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Symphysiotomy as an alternative to cesarean section
Int. J. Gynaecol. Obstet., 1987: 25,45 l-458 InternationalFederationofGynaecologyandObstetrics
SYMPHYSIOTOMY
451
AS AN ALTERNATIVE
TO CESAREAN SECTION
.I. van ROOSMALEN Leyden
State University
(Received (Accepted
Hospital,
Department
of Obstetrics
and Gynaecology,
Leiden (The Netherlands)
July 15th, 1986) November 13th, 1986)
Abstract
Introduction
The author compares the value of symphysiotomy to cesarean section in the management of cephalopelvic disproportion. He outlines the history of the procedure and reviews the literature on the subject. He then presents results of 54 symphysiotomies performed from 1976 to 1983 in two rural hospitals in the southwestern highlands of Tanzania, together with the outcome of subsequent labor in 25 other women with a history of previous symphysiotomy. The maternal risk of mortality after symphysiotomy is lower than after cesarean section when performed for cephalopelvic disproportion. Although different in nature, maternal morbidity after both operations is equally common. In contrast with findings reported in the literature, a history of previous symphysiotomy still constitutes a high obstetrical risk. The author concludes that symphysiotomy has a place in the management of cephalopelvic disproportion.
Symphysiotomy is the artificial separation of the symphysis pubis with a scalpel in order to enlarge the diameter of the pelvic opening to facilitate the process of birth. This relatively simple procedure has been very popular in Roman Catholic countries, where sterilization after repeated cesarean birth - a practice which limits the number of offspring was condemned. Thirty years ago, E. Zarate, the most ardent enthusiast of symphysiotomy in Latin America, even thought use of the procedure would result in the abolition of cesarean section [36]. In most western countries, however, symphysiotomy never became popular. Shorter, for example, in his extensive history of western childbirth [32], devotes only one sentence to the subject, as do many contemporary obstetrics textbooks. In this article the value of symphysiotomy for the management of cephalopelvic disproportion (CPD) is compared to use of cesarean section. The article is based on a search of the literature and the author’s experience with symphysiotomy in two rural hospitals in the southwestern highlands of Tanzania from 1976 to 1983.
Keywords: Symphysiotomy; Cesarean section; Cephalopelvic disproportion; Tanzania; Delivery care history; Previous symphysiotomy; Appropriate technology. OO20-7292/87/$03.50. 0 International Federation of Gynaecology Published and Printed in Ireland
& Obstetrics
Int J Gynaecol
Obstet 25
452
van Roosmalen
History of symphysiotomy
Ever since Hippocrates, childbirth was thought to be accompanied by spontaneous pelvic enlargement by separation of the symphysis pubis [7]. This view was held by Ambroise Pare in the 16th and William Harvey in the 17th century [14]. Andreas Vesalius was the first to question the notion of spontaneous pelvic enlargement in his De Humani Corporis Fabrica in 1543 [ 111. Only after Vesalius’ correct view was accepted that the symphysis pubis is an inseparable unit during the process of birth did the idea of artificially separating the symphysis take shape. In 1655, the first symphysiotomy was performed as an alternative to postmortem cesarean section. In 1777, Jean-Rene Sigault in Paris performed the first symphysiotomy on a living woman who was very stunted and had a history of four stillborn babies after difficult labor. The woman survived and had her first live-born baby. She suffered, however, from a vesico-vaginal fistulafortherestofherlife[14,33]. Though welcomed as a great innovation, the results of the first symphysiotomies were not very promising. Fourteen mothers and 18 newborns of the first 36 symphysiotomies died [34]. These bad results may be partly explained by the extremely prolonged labor for which symphysiotomy was performed. But cesarean section at that time had an almost hundred percent maternal mortality rate. The first symphysiotomy in The Netherlands was performed by Groshans in 1778 [16], and between 1778 and 1831 at least 20 symphysiotomies were reported with three maternal deaths [33]. After initial enthusiasm the operation fell into discredit. In the late 19th century a revival took place in Italy. Among others Morisani reported many cases with maternal mortality under 5% and perinatal mortality just under 12% [14]. Van Linden der presented 2801 Int J Gynuecol Obslet 25
symphysiotomies performed between 1900 and 1960 [23]. Maternal mortality in his series was as low as 14 per 1000; maternal morbidity (like vesico-vaginal fistulas, vaginal lacerations and orthopedic complications) occurred in 7%. The perinatal mortality rate was 86 per 1000 births. These symphysiotomies were performed almost exclusively in the predominantly Roman Catholic countries of Italy, Spain, France, Ireland and in some Latin American countries. An explanation for this may lie in the condemnation of sterilization by the Roman Catholic Church. The Church also put the interest of the newborn above that of the mother [35]. Cesarean section prevented the potential for large families, where tubal ligation was performed after repeated cesarean deliveries. But even in non-Catholic countries like Great Britain, where the practice was to sacrifice the child for the safety of the mother, some symphysiotomies were performed in the first half of the 20th century [26]. Bowesman [14] and Pereira [29] mention that symphysiotomy was practiced by traditional healers in several parts of Africa. Approximately 10% of symphysiotomies reported by Van der Linden [23] were performed in Africa, and since 1960, most communications on symphysiotomy have stemmed from Africa. Later in this paper, the author examines the practice of symphysiotomy in two rural hospitals in Tanzania. Maternal mortality Maternal mortality after symphysiotomy has decreased dramatically since 1960 and is almost negligible (see Table I). In the symphysiotomies series of different mentioned in Table I, there were three maternal deaths from a total of 1752 symphysiotomies (1.79’00). None of these procedure of related to the was by two were caused symphysiotomy: eclampsia and one occurred after cesarean
Symphysiotomy as alternative to cesarean section
Table I.
