Address to the National Forum on Pregnancy and Sport - 1 August 2001, The Wentworth, Sydney
Dr Michael Sedgley Chairman of Federal Council, AMA

I ceased private obstetric practice four years ago as the medical indemnity insurance levels began to rocket upwards beyond levels which neither I nor my patients could afford. I think this is much of the essence of your debate today.

The problem is not one of any real harm coming to women who play sport. Like proper medical treatment, the advantages of sport far outweigh any disadvantages. The community accepts this and I think there is legal precedent for this. If you play within the rules of the sport and an inadvertent injury occurs, there is no liability for the player. What about the organisation, though, that runs the sport and is responsible for the rules? What about the perception that courts nowadays are bending over back wards to compensate injured parties? The inevitable outcome of such awards is that people have to insure themselves against the risk of losing all they possess and more in a court Settlement. Insurance creates a huge buckets of money which can be used to great benefit in society. However as the awards get larger and larger, suing becomes more attractive. Annual premiums must get larger and larger to top up the level in the bucket. In turn, to cover these insurance premiums, costs of playing sport increase, and potentially some areas of sport could become unplayable One cerebral palsy case against a sporting body can be worth around $10,000.00. Should this type of settlement ever be reached in Australia against a sporting body it is easy to see how either playing sport or running the organisations which administer sport could simply become too expensive. After all, even the defence of a case often costs more in legal costs than the settlement amounts. In the UK the statistics show that for settlements of 50,000 English pounds or less - and that is currently about 150,000 Australian dollars - in 65% of cases the legal costs were more than the settlement. This seems outrageous, but it is true. This fear, and looking at what has happened to some areas of medical practice is driving this debate.

You have asked me to give a medial perspective and I will do so as a general obstetrician and gynaecologist. There are several eminent colleagues from my Profession here Today and they will deal with the science.

You have asked me to speak about degrees and types of trauma to cause injury to the foetus.

I would like to tee off by, open the batting or indeed take a place kick and declare that I could not find any hard clinical evidence on the effects on the foetus of women playing collision sports such as Rugby or Australian rules football. In the literature and in clinical experience, only massive trauma can disturb the foetus. This is because the foetus is so well protected throughout pregnancy by the cushioning effects of the fluid which surrounds it in the uterus. Indeed the uterus itself needs to be ruptured or torn in order to affect the well-being of the foetus or baby. Typically this occurs in massive car accidents and can occur as a result of seat belt injury. I speak carefully here, because the law and common sense still demands the wearing of seat belts when driving or being driven. However the accident generally has to so massive that the seat belt damage is the

lesser evil than being killed.

It almost impossible to envisage such serious injury occurring playing any sport. However the effects of being hit on the abdomen in late pregnancy by a cricket ball or kicked in late pregnancy can be quite disastrous. Trauma of this kind can cause what is known as abruption or separation of the placenta. The force has to be severe, but if it is, bleeding behind the placenta can reduce the surface area of the placenta in contact with the

uterus or even detach it altogether. Complete detachment is fatal. Increasing degrees of detachment will lead to increasing degrees of foetal compromise. This compromise is due to a reduced blood supply getting through the placenta to the baby, reducing the baby's capacity to breathe and obtain nutrition. Considerable force is required to cause this problem, however or this reason collision or contact sports are inadvisable during late pregnancy.

I think to take a practical look at it, there are circulatory changes and balance changes in later pregnancy which render it more difficult for a pregnant women to perform at her peak if she is an elite athlete. I believe anecdotally, for instance that although many women continue to play netball during pregnancy, many slow down and even cease at about 20 weeks or half way through the pregnancy, simply because they feel too tired.

There have also been concerns raised by animal experiments that overheating in early pregnancy could cause abnormalities in foetuses and babies. Later research published in the Journal of Perinatal Medicine of 1999 has indicated that the body has special mechanisms which come into play in pregnancy to aid the rapid dissipation of heat. This provides evidence that overheating during exercise in early pregnancy is compensated for by increased heat regulation as a result of pregnancy related changes in the circulation. Thus at this stage of understanding there seems to be no danger.

There is no doubt that there are conditions in pregnancy which contra-indicate playing sport. Examples are threatening to miscarry or when the membranes have ruptured, or premature labour. These conditions are obvious and the main concern is that a pregnant woman who suffers an unfortunate outcome to her pregnancy may blame the sport for it.

As has already been mentioned, the cost of defending a legal action is in itself an imperative to settle and pay out just to avoid trouble. The rights and the wrongs do not matter. The expert evidence will only affect the total amount of the settlement.

These are some of the problems we face in medicine and medical indemnity today. I can understand why bodies who organise sport do not wish to be caught in the same way. However there is no doubt that there is no medical reason why women should be prevented from playing sport in pregnancy if they wish. More … current thinking is that as a doctor I advise my patient but I do not tell them what decision they must make. Although my advice can be strongly in favour or against a course of action, it is the woman herself who makes the choice for her baby. There is no reason for a doctor caring for a well woman to advise her not to play sport.

A few examples:

From a Radio National transcript of Friday May 9 1997

Amanda Smith the interviewer: The last world netball championships were held in England. Michelle Fielke was the captain of the Australian team, which won the championship in a nail biting final against South Africa. But Michelle led her team to victory without telling them something …

Later in the interview … "I actually played through competitively at the highest level, to a grand final in Adelaide until I was five and a half months"

In the same interview, another athlete who competed while pregnant was Robyn Maher. In a long and illustrious basketball career she notched up her 300th game in 1997. She played for as long as she felt she could in two pregnancies and that ended up being until 22 to 23 weeks each time.

I was told by my tennis coach that Helen Gourlay won the Australian Women's singles in the seventies while pregnant.

The question is not whether women should play sport during their pregnancy it is rather is there any reason why they should not?

In other parts of the forum the advantages of exercise in pregnancy will be outlined. Suffice to say that from a health perspective the advantages of exercise in pregnancy far outweigh any disadvantages. Sports of many kinds are an enjoyable method of exercising. It is sad that our legal system is becoming so cumbersome that it should even threaten this right of women to choose for themselves.