PHYSIO OB: MATERNAL ANATOMY AND INTERNAL GENERATIVE ORGANS

CRUZ, LESLEE A. 2E

ANTERIOR ABDOMINAL WALL ABDOMINAL MUSCLES

 Contains the abdominal viscera  Rectus abdominis
 Stretches to accommodate the expanding uterus  Pyramidalis muscle
 Provides surgical access to the internal reproductive organs  External oblique
 Internal oblique
LAYERS  Transversalis muscle
LINEA ALBA
 Where the aponeuroses of the external and internal oblique, as
well as the transversus abdominis muscle fuse.
 Normally measures to 10-15 mm wide below the umbilicus
 Used as a guide during surgery
 An abnormally wide separation may reflect diastasis recti or hernia
RECTUS SHEATH

Skin  subcutaneous layer  fascia  muscle  peritoneum

SKIN
LANGER LINES
 Where the aponeurosis of the external and internal oblique and
 Describes the orientation of dermal fibers the transversus abdominis muscle are invested in the rectus
 In the abdomen, this is transversely arranged. This is important to abdominis muscle
know in terms of making incisions
∞ Vertical skin incision ARCUATE LINE
Ω More tension , more scars
∞ Low transverse (Pfannenatiel) incision
Ω This follows the langer lines
Ω Less tension, less scars (superior cosmetic /
anesthetic result)

SUBCUTANEOUS LAYER
CAMPER’S FASCIA
 Superficial layer
 Predominantly composed of fats
 Continuous onto the perineum which provides a fatty substance to
the mons pubis and the labia majora
 Blends with the fat of the ischioanal fossa
SCARPA’S FASCIA  Serves as the boundary that separates the abdominal contents and
its layers
 Deeper layer  Cephalad
 More membranous ∞ Aponeuroses invest the rectus abdominis bellies above
 Continues inferiorly to the perineum as Colle’s fascia and below
∞ Perineal infection or hemorrhage superficial to this has the  Caudal
ability to extend upward to involve the superficial layers of ∞ All aponeuroses lie anterior to the rectus abdominis
the abdominal wall muscle and only the thin transversalis fascia and
peritoneum lie beneath
NOTE
These are not discrete layers but instead represent a continuum of the
subcutaneous tissue layer.

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PHYSIO OB: MATERNAL ANATOMY AND INTERNAL GENERATIVE ORGANS
CRUZ, LESLEE A. 2E

BLOOD SUPPLY EXTERNAL GENERATIVE ORGANS

PUDENDA / VULVA

 Femoral artery’s branches

∞ Supply the skin and subcutaneous layer of the anterior
abdominal wall and the mons pubis Includes all structures visible externally from the pubis to the
∞ Superficial epigastric artery perineum:
∞ Superficial circumflex artery  Mons pubis
Ω Near the inguinal area  Labia majora and minora
∞ External pudendal artery  Clitoris
 External iliac artery’s branches  Hymen
∞ Supply the muscles and fascia of the anterior abdominal  Vestibule
wall  Urethral opening
∞ Inferior “deep” epigastric vessel  Various glandular and vascular structures
Ω Specific for the rectus abdominis muscle ∞ Greater vestibular or Bartholin’s gland
∞ Deep circumflex iliac vessel ∞ Minor vestibular glands
HESSELBACH TRIANGE ∞ Paraurethral glands