Maternal
and perinatal
mortality
in symphysiotomy
Place of study
Year of study
South Africa [22] South Africa [31] Kenya [3] Nigeria [ 171 Uganda 1121 South Africa [ 151 Zambia [25] Zimbabwe [27] Tanzania [l] Papua New Guinea Uganda [20] Zaire [28] This study
1957-1961 1957-1962 1959-1963 1961-1970 1964-1966 1964-1967 1970 1972-1977 1973-1977 1974-1980 1975 1976 1976-1983
151 505 104 138 108 201 75 161 105 86 30 34 54
1957-1983
1752
[24]
All studies
section in a symphysiotomy.
woman
with
No. of symphysiotomies
a
failed
Maternal morbidity maternal Serious morbidity after symphysiotomy, described in Table II, does not differ much from the rate reported between 1900 and 1960: 7% in 1900-1960 [23] and 8% from 1960 onward. Fifteen of the 30 vesico-vaginal fistulas appeared to be the result of pressurenecrosis of the bladderneck due to obstructed labor rather than to symphysiotomy. These presented immediately after delivery, while those due to obstructed labor developed only some days after delivery when
Table II. symphysiotomy
Serious maternal morbidity in different communities.
following
No. No. of symphysiotomies (Table 1) Vesico-vaginal fistulas Vestibular and/or urethral lesions Osteitis pubis/retropubic abscess Long-term walking disability and/or Stress-incontinence All complications
pain
in different
1752 30 33 10 32 36
Plo)
(1.7) (1.9) (0.6) (1.8) (2.1)
141 (8.1)
453
communities. Maternal mortality
Perinatal
(Qo)
(%a)
0 0 0
1 0 0 1 0 1 0 0 0 0 3 (1.7)
3/151 42/505 22/104 23/138 16/108 20/20 1 18/75 16/161 9/105 7/86 3/30 l/34 11/54 197/1752
mortality
(19) (83) (212) (167) (148) (100) (240) (99) (86) (81) (100) (296) (204)
(112)
necrotic tissue was shed off. Some of the immediate fistulas were the result of application of forceps after symphysiotomy in order to assist delivery. After the introduction of vacuum extraction, this practice was abandoned and the useofforcepscontraindicated [3,6,12,31]. Perinatal mortality Perinatal mortality differed markedly in the different series (range 19-296%0), with an overall rate of 112%~~ (Table I). Different levels of obstetrical skill and technical support explain this. may Although comparison therefore is difficult, fetal prognosis had not improved since 1900 -1960. Literature All authors regarded symphysiotomy as a procedure with a definite place in obstetric practice, at least in the circumstances they describe. Editorials in The Lancet in 1962 and 1974 conclude that its urinary and orthopedic complications have been exaggerated [g,9]. Moreover, report.s in the ill literature on the effects of symphysiotomy often lacked controls, and only three controlled studies have been Int J Gynaecol Obstet 25
454
van Roosmalen
published These [l&22,24]. studies, however, were not prospective randomized controlled trials, which made comparison with the control group difficult. Lasbrey [22] found minor symptoms at some time in the follow-up period or in a subsequent pregnancy in 58Vo of 87 women who underwent symphysiotomy as compared to 60% of the 87 parous women in his control group.
Symphysiotomy as compared to cesarean section Denying symphysiotomy to a woman in need of it results in obstructed labor and fetal death or makes necessary cesarean section as an emergency procedure late in labor. Therefore, a group of women who had cesarean section instead of symphysiotomy in relieve order to obstructed labor could provide the best control group where randomization is difficult. Retrospective comparison of the results of symphysiotomy with those of cesarean section performed in advanced labor has been the subject of the other two controlled studies [ 18,241. These studies confirm that the long-term disabling sequelae of symphysiotomy have been overemphasized. There is also less mortality risk after symphysiotomy than after cesarean section.
Table III.
Pregnancy after previous symphysiotomy The pelvis often remains permanently enlarged after a symphysiotomy is performed. The procedure could therefore provide a cure for some cases of disproportion. This is especially important when one is not sure that the patient will return to hospital for a subsequent pregnancy. Obviously cesarean section does not affect the pelvis and leaves the origin of disproportion untouched. A woman sent home with a scarred uterus may experience uterine rupture in a subsequent unattended delivery. The outcome of labor in women with a previous symphysiotomy is described in Table III. Uncomplicated vaginal delivery occurred in 739’0, while operative vaginal delivery took place in another 14%. Cesarean birth occurred in 11%. The vaginal delivery rate after previous symphysiotomy is higher than after previous cesarean section for disproportion. Nevertheless, a considerable percentage of women with previous symphysiotomy need operative vaginal and abdominal delivery for subsequent births. Symphysiotomy in Lugarawa and Mbozi Hospitals in Tanzania Lugarawa and Mbozi hospitals are rural hospitals in the southwestern highlands of Tanzania. Both hospitals are the only ones
Outcome of subsequent labor in women with previous symphysiotomy in different communities. Spontaneous vertex delivery @Jo)
Gordon 1969 [15] Hartfield 1973 (181 Armon 1978 [l] Norman 1978 [27] Mola 1981 [24] This study 1976-1983
No. of pregnancies Ve) 36 76 45 28 19 25
All cases
229 (100)
167 (73)
Author
PT~~ cases of uterine rupture included. Int J Gynaecol Obstet 25
29 58 32 26 11 11
Operative vaginal delivery
Cesarean section
(070)
(~0)
3 8 7 1 5 8 32 (14)
4 (11) 5 (7) 6 (13) 1 (4) 3 (16) 6 (24) 25 (11)
Repeat symphysiotomy (70) 0 5 0 0 0 0 5 (2)
Symphysiotomy as alternative to cesarean section
in a large rural district. In Ludewa district, 24% of all pregnant women delivered in Lugarawa Hospital. In Mbozi district, 13% of all pregnant women delivered in Mbozi Hospital. Maternal health services are provided by medical auxiliaries with by a few general doctors. supervision Transport in the districts is unreliable.
, Fibrocartilage
455
excavated
Arcuate Permeal Urethra
llgarnent membrane
Vagina
Methods Altogether 54 symphysiotomies were 18 in Lugarawa (in 2285 performed: deliveries; 0.8% during 1976- 1979) and 36 in Mbozi (in 5226 deliveries; 0.7% during 1979-1983). Symphysiotomy was practiced in both hospitals using Seedat and Crichton’s method [6,31], which is based upon Zarate’s work [36]. The method differs from that of Zarate in that it advises against partial division of the symphysis, which is then completed by forceful abduction of the thighs. It is thought that forceful abduction damages the sacroiliac joints, possibly resulting in permanent pelvic instability and The method also stresses the pain. importance of avoiding the hyaline cartilage by strict adherence to the midline in dividing the symphysis pubis. Deviating from the midline may lead to osteitis pubis and subsequent difficulty in walking. Symphysiotomy increases the pelvic diameters at all levels, although not to the same degree 151. The transverse diameters are especially increased. The bottom ends of the symphysial and sacroiliacal joints separate more than the upper ends, so the outlet diameters increase more than the inlet ones. Because of this, some authors concluded falsely that symphysiotomy is only indicated in outlet cases of disproportion [26]. Contrary to what has been taught in the past [23,36], the arcuate ligament beneath the symphysis is directly cut (Fig. 1). In
Diagram of the symphysis pubis (after Crichton Fig. 1. and Seedat [25]).
order to avoid undue strain to the sacroiliac joints, forceful abduction of the thighs Instead, should never be undertaken. complete separation is brought about by the cutting scalpel only. Indications Symphysiotomy was mainly performed in cases of cephalopelvic disproportion with a and a live fetus. vertex presentation Whether symphysiotomy was indicated in such cases mainly depended on three interrelated factors: -
-
descent of the fetal head degree of overlap as a result of fetal head molding dilatation of the cervix [ 131.
