menrut Fo 114 Fetal stl showing regions and landmarks of obstetical importance ‘An understanding of the landmarks sents ofthe fetal skull enables the midwife to recognise ‘normal presentations and. positions and to facilitate bith with the least possible trauma to mother and baby. Where malpresentation or disproportion exists she will be able to identify it and take appropriate action. Ossification. The bones ofthe fetal head originate in two different ways, The face is laid down in cartilage and is almost completely ossified at birth, the bones being fused together and firm. The bones of the vault ate laid down in membrane and are much flater and ‘more pliable. They ossify from the centre outwards and this process is incomplete at birth leaving small gaps, hich form the sutures and fontanelles. The ossification ‘entre on each bone appeats as a boss or protuberance. and measure- Bones of the vault (Fig. 11.6) ‘There are five main bones in the vault ofthe fetal skull. ‘The occipital bone. ‘This lies at the back of the head and forms the region of the occiput. Part of it con Uwibutes to the base of the skull as it contains the fora ten magnum, which protects the spinal cord asit leaves the kal. At the centre isthe occipital protuberance. Fig. 115 Comparison ofa baby’s proportions to those of fan adult. The baby’s head is wider than the shoulders ang ‘one-quarter ofthe total lengthnan ANATOMY Al ro Fo 16 ie of fetal head from above (nead Party ones. These lie on either side of parca raat tre of each is called the the shu. The ossification cent pica! “Tre we frontal bones. These form the forehead oF ee the ent of ech 2 fontal boss or frontal vrrsence The frontal bones fuse into a single bone Py 8 years of age Tr addition wo thes ive the upper part ofthe tempo- al hone is also flat and forms a small part ofthe vault sutures and fontanelles Sotutes are cranial joints and are formed where wo tones adjoin, Where two or more sutures meet, 2 fomanelle is formed. There are several sutures and fontaneles in the fetal skull (See Fig, 11.6); those of ‘mont obstetrical significance ae described below. ‘The lambdoidal suture. This suture separates the ‘occipital bone from the two parietal bones. ‘The sagittal suture. This lies between the two parietal bones ‘The coronal suture. This separates the frontal bones fom te pial bones aig fo one empl 0 the other ‘The frontal suture. ‘This runs between the two halves cf the fiontal bone. Whereas the frontal suture becomes obliterated in time, the other sutures eventually WN REPRODUCTION flexed), showing bones, sutures and fontanelies, 0c porter, Pontos fou Patt eminence become fixed joints. Ossification of the shul complete until early adulthood, ‘The posterior fontanelle or lambda junction of the lambdoidal and sagittal su small, triangular in shape and can be vaginally because a suture leaves from each three angles. It normally closes by 6 weeks of ‘The anterior fontanelle or bregma. Tis is ‘at the junction of the sagittal, coronal and sutures, It is broad, kite shaped and vaginally because a suture leaves from each four comers. It measures 3~4 cm long and 1: ‘wide and normally closes by the time the 18 months old. Pulsations of cerebral vessels felt through it ‘The sutures and fontanelles, because they membranous spaces, allow fora degree of of the skull bones during labour and deliver Regions and landmarks of the fetal skull ‘The sul is divided into the vault, the base face (Fig. 11.7). The taule is the large, part above an imaginary line drawn tbital idges and the nape of the neck. Inthe ‘and pliable at bithRegions of the skull showing the large, Pressible face and 17 ese vault and the non-comy oe sows the Shull toate slightly in shape during birth ‘he he is comprised of bones that ate firmly united so protect the vital centes in the medulla, The jae Tommposed of 14 small bones, which are also united and non-compressible. The regions of th are described as follows: ‘The occiput. This region lies between the foramen ‘magnum and the posterior fontanelle. The pant below, the octal protuberance is known a8 the subvcpital regin. The