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1. INTRODUCTION
With the exception of episiotomies, fetal and other destructive operations
are rarely if ever performed in high income countries. They however remain
a useful option in the fight against maternal morbidity and mortality resulting
from obstructed labour in most resource poor countries of the world. In
contemporary obstetric practice, obstructed labour is rarely seen in the
industrialized world. Conversely obstructed labour continues to be a major
hazard in resource poor settings, contributing about 50,000 maternal deaths
each year (or almost 10% of all maternal deaths worldwide annually) (1,
2).
The problem of management of prolonged obstructed labour is therefore of
critical concern in resource poor settings where facilities for safe cesarean
section are marginal or absent or when access to future repeat cesarean
section may be delayed, placing the mother at undue risk. This brings to
the fore the need to explore alternative methods of delivery that are safe,
with minimal risk of morbidity or mortality to the mother.
2. SYMPHYSIOTOMY
Symphysiotomy is the surgical division of the fibrocartilaginous symphysis
pubis and its reinforcing ligaments in order to enlarge the diameter of
the pelvic opening to facilitate the process of vaginal birth, which may
be spontaneous or assisted.
2.1. HISTORY
Ever since Hippocrates, childbirth was believed to be accompanied by spontaneous
pelvic enlargement by separation of the symphysis pubis (3).
This view was supported by Pare and Havey in the 16th and 17th Century respectively
(4, 5).
Vesalius was the first to question the notion of spontaneous pelvic enlargement
in his De Humani Corporis Fabrica in 1543 (6). He postulated
that the symphysis pubis was an inseparable unit during the process of birth.
Acceptance of this view gave birth to the idea of artificial separation
of the symphysis pubis (6).
The first recorded symphysiotomy was performed by de la Courvee in 1655.
It was performed as an alternative to postmortem cesarean section. It was
first performed on the living by Jean Rene Sigault in 1777. The patient
was a rachitic dwarf said to have an obstetric conjugate of 6.5cm. She had
four previous stillborn infants after difficult labours and Sigault performed
a symphysiotomy to deliver her. The woman survived and had her first live-born
baby. She suffered however, from a vesico vaginal fistula for the rest of
her life (4, 7).
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 (8). It is worthy of note that cesarean
section at that time had an almost hundred percent maternal mortality rate.
After initial enthusiasm, the operation fell into disrepute.
In the late 19th Century, a revival took place in Italy. Morisani, among
others, reported many cases with a maternal mortality under 5% and a perinatal
mortality under 12% (4). Encouraged by these results, the
procedure soon met with the support of many distinguished obstetricians
in other countries, such as Pinard,Varnier and Zweifel. These symphysiotomies
were almost exclusively performed in predominantly Roman Catholic countries
of Italy, Spain, France, Ireland and some Latin American Countries. The
opposition of the Roman Catholic Church to sterilization contributed towards
this trend. The church also put the interest of the newborn above that of
the mother (9). Cesarean section prevented the potential
for large families, where tubal ligation would have been offered after repeated
cesarean deliveries. Reports indicate that symphysiotomy was also performed
outside Roman Catholic regions, in countries such as Great Britain (10)
and in African countries (11, 12). Presently
most symphysiotomies are performed in Africa (13).
2.2. INDICATIONS
Mild to moderate cephalopelvic disproportion: Cesarean
section is now the preferred method of delivery with the problem of cephalopelvic
disproportion in high income countries but symphysiotomy has been shown
to be safer in resource poor countries (14). Mild to moderate
cephalopelvic disproportion with a vertex presentation and a live fetus
is the leading indication for symphysiotomy.
Breech presentation: A rare but dreaded complication of
vaginal breech delivery is entrapment of the after coming head due to disproportion
which despite proper management may still occur often without warning in
about 1 of 12 vaginal breech deliveries (15). Attempts
at manual methods to force the head into and through the pelvis are often
traumatic and feticidal. (16-19) A timely
symphysiotomy performed to free the trapped after-coming head will save
at least 80% of babies (20-22).
Malpresentation: When labour becomes obstructed as a result
of brow or face presentation in carefully selected cases, symphysiotomy
may be undertaken. Maharaj and Moodley have however cautioned that there
is no justification in permitting labour to continue when the diagnosis
is made early in labour in the hope that symphysiotomy will eventually be
possible. (23).
Shoulder Dystocia: Symphysiotomy has been successfully
employed in severe cases of shoulder dystocia not resolving with the usual
manoeuvres (24). There are, however, few cases reported.
Some workers have documented poor outcome for mother and fetus (25).
Proper case selection and timely intervention is likely to give better results.
