FEMALE PELVIS

INTRODUCTION The abdomen and pelvis form the single biggest cavity in the body which lodges many visceral organs. The pelvic bone gives the structure and integrity of waist. The primary function of the bone is to allow movement of the body, especially walking, running and sitting. It permits the person to sit and kneel. The womans pelvis is adapted for childbearing, and because of its increased width and rounded brim women are less speedy than men. The pelvis affords protection to the pelvic organs and, to a lesser extent, the abdominal organs. The female pelvis because of its characteristics, gives rise to no difficulties in childbirth, providing the fetus is of normal size. The knowledge of pelvic anatomy is needed for the conduct of labour as one of the way to estimate the progress made is by assessing the relationship of the fetus to certain pelvic landmarks. As a midwife we should be competent to recognize a normal pelvis in order to be able to detect deviations from normal. PELVIC BONES There are four pelvic bones: Two innominate or hip bones One sacrum One coccyx
INNOMINATE BONE [coxal

bone]

Each innominate bone is composed of three parts: The ilium: The ilium is the large flared-out part. When the hand is placed on the hip it rests on the iliac crest, which is the upper border. At the front of the iliac crest can be felt a bony prominence known as the anterior superior iliac spine. A short distance below it is the anterior inferior iliac spine. There are two similar points at the other end of the iliac crest, namely the posterior superior and the posterior inferior iliac spines. The concave anterior surface of the ilium is the iliac fossa and the lateral aspect of the ilium constitutes gluteal surfaces. The ischium: The ischium is the thick lower part. It has a large prominence known as the ischial tuberosity, on which the body rests while sitting. Behind and a little above the tuberosity there is an inward projection, the ischial spine.

The pubic bone: This bone forms the anterior part. It has a body and two oar-like projections, the superior ramus and the inferior ramus. The two pubic bones meet at the symphysis pubis and the two inferior rami form the pubic arch. The space enclosed by the body of the pubic bone, the rami and the ischium is called the obturator foramen. The innominate bone contains a deep cup to receive the head of the femur. This is termed as the acetabulum. All three parts of the bone contribute to acetabulum in the following proportions: two fifths ilium, two fifths ischium and one fifth pubic bone. On the lower border of the innominate bone are found two curves. One extends from the posterior inferior iliac spine up to the iscial spine and is called the greater sciatic notch. It is wide and rounded. The other lies between the ischial spine and the ischial tuberosity and is the lesser sciatic notch.
THE SACRUM

The sacrum is a wedge-shaped bone consisting of five fused vertebrae. The upper border of the first sacral vertebrae just forward and is known as the sacral promontory. The anterior surface of the sacrum is concave and is referred as hollow of the sacrum. Laterally the sacrum extends into a wing or ala. Four pairs of holes or foramina pierce the sacrum and through these, nerves from the cauda equina emerge to supply the pelvic organs. The posterior surface is roughened to receive attachments of muscle.
COCCYX

The coccyx consists of four fused vertebrae, forming a small triangular bone. The bone is directed downwards and forwards, making a continuous curve with the sacrum. The coccyx is slightly mobile on the sacrum, but fuses with it late in life. PELVIC JOINTS There are four pelvic joints: One symphysis pubis Two sacroiliac joints One sacrococcygeal joint The symphysis pubis Is a cartilaginous or fibrocartilaginous joint formed at the junction of two pubic bones, which are united by a pad of cartilage.

The sacroiliac joints this joint is the strongest joints in the body. It is a synovial joint of an irregular plane type between the articular surfaces of the sacrum and ilium and is covered by cartilage. The sacrococcygeal joint- this joint is cartilaginous joint formed where the base of the coccyx articulates with the tip of sacrum. PELVIC LIGAMENTS Each of the pelvic joint is held together by ligaments: Interpubic ligaments at the symphysis pubis Sacroiliac ligaments Sacrococcygeal ligaments. There are two other ligaments important in midwifery: Sacrotuberous ligament Sacrospinous ligament. The sacrospinous ligament runs from the sacrum to the ischial tuberosity and the sacrospinous ligament from the sacrum to the ischial spine. These two ligaments cross the sciatic notch and form the posterior

THE TRUE PELVIS The true pelvis is the bony canal below the pelvic brim. It has a brim, a cavity and an outlet. The pelvic brim The brim is round except where sacral promontory projects into it. The landmarks on pelvic brim includes: Sacral promontory Sacral ala or wing Sacroiliac joint Iliopectineal line Iliopectineal eminence Superior ramus of the pubic bone. Upper inner border of the body of the pubic bone Upper inner border of the symphysis pubis.

