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Shaima Abozeid Arab& Libyan Board
An understanding of the development and anatomy of the female genital tract is important in the practice of obstetrics and gynaecology. Both the urinary and genital systems develop from a common mesodermal ridge , so it is important to remember that congenital anomalies of the genital tract may be associated with congenital anomalies of the urinary tract. This is a reminder and not a comprehensive review of anatomy and embryology.
Anatomy of the female pelvis and fetus relevant to labour
It is difficult to practise perceptive and accurate medicine without a reasonably sound knowledge of the way structures relate to each other , the nature of their nerve and blood supply , and what happens when the area is cut or traumatized.
Is divided into external and internal genitalia.
These are visible on inspection and together with the vagina, serve the function of coitus. The female external genitalia, commonly referred to as the vulva, include the mons pubis, the labia majora and minora , the vestibule, the clitoris and the greater vestibular glands. Structures within the urogenital triangle arise in both sexes from common embryonic origins. In the female these include the vulva and external genitalia.
Mons Pubis This is a fibro fatty cushion lying anterior and superior to the junction of the pubic bones (symphysis pubis). the distribution of which in the female does not extend upward onto the abdominal wall. October 10 . Inferiorly it divides to become continuous with the labium majus on each side of the vulva. It is covered by hair.
and a few specialized apocrine glands and are homologous with the scrotum in the male.Labia Majora These are hair-covered fibro fatty folds that extend from the mons pubis above the perineum below. They have both sweat and sebaceous glands. A rich plexus of veins is present which may rupture with trauma to form a haematoma. In the deepest part of each is a core of fatty tissue continuous with that of the inguinal canal and the fibres of the round ligament end there. October 10 .
In the male. these structures form part of the penile urethra. They contain no hair.Labia Minora The lesser labial folds are enclosed by the labia majora and are smaller and more delicate. They are richly vascular and plentifully supplied with nerve endings. but contain sebaceous glands and a few sweat glands. and become turgid during sexual excitement. Superiorly. They are not well developed before puberty and atrophy after menopause. they divide into two to form the prepuce and frenulum of the clitoris and inferiorly merge to form the fourchette (or posterior ring of the vaginal introitus). October 10 .
October 10 .5-2 cm. It is composed of a vascular plexus (erectile tissue) arranged in a central corpus with two crura. The folds of the labia minora enclose the clitoris. has a highly developed nerve supply and is extremely sensitive. It is covered by the ischiocavernosus muscle while the bulbospongiosus muscle inserts into its root. forming the prepuce above and the frenulum below.5 cm is called the glans. which are attached to the inferior rami of the pubis.Clitoris This is the homologue of the male penis. It measures 1. the terminal 0. the corpora cavernosa.
which must be separated to expose it . It represents the lower part of the embryological urogenital sinus. The proximal two-thirds are lined with stratified transitional epithelium and the distal third by stratified squamous epithelium. for the passage of urine.5 cm below the clitoris. Urethral Meatus The external urinary orifice is 1-1. as do the paired Bartholin glands and Skenes glands. The urethra and vagina open into it. for passing a urinary catheter. It is often covered by the folds of the labia minora. and the cleft between the labia minora. for example.Vestibule This is the area enclosed by the labia majora. The urethra is a membranous tube 3-5 cm long. October 10 .
The vault of the vagina is divided into four fornices. posterior. The mid-vagina is a transverse slit and the lower portion is H shape in the transverse section. anterior and two lateral.The vagina It is a fibro muscular tube which links the uterus to the vestibule. October 10 . It is longer in the posterior wall around 9 cm than anteriorly approximately 7 cm. The vaginal walls are normally in apposition except at the vault where they are separated by the cervix.
Its muscles fuse with the anterior vaginal wall. the vagina is related. Laterally .The upper posterior vaginal wall forms the anterior peritoneal reflection of the pouch of Douglas. at the fornices . October 10 .the lip of the vagina is in contact with the base of the bladder while the urethra runs down the midline to open to the vestibule. The middle third is separated from the rectum by pelvic fascia and the lower third abuts the perineal body. to the attachment at the cardinal ligaments. Anteriorly .
