

 

 

 

199 ‘Apart from certain treatments carried out under the Mental Health Act 2001, there is no legal

requirement to obtain written consent, but it is generally considered good practice to make some

record of the consenting process.’ Medical Protection Society, Consent to Medical Treatment in

Ireland: A Guide for Clinicians 2011.

200 ‘Consent to Medical and Surgical Procedures’, The Citizen’s Advice Bureau, 2010.

201 In the case of symphysiotomy ‘on the way out’ consent was not sought as the patient was under

general anaesthetic.

202 There were many key findings in the inquiry, not the least relevant of which was no. 7 in the

summary report: ‘It is an account of a time when there was no agreed means of assessing the quality

of care. There were no standards for evaluating performance. There was confusion throughout the

NHS as to who was responsible for monitoring the quality of care.’ Bristol Royal Infirmary Final Report

Summary, Learning from Bristol: the report of the public inquiry into children’s heart surgery at the

Bristol Royal Infirmary 1984 -1995 Presented to Parliament by the Secretary of State for Health by

Command of Her Majesty, July 2001.

 

 

 

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imperative, to secure patient or family consent to medical procedures. Prior to the

Bristol Report, consent in Britain was vaguely defined, with the first important legal

engagement with the issue of consent occurring in 1954. A case for medical

negligence was taken by a patient named John Hector Bolam for injuries received

during a course of Electro Convulsive Treatment, and this resulted in a landmark

decision that governed standards of care for decades. Although it was originally

concerned with medical negligence, it became the basis of consent in Britain for

medical intervention. The original judgement determined that if a standard of care

received professional peer acceptance, it was a valid course of treatment: ‘It follows

that if a medical practice is supported by a responsible body of peers, then the

Bolam test is satisfied and the practitioner has met the required standard of care in

law.’203 Once this is established, consent, especially in the mid-twentieth century, is

implied.

 

In Ireland, the fundamental principle underpinning medical intervention is informed

consent. This is supported by a series of relatively recent judgements and

guidelines204 that stress the necessity for patient understanding of the implications of

a course of treatment, and an agreement to it. Failure to secure consent (ideally in

writing, although verbal agreement to a course of treatment is also valid) could

potentially lead to a charge of assault against the medical staff conducting treatment.

However, the area remains highly problematic, with a recognition by the courts that

patients may by reason of illness, pain or stress be temporarily incapable of the

cognitive understanding necessary for consent. One of the earliest relevant rulings

on principles of consent was in 1965, in the case of Ryan V Attorney General. This

case, brought over the addition of fluoride to the public water supply, resulted in an

influential series of subsequent judgements regarding

 

…[the] constitutional right to bodily integrity in the case of Ryan v

Attorney General [1965] IR294. What this means is that every

person has the right to object to any form of bodily interference or

restraint. The principle forms the legal underpinning to the concept

 

 

 

 

203 Ash Samanta & Jo Samanta, ‘Legal Standard of Care: a shift from the traditional Bolam Test’ in

Clinical Medicine, Vol 3, No. 5, September/October 2003, pp. 443-6.

204 See the Medical Council’s A Guide to Ethical Conduct and Behaviour (5th Edition, Dublin, 1998).

 

 

 

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that every patient must consent to any form of medical

intervention. Subsequent to this decision, it is therefore a legal

requirement that consent is obtained for all aspects of medical

treatment: from examination, diagnosis and treatment. In Walsh v

Family Planning Services Limited [1992] 1 IR 496, the Supreme

Court emphasises the right to bodily integrity as an important

constitutional right that will give rise to an action by patients for

assault or battery if a medical procedure is carried out without their

consent. Such consent can be expressly given or it may be implied

[Brazier, 1992]. It is possible in some scenarios to imply consent

from a patient’s conduct or behaviour, for example, consent can be

implied by virtue of a patient holding out his or her arm for an

injection. Implied consent as a valid and genuine consent is

recognised by both the courts and by the medical profession.205

 

The 2008 Fitzpatrick & Anor v K & Anor judgement clarifies a medical practitioner’s

responsibilities regarding informed consent and sets out the test of capacity that

should be applied.206 But these judgements are of limited use, and the law is

necessarily non-specific with regard to consent, given the circumstances under

which medical treatment may take place. Medical emergencies often require

immediate action on the part of health professionals, and patients may not be in a

position to provide consent. Moreover, there is a general acceptance in Irish law of

the principle of implied consent, which exists by virtue of the patient attending, for

example, a general practitioner for treatment. Consent, implicit or explicit, was not

required for medical interventions in the 1940s and ‘50s, and although there was an

increasing awareness of its importance after 1965, it was not legally required.

