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CONTENT 1:

Pathophysiology and mechanism of labour

THE FETUS:
FETAL SKULL AND ITS
SIGNIFICANCE IN LABOUR
ROZIAH ARABI
Module Coordinator
FFFM5024 MODULE 2: INTRAPARTUM
ADVANCED DIPLOMA IN MIDWIFERY 2014/2015
LEARNING OUTCOMES
At the end of this topic, students will be able to:
1. Describe the regions of the fetal skull
2. Describe the bones that make up the vault of
the fetal skull
3. Describe the sutures and fontanelles
4. Describe the various diameters of the fetal
skull and their significance in labour
General description of the fetal skull

 Ossified from
membranous tissue as
early as 8th weeks in-utero
 Protects the most vital
organ of the body

 Composed of:
1. The base
2. The face
3. The vault
1. The base
 Composed of hard bones firmly united that protects the vital
centres in the brain during labour
2. The face
 A part of the skull below the supra-orbital ridges (glabella) to
the junction of chin and neck
 Compose to 14 rigid bones (ossified from cartilage)
3. The vault
 Region above an imaginary line drawn from the orbital
region to the nape of the neck
 Formed by 7 pieces of bones which are incompletely
ossified at birth
Separated by sutures and fontanelles  allows the scull to
mould and compress during birth
The bones
 Vault are made up of :
 2 frontal bones
 2 parietal bones
 2 temporal bones
 1 occipital bone
The two frontal bones
 These bones form the forehead
 They are roughly square in shape
 They cover the frontal lobes of the brain
The two parietal bones
 These bones lie behind the frontal bones
 On either side of the skull
 Roughly square in shape with a bony
eminence at the centre known as the parietal
eminence (the centre of ossification)
 The largest of all bones
 Cover the parietal lobes
of the brain
THE OCCIPITAL BONE
 Is a single piece of bone lying below
the parietal bone at the back of the
head
 Is triangular shape with a small
eminence at its centre known as the
Occipital Protuberance
 It covers the occipital lobe of the
brain and cerebellum
 The lower part forms the margin
of the foramen magnum &
articulates
with the 1st cervical vertebrae
The two temporal bones
 Form part of the side walls
 Lie below the parietal bones in front of the
ears
The sutures
 Sutures are membranous junction between 2 bones
 Important because they allow the bones to overlap
 Thus reducing the size of the fetal skull and facilitating
delivery
The sutures are:
1. Frontal suture
 Runs between the frontal
bones
2. Sagittal suture
 Lies between the 2
pieces of parietal bones
3. Coronal suture
 Like a crown running
across the head
 Lies between the frontal
and the parietal bones
4. Lambdoidal sututre
 Runs obliquely between
the parietal and the
occipital bone
The fontanelles
 Fontanelles are membraneous spaces where
2 or more sutures meet
~ membraneous junction of sutures
 Out of 6 fontanelles in the fetal skull, only 2
are important
1. Anterior fontanelle (in front of the vault)
2. Posterior fontanelle (at the back of the vault)
The fontanelles
The anterior fontanelle The posterior fontanelle
 Known as the Bregma  Known as Lambda
 large diamond shaped space
 Lies at the junction of the
 At the junction of 4 sutures; the
frontal, coronal and sagittal sagittal and labdoidal
 About 3-4 cm in length  Small and triangular in shape
 1.5-2 cm in breadth  If this fontanelle is felt during
 Pulsation of cerebral vessels VE, means that the fetus is in
can be felt through it the OA position
 If this fontanelle is felt during  Close when the child is 6
VE, means that the fetus is
either in OP position or face to weeks
pubes
 Close when the child
is 18 months old
 These fontanelles are important structures of
fetal skull as they denote the position of the
fetal head
The regions of the fetal skull

 Fetal skull is divided into the following regions:


1. The occiput
 Area below the lambdoidal sutures and
the posterior fontanelle
2. The vertex
 Area between the anterior and posterior
fontanelles and the parietal eminences
laterally
3. The sinciput or brow
 Lies between the supra-orbital ridges
below and the anterior fontanelle and
coronal sutures above
4. The face
 Lies below the level of the supra-orbital
ridges
The 4 regions
 Is important because its often referred to in
obstetrics
 A midwife should remember these regions
 Besides knowing the regions, the attitude of
the fetal skull also a vital
 Attitude means the relation of the fetal parts –
head, spine and limbs to each other in this
case to fetal skull
ATTITUDE
 The fetal head is capable of a wide range of movements:
1. Well Flexion
 The head bends till its chin touches the chest
 Vertex presentation
2. Extension
 The head bends backwards till it touches the spine
 Face presentation
3. Deflexion (militiary attitude)
 The head is neither flexed nor extended, straight head
 Brow presentation
4. Rotation
 Circular movement of the head for more than 180
degress
DIAMETERS
 The presenting diameters of the fetal skull are
important because they are the distance
which the birth canal must stretch to allow the
head to go through during delivery
 These distances are known as
“the antero-posterior(AP) diameters of the
engaging diameters”
 The AP diameter varies with the degree of
flexion or extension of the head
The variation of AP diameters according to the presentation of
the fetus

Presentation Antero-posterior diameter Length in cm


(engaging diameter)

