ArticleLiterature Review

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

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

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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. Retrospective review of literature. Five thousand symphysiotomies and 1200 caesarean sections from 28 countries on four continents. 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. 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. 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. 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.

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... A UF or mater- (6) one-third of the women with UF were 515 years at the time their UF developed). Therefore, probably, the parturient will labor successfully outside a medical facility the next time or reach one alive and in time (8,11,13,14). The health worker is not unlikely to be reprimanded when all goes well. ...
... There is absolutely no evidence in the literature that (long term) morbidity and mortality are higher (as opposed to different) after a ST than after a CS (2,8,14). Quite the opposite. ...
... Quite the opposite. But whatever proper evidence (8) is collected, it is largely ignored in Africa, with marked exceptions (14). The documented (as opposed to the rumoured) complication rate of ST has little to do with the unpopularity of the operation. ...
... Björklund recently reviewed the literature on symphysiotomy published in the twentieth century [1]. There were three criteria for including a study in the review: (1) the cases reported had to be consecutive; (2) the studies had to include an acceptable description of methodology; and (3) the study size was set at a minimum of 25 cases for analysis of maternal and foetal mortality. ...
... • Symphysiotomies do not cause maternal mortality. In a systematic review of the literature Björklund found no fatal maternal complications in the period after 1950 (the era of antibiotics) directly caused by symphysiotomies [1]. Such lethal complications are probably as rare as are fatalities caused by episiotomies. ...
... Björklund's meta-analysis of 5,000 symphysiotomies [1] showed that a woman who had a symphysiotomy did better than a woman who had a CS in relation to the index delivery, as well as in future deliveries when she would have a larger pelvis and no uterine scar. However, this is an inaccurate comparison for the circumstances prevailing in many hospitals in Africa. ...
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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.
... Hiermee neemt de diameter van de bekkeningang met circa 4 mm toe. 5 De kans dat door het openen van de symfyse ook de beide sacro-iliacale(SI)-gewrichten scheuren en er complete instabiliteit van het bekken ontstaat, is nagenoeg nihil. Het scheuren van de zwakkere anterieure SI-gewrichten trad bij de onderzochte kadavers pas op bij circa 8 cm diastase, terwijl de sterke posterieure SI-gewrichten, die essentieel zijn voor de stabiliteit van het bekken, zelfs relaxeerden en onaangetast bleven door de fysiologische verweking tijdens de zwangerschap. ...
... De maternale morbiditeit en mortaliteit van symfysiotomie zijn gering. 5 De incidentie van korte-termijncomplicaties binnen 6 weken, zoals obstetrische fistels, stressincontinentie, hematoom, osteïtis en pijn bij lopen, is < 5%. De incidentie van lange-termijncomplicaties, binnen 1-10 jaar, is ook laag: 5% stressincontinentie, 6% pijn in de symfyse of SI-gewricht en 0% pijn bij lopen. ...
... De incidentie van lange-termijncomplicaties, binnen 1-10 jaar, is ook laag: 5% stressincontinentie, 6% pijn in de symfyse of SI-gewricht en 0% pijn bij lopen. 5 De maternale mortaliteit daalde sterk in de tweede helft van de 20e eeuw na de introductie van antibiotica, van 40 sterfgevallen onder 2507 vrouwen met symfysiotomie (1,6%) naar 3 sterfgevallen onder 1954 vrouwen met symfysiotomie (0,16%). De laatste 3 sterfgevallen betroffen 2 maal eclampsie en 1 maal longembolie. ...
Article
Symphysiotomy to manage shoulder dystocia is seldom used in the western world. For this reason, in well-resourced countries knowledge of its recuperation rate and the management of physical discomfort in the post-partum period is scarce. We describe two cases of symphysiotomy for shoulder dystocia. Both babies did very well in the postpartum period. The short-term 6-week and 6-month follow-up of both mothers is described. Short-term maternal complications were minor and based on prolonged immobilization. In accordance with the international literature, the short-term and long-term follow-up after symphysiotomy for shoulder dystocia was good and there were no major maternal or neonatal complications. We therefore wish to advocate symphysiotomy as a good and safe option to deliver a baby in cases of severe shoulder dystocia, when all other manoeuvres fail.
