**9. Symphysiotomy**

Cutting a parturient's symphysis pubis allows the two halves of her pelvis to separate up to 2.5 cm permitting an otherwise difficult labour to progress and allowing an assisted or spontaneous birth. The procedure is performed by cutting through the fibro-cartilage of the symphysis pubis and the supportive ligaments with a scalpel while ensuring asepsis. At its introduction, symphysiotomy was reputed to play a key role in providing an alternative mode of delivery for mild to moderate cephalo-pelvic disproportion thereby reducing caesarean delivery rates. Cynics however doubt this and worry about the risks to the pelvic bones and the nearby lower urinary tract structures. As a result, this procedure has fallen out of favour and rarely employed in obstetric practice even in least resource parts of the world. In the Zaria study, no single symphysiotomy was performed in 5 years despite the existence of indications for the procedure (Adaji et al., 2009). Moreover the skill to perform the procedure has dwindled among obstetricians over time. However, some still argue for a role for this procedure because it meets women's socio-cultural expectation of a vaginal delivery in areas with dislike and apathy for caesarean sections (Maharaj and Moodley, 2002)

Fig. 7. Performing a symphysiotomy with an instrument placed to protect the urethra

#### **9.1 Fetal destructive operations**

266 From Preconception to Postpartum

In the Zaria study, maternal/ fetal complication was found in 22.3% of cases of instrumental delivery. Table 6 above provides details of these complications. The most severe of the complications were the fetal deaths recorded for vacuum deliveries. However the deaths may have been due to the severity of the fetal distress that indicated the procedure rather

Newborn intracranial injuries and shoulder dystocia were other complications associated with operative vaginal deliveries from large reviews. Intracranial injuries documented include epidural, subdural and subarachnoid haemorrhages. The fetus could also develop

Cutting a parturient's symphysis pubis allows the two halves of her pelvis to separate up to 2.5 cm permitting an otherwise difficult labour to progress and allowing an assisted or spontaneous birth. The procedure is performed by cutting through the fibro-cartilage of the symphysis pubis and the supportive ligaments with a scalpel while ensuring asepsis. At its introduction, symphysiotomy was reputed to play a key role in providing an alternative mode of delivery for mild to moderate cephalo-pelvic disproportion thereby reducing caesarean delivery rates. Cynics however doubt this and worry about the risks to the pelvic bones and the nearby lower urinary tract structures. As a result, this procedure has fallen out of favour and rarely employed in obstetric practice even in least resource parts of the world. In the Zaria study, no single symphysiotomy was performed in 5 years despite the existence of indications for the procedure (Adaji et al., 2009). Moreover the skill to perform the procedure has dwindled among obstetricians over time. However, some still argue for a role for this procedure because it meets women's socio-cultural expectation of a vaginal delivery in areas

with dislike and apathy for caesarean sections (Maharaj and Moodley, 2002)

Fig. 7. Performing a symphysiotomy with an instrument placed to protect the urethra

sub-galeal (subaponeurotic) haemorrhage (Doumouchtsis).

than the procedure itself.

**9. Symphysiotomy** 

These refer to procedures to deliver a dead fetus in the presence of obstructed labour. The value of a caesarean section in this circumstance is low and the maternal situation may even make any resort to an abdominal operation rather dangerous. Craniotomy could be performed to reduce the diameter of the fetal head to allow vaginal delivery, and transverse lie could be relived by decapitation. Cleidotomy could be performed sometimes to reduce bisacromial diameter when the shoulders of a dead fetus are impacted while evisceration or embryotomy could be performed if the dead fetus is large and or the abdomen is swollen due to an intra-abdominal tumor. Destructive operations are no longer performed in developed countries where the indications for it no longer exists. Even in developing countries most obstetricians shy away from performing the procedure. In Zaria, only 0.1% of deliveries were by destructive procedures (Adaji et al., 2009).

#### **10. Conclusion**

Operative vaginal procedures, mainly vacuum extraction and obstetric forceps delivery have a long history but both still have a place in contemporary obstetric practice. In competent hands and with strict adherence to guidelines, the outcomes for the mother and child are excellent. There is great gain in ensuring that these arts are not lost to the modern day obstetrician. On the other hand, procedures like symphysiotomy and destructive operations may still have value in obstetric practice in low income settings. However the evidence for their value need to be laid out clearly and the guidelines for their use comprehensively updated.

#### **11. References**


**17** 

*Portugal* 

**Umbilical Cord Blood Changes in Neonates** 

*2Instituto de Biologia Molecular e Celular (IBMC), Universidade do Porto; 3Instituto Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto* 

During pregnancy, mother's well-being affects directly the newborn development. Some maternal and placental complications, such as gestational diabetes, preeclampsia (PE), preterm delivery and intrauterine growth restriction (IUGR), may contribute to fetal growth deviations or fetal development modifications. Usually the newborn weight correlates positively with placenta weight, showing the interaction between the development of

Normal human pregnancy is associated with physiological blood changes, namely, neutrophilic leukocytosis, hyperlipidemia and procoagulant, hypofibrinolytic and inflammatory conditions. PE has been associated with an enhancement in these changes and with placental abnormalities, that may condition its perfusion and, therefore, feto-maternal transfer. The placental dysfunction, characterized by a disturbance in the angiogenic/antiangiogenic factors and in the hypoxia/placental reoxygenation process, seems to trigger a maternal endothelial dysfunction. To this maternal endothelial dysfunction may also contribute the oxidative stress, dyslipidemia and the inflammatory process which are

PE is a maternal pathology involving placental modifications, which is also associated with fetal complications. Prematurity and IUGR, are the most representative complications. In this chapter we will address the impact of the maternal disturbances in the newborns from a normal and a preeclamptic (PEc) gestation. Indeed, there are several studies in literature about changes in maternal circulation, but few studies about fetal blood changes in the presence of PE. Moreover, these studies have shown controversial results. We intend to focus on neonatal consequences of PE, by assessing different biochemical and hematologic parameters in the umbilical cord blood. In this way, we will address the effect of some modifications usually observed in PEc women, such as, in lipid profile, in hematologic profile, inflammatory and antioxidant markers, angiogenic/anti-angiogenic factors and

**1. Introduction** 

placenta and fetal growth.

present in maternal circulation.

hemostatic disturbances, in umbilical cord blood.

**from a Preeclamptic Pregnancy** 

Cristina Catarino1,2, Irene Rebelo1,2, Luís Belo1,2, Alexandre Quintanilha2,3 and Alice Santos-Silva1,2 *1Departamento de Ciências Biológicas, Laboratório de Bioquímica,* 

*Faculdade de Farmácia, Universidade do Porto (FFUP);* 

