1. Pregnancy and labor at fetal malpresentations and abnormal pelvis
Prepared by N. Bahniy

2. The main external pelvic sizes
D. Spinarun - distance between anterior superior iliac spines from both sides. It has cm.
D. Cristarum – distance between iliac crista from both sides. It is cm.
D. Trochanterica – distance between trochanter majors from both sides. It has cm.

3. C. Externa - distance between midpoint of superior surface of the symphysis pubis and suprasacralis fossa. It has cm

4. Michaelis’ Rhomb and Solovjov index
Vertical 11cm, transverse – 10cm
Solovjov index- radiocarpal joint circumference cm

5. Additional external pelvic sizes
Lateral conjugate –is a distance between the anterior superior iliac spine and posterior superior iliac spine of the same iliac bone. It has cm.
Oblique conjugate –is a distance between the right anterior superior iliac spine to the left posterior superior iliac spine. It has cm.

6. Additional external pelvic sizes
Anteroposterior diameter of the pelvic outlet is a distance between the lower par4t of symphysis pubis and apex of the coccyx. It has 9.5 cm.
Transverse diameter of the pelvic outlet is a distance between the posterior portions of the ishial tuberosities. It has 11.5 cm.
Solovjov’ index. It is estimated by the circumference of radiocarpal joint. It has cm and indicates into bones’ pelvic thickness.

7. Obstetric conjugate (widest anteroposterior diameter of the pelvic ) – 11cm
Indirect ways of true conjugate estimation:
Diagonal conjugate, usually exceeds the obstetric conjugate by 1.5 to 2 cm.
External conjugate exceeds the obstetric conjugate by 9 cm.
Vertical dimension of Michael’s’ rhomb equal obstetric conjugate.

8. Estimation of diagonal conjugate

9. Fetal head station -2 (fixed to pelvic inlet)
-1(small segment of fetal head in pelvic inlet)
0 (large segment of fetal head in pelvic inlet)
+1 (fetal head in plane of greatest dimension)
+2 (fetal head in plane of least dimension)
+3 (fetal head in the pelvic outlet)

10. Diameters of the fetal head at term
1. The suboccipitobregmatic (9.5 cm, 32cm), which follows from the middle of the large fontanel to the undersurface of the occipital bone.
2. The suboccipitofrontalis (10cm,33 cm) – from subocipital fossa to border of the hair.
3. The occipitofrontal (12 cm, 34 cm), which follows a line extending from a point just above the root of the nose to the most prominent portion of the occipital bone.
4. The occipitomental ( cm, 39-41cm), from the chin to the most prominent portion of the occiput.
5.The sublingquobregmatica (9,5 cm, 32 cm).
6. The biparietal (9.5 cm), the greatest transverse diameter of the head, which extends from one parietal boss to the other.
7. The bitemporal (8.0 cm), the greatest distance between the two temporal sutures.

14. Transverse lie

15. Oblique lie

16. Breech presentations Circumference of the buttocks – 34-35cm
C.of the shoulders – 34-35cm
C. of fetal head – 32cm
Circumference of the buttocks – 28cm
C.of the shoulders – 34-35cm
C. of fetal head – 32cm
Circumference of the buttocks – 32cm
C.of the shoulders – 39-41cm
C. of fetal head – 32cm

17. From 30-32 weeks -correcting gymnastics

18. External cephalic version – at 32-36 weeks of gestation

19. Management
Breech presentations
– cesarean section !

20. The manual aid by Tsovyanov I in frank breech presentation
Aim: to keep normal fetal attitude.The extremities are flexed at the hips and extended at the knees and thus the feet lie in close proximity to the head.
The circumference of the thorax with the crossing on it arms and legs is larger than circumference of the head and the after-coming head deliveries easily.

21. The manual aid by Tsovyanov II in footling presentations
The aim: to transform the footling presentation to the incomplete breech and to prepare the maternal ways to the delivery of the head and shoulders.
The doctor puts up resistance to the delivery of the feet. The feet are flexing and the footling presentation becomes complete breech presentation.

22. The classic manual aid begins when the lower angular of the anterior scapula became visible
Aim: delivery of the shoulders and the head when in 2 pushing efforts they are not delivered.
There are 4 moments of the classic manual aid:
I - delivery of the posterior arm.
II – transformation anterior arm into posterior one
III – delivery of the second arm
IV – delivery of the head by Mauriceau-Levre maneuver

23. Dexlefed presentations
Face
D. hyo-bregmaticus
9.5cm, 32cm
Sinciput vertex
D. fronto-occipitalis
12cm, 34cm
Brow
D.Mentooccipitalis
13 – 13,5cm, 39-41cm

24. Sinciput vertex presentation
In vaginal exam: sagittal suture, large and small fontanels are on the same level.
The fetal head presents with a fronto-occipital diameter – 12cm
The leading point is the large fontanel.
The cardinal movements in labor:
deflexion;
internal rotation;
flexion;
extension;
internal rotation of body and external rotation of fetal head.
Vaginal Delivery is possible in posterior variety in:
Not large fetus
Adequate uterine contractions
Normal pelvic sizes

25. Brow presentation
In vaginal exam: the frontal suture, the large fontanel, orbital ridges, eyes, and root of the nose. The nose and mouth can not be palpable.
The fetal head presents with a mento-occipital diameter – 13 – 13,5cm
The leading point is the middle of the frontal suture.
Vaginal delivery is impossible, only cesarean section is recommended.

