o Femoral Artery I. Skin, Subcutaneous Layer and Fascia Superfical Epigastric LANGER LINES Superficial Circumflex Iliac o Anterior Abdominal Wall- Transverse Superficial External Pudendal Vertical Incisions – wider scars Supplies: Low Transverse Incision (Pfannenstiel) – Skin superior cosmetic results Subcutaneous Layers of the Anterior o Subcutaneous Layer Abdominal Wall Camper Fascia- Mons Pubis Superficial Fatty layer o External Iliac Vessels Mons Pubis and Labia Majora Inferior Deep Epigastric Blend with Ischioanal Fossa Deep Circumflex Iliac Scarpa Fascia Supplies: Continues to the perineum as Muscles COLLES FASCIA Fascia o Perineal Infection or o Internal Thoracic Vessels hemorrhage superficial to this Superior Epigastric can extend upward to involve Maylard Incision, Inferior Epigastric the superficial layers of the Artery may be lacerated lateral to the abdominal wall rectus belly and can rupture following Muscles abdominal trauma and create a rectus Midline sheath hematoma Rectus Abdominis, Pyramidalis o Hesselbach Triangle o Pyramidalis Lateral- Inferior Epigastric Vessels From the pubic crest inserts Inferior- Inguinal Ligament into the linea alba and lie on Medial- Lateral border of Rectus Muscle top of the rectus abdominis Hernia that protrudes through the beneath the anterior rectus triangle- Direct Inguinal Hernia sheath Hernia that protrudes through the Extends across the Entire Wall deep inguinal ring, lateral to the External Oblique, Internal Oblique triangle- Indirect Inguinal Area and Transversus Abdominis III. Innervation o Fascia from these untie in the Anterior Abdominal Wall Both Intercostal and Subcostal are midline to form the Linea Alba o Intercostal nerves (T7-11) Anterior rami of o Wide separation can lead to o Subcostal Nerve (T12) Thoracic Spinal Diastasis Recti or hernia o Iliohypogastric& Ilioinguinal (L1) Nerves o RECTUS SHEATH Transversus Abdominis Space- between Above the rectus sheath, anterior abdominal wall and tyransversus aponeuroses is found on abdominis both ventral and dorsal Intercostal and Subcostal can be severed surface during pfannensteil incision. Below the sheath, it is only Iliohypogastric and ilioinguinial can be found on the VENTRAL part, severed during LTCS or entrapped during only the thin Transversalis closure fascia and peritoneum lies on the dorsal surface 2|Williams Maternal Anatomy24th Ed
EXTERNAL GENERATIVE ORGANS - Vagina
I. VULVA aka PUDENDA - 2 Bartholin Gland Ducts Mons Pubis - 2 Skene (Paraurethral) Gland Ducts o Aka Mons Veneris o Fossa Navicularis- between the fourchette o Fat filled and vagina; found ONLY in nulliparas o Hair forms the escutcheon o Urethral opening is below the pubic arch Labia Majora and above the vaginal opening o Homologue of Scrotum o Round ligaments terminate at the upper Glands Description/Function borders of the Labia majora Bartholins - Aka Greater o No hair on the inner surface Vestibular Gland o Apocrine, Eccrine and Sebaceous glands - Inferior to the are abundant vascular vestibular o Rich in elastic and adipose tissue bulb Labia Minora - 5’ and 7 ‘oclock on o Homologue of ventral shaft of the penis the vestibule o Divides into lamellae o Fusion of lamella forms the frenulum of Minor Vestibular Lined by simple mucin the clitoris and the upper merge to form secreting epithelium the prepuce and open along the o Also forms the fourchette hart line o HART LINE Skene -open along the - Medial- squamous non keratinized (Paraurethral) inferior aspect of the epithelium urethra o No hair follicles, eccrine and apocrine Lie distally near the glands urethral meatus o Numerous Sebaceous glands -inflammation can Clitoris lead to urethral o Prinicipal female erogenous organ diverticulum o Homologue of Penis formation o Glans- stratified Squamous o Body II. VAGINA AND HYMEN - 2 corpora cavernosa Hymen o Blood Supply o Elastic and Collagenous connective - From Internal pudendal Artery Tissue Deep Artery of Clitoris- Body o Non-keratinized Stratified Squamous Dorsal Artery of Clitoris- Glans Epithelium and Prepuce o Imperforate Hymen- accumulation of Vestibule menstrual blood o From urogenital membrane o Pregnant Woman- thick and collagen o Almond shape rich o Border: o Hymeneal or Myrtiform caruncles- - Lateral- hart Line Multipara women - Medial- External Surface of Hymen Vagina - Anterior- Frenulum o Musculomembranous tube that extends - Posterior- Fourchette into the uterus o Openings: - Urethra 3|Williams Maternal Anatomy24th Ed
