An appeal over the rejection of a woman’s claim that an unjustified symphysiotomy was performed on her days before her first baby was born in 1963, has opened at the Court of Appeal.
The appeal by the woman (76) is seen as a test case for actions over symphysiotomy, a procedure which divides the cartilage of the pubic symphysis to facilitate easier delivery.
Her counsel Ciaran Craven SC disputed there was adequate evidence of such disproportion between the size of the woman’s pelvis and the baby’s head to justify the medical view that it was inappropriate to allow labour to be tried before doing a symphysiotomy.
The evidence did not establish symphysiotomy was a “generally approved” practice when this one was carried out in 1963 at a Dublin hospital and did not support the courts being “sanguine” about effects of the procedure, he argued.
Lifelong pain
Emily Egan SC, for the hospital, said a 1963 practice cannot be viewed “through 2016 spectacles” and the evidence was this symphysiotomy arose from a medical view that vaginal delivery was not possible. If the three Dublin teaching hospitals were practising this procedure on a limited basis in 1963, that was evidence of a reputable body of opinion practising it, she said.
Due to lapse of time, the court did not have evidence from Irish obstetricians who did symphysiotomies in 1963 about why they did so. While it may well be some saw symphysiotomy from a Catholic perspective, as encouraging larger families, there was no evidence this symphysiotomy was influenced by anything but medical reasons, she argued.
The woman said she felt “split in two” afterwards and has suffered lifelong pain, incontinence and depression.
The hospital denied the claims and disputed the procedure results in significant adverse effects.
In the High Court last May, Mr Justice Kevin Cross found the practice in 1963 of prophylactic symphysiotomy – performed without any trial of labour based on a view normal delivery would not be reasonably possible – “was not a practice without justification”. He found the procedure had adverse effects on the woman, including mental health consequences, but accepted it was “hotly disputed” the procedure generally caused adverse effects.
In appealing that judgment, Mr Craven said there was only moderate pelvic disproportion and the appropriate option was to try labour to see what happens or have a Caesarean Section. There were drugs available in 1963 allowing the uterus contract so a trial of labour was a “more realistic” option.
Historical context
The historical context is relevant, he argued. The woman would not have met the criteria for symphysiotomy which applied when it was introduced here in the 1940s and there was a “world of difference” between the Dublin of 1963 and sub-Saharan Africa (where symphsiotomies were more routine).
The fact this procedure was discussed in standard medical textbooks in 1963 did not elevate ante-natal symphysiotomy to the level of a “generally approved” practice.
While there appeared to be concern here, once a cesarean was performed, women would have to have cesareans on further pregnancies, figures from this hospital at the time showed an “impressively high” rate of vaginal birth after sections. Evidence of concern about risks from multiple sections came “nowhere near” to justifying how such concern was expressed.
Ms Egan argued said there was “compelling” evidence that a decision there was such pelvic disproportion a vaginal delivery was not possible in this case could be made in advance of trying labour. There was also compelling evidence it was acceptable practise in Ireland in 1963 to carry out a symphysiotomy rather than a cesarean.
