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Contracted Pelvis,[object Object],www.freelivedoctor.com,[object Object]
Contracted Pelvis,[object Object],Definition:,[object Object],Anatomical definition: It is a pelvis in which one or more of its diameters is reduced below the normal by one or more centimeters.,[object Object],Obstetric definition: It is a pelvis in which one or more of its diameters is reduced so that it interferes with the normal mechanism of labour.,[object Object],www.freelivedoctor.com,[object Object]
Factors influencing the size and shape of the pelvis:,[object Object],* Developmental factor: hereditary or congenital.,[object Object],* Racial factor.,[object Object],* Nutritional factor: malnutrition results in small pelvis.,[object Object],* Sexual factor: as excessive androgen may produce android pelvis.,[object Object],* Metabolic factor: as rickets and osteomalacia.,[object Object],* Trauma, diseases or tumours of the bony pelvis, legs or spines.,[object Object],www.freelivedoctor.com,[object Object]
Aetiology of Contracted Pelvis,[object Object],a.Causes in the pelvis,[object Object], Developmental (congenital):,[object Object],> Small gynaecoid pelvis (generally contracted pelvis).,[object Object],>Small android pelvis.,[object Object],>Small anthropoid pelvis,[object Object],> Small platypelloid pelvis (simple flat pelvis).,[object Object],>Naegele’s pelvis: absence of one sacral ala,[object Object],>Robert’s pelvis: absence of both sacral alae.,[object Object],>High assimilation pelvis: The sacrum is composed of 6 vertebrae.,[object Object],>Low assimilation pelvis: The sacrum is composed of 4 vertebrae.,[object Object],>Split pelvis: splittedsymphysis pubis.,[object Object],www.freelivedoctor.com,[object Object]
Aetiology of Contracted Pelvis,[object Object],a.Causes in the pelvis,[object Object],Metabolic:,[object Object],> Rickets.,[object Object],> Osteomalacia (triradiate pelvic brim).,[object Object],Traumatic: as fractures.,[object Object],Neoplastic: as osteoma.,[object Object],www.freelivedoctor.com,[object Object]
Aetiology of Contracted Pelvis,[object Object],b.Causes in the spine,[object Object], * Lumbar kyphosis.,[object Object],* Lumbar scoliosis.,[object Object],* Spondylolisthesis: The 5th lumbar vertebra with the above vertebral column is pushed forward while the promontory is pushed backwards and the tip of the sacrum is pushed forwards leading to outlet contraction.,[object Object],www.freelivedoctor.com,[object Object]
Aetiology of Contracted Pelvis,[object Object],c.Causes in the lower limbs,[object Object],* Dislocation of one or both femurs.,[object Object],* Atrophy of one or both lower limbs.,[object Object],     >N.B. oblique or asymmetric pelvis: one oblique diameter is obviously shorter than the other. This can be found in:,[object Object],* Naegele’s pelvis.,[object Object],* Scoliotic pelvis.,[object Object],* Diseases, fracture or tumours affecting one side.,[object Object],www.freelivedoctor.com,[object Object]
Diagnosis of Contracted Pelvis,[object Object],History,[object Object], * Rickets: is expected if there is a history of delayed walking and dentition. ,[object Object],* Trauma or diseases: of the pelvis, spines or lower limbs.,[object Object],* Bad obstetric history: e.g. prolonged labour ended by;,[object Object],difficult forceps,,[object Object],caesarean section or,[object Object],still birth.,[object Object],www.freelivedoctor.com,[object Object]
Diagnosis of Contracted Pelvis,[object Object],Examination,[object Object],General examination:,[object Object],>Gait: abnormal gait suggesting abnormalities in the pelvis, spines or lower limbs.,[object Object],> Stature: women with less than 150 cm height usually have contracted pelvis.,[object Object],> Spines and lower limbs: may have a disease or lesion.,[object Object],www.freelivedoctor.com,[object Object]