Securing consent has become the norm in Ireland from the late 1990s, but is still not

a legal requirement except in relation to mental health. Many branches of the

 

 

 

 

205 Brenda Daly, ‘Patient Consent, the Anaesthetic Nurse and the Peri-operative Environment: Irish

Law and Informed Consent’ in British Journal of Anaesthetic & Recovery Nursing 2009, Vol. 10(1), p.

4.

206 Fitzpatrick & Anor V K & Anor [2008] IEHC104.

 

 

 

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profession have put in place guidelines and recommendations in order to improve

the quality of patient care, but these are not legally binding.207

 

Report Summary:

 

The use of symphysiotomy from the mid 1940s to approximately 1965 was a specific

response to exceptional Irish circumstances. An extraordinarily high fertility rate

combined with a ban on artificial contraception meant that married Irishwomen faced

multiple pregnancies in swift succession. The hospital maternal mortality rate had

fallen dramatically by the 1940s, and Irish post-war obstetricians, in common with

their British counterparts, became increasingly interventionist in labour. However,

they faced particular problems that differed from the UK. An Irish mother with

contracted pelvis did not have the option of limiting her family through artificial

contraception, in the manner that was legally possible for her British counterpart.

Although many in the medical profession deplored the circumstances surrounding

incessant pregnancy and delivery, they, along with their patients, were constrained

by a rigid system that took little account of the often intolerable physical, emotional

and financial strain that large numbers of children placed upon families. The legal

restrictions regarding family limitation options ensured that symphysiotomy was

explored as a means of addressing obstructed labour, in an era when the relative

safety of repeat caesarean sections was unproven, and sections carried a high

mortality and morbidity rate. This is the context in which symphysiotomy reappeared

in Irish obstetrics. It was always a controversial development. Although some

obstetricians heralded it as a solution to a wide range of difficulties in labour, others

refused to contemplate it because of fears of both short and long-term

consequences including incontinence and pelvic instability. These reservations are

reflected in the fact that even when use of the procedure was at its height in the mid

1950s, it remained a rare event relative to overall deliveries, and was never utilised

in all maternity hospitals throughout the country. In cases of mild to moderate

disproportion, leading to obstructed delivery, symphysiotomy was an appropriate

clinical response.

 

 

 

 

207 AIMS (Association for the Improvement in Maternity services) Ireland is working with HIQA (the

Health Information and Quality Authority) to draw up guidelines for the improvement of maternity

services, which will have consent to medical procedures and treatment at its core.

 

 

 

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Symphysiotomy began to decline from the late 1950s. The period marked significant

advances in maternity care and maternal health, and saw an increasing use of

caesarean section to deal with obstructed labour, the main indication for

symphysiotomy. As the safety of repeat sections became clear, their numbers

increased steadily, and symphysiotomies declined. However, Our Lady of Lourdes

Hospital in Drogheda continued to use the procedure until 1984, almost twenty years

after it had largely ceased elsewhere in Ireland. The other area of concern is the use

of symphysiotomy immediately after caesarean section, which is not recognised as

good practice in the past or present.

 

Findings:

 

Symphysiotomy was reintroduced in certain Irish hospitals in the 1940s, and

was a clinical response to the legal limitations on contraception, and

sterilisation for contraceptive purposes. This restrictive legislation reflected a

predominantly Catholic religious ethos, which determined that contraception

and sterilisation for the prevention of pregnancy was both illegal and

unacceptable. Its use reflected the fact that in the 1940s and ‘50s the safety of

repeat caesarean sections was unproven.

It was used in the majority of cases as an emergency response to obstructed

labour, in women suffering from mild to moderate disproportion, and as such

was an appropriate clinical intervention.

It was never proposed as an alternative to caesarean section, rates of which

rose steadily in the 1950s and ‘60s.

It was a safer intervention in cases of mild to moderate disproportion, with a

minimal maternal mortality rate, and a lower foetal mortality rate, than

caesarean section.

It was an exceptional intervention, used on average in 0.36% of deliveries in

the Coombe and National Maternity Hospitals, where the usage was highest.

Its use was continually evaluated and debated, and declined as maternal

health, and caesarean delivery safety rates, improved.

 

71

 

 

 

 

 

It appears to have been inappropriately used in a number of cases. These

relate to ‘symphysiotomy on the way out’, when it was performed after

delivery, while the mother was being stitched following caesarean section.

The persistence of the procedure at Our Lady of Lourdes Hospital, Drogheda

until 1984 runs contrary to its decline elsewhere in the country from the mid1960s.

