Volume 65, Number 6

OBSTETRICAL AND GYNECOLOGICAL SURVEY

Copyright © 2010
by Lippincott Williams & Wilkins CME REVIEWARTICLE 16
CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total
of 36 AMA/PRA Category 1 CreditsTM can be earned in 2010. Instructions for how CME credits can be earned appear on the
last page of the Table of Contents.

Assessing Cephalopelvic Disproportion:

Back to the Basics
Dushyant Maharaj, MBBS, Dip Tert Teach, DMAS, FCOG (S.A.), FRANZCOG
Senior lecturer, Department of Obstetrics and Gynecology, University of Otago, Wellington, New Zealand;
and Consultant, Department of Obstetrics and Gynecology, Women’s Health, Wellington Regional Hospital,
Wellington, New Zealand

Dystocia, or abnormally slow progress in labor, can result from cephalopelvic disproportion (CPD),
malposition of the fetal head as it enters the birth canal, or ineffective uterine propulsive forces. Cephalo-
pelvic disproportion occurs when there is mismatch between the size of the fetal head and size of the
maternal pelvis, resulting in “failure to progress” in labor for mechanical reasons. Untreated, the conse-
quence is obstructed labor that can endanger the lives of both mother and fetus. Despite the use of imaging
technology in an attempt to predict CPD, there is poor correlation between radiologic pelvimetry and the
clinical outcome of labor. Clinical pelvimetry still has a place in obstetrics for predicting or confirming CPD,
but without appropriate training and repeated practice of this clinical skill, it is in danger of becoming a lost
art. For this review, a computerized search of the terms cephalopelvic disproportion, dystocia, pelvim-
etry, obstructed labor, and malposition was done using MEDLINE, PUBMED, SCOPUS, and CINAHL,
and historical articles, texts, articles from indexed journals, and references cited in published works
were also reviewed.
Target Audience: Obstetricians & Gynecologists, Family Physicians
Learning Objectives: After completion of this article, the reader will be able to interpret how cepha-
lopelvic disproportion is diagnosed. Distinguish the 4 basic pelvic shapes. Evaluate pelvic measurements
that best indicate adequacy or inadequacy of the pelvis.

Bipedal locomotion and encephalization (progres- sumed that efficient bipedalism requires a narrow
sive increase in brain size) have placed competing pelvis, whereas a wider pelvis is more advantageous
demands on the human pelvis. It is generally as- for childbirth. The likelihood of cephalopelvic dis-
proportion and obstructed labor has increased along
Unless otherwise noted below, each faculty’s spouse/life part- with the increase in brain size, and changes in pelvic
ner (if any) has nothing to disclose.
The author has disclosed that there are no financial relation-
morphology that greatly restrict the midplane of the
ships with or interests in any commercial companies pertaining to pelvis also complicate human obstetrical mechanics
this educational activity. (1). Birth injuries sustained by modern women in
The Faculty and Staff in a position to control the content of this impoverished countries who do not have access to
CME activity have disclosed that they have no financial relationships skilled obstetric care when labor becomes obstructed
with, or financial interests in, any commercial companies pertaining
to this educational activity. attest to this painful Darwinian reality (2). The evo-
There are instances where we have been unable to trace or contact lutionary consequences of these trends, if continued,
the copyright holder. If notified the publisher will be pleased to rectify are a matter for intriguing obstetrical speculation.
any errors or omissions at the earliest opportunity. Dystocia, a word that literally means difficult labor, is
Correspondence requests to: Dushyant Maharaj, MBBS, Dip Tert
Teach, D.MAS, FCOG (S.A.), FRANZCOG, Department of Obstetrics &
the overall term for slow, inadequate, or dysfunctional
Gynaecology, University of Otago, PO Box 7343, Wellington South, labor. It is generally caused by uterine dysfunction
6242 Wellington, New Zealand. E-mail: [email protected]. (inadequate propulsive forces), or a size imbalance be-
www.obgynsurvey.com | 387
388 Obstetrical and Gynecological Survey

