Cephalopelvic Disproportion (CPD)

Cephalopelvic disproportion (CPD) is a pregnancy complication in which there is a size

mismatch between the mother’s pelvis and the fetus’ head. The baby’s head is proportionally too
large or the mother’s pelvis is too small to easily allow the baby to fit through the pelvic
opening.
Risk factors and causes of cephalopelvic disproportion:
Some women are more likely to have a pregnancy with cephalopelvic disproportion than
others. Risk factors include:
 Infertility treatment
 Maternal obesity
 Previous cesarean delivery
 Polyhydramnios (1)
 Gestational diabetes
 Postmaturity or gestational age over 41 weeks
 Multiparity (mother has previously been pregnant) (2)
 Age 35 or over (advanced maternal age)
 Short stature (3)
 Transverse diagonal measurement < 9.5 cm (a measurement of the mother’s pelvis) (4)
 The mother has a history of childhood calcium deficiency or rickets (5)
 A variety of problems with the pelvis or birth canal
Cephalopelvic disproportion may be of maternal or fetal origin. In some cases, the mother’s
pelvis is unusually small; in others, the fetus’ head is unusually large. A combination of these
two issues is also possible. Some causes of CPD include the following (6):
 Contracted pelvis: This occurs when a woman’s pelvis is smaller than normal in any
important pelvic measurement (diameter).
 Pelvic exostoses: These are bony growths on the pelvis.
 Spondylolisthesis: This is a condition in which a bone in the spine slips out of its proper
position onto the bone below it.
 Large sized baby: This can be caused by gestational diabetes and other conditions that
cause a baby to be macrosomic (weight is > 4000 or 4500 grams) or large for gestational
age (LGA). Post-term pregnancies and hydrocephalus (fluid in the baby’s brain that leads
to swelling) may also cause cephalopelvic disproportion.
Signs and symptoms of cephalopelvic disproportion (CPD):
The presence of certain conditions during labor and delivery indicate that there may be a
case of cephalopelvic disproportion. If the fetus maintains a high station, even after a significant
amount of contractions, this indicates that fetal descent through the birth canal may be difficult.
Although it is not the only potential explanation, CPD should be evaluated as a possible cause of
failure to descend.
Prolonged and arrested labor can result in oxygen deprivation, so medical professionals
should also watch for signs of fetal distress.
Diagnosing cephalopelvic disproportion (CPD):
Listed below are several methods employed by physicians to try and assess the size of the pelvis
and baby, which can help to diagnose CPD:
 Pelvimetry by MRI: This is used to assess the dimensions of the pelvis, determine the
baby’s position, and examine the soft tissues of the mother and baby.
 Clinical pelvimetry: This is a process used to assess the size of the birth canal using the
hands and/or with a pelvimeter.
 Ultrasound: The baby’s head and body size are measured during a routine ultrasound
examination. Measurements are compared against standardized growth charts to
determine the relative risk of CPD by the time of delivery.
 X-ray or CT pelvimetry: This is a radiographic examination used to determine the
dimensions of the mother’s pelvis and the diameter of the baby’s head. The value of x-ray
pelvimetry needs to be weighed against the risk of radiation exposure.
Treatment for cephalopelvic disproportion (CPD):
Treatment for CPD varies based on severity and when it is diagnosed. If it is severe and
diagnosed early, a planned C-section is indicated. In other cases, CPD may be treated with a
symphysiotomy (the surgical division of pubic cartilage) or an emergency C-section after a trial
of labor. When CPD is present, continued attempts to deliver the baby vaginally can cause undue
trauma and permanent injury to the baby.
Cephalopelvic disproportion (CPD) and birth injuries:
Physicians faced with CPD must be very skilled in treating this potentially dangerous
condition. Listed below are issues and complications that can occur when CPD is present.
 Overdose of Pitocin (synthetic oxytocin): One of the major problems with CPD is that
physicians may react by administering Pitocin in an effort to speed up delivery. Too
much of this drug may cause excessive and traumatic contractions, which can harm the
baby.
 Prolonged Labor: Many physicians allow labor to progress for far too long. Labor is a
trying time for the baby, and if it is prolonged, oxygen-deprivation injuries may occur.
These injuries can lead to hypoxic-ischemic encephalopathy, cerebral palsy, and
developmental delays. Furthermore, the trauma from continued labor may result in
serious intracranial hemorrhages (brain bleeds).
 Shoulder Dystocia: When CPD is present, the baby is more likely to have shoulder
dystocia injuries, including Erb’s Palsy or Klumpke’s palsy.
 Umbilical Cord Compression: When there is decreased room in the uterus, either
because of a large baby or a small maternal pelvis, oxygen deprivation may occur due to
a trapped umbilical cord.
 Nursing Interventions Rationale

Review the history of Helpful in identifying possible causes, needed diagnostic

labor, onset, and studies, and appropriate interventions. Uterine
duration. dysfunction may be caused by an atonic or a hypertonic
state. Uterine atony is classified as primary when it
occurs before the onset of labor (latent phase) or
secondary when it occurs after well-established labor
(active phase).

Note timing/type A hypertonic contractile pattern may occur in response

of medication(s). Avoid to oxytocin stimulation; sedation/analgesia given too
administration early (or in excess of needs) can inhibit or arrest labor.
of narcotics or of epidural
block anesthetics until
the cervix is 4 cm dilated.

