JOURNAL READING

Assessing Cephalopelvic Disproportion:

Back to the Basics
By:
Brilliantine Ch Liborang, Sked
Supervisor:
dr. Apter. Patai, SpOG

GENERAL HOSPITAL JAYAPURA

DEPARTMENT of OBSTETRIC-GYNECOLOGY
MEDICAL SCHOOL UNCEN-PAPUA
2015

Background
Dystocia/abnormally slow progress in
labor, can result from:
Cephalopelvic disproportion (CPD)
Malposition of the fetal head as it
enters the birth canal
Ineffective uterine propulsive forces.
CPD mismatch between the size of the
fetal head & size of the maternal pelvis,
resulting in failure to progress in labor
for mechanical reasons.

 Despite the use of imaging technology in

an attempt to predict CPD, there is poor
correlation between radiologic pelvimetry
and the clinical outcome of labor.
Clinical pelvimetry still has a place in
obstetrics for predicting or confirming
CPD, but without appropriate training and
repeated practice of this clinical skill, it is
in danger of becoming a lost art.

Learning Objectives
The reader will be able:
To interpret how CPD is diagnosed.
Distinguish the 4 basic pelvic
shapes.
Evaluate pelvic measurements that
best indicate adequacy or
inadequacy of the pelvis.

 The likehood of CPD and obstructed labor

has increased along with the increase in
brain size & changes in pelvic
morphology that greatly restrict the
midplane of the pelvis also complicate
human obstetrical mechanics.
Dystocia difficult labor, is the overall
term for slow, inadequate or
dysfunctional labor.
It is generally caused by:

 CPD a recognized obstetric problem that

increases risk for both mother and infant,
occurs when:
The fetal head is too big,
The pelvis is too small, or
The head is malpositioned as it enters the
birth canal.
Unattended obstructed labor results in:
Fetal death
Eventual delivery of a macerated and
infected baby,
Atonic postpartum hemorrhage with or
without puerperal infection.

THE THREE Ps OF LABOR

1. Passageway: maternal bony
pelvis and tissues.
2. Passenger: the fetus.
3. Powers: primary and secondary
forces of labor.

Clinical Classification
Absolute

Relative

Permanent (Maternal)

Brow presentation
Face presentation
mentoposterior
Occipitoposterior
positions
Deflexed head

Contracted pelvis
Pelvic exostoses
Spondylolisthesis
Anterior
sacrococcygeal tumors

Temporary (Fetal)
Hydrocephalus
Large infant

 In most cases of slow or seemingly

obstructed labor, augmentation with
oxytocin is indicated.
Diagnose CPD only if there is a
prolonged first (>12 hours) or
second (>2 hours) stage of labor in
women receiving oxytocin.
ACOG dystocia cannot be
diagnosed before there has been an
adequate trial of labor.

Pelvic Shapes

The Midpelvis & Pelvic Cavity

The midpelvis level of the
ischial spines.
The ischial spines can be located
by following the sacrospinous
ligaments to their lateral ends.
The spines should be palpated to
determine if they are prominent or
unduly pronounced.
The intraspinous
the smallest
dimension of the pelvis.
It is assessed by touching both

The Pelvic Outlet

The perimeter of the pelvic outlet is
partially comprised of ligaments, and is
either ovoid or diamond shaped.
Landmarks of the pelvic outlet include:
The lower border of the symphysis pubis
The pubic arch
The ischial tuberosities
The sacrotuberous and sacrospinous
ligaments
The lower aspect of the sacrum
The coccyx.

