CONTRACTED PELVIS

DEFINITION

Anatomical definition:

• A pelvis in which one or more of it’s

diameters is reduced below the normal

by one or more centimeters.

Obstetric definition:

• Any of the essential diameters are

reduced to affect mechanism of labor.

 CEPHALOPELVIC DISPROPOTION
( CPD )

• Disparity in relationship between the

pelvis and fetal head.

 TYPES OF CONTRACTED PELVIS

A) Generally contracted pelvis.

• Small gynaecoid pelvis.

• Small android pelvis.
• Small anthropoid pelvis.
• Small platypelloid pelvis
( Simple flat pelvis )
B) Contracted at inlet / cavity / outlet.

a) Contraction at Inlet.

• Shortest AP diameter <10 cms or

• Largest transverse diameter <12 cms.
• AP diameter is assessed by diagonal
conjugate. ( DC )
• So DC < 11.5 cms is inlet contraction.
• Result: Mobile head at term.
b) Contraction at Mid pelvis.

• Interspinous diameter <10 cms.

• Result: Occipito-posterior. ( mal position )

Deep transverse arrest.
( mal rotation )
Prolonged labor.
c) Contraction at Outlet.

• Intertuberous diameter < 8cms.

• Narrow subpubic arch.

• Result: Prolonged labor.

Perineal laceration.
 AETIOLOGY

I) Diseases of pelvic bone.

• Rickets.
• Osteomalacia.

II) Development anomalies.

a) Naegle’s pelvis. ( PICTURE HERE )
lacks one sacral alae.
b) Robert’s lack both sacral alae.

( Pic here )

c) Split pelvis.

( Gap between two pelvic bones )

( pic here )
III) Assimilation pelvis.

• Variation in number of vertebrae fused

to form sacrum.

Low assimilation:
• Four vertebrae fused to form sacrum.
( PIC HERE )

• Result: Obliquity of brim is decreased.

High assimilation:

• Six vertebrae fused to form sacrum.

( PIC HERE )

Result: Obliquity of brim increased.

IV) Vertebral deformity.

a) Kyphosis.

b) Scoliosis.
c) Spondylolisthesis.

• The 5th lumbar vertebra with the above

vertebral column is pushed forward.

• The sacral promontory is pushed

backwards.

• Tip of the sacrum is pushed forwards

leading to outlet contraction. ( PIC HERE )
V) Lower limb deformity.

Dislocation of femur.

Fractures of limb bones.

Tumors.
 DIAGNOSIS
1) History:
Medical: H/o…
• Rickets.
• TB.
• Polio.
• Difficult vaginal delivery.
• Difficult instrumentation.
• Birth asphyxia.
• Still birth.
2) General examination:
• Short stature < 140 cms.
• Abnormal gait.
• Spine and lower limbs.

3) Per abdomen:
• Pendulous abdomen.
• Mobile head at term.
4) Assessment of pelvis.
a) Internal pelvimetry.

b) External pelvimetry.

c) Radiology:
X-ray.
Ultrasound.
CT scan.
MRI.
a) Internal pelvimetry.

Pelvic inlet: Assessed by……..

• Sacral promontory.
• Diagonal conjugate.
Pelvic Cavity: Assessed by………
• Sacral curve.
• Pelvic side wall.
• Ischial spine.
• Sacro sciatic notch.
Pelvic outlet: Assessed by………..

• Sub pubic arch. ( Two fingers )

• Sub pubic angle.
• Inter tuberous diameter. ( 4 knuckles )

• Mobility of the coccyx.

• Antero-posterior diameter.
( Tip of coccyx to lower margin of
symphysis )
b) External pelvimetry.

• Measures the false pelvis. ( Not of value )

• Thom’s, Jarcho’s or crossing pelvimeter is
used.
• Interspinous diameter. ( 25 cm )
( Between anterior superior iliac spines )
• Intercrestal diameter. ( 28 cm )

• External conjugate. ( 20 cm )
c) Radiological pelvimetry.

X-Ray Lateral view:

• The AP diameters of the pelvis.

• Width of sacrosciatic notch.

• Curvature of the sacrum.

Ultrasonography :

• Safe.
• Accurate .
• Easy method.

• Measures:

– Biparietal diameter. ( BPD )

– Head circumference. ( HC )
 ASSESING CPD
Munrocker muller.

• Fetal head is the best pelvimeter.

• Active labour detects brim dispropotion.
• Patient in dorsal position.
• Left hand over abdomen.
• Right hand PV at the spine.
• If head reaches spine, there is no CPD.
• Place thumb over pubic symphysis.
• If head cannot be pushed upto spine.

Minor disproportion:

• If anterior surface of the head is in line

with the posterior surface of the
symphysis.
Moderate disproportion. ( 1st degree ):
• The anterior surface of the head is in
line with the anterior surface of the
symphysis. Vaginal delivery may or may
not occur.

Marked disproportion. ( 2nd degree ):

• The head overrides the anterior surface
of the symphysis. Vaginal delivery
cannot occur.
 CPD POINTERS IN LABOR

• Prolong labor.
• High head at full dilatation.

• Cervix loosley applied to the head.

• Excess caput.
• Irreducible moulding.
 COMPLICATIONS OF CPD
a) Maternal:
PROM.
Mal presentation.
Deep Transverse Arrest. ( DTA )
Obstructed labour......rupture of uterus.
Increased instrumental delivery.
Post partum hemorrhage.
Vesico vaginal fistula.
b) Fetal:

• Birth asphyxia.
• Cord prolapse.

• Sepsis.

• Birth injuries.
• Fetal death.
 MANAGEMENT

Minor CPD: Vaginal delivery.

Moderate CPD: Trial of labor / LSCS.

Severe CPD: LSCS.

a) Elective cesarean if...…

• Malpresenation.

• High risk.

• Previous LSCS.

• Marked CPD.
2) Trial of labor.

( Clinical test for factors that cannot be

determined before start of labor as… )

• Efficiency of uterine contractions.

• Moulding of the head.

• Yielding of the pelvis and soft tissues.

Successful trial:

• Birth of a healthy baby vaginally and

maternal condition is good.

Failed Trial:

• LSCS / Delivery of dead or compromised

baby.
Conduction of Trial:

• Done where facilities for emergency

LSCS are available.
a) Select patient.
b) Monitor progress.
• Partogram.
• Per abdomen- descent of head.
• Per vaginal examination.
• CTG.
c) Augment labor.
• ARM.
• Oxytocin.

d) Terminate trial if............

• No progress on cervix dialation.
• Faliure of descent of head.
• Excess caput / Moulding.
• Maternal / Fetal distress.
 MANAGEMENT OF LABOR IN
CONTRACTED PELVIS
THE ROLE OF FORCEPS:
• No role; Don’t use if head not engaged.

SYMPHYSIOTOMY – PUBIOTOMY:
• Prior to the era of antibiotics.

DESTUCTIVE OPERATION:
• Craniotomy.