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ENGLISH II ASSIGNMENT

MIDWIFERY MANAGEMENT IN
CEPHALOPELVIC DISPROPORTION

Members of Group:

Ajeng Lyla Aisyiatul Kumala (011311223005)

Irma Sari Fitriana (011311223014)

Bintari Tri Anggraeni (011311223019)

Ginna Pratiwi Putri (011311223022)

Ridya Nurul Ridha (011311223026)

Yulia Pramita Riska (011311223049)


BACHELOR DEGREE OF MIDWIFERY

FACULTY OF MEDICINE AIRLANGGA UNIVERSITY

SURABAYA

2013
ACKNOWLEDGMENTS

Writers would like to acknowledge her countless thanks to the Most


Gracious and the Most Merciful, ALLAH SWT who always gives her all the best
of this life and there is no doubt about it. Shalawat and Salaam to the Prophet
Muhammad SAW and his family.
This study’s topic is “Midwifery Management in Cephalopelvic
Disproportion which presented to fulfill one of the English II Assignment on
Bachelor Degree of Midwifery at the Faculty of Medicine Airlangga University-
Surabaya.
Writers would like to take her opportunity to express her deep and sincere
gratitude to Mrs. Nuzul Qur’aniati , S.Kep.,Ns., M.Ng. as English II lecturer, who
has given her expertise and guidance in writing this study.
Writers do appreciate any opinion, and suggestion for the improvement of
this study.

Surabaya, December 2013


Writers
ABREVIATION

CPD Cephalopelvic Disproportion

WHO World Health Organization

SEAR WHO South-East Asia Region

MMR Maternal Mortality Rate

UNDP United Nations Development Programme

UNFPA United Nations Population Fund for Population Activities

ACOG American Colleges of Obstetricians and Gynecologists

KSPR Kartu Skor Pudji Rochyati


TABLE OF CONTENTS

CHAPTER 1 INTRODUCTION..........................................................................1

1.1 Background of the Study...........................................................................1

1.2 Problem Formulation.................................................................................2

1.3 Purpose of the Study..................................................................................2

CHAPTER 2 DISCUSSION..................................................................................3

2.1 Definition of Cephalopelvic Disproportion (CPD)...................................3

2.2 Classifications of Women’s Pelvis............................................................3

2.3 Etiologies of CPD......................................................................................5

2.4 Pathophysiology of CPD...........................................................................5

2.5 Signs and symptoms..................................................................................6

2.6 Physical examination in CPD....................................................................8

2.7 Diagnosis of CPD......................................................................................9

2.8 Labor pattern of CPD..............................................................................10

2.9 Prognosis of CPD....................................................................................10

2.10 Midwifery Management in CPD.............................................................11

CHAPTER 3 CLOSING......................................................................................13

3.1 Conclusion....................................................................................................13

REFERENCES.....................................................................................................14
CHAPTER 1
INTRODUCTION

