Diagnosis of a narrow pelvis in pregnant women, classification in obstetrics according to the degree of narrowing, clinical recommendations.

When visiting a gynecologist for the first time to register for pregnancy, a woman must have her pelvic size measured. This data is recorded in medical card pregnant, but repeated measurements must be taken in the maternity hospital before the onset of birth. Measurement is necessary in order to timely identify an anatomically narrow pelvis and select appropriate labor management tactics.

Normal sizes

The female pelvis is a short cylindrical canal made of bone tissue, in contrast to the male pelvis, the shape of which resembles a truncated cone. The structure of this area is such that a child can be born through the existing canal without hindrance. Therefore, women have a wide pubic angle, the promontory of the sacrum protrudes slightly forward, and the tailbone is not so strongly curved.

The bones are covered with layers of muscle and an accumulation of fatty tissue, the amount of which varies greatly among different women. Therefore, despite external differences in hip dimensions, normal pelvic dimensions fit into a relatively narrow range.

The volume is measured with a special device that resembles a curved compass with beads at the ends - a tazometer. When measuring, the following dimensions and distances are taken into account:

• Distantia spinarum is the space between the upper anterior iliac spines. Normally it is 25-26 cm.
• Distantia cristarum - a number that shows the distance between the most distant points of the iliac crests is 28-29 cm.
• Distantia trochanterica is a distance that reflects the distance between large skewers femur. This is the point that is the highest on her body. Normally, the distance between the trochanters is 30-31 cm.
• Conugata externa – external conjugate, means straight size. Measured while lying on your side, with the lower leg bent and the upper leg straight. One end of the pelvis gauge is pressed against the upper edge of the symphysis, and the other end is pressed against the suprasacral fossa. Normally, this distance is 20-21 cm.
• Conugata vera is a true conjugate. Its size is determined by calculation - 9 cm is subtracted from the length of the outer conjugate. Another way of determining is to subtract 1.5-2 cm from the diagonal conjugate. The norm is 11-12 cm.
• Conugata diagonalis is the length of the segment between the protruding point of the promontory of the sacrum and the upper edge of the symphysis. It is determined according to vaginal examination; normally it is 12.5-13 cm.

Correctly performed measurements make it possible to determine the risk group for the development of complications during pregnancy and childbirth.

What is included in the concept of a narrow pelvis?

If the dimensions of the pelvis in any of the indicators differ from normal by 2 cm or more, then it is considered anatomically narrow. But the main indicator is considered to be the parameter of true conjugates. It should be more than 11 cm.

There is also the concept of a clinically narrow pelvis. This functional state, which develops during childbirth due to a discrepancy between the size of the fetal head and pelvic parameters. That is, initially the measurement results may fit within the norm. The reasons for the development of the condition are:

• high fetal weight is the most common reason;
• incorrect insertion of the baby's head;
• , as a result of which the head cannot take the configuration necessary for childbirth.

Clinically and anatomically narrow pelvis require a special approach. Often such pregnancies end in childbirth. But if the narrowing, which is diagnosed during childbirth, is an absolute indication for surgery to save the life of the child and mother, then the anatomical features are divided into degrees. Management of pregnant women depends on the severity.

This condition is not so common - it is detected in 3% of cases, and clinically only in 1.5-1.7% of all births.

What forms of narrowing occur?

A unified classification of narrowing has not been approved, so they are used different approaches. In post-Soviet countries they are based on the shape and degree of change in size. The shape of the narrowing can be frequent or rare.

Commonly encountered ones include:

• transversely narrowed;
• flat, which includes simple, flat-rachitic and with a decrease in the direct diameter of the wide part;
• generally uniformly narrowed.

Rare forms account for only 4.4% of the total number of changes. These include:

• obliquely displaced and obliquely narrowed;
• changes in the pelvis due to exostoses, bone tumors, after displaced fractures;
• other forms.

Some forms of the structure of the narrow pelvis in women, accepted by the classification species in the post-Soviet space

Another approach to classifying pathology is used - according to the size of the true conjugate. The frequency of occurrence also varies. If up to 96% of cases are detected with the 1st degree of narrowing, then the second accounts for less than 4%, and the 3rd and 4th degrees of narrowing practically do not occur. This classification includes the following parameters:

• 1st degree – 11-9 cm;
• 2nd degree – 9-7.5 cm;
• 3rd degree – 7.5-5 cm;
• Grade 4 – less than 5 cm.

But this approach to setting the degree of narrowing is not always informative. Sometimes there is a decrease in the transverse size, but the true conjugate remains within normal limits. Then a classification according to degrees is applied for a transversely narrowed pelvis:

• 1st degree with a transverse entrance size of 12.5-11.5 cm;
• 2nd degree, if the diameter is 11.5-10.5 cm;
• Grade 3 when the inlet diameter narrows to less than 10.5 cm.

Such approaches to classification are not used everywhere. In the West and in the English-language literature, they adhere to a division into pelvic shapes, which are established depending on the results of an x-ray examination:

1. Gynecoid - corresponds in structure to the normal female pelvis.
2. Android - has features of the location and shape of the bones, like in men - narrowing downward, protruding promontory of the sacrum.
3. Platypeloid - flat-constricted, the pelvis looks flattened in the anteroposterior direction.
4. Anthropoid – a characteristic shape for primates, narrowing from the sides.

Structural features female pelvis, according to Western classification

In the photographs, a plane is drawn through the transverse dimension, which divides the entrance into two parts - upper and lower. Depending on the combination of their shapes, 12 additional configurations are formed. There are also large, medium and small pelvises, the latter corresponding to the narrow one.

Causes of irregular shape

The pelvic bone forms the girdle lower limbs. It is formed as a result of the fusion of several bones: ischium, pubis, ilium. At the back they are connected to the sacral spine and serve to support the lower limbs.

The bones of the lower extremity girdle develop unevenly. A child is born with unfused bones, which are connected to each other by cartilage. The most intensive growth occurs in the first 3 years. But they do not grow together in one stage. The first fusions occur at the age of 5-6 years. By 7-8 years, the ischial and pubic bones should be completely fused. At 14-16 all bones should be almost fused, and at 20-25 there are no traces of cartilage tissue between the bones.

The stages of growth of the lower extremity girdle are also extended over time. In girls, the transverse size of the entrance increases very quickly at 8-10 years, then slows down at 10-12 and again grows rapidly at 14-16. The anteroposterior size increases more gradually.

This data should be taken into account by mothers of girls, teachers and sports coaches. If during periods of intensive growth they act negative factors, this will lead to the displacement of bones that have not yet fused and the formation of an irregular shape. Such impacts include the following:

• lifting weights;
• uneven distribution of load between the right and left sides;
• improper sitting or standing position;
• jumping from great heights;
• walking in heels.

The role of properly selected clothing is also noted. Skinny jeans that squeeze the thighs and buttocks will not do any good for a teenager.

Period intrauterine development also affects the formation of bone and cartilage tissue. If the fetus experienced a lack of essential substances, there was a violation of mineral metabolism, this could affect the condition of the bone apparatus.

The reasons for the changes may lie in the nature of nutrition, living conditions and level of social environment, and previous infections. Polio, bone tuberculosis, and osteomyelitis can affect your health. Injuries directly to the bones of the lower extremity belt, spine, or legs are dangerous.

Favorable social and living conditions, level medical care and the absence of child labor led to the disappearance of the rachitic, kyphotic, oblique pelvis and severe degrees distortion of the form.

By what signs can one suspect a narrowing?

An external examination without determining the size of an anatomically narrow pelvis will not allow you to accurately determine the degree of narrowing. Women's hips are very variable in volume; the degree of adipose tissue deposition does not allow the assessment of bone parameters. Only the use of a tazometer gives an accurate assessment.

A change in size can be assumed by analyzing the life history. If you suffered injuries to the legs or spine in childhood, rickets was diagnosed, and timely treatment was not carried out, pathology cannot be avoided.

An obstetric history is collected from the following indicators:

• time, their character;
• how previous pregnancies and births proceeded;
• birth weight of children;
• whether there were ruptures and injuries, divergence of the symphysis.

This allows you to evaluate reproductive function, the possibility of childbirth naturally. Skeletal condition, joint mobility, weight and height are also necessary to assess the condition of a pregnant woman. External examination at a later date allows one to suspect changes in size. An anatomically narrow pelvis is determined by its angle of inclination. Normally it is 45-55°, and with pathological narrowing it is much greater. In this case, the sacrum is deviated posteriorly, and lumbar lordosis more pronounced.

But size measurements alone are not enough. The parameters of the large pelvis may not always indicate the condition of the birth canal. Therefore, additional indicators are used:

1. The lateral conjugate is a gap equal to 14.5-15 cm. It is measured between the upper iliac spines on each side.
2. The height of the symphysis is the length of the dense bony part of the pubis. Normally it is 5-6 cm. If this distance is less, then the true conjugate will be shorter. This means the pelvis is narrow.
3. Pelvic circumference is a conditional parameter, but 85 cm is considered normal.
4. Solovyov index. Determined by the size of the wrist circumference. 1.4-1.5 cm is considered normal. An increased value indicates greater bone thickness, which leads to a decrease in the capacity of the birth canal.
5. Sacral diamond of Michaelis. It is clearly visible on the sacrum. Normally, it is of regular shape with almost equal sides. When the shape of the bones of the lower extremity girdle changes, the muscles that form the rhombus shift and its configuration changes. The dimensions of the diagonals of a rhombus are normally 10 and 11 cm in width and height. If you divide it in half with a horizontal line into 2 triangles, then the height of the top one is 4.5 cm.
6. Measure the distance between the inner parts of the ischial tuberosities. Normally, this distance is 9.5 cm.

