Abnormalities of the

Passage

Liu Yuling M.D.

Department Of Obstetrics & Gynecology
Renmin Hospital Wuhan University
Abnormalities of the Passage

 Constitute pelvic dystocia

That is aberrations of pelvic architecture and
its relationship to the presenting part.
 Be related to
 Size or configurational alterations of the bony
pelvis
 Soft tissue abnormalities of the birth canal
 Reproductive tract masses or neoplasia
 Aberrant placental location
Abnormalities of the Passage

 Pelvic Types
 Pelvimetry
 Pelvic Contractions
 Soft-Tissue Dystocia
 Bony pelvis component

innominate
 Sacrum bone (L,R)

 Coccyx ilium (L,R)

ischium (L,R)

pubis (L,R)
The pelvis is composed of four bones: pubis (L,R)coccyx, and
the sacrum,
two innominate bones. Each innominate bone is formed by the
fusion of the ilium, ischium, and pubis. The innominate bones are
joined to the sacrum at the sacroiliac synchondroses and to one
 Pelvis anatomical marks

 Sacral promontory

 Ischial spine (L,R)

 Symphysis pubis
The sacral promontory and symphysis pubis are
important for vaginal examination to determine the true
conjugate diameter

The ischial spines are of great obstetrical importance

because the distance between them represents the
shortest diameter of the pelvic cavity

They also serve as valuable landmarks in assessing

the level to which the presenting part of the fetus has
descended into the true pelvis
 PELVIC PLANES
The pelvis is described as having
four imaginary planes:
Inlet plane
Greatest plane
Midplane (Least plane)
Outlet plane
Vertical chart of pelvic four planes

1: Inlet plane
the superior strait
2: the greatest plane
of no obstetrical
significance
3: The plane of the
midpelvis
4
the least plane
4: Outlet plane
the inferior strait
Important pelvic planes
internal parameters
Inlet plane ------11 cm
true conjugate diameter

Midplane -------10 cm
interspinous diameter

Outlet plane --- 9 cm

bituberous diameter
Important pelvic planes
internal parameters

Inlet plane ------11 cm

true conjugate diameter

The obstetrically
anteroposterior diameter is
the shortest distance
between the promontory of
the sacrum and the
symphysis pubis
Important pelvic planes Midplane -------10 cm
internal parameters interspinous diameter
Important pelvic planes Outlet plane --- 9 cm
internal parameters bituberous diameter
 Summary

Bony Pelvis : sacrum, ilium,

innominate bone
3 marks: sacrum promontory, iliac
spine, symphysis pubis
4 planes: inlet-11, greatest, least-10,
outlet-9 cm
Pelvic dystocia, particularly that is due to
small bony architecture, is the most
common cause of passage abnormalities
The etiology and diagnosis of pelvic
abnormalities begins with the shape,
classification, and clinical assessment of
the adult female pelvis
Pelvic Types
 Using roentgenographic studies, Caldwell
and Maloy classified the 4 major types of
adult pelvis
 Gynecoid pelvis
 Android pelvis
 Anthropoid pelvis
 Platypelloid pelvis
 Pure forms of the pelvic types are rare;
mixed elements are more often present in
each type of pelvis
 10.9%
36.6%

Flat(platypelloid) anthropoid
47.3% 5.8%

gynecoid android
Gynecoid
The most typically “female”
type

•Shape of inlet ； Oval configuration

•Transverse diameter is slightly greater
than the anteroposterior
•Side walls are straight
•Ischial spines are not prominent
•Sacrum is concave
•Subpubic angle is wide
•Seem suited for delivery of most fetuses
•Incidence in white women is 50%
 •Shape of inlet: Wedge-shaped
android •Side walls are convergent
•Ischial spines are prominent
•Sacrum is inclined anteriorly in its lower
third
•Incidence is 33% in white women and
15% in black women
•Be associated with persistent occiput
posterior position and deep transverse
arrest dystocia
 platypelloid

•A rare type (incidence is less than 3% in white women)

•Transverse diameter is wide with respect to the antero –
posterior diameter
•Deep transverse arrest pattern of labor are more commonly
associated with this pelvic type
 anthropoid

