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Chapter 2: Maternal Anatomy

ANTERIOR ABDOMINAL WALL


Skin, Subcutaneous Layer, and Fascia
Anterior Abdominal Wall
Confines abdominal viscera
Stretches to accommodate the expanding uterus
Provides surgical access to the internal reproductive organs.
Langer lines describe the orientation of dermal fibers within the skin.
Anterior abdominal wall: arranged transversely.
Vertical skin incisions sustain increased lateral tension thus develop
wider scars.
Low transverse incisions (Pfannenstiel) follow Langer lines and
lead to superior cosmetic results.
Subcutaneous Layer
a) Superficial
Predominantly fatty layer (Camper Fascia)
b) Deeper membranous layer (Scarpa Fascia)
Camper Fascia
Continues onto the perineum to provide fatty substance to the mons pubis
and labia majora
Blend with the fat of the ischioanal fossa.
Scarpa Fascia
Continues inferiorly onto the perineum as Colles fascia
Perineal infection or hemorrhage superficial to Colles fascia has the ability
to extend upward to involve the superficial layers of the abdominal wall.
Beneath the subcutaneous layer, the anterior abdominal wall muscles consist of
the following which extend across the entire wall
a) Midline Rectus Abdominis
b) Pyramidalis Muscles
c) External Oblique
d) Internal Oblique
e) Transversus Abdominis Muscles
Fibrous aponeuroses of these three latter muscles form the primary fascia
of the anterior abdominal wall.
Fuse in the midline at the Linea Alba
Normally measures 10 to 15 mm wide below the umbilicus
Abnormally wide separation may reflect Diastasis Recti or Hernia.
Three aponeuroses also invest the rectus abdominis muscle as the
Rectus Sheath.
Construction of this sheath varies above and below a boundary,
Arcuate Line
Cephalad: aponeuroses invest the rectus abdominis bellies on both
dorsal and ventral surfaces.
Caudal: all aponeuroses lie ventral or superficial to the rectus
abdominis muscle
Only the thin transversalis fascia and peritoneum lie beneath Innervation
the rectus Anterior Abdominal Wall is innervated by
Transition of rectus sheath composition can be seen best with a a) Intercostal Nerves (T711)
midline abdominal incision b) Subcostal Nerve (T12),
Pyramidalis Muscles c) Iliohypogastric and Ilioinguinal Nerves (L1)
Paired small triangular muscles Intercostal and Subcostal Nerves are Anterior Rami of the Thoracic Spinal
O: pubic crest, I: linea alba Nerves
Lie atop the rectus abdominis muscle but beneath the anterior rectus Run lateral and then anterior abdominal wall between the transversus
sheath. abdominis and internal oblique muscles(Transversus Abdominis Plane)
Near the rectus abdominis lateral borders, these nerve branches pierce
Blood Supply the posterior sheath, rectus muscle, and then anterior sheath to reach the
Arise from the Femoral Artery just below the inguinal ligament within the skin.
femoral triangle May be severed during a Pfannenstiel incision at the point in which the
a) Superficial Epigastric overlying anterior rectus sheath is separated from the rectus muscle.
b) Superficial Circumflex Iliac Iliohypogastric and Ilioinguinal Nerves originate from the Anterior Ramus of
c) Superficial External Pudendal the First Lumbar Spinal Nerve
Supply the skin and subcutaneous layers of the anterior abdominal wall Emerge lateral to the psoas muscle and travel across the quadratus
and mons pubis. lumborum inferomedially toward the iliac crest.
Superficial Epigastric vessels course diagonally toward the umbilicus. Near this crest, both nerves pierce the transversus abdominis muscle and
With a low transverse skin incision, can usually be identified at a depth course ventrally.
halfway between the skin and the anterior rectus sheath, above Scarpa 2 to 3 cm medial to the anterior superior iliac spine, they pierce the
fascia, and several centimeters from the midline. internal oblique muscle and course superficial to it toward the midline
Branches of the External Iliac Vessels Iliohypogastric Nerve
a) Inferior Deep Epigastric Perforates the external oblique aponeurosis near the lateral rectus border
b) Deep Circumflex Iliac to provide sensation to the skin over the suprapubic area.
Supply the muscles and fascia of the anterior abdominal wall Ilioinguinal Nerve
Inferior Epigastric vessels initially course lateral to, then posterior to the Course medially through the inguinal canal and exits through the
rectus abdominis muscles, which they supply. Superficial Inguinal Ring, which forms by splitting of external abdominal
Pass ventral to the posterior rectus sheath and course between the oblique aponeurosis fibers.
sheath and the rectus muscles. Supplies the skin of the mons pubis, upper labia majora, and medial upper
Near the umbilicus, anastomose with the Superior Epigastric Artery and thigh.
Veins, which are branches of the Internal Thoracic Vessels. Ilioinguinal and Iliohypogastric Nerves can be severed during a low
Maylard incision: Inferior Epigastric Artery may be lacerated lateral to transverse incision or entrapped during closure, especially if incisions extend
the rectus belly during muscle transection. beyond the lateral borders of the rectus muscle
These vessels rarely may rupture following abdominal trauma and create These nerves carry sensory information only and injury leads to loss of
a rectus Sheath Hematoma sensation within the areas supplied.
Hesselbach Triangle Rarely, chronic pain may develop.
Lie on each side of the lower anterior abdominal wall T10 dermatome approximates the level of the umbilicus.
Bounded: L-inferior epigastric vessels, I: inguinal ligament, M: lateral Regional analgesia for cesarean delivery or for puerperal sterilization
border of the rectus muscle. ideally blocks T10 through L1 levels.
Direct Inguinal Hernias: hernias that protrude through the abdominal wall Transversus Abdominis Plane Block can provide broad blockade to the
in Hesselbach triangle. nerves that traverse this plane
Indirect Inguinal Hernias: hernias that protrude through deep inguinal May be placed post cesarean to reduce analgesia requirements
ring, which lies lateral to this triangle, and then may exit out the superficial Rectus Sheath Block or Ilioinguinal-Iliohypogastric Nerve Block to
inguinal ring. decrease postoperative pain