Additional Research

The diagnosis and degree of narrowing of an anatomically narrow pelvis is made using more than one examination method. The doctor takes into account not only the data of numerous measurements. It is also necessary to carefully palpate during vaginal examination internal surfaces bones. They should be smooth, without irregularities, roughness and curvatures (exostoses). An experienced doctor can roughly estimate the capacity of the birth canal.

Complements obstetric research methods application X-ray images or . At the very beginning of pregnancy, the use of radiation diagnostics is contraindicated. The laying and formation of all organs and systems occurs. Therefore, radiation exposure can lead to serious consequences. But this method is safe if the child is already at 38 weeks of gestation: all organs are already formed, and short-term irradiation cannot cause disruption of their function.

Another option for x-ray examination is the study of the structure of the pelvis at the stage of pregravid preparation. Before planning a conception, you need to assess your body’s ability to bear a healthy fetus and reduce the risks of unwanted complications.

The X-ray method of examination is not often used during pregnancy. Women who, according to external measurements and taking into account additional parameters, have not identified any deviations, as well as those who have no history of complications of childbirth, can do without X-ray diagnostics. It is recommended to take photographs at a later date in the following cases:

• there are deviations in the measurements of the small and large pelvis;
• according to ultrasound and counting methods, the size of the fetus exceeds 4 kg;
• previous labor was protracted;
• a clinically narrow pelvis developed during childbirth;
• there were complications in the form of injuries to the symphysis;
• history of application of obstetric forceps;
• past fetal trauma;
• breech presentation in the current pregnancy.

Ultrasound is a safe examination method. Therefore, it can be used to determine the size of the small pelvis at any stage of gestation.

Possible complications

Childbirth with an anatomically narrow pelvis can result in the development of complications that threaten the life of the mother and fetus. This condition of the birth canal often leads to abnormal fetal position, which persists until birth. This is transverse, oblique or. Even in a normal position, the mobility of the head remains for a long time, which cannot press against the entrance to the pelvis.

Childbirth with an anatomically narrow pelvis of the 3rd degree of narrowing is carried out using cesarean section

The outcome of pregnancy depends on the degree of narrowing. If this is stage 1, then in the absence of other contraindications, natural birth is possible. With stage 2, labor may be delayed. Long duration creates a threat of antenatal fetal death. Grade 3 narrowing is an absolute indication for cesarean section.

If a decision has been made to deliver the baby through natural ways, then you need to beware of the following complications:

• prenatal or early rupture of amniotic fluid;
• loss of small parts of the fetal body;
• premature placental abruption;
• fetal hypoxia during childbirth or intracranial injury;
• anomalies labor activity;
• transition from anatomically narrow to clinically narrow pelvis;
• rupture of the symphysis pubis;
• hyperextension of the lower segment and rupture of the uterine body;
• genitourinary and enterovaginal fistulas, which arise from compression of tissue by the presenting part of the fetus;
• risk in the 3rd stage of labor and early postpartum.

An anatomically narrow pelvis in obstetrics leads to life-threatening complications. The mechanism of their development is associated with a mechanical obstacle in the path of the newborn child. Therefore, poured out ahead of schedule water will not allow the head to insert normally and form a contact zone. A a large number of amniotic fluid may drag the baby's arms or legs along with it, which will lead to their falling out of the birth canal. In this case, the biomechanism of labor will be disrupted, and it may lead to labor anomalies.

Divergence of the symphysis pubis

IN postpartum period the wrong choice of labor management tactics can lead to the appearance of signs of divergence of the symphysis pubis. Tears of this ligament are extremely rare. The provocateur of what happened is relaxin, which loosens the cartilage tissue, relaxes ligamentous apparatus. A rupture or discrepancy can be suspected if it is impossible to independently change the position of the body in bed and severe pain in the pubic area. But accurate diagnosis is established on the basis of x-ray images.

Treatment in this case involves tight bandaging of the thighs and buttocks and strict bed rest. Some women replace the traditional bed with a hammock so that the pubic bones are brought together under the force of their own weight. If the gap was recognized in early period, then 2-3 weeks are enough for treatment. If symptoms appear late, recovery will take 3-4 weeks.

Fistulas

The mechanism of formation is associated with long-term pressure on the tissue of the fetal head. In this case, a zone of blood supply disruption occurs. Tissues are exposed to hypoxia - oxygen starvation, and mechanical trauma. Therefore, a fistula later forms at the site of pressure.

This pathology is not diagnosed immediately after birth, but much later. It is accompanied by the discharge of feces, gases, pus from the vagina at the connection with the rectum, and urine at the connection with the bladder. Treatment in this case is only surgical. This is explained by the fact that an epithelial lining appears in the cavity of the fistula canal, which can no longer grow together. Therefore, it is necessary to excise it, disconnect the canals of the vagina and rectum, or Bladder.

Danger to child

With a narrow pelvis, the newborn is also at high risk of traumatic brain injury. Especially if childbirth is delayed. The structural features of the human skull are such that by the time of birth, people have only bone plates connected to each other by cartilage. And in some areas there is no cartilage, there are only dense membranes - fontanelles. After birth, they gradually close - they grow with cartilage tissue, and then are replaced by bone.

With a narrow pelvis, the newborn is at high risk of cranial injuries

But if the birth occurs with a delay of several days or more, then cartilage tissue has time to grow a little. Therefore, the fetal head will not be able to accept the configuration and will experience high pressure, which may affect neurological status child and the nature of maturation of the nervous system.

Therefore, after birth, such children should be observed by a neurologist. In the delivery room, if there is a suspected traumatic injury to a newborn, the presence of a pediatric resuscitator is required. If necessary, the child is placed under observation in the intensive care unit.

What tactics does the doctor choose?

The course of pregnancy with an anatomically narrow pelvis is no different from normal. Difficulties may arise closer to the time of birth. The protocol provides for mandatory implementation. In this case, the presenting part of the fetus is determined. Until 35-36 weeks it takes its final position. This is the deadline when you can do it. But if there are other risk factors, this technique is not used.

The birth plan is drawn up for each woman individually. 1 degree of narrowing is not an indication for surgery. But in the presence of aggravating circumstances, the choice remains with the doctor. Risk factors for 1st degree narrowing are:

• large size of the fetus, confirmed by ultrasound;
• breech presentation;
• a scar on the uterus after cesarean or other surgery;
• chronic fetal hypoxia;
• old age of the woman in labor;
• first birth;
• history of stillbirth;
• abnormal development of the genital organs.

If premature rupture of amniotic fluid occurs, labor induction is performed. But at the same time, the degree of narrowing should not exceed the first, and there should be no other aggravating factors.

When choosing a vaginal delivery, a functional assessment of the pelvis is required (determination of Vasten's and Zangheimeister's signs). A partogram is required (a temporary recording of the stages of cervical dilatation), and fetal hypoxia is prevented. The woman spends most of the time connected to a CTG monitor to assess the condition of the fetus and the degree of contractions (more about the procedure,).

The doctor and midwife must be prepared for the need to perform, apply obstetric forceps or vacuum extraction of the fetus. There must be a connection with the pediatric intensive care unit so that in the event of an emergency, the newborn is provided with timely assistance.

To prevent bleeding in the postpartum period, Oxytocin is prescribed by drip. This hormone is released naturally and leads to contraction of the myometrium. During childbirth, it is used carefully so as not to cause violent labor and rapid labor, which are dangerous with a narrow pelvis.

Level modern medicine led to a significant reduction in pelvic bone deformities. Therefore, mothers of girls should take care of their daughters’ reproductive health even in early childhood. It is not for nothing that children are scheduled for routine examinations by an orthopedist-traumatologist, who evaluates the condition of the hip joint and other bones.

Proper nutrition in childhood and vitamin D intake throughout the fall and winter by children under one year of age reduced the incidence of rickets, especially in the form of severe manifestations that lead to bone deformities. As you grow older, you need to choose the right shoes, monitor physical and labor stress, and during puberty, monitor the manifestations of puberty. Then, for a girl planning a pregnancy, the condition of her bone system will not become an obstacle to pregnancy and childbirth.

A narrow pelvis during pregnancy is a rather serious problem, since only the correspondence between the size of the mother’s pelvis and the size of the fetus makes normal childbirth possible.

The bones of a woman's pelvis form an inextensible, dense ring of bone that must be overcome by the baby's head on the way to birth. A slight stretching of this bone ring, literally 0.5 cm, is possible due to the softening of the symphysis area before childbirth, but in general the pelvis is motionless and cannot expand or change in any other way if it does not correspond to the size of the fetus.

And although today the frequency of this phenomenon is lower than in the past, only 5-7%, there are still many cases of discrepancy between the pelvis of the mother and the fetus, but not because of the mother, but due to the fact that large children have now begun to be born more often .

Which pelvis is considered narrow? One that cannot ensure the passage of the fetal head through the birth canal. At the same time, he may have normal anatomical dimensions, if the child turns out to be too large, and if normal sizes childbirth may not be possible.

In order to promptly identify this pathology in pregnant women, the first examinations are carried out by an obstetrician already upon registration with the antenatal clinic, in the future, the dimensions of the pelvis are monitored again during hospitalization in the maternity hospital.

Causes

The reasons why a woman may have an anatomically narrow pelvis are varied. Let's try to break them down into groups.

Developmental deviations associated with general health problems in childhood. If a girl suffered from rickets, was often ill, and did not have enough adequate nutrition, she will have generally low parameters of physical development.

Previous injuries to the pelvic area. If there were severe injuries to the pelvic bones, fractures of the pelvic bones, especially in childhood, then in the future it may remain deformed, leading to a decrease in some sizes.

