MATERNAL ANATOMY

EXTERNAL and INTERNAL GENERATIVE ORGANS

Anterior Abdominal Wall

confines abdominal viscera stretches to accommodate the expanding uterus provides surgical access to the internal reproductive organs

ANTERIOR ABDOMINAL WALL

Skin
Langer lines
describe the orientation of dermal fibers In the abdomen:
Transversely arranged

vertical skin incisions

more tension, wider scars

low transverse incisions (Pfannenstiel)

follow Langer lines; superior cosmetic results

Subcutaneous Layer
Campers fascia
Superficial predominantly fatty layer

Scarpas fascia
Deeper more membranous layer

These are not discrete layers but instead represent a continuum of the subcutaneous tissue layer.

Rectus Sheath
fibrous aponeuroses of the external oblique, internal oblique, and transversus abdominis muscles join in the midline

Arcuate line
Cephalad- aponeuroses invest the rectus abdominis bellies above and below Caudal- all aponeuroses lie anterior to the rectus abdominis muscle, and only the thin transversalis fascia and peritoneum lie beneath.

Blood Supply
A. Femoral Artery Branches arteries supply the skin and subcutaneous layers of the anterior abdominal wall and mons pubis
superficial epigastric superficial circumflex iliac external pudendal

B. External Iliac Artery Branches - supply the muscles and fascia of the anterior abdominal wall
inferior "deep" epigastric vessels deep circumflex iliac vessels-.

Hesselbach triangle
Bounderies Inferiorly: inguinal ligament Medially: lateral border of the rectus muscles Laterally: inferior epigastric vessels. Direct hernias- involves the Hesselbach triangle

Indirect hernias- involves the deep inguinal ring

Anterior Abdominal Wall Innervation

Intercostal nerves (T7-11) Subcostal nerve (T12) Iliohypogastric nerve- skin over suprapubic area Ilioinguinal nerves (L1) skin of the lower abdominal wall upper portion of the labia majora medial portion of the thigh

T10 dermatome- approximates the level of the umbilicus.

Clinical Significance
The ilioinguinal and iliohypogastric nerves can be entrapped during closure of low transverse incisions, especially if incisions extend beyond the lateral borders of the rectus muscle These nerves carry sensory information only, and injury leads to loss of sensation within the areas supplied.

EXTERNAL GENERATIVE ORGANS

External Generative Organs PUDENDA or VULVA

includes all structures visible externally from the pubis to the perineum:
Mons pubis Labia majora and minora Clitoris Hymen Vestibule Urethral opening Various glandular and vascular structures

External Generative Organs MONS PUBIS

Also called mons veneris
fat-filled cushion that lies over the symphysis pubis At puberty, covered by curly hair that forms the escutcheon In adult women, it is distributed in a triangular area Base: forms the upper margin of the symphysis pubis

LABIA MAJORA
Male homologue: scrotum It is where the round ligaments terminate (upper boarder) Outer surface with hair while inner surface without hairs In children and nulliparous women - close apposition In multiparous women - gapes widely continuous directly with the mons pubis Merge posteriorly to form the posterior commissure.

LABIA MINORA composed of connective tissue with many vessels and some smooth muscular fibers moist and reddish, similar in appearance to a mucous membrane extremely sensitive because its supplied with many nerve endings 2 lamellae superiorly
lower pair: forms the frenulum of the clitoris upper pair: forms the prepuce

Inferiorly, it forms the fourchette.

LABIA MINORA Lining epithelium

Outer and Lateral portion of inner surface- stratified squamous epithelium Medial portion- non-keratinized squamous epithelium Hart line- demarcation line between lateral and midline portion
Contains sebaceous follicles, few sweat glands Lack hair follicles, eccrine glands and apocrine glands

CLITORIS Male homologue: penis composed of a glans, a corpus, and two crura rarely exceeds 2 cm in length. covered by stratified squamous epithelium that is richly supplied with nerve ending
principal female erogenous organ

VESTIBULE - from embryonic urogenital membrane almond-shaped

BOUNDARIES:
Lateral- Hart line Medial external surface of hymen Anteriorly- frenulum Posteriorly- fourchette

6 openings:
urethra vagina ducts of the Bartholin glands (2) ducts of the paraurethral glands/skene glands (2)

Vestibular Glands
Bartholin glands
greater vestibular glands

Paraurethral glands
Lies in the inferior aspect of the urethra Skene glands - largest Minor vestibular glands are shallow glands lined by simple mucin-secreting epithelium and open along Hart line.

