Symphysiotomy

Overview
Symphysiotomy is a surgical procedure in which the cartilage of the symphysis pubis is divided to widen the pelvis allowing childbirth when there is a mechanical problem.

Introduction
Symphysiotomy was also advocated in 1597 by Severin Pineau after his description of a diastasis of the pubis on a hanged pregnant woman. Thus symphysiotomies became a routine surgical procedure for women experiencing an obstructed labour. In the late 19th century after the risk of maternal death after caesarean section decreased due to improvement in techniques, hygiene and clinical practice the symphysiotomy was rarely used.

Indications for the procedure
The most common indications are a trapped head of a breech baby, shoulder dystocia which does not resolve with routine manoeuvres and obstructed labour at full cervical dilation when there is no option of a caesarean section. Currently the procedure is rarely performed in developed countries, but is still routine in developing countries where caesarean section is not always an option.

Surgical application
Symphysiotomy results in a temporary increase in pelvic diameter (up to 2 cm) by surgically dividing the ligaments of the symphysis under local anaesthesia. This procedure should be carried out only in combination with vacuum extraction. Symphysiotomy in combination with vacuum extraction can be a life-saving procedure in areas of the world where caesarean section is not feasible or immediately available. Symphysiotomy leaves no uterine scar and the risk of ruptured uterus in any future labour is not increased.

The procedure is not without risk, including urethral and bladder injury, infection, pain and long-term walking difficulty. Symphysiotomy should, therefore, be carried out only when there is no safe alternative. It is advised that this procedure should not be repeated due to the risk of the woman developing long term walking problems and continued pain.

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 (occur in 2% of cases), treat with physical therapy.
 * 1) Give appropriate analgesic drugs.
 * 2) Apply elastic strapping across the front of the pelvis from one iliac crest to the other to stabilize the symphysis and reduce pain.
 * 3) Leave the catheter in the bladder for a minimum of 5 days.
 * 4) Encourage the woman to drink plenty of fluids to ensure a good urinary output.
 * 5) Encourage bed rest for 7 days after discharge from hospital.
 * 6) Encourage the woman to begin to walk with assistance when she is ready to do so.

Ireland and Symphysiotomy
Irish women who unknowingly and without consent underwent symphysiotomies during childbirth between the 1950s and 1980s say they were left them with severe side effects, including extreme pain, incontinence and depression. Irish obstetricians sought to establish this operation as an alternative to Caesarean sections because it was thought that women subjected to repeated Caesareans 'might be tempted to use contraception'.