Page 3 : Pelvis, Anteroposterior, Pelvic inlet, 11, Pelvic cavity, 12, , Pelvic Outlet, , 13, , Diameter ( cm), Oblique, Transverse, 12, 12, , 13, 12, , 12, , 11

Page 4 : CEPHALO PELVIC, DISPROPORTION, and, CONTRACTED PELVIS

Page 6 : • Cephalo pelvic disproportion is the disparity in, relation between the head of baby and the mother’s, pelvis., , • It is a pelvis in which one or more of its diameter is, reduced below the normal by one or more, centimeter

Page 7 : • It is based on clinical findings and pelvimetry:-, , a) Severe disproportion:- when the obstetric, conjugate is less than 7.5 cm (3”) then it is said to be, severe disproportion., , a) Borderline disproportion:- when the obstetric, conjugate is between 9.5 and 10 cm. In inlet, the, anterior posterior diameter is less than 10 cm and, transverse diameter is less than 12 cm.

Page 8 : • Nutritional deficiency, • Disease / injury to pelvic bones, • Developmental defects, , • A large size baby, • Abnormal fetal position, • Problem with genital tract

Page 9 : Absolute causes:- it is a true mechanical obstruction, due to:❖ Permanent maternal cause such as contracted, pelvis, anterior sacrococcygeal tumor., ❖ Temporary fetal causes such as hydrocephalus,, large baby etc., Relative cause:- the relative cause includes brow, presentation, face presentation, mento posterior,, occipito posterior position, deflexed head in vertex, presentation

Page 10 : CONTRACTED, PELVIS

Page 11 : • Anatomical - It is a pelvis in which one or more of, its diameters is reduced below the normal by one or, more centimeters., • Obstetric - It is a pelvis in which one or more of, its diameters is reduced so that it interferes with the, normal mechanism of labor.

Page 12 : • Common causes of contracted pelvis are:❖Nutritional and environmental defects:minor variation;- common, major :- rachitic and osteomalacic –rare, ❖ Disease or injury affecting the bone of the, pelvis:- fracture ,tumors, tubercular arthritis., spine:- kyphosis, scoliosis, coccygeal deformity, lower limbs:- poliomyeitis, hip joint disease, ❖ Developmental defects:- naegele’s pelvis,, robert’s pelvis, (low or high assimilation)

Page 13 : Classified by:• A) type of distortion of pelvic architecture, • B) degree of contraction

Page 14 : A) Classification by Pelvic Architecture, 1. Pelvis aequabiliter justo minor, • Characterized by general reduction of all diameters;, equally shortened usually by 1-2cm, • Occurs in short. Also occurs in women with massive, skeletal bones and developed muscles, the pelvis has, masculine features such as narrow sacrum, narrow, pubic outlet {funnel-shaped)

Page 16 : 2. Flat Pelvis, • reduced anteroposterior diameters with normal, transverse and oblique diameters, • Has 2 types of contracture, a) Simple flat (or platypellic) pelvis, , Entire sacral platform is dislocated toward the, symphysis hence all the anteroposterior, diameters of all pelvic planes are reduced

Page 18 : b) Flat rachitic, , Anteroposterior diameter of the pelvic inlet, only is reduced, 3. Generally Contracted Pelvis, • All diameters reduced, but the anteroposterior, diameters are shortened greater then the, others, • Usually connected with rickets of the childhood

Page 20 : Rare forms of contracted pelvis, • Otto’s pelvis – develop as result of inflammatory, process in the hip or knee, • Beaked (rostrate) pelvis – under development of, both sacral wings, • Spondylolithetic pelvis – formed due to partial, dislocation of last lumbar vertebra in front of 1st, sacral vertebra, • Osteomalacic pelvis, • Scoliotic pelvis – only the lumber region cause, deformity of the pelvis. The acetabulum is pushed, inwards on the weight bearing side.

Page 22 : B) Classification by degree of contracture, ❑ 4 degrees, i. First degree: true conjugate <11cm but not, <9cm, spontaneous delivery is possible, ii. Second degree:, true conjugate = 9-7.5cm, spontaneous delivery possible but complications, may arise, iii. Third, degree:, true, conjugate, 7.5-6cm, spontaneous delivery impossible, use C-section, iv. Fourth degree: true conjugate <6cm, impossible, delivery, only way is C-section ; also known as, absolutely contracted pelvis

Page 23 : Diagnosis, A. History, • Rickets: is expected if there is a history of delayed, walking and dentition., • Trauma or diseases: of the pelvis, spines or lower, limbs., • Previous tuberculosis of bones and joints

Page 24 : • Bad obstetric history: e.g. prolonged labour, ended by;, ▫ difficult forceps,, ▫ caesarean section or, ▫ still birth., ❖Weight of the baby,, ❖Evidence of maternal injuries such as complete, perineal tear, vesico vaginal fistula, recto vaginal, fistula

Page 25 : B. General examination, ✓ dystocia dystrophia syndrome: Abnormal, gait :❖ Assess woman for stockily built with bull neck., ❖ Broad shoulder and short thigh, ❖ Obese and male distribution of hair, ❖ Sub fertile with menstrual abnormalities, ❖ Android pelvis type, ✓Stature :women < 150 cm or 5 feet

Page 26 : C. Abdomen examination, Inspection:, pointed abdomen in primigravida and Pendulous in, multi-parous women, Obstetrical:, ✓fetal head fails to enter a contracted pelvis at the, end of pregnancy and floats high above inlet, failed, growth of uterus deviates upward and anteriorly., ✓Non engagement in last 3-4 wks in primigravida

Page 27 : ✓2 shapes of abdomen, • Acuminate (pointed)abdomen in primigravida, with a resilient abdominal wall, • Pendulous abdomen in multi-parous women

Page 29 : • Patient is placed in dorsal position with thigh flexes, and separated., • The head is grasped by the left hand., • 2 fingers (index and middle) of the right hand are, placed above the symphysis pubis to note the degree, of overlapping, when the head is pushed downward, and backward.

