Chapter 2: Maternal Anatomy Indirect Inguinal Hernias: hernias that protrude through deep inguinal

ring, which lies lateral to this triangle, and then may exit out the superficial
ANTERIOR ABDOMINAL WALL inguinal ring.
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
the rectus Innervation
Transition of rectus sheath composition can be seen best with a Anterior Abdominal Wall is innervated by
midline abdominal incision a) Intercostal Nerves (T711)
Pyramidalis Muscles b) Subcostal Nerve (T12),
Paired small triangular muscles c) Iliohypogastric and Ilioinguinal Nerves (L1)
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
Arise from the Femoral Artery just below the inguinal ligament within the the posterior sheath, rectus muscle, and then anterior sheath to reach the
skin.
femoral triangle
May be severed during a Pfannenstiel incision at the point in which the
a) Superficial Epigastric
b) Superficial Circumflex Iliac overlying anterior rectus sheath is separated from the rectus muscle.
c) Superficial External Pudendal Iliohypogastric and Ilioinguinal Nerves originate from the Anterior Ramus of
Supply the skin and subcutaneous layers of the anterior abdominal wall the First Lumbar Spinal Nerve
and mons pubis. Emerge lateral to the psoas muscle and travel across the quadratus
Superficial Epigastric vessels course diagonally toward the umbilicus. lumborum inferomedially toward the iliac crest.
With a low transverse skin incision, can usually be identified at a depth Near this crest, both nerves pierce the transversus abdominis muscle and
halfway between the skin and the anterior rectus sheath, above Scarpa course ventrally.
fascia, and several centimeters from the midline. 2 to 3 cm medial to the anterior superior iliac spine, they pierce the
Branches of the External Iliac Vessels internal oblique muscle and course superficial to it toward the midline
a) Inferior Deep Epigastric Iliohypogastric Nerve
b) Deep Circumflex Iliac Perforates the external oblique aponeurosis near the lateral rectus border
Supply the muscles and fascia of the anterior abdominal wall to provide sensation to the skin over the suprapubic area.
Inferior Epigastric vessels initially course lateral to, then posterior to the Ilioinguinal Nerve
rectus abdominis muscles, which they supply. Course medially through the inguinal canal and exits through the
Pass ventral to the posterior rectus sheath and course between the Superficial Inguinal Ring, which forms by splitting of external abdominal
sheath and the rectus muscles. oblique aponeurosis fibers.
Near the umbilicus, anastomose with the Superior Epigastric Artery and Supplies the skin of the mons pubis, upper labia majora, and medial upper
Veins, which are branches of the Internal Thoracic Vessels. thigh.
Maylard incision: Inferior Epigastric Artery may be lacerated lateral to Ilioinguinal and Iliohypogastric Nerves can be severed during a low
the rectus belly during muscle transection. transverse incision or entrapped during closure, especially if incisions extend
These vessels rarely may rupture following abdominal trauma and create beyond the lateral borders of the rectus muscle
a rectus Sheath Hematoma These nerves carry sensory information only and injury leads to loss of
Hesselbach Triangle sensation within the areas supplied.
Lie on each side of the lower anterior abdominal wall Rarely, chronic pain may develop.
Bounded: L-inferior epigastric vessels, I: inguinal ligament, M: lateral T10 dermatome approximates the level of the umbilicus.
border of the rectus muscle. Regional analgesia for cesarean delivery or for puerperal sterilization
Direct Inguinal Hernias: hernias that protrude through the abdominal wall ideally blocks T10 through L1 levels.
in Hesselbach triangle. Transversus Abdominis Plane Block can provide broad blockade to the
nerves that traverse this plane
Rem Alfelor Maternal Anatomy Page 1 of 9
 May be placed post cesarean to reduce analgesia requirements a) Glans
Rectus Sheath Block or Ilioinguinal-Iliohypogastric Nerve Block to b) Corpus or body
decrease postoperative pain c) Two crura
Glans
EXTERNAL GENERATIVE ORGANS Usually < 0.5 cm in diameter
Vulva Covered by stratified squamous epithelium
Mons Pubis, Labia, and Clitoris Richly innervated
Pudenda
Commonly designated the vulva Clitoral Body
Includes all structures visible externally from the symphysis pubis to the Contains two corpora cavernosa
perineal body. Extending from the clitoral body, each corpus cavernosum
Includes: Mons Pubis, Labia Majora and Minora, Clitoris, Hymen, diverges laterally to form long narrow crus.
Vestibule, Urethral Opening, Greater Vestibular (Bartholin Glands), Minor Each crus lies along the inferior surface of its respective
Vestibular Glands and Paraurethral Glands
ischiopubic ramus, deep to the ischiocavernosus muscle.
Blood supply stems from branches of the Internal Pudendal Artery
Deep Artery of the clitoris supplies the clitoral body
Dorsal Artery of the clitoris supplies the glans and prepuce.
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
Mons Pubis vaginal opening
Also called the Mons Veneris Usually observed only in nulliparas.
