UNIT IV: FOETAL DEVELOPMENT 1

FERTILIZATION

Fertilization is the fusion of the ovum and spermatozoa to form a zygote. During intercourse
about 300,000 000 spermatozoa are deposited in the vagina and the cervix under the influence of
oestrogen secretes a flow of alkaline mucus that attracts the spermatozoa. Only one sperm
nucleus fuses with the nucleus of the ovum. Fertilization takes place usually at the ampulla in the
fallopian tube usually 24 hours after ovulation.

By the process of capacitation the spermatozoa are conditioned to fertilize the ovum after they
enter the reproductive tract. The nuclear region releases an enzyme under the influence of
hyaluronidase which dissolved the zona pellucid of the ovum, the cytoplasm of the ovum then
engulfs the spermatozoa. Complex changes in the surface of the oocyte triggers three processes
in the ovum; formation of the fertilization cone which enables fusion between the ovum and
sperm membrane, instant depolarization of the ovum membrane and release of cortical granules
from the ovum which prevents fertilization by other spermatozoa.

The sperm continues the process of fertilization until its head which contains nucleus reaches the
female pronucleus, lose its tail at some points and the nucleus swell to create the male
pronucleus.

Fusion occurs when the pronuclei are next to each other causing disappearance of membranes of
ovary and sperm so that chromosomes can fuse together. This is to allow the cell to reestablish
its normal 46 chromosomes.

Development of the fertilized ovum

After fertilization the fertilized ovum is propelled along the fallopian tube towards the uterus for
implantation. While being propelled along the tube cell division takes place and the fertilized
zygote divides into 2-4-8-16 and so on until it consists of a ball of cell called the morula. 3 to 4
days is required for the journey from the fallopian tube to the uterus because the interstitial part
of the fallopian tube through which the morula must has a diameter of 1 mm, the ovum must be
very small to pass through it. Thereafter a cavity or blastocele forms in the morula which now
becomes known as the blastocyst. At one point the cells clumps together, forming the inner cell
mass while the remainder of the cells are pushed to the periphery.

IMPLANTATION (EMBEDDMENT)

About day 8 after fertilization ovum which is at the trophoblast stage is ready for embedding.
The trophoblast rest on the endometrium and tiny projections or buds appears at the area of
contact with the endometrium. The outer trophoblastic cells known as the syncytiotrophoblast
have the power to break down tissues, eroding the endometrium and allowing the trophoblast to
become embedded. The decidual reaction occurs to limit the invading propensity of the
trophoblast.

When the ovum burrows into the implantation cavity, slight vaginal bleeding may occur which
might be taken for a scanty menstrual period. The endometrial cells heal the opening and the
embedding of the fertilized ovum is complete.

On day 13 trophoblastic cells form rudimentary chorionic villi which contain no blood vessels.
They absorb nutriment from the disintegrated cells in the implantation cavity.

EMBRYONIC DEVELOPMENT or embryogenesis

Human embryology is the study development during the first 8 weeks after fertilization, typically
involving a series of well-defined stages. This important process involves cell division,
differentiation and morphogenesis leading to the formation of tissues, organs and systems within
developing the embryo. This begins at week 3 and ends at week 8.

In the 3rd week of embryonic development, the cells in the bilaminar disc (epiblast and
hypoblast) undergo a highly specialized process called gastrulation, when the 3 germ layers of
embryo form in a process called histogenesis. Thereafter the processes of neurulation and
organogenesis follow.

The primitive streak, a linear collection of cells formed by the migrating epiblast appears and
marks the beginning of gastrulation which takes place around week 3 after fertilization. The
process of gastrulation reorganizes the 2-layer embryo into 3-layer embryo, and also gives the
embryo its specific head-to-tail and front-to-back orientation, by way of primitive streak which
establishes bilateral symmetry.

The epiblast has now differentiated into 3 germ layers of embryo, so that the bilaminar disc is
now a trilaminar disc, the gastrula. The 3 germ layers are the ectoderm, mesoderm and
endoderm.

The Ectoderm is formed by the epiblast that remains in position. The ectoderm give rise to the
outer layer of the skin, central and peripheral nervous systems, eyes, inner ear and many
connective tissues.

