Contracted pelvis

Contracted pelvis
shorter pelvic diameters
difficulty for delivery of an average sized baby
effects
complications
management

1. Contracted pelvis Sharon Treesa Antony Second year M.Sc Nursing Govt. College of Nursing Kottayam

2. 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 a to alter the normal mechanism of labour in an average size baby.

3. etiology Short women Nutritional and environmental defects Diseases or injuries affecting bones of the pelvis: fracture, tumors , TB arthritis Spine: kyphosis , scoliosis, spondylolisthesis , coccygeal deformity Lower limbs: poliomyelitis, hip joint disease

4. Developmental defects: Naegel’s pelvis, Robert’s pelvis, high or low assimilation pelvis

5. Rachitic flat pelvis Inlet Sacral promontary is pushed downwards or 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 church

6. Osteomalacic pelvis Due to softening of the pubic bones The promontary 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

7. Asymmetrical/ obliquely contracted pelvis Naegel’s pelvis Scoliotic pelvis Disease affecting one hip or sacroiliac joint Tumors or fracture affecting one side of the pelvic bones during growing age

8. Naegele’s pelvis Due to arrested development of one ala of the sacrum Congenital 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

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

10. Robert’s pelvis Ala of both the sides are absent Sacrum is fused with innominate bones

11. Kyphotic pelvis Sacrum is tilted backward in the upper part and towards the lower part, it is narrow and straight APD is increased at the inlet but is decreased at the outlet Narrow suprapubic angle Pendulous abdomen

12. Pelvic diameters Inlet contraction APD: <10cm TD<12cm Diagonal conjugate<11.5cm Midpelvic contraction Transverse + posterior sagittal diameter </= 13.5cm TD< 8cm Outlet contraction Interischial tuberous diameter </= 8cm

13. diagnosis Past history Physical examination Deformities of pelvic bones, hip joint, spine Dystocia dystrophia sundrome Abdominal examination

14. Assessment of pelvis Clinical pelvimetry Sacrum: smooth, short and well curved and the promontary cannot bereached or the sacrum may be long or straight SacroSciatic notch: The notch is sufficiently wide so that 2 fingngers can be easily placed over the sacrspinous ligament covering the notch

15. Ischial spines: spines are usually smootha nd difficult to palpate. They may be prominent or encroach to the cavty Iliopectineallines : beaking suggestive of narroe forepelvis

16. Side walls: convergent Posterior surface of symphysis pubis angulation / beaking Sacrococcygeal joint: mobility and hooked coccyx Pubic arch: shoulld accomodate palmar aspect of 2 fingers Diagonal conjugate : may be less Subpubic angle: roughly corresponds to fully abducted middle and index fingers

17. TD of outlet: by placing the knuckles between the ischial tuberosities APD of outlet

18. X ray pelvimetry CT MRI USG

19. Cepahlo pelvic disproportion It is a state where the normal proportion between the size of the fetus to the pelvis is isturbed .

20. Diagnosis Clinical Abdominal Abdomino vaginal method Imaging pelvimetry Cephalometry USG MRI X ray

21. Effects of contracted pelvis Pregnancy Chance of incarceration of retroverted gravid uterus in flat pelvis Abdomen becomes pendulous Malpresentations

22. Labor Increased incidence of early rupture of membranes Cord prolapse Slow cervical dilatation Prolonged or obstructed labour Operative interference, PPH, Shock

23. Maternal injuries Fetal hazards from asphyxia

24. Management of inlet contraction Ascertain the degree of disproportion Minor inlet contraction: spontaneous delivery Moderate and severe degrees: Induction of labor CS Trial labor

25. Induction of labor 2-3 week prior to EDC in multi gravida with history previous difficult labor

26. Elective CS Major degree of inlet contraction Moderate degree of inlet contraction with outlet contraction or other complicating factors like malpresentation

27. trial labour It is the conduction of spontaneous labour i moderate degree of cephalopelvic disproportion, in an institution under supervision with watchful expectancy, hoping for a vaginal delivery

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

29. Conduction of trial labour Prefers spontaneous labor , induce only if labor doesnot start even after due date NPO, maintain hydration by IVF, adequate analgesics Maintain partograph Maternal and fetal monitoring In failure to progrs : amniotomy + oxytocin after cervix is 3cm Pelvic examination after membranes are ruptured

30. Favourable factors Flat pelvis better than android Vertex Degree of contraction: minor Intact membranes till full dialatation Good uterine contraction Emotional stability of woman

31. Unfavourable features Appearance of abnormal uterine contraction Cervical <1cm/hour in the active phase Descent of fetal head < 1cm/hour Arrest of cervical dilation and nondescent of fetal head inspite of oxytocin therapy Early rupture of membranes Formation of caput and evidence of excessive mouldng Fetal distress

32. 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

33. Midpelvic and outlet contraction CPD at the outlet is defined as one where the biparietal – suboccipitobregmatic plane fails to pass through the bispinous and anteroposterior plane of the outlet.

34. management Elective caesarean section Vaginal delivery: In minor degrees of contraction with watchful expectancy Forceps/ ventouse + deep episiotomy Patograph Oxytocin SOS

35. Cases seen late in labour Caesarean section to avoid difficu;t forceps Forceps with deep episiotomy Syphysiotomy foolowed by ventouse Craniotomy if fetus is dead

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