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1. Feto-pelvic Disproportion ( FPD) 5/15/2024 1

2. Female bony pelvis Divided into two regions by linea terminalis or pelvic brim: A) the greater or false pelvis or pelvis major B) the lesser or true pelvis or pelvis minor False pelvis h as no direct obstetric significance Its only obstetric function is to support the pregnant uterus 5/15/2024 2

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4. Pelvic bone Consists of : Innominate or Hip bones ( Ilium, Ischium and pubic bone) Sacrum Coccyx 5/15/2024 4

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6. True pelvis Pelvic inlet(brim) Mid pelvic (pelvic cavity) Pelvic out let 5/15/2024 6

7. Diameters of Pelvis AP diameter Transverse diameter Oblique diameter 5/15/2024 7

8. AP diameter of pelvic inlet - Obstetrical conjugate : the shortest distance between Sacral promontory and middle symphysis pubis - >= 10cm - 1.5 to 2 cm less than diagonal conjugate. - Diagonal conjugate : the distance from the lower margin of the symphysis pubis to the sacral promontory. - 12 cm and more . - True conjugate(Anatomical): the distance from the upper portion of the symphysis pubis to the sacral promontory . 2. The transverse diameter The greatest distance between the linea terminalis on either side (13cm)

9. MID PELVIS (PELVIC CAVITY) Measured at the level of the ischial spines The interspinous diameter( tranverse diameter of mid pelvic) measures 10cm or slightly higher. The AP diameter through the level of the ischial spine is at least 11.5 cm. Internal rotation take place at this level. Land mark for station and pudendal block .

10. THE PELVIC OUTLET Its plane is at the level of the line between the lower posterior border of the symphysis pubis and the tip of the coccyx . The AP diameter is 13 cm and the intertuberous diameter( Transverse diameter) averages 8 cm .

11. Maternal pelvis types Variations in pelvis are dependent on: - nutrition during childhood - race, genetic, environment Four variant of pelvis based on Moloy and Caldwell Gynaecoid ( typical female ) Anthropoid Android ( typical of males) Platypelloid 5/15/2024 11

12. THE FETAL HEAD Cranial vault is made of bones and sutures . Frontal or metopic : units the frontal bones. Sagital or longitudinal : unit parietal bone Lambdoi d: unit parietal and occipital bone. Coronal or transverse : unit parietal and frontal . Anterior fontanel, or bregma . -diamond shaped -made of 4 suture lines. Posterior fontanel - triangular and has only 3 sutures leading to it .

13. Fetal scalp measurement 5/15/2024 13

14. Anteroposterior diameter of fetal skull 5/15/2024 14

15. Transverse diameters fetal skull - biparietal: - bitemporal: - bimastoid 5/15/2024 15

16. Feto-pelvic Disproportion Used to describe disparity between the size of the fetus and maternal pelvis. Large baby with normal pelvis or Normal sized baby with a contracted pelvis or both. Cephalo pelvic disproportion Cephalopelvic disproportion (CPD) is disparity between the fetal head and maternal pelvis which leads to inability of the fetal head to pass through the maternal pelvis for mechanical reasons. 5/15/2024 16

17. Prevalent in developing countries. Most common cause of obstructed labour. Common indication for C/S. Difficult to diagnose before onset of labor 5/15/2024 17

18. Causes of FPD (clinical classification) 1. Absolute : true mechanical obstruction as a result of A. Permanent (maternal) factors Abnormality resulting from disease or injury affecting the pelvic bones and joints: Rickets, osteomalacia , new growth(tumor), fractures, Tb arthritis. Abnormalities resulting from developmental faults: Negele pelvis, Robert pelvis, Split pelvis, Assimilation pelvis 5/15/2024 18

19. Abnormalities associated with deformity of the vertebral column: Kyphosis , Scoliosis, Coccygeal deformity Abnormalities resulting from disease or deformity of the lower limb: Hip joint disease, Dislocation of one or more femur, Atrophy or loss of one limb 5/15/2024 19

20. B. Temporary (fetal) factors: Hydrocephalus, large foetus (Macrosomia) 2. Relative : where the fetus may be delivered vaginally if a favourable combination of other factors can be achieved. E.g. brow presentation, face presentation and occipito-posterior positions (rotation / flexion of the head may occur during labor progress 5/15/2024 20

21. Diagnosis of FPD Properly taken history , physical examination and completed labor graph allow easy and early identification and diagnosis of FPD . History Primigravid (especially teenage pregnancy) Height measurement ? Previous history of prolonged labor Previous history of perinatal death Previous history of obstetric trauma 5/15/2024 21

