THE BIRTH PROCESS AND THE NEWBORN 5

Figure 1.7. Posterior view of the fetal trunk: bisacromial diameter,

12 cm.

Figure 1.9. Breech presentation: complete presentation with the

legs flexed upon the thighs.

Breech presentations are classified according to

the position of the fetal legs. A complete breech
presentation occurs when both lower limbs are
flexed at the hip joints and the legs flexed upon the
thighs (Fig. 1.9). An incomplete breech presenta-
tion occurs when the thighs are flexed but the knees
extended (Fig. 1.10).
The term fetal presentation is used to define the
relationship between conventional parts of the fetus
relative to the maternal pelvis. The point of refer-
ence for the presenting part is the occiput in occipi-
tal presentations, the chin (or mentum) in face
presentations and the sacrum in breech presenta-
tions. The occiput, mentum or sacrum may be
located on the maternal right or left side, named
right or left occiput (RO, LO), right or left mentum
(RM, LM) or right or left sacrum (RS, LS). On each
side, it can be located transversely (T), anteriorly
(A) or posteriorly (P). Accordingly, a left occiput-
anterior is abbreviated LOA (Fig. 1.11). Cephalic or
Figure 1.8. Typical fetal position: head bent forward on the sternum, vertex presentations are the more frequent (96%),
forearms crossed on the chest, lower limbs flexed. followed by breech (3%), face (0.3%) and shoulder
6 CRANIAL OSTEOPATHY FOR INFANTS, CHILDREN AND ADOLESCENTS

arbitrary, passing through an oblique plane joining

the sacral promontory and the lineae terminales. On
each side, the linea terminalis consists of the iliac
arcuate line, the pecten pubis or iliopectineal line
and the pubic crest. The false pelvis lies above the
lineae terminales and the true pelvis below. The
false pelvis is limited posteriorly by the sacral base
and lumbar vertebrae, and laterally by the iliac
fossae. Anteriorly, the boundary consists of the lower
part of the anterior abdominal wall.
The true pelvis is in continuity with the false
pelvis. Its limits are:
• posteriorly, the concave anterior surface of the
sacrum and coccyx
• laterally, part of the fused ilium and ischium
• anteriorly, the rami and symphysis of the pubic
bones.
The true pelvis can be described as a truncated
cylinder with a superior opening, the pelvic inlet,
and an inferior opening, the pelvic outlet. This cyl-
inder is bent, following the anterior concavity of
the sacrum and coccyx. In the anatomic position,
the upper portion of the pelvic canal is directed
inferiorly and posteriorly and the lower part curves
inferiorly and anteriorly.

Pelvic inlet
Figure 1.10. Breech presentation: incomplete presentation with
extended knees. The border of the pelvic inlet, described as the
pelvic brim, is typically more round than ovoid in
human females (Fig. 1.13). Its measurements are
obstetrically important and should allow the head to
pass in descending through the pelvic inlet. Four
(0.4%). Among vertex presentations, LOA is the diameters of the pelvic inlet are usually described:
most frequent (57%).3 anteroposterior, transverse and two obliques. The
anteroposterior diameter of the pelvic inlet, also
named true conjugate, is measured between the
The maternal pelvis promontory of the sacrum and the pubic symphysis.
The obstetrical conjugate differs slightly, being mea-
BONY PELVIS sured between the promontory of the sacrum and the
most posterior point of the pubic symphysis. On
The pelvis is composed of four bones: the two pelvic average, it measures 10.5 cm or more. The trans-
bones, the sacrum and the coccyx. The pelvic bones verse diameter is the maximum distance between
articulate with the sacrum at the sacroiliac joints, the linea terminalis on opposite sides and normally
and with one another at the pubic symphysis, while measures 13.5 cm. The two oblique diameters are
the coccyx articulates with the sacrum at the sacro- measured between the sacroiliac joints and the
coccygeal joint. Very strong ligaments contribute to opposite iliopubic eminences. They are an average
pelvic stability, particularly the posterior sacroiliac of 12.5 cm and are named right or left according to
ligament and the pubic symphyseal ligaments4 the side of the iliopubic eminences from where they
(Fig. 1.12). originate.
The term pelvis also applies to the cavity within
Pelvic outlet
the bony skeletal ring, and in obstetrics the differ-
ence between the true (or lesser) and false (or The pelvic outlet is diamond shaped (Fig. 1.14). It con-
greater) pelves is of consideration. The division is sists of the sacrum and tip of the coccyx posteriorly,
 THE BIRTH PROCESS AND THE NEWBORN 7

a L.O.A. b R.O.P.

Figure 1.11. Cephalic presentations: (a) LOA,

left occiput-anterior; (b) ROP, right occiput-
posterior; (c) LOP, left occiput-posterior; (d) ROP:
right occiput-posterior. c L.O.P. d R.O.A.

