Age-related features of the pelvic bones. Complications during childbirth for mother and fetus. Additional measurements for diagnosing a narrow pelvis

In descriptive anatomy, the name pelvis refers to the part of the body bounded by the bones of the pelvic ring. Top part his, big basin, is formed by the ilium, and the small pelvis begins below the boundary line [Ostroverkhov G.E., Lubotsky D.N., Bomash Yu.M., 1963J. The distal part of the pelvis is limited by a group of muscles that form the pelvic floor (pelvic diaphragm).

In newborns, the iliac bones are located vertically, the iliac fossae are poorly expressed. The lumbar part of the spine passes into the sacral part without bending. The entrance to the cavity is ta;:i y:ky. Intensive growth pelvic bones begins at 3-4 years. During the first years of life, the size of the pelvis of girls is relatively smaller than that of boys; by the age of 8-9 years the difference disappears, and by the period of puberty the opposite ratio is established.

Douglas space in newborns is deep. According to R. Turell (1950), in newborns its bottom is 1.2-1.5 cm from the anus, which corresponds to the upper edge of the prostate gland in boys or the vagina in girls. As the baby grows and Douglas's pelvic organs descend, the space becomes flatter.

Cellular spaces. Above the pelvic diaphragm is the pelvic-rectal (pelviorectal) tissue space. It is bounded above by the peritoneum, below by the levator ani muscle, on the sides, in front and behind, by the parietal fascia, and on the medial side by the visceral fascia. This space contains the ureters, vas deferens in boys, internal iliac arteries and veins, and obturator nerves. The fiber of the pelvic-rectal space along the vessels and nerves communicates with the fiber of the gluteal region, the ischiorectal fossa, the medial and posterior surface of the thighs, and from above along the vessels and ureters with the retroperitoneal fiber.

The ischiorectal space is bounded above by the levator ani muscle, on the sides by the obturator muscle and the ischial tuberosity, and below by the thin fascia of the subcutaneous tissue.

Posteriorly, the rectal (retrorectal) fiber space is located between the rectal capsule and the fascia covering the sacrum. From below it is limited by the pelvic diaphragm. At the top, the retrorectal space communicates with the retroperitoneal space, and along the vessels and nerves - with the above-mentioned cellular spaces.

Due to the poor development of preperitoneal and pelvic fatty tissue in children, the ureters are easily displaced, and this explains the change in their position depending on filling Bladder, sigmoid and rectum. As fatty tissue develops, the ureters become less mobile. Their mouths are located relatively high, and the intramural part is bent almost at a right angle. How older child, the more the ureters are straightened.

Bladder in newborns has a spindle-shaped shape. 1a significant part of it protrudes above the symphysis, and the internal opening urethra often located at the level of the symphysis. After the first year of life, the spindle-shaped shape of the bladder begins to smooth out. In young children, the anterior wall of the bladder is adjacent to the inner surface of the anterior wall for a fairly long distance. abdominal wall.

Prostate gland in newborns and young children is located relatively high. It increases slowly. Noticeable growth is observed at the age of 12-15 years. Before this gland is softer to the touch than in adults.

Vas deferens thin, cross dimension on average it is 0.5 mm in newborns, 0.8 mm at the age of 5 years, 1.1 mm at the age of 11 years, and 1.6 mm at the age of 14 years. The seminal vesicles enlarge gradually and slowly. In newborns, their shape already resembles that of adults. The vesicles are located high in accordance with the position of the bladder, and therefore in newborns and infants they are covered on all sides by the peritoneum. By 2 years of age, the seminal vesicles have descended so much that they lie almost completely extraperitoneally, with the exception of the apices.

Ovaries in newborns located high and outside the pelvic cavity. They are deviated anteriorly and are usually shifted to the right, which corresponds to displacement of the uterus. By the age of 5, the ovaries assume a position similar to that of an adult woman.

Uterus in newborns protrudes above the pubis. Its characteristic position is anteflexio anteversio (retroflexio is rarely observed). Up to 2 years, the uterus has an elongated shape, and by 8-9 years it becomes round.

Thus, for childhood certain anatomical features colon and pelvic organs: age-related differences in the absolute and relative length of different parts of the colon, their mobility and topographic-anatomical relationships. At an early age, the sacrum is more vertical and the pelvis is less capacious than in older children. The pelvic organs are located higher.

Sexual differences in the bony pelvis are already apparent in a newborn child, whose fully formed pelvis contains an abundant amount of cartilage between the centers of ossification and in their circumference. The pelvis of a newborn girl is lower and wider than the pelvis of a newborn boy, which is expressed by the relatively large diameter of the pelvic inlet. The pubic arch of a newborn girl is also somewhat wider than that of a boy.

