Narrow pelvis in pregnant women. Complications for the fetus during childbirth

Despite the fact that recently gross deformations of the pelvis and high degrees of narrowing are rare, the problem of a narrow pelvis has not lost its relevance today - due to the acceleration and increase in body weight of newborns.

Causes

The causes of narrowing or deformation of the pelvis can be:

congenital anomalies pelvis,
malnutrition in childhood,
diseases suffered in childhood: rickets, polio, etc.
diseases or damage to the bones and joints of the pelvis: fractures, tumors, tuberculosis.
spinal deformities (kyphosis, scoliosis, coccyx deformity).
One of the factors in the formation of a transversely narrowed pelvis is acceleration, which during puberty leads to rapid growth of the body in length while the growth of transverse dimensions lags.

Kinds

Anatomically narrow A pelvis is considered to be one in which at least one of the main dimensions (see below) is 1.5-2 cm or more smaller than normal.

However, it is not the size of the pelvis that is most important, but the ratio of these sizes to the size of the fetal head. If the fetal head is small, then even with some narrowing of the pelvis there may not be a discrepancy between it and the head of the born child, and childbirth occurs naturally without any complications. In such cases, an anatomically narrowed pelvis turns out to be functionally sufficient.

Complications during childbirth can also occur with normal pelvic sizes - in cases where the fetal head is larger than pelvic ring. In such cases, the advancement of the head along the birth canal is suspended: the pelvis practically turns out to be narrow and functionally insufficient. Therefore, there is such a thing as clinically (or functionally) narrow pelvis. A clinically narrow pelvis is an indication for cesarean section during childbirth.

A true anatomically narrow pelvis occurs in 5-7% of women. The diagnosis of a clinically narrow pelvis is established only during childbirth based on a combination of signs that make it possible to identify the disproportion between the pelvis and the head. This type of pathology occurs in 1-2% of all births.

How is the pelvis measured?

In obstetrics, examination of the pelvis is very important, since its structure and dimensions have crucial for the course and outcome of childbirth. The presence of a normal pelvis is one of the main conditions correct flow childbirth

Deviations in the structure of the pelvis, especially a decrease in its size, complicate the course of natural birth, and sometimes present insurmountable obstacles for them. Therefore, when registering a pregnant woman with an antenatal clinic and upon admission to the maternity hospital, in addition to other examinations, the external dimensions of the pelvis must be measured. Knowing the shape and size of the pelvis, it is possible to predict the course of labor, possible complications, make a decision about the admissibility of spontaneous childbirth.

A pelvic examination includes examining, palpating the bones and determining the size of the pelvis.

In a standing position, the so-called lumbosacral rhombus, or Michaelis rhombus, is examined (Fig. 1). Fine vertical size The rhombus is on average 11 cm, the transverse one is 10 cm. If the structure of the small pelvis is disturbed, the lumbosacral rhombus is not clearly expressed, its shape and size are changed.

After palpating the pelvic bones, it is measured using a pelvis meter (see Fig. 2a and b).

Main dimensions of the pelvis:

Interspinous size. The distance between the superior anterior iliac spines (in Fig. 2a) is normally 25-26 cm.
The distance between the most distant points of the iliac crests (in Fig. 2a) is 28-29 cm, between the greater trochanters of the femurs (in Fig. 2a) - 30-31 cm.
External conjugate - the distance between the suprasacral fossa (upper corner of the Michaelis rhombus) and the upper edge of the pubic symphysis (Fig. 2b) - 20-21 cm.

The first two sizes are measured with the woman lying on her back with her legs extended and brought together; the third size is measured with the legs shifted and slightly bent. The external conjugate is measured with the woman lying on her side with the hip and hip flexed. knee joints the underlying leg and the extended overlying one.

Some pelvic dimensions are determined during vaginal examination.

When determining the size of the pelvis, it is necessary to take into account the thickness of its bones; it is judged by the value of the so-called Solovyov index - circumference wrist joint. average value index 14 cm. If the Solovyov index is more than 14 cm, it can be assumed that the pelvic bones are massive and the size of the small pelvis is smaller than expected.

If it is necessary to obtain additional data on the size of the pelvis, its correspondence to the size of the fetal head, deformation of the bones and their joints, an X-ray examination of the pelvis is performed. But it is performed only according to strict indications. The size of the pelvis and its correspondence to the size of the head can also be judged from the results of an ultrasound examination.

The influence of a narrow pelvis on the course of pregnancy and childbirth

Adverse influence a narrowed pelvis affects the course of pregnancy only in its last months. The fetal head does not descend into the pelvis, the growing uterus rises and makes breathing much more difficult. Therefore, at the end of pregnancy, shortness of breath appears early, it is more pronounced than during pregnancy with a normal pelvis.

In addition, a narrow pelvis often leads to an abnormal position of the fetus - transverse or oblique. 25% of women in labor with a transverse or oblique position of the fetus usually have a pronounced narrowing of the pelvis to one degree or another. Breech presentation of the fetus in women in labor with a narrowed pelvis occurs three times more often than in women in labor with a normal pelvis.

Management of pregnancy and childbirth with a narrow pelvis

Pregnant women with a narrow pelvis are at high risk for the development of complications, and should be specially registered at the antenatal clinic. Timely detection of fetal position abnormalities and other complications is necessary. It is important to accurately determine the due date in order to prevent post-term pregnancy, which is especially unfavorable with a narrow pelvis. 1-2 weeks before birth, pregnant women with a narrow pelvis are recommended to be hospitalized in the pathology department to clarify the diagnosis and choose a rational method of delivery.

The course of labor with a narrow pelvis depends on the degree of narrowing of the pelvis. With slight narrowing, medium and small fetal sizes are possible vaginal birth. During childbirth, the doctor carefully monitors the function the most important organs, the nature of labor forces, the condition of the fetus and the degree of correspondence between the fetal head and the pelvis of the woman in labor and, if necessary, promptly resolves the issue of caesarean section.

Absolute indications for caesarean section are:

anatomically narrow pelvis III-IV degrees narrowing;
the presence of bone tumors in the pelvis that impede the passage of the fetus;
severe deformations of the pelvis as a result of injury or illness;
ruptures of the symphysis pubis or other pelvic injuries that occurred during previous births.

In addition, the indication for caesarean section is a combination of a narrow pelvis with:

large fruit size,
post-term pregnancy,
chronic fetal hypoxia,
breech,
abnormal development of the genital organs,
scar on the uterus after cesarean section and other operations,
indication of a history of infertility,
the age of the primigravida is over 30 years, etc.

Caesarean section is performed at the end of pregnancy before or with the onset of labor.

The main indicator of narrowing of the pelvis is considered to be the size of the true conjugate: if it is less than 11 cm, then the pelvis is considered narrow

Complications during childbirth occur when the fetal head is disproportionately larger than the pelvic ring, which is sometimes observed with a normal pelvic size. In such cases, even with good labor activity, the advancement of the head along the birth canal may stop: the pelvis practically turns out to be narrow and functionally insufficient. If the fetal head is small, then even with a significant narrowing of the pelvis, there may be no discrepancy between the head and the pelvis, and childbirth occurs naturally without any complications. In such cases, an anatomically narrowed pelvis turns out to be functionally sufficient.

Thus, there is a need to distinguish between two concepts: an anatomically narrow pelvis and a functionally narrow pelvis.

Functionally, or clinically, a narrow pelvis means a discrepancy (disproportion) between the fetal head and the mother's pelvis. In the literature, the terms “pelvic disproportion”, “pelvic dystocia”, “inadequate (clinically narrow) pelvis”, cephalopelvic disproportion, etc. are found.

Anatomically narrow pelvis occurs in 1.04-7.7% of cases. This scatter of indicators is explained by the lack of a unified classification of narrow pelvises and different diagnostic capabilities.

Causes. There are many reasons for the development of a narrow pelvis: malnutrition in childhood, rickets, childhood cerebral paralysis(cerebral palsy), poliomyelitis, etc. Pelvic deformities are caused by diseases or damage to the bones and joints of the pelvis (rickets, osteomalacia, fractures, tumors, tuberculosis, congenital anomalies of the pelvis).

Pelvic abnormalities also occur as a result of spinal deformation (kyphosis, scoliosis, spondylolisthesis, coccyx deformity). Narrowing of the pelvis can be caused by diseases or deformities lower limbs(diseases and dislocation of the hip joints, atrophy and absence of legs, etc.).

Pelvic deformations are also possible as a result of damage from car and other accidents, earthquakes, etc.

During puberty, the formation of the pelvis occurs under the influence of estrogens and androgens. Estrogens stimulate the growth of the pelvis in transverse dimensions and its maturation (ossification), and androgens stimulate the growth of the skeleton and pelvis in length. One of the factors in the formation of a transversely narrowed pelvis is acceleration, leading to rapid growth of the body in length during puberty, when the increase in transverse dimensions is slowed down.

Significant psycho-emotional stress, stressful situations, taking hormones to block menstruation during intense sports (gymnastics, figure skating etc.) cause “compensatory hyperfunction of the body” in many girls, which ultimately contributes to the formation of a transversely narrowed pelvis (resembling a male one).

In modern conditions, there has been a decrease in the number of women with an anatomically narrow pelvis and its various forms. So, if in the past the most common were generally narrowed and various types of flat pelvis, now these pathological forms are less common, and pelvis with reduced transverse dimensions are more often detected. In second place in terms of prevalence is a pelvis with a reduced size of the wide part of the pelvic cavity.

Currently, there is an increase in the percentage of so-called erased forms of a narrow pelvis, the diagnosis of which presents significant difficulties.

Classification. Unified classification There are no forms of anatomically narrow pelvis. The classification is based either on an etiological principle or on the basis of an assessment of an anatomically narrow pelvis in terms of shape and degree of narrowing.

In our country, a classification is usually used based on the shape and degree of narrowing. In addition, there are often and rarely occurring forms of a narrow pelvis.

A. Relatively common forms of a narrow pelvis:

2. Flat pelvis:

A) simple flat pelvis;

B) flat-rachitic pelvis;

B) pelvis with a decrease in the direct size of the wide part of the cavity.

3. Generally uniformly narrowed pelvis.

B. Rarely occurring forms of a narrow pelvis:

1. Oblique and oblique pelvis.

2. Pelvis narrowed by exostoses, bone tumors due to displaced pelvic fractures.

3. Other pelvic shapes.

The Caldwell-Moloy (1933) classification is widely used abroad, taking into account the structural features of the pelvis (Fig. 17.1):

1) gynecoid ( female type pelvis);

2) android ( male type);

3) anthropoid (characteristic of primates);

4) platipeloid (flat).

