CLINICAL STUDY OF UNENGAGED HEAD IN PRIMIGRAVIDA AT TERM IN LABOUR

by

Dr. MAHENDRA G.,MBBS

Dissertation Submitted to The Rajiv Gandhi University of Health Sciences

Karnataka, Bangalore

In partial fulfillment of the requirements for the degree of

MASTER OF SURGERY in

OBSTETRICS AND GYNAECOLOGY

Under the guidance of

Dr. PRAMEELA,MD,DGO Associate Professor

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

MYSORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, MYSORE-570 001, KARNATAKA

APRIL – 2011

ii

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “CLINICAL STUDY OF UNENGAGED

HEAD IN PRIMIGRAVIDA AT TERM IN LABOUR” is a bonafide and genuine

research work carried out by me under the guidance of Dr. PRAMEELA,MD,DGO,

Associate Professor, Department of Obstetrics and Gynaecology, Mysore Medical

College and Research Institute, Mysore.

iii

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “CLINICAL STUDY OF

UNENGAGED HEAD IN PRIMIGRAVIDA AT TERM IN LABOUR” is a bonafide

research work done by Dr. MAHENDRA G. in partial fulfillment of the requirement for

the degree of Master of Surgery in Obstetrics and Gynaecology.

iv

ENDORSEMENT BY THE HEAD OF THE DEPARTMENT AND THE PRINCIPAL

This is to certify that the dissertation entitled “CLINICAL STUDY

OF UNENGAGED HEAD IN PRIMIGRAVIDA AT TERM IN LABOUR” is a

bonafide research work done by Dr. MAHENDRA G. under the guidance

of Dr. PRAMEELA,MD,DGO, Associate Professor, Department of Obstetrics and

Gynaecology, Mysore Medical College and Research Institute, Mysore.

Date: Date:

Place: Mysore Place: Mysore

v

COPYRIGHT

Declaration by the candidate

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka

shall have the rights to preserve, use and disseminate this dissertation in print or

electronic format for academic/research purpose.

© Rajiv Gandhi University of Health Sciences, Karnataka

vi

ACKNOWLEDGEMENTS

I express my sincere and deep sense of gratitude to my guide Dr. Prameela,

Associate Professor, Department of Obstetrics and Gynaecology, Mysore Medical

College and Research Institute, Mysore for the valuable guidance, expert advice and

constant encouragement given to me in the preparation of this dissertation.

I am thankful to Dr. H.C. Lokeshchandra, Professor and Head, Department of

Obstetrics and Gynaecology, Mysore Medical College and Research Institute, Mysore,

for his suggestions and encouragement during the study period.

I am also thankful to Dr. S. Radhamani, Professor, Department of Obstetrics and

Gynaecology, Mysore Medical College and Research Institute, Mysore, for her valuable

suggestions and guidance.

I am also thankful to Dr. M.A. Chiniwar and Dr. Prameela R.C., Associate

Professors; Dr. Deepa K.V., Dr. Rashmi M.D., Dr. Sudha, Dr. Mamatha K., Assistant

Professor; Dr. Sunanda and Dr. Nirmala, Senior Residents; Dr. Kumuda N., Dr.

Premakumari and Dr. Puttathayamma, Senior Specialists, and other staff, Department

of Obstetrics and Gynaecology, Mysore Medical College and Research Institute, Mysore,

for their encouragement and guidance.

I thank Staff of Medical Records Department, Cheluvamba Hospital, for their

valuable help.

I am also thankful to Director and Dean of institution and Medical

Superintendent of Cheluvamba Hospital, for allowing me to conduct this study.

I am grateful to my family who helped me profoundly by their constant support

throughout the study.

vii

I am grateful to my parents, for their constant support throughout the study.

I wish to express my gratitude to Dr. Lancy D’Souza and Dr. Nitin Kondapum,

for the statistical analysis for this dissertation.

My special thanks to Mr. B.K. Venkatesh, Kowshik DTP Center, Mysore, for

working hard on shaping the dissertation book.

I express my thanks to my friends and colleagues for their constant constructive

help.

Last, but not the least, I owe my heartfelt and sincere gratitude to all my patients

without whom this dissertation would not have been successful.

viii

LIST OF ABBREVIATIONS

AG Abdominal girth

AL Active labour

AOM Age at marriage

CDR Cervical dilatation rate

CRN Cord around the neck

DOA Date of admission

DOD Date of delivery

DTA Deep transverse arrest

EDD Expected date of delivery

EDI Engagement delivery interval

EFW Expected foetal weight

Eng Engaged

F Fixed

f Female

FF Free floating

LMP Last menstrual period

LMP Last menstrual period

LP Latent phase

LSCS Lower segment cesarean section

M Mobile

m Male

NVD Normal vaginal delivery

PNM Perinatal mortality

SFH Symphysio fundal height

UEF Uneventful

Uneng Unengaged

ix

ABSTRACT

BACKGROUND AND OBJECTIVES

A significant proportion of primigravidae present with unengaged head at the

onset of labour. The duration of different stages of labour are longer in patients with

unengaged head as compared to those of with engaged heads, though a substantial

proportion of them deliver vaginally.

The present study has been carried out to find the relationship of foetal head

station, at the onset of labour in primi gravidae with the outcome of labour, the nature of

delivery and maternal and foetal well being.

METHODS

The study done at Cheluvamba Hospital, Mysore Medical College and Research

Institute, Mysore, between November 2008 and May 2010. One hundred and thirty full

term primigravidae having cephalic presentation in early first stage of labour with intact

membranes at different station of vertex were included in the study. The cases having

obvious CPD and other complications of pregnancy were excluded.

RESULTS

Among 130 cases, 53.07% of cases delivered vaginally, 20% had instrumental

delivery and 26.92% underwent caesarean section. There was statistically significant

(p<0.01), increase in average duration of I, II stages and total duration of labour, and

incidence of instrumental and caesarean rates were higher with higher foetal station.

There was a greater need for active medical and surgical intervention and there is

no significant maternal and neonatal morbidity.

x

INTERPRETATION AND CONCLUSION

Primigravidae with unengaged foetal head at term or at the onset of labour should

be considered high risk and with proper monitoring and maintainence of partogram.

Vaginal delivery is possible in majority with minimal fetomaternal morbidity.

KEY WORDS: Primigravidae; Term pregnancy; Unengaged head

xi

CONTENTS

PAGE NO.

1. INTRODUCTION 1 2. OBJECTIVES 4 3. REVIEW OF LITERATURE 5 4. METHODOLOGY 78 5. RESULTS 81 6. DISCUSSION 103 7. CONCLUSION 110 8. SUMMARY 111 9. BIBLIOGRAPHY 113 10. ANNEXURES

(i) PROFORMA 118 (ii) STATISTICAL METHODS APPLIED 122 (iii) KEY TO MASTER CHART 123

(iv) MASTER CHART 124

xii

LIST OF TABLES Table No.

Title Page No.

1 Age distribution 81

1a The mean age and standard deviation in different station of head 82

2 Distribution of height 83

2a Mean height and standard deviation of different head station group 84

3 Distribution cases according to foetal head station 85

4 Time of engagement 86

5 Engagement and cervical dilatation 87

6 Engagement delivery internal in hours 89

7 Average duration of labour 91

8 Course of labour 92

9 Comparison of total duration in different foetal head station group and its significance 93

10 Mode of delivery 94

11 Indications for Operative Delivery 95

12 Indications for LSCS 96

13 Birth weight 97

14 Mean birth weight and standard deviation of different foetal station group 98

15 Birth weight and mode of delivery 99

xiii

16 Perinatal outcome 99

17 Caput and moulding 101

18 Maternal complications 102

19 Comparison of time of engagement with other studies 104

20 Comparison of average duration of labour with other studies 105

21 Comparison of mode of delivery with other studies 106

22 Comparison of cause for caesarian study with other studies 108

23 Comparison of birth weight and perinatal outcome 108

xiv

LIST OF FIGURES Figure

No. Title Page

No.

1 Pelvic cavity 17

2 Pelvic planes 20

3 Pelvic inlet 22

4 Pelvic cavity: The plane of least dimensions 24

5 Pelvic outlet 27

6 Pelvic inlet (Caldwell-Moloy classification) 28

7 Midpelvis (Caldwell-Moloy classification) 29

8 Pelvic outlet (Caldwell-Moloy classification) 29

9 Labor course divided functionally on the basis of expected evolution of the dilatation and descent curves 37

10 Composite of the average dilatation curve for nulliparous labor 37

11 Cardinal movements of labour and delivery from a left occipital anterior position 44

12 Posterior asynclitism 51

13 Anterior asynclitism 52

14 Synclitism in the pelvis 53

15 Station of the presenting part 54

xv

16 Clinical estimation of descent of head in fifths palpable above the pelvic brim 55

17 Abdominal method of testing cephalopelvic disproportion 56

18 Bimanual method of testing CPD 57

19 Testing for engagement. An assistant is pressing on the breech 58

20 Clinical assessment of the pelvis 61

21 Estimating the pelvic outlet with the closed hand (Jarcho) 61

22 Subpubic angle 62

23 Measuring the diagonal conjugate (Jarchio) 62

24 Semi-orthodiagraphic transverse pelvimetry 65

25 Age distribution 81

26 The mean age and standard deviation in different station of head 82

27 Distribution of height 83

28 Mean height and standard deviation of different head station group 84

29 Distribution cases according to foetal head station 85

30 Time of engagement 86

31 Engagement and cervical dilatation 88

32 Engagement delivery internal in hours 90

33 Average duration of labour 91

34 Course of labour 92

xvi

35 Mode of delivery 94

36 Indications for Operative Delivery 95

37 Indications for LSCS 96

38 Birth weight 97

39 Mean birth weight and standard deviation of different foetal station group 98

40 Perinatal outcome 100

41 Caput and moulding 101

42 Maternal complications 102

1

INTRODUCTION

Labour is an important event with unique experience exclusively in a woman’s

life, which gives her the greatest satisfaction by delivering her own child, the wonder

creation of master craftsman!1

The last few hours of human pregnancy are characterized by uterine

contraction that affect the dilatation of cervix and force the fetus through the birth

canal. Much of energy is expended during this time. Hence the use of term ‘labour’ to

describe this process.

Primigravida are the group at risk. As Ian Donald has said that “Primigravida

is a dark and untrained horse and potential for child bearing is determined by the

outcome of labour”.2

It is generally accepted that high fetal station in primigravidas in labour near

term may indicate a threat to the normal progress of labour because of feto-pelvic

disproportion or obstruction of the fetal passage by tumor or the placenta.3

Unengaged head in primigravida at term raises apprehension. The cardinal

observation in a pregnant woman at term is whether the head is engaged or not.

It is the usual clinical observation and teaching that in primigravida the head

engages in the pelvis by 37th completed weeks of pregnancy. It also has been the

subject of the controversy. According to Chogtee and Khanum (1977), observed that

in 95% primigravidae the head did not engage till the onset of labour.

In 1978 Browne stated that if head remains unengaged till 38th week, the

reason should be sought but according to Greenhill (1965) “In the primigravida the

2

fetal head is engaged a week or more before the onset of labour in the first stage and

some times in the second stage of labour”.4

According to Munroker, the head normally engages in a primigravida by 36th

week, and failure to engage by that stage is presumptive evidence of cephalopelvic

disproportion.5

The sign of high head at term in a primigravida is not a welcome finding and

calls for investigations as to find the possible causes. It has been traditional myth of

obstetrics that engagement of head can be expected before the 38th week in normal

primi. This is undoubtedly not true.6

Weeks and Flynn showed that in 50% of primigravidae engagement occurred

between the 38th and 42nd week. The modal interval between engagement and delivery

was less than 7 days and in 80% of cases, the interval was less than 14 days. Similar

findings among Indian woman were reported by Sharma and Soni. In many African

countries, engagement of the head in primigravidae does not occur until the stage of

labour has been established for sometime. However, it remains true that the level of

head in primigravida at the onset of labour gives a general indication of the likely

duration of labour, being related to the length and ripeness of the cervix.7

The primigravidae are a group at risk as their capacity for childbearing has

never been put to the test. Hence, if first pregnancy results in normal healthy child,

patient is mentally better prepared for the subsequent pregnancy.

Engagement in vertex presentation occurs by definition, when the Biparietal

diameter of the fetal head passes the inlet. Although engagement is usually regarded

as phenomenon of labour it has been taught that in nullipara it frequently takes place

3

during the last few weeks of pregnancy. Indeed it has been emphasized that one

should be suspicious of cephalopelvic disproportion if engagement has not occurred

two weeks prior to term. Certainly many obstetricians take a pessimistic attitude

toward eventual vaginal delivery if the head is not engaged by the onset of labour.

It has been reported that clinical engagement in the nullipara occurs in over

90% of cases at the onset of labour and was generally considered that mobile head at

term is due to inadequacy of the pelvis. But more modern studies have shown that. the

other two cardinal factors of labour also have a role in the phenomenon of

engagement, namely foetus and expulsive forces.

It has been said that most dangerous journey is the last 10 cms of genital tract

which is full of events with the main hazards, hypoxia and trauma, as rightly quoted,

“worst journey in the world”.

4

OBJECTIVES

1. To know the effect of station of fetal head in early labour and significance of fetal

head level.

2. To assess the course of labour, duration of labour in relation to station of head at

the onset of labour.

3. To study the maternal outcome.

4. To study the neonatal outcome.

5

REVIEW OF LITERATURE

Different observation was made by different authors in relation to the

engagement of fetal head.

The concept of “station” was first expressed by Muller in 1868 as a means of

conveying the idea of location of the fetal presenting part and degree of progression in

the birth canal.

The term was later popularized and further qualified by De Lee because of its

practical clinical applicability.

Station or degree of engagement or location is used extensively in clinical

obstetrics today both in its absolute form for prognostication. Its relative form as a

rough measure of progressive descent and as a guide in evaluation and management

of the labouring patients.8

Classically, the first stage of labour is concerned with cervical dilatation and

the second stage with descent and expulsion. Engagement of the fetal presenting part

followed by descent through the birth canal are primary features of labour

mechanisms.

It has been observed that nulliparous entering labour with the fetus well

engaged frequently do not show further descent until the second stage of labour.

Whereas those not deeply engaged may show additional slow descent throughout the

first stage of labour.8

As a corollary, nulliparas with unengaged fetal head at the onset of labour are

6

viewed with some concern since this may presage inadequate fetopelvic relationships

or abnormality.

Qualitatively, engagement of the fetal head in nulliparous is recognized to be

related to delivery outcome. In that the incidence of cesarean section in patients

starting labour with unengaged heads is 6 to 8 times that of patients with deeply

engaged fetus.9

Eastmen and Hellman point out the engagement conclusively demonstrates the

adequacy of the pelvic inlet, exceptions being recognized the absence of engagement

on the other hand may not always be indicative of pelvic contraction, where as the

incidence of inlet contraction is decidedly higher in this latter group. It is noted that

labour is normal in about 87% of nulliparous with unengaged head at the onset of

labour. They admonish that the finding of non-engagement at the onset of labour calls

for careful evaluation of the pelvis.1

Auer and Simmons (1949) found that most of their primiparas at term with

floating fetal head usually could be delivered vaginally. In other words, an unengaged

fetal head in a primipara in early labour is not alone indication for cesarean section.

To the contrary, they were of the opinion that some of their patients with floating

head would have been treated better by section because they had a midpelvic

contraction and suffered with an increased puerperal morbidity and had a greater fetal

loss than normal.9

Abraham Tamis and Jacob (1942) said that the conduct of labour in full term

primi with an unengaged vertex is not generally understood. This conclusion is based

on a survey of maternal mortality. Community records which revealed numerous

7

patients with unengaged head that were permitted to labour too long, and then were

subjected to dangerous operative procedures with severe soft-part injury, and

infection which ended fatally. The seriousness of this problem, therefore calls for a

reemphasis both in the method of reestablishing the diagnosis of the unengagement

and in its management, and he indicates trial of labour should not exceed 24 hours.10

Bishop (1955) made correlations between the station of fetal presenting part at

the onset of labour and the duration of labour, and more particularly on the latent

phase of the first stage. The latent phase duration appears to be diminished when the

labour begins with a station at a lower level. Head which remains high in the pelvis,

in general, but not invariably is associated with longer latent phase, if this condition

persist into the active phase with slowing of the maximum slope of dilatation, and this

similarly is present in the deceleration phase, the terminal portion of the first stage as

well as the second stage also tend to be prolonged. Dysfunctional labour aberrations

are significantly higher with higher fetal station.8

There appears to be clear-cut relationship between initial cervical dilatation

and initial station; greater initial dilatation with more deeply engaged presenting part

at the onset of labour and less dilatation at higher stations appear to be the rule.11

According to Calkins, etiology of high station in most of the cases was due to

disproportion, big baby/placental causes and abnormal fetal presentations. None of

the latter factors is identified as a cause in 55% of unengaged heads. Lack of

engagement in the nullipara well into the active phase of dilatation is not unusual as

anticipated. Although, worthy of critical attention it is not necessarily ominous.12

8

Louis Burke (1958) studied 256 cases of nulliparous woman and performed

X-ray pelvimetry at 38 weeks of gestation. In 74.8%, engagement had occurred and in

25% cases engagement had not occurred, of the patients without engagement at

38 weeks, engagement had occurred in 80% at the onset of labour, the vertex was

engaged in 95% of all cases at the onset of labour and still not engaged in 5.1%. The

distribution of the types of pelvis found was android pelvis, pure or mixed, was

implicated most often in the failure of engagement at the onset of labour. If the vertex

is engaged at the onset of labour, 99% will have a pelvic delivery. If it is unengaged

at the onset of labour, 63.6% will have pelvic delivery and 36.4% will require

cesarean section.13

Morris Daniel and Georden (1960) studied 162 Puerto Rican primiparas

examined at 38 weeks; 28% showed engagement of the vertex and 72%

unengagement. Of 194 patients, examined at the onset of labour, the vertex was

unengaged in 25% and engaged in 75%. Major operative delivery was required in

21% of cases showing engagement at the onset of labour and in 55% with

unengagement.14

Anderson and Turnbull (1969) states that at 38th week, commonly held to be

the time when the vertex should have engaged in primi. Engagement occurred in only

50% of the patients. The reason for non-engagement was not cephalopelvic

disproportion since all the patients had subsequent vaginal delivery nor was the

occipitoposterior position of the vertex responsible. Fetal head remained mobile until

the onset of labour in 38% of the cases.6

9

Charles G Stipp (1969) although many obstetricians believe that high fetal

station in primi in labour near term is a threat to the normal progress of labour, the

results of this study should help to allay their fears, in that, 94.6% of this group were

delivered vaginally. In comparing patients who entered the hospital with engaged

fetal head, no statistical differences was found in the length of the first and second

stages of labour, method of delivery, fetal head position, weight of the infant, or the

Apgar rating. The cesarean section rate was higher in the unengaged fetal head group.

