Maternal Anatomy

By: Ronald Oscar

Anterior Abdominal Wall

External Generative Organs
Internal Generative Organs
Musculoskeletal Pelvic Anatomy

Anterior
Abdominal Wall

Ischioana
l fossae

labia
majora

Camper
Fascia

perineum

mons
pubis

Scarpa
fascia

Perineum
as Colles
Fascia

Midline
rectus
abdominis &
M.
pyramidalis

M. External &
Internal
Oblique
M.
Tranversus
Abdominis

Anterior
Abdomina
l Wall
muscle

Aponeurosis (jalur) of 3 muscle form primary fascia

of anterior abdominal wall
Aponeuroses invest rectus abdominalis muscle as
rectus sheath.
Linea Arcuata is the boundries between the sheath
Cephalad to this border , the aponeurosis invest
the rectus abdominis bellies on the both dorsal
and ventral

Caudal to this line , all aponeurosis lie ventral or

superficial to the rectus abdominis muscle and
only the thin transversalis fascia and peritoneum
lie beneath the rectus.
Important in midline abdominal incision.

Blood Supply

A.Superfici
al
epigastric

A.
Superficial
circumflex
iliac

Skin &
Subcuta
n blood
supply

A.Superfici
al external
pudendal

The inferior deep epigastric and deep circumflex

iliac vessel supply muscle and fascia of abdominal
anterior wall.
Near the umbilicus , A.V epigasatric inferior
anastomose with A.V superior epigastric (branch
from Internal thoracic vessel)
Hesselbach triangle -> region bounded
Laterally ->inferior epigastric vessel
Medial -> rectus abdominis
Inferior -> ligamentum inguinale

Innervation
Anterior abdominal wall innervated by

T7-11 Intercostal nerve

T12 Subcostal Nerve
L1 iliohypogastric and ilioinguinal
Transversus Abdominis Plane -> Area between
M.Transversus Abdominis & M. Internal Oblique
Run Intercostal Nerve & Subcostal Nerve

Iliohipogastric nerve perforates the external

oblique aponeurosis -> provide sensation to the
suprapubic area , mons pubis, upper labia majora
& medial upper thigh.
Important in lower transverse incision

EXTERNAL
GENERATIVE
ORGAN

VULVA
VAGINA & HYMEN
PERINEUM
Ischioanal Fossae
Anal canal
Anal sphincter complex
Pudendal nerve

Vulva ( the pudenda )

mons pubis
Labia majora & minora
Clitoris
Hymen
Vestibular glands ( greater/bartholine & minor &
paraurethral gland )

Mons Pubis / Mons Veneris

Covered by curly hair -> the EXCUTCHEON

LABIA
Labia devided majora & minora
Labia majora size (L 7-8cm, D 2-3cm, T 1-5cm)
anterior limit point -> mont pubis
posterior limit point -> commisura posterior
contain appocrine,eccrine,sebaceus gland

Labia minora size ( L 2-3cm W 1-5cm)

Upper lamella -> form prepuce
Lower lamella -> form frenulum clitoris
Labia minora merge into fourchette posteriorly

LABIA
Structure epithelial :

Outer surface -> keratinized stratified squamous

epithelium

Inner surface
Lateral hart line -> keratinized stratified SE
Medial -> non keratinized SSE

CLITORIS (size 2 cm)

Located -> under prepuce above frenulum &
urethra
Composed :

1 glands (0,5cm) -> stratified SE

1 body -> contain 2 cavernosus
2 crura -> ischiopubic ramus and
ischiocavernosus muscle

VESTIBULE ( almond shaped)

Enclosed by

external surface hymen

Lateral hart line
Frenulum anterior side
Fourchette posterior side
Six opening of : 1 urethra,1 vagina,2 duct
bartholine gland,2 duct skene glands (paraurethral
glands)
Fossa navucilare -> between fourchette-vaginal
opening -> Nulipara !!

Vestibule
Major gland (bartholine) ->0,5-1 cm,L 1,5-2cm
Bilateral
Lies inferior of bulbocavernosus & vascular bulbo
glands
Opens distal to hymenal ring at 5 & 7 oclock point
Minor gland -> lined by simple mucin secreting
epthel along hart line
Paraurethral gland -> 2 skene glands ( large glands)

VAGINA AND HYMEN

Hymen
- covered non keratinized str SCE
- torn at several sites during coitus
Vagina -> musculo membranous tube

Anteriorly vesicovaginal septum (separate from

urethra and bladder)

