FETAL SKULL AND MATERNAL

PELVIS

Dr Madhavi Karki
Landmark of Fetal skull
 Occiput:- is the occipital bone/external occipital protuberance.
 Sinciput:- is the forehead region of fetal head.
 Parietal eminences:- are the eminences of parietal bone on
either side.
 Mentum:- is the chin.
 Vertical point:- is the center of sagittal suture.
 Frontal point:- is the root of nose.
 Sub occiput:- it is the junction fetal neck and Occiput.
 Sub mentum:- it is the junction between neck and chin.
 Bi parietal:- is the transverse distance between two parietal
eminences.
 Bi temporal :- is the distance between two lower end of
coronal suture
SUTURES :

• This lies in between two parietal

Sagittal suture:- bone.

• This lies in between the frontal

Coronal suture:- and parietal bone on either side.

• This lies in between two frontal

Frontal suture:- bone.

• It lies in between the parietal and

Lambdoid suture:- occipital bone on either side.
CLINICAL IMPORTANCE OF SUTURE:-

These suture permit gliding movement of one bone over other during moulding
of the head in the vertex presentation , as a result the diameter of the head get
smaller so passage of head through the birth canal become easier.

Position of fontanelle and sagittal suture can identify attitude and position of
vertex.

From the digital palpation of the sagittal suture during labour, degree of
internal rotation and degree of moulding of the head can be noticed.

In deep transverse arrest, this sagittal suture lies transversely at the level of the
ischial spines.
 • It is the quadrangular area bounded anteriorly by the
bregma and coronal sutures behind by the lambda and the
A. lambdoid sutures and laterally by the line passing through
Vertex:- the parietal eminences.

• It is an area bounded on one side by the anterior fontanelle

and the coronal sutures and on the other side by the root of
B. Brow:- the nose and supra-orbital ridges of the either side.

• It is an area bounded on one side by the root of the nose and

the supra-orbital ridges and on the other by the junction of
C. Face:- the floor of mouth with neck.
Anterior fontanelle or bregma:-

It is a diamond shaped area of unossified membrane formed by the

junction of 4 suture.
The suture are:-
Anteriorly:- frontal suture
Posteriorly:- sagittal suture
Laterally, on both side:-coronal suture.
It is felt on fetal head surface as a soft shallow depression.
It ossifies by 18 months after birth.

Clinical importance:-
1. Degree of flexion can be assessed from its position. If on vaginal
examination it is felt easily, it indicates the head is not well flexed.
2. It helps in the moulding of head.
3. From its position, internal rotation of the head can be assessed.
4. ICP can be roughly assessed from its condition after birth. Depression
in dehydration and bulging in raised ICP.
5. CSF can be collected from its lateral angles from the lateral ventricles.
Posterior fontanelle or lambda:-

It is the triangular depressed area at the junction of the three suture.
The suture are:-
Anteriorly:-sagittal suture
Posteriorly:-2 lambdoid sutures at both side.
It ossifies as term.

Clinical importance:-
1. From its relation of the maternal pelvis, position of vertex is
determined.
2. Internal rotation can be assessed from its location.
3. Degree of flexion can be assessed from its position. On vaginal
examination if it is felt easily and anterior fontanelle is not felt, this
indicates good flexion of the fetal head.
Diameter of skull

The engaging diameter of the fetal

skull depends on the degree of the
flexion of the presenting part.

A. The antero-posterior diameter

which may be engaged are:-

1.Sub-occipito bregmatic:-

It extends from the nape of the neck

to the centre of anterior fontanelle.
Length:-9.5cm
Attitude:-complete flexion
Presentation:-Vertex.

Clinical importance:-
Smallest diameter.
2.Suboccipito
frontal:-

It extends from
the nape of the
neck to root of
nose.
Length:-10cm
Attitude:-
Incomplete
flexion.
Presentation:-
Vertex.
3.Occipito-frontal:-
Extends from the
occipital eminence to
the root of the nose
(Glabella).
Length:-11.5cm
Attitude:-Marked
deflexion
Presentation:-vertex

Clinical importance:-
This engaging
diameter may give
rise to prolonged
labour.
4.Mento-vertical:-
It extends from the mid-
point of the chin to the
center of the sagittal
suture.
Length:-14cm
Attitude :- Partial
extension.
Presentation:- Brow

Clinical importance:-
In this engaging
diameter, baby has to be
delivered by caesarean
section.
5.Sub-mento vertical:-
It extends from the
junction of the floor of the
mouth and neck to the
center of the sagittal
suture,
Length:-11.5cm
Attitude: -Incomplete
extension.
Presentation:-Face

Clinical importance:-
In this engaging
diameter, baby has to be
delivered by caesarean
section.
6.Sub-mento
bregmatic:-
It extends from the
junction of the floor of
the mouth and Neck to
the centre of bregma.
Length:-9.5cm
Attitude:-Complete
extension
Presentation:-Face

Clinical importance:-
In this engaging
diameter, baby has to be
delivered by caesarean
section.
B. The transverse diameter are:-

1. Bi parietal diameter:-
It extend between 2 parietal
eminences.
Length:-9.5cm
Attitude:-irrespective of position
of head this diameter always
engages.