0.5 to 1 cm in diameter lie inferior to the vestibular bulbs and deep to the inferior ends of the bulbocavernosus muscle ducts are 1.5 to 2 cm long and open distal to the hymenal ring at 5 & 7 o'clock

Vestibular Bulbs
Male homologue: corpus spongiosum of the penis almond-shaped, mainly composed of aggregations of veins
3 to 4 cm long, 1 to 2 cm wide, and 0.5 to 1 cm thick

lie beneath the bulbocavernosus muscle on either side of the vestibule. If injured, may rupture to create a vulvar hematoma.

VAGINAL OPENING AND HYMEN

HYMEN
elastic and collagenous connective tissue Lined by stratified squamous epithelium no glandular or muscular elements, and it is not richly supplied with nerve fibers
Appearance varies with age:
Newborn- very vascular and redundant Pregnant- thick, rich in glycogen Menopause- thin; focal cornification may develop

VAGINAL OPENING AND HYMEN

Appearance of the hymen cannot be used to determine whether a woman has begun sexual activity.

VAGINAL OPENING AND HYMEN

Clinical Significance: Imperforate hymen
is a rare lesion in which the vaginal orifice is occluded completely, causing retention of menstrual blood

VAGINA Musculo-membranous structure Extends from the vulva to the uterus interposed anteriorly and posteriorly between the urinary bladder and the rectum . Lining epithelium: non-keratinized stratified squamous epithelium no glands abundant vascular supply

VAGINA embryology
upper portion - mllerian ducts lower portion - urogenital sinus o Divided by a septum from the urethra and the rectum Anteriorly- vesicovaginal septum Posteriorly- rectovaginal septum

upper fourth of the vagina is separated from the rectum by the rectouterine pouch (cul-de-sac of Douglas) subdivided into the anterior, posterior, and two lateral fornices by the uterine cervix

VAGINA usual vaginal length:

Anterior: 6 to 8 cm Posterior: 7 to 10cm

Clinical importance:
internal pelvic organs usually can be palpated through their thin walls posterior fornix provides surgical access to the peritoneal cavity

VAGINA
BLOOD SUPPLY cervicovaginal branches of uterine arteries inferior vesical arteries middle rectal and internal pudendal arteries LYMPHATIC DRAINAGE
iliac nodes internal iliac nodes inguinal lymph nodes

Upper Third Middle third Lower third

PERINEUM
Boundaries:
Anterior: Pubic symphysis Posterior: Ischiopubic rami Anterolateral: Ischial tuberosities Posterolateral: Sacrotuberous ligaments Posterior: Coccyx

Blood supply:
Internal pudendal artery (inferior rectal artery and posterior labial artery)

Ischial Tuberosities divides the perineum into an anterior and posterior triangle

PERINEUM
ANTERIOR TRIANGLE
Also called Urogenital Triangle Further subdivided into:
Superficial space closed compartment Deep space continuous superiorly with the pelvic cavity

Boundaries:
Superior: Pubic rami Lateral: Ischial tuberosities Posterior: Superficial transverse pernieal muscle

PERINEUM
SUPERFICIAL SPACE OF THE ANTERIOR TRIANGLE Helps maintain clitoral erection Ischiocavernosus Bulbocavernosus
Constrict the vaginal lumen and aid in the release of secretions of the Bartholins gland Contributes to clitoral erection
contributes to the perineal body

Superficial transverse pernineal muscles

DEEP SPACE OF THE ANTERIOR TRIANGLE

Compressor urethrae Urethrovaginal sphincter muscles External urethral sphincter Parts of urethra and vagina Branches of the internal pudendal artery Dorsal nerve Vein of the clitoris

PERINEUM
POSTERIOR TRIANGLE
Contains:
Ischiorectal fossa Anal canal Anal sphincter complex Branches of the internal pudendal vessels Pudendal nerve

Pudendal nerve
Formed by teh anterior rami of S2-S4 Lies posteromedial to the ischial spines

Pudendal nerve
3 Terminal branches:
1. Dorsal nerve supplies the skin of teh clitoris 2. Perineal nerve serves the muscles of the anterior triangle and labial skin 3. Inferior rectal branch supplies the following:
a. b. c. external anal sphincter mucous membrane of the anal perianal skin

Anus

Anus
External anal sphincter (EAS)
maintains a constant state of resting contraction Provides increased tone and strength when continence is threatened Relaxes for defacation

Internal anal sphincter (IAS)

Primarily involved in 4th degree perineal laceration

Anal cushion
Highly vascularized Aids in fecal continence Engorgement due to increased uterine size, excessive straining and hard stools, leads to hemorrhoids

INTERNAL GENERATIVE ORGANS

Embryological Development of the Uterus and Oviducts

fusion of the two mllerian ducts to form a single canal is begun at the level of the inguinal crest, that is, the gubernaculum (primordium of the round ligament) upper ends of the mllerian ducts produce the oviducts and the fused parts give rise to the uterus The vaginal canal is not patent throughout its entire length until the sixth month of fetal life

Embryological Development of the Uterus and Oviducts 5th week of embryonic development - uterus and tubes arise from the mllerian ducts, which first appear near the upper pole of the urogenital ridge
6th week of embryonic life- the growing tips of the two mllerian ducts approach each other in the midline; they reach the urogenital sinus 1 week later.

