Symphysiotomy for feto-pelvic disproportion (Review)

Hofmeyr GJ, Shweni PM

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2010, Issue 10
http://www.thecochranelibrary.com

Symphysiotomy for feto-pelvic disproportion (Review)

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 13
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Symphysiotomy for feto-pelvic disproportion (Review) i

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Symphysiotomy for feto-pelvic disproportion

G Justus Hofmeyr1 , P Mike Shweni2

1 Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort
Hare, Eastern Cape Department of Health, East London, South Africa. 2 Department of Obstetrics and Gynaecology, East London
Hospital Complex, East London, South Africa

Contact address: G Justus Hofmeyr, Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the
Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, Frere and Cecilia Makiwane Hospitals, Private Bag X
9047, East London, Eastern Cape, 5200, South Africa. [email protected].

Editorial group: Cochrane Pregnancy and Childbirth Group.

Publication status and date: New, published in Issue 10, 2010.
Review content assessed as up-to-date: 30 August 2010.

Citation: Hofmeyr GJ, Shweni PM. Symphysiotomy for feto-pelvic disproportion. Cochrane Database of Systematic Reviews 2010,
Issue 10. Art. No.: CD005299. DOI: 10.1002/14651858.CD005299.pub2.

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

Background

Symphysiotomy is an operation in which the fibres of the pubic symphysis are partially divided to allow separation of the joint and thus
enlargement of the pelvic dimensions during childbirth. It is performed with local analgesia and does not require an operating theatre
nor advanced surgical skills. It may be a lifesaving procedure for the mother or the baby, or both, in several clinical situations. These
include: failure to progress in labour when caesarean section is unavailable, unsafe or declined by the mother; and obstructed birth of
the aftercoming head of a breech presenting baby. Criticism of the operation because of complications, particularly pelvic instability,
and as being a ’second best’ option has resulted in its decline or disappearance from use in many countries. Several large observational
studies have reported high rates of success, low rates of complications and very low mortality rates.

Objectives

To determine, from the best available evidence, the effectiveness and safety of symphysiotomy versus alternative options for obstructed
labour in various clinical situations.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (31 August 2010), the Cochrane Central Register of
Controlled Trials (The Cochrane Library 2010, Issue 3) and PubMed (1966 to 31 August 2010).

Selection criteria

Randomized trials comparing symphysiotomy with alternative management, or alternative techniques of symphysiotomy, for obstructed
labour or obstructed aftercoming head during breech birth.

Data collection and analysis

Planned methods included evaluation of studies against objective quality criteria for inclusion, extraction of data, and analysis of data
using risk ratios or mean differences with 95% confidence intervals. The primary outcomes were maternal death or severe morbidity,
and perinatal death or severe morbidity.
Symphysiotomy for feto-pelvic disproportion (Review) 1
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results

We found no randomized trials of symphysiotomy.

Authors’ conclusions

Because of controversy surrounding the use of symphysiotomy, and the possibility that it may be a life-saving procedure in certain
circumstances, professional and global bodies should provide guidelines for the use (or non-use) of symphysiotomy based on the best
available evidence (currently evidence from observational studies). Research is needed to provide robust evidence of the effectiveness
and safety of symphysiotomy compared with no symphysiotomy or comparisons of alternative symphysiotomy techniques in clinical
situations in which caesarean section is not available; and compared with caesarean section in clinical situations in which the relative
risks and benefits are uncertain (for example in women at very high risk of complications from caesarean section).

PLAIN LANGUAGE SUMMARY

Symphysiotomy for feto-pelvic disproportion

Symphysiotomy is an operation to enlarge the capacity of the mother’s pelvis by partially cutting the fibres joining the pubic bones
at the front of the pelvis. Usually, when the baby is too big to pass through the pelvis, a caesarean section is performed. If caesarean
section is not available, or the mother is too ill for, or refuses, caesarean section or if there is insufficient time to perform caesarean
section (for example when the baby’s body has been born feet first, and the head is stuck), symphysiotomy may be performed. Local
anaesthetic solution is injected to numb the area, then a small cut is made in the skin with a scalpel, and most of the fibres of the
symphysis are cut. As the baby is born, the symphysis separates just enough to allow the baby through. Large observational studies have
shown that symphysiotomy is extremely safe with respect to life-threatening complications, but rarely may result in pelvic instability.
For this reason, and because the operation is viewed as a ‘second-class’ operation, it is seldom performed today. Health professionals
fear censure should they perform a symphysiotomy which leads to complications. Proponents argue that many deaths of mothers and
babies from obstructed labour in parts of the world without caesarean section facilities could be prevented if symphysiotomy was used.
This review found no randomized trials evaluating symphysiotomy.