Diagnosis of Contracted Pelvis,[object Object],Examination,[object Object],General examination:,[object Object],>Manifestations of rickets as:,[object Object],     * square head,,[object Object],     *rosary beads in the costal ridges.,[object Object],     * pigeon chest,,[object Object],     * Harrison’s sulcus and bow legs.,[object Object],  > Dystociadystrophia syndrome: the woman is,[object Object],      *short,,[object Object],      *stocky,,[object Object],      * subfertile,,[object Object],      *has android pelvis and,[object Object],       *masculine hair distribution,  ,[object Object],       * with history of delayed menarche.,[object Object],       * This woman is more exposed to occipito-posterior position and dystocia.,[object Object],www.freelivedoctor.com,[object Object]
Diagnosis of Contracted Pelvis,[object Object],Abdominal examination:,[object Object],[object Object]
 Pendulous abdomen: in a primigravida.
Malpresentations: are more common.www.freelivedoctor.com,[object Object]
Diagnosis of Contracted Pelvis,[object Object],Pelvimetry: It is assessment of the pelvic diameters and capacity done at 38-39 weeks. It includes:,[object Object],1.Clinical pelvimetry:,[object Object],A.Internalpelvimetry for:,[object Object],> inlet,,[object Object],>cavity, and,[object Object],> outlet.,[object Object],B.Externalpelvimetry for:,[object Object],> inlet and ,[object Object],>outlet.,[object Object],www.freelivedoctor.com,[object Object]
Diagnosis of Contracted Pelvis,[object Object],Pelvimetry:,[object Object],2.Imaging pelvimetry:,[object Object],> X-ray.,[object Object],>Computerised tomography (CT).,[object Object],> Magnetic resonance imaging (MRI) .,[object Object],N.B. CT and MRI are recent and accurate but expensive and not always available so they are not in common use.),[object Object],www.freelivedoctor.com,[object Object]
Internal pelvimetry,[object Object],Internal pelvimetry (is done through vaginal examination): ,[object Object],1. The inlet:,[object Object],a.Palpation of the forepelvis (pelvic brim):,[object Object],b. The index and middle fingers are moved along the pelvic brim. Note whether it is round or angulated, causing the fingers to dip into a V-shaped depression behind the symphysis.,[object Object],c. Diagonal conjugate: >Try to palpate the sacral promontory to measure the diagonal conjugate. Normally, it is 12.5 cm and cannot be reached. If it is felt the pelvis is considered contracted and the true conjugate can be calculated by subtracting 1.5 cm from the diagonal conjugate .This assessment is not done if the head is engaged.,[object Object],www.freelivedoctor.com,[object Object]
Internal pelvimetry,[object Object],2.The cavity:,[object Object],a.Height, thickness and inclination of the symphysis.,[object Object],b. Shape and inclination of the sacrum.,[object Object],c. Side walls: >To determine whether it is straight, convergent or divergent starting from the pelvic brim down to the base of ischial spines in the direction of the base of the ischialtuberosity. Then relation between the index and middle finger of the base of ischial spines and the thumb of the other hand on the ischialtuberosityisdetected. If the thumb is medial the side wall is convergent and if lateral it is divergent.,[object Object],www.freelivedoctor.com,[object Object]
Internal pelvimetry,[object Object],2.The cavity:,[object Object],d.Ischial spines:,[object Object],> Whether it is blunt (difficult to identify at all), prominent (easily felt but not large) or very prominent (large and encroaching on the mid-plane).,[object Object],>The ischial spines can be located by following the sacrospinous ligament to its lateral end.,[object Object],www.freelivedoctor.com,[object Object]
Internal pelvimetry,[object Object],2.The cavity:,[object Object],e. Interspinous diameter: By using the 2 examining fingers, if both spines can be touched simultaneously, the interspinous diameter is £ 9.5 cm i.e. inadequate for an average-sized baby.,[object Object],f. Sacrosciatic notch:> If the sacrospinous ligament is two and half fingers, the sacrosciatic notch is considered adequate.,[object Object],www.freelivedoctor.com,[object Object]