2.3. PRECONDITIONS AND CONTRAINDICATIONS
FOR SYMPHYSIOTOMY
Engagement of the Fetal Head: In order to reduce the risk
of complications, symphysiotomy should only be performed with an engaged
fetal head. Vaginal examination for fetal head engagement when labour is
obstructed could be misleading, as the presence of marked caput and moulding
may obscure the true station of the fetal head. Using the classification
described by Philpott (1973) of dividing the fetal head into fifths and
describing descents as the number of fifths of fetal head that have passed
through the brim of the maternal pelvis can be helpful in this circumstance
(26). Symphysiotomy should only be undertaken only if
less than two-fifths of fetal head is palpated above the maternal pelvic
brim. See Figure 1.
Figure 1 Abdominal palpation for descent of
the fetal head
(from Managing Complications in Pregnancy and Childbirth, WHO, 2000)
Degree of Overlap/Moulding: If there is second degree overlap/moulding
of the fetal skull or the fetal head is felt to be prominent in front of
the symphysis pubis, symphysiotomy should not be performed.
Dilation of the Cervix: The cervix should be at least 5cm dilated in a multiparous
and 7cm dilated in a primigravid patient for consideration of symphysiotomy.
Maharaj and Moodley strongly advised against performing the procedure before
or during early labour (23).
2.4. TECHNIQUE
The following symphysiotomy protocol is adapted from Crichton and Seedat
(11, 27, 28).
• Ensure that the bladder is empty
• Inject 10-15ml of 1% solution of lignocaine at the site of the symphysis
pubis. If the actual joint space is not readily identifiable, the needle
maybe left in situ as a guide. The perineum is also infiltrated along the
line of the proposed episiotomy.
• A number 14 Foley catheter is inserted into the bladder and the bulb inflated
with 5ml sterile water. If the fetal head is firmly lodged in the pelvis
a firmer silastic catheter may be necessary.
• Place the patient in the lithotomy position with two assistants supporting
the patient’s legs in their hands, with the patient’s knees and thighs resting
against their chest. The angle between the legs should never exceed 80 degrees.
Refrain from abducting the legs during and after symphysiotomy in order
to prevent straining of the sacroiliac joints.
• Place the index and middle fingers of the left hand in the vagina and
displace the catheter, and thereby the urethra, aside. The index finger
should identify and lie directly beneath the symphysical joint.
• A solid bladed scapel (bistoury knife) is inserted through the overlying
skin using a stab incision to enter the joint in the midline at the junction
of the upper and middle thirds, transversing the joint, until the point
of the blade is felt impinging on the vagina by the underlying finger of
the left hand. (See Figure 2) Using the upper one
third of the uncut symphysis as a fulcrum against which the scapel is levered,
incise the lower two-thirds of the symphysis. Cut through all the fibres
of the joint and arcuate ligament, being careful to preserve the triangular
ligament. After the desired transaction is achieved, return the scalpel
to the vertical position, without withdrawing the blade from the joint and
rotate through 180 degrees to permit incising of the remaining upper portion
of the symphysis pubis with the overlying ligamentous supports.
• When the procedure is complete, it will be possible to insert a thumb’s
breadth (2.5cm) into the divided joint. As the resultant separation leaves
the anterior vaginal wall with the urethra unsupported, any tension may
produce tearing and damage to the urethra; to obviate any such injury an
episiotomy is performed.
• Adduct the legs at crowning of the head, and whether by spontaneous or
by ventouse (vacuum) extraction, deliver the baby over the perineum and
not, as is usual, upwards over the mother’s abdomen. This manoeuvre will
avoid trauma to the soft tissues under the symphysis pubis.
• After delivery, compress the symphysis with the thumb above and the index
and middle fingers beneath for a few minutes to express blood clots and
promote hemostasis. Explore the genital tract to exclude uterine rupture
and inspect the cervix and vagina for lacerations. The stab wound should
be closed with catgut suture and the episiotomy repaired.
• Post operatively the patient is nursed on her side with strapping of the
knees. Bladder drainage maybe continued for 3 days, after which the Foley
catheter maybe removed.
• A broad spectrum antibiotic maybe prescribed.
• Ambulation should be encouraged as soon as the patient wishes to get up.
Walking-aids, physiotherapy and use of local short wave diathermy may be
of help in aiding recovery (Maharaj & Moodley, 2002). The patient may
be discharged when her gait is confident and when she is free of pain. This
may vary from 5-14 days. On discharge she must be warned against undue physical
activity for a period of 3 months and the need for delivery in a hospital
in subsequent pregnancies.
Figure 2 Coronal section of symphysis pubis
(Wikipedia: http://en.wikipedia.org/wiki/Image:Gray321.png)
2.5. COMPLICATIONS
Haemorrhage: Initial bleeding from the symphysis pubis can be brisk. However
this is usually venous in origin and responds to pressure applied by the
thumb and vaginal fingers. The bleeding is likely to be more if the incision
has been made away from the midline or too deep. Careful identification
of the midline of the symphysis with the local anaesthetic needle and guidance
of the underlying finger should reduce this risk. A retropubic hematoma
can occur post operatively, which is usually self limiting.