BACKGROUND political correctness make it difficult to reach an objective evalua-

tion of the benefits and risks of symphysiotomy.
When caesarean section is not available or not safe or unaccept-
able to the mother, symphysiotomy may be life-saving for both
Introduction mother and baby (Wykes 2003). Complications of the procedure
Symphysiotomy is an operation in which fibres of the pubic sym- have been reduced by improved operative techniques (Maharaj
physis pubis are divided with a scalpel using local analgesic in- 2002) (such as partial rather than complete symphysiotomy) and
filtration. This allows the pubic bones to separate, creating more postoperative care (early mobilisation).
space in the pelvis for the birth of the baby.
Symphysiotomy has come to be regarded as an unacceptable oper-
ation because of perceptions that it is a gruesome procedure which
may result in an unstable pelvic girdle and urinary incontinence,
Possible indications for symphysiotomy
and the view that it is a ’second-class’ operation used only in women The main indications for symphysiotomy are cephalo-pelvic dis-
from poor communities (Verkuyl 2007). In the last 20 years it has proportion with cephalic presentation, including cases of failed
virtually disappeared from practice in many low-income countries. assisted birth, and arrested aftercoming head of the breech
An article referring to symphysiotomy and pubiotomy (division of (Sunday-Adeoye 2004). It has been recommended for shoulder
the pubic bone) in Irish women in the 1950s as ’barbaric’ (Payne dystocia unresponsive to conventional procedures (Baxley 2004;
2001) provoked considerable debate. Emotions, and sensitivity to Kwek 2006), but one report of three cases of symphysiotomy as a
Symphysiotomy for feto-pelvic disproportion (Review) 2
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
last resort for shoulder dystocia recorded poor results (Goodwin vesico-vaginal fistula (a track between the bladder and the
1997), and this indication is controversial. Symphysiotomy may vagina). Necrosis of the urethra and bladder neck have been
be lifesaving for women too ill to survive caesarean section fol- described following symphysiotomy, though the fact that in all
lowing neglected labour (Maharaj 2002; Verkuyl 2001). Women cases the baby had died prior to the procedure suggested that
from some cultural backgrounds are immovably opposed to cae- pressure necrosis from prolonged obstructed labour may have
sarean section, but will accept symphysiotomy because it does not been the cause (Onsrud 2008).
contradict their cultural imperative to give birth vaginally.
Apart from the use of symphysiotomy to overcome existing ob-
struction, the availability of symphysiotomy may influence ob- Symphysiotomy in practice - results of
stetric choices. For example, caesarean section may be chosen for observational studies
breech birth because of the possibility of difficult vaginal birth in
The core issue regarding the use of symphysiotomy is the possi-
a small proportion of cases. If the mother and caregivers feel reas-
bility of long-term morbidity.
sured that the problem of obstruction to the aftercoming head can
In a report of 32 women having a symphysiotomy from Mozam-
if necessary be overcome with symphysiotomy, then routine cae-
bique and Botswana, with follow up on 31 (Bergstrom 1994),
sarean section can be avoided in a large number of cases, whereas
immediate complications were vaginal lacerations (three), haema-
symphysiotomy will be required in only a very small number in
turia (one), wound infection (one) and pain causing gait problems
which the problem actually occurs, if at all. Availability of sym-
(two). There were no cases of persistent pain or other complica-
physiotomy as an option in a health service may encourage atten-
tions at follow up.
dance by women who avoid the service because of a wish to avoid
A review and report of 54 additional women from Tanzania con-
caesarean section.
cluded that symphysiotomy is associated with lower mortality than
caesarean section and similar rates of complications (though dif-
ferent complications) (Van Roosmalen 1987).
Advantages and disadvantages A small follow-up study in Zimbabwe found no difference in long-
Symphysiotomy has several advantages over caesarean section: term morbidity between women who had symphysiotomy com-
1. it is more rapid to perform; pared with Caesarean section for similar indications (Ersdal 2008).
2. it is simpler; A retrospective comparison of 65 women having a symphysiotomy
3. it can be performed by health workers without formal and 108 having a caesarean section performed in 1988 to 1994
training in laparotomy skills; after a failed trial of assisted birth at the Port Moresby General
4. only local analgesia is used; Hospital (Papua New Guinea) revealed no significant differences
5. no operating theatre, anaesthetist, electricity or in perinatal or maternal outcomes (Mola 1995). Mothers who
sophisticated equipment are needed; had symphysiotomy required a longer hospital stay, but had fewer
6. there is no risk of scarred uterus in subsequent pregnancies, complications necessitating additional surgery. The authors cited
particularly when women may not in future have ready access to as the main complications of symphysiotomy: leg and pelvic pain,
caesarean section; pelvic instability, and stress incontinence.
7. it may be life-saving for the breech baby with entrapped A recent review of 5000 cases of symphysiotomy in the last century
aftercoming head, and possibly in shoulder dystocia; concluded: “... symphysiotomy is safe for the mother from a vital
8. it may be preferred in cultures in which caesarean section is perspective, confers a permanent enlargement of the pelvis and
viewed as a personal failure on the part of the woman (Maharaj facilitates vaginal birth in future pregnancies, and is a life saving
2002); operation for the child. Severe complications are rare. ... [T]here
9. it results in a permanent enlargement of the pelvis (Ersdal is considerable evidence to support a reinstatement of symphys-
2008); iotomy in the obstetric arsenal, for the benefit of women in ob-
10. use of symphysiotomy reduces the caesarean section rate structed labour and their offspring” (Bjorklund 2002). The com-
(Nkwo 2009). mentary on the latter paper calls for symphysiotomy to be made
Disadvantages include: widely available in order to reduce the appalling rate of death and
1. for birth of the baby the cervix must be fully dilated or morbidity from obstructed labour which persists in poor countries
progress to full dilatation; (Liljestrand 2002).
2. it is contraindicated in the presence of gross disproportion, Subsequent reports of case series of symphysiotomy have also con-
e.g. in hydrocephaly; cluded that the procedure has few complications. A report from
3. it may rarely be associated with morbidity such as pelvic Nigeria documented 1013 symphysiotomies performed between
pain and instability (Chalidis 2007); 1982 and 1999 (3.7% of 27,477 births) (Sunday-Adeoye 2004).
4. other complications include vaginal lacerations; haematuria Indications included cephalopelvic disproportion (88%), arrest of
(blood in the urine); wound infection; urinary incontinence; and the aftercoming head of the breech and previous caesarean section

