CLINICAL OBSTETRICS AND GYNECOLOGY
Volume 49, Number 1, 140146
Clinical Pelvimetry
EDWARD R. YEOMANS, MD
From the Department of Obstetric, Gynecology and Reproductive,
University of TexasHouston Health Science Center, Houston,
Texas
The word pelvimetry is of hybrid origin;
pelvi- is a combining form of the Latin word
pelvis (basin) and metron is a Greek word
for measure. Literally, then, pelvimetry means
to measure the pelvis. This can be accom-
plished by several methods: manually, instru-
mentally using a device like a caliper, and
radiographically. The last 2 have, I believe
appropriately, fallen into disuse, but manual,
hereafter referred to as clinical, pelvimetry is
inadequately emphasized in modern training
programs such that it, too, is falling into disuse.
In a symposium devoted to vaginal deliv-
ery, this chapter on clinical pelvimetry is
fundamental and therefore placed at the
beginning. Because an understanding of
pelvic anatomy is essential to mastering the
techniques of clinical pelvimetry, anatomy
is reviewed rst. Then the important aspects
of clinical pelvimetry are presented; these
techniques can be learned on a model of
the bony pelvis, but they must be practiced
on living women to appreciate the limita-
tions imposed by soft tissue and the discom-
fort associated with the complete exam-
ination. The chapter concludes with a
Correspondence; Edward R. Yeomans, MD, Department
of Obstetrics, Gynecology and Reproductive Sciences, Uni-
versity of TexasHouston Health Science Center, Lyndon
B. Johnson General Hospital, 5656 Kelley Street, Hous-
ton, TX 77026. E-mail: Edward.R.Yeomans@uth.tmc.edu
CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 49
140
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
2006, Lippincott Williams & Wilkins
discussion of fetopelvic relationships, be-
cause the station of the presenting part
may impact on the performance of clinical
pelvimetry.
Anatomy of the Bony Pelvis
The basic conguration of the bony pelvis is
that of a truncated, bent cylinder (Fig. 1).
Three bones, the pubis, the ischium, and
the ilium fuse to form the left and right inno-
minate or hip bones. Anteriorly, the left and
right pubic bones are joined at the cartilagi-
nous pubic symphysis. Posteriorly, the hips
articulate with the sacral alae (wings) at the
left and right sacroiliac joints. The coccyx
attaches to the inferior aspect of the sacrum.
The false pelvis above is demarcated
from the true pelvis below by the plane of
the pelvic inlet. Starting with the symphysis
pubis and moving clockwise, a somewhat
oval shape can be inscribed in this plane:
symphysis, right superior pubic ramus, right
linea terminalis, right sacral ala to the sacral
promontory and returning to the symphysis
in mirror image fashion on the left.
To orient a model of the bony pelvis in
the proper position for a standing woman,
the anterior superior iliac spines and the
pubic tubercles should occupy the same ver-
tical plane; the tip of the coccyx and the
/ NUMBER 1 / MARCH 2006

FIGURE 1. A line diagram that depicts the
geometry of the bony pelvis as a truncated bent
cylinder.
upper margin of the pubic symphysis should
occupy the same horizontal plane. Held in
this manner, it can be seen that the plane
of the inlet forms approximately a 50 angle
with the horizontal (Fig. 2) in the upright
FIGURE 2. The pelvis in the standing woman
showing the angle that the plane of the inlet
makes with the horizontal.
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Clinical Pelvimetry 141
woman. Also, in the upright woman, the inter-
nal aspect of the pubis faces more upward
than backward, whereas the internal aspect
of the sacrum faces more downward than
forward.1 Rotating the woman 90 to the
supine position, like for a labor bed or an
examining table, emphasizes that the sacral
promontory is several centimeters cephalad
to the inferior border of the symphysis pubis.
This will be an important concept when
we consider measurement of the diagonal
conjugate.
