It

The Journal of Obstetrics and Gynaecology -

of the British Commonwealth
11 VOL. 77 No. 5 NEW SERIES MAY 1970
ACTIVE MANAGEMENT OF LABOUR AND CEPHALOPELVIC
DISPROPORTION
BY
KI ERAN ODRISCOLL, REGINALD J. A, J ACKSON AND J OHN T. GALLAGHER
National Maternity Hospital, Dublin
Summary
A preoccupation with cephalopelvic disproportion is the main reason for a
reluctance to abandon the conservative attitude towards labour which prevails in
the United Kingdom and Ireland. I n a series of 1000 consecutive primigravidae, in
which an active approach to labour was adopted, the incidence of disproportion
was less than 1 per cent and there was notable absence of trauma, especially to the
child.
Oxytocin stimulation is recommended as an essential instrument to define dispro-
portion when the natural forces are not adequate. Excessive caution is criticized
because a diagnosis of disproportion cannot be made unless uterine action is
adequate. 1 t is concluded that the possibility of cephalopelvic disproportion does
not justify a passive attitude towards labour in a modern maternity unit.
THE special significance of cephalopelvic dispro-
portion is that it commits a young woman to
Caesarean section at every delivery. This places
a responsibility on the obstetrician to ensure
that the initial diagnosis is correct. A wide
variation in the reported incidence from similar
hospitals suggests that this is often not the case.
An aspect of the problem which has a much
wider significance concerns the general manage-
ment of labour. I t has been stated frequently
that disproportion is a common cause of
protracted labour and that ocytocin should
never be given to accelerate progress unless
disproportion has been excluded (Hellman,
19 59 ; Friedman and Sachtleben, 1962 ; Turnbull
and Anderson, 1968). The result is that few are
willing to apply stimulation effectively lest this
should result in injury to mother or child.
During recent years an active approach to
labour has been adopted at the National
Maternity Hospital in which the emphasis is on
stimulation to achieve early delivery (ODriscoll
et a! ., 1969). Prolonged labour has been elimi-
385
13
nated with the result that disproportion has been
isolated as a separate entity. The purpose of this
paper is to establish the true incidence of
disproportion and to examine the proposition
that inefficient labour in primigravidae is often
an expression of disproportion.
MATERIALS AND METHODS
A prospective study of loo0 consecutive
primigravidae was conducted between 1 st J anu-
ary and 16th September, 1968. A policy of active
management ensured that every woman had
efficient uterine action in labour. This was
achieved by early recourse to stimulation and
was measured by dilatation of the cervix. When
dilatation of the cervix was not progressive the
forewaters were ruptured, and if this did not
accelerate progress an intravenous infusion of
oxytocin was given. A standard concentration of
10 units of oxytocin per litre of 5 per cent
dextrose was used and the drip was regulated to
ensure dilatation of the cervix. The only factor
386 ODRISCOLL, JACKSON AND GALLAGHER
which limited the rate of infusion was fetal
distress. Oxytocin was never withheld because
disproportion was suspected.
Cephalopelvic disproportion was suspected on
the basis of a free head which could not be made
to engage in the pelvis after 38 weeks. X-ray
pelvimetry was performed in these cases but
assessment of the pelvis by vaginal examination
or head-fitting tests under anaesthesia were not
practised. Every patient suspected of dispropor-
tion was submitted to a trial of labour. Dispro-
portion was excluded when delivery occurred in
less than 24 hours without injury to mother or
child. A presumptive diagnosis of disproportion
was made when this was not achieved.
The possibility that disproportion may have
been overlooked in some cases not submitted to
trial of labour was recognized. These cases
would be recorded as Caesarean section per-
formed for another reason, or as cases of
prolonged labour, laceration of the birth canal
or injury to the fetus when vaginal delivery was
achieved. A critical assessment was maintained
to ensure that disproportion was not concealed
under these headings. I n the event of a second
delivery having occurred during the interval since
the series was completed, the outcome has been
stated. Malpresentations and malformations
were not included as cases of cephalopelvic
disproportion; there were 35 breech, 1 brow and
I face presentations and 2 cases of hydro-
cephal u s .