Tumors in the pelvic area. Bone tumors, such as osteomas, can narrow the lumen of the bony pelvis.

Hormonal disorders. Broad shoulders, a masculine butt... Hyperandrogenism leads to this type of physique in women. Teenage girls whose physical development came under the influence of such a factor as acceleration, often fall into this category. In this case, a transversely narrowed pelvis usually develops.

Tuberculosis, osteomyelitis and other bone infections leading to bone destruction and pelvic deformation.

Concomitant pathology for other orthopedic diseases, for severe scoliosis, for example.

Congenital structural anomaly.

Classification

First of all, you need to understand that there is clinical, and there is an anatomical narrow pelvis.

What does this mean?

Anatomical is one in which there is a real narrowing, a deviation of certain dimensions from the average statistical norm.

But sometimes the pelvis has normal dimensions, but during childbirth it turns out that the child cannot pass through it, since this pelvis is not suitable for a particular fetus. This situation is called clinical.

An anatomical case does not always serve as a reason for a caesarean section; if the baby is small, such a pelvis may turn out to be quite functionally suitable. At the same time, if one day the birth did not work out according to clinical reason, this does not mean that when next pregnancy the situation will repeat itself. It is possible that the next baby will be able to be born on its own, despite the previous caesarean section.

If we talk about the clinical variant, its classification has not been developed, since it is detected only during childbirth.

Anatomically, they are divided according to the type of narrowing; the most common are a uniformly narrowed pelvis, a flat pelvis in various versions, and a transversely narrowed pelvis.

In addition, classification according to the degree of narrowing of the pelvis is of great importance. It should be noted that unified classification does not exist, a lot of them have been developed, the working classification that is used Russian obstetricians, distinguishes 4 degrees of pelvic narrowing.

With the first degree of narrowing, childbirth is possible in many cases; with the second, it is allowed under certain conditions; degrees 3 and 4 of narrowing are always an indication for a planned cesarean section without any attempts to give birth on your own.

Diagnosis of a narrow pelvis

A narrow pelvis during pregnancy should be diagnosed before the onset of labor, since pregnant women with pronounced narrowing are hospitalized as planned. maternity ward two weeks before the expected date of birth to avoid complications.

The parameters of the narrow pelvis are calculated on an outpatient basis at the stage of registration at the antenatal clinic, during the first examination by a gynecologist.

For this, a special tool, a tazometer, is used.

Usually a woman or girl with a narrow pelvis is short in stature, short fingers And small size feet, often reminiscent of a male physique; there may be manifestations of orthopedic diseases (lameness, scoliosis, etc.)

The pelvis is measured in the following way:

Inspection:

The woman is examined while standing, noting the structure of the so-called Michaelis diamond, which is located in the lumbosacral region. Its corners are the pits, directly above the coccyx, in lumbar region along the midline and on the sides. It itself is a flat area above the sacrum, and in women it normally has a longitudinal size of 11 cm, and a transverse size of at least 10 cm.

The asymmetry of the rhombus and a decrease in its size indicate an anomaly in the structure of the pelvis itself.

The female pelvis differs from the male pelvis in having thinner bones and greater width. If the male pelvis has a cavity that tapers downwards, the female pelvis has almost the same width of the internal cavity throughout.

The large and small pelvis are distinguished; this is a conditional division along an imaginary plane passing through the entrance to the small pelvis.

From an obstetric point of view, it is the small pelvis that is important. His back wall concave in shape, and formed by the sacrum, the side walls are the ischiums, the symphysis closes it in front.

However, it is possible to judge the structure of the small pelvis during examination only indirectly, focusing on external signs, on the structure of a woman’s large pelvis.

Using a pelvic meter, the obstetrician measures the following parameters:

- Interosseous size is the distance between the anterior iliac spines (normal is more than 25 cm).
- The distance between the iliac crests (their most distant points), the norm is more than 28 cm.
- The distance between the greater trochanters of both femurs, the norm is more than 30 cm. - The external conjugate, the distance between the suprasacral fossa in the lumbosacral region and the upper edge of the pubic symphysis, the norm is more than 20 cm.
- The true conjugate, measured during vaginal examination, is the distance from the symphysis pubis to the promontory of the sacrum. Normally, the cape is unreachable; the obstetrician cannot reach it.

Some women have very massive bones, and then, with normal indicators, when measuring the pelvis, it may still turn out to be narrow. In order to assess the thickness of the bones, the Solovyov index is measured, this is the circumference of the wrist. Normally, the wrist has a circumference of no more than 14 cm; if the size is larger, the pelvis may be narrow.

IN in rare cases To clarify the size of the pelvis, radiography (x-ray pelviometry) is performed; this study is extremely undesirable, since it is not in the interests of the fetus, and is performed according to strict indications.

The size of the pelvis can also be assessed using an ultrasound examination.

Despite the fact that during the examination of the woman before childbirth everything seemed fine, during childbirth a situation may arise when an anatomically normal pelvis turns out to be functionally insufficient, this is the so-called clinical case. Its cause is most often too large the size of the fetus, incorrect presentation and insertion of the head, hydrocephalus and other malformations of the fetus.

How to determine a narrow pelvis during childbirth? The obstetrician notices that despite the fact that the contractions are strong, labor is good, the opening of the cervix is ​​complete, the fetal head does not descend into the pelvic cavity. There are specific obstetric signs and symptoms that help determine if the baby's head is not moving forward.

If a clinically narrow pelvis is suspected, the signs of which are usually quite clear, the question of an emergency caesarean section arises.

Narrow pelvis and pregnancy

During pregnancy, this deviation contributes to the formation of abnormal fetal positions.

By the end of pregnancy, normally the fetal head should descend, pressing against the entrance to the small pelvis; with a narrow pelvis, this does not happen. As a result, shortness of breath is guaranteed, since the uterus practically rises to the diaphragm, and its anterior deviation in first-time mothers gives the tummy a special, pointed shape.

In multiparous women with a weak anterior abdominal wall, the tummy looks somewhat saggy.

At to a large extent narrowing of the pelvis may lead to the formation of oblique and transverse positions of the fetus; breech presentation is very common.

Narrow pelvis and childbirth

If, when registering at the antenatal clinic, a woman’s hip bone size is not normal, she is observed in a special way, since she belongs to the category high risk complications. Timely detection of fetal position abnormalities, prevention of postmaturity, and early hospitalization in the maternity hospital at 37-38 weeks are important for the prevention of complications during childbirth.

This is enough a big problem for obstetricians and gynecologists, and deciding whether a woman can give birth on her own or not is in many cases not as easy as it seems.

The size, presence or absence of other pregnancy pathologies, and even factors such as the woman’s age and the presence of infertility in the past are taken into account.

The tactics of childbirth with a narrow pelvis is determined by the degree of its narrowing. If the fetus is small, in the correct presentation, the narrowing of the pelvis is slight, it is allowed independent childbirth.

For those who have already given birth with a narrow pelvis, the risks are the same as for first-time mothers; if the fetus turns out to be larger than the previous one, the same complications are possible, thus, in any pregnancy, the decision is made based on the specific obstetric situation.

Childbirth is carried out under special supervision.

Since the baby’s head is not pressed against the entrance to the pelvis for a long time, early rupture of amniotic fluid is prevented. During contractions, a woman has to lie down in order to preserve the amniotic sac as long as possible. When dilated to 2 fingers, an amniotomy is usually performed.

Good labor activity, satisfactory condition of the mother and fetus, good dynamics of cervical dilatation and safe movement of the baby along the birth canal allow the birth to be completed through the natural birth canal.

The occurrence of complications, incorrect insertion of the head, weak labor, and a clinically narrow pelvis are indications for cesarean section. Labor induction is not carried out with a narrow pelvis.

Typically, in 70% of cases, women give birth on their own without complications.

Indications for caesarean section with a narrow pelvis

All indications for caesarean section with a narrow pelvis can be divided into 2 large groups.

Absolute indications for caesarean section

Narrow pelvis 3-4 degrees
- bone tumors pelvis
- damage to the bones and joints of the pelvis in previous births
- severe pelvic deformities

In all these cases, a caesarean section is performed as planned, before the onset of labor or with the first contractions. Natural childbirth is not allowed under any circumstances.

Relative indications for caesarean section

2 degree of deviation
- 1st degree in combination with one or more of the following factors:
- large fruit
- breech presentation
- post-term pregnancy
- fetal hypoxia
- a scar on the uterus after a caesarean section in the past
- infertility
- abnormalities of the genital organs
- first-time mother, over 30 years old
- other obstetric situations that create an increased risk.

If there is a combination of these factors, childbirth can be allowed, if the pregnant woman really wants it, she will be allowed to try, despite the pathology, a cesarean section will be performed if there are symptoms of a worsening situation and a real threat to the mother or fetus appears.

Thus, a narrow pelvis and a caesarean section are not a necessary, but very likely combination, and you need to be mentally prepared for such a turn of events.

Finally. You may ask, if there is a narrow and a wide pelvis, it probably happens?

Yes, it happens that some women have larger pelvic sizes than normal. And oddly enough, this is also not very good, since it creates the risk of incorrect insertion of the fetal head, which can complicate childbirth.

But still, with a wide pelvis, there are fewer problems and children are almost always born independently.

Clinically narrow pelvis during pregnancy - this is exactly the diagnosis that treating specialists give to some expectant mothers. The presence of this pathology often causes various severe outcomes in women during childbirth. This is also one of the possible arguments for a planned caesarean section.