Symphysiotomy for feto-pelvic disproportion (Review) 3

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
with mild cephalopelvic disproportion. Postoperative complica- labour. For example, in a retrospective analysis of births at Jimma
tions (36) included failed symphysiotomy (10), transient pelvic hospital, south western Ethiopia from September 1990 to May
and leg pain (12), transient stress incontinence (6), para-urethral 1999, 7% (945/13,425) were complicated by obstructed labour.
lacerations (vaginal tears alongside the urethra) (3), vaginal lac- Maternal case mortality rate from obstructed labour was 9.1% and
erations (2), gait abnormality (2) and vesico-vagina fistula (suc- perinatal mortality rate 62.1%. Obstructed labour was the com-
cessfully repaired) (1). There were 104 perinatal deaths and one monest cause of maternal and perinatal mortality at the hospital
maternal death from pulmonary embolism three days after birth. during the study period, being responsible for 45.5% and 37.4%
A report from Mile Four Mission Hospital, Abakaliki, Nigeria, of the deaths respectively (Gaym 2002).
made the point that caesarean section was viewed culturally as a A hospital-based review of 86 maternal deaths (580/100,000
reproductive failure. During 2000 and 2001, 75 of 4596 women births) between 1981 and 1986 in Pondicherry, India, found the
(1.6%) gave birth with partial symphysiotomy. There were 11 following causes which may be related to obstructed labour: pro-
complications, including paraurethral lacerations (four), and tran- longed labour 8.1%; ruptured uterus 9.3%; sepsis other than post-
sient stress incontinence (four) wound infection (two) and haem- abortion sepsis 11.8%; haemorrhage 8.1%. Most of the women
orrhage (one). All the women could walk and run at follow up who died were illiterate (97.6%), poor (98.8%), and had received
(Ezegwui 2004). no prenatal care (94.2%), and 47.7% travelled more than 60 km
There have been case reports from well-resourced countries, when to the hospital. Untrained attendants had excessively interfered
symphysiotomy has been used, for example, for birth of the af- with about 33% before they reached the hospital (Rajaram 1995).
tercoming head of a breech presenting baby (Wykes 2003). The Vesico-vaginal and recto-vaginal fistulas (open channels from the
place of symphysiotomy in well-resourced countries has recently bladder or rectum to the vagina) remain an enormous problem
been addressed (Menticoglou 2009). in many poor countries, most being the result of prolonged ob-
Recent guidelines issued by the Society of Obstetricians and Gy- structed labour (Steiner 1996).
necologists of Canada recommend the use of symphysiotomy for Caesarean section for treatment of obstructed labour is often un-
obstructed aftercoming head of the breech (Kotaska 2009). available or unacceptable in poor countries. When it is available,
The importance of proper training has been emphasised (Verkuyl lack of facilities and skills often result in an operative mortality in
2008). the region of 1%. For example, in a Nigerian study, the caesarean
A survey in Zimbabwe found that doctors and midwives working section rate in Ile-Ife increased from 2.3% in 1977 to 10.6% in
in peripheral district hospitals had more positive attitudes towards 1985 due to a higher proportion of cephalopelvic disproportion
symphysiotomy than those working in central hospitals (Ersdal (39.9%). Morbidity occurred in 33% and mortality in 0.71% of
2008). caesarean sections (Okonofua 1988). In a study in seven rural dis-
The contention that symphysiotomy is an unacceptable operation trict hospitals in Zimbabwe, the post-caesarean section maternal
has seldom been based on the views of clients. A Nigerian survey mortality was 1.6%, mainly from haemorrhage (Van Eygen 2008).
of pregnant women’s views in a region where symphysiotomy has Maternal and perinatal morbidity from caesarean section may be
been practised for many years and is well know among women particularly high when performed in the second stage of labour
found that 63% of women given the choice would prefer sym- with the baby’s head deeply impacted in the mother’s pelvis and
physiotomy to caesarean section (Onah 2004). reduced amniotic fluid volume. In this situation the relative ben-
efits of symphysiotomy may be more pronounced.
A crucial question to be answered if maternal mortality from ob-
Setting-specific questions regarding structed labour in poor countries is to be taken seriously, is whether
symphysiotomy symphysiotomy is an effective and acceptable strategy to use. If
so, considerable influence from governments and health organiza-
There are two questions regarding the appropriateness of use of
tions will be needed to implement the practice and to overcome
symphysiotomy.
current negative sentiments towards it.
First: are there clinical situations in which symphysiotomy is
preferable to caesarean section or other conventional methods?
This is a straightforward clinical issue.
The second is more complex: when caesarean section is not avail- Symphysiotomy technique
able, should symphysiotomy be used as a ’second best’ option? See Appendix 1.
To place the second question in context, we need to consider the
question of maternal mortality related to obstructed labour. The
Millenium Development Goals call for a reduction in maternal
mortality ratio by 75% between 1990 and 2015. In many low-
Need for a review
income countries, maternal mortality ratios are in the region of There is a need to evaluate the available evidence, and if necessary
1000 per 100,000 births. One of the major causes is obstructed recommend further research, regarding the following questions.

