CPD

GIRMA ABRAHAM, 2016

DEFINITION
 Disproportion, in relation to the pelvis, is a state
where the normal proportion between the size of fetus
to the size of the pelvis is disturbed
Disproportion may be either due to an average size
baby with a small pelvis or due to a big baby with
normal size pelvis (hydrocephalus) or due to a
combination of both the factors
Pelvic inlet contraction is considered when the obstetric
conjugate is < 10 cm or the greatest transverse diameter is
< 12 cm or diagonal conjugate is < 11 cm
 Contracted Midpelvis: Midpelvis is considered
contracted when the sum of the inter ischial spinous and
posterior sagittal diameters of the mid pelvis (normal: 10.0
+ 5 = 15.0 cm) is 13.0 cm or below
Contracted outlet is suspected when the inter ischial
tuberous diameter is 8 cm or less
DIAGNOSIS OF CEPHALOPELVIC
DISPROPORTION (CPD) AT THE BRIM
The presence and degree of cephalopelvic
disproportion at the brim can be ascertained by the
following:
Clinical :-(a) Abdominal method; (b)
Abdominovaginal (Muller-Munro Kerr)
Imaging pelvimetry
Cephalometry :-(a) Ultrasound; (b) Magnetic
Resonance Imaging; (c) X-ray
Clinical: In multigravida, a previous history of
spontaneous delivery of an average size baby, reasonably
rules out contracted pelvis
Abdominal method of testing cephalopelvic
disproportion
 Inferences:
The head can be pushed down in the pelvis without
overlapping of the parietal bone on the symphysis pubis
no disproportion.
 Head can be pushed down a little but there is slight
overlapping of the parietal bone evidenced by touch on
the under surface of the fingers (overlapping by 0.5 cm
or 1/4” which is the thickness of the symphysis pubis)
moderate disproportion.
Head cannot be pushed down and instead the parietal
bone overhangs the symphysis pubis displacing the
fingers — severe disproportion
Abdominovaginal method (Muller-Munro
Kerr)
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
X-ray pelvimetry: Lateral X-ray view with the patient in
standing position is helpful in assessing cephalopelvic
proportion in all planes of the pelvis; inlet, Midpelvis
and outlet.
Cephalometry: ultrasonographic measurement of the
biparietal diameter or Magnetic Resonance Imaging
(MRI) gives superior information on accurate
measurement of the size of the head in relation to the
pelvis
 The average biparietal diameter measures 9.4–9.8 cm at
term
Magnetic Resonance Imaging (MRI): MRI 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 delivery
Degree of disproportion and contracted pelvis:
Based on the clinical and supplemented by imaging
pelvimetry, the following degrees of disproportion at
the brim are evaluated.
Severe disproportion: Where obstetric conjugate is <
7.5 cm (3”). Such type is rare to see
Borderline: Where obstetric conjugate is between 9.5
and 10 cm. When both the anteroposterior diameter (<
10 cm) and the transverse diameter (< 12 cm) of the
inlet are reduced, the risk of dystocia is high than when
only one diameter is contracted
 MANAGEMENT OF CONTRACTED
PELVIS
INLET CONTRACTION:-The pre requisite 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
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
The moderate and the severe degrees are to be dealt by
any one of the following:
 Preterm induction of labor
 Elective cesarean section at term
 Trial labor
Induction of labor prior to date: Induction 2–3 weeks prior
to the EDC may be considered only in cases with moderate
degrees of pelvic contraction. It is not favored nowadays
Elective cesarean section at term: Elective cesarean
section at term is indicated in
 major degree of inlet contraction and also in moderate
degree of inlet contraction associated with outlet contraction
or complicating factors like elderly primigravida,
malpresentation, post cesarean pregnancy
Trial of labor: is the conduction of spontaneous labor in a
moderate degree of CPD, in an institution under supervision
with watchful expectancy, hoping for a vaginal delivery
MIDPELVIC AND OUTLET DISPROPORTION: in
practice the two problems are jointly considered as
outlet contraction
Cephalopelvic disproportion at the outlet is defined as
one where the biparietal suboccipitobregmatic plane
fails to pass through the bispinous and anteroposterior
planes of the outlet
Management: Unlike inlet disproportion, clinical
diagnosis of Midpelvis and outlet disproportion can
only be made after the head sufficiently comes down
into the pelvis
Elective cesarean section: Contraction of both the
transverse and anteroposterior diameters of the
midpelvic plane or minor contraction associated with
other complicating factors is dealt by elective cesarean
section.
To allow vaginal delivery: In otherwise
uncomplicated cases with minor contraction, vaginal
delivery is allowed under supervision with watchful
expectancy
CASES SEEN LATE IN LABOR is not an
uncommon problem in the developing countries
 The principles of management rest on:
 Cesarean section to avoid difficult forceps
 Forceps with deep episiotomy
 Symphysiotomy followed by ventouse or
 Craniotomy if the fetus is dead.
Obstructed labor and uterine
rupture
 Introduction
Modern Obstetric care has led to the virtual disappearance of
obstructed labor in developed countries,
However, in underdeveloped countries obstructed labor is not
uncommon.