Experts distinguish between large and small pelvises. The growing uterus is located in the pelvic area. Due to its narrowness, the uterus does not expand, so the abdomen takes on a pointed shape. During childbirth, the baby moves through the open pelvis. A clinically narrow pelvis during childbirth can become a serious obstacle to the advancement of the fetus and the further outcome of delivery. There are some types of narrowing and features of gestation.

General definitions

Experts distinguish two types of narrowing: anatomically and clinically narrow pelvis. It is worth distinguishing between these concepts because they are different. The first term is detected when there is a deviation from the normal size of 2 cm. According to anatomical indicators, pelvic narrowing is classified as follows:

• Flat;
• Generally uniform narrowed;
• Narrowed in the transverse direction.

It is almost impossible to prevent such a pathology.

The main reasons for the development of anatomical pathology include the following points:

1. Infectious diseases that the fair half suffered in the past.
2. Hormonal imbalance during adolescence.
3. Rickets, tuberculosis or polio, which have damaged bone tissue.
4. Physical overexertion.

Clinically, a narrow pelvis during childbirth is detected at the moment when the doctor diagnoses discrepancies between the size of the baby’s head and the parameters of the woman’s pelvis. This occurs during the active phase of labor. Sometimes mothers learn about this feature only after the baby is born. This pathology can become a companion for mothers who did not even know about such a problem during pregnancy. There are the following degrees of pathology:

• Minor discrepancy;
• Significant;
• A complete mismatch.

The degree is determined taking into account the following important parameters, such as: nuances of head placement, absence or presence of movement, configuration feature.

Causes of narrow pelvis in pregnant women

Clinical type pelvic narrowing can develop for the following reasons:

1. Large pregnancy, that is, more than 4 kg;
2. Anatomically narrow pelvis;
3. Transition during gestation, when the baby’s head loses the ability to shape;
4. Pathological processes that contribute to an increase in the size of the fetal head;
5. Neoplasms in the pelvic area (oncology).

Narrow pelvis during pregnancy: signs

During childbirth, a woman may experience the following pathologies, indicating clinical narrowing:

• The baby's head is not pressed against the pelvic bones;
• The natural course of labor is disrupted;
• Untimely discharge of amniotic fluid;
• Impaired uterine contraction;
• The appearance of a threat of uterine rupture;
• The occurrence of an attempt while pressing the fetal head to the entrance to the pelvis;
• When the uterus is fully opened, no fetal advancement is observed;
• Prolonged stay of the head in the pelvic plane;
• Bladder problems;
• The presence of a birth tumor on the baby’s head.

During active labor, the baby's heartbeat is constantly measured; it is very important that he does not become overtired from prolonged labor. During active work The doctor notes the exit of the baby’s head, the degree of dilatation of the uterus, and the strength of contractions.

If a woman has a clinical narrowing, the classification of which is described above, or the fetus is quite large, then experts strongly recommend a cesarean section so that the baby does not die during birth or to avoid injury during passage through the birth canal. This the only way out from the current situation, given the complexity of the situation.

Often, expectant mothers who have been diagnosed with clinical constriction during childbirth experience an untimely release of water, so the baby’s head can remain in the same plane for a long period without movement. All this leads to weak labor, the occurrence of entero-genital fistulas, and traumatic brain injuries in the baby. A high probability of complications can lead to surgical intervention during labor.

Visual methods of determination

Not every woman is given such a diagnosis. IN special group Expectant mothers who have the following pathologies of body structure are at risk:

1. If a woman has short hands, no more than 16 cm;
2. Small foot size may also indicate the presence of this disorder;
3. Women of small stature, less than 165 cm, exhibit visible curvature of the spine, lameness and other gait disturbances;
4. Previous labor gave rise to certain complications;
5. The presence of disruptions during the menstrual cycle;
6. Women with a male body constitution are also predisposed to a narrow pelvis and subsequent problems during childbirth.

Degrees of narrow pelvis in pregnant women

During external measurements, the following degrees are noted:

• 1st degree – deviation from the norm by 10 cm;
• Grade 2 provides a difference of 8.5-9.9 cm;
• 3rd degree is a deviation of 5-8 cm;
• 4th degree of pelvic narrowing – 5 cm or less.

1-2 degree of narrowing of the erased form of narrowing does not interfere with the normal course of gestation. Grades 3 and 4 narrowing are extremely rare, as they can cause serious problems in the functioning of the musculoskeletal system.

Bearing a fetus with a mild degree of contraction

1-2 degrees of narrowing do not have such a pathogenic effect on the development of the fetus as a whole.

Numerous studies have confirmed the following individual characteristics pregnancy in patients with a similar diagnosis:

1. The time of active gestation in most cases is 38 weeks; cases of postmaturity are extremely rare;
2. The occurrence of various complications accounts for up to 80% of all recorded cases;
3. Expectant mothers with pelvic narrowing are most often susceptible to excessive mobility and relaxation of the pelvic joints, accompanied by severe pain and gait disturbance;
4. The occurrence of pathological shortness of breath is caused by the child’s position being too high in the abdomen.

Do not be afraid of such a diagnosis, now you know the individual characteristics of carrying a child with pelvic narrowing. There's nothing wrong with that. Slight deviation from the normal size of the pelvis for normal childbirth without complications is not scary, since the sensitive cartilage stretches during gestation.

Narrow pelvis during pregnancy: diagnosis

An anatomically narrow pelvis can be detected in an expectant mother in advance, that is, before the onset of childbirth. Expectant mothers with a narrow pelvis are hospitalized several weeks before the expected date of birth to prevent probable complications. How to identify this pathology?

• A narrow pelvis is detected during the first examination, that is, when a woman is registered. The specialist uses a special tool for this purpose - a tazometer; it is a kind of compass with a scale. With its help, you can clarify the external dimensions of the pelvis, the length of the fetus, as well as the circumference of the baby’s head. When performing calculations, the pregnant woman is placed on her side with her stomach open. This procedure involves clarifying several important parameters:
• the distance between the protruding points of the anterior surface of the pelvis, the norm is 26 cm;
• length from the distant points of the iliac bones, this value within normal limits is about 29 cm;
• the final distance between the trochanters of the femurs is 31 cm;
• length between the points of the upper angle of the cruciate and the upper edge of the pubic joint.

Long before such an examination, a suspicion of an anatomically narrow pelvis may arise. Representatives of the fair sex with this feature have a male body constitution, below average height, and small foot size. In addition, various orthopedic diseases may develop against this background. The specialist pays Special attention the structure of a woman’s bones, especially the Michaelis rhombus, located in the lumbosacral area. The dimples above the tailbone are the corners of this diamond.

Clinically, a narrow pelvis during childbirth is diagnosed exclusively by a specialist. During delivery, the obstetrician may notice that the baby’s head does not descend into the pelvis, despite good labor and full dilation. Gynecologists know the exact symptoms of a clinically narrow pelvis; when diagnosing this pathology, an emergency caesarean section is performed.

Making a final diagnosis

A few weeks before the expected birth, specialists repeat pelvic measurements again. This must be done, because the baby is constantly growing. The estimated size of the child can be found out during a routine examination. The size of the pelvis is measured from top point pubic area up to high point uterus. In the later stages of gestation, it can be felt through the distended abdominal wall.

Before the immediate start of labor, a specialist cannot make a diagnosis; he can note a certain discrepancy between the volume of the baby’s head and the parameters of the pelvis. Only in this way can a more accurate prognosis for childbirth be made.

A similar study is carried out after 38 weeks of gestation. But the final diagnosis can only be determined in the maternity ward. In the emergency room, the parameters of the baby’s pelvis and head are again measured, and the slightest changes are monitored.

Childbirth with a narrow pelvis

Increased attention is paid to a pregnant woman who has a narrow pelvis, because she may have complications during childbirth. To avoid insurmountable complications during delivery and to prevent post-maturity, the pregnant woman is hospitalized at 37-38 weeks of pregnancy. The diagnosis of pelvic narrowing is considered a serious task for obstetricians, since in each case it is decided individually: whether the expectant mother should give birth naturally or whether the need to perform an operation still remains a priority. When making such a serious decision, a number of factors are taken into account:

1. exact size of the pelvis;
2. the presence of any additional pathologies during pregnancy;
3. age of the pregnant woman (30 years or more);
4. state of the reproductive system (probability of infertility).

The specialist’s tactics are determined based on the degree of pelvic narrowing. Natural birth is possible if the fetus is small in size and is correctly presented, with a slight degree of contraction.

With anatomical narrowing due to early rupture of water, the process of uterine dilatation may slow down. Also, various dangerous infections can penetrate into the unprotected uterine cavity, which can cause infection of the fetus. Contractions against such a background of infection can be too painful, and the duration of labor is prolonged.

When a narrowing is diagnosed, a pathology of labor forces is observed, when rare and weak contractions are noted, the process of the child passing through the canal is delayed, and the woman in labor becomes tired. Prolonged exposure of the baby's head leads to irritation of the sensitive receptors of the cervix. The period of passage through the birth canal is quite long, against this background violent labor, distension of the bladder and urethra can develop.

When is a caesarean section necessary?

If the expectant mother is diagnosed with a clinically narrow pelvis, the specialist’s tactics are to perform a cesarean section or allow the mother to have a natural birth. Recommendations for surgery can be relative, when a favorable outcome and natural course of labor is possible, as well as absolute, when surgery is performed. Indications for precise operation are the following situations:

• Diagnosed narrowing of 3 and 4 degrees;
• Clearly deformed pelvis;
• Damage to the pelvic bones during previous labor;
• The presence of bone tumors in the pelvic area.

All of the above situations exclude the possibility of natural childbirth. A child can only be born through a caesarean section; it is performed as planned before the immediate onset of labor or with the appearance of the first contractions.