The shape of the pelvic inlet accounts for
the 4 basic pelvic types: anthropoid (long,
narrow oval), platypelloid (short, wide oval),
gynecoid (almost circular, but slightly at-
tened in the anteroposterior dimension), and
android (heart-shaped). For a visual refer-
ence, the reader is referred to Figure 3.2
The false pelvis lies above the plane of
the inlet and is bounded laterally by the iliac
crests and right and left iliac fossae. The
false pelvis lacks obstetric signicance and
is not considered in clinical pelvimetry.
The only reference in this entire symposium
FIGURE 3. The shape of the pelvic inlet in
the four basic pelvic types.
 142 Yeomans
to the iliac fossae is found in the chapter on
vaginal delivery of twins.
The true pelvis has great obstetric signi-
cance; its anatomic features from inlet to
outlet enable the discerning examiner to
classify an individual pelvis into one of
the 4 types. However, the inlet is the upper
boundary of the true pelvis and thus least
accessible to physical examination. In the
plane of the inlet, the key anatomic features
of the bony pelvis that are important to the
clinical examiner are the sacral promontory
and the much-less-emphasized retropubic
angle formed by the union of the left and
right superior pubic rami on their posterior
aspects. Proceeding inferiorly, important
pelvic features include the width of the sac-
rosciatic notch (in the living woman, this
notch is converted to the greater sciatic fora-
men by the sacrospinous ligament), the ante-
rior surface of the sacrum, the ischial spines
and tuberosities, the inner surface of the
ischium, the subpubic arch, the descending
pubic rami, and the coccyx. Clinical pelvim-
etry, then, consists of a series of maneuvers
designed to assess these important anatomic
features. It is insufcient to classify a partic-
ular pelvis into one of the 4 basic types because
mixed architectural features are encountered on
a daily basis in clinical practice.
Clinical Pelvimetry
THE INLET
The assessment of the diagonal conjugate
(DC) provides the clinician with information
regarding the anteroposterior (AP) diameter
of the pelvic inlet. There are, however, sig-
nicant limitations to estimating the DC.
First, to ever reach the sacral promontory,
the examiner must drop both wrist and
elbow and reach cephalad with the tip of
the middle nger. The inferior margin of
the symphysis pubis will come in contact
with the dorsal aspect of the examining
hand. The distance from the tip of the mid-
dle nger to the point of contact on the back
of the hand can be measured, but most often
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the promontory of the sacrum is not actually
touched. This enables the examiner to con-
clude only that the DC is .12 cm, for exam-
ple, and not to specify the actual length. A
further assumption is that subtracting 1.5
cm from the DC will approximate the
obstetric conjugate (OC), the shortest AP
diameter of the pelvis through which the
fetal head must pass. An OC ,10.5 cm is
considered contracted (see the concluding
section of this article concerning fetopelvic
relationship for further discussion of this
denition of contracted OC). Finally, in all
instances in which the presenting part has
entered the true pelvis, the DC cannot be
clinically assessed. Despite these signicant
limitations, the estimation of the DC is one
of the few elements of clinical pelvimetry
that has stood the test of time.
A second, and often overlooked, aspect of
inlet assessment is the retropubic angle.3
Older textbooks refer to this as the forepel-
vis and use terms like wide, round, narrow,
and angulated as descriptors. Calling it a ret-
ropubic angle, whereas not entirely accurate,
emphasizes the proper assessment of the
anterior aspect of the inlet. The examiner
should bring 2 ngers up under the pubic
arch, then acutely drop the wrist and palpate
with the volar surface of index and middle
ngers the symphysis and both superior
pubic rami along their posterior surfaces.
In an android pelvis, the retropubic angle
is sharp and acute. In the platypelloid pelvis,
the angle is so at that it nearly forms a
straight (180) angle, similar to feeling a
blackboard. In the gynecoid pelvis, the ret-
ropubic angle starts out at in the midline
but then curves gently backward laterally.
In an anthropoid pelvis, the backward curve
is detected earlier and curves back more
sharply.
