FETAL SKULL AND

MATERNAL PELVIS
Department of Obstetrics and Gynecology
 FETAL SKULL
• The fetal skull is composed of
 Bones of calvarium / Skull vault
( frontal bone ; Right and left parietal bones, occiput and temporal
bones )
 Facial bones
 Base of the skull
 LANDMARKS OF THE
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
• Definition : The membranous junction between two flat bones is
called a suture line.

• The various sutures in the fetal skull are :

 Frontal/ Metopic suture
 Coronal suture
 Sagittal suture
 Lambdoid 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.
It can aid in the diagnosis of asynclitism nd serve as a landmark during application
of forceps.

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.
Areas of skull
• 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
Vert the parietal eminences.
ex:-

B. • It is a quadrangular area bounded on one side by the

Bro anterior fontanelle and the coronal sutures and on the other
w/ side by the root of the nose and supra-orbital ridges of the
sinci either side.
put:
-
• It is a quadrangular area bounded on one side by the root of
C. the nose and the supra-orbital ridges and on the other by
Fac the junction of the floor of mouth with neck.
e:-
 FONTANELLES
• Definition : The membranous junction of three or more bones of
the skull vault is called a fontanelle.
• Fontanelles allow the brain to grow.

• The two significant fontanelle include :

 The anterior fontanelle ( Bregma)
 The posterior fontanelle ( Lambda)
 The anterolateral and posterolateral fontanelle on either side
which have no obstetric significance.
 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.
 POINTS ON THE MIDLINE
OF THE FETAL SKULL
• Sub- Mentum
• Mentum
• Nasion( Glabella) : frontal point
• Bregma - centre of the anterior fontanelle
• Vertical point – centre of the vertex area
• Occiput
• Sub- Occiput
 Diameters 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/below the occipital protuberance
to the centre of anterior
fontanelle/bregma.
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). It is the diameter of
engagement in the occipito-
posterior position; distends the
vulva in face to pubis delivery
and also if the head extends
before crowning.
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/ vertical point.
Length:-13.5cm
Attitude :- Partial extension.
Presentation:- Brow

Clinical importance:-
In this engaging diameter,
baby has to be delivered by
caesarean section as it is
longer than the largest
diameter of the pelvic brim.
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 cm
 TRANSVERSE
DIAMETERS
• Subparieto- supraparietal
Diameter :(9cms)extends from
below one parietal eminence to
above the opposite eminence.It
is the engaging diameter in a
case of asynclitism.
• Bi-mastoid diameter :
(7.5cms). It is between the two
mastoid processes. It is the
incompressible diameter of the
base of the skull.
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++:- Grade+++:-

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

subsides.
 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.
 HUMAN PELVIS
• The female human pelvis is a powerful bony pelvic girdle that
provides protection for the female organs.
• It is adapted for child bearing
• It is derived from the Latin word Basin or Bowl.
• Knowledge of the shape and dimensions of the female pelvis is
essential for a proper understanding of the second stage of labour and
its abnormalities
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)
 PLANES OF THE PELVIS
• There are four planes of Obstetric Importance :
A) Plane of Inlet / Pelvic Brim :
- It extends from the upper border of the symphysis pubis anteriorly
to the sacral promontory posteriorly and along the Brim Walls
laterally.
- The diameters of the inlet are : The Antero- posterior Diameter ,
Transverse diameter and Oblique diameter of the inlet.
 CONJUGATES
• There are three types :
A) Obstetric Conjugate :
- It is the available antero- posterior diameter of the inlet I,e the distance from a
point on the maximum convexity of posterior surface of symphysis pubis to the
middle of the sacral promontory.
- Measures 10.8cms.

B ) Diagonal Conjugate :
- It is the distance from the inferior border of the symphysis pubis to the middle of
the sacral promontory.
- Measures 12.5 cms
- It is measured clinically and subtracting 1.5cms from this gives the true conjugate.

C ) True Conjugate :
- Obtained by subtracting 1.5cms from the Diagonal Conjugate.
 PLANES OF THE PELVIS
B) Plane of greatest pelvic dimension :
- It extends from the middle of the posterior surface of the
symphysis pubis to the junction of the S2 and S3.
- AP diameter measures 13.5cms and transverse diameter measures
12.5cms.
- Importance : Forceps rotation were carried out in this space.
 PLANES OF THE PELVIS
C) Plane of least pelvic dimension :
- Extends from inferior border of pubic symphysis to sacro-coccygeal
junction I,e S4 – S5 junction ; laterally it passes through the ischchial
spines.
- Ap diameter measures 11.5cms; interspinous diameter – 10.5 cms
and posterior sagittal diameter 4.5cms.

D ) Plane of Outlet :
- Extends from inferior border of Symphysis Pubis to tip of Coccyx.
- Consists of two triangles in different planes
 WHAT IS AN ADEQUATE PELVIS ?
The following suggest an adequate pelvis :
• Pelvic Brim is round
• Diagonal conjugate is >or = 11.5cms
• Symphysis Pubis average thickness is parallel to the sacrum
• Sacrum is Hollow with Average inclination
• Pelvic side walls are straight
• Ischial spines are blunt
• Interspinous diameter > or = 10cms
• Sacrosciatic notch : 2.5-3 finger breadths
• Sub-pubic angle is atleast 2 finger breadth
• Antero-posterior diameter of outlet > or = 11cms
• Intertuberous diameter : 4 knuckles (> 8cms)
• Coccyx : mobile
 CLASSIFICATION OF
PELVIS
I. Caldwell Moloy classification
II. Thom’s classification
III. Berman Classification
IV. Abnormal pelvis :
- Negele’s pelvis (ala of sacrum absent on one side)
- Robert’s pelvis ( ala of sacrum absent on both sides)
- Dwarf pelvis
- High assimilation pelvis ( sacrum is composed of 6 vertebrae)
- Low assimilation pelvis ( sacrum is composed of 4 vertebrae)
 CALDWELL MOLLOY
CLASSIFICATION
1. Gynecoid - 50 %
2. Anthropoid – 25 %
3. Android – 20 %
4. Platypelloid - 5 %
5. Intermediate types - Here the first half of the name refers to the
features of the posterior segment and the second hlf of the name
to the anterior segment.
 ISCHIAL SPINE
• Ischial spine is an easily palpable landmark and is useful in clinical
level.
• Significance :
- Narrowest level in pelvic cavity : 10.5cms
- Level of bony attachements of pelvic floor
- - Reference point for station of presenting part- 0 station
- Marks the beginning of the forward curve of the pelvis ; internal
rotation occurs at this plane
- Level of the internal os of cervix
- Level at which pudendal nerve leaves the pelvis
- Site of injection in pudendal block.
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