cpd & cp.pptx

Cephalopelvic disproportion, contracted pelvis, Etiology, risk factors, management, assessment methods of cpd,clinical features,Munro Kerr muller method,imaging pelvimetry,trial of labour in CPD,conduct of Trial of labour,complications of CPD

1. CPD & CONTRACTED PELVIS

2. CEPHALOPELVIC DISPROPORTION CPD- disproportion between diameters of fetal head & maternal pelvis for that pregnancy, with that head and under the given circumstances. CPD need not recur in subsequent pregnancies CPD is best assessed only at the onset of labour

3. Causes for CPD Large baby due to : - hereditary factors - diabetes - post maturity - multiparity Abnormal fetal position Contracted pelvis Abnormally shaped pelvis

4. Contracted pelvis Anatomical definition: One or more diameters in one or more of the planes of the pelvis may be shorter than normal. Obstetric definition: alteration in size / shape of pelvis of sufficient degree to alter the normal mechanism of labour in an average sized baby Permanent deformity of the pelvis Recurrent cause for dystocia in subsequent labour Contracted pelvis could be a cause of CPD, all CPDs are not due to contracted pelvis Contraction may be at the level of pelvic brim/cavity/outlet It may be symmetrical or asymmetrical and it may affect either antero posterior / transverse diameter or both

5. Factors influencing the size & shape of pelvis Developmental factor- hereditary/ congenital Racial factor Nutritional factor- malnutrition leads to small pelvis Sexual factor- excess androgen may produce android pelvis Metabolic factor- Rickets / osteomalacia Trauma/ diseases/ tumors of bony pelvis/ legs/spines

6. Etiology of contracted pelvis Causes in pelvis DEVELOPMENTAL( congenital) -Small gynaecoid pelvis( generally contracted pelvis) -Small android / anthropoid pelvis -Small platypelloid pelvis(simple flat pelvis) - NAEGELE’S PELVIS- absence of one sacral ala - ROBERT’s pelvis- absence of both sacral ala - SPLIT pelvis- splitted pubic symphysis - HIGH assimilation pelvis-sacrum composed of 6 vertebrae - LOW assimilation pelvis- sacrum composed of 4 vertebrae

7. Contd., Causes in spines: Lumbar kyphosis / lumbar scoliosis/ spondylolisthesis L5 vertebra is pushed forward along with the above vertebral column while the promontory is pushed backwards & tip of the sacrum is pushed forwards leading to outlet contraction Causes in lower limbs Dislocation of one or both femur Atrophy of one or both lower limbs Diseases / tumors / fracture affecting one side

8. Diagnosis of CPD/ Contracted pelvis HISTORY h/o Rickets- if there delayed dentition/ walking h/o trauma/diseases of pelvis/spines/ lower limbs In a parous women – h/o previous deliveries -safe/vaginal delivery of normal size/live/undamaged babies at term- normal pelvic capacity -BOH- difficult vaginal delivery which ended in stillbirth/ neonatal death/ C- section/ forceps delivery -prolonged labour/ perineal tears/PPH/VVF/RVF & size of baby /neurological sequelae In LSCS- Emergency lscs followed by prolonged labour due to CPD/ h/o malpresentations / blood transfusions

9. Examination General examination: Gait – abnormal gait( limping/waddling gait) associated with abnormalities in pelvis/LL/ spines HEIGHT- -SHORT STATURE (<135 cm) have smaller pelvis and in many cases babies are too small -Pelvic dystocia is more common in a women who are less than average height - shortening of lower limbs due to fracture/surgery Spines/lower limbs- lesion/ diseases( kyphosis /polio/TB)

10. Contd., Rickets manifestations- pigeon chest/ ricketic rosary in costal ridges/ Harrison’s sulcus / bow legs DYSTOCIA DYSTROPHIA SYNDROME- Short /obese Subfertile / android type of pelvis Male distribution of hair

11. Abdominal examination UNENGAGED or FLOATING head in PRIMI at term Pendulous abdomen – CPD due to inlet contraction Mal presentations are more common Deflexed attitude of head prior to the commencement of labour should be ruled out Deflexed head may simulate or exaggerate disproportion

12. Causes for MOBILE head ( Primi /at term) Wrong dates Prematurity Placenta previa Polyhydraminos Cord around the neck Multiple pregnancy CPD/ contracted pelvis Tumors in LUS Fetal cause- hydrocephalus

