Midwifery Management in Cephalopelvic Disproportion [PDF]

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ENGLISH II ASSIGNMENT



MIDWIFERY MANAGEMENT IN CEPHALOPELVIC DISPROPORTION



Members of Group:



Ajeng Lyla Aisyiatul Kumala



(011311223005)



Irma Sari Fitriana



(011311223014)



Bintari Tri Anggraeni



(011311223019)



Ginna Pratiwi Putri



(011311223022)



Ridya Nurul Ridha



(011311223026)



Yulia Pramita Riska



(011311223049)



BACHELOR DEGREE OF MIDWIFERY FACULTY OF MEDICINE AIRLANGGA UNIVERSITY SURABAYA 2013



ACKNOWLEDGMENTS



Writers would like to acknowledge her countless thanks to the Most Gracious and the Most Merciful, ALLAH SWT who always gives her all the best of this life and there is no doubt about it. Shalawat and Salaam to the Prophet Muhammad SAW and his family. This study’s topic is “Midwifery Management in Cephalopelvic Disproportion which presented to fulfill one of the English II Assignment on Bachelor Degree of Midwifery at the Faculty of Medicine Airlangga UniversitySurabaya. Writers would like to take her opportunity to express her deep and sincere gratitude to Mrs. Nuzul Qur’aniati , S.Kep.,Ns., M.Ng. as English II lecturer, who has given her expertise and guidance in writing this study. Writers do appreciate any opinion, and suggestion for the improvement of this study. Surabaya, December 2013 Writers



ABREVIATION



CPD



Cephalopelvic Disproportion



WHO



World Health Organization



SEAR



WHO South-East Asia Region



MMR



Maternal Mortality Rate



UNDP



United Nations Development Programme



UNFPA



United Nations Population Fund for Population Activities



ACOG



American Colleges of Obstetricians and Gynecologists



KSPR



Kartu Skor Pudji Rochyati



TABLE OF CONTENTS



CHAPTER 1 INTRODUCTION..........................................................................1 1.1



Background of the Study...........................................................................1



1.2



Problem Formulation.................................................................................2



1.3



Purpose of the Study..................................................................................2



CHAPTER 2 DISCUSSION..................................................................................3 2.1



Definition of Cephalopelvic Disproportion (CPD)...................................3



2.2



Classifications of Women’s Pelvis............................................................3



2.3



Etiologies of CPD......................................................................................5



2.4



Pathophysiology of CPD...........................................................................5



2.5



Signs and symptoms..................................................................................6



2.6



Physical examination in CPD....................................................................8



2.7



Diagnosis of CPD......................................................................................9



2.8



Labor pattern of CPD..............................................................................10



2.9



Prognosis of CPD....................................................................................10



2.10



Midwifery Management in CPD.............................................................11



CHAPTER 3 CLOSING......................................................................................13 3.1 Conclusion....................................................................................................13 REFERENCES.....................................................................................................14



CHAPTER 1 INTRODUCTION 1.1



Background of the Study In accordance with the MDG’s 2015, maternal mortality rate will have



decrease to 102 per 100,000. Based on World Health Statistics 2012, Indonesia ranked seventh in SEAR maternal mortality rate which is 220 per 100,000 birth. Indonesia major medical cause of maternal death are haemorrhage (28%), eclampsia (13%), sepsis (10%), unsafe abortion (11%) and prolonged labor (8%), posted by UNDP. Varney said CPD is most common causes of prolonged labor. Thus, CPD may takes responsibility for the height of maternal mortality rate in Indonesia. An unintervented CPD can carried the mother and infant at high risk such as dysfunctional uterine contraction, fluid and electrolyte imbalance, exhaustion, hypoglycemia, infection, uterine rupture, huge lacerations, fractured sacrum or coccygx and postpartum hemorrhage for the mother. Risks to the fetus are traumatic birth



injuries, hypoxia, asphyxia, hypoglycemia, acidemia, and



infection. At worst, death for the mother, baby or both. Some literally claims that c-section is safest to deliver the baby when absolute CPD diagnosed (Sarwono P, 2010; Hanifa W, 2010; Medforth, 2011). Tukur J (2011) wrote in WHO Reproductive Health Library “symphisiotomy can be performed to fascilitate baby deliver vaginally indicate with CPD despite the evidence very rare and be controvercial.” Symphisiotomy is the surgical separation of the fibres of the pubic symphysis. All above explains CPD will lead mother and infant in dangerous situation and may need surgical intervention. Incorrect treatments absolutely can’t be approved. Midwives as a close-touchable health professional with society, must aware first. Based on the background, discuss more about cephalopelvic disproportion are midwifery students need in order to find out more detail especially about midwifery management in CPD for preventing the complication and minimizing the risk by do early screening and predict CPD.