1.1 Background of the Study


In accordance with the MDG’s 2015, maternal mortality rate will have
decrease to 102 per 100,000. Based on World Health Statistics 2012, Indonesia
ranked seventh in SEAR maternal mortality rate which is 220 per 100,000 birth.
Indonesia major medical cause of maternal death are haemorrhage (28%),
eclampsia (13%), sepsis (10%), unsafe abortion (11%) and prolonged labor (8%),
posted by UNDP. Varney said CPD is most common causes of prolonged labor.
Thus, CPD may takes responsibility for the height of maternal mortality rate in
Indonesia.
An unintervented CPD can carried the mother and infant at high risk such
as dysfunctional uterine contraction, fluid and electrolyte imbalance, exhaustion,
hypoglycemia, infection, uterine rupture, huge lacerations, fractured sacrum or
coccygx and postpartum hemorrhage for the mother. Risks to the fetus are
traumatic birth injuries, hypoxia, asphyxia, hypoglycemia, acidemia, and
infection. At worst, death for the mother, baby or both.
Some literally claims that c-section is safest to deliver the baby when
absolute CPD diagnosed (Sarwono P, 2010; Hanifa W, 2010; Medforth, 2011).
Tukur J (2011) wrote in WHO Reproductive Health Library “symphisiotomy can
be performed to fascilitate baby deliver vaginally indicate with CPD despite the
evidence very rare and be controvercial.” Symphisiotomy is the surgical
separation of the fibres of the pubic symphysis. All above explains CPD will lead
mother and infant in dangerous situation and may need surgical intervention.
Incorrect treatments absolutely can’t be approved. Midwives as a close-touchable
health professional with society, must aware first.
Based on the background, discuss more about cephalopelvic disproportion
are midwifery students need in order to find out more detail especially about
midwifery management in CPD for preventing the complication and minimizing
the risk by do early screening and predict CPD.
1.2 Problem Formulation
1. What is the definition of cephalopelvic disproportion (CPD)?
2. What are the etiologies of CPD?
3. How is the pathophysiology of CPD?
4. What are signs and symptoms of CPD?
5. How to diagnose CPD?
6. What are the labor pattern of pregnant women with CPD?
7. What are the prognosis of CPD?
8. How is midwifery management in CPD?

1.3 Purpose of the Study


1. Explain the definition of cephalopelvic disproportion (CPD).
2. Explain the etiologies of CPD.
3. Explain the pathophysiology of CPD.
4. Explain signs and symptoms of CPD.
5. Explain how to diagnose CPD.
6. Explain the labor pattern of pregnant women with CPD.
7. Explain the prognosis of CPD.
8. Explain midwifery management in CPD.
CHAPTER 2
DISCUSSION

2.1 Definition of Cephalopelvic Disproportion (CPD)


Liselele (2000) state that cephalopelvic disproportion (CPD) is a medical
term used to characterize the physical impediment of labor, which occurs when
there is ‘an absolute irrelative mechanical disparity between the fetal size and the
birth canal’.
Another references give similar statement about CPD definition. CPD is a
presence of disparity between the fetal head and the dimension of maternal pelvic,
the maternal pelvic is too small or the fetus is too big (Gupta, 2008; WHO, 2003).
Moreover added by medneg Australia, cephalopelvic disproportion is a birth
complication that happens when the infant head is larger than the opening to the
pelvis so that the baby cannot pass through the birth canal and sometimes results
in a cesarean section.
At a glance, CPD refers to a birth complication caused of mismatch between
baby head and mother’s pelvis that make baby head can’t phasing down trough
pelvic, and hard to deliver vaginally.

2.2 Etiologies of CPD


Labor have three main factors, called ‘3Ps’ : power, passage and passenger
that must goes well to bring a normal labor. If the ‘3Ps’ are not goes well, it
caused an abnormal labor. Power means uterine contraction and the mother push
power. Passage mean Maternal pelvic and birth canal. Passenger mean the infant.
CPD is a passage-passenger problem. Meanwhile, the uterine contraction checked
normal and the mother is not yet exhausted.
The passage includes the maternal bony pelvis and birth canal tissues. A
narrowed diameter in pelvic inlet and or outlet can result in CPD if the fetus head
is unfitted to the pelvic diameters. Abnormal shaped pelvic, tumors in birth canal
and another hip problem probably cause CPD as well. The passenger abnormality
such as hydrocephalus, and large baby due to post-maturity, a mother with
diabetes, hereditary reasons, and head malposition may also result in CPD
(Manuaba, 2012).
A clinical classification of CPD was proposed by Craig from Cape Town
(1961). He divided CPD into absolute and relative entities as shown below.
a. Absolute CPD – true mechanical obstruction
- Permanent (maternal):
Contracted pelvic
Pelvic exostoses
Spondylolisthesis
Anterior sacrococcygeal tumors
- Temporary (fetal):
Hydrocephalus
Large infant
b. Relative CPD
Brow presentation
Face presentation – mentoposterior
Occipitoposterior positions
Deflexed head

