HISTORY. Patients may have a family history of fetal macrosomia or pelvic contractures. Any personal history of rickets, scoliosis, or pelvic fracture should also be noted. Gestational diabetes, which may contribute to fetal macrosomia, may be present. Ask the patient about her prior deliveries to ascertain whether she has delivered an infant vaginally before.

PHYSICAL EXAMINATION. Determine the pelvic type of the woman. Android and platype-lloid pelvic classifications are not favorable for a vaginal birth; the gynecoid and anthropoid pelvis classifications are present in 75% of all women and are favorable for a vaginal birth. Perform an internal exam; the following findings indicate a contracted pelvis and a potential for FPD to occur if the woman becomes pregnant: ability to touch the sacral promontory with the index finger; significant convergence of the side walls; forward inclination of a straight sacrum; sharp ischial spines with a narrow interspinous diameter; and a narrow suprapubic arch.

346 Fetopelvic Disproportion

If FPD is suspected during labor, physical assessment should include pelvic size and shape; fetal presentation, position, attitude, and presence of molding or caput succedaneum of the fetal head (swelling on the presenting part of the fetal head during labor); fetal activity level; maternal bladder distension and presence of stool in rectum; duration, frequency, and strength of contractions; effacement and dilation of the cervix; and descent of the fetal head in relation to the mother's ischial spines. Common assessment findings with FPD during labor include delayed engagement of the fetal head, a lack of progress in cervical effacement, and dilation in the presence of adequate uterine contractions. If fetal hypoxia or hypoglycemia occurs, loss of fetal heart rate variability, late decelerations, or fetal bradycardia may be seen on the electronic fetal monitor. Fetal scalp stimulation may fail to elicit heart rate acceleration, and fetal capillary blood pH obtained by scalp sampling may indicate acidosis.

PSYCHOSOCIAL. Assess the patient and partner (or other labor support people present) for ability to cope with the difficult labor and ability to maintain a positive self-concept and role performance. Assess the presence of anxiety or fear related to the mother's or baby's well-being or to medical interventions such as forceps or vacuum extractor use or cesarean delivery. Feelings of exhaustion, disappointment, or failure are common.

Diagnostic Highlights

General Comments: FPD cannot be diagnosed except in rare cases without allowing labor to proceed for several hours. In labor, the pubic symphysis and other pelvic joints gain mobility under the influence of high levels of relaxin and other hormones. Therefore, evidence of lack of progressive dilation and fetal descent in labor is usually considered more important than pelvic measurement in diagnosing FPD.

Abnormality with

Test Normal Result Condition Explanation

Clinical pelvimetry Diagonal conjugate Diagonal conjugate An adequate pelvic inlet and

>11.5 cm; outlet >8 cm <11.5 cm; outlet <8 cm outlet is needed for a vaginal delivery

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