Acta Obstetricia et Gynecologica.

2006; 85: 821 824

ORIGINAL ARTICLE

A narrow pelvic outlet increases the risk for emergency cesarean section

KARIN STALBERG1, AKE BODESTEDT2, SVEN LYRENAS1 & OVE AXELSSON1

From the 1Department of Womens and Childrens Health and 2Department of Oncology, Radiology and Clinical Immunology, Uppsala University, Sweden

Abstract Background . The rate of cesarean section (CS) is increasing in Sweden as well as in most of the industrialized world. One of the most common indications for emergency CS is protracted labor. To what extent fetal pelvic disproportion is a cause of protracted labor is unclear. The value of pelvimetry has been questioned. The purpose of this study was to investigate whether women delivered with emergency CS because of protracted labor had a narrower pelvis than women delivered vaginally did. Methods . Thirty women delivered with CS because of protracted labor comprised the study group. Thirty women vaginally delivered served as controls. The two groups were matched for gestational age, birth weight, and parity. The study group and the control group underwent an X-ray pelvimetry within 1 month of delivery. Results. The study group and the control group did not differ in maternal age or body mass index. The mean birth weight was 3914 g in the study group and 3884 g in the control group. The mean pelvic outlet was 328 mm in the study group and 346 mm in the control group (P0/0.0024). The mean pelvic inlet was 245 mm in the study group and 255 mm in the control group (P 0/ 0.0038). Conclusion . A narrow pelvic outlet is associated with an increased risk of emergency CS because of protracted labor. A postpartum pelvimetry is recommended and should be used when to decide on route of delivery in forthcoming pregnancies.

Key words: Cesarean section, pelvimetry, pregnancy, protracted labor, X-ray

In Sweden, as in most other countries of the western world, the rate of cesarean section (CS) is increasing. Between 1992 and 2002, the rate of CS in singleton pregnancies increased from 10.8 to 16.1%. The increasing rate of emergency CS is a major concern because of the risk of complications such as blood loss, hematomas, infections, and reoperations (1) and the risks escalate the later during the delivery process the section is performed (1 3). Apart from the risk of surgical complications, an emergency CS can be associated with a negative birth experience (4). Therefore, it is in the interest of the mother and the physician to minimize the number of late CSs. One of the most common indications for emergency CS is protracted labor (5), which can be caused by inefficient uterine contractions or fetalpelvic disproportion. Even so, the importance of

fetal-pelvic disproportion has been questioned, and the use of pelvimetry in clinical practice has decreased, with a carefully monitored trial-of-labor being recommended as the method of choice (6). However, trial-of-labor in forthcoming deliveries after CS is associated with a higher rate of major maternal complications, such as hysterectomy, uterine rupture, operative injury, and transfusion (7,8), and the risk of perinatal death is increased because of uterine rupture (9,10). Therefore, it would be desirable to avoid further emergency CS in women previously abdominally delivered. The purpose of this case-control study was to see whether a narrow pelvic outlet, as measured by Xray, is a more common finding in women delivered by emergency CS because of protracted labor. Such knowledge could affect decisions on the delivery route in forthcoming pregnancies.

Correspondence: Karin Stalberg, Division of Obstetrics and Gynaecology, Akademiska Sjukhuset, 75185 Uppsala, Sweden. E-mail: karin.stalberg.@kbh.uu.se

(Received 11 April 2005; accepted 12 April 2005)

ISSN 0001-6349 print/ISSN 1600-0412 online # 2006 Taylor & Francis DOI: 10.1080/00016340600593521

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K. Stalberg et al. part when the decision for CS was taken were abstracted from the delivery chart. Statistical analysis was performed with StatView 4.01. Differences in the means of continuous variables were analyzed by two-tailed students T-test. A P-value of B/0.05 was considered statistically significant. The Ethics committee of the Medical Faculty at Uppsala University approved the study. All women included gave their consent to participate. Results Basic characteristics of the women are shown in Table I. There was no difference between the study group and controls concerning maternal age, gestational age, or prepregnant body mass index. The mean birth weight in both the study (3914 g) and control groups (3884 g) were higher than mean birth weight for singleton deliveries in primiparas in Uppsala 2001 (3654 g). One woman in the study group had previously delivered with vacuum extraction. The other 29 women were primiparas. In the study group, 29/30 women received oxytocin infusion to augment labor compared with 16/30 in the control group. At the time for decision on CS, the station of the fetal head was just above the spinal plane in 15 women, at the spinal plane in 13 and below the spinal plane in 2. The mean pelvic outlet (IS'/IT'/SO) was 328 mm in the study group compared with 346 mm in the control group (P 0/ 0.002), and all separate outlet measurements for the study group were shorter than that for the control group (Table II). However, the IS was the one measurement indicating an evident difference between the two groups: in the study group, 13 women (43%) had borderline pelvic outlets, but none had an inadequate outlet, whereas in the control group, no one had either borderline or inadequate pelvic outlet.

