Dysfunctional labour and Cephalopelvic Disproportion (CPD)

GUIDE : PROF A KRIPLANI

SR GUIDE: DR PUSHPARAJ M CANDIDATE: DR DEBJYOTI KARMAKAR DEPT OF OBSTETRICS AND GYNAECOLOGY,

AIIMS

Why is human labour difficult.?

Evolution of upright posture

Larger heads

As homo sapiens came to succeed through evolution, smaller pelvis and larger heads put woman at a disadvantage during labour
(Ruff CB Am J Phys Anthropol 1995:98;527-574)

Mechanics of normal labor

The ability of the fetus to negotiate the pelvis successfully depends on the complex interaction of three variables:

The powers,
The passenger, The passage.

The powers- contractions

Painful. Increase in frequency Increase in strength. Cervix pulled up Head passes down like

toe through hole in sock

Passages- the pelvis

Passenger - the baby

Variables which may influence the course of normal labor and delivery. Fetal size. Lie. Presentation. Attitude. Position Station. Number of fetuses. Presence of fetal anomalies.

STAGES OF LABOUR CERVICAL : Dilation Curve for Nulliparous Labor. (Data from Friedman EA. Labor: clinical evaluation and management. 2nd edition. Norwalk (CT): AppletonCentury-Crofts; 1978.)

Progression of spontaneous labor at term

Cervix in Labour
Nulliparous Multiparous

Effacement and dilatation

ABNORMAL LABOR PROGRESSION

TERMINOLOGY

Dystocia

Dysfunctional labor
Failure to progress Cephalpelvic disproportion.
DYSTOCIA

Literally: abnormal or difficult,labor or delivery, in ancient Greek

. FAILURE TO PROGRESS

General and modern term Refers to both the absence of progressive cervical dilatation or progressive fetal descent. Dystocia often involves combinations of these factors.

Classification
Friedman (1989) : 1.Prolonged latent phase

2. Protraction disorders :
1.Protracted active phase 2. Protracted descent

3.Arrest disorders:

1.Secondary arrest of cervical dilatation 2. Prolonged deceleration phase 3. Arrest of descent 4. Failure of descent

ACOG classification (1995)

Abnormalities of the expulsive forces (power)

Abnormalities of presentation, position, or

development of the fetus (passenger)

Abnormalities of the maternal bony

pelvis(passages)

ACOG (1995):
1. Protraction disorders:

Slower than normal

2. Arrest disorders

Complete cessation of progress

FIELDS CLASSIFICATION
Hypotonic dysfunction

a.Prolonged latent phase b.Prolonged active phase c. Prolonged deceleration phase d. Prolonged 2nd stage
Hypertonic dysfunction

Shifirin & Cohen(1998)

1.Disorders of dilatation:

a. Prolonged latent phase b. Protracted active phase c. Secondary arrest

2.Disorders of descent:

a. Failure of descent b. Protracted descent c. Arrest of descent.

Philpott (1979)
Prolonged latent phase
Primary dysfunctional labor Secondary arrest of labor.

THE MORBIDITY OF DYSFUNCTIONAL LABOUR

MATERNAL EFFECTS Caesarean section rates
Pelvic floor injury Pathological retraction ring Uterine rupture Obstetric fistula Intrapartum infection

Caesarean section rates

Failure to progress
section audit England and Wales 2003

20.4%
National sentinel caesarean

Dystocia

51.4% (1998 ) (7% in 1980)

National Center for Health

Statistics

AIIMS

FETAL EFFECTS OF DYSTOCIA

Prolonged membrane rupture & intrauterine

infection
Caput succedaneum The caput may reach almost to the pelvic floor

while the head is not engaged.

Fetal head molding Tentorial tears, laceration of fetal blood vessels and fetal intracranial hemorrhage

Advantages of shorter labour

To mother Reduced emotional disturbance Dehydration.,ketosis,salt depletion avoided Reduced need for analgesics To child

Decreased exposure to trauma

To staff

Improved morale
To administrators Greater efficiency of the delivery unit

CAUSES OF DYSFUNCTIONAL LABOUR

Abnormal expulsive force (POWERS)

Uterine dysfunction
hypotonic uterine dysfunction

hypertonic uterine dysfunction

Generalized abnormalities of uterine action

Hypotonic uterine dysfunction

There is no basal hypertonus Uterine contractions have a normal gradient pattern(synchronous)