o Separated from the bladder- Posterior Triangle
Vesicovaginal Septum Contains the Ischioanal fossae, anal III. PERINEUM canal and anal canal sphincter complex. Diamond shaped Pelvic Diaphragm Boundaries: o Deep to the anterior and posterior Anterior- Pubic Symphysis triangles Anterolateral-Ischiopubic Rami and Ischial o Substatntial support to the pelvic Tuberosities viscera Posdterolateral- Sacrotuberous Ligaments o Levator and and Coccygeus Posterior- Coccyx Levator: Pubococcygeous, Triangles Puborectalis and Iliococcygeus Anterior Triangle Pubococcygeus: Pubovaginalis, o Divided into 2 spaces by Perineal Puboperinealis and Puboanalis Membrane o Most Commonly Damaged Muscle o Boundaries: during Childbirth: Pubovisceral Sup: Pubic Rami greater risk for POP or Urinary Lat: Ischial Tuberosities Incontinence Post: Superficial Transverse Perineal Body Perineal muscles Fibromuscular mass Superficial Aka Central Tendon of the Perineum Superficial: Colles Fascia For Perineal support Deep: Perineal Membrane Superficial Closed Compartment Structures that converge : Contents: Bartholin Glands, Bulbocavernous Vestibular Bulbs, Clitoral Bofy Superficial Transverse Perineal and Crura, Pudendal Vessels EAS and nerve and the Deep Ischiocavernous, Perineal Membrane Bulbocavernous and Superficial Pubococcygeus muscle Transverse Perineal Muscles IAS Ischiocavernous Muscle- help Ischioanal Fossa maintain clitoral erection Aka Ischiorectal Fossa Vestibular Bulb Bulk of the Posterior Triangle Coropora Spongiosa of the Inmjury ot vessels in the posterior Penis triangle can lead to hematoma Terminate in the middle of formation in the ischioanal fossa the vaginal opening Anal Canal Deep Distal continuation of the rectum begins Continuous superiorly with ar the level of levator ani attachment to the pelvic cavity the rectum and ends at the anal skin Contents: Urethra and o Upper: Columnar Epithelium Vagina, Internal Pudendal o Dentate or Pectinate Line: Simple Artery, Compressor Stratified Squamous Epithelium Urethrae and Hemoorhoids Urethrovaginal sphincter o External- distal to the pectinate muscles lines; stratified squamous epithelium; painful 4|Williams Maternal Anatomy24th Ed
o Internal- above the dentate line, Lower Cylindrical Shape- Cervix
covered in insensitive anorectal Isthmus- union of the two parts; forms the mucosa; Painful only if it becomes lower uterine segment during pregnancy thrombosed or necrotic Uterine Cornu Origin of fallopian tube and Anal Sphincter Complex origin of round and uterovarian ligaments o Internal Anal Sphincter (IAS) Fundus- between the points of fallopian tube Continuation of rectal circular insertion and the convex upper uterine smooth muscle layer segment Parasympathetic fiber Uterine Body- muscle Superior, Middle and Inferior Pregnancy stimulates remarkable uterine Arteries growth due to muscle fiber hypertrophy Contributes the bulk of anal Cervix canal resting pressure for fecal Fusiform continence Upper boundary: Internal Os o External Anal Sphincter (EAS) o Level @ which peritoneum is Striated muscle ring reflectd up onto the bladder Ant Attachment: Perineal Body o Portio Supravaginalis- above Post. Attachment: Coccyx vagina’s attachment to the Maintains constant resting cervix; covered by contraction peritoneum; wehere the Inferior Rectal Artery- (Int. cardinal ligaments attach Pudendal Art) o Portio Vagionalis- lower cervical portion which PUDENDAL NERVE protrudes to the vagina S2-S4 Ant. Rami o Ectocervix- exterior to the Exits: Greater Sciatic Formaen EOS- nonkeratinized Ischial Spines serves as landmark for squamous epithelium Pudendal Nerve Block o Endocervis- single layer pof Lies within the Alcock’s Canal splitting mucin secreting columnar of the obturator internus investing epithelium fascia Eversion- endocervix moves out and onto the INTERNAL GENERATIVE ORGANS ectocervix o Chadwick Sign-blue tinit 1. Uterus o Goodell Sign- cervical edema Situated between the bladder (ant) and softening rectum (post) o Hegar Sign- Isthmic softening Entire posterior wall is covered by MYOMETRIUM serosa- VISCERAL PERITONEUM SMOOTH MUSCLE BUNDLE Lower portion of peritoneum Pouch Living Ligature- interlacing fibers of Douglas that surround myometrial vessels Anterior wall is united to the posterior and contract to compress these, wall Vesicouterine space integral to hemostasis at the Dissection caudally within thespace lifts the placental site during the 3rd stage bladder off the lower uterine segment for of labor hysterectomy Body>cervix (10%); inner wall>ou Pear Shaped ter wall; Lateral wall> anterior Upper Triangle- Body or Corpous and posterior wall 5|Williams Maternal Anatomy24th Ed