a Sacroiliac joints b
Interosseous sacroiliac ligament

Anterior
sacroiliac Posterior sacroiliac
ligament ligament overlying
interosseous
ligament
Pubic symphysis
Figure 1.12. Bony pelvis: (a) anterior view; (b) posterior view.
8 CRANIAL OSTEOPATHY FOR INFANTS, CHILDREN AND ADOLESCENTS

the ischial tuberosities and sacrotuberous ligaments of the ischial tuberosities and averages 11 cm. The
laterally, and the inferior ramus of the pubis and posterior sagittal diameter, normally greater than
pubic symphysis anteriorly. The pelvic outlet may 7.5 cm, is the distance between the tip of the sacrum
vary in shape according to the position of the coccyx. to a right angle intersection with the transverse
Furthermore, the elasticity of the ligaments that diameter.
contribute to the lateral part reduces pelvic rigidity.
Pelvic shapes
Three diameters are usually described: anteroposte-
rior, transverse and posterior sagittal. The antero- A thorough knowledge of the anatomy of the pelvis
posterior diameter of the pelvic outlet is measured allows for the understanding of the physiology of
from the lower margin of the pubic symphysis to the labor and how structure affects function, in this case
coccygeal apex and is between 9.5 and 11.5 cm. The how the pelvic shape determines the route of deliv-
transverse diameter extends between the inner edges ery. Caldwell and Moloy’s 1933 classification of
pelvic shape, which is still in use today, identifies
four variations of the female pelvis: gynecoid,
android, anthropoid and platypelloid:5
• The gynecoid type is the most frequently
encountered. Its transverse pelvic inlet diameter
is either equal to or slightly greater than the
anteroposterior diameter, and, therefore, the
shape of the inlet is either somewhat oval or
round.
• The android type, the second most frequently
encountered type, presents with an anterior
pelvis that is narrow and triangular. The
posterior sagittal pelvic inlet diameter is much
shorter than the anterior, with less space for the
Circular pelvic
inlet fetal head. This type has a poor prognosis for
vaginal delivery.
• The anthropoid type has a more oval shape,
80 – 85° with an anteroposterior pelvic inlet diameter
Figure 1.13. Pelvic inlet. that is greater than the transverse diameter.

Pubic symphysis Figure 1.14. Pelvic outlet.

Body of pubis
Pubic arch

Ischial tuberosity

Sacrotuberous ligament
Coccyx
 THE BIRTH PROCESS AND THE NEWBORN 9

• The platypelloid type is less frequently

encountered and presents a wide transverse
pelvic inlet diameter and a short anteroposterior
diameter.
Interestingly, the shape of the female pelvis, in
addition to the genetic predisposition, appears to be
influenced by athletic activities of adolescence,
when strenuous physical activities predispose to the
android type of pelvis.6
Contemporary methods of fetal cephalometry and
pelvimetry, as done by MRI, provide a more precise
measurement of pelvic dimensions and configura-
tion. This allows the detection of pelvic abnormali-
ties and cephalopelvic disproportion which are risk
factors for dystocia.7 These methods of detection, Figure 1.15. Pelvic movements. Anatomic flexion (craniosacral
extension): the sacral base moves anteriorly and the sacral apex moves
no matter how sophisticated, augment, but do posteriorly.
not replace, the skills of a good osteopathic
obstetrician.

Pelvic movements
Pelvic motions have been identified in the general
medical literature.8,9 Sacral motion within the pelvis
has been described as nutation and counternutation,
motions that in the osteopathic literature are
also referred to, respectively, as anatomic flexion
(craniosacral extension) and anatomic extension
(craniosacral flexion). This opposition of terms
between anatomic and craniosacral nomenclature for
movement of the sacrum is unfortunate, but it is the
terminology that is currently in use; therefore, in
order to communicate, in this chapter the anatomic
terms employed will be followed, when appropriate,
by the respective craniosacral terms in parentheses.
The hypothetical axis of motion for anatomic
flexion–extension of the sacrum is a horizontal
transverse axis said to pass through the anterior
aspect of the sacrum at the level of the second sacral Figure 1.16. Pelvic movements. Left sacral torsion: sacral rotation
segment.10 The exact location of such an axis is open to the left on the left oblique axis.
to debate, and more than likely altered by the
changes in weight distribution that occur during
pregnancy.8 tion.11 The oblique axis is named as left or right,
During anatomic flexion (craniosacral extension), determined by the side of its superior point of origin.
the sacral base moves anteriorly and the sacral apex Sidebending of the spine above establishes the side
moves posteriorly (Fig. 1.15). During anatomic of the oblique axis. Therefore, spinal sidebending to
extension (craniosacral flexion), the sacral base the right engages the sacral right oblique axis. Sacral
moves posteriorly and the sacral apex moves anteri- torsions – sacral rotation on the oblique axes – are
orly. The coccygeal bones follow the movement of named for the side toward which sacral rotation
the sacrum. occurs. Sacral rotation to the left is, therefore, a left
The other motions demonstrated by the sacrum torsion. In the absence of dysfunction, the pelvic
are sacral torsions that occur as motion around a bones follow the motion of the sacrum. Conse-
hypothetical oblique axis passing from the superior quently, following a left sacral torsion, the left pelvic
aspect of the sacroiliac articulation on one side to bone exhibits internal rotation while the right pelvic
the inferior aspect of the opposite sacroiliac articula- bone externally rotates (Figs 1.16, 3.24).
10 CRANIAL OSTEOPATHY FOR INFANTS, CHILDREN AND ADOLESCENTS

altered weight-bearing mechanics of pregnancy and

the impending birth process. In the presence of
sacral and lumbar somatic dysfunction, these adap-
tive changes are restricted and may be the sources
of pain during pregnancy and delivery. Anything
that impacts the wellbeing of the mother affects the
wellbeing of the infant. Osteopathic practice is
holistic and must consider the environment of the
child, i.e. in this case, the mother.