Coordinate hypotonic uterine dysfunction Incoordinate hypotonic uterine dysfunction

ETIOLOGY

Cephalopelvic disproportion or fetal malposition Abnormal uterus Psychological factors Endocrinal dysfunction Excessive sedation or conduction analgesia

Hypertonic uterine contraction

Basal tone is elevated appreciably

The pressure gradient is distorted

Localized abnormalities of uterine action

Constriction ring

Pathological retraction ring

Generalized abnormalities of uterine action

PRECIPITATE LABOR:

Extremely rapid-labor Total duration less than 3 hours

ETIOLOGY

Abnormally low resistance Abnormally strong uterine and abdominal contractions Very rarely, the consequence of painful sensations and thus a

lack of awareness of vigorous labor.

Maternal effects

Uterine rupture Extensive lacerations of the cervix, vagina, vulva, or perineum Amniotic fluid embolism Atonic Postpartum hemorrhage
Effects on fetus and neonate

Increased perinatal mortality and morbidity,trauma Intracranial traumaErb-Duchenne palsy

Reported causes of uterine dysfunction

Epidural analgesia Chorioamnionitis

Maternal position during labor Walking during labor have been reported to
Contraction frequency & intensity increase with sitting or standing (Miller
1983)

There is no conclusive evidence that upright maternal posture or ambulation improves labor (Lupe and Gross 1986)

 Birthing position in second-stage labor 20 to 30 percent increase in the area of the pelvic outlet with squatting compared with the supine position

Russell(1969) No advantages with use of the birthing chair

Crowley(1991) The benefits of the upright position : Less maternal pain Enhanced maternal satisfaction

Immersion in water
Advocated as a means of relaxation

Odent,

1983 The mean duration of the first stage of labour was similar in the two groups,

Abnormal Passenger
Face presentation

Brow presentation
Compound presentation Transverse lie Persistent occipito transverse Persistent occipito posterior Shoulder dystocia Fetal malformations

Abnormal Passages
BONY PASSAGE

CPD
DYSTOCIA DUE TO SOFT PARTS

Condition Stenosis of vulva vagina incision Cervix

Management Episiotomy Deep vaginoperineal Manual effort Duhrssens incision LSCS

DIAGNOSIS OF DYSFUNCTIONAL LABOUR

FRIEDMAN CURVE
The concept of partogram was first devised by Friedman and

published in 1954.The time of onset of labor based on patients

subjective perception of her contractility

Graphic explanation for the deceleration phase in Friedman curves

Corroboration of the Friedman data

Presence of latent and active phases of labour

Benefits of using labor curves to diagnose

abnormalities of first and second stage of labour Ledger and Schulman,1960

Data from the National Collaborative Perinatal Project

(1950s-1970s;including 10000 women)

STUDD
Studd in 1972 described labour stencils and reliance

on patients subjective perception of contractility was removed.

A stencil used to draw a line of expected progress of

labour

Patients crossing the line had three times higher

instrumental delivery rates.

Studd, BMJ;1972;4;426

PHILPOTT and CASTLE

Introduced the concept of alert and action lines

Initially used for African primigravidae being cared by the

paramedic staff
The alert line represented the slowest 10% of patients

admitted in active phase(slope:1cm/h) : the point where intervention should occur : arrangements for transfer
Philpott and Castle drew the action line 4hr to the right

of alert line ( shifting time ) J O G Br

Commonw 1972;79

PARTOGRAM ACTION LINE STUDY

Nearly 1000 women participants Action line 2/3/4 hr to right of alert line No clear evidence of any difference in outcome between

an early or delayed diagnosis of dysfunctional labour

The 2 hr partogram had obvious psychological benefits

BJOG : 1998 ; 105 ; 976-980

World Health Organization Partograph

A partogram was designed for use in developing

countries(1992).Labour is divided

into a latent phase ,which should last no longer than 8hours, and an active phase starting at 3cm dilatation, the rate of which should be no slower than 1cm per hour. A

4- hour wait recommended before intervention when the active phase is slow. Labor is
graphed and analysis includes use of alert and action lines.

THE PROTOCOL WAS FOUND TO BE BENEFICIAL IN SOUTHEAST ASIA.

2003: Latent phase excluded

Started at 4cm dilatation

REASONS FOR THE DYSTOCIA EPIDEMIC IN NULLIPARA

Labor inefficiency
Labor is on average longer in the nulliparous woman

Influence of the active management protocol on the concept of uterine efficiency Is the nulliparous uterus by nature inefficient?

