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Clinical and roentgen pelvimetry: A correlation
CLINICAL (From
AND
ROENTGEN
the Department
of
Obntctrics,
PELVIMETRY: l:nirrrsity
of
A CORRELATION” Jlnrylnnd
School
of
ALerl%cinri
C ONTROVERSY pelvimetry has
regarding the rrlative merits of clinical and roentgen I)irergent opinions exist, from the aroused our interest. concept that the x-ray’is unne~ssary and that clinical pelvimetry is all important, to the teaching that the x-ray is the final answer to all pelvic dystocia problems. At the outset,, we would like to agree with Eastman’ who states that the truth lies somewhere between these two extremes. We here present a review of our experiences with 200 cases followed in the dpstocia clinic of the T)epartment of Obstetrics at the TJniversity Ilospital. Patients screened from the prenatal clinic who have clinically abnormal pelves, history of previous dystocia, cesarean section, or unexplained stillbirth are There, tletailed pelvic estimation is perexamined in the dystocia clinic. formetl and roentgen Ijelvimetry ordered nea.r term if indicated. At about 38 weeks of ljregnancy the patient is examined clinically, her films evaluated and a prelabor estimation chart is completed. Copies of both the clinical pelvimetry record and prelnbor thstinlation chart are filed in the delivery suite for reference during labor and delivery. J’ollowing delivery, the patients are again seen in the clystocia clinic for their regular postnatal examination, and at this time each case is reviewecl in retrospect and suggestions made for the manayement of subsequent l’regnancies. TT’e have omitted the classical esternwl measurements of the pelvic inlet for several years.
Methods
and Material
Roentgen pelvimetry is performed in the s-ray department of the University Hospital, the Walton2-MeTlane” isometric method being used. Three films are -rout,inely made, namely; (1) N 14 by 17 inch Bucky anteroposterior film of the abdomen with the patient in the supine position, for general information; (2) an I1 by 14 inch liucky anteroposterior film at 30 inches from the maternal pelvis with the patient in a semireclining position, the pelvis tilted forward so that, the inlet, is parallel with the film; and (3) a 14 by 1’7 inch Bucky lateral film with the patient in the same position as for film number 2, but with a notched metallic centimeter rule upright between her legs, as close to the symphysis pubis as possible. Pelvic diameters are measured directly on the lateral film, but a distortion or false centimeter scale must be used in measuring the diameters on the anteroposterior film, taking into consideration the distance bet,ween the film and the top of the table upon which the patient is resting. We have enjoyed the complete cooperation of the X-ray Department under the dire&ion of Dr. Walter L. Kilby. *Read, Obstetricians. 1950.
by
invitation, Gynecologists
at
the Sixty-first and Abdominal
Annual Surgeons,
809
Meeting Hot
of the Springs,
American 1-a.. Sept.
Association 7. 8, and
of 9,
Death in utero 1 week before labor Forceps, shoulder dystocia, anoxia Forceps, atelectwia c-)nl: Neonatal deaths Forceps, intracranial hemorrhage Spontaneous, atelectasis onlv fetal ___-..--.Tots1 . ..~.mortality ‘I~‘\l~l>E I I. -xal
MATEN~AL
MOTbi~~~~~~~-.-~:-~~~~=~~=~~=~
MOIBDITY x ~--
---
AND COMPTXATIONS -----~ ~~~ .-- -:-~~--
Endometritis, puerperal Pyelonephritis and cystitis, puerprrxl Pneumonia, postoperative Perineum, cellulitis of, acute Ileus, adynamic, postoperative Infection, intrapartum Total Mater/la1
Complications.-
- ---1% 5 r, .i ; 1 3
--------my
-- ---.I
14.5c,;
-
Perineum, laceration of rompletc Preeclampsia, severe Rh negative, no antibodies Hemorrhage, postpartum (500 r.r. or mow 1 Erythema multiformr Tuberculosis, pulmonary, arrested Cardiovascular disease, rheumatic, Grade I. Total
I-I 4 :: 2 ! .I 1 26
and 50 There were Xi white and 175 Negro patients, 150 primigravidas multigravidas. There were no maternal deaths; and there was an uncorrected fetal mortality of 5 or 2.5 per cent (‘Fable I). The maternal morbidity rate Table II also shows maternal complications, of was 14.5 per cent (Table II). which there were 74 complete perineal lacerations. This is a high inci&nce of this complication in a series of 200 eases. Wowerer, it should he rememherecl
Vdume 61 Number 4
CORRELATION
OF
CLINICAL
AND
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811
PF:T,VIMETRT7
that all of these patients were delivered by house officers in the process of t.raining, and that many of these patients had contracted pelves. All lacerations were repaired immediately and healed per primam without complication.
Definitions In order to facilitate an understanding of the various concepts in this paper, which include clinic policy in many instances, the following definitions are given here and the terms are not further defined in the text. Normal pelves are those with Mengert* indices for inlet and midplane greater than 125 and 105, respectively. Contracted pelves are those with Mengert* indices for inlet and midplane of 125 and 105 or less. Normal deliveries are spontaneous or elective outlet forceps deliveries, while necessary operative deliveries include all other types of deliveries and represent the group in which dystocia is said to have occurred. Prolonged labor is actual labor lasting 24 or more hours. Prolonged second stage of labor is that condition in which complete cervical dilatation has existed for 2 or more hours, and is taken, along with other factors, as indication for operative delivery. A premature baby is one weighing less than 2,500 grams at birth. Extraperitoneal section usually means one of the Norton type, and in this series this operation was frequently done for teaching purposes and not for actual indication.
Reasons for Referral
of Patients
to Dystocia
Clinic
Table III shows the reasons why patients were referred to the dystocia clinic. The patients comprising the major group, 162, were referred because their pelves had been classified as contracted at original clinical examination. That the diagnosis of contracted pelvis is made clinically more often than it is present., a concept pointed out by Groskloss, Robbins and Moehn5 is substantiat.ed by our data. Of the 162 patients referred because of cbnically contracted pelves, only 79, or 42.5 per cent, were found by study of the x-ray films to have contracted pelves (Table IV). Of the 42 patients with inlet contraction only 18, or 42.8 per cent, had dystocia. Of the 19 patients having midplane and inlet contraction together, 10, or 52.6 per cent had dystocia. There we.re 18 patients with midplane contraction only, and 12, or 66.6 per cent, had dystocia. However, a total of 37 patients had midplane contraction, and of these, 23, or 62.1 per cent, had dystocia. (See also Table XII.) Therefore, the significance of the midplane as a factor in dystocia is emphasized, and is in a,greement with t,he findings of Eller and Mengert.6 -____ -
TABLE III. Clinically Previous
REASON FOR REFERRAL TO DYSTOCIA CLINIC
contracted pelvis cesarean section of previous dystocia
History History of previousstillbirth Breech in primigravida Dystocia dystrophia syndrome Elderly primigravida Long period involuntary sterility Primigravida with floating head
162 16
14 2 2 1
1 1
at term
Total
1 200
Types of Pelves Encountered Since the Caldwell-Moloy’ classification seemed to us to be the most practGcable, pelves were tabulated morphologically according to this method, in
Prolonged
Labor
In the eutirc series there we~c 17 patients, X..j pry* cent, in whom I&Jwas classified as l)rolonged (Table ‘I’1 1. Of these. the shortest labor was 24 hours; the longest 48 hours; a.11~1the avenge 3X.5 hours. The pPe&ctjon of prolonged labor was made in only one instance by the tlystocia clinic, and jn the x-ray department only twice. Tahte VI shows that there was prolonged labor in 9 patients with contractecl pel\-es, and in 8 with normal pelves. While this series is small. it at least points to the fact that the1.e a~ other facto~*s besick eontractetl pelvis involved in the prolongation of labor. III only :? cast’s were excessivcqizetl infants fonnd ; alld IhelY was one fetal death.