... Symphysiotomy is a potential solution in selected cases of obstructed labour with mild to moderate cephalopelvic disproportion [12,[16][17][18]. A review of 5,000 symphysiotomies performed during the twentieth century concluded that: ''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'' [16]. ...
... Symphysiotomy is a potential solution in selected cases of obstructed labour with mild to moderate cephalopelvic disproportion [12,[16][17][18]. A review of 5,000 symphysiotomies performed during the twentieth century concluded that: ''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'' [16]. A theoretical model shows that under basic circumstances only a few symphysiotomies are needed to prevent one maternal death [19]. ...
... There are no reports of maternal mortality directly related to symphysiotomy from the antibiotic era [16]. There are still large regional differences in CS-related mortality. ...
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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.
... Symphysiotomy is performed during attempted vaginal delivery by dividing the fibrocartilagenous joint of the symphysis pubis. Though rarely required in current obstetric practice, it can be a life-saving procedure in remote, resource-limited settings [1]. Physiological changes during pregnancy and labour cause significant relaxation of supporting ligaments and other connective tissue of the pelvis. ...
... Several reports have mentioned that the majority of spontaneous pubic ruptures do well with conservative treatment [1,2,15,16]. Bed rest, pelvic binder, special braces and local steroid injection provides good symptomatic relief in the majority of cases in acute settings. ...
Article
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A 35-year-old female presented with right-sided gluteal pain and difficulty in walking 10 years after surgical symphysiotomy. Radiograph of the pelvis and bilateral hip joints showed osteoarthritis of the right sacroiliac joint with pubic diastasis of 1.5 cm. She was operated with pubis symphysis reduction and fixation using two orthogonal plates with one iliosacral screw. Postoperative period was uneventful. She was able to walk independently after three months of fixation. Follow-up at 18 months showed complete relief of symptoms with maintenance of reduction and no hardware breakage. The Lindahl score was 78, indicating an excellent outcome.
... Lower limb abduction should be avoided for 7-10 days. (35) What are the main maternal and neonatal complications associated with shoulder dystocia? ...
... Prevention WHO states that reducing the incidence of unscarred uterine ruptures requires reducing unwanted pregnancies, particularly for women of high parity; increasing the ability to access obstetric services including C-section for obstructed labor; using innovative methods, such as symphysiotomy [8] or C-section with local anesthesia where conventional C-section facilities are not available; and using guidelines to ensure that only safe doses of misoprostol are used for labor induction. ...
Article
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Reducing maternal mortality constitutes one of the eight Millennium Development Goals. While significant progress has been made, system issues and professional training continue to affect maternal survival, especially when unusual, but deadly, complications arise. This rare case of survival after the rupture of an unscarred uterus in a grand multiparous woman from a remote village in Ghana illustrates how systemic transportation issues and limited access to advanced medical care put women with obstetric complications at risk. The usual clinical presentation of ruptured uteri and methods to prevent this catastrophic event are discussed. This case illustrates the systemic transportation issue that often limits access to prenatal and emergency care throughout much of the developing world and demonstrates how advanced training for emergency nurses and the use of ultrasound diagnosis can expedite difficult diagnoses and lead to maternal survival, even in the most adverse circumstances.
... WHO states that reducing the incidence of unscarred uterine ruptures requires reducing unwanted pregnancies, particularly for women of high parity; increasing the ability to access obstetric services including C-section for obstructed labor; using innovative methods, such as symphysiotomy [8] or Csection with local anesthesia where conventional C-section facilities are not available; and using guidelines to ensure that only safe doses of misoprostol are used for labor induction. ...
