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1. CEPHALO PELVIC DISPROPORTION and CONTRACTED PELVIS

2. Parts of pelvis

3. FALSE PELVIS The portion above the pelvic brim. Has no obstetrical significance relevant to passage of fetus through the pelvis The bony canal that the fetus needs to pass through during the normal mechanism of childbirth comprises brim, cavity & outlet TRUE PELVIS

4. DIAMETERS OF PELVIC INLET Antero -posterior diameters Anatomical conjugate (true conjugate)= 12cm Obstetric conjugate = 11 cm Diagonal conjugate = 12 -13 cm Oblique diameters Right oblique diameter =12 cm Left oblique diameter = 12 cm Transverse diameters = 13cm

5. DIAMETERS OF PELVIC CAVITY As the cavity of the pelvis is round in shape, all the diameter of the cavity is 12cm

6. Antero- posterior diameters=13 cm Oblique diameters = 12cm T r a n sver se d i a m e t e r s =10- 11cm Oblique diameters = 12cm DIAMETERS OF PELVIC OUTLET

7. Types of pelvis

8. 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

9. CAUSES:- Large baby due to: Hereditary factors Diabetes Postmaturity (still pregnant after due date has passed) Multiparity (not the first pregnancy) Abnormal fetal positions contracted pelvis Abnormally shaped pelvis

10. CONTRACTED PELVIS

11. 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.

12. Developmental factor : hereditary or congenital. Racia l 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 tumours of the bony pelvis, legs or spines. Factors influencing the size and shape of the pelvis

13. Etiology of Contracted Pelvis Developmental (congenital): Sma ll gynaecoid pelvis (generally contracted pelvis). Sma ll android pelvis. Sma ll anthropoid pelvis Sma ll platypelloid pelvis (simple flat pelvis) Naegele’s pelvis : absence of one sacral ala 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 4 vertebrae. Split pelvis: splitted symphysis pubis

14. Metabolic: Rickets. Osteomalacia ( triradiate pelvic brim) Traumatic : as fractures. Neoplastic : as osteoma . Infection : TB 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.

15. Causes in the lower limbs Dislocation of one or both femurs. Atrophy of one or both lower limbs. N.B. oblique or asymmetric pelvis: one oblique diameter is obviously shorter than the other. This can be found in: Diseases, fracture or tumors affecting one side.

16. 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.

17. DIAGNOSIS OF CONTRACTED PELVIS History Rickets : is expected if there is a history of delayed walking and dentition. 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.

18. Examination General examination: Gait : abnormal gait suggesting abnormalities in the pelvis, spines or lower limbs. Height : women with less than 150 cm height usual y have contracted pelvis. Spines and lower limbs : may have a disease or lesion.( kyphosis ,…)

19. 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

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

21. DIAGNOSIS OF CPD AT BRIM ABDOMINAL METHOD FOR CPD 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 .

22. 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

23. 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

24. ABDOMINAL-VAGINAL METHOD It is also called as MULLER – MUNRO KERR It is bimanual method.

25. Results :- the head can be pushed down up to the level of ischial 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 ischial spine and ther 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.

26. Pelvimetry : It is assessment of the pelvic diameters and capacity done at 38-39 weeks.It includes: 1. Clinical pelvimetry : Internal pelvimetry for: inlet cavity, and outlet. External pelvimetry for: inlet and outlet. 2. Imaging pelvimetry : X-ray. Computed tomography (CT). Magnetic resonance imaging (MRI) . N.B. CT and MRI are recent and accurate but expensive and not always available so they are not in common use.

27. CEPHALOMETRY Ultrasonography : is the safe accurate and easy method and can detect: The biparietal diameter (BPD) The occipito -frontal diameter. The circumference of the head. Radiology (X-ray) : is difficult to interpret.

28. DEGREES OF CONTRACTED PELVIS 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 asthe bimastoid diameter (7.5 cm) is not crushed.

29. Mana g ement Minor Mo d e r a t e Sev e r vaginal delivery trial labor, if failed caesarean section. caesarean section depends mainly on the degree of disproportion

30. 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:- when trial labor is failed

31. Trial labor:- It i s th e co n duc t i o n of sp o ntaneous lab o r i n a moderate in s tit ut i o n d e gre e of di s pr o po r t i o n, under supervision with i n an watchful expectancy hoping for a vaginal delivery or Trial of labor is a test of labor allowing the patient to enter into active labor putting all variable ( power, passage and passenger) into test and determine whether vaginal delivery is possible or not.

32. 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

33. 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

34. 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

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

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

37. 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

38. COMPLICATION Maternal: During pregnancy: Incarcerated retroverted gravid uterus. Mal presentations. Pendulous abdomen. Non engagement. Pyelonephritis especiall y in high assimilation pelvis due to more compression of the ureters.

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

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

41. BOOKS:- Beischer , N.A., Mackay, E.V. & Colditz , P.B. (1997). Obstetrics and the New-born. (3 rd ed.). London: W.B. Saunders. Dutta , D.C. (2004). Text book of obstetrics. (6 th ed.). Kolkata: New central book agency (P) ltd. Fraser, D.M. & Cooper,M.A . (2005). Myles Text book for Midwives. (14 th ed.). Edinburg: Churchill Livingstone. Littleton, L.V. & Engebeton , J.C. (2007). Maternity Nursing care. (1 st ed.). Australia: Thomson. BIBLIOGRAPHY

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