Chauhan AR

Symphysiotomy is the deliberate surgical separation of the pubic symphysis to aid vaginal delivery in cases of obstructed labor. Though the West has condemned this surgery and relegated it to obscurity, symphysiotomy is still practiced and in fact, its revival is recommended in resource poor settings, namely parts of central and south Africa. 
Physiologically, the pubic symphysis widens approximately 3 to 7 mm during pregnancy; when this gap is more than 10 mm, it is abnormal and is referred to as pubic symphysis diastasis. This is a rare condition that may occur either intra or postpartum, and presents with acute pelvic pain. The diagnosis is usually clinical, supported by X-rays, and management is conservative in the form of analgesia, prolonged bed rest in lateral position, pelvic binder, and subsequent physiotherapy. Rarely, if the gap exceed 3 to 4 cm, surgery for fixation and stabilization of the joint may be required. 
Interestingly, Séverin Pineau first described symphysiotomy in 1597 after observing pubic diastasis on a hanged pregnant woman; however it was not until 1777 that Jean-René Sigault performed the first successful symphysiotomy in Paris. This procedure was opposed by the famous French accoucher Baudeloque and subsequently, the fortunes of symphysiotomy waxed and waned in Europe for more than a century, till Gigli of Italy performed pubiotomy using his saw. Debate raged about symphysiotomy versus cesarean delivery, and symphysiotomy again fell into disrepute due to its many complications, namely hemorrhage, difficulty during walking and urinary incontinence and fistulae. "Subcutaneous partial symphysiotomy" described by Zarate of Argentina in the early 1920s is a relatively simple procedure, where the superior and inferior ligaments of the symphysis are not completely divided; this is the technique in use today. 
Literature on symphysiotomy is of two extremes: on the one hand, serious issues about the procedure being carried out on approximately 1500 women in Ireland in the latter half of the last century and its long -term sequelae, and on the other hand, its lifesaving role in resource poor situations. 
The practice of symphysiotomy was prevalent in parts of Ireland in the 1940s up to the 1980s, partly due to the orthodox Catholic aversion to cesarean section (CS), especially repeat CS, as contraception is usually not advocated, and partly due to disregard for women's autonomy. The Journal of Bone and Joint Surgery in 2014 carried an article on the radiographic findings after symphysiotomy in Irish women (mean duration of 41.6 years) and found that late- onset osteoarthritis of the sacroiliac joint and pelvic instability were key findings. Recently these surviving women, many of whom are now in their 70s and 80s, have raised their voice about their horrific experiences in labor, where symphysiotomy was performed without their consent, and quality of life issues including nagging pain, difficulty in walking and urinary incontinence. In 2014, this culminated in the United Nations Human Rights Committee moving the Irish government to offer compensation to these women for their physical and emotional trauma.
On the other hand, symphysiotomy has been advocated as life saving in many resource poor and rural parts of Africa, where maternal and perinatal mortality due to neglected obstructed labor is still high, as also mortality after CS. Advocates of symphysiotomy say that it is a simple underemployed surgical procedure done under local anesthesia or analgesia to widen the pelvic ring, and facilitate vaginal delivery in cases of mild to moderate cephalopelvic disproportion, without the need for sophisticated equipment or an operation theater. it can be performed by a doctor or a midwife. The procedure obviates the need for CS, is socio- culturally acceptable to women who prefer vaginal birth, and leaves the uterus unscarred. A 2012 paper by Monjok in the African Journal of Reproductive Health calls for the "revival and reinstatement of symphysiotomy in the obstetric arsenal of Nigeria and sub- Saharan Africa". Another paper by Ersdal from Zimbabwe in 2014 studied the knowledge, attitudes and practice of doctors and midwives, and found that those working in smaller district hospitals had a more positive attitude toward symphysiotomies than those working in larger referral centers, especially teaching institutes. 
A Cochrane review in 2012 by Hofmeyr and colleagues mentions "failure to progress in labour when cesarean section is unavailable, unsafe or declined by the mother; and obstructed birth of the after-coming head of a breech presenting baby" as special situations where symphysiotomy may be resorted to. Though observational studies from Africa and West Asia have reported low maternal mortality rates and high success with symphysiotomy, a large part of the problem is that there are no randomized trials. The authors suggest that evidence from good quality research is needed to compare efficacy and safety of symphysiotomy versus no symphysiotomy, or various modifications of the technique, or symphysiotomy versus CS in various clinical situations. Hence there are no clear recommendations; rather they state that "because of the possibility that symphysiotomy may be life- saving in certain situations, professional and global bodies should provide guidelines for its use (or non- use) based on best available evidence".
Sadly, symphysiotomy is a reflection on the condition of women globally. Till such time as women continue to be the lowest priority on the health ladder and till basic reproductive rights are not awarded to them, this discrimination and disparity will continue. 
This issue of the journal carries an interesting case report of spontaneous pubic diastasis which prompted this commentary on the renewed interest in symphysiotomy. The question on whether its use in modern obstetrics is justified still remains.