Apparently, due to cervical or uterine dystocia.3

Weekes ARL (1975) studied 462 primigravida. It was seen that by the end of

37th week of gestation, engagement had occurred in only 23% of them. The highest

rate of engagement was from 39 to 40 weeks of gestation and in 50% of patients,

engagement occurred between 38 and 42 weeks. There was close relationship

between engagement and duration of gestation. In 80% of the patient’s engagement

delivery interval were less than 14 days, and 46% with 7 days. Nevertheless, in 5% of

patients, engagement delivery interval was 6 weeks or more. Failure of engagement of

fetal head upto the end of 38th week of pregnancy seemed to be a normal occurrence

and only occasionally was underlying obstetric pathology present.7

Leela Chogtu and Khanum (1977) studied 250 primigravidae for the course of

labour; 95% had unengaged head at the onset of labour, descent of head occurred

throughout the first and second stages of labour, and was related to cervical dilatation.

A high station at the onset of labour lead to prolongation of the first and second stages

of labour, but the high station became correctable in 93% of patients by the

decceleration phase. A high station at the onset of labour does not mean inlet

10

contraction, although, it does reflect in higher rate of interference due to prolonged

labour. The patients with unengaged head calls for constant vigilance on the part of

the obstetrician.15

Sharma and Soni (1978) of the 462 primigravida studied 50% of the patients

did not have engaged head by 39th week and 35% by end of 39th week and highest rate

of engagement occurred between 39 and 40 weeks. Mean interval between

engagement and delivery was 10 ± 13.3 days in 44% of the patients studied, the head

was not reported to be engaged until they presented in labour. In only 20% of the

patients engagement and delivery interval was more than 14 days.16

Pronab Ghosh and Chaudari (1980) studied 240 cases showed that fetal head

in primigravidas engaged only in 43% cases before onset of labour and in 48% of

cases at the onset of labour cumulative incidence of first reported engagement of head

showed that engagement occurred in only 22.5% by 38th week when it is excepted to

be engaged and in 41% by the end of 40th week. The highest incidence of first

engagement happened at 40th week and it occurred in 62.2% cases between 38th to 40th

week. The mean time of engagement being 38.35 ± 1.5 weeks of gestation.4

Failure of engagement at term or even at the onset of labour was found to be a

normal occurrence by and large? However, age, marriage conception interval, height

of the patients, position of the fetus, and birth weight of the baby are particularly

correlated with the engagement of head in primigravida.

Earlier the engagement of head, shorter was the duration of pregnancy. Earlier

the engagement during pregnancy, shorter was the duration of labour. Duration of

11

spontaneous labour was shorter in engaged head group. Incidence of labour beyond

12 hours was more in the unengaged head group 54.7% than in engaged group 34%.

Average duration of labour in primi with unengaged head was 14.6 ± 4.2 hours and

12.2 ± 4.5 hours in the engaged head. Difference was not significant, however,

instrumental delivery and cesarean section were less in the engaged group.4

Saikia M and Gogoi MP (1987) studied 100 cases and found that no

significant difference was observed in the total duration of labour between the

engaged and unengaged group. Mean engagement delivery interval was 3.16 days

where the head engaged before the onset of labour. The incidence of spontaneous

vaginal delivery was 66.7% and that of low forceps 33.4%, the cases where the head

engaged before the onset of labour. In cases where the fetal head was engaged at the

onset of labour, spontaneous delivery was 79%, low forceps 15%, and cesarean

section was 7%. Average birth weight of the babies was higher in the unengaged

group; circumference of the head of babies had no effect on engagement of fetal head

or outcome of labour. There was significant difference in the Apgar score.17

David and Rosen (1985) states that the station itself did not appear to account

for the difference in latent phase, labour length among parity groups to the degree that

admission cervical dilatation did. Incidence of maternal and fetal morbidity in higher

fetal station was higher as compared to lower stations, although not so significantly

because of active management of labour. Stur et al. (1985) and Frank (1990) reported

that appropriate use of augmentation of labour had no adverse effect on perinatal

mortality while decreasing the duration of labour.18

12

Kushtagi, Dhall and Dhall (1989) studied 100 cases and according to them, the

station of fetal head and cervical dilatation at admission significantly affected the

course of labour. Nulliparous patients with lower fetal head station -1, showed shorter

duration of active phase when compared to patients with -2 station at admission.19

Shirotori and Ray (1994) have reported that the duration of different phases of

labour is longer for station -3 as compared to station -0. Prolonged latent phase was

the most common disorder seen in 89.5% in free floating and 93.6% in -3 group. The

incidence of primary dysfunctional labour and secondary arrest of labour was higher

in FF and -3 group as compare to 0- station group.20

Pralhad Kushtagi (1995) studied 100 cases, only 17% of nulliparous woman

had engaged fetal head at admission in labour. Engagement occurred during the

period of maximum slope of cervical dilatation in nulliparous woman. Course of

labour was uninfluenced by the degree of engagement.21

Roshanfekr and associates 1999 analyzed fetal station in 803 nulliparous

delivered at term after labour had been diagnosed. About 30% of these woman

presented to the hospital with the fetal head at or below 0 station, and the cesarean

rate was 5% compared with 14% for those with higher fetal stations. The prognosis

for dystocia, however, was not related to incremental higher fetal station above the

pelvic mid plane. Importantly, 86% of woman without fetal head engaged at diagnosis

of active labour delivered vaginally. “Thus, lack of engagement at the onset of labour

although a statistical risk factor for dystocia should not be assumed” to necessarily

predict fetopelvic disproportion.22

13

According to Fielder M (1998), of the nulliparous woman with vertex

presentation studied, there were no significant differences in maternal age, birth

weight, postpartum, or early neonatal complication rates. Neither “admission

dilatation nor effacement were predictive of route of delivery, cesarean rates” for

dystocia in the group presenting at -2 or above were significantly increased.23

According to Saropala L Chathurachinda (1993), controversy still exists over

the significance of the fetal head level in early labour whether it bears any

relationship with mode of delivery. In his study, correlation was made between fetal

head level on admission of 98 primigravidae and mode of delivery showed a higher

cesarean rate among patients who presented with high head.24

Briggs ND (1981) studied causes of unengaged fetal head at term in Negroid

primigravida, showed no correlation with fetal birth weight nor with the pelvic brim

inclination. However, there was a significant difference between the mean head

circumference of fetal head which had not engaged 34.1 cm, and those which had

engaged 33.1 cm. Labour was prolonged with high head at term, but there was no

increase in the incidence of fetal or maternal morbidity nor was it associated with an

increase in the rate of operative interference. It suggested that an unengaged fetal

head in early labour should not be itself be an indication for early delivery by

cesarean section.25

According to Kaur D and Kang M (2000) progress of labour appears to be

slow in substantial proportion of primi with unengaged head at the onset of labour.

Mean total duration of labour was higher in-patients with free-floating group and

-3 station of the 150 primigravida studied. Mean duration of latent phase, acceleration

14

phase, maximum slope, and active phase, and second stage were all longer in higher

stations as compared to lower stations. Mean cervical dilatation rate in active phase

was 0.9 cm/hr and 0.93 cm/hr for free floating, and -3 station against 2.43 cm/hr in

0 station.20

Incidence of normal labour was 95% with station 0 or below at admission.

There was need to resort to forceps or LSCS in 50% of cases with free-floating head

and -3 station. Forceps in 15.8% in free floating and 19.3% in -3 station group.

Incidence of primary dysfunctional labour and secondary arrest of labour was higher

with free floating and -3 station group. Maternal complications and perinatal mortality

was higher in higher fetal stations. Maternal complications like PPH, vaginal tears,

retained placenta, were more with the higher stations. Proportion of neonates with

Apgar less than 5 and high birth weight babies were found with higher fetal stations.20

HISTORICAL ASPECTS

From time immemorial it has been observed that majority of the births were

head first. Foot presentation was considered to be a bad omen and was thought to be

the cause of parents death. If by chance the baby was born as breech, it was passed

through a basket, with head first in order to avert evil.

Greek 500 B.C. Hippocrates stated to have postulated that in labour the bones

of the pelvis undergo a physical separation particularly at the pubic symphysis, the

result being that for centuries the importance of disproportion between the mothers

pelvis and the babies skull went unrecognised. According to this theory it was thought

that obstructed labour was never due to contracted pelvis, but due to the weak child

failing to separate the bones of the mother.

15

Andrew Vesalvis (1514-1516) showed definitely that pubic bones do not

separate in labour as they were joined by cartilage strongly. It was confirmed by

“Tuatachuns” and he also realised that tumors of the pelvis can obstruct labour and

also hydrocephalus.

Handrick Van Deventer (1651-1724) described the pelvis with inlet

contractions and pelvis with general contractions. He noted elongation of the foetal

head in the case of general contraction and also with flat pelvis. He considered the

possibility of brain injury of the baby besides from delay from its passage. He was

aware of importance of the axis of the birth canal and described it accurately.

William Smellie (1763) was the first to recognise the influence of Rickets on

the pelvis and carefully described the deformity caused by it.

Andrew Levert (1703-1780) did much on the normal tilt or the inclination of

the pelvic plane and the three planes, inlet, midpelvis and outlet, measurements and

shapes.

Gusthau Adolf (1851) says that any pelvis that measured less than 8.75 cms at

the True conjugate should be regarded as an abnormally contracted pelvis.

“Peterchamberlen” described the forceps in 1569. Edward Champman

(1680-1756) published the secrets of the Chamberlens.

“Sciopour Mercurio” (1550-1595) did caesarean section for pelvic contractions

on a living mother but no anesthesia was used.

Trail labour dates from 1925. Horner used oxytocin by intranasal route.

Hafbuger reported buccal pitocin for induction of labour.

Theobald in 1948 first used oxytocin drip.

16

The development of comprehensive hospital care, anesthesia-and X-ray

pelvimetry have ushered out high forceps, bipolar and podalic version and other crude

happenings of a sadly mechanical era. Today where obstetric care is available,

maternal death directly due to difficult labour is nearly non-existent. Now efficiency

of obstetric care is being placed rightfully on the welfare of the foetus.

PELVIS26,27

The pelvis is made up of the two innominate bones (which occupy the front

and sides) and the sacrum and coccyx (which are behind). The bones articulate

through four joints. The sacroiliac joint is the most important linking the sacrum to

the iliac part of the innominate bones. The symphysis of the pubis joins the two pubic

bones. The sacrococcygeal joint attaches the sacrum to the coccyx.

The false pelvis lies above the true pelvis, superior to the linea terminalis. Its

only obstetric function is to support the enlarged uterus during pregnancy. Its

boundaries are:

1. Posteriorly: lumbar vertebrae

2. Laterally: iliac fossae

3. Anteriorly: anterior abdominal wall

The true pelvis (Figure 1A) lies below the pelvic brim, or linea terminalis, and

is the bony canal through which the baby must pass. It is divided into three parts:

(1) the inlet, (2) the pelvic cavity, and (3) the pelvic outlet.

The inlet (pelvic brim) is bounded:

1. Anteriorly: by the pubic crest and spine

2. Laterally, by the iliopectineal lines on the innominate bones

3. Posteriorly, by the anterior borders of the ala and promontory of the sacrum

17

Figure 1: Pelvic cavity

18

The pelvic cavity (Figure 1B) is a curved canal.

1. The anterior wall is straight and shallow. The pubis is 5 cm long.

2. The posterior wall is deep and concave. The sacrum is 10 to 15 cm long.

3. The ischium and part of the body of the ilium are found laterally.

The pelvic outlet is diamond-shaped. It is bounded:

1. Anteriorly: by the arcuate pubic ligament and the pubic arch

2. Laterally: by the ischial tuberosity and the sacrotuberous ligament

3. Posteriorly: by the tip of the sacrum

The pelvic inclination (Figure 1C) is assessed when the woman is in the

upright position. The plane of the pelvic brim makes an angle of about 60° with the

horizontal. The anterior superior iliac spine is in the same vertical plane as the pubic

spine.

The axis of the birth canal (Figure 1D) is the course taken by the presenting

part as it passes through the pelvis. At first it moves downward and backward to the

level of the ischial spines, which is the area of the bony attachment of the pelvic floor

muscles. Here the direction changes and the presenting part proceeds downward and

forward.

19

The pelvic planes (Figure 2) are imaginary flat surfaces passing across the

pelvis at different levels. They are used for the purposes of description. The important

ones are as follows:

1. The plane of the inlet is also called the superior strait.

2. The pelvic cavity has many planes, two of which are the plane of greatest

dimensions and the plane of least dimensions.

3. The plane of the outlet is also called the inferior strait.

The diameters are distances between given points. Important ones are the

following:

1. Anteroposterior diameters.

2. Transverse diameters.

3. Left oblique: Oblique diameters are designated left or right according to their

posterior terminal.

4. Right oblique.

5. Posterior sagittal diameter: This is the back part of the anteroposterior

diameter, extending from the intersection of the transverse and anteroposterior

diameters to the posterior limit of the latter.

6. Anterior sagittal diameter: This is the front part of the anteroposterior diameter,

extending from the intersection of the transverse and anteroposterior diameter

to the anterior limit of the latter.

20

Figure 2: Pelvic planes

21

PELVIC INLET

Plane of Obstetric Inlet

The plane of the obstetric inlet is bounded:

1. Anteriorly: by the posterior superior margin of the pubic symphysis

2. Laterally: by the iliopectineal lines

3. Posteriorly: by the promontory and ala of the sacrum

Diameters of Inlet

The diameters of the inlet are as follows:

1. Anteroposterior diameters:

a. The anatomic conjugate (Figure 3) extends from the middle of the sacral

promontory to the middle of the pubic crest (superior surface of the pubis). It

measures 11.5 cm. It has no obstetric significance.

b. The obstetric conjugate extends from the middle of the sacral promontory to the

posterior superior margin of the pubic symphysis. This point on the pubis, which

protrudes back into the cavity of the pelvis is about 1 cm below the pubic crest.

The obstetric conjugate is about 11.0 cm in length. This is the important

anteroposterior diameter, since it is the one through which the fetus must pass.

c. The diagonal conjugate extends from the subpubic angle to the middle of the sacral

promontory. It is 12.5 cm in length. This diameter can be measured manually in

the patient. It is of clinical significance because by subtracting 1.5 cm an

approximate length of the obstetric conjugate can be obtained.

2. Transverse diameter is the widest distance between the iliopectineal lines and is

13.5 cm.

22

3. Left oblique diameter extends from the left sacroiliac joint to the right iliopectineal

eminence and is about 12.5 cm.

4. Right oblique diameter extends from the right sacroiliac joint to the left

iliopectineal eminence and is about 12.5 cm.

5. Posterior sagittal extends from the intersection of the anteroposterior and transverse

diameters to the middle of the sacral promontory and is about 4.5 cm long.

Figure 3: Pelvic inlet

23

PELVIC CAVITY

The pelvic cavity extends from the inlet to the outlet.

Plane of Greatest Dimensions

This is the roomiest part of the pelvis and is almost circular. Its obstetric

significance is small. Its boundaries are:

1. Anteriorly: midpoint of the posterior surface of the pubis

2. Laterally: upper and middle thirds of the obturator foramina

3. Posteriorly: the junction of the second and third sacral vertebrae

The diameters of importance are:

1. The anteroposterior diameter extends from the midpoint of the posterior

surface of the pubis to the junction of the second and third sacral vertebrae and

measures 12.75 cm.

2. The transverse diameter is the widest distance between the lateral aspects of

the plane and is 12.5 cm.

Plane of Least Dimensions

This is the most important plane of the pelvis (Figure 4). It has the least room,

and it is here that most instances of arrest of progress take place. This plane extends

from the apex of the subpubic arch through the ischial spines, to the sacrum, usually

at or near the junction of the fourth and fifth sacral vertebrae. The boundaries are,

from front to back:

1. Lower border of the pubic symphysis

2. White line on the fascia covering the obturator foramina

3. Ischial spines

24

4. Sacrospinous ligaments

5. Sacrum

The diameters of importance are:

1. Anteroposterior diameter, extending from the lower border of the pubic

symphysis to the junction of the fourth and fifth sacral vertebrae and measuring

12.0 cm

2. Transverse diameter, lying between the ischial spines and measuring 10.5 cm

3. Posterior sagittal diameter, extending from the bispinous diameter to the

junction of the fourth and fifth sacral vertebrae and measuring 4.5 to 5.0 cm

Figure 4: Pelvic cavity: The plane of least dimensions

25

PELVIC OUTLET

The outlet is made up of two triangular planes, having as their common

base and most inferior part the transverse diameter between the ischial tuberosities

(Figure 5).

Anterior Triangle

The anterior triangle has the following boundaries:

1. The base is the bituberous diameter (transverse diameter).

2. The apex is the subpubic angle.

3. The sides are the pubic rami and ischial tuberosities.

Posterior Triangle

The posterior triangle has the following boundaries:

1. The base is the bituberous diameter.

2. The obstetric apex is the sacrococcygeal joint.

3. The sides are the sacrotuberous ligaments.

Diameters of the Outlet

1. The anatomic anteroposterior diameter is from the inferior margin of the pubic

symphysis to the tip of the coccyx. It measures about 9.5 cm. The obstetric

anteroposterior diameter is from the inferior margin of the pubic symphysis to

the sacrococcygeal joint. This measures 11.5 cm. Because of the mobility at the

sacrococcygeal joint, the coccyx is pushed out of the way by the advancing

presenting part, increasing the available space.