IN general research pelvis in newborn children showed completely different ratios in the size and shape of the pelvis in different sexes. In addition to the degree of ossification, the newborn pelvis differs in many ways from the adult pelvis. The sacrum with its relatively narrow wings has an almost straight surface from top to bottom, and the place of its articulation with the last lumbar vertebra, located high above the entrance to the pelvis, protrudes only slightly in the form of a cape (promontorium). The anterior surface of the sacrum in both horizontal and vertical directions is devoid of concavity. The tailbone is curved slightly forward. The curvature of the spinal column in the lumbar and thoracic regions, in accordance with the absence of curvature of the sacrum, is insignificant. The iliac bones, located almost vertically, rise steeply upward and have only a slightly concave inner surface.

The shape of the child's pelvis, along with embryonic moments and growth energy, is influenced primarily by the pressure produced from the spinal column when sitting, standing and walking, the counterpressure from the lower extremities associated with the pelvic ring in the hip joints, as well as the pressure exerted from the iliac bones to the pubic symphysis.

Physiological kyphosis of the thoracic spine results in compensatory curvature of the lumbar part ( lumbar lordosis) and in addition determines the rotation of the sacrum around it horizontal axis, and the cape, under pressure from the body, moves down and forward. The apex of the sacrum, held in its lower parts strong cords of the spinosacral and tuberosacral ligaments cannot move back, which is why the entire sacrum must sometimes bend around its horizontal axis and thereby becomes concave in front. The sacral vertebrae are most strongly compressed in the back and are lower here than in the front.

If there is no burden from the spinal column, for example, when lying on the back for a long time, then the pelvis acquires features characteristic of the pelvis of a newborn. Under the influence of such factors, physiological curvatures of the spinal column and sacrum can be smoothed out, as well as increased tension of the pelvis in the transverse direction (recumbent pelvis). If, further, there is no back pressure from the thighs when existing pressure from the side of the spinal column, then the opportunity for the pelvis to expand in the transverse direction becomes disproportionately large. In the absence of a strong connection between the pelvic bones at the symphysis (split pelvis), the pelvic ring should gape widely in front.

Since the posterior ends of the iliac bones are connected to the sacrum by strong ligaments and, with a strong displacement of the promontory forward, must follow the movements of the sacrum, due to this the femurs acquire a tendency to diverge from one another and, as it were, tear the pelvic ring at the symphysis. As the symphysis resists the possibility of this rupture, it is also pulled back. Thus, the stretching of the pelvis in the transverse direction increases, while the anteroposterior size of the pelvic ring decreases accordingly. As a result, the pelvic entrance takes on a typical transverse oval shape with a promontory protruding from behind.

So, characteristic changes in the pelvis of a newborn consist of rotation and flexion of the sacrum, an increase in the transverse and a decrease in the direct size of the pelvis.

If the pressure exerted by the torso is very significant, and the pelvis is too pliable due to the elasticity and softness of its walls, then with excessive transverse tension a narrowed pelvis is formed, the so-called flat pelvis. Similar to the emergence of such a pelvis, one can generally easily imagine the emergence of all sorts of narrow pelvises, and also trace the entire process of transformation of the pelvis of the fetus and child into a sexually mature pelvis.

If you are just planning a child, then modern medicine at the most early stages allows for PGD - preimplantation genetic diagnosis. This diagnosis will make it possible to identify many deviations at the gene level in the very initial period of embryo development.

Immaturity of a joint is the slow development of its structures, in particular, underdevelopment and delay in the formation of ossification nuclei. In practice, this means that the cartilage did not turn into bone in the allotted time. Completion of ossification of the femoral head occurs at the age of 3–7 months.

While dysplasia is congenital pathology and does not mean correct formation and the articulation of the joint with the pelvis. Dysplasia in newborns is often diagnosed in the maternity hospital, and immaturity of the hip joints, due to the fact that it is less pronounced, is detected several weeks or even months after birth.

These two diagnoses are closely related and, in fact, describe the degree of pathology of the hip joint. Previously, they both referred to dysplasia, but now these concepts have been differentiated. So accurate diagnostic definition problem helps to choose a more accurate and correct treatment. Physiological immaturity is a conditional pathology, and for its treatment, in comparison with dysplasia, more gentle methods are used.

However, the line between these diseases is quite thin, and if underdevelopment of the hip joints in a newborn is not noticed in time, then it can cause various forms dysplasia, head dislocation femur and subsequent problems with the hip joint.

The importance of early diagnosis

Early diagnosis is crucial for the prevention of possible pathologies of the hip joint. With timely treatment, proper formation occurs. hip joint and maintaining all its functions. For more later diagnosis of the disease (6 months or more), treatment takes more time and effort, because by this time the cartilage ossifies, ligaments grow around the joint and fix it in the wrong position.

Dr. Komarovsky believes that early treatment is a fundamental factor in guaranteeing its success. After all, it is very important that the head of the joint is positioned correctly by the time the child begins to walk. Otherwise, hip dislocation and lameness, arthritis and arthrosis may occur, even leading to surgical intervention in adulthood.

As practice has shown, double examination of a newborn (in the maternity hospital and children's clinic) will allow early detection of physiological immaturity and dysplasia of the hip joint. Therefore, there is a mandatory routine inspection children at the orthopedist (at 1, 3 and 6 months) which should not be missed under any circumstances.

