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The birth of perinatal medicine in the United Kingdom
Seminars in Fetal & Neonatal Medicine (2006) 11, 386e397
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / s i n y
REVIEW
The birth of perinatal medicine in the United Kingdom Peter M. Dunn* Emeritus Professor of Perinatal Medicine and Child Health, University of Bristol, Southmead Hospital, Bristol BS10 5NB, UK
KEYWORDS History UK; Perinatal medicine; Evolution of care 1928e1983
Summary Slow but steady progress in the medical care of mothers and their infants during the 16the19th centuries received a setback early in the 20th century following a shift of focus from the baby towards gynaecological surgery. The development of paediatrics after 1928 and the formation of a national health service in 1948 led to a renewed interest in the fetus and newborn infant. Special care baby units (SBCUs) were created in the 1960s. At this time, too, obstetric technology arrived in the delivery room and domiciliary birth largely gave way to hospital delivery. Neonatal intensive care arrived in the 1970s. However, a severe lack of resources retarded progress. Many medical reports in the 1970s drew attention to the deplorable situation. In 1980 a House of Commons working party called for the establishment of a sound perinatal service. In 1982 the Government recognized all newborn infants as NHS patients from the moment of birth rather than after their registration. That year too the Royal College of Obstetricians and Gynaecologists (RCOG) acknowledged the need for a subspecialty in maternal and fetal medicine. Meanwhile, a paediatric perinatal pressure group, arising in 1976, became a multidisciplinary association of perinatal medicine in 1981. By 1983 the new discipline of perinatal medicine had become firmly established. ª 2006 Elsevier Ltd. All rights reserved.
Introduction The term perinatal (peri-, Greek for ‘around’; natus, Latin for ‘birth’) was coined in the 1940s to define the period of fetal life when the fetus became potentially viable (28 completed weeks of gestation, later reduced to 24 weeks), together with the first week or month of postnatal life.
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During the next 20 years the term was used to measure mortality around the time of birth. Only in the late 1960s was it widely used to describe a new speciality. As both obstetricians and paediatricians became more involved, this new field of clinical study extended backwards to embrace the whole of fetal life, and even the pre-conception clinic, and onwards beyond the neonatal period both for the management of perinatal morbidity and to include infant development. If perinatal medicine finally became established in the UK in the early 1980s, then the period 1928e 1979 may be termed its period of gestation. However,
1744-165X/$ - see front matter ª 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.siny.2006.09.001
The birth of perinatal medicine in the UK medical interest in and care of the unborn and newborn infant in the UK of course reaches back to the 16th century. In tracing progress in the brief review, it is only possible to name a small fraction of those who have contributed to this advance. Information on some of those living prior to 1950 may be found elsewhere;1e5 since 1950 so many have contributed that it seems almost invidious to mention some individuals and not others (see acknowledgement). Also for reasons of brevity, little or no mention has been made of the many important developments abroad, especially in Sweden and America. Such advances had a profound impact on the development of perinatal medicine in the UK.
Early days For many centuries childbirth was the province of midwives and other female birth attendants. Most were illiterate, and few records of their activities have survived. Increasingly throughout the 16th, 17th and 18th centuries, midwives sought the help of male medical practitioners when they had a difficult birth, especially when labour was slow or obstrctued.6 The advent of the Chamberlen obstetric forceps in particular accelerated this process of consultation.7 Gradually the man-midwives, as they came to be called e men such as William Smellie (1697e1763)8 and William Hunter (1718e1783)9 e achieved professional recognition in the 18th and 19th centuries as physician-accoucheurs. Their interest in the mother widened to encompass pregnancy as well as the problems of the newborn infant and child. Michael Underwood (1737e1820),10 Henry Maunsell (1806e1876)11 and Charles West (1816e1898)12 wrote textbooks on the newborn infant and child as well as on the mother and her fetus, an early perinatal approach. This progress reached its peak in the work of John Ballantyne (1861e1923) (Fig. 1) of Edinburgh who not only introduced inpatient antenatal care into Britain early in the 20th century but also studied in depth the pathology and management of the embryo, fetus and newborn infant.13 Sadly,
Figure 1
John Ballantyne (1861e1923).
387 his vision of perinatal medicine was not to be fulfilled for another 50 years. Indeed, during the first half of the 20th century the standard of perinatal care fell abruptly. Little was written on the newborn, nor were advances made, and much that had been known was forgotten. The main explanation for this setback lay in the advent of surgical gynaecology. This was made possible through the introduction of antisepsis by Joseph Lister (1827e1912) and subsequently of asepsis. Coupled with anaesthesia, it became possible from the 1890s onwards to deliver a mother in obstructed labour by caesarean section without almost inevitably killing both her and her child. At the end of the 19th century some 50% of British children suffered from rickets in infancy. Indeed, it was known as the English disease and arose as a result of urbanization, poverty, and poor diet.14 A frequent outcome was the deformed flat pelvis which in girls gave rise to disproportion and obstructed labour, a commonplace occurrence. Up to that time the only hope in severe cases had been in destruction of the fetus and its removal per vaginam. The caesarean delivery must have come as a blessing. But physician-accoucheurs were not licensed to undertake operations. When the need arose they must call on the services of a surgeon. As a result, at the turn of the century there was a dramatic switch from obstetric-paediatirc medicine into obstetricgynaecologic surgery. Trainees now took the FRCS rather than the MRCP. By 1910 most academic departments of obstetrics in the UK were headed by gynaecologists. In addition to the caesarean section, other areas of gynaecological surgery were opening up. With this added workload, obstetricians no longer had the time or the training to devote to care of the newborn. As a result, the latter were often consigned to the charge of the midwives and nursery nurses. In 1916 John Ballantyne commented that newborn infants had fallen into ‘no-man’s land’ between the gynaecologists and adult physicians.6
1928e1959 To meet the vacuum caused by the decline of physicianaccoucheurs, some general physicians had begun to take an increased interest in sick children. By the 1920s freestanding children’s hospitals had been built in most of our larger cities. In 1928 the British Paediatric Association (BPA) was founded with Sir Frederic Still (1868e1941) as president.4 He was also the first full-time paediatrician in Britain. At its outset membership of the BPA was 56 mainly part-time physicians; this for a country containing some 12 million children. It is no surprise that, trained as they were in adult medicine, most of the energy of these pioneer paediatricians was devoted to the care of older infants and children. Meanwhile newborn infants remained largely isolated in the women’s hospitals of the gynaecologists, who, incidentally, in 1929 found their own college. But this situation was not to last much longer. By the 1930s paediatricians such as Charles McNeill in Edinbugh, Norman Capon in Liverpool, and Frances Braid in Birmingham were regularly visiting the maternity wards in an honorary capacity. In Birmingham, too, a small maternity home for the care of women with social problems had been opened in 1929. It was called Sorrento. Two years later, in
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Figure 2
Victoria Mary Crosse (1900e1972).
1931, a young member of the city’s Department of Public Health with obstetric experience, Victoria Mary Crosse (1900e1972) (Fig. 2), was appointed to the hospital to set up and run a unit for the care of premature babies born throughout the City. Fourteen years later, in 1945, she published her experience in a slim volume called Prematurity,15 the first British text on the preterm infant. Beryl Corner of Bristol16 and others took up the challenge. The professor of child health in Birmingham, Sir Leonard Parsons (1879e1950) wrote prophetically a year later: ‘‘The paediatricians of the future must be concerned with the wellbeing of the child from the moment of its conception and sometimes even before that event . When obstetricians, paediatricians and social workers combine together . the
Figure 3
Joseph Barcroft (1872e1947).
future will indeed the radiant with promise’’.17 It was appropriate too that at this time Sir Joseph Barcroft (Fig. 3) should publish his classic studies on the physiology of the fetus,18 extending the early work by William Harvey (1578e1657)19 and, more recently, that of A.St.G. Huggett. By the mid-1940s, when J.W.B. Douglas undertook his study of British births,20 approximately half of all newborn infants were nursed at home by their mothers, with help from the midwife and family doctor. The other half, born in hospital, were for the most part still consigned to the care of the nursery nurse with the support of junior obstetricians. As has been indicated, maternity hospitals remained the territory of the gynaecologists; while consultant paediatricians might be invited to visit, there were still to junior paediatric staff. Two events changed this: the first was the creation of a National Health Service in 1948 which, by removing financial constraints, dropped a barrier to interdisciplinary collaboration; at the same time the introduction of the umbilical exchange transfusion in the treatment of Rh haemolytic disease soon led to the appointment of junior paediatric staff to undertake this rather tedious and time-consuming work. Unfortunately in those early days, with grossly inadequate staff and little experience of newborn care, many mistakes were made. Enthusiastic use of oxygen led to retrolental fibroplasia. Then there was the grey syndrome due to chloramphicol poisoning, there was drug-induced kernicterus, and small babies were frequently starred for days with a view to preventing aspiration pneumonia, or were allowed to become hypothermic. Cecil Drillien of Edinburgh catalogued the sad outocome.6 Nor were all obstetricians happy at the incursion of paediatricians into ‘their’ territory. There was even a public appeal by a senior obstetrician in 1952 for his colleagues to ‘man the barricades and repel this paediatric invasion’! Part of the problem lay in the fact that as care of the baby passed inevitably from obstetrician to paediatrician, any criticism of management necessarily returned in the opposite direction. Great tact was required if relations were not to become strained. However, some gynaecologists were showing an increasing interest in pregnancy. Eardly Holland, president of the RCOG in the mid 1940s, urged his colleagues to devote more attention to the fetus and newborn infant. A number responded. Dugald Baird’s team (Fig. 4) in Aberdeen undertook wide-ranging studied on the clinical and social causes of perinatal morbidity and mortality, while Thomas McKeown and his colleagues made similar epidemiological studies in Birmingham. In 1953 Douglas Bevis, using aminocentesis, analysed the amniotic fluid surrounding the fetus, an important diagnostic resource. Ian Donald (Fig. 5) demonstrated the practicality of mechanically ventilating newborn infants, and pursued research into the use of ultrasound as a diagnostic tool.21 Arthur Williams, Alec Turnbull (Fig. 6) and others began to monitor uterine activity and also the fetal heart rate electronically. In 1958 William Nixon initiated the National Birth Trust perinatal mortality survey in the UK, the reports of which by Neville Butler, Denis Bonham22 and Eva Alberman23 were to have an important impact in the 1960s. Meanwhile, support for the concept of neonatal care made slow but steady progress throughout the 1950s, often
The birth of perinatal medicine in the UK
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Figure 4
Dugald Baird (1899e1986).