THE MIDPLANE
Of all the various levels of the pelvis, the
midplane is the area where the most infor-
mation is missed by the inexperienced
examiner. The examination of the midpelvis
begins with the ngers ventral surface

directed posteriorly toward the sacrum. In all
pelvic types, the lower sacral vertebrae can
usually be reached. A forward lower one
third of the sacrum should alert the examiner
to the possibility of an android pelvis, the
most dangerous type of pelvis if instrumen-
tal assistance is contemplated. Following the
anterior aspect of the sacrum superiorly as
high as possible can give the impression
of either a hollow or at sacrum, the latter
being much less common. With the palmar
or volar surface of the ngers still directed
posteriorly, the ngers should slowly move
to the lateral border of the sacrum, where
the sacrospinous ligament originates. This
bandlike structure can be traced further lat-
erally to its insertion on the ischial spine,
and the entire length of the ligament can
be estimated in ngerbreadths. The sacro-
spinous ligament converts the sacrosciatic
notch (not clinically accessible for evalua-
tion) to the greater sciatic foramen. Once
again, the length and direction of this liga-
ment gives important clues to the overall
pelvic type. The ligament length is normally
estimated in ngerbreadths, a disadvant- junction of the third and fourth sacral verte-
age given the varying size of modern exam-
iners ngers. Less than 2 ngerbreadths
implies a narrow sacrosciatic notch, a fea-
ture of an android pelvis. A 3-ngerbreadth
ligament that is directed more laterally than
anteriorly suggests a platypelloid pelvis. The
ligament in an anthropoid pelvis is also 3 or
more ngerbreadths wide but is directed much
more anteriorly than laterally. The gynecoid
pelvis has a sacrospinous ligament that is
intermediate between narrow and wide.
Following the ligament from the lateral
border of the sacrum to the ischial spine is
the best method of locating the spine (and
is essential for proper performance of a pu-
dendal nerve block). Once the spine has
been reached, the examiner should record
a qualitative description using the terms promi-
nent, blunt, or average.
Just anterior to the ischial spine is the
interior surface of the ischium. With the
thumb of the opposite hand resting on the
ipsilateral ischial tuberosity externally, the
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Clinical Pelvimetry 143
slope of the pelvic sidewall (a vague term
that relates to the inner surface of the ischium)
can be determined. Practically speaking, the
sidewalls are described as either straight
(parallel) or convergent, the latter suggest-
ing a funnel-shaped or android pelvis. In
30 years of performing clinical pelvimetry,
I have never characterized a pelvis as having
divergent sidewalls. Nevertheless, such a
description exists in the literature and is
referred to as a blunderbuss pelvis,3 itself
an archaic term. Before leaving the assess-
ment of the midplane, I would briey like
to comment on the bispinous diameter, the
narrowest transverse pelvic diameter through
which the fetal head must pass. Regrettably,
this diameter cannot be readily assessed
clinically. Some authors suggest separating
the examining ngers as widely as possible
and that in rare contracted pelves, one may
be able to span the distance between the
spines. I have never found this helpful. The
perpendicular diameter that begins at the
inferior margin of the symphysis, extends
to the hollow of the sacrum at around the
brae, and bisects the bispinous diameter is
also difcult to assess clinically. The line
segment that originates at the junction of
the AP and transverse diameters of the mid-
plane and extends to the sacrum posteriorly
is referred to as the posterior sagittal diam-
eter. The posterior sagittal diameter (see Fig.
4), when short, may indicate AP narrowing,
FIGURE 4. The posterior sagittal diameter in
the plane of the ischial (difcult to assess clinically).
 144 Yeomans
a forward lower one third of the sacrum, or
both, but I have no special secret on how to
assess the posterior sagittal diameter clini-
cally either. Conceptually, if one were to
envision a coronal plane through the ischial
spines as partitioning the pelvis into anterior
and posterior halves, then a long posterior
sagittal segment bespeaks available room
for the fetal head in the posterior pelvis, a
favorable sign.
