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Institute of Obstetricians & Gynaecologists of the Royal College of Physicians of Ireland

Statement on Symphysiotomy

February 17, 2010

 Questions have been raised about the practice of symphysiotomy in Ireland. The Institute of Obstetricians and Gynaecologists, RCPI considers it important to express its position as regards the practice of the procedure.

Members of the Institute offer our unreserved sympathy and support to any mother who may have experienced complications following symphysiotomy.

The Institute has previously written in support of mothers who suffered adverse outcomes following the procedure. In these letters, the Institute has recommended that mothers should be given a full explanation, to which they were entitled, and that their grievances should be considered sympathetically.

The Institute fully supports HSE and Department of Health & Children initiatives to assist those who have suffered complications of the procedure.

The Institute recommends that data on symphysiotomy be incorporated into a National Clinical Audit on obstetric practice.  

What is surgical symphysiotomy?
Symphysiotomy may occur spontaneously in late pregnancy or labour, or as a result of a surgical procedure. Surgical symphysiotomy is a procedure carried out on the pubic symphysis joint of the pelvis, under local or other anaesthesia.

The cartilage of the joint and some of the supporting ligaments are incised. This results in permanent widening of the pelvis by up to 3.5 cms. The joint heals with laying down of dense connective tissue.

The World Health Organisation includes the procedure in its coding manual International Statistical Classification of Diseases (ICD-9-CM Code 73.94). 

What are the benefits?
The increase in pelvic size allows vaginal birth in selected cases of obstructed labour. This in turn reduces maternal and infant death and morbidity rates and complications such as urinary incontinence from vesico-vaginal fistulae that can result from prolonged obstructed labour.

The technique may also be used to aid delivery of the infant in births complicated by shoulder dystocia or entrapment of the after-coming head in breech delivery (see below).


What are the complications?
Immediate complications may include pelvic joint pain and difficulty walking. Bladder infection and incontinence may occur. There may be injury to local tissues with haematoma (bruising and clot) formation and local infection.

Reported long term problems include walking difficulties, pelvic joint pain and urinary incontinence. These may subside after 3 to 6 months (Bjorkland, 2002).   

Why was symphysiotomy used?
The procedure was introduced in the 18th century for selected cases of obstructed labour and proved effective in allowing vaginal births while reducing maternal and infant death and morbidity rates that related to prolonged labour.

Because symphysiotomy permanently enlarged the pelvis the procedure also offered the prospect of safer vaginal delivery in future pregnancies at a time when large family size was usual.

At that time, symphysiotomy was a simpler and safer practice than caesarean section (C/S), a technique that gradually replaced it during the 20th century when difficulties with the C/S procedure itself were overcome. Caesarean birth, until the operation was refined, was itself a cause of maternal death, mainly due to blood loss and infection. 

Is symphysiotomy valid nowadays?
In some countries symphysiotomy may still be used as a life saving procedure for the mother and infant in circumstances where caesarean section is technically not an option (Liljestrand, 2002; WHO, UNFPA, UNIEG, World Bank 2001).

The technique is no longer used in this country as an alternative to caesarean section for obstructed labour.

Exceptionally rare emergency situations may arise when the technique could be used such as (a) severe shoulder dystocia when, after the delivery of the head, the infant’s shoulders cannot pass under the pubic symphysis, or (b) when a baby is being born as a ‘breech’ its head becomes trapped in the mother’s pelvis.

In these situations, symphysiotomy may be considered as valid when a range of other obstetric interventions have failed.

The procedure does not form part of the Irish curriculum of specialist training. However, the technique is taught as an emergency procedure on the ‘Management of Obstetric Emergencies and Trauma’ course of the Royal College of Obstetricians and Gynaecologists, London which many Consultants and Trainees have attended.

The historic use of symphysiotomy should be assessed in the context of what was considered valid practice at the time. Medical research papers regarding symphysiotomy were produced from other countries at the time when the technique was being performed here. 

Bjorkland, K (2002) Minimally invasive surgery for obstructed labour; a review of symphysiotomy during the 20th century (including 5000 cases). BJOG, Vol, 109, pp 236-248

Liljestrand, J (2002) The value of symphysiotomy. BJOG, Vol, 109, pp. 225-226

‘Managing Obstetric Emergencies and Trauma’ (2007) Royal College of Obstetricians and Gynaecologists (RCOG), London

WHO, UNFPA, UNIEG, World Bank. (2001) Managing complications in pregnancy and childbirth. A guide for midwives and doctors. Geneva: WHO

 Since 1976 the Institute of Obstetricians and Gynaecologists has been an integral part of the Royal College of Physicians of Ireland.

It represents Obstetric and Gynaecological opinion in Ireland in a professional advisory and administrative capacity. It acts as the advisory Body in Ireland in matters relating to education, training, research and administration in the speciality of Obstetrics and Gynaecology. The Institute promotes excellence in the areas of patient care, professional standards, education and research in Obstetrics and Gynaecology.

The mission of The Royal College of Physicians of Ireland (RCPI) is to develop and maintain high professional standards in specialist medical practice in order to achieve optimum patient care and to promote health nationally and internationally. Through its Faculties and Committees, RCPI has responsibility for the postgraduate education and training of doctors in Ireland in twenty-five medical specialties.

RCPI is fully committed to playing a full and proactive part in the transformation of the health service, as evidenced by its involvement in many strategic initiatives with the Medical Council, the Health Services Executive, the Department of Health and Children, and other Irish postgraduate medical training bodies.

 Institute of Obstetricians & Gynaecologists
Royal College of Physicians of Ireland

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