One-third or more of the fetal head should have entered the pelvic brim. The fetal head should not be felt prominent in front of the symphysis pubis and the dilatation of the cervix should be more than 7 cm in a primigravida, according to Gebbie’s rules 1131. When symphysiotomy was performed in the second stage of labor, it often followed a failed trial of vacuum extraction. In this study Gebbie’s rules were followed to indicate whether symphysiotomy could be performed. Int J Gynaecol Obstet 25
456
van Roosmalen
Some characteristics of the women Most women were of low parity: 36 (67%) were primigravidae, while 11 (20%) had parity one or two. Six women (11%) had parity five or more, while the parity of one was not recorded. This parity distribution was much the same as Seedat and Crichton mentioned in their series of 505 symphysiotomies [31]. It differed significantly from the parity distribution of the whole obstetric population delivering in Lugarawa and Mobozi with 23.5% primigravidae. Maternal height was significantly lower in the symphysiotomy group (20 women (37%) were below 150 cm) than in the whole obstetric population delivering in Lugarawa and Mbozi (19% below 150 cm). Labor was augmented with oxytocin in 24 women (440/o) because of first stage delay: 21 had vertex presentations, two had a face and one a breech presentation. The four multiparous women in Lugarawa had 8 perinatal deaths and only one live birth before they were delivered by symphysiotomy of a live baby. The mean birth weight of newborns of 53 women was 3070 g (-e 460 S.D.) with a range of 23004330 g, considerably higher than the overall mean birth weight in both hospitals. Results There were no maternal deaths in this series, but major complications occurred in four women (Table IV). One patient developed osteitis pubis and was unable to walk for at least 5 months. Eventually she Serious maternal morbidity in Lugarawa and Table IV. Mbozi hospitals, Tanzania in 54 cases of symphysiotomy, 1976-1983. Complication
No. (%a)
Osteitis pubis Vesico-vaginal fistulas Laceration vaginal wall
l(l.9) 2 (3.7) l(l.9)
All complications
4 (7.5)
Int J Gynaecol Obstet 25
was cured and delivered by cesarean section in three subsequent pregnancies without Two women had complicomplications. cations (one a vesico-vaginal fistula, the other a laceration of the anterior vaginal wall), because the procedure was performed without inserting a urinary catheter. The fourth complication was a vesicovaginal fistula resulting from pressurenecrosis of the bladderneck. This was not related to the procedure. Five women were incidentally seen by the author at least 3 months after symphysiotomy and appeared to have no ill effects whatsoever. Eight women came back for delivery in a subsequent pregnancy: at that time they had no complaints. Perinatal mortality Perinatal mortality was high: 11/54 = 2040700. In two cases the fetus had already died before symphysiotomy was undertaken. This should be a contraindication for the procedure and in such cases destructive operation is an alternative. Comparison with cesarean section Comparing results of symphysiotomy section for cesarean with those of disproportion indicated less mortality risk for the mother, while maternal morbidity, although different in nature, did not differ much in frequency (Table V). Table V. Comparison of outcome of symphysiotomy and cesarean section for cephalopelvic disproportion, Lugarawa and Mbozi hospitals, Tanzania, 1976-1983. Symphysiotomy
N = 54 (To) Maternal mortality Serious maternal morbidity Perinatal mortality
Cesarean section for CPD N= LOO (%)
0 (0) 4 (7)
5 (5) 6 (6)
11 (20)
13 (13)
section vs. cesarean morbidity: Serious maternal symphysiotomy x2 = 0.114; df = 1; n.s. Perinatal mortality: cesarean section vs. symphysiotomy x2 = 1.448; df = 1; n.s. ‘Included two deaths before symphysiotomy was started.
Symphysiotomy
Outcome of subsequent labor after previous symphysiotomy Table III shows the outcome of labor after previous symphysiotomy as reported in the literature and in 25 women delivering in Lugarawa and Mbozi hospitals. Of those 25, 1 had a spontaneous vertex 8 had delivery without complications; operative vaginal delivery and 6 were delivered abdominally. Cesarean delivery for disproportion occurred in 4 of these, while 2 had a uterine rupture. There were no maternal deaths. Perinatal mortality was high: 5 out of 25 newborns died, but 4 of these were already dead on admission to hospital. Discussion
The overall results of symphysiotomy in Lugarawa and Mbozi hospitals were not The risk of maternal unsatisfactory. mortality after symphysiotomy nowadays has become negligible and is much lower than after cesarean section performed in advanced labor for the same indications. Maternal morbidity could have been lowered by strict adherence to protocol: two women had complications because a urinary catheter was not inserted. Perinatal wastage was high. Often the already compromised on was fetus admission following prolonged labor at home. Sepsis was another contributing factor. Strict adherence to the indications will lower perinatal mortality. Fetal death is a contraindication for the procedure. indications the for One of symphysiotomy is a failed trial of vacuum extraction or forceps [4,12,21]. This policy of trial first, however, may add to mortality, especially if one perinatal continues to pull too long. Some authors therefore advise against this policy [ 13,241. On the other hand, abandoning this trial will definitely lead to more symphysiotomies, which in some cases could have been
as alternative
to cesarean section
457