 Boundaries MONS PUBIS

∞ Inferior : inguinal ligament  AKA mons veneris
∞ Medial : lateral border of  Fat-filled cushion that lies over the symphysis pubis
the rectus muscle  At puberty, this is covered by curly hair that forms the escutcheon
∞ Lateral : inferior epigastric  In adult women, it is distributed in a triangular area
vessels ∞ Base: forms the upper margin of the symphysis pubis
∞ Tip: ends at the clitoris
 Clinical significance
∞ Direct hernia LABIA MAJORA
Ω Involves the Hesselbach triangle
Ω Usually happens when there is an  Male homologue: Scrotum
abnormality or loss of elasticity  Continuous directly with the mons pubis
∞ Indirect hernia  Merge posteriorly to form the Posterior Commisure
Ω Involves the deep inguinal ring  Abundantly contains the:
∞ Apocrine gland
INNERVATIONS ∞ Eccrine gland
∞ Sebaceous gland
 Intercostal nerves (T7 – T11)  In the upper border, this is where the round ligaments terminate
 Subcostal nerve (T12)  Outer surface with hair while inner surface without hairs
 Iliohypogastric nerve
∞ Skin over the suprapubic area  In children & nulliparous women – close apposition
 Ilioinguinal nerve (L1)  In multiparous women – gapes widely
∞ skin of the lower abdominal wall
∞ upper portion of the labia majora LABIA MINORA
∞ medial portion of the thigh
 T10 dermatome  Male homologue : Ventral shaft of the penis
∞ approximates the level of the umbilicus  composed of connective tissue with many vessels and some
smooth muscular fibers
 Clinical significance (Iliohypogastric and Ilioinguinal nerve)  moist and reddish, similar in appearance to a mucous membrane
∞ can be entrapped during closure of low transverse  extremely sensitive because its supplied with many nerve endings
(Pfannenstiel) incisions, especially if incisions extend  2 lamellae superiorly
beyond the lateral borders of the rectus muscle ∞ lower pair: forms
∞ carry sensory information only, and injury leads to loss the frenulum of the
of sensation within the areas supplied. clitoris
∞ upper pair:
forms the prepuce
 Inferiorly, it forms the
fourchette.
 Lining epithelium
∞ Stratified squamous
epithelium: Outer
and Lateral portion of
inner surface
∞ Non-keratinized squamous epithelium: Medial portion

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PHYSIO OB: MATERNAL ANATOMY AND INTERNAL GENERATIVE ORGANS
CRUZ, LESLEE A. 2E

 Hart line  Clinical significance:

∞ Demarcation line between lateral and midline portion ∞ Inflammation and duct obstruction of any paraurethral
 Contains sebaceous follicles, few sweat glands glands can lead to urethral diverticulum formation
 Lack hair follicles, eccrine glands and apocrine glands (usually common in children)
CLITORIS VESTIBULAR BULBS
 Male homologue: Penis
 Composed of:
∞ Glans
∞ Corpus
∞ Two crura
 Rarely exceeds 2 cm in length
 covered by stratified squamous epithelium that is richly supplied
with nerve ending
∞ Principal female erogenous organ
VESTIBULE
 From embryonic urogenital membrane
 Almond-shaped
 BOUNDARIES:
∞ Lateral- Hart line  Male homologue: Corpus spongiosum of the penis
∞ Medial – external surface of hymen  Almond-shaped, mainly composed of aggregations of veins
∞ Anteriorly- frenulum  3 to 4 cm long, 1 to 2 cm wide, and 0.5 to 1 cm thick
∞ Posteriorly- fourchette  Lie beneath the bulbocavernosus muscle on either side of the
 6 openings: vestibule.
∞ urethra  Clinical significance:
∞ vagina ∞ If injured, which is usually during childbirth, may rupture
∞ ducts of the Bartholin glands (2) to create a vulvar hematoma
∞ ducts of the paraurethral glands/skene glands (2)
 Fossa navicularis HYMEN
∞ Posterior portion of the vestibule between the
fourchette and the vaginal opening  Membrane surrounding the
∞ Usually observed only in nulliparas vaginal opening
 Usually a pinpoint or 1-2 fingertips
VESTIBULAR GLANDS wide
 Composed of elastic and
BARTHOLIN GLANDS collagenous connective tissue
 Covered by stratified squamous
 Greater vestibular glands epithelium
 0.5 to 1 cm in diameter  No glandular or muscular
 Lie inferior to the vestibular elements, and is NOT richly
bulbs and deep to the supplied with nerve fibers
inferior ends of the  The aperture of the hymen varies.
bulbocavernosus muscle ∞ Newborn: very vascular
 Ducts are 1.5 to 2 cm long and redundant
and open distal to the ∞ Pregnant: thick and rich in glycogen
hymenal ring at 5 & 7 o'clock ∞ Menopause: thin ; focal cornification may develop
 Following trauma or  Appearance of the hymen cannot be used to determine whether a
infection, either duct may swell and obstruct to form a cyst, or if woman has begun sexual activity
infected, an abscess
PARAURETHRAL GLANDS  Clinical significance:
∞ Hymen is torn at several sites during first coitus. Identical
tears may occur by other penetration. The edges of the
torn hymen soon reepithelialize  hymenal caruncle
∞ Imperforate hymen
Ω A rare congenital defect
Ω Vaginal orifice is
occluded completely /
hymen is completely
closed, causing retention
of menstrual blood
leading to amenorrhea
Ω Will also manifest as
cyclic dysmennorhea
VAGINA
 Lies in the inferior aspect of the urethra
 Maintains the moisture of the vaginal area  Musculo-membranous structure
∞ Without moisture, this makes the patient more prone to  Extends from the vulva to the uterus
infection. This is also one of the signs of menopause  Interposed anteriorly and posteriorly between the urinary bladder
 Skene glands and the rectum
∞ Largest  Lining epithelium: non-keratinized stratified squamous epithelium
 Minor vestibular glands  No glands
∞ Shallow glands lined by simple mucin-secreting  Abundant vascular supply
epithelium and open along Hart line