In addition to the indicated four “pure” forms of the pelvis, there are 14 options “ mixed forms". This classification implies the characteristics of the anterior and posterior segments of the pelvis, which play an important role in the mechanism of labor. The plane passing through the largest transverse diameter of the pelvic inlet and the posterior edge of the ischial spines divides the pelvis into anterior and posterior segments. For different forms pelvis, the size and shape of these segments are different (see Fig. 17.1). Thus, with the gynecoid form, the posterior segment is larger than the anterior one, and its contours are rounded, the shape of the entrance to the pelvis is transverse-oval. With an anthropoid pelvis, the anterior segment is narrow, long, rounded, and the posterior segment is long, but less narrow, the shape of the entrance is longitudinal-oval. With an android pelvis, the anterior segment is also narrow, and the posterior segment is wide and flat. The shape of the entrance resembles a heart. With a platypelloid pelvis, the anterior and posterior segments are wide and flat. The entrance shape is elongated, transversely oval.

1 - gynecoid; 2 - anthropoid; 3 - android; 4 - platipeloid. A line passing through the widest part of the entrance to the pelvis divides it into anterior - anterior (A) and posterior - posterior (P) segments.

In the classification of anatomically narrow pelvises, not only structural features are important, but also the degree of narrowing of the pelvis, based on the size of the true conjugate. In this case, it is customary to distinguish between four degrees of narrowing of the pelvis:

I - true conjugate less than 11 cm and more than 9 cm;

II - true conjugate less than 9 cm and more than 7.5 cm;

III - true conjugate less than 7.5 cm and more than 6.5 cm;

IV - true conjugate less than 6.5 cm.

Pelvic narrowing of degrees III and IV usually does not occur in practice.

The modern foreign manual "Williams Obstetrics" (1997) provides the following classification of narrow pelvises:

1. Narrowing of the entrance to the pelvis.

2. Narrowing of the pelvic cavity.

3. Narrowing of the pelvic outlet.

4. General narrowing of the pelvis (combination of all narrowings).

Foreign authors consider the entrance to the pelvis as narrowed if the direct dimension is less than 10 cm, the transverse dimension is less than 12 cm and the diagonal conjugate is less than 11.5 cm. A condition in which the pelvic cavity (narrow part) with an interspinous dimension of less than 10 cm should be considered as a suspicion of a narrow pelvis, and less than 8 cm - as a narrow pelvis. Narrowing of the pelvic cavity can only be determined with pelvimetry. Narrowing of the pelvic outlet should be considered if the size between the ischial tuberosities is less than 8 cm. Narrowing of the pelvic outlet without narrowing of the cavity is rare.

Transversely narrowed pelvis (Fig. 17.2). It is characterized by a decrease in the transverse dimensions of the small pelvis by 0.6-1.0 cm or more, a relative shortening or increase in the direct size of the inlet and the narrow part of the pelvic cavity, and no changes in size between the ischial tuberosities. The entrance to the small pelvis has a round or longitudinal oval shape. The transversely narrowed pelvis is also characterized by other anatomical features: small spread of the wings iliac bones and a narrow pubic arch. This pelvis resembles a male pelvis and is often observed in women with hyperandrogenism.

Based on the size of the transverse diameter of the inlet, three degrees of narrowing of the transversely narrowed pelvis are distinguished.

I - 12.4-11.5 cm;

II - 11.4-10.5 cm;

III - less than 10.5 cm.

In the diagnosis of a transversely narrowed pelvis, the greatest importance is to determine the transverse diameter of the sacral rhombus (less than 10 cm) and the transverse diameter of the pelvic outlet (less than 10.5 cm). During vaginal examination, convergence of the ischial spines and an acute pubic angle are noted. Accurate diagnosis of this shape of the pelvis and especially the degree of its narrowing is possible only with the use of X-ray pelvimetry, computer X-ray pelvimetry, and magnetic resonance imaging.

Flat pelvis. In a flat pelvis, straight diameters are shortened with the usual values of transverse and oblique diameters. In this case, there are three types of flat pelvis:

Simple flat basin;

Flat-rachitic pelvis;

Pelvis with a decrease in the direct diameter of the wide part of the cavity.

Simple flat basin (Fig. 17.3). It is characterized by a deeper retraction of the sacrum into the pelvis without changing the shape and curvature of the sacrum; As a result, the sacrum is moved closer than usual to the anterior wall of the pelvis and all direct dimensions of both the inlet and the cavity and outlet are moderately shortened. The curvature of the sacrum is average, the pubic arch is wide, cross dimension the entrance to the pelvis is usually enlarged. Women with a simple flat pelvis have a regular physique. With external pelvic measurement, the transverse dimensions of the pelvis are normal, and the external conjugate is reduced. Vaginal examination reveals a decrease in the diagonal conjugate.

Flat-rachitic pelvis. It differs sharply in its structure from normal (Fig. 17.4, a, b). It is a consequence of children suffering from rickets. With this disease, the ossification of the wide cartilaginous layers separating individual bone areas slows down; the cartilaginous layers thicken significantly. The amount of lime in the bones decreases. In this regard, the pressure of the spine on the pelvis and the tension of the muscular-ligamentous apparatus lead to deformation of the pelvis.

A - front view, b - sagittal section along the line of the direct size of the entrance to the pelvis.

The flat-rachitic pelvis is distinguished by the following features:

The direct size of the entrance to the pelvis is significantly shortened as a result of the deep retraction of the sacrum into the pelvis - the promontory protrudes into the pelvic cavity much more sharply than in a normal pelvis;

Sometimes a second “false” cape is observed;

The sacrum is flattened and rotated posteriorly around an axis passing across the lumbosacral joint;

The apex of the sacrum is further away from the lower edge of the articulation than in a normal pelvis;

The coccyx is often pulled in by the ischiosacral ligaments along with the last sacral vertebra anteriorly (hooked forward) (see Fig. 17.4, b).

The shape of the iliac bones changes: poorly developed, flat wings; deployed ridges due to significant wedging of the sacrum into the pelvis. The difference between distantia spinarum and distantia cristarum is either less compared to the normal pelvis, or they are equal to one another; with pronounced changes, the distance between the outer-superior spines is greater than between the scallops. The pubic arch is flatter than in a normal pelvis. The wire axis of the pelvis is not a regular arc, as is normal, but a broken line. The large and small pelvis are deformed; The direct size of the entrance is especially shortened with its normal transverse size; the promontory strongly protruding into the pelvic cavity gives the entrance plane a kidney-shaped shape; the remaining anteroposterior dimensions of the pelvic cavity are normal or enlarged; the exit dimensions are larger than usual; in some cases, the direct size of the exit is shortened due to the sharp protrusion of the coccyx at a right angle along with the last sacral vertebra.

A - front view; b - sagittal section along the line of the direct size of the entrance to the pelvis.

When diagnosing this form of the pelvis, one should pay attention to signs of rickets suffered in childhood ("square head", curvature of the legs, spine, sternum, etc.), a decrease in the vertical size of the sacral rhombus and a change in its shape (Fig. 17.5). During vaginal examination, the promontory is reachable, the sacrum is flattened and deviated posteriorly, sometimes a false promontory is identified, and the direct size of the outlet is increased.

A pelvis with a decrease in the direct size of the wide part of the pelvic cavity is characterized by flattening of the sacrum, up to the absence of curvature, an increase in its length, a decrease in the direct size of the wide part of the cavity (less than 12 cm), and the absence of a difference between the direct sizes of the inlet, the wide and narrow part of the cavity. Other sizes are usually normal or enlarged. Two degrees of narrowing should be distinguished: I degree - the direct size of the wide part of the pelvic cavity is 12.4-11.5 cm and II - the size of the cavity is less than 11.5 cm

Rice. 17.5.

; 4 - oblique.

Rice. 17.6. Generally uniformly narrowed Fig. 17.7..

To diagnose a narrow pelvis with a decrease in the direct size of the wide part of the cavity, it is informative to measure the pubosacral size - the distance from the middle of the symphysis to the place of articulation between the II and III sacral vertebrae. For an anatomically normal pelvis, the pubosacral size is 21.8 cm. A size of less than 20.5 cm indicates the presence of a narrow pelvis, and less than 19.3 cm is the basis for the assumption that there is a pronounced decrease in the direct diameter of the wide part of the pelvic cavity (less than 11.5 cm). A high correlation of the indicated pubosacral size with the size of the external conjugate was revealed.

Generally uniformly narrowed pelvis (Fig. 17.6). It is characterized by a decrease by the same amount in all dimensions of the pelvis (straight, transverse, oblique) by 1.5-2.0 cm or more.

With this type of pelvis, the sacral cavity is pronounced, the entrance to the pelvis is oval, the promontory is reached, and the pubic arch is reduced.

This type of pelvis is observed in women of small stature and regular physique. In the majority of such women, a uniformly narrowed pelvis is one of the manifestations of general infantilism that arose in childhood and during puberty. The bones of the pelvis, like the bones of the entire skeleton, are usually thin, so the pelvic cavity is quite spacious, despite the shortened external dimensions.

Diagnosis is based on data from external pelvimetry and vaginal examination. In table Figure 17.1 presents approximate data on the external dimensions of the main forms of a narrow pelvis. Oblique (asymmetrical) pelvis (Fig. 17.7) Occurs after rickets and gonitis suffered in childhood, dislocation of the hip joint or improperly healed fracture of the femur or leg bones. With these diseases and the consequences of injuries, the patient steps on the healthy leg, and the torso finds support in the healthy hip joint. Gradually, the pelvic area corresponding to the healthy hip (knee) joint is pressed inward; half of the pelvis on the side of the healthy leg becomes narrower.

Table 17.1.

Rare forms of narrow pelvis

The cause of a constricted pelvis can also be scoliosis, in which the weight of the body on the limbs is distributed unevenly, as a result of which the acetabulum on the healthy side is depressed and the pelvis is deformed.

A constricted pelvis does not always impede the course of labor, since the narrowing is usually small. The narrowing of one side is compensated by the fact that the other is relatively spacious.

It is noteworthy that women in labor who have such a pelvis experience during childbirth a desire to take one or another position, which usually turns out to be the most advantageous in each specific situation.

Assimilation (“long”) pelvis. It is characterized by an increase in the height of the sacrum due to its fusion with the V lumbar vertebra (“sacralization”, “assimilation”). In this case, the direct dimensions of the pelvic cavity decrease, which can serve as an obstacle to the passage of the head through the birth canal

Funnel-shaped pelvis. Rarely encountered; its occurrence is associated with impaired development of the pelvis due to endocrine disorders. A funnel pelvis is characterized by a narrowing of the pelvic outlet. The degree of narrowing increases from top to bottom, as a result of which the pelvic cavity takes on the appearance of a funnel, tapering towards the exit.

