Symphysiotomy is a surgical procedure in which the

cartilage Cartilage is a resilient and smooth type of connective tissue. Semi-transparent and non-porous, it is usually covered by a tough and fibrous membrane called perichondrium. In tetrapods, it covers and protects the ends of long bones at the joints ...

of the

pubic symphysis The pubic symphysis (: symphyses) is a secondary cartilaginous joint between the left and right superior rami of the pubis of the hip bones. It is in front of and below the urinary bladder. In males, the suspensory ligament of the penis attache ...

is divided to widen the

pelvis The pelvis (: pelves or pelvises) is the lower part of an Anatomy, anatomical Trunk (anatomy), trunk, between the human abdomen, abdomen and the thighs (sometimes also called pelvic region), together with its embedded skeleton (sometimes also c ...

allowing

childbirth Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy, where one or more Fetus, fetuses exits the Womb, internal environment of the mother via vaginal delivery or caesarean section and becomes a newborn to ...

when there is a mechanical problem (

obstructed labour Obstructed labour, also known as labour dystocia, is the baby not exiting the pelvis because it is physically blocked during childbirth although the uterus contracts normally. Complications for the baby include not getting enough oxygen which ...

). It is also known as pelviotomy and synchondrotomy. It has largely been supplanted by

C-sections Caesarean section, also known as C-section, cesarean, or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen. It is often performed because vaginal delivery would ...

, with the exception of certain rare obstetric emergencies or in resource poor settings. It is different than

pubiotomy Pubiotomy was a medical procedure where the pelvic bone was cut in two places, on either side of the pubic symphysis joint, in order to widen the pelvis during obstructed labour. By 1922, it was considered outdated and C-section preferable. Gigli s ...

, where the pelvic bone itself is cut in two places, rather than cutting through the symphysis pubis joint.

Introduction

Symphysiotomy was advocated in 1597 by Severin Pineau after his description of a diastasis of the pubis on a hanged pregnant woman. Thus symphysiotomies became a routine surgical procedure for women experiencing an obstructed labour. They became less frequent in the late 20th century after the risk of maternal death from

caesarean section Caesarean section, also known as C-section, cesarean, or caesarean delivery, is the Surgery, surgical procedure by which one or more babies are Childbirth, delivered through an incision in the mother's abdomen. It is often performed because va ...

decreased (due to improvement in techniques, hygiene, and clinical practice).

Indications

The most common indications are a trapped head of a breech baby,

shoulder dystocia Shoulder dystocia occurs after vaginal delivery of the head, when the baby's anterior shoulder is obstructed by the mother's pubic bone. It is typically diagnosed when the baby's shoulders fail to deliver despite gentle downward traction on the b ...

which does not resolve with routine manoeuvres, and obstructed labor at full

cervical dilation Cervical dilation (or cervical dilatation) is the opening of the cervix, the entrance to the uterus, during childbirth, miscarriage, induced abortion, or gynecological surgery. Cervical dilation may occur naturally, or may be induced surgically ...

, especially with failed

vacuum extraction Vacuum extraction (VE), also known as ventouse, is a method to assist delivery of a baby using a vacuum device. It is used in the second stage of labor if it has not progressed adequately. It may be an alternative to a forceps delivery and ca ...

. Use for shoulder dystocia is controversial. Currently the procedure is rarely performed in developed countries, but is still performed in "rural areas and resource-poor settings of developing countries" where caesarean sections are not available, or where obstetricians may not be available to deliver subsequent pregnancies. Current practice guidelines in Canada recommend symphysiotomy for trapped head during vaginal delivery of a breech birth. 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. There was a lower risk of infection following symphysiotomy, but a higher risk of fistula, compared to C-section.

Procedure

Symphysiotomy results in a temporary increase in pelvic diameter (up to ) by surgically dividing the

ligaments A ligament is a type of fibrous connective tissue in the body that connects bones to other bones. It also connects flight feathers to bones, in dinosaurs and birds. All 30,000 species of amniotes (land animals with internal bones) have ligam ...

of the

symphysis A symphysis (, : symphyses) is a fibrocartilaginous fusion between two bones. It is a type of cartilaginous joint, specifically a secondary cartilaginous joint. # A symphysis is an amphiarthrosis, a slightly movable joint. # A growing together o ...

under local anaesthesia. This procedure should be carried out only in combination with

. 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. Since this procedure does not scar the

uterus The uterus (from Latin ''uterus'', : uteri or uteruses) or womb () is the hollow organ, organ in the reproductive system of most female mammals, including humans, that accommodates the embryonic development, embryonic and prenatal development, f ...

, the concern of future uterine rupture that exists with cesarean section is not a factor. The procedure carries the risks of urethral and bladder injury,

fistula In anatomy, a fistula (: fistulas or fistulae ; from Latin ''fistula'', "tube, pipe") is an abnormal connection (i.e. tube) joining two hollow spaces (technically, two epithelialized surfaces), such as blood vessels, intestines, or other h ...

s, infection, pain, and long-term walking difficulty. Symphysiotomy should, therefore, be carried out only when there is no safe alternative. It is advised that this procedure should not be repeated due to the risk of

gait Gait is the pattern of Motion (physics), movement of the limb (anatomy), limbs of animals, including Gait (human), humans, during Animal locomotion, locomotion over a solid substrate. Most animals use a variety of gaits, selecting gait based on s ...

problems and continual pain. Abduction of the thighs more than 45 degrees from the midline may cause tearing of the urethra and bladder. If long-term walking difficulties and pain are reported, the patient's condition generally improves with physical therapy.

Controversial practices 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 Ireland (, ; ; Ulster Scots dialect, Ulster-Scots: ) is an island in the North Atlantic Ocean, in Northwestern Europe. Geopolitically, the island is divided between the Republic of Ireland (officially Names of the Irish state, named Irelan ...

between 1944 and 1987. In 2014 Ireland agreed to pay women who received the procedure compensation without admitting liability.

References

{{Obstetrical procedures Medical scandals in the Republic of Ireland Obstetric surgery