Diameters of pelvic brim Anteroposterior diameter (true conjugate), from the midpoint of the sacral promontory to the upper border of the pubic symphysis (11cm). when line is taken to the uppermost point of symphysis pubis it is called anatomical conjugate and measures 12cm. when it is measured to the posterior border of the upper surface, which is about 1.25cm lower it is called the obstetrical conjugate, which is about 11cm. the obstetrical conjugate represents the available space for passage of the fetus. The diagonal conjugate is from thelower border of symphysis pubis to the sacral promontory. It can be estimated onvaginal examination as a part of pelvic assessment and should measure 12-13cm. Transverse diameter is the line between the points furthest apart on the iliopectineal lines and measures 13cm. Oblique diameter is line from one sacroiliac joint to the iliopectineal eminence on the opposite side of pelvis and measures about 12cm. There are two oblique diameters. Each takes its name from the sacroiliac joint from which it arises, so the left oblique diameter arises from left sacroiliac joint and right oblique from right sacroiliac joint. Another dimension is sacrocotyloid diameter which passes from sacral promontory to the iliopectineal eminence on eminence on each side an dmeasures9-9.5cm.

The pelvic cavity The cavity extends from the brim above to the outlet below. In males, the cavity is longer, more conical and narrow. In females, the cavity is shorter and more cylindrical. the anterior wall is formed by the pubic bones and symphysis pubis and its depth is4cm. the posterior wall is formed by the curve of the sacrum, which is 12cm in length. Due to this much difference in measurements the cavity forms a curved canal. The cavity is circular in shape and although it is not possible to measure its exact diameter, they are all considered to be 12cm. The pelvic outlet It is a diamond shaped aperture bounded posteriorly by the sacrum and coccyx,

laterally by the ischial tuberosities and sacrotuberous ligaments; and anteriorly by the pubic symphysis, arcuate pubic ligament, and rami of the pubis and ischium. Two outlets are described: the anatomical and obstetrical. The anatomical outlet is formed by the lower borders of each of the bones together with the sacrotuberous ligament. The obstetrical outlet is of greater practical significance because it includes the narrow pelvic strait through which the fetus must pass. The narrow pelvic strait lies between the sacrococcygeal joint, two iscial spines and the lower border of the symphysis pubis. The obstetrical outlet is the space between the narrow pelvic strait and the anatomical outlet. Its three diameters include: The anteroposterior diameter is from the inferior margin of symphysis pubis to the sacroiliacjoint. During labour the coccyx may be deflected backwards. (13cm). Transverse diameter is the line between two ischial spines.(11cm) Oblique diameter is the line from the obturator foramen and the sacrospinous ligament. Although there are no fixed points, the measurement is taken as (12cm) THE FALSE PELVIS This is the part of pelvis that situated above the pelvic brim. It is formed by the upper flared out portions of iliac bones and protects the abdominal organs, but is of no significance in obstetrics. TYPES OF PELVIS Caldwell and Moloy developed a classification based upon the shape of the pelvis. Gynecoid type : this is the normal female pelvis seen in the majority ofwomen. The transverse diameter of the inlet is slightly more than the anteroposterior diameter andso the shape of inlet is either round or a transverse oval. Both the anterior and posterior segments are roomy. The sacrum is well curved, the side walls parallel, ischial spines not prominent, sacrosciatic notch wide and subpubic angle 900 . the fetal head engages in transverse or oblique diameter, inter nal rotation occurs anteriorly and nomal delivery occurs. Anthropoid pelvis : this is ape-like pelvis where the shape of the inlet is a long anteroposterior oval with anteroposterior diameter longer than the transverse. So the posterior segment is roomy,the head engages in anteroposterior diameter as direct occiput posterior and delivery occurs as face to pubis.

Android pelvis: this is the male type of pelvis where the inlet is wedge shaped with a small posterior segment. The cavity is funnel shaped and all the diameters of the cavity are reduced, the sacrum is flat, side walls converging, ischial spine prominent, sacrosciatic notch narrow and the subpubic angle is less than 90 degree. Engagement is delayed. The head engages in transverse diameter and deep transverse arrest is common. Difficult instrumental deliveries are likely. Platypelloid pelvis: this is the flat pelvis where inlet is a transverse oval with a long transverse diameter and short anteroposterior diameter. The capacity of the cavity is reduced. At the outlet,the subpubic angle is wide and hence intertuberous diameter is large. The head engages in transverse diameter with marked asynclitism. There is dely at the inlet and in many cases, caesarean section have to be done. Engagement occurs by exaggerated asynclitism so that the super subparietal diameter (8.5 cm) instead of the biparietal (9.4cm) passes through the pelvic brim. If the head is able to negotiate the inlet by means of asynclitism, there is usually no further problem. However, internal rotation will occur only when the head is low down in the pelvis.
DIFFERENCES BETWEEN THE FEMALE AND MALE PELVIS

The bones of the female pelvis are usually smaller , lighter, and thinner than those of the male. The inlet is transversely oval in the female and heart-shaped in the male. The outlet is larger in the female than in the male because of the everted ischial tuberosities in the female. The cavity is wider and shallower in the female than in the male. The subpubic angle or pubic arch is larger and the greater sciatic notch is wider in the female than in the male. The female sacrum is shorter and wider than the male sacrum. The obturator foramen is oval or triangular in the female and round in the male. PELVIC INCLINATION Subpubic angle is formed by the meeting of the two descending pubic rami. In normal females it measures 85-900.if the angle is less, the transverse diameter of the outlet will also be less.

