Contracted pelvis, CEPHALOPELVIC DISPROPORTION, PELVIC ABNORMALITY, CPD, TYPES OF PELVIS , TYPES OF PELVIS AND ITS OUT COME, MECHANISM OF LABOUR IN CONTRACTED PELVIS, DIAGNOSIS OF CPD, DIAGNOSIS and MANAGEMENT OF CONTRACTED PELVIS, PELVIMETRY, PELVIC ASSESSMENT, TRIAL OF LABOUR
Prelabour Rupture of Membrane (PROM) by Sunil Kumar Dahasunil kumar daha
Please find the power point on Prelabour Rupture of Membrane (PROM). I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Prelabour Rupture of Membrane (PROM) by Sunil Kumar Dahasunil kumar daha
Please find the power point on Prelabour Rupture of Membrane (PROM). I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Cervical ripening is the preparation of the cervix for labour and delivery. The Bishop score is the commonest used methodology to assess it. For more like this visit my page on YouTube https://www.youtube.com/@mudiagaakpoghene2243
This topic contains definition, incidence, types, causes, diagnosis, mechanism, management of occipito posterior position and deep transverse arrest and manual rotation of occipito posterior position
When fetal head is delivered, but shoulders are stuck and cannot be delivered it is known as shoulder dystocia.
The anterior shoulder becomes trapped behind on the symphysis pubis, whilst the posterior shoulder may be in the hollow of the sacrum or high above the sacral promontory.
Hydatidiform Mole (HM) is a rare mass or growth that forms inside the uterus at the beginning of a pregnancy. It is a type of gestational trophoblastic disease (GTD).
When a normal sperm cell fertilizes one of these oocytes, the resulting embryo has only one set of chromosomes. Because the embryo has no genes from the mother, the pregnancy cannot develop normally, resulting in a hydatidiform mole.
Cervical ripening is the preparation of the cervix for labour and delivery. The Bishop score is the commonest used methodology to assess it. For more like this visit my page on YouTube https://www.youtube.com/@mudiagaakpoghene2243
This topic contains definition, incidence, types, causes, diagnosis, mechanism, management of occipito posterior position and deep transverse arrest and manual rotation of occipito posterior position
When fetal head is delivered, but shoulders are stuck and cannot be delivered it is known as shoulder dystocia.
The anterior shoulder becomes trapped behind on the symphysis pubis, whilst the posterior shoulder may be in the hollow of the sacrum or high above the sacral promontory.
Hydatidiform Mole (HM) is a rare mass or growth that forms inside the uterus at the beginning of a pregnancy. It is a type of gestational trophoblastic disease (GTD).
When a normal sperm cell fertilizes one of these oocytes, the resulting embryo has only one set of chromosomes. Because the embryo has no genes from the mother, the pregnancy cannot develop normally, resulting in a hydatidiform mole.
Hip dysplasia in adults, types, radiographs and management!
Useful for Orthopaedic residents and Surgeons.
Include most of the basics from reliable sources, pardon for any mistakes. Contact at singh_prabhjeet@yahoo.com for any corrections.
It is a pelvis in which one or more of its diameters is reduced below the normal by one or more centimeters. 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.
For more notes: Join Us on Telegram: https://t.me/OBGYN_Note_Book Or Facebook: https://www.facebook.com/obgyn.books
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PELVIC ORGAN PROLAPSE, uterine prolapse , cystocele, rectocele, urethrocele, supports of uterus, sling surgeries, pessaries, grades of prolapse, uterine preserving surgery for pop, pelvic floor repair, vaginal hysterectomy, ward mayos surgery, pop q grading, grading of prolapse, laproscopic surgeries for prolapse, peregee, apogee , mesh repair, tot, tvt, colpo suspension, colpoclysis, SUI management, epidemiology of prolapse, decubitus ulcer, best ppt for pelvic organ prolapse, better understanding of pelvic organ prolapse and pelvic floor. dr . m. gokul reshmi, dr. gokulreshmi m
PELVIC ORGAN PROLAPSE, uterine prolapse , cystocele, rectocele, urethrocele, supports of uterus, sling surgeries, pessaries, grades of prolapse, uterine preserving surgery for pop, pelvic floor repair, vaginal hysterectomy, ward mayos surgery, pop q grading, grading of prolapse, laproscopic surgeries for prolapse, peregee, apogee , mesh repair, tot, tvt, colpo suspension, colpoclysis, SUI management, epidemiology of prolapse, decubitus ulcer, best ppt for pelvic organ prolapse, better understanding of pelvic organ prolapse and pelvic floor.