1.2



Problem Formulation 1. 2. 3. 4. 5. 6. 7. 8.



1.3



What is the definition of cephalopelvic disproportion (CPD)? What are the etiologies of CPD? How is the pathophysiology of CPD? What are signs and symptoms of CPD? How to diagnose CPD? What are the labor pattern of pregnant women with CPD? What are the prognosis of CPD? How is midwifery management in CPD?



Purpose of the Study 1. 2. 3. 4. 5. 6. 7. 8.



Explain the definition of cephalopelvic disproportion (CPD). Explain the etiologies of CPD. Explain the pathophysiology of CPD. Explain signs and symptoms of CPD. Explain how to diagnose CPD. Explain the labor pattern of pregnant women with CPD. Explain the prognosis of CPD. Explain midwifery management in CPD.



CHAPTER 2 DISCUSSION 2.1



Definition of Cephalopelvic Disproportion (CPD) Liselele (2000) state that cephalopelvic disproportion (CPD) is a medical



term used to characterize the physical impediment of labor, which occurs when there is ‘an absolute irrelative mechanical disparity between the fetal size and the birth canal’. Another references give similar statement about CPD definition. CPD is a presence of disparity between the fetal head and the dimension of maternal pelvic, the maternal pelvic is too small or the fetus is too big (Gupta, 2008; WHO, 2003). Moreover added by medneg Australia, cephalopelvic disproportion is a birth complication that happens when the infant head is larger than the opening to the pelvis so that the baby cannot pass through the birth canal and sometimes results in a cesarean section. At a glance, CPD refers to a birth complication caused of mismatch between baby head and mother’s pelvis that make baby head can’t phasing down trough pelvic, and hard to deliver vaginally. 2.2



Etiologies of CPD Labor have three main factors, called ‘3Ps’ : power, passage and passenger



that must goes well to bring a normal labor. If the ‘3Ps’ are not goes well, it caused an abnormal labor. Power means uterine contraction and the mother push power. Passage mean Maternal pelvic and birth canal. Passenger mean the infant. CPD is a passage-passenger problem. Meanwhile, the uterine contraction checked normal and the mother is not yet exhausted. The passage includes the maternal bony pelvis and birth canal tissues. A narrowed diameter in pelvic inlet and or outlet can result in CPD if the fetus head is unfitted to the pelvic diameters. Abnormal shaped pelvic, tumors in birth canal and another hip problem probably cause CPD as well. The passenger abnormality such as hydrocephalus, and large baby due to post-maturity, a mother with



diabetes, hereditary reasons, and head malposition may also result in CPD (Manuaba, 2012). A clinical classification of CPD was proposed by Craig from Cape Town (1961). He divided CPD into absolute and relative entities as shown below. a. Absolute CPD – true mechanical obstruction - Permanent (maternal): Contracted pelvic Pelvic exostoses Spondylolisthesis Anterior sacrococcygeal tumors - Temporary (fetal): Hydrocephalus Large infant b. Relative CPD Brow presentation Face presentation – mentoposterior Occipitoposterior positions Deflexed head



2.3



Pathophysiology of CPD Labor is prolonged in the presence of CPD. Describe before CPD can



carried the mother and infant at high risk such as dysfunctional uterine contractions, fluid and electrolyte imbalance, exhaustion, hypoglycemia, infection, uterine rupture, huge lacerations, fractured sacrum or coccygx and postpartum hemorrhage for the mother. Risks to the fetus are traumatic birth injuries, hypoxia, asphyxia, hypoglycemia, acidemia, and infection. At worst, death for the mother, baby or both. References from Gupta(2008), Sarwono P (2010) and other online source writers summarize that mother with abnormal pelvic shape probably have a difficulties in labor but it depend on the baby too. But, in contracted pelvic deliver baby more difficult or even impossible for some fetus to pass through an inlet that has an anteroposterior diameter of less than 10 cm. If anteroposterior and