easily prevented by a trial of vacuum extraction first [ 11. Previous symphysiotomy is said to cure cephalopelvic disproportion 151. The outcome of subsequent pregnancy in our cases could not support this, indicating the high risk of these women even after symphysiotomy. Symphysiotomy leaves the uterus unscarred. Yet, two of the women in the study sample experienced rupture of an unscarred uterus in a subsequent labor. The risk of cesarean birth after previous symphysiotomy (11 Vo) was higher than in the total obstetric population (3Oro). The percentage of abdominal delivery in our series (24%) was much higher than would have been anticipated from the few other studies in the literature (Table III). It is possible that uncomplicated delivery after previous symphysiotomy occurred at home, but this would be true for some of the other authors as well [ 1,15,27]. Symphysiotomy deserves a place in the management of cephalopelvic disproportion. It is an example of appropriate technology [2,10]. It is a relatively simple and rapid procedure to facilitate delivery in selected cases of obstructed labor. It fulfills a cultural need to achieve vaginal delivery in difficult circumstances. More research into the late sequelae of symphysiotomy should be undertaken in rural areas of African countries, where the need for symphysiotomy still exists [19]. Followup studies of women living far from hospitals often present great difficulty. In the Mbozi district of rural Tanzania, however, other studies show that follow-up for other reasons is feasible, and that high coverage can be achieved up to 100 km from hospital [30]. Acknowledgments
The author worked as Medical Officer in charge of Lugarawa Hospital, Njombe, Tanzania (1976-1979) and Mbozi Int J Gynaecol
Obstet 25
458
van Roosmalen
Designated District Hospital, Mbozi, Tanzania (1979- 1983). Financial support was provided by the “Stichting De Drie Lichten' ’, Hilversum, The Netherlands. medical assistant in Oigen Mwanyika, Lugarawa Hospital, and Richard Sangali, medical assistant in Mbozi Hospital, both helped with data collecting. References 1
2
3
4 5
6 I
8 9 10
11 12
13 14 15
16
17
Armon PJ, Philip M: Symphysiotomy and subsequent pregnancy in the Kilimanjaro Region of Tanzania. East Afr Med J 55: 306, 1978. Belsey MA: Traditional birth attendants: a resource for the health of women. Int J Gynaecol Obstet 23: 247, 1985. Bird GC, Bal JS: Subcutaneous symphysiotomy in association with the vacuum extractor. J Obstet Gynaecol Br Emp 74: 266, 1967. Cox ML: Symphysiotomy in Nigeria. J Obstet Gynaecol Br Commonw 73: 237, 1966. Crichton D, Clarke GCM: Symphysiotomy indications and contraindications. S Afr J Obstet Gynaecol4: 76, 1966. Crichton D, Seedat EK: technique of The symphysiotomy. S Afr Med J 37: 227. 1963. Eastham NJ: Pelvic mensuration: a study in the perpetuation of error. Obstet Gynecol Surv 3: 301, 1948. Editorial: Obstetrics in developing countries. Lancet i: 575, 1%2. Editorial: Symphysiotomy and vacuum extraction. Lancet i: 396, 1974. Everett J: Obstetric care. In Appropriate Technology, articles published in Br Med J, p 15-17. Tavistock Square, London, 1985. Fasbender H: Geschichte der Geburtshiilfe. Jena: 109, 1906. Gebbie DAM: Vacuum extraction and symphysiotomy in difficult vaginal delivery in a developing community. Br Med J 2: 1490, 1966. Gebbie DAM: Symphysiotomy. Trop Doct 4: 69, 1974. Gebbie DAM: Symphysiotomy. Clin Obstet Gynaecol 9: 663, 1982. Gordon YB: An analysis of symphysiotomy at Baragwanath Hospital, 1964-1967. S Afr Med J 43: 659, 1%9. Groshans GRF: Waarneming eener operatie der doorsneede van de schaambeenderen. In Varii Auctores de Symphysiotomia. Opuscula Selecta Neerlandicorum de Arte Medica, Amsterdam, vol. XII, p 65-69, 1934. Hartfield VJ: Subcutaneous symphysiotomy - Time for a reappraisal? Austr NZ J Obstet Gynaecol 13: 147, 1973.
Znt J Gynaecol Obstet 25
18
19 20
21 22 23 24
25 26
27 28 29 30
31 32 33
34 35
36
Hartfield VJ: A comparison of the early and late effects of subcutaneous symphysiotomy and of lower segment caesarean section. J Obstet Gynaecol Br Commonw 80: 508, 1973. Hartfield YJ: Late effects of symphysiotomy., Trop Doct 5: 76. 1975. Kairuki HCM: The place of symphysiotomy in the treatment of disproportion in Uganda. East Afr Med J 52: 686, 1975. Lammes FB: Symphysiotomie in ontwikkelingslanden. Ned Tijdschr Geneesk 113: 1017, 1969. Lasbrey AH: The symptomatic sequelae of symphysiotomy. S Afr Med J 37: 231, 1%3. Linden AJ van der: Symphysiotomy and Pubiotomy. Dekker & Van de Vegt, Utrecht, Thesis, 1961. Mola G, Lamang M, McGoldrick IA: A retrospective study of matched symphysiotomies and caesarean sections at Port Moresby General Hospital. Papua NG Med J 24: 103, 1981. Mottiar Y, Saria G: Symphysiotomy for mild cephalopelvic disproportion. Med J Zambia: 15, 1970. Munro Kerr JM: The investigation and treatment of “border-line” cases of contracted pelvis. J Obstet Gynaecol Br Emp 55: 401, 1948. Norman RJ: Six years’ experience of symphysiotomy in a teaching hospital. S Afr Med J 54: 1121, 1978. Onsrud M: Symphysiotomy - an out of date obstetric operation? Nord Med 91: 221, 1976. Pereira JS: A sinfisiotomia na obstetrica modema. An Inst Med Trop 21: 153, 1964. Roosmalen-Wiebenga MW van, Kusin JA, With C de: Nutrition rehabilitation in hospital - a waste of time and money? Evaluation of nutrition rehabilitation in a rural district hospital in SW Tanzania. J Trop Pediatr 33: 24, 1987. Seedat EK, Crichton D: Symphysiotomy: technique, indications, and limitations. Lancet i: 554, 1962. Shorter E: A history of women’s bodies, p 163. Penguin Books Ltd, Middlesex. 1982. Varii Auctores de Symphysiotomia. Feyfer FMG de: Ter inleiding. Opuscula Selecta Neerlandicorum de Arte Medica, Amsterdam, vol. XII, p. XI/XII, 1934. Wright St. Clair RE: The history of mutilating operations. NZ Med J 62: 468, 1963. Young JH: Caesarean Section. The History and Development of the Operation from Earliest Times, p 83, 242. Lewis & Co, London, 1944. partial symphysiotomy. Zarate E: Subcutaneous T.I.C.A. Buenos Aires, 1955.
