Bitew

Obstetrician-Gynecologist
Bahirdar,2014

02/20/24 1
 Cephalopelvic disproportion
(CPD)
Definition:
Disparity between the dimensions of the fetal head
and maternal pelvis to preclude vaginal delivery.
○ True CPD is rare and most CPDs are due to
malposition of the fetal head, asynclitism or
extension of the bony diameters of the fetal
head, ineffective ux contraction
○ Inability to achieve vaginal delivery after
reaching complete dilatation is a significant
marker of true dystocia because it is likely to
recur

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 Fetopelvic disproportion
 Arises from either
-diminished pelvic size,
-excessive fetal size, or
-more usually, a combination of both.

 Pelvic capacity
Any contracture of the pelvic diameter that
diminish the capacity of the pelvis can create
dystocia
(Contractions of the pelvic inlet, the mid pelvis, the
pelvic outlet and combinations of these).

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 Causes of CPD
A) Increased Fetal Weight:
Very large baby due to hereditary reasons - a baby
whose weight is estimated to be above 5 Kgs or 10
pounds .
Postmature baby - when the pregnancy goes above
42 weeks.
Babies of women with diabetes usually tend to be big.

Babies of mothers who have had a number of children

and if each succeeding baby tends to be larger
&heavier.

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Ctd
B) Fetal Position:
Occipto-posterior position –
In this position the fetus faces the mother’s
abdomen instead of her back
C) Fetal presentation
Brow presentation
Face presentation( mento posterior)
Shoulder presentation

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Ctd
C) Problems with the Pelvis:
Small pelvis.
Abnormal shape of the pelvis due to diseases like
rickets, osteomalacia or tuberculosis.
Abnormal shape due to previous accidents.
Tumors of the bones.
Childhood poliomyelitis affecting the shape of the
hips.
Congenital dislocation of the hips.
Congenital deformity of the sacrum or coccyx

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Ctd
D) Problems with the Genital tract:
Tumors like fibroids obstructing the birth
passage.
Congenital rigidity of the cervix.
Scarring of the cervix due to previous
operations like conization.
Congenital vaginal septum.

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 Fetopelvic disproportion

 Contracted Pelvic Inlet

○ AP diameter < 10 cm
or transverse diameter < 12 cm
○ Diagonal conjugate < 11.5 cm
 If Both AP diameter (< 10cm) and transverse diameters (<
12cm)
are contracted -> dystocia is more likely to happen
 Cervical dilatation is facilitated by hydrostatic action of the
unruptured membranes or, after their rupture, by direct
application of the presenting part against the cervix.
 In contracted pelvis, however, when the head is arrested in the
pelvic inlet, the entire force exerted by the uterus acts directly
upon the portion of membranes that overlie the dilating cervix.
Consequently, early spontaneous rupture of the membranes is
more likely to result.
 Fetal presentation and position
○ face and shoulder presentation ( x3) & cord prolapse ( x4-
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 Three anteroposterior diameters of
the pelvic inlet

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 Fetopelvic disproportion
 Average midpelvis measurements
Transverse (interspinous) 10.5cm
Anteroposterior (from the lower border of the symphysis
pubis to the junction of the fourth and fifth sacral
vertebrae) 11.5cm
Posterior sagittal (from the midpoint of the interspinous
line to the same point on the sacrum) is 5cm critical
three
 Contracted Midpelvis
Definition
○ The interischial spinous diameter
+ posterior sagittal diameter < 13.5 cm
○ The interischial spinous diameter < 8 cm

Suggestive findings
○ The ischial spines are prominent
○ The pelvic side walls converge
○ The sacrosciatic notch is narrow
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 Transverse diameter of the midpelvis

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Fetopelvic disproportion

 Contracted Pelvic Outlet

 Definition
 The interischial tuberous diameter < 8 cm
 Outlet contraction without concomitant midplane contraction
is rare.