The Mesoderm is formed by the cells that develop between the epiblast and endoderm. It gives
rise to the heart and the beginning of circulatory system as well as the bones, muscles and
kidneys.

The Endoderm is formed by the invagination of epiblast cells that migrate to the hypoblast. It
gives rise to lungs, intestine, thyroid, pancreas and bladder.

In the 4th week: Once gastrulation is complete the next stage called neurulation begins.
Following gastrulation, the ectoderm gives rise to the epithelial and neural tissue and gastrula is
now referred as neurula. The neural plate that has formed as a thickened plate from the ectoderm,
continues to broadend and it start to fold upwards as neural folds. Neurulation refers to the
folding process whereby the neural plate is transformed into the neural tube and this takes place
during the 4th week. The neural tube will eventually become the brain and spinal cord. The sac is
2.5 cm long, about the size of pigeon’s egg. The embryo measures about 1cm and weighs 1g. It
is curved like a bean so that the head and tail almost meet. The rudimentary eyes are visible and
small buds indicate where limbs will develop. Circulation of blood in the rudimentary form
exists, the heart beats.

At 6 weeks the gestational sac can be seen by ultrasound

At 8th weeks the sac is the size if a hen’s egg and the chorionic villi will have disappeared,
leaving the chorion leave except in the area where the villi are deeply embedded. The embedded
villi grow profusely and are known as the chorion frondosum which ultimately form the
placenta. The embryo is 3 cm long and weighs 4 g. amniotic fluid 5-10 mls is present. Centre of
ossification are apparent in some bones, hands and feet are recognizable. The head is large in
proportion to the body.

PLACENTAL FORMATION

At 3rd week, the ovum is completely covered with chorionic villi. The chorionic villi close to the
spongy layer of the decidua grow profusely and are known as chorion frondosum, which
eventually form the placenta. These chorionic villi penetrate the blood vessels with which they
come in contact and are bathed in a lake of maternal blood. The opened blood vessels are known
as sinuses while the areas surrounding the villi are called blood spaces.

Some of these villi are attached to the decidua and are known as anchoring villi while the
majority floats in the slowly circulating maternal blood from which they absorb nutrients. The
villi on the remainder of the trophoblast degenerate leaving the bald chorion and it is known as
chorion laeve.

The inner surface of the chorion laeve is adherent to the amnion and on its outer surface to the
deciduas capsularis and after 12th weeks to the deciduas vera.

A chorionic villus is a branching structure arising from the chorionic membrane as a single stem,
which divides and subdivides until it terminates in the fine filaments that are embedded in the
deciduas basalis. The outer layer of a chorionic villus, the syncytiotrophoblast is derived from
the cytotrophoblast the inner trophoblastic layer. By their selective action chorionic villi absorb
from the maternal blood the particular substances needed for the developing embryo. The centre
of the villus contains mesoderm and blood vessels, within which fetal blood circulates. The fetal
heart pumps 500 ml of blood through the placenta per minute.

The fetus develops its own blood as well as heart. There are 4 layers of tissue between fetal and
maternal blood: the syncytiotrophoblast, cytotrophoblast, mesoderm and the capillary wall. Fetal
blood and maternal blood do not mix except there is breakdown of the placenta. From the 12th to
20th week the placenta weighs as much as and even more than the fetus to cope with the
metabolic processes of nutrition because the fetal organs are not sufficiently developed to cope.
During the later weeks of pregnancy the cytotrophoblast and the syncytiotrophoblast gradually
degenerates as some of the fetal organs like liver begin to function.
PLACENTA AT TERM

The placenta at term is a round, flat mass about 20cm in diameter, 2.5 cm thick at the centre and
weigh about 1/6 of the baby at term. It is made up of the chorionic villi and blood vessels
containing fetal blood. It also consists of decidua basalis, in which the villi embeds, the
choriodecidual spaces and the maternal blood contained in them.

Structure of the Placenta

It has two surfaces:

 The Maternal Surface

The maternal surface is made up of chorionic villi, arranged in cotyledons or lobules that are
separated by sulci or furrows. Maternal blood gives it a bluish-red color, and the surface is
covered by a thin layer of trophoblastic cells. Frequently the maternal surface is covered with
small deposits of lime salts which has no clinical significance.