dysmenorrhea ,dysmenorrhea definition, types of dysmenorrhea, menstrual pain , pathophysiology of dysmenorrhea, management of primary dysmenorrhea, management of secondary dysmenorrhea, treatment of dysmenorrhea.
fibroid, endometriosis, medical management of fibroid, medical management of endometriosis, drug theraphy, hormonal, non hormonal. gnrh. aromatase inhibitor,COC, PAIN FULL MENSES,
REPRODUCTIVE AND CHILD HEALTH, national scheme, RCH, Maternal health, neonate, maternal and child health, Family planning program, Child survival & safe motherhood program, Components of RCH , Adolescent health care and family life education,
post term pregnancy, post dated pregnancy, prolonged pregnancy,
m.g. reshmi, management of post dated pregnancy,management of post term pregnancy, fetal maturity assesment, post maturity syndrome, mortality and morbidity ,placental dysfunction, aminotic fluid volume in prolonged pregnancy.
ultrasonography in obstetrics, usg in obstetrics, ultrasound in obstetrics, doppler in obstetrics, usg doppler in obstetrics, signs in ultrasound, anomaly scan, pregnancy scan, ultrasound in pregnancy,
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
2. DEFINITION
Anatomical definition:
• The essential diameters of one or more planes are shortened by
0.5 cm.
Obstetric definition:
• Alteration in the size and/ or shape of the pelvis of sufficient
degree as to alter the normal mechanism of labor in an average
size baby.
3. VARIATIONS OF FEMALE PELVIS
• The size and shape of the female pelvis differ widely.
• On the basis of the shape of the inlet, the female pelvis is divided
into four types:
• Gynecoid (50%)
• Anthropoid (25%)
• Android (20%)
• Platypelloid (5%)
4. GYNECOID PELVIS – 50%
• INLET:
• Shape - Round .
• Anterior and posterior segment - Almost equal and
spacious.
• Sacrum - Sacral angle (SA) more than 90°. Inclined
backwards. Well curved from above down and side to side.
• Position - Occipito-lateral or oblique Occipito-anterior.
• Diameter of engagement - Transverse or oblique.
• Engagement - No difficulty, Usual mechanism.
7. ANTHROPOID PELVIS – 25%
• INLET:
• Shape – Antero-posteriorly oval .
• Anterior and posterior segment - Both increased with slight
anterior narrowing.
• Sacrum - SA more than 90°. Inclined posteriorly. Long and narrow.
Usual curve.
• Position - Direct Occipito-anterior or posterior
• Diameter of engagement - Anteroposterior
• Engagement - No difficulty except flexion is delayed
8. ANTHROPOID PELVIS – 25%
• CAVITY:
• Sacro-sciatic notch - More wide and shallow.
• Sidewalls - Straight or divergent.
• Internal rotation - Non-rotation common.
9. ANTHROPOID PELVIS – 25%
• OUTLET:
• Ischial spines – Not prominent.
• Pubic arch - Long and curved.
• Subpubic angle - Slightly narrow.
• Bituberous diameter - Normal or short
• Delivery - More incidence of face-to-pubis delivery.
10. ANDROID PELVIS – 20%
• INLET:
• Shape – Triangular/ HEART shaped.
• Anterior and posterior segment - Posterior segment short and
anterior segment narrow.
• Sacrum - Sacral angle less than 90°. Inclined forwards and straight.
• Position – Occipito-lateral or oblique Occipito-posterior.
• Diameter of engagement - Transverse or oblique
• Engagement - Delayed and difficult.
11. ANDROID PELVIS – 20%
• CAVITY:
• Sacro-sciatic notch - Narrow and deep.
• Sidewalls - Convergent.