 The subpubic angle should be

>90o, and normally admits 2
fingers.
The distance between the ischial
tuberosities (the bituberous ) is
normally at least 8 cm equivalent
to the width of the closed fist or 4
knuckles for most examiners.
Prominent
obturator
internus
muscles may occupy space in the
cavity, and rigid, inelastic levatores
may obstruct descent of the head.
Finally the perineal muscles are

In performing clinical pelvimetry, a formula to

follow is described as the rule of
3 s,
indicating that there are 3 parts of the pelvis
to examine, and each part has 3 components.
The rule of three
Brim
Diagonal conjugate
Posterior surface of pubic symphysis
Ilio-pectineal line
Cavity
Sacrum-shape, curve and length
Ischial spines
Sacrospinous ligament
Outlet
Subpubic arch and angle
Intertuberous
Sacrococcygeal joint

FINDINGS EXPECTED IN AN ADEQUATE

PELVIS
Assessment

Finding

Pelvic brim

Round

Diagonal conjugate

12.5cm

Symphysis

Average thickness, parallel to

sacrum

Sacrum

Hollow, average inclination

Side walls

Straight

Ischial spines

Blunt

Interspinous

10.0cm

Sacrosciatic notch

2.53 finger breadths

Subpubic angle

> 90 degrees (2 finger breadths)

Bi-tuberous

> 8.0 cm (4knuckles)

Coccyx

Mobile

Anterposterior of outlet

11.0cm

15

PELVIMETRY USING IMAGING TECHNOLOGY

Dimensions of the pelvis can also be determined
by conventional x-rays, by CT scan/ MRI.
The goal of pelvimetry is to accurately predict
which patients will have CPD.
Clinical assessment of the midpelvis and the
pelvic outlet seems to be the best method of
measuring pelvic capacity.
X-ray pelvimetry was popular in obstetrical units
in developed countries from the 1950-1970, and
was used mainly for predicting outcome of labor
in cases of suspected CPD, breech presentation,
& trial of labor after a previous caesarean
section.

 Overall, the data suggest that there is no

significant role for x-ray pelvimetry in the
prediction & management of CPD when the
fetus is in cephalic presentation.
1990s
CT pelvimetry was introduced and
readily adopted in developed countries. CT
pelvimetry had the advantage of a
significant reduction in the radiation dose to
the fetus, more patient comfort, and a
shorter examination time.
Advances in imaging techniques MRI
pelvimetry.
MRI resolution superior no ionizing

INTRAPARTUM PREDICTION AND

RECOGNITION OF CPD
Fetal Head Descent
Engagement the passage of the
widest portion of the presenting
part through the pelvic brim,
and is measured in 5ths above
the symphysis pubis by
abdominal palpation.
The amount of descent and
engagement of the head is
assessed by feeling how many
fifths of the head are palpable

Station

Head-Fitting Tests

THE FETAL HEAD

Only a comparatively small part of the
fetal head is represented by the face; the
rest is composed of the firm skull (2
frontal, 2 parietal, and 2 temporal bones,
along with the upper portion of the
occipital bone and the wings of the
sphenoid)
The bones are not united rigidly but are
separated by membranous spaces the
sutures

The change in shape of the fetal skull

that occurs during labor in response
to pressure by uterine contractions
against the lower uterine segment
and cervix, and to a certain extent,
against the bony pelvis.

MOLDING

Grade of Molding
Grade 0, Bones normally separated.
Grade 1, Suture line closed, without
overlap.
Grade 2, Overlap of bones, reducible
by digital pressure from examiner.
Grade 3, Irreducible overlap.

CAPUT SUCCEDAEUM
Swelling of the scalp
over the presenting
part of the fetal
head.
It develops when
uterine contraction
pressure pushes the
scalp into the
dilating cervix, which
acts as a constricting
band around that
area of the head.

ASYNCLITISM
The situation in which the fetal head
is not aligned correctly in the
pelvis, is diagnosed when the
suture lines of the fetal skull are
not aligned exactly halfway
between the symphysis pubis and
the sacrum, and there is lateral
flexi on of the fetal head a sit
negotiates the birth canal.

CONCLUSION
Obstructed labor may result from inadequate
uterine propulsive forces or a relative CPD due to
large fetal size, an inadequate maternal pelvis, or
malposition of the fetal head.
In most cases, predicting CPD remains problematic.
Many studies report relatively poor correlation
between various pelvimetric indices and ultimate
dystocia; no single independent predictor or
combination of predictors is diagnostic of CPD.
In a world that is increasingly dependent on
technology, intrapartum clinical assessment is
avaluable predictor of CPD, which can only be
diagnosed after aproperly conducted trial of labor.

Thank You