1. Vertex : Occipitoanterior position Sub-occipito bregmatic 9.5

1. Vertex : occipitoposterior position Occipito-frontal 11.5

1. Face Submento-bregmatic 9.5

1. Brow Mentor-vertical 13.5


Diagram showing the AP diameters of the fetal skull

KEYWORDS:
Diameter Length
SOB = suboccipitobregmatic 9.5 cm

SOF = suboccipitofrontal 10.0 cm

OF = occipitofrontal 11.5 cm

MV = mentovertical 13.5 cm

SMV = submentovertical 11.5 cm

SMB = submentobregmatic 9.5 cm


The descriptions
1. SOB
 Sub-occipito bregmatic diameter runs from the point
below the occipital protuberance to the centre of the
bregma in vertex presentation
 It is the engaging diameter for vertex presentation
2. SOF
 Sub-occipito frontal diameter runs from below the
occipital protuberance to the centre of the sinciput
3. OF
 Occipito-frontal diameter runs from the occipital
protuberance to the glabella or root of the nose
 It is the engaging diameter for occipito-posterior position
(OP)
The descriptions
4. MV
 Mento-vertical diameter runs from the tip of the chin to
the centre of the vertex
 The longest diameter of the fetal skull
 It is the engaging diameter for brow presentation
5. SMV
 Sub-mento vertical diameter runs from the junction of the
chin and neck to the centre of the vertex
6. SMB
 Sub-mento bregmatic diameter runs from the junction of
the chin and neck to the bregma
 It is the engaging diameter for face presentation
CIRCUMFERENCE
 The important of knowing about the cephalic
circumferences is because it will help in
understanding why certain presentation of the
fetal head is more favorable then the others.
 Other important diameters to be
learn are:

1. Biparietal
 Biparietal diameter extends
between the two pairetal
eminence
 It measures 9.5 cm
2. Bitemporal
 Bitemporal diameter runs
between the two extremities of
the coronal suture
 It measures 8.5 cm
 The engaging diameters varies in
length, the shorter diameter are
more favourable for delivery of the
fetal head
Presentation & Denominator
 Presentation is the fetus part that presented at the
brim of pelvis or at the lower segment of the uterus

 Denominator is the bone of the presenting part that


shows the fetal position

 There are 5 types of presentation & its denominator:


1. Vertex presentation – denominator is occiput
2. Brow presentation – denominator is sinciput
3. Face presentation – denominator is mentum
4. Breech presentation – denominator is sacrum
5. Shoulder presentation – denominator is
acromium process
There are 5 types of presentation & its
denominator:

1. Vertex presentation –
denominator is occiput
2. Brow presentation –

denominator is sinciput
3. Face presentation –

denominator is mentum
4. Breech presentation –

denominator is sacrum
5. Shoulder presentation –

denominator is acromium
process
Vertex presentation
1. Well flexed head
 When the head is well flexed, the sub-occipito-
bregmatic and the biparietal are the 2 diameters of
the presenting circular area and the circumference is
29 cm
2. Deflexed head
 When the head is deflexed, it is erect as in the
military attitude. The engaging diameters are:
i. Occipito-frontal – 11.5cm
ii. Biparietal 9.5cm (transversely)
iii. Bitemporal 8.5cm (transversely)
Brow presentation
 When partial extension occurs, the engaging
diameter is mento-vertical, which is 13.5cm
 The circumference is 38cm
 So the engaging diameter is longer, and the
circumference is also larger

Shape of
Attitude of head circumference
circumference
1. Well flexed 29 cm Round
2. Deflexed 34.5 cm Ovoid
3. Partial Eextension 38 cm Round
SIGNIFICANCE OF THE FETAL SKULL IN
LABOUR

We will discuss how the attitude of the fetal


head influences labour
1. Complete flexion
 If the attitude of the fetal head is complete
flexion
 the presentation is vertex the position is
occipito-anterior,
 the engaging diameter is the sub-occipito-
bregmatic (9.5cm)
 the circumference is small and circular in shape
Significant to labour:
 The girdle of contact between the fetal skull
and the cervix is good
 Imagine that the cervix is around the fetal
skull
 There is equal stimulation and the uterine
contraction will be good
 With good uterine contractions, the mother
will have normal delivery
2. Deflexion
 If the attitude of the fetal head is one of
deflexion or deflexed
 The presentation is still vertex but the position
will be occipito-posterior
 The engaging diameter is the occipito-frontal
(11.5cm)
 The circumference is ovoid in shape
Significant to labour:
 The girdle of contact between the fetal skull and
the cervix is not good
 Imagine that the cervix is also around the fetal
skull
 However the girdle of contact between the fetal
skull and the cervix will not be good
 There is unequal stimulation and the uterine
contraction and the uterine contractions are not
good it will be irregular
 There will be delay in the engagement of the
fetal  prolonged labour
3. Extension

 If the attitude of the fetal head is one


of extension,
 the presentation will be the face
 The engaging diameter is the
submento-bregmatic (9.5 cm)
 Same as the engaging diameter for a
well flexed head
 However, the face is made up of rigid
bones
 Rigid bones do not mould like the
bones of the vault
 This also may results in prolonged
labour
4. Partial extension
 If the attitude of the fetal head is one of
partial extension
 The presentation will be brow
 The engaging diameter is the mento-vertical
(13.5 cm), which is very long
 Labour will be obstructed and caesarean
section got to be done
Bear in mind!

Attitude Significance to delivery

1. Complete flexion Normal labour


2. Deflexion Prolonged labour
3. Extension Prolonged labour
4. Partial Extension Obstructed labour
Conclusion
Having a good knowledge about the fetal
skull is very important as this will help
you to identify the presentation, the
position of the fetal head and the
diameter that is distending the vagina
so that you could conduct the delivery of
the baby with minimal trauma to the
mother and baby.
Keywords to remember!
1. Presentation
2. Position
3. Engaging diameter
4. Girdle of contact
5. Stimulation
6. Uterine contraction
7. Type of labour and delivery
That’s all.

THANK YOU VERY MUCH FOR YOUR


ATTENTION