Sunteți pe pagina 1din 9

Volume 65, Number 6 OBSTETRICAL AND GYNECOLOGICAL SURVEY Copyright 2010 by Lippincott Williams & Wilkins

CME REVIEWARTICLE

16

CHIEF EDITORS NOTE: This article is part of a series of continuing education activities in this Journal through which a total of 36 AMA/PRA Category 1 CreditsTM can be earned in 2010. Instructions for how CME credits can be earned appear on the last page of the Table of Contents.

Assessing Cephalopelvic Disproportion: Back to the Basics


Dushyant Maharaj, MBBS, Dip Tert Teach, DMAS, FCOG (S.A.), FRANZCOG
Senior lecturer, Department of Obstetrics and Gynecology, University of Otago, Wellington, New Zealand; and Consultant, Department of Obstetrics and Gynecology, Womens Health, Wellington Regional Hospital, Wellington, New Zealand Dystocia, or abnormally slow progress in labor, can result from cephalopelvic disproportion (CPD), malposition of the fetal head as it enters the birth canal, or ineffective uterine propulsive forces. Cephalopelvic disproportion occurs when there is mismatch between the size of the fetal head and size of the maternal pelvis, resulting in failure to progress in labor for mechanical reasons. Untreated, the consequence is obstructed labor that can endanger the lives of both mother and fetus. 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. For this review, a computerized search of the terms cephalopelvic disproportion, dystocia, pelvimetry, obstructed labor, and malposition was done using MEDLINE, PUBMED, SCOPUS, and CINAHL, and historical articles, texts, articles from indexed journals, and references cited in published works were also reviewed. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to interpret how cephalopelvic disproportion is diagnosed. Distinguish the 4 basic pelvic shapes. Evaluate pelvic measurements that best indicate adequacy or inadequacy of the pelvis.

Bipedal locomotion and encephalization (progressive increase in brain size) have placed competing demands on the human pelvis. It is generally asUnless otherwise noted below, each facultys spouse/life partner (if any) has nothing to disclose. The author has disclosed that there are no financial relationships with or interests in any commercial companies pertaining to this educational activity. The Faculty and Staff in a position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity. There are instances where we have been unable to trace or contact the copyright holder. If notified the publisher will be pleased to rectify any errors or omissions at the earliest opportunity. Correspondence requests to: Dushyant Maharaj, MBBS, Dip Tert Teach, D.MAS, FCOG (S.A.), FRANZCOG, Department of Obstetrics & Gynaecology, University of Otago, PO Box 7343, Wellington South, 6242 Wellington, New Zealand. E-mail: dean.maharaj@otago.ac.nz.

sumed that efficient bipedalism requires a narrow pelvis, whereas a wider pelvis is more advantageous for childbirth. The likelihood of cephalopelvic disproportion and obstructed labor has increased along with the increase in brain size, and changes in pelvic morphology that greatly restrict the midplane of the pelvis also complicate human obstetrical mechanics (1). Birth injuries sustained by modern women in impoverished countries who do not have access to skilled obstetric care when labor becomes obstructed attest to this painful Darwinian reality (2). The evolutionary consequences of these trends, if continued, are a matter for intriguing obstetrical speculation. Dystocia, a word that literally means difficult labor, is the overall term for slow, inadequate, or dysfunctional labor. It is generally caused by uterine dysfunction (inadequate propulsive forces), or a size imbalance be-

