CEPHALO-PELVIC DISPROPOTION

DEFINITION
Anatomically contracted pelvis is defined as one where the essential diameters of one or more planes are shortened by 0.5 cm

Obstetric definition which states that alteration in the size and or shape of the pelvis of sufficient degree so as to alter the normal mechanism of labour in an average size baby.

ETIOLOGY
Severe malnutrition, rickets, osteomalacia, bone tuberculosis Minor variation : common, Major variation: rare

COMMON CAUSES
Nutritional and environmental defects Diseases or injuries affecting the bones of the pelvis fracture, tumors, tubercular arthritis; Spine Kyphosis, scoliosis, coccygeal deformity; lower limbspoliomyelitis, hip joint disease. Developmental defects Naegeles pelvis, Roberts pelvis; High or low assimilation pelvis

Mechanism of labour in contracted pelvis

Flat pelvis In the flat pelvis, the head finds difficulty in negotiating the brim and once it passes through the brim, there is no cavity or outlet. The head negotiates the brim by the following mechanism The head engages with the sagittal suture in the transverse diameter Head remains deflexed and engagement is delayed.

 If the antero- posterior diameter is too short, the occiput is mobilised to the same side, to occupy the sacral bay. The biparital diameter is placed in the narrow conjugate. If lateral mobilisation is not possible, there is a chance of extension of the head leading to brow or face presentation. Engagement occurs by exaggerated parietal so that the super- subparietal diameter(8.5cm), instead of the biparietal diameter (9.5cm), passes through the pelvic brim Moulding may be extreme and often there is an indentation or even a fracture of one parietal bone. However, the caput that forms is not big.

 Once the head negotiates the brim, there is no difficulty in the cavity and outlet and normal mechanism follows

Diagnosis of contracted pelvis

1. HISTORY COLLECTION A. PAST HISTORY MEDICAL: past h/o fracture, rickets, osteomalacia, TB of the pelvic joint or spines, poliomylietis is to be obstetrical. PHYSICAL EXAMINATION: Stature : small women (less than 5 feet), Stigma: deformity of the pelvic bones, hip joint, spine

ABDOMINAL EXAMINATION
INSPECTION:- Pendulous abdomen PELVIMETRY:- Assessment can be done by bimanual examination clinical pelvimetry and also by imaging studies- radio pelvimetry, computed tomography and MRI - Time: in vertex presentation- 37 week but better at the beginning of labour

Procedure: - Empty the bladder - Dorsal position - Maintain aseptic precaution Features to be noted - Sate of cervix - Station of the head - Elasticity of the perineal muscles - Test for cephalopelvic disproportion in nonengaged head

Steps : The internal examination should be gentle. sterilised gloved fingers once taken out should not be reintroduced. Sacrum the sacrum is smooth, well curved . The length, breadth and its curvature are to be noted. Scacro sciatic notch - The notch is sufficiently wide so that two fingers can be easily placed over the sacro spinous ligament covering the notch. Ischial spines spines are usually smooth difficult to palpate. They may be prominent and encroach to the cavity thereby diminishing the available space in the mid pelvis

 Illio pectineal lines To note for any beaking . Side walls- normally they are not easily palpable by the sweeping unless convergent. Posterior surface of the symphysis pubis- it normally forms a smooth rounded . Pubic arch Normally, the pubic arch is rounded and should accommodate the palmar aspect of two fingers. After the procedure, the fingers are now taken out

X RAY PELVIMETRY It cannot reliably predict the likelihood of vaginal delivery neither in breech presentation nor in cases with with previous caesarean section. X ray pelvimetry is a poor predictor of pelvic of pelvic adequacy and success of vaginal delivery. However, X-ray pelvimetry is useful in cases with fractured pelvis and for the important diameters which are inaccessible to clinical examination. Hazards of X-ray pelvimetry includes radiation exposure to the mother and the fetus. With conventional X-ray pelvimetry radiation exposure too the gonads is about 885 milliards. So it is restricted .

 Computerised tomography (CT) involves less radiation exposure and is easier to perform. Accuracy is greater than that conventional X-ray pelivmetry. Magnetic Resonance Imaging(MRI) is more accurate to assess the bony pelvis. It is also helpful assess the fetal size and maternal soft tissue which are involved in dystocia. It has got no radiation risk, hence biologically safe. It is expensive, requires more time and availability is limited. Ultrasonography is useful to measure the fetal head dimension in the intrapartum face.