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For the world's 60 million non-facility births, addressing who is currently attending these births and what effect they have on birth outcomes is a key starting point toward improving care during childbirth. We present a systematic review of evidence for the effect of community-based cadres-community-based skilled birth attendants (SBAs), trained traditional birth attendants (TBAs), and community health workers (CHWs)-in improving perinatal and intrapartum-related outcomes. The evidence for providing skilled birth attendance in the community is low quality, consisting of primarily before-and-after and quasi-experimental studies, with a pooled 12% reduction in all cause perinatal mortality (PMR) and a 22%-47% reduction in intrapartum-related neonatal mortality (IPR-NMR). Low/moderate quality evidence suggests that TBA training may improve linkages with facilities and improve perinatal outcomes. A randomized controlled trial (RCT) of TBA training showed a 30% reduction in PMR, and a meta-analysis demonstrated an 11% reduction in IPR-NMR. There is moderate evidence that CHWs have a positive impact on perinatal-neonatal outcomes. Meta-analysis of CHW packages (2 cluster randomized controlled trials, 2 quasi-experimental studies) showed a 28% reduction in PMR and a 36% reduction in early neonatal mortality rate; one quasi-experimental study showed a 42% reduction in IPR-NMR. Skilled childbirth care is recommended for all pregnant women, and community strategies need to be linked to prompt, high-quality emergency obstetric care. CHWs may play a promising role in providing pregnancy and childbirth care, mobilizing communities, and improving perinatal outcomes in low-income settings. While the role of the TBA is still controversial, strategies emphasizing partnerships with the health system should be further considered. Innovative community-based strategies combined with health systems strengthening may improve childbirth care for the rural poor, help reduce gross inequities in maternal and newborn survival and stillbirth rates, and provide an effective transition to higher coverage for facility births.
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We analysed the data from a hospital that had practiced symphysiotomy and caesarean section (c/s) for many years and where symphysiotomy was acceptable to the parturient women, in order to determine the effects of symphysiotomy on c/s and on the overall operative delivery rates. Regression analysis revealed significant negative correlation between symphysiotomy and c/s (R = -0.610, P = 0.03 at 95% confidence interval [CI]) and a non-significant negative correlation between symphysiotomy and combined operative deliveries (R = -0.108, P = 0.383 at 5% CI). This study has confirmed that, in our environment, the practice of symphysiotomy significantly reduces the c/s rate and may save some women from operative deliveries in subsequent pregnancies. With the widespread aversion for c/s in the developing countries and a preference for symphysiotomy in some communities, symphysiotomy should be offered as an alternative to c/s whenever possible. Urgent revival of the dying skill of symphysiotomy is recommended in developing countries.
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In developed countries there is a tendency towards a small family size especially as there is a good social security system. Good nutrition is assured for the greater majority of children. Pelvic growth is usually optimal resulting in a low prevalence of cephalopelvic disproportion (CPD). Obstetric services are excellent with a low prevalence of obstructed labour; and there is little aversion to caesarean delivery. In fact delay in performing a caesarean section is often the reason for litigation. Both the obstetrician and the parturient usually concur when the need for a caesarean section arises. For the above reasons symphysiotomy is rarely necessary and has been abandoned in those countries. On the other hand most developing countries notably in Africa are characterised by large family sizes (in the absence of a good social security system). In addition they also have a high prevalence of obstructed labour from CPD (usually secondary to poor nutrition during childhood); poor obstetric services; and a cultural dislike for caesarean delivery. Because of the dislike for caesarean delivery and other factors symphysiotomy has been advocated for the management of obstructed labour resulting from CPD in resource-poor settings. (excerpt)
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Intrapartum-related neonatal deaths ("birth asphyxia") are a leading cause of child mortality globally, outnumbering deaths from malaria. Reduction is crucial to meeting the fourth Millennium Development Goal (MDG), and is intimately linked to intrapartum stillbirths as well as maternal health and MDG 5, yet there is a lack of consensus on what works, especially in weak health systems. To clarify terminology for intrapartum-related outcomes; to describe the intrapartum-related global burden; to present current coverage and trends for care at birth; and to outline aims and methods for this comprehensive 7-paper supplement reviewing strategies to reduce intrapartum-related deaths. Birth is a critical time for the mother and fetus with an estimated 1.02 million intrapartum stillbirths, 904,000 intrapartum-related neonatal deaths, and around 42% of the 535,900 maternal deaths each year. Most of the burden (99%) occurs in low- and middle-income countries. Intrapartum-related neonatal mortality rates are 25-fold higher in the lowest income countries and intrapartum stillbirth rates are up to 50-fold higher. Maternal risk factors and delays in accessing care are critical contributors. The rural poor are at particular risk, and also have the lowest coverage of skilled care at birth. Almost 30,000 abstracts were searched and the evidence is evaluated and reported in the 6 subsequent papers. Each year the deaths of 2 million babies are linked to complications during birth and the burden is inequitably carried by the poor. Evidence-based strategies are urgently needed to reduce the burden of intrapartum-related deaths particularly in low- and middle-income settings where 60 million women give birth at home.
