Guidelines urgently needed regarding treatment of mothers in pregnancy, following reports on Savita Halappanavar case

Responding to today’s leaked extracts of the draft HSE inquiry into the Savita Halappanavar case, the Pro Life Campaign called for the “urgent introduction of Guidelines regarding treatment of mothers in pregnancy.”

Commenting on the leaked extracts of the report, Dr Berry Kiely of the Pro Life Campaign said: “Assuming the media reports are accurate and reliable, a picture is emerging of a tragic series of missed warning signs that should have alerted doctors to the fact that Ms Halappanavar was suffering from an infection posing a substantial risk to her life, a condition that was treatable, but necessitated urgent intervention.”

Dr Kiely said: “The story is made all the sadder in the light of the unanimous evidence from the obstetricians speaking at the recent Oireachtas Hearings that they always intervene to expedite the delivery of the baby where they see a risk to the life of the mother.  

“It is striking that the Royal College of Obstetricians and Gynaecologists in the UK issued a new set of Guidelines on sepsis in pregnancy last year, following a 2008 report showing sepsis was the single largest cause of death for women in pregnancy.

“Rather than proceeding with legislation for abortion, the Government should ensure that Guidelines are drawn up, for example, by the Irish Institute of Obstetricians and Gynaecologists, on the recognition and management of sepsis in pregnancy, which seems to have been the key issue in this sad case.

Dr Kiely said that “those pushing for abortion legislation based on the X case ruling are ignoring the crucial ethical distinction between necessary life saving interventions in pregnancy and induced abortion, where the sole purpose of the intervention is to end the life of the baby. The obstetricians who gave evidence at the recent Oireacthas Hearings made it clear that they always intervene to save the life of the mother but in doing so do not target the life of the baby. It is shameful the way some people, including some senior members of Government, are using the tragic death of Savita Halappanavar to open the door to an abortion regime in Ireland.”

Download our new briefing document by clicking here. This document is brand new, and gives an excellent overview of the current situation, and outlines why guidelines - not legislation - are the way forward. 

Enda, Keep Your Pro-Life Promise

by Dr. Joseph McCarroll
Chairman, Pro Life Campaign

The Unite for Life Vigil outside the Dáil in freezing, windy, rainy midwinter darkness on Tuesday evening had several political messages, messages so strong that the thousands who packed Molesworth Street and Kildare Street outside the Dáil left with hearts warmer than when they’d arrived, and sending a chill through the hearts of watching it from inside the Dáil.

The crowds packed Molesworth St. and flowed out onto Kildare St.

First, it was what it said on the can – a formal collaboration among all the pro-life groups – who at something under a week’s notice organised it. The political message of this is that the Government and the political parties have awakened a sense of urgency among the pro-life majority that has washed away past differences on tactics and brought to birth in their place a strong unity on strategy. 

The pro-life response to abortion plans is going to be more coherent and organised. The politicians pushing for abortion have awakened the sleeping giant of the pro-life community. The big problem that the politicians pushing abortion face just got bigger.

Second, when you consider the short space of time there was to get the word out, and for people who wanted to come to make the practical arrangements so they could come, the fact that the streets were crowded shows the passion, the seriousness of intent, the commitment that drove so many people to make sure they were there. That pro-life political commitment is now trained on each politician who votes to bring in abortion. Pro-life electors have elephantine memories. Politicians considering voting for abortion in the Oireachtas saw that their votes in there are going to cost them votes back home in the own constituency. The vote-cost of support for abortion in Leinster House just went up.

Third, like an icon made radiant by goldleaf, the vigil was rendered radiant by the extraordinary experiences shared by the two young mothers, Cliona and Liz, who spoke about their children. Cliona spoke about John Paul and how his short life had enriched the life of her family – he had anencephaly. And Liz spoke about the how her son John, born with no limbs, had enriched the life of her family. The warmth of these mothers speaking about their children and the love they brought into their lives was the heart of the Vigil. The only shadow was the willingness of some doctors to help them have their babies aborted.

The fourth message was the political message, as clear and sharp as a rapier - Enda Kenny, Keep your pro-life promise. The video shows it -  the banner with the words, “Enda Kenny Keep your pro-life promise”, while the crowd are chanting, “Enda Kenny, Keep your promise”, and the placards read, “Fine Gael, Keep your Promise”. The stuff of which democracy is made is the trust among the people that the politicians will keep the promises on the basis of which the people elected them. Enda Kenny, show us what stuff you are made of, keep your pro-life promise.

