When administering childbirth in women with a narrow basin, one should be guided by the decisions taken on this issue at the IX All-Union Congress of Obstetricians- Hypecologists . They indicate that caesarean section with a narrow pelvis can be resorted to only with strict special indications from the mother or fetus and only in cases where the possibility of spontaneous birth by a living fetus is unconditionally excluded. M. S. Malinovsky and the overwhelming majority of domestic obstetricians formulate the tactics of delivering labor with a narrow basin as follows: “conservatively expectant or expective management of labor”.

However, this method is by no means synonymous with “trial births” in primiparous with a narrow pelvis, when, with the doctor’s complete inactivity, childbirth lasted 2-4 days , and often severe complications such as urogenital fistula, intrauterine death of the fetus due to intracranial injury or asphyxia, uterine rupture, not to mention the complete depletion of the nervous system of the woman in labor.
It can be considered a rule that with the I degree of narrowing of the pelvis, childbirth is almost always, and with II – often end spontaneously; with the III degree of narrowing of a living child can be removed only with a caesarean section; a narrow pelvis of the IV degree in all circumstances, regardless of whether the fetus is alive or dead, certainly requires a cesarean section.
All pregnant women with a narrow pelvis should be hospitalized shortly before delivery. A thorough study of the anamnesis, general and obstetric status should be carried out, as a rule, before the discharge of the waters. In order to preserve the water as much as possible, especially if a vaginal examination reveals that the amniotic fluid is strained or begins to protrude into the vagina, you should enter the woman in labor, and prevent her from standing up.

To develop a plan for the most rational management of childbirth, it is necessary to take into account, first of all, the unfavorable data of obstetric history, which ceteris paribus worsen the prognosis of childbirth for mother and child. To them repose :
1) large children in the past birth;
2) the protracted course of preceding labor, the weakness of labor, surgical interventions with it, the complicated course of the postpartum period. At the same time, it is important that a woman with a narrow I-II degree pelvis in the past cannot have a safe birth by living children, which cannot guarantee a safe course and outcome of a real birth, because with each subsequent birth the fetus is large, and the uterus exorcises the neuromuscular abilities with each birth are reduced;
3) intracranial injury to the newborn in previous births;
4) operative delivery in the past: forceps, vacuum extraction, rotation, craniotomy, cesarean section in connection with a narrow pelvis;
5) reproduction of a real pregnancy at least for 1-2 weeks ;
6) the old age of primiparous (over 30 years).

The more favorable course of labor with a narrow pelvis happens in multiparous, since their birth canal was prepared by previous births.
In the event of amniotic fluid discharge, a vaginal examination must be performed immediately to accurately determine the insertion of the head, the condition and degree of opening of the cervix, presentation or prolapse of the umbilical cord or small parts of the fetus.
For a better insertion of the head in case of a general narrowed pelvis, a woman in labor is laid on the side where the nape of the fetus is facing, and with a flat one – on the opposite side. A sagging stomach should be bandaged with two towels sewn along the length.
In the case of the umbilical cord or handle falling out, they should be tucked in behind the head, which is usually easy to do if you give the woman in a saddle- elbow position. After this, it is necessary to apply the cutaneous-head forceps according to Ivanov to the head in order to prevent repeated loss. If prolapse of small parts has not occurred and labor activity develops satisfactorily, childbirth is expectant , carefully monitoring the insertion of the head into the pelvic entrance and periodically repeating vaginal examinations. In this way, with a uniformly narrowed pelvis, the dynamics of the occipital descent is determined, which is judged by the omission and approximation to the conductor axis of the pelvis of the small fontanel, the increasing configuration of the head and lowering the level (location) in the pelvic cavity of the “contact belt” of the head. These are favorable factors testifying to the physiological course and successful development of the birth process.

With a flat pelvis, factors having the same favorable value are the median insertion of the head and a small degree of its extension with a moderately pronounced anterior asynclism . In contrast, a significant extension of the head, an extra-median insertion of the head and pronounced posterior asynclitism indicate a pathological development of the labor mechanism; the obstetrician, in the case of their nrogrossing , must timely resolve the issue of cesarean section in the absence of contraindications to it (a long anhydrous period, signs of infection, progressive, untreatable intrauterine asphyxiation or fetal death that has already occurred). The aforesaid especially applies to elderly nulliparous, as well as to multiparous with burdened obstetric history.