Internal pelvimetry,[object Object],3.The outlet:,[object Object],a. Subpubic angle:> Normally, it admits 2 fingers.,[object Object],b.Bituberous diameter:>Normally, it admits the closed   fist of the hand (4 knuckle).,[object Object],c.Mobility of the coccyx:> by pressing firmly on it while      an external hand on it can determine its mobility.,[object Object], d. Anteroposterior diameter of the outlet:> from the tip of      the sacrum to the inferior edge of the symphysis.,[object Object],www.freelivedoctor.com,[object Object]
www.freelivedoctor.com,[object Object]
External pelvimetry,[object Object],It is of little value as it measures diameters of the false pelvis.,[object Object],Thom’s, Jarcho’s or crossing pelvimeter can be used for external pelvimetry.,[object Object],* Interspinous diameter (25cm): between the anterior superior iliac spines.,[object Object],* Intercrestal diameter (28 cm): between the most far points on the outer borders of the iliac crests.,[object Object],* External conjugate (20 cm).,[object Object],* Bituberous diameter: can be measured by pelvimeter.,[object Object],www.freelivedoctor.com,[object Object]
Radiological pelvimetry,[object Object],It is indicated mainly in borderline pelvic contraction.,[object Object],*Lateral view: The patient stands with the X-ray tube on one side and the film cassette on the opposite side.,[object Object],> It is the most important view as it shows the anteroposterior diameters of the pelvis, angle of inclination of the brim, width of sacrosciatic notch, curvature of the sacrum and cephalo-pelvic relationship.,[object Object],* Inlet view: The patient sits on the film cassette and leans backwards so that the plane of the pelvic brim becomes parallel to the film.,[object Object],* Outlet view: The patient sits on the film cassette and leans forwards.,[object Object],www.freelivedoctor.com,[object Object]
Cephalometry,[object Object],* Ultrasonography: is the safe accurate and easy method and can detect:,[object Object],[object Object]
 The occipito-frontal diameter.
The circumference of the head. * Radiology (X-ray): is difficult to interpret.,[object Object],www.freelivedoctor.com,[object Object]
Cephalopelvic disproportion tests,[object Object],These are done to detect contracted inlet if the head is not engaged in the last 3-4 weeks in a primigravida.,[object Object],(1) Pinard’s method:,[object Object], >The patient evacuates her bladder and rectum.,[object Object],>The patient is placed in semi-sitting position to bring the foetal axis perpendicular to the brim.,[object Object],>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.,[object Object],www.freelivedoctor.com,[object Object]
Cephalopelvic disproportion tests,[object Object],(2) Muller - Kerr’s method:,[object Object],>It is more valuable in detection of the degree of disproportion.,[object Object],> The patient evacuates her bladder and rectum.,[object Object],>The patient is placed in the dorsal position.,[object Object],>The left hand pushes the head into the pelvis and vaginal examination is done by the right hand while its thumb is placed over the symphysis to detect disproportion.,[object Object],www.freelivedoctor.com,[object Object]
Degrees of Disproportion,[object Object],1.Minor disproportion:,[object Object],     > The anterior surface of the head is in line with the posterior surface of the symphysis. During labour the head is engaged due to moulding and vaginal delivery can be achieved.,[object Object],2.Moderate disproportion (1st degree disproportion):>The anterior surface of the head is in line with the anterior surface of the symphysis. Vaginal delivery may or may not occur.,[object Object],3. Marked disproportion (2nd degree disproportion):,[object Object],     >The head overrides the anterior surface of the symphysis. Vaginal delivery cannot occur.,[object Object],www.freelivedoctor.com,[object Object]
