Mudaliar

and
Menon’s
Clinical
Obstetrics
13TH EDITION
 Chapter 1
PELVIS

UNIVERSITIES PRESS PVT. LTD.

BOUNDARIES OF A TRUE PELVIS
•The pelvis is an important structure from the
obstetric point of view, as it forms the canal
through which the fetus has to pass.
•The pelvis is divided by the linea terminalis into
two parts:
oThe upper part known as pelvis major or false pelvis
oThe lower part called pelvis minor or true pelvis

UNIVERSITIES PRESS PVT. LTD.

 • Promontory and alae of the sacrum, linea terminalis and
the upper margin of the pubic bones
ABOVE • The linea terminalis is formed by the upper border of the
sacral vertebra, the arcuate line of the ilium and the
pectineal line of the pubis

BELOW • The pelvic outlet

UNIVERSITIES PRESS PVT. LTD.

 • The pelvic cavity is cylindrical in shape.
• Extent: Inlet lies above the outlet below.
STRUCTUR • Shape: Bent cylinder with the posterior wall
E OF THE deeper than the anterior wall.

PELVIS • The depth of the posterior wall is 10 cm.

• The anterior wall is 5 cm.

UNIVERSITIES PRESS PVT. LTD.

 •The upper part is directed downwards and
backwards.
•The lower part curves downwards and forwards.
AXIS OF
THE •Called the curve of Carus.

BIRTH •The curve of Carus is an imaginary line joining

the midpoints of the AP diameters of the inlet,
CANAL cavity and the outlet.
•This line runs downwards and backwards in the
upper half of pelvis, then turns downwards and
forwards in the lower half of the pelvis.

UNIVERSITIES PRESS PVT. LTD.

 •The descent of the fetal
head follows the curve of
Carus.
•At this level, the
contraction of the pelvic
floor muscles direct the
fetal head downwards
and forwards until
delivery.

UNIVERSITIES PRESS PVT. LTD.

Posteriorly The anterior surface of the
sacrum

Laterally The inner surface of the

ischial bones and the WALLS
OF THE
sacrosciatic notches and
ligaments

Anteriorly The pubic bones, the ascending

PELVIS
superior rami of the ischial
bones, and the obturator
foramina

UNIVERSITIES PRESS PVT. LTD.

 MUSCLES
OF THE Location Muscles forming the
TRUE walls
PELVIS Sides The pyriformis
• The pelvic diaphragm is
a musculo-aponeurotic Posteriorly The coccygeus muscles
part separating the
pelvis above from the
perineum and vulva
below. This is formed
by the levator ani and Laterally The obturator internus
the coccygei muscles.
• Three orifices, namely,
the urinary meatus, the
vulval outlet and the Inferiorly The levator ani
anus, pierce this
diaphragm.

UNIVERSITIES PRESS PVT. LTD.

 •The plane of the pelvic inlet (superior
strait)
PLANES
AND •The plane of the pelvic outlet (inferior
strait)
DIAMETERS •The plane of the least pelvic dimensions
OF THE (midpelvis)
PELVIS •The plane of the greatest pelvic dimensions
in the cavity (no obstetrical significance)

UNIVERSITIES PRESS PVT. LTD.

The three boundaries are:
1 Posterior Sacral promontory and alae of the sacrum

2 Lateral Linea terminalis

3 Anterior Horizontal rami of the pubic bones and

symphysis pubis

BOUNDARIES AND DIAMETERS OF THE PELVIC INLET

UNIVERSITIES PRESS PVT. LTD.

 The three diameters at
the brim are:
•Anteroposterior
•Transverse
•Right and left oblique

UNIVERSITIES PRESS PVT. LTD.

There are three anteroposterior
diameters:
•The obstetric conjugate
•The diagonal conjugate
•The anatomical conjugate (conjugate vera)

UNIVERSITIES PRESS PVT. LTD.

 1. ANTERO–POSTERIOR
a) Obstetric conjugate
• Middle of sacral promontory to middle of the
DIAMETE posterior margin of the pubic symphysis
• Measures 10 cm
RS OF b) Diagonal conjugate
THE • Subpubic angle to middle of the sacral
promontory
INLET • Measures 12 cm

Subtracting 1.5–2 cm from the diagonal

conjugate gives the obstetric conjugate.

UNIVERSITIES PRESS PVT. LTD.

 c) Anatomic conjugate
• Middle of sacral promontory to the
upper portion of the inner surface of
the symphysis pubis
• Measures 11 cm
• No obstetric significance

UNIVERSITIES PRESS PVT. LTD.

TRANSVERSE DIAMETER
•Widest distance between the linea terminalis on both
sides.
•Measures 13 cm.

OBLIQUE DIAMETER
•Extends from the right sacroiliac joint to the
iliopectineal eminence on the opposite side.
•It is occupied by the suboccipito bregmatic diameter
of the fetal head in occipitoanterior position.
•Measures about 13 cm.