Cesarean section Thirty-two cesarean sections were performed in this series, an incidence of 16 per cent. Table VII shows the clinic incidence of cesarean section fol* the year 1948-1949 to be 2.94 pela cent. The high incidence of cesarean section in this series was not unexpected since these were segregated cases in which the incidence of abnormality was high, and a large number of patients who had had previous cesarean sections a~ppearin this sex-ies. Maternal morbidity
813
Vulnme 61 Number 4
CORRELATION
occurred operative mortality
in ‘7 cases, an incidence of 21.8 per cent. Two patients had postpneumonia, and 5 had pnerpcral endometritis. There was no fetal in this group.
OF
P&longed labor Forceps Cesnredn
in
CLINICAL
contracted
A?JD
ROENTGEX
PELVIMETRY
pelres
section
Prolonged labor in normal Forceps Cesarean section Rreeqh extraction mortality Stillbirth-shoulder Fetal weights
pelves
Fetal
2,500-3,000 grams 3,000.3,500 grams 3.500-4.000 trranlY 4:OOO &ams"and
---
TABLE
dpetocia
over
VII.
__-
Aivar,~srs
OF CESAREAN
-.B
3
SEWIONS NTiMBER
sections Clinic incidence 19LLS-19 Indications 1. Previous s&ion with contracted pelvis (no labor) Contracted inlet only Contracted inlet and midplane Contracted midplane only 2. rndicated after trial labor Contracted inlet only Contracted inlet and midplane Contracted midplane only 3. [ndicatio,n other than fetopelvic relationship Premature separation of placenta Pre-eclampsia! fulminating Uterine inertia, primary 4. Previous section only .?. -Elective, para OOOO! breech, contracted inlet 6. IElective, elderly primigravidx, contracted inlet, 7. .Elective, previous stillbirth, contracted inlet 8. .Elective, para 0000, markedly contracted pelvis Types Laparotrachelotomy Extraperitoneal Maternal morbidity Fetal mortality
Previous
PER
32 92
Cesarean
CESl'
16.00 2.94
13 ;
1 11 9 1 1 3
1 1 1 1
1 1 25 7 7 0
Section
Sixteen patients who had had one or more previous sections were encountered in our group, an incidence of 8 per cent (Table VIII). In our clinic routine placentography is performed in all patients who have had a previous section. In this series 5 placentas were found by s-ray to be ‘located beneath the previous operative site. In such instances it is our usual practice to perform an elective repeat section-not so much hecause we fear an increased incidence of rupture of t,he uterus, but because, if rupture should
OCCUI’, it, would be intinitely more j,rmidable to both mother will be noted that only t,wo paGents wt~rr rleliverwl vaginallg prfbvions sections.
--~~~~~~~~~~~
-~ ~~ -..-.
NUMBER .--
.- ..- _-
anc( ljab>. 11 wl-ic~ had h;ld
..-
.-.
PER -.-
lfi
delivery, term baby Contracted pelvis Abdominal delivery Previous section and contracted pelv. Previous section only Types of section, laparotrachelotum) Maternal morbidity Puerperal endometritis Placentography showed placenta under war
p
Pelvic
Prema.ture
CEIST .._..
Q.ig
%, I4 I3 1 14 ,> *, in
.i
Delivery
From Table 1X we observe that there were 13 premature deliveries, or 6.5 per cent for the series. Twelve patients were delivered vaginally, and one abdominally. All premature babies survived. The clinical concept that premature labor occurs more frequently in patients with contracted pelvcs was not borne out by our study since the clinic incidence of all premature livebirths in the year 1948-1949 was 6.8 per cent, while the incidence of pre,mature delivery in the contracted pelvis group in this series was 4.32 per cent.
Contracted pklvis Normal pelvis Vaginal deliverv Abdominal deliver! Fetal mortality
7 ti
.4X0/<, I:! I il
Excessive-IJised
Infants
Table X shows that there were 5 infan& weighing o\:er 4,000 grants. one stillbirth in this group was due to shoulder dystocia. ‘I’ABI>E
x.
INI”AN’I’S
\~ElGtllNLi
O\‘r:K
__._------...-----.~ --.. - ~~-...-. -~Excessive-sized infant Vaginal deliverv abdominal deli&-y Contracted pelvis Normal pelvis Stillbirth (shoulder
dsstociai
4,000
‘l‘tttt
c;K-h&fs
..~ .~--_ . .
II 4 I ”. . .I i
A total of 27 abnormal presentations and positions, or 13.5 per cent, occurred in this series, the data being presented in Table XI. In the entire series 17 occiput posterior positions (8.5 per cent) were encountered. Of a total of 49 anthropoid pelves in the series, 8 were associated with occiput pos-
Volume 61 Number 4
CORRELATION
OF
CLINICAL
AND
ROENTGEN
815
PELVIMETRY
terior position, and all of these patients were delivered vaginally. In 9 patients, 01: 4.5 per cent, breech presentation occurred. Three were delivered abdominally, 2 because of previous section with contracted pelvis, and the third because of a very small android pelvis in a primigravida. Pelvic delivery in breech presentation was undertaken when the fetus was estimated to be small and pelvic studies failed to reveal major pelvic contraction. There was one premature breech delivery and there was no fetal mortality. There was only one transverse lie which occurred in a patient with a small androitl pelvis. -____ --__ -~___
TABLE
XI.
PRESENTATIO~L-
AND POSITION KUMBER 17 8
Occiput posterior position Anthropoid pelves associated Pelvic delivery Indicated operative delivery Abdominal delivery Breech presentation Normal pelvis Pelv$ $4:;;;~
PER CENT 8.5
-
14 14 3
9
4.5
6 6
5 1
PFemature Contracted pelvk Abdominal delivery Average fetal weight : Transverse presentation Abdominal deliverv
3
3 2,833
grams 1
0.5
1
Midplane
Contraction
Table XII presents data concerning 3’7 patients, 18.5 per cent, who wert’ found to have contracted midplanes either alone or in association with inlet Twenty-three, or 62.1 per cent, who had midplane contraction contraction. experienced dystocia. This incidence of dystocia would appear high in view of the over-all incidence in the series of 46 per cent. However, it is in line with Eller and Mengert’@ observation that there is a high incidence of necessary operative delivery in midplane contraction. There was a fetal mortality of two in this group, one being a fetus which died in utero one week prior to the onset of labor, while the other was a neonatal death following forceps clelivery. Autopsy in this case disclosed intracranial hemorrhage. TABLE
XII.