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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
What are the relative risks and benefits of symphysiotomy for: Types of interventions
1. obstructed aftercoming head during breech birth; Symphysiotomy compared with alternative technique of symphys-
2. shoulder dystocia; iotomy or alternative management, including:
3. obstructed labour when no caesarean section facilities are 1. caesarean section;
available; 2. other obstetric procedures;
4. compared with caesarean section in specific circumstances 3. allowing more time for labour to progress;
such as a mother who is not fit for anaesthesia, or who prefers 4. augmentation of labour;
symphysiotomy. 5. transfer to health centre with more advanced facilities (e.g.
for caesarean section);
6. destructive procedures (e.g. craniotomy).

OBJECTIVES Types of outcome measures

To determine, from the best available evidence, the relative bene-

fits and risks of symphysiotomy in defined clinical situations, com-
Primary outcomes
pared with alternative management; and the relative benefits and
risks of alternative symphysiotomy techniques. 1. Maternal death or severe morbidity (8, 10, 11 below)
2. Perinatal death or severe morbidity (4, 5, 7 below)

METHODS Secondary outcomes

For the mother

Criteria for considering studies for this review
1. Postoperative pain
2. Blood loss
3. Blood transfusion
Types of studies 4. Vesico-vaginal fistula
5. Anaemia
Randomized controlled trials. We planned to include quasi-ran-
6. Sepsis
domized trials, as well as studies presented only as abstracts, pro-
7. Repeat surgery
vided adequate details were available.
8. Venous thromboembolism
9. Intensive care unit (ICU) admission
10. Duration of hospital admission
Types of participants 11. Long-term severe pain
Women in labour for whom symphysiotomy is a possible option, 12. Long-term difficulty walking
including the following clinical situations: 13. Urinary incontinence
1. suspected cephalopelvic disproportion in first stage of 14. Flatus incontinence
labour; 15. Faecal incontinence
2. suspected cephalopelvic disproportion in second stage of 16. Breastfeeding failure (as defined by trial authors)
labour; 17. Depression
3. suspected cephalopelvic disproportion, baby demised 18. Satisfaction with care
(versus caesarean section or craniotomy); 19. Preference
4. suspected cephalopelvic disproportion, caesarean section 20. Subsequent infertility or obstetric problems
contraindicated, refused or not available; 21. Perinatal death
5. failed vacuum or forceps birth;
6. arrested aftercoming head during breech birth;
7. shoulder dystocia unresponsive to conservative manoeuvres. For the baby
Cephalopelvic disproportion is typically suspected when labour 1. Low five-minute Apgar score (as defined by trial authors)
fails to progress in spite of adequate uterine contractions, usually 2. Low cord blood pH or high base deficit (as defined by trial
with signs of obstruction such as excessive moulding of the baby’s authors)
head and caput succedaneum. 3. Injury

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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 4. Admission to neonatal ICU RESULTS
5. Neonatal encephalopathy
6. Duration of hospitalisation
7. Neurological deficit (as defined by trial authors)
Description of studies
8. Death
We found no randomized or quasi-randomized trials of symphys-
iotomy for either inclusion or exclusion.
For the caregivers/facility
1. Caregiver satisfaction
2. Cost Risk of bias in included studies
No studies included.

