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THE CLINICAL VALUE of X-RAY PELVIMETRY by HUMPHREY G

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THE CLINICAL VALUE of X-RAY PELVIMETRY by HUMPHREY G Postgrad Med J: first published as 10.1136/pgmj.25.284.255 on 1 June 1949. Downloaded from 255 THE CLINICAL VALUE OF X-RAY PELVIMETRY By HUMPHREY G. E. ARTHURE, M.D., M.R.C.O.G., F.R.C.S. Assistant Obstetric Physician, Charing Cross Hospital; Surgeon to In-patients, Queen Charlotte's Maternity Hospital, London Introduction pected disproportion includes the following pro- Routine radiographic studies of the pelvis in jections: obstetrics have provided valuable information (I) Antero-posterior projection, with the patient about the variations in shape and size of the supine. This film gives a general picture of the female pelvis. Improvements in technique and in- pelvis, from which gross contraction, tilting or creased experience of pelvimetry have made it asymmetry will be apparent, and from which the possible accurately to predict the outcome of general convergence or otherwise of the side walls labour in a high proportion of cases (9i per cent. of the pelvis can be noted. of 600 cases referred to the radiologist at Queen (2) Supero-inferior projection, with the patient Charlotte's Hospital). It is an opportune time, sitting, but reclining backwards so that the brim therefore, to discuss the ways in which radiography is parallel to the casette. This film shows the true may assist the clinician, and to assess the value and shape of the brim and from it the brim diameters reliability of pelvimetric methods. are calculated. Difficulty may be experienced in Radiography may be used to confirm the deciding which line on the film should be taken as presence or absence of disproportion, but it must the anterior margin of the sacrum, and in such never be thought that it can supplant clinical cases the difficulty must be resolved by checking methods. measurements of diameters the measurement of the obstetric conjugate on the X-ray pelvic by copyright. may be more accurate than clinical measurements, lateral film. As Chassar Moir (I947) has pointed but it must clearly be recognized that accurate out, the most prominent point on the sacrum is prediction of the outcome of labour cannot be made in every case, however precise the measure- ments of the pelvis and foetal head may be. It is impossible to foretell the strength of the uterine contractions, the possible expansion of the pelvi- diameters in labour and the mouldability of ths "4.5 foetal head. There must, therefore, be a border- 145 line of cases in which the outcome of labour group http://pmj.bmj.com/ depends on factors which are unknown until labour occurs. In such cases a successful outcome may depend on the skill of the obstetrician who will be 6 better armed to overcome obstetric difficulties if he has accurate knowledge of the pelvic architec- FIG. 2.-Reconstruction chart of brim. ture.. Furthermore, it must be remembered that dystocia is more often due to imperfect uterine often below the pomontory. A' reconstruction. action than to actual disproportion. chart is then drawn, which shows the exact size on October 1, 2021 by guest. Protected It is convenient to discuss problems of dis- and shape of the brim, and on this chart a circle or proportion under two headings; disproportion at ellipse with a diameter of 9.5 cm. may be super- the brim and at the outlet. These present different imposed, representing an average foetal head at problems both in diagnosis and management. term. Consideration of disproportion in midcavity is un- It will be seen that the greatest transverse necessary if, firstly, brim disproportion is taken to diameter usually lies behind the mid point of the include those cases which have an antero-posterior antero-posterior diameter, and is sometimes quite diameter shorter than and slightly below the level close to the sacrum. For this reason, Chassar of the obstetric conjugate; and, secondly, if the Moir has designated the diameter Which intersects outlet is considered not as a single plane, but as the conjugate at the mid point as the available the lower pelvic strait. transverse diameter of the brim. From these films also the prominence of the Radiological Technique ischial spines can be observed, and the ischial The standard technique at Queen Charlotte's bispinous diameter calculated, if the distance from Hospital (Rohan Wliams, x943) in cases of sus- the plane of the brim is worked out from the lateral Postgrad Med J: first published as 10.1136/pgmj.25.284.255 on 1 June 1949. Downloaded from 256 POST GRADUATE MEDICAL JOURNAL June '949 film. This diameter may also be determined from the subpubic arch is narrow. In such a case the the antero-posterior projection. foetal head will be forced