www.obgynsurvey.com | 387

388

Obstetrical and Gynecological Survey

tween the maternal pelvis and the fetal head (cephalopelvic disproportion, or CPD) that prevents the fetus from negotiating the birth canal. Cephalopelvic disproportion, 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. Although the term CPD was coined in the 19th century when the disparity in size between the fetal head and the maternal pelvis largely resulted from pelvic contracture due to rickets (3), CPD is still responsible for 8% of maternal deaths worldwide (4). Unattended, obstructed labor results in fetal death, eventual delivery of a macerated and infected baby, and atonic postpartum hemorrhage with or without puerperal infection. The survivor may be left with a vesicovaginal or rectovaginal fistula, infertility and chronic pelvic pain. Definitions of CPD vary but, barring extreme macrosomia or a severely restricted maternal pelvis, most authorities agree that it can only be diagnosed with assurance during labor. Clinical pelvimetry has traditionally been used in obstetric practice to predict CPD, and continues to be an important tool in developing countries (5). X-ray and computed tomography pelvimetry, and ultrasound and magnetic resonance imaging enable more precise assessment of pelvic dimensions, but cannot reliably diagnose CPD. After completing this CME activity, readers will be better able to diagnose cephalopelvic disproportion, distinguish the 4 basic pelvic shapes, and evaluate pelvic measurements indicating an adequate or inadequate pelvis. THE THREE Ps OF LABOR The current concept of dystocia is that it can result from CPD (a mismatch in size between the fetal head and the maternal pelvis), malposition of the fetal head as it enters the birth canal, or ineffective uterine propulsive forces. These are summarized as the 3 Ps of labor: 1. Passageway: maternal bony pelvis and tissues. 2. Passenger: the fetus. 3. Powers: primary and secondary forces of labor. A clinical classification divides CPD due to passageway or passenger into absolute and relative entities (6): Absolute CPDTrue Mechanical Obstruction Permanent (Maternal) Contracted pelvis Pelvic exostoses Spondylolisthesis Anterior sacrococcygeal tumors

Temporary (Fetal) Hydrocephalus Large infant Relative CPD Brow presentation Face presentationmentoposterior Occipitoposterior positions Deflexed head

Some clinicians consider the maternal pelvis to be proven if the woman has had a previous vaginal delivery. However, subsequent fetuses can be larger, and maternal anatomy can change between pregnancies. Occasionally, lumbosacral spondylolisthesis may develop between pregnancies and reduce the effective anteroposterior diameter of the pelvic brim, rendering a previously adequate pelvis inadequate (7). Although descent of the fetal head through the pelvis may be obstructed by the relative sizes of the fetal head and the maternal pelvis, uterine power (contraction frequency and strength) must also be assessed. In most cases of slow or seemingly obstructed labor, augmentation with oxytocin is indicated. Indeed, ODriscoll stated that, cephalopelvic disproportion cannot be excluded unless oxytocin is used (8), and others diagnose CPD only if there is a prolonged first (12 hours) or second (2 hours) stage of labor in women receiving oxytocin (9). The American College of Obstetricians and Gynecologists has stated that dystocia cannot be diagnosed before there has been an adequate trial of labor; to achieve this, women who are in the active phase of labor (cervix, 34 cm dilated) and are contracting less frequently than 3 times in 10 minutes, and whose contractions do not measure at least 25 mm Hg, and in whom fetal well being has been established, should have their labor augmented with oxytocin. Once an adequate contraction pattern is achieved (200 Montevideo units in 10 minutes), they should have at least 2 hours and possibly up to 4 hours of adequate labor without further cervical change before dystocia can be diagnosed (10). PELVIC SHAPES, DIMENSIONS, AND MEASUREMENTS Pelvic Shapes Although pelves can be categorized by the measurements of their diameters, it is usual in obstetrics to classify pelves according to the shape of the pelvic

Assessing Cephalopelvic Disproportion Y CME Review Article

389

curved. The sub-pubic arch has an angle 90 degrees, and the ischial spines are prominent, which may hinder internal rotation of the fetal head, and may ultimately lead to a deep transverse arrest. This type of pelvis is the least favorable for achieving a vaginal birth. 3. Anthropoidthis type of pelvis results from high assimilation, i.e. the sacral body is assimilated to the fifth lumbar vertebra. The pelvic brim is long, narrow, and oval in shape, and the anterior-posterior diameter is greater than the transverse diameter. The side walls of the cavity diverge, and the sacrum is long and concave. The sub-pubic angle is very wide and the ischial spines are not prominent. 4. Platypelloidthis is a wide pelvis that is flattened at the brim, with the sacral promontory pushed forward. This forms a kidney-shaped pelvic brim. The side walls of the pelvis diverge; the sacrum is flat, and the pelvic cavity shallow. As a result, the transverse diameter is greater than the anterior-posterior diameter. The subpubic angle is 90 degrees and the ischial spines are blunt. PELVIC DIMENSIONS AND CLINICAL PELVIMETRY
Fig. 1. Female pelvis. A, View from above, showing inlet and anteroposterior (conjugate) and transverse diameters and surrounded by drawings of the 4 main types of female pelves. B, View from below, showing outlet and anteroposterior (conjugate) and transverse diameters. C, The pelvic cavity with the left hip bone removed. The anterior superior iliac spines and the pubic tubercles are in the same coronal plane (CP). The linea terminalis comprises the (1) promontory, (2) ala of the sacrum, (3) medial border of the ilium (arcuate line), (4) pectineal line, and (5) pubic crest. From Smout CFV, Jacoby F, Lillie EW, Eds. Gynaecological and Obstetrical Anatomy, 4th edition. London: HK Lewis & Co. Ltd.; 1969.