tween the maternal pelvis and the fetal head (cephalo- Temporary (Fetal)
pelvic disproportion, or CPD) that prevents the fetus • Hydrocephalus
from negotiating the birth canal. Cephalopelvic dispro- • Large infant
portion, a recognized obstetric problem that increases
risk for both mother and infant, occurs when the fetal
head is too big, the pelvis is too small, or the head is Relative CPD
malpositioned as it enters the birth canal. Although the
term CPD was coined in the 19th century when the • Brow presentation
disparity in size between the fetal head and the maternal • Face presentation—mentoposterior
pelvis largely resulted from pelvic contracture due to • Occipitoposterior positions
rickets (3), CPD is still responsible for 8% of maternal • Deflexed head
deaths worldwide (4). Unattended, obstructed labor re- Some clinicians consider the maternal pelvis to be
sults in fetal death, eventual delivery of a macerated and “proven” if the woman has had a previous vaginal
infected baby, and atonic postpartum hemorrhage with delivery. However, subsequent fetuses can be larger,
or without puerperal infection. The survivor may be left and maternal anatomy can change between pregnan-
with a vesicovaginal or rectovaginal fistula, infertility cies. Occasionally, lumbosacral spondylolisthesis may
and chronic pelvic pain. Definitions of CPD vary but, develop between pregnancies and reduce the effective
barring extreme macrosomia or a severely restricted anteroposterior diameter of the pelvic brim, rendering a
maternal pelvis, most authorities agree that it can only previously adequate pelvis inadequate (7).
be diagnosed with assurance during labor. Clinical pel- Although descent of the fetal head through the
vimetry has traditionally been used in obstetric practice pelvis may be obstructed by the relative sizes of the
to predict CPD, and continues to be an important tool in fetal head and the maternal pelvis, uterine “power”
developing countries (5). X-ray and computed tomog- (contraction frequency and strength) must also be
raphy pelvimetry, and ultrasound and magnetic reso- assessed. In most cases of slow or seemingly ob-
nance imaging enable more precise assessment of structed labor, augmentation with oxytocin is indi-
pelvic dimensions, but cannot reliably diagnose cated. Indeed, O’Driscoll stated that, “cephalopelvic
CPD. After completing this CME activity, readers disproportion cannot be excluded unless oxytocin is
will be better able to diagnose cephalopelvic dispro- used” (8), and others diagnose CPD only if there is a
portion, distinguish the 4 basic pelvic shapes, and prolonged first (⬎12 hours) or second (⬎2 hours)
evaluate pelvic measurements indicating an adequate stage of labor in women receiving oxytocin (9). The
or inadequate pelvis. American College of Obstetricians and Gynecolo-
gists has stated that dystocia cannot be diagnosed
before there has been an adequate trial of labor; to
THE THREE “Ps” OF LABOR
achieve this, women who are in the active phase of
The current concept of dystocia is that it can result from labor (cervix, 3–4 cm dilated) and are contracting
CPD (a mismatch in size between the fetal head and the less frequently than 3 times in 10 minutes, and whose
maternal pelvis), malposition of the fetal head as it enters contractions do not measure at least 25 mm Hg, and
the birth canal, or ineffective uterine propulsive forces. in whom fetal well being has been established,
These are summarized as the 3 “Ps” of labor: should have their labor augmented with oxytocin.
1. Passageway: maternal bony pelvis and tissues. Once an adequate contraction pattern is achieved
2. Passenger: the fetus. (ⱖ200 Montevideo units in 10 minutes), they should
3. Powers: primary and secondary forces of labor. have at least 2 hours and possibly up to 4 hours of
A clinical classification divides CPD due to “passage- adequate labor without further cervical change before
way” or “passenger” into absolute and relative entities (6): dystocia can be diagnosed (10).

Absolute CPD—True Mechanical Obstruction PELVIC SHAPES, DIMENSIONS, AND

MEASUREMENTS
Permanent (Maternal)
Pelvic Shapes
• Contracted pelvis
• Pelvic exostoses Although pelves can be categorized by the mea-
• Spondylolisthesis surements of their diameters, it is usual in obstetrics
• Anterior sacrococcygeal tumors to classify pelves according to the shape of the pelvic
 Assessing Cephalopelvic Disproportion Y CME Review Article 389

curved. The sub-pubic arch has an angle ⬍90

degrees, and the ischial spines are prominent,
which may hinder internal rotation of the fetal
head, and may ultimately lead to a deep trans-
verse arrest. This type of pelvis is the least
favorable for achieving a vaginal birth.
3. Anthropoid—this type of pelvis results from
high assimilation, i.e. the sacral body is assim-
ilated to the fifth lumbar vertebra. The pelvic
brim is long, narrow, and oval in shape, and the
anterior-posterior diameter is greater than the
transverse diameter. The side walls of the cav-
ity diverge, and the sacrum is long and con-
cave. The sub-pubic angle is very wide and the
ischial spines are not prominent.
4. Platypelloid—this is a wide pelvis that is flat-
tened at the brim, with the sacral promontory
pushed forward. This forms a kidney-shaped
pelvic brim. The side walls of the pelvis di-
verge; the sacrum is flat, and the pelvic cavity
shallow. As a result, the transverse diameter is
greater than the anterior-posterior diameter.
The subpubic angle is ⬎90 degrees and the
ischial spines are blunt.