2. The transverse diameter is the distance between the inner surfaces of the ischial

tuberosities and measures about 11.0 cm.

26

3. The posterior sagittal diameter extends from the middle of the transverse

diameter to the sacrococcygeal junction and is 9.0 cm.

4. The anterior sagittal diameter extends from the middle of the transverse

diameter to the subpubic angle and measures 6.0 cm.

Figure 5: Pelvic outlet

27

IMPORTANT MEASUREMENTS

In assessing the obstetric capacity of the pelvis the most important

measurements are the following:

1. Obstetric conjugate of the inlet

2. Distance between the ischial spines

3. Subpubic angle and bituberous diameter

4. Posterior sagittal diameters of the three planes

5. Curve and length of the sacrum

CLASSIFICATION OF THE PELVIS

Variations in the female pelvis and in the planes of any single pelvis are so

great that a rigid classification is not possible. A pelvis of the female type in one

plane may be predominantly male in another. Many pelvis are mixed in that the

various planes do not conform to a single parent type.

For the purpose of classification the pelvis is named on the basis of the inlet,

and mention is made of nonconforming characteristics. For example, a pelvis may be

described as a female type with male features at the outlet.

We prefer the classification of Caldwell and Moloy (Table 1 and Figures 6

through 8).

28

Figure 6: Pelvic inlet (Caldwell-Moloy classification)

29

Figure 7: Midpelvis (Caldwell-Moloy classification)

Figure 8: Pelvic outlet (Caldwell-Moloy classification)

30

CLASSIFICATION OF PELVIS (CALDWELL AND MOLOY)25

Gynecoid Android Anthropoid Platypelloid INLET Sex type Incidence Shape Anteroposterior diameter Transverse diameter Posterior sagittal diameter Anterior sagittal diameter Posterior segment Anterior segment

Normal female 50% Round or transverse oval; transverse diameter is a little longer than the antero-posterior Adequate Adequate Adequate Adequate

Broad, deep, roomy Well rounded forepelvis

Male 20% Heart or wedge shaped Adequate Adequate Very short and inadequate Long Shallow; sacral promontory indents the inlet and reduces its capacity Narrow, sharply angulated forepelvis

Ape-like 25% Long antero- posterior oval Long Adequate but relatively short Very long Long Deep Deep

Flat female 5% Transverse oval Short Long Very short Short

Shallow Shallow

PELVIC CAVITY: MIDPELVIS Anteroposterior diameter Transverse diameter Posterior sagittal diameter Anterior sagittal diameter Sacrum Sidewalls Ischial spines Sacrosciatic notch Depth: iliopec- tineal eminence to tuberosities Capacity

Adequate Adequate Adequate Adequate Wide, deep curve; short; slopes back- ward; light bone Parallel, straight Not prominent Wide; short Average Adequate

Reduced Reduced Reduced Reduced Flat; inclined forward; long; narrow; heavy Convergent; funnel pelvis Prominent Narrow; long; high arch Long Reduced in all diameters

Long Adequate Adequate Adequate Inclined back- ward; narrow; long Straight Variable Wide Long Adequate

Shortened Wide Shortened Short Wide, deep curve; often sharply angu- lated with enlarged sacral fossa Parallel Variable Short Short

Reduced

31

Gynecoid Android Anthropoid Platypelloid OUTLET Anteroposterior diameter Transverse diameter (bituberous) Pubic arch Inferior pubic rami Capacity

Long Adequate Wide and round; 90° Short; concave inward Adequate

Short Narrow Narrow; deep; 70° Straight; long Reduced

Long Adequate Normal or relatively narrow Long; relatively narrow Adequate

Short Wide Very wide Straight; short Inadequate

EFFECT ON LABOR Fetal head Labor Prognosis

Engages in transverse or oblique diam- eter in slight asynclitism; good flexion; OA is common Good uterine function; early and complete internal rotation; spontaneous delivery; wide pubic arch reduces perineal tears Good

Engages in transverse or posterior diameter in asynclitism; extreme molding Deep transverse arrest is common; arrest as OP with fail- ure of rotation; delivery is often by diffj- cult forceps application, rotation, and extraction; the narrow pubic arch may lead to major perineal tears Poor

Engages in anteropos- terior or oblique; often occiput posterior Delivery and labor usually easy; birth face to pubis is common Good

Engages in transverse diameter with marked asynclitism Delay at inlet Poor; disproportion; delay at inlet; labor often terminated by cesarean section

32

CLASSES OF PELVIS DEFORMITY

I. Deformities arising for faulty development

a. Justo major pelvic

b. Justo – Minor or generally contracted pelvis

c. Simple flat non-rachitic pelvis

d. Naegele’s pelvis – Imperfect development of one sacral alae

e. Robert’s pelvis – Imperfect development of both sacral alae

f. Split pelvis – Imperfect development pelvis

g. Assimilation pelvis

h. Variety of pelvis four types

II. Deformities arising from disease of the pelvic bones and joints

a. Rickets

b. Osteomalacia

c. New growth

d. Fractures

e. Atrophy, caries, necrosis

f. Diseases of sacro-iliac, and sacro coccygeal joints

g. Luxation of sacro-iliac joints

III. Deformities resulting disease of the spinal column

a. Kyphosis

b. Scoliosis

c. Spondylolisthesis

d. Coccygeal deformity

IV. Deformities arising from diseases of lower extremities

a. Coxitis

b. Dislocation of one or both femur

c. Atrophy or loss of one limb

33

Firstly, these are those which are due to diseases affecting skeletal system as a

whole. Of these, rickets is the principal offender. Not only it produces stunting of

growth with the general contraction, but the characteristic deformity is flattening of a

type which exaggerates the worst features of the platypelloid type in as much as the

sacral promontary may bulge so far forward as to give the brim a reniform shape.

Secondly, pelvis may be deformed as a result of disease in one of the lower

limbs contracted in childhood are of congenital origin. Examples are poliomyelitis,

congenital dislocation of hip, tuberculous arthritis of the hip, serious injuries and

talipes. The woman who come to the antenatal clinic with a severe limp requires a

careful investigation of her pelvis.

Thirdly, there may be abnormalities of the spine. Scoliosis is often associated

with the disease affecting lower extremities and in these cases there may be pelvic

asymmetry.

Kyphosis is important particularly in relation to its site. A high dorsal kyphosis

is usually affected by a compensatory lordosis, so that the pelvis is not altered in

shape, although one must mention other obstetric considerations such as the reduced

distance between xiphisternum and symphysis pubis which may make a transverse lie

inevitable for want of room in the abdominal cavity. A kyphosis situated low down in

the spinal column may, for like reason, encourage a pendulous belly. The outlet tends

to be contracted in the later instance but those cases often go into the premature

labour, so that baby may be small enough to be delivered by the vaginal route.

34

There are two types of assimilation pelvis, the high and low. In the former the

last lumbar vertebra is incorporated in the body of the sacrum, thus not only

increasing the sacral length but placing the sacral promontary at a higher level than

the normal. This has the effect of steepening the angle of pelvic inclination and

reducing the sacral angle well below 90°. It may be a potent cause of dystocia. In the

low assimilation pelvis only four pieces comprise the body of the sacrum and there

are no obstetrical advantages.

NAEGLE’S AND ROBERT PELVIS

These are mainly of museum interest and only a very few cases of the latter

have been recorded, In the Naegle pelvis one sacral ala is not properly developed

resulting in profound asymmetry. In the Robert pelvis the condition is bilateral.

Spondylolisthesis too is rare. The lumbar spine is subluxated forward on the sacrum,

thus reducing the anterior-posterior diameter of the brim. In grand multiparity

something akin to this process may occur.

Osteomalacia which is rare, produces a three corner hat type of pelvis. Lastly

to complete the list, deformities of obstetrical significance may result from pelvic

fractures, chondroma and osteoma.

CLINICAL COURSE OF LABOUR1

During the first 36 to 38 weeks of gestation, the myometrium is unresponsive

after this prolonged period of quiescence, a transitional phase is required during

which myometrium unresponsiveness is suspended and the cervix is softened and

effaced. Indeed, there are multiple functional states of the uterus that must be

implemented during pregnancy and the puerperium.

35

Early signs

1. Lightening: This is a clinical manifestation of phase I parturition with the

development of a well formed lower uterine segment. The fetal head descends to

or even through the pelvic inlet.

2. Show: A rather dependable sign of the impending onset of the active labour is

‘show or bloody show’ which consists of the discharge of a small amount of

blood-tinged mucus from the vagina representing the extrusion of the plug of

mucus that was filling the cervical canal during pregnancy. Show is a late sign,

because labour usually ensures during the next several hours to few days.

Causes of painful uterine contractions are:

1. Hypoxia of the contracted myometrium

2. Compression of nerve ganglia in the cervix and lower uterus by tightly

interlocking muscle bundles.

3. Stretching of the cervix during dilatation.

4. Stretching of the peritoneum overlying the fundus.

Uterine contractions are involuntary and for the most part, independent of

extra uterine control. Mechanical stretching of cervix enhances uterine activity. This

phenomenon is called “Ferguson’s reflex” Manipulation of the cervix and stripping of

fetal membranes causes an increase in prostaglandin F2-alpha metabolites in blood

(Mitchell, 1976), this is attributable to additional trauma to the decidua of the fore bag

or lower uterine segment and the uptake of PG F2 ∝ from vaginal fluid.

36

Changes induced in the Cervix

The effective force of the first stage of labour is the uterine contraction, which

is then exerts hydrostatic pressure through the membranes against the cervix and

lower uterine segment. In the absence of intact membranes, the presenting part is

forced directly against the cervix and lower uterine segment. As the result of action of

these forces, two fundamental changes effacement and dilatation takes place in the

previously ripened cervix.

Cervical Effacement

The obliteration or taking up of the cervix is the shortening of the cervical

canal from a length of about 2 cm to mere circular orifice with almost paper – thin

edges and this process takes place from above downwards. Muscle fibers at level of

internal os are pulled upwards and thus becomes a part of lower uterine segment.

Cervical dilatation

Compared with the body of the uterus, the lower uterine segment and the

cervix are regions of lesser resistance. Therefore during a contraction these structures

are subjected to distension in the course of which a centrifugal pull is exerted on the

cervix and can be represented by letters T, Y, V and U.

Pattern of cervical dilatation

Friedman,28 in his treatise on labour (1978) stated that “The clinical features of

uterine contractions – namely, frequency, intensity and duration cannot be relied upon

as measures of progression in labour nor as indices of normality except for cervical

dilatation and fetal descent. None of the clinical features of parturient appears to be

useful in assessing labour progression.

37

Figure 9: Labor course divided functionally on the basis of expected evolution of

the dilatation and descent curves into (1) a preparatory division, including latent and acceleration phases; (2) a dilatational division, occupying the phase of maximum slope of dilatation; and (3) a pelvic division, encompassing both deceleration phase and second stage while concurrent with the phase of maximum slope of fetal descent.

Figure 10: Composite of the average dilatation curve for nulliparous labor based on analysis of the data derived from patterns traced from a large, nearly consecutive, series of gravidas. The first stage is divided into a relatively flat latent phase. In the active phase, there are three identifiable component parts: an acceleration phase, a linear phase of maximum slope, and a deceleration phase.

38

The pattern of progressive dilatation that takes place during the course of

normal labour takes the shape of sigmoid curve. Two phases of cervical dilatation can

be defined.

1. The latent phase - lasts from 1 to 3 cm dilatation

2. Active phase - lasts from 3 to 10 cm dilatation and progressing at a rate of

1.2 cm/hr in primigravida and 1.5 cm/hr in multigravida.

Active phase has been sub-divided further as: (According to Friedman, 1978)

a. Acceleration phase - 3-4 cm dilatation.

b. Phase of maximum slope - 4 - 9 cm dilatation.

c. Deceleration phase - 9-10 cm.

The duration of latent phase is more variable and subject to sensitive changes

by extraneous factors and by sedation (prolonged latent phase) and myometrial

stimulation (shortening of latent phase).

The duration of latent phase has little bearing on the subsequent course of

labour, where as the characteristics of the accelerated phase are usually predictive of

the outcome of particular labour.

Friedman considers the maximum slope as a “good measure of the overall

efficiency of the machine”, whereas the nature of the deceleration phase is more

reflective of fetopelvic relationships. The completion of cervical dilatation during the

active phase of labour is accomplished by cervical retraction above the presenting part

of the fetus. After complete dilatation, the second stage of labour commences;

thereafter only progressive descent of the presenting part is available to assess the

progress of labour.

39

Friedman developed the concept of three functional divisions of labour to

describe the physiological objectives of each division. Although little cervical

dilatation occurs during the

1. Preparatory division - considerable changes takes place in the connective tissue

components of the cervix. This division of labour may be sensitive to sedation and

conduction analgesia.

2. Dilatational division – during this time, dilatation proceeds at its most rapid rate

and is unaffected by sedation or conduction analgesia.

3. Pelvic division – commences with the deceleration phase of cervical dilatation. In

actual practice, however the onset of pelvic division is seldom clearly identifiable.

Two phases of cervical dilatation are defined, the latent phase corresponds to

preparatory division, and the active phase to the dilatational division.

Pattern of Fetal descent

In the descent pattern of normal labour, a typical hyperbolic curve is formed

when station of the fetal head is plotted as a function of the duration of labour. Active

descent usually takes place after cervical dilatation has progressed for sometime.

In nulliparous, increased rates of descent are observed ordinarily during the

phase of maximum slope of cervical dilatation. At this time, the speed of descent

increases to a maximum, and this maximal rate of descent is maintained until the

presenting fetal part reaches the perineal floor.28

Three stages of Labour

Customarily and for good clinical reasons, active labour is divided into three

separate stages.

40

First stage of labour begins when uterine contraction of sufficient frequency,

intensity, and duration are attained with periods of relaxation between contractions to

bring about effacement and progressive dilatation of cervix. The I stage of labour

ends when the cervix is fully dilated, that is when the cervix is sufficiently dilated

(about 10 cms) to allow passage of the fetal head. The first stage of labour, therefore

is the stage of cervical effacement and dilatation.

I stage of labour is characterized by

1. Mucosanguinous discharge.

2. Effacement and dilatation of the cervix.

3. Fixation and progressive descent of the presenting part.

4. Rupture of the members.

I stage accounts for 90% of the entire duration of labour in ordinary

circumstances.

- Normal duration - 12 hours.

The Second stage of labour begins when dilatation of cervix is complete and

ends with delivery of the fetus or fetuses. The II stage of labour is the stage of

expulsion of the fetus or fetuses.

It is characterized by:

1. Occurrence of characteristic uterine contractions which increase in frequency

and amplitude, leading to typical bearing down pains.

2. Action of accessory muscles i.e., the abdominal muscles and diaphragm.

3. Progressive descent of the presenting part.

41

4. Dilatation of the vagina and vulva with stretching of the pelvic floor and

finally;

5. Expulsion of the fetus.

Average duration is 50 min for primigravida and 20 min for multigravida.

According to Acog (1989), 2 hours for primigravida and extended to 3 hours

when regional analgesia was used and one hour for multigravida extended to 2 hours

with regional analgesia. Third stage of labour extends from the complete expulsion of

the fetus and ends with the delivery of placenta and membranes. The third stage is the

stage of placental separation and expulsion of the placenta. The average duration is

few to 15 minutes. Fourth stage of labour: 1 hour after delivery of placenta.

DIAGNOSIS OF LABOUR

Constitutes most important single item in the management of labour. Wrong

diagnosis invariable leads to wrong treatment. Painful uterine contractions alone do

not warrant a medical diagnosis of labour. Pain must be supported by a show,

spontaneous rupture of membranes or dilatation of the cervix. Although, dilatation of

the cervix represents the only conclusive evidence of labour in practice, a show or

spontaneous rupture of membranes combined with painful uterine contractions

affords sufficiently strong presumptive evidence to commit a woman to delivery.

After the diagnosis of labour has been confirmed, the next important item in

management is to monitor progress at short and regular intervals. The sole purpose of

uterine contractions during the first stage of labour is to open the neck of the womb

sufficiently to allow the baby to pass through. Hence, dilatation of the cervix is the

only measure of progress appropriate to the first stage of labour. The first stage

42

accounts for 90% of the entire duration of labour.

The sole purpose of the uterine action during the second stage is to propel the

fetus along the birth canal. Thus, the descent of the head is measure of progress

appropriate to the second stage of labour.

Pelvic examination is performed at the point of admission and thereafter at

regular intervals of 1 hour for the next 3 hours. Subsequent examination performed at

intervals not longer than 2 hours.

The degree of cervical dilatation is recorded on a simple graph against hours

after admission. The maximum time allotted is 10 hours. The rate of cervical

dilatation acceptable is 1 cm/hr. The whole purpose of the graph is to relate progress

in labour to the passage of time in an usual manner that is readily intelligible even to

lay persons. A clear pattern of cervical dilatation should have emerged at the end of

3 hours and on this basis it should be possible to predict the hour of delivery by

simple linear projecting.

The II stage of labour is composed of 2 distinct phases; the natural division

between abdominal and vaginal delivery comes to the end of phase I. When the

baby’s head has descended to the floor of pelvis at which level, rotation occurs.

Delivery by propulsion is almost always preferable than delivery by traction.

MECHANISM OF LABOUR1,29

Cardinal movements of labour in occipitoanterior presentation

Because of the irregular shape of the pelvic canal and the relatively large

dimensions of mature fetal head, it is evident that not all diameters of the head can

necessarily pass through all the diameters of the pelvis.

