PROBLEMS WITH THE PASSAGE

• Abnormal size or shape of the pelvis


  Narrowing of the passageway/ birth canal
• Cephalopelvic disproportion


  A disproportion between the size of the fetal head and the pelvic diameters
• Shoulder dystocia


  Delayed or difficult birth of the shoulders that may occur as they impacted above the maternal symphysis pubis
• Types of pelvis


  • Gynecoid- ideal
  • Anthropoid- oval inlet shape
  • Android- male pelvis, heart shaped
  • Platypelloid- compressed front-back, oval
• Inlet contraction


  Narrowing of the anteroposterior diameter to less than 11 cm, or the transverse diameter to 12 cm or less
• Fetal head engagement


  1. Primigravida - fetal head engage bet. 36-38 weeks of pregnancy

  2. If engagement occurs before labor, proof that pelvic inlet is adequate

  3. General rule "what goes in, comes out"

  4. If engagement does not occur in primi, fetal abnormality or pelvic abnormality

  5. Engagement does not occur in multigravida until labor begins
• Cephalopelvic disproportion (CPD)


  Fetus does not engage and remains floating, malposition may occur and may complicate the situation
• Management of inlet contraction

  1. Primigravida - should have pelvic measurements taken and recorded before 24 weeks of pregnancy

  2. Based on measurements, birth decision can be made
• Outlet contraction


  Narrowing of the transverse diameter at the outlet to less than 11 cm. distance between the ischial tuberosities
• Management of outlet contraction

  1. Trial labor - if the woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good

  2. External Cephalic Version - turning of a fetus from breech to a cephalic position before birth

  3. Forceps births - unable to push with contractions, cessation of descent, fetus in abnormal position or distress

  4. Vacuum Extraction - for a fetus positioned far enough down the birth canal
• Shoulder dystocia drill


  1. Ask for help

  2. Lift legs (McRoberts maneuver)

  3. Anterior shoulder disimpaction (Mazzanti maneuver and Rubin's maneuver)

  4. Rotation of the posterior shoulder

  5. Manual extraction of the posterior arm

  6. Episiotomy

  7. Roll on all fours (Gaskin maneuver)
• Cleidotomy


  Fracturing the clavicle with scissors
• Symphysiotomy


  Symphysis cartilage is cut
• Zavanelli maneuver


  Return the head to the occiput anterior or posterior position, give acute tocolysis, flex head and slowly push back to the vagina, then do CS