{{Short description|Surgical procedure to widen the pelvis}} {{Infobox medical intervention | Name = Symphysiotomy | Image = Skeletal pelvis-pubis.svg | Caption = The black area marked by a "5" is the pubic symphysis, which is divided during the procedure | ICD10 = | ICD9 = {{ICD9proc|73.94}} | MeshID = | OPS301 = | OtherCodes = | HCPCSlevel2 = }} '''Symphysiotomy''' is a surgical procedure in which the cartilage of the pubic symphysis is divided to widen the pelvis allowing childbirth when the baby has difficulty fitting through the pelvis (obstructed labour). It is also known as '''pelviotomy'''<ref name="dictionary" /> and '''synchondrotomy.'''<ref name="dictionary">{{Cite web |title=symphysiotomy |url=http://dictionary.reference.com/browse/symphysiotomy |archive-url=https://web.archive.org/web/20140107143821/http://dictionary.reference.com/browse/symphysiotomy |archive-date=2014-01-07 |access-date=March 22, 2012 |website=The American Heritage Stedman's Medical Dictionary |via=Dictionary.com}}</ref> It has largely been supplanted by C-sections, with the exception of certain rare obstetric emergencies or in resource poor settings. It is different from pubiotomy, where the pelvic bone itself is cut in two places, rather than cutting through the symphysis pubis joint.<ref>{{Cite OED|term=pubiotomy}}</ref>
==Introduction== Symphysiotomy was advocated in 1597 by Severin Pineau after his description of a diastasis of the pubis on a hanged pregnant woman.<ref>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</ref> Thus symphysiotomies became a routine surgical procedure for women experiencing an obstructed labour.{{Citation needed|date=January 2020|reason=where is the evidence that this was a routine procedure}} 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).<ref>{{Cite journal |last1=Bergström |first1=S. |last2=Lublin |first2=H. |last3=Molin |first3=A. |date=1994 |title=Value of symphysiotomy in obstructed labour management and follow-up of 31 cases |journal=Gynecologic and Obstetric Investigation |volume=38 |issue=1 |pages=31–35 |doi=10.1159/000292441 |issn=0378-7346 |pmid=7959323}}</ref>
==Indications== The most common indications are a trapped head of a breech baby,<ref name=":1">{{Cite journal |last1=Hofmeyr |first1=G Justus |last2=Shweni |first2=P Mike |date=2012-10-17 |editor-last=Cochrane Pregnancy and Childbirth Group |title=Symphysiotomy for feto-pelvic disproportion |journal=Cochrane Database of Systematic Reviews |volume=10 |issue=10 |article-number=CD005299 |language=en |doi=10.1002/14651858.CD005299.pub3 |pmc=7390327 |pmid=23076913}}</ref><ref>{{Cite journal |last1=Kotaska |first1=Andrew |last2=Menticoglou |first2=Savas |date=August 2019 |title=No. 384-Management of Breech Presentation at Term |url=https://linkinghub.elsevier.com/retrieve/pii/S1701216318310405 |journal=Journal of Obstetrics and Gynaecology Canada |language=en |volume=41 |issue=8 |pages=1193–1205 |doi=10.1016/j.jogc.2018.12.018|pmid=31331608 |url-access=subscription }}</ref> shoulder dystocia which does not resolve with routine manoeuvres, and obstructed labor at full cervical dilation, especially with failed vacuum extraction.<ref name=":1" /> Use for shoulder dystocia is controversial.<ref name=":1" />
Currently the procedure is rarely performed in developed countries, but is still performed in "rural areas and resource-poor settings of developing countries"<ref name="monjok2012">{{Cite journal |last1=Monjok |first1=Emmanuel |last2=Okokon |first2=Ita B. |last3=Opiah |first3=Margaret M. |last4=Ingwu |first4=Justin A. |last5=Ekabua |first5=John E. |last6=Essien |first6=Ekere J. |date=September 2012 |title=Obstructed labour in resource-poor settings: the need for revival of symphysiotomy in Nigeria |journal=African Journal of Reproductive Health |volume=16 |issue=3 |pages=94–101 |issn=1118-4841 |pmid=23437503}}</ref> where caesarean sections are not available, or where obstetricians may not be available to deliver subsequent pregnancies.