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PHYSIO OB: MATERNAL ANATOMY AND INTERNAL GENERATIVE ORGANS
CRUZ, LESLEE A. 2E

 Embryology PERINEUM
∞ Upper portion - müllerian ducts
∞ Lower portion - urogenital sinus  The diamond area between the thighs
 Boundaries are same as those of the bony pelvic outlet
∞ Anterior: Pubic symphysis
∞ Posterior: Ischiopubic rami
∞ Anterolateral: Ischial tuberosities
∞ Posterolateral: Sacrotuberous ligaments
∞ Posterior: Coccyx
 Blood supply:
∞ Internal pudendal artery (inferior rectal artery and
posterior labial artery)
 Ischial tuberosities:
∞ Divides the perineum into anterior and posterior triangle

 Vesicovaginal septum (anterior)

∞ Separates the vagina from the bladder and urethra by
connective
 Rectovaginal septum (posterior)
∞ Separates the lower
portion of the vagina and
the rectum
 Rectouterine pouch or culdesac of
Douglas ANTERIOR / UROGENITAL TRIANGLE
∞ Separates the upper
fourth of the vagina from  Further subdivided into:
the rectum ∞ Superficial space – closed compartment
 Length ∞ Deep space – deep to the perineal membrane and
∞ Anterior: 6 – 8cm extends up continuous superiorly with
∞ Posterior: 7 – 10cm the pelvic cavity
∞ Total length: 9 cm

 Subdivided by the cervix into fornices  anterior, posterior, lateral  Boundaries:

 Clinical significance: ∞ Superior: Pubic rami
∞ Internal pelvic organs can be palpated through their thin ∞ Lateral: Ischial tuberosities
walls ∞ Posterior: Superficial transverse pernieal muscle
∞ Posterior fornix provides surgical access to the peritoneal SUPERFICIAL SPACE OF THE ANTERIOR TRIANGLE
cavity ISCHIOCAVERNOUS MUSCLE HELPS MAINTAIN CLITORAL
Ω Cudocentesis / Posterior Cul de Sac ERECTION
 Patients suspected with ectopic pregnancy CONSTRICT THE VAGINAL LUMEN
has an accumulation of the AND AID IN THE RELEASE OF
hemoperitoneum in the cul de sac area SECRETIONS OF THE BARTHOLIN’S
 Fluid are drained from there and if they got BULBOCAVERNOUS MUSCLE GLAND
a non clotting fluid, it usually indicates a
CONTRIBUTES TO CLITORAL
hemoperitoneum brought about by ectopic ERECTION
pregnancy SUPERFICIAL TRANSVERSE CONTRIBUTES TO THE PERINEAL
 Not done anymore due to ultrasound PERINEAL MUSCLES BODY
∞ Chadwick sign
Ω Violatious discoloration of the vagina DEEP SPACE OF THE ANTERIOR TRIANGLE
Ω Presumptive sign of pregnancy Compressor urethrae
Urethrovaginal sphincter muslces
BLOOD SUPPLY LYMPHATIC DRAINAGE External urethral sphincter
UPPER THIRD CERVICOVAGINAL ILIAC NODES Parts of urethra and vagina
BRANCHES OF THE Branches of internal pudendal artery, dorsal nerve and vein of the
UTERINE ARTERIES clitoris
MIDDLE THIRD INFERIOR VESICAL INTERNAL ILIAC NODES
ARTERIES
LOWER THIRD MIDDLE RECTAL AND INGUINAL LYMPH
INTERNAL PUDENDAL NODES
ARTERIES
**Blood supply are all branches of the internal iliac artery