Search methods for identification of studies

Effects of interventions
No studies included.
Electronic searches
We searched the Cochrane Pregnancy and Childbirth Group’s Tri-
als Register by contacting the Trials Search Co-ordinator (August
2010).
DISCUSSION
The Cochrane Pregnancy and Childbirth Group’s Trials Register
is maintained by the Trials Search Co-ordinator and contains trials Symphysiotomy is a controversial procedure. It is regarded by
identified from: many as an outdated and even unacceptable operation. On the
1. quarterly searches of the Cochrane Central Register of other hand it is claimed to be a life-saving procedure in certain
Controlled Trials (CENTRAL); clinical situations (such as obstructed aftercoming head during
2. weekly searches of MEDLINE; breech birth), and in settings with no access to caesarean section,
3. handsearches of 30 journals and the proceedings of major for wider indications such as obstructed labour. In the absence of
conferences; information from randomized trials, policy and clinical decisions
4. weekly current awareness alerts for a further 44 journals regarding the use of symphysiotomy need to be based on evidence
plus monthly BioMed Central email alerts. from observational studies as outlined in the introduction.
Details of the search strategies for CENTRAL and MEDLINE,
the list of handsearched journals and conference proceedings, and
the list of journals reviewed via the current awareness service can
AUTHORS’ CONCLUSIONS
be found in the ‘Specialized Register’ section within the edito-
rial information about the Cochrane Pregnancy and Childbirth
Implications for practice
Group.
Trials identified through the searching activities described above In view of the emotive debates surrounding the use of symphys-
are each assigned to a review topic (or topics). The Trials Search iotomy, and the likelihood that use of symphysiotomy may be
Co-ordinator searches the register for each review using the topic lifesaving in several clinical circumstances, while awaiting results
list rather than keywords. of future high quality trials, it is important for professional and
In addition, we searched CENTRAL (The Cochrane Library 2010, global bodies to produce guidelines based on objective evaluation
Issue 3) and PubMed (1966 to 31 August 2010) using the search of available evidence. Such guidelines should take into account
term: ’symphysiotomy’. the current appalling maternal and perinatal mortality rates from
We did not apply any language restrictions. obstructed labour in communities where safe caesarean section is
not available or is unacceptable.

Implications for research

Data collection and analysis
There is a need for randomized trials to evaluate the effectiveness
No randomized or quasi-randomized trials were identified. In fu-
and safety of symphysiotomy. The following research questions
ture updates of this review, if more data become available, the
need to be addressed.
methods to be used for data collection and analysis are outlined
in Appendix 2.

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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 1. Symphysiotomy versus no symphysiotomy for failure to ACKNOWLEDGEMENTS
progress in the second stage of labour when caesarean section is
not available, not safe or is declined by the mother.
2. Symphysiotomy versus caesarean section in clinical We acknowledge the support of the Cochrane Pregnancy and
situations in which the relative risks and benefits are considered Childbirth Group team.
to be balanced (for example, in women at high risk for
abdominal surgery, general anaesthesia or regional analgesia).
As part of the pre-publication editorial process, this review has
3. Symphysiotomy versus no symphysiotomy for obstructed
been commented on by three peers (an editor and two referees
birth of the aftercoming head during breech birth.
who are external to the editorial team), a member of the Pregnancy
4. (Low priority) Symphysiotomy versus no symphysiotomy and Childbirth Group’s international panel of consumers and the
for shoulder dystocia unresponsive to conventional management. Group’s Statistical Adviser.

