Fetopelvic Disproportion Clinical Pelvimetry X-ray Pelvimetry Estimation of Fetal Weight Progress of Labor Fetopelvic disproportion is any clinically

lly significant mismatch between the size or shape of the presenting part of the fetus and the size or shape of the maternal pelvis and soft tissue. A 12-pound fetus trying to squeeze through a maternal pelvis that is only adequate for a 7-pound baby would be an example of fetopelvic disproportion. The problem of disproportion may be based strictly on size, or may be related to the way in which the fetus is trying come out. Occiput anterior is the usual position for a fetus and that position is generally the most favorable for negotiating the diameters and turns of the birth canal. Should a fetus attempt to come through the birth canal in the occiput posterior position, it is more difficult for the fetal head to negotiate the turns. If the fetus is small enough and the pelvis large enough, it can still deliver as a posterior. Otherwise, the fetal head will need to be turned to anterior, or a cesarean section performed. Some disproportions are relative, while others are absolute. The relative disproportions may allow for non-operative vaginal delivery, if labor is allowed to continue long enough and there is sufficient molding or re-shaping of the fetal head to allow it to squeeze through. In the case of absolute disproportion, no amount of fetal head re-shaping will allow for unassisted vaginal delivery, and it may not allow for a vaginal delivery at all. Even in the case of relative disproportion, that fact that eventually a fetus might squeeze through doesn't necessarily mean that continued labor is wise. Even if highly accurate measurements of the maternal pelvis and fetal size were possible (and they are not), it would still be difficult to predict in advance those who will deliver vaginally easily and those who will not. All measurements are essentially static, and do not take into account the inherent "stretchiness" of the maternal pelvis or the compressibility of the fetus. The pelvis is not a single solid bone, but is comprised of many bones, held together by cartilage and ligaments. During pregnancy, these soft-tissue attachments become more pliable and elastic, allowing considerable movement. Similarly, fetal tissues can be safely compressed, to a certain extent. For these reasons, trying to predict whether a dynamically-shaped fetus will fit through a dynamically-shaped pelvis, based only on static measurements, becomes nearly impossible. Can a basketball fit through a rubber band? Of course, it depends on how big the basketball is, how big the rubber band is, how inflated the basketball is, and how stretchy the rubber band is. Accurately measuring the size of the basketball and the rubber band won't answer all of those questions. Clinical Pelvimetry

Pelvic Exam During Labor Video Pelvic examinations during labor are used for several purposes, among them assessment of cervical dilatation,

effacement, station of the presenting part, presentation, position, and pelvic capacity. This 5-minute video demonstrates these techniques, using live patients, models and graphics. www.brooksidepress.org

Methods of performing clinical pelvimetry range from the very simple to very complex. Simple digital evaluation of the pelvis, allows the examiner to categorize it as probably adequate for an average sized baby, borderline, or contracted. Other methods include the following: Measuring the diagonal conjugate. Insert two fingers into the vagina until they reach the sacral promontory. The distance from the sacral promontory to the exterior portion of the symphysis is the diagonal conjugate and should be greater than 11.5 cm. Measure the bony outlet by pressing your closed fist against the perineum. Compare the previouslymeasured diameter of your fist to the palpable distance between the ischial tuberosities. Greater than 8 cm bituberous (or bi-ischial, or transverse outlet) is considered normal. Feel the ischial spines for their relative prominence or flatness. Spinal prominence narrows the transverse diameter of the pelvis. Feel the pelvic sidewalls to determine whether they are parallel (OK), diverging (even better), or converging (bad). True outlet obstruction is fortunately rare.

