DISCUSSIONS ON THE THREE DUBLIN MATERNITY HOSPITALS REPORTS

AN APPRAISAL OF THE REPORTS OF THE DUBLIN MATERNITY HOSPITALS FOR 1966

GEOFFREY DIXON. Ph.D., F.R.C.P.Ed., F.R.C.O.G. Professor of Obstetric~ and G~'naecology in the Utdversit~, of Bristol

at Southmead Hospital, Bristol.

It is an enormous privilege to be asked to comment on the three such reports as we have here today, and I feel it reflects great credit on all concerned that these reports are produced so speedily and so splendidly. As to their actual contents, may I say that those who so kindly gave me this invitation gave me a very firm briefing that I was to be quite ruthless in my criticisms. The problem that faces me in attempting to comply with this request is that all the reports show work of such a high standard that any attempt to find points to criticise becomes an exercise in academic nitpicking. To turn now to the overall figures for the 3 hospitals. The maternal mortality is so low that one death can make an enormous difference to a hospital's maternal mortality figure, and I feel it is a matter for congratulation that the figures in Dublin are so low when one considers the difficult material with which you have to deal. Looking over the detailed case reports of maternal deaths it is very difficu!t to see avoidable factors in any of them apart from the mild self- criticism expressed by the Master of the Coombe, but as he himself says it is very easy to be wise after the event. I think the Master of the Coombe does himself less than justice by including as a maternal death one that would not have appeared in a report in England as it occurred after the statutory 42 days from delivery. I confess to a feeling of some surprise that no postmortem was performed on the third case of the Rotunda. In the United Kingdom one would have had to report this case to the Coroner as the death occurred within 24 hours of surgery. He would undoubtedly have ordered a postmortem to be carried out.

Turning to the Perinatal Mortality it does appear that more neonatal deaths occurred at the Coombe than in the other units and one does wonder whether perhaps co-operation between paediatricians and obstetricians is as good as it might be.

Heart Disease These figures require little comment but the incidence of congenital heart disease

does seem high especially at the Rotunda, and I wonder if our teaching that 90 per cent of heart disease encountered in pregnancy is rheumatic in origin is any longer correct. This was the impression I had acquirecL at Hammersmith where it could, of course, have been due to case selection. I am interested in the two patients with coarctation of the aorta who were delivered at the National, and would very much like to know how delivery was effected as I have for long felt that the gener- ally accepted practice of delivery by Caesarean section in the presence of this lesion is unnecessary.

Diabetes As some of you know diabetes in pregnancy has been a special interest of mine

for a number of years, and I confess to a feeling of some dismay that you have not yet accepted the proposed terminology which was first put forward by the British Diabetic Association and has now been accepted by the World Health Organisation. It is surely time that we as obstetricians gave up the use of the term pre-diabetic. This should be restricted to the period between conception and the detection of the first abnormal glucose tolerance test, however the latter is provoked. It can thus only be a retrospective diagnosis and I think that the cases classified as pre-diabetic at the Rotunda should more properly be regarded as latent diabetics.

Equally I am unhappy about the practice in the National of defining as latent diabetics patients who have an abnormal G.T.T. during pregnancy but who later revert to normal. I think these patients are latent diabetics who have become biochemical diabetics during pregnancy. The problem of the diagnosis of latent diabetes both during and after pregnancy is a considerable one. The prednisone stressed G.T.T. seems quite unsuitable for use during pregnancy, but at Hammersmith we have had considerable success with the prednisone tolerance test, and we now perform this after a standard 50 gin. oral G.T.T. This detection of early diabetic changes is I feel a special responsibility for the obstetrician and I would agree with the self-criticism expressed by the Master of the Coombe in respect of the number of glucose tolerance investigations carried out during pregnancy. Turning to the actual results obtained in diabetic pregnancies in Dublin I find them extremely difficult to assess in view of the small numbers that are dealt with at any individual

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hospital. The National dealt with the largest group of patients and achieved a 60 per cent success rate for the pregnancies. Detailed scrutiny of the cases makes criticism very difficult, but I am impressed by the high incidence of pre-eclampsia and hydramnios because of the recent suggestions from Belfast and London that the incidence of both these complications is reduced by very strict diabetic control with or without bed rest.

