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TRANSCRIPT
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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