 Prognosis
 Diminution in the intertuberous diameter with consequent
narrowing of the anterior triangle must inevitably force the fetal
head posteriorly.
 Depend on the size of the posterior triangle
on the interischial tuberous diameter& posterior sagittal diameter
of outlet
 Production of perineal tears

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Fetopelvic disproportion

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 Pelvic fractures and rare pelvic contraction
 Trauma from automobile collisions:
most common cause of pelvic fractures
 Bilateral fractures of the pubic rami :

compromise birth canal capacity by callus

formation or malunion

 Careful review of previous x-ray and possibly computed

tomographic pelvimetry later in pregnancy,
unless c/sec is performed for another reason.
 Rare pelvic contraction : dwarfs, poliomyelitis,
kyphoscoliosis
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 estimation of the size of the pelvis
:

can be made by two methods

Clinical Pelvimetry

Radiological Pelvimetry

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 Clinical Pelvimetry:
The assessment of the size of the pelvis is made
manually by examining the pelvis and palpating the
pelvic bones by vaginal examination.
It is usually carried out after 37 weeks of pregnancy
or at the time of the onset of labor.
 The entire bony arch of the mother's pelvis, including
the sacrum , the sacro-coccygeal joint, the sacro-
sciatic notch, the ischial spines, the ilio-pectineal
lines
and the pubic arch are palpated and an assessment
of the size of the pelvis made.
The diameter of the pelvis is measured with the index
and middle fingers of
the hand.
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 Ctd
Radiological Pelvimetry:
Xrays or CT scans are taken of the pelvis in
different angles and views and the pelvic
diameter measured.
But this method is not
done nowadays as it can cause radiation
toxicity to the baby.

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 Clinical

 Done in countries where there is no x-ray

 Used as screening
 Less precise but is still useful
 Done by digital examination at ANC &/ or during
intra partum
 The relative size of pelvis to fetal head is much
important than absolute size

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Ctd
To assess
1.At the inlet - diagonal conjugate
- the head fit test
2.mid pelvis - ischial spine
- shape of sacrum
- side walls
3.out let - sub pubic arch
Narrow pelvic arch (<90 degrees) : narrow
pelvis
Unengaged fetal head -> excessive fetal head
size or reduced pelvic inlet capacity

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ctd

 X-ray pelvimetry
5 factors that determines successful vaginal
deliveries.
○ size and shape of the bony pelvis
○ size of fetal head
○ force of uterine contractions
○ moldability of the fetal head
○ presentation and position of the fetus
Indications for X-ray pelvimetry
○ for trial of vaginal delivery in case of breech
presentation and previous injury or disease
likely to affect bony pelvis
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 Estimation of pelvic capacity
 Computed tomographic scanning
Advantages
○ Reduction in radiation exposure
○ Greater accuracy
○ Easier to perform
○ Comparable cost

 Magnetic resonance imaging

Advantages
○ Lack of ionizing radiation
○ Accurate pelvic measurements
○ Complete fetal imaging
○ Providing the potential for evaluating reasons for soft
tissue dystocia
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 Excessive fetal size
 Although the fetal weight threshold decreased from 5000g to
4500g, has been that fetal size seldom is a suitable
explanation for failed labor.

 The greatest obstetrical concern was not that the fetal head
might fail to traverse the pelvic passage, but, rather that the
shoulders might not fit through the pelvic inlet or outlet.

 Selection of a fetal size threshold to predict fetopelvic

disproportion and prevent obstructed labor, is not possible
because most cases of disproportion occur in fetuses whose
weight is well within the range of the general obstetric
population.

 =>Thus, fetopelvic disproportion usually is not

associated with excessive fetal size.

