Mudaliar

and
Menon’s
Clinical
Obstetric
s
13TH EDITION
 Chapter 45
CEPHALOPEL
VIC
DISPROPORTI
ON (CPD)
AND
OBSTRUCTED
LABOUR

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Cephalopelvic disproportion
Cephalopelvic disproportion refers to the anatomical/mechanical
disproportion between the fetal head and the maternal pelvis for that
particular pregnancy.

Contracted pelvis
A contracted pelvis refers to a permanent deformity of the pelvis in
which one or more diameters of the pelvis are reduced.

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 TYPES OF
CONTRACTED
PELVISES
Contracted Inlet
A contracted inlet can result in
abnormal presentations
Result in malposition and
malpresentations such as
deflexed head, face or brow
presentation and transverse lie
Premature rupture of
membranes or spontaneous
rupture of the membranes early
in labour

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Contracted mid-pelvis
Midpelvis contraction causes the transverse arrest of the
fetal head and prolonged labour and obstructed labour,
resulting in cesarean delivery.
Contracted outlet
Decreased intertuberous diameter with consequent
narrowing of the anterior triangle inevitably forces the
fetal head posteriorly.
Outlet contraction occurring alone is rare and is almost
always associated with concomitant mid-cavity
contraction.
It may cause third- and fourth-degree perineal tears.

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 History
Previous obstetric performance
History of prolonged labour, difficult vaginal
delivery (forceps), cesarean section, fetal
asphyxia or stillbirth or neonatal death, in the
absence of other etiological factors, would
strongly suggest the possibility of a contracted
DIAGNOSIS OF pelvis or cephalopelvic disproportion.
CPD The delivery of a macrosomic baby with
morbidity may also suggest CPD.
Past history
History of post-polio residual paralysis,
fractures affecting the lower limbs or pelvis and
tuberculosis affecting the pelvic joints point to
the possibility of an obliquely contracted pelvis.

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Short-statured women (<145 cm)
Dystocia dystrophia syndrome
A pendulous abdomen, deformities of the spine
An unengaged or floating head in a primigravida
at term EXAMINATIO
Deflexed head N
In the presence of CPD, malpresentations such
as face, breech and transverse lie are common

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 Full bladder

CPD

Malposition and malpresentations such as

occipitoposterior position or face or brow
presentations
Placenta previa
Causes of a Tumours occupying the lower segment such as
floating head fibroids and ovarian tumours
in a Cord around the neck

primigravida Fetal anomalies such as hydrocephalus or

tumours in the region of the fetal neck
Polyhydramnios

Multiple pregnancy

Wrong dates

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ASSESSMENT OF PELVIS (CLINICAL
PELVIMETRY)
The inlet
Diagonal conjugate—if the sacral promontory of the pelvis is reached, the pelvis is
considered contracted
The cavity
Shape and inclination of the sacrum: Flattening of the sacrum - ‘transverse arrest’
Side walls: Convergent or divergent
Ischial spines: Blunt/prominent /very prominent
Interspinous diameter: <9.5 cm is inadequate for an average-sized baby
Sacrosciatic notch:Sacrospinous ligament admits two and a half fingers-adequate

The outlet
The subpubic angle should normally admit two fingers
The intertuberous diameter- should normally admit the closed fist of a hand

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Assessment of cephalopelvic disproportion
Assessment for CPD is carried out at 38 weeks of gestation. However, the
adequacy of the pelvis for the particular fetus is best assessed in labour.

Abdominal methods
1. Head fitting test
The bladder should be emptied prior to the
procedure.
The woman is placed in a semi-sitting position
with her legs semi-flexed at the thighs and
knees.
Standing to the right of the woman, the
obstetrician uses the left hand to push the fetal
head downwards and backwards into the pelvis
while the fingers of the right hand are placed
over the symphysis pubis to detect
disproportion.

