The

passanger
MID370S
Feb
The passenger
• The fetus has to negotiate the maternal passage in
order to be born
• The course of labour will be influenced by several
factors concerning the passenger:
• The number of fetuses
• The gestational age
• Position of the fetus in utero
• Size of the fetus in relation to the pelvis
 • 95% of all labour starts with the fetal head as the
presenting part over the pelvic brim
• Fetal head is relatively large in relation to the body
The • Consists of a bony skull that contains the delicate
fetal brain
passenger • Once the head is born the body follows without
any problem
(cont) • The head is the least compressible part and the
most difficult stage of the delivery
• Might be damaged during delivery and any brain
damage might be permanent
 • A fetal skull of normal shape and average
dimensions is able to pass through an average
gynaecoid pelvis without any difficulty
• Presentation is normal, well flexed (chin on the
chest)
• If abnormal presentation larger diameters will
present
Fetal skull • May cause difficulties when head attempts to
enter the pelvic brim
• Important to know the diameters of the fetal head
• Landmarks are identifiable on abdominal palpation
and vaginal examination (VE)
• Enables the midwife to identify and estimate the
size, presentation and position of the fetus
Anatomy of fetal skull
(Regions and bones)
• The base of the skull
• The face
• The vault/cranium
 Base
• Bony area
• Surrounding the opening, foramen magnum
• Bones are firmly united to protect the vital centre in the
medulla
Face:
Fetal Skull • Extends from the root of the nose to the junction of the
chin with the neck
• Bones are small and firmly united
Vault/Cranium:
• Greater, upper, dome-shaped part of the skull
• Extends above the face in fron, to the base of the skull
posteriorly and include the temporal structures laterally
The bones of the
fetal skull
• 2 halves of the frontal bone
• 2 parietal bones
• 1 occipital bone
 • Frontal suture: Bisects the frontal bones down the
centre of the forehead (sinciput) and is a forward
extension of the sagittal suture
• Sagittal suture: Lies between the parietal bones
and runs in an anteroposterior (AP) direction,

Sutures of dividing the skull into left and right halves

• Coronal sutures: Separate the frontal bones from

the fetal the parietal bones

• The two sutures run almost at right angles to the

skull sagittal suture and the frontal suture

• Bisecting these sutures and thereby forming the
anterior fontanel
•
 • Join centrally to form one long suture
• Divide the two parietal bones from the occipital
Lambdoidal bone.
• These sutures run transversely across the posterior
sutures end of the sagittal suture, forming the posterior
fontanels
The temporal sutures
• Lie on either side of the skull,
• Between the temporal bones laterally,
and the frontal and parietal bones
above
• At the point where the coronal suture
meets the temporal suture, on either
side of the skull, there is a small
temporal fontanels (the temple).
• It is between these points that the
bitemporal diameter is measured
Two important
fontanelles
The anterior fontanel or bregma
• Diamond shaped
• Formed by the junction of four sutures:
• The frontal,
• The sagittal and
• The two coronal sutures
• It is situated centrally, or at a midpoint on
the top of the fetal skull, where the frontal
and parietal bones meet
Posterior fontanelle
(lambda)
• Triangular shaped
• It is formed by the junction of three
sutures: sagittal and the lambdoidal
sutures
• It is situated centrally, on the posterior
aspect of the fetal skull where the
parietal bones meet the occipital bone
Anatomical landmarks of the fetal skull
• The submental area
• This is the area below the chin and extends to the angle where the chin meets the neck.
• The areas between the submental area and the vertex are:
• the mentum, the chin
• the face
• the root of the nose
• the orbital ridges, which are the ridges above the eye sockets
• the glabella, which is the elevated area between the orbital ridges
• the sinciput or the brow or forehead, which is the area bounded anteriorly by the
glabella and orbital ridges and posteriorly by the bregma and coronal sutures
Anatomical landmarks of the fetal skull :The
vertex
• This is the top of the cranium, and is the lowest area on the fetal head that enters the
pelvic brim in a vertex presentation
• The vertex is bounded by the
• coronal sutures and
• bregma anteriorly,
• the lambdoidal sutures and
• lambda posteriorly
• parietal eminences laterally.
 • The parietal eminences

Anatomical • Each parietal bone has a thickened and raised area

in the centre of the bone where the greatest
landmarks amount of ossification has taken place.
• The diameter between these eminences is the
of the fetal widest part of the skull
• The largest transverse diameter,
skull • Called the biparietal diameter (BPD) – 9.5cm
 • The occiput
• The area at the back of the head which is formed
Anatomical by the occipital bone.
• It is posterior and below the lamboidal sutures and
landmarks posterior fontanel.
• The sub-occipital area is the area below the
of the fetal occipital protuberance
• The suboccipital area extends from the occipital
skull protuberance to the nape of the neck
Measurements of the fetal
skull and diameters

