THE FETAL SKULL

INTRODUCTION

The fetal head is large in relation to the fetal body compared with the adult, additionally it is

large in comparison with the maternal pelvis and is the largest part of the fetal body to be born.

Adaptation between the fetal skull and the pelvis is necessary to allow the head to pass through

the pelvis without complication.

The fetal skull is the most difficult part of the baby to pass through the mother’s pelvic canal,

due to the hard bony nature of the skull. Understanding the anatomy of the fetal skull and its

diameter will help to recognise how a labour is progressing, and whether the baby’s head is

‘presenting’ correctly as it comes down the birth canal. This will give a better understanding of

whether a normal vaginal delivery is likely, or if the mother needs referral because the descent of

the baby’s head is not making sufficient progress.

IMPORTANCE OF THE FETAL SKULL

1. Largest part of the fetal body.

2. Most frequent presenting part of the fetus.

3. Least compressible of all fetal parts.

FETAL SKULL BONES

The skull bones encase and protect the brain, which is very delicate and subjected to pressure

when the fetal head passes down the birth canal. Correct presentation of the smallest diameter of

the fetal skull to the largest diameter of the mother’s bony pelvis is essential if delivery is to
proceed normally. But if the presenting diameter of the fetal skull is larger than the maternal

pelvic diameter, it needs very close attention for the baby to go through a normal vaginal

delivery.

ANATOMY OF THE FETAL SKULL

It consists of vault, face , and the base.

1-The vault (cranium): is the large, dome shaped part above an imaginary line drawn between

orbital ridge and nape of the neck. To overlap under pressure and to change shape to confirm to

the maternal pelvis (molding) , thin , weakly ossified, easily compressible, interconnected by

membranes .The vault is composed of 2 frontal bones separated by the frontal suture, 2 parietal

bones separated by the sagittal suture, the occipital bone separated by the lambdoidal suture

from the parietal bones, while the coronal suture separates the frontal from the parietal bones.

2- The face : The face is the area from the junction of the chin and neck to the root of the nose

and supra-orbital ridges .it composed of 14 small bones, that are firmly united and non-

compressible.

3-The base : to protect the vital structures, large, ossified, firmly united, non-compressible

CRANIAL BONES

The bones of the vaults are laid down in membrane, they ossify from the centre outwards in a

process known as ossification. Ossification is incomplete at birth leaving small gaps in between

the bones known as sutures and frontanelles. The ossification centre on each bone appears as a

protuberance. Ossification of the skull bones is not complete until early adulthood

The fetal skull is made up of seven cranial bones which are the following:
1. 2 Frontal

2. 2 Parietal

3. Occipital

4. 2 Temporal

The frontal, occipital and the parietal cranial bones could either be fetal presenting part if the

presentation is vertex.

The fetal skull bones are as follows:

 The 2 frontal bones, which forms the forehead or sinciput. The ossification centre of

each is the frontal eminence. In the fetus, the frontal bone is in two halves, which fuse

(join) into a single bone after the age of eight years.

 The two parietal bones, which lie on either side of the skull and occupy most of the

skull. The ossification centre is called parietal eminence.

 The occipital bone, which forms the back of the skull and part of its base as it contains

the foramen magnum, which protect the spinal cord as it leaves the skull. It joins with the

cervical vertebrae (neck bones in the spinal column, or backbone). The ossification centre

is the occipital protuberance.

 The upper part of the two temporal bones, one on each side of the head, closest to the

ear.

Understanding the landmarks and measurements of the fetal skull will help to recognize normal

and abnormal presentations of the fetus during antenatal examinations, labor and delivery.
SUTURES

The bones of the vault are united together by the non-osssified membranes attached to the

margins of the bones. These are called SUTURE. , over the other during moulding of the head

permits gliding movement of one bone. Sutures are joints between the bones of the skull. In the

fetus they can ‘give’ a little under the pressure on the baby’s head as it passes down the birth

canal. During early childhood, these sutures harden and the skull bones can no longer move

relative to one another, as they can to a small extent in the fetus and newborn.

