Abstract
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.
Keywords
A review of symphysiotomy use, as an alternative to Caesarean section, in 21st century obstetric practice in low- and middle-income, resource-poor countries.
Introduction
The place of symphysiotomy in modern obstetric practice has once more been questioned by the publication of a paper containing a detailed review of its use in Ireland during the last century. 1 It has led to media and local politicians making wildly inaccurate and inflammatory statements about the procedure. While it is right to castigate poorly-performed surgery, carried out for inadequate reasons and without the patient’s consent, the answer to the misuse of a procedure is surely not abuse but concern for its correct use in appropriate circumstances.
Symphysiotomy has had a chequered history ever since Jean Rene Sigault 2 first suggested its use in 1776. Unfortunately, he chose to demonstrate the technique, 1 year later, on a lady in Paris 3 feet 8 inches (112 cm) in height, whose pelvis was grossly deformed by Rickets. This was in the days when CS had virtually a 100% maternal mortality. It was to be another 100 years before Edoardo Porro demonstrated a method of CS that would not kill the mother. The fact that Sigault’s patient survived and was safely delivered of a live baby (after four stillbirths) was a triumph for surgery at the time – a fact that tends to be forgotten.
Sadly, in his case, the combination of the procedure and the pre-existing deformity of her pelvis led to severe problems with her gait and gross stress incontinence thereafter. His antagonists, including William Hunter, seized on these complications and castigated the procedure. Since then, symphysiotomy has always raised strong feelings in its opponents: indeed, the possibility of these two particular complications has been seared into the collective subconscious of Western-trained obstetricians ever since.
The question has to be asked therefore whether symphysiotomy still has a place today in LMICs in dealing with established obstructed labour, as suggested in the conclusions from the Irish Department of Health 1 and whether it might diminish the incidence and severity of some of its consequences, e.g. uterine rupture and vesico-vaginal fistulae (VVF).
Important facts about symphysiotomy
It is an operation carried out percutaneously, as an emergency procedure, under local anaesthesia, to enlarge the mother’s pelvis and facilitate vaginal delivery.
It is most commonly performed in obstructed labour associated with minor or moderate degrees of cephalopelvic disproportion (CPD).
The WHO Manual on ‘Managing Complications in Pregnancy’ 3 states that it ‘is a life-saving procedure in areas where CS is not feasible or immediately available’.
It is important to differentiate the procedure from the mechanism of spontaneous rupture of the symphysis which occasionally occurs in normal pregnancy.
The precise nature and reason for this extremely painful and debilitating condition is difficult to determine. Unlike the surgical procedure, the pain may take many weeks, or even months, to resolve. When the symphysis is divided at symphysiotomy, however, it is the cartilage that is divided and it quickly heals by fibrosis and is far less painful. Most patients are on their feet again within 72 h and back to normal ambulatory and urinary function within 2 weeks postpartum. Visible evidence of normal activity in 23 women all of whom had symphysiotomies is available. 4
It is also important to emphasise that symphysiotomy is not an elective procedure and should not be used in anticipation of obstructed labour. No elective indication for this procedure exists. Neither should the operation be performed early in labour because the degree of CPD cannot be reliably evaluated before descent of the head.
It is an operation that should be reserved for patients who present in established obstructed labour and/or where a trial of vacuum delivery has failed (FVE).
Every patient should be monitored during labour using a partogram; this will give the best indication of possible CPD. Slow progress, especially in the late first stage, should alert the midwife or doctor to the possibility of CPD. An assisted delivery may then be needed in the second stage and if, following appropriate augmentation and/or the use of the vacuum extractor, the patient remains undelivered, symphysiotomy should be considered. It is not the procedure of first resort.
Incidence of its use
Although symphysiotomy has been widely used in many cases of obstructed labour in resource-poor countries, the number of occasions when it is appropriate to perform the procedure is actually quite low. At the Kilimanjaro Medical Centre, Tanzania – a tertiary referral centre – between 1973 and 1978 the incidence was 0.66% of all deliveries. 5 In the recent Irish survey, 1 at the height of its use in Dublin in the 1940s and 1950s, the reported incidence was 0.6% and the mean incidence overall during the period under review was 0.4%.