• Internal rotation - Difficult anterior rotation. Not occurs early
above the ischial spines, chance of arrest.
12. ANDROID PELVIS – 20%
• OUTLET:
• Ischial spines – Prominent.
• Pubic arch - Long and straight.
• Subpubic angle – Narrow.
• Bituberous diameter - Short.
• Delivery - Difficult delivery with increased chance of perineal
injuries.
13. PLATYPELLOID PELVIS – 5%
• INLET:
• Shape -Transversely oval.
• Anterior and posterior segment - Both reduced-flat.
• Sacrum - SA more than 90°. Inclined posteriorly. Short and straight.
• Position – Occipito-lateral.
• Diameter of engagement – Transverse.
• Engagement - Difficult by exaggerated parietal presentation.
14. PLATYPELLOID PELVIS – 5%
• CAVITY:
• Sacro-sciatic notch - Slightly narrow and small.
• Sidewalls - Divergent.
• Internal rotation - Anterior rotation usually occurs late in the
perineum.
15. PLATYPELLOID PELVIS – 5%
• OUTLET:
• Ischial spines – Not prominent.
• Pubic arch - Short and curved.
• Subpubic angle - Very wide (more than 90°).
• Bituberous diameter - Wide.
• Delivery - No difficulty.
16. ETIOLOGY
Common causes of contracted
pelvis are:
• Nutritional and environmental:
minor variation: Common
major variation: Rachitic and
osteomalacic — rare
Effect of walking Effect on lying Reniform shape of
down position the inlet
Rachitic pelvis
Osteomalacic pelvis
18. ETIOLOGY
Development defects :
• Naegele’s pelvis,
• Robert’s pelvis;
• high or low assimilation pelvis.
NAEGELE’S PELVIS
ROBERT’S PELVIS
19. MECHANISM OF LABOR IN CONTRACTED PELVIS
WITH VERTEX PRESENTATION FLAT PELVIS
In THE FLAT PELVIS, the head finds
difficulty in negotiating the brim and
once it passes through the brim,
there is no difficulty in the cavity or
outlet.
GENERALLY CONTRACTED PELVIS:
The shape remains unaltered, but all
the diameters in the different
planes—inlet, cavity and outlet—are
shortened. There is difficulty from
the beginning to the end.
Mechanism of labor in flat pelvis:
• Lateralization of occiput to the sacral bay;
• Engagement of the head by exaggerated
parietal presentation
20. MECHANISM OF LABOR IN CONTRACTED PELVIS
WITH VERTEX PRESENTATION FLAT PELVIS
The head negotiates the brim by the following mechanism:
• The head engages with the sagittal suture in the transverse diameter.
• Head remains deflexed and engagement is delayed.
• If the anteroposterior diameter is too short, the occiput is mobilized to the
same side to occupy the sacral bay.
• If lateral mobilization is not possible, there is a chance of extension of the
head leading to brow or face presentation.
21. MECHANISM OF LABOR IN CONTRACTED PELVIS
WITH VERTEX PRESENTATION FLAT PELVIS
The head negotiates the brim by the following mechanism:
• Engagement occurs by exaggerated parietal presentation so that the super-
subparietal diameter (8.5 cm), instead of the biparietal diameter (9.5 cm),
passes through the pelvic brim.
• Molding may be extreme and often there is an indentation or even a
fracture of one parietal bone. However, the caput that forms is not big.
• Once the head negotiates the brim, there is no difficulty in the cavity and
outlet and normal mechanism follows.
22. DIAGNOSIS OF CONTRACTED PELVIS
• Degree of contracted pelvis is gradually declining , due to an
improved standard of living and of nutrition.
• Now the presence of fetopelvic disproportion either due to
inadequate pelvis or big baby or more commonly a combination of
the both is common.
23. DIAGNOSIS OF CONTRACTED PELVIS
Past History:
• Medical: Past history of fracture, rickets, osteomalacia, tuberculosis of the
pelvic joints or spines and poliomyelitis is to be enquired.
• Obstetrical:
• prolonged - spontaneous or difficult instrumental delivery is suggestive
of pelvic contraction.
• stillborn or early neonatal death or late neurological stigmata following a
difficult labor without any other etiological factor points towards
contracted pelvis.
