The Irish experience of Symphysiotomy: 40 years onwards.

The art of symphysiotomy for delivery in the instance of cephalopelvic disproportion has been a dying art since the advent of caesarean section but in Ireland this surgical procedure was not abolished until 1992. This practice is still present in the developing world and in some circumstances used in developed countries. This study offers some insights on the 40-year follow-up of patients who had undergone symphysiotomy.

Symphysiotomy.

The place of symphysiotomy, as an alternative to Caesarean section (CS), in the management of established obstructed labour in low- and middle-income, resource-poor countries (LMICs), is reviewed. It is suggested that it does have a very definite place, especially in mothers of low age and parity, in circumstances where medical facilities are limited, where antenatal care and hospital delivery are not assured in a future pregnancy, and in cultures where it is important to the woman that a vaginal delivery is achieved.

Radiographic findings after pubic symphysiotomy: mean time to follow-up of 41.6 years.

BACKGROUND: Pubic symphysiotomy is a rarely performed procedure in which the pubic symphysis is divided to facilitate vaginal delivery in cases of obstructed labor. Recently, many obstetricians have shown renewed interest in this procedure. The purpose of this paper is to report the long-term radiographic findings for patients who had undergone pubic symphysiotomy compared with the radiographic appearance of a group of age-matched and parity-matched controls. METHODS: This was a retrospective case-control study. Twenty-five women who had previously undergone pubic symphysiotomy for childbirth were compared with twenty-five age-matched and parity-matched controls. The radiographic parameters recorded included pubic symphysis width, pubic symphysis translation, grade of sacroiliac joint osteoarthritis, and presence of parasymphyseal degeneration. RESULTS: The mean time to follow-up after symphysiotomy was 41.6 years (range, twenty-two to fifty-five years). The symphysiotomy group had a significantly higher proportion of patients (80%) with high-grade sacroiliac joint osteoarthritis (Grade 3 or 4 according to the Kellgren and Lawrence osteoarthritis scoring system) than the control group (16%) (p < 0.001). Within the symphysiotomy group, patients with high-grade sacroiliac joint osteoarthritis tended to be older, have a longer time to follow-up, and have a larger pubic symphysis width. The control group had a higher prevalence of parasymphyseal degeneration than did the symphysiotomy group (p = 0.011). CONCLUSIONS: Late-onset sacroiliac joint osteoarthritis secondary to pelvic instability was a major finding in this study and, to our knowledge, has not been discussed previously in the literature regarding pubic symphysiotomy.

Symphysiotomy for feto-pelvic disproportion.

BACKGROUND: Symphysiotomy is an operation in which the fibres of the pubic symphysis are partially divided to allow separation of the joint and thus enlargement of the pelvic dimensions during childbirth. It is performed with local analgesia and does not require an operating theatre nor advanced surgical skills. It may be a lifesaving procedure for the mother or the baby, or both, in several clinical situations. These include: failure to progress in labour when caesarean section is unavailable, unsafe or declined by the mother; and obstructed birth of the aftercoming head of a breech presenting baby. Criticism of the operation because of complications, particularly pelvic instability, and as being a 'second best' option has resulted in its decline or disappearance from use in many countries. Several large observational studies have reported high rates of success, low rates of complications and very low mortality rates. OBJECTIVES: To determine, from the best available evidence, the effectiveness and safety of symphysiotomy versus alternative options for obstructed labour in various clinical situations. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 July 2012). SELECTION CRITERIA: Randomized trials comparing symphysiotomy with alternative management, or alternative techniques of symphysiotomy, for obstructed labour or obstructed aftercoming head during breech birth. DATA COLLECTION AND ANALYSIS: Planned methods included evaluation of studies against objective quality criteria for inclusion, extraction of data, and analysis of data using risk ratios or mean differences with 95% confidence intervals. The primary outcomes were maternal death or severe morbidity, and perinatal death or severe morbidity. MAIN RESULTS: We found no randomized trials of symphysiotomy. AUTHORS' CONCLUSIONS: Because of controversy surrounding the use of symphysiotomy, and the possibility that it may be a life-saving procedure in certain circumstances, professional and global bodies should provide guidelines for the use (or non-use) of symphysiotomy based on the best available evidence (currently evidence from observational studies). Research is needed to provide robust evidence of the effectiveness and safety of symphysiotomy compared with no symphysiotomy or comparisons of alternative symphysiotomy techniques in clinical situations in which caesarean section is not available; and compared with caesarean section in clinical situations in which the relative risks and benefits are uncertain (for example in women at very high risk of complications from caesarean section).