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practice among doctors and midwives. PLoS One 2008;3 international journal of obstetrics and gynaecology 2002;109:
(10):e3317. 225–6.
Ezegwui 2004 Maharaj 2002
Ezegwui HU, Olomu OO, Twomey ED. Symphysiotomy Maharaj D, Moodley J. Symphysiotomy and fetal
in a Nigerian hospital. International Journal of Gynecology & destructive operations. Best Practice & Research. Clinical
Obstetrics 2004;85:272–3. Obstetrics & Gynaecology 2002;16:117–31.
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Menticoglou 2009 Steiner 1996
Menticoglou SM. Is there a role for symphysiotomy in Steiner AK. The problem of post-partum fistulas in
developed countries?. Journal of Obstetrics and Gynaecology developing countries. Acta Tropica 1996;62:217–23.
2009;29:272–7.
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Mola 1995
Sunday-Adeoye IM, Okonta P, Twomey D. Symphysiotomy
Mola GD. Symphysiotomy or caesarean section after failed
at the Mater Misericordiae Hospital Afikpo, Ebonyi State
trial of assisted delivery. Papua and New Guinea Medical
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Journal 1995;38:172–7.
Obstetrics and Gynaecology 2004;24:525–9.
Nkwo 2009
Nkwo PO, Onah HE. Does a preference for symphysiotomy Van Eygen 2008
over caesarean section reduce the operative delivery rate?. Van Eygen L, Rutgers S. Caesarean section as preferred
Tropical Doctor 2009;39(4):198–200. mode of delivery in term breech presentations is not a
realistic option in rural Zimbabwe. Tropical Doctor 2008;38
Okonofua 1988 (1):36–9.
Okonofua FE, Makinde ON, Ayangade SO. Yearly trends in
caesarean section and cesarean mortality at Ile-Ife, Nigeria. Van Roosmalen 1987
Tropical Journal of Obstetrics & Gynaecology 1988;1:31–5. Van Roosmalen J. Symphysiotomy as an alternative to
cesarean section. International Journal of Gynecology &
Onah 2004
Obstetrics 1987;25(6):451–8.
Onah HE, Ugona MC. Preferences for cesarean section
or symphysiotomy for obstructed labor among Nigerian Verkuyl 2001
women. International Journal of Gynacology & Obstetrics Verkuyl DAA. Symphysiotomies are important option in
2004;84:79–81. developing world. BMJ 2001;323:809.
Onsrud 2008
Verkuyl 2007
Onsrud M, Sjøveian S, Mukwege D. Complete destruction
Verkuyl DA. Think globally act locally: the case for
of urethra and bladder neck following symphysiotomy and
symphysiotomy. PLoS Medicine 2007;4(3):e71.
results of attempted corrective surgery. Acta Obstetricia et
Gynecologica Scandinavica 2008;87(5):574–6. Verkuyl 2008
Payne 2001 Verkuyl DA, Ersdal HL, Raassen TJ. Absence of proper
Payne G. Ireland orders inquiry into “barbaric” obstetric training in symphysiotomies resulted in this operation being
practices. BMJ 2001;322(7296):1200. underused, performed when contraindicated and possibly
in a specific kind of urinary fistula. Acta Obstetricia et
Quinlan 1995
Gynecologica Scandinavica 2008;87(12):1380–3.
Quinlan DJ. Symphysiotomy. In: Hankins GDV, Clark
SL, Cunningham FG, Gilstrap LC editor(s). Operative WHO 2001
obstetrics. Connecticut: Appleton & Lange, 1995:89–92. WHO, UNFPA, UNICEF, World Bank. Managing
Rajaram 1995 complications in pregnancy and childbirth. A guide for
Rajaram P, Agrawal A, Swain S. Determinants of maternal midwives and doctors. Geneva: WHO, 2001:53.
mortality: a hospital based study from south India. Indian Wykes 2003
Journal of Maternal and Child Health 1995;6:7–10. Wykes CB, Johnston TA, Paterson-Brown S, Johanson
RevMan 2008 RB. Symphysiotomy: a lifesaving procedure. BJOG: an
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Cochrane Centre, The Cochrane Collaboration, 2008. ∗
Indicates the major publication for the study

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DATA AND ANALYSES
This review has no analyses.

APPENDICES

Appendix 1. Symphysiotomy technique

Symphysiotomy technique is included in the UK ’Managing Obstetric Emergencies and Trauma’ courses (Wykes 2003). The technique
is described in Crichton 1963, Quinlan 1995 and in WHO 2001. A brief, slightly modified description follows.
Explain the reason, the procedure and possible complications, and request consent. Ensure that conservative measures to promote birth
such as upright posture have been attempted. Symphysiotomy is usually but not exclusively performed when the cervix is fully dilated.
The head should be at most 2 cm above the ischial spines or no more than 3/5 above the pelvic inlet, with no over-riding of the head
above the symphysis pubis. A vacuum extractor cup may be applied before or after the symphysiotomy is performed. Greater traction
is possible with a large metal cup than a flexible cup (see Johanson 2000 review on vacuum extraction).
Provide emotional support and encouragement. Use local infiltration with lignocaine as soon as the decision for symphysiotomy is
made or anticipated, to allow time for the analgesic to take effect. Infiltrate the anterior, superior and inferior aspects of the symphysis
and the subcutaneous tissues with lignocaine 0.5% solution. Check that no blood can be aspirated before each infiltration. The needle
may be left inserted into the joint as a guide for the scalpel incision.
Two assistants support the woman’s legs with her thighs and knees flexed with the thighs abducted no more than 90° from each
other. Insert a large firm (plastic) catheter to identify the urethra. Apply antiseptic solution to the skin. Confirm adequate analgesia by
pinching the skin with forceps. Place an index finger in the vagina and push the catheter and the urethra away from the midline. With
the other hand, use a fixed-blade scalpel to make a vertical stab incision over the symphysis. Keeping to the midline, cut down through
the fibro-cartilage joining the two pubic bones. Cut the cartilage downwards to the bottom of the symphysis, then rotate the blade
and cut upwards to the top of the symphysis. As fixed-blade scalpels are rarely available, the author has used a normal disposable blade
scalpel (largest, curved blade available) and incised the joint in one step (without rotating the blade), with sawing action, from the top
to the bottom, taking care to leave the most posterior and inferior fibres intact. Traditionally, the finger displacing the urethra is held
directly behind the symphysis pubis and the depth of the incision judged by feeling the movement and pressure of the scalpel tip with
the internal finger. If the woman is not known to be HIV-negative, the authors advise that the internal finger displace the urethra even
further laterally to be kept well lateral to the symphysis, and that the depth of the incision be controlled by judgement.
Remove the catheter. Perform a mediolateral episiotomy to reduced tension on the para-urethral tissues. Assist the birth of the baby
by vacuum extraction, guiding the head away from the symphysis pubis. Descent of the head causes the symphysis to separate 1 cm
or 2 cm. After the birth, catheterize the bladder with a self-retaining bladder catheter. Do not suture the stab incision unless there is
bleeding. Carefully bring the supported legs together. Apply elastic strapping around the pelvis from one iliac crest to the other to
stabilize the symphysis and reduce pain. Loosely bind the knees together with elastic strapping to restrict independent movement of
the thighs. Give analgesia. Nurse the woman on her side to aid apposition of the joint surfaces. Encourage ankle exercises in bed. If
the woman is considered at high risk for venous thrombosis, give prophylaxis. Leave the catheter in the bladder for a minimum of five
days. Encourage mobilisation on crutches, weightbearing on two feet together, as soon as possible (usually within one or two days). Do
not allow weightbearing on individual feet until this can be done without discomfort in the pubic region (usually several days).