SOFT TISSUES

Figure 1.17. Fetal head entering the pelvic inlet in the left pelvic The true bony pelvis, when completed by the soft
oblique diameter. tissues of muscles and fasciae, forms a ‘basin’. The
pelvic walls and the pelvic floor are parts of the
‘basin’ and are important guides in the process of
engagement and descent of the fetus. Two groups of
muscles arise from within the pelvis: the piriformis
Craniosacral dysfunction of the pelvis, as well as and obturator internus (Fig. 1.18), and the levator
postural somatic dysfunction, will affect the dimen- ani and coccygeus (Fig. 1.19).
sions of the true pelvis. Dysfunctional anatomic On each side, the piriformis forms part of the
flexion (craniosacral extension) decreases the posterolateral wall of the lesser pelvis. It originates
anteroposterior diameter of the pelvic inlet and from the anterior surface of the sacrum and passes
increases the anteroposterior diameter of the pelvic out of the pelvis through the greater sciatic foramen
outlet. Conversely, dysfunctional anatomic exten- to insert on the greater trochanter of the femur. The
sion (craniosacral flexion) increases the anteropos- two obturator internus muscles form part of the
terior diameter of the pelvic inlet and decreases the anterolateral wall of the lesser pelvis. They arise
anteroposterior diameter of the pelvic outlet. Dys- from the surface of the obturator membrane and the
functional torsion asymmetrically affects the two surrounding parts of the obturator foramen. The
oblique diameters between the maternal sacroiliac fibers converge toward the lesser sciatic foramen and
joints and the opposite iliopubic eminences. In the reflect at a right angle around the ischium to insert
above example of a left sacral torsion, the left oblique on the greater trochanter of the femur.
diameter of the pelvic inlet decreases. (Note: The In the absence of somatic dysfunction, the sacrum
oblique diameter of the pelvic inlet should not be can be seen as balanced between the two piriformis
confused with the sacral oblique axis.) Conversely, muscles. During pregnancy, because the position
with a right sacral torsion, the right oblique diame- of the developing fetus is asymmetric, the uterus
ter of the pelvic inlet decreases. enlarges in an oblique manner. This places asym-
This is of great importance in obstetrics, in that metric tension on the sacrum which tends to accom-
it contributes to the ease, or difficulty, of the second modate by moving into a torsional position. This, in
phase of labor, and consequently impacts the infant. turn, results in greater stress being placed on
When the fetal head enters the pelvic inlet, it most the piriformis muscle, on the side toward which the
commonly does so with its anteroposterior orienta- sacrum has rotated. Any increase in tension of the
tion in one of the two pelvic oblique diameters (Fig. piriformis may affect the sciatic nerve. The sciatic
1.17). A sacral torsional dysfunction that decreases nerve leaves the pelvis through the greater sciatic
one of the oblique diameters will make orientation notch and most commonly runs posteriorly below
of the fetal head in that diameter, and consequently the inferior border of the piriformis.
the birth process, more difficult. Pregnant women often complain of back pain,
During pregnancy, relaxation of the pubic sym- located laterally in the gluteal area and which radi-
physis and sacroiliac joints occurs as a result of hor- ates into the posterior part of the thigh resembling
monal changes that peak for relaxin at the 10th to sciatica. However, as the pain does not usually radiate
12th week of gestation.12 Therefore, motions of the below the knee, and the associated deep tendon
pubic symphysis and sacroiliac joints are facilitated reflexes are normal, it cannot be considered as a
to adapt for stresses caused by the growing uterus, radicular pathology. Maternal postural imbalance
 THE BIRTH PROCESS AND THE NEWBORN 11

Piriformis muscle

SII Anterior
SIII sacral
foramina
SIV

Obturator internus muscle

Figure 1.18. Soft tissues: piriformis and obtu-

rator internus muscles.

Obturator internus muscle

Tendinous arch

Obturator canal
Coccygeus muscle

Iliococcygeus Sacrospinous ligament

muscle
Pubococcygeus Anal aperture
Levator ani
muscle
Puborectalis
muscle
Urogenital hiatus
Figure 1.19. Soft tissues: levator ani and coccygeus muscles.
12 CRANIAL OSTEOPATHY FOR INFANTS, CHILDREN AND ADOLESCENTS