43

It follows that a process of adaptation or accommodation of suitable portion of

the head to various segments of pelvis is required for completion of childbirth. These

positional changes in the presenting part constitute mechanism of labour.

The cardinal movements of labour are

Engagement,

Descent,

Flexion,

Internal rotation,

Extension,

Restitution,

External rotation,

Expulsion.

In reality, the mechanism of labour consists of a combination of movements

that are ongoing simultaneously. It is impossible for the movements to be completed

unless the presenting part descends simultaneously. Concomitantly uterine

contractions affect important modifications in fetal attitude or habitus, especially after

the head has descended into the pelvis. These changes consist principally of a

straightening of the fetus with loss of dorsal convexity and closer application of the

extremities of the body. As a result, the fetal ovoid is transformed into a cylinder. The

smallest possible cross-section normally passing through the birth canal.

Engagement

The mechanism by which the biparietal diameter, the greatest transverse

diameter of the fetal head in occiput presentation passes through the pelvic inlet. This

phenomenon may take place during the last few weeks of pregnancy or it may not

44

Figure 11: Cardinal movements of labour and delivery from a left occipital

anterior position

45

occur until after the commencement of labour. In many multiparous and some

nulliparous woman, the fetal head is freely movable above the pelvic inlet at the onset

of labour, it is referred as “floating”.

A normal-sized head usually does not engage with its sagittal suture directed

anteroposteriorly, instead, the fetal head usually enters the pelvic inlet either in the

transverse diameter or in one of the oblique diameters.30 Moderate degrees of

asynclitism are the rule in normal labour but if severe, the asynclitism may lead to

cephalopelvic disproportion even with an otherwise normal pelvis. Successive

changes from posterior to anterior asynclitism facilitate descent by allowing the fetal

head to take advantage of the roomiest areas of the pelvic cavity.

Descent

The first requisite for birth of the infant in nulliparous, engagement may take

place before the onset of labour and further descent may not follow until the onset of

second stage. In multiparous woman, descent usually begins with engagement.

Descent is brought about by one or more of four forces.

1. Pressure of the amniotic fluid.

2. Direct pressure of the fundus upon the breech with contractions.

3. Bearing down efforts with the abdominal muscles.

4. Extension and straightening of the fetal body.

Flexion

As soon as the descending head meets resistance, whether from the cervix,

walls of the pelvis, or pelvic floor, flexion of the head normally results. In this

movement, the chin is brought into more intimate contact with the fetal thorax and the

46

appreciably shorter suboccipitobregmatic diameter is substituted for the longer

occipitofrontal diameter.

Internal rotation

It is the turning of head in such a manner that occiput gradually moves from its

original position anteriorly towards the pubic symphysis or less commonly towards

the hollow of sacrum. Internal rotation is essential for completion of labour except

when the fetus is unusually small, while it always is associated with descent.31 Calkin

(1939) concluded approximately 2/3rd internal rotation completed by time head

reaches the pelvic floor, in about 1/4th internal rotation completed very shortly after

head reaches pelvic floor, in 5% anterior rotation does not take place.

Crowning

After internal rotation, further descent occurs until the subocciput lies

underneath the pubic arch. At this stage, the maximum diameter of the head stretches

the vulval outlet without any recession of the head even after the contraction is over.

Extension

After internal rotation, the sharply flexed head reaches the vulva, undergoes

extension. This begins the base of the occiput into direct contact with the inferior

margin of the pubic symphysis because the vulval outlet is directed upwards and

forwards. Extension must occur before the head can pass through it. When the head

presses upon the pelvic gutter, however, 2 forces come into play. First, exerted by the

uterus acts more posteriorly. The second, supplied by the resistant pelvic floor and the

symphysis acts more anteriorly. The resultant vector is in the direction of the vulval

opening, thereby causing extension.

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Restitution

As soon as the fetal head is free outside the vulval outlet it rotates through 45°

and thus the neck is untwisted and chin rotate towards the right side in case of LOA

position and towards left in cases of ROA position.

External rotation

Delivered head undergoes restitution. If the occiput is originally to left, it

rotates to left ischial tuberosity and if it was located towards the right, rotates towards

the right ischial tuberosity. Restitution of the head to the oblique position is followed

by completion of external rotation to the transverse position, a movement that

corresponds to rotation of the fetal body, serving to bring its bisacromial diameter into

relation with the anteroposterior diameter of the pelvic outlet. Thus, one shoulder is

anterior behind the symphysis and the other is posterior. This movement is apparently

brought about by the same pelvic factors that reduce internal rotation of the head.

Expulsion

Almost immediately after external rotation, the anterior shoulder appears

under the symphysis and the perineum soon becomes distended by the posterior

shoulder. After delivery of the shoulders, the rest of the body is quickly extruded.

Changes in shape of fetal head

Caput succedaneum

In vertex presentation, fetus undergoes important characteristic changes in

shape as the result of pressure to which it is subjected during labour. In prolonged

labour, before complete cervical dilatation, the portion of fetal scalp immediately over

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the cervical os becomes edematous forming a swelling known as caput succedaneum.

More commonly, the caput is found when the head is in lower portion of the

birth canal and frequently only after the resistance of rigid vaginal outlet is

encountered because it occurs over the most dependent part. In LOT, over the right

parietal bone and in ROT position, over the corresponding left parietal bone.

Alteration in the shape of the head that occurs from internal compression is known as

moulding. This is due to nonfirm union of skull bones and movements that occur

along the suture lines. In normal labour, an alteration of 4 mm commonly occurs.

During this process, the parietal bones tend to overlap with the adjacent bones. In

many cases, anterior parietal overlaps over the posterior parietal.32 Moulding may

account for decrease in biparietal diameter and suboccipitobregmatic diameter of

0.5 to 1 cm or even more in prolonged labour and there is lengthening of the

mentovertical diameter. These changes are of greatest importance in contracted pelvis

or asynclitic presentations. Moulding disappears within few hours of birth.

Grades of moulding are as follows:

Grade I – No overlapping of bone.

Grade II – Overlap of suture lines but reducible

Grade III – Overlap of suture lines, is irreducible.

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Slight moulding is inevitable and beneficial. It enables the head to pass more

easily through the birth canal. Extreme moulding is met with severe disproportion

may produce severe intracranial disturbances in the form of tentorial tear or subdural

hematoma.

ENGAGEMENT AND ITS SIGNIFICANCE

Engagement in vertex refers to the descent of the biparietal or largest diameter

of the normally flexed fetal head has passed through the inlet, the head is engaged.

Although, engagement of the fetal head usually is regarded as a phenomenon

of labour in nulliparous, it commonly occurs during the last few weeks of pregnancy.

When it does so, it is confirmatory evidence that the pelvic inlet is adequate for the

fetal head “with engagement the fetal head serves as an internal pelvimeter to

demonstrate that the pelvic inlet is ample for the fetus”.

The distance from the plane of the pelvic inlet to the level of ischial spines is

approximately 5 cm in most pelvis and the distance from the biparietal plane of the

unmoulded fetal head to the vertex is about 3 to 4 cm. Under these circumstances, the

vertex cannot possibly reach the level of spines unless the biparietal diameter has

passed the inlet or unless there has been considerable elongation of the fetal head

because of moulding and formation of a caput succedaneum.

CLINICAL ASPECTS

Caldwell et al. (1934) showed that a normal sized head usually does not

engage with its sagittal suture directed anteroposteriorly, instead, the fetal head

usually enters the pelvic inlet either in the transverse or in one of the oblique

diameters.

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Although, the fetal head tends to accommodate to the transverse axis of the

pelvic inlet, the sagittal suture while remaining parallel to that axis may not lie

exactly midway between the symphysis and sacral promontory. When the biparietal

diameter of the fetal head is parallel to the planes of the pelvis, the head is in

“synclitism”. Engagement in synclitism takes place when the uterus is perpendicular

to the inlet and the pelvis is roomy. The head enters the pelvis with the plane of

biparietal diameter, parallel to the plane of the inlet. The sagittal suture lies midway

between the pubic symphysis and the sacral promontory, and the parietal bone enter

the pelvis at same time.

Asynclitism

Although the fetal head tends to accommodate to transverse axis of pelvic

inlet, the sagittal suture while remaining parallel to the axis, may not be exactly

midway between the symphysis and sacral promontory.

The sagittal suture frequency is deflected either posteriorly towards the

promontory or anteriorly towards the symphysis. Such lateral deflection of the head to

a more anterior or posterior position in pelvis is called asynclitism.

Posterior Asynclitism (Litzmann Obliquity)

In most women the abdominal wall maintains the pregnant uterus in an upright

position and prevents it from lying perpendicular to the plane of the pelvic inlet. As

the head approaches the pelvis, the posterior parietal bone is lower than the anterior

parietal bone, the sagittal suture is closer to the symphysis pubis than to the

promontory of the sacrum, and the biparietal diameter of the head is in an oblique

relationship to the plane of the inlet. This is posterior asynclitism (Figure 12). It is the

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usual mechanism in normal women and is more common than engagement in

synclitism or anterior asynclitism.

Figure 12: Posterior asynclitism

As the head enters the pelvis, the posterior parietal bone leads the way and the

posterior parietal boss (eminence) descends past the sacral promontory. At this point

the anterior parietal bone is still above the pubic symphysis and has not entered the

pelvis. Uterine contractions force the head downward and into a movement of lateral

flexion. The posterior parietal bone pivots against the promontory, the sagittal suture

moves posteriorly toward the sacrum and the anterior parietal boss descends past the

symphysis and into the pelvis. This brings the sagittal suture midway between the

front and back of the pelvis and the head is now in synclitism.

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Anterior Asynclitism (Nagele Obliquity)

When the woman’s abdominal muscles are lax and the abdomen is pendulous

so that the uterus and baby fall forward, or when the pelvis is abnormal and prevents

the more common posterior asynclitism, the head enters the pelvis by anterior

asynclitism (Figure 13). In this mechanism the anterior parietal bone descends first,

the anterior parietal boss passes by the pubic symphysis into the pelvis and the sagittal

suture lies closer to the sacral promontory than to the pubic symphysis. When the

anterior parietal bone becomes relatively fixed behind the symphysis, a movement of

lateral flexion takes place so that the sagittal suture moves anteriorly toward the

symphysis and the posterior parietal boss squeezes by the sacral promontory and into

the pelvis. The mechanism of engagement in anterior asynclitism is the reverse of that

with posterior asynclitism.

Figure 13: Anterior asynclitism

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There is a mechanical advantage to the head entering the pelvis in asynclitism.

When the two parietal bosses enter the pelvic inlet at the same time (synclitism), the

presenting diameter is the biparietal of 9.5 cm. In asynclitism the bosses come into the

pelvis one at a time, and the diameter is the subsuperparietal of 8.75 cm. Thus,

engagement in asynclitism enables a larger head to pass through the inlet than would

be possible if the head entered with its biparietal diameter parallel to the plane of the

inlet (Figure 14).

Figure 14: Synclitism in the pelvis

Whenever there is a small pelvis or a large head, asynclitism plays an

important part in enabling engagement to take place. Marked and persistent

asynclitism, however is abnormal. When asynclitism is maintained until the head is

deep in the pelvis, it may prevent normal internal rotation.

Engagement can be ascertained by abdominal palpation, bimanual palpation

should begin some distance above the pubis and fingers should be moved downwards

in successive steps until the sinciput and occipit are encountered. If the head is

engaged, only sinciput is felt per abdomen and examining fingers when pushed

downwards, slide over the nape of the neck and diverge. If the head is not engaged,

fingers can palpate the lower part of the head and will converge. Engagement can be

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confirmed only when the occipital protuberance is no longer palpable.

As the head begins to enter the pelvic brim, bimanual assessment is

supplemented by single-handed palpation in midline suprapubically. Radial margin of

the index finger is used to palpate the head just above the symphysis and finger is

pressed backwards against the head at successively higher levels until the groove of

neck is reached. The amount of head felt suprapubically in fingerbreadths corresponds

reasonably well to an estimate of number of fifths still palpable. This descent concept

is owed by “Notelowitz and Crichton”.

By pelvic examination: Engagement is ascertained by vaginal examination by noting

the station of the presenting part in relation to the level of ischial spines. Above the

ischial spines, divided into 5 planes, -1 to -5, and below, +1 up to +5.10

Drawbacks: If the patient is overweight or distressed in the late stage of labour, then

abdominal level can be very difficult to define. There might be observer variability

because of moulding and caput. Station may appear lower than it actually is.26

Anteroposterior view Lateral view

Figure 15: Station of the presenting part

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Figure 16: Clinical estimation of descent of head in fifths palpable above the pelvic brim

CAUSES OF HIGH FETAL STATION

Fetal Causes33,34

1. Occipitoposterior position. The commonest fetal cause resulting in deflexion

presenting with occipitofrontal diameter with favourable pelvis and good

uterine contraction, engagement and rotation takes place in 90% of cases.

2. Fetal cervical extension, may cause incomplete flexion of the head, may be

because of cord around the neck or spasm of neck extensors or neck tumors.

3. Hydrocephalus, causing disproportion between fetal head and pelvis, and

preventing descent.

4. Mistaken maturity.

5. Big baby.

Maternal

1. Contracted pelvis

2. Disproportion as in cases of big baby or high inclination of pelvic brim with or

without compensating lordosis of spine, pendulous abdomen with or without

bony anomaly, may discourage the head from engaging.

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3. Inefficient uterine contractions, as occurs in dystocia-dystrophia syndrome.

4. Hydramnios

5. Pelvic tumors

6. Full bladder and rectum

7. Non-formation of the lower uterine segment due to either congenital weakness

in the muscle or due to insufficient uterine action.

8. Placental position (low-lying placenta and placenta previa) and

9. Idiopathic causes.

The cardinal observation of high head at term in a primi if made, the causes

that could be associated like full bladder, rectum, prematurity, occipitoposterior

position, hydramnios, malpresentations, multiple pregnancy, placenta previa, must be

excluded first. Later, an assessment of CPD must be made.2

ASSESSMENT OF DISPROPORTION

ABDOMINAL METHOD

Figure 17: Abdominal method of testing cephalopelvic disproportion

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The patient lies in dorsal position with the thighs slightly flexed. The

physician stands on the right side of the patient, the head is grasped by the left hand,

2 fingers (index and middle) of the right hand are placed in line with the anterior

surface of the pubic symphysis to note the overlapping when the head is pushed into

the pelvic brim.

Inference

If head can be pushed down in the pelvis without overlapping of the parietal

bone on the symphysis pubis – no disproportion.

If head can be pushed down, but there is slight overlapping of parital bone

moderate disproportion.

Head cannot be pushed down and parietal bones overhang the symphysis pubis

– severe disproportion.

The abdominal method can be used as a screening procedure. It is difficult to

elicit in the presence of deflexed head, thick abdominal wall, high floating head.

ABDOMINO VAGINAL METHOD (MULLER-MUNROKERR)

Figure 18: Bimanual method of testing CPD The finger tips are at the level of spines

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This method is superior as the pelvic assessment can be done simultaneously.

Muller introduced the method by placing the vaginal fingers at the level of ischial

spines to note the descent of head. Munrokerr added placement of the thumb over the

symphysis pubis to note the degree of overlapping. The patient lies in dorsal position

with knees flexed; two fingers of right hand introduced into the vagina with finger

tips placed at the level of ischial spines and thumb placed over the pubis. The head is

grasped by the left hand and pushed down into the pelvis.

Inference

The head can be pushed down up to the ischial spines and there is no

overlapping of parietal bones over the symphysis pubis; no disproportion. The head

can be pushed down a little but not up to the level of ischial spines and there is slight

overlapping of parietal bones; slight or moderate disproportion. The head cannot be

pushed down and parietal bones overhang the symphysis pubis, severe disproportion.

This method is only applicable to presence or absence of disproportion at the brim

and not to elicit midpelvic or outlet contraction.

Ion Donald’s method

Figure 19: Testing for engagement. An assistant is pressing on the breech

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Patient lying on couch with head supported by a pillow, the knees are not fully

raised and fairly widely separated. Standing on right of patient and using the 3rd, 4th,

5th fingers of both hands, the head is gripped at sinciput and occiput.

One of the index fingers usually the left now reaches over and identifies the

position of the top of the symphysis pubis. The thumbs are then passed backwards

against the parietal eminence. Complete grip of head is thus obtained and its

relationship to the symphysis pubis can be fully appreciated.

Now and not before an assistant applies his hand to baby’s breech and presses

the baby towards the pelvis. At the same time, the thumbs which are applied to the

parietal eminence press downwards and backwards. While the fingers on sinciput and

occiput can observe what is happening. The index finger of left hand is kept as before

at the upper margin of pubic symphysis. If the head is mechanically capable of

engagement, it can now steered into the brim with the thumbs and the whole

movement can be fully appreciated.

Certain features, which might help to diagnose cephalopelvic disproportion, are

1. Stature of the patient. Any patient less than 5 feet should have an accurate pelvic

assessment.

2. History of stigmata of rickets which is rare now.

3. Any spinal or limb deformities like kyphosis or scoliosis.

4. Primi with pendulous abdomen often due to inability of the head to find room for

itself in pelvis.

5. History of previous still birth or neonatal death, contracted pelvis might be the

reason.35

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CLINICAL PELVIC ASSESSMENT

Done after 38 weeks should not be done until final weeks in primigravida

before that time the pelvic tissues are not sufficiently softened and relaxation of

pelvic joints.

1. Sacral promontory: Normally, the middle finger fails to reach the promontory and

it implies that the conjugate is adequate for the average size head to pass through. It is

nothing but an indirect assessment of diagonal conjugate.

Diagonal conjugate: To obtain this measurement of diagonal conjugate, the middle

and forefinger of the right hand are passed into the vagina until the middle finger

impinges on the promontory. The forefinger of the other hand then marks off the

lower margin of the subpubic ligament. Both hands are then withdrawn and the

distance between the tip of the middle finger and point marked by the forefinger is

measured with calipers or rod, and it measures 12.5 cm.