Obstructed labour in resource-poor settings: the need for revival of symphysiotomy in Nigeria.

Symphysiotomy is an operation in which the fibres of the pubic symphysis are partially divided to allow separation of the joint and thus enlargement of the pelvic dimensions thereby facilitating vaginal delivery of the foetus in the presence of mild to moderate cephalopelvic disproportion. It is performed with local anaesthesia, does not require an operating theatre or advanced surgical skills. It can be a lifesaving procedure for both mother and baby in obstructed labour, especially in rural areas and resource-poor settings of developing countries, where a 24 hours availability of a caesarean section cannot be guaranteed. It is a simple underused technology that can be performed by a graduate doctor or midwife in rural health facilities and hospitals where most of the times, in Nigeria, there are no practicing specialist obstetricians. In rural hospital and in communities where sympysiotomy is still being performed, it is evident that it is preferred to caesarean section because of the socio-cultural desire to achieve a vaginal delivery. This paper highlights our experiences with symphysiotomy in a rural Roman Catholic hospital providing evidence on the safety of symphysiotomy and the need for its revival and reinstatement in the obstetric arsenal in Nigeria and similar countries in sub-Saharan Africa where maternal mortality as a result of prolonged and neglected obstructed labour still occur.

Symphysiotomy: Is it obsolete?

AIM: To compare the maternal and neonatal outcomes of symphysiotomy (SYM) and cesarean section (CS), when they were performed in women presenting with obstructed labor. MATERIAL AND METHODS: This was a prospective comparative cohort study. Symphysiotomy was performed in 25 women who presented with obstructed labor. The controls were 50 women on whom CS was performed due to obstructed labor. Maternal mortality and morbidity due to postpartum hemorrhage (PPH), sepsis, genitourinary trauma, pelvic pain and gait problems were analyzed and compared between cases and controls. Neonatal mortality and morbidity due to birth asphyxia, intracranial hemorrhage, cephalohematoma and hypoxic ischemic encephalopathy were also compared following the two procedures. RESULTS: Maternal mortality was similar in both the cesarean section group (CSG) and symphysiotomy group (SG), but SYM has less morbidity than CS, and also preserves the uterus from scars. Transient pelvic pain was the most common maternal morbidity following SYM, whereas PPH and wound sepsis were the most common complications after CS. Neonatal mortality and morbidity were similar in both cases and controls. Lastly, SYM is a simple, low-cost and quicker procedure than CS. CONCLUSION: Symphysiotomy is an alternative management in women with obstructed labor. It has a role in low-resource settings, where CS is unaffordable, unavailable or unsafe. For the vast majority of the poor population, who may not have even have one proper meal a day, it can be of benefit to have a woman's pelvis made permanently adequate so that traditional birth attendants can conduct her subsequent labors.

Symphysiotomy for feto-pelvic disproportion.

BACKGROUND: Symphysiotomy is an operation in which the fibres of the pubic symphysis are partially divided to allow separation of the joint and thus enlargement of the pelvic dimensions during childbirth. It is performed with local analgesia and does not require an operating theatre nor advanced surgical skills. It may be a lifesaving procedure for the mother or the baby, or both, in several clinical situations. These include: failure to progress in labour when caesarean section is unavailable, unsafe or declined by the mother; and obstructed birth of the aftercoming head of a breech presenting baby. Criticism of the operation because of complications, particularly pelvic instability, and as being a 'second best' option has resulted in its decline or disappearance from use in many countries. Several large observational studies have reported high rates of success, low rates of complications and very low mortality rates. OBJECTIVES: To determine, from the best available evidence, the effectiveness and safety of symphysiotomy versus alternative options for obstructed labour in various clinical situations. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 3) and PubMed (1966 to 31 August 2010). SELECTION CRITERIA: Randomized trials comparing symphysiotomy with alternative management, or alternative techniques of symphysiotomy, for obstructed labour or obstructed aftercoming head during breech birth. DATA COLLECTION AND ANALYSIS: Planned methods included evaluation of studies against objective quality criteria for inclusion, extraction of data, and analysis of data using risk ratios or mean differences with 95% confidence intervals. The primary outcomes were maternal death or severe morbidity, and perinatal death or severe morbidity. MAIN RESULTS: We found no randomized trials of symphysiotomy. AUTHORS' CONCLUSIONS: Because of controversy surrounding the use of symphysiotomy, and the possibility that it may be a life-saving procedure in certain circumstances, professional and global bodies should provide guidelines for the use (or non-use) of symphysiotomy based on the best available evidence (currently evidence from observational studies). Research is needed to provide robust evidence of the effectiveness and safety of symphysiotomy compared with no symphysiotomy or comparisons of alternative symphysiotomy techniques in clinical situations in which caesarean section is not available; and compared with caesarean section in clinical situations in which the relative risks and benefits are uncertain (for example in women at very high risk of complications from caesarean section).

