MWMS 4013 - ANATOMY AND PHYSIOLOGY APPLIED TO OBSTETRICS

ANATOMY AND PHYSIOLOGY OF THE FOETUS

INTRODUCTION

Foetal head contains the delicate brain and about 95% of babies present by head.
Sound knowledge of foetal diameter and measurement cause least problems during labour
and delivery through diagnosis of abnormalities presentation and position, also
disproportion between the foetal head and the pelvis can be easily recognized. Delivery can
be conducted with minimal injuries to the mother and baby. It is large in comparison with
the foetal body and true pelvis, some adaptation has to be made between the head and the
pelvis. The head is the most difficult part to be delivered either it comes first or last.

FOETAL SCALP

Macroscopic Structure

- The scalp of the foetus 1st layer:-

1) The skin – containing hairs. This is the outer covering.

2) A subcutaneous tissue: Contains blood vessels and hair follicles. Is the part where
caput succedaneum is formed.

3) Muscle layer - A layer of Tendon Galea

4) A loose layer of alveolar tissue. Limits movement of the scalp over the skull.

5) The pericranium – is the Periosteum of the cranial bones which covers the outer
surface, and is adherent to their edge. Which cover the skull bones.

- The scalp of the foetus 2nd layer:-

I. Dura mater (meninges)

II. Fibrous membranes – strong that cover outside of the brain and spinal cord and
between brain substance, formation of partition brain divide into compartment.

Microscopic Structure

The skull contains delicate membranous structure which is liable to damage during
delivery especially if subjected to abnormal moulding. Structures include: 1.Folds of Dura
matter and Venous sinuses associated with them. The membrane is in two layers, an outer
periosteal layer which is adherent to the skull bones and the inner meningeal layer which
covers the outer surface of the brain. The membrane does not only cover the brain but send
fibrous partition to divide the brain into compartments.

1. The Falx Cerebri

 It is a sickle-shaped fold of membrane which dip down between the two cerebral
hemispheres. It runs beneath the frontal and sagittal sutures – (From root of the
nose to the internal occipital protuberance).

 Attached to the foetal skull begin at the root of nose follow the line frontal and
sagittal suture and to the centre of the tentorium cereblli.

 Bottom part not merge and attach to the centre of the tentorium cereblli.

2. Tentorium Cerebelli

 This is a horizontal fold of dura matter situated at the posterior part of the cranial
cavity. It lies at right angle to the falx cerebri.

 It has a horse – shoe shape and forms a tent-like layer between the cerebrum and
the cerebellum.

 It contains large blood vessels or sinus which drains blood from the brain on their
way to become the jugular vein of the neck.

CERBRAL MEMBRANES

Cerebral membranes consist of big sinuses that drain the blood to the brain; -
 1. The superior Longitudinal(Sagittal) Sinus: 
 it runs along the upper part of the falx cerebri from front to the back (from
root of the nose to the internal occipital protuberance)
2. Inferior Longitudinal (sagittal) Sinus: 
 Runs along the lower part in the same direction.
 Drain from lower border of the falx to the junction of tentorium.
3. The straight sinus: 
 Is a continuation of the inferior sagittal sinus and drains blood from the great
cerebral vain and the inferior sagittal sinus along the junction of falx and the
tentorium.
 The point where it reaches the skull and receives blood from the superior
sagittal sinus is known as the confluence of sinus.
4. The Great Cerebral vein of Galen: 
 meet the inferior Sagittal Sinus at the inner end of the junction and where
the falx joins the tentorium.
5. Lateral Sinuses:
 These are two in number they pass from the confluence of the sinuses along
the outer edge of the tentorium cerebelli and carries blood to the internal
jugular veins.

Sinuses That Have Potential to Get Ruptured

Sinuses Ruptured
Great vein of Galen Tear from junction of the straight sinus
Straight sinus Ruptures involving deep tentorial tears
Inferior Sagittal sinus Rupture affecting the falx cerebri

POSSIBLE INJURIES THAT MAY OCCUR DURING DELIVERY

Because of the flexibility of infant’s heads, pressure on one or more parts of the skull can
cause it to take on an abnormal shape. This is referred to as deformational moulding.
Deformational moulding can occur in utero, during labour and delivery, or in early infancy.

Types of Head moulding Caused By Birth Injuries

1. Caput Succedaneum
 Is a condition marked by scalp swelling, typically during or shortly after birth. It is usually
caused by pressure from the mother’s uterus or vaginal wall during delivery. Bruising of the
scalp is more likely to happen during a long and difficult labour, especially in situations when
the amniotic sac has broken and the baby’s head is unprotected while passing through the
birth canal. Caput succedaneum can also be caused by the use of vacuum extraction devices
during a protracted delivery.