Other potential causes of dystocia in nulliparas

Maternal age Genetics Maternal anthropomorphic

characteristics
Fetal factors Psychophysiologic factors

Labor environment and care practices

Maternal age
In 7 studies spanning the past decade the following findings were consistent:

Older maternal age at first birth, particularly MA >

35 is
associated with: Increased risk of caesarean section with increased risk of dystocia Increased use of oxytocin No differences in neonatal outcomes compared to younger women. Nulliparas > 35 yrs experience cesarean at twice the rate
Main, Main & Moore
(2000). Am J. OB &GYN.

Genetics

Potential genetic mechanism of inefficient uterine action

Sweden: Berg-Lekas, Hogberg & Winkvist, 1998 Nulliparous daughter of mother who experienced dystocia was at a 1.7X greater risk (1.2-2.4 CI); dystocia with operative delivery risk 1.8 (1.0 3.1) Utah: Varner, Fraser, Hunter, Corneli, & Ward, 1996 Daughters of mothers with c/sec were 1.4 X great risk of c/sec (1.18 1.70)

Anthropomorphic Characteristics
Short-stature, particularly < 150 cm.

Maternal overweight (BMI > 26) and obesity

(BMI > 29)

prior to pregnancy

Pregnancy weight gain in excess of 35 40

pounds

Fetal factors
Fetal weight and C/sec rate < 20% with birth weight < 4000 g > 30% at 4000 4499 g 60% at > 4500 g

Persistent occipitoposterior position

Occurrence of 2.4 7.2% in nulliparas 2 to 3-fold increase in operative delivery 3 to 4-fold increase in cesarean section Unengaged head at labor onset

Maternal Psychophysiology & Dystocia: The Stress Response

Fears of childbirth in pregnancy negatively correlated

with uterine function in Montevideo units;

Catecholamines rise significantly and independently

during labor

Human myometrium richly supplied with beta-

adrenergic receptors

Psychological attributes

Environment & Care Practices

Location of birth

SUPPORTIVE CARE Information Comfort Measures Coping strategies Advocacy Techniques to support physiologic labor

Provider characteristics

Care practices

Admission to hospital Induction of labor Epidural analgesia Maternal hydration

Continuous supportive care

Social Factors & Dystocia

Is there a developing social intolerance for labor?

Are the boundaries of dystocia becoming blurred so that clinical

decision-making is affected?

Is the social acceptability of cesarean section making the concept

of dystocia an archaic discussion?

Will national goals to reduce cesarean section rates persist

Individual Dystocia Risk.???

Abnormalities of the first stage

8% to 11% of women in labor INDEPENDENT RISK FACTORS FOR CS FOR FAILURE TO PROGRESS

Induction Maternal age greater than 35 Fetal weight greater than 4 kg Hypertensive disorders Hydramnios

Fertility treatment
Nulliparous Premature rupture of membranes

Scand 2002;81:222 6.

Sheiner E, Acta Obstet Gynecol

Latent phase disorders

 The ACOG bulletin on dystocia (2003)avoids discussing the latent

phase entirely

An arrest of the latent phase implies the woman is not yet in labor.

: False Labor Prelabor. Patients with prolonged latent phase of labor might be at increased risk for

OTHER LABOR ABNORMALITIES CS LOW APGAR SCORES NEED FOR NEONATAL RESUSCITATION FEBRILE MORBIDITY BLOOD LOSS.
Gynecol 1993;81 Chelmow D Obstet

Unengaged head at presentation

Several studies have evaluated nulliparous women who present in labor with unengaged (above 0 station) or floating fetal heads (at or above -3 station)

Somewhat longer second stages but no greater risk for oxytocin use, instrumental delivery, or shoulder dystocia

Most women (over 80%) achieved a vaginal delivery Roshanfekr DObstet Gynecol 1999;93:329 31 Falzon S, J Reprod Med 1998;43:67680.

Policy of delayed admission

Significantly less oxytocin use (40% versus 23%); Epidural use (90% versus 79%); Shorter durations of labor in the hospital (13.5 versus 8.3 hours) Second stage (95 versus 77 minutes). No significant differences in CS or neonatal outcomes. 1998, McNiven et al

Relationship between cervical dilatation at initial evaluation and

the risk of CS Odds of a CS were 2.6 times higher (95% CI 1.494.61) in patients presenting less than 3 cm compared with those greater than or equal to 4 cm; In multiparas the odds were 4.7 times higher (95% CI 2.648.49). 2001, Holmes et al

Management of prolonged latent phase

Friedman suggested two options for management for prolonged latent phas The first is therapeutic sedation with 10 to 20 mg of morphine sulfate, with a

repeat dose if the patient is still awake and uncomfortable.