DISPROPORTION

DEFINITION Disproportion , in relation to the pelvis, is a state where the normal proportion between the size of fetus to the size of the pelvis is disturbed. The disparity in the relation between the head and pelvis is called cephalopelvic disproportion Disproportion may be either due to an average size baby with a small pelvis or due to a big a baby with normal size pelvis(Hydrocephalus) or due to combination of both the factors

Diagnosis of cephalopelvic disproportion (CPD) at the brim. The presence and degree of CPD at the brim can be ascertained by the following Clinical Imaging pelvimetry Cephalometry ultrasound, MRI, X-ray

1. CLINICAL - In multi gravida previous h/o spontaneous delivery of an average size baby. - Primi gravida non engagement of the head even at labour. Abdominal exanination: The patient placed in dorsal position with the thighs slightly flexed and separated. The head is grasped by the left hand two fingers (index and middle) of the right hand are placed above the symphysis pubis keeping the inner surface of the fingers in line with the anterior surface to note the degree of overlapping, if any, when the head is pushed downwards and backward.

Inferences The head can be pushed down in the pelvis without overlapping of the parietal bone on the symhysis pubis no disproportion Head can be pushed down a little but there is slight overlapping of the parietal bone (overlapping by 0.5cm) moderate disproportion Head cannot be pushed down severe disproportion

Abdomino vaginal method (Muller Munro Kerr) This bimanual method is superior to the abdominal method assessment can be done simultaneously. Muller introduced the method by placing the vaginal finger tips at the level of ischial spines to note the descent of the head. Munro Kerr added placement of the thumb over symphysis pubis to note the degree of overlapping

 Lower bowel emptied preferably by enema. The patient is asked to empty the bladder. The patient is placed in lithotomy position and the internal examination is done taking all aseptic precautions. Two fingers of the right hand are introduced into the vaginal with the fingertips placed at the level of ischial spines and thumb is placed over the symphysis pubis. The head is grasped by the left hand and is pushed in a downward and backward direction into the pelvis.

Inferences The head can be pushed down up to the level of ischial spines and there is no overlapping of the parietal bone over the symphysis pubis no disproportion The head can be pushed down a little but not up to the level of ischial spines and there is slight overlapping of the parietal bone slight or moderate disproportion The head cannot be pushed down and instead the parietal bone overhangs the symphysis pubis displacing the thumb severe disproportion.

Limitation of clinical assessment The method is only applicable to note the presence or absence of disproportion at the brim and not at all applicable to elicit mid pelvic or outlet contraction. The fetal head can be used as a pelvimeter to elicit only the contraction in the antero-posterior plane of the inlet; but when the contraction affects the transverse diameter of the inlet, it is of less use.

2. X-ray pelvimetry: Lateral X-ray view with the patient in standing position is helpful in assessing cephalo pelvic proportion in all planes of the pelvis inlet, midpelvic and outlet. 3. Cephalometry: While a rough estimation of the size of the head can be assessed clinically, accurate measurement of the biparietal diameter would have been ideal to elicit its relation with the diameters of the planes of a given pelvis through which it has to pass. In this respect ultrasonographic measurement of the biparietal diameter or MRI gives superior information. The average biparietal diameter measures 9.4 to 9.8 cm at term.

 MRI : it is useful to assess the pelvic capacity at different planes. It is equally informative to assess the fetal size, fetal head volume and pelvic soft tissues which are also important for successful vaginal delvery.

Effect of contracted pelvis on pregnancy and labour Pregnancy: The general course of pregnancy is not much affected. However, the following may occur There is more chance of incarceration of the retroverted gravid uterus in flat pelvis. Abdomen become pendulous specially in multigravida with lax abdominal wall Mal presentations are increased 3-4 times and so also increased frequently of unstable lie.

Labour: The course of events in labour is greatly modified depending upon the degree of pelvic contraction and presentation of the fetus: There is increased incidence of early rupture of the membranes Incidence of cord prolapse is increased Cervical dilatation is slowed There is increased tendency of prolonged labour and in neglected cases, obstructed labour with features of exhaustion, dehydration, keto acidosis and sepsis. There is increased incidence of operative interference, shock, post partum haemorrhage and sepsis

 Maternal injuries: The injuries of the genital tract may occur spontaneously of following operative delivery. There is increased maternal morbidity and mortality. Fetal hazards: Fetal risks are due to trauma and asphyxia. The net effect leads to increased peinatal mortality and morbidity

Management of contracted pelvis (inlet contraction) The pre-requisites in the formulation of the line of management of contracted inlet is to ascertain the degree of disproportion by clinical examination and supplemented by imaging pelvimetry. Due consideration is given to the associated complicating factor, if any

Minor degrees of inlet contraction does not give rise to any problem and the cases are left to have a spontaneous vaginal delivery at term. The moderate and severe degrees are to be dealt by any one of the following: Preterm induction of labour Elective caesarean section at term Trial labour

 Induction of labour prior to date: Induction 2-3 weeks prior to the EDD may be considered only in cases with moderate degrees of pelvic contraction. It is not favoured nowadays. However, in a selected multigravida with previous history of difficult vaginal delivery, this method may be considered 2-3 weeks before date. In any case one should be certain about the fetal gestational age.