Recommendations:

 

Recommendations will be made following the completion of the consultation process,

as the second stage in this report process.

 

 

72

 

 

 

 

 

Select Bibliography of Secondary Medical Literature on Symphysiotomy and

Caesarean Section:

 

‘Focus on Caesarean Section’, National Health Service Institute, 2007

1966.

 

Armon PJ, Philip M. ‘Symphysiotomy and subsequent pregnancy in the Kilimanjaro

region of Tanzania’ East African Medical Journal 1978, Vol. 55, pp. 306-313.

 

Barry AP. ‘Symphysiotomy or Pubiotomy: Why? when? and how?’ in Irish Medical

Journal, 1952, Vol. 6, pp. 49– 73.

 

Basiri, A, Shadpour, P, Moradi, MR, Ahmandnia H, & Madaen, K., ‘Symphysiotomy:

a viable approach for delayed management of posterior urethral injuries in children’

in Journal of Urology, Nov. 2002; No. 168, Vol. 5, pp. 2166-2169.

 

Bergström, S., Lublin, H & Molin, A. ‘Value of symphysiotomy in obstructed labour

management and follow-up of 31 cases’ in Gynecologic and Obstetric Investigation

1994, No. 38, pp. 31–5.

 

Bird, G.C. and Bal, J.S., ‘Subcutaneous Symphysiotomy In Association with the

Vacuum Extractor’ in Journal of Obstetrics and Gynaecology of the British

Commonwealth April 1967, Vol. 74, pp. 266-69.

 

Bjorklund, K. ‘Minimally invasive surgery for obstructed labour: a review of

symphysiotomy during the twentieth century (including 5000 cases)’ in British

Journal of Obstetrics and Gynaecology, March 2002, Vol. 109, pp. 236–248.

 

Broekman, A., Smit, Y., Van Dessel, T., & Dorr, P. ‘Shoulder Dystocia and

Symphysiotomy: a case report’ in European Journal of Obstetrics, Gynecology, and

Reproductive Biology 1994, No. 53, pp. 142-143.

 

Choudhury, A.P., Bhadra, B. & Roy, A. ‘Practical Symphysiotomy: an overview’ in

Journal of the Indian Medical Association August 2010, vol. 108, No. 8, pp. 503-4.

 

 

73

 

 

 

 

 

Cox, Michael L., ‘Symphysiotomy in Nigeria’ in British Journal of Obstetrics and

Gynaecology, April 1966, Vol. 73, Issue 2, pp 237-243.

 

Crichton D, Seedat EK. ‘The technique of symphysiotomy’ in South African Medical

Journal, 1963, Vol. 37, pp. 227– 231.

 

Crichton D, Clarke GCM. ‘Symphysiotomy: indications and contraindications’ in

South African Journal of Obstetrics and Gynaecology, 1966, Vol. 4, pp. 76– 79.

 

De Andrade, J D. ‘Symphysiotomy and caesarean section in relation to the modern

treatment of infection.’ Revista De Ginecologia Y Obstetricia 1951, 45.2, pp. 496

 

 

502.

Deneux-Tharaux, C., Carmona, E., Bouvier-Colle, M.-H. & Bréart, G. ‘Postpartum

Maternal Mortality and Caesarean Delivery’ in Obstetrics and Gynaecology,

September 2006, Vol. 108, No. 3, Part 1, pp. 541-8.

 

Dumont, M. ‘The Long and Difficult Birth of Symphysiotomy, or, From Severin Pineau

to Jean-Rene Sigault’ in Journal de Gynécologie, Obstétrique et Biologie de la

Reproduction (Paris) 1989; No. 18, Vol 1, pp. 11-21.

 

Eason E. et al. ‘Effects of carrying a pregnancy and of method of delivery on urinary

incontinence: A prospective cohort study.’ Bio Medical Central Pregnancy and

Childbirth 2004, 4:4.

 

Ersdal, H.L., Verkuyl, D.A.A., Bjorklund, K. & Bergström, S. ‘Symphysiotomy in

Zimbabwe; Postoperative Outcome, Width of the Symphysis Joint, and Knowledge,

Attitudes and Practice among Doctors and Midwives’ in PLoS One, 2008, Vol. 3(10),

e3317.

 

Ezegwui, HU, Olomu, OO & Twomey, ED, ‘Symphysiotomy in a Nigerian hospital’ in

International Journal of Gynaecology and Obstetrics Vol. 85, Issue 3, pp. 272-273.