I feel so strongly that the successful care of the diabetic during pregnancy demands the closest possible co-operation between physician and obstetrician, a state of affairs which is not easy to achieve in every hospital, that I am moved to suggest with due deference that perhaps thought might be given to the possibility of establishing one such joint clinic where all the diabetic patients of the 3 hospitals could be seen and managed.

X-Ray Pelv,;,metry I was a little surprised by the high overall incidence of x-ray pelvimetry, especially

in view of the remarks in the National reports about the disappearance of cephalo- pelvic disproportion and contracted pelvis. I feel the time has~ come for us to be very critical of the indications for x-ray pelvimetry and in an effort to be provocative I will put it to you that such an investigation is only justified in the presence of a breech presentation.

Rhesus Incompatibility Looking at these figures there is no doubt that the results obtained in the presence

of Rhesus incompatibility at the National are fa~ better than in the other 2 hospitals. This must be due-to the obvious intensive care that these patients receive at the National where far more amniotic taps are carried out, and also intra-uterine trans- fusions, which even at 40 per cent survival in hopeless cases are surely worth while. One has a great deal of sympathy with the Rotunda who suffer from a lack of the necessary equipment, but again I wonder whether this is not an instance where some form of inter-hospital co-operation would not be helpful. One also hopes that with the advent of Anti-D gamma globulin this problem will fast disappear from the Dublin reports. I must agree wholeheartedly with Professor Browne in his comments at the top of page 57, but after they have had all these children I am sure that these unfortunate women have some degree of prolapse and I would draw his attention to a very excellent operation known as vaginal hysterectomy and repair which would undoubtedly solve their problems for them.

Placental Praevia There is an obvious and sharp discrepancy in the results obtained at the Coombe,

and at the National and at the Rotunda, and although it is extremely difficult to find any avoidable factor in the Coombe's cases, I wonder once again if the care of premature babes could be improved. I approve of, and indeed myself practise, the ~eneral tendency in Dublin to delay interference and dispense with an examination under anaesthesia if the clinical diagnosis is reasonably certain, but I would point out that most babies face their own placenta and one can achieve a 90 per cent accuracy in placental localisation by using just one's hands and eyes. I do not think this degree of accuracy is enough to justify complacency over the method of localisation in use. Personally I feel that the future of placental localisation lies in mechanical or gamma camera scanning of the uterus after an intravenous injection of albumin tagged with some gamma emitting isotope. This provides a permanent record: and is almost foolproof, but unfortunately the equipment is expensive.

Accidental Haemorrhage I would like to congratulate all concerned on the fact that there was no maternal

death as a result of the very severe accidental haemorrhages. I have not included the Rotunda figures in this illustration as in this section of the report they refer only to " toxic " accidental haemorrhages with a perinatal mortality of 350, but group the other accidental haemorrhages with the unclassified section. I have been greatly interested by the work that has gone on in Dublin on central venous pressure recording in accidental haemorrhage and feel this is most important. At the risk of offending Dr. Gavin I must say that it is no great mystery to me where the trans- fused blood goes in accidental haemorrhage, it goes to replace the blood lost to the vascular compartment be it as revealed loss or into the myometrium or into other hidden areas. If a patient is anaemic after an accidental haemorrhage then I feel the transfusion has been inadequate. The difficulty in the past has been finding a yardstick by which we could assess the adequacy of transfusion, and it would seem that central venous pressure has given us just that. I agree that there is a worth- while olace for Caesarean section in the management of accidental haemorrhage when (he baby is alive if transfusion pre-operatively can be both rapid and adequate. I think, however, that Dr. Geoghegan has perhaps gone a little far in his suggestion that adequate transfusion in accidental haemorrhage may produce "re l ief of com-

DISCUSSIONS 549

pensatory vaso-constriction at the placental site and thus reduce perinatal mor- tality ". It seems to me equally likely that the relief of any such vaso-constriction, ff in fact it occurs, may also increase the haemorrhage. In compensation may I say that I am very much on his side in the controversy on the inter-relationship between accidental haemorrhage and folic acid deficiency.

