CONTENT 1:

Pathophysiology and mechanism of labour

THE FETUS:
FETAL SKULL AND ITS
SIGNIFICANCE IN LABOUR
ROZIAH ARABI
Module Coordinator
FFFM5024 MODULE 2: INTRAPARTUM
ADVANCED DIPLOMA IN MIDWIFERY 2014/2015

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

1.
2.

3.

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

Composed of:
The base
The face
The vault

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
1.

The bones
Vault are made up of :

2 frontal bones
2 parietal bones
2 temporal bones
1 occipital bone

The two frontal bones

These bones form the forehead
They are roughly square in shape

They cover the frontal lobes of the brain

The two parietal bones

These bones lie behind the frontal bones
On either side of the skull

Roughly square in shape with a bony

eminence at the centre known as the parietal

eminence (the centre of ossification)
The largest of all bones
Cover the parietal lobes
of the brain

THE OCCIPITAL BONE

Is a single piece of bone lying below

the parietal bone at the back of the

head
Is triangular shape with a small
eminence at its centre known as the
Occipital Protuberance
It covers the occipital lobe of the
brain and cerebellum
The lower part forms the margin
of the foramen magnum &
articulates
with the 1st cervical vertebrae

The two temporal bones

Form part of the side walls
Lie below the parietal bones in front of the

ears

The sutures
Sutures are membranous junction between 2 bones
Important because they allow the bones to overlap
Thus reducing the size of the fetal skull and facilitating

delivery

The sutures are:

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
occipital bone
1.

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)
2. Posterior fontanelle (at the back of the vault)

The fontanelles
The anterior fontanelle
Known as the Bregma
large diamond shaped space
At the junction of 4 sutures; the

frontal, coronal and sagittal

About 3-4 cm in length
1.5-2 cm in breadth
Pulsation of cerebral vessels
can be felt through it
If this fontanelle is felt during
VE, means that the fetus is
either in OP position or face to
pubes
Close when the child
is 18 months old

The posterior fontanelle

Known as Lambda
Lies at the junction of the

sagittal and labdoidal

Small and triangular in shape
If this fontanelle is felt during
VE, means that the fetus is in
the OA position
Close when the child is 6
weeks

 These fontanelles are important structures of

fetal skull as they denote the position of the

fetal head

The regions of the fetal skull

Fetal skull is divided into the following regions:
1. The occiput

Area below the lambdoidal sutures and

the posterior fontanelle
2. The vertex

Area between the anterior and posterior

fontanelles and the parietal eminences
laterally
3. The sinciput or brow

Lies between the supra-orbital ridges

below and the anterior fontanelle and
coronal sutures above
4. The face

Lies below the level of the supra-orbital

ridges

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 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

The variation of AP diameters according to the presentation of

the fetus
Presentation

Antero-posterior diameter
(engaging diameter)

Length in cm

1.

Vertex : Occipitoanterior position

Sub-occipito bregmatic

9.5

1.

Vertex : occipitoposterior position

Occipito-frontal

11.5

1.

Face

Submento-bregmatic

9.5

1.

Brow

Mentor-vertical

13.5

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
SOB

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

Sub-occipito frontal diameter runs from below the

occipital protuberance to the centre of the sinciput
3. OF

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)
1.

The descriptions
MV

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

Sub-mento vertical diameter runs from the junction of the

chin and neck to the centre of the vertex
6. SMB

Sub-mento bregmatic diameter runs from the junction of

the chin and neck to the bregma

It is the engaging diameter for face presentation

4.

CIRCUMFERENCE
The important 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.

 Other important diameters to be

learn are:
1. Biparietal

Biparietal diameter extends

between the two pairetal
eminence

It measures 9.5 cm
2. Bitemporal

Bitemporal diameter runs

between the two extremities of
the coronal suture

It measures 8.5 cm
The engaging diameters varies in
length, the shorter diameter are

more favourable for delivery of the

fetal head

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 presentation denominator is sinciput
3.
Face presentation denominator is mentum
4.
Breech presentation denominator is sacrum
5.
Shoulder presentation denominator is
acromium process

There are 5 types of presentation & its

denominator:
Vertex presentation
denominator is occiput
2. Brow presentation
denominator is sinciput
3. Face presentation
denominator is mentum
4. Breech presentation
denominator is sacrum
5. Shoulder presentation
denominator is acromium
process
1.

Vertex presentation
Well flexed head

1.

When the head is well flexed, the sub-occipitobregmatic and the biparietal are the 2 diameters of
the presenting circular area and the circumference is
29 cm

Deflexed head

2.

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 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

Attitude of head
1. Well flexed
2. Deflexed
3. Partial Eextension

29 cm

Shape of
circumference
Round

34.5 cm

Ovoid

38 cm

Round

circumference

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-occipitobregmatic (9.5cm)
the circumference is small and circular in shape

Significant to labour:
The girdle 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

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

Significant to labour:
The girdle 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 of the
fetal prolonged labour

3. Extension

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

4. Partial extension

If the attitude of the fetal head is one of

partial extension
The presentation will be brow
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
skull is 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.

Keywords to remember!
1. Presentation
2. Position

3. Engaging diameter
4. Girdle of contact

5. Stimulation
6. Uterine contraction
7. Type of labour and delivery

Thats all.

THANK YOU VERY MUCH FOR YOUR

ATTENTION