The second option is oxytocin augmentation.

After sedation, 85% of women awoke in active labor; 10% stopped contracting (prel and 5% resumed their previous pattern and required oxytocin .

Active management

Amniotomy

SIGNIFICANT REDUCTIONS IN THE DURATION OF THE FIRST STAGE OF LABOR (BY 60120 MINUTES);

LESS RISK OF SLOW LABOR IN THE ACTIVE PHASE LESS NEED FOR OXYTOCIN AUGMENTATION. THERE WAS ALSO A TREND TOWARD INCREASED CS FOR FETAL HEART

RATE ABNORMALITIES INCREASED NUMBER OF FETAL HEART RATE ABNORMALITIES PER HOUR IN THE EARLY AMNIOTOMY GROUP.

The authors conclude that, based on current evidence, amniotomy should be reserved for labors that are progressing slowly. Amniotomy is usually best delayed until cervix is >2 cm dilated and station is 2, especially if the vertex is not well applied to the cervix. (Level BI)

Evidence based Management of prolonged latent phase

Avoid early admission Counsel the patient (Level A-I) Diagnosis of a prolonged latent phase is can be based on Friedmans criteria

Evaluate patients individually to assess their level of fatigue and need for support. (Level C-III) If the mother is doing well and there is a reassuring fetal status, keep

Paradigm for management of prolonged latent phase

ACTIVE PHASE DISORDERS

Disorders of the active phase are common and can be seen in up to 25% of nulliparous labors and in 15% of labors in multiparas

Primary dysfunctional labor

dystocia 2003)

(ACOG bulletin on

Secondary arrest

Combined disorder

The most common cause of a protracted active phase in nulliparas is inadequate uterine activity, whereas in multiparas it is CPD caused by malposition

Before the diagnosis of arrest during first stage labor is made, both of these criteria should be met :
The latent phase has been completed, with the cervix

dilated 4cm or more.

A uterine contraction pattern of 200 Montevideo units or

more in a 10-minute period has been present for 2 hours without cervical change

2-hour rule on the grounds that a longer time, i.e., at least 4 hours, is necessary before concluding that the active phase of labor has failed.

Other means to assess adequacy of active phase

Malposition assessment

OCCIPUT POSTERIOR
7.2% in nulliparas, 4% in multiparas.

Only 57% of multiparas with a persistent occiput posterior had a

spontaneous vaginal delivery
Ponkey et al,1999
Extent of cervical shortening seen on ultrasound during

contractions i

Significantly greater in the normal latent and active phases of labour than in the prolonged latent phase, protracted active phase, and prelabor Ultrasound ObstetGynecol2003

Diagnostic criteria
Labour pattern PROLONGED LATENT PHASE PROTRACTION DISORDERS Protracted active phase dilatation Protracted descent ARREST DISORDERS Prolonged deceleration phase Secondary arrest of dilatation Arrest of descent Failure of descent >2 h >1 h in deceleration phase/2nd stage >2h >1 h >3 h >1h <1.2 cm/h <1.0 cm/h <1.5cm/h <2.0 cm/h Nullip ara >20 h Multipara >14 h

EVIDENCE BASED MANAGEMENT OF ACTIVE PHASE DISORDERS

Cervix must be at least 4 cm dilated (Level A II-3) Oxytocin to achieve three to five contractions every10 minutes, or contractions

every 2 to 3 minutes (Level A II-1) (ACOG)

Option of intrauterine pressure catheter (Level B II-2) Amniotomy (Level B III) At least 4 hours of adequate contractionsof which at least 2 hours with adequate

intrauterine pressure catheterproved strength, must elapse before abnormal active phase progression is entertained (Level A I)
Even after 4 hours of abnormal progression, active labor can be continued up to 6

to 8 hours with good chances of vaginal delivery as long as fetal monitoring is reassuring and there is

Use of oxytocin
Oxytocin regime

NICE has recommended the low-dose oxytocin regime for induction of labour. Amniotomy should be performed prior to the commencement of an infusion of oxytocin.

