Contracted pelvis

Rupture of the uterus

Department of Obstetrics and Gynecology
Gomel State Medical University
Ph.D. Einysh E.A.
 Contracted pelvis is a pelvis in which one or more of
its diameters is reduced more than 1.5-2 cm (false
pelvis) or more than 0.5 cm (true pelvis)
 Contracted pelvis is one of the reasons of maternal
and fetal birth traumas, perinatal mortality and morbidity
 The reasons for the formation of an anatomically
contracted pelvis:
 Nutritional and environmental defects (rickets)
 Diseases or injuries affecting the bones of the pelvis -
fracture, tumours, tubercular arthritis; spine - kyphosis,
scoliosis, spondylolisthesis, coccygeal deformity; lower
limbs - poliomyelitis, hip joint disease
 Development defects - Naegele’s pelvis, Robert’s
pelvis; high or low assimilation pelvis
 Classification of contracted pelvis
On the basis of the shape of the inlet, the female pelvis is divided into four
parent types (based on X-ray pelvimetry):

•Gynecoid(50%) •Anthropoid(25%) •Android(20%) •Platypelloid(5%)

Inlet

Cavity

Outlet
Classification of contracted pelvis
by shape

А. Common :
 Pelvis with reduced transverse
diameters (transverse pelvic contraction)
- 61,7%,
 Pelvis with reduced antero-posterior
diameters (flat pelvis) - 19,2%
 Simple flat
 Flat rachitic pelvis 
 Pelvis with reduced cavity
 Pelvis with reduced antero-posterior
and transverse diametres (generally
contracted pelvis) -18,8%
B. Rare :
Asimmetrical and obliquely contracted pelvis - 0,3%
Pelvis contracted with exostosis, bone tumors,
fractures

Obliquely contracted
pelvis
 Diagnostic algorithm of contracted pelvis

Past history Physical Examination

•Height, weight
Medical
•Infection index Abdominal Examination
•Age at menarche, menstrual dysfunction Assessment of the pelvis:
•Pelvimetry
•Endocrine pathology
•Rhombus of Michaelis,
•Diseases of the skeletal system
•Diameters of the pelvic outlet
•Pelvic trauma
•Obstetrical Obstetric grips (Leopold maneuvers)
•Clinical course of previous pregnancies Assessment of the size of the uterus:
and labor (previous safe vaginal delivery, height of the fundus and girth of the
difficult instrumental delivery, difficult vaginal abdomen
delivery ending in stillborn or early neonatal
The estimated fetal weight
death following a difficult labour) Vaginal examination
weight of the baby
evidences of maternal injuries (complete
perineal tear, vesico-vaginal or recto-vaginal
Select a group of patients
fistula) with anatomically contracted pelvis
and cephalo-pelvic disproportion
Diagnosis of contracted pelvis: external
pelvimetry

D. spinarum=25-26 см
C.externa=20-21 см

D. cristarum=28-29 см

D. trochanterica=30-31 см

TC=C.externa-9 cm
 Diagnosis of contracted pelvis:
rhombus of Michaelis

TC=the vertical size of the rhombus

Obstetric grips (Leopold maneuvers):

Fundal grip (first Leopold);

Lateral grip (second
Leopold);
Pawlik’s grip (third Leopold);
Pelvic grip (fourth Leopold)

• Transverse or oblique fetal

position. Pregnant women
abnormal position of the fetus in
25% have contracted pelvis

• Breech presentation of the fetus

in women with contracted
pelvis occurs three times more
often than in women with a
normal pelvis
Assessment of the size of the uterus:height of the
fundus and girth of the abdomen

Fetus weight=height of the fundus x girth of the abdomen

 Vaginal examination -
measurement of diagonal conjugate

True conjugate
С. diagonalis C. vera=C. diagonalis-2,5 cм

TC=C.diagonalis-1.5-2 cm
 Degrees of contracted pelvis
(according to true conjugate (TC):

 I (minor) – TC 11-9 сm
 II (moderate) –TC 9-7,5 сm
 III (severe) –TC 7,5-6 сm
 VI (extreme) –TC less than 6 сm
 Degrees of contracted pelvis
(according CT, MRI)
 I – 0,5 - 1 cm on any of the diameters
 II - more than 1 cm in any diameters of the pelvis
 Complications of pregnancy with
contracted pelvis