stimulated by advances being made abroad.24 Haematologists e including Robin Coombs, Patrick Mollison, William Walker and Geoffrey Tovey e improved our understanding of haemolytic disease of the newborn, while paediatric pathologists such as Agnes MacGregor, Edgar Morison, Albert Claireaux, John Emery, A.D. Bain and Norman Brown reflected knowledge gained at perinatal necropsy back to the cotside. William Craig of Leeds published his textbook on the care of the newly born infant in 1955.25 Bernard Laurance drew attention in 1955 to the dangers of high doses of vitamin K as a cause of neonatal jaundice. R.E. Pattle’s observations in 1957 on surface-active lung washings paved the way for the later introduction of surfactant, while in 1959 Richard Cremer observed the ability of daylight to reduce neonatal jaundice. In addition, a number of scientists e including Robert McCance, Elsie Widdowson, Geoffrey Dawes (Fig. 7) and Kenneth Cross e undertook brilliant research into the physiology of the fetus and newborn, and also contributed to the training of clinicians in this field. Already a number of paediatricians were showing an interest in newborn care, although neonatal staffing in maternity hospitals remained exceedingly poor. In particular Peter Tizard (Fig. 8) had begun to create a strong team at The Hammersmith in London. Other paediatricians included John Bound, John Davis, Mavis Gunther, Roderick Brown, Archie Norman, Douglas Gairdner, Gerald Neligan,
Tom Oppe ´ and Ben Wood, while north of the border the Scots could field, 5 among others, Ross Mitchell, James Farquhar, and John Forfar. The decade also saw neonatal surgery pioneered by Alexander MacLennon, Denis Browne, Isobella Forshall and Peter Rickham. Meanwhile, Ruth Griffiths, Ronald Illingworth and Mary Sheridan were studying infant development. In 1959 paediatricians, scientists, pathologists, a surgeon and a veterinarian joined forces to found the Neonatal Society with a view to fostering and reporting fetal and neonatal research. Strangely no obstetrician was included among the 37 invited founding members.
Personal recollections of the late 1950s After finishing National Service in 1957 I decided to train as a ‘perinatal paediatrician’. As I wrote at that time: ‘Only by studying the fetus will the paeditrician fully appreciate the problems of the newborn infant. Conversely, the obstetrician must study the newborn infant if he is to assess the results of his management of pregnancy and labour. Only when the obstetrician and paediatrician work together as a team (or are the same person) may a high standard of perinatal care be achieved.’ However, no perinatal specialty existed, and my approach to seek formal training in this field was rebuffed. So instead I decided to set my own training programme and as
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P.M. Dunn
Figure 5
Ian Donald (1910e1987).
a result spent most of the next 10 years in junior obstetric and paediatric posts in maternity hospitals. In the University maternity hospital in Birmingham in which I worked for 4 years there was no SCBU for the newborn. Only in 1960 was an incubator acquired. Infants with severe birth asphyxia were resuscitated using intragastric oxygen. Oxygen therapy was limited to 40%. Infections posed a major problem, especially those due to the ubiquitous staphylococcus and monilia. Penicillin and streptomycin were the antibiotics of choice. Exchange transfusions were a daily occurrence. All laboratory blood specimens had to be taken by venepuncture. There was no ‘rooming in’ for the babies with their mothers. The total neonatal staff consisted of one registrar (myself) who also had to cover a second maternity hospital 4 miles away.26
The 1960s This decade saw a surge in obstetric interest in the fetus. New insights were gained into biochemical and immunological changes in pregnancy and into pregnancy hypertension, placental function and fetal growth. Frank Hytten published his text, Physiology of Human Pregnancy27 and Geoffrey Dawes his on Fetal and Neonatal Physiology (1968).28
John Peel and his team improved the management of the diabetic pregnancy. In 1967 Alice Stewart demonstrated the risks to the fetus of ionizing radiation which as a result curtailed the use of obstetric radiography. Meanwhile a new generation of young obstetricians e including, among others, Alec Turnbull, Anne Anderson, Melville Kerr, Malcolm Macnaughton, Jack Dewhurst, James Walker, Peter Huntingford, Geoffrey Chamberlain and Richard Beard e began actively investigating and intervening in late pregnancy and labour.29 Diagnostic aminocentesis, sonar cephalometry and auscultation, electronic monitoring of uterine activity and of the fetal heart-rate, fetal scalp sampling, acid-base and blood gas studies on cord blood, increased induction of labour and augmentation of labour, were all introduced in the second half of the decade, along with epidural anesthesia (J. Selwyn Crawford and M. Rosen). On the untested assumption that these techniques should be available to all women, the Government accepted the recommendation of an obstetric working party (1968)30 under the chairmanship of Sir John Peel that domiciliary midwifery should in the main give way to obstetric delivery in hospital. On the paediatric side, there was slow but steady progress at this time with the establishment of SCBUs in major maternity hospitals.31 The importance of
The birth of perinatal medicine in the UK
Figure 6
391
Alec Turnbull (1925e1990).
temperature control and early feeding came to be better appreciated. Recognition of the significance of hypoglycaemia and polycythaemia led to monitoring of the blood glucose and to the use of dilution exchange transfusion. Technology arrived in the nursery with the Usher regimen from Canada and the need to monitor acid-base status and blood gases, and to infuse fluids intravenously. Bag and mask ventilation, endotracheal intubation and mechanical ventilation gradually became available. Leonard Strang undertook his studies on the physiology of the perinatal lung.32 The management of the infant of the diabetic mother and of neonatal hypocalcaemic convulsions improved. Anti-staphylococcal agents such as hexachlorophane largely banished that troublesome organism from
Figure 8
Peter Tizard (1916e1993).
the nursery, while nystain proved to be a useful weapon against monilial infection. Newborn infants came to be better examined at birth and screened for conditions such as congenital dislocation of the hip and for metabolic diseases such as phenylketonuria. Screening for hypothyroidism, retinopathy of prematurity and deafness followed. Among other advances in the neonatal service at that time were the provision of chromosomal analysis and genetic advice (John Edwards and Paul Polani), improved pathology and postmortem examination and the regular audit of perinatal outcome. Michael Dawkins and David Hull rediscovered brown fat. Aminocentesic assessment of the severity of Rh haemolytic disease led to the introduction of the intrauterine transfusion. Later in the 1960s the work of Ronald Finn and Cyril Clarke largely prevented this disorder using anti-D prophylaxis. Conditions such as phocomelia and rubella embryopathy were disappearing, their place, alas, being taken by ‘new’ diseases such as necrotizing enterocolitis and gastroschiisis. Many pediatricians contributed to the advances being made, among whom were Pamela Davies, Jon Scopes, Colin Normand, Osmund Reynolds, John Dobbing, Herbert Barrie, Alec Campbell and Forrester Cockburn, to name but a few.
Personal recollections of the 1960s
Figure 7
Geoffrey Dawes (1918e1996).
In 1963 I was firmly advised by senior colleagues to leave the ‘backwater’ of perinatal medicine and return to mainstream paeditrics. However, I remained convinced as to the importance of this neglected branch of medicine. So instead, in the absence of senior registrar posts in the field, I stepped sideways into clinical perinatal research. Five years later in 1968 I had the good fortune to be appointed the first consultant in neonatal/perinatal medicine.
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P.M. Dunn
Ironically, this title, the one I sought, was designated less to announce the inception of a new discipline than to indicate that my training with older children was insufficient to justify the usual title of consultant paediatrician. The maternity hospital to which I was appointed in Bristol catered for 6000 deliveries a year from a very large catchment area. There was a fine SCBU of 32 cots, but the technical equipment was limited to one primitive ventilator and a heart-rate monitor. The junior paediatric staffing consisted of half a registrar and two housemen. The annual budget for new equipment was £500 a year. The perinatal mortality for the previous year had been 46/1000 births. Clearly there was an urgent need for intensive care, but first much groundwork was needed in respect to organization, staffing, training and fund raising.26
The 1970s The second congress of the European Association of Perinatal Medicine was held in London in 1970 under the presidency of Peter Huntingford.33 The same year Roma Chamberlain and her colleagues undertook yet another survey of British births.34 When published in 1975 their report again revealed a high perinatal mortality (24/1000 births). In respect to neonatal mortality if could be shown that more than half the deaths in the whole of childhood were taking place within 3 days of birth. Meanwhile more and more women were being delivered in our now very overcrowded maternity hospitals. By the end of the decade home births had fallen to 1%.35 At the same time the interventionalist technology developed in the 1960s had taken over much of the obstetric management of childbirth. In particular, the widespread use of surgically induced and augmented labour together with epidural anaesthesia had led to a rising need for the use of Keillands forceps and for caesarean delivery. Protests were heard from the lay public as well as from radical midwives and others.36e38 An analysis of the impact that obstetric technology had had on perinatal outcome by Iain Chalmers and his team in 197339 also helped to make obstetricians pause and reflect on their approach. Another obstetric technique introduced at this time was the attempt to prevent premature labour using tocolytic drugs, while at the same time inducing fetal lung maturity with corticosteroids. A senior obstetrician even claimed that once obstetricians had succeeded in preventing preterm delivery there would be no need for neonatal paediatricians. In fact the tide was flowing against this view; for as the ultrasound assessment of gestational age became more reliable, as improved methods of detecting fetal distress were developed, and as neonatal care improved, obstetricians were able to electively deliver ‘at risk’ babies ever more prematurely. The incidence of preterm delivery was also increased by a rise in multiple pregnancies in association with the new managements of subfertility. From 1975 onwards the Royal College of Obstetricians and Gynaecologists organized a number of multidisciplinary conferences and scientific meetings on aspects of perinatal care. The reports that resulted under the editorship of Richard Beard and others did much to focus obstetric attention on the importance of perinatal medicine. At this time too Beard (Fig. 9) and Nathanielsz published their
Figure 9
Richard Beard (1931).