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 2. Donald’s method
The woman lies on her back with semi-
flexion of the thighs and knees and the
legs separated.
The clinician stands on the right side of
the woman, and using the third, fourth
and fifth fingers of both hands, holds the
fetal head at the sinciput and the occiput.
The index fingers of both hands palpate
the symphysis pubis while the thumbs
exert downward and backward pressure
on the parietal eminence of the fetal
head.

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ABDOMINOPELVIC METHOD—THE MUNRO–KERR–MÜLLER
METHOD

Under aseptic conditions, the obstetrician passes two

fingers into the vagina and positions them at the level of
the ischial spines.
With the other hand on the abdomen, the obstetrician
grasps the fetal head and presses it into the pelvic brim.
The thumb of the vaginal hand is used to palpate the
head over the symphysis.
If the head could be pushed down to the level of the
ischial spines, there is no CPD.
If the head could be pushed down a little but not to the
level of the ischial spines, there is a minor degree of
CPD.
When the head cannot be pushed into the pelvic cavity
and there is marked overriding of the head on the
thumb, it is known as a major degree CPD.

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Limitations of this procedure
If it is performed prior to labour, a deflexed head may simulate disproportion, which may result in
an incorrect diagnosis.
This method helps in diagnosing disproportion at the brim level but is not useful to assess CPD at
the cavity or at the outlet.
Imaging studies in the diagnosis of CPD
X-ray pelvis, MRI and USG are not very helpful and are not routinely used.

Complications of CPD
Floating head
Malpositions and malpresentations
Premature rupture of membranes
Prolonged labour
Obstructed labour and rupture uterus
Cord prolapse, fetal distress, stillbirth
Increased operative deliveries

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Management of CPD

When CPD occurs in a nulliparous woman, the uterus goes

into uterine inertia following good uterine contractions.

In a multiparous woman, the uterus contracts vigorously to

overcome the obstruction resulting in rupture uterus.

Elective cesarean section or trial of labour depending on the

degree of disproportion and the associated risk factors.

Indications for elective cesarean section

Major degree of CPD

Obliquely contracted pelvis

Minor disproportion, associated with malpresentations or

associated high-risk pregnancies

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Suitable candidates for trial of labour in CPD
Minor degree CPD
Platypelloid pelvis
Primigravida without comorbidities
Vertex presentation
No mid-cavity or outlet contractions
Average-sized baby

Contraindications for trial of labour in CPD

Major degree of CPD
Associated malpresentations
Associated obstetrical risk factors such as elderly primi, GDM, hypertension and
postdated pregnancy

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THE PROCEDURE OF TRIAL OF
LABOUR IN CPD
Trial of labour should be carried out in a hospital where facilities for cesarean section
are readily available.
Spontaneous onset of labour is preferable.
Once labour begins, its progress should be monitored by abdominal palpation as well as
vaginal examination.
Labour progress should be documented using a partograph.
Pulse chart, temperature, BP estimation and fluid balance.
When the membrane ruptures, cord prolapse should be ruled out.
The fetal condition should be monitored by continuous CTG.
The woman should be kept on nil per oral as she may require a cesarean section.
Pain relief should be given—epidural analgesia is preferable.

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The good prognostic signs of trial of The bad prognostic signs of trial of labour
labour

• Presence of good uterine • Weak uterine contractions

action • Slow descent of the head
• Early engagement of the • Rupture of the membranes
head with an uneffaced and
• The cervix is thinned out, partially dilated cervix
dilating progressively and • Slow dilatation of the cervix
well-applied to the vertex • Occipitoposterior position of
• Occipitoanterior position the head

Termination of trial of labour

If the progress of labour is unsatisfactory despite good uterine action, with
poor cervical dilatation, slow descent of head or evidence of obstruction with
excessive caput and moulding.
Maternal and fetal distress.
The trial of labour is considered failed if it results in a cesarean delivery or
perinatal complications/death.