•The antero-posterior diameter is greater than the transverse

diameter
•Side walls are divergent
•Sacrum is inclined posteriorly
•Be most often associated with persistent occiput posterior
dystocia
Pelvimetry
 In some unusual cases, pelvimetry is often
helpful in predicting the prognosis
 traumatic pelvic fractures
 rachitic pelvis
 chondrodystrophic dwarf pelvis
 Kyphotic and scoliotic
 pelvis exostoses （ Benign hypertrophy that
projects outward from the surface of bone,
often containing a cartilaginous component ）
 bony neoplasms
 X-ray pelvimetry
 Clinical pelvimetry
 X-ray pelvimetry
 Have been the most widely used
pelvimetric method
 Has fallen into limited use that radiation
exposure subjects the fetus to an
increased risk of oncogenesis
 Be useful in a few elected instances
 vaginal breech delivery
 gross bony distortion
 previous pelvic fracture
 rachitic deformity
 Both ultrasonography and magnetic
resonance imaging have been used to
investigate pelvic size and shape for
evidence of pelvic contraction obstructing
the normal progress of labor
X-ray pelvimetry

Three techniques of x-ray pelvimetry are

in general use
 Colcher-Sussman system
 Be most widely used
 Compares the anteroposterior and transverse
diameters of a given pelvis with the average and
lower limit of normal values
 Mengert’s method
 Ball method
 Clinical pelvimetry

 Has largely supplanted x-ray pelvimetry

in the routine evaluation of most
obstetric patients
 Estimation of the diagonal conjugate has
been particularly helpful
 The diagnosis of fetopelvic disproportion
has generally become a diagnosis of
exclusion
Parameters of the pelvic inlet

conjugate diameter 11cm

transverse diameter 13cm
oblique diameters 12.75cm
Three anteroposterior diameters of
the pelvic inlet
 12.5-13cm Pelvic Inlet Measurements
The diagonal conjugate is
clinically estimated by
measuring the distance from
the sacral promontory to the
lower margin of the symphysis
pubis .
The distance between the
mark and the tip of the second
finger is the diagonal
conjugate.
 The obstetrical conjugate is
computed by subtracting 1.5 to
2.0 cm, depending on the
height and inclination of the
symphysis pubis.
If the diagonal conjugate is
greater than 11.5 cm, it is
diagonal conjugate, DC justifiable to assume that the
pelvic inlet is of adequate size
 Parameters of obstetric midpelvis

anteroposterior
diamete

[*1]

transverse diameter
 10cm

坐骨棘间径
interspinous diameter
(biischial diameter)
Midpelvis Estimation
Clinical estimation of midpelvic capacity by
any direct form of measurement is not
possible.
If the ischial spines are quite prominent,
the sidewalls are felt to converge, and the
concavity of the sacrum is very shallow, then
suspicion of a contraction is aroused.
The pelvic outlet

2 triangles:
anterior triangle
posterior triangle
Base of both: intertuberous
diameter
1. transverse diameter 9cm
2. Anterior sagittal diameter 6cm
3. Posterior sagittal Diameter 8.5cm
 Pelvic Outlet Measurements
•The measurement of the
8.5-9cm transverse diameter of the outlet
can be estimated by placing a
closed fist against the perineum
between the ischial tuberosities.
•Usually the closed fist is wider
than 8 cm.
• A measurement of more than 8
transverse outlet, TO cm is considered normal.

90 度
Angle of pubic arch
Pelvic Contractions

 Inlet contraction
 Midpelvic-outlet contraction
 Pelves with abnormality of shape and bo
Inlet contraction
Definition

 The anteroposterior
diameter is less than
10 cm
 The transverse
diameter is under 12
cm
 Or both
Manifestation

 A floating vertex presentation with no

descent during labor
 An abnormal presentation
 A prolapsed cord, prolapsed extremity
or both
 Poor progress in labor and uterine
dystocia
 Manifestation
 Considerable molding of the fetal head
 Caput succedaneum formation

 Prolonged rupture of the membranes

 Pathologic retraction ring

uterine rupture
Pathological retraction ring
Diagnosis

 Inlet contraction may be detected clinically

by
 X-ray pelvimetry
 Clinical estimation of the diagonal conjugate
 Inability to perform the Müller-Hillis maneuver
Manually pushing the fetal head into
the pelvis with gentle fundal pressure
Estimation of fetal head size

