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CONTRACTED PELVIS

DEFINITION
Anatomical definition: It is a pelvis in which one or more of its main diameters are reduced below average normal by one or more centimetres Obstetric definition: It is a pelvis in which one or more of its main diameters are reduced to the extent that interferes with the normal mechanism of labour

ETIOLOGY
1. Developmental causes

Small gynaecoid -- generally contracted pelvis Small android Small anthropoid Small flat platypelloid pelvis Naegeles pelvis Roberts pelvis High assimilation pelvis Low assimilation pelvis Split pelvis

NAEGELES PELVIS

ROBERTS

PELVIS

FAULTY DEVELOPMENT

2. Diseases of the pelvic bones and joints


Metabolic diseases ---- Rickets, Osteomalacia

Bone tuberculosis
Severe malnutrition Poliomyelitis Hip joint disease Fractures of the pelvic bones, tumours of the pelvic bones

Rachitic pelvis

Osteomalacic pelvis

3.

Causes in the spine

Scoliosis Kyphosis

Spondylolisthesis
Coccygeal deformity

Kyphotic pelvis

Scoliotic pelvis

DIAGNOSING CONTRACTED PELVIS


1. HISTORY:

GENERAL: Rickets, Osteomalacia, Poliomyelitis, TB, fracture OBSTETRIC: Previous prolonged labour, difficult vaginal delivery, perineal tear, vesico-vaginal or recto-vaginal fistula

2. PHYSICAL EXAMINATION
Height: high risk <150 cm

Congenital or acquired deformities of pelvic bones, hip joint, spine Gait: abnormal gait - waddling Rickets : square head, rosary beads in costal ridges, pigeon chest, bow legs, harrisons sulcus

Dystocia - dystrophia syndrome:


short and obese stocky broad shoulders and short thighs sub-fertile has android pelvis masculine hair distribution with history of delayed menarche

3. ABDOMINAL EXAMINATION
4. PELVIMETRY * Clinical

Imaging - X- Ray, CT, MRI

Data

Findings

Forepelvis (pelvic brim) Diagonal conjugate Anterposterior diameter of outlet

Round 11.5 cm 11.0 cm

Symphysis Sacrum
Side walls Ischial spines Interspinous diameter Sacrosciatic notch Subpubic angle Bituberous diameter Coccyx

Average thickness, parallel to sacrum Hollow, average inclination


Straight Blunt 10.0 cm 2.5 -3 finger - breadths 2 finger - breadths 4 knuckles (> 8.0 cm) Mobile

Degrees of Contracted Pelvis


Minor degree: Moderate degree: The true conjugate is 9-10 cm The true conjugate is 8-9 cm

Severe degree:
Extreme degree: 6 cm.

The true conjugate is 6-8 cm


The true conjugate is less than

MECHANISM OF LABOUR
1. Flat rachitic pelvis
Engagement : with the sagittal suture in the transverse diameter Asynclitism with anterior parietal bone presentation Lateral displacement of the head Deflexion of the head and descent Rotation of the occiput 2/8 circle anteriorly

2. Simple Flat Pelvis


Persistent flattening of the pelvis Contracted outlet

No internal rotation and descent


Obstructed vaginal delivery

3. Contracted Outlet ( Funnel Pelvis )


Normal descent and engagement Extreme flexion and moulding of the head at ischial spines Narrow subpubic angle causes the head to push backward Face to pubis position is more favourable

CEPHALOPELVIC DISPROPORTION

The disparity in the relation between the head and


the pelvis which may be either due to an average size

baby with a small pelvis or due to a big baby with


normal size pelvis (hydrocephalus) or due to a combination of both.

CAUSES OF HIGH HEAD AT TERM


Occipito-posterior position - deflexion Deflexed head Multipara Half full bladder Mistaken maturity Twin, hydramnios, placenta praevia Increased angle of inclination

DIAGNOSING CPD
1. Abdominal method ( Pinards method )

2. Abdomino-vaginal method (Muller-Munro Ken)

EFFECTS OF CONTRACTED PELVIS


1. On pregnancy 2. On labour * maternal * fetal

MANAGEMENT OF CONTRACTED PELVIS


INLET CONTRACTION Preterm induction of labour Elective Caesarean section at term Trial labour

TRIAL LABOUR
The conduction of spontaneous labour in a moderate degree of cephalo-pelvic disproportion, in an institution under supervision with watchful expectancy, hoping for a vaginal delivery

CONTRAINDICATIONS
Associated mid-pelvic and outlet contraction Elderly primigravida Mal-presentation Post-maturity Post caesarean pregnancy Pre - eclampsia Medical disorders like heart disease, DM, TB Unavailability of facilities for caesarean section

GUIDELINES FOR TRIAL LABOUR Selection of patients


Monitoring progress
Augmentation of labour After rupture of membranes Termination

Favourable features of trial labour


Unfavourable features Advantages Disadvantages

MID-PELVIC AND OUTLET CONTRACTION


Cephalopelvic disproportion at the outlet is defined as one where the biparietal - suboccipitobregmatic plane fails to pass through the

bispinous and antero-posterior planes of the


outlet.

MANAGEMENT
Elective Caesarean section --In case of contraction of both the transverse and A-P diameters of the mid-pelvic plane

Vaginal delivery --- In uncomplicated cases with minor contraction * by forceps or ventouse with deep episiotomy to prevent perineal injuries

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