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MoonDragon's Women's Health Procedures Information
SYMPHYSIOTOMY


For "Informational Use Only".
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  • Symphysiotomy Description
  • Symphysiotomy Procedures
  • Post Procedure Care




  • SYMPHYSIOTOMY DESCRIPTION

    Symphysiotomy results in a temporary increase in pelvic diameter (up to 2 cm) by surgically dividing the ligaments of the symphysis under local anesthesia. 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 cesarean section is not feasible or immediately available. Symphysiotomy leaves no uterine scar and the risk of ruptured uterus in future labors 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.
  • Cesarean section is not feasible or immediately available.
  • The provider is experienced and proficient in symphysiotomy.


  • REVIEW GENERAL CARE PRINCIPLES


    1. INFECTION PREVENTION: Infection prevention (IP) has two primary objectives: To prevent major infections when providing services; To minimize the risk of transmitting serious diseases such as hepatitis B and HIV/AIDS to the woman and to service providers and staff, including cleaning and housekeeping personnel. The recommended IP practices are based on the following principles:
    • Every person (patient or staff) must be considered potentially infectious.
    • Handwashing is the most practical procedure for preventing cross-contamination.
    • Wear gloves before touching anything wet - broken skin, mucous membranes, blood or other body fluids (secretions or excretions).
    • Use barriers (protective goggles, face masks or aprons) if splashes and spills of any body fluids (secretions or excretions) are anticipated.
    • Use safe work practices, such as not recapping or bending needles, proper instrument processing and proper disposal of medical waste.

    2. HANDWASHING: Vigorously rub together all surfaces of the hands lathered with plain or antimicrobial soap. Wash for 15 to 30 seconds and rinse with a stream of running or poured water. Wash hands before and after examining the woman (or having any direct contact); after exposure to blood or any body fluids (secretions or excretions), even if gloves were worn; after removing gloves because the gloves may have holes in them. To encourage handwashing, soap and a continuous supply of clean water should be provided, either from the tap or a bucket, and single-use towels. Do not use shared towels to dry hands.

    3. GLOVES AND GOWNS: Wear gloves when performing a procedure; when handling soiled instruments, gloves and other items; when disposing of contaminated waste items (cotton, gauze or dressings). A separate pair of gloves must be used for each woman to avoid cross-contamination. Disposable gloves are preferred, but where resources are limited, surgical gloves can be reused if they are decontaminated by soaking in 0.5% chlorine solution for 10 minutes, washed and rinsed or sterilized by autoclaving (eliminates all microorganisms) or high-level disinfected by steaming or boiling (eliminates all microorganisms except some bacterial endospores). Note: If single-use disposable surgical gloves are reused, they should not be processed more than three times because invisible tears may occur. Do not use gloves that are cracked, peeling or have detectable holes or tears.

    A clean, but not necessarily sterile, gown should be worn during all delivery procedures:
    • If the gown has long sleeves, the gloves should be put over the gown sleeve to avoid contamination of the gloves.
    • Ensure that gloved hands (high-level disinfected or sterile) are held above the level of the waist and do not come into contact with the gown.

    Glove and gown requirements for common obstetric procedures:

    center>Procedure
    Preferred Gloves
    Alternative Gloves
    Gown

    Blood drawing, starting IV infusion

    Exam

    High-level disinfected surgical

    None

    Pelvic examination

    Exam

    High-level disinfected surgical

    None

    Manual vacuum aspiration, dilatation and curettage, colpotomy, repair of cervical or perineal tears

    High-level disinfected surgical

    Sterile surgical

    None

    Laparotomy, cesarean section, hysterectomy, repair of ruptured uterus, salpingectomy, uterine artery ligation, delivery, bimanual compression of uterus, manual removal of placenta, correcting uterine inversion, instrumental delivery

    Sterile surgical

    High-level disinfected surgical

    Clean, high-level disinfected or sterile

    Handling and cleaning instruments

    Utility

    Exam or surgical

    None

    Handling contaminated waste

    Utility

    Exam or surgical

    None

    Cleaning blood or body fluid spills

    Utility

    Exam or surgical

    None

  • Gloves and gowns are not required to be worn to check blood pressure or temperature, or to give injections.

  • Alternative gloves are generally more expensive and require more preparation than preferred gloves.

  • Exam gloves are single-use disposable latex gloves. If gloves are reusable, they should be decontaminated, cleaned and either sterilized or high-level disinfected before use.

  • Surgical gloves are latex gloves that are sized to fit the hand.

  • Utility gloves are thick household gloves.