The pelvic dimensions can be determined clinically during a detailed bimanual exam in which various measurements of the pelvis are estimated and recorded. Some internal pelvic diameters are not accessible to direct measurement, so must be inferred. Findings are usually recorded as adequate, borderline, or inadequate, although some practitioners prefer to record the various pelvic dimensions in centimeters. The Pelvic Inlet

inlet. Four main types are recognized (11): (1) gynecoid, a rounded inlet; (2) android, a heart-shaped inlet; (3) anthropoid, a long, narrow, oval inlet; and (4) platypelloid, an ovoid inlet with its long axis transverse (Fig. 1). 1. Gynecoidthis is the classical female pelvis, with the inlet transversely oval and a shallow pelvic cavity, with a broad well-curved sacrum. The gynecoid pelvis has a sub-pubic angle of 90 degrees and blunt ischial spines. 2. Androidthis type of pelvis is more masculine in its shape and diameters. It is characterized by a heart-shaped inlet and a funnel-shaped, deep cavity; the sacrum is straight rather than

The pelvic brim or inlet separates the false pelvis from the true pelvis that is below. The inlet is round in shape, with the sacral promontory protruding into it posteriorly. The pubic bones form the anterior border of the pelvic brim; the iliac bones form the lateral borders, and the posterior border is formed by the sacral promontory and its alae. The pelvic inlet has 3 principal diameters: anteroposterior, transverse, and oblique. The anteroposterior diameter or obstetrical conjugate extends from the sacrovertebral angle (sacral promontory) to the symphysis pubis. The obstetrical conjugate is the most important diameter of the pelvic inlet since it is the shortest distance between the sacrum and the

390

Obstetrical and Gynecological Survey

symphysis pubis. The average length of the obstetrical conjugate is 11 cm; the pelvic inlet is considered to be contracted if it is 10 cm. However, the obstetrical conjugate cannot be measured directly with the hand since the upper margin of the symphysis cannot be reached. Instead, the diagonal conjugate is measured; this is the distance from the inferior border of the symphysis pubis to the sacral promontory, and is typically 1.5 cm longer than the obstetrical conjugate or 12.5 cm. The length of the diagonal conjugate is determined during a vaginal examination by placing the lateral edge of the middle finger of the examining hand flush with the lower border of the symphysis and trying to reach the sacral promontory. Failure to reach the sacrum indicates that the conjugate is 12.5 cm. If the sacrum is reached, the point where the lowest border of the pubic symphysis impinges on the middle finger is noted, and the length of the middle finger to that point is equal to the length of the diagonal conjugate. Subtracting 1.5 cm from that distance gives the approximate length of the obstetrical conjugate. Instead of estimating the length of the diagonal conjugate in this manner, some practitioners simply note whether the sacral promontory was reached easily, with difficulty, or not at all. The transverse diameter extends across the greatest width of the superior aperture, from the middle of the brim at the level of the linea terminalis on one side to the same point on the opposite. The average length of the transverse diameter is 13.5 cm; it is considered inadequate if it is 12 cm (12,13). There are 2 oblique diameters; each extends from the iliopectineal eminence of one side to the sacroiliac articulation of the opposite side. Their average measurement is 12.5 cm. The Midpelvis and Pelvic Cavity The mid pelvis is at the 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, and the interspinous diameter should be estimated. The intraspinous diameter is the smallest dimension of the pelvis. It is assessed by touching both spines simultaneously with 2 examining fingers, and noting the distance between the fingers; it should be at least 10 cm. Assessment of the pelvic cavity is also done to determine if the walls of the cavity are straight, convergent, or divergent. While touching an ischial spine with the index and middle fingers of the examining hand, the thumb of the other hand is placed on the ischial tuberosity on the same side. If the thumb is medial to the examining fingers, the side wall is con-