Waste space of Morris : normally the angle is well rounded and if around disc of diameter 9.3cm(approximating the fetal head ) placed under pubic arch, the distance between the pubic symphysis and the edge of the disc should not be more than 1 cm. this measurement is the waste space of Morris. When it is more than 1 cm, the available anteroposterior diameter of the outlet is reduced. Inclination of the pelvis : is assessed in the standing position. The plane of the inlet makes an angle of 600 with the horizontal. This is called the inclination of pelvis. Inclination may affect engagement of fetal head. High inclination occurs when there is sacralisation of 5th lumbar veterbae, ie inclusion of 5th lumbar vertebrae in the sacrum. This can lead to delay in engagement and may predispose to an occiputo posterior position Axis of birth canal is obtained by joining the axis of inlet, cavity and outlet. This is the curve with convexity fitting the sacral curvature and is called anatomical pelvic axis or the curve of carus Obstetric axis: this is the course taken by the presenting part as it moves down through the pelvis and is not uniformly curved. At first downwards and backward the direction changes and upto the level of ischial spines, then at the outlet , it is downwards and forwards.

PELVIC FLOOR[pelvic diaphragm]

Pelvic floor is the muscular partition that fills the outlet of the pelvis. It separates the pelvic cavity above from the perineal region below. It consists of three sets of muscles on either side- pubococcygeus, iliococcygeus and ischiococcygeus and these are collectively called levator ani. They are called so because they lift or elevate the anus. The muscle with covering fascia is called pelvic diaphragm. Each levator ani arises from the back of the pubic rami, from the condensed fascia covering the obturator internus and from the inner surface of ischial spine. During child birth it influences the passive movements of the fetus through the birth canal and relaxes to allow the exit of the fetus from the pelvis.

MUSCLE LAYERS The superficial layer is composed of five muscles: * The external anal sphincter encircles the anus and is attached behind by a few fibres to the coccyx. * The transverse perineal muscles pass from the ischial tuberosities to the centre of perineum * The bulbocovernosus muscle pass from the perineum forward around the vagina to the corpora cavernosa of the clitoris just under the pubic arch. * The ischiocavernosus muscle pass from the ischial tuberosities along the pubic arch to the corpora cavernosa. * The membranous sphincter of the urethra is composed of muscle fibres passing above and below the urethra and attached to the pubic bones. The deep layer consists of three pairs of muscles which are together called levator ani muscles. * The pubococcygeus muscle passes from the pubis to the coccyx, with a few fibres crossing over in the perineal body to form its deepest part. * The iliococcygeus muscle passes from the fascia covering the obturator internus muscle to the coccyx. * The ischiococcygeus muscle passes from the ischial spine to the coccyx,in front of the sacrospinous ligament.

Functions
It is important in providing support for pelvic viscera (organs), e.g. the bladder, intestines, the uterus (in females), and in maintenance of continence as part of the urinary and anal sphincters. It facilitates birth by resisting the descent of the presenting part, causing the fetus to rotate forwards to navigate through the pelvic girdle. During pregnancy levator muscles hypertrophy, becomes less rigid and more distensible.

REFERENCES 1. Diane M.Fraser, Margaret A Cooper. Myles Textbook for Midwives. 14th edition. Churchill Livingstone. Philadelphia. page no:99-109 2. B.D. Chaurasia. Human Anatomy. 4th edition. Volume 2. Satish Kumar Jain for CBS publishers &distributors. New Delhi.(2005). Page no: 188-191, 342 3. Dr. Sampath madhyastha. Manipal manual of anatomy. 1st edition. New Delhi. (2005). CBS Publishers. Page no: 90-93. 4. Dutta D.C. Textbook of obstetrics. 6th edition. New central book agency. Calcutta. (2004) page no: 87-94, 10-11. 5. Waugh Annie, Ross Allison Grant. Anatomy and physiology in health and illness. 10th edition. Churchill Livingstone Publication. Spain. (2007). Page no: 404 6. Kulkarni V Neeta. Clinical Anatomy for students. 1st edition. Jaypee brothers medical publishers, New Delhi.(2006). Page no:712-717 7. Singh inderbir. Textbook of Anatomy. 2nd edition. Vol 1. Jaypee brothers medical publishers(P) Ltd. New Delhi. (2000). Page no:52-62 8. www.ncbi.nih.gov female pelvic floor anatomy. Sender Heischorn. Review in Urology 2004(6). 9. www.en.wikipedia.org. the pelvic floor. Female pelvis.

TOPIC PRESENTATION
ON FEMALE PELVIS AND PELVIC FLOOR

SUBMITTED TO:MRS.SOLY EARNEST ASSOCIATE PROFESSOR WESTFORT COLLEGE OF NURSING

SUBMITTED BY:SMITHA JOSE 1ST YEAR M.Sc NURSING WESTFORT COLLEGE OF NURSING

SUBMITTED ON:- 30-04-2012