Contracted pelvis

contracted pelvis

1. Contracted pelvis and Dystocia Neethu S.S. Second year MSc Nursing Govt. College of Nursing Kozhikode.

2. NORMAL PELVIS

3. Contracted pelvis

4. definition  Anatomically contracted pelvis is defined as one where the essential diameters of one or more planes are shortened by 0.5cm.  Obstetrically, it is a state in which there is alteration in size or shape of the pelvis of sufficient degree as to alter the normal mechanism of labor in an average size baby.

5. Factors influencing the size and shape of the pelvis Developmental factor: hereditary or congenital. Racial factor. Nutritional factor: malnutrition results in small pelvis. Sexual factor: as excessive androgen may produce android pelvis. Metabolic factor: as rickets and osteomalacia . Trauma, diseases or tumors of the bony pelvis, legs or spines

6. ETIOLOGY OF CONTRACTED PELVIS Causes in the pelvis Developmental (congenital): Small gynecoid pelvis (generally contracted pelvis). Small android pelvis. Small anthropoid pelvis. Small platypelloid pelvis (simple flat pelvis). Naegele’s pelvis: absence of one sacral ala.

7. Robert’s pelvis: absence of both sacral alae. High assimilation pelvis: The sacrum is composed of 6 vertebrae. Low assimilation pelvis: The sacrum is composed of 4 vertebrae. Split pelvis: splitted symphysis pubis. Metabolic: Rickets. Osteomalacia (triradiate pelvic brim). Traumatic : as fractures. Neoplastic : as osteoma.

8. Causes in the spine Lumbar kyphosis. Lumbar scoliosis. Spondylolisthesis: The 5th lumbar vertebra with the above vertebral column is pushed forward while the promontory is pushed backwards and the tip of the sacrum is pushed forwards leading to outlet contraction . Coccygeal deformity

9. Causes in the lower limbs Dislocation of one or both femurs. Atrophy of one or both lower limbs. Hip joint disease

10. Classification of contracted PELVIS According to degree of contracture Minor degree: The true conjugate is 9-10 cm. It corresponds to minor disproportion. Moderate degree: The true conjugate is 8-9 cm. It corresponds to moderate disproportion. Severe degree: The true conjugate is 6-8 cm. It corresponds to marked disproportion. Extreme degree: The true conjugate is less than 6 cm. Vaginal delivery is impossible even after craniotomy as the bimastoid diameter (7.5 cm) is not crushed. Also known as absolutely contracted pelvis.

11. According to pelvic architecture

12. RACHITIC FLAT PELVIS Rickets in early childhood cause bones to remain soft and unossified. Inlet Sacral promontory is pushed downwards and forwards producing a reniform shape Short APD Cavity Sacrum is flat and tilted backwards Sharp angulation at sacrococcygeal joint Outlet Widened transverse diameter and pubic arch

13. OSTEOMALACIC PELVIS Caused by softening of the pubic bones Due to deficiency of calcium, vitamin D and lack of exposure to sunrays The promontory is pushed downwards and forwards and the lateral pelvic walls are pushed inwards causing the anterior wall to form a beak Triradiate shape of inlet Approximation of 2 ischial tuberosities Markedly shortened sacrum Coccyx is pushed forward

14. ASYMMETRICAL OR OBLIQUELY CONTRACTED PELVIS Naegele’s pelvis Scoliotic pelvis Disease affecting one hip or sacroiliac joint Tumors or fracture affecting one side of the pelvic bones during growing age

15. Naegele’s pelvis Extremely rare Due to arrested development of one ala of the sacrum It can be Congenital: associated with urinary tract of the same side Acquired: osteitis of sacroiliac joint Pelvis is obliquely contracted at all levels but more marked in the outlet Straight iliopectineal line on the affected side

16. scoliosis Acetabulam is pushed inwards on the weight bearing side Contraction of one of the oblique diameters

17. Robert’s pelvis ( Transversely contracted pelvis) Ala of both the sides are absent Sacrum is fused with innominate bones

18. Kyphotic pelvis Developed secondary to the kyphotic changes of the vertebral column. sacrum is tilted backwards in the upper part and forwards in the lower part, it is narrow and straight APD is increased at the inlet but is decreased at the outlet Narrow suprapubic angle Extreme funneling of the pelvis Pendulous abdomen

19. Pelvis aequabiliter justo minor Characterized by general reduction of all diameters; equally shortened usually by 1-2cm Occurs in short. Also occurs in women with massive skeletal bones and developed muscles, the pelvis has masculine features such as narrow sacrum, narrow pubic outlet (funnel-shaped)