PELVIC DIMENSIONS AND

CLINICAL PELVIMETRY
Fig. 1. Female pelvis. A, View from above, showing inlet and
anteroposterior (conjugate) and transverse diameters and sur- The pelvic dimensions can be determined clinically
rounded by drawings of the 4 main types of female pelves. B, View during a detailed bimanual exam in which various mea-
from below, showing outlet and anteroposterior (conjugate) and surements of the pelvis are estimated and recorded.
transverse diameters. C, The pelvic cavity with the left hip bone Some internal pelvic diameters are not accessible to
removed. The anterior superior iliac spines and the pubic tuber-
direct measurement, so must be inferred. Findings are
cles are in the same coronal plane (CP). The linea terminalis
comprises the (1) promontory, (2) ala of the sacrum, (3) medial usually recorded as adequate, borderline, or inadequate,
border of the ilium (arcuate line), (4) pectineal line, and (5) pubic although some practitioners prefer to record the various
crest. From Smout CFV, Jacoby F, Lillie EW, Eds. Gynaecological pelvic dimensions in centimeters.
and Obstetrical Anatomy, 4th edition. London: HK Lewis & Co.
Ltd.; 1969.
The Pelvic Inlet
inlet. Four main types are recognized (11): (1) gy- The pelvic brim or inlet separates the “false” pelvis
necoid, a rounded inlet; (2) android, a heart-shaped from the “true” pelvis that is below. The inlet is
inlet; (3) anthropoid, a long, narrow, oval inlet; and round in shape, with the sacral promontory protrud-
(4) platypelloid, an ovoid inlet with its long axis ing into it posteriorly. The pubic bones form the
transverse (Fig. 1). anterior border of the pelvic brim; the iliac bones
1. Gynecoid—this is the classical female pelvis, form the lateral borders, and the posterior border is
with the inlet transversely oval and a shallow formed by the sacral promontory and its alae.
pelvic cavity, with a broad well-curved sacrum. The pelvic inlet has 3 principal diameters: antero-
The gynecoid pelvis has a sub-pubic angle of posterior, transverse, and oblique. The anteroposte-
90 degrees and blunt ischial spines. rior diameter or obstetrical conjugate extends from
2. Android—this type of pelvis is more masculine the sacrovertebral angle (sacral promontory) to the
in its shape and diameters. It is characterized by symphysis pubis. The obstetrical conjugate is the
a heart-shaped inlet and a funnel-shaped, deep most important diameter of the pelvic inlet since it is
cavity; the sacrum is straight rather than the shortest distance between the sacrum and the
390 Obstetrical and Gynecological Survey

symphysis pubis. The average length of the obstetri- vergent, and if lateral it is divergent. The sacrum is also
cal conjugate is 11 cm; the pelvic inlet is considered palpated for its curve, shape, and length. Finally, the
to be contracted if it is ⬍10 cm. However, the ob- sacrosciatic notch is evaluated; if the notch accommo-
stetrical conjugate cannot be measured directly with dates 2 and half fingers, it is considered adequate.
the hand since the upper margin of the symphysis
cannot be reached. Instead, the diagonal conjugate is
measured; this is the distance from the inferior border The Pelvic Outlet
of the symphysis pubis to the sacral promontory, and The perimeter of the pelvic outlet is partially com-
is typically 1.5 cm longer than the obstetrical conju- prised of ligaments, and is either ovoid or diamond-
gate or 12.5 cm. The length of the diagonal conjugate shaped. Landmarks of the pelvic outlet include the
is determined during a vaginal examination by plac- lower border of the symphysis pubis, the pubic arch,
ing the lateral edge of the middle finger of the ex- the ischial tuberosities, the sacrotuberous and sacro-
amining hand flush with the lower border of the spinous ligaments, and the lower aspect of the sa-
symphysis and trying to reach the sacral promontory. crum and the coccyx. The posterior surface of the
Failure to reach the sacrum indicates that the conju- pubic symphysis should be palpated; in the normal
gate is ⬎12.5 cm. If the sacrum is reached, the point female pelvis, this is a smooth rounded curve. The
where the lowest border of the pubic symphysis subpubic angle should be more than 90 degrees, and
impinges on the middle finger is noted, and the normally admits 2 fingers. The distance between the
length of the middle finger to that point is equal to ischial tuberosities (the bituberous diameter) is nor-
the length of the diagonal conjugate. Subtracting 1.5 mally at least 8 cm; this is equivalent to the width of the
cm from that distance gives the approximate length closed fist or 4 knuckles for most examiners. The mo-
of the obstetrical conjugate. Instead of estimating the bility of the coccyx is determined by pressing firmly on
length of the diagonal conjugate in this manner, some it. During the pelvic examination, the muscular struc-
practitioners simply note whether the sacral promon- ture of the pelvis is also noted. Prominent obturator
tory was reached easily, with difficulty, or not at all. internus muscles may occupy space in the cavity, and
The transverse diameter extends across the greatest rigid, inelastic levatores may obstruct descent of the
width of the superior aperture, from the middle of the head. Finally, the perineal muscles are assessed for their
brim at the level of the linea terminalis on one side to density and elasticity. In performing clinical pelvime-
the same point on the opposite. The average length of try, a formula to follow is described as the rule of 3s,
the transverse diameter is 13.5 cm; it is considered indicating that there are 3 parts of the pelvis to examine,
inadequate if it is ⬍12 cm (12,13). There are 2 oblique and each part has 3 components (Table 1) (14). The
diameters; each extends from the iliopectineal emi- findings expected in an adequate pelvis are shown in
nence of one side to the sacroiliac articulation of the Table 2 (36).
opposite side. Their average measurement is 12.5 cm.
PELVIMETRY USING IMAGING
The Midpelvis and Pelvic Cavity TECHNOLOGY
The mid pelvis is at the level of the ischial spines. The As noted above, pelvimetry can be performed dur-
ischial spines can be located by following the sacrospi- ing a bimanual exam (clinical pelvimetry), but the
nous ligaments to their lateral ends. The spines should
be palpated to determine if they are prominent or un- TABLE 1
duly pronounced, and the interspinous diameter should The rule of three
be estimated. The intraspinous diameter is the smallest
Brim
dimension of the pelvis. It is assessed by touching both Diagonal conjugate
spines simultaneously with 2 examining fingers, and Posterior surface of pubic symphysis
noting the distance between the fingers; it should be at Ilio-pectineal line
least 10 cm. Assessment of the pelvic cavity is also Cavity
Sacrum-shape, curve and length
done to determine if the walls of the cavity are straight,
Ischial spines
convergent, or divergent. While touching an ischial Sacrospinous ligament
spine with the index and middle fingers of the examin- Outlet
ing hand, the thumb of the other hand is placed on the Subpubic arch and angle
ischial tuberosity on the same side. If the thumb is Intertuberous diameter
Sacrococcygeal joint
medial to the examining fingers, the side wall is con-
 Assessing Cephalopelvic Disproportion Y CME Review Article 391