 

Gebbie, DA. ‘Vacuum Extraction and Symphysiotomy’ in the British Medical Journal

(February 4, 1967), Vol. 1, p. 301.

 

 

74

 

 

 

 

 

Gebbie DA. ‘Symphysiotomy’ Tropical Doctor 1974, Vol. 4, pp. 69-75.

 

Gebbie DA. ‘Vacuum Extraction and Symphysiotomy in Difficult Vaginal Delivery in a

Developing Community in British Medical Journal 1966, No. 528, pp. 1490-3.

 

Gharoro, E.P., Onatowokam, O., & Isiavwe, J., ‘Symphysiotomy and Shoulder

Dystocia: traumatic combined VVF, RVF and lower limbs paralysis after delivery –

case report’ in Medical Science Monitor, 1999; 5(6), pp. 1200-1.

 

Goodwin T, Banks E, Millar L, Phelan J. ‘Catastrophic Shoulder Dystocia and

Emergency Symphysiotomy’ in American Journal of Obstetrics and Gynecology

1997, 177 pp. 463-464.

 

Gordon YB. ‘An Analysis of Symphyseotomy at Barangwanath Hospital 1964-1967’

South African Medical Journal 1969, Vol. 43, pp. 659-662.

 

Greig, DS. ‘Symphysiotomy: A study based on 11 personal cases’ in Journal of

Obstetrics and Gynaecology of the British Empire, 1954, Vol. 61, pp. 192– 203.

 

Greisen G. ‘Three Year Follow-Up of Eight Patients Delivered by Symphysiotomy’ in

International Journal of Gynaecology and Obstetrics 1985, vol. 23, pp. 203-205.

 

Hartfield VJ. ‘A Comparison of the Early and Late Effects of Subcutaneous

Symphysiotomy and of Lower Segment Caesarean Section’ in Journal of Obstetrics

& Gynecology of the British Commonwealth 1973, Vol. 80, pp. 508-514.

 

Hartfield VJ. ‘Late Effects of Symphysiotomy’ in Tropical Doctor 1975, vol. 5, pp. 76

 

 

78.

Hartfield VJ. ‘Subcutaneous Symphysiotomy -Time for a Reappraisal?’ in The

Australian & New Zealand Journal of Obstetrics and Gynecology 1973, Vol. 13, pp.

147-152.

 

Hofmeyer JA. ‘Symphysiotomy: a re-appraisal’ in South African Medical Journal,

1961, Vol. 35, pp. 981 –983.

 

Hofmeyr J.G. & Shweni, M.P. ‘Symphysiotomy for feto-pelvic disproportion (Review)’

in The Cochrane Library 2010, Issue 10, p. 2.

 

 

75

 

 

 

 

 

Holder, T.M. & Peltier, L.F. ‘Symphysiotomy for Exposure in Resection of Pelvic

Tumors’ Surgery, 60:819.

 

Kairuki HC.’ The Place of Symphysiotomy in the Treatment of Disproportion in

Uganda: A study of 30 cases’ in East African Medical Journal 1975, Vol. 52, pp. 686

 

 

693.

Lasbrey, A.H. ‘The Symptomatic Sequelae of Symphysiotomy: a follow-up study of

100 patients subjected to symphysiotomy’ in South African Medical Journal 1963;

vol. 37, pp. 231-234.

 

Lewis, G. ‘Saving Mother’s Lives: reviewing maternity deaths to make motherhood

safer, 2003-2005’ The Seventh Report on Confidential Enquiries into Maternal

Deaths in the United Kingdom London: CEMACH, 2007, P. 13

 

Liljestrand, J., ‘The Value of Symphysiotomy’ in BJOG: An International Journal of

Obstetrics & Gynaecology 2002, Vol. 109, Issue 3, pp. 225-226.

 

Maharaj D. and Moodley, J. ‘Symphysiotomy and Fetal Destructive Operations’ in

Best Practice and Research in Clinical Obstetrics and Gynaecology, 2002, Vol. 16,

No. 1, pp. 117-131.

 

Menacker F. & Hamilton, B.E. ‘Recent Trends in Caesarean Delivery in the United

States’ National Center for Health Statistics Data Brief, No. 35, March 2010, pp 1-2.

 

Menticoglou, S. ‘Is there a Role for Symphysiotomy in Developed Countries?’ in

Journal of Obstetrics and Gynaecology, May 2009, Vol. 29, No. 4, pp. 272-277.

 

Menticoglou, S. ‘Symphysiotomy for the Trapped Aftercoming Parts of the Breech: a

review of the literature and a plea for its use’ in The Australian & New Zealand

Journal of Obstetrics & Gynaecology, Vol. 30 No. 1, pp. 1-9.

