CEPHALO-PELVIC DISPROPOTION

DEFINITION
• Anatomically contracted pelvis is defined as one where the essential diameters of one or more planes are shortened by 0.5 cm

• Obstetric definition which states that alteration in the size and or shape of the pelvis of sufficient degree so as to alter the normal mechanism of labour in an average size baby.

ETIOLOGY
• Severe malnutrition, • rickets, osteomalacia, • bone tuberculosis Minor variation : common, Major variation: rare

COMMON CAUSES
• Nutritional and environmental defects • Diseases or injuries affecting the bones of the pelvis – fracture, tumors, tubercular arthritis; Spine – Kyphosis, scoliosis, coccygeal deformity; lower limbspoliomyelitis, hip joint disease. • Developmental defects – Naegele’s pelvis, Robert’s pelvis; High or low assimilation pelvis

there is no cavity or outlet. . The head negotiates the brim by the following mechanism • The head engages with the sagittal suture in the transverse diameter • Head remains deflexed and engagement is delayed.Mechanism of labour in contracted pelvis Flat pelvis In the flat pelvis. the head finds difficulty in negotiating the brim and once it passes through the brim.

5cm). • Engagement occurs by exaggerated parietal so that the super.• If the antero. instead of the biparietal diameter (9.subparietal diameter(8.5cm). to occupy the sacral bay. . However. If lateral mobilisation is not possible. there is a chance of extension of the head leading to brow or face presentation. the caput that forms is not big. the occiput is mobilised to the same side. passes through the pelvic brim • Moulding may be extreme and often there is an indentation or even a fracture of one parietal bone.posterior diameter is too short. The biparital diameter is placed in the narrow conjugate.

• Once the head negotiates the brim. there is no difficulty in the cavity and outlet and normal mechanism follows .

• PHYSICAL EXAMINATION:  Stature : small women (less than 5 feet). TB of the pelvic joint or spines. hip joint. spine . osteomalacia.Diagnosis of contracted pelvis 1. poliomylietis is to be obstetrical.  Stigma: deformity of the pelvic bones. rickets. PAST HISTORY • MEDICAL: past h/o fracture. HISTORY COLLECTION A.

Assessment can be done by bimanual examination – clinical pelvimetry and also by imaging studies.37 week but better at the beginning of labour .Pendulous abdomen PELVIMETRY:.radio pelvimetry.ABDOMINAL EXAMINATION INSPECTION:.Time: in vertex presentation. computed tomography and MRI .

Empty the bladder .Test for cephalopelvic disproportion in nonengaged head .Procedure: .Sate of cervix .Elasticity of the perineal muscles .Station of the head .Dorsal position .Maintain aseptic precaution Features to be noted .

• Scacro sciatic notch . They may be prominent and encroach to the cavity thereby diminishing the available space in the mid pelvis . The length. sterilised gloved fingers once taken out should not be reintroduced.The notch is sufficiently wide so that two fingers can be easily placed over the sacro spinous ligament covering the notch. breadth and its curvature are to be noted. • Ischial spines – spines are usually smooth difficult to palpate. • Sacrum – the sacrum is smooth.Steps : The internal examination should be gentle. well curved .

• Pubic arch – Normally.it normally forms a smooth rounded . • After the procedure. • Side walls.normally they are not easily palpable by the sweeping unless convergent.• Illio pectineal lines – To note for any beaking . • Posterior surface of the symphysis pubis. the pubic arch is rounded and should accommodate the palmar aspect of two fingers. the fingers are now taken out .

So it is restricted .X RAY PELVIMETRY It cannot reliably predict the likelihood of vaginal delivery neither in breech presentation nor in cases with with previous caesarean section. X – ray pelvimetry is a poor predictor of pelvic of pelvic adequacy and success of vaginal delivery. . However. With conventional X-ray pelvimetry radiation exposure too the gonads is about 885 milliards. X-ray pelvimetry is useful in cases with fractured pelvis and for the important diameters which are inaccessible to clinical examination. Hazards of X-ray pelvimetry includes radiation exposure to the mother and the fetus.

It is expensive.• Computerised tomography (CT) involves less radiation exposure and is easier to perform. • Ultrasonography is useful to measure the fetal head dimension in the intrapartum face. It is also helpful assess the fetal size and maternal soft tissue which are involved in dystocia. requires more time and availability is limited. Accuracy is greater than that conventional X-ray pelivmetry. . • Magnetic Resonance Imaging(MRI) is more accurate to assess the bony pelvis. It has got no radiation risk. hence biologically safe.

