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Pelvimetría Clínica PDF
Pelvimetría Clínica PDF
Clinical Pelvimetry
EDWARD R. YEOMANS, MD
From the Department of Obstetric, Gynecology and Reproductive,
University of TexasHouston Health Science Center, Houston,
Texas
140
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Clinical Pelvimetry 141
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142 Yeomans
to the iliac fossae is found in the chapter on the promontory of the sacrum is not actually
vaginal delivery of twins. touched. This enables the examiner to con-
The true pelvis has great obstetric signi- clude only that the DC is .12 cm, for exam-
cance; its anatomic features from inlet to ple, and not to specify the actual length. A
outlet enable the discerning examiner to further assumption is that subtracting 1.5
classify an individual pelvis into one of cm from the DC will approximate the
the 4 types. However, the inlet is the upper obstetric conjugate (OC), the shortest AP
boundary of the true pelvis and thus least diameter of the pelvis through which the
accessible to physical examination. In the fetal head must pass. An OC ,10.5 cm is
plane of the inlet, the key anatomic features considered contracted (see the concluding
of the bony pelvis that are important to the section of this article concerning fetopelvic
clinical examiner are the sacral promontory relationship for further discussion of this
and the much-less-emphasized retropubic denition of contracted OC). Finally, in all
angle formed by the union of the left and instances in which the presenting part has
right superior pubic rami on their posterior entered the true pelvis, the DC cannot be
aspects. Proceeding inferiorly, important clinically assessed. Despite these signicant
pelvic features include the width of the sac- limitations, the estimation of the DC is one
rosciatic notch (in the living woman, this of the few elements of clinical pelvimetry
notch is converted to the greater sciatic fora- that has stood the test of time.
men by the sacrospinous ligament), the ante- A second, and often overlooked, aspect of
rior surface of the sacrum, the ischial spines inlet assessment is the retropubic angle.3
and tuberosities, the inner surface of the Older textbooks refer to this as the forepel-
ischium, the subpubic arch, the descending vis and use terms like wide, round, narrow,
pubic rami, and the coccyx. Clinical pelvim- and angulated as descriptors. Calling it a ret-
etry, then, consists of a series of maneuvers ropubic angle, whereas not entirely accurate,
designed to assess these important anatomic emphasizes the proper assessment of the
features. It is insufcient to classify a partic- anterior aspect of the inlet. The examiner
ular pelvis into one of the 4 basic types because should bring 2 ngers up under the pubic
mixed architectural features are encountered on arch, then acutely drop the wrist and palpate
a daily basis in clinical practice. with the volar surface of index and middle
ngers the symphysis and both superior
pubic rami along their posterior surfaces.
Clinical Pelvimetry In an android pelvis, the retropubic angle
is sharp and acute. In the platypelloid pelvis,
THE INLET the angle is so at that it nearly forms a
The assessment of the diagonal conjugate straight (180) angle, similar to feeling a
(DC) provides the clinician with information blackboard. In the gynecoid pelvis, the ret-
regarding the anteroposterior (AP) diameter ropubic angle starts out at in the midline
of the pelvic inlet. There are, however, sig- but then curves gently backward laterally.
nicant limitations to estimating the DC. In an anthropoid pelvis, the backward curve
First, to ever reach the sacral promontory, is detected earlier and curves back more
the examiner must drop both wrist and sharply.
elbow and reach cephalad with the tip of
the middle nger. The inferior margin of THE MIDPLANE
the symphysis pubis will come in contact Of all the various levels of the pelvis, the
with the dorsal aspect of the examining midplane is the area where the most infor-
hand. The distance from the tip of the mid- mation is missed by the inexperienced
dle nger to the point of contact on the back examiner. The examination of the midpelvis
of the hand can be measured, but most often begins with the ngers ventral surface
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Clinical Pelvimetry 143
directed posteriorly toward the sacrum. In all slope of the pelvic sidewall (a vague term
pelvic types, the lower sacral vertebrae can that relates to the inner surface of the ischium)
usually be reached. A forward lower one can be determined. Practically speaking, the
third of the sacrum should alert the examiner sidewalls are described as either straight
to the possibility of an android pelvis, the (parallel) or convergent, the latter suggest-
most dangerous type of pelvis if instrumen- ing a funnel-shaped or android pelvis. In
tal assistance is contemplated. Following the 30 years of performing clinical pelvimetry,
