Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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134 Surgery and Healing in the Developing World
sudden expulsion when resistance of the perineum is overcome results in lacerations.
Do not make more than three attempts at vacuum-assisted delivery. If possible,
attempt vacuum-assist in the OR so the patient can go immediately to section
if extraction fails.
Symphysiotomy
Definition and Indications
Symphysiotomy (separating the pubic symphysis to increase pelvic diameters)
deserves discussion as an alternative to Cesarean section for the relief of obstructed
labor that is due to mild or moderate cephalopelvic disproportion (CPD). This
procedure is not in the armamentarium of obstetricians in the developed world but
may yet have a limited place in the mission setting. For example, one might consider
symphysiotomy as an emergency procedure when clinical pelvimetry suggests that
an obstructed labor pattern is due to mild CPD, and Cesarean section would be
difficult or dangerous under existing conditions. Among the advantages of the procedure
one can count the facts that there will be no need for abdominal surgery and
no uterine scar. Future deliveries should be much easier.
The chief indication for symphysiotomy—failure to make progress in labor, associated
with CPD with the head too high for vacuum-assist (or after vacuum-assist
has failed)—presupposes that adequate clinical pelvimetry and Leopold’s assessment
have been completed to support the diagnosis of CPD. The procedure is contraindicated
in severe CPD. A Cesarean is the patient’s only option in this case. It is also
inappropriate in the setting of malpresentations with one exception. It may be useful
to release the aftercoming head in a difficult breech delivery. It may also be
contraindicated by maternal body habitus, e.g., obesity and/or musculoskeletal abnormalities
of the legs and/or spine. It won’t enable you to deliver a macrosomic
fetus.
Perform a vaginal exam to assess the degree of cervical dilatation and the station
and position of the presenting part (which must be the head!). Symphysiotomy is
performed at full dilatation and is always accompanied by an episiotomy. If the head
has descended such that 1/5 or less is above the pelvic brim, you should be able to
deliver the baby without symphysiotomy. If the head has stopped descending with
2/5 above the brim this is an indication for symphysiotomy. With 3/5 of the head
above the brim, King et al recommend the following assessment: attempt to pass a
finger between the head and the pelvis. If you are unable to, the CPD is too great for
symphysiotomy to be useful. If it passes easily, symphysiotomy isn’t called for. If it
passes with difficulty, symphysiotomy may be appropriate.
Procedure
Position the patient in lithotomy position. Her legs must be secured in such a
way that they will not further abduct when the symphysis is cut. This would result
in painful injury to the sacroiliac joints. Place a stiff catheter in her urethra, which
will be used to displace the urethra out of the path of your incision.
Cleanse and prepare the skin over the symphysis in the usual fashion. Infiltrate
with 1% lidocaine plus epinephrine (15-20 cc, maximum 7 mg/kg body weight).
With your nondominant hand, reach into the vagina and displace the urethra and
catheter. While holding the urethra out of harm’s way, locate the joint, and cut
down to its full length. Maintain hemostasis and avoid the bladder. Next, divide the