I.

INTRODUCTION

CEPHALOPELVIC DISPROPORTION

Cephalopelvic disproportion (CPD) occurs when a babys head or body

is too large to fit through the mothers pelvis.

This can be because of a small pelvis and an average sized fetus, a large
baby with an average sized pelvis or because of malposition of the fetal
head.
CPD is very frequently diagnosed and is a very common indication of
cesarean sections, especially when there is failure to progress in labor.
It is very difficult to diagnose CPD before a women has started her labor
pains since it is very difficult to anticipate how well the fetal head and
the maternal pelvis will adjust and mould to each other.
CPD is one of the commonest cause of different complications in labor,
including prolonged labor, fetal distress, and delayed second stage .

DYSTOCIA

refers to difficult labor which is usually due to uterine dysfunction, fetal

malpresentation/abnormality, or pelvic abnormality.
difficult birth, typically caused by a large or awkwardly positioned fetus,
by smallness of the maternal pelvis, or by failure of the uterus and cervix
to contract and expand normally.
pathological or difficult labor, which may be caused by an obstruction or
constriction of the birth passage or abnormal size, shape, position, or
condition of the fetus.

There are two types of Dystocia:

1) Cervical Dystocia
In cervical dystocia, the cervix fails to dilate during labor.

Failure of cervical dilatation can be due to previous cone biopsy

or cauterization for cervical dysplasia. Other reasons for failure to
dilate include trauma. Sometimes, if there are uncoordinated uterine
contractions then the failure of cervical dilation may be secondary to
this and this should respond to oxytocin. If dystocia continues
despite this then the infant will need to be delivered by cesarean
section.

2) Shoulder dystocia

During the peripartum period the infant's head usually lies to the
left and then rotates to the occipito-anterior position, and the head is
delivered first. Following this, the shoulders lie in the
 anteroposterior position and then pass the pelvic brim. However, if
the shoulders become stuck at this position, the infant can inhale, as
the mouth and nose are out of the vagina; however, the chest cannot
expand as it is stuck in the pelvic brim. This will rapidly lead to
hypoxia and death of the fetus if not delivered quickly. Usually it is
the anterior shoulder which impacts on the maternal symphysis. Less
commonly, the posterior shoulder impacts on the sacral promontory.

FETAL DISTRESS

Compromise of a fetus during the antepartum period (before labor) or

intrapartum period (during the birth process).
The term fetal distress is commonly used to describe fetal hypoxia (low
oxygen levels in the fetus), which can result in fetal damage or death if it
is not reversed or if the fetus is not promptly delivered.
Fetal distress can be detected via abnormal slowing of labor, changes in
fetal heart rate, the presence of meconium (dark green fecal material
from the fetus) or other abnormal substances in the amniotic fluid, or
fetal monitoring with an electronic device that shows a fetal scalp pH of
less than 7.2.

II. INCIDENCE

CPD INCIDENCE

DYSTOCIA INCIDENCE

FETAL DISTRESS

The exact incidence of fetal distress is uncertain, but estimates range from
one in every 25 births to one in every 100 births.
III. RISK FACTORS
CAUSES OF CPD

Increased Fetal Weight:

Very large baby due to hereditary reasons - a baby whose weight is

estimated to be above 5 kg or 10 pounds .
Post mature baby - when the pregnancy goes above 42 weeks.
Babies of women with diabetes usually tend to be big.
Babies of mothers who have had a number of children - each succeeding
baby tends to be larger and heavier.

Abnormal Fetal Position:

Occipito-posterior position - In this position the fetus faces the mothers

abdomen instead of her back.
Brow presentation
Face presentation.

Problems with the Pelvis:

Small pelvis.
Abnormal shape of the pelvis due to diseases like rickets, osteomalacia or
tuberculosis.
Abnormal shape due to previous accidents.
Tumors of the bones.
Childhood poliomyelitis affecting the shape of the hips.
Congenital dislocation of the hips.
Congenital deformity of the sacrum or coccyx.

Problems with the Genital tract:

Tumors like fibroids obstructing the birth passage.

Congenital rigidity of the cervix.
Scarring of the cervix due to previous operations like conisation.
Congenital vaginal septum.

CAUSES OF DYSTOCIA

Risk factors include:

maternal obesity
Diabetes
Preeclampsia
prolonged gestation
fetal macrosomia.
 A male infant is at a greater risk for:
Macrosomia
Dystocia

CAUSES OF FETAL DISTRESS

Prolonged Labor: Can cause fetal distress by putting excessive stress on

the fetus or by causing decreased blood supply to the placenta.
Causes of prolonged labor like CPD, breech presentation, or
failure of the cervix to dilate properly can all cause fetal distress.
Placental Insufficiency: Decreased blood flow through the placenta can
be secondary to prolonged labor or due to conditions like hypertension
(high blood pressure), diabetes, thyroid problems, infections etc.
Fetal problems: Certain problems that affect the fetus may also cause
fetal distress. A small for date fetus or a fetus with heart problems,
kidney problems or other congenital defects are more likely to develop
fetal distress.
Placental problems: Developmental defects in the placenta can also lead
to fetal distress in labor.