TABLE 2 terms of clinical accuracy and ability to predict CPD,

Findings expected in an adequate pelvis CT pelvimetry has not been shown to offer any
Assessment Finding substantial advantage over conventional x-ray pel-
Pelvic brim Round vimetry (22). During this time, x-ray pelvimetry was
Diagonal conjugate ⱖ12.5 cm still being performed in many centers as part of the
Symphysis Average thickness, parallel to sacrum management of breech presentation at term, and in
Sacrum Hollow, average inclination
Side walls Straight
patients in whom a trial of vaginal delivery after a
Ischial spines Blunt previous cesarean was planned (23). Consequent to
Interspinous diameter ⱖ10.0 cm the Term Breech Trial (24), as a result of which the
Sacrosciatic notch 2.5–3 finger breadths American College of Obstetricians and Gynecolo-
Subpubic angle ⬎90 degrees (2 finger breadths) gists recommended against planned vaginal delivery
Bi-tuberous diameter ⬎8.0 cm (4 knuckles)
Coccyx Mobile
of the singleton term breech, x-ray pelvimetry to
Anterposterior diameter ⱖ11.0 cm evaluate the pelvis in consideration of vaginal breech
of outlet delivery has been largely abandoned (25).
Advances in imaging techniques then led to the use
of MRI pelvimetry. Magnetic resonance imaging
dimensions of the pelvis can also be determined by provides contrast resolution superior to that provided
conventional x-rays, by computerized tomography, by CT and permits accurate pelvic measurements
or via magnetic resonance imaging (MRI). The goal with no ionizing radiation, thus eliminating the risk
of pelvimetry is to accurately predict which patients of fetal x-ray exposure (22). In a study to determine
will have cephalopelvic disproportion. Clinical as- whether MRI pelvimetry had the ability to identify
sessment of the midpelvis and the pelvic outlet seems women who would require cesarean delivery for
to be the best method of measuring pelvic capacity dystocia, single fetal and maternal pelvic measure-
(15). However, unless the pelvic dimensions are ments, as well as ratios of both, were analyzed in
grossly abnormal, all women should be given a trial women who underwent MRI. No single fetal mea-
of labor (16). surement was statistically associated with dystocia.
In recent years there has been an increasing emphasis Investigators found significant associations between
on the use of technology for the assessment and eval- MRI pelvimetry and labor dystocia, but MRI was not
uation of women during the antepartum and intrapar- a significant improvement over previously described
tum periods. As a result, “hands-on” skills, such as pelvimetric techniques (26). In another study that
Leopold’s maneuvers, fetal weight estimation, and clin- tested the clinical value of MR imaging for predict-
ical pelvimetry have received less emphasis in educa- ing CPD and labor outcome in women at risk for
tional programs and practice. Because some recent dystocia, none of the methods tested yielded suffi-
graduates are not adequately trained in obstetric aspects ciently high sensitivity or specificity (27). Studies of
of the physical examination, they may depend on tech- the use of ultrasound as a supplementary imaging
nology. In terms of estimating the adequacy of the modality to detect CPD have yielded varied results
female pelvis, it is unclear whether radiologic pelvim- (28–30). In a review of prognostic factors and
etry offers any advantage to clinical pelvimetry (17). screening tools in predicting vaginal birth after ce-
X-ray pelvimetry was popular in obstetrical units sarean delivery, the reviewers concluded that there is
in developed countries from the 1950s through to the little high-quality data to guide clinical decisions
1970s, and was used mainly for predicting outcome regarding which women were likely to have a suc-
of labor in cases of suspected CPD, breech presen- cessful trial of labor (31).
tation, and trial of labor after a previous caesarean
section. However, its clinical usefulness remained
controversial (18). Overall, the data suggest that INTRAPARTUM PREDICTION AND
there is no significant role for x-ray pelvimetry in the RECOGNITION OF CEPHALOPELVIC
prediction and management of CPD when the fetus is DISPROPORTION
in cephalic presentation (19–21). In the 1990s, com-
Fetal Head Descent
puted tomography (CT) pelvimetry was introduced
and readily adopted in developed countries. CT pel- CPD will result in failure of descent of the fetal
vimetry had the advantage of a significant reduction head through the pelvis. Obstruction may be at the
in the radiation dose to the fetus, more patient com- level of the pelvic brim (32). More commonly, the
fort, and a shorter examination time. However, in head is engaged in the pelvic inlet, but contraction of
392 Obstetrical and Gynecological Survey

