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Home , Pelvic inlet, Pelvic outlet, Pelvimetry

310 Postgrad Med J: first published as 10.1136/pgmj.25.285.310 on 1 July 1949. Downloaded from

PELVIMETRY IN By H. CECIL BULL, M.R.C.P.

Pregnancy is by the laws of nature the universal midplane and outlet, the surface areas of brim and experience of women, parturition no disease, a midplane and the biparietal diameter of the foetal natural act, tending to become less natural as head. Besides this we have the positive evidence woman ascends the higher reaches of civilization. of presentation and , extended legs in The native girl of Ceylon undertakes marriage breech presentations, deformities, etc. early while the are soft and the muscles In radiology, diameter measurements are be- hard, follows and parturition is an tween bony points and therefore greater than fact interlude in the working hours. With the economic because they do not take account of soft tissues. stresses of western life marriage is later, mal- Clinically or radiologically we can forecast a formations of the skeleton more frequent, par- normal labour in a of ample dimensions, or turition less easv and regard for life keener. Even the impossible delivery when the pelvis is con- Protected by copyright. so parturition for the majoritv of western women is tracted. The important group is the intermediate a natural event taking place under the kindly eye of where there may be doubt of a living child or an elder or semi-skilled female friend. danger to the mother. Here, neither clinician nor To this in the past Medicine has stood in radiologist is certain; every art and craft of benevolent and advisory capacity, willing to help medicine should therefore be impressed to save a when required. Now, the policy is to round up life or forestall a danger. Of old, ' trial labour ' pregnant women and bring them all under medical was recommended on the argument that the care in the early stages. In this antenatal period second labour would be easier, provided the she is examined to determine her general health mother survived. Now the pendulum swings, and to forecast the probable course of labour. It perhaps overswings, in the opposite direction and is an important decision to which the doctor is where there is doubt there is . guided by clinical judgment and the customary The gap between normal and impossible is too obstetric measurements, crude but accessory aids wide, and one way to narrow the gap is to en- http://pmj.bmj.com/ to build up the clinical picture. courage and develop a closer harmony between The pelvis has a certain geometrical shape, so clinical and radiological investigations. has the foetal head ; the soft parts are malleable to In the first place there should be a certain a degree, expulsion being effected by muscular standardization of radiological technique, an agree- contraction provided the passage is adequate. ment to accept some methods and reject others. The important factors therefore in prognosis are- Secondly, it should be recognized that radiology introduces rigid mathematics whose value can only knowledge of the pelvic canal and clinical on September 30, 2021 by guest. judgment. be appreciated in conjunction with clinical Now we have with X-rays accurate methods of judgment. measuring the diameters of the pelvic canal and of If radiology be accepted as a real help in fore- the foetal head as well as of checking the more casting the course of labour, we must integrate the obvious difficulties-multiple pregnancy, abnormal figures produced in terms of obstetrical difficulties. presentation and lie, anencephalic monster, etc. This has been done by Allen (I947) whose table is Full advantage is not made of these methods. an excellent beginning, though wide in its limits. Radiologists the world over have worked and The following paragraphs are concerned firstly written about it and it is difficult at first sight to with the radiological measurements of the pelvis understand why X-ray is not used in and calculations therefrom; secondly, with the every doubtful case. Radiology calculates various types of pelvis and, finally, with the mathematically, determining the diameters of the deductions that can be made from these observa- , midplane and outlet, and with approxi- tions and their relation to obstetrical difficulties. mate accuracy the posterior sagittal diameters of Radiology undertakes:- in Obstetrics 311 JUIy 1949 BULL: Pelvimetry Postgrad Med J: first published as 10.1136/pgmj.25.285.310 on 1 July 1949. Downloaded from 1. Measurements 7rab (a) PELVIC INLET 4 Anteroposterior (conjugate). where a= anteroposterior diameter of mid- Transverse. plane. Right oblique. b = transverse (bispinous). Left oblique. Area. (C) OUTLET The transverse diameter is the distance between The anteroposterior is the shortest distance be- the ischial tuberosities. tween the symphysis and the . In No full anteroposterior diameter can be measured most patients the point on the sacrum is the because the protrusion of the head through the anatomical promontory, but where there is subpubic arch cannot be measured. The only sacralization of the last lumbar vertebra and in linear measurement possible is the ischio-sacral, some other subjects, the first two pieces of the i.e. from the midpoint of the transverse diameter sacrum may be straight instead of curving back- to the last piece of the sacrum. wards from the promontory; the shortest dis-. tance is then to the second piece of the sacrum. (d) SUBPUBIC ANGLE Transverse-the widest diameter of the brim. Nicholson (1938) gives 750 as the ' critical Right and left oblique-from each angle, meaning that anything less than 750 is to the opposite pubic ramus. These measure- likely to lead to obstetrical difficulty. This is in- ments show if there is asymmetry of the brim but accurate as will be shown later. are not otherwise useful in diagnosis. Because of the variable shape of the pelvis no and of absolute standards of normal can be given, but the Anterior posterior sagittal-intersection Protected by copyright. the transverse with the anteroposterior diameter, following is a list of diameter measurements and divides the latter into anterior and posterior area calculations, being an average of routine sagittal diameters. These are of interest only in cases. the 'android' pelvis of Caldwell and Moloy Inlet Average normal about (1935)- Conjugate I20 mm. The brimn area is calculated from the formula of Transverse I28 mm. Nicholson (1938) Right oblique I17 mm. Left oblique 7 mm. 7rab II Area-~~ Brim area I20 sq. cm. 4 where a conjugate. Midplane b transverse diameter of inlet. Anteroposterior I20 mm. The error is least in the round pelvis but area Transverse (interspinous) I00 mm. measurements are necessarily inaccurate in an. Posterior sagittal 43 mm. http://pmj.bmj.com/ imperfect geometric figure. This being born in Midplane area 98 sq. cm. mind, they are useful in showing the combined value of the two diameters. Outlet Transverse (intertuberous) I20 mm. (b) MIDPLANE Anteroposterior (ischiosacral) 8o mm. The midplane is the area bounded in front by Subpubic angle-8o0.