text on fetal physiology.40 Furthermore, in 1978 the Government, at the suggestion of the RCOG and BPA, set up a National Perinatal Epidemiology Unit (NPEU) under the direction of Iain Chalmers to conduct research into the effective use of resources in the perinatal health services. One of the first actions taken by this new body was to initiate with clinicians confidential enquiry into the causes of perinatal mortality. In addition the NPEU collaborated in multicentre and multidisciplinary perinatal research. Returning to the newborn, neonatal intensive care slowly developed in the main maternity hospitals during the 1970s. Although progress was hampered by shortage of staff and resources, there was considerable support from the public and from charities such as BLISS. Great technical advances were taking place, with the electronic monitoring of the infant’s vital signs and oxygen status, using first the intra-arterial oxygen electrode and then the transcutaneous oxygen monitor. Other apparatus that had become available included infusion pumps, apnoea alarms, light therapy units, improved ventilators, methods for the delivery of continuous positive airways pressure (CPAP) and the equipment for providing parenteral nutrition. Micromethods for determining biochemical investigation, pioneered by Wilfred Payne, at last obviated the need for venepuncture. All these advances permitted for the first time the successful management of infants under 1 kg, previously regarded as pre-viable. No group did more to further the care of these extremely-low-birth-weight infants than that of Osmund Reynolds (Fig. 10) at University College, London. Ann Stewart undertook their developmental follow-up, while Jonathan Wigglesworth’s postmortem studies at The Hammersmith threw light on the cerebral morbidity to which these tiny infants were prone.24 Many other new approaches to perinatal care were introduced in the 1970s. One was an appreciation of the importance of involving the whole family in the exciting
The birth of perinatal medicine in the UK
Figure 10
Osmund Reynolds (1933).
events around childbirth, however ill the baby the might be, and also of involving the mother in her own infant’s care. There was an increasing awareness of the importance of the social and emotional problems within a family and the need to support and counsel parents, especially when there was bereavement. Once again there was a growing recognition of the importance of breastfeeding and human milk. At the same time there was an increasing interest in the ethics of decision making, particularly in regard to the withholding or withdrawing of medical care from babies with severe malformations or brain damage, as well as those of extreme prematurity. The problem then centred especially around infants with severe spina bifida. Enthusiastic efforts to treat these infants surgically in the 1960s had been disappointing. Mercifully the work of Richard Smithells and his team on the prevention of neural tube defects using folic acid eventually resolved this problem to a major extent. Mention should also be made of the introduction of ultrasound into obstetric practice by Ian Donald and his younger colleague Stuart Campbell. With amniocentesis, this technique opened up the field of prenatal diagnosis and enabled the more accurate assessment of fetal gestational age. By the end of the decade Osmund Reynolds and his team had also utilized this new form of imaging to examine the newborn infant’s brain, an invaluable method of assessing prognosis and managing care. With clinical advances in newborn care in the 1970s came those in administration and organization, including a classification of perinatal conditions,41 new clinical records, protocols for management, improved developmental surveillance and more efficient methods of transporting sick infants. More and more there was collaboration between obstetricians, paediatricians and others in prenatal and perinatal decision-making and also in discussing outcome at regular conferences on perinatal mortality and morbidity. However, while these improvements were taking place in the major centres, progress throughout much of
393 the country was slow, as the national statistics for perinatal mortality revealed.42 One problem was that neonatal care was still not recognized administratively by the NHS. The mother entered hospital as a single obstetric patient, and the fact that she went home with a baby under her arm was often overlooked. There were budgets for the obstetricians and also for paediatricians based in children’s hospitals but little for the newborn infant in between, unless admitted for special or intensive care. Ninety per cent of newborn infants remained in Ballantyne’s ‘no-man’s land’.24 In 1972 Donald Court, chairman of the BPA Academic Board, and Tony Jackson had prepared a booklet, Paediatrics in the Seventies,43 which for the first time recognized perinatal paediatrics as a subspecialty. Although stating that newborn care would remain the responsibility of general paediatricians, they recommended that a total of ten perinatal paediatricians were needed in various major centres throughout the country to supervise neonatal intensive care; this for a country with 700,000 births a year, some 70,000 newborn infants of whom might be estimated to require special or intensive care. The previous year, 1971, a government working party under the chairmanship of Sir Wilfred Sheldon44 had argued for the regionalization of at two-tier system of neonatal care and had recommended that there should be five special-care and one intensivecare cot for each 1000 births a year, with a total of eight nurses to look after their occupants. However, this totally inadequate nursing establishment was not available at that time, nor indeed for many years to come. In 1974 an editorial in the Lancet45 on the neglect of perinatal care aroused attention. Shortly afterwards working parties in England and Wales46 and in Scotland47 reported on the poor standard of perinatal care and its deficiencies, while the Child Health Services Committee chaired by Donald Court once more drew attention to the high perinatal mortality and the urgent need to improve the service.48 In 1976 a small band of consultant paediatricians involved in the provision of neonatal intensive care formed a perinatal pressure group (Fig. 11), with the aim of improving the standard and provision of newborn care.49 Over the next few years regional and national surveys were undertaken on medical and nurse staffing and on the facilities available; all highlighted the serious deficiencies that existed.50,51 Meanwhile in 1978 the BPA/RCOG Liaison Committee prepared a comprehensive series of recommendations for the improvement of infant care during the perinatal period.52 This was submitted by the BPA and RCOG to the House of Commons Social Services Committee which, under the chairmanship of Mrs Rene ´e Short, had begun a 2-year investigation (1978e80) of the perinatal services in England and Wales.53 Richard Beard, Eva Alberman and Osmund Reynolds acted as expert advisors to the Committee.
Personal recollections of the 1970s In 1970 the neonatal staff at Southmead Hospital, Bristol, took over from the junior obstetric staff responsibility for the care of all babies in the lying-in wards. That year too saw the establishment of our first neonatal intensive care cot; other cots were gradually introduced, so that by the
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Figure 11 Founding members of the British Association of Perinatal Medicine, Bristol, 1976. Left to right, standing: George Russell, Roger Harris, Niall O’Brien, David Davies, Colin Walker, David Harvey, Brian Wharton, Forrester Cockburn, Cliff Roberton, John Maclaurin, Richard Orme, Mark Reid, David Baum, Garth McClure. Sitting: Pamela Davies, Osmund Reynolds, Peter Dunn (Hon. Sec.), Margaret Kerr, Brian Speidel. In absentia: Gerald Cussen, Harold Gamsu, Gillian Gandy, Edmund Hey, Tony Milner and Jonathan Shaw.
end of the decade there were 12, or one per 1000 births in Bristol. As half our intensive care was provided for outborn infants from the region, this numbers was still seriously insufficient. It was made more so by our ability from 1976 onwards to manage babies <1 kg birth weight, previously considered previable. The successful impact of intensive care was dramatic, with a 74% fall in preventable neonatal mortality within the first 3 years. However, the provision of this intensive care service imposed an almost intolerable workload at a time when staffing was seriously inadequate. In addition, the new techniques had to be taught to junior staff as well as to midwives, nurses and students. There was also a vital need to ‘beat the drum’ on numerous committees e local, regional and national e in order to gain recognition for our new specialty. When in 1976 I helped to bring together some 20 paediatricians to form a pressure group to improve the quality of newborn care, I was censored by a senior obstetrician for using the term ‘perinatal’ to describe our new Association. That word, he told me, belonged to obstetrics! At this time too I attempted, without success, to interest the RCOG in creating a specialty of perinatal obstetrics. In spite of this we perinatal paediatricians received much-needed support from our obstetric colleagues throughout this difficult period.26
The early 1980s If the 1970s was the late period of gestation for the establishment of perinatal medicine, then its birth may
be assigned to the early 1980s. The House of Commons Social Services Committee produced a five-volume report on perinatal care in the K in 1980.53 It catalogued the inadequacies of perinatal care, and made strong recommendations on the action to be taken, including the need for the early appointment of 50 neonatal consultants. The Government response was disappointing.54 However, the message eventually percolated through to regional and area health authorities. In 1982 an NHS Health Services Information Committee under the chairmanship of Mrs E. Ko ¨rner recommended the identification of every newborn infant as an NHS patient with his or her own individual identify and clinical record from birth.55 At last all newborn infants had achieved recognition, and with it over the years that followed came the need for a neonatal budget to improve staffing and facilities. The perinatal paediatric group that had been founded in 1976 evolved in 1981 into a multidisciplinary body with the title British Association of Perinatal Medicine (Fig. 12).49 Obstetricians were included on both its Executive Committee and Council. There was also representatives of midwifery, neonatal nursing, obstetric anaesthesia, paediatric surgery, NHS administration and the lay public. A training programme, approved by the BPA and Royal Colleges in 1982,56 was devised for those seeking a career in perinatal paediatrics. Paediatricians were strongly encouraged to gain experience in obstetrics and vice versa. Further national and regional surveys were undertaken on medical and nurse staffing and on the facilities for care at ‘normal’, special and intensive levels.57,58
The birth of perinatal medicine in the UK
Figure 12
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Officers and Council of the British Association of Perinatal Medicine, Cambridge meeting, 1981.