Indications for symphysiotomy
It is essential to identify the appropriate indications and contraindications for the procedure if it is to be successful in allowing a safe, normal or assisted vaginal delivery, with the minimum of side effects. It has been its use in inappropriate situations by unskilled operators in unmonitored settings which has brought the procedure into disrepute.
Basically, there are only two indications – first, in established obstructed labour in the face of mild to moderate CPD, following failure to deliver with a vacuum extractor, 6 or where there is severe infection but the fetus is still alive; second, when the after-coming head is trapped during a breech delivery. 7 However, there is a greater risk of complications in this latter situation because the procedure must be done rapidly, if the baby is to be saved.
As a precautionary measure, it would be wise always to have the necessary instruments for symphysiotomy on the delivery trolley for all vacuum and all breech deliveries; also it would be wise to infiltrate both the perineum (for episiotomy) and the supra-clitoral area (for symphysiotomy) with local anaesthetic, in case of need, i.e. where there has been slow progress or the baby seems to be big clinically. The fact that the first stage of labour has progressed slowly with a breech presentation should always be taken as a warning.
Other reasons for maintaining this skill
It will mean that those undertaking vacuum extraction will have the confidence to proceed with a trial of vacuum extraction in the Labour Ward. In many LMICs, there may be several hours’ delay between a failed attempt and the readiness to perform a CS. However if all is ready for symphysiotomy, it can be carried out immediately and in more than 90% of cases will result in a vaginal delivery, thus rendering CS unnecessary. These facts should increase the usefulness and popularity (and therefore the experience) of using the vacuum extractor.
The frequent long delay in getting the patient to a centre where CS can be carried out, and/or the delay at such a centre in getting the operating theatre prepared for CS will mean that the baby is likely to be dead by the time of delivery and the woman suffer further unnecessary distress and damage, with possible rupture of her uterus and or VVF as a consequence. 8
Vacuum extraction rates in many LMICs have decreased to less than 1%9,10 and in some places, this important obstetric skill is in danger of being completely lost. This has resulted in South Africa in soaring CS rates leading (21% and rising) leading to CS now being top of the causes for maternal mortality. 11
The perception of many – both medical and lay persons – seems to be that if the doctor performs a CS and the baby dies, everything possible has been done for that patient, even when there has been a far from optimal outcome. Whereas, if there is a poor outcome with a vacuum extraction the perception persists that the doctor could have done better, and thus vacuum extraction is blamed. To counter that trend, it is important that more is done to ensure that operative vaginal delivery outcomes are optimised. 12
The contraindications to symphysiotomy
Contraindications to symphysiotomy include: Severe CPD, when more than two-fifths of the fetal head is palpable supra-pubically and there is severe moulding of the head; Major lower limb or pelvic deformities and any pre-existing locomotor problems; Shoulder dystocia – it is commonly stated in Western literature that symphysiotomy be considered as a third line manoeuvre in dealing with this situation. This is discouraged by the Royal College of Obstetricians and Gynaecologists.
13
In the presence of a divided symphysis, the intra-vaginal manoeuvres that may be necessary to deliver the baby are much more likely to damage other pelvic joints and the bladder neck ligaments, increasing the risk of subsequent stress incontinence and problems with mobility; Malpresentations such as face, brow or transverse lie; A history of a repaired VVF when elective CS should be performed but this may be a council of perfection. Hopefully it will have been emphasised to such patients that they should report to a Comprehensive Emergency Obstetric Care centre (CEOC) in good time for elective section in subsequent pregnancies.