Posteriorly rectovaginal septum (separate from

rectum)

 rectovaginal pouch is cul-de-sac of douglas

cavity

Vaginal size anterior 6-8 cm posterior 7-10cm

Upper end of vagina subdivided into

anterior,posterior, and two lateral fornices of

cervix

Middle portion of vagina attached to pelvis with

visceral connective tissue and then continued to

fascia levator anii

Vaginal lining composed of nonkeratinized SSE

and underlyning lamina propria -> forming
rugae

Vagina

Vagina lubricated by the Vaginal Subepithelial Capillary Plexus

Vascularity ->

cervical branch of A.Uterina and A.Vaginal and direct from A.iliaca Interna
A. rectal mediana -> posterior vagina
Lymphatic system :
1/3 lower -> inguinal lymph

1/3 mediana ->internal iliac nodes

1/3 upper ->external,internal and common iliac
nodes

PERINEUM (diamond
shaped)
Boundries :
Anterior : symphisis pubic
Anterolateral : ischiopubic rami & ischial tuberosities
Posterior : sacrotuberous ligament & coccyx

Perineum
Urogenita
l triangle
->
anterior

Perinea
l body
Anal
triangle
->posteri
or

Perineal Body
Superficial :
M. Bulbocavernosus , Superficial transversal
perinei,
Sphincter anal externus
Deep :
Perineal membrane : M.
Pubbococcygeus,internal anal
sphincter

Anterior triangle
Superior : Pubic Rami
Lateral : Ischial Tuberosities
Posterior : M. Transversus Perinei
Devided into :
Superficial and deep spaces by Perineal membrane
Perineal membrane attached : ischiopubic rami
(lateral), 1/3 distal urethra vagina (medial), perineal
body (posterior) ligamentum arcuatum pubis (anterior)

Pelvic diaphragm
Support to the pelvic viscera
Composed of levator ani and M.coccygeus
Levator ani tdd : pubbococcygeus, puborectalis,
illiococcygeus muscle

Vaginal birth makes damages to pubovisceral of

m.levator ani

Posterior triangle
Contains :
Fossa ischioanal, anal canal, anal sphincter complex
Consist :
Anal sphincter external and internal and puborectalis
muscle
Branch of pudendal nerve and pudendal vessel

Pudendal nerve
Formed from the anterior rami S2-4 Spinal nerves
The major blood supply to the perineum is via the internal pudendal artery, and its
branches mirror the divisions of the pudendal nerve.

INTERNAL
GENERATIVE
ORGAN

1. UTERUS
2. CERVIX
3. MYOMETRIUM AND ENDOMETRIUM
4. LIGAMENTS
5. BLOOD SUPPLY
6. LYMPHATICS
7. INNERVATION
8. OVARIES
9. FALLOPIAN TUBES

UTERUS

- Pear shaped.
- There is an upper
triangular portion the
body or corpus, and a
lower, clyndrical portion
the cervix, which projects
into the vagina.
- Situated in the pelvic
cavity between the
bladder anteriorly and the
rectum posteriorly.
- The entire posterior wall
is almost covered by
serosa, that is visceral
peritoneum.
- The nulligravida uterus
measures 6 to 8 cm in
length compared with 9 to
10 cm in mulriparous.
- The weight is 60 g.

CERVIX
-Composed mainly of collagen, elastin, and
proteoglycans, but very little smooth muscle.
-The cervix exterior to the external os is called the
ectocervix and is lines predominantly by
nonkeratinized stratified squamous epithelium.
-During pregnancy, the endocervical epithelium
moves out and onto the ectocervix in a
physiological process termed eversion.

 In early pregnancy, increased vascularity within

the cervix, ephithelium creates an ectocervical
blue tint called Chadwick sign.

Cervical edema leads to softeningGoodell sign,

and shereas isthmic softening is Hegar sign.

MYOMETRIUM AND ENDOMETRIUM

- Most of the uterus is
composed of
myometrium, the uterine
cavity is lined with
endometrium.
- Myometrium is integral
to hemostasis at the
placental site during the
third stage of labor, the
endometrium varies
greatly throughtout the
menstrual sycle and
during pregnancy.
- Basalis layer of
endometrium regenerate
the functionalis layer
following each menses.

LIGAMENTS

- There are several ligaments that extend from the

uterine surface toward the pelvic sidewalks.
- The round ligament originates somewhat below
and anterior to the origin of the fallopian tubes.
- The broad ligaments are two winglike structures
that extend from the lateral uterine margins to
the pelvic sidewalks.
- The cardinal ligament (the transverse cervical
ligament or Mackenrodt ligament) is the thick
base of the broad ligament, that the medially is
united to the uterus and upper vagina.