Among the relative indications for surgery are the following cases:

1. With diagnosed narrowing of the first degree;
2. Large baby;
3. Post-term pregnancy;
4. Presence of fetal hypoxia;
5. A visible scar on the uterus made during a previous birth;
6. Anomalies in the development of the organs of the reproductive system;
7. Detected narrowing of the 3rd degree.

If a pregnant woman has relative readings to surgery, this means that labor is possible naturally. If the pregnant woman’s condition worsens during delivery, if there is a real threat to the fetus and the woman in labor, then she will also undergo another section.

Possible consequences with a narrow pelvis

During the initial stages of gestation, the pathology does not in any way affect the course of pregnancy, but closer to the expected date of birth, when the uterus begins to rise upward due to the narrowness of the pelvis, this feature negatively affects the quality of breathing of a pregnant woman.

Due to increased mobility of the uterus, the baby takes the wrong position. Babies born to a woman with pelvic constriction develop spinal curvature, temporary asphyxia, and cerebral circulatory disorders.

It is very important to listen to a specialist when making a decision: he will be able to independently give valuable recommendations on how to give birth in your particular case, taking into account all the parameters of the pelvis. If there is a slight danger that the baby may be injured when passing through the birth ring, you should refrain from natural labor. Under such circumstances, caesarean delivery can be called the best solution for preserving the baby’s health and facilitating labor.

If a woman is diagnosed with a narrowing while carrying a baby, then specialists will have to determine whether the expectant mother will be able to give birth without surgery or whether she will still have to perform a cesarean section. For this purpose, a sufficient number of different studies are carried out, all kinds of measurements are taken so that the possibility of injury to the child and mother during childbirth is completely excluded. The successful birth of a baby directly depends on the level of professionalism of competent specialists and a timely decision.

If pelvic contraction is diagnosed, natural childbirth can also be used. But at the same time, a specialist monitoring the course of pregnancy must take into account a lot of nuances before authorizing such an undertaking. Among these factors, it is worth noting the progress of gestation and the size of the head. A pregnant woman will receive permission to have a natural birth only if she undergoes pregnancy several times during pregnancy, and also if during measurements it is revealed that the baby’s head is of the appropriate size, the baby’s heartbeat is normal, and the stomach does not have a pronounced pointed shape.

With a similar diagnosis, you can also give birth to a completely healthy baby. Bearing a fetus must be approached with maximum responsibility. Carrying a baby is that wonderful period of waiting for a miracle, when any mother looks at her lifestyle with more serious eyes. All pregnant women must follow the recommendations of the observing specialist so that the gestation of the fetus goes smoothly, without any additional complications.

A narrow pelvis is not considered a diagnosis that puts an end to natural childbirth. On the contrary, even in the presence of such a pathology, you can give birth on your own. The female body is a strong vessel in which the bearing and birth of a child is embedded. Often, during gestation, the cartilage on the coccyx gradually expands by 2 cm, in many cases this is enough for the natural course of labor.

To simplify the tactics and behavior of specialists during childbirth, when there is a diagnosis of a narrow pelvis, a protocol for providing assistance with anatomical and clinical form narrowing of the pelvis. Using the manual for labor management with a clinically narrow pelvis, the specialist determines delivery tactics.

Not in all cases, the observing specialist decides to carry out artificial delivery; natural labor is also possible. Each birth case is unique; during active labor, the doctor relies on many objective factors to make the right decision, which will be the optimal outcome for the mother and child.

“Narrow pelvis” is a diagnosis that raises many questions. Having heard it, the woman worries: how will the birth go, and what “pitfalls” are possible during the birth of a baby?

In the process of expulsion of the fetus from the uterine cavity during childbirth, it passes through the bony base of the birth canal - the small pelvis, an almost inflexible, solid ring of bone. Deviations in the structure of the bony pelvis, especially a decrease in its size, can complicate the course of labor and even present an insurmountable obstacle to the passage of the fetal head through it.

Anatomically, a narrow pelvis is considered to be a pelvis in which all or at least one of the main dimensions is shortened compared to normal by 1.5-2 cm or more. Pelvic narrowing may also be accompanied by deformation of the pelvic bones.

There is also the concept of the functional usefulness of the pelvis. In women with small pelvic sizes, spontaneous childbirth without any complications is observed in cases where there is no discrepancy between the size of the fetal head and the size of the pelvis, which happens with the fetal head, its good ability to shape (the head is reduced due to the fact that the skull bones have not yet fused found one on top of the other, like tiles) and satisfactory labor. Such an anatomically narrow pelvis is considered functionally complete.

A clinically narrow pelvis is a pelvis that poses a difficulty or obstacle to the course of a particular labor, regardless of its size. This is a discrepancy (disproportion) between the fetal head and the mother's pelvis. It can be observed with absolutely normal sizes of the pelvis and large sizes of the fetal head, its reduced ability to shape, with its incorrect insertion and other reasons.

Thus, it should be kept in mind that not every anatomically narrow pelvis will be both functionally narrow, while not every functionally narrow pelvis is anatomically narrow. The incidence of a clinically narrow pelvis with an anatomically narrow pelvis is 25-30%, and with normal pelvic sizes – 0.3%.

Signs of a narrow pelvis?

Make an assumption about anatomical changes bone pelvis, the doctor can see the following signs:

• low height of a pregnant woman (less than 160 cm);
• short fingers and toes (shoe size less than 23 (36), hand length less than 16 cm, fingers I and III less than 6 and 8 cm, respectively);
• a woman’s height is more than 165 cm, combined with lameness, gait disturbance, curvature of the limbs and spine;
• identification of all factors in a woman’s life that could have an impact adverse influence on the formation of the female pelvis;
• an indication of a complicated course of previous births.

Causes of anatomically narrow pelvis

The formation of the female pelvis is influenced by many factors:

• frequent, including infectious, diseases in childhood, malnutrition, lack of vitamins, metabolic disorders, damage to the bones and joints of the pelvis due to rickets, tuberculosis, poliomyelitis, tumors, and improper healing of a fracture leads to deformation of the pelvis, congenital anomalies pelvis;
• deformation of the spine (with its curvature), absence or shortening of a limb, pathology in hip joints;
• hormonal disorders during puberty (this reason is one of the main ones).

Diagnosis of a narrow pelvis

With a narrow pelvis, due to the high-standing head of the fetus, the fundus of the uterus rises very high and begins to deviate from the vertical to an almost horizontal position. In primigravidas, due to the elastic wall of the abdomen, a so-called “pointed” abdomen is observed. In multiparous women, due to weakness of the abdominal press, the uterus deviates even more anteriorly, and a “saggy” abdomen is characteristic.

Important information about the structure of the pelvis is obtained by measuring it instrumentally. The obstetrician is mainly interested in the structure and size of the small pelvis (the internal bone canal created by the pelvic bones), as it is of decisive importance when the fetus, especially its head, passes through it.

The internal dimensions of the small pelvis are indirectly judged by external measurements of the pelvis, which are carried out traditional methods– using a pelvis gauge (obstetric caliper) and a centimeter tape. Based on the data obtained, one can judge the anatomical features of the small pelvis, because There is a relationship between the sizes of the large and small pelvis.

Only after a vaginal examination, during which one of the dimensions of the small pelvis is determined, the walls of the pelvis are examined from the inside, its capacity, the presence of deformations, taking into account the data of external pelvic measurement, can a diagnosis of a narrow pelvis and the degree of its narrowing be made.

However, the final diagnosis of an anatomically narrow pelvis, its shape and degree of narrowing is established using additional research methods: the X-ray method (X-ray pelvimetry) and the computed tomographic pelvimetry method, which is more accurate and safe compared to the X-ray method, and ultrasound. These research methods are used if, based on the results of external measurements of the pelvis, there is a suspicion of its significant narrowing.

With an anatomically narrow pelvis, delivery can be carried out through the natural birth canal and promptly. Childbirth can:

• proceed normally;
• be difficult, but end happily when providing the right help;
• be very severe, with complications dangerous for the woman in labor and the fetus.

There are four degrees of narrowing of the anatomically narrow pelvis:

At III-IV degrees narrowing of the pelvis, it is considered absolutely narrow and is an indication for delivery only by cesarean section, as well as in the presence of bone tumors, gross deformations in the pelvis, which represent an obstacle to the passage of the fetus.

At II degree narrowing of the pelvis, due to possible dangerous complications for the mother and fetus, they most often resort to delivery by cesarean section. It is possible to conduct childbirth through the natural birth canal in case of premature pregnancy (in this case, the size of the fetus is small, and therefore childbirth is possible even through a narrow pelvis).

The above situations are extremely rare.

At I degree narrowing of the small pelvis, childbirth usually begins through the natural birth canal with the determination of the functional usefulness of the pelvis. A caesarean section is performed when the contraction is combined with a breech presentation (in this case, the fetus is facing the pelvic end towards the exit of the uterus), a large, especially post-mature fetus, abnormal position of the fetus, a scar on the uterus, and in combination with other aggravating factors.

Features of childbirth with an anatomically narrow pelvis

In most cases, childbirth with an anatomically narrow pelvis with an average head size and good ability to shape during vigorous labor proceeds normally. However, there are some complications characteristic of childbirth with a narrow pelvis:

Happens more often untimely rupture of amniotic fluid(premature or early). Due to the narrowness of the pelvis, the head is not inserted into the pelvis, but stands high and mobile above the entrance to the small pelvis, the waters are not divided into anterior and posterior - normally they are separated by the head, pressed against the pelvic bones, the pressure on the amniotic sac increases, it opens .