MIDPLANE
CONTRACTION
IN WHITE
AND NEGRO
Tota, ------~--4~
PATIENTS
NUMBER
PER CENT 2.0
Wi2t.e No dystocia Dystocia Premature, pelvis Fetal mortality
1 2
not
tested
Negro
1 0 Total
No dystocia Dystocia Premature, pelvis Fetal mortality Prolonged labor
not
tested
16.5
2
2 4 Total
Dystocia Dystocia
33
10 21
in entire series in midplane contraction
37
92 23
18.5 46.0 62.1
Comparison
of Clinical
and Radiologic
Data
Table Xl11 represents the results (it’ our. clinical c*lassificatiult of pel~rs in the dystocia clinic: on original pel\-ic estimation its compared with ~ht~ radiologic classification. It will he ohser\-rd that ow pr*edic*tions wer’e corset in 1% cases, or 622 per cent ; and th;il the pelvic* tJvl)tb trrisdi;ipnosetl IUliSi frequently clinically was t,hr arrthropoi*i fppe. a total ctt’ ~31such pelves I)ritls missed.
During out’ fo~ruative period in the dystocia clinic, which this survey covers, we attempted only to predict the outcome of labor as to pelvic ot abdominal delivery,. In the routine ra.diologic report, the X-ray Uepart~rnent also makes a prediction as to outeonre. Table XIV shows a comparison of the results in this speculative field. In all fairness to the radiologists! if must he pointed out that we in the dystocia clinic had the decided advantage of our clinical examinations of the patient as well as our own study of the s-ray films to aid us in making our predictions. The value of trial labor in pelvic contrxctiotr is adequately demonstrat~etl here when we consider that this was the course followed in the 17 cases which were delivered vaginally after the X-ray Department, had suggest,ed or stated as probable abdominal delivery. In a clinic where complete reliance is placed on s-ray pelvirnetry, it is possible that 17 additional and unnecessary eesarean sections might hare heen performed.
Another factor which findings was the direction
we checked in our clinical est.imation agaiust x-ray of the inclination of the side walls af the p~~lvis,
Vulrxmehl iTumber
CORRELATION
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CLINICAL
AND
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817
PELVIMETRY
4
recording our impression as convergent, straight, or divergent. Our clinical impressions were correct in 116 cases, or 58 per cent; and incorrect in 84, or 42 per cent. TABLE
(!LINICAL
XV.
,&xTY-$'I~E CASES IN WHICH CLINICAL MEASUREMENT OF TRANSVERSE ISCHIAI, DIAMETER OF PELVIC OUTLET WAS 8.5 TO 6.5 CM. MEASLIREMEXT OF TRANSB. DIAMETER OF OCTLET, CM.
ISCRIAL
Total cases Midplane interspiuous diameter 9.0 cm. or lws Mengert ‘s midplane index 105 or less Contracted inlet associated Premature, pelvis not tested Elective section Remaining cases Dystocia No dgstocia -___
(
8.5
(
:;
1 ::
1 :;
(
:: ITOTA& ~.--___
30 6 11 11 4 4
23 3 6 9 0 3
9 0 0 3 1 0
L’ 1 1 1 :
1 0 1 0 0 0
9 13
9 11
0 8
1 1
0 1
65 10 19 24 5 7 53 19 34
100 15.3 29.2 36.9 100 35.8 64.1
We were interested to learn whether or not a small clinical measurement of the t,ransverse ischial diameter of the pelvic outlet pointed to pelvic contraction in other planes of the pelvis. Table XV shows our data in 65 cases in which this clinical measurement ranged from 8.5 cm. to 6.5 cm. It will be observed that the midplane interspinous diameter was found t,o be 9.0 cm. 22 NO. CASES
20 16 16 14 12 IO 6 6 4 2
O.C. IN CM.
(x-ray) in 92 cases in which diagonal conjugate was measured at 115cm., or more. (after Dlppel).
or less in only 10, or 15.3 per cent; and Mengert’s midplane index of 105 or less was found in 19, or 29.2 per cent. It was noted that in 24, or 36.9 per cent, a contracted inlet was associated with a contracted outlet. Dystocia was encountered in 19, or. 35.8 per cent. It may therefore be stated that our data show clinical contraction of the transverse ischial diameter of the pelvic outlet may point to contraction at the midplane in one out of every 35’2 cases, and to contraction at the inlet in one out of every 3 cases.
NO. CASES
6
4
2
CENTlMETt
:l?s
Conjugate equal to or-greater IDiaganat than Obstetrical Conjugate. 76 cases.
Obstetrical Conjugate greater 1 than Diagonal Conjugate. 32 caada
Fig. 2 Distribution of the difference Obstetrical Conjugate in 108 cases
Diagonal Conjugate and the Diagonal Conjugate was
11.5
cm,
or less.
(after
between in which
Dippel).
We have attempted to demonstrate the significance and teaching value of the dystocia clinic in correlating clinical and roentgen pelvimetry. We would not wish to rely completely upon either of these methods because we believe that by a combined study we obtain ati over-all impression of the architecture and capacity of the pelvis under consideration which would not be available from either method alone. While it is realized that the trained obstet,riciarl can determine those cases in which x-ray pelvimetry should be done, certainly there are many hdividuals, devoting at least: II I)art of their time to the
Vcblilmc5 01 Nllmher 4
CORRELATION
OF
CLINTCAT,
AND
ROENTGEN
819
PELVIMETRY
practice of obstetrics, who do not have this skill. Therefore, it is recommended that all of us teach that routine x-ray pelvimetry in the primigravida should be an essential part of prenatal care. Since satisfactory methods of cephalometry and x-ray measurement of the transverse ischial diameter of the pelvic outlet are not available, these were not studied in our cases. C’lassical external measurements of the pelvic inlet, are omitted in our clinic. This concept is in agreement with that of Eastman,’ Greenhill,‘” and Titus.” The maternal morbidity rate was 14.5 per cent, the major cause being 1X cases of puerperal endometritis. The chief maternal complication was complete perineal laceration in 14 cases. We have found Mengert’s indices extremely useful as an aid in classifying pelves as contracted or not contracted. Trial labor is strongly advocated in all but grossly contracted pelves and when accompanied by vertex presentations. We believe that clinical and x-ray pelvimetry are not irreconcilable but complement each other and are of equal importance in the study of the obstetrical pelvis, and, combined, they give us invaluable assistance in the solution of clinical dystocia problems.
Summary and Conclusions 1. Two hundred are preserrted.
cases studied
by combined
clinical
and x-ray
pelvimetry
2. There was no maternal mortality; and an uncorrected fetal ,mortality of 5, or 2.5 per cent. 3. Of 162 patients referred to the dystocia clinic because of suspected contracted pelves, 79, or 42.5 per cent, were found to have contracted pelves by application of Mengert ‘s indices. 4. Anthropoid pelves barely incidence of necessary operative platypelloid groups.
outnumbered android delivery was highest
in this series. in the android
The and
5. The cesarean section incidence was 16 per cent in this series as compared to the clinic incidence of 2.94 per cent. 6. Fourteen of 16 patients who had had previous cesarean sections were subjected to repeat section. 7. The incidence of prematurity in our series was not increased over the general clinic incidence. 8. A total of 27 abnormal presentations and positions, or 13.5 per cent, was encountered. 9. Of 37 patients who had midplane contraction, 23, or 62.1 per cent, had The incidence of midplane contraction was 18.5 per cent. dystocia. 10. From clinical pelvimetry the pelvic type was correctly 62.5 per ce:nt; while the type of delivery (pelvic or abdominal) predicted in 95.23 per cent.
predicted in was correctly
References 1. 2. 3. 4. 5.