Page 31 : • The head can be pushed down in the pelvis without, overlapping of the parietal bone on the symphysis, pubis:- no disproportion, , • Head can be pushed down a little but there is, slightly overlapping of the parietal bone evidence, by touch on the under surface of finger overlapping, by 0.5cm:- moderate disproportion

Page 32 : • Head can not be pushed down and instead the, partial bone overhangs the symphysis pubis, displacing the finger – sever disproportion, , Some times the degree of disproportion is difficult, to found by this method because of:• Deflexed head, • Thick abdominal wall, • Irritable uterus, • High floating head

Page 33 : • It is also called as MULLER – MUNRO KERR, • It is bimanual method.

Page 34 : Results :• the head can be pushed down up to the level of, ischial spines and there is no overlapping of the, parietal bone over the symphysis pubis:- no, disproportion, • The head can be pushed down a little but not up, to the level of ischial spine and there is slight, overlapping of the parietal bone:- slight or, moderate disproportion, • The head can not be pushed down and instead, the parietal bone overhangs the symphysis pubis, displacing the thumb:- sever disproportion.

Page 35 : D. Pelvimetry, • It is assessment of the pelvic diameters and capacity, done at 38-39 weeks. It includes:, • Clinical pelvimetry:, ▫ Internal pelvimetry for:,  inlet,,  cavity, and,  outlet., , ▫ External pelvimetry for:,  inlet and,  outlet., , • Imaging pelvimetry:, ▫ X-ray., ▫ Computerised tomography (CT)., ▫ Magnetic resonance imaging (MRI) .

Page 38 : Disproportion, , Moderate, degree, , Sever degree

Page 39 : Preterm, labor, , Induction of, labor, , Term, labor, , Cesarean, section, , Trial labor

Page 40 : • Elective cesarean section at term is indicated in:❖Major degree of contraction, ❖Major disproportion, ❖Absolute contraction, ❖Dead fetus, ❖Patient not fit for trial labor, The operation is done in planned way any time, during last week of pregnancy., • Emergency:when trial labor is failed

Page 41 : Trial labor:• It is the conduction of spontaneous labor in a, moderate degree of disproportion, in an, institution under supervision with watchful, expectancy hoping for a vaginal delivery, or, Trial of labor is a test of labor allowing the patient, to enter into active labor putting all variable, ( power, passage and passenger) into test and, determine whether vaginal delivery is possible or, not.

Page 42 : ❖Careful fetal and maternal monitoring by, electronic fetal monitoring and non stress test, ❖Oral feeding remain suspended and hydration is, maintained by intravenous drip, ❖Adequate analgesic is administered, ❖Augmentation of labor by pitocin

Page 43 : ❖The progress of labor is mapped with partograph:i) progressive descent of the head, ii) progressive dilatation of the cervix, ❖After the membrane rupture, pelvic examination is, to be done:i) to exclude cord prolapse, ii) to note the color of liquor, iii) to assess the pelvis once or more, iv) to note the condition of the cervix, including pressure of the presenting part of the, cervix

Page 44 : ❖ in favorable cases, end spontaneously, low forceps and low, ventouse., , ❖In unfavorable cases, do caesarean section., Successful trial:-, , A trial is called successful, if a healthy baby is born, vaginally, spontaneous or by forceps or ventouse with the, mother in good condition, Failure of trial labor:Delivery is by cesarean section or delivery of a dead, baby spontaneously or by craniotomy is called failure of trial, labor

Page 45 : • Lower incidence of cesarean section., • A successful trial ensures the women a good, future obstetrics.

Page 46 : • May end before full cervix dilatation, • Increased fetal mortality and morbidity, , • In failed trial operative risk increases.

Page 47 : •, •, •, •, , Check vitals every 4 hourly, Monitor both contraction and fetus continuously, Report immediately the sign of fetal distress, Position the mother in ways to increase the pelvic, diameter such as sitting or squatting which increase, the outlet diameter and also aid in fetal descent, • Assess the fetus for hypoxia, • Provide support to the client and the family, members in coping with stress of a complicated, labor

Page 48 : Complications of Contracted Pelvis, • Maternal:, During pregnancy:, > Incarcerated retroverted gravid uterus., > Malpresentations., > Pendulous abdomen., > Nonengagement., > Pyelonephritis especially in high assimilation, pelvis due to more compression of the ureter.

Page 49 : www.freelivedoctor.com, , Complications of Contracted Pelvis, During labour:, >Inertia, slow cervical dilatation and prolonged, labour., > Premature rupture of membranes and cord, prolapse., > Obstructed labour and rupture uterus., > Necrotic genito-urinary fistula., > Injury to pelvic joints or nerves from difficult, forceps delivery., > Postpartum haemorrhage.

Page 50 : First stage, , Fetal, distress, , Prolonged, labor