The sacrum is elongated, the pubic arch is narrow, the transverse size of the outlet can be significantly narrowed. Childbirth can end on its own if the fetus is small and the narrowing of the pelvic outlet is not pronounced

Kyphotic pelvis Belongs to the funnel-shaped pelvis Kyphosis of the spine most often occurs as a result of tuberculous spondylitis suffered in childhood, less often rickets When a hump occurs in lower section spine, the center of gravity of the body shifts anteriorly, top part the sacrum is displaced posteriorly, the true conjugate increases, the transverse size may remain normal, the entrance to the pelvis takes on a longitudinal oval shape. The transverse size of the pelvic outlet decreases due to the convergence of the ischial tuberosities, the pubic angle is acute, the pelvic cavity narrows funnel-shaped towards the outlet. Childbirth with kyphosis often proceeds normally , if the hump is located in the upper part of the spine. The lower the hump is located and the more pronounced the pelvic deformity, the worse the prognosis for childbirth.

Spondylolisthetic pelvis This rare form of the pelvis is formed as a result of the Ly body slipping from the base of the sacrum. In the case of mild slippage, Ly protrudes only slightly above the edge of the sacrum. In complete slippage bottom surface body lumbar vertebra covers the anterior surface of Sj and prevents the lowering of the presenting part into the small pelvis The narrowest size of the entrance is not the true conjugate, but the distance from the symphysis to the protruding part into the pelvis Ly The prognosis of labor depends on the degree of slipping of the vertebra and the narrowing of the direct size of the entrance to the pelvis

Osteomalactic pelvis (Fig. 178) This pathology practically does not occur in our country. Osteomalacia is characterized by softening of the bones due to decalcification of bone tissue. The pelvis is sharply deformed; with severe deformation, a collapsed pelvis is formed. The literature describes a deformation of the pelvis, characterized by a sharp transverse narrowing due to underdevelopment of the wings of the sacrum (“Robert’s pelvis")

Pelvis narrowed by exostoses and bone tumors Exostoses and bone tumors in the pelvic area are observed very rarely Exostoses can be located in the symphysis, sacral promontory and other places Tumors arising from bones and cartilage (osteosarcomas) can occupy a significant part of the pelvic cavity With significant exostoses obstructing the advancement of the presenting part of the fetus, a cesarean section is indicated. In the presence of tumors, surgical delivery and subsequent special treatment are also indicated.

Diagnosis of a narrow pelvis is carried out on the basis of anamnesis, external examination, objective research(external pelvimetry, vaginal examination) If possible and according to indications (impossibility of assessing the size of the pelvic cavity) are used additional methods Ultrasound studies, X-ray pelvimetry, computed tomographic pelvimetry, magnetic resonance imaging

When collecting anamnesis, attention should be paid to the presence of rickets suffered in childhood, traumatic injuries pelvic bones, complicated course and unfavorable outcome of previous births, surgical delivery (obstetric forceps, vacuum extraction of the fetus, cesarean section), stillbirth, traumatic brain injury in newborns, impaired neurological status in the early neonatal period, early infant mortality

External inspection is carried out first in vertical position women First of all, determine body weight and height. Height of 150 cm and below with certain certainty indicates an anatomical narrowing of the pelvis

During the examination, special attention is paid to the structure of the skeleton - traces of past diseases in which changes in bones and joints are observed (rickets, tuberculosis, etc.) The condition of the skull is studied (whether it has square shape), spine (scoliosis, kyphosis, lordosis), limbs (saber-shaped curvature of the legs, shortening of one leg), joints (ankylosis in the hip, knee and other joints), gait (a waddling “duck” gait indicates excessive mobility of the joints pelvic bones) etc. Find out whether the abdomen has a pointed shape, as if pointed upward in primiparous women, or drooping in multiparous women (Fig. 179), which is typical at the end of pregnancy for women with a narrowed pelvis

Rice. 17.9.

a - in a primigravida (pointed belly), b -

In an upright position, the examinee has an idea of the angle of inclination of the pelvis, the exact determination of which is possible using a pelvic angle gauge (goniometer). For practical purposes, indicative data obtained by simple examination are sufficient. When the angle of inclination of the pelvis exceeds 55°, the sacrum, buttocks and external genitalia are deviated posteriorly , there is pronounced lordosis of the lumbar spine, internal surfaces thighs do not touch each other completely. With a lower pelvic inclination angle (less than 55°), the sacrum is vertical, the symphysis pubis is raised up, the external genitalia protrude forward, there is no lordosis of the lumbar spine, and the inner surfaces of the thighs are in close contact with each other. By the degree of change in the angle of inclination of the pelvis in different positions of the pregnant woman, one can judge the mobility of the joints of the pelvis.

The shape of the sacral diamond is of great importance for assessing the pelvis. It is clearly visible if the woman’s naked back is viewed from the side.

In infantile women with a generally uniformly narrowed pelvis, the longitudinal and transverse dimensions of the rhombus are proportionally reduced.

The wider the sacrum, and therefore the larger the transverse dimensions of the pelvic cavity, the further the lateral fossae of the sacral rhombus are spaced from each other. As the transverse dimensions decrease, the distance between the lateral fossae becomes closer.

As the anteroposterior size decreases (pelvic flattening), the distance between the upper and lower corners of the diamond decreases.

With significant flattening of the pelvis, the base of the sacrum moves forward and the spinous process of the last lumbar vertebra appears at the level of the lateral fossae, as a result of which the rhombus takes the shape of a triangle, the base of which is the line connecting the lateral fossae, and the sides are the converging lines of the buttocks. With severe deformations of the pelvis, the rhombus has irregular outlines, which depend on the structural features of the pelvis and its size.

With an external obstetric examination, one can assume a narrowing of the pelvis in a situation where a high (above the entrance) position of the head of a primigravida is determined ("moving head") or when it is deviated from the entrance to the pelvis in one direction or another, which is observed with oblique and transverse fetal position.

Important information about the size of the pelvis can be obtained from external pelvimetry, although a correlation between the sizes of the large and small pelvis is not always revealed. In addition to measurements of d.spinarum, d.cristarum, d.trochanterica, conjugata externa, the lateral conjugates should be determined - the distance between the anterior and posterosuperior iliac spines on each side (normally they are 14-15 cm). Reducing them to 13 cm indicates a narrowing of the pelvis. At the same time, oblique dimensions are measured:

1) the distance from the anterosuperior spine of one side to the posterosuperior spine of the other side (normally equal to 22.5 cm);

2) the distance from the middle of the symphysis to the posterosuperior spines of the right and left iliac bones;

3) the distance from the suprasacral fossa to the anterosuperior spines on the right and left. The difference between the right and left sizes indicates asymmetry of the pelvis.

Determining the size of the pelvic outlet: direct and transverse is also important in assessing the pelvis and prognosis of childbirth.

To correctly judge the size of the true conjugate based on the diagonal conjugate data, it is necessary to take into account the height of the symphysis pubis (normally 4-5 cm). Pelvic capacity in to a large extent depends on the thickness of the pelvic bones. When the circumference of the wrist joint increases above 16 cm, one should assume a greater thickness of the pelvic bones and, consequently, a decrease in the capacity of the small pelvis.

Vaginal examination is important, during which the relief of the inner surface of the pelvis should be examined in detail. Pay attention to the capacity of the pelvis (wide, narrowed pelvis), the condition of the sacrum (concave, characteristic of a normal pelvis; flat and bent posteriorly along the axis running through the articulation between the V lumbar and I sacral vertebrae in a rachitic pelvis), the presence of a coracoid or double promontory , the condition of the coccyx (the degree of its mobility, whether it is hooked anteriorly), the condition of the pubic arch (the presence of protrusions, spines and growths on the inner surface of the pubic bones, the height and curvature of the pubic arch, how narrow is the notch formed by the descending branches of the pubic bones), the condition pubic symphysis (the density of the junction of the pubic bones with each other, the mobility and width of the pubic symphysis, the presence of a dense growth on it), etc.

The main indicator of the degree of narrowing of the pelvis is the value of the true conjugate. In all cases when this is not prevented by the presenting part of the fetus descending into the pelvic cavity, it is necessary to measure the diagonal conjugate and, subtracting 1.5-2 cm, determine the length of the true conjugate.

X-ray pelvimetry allows you to determine the direct and transverse dimensions of the small pelvis in all planes, the shape and inclination of the pelvic walls, the degree of curvature and inclination of the sacrum, the shape of the pubic arch, the width of the symphysis, exostoses, deformations, the size of the fetal head, features of its structure (hydrocephalus), configuration, position heads in relation to the planes of the pelvis, etc. Modern domestic x-ray equipment (digital scanning x-ray installation) allows a 20-40-fold reduction in radiation exposure compared to film x-ray pelvimetry.

An ultrasound examination is less informative than a radiographic examination, since transabdominal scanning can only determine true conjugate, as well as the location of the fetal head, its size, features of insertion, and during childbirth - the degree of dilatation of the cervix.

Transvaginal echography allows you to measure the direct and transverse dimensions of the small pelvis.

A combination of ultrasound and X-ray pelvimetry is very informative when diagnosing a narrow pelvis.

When using magnetic resonance imaging, the accuracy of measuring the pelvis, the presenting part of the fetus, and the soft tissues of the pelvis is ensured and there is no ionizing radiation. The method is limited due to the high cost and difficulty of learning the technique.

The course and management of pregnancy with a narrow pelvis. The adverse effect of a narrowed pelvis on the course of pregnancy is felt only in its last months.

In primiparous women, due to spatial discrepancies between the pelvis and the fetal head, the latter does not enter the pelvis and can remain mobile above its entrance throughout pregnancy, until the onset of labor. High position of the head in primiparous women recent months pregnancy affects the course of pregnancy. The fetal head does not descend into the pelvis, and the abdominal wall of the pregnant woman is not very flexible. In this regard, the growing uterus can only rise upward and, approaching the diaphragm, raises it much higher than in pregnant women with a normal pelvis. As a consequence of this, the excursion of the lungs is significantly limited and the heart is displaced. Therefore, when the pelvis is narrowed, shortness of breath at the end of pregnancy appears earlier, lasts longer and is more pronounced than during pregnancy in women with a normal pelvis.

Rice. 17.10.

(a) and anatomically narrow (b) pelvis The head stands above the entrance to the small pelvis, the anterior and posterior waters are not delimited

Rice. 17.11..

The uterus in pregnant women with a narrowed pelvis is characterized by mobility. Its bottom, due to its heaviness, easily lends itself to any movement of the pregnant woman, which, along with the high position of the head, predisposes to the formation of incorrect positions of the fetus - transverse and oblique. 25% of women in labor with established transverse and oblique position of the fetus usually have a pronounced narrowing of the pelvis to one degree or another. Breech presentation of the fetus in women in labor with a narrowed pelvis occurs three times more often than in women in labor with a normal pelvis.