Drawbacks: Depth of symphysis, inclination, and height of pubic symphysis alter the

measurement and false promontory may give false reading.

2. Sacral concavity: Flattening of the sacrum is an unfavorable sign which may

produce transverse arrest. Sacrum should be well curved.

3. Sacrosciatic notch: Normally 2 fingers can be easily placed over the

sacrospinous ligament. It serves as an useful index of the adequacy of the

pelvis at lower level.

4. Ischial spines: There should be no marked projection into the cavity.

5. Pelvic side walls: Normally are parallel or some times divergent and not

easily palpable by the sweeping fingers unless they are convergent.

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6. Pubic arch: Normally, rounded and should accommodate palmar aspect of

2 fingers.

7. Transverse diameter of the outlet: is measured by placing knuckles or

closed fist and measure the bituberous diameter. The patient should be in

either left lateral position or lithotomy position.

Figure 20: Clinical assessment of the pelvis a. Sacrum; b. Pelvic side walls; c. Ischial spines; d. Sacrosciatic nortch

Figure 21: Estimating the pelvic outlet with the closed hand (Jarcho)

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Figure 22: Subpubic angle

Figure 23: Measuring the diagonal conjugate (Jarchio)

PELVIMETRY BY X-RAY

Radiography can be of real value in measuring pelvic size and revealing

certain features of the mechanics of child birth so that a fore warning of likely

difficulties in labour is sounded. It is well known that all exposure to ionizing

radiations is potential harmful. The dangers considered are:

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1. Derrangement of the genetic pattern of the chromosomes in the germ cell of the

gonads with possible harmful consequences to future generations through

induction of mutation.

2. Interferences: with the development of the embryo.

3. Increased risk to the child after birth for leukaemia and other forms of malignant

disease.

In subsequent years the exposure to radiation resulting from obstetric

radiology has decreased. The dose received during pelvimetry using a standard

contemporary techniques to minimize exposure is only about 200 millirads.

Measurement of the maternal pelvis

1. Isometric method – Lateral pelvimetry: The lateral view of the pelvis is the most

useful single radiographic examination.

Procedure

Isometric method lateral pelvimetry. It is the most useful single radiographic

examination. The radiograph can be obtained with the patient standing erect, and with

X-ray tube at a constant range (not < 1.2 m) from the film, or in recumbent position.

After position, a metal rod mounted on a firm stand is placed between patients legs so

that a centimeter measure rests along the cleft of the buttocks. A scale equally

magnified with pelvis in its mid sagittal plane is thus impressed on the resulting film.

Results

If the patient has been correctly positioned, the resulting radiograph should

show the two acetabula nearly superimposed and the ischial spine quite super

imposed.

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The erect standing posture makes exact positioning much easier for obliquity

of the pelvis, a common fault in lateral radiography is thereby reduced to minimum.

The lateral picture gives more exact information of the brim conjugate than

any other view. It shows

1. The true and false promontory

2. The inclination of the pelvic brim

3. The position of the fetal head relative to the brim and the degrees of its

engagement.

4. The shortest diameter of the fetal head, i.e. biparietal diameter.

5. The length and shape of the sacrum.

6. The size and shape of the sacro sciatic notch.

7. The length of the lower anterior posterior diameter.

8. The length of the posterior sagittal diameter of the outlet.

1. Transverse pelvimetry

Involves least exposure to radiation and greatest degree of accuracy. Its called

the orthodiagraphic tube shift method.

Accurate measurements of both the brim transverse diameter and the bispinous

diameter are obtained and areas at both levels can be calculated.

Position – Patient is placed in dorsal position with a pad under the small of the

back to cause lordosis. Ischial spines are more easily identified on the film but the

true shape of brim is lost however, the available transverse diameter of the brim can

be calculated.

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Figure 24: Semi-orthodiagraphic transverse pelvimetry Note the limited fields of exposure. The horizontal tube shift, which may be 10 or 11 cm, almost eliminates the distortion produced by a single divergent beam. Results

The resulting radiography which shows the outlines of superior and inferior

pubic rami superimposed and gives an idea of

• Shape of the brim

• The length of widest transverse diameter of the brim

• Inter ischial spinous diameter

• Position of the presenting part.

2. Outlet radiograph

Pubic and pelvimetry: Here the patient sits on film cassette leaning well forward. The

tube is then centred vertically over the ischial tuberositis. By this means, the pubic

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arch is made to lie approximately parallel to the film and distortion is reduced to a

minimum.

• From this sub pubic angle can be measured.

• The inter tuberous diameter can also be measured but it is not accurate.

• The character of the pelvic side walls can be noted as well.

3. Antero-posterior radiograph

A straight forward picture taken with the patient supine give the following

information.

• The direction of the pelvic side wall.

• The inter ischial bispinous diameter.

A Cochrane review in 2000 which include four trials (not of good quality) on

pelvimetry found that the rate of cesarean was higher in the pelvimetry arm and

therefore concluded that there was not enough evidence to support the use of

pelvimetry in women with cephalic presentation.37

Postpartum X-ray pelvimetry with antenatal USG in subsequent pregnancy has

been shown to predict fetal-pelvic disproportion but the data is limited.38

ULTRASONOGRAPHY

Although USG has become an indispensable clinical tool in the practice of

obstetrics, it has not been useful for maternal pelvic mensuration. A technique for

ultrasound imaging of the pelvis was described, that required 5 transactions on each

patient. Using this approach, traced figures of the pelvic outline obtained from the

original data must be converted to a numeric system for quantitative analysis of the

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pelvic cavity. Others described a method for measuring the interspinous diameter by

means of ultrasound. However, other pelvic diameters were considered. Thus, all

ultrasound pelvimetry techniques are complicated tedious, incomplete, and without

immediate clinical utility. But, it is useful for fetal biometry like BPD, HC, FL, AC,

and effective fetal weight. Effective fetal weight estimates within error range of

±10%. Some investigators believe that an effective fetal weight of 4000 g or more

indicator of fetopelvic disproportion, and that a cesarean section should be done

without a labour trial.39

The obstetric conjugate was measured by ultrasound in a study. It was found

that the cesarean section rate in women with an ultrasound obstetric conjugate <12 cm

was 50% as compared to 7% in those with a conjugate more than 12 cm.40

PELVIMETRY BY CT-SCAN

Federle and Associates were the first to describe pelvimetry by digital

radiography generated on a CT scanner to reduce the radiation exposure in

comparable with axial CT section, which produces more radiation (22 mrad with

digital and 380 mrad with axial). Measurements of pelvis were made using 2 digital

radiographs. The transverse diameter of the inlet, interspinous distance, and

intertuberous diameter were obtained by anteroposterior digital radiograph. Using

lateral radiograph, anteroposterior diameter of the inlet and low sagittal diameter of

pelvis were measured, and was compared with X-ray pelvimetry. An error of 1% by

digital radiograph and 10% conventional method was reported. This appears to be

accurate and simple procedure with films that are easier to interpret. More

importantly, CT pelvimetry reduces radiation exposure of the fetus when compared to

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X-ray pelvimetry at a range of 21-35 mrad with digital radiograph and 160 to

250 mrad with X-ray pelvimetry.

PELVIMETRY BY MRI

The MRI can be used to accurately measure maternal pelvic dimensions and

assess the position of fetal head also provide information regarding contributions of

soft tissue dystocia to obstructed labour. MRI is completely noninvasive technique,

suitable for studying fetal/pelvic proportions; and changes in the lower uterine

segment. Sagittal and transverse images can be obtained. Transverse images centered

5 cm above the symphysis pubis and other more caudal section through ischial spines

gives transverse diameters of inlet and midpelvis. Sagittal images gives information

regarding presentation and lie of fetus and also AP diameter, musculoskeletal

anatomy or presenting fetal part were also delineated.

Errors are less than 1% and not influenced by uterine and fetal motion. Fetus is

not exposed to radiation and also it evaluates soft tissue dystocia in obstructed labour.

Contraindications are patients with pacemakers, artificial valves, or vascular metal

clips. Disadvantages are expensive, lack or real-time capability, fetal movement, and

lack of availability to a large number of patients on a 24-hour basis.41

TRIAL OF LABOUR

Selection of cases for trial labour5

In any consideration of trial of labour in a distinction must be made between

its uses in

a) the classical rachitic flat pelvis in which the contracting is solely at brim level and

usually solely in conjugate diameter.

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b) other varieties of contracted pelvis in which contraction is present in several

dimension, usually including the mid and lower pelvis.

In prime effect of labour forces in causing head to mould and overcome the

one-dimensional obstruction is truly remarkable.

In latter, moulding even if it is pronounced is far less successful in overcoming

the multidimensional obstruction.

Before the onset of labour it is possible on the basis of pelvimetry to segregate

with more exactness than can be done clinically.

a. cases in which disproportion is so slight that the head will certainly pass through

pelvic brim and cavity provided forces are normal.

b. the cases in which head cannot possible to pass no matter how strong the forces.

Between these two extremes, however, come a large number of ‘borderline’

cases in which there is still uncertainty. For such cases ‘trial labour’ is the correct

management.

Management of ‘trial labour’

The proper conduct of trial labour rests on the same principles and observation

as the conduct of a normal labour, but there are certain special features on which

attention must be focused.

Avoidance of infection

This is clearly of great importance when labour may cumulate in abdominal

delivery and when repeated vaginal examination will be necessary to ease progress

each one of which will add to the risk.

It is a wise precaution, in a patient for whom trial labour is planned to culture

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the vaginal flora in last weeks of pregnancy and so to detect those individuals

carrying group B streptococci toxigenic strains of Escherichia coli and other pathogen

so treatment can be given.

Monitoring progress of labour

The partogram is used, as in normal labour to record the progress of dilatation

of cervix and descent of head. Accuracy in defining the level of the head is promoted

by using Notelowitz’s technique. Vaginal assessment should be made every 4 hours.

It is worth commenting here how necessary it is to recognize slowing in the rate of

dilatation during the later part of the active phase in any labour. This is an important

clinical sign of disproportion. In contrast, dilatation in a primigravida usually justifies

continuance of the trial.

Monitoring fetal well being

Fetal heart rate, as well as usual manifestations of fetal diseases which may

occur in any labour, the presence of substantial CPD may lead to an additional

deceleration pattern which Stewart called an “early prolonged” dip. The initial heart

slowing access with onset of contraction, the trough coincides with the peak of uterine

pressure, but recovery of the fetal heart rate is slow and prolonged.

This pattern is perhaps, distinct from other variable decelerations and appears

specific to mechanical dystocia where there is considerable compression and

moulding of fetal skull.

Head moulding

Degree of head moulding must clearly be related to stresses imposed on child.

Stewart described useful moulding score. Degree of moulding is noted at both

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the ‘parieto-occipital’ (lambdoidal) and parieto parietal (sagital) sutures.

At each site moulding is scored.

1 if suture lines is closed without overlap of bones

2 if the bones overlap but reducible

3 if there is irreducible overlap

Total moulding score range 0-6.

Marked moulding (5) serious disproportion

Excessive moulding (6) sign of foetal distress calling for early delivery

Formation of ‘pelvic’ caput

In some cases of marked disproportion the caput on the infants scalp is

bounded not by the margin of the dilating cervix but by the rim of contact between the

head and pelvic brim. Appearance of such a pelvic caput is evidence that the trial

labour should not be allowed to continue because of gross disproportion present.

Augmentation of labour

At the outset of a trial labour, the obstetrician hopes frequently that uterus will

rise to the occasion and that the natural forces will suffice to thrust the infant

gradually through the birth canal.

But uterine inertia is always possibility, especially in a primigravida and so if

the pace of dilatation recorded on partogram lags to the right from the anticipated

‘norm’ by 3 or 4 hours, oxytocin should be given with due caution.

It may also be necessary to attempt to enhance the progress of labour by

performing ‘amniotomy’ provided the cervix is reasonably effaced and 2 cm dilated.

The real test as to whether the head is or is not going to pass access only after the

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membranes have ruptured, from then onwards progress must be noted more carefully.

Duration of trial labour

The adoption of the active measures described above shortens the time-scale of

trial labour and therefore spares both mother and infant. To name an exact time-limit

in terms of hours is not really practicable. Eight hours may be too long in one case,

while 10 hours may barely suffice in another.

Stewart concluded that the trial of labour should be brought to an end by

caesarean section in the following circumstances.

1. If after 6 hours of oxytocin infusion there was minimal advance in dilatation.

2. If excessive moulding (score 6) was present during 2 hours of good contractions.

3. If a pelvic caput formed.

Analgesia and Anaesthesia in ‘Trial Labour’

For many patients caudal or lumbar epidural analgesia can be most helpful.

Paracervical block is less desirable when the fetus is already under extra stress

and duration of relief from pain is comparitively brief.

• Normally prevention of physical exhaustion of patient is important.

• An intravenous infusion of glucose-saline should be instituted.

• Fluid or semi-fluid food may be given according to the patients desire.

• Indeed, when need for anaesthesia is foreseen all food must be withheld.

LABOUR DYSTOCIA

Dystocia literally means difficult labour, is characterized by abnormally slow

progress of labour. It is the consequences of four distinct abnormalities that may exist

singly or in combination.

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1. Abnormalities of the expulsive forces: Uterine forces insufficiently strong or

inappropriately coordinated to efface and dilate the cervix (uterine dysfunction).

2. Abnormal presentation, position, or developmental anomalies of the fetus.

3. Abnormality of maternal bony pelvis that is pelvic contraction.

4. Abnormalities of soft tissues of the reproductive tract.

Pelvic contraction is often accompanied by uterine dysfunction and together

constitute the most common cause of dystocia.

Failure to progress in spontaneous labour has been increasingly popular

description of ineffective labour. Olah and Neilson (1994) concluded that failure of

progress is not a diagnosis but an observation. According to the ACOG, neither

failure to progress nor CPD are precise terms. They concluded that more practical

classification is to divide labour abnormalities into prolongation, protraction and

arrest disorders.

Pelvic contraction is often accompanied by uterine dysfunction and together

constitute the most common cause of dystocia.

PARTOGRAM

It was first revised by Friedman in 1954. Partogram are an essential feature of

management of labour. Originally, Friedman described the sigmoid curve based on

the graphic analysis of labour. Delay in labour can be detected at an early stage by

reference to such normal cervical dilatation time curve, and dysfunctional labour can

be corrected before the problem of prolonged labour manifest. It has been

recommended that a partograph that is a graphic recording of the progress of labour

and the salient features of both mother and the fetus be used in order to be able to

74

detect as early as possible labour not progressing normally and requiring intervention.

Being a graphic record of labour, the partograph increases the quality and the

regularity of observations of the mother and the fetus and acts as an early warning

system for the detection of abnormal progress, enabling early decision for referral,

intervention, and termination of such a labour.

Components of a partogram

In a partogram, the events of labour are plotted along the Y-axis against time

in hours along the x-axis, it has 3 components.

1. The topmost is the fetal record, which includes FHR, presence or absence of

fetal membranes, the nature of liquor, and the presence of moulding if any.

2. The middle section depicts the progress of labour where cervical dilatation,

effacement, descent of the fetal head, and frequency, strength, and duration of

uterine contractions are recorded.

3. The lowest portion records maternal pulse, BP, and temperature. The volume

of urine passed and presence of albumin and acetone, and medication or fluids

administered including oxytocin augmentation.

75

76

According to WHO Partograph, 1992, labour is divided into latent phase,

which should last no longer than 8 hours, and an active phase, starting at 3 cm

dilatation. The rate of which should not be slower than 1 cm/hr. A 4 hours wait (lag

time) is recommended before intervention when the active phase is slow. Labour is

graphed and analysis includes use of alert and action lines.

Philpott and Castle43 suggested that alert and action lines be used to highlight

the abnormal progress of labour. Friedman’s curve was modified accordingly. A

guideline was drawn from 3 cm dilatation upwards at a slope of 1 cm/hr to full

dilatation. This was termed as Alert line because it alerts the obstetrician of delayed

progress. An action line drawn 4 hours to start of and parallel to alert line. When

labour progress cross the alert line, assessment was made to rule out CPD and

malpresentations.

There is no consensus as to placement of action line, whether it should be 1, 2,

3, or 4 hours to the right of alert line. Various centers use different cut off points.

Modifying factors include the level of medical care available for the supervision of

labour, the risks of complications associated with prolonged labour, the social mileu,

and preference of the patient.

Active management of labour

Basis of active management of labour rests in terms of accurate diagnosis of

true labour, early amniotomy, selective use of high dose oxytocin, and limitation of

duration of labour to 12 hours, supportive maternal intrapartum care, and antenatal

education.

77

O’Driscoll et al. (1969)44 pioneered this concept when the patient is admitted

first definitive diagnosis of labour is made. If diagnosed, graphic recordings started

along the close observation, if there is no progress amniotomy and oxytocin are used.

Lopez-Zeno et al. (1992)45 prospectively compared active management with

traditional approach. The cesarean section rate was less with actively managed group.

More recently, Frigoletto et al. in randomized trial of active labour in nullipara

showed no effect on cesarean section rate, but it shortened labour duration.

EVALUATION OF THE NEW BORN

APGAR score is recorded 60 seconds after delivery of the baby. The baby is

rated 0, 1 or 2 for each of the signs described.

The overall score of 0-10 is the sum of the rating of five individual signs.

Infants with score of 4 or less need help with breathing.

APGAR SCORING CHART

Sign 0 1 2

Heart rate Absent Slow (100) Over 100

Respiratory effort Absent Slow, irregular Good crying

Muscle tone Flaccid Some limb flexion Active motion

Reflexed irritability No response Grimace Cry

Colour Blue, pale Body pink extremities – blue

Completely pink

78

METHODOLOGY

The present study is to determine the effect of unengaged head in primigravida

at term in labour. The study was conducted on primigravidae admitted in the labour

room in the Department of Obstetrics and Gynecology, Cheluvamba Hospital, Mysore

Medical College and Research Institute, Mysore.

In this study 130 primigravidae who fulfilled the inclusion criteria were

included from November 2008 to May 2010.