Address for reprints: Jos van Roosmalea Leydea State University Hospital Department of Obstetrics aad Gynecology Rijasburgenveg 10 2333 AA L&den The Netherlands
SYMPHYSIOTOMY
451
AS AN ALTERNATIVE
TO CESAREAN SECTION
.I. van ROOSMALEN Leyden
State University
(Received (Accepted
Hospital,
Department
of Obstetrics
and Gynaecology,
Leiden (The Netherlands)
July 15th, 1986) November 13th, 1986)
Abstract
Introduction
The author compares the value of symphysiotomy to cesarean section in the management of cephalopelvic disproportion. He outlines the history of the procedure and reviews the literature on the subject. He then presents results of 54 symphysiotomies performed from 1976 to 1983 in two rural hospitals in the southwestern highlands of Tanzania, together with the outcome of subsequent labor in 25 other women with a history of previous symphysiotomy. The maternal risk of mortality after symphysiotomy is lower than after cesarean section when performed for cephalopelvic disproportion. Although different in nature, maternal morbidity after both operations is equally common. In contrast with findings reported in the literature, a history of previous symphysiotomy still constitutes a high obstetrical risk. The author concludes that symphysiotomy has a place in the management of cephalopelvic disproportion.
Symphysiotomy is the artificial separation of the symphysis pubis with a scalpel in order to enlarge the diameter of the pelvic opening to facilitate the process of birth. This relatively simple procedure has been very popular in Roman Catholic countries, where sterilization after repeated cesarean birth - a practice which limits the number of offspring was condemned. Thirty years ago, E. Zarate, the most ardent enthusiast of symphysiotomy in Latin America, even thought use of the procedure would result in the abolition of cesarean section [36]. In most western countries, however, symphysiotomy never became popular. Shorter, for example, in his extensive history of western childbirth [32], devotes only one sentence to the subject, as do many contemporary obstetrics textbooks. In this article the value of symphysiotomy for the management of cephalopelvic disproportion (CPD) is compared to use of cesarean section. The article is based on a search of the literature and the author’s experience with symphysiotomy in two rural hospitals in the southwestern highlands of Tanzania from 1976 to 1983.
Keywords: Symphysiotomy; Cesarean section; Cephalopelvic disproportion; Tanzania; Delivery care history; Previous symphysiotomy; Appropriate technology. OO20-7292/87/$03.50. 0 International Federation of Gynaecology Published and Printed in Ireland
& Obstetrics
Int J Gynaecol
Obstet 25
452
van Roosmalen
History of symphysiotomy
Ever since Hippocrates, childbirth was thought to be accompanied by spontaneous pelvic enlargement by separation of the symphysis pubis [7]. This view was held by Ambroise Pare in the 16th and William Harvey in the 17th century [14]. Andreas Vesalius was the first to question the notion of spontaneous pelvic enlargement in his De Humani Corporis Fabrica in 1543 [ 111. Only after Vesalius’ correct view was accepted that the symphysis pubis is an inseparable unit during the process of birth did the idea of artificially separating the symphysis take shape. In 1655, the first symphysiotomy was performed as an alternative to postmortem cesarean section. In 1777, Jean-Rene Sigault in Paris performed the first symphysiotomy on a living woman who was very stunted and had a history of four stillborn babies after difficult labor. The woman survived and had her first live-born baby. She suffered, however, from a vesico-vaginal fistulafortherestofherlife[14,33]. Though welcomed as a great innovation, the results of the first symphysiotomies were not very promising. Fourteen mothers and 18 newborns of the first 36 symphysiotomies died [34]. These bad results may be partly explained by the extremely prolonged labor for which symphysiotomy was performed. But cesarean section at that time had an almost hundred percent maternal mortality rate. The first symphysiotomy in The Netherlands was performed by Groshans in 1778 [16], and between 1778 and 1831 at least 20 symphysiotomies were reported with three maternal deaths [33]. After initial enthusiasm the operation fell into discredit. In the late 19th century a revival took place in Italy. Among others Morisani reported many cases with maternal mortality under 5% and perinatal mortality just under 12% [14]. Van Linden der presented 2801 Int J Gynuecol Obslet 25
symphysiotomies performed between 1900 and 1960 [23]. Maternal mortality in his series was as low as 14 per 1000; maternal morbidity (like vesico-vaginal fistulas, vaginal lacerations and orthopedic complications) occurred in 7%. The perinatal mortality rate was 86 per 1000 births. These symphysiotomies were performed almost exclusively in the predominantly Roman Catholic countries of Italy, Spain, France, Ireland and in some Latin American countries. An explanation for this may lie in the condemnation of sterilization by the Roman Catholic Church. The Church also put the interest of the newborn above that of the mother [35]. Cesarean section prevented the potential for large families, where tubal ligation was performed after repeated cesarean deliveries. But even in non-Catholic countries like Great Britain, where the practice was to sacrifice the child for the safety of the mother, some symphysiotomies were performed in the first half of the 20th century [26]. Bowesman [14] and Pereira [29] mention that symphysiotomy was practiced by traditional healers in several parts of Africa. Approximately 10% of symphysiotomies reported by Van der Linden [23] were performed in Africa, and since 1960, most communications on symphysiotomy have stemmed from Africa. Later in this paper, the author examines the practice of symphysiotomy in two rural hospitals in Tanzania. Maternal mortality Maternal mortality after symphysiotomy has decreased dramatically since 1960 and is almost negligible (see Table I). In the symphysiotomies series of different mentioned in Table I, there were three maternal deaths from a total of 1752 symphysiotomies (1.79’00). None of these procedure of related to the was by two were caused symphysiotomy: eclampsia and one occurred after cesarean
Symphysiotomy as alternative to cesarean section
Table I.