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PHYSIO OB: MATERNAL ANATOMY AND INTERNAL GENERATIVE ORGANS
CRUZ, LESLEE A. 2E

POSTERIOR / ANAL TRIANGLE  Innervation: Motor fibers come from the inferior rectal branch of
the pudendal nerve
 Contains:
∞ Ischiorectal fossa INTERNAL ANAL SPHINCTER
Ω Two fat filled wedge shaped spaces on either side
of the anal canal  Contributes the bulk of the anal
Ω Provide support to surrounding structures, yet canal resting pressure for fecal
allow distension of the rectum during defecation continence
and stretching of the vagina during delivery  Formed by the distal
Ω Continuous across the perineal compartment and continuation of the inner circular
allows fluid, infection and malignancy to spread muscle layer of the rectum and
∞ Anal canal colon
∞ Anal sphincter complex  Primarily involved in 4th degree
Ω Internal and external anal sphincter perineal laceration
Ω Puborectalis muscles
ANAL SPHINCTER
SIDE NOTE
 Highly vascularized
Anal canal and sphincter lie in the center of the fossae.  Aids in fecal continence
 Clinical significance:
 Blood supply: Branches of the internal pudendal vessels ∞ Engorgement due to increased uterine size, excessive
 Innervation: Pudendal nerve straining and hard stools, can increase venous
engorgement within these cushions to form
PUDENDAL NERVE hemorrhoids
PERINEAL BODY
 Structures that contribute to
the perineal body:
∞ Median raphe of
the levator ani
∞ Central tendon of
the perineum
∞ Bulbocavernosus
muscle
∞ Superficial
transverse perineal muscle
∞ External anal
sphincter

 Formed by the anterior rami of S2-S4  Functions

 Lies posteromedial to the ischial spines ∞ Anchors the anorectum and vagina
∞ Helps maintain urinary and fecal continence
 3 terminal branches: ∞ Maintains the orgasmic platform
∞ Dorsal nerve of the clitoris – supplies the skin of the ∞ Prevents expansion of the urogenital hiatus
clitoris ∞ Provides a physical barrier between the vagina and
∞ Perineal nerve – supplies the muscles of the anterior rectum
triangle and labial skin  Potential morbidity
∞ Inferior rectal nerve – supplies the external anal ∞ Episiotomy may injure this
sphincter, mucous membrane of anal canal and the ∞ Pudendal nerve injury may be associated with concurrent
perineal skin perineal body injury
 Clinical significance:
∞ Pudendal nerve block: INTERNAL GENERATIVE ORGANS
Ω Where anesthesia is injected during delivery to
numb the whole peritoneum EMBRYOLOGICAL DEVELOPMENT OF THE UTERUS AND OVIDUCTS
ANAL
EXTERNAL ANAL SPHINCTER

 A ring of striated muscle attached to the perineal body anteriorly

and the coccyx posteriorly
 Maintains the constant state of resting contraction
 Provides increased tone and strength when continence is
threatened
 Blood supply: Inferior rectal artery
 Fusion of the two müllerian (paramesonephric) ducts to form a
single canal begins at the level of the inguinal crest, that is, the
gubernaculum (primordium of the round ligament) – 5th week of
development

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PHYSIO OB: MATERNAL ANATOMY AND INTERNAL GENERATIVE ORGANS
CRUZ, LESLEE A. 2E