the .symphysis pubis, behind by the sacrum from Perpendicular-62 mm. on September 30, 2021 by guest. promontory to the last piece excluding the , and laterally by the , pubis and sacro- 2. Shape sciatic ligaments. For linear measurements of Pelves are classified by the shape of the inlet, this space we take:-- by the .roportion of the conjugate to the trans- Anteroposterior-from lower edge of symphysis verse diameter. to the lower end of the last sacral segment. (a) Round (mesatipellic), the transverse diameter Lateral-the distance between the ischial spines. is equal or nearly equal to the conjugate. Posterior sagittal-from the midpoint of the (b) Long oval (dolichopellic or anthropoid), the above lateral (bispinous diameter) to the lower end transverse is smaller than the conjugate. of the last sacral segment. (c) Flat (platypellic), the transverse is greater Midplane area. Calculation is made from the than the conjugate. anteroposterior and lateral diameters according to This relationship is expressed by the brim the formula index: 312 POST GRADUATE MEDICAL JOURNAL Yuly I949 Postgrad Med J: first published as 10.1136/pgmj.25.285.310 on 1 July 1949. Downloaded from Conjugate In other words the normal posterior sagittal Transverse measurement is 40 to 50 per cent. of the length of Brim Index the conjugate and when we find it to be less than Per Cent. 40 per cent. we are dealing with an android pelvis. Round pelvis 85 to IOO The small inaccuracy due to the slightly different Long oval pelvis over ioo plane levels of conjugate and transverse diameters Flat pelvis under 85 is not significant. A fourth, the triangular shaped pelvic inlet The brim area calculated from the conjugate where the rami tend to narrow anteriorly, has and transverse diameters is but another, not very been named the 'android' pelvis by Caldwell accurate figure expressing plane area. It would be and Moloy (I935). It may be regarded as a accurate if the pelvic inlet were a circle; in- modified anthropoid shape but is imnportant be- exactitude grows in proportion as it departs cause it leads to obstetrical difficulties. In such therefrom. cases nothing is learnt from the brim index. The anterior narrowing of the pelvis means there must Midplane be more space posteriorly if the head is to pass Once through the brim in a normal pelvis the through. For recognition of the android pelvis we head has more room to move and can rotate since use the relation of the posterior sagittal diameter the backward curve of the sacrum gives a greater of the inlet to the conjugate expressed as a anteroposterior diameter. There are, however, percentage: some which do not curve backwards and Posterior sagittal some, indeed, which come a little forward so that Conjugate the anteroposterior diameter between symphysis and sacrum is less than between symphysis and