Conditions which increase the Risks of Fetal Distress

Some conditions may increase the risks of development of fetal distress:

Anemia
Hydramnios or Oligohydramnios (a condition in which there is a lower
level of amniotic fluid)
Pregnancy induced hypertension or Pre-eclamptic toxemia (PET)
Post term pregnancy in which the pregnancy is of more than 42 weeks
duration.
Intrauterine Growth Retardation.

IV. MANIFESTATION (s/s)

Signs of CPD
One of the main signs of cephalopelvic disproportion is that the woman
will fail to progress in her pregnancy. This means that she will continue to be
pregnant without any signs that labor is a possibility.

Signs of Shoulder Dystocia

Turtle Sign, which involves the appearance and retraction of the fetal
head (analogous to a turtle withdrawing into its shell)
 Erythematous (red), puffy face indicative of facial flushing.

Signs of Fetal Distress

The fetus may show signs of distress at any time in the first stage or the
second stage of labor. The signs of fetal distress are:
Passage of meconium (fetal stool) in the liquor amnii.
Increase of fetal heart rate above 160 per minute.
Deceased oxygen saturation in the fetal blood as diagnosed by fetal
scalp blood sampling.
Decrease of fetal heart rate below 100 per minute.

V. MEDICAL MANAGEMENT

DIAGNOSIS OF CPD
The diagnosis of cephalopelvic disproportion is often used when labor
progress is not sufficient and medical therapy such as use of oxytocin is not
successful or not attempted. CPD can rarely be diagnosed before labor begins if the
baby is thought to be large or the mothers pelvis is known to be small.

Ultrasound is used in estimating fetal size but not totally reliable for
determining fetal weight. A physical examination that measures pelvic
size can often be the most accurate method for diagnosing CPD. If a true
diagnosis of CPD cannot be made, oxytocin is often administered to help
labor progression. Alternatively, the fetal position is changed.
Clinical Pelvimetry. The assessment of the size of the pelvis is made
manually by examining the pelvis and palpating the pelvic bones by
vaginal examination. It is usually carried out after 37 weeks of
pregnancy or at the time of the onset of labor
Radio-logical Pelvimetry. X-rays or CT scans are taken of the pelvis in
different angles and views and the pelvic diameter measured. But this
method is not done nowadays as it can cause radiation toxicity to the
baby.

Management for Dystocia:

Medical Care: Management of dystocia depends on the underlying factors

of maternal condition and fetal status. When dystocia is the result of inadequate
uterine contractions, oxytocin is used. Dystocia as the result of the abnormal fetal
position can be corrected and managed by forceps delivery.

Surgical Care: Forceps delivery can be performed for transverse arrest of

the fetal head. Tucker-McLane or Kielland forceps can be used. An abnormal
position such as occiput posterior can be managed with forceps. Vacuum
extraction also can be used in some cases with abnormal position. Criteria for use
 of vacuum extraction should mirror the criteria for use of forceps. Rotation is
contraindicated with the vacuum extractor. Any instrument delivery must be
performed by a person who is familiar with the instrument and associated criteria.

Outlet forceps delivery: The scalp is visible at the introitus without

separating labia; the fetal skull has reached the pelvic floor; sagittal suture
is anteroposterior, right or left occiput anterior, or posterior; and rotation is
less than 45 degrees.
Low forceps delivery: The fetal head is at greater than +2 station and
rotation is greater than 45 degrees.
Midforceps delivery: The head is above +2 cm, but engaged.
High forceps delivery is no longer practiced.

Fetal Distress

VI. TREATMENT

CPD TREATMENT

Cesarean Section is the only option to deliver the baby.

DYSOCIA TREATMENT

Cesarean Delivery

FETAL DISTRESS TREATMENT

The immediate aim of treatment is to increase oxygen supply to the

fetus. This is done by:

Ensuring that the mother has adequate oxygen, preferably with an

oxygen mask.
Turning the mother to her left side - this removes pressure on the blood
vessels carrying blood to the uterus.
Ensuring that the mother is adequately hydrated - preferably with an IV
line.
 Tocolysis - this is a method in which drugs are used to decrease the
intensity and frequency of uterine contractions. This will cause
increased blood flow to the fetus.
Intravenous hypertonic dexctrose infusion.

VII. PHARMACOLOGICAL MANAGEMENT

DYSTOCIA

The most common medication used for treatment of dystocia is oxytocin.

VIII. NURSING MANAGEMENT

IX. REFERENCES
http://gynaeonline.com/cpd.htm
http://americanpregnancy.org/labor-and-birth/cephalopelvic-disproportion/
http://gynaeonline.com/fetal_distress.htm
http://medical-dictionary.thefreedictionary.com/dystocia
http://www.medicinenet.com/script/main/art.asp?articlekey=3418
http://www.whattoexpect.com/pregnancy/pregnancy-health/complications/fetal-di
stress.aspx
http://www.shoulderdystociainfo.com/anticipated.htm
http://patient.info/doctor/dystocia
http://pregnancytips.org/pregnancy/labor-and-childbirth/cephalopelvic-disproport
ion-signs-and-symptoms/
 https://www1.cgmh.org.tw/intr/intr5/c6700/OBGYN/f/web/Dystocia/index.htm