THE FETUS:FETAL SKULL

AND ITS SIGNIFICANCE IN

LABOUR

Mihai Banacu

UMF CAROL DAVILA, DPT. OF OBSTETRICS AND

GYNECOLOGY
CLINICAL EMERGENCY HOSPITAL SF. PANTELIMON
BUCHAREST
 LEARNING OUTCOMES

At the end of this topic, students will be able to:

1.Describe the regions of the fetal skull
2.Describe the bones that make up the vault of the fetal
skull
3.Describe the sutures and fontanelles
4.Describe the various diameters of the fetal skull and their
significance in labour
 General description of the fetal skull

Ossified from
membranous tissue as
early as 8th week in-
utero
Protects the most vital
organ of the body

Composed of:
1.The base
2.The face
3.The vault
1.The base
Composed of hard bones firmly united that protects
the vital centres in the brain during labour
2.The face
A part of the skull below the supra-orbital ridges
(glabella) to the junction of chin and neck
Compose to 14 rigid bones (ossified from cartilage)
3.The vault
Region above an imaginary line drawn from the orbital
region to the nape of the neck
Formed by 7 pieces of bones which are incompletely
ossified at birth
Separated by sutures and fontanelles - allows the scull to
mould and compress during birth
 The bones

Vault are made up of :

2 frontal bones
2 parietal bones
2 temporal bones
1 occipital bone
 The sutures are:

1.Frontal suture
Runs between the frontal
bones
2.Sagittal suture
Lies between the 2 pieces
of parietal bones
3.Coronal suture
Like a crown running
across the head
Lies between the frontal
and the parietal bones
4.Lambdoidal sututre
Runs obliquely between
the parietal and
 The fontanelles

Fontanelles are membraneous spaces where 2

or more sutures meet
~ membraneous junction of sutures
Out of 6 fontanelles in the fetal skull, only 2
are important
1.Anterior fontanelle (in front of the vault)
=BREGMATIC
2.Posterior fontanelle (at the back of the vault)
=LAMBROID
 The fontanelles

These fontanelles are important structures of fetal skull

as they denote the position of the fetal head
 The 4 regions

Is important because its often referred to in

obstetrics
A midwife should remember these regions
Besides knowing the regions, the attitude of
the fetal skull also a vital
Attitude means the relation of the fetal parts
head, spine and limbs to each other in this
case to fetal skull
 ATTITUDE

The fetal head is capable of a wide range of movements:

1.Well Flexion
The head bends till its chin touches the chest
Vertex presentation
2.Extension
The head bends backwards till it touches the spine
Face presentation
3.Deflexion (militiary attitude)
The head is neither flexed nor extended, straight head
Brow (Facial) presentation
4.Rotation
Circular movement of the head for more than 180 degress
 DIAMETERS

The presenting diameters of the fetal skull are

important because they are the distance which the
birth canal must stretch to allow the head to go
through during delivery

These distances are known as

the antero-posterior(AP) diameters of the
engaging diameters

The AP diameter varies with the degree of flexion

or extension of the head
 Diagram showing the AP
diameters of the fetal skull

KEYWORDS:

Diameter Length
SOB = suboccipitobregmatic 9.5 cm
SOF = suboccipitofrontal 10.0 cm
OF = occipitofrontal 11.5 cm
MV = mentovertical 13.5 cm
SMV = submentovertical 11.5 cm
SMB = submentobregmatic 9.5 cm
 The descriptions

1.SOB (suboccipito bregmatic)

Sub-occipito bregmatic diameter runs from the point below
the occipital protuberance to the centre of the bregma in
vertex presentation
It is the engaging diameter for vertex presentation
2.SOF (suboccipito frontal)
Sub-occipito frontal diameter runs from below the occipital
protuberance to the centre of the sinciput
3.OF (occipito frontal)
Occipito-frontal diameter runs from the occipital
protuberance to the glabella or root of the nose
It is the engaging diameter for occipito-posterior position
(OP)
 The descriptions

4.MV (mentono-vertical)
Mento-vertical diameter runs from the tip of the chin to the
centre of the vertex
The longest diameter of the fetal skull
It is the engaging diameter for brow presentation
5.SMV (submentonovertical)
Sub-mento vertical diameter runs from the junction of the
chin and neck to the centre of the vertex
6.SMB (submentonobregmatic)
Sub-mento bregmatic diameter runs from the junction of the
chin and neck to the bregma
It is the engaging diameter for face presentation
 CIRCUMFERENCE

The importance of knowing about the

cephalic circumferences is because it will
help in understanding why certain
presentation of the fetal head is more
favorable then the others.
 Presentation & Denominator

Presentation is the fetus part that presented at the

brim of pelvis or at the lower segment of the uterus
Denominator is the bone of the presenting part that
shows the fetal position