 The lambdoidal suture; forms the junction between the occipital and the two parietal

bones.

 The sagittal suture; joins the two parietal bones together.

 The coronal suture; joins the frontal bone to the two parietal bones.

 The frontal suture; joins the two frontal bones together.

THE FONTANELLS

A fontanel is the space created by the joining of two or more sutures. It is covered by thick

membranes and the skin on the baby’s head, protecting the brain underneath the fontanel from

contact with the outside world.

Identification of the two large fontanels on the top of the fetal skull helps to locate the angle at

which the baby’s head is presenting during labor and delivery.

Or Definition: the membrane-filled space located at the point where the sutures intersect. The

most important of which are the anterior and posterior fontanel’s. More useful in diagnosing

the fetal head position than sutures

  The anterior fontanel (also known as the bregma) is a diamond-shaped (2 × 3 cm)

space towards the front of the baby’s head, at the junction of the sagittal, coronal and

frontal sutures. It is very soft and can feel the pulsation of cerebral vessels by placing the

fingers gently on the fontanel. Ossified at 18-24 month after birth. Floor is made by a

membrane. ICP can be roughly assessed from its condition after birth. Depression in

dehydration and bulging in raised ICP.

 The posterior fontanel (or lambda) has a triangular shape, and is found towards the

back of the fetal skull. It is formed by the junction of the lamboidal and sagittal sutures.

Closes at 6 to 8 weeks of life. From its relation of the maternal pelvis, position of vertex

is determined. Internal rotation can be assessed from its location

DIFFERENCE BETWEEN ANTERIOR AND POSTERIOR FRONTANNEL

Anterior Fontanelle (Bregma) Posterior Fontanelle (Lambda

1. Large, and lozenge-shaped. Small and triangular.

2. Its floor is membranous Its floor is bony..

3. Surrounded by 4 bones Surrounded by 3 bones.

4. (2 frontal and 2 parietal) (2 parietal and occipital).

5. The floor is completely ossified 1.5 years The floor is completely ossified at full

after birth. term.

6. The surrounding bones are not The surrounding bones are overlapping

overlapping during molding during molding.

REGIONS AND LANDMARKS IN THE FETAL SKULL

The skull is further seprated into regions and within these, there are important landmarks. The

midwife feels for the landmarks on vaginal examination as they help ascertain presenting part of

the fetus

 The vertex; is the area midway between the anterior fontanel, the two parietal bones and

the posterior fontanel. A vertex presentation occurs when this part of the fetal skull is

leading the way. This is the normal and the safest presentation for a vaginal delivery.

 The brow (forehead/sinciput); is the area of skull which extends from the anterior

fontanel to the upper border of the eye (orbital ridge). A brow presentation is a significant

risk for the mother and the baby.

 The face ; extends from the upper ridge of the eye (orbital ridge) to the nose and chin

(lower jaw). The space between the eye brows is known as glabella. A face presentation

is also a significant risk for the mother and baby.

 The occiput ; is the area between the base of the skull and the posterior fontanel. It is

unusual and very risky for the occiput to be the presenting part. The part below the

occipital protuberance is the sub-occipital region

DIAMETER OF FETAL SKULL

1-Anteroposterior diameters:( Longitudinal diameters)

 Suboccipito-bregmatic (SOB) = 9.5cm, from below the occipital protuberance to the

centre of the anterior fontanelle (bregma). It is the engagement diameter in occipito-

anterior with complete flexion.

  Suboccipito-frontal (SOF) = 10 cm, from below the occipital protuberance to the centre

of frontal suture, It is the engagement diameter in occipito anterior with incomplete

flexion. It is the diameter that distends the vulva in occipito anterior if the head is allowed

to extend after crowning.

 Occipito-frontal (OF) = 11.5 cm, form the occipital protuberance to the root of the nose

(glabella). It is the engagement diameter in occipito-posterior position. It is the diameter

that distends the vaginal orifice

 Mento-vertical (MV) =13.5 cm, from the point of the chin to the highest point on the

vertex. It is the engagement diameter in brow presentation. As it is longer than the

largest diameter of the pelvic brim, the head cannot enter the pelvis.