Fat-filled cushion overlying the symphysis pubis. bilateral Bartholin Glands
After puberty, it is covered by curly hair that forms the escutcheon. In Also termed Greater Vestibular Glands
women, hair is distributed in a triangle, whose base covers the upper 0.5 -1 cm in diameter
margin of the symphysis pubis Each lies inferior to the vascular vestibular bulb and deep to the
In men and some hirsute women, the escutcheon is not so well inferior end of the bulbocavernosus muscle
circumscribed and extends onto the anterior abdominal wall toward the Duct from each measures 1.5 - 2 cm long
umbilicus. Opens distal to the hymeneal ring
Labia Majora One at 5 and the other at 7 oclock on the vestibule.
Homologous with the male scrotum. Following trauma or infection, either duct may swell and obstruct to
7-8 cm in length, 2-3 cm in depth, and 1-1.5 cm in thickness form a cyst or, if infected, an abscess.
S: continuous directly with the mons pubis and round ligaments terminate Minor Vestibular Glands
at their upper borders. Shallow glands lined by simple mucin-secreting epithelium
P: taper and merge into the area overlying the perineal body to form the Open along Hart line
Posterior Commissure. Paraurethral Glands
Hair covers the labia majora outer surface but is absent on their inner
Collective arborization of glands whose multiple small ducts open
surface.
predominantly along the entire inferior aspect of the urethra.
Apocrine, eccrine, and sebaceous glands are abundant.
Two Largest are called Skene Glands
Beneath the skin is a dense connective tissue layer, which is nearly void
Ducts typically lie distally and near the urethral meatus.
of muscular elements but is rich in elastic fibers and adipose tissue.
Inflammation and duct obstruction of any of the paraurethral glands
Mass of fat provides bulk to the labia majora
can lead to urethral diverticulum formation.
Supplied with a rich venous plexus
Lower two thirds of the urethra lie immediately above the anterior vaginal
During pregnancy: vasculature commonly develops varicosities, especially
wall
in parous women
Urethral opening or meatus is in the midline of the vestibule
Due to increased venous pressure created by the enlarging uterus.
1-1.5 cm below the pubic arch and short distance above the vaginal
Appear as engorged tortuous veins or as small grapelike clusters
opening.
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.
Inner surface: lateral portion is covered by this same epithelium up to a
demarcating line (Hart Line)
Medial: each labium is covered by nonkeratinized squamous
epithelium
Lack hair follicles, eccrine glands, and apocrine glands but many Vagina and Hymen
sebaceous glands Hymen
Clitoris Membrane of varying thickness that surrounds the vaginal opening more
Principal female erogenous organ or less completely.
Erectile homologue of the penis. Composed mainly of elastic and collagenous connective tissue
Located beneath the prepuce, above the frenulum and urethra, Both outer and inner surfaces are covered by non-keratinized stratified
projects downward and inward toward the vaginal opening squamous epithelium
Rarely exceeds 2 cm in length Aperture of the intact hymen ranges in diameter from pinpoint to one that
Composed of admits one or even two fingertips.
Imperforate Hymen
Rem Alfelor Maternal Anatomy Page 2 of 9
 Rare malformation in which the vaginal orifice is occluded
completely causing retention of menstrual blood
As a rule, the hymen is torn at several sites during first coitus.
Edges of the torn tissue soon reepithelialize
Pregnant women: hymeneal epithelium is thick and rich in glycogen.
Over time, the hymen transforms into several nodules of various sizes,
termed Hymeneal or Myrtiform Caruncles.
Vagina
Proximal to the hymen
Musculomembranous tube that extends to the uterus
Interposed lengthwise between the bladder and the rectum
Anteriorly, separated from the bladder and urethra by connective tissue
(Vesicovaginal Septum)
Posteriorly, between the lower portion of the vagina and the rectum
together form the Rectovaginal Septum.
upper fourth is separated from the rectum by the Rectouterine Pouch
Also called the Cul-De-Sac or Pouch of Douglas.
Anterior wall measures 6-8 cm
Posterior vaginal wall is 7-10 cm
Upper end of the vaginal vault is subdivided by the cervix into
a) Anterior
b) Posterior
c) two Lateral Fornices
Clinical importance because the internal pelvic organs usually
can be palpated through the thin walls of these fornices.
Posterior fornix provides surgical access to the peritoneal
cavity.
Midportion of the vagina: lateral walls are attached to the pelvis by visceral
connective tissue.
Lateral attachments blend into investing fascia of the levator ani.
Create the anterior and posterior lateral vaginal sulci.
Run the length of the vaginal sidewalls and give the vagina an H
shape when viewed in cross section.
Lining is composed of non-keratinized stratified squamous epithelium and
underlying lamina propria.
Premenopausal women: lining is thrown into numerous thin
transverse ridges, known as Rugae
Line the anterior and posterior vaginal walls along their
length.
Deep to this is a muscular layer, which contains smooth muscle, collagen,
and elastin.
Beneath lies an adventitial layer consisting of collagen and elastin
No vaginal glands
Lubricated by a transudate that originates from the vaginal subepithelial
capillary plexus and crosses the permeable epithelium
Due to increased vascularity during pregnancy, vaginal secretions
are notably increased.
After birth-related epithelial trauma and healing, fragments of stratified
epithelium occasionally are embedded beneath the vaginal surface.
Buried epithelium continues to shed degenerated cells and keratin.
Result a firm epidermal inclusion cysts, which are filled with keratin
debris, may form and are a common Vaginal Cyst.
Proximal portion is supplied by the Cervical Branch of Uterine Artery
and Vaginal Artery
May variably arise from the Uterine or Inferior Vesical or directly
from the Internal Iliac Artery.