A.P;H. of Doubtlul Origin I am surprised by the low incidence of this complication at the Coombe and to

some extent at the Rotunda because, as I have already said, their figure includes some accidental haemorrhages. I wonder if any of us pay quite enough attention to these cases. When be was my colleague a t Hammersmith Duncan Murdoch showed that we were sustaining a perinatal mortali ty of about 130 per 1,000 in these cases as opposed to under 50 in placenta Draevia. It seems probable that most patients in this group are actually mild accidental haemorrhages and I wonder whether they do not merit induction after the E.U.A. at 38 weeks.

Pre-eclampsia I found these figures about the hardest to explain in any way. Quite obviously, and

in my opinion quite rightly, the National is using more generous criteria for diagnosis in order to produce an incidence three times that found in the other hospitals and, therefore, one would expect that more of its patients would come into the category of mild pre-eclampsia, and yet its perinatal mortali ty is the highest in the city foa" this complication. I am quite at a loss to explain this. The high perinatal wastage is certainly not accounted for by Stillbirths Nos. 19 and 28 which could possibly have been avoided by earlier caesarean section. It also seems possible that some of the perinatal loss could have been avoided by sequential urinary oestriols or even by a simple watch on girth and weight as advocated by Professor J. C. McClure Browne. Al though I appreciate the difficulties caused by the shortage of beds in Dublin I wonder whether some of the losses at the National (e.g. cases 9 and 12) could have been avoided by earlier admission.

Turning for a moment to eclampsia the figures here are so small that comparison would be meaningless, and I feel there is no real point in discussing them. I agree with the " aggressive" management but would underline the remark that has been made about the necessity for good anaesthesia being available.

I also find myself in some difficulty discussing the results obtained in the essential hypertensive women as there is some conflict in definitions and tabulation that invalidates comparison. Although there is obviously often a place for induction I agree wholeheartedly with Alan Browne that this must be based on the clinical picture in each female and it is unwise to apply any rule of thumb about induction.

Surgical Induction o] Labottr It seems very difficult to consider the perinatal mortali ty here as many inductions

are undertaken in all units for intra-uterine death and foetal abnormality. Personally I question the wisdom of rupture of the membranes in the presence of an intra- uterine death and prefer to use intravenous oxytocin. To consider the inductions in the individual units I wonder whether perhaps the National tends to leave the induction/delivery too long. A three and four day induction/delivery interval for postmaturity suggests that the diagnosis was not certain and action correspondingly half hearted. If one feels that pregnancy needs ending for hypertension surely one can ' t wait 3 days for delivery. The report frankly admits that some perinatal deaths were due to surgical rupture of the membranes but doesn't mention cases such as No. 26 where death was probably due to delay.

Turning now to the Coombe I agree wholeheartedly with the Master's comments on the necessity of keeping the induction/delivery interval short, but in such a climate of opinion it seems a pity that case B3568 lost her baby after a 55-hour induction/de!ivery interval. In a more light hearted vein I also fail to understand entry B1090 in a section headed " Surgical Induction of Labour " as the report begins " Admitted in labour ".

Now, the Rotunda, where the sharp drop in the induction rate is due allegedly to the amnioscopy programme. If you look at the figures that Professor Browne wishes one to consider there is no doubt that the reduction of perinatal mortali ty in the amnioscopy group is significant (P=less than 0.001) Where compared with the general hospital perinatal mortality, but I honestly do not feel that Professor Browne has olayed quite fair. Firstly, he does not tell us what cases are covered by the " O t h e r indications for Amnioscopy " which do have a high percentage of positive findings. Secondly, there is no way of predicting what the loss would have been if no amnioscopy had been done. Thirdly, amnioscopy was only performed after the 36th week and this fact alone cut out many deaths from plematurity. Fourthly, the hospital practice figures are loaded by perhaps even higher risk groups than those submitted to amnioscopy, these include the breech, where in the Rotunda alone 40 perinatal deaths occurred, prolapsed cord, accidental haemorrhage and so on. With

