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Three-year follow-up of eight patients delivered by symphyseotomy
Int. J. Gynaecol. Obstet., 1985, 23: 203-205 International Federation of Gynaecology & Obstetrics
THREE-YEAR
FOLLOW-UP
203
OF EIGHT PATIENTS DELIVERED BY SYMPHYSEOTOMY
CORM GREISEN Formerly District Medical Ojjker, Namwla
(Zambirrl
(Received December 13th, 1984) (Accepted February 19th, 1985)
Abstract District Medical G (Formerly Three-year Namwala, Zambia). Officer, follow-up of eight patients delivered by symphyseotomy. Int J Gynaecol Obstet 23: 203-205, 198.5 Eight symphyseotomies were carried out in a small hospital in rural Afrika by a medical generalist during a 2-year period. There were no maternal or infants deaths. Follow-up after 3 years demonstrated the absence of long-tern complications. Five patients had later delivered, all normally, four of them at home unattended by medically-trained personnel. G re isen
Keywords: Developing countries; Follow-up; Primary health care; Symphyseotomy.
about 40,000 in 1977. The district hospital had 50 beds but no facilities for major surgery, thus cesarian section was unavailable to the patients. During my service from August 1977 to June 1979, 43 1 women, were delivered in the hospital, about half of whom were referred from surrounding health centers. Eight symphyseotomies were performed (Table I) according to the procedure described by Lawson and Stewart [ 3 I. The author had 3 months post-graduate training in obstetrics and no prior experience with the procedure.
Table I. Data on eight patients delivered by symphyseotomy. Patient No.
Introduction Symphyseotomy has been recommended as the method of choice to relieve obstructed labour due to mild-to-moderate cephalo-pelvic disproportion (CPD) in developing countries [ 2 I. Here cesarian section is less useful than in the developed countries because of the common wish to have many children, because of the increased risk of uterine.rupture, in subsequent unattended labour and because of the relatively high demands on medical facilities.
5 6
7
Patients and methods 8
Namwala district is situated in the Southern Province of Zambia and had ;i population of 0020-7292/85/$03.30 0 1985 International Federation of Gynaecology & Obstetrics Published and Printed in Ireland
age/parity
Delivery
Pueperium
18 years para 0 20 years para 0 19 years para 0 17 years para 0
CPD CPD
Deep thrombophlebitis right leg Urinary tract infection
CPD
Uncomplicated
CPD + incision of bladder CPD
Urinary tract infection Spontaneous healing of fistual Urinary tract infection
Obstruction by partial placenta praevia CPD
Urinar) tract infection Slow to mobilise
Obstruction by pelvic
Uncomplicated
19 years para 0 31 years para 8
21 years para 1 33 years para 8
Uncomplicated
Int J G,vnaccol Obster 23
204
Greisen
Procedure
With the patient in the lithotomy position, a bladder catheter was inserted and the patient shaved. Local anesthesia was used for the skin and presymphyseal tissues. Through a 1 cm long incision of the skin, the symphyseal cartilage was located with the tip of the scalpel. While the urethra was pushed out of the midline by the fingers of the left hand, the symphysis was sectioned until the tip of the scalpel was felt through the vaginal mucosa by the left hand, first downwards to the arcuate ligament, which was not sectioned, then upwards. Assistants held the legs, which were not allowed to abduct more than 30 degrees from the midline. The vacuum extractor was re-applied, a wide episeotomy performed, and the delivery of the head controlled, seeing that the symphyseal diastasis did not exceed the width of a finger. After conclusion of the delivery, the skin incision was close with one suture, the pelvis strapped with a bedsheet, and the bladder catheter left in place. The patient was nursed on her side for 48 h, the catheter was removed on the third day and the patient mobilized on the fifth day. All patients were examined 1 month after delivery. Patients No. 1 to No. 7 were reexamined from 22 to 60 months after the symphyseotomy. Information was collected on the health and development of the child, on subsequent obstetric history, stress-incontinence of urine, and on problems of walking for long distances, carrying heavy burdens, low backache or symphyseal pain. General clinical examination was performed and provoking of symphyseal pain or instability was attempted by letting the patient jump on either leg in turn. Patient No. 8 left the country 29 months after the symphyseotomy without further pregnancy and apparently in good health. Results