A narrowed pelvis also affects the insertion of the fetal head. In severe cases of a pointed and saggy abdomen, moderate asynclitism, which favors the physiological course of labor, intensifies and turns into a pathological asynclitic insertion, which is a serious complication of childbirth (Fig. 17.10). The mobility of the fetal head above the narrowed entrance to the pelvis contributes to the occurrence of extensor presentations of the head (anterocephalic, frontal and facial), which relatively often complicate the course of labor with a narrowed pelvis. One of the most common and serious complications pregnancy with this pathology is premature rupture of amniotic fluid due to the lack of a sealing belt. With premature rupture of amniotic fluid (before the onset of labor), cases of prolapse of umbilical cord loops are common (Fig. 17.11).

Pregnant women with a narrow pelvis are at high risk of developing complications and should be specially registered at the antenatal clinic. Timely detection of fetal position abnormalities and other complications is necessary. It is important to determine the date of birth in order to prevent post-term pregnancy, which is especially unfavorable in a narrow pelvis. 1-2 weeks before giving birth, pregnant women should be hospitalized in the pathology department to clarify the diagnosis and choose a rational method of delivery. In the presence of gestosis and other complications, the pregnant woman is sent to the maternity hospital, regardless of gestational age.

The course of labor with a narrow pelvis. The course of labor with a narrow pelvis depends primarily on the degree of narrowing of the pelvis. Thus, with I and, less often, II degrees of narrowing, medium and small fetal sizes, childbirth through the natural birth canal is possible. With II degree of pelvic narrowing, complications during childbirth are much more common than with I degree. As for the III and IV degrees of pelvic narrowing, childbirth in these cases with a live, full-term fetus is impossible.

With a narrow pelvis, early rupture of amniotic fluid is often observed due to the high position of the head and the lack of differentiation of the waters into anterior and posterior. At the moment of rupture of water, a loop of the umbilical cord or a fetal hand may fall out into the vagina. If assistance is not provided in a timely manner, the umbilical cord is pressed by the head against the pelvic wall and the fetus dies from hypoxia. The prolapsed handle reduces the volume of the narrow pelvis, creating an additional obstacle to the expulsion of the fetus

With premature and early rupture of water, the process of dilation of the cervix slows down, a birth tumor forms on the head, and uteroplacental blood flow is disrupted, which contributes to the development of hypoxia in the fetus. In the case of a long anhydrous interval, microbes from the vagina penetrate the uterine cavity and can cause endometritis during childbirth (chorioamnionitis), placentitis, and infection of the fetus.

With a narrow pelvis, labor anomalies are often observed, which manifest themselves in the form of primary and secondary weakness, discoordination. Labor becomes slow, the woman in labor becomes tired, and the fetus often experiences hypoxia.

With a narrow pelvis, a slow dilation of the cervix is characteristic and at the end of the dilatation period there may be a desire to push - “false attempts”, which is caused by irritation of the cervix due to its pressing against the entrance to the pelvis.

With a narrow pelvis during the expulsion period, the head remains in all planes of the pelvis for a long time. Under the influence of labor, the head, fixed at the entrance to the pelvis, undergoes a significant configuration and at the same time adapts to the shape of the pelvis, which facilitates its passage through the birth canal. The head, fixed at the entrance to the pelvis, undergoes a significant configuration and at the same time adapts to the shape of the narrow pelvis, which and promotes its passage through the birth canal.

The period of exile. With a narrow pelvis, this period is usually prolonged: good labor is required to expel the fetus through the narrow pelvic ring. If there is a significant obstacle to expulsion, violent labor and overdistension of the lower segment of the uterus may occur, which can ultimately lead to uterine rupture. In some women in labor, after vigorous labor, secondary weakness of labor forces occurs, pushing stops and the fetus may die from hypoxia.

When the head stands for a long time at the entrance or in the pelvic cavity, compression of the soft tissues of the birth canal between the pelvic bones and the fetal head can occur. In addition to the cervix and vagina, the bladder and urethra are compressed in front, and the rectum in the back. Pressing soft tissues leads to disruption of blood circulation in them; cyanosis and swelling of the cervix and walls occur Bladder, and subsequently - the vagina and external genitalia.

Due to the compression of the urethra and bladder, urination stops, circulatory disorders occur and subsequently tissue necrosis. On the 5-7th day after birth, necrotic tissue can be rejected and genitourinary or rectovaginal fistulas are formed. With a generally narrowed pelvis, circular infringement of the cervix is possible, which leads to its amputation. Swelling of the cervix and difficulty urinating are symptoms of significant tissue compression. Blood in the urine - threatening sign, indicating a discrepancy and the possibility of fistula formation. The appearance of bloody discharge (even moderate) from the genital tract, frequent and painful contractions, thinning and pain in the lower segment of the uterus indicate the threat of its rupture. With a prolonged and difficult period of expulsion, compression of the nerves is possible, followed by paresis of the leg muscles. If the passage of the head through the pelvis is associated with significant difficulties, then damage to the pubic symphysis sometimes occurs, especially if the Kristeller maneuver is used during the expulsion period.

Succession period. IN succession period with a narrow pelvis, bleeding often occurs due to a violation of placental abruption. The reason for this is that when the walls of the uterus and the abdominal press are overstretched during a long and difficult period of expulsion, a tired woman in labor cannot develop good afterbirth contractions and attempts necessary for the physiological detachment and birth of the placenta. As a result, partial placental abruption occurs with dangerous bleeding from the uterus.

Postpartum period. In the early postpartum period, hypotonic bleeding from the uterus is often observed, since the uterus has a temporarily reduced or lost ability to contract. Bleeding from ruptures of the cervix and other tissues of the birth canal may also occur.

In the late postpartum period, postpartum infectious diseases are possible, and if labor is not managed correctly, genitourinary and intestinal fistulas, damage to the pelvic joints, etc.

Complications that threaten the fetus. Such complications often occur with a narrow pelvis. Prolonged labor and frequently observed anomalies of labor forces cause disturbances in uteroplacental blood flow and fetal hypoxia. In this case, hemorrhages in the brain and other organs of the fetus are possible. Hemorrhages in the brain intensify with sharp compression of the head and excessive displacement of the skull bones in the area of the sutures. Rupture of the vessels can lead to hemorrhage under the periosteum of one or both parietal bones - cephalohematoma. With a narrow pelvis, a large birth tumor often forms, sometimes a depression (Fig. 17.12) and cracks in the bones of the skull.

Rice. 17.12..

Stillbirths, early infant mortality and morbidity with a narrow pelvis are significantly higher than with a normal pelvis.

Complications that often appear during the period of cervical dilatation, characteristic of childbirth with a narrow pelvis, are eliminated after some time by the forces of nature, and in the future childbirth proceeds physiologically. In other cases, these complications begin to emerge only

During the period of exile. Despite the fact that childbirth occurs with great difficulty, it often ends spontaneously. In such women in labor, after the opening of the uterine pharynx and the release of amniotic fluid, with good contractions and attempts, the fetal head is first pressed against the entrance to the pelvis and then fixed in it. Despite the absence of noticeable advancement of the head, it makes a slow movement, often returning to its original position again as soon as the pushing stops. The fetal head performs rotational movements, and the relative position of the fontanelles changes: the small and then the large fontanel alternately descend into the pelvis. As a result of prolonged pushing, the fetal head wedges deeper and deeper into the pelvis. Adapting, it changes its shape, more and more corresponding to the shape of the birth canal.

Parietal bones due to asynclitic insertion into varying degrees protrude into the pelvic cavity, so one of them goes under the other at the site of the sagittal suture. As a rule, the overlying parietal bone (posterior), delayed by the promontory, extends under the underlying one (anterior). If the overlying bone is anterior (with posterior asynclitism), then it moves under the underlying counterpressure of the symphysis pubis. Less pronounced overlap of one bone under another is observed in the area of the frontal, coronal and lambdoid sutures.

This configuration of the head occurs very slowly as a result of prolonged contractions and pushing. A slight decrease in the total volume of the fetal head occurs due to the outflow cerebrospinal fluid into the spinal canal.

If there is an obstacle to the nascent head only at the entrance to the pelvis, then the head, having passed it, will be born in the future without any special difficulties. If other parts of the pelvis are also narrowed, then the well-configured head of the fetus, under the influence of contractions and pushing, moves along the latter, performing, together with the body, the mechanism of childbirth, which is different for each form of narrowing of the pelvis.

The mechanism of birth with a narrow pelvis differs from the mechanism of birth typical of a normal pelvis and has characteristic features characteristic of the form of narrowing.

The mechanism of childbirth with a transversely narrowed pelvis. With a transversely narrowed pelvis and the absence of a significant reduction in its transverse dimensions and the average size of the fetal head, the mechanism of labor does not differ from that with a normal pelvis.

Characteristic of a transversely narrowed pelvis without increasing the direct size of the inlet is the asynclitic insertion of the head, when it is inserted in one of the oblique dimensions of the inlet plane by the anterior parietal bone, the sagittal suture is displaced posteriorly.

The bent head gradually lowers into the pelvic cavity and subsequently makes the same movements as during the normal mechanism of childbirth: internal rotation (occiput to the front), extension, external rotation. The duration of labor with a transversely narrowed pelvis is longer than with a normal one. However, when a transverse narrowing of the pelvis is combined with an increase in the true conjugate and other direct dimensions of the pelvis, especially when the true conjugate is larger than the transverse size of the inlet, the head is often installed with a sagittal suture in a straight dimension, with the occiput in front, which is favorable for this form of pelvic narrowing. In this case, the head bends and lowers to the exit of the pelvis, without making an internal rotation, and then unbends (is born).

If the head is installed with a straight arrow-shaped suture and the back of the fetal head is turned posteriorly, then a rotation of the bent head by 180° can occur in the pelvic cavity (with a small head and vigorous labor), and it will erupt in front view.

If the occiput of the fetus does not rotate anteriorly, a high, erect position of the head may occur and signs of clinical discrepancy may appear, which is an indication for cesarean section.

The mechanism of childbirth in a flat-rachitic pelvis. The direct size of the pelvic inlet is reduced. The resulting difficulties are overcome as a result of the following features of the mechanism of childbirth, which are adaptive in nature:

1. Prolonged standing of the head with a sagittal suture in the transverse dimension of the entrance to the pelvis. Due to the narrowing of the entrance, the head can remain in this position for several hours even with good labor.

2. Slight extension of the head, as a result of which the large fontanel is located at the same level as the small one or below it (Fig. 17.13). With such extension through smallest size- true conjugate - the head has a small transverse size (8.5 cm). The large transverse dimension (9.5 cm) deviates to the side where there is more space. The head in this state adapts to the entrance to the pelvis also because the size of the slightly extended head (12 cm) is smaller than the transverse size of the entrance (13-13.5 cm).

