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Symphysiotomy
‘I believe the operation fills a most useful place in practice, and that is the opinion of many others, and if everyone would deliberately struggle against taking up an extensive extreme position with regard to the operation, that place could be more exactly determined’. Munro Kerr, 1908
The operation of symphysiotomy has had a rather chequered history. It was originally performed upon the dead as an alternative to postmortem caesarean section in 1665. It was performed on the living by Jean René Sigault in 1777. The patient was a rachitic dwarf, said to have an obstetric conjugate of 6.5 cm. She had four previous stillborn infants and Sigault performed a symphysiotomy and produced a live child. Symphysiotomy enjoyed some popularity in Europe but this was short lived due to the postoperative urological and orthopaedic morbidity. It enjoyed resurgence in Europe, Ireland and in South America in the late 19th and early 20th centuries.
In modern obstetrics the use of symphysiotomy is almost completely confined to the developing world, although guidelines from developed countries do recommend the use for obstructed after-coming head in breech deliveries.
Symphysiotomy, an operation carried out as an emergency procedure, is the surgical division of the fibrocartilaginous symphysis pubis. It should not be used in anticipation of obstructed labour. A 2–3 cm separation of the pubic symphysis increases the area of the pelvic brim by 15–20% and increases all the pelvic transverse diameters by about 1 cm. This increase is permanent and carries over into subsequent pregnancies. About 85% of women with cephalopelvic disproportion treated by symphysiotomy will deliver vaginally in a subsequent pregnancy.
Although global caesarean section rates have increased dramatically, rates in regions such as sub-Saharan Africa have remained low and largely unchanged from 1990–2014. This has been attributed to health system deficiencies and lack of resources. The World Health Organization therefore recommends that symphysiotomy be performed in areas where caesarean section is not feasible or immediately available.
Indications
Cephalopelvic Disproportion
Women with obstructed labour and mild-to-moderate cephalopelvic disproportion may be managed with symphysiotomy. Symphysiotomy is not indicated in cases of severe disproportion. Thus, only two-fifths or less of the fetal head should be palpable above the maternal pelvic brim and the degree of moulding of the fetal head should not show an irreducible overlap of the cranial bones.
Breech Presentation
A rare but dreaded complication of vaginal breech delivery is entrapment of the after-coming head due to disproportion. This should be rare in a properly conducted labour for vaginal breech delivery. A number of case series have shown that symphysiotomy will save about 80% of such infants. The routine availability of symphysiotomy may influence obstetric choices. Routine caesarean section can be avoided in several cases if the problem of obstruction to the after-coming head can be overcome with symphysiotomy.
Shoulder Dystocia
Symphysiotomy has been proposed as a solution to severe cases of shoulder dystocia that does not resolve with usual manoeuvres. Although this treatment has been suggested, there are very few reported cases and most show poor outcome for both mother and infant.
Maternal Choice/Maternal Health
Symphysiotomy has an important role in countries where cultural factors mitigate against caesarean section for cases of mild-to-moderate cephalopelvic disproportion. This is especially so in some African countries in which caesarean section may be seen as a ‘failure’ of maternal achievement. The procedure may be lifesaving for women who are too ill/unfit for caesarean section.
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