RESULTS
In this series of 1000 consecutive primigravidae
no elective Caesarean section was performed for
disproportion and no perinatal death was caused
by traumatic intracranial haemorrhage. No
mother sustained an injury more severe than a
second degree laceration of the perineum and the
duration of labour exceeded 24 hours in only one
instance. Oxytocin was infused to induce labour
in 79 cases with 2 perinatal deaths from congeni-
tal malformations and to accelerate labour in
120 cases with one perinatal death from hypoxia
in a second twin. Disproportion was suspected
in 30 cases, but these were reduced to 22 when
the head subsequently engaged in 8 cases.
Trial of Labour
A trial of labour was conducted in 22 cases i n
which the head was not engaged at the onset of
labour. This proved successful on 13 occasions
when vaginal delivery was achieved in less than
24 hours without injury to mother or child. The
unsuccessful cases included 7 Caesarean sections,
2 perinatal deaths of which one occurred in a
case delivered by Caesarean section, and the
only prolonged labour in the series. This group
of 9 failures included all the cases of cephalo-
pelvic disproportion in I000 primigravidae
(0-9 per cent). Three of these patients became
pregnant again and each had a normal delivery.
The extraneous factors which affected the trial of
labour in these cases were prolapsed cord,
infertility at 35 years of age and prolonged
pregnancy. The other six patients have not
become pregnant again. Pregnancy was pro-
longed to 42 weeks in 10 cases submitted to trial
of labour; 5 Caesarean sections and both perinatal
deaths were included in these 10 cases.
Oxytocin was infused to induce labour for 4
patients all of whom were subsequently delivered
by Caesarean section, and to accelerate labour for
7 patients all of whom achieved vaginal delivery.
Neither of the perinatal deaths was associated
with oxytocin. There was radiological evidence
of contracted pelvis in 13 cases; the antero-
posterior diameter of the brim was less than
10 cm. in 4 cases and the transverse diameter
less than 12 cm. in 9 cases. Oxytocin was infused
in 5 cases with contracted pelvis and 4 of these
patients achieved vaginal delivery. The height of
the mother was less than 155 cm. in 12 cases and
only one mother exceeded 160 cm.
Caesarean Sections
There were 40 Caesarean sections (4 per cent).
The operation was performed during labour in
12 cases and before labour in 28 cases. The
indications for Caesarean section during labour
were: disproportion (9, fetal distress (3),
prolapsed cord (l), abruptio placentae (I ), brow
presentation (1) and breech presentation (1). A
diagnosis of disproportion was made in 4 cases
when the head did not engage during labour
and in one case when trial of labour was cur-
tailed by fetal distress. A trial of labour was
interrupted by prolapse of the cord in a sixth
case. The head was engaged before 38 weeks in
the cases of fetal distress and abruptio placentae.
ACTIVE MANAGEMENT OF LABOUR AND CEPHALOPELVIC DISPROPORTION 387
The indications for Caesarean section before
labour were : toxaemia (12), breech presentation
(8), placenta praevia (2), abruptio placentae (2),
ovarian cyst (1) maternal age (l), face presenta-
tion (1) and fetal distress (1). Caesarean section
was performed because meconium was seen
when the membranes ruptured before labour in
the case of fetal distress, and this is included as
an unsuccessful trial of labour because the head
was not engaged. Disproportion was not
suspected in any other case.
Perinatal Deaths
There were 25 perinatal deaths (2.5 per cent).
Necropsy was performed in every case. Congeni-
tal malformations caused 8 deaths. The circum-
stances in the other cases were that 10 deaths
occurred before labour, 3 during labour and 4
after birth. Two of the liveborn infants, who died
from respiratory distress, had been delivered
before labour by Caesarean section. All 5 infants
who died during or after labour suffered pro-
found distress and showed evidence of hypoxia
at necropsy.
Two deaths occurred in cases suspected of
disproportion ; prolonged pregnancy was a
critical factor on both occasions, one occurred at
44 weeks before labour began and Caesarean
section was performed subsequently for dispro-
portion, the other occurred after the head
engaged in labour at 42 weeks.