Practical symphysiotomy: an overview.

Symphysiotomy is an alternative operative procedure where a deliberate division of symphysis pubis is carried out to facilitate delivery in cases of cephalopelvic disproportion, so as to permit the birth of baby by natural passages. Symphysiotomy results in a permanent increase in pelvic diameter (up to 1 cm) by surgically dividing the ligaments of the symphysis under local or general anaesthesia. Symphysiotomy should only be done in a established case of obstructed labour but not in anticipation of obstructed labour. This operation was reviewed in 21 cases of established obstructed labour in Silchar Medical College with little modifications of original operations. All the cases were done by subcutaneous method which is cosmetic and simple. The operation was carried out by dividing upper ligament completely and anterior arcuate ligament partially under local anaesthesia. The posterior arcuate ligament was not touched at all. None of the cases required forceps or vaccum extraction. It resulted in almost negligible complications in comparison to morbidity and mortality in primary caesarean section. Considering the usefulness of the operation it can even be started in rural hospitals by the gynaecologist if they are properly trained to do it in a justified manner in properly selected cases.

Symphysiotomy in Zimbabwe; postoperative outcome, width of the symphysis joint, and knowledge, attitudes and practice among doctors and midwives.

BACKGROUND: Obstructed labour remains one of the leading causes of maternal and foetal death and morbidity in poorly resourced areas of the world, where the 24 hours availability of a caesarean section (CS) cannot be guaranteed, and the CS related mortality rate is still high. In these settings, reinstatement of symphysiotomy has been advocated. The objectives were, in1994; to study perioperative and long-term complications of symphysiotomy and compare them to those related to CS for similar indications, in 1996; to measure the symphyseal width after symphysiotomy and compare it to that after normal vaginal delivery, and, in 1998; to assess knowledge, attitudes and practice related to symphysiotomy among doctors and midwives in Zimbabwe. METHODS AND FINDINGS: Thirty-four women who had undergone symphysiotomy and 29 women who had undergone a CS for obstructed labour were interviewed. The symphyseal widths of 19 women with a previous symphysiotomy were compared to that of 92 women with previous normal vaginal deliveries, using ultrasound technique. Forty-one doctors and 39 midwives, in three central hospitals and seven district hospitals in Zimbabwe, were interviewed about symphysiotomy. None of the 34 women reported serious soft tissue injuries or infections post symphysiotomy. Long-term complications after symphysiotomy do not differ notably from those after CS for similar indications. The intra-articular width of the symphysis pubis is increased after a symphysiotomy. Seventy-nine of the 80 interviewed health care workers knew about symphysiotomy. One obstetrician had performed symphysiotomies. Two-thirds of the participants considered symphysiotomy an obsolete and second-class operation, but lifesaving and appropriate in remote areas of Zimbabwe. Ten of 13 midwives in remote areas wanted to carry out symphysiotomies themselves. CONCLUSIONS: No severe complications due to symphysiotomy were revealed in this study. The results suggest that a modest permanent enlargement of the pelvis post symphysiotomy (together with the absence of a scarred uterus) may facilitate subsequent vaginal delivery. Doctors and midwives working in district hospitals have a more positive attitude to symphysiotomies than the colleagues in central hospitals. Obstetricians (who would have to do the teaching), working in the large urban hospitals almost exclude symphysiotomy as an alternative management in Zimbabwe.

Complete destruction of urethra and bladder neck following symphysiotomy and results of attempted corrective surgery.

Four (0.8%) out of 526 obstetric fistulas were related to a preceding symphysiotomy procedure. Complete destruction of the urethra and bladder neck with retropubic fibrosis was found. Faulty technique is the most probable cause. All women had stillborn babies before the symphysiotomy delivery, and tissue damage due to obstructed labor could have been a predisposing factor. A neo-urethra was successfully constructed in three of the four women, but continence in standing position was not obtained.

Think globally act locally: the case for symphysiotomy.

When expatriate doctors from developed countries working in sub-Saharan Africa suggest to the local doctors and midwives that symphysiotomies should sometimes be done, they are silenced neither with quotations from the medical literature nor with tales of patients seen, but with: "If symphysiotomies are such good operations why don't you perform them at home?" Here is why.

Minimally invasive surgery for obstructed labour: a review of symphysiotomy during the twentieth century (including 5000 cases).