All patients were fully mobilized 1 month after delivery. There were no urinary symptoms and Trendelenburg’s test was negative, Int J Gynaecol Obstet 23
The 7 patients re-examined after 2-5 years were all in good health, only symphyseal pain on heavy lifting could be ascribed to the symphyseotomy. Child No. 6 showed signs of psychomotor retardation. Five patients had later deliveied, all normally, four of them at home. Two were again pregnant. Discussion
The applicability of symphyseotomy in obstetric units in developing countries has been well documented. The maternal mortality is very low compared to cesarian section [4], the acute complications are mild but rather frequent, while serious complications as vesico-vaginal fistula or severe locomotor problems occur but rarely [ 5 I. Hartfield [ 11 has reviewed the few published series of patients followed-up for 2 years or more and conclude that permanent urinary of orthopedic disability only occurs in l-2% of cases. Subsequent deliveries often are spontaneous. It is stressed that care should be taken in selection of patients for symphyseotomy to obtain such good results. In smaller health institutions, where cesarian section is unavailable as an alternative to symphyseotomy there is a possibility that indications are stretched. It is therefore important to maintain prenatal referral of all patients in which complications of delivery can be predicted. But then, as an emergency measure, when disproportion is unexpected, or if antenatal referral has been disregarded by the patient, symphyseotomy may be even more worthwhile as it may be lifesaving for the infant and even for the mother,
References 1 Hartfield VJ: Late effects of symphyseotomy. Trop Doct 5: 76.1975. 2 King M: Medical care in developing countries. Oxford University Press, Nairobi, 1966.
Follow-up
3 Lawson JB, Stewart DB: Obstetrics and gynecology in the tropics and developing countries. E.L.B.S., London, 1967. 4 Mola G, Lamang M, Goldrik IA: A retrospective study of matched symphyseotomies and caesarian sections at Port Moresby General Hospital. Papua New Guinea Med J 24: 103,198l. 5 Norman RJ: Six years’ experience of symphyseotomies in a teaching hospital. S Afr Med J 54: 1121, 1978.
after symphyseotomy
205
Address for reprints: Germ Greisen Department of Neonatology Rigshospitalet Blegdamsvej 9 2 100 Copenhagen 0 Denmark
Int J
GJsnaecol Obster
-13
THREE-YEAR
FOLLOW-UP
203
OF EIGHT PATIENTS DELIVERED BY SYMPHYSEOTOMY
CORM GREISEN Formerly District Medical Ojjker, Namwla
(Zambirrl
(Received December 13th, 1984) (Accepted February 19th, 1985)
Abstract District Medical G (Formerly Three-year Namwala, Zambia). Officer, follow-up of eight patients delivered by symphyseotomy. Int J Gynaecol Obstet 23: 203-205, 198.5 Eight symphyseotomies were carried out in a small hospital in rural Afrika by a medical generalist during a 2-year period. There were no maternal or infants deaths. Follow-up after 3 years demonstrated the absence of long-tern complications. Five patients had later delivered, all normally, four of them at home unattended by medically-trained personnel. G re isen
Keywords: Developing countries; Follow-up; Primary health care; Symphyseotomy.
about 40,000 in 1977. The district hospital had 50 beds but no facilities for major surgery, thus cesarian section was unavailable to the patients. During my service from August 1977 to June 1979, 43 1 women, were delivered in the hospital, about half of whom were referred from surrounding health centers. Eight symphyseotomies were performed (Table I) according to the procedure described by Lawson and Stewart [ 3 I. The author had 3 months post-graduate training in obstetrics and no prior experience with the procedure.
Table I. Data on eight patients delivered by symphyseotomy. Patient No.
Introduction Symphyseotomy has been recommended as the method of choice to relieve obstructed labour due to mild-to-moderate cephalo-pelvic disproportion (CPD) in developing countries [ 2 I. Here cesarian section is less useful than in the developed countries because of the common wish to have many children, because of the increased risk of uterine.rupture, in subsequent unattended labour and because of the relatively high demands on medical facilities.