vergent, and if lateral it is divergent. The sacrum is also palpated for its curve, shape, and length. Finally, the sacrosciatic notch is evaluated; if the notch accommodates 2 and half fingers, it is considered adequate. The Pelvic Outlet The perimeter of the pelvic outlet is partially comprised of ligaments, and is either ovoid or diamondshaped. Landmarks of the pelvic outlet include the lower border of the symphysis pubis, the pubic arch, the ischial tuberosities, the sacrotuberous and sacrospinous ligaments, and the lower aspect of the sacrum and the coccyx. The posterior surface of the pubic symphysis should be palpated; in the normal female pelvis, this is a smooth rounded curve. The subpubic angle should be more than 90 degrees, and normally admits 2 fingers. The distance between the ischial tuberosities (the bituberous diameter) is normally at least 8 cm; this is equivalent to the width of the closed fist or 4 knuckles for most examiners. The mobility of the coccyx is determined by pressing firmly on it. During the pelvic examination, the muscular structure of the pelvis is also noted. 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 assessed for their density and elasticity. In performing clinical pelvimetry, a formula to follow is described as the rule of 3s, indicating that there are 3 parts of the pelvis to examine, and each part has 3 components (Table 1) (14). The findings expected in an adequate pelvis are shown in Table 2 (36). PELVIMETRY USING IMAGING TECHNOLOGY As noted above, pelvimetry can be performed during a bimanual exam (clinical pelvimetry), but the
TABLE 1 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 diameter Sacrococcygeal joint

Assessing Cephalopelvic Disproportion Y CME Review Article


TABLE 2 Findings expected in an adequate pelvis Assessment Pelvic brim Diagonal conjugate Symphysis Sacrum Side walls Ischial spines Interspinous diameter Sacrosciatic notch Subpubic angle Bi-tuberous diameter Coccyx Anterposterior diameter of outlet Finding Round 12.5 cm Average thickness, parallel to sacrum Hollow, average inclination Straight Blunt 10.0 cm 2.53 finger breadths 90 degrees (2 finger breadths) 8.0 cm (4 knuckles) Mobile 11.0 cm

391

dimensions of the pelvis can also be determined by conventional x-rays, by computerized tomography, or via magnetic resonance imaging (MRI). The goal of pelvimetry is to accurately predict which patients will have cephalopelvic disproportion. Clinical assessment of the midpelvis and the pelvic outlet seems to be the best method of measuring pelvic capacity (15). However, unless the pelvic dimensions are grossly abnormal, all women should be given a trial of labor (16). In recent years there has been an increasing emphasis on the use of technology for the assessment and evaluation of women during the antepartum and intrapartum periods. As a result, hands-on skills, such as Leopolds maneuvers, fetal weight estimation, and clinical pelvimetry have received less emphasis in educational programs and practice. Because some recent graduates are not adequately trained in obstetric aspects of the physical examination, they may depend on technology. In terms of estimating the adequacy of the female pelvis, it is unclear whether radiologic pelvimetry offers any advantage to clinical pelvimetry (17). X-ray pelvimetry was popular in obstetrical units in developed countries from the 1950s through to the 1970s, and was used mainly for predicting outcome of labor in cases of suspected CPD, breech presentation, and trial of labor after a previous caesarean section. However, its clinical usefulness remained controversial (18). Overall, the data suggest that there is no significant role for x-ray pelvimetry in the prediction and management of CPD when the fetus is in cephalic presentation (1921). In the 1990s, computed tomography (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. However, in

terms of clinical accuracy and ability to predict CPD, CT pelvimetry has not been shown to offer any substantial advantage over conventional x-ray pelvimetry (22). During this time, x-ray pelvimetry was still being performed in many centers as part of the management of breech presentation at term, and in patients in whom a trial of vaginal delivery after a previous cesarean was planned (23). Consequent to the Term Breech Trial (24), as a result of which the American College of Obstetricians and Gynecologists recommended against planned vaginal delivery of the singleton term breech, x-ray pelvimetry to evaluate the pelvis in consideration of vaginal breech delivery has been largely abandoned (25). Advances in imaging techniques then led to the use of MRI pelvimetry. Magnetic resonance imaging provides contrast resolution superior to that provided by CT and permits accurate pelvic measurements with no ionizing radiation, thus eliminating the risk of fetal x-ray exposure (22). In a study to determine whether MRI pelvimetry had the ability to identify women who would require cesarean delivery for dystocia, single fetal and maternal pelvic measurements, as well as ratios of both, were analyzed in women who underwent MRI. No single fetal measurement was statistically associated with dystocia. Investigators found significant associations between MRI pelvimetry and labor dystocia, but MRI was not a significant improvement over previously described pelvimetric techniques (26). In another study that tested the clinical value of MR imaging for predicting CPD and labor outcome in women at risk for dystocia, none of the methods tested yielded sufficiently high sensitivity or specificity (27). Studies of the use of ultrasound as a supplementary imaging modality to detect CPD have yielded varied results (2830). In a review of prognostic factors and screening tools in predicting vaginal birth after cesarean delivery, the reviewers concluded that there is little high-quality data to guide clinical decisions regarding which women were likely to have a successful trial of labor (31). INTRAPARTUM PREDICTION AND RECOGNITION OF CEPHALOPELVIC DISPROPORTION Fetal Head Descent CPD will result in failure of descent of the fetal head through the pelvis. Obstruction may be at the level of the pelvic brim (32). More commonly, the head is engaged in the pelvic inlet, but contraction of

