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7/23/2019 Pp Journal

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JOURNAL READING

Assessing Cephalopelvic Disproportion:

Back to the Basics

By:

Brilliantine Ch Liborang, Sked

Supervisor:

dr. Apter. Patai, SpOG

GENERAL HO!I"AL JA#A!URADE!AR"$EN" o% OB"E"RIC&G#NECOLOG#

$EDICAL CHOOL UNCEN&!A!UA

'()*


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Backgro+n,

D-stocia.a/nor0all- slo1 progress inla/or2 can res+lt %ro0:

Cephalopelvic ,isproportion 3C!D4 $alposition o% the %etal hea, as it

enters the /irth canal

Ine5ective +terine prop+lsive %orces6 C!D 7 0is0atch /et1een the si8e o% the

%etal hea, 9 si8e o% the 0aternal pelvis2res+lting in %ail+re to progress; in la/or

%or 0echanical reasons6


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Despite the +se o% i0aging technolog- inan atte0pt to pre,ict C!D2 there is poor

correlation /et1een ra,iologic pelvi0etr-an, the clinical o+tco0e o% la/or6

Clinical pelvi0etr- still has a place in

o/stetrics %or pre,icting or con


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Learning O/=ectives

"he rea,er 1ill /e a/le:"o interpret ho1 C!D is ,iagnose,6

Disting+ish the > /asic pelvicshapes6

Eval+ate pelvic 0eas+re0ents that/est in,icate a,e?+ac- orina,e?+ac- o% the pelvis6


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"he likehoo, o% C!D an, o/str+cte, la/orhas increase, along 1ith the increase in/rain si8e 9 changes in pelvic

0orpholog- that greatl- restrict the0i,plane o% the pelvis also co0plicateh+0an o/stetrical 0echanics6

D-stocia

,i@c+lt la/or2 is the overallter0 %or slo12 ina,e?+ate or,-s%+nctional la/or6

It is generall- ca+se, /-:


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C!D a recogni8e, o/stetric pro/le0 thatincreases risk %or /oth 0other an, in%ant2

occ+rs 1hen:"he %etal hea, is too /ig2

"he pelvis is too s0all2 or

"he hea, is 0alpositione, as it enters the/irth canal6

Unatten,e, o/str+cte, la/or res+lts in:

etal ,eath

Event+al ,eliver- o% a 0acerate, an,in%ecte, /a/-2

Atonic postpart+0 he0orrhage 1ith or

1itho+t p+erperal in%ection6


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"HE "HREE !s; O LABOR

)6 !assage1a-: 0aternal /on-pelvis an, tiss+es6

'6 !assenger: the %et+s6

6 !o1ers: pri0ar- an, secon,ar-

%orces o% la/or6


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Clinical Classi


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In 0ost cases o% slo1 or see0ingl-o/str+cte, la/or2 a+g0entation 1itho-tocin is in,icate,6

Diagnose C!D onl- i% there is aprolonge,


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!elvic hapes


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"he $i,pelvis 9 !elvic Cavit-

"he 0i,pelvislevel o% theischial spines6

"he ischial spines can /e locate,/- %ollo1ing the sacrospino+sliga0ents to their lateral en,s6

"he spines sho+l, /e palpate, to

,eter0ine i% the- are pro0inent or+n,+l- prono+nce,6

"he intraspino+s the s0allest,i0ension o% the pelvis6

It is assesse, /- to+ching /oth


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"he !elvic O+tlet

"he peri0eter o% the pelvic o+tlet ispartiall- co0prise, o% liga0ents2 an, iseither ovoi, or ,ia0on, shape,6

Lan,0arks o% the pelvic o+tlet incl+,e:"he lo1er /or,er o% the s-0ph-sis p+/is

"he p+/ic arch

"he ischial t+/erosities

"he sacrot+/ero+s an, sacrospino+sliga0ents

"he lo1er aspect o% the sacr+0

"he cocc-6


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"he s+/p+/ic angle sho+l, /e

(o

2 an, nor0all- a,0its '


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In per%or0ing clinical pelvi0etr-2 a %or0+la to%ollo1 is ,escri/e, as the r+le o% s2in,icating that there are parts o% the pelvis

to ea0ine2 an, each part has co0ponents6The rule of three

Brim

Diagonal conjugatePosterior surface of pubic symphysisIlio-pectineal line

Cavity

Sacrum-shape, curve an lengthIschial spines

Sacrospinous ligament!utlet

Subpubic arch an angleIntertuberous "Sacrococcygeal joint


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INDING E!EC"ED IN AN ADEKUA"E!ELI