OBJECTIVE: To compile and make available essential data on symphysiotomy for evaluation in the struggle against maternal and fetal mortality and morbidity from obstructed labour, which causes the death of 50,000 women each year in low-resourced countries. DESIGN: Retrospective review of literature. SAMPLE: Five thousand symphysiotomies and 1200 caesarean sections from 28 countries on four continents. METHODS: The review is based on original papers published 1900 to 1999, stepwise traced through reference lists. Inclusion criteria were: firstly, that the cases reported be consecutive, secondly the presence of an acceptable description of methodology and thirdly, the study size was set at a minimum of 25 cases for analysis of maternal and fetal mortality. Papers comprising only five to 24 cases were included in other analyses. All studies were retrospective, except the follow up studies. MAIN OUTCOME MEASURES: Maternal and fetal mortality; causes of maternal death; fetal mortality in previous deliveries; mode of delivery in subsequent pregnancies; symphyseal width after symphysiotomy; immediate, short and long term complications; maternal and fetal mortality comparing symphysiotomy and caesarean section. RESULTS: Symphysiotomy has been extensively studied, modified and refined over the last century, and the scientific documentation is substantial. The results indicate that symphysiotomy is safe for the mother from a vital perspective, confers a permanent enlargement of the pelvis and facilitates vaginal delivery in future pregnancies, and is a life saving operation for the child. Severe complications are rare. Symphysiotomy compares favourably with caesarean section in terms of risk for the mother's life. CONCLUSION: If valid conclusions can be drawn from one hundred years of retrospective studies, there is considerable evidence to support a reinstatement of symphysiotomy in the obstetric arsenal, for the benefit of women in obstructed labour and their offspring.

[Current aspects of symphysiotomy. Apropos of 1 case and review of the literature]. / Aspects actuels de la symphysiotomie. A propos d'un cas et revue de la littérature.

Symphysiotomy is regularly performed in developing countries where cesarean section can be a source of significant short-term and long-term morbidity. However, this method can be useful in some rare occasions and should be taught in our countries, at least theoretically. Such a case is presented with a review describing the present surgical technique, its indications and limits with special reference to its possible complications.

[Symphysiotomy. A thought-provoking example of appropriate technique in the Third World]. / Symfysiotomi. Et tankevekkende eksempel på hensiktsmessing teknikk i den tredje verden.

Cutting through the symphysis pubis cartilage as a means of widening the birth canal during long, drawn-out deliveries was probably common in Europe at the turn of the century and presumably occurred even later. As a result of progress in hygiene and clinical practice, Caesarean section has become much more common in such situations. In developing countries, where supervision of pregnant women is non-existent or extremely poor, Caesarean section can be a dangerous operation. Mortality figures around 1-3% are common, and the women are left with the unfavourable prognosis of a uterine scar. Therefore, symphysiotomy is still practised in settings where neither hygiene nor material resources permit. Caesarean section, because it is simple to perform and makes a negligible demand on resources.

Symphysiotomy or caesarean section after failed trial of assisted delivery.

The perinatal and maternal outcomes of 65 symphysiotomies and 108 caesarean sections carried out after failed trial of assisted delivery at the Port Moresby General Hospital between 1988 and 1994 were retrospectively analyzed. There were no significant differences in perinatal outcomes between the treatment groups. There were no maternal deaths in either group. Mothers who had symphysiotomy had a longer postoperative stay in hospital but fewer complications requiring further surgery. There are many advantages of symphysiotomy, particularly in developing countries, following a failed trial of assisted delivery, provided the indications for it are strictly met. Obstetricians experienced in the technique are able to apply it at the optimal time, with long-term benefit to their patients, who thereby avoid the risks of pregnancy subsequent to caesarean section.

PIP: A retrospective analysis of 65 symphysiotomies and 108 cesarean sections performed in 1988-94 after a failed trial of assisted delivery at the Port Moresby General Hospital (Papua New Guinea) revealed no significant differences in perinatal or maternal outcomes. There were no significant differences between groups in terms of duration of first and second-stage labor, Apgar scores, admission to a special care neonatal unit, or perinatal mortality. There were no maternal deaths. Mothers who had symphysiotomy required a longer hospital stay, but had fewer complications necessitating additional surgery (e.g., wound infection) than women delivered by cesarean section. These findings confirm that, with proper technique and selection of cases, symphysiotomy can both eliminate difficult vaginal deliveries and reduce maternal morbidity and mortality. Indications for this procedure include presentation of the vertex, moderate cephalopelvic disproportion, and a live fetus. The main complications are leg and pelvic pain, pelvic instability, and stress incontinence.