Maternal
and perinatal
mortality
in symphysiotomy
Place of study
Year of study
South Africa [22] South Africa [31] Kenya [3] Nigeria [ 171 Uganda 1121 South Africa [ 151 Zambia [25] Zimbabwe [27] Tanzania [l] Papua New Guinea Uganda [20] Zaire [28] This study
1957-1961 1957-1962 1959-1963 1961-1970 1964-1966 1964-1967 1970 1972-1977 1973-1977 1974-1980 1975 1976 1976-1983
151 505 104 138 108 201 75 161 105 86 30 34 54
1957-1983
1752
[24]
All studies
section in a symphysiotomy.
woman
with
No. of symphysiotomies
a
failed
Maternal morbidity maternal Serious morbidity after symphysiotomy, described in Table II, does not differ much from the rate reported between 1900 and 1960: 7% in 1900-1960 [23] and 8% from 1960 onward. Fifteen of the 30 vesico-vaginal fistulas appeared to be the result of pressurenecrosis of the bladderneck due to obstructed labor rather than to symphysiotomy. These presented immediately after delivery, while those due to obstructed labor developed only some days after delivery when
Table II. symphysiotomy
Serious maternal morbidity in different communities.
following
No. No. of symphysiotomies (Table 1) Vesico-vaginal fistulas Vestibular and/or urethral lesions Osteitis pubis/retropubic abscess Long-term walking disability and/or Stress-incontinence All complications
pain
in different
1752 30 33 10 32 36
Plo)
(1.7) (1.9) (0.6) (1.8) (2.1)
141 (8.1)
453
communities. Maternal mortality
Perinatal
(Qo)
(%a)
0 0 0
1 0 0 1 0 1 0 0 0 0 3 (1.7)
3/151 42/505 22/104 23/138 16/108 20/20 1 18/75 16/161 9/105 7/86 3/30 l/34 11/54 197/1752
mortality
(19) (83) (212) (167) (148) (100) (240) (99) (86) (81) (100) (296) (204)
(112)
necrotic tissue was shed off. Some of the immediate fistulas were the result of application of forceps after symphysiotomy in order to assist delivery. After the introduction of vacuum extraction, this practice was abandoned and the useofforcepscontraindicated [3,6,12,31]. Perinatal mortality Perinatal mortality differed markedly in the different series (range 19-296%0), with an overall rate of 112%~~ (Table I). Different levels of obstetrical skill and technical support explain this. may Although comparison therefore is difficult, fetal prognosis had not improved since 1900 -1960. Literature All authors regarded symphysiotomy as a procedure with a definite place in obstetric practice, at least in the circumstances they describe. Editorials in The Lancet in 1962 and 1974 conclude that its urinary and orthopedic complications have been exaggerated [g,9]. Moreover, report.s in the ill literature on the effects of symphysiotomy often lacked controls, and only three controlled studies have been Int J Gynaecol Obstet 25
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van Roosmalen
published These [l&22,24]. studies, however, were not prospective randomized controlled trials, which made comparison with the control group difficult. Lasbrey [22] found minor symptoms at some time in the follow-up period or in a subsequent pregnancy in 58Vo of 87 women who underwent symphysiotomy as compared to 60% of the 87 parous women in his control group.
Symphysiotomy as compared to cesarean section Denying symphysiotomy to a woman in need of it results in obstructed labor and fetal death or makes necessary cesarean section as an emergency procedure late in labor. Therefore, a group of women who had cesarean section instead of symphysiotomy in relieve order to obstructed labor could provide the best control group where randomization is difficult. Retrospective comparison of the results of symphysiotomy with those of cesarean section performed in advanced labor has been the subject of the other two controlled studies [ 18,241. These studies confirm that the long-term disabling sequelae of symphysiotomy have been overemphasized. There is also less mortality risk after symphysiotomy than after cesarean section.
Table III.
Pregnancy after previous symphysiotomy The pelvis often remains permanently enlarged after a symphysiotomy is performed. The procedure could therefore provide a cure for some cases of disproportion. This is especially important when one is not sure that the patient will return to hospital for a subsequent pregnancy. Obviously cesarean section does not affect the pelvis and leaves the origin of disproportion untouched. A woman sent home with a scarred uterus may experience uterine rupture in a subsequent unattended delivery. The outcome of labor in women with a previous symphysiotomy is described in Table III. Uncomplicated vaginal delivery occurred in 739’0, while operative vaginal delivery took place in another 14%. Cesarean birth occurred in 11%. The vaginal delivery rate after previous symphysiotomy is higher than after previous cesarean section for disproportion. Nevertheless, a considerable percentage of women with previous symphysiotomy need operative vaginal and abdominal delivery for subsequent births. Symphysiotomy in Lugarawa and Mbozi Hospitals in Tanzania Lugarawa and Mbozi hospitals are rural hospitals in the southwestern highlands of Tanzania. Both hospitals are the only ones
Outcome of subsequent labor in women with previous symphysiotomy in different communities. Spontaneous vertex delivery @Jo)
Gordon 1969 [15] Hartfield 1973 (181 Armon 1978 [l] Norman 1978 [27] Mola 1981 [24] This study 1976-1983
No. of pregnancies Ve) 36 76 45 28 19 25
All cases
229 (100)
167 (73)
Author
PT~~ cases of uterine rupture included. Int J Gynaecol Obstet 25
29 58 32 26 11 11
Operative vaginal delivery
Cesarean section
(070)
(~0)
3 8 7 1 5 8 32 (14)
4 (11) 5 (7) 6 (13) 1 (4) 3 (16) 6 (24) 25 (11)
Repeat symphysiotomy (70) 0 5 0 0 0 0 5 (2)
Symphysiotomy as alternative to cesarean section
in a large rural district. In Ludewa district, 24% of all pregnant women delivered in Lugarawa Hospital. In Mbozi district, 13% of all pregnant women delivered in Mbozi Hospital. Maternal health services are provided by medical auxiliaries with by a few general doctors. supervision Transport in the districts is unreliable.
, Fibrocartilage
455
excavated
Arcuate Permeal Urethra
llgarnent membrane
Vagina
Methods Altogether 54 symphysiotomies were 18 in Lugarawa (in 2285 performed: deliveries; 0.8% during 1976- 1979) and 36 in Mbozi (in 5226 deliveries; 0.7% during 1979-1983). Symphysiotomy was practiced in both hospitals using Seedat and Crichton’s method [6,31], which is based upon Zarate’s work [36]. The method differs from that of Zarate in that it advises against partial division of the symphysis, which is then completed by forceful abduction of the thighs. It is thought that forceful abduction damages the sacroiliac joints, possibly resulting in permanent pelvic instability and The method also stresses the pain. importance of avoiding the hyaline cartilage by strict adherence to the midline in dividing the symphysis pubis. Deviating from the midline may lead to osteitis pubis and subsequent difficulty in walking. Symphysiotomy increases the pelvic diameters at all levels, although not to the same degree 151. The transverse diameters are especially increased. The bottom ends of the symphysial and sacroiliacal joints separate more than the upper ends, so the outlet diameters increase more than the inlet ones. Because of this, some authors concluded falsely that symphysiotomy is only indicated in outlet cases of disproportion [26]. Contrary to what has been taught in the past [23,36], the arcuate ligament beneath the symphysis is directly cut (Fig. 1). In
Diagram of the symphysis pubis (after Crichton Fig. 1. and Seedat [25]).
order to avoid undue strain to the sacroiliac joints, forceful abduction of the thighs Instead, should never be undertaken. complete separation is brought about by the cutting scalpel only. Indications Symphysiotomy was mainly performed in cases of cephalopelvic disproportion with a and a live fetus. vertex presentation Whether symphysiotomy was indicated in such cases mainly depended on three interrelated factors: -
-
descent of the fetal head degree of overlap as a result of fetal head molding dilatation of the cervix [ 131.