Eastman, Walton, &IcLane,
Mengert, Groskloss,
N. J.: Old. H. J.: Surg.,
& Gpx. rC;urvey 3: :wlj 194x. Gynec. % Obst. 53: Xfi, 1~31. t‘. M.: AM. J. (h3T. & (+YNEt’. 50: -l!ls, 1!&5. W. F.: .I. A. Xl. x. 138: 169, 194X. IT. H., RljIllsius, 0. F., and Afo+>hn. .J. ‘I’.:
AM
.I. C&is?. 6 (+YxE~‘.
56:
111911.
1948. fi. 7. 8. 9.
10.
ii
&ST
READ
STPKEt:‘l
Discussion DR. PAI’L Tl’VCS, Pittsburgh, Pa,----‘i’hP first, point allout Dr. Savage’s paper to l,e commended is that there should be correlation between these Iwo methods of pelvimetry. roentgen pel~imetry has acIded to the informatioa to Neither met,hod displaces the other; lw gained from clinical ylvimetry so that :r~‘c’w’~~‘~- of predirtions regarding dystoeia has heen greatly increased tug t,hia c*orrel:Lti~rrl I~vtwe~~n methods. Two findings in this study arc cnlxvialiy worthy of cv,nrment. Dr. Savage rea,tirm~ the belief that outlet vontraction in the l,idixlliai tlian~rter ja clinical measurement) will l)e accompanied in at least one-third of all instances by sigrritirant midplane contratt ir)ll (*an x-ray finding of greatest import:tnrP j. He repeats the entirely rclrrevt vonteution that the linding of a diagonal conjugatt% Ftow-everl a longer diagonal conjugate does of 11.5 cm. ix a definite indication for a-r:,?. dystocia can occur in an anthropoid Cype not make an x-ray unneressarv beeaunr~ serious of pelvis. I van make 110 more than a small contrif,ution to thiH excellent paper. What I wish to ofier is a capp of the x-ray obstetrical Chart used in the Ht. Margaret Memorial Hospit,al It combines the essential diameters taken by the Thorns technique with in Pittsburgh. the area estimations of hlengert, vonrbinrs thv (‘ald\~.ell-R~ctloy and the Thorns morphologic classifications, presents tables of normal diameters for reference, and in addition tl, the x-ray study has a #pace for the obstetrician% evaluation of the films and his prediction based on this correlated with his clinical findings.
Volume 51 Number
4
CORRELATION
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8”l_
PELVIMETRY
with the views presented DR. J. BAY JACOBS, Washington, I). C.--l ai II in accord by the essayist. I believe that all obstetricians should evaluate pelves as described. I have been following this procedure since 1928, both in pri\-ate and clinic practice, I like the method l)y which Dr. Savage selects his eases for the dystocia clinic-those patienta who have had previous cenarean section, history of previous dyxtoeia, unexpla.ined stillbirth, prolonged labor, or who actuall,v xppwr to hxve :L rwntmctwl or llortlerline pelvis; that, just about tovers the field. It merits
is surprising that and x-ray pelvimetry.
there is any They both
question about the have definite value.
evalmtiion
of
external
~nc~a~ure-
I am opposed to discarding external measurements, from the teaching point of view-. We know that where the external conjugate is diminished markedly in size, one might expect difficulty. That of course, depends upon the type of individual; for instance, sue11 factors as the amount of adiposity, the thickness of skeletal bones and the general strut-
DR. ‘I’. I,. MONTGOMERY, Philadelphia, Pa.--1 have been particularlyiuterestetl in this paper because it presents the organization of a clinic ffn The rtudy of disproport,ion in a teaching institution and illustrates especially well how such R. elinir* raan be correIated in the educationa program. That, 1 feel, is an exceedingly important. consideration, especially that these cases shoulll not br withdrawn from the general rliuic cc here students have contart with them and have an opportunity lo study this problem with competent instructors. The problem of whether x-ray pelvimetry shall or shall not he taught is rather an academic aubjent. I think all of us realize that x.ray pelvimetr> is a relatively small part. I sometimes wonder whether if the x-ray techniques are routinely employed ihe resident or the intern would really study the pelvis and study t.he anatomic eontlgnration and the relation as if external pelvimetry were not. practiced. Routine x-ray of our , R medium of insisting prunigravtda patients 1s a 1 least upon the general relationship.
Volume Number
61 4
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823
And again, from the academic standpoint, I think much can be said for it, but I am not sure yet, and I am not sure that anyone is certain, that x-ray is entirely unharmful, particularly where x-ray may have to be repeated later. There have been so many instances where we have had to change our mind at a later date, realizing that what we have been doing has been detrimental. I would like to hold off on the x-ray until we have clinical evidence of disproportion. I would rather hold fire until the patient is in labor. Granted that these studies should be made often, it is most helpful to repeat the x-ray during labor and often the information with regard to the fetal head or fetal parts, and partieularl, after rupture of the membranes, is the important consideration in the final decision as to what should be done. DR. E. L. KING, New Orleans, La.-1 feel that we should by all means teach ant1 practice clinical pelvimetry. In doubtful cases I believe that we .should do both clinical and x-ray studies. In many primigravidas, granted the fetus is not too large, we can determine whether it can come through by clinical methods alone. If in doubt we fall lntek on the x-ray; also in multigravidas who have had trouble or in whom there is evidence of’ a small pelvis. The Mengert index is good but it must be correlated with the size of the baby. The roentgenologists who do our work give us very good estimates of the size of the fetal head. We have checked this many times immediately after delivery, especialI) after cesarean section, when the head has not been molded, and we find very close correlation. DR. SAVAGE (Closing).-In regard to Dr. Jacobs point concerning exact cephalometry, we have not had the good fortune he has had in his clinic to correlate exactly the actual measurements of the diameters of the fetal skull with those obtained roentgenographically. We do agree with him that the degree of maturity of the fetus and many other valuable considerations regarding cephalometry may be obtained from the films. We also agree that the films taken during labor are very valuable. Many of the cases we presented had lateral films taken during labor. We agree that 14 complete lacerations of These patients were all delivered over midline epithe perineum are not to be desired. siotomies, which are routine in our clinic, and I think that probably explains the high incidence in this group. In reference to Dr. Montgomery’s remarks concerning the routine x-ray, you eee from our presentation we are not doing it but simply advocating it so that we were speaking of the ideal in clinics such as that of Thorns, where all patients have routine roentgen pelvimetry. We agree with Dr. Montgomery that x-ray is valuable, and further agree with Dr. King that clinical and x-ray studies of the pelvis should go hand in hand. We We also agree with Dr. King that we must do not wish to displace one with the other. correlate the architecture as well as the indices of the various planes with the size of the baby, the presentation, the forces of labor, and all other factors which enter into the management of dystocia.