Meanwhile, in 1982 the RCOG set up a working party under the chairmanship of Malcolm Macnaughton to review antenatal and intrapartum care. It made many important recommendations.59 A second RCOG working party set up the same year under the chairmanship of Charles Whitfield recommended at last that maternal and fetal medicine should be identified as a subspecialty of obstetrics and gynaecology.60 This was accepted by the College. In March of 1982 a National Birthday Trust International Perinatal Symposium was held in Bristol61 with many distinguished participants from around the world. Perinatal medicine had at last become established in the UK.
Personal recollections of the early 1980s This was a period of intense activity, with numerous working parties, surveys and meetings. Perinatal medicine was a crossroads that involved many disciplines. At this time I found myself a member of more than 40 national, regional and local committees. Finance remained a major problem. Indeed in 1980 my one academic lecturer post was ‘frozen’ for 3 years. However, as we showed following a perinatal survey of our region, much could be achieved within budget by reorganization and improved practice. Between 1980 and 1983 the perinatal mortality in the South West fell from 13 to 9. Similar falls were taking place around the country as perinatal medicine gathered momentum. Ironically, the Government issued a press release in 1983 actually claiming credit for this improved outcome.
In our own University department, which accepted many problems cases, the perinatal mortality for infants (birth weight >1 kg) without lethal malformation had fallen to three per 1000 births. In 1981 we had our first 24-week gestational age (640 g) survivor; 25 years later she is now just completing her final year at University. In 1983 David Baum, later to become president of the newly founded RCPCH, gave his opinion that perinatal/neonatal medicine had become the most rapidly growing and effective specialty. To cap these developments, in 1983 the RCOG honoured Osmund Reynolds and the writer by making them fellows ad_eundem of their College. On behalf of our colleagues we were most happy at this formal recognition of the partnership that had been forged between maternofetal and neonatal medicine.
Acknowledgement It was only possible in the text and captions to mention a few of the British clinicians, pathologists, scientists and others who contributed to the birth of perinatal medicine in the UK. More are listed below. Even this list is far from complete, and also omits the very important contribution made by many midwives and neonatal nurses without whose help little could have been achieved. Albert Aynesley-Green, Tony Barson, Harry Baumer, John Beazley, Jeffery Bissenden, John Black, Ken Boddy, Robert Boyd, Oliver Brooke, Fiona Broughton-Pipkin, R.K. Brown,
396 Michael Brudenall, Elizabeth Bryan, Andrew Calder, Jean Chapple, Time Chard, Richard Cooke, Kate Costeloe, David Curnock, Peter Dear, Robert Dinwiddie, Lily and Victor Dubowitz, Sheila Duncan, Geoffrey Durbin, John Edwards, Mostyn Embrey, Denys Fairweather, Jean Fedrick, Peter Fleming, Ann Flynn, Stewart Forsyth, Harold Fox, Robert Frazer, Paul Galea, George Godber, Adrian Grant, Ann Greenough, Marion Hall, Michael Hall, Henry Halliday, Brian Hibbard, June Hill, Barbara Holland, Peter Hope, Peter Howie, John Jenkins, Ann Johnson, Paul Johnson, Jean Keeling, John Kelly, Ilya Kovar, Malcolm Levene, Tom Lind, Tom Lissauer, David Lloyd, Iain McFadyen, Gillian McIlwaine, Neil McIntosh, Ian McGillvary, Aiden Macfarlane, Trevor Mann, Michael Maresh, David Milligan, R.E. Moore, W.M.O. Moore, Colin Morley, Jean Mott, L.E. Mount, Ann Oakley, Richard Oliver, Michael Parkin, Naren Patel, Richard Pearse, James Pearson, Peter Pharoah, R.G. Record Chris Redmond, Mark Reid, Janet Rennie, Martin Richards, Knox Ritchie, Rodney Rivers, Michael Robinson, Charles Rodeck, Peter Rolfe, Ian Rushton, Nicholas Rutter, James Scott, Heather Shelley, Roger Short, Marion Silver, Douglas Sims, R.G. Spector, John Spencer, Phil Steer, Gordon Stirrat, Malcolm Symonds, Majorie Tew, Angus Thomson, Geoffrey Thorburn, Tom Tuner, Paul Vinall, Judith Weaver, Andrew Whitelaw, Matthew White, Martin Whittle, Andrew Wilkinson, Maureen young.
References 1. Spencer HR. The history of British midwifery from 1650 to 1800. London: John Bale; 1927. 2. Still GF. The history of paediatrics. Oxford University: Press; 1931. 3. Kerr JMM, Johnstone RW, Phillips MH. Historical review of British obstetrics and gynaecology, 1800e1950. Edinburgh: E & S Livingstone; 1954. 4. Cameron HC. The British Paediatric Association, 1928e1952. London: BPA; 1955. 5. Dunn PM. Perinatal lessons from the past. Arch Disc Child 1998 onwards. 6. Dunn PM. Perinatal medicine in the United Kingdom e past, present and future. Proceedings of the Inaugrual Congress, Excerpta Medica, Asia Pacific Congress Series. J Aust Perinat Soc 1983; 18: 4e22. 7. Dunn PM. The Chamberlen family (1560e1728) and obstetric forceps. Arch Dis Child Fetal Neonatal Ed 1999;81:F232e5. 8. Smellie W., Treatise on the theory and practice of midwifery. Vols. I, II & III. 1752e61. London: New Sydenham Society, 1876e78. 9. Hunter W. An anatomical description of the human gravid uterus and its contents. In: Baillie M, editor. London: Johnson; 1794. 10. Underwood M. A treatise on the disease of children; with directions for the management of infants from birth. London: J Mathews; 1784. 11. Evanson RT, Maunsell H. A practical treatise on the management and disease of children. 2nd ed. Dublin: Fannin and Co.; 1838. 12. West C. Lectures on the disease of infancy and childhood. 5th Ed. London: Longman, Green, Longman, Roberts and Green; 1865. 13. Ballantyne JW. Antenatal pathology and hygiene: the embryo and the foetus. Vols. I & II, Edinburgh: William Green and Sons; 1902 and 1904. 14. Hutchison R. Rickets. In: Lectures on disease in children. London: Edward Arnold; 1904. p. 107e21.
P.M. Dunn 15. Crosse VM. The premature baby. London: Churchill Livingstone; 1945. p. 1e167. 16. Corner B. Prematurity. London: Cassell; 1960. 17. Parsons LG. Antenatal paediatrics. First Charles West Lecture. J Obstet Gynaecol 1946;53:1e16. 18. Barcroft Sir J. Research on prenatal life. Part I. Oxford: Balckwell Scientific Publications; 1947. 19. Harvey W. The works of William Harvey. Translated from the Latin by R Willis. London: The Sydenham Society; 1847. p. 1e624. 20. Douglas JWB. Maternity care in Great Britain. Oxford University Press; 1948. 21. Donald I. Practical obstetric problems. London: Lloyd-Luke Ltd.; 1955. 22. Butler NR, Bouham DG. Perinatal mortality. First Report of the 1958 British Perinatal Mortality Survey. Edinburgh: Livingstone; 1963. 23. Butler NR, Alberman ED, editors. Perinatal problems. 2nd report of the 1958 British perinatal mortality survey. Edinburgh: E & S Livingstone; 1969. 24. Dunn PM. The development of newborn care in the UK since 1930. American Academy of Pediatrics, Thomas E. Cone Jr. Lecture on Perinatal History. J Perinat 1998;18:471e6. 25. Craig WS. Care of the newly born infant. Edinburgh: E & S Livingstone; 1955. 26. Dunn PM. Perinatal perceptions. The Victor Neal Memorial Lecture. Aesculapius: Univ. of Birmingham Medical Graduates Journal; 1994. p. 28e33. 27. Hytten FE, Leitch I. The physiology of human pregnancy. Oxford: Blackwell Scientific Publ.; 1964. 28. Dawes GS. Foetal and neonatal physiology. Chicago: Year Book Medical Publ.; 1968. 29. Cristie DA, Tansey EM, editors. Maternal care. Wellcome witnesses to twentieth century medicine. London: The Wellcome Trust; 2001. 30. Peel Sir J, chairman. Domiciliary midwifery and maternity bed needs. Department of Health and Social Security. London: HMSO; 1970. 31. Cristie DA, Tansey EM, editors. Origins of neonatal intensive care in the UK. Wellcome witnesses to twentieth century medicine, Vol. 9. London: The Wellcome Trust; 2001. 32. Strang LB. Neonatal respiration. Physiological and clinical studies. Oxford: Blackwell Scientific Publ.; 1977. 33. Perinatal medicine, 2nd Europ. Congr. Perinatal Medicine, London. In: Huntingford PJ, Beard RW, Hytten FE, Scopes JW, editors. April 1970. Basel: S Karger; 1971. 34. Chamberlain R, Chamberlain G, Howlett B, Claireaux A. British births, Vols. I & II. London: Heinemann Medical; 1975. 35. Kitzinger S, Davis JA, editors. The place of birth. Oxford Medical Publ; 1978. 36. Dunn PM. Obstetric delivery today: for better or for worse? Lancet 1976;1:790e4. 37. Tew M. Effect of scientific obstetrics on perinatal mortality. Health Soc Serv J 1981;91:444e6. 38. Chard T, Richards M, editors. Benefits and hazards of the new obstetrics. London: W Heinemann Med. Bks; 1977. 39. Chalmers I, Zlosnik JE, Johns KA, Campbell H. Obstetric practice and outcome of pregnancy in Cardiff residents. Brit Med J 1976;1:735e8. 40. Beard RW, Nathanielsz PW, editors. Fetal physiology in medicine: the basis of perinatology. Philadelphia: WB Saunders; 1976. 41. Walker CHM, chairman. British Paediatric Association Classification of Diseases: codes designed for use in the classification of paediatric and perinatal disorders, Vols. I & II. London: BPA; 1979. 42. Dunn PM. Perinatal statistics. In: House of Commons Social Services Committee Session 1979e1980. Second report: perinatal and neonatal mortality, Vol. 2. London: HMSO; 1980. p. 256e67.
