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THE CLINICAL ASSESSMENT of DISPROPORTION' by WILLIAM HUNTER, M.D., F.R.C.O.G

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THE CLINICAL ASSESSMENT of DISPROPORTION' by WILLIAM HUNTER, M.D., F.R.C.O.G 494 POSTGRADUATE MEDICAL JOURNAL October 1951 Postgrad Med J: first published as 10.1136/pgmj.27.312.494 on 1 October 1951. Downloaded from infection is the precipitating factor. Intramuscular sidering the use of antibiotics in non-tuberculous penicillin, combined where indicated, with inhala- disease of the chest. tion therapy should be commenced at once if chest 2. Bacteriological investigation and sensitivity infection is felt to be a contributory factor in tests of organisms obtained are essential. cardiac breakdown. Meanwhile investigations 3. Blunderbuss therapy must not be used. should be started and modification of treatment 4. Newly discovered and comparativelyuntested may be made as indicated. The effective treat- antibiotics must not easily replace tried remedies. ment of the lung lesion associated with the correct 5. The wider aspects of aetiology such as social approach to the heart condition may lead to factors must be evaluated. dramatic improvement in what may otherwise 6. The important part that lung infection plays seem to be a hopeless problem. in heart failure has been touched upon. I should like to thank my colleagues, and many Conclusions others in the hospital for their constant cooperation I. Dogmatism must be avoided when con- and help with these problems. BIBLIOGRAPHY GUNNISON, J. B., COLEMAN, V. R., and JAWITZ, E. (I95oa), FATTI, L., FLOREY, M. E., JOULES, H., HUMPHREY, Proc. Soc. exp. Biol. N.Y., 75, 549; (I95ob), J. lab. Clin. J. H., and SAKULA, J. (1946), Lancet, i, 295. Med., 36, 900oo. DAVIES, D., and ASHER, R. A. J. (I951), Lancet, i, 924. LEHR, D. (195ob), Brit. med. J., ii, 6o0. Protected by copyright. THE CLINICAL ASSESSMENT OF DISPROPORTION' By WILLIAM HUNTER, M.D., F.R.C.O.G. Obstetrician, Princess Mary Maternity Hospital; Associate Surgeon, Royal Victoria Infirmary, Newcastle upon Tyne; Senior Obstetrician and Zynaecologist, North-West Durham Hospital Group Attention has been devoted during recent years other findings, to decide upon the further manage- to radiological methods of assessment of the sizes ment of the case. The words of the pious i8th of the maternal pelvis and foetal head and much century German midwife, Justine Siegemundin- has been achieved. The greatest strides have been 'All I do depends on God's help and on the made in the estimation of the size of the pelvis, skilful motions of my hands '-have a particular http://pmj.bmj.com/ but progress has not been limited to actual measure- application to this type of case. ment of the bony structures. There is now a Some indication of possible difficulty at the better understanding of the architecture of the time of the confinement may be discovered during pelvis-of its variations in shape as well as in the course of the routine antenatal investigation size-and of the significance of these variations. of a case. The patient may be of small stature, she So much thought has, in fact, been directed into may have an obvious limp, occasionally due to these new channels that of the of the or she show comparatively many ankylosis hip, may gross de- on September 25, 2021 by guest. methods of clinical assessment previously in use formities of the long bones or spine and, for in- seem to have been forgotten or to have fallen stance, there may be obvious rachitic manifesta- largely into disuse. For this reason the time now tions. In giving the medical or surgical history seems opportune to re-consider some of the she may bring forward an account of fractures, clinical methods available for estimating the tumours or diseases of the pelvic bones or spine, relative sizes of the foetal head and the maternal or tumours of the pelvic organs. The previous pelvis. It is, after all, upon these methods that we obstetric history may suggest the possibility of re- must rely to select those cases which require fuller current complications arising in the approaching investigation and ultimately, in conjunction with confinement. There may have been a prolonged or complicated labour, a difficult delivery or Caesarean *A paper read at a meeting of the Newcastle and section, maternal trauma or a stillborn Northern Counties Medical Society in Newcastle upon or injured child, possibly of large size, on a pre- Tyne on Thursday, February i, 1951. vious occasion. In all such cases every effort October 1951 HUNTER: Clinical Assessment of Disproportion 495 Postgrad Med J: first published as 10.1136/pgmj.27.312.494 on 1 October 1951. Downloaded from should be made to elicit as much information as made by this method than by the alternative possible about the previous confinement. This ' pelvic grip ' with the hands laid on either side of applies especially to confirmation of the patient's the midline in the supra-pubic region with the story, and a report upon the efficiency of the fingers pointing towards the pubes and palpating uterine contractions and the immediate cause of the foetal head bimanually as it lies above the pelvic any difficulties which may have arisen. Further brim. This is as one would expect. It is much information should be obtained whenever possible easier to judge the size of a ball or an orange by from the doctor in attendance at the time of this holding it in one hand than by rolling it between complicated labour. the fingers of the two hands. A general examination is necessary in all cases Next the flexed foetal head is depressed down- in early pregnancy, and abdominal palpation wards and backwards into the pelvic brim by the should be carried out repeatedly, especially during examining hand to gain some impression of the the last six weeks of pregnancy, the bladder and ease with which it can be fitted into the pelvis. It rectum being empty. The height of the uterus is important that the sagittal suture should be may be checked by sinking the edge of the left directed into the axis of the brim and not tilted hand into the abdominal wall above the fundus. to front or back. It is sometimes recommended The presentation, position, attitude and, to a lesser that the head should be fitted into the brim with extent, the size of the foetus can usually be deter- the patient sitting. This, however, by tilting the mined with a reasonable degree of accuracy by pelvic brim may give fallacious and over-optimistic Pawlik's grip followed by the fundal and umbilical impressions. In fitting the head into the pelvic grips carried out in the standard textbook manner. brim, not only is the amount of descent noticed but As a supplementary method of examination, the degree of over-riding of the pubes by the skull ballotting the foetus by rocking the hand with the is estimated by the fingers of the right hand. finger and thumb outstretched, as in Pawlik's grip, There should normally be a step-up from the Protected by copyright. in different parts of the abdomen may be helpful foetal head on to the pubes and not vice versa, especially for identifying the foetal back and, when when the head is pressed back against the spine. carried out with the left hand, for locating the It is frequently stated that the foetal head foetal head when it lies in the uterine fundus. It is engages in the pelvic brim in the primigravida unhelpful to feel for the foetal parts by a rotatory between the 34th and 36th weeks and in the multi- movement of the finger-tips on the uterine wall. gravida shortly before the onset of labour. While This tends to rub up a contraction of the uterus and it is true that lightening, and so engagement of the so to mask the underlying foetal parts. It there- head, usually occurs earlier in the primigravida fore makes identification still more difficult. In than in the multigravida, it is not unusual, even applying Pawlik's grip and the umbilical and under normal conditions, to find the head high at fundal grips the method of ballottement should be the 36th week or even later in either case. If the used. Pawlik's grip should be carried out by a head has not competely engaged in the pelvic side to side rocking movement of the hand and cavity by the 36th week of pregnancy at latest, in wrist from the forearm, tapping the foetal head either a primigravida or a multigravida, a vaginal http://pmj.bmj.com/ alternately with the thumb and the fingers rather examination is essential. If the head is engaging, than by firmly grasping the foetal head as it lies in that is if part of the head has entered the pelvic the lower uterine segment, a procedure which cavity although the greatest engaging diameter tends to cause unnecessary pain. The estimation has not yet passed the brim, the examination may of the size of the foetus is largely based upon the be deferred for a further two weeks. If at the assessment of the size of the foetal head, but a 38th week the head is not completely engaged, estimate of the relative bulk of foetal sub- examination must then be carried out. rough vaginal on September 25, 2021 by guest. stance and liquor amnii, the height of the breech Repeated abdominal and, when necessary, vaginal in the uterus considered together with the degree examinations will minimize the risk of any case of of engagement of the head and the apparent size disproportion being overlooked and will make the ofthe various foetal parts provide valuable auxiliary ultimate findings more reliable. information. The appraisal of the high foetal head It is often recommended that the external pelvic is, however, of first importance.
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