Ireland is safe, despite the propaganda

David Quinn, in the Irish Independent. On the Independent's site here. 

IN the debate about abortion we are constantly dealing with what can only be described as 'asymmetrical hysteria', that is we are only ever outraged by anti-abortion laws and their consequences and never by the consequences of pro-abortion laws.

The result of this 'asymmetrical hysteria' is that public opinion is constantly being pushed to favour more liberal abortion laws rather than more restrictive ones.

Indeed, we are conditioned to believe that laws against abortion are the result of irrational dogmas that are placing women's lives at risk.

Thus we now think that if only we were more like our more 'rational' next-door neighbour, Britain, Savita Halappanavar would be alive today.

In fact, it is impossible to know that, and certainly not before the completion of the investigation into her death.

In the meantime, what we do know is that the Irish maternal death rate is one of the very lowest in the world at roughly three women per 100,000. The British figure is four times higher at 12 per 100,000 and the US figure is eight times higher at 24 per 100,000.

How is it that Ireland without abortion is so much safer for pregnant women than Britain and America, which both have highly liberal abortion laws?

The above data has been obtained from 'Trends in Maternal Mortality: 1990 to 2008', which has been developed by the World Health Organisation, the UN and the World Bank.

However, thanks to the highly tendentious coverage of the tragic case of Mrs Halappanavar, particularly by RTE, most Irish people probably believe that Ireland is a particularly dangerous place for women to have a baby.

This notion, now commonplace and gaining worldwide traction, is actually a gross calumny against our country.

Our politicians ought to defend the medical record of this country and point out that our maternal healthcare system is superb at bringing babies to full term without compromising the lives or health of their mothers.

We would also do well to point out how the dogmas behind the abortion laws of other countries cost lives.

For example, in Britain, how many babies are unnecessarily aborted because a doctor erroneously imagines that the only way to save the mother is to abort the baby?

What kind of dogma makes some of us think that 190,000 abortions in England and Wales each year is 'normal', meaning that one pregnancy in every four ends in a termination?

What dogma leads abortion clinics to think 'gendercide' is okay, namely the killing of an unborn child simply because it is the 'wrong' sex, usually a girl?

The 'Daily Telegraph' discovered in a sting operation earlier this year that sex-selective abortions take place in UK abortion clinics.

What kind of dogma thinks it is okay to abort a child simply because the child has Down's Syndrome or cystic fibrosis?

In Ireland, a service is now on offer which allows couples to have their embryos screened to ensure they are in no way 'defective'. This is eugenics and it is common practice today.

None of the scandals just listed ever causes anything like the outrage generated by the hard cases an anti-abortion law will cause from time to time.

There are two reasons for this. The first is that they do not attract anything like the same publicity and so most of us are completely unaware of them.

The second reason is a dogmatic attachment to the ideology of 'choice', which causes many of us to simply turn a blind eye to the innumerable scandals caused by abortion laws.

We must not allow ourselves to be conditioned by ceaseless one-sided propaganda into thinking our law on abortion is inhumane and unjust.

The truth is that our law with respect both to mother and child is far more humane than in other Western countries, including Britain, and we should be very proud of that.

Rotunda head: No confusion

A report in the Irish Examiner. 

A senior consultant has said he sees no evidence of confusion in medical ranks in Ireland over whether or not a woman can have an abortion if her life is at risk.

Dr Sam Coulter-Smith, master of the Rotunda Hospital in Dublin and consultant in obstetrics and gynaecology, said it would be preferable to have legislation to bring clarity.

But he said that in his experience he has not seen confusion among doctors on whether a woman is entitled to an abortion on clinical grounds.

“No. Not in relation to where a mother’s health is at risk,” he said.

“I think most of us who work in obstetrics and gynaecology, there may be individual differences, but the majority would be of the view that if the health is such a risk that there is a risk of death and we are dealing with a foetus that is not viable, there is only one answer to that question, we bring the pregnancy to an end.”

Dr Coulter-Smith is also clinical professor of obstetrics and gynaecology at the Royal College of Surgeons in Dublin and has headed the Rotunda for the last three and a half years.

“It’s a complex area. There are a whole series of issues that need to be resolved,” he said.

Dr Coulter-Smith said he could not discuss Mrs Halappanavar’s death directly but that introducing laws would offer further clarity.

“This case probably does not have a lot to do with abortion laws,” he said.

“It is a clinical scenario – someone in the process of miscarriage and had infective complications as a result of that process, whether or not if the situation had been actively managed in the 24-36 hours proceeding the tragedy of the baby’s death, would that have changed anything? No-one can answer that.