DISPROPORTION .

in relation to the pelvis. • The disparity in the relation between the head and pelvis is called cephalopelvic disproportion Disproportion may be either due to an average size baby with a small pelvis or due to a big a baby with normal size pelvis(Hydrocephalus) or due to combination of both the factors .DEFINITION • Disproportion . is a state where the normal proportion between the size of fetus to the size of the pelvis is disturbed.

X-ray . MRI. The presence and degree of CPD at the brim can be ascertained by the following • Clinical • Imaging pelvimetry • Cephalometry – ultrasound.Diagnosis of cephalopelvic disproportion (CPD) at the brim.

The head is grasped by the left hand two fingers (index and middle) of the right hand are placed above the symphysis pubis keeping the inner surface of the fingers in line with the anterior surface to note the degree of overlapping. if any. .In multi gravida – previous h/o spontaneous delivery of an average size baby. Abdominal exanination: The patient placed in dorsal position with the thighs slightly flexed and separated.1. CLINICAL . .Primi gravida – non engagement of the head even at labour. when the head is pushed downwards and backward.

Inferences • The head can be pushed down in the pelvis without overlapping of the parietal bone on the symhysis pubis – no disproportion • Head can be pushed down a little but there is slight overlapping of the parietal bone (overlapping by 0.5cm) – moderate disproportion • Head cannot be pushed down– severe disproportion .

Munro Kerr added placement of the thumb over symphysis pubis to note the degree of overlapping .Abdomino – vaginal method (Muller Munro Kerr) • This bimanual method is superior to the abdominal method assessment can be done simultaneously. Muller introduced the method by placing the vaginal finger tips at the level of ischial spines to note the descent of the head.

The head is grasped by the left hand and is pushed in a downward and backward direction into the pelvis. .• Lower bowel emptied preferably by enema. The patient is placed in lithotomy position and the internal examination is done taking all aseptic precautions. Two fingers of the right hand are introduced into the vaginal with the fingertips placed at the level of ischial spines and thumb is placed over the symphysis pubis. The patient is asked to empty the bladder.

Inferences • The head can be pushed down up to the level of ischial spines and there is no overlapping of the parietal bone over the symphysis pubis – no disproportion • The head can be pushed down a little but not up to the level of ischial spines and there is slight overlapping of the parietal bone – slight or moderate disproportion • The head cannot be pushed down and instead the parietal bone overhangs the symphysis pubis displacing the thumb – severe disproportion. .

• The fetal head can be used as a pelvimeter to elicit only the contraction in the antero-posterior plane of the inlet. it is of less use.Limitation of clinical assessment • The method is only applicable to note the presence or absence of disproportion at the brim and not at all applicable to elicit mid pelvic or outlet contraction. . but when the contraction affects the transverse diameter of the inlet.

midpelvic and outlet. • 3. The average biparietal diameter measures 9. In this respect ultrasonographic measurement of the biparietal diameter or MRI gives superior information. accurate measurement of the biparietal diameter would have been ideal to elicit its relation with the diameters of the planes of a given pelvis through which it has to pass.4 to 9. Cephalometry: While a rough estimation of the size of the head can be assessed clinically.8 cm at term. X-ray pelvimetry: Lateral X-ray view with the patient in standing position is helpful in assessing cephalo pelvic proportion in all planes of the pelvis – inlet.2. .

.• MRI : it is useful to assess the pelvic capacity at different planes. It is equally informative to assess the fetal size. fetal head volume and pelvic soft tissues which are also important for successful vaginal delvery.

. However.Effect of contracted pelvis on pregnancy and labour Pregnancy: The general course of pregnancy is not much affected. the following may occur • There is more chance of incarceration of the retroverted gravid uterus in flat pelvis. • Abdomen become pendulous specially in multigravida with lax abdominal wall • Mal presentations are increased 3-4 times and so also increased frequently of unstable lie.

shock. keto –acidosis and sepsis. post partum haemorrhage and sepsis .Labour: The course of events in labour is greatly modified depending upon the degree of pelvic contraction and presentation of the fetus: • There is increased incidence of early rupture of the membranes • Incidence of cord prolapse is increased • Cervical dilatation is slowed • There is increased tendency of prolonged labour and in neglected cases. dehydration. obstructed labour with features of exhaustion. • There is increased incidence of operative interference.

• Fetal hazards: • Fetal risks are due to trauma and asphyxia. The net effect leads to increased peinatal mortality and morbidity . There is increased maternal morbidity and mortality.• Maternal injuries: • The injuries of the genital tract may occur spontaneously of following operative delivery.

Management of contracted pelvis (inlet contraction) • The pre-requisites in the formulation of the line of management of contracted inlet is to ascertain the degree of disproportion by clinical examination and supplemented by imaging pelvimetry. Due consideration is given to the associated complicating factor. if any .

