CPD cephalo pelvi. .pptx

Cpd

1. Banu Priya N M.Sc. Nursing 2 nd Year Saveetha College Of Nursing SIMATS CONTRACTED PELVIS- CPD,DYSTOCIA

2. CONTRACTED PELVIS

3. Anatomical - It is a pelvis in which one or more of its diameters is reduced below the normal by one or more centimeters. Obstetric - It is a pelvis in which one or more of its diameters is reduced so that it interferes with the normal mechanism of labor.

4. Common causes of contracted pelvis are:- Nutritional and environmental defects :- minor variation ;- common major :- rachitic and osteomalacic –rare o r injury a f fe c tin g th e bone fracture ,tumors, tubercular artheritis. Dise a se pelvis:- spine:- kyphosis, scoliosis, coccygeal deformity lower limbs:- poliomyeitis, hip joint disease Developmental defects:- naegele’s pelvis, Robert's pelvis

5. Classified by:- A) type of distortion of pelvic architecture B) degree of contraction

6. A) Classification by Pelvic Architecture 1. 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)

7. 2. Flat Pelvis R edu c e d an t erop o ster i o r d iameters wit h no r m a l transverse and oblique diameters Has 2 types of contracture Simple flat (or platypellic) pelvis Entire sacral platform is dislocated toward the symphysis hence all the anteroposterior diameters of all pelvic planes are reduced

8. b) Flat rachitic Anteroposterior diameter of the pelvic inlet only is reduced 3. Generally Contracted Pelvis All diameters reduced, but the anteroposterior diameters are shortened greater then the others Usually connected with rickets of the childhood

9. Rare forms of contracted pelvis Otto’s p e l v is – d e ve l o p a s result o f inf l ammat o ry 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 Osteomalacic pelvis Scoliotic pelvis – only the lumber region cause deformity of the pelvis. The acetabulum is pushed inwards on the weight bearing side.

10. B) Classification by degree of contracture 4 degrees First degree : true conjugate <11cm but not <9cm, spontaneous delivery is possible Second degree : true conjugate = 9-7.5cm spontaneous delivery possible but complications may arise Third degree : true conjugate 7.5-6cm spontaneous delivery impossible, use C-section Fourth degree : true conjugate <6cm, impossible delivery, only way is C-section ; also known as absolutely contracted pelvis

11. Diagnosis History Rickets: is expected if there is a history of delayed walking and dentition. Trauma or diseases: of the pelvis, spines or lower limbs. Infantilism Previous tuberculosis of bones and joints

12. Bad obstetric history: e.g. prolonged labour ended by ; Difficult forceps Caesarean section or Still birth. Weight of th e baby Evidence of maternal injuries such as complete perineal tear, vesico vaginal istula, recto vaginal fistula

13. B. General examination : Abnormal gait :- Assess woman for stockily built with bull neck. Broad shoulder and short thigh Obese and male distribution of hair Stature :women < 150 cm or 5 feet

14. Abdomen examination Pendulous abdomen in primigravida Fetal head fails to enter a contracted pelvis at the end of pregnancy and floats high above inlet, failed growth of uterus deviates upward and anteriorly Non engagement in last 3-4 wks. in primigravida

15. 2 shapes of abdomen Acuminate (pointed)abdomen in primigravida with a resilient abdominal wall Pendulous abdomen in multiparous women

16. Patient is placed in dorsal position with thigh flexes and separated. The head is grasped by the left hand. 2 fingers (index and middle) of theright hand are placed above the symphysis pubis to note the degree of overlapping. If when the head is pushed downward and backward.

17. The head can be pushed down in the pelvis without overlapping of the parietal bone on the symphysis pubis:- No disproportion Head can be pushed down a little but ther is slightly overlapping of the parietal bone evidence by touch on the under surface of finger overlapping by 0.5cm:- Moderate disproportion

18. Head can not be pushed down and instead the partial bone overhangs the symphysis pubis displacing the finger – sever disproportion Some times the degree of disproportion is difficult to found by this method because of:- Deflexed head Thick abdominal wall Irritable uterus High floating head

19. It is also called as MULLER – MUNRO KERR It is bimanual method.

20. Results :- The head can be pushed down up to the level of ischia 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 ischia spine and there is slight overlapping of the parietal bone :- slight or moderate disproportion The head can not be pushed down and instead the parietal bone overhangs the symphysis pubis displacing the thumb:- sever disproportion .