Immaturity of the hip joint from physiological abnormality moves to the pathology section only if a child aged 3–5 months is diagnosed with a significant delay in the development of nuclei and there is pronounced asymmetry.

Physiological immaturity

Regarding newborns, the term “physiological immaturity” denotes a situation when the degree of maturity of organs lags behind calendar age. This is more common in premature babies and severe course pregnancy. Doctors believe that one of the reasons for the pathology of the hip joint is a violation motor activity fetus

In particular, pathology of the left joint is much more common than the right one, due to the special location of the fetus in the womb, in which the mobility of the left leg is limited. It is also necessary to take into account the aspect that in newborns the physiological immaturity of both hip joints is the norm, and their formation ends by 3-7 months.

Causes of joint underdevelopment in a newborn

Most orthopedic doctors believe that the cause various pathologies The hip joint disrupts the formation of tissues even at the level of embryogenesis. However, there are quite a lot of predisposing factors that lead to immaturity or dysplasia:

• genetic predisposition;
• acute toxicosis;
• large fruit;
• breech presentation of the fetus;
• late pregnancy;
• poor nutrition and treatment of the expectant mother with potent medications;
• limited fetal mobility, which may be caused by oligohydramnios;
• difficult childbirth.

Dr. Komarovsky considers the first independent birth to be one of the factors predisposing to the development of joint pathology, during which the woman’s body produces maximum amount relaxin hormone. It is responsible for relaxing the pelvic ligaments to facilitate childbirth and indirectly causes weakening of the baby's ligaments.

Risk group

If there are quite a lot of predisposing factors for the occurrence of joint pathology, the newborn is registered with an orthopedist and an ultrasound is performed. One of them is the gender of the child.

Thus, Dr. Komarovsky notes that in girls, hip joint immaturity occurs 5-9 times more often than in boys. This is due to the fact that physiologically in women, the pelvic ligaments are highly elastic and are more susceptible to stretching.

Negative factors that worsen the ossification process include rickets, lack of breastfeeding, endocrine diseases The child has.

Signs of immaturity

There are several characteristic features, the presence of which may indicate underdevelopment of the hip joint:

1. asymmetry of the inguinal or gluteal folds;
2. different leg lengths or knee heights when bending the legs;
3. the bent legs do not spread out to the sides equally;
4. clicks when moving your foot to the side.

If you notice any of the listed signs in your child, immediately consult an orthopedic doctor.

Prevention of immaturity

It has been proven that tight swaddling contributes to the aggravation of orthopedic pathology. Dr. Komarovsky will clearly demonstrate why infants should not be swaddled tightly in a program dedicated to hip dysplasia in newborns.

An excellent means for the prevention and treatment of underdevelopment is wide swaddling. It helps to fix the joints in an extended position, which contributes to their proper formation.

Since hip joint pathology is more common in girls, for prevention purposes, Dr. Komarovsky advises using the thickest diapers that parents can find, and preferably one size larger.

Treatment of underdevelopment

They use an integrated approach:

• multivitamins;
• physiotherapy;
• wide swaddling;
• physiotherapy;
• massage.

A narrow pelvis is considered one of the most complex and difficult sections of obstetrics, since this pathology can lead to the development of dangerous complications during childbirth, especially if they are performed incorrectly. According to statistics, anatomical narrowing of the pelvic bones occurs in 1-7.7% of cases, while during childbirth such a pelvis becomes clinically narrow in 30%. If we take the total number of all births, then this pathology accounts for about 1.7% of cases.

The concept of “narrow pelvis”

During the period when the fetus is expelled from the uterus or during the pushing period, the child must overcome the bone ring that is formed by the pelvic bones. This ring consists of 4 bones: the coccyx, the sacrum and two pelvic bones, which are formed by the ischium, pubis and iliac bones. These bones are connected to each other using ligaments and cartilage. The female pelvis, unlike the male one, is larger and wider, but has less depth. A pelvis with normal parameters plays an important role in the normal, physiological course of childbirth without complications. If there are deviations in the symmetry and configuration of the pelvis, its size decreases, then the bony pelvis serves as a kind of obstacle to the passage of the fetal head.

IN in practical terms There are two types of narrow pelvis:

a clinically narrow pelvis occurs in the event of a discrepancy between the anatomical dimensions of the woman’s pelvis and the dimensions of the child’s head during childbirth (however, even in the presence of an anatomical narrowing of the pelvis during childbirth, a functionally narrow pelvis may not always occur, for example, when the fetus has small sizes, or vice versa, when functional indicators pelvis are normal, but large sizes baby lead to the development of a clinically narrow pelvis);

An anatomically narrow pelvis is characterized by a narrowing of several or one size by 2 or more centimeters.

Causes

The causes of a narrow pelvis are different - in the event of a disproportion between the parameters of the mother’s pelvic bones and the baby’s head or in the presence of an anatomical narrowing.