Urinary Tract: Urinary tract infection is common on account of catheterization.
This tends to settle within 48hrs of removing the catheter (11,
27). Prophylactic antibiotics will reduce the incidence.
Inadvertent incision of the bladder can occur and if identified and small
it should heal within 10-14 days of continuous bladder drainage. Another
potential complication is vesicovaginal fistula, which needs to be managed
with continuous bladder drainage for 6 weeks often and will often heal without
the need for subsequent surgery (28). The true incidence
of urinary stress incontinence resulting from symphysiotomy is difficult
to assess in the majority of women. Reports vary from 2.0-3.0% in patients
followed up for a period of up to 10 years after the operation. The duration
of this complication can last for an average of 4 months (29).
Bone: Osteitis pubis can occur, but this complication is reported in less
than 1% of cases (30). In all the published series, adherence
to the principles of symphysiotomy and proper use of antibiotics are shown
to prevent severe infection. Instability of the sacroiliac joint and symphysis
pubis leading to ambulatory difficulty is difficult to ascertain as follow
up is difficult in areas where symphysiotomies are undertaken. Overall,
in large series of symphysiotomy conducted by appropriately trained personnel,
the incidence of long term orthopedic complication is around 2% (11,
13, 30) Sacro-iliac pain and backache
are frequent complications in the post-operative period, however the reported
incidence is no different from that in women who have not undergone symphysiotomy
(31).
2.6. COMPARISON WITH CESAREAN SECTION
Maternal mortality after symphysiotomy has decreased dramatically since
1960. In the analysis by Van Roosmalen there were three maternal deaths
from a total of 1752 symphysiotomies, a rate of 1.7 per 1000 births (13),
none of which were related to the procedure; two were due to eclampsia and
the other followed a cesarean section in a woman with a failed symphysiotomy.
This compares favourably with maternal mortality rates of 0.6-5.0% following
cesarean section in resource poor countries (32, 33).
A maternal morbidity of 2% is probably a realistic estimate and compares
favourably with that following caesarean section (34).
Strict adherence to guidelines will further improve the outcome.
There is a wide difference in the range of perinatal mortality reported
in different series with an overall rate of 112 per 1000 (range 19-296 per
1000). This may reflect different levels of obstetric skills and technical
support (23). Hartfield pointed out that the results in
his series improved when symphysiotomy was no longer reserved for desperate
cases only (35). Fetal prognosis does not appear to have
greatly improved since the period between 1900-1960 (13).
Other noted benefits of symphysiotomy over cesarean section include shorter
hospital stay. Hartfield (1973) (35) reported a mean of
11.2 days’ admission after symphysiotomy and 11.4 days after cesarean section.
Also, the need for blood transfusion appears to be much less following symphysiotomy
compared to cesarean section. Saving on hospital stay and blood transfusion
is a significant advantage in areas where resources are limited (23).
An important feature distinguishing cesarean section from symphysiotomy
in the management of obstructed labour is that cesarean section leaves a
scar in the uterus. In a subsequent pregnancy the combination of obstructed
labour and a uterine scar may prove disastrous in areas where cesarean section
is not readily available. Conversely, symphysiotomy facilitates future vaginal
deliveries by conferring a permanent enlargement of the pelvis (36).
2.7. MODE OF SUBSEQUENT DELIVERY
BjorKlund reviewed mode of delivery and perinatal outcome in pregnancies
subsequent to a delivery by symphysiotomy. There were 351 deliveries, where
72% had spontaneous vaginal delivery, 18% were delivered by forceps or vacuum
extraction and 7% by Cesarean section. 3% had repeat symphysiotomy (36).
This is in agreement with the observation by Roosmalen that vaginal delivery
rate after previous symphysiotomy is higher than after previous cesarean
section for cephalopelvic disproportion (13). The explanation
for this is in the fact that symphysiotomy permanently widens the symphysical
joint to between one and one half centimeters (37). This
translates to an increase in the area of the pelvic brim of about 15%-20%
and increases all the pelvic transverse diameters by 1cm (38).
3.1. HISTORICAL PERSPECTIVE
The episiotomy, intentional cutting of the tissues of the maternal perineum
to surgically enlarge the vagina and facilitate delivery, has been described
for over 300 years, initially in Europe and first introduced to North America
approximately 150 years ago (39). The term “episiotomy”
was coined in 1857. The practice became more routine in the 1920’s, as papers
were published about the practice and more deliveries started to occur in
the hospital setting, where multiple forms of intervention became more common
(ACOG Committee on Practice Bulletins - Obstetrics, 2006). It was at this
time that the performance of episiotomies started to become routine, for
the prevention of perineal tearing at delivery, having been previously reserved
for difficult births (39). Initially, more mediolateral
episiotomies were performed in North America but evidence produced in the
1970s shifted the practice towards midline procedures. Evidence then showed
a significantly heightened incidence of third and fourth degree tears as
a direct result and practice again reverted to mediolateral episiotomies.