Brain Damage
Four infants (0.4 per cent) showed signs of
brain damage at discharge from hospital. The
obstetrical factors were abruptio placentae (2
cases), and prolonged pregnancy (2 cases).
Disproportion was not suspected in any case.
The infants were examined after six months
when three had cerebral palsy, and the only case
stimulated with oxytocin was normal.
DIscussioN
The incidence of cephalopelvic disproportion
cannot be stated precisely but a reasonable
estimate can be made when this is based on
objective clinical standards. The simple standard
adopted in this series was failure to achieve a
vaginal delivery in 24 hours without injury to
mother or child. A diagnosis was made on this
basis on 9 occasions in lo00 consecutive primi-
gravidae. The diagnosis was influenced in some
cases by other factors with the result that the
only three patients who became pregnant again
had normal deliveries. It is concluded that the
incidence of cephalopelvic disproportion was
less than 1 per cent.
Safe delivery within a reasonable time is the
only proof of the functional capacity of a pelvis,
and failure to achieve this in cases suspected of
disproportion is due usually to inefficient
uterine action (Donald, 1969). Early stimulation
to ensure progress in labour corrects inefficient
uterine action and therefore isolates dispropor-
tion. It has been stated that disproportion is
often the cause of delay in labour (Hellman,
1959; Friedman and Sachtleben, 1962) but our
experience lends no support to this observation.
In this series of 1000 primigravidae there were
120 cases of inefficient labour in which stimula-
tion was applied; one patient was subsequently
delivered by Caesarean section, one perinatal
death occurred in a second twin and one infant
suspected of cerebral damage was normal when
six months old.
The purpose of stimulation is to ensure normal
progress in labour which is measured by dilata-
tion of the cervix. A diagnosis of disproportion is
established when there is no corresponding
descent of the fetal head. Stimulation is exploited
in this hospital as an instrument to define
disproportion when the natural forces are
inadequate. It is never the intention to surmount
obstruction by force and fetal distress is of
paramount importance i n the conduct of labour,
whether or not this is stimulated with oxytocin.
The effect has been that, as prolonged labour
has been eliminated, the incidence of dispropor-
tion has been greatly reduced. Disproportion
was suspected in seven cases treated to accelerate
labour in the present series and all achieved safe
vaginal delivery ; suggestions that disproportion
may have been surmounted by force have no
meaning in these circumstances.
There is a considerable difference of opinion
about the safety of stimulation in primigravidae
in whom cephalopelvic disproportion is suspec-
ted. Theobald et al. (1956) and Hannah (1965)
did not consider this a contraindication, and
Goodwin and Reid (1963) concluded that
oxytocin demonstrated safely and quickly the
388 ODRISCOLL, JACKSON AND GALLAGHER
limits of uterine ability in trial of labour.
Ledger (1969) advocated an aggressive policy
towards labour in patients with abnormal
patterns of cervical dilatation, provided there
was no cephalopelvic disproportion, and Hell-
man (1 959) warned that pelvic contraction even
of a minor degree was the principal contra-
indication to stimulation. Turnbull and Ander-
son (1968) were especially concerned about the
possibility of injury to the fetus resulting in
traumatic intracranial haemorrhage, and recom-
mended that only when full clinical and radio-
logical assessment excluded disproportion should
oxytocin be used.
During the three years 1963-65 when stimula-
tion was restricted for conventional reasons,
there were 4538 primigravidae delivered in this
hospital. Necropsy was performed in all cases of
perinatal death and traumatic intracranial
haemorrhage was demonstrated in 6 breech and
15 cephalic deliveries; the fetus was mature in 14
cephalic deliveries. During the next three years
1966-68, when stimulation to accelerate ineffi-
cient labour became standard practice, 41 53
primigravidae were delivered. Necropsy was
performed in all cases of perinatal death and
traumatic intracranial haemorrhage was demon-
strated in 6 breech and 2 cephalic deliveries;
the maturity in the cephalic deliveries was 28 and
30 weeks and oxytocin was not given in either
case. Although the indications were not altered
the incidence of forceps delivery declined
sharply during these years and difficult extrac-
tions, when the head was high and not rotated,
became rarely necessary. Twelve mature infants
died from traumatic intracranial haemorrhage
after forceps delivery between 1963 and 1965 but
none died between 1966 and 1968. The conclusion
is that adequate uterine action reduces the risk of
trauma because it protects the fetus from difficult
forceps extraction. A reduction in fatal head
injuries has implications also for the develop-
ment of infants who survive.