The birth of perinatal medicine in the UK 43. Court D, Jackson A, editors. Paediatrics in the seventies. Developing the child health services. Oxford University Press; 1972. p. 45. 44. Sheldon Sir W, chairman. Report of the expert group on special care for babies. Rep. Publ. Hlth. Med. Subj. No. 127, London: HMSO; 1971. 45. Editorial. The price of perinatal neglect. Lancet 1974;1:437. 46. Oppe ´ TE, chairman. Prevention of early neonatal mortality, and morbidity (report of a working party). London: HMSO; 1975. 47. Walker J, chairman. National medical consultative committee, report of the joint working party on standards of perinatal care in Scotland. Edinburgh: Scottish Home and Health Office; 1980. p. 1e76. 48. Court SDM, chairman. Fit for the future. Report of the committee on child health services. London: HMSO; 1976 [Cmmd 6684, vol. I & II]. 49. Dunn PM. The British Association of perinatal medicine: the first 25 years (1976e2000). Arch Dis Child 2003;88:181e4. 50. Dunn PM. Newborn care in England 1978. In: . House of Commons Social Services Committee Session 1979e1980. Second report: perinatal and neonatal mortality, Vol. V. London: HMSO; 1980. p. 65e73. 51. Dunn PM. Memorandum on paediatric staffing for newborn care in the United Kingdom, 1980. In: . House of Commons Social Services Committee Session 1979e1980. Second report: perinatal and neonatal mortality, Vol. V. London: HMSO; 1980. p. 52e7.
397 52. Dunn PM, chairman. Recommendations for the improvement of infant care during the perinatal period in the United Kingdom. British Paediatric Association/Royal College of Obsetricians and Gynaecologists Liaison Committee consultative document. London: BPA/RCOG; 1978. 53. Short R, chairman. House of Commons Social Services Committee Session, 1979e80. Second report: perinatal and neonatal mortality. London: HMSO; 1980. 54. Reply to Second Report from the Social Services Committee on perinatal and neonatal mortality, Cmnd 8084. London: HMSO; 1980. 55. Ko ¨rner E, chairman. National Health Service and Department of Health and Social Services Steering Group on Health Services Information. London: HMSO; 1982. 56. Joint Committee of the Royal College of Physicians of Higher Medical Training, Guidelines on training for perinatal paediatrics. London: Royal College of Physicians; 1982. p. 44e5. 57. Yu VYH, Dunn PM. Development of regionalized perinatal care. Semin Neonatol 2004;9:89e97. 58. British Paediatric Association. Minimum standards of neonatal care. Arch Dis Child 1983;58:943e4. 59. Macnaughton MC, chairman. RCOG working party report on antenatal and intrapartum care. London: RCOG; 1982. 60. Whitfield CR, chairman. Report on further specialisation with obstetrics and gynaecology. London: Royal College of Obstetricians and Gynaecology; 1982. 61. National Birthday Trust International Symposium on Perinatal Care, Bristol, UK, 24e27 March 1982.
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / s i n y
REVIEW
The birth of perinatal medicine in the United Kingdom Peter M. Dunn* Emeritus Professor of Perinatal Medicine and Child Health, University of Bristol, Southmead Hospital, Bristol BS10 5NB, UK
KEYWORDS History UK; Perinatal medicine; Evolution of care 1928e1983
Summary Slow but steady progress in the medical care of mothers and their infants during the 16the19th centuries received a setback early in the 20th century following a shift of focus from the baby towards gynaecological surgery. The development of paediatrics after 1928 and the formation of a national health service in 1948 led to a renewed interest in the fetus and newborn infant. Special care baby units (SBCUs) were created in the 1960s. At this time, too, obstetric technology arrived in the delivery room and domiciliary birth largely gave way to hospital delivery. Neonatal intensive care arrived in the 1970s. However, a severe lack of resources retarded progress. Many medical reports in the 1970s drew attention to the deplorable situation. In 1980 a House of Commons working party called for the establishment of a sound perinatal service. In 1982 the Government recognized all newborn infants as NHS patients from the moment of birth rather than after their registration. That year too the Royal College of Obstetricians and Gynaecologists (RCOG) acknowledged the need for a subspecialty in maternal and fetal medicine. Meanwhile, a paediatric perinatal pressure group, arising in 1976, became a multidisciplinary association of perinatal medicine in 1981. By 1983 the new discipline of perinatal medicine had become firmly established. ª 2006 Elsevier Ltd. All rights reserved.
Introduction The term perinatal (peri-, Greek for ‘around’; natus, Latin for ‘birth’) was coined in the 1940s to define the period of fetal life when the fetus became potentially viable (28 completed weeks of gestation, later reduced to 24 weeks), together with the first week or month of postnatal life.
* Tel.: þ44 117 950 5050. E-mail address: [email protected]
During the next 20 years the term was used to measure mortality around the time of birth. Only in the late 1960s was it widely used to describe a new speciality. As both obstetricians and paediatricians became more involved, this new field of clinical study extended backwards to embrace the whole of fetal life, and even the pre-conception clinic, and onwards beyond the neonatal period both for the management of perinatal morbidity and to include infant development. If perinatal medicine finally became established in the UK in the early 1980s, then the period 1928e 1979 may be termed its period of gestation. However,
1744-165X/$ - see front matter ª 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.siny.2006.09.001
The birth of perinatal medicine in the UK medical interest in and care of the unborn and newborn infant in the UK of course reaches back to the 16th century. In tracing progress in the brief review, it is only possible to name a small fraction of those who have contributed to this advance. Information on some of those living prior to 1950 may be found elsewhere;1e5 since 1950 so many have contributed that it seems almost invidious to mention some individuals and not others (see acknowledgement). Also for reasons of brevity, little or no mention has been made of the many important developments abroad, especially in Sweden and America. Such advances had a profound impact on the development of perinatal medicine in the UK.
Early days For many centuries childbirth was the province of midwives and other female birth attendants. Most were illiterate, and few records of their activities have survived. Increasingly throughout the 16th, 17th and 18th centuries, midwives sought the help of male medical practitioners when they had a difficult birth, especially when labour was slow or obstrctued.6 The advent of the Chamberlen obstetric forceps in particular accelerated this process of consultation.7 Gradually the man-midwives, as they came to be called e men such as William Smellie (1697e1763)8 and William Hunter (1718e1783)9 e achieved professional recognition in the 18th and 19th centuries as physician-accoucheurs. Their interest in the mother widened to encompass pregnancy as well as the problems of the newborn infant and child. Michael Underwood (1737e1820),10 Henry Maunsell (1806e1876)11 and Charles West (1816e1898)12 wrote textbooks on the newborn infant and child as well as on the mother and her fetus, an early perinatal approach. This progress reached its peak in the work of John Ballantyne (1861e1923) (Fig. 1) of Edinburgh who not only introduced inpatient antenatal care into Britain early in the 20th century but also studied in depth the pathology and management of the embryo, fetus and newborn infant.13 Sadly,
Figure 1
John Ballantyne (1861e1923).
387 his vision of perinatal medicine was not to be fulfilled for another 50 years. Indeed, during the first half of the 20th century the standard of perinatal care fell abruptly. Little was written on the newborn, nor were advances made, and much that had been known was forgotten. The main explanation for this setback lay in the advent of surgical gynaecology. This was made possible through the introduction of antisepsis by Joseph Lister (1827e1912) and subsequently of asepsis. Coupled with anaesthesia, it became possible from the 1890s onwards to deliver a mother in obstructed labour by caesarean section without almost inevitably killing both her and her child. At the end of the 19th century some 50% of British children suffered from rickets in infancy. Indeed, it was known as the English disease and arose as a result of urbanization, poverty, and poor diet.14 A frequent outcome was the deformed flat pelvis which in girls gave rise to disproportion and obstructed labour, a commonplace occurrence. Up to that time the only hope in severe cases had been in destruction of the fetus and its removal per vaginam. The caesarean delivery must have come as a blessing. But physician-accoucheurs were not licensed to undertake operations. When the need arose they must call on the services of a surgeon. As a result, at the turn of the century there was a dramatic switch from obstetric-paediatirc medicine into obstetricgynaecologic surgery. Trainees now took the FRCS rather than the MRCP. By 1910 most academic departments of obstetrics in the UK were headed by gynaecologists. In addition to the caesarean section, other areas of gynaecological surgery were opening up. With this added workload, obstetricians no longer had the time or the training to devote to care of the newborn. As a result, the latter were often consigned to the charge of the midwives and nursery nurses. In 1916 John Ballantyne commented that newborn infants had fallen into ‘no-man’s land’ between the gynaecologists and adult physicians.6
1928e1959 To meet the vacuum caused by the decline of physicianaccoucheurs, some general physicians had begun to take an increased interest in sick children. By the 1920s freestanding children’s hospitals had been built in most of our larger cities. In 1928 the British Paediatric Association (BPA) was founded with Sir Frederic Still (1868e1941) as president.4 He was also the first full-time paediatrician in Britain. At its outset membership of the BPA was 56 mainly part-time physicians; this for a country containing some 12 million children. It is no surprise that, trained as they were in adult medicine, most of the energy of these pioneer paediatricians was devoted to the care of older infants and children. Meanwhile newborn infants remained largely isolated in the women’s hospitals of the gynaecologists, who, incidentally, in 1929 found their own college. But this situation was not to last much longer. By the 1930s paediatricians such as Charles McNeill in Edinbugh, Norman Capon in Liverpool, and Frances Braid in Birmingham were regularly visiting the maternity wards in an honorary capacity. In Birmingham, too, a small maternity home for the care of women with social problems had been opened in 1929. It was called Sorrento. Two years later, in
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Figure 2
Victoria Mary Crosse (1900e1972).
