The female pelvis and

fetal skull
Dr.Inaam Faisal Mohamed
 
: The bony pelvis is made of four bones

The sacrum ,coccyx ,and two

.innominates(ilium, ischium and pubis)
These bones are held together by symphsis
pubis ,sacroiliac joints and sacrococcygeal
.joint
The sacrum consists of 5 fused vertebrae,the
anterior –superior edge of the first vertebra
is called sacral promontory,which protrudes
.slightly into the cavity of the pelvis
the anterior surface of the sacrum is usually
concave.it articulates with the illium at its
upper segment ,with coccyx at its lower
segment ,and with the sacrospinous and
.sacrotuberous ligaments laterally
The coccyx is composed of three to five
rudimentary vertebrae. it articulate with the
.sacrum
The pelvic brim and
inlet

The pelvic brim is the inlet

of the pelvis and bounded
in front by the symphysis
pubis (the joint separating
the two pubic bones) on
each side by the upper
margin of the pubic bone
the ileopectineal line and
the ala of the sacrum
posteriorly by the
.promontory of the sacrum
The pelvic brim and
inlet:
the normal transverse
diameter in this plane is
13.5 cm and is wider than
the anterior-posterior
diameter which is
normally 11cm ,angle of
the inlet is normally 60
degree to the horizontal
in the erect position.
The pelvic midcavity
The pelvic midcavity can be
described as an area
bounded in front by the
middle of the symhysis
pubis on each side by the
pubic bone the obturator
fascia and the inner aspect
of the ischial bone and spine
poteriorly by the junction of
the2nd and 3rd section of
the sacrum.
The cavity is almost rounded
,as the transverse and anterior
diameter are similar at 12cm
,the ischial spine are palpable
vaginally and are used as land
mark to asses the descent of
the head during vaginal
examination (station) they are
also used as land marks for
providing an anesthesia block
to the pudendal nerve.
Pudendal nerve passes behind
and below the ischial spine on
each
The pelvic out let
The pelvic outlet is
bounded in front by the
lower margin of the
symphysis pubis
on each side by the
descending ramus of
the pubic bone,the
ischial tuberosity and
the sacrotuberous
ligment posteriorly by
the last piece of sacrum
The pelvic out let
The AP diameter of
the pelvic out let is 13.5
cm and the trasverse
diameter is 11cm .
Avariety of pelvic shapes has been
described and these may
contributed to difficulties in labor
Gynaecoid pelvis

Present in 40%of women

pelvic inlet is rounded
with transverse diameter
larger than
antero-posterior
diameter
side wall is straight ,well
rounded sacroscaitic
notch,
well curved sacrum
,spacious sub pubic
angle =90 degree,
average prominence of
spine ,head forced to
occipital anterior
position
Anthropoid pelvis

20% of female ,long

narrow oval inlet ,long
antero-posterior
diameter large posterior
inclination of sacrum
,spine not prominent but
close ,narrow subpubic
angle ,precipitate
occipital-posterior
position and delivery in
such
Android pelvis

In 30% of women
tringular inlet with flat
post segment widest
diameter closed to
sacrum , side is
convergent ,long and
narrow sacrosciatic
notch, shallow sacral
curve ,narrow subpubic
arch ,prominent spine
,forced to be
occipit-trasverse position
(funnel shape) deep
trasverse arrest
Platypelloid pelvis
Flattened gynaecoid
pelvis 3%of female
pelvis
oval shape inlet ,straight
or divergent round
sacrosciatic notch
posterior inclination of
sacrum wide bispinous
diameter wide subpubic
angle , fetal head
engage in transverse
diameter increased risk
of obstructed labour.
The pelvic floor

This is formed by the two

levator ani muscles which
with their fascia form a
musculofascial gutter
during the 2nd stage of
labour.
The perineal body is a
codensation of fibrous and
muscular tissue lying
between the vagina and the
anus .
It receives attachments of
the posterior ends of the
bulbocavernous muscles
,the medial ends of the
superficial and deep
transverse perineal
muscles and the anterior
fibers of the external anal
sphincter ,it is always
involved in a 2nd degree
perineal tear and an
episiotomy.
The FETAL skull
The fetal skull is made up
of the vault ,face ,base.
the sutures are the lines
formed where the individual
bony plates of the skull
meets one another.
At the time of labour ,the
sutures joining the bones of
the face and base of the
skull are firmly united the
vault of the skull is formed
by the parietal bones and
parts of the occipital ,frontal
and temporal bones.
Between these bones
there are four
membaranous sutures,the
sagital ,frontal coronal and
lumbdoidal sutures
▪ The anterior fontanelle or bregma closed at 18 months (diamond
shape)is at the junction of the sagittal ,frontal coronal sutures

