Fetal Skull

Badeea Seliem Soliman

Assistant Prof. of gynecology and obstetrics
Zagazig university
 Fetal Skull
Vault – Face – Base

The vault is composed

of soft bones separated
by sutures and
.fontanelles
Vault is subdivided into

1. Forehead

2. Vertex

3. Occiput
1) Forehead

From Bregma

to root of the

nose.
 (2) Vertex
It is an area of the vault of skull

Bounded:
 Anteriorly
anterior fontanelle
 Posteriorly
posterior fontanelle
 Laterally
line passing through
parietal eminence
3) Occiput

From posterior

fontanelle to the

external occipital

Protuberance.
Bones of the vault IS (7 bones)
2 frontal bones
2 parietal bones
2 temporal bones
1 occipital bone

• The bones of the vault are not joined thus changes in the
shape of the fetal head during labor can occur due to
moulding
 Sutures
(number = 6)

Spaces between skull bones.

Made of un-ossified membranes which

allows movements of cranial bones to
decrease the skull diameters.
 Sutures = 6 in number

- Sagittal suture

- Frontal suture

- Coronal suture

- Lambdoidal sutures

- 2 Temporal sutures
Fontanels : Areas where sutures meet
6 in numbers
2 anterior temporal
fontanelles
at the junction of
temporal and
coronal sutures

Posterior temporal 2
fontanelles
at the junction of
temporal &lambdoidal
sutures

no obstetric importance.
Anterior fontanelle

Posterior fontanelle

obstetric importance.
 Posterior fontanelle Anterior fontanelle
(Lambda) )Bregma(
Small - Lozenge shaped - Large

Obliterated at FT Obliterated at 1.5y after birth

Formed by meeting of 3 bones - Formed by meeting of 4 bone -

Connected to 3 sutures - Connected to 4 sutures -

Bony floor Soft membranous floor

With moulding of the head, over-riding With moulding —> no over-riding of

of surrounding bones one parietal bond-­ bones as they are widely separated
overrides the other and both override from the start
the occipital bone
Obstetric importance of ant. & post.
Fontanelle

1- Diagnosis of vertex presentation

2- Detection of the position of the occiput
(anterior or posterior or lateral)
3- Detection of the degree of flexion or
deflexion of the head.
 FETAL SKULL DEFINITIONS

Bregma  Ant fontanelle

Brow  lies between Bregma &root of the
nose
Face  lies between root of the nose &
subra orbital ridges and chin
Occiput boney prominence behind post
fontanelle
Vertex Diamond shaped area between ant
& post fontanelles & parietal eminences
 FETAL SKULL SUTURES

• Frontal suture  between 2 frontal bones

• Sagittal suture  between 2 parietal bones

• Coronal suture  between parietal & frontal

• Lambdoid suture  between parietal & occipital

• Temporal suture  between inferior margin of

the parietal & temporal bones

 FETAL SKULL FONTANELLES

• Anterior fontanelle 
Diamond shaped space between coronal
& sagittal suture - ossifies at 18 m

• Posterior fontanelle (lambda) 

Triangle shaped space between sagital
suture & Lambdoidal suture
Diameters of Fetal
Skull
 Diameters of fetal skull

Longitudinal Transverse
)6( )4(
Longitudinal Diameters
(6)
1- Suboccipito bregmatic (9.5 cm)

• From sub occipital point

to center of anterior fontanelle

• The diameter of engagement

in occipito anterior position
when head is completely flexed
2- Suboccipito - frontal (10 cm)

From sub occipital point to

anterior end of Bregma.

1- Diameter of engagement
in vertex presentation with
mild deflexion of the head.
2- Diameter that distends the vulva in occipito
anterior if the head is allowed to extend after
crowning.
 3- Occipito -frontal (11.5 cm):
From the occipital protuberance
to the root of the nose.
Importance:
-Diameter of engagement
in O.P.
2- The diameter that distends the vulva in face to
pubis delivery with O.P.
3-The diameter that distends the vulva if the head
extends before crowning in O A.
 Sub mento- bregmatic (9.5 cm) -4

From the junction of the

neck and chin to the
centre of the bregma.
Importance:
It is the engaging diameter
in face presentation with
completely extended head.
 Sub mento -vertical (11.5 cm) -5

From the junction of the neck and chin to the vertical

point (a point on the sagittal suture midway between the
anterior and posterior fontanelles)
1- Diameter of engagement
in face presentation with the
head incompletely extended.

2- Diameter that distends the

vulva in face delivery (m.a.).
 :Mento- vertical (13.5-14 cm) -6

From the tip of the chin

to the vertical point.