 Upper ends of the müllerian ducts produce the oviducts and the ∞ Multiparous: 9-10cm, cervix is 1/3 of the total length
fused parts give rise to the uterus  Entire posterior wall of the uterus is covered by serosa, or
 The vaginal canal is not patent throughout its entire length until peritoneum, the lower portion of which forms the anterior
the sixth month of fetal life boundary of the recto-uterine cul-de-sac, or pouch of Douglas.
∞ The anterior wall, on the otherhand is not completely
 5TH week of embryological development – uterus and tibes arise covered and is used to deflect the bladder downwards
from the mullerian ducts, which first appear near the upper pole of during CS
the urogenital ridge  Blood supply:
 6th week – the growing tips of the two mullerian ducts approach ∞ Uterine artery
each other in the midline ; they reach the urogenital sinus 1 week ∞ Ovarian artery
later
PARTS
CERVIX  Corpus or body
 Cervix
 Continuous with the uterus  Isthmus
∞ between the internal cervical os and the endometrial
PARTS cavity
∞ forms the lower uterine segment during pregnancy
 Internal cervical os  Cornua
∞ upper boundary ∞ at the junction of the superior and lateral margins
∞ level at which the ∞ insertion of the fallopian tube
peritoneum is reflected up onto the  Fundus
bladder ∞ convex upper segment between the points of insertion of
the fallopian tubes
 Portio supravaginalis (upper portion) ∞ where the pressure during uterine contraction is the
∞ covered by peritoneum on its greatest because it will push down the fetus
posterior surface
∞ attached to the cardinal LAYERS
ligaments laterally
∞ Separated from the overlying
bladder by loose connective tissue
 Portio vaginalis (lower portion)

 External cervical os
∞ Before childbirth: small, oval
opening
∞ After childbirth: transverse
slit, giving rise to the anterior and
posterior cervical lip
∞ Serosa (top)
Ω Formed by the peritoneum that covers the uterus
∞ Muscular (myometrium)
Ω Makes up the bulk of the uterus
Ω Bundles of smooth muscle united by connective
tissue in which there are many interlacing elastic
fibers
Ω Inner, anterior and posterior wall: greater
musculature
Ω Outer and lateral walls: lesser
Ω Muscle fibers diminish caudally such that the
 Cervical stroma – compose mainly of collagen, elastin and muscle comprises only 10% of the tissue mass in
proteoglycan but very little smooth muscle the cervix
 Ectocervix – nonkeratinized squamous epithelium Ω Facilitates the contraction
 Endocervix – mucin-secreting columnar epithelium Ω The interlacing myometrial fibers that surround
the myometrial vessels are integral to control of
bleeding from the placental site during the third
 The mucosa is a single layer of very high ciliated columnar stage of labor  prevent hemorrhage
epithelium that rests on a thin basement membrane Ω During pregnancy, the upper myometrium
 Glands furnish the thick, tenacious cervical secretions undergoes marked hypertrophy, but there is no
 Lymphatics: significant change in cervical muscle content
∞ terminate mainly in the hypogastric nodes, which are
situated near the bifurcation of the common iliac vessels ∞ Mucosa (endometrium)
 Clinical significance: Ω Thin, pink, velvet-like membrane perforated by a
∞ Nabothian cysts large number of minute ostia of the uterine glands.
Ω Otherwise known as retention cysts Ω Basalis layer
Ω Happens when the ducts of the cervical glands are  regenerates into a new endometrium
occluded  not affected by hormones
∞ Hegar sign Ω Functionalis layer
Ω Softening of the isthmus  sloughs off during menses
∞ _________ sign  reacts to estrogen which is responsible for
Ω Softening of the cervix endometrial growth
UTERUS
Ω Histology (don’t focus much daw on this)
 Thick- walled, hollow, muscular organ  Epithelium - single layer of closely packed
∞ Nulliparous: 6- 8cm, fundus and cervix almost equal in high columnar cells than rests on a thin
length basement membrane

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PHYSIO OB: MATERNAL ANATOMY AND INTERNAL GENERATIVE ORGANS
CRUZ, LESLEE A. 2E

 Uterine glands – invaginations of the ROUND LIGAMENT

epithelieum that extend to the
myometrium
 Interglandular mesenchymal stroma –
varies remarkably throughout the ovarian
cycle, undergoes decidualization following
ovulation
 Blood supply:
 Homologue: gubernaculum testis
 Extend from the lateral portion of the uterus
 Composed of smooth muscle cells
 Arise below and anterior to the origin of the oviducts / fallopian
tube.
 Terminate in the upper portion of the labium majora
 Sampson artery runs within this ligament (branch of the uterine
artery)
 During pregnancy, this undergo considerable hypertrophy and
increase appreciably in both length and diameter
 Clinically significant when doing puerperal tubal sterilization due to
its proximity to the fallopian tube
CARDINAL LIGAMENT