should be addressed in order to alleviate discomfort,

further knowing that maternal pelvic dysfunctions
affect normal parturition.
The pelvic diaphragm consists of the bilateral
levator ani and coccygeus muscles and their fasciae
(Fig. 1.19). The levator ani muscles form the greater
part of the pelvic floor and present several parts,
described according to their areas of origin and the
relationships of the muscles, i.e. the pubococcygeus,
puborectalis and iliococcygeus muscles. The coccyg-
eus muscles form the posterior part of the pelvic
diaphragm, arise from the ischial spines, are fused
with the sacrospinous ligaments, and insert to the
sacrum and coccyx. The central tendinous point of
the perineum (i.e. the perineal body) is an area of
connective tissue between the anus and the vagina.
During parturition, after rupture of the chorioamni-
otic membranes, the fetal presenting part exerts
great pressure on the pelvic floor. The perineum
must accommodate or tear. The fibers of the levator
ani muscles are considerably stretched and the
central portion of the perineum becomes progres-
sively thinner. At the same time, during the delivery
Figure 1.20. Right rotation of the uterus.
process, in the case of a cephalic presentation, the
pelvic floor resistance acts as a fulcrum, allowing the
fetal head to rotate and extend. In the absence of
sufficient rotation, the use of forceps is more likely
to be necessary.
A functional pelvic floor that should accompany positioning is also thought to be determined by the
a well-balanced pelvis and intrapelvic viscera, and right-sided location of the maternal liver,3 but the
functional abdominal muscles with a balanced location of the placenta appears to have no influ-
lumbar spine, is of paramount importance to facili- ence.15 Another factor that affects fetal position is
tate pregnancy and delivery. Somatic dysfunction of the presence of the iliopsoas muscles that reduce the
these areas will result in impaired function of their transverse diameter of the pelvis. In vertex presenta-
‘skeletal, arthroidal and myofascial structures and tions, the iliopsoas muscles direct the fetal head
related vascular, lymphatic and neural element’,13 obliquely.
and therefore affect the development and delivery The pelvis and fetal presentation appear to be
of the child. The use of prenatal manipulative treat- related. Accommodation causes the largest diameter
ment of the mother improves outcomes in labor and of the fetus to align with the largest diameter of the
delivery.14 pelvis. Under normal conditions, without fetopelvic
disproportion, the typical vertex presentation, at
term, is considered to be physiologic. It is attributed
The birth process to the effect of gravity16 and the need for the fetus
to maintain functional limb position by stretching,
Most commonly, the uterus is turned to the right extending and kicking the legs, therefore maximiz-
(Fig. 1.20), such that its left side is displaced anteri- ing the use of uterine space.17
orly and its right side posteriorly. The long diameter Fetal somatic dysfunction may occur before the
of the fetal presenting part most frequently lies in onset of labor. Intrauterine conditions such as
the left oblique diameter of the pelvic inlet, with the uterine fibroids, deficiency in the amount of amni-
spine of the fetus directed anteriorly and to the otic fluid (oligohydramnios), or excessive amniotic
maternal left side, or posteriorly and to the maternal fluid (polyhydramnios) associated with increased
right side. It has been suggested that positioning of intrauterine pressure, limit fetal movements and
the uterus is influenced by the position of the may, therefore, constrain the fetus in a dysfunctional
descending colon and the sigmoid flexure. Fetal position. Multiple births may have the same effect,
 THE BIRTH PROCESS AND THE NEWBORN 13

where one fetus applies pressure on the other(s). process, with a combination of movements that
Intermittent uterine contractions are also source of adapt the fetus to the birth canal. The understand-
compression. They increase in force and frequency ing of these mechanisms of labor, involving a pas-
as gestation advances and augment intrauterine senger (i.e. the fetus), a passage (i.e. the maternal
pressure. They also push the fetal head down in the birth canal) and expulsive forces, is very helpful in
direction of the lower uterine segment and, conse- appreciating the complexity of somatic dysfunction
quently, the pelvic inlet. The resilience of the fetal in the newborn and, therefore, in the future adult.
tissues usually allows for adaptation to these pres- Molding of the fetal head is another frequently
sures. When this does not happen, or when the described process of accommodation during labor.
pressure is significant, compression of the fetal head Some authors have linked molding depressions with
may occur. excessive forces applied to the skull through the use
Before the onset of labor, the frontoparietal area of forceps, from digital pressure of the obstetrician’s
of the fetal head is particularly vulnerable to com- hand, and more commonly from compression of the
pressive forces. The fetus most commonly lies on the fetal head on the pubic symphysis or the sacral
maternal left side, i.e. with their back toward the promontory.18 As a result of molding during parturi-
mother’s left side. In such cases, the left side of tion, a displacement of the bones of the calvaria is
the fetal head is more constrained by the maternal also commonly described, associated with over-
pelvis and lumbar spine than is the right. If the fetus lapping of the parietal, frontal and occipital bones
stays in this position for any length of time, the at the sutural level. Furthermore, in severe cases,
frontoparietal area may remain in contact with part molding has been reported potentially to exert
of the bony pelvis, usually the sacral promontory. tension on the great cerebral vein to the point of
This can result in the left frontal bone or the left rupture.2 The classic pattern of overlapping usually
frontoparietal area being compressed by a force that described consists of the parietal bones overlapping
is directed toward the base of the fetal head, with a the frontal and the occipital bones. Of the two pari-
resultant lower frontal bone and decreased orbital etal bones, the one that receives the greater pressure
size on that side. – always the one lying posteriorly in the pelvis – is
The beginning of labor is defined as the onset of said to slide under its counterpart.19
regular, intense, uterine contractions, with dilata- Overlapping of the parietal bones at the sagittal
tion of the cervix. The process of labor is described suture seems, however, to be less common than
as three stages: usually thought.20 A locking mechanism in the
sutures of the calvaria possibly acts as a protective
• the first stage lasts from onset of labor to full
mechanism for the fetal brain. The dural reciprocal
dilatation of the cervix
tension membranes may also be part of this locking
• the second stage ends with the delivery of the
mechanism. Most often the skull changes shape,
child
demonstrating shortening of the suboccipito-
• the third stage is the time from delivery of the
bregmatic diameter and a tendency for flattening of
child until the delivery of the placenta.
the parietal bones.20 When labor is prolonged, sig-
During these stages, several mechanisms influence nificant stresses can be applied to the dural mem-
the delivery and determine the best route for the branes. Membranous articular strains can result,
fetus to pass through the maternal birth canal. which, unless treated, persist throughout life, acting
Accommodation and orientation of the fetal pre- as a framework upon which additional dysfunctional
senting part are two processes that occur during mechanisms can arise.
labor to result in normal delivery. Accommodation As well as molding, orientational processes occur
is the process by which the fetal volume decreases as mechanisms of labor. These include engagement,
in order to pass through the maternal birth canal. descent and expulsion. They occur mainly during
This may occur through changes in the fetal body the second stage, although engagement may start
position or by displacement of fetal body fluids. Ori- before the onset of labor, particularly in
entation is the process by which the fetal presenting primigravidae.
part is positioned to best fit the shape of the birth
canal.
The increase in frequency and intensity of con- ENGAGEMENT
tractions cause the fetus to move inferiorly and to
approach the pelvic inlet. During that time, fetal Engagement is defined as the time when the fetal
positional adjustments are constant. It is a dynamic head passes through the pelvic inlet. The biparietal
14 CRANIAL OSTEOPATHY FOR INFANTS, CHILDREN AND ADOLESCENTS

a b

Figure 1.21. Engagement: (a) head not engaged; (b) head engaged.