 Fetal head does not descend into the pelvis, the growing
uterus rises and makes it difficult to breath – so early
manifestate shortness of breath, palpitations, fatigue,
and they manifestate more than in a pregnancy with
normal pelvis.
 Transverse or oblique fetal position. Pregnant women
abnormal position of the fetus in 25% have contracted
pelvis
 Breech presentation of the fetus in women with
contracted pelvis occurs three times more often than in
women with a normal pelvis
 Complications of pregnancy with
contracted pelvis
Fetal head does not descend
into the pelvis - preterm
rupture of membranes
Umbilical cord prolapse
Management of pregnancy with contracted
pelvis

 Pregnant women with contracted pelvis are at high risk

of obstetric and perinatal pathology
 Prevention of big baby syndrome
 Timely diagnosis of abnormalities of the fetus position
and their correction
 The exact definition of date of labor to prevent prolonged
pregnancy
 Admission to the department of pathology of pregnancy
for the diagnosis and choice of optimal way of delivery
 Management of labor

 Elective cesarean section at term

 Trial labor
 Indications to Cesarean section
Combination of contracted
 anatomically contracted pelvis of I degree with
pelvis of II-IV degree  macrosomia
 prolonged pregnancy
 bone tumors in the true
 breech presentation
pelvis, obstructed labor
 chronic hypoxia of the
 posttraumatic fetus
deformations of the pelvis  congenital abnormalities
of reproductive organs
 rupture of symphysis  uterine scar after
pubis in previous labor previous C-section
 rupture of perineum of III  infertility in anamnesis

degree  primipara 30 years old

and older
 Trial labor

 It is the conduction of spontaneous labor

in a moderate degree of cephalo-pelvic
disproportion with watchful expectancy,
hoping for a vaginal delivery
 A trial labor aims are avoiding cesarean
section and delivery a healthy baby
Complications of labor with contracted pelvis

 preterm rupture of membranes (44.7%)

 acute hypoxia (22.5%) as a result of prolapse of cord or
small parts of the fetus
 abnormal uterine activity (20.1%)
 cephalo-pelvic disproportion (11.0%)
 shoulder dystocia (5%)
 prolonged duration of labor
 fetal hypoxia and fetal injury
 maternal trauma (lacerations of birth canal, uterine
rupture, fistulas)
 inflammatory diseases of pelvic organs in postpartum
period
 Management of trial labor
 The management of a trial labor requires careful supervision
 The labor should be spontaneous in onset. But in cases where the labor
fails to start even on due date, induction of labor may be done
 Adequate analgesic is administered
 The progress of the labor is mapped with a partograph -progressive
dilatation of the cervix and progressive descent of the head
 To monitor the maternal health
 Fetal monitoring is done clinically and or using CTG
 If there is failure to progress due to inadequate uterine contraction,
augmentation of labor may be done by amniotomy along with oxytocin
infusion.
 After the membranes rupture, pelvic examination is to be done:
 to exclude cord prolapse;
 to note the color of liquor;
 to assess the pelvis once more
Сephalopelvic disproportion: disproportion
between the head of the fetus and the
mother pelvis
 Causes of cephalopelvic disproportion:
Normal size baby with a narrow pelvis
 Big baby with normal size pelvis
 Combination of both the factors
 Malpresentations
 Malformations
 When cephalopelvic disproportion tests must be
established?

