Symphysiotomy

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Symphysiotomy
Skeletal pelvis-pubis.svg
The black area marked by a "5" is the pubic symphysis, which is divided during the procedure
ICD-9-CM 73.94

Symphysiotomy is a surgical procedure in which the cartilage of the pubic symphysis is divided to widen the pelvis allowing childbirth when there is a mechanical problem (obstructed labour). It is also known as pelviotomy [1] and synchondrotomy. [1] It has largely been supplanted by C-sections, with the exception of certain rare obstetric emergencies or in resource poor settings. It is different than pubiotomy, where the pelvic bone itself is cut in two places, rather than cutting though the symphysis pubis joint. [2]

Contents

Introduction

Symphysiotomy was advocated in 1597 by Severin Pineau after his description of a diastasis of the pubis on a hanged pregnant woman. [3] Thus symphysiotomies became a routine surgical procedure for women experiencing an obstructed labour.[ citation needed ] They became less frequent in the late 20th century after the risk of maternal death from caesarean section decreased (due to improvement in techniques, hygiene, and clinical practice). [4]

Indications

The most common indications are a trapped head of a breech baby, [5] [6] shoulder dystocia which does not resolve with routine manoeuvres, and obstructed labor at full cervical dilation, especially with failed vacuum extraction. [5] Use for shoulder dystocia is controversial. [5]

Currently the procedure is rarely performed in developed countries, but is still performed in "rural areas and resource-poor settings of developing countries" [7] where caesarean sections are not available, or where obstetricians may not be available to deliver subsequent pregnancies. [8] Current practice guidelines in Canada recommend symphysiotomy for trapped head during vaginal delivery of a breech birth.

A 2016 meta-analysis found that in low and middle income countries, there was no difference between maternal and perinatal mortality following either symphysiotomy or C-section. [9] There was a lower risk of infection following symphysiotomy, but a higher risk of fistula, compared to C-section. [9]

Procedure

Patient in a symphysiotomy hammock after surgery, 1907 Postoperative treatment; an epitome of the general management of postoperative care and treatment of surgical cases as practised by prominent American and European surgeons (1907) (14762160486).jpg
Patient in a symphysiotomy hammock after surgery, 1907

Symphysiotomy results in a temporary increase in pelvic diameter (up to 2 centimetres (0.79 in)) by surgically dividing the ligaments of the symphysis under local anaesthesia. This procedure should be carried out only in combination with vacuum extraction. [10] Symphysiotomy can be a life-saving procedure in areas of the world where caesarean section is not feasible or immediately available as it does not require an operating theatre or "advanced" surgical skills. [5] Since this procedure does not scar the uterus, the concern of future uterine rupture that exists with cesarean section is not a factor. [11]

The procedure carries the risks of urethral and bladder injury, fistulas, [9] infection, pain, and long-term walking difficulty. [10] Symphysiotomy should, therefore, be carried out only when there is no safe alternative. [10] It is advised that this procedure should not be repeated due to the risk of gait problems and continual pain. [10] Abduction of the thighs more than 45 degrees from the midline may cause tearing of the urethra and bladder. If long-term walking difficulties and pain are reported, the patient's condition generally improves with physical therapy. [10]

Controversial practices in Ireland

In 2002 an advocacy group called Survivors of Symphysiotomy (SoS) was set up alleging religiously motivated symphysiotomies were performed without consent and against best medical practice in Republic of Ireland between 1944 and 1987. [12] [13] In 2014 Ireland agreed to pay women who received the procedure compensation without admitting liability. [14]

Related Research Articles

<span class="mw-page-title-main">Caesarean section</span> Surgical procedure to deliver a baby through an incision in the mothers abdomen

Caesarean section, also known as C-section, cesarean, or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen. It is often performed because vaginal delivery would put the mother or child at risk. Reasons for the operation include obstructed labor, twin pregnancy, high blood pressure in the mother, breech birth, shoulder presentation, and problems with the placenta or umbilical cord. A caesarean delivery may be performed based upon the shape of the mother's pelvis or history of a previous C-section. A trial of vaginal birth after C-section may be possible. The World Health Organization recommends that caesarean section be performed only when medically necessary.

Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgical field.

<span class="mw-page-title-main">Childbirth</span> Conclusion of the human pregnancy with the expulsion of a fetus from mothers womb

Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In the developed countries, most deliveries occur in hospitals, while in the developing countries most are home births.

<span class="mw-page-title-main">Pubic symphysis</span> Cartilaginous joint between the front of the left and right hip bones

The pubic symphysis is a secondary cartilaginous joint between the left and right superior rami of the pubis of the hip bones. It is in front of and below the urinary bladder. In males, the suspensory ligament of the penis attaches to the pubic symphysis. In females, the pubic symphysis is attached to the suspensory ligament of the clitoris. In most adults, it can be moved roughly 2 mm and with 1 degree rotation. This increases for women at the time of childbirth.