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the help of Dr. Avril Snodgrass at Hammersmith I attempted to overcome these difficulties by comparing the results of amnioscopy with the results of induction in the same high risk groups at the other hospitals. I was slightly bedevilled by not knowing how many of the amnioscopy " others " resulted in Derinatal deaths, but nonetheless we tried with the following figures. If you compare all 3 groups against each other there is no significant difference whatsoever between the perinatal loss and if, because of the fact that only the Coombe uses bad obstetrical history as a recorded indication for induction, one simply compares the National figures, against the amnioscopy group at the Rotunda there is once again no significant difference.

I do not wish in any way to detract from the important work that has been done at the Rotunda in this respect but think we must be a little cautions in assessing the results. The other point about amnioscopy which worries me is that at Professor Browne's estimate of 5 minutes to an examination only 36 hours of doctor time were uti!ised but I think this is certainly an under estimate. I presume that these were sterile examinations and its takes me 3 minutes to scrub, 2 minutes to get dressed, another 2 at least to clean the patient and I still have not started the amnioscopy.

As I said earlier I would not wish in any way to make it appear that I do not agree with every word that Professor Browne has had to say on the undesirability of a cavalier attitude to A.R.M. but I wonder whether the other nerhaos simpler tests to which I have referred are not as good as amnioscopy especially when they are assisted by what I consider to be one of the most important facets of modern antenatal care, namely the careful checking and re-checking of maturity at all stages of pregnancy. Finally I note that caesarean section was apparently t~erformed for failed induction twice at the Rotunda but only once at the Coombe and apparently not at all at the National in spite of the lack of amnioscopy at the last two places.

Forceps The low perinatal mortality in the forceps delivery at the Rotunda is striking

especially when one looks at the detailed cases and finds that all the stillbirths were due to intra-uterine death before the application of forceps. One so called neonatal death was in point of fact an abortion that breathed. The second neonatal death was a 31 week twin, and indeed the third neonatal death is the only one in which trauma seems ~ remote possibility. Once again I would endorse what has been said in several of the repo.rts about the necessity for skilled anaesthesia in an obstetrical department. I am sure that not aU forceps can be done under a pudendal block, even now that complicated vaginal manipulations have so little place in modern obstetrics and it is time that the long tradition that obstetrical anaesthesia could be administered by the most junior anaesthetist on the staff was broken. At the National. the perinatal mortality in forceps delivery was higher but again no deaths were due to trauma and in several prematurity was obviously the major factor. I wonder whether the stillbirth in Case 1 could have been avoided by earlier de!ivery, and whether the neonatal death in Case 4 could have been avoided by timely caesarean section in a 39 year old primigravida with severe pre-eclampsia and an unfavourable cervix at term. In the Coombe reports I confess to a feeling of some slight dismay when in the storv about N801 I read " h o m e from England, no ante- natal care for 5 months before admission ". I assure you the lady could have had ante-natal care if she had asked for it! As the Master of the Coombe ooints out two deaths are certainly due to forceps delivery and one probably. Keillan~l's forceps is obviously a dangerous instrument unless handled by an expert, and if one thinks it has any place in modern obstetrics 1 am sure that those who hold this opinion and are responsible for training the younger ~eneration of obstetricians must be prepared to go into the Labour Ward at all hours of the day and night to supervise their pupils until they have attained the necessary degree of skill.

Caesarean Section There seems a v e r v sharla contrast between the perinatal mortality at the Rotunda

and the Coombe with virtually the same incidence of caesarean section. I am afraid I have been unkind enough to go through the cases in some details and would make the following comments.

Case B.165. I wonder whether a caesarean section was indicated at all here with an x-ray already showing marked hydrops.

Case B.753. 1 am not quite sure of the time intervals but overall it sounds as if :someone was "unhappy about the presentation " for far too long. It seems that a ,caesarean section at the time of the onset of labour with an unstable lie might well have saved this baby.