With the flow of water, umbilical cord loops or fetal limbs (arm or leg) may fall out. If the small part of the fetus cannot be tucked behind the head, the volume of the narrow pelvis is reduced and an additional obstacle is created for the expulsion of the fetus. A dropped loop of the umbilical cord can press the head against the pelvic wall and lead to the death of the fetus from hypoxia (oxygen deficiency). If the umbilical cord prolapses, the birth is completed by caesarean section.

Excessive mobility of the uterus and a high-standing head predispose to abnormal fetal position(transverse, oblique, pelvic presentation), incorrect positioning of the head (lateral), its extension with the formation of extensor presentations of the fetus (normally the head is bent during childbirth, the back of the head is born first, with extension insertions the head is unbent, the forehead or face is presented).

Arises primary or secondary weakness of labor, which are facilitated by untimely outpouring of water, prolonged high location heads, which excessively stretches the lower segment of the uterus, slows down the dilation of the cervix, delays labor, and leads to fatigue of the woman in labor. In primiparous women, primary weakness of labor often occurs, due to the need for a long time to overcome the obstacle of a narrowed pelvis, and in multiparous women, it is due to overstretching of the uterine muscles, its changes in previous births or abortions.

A protracted course of labor, a long anhydrous interval can lead to infection of mother and fetus due to the penetration of pathogenic microflora from the vagina into the uterus.

Developing intrauterine fetal hypoxia. During a contraction or pushing, the fetal head undergoes a strong configuration (its volume decreases due to the fact that the bones of the head overlap one another at the sutures and fontanelles), which leads to excitation of the centers nervous regulation the fetal heart, causing a decrease in the fetal heart rate, exceeding in duration the uterine contraction, and thus becomes the cause of hypoxia.

Often, fetal hypoxia is aggravated by a violation of the uteroplacental circulation caused by abnormalities in the contractile activity of the uterus (violent labor, weakness). That's why therapeutic measures turn out to be short-lived and ineffective.

The course of labor is different longer duration, than usual.

Happening compression of the soft tissues of the birth canal between the pelvic bones and the fetal head, caused by prolonged standing of the head in one plane of the pelvis. In addition to the cervix and vagina, the bladder and rectum are compressed, which is accompanied by impaired circulation in them and swelling of the cervix, vagina, bladder, and external genitalia.

A sharp difficulty in the passage of the head, prolonged standing in one plane of the pelvis causes painful, intense, sometimes convulsive contractions, which can lead to hyperextension of the lower segment of the uterus, which is a symptom of impending uterine rupture.

With some types of narrow pelvis, the fetal head deviates towards the perineum to a greater extent than with a normal pelvis, the tissues of the perineum are greatly stretched, and if the perineum is not cut, it occurs deep gap.

Prolonged labor, fatigue of the woman in labor, and a long period of waterlessness can cause bleeding in the postpartum and early postpartum period due to poor uterine contractions. This complication requires an operation to manually enter the uterine cavity.

Occur more often complications that threaten the fetus. Hypoxia during childbirth can lead to the birth of a child in a state of asphyxia, impaired cerebral circulation, cranial and spinal injuries of varying severity occur, which subsequently requires observation by a neurologist and rehabilitation measures.

Actions of doctors during childbirth with a narrow pelvis

Managing childbirth with a narrow pelvis requires great endurance and skill from the obstetrician. Only in time (at the end of the first and in the second period) is the question resolved whether a given anatomically narrow pelvis will be functionally narrow or normal. The functional assessment of the pelvis is preceded by its anatomical assessment (determining the shape of the pelvis and the degree of narrowing) and determining the size of the fetus.

The causes of a clinically narrow pelvis, in addition to its anatomical narrowing, can be: a large fetus, hydrocephalus (dropsy of the brain with a large size of the fetal head), incorrect insertion of the head, postmaturity.

A clinically narrow pelvis is said to occur when, with the cervix fully dilated, the fetal head does not move through the birth canal. Conditional time the wait for the head to lower in primiparous women is 1-1.5 hours, in multiparous women - up to 1 hour, although this primarily depends on the condition of the mother and fetus.

In the presence of a clinically narrow pelvis, expectant management of labor is abandoned and, in the interests of the fetus and mother, they are inclined towards a cesarean section. In some pathological mal-insertions of the head, a functional assessment of the pelvis is not carried out at all, because vaginal delivery is not possible.

It is important to maintain the integrity of the fetal bladder for as long as possible; for this, the woman in labor observes bed rest, lies on the side where the deviated head is located, or where the back of the fetus is facing, which helps to lower and preserve the amniotic fluid.

Childbirth is carried out under constant close monitoring of the condition of the fetus and contractile activity of the uterus using cardiotocographs. Medicines that improve uteroplacental circulation are regularly used.

In order to prevent weakness of labor, vitamins, glucose to increase energy potential, painkillers and antispasmodics are widely used. With the development of weakness of labor, labor intensification is rarely used - with mild degrees of relative clinical discrepancy.

Careful monitoring of the mother's condition, discharge from the birth canal, and urination is carried out. If there is difficulty urinating, urine is removed with a catheter. Vaginal examinations are usually carried out more often: they are mandatory after the rupture of water in order to timely diagnose the prolapse of the umbilical cord loop or a small part of the fetus; they are needed for a functional assessment of the pelvis (insertion of the head, its configuration, movement along the birth canal).

During childbirth in women with a narrow pelvis, perineal dissection is widely used. At the moment of birth of the head or immediately after the birth of the baby, uterine contractions are administered to prevent bleeding.

Pregnant women with an anatomically narrow pelvis are at high risk due to possible complications for mother and fetus. Timely prenatal hospitalization allows you to prevent post-maturity, conduct additional examinations to clarify the shape and degree of pelvic narrowing, and develop optimal tactics for childbirth.

Update: October 2018

A narrow pelvis is rightfully considered one of the most difficult and complex areas in obstetrics, since this pathology is fraught with the development of various complications during childbirth, especially if they are managed incorrectly. According to statistics, anatomical narrowing of the pelvis occurs in 1–7.7%, and during childbirth such a pelvis becomes clinically narrow in 30%. The total number of all births accounts for 1.7% of clinically narrow pelvises.

The concept of “narrow pelvis”

During the pushing period, when the fetus is expelled from the uterus, it must overcome the bony ring of the birth canal, that is, the small pelvis. The pelvis consists of 4 bones: 2 pelvic bones, formed by the iliac, pubic and ischial bones, sacrum and coccyx. These bones contact each other with the help of cartilage and ligaments. In women, the pelvis, unlike in men, is wider and more voluminous, but has less depth. Normal pelvic parameters play an important role in the physiological, without complications, course of childbirth. If there are deviations in the configuration and symmetry of the pelvis and a decrease in size bony pelvis acts as an obstacle to overcoming the fetal head.

In practical terms, a narrow pelvis is divided into 2 types:

• anatomically narrow pelvis, which is characterized by a decrease in one/several dimensions by 2 cm or more;
• a clinically narrow pelvis develops when there is a discrepancy between the size of the child’s head and the anatomical size of the woman’s pelvis during childbirth (but even in the case of anatomical narrowing of the pelvis during childbirth, the occurrence of a functionally narrow pelvis is not always possible, for example, if the fetus is small in size, and vice versa, with normal anatomical indicators pelvis and a large baby, the occurrence of a clinically narrow pelvis is quite likely).

Causes

The reasons for the formation of a narrow pelvis differ in its anatomical narrowing or the occurrence of a disproportion between the size of the baby’s head and the pelvic size of the mother.

Etiology of anatomically narrowed pelvis

The following factors can provoke the formation of an anatomically narrowed pelvis:

• failures in menstrual function, impaired fertility, late onset of menstruation;
• neuroendocrine pathology;
• frequent colds and excessive physical activity in adolescence;
• insufficient nutrition, heavy physical work in childhood.

Anatomical narrowing of the pelvis is caused by the following reasons:

• infantilism, both general and sexual;
• delayed sexual development;
• rickets;
• osteomalacia, bone tuberculosis and bone tumors;
• pelvic bone fractures;
• curvature of the spine (lordosis and kyphosis, scoliosis and coccyx fractures);
• cerebral palsy;
• constitutional features and heredity;
• polio;
• exostoses and pelvic tumors;
• damaging factors in the antenatal period;
• acceleration (rapid growth of the body in length and at the same time a slowdown in the increase in transverse pelvic dimensions);
• stressful situations and psycho-emotional stress, which contribute to the emergence of “compensatory hyperfunction of the body”, which forms a transversely narrowed pelvis;
• classes professional sports(gymnastics, skiing, swimming);
• impaired mineral metabolism;
• hypo- and hyperestrogenism, excess androgens;
• dislocations of the hip joints.

Etiology of a functionally narrow pelvis

Disproportion in labor between the baby's head and the mother's pelvis is caused by:

• anatomical narrowing of the pelvis;
• large size and weight of the fruit;
• difficulties in the configuration of the fetal cranial bones (true post-maturity);
• incorrect position of the unborn baby;
• pathological insertion of the head (asynclitism, frontal insertion, etc.);
• neoplasms of the uterus and ovaries;
• narrowing (atresia) of the vagina;
• presentation with the pelvic end (rare).

Childbirth complicated by a clinically narrow pelvis ends in 9–50% by caesarean section.

Narrow pelvis: varieties

There are many classifications of anatomically narrowed pelvis. Often in the obstetric literature there is a classification based on morphological and radiological characteristics:

Gynecoid type

Makes up 55% of the total number of cans and is normal pelvis female type. The body type of the expectant mother is female, she has a thin neck and waist, and her hips are quite wide, her weight and height are within the average range.

Android pelvis

It occurs in 20% and is a male-type pelvis. A woman has a masculine physique; against the background of broad shoulders and narrow hips, there is a thick neck and an undefined waist.