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EXTERNAL GENERATIVE ORGANS Clitoral Body
Vulva Contains two corpora cavernosa
Mons Pubis, Labia, and Clitoris Extending from the clitoral body, each corpus cavernosum
Pudenda diverges laterally to form long narrow crus.
Commonly designated the vulva Each crus lies along the inferior surface of its respective
Includes all structures visible externally from the symphysis pubis to the ischiopubic ramus, deep to the ischiocavernosus muscle.
perineal body. Blood supply stems from branches of the Internal Pudendal Artery
Includes: Mons Pubis, Labia Majora and Minora, Clitoris, Hymen, Deep Artery of the clitoris supplies the clitoral body
Vestibule, Urethral Opening, Greater Vestibular (Bartholin Glands), Minor Dorsal Artery of the clitoris supplies the glans and prepuce.
Vestibular Glands and Paraurethral Glands Vestibule
Functionally mature female structure derived from the embryonic
urogenital membrane
An almond-shaped area
Enclosed by
L: Hart line, M: external surface of the hymen, A: clitoral frenulum,
P: fourchette
Perforated by six openings:
a) Urethra
b) Vagina
c) two Bartholin gland ducts
d) two ducts of the largest Paraurethral Glands (Skene glands)
Fossa Navicularis
Posterior portion of the vestibule between the fourchette and the
vaginal opening
Usually observed only in nulliparas.
bilateral Bartholin Glands
Also termed Greater Vestibular Glands
0.5 -1 cm in diameter
Mons Pubis Each lies inferior to the vascular vestibular bulb and deep to the
Also called the Mons Veneris inferior end of the bulbocavernosus muscle
Fat-filled cushion overlying the symphysis pubis. Duct from each measures 1.5 - 2 cm long
After puberty, it is covered by curly hair that forms the escutcheon. In Opens distal to the hymeneal ring
women, hair is distributed in a triangle, whose base covers the upper One at 5 and the other at 7 oclock on the vestibule.
margin of the symphysis pubis Following trauma or infection, either duct may swell and obstruct to
In men and some hirsute women, the escutcheon is not so well form a cyst or, if infected, an abscess.
circumscribed and extends onto the anterior abdominal wall toward the Minor Vestibular Glands
umbilicus. Shallow glands lined by simple mucin-secreting epithelium
Labia Majora Open along Hart line
Homologous with the male scrotum. Paraurethral Glands
7-8 cm in length, 2-3 cm in depth, and 1-1.5 cm in thickness Collective arborization of glands whose multiple small ducts open
S: continuous directly with the mons pubis and round ligaments terminate predominantly along the entire inferior aspect of the urethra.
at their upper borders. Two Largest are called Skene Glands
P: taper and merge into the area overlying the perineal body to form the Ducts typically lie distally and near the urethral meatus.
Posterior Commissure. Inflammation and duct obstruction of any of the paraurethral glands
Hair covers the labia majora outer surface but is absent on their inner can lead to urethral diverticulum formation.
surface. Lower two thirds of the urethra lie immediately above the anterior vaginal
Apocrine, eccrine, and sebaceous glands are abundant. wall
Beneath the skin is a dense connective tissue layer, which is nearly void Urethral opening or meatus is in the midline of the vestibule
of muscular elements but is rich in elastic fibers and adipose tissue. 1-1.5 cm below the pubic arch and short distance above the vaginal
Mass of fat provides bulk to the labia majora opening.
Supplied with a rich venous plexus
During pregnancy: vasculature commonly develops varicosities, especially
in parous women
Due to increased venous pressure created by the enlarging uterus.
Appear as engorged tortuous veins or as small grapelike clusters
but typically asymptomatic.
Each is a thin tissue fold that lies medial to each labium majus
Males: homologue forms the ventral shaft of the penis.
Labia Minora
Extends superiorly where each divides into two lamellae
From each side, lower lamellae fuse to form the frenulum of the
clitoris
Upper merge to form the prepuce
Inferiorly extend to approach the midline as low ridges of tissue that join to
form the fourchette
Lengths: 2 -10 cm, widths 1-5 cm
Composed of connective tissue with numerous vessels, elastin fibers, and
very few smooth muscle fibers
Supplied with many nerve endings and extremely sensitive.
Thinly keratinized stratified squamous epithelium covers the outer surface
of each labium. Vagina and Hymen
Inner surface: lateral portion is covered by this same epithelium up to a Hymen
demarcating line (Hart Line) Membrane of varying thickness that surrounds the vaginal opening more
Medial: each labium is covered by nonkeratinized squamous or less completely.
epithelium Composed mainly of elastic and collagenous connective tissue
Lack hair follicles, eccrine glands, and apocrine glands but many Both outer and inner surfaces are covered by non-keratinized stratified
sebaceous glands squamous epithelium
Clitoris Aperture of the intact hymen ranges in diameter from pinpoint to one that
Principal female erogenous organ admits one or even two fingertips.
Erectile homologue of the penis. Imperforate Hymen
Located beneath the prepuce, above the frenulum and urethra, Rare malformation in which the vaginal orifice is occluded
projects downward and inward toward the vaginal opening completely causing retention of menstrual blood
Rarely exceeds 2 cm in length As a rule, the hymen is torn at several sites during first coitus.
Composed of Edges of the torn tissue soon reepithelialize
a) Glans Pregnant women: hymeneal epithelium is thick and rich in glycogen.
b) Corpus or body Over time, the hymen transforms into several nodules of various sizes,
c) Two crura termed Hymeneal or Myrtiform Caruncles.
Glans Vagina
Usually < 0.5 cm in diameter Proximal to the hymen
Covered by stratified squamous epithelium Musculomembranous tube that extends to the uterus
Richly innervated Interposed lengthwise between the bladder and the rectum