▪ The posterior fontanelle triangular in shape lies at the junction of

the sagittal and lambdoidal sutures between the two parietal
bones and the occipital bone closed at 6-8 weeks of life.
▪ It allow these bone to move together and even to overlap the
parietal bones usually tend to slide over the frontal and occipital
bones.
▪ The bones themselves are compressible together these
characteristics of the fetal skull allow a process called moulding to
occur ,which effectively reduces the diameter of the fetal skull and
encourages progress through the bony pelvis with out harming the
under lying brain.
:Defenitions
Vertex the area of the
fetal skull bounded by
the two parietal
eminences and the
anterior and posterior
fontanelle.
Attitude of the fetal
head refers to the
degree of flexion and
extension at the upper
cervical spine.
Different longitudinal
diameters are presented
to the pelvis in labor
depending on the
attitude of the fetal
head.
Engagment
occurs when the widest
diameter of the fetal
presenting part has
passed through the
pelvic inlet . .
In vertex –biparietal ,
breech-intertrochanteric
:Station

of the presenting part in the

pelvis canal is define as its
level above or below the
plane of the ischial spines.
Ischial spine level =zero station
eacn 1 cm above or below the
level of ischial spine, given -1
and +1
:Synclitic

when the biparietal diameter is

parallel to the pelvic plane
and the sagital suture is mid
way between the anterior and
posterior planes of the pelvis
when this relationship not
present the head is
considered to be asynclitic
:The diameter of fetal skull

▪ Vertex presentation
▪ Well flexed head the
longitudinal diameter ,is the
suboccipito –bregmatic
diameter 9.5 cm and
measured from the sub
occipital to the anterior
fontanelle
▪ longitudinal diameter that
present in a less well flexed
head such as is found in the
occipito- posterior position is
the Sub-occipito-frontal
diameter and is measured
from the suboccipital region
to the prominence of the
forehead 10 cm .
▪ Further extension of the head
Occipito-frontal daimeter
present this is measured from
the root of the nose to the
posterior fontanelle and is
11.5 cm.
The largest longitudinal ▪
daimeter that may present is
the Mentvertical which is
taken from the chin to the
furthest point of the vertex
and measure 13 cm known as
Brow presentation and it is
usually too large to pass
.through the normal pelvis
▪ Extension of the fetal
head beyond this point
result in a smaller
daimeter,submentobreg
matic daimeter is
measured below the chin
to the anterior fontanelle
and is 9.5cm this is
clinically a face
presentation.
▪ Transverse diameters of
fetal skull are:
▪ Biparietal (9.5 cm)this is
largest
transverse,diameter
(between two parietal
bones).
▪ Bitemporal 8 cm shortest
transverse diameter
,between two temporal
bones.
 
:Clinical pelvimetry
.The clinical evaluation is started by assessing the pelvis inlet
:Pelvic inlet
. can be assess clinically for its anteroposterior diameter
The obstetric conjugate can be estimated from the diagonal
. conjugate ,which is obtained on clinical examination

The diagonal conjugate is approximated by measuring from the lower

border of pubis to the sacral promontory using the tip of the
second figure and the point where the base of the index figure
meets the pubis
The obstetric conjugate is then estimated by subtracting 1.5 to 2 cm,
.depending on the height and inclination of the pubis

Often the middle figure of the examining hand cannot reach the
sacral promontory, thus the obstetric conjugate is considered
adequate .If the diagonal conjugate is greater than or equal to
11.5 cm the anteroposterior diameter of the inlet is considered to
.be adequate
The anterior surface of the sacrum is then palpated to assess its
. curvature. The usual shape is concave
Aflat or convex shape may indicate anteroposterior constriction
throughout the pelvis

.▪
The midpelvis
cannot accurately be measured clinically in either the ▪
. anteropoterior or transverse diameter
A reasonable estimate of the size of the mid pelvis ,however ,can be
obtained as follows. the pelvis side walls can be assessed to
determine whether they are convergent rather than having the
.normal ,almost parallel,configuration
The ischial spines are palpated carefully to assess their prrominance
and several passes are made between the spines to approximate
. the bispinous diameter
The lenghth of the sacrospinous
ligment is assessed by placing
one fingure on the ischial spine
and on the sacrum in the
.midline
The average length is 3 fingure
.breadths
If the sacrospinous notch that is
located lateral to the ligament
can accommodate two-and half
fingure tips,the posterior mid
pelvis is most likely of adequate
dimensions. short ligament
suggests a forward inclination
of the sacrum and a narrwed
.sacrospinous notch
.pelvic outlet is assessed

This is done by first placing a fist

.between the ischial tuberosities
An 8.5cm distance is considered an
.adequate transverse diameter
The posterior sagittal measurement
.should also be greater than8cm
The infrapubic angle is assessed by
placing thumb next to each
inferior pubic ramus and then
estimating the angle at which
they meet.An angle of less than
90 degree is associated with a
contracted transverse diameter in
.the midplane and out let
Radiological assessment
:of the pelvis
▪
When an accurate measurement of the pelvis is indicated nuclear
magnetic resonance may be used .The advantage of MRI over the
X-Ray or CT for the pelvic assessment is the lack of ionizing
.radiation exposure
:Indications
Clinical evidence or obstetric history suggestive of pelvic-1
.abnormalities
.Ahistory of pelvic trauma-2