Article
In developed countries there is a low prevalence of obstructed labor and little aversion to cesarean delivery. In fact delay in performing a cesarean section often results in lawsuits. For these reasons symphysiotomy is rarely necessary and has been abandoned in those countries. However developing countries are characterized by a high prevalence of obstructed labor (from cephalopelvic disproportion—CPD) poor obstetric services and a cultural dislike for cesarean delivery. Because of the dislike for cesarean delivery and the higher mortality and morbidity associated with cesarean section than symphysiotomy for obstructed labor symphysiotomy has been advocated for the management of obstructed labor from CPD in resource-poor settings. Despite this we have observed surprisingly that indigenous Nigerian obstetricians rarely offer symphysiotomy as a therapeutic option for obstructed labor because they consider it dangerous compared with cesarean section. Currently we do not know whether Nigerian women prefer symphysiotomy or cesarean section for obstructed labor. The objective of this study was to determine the preferences for either symphysiotomy or cesarean section for obstructed labor in a Nigerian obstetric population. (excerpt)
Article
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Malpresentations of the fetus may arise by chance but can also be associated with maternal or fetal pathology. Excluding pathology is an important preliminary in their management, but even then they are associated with increased risks to both mother and fetus including prolonged labour, cord prolapse, traumatic delivery and Caesarean section. Early diagnosis and expert timely management are the cornerstones of good obstetric care generally, but they are crucial when malpresentations are first recognized in labour.The increasingly liberal use of Caesarean section combined with the reduction in junior doctor working hours is decreasing clinical exposure and experience to these relatively rare obstetric complications. They will continue to occur, however, and therefore training to acquire and maintain skills in clinical assessment, decision making and obstetric manoeuvres requires urgent attention.
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Background Shoulder dystocia is an obstetric emergency which occurs in 0.2–3% of all births ACOG Committee on Practice Bulletins-Obstetrics and The American College of Obstetrician and Gynecologists (2002) . Symphysiotomy is a treatment option reserved primarily for developing countries where mortality rates of Cesarean delivery are 1–2% Monjok et al. (2013) . Case A G3P2002 with a history of two prior vaginal deliveries had a term delivery complicated by a severe shoulder dystocia. She underwent emergent symphysiotomy at an outside institution, with delivery of a dead macrosomic infant. She was transferred to our tertiary care center for further care. Conclusion Symphysiotomy is rarely performed in the United States. We submit our postoperative management to add to the literature of this rarely performed obstetric intervention. Précis Symphysiotomy for severe shoulder dystocia is rarely utilized in the United States. We describe a case of symphysiotomy done for severe shoulder dystocia at an outside institution, and the patient's subsequent care at our institution.
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Shoulder dystocia is a complication of vaginal delivery and the primary factor associated with brachial plexus injury. In this review, we discuss the risk factors for shoulder dystocia and propose a framework for the prediction and prevention of the complication. A recommended approach to management when shoulder dystocia occurs is outlined, with review of the maneuvers used to relieve the obstruction with minimal risk of fetal and maternal injury.
