Feto Pelvic Disproportion

Feto-Pelvic Disproportion
Cephalopelvic Disproportion
Asheber Gaym M.D.

January 2009
Outline
• Define fetopelvic/cephalopelvic disproportion

• Discuss etiology of fetopelvic disproportion
• Discuss types of female pelvis and their
significance
• List steps of fetal size estimation
• Outline diagnosis of fetopelvic disproportion
• List complications of fetopelvic disproportion
Asheber Gaym,2009 2
Definitions
• Fetopelvic disproportion refers to a discrepancy between the
fetal parts and the bony pelvic dimensions through which it has
to pass during delivery.
• As the structure with large diameters and being the least
pliable, the fetal head is the fetal part often creating
disproportion with the pelvis
• This and the fact that the cephalic presentation is the
commonest presentation makes cephalopelvic disproportion to
be the most important fetopelvic disproportion
• Fetopelvic disproportion can however occur in other
presentations such as the breech and shoulder as well
• Fetopelvic disproportion occurs on an individual basis; i.e. it is
an event that involves a particular fetus with a particular pelvis.
Asheber Gaym,2009 3
Definitions
• The same pelvis that could not pass a particular fetus may
easily deliver a smaller fetus and vice versa. Hence, fetopelvic
disproportion diagnosis always entails the comparison
between two variables at the same time.
• The diagnosis of fetopelvic disproportion often requires the
test of labor to diagnose it. It often cannot be accurately
predicted beforehand. The best pelvimeter is the fetal head;
CPD is often diagnosed with certainty after a trial of labor with
adequate augmentation of inefficient uterine contractions.
• Most diagnoses of CPD are often considered to be inaccurate
as nearly 90% of women whose primary indication for
caesarean section was CPD have a successful VBAC in
subsequent deliveries.
Asheber Gaym,2009 4
Etiology of Fetopelvic Disproportion
Fetal Maternal (Contracted Pelvis)
•Fetal macrosomia •Genetic variations in maternal pelvic size