AND
ROENTGEN
the Department
of
Obntctrics,
PELVIMETRY: l:nirrrsity
of
A CORRELATION” Jlnrylnnd
School
of
ALerl%cinri
C ONTROVERSY pelvimetry has
regarding the rrlative merits of clinical and roentgen I)irergent opinions exist, from the aroused our interest. concept that the x-ray’is unne~ssary and that clinical pelvimetry is all important, to the teaching that the x-ray is the final answer to all pelvic dystocia problems. At the outset,, we would like to agree with Eastman’ who states that the truth lies somewhere between these two extremes. We here present a review of our experiences with 200 cases followed in the dpstocia clinic of the T)epartment of Obstetrics at the TJniversity Ilospital. Patients screened from the prenatal clinic who have clinically abnormal pelves, history of previous dystocia, cesarean section, or unexplained stillbirth are There, tletailed pelvic estimation is perexamined in the dystocia clinic. formetl and roentgen Ijelvimetry ordered nea.r term if indicated. At about 38 weeks of ljregnancy the patient is examined clinically, her films evaluated and a prelabor estimation chart is completed. Copies of both the clinical pelvimetry record and prelnbor thstinlation chart are filed in the delivery suite for reference during labor and delivery. J’ollowing delivery, the patients are again seen in the clystocia clinic for their regular postnatal examination, and at this time each case is reviewecl in retrospect and suggestions made for the manayement of subsequent l’regnancies. TT’e have omitted the classical esternwl measurements of the pelvic inlet for several years.
Methods
and Material
Roentgen pelvimetry is performed in the s-ray department of the University Hospital, the Walton2-MeTlane” isometric method being used. Three films are -rout,inely made, namely; (1) N 14 by 17 inch Bucky anteroposterior film of the abdomen with the patient in the supine position, for general information; (2) an I1 by 14 inch liucky anteroposterior film at 30 inches from the maternal pelvis with the patient in a semireclining position, the pelvis tilted forward so that, the inlet, is parallel with the film; and (3) a 14 by 1’7 inch Bucky lateral film with the patient in the same position as for film number 2, but with a notched metallic centimeter rule upright between her legs, as close to the symphysis pubis as possible. Pelvic diameters are measured directly on the lateral film, but a distortion or false centimeter scale must be used in measuring the diameters on the anteroposterior film, taking into consideration the distance bet,ween the film and the top of the table upon which the patient is resting. We have enjoyed the complete cooperation of the X-ray Department under the dire&ion of Dr. Walter L. Kilby. *Read, Obstetricians. 1950.
by
invitation, Gynecologists
at
the Sixty-first and Abdominal
Annual Surgeons,
809
Meeting Hot
of the Springs,
American 1-a.. Sept.
Association 7. 8, and
of 9,
Death in utero 1 week before labor Forceps, shoulder dystocia, anoxia Forceps, atelectwia c-)nl: Neonatal deaths Forceps, intracranial hemorrhage Spontaneous, atelectasis onlv fetal ___-..--.Tots1 . ..~.mortality ‘I~‘\l~l>E I I. -xal
MATEN~AL
MOTbi~~~~~~~-.-~:-~~~~=~~=~~=~
MOIBDITY x ~--
---
AND COMPTXATIONS -----~ ~~~ .-- -:-~~--
Endometritis, puerperal Pyelonephritis and cystitis, puerprrxl Pneumonia, postoperative Perineum, cellulitis of, acute Ileus, adynamic, postoperative Infection, intrapartum Total Mater/la1
Complications.-
- ---1% 5 r, .i ; 1 3
--------my
-- ---.I
14.5c,;
-
Perineum, laceration of rompletc Preeclampsia, severe Rh negative, no antibodies Hemorrhage, postpartum (500 r.r. or mow 1 Erythema multiformr Tuberculosis, pulmonary, arrested Cardiovascular disease, rheumatic, Grade I. Total
I-I 4 :: 2 ! .I 1 26
and 50 There were Xi white and 175 Negro patients, 150 primigravidas multigravidas. There were no maternal deaths; and there was an uncorrected fetal mortality of 5 or 2.5 per cent (‘Fable I). The maternal morbidity rate Table II also shows maternal complications, of was 14.5 per cent (Table II). which there were 74 complete perineal lacerations. This is a high inci&nce of this complication in a series of 200 eases. Wowerer, it should he rememherecl
Vdume 61 Number 4
CORRELATION
OF
CLINICAL
AND
ROENTGEN
811
PF:T,VIMETRT7
that all of these patients were delivered by house officers in the process of t.raining, and that many of these patients had contracted pelves. All lacerations were repaired immediately and healed per primam without complication.
Definitions In order to facilitate an understanding of the various concepts in this paper, which include clinic policy in many instances, the following definitions are given here and the terms are not further defined in the text. Normal pelves are those with Mengert* indices for inlet and midplane greater than 125 and 105, respectively. Contracted pelves are those with Mengert* indices for inlet and midplane of 125 and 105 or less. Normal deliveries are spontaneous or elective outlet forceps deliveries, while necessary operative deliveries include all other types of deliveries and represent the group in which dystocia is said to have occurred. Prolonged labor is actual labor lasting 24 or more hours. Prolonged second stage of labor is that condition in which complete cervical dilatation has existed for 2 or more hours, and is taken, along with other factors, as indication for operative delivery. A premature baby is one weighing less than 2,500 grams at birth. Extraperitoneal section usually means one of the Norton type, and in this series this operation was frequently done for teaching purposes and not for actual indication.
Reasons for Referral
of Patients
to Dystocia
Clinic
Table III shows the reasons why patients were referred to the dystocia clinic. The patients comprising the major group, 162, were referred because their pelves had been classified as contracted at original clinical examination. That the diagnosis of contracted pelvis is made clinically more often than it is present., a concept pointed out by Groskloss, Robbins and Moehn5 is substantiat.ed by our data. Of the 162 patients referred because of cbnically contracted pelves, only 79, or 42.5 per cent, were found by study of the x-ray films to have contracted pelves (Table IV). Of the 42 patients with inlet contraction only 18, or 42.8 per cent, had dystocia. Of the 19 patients having midplane and inlet contraction together, 10, or 52.6 per cent had dystocia. There we.re 18 patients with midplane contraction only, and 12, or 66.6 per cent, had dystocia. However, a total of 37 patients had midplane contraction, and of these, 23, or 62.1 per cent, had dystocia. (See also Table XII.) Therefore, the significance of the midplane as a factor in dystocia is emphasized, and is in a,greement with t,he findings of Eller and Mengert.6 -____ -
TABLE III. Clinically Previous
REASON FOR REFERRAL TO DYSTOCIA CLINIC
contracted pelvis cesarean section of previous dystocia
History History of previousstillbirth Breech in primigravida Dystocia dystrophia syndrome Elderly primigravida Long period involuntary sterility Primigravida with floating head
162 16
14 2 2 1
1 1
at term
Total
1 200
Types of Pelves Encountered Since the Caldwell-Moloy’ classification seemed to us to be the most practGcable, pelves were tabulated morphologically according to this method, in
Prolonged
Labor
In the eutirc series there we~c 17 patients, X..j pry* cent, in whom I&Jwas classified as l)rolonged (Table ‘I’1 1. Of these. the shortest labor was 24 hours; the longest 48 hours; a.11~1the avenge 3X.5 hours. The pPe&ctjon of prolonged labor was made in only one instance by the tlystocia clinic, and jn the x-ray department only twice. Tahte VI shows that there was prolonged labor in 9 patients with contractecl pel\-es, and in 8 with normal pelves. While this series is small. it at least points to the fact that the1.e a~ other facto~*s besick eontractetl pelvis involved in the prolongation of labor. III only :? cast’s were excessivcqizetl infants fonnd ; alld IhelY was one fetal death.