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Background: Rupture of uterus is a catastrophic complication associated with significant maternal and fetal morbidity and mortality. The prevalence of an unscarred uterine rupture is very rare. Although the most important complication of dilatation and curettage is perforation of uterus, dilatation and curettage is not introduced as an important cause of uterine rupture. Case presentation: Here we present a case of uterine rupture in a pregnant woman that was admitted in Tehran General Women Hospital, in December 2014, with reducing fetal movement in her 41th weeks of pregnancy. She did not have any risk factors for rupture of uterus including cephalo-pelvic disproportion and polyhydramnios, also there was no history of uterine surgery such as myomectomy and uterine abnormality repair. A term dead male neonate was delivered by cesarean section due to arrest of descending in stage 2 of labor. The baby weighed 3400 gr and had anomaly in ears, larynx, uvula and soft palate. Its chromosomal study depicted both trisomy and monosomy for chromosome 13 and 21. Mother had a history of illegal curettage and trauma to the uterus in her first pregnancy two years ago. She did not say to us this history and abortion during admission. After cesarean section we saw that in the left side of the posterior wall of uterus was ruptured and baby was died. At surgical exploration, moderate hemoperitoneum was evident. Fetus was already dead at the time of extraction. Total estimated blood loss was 100 ml, the patient was transfused with two units of packed cell. The woman was discharged on the fifth postoperative day in good condition. Conclusion: Effective contraception and safe curettage can reduce maternal mortality and morbidity. Also special attention to a history of curettage to predict uterine rupture is critical.
Article
Background. This study describes the demographics and clinical characteristics of women with obstetric fistulas attending the urogynaecological unit at King Edward VIII Hospital (KEH), KwaZulu-Natal (KZN), South Africa. Method. A prospective clinical review of all women admitted with the diagnosis of an obstetric fistula at KEH from 1999 to 2003. Results. A total of 41 cases from the rural areas of KZN and the Eastern Cape were identified. The mean age as 29 years (range 15-51 years), and 21 were primigravidas, 14 of whom had unplanned pregnancies. All were from low socioeconomic backgrounds and had limited or no access to antenatal care, either due to their social circumstances or to lack of health care facilities. The duration of labour was prolonged in all; there were 5 live births, and 2 neonatal deaths. Conclusion. Obstetric fistulas are still common in KZN and the Eastern Cape, and occur mainly in women from rural areas.
Article
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. © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.
Article
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. 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. 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). 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. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Article
Each year 1.02 million intrapartum stillbirths and 904,000 intrapartum-related neonatal deaths (formerly called "birth asphyxia") occur, closely linked to 536,000 maternal deaths, an estimated 42% of which are intrapartum-related. To summarize the results of a systematic evidence review, and synthesize actions required to strengthen healthcare delivery systems and home care to reduce intrapartum-related deaths. For this series, systematic searches were undertaken, data synthesized, and meta-analyses carried out for various aspects of intrapartum care, including: obstetric care, neonatal resuscitation, strategies to link communities with facility-based care, care within communities for 60 million non-facility births, and perinatal audit. We used the Lives Saved Tool (LiST) to estimate neonatal deaths prevented with relevant interventions under 2 scenarios: (1) to address missed opportunities for facility and home births; and (2) assuming full coverage of comprehensive emergency obstetric care and emergency newborn care. Countries were first grouped into 5 Categories according to level of neonatal mortality rate and examined, and then priorities were suggested to reduce intrapartum-related deaths for each Category based on health performance and possible lives saved. There is moderate GRADE evidence of effectiveness for the reduction of intrapartum-related mortality through facility-based neonatal resuscitation, perinatal audit, integrated community health worker packages, and community mobilization. The quality of evidence for obstetric care is low, requiring further evaluation for effect on perinatal outcomes, but is expected to be high impact. Over three-quarters of intrapartum-related deaths occur in settings with weak health systems marked by low coverage of skilled birth attendance (<50%), low density of skilled human resources (<0.9 per 1000 population) and low per capita spending on health (<US $20 per year). By providing comprehensive emergency obstetric care and emergency newborn care for births already occurring in facilities, 327,200 intrapartum-related neonatal deaths could be averted globally, and with full (90%) coverage, 613,000 intrapartum-related neonatal deaths could be saved, primarily in high mortality settings. Even in high-performance settings, there is scope to improve intrapartum care and especially reduce impairment and disability. Addressing missed opportunities for births already occurring in facilities could avert 36% of intrapartum-related deaths. Improved quality of care through drills and audit are promising strategies. However, the majority of deaths occur in poorly performing health systems requiring urgent strategic planning and investment to scale up effective care at birth, neonatal resuscitation, and community mobilization as well as to develop, adapt, and introduce tools, technologies, and task shifting to reach the poorest.
