CEPHALO PELVIC DISPROPORTION

(CPD)

DR. SASHMI MANANDHAR

LECTURER
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
GMCTHRC
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Must know basics

 Fetal Skull: Diameters

 Maternal Pelvis:
 Anatomy: Parts
 True Pelvis: Inlet, Cavity, Outlet
 Diameters
 Variations/Types of pelvis
 The Fetus In Utero
 Obstetric examination
 Engagement
 Pelvic assessment

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Terminology

 Cephalo Pelvic Disproportion (Cephalo = fetal head, Pelvic = Maternal Pelvis, Disproportion = Not
proportionate/mismatch for one another)
 Abnormal condition in pregnancy

 Disparity in the relation between the fetal head and maternal pelvis

 Resulting in complete halt of vaginal delivery or difficulty in vaginal delivery

 Size of fetal head too large and/or maternal pelvis too small or of inappropriate
shape → fetal head cannot fit in the maternal pelvis
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Terminology

REMEMBER!!!

CPD DOES NOT MEAN CONTRACTED PELVIS

CONTRACTED PELVIS MIGHT BE THE CAUSE OF CPD

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Incidence

 20 out of 250 pregnancy (American College of Nursing Midwives)

 Incidence is higher in poor countries

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Causes/Risk Factors
 Maternal
 Short stature
 Teenage
 Nutritional Deficiency
 Contracted pelvis
 Pelvic Trauma
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 Fetal
 Abnormal fetal head (Hydrocephalous)
 Large size fetus
 Genetic
 Post dated/Post term pregnancy
 Multiparity
 Gestational diabetes
 Maternal Obesity
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Causes of Contracted Pelvis

 Nutritional or Environmental:
 Rachitic Flat Pelvis: Rickets

 Osteomalacic Pelvis: Deficiency of calcium and Vitamin D

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Causes of Contracted Pelvis

 Diseases or Injuries

Pelvis Spine Lower Limbs

Fracture Kyphosis Poliomyelitis

Tumor Scoliosis Joint diseases
Tubercular arthritis Spondylolisthesis
Coccyceal deformities

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Causes of Contracted Pelvis

 Developmental defects (Remember for MCQs)

 Naegele’s Pelvis: Absence of one ala

 Robert’s Pelvis: Absence of both ala

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Types/ Degree of disproportion

Type or degree Mode of Delivery

Minor Anterior surface of fetal skull in line with posterior surface of Vaginal delivery can
symphysis pubis occur

Moderate/1st degree Anterior surface of fetal skull in line with the anterior surface Vaginal delivery may
of symphysis pubis or may not occur

Marked/ 2nd degree Fetal head overrides anterior surface of symphysis pubis (Fetal Caesarean Section
head bulge over symphysis pubis)
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Effect on Pregnancy and labour

 Incarceration of retroverted gravid uterus

 Non engagement or delayed engagement of fetal head
 Malpresentation

 PROM
 Cord Prolapse
 Molding or Caput formation
 Non Progress of labour, Prolonged labour
 Most common cause of Obstructed Labour

 Traumatic delivery
 Adverse fetal outcome

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Clinical Features and Assessment

 History:
 Ask about causes of CPD and Contracted Pelvis
 Obstetric (in previous delivery)
 Prolonged or Obstructed labour
 Difficult instrumental delivery
 Traumatic delivery
65% of the ladies who were diagnosed to
have CPD in previous pregnancy deliver
vaginally in subsequent pregnancy.
↓
Remember!!!

 Weight of the baby

CPD is not a recurrent indication of
Caesarean Section.
 Adverse neonatal outcome

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Clinical Features and Assessment

 Examination:
 Stature

 Any Deformities, Abnormal Gait

 Abdominal Examination:
Inspection: Pendulous abdomen
Obstetric: Non engagement of head, Malpresentation

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Clinical Features and Assessment

 Examination: Abdominal Examination

 Dorsal position, thighs slightly flexed and
separated

 Head grasped by left hand

 Index and middle finger of right hand above

symphysis pubis

 Head pushed downwards and backwards

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Clinical Features and Assessment

 Examination: Abdominal Examination

No disproportion Head pushed down in the pelvis without overlapping of parietal bone on
symphysis pubis

Moderate disproportion Head pushed down a little with slight overlapping of parietal bones

Marked disproportion Head not pushed down with parietal bones displacing the finger

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Clinical Features and Assessment

 Examination: Assessment of Pelvis

 Additional things to be assessed during clinical
 Clinical pelvimetry: Timing
pelvimetry
 In vertex presentation:
 Once
 State of the cervix
after 37 weeks of gestation
 Repeat at the beginning of or  Head station
during labour  Engagement of head

 Elasticity of perineal tissue

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Clinical Pelvimetry (Imp for Practicals)

 Explanation and Consent

 Empty the bladder and rectum

 Privacy

 Dorsal position

 Sterilized gloves, Lignocaine jelly

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Clinical Pelvimetry (Imp for Practicals)

 Sacrum: sacral promontory not reached

 Sacrosciatic notch: wide enough to admit two fingers over sacrospinous ligament

 Ischial spines: not prominent

 Illiopectineal lines: smooth without any break

 Sidewalls: parrel and divergent

 Posterior surface of symphysis pubis: smooth rounded curve

 Pubic arch: accommodate palmer aspect of two fingerss

 Subpubic angle: corresponds to fully abducted thumb and index finger

 Transverse diameter of outlet: adjust knuckles of clinched fist between two ischial tuberosity

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Clinical Features and Assessment

 Examination: Abdomino vaginal method (Muller Munro Kerr)

 Bimanual method

 At the time of pelvic assessment

 Head grasped with left hand, pushed downward and backward

 Thumb over the symphysis pubis: for assessment of degree of overlapping

 Vaginal finger tips at the level of ischial spine: for assessment of head descent

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Clinical Features and Assessment

 Examination: Abdomino vaginal method (Muller Munro Kerr)

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Clinical Features and Assessment

 Examination: Muller Munro Kerr Inferences

No disproportion Head pushed down up to the level of ischial spine without overlapping of parietal
bone on symphysis pubis

Moderate disproportion Head pushed down a little but not up to the level of ischial spine with slight
overlapping of parietal bones

Marked disproportion Head not pushed down with parietal bones displacing the finger

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Investigation

 Radiological evaluation for diagnosis:

 Radiopelvimetry/ X ray pelvimetry

Poor predictor of pelvic adequacy, Diagnosis of injury or deformity

Erect lateral view: most reliable

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Investigation

 Radiological evaluation for diagnosis:  MRI:

 CT Scan:  Assessment of fetal head and maternal

 More informative than Xray pelvimetry soft tissue

 Lateral AP and axial slice

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Investigation

 Additional:
 USG Obstetric Scan: Estimated fetal weight, Fetal head deformities

 All pre operative investigations

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Management

 Spontaneous delivery at term: Minor disproportion

 Induction of labour
 Minor to moderate disproportion

 2-3 weeks prior to EDD

 In selected cases

 Trial of labour

 Elective caesarean section

 Marked disproportion

 Moderate disproportion

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Further study

 Trial of labour:
 Conduction of spontaneous labour
 Moderate degree of CPD
 Strict supervision

 Can result in instrumental or caesarean section at any time

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Further study

 Trial of labour:
 Contraindications:

Any sign of contracted pelvis

High risk pregnancy
No facility of caesarean section

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