by JuLIET DE SA SouzA, M.D., F.R.C.S., Projesso1· of Obstetrics & Gynaecology, Grant Medical College; Hon. Obstetrician & Gynaecologist, Bai Motlibai & Petit Hospitals, Bombay; Hon. Visiting Obstetrician, Nowrosji Wadia Maternity Hospital, Bombay.
No operation has had· a more never viewed either operation with __ chequered history in Obstetrics than favour. In modern times, since that of symphysiotomy. As early as caesarean section is so safe and easy' · 1655 Claude de la Courvee performed a great revival in symphysiotomy is it on the dead as an alternative to doubtful. Nevertheless, since pelvic post-motem caesarean section. radiography has demonstrated a de However, it was Sigault who per finite and permanent increase in all formed it for the first time on the transverse diameters and especially living in 1777. For a few succeeding those of the outlet, it is worthwhile years it was performed many times considering symphysiotomy, in cer especially in It.aly, France and Ger tain selected cases of funnel-shaped many. Baudelocque was a strong pelvis and outlet contraction and the opponent of it and it was soon aban results are gratifying. As Smellie doned entirely. has very wisely said well over 150 After an interval of 100 years, inte years ago: "We ought never to trust rest in it was again aroused by Mori too much or be over-sanguine in res sani of Italy. Soon Pinard, Varnier, pect to any particular method of and Bar in France, and Zweifel in practice, but vary the same as we feel Germany followed suite and in the it necessary." last decade of the 19th century it was Indications the burning question in obstetric surgery. Again in the beginning of (i) Pelvic deformity affecting the the present century, pubiotomy, outlet: In a funnel-shaped pelvis advocated by Van de Velde, Gigli, when the inter-tuber ischii is 3!" or and Doderlein, almost completely less or below 8 ems. and one is con supplanted symphysiotomy. But fronted with a difficult forceps extrac there remained a few, amongst whom tion, symphysiotomy is an example was Frank, who even in 1912 advo of finesse in obstetric surgery. Late cated it and presented a series of 117 in labour when the head is deeply cases with one maternal and eleven jammed in the pelvis, when the lower foetal deaths. segment is thinned out and oedemat ous and vulnerable to tear easily British and American obstetricians during attempts at extraction of the *Paper read at the 11th All-India head; when the patient is exhausted - Obstetric and Gynaecological Congress after many hours of labour, and in at Calcutta in January 1961. fected after many vaginal examina-
t \ 438 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA tions and attempts at vaginal deli workers. I have preferred the sub very, caesarean section involves cutaneous technique. The patient is greater risk to the mother. Even if .anaesthetised, placed in the lithotomy all these disadvantages are overcome position and her pelvis brought to the by the modern facilities of broad end of the operation table. The legs spectrum antibiotics and blood trans should not be fixed on supports, but fusions, a caesarean section at best two assistants should hold them so as leaves the patient with an uterine to be able to regulate the degree of scar and the original pelvic deformity, abduction of the thigh with one hand which will trouble the patient more and apply steady pressure on the in subsequent labours with bigger trochanter with the other hand. Be babies. fore division of the joints forceps may ( ii) In exceptional cases of mal be applied to the head provided the position of the vertex like occipito position is satisfactory. If position is I po~terior , deep transverse arrest or abnormal, because of the outlet con .I face presentation where both manual traction, forceps should- not be ap and forceps rotation has failed, trac plied until after division of the joints tion will be great and craniotomy is when the head can be more easily the only alternative; A timely sym rotated into the ideal position and physiotomy just allows the head to blades properly applied. A catheter be easily rotated and pulled out with is inserted into the urethra. A small ease. It is most valuable in a primi transverse incision about 2" in length para with a breech arrested at a con is made over symphysis pubis. The tracted outlet. After symphysiotomy rectus sheath and the fibres of rectus breech extraction becomes easy and muscle separated from the upper the head just slips out. border of symphysis pubis. The (iii) Symphysiotomy has an ethi handle of the bistoury is first passed cal indication. With the probability along the posterior surface of the of having to do repeat caesarean sec pubis, separating the joint from the tions in contracted outlet of the pel adjacent structures. The handle ]s vis, contraception and sterilization withdrawn and blade of the bistoury has to follow very soon. Obstetri is inserted fiat against the pubic joint cians working in Roman Catholic guided with the left index finger in communities and especially where the vagina. (see fig. I) It is then sterilization is not allowed by the turned to a right angle bringing the Roman Catholic Church and where cutting edge against the pubic joint. - families tend to be large, one can em (see fig. II) With movements to and ploy symphysiotomy which perma fro the joint is cut into from above nently cures an outlet contraction downwards and behind forwards. and allows future normal labours. When ith of the joint has been cut, the legs are abducted with careful Method pressure on the trochanter and the In olden days the symphysis was rest of the joint is felt to separate devided by the open method and, in with the left finger in the vagina. modified fori:ns, it has again been Now the whole joint should never be used in recent years by the Dublin cut and the separation of the lower SYMPHYSIOTOMY 439 -
Fig. 1 Bistoury inserted fiat against the Symphysis Pubis jt.