October 10 . The cardinal ligaments and the uterosacral ligaments which form posteriorly from the parametrium . the vagina is under the influence of maternal oestrogens so the epithelium is well developed.Below this are the levator ani muscles and the ischiorectal fossa. support the upper part of the vagina and the ischiorectal fossa. At puberty the reverse occurs and finally at the menopause the vagina tends to shrink and the epithelium atrophies. After a couple of weeks the effects of the oestrogens disappear and the pH rises to 7 and the epithelium atrophies. Age changes At birth.
Uterus This is the centrepiece of the reproductive apparatus. a barrier and a reservoir. and (2)-an upper body.which functions as a passageway.5 cm and the length of the cavity is 5-6 cm in the mature woman. It has two functional elements: (1).a lower cervix. October 10 . The uterus measures 7.5x 5x2. in which the fetus develops.
Premature bearing down in labour may seriously damage and weaken these ligaments causing uterine prolapse.Cervix There is a vaginal and supravaginal component. The cervix is 2-3 cm long . uterosacral ligaments posteriorly and the transverse cervical ligaments laterally. and is delineated by the external os inferiorly and the interior os superiorly. October 10 . The cervix is a strong pivotal point for uterine stability being attached to the pelvic walls by pubocervical ligaments anteriorly .
October 10 .The internal os separates the proximal cervix from the uterine body while the external os separates the distal cervix from the vagina. and also the small orifices of the cervical glands. The reddish columnar epithelial lining the endocervix may be seen (exaggerated by ectropion formation). The shape of the external os is spherical pinpoint in a nullipara and transverse (slit-like) in a multipara. When the ducts of the glands are blocked by inflammation small retention cysts form and are obvious as Nabothian follicles.
The lower segment lies at the junction of the uterus and cervix and expands during pregnancy and labour.the larger upper body above the isthmus. October 10 . It is at this loose attachment that the incision is made in the lower segment Caesarean section operation (Bandl ring). (C) Cornu -is the lateral part of the uterine body at the point of entry of the fallopian tubes.The uterine body (A) Corpus. In pregnancy the uterus is usually dextrorotated (rotated to the right side). The uterus is covered externally by peritoneum. except the lower part anteriorly. (B) Isthmus. where the peritoneum is reflected onto the bladder.the transverse constriction between the corpus and the cervix.
Occasionally various duplications and deletions can occur resulting in a variety of uterine congenital anomalies. but flattened in the anteroposterior direction. in more than 50% of women.The uterus is globular in shape. (representing the fused distal portions of the Mullerian ducts). The fallopian tubes (representing the unfused proximal parts of the Mullerian ducts) are continuous with the uterus. In about 20% of women it is rotated backwards lying more in relation to the rectum than the bladder (retroverted) and (retroflexed) (bent backwards on itself).it is both anteverted (rotated forward) and anteflexed (bent forward on itself). The remaining percentages of women have a midposition uterus. October 10 . Normally . It is in this group that the rare complication of incarceration of the uterus occurs in the late first trimester of pregnancy (the uterus is caught in the hollow of the sacrum).
Both are responsive to oestrogen and progesterone. (2)Myometrium (smooth muscle) .Layers (1)Mesometrium (serosa) . During pregnancy under the influence of oestrogen.is the inner lining composed of columnar epithelium and branched tubular glands. lymphatics and nerves and it covers the surface of the uterus.ranging from 0. ready for the task of expelling the fetus in labour. great enlargement of the muscle fibres occurs (10-20 Xs increase in length).050.is the middle muscular layer and is composed of several interlacing layers of smooth muscle. The thickness of the lining depends on the stage of the menstrual cycle. The content of muscle in the cervix is small (10%). (3)Endometrium (mucosa) . October 10 .5 cm.is formed by the peritoneal covering and its associated blood vessels.
is the layer shed during each menstrual cycle. October 10 . and they form the maternal contribution to the placental blood supply. During pregnancy they enlarge especially in the region of the placenta. An additional feature is the typical coiled arteries which are also under hormonal influence. 2-Zona basalis. or Asherman¶s syndrome).The two layers of the inner lining undergo changes during menstruation. (removal of which during over-curettage results in intrauterine adhesions. 1-Zona functionalis. is the layer from which regeneration of the endometrium occurs.
however. These changes affect the cervix more than the corpus. the mucosa becomes very thin. The cervix is then twice the length of the uterus.Age changes The disappearance of maternal oestrogens after birth causes the uterus to decrease in length by around one-third and in weight by about one-half. the corpus grows much faster and the size ratio reverses. cervical loops disappear and the external os becomes more or less flush with the vault. After the menopause the uterus atrophies. the glands almost disappear and the wall becomes relatively less muscular. October 10 . At puberty.