1931, a young member of the city’s Department of Public Health with obstetric experience, Victoria Mary Crosse (1900e1972) (Fig. 2), was appointed to the hospital to set up and run a unit for the care of premature babies born throughout the City. Fourteen years later, in 1945, she published her experience in a slim volume called Prematurity,15 the first British text on the preterm infant. Beryl Corner of Bristol16 and others took up the challenge. The professor of child health in Birmingham, Sir Leonard Parsons (1879e1950) wrote prophetically a year later: ‘‘The paediatricians of the future must be concerned with the wellbeing of the child from the moment of its conception and sometimes even before that event . When obstetricians, paediatricians and social workers combine together . the
Figure 3
Joseph Barcroft (1872e1947).
future will indeed the radiant with promise’’.17 It was appropriate too that at this time Sir Joseph Barcroft (Fig. 3) should publish his classic studies on the physiology of the fetus,18 extending the early work by William Harvey (1578e1657)19 and, more recently, that of A.St.G. Huggett. By the mid-1940s, when J.W.B. Douglas undertook his study of British births,20 approximately half of all newborn infants were nursed at home by their mothers, with help from the midwife and family doctor. The other half, born in hospital, were for the most part still consigned to the care of the nursery nurse with the support of junior obstetricians. As has been indicated, maternity hospitals remained the territory of the gynaecologists; while consultant paediatricians might be invited to visit, there were still to junior paediatric staff. Two events changed this: the first was the creation of a National Health Service in 1948 which, by removing financial constraints, dropped a barrier to interdisciplinary collaboration; at the same time the introduction of the umbilical exchange transfusion in the treatment of Rh haemolytic disease soon led to the appointment of junior paediatric staff to undertake this rather tedious and time-consuming work. Unfortunately in those early days, with grossly inadequate staff and little experience of newborn care, many mistakes were made. Enthusiastic use of oxygen led to retrolental fibroplasia. Then there was the grey syndrome due to chloramphicol poisoning, there was drug-induced kernicterus, and small babies were frequently starred for days with a view to preventing aspiration pneumonia, or were allowed to become hypothermic. Cecil Drillien of Edinburgh catalogued the sad outocome.6 Nor were all obstetricians happy at the incursion of paediatricians into ‘their’ territory. There was even a public appeal by a senior obstetrician in 1952 for his colleagues to ‘man the barricades and repel this paediatric invasion’! Part of the problem lay in the fact that as care of the baby passed inevitably from obstetrician to paediatrician, any criticism of management necessarily returned in the opposite direction. Great tact was required if relations were not to become strained. However, some gynaecologists were showing an increasing interest in pregnancy. Eardly Holland, president of the RCOG in the mid 1940s, urged his colleagues to devote more attention to the fetus and newborn infant. A number responded. Dugald Baird’s team (Fig. 4) in Aberdeen undertook wide-ranging studied on the clinical and social causes of perinatal morbidity and mortality, while Thomas McKeown and his colleagues made similar epidemiological studies in Birmingham. In 1953 Douglas Bevis, using aminocentesis, analysed the amniotic fluid surrounding the fetus, an important diagnostic resource. Ian Donald (Fig. 5) demonstrated the practicality of mechanically ventilating newborn infants, and pursued research into the use of ultrasound as a diagnostic tool.21 Arthur Williams, Alec Turnbull (Fig. 6) and others began to monitor uterine activity and also the fetal heart rate electronically. In 1958 William Nixon initiated the National Birth Trust perinatal mortality survey in the UK, the reports of which by Neville Butler, Denis Bonham22 and Eva Alberman23 were to have an important impact in the 1960s. Meanwhile, support for the concept of neonatal care made slow but steady progress throughout the 1950s, often
The birth of perinatal medicine in the UK
389
Figure 4
Dugald Baird (1899e1986).
stimulated by advances being made abroad.24 Haematologists e including Robin Coombs, Patrick Mollison, William Walker and Geoffrey Tovey e improved our understanding of haemolytic disease of the newborn, while paediatric pathologists such as Agnes MacGregor, Edgar Morison, Albert Claireaux, John Emery, A.D. Bain and Norman Brown reflected knowledge gained at perinatal necropsy back to the cotside. William Craig of Leeds published his textbook on the care of the newly born infant in 1955.25 Bernard Laurance drew attention in 1955 to the dangers of high doses of vitamin K as a cause of neonatal jaundice. R.E. Pattle’s observations in 1957 on surface-active lung washings paved the way for the later introduction of surfactant, while in 1959 Richard Cremer observed the ability of daylight to reduce neonatal jaundice. In addition, a number of scientists e including Robert McCance, Elsie Widdowson, Geoffrey Dawes (Fig. 7) and Kenneth Cross e undertook brilliant research into the physiology of the fetus and newborn, and also contributed to the training of clinicians in this field. Already a number of paediatricians were showing an interest in newborn care, although neonatal staffing in maternity hospitals remained exceedingly poor. In particular Peter Tizard (Fig. 8) had begun to create a strong team at The Hammersmith in London. Other paediatricians included John Bound, John Davis, Mavis Gunther, Roderick Brown, Archie Norman, Douglas Gairdner, Gerald Neligan,
Tom Oppe ´ and Ben Wood, while north of the border the Scots could field, 5 among others, Ross Mitchell, James Farquhar, and John Forfar. The decade also saw neonatal surgery pioneered by Alexander MacLennon, Denis Browne, Isobella Forshall and Peter Rickham. Meanwhile, Ruth Griffiths, Ronald Illingworth and Mary Sheridan were studying infant development. In 1959 paediatricians, scientists, pathologists, a surgeon and a veterinarian joined forces to found the Neonatal Society with a view to fostering and reporting fetal and neonatal research. Strangely no obstetrician was included among the 37 invited founding members.
Personal recollections of the late 1950s After finishing National Service in 1957 I decided to train as a ‘perinatal paediatrician’. As I wrote at that time: ‘Only by studying the fetus will the paeditrician fully appreciate the problems of the newborn infant. Conversely, the obstetrician must study the newborn infant if he is to assess the results of his management of pregnancy and labour. Only when the obstetrician and paediatrician work together as a team (or are the same person) may a high standard of perinatal care be achieved.’ However, no perinatal specialty existed, and my approach to seek formal training in this field was rebuffed. So instead I decided to set my own training programme and as
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Figure 5
Ian Donald (1910e1987).
a result spent most of the next 10 years in junior obstetric and paediatric posts in maternity hospitals. In the University maternity hospital in Birmingham in which I worked for 4 years there was no SCBU for the newborn. Only in 1960 was an incubator acquired. Infants with severe birth asphyxia were resuscitated using intragastric oxygen. Oxygen therapy was limited to 40%. Infections posed a major problem, especially those due to the ubiquitous staphylococcus and monilia. Penicillin and streptomycin were the antibiotics of choice. Exchange transfusions were a daily occurrence. All laboratory blood specimens had to be taken by venepuncture. There was no ‘rooming in’ for the babies with their mothers. The total neonatal staff consisted of one registrar (myself) who also had to cover a second maternity hospital 4 miles away.26
The 1960s This decade saw a surge in obstetric interest in the fetus. New insights were gained into biochemical and immunological changes in pregnancy and into pregnancy hypertension, placental function and fetal growth. Frank Hytten published his text, Physiology of Human Pregnancy27 and Geoffrey Dawes his on Fetal and Neonatal Physiology (1968).28
John Peel and his team improved the management of the diabetic pregnancy. In 1967 Alice Stewart demonstrated the risks to the fetus of ionizing radiation which as a result curtailed the use of obstetric radiography. Meanwhile a new generation of young obstetricians e including, among others, Alec Turnbull, Anne Anderson, Melville Kerr, Malcolm Macnaughton, Jack Dewhurst, James Walker, Peter Huntingford, Geoffrey Chamberlain and Richard Beard e began actively investigating and intervening in late pregnancy and labour.29 Diagnostic aminocentesis, sonar cephalometry and auscultation, electronic monitoring of uterine activity and of the fetal heart-rate, fetal scalp sampling, acid-base and blood gas studies on cord blood, increased induction of labour and augmentation of labour, were all introduced in the second half of the decade, along with epidural anesthesia (J. Selwyn Crawford and M. Rosen). On the untested assumption that these techniques should be available to all women, the Government accepted the recommendation of an obstetric working party (1968)30 under the chairmanship of Sir John Peel that domiciliary midwifery should in the main give way to obstetric delivery in hospital. On the paediatric side, there was slow but steady progress at this time with the establishment of SCBUs in major maternity hospitals.31 The importance of
The birth of perinatal medicine in the UK
Figure 6
391
Alec Turnbull (1925e1990).
temperature control and early feeding came to be better appreciated. Recognition of the significance of hypoglycaemia and polycythaemia led to monitoring of the blood glucose and to the use of dilution exchange transfusion. Technology arrived in the nursery with the Usher regimen from Canada and the need to monitor acid-base status and blood gases, and to infuse fluids intravenously. Bag and mask ventilation, endotracheal intubation and mechanical ventilation gradually became available. Leonard Strang undertook his studies on the physiology of the perinatal lung.32 The management of the infant of the diabetic mother and of neonatal hypocalcaemic convulsions improved. Anti-staphylococcal agents such as hexachlorophane largely banished that troublesome organism from
Figure 8
Peter Tizard (1916e1993).
the nursery, while nystain proved to be a useful weapon against monilial infection. Newborn infants came to be better examined at birth and screened for conditions such as congenital dislocation of the hip and for metabolic diseases such as phenylketonuria. Screening for hypothyroidism, retinopathy of prematurity and deafness followed. Among other advances in the neonatal service at that time were the provision of chromosomal analysis and genetic advice (John Edwards and Paul Polani), improved pathology and postmortem examination and the regular audit of perinatal outcome. Michael Dawkins and David Hull rediscovered brown fat. Aminocentesic assessment of the severity of Rh haemolytic disease led to the introduction of the intrauterine transfusion. Later in the 1960s the work of Ronald Finn and Cyril Clarke largely prevented this disorder using anti-D prophylaxis. Conditions such as phocomelia and rubella embryopathy were disappearing, their place, alas, being taken by ‘new’ diseases such as necrotizing enterocolitis and gastroschiisis. Many pediatricians contributed to the advances being made, among whom were Pamela Davies, Jon Scopes, Colin Normand, Osmund Reynolds, John Dobbing, Herbert Barrie, Alec Campbell and Forrester Cockburn, to name but a few.