Inclusion Criteria

• Full term gestation (between 38 and 42 weeks of gestation)

• Live singleton fetus

• Vertex presentation

• No obvious cephalopelvic disproportion

• Intact membrane

• Cervix less than 3 cm

Exclusion Criteria

• Multigravida

• Previous history of abortion

• Primi with medical complication like diabetes mellitus and hypertension, etc.

The patients were admitted to the labour room. Name, age and detailed history

was noted in a pretested proforma. A thorough general examination and systemic

examination was done.

79

Per abdomen examination was done to confirm the period of gestation, to note

the position of the presenting part and the fifth of fetal head palpable.

Per vaginum examination done and a note of cervical consistency, position

effacement and dilatation (in cm) and status of membrane was made.

Criteria for Engagement ‘O Station

On per abdomen examination, 2/5th of head should be palpable by Crichton’s

method or only one pole of the head should be palpable by II-pelvic grip.

On per vaginal examination lower most portion of the head must be at or

below the level of ischial spine.

Head was considered FREE FLOATING when

1. 5/5th of head was palpable per abdomen.

2. Head is mobile.

3. Lower most portion of the head is above the brim.

Head was considered as -3 station when

1. 4/5th of head palpable per abdomen

2. Head is dipping.

3. Lower most portion of head is above 3 cm from ischial spine.

Head was considered to be at 2 station when 3/5th of head was palpable, head

is fixed and both the poles felt per abdomen, and it is above 1.5 cm from ischial

spines.

Head was considered as to be at -1 station, when >2/5th of head was palpable

and when occiput felt and sinciput is easily felt and it is above the ischial spines.

All the relevant data was filled in the partogram also. The admission time was

80

taken as zero hour and the dilatation of cervix at the time of admission was plotted on

dilatation curve along with number of fifths palpable per abdomen.

One hundred thirty cases analysed and observations made was,

1. Time of engagement in those in higher head station.

2. The station of head at the onset of labour.

3. Course of labour, duration of labour, progress of labour using partogram and

complications of labour.

4. Mode of delivery and operative interventions.

5. Maternal and perinatal outcome considering the birth weight and apgar score at

1 and 5 min and follow-up during puerpeurium till the patient was discharged.

And the above parameters were compared in different station.

81

RESULTS

Table 1: Age distribution

Groups Age group (years) -3 -2 -1 FF

Total

< 20 18 12 2 19 51

21-25 31 12 3 16 62

26-30 08 4 0 04 16

> 30 0 0 0 01 01

Figure 25: Age distribution

0

5

10

15

20

25

30

35

-3 -2 -1 FF

Groups< 20 21-25 26-30 > 30

The present study cases studied were between 17-34 years. Majority of cases

were of the age group 21-25 years.

82

Table 1a: The mean age and standard deviation in different station of head

Group N Mean (years) SD

FF 40 21.72 3.27

-3 57 22.19 2.91

-2 28 22.42 3.46

-1 05 21.40 2.70

p>0.05, Not significant

Figure 26: The mean age and standard deviation in different station of head

0

10

20

30

40

50

60

FF -3 -2 -1

Groups Number of casesMean (years)

There is no difference in the mean age between FF, -3, -2, -1 groups.

83

Table 2: Distribution of height

Height (cm) FF -3 -2 -1 Total

< 144 04 -04 03 0 11

145-150 20 29 17 3 71

151-155 12 18 07 2 38

> 155 04 06 01 0 10

Total 40 57 28 05 130

Figure 27: Distribution of height

0

5

10

15

20

25

30

Num

ber o

f cas

es

FF -3 -2 -1

Groups< 144 cm 145-150 cm151-155 cm > 155 cm

The height of the patients were between 145-162 cm in FF group, in -3 group

varied from 144-158 cm, in –2 group 140-160 cm and –1 group 145-155 cm.

84

Table 2a: Mean height and standard deviation of different head station group

Group N Mean (cm) SD (cm)

FF 40 151.3 7.05

-3 57 148.38 11.70

-2 28 149.61 5.01

-1 05 150.60 2.60

p > 0.05 not significant

Figure 28: Mean height and standard deviation of different head station group

0

20

40

60

80

100

120

140

160

FF -3 -2 -1

Groups Number of casesMean (cm)

There is no difference in mean between above groups. The groups are

homogenous.

85

57(43.8%)

40(30.8%)28(21.5%)

5(3.8%)

FF

a-3

a-2

a-1

Table 3: Distribution cases according to foetal head station

Group Number of cases Percentage

FF 40 30.8

a-3 57 43.8

a-2 28 21.5

a-1 05 3.8

Figure 29: Distribution cases according to foetal head station

Total number of primigravida with unengaged head were divided into four

groups based on station of foetal head on admission.

Above table shows number of primigravida in each group of which, 30.8%

were FF, 43.8% at -3 station group, 21.5% in –2 group and 3.8% in –1 group.

-3

-2

-1

86

Table 4: Time of engagement

Time of engagement FF -3 -2 -1 Total

Latent phase 01 01 04 0 6

Active 35 56 24 05 120

Unengaged 04 0 0 0 4

Total 40 57 28 05 130

Figure 30: Time of engagement

0

10

20

30

40

50

60

FF -3 -2 -1Groups

Latent phase Active Unengaged

Majority of head is primigravida were FF, -3, -2, and –1 groups, head was

engaged during active phase of labour in 93.2%, in 4.6% of patients head engaged in

latent phase and 3.75% head did not engage.

87

Table 5: Engagement and cervical dilatation

Cervical dilatation

(cm) FF -3 -2 -1 Total

3cm 02 05 04 0 11 (8.4%)

4-5cm 15 26 15 2 58 (44.61%)

6-7cm 23 26 09 3 61 (46.9%)

40 57 28 05 130

Of the 93.2% of cases head engaged during active labour, in majority of cases

engagement took place during the acceleration phase at 4-5 cm. 44.6%, 46.9% at

6-7 cm and 8.4% of cases head engaged at the onset of labour.

In FF group, 37.5% cases head engaged at 4-5 cm and 57.5% cases head

engaged at 6-7 cm dilatation.

In –3 group, 45.6% cases head engaged at 4-5 and 45.61% at 6-7 cm.

In –2 group, 53.57% cases head engaged at 4-5 cm, 32.14% at 6-7 cm. In

14.2% at the onset of labour. In –1 group 40% head engaged at 4-5 cm and 60% at

6-7 cm.

88

Figure 31: Engagement and cervical dilatation

0

5

10

15

20

25

30

FF -3 -2 -1

Groups3cm 4-5cm 6-7cm

89

Table 6: Engagement delivery internal in hours

Interval (hours) FF -3 -2 -1 Total

< 2 hours 0 1 3 0 04

2-6 hours 23 45 23 5 96

6-10 hours 3 1 01 0 05

Total 26 47 27 05 105

In 91.4% engagement delivery interval was between 2-6 hours.

In 3.8% engagement delivery interval was between <2 hours.

In 4.7% engagement delivery interval was between 6-10 hours.

In FF group, 88.46% of cases engagement delivery interval was between

2-6 hours and in 11.53% it was 6-10 hours.

In -3 group, 95.74% had engagement delivery interval between 2-6 hours and

is 2.12% cases between 6-10 hours and <2 hours.

In -2 group, 85.18% had engagement delivery interval between 2-6 hours,

11.11% in <2 hours and 3.7% cases > 6 hours.

In -1 group, 100% between 2-6 hours.

90

Figure 32: Engagement delivery internal in hours

0

5

10

15

20

25

30

35

40

45

FF -3 -2 -1

Groups< 2 hours 2-6 hours6-10 hours

91

Table 7: Average duration of labour

Group 1st stage (hr) 2nd stage (min) 3rd stage (min) Total

duration (hr-min)

FF 12.20 46 7.30 13.13

-3 11.22 37 7.55 12.06

-2 10.31 28 7.03 11.06

-1 8.02 26 6.00 8.34

Figure 33: Average duration of labour

0

5

10

15

20

25

30

35

40

45

50

FF -3 -2 -1

Groups 1st stage (hr)2nd stage (min)3rd stage (min)

92

Table 8: Course of labour

1st stage (hr) 2nd stage (hr) Groups

4 to 8 9 to 12 > 12 <1 1 to 2

FF 2 12 13 20 6

-3 7 28 14 44 3

-2 9 10 08 27 0

-1 3 1 1 5 0

Figure 34: Course of labour

0

5

10

15

20

25

30

35

40

45

4 to 8 9 to 12 > 12 <1 1 to 2

1st stage (hr) 2nd stage (hr)

FF-3-2-1

93

Table 9: Comparison of total duration in different foetal head station group and its significance

p-value Inference FF v/s –3 < 0.01 Significant FF v/s –2 < 0.01 Significant FF v/s –1 <0.01 Significant -3 v/s –2 < 0.05 Significant -3 v/s –1 < 0.01 Significant -2 v/s –1 < 0.01 Significant

Average duration of 1st stage of labour in FF group was 13 hour 13 min and it

varied from 19 hour to 10 hour 30 min, of 27 patients 13 cases duration was

prolonged and it was >12 hour accounting for 48.14% and in 12 cases the duration

between 9-12 hours accounting for 44.44%. Average duration of second stage was

46 min. 76.9% had duration <1 hr and in 23.7% varied from 1-2 hr. Average total

duration was 13 hr 13 min.

In the -3 station group duration of 1st stage varied from 5 hr 30 min to 19 hr

and average was 11 hr 20 min.

Of the 49 cases, in 28 of them the duration of 1st stage varied from 9-12 hr

(57.14%). Fourteen cases had duration >12 hr (50%) and in 7 cases the duration

varied from 4-8 hour. Average duration of second stage was 37 min, in 44 cases

(93.61%) it was <1 hr and in 3 cases (6.3%) varied from 1-2 hr. The average total

duration of labour is 12 hr 6 min.

In -2 station group 1st stage varied from 6 hr to 15 hr average being

10 hr 33 min, of 27 cases, in 10 (37.03%) patients the duration varied between

9-12 hours, in 9 cases (33.33%) it was 4-8 hour and in 8 cases (29.62%) the duration

was >12 hour. Average duration of second stage was 28 min and it varied from

20 to 55 min.

94

Average total duration of labour was 11 hr 6 min. In -1 group 1st stage varied

from 3 hr to 12 hr and the average was 8 hr 2 min. Of the 5 cases, in 3 cases (75%)

duration varied between 4-8 hours and in 1 case (25%) between 9-12 hours and in

1 case (25%) duration was more than 12 hours.

Table 10: Mode of delivery

NVD Instrumental LSCS Station Total No. % No. % No. % FF 40 11 27.5 7 17.5 22 55 -3 57 34 59 12 21.05 11 19.29 -2 28 20 71.4 6 21.4 2 7.2 -1 5 4 80 1 20 - - 53.08% 20% 26.92%

Figure 35: Mode of delivery

0

5

10

15

20

25

30

35

Num

ber o

f pat

ient

s

FF -3 -2 -1

GroupsNVD Instrument LSCS

Out of 130 cases, 69 cases (53.08%) had normal vaginal delivery, 20% had

instrumental delivery and 26.92% underwent caesarean section. According to

Chi-square test p<0.01, which is statistically significant.

95

In FF group, NVD, either spontaneous or accelerated with syntocin or ARM,

occurred in 27.5%, 17.5% had to undergo forceps delivery and 55% of them had to be

taken for EM LSCS.

In -3 station group of 57 cases, 34 (59%) had normal vaginal delivery,

12 (21.05%) had forceps delivery and 11 (19.29%) had emergency LSCS.

In -2 group of 28 cases, 20 (71.4%) had normal vaginal delivery, 6 (21.4%)

had forceps delivery and 2 (7.2%) had emergency LSCS.

In -1 group of 5 cases, 4 (80%) had normal vaginal delivery, 1 (20%) had

forceps delivery.

Table 11: Indications for Operative Delivery Instrumental delivery Number of cases Percentage

Foetal distress 15 57.69

Failure of secondary forces 11 42.31 Figure 36: Indications for Operative Delivery

15(57.69%)

11(42.31%)

Foetal distressFailure of secondary forces

96

Indication for instrumental delivery varied from prolonged 2nd stage or failure

of secondary forces 42.30% and foetal distress 57.69%. More number of instrumental

delivery was noted with higher foetal station, 12 in -3 cm, 7 in FF, 6 in -2 and 1 in -1

station. Among 26 instrumental deliveries, 18 cases are outlet forceps delivery,

3 cases with mid cavity and 5 cases with ventose delivery.

Table 12: Indications for LSCS

Indication Number of cases Percentage

Failure to progress 19 54.29

Foetal distress 13 37.19

DTA 03 8.52 Figure 37: Indications for LSCS

3(9%)

19(54%)13(37%)

Failure to progressFoetal distress DTA

Indication for LSCS in majority of cases was failure to progress 54.28% and in

37.14% it was foetal distress and in 8.5% it was deep transverse arrest.

97

In FF group, 22 cases had LSCS (62.99%), 11 cases for failure to progress,

3 cases for DTA and 8 cases for foetal distress. In -3 group 11 cases, 3 cases for foetal

distress and 8 cases for failure to progress. In -2 group, 2 had LSCS both of which

were for foetal distress.

Table 13: Birth weight

Birth weight group (kg) Groups

2-2.5 2.6-3 3.1-3.5 >3.6 Total

FF 4 17 18 1 40

-3 7 35 13 2 57

-2 3 18 6 1 28

-1 3 2 0 0 5

Figure 38: Birth weight

0

5

10

15

20

25

30

35

FF -3 -2 -1

Groups Birth weight group (kg) 2-2.5Birth weight group (kg) 2.6-3Birth weight group (kg) 3.1-3.5Birth weight group (kg) >3.6

98

Table 14: Mean birth weight and standard deviation of different foetal station group

Group Mean birth weight (kg) SD

FF 2.37 0.74

-3 2.17 0.68

-2 2.10 0.62

-1 1.6 0.5

p>0.05, not significant Figure 39: Mean birth weight and standard deviation of different foetal station

group

0

0.5

1

1.5

2

2.5

FF -3 -2 -1

Groups

The average birth weight in FF group was 2.37 kg ranged from 2.5-4.5 kg, in

-3 group the average birth weight was 2.17 and ranged from 2.25 to 3.5 kg. In

-2 group average birth weight 2.10 and ranged from 2.0-3.25 kg and in -1 group

average birth weight was 1.6 kg ranged from 2.3-3 kg.

99

Table 15: Birth weight and mode of delivery

Birth weight Groups Number of

cases NVD Instrumental LSCS

FF 4 4 - - -3 8 6 2 - -2 3 3 - -

2-2.5 (N=17)

-1 2 2 - - FF 19 6 5 8 -3 32 26 5 1 -2 20 15 5 -

2.6-3 (N=74)

-1 3 2 1 - FF 15 1 2 12 -3 16 1 5 10 -2 4 1 1 2

3.1-3.5 (N=35)

-1 - - - - FF 2 0 - 2 -3 1 1 - - -2 1 1 - -

>3.6 (N=4)

-1 - - - - There is significant increase in instrumental delivery and LSCS in birth weight

group 3-3.5 kg, 8 instrumental delivery (22%) and 24 (68%) LSCS. Among 24,

12 was from FF, 10 from -3 and 2 from -2 group.

Table 16: Perinatal outcome

APGAR Group

7 to 10 4 to 6 <4 PNM

FF 36 3 1

-3 54 2 1

-2 25 1 2

-1 1 0 1

1

In FF group, among 40 babies 36 had apgar >7 at 1 min and 3 had mild

asphyxia and 1 had severe birth asphyxia with apgar <4, baby was shifted to NICU in

100

view of severe birth asphyxia and died after 1 week because of severe birth asphyxia

with meconium aspiration syndrome.

In -3 group of 57 cases, 54 has apgar >7 at 1 min, 2 had mild asphyxia and

1 had moderate asphyxia with apgar <4, recovered and shifted to mother side after

observation for 2 hours.

In -2 group of 28 cases, 25 had apgar >7 and 2 babies had severe birth

asphyxia and were shifted to NICU. Both the babies recovered after 7 days of IV

antibiotics.

Figure 40: Perinatal outcome

0

10

20

30

40

50

60

FF -3 -2 -1

Groups APGAR 7 to 10APGAR 4 to 6APGAR <4

101

Table 17: Caput and moulding

Caput Group

+ ++ Moulding CRN

FF 17 5 7 2

-3 30 1 7 1

-2 17 4 6 2

-1 2 2 - -

Figure 41: Caput and moulding

0

5

10

15

20

25

30

FF -3 -2 -1

GroupsCaput + Caput ++Moulding CRN

Caput was seen more in -3 and FF groups and moulding was also seen in

higher station group.

Cord round neck (CRN) was noted in 5 babies, 2 delivered normally and

3 delivered by forceps.

102

Table 18: Maternal complications

Groups Maternal complications FF -3 -2 -1

Cervical tear 2 1 - -

Perineal tear 4 3 1 -

Figure 42: Maternal complications

0

0.5

1

1.5

2

2.5

3

3.5

4

FF -3 -2 -1

Groups Cervical tearPerineal tear

Perineal tear was seen in 8 cases, 4 cases in FF group, 3 in -3 group and 1 in

-2 group and 2 had 3° perineal tear 1 in FF and other in -2 group. Cervical tear was

seen in 3 cases, 2 in FF and 1 in -3 group.

103

DISCUSSION

The present study was conducted in the Department of Obstetrics and

Gynaecology, Cheluvamba Hospital, Mysore Medical College and Research Institute,

Mysore. We studied 130 cases of primigravida at term attending labour room. Of 130

cases, 40 cases free floating head, 57 cases vertex is at -3 station, 28 cases had -2

station and 5 cases had -1 station at the onset of labour.

In the present study, we evaluated the relationship of the foetal head station at

the onset of labour with prognosis of labour.