Cesarean section Thirty-two cesarean sections were performed in this series, an incidence of 16 per cent. Table VII shows the clinic incidence of cesarean section fol* the year 1948-1949 to be 2.94 pela cent. The high incidence of cesarean section in this series was not unexpected since these were segregated cases in which the incidence of abnormality was high, and a large number of patients who had had previous cesarean sections a~ppearin this sex-ies. Maternal morbidity
813
Vulnme 61 Number 4
CORRELATION
occurred operative mortality
in ‘7 cases, an incidence of 21.8 per cent. Two patients had postpneumonia, and 5 had pnerpcral endometritis. There was no fetal in this group.
OF
P&longed labor Forceps Cesnredn
in
CLINICAL
contracted
A?JD
ROENTGEX
PELVIMETRY
pelres
section
Prolonged labor in normal Forceps Cesarean section Rreeqh extraction mortality Stillbirth-shoulder Fetal weights
pelves
Fetal
2,500-3,000 grams 3,000.3,500 grams 3.500-4.000 trranlY 4:OOO &ams"and
---
TABLE
dpetocia
over
VII.
__-
Aivar,~srs
OF CESAREAN
-.B
3
SEWIONS NTiMBER
sections Clinic incidence 19LLS-19 Indications 1. Previous s&ion with contracted pelvis (no labor) Contracted inlet only Contracted inlet and midplane Contracted midplane only 2. rndicated after trial labor Contracted inlet only Contracted inlet and midplane Contracted midplane only 3. [ndicatio,n other than fetopelvic relationship Premature separation of placenta Pre-eclampsia! fulminating Uterine inertia, primary 4. Previous section only .?. -Elective, para OOOO! breech, contracted inlet 6. IElective, elderly primigravidx, contracted inlet, 7. .Elective, previous stillbirth, contracted inlet 8. .Elective, para 0000, markedly contracted pelvis Types Laparotrachelotomy Extraperitoneal Maternal morbidity Fetal mortality
Previous
PER
32 92
Cesarean
CESl'
16.00 2.94
13 ;
1 11 9 1 1 3
1 1 1 1
1 1 25 7 7 0
Section
Sixteen patients who had had one or more previous sections were encountered in our group, an incidence of 8 per cent (Table VIII). In our clinic routine placentography is performed in all patients who have had a previous section. In this series 5 placentas were found by s-ray to be ‘located beneath the previous operative site. In such instances it is our usual practice to perform an elective repeat section-not so much hecause we fear an increased incidence of rupture of t,he uterus, but because, if rupture should
OCCUI’, it, would be intinitely more j,rmidable to both mother will be noted that only t,wo paGents wt~rr rleliverwl vaginallg prfbvions sections.
--~~~~~~~~~~~
-~ ~~ -..-.
NUMBER .--
.- ..- _-
anc( ljab>. 11 wl-ic~ had h;ld
..-
.-.
PER -.-
lfi
delivery, term baby Contracted pelvis Abdominal delivery Previous section and contracted pelv. Previous section only Types of section, laparotrachelotum) Maternal morbidity Puerperal endometritis Placentography showed placenta under war
p
Pelvic
Prema.ture
CEIST .._..
Q.ig
%, I4 I3 1 14 ,> *, in
.i
Delivery
From Table 1X we observe that there were 13 premature deliveries, or 6.5 per cent for the series. Twelve patients were delivered vaginally, and one abdominally. All premature babies survived. The clinical concept that premature labor occurs more frequently in patients with contracted pelvcs was not borne out by our study since the clinic incidence of all premature livebirths in the year 1948-1949 was 6.8 per cent, while the incidence of pre,mature delivery in the contracted pelvis group in this series was 4.32 per cent.
Contracted pklvis Normal pelvis Vaginal deliverv Abdominal deliver! Fetal mortality
7 ti
.4X0/<, I:! I il
Excessive-IJised
Infants
Table X shows that there were 5 infan& weighing o\:er 4,000 grants. one stillbirth in this group was due to shoulder dystocia. ‘I’ABI>E
x.
INI”AN’I’S
\~ElGtllNLi
O\‘r:K
__._------...-----.~ --.. - ~~-...-. -~Excessive-sized infant Vaginal deliverv abdominal deli&-y Contracted pelvis Normal pelvis Stillbirth (shoulder
dsstociai
4,000
‘l‘tttt
c;K-h&fs
..~ .~--_ . .
II 4 I ”. . .I i
A total of 27 abnormal presentations and positions, or 13.5 per cent, occurred in this series, the data being presented in Table XI. In the entire series 17 occiput posterior positions (8.5 per cent) were encountered. Of a total of 49 anthropoid pelves in the series, 8 were associated with occiput pos-
Volume 61 Number 4
CORRELATION
OF
CLINICAL
AND
ROENTGEN
815
PELVIMETRY
terior position, and all of these patients were delivered vaginally. In 9 patients, 01: 4.5 per cent, breech presentation occurred. Three were delivered abdominally, 2 because of previous section with contracted pelvis, and the third because of a very small android pelvis in a primigravida. Pelvic delivery in breech presentation was undertaken when the fetus was estimated to be small and pelvic studies failed to reveal major pelvic contraction. There was one premature breech delivery and there was no fetal mortality. There was only one transverse lie which occurred in a patient with a small androitl pelvis. -____ --__ -~___
TABLE
XI.
PRESENTATIO~L-
AND POSITION KUMBER 17 8
Occiput posterior position Anthropoid pelves associated Pelvic delivery Indicated operative delivery Abdominal delivery Breech presentation Normal pelvis Pelv$ $4:;;;~
PER CENT 8.5
-
14 14 3
9
4.5
6 6
5 1
PFemature Contracted pelvk Abdominal delivery Average fetal weight : Transverse presentation Abdominal deliverv
3
3 2,833
grams 1
0.5
1
Midplane
Contraction
Table XII presents data concerning 3’7 patients, 18.5 per cent, who wert’ found to have contracted midplanes either alone or in association with inlet Twenty-three, or 62.1 per cent, who had midplane contraction contraction. experienced dystocia. This incidence of dystocia would appear high in view of the over-all incidence in the series of 46 per cent. However, it is in line with Eller and Mengert’@ observation that there is a high incidence of necessary operative delivery in midplane contraction. There was a fetal mortality of two in this group, one being a fetus which died in utero one week prior to the onset of labor, while the other was a neonatal death following forceps clelivery. Autopsy in this case disclosed intracranial hemorrhage. TABLE
XII.