392

Obstetrical and Gynecological Survey

the midpelvis prevents further decent. Contraction can also occur at the level of the pelvic outlet, but in most cases outlet contraction is associated with midpelvic contraction. Successful descent of the fetal head through the pelvis also depends on compliance of maternal soft tissues, the strength of contractions, and maternal expulsive efforts in the second stage. Engagement is 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. For a cephalic presentation, the widest portion of the presenting part is the biparietal diameter. A head that is 2/5 palpable or lower is engaged in the pelvis. The amount of descent and engagement of the head is assessed by feeling how many fifths of the head are palpable above the brim of the pelvis: 5/5 of the head palpable mean that the whole head is above the brim of the pelvis. 4/5 of the head palpable means that a small part of the head is below the brim of the pelvis and can be lifted out of the pelvis with a deep pelvic grip. 3/5 of the head palpable means that the head cannot be lifted out of the pelvis. On deep pelvic grip, the examining fingers will move outwards from the neck of the fetus, then inwards before reaching the pelvic brim. 2/5 of the head palpable means that most of the head is below the pelvic brim, and on deep pelvic grip, the examining fingers splay outwards from the fetal neck to the pelvic brim. 1/5 of the head palpable means that only the base of the fetal head can be felt above the pelvic brim. If 2/5 or less of the head is palpable, then engagement has taken place and the possibility of disproportion at the pelvic inlet can be ruled out. Station is the distance between the leading edge of the vertex and the ischial spines. Zero station is when the biparietal diameter has passed through the pelvic brim, and the leading edge of the vertex is in the midpelvis at the level of the ischial spines (33). If the leading edge is 1 cm below the level of the spines, this is referred to as station 1. Conversely, if the leading edge of the vertex is 1 cm above the spines, this is 1 station. Usually, a head on the pelvic floor is at station 4 or 5. A head not yet engaged and still 2 cm above the level of the spines is at station 2, and so on (Fig. 2). An alternate method to describe station is to divide the distance between the ishial spines and the vaginal outlet into thirds, and express the station as 1, 2, or 3. With this

Fig. 2. Station. From Smout CFV, Jacoby F, Lillie EW, Eds. Gynaecological and Obstetrical Anatomy, 4th edition. London: HK Lewis & Co. Ltd.; 1969.

method, station above the spines is still measured in centimeters (i.e., 1 station means 1 cm above the spines). Normal labor usually involves a slow but sustained descent of the fetal head during the first stage of labor, with acceleration late in the first stage and more so in the second stage. In nulliparae, CPD is more likely when the vertex remains at a high station during the first and second stages and/or there is a dysfunctional labor pattern. In multiparae, however, the fetal head often remains high longer and starts to descend later in the labor course than in nullparae (34). Head-Fitting Tests When the fetal head is not engaged at term, there are 2 methods to determine if the pelvic inlet is adequate for the fetal head. These tests are mostly of historical significance, since neither is typically used in advance of labor to determine the mode of delivery. Importantly, nonengagement of the fetal head at term is only a concern in nulliparas, since in multiparous patients the fetal head can remain unengaged until late in gestation or until the onset of labor, after which rapid decent is typical. One method to determine if the pelvic inlet is adequate is the head-fitting test. If the head can be pushed into the pelvis, CPD due to a contracted inlet may be excluded. This maneuver is purely a test of fit, and the head is not expected to stay engaged in the pelvis. Munro- Kerrs head-fitting test is probably the most well known (Fig. 3) (14). The obstetrician stands on the womans right side, and attempts to push the head into the pelvis with the left hand while feeling for descent with fingers of the right hand in the vagina. Descent and engagement of the head provides reassurance, while failure of descent,