Obstructed labor is one of the four leading causes of direct
maternal death.
 DEFINITION AND
SIGNIFICANCE
Obstructed labor is failure of descent of the fetus
in the birth canal for mechanical reasons in spite
of good uterine contractions.
It accounts for about 8% of maternal deaths
globally.
In Ethiopia we host the biggest fistula hospital
in the world due to obstructed labor.
Obstructed labor is an outcome of a neglected and
mismanaged labor.
 Causes
Obstructed labor is usually an end result of improperly
managed CPD
Maternal causes:
Contracted pelvis,
Abnormal shaped pelvis,
Soft tissue obstruction
Uterus – impacted subserous pedunculated myoma,
Cervix - cervical dystocia( Difficult childbirth)
Vagina – septum, stenosis, or tumors
Ovaries – impacted ovarian tumors
Trauma to bony pelvis, polio, Congenital Deformity
of bony pelvis
 Causes
Fetal causes:
1- Malpresentations and malpositions :
Persistent Occipito-posterior and deep transverse
arrest,
Persistent mento-posterior and Transverse arrest of
the face presentation.
Brow presentation,
Shoulder,
Impacted frank breech.
 Causes
2- Large sized fetus ( macrosomia).
3- Congenital anomalies :
- Hydrocephalus.
- Fetal Ascites.
- Fetal tumors.
4- Locked and conjoined twins.
 CLINICAL PRESENTATION
Hx:
Prolonged labor often extending to days rather than
hours
Prolonged rupture of membranes
Painful contractions (contractions eventually might
cease due to uterine hypotonia or rupture)
Fever
 PHYSICAL FINDING
Exhausted, tired and anxious
Dehydrated and acidotic
Rapid pulse and often febrile
Hypotension or shock (septic or hemorrhagic due to
infection or uterine rupture)
Distended hypoactive bowels due to electrolyte deficit
Hypotonic or hyperactive uterine contractions
depending on the progress of labor
The cause of the obstruction may be evident on
abdominal examination (abnormal lie, big baby)
 PHYSICAL FINDING
In the presence of uterine rupture:
The abdomen will be tender,
Fetal parts are easily felt, lie and presentation may be difficult
to detect as the baby has been displaced into the peritoneal
cavity.
There will be flank dullness suggestive of hemoperitoneum.
The fetus may be distressed or dead
Distended bladder due to retention or edema
In multiparous woman and in a primigravid patient with
advanced obstructed labor the three tumour abdomen
may be evident (bladder, lower and upper uterine
segments separated by pathological Bandl’s ring.)
 PHYSICAL FINDING
Vaginal examination will reveal edematous vulva
(Cannula sign), and cervix, foul smelling meconium
stained liquor, severe caput and moulding.
The cervix may or may not be fully dilated and the
station may be high or low depending on the level of
obstruction.
Catheterization is often difficult because of the impacted
presenting part necessitating insertion of two fingers
behind symphysis pubis to pass Foley catheter.
 MANAGEMENT
When obstructed labor is diagnosed it must be relieved with
out delay.
However the effects of the preceding prolonged labor must
be partially rectified.
Fluid and electrolyte imbalance
Control of infection
Emptying the bladder
Emptying the stomach
Crossmatching Blood
 MANAGEMENT
RESUSCITATION:
If delivery is not imminent or likely to be so shortly,
resuscitation is the first step before facilitating transfer
of the patient to higher health institution.
In a hospital admit the patient straight to the delivery
unit or operating theatre
Update Hct, Blood group and Rh type, and white blood
cell count
Start intravenous fluid right away to correct dehydration
Vital signs should be checked regularly.
 MANAGEMENT
Start Oxygen 6 lit/min if there is fetal distress or maternal
distress
Start broad spectrum antibiotics.
Ampicillin
Chloramphenicol and
Gentamycin. Clindamycin and Metronidazole iv are alternatives
to Chloramphenicol
Insert indwelling catheter into the urinary bladder.
If cesarean section is planned empty stomach with NGT
If uterine rupture is strongly suspected, prepare two units
of blood.
Give sometime for the patient and family before major
operative delivery and provide reassurance.
 Operative delivery
A balanced decision should be taken on the method of
delivery and there is no place for “wait and see” policy
in obstructed labor.
The obstruction should therefore be relieved by
operation (abdominal or vaginal)
Choice of the operative intervention should depend on:
Fetal condition (dead or alive)
Station or descent of the presenting part
The presence or absence of evidence of imminent or overt
uterine or rupture
Fetal presentation
Extent of cervical dilatation
The cause of obstruction
 Operative delivery
Vaginal:
Episiotomy
Instrumental delivery
Destructive delivery
An operative vaginal delivery should never be tried
if there is uterine rupture as it can cause:
 extension of the rupture
 release of the tamponade effect of the presenting part
aggravating blood loss
Explore the uterus after any vaginal operative
delivery.
 Operative delivery
 Episiotomy
 Episiotomy may be the only intervention required in a
patient with the presenting part in the perineum.
 This is often the case when obstruction is due to tight
perineum.
 Obstructed labor due to CPD at the outlet level, such as due
to occiput posterior position, could be effected by generous
episiotomy.
 VACUUM AND FORCEPS
DELIVERY