Etiology of anatomically narrowed pelvis

The following factors can provoke the occurrence of an anatomically narrowed pelvis:

heavy physical labor and malnutrition in childhood;

frequent colds, as well as increased exercise stress in adolescence;

neuroendocrine pathologies;

late onset of menstruation, impaired fertility, disruptions in menstrual function.

Anatomical narrowing of the pelvis occurs due to the following reasons:

dislocations of the hip joints;

excess androgens, hyper- and hypoestrogenism;

impaired mineral metabolism;

practicing professional sports (swimming, gymnastics, licking);

psycho-emotional stress and stressful situations, which provoke the occurrence of “compensatory hyperfunction of the body”, as a result of which a transversely narrowed pelvis is formed;

acceleration (rapid growth of the body in length against the background of a slow increase in transverse pelvic parameters);

damaging factors that affected the fetus in the antenatal period;

tumors and exostoses of the pelvis;

polio;

heredity and constitutional features;

cerebral palsy;

curvature of the spine (coccyx fractures, scoliosis, kyphosis, lordosis);

pelvic bone fractures;

bone tumors, bone tuberculosis, osteomalacia;

• delayed sexual development;

  infantilism, both sexual and general.

Etiology of a functionally narrow pelvis

Disproportion between the mother's pelvis and the baby's head during childbirth is caused by:

preposition with the pelvic end;

atresia (narrowing) of the vagina;

neoplasms of the ovaries and uterus;

pathological insertion of the head (frontal insertions, asynclitism);

malposition;

difficulty in the process of configuration of the bones of the baby’s skull (in case of true postmaturity);

large weight and size of the fetus;

anatomical narrowing of the pelvis.

Childbirth, which is complicated by a clinically narrow pelvis, ends with a cesarean section in 9-50% of cases.

Narrow pelvis: varieties

There are many classifications of anatomically narrowed pelvis. Quite often in the obstetric literature a classification is presented that is based on morphological and radiological characteristics:

Gynecoid type

Makes up about 55% of total number pelvis, is a normal type female pelvis. The future mother has a female body type, thin waist and neck, wide hips, height and weight are within the average range.

Android pelvis

Is the pelvis male type and occurs in 20% of cases. The woman has a masculine physique, namely an undefined waist, a thick neck against the backdrop of narrow hips and broad shoulders.

Anthropoid pelvis

It is characteristic of primates and accounts for about 22% of cases. This form is distinguished by an increase in the direct size of the entrance, which significantly exceeds the transverse size. Women with this pelvic configuration have high growth, lean, their shoulders are quite wide, while the hips and waist are narrow, the legs are thin and elongated.

Platypeloid pelvis

Its shape resembles a flat pelvis and occurs in 3% of women. A woman with such a pelvis is tall, markedly thin, has reduced skin elasticity and underdeveloped muscles.

Narrowed pelvis: forms

Classification of a narrow pelvis according to Krassovsky:

Common forms:

transversely narrowed pelvis (Robertovsky);

generally uniformly narrowed pelvis (ORST) – the most common species, which is observed in 40-50% of the total number of basins;

flat pelvis, occurs in 37% of cases, is divided into:

• pelvis with reduced wide part pelvic cavity;

  flat-rachitic;

  simple flat (Deventrovsky).

Rare forms:

pelvic deformation by fractures, exostoses, bone tumors;

obliquely contracted and obliquely displaced;

other forms:

• assimilation;

  osteomalatic;

  spondylolisthetic form;

  kyphotic form;

  funnel-shaped;

  generally narrowed flat.

Degrees of narrowing

The classification proposed by Palmov is based on the degree of narrowing of the pelvis:

along the length of the true conjugate (normally 11 cm) refers to the flat pelvis and ORST:

• first degree – less than 11 cm, not shorter than 9 cm;

  second degree - true conjugate indicators from 9 to 7.5 cm;

  third degree – the length of the true conjugate is from 7.5 to 6.5 cm;

  fourth degree – absolutely narrow pelvis, shorter than 6.5 cm.

according to the parameter of the transverse diameter of the pelvic inlet (the norm is 12.5-13 cm), it refers to a transversely narrowed pelvis:

• first degree - the transverse diameter of the entrance to the pelvis is within 12.4-11.5 cm;

  second degree - transverse diameter of the entrance - 11.4-10.5 cm;

  third degree - the transverse diameter of the entrance to the small pelvis is shorter than 10.5 cm.

in terms of the diameter of the wide part of the pelvic cavity (norm 12.5 cm):

• first degree – diameter is 12.4-11.5 cm;

  second degree – diameter less than 11.5 cm.

Dimensions of anatomically narrowed pelvis of various shapes

Narrow pelvis: size table in centimeters

Diagnostics

A narrowed pelvis is diagnosed and assessed under conditions antenatal clinic, on the day of registration of a pregnant woman. To determine a narrow pelvis during pregnancy, the doctor must study the anamnesis, perform an objective examination, including a vaginal examination, measurement of the pelvis, palpation of the uterus and pelvic bones, examination of the body, and anthropometry. If necessary, additional research methods may be prescribed: ultrasound scanning and X-ray pelviometry.