transverse, both diameters are contracted, dystocia is much greater than when only one is contracted. A small women is likely to have a small pelvis, but she is also likely to have a small neonate. Normally, cervical dilatation is facilitated by hydrostatic action of the unruptured membrane, or after their rupture by direct application of the presenting part against the cervix. In pelvic inlet contraction, the head is arrested in the pelvic inlet, the entire force exerted by uterus acts directly on the portion of membranes that overlie the dilatation cervix. So early spontaneous rupture of membrane is more likely. After rupture of membrane the absence of pressure by head against the cervix and lower uterus segment predisposes to less effective contraction, so further dilatation is arrested or slowed. So cervical response to labor provide a prognostic view of the labor outcome with inlet contraction. A contracted inlet plays an important role in production of abnormal presentation. Because the head does not descent into pelvic cavity before onset of labor, face and shoulder presentation are encountered three times more frequently and cord prolapse occur 4 to 6 times more frequently. The midpelvic contrction frequently cause transverse arrest of the fetal head which potentially can lead to a difficult instrumental delivery or cesarean delivery. Diminution of the intuberous diameter with consequent narrowing of the anterior triangle must inevitably force the fetal head posteriorly. Usually inlet contraction is associated with mid pelvic contraction. The diproportion with the pelvic outlet may play an important part in causing perineal tears. If the midwives not predict or aware CPD earlier, and the mother keep pushing the baby out, the mother will be exhausted and have hypoglycemia as result. It worsened by amniorrhexys that can caused infection during prolonged labor and continuously consist fluid and electrolyte imbalance. In this situation, women will need to drink and IV fluid to exchange the lost body fluid. Membrane rupture can result from the force of the unequally distributed contractions being exerted on the fetal membranes. In obstructed labor, in which the fetus cannot descent, uterine rupture can occur.



With delayed descent,



necrosis of maternal soft tissues can result from pressure exerted by the fetal head.



Eventually, necrosis can cause fistulas from the vagina to other nearby structures. Difficult, forceps-assisted births can also result in damage to maternal soft tissue (Sarwono P, 2010). 2.4



Signs and symptoms Gupta (2008) consider the probably sign and symptomps of CPD below: 1. Abdominal examination  Large fetal size (MacDonald measurement over 40 cm or much larger than pregnancy before)  Fetal head overriding the pubic symphysis 2. Pelvic examination  Cervix shrinking after amniotomy  Edema of cervix  Head not well applied against the cervix  Head not engaged  Caput formation  Molding  Deflexion  Asynclitism 3. Contracted pelvic inlet The pelvic inlet is usually considered to be contracted if its shortest anteroposterior diameter is less than 10 cm or id greatest transverse diameter is less than 12 cm. The anteroposterior diameter of pelvic inlet is commonly approximated by manually measuring the diagonal conjugate, which is about 1, 5 cm greater. So inlet contraction usually is defined as diagonal conjugate of less than 11.5 cm. 4. Mid pelvis contraction It is more common than inlet contraction. It frequently cause transverse arrest of the fetal head which potentially can lead to a difficult instrumental delivery or cesarean delivery. The definition of mid pelvic contraction has not been established with same precision possible for inlet contraction. Even so, mid pelvis is likely



to be contracted when the sum of interischial spinous and posterior sagittal diameter of the mid pelvis (normal 10.5+5 cm or 15.5 cm) falls to 13,5 cm or below. There is reason to suspect mid pelvic contraction, whenever the interischial diameter is less than 10 cm. if intraspinous diameter is less than 8 cm, the mid pelvis is contracted. Although there is no precise manual method of measuring mid pelvis dimension, a suggestion of contraction sometimes can be inferred, if the spines are prominent, pelvic side walls converge, or the sacrosciatic notch is narrow. 5. Contracted pelvic outlet This finding is usually defined as the interischial tuberous diameter of 8 cm or less. 6. Estimation of Pelvic capacity Briefly the examiner attempt to judge the anteroposterior diameter of the inlet (diagonal conjugate), the interspinous diameter of the mid pelvis and the intertuberous distance of the pelvic outlet. Gill’s muller test is one of the important clinical maneuver for evaluating feto pelvic relationship. During pelvic examination, when a contraction is at its peak, an attempt is made to push the presenting part into the pelvis by pressing on the uterus fundus with the free hand. The hand in the vagina is used to determine whether or not there is downward mobility of the presenting part. If the presenting part does not move, or moves very little, the possibility of CPD is high. If the presenting part moves easily into the plevis, the possibility of disproportion is low. 7. Others 



Maternal pushing before complete dilatation







Early deceleration



An earlier source, Fadel (1982) manual pelvimetry should be done at the first visit, but the examination may be unsatisfactory, particularly in primigravida. A more satisfactory result may be obtained during the third trimester when the patient is more at ease with the examiner and the soft tissue are more relaxed.