THE OUTLET
There are 3 important aspects of the pelvic
outlet that require evaluation. The rst is
the coccyx, which is sometimes sharply
angulated anteriorly in a sh-hook or
J-shape. Both the shape and mobility of
the coccyx should be described. Next, the
subpubic (not to be confused with the retro-
pubic discussed earlier) angle is estimated,
which gives information about the pubic
arch. A gynecoid pelvis has a subpubic
angle .90, whereas an android pelvis
has a subpubic angle that is always acute
and may be as narrow as 60. However,
examiners do not usually have a protractor
or a goniometer handy during the perform-
ance of clinical pelvimetry. Therefore, the
examining ngers once again can be used
to advantage. A gynecoid pelvis has a sub-
pubic arch characterized as Norman, that
is, rounded and roomy; the 2 examining n-
gers can be raised, ventral side up, all the
way to the lower border of the symphysis
without being displaced. Then palpation of
the descending pubic rami (which form
the hypotenuses of 2 mirror-image right tri-
angles with the apex at the symphysis and
the base along the bituberous diameter
bisected in the midline) will trace out a
rounded arch terminating in the tuberosities.
In contrast, the examining ngers will often
be forced to overlap at the top of the
Gothic arch found in an android pelvis.
The descending pubic rami that form the
Gothic arch are closely spaced and end more
medially in the tuberosities.
This brings us to what I consider the most
important element in outlet assessment: the
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bituberous diameter (BTD). Recently, one of
our residents completed a research project in
which the BTD was estimated as a dichoto-
mous variable (,8 cm, .8 cm) in more
than 250 nulliparous women. The technique
described more than 50 years ago was used,
placing the previously measured st exter-
nally between the ischial tuberosities. The
study yielded the clinically and statistically
signicant result that a narrow (,8 cm)
BTD is associated (odds ratio of 15) with
a markedly increased risk of either deep
perineal laceration or extension of a midline
episiotomy compared with a BTD .8 cm.
At our institution, we record the BTD on
almost every woman admitted through tri-
age. A narrow BTD is a very strong indica-
tor of an android pelvis, although occasion-
ally a narrow BTD can also be found in an
anthropoid pelvis. Whether a narrow BTD
may be an indication for a mediolateral
rather than a midline episiotomy was not
addressed in this research project.
Fetopelvic Relationships
The preceding description of the basic tech-
niques of clinical pelvimetry serves to set
the stage for practical application of this
art. One of the risks of vaginal breech deliv-
ery is head entrapment not by just the cervix,
but by a contracted bony pelvis. Fetal heads
in cephalic presentations have ample time to
mold, ex, and adapt to a relatively con-
tracted pelvis, but the aftercoming head of
the breech must negotiate the pelvis in sec-
onds to minutes. I believe, as did the authors
of the Term Breech Trial,4 that a pelvis can
be clinically determined by an experienced
examiner to be adequate for vaginal breech
delivery. Others feel strongly that computed
tomographic pelvimetry is indicated in just
this circumstance.5 In disagreement with
the conclusions of the Term Breech Trial,
however, I believe that there is still a place
in modern obstetric practice to deliver vag-
inally a breech fetus for a woman who meets
rigorous selection criteria in addition to hav-
ing an adequate pelvis.

Because over 95% of all fetal presenta-
tions are cephalic, the emphasis in the re-
mainder of this section is on head-rst deliv-
eries. A separate article in this symposium
deals with vaginal breech delivery.
The term fetopelvic merges 2 separate
entities that must be evaluated before under-
taking operative vaginal delivery. Too much
emphasis has been accorded to the estima-
tion of fetal weight by either clinical or sono-
graphic methods, neglecting the importance
of careful clinical pelvimetry. The overall
stature of the woman (tall, short, obese, petite)
should be considered and the pelvis eval-
uated with this and estimated fetal weight
in mind. The bony pelvis itself may be
adequate but fetal malposition, deexion,
and asynclitism may contribute to an arrest
of descent. Correction of the fetal abnormal-
ity may reveal that the pelvis was clinically
adequate despite inability to achieve a spon-
taneous delivery. Consider the following
representative case.
