OSCE

ON
FETAL SKULL
&
MATERNAL
PELVIS
 Q No.1

WHICH ARE THE BONES OF

THE FETAL SKULL?
 Q No.2
WHAT IS ‘VERTEX’ ?
 ‘Vertex’ is the diamond
shaped area bounded by the
midpoints of

• The anterior fontanelle

• The posterior fontanelle

• The parietal eminences on either side

 Q No.3
WHAT IS THE SIGNIFICANCE
OF THE ANTERIOR
FONTANELLE ?
The Anterior Fontanelle

• Can be felt on vaginal examination in

case of deflexion

• Is widely separated in the case of

hydrocephalus

• Helps to identify asynclitism

• Can be utilized for cephalocentesis

 Q No.4

WHAT IS THE SIGNIFICANCE OF

THE POSTERIOR FONTANELLE?
 The Posterior Fontanelle
• Is the only fontanelle palpated in a well
flexed head

• Is used to trace the sagittal suture and

thereby to determine the position and
attitude of the fetal head

• Moulding first occurs at the occipito

parietal junction which can be palpated
adjacent to the fontanelle
 Q No.5

DEFINE ‘ENGAGEMENT’
 The presenting part is said to
be ‘ENGAGED’

• When the largest diameter of the presenting

part has crossed the pelvic brim

• In case of cephalic presentation,

*when the BPD crosses the pelvic brim
*either no pole or 1 pole palpable per abdomen
* head is at ‘0’ station per vaginally
 Q No.6

WHAT IS THE
‘BITEMPORAL’ DIAMETER ?
 Bitemporal diameter is
the distance between the
antero-inferior ends of
the coronal sutures.
•It measures 8cm.
 Q No.7
WHAT IS THE SUPER-SUB
PARIETAL DIAMETER?

WHAT IS THE
SIGNIFICANCE?
 SUPER-SUB PARIETAL
DIAMETER
• Is the distance between a point just
above one parietal eminence to a point
just below the opposite parietal
eminence.

• It measures 8.5 cm.

• Significance: In case of flat pelvis, by

changing asynclitism, the head
negotiates the pelvic brim using this
diameter.
 Q No.8

WHAT IS ‘ASYNCLITISM’ ?
 ‘Asynclitism’ is the tilting of the
sagittal suture in labour
• Towards the symphysis pubis
• Litzman’s Obliquity
• Posterior parietal bone
presenting

OR
• Towards the sacral promontory
• Naegele’s Obliquity
• Anterior parietal bone
presenting

•A certain amount occurs even in normal labour & is transient.

•If posterior parietal bone presentation persists, vaginal delivery is
impossible.
 Q No.9
WHICH ARE THE DIAMETERS OF
ENGAGEMENT OF THE FETAL
SKULL ACCORDING TO THE
ATTITUDE?
 Q No.10

WHAT IS ‘MOULDING’ ?
 Moulding

• The intra-partum ‘sliding’ & ‘shifting’ of

the fetal cranial bones over one another
so as to accommodate the fetal skull
according to the size and shape of the
maternal pelvis.

• Made possible by the thin layers of

fibrous tissue connecting the skull bones.
 Q No.11
WHAT IS THE ‘POINT OF
CRANIAL FLEXION’ OR THE
‘PIVOT POINT’ ?

WHAT IS ITS
SIGNIFICANCE?
 Pivot Point
• Is a point on the sagittal suture
*3cm anterior to the midpoint
of the posterior fontanelle or
*6cm posterior to the midpoint
of the anterior fontanelle.

• The flexion of the head is well

maintained, it is neither twisted
obliquely nor extended when traction
is applied exactly over this point.
When correctly applied, the edge of the
standard vacuum cup (6 cm) lies
approximately 2 finger breadth behind
the centre of the anterior fontanelle.
Hence this is the reference point AFTER
the application of the cup.

If applied posteriorly, extension occurs.

If applied asymmetrically, asynclitism
develops.
 Q No.12

WHAT IS THE RELATION OF THE

FORCEPS BLADES TO THE FETAL
HEAD WHEN CORRECTLY APPLIED ?
• Long axis of the blades will correspond to
the occipito-mental diameter.

• BPD will occupy the widest distance

between the two blades (7.5 cm).