Middle Rectal Artery supply the posterior vaginal wall
Internal Pudendal Artery supplies distal walls
Blood supply from each side forms anastomoses on the anterior and
posterior vaginal walls with contralateral corresponding vessels.
Extensive venous plexus immediately surrounds the vagina and follows
the course of the arteries.
Lymphatics from the lower third, along with those of the vulva, drain
primarily into the Inguinal Lymph Nodes.
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
the bony pelvic outlet:
Rem Alfelor Maternal Anatomy
A: pubic symphysis, AL: ischiopubic rami and ischial tuberosities,
PL:sacrotuberous ligaments, P:coccyx
An arbitrary line joining the ischial tuberosities divides the perineum into an
anterior triangle (urogenital triangle) and posterior triangle (anal triangle)
Perineal Body
Fibromuscular mass found in the midline at the junction between these
anterior and posterior triangles
Also called the Central Tendon of the Perineum
Measures 2 cm tall and wide and 1.5 cm thick
Serves as the junction for several structures and provides significant
perineal support
Superficially, the bulbocavernosus, superficial transverse perineal, and
external anal sphincter muscles converge on the central tendon. More
deeply, perineal membrane, portions of the pubococcygeus muscle, and
internal anal sphincter contribute
Incised by an episiotomy incision and is torn with second-, third-, and
fourth-degree lacerations.
Superficial Space of the Anterior Triangle
Bounded by: S:pubic rami, L:ischial tuberosities, P: superficial transverse
perineal muscles
Divided into superficial and deep spaces by the Perineal Membrane.
Membranous partition is a dense fibrous sheet that was previously known
as the Inferior Fascia of the Urogenital Diaphragm.
Attaches: L:ischiopubic rami, M: distal third of the urethra and vagina, P:
perineal body, A:arcuate ligament of the pubis.
Superficial space of the anterior triangle is bounded deeply by the Perineal
Membrane and superficially by Colles Fascia.
Colles fascia is the continuation of Scarpa fascia onto the perineum.
On the perineum, Colles fascia securely attaches L: pubic rami and fascia
lata of the thigh, I: superficial transverse perineal muscle and inferior
border of the perineal membrane, M: urethra, clitoris, and vagina.
Superficial space of the anterior triangle is a relatively closed compartment, and
expanding infection or hematoma within it may bulge yet remains contained.
Superficial pouch contains several important structures: Bartholin glands,
vestibular bulbs, clitoral body and crura, branches of the pudendal vessels
and nerve, and ischiocavernosus, bulbocavernosus, and superficial
transverse perineal muscles.
Ischiocavernosus muscles each attach on their respective side:
I: medial aspect of the ischial tuberosity
L: ischiopubic ramus
A: clitoral crus
Help maintain clitoral erection by compressing the crus to obstruct venous
drainage.
Bilateral bulbocavernosus muscles
Overlie the vestibular bulbs and Bartholin glands.
A: body of the clitoris (A) and the perineal body (P).
Constrict the vaginal lumen and aid release of secretions from the
Bartholin glands.
Contribute to clitoral erection by compressing the deep dorsal vein
of the clitoris.
Bulbocavernosus and ischiocavernosus muscles also pull the clitoris
downward.
Superficial transverse perineal muscles are narrow strips that attach to the
ischial tuberosities (L) and the perineal body (M)
May be attenuated or even absent, but when present, they contribute to
the perineal body
Vestibular Bulbs
Embryologically correspond to the corpora spongiosa of the penis
Almond-shaped aggregations of veins
3-4 cm long, 1-2 cm wide, and 0.5-1 cm thick
Lie beneath the bulbocavernosus muscle on either side of the vestibule.
Terminate inferiorly at the middle of the vaginal opening
Extend upward toward the clitoris.
Anterior extensions merge in the midline, below the clitoral body.
During childbirth, veins may be lacerated or even rupture to create a
vulvar hematoma enclosed within the superficial space of the anterior
triangle.
Page 3 of 9
 Begins at the level of levator ani attachment to the rectum and ends at the anal
Deep Space of the Anterior Triangle skin.
Space lies deep to the perineal membrane and extends up into the pelvis 4-5 cm length
Continuous superiorly with the pelvic cavity Mucosa consists of
Contains a) Columnar epithelium (uppermost portion)
a) Portions of urethra and vagina b) Simple stratified squamous epithelium (begins at dentate or pectinate line
b) Certain portions of internal pudendal artery branches, continues to the anal verge)
c) Compressor urethrae Keratin and skin adnexa join the squamous epithelium.
d) Urethrovaginal sphincter muscles Has several lateral tissue layers
Comprise part of the striated urogenital sphincter complex. Inner layers include
Pelvic Diaphragm a) Anal Mucosa
Found deep to the anterior and posterior triangles b) Internal Anal Sphincter
Broad muscular sling provides substantial support to the pelvic viscera. c) Intersphincteric Space
Composed of Contains continuation of the rectums longitudinal smooth
a) Levator ani muscle layer.
b) Coccygeus muscle. Outer layer contains
c) Levator ani a) Puborectalis Muscle (S)
Composed of b) External Anal Sphincter (I)
1) Pubococcygeus Within the anal canal, three highly vascularized submucosal arteriovenous
2) Puborectalis plexuses (anal cushions)
3) Iliococcygeus Aid complete closure of the canal and fecal continence when apposed.