•Fetal malpresentations- Breech, Face, and shape
Brow ( the same fetus which would have •Pelvic fractures in childhood
been delivered had it been a vertex, •Skeletal deformities leading to pelvic
develops a disproportion in these deformities- poliomyelitis; kyphoscoliosis
positions) •Childhood malnutrition and rickets
•Fetal malpositions- Occipitoposterior – •Congenital pelvic abnormalities- very
the same fetus which would have been rare such as Naegle’s pelvis ( one ala of
delivered if in occipitoanterior fails to be the sacrum is missing) and Robert’s pelvis
delivered in OP positions ( both ala of the sacrum are missing)
•Fetal anomalies- hydrocephalus,
encepalocele
Asheber Gaym,2009 5
Types of Female Pelvis
Female pelvis type Description and importance
Gynecoid pelvis Inlet shaped circular or ovoid with wide transverse and
(woman type anteroposterior diameters; straight or divergent pelvic side
pelvis) walls; flat ischial spines and convex spacious sacral wall
Anthropoid pelvis Inlet wide anteroposterior than its transverse diameter. Other
( ape like pelvis) characteristics the same as gynecoid. Commonly associated with
occipitoposterior positions.
Android pelvis Inlet triangular shaped with both diameters narrow. Side walls
(man like pelvis) are convergent with prominent or spiking spines. Sacrum
concavity is flat or even concave reducing the posterior
dimensions of the pelvis.
Platypelloid pelvis Inlet has a very wide transverse compared with its
anteroposterior diameter.
Mixed pelvic types Most pelvic types are not of any of the above “pure” types but
often have various mixtures of the pure types in their anterior
and posterior segments.
Asheber Gaym,2009 6
Assessment of the Female Pelvis
General physical Clinical Pelvimetry Radiological
exam Pelvimetry
•History of difficult •Performed at term for every mother •Anteroposterior
vaginal delivery with the risk factors indicated in general and lateral X-ray
•History of physical exam views of the pelvis
prolonged labor •Performed for every mother at obtained and the
•History of admission to labor or induction various relevant
operative delivery •Assess the following: diameters
•History of pelvic •Diagonal conjugate- reachability of the measured.
fracture sacral promontory Abandoned from
•Short maternal •Pelvic side walls- convergent or clinical practice as
stature divergent there are no strict
•Kyphoscoliosis •Ischial spines- prominent or flat measurements
•Lower extremity •Sacrum – flat, concave or convex and indicating a pelvis
deformity pushed anteriorly that cannot deliver a
•Sub pubic arch- accommodates two fetus. Diagnosis of
fingers CPD involves the
•Intertuberous space- accommodates the fetus size as well.
four knuckles
Asheber Gaym,2009 7
Methods of Fetal Weight Estimation
Method Description
Maternal estimation of Mother is asked to estimate if current pregnancy feels
fetal weight heavier or lighter than previous babies. Weight is
estimated in reference to previous weight based on her
estimate.
Clinical estimation Fetal weight estimated during abdominal exam based on
the clinician’s experience.
Johnson’s formula Estimated fetal weight= SFH in cms- 11(12) X 155 grams.
Accurate within 375 grams range.
Sonographic estimation Fetal weight is estimated by sonographic machines based
on inbuilt formulas after certain fetal biometric variables
are measured by the sonographer. Accurate to within 300
grams range.
Estimated fetal weight greater than 4500 grams- most protocols suggest a caesarean
delivery assuming that such a large fetal weight cannot be accommodated by even a
capacious pelvis.
Asheber Gaym,2009 8
Diagnosis of Fetopelvic Disproportion
Antepartum diagnosis Intrapartum diagnosis
•Assessment of the female pelvis at term in those at Fetopelvic or CPD is diagnosed
high risk for contracted pelvis during labor follow up by the
•Assessment of fetal weight at term or post term following:
•If a diagnosis of “gross pelvic contracture” or “very •Abnormal labor patterns such
large fetal weight” i.e. > 4500 grams is made then a as secondary arrest of cervical
decision for elective caesarean section can be made. dilatation and protracted
•Gross pelvic contracture signifies an easily dilatation
reachable sacral promontory; highly convergent •Failure of augmentation to
pelvic side walls; prominent ischial spines; flat or correct the abnormal labor
forward sacrum; acute sub pubic arch and a narrow •Failure of descent of
intertuberous diameter that does not allow the four presenting part particularly in
knuckles. Gross contracture is a rare diagnosis. late first stage or second stage
•In most cases either a adequate; capacious or a “ of labor
suspected” or “borderline” pelvic contracture is •Excessive fetal head caput or
diagnosed in which case a trial of labor is allowed so molding
that labor will decide the true pelvic capacity. •Plus a clinical pelvimetry
indicating a contracted pelvic
dimensions
Asheber Gaym,2009 9
Complications of Fetopelvic Disproportion or CPD
Maternal complications Fetal and Neonatal complications
•Prolonged labor •Fetal asphyxia and distress

•Obstructed labor •Neonatal asphyxia
•Infections- chorioamnionitis/ puerperal •Neonatal sepsis
sepsis •Increased stillbirth and neonatal
•PROM mortality
•Cord presentation/prolapse •Birth trauma either following
•Other malpresentations are more spontaneous or operative delivery
common in gross CPD due to failure of •Malpresentations and related
descent and engagement of the fetal head complications
into the pelvis resulting in unstable lie
•Increased operative vaginal delivery
•Increased caesarean delivery
•Genital trauma
•Post partum hemmorhage
Asheber Gaym,2009 10

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Feto-Pelvic Disproportion

Asheber Gaym M.D.

• Define fetopelvic/cephalopelvic disproportion

•Fetal macrosomia •Genetic variations in maternal pelvic size

•Prolonged labor •Fetal asphyxia and distress

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