Pelvic Fascia Dystocia*

roentgen. i radiol. 3: 13, 1924. (16) E’dto: Zentmlbl. f. C+yn%k. 48: lliX, 192-i. (17) Roffo, A. H.: Prensa med. argent. 11: 121, 1924. (18) P~txeddu, B.: Clin. med. ital. 56: 42, 1925. (19) Neumann, H. 0.: Zentralbl. f. (;yn%k. 49: 354, 1925. (20) Bakwhowsky, S. : Presse med. 33: 626, 19%. (21) Baev, J. L., and Reis, R. A.: AM. J. OBST. & GYNEC. 10: 397, 1925. (22) Connerth, 0.: Deutsche Med. Wchnschr. ;::$25, 1925. (23) Cnrtis, A. LT.: Rurg. Gynee. Obst. 42: 6, 192G. (24) Rubin, 1. .: Surg. Bynrc. Obst. 42: 652, 1926. (25) Czctler, b.: $m. J. X. Se. 171: X2” 19“6 u . (26) Baer, 6. J,., and Rris, R. il.: Ahf. .I. ORST. s: GYSEI.. 12: 740, 19%. (27) Noyes, I. a., rind Gorwwr , A.: Boston M. 6; S. .J. 195: 891, 1%X. (28) Eastman, N. .I.: China M. J. 41: 517, 1937. (29) Rw~,ischek, 11’. I,., u~d Douglas, Y. D. : Asr. J. OBST. & GYNEC. 14: Z?n, 1937. (31) Gr&hei?wr, 23. M.: Am. J. M. Sr. 174: :K;8, 1927. (21) Lindstcdt, E’.: 1Iygiea, 89: S76, 1927. (32) Pohdc, J. O., rind Tollefson~, Il. G.: J. A. M. A. 90: 168, 1928.

BY

(Adjunct

T

IRA

Obstetrioian

WILENS,

and

B.S., Gynecologist,

M.D.,

NEW

Sydenham

YORK, a’nd Beth

S.

Y. David

Jtoapilnls)

ME commoner causes of dystocia are well known and readily diagnosed. In my practice, I have recently observed several cases in which the cause of the difficulty in labor was a structure not commonly recognized or even described as one capable of causing dystocia. I am therefore reporting the following cases as illustrative of what may be called pelvic fascia dystocia. The pelvic fascia is the continuation of the endo-abdominal and iliac fascia. When passing beyond the brim of the pelvis it is known as the pelvic fascia. Just below the pelvic brim at th(J so-called white line it splits into three layers. One descends alon? the lateral pelvic wall lying on the obturator internus muscle, the obturator fascia. The othcl two layers split t,o enclose the levator muscle at part of its origin. Tht: #uperficial layer covers the anterior portion of the levator and forms with the corresponding half of the other side one layer of the triangular ligament. The deep layer is known as the fascia endopelvina or rectovesical fascia. This is the important fascial structure. The portion of this fascia which lies between the symphysis pubis in front and the cervix behind is known as the uteropubic fascial plane. It is this uteropubic fascia.1 plane which may cause difficulty in labor. In short stocky women, with the so-called male type of pelvis, in which the bones are heavy and the symphysis long and high and in whom the inclination of the pelvis is faulty, we find the uteropubic fascia unusually tough and strong. In these women, who do not readily become pregnant in the first place, labor is l)rolongrd, dilatation of the cervix is interfered with? and retraction of t hc vcsrvix does not occur, as it is prevented by the inelasticity ol’ tlli~ l’asrial plan,e. The presenting part is hold up by the incomplc~tclty tlilated cervix and rides upon this structure. Descent does not occur unless and until this

WILENS

:

PELVIC

FASCIA

DYSTOCIA

95

fascia is lacerated either spontaneously by efYective uterine contractions or artificially as a result of operative interference from below. At this point, may I mention that it is most important to differentiate between the above and that type of dystocia where the bony pelvis is not ample for descent. The following cases are reported as illustrative of pelvic fascia dystocia : CASE l.-Mrs. L. S., admitted to Sydenham Hospital, September 2, 1927, was a primipara, twenty-six years of age who went into labor spontaneously one week after expected date of confinement. The membranes ruptured at the onset of labor. The physical examination revealed a short stocky young woman, 4 feet 10 inches tall, weighing 140 pounds. The pelvic measurements were as follows: interspinoua 19 cm., intercristal 24 cm., intertrochanteric 30.5 cm., left oblique 20.5 cm., right oblique 20 cm., external conjugate 18.5 cm., transverse diameter of outlet 8.5 cm., symphysis pubis 6.5 cm., heavy and directed vertically upwards (with patient in lithotomy position). After twenty-four hours of first stage pains there was no Cervical (lescent of the presentin y part which was dipping deeply in the brim. dilatation was four fingers’ (rectal). From abdominal examination it was felt that the fetal head was small and should easily have come through. Examination per vaginam under gas and oxygen anesthesia disclosed a vertex presentation, the occiput pointing directly anterior to the symphysis pubis, a small fetal head, and a relatively ample inlet. The cervix was 4ys fingers dilated and not retracted. After allowing the patient to come out of the anesthesia, a small dose of pituitrin was given to increase slightly the uterine contractions. One hour later, although the patient was having good uterine contractions, there was no progress of the presenting part.. Labor was, therefore, terminated by a median forceps operation. Before this was done, the pelvic floor was thoroughly ironed out. When traction was begun, the uteropubic fascial plane was felt as a dense, tough, thick, leathery sheet, stretching across the roof of the birth canal. Long and slow traction was required to bring down the vertex and to spare this fascia as much as possible from extensive laceration. A small living female child, weighing 5 pounds 9 ounces was delivered. The perineum offered no difficulty whatsoever, first, because it was manually stretched at the onset of the operation and secondly, because of the small fetal head. The postpartum course was entirely uneventful. An examination six weeks later revealed a cystocclr, a retrovertctl uterus, and a pelvic floor which was only slightly relaxed. This patient has :I her~nia of the bladder caused by the laceration of the uteropubic fascial plane. CASE 2.-Mrs. L. T., a primipara, aged twent,y-four, was admitted to Mount Morris Park Hospital, March 11, 1927. Labor began two weeks after expected date. The patient was 5 feet tall and weighed 172 pounds at term, gaining 45 pounds (luring her pregnancy. Physical examination revealed a funnel pelvis. Measurements were as follows: interspinous 23 cm., intercristal 27 cm., left oblique 33 cm., right oblique 21.5 cm., external conjugate 21.5 cm., true conjugate ample, transverse diameter of outlet 7.5 cm., symphysis pubis 6.5 cm., heavy and with vertical inclination (with patient in lithotomy position). First stage of labor very much ~~rolonged. Cervix dilated up to 5 fingers but was not retracted. Presenting part (vertexL. 0. T.) at the brim; not too large to come through. Uterine rontraetions irregular and ineffectual. Under anesthesia, patient was delivered by a mid-forceps operation (Kielland). At the time of the forceps delivery the roof of the birth canal could be felt as a rigid, dense, tough fascial sheet which offered considerable resistance. The vertex was brought down with great difficulty and only after extensive larer~atiorr

96

THE

AMERIC’AX

JOURNAL

OF

OUSTETRICS

ASD

(:YSEC’OI~OCiF

CASE 3.-&b . _.4 *M ., a primipara, twenty-three years of age, was admitted to Mt. Morris Park Hospital, July 1, 1925, in labor at term. She mas a short heavy The pelvic examination revealed a set woman, 5 feet tall, weighing 155 pounds. with the following measurements : interspinous 22 cm., male type funnel pelvis, intercristal 24 cm., left oblique PO.5 cm., right oblique 21 ~111.~ external conjugate diameter of outlet 7 cm., spmphysis pubis Ii cm., prnmontory not 30 cm., transverse reached, true conjugate ample.