• Transverse diameters
• The biparietal diameter (BPD) measures
9.5cm between the two parietal eminences
• The bitemporal diameter of 8.2 cm is
measured
• Between the junctions of the corona and
temporal sutures on either side of the skull
(between the temples)
 • The subocciput-bregmatic diameter (9.5cm)
• Measured from below the occipital
protuberance,to the centre of the anterior
fontanel,
The • As all the diameters in this presentation are small
anteroposterior and are also equal, the presenting part is an almost
perfect circle, which fits well onto the circle of the
(AP) diameters internal cervical os.
• This creates an even pressure all round the cervix
and brings about an even dilatation of the cervix
during labour.
AP • The subocciput-frontal diameter 10cm
• Is measured from below the occipital

diameters protuberance, to the centre of the sinciput

• This is the diameter that presents a slightly

(cont.) deflexed vertex presentation, usually with the

occiput lying posteriorly in relation to the pelvis
 • The occiput-frontal diameter 11.5cm
• Measured from the occipital protuberance to the
glabella
AP • This large diameter presents in a deflexed vertex
presentation
diameters • And is known as the 'military attitude

(cont.)
• Where the spine is straight, and the head erect on
the spine and the occiput lies posteriorly in the
pelvis
• This presentation often develops into a persistent
occipitoposterior position
AP diameters (cont.)
• The submento-bregmatic diameter 9.5 cm
• Measured from the angle of the chin with the neck, to the centre of
the anterior fontanel
• This diameter presents in a fully extended face presentation.
• Although this diameter is smaller than the sub occiput-bregmatic
diameter, it is not circular and therefore does not exert an even
pressure on the cervix.
• In addition, although these diameters may negotiate the pelvic brim,
the wide biparietal diameter, which still must enter the pelvic brim,
may become caught up as the face descends into the pelvic cavity .
AP diameters (cont.)
• The submento-vertical diameter ll.5 cm
• Measured from the angle of the chin with the neck, to the highest
point on the vertex
• This diameter presents in an incompletely extended face
presentation, particularly common in a mentoposterior position
• This wide diameter also distends the vulva during the birth of a face
presentation
AP diameters (cont.)
• The mentovertical diameter 13.5 cm
• Measured from the tip of the chin or mentum, to a point on the
vertex which is just above the posterior fontanel.
• This diameter is the largest on the fetal head.
• This extremely large diameter presents in a brow presentation.
• It is larger than any of the diameters of a gynaecoid pelvis
• Usually become obstructed should it attempt to negotiate the pelvic
brim.
Movements of the fetal head (attitude)
• Fetal head is capable of a wide range of movements. Can rotate the
neck 90° on the neck to either side of the body
Important movements:
• Flexion: The head is completely flexed, so that the chin of the fetus is
in contact with the chest
• Extension: The head is completely extended, so that the occiput is in
contact with the fetal back
• Deflexion: Neither flexion or extension, but between the two. The
fetal back is straight, with head erect. Known as the military attitude
AP diameters vs Attitude
• Complete flexion: Sub-occipito-bregmatic diameter
• Incomplete/partial flexion: sub-occipito-frontal diameter
• Deflexion/military attitude: occipito-frontal diameter
• Complete extension: sub-mento-bregmatic diameter
• Incomplete/partial extension: sub-mento-vertical diameter
Summary of diameters (AP diameters)
SUB-OCCIPITO BREGMATIC DIAMETER
• 9.5cm is measured from below the occipital protuberance to the
centre of the anterior fontanelle
SUB-OCCIPITO FRONTAL DIAMETER
• 10cm is measured from below the occipital protuberance to the
sinciput
OCCIPITO-FRONTAL DIAMETER
• 11.5cm is measured from the occipital protuberance to the glabella
Summary of diameters
SUBMENTO-BREGMATIC DIAMETER
• 9.5cm is measured form the angel of the chin with the neck, to the
centre of the anterior fontanelle
SUBMENTO-VERTICAL DIAMETER
• 11.5cm is measured from the angle of the chin with the neck, to the
highest point on the vertex
MENTO-VERTICAL DIAMETER
• 13.5cm is measured from the tip of the chin, to a point on the vertex
which is just above the posterior fontanelle
Engagement of
the fetal skull
• Has taken place when the widest
presenting diameter, the biparietal
diameter, has passed through the
pelvic brim (Inlet)
• Engagement of the fetal head is the
most important facet in the delivery
unless the biparietal diameter is able
to pass through the pelvic brim,
vaginal delivery cannot take place
Synclitism
• The fetal head is aligned with the fetal spine and
• The sagittal suture divide the pelvic cavity in two equal parts
• Regardless of the position of the head
• On vaginal examination:
• Sagittal suture can be felt in the middle
• Application may be good
• Synclitism will provide a better 'fit' or application on the cervix.
Asynclitism
• The pelvis is wide and the fetal head tilts on the fetus's shoulder and
is misaligned.
• The suture line is off-centre and
• An ear can be felt on vaginal examination
• Poor application.
• This may influence application of the presenting part on the cervix.
• posterior asynclitism (Litzmann's obliquity) - ear can be felt
posteriorly
• anterior asynclitism (Naegele's obliquity) - ear can be felt anteriorly
Moulding of the fetal skull
• Moulding is the change in shape of the fetal head during its passage
through the birth canal
• Due to prolonged compression on the presenting diameters of the head, as
the
• Head is forced through the bony pelvic canal.
• The presenting diameters are reduced,
• The diameters at right angles to the presenting diameters are increased.
• Moulding is of the greatest value:
• It allows the widest presenting diameters of the fetal head to enter the
pelvic brim and to
• Negotiate the pelvic canal
Moulding of the fetal skull
• Moulding should be a
• Slow process, occurring as the head passes into and through the pelvis.
• No damage of any consequence is caused to the brain of the baby as long
as the moulding is not excessive
• Damage can occur in the following circumstances:
• With prolonged labour,
• In a preterm baby, due to large sutures and soft skull bones
• With sudden decompression, as in precipitate labour
• In the after-coming head of a breech presentation or assisted delivery
• In a difficult or traumatic forceps delivery or vacuum extraction
Moulding of the fetal skull
• The change in shape of the fetal skull depends:
• The state of flexion or extension of the fetal head.
• This, in turn, determines which will be the largest presenting diameter and
• When this diameter is diminished, the head increases in size at right angles
to this largest presenting diameter