  • 4. HANDLING SHARP INSTRUMENTS AND NEEDLES:

    Operating theaters and labor wards
    • Do not leave sharp instruments or needles ("sharps") in places other than "safe zones".
    • Tell other workers before passing sharps.
    Hypodermic needles and syringes
    • Use each needle and syringe only once.
    • Do not disassemble needle and syringe after use.
    • Do not recap, bend or break needles prior to disposal.
    • Dispose of needles and syringes in a puncture-proof container.
    • Make hypodermic needles unusable by burning them.
    Note: Where disposable needles are not available and recapping is practiced, use the "one-handed" recap method:
    • Place the cap on a hard, flat surface
    • Hold the syringe with one hand and use the needle to "scoop up" the cap
    • When the cap covers the needle completely, hold the base of the needle and use the other hand to secure the cap.

    5. WASTE DISPOSAL: The purpose of waste disposal is to prevent the spread of infection to hospital personnel who handle the waste; prevent the spread of infection to the local community; protect those who handle waste from accidental injury. Non-contaminated waste (e.g. paper from offices, boxes) poses no infectious risk and can be disposed of according to local guidelines. Proper handling of contaminated waste (blood- or body fluid-contaminated items) is required to minimize the spread of infection to hospital personnel and the community. Proper handling means:
    • Wearing utility gloves.
    • Transporting solid contaminated waste to the disposal site in covered containers.
    • Disposing of all sharp items in puncture-resistant containers.
    • Carefully pouring liquid waste down a drain or flushable toilet.
    • Burning or burying contaminated solid waste.
    • Washing hands, gloves and containers after disposal of infectious waste.

    6. STARTING AN IV INFUSION: Start an IV infusion (two if the woman is in shock) using a large-bore (16-gauge or largest available) cannula or needle. Infuse IV fluids (normal saline or Ringer's lactate) at a rate appropriate for the woman's condition. Note: If the woman is in shock, avoid using plasma substitutes (e.g. dextran). There is no evidence that plasma substitutes are superior to normal saline in the resuscitation of a shocked woman and dextran can be harmful in large doses. If a peripheral vein cannot be cannulated, perform a venous cut-down.





    SYMPHYSIOTOMY PROCEDURE

    PRINCIPLES FOR PROCEDURES

    Before any simple (non-operative) procedure, it is necessary to:
    • Gather and prepare all supplies. Missing supplies can disrupt a procedure.
    • Explain the procedure and the need for it to the woman and obtain consent.
    • Provide adequate pain medication according to the extent of the procedure planned. Estimate the length of time for the procedure and provide pain medication accordingly.
    • Place the patient in a position appropriate for the procedure being performed. The most common position used for obstetric procedures is the lithotomy position.

    lithotomy position
    • Wash hands with soap and water and put on gloves appropriate for the procedure.
    • If the vagina and cervix need to be prepared with an antiseptic for the procedure (e.g. manual vacuum aspiration).
      • Wash the woman's lower abdomen and perineal area with soap and water, if necessary.
      • Gently insert a high-level disinfected or sterile speculum or retractor(s) into the vagina.
      • Apply antiseptic solution (e.g. iodophors, chlorhexidine) three times to the vagina and cervix using a high-level disinfected or sterile ring forceps and a cotton or gauze swab.
    • If the skin needs to be prepared with an antiseptic for the procedure (e.g. symphysiotomy).
      • Wash the area with soap and water, if necessary.
      • Apply antiseptic solution (e.g. iodophors, chlorhexidine) three times to the area using a high-level disinfected or sterile ring forceps and a cotton or gauze swab. If the swab is held with a gloved hand, care must be taken not to contaminate the glove by touching unprepared skin.
      • Begin at the center of the area and work outward in a circular motion away from the area.
      • At the edge of the sterile field discard the swab.
    • Never go back to the middle of the prepared area with the same swab. Keep your arms and elbows high and surgical dress away from the surgical field.

  • Provide emotional support and encouragement.

  • Use local infiltration with lignocaine.

  • Ask two assistants to support the woman's legs with her thighs and knees flexed. The thighs should be abducted no more than 45° from the midline.



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


    position for symphyiostomy


    POSITION OF THE WOMAN FOR SYMPHYSIOTOMY

  • Perform a mediolateral episiotomy. If an episiotomy is already present, enlarge it to minimize stretching of the vaginal wall and urethra.

  • Infiltrate the anterior, superior and inferior aspects of the symphysis with lignocaine 0.5% solution.

  • 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.


  • Anesthetize 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.

  • Pushing urethra to one side after inserting the catheter.
    pushing urethra aside


  • 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.

  • DIVIDING THE CARTILAGE

    dividing 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.





  • POST-PROCEDURE CARE

  • 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 percent of cases), treat with physical therapy.






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