The minimum dose possible of oxytocin should be used and this

should be titrated against uterine contractions, aiming for a maximum of 34 contractions every 10 min.
Adequate contractions may be established at 12 mU/min. If a high

dose is used the maximum mU/min.

dose used should not exceed 32

Suggested protocols:
30 IU in 500 ml of normal saline; hence 1 ml/h=1 mU/min. 10 IU in 500 ml of normal saline; hence 3 ml/h=1 mU/min.

One or two studies have looked at highdose versus low-dose oxytocin. High-dose oxytocin benefits both nulliparous and multiparous women requiring labour augmentation by significantly lowering both the time necessary to correct any labour abnormality and the need for Caesarean section. Further studies are needed in this area.

INTERVAL FOR DOSE INCREMENTS Every 30 min.

Dosetitration every 15 min does not appear to have any major advantages

or disadvantages, although the incidence of hyperstimulation may be slightly greater.

TARGET UTERINE ACTIVITY Four contractions every 10 min, each contraction lasting for more than 40 s.

INTRAUTERINE PRESSURE MEASUREMENT In some centres intrauterine pressure is measured to calculate uterine activity in Montevideo units or in k Pas s over every 15 min

No improvement in outcome with the use of intrauterine pressure

DURATION OF OXYTOCIN INFUSION

The duration for which oxytocin should be used for most women

to deliver appears to be 68h.

Two reviews, 34 h apart, after starting oxytocin, should provide

information about the likely success of augmentation.

If there is failure to progress despite optimal contractions in the

first 68 h of oxytocin augmentation in the active phase, continuation of oxytocin for further periods is unlikely to be of benefit.

SIDE EFFECTS OF OXYTOCIN INFUSION Hyperstimulation may lead to iatrogenic fetal distress and operative delivery. Antidiuretic effect and water intoxication

Intrapartum strategies

Shown to decrease risk

12,000 women in 15 trials

Continuous support (Level A I) A Cochrane systematic review of over

Maternal erect position (Level B I)

Judicious use of regional anesthesia (Level B I) Cochrane review of

11 randomized trials

Adequate hydration (Level B I) 2000, Garite et al

Not shown to decrease risk

Ambulation (Level A I)

Parkland Hospital Labor Management Protocol

Pelvic examinations 2 hours Amniotomy when the cervix

does not dilate within about 2 hours of admission An intrauterine pressure catheter
High-dose oxytocin regimen

Admission Cervix 4cm

2 to 3 hours depending on parity

Amniotomy

2 hours

Cesarean rates in nulliparous

and parous women were 8.7 and 1.5 %, respectively

These labor interventions

Internal contraction monitor

3 hours

Oxytocin

and the relatively infrequent use of cesarean delivery did not jeopardize the fetusnewborn infant

2 to 4 hours depending on parity

Delivery

Paradigm for management of protracted active phase

Paradigm for management of arrest of dilation

Second stage of labor (arrest of descent)

ACOG defines a prolonged second stage as follows: In nulliparas2 hours; In multiparas1 hr. (add 1 hr for epidural)

As with dilatation, recent studies have documented slower rates

of descent than

did Friedman

Management of second stage

Conservative suggestions are:
Second stage can be allowed to continue beyond these limits as long as

some progress has been made. (Level B II-3)

Pushing should start as soon as complete dilatation has been detected,

unless the fetus is malpositioned (eg, occiput posterior), or the epidural so dense that the woman has no urge to push. (Level B I) Delayed pushing has been associated with longer second stage, with the consequent increased maternal and fetal neonatal infection risk, and with lower neonatal pH.. (Level B I)

Paradigm for management of the second stage

ACTIVE MANAGEMENT OF LABOUR

First implemented by ODriscoll and colleagues at the National Maternity Hospital in Dublin in 1968 The largest prospective study, demonstrated a significant decrease in
neonatal culture-proved sepsis with a high-dose oxytocin protocol.
Satin et al Obstet Gynecol 1992;80:111 6.

Programmed labour
Programed labor protocol is based on
incorporation of labor analgesia active management of labor

monitoring events of labor by a partogram

Frequency of side effects observed in the two groups was similar

Conclusion Programming of labor is simple, easy and effective method for painless and safe delivery. The analgesia produced is quite effective duration of labor is significantly reduced. Blood loss in third stage is also significantly reduced. Maternal side effects are minor without any fetal or neonatal respiratory depression. Minimal side effects in women receiving tramadol
Meena Jyoti, Obstet Gynecol India Vol. 56, No. 1 2006

Sarkar B, J Obstet Gynecol

India 1997;47:42-8.7.