Pubococcygeus Muscle Increasing uterine size, excessive straining, and hard stool create increased
Also termed the Pubovisceral Muscle pressure that ultimately leads to degeneration and subsequent laxity of the
Subdivided based on points of insertion and function cushions supportive connective tissue base.
Include These protrude into and downward through the anal canal
1) Pubovaginalis Leads to venous engorgement within the cushions (Hemorrhoids)
2) Puboperinealis Venous stasis results in inflammation, erosion of the
3) Puboanalis cushions epithelium, and then bleeding.
Insert into the vaginal, perineal body, and anus, respectively External Hemorrhoids
Vaginal birth conveys significant risk for damage to the levator ani or to its Those that arise distal to the pectinate line.
innervation Covered by stratified squamous epithelium
Pubovisceral Muscle is more commonly damaged Receive sensory innervation from the Inferior Rectal Nerve.
Injuries may predispose women to greater risk of pelvic organ prolapse or Pain and a palpable mass are typical complaints.
urinary incontinence Following resolution, a hemorrhoidal tag may remain composed of
Efforts are aimed at minimizing these injuries.
redundant anal skin and fibrotic tissue.
Internal Hemorrhoids
Posterior Triangle
Those that form above the dentate line
contains
Covered by insensitive anorectal mucosa
a) Ischioanal Fossae
May prolapse or bleed but rarely become painful unless they
b) Anal Canal
c) Anal Sphincter Complex undergo thrombosis or necrosis.
Anal Sphincter Complex
Anal Sphincter Complex
Consists of
Two sphincters surround the anal canal to provide fecal continence
a) Internal anal sphincter
a) External Sphincter
b) External anal sphincter
b) Internal Anal Sphincters
c) Puborectalis muscle
Both lie proximate to the vagina
d) Branches of the pudendal nerve and internal pudendal vessels
One or both may be torn during vaginal delivery
Ischioanal Fossae Internal Anal Sphincter (IAS)
Also known as Ischiorectal Fossae Distal continuation of the rectal circular smooth muscle layer.
two fat-filled wedge-shaped spaces Receives predominantly parasympathetic fibers, which pass through the
found on either side of the anal canal pelvic splanchnic nerves.
comprise the bulk of the posterior triangle Supplied by the Superior, Middle, and Inferior Rectal Arteries
Each fossa has skin as its superficial base Contributes the bulk of anal canal resting pressure for fecal continence
Deep apex is formed by the junction of the levator ani and obturator internus and relaxes prior to defecation
muscle. Measures 3- 4 cm in length
Other borders include: At its distal margin, it overlaps the external sphincter for 1-2 cm
Obturator internus muscle fascia and ischial tuberosity (L) Distal site at which this overlap ends (Intersphincteric Groove)
Anal canal and sphincter complex (IM) Palpable on digital examination.
Inferior fascia of the downwardly sloping levator ani (SM) External Anal Sphincter (EAS)
Maximus muscle and sacrotuberous ligament (P) Striated muscle ring
Inferior border of the anterior triangle (A). Anteriorly attaches to the perineal body
Fat found within each fossa provides support to surrounding organs yet allows Posteriorly connects to the coccyx (anococcygeal ligament)
rectal distention during defecation and vaginal stretching during delivery. Maintains a constant resting contraction to aid continence
Injury to vessels in the posterior triangle can lead to hematoma formation in the Provides additional squeeze pressure when continence is threatened, yet
ischioanal fossa relaxes for defecation.
Potential for large accumulation in these easily distensible spaces. Three parts include
Two fossae communicate dorsally, behind the anal canal a) Subcutaneous
Episiotomy infection or hematoma may extend from one fossa into the b) Superficial
other. c) Deep Portions
Deep portion is composed fully or in part by the puborectalis muscle
Receives blood supply from the inferior rectal artery
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

Rem Alfelor Maternal Anatomy Page 4 of 9

 Uterus
Nonpregnant uterus: situated in the pelvic cavity
Between the bladder (A) and rectum (P)
Entire posterior wall of the uterus is covered by serosa (Visceral Peritoneum)
Lower portion of this peritoneum forms the anterior boundary of the
Rectouterine Cul-De-Sac (Pouch Of Douglas)
Only the upper portion of the anterior wall of the uterus is so covered.
Peritoneum in this area reflects forward onto the bladder dome to create
the Vesicouterine Pouch
Lower portion of the anterior uterine wall is united to the posterior wall of the
bladder by well-defined loose connective tissue layer (Vesicouterine Space)
During cesarean delivery, peritoneum of the vesicouterine pouch is
sharply incised, and the vesicouterine space is entered.
