PELVIC ASSESSMENT CLINICAL PELVIMETRY

SIGNIFICANCE
• A process used to assess the size of the birth canal by means of systematic vaginal palpation of specific bony landmarks in the pelvis. • By doing pelvimetry obstetrician can measure various diameters of the true pelvis in order to determine if the head can easily negotiate the dimensions during parturition & to conduct delievery vaginally or do caesarean section.

BONY PELVIS

.Iliopectineal line.PELVIS • Anatomically pelvis is divided into two partsTrue pelvis False pelvis Boundary line being the brim of the pelvis.Anterior border of ala of sacrum and Sacral promontary.Iliopubic eminence.Pubic crest . Pubic tubercle. Pectineal line . Bony land marks on the brim of pelvis from anterior to posterior on each side are Upper border of pubic symphysis.Sacro iliac articulation.

Iliac fossa • Anteriorly-Anterior abdominal wall. • Posteriorly-lumbar vertebrae.FALSE PELVIS • Formed by iliac portion of innominate bonesand limited above by the iliac crest. • Laterally. • Predicts the size and configuration of true pelvis. . • Little obstetric significance.

It is deep posteriorly formed by sacrum and coccyx and measures 11. Outlet. • For descriptive purposes divided into • Inlet. Cavity.TRUE PELVIS • Chief concern of the obstetrician. . • Shallow in front formed by symphysis pubis and measures 4 cm.5 cm.

INLET .

– anteroposterior diameter of inlet as measured par vaginum – inability to palpate the sacral promontory suggests that the conjugate diameter of the inlet is adequate for parturition • palpated means contracted pelvis – distance between the lower margin of pubic symphysis & sacral promontory – Subtraction of diagonal conjugate by 1.DIAMETERS OF INLET • What are the conjugates related to pelvic diameter? • Anatomical conjugate – anteroposterior conjugate diameter -11.5cm gives approximate measurement of anatomical conjugate .5 CM – extends from the upper margin of the pubic symphysis to the middle of the sacral promontory • Obstetrical conjugate-10 CM – shortest diameter through which foetal head must pass in it’s course throught the inlet – measured from middle of back of pubic symphysis to the sacral promontory • Diagonal conjugate-12CM.

-13 cm.-12cm Right or left denotes the sacroiliac joint.DIAMETERS OF INLET • Tranverse diameters-Two farthest point on the pelvic brim over the iliopectineal line. • Oblique diameters.There are two right. left Measures from sacro iliac joint to opposite iliopubic eminence. .

CAVITY Cavity is bounded above by the inlet and below by plane of least pelvic dimensions. 12cm • Transverse diameter.and posteriorly to meet the tip of the 5 sacral vertebra. . Diameters• Antero posterior diameter-From mid point on the posterior surface of the pubic symphysis to the junction of 2 & 3 sacral vertebrae.canot be precisely measured as soft tissues cover the sacroiliac notches and obturator foramina.It starts from the lower border of the symphysis pubis to the tip of ischial spines.

OUTLET • It is the segment of the pelvis bounded by the plane of least pelvic dimension and below by the anatomical outlet. • DiametersTranverse-Bispinous-10. • Lateral walls formed by ischial bones • Posterior –whole of coccyx.5 cm Antero posterior-11cm Posterior saggital 5cm . • Anterior wall is deficient at the pubic arch.

MID PELVIS • Segment of the pelvis bounded above by the plane of greatest pelvic dimensions and below by the mid pelvic plane. • Midpelvic plain-starts from lower margin of the pubic symphysis through the level of ischial spines to meet either junction of s4 5 s5or tip of the sacrum depending upon the configuration of sacrum. .

DIAMETERS OF MID PELVIS • Transverse diameter-bispinous diameter10.5 cm . 4.5 • Antero posterior. 11.5 cm Posterior saggital diameter-extends from the midpoint of the bispinous diameter to the point on the sacrum at which the mid pelvic plain meets.extends from lower border of pubic symphysis to the point on the sacrum at which the midpelvic plain meets.