20. Rare forms of contracted pelvis Otto’s pelvis – develop as result of inflammatory process in the hip or knee Beaked (rostrate) pelvis – under development of both sacral wings Spondylolithetic pelvis – formed due to partial dislocation of last lumbar vertebra in front of 1 st sacral vertebra

21. DIAGNOSIS OF CONTRACTED PELVIS History Rickets: is expected if there is a history of delayed walking and dentition. Osteomalacia Tuberculosis of the pelvic joints or spines poliomyelitis Trauma or diseases: of the pelvis, spines or lower limbs. Bad obstetric history: e.g. prolonged labour ended by; difficult forceps, caesarean section or still birth. Weight of the baby, evidence of maternal injuries such as complete perineal tear, vesicovaginal or rectovaginal fistula.

22. Physical examination General examination: Gait: abnormal gait suggesting abnormalities in the pelvis, spines or lower limbs. Stature: women with less than 150 cm height usually have contracted pelvis. Spines and lower limbs: may have a disease or lesion. Manifestations of rickets as: square head, rosary beads in the costal ridges. pigeon chest, Harrison’s sulcus and bow legs.

23. Dystocia dystrophia syndrome : the woman is short, Stocky built with bullneck Broad shoulders and short thighs Sub fertile, dysmenorrhea or irregular periods has android pelvis Obese, masculine hair distribution,   with history of delayed menarche. Increased incidence of pre-eclampsia, post maturity This woman is more exposed to occipito -posterior position, inertia during labor, tendency for deep transverse arrest or outlet dystocia. Result in difficult instrumental delivery or CS, lactation failure

24. Abdominal examination: Nonengagement of the head: in the last 3-4 weeks in primigravida. Pendulous abdomen: in a primigravida. Malpresentations: are more common.

25. Pelvimetry It is assessment of the pelvic diameters and capacity done at 38-39 weeks. It includes: Clinical pelvimetry: Internal pelvimetry for: inlet, cavity, and outlet. External pelvimetry for: inlet and  outlet. Imaging pelvimetry: X-ray. Computed tomography (CT). Magnetic resonance imaging (MRI)

26. Internal pelvimetry (is done through vaginal examination) The inlet: Palpation of the fore pelvis (pelvic brim): The index and middle fingers are moved along the pelvic brim. Note whether it is round or angulated, causing the fingers to dip into a V-shaped depression behind the symphysis.

27. Diagonal conjugate: Try to palpate the sacral promontory to measure the diagonal conjugate. Normally, it is 12.5 cm and cannot be reached. If it is felt the pelvis is considered contracted and the true conjugate can be calculated by subtracting 1.5 cm from the diagonal conjugate. This assessment is not done if the head is engaged.

28. The cavity: Height, thickness and inclination of the symphysis. Shape and inclination of the sacrum. Side walls: To determine whether it is straight, convergent or divergent starting from the pelvic brim down to the base of ischial spines in the direction of the base of the ischial tuberosity. Then relation between the index and middle finger of the base of ischial spines and the thumb of the other hand on the ischial tuberosity is detected. If the thumb is medial the side wall is convergent and if lateral it is divergent.

29. Ischial spines: Whether it is blunt (difficult to identify at all), prominent (easily felt but not large) or very prominent (large and encroaching on the mid-plane). The ischial spines can be located by following the sacrospinous ligament to its lateral end. Interspinous diameter: By using the 2 examining fingers, if both spines can be touched simultaneously, the interspinous diameter is £ 9.5 cm i.e. inadequate for an average-sized baby. Sacro sciatic notch: If the sacrospinous ligament is two and half fingers, the sacrosciatic notch is considered adequate.

30. The outlet: Subpubic angle: Normally, it admits 2 fingers. Bituberous diameter: Normally, it admits the closed fist of the hand (4 knuckle). Mobility of the coccyx. by pressing firmly on it while an external hand on it can determine its mobility. Anteroposterior diameter of the outlet: from the tip of the sacrum to the inferior edge of the symphysis.  