13. Clinical methods for diagnosing CPD ABDOMINAL method- Screening method Difficult in obese/ deflexed head/ floating head Procedure After emptying the bladder, in dorsal position with thighs and knees are semi flexed & abducted . Left hand is used to grasp the fetal head Middle finger & index finger of right hand is placed above the pubic symphysis , keeping the inner surface of the middle finger in line with pubic symphysis

14. Contd., Head is pushed downwards into pelvis Fingers of right hand placed on pubic symphysis will assess CPD Interpretation Head can be pushed down into pelvis- NO CPD Head is flushed with pubic symphysis - MILD degree of CPD Head cannot be pushed down & there is over riding of head over pubic symphysis - MAJOR degree of CPD

15. Contd., Ian Donald method: In dorsal position, pt’s knee is not fully raised but widely separated Using 3 rd , 4 th , 5 th fingers of both hands , head is grasped at sinciput & occiput Index finger reaches pubic symphysis Thumbs of both hands are placed over parietal eminence Thumbs on parietal eminence press the head downwards & index fingers on pubic symphysis can assess the degree of CPD

16. Pelvic assessment Pelvimetry – Assessment of pelvic diameters & capacity done at 38-39 weeks of gestation. It includes, CLINICAL PELVIMETRY- Internal pelvimetry External pelvimetry Inlet/ cavity/ outlet Inlet / outlet

17. Pre requisites for assessing CPD Explain the procedure to the patient Bladder should be empty Patient should be in dorsal position Done under aseptic precautions, internal examination should be gentle Pelvic capacity can be estimated clinically by evaluating various measurements with middle / index finger of right hand during bimanual examination

18. Vaginal examination Sacral promontory- reached easily or not Sacral curvature-well curved or not (from promontory to tip of sacrum – if it is well developed at the level of mid pelvic / higher level ,bone can be reached with difficulty) Flattening of sacrum- unfavourable sign- transverse arrest Sacro sciatic notch-admits 2 fingers or not Adequacy of pelvis at the lower level can be assessed. Less space – narrowing of sacrosciatic foramen & diminished capacity of lower pelvis.

19. Contd., Pelvic sidewalls- parallel/ divergent / convergent(dangerous) Ischial spines- prominent or not. It should be reached when fingers are spanned. Sub pubic arch/ sub pubic angle-acute/obtuse. ( corresponds to angle substended by fully abducted thumb/index finger) Ischial tuberosities -admits 4 knuckles when clenched fist is kept between ischial tuberosities Coccyx –mobile or tipped

20. Diagonal conjugate DC- is the distance between lower border of pubic symphysis to sacral promontory(12.5 cm) Procedure Under SAP, pt in dorsal position, after emptying the bladder Introduce index finger/ middle finger of right hand into vagina until middle finger reaches sacral promontory Index finger of left hand marks off the lower border of pubic symphysis over the right hand Right hand is withdrawn & distance between the tip of middle finger and point marked by index finger is measured.

21. True conjugate TC is estimated by deducting 1.5-2cm from DC (10.5 cm) Accuracy depends on Depth of pubic symphysis -If it is deeper, more must be deducted Inclination of pubic symphysis -if it is obtuse, more must be deducted Height of promontory- if it is higher, more must be deducted However DC and through that TC are not assessed as a routine

22. Munro-Kerr-Muller method Abdomino pelvic method Assess the relative size of fetal head and maternal pelvis Procedure After emptying the bladder, in dorsal lithotomy position with thigh /knee are semi flexed Obstetrician stands on right side Grasps the fetal head with the left hand & pushes it into pelvic brim Middle /index fingers of right hand are kept at the level of ischial spines and thumb of right hand is kept over the pubic symphysis

23. Contd., Extent of fetal head into maternal pelvis or degree of over riding of head over symphysis , severity of CPD can be assessed. If the head could be pushed down upto the level of ischial spines & there is no overlapping of parietal bone over pubic symphysis - NO CPD Not upto the level of ischial spines & parietal bone is flushed with pubic symphysis - MINOR CPD When head could not be pushed down and there is marked over riding of head on thumb- MAJOR CPD

24. Limitations If done before labour, a deflexed head may simulate disproportion and gives wrong prediction It assess only contraction at the level of pelvic brim Once ACTIVE LABOUR starts , the preliminary adjustment between head & brim occurs, mild disproportion is usually corrected, thereby accuracy of this method is enhanced Inspite of limitations, it must be essential part of routine antenatal examination near term in all Primigravidas with unengaged head Multigravidas with BOH