By the 1980’s, episiotomy was performed in 64% of American births (39).
The practice then came under increased scrutiny and study into the purported
benefits of the practice. The evidence has since shown both a failure to
demonstrate benefit and proof of increased complications (39).
Recent data from North American practice suggests that the practice has
been decreasing over the last two decades (ACOG Committee on Practice Bulletins
- Obstetrics, 2006).
3.2. TYPES OF EPISIOTOMY
In general, two types of episiotomy are described: the median and the mediolateral.
The median episiotomy is cut along the midline plane inferior to the perineum.
Advantages include ease of repair and the major noted disadvantage of the
median episiotomy is the risk of extension to third or fourth degree tear.
A median episiotomy is one of the direct risk factors for third or fourth
degree perineal tear (ACOG Committee on Practice Bulletins - Obstetrics,
2006). Of note, resumption of intercourse has been noted to be sooner with
median episiotomy as compared to mediolateral (39), indicating
that it may be associated with less pain during recovery.
A mediolateral episiotomy is cut at least 45 degrees from the midline, either
to the right or the left (more commonly to the patient’s right as the operator
is typically right-handed). A large advantage of the mediolateral episiotomy
is that it is less likely than a median episiotomy to extend into a third
or fourth degree tear. Disadvantages compared to median episiotomy include
greater difficulty of repair, greater blood loss and a possible association
with greater discomfort in the early postpartum period (ACOG Committee on
Practice Bulletins - Obstetrics, 2006) (40).
Reviews in the literature of episiotomy have not conclusively resolved the
issue of which episiotomy is preferred.
An anterior episiotomy refers to an incision anteriorly on the perineum
to enlarge the vagina and facilitate vaginal delivery. This may be appropriate
in the case of a patient who has undergone female genital cutting (FGC)
(39).
3.3. INDICATIONS
It is the indication for performing the episiotomy which is perhaps the
most controversial component of this discussion as many different opinions
exist and there is little evidence to guide clinical practice. Stated indications
include the need to expedite delivery in the second stage or the perception
of a high likelihood of significant spontaneous tearing. Circumstances where
an episiotomy may, therefore, be warranted can include: abnormal fetal monitoring
indicating fetal distress, shoulder dystocia, operative vaginal delivery
(vacuum delivery and forceps delivery, in particular, are associated with
greater risk of severe perineal trauma (39) or a short
maternal perineum. To date, however, there is only a poor level of data
to support these claims and improved outcomes have never been conclusively
demonstrated. The use of episiotomy overall appears to increase the likelihood
of perineal laceration (especially third and fourth degree tears in the
case of median episiotomy), although restricting episiotomy does appear
to increase the rate of anterior lacerations (which are, however, far less
likely to require suturing and are therefore presumed to be less severe)
(41). In addition, there is no evidence to support the
performance of an episiotomy for the prevention of pelvic floor relaxation
and incontinence (42). Therefore the use of episiotomy,
especially routinely, cannot be recommended. Restriction is encouraged and
clinical judgement of the surgeon must be utilized (ACOG Committee on Practice
Bulletins - Obstetrics, 2006) (41).
Failing to perform episiotomy is associated with increased anterior perineal
trauma. That said, the anterior perineal trauma is less likely to require
suturing and is not associated with an increase in the incidence of severe
perineal trauma.
3.4. REPAIR
Adequate analgesia must be considered a prerequisite for any repair. This
can be achieved by local, regional or general anaesthesia. In the case of
anal sphincter injury, adequate analgesia not only facilitates maternal
comfort but relaxes the anal sphincter to better approximate the torn ends
(43).
Regardless of the type of episiotomy, a two-layer closure of the wound has
been identified to decrease postpartum pain and be associated with less
complications of healing as compared to a three layer closure. Systematic
review has also reported less postpartum pain with a continuous method of
suturing as compared with an interrupted suture method (44,
45). Specifically, continuous suturing at all layers is
associated with decreased pain by report in the first 10 days postpartum,
decreased need for analgesia and a trend towards decreased dyspareunia (45).
There is limited data to recommend one suture over another for repair although,
where available, many surgeons are now using absorbable polyglycolic acid
sutures as polyglycolic acid sutures have been shown to be associated with
less perineal pain than catgut, likely due to less reactivity of the materials
in the process of absorption (although they also absorb more slowly, causing
many surgeons to now opt for a rapidly absorbable monofilament) (ACOG Committee
on Practice Bulletins - Obstetrics, 2006).