3. Asynclitic insertion of the head. Anterior - non-Gel - asynclitism (anteroparietal insertion of the head) is usually observed (Fig. 17.14, a); in this case, the posterior parietal bone rests on the promontory protruding anteriorly and lingers in this place, and the anterior parietal bone gradually descends into the pelvic cavity. The sagittal suture is located closer to the promontory. In this position (the sagittal suture in the transverse dimension of the pelvis is closer to the promontory, the large fontanel is lower than the small one), the fetal head stands at the entrance to the pelvis until its configuration is strong enough. After this, the posterior parietal bone slides off the promontory, asynclitism disappears, and the head bends. Subsequently, the mechanism of labor is the same as with the anterior view of the occipital presentation (internal rotation, extension, external rotation of the head). Less commonly observed is a more unfavorable posterior one - Litzmann asynclitism (Fig. 17.14, b) (posterior parietal insertion of the head), characterized by a deeper insertion of the posterior parietal bone. Sometimes a newborn experiences an indentation on the bones of the head due to prolonged pressing against the promontory.

Rice. 17.13.

Extension of the head at the entrance to the pelvis.

Rice. 17.14..

A - asynclitic insertion of the head (anteroparietal); b - asynclitic insertion of the head (posterior-non-parietal).

The mechanism of childbirth with a simple flat pelvis. The head enters the entrance in the same way as with a flat-rachitic pelvis. Subsequently, it descends into the pelvic cavity and is born as an occipital presentation. However, often the internal rotation of the head does not occur because, along with the direct size of the entrance to the pelvis, the direct dimensions of the cavity and outlet of the pelvis are reduced. The fetal head reaches the plane of the narrow part of the pelvic cavity, sometimes even its bottom, and the sagittal suture is located in the transverse dimension of the pelvis. This feature of the labor mechanism is called low transverse position of the head. In some cases, the fetal head at the bottom of the pelvis turns with the back of the head anterior and is born independently. If the turn does not occur, complications arise (secondary weakness of labor forces, fetal asphyxia, etc.), which are an indication for surgical delivery.

The internal rotation of the head with the occiput anteriorly occurs during the transition from the wide part of the cavity to the narrow one, and the extension of the head occurs at the outlet of the pelvis. Sometimes oblique asynclitic insertion of the head is observed. Childbirth with a posterior view of the occipital presentation of the fetus contributes to the development of clinical discrepancy between the pelvis and the head.

The mechanism of childbirth with a generally uniformly narrowed pelvis. By the beginning of labor, the fetal head is in a slightly bent position above the entrance to the pelvis - with a sagittal suture above the transverse or one of the oblique dimensions. The head, fixed at the entrance, due to the pressure it experiences from the uterus, begins to bend as much as necessary to enter and then pass through the entrance to the pelvis. The first feature of the mechanism of childbirth with a uniformly narrowed pelvis is the beginning of pronounced flexion of the head at the entrance to the pelvis (Fig. 17.15, a).

Having descended into the wide part of the pelvic cavity and encountering resistance here from the walls of the pelvis, the head slowly continues its translational and flexion movement, adding another one to them - rotation.

When the head approaches the plane of the narrow part of the pelvis, it is already in a pronounced bent position; its sagittal suture is located in an oblique, and sometimes even almost straight, narrow part of the pelvic cavity. Here the fetal head encounters an obstacle from the narrowest part of the pelvis. This obstacle is overcome due to further bending of the head, which occurs during its transition from the wide to the narrow part of the pelvic cavity. Flexion becomes maximum. In this case, the small fontanel occupies a central position in the pelvic cavity - it is located on center line pelvis This sign, determined during vaginal examination, is very characteristic of maximum flexion of the head. Thanks to this bending, the head passes through the narrowest place of the pelvis with its smallest circumference, passing through the small oblique dimension.

The maximum flexion of the head, which occurs during the transition of the head from the wide part of the pelvic cavity to the narrow one, is the second feature of the mechanism of childbirth with a generally uniformly narrowed pelvis.

With a significant narrowing of the pelvis, even such a pronounced flexion of the head is not enough to overcome the narrowed birth canal. The discrepancy between the fetal head and the pelvis is compensated by a sharp configuration of the head, sometimes so strong that it extends in length towards the small fontanelle - a dolichocephalic shape of the head is formed (Fig. 17.15, b). Often the fetal head, standing with its large segment in the wide part of the pelvic cavity or slightly higher, with its lower pole is at the exit and even appears from the genital slit, which can lead to an erroneous conclusion regarding the height of the head in the pelvis.

Rice. 17.15..

A - flexion of the head at the entrance to the pelvis; b - sharp configuration of the head (dolichocephalic head).

The sharp dolichocephalic configuration of the head is the third feature of the mechanism of childbirth with a generally uniformly narrowed pelvis.

Approaching the outlet of the pelvis with a sagittal suture in its direct size, the head begins to unbend, and subsequently the birth mechanism proceeds in the same way as with a normal pelvis.

Naturally, the narrowing of the pelvis and the need for additional movement of the head - maximum flexion and its sharp configuration - require more time for the head to pass than with a normal pelvis. Therefore, childbirth in general and the period of exile in particular are long. This explains the emergence of large birth tumor in the area of the small fontanelle, which lengthens the already sharply elongated dolichocephalic head of the fetus.

Childbirth is especially unfavorable when combined with a generally uniformly narrowed pelvis with a large fetus, with extensor insertions of the head (antecephalic, facial, frontal anticipation) and a posterior view of the occipital presentation. In such cases, the head is firmly driven into the pelvis, and its further advancement is completely stopped, which requires surgical termination of labor.

In obstetrics, there are two concepts of a narrow pelvis: anatomically narrow pelvis and clinically narrow pelvis.

A narrow pelvis is considered to be a pelvis whose bone skeleton is so altered that it creates mechanical obstacles for the passage of a full-term fetus, especially its head. Anatomically narrow is considered to be a pelvis, one or more dimensions of which are reduced by 2 cm or more compared to the norm accepted in obstetrics; it is formed during the development of the female body. In some cases, the narrowing may be accompanied by deformation of the pelvic bones, in others not. Clinically or functionally narrow is a pelvis that makes the birth of the fetus (head) difficult in a given particular birth.

Anatomical narrowing of the pelvis does not always prevent the birth of the fetus, while a discrepancy between the size of the pelvis and the fetal head can be observed with normal pelvic sizes.

The reasons for the development of an anatomically narrow pelvis are varied. One of them is heredity. In the antenatal period, damaging factors are important, in childhood - poor nutrition, tuberculosis, rickets. During puberty, the leading role in the development of the bone pelvis belongs to the sex hormones of the ovaries and adrenal glands. Under the influence of estrogens, an increase in the transverse dimensions of the pelvis and bone maturation occurs, and androgens determine bone growth in length and accelerate the fusion of the epiphyses of the bones. In patients with excessive androgen production, one can distinguish following forms entrance to the pelvis: longitudinal-oval, round, transverse-oval with normal or increased direct dimensions of the pelvis. A characteristic feature of these forms of the pelvis is a narrow pubic arch.

At present, it is impossible not to take into account the importance of acceleration in the formation of a transversely narrowed pelvis: due to the rapid growth of the body in length, the increase in transverse dimensions does not occur quickly enough. Most authors note: the shape of the pelvis is a sensitive indicator of the dynamics of sexual development. There is a relationship between the onset of puberty and the corresponding shape of a woman’s pelvis.

Professional sports can have a significant impact on the formation of the bone pelvis. Excessively intense, long-term physical activity on certain muscle groups during the development of a girl’s body, when systematically practicing the same sport, leads to a change in the normal proportions of the body. The incidence of anatomically narrow pelvis among female athletes is 64.1%, it is highest among gymnasts (78.3%), skiers (71.4%), and swimmers (44.4%).

Pelvic deformation in adults can occur as a result of bone tumors, osteomalacia, and trauma.

Many classifications of the narrow pelvis have been proposed. Most authors consider it advisable to use the classification of A.Ya. Krassovsky, based on an assessment of the shape of the entrance to the pelvis and the degree of narrowing of the pelvis, depending on the size of the true conjugate.

Classification of anatomically narrow pelvis (according to the shape of the narrowing)

A. Common forms of the pelvis.

1. Generally uniformly narrowed pelvis.

2. Transversely narrowed pelvis.

3. Flat: simple flat pelvis, flat-rachitic pelvis, pelvis with a decrease in the wide part of the cavity.

B. Rarely occurring forms of the pelvis.

1. Obliquely displaced (asymmetrical).

2. Pelvis narrowed by exostoses and tumors.

3. Generally narrowed flat pelvis.

4. Other forms of narrow pelvis.

The incidence of anatomically narrow pelvis varies widely (from 2.6 to 15-20%), and in the last decade has remained fairly stable: 3.6-4.7%.

The prevalence rate has changed significantly various forms narrow pelvis. The most common form is uniformly narrowed (40-50%). A flat pelvis is less common -

0 degree of pelvic narrowing is usually judged by the size of the true conjugate.

Classification of anatomically narrow pelvis (by degree of narrowing)

1st degree - c.vera not less than 9 cm. II degree - c.vera from 9 to 7 cm.

III degree - c.vera from 7 to 5 cm.

IV degree - c.vera 5 cm or less. With a transversely narrowed pelvis:

I degree - transverse size of the entrance 12.4-11.5 cm;

II degree - transverse size of the entrance 11.5-10.5 cm;

III degree - the transverse size of the entrance is less than 10.5 cm. I degree narrowing is observed in 90-91%, II degree - in 8-9%,

III degree - 0.2-0.3%.

In modern conditions, there are no sharp degrees of narrowing of the pelvis, but more and more often erased forms are being discovered, a combination of small degrees of narrowing of the pelvis and large fetuses, as well as unfavorable presentations and insertions of the fetal head. IN last years obstetricians pay attention to significant changes in the structure of various forms of anatomical narrow pelvis.

Depending on the shape of the entrance, the radiological classification includes four types of pelvis (Fig. 71).

Rice. 71. Caldwell and Moloy classification

Gynecoid type(55% of all pelvises) corresponds to a normal female pelvis. This is a short, wide and capacious pelvis. The pubic arch is wide, the slope is average, the curvature of the sacrum is pronounced. The physique is female, the neck and waist are thin, the hips are wide, the weight and height are average.

Android type(20% of all pelvises) - male pelvis. There is a wedge-shaped entrance, a narrow pubic angle, the sacrum is insufficiently curved, and deviated anteriorly. The pelvis narrows funnel-shaped downwards. The woman's masculine body type is noted: broad shoulders, a thick neck, and the waist is not defined. With this form of the pelvis, the greatest amount of pathology is observed.