21. D. 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 . Computerized tomography (CT). Magnetic resonance imaging (MRI) .

22. Disproportion Moderate degree Sever degree

23. Preterm labor Term labor Induction of labor C e sarean section Trial labor

24. Elective cesarean section at term is indicated in:- Major degree of contraction Major disproportion Absolute contraction Dead fetus Patient not fit for trial labor The operation is done in planned way any time during last week of pregnancy. Emergency W hen trial labor is failed

25. C a reful feta l and maternal moni t o ring by electronic fetal monitoring and non stress test Oral feeding remain suspended and hydration is maintained by intravenous drip Adequate analgesic is administered Augmentation of labor by pitocin

26. The progress of labor is mapped with partograph:- progressive descent of the head progressive dilatation of the cervix After the membrane rupture, pelvic examination is to be done:- to exclude cord prolapse to note the color of liquor to assess the pelvis once or more to note the condition of the cervix including pressure of the presenting part of the cervix

27. in favorable cases, end spontaneously, low forcep and low ventose. In unfavorable cases, do caesarean section. Successful trial:- A trial is called successful, if a healthy baby is born vaginally, spontaneous or by forcep or ventose with the mother in good condition Failure of trial labor:- Delivery is by cesarean section or delivery of a dead baby spontaneously or by craniotomy is called failure of trial labor

28. Lower incidence of cesarean section. A successful trial ensures the women a good future obstetrics.

29. May end before full cervix dilatation Increased fetal mortality and morbidity In failed trial operative risk increases.

30. 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

31. First stage Fetal distress Pro l onge d labor

32. Second stage Delay e d second stage Sh o ul d er dystocia

33. Third stage Retained placenta Maternal injury PPH

34. Cephalo pelvic disproportion is the disparity in relation between the head of baby and the mother’s pelvis. It is a pelvis in which one or more of its diameter is reduced below the normal by one or more centimeter

35. It is based on clinical findings and pelvimetry:- Severe disproportion :- when the obstetric conjugate is less than 7.5 cm (3”) then it is said to be severe disproportion. Borderline disproportion :- when the obstetric conjugate is between 9.5 and 10 cm. In inlet the anterior posterior diameter is less than 10 cm and transverse diameter is less than 12 cm.

36. According to American College of Nursing Midwives, occur 20 out of 250 pregnancy. “It has been seen through studies that 65% of women who have been diagnosed with CPD in previous pregnancies, deliver vaginally in subsequent pregnancies.”

37. Nutritional deficiency Disease / injury to pelvic bones Developmental defects A large size baby Abnormal fetal position Problem with genital tract

38. Absolute causes :- it is a true mechanical obstruction due to:- Permanent maternal cause such as contracted pelvis, anterior sacrococcygeal tumor. Temporary fetal causes such as hydrocephalus, large baby etc. Relative cause:- the relative cause includes brow presentation, face presentation, mento posterior, occipito posterior position, deflexed head in vertex presentation

39. MANAGEMENT: The treatment for CPD is to continue with labour or move on to a caesarean section. The goal of treatment is to have a safe delivery, so the doctors will decide how to treat the condition based on how the delivery is going.  TRIAL OF LABOR: When there is a possibility of CPD, the doctors may decide to let you try to labour. If your labor is moving along well, it may continue along with:  Close monitoring of your contractions, dilation, and the baby's progression down the birth canal. Close monitoring of the baby's movements and  heart rate. Confirmation of the baby's position with a vaginal exam. Other tests such as X-ray, ultrasound, or MRI to visualize the baby's head and your pelvis.

40. During the trial of labour, you can help to open your pelvis and move the labour along by changing positions with the help of your nurse, doula, or partner. You can try:  Sitting Squatting Changing sides Going on your hands and knees  If labour continues, forceps or a vacuum may be needed to help deliver the baby. But, if problems arise such as ineffective contractions, slow dilation and effacement, no descent, or fetal distress, the doctors will end the trial, and a C-section will be necessary. 

41. Caesarean Section When the labour is very long, not progressing as it should, or causing complications for you or the baby, the next step is a C-section. You may need a C-section if: You have had a previous C-section. You are an older first-time mom. The baby is not in a good position for delivery. The baby is overdue by a week or more. You are having complications such as pre-eclampsia. You or the baby are having other medical issues .