INTERNAL GENERATIVE ORGANS

Cervix Anteriorly, upper boundary- internal os Supravaginal segment
is covered by peritoneum on its posterior surface attached to the cardinal ligaments anteriorly, and it is separated from the overlying bladder by loose connective tissue.

Lower vaginal portion- portio vaginalis.

Cervix
The mucosa is a single layer of very high ciliated columnar epithelium that rests on a thin basement membrane Glands furnish the thick, tenacious cervical secretions.

If the ducts of the cervical glands are occluded, retention cysts, known as nabothian cysts, are formed.

Uterus Thick- walled, hollow, muscular organ entire posterior wall of the uterus is covered by serosa, or peritoneum, the lower portion of which forms the anterior boundary of the recto-uterine cul-de-sac, or pouch of Douglas.
Blood supply: uterine artery ovarian artery

Uterus The bulk of the body of the uterus is composed of muscle. The cervical canal is fusiform and is open at each end by small apertures, the internal os and the external os.

Body of the Uterus composed of serosal, muscular, and mucosal layers. The serosal layer is formed by the peritoneum that covers the uterus.

Layers:

Endometrium thin, pink, velvet-like membrane perforated by a large number of minute ostia of the uterine glands. Histologically- inner glands resemble the epithelium of the surface and are lined by a single layer of columnar, partially ciliated epithelium that rests on a thin basement membrane.

Myometrium
makes up the bulk of the uterus of bundles of smooth muscle united by connective tissue in which there are many elastic fibers. the number of muscle fibers of the diminishes caudally musculature: Inner> outer wall; A and P walls > lateral walls During pregnancy, the upper myometrium undergoes marked hypertrophy, but there is no significant change in cervical muscle content.

Blood supply of the uterus

 BROAD LIGAMENT
are made up of two winglike structures that extend from the lateral margins of the uterus to the pelvic walls. divide the pelvic cavity into anterior and posterior compartments. upper part is made up of three folds that nearly cover the oviduct

CARDINAL LIGAMENT transverse cervical ligament or the Mackenrodt ligament densest portion composed of connective tissue that medially is united firmly to the supravaginal portion of the cervix.

ROUND LIGAMENTS
extend from the lateral portion of the uterus, arising below and anterior to the origin of the oviducts. In nonpregnant women, the round ligament varies from 3 to 5 mm in diameter is composed of smooth muscle cells. corresponds embryologically to the gubernaculum testis of men During pregnancy, undergo considerable hypertrophy and increase appreciably in both length and diameter.

Lymphatics Cervix
terminate mainly in the hypogastric nodes, which are situated near the bifurcation of the common iliac vessels.

body of the uterus

internal iliac nodes and periaortic lymph nodes

Blood Vessels

Oviducts
commonly called the fallopian tubes, vary in length from 8 to 14 cm. lumen is lined by mucous membrane.

PARTS
interstitial portion isthmus ampulla infundibulum or fimbriated extremity- funnel-shaped opening at the distal

 Musculature
inner circular and outer longitudinal layer.

Lined by a single layer of columnar cells, some of them ciliated and others secretory. No submucosa
the epithelium is in close contact with the underlying muscle.

Tubal peristalsis is believed to be an extraordinarily important factor in transport of the ovum.

 Supplied richly with elastic tissue, blood vessels, and lymphatics. Sympathetic innervation of the tubes is extensive, in contrast to their parasympathetic innervation. Diverticula may extend occasionally from the lumen of the tube; may play a role in the development of ectopic pregnancy.

Ovaries the ovaries vary considerably in size.

During childbearing years, they are from 2.5 to 5 cm in length, 1.5 to 3 cm in breadth, and 0.6 to 1.5 cm in thickness. After menopause, ovarian size diminishes remarkably.

attached to the broad ligament by the mesovarium.

Ovaries
utero-ovarian ligament extends from the lateral and posterior portion of the uterus, just beneath the tubal insertion, to the uterine pole of the ovary. It is covered by peritoneum and is made up of muscle and connective tissue fibers. infundibulopelvic or suspensory ligament of the ovaryextends from the upper or tubal pole to the pelvic wall

Ovaries
PARTS: Cortex- outer layer Medulla- central portion BLOOD SUPPLY The ovaries are supplied with both sympathetic and parasympathetic nerves.

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