MIDPLANE
CONTRACTION
IN WHITE
AND NEGRO
Tota, ------~--4~
PATIENTS
NUMBER
PER CENT 2.0
Wi2t.e No dystocia Dystocia Premature, pelvis Fetal mortality
1 2
not
tested
Negro
1 0 Total
No dystocia Dystocia Premature, pelvis Fetal mortality Prolonged labor
not
tested
16.5
2
2 4 Total
Dystocia Dystocia
33
10 21
in entire series in midplane contraction
37
92 23
18.5 46.0 62.1
Comparison
of Clinical
and Radiologic
Data
Table Xl11 represents the results (it’ our. clinical c*lassificatiult of pel~rs in the dystocia clinic: on original pel\-ic estimation its compared with ~ht~ radiologic classification. It will he ohser\-rd that ow pr*edic*tions wer’e corset in 1% cases, or 622 per cent ; and th;il the pelvic* tJvl)tb trrisdi;ipnosetl IUliSi frequently clinically was t,hr arrthropoi*i fppe. a total ctt’ ~31such pelves I)ritls missed.
During out’ fo~ruative period in the dystocia clinic, which this survey covers, we attempted only to predict the outcome of labor as to pelvic ot abdominal delivery,. In the routine ra.diologic report, the X-ray Uepart~rnent also makes a prediction as to outeonre. Table XIV shows a comparison of the results in this speculative field. In all fairness to the radiologists! if must he pointed out that we in the dystocia clinic had the decided advantage of our clinical examinations of the patient as well as our own study of the s-ray films to aid us in making our predictions. The value of trial labor in pelvic contrxctiotr is adequately demonstrat~etl here when we consider that this was the course followed in the 17 cases which were delivered vaginally after the X-ray Department, had suggest,ed or stated as probable abdominal delivery. In a clinic where complete reliance is placed on s-ray pelvirnetry, it is possible that 17 additional and unnecessary eesarean sections might hare heen performed.
Another factor which findings was the direction
we checked in our clinical est.imation agaiust x-ray of the inclination of the side walls af the p~~lvis,
Vulrxmehl iTumber
CORRELATION
OF
CLINICAL
AND
ROENTGEN
817
PELVIMETRY
4
recording our impression as convergent, straight, or divergent. Our clinical impressions were correct in 116 cases, or 58 per cent; and incorrect in 84, or 42 per cent. TABLE
(!LINICAL
XV.
,&xTY-$'I~E CASES IN WHICH CLINICAL MEASUREMENT OF TRANSVERSE ISCHIAI, DIAMETER OF PELVIC OUTLET WAS 8.5 TO 6.5 CM. MEASLIREMEXT OF TRANSB. DIAMETER OF OCTLET, CM.
ISCRIAL
Total cases Midplane interspiuous diameter 9.0 cm. or lws Mengert ‘s midplane index 105 or less Contracted inlet associated Premature, pelvis not tested Elective section Remaining cases Dystocia No dgstocia -___
(
8.5
(
:;
1 ::
1 :;
(
:: ITOTA& ~.--___
30 6 11 11 4 4
23 3 6 9 0 3
9 0 0 3 1 0
L’ 1 1 1 :
1 0 1 0 0 0
9 13
9 11
0 8
1 1
0 1
65 10 19 24 5 7 53 19 34
100 15.3 29.2 36.9 100 35.8 64.1
We were interested to learn whether or not a small clinical measurement of the t,ransverse ischial diameter of the pelvic outlet pointed to pelvic contraction in other planes of the pelvis. Table XV shows our data in 65 cases in which this clinical measurement ranged from 8.5 cm. to 6.5 cm. It will be observed that the midplane interspinous diameter was found t,o be 9.0 cm. 22 NO. CASES
20 16 16 14 12 IO 6 6 4 2
O.C. IN CM.
(x-ray) in 92 cases in which diagonal conjugate was measured at 115cm., or more. (after Dlppel).
or less in only 10, or 15.3 per cent; and Mengert’s midplane index of 105 or less was found in 19, or 29.2 per cent. It was noted that in 24, or 36.9 per cent, a contracted inlet was associated with a contracted outlet. Dystocia was encountered in 19, or. 35.8 per cent. It may therefore be stated that our data show clinical contraction of the transverse ischial diameter of the pelvic outlet may point to contraction at the midplane in one out of every 35’2 cases, and to contraction at the inlet in one out of every 3 cases.
NO. CASES
6
4
2
CENTlMETt
:l?s
Conjugate equal to or-greater IDiaganat than Obstetrical Conjugate. 76 cases.
Obstetrical Conjugate greater 1 than Diagonal Conjugate. 32 caada
Fig. 2 Distribution of the difference Obstetrical Conjugate in 108 cases
Diagonal Conjugate and the Diagonal Conjugate was
11.5
cm,
or less.
(after
between in which
Dippel).
We have attempted to demonstrate the significance and teaching value of the dystocia clinic in correlating clinical and roentgen pelvimetry. We would not wish to rely completely upon either of these methods because we believe that by a combined study we obtain ati over-all impression of the architecture and capacity of the pelvis under consideration which would not be available from either method alone. While it is realized that the trained obstet,riciarl can determine those cases in which x-ray pelvimetry should be done, certainly there are many hdividuals, devoting at least: II I)art of their time to the
Vcblilmc5 01 Nllmher 4
CORRELATION
OF
CLINTCAT,
AND
ROENTGEN
819
PELVIMETRY
practice of obstetrics, who do not have this skill. Therefore, it is recommended that all of us teach that routine x-ray pelvimetry in the primigravida should be an essential part of prenatal care. Since satisfactory methods of cephalometry and x-ray measurement of the transverse ischial diameter of the pelvic outlet are not available, these were not studied in our cases. C’lassical external measurements of the pelvic inlet, are omitted in our clinic. This concept is in agreement with that of Eastman,’ Greenhill,‘” and Titus.” The maternal morbidity rate was 14.5 per cent, the major cause being 1X cases of puerperal endometritis. The chief maternal complication was complete perineal laceration in 14 cases. We have found Mengert’s indices extremely useful as an aid in classifying pelves as contracted or not contracted. Trial labor is strongly advocated in all but grossly contracted pelves and when accompanied by vertex presentations. We believe that clinical and x-ray pelvimetry are not irreconcilable but complement each other and are of equal importance in the study of the obstetrical pelvis, and, combined, they give us invaluable assistance in the solution of clinical dystocia problems.
Summary and Conclusions 1. Two hundred are preserrted.
cases studied
by combined
clinical
and x-ray
pelvimetry
2. There was no maternal mortality; and an uncorrected fetal ,mortality of 5, or 2.5 per cent. 3. Of 162 patients referred to the dystocia clinic because of suspected contracted pelves, 79, or 42.5 per cent, were found to have contracted pelves by application of Mengert ‘s indices. 4. Anthropoid pelves barely incidence of necessary operative platypelloid groups.
outnumbered android delivery was highest
in this series. in the android
The and
5. The cesarean section incidence was 16 per cent in this series as compared to the clinic incidence of 2.94 per cent. 6. Fourteen of 16 patients who had had previous cesarean sections were subjected to repeat section. 7. The incidence of prematurity in our series was not increased over the general clinic incidence. 8. A total of 27 abnormal presentations and positions, or 13.5 per cent, was encountered. 9. Of 37 patients who had midplane contraction, 23, or 62.1 per cent, had The incidence of midplane contraction was 18.5 per cent. dystocia. 10. From clinical pelvimetry the pelvic type was correctly 62.5 per ce:nt; while the type of delivery (pelvic or abdominal) predicted in 95.23 per cent.
predicted in was correctly
References 1. 2. 3. 4. 5.