The episiotomy should be carefully examined before repair for evidence of
injury to the anal sphincter. If the anal sphincter is noted to be injured
by an episiotomy or its extension, this should be repaired immediately.
A short delay in repair, however, has not been noted to affect outcome and
therefore a delay of up to 24 hours, to wait for appropriate assistance
to achieve good repair, is felt to be appropriate (43).
Accepted methods of repair of the external anal sphincter include an end-to-end
and overlapping method; both are acceptable although colorectal surgeons
tend to use the overlapping method (43). Systematic review
recommends a technique using interrupted sutures with monofilament. If the
internal anal sphincter requires repair, a continuous braided suture such
as polyglycolic acid is recommended (43). Postpartum laxatives,
such as lactulose, have been proven helpful post-anal sphincter repair and
many authorities consider it prudent to prescribe a course of post-repair
antibiotics, such as metronidazole, for the prevention of post-repair infection
(43). While over 95% of women who experience an anal sphincter
injury in one delivery will not have the event repeated at a subsequent
delivery, some women may find the event so devastating as to warrant discussion
of elective cesarean delivery for their next pregnancies (43).
3.5. COMPLICATIONS
Complications of the episiotomy include bleeding, infection, anal incontinence
and fistula:
Bleeding: Most bleeding from episiotomy sites is minor
and can be managed conservatively, in particular with the local application
of pressure, although hematomas can form (ACOG Committee on Practice Bulletins
- Obstetrics, 2006). There is no evidence of benefit from the performance
of an early episiotomy but regardless of the timing, episiotomy is associated
with increased blood loss at delivery (46).
Postpartum pain may be increased with episiotomy although good studies in
this area are lacking in the literature. Episiotomy is not associated with
an increased time to resumption of intercourse, which may be a reflection
of pain and healing (ACOG Committee on Practice Bulletins - Obstetrics,
2006). Of note, resumption of intercourse has been noted to be sooner with
median episiotomy as compared to mediolateral (39).
Infection: Most infections are minor and will resolve with
conservative management and good perineal wound care. Rarely, an abscess
will result, either requiring drainage or disrupting the wound with spontaneous
drainage. In the event of wound breakdown, conservative management may permit
the wound to close spontaneously or, alternatively, primary closure can
sometimes be appropriate (ACOG Committee on Practice Bulletins - Obstetrics,
2006) (47).
Anal incontinence: The largest risk factor for anal incontinence
in women is obstetric injury to the anal sphincter (43).
Episiotomy leading to damage to the anal sphincter can therefore lead to
anal incontinence (as can spontaneous tearing). Median episiotomy is more
likely to lead to anal sphincter damage than is mediolateral episiotomy
(43).
Fistula: In rare cases, inadequate closure or healing of the episiotomy
can lead to a rectovaginal fistula. The repair of such a fistula should
be referred to someone with demonstrated expertise in their closure and
is beyond the scope of this review (ACOG Committee on Practice Bulletins
- Obstetrics, 2006).
3.6. PROPOSED BENEFITS OF EPISIOTOMY
There are many proposed benefits of episiotomy, including substitution of
a clean cut for a ragged tear (this benefit clearly favours only the operator
though a skilled obstetrician should be capable of repairing either), protection
of the fetal cranium, especially for the premature fetus, shortening the
second stage of labour and reduction of fetal distress and asphyxia by facilitating
delivery, but none of these are supported by good evidence (ACOG Committee
on Practice Bulletins - Obstetrics, 2006; (39). Episiotomy
is a recognized component of the strategies to manage shoulder dystocia
and, although it may be helpful to facilitate the management of shoulder
dystocia (again, no evidence exists in the literature to prove this benefit),
performance of routine episiotomy has not been found to reduce the incidence
of shoulder dystocia (48).
Given the concern of the HIV epidemic in many regions of the world, and
the fact that in many of the most affected countries, up to one third or
more of parturients may be HIV-infected, there must be consideration given
to the theoretical possibility of transmission of HIV to the healthcare
worker from the creation or repair of episiotomy. A needle-stick injury
is possible during repair, especially with the combination of small needles,
poorly maintained suture equipment and lack of adequate analgesia that may
exist in some settings. In addition, any interventions may be associated
with an increased risk of mother-to-child transmission of HIV.
3.7. CONCLUSIONS ON ROLE OF EPISIOTOMY
There is no evidence to support the routine use of episiotomy in obstetric
and their performance should be limited to an as-needed, restrictive basis
(41). Restrictive use of episiotomy limits perineal trauma,
decreases the need for perineal suturing, elicits fewer complications and
does not demonstrate an increase in severe perineal trauma although is associated
with an increased, but not clinically significant, rate of anterior perineal
trauma (41). Episiotomy retains a place in obstetrics
for fatal distress, selected operative vaginal deliveries and as a potential
manoeuvre to relieve shoulder dystocia. Further evidence is still required
to decide the optimal management of the perineum during vaginal delivery.