Since gross abnormalities are usually easily detected and most cases of suspected disproportion will be managed by a trial of labor, some physicians tend to do only a perfunctory evaluation, but foreknowledge of the size and configuration of the pelvis is very important for an intelligent evaluation of such a course. Careful, systematic manual pelvimetry is imperative. A proper examination begins with an evaluation of the pubic arch and the angle of pubic rami. The arch should be rounded and the angle greater than 90. The anterior capacity of the pelvic inlet can be estimated by palpating the area behind symphysis. The forepelvis should be well rounded and ample. One then palpates the ischial spines and determines whether they are sharp and prominent or blunt and flat. The side walls are palpated to determine whether or not they tend to converge. The sacrostic notch should be rounded, and the sacrostic ligaments should be at least two fingerbreadths in length. The coccyx is grasped between the two fingers in the vagina and the thumb on the outside and its angle and mobility are determined. The examiner can then work his finger up the curve of the sacrum, estimating its width and curvature. The anteroposterior (AP) diameter of the mid pelvis, at the level of the spines, can be measured. It will average 11, 5 cm. 2.5



Diagnosis of CPD Diagnosis of CPD is important because it does indicate the need for



caesarean delivery. Some clinicians consider the maternal pelvis to be proven. If the woman has had a previous difficulties of vaginal delivery. However, subsequent fetuses can be larger and maternal anatomy can change between pregnancies. For this reason, a measurement are very helped. Measurement of mother and fetus has been attempted as a means of detecting CPD before the onset of labor. Gupta (2008), ACOG (2010), and some other online source agreed there are no objective and precise method for assesing the feto-pelvic relationship. A term discussion evaluate external maternal measurements, internal clinical pelvic assessment, X-ray pelvimetry, and ultrasound and magnetic resonance imaging. It shown that none of these methods can reliably diagnose CPD. They may improve the predictive value, but many if



not most women will give birth normally even when such measurements suggest an unfavorable cephalic-pelvic relationship. CPD is best diagnosed by trial of labor. The assumption is that adequate uterine contractions, augmented if necessary by oxytocin infusion, will effect descent and delivery of the fetal head through the birth canal. Failure to do so constitutes CPD. Diagnosing CPD is an imperfect activity and it should be accepted that many women whose labor is terminated for relative ‘CPD’ or inadequate uterine contractions. CPD is less frequent in multiparous women who have had a previous normal delivery. It may occur if the woman carries a much larger baby than in previous pregnancies, or if there is relative CPD with a fetal malposition. Occasionally, lumbosacral spondylolisthesis may develop between pregnancies and reduce the effective anteroposterior diameter of the pelvic brim, rendering a previously adequate pelvis inadequate. Trial of labor in a multipara is problematic as the uterus may rupture in the presence of CPD if labor is augmented with oxytocin. Where labor progress is poor in a multipara, Philpott has advised that careful attention be paid to head descent and moulding, as CPD is diagnosed when there is increasing moulding of the fetal head without descent into the pelvis. Clinical experience and skill are thus prerequisites in the assessment of poor labor progress in a multipara. 2.6



Labor pattern of CPD C-Section is a safest way to deliver the baby right after CPD diagnosis is



made. If it is ruled out, labor can be allowed to continue, oxytocin may be carefully administered if the contraction pattern is unsatisfactory. One should not be bound to arbitrary time limits. Prolonged labor itself is not necessarily deleterious to mother or baby. Careful fetal monitoring is imperative under these circumstances, and cesarean section may occasionally become necessary because of fetal distress. There is a place for midforceps operations, in skillful hands, but not in cases of cephalopelvic disproportion. Even when the fetal head is well down in the pelvis, cesarean section is preferable to traumatic vaginal delivery. There is no



place for the difficult forceps delivery (Fadel, 1982; Sarwono P, 2010; Gupta, 2008; Medforth, 2011; Hanifah W, 2010; Manuaba, 2012). 2.7



Prognosis of CPD The consequences of CPD can be serious when this condition transpires. In



severe cases childbirth is unable to progress because the fetal head becomes impacted in the pelvis. Without intervention this condition can result in uterine rupture, fistulas, and even fetal and maternal death. CPD Management includes procedures such as fetal monitoring, oxytocyn and c-section. Women who have been delivered by cesarean section in conditions suggestive of cephalopelvic disproportion may have x-ray pelvimetry performed in the puerperium to help management of future deliveries. The reason for the cesarean section and outlook for future deliveries should be discussed in the postnatal ward and at the postnatal visit (Gibb, 1991). The current literature says a woman has had a CPD before, doesn’t mean it will happen again in the next pregnancy or labor and possibly can have a normal delivery altough still must be carefully monitored by midwives and or obstetrician. 2.8