2. Bi temporal diameter:-
Distance between the anterior-
inferior ends of the coronal
suture.
Length:- 8.5 cm
FETAL SKULL CHANGES IN LABOUR

Moulding:-It is the
changes in shape of
the head in vertex
presentation during
labour while passing
through the resistant
birth canal.
 Mechanism:-

1. Overlapping of cranial bones at the membranous joints

due to compression of the engaging diameter of the head.

2. It is physiological, harmless and disappears within a few

hours after birth.
 GRADING

Grade 0:- the

Grade +:- the Grade++:- Grade+++:-
bones lies
bone overlapping fixed
side by side
touching but but easily overlapping
having an
not separated by and cannot
intervening
overlapping pressure. be separated.
membrane.
CAPUT SUCCEDANEUM

It is localized area of edema on fetal scalp on vertex presentation due

to pressure effect of dilating cervical ring and vaginal introitus.

Characteristics:-
1. It is physiological, present at birth and disappears within 24 hours.
2. It is soft, diffuse and pits on pressure.
3. No underlying skull bone fracture.
Mechanism:-

Pressure effect of dilated cervical ring and vaginal introitus

on descending head

interference normal venous return and lymphatic

drainage

stagnation of fluid

appearance of swelling in the scalp

Cephalhematoma

It is a collection of blood between periosteum and skull bone which is

limited by the periosteal attachments at the suture lines.

Characteristics:-
Appears after 12 hours of birth.
Limited by suture lines.
Tends to grow larger.
Disappears within 6-8 weeks.
It is circumscribed, soft and non pitting.
May be associated with skull bone fracture.

Treatment:- No treatment required. The blood is absorbed and the

swelling subside.
 DIFFERENCES

CAPUT SUCCEDANEUM CEPHAL HAEMATOMA

1. Present at birth on normal vaginal 1. Appears within a few days after birth
delivery. on normal or forceps delivery.

2. May lie on sutures, not well defined. 2. Well defined by suture, gradually
developing hard edge.

3. Soft, pits on pressure. 3. soft, elastic but does not pits on

pressure.

4. Skin ecchymotic. 4. No skin change.

5. Size largest at birth , gradually 5. Become largest after birth and then
subsides within a day. disappears within 6-8 weeks to few
months.

6. No underlying skull bone fracture. 6. May underlying skull bone fracture.

7. No treatment required. 7. No treatment required.
BONY PELVIS

•Hip bone (Ilium, ischium and

pubis)
•Sacrum
•Coccyx
Joined anteriorly by pubic
symphysis
Posteriorly by sacro -iliac joint
 Female
Bony Pelvis

False pelvis True pelvis

Greater Pelvis (pelvis major)

Also known as false pelvis.

• Anteriorly:- abdominal wall

Postero-laterally:- iliac fossa

• Posteriorly:- L5, S1vertebrae

Lesser Pelvis (pelvis minor)

Also known as True Pelvis.

It is composed of inlet (brim), cavity, and outlet.
Cavity:- formed by the hip bone (pubic bones, ischium,
ilium) and sacrum and consist of pelvic viscera – the
urinary bladder, rectum, uterus and ovaries.
Outlet: diamond-shaped made up of the pubic bones,
ischium, ischial tuberosities, sacrotuberous ligament, and
5th segment of sacrum.
The Pelvic Inlet (Brim):-
Boundaries:-
 Sacral promontory,
 Ala of the sacrum,
 sacroiliac joints,
 iliopectineal lines,
 iliopubic eminencies,
 upper border of the
superior pubic rami,
 pubic tubercles,
 pubic crests and
 upper border of
symphysis pubis.
Measurement of pelvis

Pelvic inlet/ brim:-

A-P diameter:-it is the distance between
mid point of sacral promontory to the mid
point of upper border of pubic symphysis.

Transverse diameter:- distance between

the iliopectineal lines.

Oblique diameter:- distance between one

sacro –iliac joint to opposite ilio-pubic
eminence.
Pelvic outlet:-
A-P diameter:-it is the distance between tip of sacrum to the mid
point of inferior border of pubic symphysis.

Transverse or bispinous diameter:- distance between the tip of

two ischial spine.

Brim Cavity Outlet

Transverse 13 12 10.5
(cm)

Oblique (cm) 12 12 ----

Antero 11 12 11
posterior(cm)