Article
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Rectal foreign bodies (RFB) present the modern surgeon with a difficult management dilemma, as the type of object, host anatomy, time from insertion, associated injuries and amount of local contamination may vary widely. Reluctance to seek medical help and to provide details about the incident often makes diagnosis difficult. Management of these patients may be challenging, as presentation is usually delayed after multiple attempts at removal by the patients themselves have proven unsuccessful. In this article we report the case of a male who presented with a large ovoid rectal object wedged into his pelvis. As we were unable to extract the object with routine transanal and laparotomy approach, we performed a pubic symphysiotomy that helped widen the pelvic inlet and allow transanal extraction. We review currently available literature on RFB and propose an evaluation and management algorithm of patients that present with RFB. Management of patients with rectal foreign bodies can be challenging and a systematic approach should be employed. The majority of cases can be successfully managed conservatively, but occasional surgical intervention is warranted. If large objects, tightly wedged in the pelvis cannot be removed with laparotomy, pubic symphysiotomy should be considered.
Article
Should the indications for therapies differ from one nation to the next? What are the reasons behind controversial therapeutic variations? What roles do cultural history and authoritarian conflict among clinicians play in the adoption of therapies? When I worked at a rural hospital in Kenya, a woman experiencing obstructed labor made me ponder many questions-but only after our emergency ended in the death of her newborn son. In recounting and learning from this episode, I listened to the disparate Kenyan voices of the patient, the hospital's director, the consultant obstetrician, and to the even more controversial voices of evidence-based medicine. In reflecting on this process, I have learned at least 3 lessons-about the transmissibility of arrogance, the role of guests in other countries, and the nature of science.
Article
To compare the maternal and neonatal outcomes of symphysiotomy (SYM) and cesarean section (CS), when they were performed in women presenting with obstructed labor. 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. 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. 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.
Article
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).
Article
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To explore the possibility that in obstructed labour with a live baby, a delivery by symphysiotomy is an ethical option. Retrospective cohort study. Teaching hospital with busy maternity wards. Women in (nearly) second stage obstructed labour who were either delivered by Caesarean Section (79), or symphysiotomy, (172). Comparing perinatal mortality and morbidity and maternal complications, pain, long term morbidity and subsequent reproductive behaviour. There is no evidence of more foetal mortality or morbidity after a symphysiotomy. Short term maternal morbidity is more serious after Caesarean Section. Long term maternal morbidity might be increased after symphysiotomies, compared with Caesarean Section. Because there are more repeat operative deliveries and trials of scar after a Caesarean Section, future maternal, foetal and infant mortality is higher. Rejection of symphysiotomies as an option for delivery in cases of obstructed labour is not evidence based. It is very likely that lives could be saved if symphysiotomies were taught in the sub-Saharan teaching hospitals and practiced in the district hospitals. Those who oppose symphysiotomies should provide the relevant data.
Article
In high-income countries, national mortality audits are associated with improved quality of care, but there has been no previous systematic review of perinatal audit in low- and middle-income settings. To present a systematic review of facility-based perinatal mortality audit in low- and middle-income countries, and review information regarding community audit. Ten low-quality evaluations with mortality outcome data were identified. Meta-analysis of 7 before-and-after studies indicated a reduction in perinatal mortality of 30% (95% confidence interval, 21%-38%) after introduction of perinatal audit. The consistency of effect suggests that audit may be a useful tool for decreasing perinatal mortality rates in facilities and improving quality of care, although none of these evaluations were large scale. Few of the identified studies reported intrapartum-related perinatal outcomes. Novel experience of community audit and social autopsy is described, but data reporting mortality outcome effect are lacking. There are few examples of wide-scale, sustained perinatal audit in low-income settings. Two national cases studies (South Africa and Bangladesh) are presented. Programmatic decision points, challenges, and key factors for national or wide scale-up of sustained perinatal mortality audit are discussed. As a minimum standard, facilities should track intrapartum stillbirth and pre-discharge intrapartum-related neonatal mortality rates. The effect of perinatal audit depends on the ability to close the audit loop; without effectively implementing the solutions to the problems identified, audit alone cannot improve quality of care.
