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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 


Section 3 - Procedures


Symphysiotomy results in a temporary increase in pelvic diameter (up to 2 cm) by surgically dividing the ligaments of the symphysis under local anaesthesia. This procedure should be carried out only in combination with vacuum extraction.. Symphysiotomy in combination with vacuum extraction is a life-saving procedure in areas where caesarean section is not feasible or immediately available. Symphysiotomy leaves no uterine scar and the risk of ruptured uterus in future labours is not increased.

These benefits must, however, be weighed against the risks of the procedure. Risks include urethral and bladder injury, infection, pain and long-term walking difficulty.  Symphysiotomy should, therefore, be carried out only when there is no safe alternative.

  • Review for indications:

- contracted pelvis;

- vertex presentation;

- prolonged second stage; 

- failure to descend after proper augmentation;

- AND failure or anticipated failure of vacuum extraction alone.

  • Review conditions for symphysiotomy:

- fetus is alive;

- cervix is fully dilated;

- head at -2 station or no more than 3/5 above the symphysis pubis; 

- no over-riding of the head above the symphysis;

- caesarean section is not feasible or immediately available;

- the provider is experienced and proficient in symphysiotomy.

Abduction of the thighs more than 45̊ from the midline may cause tearing of the urethra and bladder. 


Figure P-25

 Position of the woman for symphysiotomy 


Note: Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated. If blood is returned in the syringe with aspiration, remove the needle. Recheck the position carefully and try again. Never inject if blood is aspirated. The woman can suffer seizures and death if IV injection occurs.

  • At the conclusion of the set of injections, wait 2 minutes and then pinch the incision site with forceps. If the woman feels the pinch, wait 2 more minutes and then retest.

Anaesthetize early to provide sufficient time for effect. 

  • Insert a firm catheter to identify the urethra.

  • Apply antiseptic solution to the suprapubic skin.

  • Wearing high-level disinfected gloves, place an index finger in the vagina and push the catheter, and with it the urethra, away from the midline (Fig P-26). 

Figure P-26

 Pushing urethra to one side after inserting the catheter 

  • With the other hand, use a thick, firm-bladed scalpel to make a vertical stab incision over the symphysis.

  • Keeping to the midline, cut down through the cartilage joining the two pubic bones until the pressure of the scalpel blade is felt on the finger in the vagina.

  • Cut the cartilage downwards to the bottom of the symphysis, then rotate the blade and cut upwards to the top of the symphysis.

  • Once the symphysis has been divided through its whole length, the pubic bones will separate. 

Figure P-27

 Dividing the cartilage


  • After separating the cartilage, remove the catheter to decrease urethral trauma.

  • Deliver by vacuum extraction. Descent of the head causes the symphysis to separate 1 or 2 cm.

  • After delivery, catheterize the bladder with a self-retaining bladder catheter.

There is no need to close the stab incision unless there is bleeding.



  • If there are signs of infection or the woman currently has fever, give a combination of antibiotics until she is fever-free for 48 hours:

- ampicillin 2 g IV every 6 hours; 

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours;

- PLUS metronidazole 500 mg IV every 8 hours.

  • Give appropriate analgesic drugs.

  • Apply elastic strapping across the front of the pelvis from one iliac crest to the other to stabilize the symphysis and reduce pain.

  • Leave the catheter in the bladder for a minimum of 5 days.

  • Encourage the woman to drink plenty of fluids to ensure a good urinary output. 

  • Encourage bed rest for 7 days after discharge from hospital.

  • Encourage the woman to begin to walk with assistance when she is ready to do so.

  • If long-term walking difficulties and pain are reported (occur in 2% of cases), treat with physical therapy.

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Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support


General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages



Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems


Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia


External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section


Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy


Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy



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