<span class="mw-page-title-main">Breech birth</span> Birth of a baby bottom first

A breech birth is when a baby is born bottom first instead of head first, as is normal. Around 3–5% of pregnant women at term have a breech baby. Due to their higher than average rate of possible complications for the baby, breech births are generally considered higher risk. Breech births also occur in many other mammals such as dogs and horses, see veterinary obstetrics.

<span class="mw-page-title-main">Placenta praevia</span> Medical condition

Placenta praevia is when the placenta attaches inside the uterus but in a position near or over the cervical opening. Symptoms include vaginal bleeding in the second half of pregnancy. The bleeding is bright red and tends not to be associated with pain. Complications may include placenta accreta, dangerously low blood pressure, or bleeding after delivery. Complications for the baby may include fetal growth restriction.

Labor induction is the process or treatment that stimulates childbirth and delivery. Inducing (starting) labor can be accomplished with pharmaceutical or non-pharmaceutical methods. In Western countries, it is estimated that one-quarter of pregnant women have their labor medically induced with drug treatment. Inductions are most often performed either with prostaglandin drug treatment alone, or with a combination of prostaglandin and intravenous oxytocin treatment.

<span class="mw-page-title-main">Obstructed labour</span> Medical condition

Obstructed labour, also known as labour dystocia, is the baby not exiting the pelvis because it is physically blocked during childbirth although the uterus contracts normally. Complications for the baby include not getting enough oxygen which may result in death. It increases the risk of the mother getting an infection, having uterine rupture, or having post-partum bleeding. Long-term complications for the mother include obstetrical fistula. Obstructed labour is said to result in prolonged labour, when the active phase of labour is longer than 12 hours.

<span class="mw-page-title-main">Shoulder dystocia</span> Birthing obstruction complication

Shoulder dystocia is when, after vaginal delivery of the head, the baby's anterior shoulder gets caught above the mother's pubic bone. Signs include retraction of the baby's head back into the vagina, known as "turtle sign". Complications for the baby may include brachial plexus injury, or clavicle fracture. Complications for the mother may include vaginal or perineal tears, postpartum bleeding, or uterine rupture.

Pelvimetry is the measurement of the female pelvis. It can theoretically identify cephalo-pelvic disproportion, which is when the capacity of the pelvis is inadequate to allow the fetus to negotiate the birth canal. However, clinical evidence indicate that all pregnant women should be allowed a trial of labor regardless of pelvimetry results.

Caesarean delivery on maternal request (CDMR) is a caesarean section birth requested by the pregnant woman without a medical reason.

In case of a previous caesarean section a subsequent pregnancy can be planned beforehand to be delivered by either of the following two main methods:

<span class="mw-page-title-main">Pubic symphysis diastasis</span> Medical condition

Pubic symphysis diastasis is the separation of normally joined pubic bones, as in the dislocation of the bones, without a fracture that measures radiologically more than 10 mm. Separation of the symphysis pubis is a rare pathology associated with childbirth and has an incidence of 1 in 300 to 1 in 30,000 births. It is usually noticed after delivery but can be observed up to six months postpartum. Risk factors associated with this injury include cephalopelvic disproportion, rapid second stage of labor, epidural anesthesia, severe abduction of the thighs during delivery, or previous trauma to the pelvis. Common signs and symptoms include symphyseal pain aggravated by weight-bearing and walking, a waddling gait, pubic tenderness, and a palpable interpubic gap. Treatment for pubic symphysis diastasis is largely conservative, with treatment modalities including pelvic bracing, bed rest, analgesia, physical therapy, and in some severe cases, surgery.

<span class="mw-page-title-main">Vaginal delivery</span> Delivery through the vagina

A vaginal delivery is the birth of offspring in mammals through the vagina. It is the most common method of childbirth worldwide. It is considered the preferred method of delivery, as it is correlated with lower morbidity and mortality than caesarean sections (C-sections), though it is not clear whether this is causal.

An asynclitic birth or asynclitism are terms used in obstetrics to refer to childbirth in which there is malposition of the head of the fetus in the uterus, relative to the birth canal. Asynclitic presentation is different from a shoulder presentation, in which the shoulder is presenting first. Many babies enter the pelvis in an asynclitic presentation, and most asynclitism corrects spontaneously as part of the normal birthing process.

An obstetric labor complication is a difficulty or abnormality that arises during the process of labor or delivery.

The following outline is provided as an overview of and topical guide to obstetrics:

<span class="mw-page-title-main">Prolonged labor</span> Medical condition

Prolonged labor is the inability of a woman to proceed with childbirth upon going into labor. Prolonged labor typically lasts over 20 hours for first time mothers, and over 14 hours for women that have already had children. Failure to progress can take place during two different phases; the latent phase and active phase of labor. The latent phase of labor can be emotionally tiring and cause fatigue, but it typically does not result in further problems. The active phase of labor, on the other hand, if prolonged, can result in long term complications.

