Symphysiotomy

Caoilfhionn Ní Dhonnabháin has a post here about separating the state and religion in the Republic; there is a brief reference in it to symphysiotomy:

Nowhere was this more evident than in the practice of symphysiotomy where religion and conservatism triumphed over the rights of women. This was almost uniquely practiced in Ireland up until the 1980’s. And even within Ireland it was most commonly carried out in Catholic run hospitals.

In line with Catholic thinking, symphysiotomy was carried out in place of a caesarean section because caesarean sections would limit the number of children a woman could have.

Symphysiotomy, the sawing of a woman’s pelvis in half, created misery, lifelong pain and hardship for those who were brutalised in this way. Today the victims of symphysiotomy continue to fight for justice.

Briefly, there was a vogue for symphysiotomy in some hospitals in Ireland for several decades, at a time when the procedure was generally considered obsolete.

What is a symphysiotomy? What is a symphysis?

A symphysis is a type of joint or “articulation” between two bones. It’s not the sort of joint at the knee or knuckles; a symphysis has a layer of fibro-cartilage between the bones, as a “shock absorber”.

Here, we are concerned with the symphysis pubis, the “joint” between the two superior pubic rami of the pelvis. It’s at the front, directly in front of the bladder, and very near the clitoris and urethra. There is about 2mm of movement, and perhaps 1º of rotation normally. This does increase in pregnancy, under hormonal influence.

fig1.small

The normal female pelvis is only just big enough for the foetal head during delivery. Compared to other mammals, humans are born very prematurely. This is because of the evolution of our big brains and big heads, and because walking upright needs relatively narrow hips for balance and stability.

What’s a symphysiotomy? It is the division of the symphysis, to allow greater separation of the two pubic rami. It used to be done for “disproportion”, that is where the mother’s pelvis was too small to allow the foetal head to pass through during labour. This problem was often related to poor diet and rickets.

It’s important to note that a symphysiotomy was done during labour, to allow the labour to proceed; it was in no way a prophylactic procedure.

I checked in a gynaecological textbook*: it describes the increase in the diameters of the pelvis which can be expected from the operation, that is, how much bigger the pelvis becomes. It continues,

“The writer does not approve of or recommend the operation, on account of the danger of leaving the patient in a crippled condition after it”. The author, however, describes how to do it, then, “When delivery has been completed…” describes how to attempt to repair the symphysiotomy. He recommends in addition bed rest for four weeks, and then the use of a pelvic binder “for at least a year”.

“There are certain risks connected with the operation which greatly detract from its value. The urethra or bladder or both may be torn. There may be lacerations about the clitoris, which may give rise to troublesome haemorrhage. The sacro-iliac joints may be much damaged or even ruptured. The pelvic symphysis may fail to unite, and thus leave the woman unable to walk properly.” [My italics.]

What’s disturbing about the cases in Ireland is that:

The procedure was done as a prophylactic, to enable easier future deliveries. Contraception was not available at this time; the mores of the Catholic church prevailed.

It was done as an “alternative” to Caesarian section which was felt to be more dangerous, specially for repeated pregnancies; again, there was no contraception, and “grand multipara” were very common in Ireland. The problem with repeated Caesarian sections is the weakening of the scar that develops at the site of the incision into the uterus. The “classical” uterine incision used previously was much more liable to rupture during subsequent pregnancies than the “lower segment” incision used today.

The women were not told that the procedure had been done; their permission was not sought.

Even when it was done, it was outmoded, outdated.

And it took some women many decades to discover the truth, to discover why they couldn’t walk properly, why they were in pain.

* Full disclosure: My grandfather wrote the textbook; it was a published in 1908.

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2 thoughts on “Symphysiotomy

  1. symphysiotomysosireland

    Safe lower-segment Caesarean replaced classical Caesareans from the 1930s in Ireland. Caesarean that is used today is the same Caesarean practiced in Ireland from the 1930s. There is no evidence in any literature from the 1940s to suggest that medical practitioners believed that Caesarean was dangerous. In fact, in 1949, Alex Spain of the National Maternity Hospital, who a leading proponent of symphysiotomy, boasted of having performed 7 Caesareans on the same woman. Moreover, the rate of vaginal birth after Caesarean section was 85% in the Coombe Hospital during the 1950s and 1960s. The practice of symphysiotomy was therefore all the more unjustified when lower segment Caesarean was a safe alternative available in hospital during the period 1944-1984 as the likelihood of repeat Caesarean was remote.

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    1. korhomme Post author

      Thank you for those details—as you can gather, I’m not an obstetrician. I do get slightly annoyed when I read that a woman’s pelvis was ‘broken’. It may be graphic, but it’s not really correct.

      Still, I agree with grandfather; there was no place for it in Ireland, no place for it as a prophylactic.

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