24. DIAGNOSIS OF CONTRACTED PELVIS
Physical Examination:
• Stature: less than 5 ft is likely to have a small pelvis.
• Stigma: Deformities (congenital or acquired) of pelvic bones, hip
joint, spine.
25. DIAGNOSIS OF CONTRACTED PELVIS
• Dystocia dystrophia syndrome:
• The patient is stockily built with bull neck, broad shoulders and short thighs,
obese with a male distribution of hairs.
• Usually subfertile, having dysmenorrhea, oligomenorrhea or irregular periods
with increased incidence of pre-eclampsia and a tendency for postmaturity.
• Pelvis is of the android type. Occipito-posterior position is common with
tendency for deep transverse arrest or outlet dystocia increased
incidence of difficult instrumental delivery or cesarean section.
• There is a chance of lactation failure.
26. DIAGNOSIS OF CONTRACTED PELVIS
• Abdominal Examination Inspection: Pendulous abdomen, especially in
primigravidae.
• Obstetrical: unengagement of the head before the onset of labor.
Presence of malpresentation in primigravidae gives rise to a suspicion
of pelvic contraction.
28. PELVIMETRY
• Clinical pelvimetry done around 37 completed weeks, but better at the
onset of labour.
• Bladder should be empty.
• Patient in dorsal position
• Under aseptic preparations.
• The following features are to be noted simultaneously:
• (1) State of the cervix;
• (2) To note the station of the presenting part in relation to ischial spines;
• (3) To test for cephalopelvic disproportion in nonengaged head (described later);
• (4) To note the resilience and elasticity of the perineal muscles.
29. PELVIMETRY - The internal examination
• Sacrum - The sacrum may be smooth, short and
well curved, and the sacral promontory usually
cannot be reached or the sacrum may be long or
straight.
• Sacrosciatic notch - The notch is sufficiently wide
so that two fingers can be easily placed over the
sacrospinous ligament covering the notch. The
configuration of the notch denotes the capacity
of the posterior segment of the pelvis and the
sidewalls of the lower pelvis.
30. PELVIMETRY -The internal examination
• Ischial spines — Spines are usually smooth
(everted) and difficult to palpate. They may be
prominent and encroach to the cavity thereby
diminishing the available space in the mid-
pelvis.
• Iliopectineal lines — To note for any breaking
suggestive of narrow fore pelvis (android
feature).
31. PELVIMETRY - The internal examination
• Sidewalls — Normally they are parallel or divergent. They may be
convergent.
• Posterior surface of the symphysis pubis — It normally forms a smooth
rounded curve. Presence of angulation or breaking suggests abnormality.
• Sacrococcygeal joint — Its mobility and presence of hooked coccyx, if any,
are noted.
• Pubic arch — Normally, the pubic arch is rounded and should
accommodate the palmar aspect of two fingers. Configuration of the arch
is more important than pubic angle.
• Diagonal conjugate — It is the distance between the lower border of
symphysis pubis to the midpoint on the sacral promontory.
32. PELVIMETRY
• Subpubic angle:
• The inferior pubic rami are
defined and in female, the
angle roughly corresponds to
the fully abducted thumb and
index fingers.
• In narrow angle, it roughly
corresponds to the fully
abducted middle and index
fingers.
33. PELVIMETRY
• Transverse diameter of the outlet (TDO) — It
is measured by placing the knuckles of the
first interphalangeal joints or knuckles of the
clinched fist between the two ischial
tuberosities. Normally, it accomodates four
knuckles.
• Anteroposterior diameter of the outlet—The
distance between the inferior margin of the
symphysis pubis and the skin over the
sacrococcygeal joint can be measured either
with the method employed for diagonal
conjugate or by external calipers
36. DEFINITION
• The disparity in the relation between the head and the pelvis is called
cephalopelvic disproportion.
• Disproportion may be either due to an average size baby with a small
pelvis or due to a big baby (hydrocephalus) with normal size pelvis or
due to a combination of both the factors.
• Fetal head is the best pelvimeter.
• Isolated outlet contraction without midpelvic contraction is a rarity.