 The Fetal Surface

The fetal surface is smooth, white and shiny, and on it can be seen branches of the umbilical
veins and arteries and the insertion of the umbilical cord. It is covered with two membranes, the
chorion and the amnion, which are continued beyond its outer edge to form the sac that contains
the fetus and amniotic fluid.

FUNCTIONS OF THE PLACENTA

The placenta is a metabolic and incomplete endocrine organ as well as the means through which
the fetus obtains its needs. The placenta selects and transports from the mother’s blood the
substances necessary for fetal life and growth. It also changes some of these so that the fetus can
utilize them. Placenta and fetus are a functioning unit. The fetus depends on the placenta for
survival in utero.

The function of the placenta can be classified as:

NUTRITIVE
The fetus needs amino acids for building tissue; glucose for growth and energy; calcium and
phosphorus for the composition of bones and teeth; water, vitamins, electrolytes iron and other
minerals for blood formation, growth and various body processes. The placenta metabolizes
glucose, stores it in the form of glycogen and converts it into glucose as required. These products
of digestion from the mother’s blood pass to fetus through placenta by enzymatic carriers.

RESPIRATORY

The fetus obtains oxygen from the mother’s hemoglobin by diffusion and gives off carbon
dioxide into the maternal blood. There is fetal respiratory movement in utero but no pulmonary
exchange of gases.

EXCRETORY

Excretion from the fetus is very minimal because its metabolism is mainly anabolic.

ENDOCRINE

The placenta produces several hormones, namely:

 Human chorionic gonadotrophin (HCG): It is produced in the chorionic villi and forms
the basis of immunological and pregnancy tests. It can be detected in the urine and blood
14 days after fertilization. Large volume of this hormone is secreted during the 7th to 10th
week but after the 12th week there is a decline in secretion and maintained till term.
 Progesterone: It is produced by the placenta at about the 12th week and the amount rises
steadily throughout pregnancy and falls after the delivery of the placenta.
 Oestriol: It is produced by the feto-placental unit from 6th to 12th weeks and the amount
rises steadily until term. The fetus provides the fetus with the necessary precursors for the
production of oestriol. The amount secreted in urine during pregnancy is an index of feto-
placental function.
 Human placental lactogen (HPL): This is produced by the syncythiotrophoblast. The
level of HPL in the blood reflects placental function. HPL level below 4 micrograms/ml
at 38 weeks indicates the possibility of fetal hypoxia during labor. It is also believed that
the placenta contains all enzymes.
INACTIVATION

Enzymatic function of the placenta inactivates numerous unwanted substances from reaching the
fetus. With the exception of the certain viruses and rarely the tubercle bacillus, few organisms
pass the placenta to the fetus. These organisms include treponema pallidum, protozoa of malaria,
toxoplasmosis, rubella virus (if the fetus contacts it at 12th weeks, it may suffer cardiac defects,
cataract or deaf mutism), sedatives and analgesic gases, antibiotics as well as teratogenic drugs.

ABNORMALITIES OF THE PLACENTA

 Placental Succenturiata: This consists of an accessory lobe of placental tissue situated

in the fetal sac membrane with blood vessels running to the main placenta. It is formed
by the hypertrophy of some chorionic villi in the chorion leave which fail to atrophy.
Such lobe is likely to be retained in the uterus after birth causing profuse post partum
hemorrhage. This can be identified if the membrane has hole with blood vessels running
to it.
 Placenta bipartite or tripartita: this is a condition where there are 2 or 3complete or
almost complete lobes. The blood vessels unite when joining the umbilical cord, whereas
the vessels of the succenturiate lobe do not directly join the cord vessels. The umbilical
vessels bifurcate at the point of insertion of the cord on the placenta. In twin placentae
there are two cords.
 Placenta Circumvallata: this is a condition in which the placenta has a double layer of
amnion and chorion which has undergone infarction. This is seen as an opaque ring on
the fetal surface.