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Anteriorly, separated from the bladder and urethra by connective tissue Incised by an episiotomy incision and is torn with second-, third-, and
(Vesicovaginal Septum) fourth-degree lacerations.
Posteriorly, between the lower portion of the vagina and the rectum
together form the Rectovaginal Septum. Superficial Space of the Anterior Triangle
upper fourth is separated from the rectum by the Rectouterine Pouch Bounded by: S:pubic rami, L:ischial tuberosities, P: superficial transverse
Also called the Cul-De-Sac or Pouch of Douglas. perineal muscles
Anterior wall measures 6-8 cm Divided into superficial and deep spaces by the Perineal Membrane.
Posterior vaginal wall is 7-10 cm Membranous partition is a dense fibrous sheet that was previously known
Upper end of the vaginal vault is subdivided by the cervix into as the Inferior Fascia of the Urogenital Diaphragm.
a) Anterior Attaches: L:ischiopubic rami, M: distal third of the urethra and vagina, P:
b) Posterior perineal body, A:arcuate ligament of the pubis.
c) two Lateral Fornices Superficial space of the anterior triangle is bounded deeply by the Perineal
Clinical importance because the internal pelvic organs usually Membrane and superficially by Colles Fascia.
can be palpated through the thin walls of these fornices. Colles fascia is the continuation of Scarpa fascia onto the perineum.
Posterior fornix provides surgical access to the peritoneal On the perineum, Colles fascia securely attaches L: pubic rami and fascia
cavity. lata of the thigh, I: superficial transverse perineal muscle and inferior
Midportion of the vagina: lateral walls are attached to the pelvis by visceral border of the perineal membrane, M: urethra, clitoris, and vagina.
connective tissue. Superficial space of the anterior triangle is a relatively closed compartment, and
Lateral attachments blend into investing fascia of the levator ani. expanding infection or hematoma within it may bulge yet remains contained.
Create the anterior and posterior lateral vaginal sulci. Superficial pouch contains several important structures: Bartholin glands,
Run the length of the vaginal sidewalls and give the vagina an H vestibular bulbs, clitoral body and crura, branches of the pudendal vessels
shape when viewed in cross section. and nerve, and ischiocavernosus, bulbocavernosus, and superficial
Lining is composed of non-keratinized stratified squamous epithelium and transverse perineal muscles.
underlying lamina propria. Ischiocavernosus muscles each attach on their respective side:
Premenopausal women: lining is thrown into numerous thin I: medial aspect of the ischial tuberosity
transverse ridges, known as Rugae L: ischiopubic ramus
Line the anterior and posterior vaginal walls along their A: clitoral crus
length. Help maintain clitoral erection by compressing the crus to obstruct venous
Deep to this is a muscular layer, which contains smooth muscle, collagen, drainage.
and elastin. Bilateral bulbocavernosus muscles
Beneath lies an adventitial layer consisting of collagen and elastin Overlie the vestibular bulbs and Bartholin glands.
No vaginal glands A: body of the clitoris (A) and the perineal body (P).
Lubricated by a transudate that originates from the vaginal subepithelial Constrict the vaginal lumen and aid release of secretions from the
capillary plexus and crosses the permeable epithelium Bartholin glands.
Due to increased vascularity during pregnancy, vaginal secretions Contribute to clitoral erection by compressing the deep dorsal vein
are notably increased. of the clitoris.
After birth-related epithelial trauma and healing, fragments of stratified Bulbocavernosus and ischiocavernosus muscles also pull the clitoris
epithelium occasionally are embedded beneath the vaginal surface. downward.
Buried epithelium continues to shed degenerated cells and keratin. Superficial transverse perineal muscles are narrow strips that attach to the
Result a firm epidermal inclusion cysts, which are filled with keratin ischial tuberosities (L) and the perineal body (M)
debris, may form and are a common Vaginal Cyst. May be attenuated or even absent, but when present, they contribute to
Proximal portion is supplied by the Cervical Branch of Uterine Artery the perineal body
and Vaginal Artery Vestibular Bulbs
May variably arise from the Uterine or Inferior Vesical or directly Embryologically correspond to the corpora spongiosa of the penis
from the Internal Iliac Artery. Almond-shaped aggregations of veins
Middle Rectal Artery supply the posterior vaginal wall 3-4 cm long, 1-2 cm wide, and 0.5-1 cm thick
Internal Pudendal Artery supplies distal walls Lie beneath the bulbocavernosus muscle on either side of the vestibule.
Blood supply from each side forms anastomoses on the anterior and Terminate inferiorly at the middle of the vaginal opening
posterior vaginal walls with contralateral corresponding vessels. Extend upward toward the clitoris.
Extensive venous plexus immediately surrounds the vagina and follows Anterior extensions merge in the midline, below the clitoral body.
the course of the arteries. During childbirth, veins may be lacerated or even rupture to create a
Lymphatics from the lower third, along with those of the vulva, drain vulvar hematoma enclosed within the superficial space of the anterior
primarily into the Inguinal Lymph Nodes. triangle.
Middle third drain into the Internal Iliac Nodes
Upper third drain into the External, Internal, and Common Iliac
Nodes.