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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Appendix 2. Methods of data collection and analysis to be used in future updates
The following methods will be used for data collection and analysis in future updates of this review if more data become available.

Data collection and analysis

Selection of studies
Both review authors will independently assess for inclusion all the potential studies we identify as a result of the search strategy. We
will resolve any disagreement through discussion.

Data extraction and management

We will design a form to extract data. For eligible studies, both review authors will extract the data using the agreed form. We will
resolve discrepancies through discussion. We will enter data into Review Manager software (RevMan 2008) and check for accuracy.
When information regarding any of the above is unclear, we will attempt to contact authors of the original reports to provide further
details.

Assessment of risk of bias in included studies

Two review authors will independently assess risk of bias for each study using the criteria outlined in the Cochrane Handbook for
Systematic Reviews of Interventions (Higgins 2009). We will resolve any disagreement by discussion.

(1) Sequence generation (checking for possible selection bias)

We will describe for each included study the method used to generate the allocation sequence in sufficient detail to allow an assessment
of whether it should produce comparable groups.
We will assess the methods as:
• adequate (any truly random process, e.g. random number table; computer random number generator);
• inadequate (any non random process, e.g. odd or even date of birth; hospital or clinic record number);
• unclear.

(2) Allocation concealment (checking for possible selection bias)

We will describe for each included study the method used to conceal the allocation sequence in sufficient detail and determine whether
intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment.
We will assess the methods as:
• adequate (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);
• inadequate (open random allocation; unsealed or non-opaque envelopes, alternation; date of birth);
• unclear.

(3) Blinding (checking for possible performance bias)

We will describe for each included study the methods used, if any, to blind study participants and personnel from knowledge of which
intervention a participant received. We will judge studies at low risk of bias if they are blinded, or if we judge that the lack of blinding
could not have affected the results. We will assess blinding separately for different outcomes or classes of outcomes.
We will assess the methods as:
• adequate, inadequate or unclear for participants;
• adequate, inadequate or unclear for personnel;
• adequate, inadequate or unclear for outcome assessors.

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(4) Incomplete outcome data (checking for possible attrition bias through withdrawals, dropouts, protocol deviations)
We will describe for each included study, and for each outcome or class of outcomes, the completeness of data including attrition and
exclusions from the analysis. We will state whether attrition and exclusions were reported, the numbers included in the analysis at each
stage (compared with the total randomised participants), reasons for attrition or exclusion where reported, and whether missing data
were balanced across groups or were related to outcomes. Where sufficient information was reported, or can be supplied by the trial
authors, we will re-include missing data in the analyses which we undertake. We will assess methods as:
• adequate (less than 10% attrition, balanced between groups and not related to outcomes);
• inadequate;
• unclear

(5) Selective reporting bias

We will describe for each included study how we investigated the possibility of selective outcome reporting bias and what we found.
We will assess the methods as:
• adequate (where it is clear that all of the study’s pre-specified outcomes, preferably based on a published protocol, and all
expected outcomes of interest to the review have been reported);
• inadequate (where not all the study’s pre-specified outcomes have been reported; one or more reported primary outcomes were
not pre-specified; outcomes of interest are reported incompletely and so cannot be used; study fails to include results of a key outcome
that would have been expected to have been reported);
• unclear.

(6) Other sources of bias

We describe for each included study any important concerns we have about other possible sources of bias.
We will assess whether each study was free of other problems that could put it at risk of bias:
• yes;
• no;
• unclear.

(7) Overall risk of bias

We will make explicit judgements about whether studies are at high risk of bias, according to the criteria given in the Handbook (Higgins
2009). With reference to (1) to (6) above, we will assess the likely magnitude and direction of the bias and whether we consider it likely
to impact on the findings. We will explore the impact of the level of bias through undertaking ’Sensitivity analysis’.