Degrees of Contracted Pelvis,[object Object],1. Minor degree: The true conjugate is 9-10 cm. It corresponds to minor disproportion.,[object Object],2.Moderate degree: The true conjugate is 8-9 cm. It corresponds to moderate disproportion.,[object Object],3.Severe degree: The true conjugate is 6-8 cm. It corresponds to marked disproportion.,[object Object],4.Extreme degree: The true conjugate is less than 6 cm. Vaginal delivery is impossible even after craniotomy asthebimastoid diameter (7.5 cm) is not crushed.,[object Object],www.freelivedoctor.com,[object Object]
Mechanism of Labour in Contracted Pelvis,[object Object],The Flat Rachitic Pelvis:Characters,[object Object],1. Inlet: reduced antero-posterior diameter.,[object Object],2. The pelvic inclination: is exaggerated due to increased lumbar lordosis.,[object Object],3.The sacrum has the following characters:,[object Object], > The promontory is pushed forwards so the tip is pushed backwards.,[object Object], >Diminished or obliterated concavity.,[object Object], > Bent at the middle may be present.,[object Object],www.freelivedoctor.com,[object Object]
Mechanism of Labour in Contracted Pelvis,[object Object],The Flat Rachitic Pelvis,[object Object],Characters,[object Object],4.The outlet has the following characters:,[object Object],> Increased antero-posterior diameter.,[object Object],> Increased bituberous diameter.,[object Object],5. The interspinous equal the intercrestal diameter.,[object Object],www.freelivedoctor.com,[object Object]
Mechanism of labour:,[object Object],a.Engagement: with the sagittal suture in the transverse diameter.,[object Object],b.Asynclitism with anterior parietal bone presentation so that the shorter subparietalsupraparietal diameter (9cm) is passed instead of the biparietal (9.5cm) in the narrow true conjugate.,[object Object],c. Lateral displacement of the head so that the bitemporal diameter is passed through the narrow true conjugate ,[object Object],www.freelivedoctor.com,[object Object]
Mechanism of labour:,[object Object],d. Deflexion of the head as the descent of the occiput is resisted by the lateral pelvic wall .,[object Object],e.Correction of the asynclitism and deflexion with further descent of the head.,[object Object],f. Rotation of the occiput 2/8 circle anteriorly and the head is delivered easily due to wide outlet.,[object Object],www.freelivedoctor.com,[object Object]
Simple Flat Pelvis,[object Object],Characters:,[object Object],> Reduced antero-posterior diameters of the inlet, cavity and outlet.,[object Object],> No rachitic manifestations.,[object Object],www.freelivedoctor.com,[object Object]
Simple Flat Pelvis,[object Object],Mechanism of labour:,[object Object],The process passes as flat rachitic pelvis till the mid cavity where internal rotation and further descent cannot occur due to persistence of flattening of the pelvis and contracted outlet. So deep transverse arrest is common and vaginal delivery is obstructed.,[object Object],www.freelivedoctor.com,[object Object]
Contracted Outlet (Funnel Pelvis),[object Object],Characters:,[object Object], * The pelvic capacity is diminished from the inlet to the outlet.,[object Object],* Subpubic angle is acute.,[object Object],* Convergent side walls. ,[object Object],* Bituberous diameter is 8 cm or less.,[object Object],www.freelivedoctor.com,[object Object]
Contracted Outlet (Funnel Pelvis),[object Object],Causes:,[object Object], * Android pelvis.,[object Object],* Anthropoid pelvis.   ,[object Object],* Osteomalacia.  ,[object Object],* High assimilation pelvis.,[object Object],* Spondylolisthesis.,[object Object],* Oblique pelvis.               ,[object Object],* 20% of generally contracted pelvis.,[object Object],www.freelivedoctor.com,[object Object]
Mechanism of labour:,[object Object],* Normal descent and engagement as the pelvic inlet is normal.,[object Object],*Extreme flexion and moulding of the head at the level of the jutting ischial spines.,[object Object],*Because of the narrow subpubic angle, the head is pushed backwards with more liability to perineal tears.,[object Object], * In case of occipito-posterior, the funnel pelvis interferes with long anterior rotation so persistent occipito-posterior and deep transverse arrest are common. The face to pubis position is more favourable as it brings the short bitemporal diameter in the narrow subpubic angle.,[object Object],www.freelivedoctor.com,[object Object]