Anthropoid type(20-22% of all pelvises) resembles the pelvis of great apes. The shape of the cavity is elongated-oval, the sacrum is narrow and long, the pubic arch is narrow. The physique features of such women are: tall, lean, broad shoulders, narrow waist and hips, long, thin legs.

Platypeloid type resembles a simple flat basin (3% of all basins). The shape of the entrance to the pelvis is transversely oval, the slope of the sacrum is average, the pubic arch is wide. This type is found in tall, thin women with underdeveloped muscles and reduced skin turgor.

Foreign manuals provide two classifications of anatomically narrow pelvises. One of them is based on an assessment of the shape and degree of narrowing, the other - on the structural features of the pelvis - gynecoid, android, anthropoid, platypeloid.

diagnostics of anatomically narrow pelvis

Timely recognition of a narrow pelvis allows you to prevent a number of complications that arise during pregnancy and childbirth.

For the diagnosis of a narrow pelvis, anamnesis data are of great importance, first of all - about infectious diseases, contributing to delayed development of the girl’s body, the emergence of infantilism and the formation of a narrow pelvis. It is necessary to find out whether the pregnant woman suffered rickets in childhood, tuberculosis of the pelvic bones and joints, trauma to the pelvic bones and lower extremities with subsequent lameness.

Information about previous labor (duration of labor, weakness of labor, surgical interventions) is of great importance.

injuries, injuries to the fetus and mother, body weight of newborns, health status of children in the future).

In the diagnosis of a narrow pelvis, an important place is given to objective research methods. During the examination, the general physical development of the pregnant woman is assessed, her height and body weight, and changes in the skeleton are determined. Pay attention to the shape of the abdomen: with a narrow pelvis, it has a pointed shape in primiparous women and becomes saggy in multiparous women.

The main method for diagnosing a narrow pelvis in practical obstetrics is an external obstetric examination, which includes pelvic measurement to determine the shape of the pelvis. Along with the traditional measurement of the size of the pelvis, the sizes of the lateral conjugates (normally 14-15 cm) and oblique conjugates (normally 22.5 cm) are sometimes determined. Measure the size of the pelvic outlet. An important role in assessing the pelvis is played by the measurement of the sacral rhombus (normally 10-11 cm).

The true conjugate is calculated:

Along the diagonal conjugate;

On the outer conjugate;

According to the vertical size of the Michaelis rhombus;

According to Frank's size;

Using X-ray pelviometry;

According to ultrasound data.

The capacity of the small pelvis depends on the thickness of its bones, which is indirectly determined by measuring the circumference of the wrist joint and calculating the Solovyov index.

Generally uniformly narrowed pelvis. It differs from normal in a uniform narrowing of all sizes, for example: 23-26-29-18 cm, a sacral rhombus of regular shape with sides of 9 cm. Solovyov index - 13 cm. The pelvis has typical features of the female pelvis with reduced dimensions. I.F. Jordania distinguishes several types of such pelvis: hypoplastic, children's, male and dwarf pelvis.

Hypoplastic pelvis differs from normal only in its miniature size while maintaining the outlines and relationships of the bones inherent in a normal pelvis. This pelvic shape is typical for short peoples.

Children's (infantile) pelvis resembles in shape and structure the pelvis of young girls. The wings of the ilium are more vertical, pubic

The arch is narrow, the sacrum is curved and located vertically far posteriorly between the ilia. The promontory is located high and protrudes slightly under the sacral cavity. For this reason, the entrance to the pelvis is not transversely oval, but round or even longitudinally oval. Women usually exhibit other signs of infantilism: short stature, insufficient development of the external genitalia, mammary glands, pubic hair, armpits, etc.

Male pelvis. It is found in tall, strong women with massive skeletal bones. The wings of the ilium are steep, the pubic arch is narrow, and the promontory is very high. The pelvic cavity is funnel-shaped.

Pelvis of dwarfs. Characterized by a lag in bone development. The pelvis is usually proportional to the torso.

Transversely narrowed pelvis characterized by a decrease in the transverse dimensions of the small pelvis with normal or increased direct dimensions. The sacrum is often flattened. Identification of such a pelvis conventional methods difficult. However, it has a number of anatomical features: steep standing of the wings of the ilium, narrow pubic arch, convergence of the ischial spines, high standing of the promontory, reduction in the transverse size of the pelvic outlet and the transverse size of the sacral rhombus. A classification of transversely narrowed pelvises has been proposed, based on the transverse size of the pelvic inlet (according to X-ray pelviometry): I degree of narrowing - 12.4-11.5 cm; P - 11.4-10.5 cm; III - less than 10.5 cm.

Simple flat pelvis characterized by a wide pubic arch; deeper retraction of the sacrum; into the pelvis without changing the shape and curvature of the sacrum; all direct dimensions of both the inlet, cavity, and outlet are moderately shortened; pelvis dimensions: 25-28-31-18(17) cm.

The following pelvic variants have been identified.

1. With an increase in all direct dimensions (55%).

2. With a decrease in the direct diameter of the wide part of the pelvic cavity

3. With an increase in only the direct size of the entrance (16.5%). This form most often causes a clinically narrow pelvis.

Flat-rachitic pelvis is a consequence of rickets. At the same time, the amount of lime in the bones decreases, and the cartilaginous layers thicken. The pressure of the spine on the pelvis and the tension of the muscular-ligamentous apparatus lead to deformation of the pelvis: straight

the entrance to the pelvis is sharply shortened as a result of the deep retraction of the sacrum into the pelvis, the promontory protrudes into the pelvic cavity much more sharply than normal. The sacrum is flattened and rotated with its base anteriorly and its apex posteriorly. The coccyx is beak-shaped and bent anteriorly. The shape of the iliac bones has also changed: their wings are poorly developed, the crests are deployed, as a result of which the distances Spinarum And Cristarum almost equal. The pubic arch is wide and low. The direct size of the entrance is increased, the transverse size is normal. The pelvis is widened, shortened, flattened, and thinned. Its dimensions: 26-27-31-17 cm. Sacral rhombus - with a reduced vertical size, may resemble a triangle.

Generally narrowed flat pelvis is a combination of a generally uniformly narrowed and flat pelvis, and is rare. Dimensions 23-26-29-16 cm.

Determining the position and presentation of the fetus is also important. With a narrow pelvis, oblique, transverse position of the fetus, and breech presentation are more common. Before birth, the presenting head of the fetus often remains mobile above the entrance to the pelvis.

One of the main methods for assessing the shape and size of the pelvis is a vaginal examination, in which the capacity of the pelvis is determined, an attempt is made to measure the diagonal conjugate and calculate the true one, i.e. determine the degree of narrowing.

The most reliable information about the shape and size of the pelvis can be obtained using X-ray pelviometry. It is recommended to be performed at 38-40 weeks of pregnancy or before the onset of labor. This method allows you to determine all the diameters of the small pelvis, shape, inclination of the pelvic walls, shape of the pubic arch, degree of curvature and inclination of the sacrum.

Last two decades wide use got an ultrasound. The use of ultrasound scanning to diagnose an anatomically narrow pelvis is reduced to obtaining the size of the true conjugate and the biparietal size of the fetal head.

course of pregnancy

The adverse effect of a narrowed pelvis on the course of pregnancy is felt only in its last months. In primiparous women due to

spatial discrepancies between the pelvis and the head, the latter does not enter the pelvis and remains mobile above the entrance throughout pregnancy and even at the beginning of labor. A high position of the head entails a number of other complications. A high position of the diaphragm and limited excursion of the lungs contribute to the appearance of shortness of breath earlier than normal. One of the frequent and serious complications of pregnancy with a narrow pelvis is premature (prenatal) rupture of water, which contributes to the possible development of infection in the uterus and fetal hypoxia.

Complications during pregnancy:

Premature rupture of water;

Malposition;

Fetal hypoxia;

Loss of small parts of the fetus.

MANAGEMENT OF PREGNANT WOMEN WITH NARROW PELVIS

Pregnant women with a narrow pelvis should be specially registered in the antenatal clinic; 1-2 weeks before the expected date of birth, they should be hospitalized in the department of pathology of pregnant women to clarify the weight of the fetus and the size of the pelvis. A labor management plan is developed and possible routes of delivery are clarified. Post-term pregnancy is extremely undesirable. If a pregnant woman has a narrow pelvis and other complications (age, post-term pregnancy, breech presentation of the fetus, etc.), delivery can be performed by a planned cesarean section.

Features of the course of labor:

Early rupture of water;

Loss of small parts of the fetus;

Clinically narrow pelvis;

Trauma to the mother (urogenital fistula, uterine rupture) and fetus, bleeding in the third and early postpartum period.

COURSE AND COMPLICATIONS OF THE 1ST STAGE OF LABOR

In the first stage of labor, the main complication is weakness of labor (in 10-37.7% of cases). The second quite common complication

Nenia - early rupture of water, which can lead to prolapse of the umbilical cord and small parts of the fetus. With a protracted course of labor with a long anhydrous interval, the risk of developing endometritis, chorioamnionitis, and ascending infection of the fetus increases significantly.

MANAGEMENT OF THE 1ST STAGE OF LABOR

Currently, active expectant management of labor is generally accepted. During childbirth, cardiac monitoring is desirable. The tactics of labor management with a narrow pelvis are determined individually, taking into account all the data from an objective study, the degree of narrowing of the pelvis and the prognosis for the woman in labor and the fetus. Childbirth through the natural birth canal can occur: normally; with difficulties, but end happily if the right help is provided; with complications dangerous to the life of the mother and fetus. With I and II degrees of pelvic narrowing, the outcome of labor depends on the size of the head, its ability to shape, presentation and the nature of insertion, and the intensity of labor. It should be noted that with the first degree of pelvic narrowing, delivery of a full-term fetus is possible provided that the fetus is of average size, has a good head configuration, good labor and the labor mechanism corresponds to the shape of the pelvic narrowing.

With stage II pelvic contraction, delivery of a full-term fetus is possible in some cases, but with a high risk to the life of the fetus and the health of the mother. Mainly the feasibility of childbirth through the birth canal depends on the size of the fetal head, i.e. clinical compliance.

With the third degree of pelvic narrowing, delivery of a full-term fetus through the natural birth canal is possible only after a fetal destruction operation. If the fetus is alive, only cesarean section is indicated.

IV degree of narrowing - an absolutely narrow pelvis. Childbirth through the natural birth canal is impossible even after fetal destruction surgery. The only method of delivery is caesarean section. Currently, III and IV degrees of narrowing are extremely rare.

A fetus during childbirth with a narrow pelvis often suffers from intrauterine hypoxia, which occurs approximately three times more often than with a normal pelvis.

The main cause of death in children is intrauterine hypoxia and intracranial trauma. When the fetal head stands in one plane for a long time, cardiac activity is disrupted in almost all fetuses.