• This change in the shape of the fetal head is possible because;

• the sutures between the bones allow the edges of the bones to override
one another, and because
• the bone edges are thin and pliable.
Moulding of the
fetal skull
• In a normal vertex presentation, the
Occiput lies over the cervical os and
therefore, early in
• After delivery, by examining and
feeling the overriding of the sutures, it
may be possible to determine what
the position of the fetus was during
the labour
Importance of the fetal skull in obstetrics
• The fetal head have certain landmarks which is identifiable on abdominal
palpation and on vaginal examination
• This enable the midwife to make out the size, presentation, position and
state of flexion of the fetal head
• Significance of the sutures and fontanel's in obstetrics:
• Sutures allow bones to overlap or ‘override’ when the head is compressed
• Decreasing the dimensions of the presenting diameters (moulding)
• This allows the head to pass through the pelvic canal more easily
• Useful for identifying the position of the head during labour by the vaginal
assessment
• Means an accessory or substitute head.
• The caput succedaneum is a collection of serous fluid between;
• The aponeurosis (muscle sheath) of the fetal scalp and
• The periosteum (outer covering) of the fetal skull bones
• The fetal scalp is pressed at pressures above 200 mmHg
• This pressure impedes the venous and lymphatic drainage of the fetal scalp within the area of this
ring
• causes an effusion of serous fluid into the subaponeurotic space.
• A caput is present on the heads of all babies born as vertex deliveries and
• starts to reduce in size soon after birth and has
• disappeared within 12 to 24 hours. If, however, the
• labour has been prolonged and difficult, the caput will be excessive and may persist for up to 36
hours.
Caput succedaneum and cephalohaematoma
• At vaginal examinations this caput can easily be felt as a small soft
swelling.
• The labour is prolonged, the caput may become excessive
• It will feel large and harder, and the midwife may mistake it for the
fetal skull and may think that the head has progressed further down
the pelvic canal than it has
• This is a dangerous mistake as the head may not yet be engaged
• The descent of the fetal head should, therefore, always be checked by
both abdominal palpation and vaginal examination in order to obviate
this mistake.
Concepts
• Fetal lie: The relationship of the long axis of the fetus to the long axis
of the uterus, may be longitudinal, transverse or oblique
• Presentation: The part of the fetus which lies over the brim of the
pelvis
• Attitude: The relationship of the fetal parts to one another in utero
• Fetal position: The relationship of the denominator to the brim of the
mother’s pelvis
• Moulding: The shaping of the fetal head as it passes through the birth
canal. The presenting diameter is decreased by the overlapping of the
skull bones at the sutures and fontanelle
Concepts
• Caput succedaneum: An oedematous subcutaneous swelling on the
presenting part of the fetal head caused by pressure during labour
• Cephalohematoma: A swelling on the head caused by bleeding under
the periosteum of the skull, usually the parietal bone/s
Self study: Attitude
Self study: Anatomy of the feta skull
Self study: Diameters
References
• Joan Dippenaar & Dicky da Serra. (2018). Seller’s Midwifery. 3rd
Edition. Landsdowne: Juta and Company Ltd.
• Theron, G. (2017). Maternal Care - Bettercare. Cape Town: EBW.
Retrieved from http://bettercare.co.za/learning-
programmes/maternal-care/