There are 5 types of presentation & its denominator:

1.Vertex presentation denominator is occiput
2.Brow(facial) presentation denominator is the nose
3.Face presentation denominator is mentum
4.Breech presentation denominator is sacrum
5.Shoulder presentation denominator is acromium process
Diagram showing the AP diameters of the fetal skull
 There are 5 types of presentation & its
denominator:

1. Vertex presentation
denominator is occiput
2. Brow (frontal) presentation
denominator is nose
3. Face presentation
denominator is mentum
4. Breech presentation
denominator is sacrum
5. Shoulder presentation
denominator is acromium
process
 Vertex presentation

1.Well flexed head

When the head is well flexed, the sub-occipito-bregmatic
and the biparietal are the 2 diameters of the presenting
circular area and the circumference is 29 cm
2.Deflexed head
When the head is deflexed, it is erect as in the military
attitude. The engaging diameters are:
i.Occipito-frontal 11.5cm
ii.Biparietal 9.5cm (transversely)
iii.Bitemporal 8.5cm (transversely)
 Brow (frontal) presentation

When partial extension occurs, the

engaging diameter is mento-vertical,
which is 13.5cm
The circumference is 38cm
So the engaging diameter is longer, and
the circumference is also larger
SIGNIFICANCE OF THE FETAL SKULL IN
LABOUR

We will discuss how the attitude of the fetal

head influences labour
1.Complete flexion
If the attitude of the fetal head is complete
flexion
the presentation is vertex the position is occipito-
anterior,
the engaging diameter is the sub-occipito-
bregmatic (9.5cm)
the circumference is small and circular in shape
SIGNIFICANCE OF THE FETAL SKULL IN
LABOUR

The girdle (belt) of contact between the

fetal skull and the cervix is good
Imagine that the cervix is around the fetal
skull
There is equal stimulation and the uterine
contraction will be good
With good uterine contractions, the
mother will have normal delivery
SIGNIFICANCE OF THE FETAL SKULL IN
LABOUR

2.Deflexion
If the attitude of the fetal head is one of
deflexion or deflexed
The presentation is still vertex but the
position will be occipito-posterior
The engaging diameter is the occipito-frontal
(11.5cm)
The circumference is ovoid in shape
SIGNIFICANCE OF THE FETAL SKULL IN
LABOUR
The girdle (belt) of contact between the fetal skull
and the cervix is not good
Imagine that the cervix is also around the fetal
skull
However the girdle of contact between the fetal
skull and the cervix will not be good
There is unequal stimulation and the uterine
contraction and the uterine contractions are not
good - it will be irregular
There will be delay in the engagement =
PROLONGED LABOUR
SIGNIFICANCE OF THE FETAL SKULL IN
LABOUR

3. Extension - face
If the attitude of the fetal head is one of extension,
the presentation will be the face
The engaging diameter is the submento-bregmatic
(9.5 cm)
Same as the engaging diameter for a well
flexed head
However, the face is made up of rigid bones
Rigid bones do not mould like the bones of the vault
This also may results in prolonged labour
SIGNIFICANCE OF THE FETAL SKULL IN
LABOUR

4.Partial extension - BROW

If the attitude of the fetal head is one of
partial extension
The presentation will be brow (frontal)
The engaging diameter is the mento-
vertical (13.5 cm), which is very long
Labour will be obstructed and caesarean
section got to be done
 Bear in mind!
Attitude Significance to delivery

1. Complete flexion Normal labour

2. Deflexion Prolonged labour

3. Extension Prolonged labour

4. Partial Extension Obstructed labour

 Conclusion
Having a good knowledge about the fetal
skullis very important as this will help you
to identify the presentation, the position of
the fetal head and the diameter that is
distending the vagina so that you could
conduct the delivery of the baby with
minimal trauma to the mother and baby.
 K ey points
Normal presentation is with the vertex of the fetal head, and the word
malpresentation describes any non-vertex presentation. It may
be of the face, brow, breech, or some other part of the body if the lie is
oblique or transverse.
Those who are presenting by the brow USUALLY become obstructed,
and those who are lying transversely ALWAYS become obstructed.
Babies presenting by the breech can often deliver vaginally, but there is
a small risk of intrapartum injury. Women whose baby is presenting by
the breech at term should be offered ECV if there is no contraindication.
Babies with a face presentation usually deliver without significant
problems.
The term malposition refers to the situation when the head, coming
vertex first, does not rotate to occipitoanterior, and presents instead as
persistent occipitotransverse or occipitoposterior. It is associated with
prolonged labour and relative cephalopelvic disproportion.
Those presenting by the
breech may be:

(A) extended (or

frank)

(B) Flexed

(C) footling