Supports and uterine attachments Broad ligaments ±are folds of peritoneum that extend between the uterus and the pelvic organs to the lateral pelvic walls. October 10 . The embryological importance of the Wolffian duct remnants is that they may become cystic and enlarge (Gartner¶s cyst). vessels and nerves and embryological remnants related to the Wolffian ducts. Uterine perforation or rupture may occur into the broad ligament. The tissue adjacent to the uterus in the broad ligament is called the parametrium. and similarly an ectopic pregnancy may rupture downwards into it. its importance is that it represents one of the pathways in the spread of uterine infection (parametritis). and the remainder delicate areolar tissue. In the upper part lie the round ligament and the fallopian tubes and at the base the uterine vessels and ureter.
Cardinal ligaments ±are condensations of subserous fascia that extend from the uterus to the lateral pelvic walls. and providing support for the middle and upper thirds of the vagina and cervix. and extend from the fundus to the pelvic walls and into the inguinal canal. when they enlarge markedly.Round ligaments . the round ligament syndrome. The round ligaments provide some anterior support for the uterus. Functions include containing the uterine blood supply and ureter. October 10 .are continuous with the ovarian ligaments. Uterosacral ligaments ² are condensations of fascia that extend from the sacrum around the rectum to the cervix. representing an embryonic structure called the gubernaculum. especially during pregnancy. Stretching may cause pain. Uterovesical ligaments ² are connective tissue attaching the bladder to the lower uterine segment.
Lymphatic drainage (1)-Aortic (2)-Lumbar (3)-Internal iliac lymph nodes Nerve supply This passes through the uterosacral ligament. Afferent pain fibres (T11-12) cause referred pain from the uterus to the lower abdomen. October 10 . Sympathetic innervation arises from the hypogastric and ovarian plexus. Parasympathetic innervation from the pelvic nerves(S2-4).Blood supply of the uterus (1)-Uterine artery (2)-Ovarian artery and an anastomosis between them.
Parts of the fallopian tubes: 1.1 cm segment that penetrates the myometrial wall into the uterine cavity.Isthmus ± is the narrow proximal end with simple mucosal folds and a thick muscular wall. Laterally they are attached to the pelvic side wall (infundibulopelvic ligament).Interstitial.Fallopian tubes These are 10-14 cm long and their function is indicated by their other name (oviduct) that is to transfer the fertilized ovum to the uterus.Infundibular ± is the distal segment that terminates in mobile tentacle-like fimbriae that become turgid at ovulation entrapping the ovum. Attachments Medially they are attached to the uterine cornu. 4. 3. 2. The mesosalphinx attaches the oviducts to the broad ligament. October 10 .Ampullary ± is the relatively dilated lateral half of the tube with a wide lumen and complex mucosal folds.
(1)-Serosa is derived from the visceral peritoneal folds of the broad ligament. (B) -Transport the fertilized ovum toward the uterus.Layers -vary in size and thickness. Function (A) -Facilitate sperm migration from the uterus to the ampulla to fertilize the ovum. Partial obstruction of the lumen whether congenital or acquired or delay in transport of the fertilized ovum for other reasons may result in an ectopic pregnancy. October 10 . (2)-Loose adventia contains lymphatics and blood vessels. (3)-Smooth muscles are mixed among the outer longitudinal and inner circular layers and spiral bands. (4)-Lamina propria is composed of vascular connective tissue elements. Blood supply Through the mesosalphinx from the ascending uterine artery and ovarian artery. Cilia beat in the direction of the uterus. (5)-Ciliated columnar epithelium produces tubal fluid and secretions that nourish the dividing blastocyst.