anterior aspect of the sacrum superiorly as I have never characterized a pelvis as having
high as possible can give the impression divergent sidewalls. Nevertheless, such a
of either a hollow or at sacrum, the latter description exists in the literature and is
being much less common. With the palmar referred to as a blunderbuss pelvis,3 itself
or volar surface of the ngers still directed an archaic term. Before leaving the assess-
posteriorly, the ngers should slowly move ment of the midplane, I would briey like
to the lateral border of the sacrum, where to comment on the bispinous diameter, the
the sacrospinous ligament originates. This narrowest transverse pelvic diameter through
bandlike structure can be traced further lat- which the fetal head must pass. Regrettably,
erally to its insertion on the ischial spine, this diameter cannot be readily assessed
and the entire length of the ligament can clinically. Some authors suggest separating
be estimated in ngerbreadths. The sacro- the examining ngers as widely as possible
spinous ligament converts the sacrosciatic and that in rare contracted pelves, one may
notch (not clinically accessible for evalua- be able to span the distance between the
tion) to the greater sciatic foramen. Once spines. I have never found this helpful. The
again, the length and direction of this liga- perpendicular diameter that begins at the
ment gives important clues to the overall inferior margin of the symphysis, extends
pelvic type. The ligament length is normally to the hollow of the sacrum at around the
estimated in ngerbreadths, a disadvant- junction of the third and fourth sacral verte-
age given the varying size of modern exam- brae, and bisects the bispinous diameter is
iners ngers. Less than 2 ngerbreadths also difcult to assess clinically. The line
implies a narrow sacrosciatic notch, a fea- segment that originates at the junction of
ture of an android pelvis. A 3-ngerbreadth the AP and transverse diameters of the mid-
ligament that is directed more laterally than plane and extends to the sacrum posteriorly
anteriorly suggests a platypelloid pelvis. The is referred to as the posterior sagittal diam-
ligament in an anthropoid pelvis is also 3 or eter. The posterior sagittal diameter (see Fig.
more ngerbreadths wide but is directed much 4), when short, may indicate AP narrowing,
more anteriorly than laterally. The gynecoid
pelvis has a sacrospinous ligament that is
intermediate between narrow and wide.
Following the ligament from the lateral
border of the sacrum to the ischial spine is
the best method of locating the spine (and
is essential for proper performance of a pu-
dendal nerve block). Once the spine has
been reached, the examiner should record
a qualitative description using the terms promi-
nent, blunt, or average.
Just anterior to the ischial spine is the
interior surface of the ischium. With the
thumb of the opposite hand resting on the FIGURE 4. The posterior sagittal diameter in
ipsilateral ischial tuberosity externally, the the plane of the ischial (difcult to assess clinically).
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144 Yeomans
a forward lower one third of the sacrum, or bituberous diameter (BTD). Recently, one of
both, but I have no special secret on how to our residents completed a research project in
assess the posterior sagittal diameter clini- which the BTD was estimated as a dichoto-
cally either. Conceptually, if one were to mous variable (,8 cm, .8 cm) in more
envision a coronal plane through the ischial than 250 nulliparous women. The technique
spines as partitioning the pelvis into anterior described more than 50 years ago was used,
and posterior halves, then a long posterior placing the previously measured st exter-
sagittal segment bespeaks available room nally between the ischial tuberosities. The
for the fetal head in the posterior pelvis, a study yielded the clinically and statistically
favorable sign. signicant result that a narrow (,8 cm)
BTD is associated (odds ratio of 15) with
THE OUTLET a markedly increased risk of either deep
There are 3 important aspects of the pelvic perineal laceration or extension of a midline
outlet that require evaluation. The rst is episiotomy compared with a BTD .8 cm.
the coccyx, which is sometimes sharply At our institution, we record the BTD on
angulated anteriorly in a sh-hook or almost every woman admitted through tri-
J-shape. Both the shape and mobility of age. A narrow BTD is a very strong indica-
the coccyx should be described. Next, the tor of an android pelvis, although occasion-
subpubic (not to be confused with the retro- ally a narrow BTD can also be found in an
pubic discussed earlier) angle is estimated, anthropoid pelvis. Whether a narrow BTD
which gives information about the pubic may be an indication for a mediolateral
arch. A gynecoid pelvis has a subpubic rather than a midline episiotomy was not
angle .90, whereas an android pelvis addressed in this research project.