22. Properly documented obstetric record (e.g. intraoperative direct measurement of the obstetric conjugate) Instrumental deliveries in previous pregnancy History of previous caesarean delivery for CPD Baby born with birth asphyxia 5/15/2024 22

23. physical examination Antepartum evaluation Measurement of the mother and the fetus has been attempted as a means of detecting FPD before the onset of labor but is found to have poor prediction value . Therefore , antepartum examination, measurement and imaging cannot reliably diagnose FPD to preclude a trial of labor. 5/15/2024 23

24. Intrapartum evaluation Generally FPD, with very few exceptions, is diagnosed after a properly conducted trial of labor. Abdominal and pelvic assessment should be done in all labouring mothers to rule out FPD . Findings that may indicate FPD are:- Abnormal progress of labor : Arrest and protraction disorders of cervical dilatation, or crossing an alert or action line on a partograph. 5/15/2024 24

25. Failure of head descent especially in the presence of arrested or protracted cervical dilatation High station of the head during late active first stage of labor or second stage of labor may suggest presence of FPD, particularly in primigravid woman . Failure of progress of labor after correction of inadequate uterine activity ( by amniotomy or oxytocin infusion or both) 5/15/2024 25

26. Abnormal clinical pelvimetry A true conjugate less than 10 cm or inter-tuberous diameter of less than 8 cm (a fist size) indicates a grossly contracted pelvis through which a fair-sized fetus (with BPD of 9.5 cm) cannot be delivered safely Easily reachable sacral promontory, prominent ischial spines, convergent pelvic side walls Flat sacrum , narrow sub pubic angle and narrow sacrosciatic notch. 5/15/2024 26

27. Molding : An increasing degree of molding in the absence of descent of the head is the hallmark feature of CPD (the ultimate index of CPD). Severe moldings (+2/+3) at a higher station (3/5th or more above the pelvic prim ). Parieto-parietal molding (overlap) is highly associated with CPD . 5/15/2024 27

28. Caput Succedaneum A severe degree of caput has been associated with prolonged labor and CPD. Severe degree of caput is diagnosed when the scalp edema hampers identification and assessment of the suture lines . 5/15/2024 28

29. Fetal Macrosomia Clinical , maternal or ultrasound estimation of fetal size have the potential for identifying macrosomia pregnancies at risk for CPD. Fetal distress In the presence of marked CPD, the fetus responds with fetal heart 5/15/2024 29

30. Imaging Ultrasound examination may reveal macrosomia or congenital anomalies e.g. hydrocephalus. 5/15/2024 30

31. Management of FPD Elective c/s - this is indicated in extreme form of contracted pelvis or large fetal size Trial of labor Trial of labor is conducted in a woman with suspected CPD to determine whether it is safe for the woman to deliver vaginally or not. It is done in an equipped and staffed hospital for operative procedures in case vaginal delivery fails . 5/15/2024 31

32. Management of FPD Borderline CPD is entertained if the obstetric conjugate is 8 to 10 cm or in the presence of other less specific clinical findings. If there is no other risk factor (such as previous CS), trial of labor is the best diagnostic approach. The trial continues as long as labor progresses well and as long as there is reassuring fetal and maternal status 5/15/2024 32

33. Route of delivery Generally, presence of FPD during labor is an indication for caesarean delivery. In permanent absolute disparities (e.g. severe pelvic contracture (OC of 6-8 cm) or extreme pelvic contracture (OC < 6 cm)), there is no possibility of vaginal delivery and elective caesarean section should be done. 5/15/2024 33

34. Induction and augmentation of labor is contraindicated in fetal macrosomia Caesarean delivery is recommended for macrocosmic fetus with estimated fetal weight of greater than 4.5 kg (4.0 kg if the mother is diabetic) regardless of the status of labor. Fetal hydrocephalus may be managed by cephalocenthesis. Craniotomy is indicated if the fetus is dead and prerequisites for destructive delivery are fulfilled 5/15/2024 34

35. Discharge counselling and education A woman who delivered by CS should be explained about the indication (CPD) and the need for repeat CS in future pregnancy. Besides verbal explanation, a written note should be given that could also serve as R eferral feedback to referring health centres. Previous CS for CPD can be followed at a nearby health centre and referred after 36 -37 weeks of gestation 5/15/2024 35

36. Complications Maternal Prolonged / obstructed labor PPH Maternal sepsis Fetal / neonatal Fetal distress Perinatal asphyxia Neonatal infections Perinatal death 5/15/2024 36

37. Thank you for your Attention! 37