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 Labour is considered obstructed if it does not
progress due to anatomical/mechanical factors
causing obstruction to delivery.
With the use of a partograph, prolonged labour
should be identified early, and necessary action
should be taken before obstruction develops.

Etiology:
OBSTRUC CPD
TED Persistent occipitoposterior position and deep
transverse arrest
LABOUR Fetal anomalies such as hydrocephalus, fetal ascites
and conjoined twins
Malpresentations such as brow presentation, mento
posterior, shoulder presentation or compound
presentation
Pregnancy complicated by tumours - fibroids and
ovarian tumours
Uterine anomalies

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DIAGNOSIS OF OBSTRUCTED LABOUR

History of prolonged labour, prolonged rupture of membranes, loss of fetal

movements and use of oxytocic drugs
On examination, the woman may be cold and clammy, anxious, restless,
exhausted or in agony.
She will be febrile, dehydrated and pale, and her tongue will be dry. The pulse
will be rapid with tachycardia; there may be laboured respiration.
On abdominal examination, the uterus is hard and tender and tonically
contracted on the baby, making palpation difficult.
The major portion of fetal head is palpable per abdomen. The round ligaments
are prominent.
Pathologic retraction ring or Bandl’s ring is formed.

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 Most often, the fetus is in distress or the fetal heart is
absent as the child is dead.
There may be distended bowel loops due to sepsis or
ileus.

DIAGNOS On vaginal examination, the vagina is hot and dry, the
perineum, vagina, cervix, urethra and bladder may be

IS OF lacerated due to attempts at vaginal delivery. There

may bean offensive vaginal discharge. A large caput
may be visible on the presenting part. In many cases,
OBSTRU though a large caput is visible at the introitus, 3/5th or
more of the fetal head is still palpable per abdomen.
CTED If a partograph was maintained, it will show slow

LABOUR progress in the first stage of labour/arrest of labour in

the second stage.
Threatened rupture - at this stage, and if the uterus
is not emptied, rupture uterus will result. The
woman’s consent should be taken for a hysterectomy
if it is required.

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 The woman shows signs of shock
Uterine contractions cease
Fetal parts are easily palpable, fetal heart is
absent, presenting part recedes from pelvis
There may be vaginal bleeding
ONCE THE The bladder may be distended with retained
UTERUS urine, which may be concentrated or
bloodstained
RUPTURES the tamponade effect of an impacted head
prevents bleeding, if the head is dislodged,
bleeding will be obvious

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The woman should be resuscitated with NS or Ringer’s lactate solution
Blood should be grouped, cross-matched and kept available
Dehydration, acidosis and hypovolemia should be corrected
Hemoglobin, renal function and electrolytes should be checked
Continuous bladder drainage
Parenteral antibiotics - aerobic and anaerobic organisms
The stomach should be emptied by nasogastric aspiration
Immediate steps should be taken to empty the uterus

MANAGEMENT

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 OBSTETRIC MANAGEMENT
Even if the fetus is dead, cesarean section must be undertaken without delay in the interests of the
mother.

At the time of cesarean section, care should be taken while opening the abdomen as the bladder may
be drawn up and may be injured. The uterovesical fold of the peritoneum should be opened at a higher
level.

The headmay have to be disimpacted by the vaginal route by an assistant.

The uterus should be delivered outside the abdominal incision and carefully evaluated for rupture in
the posterior surface, the presence of broad ligament hematoma and downward and lateral extension
of the uterine incision.

Atonic/traumatic PPH should be anticipated, and necessary preventive measures should be taken to
avoid such an occurrence.

Following cesarean section, it is important to leave the catheter for 10–14 days in order to prevent
avascular necrosis of the bladder and vesicovaginal fistulae.

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Complications of obstructed labour
Rupture uterus
Postpartum hemorrhage
Puerperal sepsis
Perineal and vaginal tears
VVF and RVF
Foot-drop
Subluxation of the symphysis pubis/sacroiliac
joints
Maternal, fetal and neonatal death

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