A urogenital fistula is an abnormal tract that exists between the urinary tract and bladder, ureters, or urethra. A urogenital fistula can occur between any of the organs and structures of the pelvic region. A fistula allows urine to continually exit through and out the urogenital tract. This can result in significant disability, interference with sexual activity, and other physical health issues, the effects of which may in turn have a negative impact on mental or emotional state, including an increase in social isolation. Urogenital fistulas vary in etiology. Fistulas are usually caused by injury or surgery, but they can also result from malignancy, infection, prolonged and obstructed labor and deliver in childbirth, hysterectomy, radiation therapy or inflammation. Of the fistulas that develop from difficult childbirth, 97 percent occur in developing countries. Congenital urogenital fistulas are rare; only ten cases have been documented. Abnormal passageways can also exist between the vagina and the organs of the gastrointestinal system, and these may also be termed fistulas.

<span class="mw-page-title-main">Operative vaginal delivery</span>

Operative vaginal delivery, also known as assisted or instrumental vaginal delivery, is a vaginal delivery that is assisted by the use of forceps or a vacuum extractor.

References

  1. 1 2 "symphysiotomy". The American Heritage Stedman's Medical Dictionary. Archived from the original on 2014-01-07. Retrieved March 22, 2012– via Dictionary.com.
  2. ↑ "pubiotomy" . Oxford English Dictionary (Online ed.). Oxford University Press.(Subscription or participating institution membership required.)
  3. ↑ Dumont M: La longue et laborieuse naissance de la symphyséotomie ou de Séverin Pineau à Jean-René Sigault. J Gynecol Obstet Biol Reprod 1989;18:11-21
  4. ↑ Bergström, S.; Lublin, H.; Molin, A. (1994). "Value of symphysiotomy in obstructed labour management and follow-up of 31 cases". Gynecologic and Obstetric Investigation. 38 (1): 31–35. doi:10.1159/000292441. ISSN   0378-7346. PMID   7959323.
  5. 1 2 3 4 Hofmeyr, G Justus; Shweni, P Mike (2012-10-17). Cochrane Pregnancy and Childbirth Group (ed.). "Symphysiotomy for feto-pelvic disproportion". Cochrane Database of Systematic Reviews. 10 (10): CD005299. doi:10.1002/14651858.CD005299.pub3. PMC   7390327 . PMID   23076913.
  6. ↑ Kotaska, Andrew; Menticoglou, Savas (August 2019). "No. 384-Management of Breech Presentation at Term". Journal of Obstetrics and Gynaecology Canada. 41 (8): 1193–1205. doi:10.1016/j.jogc.2018.12.018. PMID   31331608.
  7. ↑ Monjok, Emmanuel; Okokon, Ita B.; Opiah, Margaret M.; Ingwu, Justin A.; Ekabua, John E.; Essien, Ekere J. (September 2012). "Obstructed labour in resource-poor settings: the need for revival of symphysiotomy in Nigeria". African Journal of Reproductive Health. 16 (3): 94–101. ISSN   1118-4841. PMID   23437503.
  8. ↑ Verkuyl, Douwe Arie Anne (2007-03-27). "Think globally act locally: the case for symphysiotomy". PLOS Medicine. 4 (3): e71. doi: 10.1371/journal.pmed.0040071 . ISSN   1549-1676. PMC   1831724 . PMID   17388656.
  9. 1 2 3 Wilson, A; Truchanowicz, Eg; Elmoghazy, D; MacArthur, C; Coomarasamy, A (August 2016). "Symphysiotomy for obstructed labour: a systematic review and meta-analysis". BJOG: An International Journal of Obstetrics & Gynaecology. 123 (9): 1453–1461. doi:10.1111/1471-0528.14040. ISSN   1470-0328. PMID   27126671.
  10. 1 2 3 4 5 Mathai, Matthews, ed. (2003). Managing complications in pregnancy and childbirth: a guide for midwives and doctors. Integrated management of pregnancy and childbirth (1st ed.). Geneva: WHO, RHR Department of Reproductive Health and Research. ISBN   978-92-4-154587-7. Archived from the original on 2002-08-09.
  11. ↑ van Roosmalen, Jos (July 1990). "Safe motherhood: cesarean section or symphysiotomy?". American Journal of Obstetrics and Gynecology. 163 (1 Pt 1): 1–4. doi:10.1016/S0002-9378(11)90653-X. ISSN   0002-9378. PMID   2375330.
  12. ↑ "SOS Ireland - survivors of symphysiotomy". Survivors of Symphysiotomy ireland. Retrieved 2018-04-16.
  13. ↑ "Draft Report on Symphysiotomy in Ireland 1944 - 1987, Dr Oonagh Walsh"
  14. ↑ "Symphysiotomy compensation agreed in Republic of Ireland". BBC News. 2014-07-01. Retrieved 2024-08-10.
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