Each ovary is almond shaped and measures 2-4 cm in length. which anatomise with the uterine arteries in the mesosalphinx. They are attached medially to the uterine fundus by the ovarian ligaments. Its functions are production of ova during the woman¶s reproductive years and the secretion of the key hormones during the early months of pregnancy. The mesovarium attaches the ovaries to the broad ligament. Venous drainage ± ovarian veins drain on the left to the left renal vein and to the right to the inferior vena cava. and laterally to the pelvic side wall by the suspensory ligament. Blood supply Ovarian arteries (from the aorta).aortic lymph nodes. Lymphatic drainage ±through the infundibulopelvic ligaments to the pelvic and para. October 10 .Ovaries They are paired structures which are situated on the back of the broad ligaments attached by a mesentery (mesovarium).
which stretches from the pubis to the cervix. with only a thin layer of connective tissue intervening. The ureters open into the base of the bladder after running medially for about 1 cm through the vesical wall. October 10 .The bladder The average capacity of the bladder is 400 ml. a middle circular layer and an outer longitudinal layer. It is separated from the anterior vaginal wall below the pubocervical fascia. The upper part of the urethra is mobile but the lower part relatively fixed. The base of the bladder is related to the cervix. lined with transitional epithelium. The bladder is lined with transitional epithelium. The urethra It is about 3. The urethra leaves the bladder in front of the ureteric orifices. The smooth muscle is arranged in outer longitudinal and inner circular layers. The involuntary muscle of its wall is arranged in an inner longitudinal layer. the triangular area lying between the ureteric orifices and the internal meatus is known as the trigone.5 cm long .
it runs close to the lateral vaginal fornix to enter the trigone of the bladder. Finally. in the upper part of the cardinal ligament. the uterine artery and the vesical arteries. to pass beneath the uterine artery.Ureters They cross the lateral pelvic wall at the bifurcation of the internal and external arteries. the ureter may be damaged during hysterectomy. the ureteric canal. attached to the peritoneum of the back of the broad ligament. the vault of the vagina and the uterine artery. passes inwards and forwards. Because of its close relationship to the cervix. October 10 . It then passes through a fibrous tunnel. The ureters are inferior and posterior to the pelvic blood supply and traverse the entire route retroperitoneally. it runs on the lateral pelvic wall. Its blood supply is from branches of the ovarian artery.
Lateral to the rectum are the two uterosacral ligaments. Its direction follows the curve of the sacrum and is about 11 cm long.5 cm in front of the coccyx. Its direction follows the curve of the. In the lower third there is no peritoneal covering and the rectum is separated from the posterior wall of the vagina by the rectovaginal septum. where the introitus is enlarged to facilitate the birth of the baby or where lacerations can occur. October 10 . in the middle third only the front is covered by the peritoneum. It is the area that is incised in the operation of episiotomy. The front and sides of the upper third are covered by peritoneum of the rectovaginal pouch. where it passes through the pelvic floor to become continuous with the anal canal. beside which run some of the lymphatics draining the cervix and the vagina. Perineum It is outlined by the vaginal fourchette anteriorly and the anus posteriorly. Deep to it is the perineal body which lies between the anal canal and the lower one third of the posterior vaginal wall.The rectum The rectum extends from the level of the third sacral vertebra to a point about 2.
It inserts into the pre-anal raphe. It arises from the lower part of the body of the pubis. October 10 . where its fibres join the external sphincter muscle. The main muscle is the levator ani which forms the floor of the pelvis and roof of the perineum. and vagina which all pass through it. rectum. the postanal raphe and the lower part of the coccyx. The pubococcygeus is the most significant component of the levator ani and has attachments to the urethra. and the pelvic surface of the ischial spine.Pelvic diaphragm This muscular layer forms the inferior border of the abdominal-pelvic cavity and extends from the pubic bone to the coccyx and between the pelvic walls. Other components include the pubovaginalis muscle. the puborectalis and iliococcygeus muscles. the internal surface of the parietal pelvic fascia along the white line. the wall of the anal canal.
while the pubococcygeus supports the pelvic and abdominal viscera. It is the point of insertion of the superficial perineal muscles and is bounded above by the levator ani muscles where they come into contact in the midline between the posterior vaginal wall and the rectum. including the bladder.Functions of the levator ani include flexing the coccyx and constricting the rectum and vagina. Its apex is at the lower end of the rectovaginal septum. October 10 . The perineal body This is the perineal mass of muscular tissue that lies between the anal canal and the lower third of the vagina. Its base is covered with skin and extends from the fourchette to the anus. at the point where the rectum and posterior vaginal walls come into contact.