Perineum
Diamond-shaped area between the thighs has boundaries that mirror those of Deep Space of the Anterior Triangle
the bony pelvic outlet: Space lies deep to the perineal membrane and extends up into the pelvis
A: pubic symphysis, AL: ischiopubic rami and ischial tuberosities, Continuous superiorly with the pelvic cavity
PL:sacrotuberous ligaments, P:coccyx Contains
An arbitrary line joining the ischial tuberosities divides the perineum into an a) Portions of urethra and vagina
anterior triangle (urogenital triangle) and posterior triangle (anal triangle) b) Certain portions of internal pudendal artery branches,
Perineal Body c) Compressor urethrae
Fibromuscular mass found in the midline at the junction between these d) Urethrovaginal sphincter muscles
anterior and posterior triangles Comprise part of the striated urogenital sphincter complex.
Also called the Central Tendon of the Perineum Pelvic Diaphragm
Measures 2 cm tall and wide and 1.5 cm thick Found deep to the anterior and posterior triangles
Serves as the junction for several structures and provides significant Broad muscular sling provides substantial support to the pelvic viscera.
perineal support Composed of
Superficially, the bulbocavernosus, superficial transverse perineal, and a) Levator ani
external anal sphincter muscles converge on the central tendon. More b) Coccygeus muscle.
deeply, perineal membrane, portions of the pubococcygeus muscle, and c) Levator ani
internal anal sphincter contribute Composed of
1) Pubococcygeus
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2) Puborectalis Increasing uterine size, excessive straining, and hard stool create increased
3) Iliococcygeus pressure that ultimately leads to degeneration and subsequent laxity of the
Pubococcygeus Muscle cushions supportive connective tissue base.
Also termed the Pubovisceral Muscle These protrude into and downward through the anal canal
Subdivided based on points of insertion and function Leads to venous engorgement within the cushions (Hemorrhoids)
Include Venous stasis results in inflammation, erosion of the
1) Pubovaginalis cushions epithelium, and then bleeding.
2) Puboperinealis External Hemorrhoids
3) Puboanalis Those that arise distal to the pectinate line.
Insert into the vaginal, perineal body, and anus, respectively Covered by stratified squamous epithelium
Vaginal birth conveys significant risk for damage to the levator ani or to its Receive sensory innervation from the Inferior Rectal Nerve.
innervation Pain and a palpable mass are typical complaints.
Pubovisceral Muscle is more commonly damaged Following resolution, a hemorrhoidal tag may remain composed of
Injuries may predispose women to greater risk of pelvic organ prolapse or redundant anal skin and fibrotic tissue.
urinary incontinence Internal Hemorrhoids
Efforts are aimed at minimizing these injuries. Those that form above the dentate line
Covered by insensitive anorectal mucosa
Posterior Triangle May prolapse or bleed but rarely become painful unless they
contains undergo thrombosis or necrosis.
a) Ischioanal Fossae
b) Anal Canal Anal Sphincter Complex
c) Anal Sphincter Complex Two sphincters surround the anal canal to provide fecal continence
Anal Sphincter Complex a) External Sphincter
Consists of b) Internal Anal Sphincters
a) Internal anal sphincter Both lie proximate to the vagina
b) External anal sphincter One or both may be torn during vaginal delivery
c) Puborectalis muscle Internal Anal Sphincter (IAS)
d) Branches of the pudendal nerve and internal pudendal vessels Distal continuation of the rectal circular smooth muscle layer.
Receives predominantly parasympathetic fibers, which pass through the
Ischioanal Fossae pelvic splanchnic nerves.
Also known as Ischiorectal Fossae Supplied by the Superior, Middle, and Inferior Rectal Arteries
two fat-filled wedge-shaped spaces Contributes the bulk of anal canal resting pressure for fecal continence
found on either side of the anal canal and relaxes prior to defecation
comprise the bulk of the posterior triangle Measures 3- 4 cm in length
Each fossa has skin as its superficial base At its distal margin, it overlaps the external sphincter for 1-2 cm
Deep apex is formed by the junction of the levator ani and obturator internus Distal site at which this overlap ends (Intersphincteric Groove)
muscle. Palpable on digital examination.
Other borders include: External Anal Sphincter (EAS)
Obturator internus muscle fascia and ischial tuberosity (L) Striated muscle ring
Anal canal and sphincter complex (IM) Anteriorly attaches to the perineal body
Inferior fascia of the downwardly sloping levator ani (SM) Posteriorly connects to the coccyx (anococcygeal ligament)
Maximus muscle and sacrotuberous ligament (P) Maintains a constant resting contraction to aid continence
Inferior border of the anterior triangle (A). Provides additional squeeze pressure when continence is threatened, yet
Fat found within each fossa provides support to surrounding organs yet allows relaxes for defecation.
rectal distention during defecation and vaginal stretching during delivery. Three parts include
Injury to vessels in the posterior triangle can lead to hematoma formation in the a) Subcutaneous
ischioanal fossa b) Superficial
Potential for large accumulation in these easily distensible spaces. c) Deep Portions
Two fossae communicate dorsally, behind the anal canal Deep portion is composed fully or in part by the puborectalis muscle
Episiotomy infection or hematoma may extend from one fossa into the Receives blood supply from the inferior rectal artery
other. Branch of the internal pudendal artery
Somatic motor fibers from the Inferior Rectal Branch of the Pudendal
Nerve supply innervation.
IAS and EAS may be involved in fourth-degree laceration during vaginal delivery
Reunion of these rings is integral to defect repair

Anal Canal
Distal continuation of the rectum
Begins at the level of levator ani attachment to the rectum and ends at the anal
skin.
4-5 cm length
Mucosa consists of
a) Columnar epithelium (uppermost portion)
b) Simple stratified squamous epithelium (begins at dentate or pectinate line
Pudendal Nerve
continues to the anal verge)
Formed from the anterior rami of S24 spinal nerves
Keratin and skin adnexa join the squamous epithelium.
Courses between the piriformis and coccygeus muscles
Has several lateral tissue layers
Exits through the greater sciatic foramen
Inner layers include
Posterior to the sacrospinous ligament
a) Anal Mucosa
Medial to the ischial spine
b) Internal Anal Sphincter
When injecting local anesthetic for a pudendal nerve block, the ischial spine
c) Intersphincteric Space
serves an identifiable landmark
Contains continuation of the rectums longitudinal smooth Runs beneath the sacrospinous ligament and above the sacrotuberous ligament
muscle layer. Reenters the lesser sciatic foramen to course along the obturator internus
Outer layer contains muscle.
a) Puborectalis Muscle (S) Lies within the pudendal canal (Alcock canal)
b) External Anal Sphincter (I) Formed by splitting of the obturator internus investing fascia
Within the anal canal, three highly vascularized submucosal arteriovenous Relatively fixed as it courses behind the sacrospinous ligament and within
plexuses (anal cushions) the pudendal canal
Aid complete closure of the canal and fecal continence when apposed. May be at risk of stretch injury during downward displacement of the
pelvic floor during childbirth