Personal recollections of the 1960s
Figure 7
Geoffrey Dawes (1918e1996).
In 1963 I was firmly advised by senior colleagues to leave the ‘backwater’ of perinatal medicine and return to mainstream paeditrics. However, I remained convinced as to the importance of this neglected branch of medicine. So instead, in the absence of senior registrar posts in the field, I stepped sideways into clinical perinatal research. Five years later in 1968 I had the good fortune to be appointed the first consultant in neonatal/perinatal medicine.
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Ironically, this title, the one I sought, was designated less to announce the inception of a new discipline than to indicate that my training with older children was insufficient to justify the usual title of consultant paediatrician. The maternity hospital to which I was appointed in Bristol catered for 6000 deliveries a year from a very large catchment area. There was a fine SCBU of 32 cots, but the technical equipment was limited to one primitive ventilator and a heart-rate monitor. The junior paediatric staffing consisted of half a registrar and two housemen. The annual budget for new equipment was £500 a year. The perinatal mortality for the previous year had been 46/1000 births. Clearly there was an urgent need for intensive care, but first much groundwork was needed in respect to organization, staffing, training and fund raising.26
The 1970s The second congress of the European Association of Perinatal Medicine was held in London in 1970 under the presidency of Peter Huntingford.33 The same year Roma Chamberlain and her colleagues undertook yet another survey of British births.34 When published in 1975 their report again revealed a high perinatal mortality (24/1000 births). In respect to neonatal mortality if could be shown that more than half the deaths in the whole of childhood were taking place within 3 days of birth. Meanwhile more and more women were being delivered in our now very overcrowded maternity hospitals. By the end of the decade home births had fallen to 1%.35 At the same time the interventionalist technology developed in the 1960s had taken over much of the obstetric management of childbirth. In particular, the widespread use of surgically induced and augmented labour together with epidural anaesthesia had led to a rising need for the use of Keillands forceps and for caesarean delivery. Protests were heard from the lay public as well as from radical midwives and others.36e38 An analysis of the impact that obstetric technology had had on perinatal outcome by Iain Chalmers and his team in 197339 also helped to make obstetricians pause and reflect on their approach. Another obstetric technique introduced at this time was the attempt to prevent premature labour using tocolytic drugs, while at the same time inducing fetal lung maturity with corticosteroids. A senior obstetrician even claimed that once obstetricians had succeeded in preventing preterm delivery there would be no need for neonatal paediatricians. In fact the tide was flowing against this view; for as the ultrasound assessment of gestational age became more reliable, as improved methods of detecting fetal distress were developed, and as neonatal care improved, obstetricians were able to electively deliver ‘at risk’ babies ever more prematurely. The incidence of preterm delivery was also increased by a rise in multiple pregnancies in association with the new managements of subfertility. From 1975 onwards the Royal College of Obstetricians and Gynaecologists organized a number of multidisciplinary conferences and scientific meetings on aspects of perinatal care. The reports that resulted under the editorship of Richard Beard and others did much to focus obstetric attention on the importance of perinatal medicine. At this time too Beard (Fig. 9) and Nathanielsz published their
Figure 9
Richard Beard (1931).
text on fetal physiology.40 Furthermore, in 1978 the Government, at the suggestion of the RCOG and BPA, set up a National Perinatal Epidemiology Unit (NPEU) under the direction of Iain Chalmers to conduct research into the effective use of resources in the perinatal health services. One of the first actions taken by this new body was to initiate with clinicians confidential enquiry into the causes of perinatal mortality. In addition the NPEU collaborated in multicentre and multidisciplinary perinatal research. Returning to the newborn, neonatal intensive care slowly developed in the main maternity hospitals during the 1970s. Although progress was hampered by shortage of staff and resources, there was considerable support from the public and from charities such as BLISS. Great technical advances were taking place, with the electronic monitoring of the infant’s vital signs and oxygen status, using first the intra-arterial oxygen electrode and then the transcutaneous oxygen monitor. Other apparatus that had become available included infusion pumps, apnoea alarms, light therapy units, improved ventilators, methods for the delivery of continuous positive airways pressure (CPAP) and the equipment for providing parenteral nutrition. Micromethods for determining biochemical investigation, pioneered by Wilfred Payne, at last obviated the need for venepuncture. All these advances permitted for the first time the successful management of infants under 1 kg, previously regarded as pre-viable. No group did more to further the care of these extremely-low-birth-weight infants than that of Osmund Reynolds (Fig. 10) at University College, London. Ann Stewart undertook their developmental follow-up, while Jonathan Wigglesworth’s postmortem studies at The Hammersmith threw light on the cerebral morbidity to which these tiny infants were prone.24 Many other new approaches to perinatal care were introduced in the 1970s. One was an appreciation of the importance of involving the whole family in the exciting
The birth of perinatal medicine in the UK
Figure 10
Osmund Reynolds (1933).
events around childbirth, however ill the baby the might be, and also of involving the mother in her own infant’s care. There was an increasing awareness of the importance of the social and emotional problems within a family and the need to support and counsel parents, especially when there was bereavement. Once again there was a growing recognition of the importance of breastfeeding and human milk. At the same time there was an increasing interest in the ethics of decision making, particularly in regard to the withholding or withdrawing of medical care from babies with severe malformations or brain damage, as well as those of extreme prematurity. The problem then centred especially around infants with severe spina bifida. Enthusiastic efforts to treat these infants surgically in the 1960s had been disappointing. Mercifully the work of Richard Smithells and his team on the prevention of neural tube defects using folic acid eventually resolved this problem to a major extent. Mention should also be made of the introduction of ultrasound into obstetric practice by Ian Donald and his younger colleague Stuart Campbell. With amniocentesis, this technique opened up the field of prenatal diagnosis and enabled the more accurate assessment of fetal gestational age. By the end of the decade Osmund Reynolds and his team had also utilized this new form of imaging to examine the newborn infant’s brain, an invaluable method of assessing prognosis and managing care. With clinical advances in newborn care in the 1970s came those in administration and organization, including a classification of perinatal conditions,41 new clinical records, protocols for management, improved developmental surveillance and more efficient methods of transporting sick infants. More and more there was collaboration between obstetricians, paediatricians and others in prenatal and perinatal decision-making and also in discussing outcome at regular conferences on perinatal mortality and morbidity. However, while these improvements were taking place in the major centres, progress throughout much of
393 the country was slow, as the national statistics for perinatal mortality revealed.42 One problem was that neonatal care was still not recognized administratively by the NHS. The mother entered hospital as a single obstetric patient, and the fact that she went home with a baby under her arm was often overlooked. There were budgets for the obstetricians and also for paediatricians based in children’s hospitals but little for the newborn infant in between, unless admitted for special or intensive care. Ninety per cent of newborn infants remained in Ballantyne’s ‘no-man’s land’.24 In 1972 Donald Court, chairman of the BPA Academic Board, and Tony Jackson had prepared a booklet, Paediatrics in the Seventies,43 which for the first time recognized perinatal paediatrics as a subspecialty. Although stating that newborn care would remain the responsibility of general paediatricians, they recommended that a total of ten perinatal paediatricians were needed in various major centres throughout the country to supervise neonatal intensive care; this for a country with 700,000 births a year, some 70,000 newborn infants of whom might be estimated to require special or intensive care. The previous year, 1971, a government working party under the chairmanship of Sir Wilfred Sheldon44 had argued for the regionalization of at two-tier system of neonatal care and had recommended that there should be five special-care and one intensivecare cot for each 1000 births a year, with a total of eight nurses to look after their occupants. However, this totally inadequate nursing establishment was not available at that time, nor indeed for many years to come. In 1974 an editorial in the Lancet45 on the neglect of perinatal care aroused attention. Shortly afterwards working parties in England and Wales46 and in Scotland47 reported on the poor standard of perinatal care and its deficiencies, while the Child Health Services Committee chaired by Donald Court once more drew attention to the high perinatal mortality and the urgent need to improve the service.48 In 1976 a small band of consultant paediatricians involved in the provision of neonatal intensive care formed a perinatal pressure group (Fig. 11), with the aim of improving the standard and provision of newborn care.49 Over the next few years regional and national surveys were undertaken on medical and nurse staffing and on the facilities available; all highlighted the serious deficiencies that existed.50,51 Meanwhile in 1978 the BPA/RCOG Liaison Committee prepared a comprehensive series of recommendations for the improvement of infant care during the perinatal period.52 This was submitted by the BPA and RCOG to the House of Commons Social Services Committee which, under the chairmanship of Mrs Rene ´e Short, had begun a 2-year investigation (1978e80) of the perinatal services in England and Wales.53 Richard Beard, Eva Alberman and Osmund Reynolds acted as expert advisors to the Committee.