A 22-year-old G1P0 at term reached
complete dilation after oxytocin augmenta-
tion for active phase arrest. At 1 hour of
pushing, her pelvic examination revealed
the fetal head to be at +2 station, left occiput
anterior, but markedly asynclitic. Mild caput
had formed over the anterior parietal bone.
At that point, clinical pelvimetry was per-
formed. The diagonal conjugate could not
be assessed as a result of the low station.
The retropubic angle was gently rounded,
the ischial spines were blunt, the hollow of
the lower sacrum was only partially lled,
and the sidewalls were straight. The subpu-
bic arch was greater than 90, and the bitu-
berous diameter was .8 cm. The coccyx
was mobile. Although the diagonal conju-
gate was not evaluated, the impression of
the examiner was that the pelvis was gy-
necoid. The estimated fetal weight was
3600 g. It was decided to allow the patient
to continue pushing, but after 1 more hour,
an arrest of descent was diagnosed. The
fetal heart rate pattern was reassuring and
there was a functioning epidural in place.
Putting together all the clinical data,
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Clinical Pelvimetry 145
including the clinical pelvimetry assess-
ment, the arrest of descent was attributed
to asynclitism. Luikart forceps with a sliding
lock were placed, the asynclitism was cor-
rected instrumentally, and a 3850-g fetus
was delivered by forceps over a midline epis-
iotomy. There was no birth trauma, the infant
was vigorous, and the episiotomy did not
extend. This case demonstrates the contribu-
tion of pelvic assessment to achievement of
a vaginal delivery with an excellent maternal
and fetal outcome.
Sometimes, instead of contributing to a
successful vaginal delivery, clinical pelvim-
etry can prompt a decision to proceed with
primary cesarean delivery. In a woman
undergoing labor augmentation with oxyto-
cin, adequate contractility of 250 Montevi-
deo units was achieved. No progress in dila-
tion ensued over 2 hours. Recent work sug-
gests extending the labor for another 2 hours
before resorting to cesarean,6 but vaginal
examination revealed the fetal head to be
at 3 station with moderate caput forma-
tion. The sacral promontory was easily
reached and the DC was estimated at 10
cm, giving an estimated OC of 8.5 cm. This
nding had been overlooked at the start of
the augmentation. It was elected to proceed
immediately to cesarean delivery for sus-
pected inlet contraction instead of pursuing
further, probably futile augmentation.
If rotational forceps delivery is consid-
ered, adequate assessment of the pelvis is
imperative. I do not agree that all occiput pos-
terior (OP) fetuses should be rotated before
delivery nor do I agree that instrumental deliv-
ery as an OP is always appropriate. Instead,
the method of delivery should depend on
the integration of all clinical variables with
special emphasis on clinical pelvimetry.
A contracted pelvis diagnosed clinically
may still allow delivery of a small to average
fetus after adequate rst and second stages
of labor. A second twin may be larger than
the rst, but still considerably smaller than a
term singleton infant. Therefore, I seldom
choose cesarean delivery simply because
twin B is larger than twin A.
 146 Yeomans
Finally, although my strong preference is
forceps delivery over vacuum extraction, I
must concede that forceps take up additional
space in the pelvis compared with a vacuum
cup. There are times when this may affect
the choice of instrument.
Conclusion
Older textbooks devoted many chapters to
the mechanical aspects of obstetrics, partic-
ularly pelvic assessment. Some of the tech-
niques used in those years have been right-
fully discarded. However, the techniques of
clinical pelvimetry outlined in this chapter
and considered in greater detail in some of
the references are still the foundation of
an obstetric practice that does not limit
delivery of babies to those that either fall
out or get cut out abdominally. Pelvic anat-
omy is to the obstetrician what abdominal
anatomy is to the general surgeonor
should be.
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