Physicians Fail to Recognize Cephalopelvic Disporto (CPD) and Baby Dies from Traumatic Birth Injuries

A newborn baby, Lucy, recently died due to a traumatic birth that left her with extensive injuries, including fractures to her back.  The traumatic birth was brought on by a condition that occurs during pregnancy called cephalopelvic disproportion (CPD).  CPD exists when the capacity of the mother’s pelvis is inadequate to allow the baby to pass safely through the birth canal.  This can occur when the baby’s head or body is too large or the mother’s pelvis is too small.  When CPD is suspected, physicians must be prepared to perform a C-section delivery.

In Lucy’s case, the physician did not attempt a C-section.  Lucy had a condition known as Hydrops Fetalis, which meant she had an accumulation of fluid in some of her body compartments, and her abdomen was larger than her head, making it extremely difficult to get through the birth canal.  Even though physicians recognized the fetus was large and CPD was suspected, physicians did not perform an ultrasound on Lucy’s mother.  If one had one been performed shortly before birth, the Hydrops Fetalis would have been diagnosed and a C-section would have been carried out.

Physicians struggled to deliver Lucy, using forceps to assist in the delivery.  Lucy sustained extensive fractures, and despite attempts to resuscitate her at birth, she died a few hours later.  It was officially determined that Lucy’s death was caused by a combination of the injuries she sustained at birth as a result of her abdominal dystocia and underlying Hydrops Fetalis.

Knowing she had a large baby, Lucy’s mother actually requested a C-section.  During the inquest into Lucy’s death, a consultant stated that the hospital did not perform an ultrasound because it had a “lack of capacity,” meaning that ultrasounds are only performed when there are serious concerns about the mother and baby.

Diagnosis of Cephalopelvic Disproportion (CPD)

A large baby is a serious concern, as well as a significant risk factor CPD.  When risk factors for the condition are present, physicians typically use diagnostic techniques to assess the size of the pelvis and baby.  An ultrasound is one such method, and during this test, measurements are compared against standardized growth charts to determine the relative risk of CPD by the time of delivery.  Other diagnostic methods for CPD include the following:

• Pelvimetry by MRI.  This is used to assess the dimensions of the pelvis, determine the baby’s position, and examine the soft tissues of the mother and baby.
• Clinical pelvimetry.  This is a process used to assess the size of the birth canal using the hands and/or with a pelvimeter.
• X-ray or CT pelvimetry. This is a radiographic examination used to determine the dimensions of the mother’s pelvis and the diameter of the baby’s head. The value of x-ray pelvimetry needs to be weighed against the risk of radiation exposure.

Risk Factors for and Causes of CPD

CPD is a serious and potentially devastating condition.  When risk factors for CPD are present, physicians should be prepared for a delivery by C-section.  Risk factors for and causes of CPD include the following:

• Large sized baby. This can be caused by gestational diabetes and other conditions that cause a baby to be macrosomic (weight is > 4000 or 4500 grams) or large for gestational age. Post-term pregnancies and hydrocephalus (fluid in the baby’s brain that leads to swelling) may also cause a baby to be large.
• Contracted pelvis.  This occus when a woman has a decrease of 1.5 to 2 cm in any important pelvic measurement (diameter).
• Unusual presentations: Brow presentation (brow of the fetus is lying over the opening of the pelvis); face presentation (baby’s face is lying over the opening of the pelvis); occipitoposterior positions (head of the baby is facing the base of the mother’s spine); deflexed head (baby’s head is lifted instead of flexed onto her chest; the baby’s chin is not tucked).
• Mother older than 35 years of age
• Mother shorter than 5’ 3”
• Gestational age over 42 weeks
• Osteomalacia of the pelvis (softening of the pelvic bones)
• History of previous pelvis trauma, rickets or tuberculosis
• History of tumors of the pelvic bone, or fibroid tumors of the uterus
• Congenital deformity of the tailbone, or flattening of the anterior part of the pelvis
• Congenital vaginal septum (partition within the vagina)
• A cervix that does not dilate properly

Treatment of CPD

The main treatment for CPD is delivery by C-section.  When CPD occurs, a C-section is necessary as attempts at vaginal delivery may cause undue trauma to the baby, as was the case with Lucy.

Indeed, when risk factors for CPD are present, it is essential that the physician properly assess the size of the fetus as well as the mother’s pelvis, monitor the mother and baby very closely, and be ready for an emergency C-section delivery. In certain situations, an early delivery may even be necessary.

This incident underscores the importance of recognizing CPD, appreciating the dangers associated with the condition, and being prepared for a C-section.  Trying to force a the baby through a vaginal delivery can result in permanent injury, such as hypoxic ischemic encephalopathy (HIE), brachial plexus injury, intracranial hemorrhages (brain bleeds), cerebral palsy, and even death.