Fig. 2 Bistoury turned to a rt. angle to bring the cutting edge against thE! S. P. jt, 14 \ 440 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA
half of the joint must be gradual as week. A pulley attached to the top of otherwise severe haemorrhage can the bed with strings clipped on to the arise from the inferior vesical plexus patient's binder assists greatly in and the dorsal vein to the clitoris. lifting up the pelvis for bed-pans etc. Usually the haemorrhage is con Especially designed corset coming trolled with pressure and packing for low over the trochanter has been a while. The child is now easily ex used by Dublin workers but I have tracted by forceps after a liberal been contented with strapping broad. episiotomy, to relieve the pressure of elastoplast about four inches wide the head on the unsupported urethra wound 3 or 4 times round the pelvis and vestibule. The wound is closed at the level of the trochanters. I in layers leaving behind a cigarette encouraged the patient to lie on one - drain. We strapped the pelvis with or other side during 3 weeks of her 3 layers of 4" wide sticking plaster convalescence. Many allow the which was removed completely after patient to leave the bed on lOth or 35 days. The patient was not allow 11th day. ed to turn in bed only for 48 hours. (iii) Difficulty m locomotion: Then she was turned on one side or Union of the pubic joint is fibrous, the other for 7 days; then allowed to but it does not produce any pain, turn on her own. She sat up after 2 instability or difficulty in walking. weeks and walked after 3 weeks. After one month the patient could stand on one leg and hop and jump Disadvantages and complications and even squat down without any (i) Haemorrhage from the inferior pain. vesical plexus and the dorsal vein of The advantages of symphysiotomy the clitoris and injury to the urethra over pubiotomy are the following:- and bladder. Both these can be reduced to a minimum if only the 1. Much less bleeding, as you do upper half of the pubic joint is cut not have to disturb the rich through and the lower half is allowed plexus of veins behind the pubic to separate by gentle abduction of arch. the thighs. If haemorrhage occurs 2. No need of wiring and hence firm packing of the vagina and of the symphysiotomy is a much sim wound in most cases controls it. A pler operation. self-retaining catheter should be left 3. As you do not cut through th•.) - in for 5 to 7 days. Episiotomy after bone tissue there are less chan symphysiotomy, before extraction of ces of osteomylitis and much the head reduces the strain on the un less pain after symphysiotomy. supported urethra and prevents in . Moreover in pubiotomy you jury to it and the bladder, especially have two wounds, one above that of stress incontinence. and one below the pubic bone (ii) Troublesome after-treatment: and therefore more chances of Prolonged convalescence. The patient sepsis, while in symphysiotomy is unable to lift her pelvis and turn you will have only one above in bed by h~rself for at Je~st one the symphysis pubis. SYMPHYSfOTOMY 441