“But from the medical point of view it would be nice to have clarity – what is and isn’t possible and feasible.

“What is reasonably clear is that in a position where senior clinicians feel a woman’s health and life is at risk then it is permissible in this country to end the pregnancy.

“There isn’t legislation but the issues that have been judged on have set a precedent. It would be nice if there was legislation.”

Ireland’s Medical Council regulations on abortion state that the procedure is illegal unless there is a real and substantial risk to the life (as distinct from the health) of the mother.

The Rotunda is one of the three main maternity hospitals in Dublin alongside Holles Street and the Coombe.

The Medical Council's Guide to Professional Conduct and Ethics for Registered Medical Practitioners, states:

“Under current legal precedent, this exception includes where there is a clear and substantial risk to the life of the mother arising from a threat of suicide. You should undertake a full assessment of any such risk in light of the clinical research on this issue.

“It is lawful to provide information in Ireland about abortions abroad, subject to strict conditions. It is not lawful to encourage or advocate an abortion in individual cases.

“You have a duty to provide care, support and follow-up services for women who have an abortion abroad.

“In current obstetrical practice, rare complications can arise where therapeutic intervention (including termination of a pregnancy) is required at a stage when, due to extreme immaturity of the baby, there may be little or no hope of the baby surviving. In these exceptional circumstances, it may be necessary to intervene to terminate the pregnancy to protect the life of the mother, while making every effort to preserve the life of the baby.”

Ireland's abortion laws: we need to get the facts straight

Dr. Tim Stanley writing in the Telegraph. Click here for the article on the Telegraph's site. 

This post is neither for nor against legalised abortion – it’s simply about laying out the facts of a very tragic story.

On October 21, Savita Halappanavar visited Galway University Hospital, Ireland. The 31-year-old dentist was 17 weeks pregnant and suffering terrible back pain. Savita was told that she was having a miscarriage, so she requested an abortion. The doctors denied her request because they said that they detected a foetal heartbeat and that Irish law ruled out a termination. Savita’s pain continued for three days and she eventually died of septicaemia.

Inevitably, this awful story has prompted demands for a rethink of Ireland’s abortion laws. That’s understandable and will almost certainly happen. Ireland has been liberalising for decades; Irishness and Catholic conservatism are no longer as synonymous as they once were. The European Court of Human Rights 2010 ruling on abortion gives Taoiseach Enda Kenny good legal grounds for a review of the law, and Kenny has branded himself as a critic of the privileged status of Catholicism in Ireland. Change will probably come.

But some would dispute whether or not Savita’s death is an appropriate catalyst for that change. In Ireland, it actually is legal to induce a birth when a mother’s life is at risk. Eilís Mulroy notes the following:

The decision to induce labour early would be fully in compliance with the law and the current guidelines set out for doctors by the Irish Medical Council. Those guidelines allow interventions to treat women where necessary, even if that treatment indirectly results in the death to the baby. If they aren't being followed, laws about abortion won't change that. The issue then becomes about medical protocols being followed in hospitals and not about the absence of legal abortion in Ireland.

Because Savita's case is under investigation, Mulroy asks questions but, wisely, avoids inferring answers: why, in this instance, did the hospital not induce (as it could and should) and is its decision not to induce reflective of a wider institutional failure?

It is possible that new legislation is necessary to clarify the existing medical consensus. But it does not logically follow that Ireland needs a total rethink of its entire approach to abortion that brings it in line with Europe’s essentially pro-choice culture. Aside from the specific medical case for abortion in Savita’s situation, inducing labour to save her life would not necessarily have conflicted with Catholic moral teaching, either. In 1951, Pope Pius XII explicitly ruled that such a procedure “can be lawful.” If it is true, as the Halappanavar family claims, that the Galway doctors said they would not provide a termination because "this is a Catholic country", then they got their theology unforgivably wrong.

Savita Halappanavar’s death demands investigation and answers. Aside from giving justice to her family, the implications of any investigation for the wider abortion debate are so wide-ranging that it is crucial that we get the facts unbiased and 100 per cent accurate. Alas, such objectivity is not always applied when it comes to media reporting of the Irish and/or Catholic approach to abortion. Indeed, much of it is misleading and unhelpful.

We won't let women die, says professor

Eilish O'Reagan, Health Correspondent of the Irish Independent. You can read the article on the Independent's website by clicking here. 