∞ From the internal iliac artery, it will go medially to supply

the lateral part of the uterus  will go upward and
anastomose with the ovarian artery
∞ Uterine and ovarian arteries  arcuate arteries  radial
arteries  spiral/coiled arteries and basal/straight
arteries
∞ Spiral arteries – midportion and superficial third of the
endometrium, responsive to hormones
∞ Basal arteries – basal layer, not responsive to hormones
 Transverse cervical or Mackendrodt ligament
 Densest portion
 Thick base of the broad ligament that is continuous with the
connective tissue of the pelvic floor
 Medially, this is united firmly to the supravaginal portion of the
cervix

 Lymphatics: UTEROSACRAL LIGAMENT

∞ Body of the uterus: internal iliac nodes and periaortic
lymph nodes
LIGAMENTS

 From its attachment posterolaterally to the supravaginal portion of

the cervix and inserts into the fascia over the sacram
 Form the lateral boundaries of the pouch of Douglas
FALLOPIAN TUBES / OVIDUCT
 Supports the reproductive tract
 Loss of elasticity, which usually happens during menopause kasi  Vary in length from 8 to 14 cm.
estrogen ang nagpoprovide ng elasticity dito (sorry, nauubusan na  lumen is lined by mucous membrane.
ko ng English), will usually result into pelvic organ prolapse PARTS
BROAD LIGAMENT  Interstitial portion
 2 winglike structures from lateral margins to pelvic sidewall  Isthmus
 Each consist of an anterior leaf and a posterior leaf  Ampulla
 Divide the pelvic cavity inyo anterior and posterior compartments ∞ common site of
 Drapes over structures extending from the cornu fertilization and ectopic
∞ Mesosalpinx - covers the fallopian tube pregnancy
∞ Mesoteres – covers the round ligament  Infundibulum or fimbriated
∞ Mesovarium – covers the ovary extremity
∞ Mesometrium – mesentery of the uterus ∞ funnel-shaped opening
 Suspensory ligament or infundibulopelvic ligament – from the at the distal
fimbriated end of the fallopian tube to the pelvic wall, where  Tubal smooth muscle
ovarian vessels traverse ∞ inner circular and outer longitudinal
∞ Undergo rhythmic contraction or peristalsis toward the
uterine cavity

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PHYSIO OB: MATERNAL ANATOMY AND INTERNAL GENERATIVE ORGANS
CRUZ, LESLEE A. 2E

 Epithelium
∞ Close contact with muscle layer because there is no
submucosa
∞ Composed of columnar cells (some ciliated, others FEMALE MALE
secretory LABIA MAJORA SCROTUM
LABIA MINORA VENTRAL SHAFT OF THE PENIS
 Has the ability to go into tubal peristalsis which is believed to be an CLITORIS PENIS
extraordinary important factor in the transport of the ovum to the VESTIBULAR BULBS CORPUS SPONGIOSUM OF THE PENIS
endometrium ROUND LIGAMENT GUBERNACULUM TESTIS
 Diverticula may extend occasionally from the lumen of the tube
and may play a role in ectopic pregnancy
 Supplied richly with elastic tissue, blood vessels and lymphatics
 Innervation : sympathetic innervation of the tubes is extensive, in
contrast to their parasympathetic innervation
OVARIES

 Vary considerably in size.

∞ During childbearing years, they are from 2.5 to 5 cm in
length, 1.5 to 3 cm in breadth, and 0.6 to 1.5 cm in
thickness. SOURCES:
∞ After menopause, ovarian size diminishes remarkably as
well as the function. Last year’s lecture ppt
 Rest in a slight depression on the lateral wall of the pelvis, called
ovarian fossa of Waldeyer between the divergent external and Pacis trans
internal iliac vessels
 Attached to the broad ligament by the mesovarium and the uterus
by the utero-ovarian ligament
 Covered by the peritoneum
 Made up of muscles and connective tissues
PARTS:
 Cortex
∞ outer layer
∞ contains oocytes and developing follicles
 Medulla
∞ central portion
∞ composed of loose connective tissue
 Blood supply: Ovarian artery  direct branch of the aorta
 Innervation: both sympathetic nerves from the ovarian plexus and
parasympathetic nerves.

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