Anomalies of labor activity — its weakness (primary, secondary) or the erratic, sometimes tetanic nature of contractions accompanied by severe pain, are a frequent complication of labor in a narrow pelvis.
Weak labor should be treated according to general rules, choosing the means and methods that are most physiological and able to improve the condition of the fetus, increase its resistance under conditions of hypoxia and intracranial injury, which is almost inevitable in such cases.
If there is a need to stimulate labor in the presence of a still insufficiently smoothed cervix and its incomplete opening, we consider it absolutely necessary to first introduce one of the antispasmodics under the skin or directly into the thickness of the anterior lip of the cervix. If the contractions are excessively strong, erratic, very painful, have a tetanic character, it is necessary to regulate them immediately, and reduce pain by applying painkillers with medications. At the same time, it is necessary to combat the excessive emotional arousal of the woman in childbirth, which is almost always accompanied by a feeling of anxiety and fear. This condition of the woman in childbirth sometimes occurs in connection with the infringement between the fetal head and the bosom of the edematous anterior lip of the cervix. Having made sure of the atom by vaginal examination and examination with the help of mirrors, the obstetrician should immediately put a restrained lip by the finger with his finger, moving it up. Usually immediately after this manipulation the pain subsides, the woman in labor calms down, contractions become regular again. If Hie infringement no lips or after tucked infringe upon the lips of pain does not decrease and the nature of labor is not normal, it is necessary to apply the medication. For this purpose, promedol (2 ml of a 1% solution), isopromedol (at the same dosage), estocin (at the same dosage) in combination with antispasmodics and ataractics : andaxine (0.4 g 1-2 times inside) or trioxazine are prescribed (0.3 g). It may also be useful to take oral chlorpromazine (0.025 g) or etaperazine (0.004 g) 1-2 times a day.
Odpako must take into account the following: convulsive contractions, intolerable pains, a feeling of irresistible fear are sometimes harbingers of a threatening uterine rupture. Therefore, the use of these drugs is permissible only in cases where, through careful investigation and observation, it is established that such a threat is absent or when it is necessary to win some time to prepare an operating room for an immediate delivery of one or another delivery (craniotomy, cesarean section).
In especially severe cases, when the need arises for the urgent suppression of pathological labor due to the threat of uterine rupture, you should immediately introduce a woman in labor morphine or pantopon and give a fairly deep ether anesthesia.

Along with all these measures, you should periodically measure the temperature, count the pulse, respiration, measure blood pressure, often listen to the fetal heartbeat and, if possible, remove its fopocardiogram . It is necessary to monitor the timely emptying of the bladder and empty it if necessary using a soft catheter. Urine should also be carefully examined: the slightest admixture of blood, especially in combination with an increase in body temperature and signs of developing endometritis, indicates the beginning of the destruction of the soft tissues of the birth canal with the possible formation of a subsequent urogenital fistula. In such a situation, it is necessary to resolve the issue of immediate delivery . However, with a prolonged anhydrous period, a febrile state of a woman in childbirth, endometritis, the presence of infection, cesarean section is certainly contraindicated.
Often during childbirth, women in labor with a narrow pelvis experience false attempts with a still high head, which is accompanied by severe pain, sharp motor and mental excitement. Such pathological contractions of the muscles of the uterus and abdominal press have nothing to do with true attempts, are dangerous for the mother and fetus, and should be immediately stopped with the help of clarification, persuasion, suggestion, medications: tranquilizers, sedatives , anticonvulsants, or, in extreme cases, the use of ether anesthesia.

With physical fatigue, it is necessary to provide the woman in labor with rest. After the spa , the woman in labor resumes regular, energetic labor and delivery progresses successfully. Proper nutrition of women in labor can greatly contribute to this: hot broth, strong, very sweet coffee or tea with ascorbic acid (0.5 g) instead of lemon, half a bar of chocolate, and orange. Along with this, it is necessary to apply prolonged inhalation of oxygen. Sometimes all this is enough for the head to sink to the pelvic floor and create the opportunity to apply obstetric forceps or apply vacuum extraction.
If the head is in the pelvic cavity, and labor is insufficient, the woman in labor is tired or there are indications from the fetus (asphyxia), forceps should be applied. However, it must be remembered that an attempt to impose with a narrow basin of high forceps, that is, on the head, which has not yet passed its largest circumference through the entrance of the pelvis, is extremely dangerous for both the mother and the fetus.