the midpelvis prevents further decent. Contraction

can also occur at the level of the pelvic outlet, but in
most cases outlet contraction is associated with mid-
pelvic contraction. Successful descent of the fetal
head through the pelvis also depends on compliance
of maternal soft tissues, the strength of contractions,
and maternal expulsive efforts in the second stage.
Engagement is the passage of the widest portion of
the presenting part through the pelvic brim, and is
measured in 5ths above the symphysis pubis by ab-
dominal palpation. For a cephalic presentation, the
widest portion of the presenting part is the biparietal
diameter. A head that is 2/5 palpable or lower is Fig. 2. Station. From Smout CFV, Jacoby F, Lillie EW, Eds.
Gynaecological and Obstetrical Anatomy, 4th edition. London: HK
engaged in the pelvis. The amount of descent and Lewis & Co. Ltd.; 1969.
engagement of the head is assessed by feeling how
many fifths of the head are palpable above the brim
of the pelvis: method, station above the spines is still measured in
centimeters (i.e., ⫺1 station means 1 cm above the
• 5/5 of the head palpable mean that the whole spines).
head is above the brim of the pelvis. Normal labor usually involves a slow but sustained
• 4/5 of the head palpable means that a small part of descent of the fetal head during the first stage of
the head is below the brim of the pelvis and can be labor, with acceleration late in the first stage and
lifted out of the pelvis with a deep pelvic grip. more so in the second stage. In nulliparae, CPD is
• 3/5 of the head palpable means that the head more likely when the vertex remains at a high station
cannot be lifted out of the pelvis. On deep pelvic during the first and second stages and/or there is a
grip, the examining fingers will move outwards dysfunctional labor pattern. In multiparae, however, the
from the neck of the fetus, then inwards before fetal head often remains high longer and starts to de-
reaching the pelvic brim. scend later in the labor course than in nullparae (34).
• 2/5 of the head palpable means that most of the
head is below the pelvic brim, and on deep
pelvic grip, the examining fingers splay out- Head-Fitting Tests
wards from the fetal neck to the pelvic brim. When the fetal head is not engaged at term, there
• 1/5 of the head palpable means that only the are 2 methods to determine if the pelvic inlet is
base of the fetal head can be felt above the adequate for the fetal head. These tests are mostly of
pelvic brim. historical significance, since neither is typically used
If 2/5 or less of the head is palpable, then engage- in advance of labor to determine the mode of deliv-
ment has taken place and the possibility of dispro- ery. Importantly, nonengagement of the fetal head at
portion at the pelvic inlet can be ruled out. term is only a concern in nulliparas, since in multip-
Station is the distance between the leading edge of arous patients the fetal head can remain unengaged
the vertex and the ischial spines. Zero station is when until late in gestation or until the onset of labor, after
the biparietal diameter has passed through the pelvic which rapid decent is typical.
brim, and the leading edge of the vertex is in the One method to determine if the pelvic inlet is
midpelvis at the level of the ischial spines (33). If the adequate is the head-fitting test. If the head can be
leading edge is 1 cm below the level of the spines, pushed into the pelvis, CPD due to a contracted inlet
this is referred to as station ⫹1. Conversely, if the may be excluded. This maneuver is purely a test of
leading edge of the vertex is 1 cm above the spines, fit, and the head is not expected to stay engaged in
this is ⫺1 station. Usually, a head on the pelvic floor the pelvis. Munro- Kerr’s head-fitting test is proba-
is at station ⫹4 or ⫹5. A head not yet engaged and bly the most well known (Fig. 3) (14). The obstetri-
still 2 cm above the level of the spines is at station cian stands on the woman’s right side, and attempts
⫺2, and so on (Fig. 2). An alternate method to to push the head into the pelvis with the left hand
describe station is to divide the distance between the while feeling for descent with fingers of the right
ishial spines and the vaginal outlet into thirds, and hand in the vagina. Descent and engagement of the
express the station as ⫹1, ⫹2, or ⫹3. With this head provides reassurance, while failure of descent,
 Assessing Cephalopelvic Disproportion Y CME Review Article 393