Relative contraindications
Relative contraindications to symphysiotomy are:
Older patients appear to suffer a greater risk of severe stress incontinence while teenagers have few subsequent problems; Obesity may make it difficult to identify the anatomy and assess the size of the baby. Overweight patients also have a greater risk of subsequent mobility problems; A previous symphysiotomy may make the urethra adherent to the back of the symphysis and difficult to displace. The feel also of cutting through a fibrous rather than a cartilaginous joint will be very different, and its division more difficult; A history of a previous CS, or previous VVF repair are usually strict indications for CS in the subsequent pregnancy, but if a CS will take hours or is impossible to organize, a symphysiotomy may well prevent a ruptured uterus.
Alternatives to symphysiotomy
Alternatives to symphysiotomy are:
Caesarean section – if the baby is alive. However, this option may not be acceptable to the woman or her family and in the rural areas of a LMIC will not be an available option. CS can only be performed in a CEOC, and these are few and far between. Forceps delivery – but this is likely not only to be difficult in a grossly obstructed labour but will very probably cause serious damage to the mother’s oedematous tissues and the fetus. For this reason forceps should, in most circumstances, never be used following failure with the vacuum extractor. A destructive operation – if the baby is dead or grossly deformed and unlikely to survive.
Advantages of symphysiotomy over Caesarean section
There are numerous advantages of symphysiotomy over CS. These are: It is a far simpler procedure; It requires the minimum of inexpensive equipment; Blood loss is minimal, which is especially important if the patient is anaemic; It avoids the need for, and the risks of, spinal or general anaesthesia. It allows the mother the possibility of a vaginal delivery; The joint heals by fibrous union so that the pelvis will usually remain permanently broader, leading to easier vaginal delivery in subsequent pregnancies; It will be life-saving for the baby when the after-coming head of the breech becomes stuck; It may be life-saving for both mother and baby where CS is not available and will diminish the morbidity to both if speedy transfer to a CEOC is not possible; It has fewer and less serious complications than CS with no recorded deaths from operative or anaesthetic complications; Most importantly, it avoids a scar in the uterus and the added risks of an unsupervised birth in subsequent pregnancies; It avoids the need for transfer to a CEOC for a trial of scar in subsequent pregnancies; It avoids the need to disimpact the fetal head from deep within the pelvis at CS. This may be very difficult, leading to tearing of the thin, oedematous and bruised lower segment which readily bleeds copiously and is often very difficult to repair, as well putting considerable mechanical stress on the fetal head potentially causing cerebral damage; In the presence of intra-uterine sepsis, it avoids the risk of intra-peritoneal septic spread; It carries a lower risk of exposure for the operator in the presence of HIV, or hepatitis; It may carry a lower risk of mother-to-fetus HIV transmission after the rupture of membranes, if the delivery is fast (effected in less than 10 min) and the alternative is having to wait 2 h or more for a CS. The latter may anyway not provide any real benefit as a prophylactic measure if the fetus is exposed to maternal fluids for 4 h or more.
Complications
In an extensive review of published papers relating to 5000 symphysiotomies carried out in 28 countries on four continents between 1900 and 1999, 14 there were only two reported cases of maternal death directly related to the procedure. These both involved sepsis and occurred in the pre-antibiotic area. The morbidity was no greater than that of CS.
Stress incontinence, backache and problems with gait remain the main concerns. The incidence of these complications was minimal in the papers reviewed. In the author’s personal experience, they were problems rarely mentioned by patients in the postnatal clinics in Tanzania, despite theirs being a society where women carry out much of the agricultural manual labour.
Specific complications are urethral damage, owing to the urethra not being laterally displaced and osteitis pubis, owing to incision into bone rather than the cartilage of the symphyseal joint. Both rarely occurred and are readily avoided if the correct procedural steps are followed.
Problems of gait are likely to be attributable to allowing the legs to fall apart, or permitting too early unassisted mobilisation and thus stressing the sacral ligaments. If fetal hydrocephalus is unrecognised, a very large fetal head may stretch the symphysis excessively during vaginal delivery and cause pelvic instability.
Urinary infection is a risk, but no more so than in CS.