42. Shoulder dystocia

43. Definition Wh e n f eta l hea d i s d elivered , bu t sho u ld e rs ar e stuck an d canno t b e deli v ere d i t i s know n a s shoul d er dystocia

44. Shoulder dystocia The anterior shoulder becomes trapped behind on the symphysis pubis, whilst the posterior shoulder may be in the hollow of the sacrum or high above the sacral promontory.

45. Inciden c e Overall incidence varies between 0.2 and 1 percent

46. Predisposing factors Fetal macrosomia Obesity Diabetes Midpelvic instrumental delivery Post maturity Multiparty AnencephalFetal ascitis

47. Warning signs and diagnosis The delivery may have been uncomplicated initially, but the head may have advanced slowly and the chin may have had difficulty in sweeping over the perineum. Once the head is delivered it may look as if it is trying to return into the vagina, which is caused by reverse traction. Diagnosed when maneouvers normally used by the midwife fail to accomplish delivery.

48. Turtle sign

49. Management Principles DONTs’: Do not be panicky Do not give traction over baby’s head Do not apply fundal pressure Dos’ Call for extra help Clear the infant’s mouth and nose Involve the anaesthesist and the paediatrician Perform episiotomy if not performed earlier

50. Management

51. Management Pre-procedure steps and considerations: Shout for help Explain procedure Follow general principles of basic care and infection prevention Perform episiotomy

52. Management… 2. Perform the Mc Roberts maneuver:

53. McRoberts maneuver

54. Rubin’s Maneuver 3. If the shoulder is still not delivered: insert a hand into the vagina and apply pressure to the anterior shoulder in the direction of the baby’s sternum to rotate the shoulder and decrease the shoulder diameter. If the needed, apply pressure to the posterior shoulder in the direction of the baby’s sternum

55. Wood’s maneuver 4. If the shoulder is still not delivered despite the above measures: Insert a hand into the vagina Grasp the humerus of the posterior arm and keeping the arm flexed at the elbow, sweep the arm across the chest, grasp the hand and deliver the entire arm. With one hand on each side of the fetal head, apply firm, continuous traction downward to move the anterior shoulder under the symphysis pubis

56. Management…

57. Cockscrew maneyver If the posterior arm cannot be extracted, perform the cockscrew maneuver.

58. Cleidotomy If all of the measures fail to deliver the anterior shoulder ; Another option is to fracture the baby’s anterior clavicle to decrease the width of the shoulder. This is done by pressing the anterior clavicle against the symphysis pubis . After birth, facilitate urgent and immediate newborn care or transfer of the newborn .

59. Zavanelli manoeuvre

60. Maneuvers Method

61. Post Procedure care Repair the episiotomy If needed, provide emotional support to the woman and family following a traumatic birth and possible death of the newborn or injury to the baby.

62. JOURNAL PRESENTATION: Topic: “ Fetal pelvic index to predict cephalopelvic disproportion – a retrospective clinical cohort study” Author:   Pekka Taipale  et al.., First published: 12 February 2019 Published At: Acta obstetrician and gynaecological scandinavica  

63. ABSTRACT OBJECTIVE: To investigate the diagnostic accuracy of the fetal pelvic index to predict cephalopelvic disproportion. DESIGN : Retrospective observational cohort study. SETTING: Pregnant women who had been examined by X‐ray or magnetic resonance imaging pelvimetry because of an increased risk of fetal–pelvic disproportion during 2000–2008 in North Karelia Central Hospital.

64. POPULATION: A total of 274 pregnant women. METHODS: Univariable and multivariable regression analyses were carried out to identify risk factors for caesarean section. Diagnostic accuracy was tested with a receiver operating characteristic curve, and the optimal cut‐off value for fetal pelvic index was calculated .

65. RESULTS A total of 242 women delivered vaginally, and 32 delivered with caesarean section caused by labour arrest. In multivariable modelling, the fetal pelvic index, maternal pelvic inlet size, fetal head circumference and maternal age were significantly associated with a risk of caesarean section. In the receiver operating characteristic analysis, the area under curve was 0.686 with a p‐value of 0.001 and a 95% confidence interval of 0.595–0.778. The optimal fetal pelvic index cut‐off value according to the receiver operating characteristic was −0.65. The caesarean section rate was 8% below the fetal pelvic index value of −0.65 and 20% above the fetal pelvic index value of −0.65 . CONCLUSIONS: The fetal pelvic index was not a clinically useful tool to predict the mode of delivery for patients at high risk of cephalopelvic disproportion. The pooled analysis of the current and previous studies strengthened this conclusion .

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