Midwifery Management in CPD Cephalopelvic disproportion can be early assessed by detecting the risk



within the antenatal period begins with noting any history of prolonged labor or difficult births. Antenatal assessments include abdominal examination which should alert the midwives to any malpresentation or signs of cephalopelvic disproportion. Pelvimetry and ultrasound is a big help to predict CPD. In Indonesia as the writers experiences, many of CPD cases occurs during the labor as a prolonged labor. So, using WHO partograf is a must to alert about labor abnormality not just CPD. In management of labor with CPD, midwives have to collaborate with obstetrician. As described, labor pattern for primigravidas can be vaginal labor with trial of labor first. It’s according to the condition of mother and baby. If normal labor pattern are not reestablished in a reasonable period, probably within



4 hours, the cephalopelvic relationship must again be evaluate and cesarean section may become necessary. Private midwives should not do trial of labor because if obstructed labor is recognized in the first stage of labor, as when the head is extended to brow presentation or obstruction cannot be overcome by rotation and assisted birth, delivery should be caesarean section as soon as possible. C-section only can be done in hospital with surgery room; surgical team such as obstetrician, anesthesiologist, surgical nurse; and neonatologist. Following the birth of the baby and prior to repair of the uterus and abdomen, the surgeon will check carefully for any indication that the uterus has ruptured. From many sources of literature, there are some different assignment of diagnostic criteria for cephalopelvic disproportion (CPD) in nulliparous women. First author Management for CPD (O’Driscoll, Jackson, Caesarean section for delivery not occurring & Gallagher, 1970)



within 24 hours of admission in labour, following active management (early amniotomy



and oxytocin augmentation) (Stewart, Cowan, & Minor = assisted vaginal delivery following 6 Philpott, 1979)



hours of oxytocin augmentation for poor labour progress (cervix 12 hours in spite of effective uterine activity or 2) failure of the head to descend or evidence of severe moulding or fetal distress in later first stage with secondary arrest or prolonged second



(Tsu, 1992)



stage Caesarean section or assisted vaginal delivery with arrest or delay of labour, and moulding (+) or caput (+++), with later review of clinical notes



by a panel of experienced obstetricians. Includes multiparous women. Caesarean section at term for a normally formed



(Impey L, 1998)



fetus with a flexed non-occipitoposterior vertex presentation, with secondary arrest of cervical dilatation with the cervix at least 6 cm dilated, unresponsive to oxytocin infusion, in accordance with a standardized protocol for active (Liselele, Boulvain,



management of labour. 1) Caesarean section for failure to progress in



Tshibangu, & Meuris,



labour, or 2) vacuum or forceps delivery, or 3)



2000) (Young Woodmansee, 2002)



vaginal delivery with intrapartum stillbirth & Caesarean section for little or no progress over 24 hours with adequate uterine contractions and the cervix at least 3 cm dilated



Newest research done at 2012 by University of California, San Francisco posted in savinglivesbirth.net propose a simple tool that can be employed by frontline health workers to risk-stratify women early in their pregnancy as high risk to low risk for CPD using an objective method. Indonesia especially East Java has earlier made a somekind of similar category, not only for CPD but for other abnormalities, for increasing maternalneonatal health service called KSPR (Kartu Skor Pudji Rochyati).



CHAPTER 3 CLOSING 3.1 Conclusion Cephalopelvic disproportion (CPD) is a condition in which the presenting part of the fetus (usually the head) is too large to pass through the woman’s pelvis. Because of the disproportion, it becomes physically impossible for the fetus to be delivered vaginally, and cesarean birth is necessary. CPD is suspected when the newborn’s head does not continue to descend even though the woman is having strong uterine contractions. Excessive fetal size may be associated with diabetes mellitus, multiparity, and genetics (one or both parents of large size). A large newborn (macrosomia) can cause difficulty in birth of the shoulders (shoulder dystocia). Physical examination and ultrasound are very useful in evaluating CPD. Labor pattern for primigravidas can be vaginal labor with trial of labor first. If normal labor pattern are not reestablished in a reasonable period, the cephalopelvic relationship must again be evaluate and cesarean section may become necessary Maternal complications that can occur are exhaustion, hemorrhage, and infection. Birth trauma and anoxia are complications for the fetus.



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