Measures of treatment effect

Dichotomous data
For dichotomous data, we will present results as summary risk ratio with 95% confidence intervals.

Continuous data
For continuous data, we will use the mean difference if outcomes are measured in the same way between trials. We will use the
standardised mean difference to combine trials that measure the same outcome, but use different methods.

Dealing with missing data

For included studies, we will note levels of attrition. We will explore the impact of including studies with high levels of missing data in
the overall assessment of treatment effect by using sensitivity analysis.
For all outcomes, we will carry out analyses, as far as possible, on an intention-to-treat basis, i.e. we will attempt to include all participants
randomised to each group in the analyses, and all participants will be analysed in the group to which they were allocated, regardless of
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whether or not they received the allocated intervention. The denominator for each outcome in each trial will be the number randomised
minus any participants whose outcomes are known to be missing.

Assessment of heterogeneity
We will assess statistical heterogeneity in each meta-analysis using the T2 , I² and Chi² statistics. We will regard heterogeneity as
substantial if I2 is greater than 30% and either T2 is greater than zero, or there is a low P-value (< 0.10) in the Chi² test for heterogeneity.

Assessment of reporting biases

If there are 10 or more studies in the meta-analysis we will investigate reporting biases (such as publication bias) using funnel plots. We
will assess funnel plot asymmetry visually, and use formal tests for funnel plot asymmetry. For continuous outcomes we will use the
test proposed by Egger 1997, and for dichotomous outcomes we will use the test proposed by Harbord 2006. If asymmetry is detected
in any of these tests or is suggested by a visual assessment, we will perform exploratory analyses to investigate it.

Data synthesis
We will carry out statistical analysis using the Review Manager software (RevMan 2008). We will use fixed-effect meta-analysis for
combining data where it is reasonable to assume that studies are estimating the same underlying treatment effect: i.e. where trials are
examining the same intervention, and the trials’ populations and methods are judged sufficiently similar. If there is clinical heterogeneity
sufficient to expect that the underlying treatment effects differ between trials, or if substantial statistical heterogeneity is detected, we
will use random-effects meta-analysis to produce an overall summary if an average treatment effect across trials is considered clinically
meaningful. The random-effects summary will be treated as the average range of possible treatment effects and we will discuss the
clinical implications of treatment effects differing between trials. If the average treatment effect is not clinically meaningful we will not
combine trials.
If we use random-effects analyses, the results will be presented as the average treatment effect with its 95% confidence interval, and the
estimates of T2 and I2 .

Subgroup analysis and investigation of heterogeneity

The primary comparisons will be between symphysiotomy and alternative symphysiotomy techniques and other methods of birth
(see Types of interventions). We will perform subgroup analyses for the various clinical indications for symphysiotomy (see Types of
participants).
If we identify substantial heterogeneity, we will investigate it using subgroup analyses and sensitivity analyses. We will consider whether
an overall summary is meaningful, and if it is, use random-effects analysis to produce it.
For fixed-effect inverse variance meta-analyses we will assess differences between subgroups by interaction tests. For random-effects and
fixed-effects meta-analyses using methods other than inverse variance, we will assess differences between subgroups by inspection of the
subgroups’ confidence intervals; non-overlapping confidence intervals indicate a statistically significant difference in treatment effect
between the subgroups.

Sensitivity analysis
We will conduct sensitivity analyses to assess the effect of inclusion of studies with higher risks of bias as outlined above. Sensitivity
analyses will include all outcomes.

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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
HISTORY
Protocol first published: Issue 2, 2005
Review first published: Issue 10, 2010

Date Event Description

24 September 2008 Amended Converted to new review format.

CONTRIBUTIONS OF AUTHORS
GJ Hofmeyr conducted the literature search and contributed to the writing of the review. PM Shweni provided clinical input to the
writing of the paper.

DECLARATIONS OF INTEREST
None known.

SOURCES OF SUPPORT

Internal sources
• (GJH) Effective Care Research Unit, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of
Health, South Africa.
• (PMS) Eastern Cape Department of Health, South Africa.

External sources
• (GJH) HRP-UNDP/UNFPA/WHO/World Bank Special Programme in Human Reproduction, Geneva, Switzerland.
• (GJH) Rockefeller Foundation Residency, October 2004, USA.

DIFFERENCES BETWEEN PROTOCOL AND REVIEW

Since the protocol was published the Pregnancy and Childbirth Group has updated its methods; we have incorporated these into the
review.
We have added ’vesico-vaginal fistula’ as a secondary outcome. This was not prespecified in our protocol.
We have modified the prespecified maternal secondary outcome ’death’ to ’perinatal death’.

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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
INDEX TERMS

Medical Subject Headings (MeSH)

∗ Symphysiotomy [adverse effects; methods]; Cephalopelvic Disproportion [∗ surgery]; Pelvimetry

MeSH check words

Female; Humans; Pregnancy

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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.