This action might not be possible to undo. Are you sure you want to continue?
of both. Pelvic Capacity Any contraction of the pelvic diameters that diminishes its capacity can create dystocia during labor. There may be contractions of the pelvic inlet, the midpelvis, or the pelvic outlet, or a generally contracted pelvis may be caused by combinations of these. Normal pelvic dimension are additionally discussed in Chapter 2 (Planes and Diameters of the Pelvis). Contracted Inlet The pelvic inlet usually is considered to be contracted if its shortest anteroposterior diameter is less than 10 cm or if the greatest transverse diameter is less than 12 cm. The anteroposterior diameter of the inlet is commonly approximated by manually measuring the diagonal conjugate, which is approximately 1.5 cm greater (see Chap. 2, Pelvic Inlet). Therefore, inlet contraction usually is defined as a diagonal conjugate of less than 11.5 cm. Using clinical and at times, imaging pelvimetry, it is important to identify the shortest anteroposterior diameter through which the fetal head must pass. Occasionally, the body of the first sacral vertebra is displaced forward so that the shortest distance may actually be between this abnormal sacral promontory and the symphysis pubis. Prior to labor, the fetal biparietal diameter has been shown to average from 9.5 to as much as 9.8 cm. Therefore, it might prove difficult or even impossible for some fetuses to pass through an inlet that has an anteroposterior diameter of less than 10 cm. Mengert (1948) and Kaltreider (1952), employing x-ray pelvimetry, demonstrated that the incidence of difficult deliveries is increased to a similar degree when either the anteroposterior diameter of the inlet is less than 10 cm or the transverse diameter is less than 12 cm. As expected, when both diameters are contracted, dystocia is much greater than when only one is contracted. A small woman is likely to have a small pelvis, but she is also likely to have a small neonate. Thoms (1937) studied 362 nulliparas and found the mean birthweight of their offspring was significantly lower—280 g—in women with a small pelvis than in those with a medium or large pelvis. In veterinary obstetrics, in most species, maternal size rather than paternal size is the important determinant of fetal size. Normally, cervical dilatation is aided by hydrostatic action of the unruptured membranes or after their rupture, by direct application of the presenting part against the cervix (see Fig. 6-8). In contracted pelves, however, because the head is arrested in the pelvic inlet, the entire force exerted by the uterus acts directly on the portion of membranes that contact the dilating cervix. Consequently, early spontaneous rupture of the membranes is more likely.
or the sacrosciatic notch is narrow. There is reason to suspect midpelvic contraction whenever the interspinous diameter is less than 10 cm. the midpelvis is contracted. cervical response to labor provides a prognostic view of labor outcome in women with inlet contraction. A transverse line theoretically connecting the ischial spines divides the midpelvis into anterior and posterior portions. In women with contracted pelves. or interischial spinous. the midpelvis is likely contracted when the sum of the interspinous and posterior sagittal diameters of the midpelvis—normal. if at all. a suggestion of contraction sometimes can be inferred if the spines are prominent. absent pressure by the head against the cervix and lower uterine segment predisposes to less effective contractions. or 15. the more efficient are the contractions. and posterior sagittal. Contracted Midpelvis This finding is more common than inlet contraction. Even so. Hence. Eller and Mengert (1948) noted that the relationship between the intertuberous and interspinous diameters of the ischium is sufficiently constant that narrowing of the interspinous diameter can be anticipated when the intertuberous . It frequently causes transverse arrest of the fetal head. the presenting part at term commonly descends into the pelvic cavity before the onset of labor. the pelvic sidewalls converge. Midpelvis).5 plus 5 cm. Thus.5 cm or less. 11. further dilatation may proceed very slowly or not at all.5 cm. 5 cm. Accordingly. anteroposterior. forming the lower limits of the sacrosciatic notch. The posterior portion is bounded dorsally by the sacrum and laterally by the sacrospinous ligaments. 10. however. Average midpelvis measurements are as follows: transverse. from the lower border of the symphysis pubis to the junction of S4-S5. Cephalic presentations still predominate.5 cm. When it measures less than 8 cm. Although there is no precise manual method of measuring midpelvic dimensions. A contracted inlet plays an important part in the production of abnormal presentations. which potentially can lead to a difficult midforceps operation or to cesarean delivery. The better the adaptation. very slight influences may cause the fetus to assume other presentations. In normal nulliparas. This concept was emphasized by Chen and Huang (1982) in evaluating possible midpelvic contraction. 10. from the midpoint of the interspinous line to the same point on the sacrum. When the inlet is contracted considerably. The definition of midpelvic contractions has not been established with the same precision possible for inlet contractions. 2.5 cm—falls to 13.After membrane rupture. Moreover. and the cord prolapses four to six times more often. The former is bounded anteriorly by the lower border of the symphysis pubis and laterally by the ischiopubic rami. face and shoulder presentations are encountered three times more frequently. The obstetrical plane of the midpelvis extends from the inferior margin of the symphysis pubis through the ischial spines and touches the sacrum near the junction of the fourth and fifth vertebrae (see Chap. but the head floats freely over the pelvic inlet or rests more laterally in one of the iliac fossae. Cibils and Hendricks (1965) reported that the mechanical adaptation of the fetal passenger to the bony passage plays an important part in determining the efficiency of contractions. descent usually does not take place until after labor onset.
