22 cephalo-pelvic disproportion

8/12/2019 22 Cephalo-pelvic Disproportion

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CONTRACTED PELVIS


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DEFINITION

Anatomical definition:

It is a pelvis in which one or more of its main

diameters are reduced below average normal by one

or more centimetres

Obstetric definition:

It is a pelvis in which one or more of its main

diameters are reduced to the extent that interferes

with the normal mechanism of labour


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ETIOLOGY

1. Developmental causes Small gynaecoid -- generally contracted pelvis

Small android

Small anthropoid Small flat platypelloid pelvis

Naegeles pelvis

Roberts pelvis

High assimilation pelvis Low assimilation pelvis

Split pelvis


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NAEGELES PELVIS


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ROBERTS PELVIS


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FAULTY DEVELOPMENT


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2. Diseases of the pelvic bones and joints

Metabolic diseases ---- Rickets, Osteomalacia

Bone tuberculosis

Severe malnutrition

Poliomyelitis

Hipjoint disease

Fractures of the pelvic bones, tumours of the pelvic

bones


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Rachitic pelvis Osteomalacic pelvis


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3. Causes in the spine

Scoliosis

Kyphosis

Spondylolisthesis

Coccygeal deformity


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Kyphotic pelvis Scoliotic pelvis


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DIAGNOSING CONTRACTED PELVIS

1. HISTORY:

GENERAL: Rickets, Osteomalacia,

Poliomyelitis, TB, fracture

OBSTETRIC: Previous prolonged labour,

difficult vaginal delivery, perineal tear,

vesico-vaginal or recto-vaginal fistula


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2. PHYSICAL EXAMINATION

Height: high risk


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Dystocia - dystrophia syndrome:

short and obese

stocky

broad shoulders and short thighs

sub-fertile

has android pelvis

masculine hair distribution

with history of delayed menarche


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3. ABDOMINAL EXAMINATION

4. PELVIMETRY

* Clinical

* Imaging - X- Ray, CT, MRI


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Data Findings

Forepelvis (pelvic brim) RoundDiagonal conjugate 11.5 cmAnterposterior diameter of outlet 11.0 cm

Symphysis Average thickness, parallel to sacrumSacrum Hollow, average inclinationSide walls StraightIschial spines BluntInterspinous diameter 10.0 cmSacrosciatic notch 2.5 -3 finger - breadthsSubpubic angle 2 finger - breadthsBituberous diameter 4 knuckles (> 8.0 cm)Coccyx Mobile


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Degrees of Contracted Pelvis

Minor degree: The true conjugate is 9-10 cm

Moderate degree: The true conjugate is 8-9 cm

Severe degree: The true conjugate is 6-8 cm

Extreme degree: The true conjugate is less than6 cm.


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MECHANISM OF LABOUR

1. Flat rachitic pelvis

Engagement : with the sagittal suture in the

transverse diameter

Asynclitism with anterior parietal bone

presentation

Lateral displacement of the head

Deflexion of the head and descent

Rotation of the occiput 2/8 circle anteriorly


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2. Simple Flat Pelvis

Persistent flattening of the pelvis

Contracted outlet

No internal rotation and descent

Obstructed vaginal delivery


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3. Contracted Outlet ( Funnel Pelvis )

Normal descent and engagement

Extreme flexion and moulding of the head at

ischial spines

Narrow subpubic angle causes the head to push

backward

Face to pubis position is more favourable


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CEPHALOPELVIC DISPROPORTION

The disparity in the relation between the head and

the pelvis which 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.


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CAUSES OF HIGH HEAD AT TERM

Occipito-posterior position - deflexion

Deflexed head

Multipara

Halffull bladder

Mistaken maturity

Twin, hydramnios, placenta praevia

Increased angle of inclination


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DIAGNOSING CPD

1.Abdominal method ( Pinards method )


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2. Abdomino-vaginal method (Muller-Munro

Ken)


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EFFECTS OF CONTRACTED PELVIS

1. On pregnancy

2. On labour* maternal

* fetal


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MANAGEMENT OF CONTRACTED

PELVIS

INLET CONTRACTION

Preterm induction of labour

Elective Caesarean section at term

Trial labour


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TRIAL LABOUR

The conduction of spontaneous labour in a

moderate degree of cephalo-pelvic disproportion,

in an institution under supervision with watchful

expectancy, hoping for a vaginal delivery


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CONTRAINDICATIONS

Associated mid-pelvic and outlet contraction

Elderly primigravida

Mal-presentation

Post-maturity

Post caesarean pregnancy

Pre - eclampsia

Medical disorders like heart disease, DM, TB

Unavailability of facilities for caesareansection


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GUIDELINES FOR TRIAL LABOUR

Selection of patients

Monitoring progress

Augmentation of labour

After rupture of membranes

Termination


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Favourable features of trial labour

Unfavourable features

Advantages

Disadvantages


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MID-PELVIC AND OUTLET

CONTRACTION

Cephalopelvic disproportion at the outlet is

defined as one where the biparietal - suboccipito-

bregmatic plane fails to pass through the

bispinous and antero-posterior planes of the

outlet.


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MANAGEMENT

Elective Caesarean section --- In case of

contraction of both the transverse and A-P

diameters of the mid-pelvic plane

Vaginal delivery --- In uncomplicated cases with

minor contraction

*by forceps or ventouse with deep episiotomy to

prevent per ineal injur ies


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22 cephalo-pelvic disproportion

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