4. FETAL DESTRUCTIVE OPERATIONS – OBSTRUCTED LABOUR
WITH A DEAD FETUS
In many settings where obstetrical expertise is lacking, the majority of
cases with a dead fetus will need to be delivered by cesarean section before
full dilatation of the cervix. The situation is different, however, when
the cervix is fully dilated. Not infrequently cases will be compounded by
gross infection, and an abdominal operation carries the risk of maternal
death which can be as high as 70%. (49) (50).
These procedures have, as their objective, the diminution of the bulk of
the fetus in order to permit its passage through the birth canal. Such procedures
are only performed on a fetus with a lethal abnormality or on a fetus which
is already dead. Other than the special case of the drainage of the hydrocephalic
fetal head, these procedures have no place in modern obstetrics in high
income regions with well developed health services (30).
In cases of obstructed labour, the options may vary with the circumstances.
If the fetus is alive and there is mild to moderate cephalo pelvic disproportion,
symphysiotomy (see above) should be considered. If there is gross disproportion,
however, a cesarean section may have to be performed in spite of the risks.
When labour is obstructed by transverse lie or compound presentation and
the fetus is alive, the route of delivery is by cesarean section. Internal
version and breech extraction is not a safe alternative as any attempt at
manipulating the fetus is almost certain to rupture the uterus. When the
fetus is dead, cephalopelvic disproportion can be relieved by reducing the
size of the head by craniotomy, and obstruction due to transverse lie can
similarly be relieved by decapitating the fetus (23, 30,
51).
The incidence of fetal destructive operations vary between 0.2 and 1.6%
of deliveries from reports originating in Nigeria, Ghana and India; (52),
(49).
4.1. GENERAL PRINCIPLES OF MANAGEMENT
• For most cases of obstructed labour, as the woman would have been in labour
for a long time, she is likely to be ill, in painful distress, demoralized,
exhausted and potentially infected.
• A quick resuscitation will be needed since the need for operative intervention
is usually urgent. Important principles of management in the mother would
be to correct the shock, dehydration, electrolyte deficit and acidosis.
Hypovolemic shock may require infusion of crystalloids or colloids and blood
transfusion. A Foley catheter should be passed to monitor and guide fluid
management. Infection must be assumed and broad spectrum antibiotics should
be prescribed.
• A Rhyle’s (stomach) tube may be passed to empty the stomach contents,
and a non particulate antacid is administered followed by an anti-emetic.
• Blood should be taken for full blood count, crossmatch and coagulation
screen if possible. Many of these women are already anemic and with prolonged
obstructed labour, atonic postpartum hemorrhage is more likely. In addition,
trauma to the genital tract during the destructive procedure may increase
blood loss.
• Confirming fetal demise should be done with ultrasound, where available;
by Doppler assessment of absent fetal heart tones, where available; or by
fetoscope auscultation of absent fetal heart tones. Occasionally, part of
the fetus may be delivered (such as an impacted breech) and fetal demise
will be easily ascertained by the lack of pulse)
• Often the woman is exhausted, demoralized and may not even know that the
fetus is dead. After resuscitation efforts have been implemented, the woman,
her husband, and if appropriate a senior relative, should be involved in
the discussion and plan for delivery. Fully informed consent is difficult
in these situations, but every effort must be made to obtain this to the
extent feasible (30).
• The abdomen should be examined for signs of uterine rupture or impending
rupture and if present, a laparotomy is indicated, even if the fetus is
dead (23).
• The cervix should be fully dilated, although destructive surgery may still
be performed by an experienced operator when the cervix is 7cm or more dilated.The
true conjugate of the pelvic brim should not be less than 8cm.
• General anesthesia or regional anesthesia combined with sedation is ideal
for the procedure. Where these forms of anesthesia are not available or
unusable because of the poor state of the patient, an intravenous injection
of pentazocin 30mg and diazepam 10mg will provide sufficient analgesia and
relaxation.
• After performing the procedure, it is imperative that the uterus and genital
tract be explored for rupture or lacerations, and appropriate steps taken
at the time. Removal of any fetal bones through the maternal genital tract
must be done gently to avoid injury to tissue that is already compromised.
• A self retaining catheter should be left in the bladder for at least 48hours.
If there has been prolonged pressure of the presenting part on the pelvic
structures, there is danger of fistula formation and the catheter should
be left in the bladder for 10-14days.
• For 2-4 hours post partum the patient should be on 20-40u of oxytocin/L
of IV fluids to prevent post partum hemorrhage resulting from an atonic
uterus.
