Birth history meets Halloween. Listen in for the absolutely horrifying fact of why the chainsaw was invented and the horrifying history of Symphysiotomy in Ireland from 1944 to 1987.

Summary

The history of symphysiotomy

Symphysiotomy, also called a pelviotomy, is an outdated surgical procedure where the cartilage of the pubic symphysis is divided to widen the pelvis allowing childbirth when there was a mechanical problem or obstruction.

In 1597 Séverin Pineau first advocated for Symphysiotomy in labor after he observed the diastasis of the pubis on a hanged pregnant woman. This was the first time he saw the pelvis ability to separate.

In the 18th century, medical experts changed their view of surgery called the clockwork rational. Just as a clock could be taken apart and repaired, so too might the human body.

We see symphysiotomy again in the 18th century. Petrus Camper, a carpenter, went to medical school and entered a field claimed by men, the earliest obstetrics. He became one of the new man-midwives who brought their new tools into the birthing process and pushed midwives out of birth.

In the 18th century cesarean was very dangerous, painful and unsanitary and many women did not survive. Because of this, Petrus Camper tried a NEW operation on pregnant pigs. He cut the cartilage between the pubic bones to enlarge the birth canal to let the piglets through. Petrus Camper never attempted this on a woman but Jean Sigault de LaFond, the son of a clock maker did. 

Jean performed his first successful symphysiotomy in 1777. The faculty of the medicine of paris ordered his thesis be printed and Jean received a medal for his work. Thus symphysiotomies became the routine surgical procedure for a woman experiencing an obstructed labor.

The Symphysiotomy procedure

The procedure was originally performed by hand using a small knife and saw to remove the bone. In fact, two doctors invented the first hand powered chainsaw in 1780 to make the removal of the pelvic bone easier and less time consuming during childbirth.

The procedure is performed in nearly the second stage of labor to temporarily enlarge the pelvis 1–3 cm when there is a mechanical problem. It involves the use of local anaesthesia, scalpel, catheter, vacuum extractor, and good support for the legs to prevent abduction of more than 40° per leg. A 1-3 cm incision is made in the skin, through to the symphysis and then the cartilage between the pubic bones is severed. The whole procedure takes 2–3 minutes.

A symphysiotomy would not be performed if the baby was still born, if the cervix was not dilated or if the baby was in a transverse lie.

The most common reasons for symphysiotomy are trapped head of a breech baby, shoulder dystocia that is not resolved with maneuvers, and obstructed labor at full dilation when there is no option of cesarean. This can be life saving when a cesarean is not immediately available. Since this procedure does not scar the uterus, the concern of uterine rupture in future pregnancies is not an issue.

This procedure carries risk too. Urethral damage, bladder injury, incontinence, fistulas, infection, long term pain, and long term difficulty walking. It’s advised to only be used when there is no safe alternative, and should not be repeated due to risk of walking issues and continuous pain. Symphysiotomy results in a permanent increase in pelvic diameter due to scar tissue formation post procedure.

Symphysiotomy became less frequent in the late 20th century with improved cesarean techniques and hygiene and we saw less maternal deaths. Along with criticism of the operation itself causing too many complications. Currently, symphysiotomies are rarely performed in developed countries, but still happen in rural and resource poor developing countries. 

As barbaric and torturous as that all sounds for the 18th century woman.. Were not done yet. 

The Nightmare in Ireland

It is estimate that 1500 women unknowingly and without consent underwent symphysiotomies during childbirth in the Republic of Ireland between 1944 and 1987. LONG after cesareans were well developed and considered a safe option. 

I’m going to play a clip from a survivor Rita McCan to hear first hand her experience of the joy of childbirth turning into a nightmare (listen to the podcast to hear it!).

It was December 15th, 1957 when she went into labor at a hospital in Dublin, Ireland. As she floated in and out of consciousness, she remembers being taken into a room with a single bed. As a room full of medical students and doctors looked on, McCann says she could feel the pressure of a scalpel cutting into her. From then on, it was “just agony, literally agony,” she recalls. “I got a cramp down my left side and I could not move at all to get myself any relief.” McCann, struggling against the searing pain, couldn’t see what the surgeon was doing to her.

She assumed he was performing a Cesarean section, but he wasn’t. He was slicing into her pelvis to make way for her baby.

McCann was undergoing a symphysiotomy – a procedure seldom used by other industrialized nations by the mid-2oth century. She didn’t find out about the symphysiotomy until she was 88 years old and requested her medical records from that day.

More horror stories from the women in Ireland

Philomena gave birth to her third child in 1959, at the same hospital where Rita McCann had given birth two years before. 

“I just remember being brought into a theater and the place was packed with people. I wasn’t told what was happening … I was screaming and being restrained .I couldn’t see much except for them sawing.”

It was excruciating pain. I was just 27 and I was butchered.