Of the additional techniques that sometimes prove useful for delivering labor in women with a narrow pelvis, it should be pointed out that it is possible to increase (by 0.3-0.5 cm) the direct size of the entrance to the pelvis (true conjugates ) using the Walcher position of the woman in labor, which indicated for prolonged non-insertion of the head. G. G. Genter (1936) recommends giving the woman in labor the position of Willinka , laying a firm pillow under the sacrum for 30 minutes, a De Lee , S. D. Astrinsky , III. Y. Mikeladze, when narrowing the exit of the pelvis, they offer a position for stone cutting with knees sharply drawn to the stomach. At the same time, both the transverse and direct sizes of the exit of the pelvis slightly increase (by 0.35-0.5 cm). Thus, the main method of birth management with a general narrowed and flat pelvis is moderately expectant. Moreover, the only correct method of birth management is a strictly individual approach to each woman in labor. An obstetrician, individually resolving the issue of conducting labor with a narrow pelvis in each woman in labor and adhering, as a rule, to expectant tactics, should at the same time reasonably evaluate the conditions and indications for surgical benefits. 1. The application of obstetric forceps or a vacuum extractor is indicated when the fetal head has completely overcome the obstacle from the entrance to the pelvis. The most frequent indications for these operations: secondary weakness of labor, cardiovascular disease, physical and neuropsychic exhaustion of the woman in labor, fetal asphyxiation. 2. A fetal mutilation on the leg is permissible only if the umbilical cord, small parts of the fetus, incorrect insertions of the head ( posterior , frontal, facial presentation ) occur , but only under the following conditions: a) full mobility of the fetus in the uterus; b) a small fruit (especially the head); c) the complete absence of signs of overstretching of the lower segment of the uterus; d) a successful obstetric history in multiparous. 3. If the fetus is live, craniotomy should not be used. But as a last resort, in exceptional cases, this operation is permissible if the life of the woman in labor is in imminent danger, and there are no conditions for other delivery methods , including for caesarean section (or, more often, time is lost). In such cases, refusing a craniotomy and motivating this refusal by the presence of a living child, we rather sacrifice the life of the mother than save the life of the baby . 4. Cesarean section, of course, shown at III and IV degrees of narrowing of the pelvis. At grade IV, the narrowing is such that even a dissected fetus with a perforated head cannot be removed through the vagina; with the III degree of narrowing, it can be removed through the natural birth canal only after perforation of the head. 

Cesarean delivery may be shown in some cases and with a narrow degree of pelvic II: nulliparous, especially for breech, lobpom , personal predlezhapiyah transverse position of the fetus and categorical parents wish to have rebepka ; it is also shown at the II (and sometimes even at I) degree of narrowing at large deformations of the pelvis. Indications for cesarean section can sometimes be adverse combinations of different types of pathology, aggravating the prognosis of the outcome of childbirth, for example, narrowing of the pelvis and preeclampsia or eclampsia; narrowing of the pelvis and rapidly developing cardiovascular failure in the parturient woman; narrowing of the pelvis and Addison’s disease, etc. Finally, a cesarean section with II degree of narrowing of the pelvis is also shown in those cases when, despite a good regular, unremitting labor, the head of the fetus remains at the same height for 6 hours after draining the water or only pressed to the entrance to the basin. In these cases, waiting further, you can delay the time when it is not too late to perform a cesarean section (no infection). Ante- and postnatal prophylaxis of rickets, the correct physical and neuropsychic development of women from early childhood, rational drinking , gymnastics, moderate, rational exercise, prevention of infectious and other diseases, and further careful medical supervision in the antenatal clinic, regulation of work the load of a woman, the elimination of some possible occupational hazards (forced body position, prolonged sitting or standing, etc.), timely identification and eliminated ie the various complications of pregnancy – all of this is of great importance in the prevention of a narrow pelvis and aggravating his other complications of pregnancy. Timely detection of a narrow pelvis and timely hospitalization of a pregnant woman are the key to a successful outcome of childbirth.