The risk of HIV transmission from mother to fetus may be increased by using a vacuum (through abrasions on the fetal head), but this may be countered by using chlorhexidine cream on the vacuum cup.
The risk of injury to the surgeon’s finger has not been reported, unlike the significant risk of needle stick injury at CS.
Description of the procedure itself
Preparation
The necessary equipment consists of: a delivery bed with lithotomy poles; a standard delivery set; two pairs of sterile gloves; local anaesthetic solution; syringe; and a urinary catheter and a scalpel. The apparatus for vacuum extraction is a prerequisite to correct performance of symphysiotomy. Two assistants, apart from the labour ward attendant, are virtually indispensible. Finally, a walking frame or trolley with wheels is needed to assist early ambulation during post-delivery care.
A careful history and examination – looking for any contraindications or signs of uterine rupture and/or fistula formation – is mandatory. Such patients will need immediate referral on to a CEOC, if at all possible.
The fetal presenting part should be the vertex and the cervix fully dilated. Experienced operators may wish to proceed even at 8 cm cervical dilation if it is well thinned out.
No more than two-fifths of the fetal head should be palpable per abdomen. Of note, a grossly moulded fetal head with caput formation may be visible at the vaginal introitus while there is still three-fifths or more of the head palpable per abdomen. It is therefore essential carefully to assess how much of the fetal head is palpable above the symphysis before carrying out a vaginal assessment.
The fetal heart must be auscultated and any signs of fetal distress noted – the fetus must be alive. Signs of fetal distress are not contraindications to the procedure, but on the contrary predicate a speedy delivery possible by symphysiotomy.
A trial by vacuum extraction – as per local protocol – should be attempted, but forceps never used.
The surgical intervention
The procedure is well described in a number of textbooks and manuals;3,15–17 all describe variations of Zarate’s technique, 18 which seeks to avoid complete division of the fibrous ligaments around the symphyseal joint thereby diminishing the possibility of pelvic instability.
As with any surgical procedure, it is essential to explain the proposed procedure to the mother and obtain her consent. Even in an emergency situation, where time is of the essence, this should not be omitted.
Throughout the procedure, strict attention must be paid to antiseptic technique and it would be wise to employ double gloving, especially if the patient is known to be HIV positive, or a high prevalence of HIV exists in the community.
Two assistants should be asked carefully to hold and stabilize the patient’s legs inside the lithotomy poles and ensure that the abduction angle between the legs is never allowed to exceed a maximum of 90 degrees, i.e. each leg is abducted a maximum of 45 degrees from the midline.
Insertion of index finger or left hand behind symphysis to protect bladder and urethra.
The fetal heart is re-checked before the procedure is commenced. Careful antiseptic cleaning of the vulva is carried out and the bladder is catheterised.
The vulva is anaesthetised with 10 mL 0.5% lidocaine with adrenaline, to allow also for an episiotomy. The skin over the mons pubis is also anaesthetised, carrying the needle down in the midline, into the symphyseal joint itself, using a similar amount of lidocaine.
The non-dominant index finger is inserted into the vagina to displace the urethra sideways – this may entail displacing the head upwards a little (Figure 1), ensuring that the index finger is lying centrally and tightly against the back of the symphysis and that the urethra is pushed well laterally. The finger is kept behind the symphysis until the operation is complete.
Incision of middle and lower third fibres of symphysis.
The symphysis is palpated, feeling for the midline depression in the symphysis cartilage and then, with a stabbing motion, the skin is pierced over the mons. The incision should be made in the midline and carried vertically downwards into the centre of the joint. When the blade has cut through the cartilage, the pressure of the blade point will be felt against the internal finger. The thick band of ligamentous tissue behind the symphysis is not divided, and so protects the surgeon’s finger. The blade is then gently withdrawn a few millimetres and the cartilage cut through with a downwards sweeping (rather than ‘sawing’) movement to divide the lower half of the synostosis. The knife is then withdrawn from the joint, reversed, re-inserted and an upward sweeping movement made to divide the upper portion of the synostosis (Figures 2 and 3).