a b c

Figure 1.22. Synclitism and asynclitism: (a) synclitism; (b) anterior asynclitism, fetal head sidebent toward the maternal sacrum; (c) posterior
asynclitism, fetal head sidebent toward the maternal pubic symphysis.

plane, the largest diameter of the normally flexed head should be oriented in a direction perpendicular
fetal head, is the reference. The head is engaged to the plane of the pelvic inlet. This phenomenon
when this diameter is below the pelvic inlet (Fig. is referred to as synclitism (Fig. 1.22a). Conse-
1.21). In nulliparous women, engagement usually quently, when the head is laterally deflected, asyn-
starts in the last few weeks of pregnancy. It may also clitism is present. Asynclitism may be anterior, when
occur as late as the beginning of the second stage of the fetal head sidebends toward the maternal sacrum
labor, as is the case for most multiparous women. (Fig. 1.22b), the sagittal suture is closer to the sacrum
Engagement normally occurs with the fetal sagit- and the anterior parietal bone closer to the pubic
tal suture aligned in the transverse pelvic diameter, symphysis is palpable intravaginally. Posterior asyn-
or, more often, in one of the two oblique pelvic clitism occurs when the fetal head sidebends toward
diameters. Normal-sized fetuses do not usually orient the maternal pubic symphysis (Fig. 1.22c) and the
their heads in the smaller AP diameter. Further- posterior parietal bone is palpable intravaginally.
more, in order to facilitate engagement, the fetal Although moderate asynclitism is usual, a greater
 THE BIRTH PROCESS AND THE NEWBORN 15

degree of asynclitism may be a cause for a difficult The craniocervical junction and the upper thoracic
engagement, resulting in fetopelvic disproportion. area may also be placed under stress, resulting in
Asynclitism also causes a greater amount of pres- somatic dysfunction and associated parasympathetic
sure to one side of the calvaria, with the resultant and sympathetic hyperactivity, respectively. Nor-
potential for cranial dysfunction. A sidebending– mally, in vertex presentation, with an anterior-
rotation of the sphenobasilar synchondrosis (SBS) occiput engagement, the descent that follows is
on the side of the pressure on the parietal bone may easier and more rapid.
result, with an associated sidebending of the cranio- In the process of descent, the fetus will have to
cervical junction and cervical spine. This pressure turn their head when approaching the pubic sym-
may also produce an intraosseous dysfunction of the physis to align the sagittal suture along the AP diam-
homolateral temporal bone and associated temporo- eter of the pelvic outlet. This process is called
mandibular structures. Under normal circumstances, internal rotation. With the progression of the pre-
the fetal head will move from anterior to posterior sentation inferiorly, the maternal coccyx is pushed
asynclitism alternatively, like the clapper of a bell, posteriorly. This increases the tension of the pelvic
in order to progress toward the direction of the floor and normally results in a greater amount of
pelvic outlet. resistance posteriorly. As such, the levator ani
muscles, together with the surrounding tissues,
which are shaped like a gutter, act as a fulcrum and
DESCENT a guide for the fetal head. The internal rotation that
is essential to achieve delivery may occur at this
Increased uterine contractions push the fetus inferi- time, if it has not already happened. The contribu-
orly. Cervical flexion causes the chin of the fetus to tion of the muscles of the pelvic floor to this process
be brought into contact with their sternum. This is is significant. First, they provide sufficient support to
part of the accommodation process. Consequently, resist the pressure of the fetal head, and therefore
the shortest diameter of the fetal head, the sub- serve as a guide to direct the head anteriorly towards
occipito-bregmatic diameter, becomes the present- the vulva. Second, the muscles of the pelvic floor
ing diameter, and facilitates better passage through must relax to allow the expulsion of the presenting
the birth canal. Normally internal rotation follows. part. A hypotonic pelvic floor does not provide suf-
(Note: In this instance, the term internal rotation ficient resistance, nor can it effectively serve as a
refers to a rotation of the fetus that occurs inside the fulcrum and guide during this stage of the delivery
pelvic cavity, whereas external rotation refers to a process. Other means, such as the use of forceps, may
fetal rotation that occurs outside the pelvic cavity. be necessary to assist the rotation of the head. On
These terms are used in the context of obstetrics and the other hand, a hypertonic pelvic floor does not
have a different meaning from the one used in the allow the necessary relaxation at the time of expul-
rest of this book.) sion, and episiotomy may be required to avoid
After engagement of the fetal head, failure to perineal tear.
progress further, or lack of fetal descent, may occur. After being guided anteriorly through the moth-
Either malposition of the fetal head or ineffective er’s true pelvis, the base of the occiput is pushed
uterine contractions is usually responsible. Malposi- under the inferior margin of the pubic symphysis
tion of the fetal head may arise, for instance, from a (Fig. 1.23). The vulvar outlet is oriented anteriorly
brow presentation with resultant increase in the and superiorly. As a result, the fetal cervical spine
head circumference. In such circumstances, the fetus and craniocervical junction must change from an
is compressed against the maternal pelvis in response attitude of flexion to an attitude of extension in
to the contractions of the uterine fundus putting order for the fetal head to pass through it. Extension
pressure on the breech. The compressive forces are of the cervical spine and passage of the head under
transmitted along the fetal spine to the cranial base the pubic symphysis are significant points during
and skull, against the resistance of the maternal delivery, as this is the time when cranial dysfunction
pelvis. Some areas are, therefore, placed under stress. may develop. The pubic symphysis acts as a fulcrum
The stress may be localized to the anterior part of for the craniocervical junction that turns around it.
the fetal calvaria and may produce a vertical strain A significant amount of this extension takes place
or frontal bone dysfunction, with compression of the at the level of the condyles of the occiput. They
frontoethmoidal suture. A sphenobasilar compres- have to move forward on the atlantal articular sur-
sion dysfunction may result if the pressure is applied faces to provoke extension of the craniocervical
in the direction of the AP diameter of the fetal head. junction. In so doing, an extension dysfunction
16 CRANIAL OSTEOPATHY FOR INFANTS, CHILDREN AND ADOLESCENTS