26. Face presentation
On vaginal exam: face line with mouth, nose, the, orbits and chin are presented
The leading point is chin
The fetal head presents with hyo-bregmaticus diameter 9,5cm
The cardinal movements in labor are:
deflexion;
internal rotation;
extension;
internal rotation of the fetal body and external rotation of the fetal head.
Vaginal delivery – in face posterior(chin anteriorly)
Cesarean section in face posterior.

27. CONTRACTED PELVIS
Anatomically contracted pelvis is characterized by shortening of all or one diameters of the true pelvis into 1,5 - 2 cm and more.

28. Clinically or functional contracted pelvis - pelvis with normal dimensions, but vaginally delivery is impossible due to “cephalopelvic disproportion”.
The main causes:
fetal macrosomia
postdate pregnancy
uterine inertia
fetal malpresentation, especially fetal head extension – sinciput vertex, brow, face anterior position.

29. Signs of clinically contracted pelvis
1.Arresting of the head in the pelvic inlet
2.Uterine contractions abnormality.
3. Positive Vasten’ sign
4. Signs of urinary bladder compression.
5. Edema of the cervix, and vaginal walls, productions of fistulas.
6. Danger of uterine rupture – overdistension of lower uterine segment
7. Pushing occurs in location of fetal head in inlet.
Negative
Positive
At the same level

30. Uterine rupture

31. In clinically contracted pelvis – only cesarean section

32. Pelvic classification according to form of contractions
1. Often occurred
generally contracted pelvis;
flat pelvis: simple flat pelvis, flat rachitic pelvis, generally contracted flat pelvis.
2. Rare occurred:
obliquely contracted pelvis,
obliqualy dislocated pelvis,
transverse contracted pelvis,
osteomalacic pelvis,
funnel-shaped pelvis,
spondylolisthetic pelvis,
contracted pelvis as a result of exostosis and bone tumors.
Management of labor. Cesarean section should be performed in all of these types of pelvis.

33. Pelvic classification according to degree of contraction
Four degrees of pelvic contractions should be distinguished:
I degree – True conjugate is 11-9 cm. Vaginal delivery is possible.
II degree – True conjugate is 9-7,5 cm. Vaginal delivery is possible.
III degree – True conjugate is 7,5 – 5,5 cm Cesarean section is performed.
IV – degree – True conjugate is 5.5 cm. Cesarean section is performed.

34. Generally contracted pelvis
Is characterized by diminution of all true pelvic diameters (anteroposterior, transverse, and oblique) into 1-2 cm. Subpubic arch is narrow.
Average sizes of the pelvis are:
D. spinarum – 23 cm,
D. cristarum – 26 cm.
D. trochanterica cm
C. externa – 18 cm
C. diagonalis – 11 cm
C. vera – 9 cm.

35. Course of labor in generally contracted pelvis
prolongation of labor
considerable fetal head flexion thanks to which it is elongated in the ocipitofrontal diameter (dolichocephaly)
posterior fontanel is situated into the axis of pelvis
considerable molding of the fetal head. Caput succedaneum is formed in the area of posterior fontanel
with increasing narrowing of the pubic arch, the occiput cannot emerge directly beneath the symphysis as a result perineal tears occur.
Management of labor. Vaginally delivery is possible.

36. Simple flat pelvis
Is defined as shortening of anteroposterior diameters at all levels of true pelvis, as a result of this sacrum is inclined anteriorly to pubis.
Average sizes of the pelvis are:
D. spinarum – 26cm
D. cristarum – 29 cm
D. trochanterica cm
C. externa – 18 cm
C. diagonalis – 11 cm
C. vera – 9 cm.

37. Flat rachitic pelvis
True conjugate is shortened.
Sidewalls tend to converge, as result of this D. spinarum and D. cristarum are the same.
Additional promontorium may be presented between 1 and 2 vertebrae of sacrum
Subpubic arch is shallow and wide
Top of the sacrum is situated posteriorly that’s why dimensions of the pelvic outlet are normal or even increased.
Average sizes of the pelvis are:
D. spinarum – 26cm
D. cristarum – 26 cm
D. trochanterica cm
C. externa – 17 cm
C. diagonalis – 10 cm
C. vera – 8 cm. .

38. Course of labor in flat pelvis
prolongation of labor;
sagittal suture arresting in the transverse diameter of the plane of inlet;
anterior fontanel is the leading point of the fetal head
asynclitism should be presented
Management of labor. In the case of posterior asynclitism cesarean section should be performed. Vaginal delivery in a flatrachitic pelvis

39. Generally contracted flat pelvis
Is characterized by combination of the signs of generally contracted and flat pelvis.
Average sizes of the pelvis are:
D. spinarum – 24cm
D. cristarum – 25 cm
D. trochanterica cm
C. externa – 16 cm
C. diagonalis – 9 cm
C. vera – 7 cm.
Course of labor depends from predominance of kind of pelvis contraction.
Management of labor. Cesarean section is the method of choice.

40. Thanks for attention