 Submento-vertical (SMV) =11.5 cm from the junction of the chin and neck to the

highest point of the vertex which is a point on the sagittal suture midway between

anterior and posterior fontanelles. It is the engagement diameter in the incompletely

extended face. It is the diameter that distends the vulva during face delivery.

 Submento-bregmatic (SMB) = 9.5 cm, from the junction of the chin and neck to the

centre of the bregma., It is the engagement diameter in face presentation when the head

is completely extended.

2-Transverse diameters :

 Biparietal (BP) =9.5 cm, between the 2 parietal eminencies.

 Bitemporal (BT) = 8.2 cm, between the anterior ends of the temporal sutures .

PRESENTING DIAMETERS
Some of the presenting diameters are more favorable than others for easy passage through the

pelvis and this will depend on the attitude of the head, the term is attitude is used to describe the

degree of flexion or extension of the head on the neck. The attitude of the head determines which

diameters will present in labor and therefore influences the outcome. The presenting diameters

determine the presentation of the fetal head, for which there are three;

 Vertex presentation; when the head is well flexed the SOB diameter (9.5cm) and the

BP diameter (9.5cm) present. As these two diameters are the same length the presenting

area is circular, which is the most favourable shape for dilating the cervix and birth of the

head. The diameter that distends the vaginal orifice is the SOF diameter (10cm)

When the head is deflexed, the presenting diameters are the OF (11.5cm) and the BP

diameter (9.5cm). This situation often arises when the occiput is in a posterior position.

If it remains so, the diameter distending the vaginal orifice will be the OF (11.5cm)

 Face presentation; when the head is completely extended the presenting diameters are

the SMB diameters (9.5cm) and the BT diameter (8.2cm). The SMV (11.5cm) will

distend the vaginal orifice.

 Brow Presentation; When the head is partially extended and the MV diameter

(13.5cm) and the BT (8.2cm) present. If this presentation persists, vaginal birth is

unlikely.
 The anteroposterior diameters of the head which may engage are:

Measurement in Cm
Diameters (inches) Attitude of the Head Presentatio

Suboccipitobregmatic 9.5 cm Complete flexion Vertex

Suboccipito-frontal 10 cm Incomplete flexion Vertex

Occipitofrontal 11.5 cm Marked deflexion Vertex

Mento-vertical 13.5 cm Partial extension Brow

Submentovertical 11.5 cm Incomplete extension Face

Submentobregmatic 9.5 cm Complete extension Face

The transverse diameters:

Diameters Measurement in Cm (inches)

Biparietal 9.5 cm(3 ¾”)

Super-
subparietal 8.5 cm (3 ½”)

Bitemporal 8 cm (3 ¼”)

Bimastoid 7.5 cm (3″)

CIRCUMFERENCES:
MOULDING

This is the term applied to the change in shape of the fetal head which takes place as it passes

through the birth canal. It is brought about by pressure between the fetal skull and the maternal

pelvis. It results in compression of the movable bones and elongation of those which are not

compressed. 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 biperiatal diameter, sub occipito

bregmatic reduce while the mentovertical lengthens. During moulding the anterior parietal bone

override the posterior one, the frontal and occipital bones go under the parietal bones. The

shortening of the fetal head diameters may be by as much as 1.25cm.

Additionally, moulding is a protective mechanism and prevents the fetal brain from being

compressed as long as it is not excessive, too rapid or in an unfavourable direction. The skull of

the preterm infant is softer and has wider sutures than that of the term baby, and hence mould

excessively. Venous sinuses are closely associated with the intracranial membranes and if

membranes are torn due to excessive moulding there is danger of bleeding. A tear from

tentorium cerebelli may result in bleeding from the great cerebral vein. 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 INTRACRANIAL MEMBRANES AND VENOUS SINUSES

The skull contains delicate membranous structure which is liable to damage during delivery

especially if subjected to abnormal molding. Structures include:

 1.  Folds of Dura matter and

2. 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, which are

the falx cerebri and tentorium cerebelli

A; 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).