o Ovarian Branch Tubal and
ENDOMETRIUM Fundal branch to the Varies greatly throughout the fallopian tube menstrual cycle Ovarian Artery Functionalis vs. basalis o Direct branch of the aorta o Enters the broad ligament LIGAMENTS through the Round infundibulopelvic ligament o Male Gubernaculum o The uterus has dual blood o Extends lateral and supply to prevent ischemia if downward into the inguinal ligation of the uterine or IIA canal Veins o Location of the Sampson o Arcuate Veins from Uterine artery from the Uterine Vein IIV CIV Artery o Pampiniform plexus Broad Ovarian vein o Winglike structure Rt. Ovarian Vein IVC o Uterine vessels and ureter are Lt. Ovarian Vein Left found in its base Renal Vein o Divides the pelvic cavity into ANTERIOR DIVISION anterior and posterior o Pelvic Organs compartments o Perineum o Suspensory Ligament of the POSTERIOR DIVISION Ovary- from the peritoneum o Buttock and Thigh that extends beneath the end o Superior Gluteal, Lateral of the fallopian tube; contains Sacral and Iliolumbar nerves and ovarian vessls o Ligation distal to the Cardinal posterior division avoid o Aka Mackenrodt or compromised blood flow to Transverse Cervical Ligament these areas o Thick base of the broad Endometrium Lymphatics ligament o Confined in the basalis layer Uterosacral o LN from the cervix Internal o Forms the lateral boundaries Iliac Nodes of the pouch of Douglas o LN from Uterine Cornu: BLOOD SUPPLY and LYMPHATICS Internal Iliac Nodes Uterine Artery From the Ovarian LN o Main branch of the IIA Paraaortic LN enters the base of the broad INNERVATION ligament o Predominantly Autonomic o Crosses over the ureter Sympathetic o Spiral Arteries- supply Superior Hypogastric Plexus functionalis layer; (Presacral) hormonally responsive T10-L2 o Basal Arterie/Straight Sacaral promontory Rt. And Arteriesbasalis layer; not Lt Hypogastric Nerves hormonally sensitive Parasympathetic From S2 –S4 6|Williams Maternal Anatomy24th Ed
o Inferior Hypogastric Plexus
3 Plexuses o Vesical Plexus- bladder o Middle Rectal- Rectum o Uterovaginal Plexus- Frankenhauser Plexus; proximal FT, Uterus and Upper Vagina o Uterosacral o Sensory Fibers Inferior Hypogastric Plexus T10-T12,L1 Pelvic Splanchnic (S2-S4) cervix and upper part of the birth canal 2 Hypogastric Nerves (Sympathetic) and 2 Pelvic Splanchnic Nerves S4-S5 2. Ovaries Ovarian Fossa of Waldeyer 3. Fallopian Tubes 7|Williams Maternal Anatomy24th Ed
PELVIS
4 bones: Sacrum, Coccyx and 2 Innominate Characteristic Male Female
Bones Built Massive, Bony Slender, o Innominate Bones: Ilium, Ischiuma Prominence Smooth, Light dn Pubis bones Joints Shape Deep Funnel Flat Bowl Brim Heart Shaped Circular or Joints Types Elliptical Symphysis Pubis Fibrocartilagenous Cavity Conical/Funnel Broad and Sacroiliac Joint Synovial Round Sacrocaoccygeal Joint Synovial Hinge Outlet Smaller Larger “Great international Bodies, So Punctual” False Pelvis True Pelvis Broad in Females ABOVE the Pelvic Brim BELOW the Pelvic Brim No Obstetric Bony canal which the Greater Scaitic Notch Significance fetus passes at time of Ischial Tuberosities labor Body of Pubis Subpubic Angle (90-100°) Preauricular Sulcus
Diameters of the Pelvis