Currently perinatal mortality with a narrow pelvis it decreases, which is associated with an increase in the frequency of cesarean sections and with improved intensive care for newborns.

Which option the birth will take can often be decided only during the birth itself, i.e. when conducting a functional assessment of the pelvis. Therefore, childbirth is carried out expectantly until signs of a clinically narrow pelvis are revealed. The degree of discrepancy between the head and pelvis of the mother is judged by the following criterion: the absence of forward movement of the fetus along the birth canal (insertion of the head into the pelvis) with good labor activity. The discrepancy between the fetal head and the mother's pelvis can be detected using the Vasten method (V.A. Vasten - Russian scientist).

Vasten's sign is positive: when the obstetrician's palm moves from the plane of the pubis to the head, it is noted that there is an “overhang” of the head, i.e. the plane of the head is above the pubis. The head does not correspond to the mother's pelvis.

Vasten's sign is weakly positive (level): the plane of the pubis and head are at the same level - there is a slight discrepancy.

Vasten's sign is negative: the plane of the head is lower than the womb - the head corresponds to the mother's pelvis.

REASONS FOR NONCONFORMITY

HEAD OF THE FETUS AND PELVUS OF THE MOTHER

1. A slight degree of narrowing of the pelvis and a large fetus (60%).

2. Incorrect insertion of the head - high straight position of the sagittal suture, anterior cephalic or frontal insertion (23%).

3. Large size of the fetus with normal pelvic sizes (10%).

4. Rare anatomical changes pelvis - post-traumatic changes, tumors (7%).

5. Insufficient configuration of the head during post-term pregnancy.

Various forms of the narrow pelvis and its anatomical changes determine the corresponding features of the biomechanism of childbirth.

The biomechanism of childbirth with a generally uniformly narrowed pelvis has the following features.

1. The 1st moment of the biomechanism of childbirth - flexion of the head occurs in the plane of the entrance to the pelvis, because it is already the first obstacle for the head. The small fontanel becomes lower than the large one.

2. 2nd moment - maximum flexion occurs during the transition from the wide part of the pelvic cavity to the narrow one (where flexion normally occurs). A vaginal examination reveals that the small fontanelle is located along the axis of the pelvis, being the leading point in childbirth.

3. As a measure of adaptation of the head to the narrowed pelvis during childbirth, a sharp configuration of the head occurs - a dolichocephalic head (cucumber-shaped) is formed.

4. 3rd moment of the biomechanism of childbirth - the internal rotation of the head begins in the plane of the narrow part and ends at the outlet of the pelvis with the cutting in of the head; in this case, the sagittal suture becomes straight, and a fixation point is formed - the suboccipital fossa. With a narrow pubic arch, the head is fixed under the pubic arches by two points.

5. 4th moment - extension of the head occurs at the outlet of the pelvis through the eruption and birth of the head.

6. 5th moment - internal rotation of the shoulders occurs as usual.

Features of the biomechanism with a transversely narrowed pelvis

Asynclitic insertion of the head into one of the oblique dimensions of the pelvic inlet plane, and with increased direct dimensions of the pelvis, the head is inserted with a sagittal suture into the straight dimension of the pelvic inlet, which is called the high straight position of the sagittal suture.

At transversely narrowed pelvis, the mechanism of childbirth may not differ from normal. With mild degrees of discrepancy, the most characteristic mechanism of labor is oblique asynclitic insertion of the head (see above). When a transverse narrowing of the pelvis is combined with an increase in the true conjugate, a high, straight position of the head is often formed, which is a measure of the adaptation of the head to the pelvis. If there is a correspondence between the head and pelvis, the biomechanism of childbirth consists of the following points: 1) flexion of the head at the entrance to the pelvis; 2) extension of the head at the outlet of the pelvis, i.e. no internal

gates; 3) internal rotation of the shoulders, birth of the fetus. If the head does not fit, a clinically narrow pelvis is determined and a cesarean section is performed.

BIOMECHANISM OF BIRTH WITH A FLAT PELVIS

Features of the biomechanism of childbirth with a simple flat pelvis

Prolonged standing of the head with a sagittal suture in the transverse dimension of the pelvic inlet in a state of moderate extension; the sagittal suture can be located asynclitically. Anterior parietal asynclitism is most often observed.

In the pelvic cavity, due to the reduced direct dimensions of its planes, rotation of the head does not occur and the so-called low transverse position of the sagittal suture may occur.

By the beginning of labor, the head, as a rule, is mobile above the entrance to the pelvis. Insertion of the head with a sagittal suture into the transverse (most favorable) size of the pelvis is the first feature of childbirth. 2nd - prolonged standing of the head at the entrance to the pelvis (especially with a rachitic pelvis). The 1st moment of the biomechanism is extension of the head, the leading point is the large fontanel. The formation of asynclitic insertion of the head is the 3rd feature. Anterior asynclitism is usually observed, in which the anterior parietal bone descends below the posterior one, located on a protruding promontory. The sagittal suture is located closer to the cape, remaining so until a pronounced configuration of the head appears. After this, the posterior parietal bone slides off the promontory and the head bends. In the future, the biomechanism proceeds normally. Here, asynclitism is observed, in which the posterior parietal bone descends below the anterior one, and the anterior one, resting on the pubic symphysis, contributes to a more pronounced and longer-lasting configuration of the head, which often leads to birth trauma for the woman in labor and the fetus. If the head passes into the plane of the entrance to the pelvis, then with a simple flat pelvis it often remains in a state of extension, and labor proceeds according to the type of birth in the anterior cephalic presentation: internal rotation to the posterior view, formation of the 1st point of fixation (glabella), flexion of the head and formation of the 2nd point (suboccipital fossa), extension of the head and its birth, internal rotation of the shoulder and birth of the fetus.

Features of the biomechanism of childbirth with a flat-rachitic pelvis are reflected in table. 18.

Table 18

Features of the biomechanism of childbirth with a flat-rachitic pelvis

Options for inserting the head in a flat-rachitic pelvis.

1. Synclitic insertion of the head.

2. Asynclitic insertion of the head.

A. Anterior parietal (non-Gel) asynclitism - the sagittal suture is located closer to the promontory, the anterior parietal bone is inserted (Fig. 72).

B. Posterior parietal (Litzman) asynclitism - the sagittal suture is located closer to the symphysis (Fig. 73).

With a flat-rachitic pelvis, after entering the pelvis, “assault”, rapid labor may be observed. And the biomechanism can follow the type of birth in the anterior or occipital presentation, i.e. the head in the plane of the narrow part will perform flexion, rotation, at the exit - extension, etc. Due to the prolonged standing of the head and the presence of obstacles, a sharp configuration of the head occurs with the formation of a birth tumor in the area of the greater fontanel (brachycephalic, or tower, head), and in case of asynclitism - on one of the parietal bones.

Rice. 72. Anteroparietal asynclitism

Rice. 73. Posterior parietal asynclitism

The biomechanism of childbirth with a generally narrowed flat pelvis depends on what predominates: flattening or narrowing. The biomechanism of labor is often mixed, and its course is usually severe.

COURSE AND CONDUCT OF THE PERIOD OF EXILE

The greatest dangers in childbirth with a narrow pelvis threaten the mother and fetus in the second stage of labor, when the clinical discrepancy between the pelvis and the fetal head is finally revealed.

The main complications of the exile period should be considered:

Weakness of labor (secondary);

Rupture of the uterus in the lower segment when it is overstretched against the background of a discrepancy between the head and pelvis and strong labor;

Possible pinching of soft tissues with the subsequent formation of genitourinary and enterogenital fistulas when the head stands in one plane of the pelvis for a long time;

Injuries to the joints and nerves of the pelvis.

During the second stage of labor, a functional assessment of the pelvis should be performed. During prolonged labor, a large birth tumor appears on the baby’s head, and a cephalohematoma may also appear.

clinically narrow pelvis

Clinically narrow pelvis is a concept associated with the process of childbirth. All cases of discrepancy between the fetal head and the woman's pelvis, regardless of its size, should be classified as a clinically narrow pelvis. If in recent years there has been a decrease in the incidence of an anatomically narrow pelvis, especially pronounced degrees of narrowing, then the incidence of a clinically narrow pelvis is quite stable and amounts to 1.3-1.7% of cases. This is due to an increase in the number of births with a large fetus.

The reasons for the discrepancy between the mother's pelvis and the fetal head can be different: a slight degree of narrowing of the pelvis and a large fetus (60%); unfavorable presentation and insertion of the fetal head with small degrees of narrowing and normal pelvic sizes (23.7%); large fetal sizes with normal pelvic sizes (10%); sudden anatomical changes in the pelvis (6.1%) and other reasons (0.9%); and in post-term pregnancy - insufficient configuration of the head.

Diagnostic signs of a clinically narrow pelvis:

Prolonged standing of the fetal head in one plane and lack of advancement in the second stage of labor;

Pronounced configuration of the head and birth tumor;

Swelling of the cervix, external genitalia, vaginal mucosa;

Overstretching of the lower segment and high standing of the contraction ring;

Positive signs of Vasten, Zangemeister (only in anterior view!);

Involuntary straining and the appearance of symptoms of impending uterine rupture.

Signs of a clinically narrow pelvis can be diagnosed when:

Opening of the cervix more than 8 cm;

Absence of amniotic sac;

Empty bladder;

Normal contractile activity of the uterus.

Zangemeister's maneuver. After measuring the external conjugate of the pelvis, the anterior branch of the pelvis meter is shifted upward to the most protruding one

part of the fetal head. If this size is less than the external conjugate, then the prognosis for childbirth is good; if more, the prognosis is poor; with equal sizes, the prognosis is uncertain (doubtful) and depends on the nature of labor and the ability of the head to change.

Obstetric tactics for the development of a clinically narrow pelvis - emergency delivery by cesarean section!

Thus, childbirth with a narrow pelvis occurs through the natural birth canal if there is a correspondence between the fetal head and the mother’s pelvis.

Indications for planned caesarean section.

1. Narrowing of the pelvis III-IV degree.

2. Narrowing of the pelvis I and II degrees in combination with a large fetus, breech presentation, post-term pregnancy.

3. Complicated obstetric history: history of stillbirth, infertility.

4. Scar on the uterus.

5. Presence of genitourinary and enterogenital fistulas.

6. Incorrect position of the fetus.

To relieve pain during labor with a narrow pelvis, inhalational anesthetics are used, and antispasmodics are widely used. During childbirth, fetal hypoxia is repeatedly prevented (glucose, sigetin, cocarboxylase, oxygen). In order to prevent perineal ruptures and speed up labor, an episiotomy is often required.

At the end of the second stage of labor, bleeding is prevented (methylergometrine intravenously).

If a clinically narrow pelvis occurs during childbirth, delivery is carried out by cesarean section (with a living fetus).