• When the patient has recovered, the cause of her traumatic experience
and its prevention must be fully explained to her.
4.2. CRANIOTOMY
Craniotomy is the most commonly performed destructive operation and is used
for a neglected obstructed labour with a dead fetus in cephalic presentation,
(54, 55) where the head is driven firmly
into the pelvic brim where it becomes impacted. If the head is palpable
more than three fifth above the pelvic brim or mobile, craniotomy is difficult
and dangerous, in which case delivery by cesarean section is the safer option
(23).
4.2.1. METHODS OF CRANIOTOMY
a) Perforation of the fetal head with a Simpson’s perforator (Figure
3) which is passed into the skull up to the shoulders of the blades
and opened widely, it is then closed and rotated through 90 degrees and
opened again to produce a cruciate opening in the vault. The septa and brain
substance is broken by inserting the closed perforator deep in the skull
then opening the blades and rotating briskly. Extraction of the fetus is
facilitated by traction on the edges of the cranium by application of vulsella,
kocher’s forceps, Morris’s craniotomy forceps or Maingot clamps.
The Simpson’s perforator is the ideal and safest instrument; the depth of
the two cutting blades is limited by the instruments shoulders beneath them.
This prevents excessive penetration into the fetal skull which may endanger
maternal soft tissues. Unfortunately this instrument may not be available
in most rural hospitals in which case the alternative procedure described
below may be used.
Figure 3 Simpson’s Perforator
b) The procedure described by Lister commences with a cruciate incision
on the fetal scalp and the lifting of the four flaps off the cranium. A
sharp instrument such as a Mayo’s scissors is then introduced into the fetal
head through the most accessible suture line. The scissors is then retained
in the fetal skull and opened repeatedly in all directions to facilitate
evacuation of the brain tissue.
c) In a & b above the cervix has to be fully dilated. When the cervix
is not fully dilated, the method put forward by St Georges (56)
can be employed when the cervix is 7cm dilated. The steps are similar to
those described by Lister (b) but differ in that the posterior fontanelle
is perforated to enter the skull. After emptying the brain tissue, two Kocher’s
forceps are clamped unto the incised scalp and suitable weights are tied
to the handles by lengths of bandage. The patients legs are removed from
the lithotomy poles and rested on stools. The weight hanging from the forceps
is allowed to hang gently and effectively completes the delivery. Use of
obsolete crushing instruments, like cranioclast or cephalotribe, is condemned
and should be confined to the museum (51, 57,
58).
4.3. CRANIOCENTESIS
Craniocentesis refers to drainage of excess cerebrospinal fluid from the
hydrocephalic fetal head. Often there is either severe hydrocephalus causing
fetal demise or fetal demise due to other associated anomalies. If the fetus
is alive in such circumstances, the chance of infant survival after birth
is remote and, after discussion with the family to ascertain their wishes,
it may be appropriate to proceed with cranioscentesis even for a live fetus
(otherwise, Cesarean section in indicated). The fetus invariably presents
by the head or breech. If presentation is cephalic, cerebrospinal fluid
(CSF) can be drained abdominally using a spinal needle, preferably under
ultrasound guidance. As labour progresses it may be necessary to drain additional
fluid transvaginally using a sharp instrument such as Simpson’s perforator,
Drew-Smythe catheter, or spinal needle or a pair of scissors.
In breech presentation, the baby is delivered at full cervical dilatation
and the base of the occiput is perforated per vaginam to facilitate decompression.
If there is an accompanying spina bifida the CSF can be drained by passing
a catheter through the defect up the vertebral column into the cranium (58).
4.4. DECAPITATION
This is the procedure of choice following obstructed labour in the transverse
lie with shoulder or arm presentation. It consists of severing the head
of the dead fetus from its trunk followed by extraction of trunk and head.
Considerable skill is required, and careful vaginal examination must be
undertaken to determine the exact position of the fetal neck. If the fetus
is small or macerated, pulling on the arm or severing the neck with a pair
of stout scissors will result in delivery. For average size fetuses, the
safest method of performing a decapitation is to use the Blond-Heidler saw
(Figure 4) (51). This 43cm long
Gigli-type wire saw with the central portion bare and two ends protected
with rubber tubing is threaded around the fetal neck which is severed by
a saw motion. Traction on the arm delivers the trunk, and the aftercoming
head is manipulated in the uterus to enable the operator grasp the stump
of the neck with a volsellum. The head is then delivered like the aftercoming
head of a breech with the operator’s finger in its mouth.
Figure 4 Blond-Heidler Saw
It is sometimes easier to deliver the head if the prolapsed arm is left
attached to the neck when doing the operation to act as a handle on the
decapitated head (57). The Ramsbotham’s or Jardine’s
decapitation hook is an alternative instrument that can be used for this
procedure. The instrument is passed round the fetus under cover of the operator’s
palm to severe the neck. However it is clumsy (30) and
difficult to use, particularly if the blade is blunt (51).