X-ray Pelvimetry This technique is primarily of historical interest. It was believed in the past that accurate x-ray measurements of the pelvis would allow for identification of those patients who would have disproportion. X-ray pelvimetry (or CT pelvimetry) allows for reasonably accurate measures of various internal measurements not available to clinical examination. Among these ate the true obstetrical conjugate, transverse diameter of the inlet, and bispinous diameter (transverse diameter of the midpelvis).. In numerous studies since then, the usefulness of x-ray pelvimetry has been discredited to the point that x-ray pelvimetry is rarely performed today. The problem is not that the internal measurements cannot be assessed with reasonable accuracy, but that the measurements rarely have any clinical meaning. Vaginal delivery may still occur (and usually does) despite small measurements. Cesarean section may still be needed even if the internal measurements look acceptable. Finally, the most contracted of pelvises can usually be defined on clinical examination alone. Occasionally, x-ray pelvimetry is still used. One example could be a maternal history of pelvic deformity where the wisdom of allowing a vaginal trial of labor is in question. Estimation of Fetal Weight Estimates of pelvic capacity and shape are only half of the fetopelvic disproportion evaluation. The other half is the estimate of fetal size. Estimates can be made by feeling the mother's abdomen, by ultrasound scan estimates, or by asking the mother how big she believes the fetus is.

Ultrasound estimates of fetal weight are based on formulas that weigh various fetal dimensions (biparietal diameter, abdominal circumference, femur length, etc.), then apply mathematical modeling to come up with an estimated fetal weight. Ultrasound estimates are considered by many to be the most accurate means of predicting fetal weight. Accuracy of ultrasound varies, but its predictions generally come within 10% of the actual birthweight two-thirds of the time, and within 20% of the actual birthweight in 95% of cases. That means that if ultrasound predicts and average-sized, 7 1/2 pound baby, that most of the time (95% of the time), the baby will weigh somewhere between 6 pounds and 9 pounds, and occasionally (5% of the time), the baby will weigh less than 6 pounds or more than 9 pounds. We would all prefer that ultrasound be more consistently reliable in its estimates of fetal weight. Clinical estimates by an experienced examiner, based on feeling the mother's abdomen, are, in some studies, just as accurate as ultrasound (in other words, somewhat reliable). Interestingly, some studies also demonstrate that the mother's guess about her own baby's size is also about as accurate as ultrasound, if she has delivered a baby in the past. If she hasn't, then her estimates are less accurate. Progress of Labor Monitoring the progress of labor is another technique that is used to assess the presence or absence of fetopelvic disproportion. This technique hinges on the belief that if the fetus is too big to come through, there will be an arrest of progress of labor. After confirming that the arrest is not due to other factors (inadquate contractions, for example), and allowing adequate time for the arrest to resolve, fetopelvic disproportion is presumed to be present and operative delivery (usually cesarean section) is undertaken. Many physicians use a "2-hour rule," depending on the clinical circumstances, to allow for active labor to show advancement before resorting to cesarean section. Others have different time frames in mind.

The term 'cephalopelvic disproportion' implies disproportion between the head of the baby ('cephalus') and the mother's pelvis. Complications can occur if the fetal head is too large to pass thorugh the mother's pelvis or birth canal. It is one of the commonest cause of different complications in labor, including prolonged labor, fetal distress, and delayed second stage . Cephalo-pelvic disproportion (CPD) is very frequently diagnosed and is a very common indication of cesarian sections. But it is very difficult to diagnose CPD before a women has started herlabor pains since it is very difficult to anticipate how well the fetal head and the maternal pelvis will adjust and mould to each other. Causes of Cephalopelvic Disproportion (CPD): Increased Fetal Weight: o Very large baby due to hereditary reasons - a baby whose weight is estimated to be above 5 Kgs or 10 pounds . o Postmature baby - when the pregnancy goes above 42 weeks. o Babies of women with diabetes usually tend to be big. o Babies of mothers who have had a number of children - each succeeding baby tends to be larger and heavier. Fetal Position: o Occipito-posterior position - In this position the fetus faces the mothers abdomen instead of her back. o Brow presentation o Face presentation. Problems with the Pelvis: o Small pelvis. o Abnormal shape of the pelvis due to diseases like rickets, osteomalacia or tuberculosis. o Abnormal shape due to previous accidents. o Tumors of the bones. o Childhood poliomyelitis affecting the shape of the hips. o Congenital dislocation of the hips. o Congenital deformity of the sacrum or coccyx. Problems with the Genital tract: o Tumors like fibroids obstructing the birth passage. o Congenital rigidity of the cervix. o Scarring of the cervix due to previous operations like conisation. o Congenital vaginal septum.