Physiology of Caput Succedaneum

Due to pressure from cervix on Prevent blood &
the fetal head in longer period lymph circulation

Presenting part become Collection of serum between

congested & oedematour aponeurosis and peristeum

2. Cephalohematoma

Is an accumulation of blood below the baby’s periosteum, the protective membrane that
covers an infant’s skull. Cephalohematoma shows up as lumps on a baby’s head, usually
several hours after delivery. The lumps feel soft and may grow larger during the baby’s first
hours postpartum. Most cephalohematomas do not require medical attention and
disappear within a few weeks or months as the body reabsorbs the blood. However, some
cephalohematomas may cause jaundice if they are too large and too many red blood cells
break down.

3. Skull Fractures

Infant skulls are also susceptible to fractures. Sometimes they appear as crater-like
indentations and can be called “ping-pong” fractures because the size and shape resembles
half of a ping-pong ball. These can be caused by difficult labour or a lack of space in utero.
Depending on the severity, ping-pong fractures may require surgical correction. They are
also associated with other complications such as hematomas.
MOULDING

This is the term applied to the change in shape of the foetal head which takes place
as it passes through the birth canal. It is brought about by pressure between the foetal skull
and the maternal pelvis. It results in compression of the movable bones and elongation of
those which are not compressed. The bones of the foetal head can move closer together or
overlap to help the head fit through the pelvis. Parietal bones overlap occipital and frontal
bones.
Moulding brings about a considerable reduction in the size of the presenting
diameters while the diameter at right angle to them elongates. This is possible because of
the sutures and fontanelles on the vault which allows slight degree of movement and the
bones to override each other.
In normal vertex presentation, the biparietal diameter, sub occiput bregmatic reduce
while the mento vertical lengthens. During moulding the anterior parietal bone override the
posterior one, the frontal and occipital bones go under the parietal bones. The advantage of
moulding is that it is a protective mechanism and prevents compression of the foetal brain,
once it is not excessive, too rapid or unfavourable direction.

DIAGNOSE EXCESSIVE MOULDING ON VAGINAL EXAMINATION

In a cephalic (head) presentation, moulding is diagnosed by feeling the overlap of the

sutures of the skull on vaginal examination, and assessing whether or not the overlap can be
reduced (corrected) by pressing gently with the examining finger. The presence of caput
succedaneum can also be felt as a soft, boggy swelling, which may make it difficult to
identify the presenting part of the foetal head clearly. With severe caput the sutures may be
impossible to feel.

Up to 2+ occipito-parietal moulding may be normal in the later stages of labour.

No moulding – parietal bones (sagittal suture) are not apposed

+1 moulding – parietal bones are touching but not overlapping.

+2 moulding – parietal bones are overlapped but easily reduced. If CPD is excluded,
consideration should be given to whether a forceps delivery is more appropriate than
vacuum (especially if there is significant caput).

+3 moulding – parietal bones have overlapped and are irreducible. Severe parietal moulding
is never normal and should be interpreted as a sign of relative or absolute cephalopelvic
disproportion.
THE EFFECTS OF ABNORMAL MOULDING
Deformational moulding In Utero Or During Birth: Risk Factors
If an infant’s head is pressed upon in utero or during the birthing process, this can lead
to deformational moulding. Some pregnancy and birth-related factors that can contribute to
deformational moulding include:

1. Cephalopelvic disproportion (CPD): When an infant’s head is too large to fit through
the mother’s pelvis.

2. Oligohydramnios: Insufficient levels of amniotic fluid

3. Twins/multiple births

4. Prolonged or arrested labour

5. Breech birth

Birth Injuries from Cerebral Compression and Excessive Head moulding

In certain types of moulding the internal structure maybe damage given rise to oedema or
haemorrhage and congestion may give rise to mild cerebral irritation. This can lead to death
or permanent brain damage. These dangerous moulding includes:

1) Excessive moulding: In cases of prolonged labour, due to cephalo pelvic

disproportion, prematurity.

2) Upward moulding: Occipito posterior position resulting in “face to Pubis” and after
coming head of the breech .

3) Rapid moulding: Precipitate labour Rapid compression and decompression result in

rupture of cerebral membranes. Any baby with any of this dangerous moulding
should be cot – nursed and observed for 24hrs for signs of cerebral irritation.

The causes of cerebral compression injuries

Cerebral compression injuries can happen when excessive pressure on a baby’s head
during labour and delivery causes brain damage. A certain amount of cerebral compression
during birth is normal, but excessive pressure on the baby’s head can cause hypoxic-
ischemic brain damage and other birth injuries from reduced blood flow and oxygenation
within the brain. In these cases, oxygen deprivation can happen within the brain itself due
to excessive cerebral compression restricting blood flow.
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