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Leaves this canal to enter the perineum Pregnancy stimulates remarkable uterine growth due to muscle
Divides into three terminal branches fiber hypertrophy
1) Dorsal Nerve of the Clitoris Uterine fundus, previously flattened convexity between tubal
Runs between the ischiocavernosus muscle and perineal insertions, now becomes dome shaped.
membrane Round ligaments appear to insert at the junction of the middle and
Supply the clitoral glans upper thirds of the organ.
2) Perineal Nerve Fallopian tubes elongate, but the ovaries grossly appear
Runs superficial to the perineal membrane unchanged.
Divides into Posterior Labial Branches and Muscular Branches Cervix
Serve the labial skin and the anterior perineal triangle Fusiform and open at each end by small apertures
muscles, respectively. a) Internal Cervical Ora
3) Inferior Rectal Branch b) External Cervical Ora
Runs through the ischioanal fossa Proximally, the upper boundary of the cervix is the internal os, corresponds to
Supply the external anal sphincter, the anal mucosa, and the the level at which the peritoneum is reflected up onto the bladder
perianal skin Portio Supravaginalis
Major blood supply to the perineum is via the Internal Pudendal Artery Upper cervical segment
Branches mirror the divisions of the pudendal nerve. Lies above the vaginas attachment to the cervix
Covered by peritoneum on its posterior surface
INTERNAL GENERATIVE ORGANS Cardinal ligaments attach laterally
Separated from the overlying bladder by loose connective tissue.
Lower cervical portion protrudes into the vagina as the Portio Vaginalis.
Before childbirth, the external cervical os is a small, regular, oval opening.
After labor, especially vaginal childbirth, the orifice is converted into a
transverse slit that is divided such that there are the so-called Anterior
and Posterior Cervical Lips.
If torn deeply during labor or delivery, the cervix may heal in such a
manner that it appears irregular, nodular, or stellate.
Ectocervix
Portion of the cervix exterior to the external os
Lined by nonkeratinized stratified squamous epithelium
Endocervical Canal
Covered by a single layer of mucin-secreting columnar epithelium, creates
deep cleftlike infoldings or glands.
Commonly during pregnancy, the endocervical epithelium moves out and onto
the ectocervix in a physiological process (Eversion)
Stroma is composed mainly of collagen, elastin, and proteoglycans, but very
little smooth muscle.
Changes in the amount, composition, and orientation of these
components lead to cervical ripening prior to labor onset.
In early pregnancy, increased vascularity within the cervix stroma beneath the
epithelium creates an ectocervical blue tint (Chadwick Sign).
Cervical edema leads to softening (Goodell Sign), isthmic softening (Hegar
Sign)

Myometrium and Endometrium


Most of the uterus is composed of
Myometrium
Smooth muscle bundles united by
connective tissue containing
many elastic fibers.
Interlacing myometrial fibers surround
myometrial vessels and contract to
compress these.
Uterus Integral to hemostasis at the
Nonpregnant uterus: situated in the pelvic cavity placental site during the third
Between the bladder (A) and rectum (P) stage of labor.
Entire posterior wall of the uterus is covered by serosa (Visceral Peritoneum) Number of myometrial muscle fibers
Lower portion of this peritoneum forms the anterior boundary of the varies by location
Rectouterine Cul-De-Sac (Pouch Of Douglas) Levels progressively diminish caudally such that, in the cervix, muscle
Only the upper portion of the anterior wall of the uterus is so covered. makes up only 10% of the tissue mass
Peritoneum in this area reflects forward onto the bladder dome to create Uterine body inner wall: more muscle than in outer layers
the Vesicouterine Pouch Anterior and posterior walls: more muscle than in the lateral walls.
Lower portion of the anterior uterine wall is united to the posterior wall of the During pregnancy, the upper myometrium undergoes marked hypertrophy, but
bladder by well-defined loose connective tissue layer (Vesicouterine Space) there is no significant change in cervical muscle content.
During cesarean delivery, peritoneum of the vesicouterine pouch is Uterine cavity is lined with Endometrium
sharply incised, and the vesicouterine space is entered. Composed of an overlying epithelium, invaginating glands, and
Dissection caudally within this space lifts the bladder off the lower uterine supportive, vascular stroma
segment for hysterotomy and delivery Varies greatly throughout the menstrual cycle and during pregnancy.
Pear shaped Divided into
Consists of two major but unequal parts. a) Functionalis Layer
a) Body or Corpus Sloughed with menses
upper triangular portion b) Basalis Layer
b) Cervix Serves to regenerate the functionalis layer following each
Lower, cylindrical portion menses.
Projects into the vagina
c) Isthmus Ligaments
Union site of these two Several ligaments that extend from the uterine surface toward the pelvic
Special obstetrical significance because it forms the lower uterine sidewalls
segment during pregnancy. Include
At each superolateral margin of the body is a Uterine Cornu a) Round Ligaments
From which a fallopian tube emerges b) Broad Ligaments
This area is the origins of the round and uteroovarian ligaments. c) Cardinal Ligaments
Between the points of fallopian tube insertion is the convex upper uterine d) Uterosacral Ligaments
segment (fundus) Round Ligament
Bulk of the uterine body is muscle Corresponds embryologically to the male gubernaculum testis
Inner surfaces of the anterior and posterior walls lie almost in contact Originates below and anterior to the origin of the fallopian tubes.
Cavity between these walls forms a mere slit Orientation can aid in fallopian tube identification during puerperal
Nulligravid uterus: 6-8 cm in length sterilization
Multiparous uterus: 9-10 cm Important if pelvic adhesions limit tubal mobility and thus limit fimbria
Averages 60 g and typically weighs more in parous women visualization prior to tubal ligation.
Nulligravidas: fundus and cervix are approximately equal in length Each extends laterally and downward into the inguinal canal, through
Multiparas: cervix is only a little more than a third of the total length. which it passes, to terminate in the upper portion of the labium majus.