Age distribution

In the present study the maximum number of cases were in the age group

between 21-25 years. In the study done by Ranjini Koul et al.46 and the study by

Ambani BM.47 Maximum number of cases were in age group of 22-25 years. In our

study mean age group was 21 years compared with study by Chaudhary et al.48 (2009)

where mean age was 21±3.45 years and study by Assadi AL49 (2005) mean age was

24.59±1.21 years.

Time of engagement

Engagement occurred during active phase in 93.2% and 4.6% occurred in

latent phase, engagement did not occur in 3.75%. Comparison with other studies

showed similar results.

104

Table 19: Comparison of time of engagement with other studies

Author Engagement in latent labour

Engagement in active labour Unengaged

Meenakshi et al.17 6% 88% 6%

Khanum et al.15 5% 95% -

Present study 4.6% 93.2% 3.75% Engagement and cervical dilatation

In 44.6% cases engagement occurred when cervical dilatation was 4-5 cm, in

46.9% cases engagement occurred at 6-7 cm and 8.4% of cases head engaged at the

onset of labour.

In higher foetal station group FF and -3 engagement was delayed i.e. 57.5%

and 45.61% respectively, occurred at 6-7 cm when compared to -2 and -1 where the

engagement occurred at 4-5 cm, i.e. 53.37% and 40% respectively.

In higher foetal station the descent was slow and engagement occurred at a

later part of cervical dilatation.

Engagement delivery interval

In the present study, the average duration of engagement delivery interval

was 3 hr 10 min when compared to Meenakshi et al.17 (1987) the average time was

1 hr 56 min.

In the present study, engagement delivery interval varied from 60 min to 7 hr

when compared to Meenakshi et al.17 study it varied from 20 min to 5 hr 55 min.

The engagement delivery interval was between 2 to 6 hr in FF, -3, -2 and -1

was 88.46%, 95.74%, 85.8% and 100% respectively and in FF group 11.53% had

engagement delivery interval >6 hr.

105

Average duration of labour

Table 20: Comparison of average duration of labour with other studies

Kaur D et al.20 (2000) Friedman et al.8 (1965) Present study

Station 1st

stage 2nd

stage Total 1st stage

2nd stage Total 1st

stage 2nd

stage Total

FF 18’52” 0.92 19’44” - - - 12’20” 46” 13.13

-3 18’52” 0.95 19’47” 22’6” 0.71” 23’31” 11’22” 37” 12’6”

-2 14’9” 0.64 14’73” 20’9” 0.98” 21’97” 10’31” 28” 11’6”

-1 11’9” 0.53 11’62” 18’3” 0.92” 18’95” 8’2” 26” 8’34”

The mean duration of I, II stage and total duration was longer in higher foetal

station, i.e. FF and -3 compared to lower foetal station -2, -1 station p<0.01

statistically significant.

When compared to Kaur et al. (2000) and Friedman et al. (1965) the duration

of I, II and total duration of labour was more than the present study.

In Chaudhary et al.48 (2009) duration of 1st stage was 11.04±2.09 hr and 2nd

stage was 37.8±20.3 min and according to Salma Iqbal50 (2009) total duration

prolonged to >12 hr in 66% of cases of unengaged head and in Ambwani BM47

(2004) study 64% of cases labour lasted more than 12 hr. In the present study there

was significant increase in I, II stages and total duration with high foetal head station

when compared to lower station.

106

Mode of delivery

Table 21: Comparison of mode of delivery with other studies

Kaur D20 (2000) (%) Fielder

M23 (1997) (%)

Roshan Fekr D et al.22 (1999) (%)

Chaudhary et al.48 (2009) (%) Present study (%)

Station

N NVD ID LSCS N LSCS N NVD ID LSCS N NVD ID LSCS N NVD ID LSCS

FF 19 42.1 15.8 42.1 50 46 - - - - - - - - 40 27.5 17.5 55

-2 31 58.1 22.6 19.3 181 27 75 66 21 13 22 55.5 27 25 57 59 21.05 19.29

-2 56 85.7 5.4 5.4 210 16 170 64 19 17 40 60 17 17 28 71.4 21.4 7.2

-1 24 87.5 4.2 4.2 34 17 322 60 28 28 86 60 25 14 5 80 20 -

107

In the present study 53% had normal vaginal delivery, 20% instrumental

delivery and 26.9% deliveries by LSCS. There was need to resort to forceps/ventose

or LSCS in nearly half of the cases.

The present study compared to Kaur D et al.,20 Fielder M et al.,23 Chaudhary

et al.,48 Roshanfekr D et al.22 rate of caesarian section in higher foetal station are

comparable and statistically significant.

In higher foetal station i.e. FF, -3, 17.5% and 21.05% delivered by forceps and

55% and 19.29% had undergone caesarian section, respectively.

Study done by Auer et al.9 (1949) studied floating head in primigravida

showed that 61% delivered normally, in 15% delivery was by forceps and in 24%

cases LSCS was required and also Ambawani BM47 (2004) studied primigravida with

floating head at term or onset of labor showed 66% of cases delivered vaginally and

lower segment caesarian section in 34% of cases, no interference by ventose or

forceps.

The incidence of normal vaginal delivery was only 27.5% in FF and 59% in

-3 group as compared to 71.4% in -2 station and 80% in -1 station.

Study by Salma Iqbal50 (2009) shows 47% were delivered by spontaneous

vaginal delivery and 15% assisted vaginal delivery and 38% cases required lower

segment caesarian section.

108

Cause for caesarian delivery

Table 22: Comparison of cause for caesarian study with other studies

Chaudhary et al.48 (2009) Present study Indication

No. % No. %

Failure to progress 12 48 19 54.29

Foetal disorder 6 24 13 37.19

DTA 2 8 3 8.52

Other 5 20 - - In the present study, out of 35 cases, 19 cases (54.29%) underwent LSCS for

failure to progress and foetal distress was second common indication. In 13 cases

(37.29%) and 3 cases (8.57%) underwent LSCS for DTA. Compared with study by

Chaudhary et al. caesarian were performed due to failure to progress in 12 cases (48%)

for foetal distress in 6 cases (24%) and 2 cases (8%) underwent LSCS for DTA.

Birth weight and perinatal outcome

Table 23: Comparison of birth weight and perinatal outcome

Group Studies

FF -3 -2 -1

Kaur D et al.20 3.14 3.05 2.95 2.79

Present study 2.37 2.17 2.1 1.6 There was no significant difference in mean birth weight in the present study

p>0.05. Kaur D et al.20 and Fielder M et al.23 also observed no difference in mean

birth weight.

109

Perinatal and maternal outcome

The proportion of neonate born with apgar score <6 was higher with higher

station.

Incidence of perinatal morbidity was higher with FF, -3 and station compared

to -2 and -1 station.

In Salma Iqbal50 (2009) study, there was no significant neonatal or maternal

morbidity except for 3° perineal tear although it was slightly higher in unengaged

group, and also study by Ambwani BM47 (2004) the maternal and neonatal outcome

was good.

We had one case of perinatal mortality in FF group delivered by forceps baby

died after 7 days because of meconium aspiration syndrome with severe asphyxia.

Maternal complications like perineal tear in 8 cases, 4 in FF group, 3 in

-3 group and 1 in -2 group, and cervical tear was seen in 3 cases, 2 in FF and 1 in

-3 group.

110

CONCLUSION

The primigravida with unengaged head at term during labour should be

regarded with suspicion and the same woman in labour should be regarded with

apprehension. Labour appeared to be dysfunction in only small proportion of the

patients with unengaged head. It is concluded that the incidence of active medical and

surgical intervention in primigravida with unengaged fetal head at term or at the onset

of labour is quite high. An increase in total duration of labour can also be expected in

these cases. If the attitude of watchful expectancy and timely intervention is used in

these cases especially in cases in which no significant aetiological factors is found, by

plotting a progressive labour on a partogram and using oxytocin judiciously when

labour appears to be taking a protracted course, most of these will deliver vaginally

with minimal maternal and foetal morbidity.

111

SUMMARY

One hundred and thirty cases of primigravida with unengaged head at term

during labour was studied to assess the relationship of foetal head station with

progress of labour.

The main objective was to allow primigravida mother with unengaged head,

in the absence of obvious CPD to delivery vaginally under vigilant supervision and

judicious use of oxytocin and/or artificial rupture of membrane.

1. 93.2% of cases with unengaged head, engagement occurred during active phase.

4.6% engaged in latent phase with 3.75% head did not engage.

2. Most of the cases were between 21 and 25 years.

3. In higher foetal stations the descent was slower and engagement occurs in later

part of cervical dilatation and engagement delivery interval was significantly

increased in FF group.

4. There was statistically significant (p<0.01) increase in average duration of I, II

stages and total duration of labour.

5. The incidence of instrumental deliveries and caesarean rates were higher with

higher foetal station and it was statistically significant p<0.01.

6. There is significant increase in the instrumental delivery and LSCS in birth weight

3-3.5 kg.

7. The incidence of perinatal morbidity was more in higher fetal station and one case

of perinatal mortality was seen in FF group.

112

8. Induction and augmentation was done by PGE2 gel/artificial rupture of

membranes and /or oxytocin infusion. Maternal complications were in the form of

perineal tears and cervical tears. There was no maternal death in the present study.

Out of 130 cases, 53.07% of cases had normal vaginal delivery, 20% had

instrumental delivery and 26.92% underwent caesarean section.

9. Patients with higher fetal station call for constant vigilance on part of the

obstetrician.

113

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118

PROFORMA

Sl.No. Date: I P no:

Name of the Patient: Age:

Address: DOA:

Booked/Unbooked/Booked Else Where

H/o-Ammenorhoea

History of Present Pregnancy:

1. Trimester : Morning Sickness_______ Yes/No

Bleeding PV _______ Yes/No

Any Other _______

2. Trimester: Quickening _______

3. Trimester: Bleeding PV _______

Symptoms of PET_______

Any other _______

Obstetric history: Married life: Primigravida Consanguinity

Menstrual history: A.O.M.: Past Menstrual cycles: L.M.P.:

E.D.D:

Past History: 1. Disease of Joints :

2. Poliomyelitis :

3. Rickets :

4. Epilepsy :

5. Congenital deformity :

6. Operations :

7. Traumatic injuries :

119

Family History:

Personal History: Diet: Appetite: Sleep:

Bowel/Bladder:

General Physical Examination: Gait: Pedal edema:

Pallor: P.R.: B.P.:

Temperature: Height: Weight:

Breast: Thyroid: Spine:

Systemic Examination: C.V.S R.S:

Per Abdomen:

Inspection: Uterus Size: Pendulous abdomen/Flanks

Palpation: Uterine Size: Contractions/10 mins:

A.G: S.F.H: E.F.W

Fundal Grip: Lie:

Umbilical Grip: Attitude:

Pelvic Grip I: Presentation:

Pelvic Grip II: Position:

Number of fifths palpable:

Auscultation: P/V: Cervix: Effacement: Dilatation:

Consistency : Position :

Station : Membranes :

Pelvis : Sacral Promontory : Reached / Not Reached Curvature of Sacrum:

Side walls: Converging/Parallel/Divergent

120

Ischial Spines: Not prominent/Prominent/Average

Interspinous diameter: Narrow/Average/Wide

Length of Sacrospinous Ligament: Short/Average/Long

Subpubic arch: Narrow/Average/Long

Disproportion: Mild/Moderate/Severe/Normal

Diagnosis:

Investigations: Hb% : Blood group: Urine-routine

R.B.S VDRL HIV HbsAg:

USG: Gest, Age- Anomalies- EFW-

Liquor: Placental Location: Others:

Treatment and advice:

Delivery: Vaginal/Abdominal

Labour: Time of engagement: Cervical dilatation:

Time of onset of labour:

Duration: 1st Stage 2nd Stage 3rd Stage

Total duration:

Assistance if any: Episiotomy

Forceps: Outlet/Low mid cavity/Kieland’s

Abdominal: PV just before operation : Cervix- OS- Memb- Station-

Operation: LSCS : Elective Emergency

Per operative findings:

121

Baby: Sex: Weight: Apgar Score: 1min 5min

Caput: Moulding:

Congenital Anomalies:

Condition of the Mother: Immediate After 2hrs.

G.C.-

Temperature-

Pulse-

B.P.-

CVS/RS

Per abdomen-

Per vaginal-

Puerperium

Result:

122

STATISTICAL METHODS APPLIED

Frequencies

The Frequencies procedure provides statistics and graphical displays that are

useful for describing many types of variables. For a first look at your data, the

Frequencies procedure is a good place to start.

For a frequency report and bar chart, you can arrange the distinct values in

ascending or descending order or order the categories by their frequencies. The

frequencies report can be suppressed when a variable has many distinct values. You

can label charts with frequencies (the default) or percentages.

Descriptives

The Descriptives procedure displays univariate summary statistics for several

variables in a single table and calculates standardized values (z scores). Variables can

be ordered by the size of their means (in ascending or descending order),

alphabetically, or by the order in which you select the variables (the default).

Crosstabs

The Crosstabs procedure forms two-way and multiway tables and provides a

variety of tests and measures of association for two-way tables. The structure of the

table and whether categories are ordered determine what test or measure to use.

Chi-Square Test

The Chi-Square Test procedure tabulates a variable into categories and

computes a chi-square statistic. This goodness-of-fit test compares the observed and

expected frequencies in each category to test either that all categories contain the

same proportion of values or that each category contains a user-specified proportion

of values.

All the statistical methods were carried out through the SPSS for Windows (version 16.0)

123

KEY TO MASTER CHART

AL Active labour

CD Cervical dilatation

CRN Cord around neck

EDI Engagement delivery interval

EM LSCS Emergency lower segment caesarean section

F Fixed

f Female

FD Foetal distress

FSF Failure of secondary forces

LP Latent labour

M Mobile

m Male

NICU Neonatal intensive care unit

NVD Normal vaginal delivery

PNM Perinatal mortality

UEF Uneventful

Sl. No. IP No.

Age

(yea

rs)

Hei

ght (

cm)

Hea

d

Stat

ion

Tim

e of

eng

age

CD

(cm

)

1st s

tage

(hr)

2nd

stag

e (m

in)

3rd

stag

e (m

in)

Tot

al d

urat

ion

(hr)

ED

I (hr

)

Indu

ctio

n

Acc

eler

atio

n

Mod

e of

del

iver

y

Indi

catio

n

Bir

th w

eigh

t (kg

)

Sex

APG

AR

(1 m

in)

APG

AR

(5 m

in)

Cap

ut

Mou

ldin

g

CR

N

PNM

Peri

neal

tear

Puer

peri

um

1 1393/C 23 156 Uneng -3 AL 4 15.45 40 5 16.5 4 PGE2 - NVD - 3 f 7 9 - - - - - UEF2 1426/A 18 150 Uneng/F -1 AL 5 5 30 10 6.15 1.5 - - NVD - 2.6 m 7 9 - - - - - UEF3 1325/D 21 152 Uneng/F -3 AL 7 9.45 55 5 10.45 3 - - NVD - 2.6 m 3 4 + - - - - -4 1477/A 20 158 Uneng/F FF AL 5 8.3 35 5 9.1 6.5 - - NVD - 2.8 f 7 9 + - - - - -5 1509/A 21 146 Uneng -3 LP 5 13.3 20 10 14 3 - Synto NVD - 2.3 f 7 9 - - - - - -6 1504/D 18 150 Uneng/F -2 AL 7 12.45 15 5 13.5 1 - Synto NVD - 2.4 f 4 9 + - - - - -7 1532/D 20 148 Uneng/F -3 AL 4 14 40 10 14.5 2 - Synto NVD - 3.6 f 6 9 + - - - - -8 1597/C 22 152 Uneng/F -1 AL 5 5 10 5 5.15 3 - Synto NVD - 2.5 f 2 4 ++ - - - - -9 1636/C 20 152 Uneng/M -3 AL 5 5.3 40 10 6.2 2 - - NVD - 2.5 m 7 9 + - - - - -

10 1680/D 23 152 Uneng -2 LP 4 3.15 15 15 3.3 2 - - NVD - 2.8 f 6 8 + - - - - -11 1710/D 20 148 Uneng/F FF AL 6 11.45 23 5 12.13 3 - - NVD - 2.6 m 7 9 - - - - + -12 1770/D 25 155 Uneng/F -2 AL 5 9 60 5 10.05 1 - - NVD - 2.5 m 7 9 + - - - - -13 1793/E 20 148 Uneng/F -3 AL 6 7.1 15 5 7.3 2.3 PGE2 - NVD - 2.2 f 7 8 + - - - + -14 1885/A 24 147 Uneng -1 AL 6 8 30 5 8.45 4 - 5 NVD - 3 f 7 9 + - - - - -15 1862/D 26 155 Uneng -3 AL 5 6.3 30 5 7.5 6 - - NVD - 2.7 m 7 9 + - - - - -16 1968/A 22 148 Uneng/F FF AL 6 12 10 5 12.15 1 - - NVD - 2.25 f 6 8 + - - - - -17 1964/D 29 160 Uneng/F -2 AL 5 8.2 20 5 8.45 3.4 - - NVD - 2.75 f 7 8 + - 1 LOOP - - -18 1901/E 20 146 Uneng/F -2 AL 5 8 45 5 8.5 4 - - NVD - 3 m 7 9 + - - - - -19 1958/A 22 155 Uneng FF AL 4 12.1 45 5 8 6 - Synto NVD - 2.5 m 7 9 + - - - Cervical tear -20 2027/D 20 148 Uneng -2 AL 3 6.15 20 5 6.4 4 - - NVD - 2.6 m 7 9 - - - - - -21 2062/A 21 140 Uneng -3 AL 5 10.15 20 5 10.45 3 - - NVD - 2.75 f 7 9 - - - - - -22 2116/D 21 148 Uneng FF AL 6 13 50 10 14 2 - Synto NVD - 2.5 m 7 9 - - - - + -23 2141/D 20 146 Uneng -2 AL 4 10.3 25 5 11 2 - Synto NVD - 2.6 m 7 9 - - - - - -24 2166/D 19 148 Uneng/M -1 AL 6 9 25 5 9.3 3 - - NVD - 2.3 m 7 9 ++ - - NICU - -25 2104/C 19 145 Uneng/M -3 AL 7 17 35 5 17.4 3 - Synto NVD - 2.75 f 6 8 + - - - - -26 2159/D 25 148 Uneng/F -3 AL 6 15 20 10 15.3 3 - - NVD - 3 f 7 9 ++ + - - - -27 2179/B 23 157 Uneng/F -3 AL 6 11 30 10 11.4 5 PGE2 - NVD - 2.7 f 4 8 + - - - - -28 2142/D 19 152 Uneng/M -3 AL 5 9.45 10 5 10 3.5 - Synto NVD - 3 f 7 9 + - - - + -29 2148/D 22 148 Uneng -3 AL 5 8.45 10 5 9 3 - Sur NVD - 2.8 m 7 9 - - - - Cervical tear -30 2156/D 22 149 Uneng -2 AL 3 4 15 5 4.2 2 - Synto NVD - 2.6 f 6 8 + - - - - -31 2173/A 20 155 Uneng/M FF AL 5 10 25 5 10.3 3 - Synto NVD - 2.65 m 2 4 ++ + - NICU - -32 2080/C 18 154 Uneng/M FF AL 6 18 40 5 18.45 2 - Synto NVD - 3 f 7 9 - - - - - -33 2209 21 145 Uneng/M FF AL 7 13.15 20 10 13.45 4 - Synto NVD - 2.7 f 5 7 ++ + - NICU - -34 2219/E 24 150 Uneng/M -2 AL 6 11.3 25 5 12 5 PGE2 Synto NVD - 2.9 f 7 9 + + - - + -35 2210/E 20 150 Uneng/M FF AL 7 10 25 5 10.3 2 PGE2 - NVD - 2.5 f 7 9 - - 1 LOOP + + -

124

Sl. No. IP No.