Anamnesis

It is important to pay attention and study the living conditions and illnesses of a pregnant woman in childhood ( chronic pathology and injuries, intense stress in sports, heavy physical work and poor nutrition, hormonal imbalance, bone tuberculosis and osteomyelitis, polio and rickets). Important also have obstetric history data:

whether there was stillbirth or death of the newborn in the neonatal period;

for what reason was it held operative delivery whether traumatic brain injuries were present in the fetus during childbirth;

how the previous births proceeded.

Objective research

Anthropometry

Low height (less than 145 cm) in most cases indicates the presence of a narrowed pelvis. However, it is possible to have a transversely narrowed pelvis in tall women.

Assessment: silhouette, build, gait

It has been proven that in the presence of a strongly protruding belly forward, the center of the upper body shifts posteriorly, to maintain balance, the lower back moves forward, increasing lumbar lordosis, as well as the angle of inclination of the pelvis.

Abdominal shape assessment

It is known that primiparous women have an elastic abdominal anterior wall, as a result of which the abdomen acquires a pointed shape. Multiparous women have a saggy abdomen, since the head at the end of the gestation period is not inserted into the entrance of the pelvis (narrowed), while the uterine fundus is high, and the uterus itself has a deviation anteriorly and upwardly from the hypochondrium.

Palpation of the Michaelis diamond and inspection.

Identification of signs of virilization and sexual infantilism.

The Michaelis rhombus is formed by the following anatomical formations:

on the sides - the upper posterior projections (or spines) of the ilium;

below – the apex of the sacrum;

above – the lower border of the fifth lumbar vertebra.

Pelvic palpation

During palpation of the iliac bones, their location, contours and slope are determined. During palpation of the trochanters (greater trochanters of the femurs), it is possible to determine the presence of an obliquely displaced pelvis if the trochanters are located on different levels and deformed.

Vaginal examination

Allows you to determine the capacity of the pelvis, evaluate the shape and examine the sacrum, the presence of bony protrusions, and the depth of the sacral cavity. It is also possible to determine the deformation of the lateral walls of the pelvis, determine the diagonal conjugate and the height of the symphysis.

Pelvis measurement

Basic measurements:

the uterus is measured to determine the approximate weight of the fetus;

the height of the pubic symphysis is set;

the pubic angle is determined (the norm is 90 degrees);

measuring the pubosacral size (measure the segment from the junction of the second and third sacral vertebrae to the middle of the symphysis). Normal is 21.8 cm;

Solovyov index – measurement of the wrist circumference at the level of the forearm condyles. Using this index, the thickness of the bones is determined: a small index is responsible for thin bones, and a large index for thick bones, respectively. The norm is 14.5 - 15 centimeters;

Michaelis rhombus measurement (horizontal diagonal 10 cm, vertical diagonal 11 cm). The presence of diamond asymmetry indicates curvature of the spinal column or pelvis;

external conjugate - measuring the distance from the upper edge of the womb to the upper corner of the Michaelis rhombus. Normal is 20 centimeters;

Distantia trohanterica - the segment between the two trochanters of the femur, normally 31-32 centimeters;

Distantia cristarum - the segment between the most distant points of the iliac crests. Normally – 28-29 centimeters;

Distantia spinarum - the segment between the upper anterior projections of the ilium. Normal is 25-26 centimeters.

Additional dimensions:

if pelvic asymmetry is suspected, the lateral Kerner conjugate and oblique dimensions are determined;

measure the pelvic outlet;

measure the angle of inclination of the pelvis.

Special research methods

X-ray pelviometry

Allowed to execute x-ray examination only during childbirth or after 37 weeks of pregnancy. With its help, the nature of the structure of the pelvic walls, the size and shape of the pubic arch, the severity of the sacral curvature, the features of the ischial bones are determined; this method also allows you to determine all the diameters of the pelvis, the size of the fetal head and its position relative to the pelvic planes, the presence of fractures and tumors.

Ultrasound

Allows you to determine the size of the head and its location, true conjugate, evaluate the features of insertion of the fetal head into the entrance. Using a transvaginal sensor, you can set all the necessary pelvic diameters.

Method for calculating true conjugates

For this purpose, the following methods are used:

By ultrasound examination pelvis;

according to X-ray pelviometry;

according to the Michaelis diamond: the upper size of the diamond corresponds to the conjugate (true) indicator;

1.5-2 centimeters are subtracted from the diagonal conjugate index (if the Solovyov index is 14-16 cm or less, 1.5 cm is subtracted, if the Solovyov index exceeds 16 cm, then 2 cm is subtracted);

subtract 9 from the size of the external conjugate (the norm is at least 11 cm).