<ref name="pmid17388656">{{Cite journal |last=Verkuyl |first=Douwe Arie Anne |date=2007-03-27 |title=Think globally act locally: the case for symphysiotomy |journal=PLOS Medicine |volume=4 |issue=3 |article-number=e71 |doi=10.1371/journal.pmed.0040071 |issn=1549-1676 |pmc=1831724 |pmid=17388656 |doi-access=free }}</ref> Current practice guidelines in Canada recommend symphysiotomy for trapped head during vaginal delivery of a breech birth.<ref>{{Cite journal |last=Hofmeyr |first=G. Justus |last2=Shweni |first2=P. Mike |date=2012-10-17 |title=Symphysiotomy for feto-pelvic disproportion |url=https://pmc.ncbi.nlm.nih.gov/articles/PMC7390327/ |journal=The Cochrane Database of Systematic Reviews |volume=10 |issue=10 |article-number=CD005299 |doi=10.1002/14651858.CD005299.pub3 |issn=1469-493X |pmc=7390327 |pmid=23076913}}</ref>
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.<ref name=":0">{{Cite journal |last1=Wilson |first1=A |last2=Truchanowicz |first2=Eg |last3=Elmoghazy |first3=D |last4=MacArthur |first4=C |last5=Coomarasamy |first5=A |date=August 2016 |title=Symphysiotomy for obstructed labour: a systematic review and meta-analysis |url=https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.14040 |journal=BJOG: An International Journal of Obstetrics & Gynaecology |language=en |volume=123 |issue=9 |pages=1453–1461 |doi=10.1111/1471-0528.14040 |pmid=27126671 |issn=1470-0328}}</ref> There was a lower risk of infection following symphysiotomy, but a higher risk of fistula, compared to C-section.<ref name=":0" />
==Procedure== thumb|right|270px|Patient in a symphysiotomy hammock after surgery, 1907 Symphysiotomy results in a temporary increase in pelvic diameter (up to {{convert|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.<ref name="multiple" /> 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.<ref name=":1" /> Since this procedure does not scar the uterus, the concern of future uterine rupture that exists with cesarean section is not a factor.<ref>{{Cite journal |last=van Roosmalen |first=Jos |date=July 1990 |title=Safe motherhood: cesarean section or symphysiotomy? |journal=American Journal of Obstetrics and Gynecology |volume=163 |issue=1 Pt 1 |pages=1–4 |doi=10.1016/S0002-9378(11)90653-X |issn=0002-9378 |pmid=2375330}}</ref>
The procedure carries the risks of urethral and bladder injury, fistulas,<ref name=":0" /> infection, pain, and long-term walking difficulty.<ref name="multiple" /> Symphysiotomy should, therefore, be carried out only when there is no safe alternative.<ref name="multiple">{{Cite book |url=http://www.who.int/reproductive-health/impac/Procedures/Symphysiotomy_P53_P56.html |title=Managing complications in pregnancy and childbirth: a guide for midwives and doctors |date=2003 |publisher=WHO, RHR Department of Reproductive Health and Research |isbn=978-92-4-154587-7 |editor-last=Mathai |editor-first=Matthews |edition=1st |series=Integrated management of pregnancy and childbirth |location=Geneva |archive-url=https://web.archive.org/web/20020809152505/http://www.who.int/reproductive-health/impac/Procedures/Symphysiotomy_P53_P56.html |archive-date=2002-08-09}}</ref> It is advised that this procedure should not be repeated due to the risk of gait problems and continual pain.<ref name="multiple" /> 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.<ref name="multiple"/>
==Controversial practices in Ireland== {{Main|Symphysiotomy controversy 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 Ireland between 1944 and 1987.<ref>{{Cite web |title=SOS Ireland - survivors of symphysiotomy |url=http://www.symphysiotomyireland.com |access-date=2018-04-16 |website=Survivors of Symphysiotomy ireland |language=en-GB}}</ref><ref>"Draft Report on Symphysiotomy in Ireland 1944 - 1987, Dr Oonagh Walsh"</ref> In 2014 Ireland agreed to pay women who received the procedure compensation without admitting liability.<ref>{{Cite news |date=2014-07-01 |title=Symphysiotomy compensation agreed in Republic of Ireland |url=https://www.bbc.com/news/world-europe-28112077 |access-date=2024-08-10 |work=BBC News |language=en-GB}}</ref>
==References== {{reflist}}
{{Obstetrical procedures}}
Category:Medical scandals in the Republic of Ireland Category:Obstetric surgery