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Obstetrics Simplified - Diaa M. EI-Mowafi

Symphysiotomy

Definitions

  • Symphysiotomy: is division of the symphysis pubis with a scalpel.
  • Pubiotomy: is division of the pubic ramus half an inch from the symphysis pubis with a Gigli saw to avoid injury to the urethra and bladder. It is out of modern obstetrics due to higher incidence of pubic pain and infection.

Indications

It is particularly indicated in women living in distant areas where caesarean section cannot be done and even patient will be left with a caesarean scar is in a high risk of rupture in the next labour.

As symphysiotomy gives a permanent increase of the pelvic capacity, it can be an alternative to C.S. and indicated in the following conditions:

  • Moderate cephalopelvic disproportion.
  • Contracted outlet in funnel shaped pelvis.
  • Retained aftercoming head in breech delivery failed to be delivered by other means.
  • Shoulder dystocia with a living foetus cannot be delivered by other means.

Procedure

Subcutaneous symphysiotomy is the commonly done operation and done as follow:

  • A firm catheter is applied and the urethra is displaced to one side with two fingers in the vagina.
  • A 1-2 cm vertical suprapubic incision is made with a scalpel just above the symphysis.
  • The scalpel is introduced through the incision to the upper border of the symphysis with its sharp edge facing anteriorly i.e. towards the operator.
  • The joint is gradually divided by a rocking motion, checking with the vaginal fingers for posterior perforation of the joint capsule. Complete division is rarely, if ever,required.
  • The thighs are held by assistants so that abduction and joint separation can be controlled.
  • A large episiotomy is required to minimise strain on the soft tissue anteriorly.
  • Forceps or preferably, ventouse is used to deliver the foetus.
  • The skin incision is closed by one or two sutures.

Postoperative

  • Rest for 2 weeks.
  • A tight binder of "Elastoplast" is strapped around the pelvic girdle and hips.
  • Bladder drainage is continued for 3-4 days.
  • A prophylactic antibiotic may be given.

Complications

  • Haemorrhage, compression for few minutes usually stop it.
  • Injury to the urethra or bladder.
  • Vesico-vaginal or urethro-vaginal fistula.
  • Stress incontinence.
  • Sepsis.
  • Pelvic osteoarthropathy.
  • Difficulty of walking and unstable pelvis usually improved by time.