2.3 Pathophysiology of CPD


Labor is prolonged in the presence of CPD. Describe before CPD can
carried the mother and infant at high risk such as dysfunctional uterine
contractions, fluid and electrolyte imbalance, exhaustion, hypoglycemia,
infection, uterine rupture, huge lacerations, fractured sacrum or coccygx and
postpartum hemorrhage for the mother. Risks to the fetus are traumatic birth
injuries, hypoxia, asphyxia, hypoglycemia, acidemia, and infection. At worst,
death for the mother, baby or both.
References from Gupta(2008), Sarwono P (2010) and other online source
writers summarize that mother with abnormal pelvic shape probably have a
difficulties in labor but it depend on the baby too. But, in contracted pelvic deliver
baby more difficult or even impossible for some fetus to pass through an inlet that
has an anteroposterior diameter of less than 10 cm. If anteroposterior and
transverse, both diameters are contracted, dystocia is much greater than when only
one is contracted.
A small women is likely to have a small pelvis, but she is also likely to
have a small neonate. Normally, cervical dilatation is facilitated by hydrostatic
action of the unruptured membrane, or after their rupture by direct application of
the presenting part against the cervix. In pelvic inlet contraction, the head is
arrested in the pelvic inlet, the entire force exerted by uterus acts directly on the
portion of membranes that overlie the dilatation cervix. So early spontaneous
rupture of membrane is more likely.
After rupture of membrane the absence of pressure by head against the
cervix and lower uterus segment predisposes to less effective contraction, so
further dilatation is arrested or slowed. So cervical response to labor provide a
prognostic view of the labor outcome with inlet contraction. A contracted inlet
plays an important role in production of abnormal presentation. Because the head
does not descent into pelvic cavity before onset of labor, face and shoulder
presentation are encountered three times more frequently and cord prolapse occur
4 to 6 times more frequently.
The midpelvic contrction frequently cause transverse arrest of the fetal head
which potentially can lead to a difficult instrumental delivery or cesarean delivery.
Diminution of the intuberous diameter with consequent narrowing of the anterior
triangle must inevitably force the fetal head posteriorly. Usually inlet contraction
is associated with mid pelvic contraction. The diproportion with the pelvic outlet
may play an important part in causing perineal tears.
If the midwives not predict or aware CPD earlier, and the mother keep
pushing the baby out, the mother will be exhausted and have hypoglycemia as
result. It worsened by amniorrhexys that can caused infection during prolonged
labor and continuously consist fluid and electrolyte imbalance. In this situation,
women will need to drink and IV fluid to exchange the lost body fluid.
Membrane rupture can result from the force of the unequally distributed
contractions being exerted on the fetal membranes. In obstructed labor, in which
the fetus cannot descent, uterine rupture can occur. With delayed descent,
necrosis of maternal soft tissues can result from pressure exerted by the fetal head.
Eventually, necrosis can cause fistulas from the vagina to other nearby structures.
Difficult, forceps-assisted births can also result in damage to maternal soft tissue
(Sarwono P, 2010).