Incision of middle and upper fibres of symphysis.
Cutting cartilage is rather like cutting through a raw sweet potato. While there may be advantages in using a fixed blade, disposable blades are perfectly adequate, and much more readily available and the norm in most places. Size 21 or 22 blades are ideal.
The pubic bones are allowed to separate. At this point, the assistants must be careful not to let the legs fall further apart. The head will begin to descend. An episiotomy is then mandatorily performed.
Upon encouraging the mother to bear down, the head will often deliver with remarkable ease. Occasionally the head will come down extremely rapidly and open the symphysis 4–5 cm. The importance of holding the legs and not allowing stress on the sacral ligaments cannot be over-emphasised.
Re-application of the cup of the vacuum extractor to assist the delivery may, however, still be necessary and some prefer to leave the cup attached while carrying out the procedure. Delivering the baby with the vacuum extractor does allow more control in the delivery and may help avoid friction in the area of the urethra.
Forceps are never used to deliver the fetus after dividing the symphysis: nothing other than the vacuum cup should be inserted into the vagina once the symphysis has been divided.
After delivery, one or two sutures may need to be inserted to close the tiny skin incision. The knees should then be brought together and pressure applied to pubis which will prevent postoperative haematoma formation.
The legs are then gently lowered and strapped together at the knees. This is primarily done to prevent unassisted mobilisation too soon. The patient is then moved from the delivery bed and encouraged to lie on her side. This too will help to also compress the joint and stop any bleeding. Leg strapping is maintained for 24 h.
Aftercare
Catheter drainage is maintained until the patient has been mobilised. Suspicion of a VVF as a result of the obstructed labour may, however, not be immediately evident and take 72 h to present itself as necrotic tissue sloughs away. Consequently, the catheter is retained for 10 days if there has been over 6 h of obstructed labour in the second stage, or any haematuria.
If there is evidence of pre-existing fever or infection, a combination of antibiotics – Ampicillin, Gentamycin and Metronidazole – is useful. Analgesia is administered as necessary.
Most patients wish to mobilise as soon as possible. It is important that a careful watch is kept to prevent unassisted early mobilisation. A fall at this stage, before the joint has healed, can injure urethral and bladder suspensory ligaments and cause stress incontinence later. A recommendation of 3–5 days of bed rest before mobilising with a walking frame, trolley or light chair is usual. An assistant should be available to assist walking for the first 2–3 days.
Advice concerning subsequent pregnancies
The author was personally involved with 120 patients who underwent symphysiotomy at the Kilimnajaro Christian Medical Centre in Tanzania between 1973 and 1978. A study of 105 of these cases was subsequently published with an emphasis on 39 patients who were followed through 47 subsequent pregnancies. 5 Spontaneous delivery was achieved by 32 women and a further seven were delivered vaginally by vacuum extraction. In 14/47 cases the baby was larger than the first and in 12 of these cases the baby was delivered vaginally.
Seven patients needed CS and one ruptured a previous CS scar. The latter was the only perinatal loss and there were no maternal fatalities. Three patients complained of some symphyseal pain immediately after delivery which had disappeared by the fifth day.
Discussion
The fact that symphysiotomy is considered inappropriate in a rich developed nation like Ireland does not mean it is necessarily inappropriate for other parts of the world. Unfortunately, the fact that it is not practised in resource-rich nations and very few obstetricians trained in those countries have any practical experience of its use, has given it an ‘inferior’ status in the eyes of many overseas practitioners. It has often been said that ‘if you don’t practice it in your country, why should we do so here?’
However, the recent Irish report and many other publications over the years have clearly stated and demonstrated that symphysiotomy does have a role in the management of established obstructed labour in LMICs.
A 2010 review for the Cochrane Library 19 concludes that ‘the procedure has a potentially life-saving role in the developing world and with proper training and aftercare, offers a clinically acceptable response to obstructed labour where Caesarean section is unavailable or unacceptable’.