Regional analgesia and progress of labor

ACOG STATEMENT
Epidural analgesia was associated with increases in the duration of the

first and second stages of labor,incidence of fetal malpositions,use of oxytocin,and operative vaginal delivery Epidural analgesia was not shown to increase the cesarean delivery rate for dystocia. Prolongs labor by 4090 minutes (ACOG Practice BulletinNo. 49) NICE CLINICAL GUIDELINE
Epidural analgesia during labour has no influence on likelihood of CS

April 2004

FURTHER CONCLUSIONS
Epidural did not indeed lengthen the first stage of labor when considering that

patients who receive epidurals tend to be admitted earlier to the ward .

Cammu H,..Acta Obstet Gynecol Scand 1994;73:235 9.

Epidurals placed before 4 cm in patients actively managed led to shorter labors

The AIIMS experience

PROF. CHANDRALEKHA AND DR LENIN ,2005 Dept of anaesthesia
Second stage prolonged more compared active

phase
Slight increase in in instrumental deliveries No change in caesarean section rates

STUDIES ON CSE IN LABOUR

RECENT ADVANCES AND FUTURE DIRECTIONS

ZHANG CURVE AND DATA

Sample: 1329 nulliparous women with

a term, singleton, vertex fetus of normal birth weight after spontaneous onset of labor 1992-1996. Cesarean deliveries were excluded, n=1162. 65% non-Hispanic White
Other features of the sample: 48% Caudal/epidural 50% oxytocin augmentation 13% low forceps/vacuum Primarily resident managed

Medium labor admission to complete = 7.3 hrs (3.3 hrs 10th and 13.7 hrs 90th) Transition from latent to active labor appears more gradual than the Friedman curve No deceleration phase was observed Median complete to birth = 53 minutes (18 min 10th and 138 min 90th

CONCLUSION:

Labor in nulliparous women progresses more slowly than the Friedman curve indicates. This has been previously suggested in other studies in the 1980s and 1990s:

Zhang, J., Troendle, J. F., & Yancey, M. K. (2002). Reassessing the labor curve in nulliparous women. American Journal of Obstetrics & Gynecology, 187, 824-828

Myometrial physiology

pH of myometrium capillary blood as a basis for dysfunctional labour

Quenby s et al Obstet Gynecol

CONNEXIN 43 EXPRESSION IN NORMAL VERSUS DYSFUNCTIONAL LABOR

Cx43 immunohistochemical staining of human myometrial tissue from a term patient (39weeks gestation) not in labor

Dysfunctional labor results neither from aberrant Cx43 mRNA or protein expression nor from a reduction in immunodetectable Cx43 gap junctions. Further study is needed
Pierce et al ,186, Number 3 ,505 Am J Obstet Gynecol

Research directions
Randomised studies are needed to determine

when to augment using alert and action lines, the optimal dose regime for oxytocin infusion, target uterine activity and duration of augmentation for optimal outcome.
The optimal management of the second stage of

labour in terms of its duration and the incidence of immediate and long-term maternal outcomes needs further study

(CPD)

Definition : The disparity in the relation

between the head and the pelvis

Diagnosis : Clinical

Imaging pelvimetry
Cephalometry

When to suspect CPD

Primigravida :

The dark horse

Multipara

: A detailed history of previous labours

Dystocia dystrophica syndrome : A historical curiosity

Signs which should alert to the possibility

of CPD
Abdominal:
High head at term Large fetal size Fetal head overlapping the symphysis

Pelvic examination
Cervix shrinking after amniotomy Edema of the cervix Head poorly applied against the cervix Head not engaged Caput Molding Deflexion Asynclytism

Others
Maternal pushing before complete dilatation Early decelerations Negative Hillis Muller test Reverse Hillis Muller test

Abdominal Assessment of Disproportion

Pressing the head into the brim
The Ian Donald method
The Chassar Moir technique The Vasten Sign
Preparation of the patient The technique Inference

The Ian Donald method

The Chassar Moir technique

Abdominovaginal examination to assess CPD

The Muller-Munro Kerr Technique

Preparation of the patient

The technique

Inference

The Zangemeister Observation The Muller -Hillis maneuver

The Muller Hillis Maneuver

Manual and instrumental methods

External pelvimetry with hands & callipers
Interspinous diameter
Intercristal diameter External conjugate Pubotuberous Diameter (Thoms) The outlet