UNIVERSITIES PRESS PVT. LTD.

UNIVERSITIES PRESS PVT. LTD.
SACROCOTYLOID DIAMETER
• It is the distance from the midpoint of the sacral
promontory to the ilio-pectineal eminence on the same
side
• Measures 9 cm
POSTERIOR SAGITTAL DIAMETER:
• It is that part of the AP diameter which lies posterior to
the transverse diameter
• This diameter increases from the pelvic brim to the
outlet.
• At the brim, the posterior sagittal diameter measures 5
cm
Clinical importance at the pelvic brim
The cardinal movement of engagement occurs at the pelvic
brim

UNIVERSITIES PRESS PVT. LTD.

 PELVIC
OUTLET
Boundaries
• Diamond-shaped
Posteriorly By the tip of the
• Lithotomy
coccyx ◦ Produces upward gliding movement
Laterally By the ischial of the sacroiliac joint and thus
increases the transverse diameter of
tuberosities outlet (ITD) by 1.5 to 2 cm
Anteriorly By the pubic arch formed by
inferior rami of the ischium
and the pubis as they converge
towards the symphysis pubis

UNIVERSITIES PRESS PVT. LTD.

 Pubic Symphysis
Pubic Arch

Ischial Tuberosity

Pelvic Outlet

Sacrotuberous Ligament

UNIVERSITIES PRESS PVT. LTD.

 2. Triangular planes

• Anterior
• Posterior
• Anterior apex–subpubic angle
Base – bituberous diameter
PELVIC Sides – pubic rami, ischial
OUTLET tuberosity
• Posterior apex–
sacrococcygeal joint
Base – bituberous diameter
Sides – sacrotuberous
ligament

UNIVERSITIES PRESS PVT. LTD.

 Anteroposterior diameter
•Inferior margin of the pubic symphysis to the
DIAMETERS posterior aspect of tip of sacrum

OF THE •Measures 12 cm
PELVIC Transverse diameter
OUTLET • Distance between the inner edges of 2
ischial tuberosities
• Measures 10.5–11 cm

UNIVERSITIES PRESS PVT. LTD.

 Posterior sagittal diameter:
•Extends from the middle of the transverse
diameter to the tip of the sacrum
•The posterior sagittal diameter of the outlet
DIAMETERS usually exceeds 7 cm

OF THE
PELVIC Anterior sagittal diameter:
OUTLET • Extends from the lower border of the
symphysis pubis to the centre of the
bituberous diameter
• Measures 6 cm

UNIVERSITIES PRESS PVT. LTD.

 • Normally, the width of the pubic arch is such
WASTE that a round disk of 9.4 cm (diameter of a well-
flexed head) can pass through the pubic arch at
SPACE OF a distance of 1 cm from the inferior border of
the symphysis pubis.
MORRIS • This distance is known as the waste space of
Morris.

UNIVERSITIES PRESS PVT. LTD.

 •Angle formed by approximation of
the two descending pubic rami
forming the pubic arch
•In a normal gynecoid pelvis, this
SUBPUBIC angle should be >90o
ANGLE •If this angle is smaller, the
transverse diameter of the outlet is
also smaller
•Clinically, the subpubic angle
should admit two fingers

UNIVERSITIES PRESS PVT. LTD.

 Extends from the inlet to the outlet
Plane of greatest pelvic dimension
CAVITY Plane of least pelvic dimension

UNIVERSITIES PRESS PVT. LTD.

•This plane has no obstetrical significance
•Roomiest part.
•It passes through the junction of the second and third sacral vertebrae,
and laterally through the ischial bones over the middle of the acetabulum
and posterior surface of the symphysis pubis
•It is nearly circular
•The anteroposterior diameter measures 12.5 cm
•The transverse diameter measures 12.75 cm

PLANE OF GREATEST PELVIC

DIMENSION
UNIVERSITIES PRESS PVT. LTD.
 •Midpelvis
•Important plane of pelvis
•The arrest of labor can take place here
•Extends from the apex of the subpubic arch
through the ischial spines to the sacrum (s4
PLANE OF & s5)
LEAST
PELVIC
Boundaries
DIMENSIO
N 1. Lower border of the pubic symphysis
2. White line
3. Ischial spine
4. Sacrospinous ligament
5. Sacrum

UNIVERSITIES PRESS PVT. LTD.

DIAMETERS
Transverse diameter or
interspinous diameter
Antero-posterior diameter
Posterior sagittal diameter
This is the distance between the two ischial
spines and is the smallest diameter of the
pelvis. It measures 10 cm.
It extends from the lower border of the
symphysis pubis to the junction of the 4th and
5th sacral vertebrae. This distance should be a
minimum of 11.5 cm.
It extends from the mid point of the inter
ischial diameter to the junction of the 4th and
5th sacral vertebrae. This measures 6 cm.
UNIVERSITIES PRESS PVT. LTD.
 In a mid-cavity contraction:
•The ischial spines are prominent
•The sacrum is not curved and is flat
MID- •The pelvic side walls are converging
CAVITY •The sacrosciatic notch does not allow 2
ASSESSME fingers
NT •The subpubic arch is narrow and does not
admit 2 fingers

UNIVERSITIES PRESS PVT. LTD.