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Sampson Artery
Branch of the uterine artery Enters the base of the broad ligament and makes its way medially to the
Runs within this ligament side of the uterus.
Nonpregnant women: 3-5 mm in diameter 2 cm lateral to the cervix, the uterine artery crosses over the ureter.
Composed of smooth muscle bundles separated by fibrous tissue septa This proximity is of great surgical significance as the ureter may be
During pregnancy, these ligaments undergo considerable hypertrophy and injured or ligated during hysterectomy when the vessels are
increase appreciably in both length and diameter. clamped and ligated.
Once the uterine artery has reached the supravaginal portion of the cervix,
it divides
Cervicovaginal Artery
Supplies blood to the lower cervix and upper vagina
Main branch turns abruptly upward and extends as a highly
convoluted vessel that traverses along the lateral margin of the
uterus
Extends into the upper portion of the cervix,
Numerous other branches penetrate the body of the uterus to form
the Arcuate Arteries
Encircle the organ by coursing within the myometrium just
beneath the serosal surface.
These vessels from each side anastomose at the uterine
midline.
From the arcuate arteries, Radial Branches originate at right
angles, traverse inward through the myometrium, enter the
endometrium, and branch there to become Basal Arteries or coiled
Spiral Arteries.
Spiral Arteries
Supply the functionalis layer.
Broad Ligaments Vessels respond by vasoconstriction and dilatation to a
Two wing like structures that extend from the lateral uterine margins to the number of hormones
pelvic sidewalls. serve an important role in menstruation
With vertical sectioning through this ligament proximate to the uterus Basal Arteries
Triangular shape can be seen Also called Straight Arteries
Uterine vessels and ureter are found at its base Extend only into the basalis layer
Divide the pelvic cavity into anterior and posterior compartments. Not responsive to hormonal influences.
Each consists of a fold of peritoneum (Anterior and Posterior Leaves) Just before the main uterine artery vessel reaches the fallopian tube, it
This peritoneum drapes over structures extending from each cornu. divides into three terminal branches
Peritoneum Ovarian Branch of the uterine artery
a) Mesosalpinx: Overlies the fallopian tube Forms an anastomosis with the terminal branch of the Ovarian
b) Mesoteres : Around the round ligament is the Artery
c) Mesovarium: Over the uteroovarian ligament Tubal branch
Infundibulopelvic Ligament or Suspensory Ligament of the Ovary Makes its way through the mesosalpinx
Peritoneum that extends beneath the fimbriated end of the fallopian tube Supplies part of the fallopian tube
toward the pelvic wall forms the. Fundal branch
Contains nerves and the ovarian vessels penetrates the uppermost uterus
During pregnancy, these vessels, especially the venous plexuses, are Ovarian Artery
dramatically enlarged. Direct branch of the aorta
Diameter of the ovarian vascular pedicle increases from 0.9 cm to reach Enters the broad ligament through the infundibulopelvic ligament.
2.6 cm at term Ovarian hilum: divides into smaller branches that enter the ovary.
Cardinal Ligament As the ovarian artery runs along the hilum, it also sends several branches
Also called the Transverse Cervical Ligament or Mackenrodt Ligament through the mesosalpinx to supply the fallopian tubes.
Thick base of the broad ligament Main stem traverses the entire length of the broad ligament and makes its
Medially united firmly to the uterus and upper vagina way to the uterine cornu.
Each uterosacral ligament originates with a posterolateral attachment to Forms an anastomosis with the ovarian branch of the uterine artery. Dual
the supravaginal portion of the cervix uterine blood supply creates a vascular reserve to prevent uterine
Inserts into the fascia over the sacrum ischemia if ligation of the uterine or internal iliac artery is performed to
Ligaments are composed of connective tissue, small bundles of vessels control postpartum hemorrhage.
and nerves, and some smooth muscle. Uterine veins accompany their respective arteries.
Covered by peritoneum, these ligaments form the lateral boundaries of the Arcuate Veins unite to form the Uterine Vein
pouch of Douglas. Empties into the internal iliac vein and then the Common Iliac Vein.
Parametrium Within the broad ligament, these veins form the large pampiniform plexus
Describe the connective tissues adjacent and lateral to the uterus that terminates in the Ovarian Vein.
within the broad ligament. Right Ovarian Vein empties into the Vena Cava
Paracervical tissues are those adjacent to the cervix Left Ovarian Vein empties into the Left Renal Vein.
Paracolpium Blood supply to the pelvis is predominantly supplied from branches of the
Tissue lateral to the vaginal walls. Internal Iliac Artery.
Organized into anterior and posterior divisions
Anterior Division
Provides blood supply to the pelvic organs and perineum
Includes the inferior gluteal, internal pudendal, middle rectal,
vaginal, uterine, obturator arteries and umbilical artery
Continuation as the superior Vesical Artery

Posterior Division
Extend to the buttock and thigh
Include the superior gluteal, lateral sacral, and iliolumbar
arteries. during internal iliac artery ligation
Many advocate ligation distal to the posterior division to avoid
compromised blood flow to the areas supplied by this division

Lymphatics
Endometrium is abundantly supplied with lymphatic vessels that are confined
largely to the basalis layer.
Lymphatics of the underlying myometrium are increased in number toward
the serosal surface and form an abundant lymphatic plexus just beneath
it.
Lymphatics from the cervix terminate mainly in the internal iliac nodes
Blood Supply
Situated near the bifurcation of the common iliac vessels
During pregnancy, there is marked hypertrophy of the uterine vasculature
Lymphatics from the uterine corpus are distributed to two groups of nodes.
Supplied principally from the Uterine and Ovarian Arteries
Vessels drains into the Internal Iliac Nodes
Uterine Artery
After joining certain lymphatics from the ovarian region, terminates in the
main branch of the Internal Iliac Artery
Paraaortic Lymph Nodes.
previously called the Hypogastric Artery
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Innervation On its surface, there is a single layer of cuboidal epithelium, (Germinal
Peripheral nervous system is divided Epithelium of Waldeyer)
a) Somatic Division Beneath this epithelium, the cortex contains oocytes and developing
Innervates skeletal muscle follicles.
b) Autonomic Division Medulla
Innervates smooth muscle, cardiac muscle, and glands. Central portion
Pelvic visceral innervation is predominantly autonomic Composed of loose connective tissue.
Further divided in Sympathetic and Parasympathetic There are a large number of arteries and veins and small number of
Components. smooth muscle fibers.
Sympathetic Innervation to pelvic viscera begins with the Superior Supplied with both sympathetic and parasympathetic nerves.
Hypogastric Plexus (Presacral Nerve) Sympathetic nerves: Ovarian Plexus that accompanies the ovarian
Beginning below the aortic bifurcation and extending downward vessels
retroperitoneally, this plexus is formed by sympathetic fibers arising from Originates in the renal plexus.
spinal levels T10-L2. Others are derived from the plexus that surrounds the ovarian
At the level of the sacral promontory, divides into a Right and a Left branch of the uterine artery.
Hypogastric Nerve, which run downward along the pelvis side walls Parasympathetic input: Vagus Nerve
Sensory afferents follow the ovarian artery and enter at T10 spinal
cord level.

