CONTRACTED PELVIS
DEFINITION
Anatomical definition: It is a pelvis in which one or more of its main diameters are reduced below average normal by one or more centimetres Obstetric definition: It is a pelvis in which one or more of its main diameters are reduced to the extent that interferes with the normal mechanism of labour
ETIOLOGY
1. Developmental causes
Small gynaecoid -- generally contracted pelvis Small android Small anthropoid Small flat platypelloid pelvis Naegeles pelvis Roberts pelvis High assimilation pelvis Low assimilation pelvis Split pelvis
NAEGELES PELVIS
ROBERTS
PELVIS
FAULTY DEVELOPMENT
2. Diseases of the pelvic bones and joints
Metabolic diseases ---- Rickets, Osteomalacia
Bone tuberculosis
Severe malnutrition Poliomyelitis Hip joint disease Fractures of the pelvic bones, tumours of the pelvic bones
Rachitic pelvis
Osteomalacic pelvis
3.
Causes in the spine
Scoliosis Kyphosis
Spondylolisthesis
Coccygeal deformity
Kyphotic pelvis
Scoliotic pelvis
DIAGNOSING CONTRACTED PELVIS
1. HISTORY:
GENERAL: Rickets, Osteomalacia, Poliomyelitis, TB, fracture OBSTETRIC: Previous prolonged labour, difficult vaginal delivery, perineal tear, vesico-vaginal or recto-vaginal fistula
2. PHYSICAL EXAMINATION
Height: high risk <150 cm
Congenital or acquired deformities of pelvic bones, hip joint, spine Gait: abnormal gait - waddling Rickets : square head, rosary beads in costal ridges, pigeon chest, bow legs, harrisons sulcus
Dystocia - dystrophia syndrome:
short and obese stocky broad shoulders and short thighs sub-fertile has android pelvis masculine hair distribution with history of delayed menarche
3. ABDOMINAL EXAMINATION
4. PELVIMETRY * Clinical
Imaging - X- Ray, CT, MRI
Data
Findings
Forepelvis (pelvic brim) Diagonal conjugate Anterposterior diameter of outlet
Round 11.5 cm 11.0 cm
Symphysis Sacrum
Side walls Ischial spines Interspinous diameter Sacrosciatic notch Subpubic angle Bituberous diameter Coccyx
Average thickness, parallel to sacrum Hollow, average inclination
Straight Blunt 10.0 cm 2.5 -3 finger - breadths 2 finger - breadths 4 knuckles (> 8.0 cm) Mobile
Degrees of Contracted Pelvis
Minor degree: Moderate degree: The true conjugate is 9-10 cm The true conjugate is 8-9 cm
Severe degree:
Extreme degree: 6 cm.
The true conjugate is 6-8 cm
The true conjugate is less than
MECHANISM OF LABOUR
1. Flat rachitic pelvis
Engagement : with the sagittal suture in the transverse diameter Asynclitism with anterior parietal bone presentation Lateral displacement of the head Deflexion of the head and descent Rotation of the occiput 2/8 circle anteriorly
2. Simple Flat Pelvis
Persistent flattening of the pelvis Contracted outlet
No internal rotation and descent
Obstructed vaginal delivery
3. Contracted Outlet ( Funnel Pelvis )
Normal descent and engagement Extreme flexion and moulding of the head at ischial spines Narrow subpubic angle causes the head to push backward Face to pubis position is more favourable
CEPHALOPELVIC DISPROPORTION
The disparity in the relation between the head and
the pelvis which may be either due to an average size
baby with a small pelvis or due to a big baby with
normal size pelvis (hydrocephalus) or due to a combination of both.
CAUSES OF HIGH HEAD AT TERM
Occipito-posterior position - deflexion Deflexed head Multipara Half full bladder Mistaken maturity Twin, hydramnios, placenta praevia Increased angle of inclination
DIAGNOSING CPD
1. Abdominal method ( Pinards method )
2. Abdomino-vaginal method (Muller-Munro Ken)
EFFECTS OF CONTRACTED PELVIS
1. On pregnancy 2. On labour * maternal * fetal
MANAGEMENT OF CONTRACTED PELVIS
INLET CONTRACTION Preterm induction of labour Elective Caesarean section at term Trial labour
TRIAL LABOUR
The conduction of spontaneous labour in a moderate degree of cephalo-pelvic disproportion, in an institution under supervision with watchful expectancy, hoping for a vaginal delivery
CONTRAINDICATIONS
Associated mid-pelvic and outlet contraction Elderly primigravida Mal-presentation Post-maturity Post caesarean pregnancy Pre - eclampsia Medical disorders like heart disease, DM, TB Unavailability of facilities for caesarean section
GUIDELINES FOR TRIAL LABOUR Selection of patients
Monitoring progress
Augmentation of labour After rupture of membranes Termination
Favourable features of trial labour
Unfavourable features Advantages Disadvantages
MID-PELVIC AND OUTLET CONTRACTION
Cephalopelvic disproportion at the outlet is defined as one where the biparietal - suboccipitobregmatic plane fails to pass through the
bispinous and antero-posterior planes of the
outlet.
MANAGEMENT
Elective Caesarean section --In case of contraction of both the transverse and A-P diameters of the mid-pelvic plane
Vaginal delivery --- In uncomplicated cases with minor contraction * by forceps or ventouse with deep episiotomy to prevent perineal injuries