• The max. compression caused by the

blades is 4mm.(the remaining diameter of
the head is accommodated by the
fenestrations of the two blades).
 Q No.13

HOW DO YOU HOLD THE

FETAL HEAD FOR
MANUAL ROTATION?
Manual Rotation

For the more common ROP,

the right hand grasps the sinciput,
the head is pushed up to
disimpact it and increase flexion.
The forefinger is placed on the
frontal suture acting as a marker ,
and the hand is supinated to
accomplish rotation. There is no
need to change the grip of the
hand during rotation or after. The
hand is held like this itself and the
forceps blades can be applied.
 Q No.14

WHAT IS THE ANGLE OF

PELVIC INCLINATION ?
 It is the
angle
formed
between the
superior
strait of the
pelvis & the
vertical axis
of the
vertebral
column. It is
135°.
 Q No.15
MENTION A FEW
CONDITIONS IN WHICH THE
ANGLE OF PELVIC
INCLINATION IS INCREASED.
1. Extreme lordosis

2. High assimilation pelvis

3. Spondylolisthesis
 Q No.16

HOW DOES AN INCREASE IN THE

ANGLE OF PELVIC INCLINATION
AFFECT LABOUR?
1. Abnormal presentation

2. Mobile head and its

complications
 Q No.17
WHAT ARE THE COMMON
CAUSES OF MOBILE HEAD AT
TERM IN RELATION TO THE
BONY PELVIS?
 Mobile Head

i. Contracted pelvis
ii. Flat pelvis
iii. False promontory
iv. Spondylolisthesis
v. High assimilation pelvis
vi. Asymmetric pelvis
vii. Anthropoid pelvis
 Q No.18
DEFINE ‘SACRO-COTYLOID’
DIAMETER.
• It is the distance from the
midpoint of the sacral
promontory to the ilio-pubic
eminence.

• It measures 9.5 cm.

 Q No.19

WHAT IS THE SIGNIFICANCE OF

THE SACROCOTYLOID
DIAMETER?
i. In ROP, the BPD falls on the
sacrocotyloid diameter.

ii. It is also a diameter for

engagement in the flat pelvis.

iii. In the case of an asymmetric

pelvis (as in the case of post-
polio residual paralysis), the
BPD of the fetal head may
accommodate itself in the SC
diameter of the affected side.
 Q No.20

INTRA PARTUM ASSESSMENT OF

THE PELVIS IS VERY IMPORTANT IN
CASE OF HIGH ASSIMILATION
PELVIS AND LOW KYPHOSIS. WHY?
In both of these situations, the
lower end of the sacrum is
pushed forwards. So the AP
diameter of the outlet is
decreased.

Hence the head engages, though

the outlet may still be
inadequate.
 Q No.21
WHICH ARE THE CONDITIONS
WHERE THE HEAD APPEARS TO
BE AT ‘0’ STATION BUT THE BPD
IS ACTUALLY HIGHER?
 False ‘0’

• Asynclitism

• Occipito-posterior

• Deflexed head
 Q No.22
HOW CAN THE ACTUAL
LEVEL OF THE HEAD BE
THEN CONFIRMED?
• Clinically – By bimanual palpation

• Definitive – By USS. Place the

transducer suprapubically
 Q No.23

DEFINE
‘WASTE SPACE OF
MORRIS’ .
Waste Space of Morris
• When the
anterior half of
the pelvis is
beaked, the fetal
head cannot
utilise the
anterior space to
descent into the
pelvis.

• Here, the
available
conjugate is less
than the true
conjugate.
 Q No.24
HOW IS ‘WASTE SPACE OF
MORRIS’ DIAGNOSED?
• On pelvic examination, the
anterior half of the pelvis
appears beaked with narrow
sub-pubic angle (<85°)

• Pelvis is usually android

• Lateral X-ray pelvis

 Q No.25
WHAT ARE THE
COMPLICATIONS
ASSOCIATED WITH ANDROID
PELVIS?
 Android Pelvis Complications

• Occipito Posterior & its complications

• Prolonged labour

• Incomplete rotation & DTA

• Perineal injuries, as head is pushed

posteriorly
 Q No.26

PERINEAL INJURIES ARE MORE

COMMON IN FACE-TO-PUBIS
DELIVERIES AND ANDROID
PELVIS – WHY ?
In these two situations the BPD of
the bony portion of the head distend
the perineum rather than the
bitemporal diameter.