2.4 Signs and symptoms


Gupta (2008) consider the probably sign and symptomps of CPD below:
1. Abdominal examination
 Large fetal size (MacDonald measurement over 40 cm or much
larger than pregnancy before)
 Fetal head overriding the pubic symphysis
2. Pelvic examination
 Cervix shrinking after amniotomy
 Edema of cervix
 Head not well applied against the cervix
 Head not engaged
 Caput formation
 Molding
 Deflexion
 Asynclitism
3. Contracted pelvic inlet
The pelvic inlet is usually considered to be contracted if its shortest
anteroposterior diameter is less than 10 cm or id greatest transverse
diameter is less than 12 cm. The anteroposterior diameter of pelvic inlet
is commonly approximated by manually measuring the diagonal
conjugate, which is about 1, 5 cm greater. So inlet contraction usually is
defined as diagonal conjugate of less than 11.5 cm.
4. Mid pelvis contraction
It is more common than inlet contraction. It frequently cause transverse
arrest of the fetal head which potentially can lead to a difficult
instrumental delivery or cesarean delivery.
The definition of mid pelvic contraction has not been established with
same precision possible for inlet contraction. Even so, mid pelvis is likely
to be contracted when the sum of interischial spinous and posterior
sagittal diameter of the mid pelvis (normal 10.5+5 cm or 15.5 cm) falls to
13,5 cm or below.
There is reason to suspect mid pelvic contraction, whenever the
interischial diameter is less than 10 cm. if intraspinous diameter is less
than 8 cm, the mid pelvis is contracted. Although there is no precise
manual method of measuring mid pelvis dimension, a suggestion of
contraction sometimes can be inferred, if the spines are prominent, pelvic
side walls converge, or the sacrosciatic notch is narrow.
5. Contracted pelvic outlet
This finding is usually defined as the interischial tuberous diameter of 8
cm or less.
6. Estimation of Pelvic capacity
Briefly the examiner attempt to judge the anteroposterior diameter of the
inlet (diagonal conjugate), the interspinous diameter of the mid pelvis
and the intertuberous distance of the pelvic outlet.
Gill’s muller test is one of the important clinical maneuver for evaluating
feto pelvic relationship. During pelvic examination, when a contraction is
at its peak, an attempt is made to push the presenting part into the pelvis
by pressing on the uterus fundus with the free hand.
The hand in the vagina is used to determine whether or not there is
downward mobility of the presenting part. If the presenting part does not
move, or moves very little, the possibility of CPD is high. If the
presenting part moves easily into the plevis, the possibility of
disproportion is low.
7. Others
 Maternal pushing before complete dilatation
 Early deceleration
An earlier source, Fadel (1982) manual pelvimetry should be done at the
first visit, but the examination may be unsatisfactory, particularly in primigravida.
A more satisfactory result may be obtained during the third trimester when the
patient is more at ease with the examiner and the soft tissue are more relaxed.
Since gross abnormalities are usually easily detected and most cases of
suspected disproportion will be managed by a trial of labor, some physicians tend
to do only a perfunctory evaluation, but foreknowledge of the size and
configuration of the pelvis is very important for an intelligent evaluation of such a
course. Careful, systematic manual pelvimetry is imperative.
A proper examination begins with an evaluation of the pubic arch and the
angle of pubic rami. The arch should be rounded and the angle greater than 90.
The anterior capacity of the pelvic inlet can be estimated by palpating the
area behind symphysis. The forepelvis should be well rounded and ample. One
then palpates the ischial spines and determines whether they are sharp and
prominent or blunt and flat. The side walls are palpated to determine whether or
not they tend to converge. The sacrostic notch should be rounded, and the
sacrostic ligaments should be at least two fingerbreadths in length.
The coccyx is grasped between the two fingers in the vagina and the thumb
on the outside and its angle and mobility are determined. The examiner can then
work his finger up the curve of the sacrum, estimating its width and curvature.
The anteroposterior (AP) diameter of the mid pelvis, at the level of the spines, can
be measured. It will average 11, 5 cm.