a b

Figure 1.23. Passage of the head under the pubic symphysis.

between the occiput and the atlas may develop. The may be the foundation for future axial skeletal dis-
extension may also take place in the synchondroses orders such as plagiocephaly or scoliosis.
of the cranial base. The posterior intraoccipital car- Gradually, and with further extension of the
tilaginous synchondrosis participates in the exten- occiput, the head will emerge from the pelvis. The
sion. When the resilience of the tissue is overwhelmed, forehead, the nose, the mouth and the chin will
this can produce an intraosseous dysfunction within appear after sliding along the perineal gutter. This
the occiput. sequence may be another cause of cranial somatic
Most of the time extension of the head does not dysfunction, particularly if the maternal coccyx is
occur in the pure sagittal plane, but rather in asso- anteriorly hooked. At this time the forces applied to
ciation with lesser or greater amounts of rotation the forehead and the facial skeleton are directed
and sidebending. Consequently, the resultant dys- inferiorly, toward the fetal chin, and may result in
functions may be asymmetric, with one occipital vertical strain of the SBS or other dysfunctional
condyle being more compressed than the other, or patterns involving the frontal bone and/or the facial
one side of the squamous occiput being more ante- bones. The areas of the frontoethmoidal and fronto-
rior, superior or inferior to the other. This, in turn, nasal sutures, as well as the maxillae, are particularly
 THE BIRTH PROCESS AND THE NEWBORN 17

vulnerable. Once again, these motions, as they occur as it passes under the pubic symphysis and then the
during the delivery process, and, consequently, posterior shoulder is delivered (Fig. 1.24). After the
any resultant dysfunction, are never perfectly shoulders, the rest of the body follows. Difficulty at
symmetrical. the time of delivery of the shoulders can result in
When the head is delivered occiput anterior, it myofascial and ligamentous articular strain in the
declines anteriorly, with the newborn’s chin close to cervical and upper thoracic regions. In severe cases
the maternal anal area. The next phase of the deliv- this can result in brachial plexus injury and clavicu-
ery process consists of the restitution of the head to lar fractures.
its original rotation. In an LOA presentation, the A child delivered in the LOA presentation may
head rotates to face the right maternal thigh. This demonstrate a flattening of the area between the
restitution results in an external rotation that posi- brow and the anterior fontanelle, and, typically, an
tions the infant’s head in the transverse diameter of asymmetric vault, with one parietal bone (the one
the maternal pelvis, and an internal rotation of the located on the presenting side) being more arched,
fetal trunk. The shoulders usually enter the pelvic while the opposite parietal bone is more flattened.
inlet in the oblique diameter opposite to the one in Asynclitism further increases the pressure of the
which the head entered. Therefore, during delivery, infant’s head against the pelvic bones. If the right
the global motion of the body follows a dynamic side of the infant’s occipital bone is in contact with
spiral. There is a limit to the resilience of the fetal the maternal pubic symphysis while the left frontal
tissues, however, and during the process of produc- bone is against the sacrum, it will result in occipital
ing the external rotation this limit may be exceeded. flattening on the right and frontal flattening on the
As a consequence, dysfunction that develops during left. The reverse – occipital flattening on the left and
this period may result in the establishment of a frontal flattening on the right – would follow the
torsional pattern between the pectoral and pelvic LOP position. At the end of the descent, the head
girdles. This is a global pattern involving the whole contacts the pelvic floor and turns in such a way as
body – fasciae, membranes, muscles and joints to position the occiput under the pubic symphysis.
included. Interestingly, this pattern is quite fre- In the occiput-anterior position, the right side of the
quently encountered with newborn babies. occiput, eventually the occipitomastoid area, can be
exposed to greater pressure. Later, during expulsion,
compressive forces may be applied to both sides of
EXPULSION the occipital bone by the pubic symphysis.
In the presence of calvarial molding, the present-
Once the shoulders are engaged in the pelvic inlet, ing part, which is the lowest, is usually forced out,
the bisacromial diameter must fit the AP diameter and is cone shaped (Fig. 1.25). In an LOA presenta-
of the pelvic outlet. The anterior shoulder is expelled tion, the apex of the cone is commonly the postero-

Figure 1.24. Expulsion of the shoulders.