Subpubic arch
A-P diameter of the outlet

Internal pelvimetry by hands and by

instruments
Manual methods
The diagonal conjugate (William Smellie ,later by Baudelocque) Obliquity of the pelvic brim (Malpas and Hamilton) Transverse diameter of the brim

Sacral concavity
Ischial bispinous diameter Length of the sacrotuberous ligment (Caldwell and Moloy) Normally two fingers can be placed over the ligament

Internal pelvimetry by instruments

Stein the elder Zweifel

Skutsch

Radiographic diagnosis of CPD

PELVIMETRY

Stereoscopic method (Caldwell and Moloy)

Frame or isometric method (Rowden, Jarcho,

Herbert Thoms) Poor predictive value

KRISHNAMURTHY S, BJOG,1991;98

Isometric pelvimetry
Lateral pelvimetry
Brim pelvimetry Pubic arch pelvimetry

AP View The Chassard Lapine Technique

X ray cephalometry (obsolete)

Principles: Shortest diameter of fetal head is taken. Lateral > Anteroposterior Breech Presentation: Erect posture
Complexities reviewed by Derk

Crichton,1952

Favorable findings on x ray

Adequate obstetric conjugate

Full,even,sacral curve
Pubic bone and descending rami parallel to line

joining promontory to the sacral tip

Rounded brim with adequate transverse diameter Divergent pubic arch Favorable cephalometry

Ultrasound pelvimetry and cephalometry

Ultra sound Cephalometry :Ian Donald ,1960 RECENT CONCLUSIONS: Although statistically significant, neither ultrasound measurements nor actual birth weight account for sufficient variation in cesarean delivery for CPD to be useful clinically
MR Leonardi ,January 1995,Am J Obstet Gynecol
CEPHALOPELVIC DISPROPORTION INDEX

The smallest pelvic diameter (x-ray pelvimetry )and biparietal diameter of the fetal

head at term as (sonography) taken. The difference between the two is the cephalopelvic disproportion index.
Vaginal delivery was impossible when the index was less than 9 mm and impossible

:very difficult when between 9 and 12 mm.

When it was greater than or equal to 13 mm, 26% needed a cesarean section,

CT PELVIMETRY
Advantages over x ray pelvimetry Reduced radiation exposure Fetal doses 250-1500 mrad
Moore And Shearer 1989

Mean gonadal exposure 885 mrads

Committee On Radiological Hazards To Patients(1963)

Greater accuracy

MRI pelvimetry
Advantages over x ray pelvimetry
Lack of ionizing radiation
Accurate measurements Soft tissue dystocia evaluation
Stark(1985) McCarthy(1986) Sporri(1997) GREY AREAS)

Role still investigational

THE TECHNIQUE OF MRI PELVIMETRY

A 0.5-T low-field vertically open configuration magnet system .

Bodyflex surface coil. Imaging is performed

A T 1-weighted fast spoiled gradient-echo sequence is performed with the patient in

the midsagittal,axial, and oblique (in the plane of sacral promontory to the top of the symphysis) planes using the following parameters: TR/TE, 150/8.5; flip angle, 60; field of view, 3034 cm; slice thickness,5 mm; gap, 0 mm;

number of excitations, 2;matrix, 256192; and bandwidth, 21 kHz.

Each sequence takes approximately 3 min to acquire
The obstetric conjugate; sagittal outlet; and interspinous,intertuberous, and transverse

diameterswere measured on the MR console

MR Obstetric Pelvimetry:Effect ofBirthing Position on Pelvic Bony Dimensions

Results indicate that differences in posture can significantly increase female pelvic dimensions and thus provide objective confirmation

MR pelvimetry in vertical open configuration magnet system.

Nomal and abnormal pelvis types

Classification of contracted pelvis
By architecture
PELVIS JUSTO MINOR

FLAT PELVIS

simple flat (platypellic) flat rachitic pelvis

GENERALLY CONTRACTED FLAT

PELVIS
OTHERS

Naegeles(obliquely contracted) Funnel

Roberts(transversely contracted)
Ottos Coxalgic Beaked(rostrate) Spondylolisthetic ,Osteomalacic

Classification of contracted pelvis according to degree

First degree

True conjugate 9-11 cm

Second degree

True conjugate 7.5-9 cm

Third degree

True conjugate 6-7.5 cm

Fourth degree

True conjugate <6 cm

Classification of contracted pelvis according to etiology

DEFECTS OF NUTRITION AND ENVIRONMENT

Minor (triangular and flat pelvic brim)