Disease of the Placenta

 Hydatidiform mole: this is a cystic degenerative proliferation of the chorionic villi. The
distended villi form vesicles varying in size from a pin-head to a small grape. This
process begins about the 6th week of pregnancy and the embryo is absorbed. The
exuberant growth of the chorionic villi gives rise to the production of excessive quantities
of chorionic gonadotrophin and large amount excreted in the urine. It is characterized
vaginal bleeding and undue enlargement of the uterus.
  Infarcts: Infarcts are areas of necrosed chorionic villi, red in the early stage and white
later with a solid cartilaginous consistency, produced by increased concentration of tissue
thromboplastin. They are commonly seen on the maternal surface and rarely on the fetal
surface.
 Calcareous degeneration: This is characterized by gritty particles that feel like
sandpaper and sometimes form plaques on the maternal surface. It is associated with the
normal degenerative processes of the placenta at term.
 Syphilis: it causes inflammation of the wall of the arteries (endarteritis).
 Oedema of the placenta: this is characterized by a large, pale placenta with water oozing
from it. It is associated with hydrops fetalis and is due to haemolytic disease of the
newborn caused by rhesus immunization.

FOETO-PLACENTAL EXCHANGE

Blood which has circulated throughout the fetus requires oxygenation and replenishment. The
deoxygenated blood is carried by the two umbilical arteries in the umbilical cord to the placenta,
where an interchange takes place between the fetus and the maternal blood by the process of
osmosis and diffusion as well as by the selective action of the cytotrophoblast and
syncytiotrophoblast. Four layers separate fetal from maternal blood. They are;
syncytiotrophoblast, cytotrophoblast, mesoderm and the capillary wall. Carbon dioxide and other
waste products are given off into the maternal blood, while nutrients and oxygen are picked up.

The replenished blood returns to the fetus by the veins in the umbilical cord which goes directly
to the liver but before reaching the liver a large branch, the ductus venosus, is given off and
empties the oxygenated blood into the inferior vena cava which returns all deoxygenated blood
to the heart from all the vessels below the diaphragm, including the portal vein. The oxygenated
blood therefore mixed with venous (deoxygenated) blood.

Through the foramen ovale of the fetal heart, the oxygenated blood returning from the placenta
via the inferior vena cava is shunted from the right into the left atrium. The blood then passes
from left atrium to the left ventricle where it is pumped out through the aorta.
This blood has the highest oxygen content in the fetal circulation and the major portion of it goes
via branches of the arch of the aorta to the great vessels of the neck that supply the brain and the
upper limbs. A smaller percentage of the blood passes down the descending arch of the aorta.

The deoxygenated blood from the head and upper limbs return to the heart via the superior vena
cava and passes from the right atrium to the right, and leaves the right ventricle by the pulmonary
artery.

The pulmonary circulation functions very slightly before birth, the major amount of blood
leaving the right ventricle of the fetus is therefore diverted from the lungs via the ductus
arteriosus which conveys the blood from the pulmonary artery to the descending arch of the
aorta, where it is distributed to the abdomen and pelvic viscera and to the lower limbs, though
the greater proportion of this blood is returned to the placenta via the hypogastric arteries, which
are branches of the internal iliac arteries.

FOETAL CIRCULATION
The fetus develops its own blood and the fetal and maternal blood does not mix except there is
an abnormality in the placenta. The fetus also produces its own erythrocytes and leukocytes. In
utero, the fetal gastro-intestinal and respiratory systems are not functioning. As a result the fetus
obtains nutrients and oxygen from the maternal blood as described below.

STRUCTURE IN THE FOETAL CIRCULATION

There are 4 temporary structures in the fetal circulation, they include:

 The Ductus Venosus (from a vein to a vein): This vessel carries oxygenated blood that
has been replenished by the placenta from the umbilical vein to the inferior vena cava and
to the heart for circulation throughout the heart.
 The Foramen Ovale: This is a temporary opening between the right and the left atrium
in the fetal heart which allows the oxygenated blood to shunt (flow directly) from right to
left atrium and be pumped out through the aorta.
 The Ductus Arteriosus (from an artery to an artery): This vessel carries deoxygenated
blood returned from the head and upper from the pulmonary artery to the descending arch
of the aorta, thereby by-passing the pulmonary circulation.
 The Hypogastric arteries: These 2 vessels branch off from the internal iliac arteries and
are known as the umbilical arteries when they enter the umbilical cord. They return
deoxygenated blood to the placenta for oxygenation and replenishment.

