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Symphysiotomy as an alternative to cesarean section.

The author compares the value of symphysiotomy to cesarean section in the management of cephalopelvic disproportion. He outlines the history of the procedure and reviews the literature on the subject. He then presents results of 54 symphysiotomies performed from 1976 to 1983 in two rural hospitals in the southwestern highlands of Tanzania, together with the outcome of subsequent labor in 25 other women with a history of previous symphysiotomy. The risk of maternal mortality after symphysiotomy is lower than after cesarean section when performed for cephalopelvic disproportion. Although different in nature, maternal morbidity after both operations is equally common. In contrast with findings reported in the literature, a history of previous symphysiotomy still constitutes a high obstetrical risk. The author concludes that symphysiotomy has a place in the management of cephalopelvic disproportion.

Africa↗

Trial of labor following cesarean section--a study of 212 patients.

Data on the trial of labor of patients with a prior cesarean section are largely confined to studies in the First World. These results and methods may not apply to patients in developing countries. This trial studied the management of rural patients with a prior cesarean section, and tested exclusion criteria in use at the base hospital. Of those allowed a trial labor, 52% delivered vaginally. No maternal or fetal mortality occurred, and the outcome suggested a place for the controlled trial labor in selected patients.

Adolescent↗

Breech delivery: a critical evaluation of the mode of delivery and outcome of labor.

This is a retrospective study of 213 term, singleton, uncomplicated pregnancies presenting as breech. Thirty-two percent had elective cesarean section and 61% of those selected for vaginal delivery actually did so. Events in labor and fetal outcome suggest that vaginal delivery of a breech infant, after careful feto-maternal assessment, continuous fetal monitoring, adequate progress in labor and delivery by an experienced "midwife", provides comparable fetal outcome to delivery by elective cesarean section.

Adolescent↗

Pelvic assessment and cephalo-pelvic disproportion in Central Tanzania.

Among 201 primigravidae, pelvic assessment was analyzed prospectively during the third trimester to detect patients likely to suffer from cephalo-pelvic disproportion (CPD). If the sacral promontory (SP) was reached by the index finger (9.0-9.5 cm true conjugate) the pelvis was regarded as "suspect". All patients who later developed CPD were in this group. Of the screened primigravidas, 22% were advised to deliver in the hospital. Pelvic assessment is an important screening tool during antenatal care to detect high-risk primigravidas.

Cesarean Section↗

The relation of the true conjugate to maternal height and obstetric performance in Ghanaians.

The true conjugate was determined intraoperatively with a caliper in 114 Ghanaian women and was correlated with their height, obstetric performance and fetal dimensions. Those patients undergoing cesarean section for cephalopelvic disproportion (Group Ia) were found to have a significantly shorter mean true conjugate (9.54 cm +/- 0.63 S.D.) and mean body height (152.68 cm +/- 5.46 S.D.) and a smaller true conjugate - fetal biparietal diameter difference (10.93 mm) than those who had no cephalopelvic disproportion (Group Ib) and whose mean measurements were 10.61 cm +/- 0.81 S.D., 157.20 cm +/- 5.69 S.D. and 21.50 mm, respectively (P = 0.0001). Recommendations for appropriate referral of rural clinic patients and for selection of patients for repeat cesarean sections are based on the above findings.

Birth Weight↗

Perinatal mortality and cesarean section in Jos University Teaching Hospital, Nigeria.

The experience on perinatal mortality among 757 patients who underwent cesarean section in Jos University Teaching Hospital serving a high risk urban and rural population in Jos, Plateau State of Nigeria is presented. During the 2 years of study the cesarean section rate was found to be 4.4%. There were 69 stillbirths, 107 deaths during the first week of life giving a perinatal mortality rate of 235 per 1000. The possible factors responsible for this high rate are discussed and suggestions made to improve on this figure. These results were also compared with figures from studies carried out in other parts of Nigeria, and in other countries.

Adolescent↗

Short stature and cephalopelvic disproportion in Burkina Faso, West Africa. Operations Research Team.