Dissection caudally within this space lifts the bladder off the lower uterine
segment for hysterotomy and delivery
Pear shaped
Consists of two major but unequal parts.
a) Body or Corpus
upper triangular portion
Pudendal Nerve b) Cervix
Formed from the anterior rami of S24 spinal nerves Lower, cylindrical portion
Courses between the piriformis and coccygeus muscles Projects into the vagina
Exits through the greater sciatic foramen c) Isthmus
Posterior to the sacrospinous ligament Union site of these two
Medial to the ischial spine Special obstetrical significance because it forms the lower uterine
When injecting local anesthetic for a pudendal nerve block, the ischial spine segment during pregnancy.
serves an identifiable landmark At each superolateral margin of the body is a Uterine Cornu
Runs beneath the sacrospinous ligament and above the sacrotuberous ligament From which a fallopian tube emerges
Reenters the lesser sciatic foramen to course along the obturator internus This area is the origins of the round and uteroovarian ligaments.
muscle. Between the points of fallopian tube insertion is the convex upper uterine
Lies within the pudendal canal (Alcock canal) segment (fundus)
Formed by splitting of the obturator internus investing fascia Bulk of the uterine body is muscle
Relatively fixed as it courses behind the sacrospinous ligament and within Inner surfaces of the anterior and posterior walls lie almost in contact
the pudendal canal Cavity between these walls forms a mere slit
May be at risk of stretch injury during downward displacement of the Nulligravid uterus: 6-8 cm in length
pelvic floor during childbirth Multiparous uterus: 9-10 cm
Leaves this canal to enter the perineum Averages 60 g and typically weighs more in parous women
Divides into three terminal branches Nulligravidas: fundus and cervix are approximately equal in length
1) Dorsal Nerve of the Clitoris Multiparas: cervix is only a little more than a third of the total length.
Runs between the ischiocavernosus muscle and perineal Pregnancy stimulates remarkable uterine growth due to muscle
membrane fiber hypertrophy
Supply the clitoral glans Uterine fundus, previously flattened convexity between tubal
2) Perineal Nerve insertions, now becomes dome shaped.
Runs superficial to the perineal membrane Round ligaments appear to insert at the junction of the middle and
Divides into Posterior Labial Branches and Muscular Branches upper thirds of the organ.
Serve the labial skin and the anterior perineal triangle Fallopian tubes elongate, but the ovaries grossly appear
muscles, respectively. unchanged.
3) Inferior Rectal Branch Cervix
Runs through the ischioanal fossa Fusiform and open at each end by small apertures
Supply the external anal sphincter, the anal mucosa, and the a) Internal Cervical Ora
perianal skin b) External Cervical Ora
Major blood supply to the perineum is via the Internal Pudendal Artery Proximally, the upper boundary of the cervix is the internal os, corresponds to
Branches mirror the divisions of the pudendal nerve. the level at which the peritoneum is reflected up onto the bladder
Portio Supravaginalis
INTERNAL GENERATIVE ORGANS Upper cervical segment
Lies above the vaginas attachment to the cervix
Covered by peritoneum on its posterior surface
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)

Rem Alfelor Maternal Anatomy Page 5 of 9

 Infundibulopelvic Ligament or Suspensory Ligament of the Ovary
Myometrium and Endometrium Peritoneum that extends beneath the fimbriated end of the fallopian tube
Most of the uterus is composed of toward the pelvic wall forms the.
Myometrium Contains nerves and the ovarian vessels
Smooth muscle bundles united by During pregnancy, these vessels, especially the venous plexuses, are
connective tissue containing dramatically enlarged.
many elastic fibers. Diameter of the ovarian vascular pedicle increases from 0.9 cm to reach
Interlacing myometrial fibers surround 2.6 cm at term
myometrial vessels and contract to Cardinal Ligament
compress these. Also called the Transverse Cervical Ligament or Mackenrodt Ligament
Integral to hemostasis at the Thick base of the broad ligament
placental site during the third Medially united firmly to the uterus and upper vagina
stage of labor. Each uterosacral ligament originates with a posterolateral attachment to
Number of myometrial muscle fibers
the supravaginal portion of the cervix
varies by location Inserts into the fascia over the sacrum
Levels progressively diminish caudally such that, in the cervix, muscle
Ligaments are composed of connective tissue, small bundles of vessels
makes up only 10% of the tissue mass
and nerves, and some smooth muscle.
Uterine body inner wall: more muscle than in outer layers
Covered by peritoneum, these ligaments form the lateral boundaries of the
Anterior and posterior walls: more muscle than in the lateral walls.
pouch of Douglas.
During pregnancy, the upper myometrium undergoes marked hypertrophy, but Parametrium
there is no significant change in cervical muscle content. Describe the connective tissues adjacent and lateral to the uterus
Uterine cavity is lined with Endometrium
within the broad ligament.
Composed of an overlying epithelium, invaginating glands, and Paracervical tissues are those adjacent to the cervix
supportive, vascular stroma Paracolpium
Varies greatly throughout the menstrual cycle and during pregnancy.
Tissue lateral to the vaginal walls.
Divided into
a) Functionalis Layer
Sloughed with menses
b) Basalis Layer
Serves to regenerate the functionalis layer following each
menses.

Ligaments
Several ligaments that extend from the uterine surface toward the pelvic
sidewalls
Include
a) Round Ligaments
b) Broad Ligaments
c) Cardinal Ligaments
d) Uterosacral Ligaments
Round Ligament
Corresponds embryologically to the male gubernaculum testis
Originates below and anterior to the origin of the fallopian tubes.
Orientation can aid in fallopian tube identification during puerperal
sterilization
Important if pelvic adhesions limit tubal mobility and thus limit fimbria
Blood Supply
visualization prior to tubal ligation.