Anthropoid pelvis

It makes up 22% and is characteristic of primates. This form is distinguished by an increase in the direct size of the entrance and its significant excess in the transverse size. Women with such a pelvis are tall and lean, their shoulders are quite wide, their waist and hips are narrow, and their legs are elongated and thin.

Platypeloid pelvis

Its shape is similar to a flat pelvis, observed in 3% of cases. Women with a similar pelvis are tall and thin, have underdeveloped muscles and reduced skin elasticity.

Narrowed pelvis: forms

Classification of the narrow pelvis proposed by Krassovsky:

Forms that occur frequently

• Generally uniformly contracted pelvis (ORST) is the most common species and is observed in 40 - 50% of all basins;
• transversely narrowed pelvis (Robertovsky);
• flat pelvis, 37%;
  • simple flat (Deventrovxii);
  • flat-rachitic;
  • pelvis with a reduced wide part of the pelvic cavity.

Forms that are rare

• obliquely displaced and obliquely narrowed;
• pelvic deformation due to bone tumors, exostoses and fractures;
• other forms:
  • generally narrowed flat;
  • funnel-shaped;
  • kyphotic form;
  • spondylolisthetic form;
  • osteomalatic;
  • assimilation.

Degrees of narrowing

Classification based on the degree of narrowing proposed by Palmov:

• According to the length of the true conjugate (norm 11 cm) and refers to ORST and flat pelvis:
  • 1 tbsp. – less than 11 cm and not shorter than 9 cm;
  • 2 tbsp. – indicators of true conjugate 9 – 7.5 cm;
  • 3 tbsp. – the length of the true conjugate is 7.5 – 6.5 cm;
  • 4 tbsp. – shorter than 6.5 cm, which is called an “absolutely narrow pelvis.”
• According to the transverse diameter of the entrance to the small pelvis (normal sizes are 12.5 - 13 cm) and refers to the transversely narrowed pelvis:
  • 1 tbsp. – transverse diameter of the inlet in the range of 12.4 – 11.5;
  • 2 tbsp. – the value of the transverse diameter of the entrance is 11.4 – 10.5;
  • 3 tbsp. – transverse diameter is shorter than 10.5.
• According to the direct diameter of the wide part of the pelvic cavity (normally 12.5 cm):
  • 1 tbsp. – diameter 12.4 – 11.5;
  • 2 tbsp. – diameter less than 11.5.

Dimensions of anatomically narrowed pelvis of different shapes

Narrow pelvis: dimensions (table, in cm)

Dimensions Pelvic shape
	normal	transversely narrowed	ORST	flat-rachitic	Simple flat
external	25/26 – 28/29 – 30/31	24 – 26 – 29	24 – 26 – 28	26 – 26 – 31	26 – 29 – 30
External conjugate	20 – 21	20 – 21	18	17	18
Diagonal conjugate	13	13	11	10	11
True conjugate	11	11 – 11,5	9	8	9
Michaelis rhombus:
Vertical diagonal	11	11	Under 11	Less than 9	Less than 9
Horizontal diagonal	10 — 11	Less than 10	Less than 10	Less than 10	Less than 10
Exit plane:
straight	9,5	9,5	Less than 9.5	9,5	Less than 9.5
transverse lateral conjugate
Differential criterion	None	Shortening transverse dimensions	Uniform decrease in all parameters by 1.5 cm or more	Reducing the direct size of the pelvic inlet plane	Reducing the direct dimensions of all planes

Diagnostics

A narrowed pelvis is assessed and diagnosed in the antenatal clinic, on the day the pregnant woman is registered. To identify a narrow pelvis during pregnancy, the doctor examines the anamnesis, conducts an objective examination, which includes anthropometry, examination of the body, palpation of the pelvic bones and uterus, measurement of the pelvis and vaginal examination. If necessary, appointed special methods: X-ray pelvimetry and ultrasound scanning.

Anamnesis

It is very important to pay attention to the diseases and living conditions of a pregnant woman in childhood and adolescence (rickets and poliomyelitis, osteomyelitis and bone tuberculosis, hormonal imbalance, poor nutrition and hard physical work, intense sports activities, injuries and chronic pathology). Obstetric history data are essential:

• how the previous birth proceeded;
• why surgical delivery was performed, whether the newborn had traumatic brain injuries;
• whether there was stillbirth or death of the child in the neonatal period.

Objective research

Anthropometry

Low height (145 cm or less) usually indicates a narrowed pelvis. But narrowing of the pelvis (transversely narrowed) is also possible in tall women.

Evaluated: gait, physique, silhouette

It has been proven that in case of strong protrusion of the abdomen forward, the center of upper half the torso in order to maintain balance, and the lower back moves forward, thereby increasing the lumbar lordosis and the angle of the pelvis.

The shape of the abdomen is assessed

It is known that in a first-time pregnant woman, the elastic abdominal wall and belly take on a pointed shape. In a multiparous woman, the belly is saggy, since the head is not inserted into the entrance of the narrow pelvis at the end of the gestation period, and the uterine fundus stands high, while the uterus itself deviates from the hypochondrium upward and anteriorly.

• Identification of signs of sexual infantilism or virilization.
• Inspection and palpation of the Michaelis rhombus

The Michaelis rhombus consists of the following anatomical structures:

• at the top - bottom line 5 lumbar vertebrae;
• below – the apex of the sacrum;
• on the sides - the posterior upper projections (spines) of the ilium.

Pelvic palpation

When palpating the iliac bones, their slope, contours and location are revealed. By palpating the trochanters (greater trochanters of the femurs), an obliquely displaced pelvis can be diagnosed if they are deformed and stand at different levels.

Vaginal examination

Makes it possible to determine the capacity of the pelvis, examine and evaluate the shape of the sacrum, the depth of the sacral cavity, whether there are bony protrusions, deformation of the lateral pelvic walls, measure the height of the symphysis and the diagonal conjugate.

Pelvis measurement

Basic measurements:

• Distantia spinarum - the segment between the anterior superior projections of the ilium. The norm is 25 – 26 cm.
• Distantia cristarum – the segment between the most remote places crests of the iliac bones. The norm is 28 – 29 cm.
• Distantia trohanterica - the segment between the trochanters of the thigh bones, the norm is 31 - 32 cm.
• External conjugate - the distance is measured that starts from the upper edge of the womb and ends at the upper corner of the Michaelis rhombus. The norm is at least 20 cm.
• Michaelis rhombus measurement (vertical diagonal 11 cm, horizontal diagonal 10 cm). The asymmetry of the diamond indicates a curvature of the pelvis or spinal column.
• Solovyov index - the circumference of the wrist is measured at the level of the prominent condyles of the forearm. Using this index, the thickness of the bones is assessed: a small index indicates thinness of the bones, and, therefore, a greater capacity of the pelvis. The norm is 14.5 – 15 cm.
• Determination of the pubosacral size (the segment is measured from the middle of the symphysis to the point where 2 and 3 join sacral vertebrae). The norm is 21.8 cm.
• The pubic angle is measured (normally 90 degrees).
• The height of the pubic symphysis is determined
• The uterus is measured (OB and VDM) to determine the expected weight of the fetus.

Additional measurements:

• measure the angle of the pelvis;
• measure the pelvic outlet;
• if pelvic asymmetry is suspected, oblique dimensions and lateral Kerner conjugate are determined.

Special research methods

X-ray pelviometry

X-ray examinations are allowed after 37 weeks and during childbirth. With its help, the structure of the pelvic walls, the shape of the inlet, the degree of inclination of the pelvic walls, features of the ischial bones, the severity of the sacral curvature, the shape and size of the pubic arch are determined. This method also makes it possible to find out all the diameters of the pelvis, bone tumors and fractures, the size of the child’s head and its position in relation to the pelvic planes.

Ultrasound

Makes it possible to determine the true conjugate, the location of the head and its size, and evaluate the features of head insertion. Using a transvaginal sensor, all pelvic diameters are determined.

How to calculate true conjugate

The following methods are used:

• subtract 9 from the size of the outer conjugate (normally no less than 11 cm);
• 1.5 - 2 cm is subtracted from the value of the diagonal conjugate (for Solovyov index values ​​of 14 - 16 cm and less, 1.5 is subtracted, in the case of the Solovyov index greater than 16, 2 is subtracted);
• according to the Michaelis diamond: its vertical size corresponds to the indicator of the true conjugate;
• according to X-ray pelviometry;
• according to ultrasound examination of the pelvis.

How is pregnancy progressing?

In the first half of the gestation period, complications with a narrowed pelvis are not observed. The nature of the course of the second half of gestation is affected by the underlying disease, which led to the formation of a narrow pelvis; in addition, extragenital pathology and emerging complications (preeclampsia, intrauterine infection and others). Pregnant girls with a narrow pelvis are characterized by:

• the formation of a pointed abdomen in primiparous women and a saggy abdomen in multiparous women, which provokes asynclitic insertion of the head during childbirth;
• the risk of premature birth increases;
• excessive fetal mobility, which contributes to abnormal fetal positions, breech presentation and extensor presentation;
• pregnancy is often complicated by premature rupture of water due to the lack of a contact belt with a high position of the head;
• high position of the head due to the impossibility of its insertion into the pelvis, which causes a high position of the uterine fundus and diaphragm and leads to increased heart rate, shortness of breath and rapid fatigue.

Management of pregnant women

All expectant mothers with a narrow pelvis are specially registered with an obstetrician-gynecologist. A couple of weeks before giving birth, the woman is hospitalized in the antenatal department as planned, where the gestational age is clarified, the expected weight of the fetus is calculated, the pelvis is re-measured, the position/presentation of the fetus and its condition are clarified, and the issue of choosing a method of delivery is decided (a labor management plan is developed).

