CEPHALOPELVIC

DISPROPORTION
DEFINITION
◦ CPD is apregnancy complication where there is mismatch between the
maternal pelvis and the fetal head.
◦ This can delay labour and can make vaginal delivery impossible or associated
with danferous complications
◦ The mother’s pelvis is either too small or the fetal head is too large
CAUSES
◦ Macrosomia
◦ Abnormal fetal position
◦ Contracted pelvis
when one or more dimensions of the pelvis is reduced by 1cm or
more
◦ Abnormal pelvic shape
Aetiology of contracted pelvis
◦ Contracted gynaecoid, android, anthropoid or plattypelloid pelvis, high and low assimilation
pelvis, naegeles pelvis, Roberts pelvis
◦ Metabolic eg rickets
◦ Traumatic
◦ Neoplastic
◦ Infection
◦ Lumber kyphosis, scoliosis, spondylolisthesis
◦ Dislocation of one or both femurs
◦ Atrophy of one or both lower limbs
Clinical features
◦ Chronic disease affecting spine, hip or lower limbs
◦ BOH, difficult delivery, prolonged labour, cs, still bith
◦ Gait
◦ Height, 150cm
◦ Spine and lower limbs
◦ Non engagement of head after 37weeks in primigravida
◦ Pendulous abdomen
◦ malpresentation
Assessment
◦ Clinical pelvimetry
◦ Radiological pelvimetry
◦ Ultrasound measurement of BPD. OFD,HC
◦ CPD tests, pinard method, muller-kerr method
management
◦ Mainly depends on the degree
◦ Minor. Vaginal delivery
◦ Moderate- trail of labour, if fails then cs
◦ Major- cs
Trial of labour
◦ Done for moderate cpd to see if good contractions and moulding can help
overcome the disproportion
◦ Done for young primigravida with good health
◦ Vertex presentation
◦ Moderate disproportion
◦ Normal outlet
◦ Average size baby
How is it done?
◦ Carried out in a hospital setting where emergency cs can be done
◦ Adequate analgesia in labour
◦ Nil per os
◦ Avoid early rupture of membranes
◦ Give up to 2 hours for 2nd stage if condition of both mother and baby is stable
complications
Maternal fetal

◦ Retroverted gravid uterus impacted ◦ Intracranial hemoorhage

◦ Malpresentation ◦ Asphyxia
◦ Cord prolapse ◦ Skull fracture
◦ Nerve injuries ◦ sepsis
◦ Obstructed labour
OBSTRUCTED
LABOUR
 Definition

◦ Obstructed labour is said to occur when there is lack of

progress of labour (particularly descent of the presenting
part) despite adequate uterine contractions, from a
mechanical cause.
 Why Obstructed Labour?

◦ It is one of the leading causes of maternal mortality

worldwide
◦ It causes significant morbidity to the patient and her infant
if they survive
 Why Obstructed Labour?

◦ Obstructed labour is almost non existent in other parts of

the world now, due to good antenatal care and supervised
deliveries - meaning it can be prevented.

◦ Prevention is well within our ability to implement, given

the progress we have made so far in building capacity.
epidemiology
◦ Prevalence about 2-8% worldwide

◦ Obstructed labour is responsible for 8% of all maternal mortalities worldwide

◦ 8% of patients who develop develop obstructed labour will die from it.
Pathophysiology
Obstructed labour usually occurs in patients who are non
attendants or poor attendants at ANC

History of unsupervised labour in a spiritual home or with an

untrained birth assistant.

They may also be seen after failed attempts at operative

vaginal delivery

There is dehydration from inadequate fluid intake

Increased muscular activity leading to release and

accumulation of lactic acid.
Urine is scanty and highly concentrated

Catabolism of fat leads to increased acidosis from production

of ketone bodies.