In addition, since the anterior portion

of the pelvis is not utilised in an
android pelvis the head as such is
pushed posteriorly
 Q No.27
WHAT IS THE BASIS OF THE
LOVSET’S MANOEUVRE IN
RELATION TO THE BONY
PELVIS?
I. Post. Shoulder is always at a lower level
than the anterior shoulder due to
*angle of pelvic inclination
*Curve of Carus / obstetric axis

II. Difference in height between the

symphysis pubis and the sacrum
*ht of pubis – 5cm
*ht of sacrum – 10 cm

Hence, when the post shoulder is

rotated anteriorly , it will come to lie
below the lower border of symphysis.
 Q No.28

WHAT IS THE BASIS OF

WOOD’S CORKSCREW
MANOEUVRE?
 Wood’s Manoeuvre

• The same principle as in

Lovset’s manoeuvre applies
here as well.
 Q No.29
WHAT IS THE BASIS OF
McROBERT’S MANOEUVRE ?
 Mc Robert’s - Basis
• Abduction & flexion of the thighs cause
upward gliding of the sacro-iliac joint &
increase the AP diameter of the outlet of
pelvis by 2 cm.

• It rotates the pelvis cephalad and

dislodges the impacted anterior shoulder

Along with this, suprapubic

pressure is given to reduce the
bisacromial diameter.
 Q No.30

WHY IS VAGINAL DELIVERY

NOT POSSIBLE IN
PERSISTENT MENTO-
POSTERIOR POSITION ?
 The length of the
fetal neck is approx.
7 cm, while the total
ht of the sacrum is
10 cm. Hence to
reach the tip of the
sacrum, a portion of
the chest is also
pushed into the
pelvis. This can lead
to obstructed labour .
 Q No.31
WHAT ARE THE METHODS
TO ASSESS THE TRUE
PELVIS?
• Clinical Methods
* internal pelvimetry
* external pelvimetry

• Radiopelvimetry
* X-ray pelvimetry
* USS
* MRI
 Q No.32

WHAT IS EXTERNAL
PELVIMETRY?
Ext. Pelvimetry
1. the sub pubic arch
- by direct
palpation (85°)

2. Bi-tuberous
diameter – using
the closed fist
(4knuckles = 8cm
approx.)

3. AP diameter of the
outlet – by external
caliper (12.5 cm)

4. Post. Sagittal
Diameter(7.5 cm)
 Q No.33

WHAT ARE THE POINTS TO BE

NOTED IN INTERNAL
PELVIMETRY ?
Int. Pelvimetry
1. Sacral
promontory
2. Sacral bay
3. Brim of the
pelvis
4. Sacrosciatic
notch
5. Pelvic sidewalls
( converging /
diverging )
6. Ischial spine
7. Sub pubic arch
8. Diagonal
conjugate
 Q No.34

WHICH IS THE SINGLE MOST

USEFUL X-RAY IN
ASSESSMENT OF THE
PELVIS?
 Lateral X-ray Pelvis - Erect
Such that the two acetabula are nearly superimposed and
the ischial spines are well superimposed
Inferences
1. True & false promontory
2. Inclination of the pelvic brim
3. Position of the fetal head
relative to the brim & degree
of engagement
4. Length & shape of the
sacrum
5. Size & shape of the S-S
notch
6. AP diameter
7. Posterior Sagittal diameter
 Q No.35

WHAT ARE THE PELVIC

CRITERIA FOR SELECTING
PATIENTS FOR TRIAL OF
LABOUR ?
 Trial of labour

A pelvis in which there is

suspicion of one diameter in any one
plane.

Suspicious diameter of the brim is

associated with the most favourable
prognosis ( as in platypelloid pelvis )
 Q No.36

HOW IS THE MUNRO KERR

TEST PERFORMED ?
 Munro Kerr Test
•Patient in dorsal position

•After pelvic assessment, the

gloved index and forefinger of the rt
hand placed in vagina at the level
of the ischial spine, with the thumb
over the symphysis pubis.

•The fetal head is pushed

downwards and backwards with
the left hand.

•If head goes to 0 station , no CPD

•If head can be pushed into the cavity, but parietal
bone slightly overlaps the symphysis, mild CPD
•If parietal bone grossly overhangs the symphysis
severe CPD
 Q No.37

MENTION THE FALLACIES

OF THE MUNRO KERR
METHOD.
• It does not take into account the changes occuring in
labour.

• In the case of a flat pelvis, when there is asynclitism

(post parietal ), the overlap of the head may appear
unduly great.

• In the case of an extended head, occipito-posterior

position or deflexed head it may not be possible to
push the head into the pelvis even in the absence of
CPD.

• Failure of development of the lower uterine segment

may lead to the head riding high over the brim.
INTERPRET THIS PARTOGRAM