to emerge further back (3) Lateralprojection, with the patient erect. In than usual, and much of the antero-posterior this position the femoral shafts do not obscure the diameter is wasted. symphysis pubis, and the postural tone of the (b) The anterior border of the sacrum is abdominal muscles tends to engage the foetal head normally concave, but variations are common, so into the brim. From this film measurements are that it may be roughly straight or even slightly made of the antero-posterior diameter of the brim convex; in this case it is usually the second sacral (from the upper posterior margin of the symphysis segment which projects more than the promontory, to the most prominent anterior margin of the.upper forming a conjugate which must be considered in- sacrum), and of the antero-posterior diameter of stead of the true conjugate of the brim. There are the outlet (from the lower posterior margin of the two sacral variations which may shorten the symphysis to the anterior margin of the lowest part antero-posterior ,diameter of the outlet; firstly, of the sacrum, or to the coccyx if the sacro- the deeply hollowed sacrum in which the sacro- coccygeal junction is fixed). coccygeal shelf projects forward to lie almost The lateral film also gives information on the under the ischial spines ; secondly, a long sacrum inclination of the pelvic brim to the lumbar spine. having perhaps six segments instead of five, which This can be measured as the angle between the may be comparatively straight without a prominent true conjugate and the anterior margin of the fifth sacro-coccygeal shelf, yet because it is often more lumbar vertebra. A very large angle may account vertical than normal, the antero-posterior diameter for delayed engagement of the foetal head and of the outlet may be seriously shortened. perhaps asynclitism, but the angle will be con- (4) Subpubic arch projection, taken with the siderably reduced by drawing up the knees, a patient sitting well forwards, so that the arch is point to be remembered in the management of the parallel with the casette. The manner in which first stage of )abour. the foetal head will fit into the arch de- subpubic by copyright. ,A reconstruction chart is made from the lateral pends on the angle of the arch and on the curvature film of the median or sagittal plane of the pelvis, of the descending pubic rami. These factors are and from this the curve of the pelvic canal can be best assessed by using a disc with a diameter of http://pmj.bmj.com/ FIG. 4.--Lateral reconstruction chart. on October 1, 2021 by guest. Protected studied, using a disc representing the average FIG. 6.-Subpubic arch reconstruction chart. foetal head at term. It must, however, be re- membered that part of the antero-posterior 9.5 cm. representing the average foetal head at diameters may not be available to the foetal head, term: When the arch is wider than normal (90go and it is best to observe the general shape and lie or more) the disc occupies the whole of the arch, of the symphysis and descending pubic rami in with an average arch (about 850) there is a gap of front, and of the sacrum behind. 0.5 to I cm. between the circumference of the disc (a) The symphysis tends to slope backwards and the symphysis; when the arch is narrow (less roughly parallel with the backward inclination of than 80o) there will be a still wider gap. The the sacrum; if it has a greater backward slope length of this gap is measured on the film and than. usual, the antero-posterior diameter of the reduced to actual size, which will represent the outlet will be shortened. The descending pubic distance an average-sized unmoulded foetal head rami normally slope backwards more than the will lie from the lower border of the symphysis symphysis, but this is variable, and a marked during delivery. backward slope is particularly unfavourable when This distance can be marked off on the lateral Postgrad Med J: first published as 10.1136/pgmj.25.284.255 on 1 June 1949. Downloaded from June I949 ARTHURE : The Clinical Value of X-Ray Pelvimetry *..:: '::': . .. 1-1~~~· i:" |lI E:it1SI :''.il .i ......: ::: ... .. ..: FIG. I.-Supero-inferior projection. by copyright. FIG. 3.-Lateral projection, patient erect. http://pmj.bmj.com/ on October 1, 2021 by guest. Protected into: i::' A:i ....:. FIG. 5.-Subpubic arch projection; narrow arch D Postgrad Med J: first published as 10.1136/pgmj.25.284.255 on 1 June 1949. Downloaded from POST GRADUATE MEDICAL JOURNAL June i949 i.: ·i: ::·:'· ·· 'i' ii' " :i·· .i. .:::::· ···.:··ii:.::: I by copyright. ii:.. ;.s.S. FIG. 8.-Lateral X-ray. Head now engaged. http://pmj.bmj.com/ :iT .::' :·.·.. .~ on October 1, 2021 by guest. Protected FIG. 9.-Lateral X-ray. Head free and occiput slightly posterior; no disproportion.
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