37. DEFINITION
• Pelvic inlet contraction : the obstetric conjugate is < 10 cm or the greatest
transverse diameter is < 12 cm or diagonal conjugate is < 11 cm.
• Contracted Midpelvis: the sum of the interischial spinous and posterior
sagittal diameters of the midpelvis (normal: 10.0 + 5 = 15.0 cm) is 13.0 cm
or below.
• Contracted outlet: the interischial tuberous diameter is 8 cm or less. A
contracted outlet is often associated with mid - pelvic contraction. Isolated
outlet contraction is a rarity.
38. DIAGNOSIS OF CEPHALOPELVIC
DISPROPORTION (CPD)
Degree of cephalopelvic disproportion at the brim can be ascertained
by the following:
• Clinical — (a) Abdominal method; (b) Abdominovaginal (Muller-
Munro Kerr)
• Imaging pelvimetry
• Cephalometry — (a) Ultrasound; (b) Magnetic Resonance Imaging;
(c) X-ray
39. DIAGNOSIS OF CEPHALOPELVIC
DISPROPORTION (CPD)
ABDOMINAL METHOD:
• The patient is placed in dorsal position
with the thighs slightly flexed and
separated.
• The head is grasped by the left hand.
• Two fingers (index and middle) of the
right hand are placed above the
symphysis pubis keeping the inner
surface of the fingers in line with the
anterior surface of the symphysis
pubis to note the degree of
overlapping, if any, when the head is
pushed downwards and backwards.
Clinical: In a primigravida with nonengagement of the head
even at labor, disproportion should be ruled out.
40. DIAGNOSIS OF CEPHALOPELVIC
DISPROPORTION (CPD)
INFERENCES:
• No disproportion - The head can be pushed down in the pelvis without
overlapping of the parietal bone on the symphysis pubis.
• Moderate disproportion - Head can be pushed down a little but there is slight
overlapping of the parietal bone evidenced by touch on the under surface of the
fingers.
• Severe disproportion - Head cannot be pushed down and instead the parietal
bone overhangs the symphysis pubis displacing the fingers.
Difficult to elicit in deflexed head, thick abdominal wall, irritable uterus and high-
floating head
41. DIAGNOSIS OF CEPHALOPELVIC
DISPROPORTION (CPD)
• ABDOMINOVAGINAL METHOD (Muller-Munro
Kerr):
• The patient is placed in lithotomy position and
the internal examination is done taking all
aseptic precautions.
• Two fingers of the right hand are introduced
into the vagina with the finger tips placed at
the level of ischial spines and thumb is placed
over the symphysis pubis.
• The head is grasped by the left hand and is
pushed in a downward and backward direction
into the pelvis.
• This bimanual method is superior to the
abdominal method.
• Lower bowel is emptied, preferably by enema.
• The patient is asked to empty the bladder.
42. DIAGNOSIS OF CEPHALOPELVIC
DISPROPORTION (CPD)
INFERENCES:
(1) No disproportion - The head can be pushed down up to the level of
ischial spines and there is no overlapping of the parietal bone over the
symphysis pubis.
(2) Slight or moderate disproportion - The head can be pushed down a little
but not up to the level of ischial spines and there is slight overlapping of the
parietal bone.
(3) Severe disproportion - The head cannot be pushed down and instead the
parietal bone overhangs the symphysis pubis displacing the thumb.
43. DEGREE OF DISPROPORTION AND
CONTRACTED PELVIS
Based on the clinical and supplemented by imaging pelvimetry, degrees
of disproportion at the brim are evaluated:
• Severe disproportion: Where obstetric conjugate is < 7.5 cm (3").
Such type is rare to see.
• Borderline: Where obstetric conjugate is between 9.5 cm and 10 cm.
When both the anteroposterior diameter (< 10 cm) and the
transverse diameter (< 12 cm) of the inlet are reduced, the risk of
dystocia is high than when only one diameter is contracted.
44. EFFECTS OF CONTRACTED PELVIS ON
PREGNANCY AND LABOR
Pregnancy: The general course of pregnancy is not much affected.