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 Estimation of fetal head size
 Clinical estimation - Muller method=> Head fitting test
In an occiput presentation, the brow and the suboccipital
region are grasped through the abdominal wall with the
fingers and firm pressure is directed downward in the axis
of the inlet.
Fundal pressure by an assistant usually is helpful.
The effect of the forces on the descent of the head can
be evaluated by concomitant vaginal examination.
 No disproportion -> the head readily enters the pelvis, and
vaginal delivery can be predicted.
 Inability to push the head into the pelvis does not
necessarily indicate that vaginal delivery is impossible.
 Flexed fetal head that overrides the symphysis pubis ->
presumptive evidence of disproportion
 No relation between dystocia and failure of descent of
the head
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Maternal-fetal effects of dystocia
 Maternal effects
 Acute and chronic
1. Intrapartum infection
2. Uterine rupture
3. Pathological retraction ring Bandl's ring
4. Fistula formation due to pressure necrosis
5. Pelvic floor injury
6. Air embolism
7. Recurrence if there is contracted pelvis
8. Purpural sepsis
9. Ectopic pregnancy
10. Infertility and amenorrhea
11. Paralysis and mental disorder

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 Differentiation of Uterine Activity
 During active labor, uterus differentiates into 2 distinct
parts
 Upper segment
actively contracting , becomes thicker as labor advances
quite firm or hard on abdominal palpation1
 Lower segment
relatively passive
develops into a much thinly walled passage for the fetus
much less firm on abdominal palpation
 Physiologic retraction ring :
As labor progresses -> thinning of the lower uterine segment
and the concomitant thickening of upper segment ->
the boundary between the two is marked by a ridge on inner
uterine surface
 Pathologic retraction ring (the ring of Bandle)
In obstructed labor -> lower uterine segment’s extreme
thinning
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Pathological retraction ring

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Maternal-fetal effects of dystocia

 Fetal effects of dystocia

Prolonged membrane rupture & intrauterine

infection

Caput succedaneum
○ The caput may reach almost to the pelvic floor while
the
head is not engaged.

Fetal head molding

○ Tentorial tears, laceration of fetal blood vessels and

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fetal intracranial hemorrhage 27
 DIAGNOSIS OF CPD
 Check for CPD before labor
- height
- unengaged head
- previous Hx of CPD or difficult
delivery
- clinical pelvic assessment
- radiological assessment
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 Ctd
 During labour
- Hx & P/E
–to previous difficult delivery,
trauma ,diseases,
_engagement of the head
_position &presentation both
by pelvic &abdominal examination
_during follow up – dystocia in the
form of protracted & arrest disorders

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 Ctd
 development of the following will indicate presence
of
CPD
* fetal distress
* molding
* excessive caput
* unable to descend or
to engage despite adequate
contraction
 -Disproportion at different pelvic planes

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 MANAGEMENT OF CPD

 Elective c/s - this is indicated in extreme form

of contracted pelvis or large fetal size

 Trial of labor: the reason behind this is

-majority of the cases have border line
-minor degree of CPD can be over come
by good uterine contraction
-the head can be moulded & pass the pelvis

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 Management of trial of labor
1. Maternal
- prevent physical exhaustion by IV fluids, &/or semi
fluid diet
- proper analgesia or anesthesia
- avoid multiple vaginal examination

2. Monitor progress of labour

-adequacy of uterine contraction
-progress of cervical dilatation
-level of the head
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 Ctd
3. Monitoring of fetal well being
-FHB (prolonged deceleration, late, loss of -
passage of
meconium
-moulding ,excessive caput
 Duration of trial of labor - there is no time
limit but it should come to an end if :
 excessive caput &/or mouldig
 feta distress confirmed
 moulding occurs with in 2hrs.
 in 6hrs of infusion there is minimal
change in
 cervical dilatation
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Ctd
Mode of delivery = depends on level of the

head ,fetal distress, degree of moulding

1. c/s

2. symphysiotomy

3. forceps /vacuum

4. craniotomy
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Complications of CPD
 prolonged labor,

 fetal distress

 delayed second stage .