Article
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.
Article
Full-text available
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.
Article
1. The indications for and technique of symphysiotomy are described. 2. A series of 42 cases is presented to illustrate the place of the operation in the management of disproportion. 3. Records are presented of 18 patients who have undergone one or more labours subsequent to the operation.
Article
One hundred and five women who had a subcutaneous symphysiotomy were compared with 105 women who had a first lower segment Caesarean section. All operations were performed for cephalopelvic disproportion during the years 1961 to 1969. The perinatal mortality for both operations was the same when they were performed for similar indications. There were two maternal deaths after Caesarean section and one after symphysiotomy. In 1971, 109 of the 207 survivors were interviewed and 29 other women were known to be alive. No difference was noted between non-pregnant women who had had a properly performed symphysiotomy and those who had had a lower segment Caesarean section. Subsequent fertility was similar, but delivery was more often associated with problems in the Caesarean section group. In the economic and social conditions prevailing in some developing countries it would be beneficial if subcutaneous symphysiotomy were to replace lower segment Caesarean section in cases of moderate cephalopelvic disproportion.
Article
EDITORIAL COMMENT: This is a scholarly clinical essay and we commend it to readers even if they feel symphysiotomy is not an option in their armamentarium — it will at the very least provide an excellent revision of the possible mechanisms of difficult breech extraction. This paper is a masterpiece with the right amount of repetition to make its central point. Summary: The most dreaded complication of vaginal breech delivery is entrapment of the aftercoming head. When this is due to disproportion, persistent attempts at vaginal extraction are likely to result in a dead or damaged baby. A largely unknown solution in this desperate predicament is to surgically enlarge the pelvis by means of a symphysiotomy. A review of the literature shows that symphysiotomy performed to free the trapped aftercoming head will save at least 80% of babies if the procedure is performed without delay. Every obstetrician should be prepared to perform a symphysiotomy if the aftercoming head is trapped.
Article
105 cases of symphysiotomy to relieve obstructed labor were performed at Kilimanjaro Christian Medical Centre between 1973 and 1977. 70% of the patients were primigravida. In 96 patients the presentation was cephalic, and 9 were breech presentation. The patients were followed at 6 months and 4 years. Complications included urinary infection, stress, incontinence, fistulas, and backache. 39 patients subsequently became pregnant, of whom 7 required cesarean section. Symphysiotomy should be done with a blunt scalpel to avoid damaging other organs. It should be done only to relieve obstructed labor, and repeat symphysiotomy is to be avoided.
Article
One hundred and sixty-one symphysiotomies were performed at Harari Maternity Hospital, Rhodesia, over a 6-year period. Indications for the operation are discussed and fetal and maternal results reviewed. Seventy-two patients suffered from postoperative complications but the majority of these were minor and of short duration. Multiparous patients did not have a higher morbidity than did primiparous ones. It is concluded that symphysiotomy has a useful role to play in a teaching hospital, provided it is performed by an experienced surgeon on carefully selected patients.
Article
Eight symphyseotomies were carried out in a small hospital in rural Africa by a medical generalist during a 2-year period. There were no maternal or infants deaths. Follow-up after 3 years demonstrated the absence of long-term complications. Five patients had later delivered, all normally, four of them at home unattended by medically-trained personnel.
Article
The author compares the value of symphysiotomy to cesarean section in the management of cephalopelvic disproportion. He outlines the history of the procedure and reviews the literature on the subject. He then presents results of 54 symphysiotomies performed from 1976 to 1983 in two rural hospitals in the southwestern highlands of Tanzania, together with the outcome of subsequent labor in 25 other women with a history of previous symphysiotomy. The risk of maternal mortality after symphysiotomy is lower than after cesarean section when performed for cephalopelvic disproportion. Although different in nature, maternal morbidity after both operations is equally common. In contrast with findings reported in the literature, a history of previous symphysiotomy still constitutes a high obstetrical risk. The author concludes that symphysiotomy has a place in the management of cephalopelvic disproportion.