October 10 . The sacrum is composed of 5 fused vertebrae. At the sides are the paired hip bones. behind. The fourth bone the coccyx. and this throws its superior border into prominence as the sacral promontory.Skeletomuscular supports Supporting the genitalia are the bony and fibro muscular structures that make up the birth canal. is loosely articulated with the lower border of the sacrum. an important bony landmark for assessing the size of the pelvis. and is directed backwards and downwards. they articulate with the ala of the sacrum forming the sacroiliac joints. its pelvic aspect.pubis. The hip bone is composed of 3 separate elements. especially the antero-posterior diameter. These are joined in front at the symphysis pubis and. providing in part the characteristic curve of the birth canal. ischium and ilium. The bony pelvis This is made up of 4 bones joined together by ligaments.
5 cm and is wider than the anterior-posterior diameter. which is normally 11cm. the arcuate line of the ilium.The pelvis is divided into a true and false pelvis. October 10 . The angle of the inlet is normally 60 degrees to the horizontal in the erect position but in the Afro-Caribbean woman this angle may be 90 degrees. The canal is made up only of the symphysis pubis and is added to the fibro muscular perineal body describes the Curve of Carus. the alae of the sacrum. Pelvic brim The pelvic brim is formed by the superior aspect of the pubic crest. and the sacral promontory. The canal is made up only of the symphysis pubis and is short while posteriorly. there is the sweep of sacrum and the coccyx (11-13 cm). the pectineal line of the pubis. This increased angle may delay the head entering the pelvis in labour. which when added to the fibro muscular perineal body describes the curve of Carus. The normal transverse diameter in this plane is 13. delineated by the iliopectineal line.
Pelvic inclination The lateral view of the pelvis indicates that the pelvic brim makes an angle of 40-50 degrees with the horizontal. It is bounded by the pubic bones anteriorly. The cavity is almost round as the transverse and anterior diameters are similar at 12 cm. October 10 . The ischial spines are important landmarks. being about 30 degrees in the midpelvis and 10 degrees at the outlet. The pelvic axis describes an imaginary line that shows the path that the centre of the fetal head takes during its passage through the pelvis. the curve of the sacrum posteriorly. this is called the angle of inclination. (the second and third pieces of the sacrum) and parts of all 3 components of the hip bone laterally. The ischial spines are prominent in the android pelvis. Pelvic cavity It is the area between the inlet above and the outlet below. but also as a reference point for the station of the presenting part. They are also used as landmarks for providing an anaesthetic block to the pudendal nerve. not only as indicators of the type of pelvis and size. The inclination lessens as the birth canal is descended.
Where the subpubic arch is narrow. as in the android pelvis the angle may be 60-7OÛ. The anteriorposterior diameter of the pelvic outlet is 13. which with their fascia form a musculofascial gutter during the second stage of labour. October 10 . ischial tuberosities. compared with the normal angle of 90Û. The pelvic floor This is formed by the two levator ani muscles.5 cm and the transverse diameter 11 cm. the sacrotuberous ligaments and the coccyx .The pelvic outlet It is outlined by the subpubic arch. the descending ramus of the pubic bone.
The female pelvis It differs from the male pelvis in that. The major obstetric interest in the bony pelvis is that it is not distensible and minor degrees of movement are possible at the symphysis pubis and sacroiliac joints. (3 )-the outlet is wider and the subpubic arch is round while the male subpubic angle is acute. Its dimensions are critical at childbirth. October 10 . (1 )-the female pelvis is wider (2)-the female pelvic brim is transversely oval (less prominent sacral promontory) while the male pelvic brim is heart shaped.