 

Mola G, Lamang M, Mcgoldrick I. ‘A Retrospective Study of Matched

Symphysiotomies and Caesarean Sections at Port Moresby General Hospital’ Papua

New Guinea Medical Journal 1981, Vol. 24, pp. 103-112.

 

 

76

 

 

 

 

 

Mola G, Lamang M, Mcgoldrick I. A retrospective study of matched symphysiotomies

and caesarean sections at Port Moresby General Hospital. Papua New Guinea

Medical Journal 1981; 24: 103-112.

 

Mola GD. ‘Symphysiotomy or Caesarean Section after Failed Trial of Assisted

Delivery’ Papua and New Guinea Medical Journal 1995, Vol. 38, pp. 172-177.

 

Mola GD. ‘Symphysiotomy: technique, problems and pitfalls, and how to avoid them’

in Papua and New Guinea Medical Journal 1995, vol. 38, pp. 231-238.

 

Murphy Goodwin, T., Banks, E. Millar, L.K. & Phelan, J.P. ‘Catastrophic Shoulder

Dystocia and Emergency Symphysiotomy’ in American Journal of Obstetrics and

Gynaecology, 1997, Vol. 177, pp. 463–4.

 

Norman RJ. ‘Six Years’ Experience of Symphysiotomy in a Teaching Hospital’, in

South African Medical Journal 1978, Vol. 54, pp. 1121– 1125.

 

Pape GL. ‘27 Symphysiotomies’ in Tropical Doctor 1999, Vol. 29, pp. 248-249.

 

Pust RE, Hirschler RA, Lennox, CE. ‘Emergency Symphysiotomy for the Trapped

Head in Breech Delivery: indications, limitations, and method’ in Tropical Doctor

1992, Vol. 22, pp. 71-75.

 

Seedat EK, Crichton D. ‘Symphysiotomy: Technique, Indications, and Limitations’ in

the Lancet, 1962, Vol 1, pp. 554 –559.

 

Selikowitz, S.M. ‘The Symphysiotomy Approach to High Velocity Missile Trauma’ in

Annals of Surgical Oncology, Vol 178, No. 5, pp. 616-20.

 

Spencer, JA. ‘Symphysiotomy for Vaginal Breech Delivery: Two case studies’ British

Journal of Obstetrics and Gynaecology 1987, Vol. 94, pp. 716-718.

 

Stanton, S., Kerr-Wilson., R & Grant Harris, V.‘The incidence of urological symptoms

in normal pregnancy’ in British Journal of Obstetrics and Gynaecology, 1980,

Vol. 87, pp. 897-900.

Sunday-Adeoye, IM, Okonta, P & Twomey, D, ‘Symphysiotomy at the Mater

Misericordiae Hospital Afikpo, Ebonyi State of Nigeria (1982–1999): a review of

 

1013 cases’ in Journal of Obstetrics and Gynaecology, 2004, Vol. 24, No. 5, pp. 525

 

 

 

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‘Symphysiotomy and vacuum extraction’ [editorial], in the Lancet 1974, Vol. 1 pp.

396– 397.

 

Thom D. et al. ‘Evaluation of parturition and other reproductive variables as risk

factors for urinary incontinence in later life’ in Obstetrics and Gynaecology 1997, Vol.

90 (6), pp. 983-9.

 

Van Heiningen, T.W., ‘Section or Pubic Symphysis and Caesarean Section: Analysis

of a Controversy’ in Histoire des Sciences Médicales 2009; July-September, No. 43.

Vol 3, pp. 249-60.

 

Van Roosmalen J. ‘Safe Motherhood: Caesarean section or symphysiotomy?’

American Journal of Obstetrics & Gynaecology 1990, Vol. 163, pp. 1-4.

 

Van Roosmalen J. ‘Symphysiotomy as an Alternative to Caesarean Section’ in

International Journal of Gyneacology and Obstetrics 1987, vol. 25, pp. 451-458.

 

Villar, J. Et al, ‘Maternal and Neonatal Individual Risks and Benefits Associated with

Caesarean Delivery: multicentre prospective study’ in British Medical Journal, 2007,

November 17; 335 (7628) 1025.

 

Wykes, C.B., Johnston, T.A., Paterson-Brown, S. and Johanson, R.B. (2003),

‘Symphysiotomy: a lifesaving procedure’ in BJOG: An International Journal of

Obstetrics & Gynaecology, Vol. 110, pp. 219–221.

 

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