Birth canal infection due to multiple vaginal examinations

Distended abdomen from bowel atony due to hypokalemia,

bladder distension from the fetal head acting as a tamponade

Prolonged impaction of the fetal head on the bladder and rectum may lead to
necrosis and fistulas either between the vagina and bladder (vesicovaginal fistulae or
rectovaginal fistulae.
Risk Factor – Passage ◦ Soft passage
1. Tumors
◦ Bony passage
2. Uterine eg. Impacted subserous,
1. Inadequate pelvis pedunculated or lower segment
2. Android pelvis fibroids, constriction ring at the
neck of the uterus
3. Platypelloid pelvis
3. Cervix: cervical dystocia, cervical
4. Anthropoid pelvis
fibroids
4. Vagina: septa, stenosis,
5. Ovaries: Impacted ovarian
tumours
6. Genital lacerations (FGM)
7. Acquired gynaetresia
Risk Factor – Passenger
◦ Foetal macrosomia ◦ Congenital abnormalities
◦ Malpresentation/ malposition ◦ Hydrocephalous
◦ ◦ Fetal ascites
Persistent occipito-posterior position
◦ deep transverse arrest ◦ Double monsters
◦ persistent mento - posterior position ◦ Cystic hygroma
◦ ◦ Locked twins
brow
◦ shoulder dystocia
◦ impacted frank breech
 ◦ The diagnosis is mainly clinical
Diagnosis ◦ History
◦ Physical Examination
 ◦ Non attendant or poor attendants at ANC

◦ Unsupervised labour In a spiritual home or with

an untrained birth assistant. They may also be

History seen after failed attempts at operative vaginal

delivery

◦ Frequent and strong uterine contractions

◦ Ruptured membranes
 Physical Examination - Maternal
Vaginal
General Abdominal examination
examination
examination
• In the nullip, the uterus is hard
and tender, its goes into tetanic • Vulva is edematous
contraction over a prolonged • Vagina is dry and
• Maternal period and contractions cease. hot
distress Uterine rupture is not very • Cervix: may be
• Exhaustion common. fully or partially
• In the multip, there are tetanic dilated and
• Pyrexia oedematous
• Tachycardia contractions which result in a
Bandyl’s ring forming with • Membranes
• Dehydration susbsequent uterine rupture if ruptured
there is no timely intervention.
• Bladder is distended
Physical Examination - Foetal
◦ FH may be present if in early stages of obstruction or
absent if obstruction has been prolonged OR uterus is
ruptured.

◦ Fetal parts not easily felt if uterus is not ruptured, but may
be easily palpable if uterus is ruptured
Management – General Principles
◦Resuscitate
◦Analgesia
◦Definitive management
Resuscitation
◦ Airway, Breathing, Circulation
◦ IV line with 2 wide bore cannulae
◦ Laboratory investigations
◦ FBC, GXM, BUE Cr, Blood CS, ABG’s, ECS, HVS RE & CS,
◦ Hydrate adequately: Monitor CVP (normal range between 5 – 8
cm of water or higher)
◦ Broad spectrum antibiotics
◦ Pass urethral catheter (Foley catheter)
◦ NG tube
◦ Antitetanus serum
 After the patient is
adequately resuscitated, a
balanced decision is made
on the best mode of delivery.

Management -
Definitive
Options available are:
• Abdominal delivery
• Operative vaginal delivery
 ◦ INDICATIONS
◦ Uterine rupture
◦ Live fetus
◦ Surgeon unskilled in operative vaginal
techniques, even if the fetus is dead
Abdominal
delivery
◦ It is worth noting that Caesarean
delivery may be difficult and it would
be good to inform a senior obstetrician
before proceeding.
Post Operative Management
◦ Broad spectrum antibiotics
◦ Adequate analgesia
◦ Adequate hydration
◦ Retain urethral catheter on continuous drainage for 10 to 14 days to
allow small vesicovaginal fistulae to heal
◦ Encourage early ambulation
◦ Anticoagulation
◦ Close monitoring of vitals
Post Operative Management
◦ Dietary counselling is needed. Avoid constipation but have a
balanced diet rich in protein to promote good wound healing.
◦ Lactulose may be needed to ensure soft stools (2 to 3 stools daily)
◦ Initiate breastfeeding early to help with bonding
◦ Psychologist assessment as the trauma of the delivery may cause
the mother to have acute stress disorder
 Operative Vaginal Delivery