• There is more chance of incarceration of the retroverted gravid uterus
in flat pelvis;
• Abdomen becomes pendulous especially in multigravida with lax
abdominal wall;
• Malpresentations are increased three to four times and so also
increased frequency of unstable lie.
45. EFFECTS OF CONTRACTED PELVIS ON
PREGNANCY AND LABOR
Labor:
The course of events in labor
is greatly modified depending upon
the degree of pelvic contraction and
presentation of the fetus:
• There is increased incidence of
early rupture of the membranes;
• Incidence of cord prolapse is
increased;
• Cervical dilatation is slowed;
• There is increased tendency of
prolonged labor and in neglected
cases, obstructed labor with
features of exhaustion,
dehydration, ketoacidosis and
sepsis.
• There is increased incidence of
operative interference, shock,
postpartum; and hemorrhage and
sepsis.
46. EFFECTS OF CONTRACTED PELVIS ON
PREGNANCY AND LABOR
Maternal injuries:
• The injuries of the genital tract may occur spontaneously or following
operative delivery.
• There is increased maternal morbidity and mortality.
Fetal hazards:
• Fetal risks are due to trauma and asphyxia.
• The net effect leads to increased perinatal mortality and morbidity.
48. TRIAL LABOR
• Definition: The conduction of spontaneous labor in a moderate
degree of cephalopelvic disproportion, in an institution under
supervision with watchful expectancy, hoping for a vaginal delivery.
• Aims : A trial labor aims at avoiding an unnecessary cesarean section
and at delivering a healthy baby.
49. CONTRAINDICATIONS
(1) Associated midpelvic and outlet contraction;
(2) Presence of complicating factors like elderly primigravida,
malpresentation, postmaturity, post-cesarean pregnancy, pre-
eclampsia, medical disorders like heart disease, diabetes, tuberculosis,
etc.;
(3) Where facilities for cesarean section is not available round the
clock.
50. CONDUCTION OF TRIAL LABOR
• The labor should ideally be spontaneous in onset. But in cases where
the labor fails to start even on due date, induction of labor may be
done.
• Oral feeding remains suspended and hydration is maintained by
intravenous drip. Adequate analgesic is administered.
• The progress of the labor is mapped with a partograph.
• Monitor the maternal health.
• Fetal monitoring is done clinically and/or using EFM.
51. CONDUCTION OF TRIAL LABOR
• If there is failure to progress due to inadequate uterine contraction,
augmentation of labor may be done by amniotomy along with
oxytocin infusion. On no account should the procedure be employed
before the cervix is at least 3 cm (2 fingers) dilated.
• After the membranes rupture, pelvic examination is to be done:
(a) To exclude cord prolapse;
(b) To note the color of liquor;
(c) To assess the pelvis once more and
(d) To note the condition of the cervix including pressure of the presenting part
on the cervix.
52. SUCCESSFUL OUTCOME
Depends on:
(1) Degree of pelvic contraction;
(2) Shape of the pelvis—flat pelvis is better than android or generally contracted pelvis;
(3) Favorable vertex presentation—anterior parietal presentation with less parietal obliquity is
favorable;
(4) Intact membranes till full dilatation of cervix;
(5) Effective uterine contractions and
(6) Emotional stability of the woman.
53. UNFAVORABLE FEATURES
(1) Appearance of abnormal uterine contraction;
(2) Cervical dilatation less than 1 cm per hour in the active phase (protracted active
phase);
(3) Descent of fetal head less than 1 cm per hour (protracted active phase) inspite
of regular uterine contractions;
(4) Arrest of cervical dilatation and nondescent of fetal head in spite of oxytocin
therapy;
(5) Early rupture of the membranes;
(6) Formation of caput and evidence of excessive molding;
(7) Fetal distress.
54. TERMINATION OF TRIAL LABOR
• Spontaneous delivery with or without episiotomy (30%).
• Forceps or ventouse (30%)—Difficult forceps delivery is to be avoided.
• Cesarean section (40%)—Judicious and timely decision for cesarean
delivery is to be taken.
• However, in significant cases, the section is done even before full
dilatation of the cervix, the indication being uterine inertia or fetal
distress.