#$

Assessment Finding

Pelvic brim %oun

Diagonal conjugate & #'($cm

Symphysis )verage thic*ness, parallel tosacrum

Sacrum +ollo, average inclinationSie alls Straight

Ischial spines Blunt

Interspinous " & #(cm

Sacrosciatic notch '($./ finger breathsSubpubic angle 0 1 egrees 2' finger breaths3

Bi-tuberous " 0 4( cm 25*nuc*les3

Coccy6 7obile

)nterposterior " of outlet & ##(cm


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!ELI$E"R# UING I$AGING "ECHNOLOG#

Di0ensions o% the pelvis can also /e ,eter0ine,/- conventional &ra-s2 /- C" scan. $RI6

"he goal o% pelvi0etr- is to acc+ratel- pre,ict1hich patients 1ill have C!D6

Clinical assess0ent o% the 0i,pelvis an, thepelvic o+tlet see0s to /e the /est 0etho, o%0eas+ring pelvic capacit-6

&ra- pelvi0etr- 1as pop+lar in o/stetrical +nits

in ,evelope, co+ntries %ro0 the )*(&)M(2 an,1as +se, 0ainl- %or pre,icting o+tco0e o% la/orin cases o% s+specte, C!D2 /reech presentation29 trial o% la/or a%ter a previo+s caesareansection6


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Overall2 the ,ata s+ggest that there is no

signi


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I!"APA"!#$ P"%&IC!IO A&"%COGI!IO O' CP&

'etal (ead &es)ent

Engage0entthe passage o% the1i,est portion o% the presentingpart thro+gh the pelvic /ri02an, is 0eas+re, in *ths a/ovethe s-0ph-sis p+/is /-

a/,o0inal palpation6 "he a0o+nt o% ,escent an,

engage0ent o% the hea, isassesse, /- %eeling ho1 0an-


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tation


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Hea,&itting "ests


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"HE E"AL HEAD

Onl- a co0parativel- s0all part o% the%etal hea, is represente, /- the %ace therest is co0pose, o% the


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"he change in shape o% the %etal sk+ll

that occ+rs ,+ring la/or in responseto press+re /- +terine contractionsagainst the lo1er +terine seg0ent

an, cervi2 an, to a certain etent2against the /on- pelvis6


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Gra,e o% $ol,ing

8rae , Bones normally separate(

8rae #, Suture line close, ithout

overlap( 8rae ', !verlap of bones, reucible

by igital pressure from e6aminer(

8rae /, Irreucible overlap(


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CA!U" UCCEDAEU$

1elling o% the scalpover the presentingpart o% the %etalhea,6

It ,evelops 1hen+terine contractionpress+re p+shes thescalp into the,ilating cervi2 1hichacts as a constricting/an, aro+n, that

area o% the hea,6


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A#NCLI"I$

"he sit+ation in 1hich the %etal hea,is not aligne, correctl- in thepelvis2 is ,iagnose, 1hen the

s+t+re lines o% the %etal sk+ll arenot aligne, eactl- hal%1a-

/et1een the s-0ph-sis p+/is an,

the sacr+02 an, there is lateralFei on o% the %etal hea, a sit

negotiates the /irth canal6


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CONCLUION O/str+cte, la/or 0a- res+lt %ro0 ina,e?+ate

+terine prop+lsive %orces or a relative C!D ,+e tolarge %etal si8e2 an ina,e?+ate 0aternal pelvis2 or0alposition o% the %etal hea,6

In 0ost cases2 pre,icting C!D re0ains pro/le0atic6

$an- st+,ies report relativel- poor correlation/et1een vario+s pelvi0etric in,ices an, +lti0ate,-stocia no single in,epen,ent pre,ictor orco0/ination o% pre,ictors is ,iagnostic o% C!D6

In a 1orl, that is increasingl- ,epen,ent ontechnolog-2 intrapart+0 clinical assess0ent isaval+a/le pre,ictor o% C!D2 1hich can onl- /e,iagnose, a%ter aproperl- con,+cte, trial o% la/or6


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Thank You

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