4.5. CLEIDOTOMY
This is considered in cases where the head is delivered, large shoulders
are obstructing delivery and other manoeuvres for shoulder dystocia have
been unsuccessful, or the fetus is already known to have demised. If delivery
of the shoulder cannot be achieved by the usual manoeuvres used to overcome
shoulder dystocia, division of one or both clavicles can be done as an advanced
maneuver in resolving a shoulder dystocia to reduce the bulk of the shoulder
girdle. One hand is placed vaginally along the ventral aspect of the fetus
and under this protection a Kocher clamp can be introduced anteriorly to
the clavicle and pulled back against the clavicle to fracture it. Alternatively,
if the fetus is dead, strong straight embryotomy scissors can be introduced
to cut the clavicle. It is best to cut the skin over the clavicle first
and push the scissors round the bone. Considerable strength is often required
to break the bone at its midpoint (30).
4.6. EVISCERATION
The operation consists in the removal of the abdominal and/or thorax contents
with the object of diminishing the bulk of the child so it can be extracted
vaginally. This is only considered for dead fetuses when the abdomen may
have been distended by fluid or tumour. Using a perforator or embryotomy
scissors, the abdomen or thorax (whichever is accessible) is opened. The
organs are removed manually or by traction with sponge forceps. Entry from
the thorax to the abdomen and vice versa can be gained via the diaphragm
(30).
4.7. COMPLICATIONS
Maternal morbidity in reported series was felt due to prolonged obstructed
labour for which the operations were performed. Vesico-vaginal fistula and
recto-vaginal fistula were the more common (27.2%), followed by foot drop
(18.2%), puerperal sepsis (18.2%), post partum hemorrhage (18.2%) and vaginal
lacerations (9.1%). Amo-Mensah et al (49) reported a (9.1%)
incidence of uterine rupture following destructive operations in Ghana.
Shahu and Shina give figures of 2.6% for ruptured uterus, 4.5% for post
partum hemorrhage and 1.3% for cervical and vaginal tears (59).
Minor complications such as urinary retention in the patients and stiffness,
pain and cuts to the operator were also reported (60,
61).
Maternal mortality arising from destructive operations in various reports
range from nil to 9.5% (49, 59, 62).
Truly prolonged obstructed labour may result in excessive maternal mortality
rates when cesarean sections are performed rather than destructive procedures.
Sahu reported a figure of 7.5% maternal mortality for cesarean section deliveries
as opposed to 2.7% when alternative methods were undertaken, in patients
presenting with obstructed labour and fetal demise (59).
In another report, the figures for the respective procedures were 12.5%
and 5.8% (63). These confirm the efficacy and safety of
destructive operations over cesarean section in dealing with obstructed
labour.
5. SUMMARY
Whereas prolonged obstructed labour is rarely ever seen in the high income
countries, it is regrettably a fairly common occurrence in obstetric practice
in most resource poor countries, particularly in rural areas. The cause
of the obstruction of labour is often multifactorial including lack of confidence
in modern obstetric care, lack of health facilities, or tradition. Other
causative factors include problems with roads and transportation, the vast
distances patients have to travel to reach maternity services, the relatively
high demands on under-resourced medical facilities and the socio-cultural
need to achieve vaginal delivery under difficult circumstances, especially
in those with a scarred uterus (23). A cesarean section
for a case of prolonged obstructed labour that is potentially infected can
be extremely hazardous and fraught with significant maternal mortality (23).
A symphysiotomy or destructive fetal procedure therefore should be ideal
in these settings and circumstances.
Treatment for obstructed labour must be individualized. The attendant must
weigh the options before deciding on the mode of delivery. If s/he is unsure
of which procedure to embark upon, is not confident that s/he can safely
perform it or whether s/he can competently do it, the safer route of delivery
for the patient would be a cesarean section (58).
The following assertion of Hartfield in 1973 is still relevant and merits
serious consideration: “The risk of maternal mortality and morbidity after
symphysiotomy has become negligible and is lower than that following cesarean
section performed in advanced labour for the same indications.” (35)
This warrants a continuation of its use, not only in less developed areas
of the world, but also its inclusion in the curricula of all teaching hospitals.
Rachel F. Spitzer, BSc, MD, MPH, FRCS(C)1 and Chuks I. Kamanu, MBBCh, FWACS,
FICS2
1 Assistant Professor, Department of Obstetrics and Gynecology, University
of Toronto
2 Honorary Consultant and Head of Dept. of Obstetrics and Gynaecology, Abia
State University Teaching Hospital, Aba, Nigeria
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