31. Data Finding Forepelvis (pelvic brim) Diagonal conjugate Symphysis Sacrum Side walls Ischial spines Interspinous diameter Sacrosciatic notch Subpubic angle Bituberous diameter Coccyx Anterposterior diameter of outlet Round. ≥11.5 cm. Average thickness, parallel to sacrum. Hollow, average inclination. Straight. Blunt. ≥10.0 cm. 2.5 -3 finger - breadths. 2finger - breadths. 4 knuckles >8.0 cm). Mobile. ≥11.0 cm.   FINDINGS INDICATING ADEQUATE PELVIS :

32. External pelvimetry It is of little value as it measures diameters of the false pelvis. Thom’s, Jarcho’s or crossing pelvimeter can be used for external pelvimetry. Interspinous diameter (25cm): between the anterior superior iliac spines. Intercrestal diameter (28 cm): between the most far points on the outer borders of the iliac crests. External conjugate (20 cm). Bituberous diameter: can be measured by pelvimeter. In rickets, the interspinous equals or even exceeds the intercrestal diameter.

33. Radiological pelvimetry It is indicated mainly in borderline pelvic contraction. Lateral view: The patient stands with the X-ray tube on one side and the film cassette on the opposite side. It is the most important view as it shows the anteroposterior diameters of the pelvis, angle of inclination of the brim, width of sacro sciatic notch, curvature of the sacrum and cephalo-pelvic relationship. Inlet view: The patient sits on the film cassette and leans backwards so that the plane of the pelvic brim becomes parallel to the film. Outlet view: The patient sits on the film cassette and leans forwards .

34. Effect of contracted pelvis On pregnancy More chance of incarceration of the retroverted gravid uterus in flat pelvis. Abdomen becomes pendulous in multigravida Malpresentations Unstable lie

35. On labor Increased incidence of: Early rupture of membranes Cord prolapse Slow cervical dilatation Prolonged labor Obstructed labor with exhaustion, dehydration, ketoacidosis and sepsis Operative interference Shock Postpartum hemorrhage and sepsis

36. Maternal injuries Fetal hazards due to trauma and asphyxia

37. Mechanism of labor in contracted pelvis Generally in contracted pelvis all the diameters in the different planes are shortened. So there is difficulty from beginning to the end. In the flat pelvis, the head finds difficulty in negotiating the brim and once it passes through the brim, there is no difficulty in the cavity and outlet. The head negotiates the brim by the following mechanism: The head engages with the sagittal suture in transverse diameter. Head remains deflexed and engagement is delayed.

38. If the APD is too short, the occiput is mobilized to the same side to occupy the sacral bay. The biparietal diameter is thus placed in the sacrocotyloid diameter and the narrow bitemporal diameter is placed in the narrow conjugate. If lateral mobilization is not possible, there is a chance of extension of the head leading to brow or face presentation. Engagement occurs by exaggerated parietal presentation so that the super- sub parietal diameter, instead of the biparietal diameter 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.

39. MANAGEMENT OF CONTRACTED PELVIS Ascertain the degree of disproportion Minor inlet contraction: spontaneous delivery Moderate and severe degrees: Induction of labor Elective cesarean section at term Trial labor

40. Induction of labor Induction 2-3 weeks prior to the EDC may be considered only in cases with minor to moderate degrees of pelvic contraction. 2-3 weeks before the date in selected multigravida with previous history of difficult vaginal delivery.

41. Elective cesarean section at term INDICATIONS: Major degree of inlet contraction Moderate degree of inlet contraction associated with outlet contraction or complicating factors like elderly primigravida, malpresentation, post- cesarean pregnancy. Ascertain maturity of fetus before planning.

42. Trial labor It is the conduction of spontaneous labor in moderate degree of cephalopelvic disproportion, in an institution under supervision with watchful expectancy, hoping for a vaginal delivery.

43. AIM Aims at avoiding an unnecessary cesarean section and at delivering a healthy baby.

44. contraindications Associated mid pelvic and outlet contraction Presence of complicating factors like primigarvida , malpresentation, post maturity, post caesarean pregnancy, pre eclampsia, medical disorders like heart disease, diabetes, TB etc Lack of facilities for caesarean section round the clock

45. Conduction of trial labor Prefers spontaneous labor, induce only if labor does not start even after due date NPO, maintain hydration by IVF, adequate analgesics Maintain partograph Maternal and fetal monitoring In failure to progress: amniotomy+ oxytocin after cervix is 3cm Pelvic examination after membranes are ruptured

46. FAVOURABLE FACTORS Flat pelvis better than android Vertex Degree of contraction: minor Intact membranes till full dilatation Good uterine contraction Emotional stability of woman

47. UNFAVOURABLE FEATURES Appearance of abnormal uterine contraction Cervical < 1cm/hour Arrest of cervical dilation and no descent of fetal head in spite of oxytocin therapy Early rupture of membranes Formation of caput and evidence of excessive moulding Fetal distress

48. HOW LONG TRIAL TO BE CONTINUED Termination of trial Spontaneous delivery with or without episiotomy Forceps/ ventouse : difficult forceps delivery is to be avoided Caesarean section

49. Successful trial A healthy baby is born vaginally, spontaneously or by forceps or ventouse with the mother in good condition. Delivery by cesarean section or delivery of a dead baby, spontaneously or by craniotomy, is called failure of trial labor.