Features of pregnancy

In the first half of the gestation period, complications in the presence of a narrowed pelvis are not observed. However, the nature of the course of pregnancy in the second half is aggravated by the influence of the underlying pathology, which led to the formation of a narrow pelvis, while the complications that arise have a certain influence ( intrauterine infection, gestosis) and extragenital pathologies. Pregnant women with a narrow pelvis are characterized by:

high position of the head against the background of the inability to insert it into the pelvis. This is due to the high position of the diaphragm and uterine fundus, causing increased heart rate, fatigue and shortness of breath;

Quite often, pregnancy can be complicated by premature discharge of amniotic fluid due to lack of contact with the pelvic inlet due to the high position of the head;

significant fetal mobility can cause extension or breech presentation and incorrect position fetus;

the risk of premature birth increases;

the formation of a saggy abdomen in multiparous women and a pointed abdomen in primiparous women can provoke asynclitic insertion of the head during labor.

Pregnancy management

All pregnant women with a narrow pelvis are placed on a special register with an obstetrician. A few weeks before the onset of labor, a woman must be routinely hospitalized in the antenatal department. Here the gestational age is clarified, and the estimated weight of the fetus is calculated, the pelvis is measured, the presentation of the fetus and its condition are clarified, and based on the data obtained, the most suitable delivery option is selected (a labor management plan is formed).

The method of delivery is selected based on medical history, the degree and form of anatomical narrowing of the pelvis, the approximate weight of the child, as well as other complications of pregnancy. Natural childbirth can be carried out in the case of prematurity, first degree contraction with a mature cervix and normal fetal size, in the absence of an aggravating medical history.

Planned surgical delivery (caesarean section) is performed if there are the following indications:

3-4 degree of narrowing of the pelvis (very rare);

a combination of any obstetric pathology requiring a cesarean section and a narrow pelvis;

birth of a fetus with birth trauma, complications in previous births, history of stillbirth, older women in labor;

a combination of the first or second degree of contraction with the presence of a large fetus, post-term pregnancy, abnormal position of the child, breech presentation.

Pregnancy and pain in the pelvic bones

Pain in the pelvic bones begins to appear after 20 weeks and can be caused by various reasons:

Calcium deficiency

Aching constant pain, which are not associated with changes in body position or movement. It is recommended to take vitamin D in combination with calcium supplements.

Separation of the pelvic bones and sprain of the uterine ligaments

How larger size uterus, the more intense the tension is experienced by the uterine ligaments that hold it, this manifests itself in discomfort and pain while walking, as well as when the child moves. The provocateurs of the process are relaxin and prolactin, under the influence of which the pelvic cartilage and ligaments swell and soften in order to facilitate the passage of the fetus through the bone ring. To relieve such pain, it is recommended to wear a bandage.

Divergence of the symphysis pubis

Excessive swelling of the symphysis, which is quite rare pathology, accompanied by bursting pain in the pubic area, it also becomes impossible to raise the leg while in a horizontal position. This pathology is called symphysitis, it is accompanied by divergence of the symphysis pubis. Effective treatment by surgical intervention after delivery.

Course of labor

Today, the tactics of labor management in the presence of a narrow pelvis imply a significant increase in the indications for performing abdominal delivery, both planned and emergency, in the presence of complications during childbirth. Natural childbirth is a very difficult task, since the outcome can be either favorable or unfavorable for both the child and the woman. If there is a third and fourth degree of narrowing, the birth of a full-term live child is impossible - only a planned operation. If there is a narrowing of the pelvis to the first or second degree, a successful outcome natural birth depends on the parameters of the fetal head, its ability to configure, the nature of insertion and the intensity of the labor activity.

Complications during childbirth in the presence of a narrow pelvis

First period

During the opening of the uterine pharynx, the following complication of childbirth may occur:

oxygen starvation of the fetus;

loss of small parts or loops of the baby’s umbilical cord;

early effusion amniotic fluid;

weakness of labor forces (in 10-38% of cases).

Second period

During the expulsion of the fetus through the birth canal, the following complications may occur:

damage to the nerve plexuses of the pelvis;

damage to the symphysis pubis;

necrosis (death) of tissues of the birth canal with subsequent formation of fistulas;

birth injury;

threat of uterine rupture;

intrauterine hypoxia;

development of secondary weakness of generic forces.

Third period

In the last stage of labor, as well as in the early postpartum period Bleeding may occur, which occurs due to a long anhydrous interval and the course of labor.

Management of childbirth

Today, the most correct tactics for managing childbirth in the presence of similar pathology is an active wait-and-see tactic. At the same time, the tactics birth process should be purely individual and based not only on the degree of narrowing of the pelvis and the results of an objective study of the expectant mother, but also on the prognosis for the child and the woman. The birth plan should have the following points:

fruit-destroying surgery for intrauterine fetal death;

performing a cesarean section when the fetus is alive and there are indications for surgery;

preventive measures in the afterbirth and early postpartum periods;

identifying signs of clinical inconsistency;

prevention of infectious complications;

prevention of intrauterine starvation of a child;

prevention of the development of weakness of generic forces;

bed rest during labor, which can prevent early release of water (the woman should be on the side to which the baby’s back is adjacent).