The fact that the MOET Manual, 20 a core training text for British obstetricians and midwives, developed under the auspices of the Royal College of Obstetricians and Gynaecologists for those planning to work in LMICs, and the WHO Manual 3 both include sections on its place in the obstetrician’s armamentarium, should validate it.
Primary Surgery 16 – a ‘Bible’ for all surgeons who are working in resource-poor countries describes it as ‘an invaluable operation which needs to be reinstated and given its proper place in obstetric practices in poorly-resourced centres’.
In the detailed review of 5000 symphysiotomies referred to earlier, 14 the author compares the results of the procedure with 1200 Caesarean sections. He comes to the conclusion that ‘there is considerable evidence to support a re-instatement of symphysiotomy in the obstetric arsenal for the benefit of women in obstructed labour and their offspring’. He found it to be safe for the mother, conferring permanent pelvic enlargement which facilitates vaginal delivery in future pregnancies and is life-saving for the child. Severe complications were rare and it compared favourably with CS.
In many resource-poor countries it is not unusual for women in the rural areas to have to walk for days to get to a road where they will then have to await transport to get them to a place providing basic emergency obstetric care (BEOC), which will not be equipped to carry out CS. An alternative approach to delivery will save valuable time spent in waiting for a transfer to a CEOC and the added complications which that delay might cause.
The fact that the obstruction can be quickly overcome by symphysiotomy, that it does not require expensive equipment, that it can easily be taught to healthcare professionals (and so carried out in a BEOC) must give this procedure credence. Furthermore if precious time can be saved, the life of the baby saved, rupture of the uterus avoided, and the severity of necrosis of the vaginal wall substantially reduced, it may even be considered a spectacularly beneficial intervention. The fact that the uterus is left unscarred in the process diminishes the risk of subsequent rupture; that the pelvis may be permanently widened enables the woman often to be able to deliver vaginally in future pregnancies. Surely all these factors mean the procedure has much to commend it?
Those who work or have worked in a resource-poor country will be acutely aware of the patients they have seen who avoided attending for antenatal care and hospital delivery for fear of having to have a CS simply because they or their family wished for a vaginal delivery. In many instances, the outcome was either a VVF, a dead baby, a ruptured uterus and/or a maternal death. All these could be avoided with the safe alternative of correctly performed symphysiotomy.
Doctors are enjoined to provide the best for their patients in all circumstances. There are occasions when symphysiotomy is the best procedure to offer. It is therefore incumbent upon obstetric practitioners to develop and maintain all the skills necessary to provide an effective service for their patients. Much has been written about symphysiotomy but little is being done to give trainees ‘hands on’ practical experience on how to do it. There are now perhaps only a few practitioners left with the necessary skills to teach the procedure! However, it is surely not beyond the wit of man to design a model or simulator to allow todays’ obstetricians and midwives to learn and practice the skill and keep that skill alive.
Conclusions
Symphysiotomy has a very real place in managing established obstructed labour in LMICs. When correctly performed by trained operators in appropriate circumstances, it can be life-saving for both mother and baby and has long-term benefits in future pregnancies. Even in sophisticated circumstances, there may be the rare occasion when this skill can be life-saving – in dealing with the trapped after-coming head of a breech. All obstetricians should therefore know how to perform a symphysiotomy, and when to use it.
In dealing with one of the consequences of obstructed labour – rupture of the uterus – it has been wisely said 21 that ‘the correct procedure in each individual case is the one which is the shortest and produces the least shock and thus gets the patient off the operating table in the best condition’. There is little doubt that symphysiotomy (with vacuum extraction) is such a procedure for the indications described.
Footnotes
Acknowledgements
The author would like especially to thank Douwe AA Verkuyl
Declaration of conflicting interest
None declared.
Funding
This research received no specific grant from any funding agency in the public, commercial or non-profit sectors.