bones are not united rigidly but are separated by

membranous spaces, the sutures, which allow the
bones of the head to overlap somewhat in order to
navigate the pelvis, in a process called molding (dis-
cussed below). The most important sutures are:
• Sagittal, between the 2 parietal bones,
• Frontal, between the 2 frontal bones,
• 2 coronal, between the frontal and parietal
bones, and
• 2 lambdoid, between the posterior margin of the
parietal bones and upper margin of the occipital
bone.
Where several sutures meet an irregular space
forms, enclosed by a membrane and designated a
fontanel. The anterior fontanel is a lozenge-shaped
Fig. 3. Munro Kerr’s head-fitting test. From Smout CFV, Jacoby space situated at the junction of the sagittal and
F, Lillie EW, Eds. Gynaecological and Obstetrical Anatomy, 4th coronal sutures. The posterior fontanel is represented
edition. London: HK Lewis & Co. Ltd.; 1969.
by a small triangular area at the intersection of the
sagittal and lambdoid sutures. The dimensions and
and especially overlap of the head over the symphy- measurements of the fetal head in the different pre-
sis, suggests the possibility of CPD. If the head sentations are shown in Table 3 (36).
cannot be made to pass the brim of the pelvis, the During labor, the examiner can palpate the fetal
thumb of the right hand is then passed over the pubic head and sutures to determine how much molding
symphysis to estimate the degree of overlap. First has occurred; significant molding without descent of
degree overlap is said to exist when the presenting the head is another indication of possible CPD.
portion of the head is level with the pubic symphysis,
suggesting that there is a moderate degree of CPD.
Second degree overlap exists when the presenting MOLDING
part is found to be anterior to the pubic symphysis, Molding is the change in shape of the fetal skull that
and suggests a serious degree of disproportion. If occurs during labor in response to pressure by uterine
descent occurred, i.e. a positive test, the test was contractions against the lower uterine segment and cer-
significant; a negative test, however, could be attrib- vix, and to a certain extent, against the bony pelvis.
uted to factors other than CPD (35). Cephalopelvic disproportion is thought to result in a
The other way to detect a contracted inlet if the high degree of molding, consequent to the head being
head is not engaged in the last 3 to 4 weeks of squeezed into a contracted pelvic cavity and high head
pregnancy in a primigravida is Pinard’s method. The to cervix pressure at the equator of the fetal head (37).
patient evacuates her bladder and rectum, and is Occipitoparietal (lambdoidal suture) molding, in which
placed in a semi-sitting position to bring the fetal axis the parietal bones are elevated in relation to the frontal
perpendicular to the brim. The left hand pushes the
head downwards and backwards into the pelvis while TABLE 3
the fingers of the right hand are put on the symphysis Dimensions and measurements for the different fetal presentations
to detect disproportion (36). Measurement
Dimension (cm) Presentation
Suboccipitobregamatic 9.5 Vertex
THE FETAL HEAD
Suboccipitofrontal 10.0 Sinciput
An essential feature of labor is the adaptation be- Occipitofrontal 11.24 Occipitoposterior
Mentovertical 13.8 Brow
tween the fetal head and the maternal pelvis. Only a
Submentobregmatic 9.5 Face
comparatively small part of the fetal head is repre- Submentovertical 11.25 Incompletely extended
sented by the face; the rest is composed of the firm face
skull, which is made up of 2 frontal, 2 parietal, and 2 Biparietal diameter 9.5
temporal bones, along with the upper portion of the Bitemporal diameter 8.0
Bimastoid diameter 7.5
occipital bone and the wings of the sphenoid. The
394 Obstetrical and Gynecological Survey