5 6
7
Patients and methods 8
Namwala district is situated in the Southern Province of Zambia and had ;i population of 0020-7292/85/$03.30 0 1985 International Federation of Gynaecology & Obstetrics Published and Printed in Ireland
age/parity
Delivery
Pueperium
18 years para 0 20 years para 0 19 years para 0 17 years para 0
CPD CPD
Deep thrombophlebitis right leg Urinary tract infection
CPD
Uncomplicated
CPD + incision of bladder CPD
Urinary tract infection Spontaneous healing of fistual Urinary tract infection
Obstruction by partial placenta praevia CPD
Urinar) tract infection Slow to mobilise
Obstruction by pelvic
Uncomplicated
19 years para 0 31 years para 8
21 years para 1 33 years para 8
Uncomplicated
Int J G,vnaccol Obster 23
204
Greisen
Procedure
With the patient in the lithotomy position, a bladder catheter was inserted and the patient shaved. Local anesthesia was used for the skin and presymphyseal tissues. Through a 1 cm long incision of the skin, the symphyseal cartilage was located with the tip of the scalpel. While the urethra was pushed out of the midline by the fingers of the left hand, the symphysis was sectioned until the tip of the scalpel was felt through the vaginal mucosa by the left hand, first downwards to the arcuate ligament, which was not sectioned, then upwards. Assistants held the legs, which were not allowed to abduct more than 30 degrees from the midline. The vacuum extractor was re-applied, a wide episeotomy performed, and the delivery of the head controlled, seeing that the symphyseal diastasis did not exceed the width of a finger. After conclusion of the delivery, the skin incision was close with one suture, the pelvis strapped with a bedsheet, and the bladder catheter left in place. The patient was nursed on her side for 48 h, the catheter was removed on the third day and the patient mobilized on the fifth day. All patients were examined 1 month after delivery. Patients No. 1 to No. 7 were reexamined from 22 to 60 months after the symphyseotomy. Information was collected on the health and development of the child, on subsequent obstetric history, stress-incontinence of urine, and on problems of walking for long distances, carrying heavy burdens, low backache or symphyseal pain. General clinical examination was performed and provoking of symphyseal pain or instability was attempted by letting the patient jump on either leg in turn. Patient No. 8 left the country 29 months after the symphyseotomy without further pregnancy and apparently in good health. Results
All patients were fully mobilized 1 month after delivery. There were no urinary symptoms and Trendelenburg’s test was negative, Int J Gynaecol Obstet 23
The 7 patients re-examined after 2-5 years were all in good health, only symphyseal pain on heavy lifting could be ascribed to the symphyseotomy. Child No. 6 showed signs of psychomotor retardation. Five patients had later deliveied, all normally, four of them at home. Two were again pregnant. Discussion
The applicability of symphyseotomy in obstetric units in developing countries has been well documented. The maternal mortality is very low compared to cesarian section [4], the acute complications are mild but rather frequent, while serious complications as vesico-vaginal fistula or severe locomotor problems occur but rarely [ 5 I. Hartfield [ 11 has reviewed the few published series of patients followed-up for 2 years or more and conclude that permanent urinary of orthopedic disability only occurs in l-2% of cases. Subsequent deliveries often are spontaneous. It is stressed that care should be taken in selection of patients for symphyseotomy to obtain such good results. In smaller health institutions, where cesarian section is unavailable as an alternative to symphyseotomy there is a possibility that indications are stretched. It is therefore important to maintain prenatal referral of all patients in which complications of delivery can be predicted. But then, as an emergency measure, when disproportion is unexpected, or if antenatal referral has been disregarded by the patient, symphyseotomy may be even more worthwhile as it may be lifesaving for the infant and even for the mother,
References 1 Hartfield VJ: Late effects of symphyseotomy. Trop Doct 5: 76.1975. 2 King M: Medical care in developing countries. Oxford University Press, Nairobi, 1966.
Follow-up
3 Lawson JB, Stewart DB: Obstetrics and gynecology in the tropics and developing countries. E.L.B.S., London, 1967. 4 Mola G, Lamang M, Goldrik IA: A retrospective study of matched symphyseotomies and caesarian sections at Port Moresby General Hospital. Papua New Guinea Med J 24: 103,198l. 5 Norman RJ: Six years’ experience of symphyseotomies in a teaching hospital. S Afr Med J 54: 1121, 1978.
after symphyseotomy
205
Address for reprints: Germ Greisen Department of Neonatology Rigshospitalet Blegdamsvej 9 2 100 Copenhagen 0 Denmark
Int J
GJsnaecol Obster
-13