Anthropoid type . narrow and oval.The inlet is heart shaped. 20%) . flattened at the brim with the sacral promontory pushed forwards. (5%) .Four basic types of pelvis have been described.Platypelloid type ±This is a wide flat pelvis.Gynaecoid type ± The classical female pelvis has an oval transverse inlet and a wide pelvic cavity. where the largest diameter is the transverse one.This is long. (2) . This results from high assimilation (the sacral body assimilated on the fifth lumbar vertebra . It is almost round except for the intrusion of the sacral promontory posteriorly. (1 ).Android type . ( 20%) (3) . and the cavity is like a funnel with a contracted outlet . October 10 . (55%) . (4) .
In general. The transverse diameter (13. the mechanism which is adopted by the fetus in passing through the birth canal. (11.5 cm).5 cm) .These differences in pelvic shape are of more than radiological interest. moderately contracted if reduced by 1. and markedly contracted if reduced 2 cm or more.2 cm. but an approximate idea is given by the ( diagonal conjugate). run from the right and left sacroiliac joints to the opposite iliopectineal eminences. The anteroposterior diameter (obstetrical conjugate). since they determine. the pelvis is considered to be mildly contracted if the diameter is reduced 1 cm. from the bottom of the symphysis pubis to the sacral promontory as measured during vaginal examination. The oblique diameters. in large measure.5 cm) is taken as the widest part of the brim. This measurement can only be made accurately by radiography. right and left . respectively. is measured from the back of the symphysis to the tip of the sacral promontory. (12. October 10 .
considerable strain occurs here during pregnancy. although a layer of cartilage remains between them. Symphysis pubis The two pubic bones are joined anteriorly by fibrous tissue. October 10 . Because of the backward inclination of the sacrum. The lumbosacral joint lies between the fifth lumbar vertebra and the sacrum.usually associated with a rapid second stage of labour. partly fibrous and are very strong. Despite this. In about 1 in 750 women there is an abnormal separation of the pubic bones. and the weight of the pregnant uterus is added to that of the head and trunk. In extreme cases (spondylolisthesis). the fifth lumbar vertebra projects downwards into the area of the pelvic brim.The pelvic joints The sacroiliac joints are partly cartilaginous. It is through this cartilage that the operation of symphysiotomy is occasionally carried out to increase pelvic diameters in cases of obstructed labour. pain is often experienced late in pregnancy as joint mobility increases with softening of the ligaments.
however. Ligaments These are well developed in the pelvis because of the stresses to which the pelvic bones are subjected. which is especially noticed on sitting. Together. and the ischial tuberosity. October 10 . giving rise to the condition of coccydynia or pain. overstretch the ligaments.The sacrococcygeal joint is much looser than the others. allowing the coccyx to bend backwards as the fetus passes through the birth canal. the posterior aspect of the pelvic outlet. there are two others of importance. These run from the sacrum to the ischial spine. Undue displacement may. respectively. they form. Apart from the ligaments specifically related to the above joints.the sacrospinous and sacrotuberous ligaments. with the coccyx and the lowest part of the sacrum.
and occupies the space between the inferior borders of the ischiopubic rami and extends posteriorly to the front wall of the rectum. Inability to relax this part of the levator ani at the time of delivery is often responsible for delay in the birth of the baby in the second stage. which is a triangular diaphragm through which the pass the urethra and vagina.The pelvic soft tissues A-The pelvic floor . which comprise the various parts of the levator ani muscles which run on each side from the back of the symphysis pubis around the lateral pelvic wall on the fascia over the obturator internus muscle to the ischial spine and side of the coccyx. together with the puborectalis. The puborectalis is important in maintaining closure of the outlet by drawing the different structures passing through it anteriorly toward the shelf of the symphysis pubis. October 10 . B-The urogenital diaphragm.
