Cephalopelvic Disproportion (CPD)

Dfn: When the head of the fetus does not fit in to the
mother’s pelvis or a delivery condition in which the
mother’s pelvis is too small to allow the fetal head to pass
through.
It can be classified as mild, moderate or severe.
Causes
- Contracted pelvis
- Big baby
- Occipito posterior position
- Pelvic tumors
- Malpresentations: Face, brow
 Degrees of cephalopelvic disproportion

• Mild - Where the anterior parietal bone is at level

with symphysis pubis.
• Moderate - The head slightly overlaps at the edge
of the pubis
• Severe - The head bulges over the symphysis
pubis
• Methods of determining C.P.D.
• 1. Determining the degree of overlap by placing
the fingers on the symphysis pubis while pressing
the head down and with the other hand.
2. Head fitting - Sitting patient up method - patient lies
on the bed. Let the patient to sit up by her own effort.
The effort should force the head into the pelvis and
the midwife will feel its slip past her hand.

3. Head fitting - left hand grip method - Grasp head

with left hand and push it downward and backward if
a sense of giveness felt there is no overlap or C.P.D.
Management
• For mild and moderate C.P. D- Trial of labour is
given
• Severe C.P. D. Cesarean section will be performed.
TRIAL OF LABOUR
• Defn: - A test given to a woman with mild or
moderate CPD to see if she can deliver her
baby with least damage to herself & baby.
• The outcome of a trial of labor depends on:-
1. The strength of uterine contraction
2. The stretch of the pelvic joints & ligaments
3. The degree of moulding
Management of a trial of labor
- The trial of labour must be carried out in the
health where there is a service for caesarean
section at any time.
1. The Pregnancy is allowed to go to term
2. Careful observations are kept. Descent of the
head assessed frequently.
Strict asepsis is maintained as there is possibility of
caesarean section FHR and mother’s pulse and
B/P are also observed
N.B:- Descent is the most important observation
• 3. Keep her comfortable
• 4. Stay with the patient, talk to her about the labor
progress, and help her to be relaxed
 The following conditions should be reported to
doctor:-
a) Head still high after 6-8 hrs of good
contraction
b) Rupture of membrane before full dilation.
c) Un satisfactory uterine action
d) Change of vertex to face or brow
e) Fetal distress
f) Maternal distress
A trial of labor has failed when one of the
following occurs
1. Fetal distress
2. Maternal distress
3. Failure to advance after 6-8hrs of good
contraction
When any of the three complications occurs
caesarean section will be done
Trial of scar
• When a woman has had a scar of caesarean section is
given chance to deliver vaginally. This trial is given
to see if the scar is strong enough to withstand the
labour. Like trial of labour it has to be conducted in
hospital.
• Conditions in which trial of scar is considered are:
- Spontaneous labour
- Only one caesarean section scar
- Vertex presentation
- No cephalo pelvic disproportion
- No doubt about the presentation
Failure of trial scar is indicated by:
- Pain and tenderness over the scar
- Slight vaginal bleeding
- Slight raise in pulse
Vacuum is usually applied in 2nd stage if there is no
sign of rupture.
Amniotic Fluid Embolism
• Amniotic fluid embolism is a rare obstetric
emergency in which amniotic fluid, fetal cells,
hair, or other debris enter the maternal
circulation, causing cardio respiratory collapse
• It is one of the obstetric emergencies
 signs and symptoms
• Hypotension
• Dyspnea
• Seizure
• Cough
• Cyanosis
• Fetal bradycardia
• Pulmonary edema
• Cardiac arrest
• Uterine atony
 DIFFERENTIAL DIAGNOSIS
• Anaphylaxis
Myocardial Infarction
Pulmonary Embolism
Septic Shock
 Treatment is supportive
• Administer oxygen to maintain normal saturation
• Initiate cardiopulmonary resuscitation (CPR) if the
patient arrests
• Treat hypotension with crystalloid and blood
products.
• Continuously monitor the fetus.
• Treat coagulopathy with Fresh Frozen Plasma / fresh
whole blood
• Perform emergency cesarean delivery in arrested
mothers who are unresponsive to resuscitation
• Women who survive amniotic fluid embolism will
probably require admission to an ICU.
Drugs are used in amniotic fluid embolism to stabilize
the patient
• vasopressor agents e.g. Dopamine 2-5 mcg/kg/min
IV - Used to maintain blood pressure.
• inotropic agents e.g. Digoxin 0.5 mg IV push, then
0.25 mg IV 4h for 2 doses, followed by 0.25 mg PO
b.d - Used to improve myocardial contractility in
patients with amniotic-fluid embolism.
• Steroids e.g. Hydrocortisone 500 mg IV 6hrly
Because amniotic fluid embolism is more similar to
an anaphylactic reaction
• Uterotonics e.g. -Pitocin 10 U IM or 10-40 U IV
Cause the uterus to contract

• Methylergonovine -0.2 mg IM may repeat after 10-

15min for 3 doses
-Acts directly on uterine smooth muscle, causing a
sustained tetanic uterotonic effect that reduces uterine
bleeding.

Deterrence/Prevention
Complications:
• Pulmonary edema is a common occurrence in
survivors. Pay close attention to fluid input and
output.
• heart failure may occur. Some sources
recommend inotropic support.
• Treat DIC with blood components
• Maternal mortality is 61%.
• Most survivors have neurologic deficits.
• The intact infant survival rate is 70%.
Neurologic status of the infant is directly
related to the time elapsed between maternal
arrest and delivery