Cases B.1685 and 1375. In both of these I wonder whether an intra-uterine transfusion would have been worthwhile.

Cases N.1728 and N.1573. If straight x-rays of the abdomen had been taken here I do not think that caesarean section would have been performed for either of them. Like most of us I have been caught and delivered an abnormal baby by an elective Caesarean section. It is now my practice whenever possible to take a straight

DISCUSSIONS 551

film before embarking on this operation in the hope that I will be able to exclude at any rate major defects of the skeleton and central nervous system. Indeed I think there is much to be said for undertaking a straight abdominal x-ray before under- taking a surgical induction of labour and perhaps case B67521 at the National under- lines the necessity for this investigation.

Vaginal Delivery after Caesarean Section There is obviously a more conservative attitude at the National where even patients

with 3 previous sections are delivered vaginally. Is this attitude correct or does the National simply inherit all the patients who have previously been sectioned in London ?

I do seriously auestion the wisdom of routine exploration of the lower segment after vaginal delivery of a patient who has had a previous caesarean section. We have all found windows in the lower segment at the time of an elective retpcat Caesarean section in a quite asymptomatic woman, and I am sure that some patients with such windows are quite successfully and uneventfully de!ivered vaginally. Routine exploration always seems to me to raise the possibility of a detected defect being in fact iatrogenetic.

Symphysiotomy The low incidence of symphysiotomy in all units has tempted me into venturing

into a prophecy of what your invited speaker wilt have to show for symphysiotomy in 10 years time i.e. 0.0~o. There seem to me two possible explanations for this falling incidence, either you are adopting a United Kingdom policy in relationship to caesarean section and symDhysiotomy, or improved nutrition in Dublin is bringing your patients' pelves into line with their United Kingdom sisters. The figures from the Rotunda and the comments from the Coombe and the National strongly suggest that the latter is the true explanation. With regard to symphysiotomy for a breech presentation and a small pelvis I can only take off my hat, bow and salute you. Personally I would do a caesarean section--even in Bristol.

P.P.H. and Manual Removal Whilst scientifically one must agree with the attitude of the Master of the National

about post-partum haemorrhage, indeed it was very much borne out by the work of one of my late Senior Registrars, Mr. Brant, I just wonder if it may engender a cavalier attitude to b!ood loss in the third stage although I was struck by the very low incidence of transfusions associated with manual removal at the National as contrasted with the Coombe, and oresumably with the Rotunda who show a high incidence of transfusion for post-partum haemorrhage as a whole but do not refer specifically to transfusion in association with manual removal.

Disproportion These sections hardly merit comment. The incidence is much higher at the

Rotunda than the National but whether this is due to a different population or more liberal criteria of diagnosis I do not know and on the data presented I am unable to formulate any opinion.

Prolonged Labour Here again the incidence is highest at the Rotunda but all the nerinatal mortality

seems unavoidable except perhaps the primigravida with uncertain-dates who went to 44½ weeks. Was this not a case for amnioscopy ?

Multiple Pregnancy The incidence of twinning at the 3 hospitals is so remarkably similar that it sug-

gests a fairly homogeneous population is dealt with at the 3 hosr~itals. Looking through the reports it seems that prematurity is the commonest cause of death and is perhaps lowest at the National where I gather routine ante-natal admission is practiced. I agree with the remarks of the Master of the Rotunda about the difficulty of this policy, but nonetheIess feel it pays dividends. The figures that Dr. Browne and I collected from Hammersmith bore out the value of bed rest and also suggested that twins should never pass term and that even in the presence of a relatively slight rise of blood pressure induction at 38 weeks was justified.

Piolapse of the Cord I noted the remarks in the Coombe's renort about the selection of cases for

caesarean section and wonder oerhaps whether the National has gone a little too far in its use of Caesarean sect/on. I am a/so intrigued that the incidence at the Coombe is only half that at the other hospitals in spite of the introductory remarks on the high incidence of grand multiparae at the Coombe.