It is not established Protected by copyright. how low this ratio may be promontory. The narrower diameter is then re- to come into the classification of android. Opinion garded as the true conjugate. The straight sacrum ranges between 24 and 40. The formula applies is usually associated with a congenital anomalv of only to the android pelvis and is not an index for the first piece; either the last lumbar vertebra other pelvic types. is sacralized or the first piece of the sacrum 3. resembles a lumbar vertebra (Fig. 3). The placenta can often be identified in shaded Diameters of the Midplane films as a soft tissue shadow on the anterior or posterior wall of The anteroposterior diameter of the midplane the uterus (Fig. 2). from the inner surface of the svmphysis to the last Commentary piece of the sacrum might be called the outlet of the midplane. It is the smallest anteroposterior To the pelhic brim most attention has been given length of the midplane and varies with the forward in obstetrics and it is from the that the http://pmj.bmj.com/ classification of types is derived. Most important curve of the sacrum. It is one of the essential of the measurements of the brim has been and is diameters, rarely measuring as little as ioo mm. the conjugate diameter. The minimum diameter in the female, but if it does there will be difficulty, of the foetal head at term is 98 mm. ; if either especially if the interspinous is also ioo mm. This conjugate or transverse diameter is less, the head anteroposterior measurement disregards the coccyx will not easily pass through. on the assumption that it will dislocate backwards The relationship of the transverse to the con- ifnecessary. jugate is the other important brim characteristic The interspinous, the diameter between the on September 30, 2021 by guest. expressed as a percentage in the brim index. ischial spines, is an essential diameter through The oblique diameters measured from the sacro- which the full width of the head must pass. There liac joints to pubic rami are equal in the is no slipping in front or behind it, the fact of symmetrical pelvis. narrowing here also meaning that the body of the Shortening of the posterior sagittal diameter of ischia below come together and the whole length the inlet is a feature of the ' android ' pelvis. of descent will be a close fit of approximately the There is as yet no agreement as to how low th same transverse width as that between the ischial Posterior spines. A measurement below go mm. therefore index sagittal x ioo may be to be is on the danger level. The transverse diameter Conjugate of the outlet (intertuberous) is proportional to the classified as android, figures from 24 to 36 are interspinous. It is uncommon to find it less than given by various workers. It is suggested by IOO mm. but, if so, it is an index of trouble, not Allen (I947) that 40 per cent. should be regarded so much on its own account but as a warning that as the dividing line, ratios below this being android. the whole passage through the midplane is narrow. uly 1949 BULL: Pelvimetry in Obstetrics 3[3 Postgrad Med J: first published as 10.1136/pgmj.25.285.310 on 1 July 1949. Downloaded from

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FIG. 3. Sacralization. Breech presentation. The various measured di'ameters are shown. The patient had two FIG. 2.-Placenta on posterior wall of fundus. normal births previously but this was complicated by an ovarian cyst. Caesarean section. 314 POST GRADUATE MEDICAL JOURNAL Yuly. 1949 Postgrad Med J: first published as 10.1136/pgmj.25.285.310 on 1 July 1949. Downloaded from

