Introduction

Obstructed labor is increasing the morbidity and mortality of mother and newborn, leading to death. About fifty thousand women every year died in developing countries because of obstructed labour (World Health Organization, 1997). Many interventions have been tried to reduce maternal mortality and morbidity. The World Health Organization (WHO) emphasize that women should have access to the health care facilities where caesarean section and blood transfusion are available. (Anderson, 2017; Björklund, 2002) The incidence of caesarean section rate is about (5%-15%) (World Health Organization, 1985). In developing countries, the ideal caesarean section rate necessary to avoid morbidity and mortality of mother and newborn is unknown (Weil & Fernandez, 1999).

Since 1985, the caesarean sections have become increasingly common in both developed and developing countries (Nkwo & Onah, 2009). When medically indicated, a caesarean section can effectively reduce mortality and morbidity of mother and newborn.

Description of Apparatus

The apparatus consists of 3 parts: Size 14G cannula which is 14cm in length, made of stainless steel and has a sharp bevel and thickened posterior part to enable the user to have a good grip on it during usage (Figure 1).

A stylet 14cm long made of stainless steel to fit in the inside of the cannula to prevent coring of the tissues during the introduction of the cannula. It has a vertical end to stop the advancement inside the cannula (Figure 2).

A cutter which is 14cm long and made of stainless steel and fits inside the cannula when the stylet is removed. Its front part is sharp on one side to cut through the ligament and cartilage of the symphysis pubis from its posterior aspect (Figure 3).

Its back has a half-circle end to prevent the cutter from advancing beyond the bevel of the cannula inside the tissues (Figure 4).

The use of the invention avoids bleeding, injury to urethra and bladder, and avoids the formation of skin scar. Its back has a half-circle end to prevent the cutter from advancing beyond the bevel of the cannula inside the tissues. The use of the invention avoids bleeding, injury to urethra and bladder, and avoids the formation of skin scar. The symphysiotomy scalpel obtained patent status from the King Abdulaziz City for Science & Technology (5910 dated 20 May 2018).

Discussion

Symphysiotomy defined as a procedure in which the pubic joint is divided to increase the pelvis size. This surgical procedure will dramatically increase the pelvic outlet and the size of the pelvic by 2.5cm to allow normal vaginal delivery of a baby (Ersdal, 2008; Gebbie, 1966; Holmer, 2019; Wilson, 2016). Symphysiotomy can be done as an alternative procedure to reduce the mortality and morbidity of mother and newborn with obstructed labor, but it doesn’t require innovative surgical skills like caesarian section and it can be performed under local anesthesia by a well-trained midwife, clinical officer, and surgeon (Basak, 2011; Fasubaa, 2002). Post-operative care usually consists of applying elastic strapping to stabilize the pelvis and reduce the pain.

Bed rest is recommended for up to three days. During this period, anti-embolic measures should be implemented. Bladder catheterization is also advised for three days (Basak, 2011; Hartfield, 1973).

Indications of symphysiotomy are obstructed labor, small pelvis, prolonged second-stage labor, failure of vacuum extraction (Verkuyl, 2017). It is important to examine the cervix and make sure it is fully dilated before symphysiotomy. The procedure of symphysiotomy is as follows: Two nurses are required to flexed and abduct the thighs from the midline no more than 45°.

After that local anaesthesia using lignocaine 0.5% solution and it is important to aspirate to make sure no vessel has been entered. Don’t inject if blood is aspirated because this may lead to seizures and death. Insert Foley catheter to the urethra. Prepare and dropped the suprapubic area by the antiseptic solution. Used sterile gloves, do episiotomy to minimize stretching the urethra and vaginal wall, place a left index finger in the vagina and try to push the catheter and urethra away from the midline. In the past, the symphysiotomy done by using 15 scalpels to make stab incision over the symphysis. Cut down through the pubic joint to the bottom of the symphysis, then rotate the knife and cut upwards to the top of the symphysis. After the symphysis has been divided, this will lead to an increase in the size of pelvis up to 2.5cm. There is no need to close the skin incision unless there is bleeding (Figure 5).

On the other hand, our innovative scalpel as described previously can be done using a posterior approach without cutting the skin by introduce the cannula through the skin and the subcutaneous tissue keeping proximity all the time to the inferior edge of the pubis and its posterior aspect in the midline until the end of the pubis (which equals half the length of the cannula). Remove the stylet from the cannula and replace it with the cutter making sure the sharp end points towards the posterior aspect of the pubis, with a good grip on the thickened distal half of the cannula start cutting the pubis ligament and cartilage moving forwards. The surgeon will put the other hand on the pubis, guiding and supporting the force of cutting. Continue until the pubis is separated.

Post-Procedure Care

Administer appropriate analgesia, apply elastic strapping to stabilize the pelvis and reduce pain. Leave the urinary catheter for a minimum of 3 days. Encourage oral intake, especially fluid. Insure good urine output. Advice bed rest for three days after hospital discharge. Instruct the women to start walking with assistant after one week. Encourage the woman to drink plenty of fluids to ensure a good urine output. Encourage bed rest for seven days after discharge from the hospital. Encourage the woman to begin to walk with assistance when she is ready to do so. The advantages of cutting the symphysis ligament and cartilage from the posterior aspect are: To avoid skin incision. No possibility of bleeding.

To avoid injury to urethra or bladder. No scar left on healing. In summary, once the decision of symphysiotomy has been reached, the operator should explain the procedure to the woman and obtain her consent. The woman's legs are supported by two nurses. Both knees and thighs are flexed and abducted from the midline no more than 45°. The operator wears a pair of sterile hand gloves. Apply the antiseptic solution to the pubic area and external genitalia. Feel the symphysis pubis to identify its inferior edge. Infiltrate the skin and subcutaneous tissue with plain lignocaine 0.5%. Catheterize the bladder with urinary catheter to empty the bladder and fix the catheter as usual.

Introduce the cannula through the skin and the subcutaneous tissue keeping proximity all the time to the inferior edge of the pubis and its posterior aspect in the midline until the end of the pubis (which equals half the length of the cannula). Remove the stylet from the cannula and replace it with the cutter making sure the sharp end points towards the posterior aspect of the pubis, with a good grip on the thickened distal half of the cannula start cutting the pubis ligament and cartilage moving forwards. The surgeon will put the other hand on the pubic guiding and supporting the force of cutting. Continue until the pubis is separated. This will increase the pelvic size by 2.5cm to allow normal vaginal delivery and prevent possible complication like bleeding and skin scar formation.

Conclusion

This new innovative symphysiotomy scalpel provides a more efficient solution to the caesarean section and will help to avoid skin incision eliminates scar left on healing. Once this scalpel is ready to be used, it will help to save the life of newborns and mothers and improve the quality of the health care system.