Parasympathetic Innervation
Derives from neurons at spinal levels S2-S4
Axons exit as part of the anterior rami of the spinal nerves for those levels.
These combine on each side to form the pelvic splanchnic nerves (Nervi
Erigentes)
Blending of the two Hypogastric Nerves (sympathetic) and the two Pelvic
Splanchnic Nerves (parasympathetic) gives rise to the Inferior Hypogastric Fallopian Tubes
Plexus (Pelvic Plexus) Called Oviducts
Retroperitoneal plaque of nerves lies at the S4-S5 level Serpentine tubes extend 8-14 cm from the uterine cornua
From here, fibers of this plexus accompany internal iliac artery branches Anatomically classified along their length as an
to their respective pelvic viscera. a) Interstitial Portion
Inferior Hypogastric Plexus b) Isthmus
Divides into three plexuses c) Ampulla
a) Vesical Plexus d) Infundibulum
Innervates the bladder and the middle rectal travels to the Interstitial Portion
rectum Most proximal
b) Uterovaginal Plexus (Frankenhuser Plexus) Embodied within the uterine muscular wall.
Reaches the proximal fallopian tubes, uterus, and upper Isthmus
vagina. Narrow 2-3 Mm
Extensions of the inferior hypogastric plexus also reach the perineum Adjoins the uterus and widens gradually
along the vagina and urethra to innervate the clitoris and vestibular bulbs Ampulla
Composed of variably sized ganglia, but particularly of a large ganglionic 5-8 mm
plate that is situated on either side of the cervix, proximate to the More lateral
uterosacral and cardinal ligaments Infundibulum
Most afferent sensory fibers from the uterus ascend through the inferior funnel-shaped fimbriated distal extremity of the tube
hypogastric plexus and enter the spinal cord via T10-T12 and L1 spinal opens into the abdominal cavity
nerves Latter three extrauterine portions are covered by the Mesosalpinx at the
Transmit the painful stimuli of contractions to the central nervous superior margin of the broad ligament.
system Extrauterine fallopian tube contains a mesosalpinx, myosalpinx, and
Sensory nerves from the cervix and upper part of the birth canal pass through endosalpinx
the pelvic splanchnic nerves to the second, third, and fourth sacral nerves.
Those from the lower portion of the birth canal pass primarily through the Mesosalpinx
Pudendal Nerve. Single-cell mesothelial layer
Anesthetic blocks used in labor and delivery target this innervation. Functioning as visceral peritoneum
Ovaries Myosalpinx
During childbearing years: 2.5 -5 cm in length, 1.5-3 cm in breadth, and 0.6-1.5 Smooth muscle
cm in thickness. Arranged in an inner circular and an outer longitudinal layer.
Usually lie in the upper part of the pelvic cavity In the distal tube, the two layers are less distinct and are replaced
Rest in a slight depression on the lateral wall of the pelvis (Ovarian Fossa of near the fimbriated extremity by sparse interlacing muscular fibers.
Waldeyer) Tubal musculature undergoes rhythmic contractions constantly, the
Between the divergent external and internal iliac vessels. rate of which varies with cyclical ovarian hormonal changes.
Uteroovarian Ligament Endosalpinx
Originates from the lateral and upper posterior portion of the uterus Tubal mucosa
Beneath the tubal insertion level Single columnar epithelium composed of ciliated and secretory cells
Extends to the uterine pole of the ovary resting on a sparse lamina propria
3-4 mm in diameter In close contact with the underlying myosalpinx.
Made up of muscle and connective tissue Ciliated cells are most abundant at the fimbriated extremity, but
covered by Mesovarium elsewhere, they are found in discrete patches
Blood supply traverses to and from the ovary through this double-layered Mucosa is arranged in longitudinal folds that become progressively
mesovarium to enter the ovarian hilum. more complex toward the fimbria
Consists of a cortex and medulla Ampulla: lumen is occupied almost completely by the arborescent mucosa
Young women: outermost portion of the cortex is smooth Current produced by the tubal cilia is such that the direction of flow is
Tunica Albuginea: dull white surface toward the uterine cavity.

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Tubal peristalsis created by cilia and muscular layer contraction is Frequently designated the arcuate ligament of the pubis.
believed to be an important factor in ovum transport P: pelvic bones are joined by articulations
Supplied richly with elastic tissue, blood vessels, and lymphatics. Between the sacrum and the iliac portion of the innominate bones to form
Sympathetic innervation is extensive in contrast to their parasympathetic the Sacroiliac Joints.
innervation These joints in general have a limited degree of mobility.
Nerve supply derives partly from the Ovarian Plexus and partly from the During pregnancy, there is remarkable relaxation of these joints at term,
Uterovaginal Plexus. caused by upward gliding of the sacroiliac joint
Sensory afferent fibers ascend to T10 spinal cord levels. Displacement, which is greatest in the dorsal lithotomy position,
may increase the diameter of the outlet by 1.5-2.0 cm.
MUSCULOSKELETAL PELVIC ANATOMY Main justification for placing a woman in this position for a
vaginal delivery.
But this pelvic outlet diameter increase occurs only if the
sacrum is allowed to rotate posteriorly.
Thus, it will not occur if the sacrum is forced anteriorly by the
weight of the maternal pelvis against the delivery table or bed
Sacroiliac joint mobility is also the likely reason that the McRoberts maneuver
often is successful in releasing an obstructed shoulder in a case of shoulder
dystocia
Attributed to the success of the modified squatting position to hasten
second-stage labor
Squatting position may increase the interspinous diameter and the pelvic
outlet diameter