During pregnancy, there is marked hypertrophy of the uterine vasculature
Each extends laterally and downward into the inguinal canal, through
Supplied principally from the Uterine and Ovarian Arteries
which it passes, to terminate in the upper portion of the labium majus.
Sampson Artery Uterine Artery
Branch of the uterine artery main branch of the Internal Iliac Artery
Runs within this ligament previously called the Hypogastric Artery
Nonpregnant women: 3-5 mm in diameter
Enters the base of the broad ligament and makes its way medially to the
Composed of smooth muscle bundles separated by fibrous tissue septa
side of the uterus.
During pregnancy, these ligaments undergo considerable hypertrophy and
2 cm lateral to the cervix, the uterine artery crosses over the ureter.
increase appreciably in both length and diameter.
This proximity is of great surgical significance as the ureter may be
injured or ligated during hysterectomy when the vessels are
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
Broad Ligaments Spiral Arteries.
Two wing like structures that extend from the lateral uterine margins to the Spiral Arteries
pelvic sidewalls. Supply the functionalis layer.
With vertical sectioning through this ligament proximate to the uterus Vessels respond by vasoconstriction and dilatation to a
Triangular shape can be seen number of hormones
Uterine vessels and ureter are found at its base serve an important role in menstruation
Divide the pelvic cavity into anterior and posterior compartments. Basal Arteries
Each consists of a fold of peritoneum (Anterior and Posterior Leaves) Also called Straight Arteries
This peritoneum drapes over structures extending from each cornu.
Extend only into the basalis layer
Peritoneum
Not responsive to hormonal influences.
a) Mesosalpinx: Overlies the fallopian tube
Just before the main uterine artery vessel reaches the fallopian tube, it
b) Mesoteres : Around the round ligament is the
c) Mesovarium: Over the uteroovarian ligament divides into three terminal branches
Rem Alfelor Maternal Anatomy Page 6 of 9
 Ovarian Branch of the uterine artery
Forms an anastomosis with the terminal branch of the Ovarian
Artery
Tubal branch
Makes its way through the mesosalpinx
Supplies part of the fallopian tube
Fundal branch
penetrates the uppermost uterus
Ovarian Artery
Direct branch of the aorta
Enters the broad ligament through the infundibulopelvic ligament.
Ovarian hilum: divides into smaller branches that enter the ovary.
As the ovarian artery runs along the hilum, it also sends several branches
through the mesosalpinx to supply the fallopian tubes.
Main stem traverses the entire length of the broad ligament and makes its
way to the uterine cornu.
Forms an anastomosis with the ovarian branch of the uterine artery. Dual
uterine blood supply creates a vascular reserve to prevent uterine
ischemia if ligation of the uterine or internal iliac artery is performed to
control postpartum hemorrhage.
Uterine veins accompany their respective arteries.
Arcuate Veins unite to form the Uterine Vein Parasympathetic Innervation
Empties into the internal iliac vein and then the Common Iliac Vein. Derives from neurons at spinal levels S2-S4
Within the broad ligament, these veins form the large pampiniform plexus Axons exit as part of the anterior rami of the spinal nerves for those levels.
that terminates in the Ovarian Vein. These combine on each side to form the pelvic splanchnic nerves (Nervi
Right Ovarian Vein empties into the Vena Cava Erigentes)
Left Ovarian Vein empties into the Left Renal Vein. Blending of the two Hypogastric Nerves (sympathetic) and the two Pelvic
Blood supply to the pelvis is predominantly supplied from branches of the Splanchnic Nerves (parasympathetic) gives rise to the Inferior Hypogastric
Internal Iliac Artery. Plexus (Pelvic Plexus)
Organized into anterior and posterior divisions Retroperitoneal plaque of nerves lies at the S4-S5 level
Anterior Division From here, fibers of this plexus accompany internal iliac artery branches
Provides blood supply to the pelvic organs and perineum to their respective pelvic viscera.
Inferior Hypogastric Plexus
Includes the inferior gluteal, internal pudendal, middle rectal,
Divides into three plexuses
vaginal, uterine, obturator arteries and umbilical artery
a) Vesical Plexus
Continuation as the superior Vesical Artery
Innervates the bladder and the middle rectal travels to the
rectum
Posterior Division
b) Uterovaginal Plexus (Frankenhuser Plexus)
Extend to the buttock and thigh
Reaches the proximal fallopian tubes, uterus, and upper
Include the superior gluteal, lateral sacral, and iliolumbar vagina.
arteries. during internal iliac artery ligation Extensions of the inferior hypogastric plexus also reach the perineum
Many advocate ligation distal to the posterior division to avoid along the vagina and urethra to innervate the clitoris and vestibular bulbs
compromised blood flow to the areas supplied by this division Composed of variably sized ganglia, but particularly of a large ganglionic
plate that is situated on either side of the cervix, proximate to the
Lymphatics uterosacral and cardinal ligaments
Endometrium is abundantly supplied with lymphatic vessels that are confined Most afferent sensory fibers from the uterus ascend through the inferior
largely to the basalis layer. hypogastric plexus and enter the spinal cord via T10-T12 and L1 spinal
Lymphatics of the underlying myometrium are increased in number toward nerves
the serosal surface and form an abundant lymphatic plexus just beneath Transmit the painful stimuli of contractions to the central nervous
it. system
Lymphatics from the cervix terminate mainly in the internal iliac nodes Sensory nerves from the cervix and upper part of the birth canal pass through
Situated near the bifurcation of the common iliac vessels the pelvic splanchnic nerves to the second, third, and fourth sacral nerves.