Assessing Cephalopelvic Disproportion Y CME Review Article

393

bones are not united rigidly but are separated by membranous spaces, the sutures, which allow the bones of the head to overlap somewhat in order to navigate the pelvis, in a process called molding (discussed below). The most important sutures are: Sagittal, between the 2 parietal bones, Frontal, between the 2 frontal bones, 2 coronal, between the frontal and parietal bones, and 2 lambdoid, between the posterior margin of the parietal bones and upper margin of the occipital bone. Where several sutures meet an irregular space forms, enclosed by a membrane and designated a fontanel. The anterior fontanel is a lozenge-shaped space situated at the junction of the sagittal and coronal sutures. The posterior fontanel is represented by a small triangular area at the intersection of the sagittal and lambdoid sutures. The dimensions and measurements of the fetal head in the different presentations are shown in Table 3 (36). During labor, the examiner can palpate the fetal head and sutures to determine how much molding has occurred; significant molding without descent of the head is another indication of possible CPD. MOLDING Molding is 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. Cephalopelvic disproportion is thought to result in a high degree of molding, consequent to the head being squeezed into a contracted pelvic cavity and high head to cervix pressure at the equator of the fetal head (37). Occipitoparietal (lambdoidal suture) molding, in which the parietal bones are elevated in relation to the frontal
TABLE 3 Dimensions and measurements for the different fetal presentations Dimension Measurement (cm) 9.5 10.0 11.24 13.8 9.5 11.25 9.5 8.0 7.5 Presentation Vertex Sinciput Occipitoposterior Brow Face Incompletely extended face

Fig. 3. Munro Kerrs head-fitting test. From Smout CFV, Jacoby F, Lillie EW, Eds. Gynaecological and Obstetrical Anatomy, 4th edition. London: HK Lewis & Co. Ltd.; 1969.

and especially overlap of the head over the symphysis, suggests the possibility of CPD. If the head cannot be made to pass the brim of the pelvis, the thumb of the right hand is then passed over the pubic symphysis to estimate the degree of overlap. First degree overlap is said to exist when the presenting portion of the head is level with the pubic symphysis, suggesting that there is a moderate degree of CPD. Second degree overlap exists when the presenting part is found to be anterior to the pubic symphysis, and suggests a serious degree of disproportion. If descent occurred, i.e. a positive test, the test was significant; a negative test, however, could be attributed to factors other than CPD (35). The other way to detect a contracted inlet if the head is not engaged in the last 3 to 4 weeks of pregnancy in a primigravida is Pinards method. The patient evacuates her bladder and rectum, and is placed in a semi-sitting position to bring the fetal axis perpendicular to the brim. The left hand pushes the head downwards and backwards into the pelvis while the fingers of the right hand are put on the symphysis to detect disproportion (36). THE FETAL HEAD An essential feature of labor is the adaptation between the fetal head and the maternal pelvis. Only a comparatively small part of the fetal head is represented by the face; the rest is composed of the firm skull, which is made up of 2 frontal, 2 parietal, and 2 temporal bones, along with the upper portion of the occipital bone and the wings of the sphenoid. The

Suboccipitobregamatic Suboccipitofrontal Occipitofrontal Mentovertical Submentobregmatic Submentovertical Biparietal diameter Bitemporal diameter Bimastoid diameter