18 CRANIAL OSTEOPATHY FOR INFANTS, CHILDREN AND ADOLESCENTS

a b

Figure 1.25. Calvarial molding: (a) occiput-anterior presentation; (b) occiput-posterior presentation.

superior (or occipital) angle of the right parietal

bone, at the lambda. This is frequently the location
of caput succedaneum and of cephalhematoma.
Caput succedaneum, a serosanguineous fluid collec-
tion above the periosteum, results from the changes
in the pressure to which the presenting portion of
the scalp is subjected. The swelling occurs on the
posterior and superior part of the vault. In an LOA
presentation, it is on the right side, but may extend
across suture lines; in an ROA presentation, it is on
the left side. Its thickness is generally of a few milli-
meters, although in difficult labors it may be more
significant. Caput succedaneum typically resolves in
a few days.
A cephalhematoma is a subperiosteal hematoma
of the calvaria, caused by the rupture of vessels
beneath the periosteum. Cephalhematomas occur in
approximately 1–2% of newborns and are associated
with the use of forceps.21 A cephalhematoma pres-
Figure 1.26. Cephalhematomas.
ents as a firm, soft-tissue mass, usually over a parietal
or occipital bone that does not cross a suture line,
being limited by the outer layer of the periosteum The birth process, through normal vaginal deliv-
and the sutures. Because of the slow subperiosteal ery, when considered as a potential source for cranial
bleeding, it may not appear immediately after birth. dysfunction, may appear as an undesirable life event.
Cephalhematomas may be unilateral or bilateral Nevertheless, the stress of being born is thought to
(Fig. 1.26), and normally resolve over a few weeks, be beneficial, through the production of catechol-
although some calcification may occur that gradu- amines that enhance the infant’s ability to survive,
ally integrates with the calvaria.21 promote breathing, speed up the metabolic rate at
 THE BIRTH PROCESS AND THE NEWBORN 19

birth and increase blood flow to vital organs.22 This Occiput-posterior presentations, either right occiput-
stressful process also appears to be beneficial to the posterior (ROP) or left occiput-posterior (LOP),
child’s health in assisting the development of their represent 15% of all presentations.27 They may be
immune system.23 associated with prolonged stages of labor. Internal
rotation of the fetal head is greater. The fetal head
has to turn 135° in order for the occiput to move
DYSTOCIA from a posterior position, adjacent to one of the
maternal sacroiliac joints, to an anterior position
Dystocia means difficult childbirth, as compared to near the pubic symphysis.
eutocia, i.e. normal labor. Dystocia most often results The position of caput succedaneum, when present,
from a combination of fetal and pelvic dynamics. reflects the position of the presentation. In ROP
Maternal pelvic structures are of paramount impor- presentations, it is located on the anterosuperior
tance, as addressed by Still: ‘The first duty of the angle of the left parietal bone, but may extend across
obstetrician is to carefully examine the bones of the the coronal suture. In LOP presentations caput suc-
pelvis and spine of the mother, to ascertain if they cedaneum is to be found on the anterosuperior angle
are normal in shape and position.’24 During fetal of the right parietal bone, with frequent overlapping
engagement, in order to increase the pelvic inlet of the coronal suture.
diameter, the sacral base should move posteriorly in In some instances, the head will not turn, leading
anatomic extension (craniosacral flexion) while the to a persistent occiput-posterior presentation.
sacral apex moves anteriorly. During the phase of However, in 62% of persistent occiput-posterior
expulsion, in order to increase the pelvic outlet presentations, sonography at the onset of labor has
diameter, the coccyx and apex of the sacrum should demonstrated that the initial presentation is an
move posteriorly and the sacral base anteriorly, i.e. occiput-anterior position followed by a malrotation
anatomic flexion (craniosacral extension). The need during labor.27 Persistent occiput-posterior presenta-
for sacral mobility has always been recognized.25 tion is associated with induction of labor, use of
Somatic dysfunction or disproportions in the oxytocin to increase labor and epidural use.28,29
maternal pelvis may be responsible for dystocia by Additionally, persistent occiput-posterior presenta-
influencing the fetal position during labor. A dys- tion is related to greater risk of poor neonatal
functional pattern of uterine contraction may follow, outcome, including birth trauma, when compared to
with the need for increased use of oxytocin, estab- occiput-anterior presentation.30 With persistent
lishing a vicious cycle that ends with the need for occiput-posterior presentation, operative deliveries
the performance of a cesarean section.26 are more frequent, and spontaneous vaginal delivery
Over the years, in order to deliver their babies, in nulliparas occurs in only 26% of cases.29
women have tried various positions, such as squat-
ting, sitting on birthing chairs or lying down. The Breech presentation
dorsal lithotomy position, where the mother is lying Breech presentation at term occurs in about 3% of
on her back with her buttocks at the end of the all deliveries,31 and prematurity is a risk factor.3
delivery table, her hips and knees flexed, and her Term breech presentation is less frequent because of
legs or feet supported and strapped into stirrups, is the increased practice of external fetal version at 37
typical. This position may increase the pelvic outlet weeks’ gestation. External version should be per-
diameter by 1.5–2 cm, but at the same time the formed in a setting in which the fetus can be moni-
posterior displacement of the sacral base, in ana- tored and only by physicians familiar with this
tomic extension (craniosacral flexion), may be procedure. In this instance, having skilled osteo-
restricted by the resistance of the table. Further- pathic touch and an appreciation for the use of indi-
more, this position is less efficient for pushing. rect manipulative techniques can be a significant
Women should be advised to change position during advantage. External version should never be forced:
labor as needed and, if possible, to give birth in the the umbilical cord may be too short, or it may be
position that they find most comfortable. This may coiled around the neck, therefore not allowing fetal
facilitate sacral positional release and, therefore, version.
facilitate delivery. Breech presentation is classified according to the
location of the fetal sacrum, i.e. left sacroanterior,
Occiput-posterior presentation which is the most frequent, right sacroanterior,
All vertex presentations follow the same principles right sacroposterior or left sacroposterior. Further,
and mechanics as occiput-anterior presentations. according to the position of the fetal legs, breech
20 CRANIAL OSTEOPATHY FOR INFANTS, CHILDREN AND ADOLESCENTS