 Clinical estimation - Muller method

 In an occiput presentation, the brow and the
suboccipital region are grasped through the
abdominal wall with the fingers and firm
pressure is directed downward in the axis of
the inlet.
 Fundal pressure by an assistant usually is
helpful.
 The effect of the forces on the descent of the
head can be evaluated by concomitant vaginal
examination.
 The Müller-Hillis maneuver
No disproportion No disproportion maybe
The head readily enters Inability to push the
the pelvis, and vaginal head into the pelvis does
delivery can be not necessarily indicate
predicted. that vaginal delivery is
impossible
fetaopelvic disproportion
Flexed fetal head that
overrides the synphysis
pubis → presumptive
evidence of disproportion
Treatment
 Neglected cases of inlet contraction are rare
and prognosis is excellent
 Compare the patient’s progress with known labor
curves
 Suspect possible inlet contraction on the basis of
clinical examination
 With continuous fetal monitoring in these cases,
fetal well – being may be ensure, even with
concurrent use of dilute oxytocin
 Cesarean section is the treatment of choice in
true inlet contraction
Midpelvic-outlet
contraction
 Parameters of obstetric midpelvis

anteroposterior
diamete

[*1]

transverse diameter
The pelvic outlet

2 triangles:
anterior triangle
posterior triangle
Base of both: intertuberous
diameter
1. transverse diameter 9cm
2. Anterior sagittal diameter 6cm
3. Posterior sagittal Diameter 8.5cm
 Midpelvic-outlet contraction
Anterior transverse Posterior Sum of
sagittal diameter sagittal transverse diameter
diameter (cm) Diameter and
(cm) (cm) Posterior sagittal
diameter(cm)
The <11.5 <9.5 <5 <13.5
midpelvis (Interspinous
diameter)

The pelvic <8 <15

outlet (intertuberous
diameter)
 Transverse diameter
8.5-9cm

Sum =
transverse diameter
+
Posterior sagittal
diameter(cm)
Sum >15cm Sum <15cm
Manifestation 1

 a prolonged second stage

 persistent occiput posterior position
deep transverse arrest
 Molding of the fetal head
caput succedaneum formation
Manifestation 2

 Uterine rupture
 pressure necrosis of the surrounding
tissues of the birth canal by the fetal
head
 Vesicovaginal fistula
 rectovaginal fistula
Prognosis
Poor prognosis is typical in
midpelvic – outlet contraction
 Due to difficult midforceps rotation
 Duo to difficult vaginal delivery

Treatment
 Cesarean section is therefore the delivery
method of choice in this complication
 Pelvic contraction
Anteropost Transverse Posterior Sum of
erior diameter sagittal transverse diameter
diameter (cm) Diameter and
(cm) (cm) Posterior sagittal
diameter(cm)
Inlet < 10 < 12

The <9.5 <5 <13.5

midpelvis (Interspinous
diameter)
The pelvic <8 <15
outlet (intertuberous
diameter)
Soft-Tissue Dystocia

 Congenital anomalies
 Scarring of the birth canal
 Pelvic masses
 Low-lying placenta
Congenital anomalies
 Bicornuate uterus
 Generally causes malpresentation
 Congenital anomalies
Longitudinal and transverse vaginal septa
 A longitudinal septum is usually pushed aside or
spontaneously lacerated during labor
 Transverse septa may require incision to permit
vaginal delivery

Imperforate transverse vaginal septa Transverse Vaginal Septum

Congenital anomalies
 Conglutination of the external cervical
os
 Is of uncertain etiology
 may be either congenital
or acquired following previous injury
 Is manifested as a small external os that
fails to dilate after full effacement
 Mechanical dilatation is usually required
and os often easily accomplished with just
the examining digit
Scarring of the birth canal

Previous scarring from injury to the birth

canal may cause tissue rigidity and
dystocia
 Previous birth laceration
 Conization
 Cauterization, rape injury in a small child
 Caustic abortifacient injury to the vaginal
vault and cervix
Management

 Episiotomy
repair of extensive laceration
 Cesarean section
occasionally be required to treat these
rare occurrences
 Pelvic masses
 Carcinoma of the cervix
 Leiomyomas of the cervix or
lower-uterine segment
 Distended bladder
 Ovarian neoplasm
 A transplanted pelvic kidney

Management
Cesarean section and removal of the
neoplasm may be required.
Low-lying placenta
 A marginal or low-lying placenta may prevent
normal fetal descent in labor.
THANKS