394

Obstetrical and Gynecological Survey

and occipital bones, results in a level difference in the coronal and lambdoid sutures. Molding is to be expected at the lambdoid and coronal sutures in normal labor. Parietoparietal (sagittal suture) molding occurs after occipitoparietal molding, and is associated with CPD. The failure of descent of the head during labor with an increase in degree of molding is the ultimate index of CPD, with the hallmark being excessive parietoparietal overlap. Molding is graded as follows (32): 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. When labor progress is poor in a multipara, careful attention should be paid to head descent and molding; when there is increasing molding of the fetal head without descent into the pelvis, there may be CPD. Clinical experience and skill are prerequisites in the assessment of poor labor progress in a multipara (35). CAPUT SUCCEDANEUM Caput succedaneum is swelling of the scalp over the presenting part of the fetal head (38). 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. This process obstructs venous return from the scalp and results in subcutaneous edema. Marked caput has been associated with prolonged labor and CPD (37,39). Caput has been observed on ultrasound examination even before the onset of labor, so it does not always reflect prolonged labor or strong uterine contractions (40). Caput succedaneum is classified as absent (), moderate () or marked (); it may be a finding in normal labor, but is also a predictor of CPD (32). ASYNCLITISM Asynclitism, a term used to describe 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 flexion of the fetal head as it negotiates the birth canal. Small degrees of asynclitism are normal and not a cause for alarm. Anterior asynclitism (Naegeles obliquity), in which the anterior parietal bone presents predominantly, with the sagittal suture facing the sacrum, is the most frequent. The converse is

posterior asynclitism (Litzmanns obliquity), which is frequently associated with CPD (38). 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 cephalopelvic disproportion 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 a valuable predictor of CPD, which can only be diagnosed after a properly conducted trial of labor. The best indicator of maternal pelvic capacity is the fetus, or as stated by Pinard, the fetal head is the best pelvimeter (41). After completing this CME activity, readers will be better able to diagnose cephalopelvic disproportion, distinguish the 4 basic pelvic shapes, and evaluate pelvic measurements indicating an adequate or inadequate pelvis. REFERENCES
1. Wittman AB, Wall LL. The evolutionary origins of obstructed labor: bipedalism, encephalization, and the human obstetric dilemma. Obstet Gynecol Surv 2007;62:739748. 2. Wall L. Obstetric vesicovaginal fistula as an international public health problem. Lancet 2006;368:12011209. 3. Olah KS, Neilson J. Failure to progress in the management of labour. Br J Obstet Gynaecol 1994;101:1. 4. World Health Organisation. The World Health Report 2005: Making every mother and child count. Geneva, Switzerland: WHO, 2005. Available at: http://www.who.int/whr/2005/en/ index.html. Accessed April 5, 2010. 5. Adinma JL, Aqbai AO, Anolue FC. Relevance of clinical pelvimetry to obstetric practice in developing countries. West Afr J Med 1997;16:4043. 6. Craig CJ. A clinical classification of cephalopelvic disproportion. S Afr Med J 1961;35:878879. 7. Neilson JP, Lavender T, Quenby S, et al. Obstructed labour. Br Med Bull 2003;67:191204. 8. ODriscoll K, Meagher D, eds. Active Management of Labour. 2nd ed. London: Bailliere Tindall, 1986. 9. Frame S, Moore I, Peters A, et al. Maternal height and shoe size as predictors of pelvic disproportion: an assessment. Br J Obstet Gynaecol 1985;92:12391245. 10. American College of Obstetricans and Gynecologists. Dystocia and Augmentation of Labor. Washington, DC: American College of Obstetricans and Gynecologists, 2003. Practice Bulletin 49. 11. The female pelvis. Midirs. Available at: http://www.midirs.org/ development/studentmidwife.nsf/0/18981b4099e3a3458025 76f00040945a/$FILE/The%20Female%20Pelvis.pdf. Accessed May 8, 2010. 12. Cunningham FG, Gant NF, Leveno KJ, et al, eds. Williams Obstetrics. 21st ed. New York, NY: McGraw Hill, 2001:436.