On its deep aspect are two sets of muscles. there are the ischiocavernosus muscles. and the deep transverse perinei.the constrictor of the urethra and vagina . decussate and join forming the strong perineal body. Between the vagina and rectum. Superficially. It is in this region that the presenting part is felt as it approaches the pelvic outlet. the sphincter muscles decussate to form the anococcygeal raphe. the superficial perineal muscles. the bulbocavernous muscles. and the Bartholin glands. October 10 . including the anal sphincter. the superficial and deep perineal muscles. Behind the anal canal.
these are separated by sutures and fontanelles and so the cranium is more compressible than the base of the skull.i. THE SKULL The shoulders normally represent the largest fetal diameter but the skull diameters are the more important since the cranium is less compressible.THE FETUS The size.e. the movements that the fetus undergoes during negotiation of the birth canal. 2 parietal. October 10 . 2 temporal bones and 1 occipital bone . position and attitude of the fetus influence the mechanism of birth. The bones of the cranium comprise of 2 frontal.
between the 2 parietal bones. Lamboidal suture. Sagittal suture. Temporal suture. between the temporal and parietal bones. The anterior fontanelle or Bregma. between the frontal and parietal bones. is the large diamond shaped depression at the anterior end of the cranium where frontal. It closes at 18 months of age. The posterior fontanelle. between the occipital bone behind and the parietal and temporal bones in front. coronal and sagittal sutures meet.Landmarks Frontal suture between the 2 frontal bones. Coronal suture. October 10 . It allows moulding in labour and growth of the skull after birth. the posterior fontanelle is a smaller triangular space at the posterior end of the cranium where the sagittal suture meets the lamboidal sutures.
5 cm). This diameter is seen with brow presentation. Sagittal diameters Suboccipito-bregmatic (9.5 cm). Thus deflexion has the effect of increasing the presenting diameter of the fetal head by 20%.e. a face presentation. it cannot negotiate a normal sized pelvis. Submento-bregmatic (9. i. Mentovertical (14 cm).Transverse diameters Bitemporal (8 cm).5 cm). October 10 . the angle between the neck and chin to the centre of the bregma. from the occipital protuberance to the root of the nose. Biparietal (9. between the lower ends of the coronal sutures. from the point of the chin to the centre of the sagittal suture. It is the diameter that presents when the head is flexed. and if the fetal head is of normal size and shape. This diameter presents when the head is partly deflexed (military µ¶eyes front¶¶ attitude). Occipitofrontal (11-12 cm). between the parietal eminences. from the foramen magnum to the centre of the bregma. This diameter is seen when the head is completely extended.
(the top of the skull). October 10 . that part which lies behind the posterior fontanelle.Areas of the skull Vertex . is that part of the head in front of the anterior fontanelle. Occiput: (the back of the head). and the face (the area below the root of the nose and the orbital ridges). is the area between the anterior and posterior fontanelles and the 2 parietal eminences. Sinciput . It is subdivided into the brow (the area between the root of the nose and the anterior fontanelle).
it does not cross the midline. pressure of the cervix on the fetal head impedes venous and lymphatic drainage and a serous effusion collects between the aponeurosis and periosteum to form a caput. The caput disappears within a few hours of birth. i.it is a sign of incoordinate uterine action and is accompanied by excessive moulding when labour is obstructed. It must be distinguished from cephalohaematoma which is a subperiosteal collection of blood. This is most marked when there is slow dilatation of the cervix and when the woman bears down before full dilatation.5 cm). the distance between the tips of the processes. a cephalohaematoma only overlies a single bone.Caput succedaneum and cephalohaematoma During labour. the distance between the outer surfaces of the greater trochanters.usually the parietal.e. The fetal trunk Diameters Bisacromial (12. October 10 . This presents some hours after birth and may enlarge for 12-24 hours. because of the attachments of periosteum to the suture lines.5 cm). Bitrochanteric (9.
Moulding Moulding is due to compression which the head undergoes during its passage through the birth canal. the hard inelastic fetal head characteristic of prolonged pregnancy resists alteration. Moulding occurs relatively easily in the soft head of the premature fetus.The suture lines meet. October 10 . the hard inelastic fetal head characteristic of prolonged pregnancy resists alteration in shape. Grades of moulding Grade 0 ± The suture lines are separate. Size. shape. Rate of cervical dilatation and position of the cervix. Grade 3 -When the sutures overlap and are irreducible with digital pressure. Grade 2 . whereas.If the sutures overlap but can be reduced with gentle digital pressure. There is diminution of those diameters most compressed and compensatory elongation of those least compressed. elasticity and attitude of the fetal head. Size and shape of the maternal pelvis Presentation and position of the head Strength of uterine contractions and duration of labour. The degree and direction of moulding are determined by a number of factors. Grade 1 .
October 10 .
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