552 IRISH JOURNAL OF MEDICAL SCIENCE

Rupture o/ the Uterus Happily the figures here are too small for comment but as I have already said 1

am a little worried that " routine exploration " does not occasionally lead to !atrogenetic ruptures. I am also intrigued by the second case in the National report m which as written, one learned that an E.C.V. followed by P.O.M. was good treatment for A.P.H. (Sic!).

Breech Delivery In spite of the comment by the Master of the Coombe in this section that breech

results are used as a yardstick of obstetrical expertise I am not going to compare the results as only the Rotunda and Coombe make clear the differentiation between complicated and uncomplicated breech deliveries. This surely is a necessary one, and I am sorry that the National does not think fit to do so. I would also agree with the Rotunda that prematurity is a common and serious complication of breech delivery and suggest to the Coombe that they should transfer such patients into the Complicated table.

Transverse and Oblique Lie As the Coombe report includes cases not in labour this accounts for the incidence

being 3 times greater than the Rotunda and 4 times greater than the National. It also explains the very low perinatal loss. Taking the comparable two the perinatal mortality per 1,000 at the National was 230 and the Rotunda 97.5. This difference is striking but looking through the individual reports I could see little that could be improved in the National management. It interests me to read the comments of the Master of the Rotunda on the desirability of effective family planning for these patients. We, of course, tie the tubes of grand multiparae who need caesa,rean section for transverse lie. In Belgium they are often dealt with by Caesarean hysterectomy, but I appreciate the reluctance to undertake this major procedure when future fertility can be dealt with so easily. Professor Alan Browne grumbles a good deal about the lack of an accurate index of maturity. I agree with him that knowledge of maturity is a sine qua non of modern obstetrics and personally when in real doubt I have no hesitation in resorting to amniocentesis and staining the liquor with Nile blue sulphate along the lines advocated by Brosens and Gordon.

Persistent Occipito-Posterior The low incidence of this complication associated with a high perinatal mortality

at the National could suggest the diagnosis is not being made until the patient has been a long time irt the second stage, but this suggestion is not borne out by the study of individual cases and once again I am afraid I cannot explain these figures.

Now Mr. Chairman if I may I would just like to make some general comments on these splendid reports. Taking the Coombe first I was intrigued by some of the special cases. The abdominal pregnancy must have been a nasty shock to whoever opened it expecting to do a straight Caesarean section, but I think it does underline the limitations of placentograms. I also wonder whether the x-ray agreed that the babe was at term because it seems possible to me that this child was premature and would have succumbed even if it had been in utero. Of Case 2 I can only say that I am also so glad that this unfortunate female has lost her uterus at last. Would it perhaps have been kinder to have performed a Caesarean hysterectomy in 1965 ? I found Case 7 very interesting. It is a complication I have never seen but my veterinary colleagues tell me it is a common indication for Caesarean section in cattle. I must again emphasise that I come from an area that is free from foot and mouth otherwise I do not thi~k I would da.re confess to having veterinary colleagues. [ thought Case B.2890 on page 86 of the Coombe report raised a problem that is going to face obstetricians and paediatricians in the future and that is the place of surgery for the hydrocephalic child with spina bifida. Even if surgery is " success- ful " these children present formidable problems to their parents, the social and educational services and if such operations are to be undertaken I think we must give a thought to the future care of the child.

I would like to ask for guidance from Dr. Gavin on two points in his introduc- tion. I presume that a bed occupancy rate of 108.5%, which to me works out at 1'/1, patients in each bed, is due to extra beds having been set up, but I am quite at a loss to know what is meant by the word " innupta ". Finally, may I once again underline Dr. Gavin's remarks on the necessity of skilled and constant anaesthetic cover and say how particularly glad I am at being invited to discuss the last full year's work in the old Coombe, and wish him and his staff every success in their new home.