Lymphatics from the uterine corpus are distributed to two groups of nodes. Those from the lower portion of the birth canal pass primarily through the
Vessels drains into the Internal Iliac Nodes Pudendal Nerve.
After joining certain lymphatics from the ovarian region, terminates in the Anesthetic blocks used in labor and delivery target this innervation.
Paraaortic Lymph Nodes. Ovaries
During childbearing years: 2.5 -5 cm in length, 1.5-3 cm in breadth, and 0.6-1.5
Innervation cm in thickness.
Peripheral nervous system is divided Usually lie in the upper part of the pelvic cavity
a) Somatic Division Rest in a slight depression on the lateral wall of the pelvis (Ovarian Fossa of
Innervates skeletal muscle Waldeyer)
b) Autonomic Division Between the divergent external and internal iliac vessels.
Innervates smooth muscle, cardiac muscle, and glands. Uteroovarian Ligament
Pelvic visceral innervation is predominantly autonomic Originates from the lateral and upper posterior portion of the uterus
Further divided in Sympathetic and Parasympathetic Beneath the tubal insertion level
Components. Extends to the uterine pole of the ovary
Sympathetic Innervation to pelvic viscera begins with the Superior
3-4 mm in diameter
Hypogastric Plexus (Presacral Nerve)
Made up of muscle and connective tissue
Beginning below the aortic bifurcation and extending downward
covered by Mesovarium
retroperitoneally, this plexus is formed by sympathetic fibers arising from
spinal levels T10-L2. Blood supply traverses to and from the ovary through this double-layered
At the level of the sacral promontory, divides into a Right and a Left mesovarium to enter the ovarian hilum.
Hypogastric Nerve, which run downward along the pelvis side walls Consists of a cortex and medulla
Young women: outermost portion of the cortex is smooth
Tunica Albuginea: dull white surface
On its surface, there is a single layer of cuboidal epithelium, (Germinal
Epithelium of Waldeyer)
Beneath this epithelium, the cortex contains oocytes and developing
follicles.
Medulla
Central portion
Composed of loose connective tissue.
There are a large number of arteries and veins and small number of
smooth muscle fibers.
Supplied with both sympathetic and parasympathetic nerves.
Sympathetic nerves: Ovarian Plexus that accompanies the ovarian
vessels
Originates in the renal plexus.

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 Others are derived from the plexus that surrounds the ovarian
branch of the uterine artery.
Parasympathetic input: Vagus Nerve
Sensory afferents follow the ovarian artery and enter at T10 spinal
cord level.

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
symphysis pubis
Conceptually divided into false and true components
a) False Pelvis
Lies above the linea terminalis
Fallopian Tubes
Bounded: p:lumbar vertebra, l: iliac fossa, a:lower portion of the
Called Oviducts
anterior abdominal wall
Serpentine tubes extend 8-14 cm from the uterine cornua
b) True Pelvis
Anatomically classified along their length as an Portion important in childbearing
a) Interstitial Portion Obliquely truncated, bent cylinder with its greatest height posteriorly.
b) Isthmus
Borders:
c) Ampulla
d) Infundibulum S:linea terminalis
Interstitial Portion I: pelvic outlet
Most proximal P: anterior surface of the sacrum
Embodied within the uterine muscular wall. L:inner surface of the ischial bones and the sacrosciatic
Isthmus notches and ligaments
Narrow 2-3 Mm A: pubic bones, ascending superior rami of the ischial bones,
Adjoins the uterus and widens gradually and obturator foramina.
Ampulla Sidewalls converge
5-8 mm Extending from the middle of the posterior margin of each
More lateral ischium are the ischial spines.
Infundibulum Great obstetrical importance because the distance
funnel-shaped fimbriated distal extremity of the tube between them usually represents the shortest diameter
opens into the abdominal cavity of the true pelvis.
Serve as valuable landmarks in assessing the level to which the presenting part
Latter three extrauterine portions are covered by the Mesosalpinx at the
of the fetus has descended into the true pelvis
superior margin of the broad ligament.
Aid pudendal nerve block placement.
Extrauterine fallopian tube contains a mesosalpinx, myosalpinx, and
Sacrum
endosalpinx
Forms the posterior wall of the true pelvis
Mesosalpinx Upper anterior margin corresponds to the promontory that may be felt
Single-cell mesothelial layer during bimanual pelvic examination in women with a small pelvis. Provide
Functioning as visceral peritoneum a landmark for clinical pelvimetry
Normally, the sacrum has a marked vertical and a less pronounced
Myosalpinx
horizontal concavity, which in abnormal pelves may undergo important
Smooth muscle
variations.
Arranged in an inner circular and an outer longitudinal layer. Straight line drawn from the promontory to the tip of the sacrum usually
In the distal tube, the two layers are less distinct and are replaced measures 10 cm
near the fimbriated extremity by sparse interlacing muscular fibers. Distance along the concavity averages 12 cm
Tubal musculature undergoes rhythmic contractions constantly, the
rate of which varies with cyclical ovarian hormonal changes.