Management:,[object Object],It depends on Thom’s dictum:,[object Object],* If the sum of bituberous + posterior sagittal is >15 cm and bituberous diameter is >8cm: vaginal delivery is allowed with episiotomy and low forceps.,[object Object], * If the Thom’s dictum is <15 cm or the bituberous diameter is <8cm: caesarean section is performed.,[object Object],* Symphysiotomy: may be done in distant areas with no facilities for C.S. and the foetus is living.,[object Object],www.freelivedoctor.com,[object Object]
Management of Contracted Pelvis,[object Object],It depends mainly on the degree of disproportion.,[object Object],* Minor disproportion (minor degree of contracted pelvis): vaginal delivery.,[object Object],* Moderate disproportion (moderate degree of contracted pelvis): trial labour, if failed ® caesarean section.,[object Object],* Marked disproportion (severe or extreme degree ofcontracted pelvis): caesarean section.,[object Object],www.freelivedoctor.com,[object Object]
Trial of Labour,[object Object],It is a clinical test for the factors that cannot be determined before start of labour as:,[object Object],* Efficiency of uterine contractions.,[object Object],* Moulding of the head.,[object Object],* Yielding of the pelvis and soft tissues.,[object Object],www.freelivedoctor.com,[object Object]
Procedure:,[object Object],* Trial is carried out in a hospital where facilities for C.S is available.,[object Object],* Adequate analgesia.,[object Object],* Nothing by mouth.,[object Object],* Avoid premature rupture of membranes by:,[object Object],> rest in bed,,[object Object],> avoid high enema,,[object Object],>minimise vaginal examinations.,[object Object],* The patient is left for 2 hours in the 2nd stage with good uterine contractions under close supervision to the mother and foetus,[object Object],www.freelivedoctor.com,[object Object]
Suitable cases for trial of labour:,[object Object],* Young primigravida of good health.,[object Object],* Moderate disproportion.,[object Object],* Vertex presentation.,[object Object], * No outlet contractions.,[object Object],* Average sized baby.,[object Object],www.freelivedoctor.com,[object Object]
Termination of trial of labour:,[object Object],* Vaginal delivery:> either spontaneously or by forceps if the head is engaged.,[object Object],* Caesarean section if:> failed trial of labour i.e. the head did not engage or,[object Object],    >complications occur during trial as foetal distress or prolapsed pulsating cord before full cervical dilatation.,[object Object],www.freelivedoctor.com,[object Object]

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Normal and abnormal puerperiumNormal and abnormal puerperium
Normal and abnormal puerperium
 
Version
VersionVersion
Version
 
Vacuum extraction (ventouse)
Vacuum extraction (ventouse)Vacuum extraction (ventouse)
Vacuum extraction (ventouse)
 
Symphysiotomy
SymphysiotomySymphysiotomy
Symphysiotomy
 
Forceps delivery
Forceps deliveryForceps delivery
Forceps delivery
 
Episiotomy
EpisiotomyEpisiotomy
Episiotomy
 
Caesarean section
Caesarean sectionCaesarean section
Caesarean section
 
Normal labour
Normal labourNormal labour
Normal labour
 
Anatomy of the foetal skull
Anatomy of the foetal skullAnatomy of the foetal skull
Anatomy of the foetal skull
 
Anatomy of the female pelvis
Anatomy of the female pelvisAnatomy of the female pelvis
Anatomy of the female pelvis
 
Active management of normal labour
Active management of normal labourActive management of normal labour
Active management of normal labour
 
Thyrotoxicosis in pregnancy
Thyrotoxicosis in pregnancyThyrotoxicosis in pregnancy
Thyrotoxicosis in pregnancy
 

Contracted pelvis

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