One-third or more of the fetal head should have entered the pelvic brim. The fetal head should not be felt prominent in front of the symphysis pubis and the dilatation of the cervix should be more than 7 cm in a primigravida, according to Gebbie’s rules 1131. When symphysiotomy was performed in the second stage of labor, it often followed a failed trial of vacuum extraction. In this study Gebbie’s rules were followed to indicate whether symphysiotomy could be performed. Int J Gynaecol Obstet 25
456
van Roosmalen
Some characteristics of the women Most women were of low parity: 36 (67%) were primigravidae, while 11 (20%) had parity one or two. Six women (11%) had parity five or more, while the parity of one was not recorded. This parity distribution was much the same as Seedat and Crichton mentioned in their series of 505 symphysiotomies [31]. It differed significantly from the parity distribution of the whole obstetric population delivering in Lugarawa and Mobozi with 23.5% primigravidae. Maternal height was significantly lower in the symphysiotomy group (20 women (37%) were below 150 cm) than in the whole obstetric population delivering in Lugarawa and Mbozi (19% below 150 cm). Labor was augmented with oxytocin in 24 women (440/o) because of first stage delay: 21 had vertex presentations, two had a face and one a breech presentation. The four multiparous women in Lugarawa had 8 perinatal deaths and only one live birth before they were delivered by symphysiotomy of a live baby. The mean birth weight of newborns of 53 women was 3070 g (-e 460 S.D.) with a range of 23004330 g, considerably higher than the overall mean birth weight in both hospitals. Results There were no maternal deaths in this series, but major complications occurred in four women (Table IV). One patient developed osteitis pubis and was unable to walk for at least 5 months. Eventually she Serious maternal morbidity in Lugarawa and Table IV. Mbozi hospitals, Tanzania in 54 cases of symphysiotomy, 1976-1983. Complication
No. (%a)
Osteitis pubis Vesico-vaginal fistulas Laceration vaginal wall
l(l.9) 2 (3.7) l(l.9)
All complications
4 (7.5)
Int J Gynaecol Obstet 25
was cured and delivered by cesarean section in three subsequent pregnancies without Two women had complicomplications. cations (one a vesico-vaginal fistula, the other a laceration of the anterior vaginal wall), because the procedure was performed without inserting a urinary catheter. The fourth complication was a vesicovaginal fistula resulting from pressurenecrosis of the bladderneck. This was not related to the procedure. Five women were incidentally seen by the author at least 3 months after symphysiotomy and appeared to have no ill effects whatsoever. Eight women came back for delivery in a subsequent pregnancy: at that time they had no complaints. Perinatal mortality Perinatal mortality was high: 11/54 = 2040700. In two cases the fetus had already died before symphysiotomy was undertaken. This should be a contraindication for the procedure and in such cases destructive operation is an alternative. Comparison with cesarean section Comparing results of symphysiotomy section for cesarean with those of disproportion indicated less mortality risk for the mother, while maternal morbidity, although different in nature, did not differ much in frequency (Table V). Table V. Comparison of outcome of symphysiotomy and cesarean section for cephalopelvic disproportion, Lugarawa and Mbozi hospitals, Tanzania, 1976-1983. Symphysiotomy
N = 54 (To) Maternal mortality Serious maternal morbidity Perinatal mortality
Cesarean section for CPD N= LOO (%)
0 (0) 4 (7)
5 (5) 6 (6)
11 (20)
13 (13)
section vs. cesarean morbidity: Serious maternal symphysiotomy x2 = 0.114; df = 1; n.s. Perinatal mortality: cesarean section vs. symphysiotomy x2 = 1.448; df = 1; n.s. ‘Included two deaths before symphysiotomy was started.
Symphysiotomy
Outcome of subsequent labor after previous symphysiotomy Table III shows the outcome of labor after previous symphysiotomy as reported in the literature and in 25 women delivering in Lugarawa and Mbozi hospitals. Of those 25, 1 had a spontaneous vertex 8 had delivery without complications; operative vaginal delivery and 6 were delivered abdominally. Cesarean delivery for disproportion occurred in 4 of these, while 2 had a uterine rupture. There were no maternal deaths. Perinatal mortality was high: 5 out of 25 newborns died, but 4 of these were already dead on admission to hospital. Discussion
The overall results of symphysiotomy in Lugarawa and Mbozi hospitals were not The risk of maternal unsatisfactory. mortality after symphysiotomy nowadays has become negligible and is much lower than after cesarean section performed in advanced labor for the same indications. Maternal morbidity could have been lowered by strict adherence to protocol: two women had complications because a urinary catheter was not inserted. Perinatal wastage was high. Often the already compromised on was fetus admission following prolonged labor at home. Sepsis was another contributing factor. Strict adherence to the indications will lower perinatal mortality. Fetal death is a contraindication for the procedure. indications the for One of symphysiotomy is a failed trial of vacuum extraction or forceps [4,12,21]. This policy of trial first, however, may add to mortality, especially if one perinatal continues to pull too long. Some authors therefore advise against this policy [ 13,241. On the other hand, abandoning this trial will definitely lead to more symphysiotomies, which in some cases could have been
as alternative
to cesarean section
457