In order to reduce maternal mortality due to cephalopelvic disproportion (CPD), it is important to screen women for short stature, especially in rural areas of developing countries. We measured the height of 1733 women as they left the maternity services in Ouagadougou and recorded the type of delivery. Women less than 155 cm tall were 4.9 times more likely to have a cesarean section delivery. We propose simplified screening criteria for use by traditional birth attendants.

Body Height↗

Movement of the human pelvis and displacement of related anatomical landmarks on the body surface.

Anatomical landmarks on the body surface can be measured with high accuracy by using rasterstereography and surface curvature analysis. The present study shows that the lumbar dimples can be localized with a statistical error of about 1 mm. It is generally assumed that the dimples are in close relation to the pelvis (in particular to the PSISs) and may thus be taken as indicators for pelvis movements. By introducing an artificial pelvis tilt of up to +/- 10 degrees this relation was examined. In fact, a nearly perfect correlation (r approximately equal to 0.99) between landmark and pelvis movements was observed. Asymmetries of pelvis motion due to scoliotic deformity were not observed. There was, however, a systematic lag of the dimple movements, resulting in a displacement of the dimples of up to +/- 1.5 mm relative to the pelvis (for +/- 10 degrees pelvis tilt). Either a soft tissue effect or a torsion of the pelvis may be responsible for this behaviour. The theory of pelvis torsion is confirmed by the fact that the orientation of the back surface at the locus of the dimples reveals a corresponding torsion of similar magnitude and sign. A torsion angle of about +/- 1.5 degrees in either sacro-iliac joint is sufficient to explain the observed dimple lag and the surface torsion. An independent measurement (e.g. using roentgenphotogrammetry) would be desirable to further validate this theory. According to our measurements the dimples of the PSISs cannot be taken as exact indicators for orientation and movement of the pelvis.(ABSTRACT TRUNCATED AT 250 WORDS)

Biomechanical Phenomena↗

Symphysis-fundus measurements in Asian and Caucasian women in Bradford.

A study was undertaken to assess the need for a separate chart of symphysis-fundus measurements for the large Asian population of Bradford. 129 measurements from 47 pregnant Asian patients were compared with 193 measurements from 87 pregnant Caucasian patients. There was insufficient evidence to support the production of a separate chart for the Asian population.

Asia↗

Safe motherhood: cesarean section or symphysiotomy?

The place of symphysiotomy in the management of cephalopelvic disproportion is discussed on the basis of the existing literature, reviewing maternal mortality and morbidity after symphysiotomy and the vaginal delivery rate in a subsequent pregnancy after a previous symphysiotomy. These are compared with the outcome of cesarean section performed in similar circumstances.

Cesarean Section↗

Cesarean section deliveries among adolescent mothers enrolled in a comprehensive prenatal care program.

A comparison was made of the incidences of cesarean section deliveries between mothers 18 years of age or younger and those 19 to 21 years of age, all of whom were enrolled in a comprehensive program of prenatal care. Also compared were the indications for surgical delivery between the two groups. The rate of cesarean section deliveries was 8.7% among mothers 18 years of age or younger, compared to 14.5% among mothers 19 to 21 years of age. The general-ward cesarean section rate at the same hospital was 19.4%. Since maternal height and weight, and infant's birth weight may affect the diagnosis of cephalopelvic disproportion, these parameters were also evaluated. However, these did not differ significantly between mothers 18 years of age or younger and those 19 to 21 years of age or between vaginal and surgical births in mothers 18 years of age or younger. Thus, cephalopelvic disproportion did not contribute importantly to the cesarean section rate.

Adolescent↗

The fetal-pelvic index has minimal utility in predicting fetal-pelvic disproportion.