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FIC. 5.-Antero-poster;()r. Postgrad Med J: first published as 10.1136/pgmj.25.285.310 on 1 July 1949. Downloaded from YulY I 949 BULL: Pelvimetry in Obstetrics 315 Posterior Sagittal of Midplane the head through the outlet. It is no longer The measurement from the midpoint of the possible to go back; it is late for Caesarean interspinous diameter to the last piece of the section, the head is moulding perhaps excessively sacrum is an accessory help in determining the and the child must be delivered soon; forceps available space for the head in its final passage to are necessary but increase the risk of damage to the outlet. the head and if force is used may result in a The writer has not been able to appreciate the tentorial tear. value of the posterior sagittal measurement of the Such disasters and near-tragedies still happen. midplane. If the full anteroposterior diameter is They should be largely avoided if all the help adequate the posterior sagittal is of no con- modern science can give is correctly brought to sequence. If the anteroposterior is not adequate bear. Because the head is capable of moulding the head will not pass. Similarly if the ischia come and the sacroiliac joints allow some backward together and the transverse interspinous diameter movement of the sacrum, much is left to chance. is inadequate no power and no extra room behind Let us consider the matter mathematically from the spines will bring the head through. the limits of the fixed bony points to see whether The bi-parietal diameter of the head at term it is not possible to anticipate trouble. In so being 98 mm., any pelvic diameter of 98 mm. may doing the writer sees no reason for making allow- cause difficulty, and when it is as small as 85 mm. ance for moulding of the head. Moulding is an passage of the head borders on the impossible. undesirable, however common, insult to the foetal The most certain bar to progress is when the two head and slight moulding is accepted only as a diameters, anteroposterior and lateral, of one plane compensation for small errors of calculation. In are narrowed. Thus an anteroposterior and lateral the interests of the breed, extreme moulding and of 95 mm. is a more likely stop than an antero- the use of forceps to overcome mechanical dis- Protected by copyright. posterior of i IO and a transverse of 90 mm. proportion should be discouraged. We have already noted that the transverse Outlet diameter of the outlet is adequate. The difficulties This is the most difficult part of the pelvis to resolve themselves, therefore, into the measure- reduce to terms of mathematics because of its ment of the anteroposterior diameter and of the peculiar anatomical shape. The maximum trans- angle of the . In default of obtaining a verse diameter of the outlet is the distance between large number of pelves correctly articulated and the ischial tuberosities and apart from gross de- not too dry for experimental test, the writer has formity is never a narrow diameter. This trans- used a geometric figure, a ball of ioo mm. diameter verse diameter marks the division of the outlet and a variable subpubic angle and ischiosacral into anterior and posterior triangles which lie in length. The rami of the subpubic arch were kept different planes. The anterior, subpubic triangle constant at IOO mm. (a little greater than the faces forward, having sides formed by the ischio- average normal) and two characteristic inter- http://pmj.bmj.com/ pubic rami and base by the imaginarv transverse tuberous diameters of 115 and I25 mm. were used intertuberous diameter (Fig. 4). The posterior as base lines (Figs. 5 and 6). It may be that the triangle makes a wide angle with the anterior and results can be expressed as a formula but they can faces somewhat backwards. Its anterior boundary be understood and appreciated more easily as is the intertuberous diarneter, the lateral walls the graphs; no reason appears for believing that the sacro-sciatic ligaments and the posterior limit the facts which emerge differ materially from those of

last piece of the sacrum. The distance from the the pelvis in life. on September 30, 2021 by guest. midpoint of the intertuberous diameter to the last For experimental purposes the foetal head may piece of the sacrum is the anteroposterior or sagittal be looked upon as a circle of ioo mm. diameter diameter of this posterior area of the outlet, it is which is approximately the biparietal or minimum not a measurement which has been employed in essential diameter of the uncompressed head. In radiological pelvimetry and may be called the order that the head may pass through the outlet ischiosacral diameter of the outlet. the anteroposterior and lateral diameters must Too little attention has been paid in the past to each measure not less than ioo mm. The antero- outlet measurements. Much has been written on posterior diameter consists of the ischiosacral the size and shape of the inlet and we can forecast diameter plus the distance the head can push with fair accuracy whether or not the head will through the pubic arch above the tuberosities. If pass through the brim. If our judgment is at we imagine for a moment that the pubic arch is fault there is still time to delivery by Caesarean filled in by a rigid membrane then the antero- section. Once through the inlet there is space posterior diameter is easy to measure; it is the enough for movement through the midplane, but ischiosacral diameter and must be ioo mm. long difficulty may begin in the last act, the passing of ifthe head is to pass. But the ischiosacral diameter 3I6 POST GRADUATE MEDICAL JOURNAL July 1949 Postgrad Med J: first published as 10.1136/pgmj.25.285.310 on 1 July 1949. Downloaded from