and occipital bones, results in a level difference in the posterior asynclitism (Litzmann’s obliquity), which
coronal and lambdoid sutures. Molding is to be ex- is frequently associated with CPD (38).
pected at the lambdoid and coronal sutures in normal
labor. Parietoparietal (sagittal suture) molding occurs
after occipitoparietal molding, and is associated with CONCLUSION
CPD. The failure of descent of the head during labor Obstructed labor may result from inadequate uter-
with an increase in degree of molding is the ultimate ine propulsive forces or a relative CPD due to large
index of CPD, with the hallmark being excessive pari- fetal size, an inadequate maternal pelvis, or malpo-
etoparietal overlap. Molding is graded as follows (32): sition of the fetal head. In most cases, predicting
Grade 0, Bones normally separated. cephalopelvic disproportion remains problematic.
Grade 1, Suture line closed, without overlap. Many studies report relatively poor correlation be-
Grade 2, Overlap of bones, reducible by digital pres- tween various pelvimetric indices and ultimate dys-
sure from examiner. tocia; no single independent predictor or combination
Grade 3, Irreducible overlap. of predictors is diagnostic of CPD. In a world that is
When labor progress is poor in a multipara, increasingly dependent on technology, intrapartum
careful attention should be paid to head descent clinical assessment is a valuable predictor of CPD,
and molding; when there is increasing molding of which can only be diagnosed after a properly con-
the fetal head without descent into the pelvis, there ducted trial of labor. The best indicator of maternal
may be CPD. Clinical experience and skill are pre- pelvic capacity is the fetus, or as stated by Pinard,
requisites in the assessment of poor labor progress in “the fetal head is the best pelvimeter” (41). After
a multipara (35). completing this CME activity, readers will be better
able to diagnose cephalopelvic disproportion, distin-
guish the 4 basic pelvic shapes, and evaluate pelvic
CAPUT SUCCEDANEUM measurements indicating an adequate or inadequate
pelvis.
Caput succedaneum is swelling of the scalp over
the presenting part of the fetal head (38). It develops
when uterine contraction pressure pushes the scalp REFERENCES
into the dilating cervix, which acts as a constricting 1. Wittman AB, Wall LL. The evolutionary origins of obstructed
band around that area of the head. This process labor: bipedalism, encephalization, and the human obstetric
obstructs venous return from the scalp and results in dilemma. Obstet Gynecol Surv 2007;62:739–748.
2. Wall L. Obstetric vesicovaginal fistula as an international pub-
subcutaneous edema. Marked caput has been associ- lic health problem. Lancet 2006;368:1201–1209.
ated with prolonged labor and CPD (37,39). Caput 3. Olah KS, Neilson J. Failure to progress in the management of
has been observed on ultrasound examination even labour. Br J Obstet Gynaecol 1994;101:1.
4. World Health Organisation. The World Health Report 2005:
before the onset of labor, so it does not always reflect Making every mother and child count. Geneva, Switzerland:
prolonged labor or strong uterine contractions (40). WHO, 2005. Available at: http://www.who.int/whr/2005/en/
Caput succedaneum is classified as absent (⫺), mod- index.html. Accessed April 5, 2010.
5. Adinma JL, Aqbai AO, Anolue FC. Relevance of clinical pel-
erate (⫹) or marked (⫹⫹); it may be a finding in vimetry to obstetric practice in developing countries. West Afr
normal labor, but is also a predictor of CPD (32). J Med 1997;16:40–43.
6. Craig CJ. A clinical classification of cephalopelvic dispropor-
tion. S Afr Med J 1961;35:878–879.
7. Neilson JP, Lavender T, Quenby S, et al. Obstructed labour.
ASYNCLITISM Br Med Bull 2003;67:191–204.
8. O’Driscoll K, Meagher D, eds. Active Management of Labour.
Asynclitism, a term used to describe the situation 2nd ed. London: Bailliere Tindall, 1986.
in which the fetal head is not aligned correctly in the 9. Frame S, Moore I, Peters A, et al. Maternal height and shoe
pelvis, is diagnosed when the suture lines of the fetal size as predictors of pelvic disproportion: an assessment. Br J
Obstet Gynaecol 1985;92:1239–1245.
skull are not aligned exactly halfway between the 10. American College of Obstetricans and Gynecologists. Dysto-
symphysis pubis and the sacrum, and there is lateral cia and Augmentation of Labor. Washington, DC: American
flexion of the fetal head as it negotiates the birth College of Obstetricans and Gynecologists, 2003. Practice
Bulletin 49.
canal. Small degrees of asynclitism are normal and 11. The female pelvis. Midirs. Available at: http://www.midirs.org/
not a cause for alarm. Anterior asynclitism (Nae- development/studentmidwife.nsf/0/18981b4099e3a3458025
gele’s obliquity), in which the anterior parietal bone 76f00040945a/$FILE/The%20Female%20Pelvis.pdf. Ac-
cessed May 8, 2010.
presents predominantly, with the sagittal suture fac- 12. Cunningham FG, Gant NF, Leveno KJ, et al, eds. Williams
ing the sacrum, is the most frequent. The converse is Obstetrics. 21st ed. New York, NY: McGraw Hill, 2001:436.
 Assessing Cephalopelvic Disproportion Y CME Review Article 395