The moderate and severe degrees are to be dealt by any one of the following: • Preterm induction of labour • Elective caesarean section at term • Trial labour .Minor degrees of inlet contraction does not give rise to any problem and the cases are left to have a spontaneous vaginal delivery at term.

• Induction of labour prior to date: Induction 2-3 weeks prior to the EDD may be considered only in cases with moderate degrees of pelvic contraction. . However. It is not favoured nowadays. In any case one should be certain about the fetal gestational age. this method may be considered 2-3 weeks before date. in a selected multigravida with previous history of difficult vaginal delivery.

• Moderate degree of inlet contraction associated with outlet contraction • Moderate degree of inlet contraction associated with outlet contraction or complicating factors like elderly primigravida. post caesarean pregnancy. malpresentation.Elective caesarean section at term: Elective caesarean section at term is indicated in: • Major degree of inlet contractiuon . etc. the operation can be done as a planned way . If there is no doubt about the maturity of the fetus.

either vaginal or abdominal.Trial labour • It is the conduction of spontaneous labour in a moderate degree of cephalo pelvic disproportion. if the condition do arises. an institution under supervision with watchful expectancy. hoping for a vaginal delivery. • Aims : A trail labour aims at avoiding an unnecessary caesarean section and at delivering a healthy baby . Every arrangement should be made available for operative delivery.

eclampsia.Contraindications : • Associated midpelvic and outlet contraction • Presence of complicating factors like elderly primigravida. diabetes Tb. malpresentation. pre. post caesarean pregnancy. • Where facilities for caesarean section is not available round the clock . medical disorders like heart disease. postmaturity.

• Successful outcome depends on: • Degree of pelvic contraction • Shape of the pelvis – flat pelvis is better than android or generally contracted pelvis • Favourable vertex presentation – anterior parietal presentation with less parietal obliquety is favourable • Intact membranes till full dilatation of cervix • Effective uterine contractions • Emotional stability of the women .

Unfavourable features: • Appearance of abnormal uterine contraction • Cervical dilatation <1cm per hour inspite of regular uterine contractions • Arrest of cervical dilatation and non descent of fetal head in spite of oxytocin therapy • Early rupture of the membranes • Formation of caput and evidence of excessive moulding • Fetal distress .

difficult forceps delivery is to be avoided • Caesarean section(40%) – Judicious and timely decision for caesarean section is done even before full dilatation of the cervix..• Termination of trial labour: The methods of termination are any one of the following • Spontaneous delivery with or without episiotomy (30%) • Forceps or vetouse (30%). the indication being uterine inertia or fetal distress Successful trial: A trial is called successful. . if a healthy baby is born vaginally spontaneously or by forceps or ventouse with the mother in good condition.

• Advantages of trail labour: • It eliminates unnecessary caesarean section electively decided upon • It eliminates injudicious use of premature induction of labour with its antecedent hazards • A successful trial ensures the woman a good future obstetrics .

• Disadvantages of trail labour : • Test of disproportion remains unproven when caesarean delivery is done due to fetal distress or uterine dysfunction • Increased perinatal morbidity and or mortality due to asphyxia or intracaranial haemorrhage when the trial is prolonged and/or ends in difficult delivery • Increased psychological morbidity when trial ends with a traumatic vaginal delivery or in caesarean delivery .

. it is difficult to determine where the midpelvic contraction is rarity. in practice the two problems are jointly considered as outlet contraction.Midpelvic and outlet disproportion • In clinical assessment.posterior place of the outlet. Cephalopelvic disproportion at the outlet is defined as one when the biparietal suboccipito bregmatic plane fails to apss through the bispinous and antero. As such.

. clinical diagnosis of mid pelvic and outlet disproportion can only be made after the head sufficiently comes down into the pelvis.• Management • Unlike inlet disproportion.

• Elective caesarean section: Contraction of both the transverse and antero.posterior diameter of the midpelvic plane or minor contraction associated with other complicating factors is dealt by elective caesarean section .

allowed under supervision with watchful expectancy • Delivery is accomplished by forceps or ventouse with deep episiotomy to prevent perineal injuries. Once arrest disorder is diagnosed . vaginal delivery. arrest of labour is considered.• To allow vaginal delivery: In otherwise uncomplicated cases with minor contraction. • If there is no dilatation of cervix or descent of the fetal head after a period f 2 hours in the active phase of labour. specially with narrow pubic arch. caesarean delivery is the option. .

The principles of management rest on • Caesarean section to avoid difficult forceps • Forceps with deep episiotomy • Symphysiotomy followed by ventouse • Craniotomy if the fetus is dead • .Cases seen late in labour is not an uncommon problem in the developing countries.