is usually less than ioo mm.; in fact, it averages Perpendicular to Base line 8o mm. The additional length is obtained by the Millimetres head passing partway through the pubic arch as soon as the divergence of the rami allows, and by backward rocking of the sacrum. A mistaken con- ception of the geometrics of the pubic arch has crept into the literature. It is written that a wide angle of the pubic arch makes for ease in delivery and that difficulties may be expected when the arch is narrow. The converse is the geometric truth; the narrower the angle the easier for the head to come forward. lpp The anteroposterior measurement of the outlet cannot be assessed as a simple figure since, as noted above, it consists of two parts-the ischio- 70 \_\_l sacral from the midpoint of the intertuberous diameter Ito the last piece of the sacrum, and the indefinite space the head may occupy by pushing forward through the subpubic arch. This antero- 6o posterioi ' space ' of the outlet is best resolved in two graphs using the intertuberous diameter as a base line and taking note of the perpendicular measurement from the subpubic angle to the base 79 rg o 7 Protected by copyright. line, the ' ischiosacral ' from the base line to the ;7' sacrum, and the subpubic angle. The graphs Millimetres (Figs. 7 and 8) demonstrate that the lengths desir- FIG. 8.-Ischiosacral diameter. Graph B. Degrees Subpubic Angle able to secure an easy passage are the perpendicular of the subpubic angle and the base line. The angle which the rami make as they come together is of secondary importance and since individual rami do not vary greatly in length the narrower the

subpubic angle the greater will be the ease of http://pmj.bmj.com/ passage, given an adequate base line width. The necessary length required of the ischiosacral diameter is shown on the graphs and need only 7o. be a large one when the subpubic angle is wide, the perpendicular short and the base line narrow. It must be added, however, that this ischiosacral diameter which is measured in the still subject is by no means a fixed diameter during parturition. on September 30, 2021 by guest. It is a diameter which is increased in length by the backward movement of the sacrum, an increase which varies with the age of the patient and the mobility at the sacroiliac joints. Graph A shows that a biparietal diameter of IOO mm. requires an ischiosacral measurement of 89 mm. when the subpubic angle is go9, whereas 8z mm. is sufficient for an angle of 700, the base line berng I 5 mm. in each case. As the base line increases, the need for length in the ischiosacral 70o 7sTO line decreases, but the decrease is proportional to Millimetres the subpubic angle (or perpendicular bisector of FIG. 7.-Jschiosacral diameter the base) and the graphs are straight lines Graph A. (Graph B). J7uly 1949 BULL: Pelvimetry in Obstetrics . 317 Postgrad Med J: first published as 10.1136/pgmj.25.285.310 on 1 July 1949. Downloaded from It will be seen that the important linear measure- vaginal delivery is certain are above those of the ments of the outlet are the transverse (inter- usual normal. tuberous) diameter and the perpendicular to it The foetus makes full use of the available space from the subpubic angle. Knowing these measure- between the bony points and for most women it is ments we can postulate the length of the ischio- a close fit, however adequate. The interspinous is sacral diameter necessary for the head to pass an important diameter and it is interesting to note through. that the average measurement does not allow much We progress so far by reducing labour to a over the minimum. It is not a diameter that geometric figure and one feels that it expresses a varies greatlv and, of course, the head can pass basic truth correcting some of the minor errors. even when it is less than go mm., but must It does not follow in practice, however, that rigid inevitably be compressed in passage. measurements constitute a bar to natural delivery. The least informative in this table are the outlet We find that the ischiosacral diameter can fall measurements since they are more interdependent short of the desired length by anything up to I5 than any of the others. mm. without obstructing delivery. This is held to be due chiefly to the backward rocking of the Conclusion sacrum which results from loosening of the sacro- Radiology endeavours to give all the help it can iliac joints during pregnancy and which is at by pelvimetry in obstetrics. The best line of present immeasurable and likely to be variable in approach has not yet been reached a-nd the writer different subjects. has outlined within his own knowledge the This is one of the problems in which radiology accepted measurements and calculations of the extends help to the limits of its ability and invites inlet and midplane. There is less unanimity about the cooperation of clinical obstetrics to assess its outlet measurements and in these he has written value. The argument cannot be accepted that his own views and how those views have been Protected by copyright. practice bears no relation to theory merely because reached. They are offered for criticism by nature can make an extra effort to overcome radiologists and obstetricians in the hope that by difficulties. There is a point beyond which no their experience they will modify or amplify the effort will be successful and we should be able to findings of the geometrics of the . make better forecasts of whether or no it is possible The difficulty often mentioned in this article is to deliver naturally without injury to mother or to link up the known with the unknown, that is to child. relate fixed diameters to variables. The con- clusions here expressed are based on the law that Table of Pelvimetry Values an object of certain size will not pass through a A table of values wherein to check results and channel smaller than itself. Radiological pel- read off the chances of easy or difficult delivery vimetry must take its stand here and propound would be a helpful summary. Such a table is not the theoretical view of obstetrics according to the easily compiled ; the diameters are too intimately calculations of its own science. It only confuses http://pmj.bmj.com/ related. The accompanying table (Fig. 9) is an the issue if we begin to make allowance for the average of normal cases wherein the diameters variable and immeasurable factors such as mould- have been sufficient for natural birth, and with it ing of the head and movement of the sacrum at the are shown measurements theoretically inadequate sacroiliac joints. Such factors lie in the realm of for the passage of a foetal head at term. the obstetrician. Allen gives a guide to prognosis which is a It is the purpose of radiology to supply all direction but suffers from the possible information to the clinician in such manner valuable lead in this on September 30, 2021 by guest. same disadvantages. His upper limits in which as may be most useful to him. There are many