protuberance itself can be seen and felt ay a prominent point on the posterior aspect ofthe skull The vertex. This is bounded by the posterior fontanelle, the two parietal eminences and the ante. ‘ior fontanelle. Of the 96% of the babies born head fis, 954 present by the verte. ‘The sinciput or brow. This extends from the ante- rior fontanelle and the coronal suture to the orbital fides ‘The face. The face is small in the newborn baby. It cxends from the orbital ridges and the root of the nose to the junction of the chin and the neck. The point between the eyebrows is known as the glabella The chin is termed the mentum and is an important landmar firmly e skull Diameters of the fetal skull ‘The measurements of the skull are important because the midwife needs a practical understanding of the ‘elationship between the fetal head and the mother’s ke Fig. 11.8 diag ram showing the transverse diameters of the feta skull See Pelvis. It will become clear that some diameters are ‘more favourable than others for easy passage through the pelvic canal and this will depend on the attitude of the head, ‘There are two transverse diameters (Fig 11.8) Biparietal diameter. ‘This is 9.5 cm - the diameter between the two parietal eminences. Bitemporal diameter. This is 8.2 cm - the diameter between the furthest points ofthe coronal suture at the temples, ‘The remaining diameters described are anteroposterior orlongiudinal (Fig 11.9) Suboccipitobregmatic. This is 9.5 cm ~ the diame- ter from below the occipital protuberance wo the entre ofthe anterior fontanelle or bregma Suboccipitofrontal. This is 10 em ~ the diameter fiom below the occipital protuberance tothe centre of the frontal suture. Oceipitofrontal, This is 11 5m ~ the diameter from the occipital protuberance to the label. Mentoverical. Thisis 13.5 em - the dlamete fom the point ofthe chin to the highest point onthe vertex, slighty nearer to the posterior than to the anterior fontanlle Submentovertical, This is 11.5 cm ~ the diameter “from the point where the chin joins the neck to the highest point onthe vertexr WUMAN ANATOMY AND REPRODUCTION a fog 119 Diagram showing the anteroposterior diameters of the fetal kul. “ Length Soe ssbocoptobregmatic Sem Sot 2 Suboceptorontal 100cm SF bepteronal ihsem tv memoverical 135em Sty = Rlbmentvertcal iiSem Site submentsbeegmatic 35cm Submentobregiatic. Ths is 9.5 em ~ the diameter ‘om the point where the chin joins the neck to the centre ofthe bregma ‘Attitude of the fetal head Tis term is used to describe the degree of flexion or ‘extension of the head on the neck. The attitude of the head determines which diameter labour and therefore influences the py”! rg "come Presenting diamete the diameters of the head, which are ¢ senting diameters, ate those that are yal he the curve of Carus, There ate always posterior oF longitudinal diameter aq diameter. The diameters presentin 2m inthe cephalic or head presentations areas Vertex presentation. When the hea. the suboccipitobregmatic diameter an diameter present (Fig. 11.10). As th ate the same length, 9.5 cm, the prese ‘cular, which is the most favourable shape a the cervix. The diameter that distends onic isthe subocciptoontal diameter, When the head isnot flexed but ere they diameters are the occptofional, 11.5 em biparietal, 9.5 cm. Ths situation often arse oxciput is in a posterior poston. ft remain diameter distending the vaginal once wit occipitofrontal, 11.5 cm Brow presentation. When the head is extended, the mentovertical diameter, 13.5 cma bitemporal diameter, 8.2 cm, present. hie tion persists, vaginal delivery is extremely uni Face presentation. When the head is co extended, the presenting diameters are thes bregmatic, 95cm, and the bitemporal, 82¢m, submentovertical diameter, 11.5 cm, will ditend vaginal orifice rel 1d the bi, SE (Wo di‘ox 11.2 Diameters of the fetal trunk alin pisacromial diameter 12 em ‘hiss the distance between the acromion processes on the two shoulder blades and isthe «dimension that needs to pass through the peive forthe shoulders to be born The articulator oy the clavicles on the sternum allows forward