Elective caesarean section at term: Elective caesarean section at term is indicated in: Major degree of inlet contractiuon . Moderate degree of inlet contraction associated with outlet contraction Moderate degree of inlet contraction associated with outlet contraction or complicating factors like elderly primigravida, malpresentation, post caesarean pregnancy, etc. If there is no doubt about the maturity of the fetus, the operation can be done as a planned way

Trial labour It is the conduction of spontaneous labour in a moderate degree of cephalo pelvic disproportion, an institution under supervision with watchful expectancy, hoping for a vaginal delivery. Every arrangement should be made available for operative delivery, either vaginal or abdominal, if the condition do arises. Aims : A trail labour aims at avoiding an unnecessary caesarean section and at delivering a healthy baby

Contraindications : Associated midpelvic and outlet contraction Presence of complicating factors like elderly primigravida, malpresentation, postmaturity, post caesarean pregnancy, pre- eclampsia, medical disorders like heart disease, diabetes Tb, Where facilities for caesarean section is not available round the clock

 Successful outcome depends on: Degree of pelvic contraction Shape of the pelvis flat pelvis is better than android or generally contracted pelvis Favourable vertex presentation anterior parietal presentation with less parietal obliquety is favourable Intact membranes till full dilatation of cervix Effective uterine contractions Emotional stability of the women

Unfavourable features: Appearance of abnormal uterine contraction Cervical dilatation <1cm per hour inspite of regular uterine contractions Arrest of cervical dilatation and non descent of fetal head in spite of oxytocin therapy Early rupture of the membranes Formation of caput and evidence of excessive moulding Fetal distress

 Termination of trial labour: The methods of termination are any one of the following Spontaneous delivery with or without episiotomy (30%) Forceps or vetouse (30%)- difficult forceps delivery is to be avoided Caesarean section(40%) Judicious and timely decision for caesarean section is done even before full dilatation of the cervix,, the indication being uterine inertia or fetal distress Successful trial: A trial is called successful, if a healthy baby is born vaginally spontaneously or by forceps or ventouse with the mother in good condition.

 Advantages of trail labour: It eliminates unnecessary caesarean section electively decided upon It eliminates injudicious use of premature induction of labour with its antecedent hazards A successful trial ensures the woman a good future obstetrics

 Disadvantages of trail labour : Test of disproportion remains unproven when caesarean delivery is done due to fetal distress or uterine dysfunction Increased perinatal morbidity and or mortality due to asphyxia or intracaranial haemorrhage when the trial is prolonged and/or ends in difficult delivery Increased psychological morbidity when trial ends with a traumatic vaginal delivery or in caesarean delivery

Midpelvic and outlet disproportion In clinical assessment, it is difficult to determine where the midpelvic contraction is rarity. As such, in practice the two problems are jointly considered as outlet contraction. Cephalopelvic disproportion at the outlet is defined as one when the biparietal suboccipito bregmatic plane fails to apss through the bispinous and antero- posterior place of the outlet.

 Management Unlike inlet disproportion, clinical diagnosis of mid pelvic and outlet disproportion can only be made after the head sufficiently comes down into the pelvis.

 Elective caesarean section: Contraction of both the transverse and antero- posterior diameter of the midpelvic plane or minor contraction associated with other complicating factors is dealt by elective caesarean section

 To allow vaginal delivery: In otherwise uncomplicated cases with minor contraction, vaginal delivery, allowed under supervision with watchful expectancy Delivery is accomplished by forceps or ventouse with deep episiotomy to prevent perineal injuries, specially with narrow pubic arch. If there is no dilatation of cervix or descent of the fetal head after a period f 2 hours in the active phase of labour, arrest of labour is considered. Once arrest disorder is diagnosed , caesarean delivery is the option.

Cases seen late in labour is not an uncommon problem in the developing countries. The principles of management rest on Caesarean section to avoid difficult forceps Forceps with deep episiotomy Symphysiotomy followed by ventouse Craniotomy if the fetus is dead