25. Contracted pelvis Contracted inlet Contracted midpelvis Contracted outlet If AP diameter<10cm If DC< 11.5 cm Complications : Early spontaneous ROM Slow dilatation of cervix Malpresentations If interischial diameter <10cm Ischial spines are prominent Converging sidewalls Narrow sacro sciatic notch More common than inlet contraction Malrotation of fetal head Deep transverse arrest If intertuberus diameter <8cm Isolated outlet contraction is rare. commonly associated with midpelvis contraction

26. IMAGING PELVIMETRY To supplement the observations obtained on clinical examination X ray CT MRI USG For pelvis assessment / CPD Lateral view- AP diameters of pelvis/ sacral curvature/ pelvis brim/ sacroscaitic notch -More accurate -Restricted use because of unnecessary radiation exposure Advantages -No ionising radiation - Fetus can be completely imaged -Soft tissue dystocia can be diagnosed - Biparietal diameter can be measured accurately - Occipito frontal diameter -Head circumference

27. Management of labour Early diagnosis & proper management influence the maternal/ fetal prognosis All cases of suspected contracted pelvis/ CPD should be delivered only in well equipped centres In modern obstetrics, ELECTIVE C-section is the method of choice for contracted pelvis Trial of labour can be attempted when there is Minor CPD, in a well equipped facility & well experienced Obstetrician & team is available

28. Trial of labour Definition – Trial of labour is conducted in a woman with minor degree of CPD with vertex presentation, with no obstetric or medical complications in an attempt to deliver vaginally. Pre requistes for Trial of labour Should be conducted in an institution with facilities for LSCS Counselling of the woman( advanatges / disadvanatges & it may end up in LSCS) Monitor with PARTOGRAM NO TIME LIMIT for trial of labour

29. Factors affecting TOL TOL is dependent on 3 factors that cannot be assessed before labour Uterine contractions Moulding of fetal head leading to decrease in diameters of fetal head Yield of the pelvis at the sacroiliac joints / pubic symphysis with resultant increase in pelvic dimensions and giving up of perineum

30. Contd., Indications Contra indications Minor or first degree CPD Elderly woman Average size fetus Outlet contraction No obstetric complications True conjugate<9cm Medical /obstetric complications of pregnancy

31. Outcome of TOL SUCCESSFUL TRIAL FAILED TRIAL Vaginal delivery Normal /assisted with forceps/ vaccum Good maternal/ fetal outcome LSCS /vaginal delivery With poor maternal/ fetal outcome

32. Conduct of TOL During trial labour, adeqaute hydration/ nutrition and analgesia should be maintained Informed consent Nil oral, only IV fluids Analgesia – Epidural Progress of labour can be monitored by Partogram If inadequate uterine contractions- oxytocin drip can be started Apply forceps when needed AMTSL

33. Termination of TOL LSCS- if there is fetal / maternal distress -inadequate progress of labour Trial FORCEPS- tentative attempt in MILD CPD it should be attempted in OT after informed consent, to expedite the delivery Abandon the procedure , if there is difficulty in application while locking/ traction then proceed to C- section. FAILED FORCEPS- Error in judgement of CPD Failure to deliver fetus vaginally after applying forceps

34. Role of ELECTIVE LSCS in CPD Indications MAJOR degree of CPD CPD associated with -BOH -APH -Pre eclampsia -GDM -FGR -Prolonged pregnancy

35. Signs in progression of TOL Favourable signs Unfavourable signs Good uterine contractions- 3 in 10 mins each lasting for 30-45 secs Ineffective uterine contractions Early engagement of head in OA position Head remaining high at full cervical dilatation Occipito posterior position Closely applied cervix( well thinned out & effaced) Loosely hanging cervix not applied to head Rupture of membranes after full dilatation of cervix Early rupture of membranes

36. Complications of CPD Maternal complications Fetal complications PROM/ Cord prolapse Fetal hypoxia Prolonged labour Birth asphyxia/ intrapartum death Obstructed labour leads to uterine rupture/VVF/sepsis Cephalhematoma High chance for instrumental delivery Hypoxic ischemic encephalopathy(HIE) PPH( atonic / traumatic) Multiple fractures