OBJECTIVE: Our purpose was to evaluate the fetal-pelvic index in our patient population and to determine whether it would be predictive of route of delivery. STUDY DESIGN: One hundred seventy-six patients with a previous history or clinical findings in the current pregnancy suggestive of fetal-pelvic disproportion participated in this Human Investigation Committee-approved study. All underwent fetal ultrasonographic examinations and modified digital radiography before labor. Fetal head and abdominal circumferences and maternal inlet and midpelvic circumferences were determined, and the fetal-pelvic index was calculated. RESULTS: Ninety-one patients fulfilled all aspects of the study, including rigorous criteria pertaining to labor management. Thirty of these patients underwent cesarean delivery and 61 were delivered vaginally. The fetal-pelvic index value for the vaginal delivery group was -5.4 +/- 5.3, as opposed to -2.4 +/- 5.8 in the cesarean delivery group (P <.02). Notwithstanding this difference, the fetal-pelvic index had a low overall ability to predict fetal-pelvic disproportion (0.65) and had associated sensitivity and specificity of 0.27 and 0.84, respectively. Predictive thresholds other than zero were tested, but optimal predictive ability, at a fetal-pelvic index cutoff of 2, was only 70% (sensitivity 0.20, specificity 0.95). CONCLUSION: In our patient population the fetal-pelvic index was only moderately predictive of fetal-pelvic disproportion. Factors other than those assessed by the fetal-pelvic index are probably important in determining the route of delivery. Further studies are indicated.

Adult↗

In vivo ultrasonographic exposimetry: human tissue-specific attenuation coefficients in the gynecologic examination.

OBJECTIVE: The purpose of the current study was to determine in vivo, tissue-specific ultrasonic attenuation coefficients for each of the tissue layers comprising the anterior abdominal wall, uterus, and vagina with use of a quantitative multilayer tissue model. We wanted to validate the "homogeneous" tissue model-based Food and Drug Administration derating factor of 0.3 dB/cm-MHz applied to obstetric-use ultrasonography systems. STUDY DESIGN: With use of a 3. 0-MHz mechanical sector scanner and our previously tested exposimetry equipment, we obtained a set of at least 5 separate acoustic pressure waveforms from each test subject by placing a calibrated 7-element linear-array hydrophone in the anterior vaginal fornix while she was undergoing transabdominal ultrasonography. Corresponding sets of reference in vitro acoustic pressure waveforms were also recorded for each test subject in a 37 degrees C water bath. All linear measurements of individual layer thicknesses and total distances were made on-line with use of electronic calipers. A set of multiple and independent insertion loss values, denoted ILn, was calculated for path n between the abdominal surface and the hydrophone from n sonograms for each test subject. Each tissue layer type was identified and its thickness along each path n was measured. The thickness of tissue type m along path n was denoted by dnm. The only unknown quantities left were the attenuation coefficients Am of each of the m tissue layers for that test subject. The overestimated set of equations dnm Am = ILn was solved for Am with use of a nonnegative least-squares solution technique. RESULTS: With use of data from 162 independent insertion loss estimate paths, the overall tissue-specific attenuation coefficients for each of the tissue layer types, expressed as mean value +/- SD, were 2.3 +/- 1.5 dB/cm-MHz for the skin and subcutaneous layer, 3.1 +/- 2.5 dB/cm-MHz for skeletal muscle, 0.6 +/- 0.5 dB/cm-MHz for myometrium, and 3.6 +/- 2.7 dB/cm-MHz for the vaginal wall. The overall insertion loss assuming the "homogeneous" tissue model was 0.7 +/- 0.3 dB/cm-MHz. CONCLUSIONS: We have determined the specific ultrasonic attenuation coefficients for each of the tissue layers comprising the anterior abdominal wall, uterus, and vagina and validated the Food and Drug Administration derating factor of 0.3 dB/cm-MHz applied to obstetric use ultrasonography systems. Of all the models proposed, the "homogeneous" tissue model appears to be the best model for determining ultrasonic exposure risk during reproductive ultrasonographic examinations.

Abdomen↗

Comparative pelvimetric measurements in Nigerian and Welsh women.

The authors compared the pelvic measurements of a group of Nigerian women with those of a similar group of Welsh women. The Nigerian pelvis is smaller than the Welsh especially when account is taken of the Nigerian women being taller. Base-line data for radiologists working in Nigeria are provided.

Adult↗