No major degree CPD

Descent not more than 1/5 above brim
Other pre-conditions for forceps and vacuum are met
The procedure preferably should be a lift out
The fetus must be alive
 CESAREAN SECTION
 Cesarean section is indicated if:
 The fetus is alive and exceptional conditions for
instrumental delivery are not satisfied
 The fetus is dead and conditions for vaginal
operative deliveries (instrumental or destructive) are
not met.
 DESTRUCTIVE DELIVERIES
Destructive operations (craniotomy, decapitation,
evisceration and cleidotomy) are indicated if:
 The baby is dead or hopelessly malformed
 Descent is 2/5 or below pelvic brim
 No evidence of imminent or overt uterine rupture. If
imminent uterine rupture is suspected, destructive
delivery under direct vision is indicated.
 Cervix at least dilated to 8cm but preferably should be
fully dilated.
 OTHER INTERVENTIONS

 Cesarean hysterectomy (if the uterus is found

severely infected or necrotic at cesarean section)
 Symphysiotomy done in some areas to deliver
obstructed labor due to borderline CPD with a live
baby in cephalic presentation
 Hysterectomy is indicated if the uterus is ruptured
 PREVENTION
Obstructed labor is preventable!!
Good obstetric service
Risk assessment: short stature, bony deformity, big
baby, malpresentation, malpositions, pelvic
assessment antenatally for selected patients
Careful assessment of labor progress with Partograph
 COMPLICATIONS
Uterine rupture
Fistula-faecal, urinary and its psychosocial effects
Cervical and vaginal scarring and stenosis
Pressure sores and contractures
Foot injury
Sepsis
PPH, amenorrhea, infertility
Fetal loss and maternal death
“If a woman in the battle to reproduce her
race has ruptured her uterus , she should
be invalidated from the service, for it is
not with cripples that an army takes the
field!!”