Subjects and methods The study group consisted of 30 women delivered with emergency CS on indication protracted labor. Thirty women with spontaneous vaginal delivery were included as controls. All deliveries took place at Uppsala University Hospital during 1999 2003. Inclusion criteria were gestational age from 37'/0 to 41'/ 6 weeks, spontaneous onset of labor, singleton birth, and cephalic presentation. In the study group, cervix was dilated at least 4 cm at the time of decision on CS. Exclusion criteria were previous CS, induction of labor, maternal intercurrent disease, such as diabetes mellitus, preeclampsia, or severe hypertension; and for the controls vacuum extraction or forceps delivery. Both study and control groups were matched for gestational length (9/10 days), birth weight (9/200 g), and number of deliveries. All women underwent a low-dose technique X-ray pelvimetry within 1 month of delivery. The X-rays were taken with the women in standing position and included one anterior and one lateral view. A metal ruler was used on the lateral view to correct for the magnification factor. All examinations were evaluated by the same radiologist. The pelvic measurements estimated were: anterior-posterior inlet (API) between the upper inner symphysis and the nearest point on sacrum; transversal distance (TD) at the widest part of the transverse pelvic inlet; saggital outlet (SO) between the lower inner symphysis and the lowest part of the sacrum; interspinous distance (IS); and intertuberous distance (IT) (Figure 1). The pelvic inlet was defined as the sum of API'/TD. The pelvic outlet was defined as IS'/IT'/SO. A pelvic outlet less than 29.5 cm was considered as inadequate. A pelvic outlet between 29.5 and 31.4 cm was considered as borderline (11). Information on maternal prepregnant weight and length was obtained from the antenatal chart. The use of oxytocic agents and the position of the presenting

Figure 1. The estimated pelvic measurements.

The risk for emergency CS

Table I. Basic characteristics Study group (cesarean section delivery n 0/30) Maternal age (years) Maternal length (cm) Prepregnant BMI Gestational age (days) Birth weight (g) 29.1 (27.2 31.1) 165 (1627 168) 24.8 (23.3 26.2) 283 (281 285) 3914 (3746 4083) Control group (vaginal delivery n0/30) 28.6 (26.9 30.3) 168 (165 170) 24.7 (23.2 26.2) 283 (281 286) 3884 (3719 4050) Statistical significance NS NS NS NS (matched) NS (matched)

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BMI, body mass index; NS, not significant. Data are expressed as means (95% confidence interval).

Table II. Pelvimetry measurements (cm) Study group (cesarean section delivery n 0/30) Pelvic inlet (API'/TD) Anterior-posterior inlet Transversal distance Pelvic outlet (IS'/IT'/SO) Interspinous distance Intertuberous distance Sagittal outlet 245 119 126 328 98 112 116 (241 250) (116 122) (123 129) (319 337) (95 102) (108 115) (112 120) Control group (vaginal delivery n0/30 ) 255 122 133 346 107 119 121 (251 260) (120 125) (130 136) (340 353) (104 109) (115 123) (118 125) Statistical significance 0.0038 0.098 0.0024 0.0024 0.0015 0.012 0.029

API, anterior-posterior inlet; TD, transversal distance; IS, interspinous distance; IT, intertuberous distance; SO, saggital outlet Results are expressed as means (95% confidence interval).

Discussion The perfect delivery, when baby and mother are healthy and the parents are satisfied, is the goal for obstetric care. Emergency CS seldom fulfill these criteria and may cause harm to both mother and child (1,2). The rate of successful vaginal births in trial of labor after a previous CS varies between 60 and 87% (7,12,13) which implies a substantial risk of another emergency CS. Medical risks are also connected with trial of labor after CS (7,8,14). The incidence of uterine rupture is 5.2 7.0/1000 (8,10,15). The highest risk is observed after induced labors (14 16) and in women not previously giving birth vaginally (14). There are several studies on factors affecting the success rate of vaginal delivery in trial of labor after a previous CS. An increased risk of another emergency CS is associated with: age over 35 years (17), advanced gestational age (18), fetal weight more than 4000 g (19), and induction of labor (16). A vaginal birth prior to emergency CS is associated with a decreased risk of further emergency CS (17,20). This study focused on postpartum X-ray and its role in clinical practice. There was a difference in pelvic outlet and inlet between women delivered with CS on indication-protracted labor and women giving birth vaginally (Table II). Forty-three percent of the women in the study group had borderline

