I.

Brief Description

Cephalopelvic disproportion (CPD) occurs in a pregnancy where there is mismatch in size

between the fetal head and the maternal pelvis, resulting in failure of the fetus to pass safely

through the birth canal for mechanical reasons.1 This may be caused by the fetal head

outgrowing the capacity of the maternal birth canal, or by presentation in a position or

attitude that will not allow descent through the pelvis. Untreated, the consequence is

obstructed labour, which endangers the lives of both mother and fetus. A clinical

classification of CPD was proposed by Craig2 from Cape Town in 1961. He divided CPD

into absolute and relative entities as shown below:

1. Absolute CPD true mechanical obstruction

a.) Permanent (maternal):
Contracted pelvis
Pelvic exostoses
Spondylolisthesis
Anterior sacrococcygeal tumors
b.) Temporary (fetal):
Hydrocephalus
Large infant
2. Relative CPD
Brow presentation
Face presentation mentoposterior
Occipitoposterior positions
Deflexed head

II. Incidence

CPD is more frequent in African than in European women, and complicates between 1.4

and 8.5% of pregnancies. Untreated CPD results in obstructed labour, which is responsible

for 8% of maternal deaths worldwide. Most of these deaths occur in sub-Saharan Africa.

Most women with CPD have a successful pregnancy outcome after a cesarean

delivery and there is no evidence to suggest that CPD affects a baby after its birth.

Statistics suggest that about one out of 3 cesarean sections are the result of some form of

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CPD. Another study shows that 65 percent of women who received a diagnosis of

cephalopelvic disproportion in an earlier pregnancy went on to deliver vaginally in

subsequent pregnancies. In fact, many of these women had larger babies on subsequent

pregnancies than with the CPD baby.

III. Risk Factors

Increased Fetal Weight:

Very large baby due to hereditary reasons - a baby whose weight is estimated to be

above 5 Kgs or 10 pounds .

Postmature baby - when the pregnancy goes above 42 weeks.
Babies of women with diabetes usually tend to be big.
Babies of mothers who have had a number of children - each succeeding baby

tends to be larger and heavier.

Abnormal Fetal Position:

Occipito-posterior position - In this position the fetus faces the mothers abdomen

insteadof her back.

Brow presentation
Face presentation.

Problems with the Pelvis:

Small pelvis.
Abnormal shape of the pelvis due to diseases like rickets, osteomalacia or

tuberculosis.
Abnormal shape due to previous accidents.
Tumors of the bones.
Childhood poliomyelitis affecting the shape of the hips.
Congenital dislocation of the hips.
Congenital deformity of the sacrum or coccyx.
Problems with the Genital tract:
Tumors like fibroids obstructing the birth passage.
Congenital rigidity of the cervix.
Scarring of the cervix due to previous operations like conisation.
Congenital vaginal septum.

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Risk of having CPD

Mother

There are a number of reasons why children develop the condition. The most

common factor associated with cases of CPD is a mother with abnormally high maternal

sugar levels from gestational diabetes or diabetes mellitus.

Labor progression problems CPD may cause a child to become lodged in the

birth canal, potentially requiring the use of forceps and other invasive devices and methods to

free the child. This can lead to injuries to the birth canal such as lacerations, vaginal and

perineal tearing, excessive bleeding during delivery and a fractured tailbone.

Uterine rupture If you had a cesarean section in your previous pregnancy or

major uterine surgery, CPD increases the risk of uterine rupture. Uterine rupture is a rare, yet

serious, complication in which the uterus tears along the scar line of a previous cesarean

section or uterine surgery. Oftentimes, an emergency c-section is necessary to prevent life

threatening complications associated with this serious complication.

Bleeding post-delivery CPD increases the risk that a womans uterine muscles

will not properly contract after giving birth, referred to as uterine atony (a condition that

involves the loss of tone in the uterine musculature). This can cause excessive bleeding post-

delivery.