Assessing Cephalopelvic Disproportion Y CME Review Article


13. Bathla S, Rajaram S, Singh KC, et al. Ultrasonic obstetric conjugate measurement: a practical pelvimetric tool. J Obstet Gynecol India 2006;56:212215. 14. Smout CF, Jacoby F, Lillie EW, eds. Gynaecological and Obstetrical Anatomy. 4th ed. London: HK Lewis & Co. Ltd, 1969. 15. Suonio S, Saarikoski S, Ra ty E, et al. Clinical assessment of the pelvic cavity and outlet. Arch Gynecol Obstet 1986;239: 1116. 16. Hankins GD, Clark SL, Cunningham FG, et al. Operative obstetrics. In: Gilstrap L, Cunningham F, van Dorsten JP, eds. 2nd ed. New York, NY: McGraw-Hill, 1995:7475. 17. Jacobson AK. Are we losing the art of midwifery? J Nurse Midwifery 1993;38:168169. 18. Rozenberg P. Is there a role for x-ray pelvimetry in the twentyfirst century? Gynecol Obstet Fertil 2007;35:612. 19. Thubisi M, Ebrahim A, Moodley J, et al. Vaginal delivery after previous caesarean section: is x-ray pelvimetry necessary? Br J Obstet Gynaecol 1993;100:421424. 20. Pattinson RC, Farrell EM. Pelvimetry for fetal cephalic presentations at or near term. Cochrane Database Syst Rev 1997: CD000161. DOI: 10.1002/14651858.CD000161. 21. Hofmeyr GJ. Obstructed labor: using better technologies to reduce mortality. Int J Gynaecol Obstet 2004;85:S62S72. 22. Ferguson JE II, Sistrom CL. Can fetal-pelvic disproportion be predicted? Clin Obstet Gynecol 2000;43:247264. 23. Raman S, Samuel D, Suresh KA. Comparative study of x-ray pelvimetry and CT pelvimetry. Aust NZ J Obstet Gynaecol 1991;31:217220. 24. Hannah ME, Hannah WJ, Hewson SA, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000; 356:13751383. 25. American College of Obstetricians and Gynecologists. Mode of term single breech delivery: ACOG committee opinion number 265. Obstet Gynecol 2001;98:11891190. 26. Zaretsky MV, Alexander JM, McIntire DD, et al. Magnetic resonance imaging pelvimetry and the prediction of labor dystocia. Obstet Gynecol 2005;106(5 Pt 1):919926. 27. Sporri S, Theony HC, Raio L, et al. MR imaging pelvimetry: a useful adjunct in the treatment of women at risk for dystocia? Am J Roentgenol 2002;179:137144.

395

28. Sporri S, Gyr T, Schollerer A, et al. Methods, techniques and assessment criteria in obstetric pelvimetry [in German]. Z Geburtshilfe Perinatol 1994;198:3746. 29. Abitbol MM, Bowen-Ericksen M, Castillo I, et al. Prediction of difficult vaginal birth and of cesarean section for cephalopelvic disproportion in early labor. J Matern Fetal Med 1999;8: 5156. 30. Bian X, Zhuang J, Cheng X. Combination of ultrasound pelvimetry and fetal sonography in predicting cephalopelvic disproportion. Chin Med J 1997;110:942945. 31. Hashima JN, Eden KB, Osterweil P, et al. Predicting vaginal birth after cesarean delivery: a review of prognostic factors and screening tools. Am J Obstet Gynecol 2004;190:547555. 32. Stewart KS, Philpott RH. Fetal response to cephalopelvic disproportion. Br J Obstet Gynaecol 1980;87:641649. 33. Friedman EA. Labour: Clinical Evaluation and Management. New York, NY: Appleton-Century-Crofts, 1978:3744. 34. Debby A, Rotmensch S, Girtler O, et al. Clinical significance of the floating fetal head in nulliparous women in labor. J Reprod Med 2003;48:3740. 35. Philpott RH. The recognition of cephalopelvic disproportion. Clin Obstet Gynaecol 1982;9:609624. 36. El-Mowafi DM. Contracted pelvis. Geneva Foundation for Medical Education and Research. Available at: http://www. gfmer.ch/Obstetrics_simplified/contracted_pelvis.htm. Accessed April 11, 2010. 37. Chua S, Arulkumeran S. Poor progress in labor including augmentation, malpositions, and malpresentations. In: James DK, Steer PJ, Weiner CP, et al, eds. High Risk Pregnancy: Management Options. 2nd ed. Edinburgh, United Kingdom: WB Saunders, 1999:11031119. 38. Cunningham FG, Leveno KJ, Bloom SL, et al, eds. Williams Obstetrics. 22nd ed. New York, NY: McGraw-Hill, 2005:409441. 39. Odendaal HJ. Poor progress during the first stage of labour. In: Cronje HS, Grobler CJ, eds. Obstetrics in Southern Africa. 2nd ed. Pretoria, South Africa: Van Schaik, 2003:303313. 40. Petrikovsky BM, Schneider E, Smith-Levitin M, et al. Cephalohematoma and caput succedaneum: do they always occur in labor? Am J Obstet Gynecol 1998;179:906908. 41. Dunn PM. Adolphe Pinard (18441934) of Paris and intrauterine paediatric care. Arch Dis Child Fetal Neonatal Ed 2006; 91:F231F232. Doi: 10.1136/adc. 2005.074518.