Midwife-led care which allows normal labours to take their own course are as safe, and cheaper, than consultant-led care, writes Victoria White.

THERE isn’t a mention of the drug Syntocinon in the HSE’s Maternity Clinical Review of serious complaints about maternity care in nine hospitals over four decades which was published on Tuesday. Fourteen families have been issued with apologies, eight of which involve the death of a precious baby.

In all, 153 patients participated in the review process in nine hospitals: Portlaoise’s Midlands Regional Hospital, Dublin’s Rotunda and Coombe, Limerick’s University Hospital, Cork’s University Maternity Hospital, Kerry’s General Hospital, Mullingar’s Midland Regional Hospital, Tullamore’s Midland Regional Hospital and Galway’s University Hospital.

But no general trend has been found in the records. And there is not a single word in the report about the routine use of the artificial hormone to speed up women’s labours in our hospitals despite the fact that inappropriate use of the drug was found to have been a contributory factor in the deaths of three babies in one of the hospitals under review: Mark Molloy and Joshua Keyes Cornally and Nathan Molyneux, who died in the Midlands Regional Hospital, Portlaoise, in 2012, 2009 and 2008 respectively.

We know there have been other baby deaths in hospitals in which the inappropriate use of Syntocinon was a contributory factor. Some €4m was awarded to young Paul Fitzpatrick who was left severely mentally and physically disabled in 2001 when the National Maternity Hospital kept pumping his mother with Syntocinon despite a foetal heart trace showing distress. The hospital did not admit liability.

New guidelines on the use of Syntocinon were finally issued last year and they counsel against its use when foetal distress is present. In the cases of Mark Molloy, Joshua Keyes Cornally and Nathan Moloyneux it continued to be administered despite signs of foetal distress and the Clinical Review emphasises the training of staff to read CTG scans carefully and accurately.

Tullamore’s Midland Regional Hospital
Tullamore’s Midland Regional Hospital 

But why don’t guidelines for the administration of Syntocinon counsel against its use except when clinically indicated? Why is Syntocinon in routine use in our hospitals at all?

Haven’t Irish women got birth hormones? If not, why were the Irish not extinct before doctors learned how to hook them up to artificial hormones?

They gave birth in their own time? Outrageous! That has been the stance of the Irish maternity services since the 1960s when Dr Kieran O’Driscoll at the National Maternity Hospital developed a system which obliged women to give birth to a time-table and enforced it by using Syntocinon.

At first women were given 36 hours to give birth. From 1968 they were given 24 hours. And in 1972 he developed an Irish speciality, the sprint-labour, obliging women to pop their babies in 12 hours or else.

This regime is still in place in the National Maternity Hospital, as I know to my cost, having been painfully and pointlessly hooked up to Syntocinon on my third labour. A version of the system is in place in all Irish maternity hospitals, apart from the midwife-led units. The “Dublin system” has been exported all over the world. And Dr Peter Boylan, who chaired the HSE’s Maternity Clinical Complaints Review published this week, co-authored the 1993 edition of the Active Management of Labour handbook.

The handbook describes labour, and particularly first labour as potentially “the most disturbing emotional event in the life-time of one-half of humankind”. I find myself thinking it must be the male half they are talking about. Active Management, as articulated here and in the 2003 edition which was co-authored by Michael Robson, a member of the Clinical Review team for the first phase of Peter Boylan’s review, seems grounded in a basic horror of labour.

By forcing women to give birth to timetables which are carefully printed out and called “partograms” and by using Syntocinon to make sure she complies, the medics assert their power over labouring women by intervening early “rather than remaining off-stage awaiting the occasional summons to perform an emergency operation in a belated attempt to retrieve a situation which could have been anticipated at a much earlier stage”. The 1993 handbook is spectacularly sexist in its dire warnings as to the effects of long labours on women which are said to haunt them for the rest of their lives and affect their relationships with their husbands and even their children.

Review of birth outcomes will change nothing in maternity care

But the Syntocinon system itself is far more worrying. Yes, it was evolved in a time when the NMH was the busiest hospital in these islands and was desperately short of resources. It is a factory system to mass-produce babies in what was thought to be the safest possible way. Obstetricians then, as now, work desperately hard to ensure the welfare of mothers and babies.

But Ireland has come a long way since the 1960s. And the latest Cochrane review tells us that the use of Syntocinon does not reduce the risk of caesarian section, as has always been argued by the NMH.

We know from the success of midwife led units in Cavan and Drogheda and from the 2008 KPMG report into maternity care — as well as from consistent international evidence — that midwife-led care which respects the wisdom of a woman’s body and allows normal labours to take their own course are as safe, and cheaper, than consultant-led care. And it did seem as if the HSE was finally listening because last year’s Maternity Strategy foresaw most births in Ireland being led by midwives without the routine use of interventions including Syntocinon drips and epidurals.

There are strong indications from several quarters internationally that the routine use of Syntocinon is unnecessary and risky. In the UK in 2005, baby Jack Clayton was left seriously disabled when the flow of Syntocinon to his mother was doubled while he was showing signs of distress. The solicitor handling the case stated that her firm had seven malpractice suits related to the over-use of Syntocinon.

The Presbyterian Weill Cornell Hospital in New York has banned the routine use of Syntocinon and the number of malpractice cases against them has plummeted. Philip Steer, a consultant at London’s Chelsea and Westminster Hospital, believes the use of Syntocinon should be banned except in rare cases when a woman is overdue or has pre-eclampsia.

He reckons that 70% of malpractice cases are linked to the use of Syntocinon but says doctors and midwives like using it because “it feels as though they are making a difference”. This is the crux of it: Syntocinon means doctors control birth in this country. The HSE’s clinical review of poor birth outcomes over four decades was produced by doctors for doctors. It will change nothing.


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