Active phase of the 1 stage or the second stage of labor

Full or almost full dilatation of the cervix
Ruptured membranes
Adequate uterine contractions
Evacuated bladder
Nowadays there is a tendency to shorten the duration of trial:
3-4 hours in the active phase of the first stage, 1 hour in the
second stage
 Symptoms of cephalopelvic
disproportion
 Hypertonic disfunction of uterus
 Bearing down efforts in engaged to inlet head
 Absence of descent of the fetal head during uterine
contraction
 Secondary uterine inertia
 Positive Vasten's and Zangemeister signs, which show the
ratio of the head to the pelvic brim
 A distended tender lower segment
 Bandl’s ring may be visible
 Evidences of fetal distress
 Edema of internal and external genitalia
 Particularities of engagement of fetal head: configuration,
moulding, abnormal succedaneum, asynclitism,
Positive Vasten's  sign, which show the ratio of
the head to the pelvic brim
 Abdominal method

-The head can be pushed down in the pelvis without overlapping of the
parietal bone on the symphysis pubis - no 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
(overlapping by 0.5 cm or 1/4 of the thickness of the symphysis pubis) -
moderate disproportion.
- Head cannot be pushed down and instead the parietal bone overhangs the
symphysis pubis displacing the fingers - severe disproportion.
Abdominovaginal method (Muller-Munro-Kerr):
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
-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 - no
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 - slight or
moderate disproportion
-The head cannot be pushed down and instead
the parietal bone overhangs the symphysis pubis
displacing the thumb - severe disproportion
 Edema of external genitalia

Bandl’s ring
Particularities of engagement: moulding,
abnormal succedaneum
 Symptoms of
cephalopelvic
disproportion
-emergency CS
 Rupture of the uterus

Rupture of the uterus is

violation of the integrity of
its walls
Frequency is 0,015% - 0,1
 Mortality is 3-4%

 Fetal death is up to 100%

 During pregnancy

Scar rupture:
dull abdominal pain over the scar area

slight vaginal bleeding

tenderness of uterus during palpation
FHS may be irregular or absent

Spontaneous rupture in uninjured

uterus:
acute pain in abdomen
collapse, features of shock

 acute tenderness on abdominal

examination
 palpation of superficial fetal parts, if the
rupture is complete
absence of fetal heart rate
 During labor
 Scar rupture: The features are the same as those occur during pregnancy
 Spontaneous obstructive rupture:

 Premonitory phase:
 the patient with features of obstruction

 Initially, the pains become severe in an attempt to overcome the

obstruction and come at quick intervals. Gradually, the pains become
continuous and mainly confined to the suprapubic region.
On general examination the patient is dehydrated and exhausted. The pulse
rate and temperature rise
Abdominal examination reveals
 a distended tender lower segment

 Bandl’s ring may be visible

 evidences of fetal distress or FHS may be absent

On vaginal examination
• the presenting part is found jammed in the pelvis
• vagina becomes edematous
 During labor
 Phase of rupture:
 The constant pain is changed to acute pain at the height of
uterine contraction
General examination reveals features of exhaustion and
shock
Abdominal examination reveals
 superficial fetal parts

 absence of FHS

 absence of uterine contour

 two separate swellings, one contracted uterus and the other

— fetal ovoid
Vaginal examination reveals
 recession of the presenting part

 varying degrees of bleeding

 In premonitory phase - prevent the
rupture

 immediate reduction of uterine activity

(general anesthesia)
 emergency cesarean section
 Treatment of uterine rupture:

 1) operation
 2) adequate analgesia
 3) infusion and transfusion
 4) correction of blood coagulation
 Particularities of operation:
 Lower midline laparotomy
 Revision of pelvic and abdominal organs
 Plan of operation is strictly individual and solved during the
operation
 Suturing the rupture on the uterus (in the absence of
infection, shock and DIC, normal contraction activity of the
uterus)
 Hysterectomy with tubes (for big lesions of the lower
segment, rupture of the cervix, rupture of the uterus from
the vaginal part, peritonitis, DIC).
 Abdominal drainage
 Group of high risk of uterine rupture
 uterine scar after prior cesarean delivery,
conservative myomectomy, uterine perforation during
the abortion;
 complicated obstetric history (multipara, who had
several abortions, complicated course of post-
abortion period);
 cephalopelvic disproportion (big fetus, contracted
pelvis, abnormal fetal presentation or position, fetal
hydrocephalus);
 abnormal labor with oxytocics
 Lacerations of the birth canal

 Ruptures of the uterus, cervix, vagina, external

genital organs, perineum
 Hematomas of vagina and external genital
organs
 Inversion of the uterus
 Ruptures of pelvic junctions
 Fistulas
Thank you for your attention!