At the last prenatal examination ma& the following was noted : Vortex presentation, brim, beginning effacement of cervix.

one

week befort, the onset of Id. 0. A., small head dipping

labor into

After twenty-eight hours of labor with the cervix fully dilated but not retracted, there was no descent of the presenting part. When the membranes were artificially ruptured at this time, deeply meconium stained liquor amnii escaped. Labor therefore, was, terminated by a median (Kielland) forceps operation. The first stage of the extraction was very difficult berause of an unusually strong obstructing uteropubic fascia. h right lateral episiotomy spared the pelvic floor; a living male child weighing 7 pounds 10 ounl’es was delivered. The postpartum convalescence was uncvmtful. fair

Three months pelvic floor,

later :I pelvic examination a slightly retroverted uterus,

rrrealcd a firm and a moderate

episiotomp scar sized cpstocele.

with

CASE 4.-Mrs. F‘. K., a primipara, twenty-eight years old, was admitted to fiydenham Hospital in labor, on May 10, 1927. The patient was 5 ft. 5 in. tall, and weighed 156 pounds at term (with a gain of 31 pounds during pregnancy). Pelvic measurements: intcrspinous 23 cm., intercristal 28 cm., left oblique 21 em., right oblique 20 cm., external conjugate 20 cm., transverse of outlet 8 cm., symphysis pubis 6.5 cm. Promontory could not b11 reached on pelvic examination. Vertex presentation, 1;. 0. b. positiou, head deep in brim.

The first stage of labor was very much prolonged; cervix was not retracted but dilated up to 4 fingers. Second stag’s pains w,‘r’c ineffectual. A median forceps (Kielland) operation was performed and a living male child weighing The extraction was rxt:edingly difficult because ‘7 pounds 14 ounces, was delivered, of the obstructing uteropubic fascia, which was rather extensively lacerated in this case. Pelvic examination pelvic floor, a slightly presented two small

two months postpartum retroverted uterus, and lateral scars.

This patient has been fitted tams caused by the cystocele.

with

a supporting

revealed a lacerated a very large cystocele. pcssary

for

the

and relaxed The cervix relief

of

spmp-

DISCUSSlOX

That the fascia caused the dystocia in each of the above cases was evident at the time of delivery and again clearly demonstrated by the easy, rapid, and often precipitate labors which these women had in subsequent deliveries. However, it must not be construed that these patients are peculiar individuals with developmental abnormalities of their pelvic fascia. They rather fit in a class of difficult labors to which the name dystvophia dystocia syndrome has been given by

WILENS

DeLee.’ are :

:

PELVIC

FASCIA

Some of the main features

97

DYSTO(!IA

of this class as ment,ioued

1. Justominor or masculine type pelvis with other signs pituitarism, such as small cervix, narrow rigid vagina. 2. Old primipara. 3. Postmaturity of the child (prolonged pregnancy). 4. Nonengagement of the fetal head when labor begins. 5. Premature rupture of the membranes. 6. Weak pains with prolonged first stage. 7. Familial dystocia.

by him of hypo-

Since all of these patients Ihave difficult labors, often with extensive injury of the soft parts, it is questionable whether delivery per Gas naturales should be the method of choice. Some authorities1 feel that cesarean section is perhaps the better procedure. When the diagnosis is made early in labor and no manipulation from below has been attempted, section is far less damaging to the patient. By this method the woman is returned to good health, well able to take up her maternal duties and without the invalidism which follows extensive injury to the supporting pelvic structures. CONCLUSIONS

1. The uteropubic fascia is an infrequent and not commonly recognized cause of dystocia. 2. It is important to differentiate the pelvic fascia from other causes preventing descent of the presenting part. 3. Certain injuries of the birth canal are unavoidable. REFERENCE

(1) W.

B.

1133

De

Lee,

J.:

Saunders

Co.,

PARK

AVENUE.

Principles p. 686.

and

Practirc

of

Obstetrics,

Philadelphia,

1924,