During childbirth, monitoring of discharge from the genital tract (bloody, leakage of water, mucous membranes), urination, and the condition of the vulva (presence of swelling) is carried out. If there is urinary retention, bladder catheterization is performed, but it should be remembered that such a sign may indicate a disproportion between the baby’s head and the pelvic dimensions of the woman in labor.

The most common complication during childbirth in the presence of a narrowed pelvis is premature rupture of amniotic fluid. If there is an “immature” cervix, surgical delivery is required. With a “mature” cervix, labor-inducing manipulations are indicated (provided that the child’s weight does not exceed 3.6 kg and the first degree of narrowing is present).

During the period of contractions, in order to prevent their weakness, it is necessary to create an energy background; the woman in labor receives medicated sleep and rest in a timely manner. When assessing the effectiveness of labor, the obstetrician must monitor not only the dynamics of cervical dilatation, but also the nature of the movement of the head along the birth canal.

Induction of labor should be performed carefully, and its duration cannot exceed 3 hours (if there is no effect, a caesarean section). In addition, in the first stage of labor in mandatory Antispasmodics should be administered (with an interval of 4 hours), to prevent hypoxia, Nikolaev’s triad is performed and antibiotics are prescribed when the anhydrous period increases.

The period of expulsion may be complicated by secondary weakness, the development of fetal hypoxia, and in the case of prolonged stay of the fetal head in birth canal fistulas may form. Therefore, timely emptying of the bladder and episiotomy are required.

Disproportions between the mother's pelvis and the baby's head

The occurrence of a clinically narrow pelvis is promoted by:

abnormal forms of a narrow pelvis;

large baby head if available normal sizes pelvis;

incorrect presentation of the fetus or unsuccessful insertion of the head;

large fetus and slight narrowing of the pelvis.

During childbirth, a functional assessment of the pelvis must be performed, which consists of:

in identifying signs of Zangheimester and Vasten (after the discharge of amniotic fluid);

in the diagnosis of a generic tumor of the soft tissues of the head, the rate of its growth and appearance;

assessing the configuration of the child’s head;

in determining the characteristics of the insertion and subsequent assessment of the biomechanism of labor based on insertion data.

Signs of a clinically narrow pelvis:

premature and early rupture of water;

significant head configuration;

protracted course of 1st period;

the emergence of a clinical threat of uterine rupture;

positive signs according to Zangheimester, Vasten;

symptoms of constriction of the bladder and soft tissues (blood in the urine, urinary retention, swelling of the vulva and cervix);

the occurrence of attempts when the fetal head is pressed to the entrance to the pelvis;

the head does not move forward when contractions are strong enough, water breaks and full disclosure uterine pharynx;

the biomechanism of labor is disrupted, does not respond this species narrowing of the pelvis.

Vasten's sign is determined by palpation (the relationship between the inlet of the pelvis and the baby's head is determined). A negative sign of Vasten is a condition in which the head is inserted into the pelvis, located below the pubic symphysis (the obstetrician’s palm drops below the pubis). Level symptom – the doctor’s palm is located at the level of the womb (the symphysis and the head are in the same plane). A positive sign is that the obstetrician’s palm is located higher from the symphysis (the head is located above the plane of the pubis).

If a negative sign is present, labor ends on its own (since the sizes of the pelvis and head correspond). If the symptom is level, with an adequate configuration of the head and effective labor, labor is also independent. If the sign is positive, spontaneous childbirth is excluded.

Kalganova proposed using three degrees of discrepancy between the head and pelvic dimensions:

First degree, or relative non-conformity.

There is correct head insertion and adequate configuration. The contractions are of sufficient strength and duration, however, the advancement of the head and the opening of the uterus are slowed down, in addition, the discharge of water is untimely. Urination is difficult, but Vasten's sign is negative. Another option is to complete the birth on your own.

Second degree, or significant discrepancy.

The insertion of the head and the biomechanism of labor are not normal; the head has a sharp configuration and remains in the same plane for a long time. Urinary retention and abnormalities in labor forces (weakness or incoordination) appear. Westen's sign - level.

Third degree, or absolute inconsistency.

Attempts occur prematurely against the background of a complete lack of advancement of the head, even despite complete opening and good contractions. The birth tumor grows rapidly, signs of compression of the bladder appear, and there is a threat of uterine rupture. Westen's sign is positive.

The presence of second and third degrees of discrepancy is an indication for immediate surgical delivery.

Case Study

A woman with her first birth (20 years old) was admitted to the maternity hospital complaining of contractions for two hours. There was no outpouring of water. General state the woman in labor is satisfactory, pelvic dimensions: 24.5-26-29-20, abdominal circumference - 103 centimeters, height of the uterine fundus - 39 centimeters. The position of the fetus is longitudinal, the head is pressed to the entrance to the pelvis. Auscultation: no pain, heartbeat is clear. Contractions are of good duration and strength. Approximate weight fruit 4 kg.