Diagnosis of Cephalopelvic Disproportion (CPD) Diagnosis of CPD is very difficult. This is because it is difficult to estimate exactly how much the mother's ligaments and joints will 'give' or relax before labor starts. The fetal head also has a great capacity to mould - the skull bones can overlap to some extent and decrease the diameter of the head. As such a baby who appears to be too big to pass through its mother's birth passage may do so without much problem. A 'trial of labour' should always be given to all women whose pelvis is apparently too small for the baby.

An estimation of the size of the pelvis can be made by two methods: Clinical Pelvimetry: The assessment of the size of the pelvis is made manually by examining the pelvis and palpating the pelvic bones by vaginal examination. It is usually carried out after 37 weeks of pregnancy or at the time of the onset of labor. The entire bony arch of the mother's pelvis, including the sacrum , the sacro-coccygeal joint, the sacrosciatic notch, the ischial spines, the ilio-pectineal lines and the pubic arch are palpated and an assessment of the size of the pelvis made. The diameter of the pelvis is measured with the index and middle fingers of the hand. Radiological Pelvimetry: Xrays or CT scans are taken of the pelvis in different angles and views and the pelvic diameter measured. But this method is not done nowadays as it can cause radiation toxicity to the baby.

Ultrasound: The estimation of the baby's size can be made by ultrasonogram and an assessment of potential CPD can be made when the results are compared with the clinical pelvimetry . Treatment of Cephalopelvic Disproportion (CPD): If the surgeon is absolutely certain that there is cephalopelvic disproportion, then a Cesarian section is the only option to deliver the baby. However women who have an average size baby and and an average sized pelvis or even in women in whom vaginal delivery is doubtful, should always be offered a 'trial of labor'. If, after sufficient time has passed in labor without a delivery, and symptoms of prolonged labor or fetal distress begins to develop, a cesarian section needs to be carried out. Cephalopelvic disproportion (CPD) occurs when a baby's head or body is too large to fit through the mothers pelvis. It is believed that true CPD is rare, but many cases of failure to progress during labor are given a diagnosis of CPD. When an accurate diagnosis of CPD has been made, the safest type of delivery for mother and baby is a cesarean.What causes cephalopelvic disproportion (CPD)? Possible causes of cephalopelvic disproportion (CPD) include: Large baby due to: Hereditary factors Diabetes Postmaturity (still pregnant after due date has passed) Multiparity (not the first pregnancy) Abnormal fetal positions Small Pelvis Abnormally shaped pelvis

How is cephalopelvic disproportion diagnosed (CPD)? The diagnosis of cephalopelvic disproportion is often used when labor progress is not sufficient and medical therapy such as use of oxytocin is not successful or not attempted. CPD can rarely be

diagnosed before labor begins even if the baby is thought to be large or the mothers pelvis is known to be small. During labor, the babys head molds and the pelvis joints spread, creating more room for the baby to pass through the pelvis. Ultrasound is used in estimating fetal size but not totally reliable for determining fetal weight. A physical examination that measures pelvic size can often be the most accurate method for diagnosing CPD. If a true diagnosis of CPD cannot be made, oxytocin is often administered to help labor progresssion or change fetal postioning. What about future pregnancies? Cephalopelvic disproportion is rare. According to the American College of Nurse Midwives(ACNM), CPD occurs in 1 out of 250 pregnancies. If you have been diagnosed with CPD, it does not mean that you will have this problem in future deliveries. According to a study published by the American Journal of Public Health, more than 65 % of women who had been diagnosed with CPD in earlier pregnancies, were able to deliver vaginally in subsequent pregnancies.