FIG. 9

INLET MID-PLANE OUTLET

Inter- -Ischio- Conj. Trans. Area A.P. Spi. Area Trans. Perp. sacral Average measurements. Natural de- 120 128 I20 120 100 98 120 75 8o livery should be possible mm. mm. sq. cm. mm. mm. sq. cm. mm. mm. mm. Natural delivery theoretically im- 95 95 78 95 95 78 95 55 70 possible mm. mm. sq. cm. mm. mm. sq. cm. mm. mm. mm. 3I8 POST GRADUATIE MEDICAL JOURNAL JulY 1949 Postgrad Med J: first published as 10.1136/pgmj.25.285.310 on 1 July 1949. Downloaded from factors in obstetrics besides mathematics, and Dr. Joseph of the Department of Anatomy of the judgment will be made oi the case as a whole, University of London, Dr. Delmas of the Institut pelvimetry forming a small but important part of de M&d1cin of Paris and Dr. Horin, Assistant the evidence. Obstetrician to the Maternity Hospital, Port It is to be hoped that if radiological pelvimetry Royal, Paris. can be standardized and put into general use, a closer correlation may be achieved and a more accurate forecast of difficulties obtained by a study BIBLIOGRAPHY of pelvimetric results. ALLEN, E. P. (1947), Brit. .7. Rad., 20, 45, IoS, I64, 20S. CALDWELL MOLOY, and D'ESOPO (193s), Am. Y. Obst. and GYn., 30,793 Acknowledgments NICHOLSON, C. (1938), Obst. and Gyn., BEit. Emp., 45, 950. PIZON, PIERRE (1948) 'Radiodiagnostic Obstetrical, I'Ex- Apart from the books and articles of which a pansion Scientifique Francais.' few only are mentioned I am grateful for thie REECE, L. N. (193S), Proc. Roy. Soc. Med., 489. WILLIAMS, E. R., and PHILLIPS, L. G. (Ir946),.Y. Obst. and facilities given me in the examination of pelves by Gyn., Brit. Emp. Protected by copyright.

SIR JAMES YOUNG SIMPSON http://pmj.bmj.com/ Sir James Young Simpson (i8i8-I870) was born and educated in Edinburgh. His great ability and fascinating personality resulted in his appointment to the chair of Obstetrics in I840. Following his introduction of ether to he experimented in other less un- pleasant agents until in I847 he published the results offive cases anaesthetized with chloro- form. His advocacy of the use of anaesthesia in involved him in prolonged and on September 30, 2021 by guest. bitter controversies, which were only ended in i853 when Queen Victoria herself received chloroform at the birth of Prince Leopold. His great inventive powers led to the introduction of the long obstetric forcep, uterine sounds, sponge tents and the use of dilation of the cervix uteri as a diagnostic measure.