 Obstracted labor

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 Definition of obstructed Labor
Defin: failure of the fetal head to pass
through the maternal birth canal
despite adequate contractions for
mechanical reasons.
Abnormal orientation of fetal head
Any unsuccessful vaginal delivery
 Prevalent in developing countries
Common indication for c/s

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Obstructed labor
 Cause:

Passage

Passenger

Power

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Passage
 Pelvimetry
􀁺 Inlet
􀁺 Midplane
􀁺 Outlet

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Passenger
 Fetal weight estimation
 Palpation

 Ultrasound

 CT scan/ MRI

 Johnson’s formula

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Power
 Uterine contraction
 Palpation
 External monitoring
 Internal monitoring

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Assessment
 History&physical examination

 Partogram

 Friedman curve

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Prevention
○ Good nutritional supply? since childhood.
○ Avoid early marriage?
○ Emergency obstetric Care
○ Universal ANC is outdated
○ Monitor labor using partograph?
○ Promote family planning? services
○ Maternal waiting area (MWA)? for high risk
mothers in remote area
○ Elective caesarean delivery? when
indicated
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 complications

 Uterine rupture - PPH

 Avascular necrosis - Sepsis
 Vaginal stenosis & - Psychological
atresia trauma
 Sloughing of cervical & - cerebral palsy
lower uterine segment - Fetal death
 - Pelvic laceration - Fistula

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Management of Obstructed
labor
 Diagnosis
 Counseling & Treatment

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Management of Obstructed Labor

General Measures Obstruction relief

Resuscitation Vaginal Route

Oxygen Operative Delivery
Antibiotics Destructive Delivery
Catheterization Abdominal Route
Pain relief Caesarean Delivery
NG tube drainage of Laparotomy –
gastric contents Uterine repair or
Hemogram and Hysterectomy
blood as necessary

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B. Specific Treatment
The initial management of OL and ruptured uterus
involves two concurrently on going activities:

Resuscitationand monitoring of the life

endangering conditions such as
Shock
Sepsis

Identifyingthe cause of OL? and other

complications and Intervening accordingly

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 Resuscitation (ABC) and Monitoring
− Shock :Treat with ongoing resuscitation

− Rehydration: Fluid and electrolyte replacement

If the woman is not in shock but she is dehydrated
and ketotic, give 1 liter of ringers lactate or (DNS)
rapidly and repeat (x3) till dehydration and ketosis
are corrected then reduce to 1 liter in 4–6 hours.
− Monitor closely
Keep an accurate record of all intravenous fluids
infused, drugs given, vital signs and urinary
output.

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− Sepsis
In Severe cases the following antibiotic regimen can be
used:
• Ampicillin 2 g every 6 hours (QID) or ceftriaxone and
• Gentamicin 5 mg/ body weight every 24 hours IV (adjusted
with renal status)
• Metronidazole 500 mg IV every 8 hours or Clindamycin
or Chloramphenicol
In Less severe cases, ampicillin and gentamicin may be
adequate.
− Analgesics can be given while resuscitating and
preparing her for operative delivery.
There is no reason to withhold anti-pain treatment in
a woman with obstructed labor which developes
peritonitis.
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 Preparation before intervention
o Empty bladder

o Empty stomach with NG tube

o Laboratory tests required for preoperative assessment

and evaluation:
− Hemoglobin/ Hct
− Blood group (ABO, Rh) prepare 2 units.
− Urine analysis
− Renal function tests (especially with decreased urine
output)
− Blood culture and sensitivity
− Others test depending on individual clinical findings

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 Operations to Relieve obstruction

–Abdominal delivery
 Cesarean delivery
 Laparotomy if Ux Ruptures deliver the fetus abdominally.

Operative Vaginal delivery

 Forceps delivery
 Vacuum Extraction
 Symphysiotomy
 Destructive delivery
 Craniotomy
 Cleidotomy
 Decapitation

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Caesarean Delivery
Indications
Alive fetus with incomplete cervical dilatation or high station.
Alive fetus with Brow or Mentoposterior face position.
Alive or dead fetus with evidence of imminent uterine rupture.
Dead fetus with unmet criteria for destructive/ instrumental delivery.
Placenta Previa Totalis placenta previa partials and placenta previa
marginalis posterior is one criteria .
Complications
Less safe in small rural hospitals where most of obstructed labor have to
be dealt with.
Risk of Hemorrhage.
Risk of Injury to bladder and ureter.
Risk of rupture for women who come to hospitals as a last resort.
So for subsequent Px she might not come.
Risk02/20/24
of Reproductive failure. 51
Laparotomy
Simple repair of ruptured uterus (with or without tubal
ligation).
○ Clean wound, lower segment transverse incision (Prev. C/S).
○ Recent rupture.
○ Tear is not too large, clean edge.
○ Preservation of fertility or menstruation if needed.
○ Little or no infection.
○ Easy procedure.