Endosalpinx
Tubal mucosa
Single columnar epithelium composed of ciliated and secretory cells
resting on a sparse lamina propria
In close contact with the underlying myosalpinx.
Ciliated cells are most abundant at the fimbriated extremity, but
elsewhere, they are found in discrete patches
Mucosa is arranged in longitudinal folds that become progressively
more complex toward the fimbria
Ampulla: lumen is occupied almost completely by the arborescent mucosa
Current produced by the tubal cilia is such that the direction of flow is
toward the uterine cavity.
Pelvic Joints
Tubal peristalsis created by cilia and muscular layer contraction is
A: pelvic bones are joined together by the symphysis pubis.
believed to be an important factor in ovum transport
Consists of fibrocartilage and the superior and Inferior Pubic Ligaments.
Supplied richly with elastic tissue, blood vessels, and lymphatics.
Frequently designated the arcuate ligament of the pubis.
Sympathetic innervation is extensive in contrast to their parasympathetic
P: pelvic bones are joined by articulations
innervation
Nerve supply derives partly from the Ovarian Plexus and partly from the Between the sacrum and the iliac portion of the innominate bones to form
Uterovaginal Plexus. the Sacroiliac Joints.
Sensory afferent fibers ascend to T10 spinal cord levels. These joints in general have a limited degree of mobility.
During pregnancy, there is remarkable relaxation of these joints at term,
MUSCULOSKELETAL PELVIC ANATOMY caused by upward gliding of the sacroiliac joint

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 Displacement, which is greatest in the dorsal lithotomy position, Each of the two oblique diameters extends from one sacroiliac
may increase the diameter of the outlet by 1.5-2.0 cm. synchondrosis to the contralateral iliopubic eminence.
Main justification for placing a woman in this position for a Each eminence is a minor elevation that marks the union site of the
vaginal delivery. ilium and pubis.
But this pelvic outlet diameter increase occurs only if the These oblique diameters average less than 13 cm.
sacrum is allowed to rotate posteriorly.
Thus, it will not occur if the sacrum is forced anteriorly by the Midpelvis and Pelvic Outlet
weight of the maternal pelvis against the delivery table or bed Midpelvis
Sacroiliac joint mobility is also the likely reason that the McRoberts maneuver Measured at the level of the ischial spines
often is successful in releasing an obstructed shoulder in a case of shoulder Also called the Midplane or Plane of Least Pelvic Dimensions
dystocia During labor, the degree of fetal head descent into the true pelvis may be
Attributed to the success of the modified squatting position to hasten described by station, and the midpelvis and ischial spines serve to mark
second-stage labor zero station
Squatting position may increase the interspinous diameter and the pelvic Interspinous Diameter
outlet 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
Planes and Diameters of the Pelvis Rami unite at an angle of 90-100 degrees to form a rounded arch under
Pelvis is described as having four imaginary planes: which the fetal head must pass.
a) The plane of the pelvic inlet (Superior Strait) Clinically, three diameters of the pelvic outlet usually are describe
b) The plane of the pelvic outlet (Inferior Strait) Anteroposterior
c) The plane of the midpelvis: least pelvic dimensions Transverse
d) The plane of greatest pelvic dimension: no obstetrical significance. Posterior sagittal
Unless there is significant pelvic bony disease, the pelvic outlet seldom
obstructs vaginal delivery.

Pelvic Inlet
Also called the Superior Strait
Superior plane of the true pelvis
Bounded:
P: promontory and alae of the sacrum
L: linea terminalis
A: horizontal pubic rami and the symphysis pubis.
During labor, fetal head engagement (fetal heads biparietal diameter)
passing through this plane.
To aid this passage, the inlet of the female pelvis typically is more
nearly round than ovoid.
Nearly round or gynecoid pelvic inlet in approximately half of white
women.
Four diameters of the pelvic inlet are usually described:
a) Anteroposterior
b) Transverse
c) Two oblique diameters Pelvic Shapes
Distinct anteroposterior diameters have been described using specific Caldwell-Moloy anatomical classification of the pelvis based on shape, and its
landmarks. concepts aid an understanding of labor mechanisms.
a) Anteroposterior Diameter Greatest transverse diameter of the inlet and its division into anterior and
Most cephalad posterior segments are used to classify the pelvis as
Termed the True Conjugate a) Gynecoid
b) Anthropoid
Extends from the uppermost margin of the symphysis pubis to the
c) Android
sacral promontory d) Platypelloid
Clinically important Obstetrical Conjugate is the shortest distance Posterior segment determines the type of pelvis
between the sacral promontory and the symphysis pubis. Anterior segment determines the tendency.
Normally, this measures 10 cm or more, but cannot be
Both determined because many pelves are not pure but are mixed
measured directly with examining fingers.
types.
Estimated indirectly by subtracting 1.5-2 cm from the Gynecoid pelvis with an android tendency means that the posterior pelvis
Diagonal Conjugate is gynecoid and the anterior pelvis is android shaped.
Determined by measuring the distance Configuration of the gynecoid pelvis would intuitively seem suited for
Transverse diameter is constructed at right angles to delivery of most fetuses.
the obstetrical conjugate Gynecoid pelvis was found in almost half of women.
Represents the greatest distance between the linea
terminalis on either side
Usually intersects the obstetrical conjugate at a point
approximately 5 cm in front of the promontory and
measures approximately 13 cm.

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