13. Bathla S, Rajaram S, Singh KC, et al. Ultrasonic obstetric 28. Sporri S, Gyr T, Schollerer A, et al. Methods, techniques and
conjugate measurement: a practical pelvimetric tool. J Obstet assessment criteria in obstetric pelvimetry [in German]. Z
Gynecol India 2006;56:212–215. Geburtshilfe Perinatol 1994;198:37–46.
14. Smout CF, Jacoby F, Lillie EW, eds. Gynaecological and 29. Abitbol MM, Bowen-Ericksen M, Castillo I, et al. Prediction of
Obstetrical Anatomy. 4th ed. London: HK Lewis & Co. Ltd, difficult vaginal birth and of cesarean section for cephalopel-
1969. vic disproportion in early labor. J Matern Fetal Med 1999;8:
15. Suonio S, Saarikoski S, Räty E, et al. Clinical assessment of 51–56.
the pelvic cavity and outlet. Arch Gynecol Obstet 1986;239: 30. Bian X, Zhuang J, Cheng X. Combination of ultrasound pel-
11–16. vimetry and fetal sonography in predicting cephalopelvic dis-
16. Hankins GD, Clark SL, Cunningham FG, et al. Operative ob- proportion. Chin Med J 1997;110:942–945.
stetrics. In: Gilstrap L, Cunningham F, van Dorsten JP, eds. 31. Hashima JN, Eden KB, Osterweil P, et al. Predicting vaginal
2nd ed. New York, NY: McGraw-Hill, 1995:74–75. birth after cesarean delivery: a review of prognostic factors
17. Jacobson AK. Are we losing the art of midwifery? J Nurse and screening tools. Am J Obstet Gynecol 2004;190:547–555.
Midwifery 1993;38:168–169. 32. Stewart KS, Philpott RH. Fetal response to cephalopelvic
18. Rozenberg P. Is there a role for x-ray pelvimetry in the twenty- disproportion. Br J Obstet Gynaecol 1980;87:641–649.
first century? Gynecol Obstet Fertil 2007;35:6–12. 33. Friedman EA. Labour: Clinical Evaluation and Management.
19. Thubisi M, Ebrahim A, Moodley J, et al. Vaginal delivery after New York, NY: Appleton-Century-Crofts, 1978:37–44.
previous caesarean section: is x-ray pelvimetry necessary? 34. Debby A, Rotmensch S, Girtler O, et al. Clinical significance of
Br J Obstet Gynaecol 1993;100:421–424. the floating fetal head in nulliparous women in labor. J Reprod
20. Pattinson RC, Farrell EM. Pelvimetry for fetal cephalic presen- Med 2003;48:37–40.
tations at or near term. Cochrane Database Syst Rev 1997: 35. Philpott RH. The recognition of cephalopelvic disproportion.
CD000161. DOI: 10.1002/14651858.CD000161. Clin Obstet Gynaecol 1982;9:609–624.
21. Hofmeyr GJ. Obstructed labor: using better technologies to 36. El-Mowafi DM. Contracted pelvis. Geneva Foundation for
reduce mortality. Int J Gynaecol Obstet 2004;85:S62–S72. Medical Education and Research. Available at: http://www.
22. Ferguson JE II, Sistrom CL. Can fetal-pelvic disproportion be gfmer.ch/Obstetrics_simplified/contracted_pelvis.htm. Ac-
predicted? Clin Obstet Gynecol 2000;43:247–264. cessed April 11, 2010.
23. Raman S, Samuel D, Suresh KA. Comparative study of x-ray 37. Chua S, Arulkumeran S. Poor progress in labor including
pelvimetry and CT pelvimetry. Aust NZ J Obstet Gynaecol augmentation, malpositions, and malpresentations. In: James
1991;31:217–220. DK, Steer PJ, Weiner CP, et al, eds. High Risk Pregnancy:
24. Hannah ME, Hannah WJ, Hewson SA, et al. Planned caesar- Management Options. 2nd ed. Edinburgh, United Kingdom:
ean section versus planned vaginal birth for breech presen- WB Saunders, 1999:1103–1119.
tation at term: a randomised multicentre trial. Lancet 2000; 38. Cunningham FG, Leveno KJ, Bloom SL, et al, eds. Williams Ob-
356:1375–1383. stetrics. 22nd ed. New York, NY: McGraw-Hill, 2005:409–441.
25. American College of Obstetricians and Gynecologists. Mode 39. Odendaal HJ. Poor progress during the first stage of labour.
of term single breech delivery: ACOG committee opinion In: Cronje HS, Grobler CJ, eds. Obstetrics in Southern Africa.
number 265. Obstet Gynecol 2001;98:1189–1190. 2nd ed. Pretoria, South Africa: Van Schaik, 2003:303–313.
26. Zaretsky MV, Alexander JM, McIntire DD, et al. Magnetic 40. Petrikovsky BM, Schneider E, Smith-Levitin M, et al. Cepha-
resonance imaging pelvimetry and the prediction of labor lohematoma and caput succedaneum: do they always occur
dystocia. Obstet Gynecol 2005;106(5 Pt 1):919–926. in labor? Am J Obstet Gynecol 1998;179:906–908.
27. Sporri S, Theony HC, Raio L, et al. MR imaging pelvimetry: a 41. Dunn PM. Adolphe Pinard (1844–1934) of Paris and intrauter-
useful adjunct in the treatment of women at risk for dystocia? ine paediatric care. Arch Dis Child Fetal Neonatal Ed 2006;
Am J Roentgenol 2002;179:137–144. 91:F231–F232. Doi: 10.1136/adc. 2005.074518.