Total abdominal hysterectomy/ Subtotal hysterectomy

○ Severe infection of uterus
○ Rupture compromising blood supply of uterine muscle
○ Extensive tear with Necrotic edges
○ Tears difficult to stitch such as posterior tears and extension
into the vagina
○ Rupture after prolonged labor
○ Future cervical cancer concern
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Forceps Delivery
Indications
Alive fetus and head < 1/5 above pelvic brim. ( Well Engaged)
Mild-moderate moulding.
OT or OP position with no or minimal CPD. (Incomplete rotation +
Minor disproportion)
Complications
Posterior rupture of Uterus or Colporrhexis (Tearing of vagina) due
to “Boot-Scrapper effect”
Bladder neck injury
Inc. distortion of already moulded fetal head likely to produce
Tentorial Tear.
Contraindications
Dead fetus
Pelvic Tumors
Mentoposterior Face or a Brow Presentation. B/c Impacted head
can’t be flexed for delivery
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Vacuum Extraction
Indication
Same as Forceps but its benefit
Easier to apply b/c there is no need to define
exact position of head, nor to rotate it.
Doesn’t occupy space b/n fetal head and
pelvic side walls.
Laceration of Vagina is less
Complications and Contraindications
Same as Forceps

One useful function over Forceps is to complete

delivery after symphysiotomy.
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 Symphysiotomy
Indications
Done for Gross CPD as a cause of Obstructed Labor in a patient
with no Previous Obstetric Care.
Complication
Serious urinary and Locomotory disabilities.
Pubic pain and Back pain.
Contraindications
Dead fetus.
Previous C/S.
Extreme degree of contraction of pelvis (TC< 6cm).
Breech, Brow or mento-posterior face presentation.
Preexisting locomotor disturbance (Hip joint d/s).
Gross Obesity.
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 Destructive Delivery
Indication
Dead fetus
Fully dilated cervix and
No evidence of rupture or imminent rupture.
2/5 or less of his head must be above the brim (Impacted
Head)
His mother's cervix must be at least 7 cm dilated, and
preferably fully dilated.
Her uterus must be unruptured, and not in imminent danger of
rupturing.
Caution
If she is a multiparous with a dead fetus, and has been in
labour for a long time, her lower segment will be very thin. She
can only be saved by Caesarean section; any destructive
operation, except Craniotomy, will rupture it.
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C. Postoperative care and follow up
Intensive resuscitation and monitoring should be continued
till condition (K+ corrected) improves.
Puerperal Sepsis is almost Inevitable so Antibiotics IV till
fever free for 2-3 days and continue coarse PO.
Close monitoring to identify complications early (e.g.,
Peritonitis; Abscess).
Bladder drainage for 5-7 days by indwelling catheter.
Blood transfusion.
Investigation including blood and urine culture and sensitivity
as indicated.
Analgesics including pethidine.
Breast care for those with stillbirths or neonatal deaths.
Fistula care and follow-up: Women with fistula are kept in the hospital until
infection is controlled. They should get informed about when and where they can
have the fistula repair. Usually, the fistula repair is undertaken 2-3 months after
delivery.
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 Explain condition and Counsel on future
pregnancy
o Repaired uterine rupture without tubal ligation or
CS: Always hospital delivery.
o Total or sub-hysterectomy or tubal ligation:
Amenorrhea and Infertility.
o Severe postpartum infection:
Possibility of ectopic pregnancy in future
pregnancy and need for early check up if
pregnant;
Infertility(one child syndrome)

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