Importance:
It is the diameter facing the pelvic brim in brow
presentation.
It is more than the largest diameter of the pelvic brim
 Longitudinal Diameters (6)

1. Suboccipito bregmatic (9.5 cm)

2. Suboccipito -frontal (10 cm)

3. Occipito -frontal (11.5 cm)

4. Sub mento- bregmatic (9.5 cm

5. Sub mento -vertical (11.5 cm)

6. Mento-vertical (13.5-14 cm)

Q: What is the name of diameter number
3 – 4 – 5?
Transverse diameters

(4)
 (1) Biparietal diameter (9.5 cm):
Between: The 2 parietal eminences
It is the engaging diameter with synclitism.
2- Supraparietal -subparietal diameter (9 cm)
From above the parietal eminence to below the opposite eminence.
Importance:
It engages in A. P. diameter of the inlet in case of
asynclitism.
 3- Bitemporal (= 8 cm):
Between the anterior ends of the
temporal sutures.

Importance:
It engages in the
oblique diameter
in O.P. Position
 4- Bimastoid (= 7.5 cm)
Between The tips of the 2 mastoid
processes.
 Transverse diameters of Fetal Skull
Diameter Length Measurement and
position
Biparietal 9.5 cm Between 2 parietal
eminence
Sub-parietal 9 cm From below one parietal
Supra-parietal eminence to above the
opposite eminence
Bitemporal 8 cm Between the anterior ends
of the temporal sutures
Bimastoid 7.5 cm Between the tips of 2
mastoid process
Biparietal

Bitemporal
Important Definitions
 Fetal Attitude
• It is the relations of the fetal parts to each
other, it is in a general flexion attitude i.e. all
joints are flexed
Complete Flexion
Most common ( in Vertex presentation)
Deflexion: In O.P position.

Military attitude: Midway between flexion &

extension (brow).
Complete extension In face presentation.
 Lie
The relation between the longitudinal axis of the fetus to that of
.the mother

Types:
1) Longitudinal (99.5 %). 2-Oblique or transverse (0.5 %).
 Presentation
It is the lowermost part the fetus & the part related to the pelvic
.brim and first felt by vaginal examination

Presentation

Cephalic
Breech Transverse
)96%(
)3.5%( )0.5%(

Vertex Brow Face

 N.B:
In term pregnancy cephalic presentation is more common than breech

Because of:
1. The head is heavier so it occupies the
LUS
2. The buttocks are larger so it occupies
the fundus
 Position
The relation of the back of the fetus to the
right or to the left sides of the mother and
.whether it is directed anteriorly or posteriorly

• 1 st position: The back is left and anterior.

• 2 nd position: The back is right and anterior.

• 3 rd position: The back is right and posterior.

• 4 th position: The back is left and posterior

 The denominator
A landmark on the presenting part denoting
the position

• Occiput ------------------- in vertex.

• Frontal bone------------- in brow .
• Chin ----------------------- in Face.
• Scapula ------------------- in shoulder
Vertex ---------------- occiput
 In vertex presentation
(the commonest),
There are 8 positions
- Right and left
occipito-anterior

- Right and left

occipito- posterior

- Right and left

occipito-transverse

- Direct occipito
anterior and posterior
positions 8
Fetal Position
The fetal compass rose
 O.A is more common than O.P
because
• The concavity of the front of the fetus

(due to its flexion) fits

into the convexity of
lumbar lordosis of
maternal spine.
LOA is more common than ROA and ROP is
more common than LOP because

(1) In LOA and ROP the head enters the pelvis in

the right oblique diameter which is more
favorable than the left oblique

Dextro-rotation of the head favours LOA if )2( •

the back is directed to left side and ROP if the
.back is directed to right side
 Engagement

Passage of the widest

transverse diameter
of the presenting part
through the plane of
the pelvic inlet.
Example: B.P.D. in cephalic presentation
 Timing of engagement
In PG: (last 3 – 4 weeks)
In MP: it usually occurs in the 1st
stage or with onset of 2 nd stage

Detection of engagement
• Abdominally: by 1st pelvic grip (Rule of fifths).

• Vaginally: (Rule of station).

 Station
The level of the head in the pelvis.
 Detection of engagement

Abdominally (Rule of fifths).

 Rule of fifths
0 station: 2/5 of the head are felt abdominally
above symphysis pubis

+1 station: 1/5 of the head is felt

+2 station: none of the fetal head is felt

-1 station: 3/5 head is felt

-2 stations: 4/5 head is felt

-3 station : the whole head (5/5) is felt

 Vaginally(Station of the head)
The level of the vertex is assessed in relation to the level of ischeal spines
At this level it is called station (0) above this level is by minus every 1 cm
and below by pulse every 1 cm
Assessing the Descent of the Fetal Head
by Vaginal Examination
 Station of the head
0 = The lowest part of the head is felt vaginally at
the level of the ischial spine.

+ 1= If 1 cm. below the level of ischial spines.