2.5 Diagnosis of CPD


Diagnosis of CPD is important because it does indicate the need for
caesarean delivery. Some clinicians consider the maternal pelvis to be proven. If
the woman has had a previous difficulties of vaginal delivery. However,
subsequent fetuses can be larger and maternal anatomy can change between
pregnancies. For this reason, a measurement are very helped.
Measurement of mother and fetus has been attempted as a means of
detecting CPD before the onset of labor. Gupta (2008), ACOG (2010), and some
other online source agreed there are no objective and precise method for assesing
the feto-pelvic relationship. A term discussion evaluate external maternal
measurements, internal clinical pelvic assessment, X-ray pelvimetry, and
ultrasound and magnetic resonance imaging. It shown that none of these methods
can reliably diagnose CPD. They may improve the predictive value, but many if
not most women will give birth normally even when such measurements suggest
an unfavorable cephalic-pelvic relationship.
CPD is best diagnosed by trial of labor. The assumption is that adequate
uterine contractions, augmented if necessary by oxytocin infusion, will effect
descent and delivery of the fetal head through the birth canal. Failure to do so
constitutes CPD.
Diagnosing CPD is an imperfect activity and it should be accepted that
many women whose labor is terminated for relative ‘CPD’ or inadequate uterine
contractions. CPD is less frequent in multiparous women who have had a previous
normal delivery. It may occur if the woman carries a much larger baby than in
previous pregnancies, or if there is relative CPD with a fetal malposition.
Occasionally, lumbosacral spondylolisthesis may develop between pregnancies
and reduce the effective anteroposterior diameter of the pelvic brim, rendering a
previously adequate pelvis inadequate.
Trial of labor in a multipara is problematic as the uterus may rupture in the
presence of CPD if labor is augmented with oxytocin. Where labor progress is
poor in a multipara, Philpott has advised that careful attention be paid to head
descent and moulding, as CPD is diagnosed when there is increasing moulding of
the fetal head without descent into the pelvis. Clinical experience and skill are
thus prerequisites in the assessment of poor labor progress in a multipara.

2.6 Labor pattern of CPD


C-Section is a safest way to deliver the baby right after CPD diagnosis is
made. If it is ruled out, labor can be allowed to continue, oxytocin may be
carefully administered if the contraction pattern is unsatisfactory.
One should not be bound to arbitrary time limits. Prolonged labor itself is
not necessarily deleterious to mother or baby. Careful fetal monitoring is
imperative under these circumstances, and cesarean section may occasionally
become necessary because of fetal distress.
There is a place for midforceps operations, in skillful hands, but not in cases
of cephalopelvic disproportion. Even when the fetal head is well down in the
pelvis, cesarean section is preferable to traumatic vaginal delivery. There is no
place for the difficult forceps delivery (Fadel, 1982; Sarwono P, 2010; Gupta,
2008; Medforth, 2011; Hanifah W, 2010; Manuaba, 2012).

2.7 Prognosis of CPD


The consequences of CPD can be serious when this condition transpires. In
severe cases childbirth is unable to progress because the fetal head becomes
impacted in the pelvis. Without intervention this condition can result in uterine
rupture, fistulas, and even fetal and maternal death. CPD Management includes
procedures such as fetal monitoring, oxytocyn and c-section.
Women who have been delivered by cesarean section in conditions
suggestive of cephalopelvic disproportion may have x-ray pelvimetry performed
in the puerperium to help management of future deliveries. The reason for the
cesarean section and outlook for future deliveries should be discussed in the
postnatal ward and at the postnatal visit (Gibb, 1991).
The current literature says a woman has had a CPD before, doesn’t mean it
will happen again in the next pregnancy or labor and possibly can have a normal
delivery altough still must be carefully monitored by midwives and or
obstetrician.