has a subpubic angle that is always acute
and may be as narrow as 60. However,
examiners do not usually have a protractor Fetopelvic Relationships
or a goniometer handy during the perform- The preceding description of the basic tech-
ance of clinical pelvimetry. Therefore, the niques of clinical pelvimetry serves to set
examining ngers once again can be used the stage for practical application of this
to advantage. A gynecoid pelvis has a sub- art. One of the risks of vaginal breech deliv-
pubic arch characterized as Norman, that ery is head entrapment not by just the cervix,
is, rounded and roomy; the 2 examining n- but by a contracted bony pelvis. Fetal heads
gers can be raised, ventral side up, all the in cephalic presentations have ample time to
way to the lower border of the symphysis mold, ex, and adapt to a relatively con-
without being displaced. Then palpation of tracted pelvis, but the aftercoming head of
the descending pubic rami (which form the breech must negotiate the pelvis in sec-
the hypotenuses of 2 mirror-image right tri- onds to minutes. I believe, as did the authors
angles with the apex at the symphysis and of the Term Breech Trial,4 that a pelvis can
the base along the bituberous diameter be clinically determined by an experienced
bisected in the midline) will trace out a examiner to be adequate for vaginal breech
rounded arch terminating in the tuberosities. delivery. Others feel strongly that computed
In contrast, the examining ngers will often tomographic pelvimetry is indicated in just
be forced to overlap at the top of the this circumstance.5 In disagreement with
Gothic arch found in an android pelvis. the conclusions of the Term Breech Trial,
The descending pubic rami that form the however, I believe that there is still a place
Gothic arch are closely spaced and end more in modern obstetric practice to deliver vag-
medially in the tuberosities. inally a breech fetus for a woman who meets
This brings us to what I consider the most rigorous selection criteria in addition to hav-
important element in outlet assessment: the ing an adequate pelvis.
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Clinical Pelvimetry 145
Because over 95% of all fetal presenta- including the clinical pelvimetry assess-
tions are cephalic, the emphasis in the re- ment, the arrest of descent was attributed
mainder of this section is on head-rst deliv- to asynclitism. Luikart forceps with a sliding
eries. A separate article in this symposium lock were placed, the asynclitism was cor-
deals with vaginal breech delivery. rected instrumentally, and a 3850-g fetus
The term fetopelvic merges 2 separate was delivered by forceps over a midline epis-
entities that must be evaluated before under- iotomy. There was no birth trauma, the infant
taking operative vaginal delivery. Too much was vigorous, and the episiotomy did not
emphasis has been accorded to the estima- extend. This case demonstrates the contribu-
tion of fetal weight by either clinical or sono- tion of pelvic assessment to achievement of
graphic methods, neglecting the importance a vaginal delivery with an excellent maternal
of careful clinical pelvimetry. The overall and fetal outcome.
stature of the woman (tall, short, obese, petite) Sometimes, instead of contributing to a
should be considered and the pelvis eval- successful vaginal delivery, clinical pelvim-
uated with this and estimated fetal weight etry can prompt a decision to proceed with
in mind. The bony pelvis itself may be primary cesarean delivery. In a woman
adequate but fetal malposition, deexion, undergoing labor augmentation with oxyto-
and asynclitism may contribute to an arrest cin, adequate contractility of 250 Montevi-
of descent. Correction of the fetal abnormal- deo units was achieved. No progress in dila-
ity may reveal that the pelvis was clinically tion ensued over 2 hours. Recent work sug-
adequate despite inability to achieve a spon- gests extending the labor for another 2 hours
taneous delivery. Consider the following before resorting to cesarean,6 but vaginal
representative case. examination revealed the fetal head to be
A 22-year-old G1P0 at term reached at 3 station with moderate caput forma-
complete dilation after oxytocin augmenta- tion. The sacral promontory was easily
tion for active phase arrest. At 1 hour of reached and the DC was estimated at 10
pushing, her pelvic examination revealed cm, giving an estimated OC of 8.5 cm. This
the fetal head to be at +2 station, left occiput nding had been overlooked at the start of
anterior, but markedly asynclitic. Mild caput the augmentation. It was elected to proceed
had formed over the anterior parietal bone. immediately to cesarean delivery for sus-
At that point, clinical pelvimetry was per- pected inlet contraction instead of pursuing
formed. The diagonal conjugate could not further, probably futile augmentation.
be assessed as a result of the low station. If rotational forceps delivery is consid-
The retropubic angle was gently rounded, ered, adequate assessment of the pelvis is
the ischial spines were blunt, the hollow of imperative. I do not agree that all occiput pos-
the lower sacrum was only partially lled, terior (OP) fetuses should be rotated before
and the sidewalls were straight. The subpu- delivery nor do I agree that instrumental deliv-
bic arch was greater than 90, and the bitu- ery as an OP is always appropriate. Instead,
berous diameter was .8 cm. The coccyx the method of delivery should depend on
was mobile. Although the diagonal conju- the integration of all clinical variables with
gate was not evaluated, the impression of special emphasis on clinical pelvimetry.
the examiner was that the pelvis was gy- A contracted pelvis diagnosed clinically
necoid. The estimated fetal weight was may still allow delivery of a small to average
3600 g. It was decided to allow the patient fetus after adequate rst and second stages
to continue pushing, but after 1 more hour, of labor. A second twin may be larger than
an arrest of descent was diagnosed. The the rst, but still considerably smaller than a
fetal heart rate pattern was reassuring and term singleton infant. Therefore, I seldom
there was a functioning epidural in place. choose cesarean delivery simply because
Putting together all the clinical data, twin B is larger than twin A.
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146 Yeomans
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.