movement of the shoulders, which may reduce the diameter slighty, i Bitrochanteric diameter 10 cm ‘This is measured between the greater uochanters ofthe femurs andistheppresenting iameter in breech presentation, Diameters of the fetal trunk are given in Box 11.2 | Moulding “This is the term applied to the change in shape of the feral head that takes place during its passage through thebirh canal Alteration in shape is possible because _thebones of the vault allow a slight degree of bending andthe skull bones are able to override atthe sutures, This overriding allows a considerable reduction in the size of the presenting diameters while the diameter at tight angles to them is able to lengthen owing to the give ofthe skull bones (Fig. 11.11). In a normal vertex presentation with the fetal head ina fully Nexed attitude the suboccipitobregmatic and the biparietal diameters will be reduced and the “mentovertcal will be lengthened, The shortening may be by as much as 1.25 cm (Figs 11.12-11.17 illustrate ‘moulding in various presentations). Moulding is a protective mechanism and prevents the fetal brain from being compressed as long as it is ‘ot excessive, too rapid or in an unfavourable direc- tion. The skull of the preterm infant, being softer and having wider sutures, may mould excessively; the skull of the post-ierm infant does not mould well and its sreater hardness tends to make labour more difficult. The intracranial membranes and Sinuses (Figs 11.18 and 11.19) : ‘The skull contains delicate struct Fs Glatt Demonstration of the principle of moulding. Thx diameter compressed is diminished: the diameter at Fight angles to it i elongated. associated with them, These membranes are contin (ous with the dura mater that lines the cranium. ‘The falx cerebri. This is a sickleshaped fold of membrane that dips down between the two cerebral ‘hemispheres and runs beneath the frontal and sagittal sutures, from the root of the nose to the internal ‘occipital protuberance ‘The tentorium cerebell, This is a horizontal fold of dura mater that lies inthe posterior part of the skull AK right angles to the fax cereri Its shaped like a horseshoe and situated between the cerebrum and the cerebellum, over which it forms a sort of tent. The ‘membranes contain large veins or sinuses that drain blood from the bran, ‘may be damaged ifthe head is subjected to abnormal ‘moulding during delivery. Among the most important ate the folds of dura mater and the venous sinuses Fig. 1.12. Moulding in a normal vertex presentation with ‘the head wel flexed. The suboccipitobregmatic diameter is reduced and the mentovertcal elongated.MAN ANATOMY AM erm ‘ ; Y a fig, 11.4 Vertex FiBA135 Vere F910 Eat sentation head resentation te os partially flexed. deflexed, Fig. 11.17 Brow presentation, Fig, 11.16 Face presentation, Figs 11.13-11.17 Series of diagrams showing moulding when the head presents. Moulding is shown by tPra mater wo tyes of "Sra meter THE FET _ Superior sagittal Inferior sagittal gg. 1149 Coronal section through the fetal head to show intracranial membranes and venous sinuses. jor sagittal sinus. This runs along the a pete fax cere from front to back rr inferior sagittal sinus. This runs along the owes edge ofthe fbx cerebr in the same direction, pe reat cerebral vein of Galen. This meets the infenotsagital sinus atthe inner end of the junction terween te falx and the tentorium. he straight sinus. This drains blood from both the gx cera vein and the inferior sagital sinus along ge jnaion of the falx and the tentorium. The point where it reaches the skull and receives blood from the superior sagittal sinus is known as the confluence of sinuses. ‘The two lateral sinuses. These pass from the conflu- cence of sinuses along the outer edge of the tentorium cerebelli and carry blood to the internal jugular veins. ‘The most vulnerable point of these structures is where the falx is attached to the tentorium. The tento- rium is liable to tear and there is a danger of bleeding from the great cerebral vein, REFERENCE Johnson M H, Everitt B J 2000 Essential reproduction, ‘sth ed Blackwell Science, Oxford