Symphysiotomy for feto-pelvic disproportion.
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.


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


METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 July 2012).


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


METHODS
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.


RESULTS
We found no randomized trials of symphysiotomy.


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).
Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of FortHare, Eastern Cape Department of Health, East London, South Africa. justhof@gmail.com.
G Justus
GJ
Hofmeyr
P Mike
PM
Shweni
D052178:Cephalopelvic Disproportion / Q000601:surgery*; D005260:Female; D006801:Humans; D010387:Pelvimetry; D011247:Pregnancy; D011631:Pubic Symphysis / Q000601:surgery; D013567:Symphysiotomy / Q000009:adverse effects / Q000379:methods