+2 = If 2 cm below the level of ischial spines.
+3= If 3 cm. below the level of ischial spines
-1 = If 1 cm above the level of ischial spines.
-2 = If 2 cm above the level of ischial spines.
-3 = If 3 cm above the level of ischial spines.
 Causes of Non-engagement of fetal head
Fetal causes Maternal causes
• Large sized head • Pelvic contraction
• Hydrocephalic head • Pelvic tumors
• Malposition • Placenta previa
• Malpresentation • Hypertonic LUS
• Multiple pregnancy • Atony of abdominal or
• Short umbilical cord uterine muscles
• Polyhydraminos

In 20% of cases no cause is found.

Synclitism
&
Asynclitism
 Synclitism
When the 2 parietal bones are at
the same level
Sa
g git
al
su
t ur
e
Synclitism

Anterior parietal

Posterior parietal
 Asynclitism

One parietal bone is presented below

the other due to lateral inclination of
the head, the sagittal suture lies
nearer to the promontory or
.symphysis
• Value

• Asynclitism brings the shorter sub

parietal - Supraparietal (9 cm) to

enter the pelvis instead of B.P.D.
(9.5cm).
Slight degree of asynclitism may occur -
in normal labour
 Posterior asynclitism Anterior asynclitism
(anterior parietal bone (posterior parietal bone
presentation ,presentation

The anterior parietal bone is The posterior parietal

lower and the sagittal suture bone is lower and the
is nearer to the promontory.
sagittal suture is nearer
- It occurs more in MP due to
to the symphysis pubis.
laxity of the anterior
abdominal wall. - It occurs more in PG due
to tense abdominal wall.
Anterior parietal bone presentation is
more favorable than posterior parietal
bone presentation because
 Because
(1) During correction of asynclitism, the head
meets only the resistance of the sacral
promontory while in posterior parietal bone
presentation the head meets the resistance of
the whole length of symphysis.

(2) The head lies more in the pelvic axis with

anterior parietal bone presentation.

(3) With posterior parietal bone presentation ------

LUS more liable to stretch and rupture.
MCQ
 The greatest diameters of the )1(
normal fetal head is which of the
?following
A. Occipito – frontal
B. Suboccpito bregmatic
C. Bitemporal
D. Biparital
E. Mento – vertical

(E)
 The relation of the fetal parts to each )2(
?other determines which of the following

A. Presentation of the fetus

B. Lie of the fetus
C. Attitude of the fetus
D. Position of the fetus
E. Intention of the fetus

(c )
 In vertex presentation, what )3(
fetal part determined the fetal
?position
A. Mentum
B. Sacrum
C. Acromion
D. Occiput
E. Sinciput

(D)
The relationship of the long axis )4(
of the fetus to that of the mother
:called IS

a) Lie
b) Presentation
c) Attitude
d) Posture
e) Position
(A)
 Regarding the fetal skull fontanelles, )5(
:one of the following is true

A. There are 3 fontanelles

B. The posterior fontanelle is closed at 28 weeks
of gestation
C. The anterior fontanelle is closed at birth
D. The anterior fontanelle is irregular in shape
E. The posterior fontanelle is triangular in shape

(E)
 The incorrect statement regarding fetal presentation )6(

a) It is the part of the fetus that enters the maternal

pelvis first.
b) It is always cephalic
c) In cephalic presentation, it is more common to be
vertex
d) In face presentation the head is completely
extended
e) The denominator is always the lowest part of the
presenting area

(E)
 The correct statement for )7(
:anterior fontanelle (Bregma) is

a) Triangular in shape
b) Smaller than the posterior
fontanelle
c) Has bony floor
d) Becomes obliterated 18 months
after birth

(D)
The correct statement for )8(
biparietal diameter of fetal head
a) Extend from a point below one parietal
bone to a point above the opposite
eminence
b) It is the engaging diameter in brow
presentation
c) It is 9.5 cm in length
d) All of the above

(c)
Concerning the occipto frontal )9(
diameter, all of the following are true
:EXCEPT
a) It extends from occipital protuberance to root
of the nose
b) It is 9.5 cm I length
c) It is the diameter of engagement in after
coming head of breech.
()
d) It is the diameter distending the vulva in face to
pubis delivery
(B)
As regards the mento vertical )10(
diameter, all of the following are true
:EXCEPT

a) It is 13.75 cm in length
b) It is the diameter of engagement in face
presentation
c) It extends from tip of chin to the verticle point
d) It is larger than the largest diameter of pelvic
inlet
(B)
(11) The shortest diameter of the
pelvic cavity is:
a) The external conjugate
b) Diagonal conjugate
c) The bispinous
d) The true conjugate
e) The transverse
(C)
Short questions

Gives Short

Account
?on
 What are the various types of
?fetal presentations

What are the different cephalic

presentations?

How is position determined?

What is the definition of
?mal presentation

What is the Rule of fifths?

Causes of non engagement ?

 Definition of
1. Lie
2. Vertex
3. Attitude
4. Engagement
5. Pelvic brim
6. Synclitism
7. Asynclitism
8. Station of the head