PELVIC JOINTS
Pubic symphysis

Sacroiliac joint

Sacrococcygeal joint

UNIVERSITIES PRESS PVT. LTD.

CLINICAL SIGNIFICANCE OF THE PELVIC JOINTS
• There is relaxation of the sacroiliac joints during pregnancy due to hormonal
changes.
• Marked mobility of the pelvis—upward gliding movement of the sacroiliac
joint.
• Relaxation of the symphysis pubis—starts in early pregnancy but increases
during the last three months and regresses after delivery.
• When vaginal delivery is conducted in the dorsal lithotomy position,
displacement of the sacroiliac joint is greatest and increases the diameter of
the outlet by 1.5–2 cm.
• In shoulder dystocia, McRobert’s maneuver is successful due to the mobility of
the sacroiliac joint.

UNIVERSITIES PRESS PVT. LTD.

CALDWELL–
MOLLOY
CLASSIFICATION
Four types of pelvises:
• Gynacoid
• Anthropoid
• Platypelloid
• Android

UNIVERSITIES PRESS PVT. LTD.

 Inlet • Since the transverse diameter is only slightly
greater than or equal to the anteroposterior
diameter, the inlet is slightly oval or round.
• The posterior sagittal diameter at the inlet is
slightly less than the anterior sagittal diameter.
• The sides of the posterior segment are well
rounded and wide.
1. GYNECOID
PELVIS Midpelvis In the midpelvis, the side walls of the pelvis
•
CHARACTERISTI are straight, and the spines are not
CS prominent. The transverse diameter at the
ischial spines is 10 cm or more.

Outlet At the outlet, the pubic arch is wide.

•

Sacrum The sacrosciatic notch is well-rounded.

•

UNIVERSITIES PRESS PVT. LTD.

2. ANDROID PELVIS: CHARACTERISTICS
Inlet The posterior sagittal diameter is less than the
anterior sagittal diameter. This restricts the use of
posterior space. The sides of the posterior
segment are not rounded, and the anterior pelvis
is narrow and triangular.

Midpelvis The side walls are usually convergent, and the

ischial spines are prominent.
Outlet The subpubic arch is narrowed.
Sacrum It is set forward in the pelvis and is usually
straight, with little or no curvature. The
sacrosciatic notch is narrow and highly arched.

UNIVERSITIES PRESS PVT. LTD.

3. ANTHROPOID PELVIS:
CHARACTERISTICS
Inlet The anteroposterior diameter is greater than the
transverse diameter. The anterior segment is narrow
and pointed.
Midpelvis The sidewalls are often convergent, and the ischial
spines are likely to be prominent.
Outlet The subpubic arch is narrowed but well shaped.
Sacrum It usually has six segments and is straight. The
sacrosciatic notch is large.

UNIVERSITIES PRESS PVT. LTD.

4. PLATYPELLOID PELVIS:
CHARACTERISTICS
•This pelvis is the rarest of the pure varieties and is found in less
than 3% of women.
•The characteristics of the platypelloid pelvis are:
Transverse oval inlet
Very wide rounded subpubic angle
Very wide flat posterior segment
Narrow sacrosciatic notch
Average sacral inclination
Very wide subpubic arch
Straightside walls
Very wide interspinous and intertuberous diameters
UNIVERSITIES PRESS PVT. LTD.
 Small gynecoid pelvis
• In this type, the diameters are proportionately reduced,
but the shape is normal.
• Hence, there is a delay at every stage of labour due to
the lack of space.
CLINICAL • Powerful uterine contractions are required to push the
SIGNIFICAN presenting part downward. Can cause CPD.
Android pelvis
CE
• With this type of pelvis, the occipitoposterior position is
common.
• Due to the funnel shape of the pelvis, progressive
difficulty is faced, rotation fails to occur, and transverse
arrest is common.

UNIVERSITIES PRESS PVT. LTD.

 Anthropoid pelvis
• In this pelvis, persistent occipito posterior position is
CLINICAL common.
SIGNIFICAN Platypelloid pelvis
CE • In this type of pelvis, there is asynclitic engagement.
• Face presentation can occur.

UNIVERSITIES PRESS PVT. LTD.

 •Rachitic flat pelvis
•Nagele’s pelvis
ABNORMALITIES •Robert’s pelvis
OF THE PELVIS
•Kyphoscoliosis
•Obliquely contracted pelvis

UNIVERSITIES PRESS PVT. LTD.