Eastman, Walton, &IcLane,
Mengert, Groskloss,
N. J.: Old. H. J.: Surg.,
& Gpx. rC;urvey 3: :wlj 194x. Gynec. % Obst. 53: Xfi, 1~31. t‘. M.: AM. J. (h3T. & (+YNEt’. 50: -l!ls, 1!&5. W. F.: .I. A. Xl. x. 138: 169, 194X. IT. H., RljIllsius, 0. F., and Afo+>hn. .J. ‘I’.:
AM
.I. C&is?. 6 (+YxE~‘.
56:
111911.
1948. fi. 7. 8. 9.
10.
ii
&ST
READ
STPKEt:‘l
Discussion DR. PAI’L Tl’VCS, Pittsburgh, Pa,----‘i’hP first, point allout Dr. Savage’s paper to l,e commended is that there should be correlation between these Iwo methods of pelvimetry. roentgen pel~imetry has acIded to the informatioa to Neither met,hod displaces the other; lw gained from clinical ylvimetry so that :r~‘c’w’~~‘~- of predirtions regarding dystoeia has heen greatly increased tug t,hia c*orrel:Lti~rrl I~vtwe~~n methods. Two findings in this study arc cnlxvialiy worthy of cv,nrment. Dr. Savage rea,tirm~ the belief that outlet vontraction in the l,idixlliai tlian~rter ja clinical measurement) will l)e accompanied in at least one-third of all instances by sigrritirant midplane contratt ir)ll (*an x-ray finding of greatest import:tnrP j. He repeats the entirely rclrrevt vonteution that the linding of a diagonal conjugatt% Ftow-everl a longer diagonal conjugate does of 11.5 cm. ix a definite indication for a-r:,?. dystocia can occur in an anthropoid Cype not make an x-ray unneressarv beeaunr~ serious of pelvis. I van make 110 more than a small contrif,ution to thiH excellent paper. What I wish to ofier is a capp of the x-ray obstetrical Chart used in the Ht. Margaret Memorial Hospit,al It combines the essential diameters taken by the Thorns technique with in Pittsburgh. the area estimations of hlengert, vonrbinrs thv (‘ald\~.ell-R~ctloy and the Thorns morphologic classifications, presents tables of normal diameters for reference, and in addition tl, the x-ray study has a #pace for the obstetrician% evaluation of the films and his prediction based on this correlated with his clinical findings.
Volume 51 Number
4
CORRELATION
OF
CLINICAL
AND
ROENTGEN
8”l_
PELVIMETRY
with the views presented DR. J. BAY JACOBS, Washington, I). C.--l ai II in accord by the essayist. I believe that all obstetricians should evaluate pelves as described. I have been following this procedure since 1928, both in pri\-ate and clinic practice, I like the method l)y which Dr. Savage selects his eases for the dystocia clinic-those patienta who have had previous cenarean section, history of previous dyxtoeia, unexpla.ined stillbirth, prolonged labor, or who actuall,v xppwr to hxve :L rwntmctwl or llortlerline pelvis; that, just about tovers the field. It merits
is surprising that and x-ray pelvimetry.
there is any They both
question about the have definite value.
evalmtiion
of
external
~nc~a~ure-
I am opposed to discarding external measurements, from the teaching point of view-. We know that where the external conjugate is diminished markedly in size, one might expect difficulty. That of course, depends upon the type of individual; for instance, sue11 factors as the amount of adiposity, the thickness of skeletal bones and the general strut-
DR. ‘I’. I,. MONTGOMERY, Philadelphia, Pa.--1 have been particularlyiuterestetl in this paper because it presents the organization of a clinic ffn The rtudy of disproport,ion in a teaching institution and illustrates especially well how such R. elinir* raan be correIated in the educationa program. That, 1 feel, is an exceedingly important. consideration, especially that these cases shoulll not br withdrawn from the general rliuic cc here students have contart with them and have an opportunity lo study this problem with competent instructors. The problem of whether x-ray pelvimetry shall or shall not he taught is rather an academic aubjent. I think all of us realize that x.ray pelvimetr> is a relatively small part. I sometimes wonder whether if the x-ray techniques are routinely employed ihe resident or the intern would really study the pelvis and study t.he anatomic eontlgnration and the relation as if external pelvimetry were not. practiced. Routine x-ray of our , R medium of insisting prunigravtda patients 1s a 1 least upon the general relationship.
Volume Number
61 4
CORRELATION
OF
CLINICAL
AND
ROENTGEN
PELVIMETRY
823
And again, from the academic standpoint, I think much can be said for it, but I am not sure yet, and I am not sure that anyone is certain, that x-ray is entirely unharmful, particularly where x-ray may have to be repeated later. There have been so many instances where we have had to change our mind at a later date, realizing that what we have been doing has been detrimental. I would like to hold off on the x-ray until we have clinical evidence of disproportion. I would rather hold fire until the patient is in labor. Granted that these studies should be made often, it is most helpful to repeat the x-ray during labor and often the information with regard to the fetal head or fetal parts, and partieularl, after rupture of the membranes, is the important consideration in the final decision as to what should be done. DR. E. L. KING, New Orleans, La.-1 feel that we should by all means teach ant1 practice clinical pelvimetry. In doubtful cases I believe that we .should do both clinical and x-ray studies. In many primigravidas, granted the fetus is not too large, we can determine whether it can come through by clinical methods alone. If in doubt we fall lntek on the x-ray; also in multigravidas who have had trouble or in whom there is evidence of’ a small pelvis. The Mengert index is good but it must be correlated with the size of the baby. The roentgenologists who do our work give us very good estimates of the size of the fetal head. We have checked this many times immediately after delivery, especialI) after cesarean section, when the head has not been molded, and we find very close correlation. DR. SAVAGE (Closing).-In regard to Dr. Jacobs point concerning exact cephalometry, we have not had the good fortune he has had in his clinic to correlate exactly the actual measurements of the diameters of the fetal skull with those obtained roentgenographically. We do agree with him that the degree of maturity of the fetus and many other valuable considerations regarding cephalometry may be obtained from the films. We also agree that the films taken during labor are very valuable. Many of the cases we presented had lateral films taken during labor. We agree that 14 complete lacerations of These patients were all delivered over midline epithe perineum are not to be desired. siotomies, which are routine in our clinic, and I think that probably explains the high incidence in this group. In reference to Dr. Montgomery’s remarks concerning the routine x-ray, you eee from our presentation we are not doing it but simply advocating it so that we were speaking of the ideal in clinics such as that of Thorns, where all patients have routine roentgen pelvimetry. We agree with Dr. Montgomery that x-ray is valuable, and further agree with Dr. King that clinical and x-ray studies of the pelvis should go hand in hand. We We also agree with Dr. King that we must do not wish to displace one with the other. correlate the architecture as well as the indices of the various planes with the size of the baby, the presentation, the forces of labor, and all other factors which enter into the management of dystocia.