A LEADING obstetrician has said doctors do intervene to save the life of a pregnant woman, even if it means the loss of a baby.

Prof Fionnuala McAuliffe said obstetricians who were caring for pregnant women in life-threatening situations were working without specific legislation – but there was "no evidence they are letting people die".

She said obstetricians believed they had the freedom to intervene to save a woman's life, even if it meant the loss of the foetus.

Prof McAuliffe, who works in the National Maternity Hospital in Holles Street, Dublin, said from time to time doctors came across pregnant women who had uncontrollable blood pressure or severe pre-eclampsia, which can lead to severe complications.

"If uncontrollable blood pressure continues, the woman could have a stroke, a brain haemorrhage or die. The only effective way of (avoiding) that is to deliver the baby," she told theIrish Independent.

"If it happens after 24 weeks there is some chance the baby could live. If it is under 24 weeks it will not survive."

Prof McAuliffe, who is spokesperson for the Institute of Obstetricians and Gynaecologists, said obstetricians would welcome legislative clarity.

While the Medical Council's code of ethics states that doctors can intervene to terminate a pregnancy to protect the life of the mother, the institute has not provided any specific guidelines.

Most patients who come to a maternity hospital with threatened miscarriage would want to do everything they could to continue the pregnancy, Prof McAuliffe said.

She said: "the outcomes for pregnant women in Ireland are among the best in the world. We have excellent maternity services. There is no evidence that we are letting patients die to prolong the pregnancy."

Another leading obstetrician, who did not want to be named, said it was his view that doctors were legally protected if they intervened to save the life of a pregnant woman.

Referring to a report that pregnant Savita Halappanavar developed septicaemia, he said a woman could appear relatively well and collapse quickly.

"An infection can creep up on you very quickly without showing great signs. Infection is something that used to kill large numbers of women. It was the greatest cause of maternal mortality.

"It spreads from the vaginal tract up into the womb where the baby is and that is an ideal place for bugs to grow because it is warm and moist."

Rare

A case where a mother developed septicaemia was quite rare and even big maternity hospitals would only see maybe one every two years.

He added: "In my view it is very clear if the mother's life is at risk due to pregnancy continuing you have a choice to bring it to an end. It's very difficult to create guidelines for every individual scenario."

Asked how doctors would respond in the case of a woman who was miscarrying and was in pain, he said that she would be given pain relief.

Dr Peter Boylan, a former master of Holles Street, said doctors would welcome more guidance on when to save the life of a pregnant woman in grey areas where the threat was not dramatic.

Death as a result of infection during miscarriage rare

Dr. Muiris Houston, writing in the Irish Times. Article on the Times' website here. 

Background: A death as a result of an infection during a miscarriage is a rare event in the developed world. Referred to as a septic abortion or miscarriage, most cases are due to infection with bacteria such asE.coli or streptococci.

In a more severe form that spreads to the wall of the uterus, the patient will usually have a fever and a raised pulse.

The initial management of a suspected septic abortion involves taking a swab from the vagina and the neck of the womb. If the woman’s temperature goes above 38.4 degrees Celsius then blood is taken and sent to the laboratory to see if the bugs have spread to the bloodstream.

A combination of antibiotics is started even before the results of these tests are available. However, it is possible that despite the treatment the patient will go into medical shock, their blood pressure drops and a serious complication called disseminated intravascular coagulation (DIC) may ensue.

In this situation it is normal practice to wait until the patient has stabilised before surgically removing the contents of the uterus.

On rare occasions, a hysterectomy may be needed if the infection remains uncontrolled.

A miscarriage is defined as loss of pregnancy in first 24 weeks of gestation.

There are different types of miscarriage including:

* a threatened miscarriage with mild symptoms of bleeding and usually little or no pain. The neck of the womb remains closed;

* an incomplete miscarriage occurs if either the conception sac or the placenta remains in the womb;

* an inevitable miscarriage occurs with heavy bleeding, and the neck of the womb is now open. If the bleeding is severe the mother may slip into medical shock.

In an inevitable miscarriage, even though a foetal heart beat is present, the pregnancy cannot continue to term.

With the neck of the womb already open, the woman’s body prepares to naturally evacuate her womb.

However, with the neck of the womb open, there is an opportunity for bugs such as E.coli to travel from the vagina into the womb before multiplying and infecting the inside wall of the uterus.

Infection can then spread to the woman’s bloodstream, leading to shock and the onset of DIC, which occurs when the normal functioning of blood cells is progressively impaired, leading to multi-organ failure.