Surgical delivery is also carried out when a narrow pelvis is combined with other obstetric or extragenital pathology, or with a burdened obstetric history.

Imposition during childbirth with a narrow pelvis obstetric forceps or vacuum extraction of the fetus are very undesirable.

In the afterbirth and early postpartum periods with a narrow pelvis, bleeding often occurs due to impaired placental abruption, uterine hypotension, which can be caused not only by complications in the first and second stages of labor, but also (in some cases) by general etiological causes of obstetric bleeding and narrow pelvis

Therefore, at the beginning of the third stage of labor, urine should be removed with a catheter, and after the placenta is released, an external massage of the uterus should be performed and cold (ice) placed on the stomach (uterus).

In case of a burdened obstetric history and the threat of bleeding, it is recommended to administer intravenous drips of oxytocin with glucose or saline solution within 2 hours after birth.

In the late postpartum period, if labor is managed incorrectly with a narrow pelvis, postpartum infectious diseases, genitourinary and enterogenital fistulas, and damage to the pelvic joints can occur.

Health measures and protection of motherhood and childhood are the key to reducing the number of women with a narrow pelvis.

Until the 16th century, it was believed that the pelvic bones diverge during childbirth, and the fetus is born with its legs resting on the bottom of the uterus. In 1543, the anatomist Vesalius established that the bones of the pelvis are connected motionlessly. Anomalies of the pelvic bone are among the most common causes of disruption of the normal course of labor. Despite the recent significant decrease in the frequency of cases of gross deformation of the pelvis and high degrees of its narrowing, the problem of a narrow pelvis has not lost its relevance today - in connection with the process of acceleration and increase in body weight of newborns.

Anatomically narrow pelvis A pelvis is considered to be one in which at least one of the main dimensions (see below) is 1.5-2 cm or more smaller than normal.

Complications during childbirth occur when the fetal head is larger than the pelvic ring, which is sometimes observed with normal pelvic sizes. In such cases, the advancement of the head along the birth canal is suspended: the pelvis practically turns out to be narrow and functionally insufficient. If the fetal head is small, then even with some narrowing of the pelvis there may not be a discrepancy between it and the head of the born child, and childbirth occurs naturally without any complications. In such cases, an anatomically narrowed pelvis turns out to be functionally sufficient. Therefore there is a concept functional, or clinically, narrow pelvis. A clinically narrow pelvis is an indication for cesarean section during childbirth.

Anatomically narrow pelvis occurs in 5-7% of women. The diagnosis of a clinically narrow pelvis is established only during childbirth based on a combination of signs that make it possible to identify the disproportion between the pelvis and the head. This type of pathology occurs in 1-2% of all births.

How to measure the small pelvis

In obstetrics, examination of the pelvis is very important, since its structure and size are crucial for the course and outcome of childbirth. The presence of a normal pelvis is one of the main conditions for the correct course of labor. Deviations in the structure of the pelvis, especially a decrease in its size, complicate the course of natural childbirth, and sometimes present insurmountable obstacles to it. Therefore, when registering a pregnant woman with an antenatal clinic and upon admission to the maternity hospital, in addition to other examinations, the external dimensions of the pelvis must be measured. Knowing the shape and size of the pelvis, it is possible to predict the course of labor, possible complications, and decide whether spontaneous childbirth is permissible.

A pelvic examination includes examining, palpating the bones and determining the size of the pelvis.

In a standing position, the so-called lumbosacral rhombus, or Michaelis rhombus ( rice. 1). Normally, the vertical size of the rhombus is on average 11 cm, the transverse size is 10 cm. If the structure of the small pelvis is disturbed, the lumbosacral rhombus is not clearly expressed, its shape and size are changed.

After palpating the pelvic bones, it is carried out measurement using a pelvis meter(cm. rice. 2a And b).
Main dimensions of the pelvis:

1. Interspinous size. The distance between the superior anterior iliac spines (in Fig. 2a) is normally 25-26 cm.

2. Distance between the most distant points of the iliac crests(in Fig. 2a) - 28-29 cm, between the greater trochanters of the femurs (in Fig. 2a) - 30-31 cm.

3. External conjugate- the distance between the suprasacral fossa (upper corner of the Michaelis diamond) and the upper edge of the pubic symphysis (Fig. 2b) - 20-21 cm.

The first two sizes are measured with the woman lying on her back with her legs extended and brought together; the third size is measured with the legs shifted and slightly bent. The external conjugate is measured with the woman lying on her side with the underlying leg bent at the hip and knee joints and the overlying leg extended.

Some pelvic dimensions are determined during a vaginal examination.

When determining the size of the pelvis, it is necessary to take into account the thickness of its bones; it is judged by the value of the so-called Solovyov index - the circumference of the wrist joint. The average index value is 14 cm. If the Solovyov index is more than 14 cm, it can be assumed that the pelvic bones are massive and the size of the small pelvis is smaller than expected.

Shapes of a narrow pelvis

In obstetrics, it is customary to distinguish the following forms of a narrow pelvis (see Fig. 3):

transversely narrowed (1);
simple flat (2);
flat-rachitic (3);
generally uniformly narrowed (1);
rare forms:
- oblique (5);
- osteomalatic (6), etc.

In addition, the degree of narrowing is assessed (from I to IV). In the past, the most common types of flat pelvis were generally narrowed and various types. Recently, a pelvis with reduced transverse dimensions has become more common.

Reasons for the development of a narrow pelvis

There are congenital anomalies of the pelvis. In addition, the reasons for the development of a narrow pelvis can be malnutrition in childhood and diseases suffered in childhood: rickets, poliomyelitis, etc. Pelvic deformities are caused by diseases or damage to the bones and joints of the pelvis: fractures, tumors, tuberculosis. Pelvic abnormalities also occur as a result of spinal deformation (kyphosis, scoliosis, coccyx deformity). One of the factors in the formation of a transversely narrowed pelvis is acceleration, which during puberty leads to rapid growth of the body in length while the growth of transverse dimensions lags.

It should be noted that currently there is a decrease in the number of women with an anatomically narrow pelvis.

The influence of a narrow pelvis on the course of pregnancy and childbirth

The adverse effect of a narrowed pelvis on the course of pregnancy is felt only in its last months. The fetal head does not descend into the pelvis, the growing uterus rises and makes breathing much more difficult. Therefore, at the end of pregnancy, shortness of breath appears early, it is more pronounced than during pregnancy with a normal pelvis. The uterus in such pregnant women is more mobile. Its bottom, due to its gravity, easily responds to the movements of the pregnant woman, which, along with high location head leads to the formation of incorrect positions of the fetus - transverse and oblique. 25% of women in labor with a transverse or oblique position of the fetus usually have a pronounced narrowing of the pelvis to one degree or another. Breech presentation of the fetus in women in labor with a narrowed pelvis occurs three times more often than in women in labor with a normal pelvis.

Management of pregnancy and childbirth with a narrow pelvis

Pregnant women with a narrow pelvis are at high risk for the development of complications and should be specially registered at the antenatal clinic. Timely detection of fetal position abnormalities and other complications is necessary. It is important to accurately determine the due date in order to prevent post-term pregnancy, which is especially unfavorable with a narrow pelvis. 1-2 weeks before birth, pregnant women with a narrow pelvis are recommended to be hospitalized in the pathology department to clarify the diagnosis and choose a rational method of delivery.

The course of labor with a narrow pelvis depends on the degree of narrowing of the pelvis. With a slight narrowing, medium and small size of the fetus, childbirth through the birth canal is possible. During childbirth, the doctor carefully monitors the function of the most important organs, the nature of labor forces, the condition of the fetus and the degree of correspondence between the fetal head and the pelvis of the woman in labor and, if necessary, promptly decides on a caesarean section.

The absolute indication for cesarean section is an anatomically narrow pelvis of III-IV degree of narrowing; the presence of bone tumors in the pelvis that impede the passage of the fetus; severe deformations of the pelvis as a result of trauma; the presence of ruptures of the symphysis pubis or other pelvic injuries during previous births. In addition, the indication for cesarean section is a combination of a narrow pelvis with a large fetus, post-term pregnancy, chronic fetal hypoxia, breech presentation, anomalies in the development of the genital organs, a scar on the uterus after cesarean section and other operations, an indication of the presence of infertility in the past, the age of the primigravida over 30 years old, etc. Caesarean section is performed at the end of pregnancy before or with the onset of labor.

References:

Obstetrics/Ed. G. M. Savelyeva. - M., 2000.
Bodyazhina V.I. Obstetric care in antenatal clinic. - M., 1987.

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 accumulation of adipose tissue, the amount of which varies greatly from person to person. different women. Therefore, despite external differences in the dimensions of the hips, 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 tazomer. 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 – distance that reflects the distance between the greater trochanters 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 absolute indication to an operation 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 different approaches are used. 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 of 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:

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

Features of the structure of the 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 of the lower limbs. It is formed as a result of the fusion of several bones: ischium, pubis, ilium. At the back they are connected to sacral region spine and serve to hold 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.

The period of 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 past 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, the level of medical care and the absence of child labor led to the disappearance of rachitic, kyphotic, oblique pelvis and severe degrees of curvature.

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 did it proceed previous pregnancies and childbirth;
birth weight of children;
whether there were ruptures and injuries, divergence of the symphysis.

This allows you to evaluate reproductive function, the possibility of giving birth 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. Not always parameters large pelvis may indicate the condition of the birth canal. Therefore, additional indicators are used:

The lateral conjugate is a gap equal to 14.5-15 cm. It is measured between the upper iliac spines on each side.
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.
Pelvic circumference is a conditional parameter, but 85 cm is considered normal.
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.
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.
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 the internal surfaces of the bones during a vaginal examination. They should be smooth, without irregularities, roughness and curvatures (exostoses). An experienced doctor can roughly estimate the capacity of the birth canal.

The use of x-rays or X-rays complements obstetric research methods. 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 severe 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 pictures on later 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 safe method examinations. 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 labor or intracranial injury;
anomalies of labor;
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 tissues 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, prematurely poured water will not allow the head to be inserted normally and form a contact zone. And a large number 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 the 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 this incident is relaxin, which loosens the cartilage tissue and relaxes the 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, 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. At late appearance Symptoms will take 3-4 weeks to recover.

Fistulas

The mechanism of formation is associated with prolonged 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 when connected to the rectum, and urine when connected to 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, disconnecting the canals of the vagina and rectum or bladder.

Danger to child

With a narrow pelvis, the newborn is also exposed to high risk cranial injuries. 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 birth occurs with a delay of several days or more, then the cartilage tissue has time to grow a little. Therefore, the fetal head will not be able to accept the configuration and will experience great 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 is dangerous with a narrow pelvis.

The level of modern medicine has led to a significant reduction in deformities of the pelvic bones. Therefore, mothers of girls should take care reproductive health daughters 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.