measurements of the pelvic outlet compared to none in the control group. As the study group and controls were matched for birth weight, gestational age, and parity, the results indicated that size of pelvis was important for delivery outcome. However, mean birth weight in the study and control groups was 260/230 g higher than mean birth weight of the population, which indicated that birth weight affected labor progress. As the fetal head had passed the pelvic inlet in all subjects, we focused on the outlet measurements. The use of pelvimetry to determine method of delivery has decreased during the last decades (21). A combination of antenatal X-ray to estimate pelvic capacity and ultrasound to estimate fetal size, fetalpelvic index has not been a successful method for predicting successful vaginal birth after CS (22). The Cochrane review on pelvimetry for fetal cephalic presentation (23) concludes that there is not enough evidence to support the use of X-ray pelvimetry and that the trials included are not of good quality. However, this review does not focus on postpartum X-ray pelvimetry in women sectioned because of protracted labor. If pelvimetry is considered during pregnancy, radiation is a potential hazard for the fetus. This is not the case with postpartum X-ray. A recent Cochrane review concerning elective CS versus vaginal birth for women

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morbidity between trial of labor and elective cesarean section among women with previous cesarean delivery. Am J Obstet Gynecol. 2004;191:1263 9. Smith GCS, Pell JP, Cameron AD, Dobbie R. Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. JAMA. 2002; 287:2684 90. Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med. 2004;351:2581 9. Borell U. Orthodiagraphic pelvimetry with special reference to capacity of distal part of pelvis and pelvic outlet. Acta Radiol Diagn (Stockh). 1964;61:273 82. Melnikow J, Romano P, Gilbert WM, Schembri M, Keyzer J, Kravitz RL. Vaginal birth after cesarean in California. Obstet Gynecol. 2001;98:421 6. Lieberman E, Ernst EK, Rooks JP, Stapleton S, Flamm B. Results of the national study of vaginal birth after cesarean in birth centers. Obstet Gynecol. 2004;104:933 42. Smith GC, Pell JP, Pasupathy D, Dobbie R. Factors predisposing to perinatal death related to uterine rupture during attempted vaginal birth after caesarean section: retrospective cohort study. BMJ. 2004;329:375. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med. 2001;345:3 8. Sims EJ, Newman RB, Hulsey TC. Vaginal birth after cesarean: to induce or not to induce. Am J Obstet Gynecol. 2001;184:1122 4. Bujold E, Hammoud AO, Hendler I, Berman S, Blackwell SC, Duperron L, et al. Trial of labor in patients with a previous cesarean section: does maternal age inuence the outcome? Am J Obstet Gynecol. 2004;190:1113 8. Hammoud A, Hendler I, Gauthier RJ, Berman S, Sansregret A, Bujold E. The effect of gestational age on trial of labor after cesarean section. J Matern Fetal Neonatal Med. 2004;15: 202 6. Zelop CM, Shipp TD, Cohen A, Repke JT, Lieberman E. Trial of labor after 40 weeks gestation in women with prior cesarean. Obstet Gynecol. 2001;97:391 3. Hendler I, Bujold E. Effect of prior vaginal delivery or prior vaginal birth after cesarean delivery on obstetric outcomes in women undergoing trial of labor. Obstet Gynecol. 2004;104: 273 7. Radley BB. Pelvimetry: changing trends and attitudes. J Obstet Gynaecol. 2001;21:459 62. Wong KS, Wong AY, Tse LH, Tang LC. Use of fetal-pelvic index in the prediction of vaginal birth following previous cesarean section. J Obstet Gynaecol Res. 2003;29:104 8. Pattinson RC. Pelvimetry for fetal cephalic presentations at term. Cochrane Database Syst Rev 2000 (2): CD000161. Dodd J, Crowther C, Huertas E, Guise J, Horey D. Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth. Cochrane Database Syst Rev 2004 (4): CD004224.
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with a previous cesarean birth (24) concludes that randomized controlled trials are needed. Awaiting such studies, our results indicate that women abdominally delivered due to protracted labor could benefit from a postpartum X-ray. If the X-ray reveals a narrow or borderline pelvic outlet, it is reasonable to assume that this might have caused the protracted labor, and this determination should be taken into account when deciding the delivery route for the next pregnancy. If the infant is of the same or higher birth weight, the risk for another emergency CS is evident and an elective CS should be an attractive option. Moreover, women undergoing CS after protracted labor are motivated to find out the causes. In conclusion, this study has shown that women undergoing emergency CS because of protracted labor had narrower pelvic outlet than women vaginally delivered had. A postpartum pelvimetry is recommended and should be used when to decide on the delivery route in forthcoming pregnancies. Acknowledgement This study was supported by grants from Uppsala University, Uppsala, Sweden.

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