50. Advantages of trial labor It eliminates unnecessary cesarean section electively decided upon It eliminates injudicious use of premature induction of labor with its antecedent hazards A successful trial ensures the women a good future obstetrics

51. Disadvantages of trial LABOR Test of disproportion remains unproven when cesarean delivery is done due to fetal distress or uterine dysfunction Increased perinatal morbidity or mortality due to asphyxia or intracranial hemorrhage Increased maternal morbidity Increased psychological morbidity

52. Nursing management Check vitals every 4 hourly Monitor both contraction and fetus continuously Report immediately the sign of fetal distress Position the mother in ways to increase the pelvic diameter such as sitting or squatting which increase the outlet diameter and also aid in fetal descent Assess the fetus for hypoxia Provide support to the client and the family members in coping with stress of a complicated labor

53. COMPLICATIONS OF CONTRACTED PELVIS Maternal: During pregnancy: Incarcerated retroverted gravid uterus.   Malpresentations. Pendulous abdomen.                         Nonengagement. Pyelonephritis especially in high assimilation pelvis due to more compression of the ureter .

54. During labour : Inertia, slow cervical dilatation and prolonged labor. Premature rupture of membranes and cord prolapse. Obstructed labor and rupture uterus. Necrotic genito -urinary fistula. Injury to pelvic joints or nerves from difficult forceps delivery. Postpartum hemorrhage.

55. Fetal: Intracranial hemorrhage.      Asphyxia.                Fracture skull. Nerve injuries.                    Intra-amniotic infection.

56. dystocia Dystocia refers to the abnormal progress of labor. The labor is longer, more painful, or abnormal because of problems with the mechanics of labor, powers, passageway, passenger, or psyche. Dystocia is the most common indication for primary cesarean section, accounting for 50% of surgical deliveries.

57. causes 4 P’s 1.Powers: uterine contractions that are not sufficiently strong to cause cervical dilatation and effacement Voluntary pushing combined with uterine contractions not be sufficient to cause descent and expulsion of the fetus.

58. 2.Passageway: Variations in the size and shape of the bony pelvis like contracture of the pelvic diameter Abnormalities of the reproductive tract like immature pelvic size or deformities

59. 3. Passenger Malpresentation Malposition Unusual size Abnormal development of the fetus

60. 4.Psyche Maternal factors: Anxiety Lack of preparation fear

61. Problems with the power Problems with the powers of labor involve the forces of labor, uterine contractions, and bearing down efforts. Dysfunctional labor is a term commonly used to describe abnormal uterine contractions that interfere with normal progress of labor.

62. Types of uterine dysfunction Hyper tonic contraction pattern Hypotonic contraction pattern

63. Hypertonic contraction pattern Involves a distortion of the pressure gradient . The midsegment may contract with more force than the fundus, or there could be complete asynchronism of the impulses originating in each cornu . Increased frequency or elevated resting tone > 15 mmHg Occurs during latent phase. Ineffective in accomplishing dilatation Increased uterine tone result in maternal discomfort Contraction described as ‘colicky’ and extremely painful Uterus tender to palpate even between contractions.

64. management Rest Administration of fluids to maintain hydration and electrolyte balance Inj. Morphine 10-15 mg IM to inhibit abnormal excitability Short acting barbiturates Oxytocin is contraindicated as it may cause even greater resting tension. 90% resume normal labor when the sedation is disappeared. CS if the contractions remain uncoordinated and ineffective even after rest and with evident signs of fetal distress.

65. Hypotonic contraction pattern Occurs in approximately 4% of all labor Uterine contractions are less frequent, no basal tone and their slight rise in pressure is insufficient to dilate the cervix at satisfactory rate. Occurs in active phase Contractions also may become hypotonic during second stage It is a pattern of uterine activity that is less than the adequate labor pattern

66. management Timely diagnosis Vaginal examinations every 4 th hourly Rest and fluids enema Augmentation of contraction by amniotomy or Oxytocin administration ARM

67. Active phase disorders Protraction disorders Arrest disorders

68. Protraction disorders Characterized by a slower than normal rate of cervical dilation and by delayed descent of the fetal head in the active phase of labor. Cervical dilation < 1 cm/ hr in nulliparous Cervical dilation <2 cm/ hr in multiparas Treated by supportive fluids, reassurance and minimum sedation.