easily prevented by a trial of vacuum extraction first [ 11. Previous symphysiotomy is said to cure cephalopelvic disproportion 151. The outcome of subsequent pregnancy in our cases could not support this, indicating the high risk of these women even after symphysiotomy. Symphysiotomy leaves the uterus unscarred. Yet, two of the women in the study sample experienced rupture of an unscarred uterus in a subsequent labor. The risk of cesarean birth after previous symphysiotomy (11 Vo) was higher than in the total obstetric population (3Oro). The percentage of abdominal delivery in our series (24%) was much higher than would have been anticipated from the few other studies in the literature (Table III). It is possible that uncomplicated delivery after previous symphysiotomy occurred at home, but this would be true for some of the other authors as well [ 1,15,27]. Symphysiotomy deserves a place in the management of cephalopelvic disproportion. It is an example of appropriate technology [2,10]. It is a relatively simple and rapid procedure to facilitate delivery in selected cases of obstructed labor. It fulfills a cultural need to achieve vaginal delivery in difficult circumstances. More research into the late sequelae of symphysiotomy should be undertaken in rural areas of African countries, where the need for symphysiotomy still exists [19]. Followup studies of women living far from hospitals often present great difficulty. In the Mbozi district of rural Tanzania, however, other studies show that follow-up for other reasons is feasible, and that high coverage can be achieved up to 100 km from hospital [30]. Acknowledgments
The author worked as Medical Officer in charge of Lugarawa Hospital, Njombe, Tanzania (1976-1979) and Mbozi Int J Gynaecol
Obstet 25
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Designated District Hospital, Mbozi, Tanzania (1979- 1983). Financial support was provided by the “Stichting De Drie Lichten' ’, Hilversum, The Netherlands. medical assistant in Oigen Mwanyika, Lugarawa Hospital, and Richard Sangali, medical assistant in Mbozi Hospital, both helped with data collecting. References 1
2
3
4 5
6 I
8 9 10
11 12
13 14 15
16
17
Armon PJ, Philip M: Symphysiotomy and subsequent pregnancy in the Kilimanjaro Region of Tanzania. East Afr Med J 55: 306, 1978. Belsey MA: Traditional birth attendants: a resource for the health of women. Int J Gynaecol Obstet 23: 247, 1985. Bird GC, Bal JS: Subcutaneous symphysiotomy in association with the vacuum extractor. J Obstet Gynaecol Br Emp 74: 266, 1967. Cox ML: Symphysiotomy in Nigeria. J Obstet Gynaecol Br Commonw 73: 237, 1966. Crichton D, Clarke GCM: Symphysiotomy indications and contraindications. S Afr J Obstet Gynaecol4: 76, 1966. Crichton D, Seedat EK: technique of The symphysiotomy. S Afr Med J 37: 227. 1963. Eastham NJ: Pelvic mensuration: a study in the perpetuation of error. Obstet Gynecol Surv 3: 301, 1948. Editorial: Obstetrics in developing countries. Lancet i: 575, 1%2. Editorial: Symphysiotomy and vacuum extraction. Lancet i: 396, 1974. Everett J: Obstetric care. In Appropriate Technology, articles published in Br Med J, p 15-17. Tavistock Square, London, 1985. Fasbender H: Geschichte der Geburtshiilfe. Jena: 109, 1906. Gebbie DAM: Vacuum extraction and symphysiotomy in difficult vaginal delivery in a developing community. Br Med J 2: 1490, 1966. Gebbie DAM: Symphysiotomy. Trop Doct 4: 69, 1974. Gebbie DAM: Symphysiotomy. Clin Obstet Gynaecol 9: 663, 1982. Gordon YB: An analysis of symphysiotomy at Baragwanath Hospital, 1964-1967. S Afr Med J 43: 659, 1%9. Groshans GRF: Waarneming eener operatie der doorsneede van de schaambeenderen. In Varii Auctores de Symphysiotomia. Opuscula Selecta Neerlandicorum de Arte Medica, Amsterdam, vol. XII, p 65-69, 1934. Hartfield VJ: Subcutaneous symphysiotomy - Time for a reappraisal? Austr NZ J Obstet Gynaecol 13: 147, 1973.
Znt J Gynaecol Obstet 25
18
19 20
21 22 23 24
25 26
27 28 29 30
31 32 33
34 35
36
Hartfield VJ: A comparison of the early and late effects of subcutaneous symphysiotomy and of lower segment caesarean section. J Obstet Gynaecol Br Commonw 80: 508, 1973. Hartfield YJ: Late effects of symphysiotomy., Trop Doct 5: 76. 1975. Kairuki HCM: The place of symphysiotomy in the treatment of disproportion in Uganda. East Afr Med J 52: 686, 1975. Lammes FB: Symphysiotomie in ontwikkelingslanden. Ned Tijdschr Geneesk 113: 1017, 1969. Lasbrey AH: The symptomatic sequelae of symphysiotomy. S Afr Med J 37: 231, 1%3. Linden AJ van der: Symphysiotomy and Pubiotomy. Dekker & Van de Vegt, Utrecht, Thesis, 1961. Mola G, Lamang M, McGoldrick IA: A retrospective study of matched symphysiotomies and caesarean sections at Port Moresby General Hospital. Papua NG Med J 24: 103, 1981. Mottiar Y, Saria G: Symphysiotomy for mild cephalopelvic disproportion. Med J Zambia: 15, 1970. Munro Kerr JM: The investigation and treatment of “border-line” cases of contracted pelvis. J Obstet Gynaecol Br Emp 55: 401, 1948. Norman RJ: Six years’ experience of symphysiotomy in a teaching hospital. S Afr Med J 54: 1121, 1978. Onsrud M: Symphysiotomy - an out of date obstetric operation? Nord Med 91: 221, 1976. Pereira JS: A sinfisiotomia na obstetrica modema. An Inst Med Trop 21: 153, 1964. Roosmalen-Wiebenga MW van, Kusin JA, With C de: Nutrition rehabilitation in hospital - a waste of time and money? Evaluation of nutrition rehabilitation in a rural district hospital in SW Tanzania. J Trop Pediatr 33: 24, 1987. Seedat EK, Crichton D: Symphysiotomy: technique, indications, and limitations. Lancet i: 554, 1962. Shorter E: A history of women’s bodies, p 163. Penguin Books Ltd, Middlesex. 1982. Varii Auctores de Symphysiotomia. Feyfer FMG de: Ter inleiding. Opuscula Selecta Neerlandicorum de Arte Medica, Amsterdam, vol. XII, p. XI/XII, 1934. Wright St. Clair RE: The history of mutilating operations. NZ Med J 62: 468, 1963. Young JH: Caesarean Section. The History and Development of the Operation from Earliest Times, p 83, 242. Lewis & Co, London, 1944. partial symphysiotomy. Zarate E: Subcutaneous T.I.C.A. Buenos Aires, 1955.
Address for reprints: Jos van Roosmalea Leydea State University Hospital Department of Obstetrics aad Gynecology Rijasburgenveg 10 2333 AA L&den The Netherlands