CIRCULATORY CHANGES AT BIRTH

Circulatory changes occur due to establishment of respiration. As the neonate cries, the lung field
expands with increase in the vascular field. As a result the shunting of blood through the ductus
arteriosus to aorta is sealed off and blood now flows through the pulmonary arteries to the lungs
for oxygenation. The ductus arteriosus ceases to function within 5 minutes after birth and within
2 months it is closed anatomically and eventually becomes a cardiac ligament.

If the ductus arteriosus remains patent, cyanosis will occur and this requires surgical intervention
especially during childhood.
Also the foramen ovale closes when the increased blood flow to the lungs reduces the pressure in
the right side of the heart and increases tension in the left side. When this fails to occur, the
venous blood in the right atrium mix with the arterial blood in the left atrium of the heart and
cause marked cyanosis.

THE FOETAL SKULL

The fetal skull is very crucial in obstetrics because it is so large compare to the true pelvis. As a
result some adaptation must take place between the skull and pelvis during labor. 96% of babies
are born head first and the head is the most difficult part to deliver whether it comes first or last.
Regions of the head may present which increases hazards of birth to the mother and the baby but
with good knowledge of the landmarks and measurements of the fetal skull, the midwife will
recognize malpresentation or cephalopelvic disproportion and deliver normal baby with minimal
amount of trauma to both the mother and baby.

Development of the Fetal Skull

The fetal skull bones comprised of 2 parietal bones, the frontal bone and the occipital bone. The
skull bones develop from membrane. The intra-membranous ossification of the skull bones
begins as early as the eight week of intra-uterine life. At term the skull bones are thin and pliable,
and as ossification at their edges is not quite complete, areas of membrane persist between the
bones. The membranous spaces between the bones of the vault of the skull are known as sutures.

During labor considerable overlapping of the skull bones (moulding) take place at these
membranous spaces.

REGIONS OF THE FETAL SKULL

The skull is divided into the vault, face and base.

The Vault

The vault is the large dome-shaped compressible part made up of the 2 parietal, the upper parts
of the frontal, occipital and temporal bones. It is the region above an imaginary line drawn from
the orbital ridges to the nape of the neck.
The Base

The base is comprised of bones firmly united to afford protection to the vital centres in the
medulla.

The Face

The face in a newborn is very small because of the poorly developed mandible. The face is the
area from the root of the nose to the junction of the chin and neck. The chin or mentum is an
important landmark. The bones of the face are firmly united at birth and do not permit moulding.

The Vertex

The vertex is the area bounded in front by the anterior fontanelle, behind by the posterior
fontanelle and laterally by the 2 parietal eminences which are seen as two prominent points on
the parietal bones. 95 of 96% of babies who are born head first present by the vertex.

The Brow or Sinciput

The Brow or Sinciput is composed of the frontal bone and is bounded by the orbital ridges and
the coronal suture.

The Occiput

The Occiput is the region over the occipital bone and extends from the posterior fontanelle to the
foramen magnum. The suboccipital region is the part under the occipital protuberance, a
prominent point on the posterior aspect of the skull.

EXTERNAL STRUCTURES OF THE FETAL SKULL

SUTURES
Sutures are membranous spaces between the bones of the vault of the skull. The sutures form
very useful landmarks to determine presentation and position when making a vaginal
examination during labor. The sutures include:

 Sagittal suture: This suture lies between the parietal bones.

 Lambdoidal suture: This suture separates the occipital and the parietal bones.
 Coronal suture: This suture runs between the parietal and frontal bones, crossing from
one temple to the other.
 Frontal suture: This suture separates two halves of the frontal bone.

FONTANELLES
Fontanelle is where 2 or more sutures meet the membranous space at the junction. There are 6
fontanells on the skull but only the anterior and posterior fontanelles are of obstetrics
importance.

The anterior fontanelle (bregma) is the membranous space at the junction of the sagittal, coronal
and frontal sutures. It is diamond –shaped, about 2.5 cm long and 1.25 cm wide. It is recognized
vaginally as a junction of four sutures. Pulsations of the cerebral vessels can be felt through it.
The bregma should be closed by 18 months old.