Case Reports marked moulding was jammed at the out let, the sagittal suture lying transversely. The first case was a very fat primipara, A subcutaneous symphysiotomy, with a well bUJlt and tall, in whom no one would bistoury was done and head delivered after suspect pelvic contraction. The head was an episiotomy. Th_s patient had oedema of arrested at the outet. A big caput could the vulva, not anterior near the pubic joint be seen, but even with moderate forceps but near the episiotomy wound. It cleared traction no advance was made. It was a with mag. sulph compresses, etc. Patient precious baby, the patient being an elderly was not allowed to move for 48 hours and primipara about 34 years of age, having then was turned on one side from time to conceived after many years of treatment. time. The self-retaining catheter was re Symphysiotomy, as described by the sub moved on the 11th post-operative day, but cutaneous method, was done and an 8- the urine was always clear. On the 3rd pound baby delivered. The recovery was day she turned in bed herself, sat up on the uneventful. I do not know if she has had 21st day and walked on the 27th day. any more deliveries. The second was a young primipara in Nowadays they make them leave whom X-ray pelvimetry showed definite the bed even as early as the 8th or marked outlet contraction. See fig . III. ·lOth day. X-ray pelvimetry (See Clinically the head with a big caput and Table) shows increase in all trans-
Fig. 3 . Note the narrow and deep sacro-sciatic notch, the stra1ght sacrum and the marked moulding of foetal head. 442 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA
TABLE SYMPHYSIOTOMY Pelvimetry Measurements
Before symphy Increase after After symphy siotomy. symphysiotomy siotomy. em. em. em.
Transverse of inlet 12.00 0.8 12.8 Inter-ischilal spines 9.2 0.7 9.9 Bituberous 9.0 1.3 10.3 Width of symphysis joint. space (uncorrected) 0.5 0.9 1.4 A.P. of inlet 8.7 8.7 P.S. of Caldwell Moloy 3.3 3.3 P.S. of Thoms 2.4 2.4 P.S. of outlet 5.3 5.3
Index- Inlet 20.7 c 21.6 B Midcavity 12.5 D 13.2 c Outlet 14.3 c 156 B verse diameters, especially the hi ing to our indexing a D pelvis was tuberous ( 1.3 ems.) whereas the an converted into a B. Fortunately be tero-posterior diameters showed no fore the conclusion of this paper, the change at all. (see fig. IV) Acc0rd- patient was admitted at the Nowros-
)
} I
Fig. 4 There is increase in all transverse diameters, especially the hi-tuberous. Note the width of the pubic jt.
t SYMPHYSIOTOMY 443 jee Wadia Maternity Hospital again, Dr. M. N. Parikh for their unstinted for her second delivery and delivered cooperation. spontaneously of a 6 lb. 8 ozs. baby . (the weight of the 1st baby was 6 References lbs.). The whole labour this time 1. Surg. Gynaec: Obst. (1934) , 58 No. lasted 2 hrs. 55 min. 1st stage: 2! 3 P. 595. ( hrs.; 2nd stage: 15 min. and 3rd 2. Proc: R. Soc: Med. (1934) 27. stage: 10 min. ( Obst. Section pp. 51-59). 3. Proc: R. Soc: Med. (1939) 32 , Summary 1591. Symphysiotomy is only indicated 4. J. Obst. Gynaec: (1940) 47 493-532. in outlet contraction. When one is 5. Proc: R. Soc: Med. (1945) 38, 329 confronted with this complication (Section p. 25). late in labour with the head jammed 6. J. Obst. & Gynaec. (1949) 56, 576. down in a fat and exhausted patient, 7. J . Obst. & Gynaec. (1954) 61, 192. it is a finesse in obstetric surgery. As 8 . Am: J. Obst. & Gynaec, (1901) 66 seen from X-ray pelvimetry, symphy 385. siotomy is the permanent cure for an 9. J .. Obst. Gynaec. (1949) 56, 576. outlet contraction. 10 . West J. Surg. Obst. Gynaec. (1943) . My sincere thanks are due to Dr. 11. Munro-Kerr's Operative Obstet E. J. Siqueira, Dr. Mrs. C. S. Patel, rics <1956) 6th Ed. P. 610 .