Personal recollections of the 1970s In 1970 the neonatal staff at Southmead Hospital, Bristol, took over from the junior obstetric staff responsibility for the care of all babies in the lying-in wards. That year too saw the establishment of our first neonatal intensive care cot; other cots were gradually introduced, so that by the
394
P.M. Dunn
Figure 11 Founding members of the British Association of Perinatal Medicine, Bristol, 1976. Left to right, standing: George Russell, Roger Harris, Niall O’Brien, David Davies, Colin Walker, David Harvey, Brian Wharton, Forrester Cockburn, Cliff Roberton, John Maclaurin, Richard Orme, Mark Reid, David Baum, Garth McClure. Sitting: Pamela Davies, Osmund Reynolds, Peter Dunn (Hon. Sec.), Margaret Kerr, Brian Speidel. In absentia: Gerald Cussen, Harold Gamsu, Gillian Gandy, Edmund Hey, Tony Milner and Jonathan Shaw.
end of the decade there were 12, or one per 1000 births in Bristol. As half our intensive care was provided for outborn infants from the region, this numbers was still seriously insufficient. It was made more so by our ability from 1976 onwards to manage babies <1 kg birth weight, previously considered previable. The successful impact of intensive care was dramatic, with a 74% fall in preventable neonatal mortality within the first 3 years. However, the provision of this intensive care service imposed an almost intolerable workload at a time when staffing was seriously inadequate. In addition, the new techniques had to be taught to junior staff as well as to midwives, nurses and students. There was also a vital need to ‘beat the drum’ on numerous committees e local, regional and national e in order to gain recognition for our new specialty. When in 1976 I helped to bring together some 20 paediatricians to form a pressure group to improve the quality of newborn care, I was censored by a senior obstetrician for using the term ‘perinatal’ to describe our new Association. That word, he told me, belonged to obstetrics! At this time too I attempted, without success, to interest the RCOG in creating a specialty of perinatal obstetrics. In spite of this we perinatal paediatricians received much-needed support from our obstetric colleagues throughout this difficult period.26
The early 1980s If the 1970s was the late period of gestation for the establishment of perinatal medicine, then its birth may
be assigned to the early 1980s. The House of Commons Social Services Committee produced a five-volume report on perinatal care in the K in 1980.53 It catalogued the inadequacies of perinatal care, and made strong recommendations on the action to be taken, including the need for the early appointment of 50 neonatal consultants. The Government response was disappointing.54 However, the message eventually percolated through to regional and area health authorities. In 1982 an NHS Health Services Information Committee under the chairmanship of Mrs E. Ko ¨rner recommended the identification of every newborn infant as an NHS patient with his or her own individual identify and clinical record from birth.55 At last all newborn infants had achieved recognition, and with it over the years that followed came the need for a neonatal budget to improve staffing and facilities. The perinatal paediatric group that had been founded in 1976 evolved in 1981 into a multidisciplinary body with the title British Association of Perinatal Medicine (Fig. 12).49 Obstetricians were included on both its Executive Committee and Council. There was also representatives of midwifery, neonatal nursing, obstetric anaesthesia, paediatric surgery, NHS administration and the lay public. A training programme, approved by the BPA and Royal Colleges in 1982,56 was devised for those seeking a career in perinatal paediatrics. Paediatricians were strongly encouraged to gain experience in obstetrics and vice versa. Further national and regional surveys were undertaken on medical and nurse staffing and on the facilities for care at ‘normal’, special and intensive levels.57,58
The birth of perinatal medicine in the UK
Figure 12
395
Officers and Council of the British Association of Perinatal Medicine, Cambridge meeting, 1981.
Meanwhile, in 1982 the RCOG set up a working party under the chairmanship of Malcolm Macnaughton to review antenatal and intrapartum care. It made many important recommendations.59 A second RCOG working party set up the same year under the chairmanship of Charles Whitfield recommended at last that maternal and fetal medicine should be identified as a subspecialty of obstetrics and gynaecology.60 This was accepted by the College. In March of 1982 a National Birthday Trust International Perinatal Symposium was held in Bristol61 with many distinguished participants from around the world. Perinatal medicine had at last become established in the UK.
Personal recollections of the early 1980s This was a period of intense activity, with numerous working parties, surveys and meetings. Perinatal medicine was a crossroads that involved many disciplines. At this time I found myself a member of more than 40 national, regional and local committees. Finance remained a major problem. Indeed in 1980 my one academic lecturer post was ‘frozen’ for 3 years. However, as we showed following a perinatal survey of our region, much could be achieved within budget by reorganization and improved practice. Between 1980 and 1983 the perinatal mortality in the South West fell from 13 to 9. Similar falls were taking place around the country as perinatal medicine gathered momentum. Ironically, the Government issued a press release in 1983 actually claiming credit for this improved outcome.
In our own University department, which accepted many problems cases, the perinatal mortality for infants (birth weight >1 kg) without lethal malformation had fallen to three per 1000 births. In 1981 we had our first 24-week gestational age (640 g) survivor; 25 years later she is now just completing her final year at University. In 1983 David Baum, later to become president of the newly founded RCPCH, gave his opinion that perinatal/neonatal medicine had become the most rapidly growing and effective specialty. To cap these developments, in 1983 the RCOG honoured Osmund Reynolds and the writer by making them fellows ad_eundem of their College. On behalf of our colleagues we were most happy at this formal recognition of the partnership that had been forged between maternofetal and neonatal medicine.
Acknowledgement It was only possible in the text and captions to mention a few of the British clinicians, pathologists, scientists and others who contributed to the birth of perinatal medicine in the UK. More are listed below. Even this list is far from complete, and also omits the very important contribution made by many midwives and neonatal nurses without whose help little could have been achieved. Albert Aynesley-Green, Tony Barson, Harry Baumer, John Beazley, Jeffery Bissenden, John Black, Ken Boddy, Robert Boyd, Oliver Brooke, Fiona Broughton-Pipkin, R.K. Brown,
396 Michael Brudenall, Elizabeth Bryan, Andrew Calder, Jean Chapple, Time Chard, Richard Cooke, Kate Costeloe, David Curnock, Peter Dear, Robert Dinwiddie, Lily and Victor Dubowitz, Sheila Duncan, Geoffrey Durbin, John Edwards, Mostyn Embrey, Denys Fairweather, Jean Fedrick, Peter Fleming, Ann Flynn, Stewart Forsyth, Harold Fox, Robert Frazer, Paul Galea, George Godber, Adrian Grant, Ann Greenough, Marion Hall, Michael Hall, Henry Halliday, Brian Hibbard, June Hill, Barbara Holland, Peter Hope, Peter Howie, John Jenkins, Ann Johnson, Paul Johnson, Jean Keeling, John Kelly, Ilya Kovar, Malcolm Levene, Tom Lind, Tom Lissauer, David Lloyd, Iain McFadyen, Gillian McIlwaine, Neil McIntosh, Ian McGillvary, Aiden Macfarlane, Trevor Mann, Michael Maresh, David Milligan, R.E. Moore, W.M.O. Moore, Colin Morley, Jean Mott, L.E. Mount, Ann Oakley, Richard Oliver, Michael Parkin, Naren Patel, Richard Pearse, James Pearson, Peter Pharoah, R.G. Record Chris Redmond, Mark Reid, Janet Rennie, Martin Richards, Knox Ritchie, Rodney Rivers, Michael Robinson, Charles Rodeck, Peter Rolfe, Ian Rushton, Nicholas Rutter, James Scott, Heather Shelley, Roger Short, Marion Silver, Douglas Sims, R.G. Spector, John Spencer, Phil Steer, Gordon Stirrat, Malcolm Symonds, Majorie Tew, Angus Thomson, Geoffrey Thorburn, Tom Tuner, Paul Vinall, Judith Weaver, Andrew Whitelaw, Matthew White, Martin Whittle, Andrew Wilkinson, Maureen young.
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The birth of perinatal medicine in the UK 43. Court D, Jackson A, editors. Paediatrics in the seventies. Developing the child health services. Oxford University Press; 1972. p. 45. 44. Sheldon Sir W, chairman. Report of the expert group on special care for babies. Rep. Publ. Hlth. Med. Subj. No. 127, London: HMSO; 1971. 45. Editorial. The price of perinatal neglect. Lancet 1974;1:437. 46. Oppe ´ TE, chairman. Prevention of early neonatal mortality, and morbidity (report of a working party). London: HMSO; 1975. 47. Walker J, chairman. National medical consultative committee, report of the joint working party on standards of perinatal care in Scotland. Edinburgh: Scottish Home and Health Office; 1980. p. 1e76. 48. Court SDM, chairman. Fit for the future. Report of the committee on child health services. London: HMSO; 1976 [Cmmd 6684, vol. I & II]. 49. Dunn PM. The British Association of perinatal medicine: the first 25 years (1976e2000). Arch Dis Child 2003;88:181e4. 50. Dunn PM. Newborn care in England 1978. In: . House of Commons Social Services Committee Session 1979e1980. Second report: perinatal and neonatal mortality, Vol. V. London: HMSO; 1980. p. 65e73. 51. Dunn PM. Memorandum on paediatric staffing for newborn care in the United Kingdom, 1980. In: . House of Commons Social Services Committee Session 1979e1980. Second report: perinatal and neonatal mortality, Vol. V. London: HMSO; 1980. p. 52e7.
397 52. Dunn PM, chairman. Recommendations for the improvement of infant care during the perinatal period in the United Kingdom. British Paediatric Association/Royal College of Obsetricians and Gynaecologists Liaison Committee consultative document. London: BPA/RCOG; 1978. 53. Short R, chairman. House of Commons Social Services Committee Session, 1979e80. Second report: perinatal and neonatal mortality. London: HMSO; 1980. 54. Reply to Second Report from the Social Services Committee on perinatal and neonatal mortality, Cmnd 8084. London: HMSO; 1980. 55. Ko ¨rner E, chairman. National Health Service and Department of Health and Social Services Steering Group on Health Services Information. London: HMSO; 1982. 56. Joint Committee of the Royal College of Physicians of Higher Medical Training, Guidelines on training for perinatal paediatrics. London: Royal College of Physicians; 1982. p. 44e5. 57. Yu VYH, Dunn PM. Development of regionalized perinatal care. Semin Neonatol 2004;9:89e97. 58. British Paediatric Association. Minimum standards of neonatal care. Arch Dis Child 1983;58:943e4. 59. Macnaughton MC, chairman. RCOG working party report on antenatal and intrapartum care. London: RCOG; 1982. 60. Whitfield CR, chairman. Report on further specialisation with obstetrics and gynaecology. London: Royal College of Obstetricians and Gynaecology; 1982. 61. National Birthday Trust International Symposium on Perinatal Care, Bristol, UK, 24e27 March 1982.