◦ Forceps delivery ◦ Destructive operations

◦ Craniotomy
◦ Vacuum extraction ◦ Decapitation
◦ Embryotomy
◦ Cleidotomy
◦ Symphysiotomy
◦ Decompression
Forceps Delivery
Ventouse Delivery
 Complications
Maternal Fetal
◦ Uterine rupture ◦ Birth asphyxia
◦ Reduced fertility ◦ Birth injuries
◦ Lower genital tract injuries and ◦ Cerebral palsy in later life
fistulae ◦ Fetal death
◦ Peripheral nerve injuries
◦ Osteitis pubis
◦ Pressure sores
◦ Amenorrhoea
◦ Maternal death
Ruptured Uterus

Definition:
Total disruption of the wall of the pregnant uterus
with or without the extrusion of its contents (either the fetus or
the placenta).
Types
◦ Complete: when the visceral peritoneum overlying the uterus
is also disrupted.
◦ Incomplete: When the overlying peritoneum is intact.
◦The term traumatic is used when the
rupture is preceded by some form of
intervention such as manipulation,
obstetric instrumentation, pharmacologic
stimulation or external physical force.
Otherwise it is termed spontaneous.
Aetiology/ Predisposing factors
1. Obstructed labour
2. High parity
3.Uterine hyperstimulation with oxytocics
4. Previously scarred uterus
5. Intrauterine manipulation during labour and delivery.
6. Operative vaginal delivery
7. Congenitally malformed uterus with pregnancy
8. Placenta growth abnormalities
Clinical Features
1. Abdominal pain
2. Abdominal tenderness
3. Haemoperitoneum, leading to anemia, shock.
4. Signs of fetal distress/fetal death.
5. Cessation of uterine contractions with or without
vaginal bleeding.
6.Distortion of the shape/ contour of abdomen and possible position
of uterus.
7. Fetal parts are easily palpable with displacement of the presenting
part from the pelvis
8. There may be vomiting, ileus, shock or maternal distress
9. Urine may be stained with blood or meconium
Differential Diagnosis
-Abruptio Placenta
- Advanced Abdominal Pregnancy
Management
1. Intensive resuscitation. Correct hypovolaemia, dehydration. Correct anaemia
and sepsis before surgery.
2. Emergency laparotomy. Surgical options are:
- Subtotal hysterectomy
- Total hysterectomy
- Repair of the uterus with or without bilateral tubal ligation
The best surgical option is the one that gets the
patient off the theatre table in the shortest possible
time and in the best condition.
3. Broad spectrum antibiotic
4. Adequate post operative care
Complications
Maternal
Immediate: Hypovolaemic shock, sepsis and maternal death.
Late: Pyrexia, Anaemia, genital tract/wound
sepsis, urogenital fistula, Intestinal obstruction
from adhesions, repeat uterine rupture in
subsequent pregnancy, obstetric palsy.
Fetal
Hypoxia, Shock, Anaemia and Death.
Primary Prevention
◦ Good nutrition in the early years of development
◦ Education for all with emphasis on girl child education
◦ Reduce teenage pregnancy
◦ Female empowerment
◦ Trade initiatives for women
◦ Legislation and enforcement to ban the practice of female genital mutilation

◦ Health education which will encourage all women to attend antenatal care
and to have supervised deliveries
Secondary Prevention

◦ Positive pregnancy experience

◦ Select at risk patients for elective Caesarean delivery during the ANC
◦ Train health workers and ensure proper use of the parthograph
◦ Equip the health facilities with the needed resources to enable them
deliver the best standard of care
Tertiary Prevention
◦ Multidisciplinary help for those who survive the ordeal of
Obstructed labour (urogynaecologist, clinical psychologist, medical
team)
◦ Rehabilitation facilities that can help women who have develop
fistulae to help improve their quality of life
◦ Financial support to help them get it repaired.
 Obstructed labour is a preventable
calamity in obstetric practice.

Good antenatal care can select at risk

patients for supervised delivery by
Conclusion Physicians or for elective Caesarean
Section

The use of Parthograph to monitor labour can

also help to identify patients whose labour may
be difficult and thus facilitate prompt referral
to another facility with the capacity to give the
patient the needed care.