Diameter Inlet Cavity Outlet TRUE PELVIS AP Obstetric 11.5cm 11.5-13.5cm o Pelvic Inlet Conjugate- Narrowest in APD and Widest on TD 10-10.5cm Plane of Pelvic Inlet is tilted forwards True Superior Straight Conjugate- 55° Angle of Inclination (L5 and 11cm Plane of Inlet) Diagonal o Increase in the Angle of Conjugate- 12cm Inclination (High Inclination) Oblique 12cm can cause delayed engagement Transverse 13-13.5cm Interspinous Intertuberous of the fetal head and descent – 10cm -11cm of fetal head; favors Occipitoposterior position Longest Diameter of TD of Inlet and APD of ◊For the proper descent and engagement of Pelvis Anatomic outlet fetal head, it is important that the uterine axis Shortest Major Interspinous Diameter coincides with the axis of inlet Diameter Longest AP of Inlet Diagonal Conjugate o Pelvic Cavity Shortest AP of Inlet Obstetric Conjugate Boundaries: Only AP measured Diagonal Conjugate Above: Pelvic Brim Clinically Below: Plane of Least Pelvic Critical Obstetric 10cms ( if obstetric Dimension Conjugate conjugate <10cm Ant: Symphysis Pubis vaginal delivery is not Post: Sacrum possible 8|Williams Maternal Anatomy24th Ed
** Internal Rotation of the Fetal head occurs 013cms or 5 1/4in
when the BPD of the Fetal Skull occupies this when the head is wide pelvic plane while the occiput is on the passing through the pelvic floor at the plane of least pelvic introitus in the 2nd dimension stage of labor
o Pelvic Outlet Transverse Intertuberous
Midpelvis- Ischial Spine 11cm Plane of Least Pelvis Dimension Innerborders of ischial IR occurs at this level tuberosities Marks the beginning of forward Subpubic Angle 2 descending pubic curve of the pelvic axis rami Most cases of Deep Transverse 85° Arrest occur here WASTE SPACE of MORRIS Ischial Spines represent St.0 of the head - 1cm from the midpoint of the inferior External Os lies at this level border of the symphysis pubis Landmark for Pudendal Block Interspinous Diameter- smallest pelvic PELVIC SHAPE diameter and is important in cases of Characteristic Gynecoid Android obstructed labor Intro Female Male Anatomical Pelvic Outlet Type Lozenge Shape Shape Oval Heart Boundaries AP DIameter TD slightly TD >AP o Symphysis Pubis bigger than o Pubic Arch AP o Ischial Tuberosities Subpubic 90 <90 o Sacrotuberous Ligaments Angle o Sacrospinbous Ligaments Outcome -No -Delayed o Tip of Coccyx difficulty in Engagement Plane of Anatomical Outlet Engagement -Deep Anterior Sagittal Plane -MC Transverse o Ant. Sagittal Diameter (6-7cm)- Position of Arrest lower border of the pubic Head: Left -Persistent symphysis to the center of Occiput Occiptoposterior bituberous diameter Transverse Position Posterior Sagittal Plane or Left common o Apex lies at the tip of the Occiput coccyx Anterior o Posterior Sagittal Diameter Type of Normal Difficult (7.5-10cm) from the tip of the Delivery Instrumental sacrum to the center of Delivery bituberous diameter
Diameters of Pelvic Outlet
Characteristic Anthropoid Platypelloid AP Diameter Lower border of the Intro Ape Like Flat Pelvis; Least symphysis pubis to tip Pelvis Common of coccyx 9|Williams Maternal Anatomy24th Ed
Variety Mentovertical Partial / Brow
Shape AP Oval Flat Bowl Submentovertical Inc. / Face AP DIameter ONLY pelvis TD >>>APD Submentobregmatic Comp. / Face in which **Brow presentation always CS is done APD >TD Subpubic Engaging Diameters Angle Presentation AP Cms Outcome -Diameter of -Head engages Vertex Suboccipitobregmatic 9.5 Engagement in TD with Brow Mentovertical 14 is APD marked Face Submento bregmatic 9.5 -Mc asynctitism Submentovertical 11.5 Position: -Engaging Occipito- diameter is TYPES OF CONTRACTED PELVIS Posterior supersub - parietal Type Etiology Feature Nonrotation diameter Rachitic Rickets -Reniform is common (18.5cm) Shape of Inlet instead of usual Marked BPD (9.5) shortening of APD w/o Type of Face to -If head is able affecting TD Delivery Pubes to negotiate the -Flat Sacrum inlet by means -Widening of of asynclitism TD of outlet Normal labor and arch otherwise CS Triradiate Osteomalacia -Triradiate TRANSVERSE DIAMETER Severe Rickets shape of Inlet in Adults -tuberosities “Miss Tina So Pretty” are closer and M- biMastoid- 7.5cm arch is T- biTemporal-8cm narrower S- Super Subparietal Diameter- 8.5cm -short sacrum P- biParietal Diameter- 9.5cm with coccyx pushed **APD of the skull are always bigger than TD forward ** The longest APD of Fetal skull- Naegeles Congenital One ALA is Mentovertical- 14cm Osteitis of SI jt absent The 2nd longest AP diameter is Mode of Submentovertical/Occipitofrontal- 11.5cm Delivery: CS Roberts Both ala AP Diameters of the Fetal Skull absent Diameters Attitude Presentation of the Head Suboccipitobregmatic Comp. Vertex Suboccipitofrontal Inc. Vertex Occipitofrontal Marked Vertex de