69. Arrest disorders Prolonged deceleration phase: > 3 hrs in nullipara and > 1 hr in a multipara Secondary arrest of dilation: no progress in cervical dilation occurs for > 2 hours Arrest of descent: fetal head dose not descent for > 1 hr in nulliparous and > 0.5 hours for a multipara. Failure of descent: no descent during first stage, deceleration phase or active phase. It may occur following protraction disorders or when a normally progressing labor suddenly stops Frequently associated with CPD.

70. PROBLEMS WITH EXPULSIVE FORCES Inadequate voluntary expulsive forces Pathologic retraction ring Constriction ring

71. Inadequate voluntary expulsive forces Affected by Anesthesia or heavy sedation Fatigue or intensification of pain during pushing Rarely physical problems such as spinal cord injury Management related to the cause. Appropriate encouragement, support, instruction and positioning.

72. Pathologic ring and constriction ring Pathologic retraction ring or Bandl’s ring is an exaggeration of the normal physiologic retraction ring which occurs at the junction of the upper and lower uterine segments. Uterus above the ring becomes thicker, lower uterine segment thins out and rupture unless the obstruction is relieved or delivery is accomplished by cesarean section. Constriction ring usually conform to a depression in the fetus such as the neck or abdomen . The area pf spasm is thick, but the lower uterine segment does not become stretched or thinned out. Managed by CS

73. Classification of dystocia 1. PELVIC DYSTOCIA This occurs when there is a significant shortening of the internal diameters of the bony pelvis. 2. SOFT TISSUE DYSTOCIA This is caused by an obstruction of the birth passage by an anatomic abnormality other than that of bony pelvis. Those abnormalities may be tumor, injuries that prevent dilatation, and congenital anomalies ( bicornuate uterus)

74. 3.FETAL DYSTOCIA This refers to conditions that involve the passenger that can delay and complicate the process of labor. It may be excessive size of fetus, fetal anomaly( hydrocephalus, conjoined twins, gross ascites) or fetal malpresentations. 4.UTERINE DYSTOCIA This is an abnormality of the contractile pattern of the uterine muscles that prevents normal progress in labor. The contractions may be too weak, too short, or too infrequent. Labor may also be extremely forceful, rapid or traumatic.

75. NURSING MANAGEMENT ASSESSMENT condition of the fetus FHR and baseline variability Signs of fetal distress: meconium stained amniotic fluid, increased fetal activity Maternal vital signs Urine checked for acetone Intake and output Contractions: frequency, strength, duration Cervical dilation and effacement

76. diagnosis Acute pain related to intense uterine contractions Fatigue related to prolonged labor Anxiety related to unexpected length of labor Fear related to uncertainty of outcome Knowledge deficit related to dystocia, treatment and care Ineffective individual coping related to fatigue and fear Risk for infection related to prolonged rupture of membranes Risk for fluid volume deficit related to increased insensible fluid loss during prolonged labor

77. interventions Emotional support Repeated reinforcement of the explanations Encourage feedback Comfort measures to promote relaxation Sponge bath, soothing back rubs Changes in position: Diversional activities Companionship Emptying of bladder Enema Maintain partograph

78. Labor care guide The LCG has been designed for the care of women and their babies during labour and childbirth. It includes assessments and observations that are essential for the care of all pregnant women, regardless of their risk status. Documentation on the LCG of the well-being of the woman and her baby as well as progression of labour should be initiated when the woman enters active phase of the first stage of labour (5 cm or more cervical dilatation), regardless of her parity and membranes status.

79. Structure of lcg The LCG has seven sections, which were adapted from the previous partograph design. The sections are as follows : 1. Identifying information and labour characteristics at admission 2. Supportive care 3. Care of the baby 4. Care of the woman 5. Labour progress 6. Medication 7. Shared decision-making

80. Related studies Study of anthropometric measurements to predict contracted pelvis Deepika N, Arun kumar International journal of clinical obstetrics and gynecology, 2019; 3(1).07-11 This cohort study is done to know the efficacy of using maternal height, foot length, external pelvic measurements, sacral rhomboid dimensions as predictors of CP. 1000 uncomplicated primigravid are selected. Found that CPD was present in 123 women. In univariant analysis, maternal height, foot length, biacromial diameters were found to be associated with CP. Smaller dimensions of sacral rhomboid are promising screening parameters for contracted pelvis which can be used in community to pick up high risk primigravid women.

81. Thank you