B; Tentorium Cerebelli: This is a horizontal fold of duramatter 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.
The dural sinuses are

1- The superior Longitudinal (sagittal) Sinus: it runs along the upper part of the falx corebri

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.

 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.

 NB; 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.

 4- Lateral Sinuses: These are two in number they pass from the confluence of the sinuses along

the outer edge of the tentorum cerebelli and carries blood to the internal jugular veins.

5-Occipital sinus: found in the posterior aspect of the tentorium cerebelli, is a small channel

draining contents from the occiput into the confluence of sinuses.

6-Sigmoid sinuses; are also paired sinuses known for its S-shape sinus found in the base of the

cranial fossa posteriorly. Left and right sigmoid sinuses collectively drain venous blood into the

internal jugular vein which exits at the jugular foramen.

7-Cavernous sinus; is located on the cavity of the sphenoid bone surrounding the pituitary gland

which drains contents from the ophthalmic veins (orbit) and pterygoid venous plexus (deep face).
8- Petrosal sinuses; Cavernous sinuses further drain into both petrosal sinuses superiorly (into

the sigmoid sinus) and inferiorly (into the internal jugular vein).

 During monlding the falx and the tentorium are stretched. The tentorium is most vulnerable to

tear near its attachment to the falx – (Tentorial Tears), this leads to bleeding from the great

cerebral vain giving rise to intracranial hemorrhage.

Blood flow through the sinuses

Dural venous sinuses are a group of sinuses or blood channels which drains venous blood

circulating from the cranial cavity. It collectively returns deoxygenated blood from the head to

the heart to maintain systemic circulation.

Major dural venous sinuses differ in their specific functions depending on their location within

the cranium and its associated structures which pass through the sinuses. Superior sagittal sinus

is found midsagittal and superior to the falx cerebri. It collects blood from cerebral and cerebelli

veins going to the confluence of sinuses (torcular herophili). Inferior sagittal sinus lies within the

inferior aspect of the falx cerebri and connects with the great cerebral vein forming the straight

sinus. Straight sinus drains contents from inferior sagittal sinus and great cerebral vein and

terminates into the confluence of sinuses. It can also drain into the transverse sinus. Occipital

sinus found in the posterior aspect of the tentorium cerebelli, is a small channel draining contents

from the occiput into the confluence of sinuses. Transverse sinuses are located bilaterally in the

tentorium cerebelli. It forms as an attachment into the occipital bone transporting venous blood

from the confluence of sinuses to the left and right sigmoid sinuses. Sigmoid sinuses are also

paired sinuses known for its S-shape sinus found in the base of the cranial fossa posteriorly. Left

and right sigmoid sinuses collectively drain venous blood into the internal jugular vein which
exits at the jugular foramen. Cavernous sinus is located on the cavity of the sphenoid bone

surrounding the pituitary gland which drains contents from the ophthalmic veins (orbit) and

pterygoid venous plexus (deep face). Cavernous sinuses further drain into both petrosal sinuses

superiorly (into the sigmoid sinus) and inferiorly (into the internal jugular vein). Left and right

cavernous sinus connect via the intercavernous sinuses. This is considered as the most clinically

important venous sinus because of its association with the other significant structures in the head

including cranial nerves III (oculomotor), IV (trochlear), ophthalmic and maxillary branches of

cranial nerve V (trigeminal), and cranial nerve VI (abducens) which lies below the internal

carotid artery. For these reasons, the cavernous sinus is also known as the “anatomic jewel box.”

The confluence of sinuses drains blood from superior sagittal, straight and occipital sinuses and

lies along the occipital bone posteriorly. This is where these three sinuses meet to transmit

venous blood to the left and right transverse sinuses.

FIGURE 1
FIG 2; BONES, SUTURES AND FRONTANELLES OF THE VAULT (CRANIUM)
FIGURE 3; CRANIAL BONES SHOWING THEIR OSSIFICATION CENTRE
FIGURE 4; LANDMARKS AND REGIONS OF THE SKULL BONE
FIGURE 5; DIAMETERS OF THE FETAL SKULL