presentations may be complete when the legs are

flexed (see Fig. 1.9) or incomplete when the legs are
extended (see Fig. 1.10). During engagement and
descent the principles and mechanics described for
vertex presentations apply.
During delivery, when the breech reaches the
pubis, the fetal trunk sidebends, followed by the
delivery of the hips. This may be the cause of articu-
lar or intraosseous somatic dysfunction for the infant,
including hip, pelvic bone, and sacrum or lumbar
spine dysfunctions. Expulsion of the head in the
occiput-anterior position occurs, with the fetal chin,
mouth, nose and forehead sliding along the anterior
surfaces of the maternal sacrum and coccyx. This
can produce facial dysfunction, particularly affecting
the maxillae, frontonasal and frontoethmoidal
sutures. Figure 1.27. Calvarial molding: face presentation.
The outcomes for breech deliveries are controver-
sial. Vaginal delivery of term infants presenting as
breech, when compared to infants delivered by elec-
tive cesarean section, demonstrates greater risks of
neonatal mortality and morbidity.32,33 On the other against the maternal pubic bones. Deliveries with
hand, a higher risk of maternal complications has associated shoulder dystocia necessitate the use of
been correlated with cesarean delivery without cor- specific maneuvers to release the impacted shoul-
responding improvement in neonatal outcomes.31 ders: the McRoberts’ maneuver reorients the pelvis
by pushing the mother’s knees to her chest, the
Face presentation Barnum maneuver delivers the posterior shoulder
Face presentations are associated with a hyperexten- first and other procedures attempt to release the
sion of the fetal cervical spine. The occiput is posi- shoulders by maneuvering the fetal trunk.
tioned contacting the fetal back and the presenting Delivery with shoulder dystocia can result in sig-
part is the chin (mentum). Four varieties of face nificant neonatal morbidity, including asphyxia and
presentation exist. The two mentum posterior pre- trauma. Shoulder dystocia is associated with a second
sentations, with the fetal brow being compacted stage of labor greater than 2 hours’ duration and an
against the maternal pubic symphysis, and resultant increased need for operative vaginal delivery.36 In
difficult labor, require cesarean section. The two the process of delivery, traction applied to the
mentum anterior presentations may deliver vagi- neonate may introduce significant sidebending, with
nally, but usually with significant molding of the the potential for obstruction of the venous return
fetal skull. Swelling and edema of the facial tissues from the head. Intracranial hemorrhage and anoxia
are typically present and change the appearance of may result.
the face (Fig. 1.27). Cranial somatic dysfunction is Traction applied to the head may also be respon-
common and affects the cervical spine, particularly sible for brachial plexus injury, most often affecting
the occipitoatlantal joint, and the viscerocranium. the right arm in cases of LOA presentations. Green-
stick fracture of the clavicle may also occur. The
Shoulder dystocia forces responsible for these injuries will also readily
The incidence of shoulder dystocia varies from 0.2 result in somatic dysfunction of the upper thoracic
to 3% of all deliveries.34,35 Changes in fetal body area, associated ribs, pectoral girdle and cervicotho-
with increasing birth weight disproportion between racic junction.
the fetal shoulders and the maternal pelvis, signifi-
Forceps delivery
cantly greater shoulder-to-head and chest-to-head
disproportions and increased bisacromial diameters Forceps deliveries are completed in 5–10% of deliv-
are commonly described risk factors. During fetal eries.37 The use of forceps may be an aid to the
descent, the posterior fetal shoulder may be forced mother who is exhausted or in whom anesthesia
against the maternal sacral promontory. After deliv- prevents spontaneous delivery. Forceps may also be
ery of the head, the anterior shoulder may be lodged indicated by fetal conditions, such as bradycardia
 THE BIRTH PROCESS AND THE NEWBORN 21

and malposition.38,39 Although associated with neo- L2–L3 or L3–L4 interspace. Normally, when cor-
natal complications, including facial nerve palsy, rectly applied, epidural anesthesia eases the pain
skull fractures and intracranial hemorrhage, the use from cervical dilatation without influencing uterine
of forceps is described as a fairly safe procedure in contractions, and later, when delivery is imminent,
the hands of experienced practitioners.39,40 it produces a perineal anesthesia. However, epidural
The use of forceps may, however, be a potential anesthesia in some instances may slow the labor,
source for cranial dysfunctions. Compressive forces with a decrease in abdominal pushing and relaxation
that are applied through the forceps blades may be of the pelvic floor. It may also predispose to incom-
slight or of greater intensity. In delivery of the head, plete fetal internal rotation during the descent. Epi-
pulling forces are also involved. These pulling forces dural anesthesia has been associated with an
are rarely directed in a straight line, and membra- increased incidence of occiput-posterior presenta-
nous dysfunction, reflecting the combination of tion43 and with the need for the physician to employ
compression and traction, may result. The forceps more force to deliver the fetus.42
blades are usually set up on each side of the head
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