Another theoretical contraindication to stimu-
lation is the risk of rupture of the uterus.
Goldman (1959) could find no report in the
literature of ruptured uterus in a primigravida
after oxytocin, and ODriscoll et al. (1969)
concluded that the primigravid uterus is almost
immune to rupture except at manipulation with
forceps. Stimulation reduces the need for
manipulation and protects the mother from
trauma for the same reason that it protects her
child.
I n this series of 1000 primigravidae, from
which the problem of inefficient uterine action
was eliminated, the most important complicating
factor in cases suspected of disproportion was
prolonged pregnancy. In 12 cases of trial of
labour before 42 weeks only 2 were delivered by
Caesarean section, but in 10 cases after 42 weeks
5 were delivered by Caesarean section and there
were 2 perinatal deaths. Prolonged pregnancy
prejudices the outcome of labour because it is
associated with fetal hypoxia. It is recommended
that when Caesarean section is performed for
fetal distress after 42 weeks the mother should
not be committed to Caesarean section for
disproportion in subsequent pregnancies.
The value of X-ray pelvimetry has been
seriously questioned by Hannah (1965) who
emphasizes the statement that the result of a
trial of labour should depend entirely on
progress without regard to radiological appear-
ances. We agree that pelvimetry should not
influence management except in the rare instance
of gross contraction. There was no such case in
the present series. An incorrect diagnosis of
cephalopelvic disproportion is often made i n
cases of inefficient uterine action and some
feature of pelvic architecture is accepted as
evidence in support of this error (Hawksworth,
1952).
The problem of disproportion should be
considered separately in primigravidae, because
disproportion in multigravidae presents a more
complex and dangerous problem. The practice
of expressing the incidence in all mothers
provides no useful information and offers no
basis for comparison between different series.
Malpreseiitations and malformations should be
excluded because a trial of labour in these
circumstances has no place in modern obstetric
practice (Donald, 1969).
The problem of cephalopelvic disproportion
directly affects comparatively few women, but
the indirect effects have much wider implications
because it is fear of the possible consequence of
stimulation in women in whom disproportion
has not been excluded which represents the chief
impediment to active management in labour.
The result is confusion between inefficient
ACTIVE MANAGEMENT OF LABOUR AND CEPHALOPELVIC DISPROPORTION
389
uterine action and cephalopelvic disproportion
and these are the main constituents of prolonged
and difficult labour i n a primigravida. This
confusion, we believe, is the explanation for the
relatively high incidence of dystocia reported
from other centres.
Active management in labour must be
practised under continuous supervision, but
sophisticated equipment to control the rate of
oxytocin infusion or to monitor uterine activity
is not required. An important consequence of
active management is high utilization of special
care facilities, particularly of skilled nursing
personnel.
ACKNOWLEDGEMENTS
We are grateful to Dr. Francis Geoghegan
who performed the postmortem examinations
and to Dr. Niall O'Brien who assessed the
infants for residual brain damage, and especially
to the Nursing Sisters in the delivery unit at the
National Maternity Hospital to whom most of
the credit for the management of these patients
is due.
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Friedman, E. A., and Sachtleben, M. R. (1962): Obstetrics
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Goldman, L. (1959): Journal of Obstetrics and Gynae-
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Goodwin, J. W., and Reid, D. E. (1963): American
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Hannah, W. J. (1965): American Journal of Obstetrics and
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Hawksworth, W. (1952): Proceedings of the Royal Society
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Hellman, L. M. (1959): Clinical Obstetricsand Gynecology,
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Ledger, W. J. (1969): Obstetrics and Gynecology, 34, 114.
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