 Each uterosacral ligament originates with a

posterolateral attachment to the supravaginal
portion of the cervix and inserts into the fascia
over the sacrum with some variations.

BLOOD SUPPLY

 The uterine artery, a main branch of the internal

iliac arterypreviously called the hypogastric
arteryenters the base of the broad ligament.

The uterus receives blood supply from the ovarian

artery.

LYMPHATICS

The endometrium is abundantly supplied with

lymphatic vessels that are confined largely to the
basalis layer.

The lymphatics of the underlying myometrium are

increased in number toward the serosal surface
and form an abundant lymphatic plexus just
beneath it.

INNERVATION

 Pelvic visceral innervation is perdominantly

autonomic.

The autonomic portion is further divided in

sympathetic (from spinal level T-10 through L-2)
and parasympathetic components (from neurons
at spinal level S-2 through S4).

Most afferent sensory fibers from the uterus

ascend through the inferior hypogastric plexus
and enter the spinal cord via T-10 through T-12
and L-1 spinal nerves.

OVARIES
Ovaries position are varies, but usually lie in the upper part of the
pelvic cavity and rest in a slight depression on the lateral wall of
pelvic.

The ovary consists of a cortex and medulla.

Epithelium of the cortex contains oocytes and developing
follicles.

The medulla is the central portion, which is composed of loose

connective tissue. There are a large number of arteries and veins
in the medulla and a small number of smooth muscle fibers.

FALLOPIAN TUBES

- These tubes extend 8 to 14 cm from the uterine

cornua and are anatomically classified as an
interstitial portion, isthmus, ampulla and
infundibulum.
- In cross section, the extrauterine fallopian tube
contains a mesosalpinx, myosalpinx , and
endosalpinx.
- The tubes are supplied richly with elastic tissue,
blood vessels and lymphatics.

MUSCULOSKELET
AL PELVIC
ANATOMY

The pelvis is composed of four bones:

1.the sacrum,
2.coccyx,
3. two innominate : the ilium, ischium, and
pubis

Pelvic Joints:
Anteriorly
-> the symphysis pubis: fibrocartilage and
the superior and inferior pubic ligaments.

Posteriorly
-> sacroiliac articulations : the sacrum and the
iliac portion of the innominate bones

 The pelvis is conceptually divided into

False components -> is bounded posteriorly by
the lumbar vertebra and laterally by the iliac
fossa. In front, theboundary is formed by the
lower portion of the anterior abdominal wall.

 True components -> the linea terminalis serves

as the superior border, whereas the pelvic outlet
is the inferior margin. The posterior boundary is
the anterior surface of the sacrum, and the
lateral limits are formed by the inner surface of
the ischial bones and the sacrosciatic notches
and ligaments. In front, the true pelvis is
bounded by the pubic bones, by the ascending
superior rami of the ischial bones, and by the
obturator foramina.

Planes and Diameters of the Pelvis

as having four imaginary planes:
1. The plane of the pelvic inletthe superior strait.
2. The plane of the pelvic outletthe inferior strait.
3. The plane of the midpelvisthe least pelvic
dimensions.
4. The plane of greatest pelvic dimensionof no
obstetrical significance.

Pelvic inlet
the pelvic inlet is bounded posteriorly by the
promontory and alae of the sacrum, laterally by
the linea terminalis, and anteriorly by the
horizontal pubic rami and the symphysis pubis.

 Four diameters of the pelvic inlet are usually

described:

Anteroposterior -> is the shortest distance

between the sacral promontory and the
symphysis pubis. Normally, this measures 10 cm
or more.

 Transverse -> is constructed at right angles to

the obstetrical conjugate and represents the
greatest distance between the linea terminalis
on either side. It usually intersects the
obstetrical conjugate at a point approximately 5
cm in front of the promontory and measures
approximately 13 cm.

 Two oblique diameters -> extends from one

sacroiliac synchondrosis to the contralateral
iliopubic eminence. These oblique diameters
average less than 13 cm.

Midpelvis and Pelvic

Outlet
The midpelvis is measured at the level of the
ischial spines, also called the midplane or plane
of least pelvic dimensions.

The apex of the posterior triangle is the tip of

the sacrum, and the lateral boundaries are the
sacrotuberous ligaments and the ischial
tuberosities. The anterior triangle is formed by
the descending inferior rami of the pubic bones.

Pelvic Shapes
The Caldwell-Moloy (1933, 1934) anatomical
classification of the pelvis is based on shape.

Specifically, the greatest transverse diameter of

the inlet and its division into anterior and
posterior segments are used to classify the
pelvis as gynecoid, anthropoid, android, or
platypelloid.

TERIMA KASIH