55. SUCCESSFUL TRIAL
• A trial is called successful, if a healthy baby is born vaginally,
spontaneously or by forceps or ventouse with the mother in good
condition.
• Delivery by cesarean section or delivery of a dead baby,
spontaneously or by craniotomy, is called failure of trial labor.
56. ADVANTAGE OF TRIAL LABORS
(1) It eliminates unnecessary cesarean section electively decided upon;
(2) It eliminates injudicious use of premature induction of labor with its
antecedent hazards;
(3) A successful trial ensures the woman a good future obstetrics.
57. DISADVANTAGES OF TRIAL LABORS
1) Test of disproportion remains unproven when cesarean delivery is done
due to fetal distress or uterine dysfunction;
(2) Increased perinatal morbidity or mortality due to asphyxia or intracranial
hemorrhage when the trial is prolonged and/or ends in difficult delivery;
(3) Increased maternal morbidity due to the effects of prolonged labor
and/or operative delivery;
(4) Increased psychological morbidity when trial ends with a traumatic
vaginal delivery or in cesarean delivery.
59. INLET CONTRACTION
• Minor degrees of inlet contraction does not give rise to much
problem and the cases are left to have a spontaneous vaginal delivery
at term.
• The moderate and the severe degrees are to be dealt by any one of
the following:
• Induction of labor
• Elective cesarean section at term
• Trial labor
60. DELIVERY
Induction of labor prior EDC:
• Induction 2–3 weeks prior to the EDC may be considered only in cases with
minor to moderate degrees of pelvic contraction.
• It is not favored nowadays.
• In a selected multigravida with previous history of difficult vaginal delivery,
this method may be considered 2–3 weeks before the date.
• In any case, one should be certain about the fetal gestational age.
61. DELIVERY
Elective cesarean section at term:
This is commonly done. Elective cesarean section at term is indicated in:
(1) major degree of inlet contraction
(2) moderate degree of inlet contraction associated with outlet contraction or
complicating factors like elderly primigravida, malpresentation, post-cesarean
pregnancy, etc.
• If there is no doubt about the maturity of the fetus, the operation is done in
planned way any time during last week of pregnancy.
• In doubtful maturity, investigations are done to ascertain maturity; otherwise
the operation is withheld till the pains start or the membranes rupture,
whichever occurs early.
63. MIDPELVIC AND OUTLET DISPROPORTION
• Isolated outlet contraction without midpelvic contraction is a rarity.
• In practice the midpelvic and outlet contraction are jointly considered
as outlet contraction.
• Cephalopelvic disproportion at the outlet is defined as one where the
biparietal-suboccipito bregmatic plane fails to pass through the
bispinous and anteroposterior planes of the outlet.
64. MANAGEMENT
Unlike inlet disproportion, clinical diagnosis of midpelvic and outlet
disproportion can only be made after the head sufficiently comes down
into the pelvis.
• Elective cesarean section: Contraction of both the transverse and
anteroposterior diameters of the midpelvic plane or minor
contraction associated with other complicating factors is dealt by
elective cesarean section.
65. TO ALLOW VAGINAL DELIVERY
• In uncomplicated cases with minor contraction, vaginal delivery is
allowed under supervision with watchful expectancy.
• Molding and adaptation of the head and “give” of the pelvis may
allow the head to pass through the contracted zone.
• Delivery is accomplished by forceps or ventouse with deep
episiotomy to prevent perineal injuries, especially with narrow pubic
arch.
66. TO ALLOW VAGINAL DELIVERY
• Labor progress should be mapped with a partograph to make an early
diagnosis of dysfunctional labor due to disproportion.
• Oxytocin may be used to augment labor for adequate uterine
contractions.
• If there is no dilatation of cervix or descent of the fetal head after a
period of 2 hours in the active phase of labor, arrest of labor is
considered. Once arrest disorder is diagnosed, cesarean delivery is
the option.
67. CASES SEEN LATE IN LABOR
• It is not an uncommon problem in the developing countries.
• The principles of management rest on:
(i) Cesarean section to avoid difficult forceps;
(ii) Forceps with deep episiotomy;
(iii) Symphysiotomy followed by ventouse or
(iv) Craniotomy if the fetus is dead.