The posterior fontanel (Lamda) is situated at the junction of the sagittal and lamboidal sutures. It
is smaller than the bregma and can be recognized vaginally as the junction of three (3) sutures. It
is triangular in shape and should be closed by six (6) after birth.

DIAMETERS

Biparietal Diameter: This diameter measures between the two parietal eminences. It is 9.5 cm.

Bitemporal: This is measured from the furthest points of the coronal suture (i.e. between the
temples). It is 8.2 cm

Suboccipito-bregmatic: This is measured from below the occipital protuberance (the nape of
the neck) to the center of the anterior fontanelle or bregma. It is 9.5 cm.

Suboccipito-frontal: This is measured from below the occipital protuberance to the center of the
sinciput. It is 10 cm.

Occipito-frontal: This is measured from the occipital protuberance to the glabella, a point above
the bridge of the nose. It is 11.5 cm.

Submento-bregmatic: This extends from where the chin joins the neck to the centre of the
anterior fontanelle or bregma. It is 9.5 cm.

Submento-vertical: This extends from where the chin joins the neck to the highest point on the
vertex. It is 11.5 cm.

Mento-vertical: This is measured from the tip of the chin to the highest point on the vertex. It is
13.5 cm.
INTERNAL STRUCTURES

The skull contains delicate membranous structure which is liable to damage during delivery
especially if subjected to abnormal moulding. The structures include:

 Folds of dura matter

 Venous sinuses associated with them.

The membrane is in two layers, an outer periosteal layer which is adherent to the skull bones and
the inner meningeal layer which covers the outer surface of the brain. The membrane also sends
fibrous partition to divide the brain into compartments.
 The falx cerebri: It is a sickle- shaped fold of membrane which dips down between the
two cerebral hemispheres. It runs beneath the frontal and sagittal sutures (from root of the
nose to the internal occipital protuberance).
 Tentorim Cerebelli: This is a horizontal fold of dura matter situated at the posterior part
of the cranial cavity. It lies at the right angle to the falx cerebri. It has a horse-shoe shape
and forms atent-like layer between the cerebrum and the cerebellum. It contains large
blood vessels or sinus which drains blood from the brain on their way tobecome the
jugular vein of the neck.
 The superior longitudinal (sagittal) sinus: It runs along the upper part of the falx
cerebri from anterior to posterior (from the root of the nose to the internal occipital
protuberance)
 The inferior longitudinal (sagittal) sinus: It runs along the lower part in the same
direction.
 The straight sinus: It is a continuation of the inferior sagittal sinus and drains blood
from the great cerebral vein and the inferior sagittal sinus along the junction of 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 sinus.
 The Great Cerebral vein of Galen: It meet the inferior sagittal sinus at the inner end of
the junction and where the falx joins the tentorium.
 Lateral Sinuses: They are two in number that passes from the confluence of the sinuses
along the outer edge of the tentorium cerebella and carries blood to the internal jugular
veins.

During moulding, the falx and the tentorium are stretched. The tentorium is most vulnerable to
tear near its attachment to the falx (tentorial tear). Tentorial tear leads to bleeding from the great
cerebral vein giving rise to intracranial hemorrhage which may manifest as flaccid paralysis of
one side of the body

CHANGES THAT TAKES PLACE DURING LABOUR

MOULDING

Moulding is the term applied to the changes in shape of the fetal head that takes place due to the
prolonged compression to which it is subjected during its passage through the birth canal. This
alteration in shape of the fetal head is because the bones of the vault are not well ossified, are
somewhat pliabe and permit a slight degree of bending. The overriding of the skull bones takes
place at the sutures and is the most important factor in moulding. A certain amount of moulding
is present in every baby’s head except babies born by elective caesarean section. During
moulding the engaging diameter is compressed and may be shortened by as much as 1.25 cm and
the diameter at right angles to it will be elongated. In the vertex presentation, LOA, the sub
occipito-bregmatic diameter is reduced and the mento-vertical diameter is lengthened.

In small preterm babies moulding is excessive. The soft skull bones and wide suture afford little
protection to the delicate brain substance. In post mature babies the suture are almost closed and
the head does not mould well. The hardness of the head rather than its increased size tends to
make labor more difficult.