.ASSESSMENT METHODS • 1 Bimanual examination. 3 Magnetic resonance imaging. • 2 Imaging studies 1 Radio pelvimetry • • 2Computed tomography.

previous caesarian section . • Suspicion of pelvic contraction a-Malpresentations in primi b-Head not engaged. • Time – In vertex presentation a-beyond 37 wks b-beginning of labour. c.CLINICAL PELVIMETRY • Done manually.previous premature delievery d.

thorough. Following features should be noted simultaneously. Patient is lying in the dorsal position.methodical. Station of the presenting part in relation to ischial spines. Verbal consent of the patient. Examination should be gentle. Presence of lady attendent if male gynaecologist is examining.PROCEEDURE • • • • • • • • Empty the bladder. To test for CPD in non engaging head.purposeful. To note the resiliance and elasticity of the perineal muscle. • • • • • .— state of the cervix. Sterilised gloved fingers once taksten out should not be reintroduced.

LEVEL OF ASSESSMENT BRIM DIAGONAL CONJUGATEPOSTERIOR SURFACE OF THE PUBIC SYMPHYSISILIO PECTINEAL LINESACRO SCIATIC NOTCH- MID PELVIS SACRUM ISCHIAL SPINES OUTLET SIDE WALLS SACRO COCCYGEAL JOINT SUB PUBIC ARCH SUB PUBIC ANGLE TRANSVERSE DIAMETER OF OUTLET SACRO SCIATIC NOTCH SIDE WALLS .

STEPS • SACRUM. • well curved. • inaccessible beyond lower 3 pieces.smooth. • The length breadth and its curvature • from above down and side to side • are to be noted. .

STEPS • SACRO-SCIATIC NOTCH • Notch is sufficiently wide so that 2 fingers can be easily placed over the sacro spinous ligament covering the notch. . • Configuration of the notch denotes the capacity of the posterior segment of the pelvis and side walls of the lower pelvis.

• May be prominent and encroach to the cavity diminishing the available space in the mid pelvis. .STEPS • ISCHIAL SPINE • Spines are usually smooth everted and difficult to palpate.

• Side walls. .STEPS • Ilio pectineal lines• if beaking suggests fore pelvis contraction.normally not palpable by sweeping fingers unless convergent.

• • • • • presence of beaking or angulation suggests abnormality. SACRO-COCCYGEAL JOINTMobility and presence of hooked coccyx.normally forms smooth curve. .STEPS • Posterior surface of the symphysis pubis • .

5-2cm from the diaognal conjugate.It is the distance between the lower border of pubic symphysis to midpoint of sacral promontory.STEPS • Pubic arch – normally rounded and • • accomodates palmer aspect of two fingers. . • Diagonal conjugate. 12 cm. • Obstetric conjugate is obtained by substracting 1.

DIAOGNAL CONJUGATE .

Pubic angle. In narrow corresponds to fully abducted middle and index finger.In normal pelvis angle corresponds to fully abducted thumb and index finger.STEPS • If the middle finger fails to reach the sacral promontary or touches it with great difficulty • it is likely that the conjugate is adequate for average size head to pass through. .

INTER TUBEROUS DIAMETER .

STEPS • Transverse diameter of the outletMeasured by placing the knuckles of the first interphalangeal joints or knuckles of the clinched fist betweeen the ischial tuberosities. . • Antero-posterior diameter of the outlet – the distance between the inferior margin of the symphysis pubis and the skin over the sacro-coccygeal joint.

• OUTLET CONTRACTION. • INLET CONTRACTION• Obstetric conjugate <10 cm • Greatest tranverse dia <12 cm • Diaognal conjugate <11cm • MIDPELVIS CONTRACTION• Sum of inter ischial spinous diameter • and posterior saggital diameter is 13cm or below.DISPRORTION • Disparity between the head and the pelvis.inter ischial tuberous diameter • 8cm or less • .

• Fetal head is the best pelvimeter. • A thorough assessment of the pelvis and the identification of the presence and degree of CPD are to be noted while evaluating a case of contracted pelvis. • Isolated outlet contraction without midcavity is a rarity. . • Satisfactory progress of labour is the best indicator of pelvic adequacy.

Abdominal method Abdomino vaginal Muller munro kerr. IMAGING PELVIMETRYCEPHALOMETRY- .DIAGNOSIS OF CPD AT THE LEVEL OF BRIM • CLINICAL.

• useful in cases of fractured pelvis and for the important diameters not assessed by clinical examination.IMAGING METHODS • X-Ray pelvimetry• Poor predictor of pelvic adequacy. .

• Accuracy greater than x-ray. .IMAGING METHODS • Computed tomography-involves less radiations and easier to perform .

. • Has no radiation risk. • Can also assess the fetal size and maternal soft tissue which are involved in dysocia.IMAGING METHODS • MRI • Most accurate to assess the bony pelvis.

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