Turning now to the report from the National, the whole tenor of Dr. O'Driscoll's introduction underlines the tremendous work that has been done by all the hospitals in Dublin to alter the standards of Dublin obstetrics and how very well they have succeeded. You are now facing up to the problem that any further lowering of the perinatal mortality rate is going to be very hard work. Personally, and for what it

DISCUSSIONS 553

is worth, I think better antenatal care is the most likely answer because this will at the same time keep down the maternal mortality. As I have implied earlier I agree wholeheartedly that there is great scope for co-operation with other disciplines especially with the physicians.

To turn to Dr. Geoghegan. the achievement of a 100% P.M. rate is a remarkable and a praiseworthy one. The high incidence of intra-uterine sepsis to which he refers does prompt me to ask whether antibiotics are given to ~atients routinely if they are not delivered 24 hours after artificial rupture of the membranes. I do just wonder if women need a 120 mgms. of elemental iron as a prophylactic. My practice is to give only 60 as I think the pregnant woman needs about 3.7 mgms. a day, will absorb this just as easily from 60 as 120, and is far less likely to get side effects leading to her takin~ no iron at all. I think the introduction of 500 micrograms of folie acid is splendid and I intend to make some enquiries about these tablets which I gather are being specially made for the National.

Lastly the Rotunda report. As you will have appreciated it took me much thought before I cou!d find some way of being unpleasant to Professor Browne about amnioscopy and indeed it is impossible to find much call for comment in his report. I do not have his faith in Puroverine but I am going to be in a similar fix as the manufacture of Avertin is to cease. I have already said how much I agree with his comments on recurring pregnancy in the Rhesus negative woman with antibodies and on the surgical induction of labour. I am also wondering whether there is any copyright which prevents me having his outburst on the subject of postmaturity reprinted and circulated around my area. Finally, as you kr~ow, we insular English refer to certain ouaint phrases as " Irish ". I present the #~'ize for this for 1966 to the Rotunda in whose report on page 23 we read " T h e foetal heart went out early in labour ". This was indeed the light that failed !

Mr. Chairman, may I once again thank you for inviting me to be present tonight, and hope that you and the Masters of the hospitals will understand that I have had to descend to such minutiae in order to find subjects to criticise only because the overall standard is so excellent.

ROYAL ACADEMY OF MEDICINE IN IRELAND

THE A NNUAL REPORTS OF THE ROTUNDA, COOMBE AND NATIONAL MATERNITY HOSPITALS FOR THE YEAR 1966.

SECTION OF OBSTETRICS.

President: PROFESSOR ALAN D. H. BROWNE.

Guest Speaker: PROFESSOR GEOFFREY DIXON. (Dept. of Obstetrics and Gynaecology, Southmead Hospital, Bristol).

Meeting held on 1st December, 1967.

Chairman: DOCTOR A. P. BARRY.

DISCUSSION.

DR. A. P. BARRY (Chairman) : Ladies and Gentlemen, we have listened to many analyses of our Hospital Repor ts- -some have listened more carefully and over more years than others--but I do not think any of us here this evening will consider that we have listened to a better analysis of these Reports and to a more genuine and helpful criticism than that of Professor Dixon. The idea of publishing these Reports is twofold : firstly to show bow you are doing, and secondly to see where you are going wrong with a view to taking steps to avoid these pitfalls tbe following year. Surely we have never been told these things in a better fashion than this evening. Professor Dixon, on behalf of the Section, I offer you our most sincere thanks for this address. This meeting is now open to you all to raise your points for discussion - - i t is no good coming if you are only go ing to listen.

I heard with great joy Professor Dixon's condemnation of routine exploration of the uterus after vaginal delivery following Caesarean Section. I think this is an abominable nractice likely to produce a rupture and at least to introduce infection. I would like to hear discussion in relation to the question of the administration of iron and folio acid. I do not believe we are going to cure accidental haemorrbage in this city by giving folio acid. But I rather think that people should make a very careful distinction between the prevention of anaemia in pregnancy and the treat- ment of anaemia in pregnancy and I don't think in Dublin that we are making a sufficiently careful distinction in this. I think they are very different problems and I would agree that in the prevention of anaemia it is correct to give small doses of