Although the disproportion between the fetal head and the pelvic outlet is not sufficiently great to give rise to severe dystocia. The posterior triangle has no bony sides but is limited at its apex by the tip of the last sacral vertebra—not the tip of the coccyx. The pelvic outlet may be roughly likened to two triangles. the occiput cannot emerge directly beneath the symphysis pubis but is forced increasingly farther down upon the ischiopubic rami. x-ray pelvimetry is considered to be of limited value in the management of labor with a cephalic presentation (American College of Obstetricians and Gynecologists. . Outlet contraction without concomitant midplane contraction is rare. A contracted outlet may cause dystocia not so much by itself as through the often-associated midpelvic contraction. A narrow pelvic arch of less than 90 degrees can signify a narrow pelvis. Thus. An unengaged fetal head can indicate either excessive fetal head size or reduced pelvic inlet capacity. The sides of the anterior triangle are the pubic rami. Briefly. does not always exclude a narrow interspinous diameter. Contracted Outlet This finding usually is defined as an interischial tuberous diameter of 8 cm or less. however.diameter is narrow. and the intertuberous distances of the pelvic outlet. A history of pelvic fracture warrants careful review of previous radiographs and possibly computed tomographic pelvimetry later in pregnancy. With increasing narrowing of the pubic arch. A normal intertuberous diameter. 1948). The perineum. and its apex is the inferoposterior surface of the symphysis pubis. Pelvic Fractures Speer and Peltier (1972) reviewed experiences with pelvic fractures and pregnancy. 1995b). compromise of the birth canal capacity by callus formation or malunion was common. becomes increasingly distended and thus exposed to greater danger of laceration. it may play an important part in the production of perineal tears. the interspinous diameter of the midpelvis. With bilateral fractures of the pubic rami. Estimation of Pelvic Capacity The techniques for clinical evaluation using digital examination of the bony pelvis during labor are described in detail in Chapter 2 (Planes and Diameters of the Pelvis). X-Ray Pelvimetry Even when widely used. consequently. Diminution of the intertuberous diameter with consequent narrowing of the anterior triangle must inevitably force the fetal head posteriorly. the examiner attempts to judge the anteroposterior diameter of the inlet—the diagonal conjugate. Trauma from automobile collisions was the most common cause of pelvic fractures. the prognosis for successful vaginal delivery in any given pregnancy cannot be established using x-ray pelvimetry alone (Mengert. Floberg and associates (1987) reported that outlet contractions were found in almost 1 percent of more than 1400 unselected nulliparas with term pregnancies. with the interischial tuberous diameter constituting the base of both.
compared with those of conventional x-ray pelvimetry include reduced radiation exposure. 1997). 41. Fetal Dimensions in Fetopelvic Disproportion Fetal size alone is seldom a suitable explanation for failed labor. Stark and co-workers. Thus. such as that shown in Figure 20-4. complete fetal imaging. and the potential for evaluating soft tissue dystocia (McCarthy. and firm pressure is directed downward in the axis of the inlet. . occiput posterior position. other factors. With either method. two thirds of neonates who required cesarean delivery after failed forceps delivery weighed less than 3700 g. Although significant associations were found with some of the measures and cesarean delivery for dystocia. greater accuracy. Most cases of disproportion arise in fetuses whose weight is well within the range of the general obstetrical population. such as malposition of the head. Depending on the machine and technique employed. fetal doses with computed tomography may range from 250 to 1500 mrad (Moore and Shearer. 1986. Even with the evolution of current technology. the mean gonadal exposure is estimated by the Committee on Radiological Hazards to Patients to be 885 mrad (Osborn. Figure 20-5 Birthweight distribution of 362 newborns delivered by cesarean at Parkland Hospital (1989– 1999) after a failed attempt to effect vaginal delivery with forceps. costs are comparable and x-ray exposure is small (see Chap. Müller (1880) and Hillis (1930) described a clinical maneuver to predict disproportion. 1989). These include asynclitism. Others have reported similar findings (Sporri and co-workers. 1963). obstruct fetal passage through the birth canal. With conventional x-ray pelvimetry. accurate measurements. they could not with accuracy predict which woman would require cesarean delivery. and face and brow presentations. Only 12 percent (n = 44) of the newborns weighed > 4000 g (dark bars). and easier performance. 1985). The fetal brow and the suboccipital region are grasped through the abdominal wall with the fingers.Computed Tomographic (CT) Scanning Advantages of CT pelvimetry. Zaretsky and colleagues (2005) used MR imaging to measure pelvic and fetal head volume in an effort to identify those women at greatest risk of undergoing cesarean delivery for dystocia. As shown in Figure 20-5. Estimation of Fetal Head Size Efforts to clinically and radiographically predict fetopelvic disproportion based on fetal head size have proved disappointing. a fetal size threshold to predict fetopelvic disproportion is still elusive. Computed Tomography). Magnetic Resonance (MR) Imaging The advantages of MR pelvimetry include lack of ionizing radiation.
Thurnau and co-workers (1991) used the fetal-pelvic index to identify labor complications. 1998). the head readily enters the pelvis. Measurements of fetal head diameters using plain radiographic techniques are not used because of parallax distortions. The biparietal diameter and head circumference can be measured sonographically. and vaginal delivery can be predicted. . Unfortunately. and there have been attempts to use this information in the management of dystocia.If no disproportion exists. Thorp and colleagues (1993b) performed a prospective evaluation of the MuellerHillis maneuver and concluded that there was no relationship between dystocia and failed descent during the maneuver. We are of the view that there is no currently satisfactory method for accurate prediction of fetopelvic disproportion based on head size. the sensitivity of such measurements to predict cephalopelvic disproportion is poor (Ferguson and associates.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue listening from where you left off, or restart the preview.