The method of delivery is determined based on anamnestic data, anatomical shape narrowing of the pelvis and degree, estimated weight of the child and other complications of gestation. Childbirth by physiological means can be carried out in the case of premature pregnancy, 1st degree of contraction and normal size of the child, a mature cervix and in the absence of a burdened obstetric history.

A planned caesarean section is performed if the following indications are present:

• a combination of 1 - 2 degrees of narrowing and a large fruit, breech presentation, abnormal position of the fetus, post-term pregnancy;
• “old” primiparas, the presence of stillbirth in previous births or complicated births and the birth of a fetus with a birth injury;
• combination of a narrow pelvis and another obstetric pathology which requires surgical delivery;
• 3 – 4 degree of narrowed pelvis (rare today).

Pregnancy and pain in the pelvic bones

Pain in the pelvic bones appears after 20 weeks and is due to various reasons:

Calcium deficiency

The pain is constant and aching, not associated with movement or change in body position. It is recommended to take calcium supplements in combination with vitamin D.

Sprain of the uterine ligaments and divergence of the pelvic bones

How larger sizes uterus, the stronger the tension of the uterine ligaments that hold it, which manifests itself in pain and discomfort when the child walks and moves. This is caused by prolactin and relaxin, under the influence of which the ligaments and pelvic cartilage swell and soften in order to “soften” the passage of the child through the bone ring. To relieve pain, you should wear a bandage.

Divergence of the symphysis pubis

Too much swelling of the symphysis (a rare pathology) is accompanied by bursting pain in the pubis, and it is also impossible to raise a straight leg in horizontal position. This pathology is called symphysitis, which is accompanied by divergence of the symphysis pubis. Effectively surgical treatment which is carried out after childbirth.

Course of labor

Today, the tactics of childbirth with a narrow pelvis provide for a significant increase in the indications for abdominal delivery, both planned and emergency in case of complications. Maintaining birth process through the natural birth canal is a difficult task, since the outcome can be either favorable or unfavorable for the woman and child. In cases of 3-4 degrees of narrowing, the birth of a live and full-term fetus is impossible - a planned operation is performed. If the pelvis is narrowed to degrees 1 and 2, the successful completion of labor depends on the indicators of the child’s head, its ability to be configured, the nature of the insertion of the head and the intensity of labor.

What complications arise with a narrow pelvis during childbirth?

First period

During the period of opening of the uterine pharynx, childbirth can be complicated:

• weakness of generic forces (10 – 38%);
• early discharge of amniotic fluid;
• prolapse of the umbilical cord/small parts of the baby;
• oxygen starvation of the fetus.

Second period

During the period of expulsion of the fetus, the following complications may develop:

• the occurrence of secondary weakness of generic forces;
• intrauterine hypoxia;
• threat of uterine rupture;
• necrosis of tissues of the birth canal with the formation of fistulas;
• damage to the symphysis pubis;
• damage to the pelvic nerve plexuses.

Third period

The last stage of labor, as well as the early postpartum period, are fraught with bleeding due to long course childbirth and anhydrous interval.

Management of childbirth

Today, the most reasonable tactic for childbirth with the described pathology is recognized as active expectant. Moreover, the tactics of childbirth should be individual and take into account not only the results objective research women in labor, the degree of pelvic narrowing, but also the prognosis for the woman and child. The completed birth plan should include the following items:

• bed rest, which prevents early release of water (the woman’s position should be on the side to which the back of the fetus is adjacent);
• prevention of weakness of labor forces;
• prevention of intrauterine starvation of the fetus;
• prevention of infectious complications;
• identifying signs of clinical inconsistency;
• preventive measures for subsequent and early postpartum hemorrhage;
• performing a cesarean section (if indicated) with a living fetus;
• fetal destruction surgery in case of fetal death.

During childbirth, discharge from the genital tract (mucous, leaking water or bloody), the condition of the vulva (swelling), and urination are monitored. In case of urinary retention, catheterization of the bladder is performed, but it should be remembered that this sign may also indicate a disproportion between the pelvic sizes of the woman in labor and the baby’s head.

The most common complication of childbirth with a narrowed pelvis is premature rupture of water. If an “immature” cervix is ​​detected, then surgical delivery is performed. In the case of a “mature” cervix, labor induction is indicated (if the estimated weight of the fetus is not more than 3600 grams and there is 1 degree of narrowing).

During the period of contractions, to prevent their weakness, an energy background is created, and the woman in labor is provided with medicated sleep and rest in a timely manner. In the process of assessing the effectiveness of labor, the doctor must monitor not only the dynamics of cervical dilatation, but also how the head moves through the birth canal.

Labor stimulation should be carried out with caution, and its duration should not exceed 3 hours (if there is no effect, a caesarean section is performed). In addition, in the first period, antispasmodics are necessarily administered (every 4 hours), Nikolaev’s triad is performed (prevention of hypoxia) and antibiotics are prescribed for an increasing anhydrous interval.

The period of expulsion is complicated by the development of secondary weakness, intrauterine hypoxia of the baby, and prolonged standing of the baby's head in the birth canal provokes the formation of fistulas. Therefore, an episiotomy is performed and the bladder is emptied in a timely manner.

Disproportion of the head and pelvis of a woman in labor

The occurrence of a clinically narrow pelvis is mainly promoted by:

• slight degree of narrowing and large baby;
• unsuccessful insertion of the head or incorrect presentation of the fetus;
• large fetal head with normal pelvic dimensions;
• abnormal forms of narrowing of the pelvis.

During childbirth, a functional assessment of the pelvis is required, which includes:

• determination of the characteristics of the insertion and assessment of the biomechanism of labor in case of identified insertion;
• head configuration is assessed;
• diagnosis of birth tumor soft tissues head, the speed of its appearance and growth;
• identification of signs of Vasten and Zangheimester (assessed after the rupture of water).

The signs of a clinically narrow pelvis are as follows:

• the biomechanism of childbirth is disrupted, that is, it does not respond this species narrowing of the pelvis;
• the fetal head does not move forward, although the uterine os is fully dilated, the waters have broken, and the contractions are of sufficient strength;
• the appearance of attempts when the baby’s head is pressed to the entrance to the pelvis;
• symptoms of compression of soft tissues and urinary tract (swelling of the cervix and vulva, urination is delayed, blood is detected in the urine);
• positive signs of Vasten, Zangheimester;
• a clinic for the threat of uterine rupture appears;
• protracted course of the first period;
• significant head configuration;
• early or premature rupture of water.

Vasten's sign is determined by touch (the relationship between the baby's head and the inlet of the pelvis is determined). A negative sign of Vasten is a condition when the head is inserted into the small pelvis, located below the pubic symphysis (the doctor’s palm has dropped below the pubis). Level symptom - the obstetrician’s palm lies at the level of the womb (the head and symphysis are in the same plane). A positive sign is that the doctor’s palm is located above the symphysis (the head is higher than the pubis). In the case of a negative sign, labor ends on its own (the head and pelvic dimensions correspond to each other). If the symptom is level, spontaneous childbirth is possible, provided that labor is effective and the head is adequately configured. If the sign is positive, independent childbirth is impossible.

Kalganova proposed to distinguish 3 degrees of discrepancy between the pelvic dimensions and the baby’s head:

1 tbsp. or relative disparity

Correct insertion of the head and its good configuration are noted. The contractions are of sufficient strength and duration, but the dilation of the cervix and the advancement of the head are slowed down, in addition, the water does not leave in a timely manner. Urination is difficult, but Vasten's sign is negative. It is possible to complete labor on your own.

2 tbsp. or significant discrepancy

The biomechanism of labor and the insertion of the head do not correspond to normal, the head is sharply configured and stands in the same plane for a long time. Anomalies of labor forces (discoordination or weakness), urinary retention are added. Vasten's sign is level.

3 tbsp. or absolute inconsistency

Attempts appear prematurely against the background of a lack of forward movement of the head, despite good contractions and full opening. The birth tumor is rapidly growing, there are signs of compression of the urethra, and a clinical picture of the threat of uterine rupture appears. A positive Vasten sign is diagnosed.

The second and third degrees of discrepancy serve as an indication for immediate surgical delivery.

Case Study

A 20-year-old primiparous woman was admitted to the maternity ward with complaints of contractions lasting 2 hours. There was no outpouring of water. The condition of the woman in labor is satisfactory, pelvic dimensions: 24.5 – 26 – 29 – 20, coolant - 103 cm, height of the uterine fundus 39 cm. The fetus is located longitudinally, the head is pressed to the entrance. Auscultation: the fetal heartbeat is clear and does not suffer. Contractions of good strength and duration. The estimated weight of the child is 4000 g.

A vaginal examination revealed: the cervix is ​​smoothed, has thin and stretchable edges, dilation is 4 cm. The fluid is intact, the amniotic sac is functioning. The head is pressed to the entrance. The cape is not accessible. Diagnosis: Pregnancy 38 weeks. 1 period 1 first urgent birth. Large fruit. Transversely narrowed pelvis of the 1st degree.

After 6 hours of active contractions, a second vaginal examination was performed: the cervix is ​​dilated to 6 cm, there is no amniotic sac. The head is pressed to the entrance by a sagittal suture in a straight size, the small fontanel anterior.

Diagnosis: Pregnancy 38 weeks. 1st period of 1st term birth. Transversely narrowed pelvis of the 1st degree. Large fruit. High straight position of the swept seam.

It was decided to finish the birth operationally(incorrect insertion, narrowing of the pelvis, large fetus). The caesarean section went without complications, and a fetus weighing 4300 grams was extracted.