Child

Complications from CPD could include interruption to the oxygen supply and

injury to the head, neck, and shoulder area due to misuse of forceps or vacuum extractors,

potentially resulting in:

-Hemorrhaging

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 -Cerebral palsy
-Developmental delays
-Seizure disorders
-Paralysis

IV. Manifestations
There are a number of tell-tale signs that a child is suffering from CPD. They

are:

Prolonged labor This refers to a situation where labor, for whatever reason, is not

progressing. One of the major reasons why some womans labor cannot progress is due to

CPD.

Fetal distress If a child is exhibiting a low fetal heartbeat and other similar symptoms

associated with a lack of oxygen, he or she may be suffering from fetal distress, which can be

caused by CPD.

Large fundal height Fundal height is a measurement of the distance between the pubic

bone and the top of your uterus. This is often used to determine whether a child suffers from

macrosomia, which can also lead to CPD during delivery.

A higher than average volume of amniotic fluid Medically referred to as

polyhydramnios, too much amniotic fluid (the fluid that surrounds and protects a baby while

in utero), may be indicative that your child is overly large, sometimes leading to CPD.

Specifically, the amount of amniotic fluid reflects an unborn childs urine output the larger

the child, the more urine he or she produces.

V. Medical Management

Diagnostic Procedures and Lab examinations

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Doctors may not always predict the presence of CPD. Listed below are

several methods employed by physicians to try and assess the size of the

pelvis and baby.

Pelvimetry by MRI: This is used to assess the dimensions of the pelvis,

determine the babys position, and examine the soft tissues of the mother and

baby.

Clinical pelvimetry: This is a process used to assess the size of the birth canal

using the hands and/or with a pelvimeter.

Ultrasound: The babys head and body size are measured during a routine

ultrasound examination. Measurements are compared against standardized

growth charts to determine the relative risk of CPD by the time of delivery.

X-ray or CT pelvimetry: This is a radiographic examination used to determine

the dimensions of the mothers pelvis and the diameter of the babys head. The

value of x-ray pelvimetry needs to be weighed against the risk of radiation

exposure.

Although the techniques discussed may help the physician predict

the presence of CPD, the medical standard for diagnosis of CPD is to

attempt labor and delivery before proceeding to a C-section. Sometimes,

the maternal pelvis is able to separate and stretch allowing the baby to

pass through the birth canal even when a previous ultrasound had

indicated a large fetal head.

The diagnosis can be made when the progress of labor stops or fails

to follow the expected rate of descent. When cervical dilatation stops or

the baby fails to move down for a period of two hours or more is indication

that a C-section is necessary.

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 VI. Treatment

If the surgeon is absolutely certain that there is cephalopelvic disproportion, then a

Cesarian section is the only option to deliver the baby.

However, women who have an average sized baby and and an average sized pelvis or

even women in whom vaginal delivery is doubtful, should always be offered a 'trial of labor'.

If, after sufficient time has passed in labor without a delivery, and symptoms of prolonged

labor or fetal distress begins to develop, a cesarian section needs to be carried out.

VII. Pharmacologic management

Name of drug: Oxytocin

Drug category: Oxytocic agents

Indication: Produces rhythmic uterine contractions and can stimulate contraction

of the gravid uterus.

VIII. Nursing Care Management

Interventions Rationale
To monitor premature labor
1. Monitor contractions
2. Encourage sitting or squatting To increase the outlet diameter
3. Position mother in ways To increase the pelvic diameter
4. Monitor fetus To check for signs of hypoxia or

distress

IX. References

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 1. Liselele HB, Boulvain M, Tshibangu KC, Meuris S (August 2000). "Maternal height
and external pelvimetry to predict cephalopelvic disproportion in nulliparous African
women: a cohort study".

2. "Cephalopelvic Disproportion (CPD): Causes and Diagnosis". American Pregnancy

Association. Retrieved 2016-03-22.

3. McKenry, Patrick C.; Walters, Lynda Henley; Johnson, Carolyn (1979-01-01).

"Adolescent Pregnancy: A Review of the

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