Note the condition of
cervix. Monitor for signs
of amnionitis. Note
elevated temperature or
WBC; odor and color of
vaginal discharge.
A rigid or unripe cervix will not dilate, impending fetal
descent/labor progress. Development of amnionitis is
directly related to length of labor, so that delivery should
occur within 24 hr after rupture of membranes.
 Assess uterine contractile
pattern
manually (palpation) or
electronically via
external, or
internal monitor with
internal uterine pressure
catheter (IUPC).
Dysfunctional contractions lengthen labor increasing the
risk of maternal/fetal complications. A hypotonic pattern
is reflected by frequent, mild contractions measuring less
than 30 mm Hg via IUPC or “soft as chin” per palpation.
A hypertonic pattern is reflected by increased frequency,
an elevated resting tone per palpation or greater than 15
mm Hg via IUPC, and possibly decreased intensity of
contractions. Note: Intensity of contractions cannot be
measured by an external monitor.

Evaluate the current level Excess maternal exhaustion contributes to secondary

of fatigue, as well as dysfunction, or may be the result of prolonged labor/false
activity and rest prior to labor.
onset of labor.

Note effacement, fetal These indicators of labor progress may identify a

station, and fetal contributing cause of prolonged labor. For
presentation. example, breech presentation is not as effective a wedge
for cervical dilation as is vertex presentation.

Evaluate degree of Prolonged labor can result in a fluid-electrolyte

hydration. Note amount
and type of intake.
imbalance as well as depletion of glucose reserves,
resulting in exhaustion and prolonged labor with
increased risk of uterine infection, postpartal
hemorrhage, or precipitous delivery in the presence of
hypertonic labor.

Graph cervical dilation May be used on occasion to record progress/

and fetal descent against prolongation of labor.
time (i.e., Friedman
curve).

Review bowel habits and Bowel fullness may hinder uterine activity and interfere
regularity of evacuation with the fetal descent.

Encourage client to void A full bladder may inhibit uterine activity and interfere
every 1–2 hr. Assess with the fetal descent.
for bladder fullness over
symphysis pubis.

Place client in lateral Relaxation and increased uterine perfusion may correct a
recumbent position and hypertonic pattern. Ambulation may assist gravitational
encourage bed rest or forces in stimulating normal labor pattern and cervical
sitting dilation.
position/ambulation,as
tolerated.

Have emergency delivery May be needed in the event of a precipitous labor and
kit available. delivery, which are associated with uterine hypertonicity.

Remain with the client if Decrease external stimuli may be important

possible, arrange for to allow sleep after administration of medication to
the presence of doula as a client in the hypertonic state. Also helpful in decreasing
appropriate; provide the level of anxiety, which can contribute to both primary
a quiet environment as and secondary uterine dysfunction.
indicated.

Palpate the abdomen of In obstructed labor, a depressed pathological ring

thin client for (Bandl’s ring) may develop at the juncture of lowerand
the presence of upper uterine segments, indicating an impending uterine
pathological retraction rupture.
ring between uterine
segments. (These rings
are not palpable through
the vagina or through the
abdomen, in the obese
client).

Investigate reports of May indicate developing uterine tear/acute rupture

severe abdominal pain. necessitating emergency surgery. Note: Hemorrhage is
Note signs of fetal
 distress, cessation of
contractions, presence of
vaginal bleeding.
Prepare client for
amniotomy, and assist
with the procedure, when
the cervix is 3–4 cm
dilated.
Administer narcotic or
sedative, such as
morphine, pentobarbital
(Nembutal), or
secobarbital
(Seconal), for sleep as
indicated.
Use nipple stimulation to
produce endogenous
oxytocin or initiate
infusion of exogenous
oxytocin (Pitocin) or
prostaglandins.
Prepare for forceps
delivery, as necessary.
Assist with preparation
for cesarean delivery, as
indicated, e.g.,
malposition, CPD, or
Bandl’s ring.
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birth-injuries/cephalopelvic-disproportion/
usually occult since it is intraperitoneal with hematomas
of the broad ligament.
Rupture of membranes relieves uterine overdistension (a
cause of both primary and secondary dysfunction) and
allows presenting part to engage and labor to progress in
the absence of cephalopelvic disproportion (CPD). Note:
Active management of labor (AML) protocols may
support amniotomy once presenting part is engaged to
accelerate labor/help prevent dystocia.
May help distinguish between true and false labor. With
false labor, contractions cease; with true labor, a more
effective pattern may happen following a rest. Morphine
helps promote heavy sedation and eliminate hypertonic
contractile pattern. A period of rest conserves energy and
reduces utilization of glucose to relieve fatigue.
Oxytocin may be necessary to increase or institute
myometrial activity for a hypotonic uterine pattern.It is
usually contraindicated in hypertonic labor pattern
because it can accentuate the hypertonicity, but may be
tried with amniotomy if the latent phase is prolonged and
if CPD and malpositions are ruled out.
Excessive maternal fatigue, resulting in ineffective
bearing-down efforts in stage II labor, necessitates
the use of forceps.
Immediate cesarean birth is indicated for Bandl’s ring or
fetal distress due to CPD. Note: Once labor is diagnosed,
if delivery has not occurred within 12 hr, and amniotomy
and oxytocin have been used appropriately, then a
cesarean delivery is recommended by some protocols.