Cora was just 17 when doctors performed a symphysiotomy on her during the birth of her first child in 1972.

“I was screaming. The anesthetic was not working. I said, I can feel everything … I seen him go and take out a proper hacksaw, like a wood saw … a half-circle with a straight blade and a handle. The blood shot up to the ceiling, up onto his glasses, all over the nurses… Then he goes to the table, and gets something like a solder iron and puts it on me, and stopped the bleeding.

… They told me to push her out. She must have been out before they burnt me. He put the two bones together, there was a burning pain, I knew I was going to die.”

The surgery was initially carried out under general anesthetic, but the policy changed in 1952: henceforth, in the fetal interest, the surgery was to be performed under local anesthetic. This added greatly to the burden of intense physical and mental suffering that these operations generally entailed. And anesthetic failures were common.

Some surgical techniques were more cruel than others. One method which was widely used, was particularly inhuman. It entailed the partial cutting of the woman’s symphysis, followed by the manual separation of her pubic bones by forceful separation of the thighs’.

Mothers were then forced to go on for as long as it took, post-operatively until the baby came, the pain of labor forcing its way through the agony of the surgery, the fetal head further prying open the mother’s pelvis.

Victims then gave birth usually by forceps or vacuum extraction, in these brutal vaginal deliveries. The use of such instruments and machines, also required an episiotomy to enlarge the birth canal, adding another dimension of pain and suffering.

There are even records of symphysiotomies performed in postpartum and during cesareans as an obvious experimental medical practice. Again, all without knowledge or consent. Symphysiotomy was performed routinely in Ireland in the absence of medical necessity. When a labor became obstructed, Cesarean section, the appropriate intervention, was readily available.

But why?

The Practice of Forced Symphysiotomy 

The practice of forced symphysiotomy was carried out purely for involuntary medical experimentation. Half a century after Cesarean section had established itself in the

Dublin maternity system, Dr Alex Spain embarked on a mass medical experiment at the National Maternity Hospital with the goal of replacing Cesarean section (in some cases) with symphysiotomy.

Young healthy women who were pregnant with their first child were the preferred subjects for this experiment (ironically the same subjects of our current day arrive trial findings). 

Now this is a heavy topic, and at the same time we can learn alot about where obstetrics is today by where it started. I want you to be on the lookout for a new series I am hosting called Understanding Unmedicated, which if you listen to this episode in real time is next week. Head over to @fiercelizzie on IG to get access to the series all about why we want unmedicated birth and why it can be so hard to achieve in the hospital. 

Back to 1950s Ireland, Spain’s successor, Dr Arthur Barry, repeatedly urged his colleagues to experiment with symphysiotomy: ‘I do not yet know what limits should be placed on the operation … enlarge the pelvis and the baby’s head will fit through’.

When challenged by visiting obstetric experts over the non-consensual practice of symphysiotomy, Barry replied: ‘Surely it will be a sad day for obstetrics when we allow the patient to direct us as to the line of treatment which is best for the case’

Dublin’s symphysiotomy experiment was driven by religious, not medical, considerations. The performance of postnatal symphysiotomies, in particular, highlighted the fact that social control, not therapeutic treatment, was the specific purpose. Powerful Catholic doctors who subscribed to the natural law viewed women, stereotypically, as vessels for procreation: nine or ten children was seen by them as the ideal family size. Proponents of symphysiotomy, such as Barry, sectioned the pelvis of selected women to surgically ensure childbearing without limitation.

The so-called rule of three capped the number of Cesarean sections that could safely be performed on the same woman. C-section, in Barry’s view, was a moral hazard that led to birth control, a practice which was prohibited by the Church.

And this went on for 43 years. Hospitals that were performing this abusive surgery were repeatedly accredited for training purposes in obstetrics, nursing and midwifery by State regulatory boards. Such regulators failed in their duty to halt the practice of these harmful, unwarranted and involuntary operations.

The Survivors of Symphysiotomy

Almost every survivor left hospital not knowing she had been subjected, covertly, to symphysiotomy. That knowledge came some fifty years later, sparked by media coverage.

Annual clinical reports detailing the practice of forced symphysiotomy were sent to the Irish Department of Health. Despite wide powers of investigation, the State failed to investigate the practice, and to prevent acts of torture

None of the perpetrators of these non-consensual surgeries have been held to account. Twelve years after the practice had been publicly exposed, following repeated demands for an inquiry from Survivors of Symphysiotomy, the State commissioned a partial and narrow review that was heavily biased, and used their resources to defend symphysiotomy.

As we know, cases of mistreatment and violence against women in obstetric units have been widely reported, then, now, in Ireland, in the US and around the world. Many obstetric models of care (Ireland and the US included) are based on the active management of women in labor that focuses on acceleration labor and assumes patient consent. 

Mentioned on the show

Check out the free masterclass series on ⁠Understanding Unmedicated Birth

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