Age

(yea

rs)

Hei

ght (

cm)

Hea

d

Stat

ion

Tim

e of

eng

age

CD

(cm

)

1st s

tage

(hr)

2nd

stag

e (m

in)

3rd

stag

e (m

in)

Tot

al d

urat

ion

(hr)

ED

I (hr

)

Indu

ctio

n

Acc

eler

atio

n

Mod

e of

del

iver

y

Indi

catio

n

Bir

th w

eigh

t (kg

)

Sex

APG

AR

(1 m

in)

APG

AR

(5 m

in)

Cap

ut

Mou

ldin

g

CR

N

PNM

Peri

neal

tear

Puer

peri

um

36 2252/A 20 150 Uneng/M -3 AL 5 10.2 30 10 11 5 PGE2 Synto NVD - 2.6 f 7 9 + + - - - -37 2282/A 23 152 Uneng -3 AL 6 11 20 10 11.3 4 - Synto NVD - 3 f 7 9 + + - - - -38 2196/A 20 150 Uneng -2 AL 6 6 20 10 6.3 2 - - NVD - 3 m 6 8 + - - - - -39 2292/A 25 154 Uneng/F -2 AL 6 10.3 25 5 11 4 - - NVD - 3 f 7 9 + - - - - -40 2296/C 24 148 Uneng -2 AL 5 6.25 30 5 7 4 - - NVD - 2.7 m 7 9 - - - - - -41 2337/C 25 150 Uneng -3 AL 3 8.25 30 5 9 6 - Synto NVD - 3 f 7 9 - - - - - -42 2300/A 21 146 Uneng -3 AL 5 9.45 45 5 10.05 4 - Synto NVD - 2.9 m 6 4 - - - NICU - -43 3061/D 20 142 Uneng FF AL 6 16.15 15 5 16.35 4 - - NVD - 2.8 f 7 9 - - - - - -44 3165/D 24 147 Uneng/M -3 AL 7 8 30 5 8.35 5 - Synto NVD - 2.8 m 7 9 + - - - - -45 3151/B 22 144 Uneng -3 AL 4 12 25 5 12.3 4 - - NVD - 2.5 f 6 9 + - - - - -46 2998/C 23 150 Uneng/F -2 AL 3 6.2 30 10 7 4 - Synto NVD - 3 f 7 9 + + - NICU Cervical tear+ -47 3150/D 21 155 Uneng/M FF AL 6 10.3 120 10 12.4 6 - Synto NVD - 3.2 m 7 9 ++ + - - - -48 3369/B 21 152 Uneng/M -3 AL 6 7.3 60 10 8.4 4 - - NVD - 2.8 m 7 9 + - - - - -49 3333/B 22 148 Uneng/M -3 AL 6 11 30 10 11.4 6 - Synto NVD - 3 f 7 8 + + - - - -50 3454 24 150 Uneng/M -2 AL 5 8 30 5 8.35 3 - Synto NVD - 2.7 f 6 8 + - - - - -51 3493 26 152 Uneng -3 AL 3 12.15 15 10 12.4 3 - Synto NVD - 2.8 m 6 9 + - - - - -52 3563 29 153 Uneng -3 AL 4 10 50 10 11 2 - Synto NVD - 2.5 m 7 9 - - - - - -53 3471/D 18 149 Uneng -3 AL 4 16 25 5 16.3 4 - - NVD - 3 f 7 9 - - - - - -54 3537/C 22 142 Uneng -3 AL 3 16 30 10 16.4 6 - Synto NVD - 2.8 f 7 9 - - - - - -55 3550/B 20 145 Uneng -3 AL 4 10 20 10 10.3 5 - - NVD - 2.7 m 7 9 - - - - - -56 3607/B 19 150 Uneng -3 AL 5 16 45 5 16.5 8 - Synto NVD - 3 m 6 8 + - - - - -57 3661/B 24 151 Uneng -2 AL 4 14.3 25 5 15 4 - Synto NVD - 2.8 m 5 9 + - - - - -58 3693/B 25 155 Uneng -3 AL 6 10 30 5 10.35 4 - - NVD - 2.75 f 7 9 - - - - - -59 3637/C 26 150 Uneng -2 AL 3 18 45 5 18.5 6 - - NVD - 2.9 f 7 9 + - - - - -60 3764/C 17 152 Uneng -3 AL 6 9 40 5 9.45 2 - - NVD - 3 f 6 9 - - - - - -61 3848/B 18 153 Uneng -2 LP 5 11 45 5 11.5 4 - - NVD - 3.2 m 5 9 + - - - + -62 3901/C 23 148 Uneng -3 AL 4 15.15 60 5 16.2 3 - - NVD - 2.5 m 6 9 - - - - - -63 3947/D 21 147 Uneng -3 AL 6 10 50 5 10.55 2 - - NVD - 2.7 m 7 9 + - - - - -64 10370/C 20 146 Uneng/F -2 AL 5 10 25 5 10.3 3 - Synto NVD - 2.5 m 2 4 ++ + - NICU - -65 10418/A 20 148 Uneng/F -2 AL 6 18 40 5 18.45 2 - Synto NVD - 3 f 7 9 - - - - - -66 10448/B 19 146 Uneng/F -2 AL 7 13.15 20 10 13.45 4 - Synto NVD - 3.7 f 5 7 ++ + - NICU - -67 10509/B 22 152 Uneng/M -3 AL 4 10.15 20 5 10.4 5 PGE2 Synto NVD - 3.2 f 7 9 + + - - - -68 10503/B 24 160 Uneng/M -3 AL 7 8.3 30 10 9.1 4 - Synto NVD - 2.8 m 7 9 + - - - - -69 10628/B 24 149 Uneng/M -3 AL 5 9 60 5 10.05 4 - Synto NVD - 2.7 f 6 8 + - - - - -

125

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ght (

cm)

Hea

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Tim

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age

CD

(cm

)

1st s

tage

(hr)

2nd

stag

e (m

in)

3rd

stag

e (m

in)

Tot

al d

urat

ion

(hr)

ED

I (hr

)

Indu

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n

Acc

eler

atio

n

Mod

e of

de

liver

y

Indi

catio

n

Bir

th w

eigh

t (k

g)

Sex

APG

AR

(1

min

)

APG

AR

(5

min

)

Cap

ut

Mou

ldin

g

CR

N

PNM

Peri

neal

tear

Puer

peri

um

1 4478/D 22 155 Uneng/M FF AL 6 12 45 15 13 6 PGE2 - Outlet FD 2.6 m 2 6 + ++ - - + -

2 4650/D 20 163 Uneng/M FF AL 6 18 60 5 19.05 2 PGE2 Synto Outlet FSF 2.8 f 7 9 + - - - + -

3 4997/B 29 154 Uneng/F -2 AL 4 12 35 10 12.45 7 - - Outlet FD 3 f 7 9 - - - - - -

4 5264/B 18 142 Uneng/F -2 LP 5 11.4 15 5 12 5 - Synto Outlet FD 2.7 f 5 8 + - - - + -

5 5319/C 27 152 Uneng/F -3 AL 6 13.1 20 5 13.35 2 - - Midcavity FD 3.2 f 7 9 + - - - - -

6 5439/A 25 150 Uneng/M -3 AL 6 19 110 10 21 2 - Synto Outlet FSF 3 f 7 9 + - - - - -

7 5464/C 19 145 Uneng/M -3 AL 7 14 25 5 14.3 4 - Synto Outlet FD 2.5 m 6 8 + - - - + -

8 5847/C 20 148 Uneng/F -3 AL 4 14.3 30 5 15.05 2 - - Outlet FD 3.5 f 7 9 - - - - + -

9 5750/A 24 153 Uneng/M -3 AL 7 9 90 5 10.35 4 PGE2 - Ventose FSF 3.2 m 7 9 + - - - - -

10 5960/D 18 140 Uneng/F -2 AL 6 10.2 10 5 10.35 1.3 - Synto Outlet FD 3 m 5 8 ++ + 2 LOOP - - -

11 6350/D 25 152 Uneng/F -2 AL 6 6.5 45 10 7.45 4 - Synto Outlet FD 3 f 7 9 + - 2 LOOP - - -

12 6361/D 24 150 Uneng -1 AL 3 5 90 10 6.4 2 - - Ventose FSF 3 f 7 9 + - - - - -

13 7039/A 26 150 Uneng/M -3 AL 7 10.2 90 15 12.05 3 - Synto Outlet FSF 2.5 f 7 9 + - - - - -

14 7042/A 26 180 Uneng/M FF AL 3 10.45 80 5 12.1 6 - Synto Midcavity FD 3 m 7 9 + - - - Cervical tear -

15 7556/D 18 150 Uneng/M -3 AL 7 9.3 115 5 12.3 2 - Synto Midcavity FSF 3 m 6 8 ++ + 2 LOOP - - -

16 7598 22 154 Uneng/M FF AL 4 12 15 5 12.2 4 - Synto Outlet FD 3.25 f 7 9 + - - - + -

17 74531 22 150 Uneng/F -2 AL 4 6 25 5 6.3 4 - - Outlet FD 3.5 f 1 8 ++ + - NICU - -

18 7693 21 65 Uneng/M -3 AL 7 9.2 30 10 11 2 - Synto Outlet FSF 3.2 m 7 9 + + - - - -

19 7807/D 18 168 Uneng/M FF AL 6 14.15 100 5 16 6 - Synto Outlet FSF 3.25 m 4 7 ++ + - NICU - -

20 7864/A 18 160 Uneng/M -3 AL 6 9 15 10 9.25 2.5 - Synto Outlet FD 3 m 6 8 + + - - - -

21 10546/C 21 149 Uneng/M -3 AL 7 12 60 15 13.15 6 PGE2 - Ventose FSF 2.6 m 2 6 + - - - - -

22 1010/A 20 150 Uneng/M FF AL 6 15 45 5 15.5 2 - Synto Outlet FD 2.8 f 7 9 + ++ - - - -

23 11412/D 29 152 Uneng/F -3 AL 5 12.3 30 10 13.1 6 - - Ventose FSF 3 f 7 9 - - - - - -

24 11598 18 140 Uneng/F -2 LP 4 11.3 30 10 12.1 5 - Synto Ventose FSF 2.7 f 5 8 + - - - + -

25 11559/D 27 152 Uneng/F -3 AL 6 13 45 20 14.05 2 - - Outlet FD 3.2 f 7 9 + - - - - -

26 11654/B 25 148 Uneng/F FF AL 6 16 75 10 17.25 2 - Synto Outlet FSF 3 f 7 9 + - - - - -

126

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CD

(cm

)

1st s

tage

(hr)

2nd

stag

e (m

in)

3rd

stag

e (m

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Tot

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ion

(hr)

ED

I (hr

)

Indu

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n

Acc

eler

atio

n

Mod

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del

iver

y

Indi

catio

n

Bir

th w

eigh

t (kg

)

Sex

APG

AR

(1 m

in)

APG

AR

(5 m

in)

Cap

ut

Mou

ldin

g

CR

N

PNM

Peri

neal

tear

Puer

peri

um

1 10082/B 20 160 Uneng/F FF AL 5 - - - - - Synto EMLSCS FD 3 m 7 9 - - - - - UEF2 10555/C 34 158 Uneng/M FF AL 5 - - - - - PGE2 - EMLSCS FD 2.6 m 7 9 - - - - - -3 10715/B 22 155 Uneng/M FF AL 5 12 - - - - - Synto EMLSCS DTA 3.3 m 5 8 + - - - - -4 10684/B 20 150 Uneng/F FF AL 5 8 - - - - - - EMLSCS DTA 3 m 7 9 - - - - - -5 10731/A 26 148 Uneng/F FF AL 6 - - - - - PGE2 - EMLSCS Failure to Progress 3.3 m 6 8 - - - - - -6 10760/B 29 145 Uneng/F -2 AL 4 11.3 - - - - - Synto EMLSCS FD 3.2 m 6 8 - - - - - -7 10764/A 22 152 Uneng/F FF AL 7 - - - - - - - EMLSCS Failure to Progress 3 f 7 9 - - - - - -8 10797/B 21 150 Uneng/F FF AL 5 - - - - - PGE2 - EMLSCS Failure to Progress 3.2 f 7 9 - - - - - -9 10872/C 24 145 Uneng/M FF AL 5 - - - - - - Synto EMLSCS Failure to Progress 3.5 f 7 9 - - - - - -

10 11183/C 22 152 Uneng/M -3 AL 5 - - - - - PGE2 - EMLSCS Failure to Progress 3.2 m 7 9 - - - - - -11 11163/A 18 147 Uneng/F -3 AL 6 - - - - - - Synto EMLSCS FD 3 f 7 9 - - - - - -12 12343/A 19 146 Uneng/M FF AL 3 - - - - - PGE2 - EMLSCS FD 3.4 f 7 9 - - - - - -13 12441/B 21 147 Uneng/F FF AL 4 - - - - - - - EMLSCS FD 3.2 m 7 9 - - - - - -14 12709/C 20 144 Uneng/M -3 AL 6 - - - - - - Synto EMLSCS FD 3.2 f 7 9 - - - - - -15 12829/C 29 150 Uneng/M FF AL 4 - - - - - - - EMLSCS FD 4.5 f 7 9 - - - - - -16 13553/A 23 146 Uneng/F -3 AL 6 - - - - - PGE2 - EMLSCS FD 3.1 m 6 8 - - - - - -17 14823/B 22 142 Uneng/F -3 AL 5 - - - - - - - EMLSCS FTP 3.2 m 6 8 - - - - - -18 3132/D 20 154 Uneng/M FF AL 6 - - - - - - Synto EMLSCS FTP 3.6 f 5 8 + - - - - -19 3154/A 22 150 Uneng/M FF AL 6 12.5 - - - - PGE2 - EMLSCS DTA 3.5 m 7 9 - - - - - -20 10854/C 20 148 Uneng/M FF AL 3 - - - - - - Synto EMLSCS Failure to Progress 3.4 m 7 9 - - - - - -21 10920/D 23 146 Uneng/M -3 AL 4 - - - - - - - EMLSCS FTP 3.3 f 6 8 + - - - - -22 10943/B 23 148 Uneng/M -3 AL 6 - - - - - - Synto EMLSCS FTP 3.5 m 5 8 - - - - - -23 1097/A 18 152 Uneng/F FF AL 5 - - - - - PGE2 - EMLSCS FD 3.5 m 7 9 - - - - - -24 10901/A 19 145 Uneng/M FF AL 4 - - - - - - - EMLSCS Failure to Progress 3 m 7 9 - - - - - -25 11017/A 29 154 Uneng/F -3 AL 4 - - - - - PGE2 - EMLSCS Failure to Progress 3.25 f 7 9 - - - - - -26 11865/D 25 150 Uneng/M -2 AL 6 - - - - 2 - Synto EMLSCS Failure to Progress 3.2 f 6 9 + - - - - -27 12189/D 24 146 Uneng/F FF AL 4 - - - - 2 - - EMLSCS FD 3 f 7 9 - - - - - -28 12772/C 24 153 Uneng/M FF AL 7 - - - - 4 PGE2 - EMLSCS Failure to Progress 3.5 m 7 9 + - - - - -29 10678/B 20 152 Uneng/F FF AL 6 - - - - 2.3 PGE2 - EMLSCS FD 3 f 7 8 + - - - - -30 10719/B 28 153 Uneng/F FF AL 7 - - - - 1.3 - Synto EMLSCS FD 3.5 f 4 9 + - - - - -31 10729/A 18 150 Uneng/F FF AL 4 - - - - 2 - Synto EMLSCS FD 3 m 7 9 - - - - - -32 10679/A 20 144 Uneng/F -3 LP 4 - - - - 2 - - EMLSCS Failure to Progress 3.3 f 6 8 + - - - - -33 10777/B 20 148 Uneng/F FF AL 6 - - - - 2 - Synto EMLSCS FD 3.2 f 7 9 - - - - - -34 10845/C 19 152 Uneng/M -3 AL 7 - - - - 4 EMLSCS Failure to Progress 3.4 m 7 935 10808/D 23 150 Uneng/F -3 AL 6 - - - - 2 Synto EMLSCS Failure to Progress 3.4 f 6 8 +

127