Major (rickets.osteomalacia)
DISEASE AND INJURY

Spinal
Kyphosis

Scoliosis
Spondylolisthesis

Pelvic
New growths Tuberculosis Fracture pelvis

Lower limbs
Tuberculosis,polio ,Coxalgia,congenital dislocation of hip

CONGENITAL DEFECTS

Naegeles ,Roberts , Assimilation , split Pelves

pelvis according to level of contraction

Contracted pelvic inlet
Shortest AP diameter<10 cm

Greatest transverse diameter <12 cm

Face &shoulder presentations(three times more common) Cord prolapse occurs 4-6 times more frequently

Contracted midpelvis
Sum of interischial and posterior sagittal diameters of midpelvis </=13.5 cm
Interischial dimeter <8 cm
Potential for transverse arrest

Contracted outlet Interischial tuberous diameter </= 8 c m

Perineal lacerations

Prediction of CPD
UTERINE CONTRACTION OR FETAL HEART RATE P ATTERNS
Asymmetric contractions and characteristic FHR

Decelerations appear to be suggestive of CPD. It is important to

recognize an FHR pattern which closely resembles but is different f rmn late decelerations. The described decelerations found with CPD may be a vagal response due to compression of the fetal vertex. Recognition of this may allow tor earlier, nonemergent
JESSICA et al VOLUME 185, 6 AmJ Obstet Gynecol

ULTRASOUND: PREDICTOR OF CEPHALOPELVIC DISPROPORTION.

Although statistically significant, neither ultrasound measurements nor

actual birth weight account for sufficient variation in cesarean delivery for CPD to be useful clinically.
BENSTOCK et alJanuary 1995 Am J Obstet

Maternal demographics to predict CPD

Average F:R for the C/S group was 1.77 versus 1.55 in the SVD group,indicating that those patients diagnosed with CPD had a longer return to baseline for each contraction Cephalopelvic disproportion is associated with an altered uterine conJanyne E.traction shape in the active phase of labor

The Traditional Management of CPD

INLET CONTRACTION

Minor degree Left to have spontaneous vaginal delivery at termModerare or severe degree

Preterm induction of labour:

not favored nowadays

CASE SELECTION
Multipara,

Avg Size Baby

Previous difficult delivery

Elective LSCS at term Trial labour

TRIAL LABOUR
Definition Conduction of spontaneous labour in a moderate degree

cpd in an institution with watchful expectancy ,hoping for a vaginal delivery Arrangements for operative delivery is a prerequisite Conduct of labor Determinants of outcome Time frame?? Termination of trial SVD(30%) Instrumental delivery(30%) LSCS(40%)
Advantages
lscs rates

Disadvantages

perinatal and

MIDPELVIC AND OUTLET CONTRACTION Not in labour Elective LSCS for moderate contraction minor contraction with other complicating factors Vaginal delivery for minor degrees in a competent setup Deep episiotomy -----> forceps/ventouse Late in labour Emergency LSCS Forceps with liberal episiotomy Symphysiotomy

Obstructed labour
2003)

INCIDENCE 6% IN INDIA (WHO

Obstructed labor is said to cause 8% of maternal

deaths worldwide . Causes WHO 1998 Absolute fetopelvic disproportion, Unfavorable orientation ofthe fetus Pelvic tumors may cause obstruction. Scarring due to female genital cutting has also been implicated The immediate causes of maternal death resulting from obstructed labor include ruptured uterus, complications of caesarean section and anesthesia, postpartum hemorrhage and

Prevention of obstructed labour

G.J. Hofmeyr International Journal of Gynecology and Obstetrics 85 Suppl. 1 (2004)

MANAGEMENT OF OBSTRUCTED LABOR (IMPAC ,WHO 2003)

LIVE FETUS Cervix fully dilated,

Head at 0 station :vacuum Head at -2: symphysiotomy and

Vacuum/ CS Cervix not fully dilated/head high up: CS
DEAD FETUS :craniotomy/ CS

Key practice points

Primary dysfunctional labour and secondary arrest are not

diagnoses.

Every effort should be made to define the cause of poor progress in labour

Only a proportion of cases of poor progress are due to inefficient uterine activity.

Augmentation of labour with oxytocin probably reduces CS and

instrumental delivery rates.

Active management of labour may further reduce the need for

these interventions.