During a vaginal examination, it was determined: the cervical dilatation is 4 cm, has stretchable thin edges, and is smoothed. The amniotic sac is functioning normally, the fluid is intact. The head is pressed down, the cape is not accessible. Diagnosis: pregnancy 38 weeks, first stage of first labor at term. Transversely narrowed pelvis of the first degree, the fetus is large.

After six hours of active contractions, a second vaginal examination was performed: cervical dilatation to six centimeters, amniotic sac absent. The head is pressed with a sagittal suture in straight size, placement of the small fontanel anteriorly.

Diagnosis: pregnancy 38 weeks, first stage of first labor at term. Transversely narrowed pelvis of the first degree, the fetus is large, straight high standing sagittal suture.

It was decided to end the birth through surgery (large fetus, narrowing of the pelvis, incorrect insertion). C-section performed without complications, a child weighing 4.3 kilograms was removed.

In newborns, the pelvis has funnel-shaped. The wings of the iliac bones are located more vertically, their ridges are cartilaginous (weakly, S-shaped curved). The small pelvis is underdeveloped, the entrance to it is narrow, longitudinally oval in shape. The promontory is weakly expressed and formed by the I and II sacral vertebrae. Each innominate bone consists of three parts: the ossification nuclei of the iliac, ischial and pubic bones, connected to each other by a layer of cartilage.

The coccyx consists of 4-5 cartilaginous vertebrae. In the thickness of the I-III sacral vertebrae there are five ossification nuclei. During early childhood, the ossification nuclei of the sacrum significantly increase in size, and in the preschool period they begin to merge with each other, forming individual vertebrae (segments) of the sacrum. In parallel with the growth of individual bones, the structure of the pelvis changes, and the position of the pelvis changes. In the preschool period, the first sacral vertebra shifts in the ventral direction, and the P-III in the dorsal direction. As a result, the sacrum acquires kyphosis, and a promontory is formed between the V lumbar and I sacral vertebrae.

At the same time, the position of the iliac bones changes, the bodies of which undergo rotation around the sagittal axis. As a result, their wings begin to diverge to the sides and the pelvis loses its funnel-shaped shape. The line of entry into the small pelvis becomes clearly defined. The size of the entrance to the small pelvis changes. During puberty, the pelvis acquires features characteristic of the adult pelvis. The pelvic cavity takes on a cylindrical shape in girls. The pelvic surface of the sacrum loses its fragmented structure.

In newborns, the muscle that lifts the anus into its main parts is not differentiated and is a thin (0.8-1 mm) muscular plate. During early childhood and preschool age, the muscle thickens and differentiates into two parts: m rubococygeus and m iliococygeus, turning into one another.

The rectum in newborns is relatively long (50-60 mm), its sections are poorly differentiated. The pelvic region is short, stretched and completely occupies the pelvic cavity. The ampullary section is usually absent. The anal section has a significant length (30-40 mm), its narrowed diameter in the perineal part does not exceed 15 mm (V. Frolovsky). At the site of the transition of the pelvic to the anal region there is a pronounced transverse fold of the mucous membrane - plica transversalis interior. The level of location corresponds to the bottom of the rectovesical or rectouterine recess and is projected onto the first coccygeal vertebra. The wall of the rectum is not fully formed, its muscular wall is poorly developed. The mucous membrane is not sufficiently fixed, which can lead to its loss. Throughout the anal part, the mucous membrane forms high longitudinal folds (columna anales), between which lie the deep sinus analis. The hemorrhoidal zone is individually different; in some newborns it is well defined, in other cases it is only outlined in the form of a narrow strip.

As the child grows, the structure of the rectum and its topography change. In the first year of a child’s life, its diameter increases significantly, while the intestine shortens (up to 37-47 mm). In the second half of infancy, a sacral bend appears in the intestine, and in early childhood it becomes clearly pronounced.

In children 1-3 years old, the transitional form of the rectum is much more common, and in the preschool years the ampullary form of rectum is observed (L.V. Loginova-Katricheva).

• Surgical anatomy birth defects, pelvic and perineal organs.
• Bladder exstrophy and diverticulum are developmental abnormalities of the bladder.
• Exstrophy of the bladder occurs as a result of a violation of embryogenesis, due to a violation of the development of the genital tubercle and especially the anterior abdominal wall, a severe defect develops, accompanied by the absence of the anterior wall of the bladder and the corresponding part of the anterior abdominal wall. IN lower sections In the abdomen of such children, the mucous membrane of the posterior wall of the bladder with hypertrophied folds is visible, its edges are fused to the skin of the anterior abdominal wall. In the lower parts of the protrusion, the openings of the ureters are visible. With age, it scars and becomes covered with papillomatous growths. The defect is characterized by divergence of the pubic bones, congenital inguinal hernia, cryptorchidism; in girls - cleft clitoris, etc.

The cause of diverticula is explained by the presence of “weak” spots in the walls of the bladder, or incomplete reverse development of the urachus.

V. D. Ivanova, A. V. Kolsanov, S.S. Chaplygin, P.P. Yunusov, A.A. Dubinin, I.A. Bardovsky, S. N. Larionova