2.8 Midwifery Management in CPD


Cephalopelvic disproportion can be early assessed by detecting the risk
within the antenatal period begins with noting any history of prolonged labor or
difficult births. Antenatal assessments include abdominal examination which
should alert the midwives to any malpresentation or signs of cephalopelvic
disproportion. Pelvimetry and ultrasound is a big help to predict CPD. In
Indonesia as the writers experiences, many of CPD cases occurs during the labor
as a prolonged labor. So, using WHO partograf is a must to alert about labor
abnormality not just CPD.
In management of labor with CPD, midwives have to collaborate with
obstetrician. As described, labor pattern for primigravidas can be vaginal labor
with trial of labor first. It’s according to the condition of mother and baby. If
normal labor pattern are not reestablished in a reasonable period, probably within
4 hours, the cephalopelvic relationship must again be evaluate and cesarean
section may become necessary.
Private midwives should not do trial of labor because if obstructed labor is
recognized in the first stage of labor, as when the head is extended to brow
presentation or obstruction cannot be overcome by rotation and assisted birth,
delivery should be caesarean section as soon as possible. C-section only can be
done in hospital with surgery room; surgical team such as obstetrician,
anesthesiologist, surgical nurse; and neonatologist. Following the birth of the baby
and prior to repair of the uterus and abdomen, the surgeon will check carefully for
any indication that the uterus has ruptured.
From many sources of literature, there are some different assignment of
diagnostic criteria for cephalopelvic disproportion (CPD) in nulliparous women.
First author Management for CPD
(O’Driscoll, Jackson, Caesarean section for delivery not occurring
& Gallagher, 1970) within 24 hours of admission in labour,
following active management (early amniotomy
and oxytocin augmentation)
(Stewart, Cowan, & Minor = assisted vaginal delivery following 6
Philpott, 1979) hours of oxytocin augmentation for poor labour
progress (cervix <1 cm/hour)
Major = caesarean section for poor progress
(cervix <1 cm/hour or head >2/5 above brim
with moulding) following 6 hours of oxytocin
augmentation for poor labour progress
(Mahmood, Campbell, Caesarean section associated with 1) first stage
& Wilson, 1988) >12 hours in spite of effective uterine activity or
2) failure of the head to descend or evidence of
severe moulding or fetal distress in later first
stage with secondary arrest or prolonged second
stage
(Tsu, 1992) Caesarean section or assisted vaginal delivery
with arrest or delay of labour, and moulding (+)
or caput (+++), with later review of clinical notes
by a panel of experienced obstetricians. Includes
multiparous
women.
(Impey L, 1998) Caesarean section at term for a normally formed
fetus with a flexed non-occipitoposterior vertex
presentation, with secondary arrest of cervical
dilatation with the cervix at least 6 cm dilated,
unresponsive to oxytocin infusion, in accordance
with a standardized protocol for active
management of labour.
(Liselele, Boulvain, 1) Caesarean section for failure to progress in
Tshibangu, & Meuris, labour, or 2) vacuum or forceps delivery, or 3)
2000) vaginal delivery with intrapartum stillbirth
(Young & Caesarean section for little or no progress over 2-
Woodmansee, 2002) 4 hours with adequate uterine contractions and
the cervix at least 3 cm dilated

Newest research done at 2012 by University of California, San Francisco


posted in savinglivesbirth.net propose a simple tool that can be employed by
frontline health workers to risk-stratify women early in their pregnancy as high
risk to low risk for CPD using an objective method.
Indonesia especially East Java has earlier made a somekind of similar
category, not only for CPD but for other abnormalities, for increasing maternal-
neonatal health service called KSPR (Kartu Skor Pudji Rochyati).
CHAPTER 3
CLOSING

3.1 Conclusion
Cephalopelvic disproportion (CPD) is a condition in which the presenting
part of the fetus (usually the head) is too large to pass through the woman’s pelvis.
Because of the disproportion, it becomes physically impossible for the fetus to be
delivered vaginally, and cesarean birth is necessary.
CPD is suspected when the newborn’s head does not continue to descend
even though the woman is having strong uterine contractions. Excessive fetal size
may be associated with diabetes mellitus, multiparity, and genetics (one or both
parents of large size). A large newborn (macrosomia) can cause difficulty in birth
of the shoulders (shoulder dystocia).
Physical examination and ultrasound are very useful in evaluating CPD.
Labor pattern for primigravidas can be vaginal labor with trial of labor first. If
normal labor pattern are not reestablished in a reasonable period, the
cephalopelvic relationship must again be evaluate and cesarean section may
become necessary
Maternal complications that can occur are exhaustion, hemorrhage, and
infection. Birth trauma and anoxia are complications for the fetus.
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