Article
The caesarian section rate at Port Moresby General Hospital (PMGH) is 26.7/1000 and the symphysiotomy rate 2.5/1000 deliveries respectively. 40% of the caesarian sections are for cephalopelvic disproportion and in 50% of these cases the diagnosis is made late in labour; it is this group that is compared with the symphysiotomy group. The morbidities of each group are similar, 64% and 62% respectively. The maternal mortality rate in the caesarian section group was 11.6/1000 and the perinatal mortality 160/1000. There were no maternal deaths in the symphysiotomy group and the perinatal mortality rate was 82/1000. It is recommended that symphysiotomy should be more widely accepted as a safe alternative to caesarian section from both the maternal and foetal point of view.
Article
Experience of 32 cases of symphysiotomy carried out in Mozambique and in Botswana is reviewed. Of all cases only 1 was lost to follow-up. The observation period varied from 7 days to 6 months. Among 31 cases examined at discharge or on return from check-up few complications occurred. Vaginal laceration occurred in 3 cases, haematuria in 1 case and wound infection in 1 case. In 2 cases there was significant postoperative pain causing gait problems, but in no case were there significant problems with pain at discharge or at follow-up. It is concluded that the intervention is seldom complicated by severe sequelae, provided strict adherence to given indications is respected. In rural areas in the third world symphysiotomy is a life-saving and simple surgical intervention, which should be regarded as an adjunct measure in some cases with a moderately contracted pelvic outlet incompatible with normal vaginal delivery.
Article
The width of the symphysis pubis was measured in a skeleton model using slide rule, ultrasonography and x-ray. Ultrasonography gave a 0.5-mm and x-ray a 1.0-mm narrower gap than the slide rule. Further, 15 nonpregnant females undergoing urography volunteered for an extra ultrasonography of the symphysis pubis. The widths of the symphysis as measured from the x-ray exposures and the ultrasonography were compared. Regression analysis gave a regression coefficient of 0.979 and a correlation coefficient of 0.850. Ultrasonography offers at least the same precision as x-ray for assessing the width of the symphyseal gap.
Article
To elucidate whether there is an association between symphyseal distention, circulating relaxin levels and pelvic pain in pregnancy. Serum relaxin and symphyseal width were assessed in 19 consecutive referral cases with severe pelvic pain at 35 weeks of pregnancy and in a cohort of 49 women at 12 and 35 weeks of pregnancy. The referral cases were received over a period of two years and four months and the cohort was recruited over a period of two months. Relaxin was measured with an ELISA test and symphyseal width assessed using ultrasonography. All women with pelvic pain were clinically assessed. The women were divided into three groups; Group A (n= 38), cohort cases with no or mild pain; Group B (n= 11), cohort cases with disabling pain; and Group C (n= 19), referral cases. At 35 weeks of pregnancy, mean symphyseal width was 4.5 mm (s.d. 1.0 mm) in Group A, 5.7 mm (s.d. 2.6 mm) in Group B, and 7.4 mm (s.d. 3.5 mm) in Group C. The difference between Groups A and B is statistically significant (p=0.044) as is that between Groups A and C (p<0.0001). Serum relaxin levels were not associated with symphyseal distention or disabling pain. Severe pelvic pain during pregnancy was strongly associated with an increased symphyseal distention. However, the severity of pain did not predict the degree of symphyseal distention in the individual case, indicating that other mechanisms are also involved. Serum relaxin levels were not associated with the degree of symphyseal distention or with pelvic pain in pregnancy.
Sinfisiotomí partialis (operacion de Zá)
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Palacios Costa N. Sinfisiotomí partialis (operacion de Zá). Bol Soc Chil Obstet Ginec 1943;8:94 – 106.
La sinfisiotomía sub-cutanea parcial de Zárate en el Instituto de maternidad del hospital Alvear
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Rodriguez R. La sinfisiotomía sub-cutanea parcial de Zárate en el Instituto de maternidad del hospital Alvear. Bol Soc Chil Obstet Ginec. 1940 -41:64 -76.