Pelvic Bones
Pelvis
Composed of four bones
a) Sacrum
b) Coccyx
c) Two Innominate Bones
Each innominate bone is formed by the fusion of three bones
1) Ilium
2) Ischium
3) Pubis
Joined to the sacrum at the sacroiliac
synchondroses and to one another at the Planes and Diameters of the Pelvis
symphysis pubis Pelvis is described as having four imaginary planes:
Conceptually divided into false and true components a) The plane of the pelvic inlet (Superior Strait)
a) False Pelvis b) The plane of the pelvic outlet (Inferior Strait)
Lies above the linea terminalis c) The plane of the midpelvis: least pelvic dimensions
Bounded: p:lumbar vertebra, l: iliac fossa, a:lower portion of the d) The plane of greatest pelvic dimension: no obstetrical significance.
anterior abdominal wall
b) True Pelvis
Portion important in childbearing
Obliquely truncated, bent cylinder with its greatest height
posteriorly.
Borders:
S:linea terminalis
I: pelvic outlet
P: anterior surface of the sacrum
L:inner surface of the ischial bones and the sacrosciatic
notches and ligaments
A: pubic bones, ascending superior rami of the ischial bones,
and obturator foramina.
Sidewalls converge
Pelvic Inlet
Extending from the middle of the posterior margin of each
Also called the Superior Strait
ischium are the ischial spines.
Superior plane of the true pelvis
Great obstetrical importance because the distance
Bounded:
between them usually represents the shortest diameter
P: promontory and alae of the sacrum
of the true pelvis.
L: linea terminalis
Serve as valuable landmarks in assessing the level to which the presenting part
A: horizontal pubic rami and the symphysis pubis.
of the fetus has descended into the true pelvis
During labor, fetal head engagement (fetal heads biparietal diameter)
Aid pudendal nerve block placement.
passing through this plane.
Sacrum
To aid this passage, the inlet of the female pelvis typically is more
Forms the posterior wall of the true pelvis
nearly round than ovoid.
Upper anterior margin corresponds to the promontory that may be felt
Nearly round or gynecoid pelvic inlet in approximately half of white
during bimanual pelvic examination in women with a small pelvis. Provide
women.
a landmark for clinical pelvimetry
Four diameters of the pelvic inlet are usually described:
Normally, the sacrum has a marked vertical and a less pronounced
a) Anteroposterior
horizontal concavity, which in abnormal pelves may undergo important
b) Transverse
variations.
c) Two oblique diameters
Straight line drawn from the promontory to the tip of the sacrum usually
Distinct anteroposterior diameters have been described using specific
measures 10 cm
landmarks.
Distance along the concavity averages 12 cm
a) Anteroposterior Diameter
Most cephalad
Termed the True Conjugate
Extends from the uppermost margin of the symphysis pubis to the
sacral promontory
Clinically important Obstetrical Conjugate is the shortest distance
between the sacral promontory and the symphysis pubis.
Normally, this measures 10 cm or more, but cannot be
measured directly with examining fingers.
Estimated indirectly by subtracting 1.5-2 cm from the
Diagonal Conjugate
Determined by measuring the distance
Transverse diameter is constructed at right angles to
the obstetrical conjugate
Pelvic Joints Represents the greatest distance between the linea
A: pelvic bones are joined together by the symphysis pubis. terminalis on either side
Consists of fibrocartilage and the superior and Inferior Pubic Ligaments.
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Usually intersects the obstetrical conjugate at a point
approximately 5 cm in front of the promontory and
measures approximately 13 cm.
Each of the two oblique diameters extends from one sacroiliac
synchondrosis to the contralateral iliopubic eminence.
Each eminence is a minor elevation that marks the union site of the
ilium and pubis.
These oblique diameters average less than 13 cm.

Midpelvis and Pelvic Outlet


Midpelvis
Measured at the level of the ischial spines
Also called the Midplane or Plane of Least Pelvic Dimensions
During labor, the degree of fetal head descent into the true pelvis may be
described by station, and the midpelvis and ischial spines serve to mark
zero station
Interspinous Diameter
10 cm or slightly greater
Usually the smallest pelvic diameter
Anteroposterior Diameter
Through the level of the ischial spines
Normally measures at least 11.5 cm
Pelvic Outlet
Consists of two approximately triangular areas whose boundaries mirror
those of the perineal triangle
Base is a line drawn between the two ischial tuberosities
Apex of the posterior triangle is the tip of the sacrum
Lateral boundaries are the sacrotuberous ligaments and the ischial
tuberosities
Anterior triangle is formed by the descending inferior rami of the pubic
bones
Rami unite at an angle of 90-100 degrees to form a rounded arch under
which the fetal head must pass.
Clinically, three diameters of the pelvic outlet usually are describe
Anteroposterior
Transverse
Posterior sagittal
Unless there is significant pelvic bony disease, the pelvic outlet seldom
obstructs vaginal delivery.

Pelvic Shapes
Caldwell-Moloy anatomical classification of the pelvis based on shape, and its
concepts aid an understanding of labor mechanisms.
Greatest transverse diameter of the inlet and its division into anterior and
posterior segments are used to classify the pelvis as
a) Gynecoid
b) Anthropoid
c) Android
d) Platypelloid
Posterior segment determines the type of pelvis
Anterior segment determines the tendency.
Both determined because many pelves are not pure but are mixed
types.
Gynecoid pelvis with an android tendency means that the posterior pelvis
is gynecoid and the anterior pelvis is android shaped.
Configuration of the gynecoid pelvis would intuitively seem suited for
delivery of most fetuses.
Gynecoid pelvis was found in almost half of women.

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