The Anatomy of

Obstetrics

Kurt Kauffman, MD, FACOG

Objectives:
 Describe the muscular, neurologic and vascular anatomy
of the pelvis and vulva

 Describe the anatomic changes in the woman caused by

normal physiologic adaptation to pregnancy

 Describe the anatomic changes that occur during the

intrapartum period

 Describe the anatomic changes that occur during the

puerperium, such as alterations in the breast and
uterine involution
Pelvic anatomy - muscular
 Pelvic blood supply
 Internal illiac artery
 Anterior branch
 Obturator artery
 Superior vesical artery
 Uterine artery
 Middle vesical artery
 Internal pudendal artery
 Posterior branch
 Illiolumbar artery
 Lateral sacral artery
 Anterior gluteal artery
 Vulva
 Labia Majora

 Labia Minora

 Clitorus

 Vestibule

 Urethral meatus

 Vaginal introitus

 Perineum
Vulvar Cutaneous Innervation
 Anatomic changes caused by
normal physiologic adaptation to
pregnancy

 Abdominal wall

 Pelvic organs

 Breasts
Rectus muscles
 Pelvic organs
 Uterus enlarges to about 5 Liters total size (including all
contents (12 lbs)
 Uterine muscle
 Fetus
 Placenta
 Fluids

 Vagina lengthens

 Round ligaments lengthens

 Broad ligament stretches (venous plexus engorges)

Uterine size and gestational age
 Pudendal Nerve

Controls:
External anal sphincter
External Urethral sphincter
Clitoral erection & Orgasm
Posterior perineum sensation
 Vaginal/Labial changes with
pregnancy
 Increased vascularity

 Varicosities
 Unilateral or bilateral – may be quite tender
 May need supportive garment

 Enlargement
 Breast Changes with Pregnancy
 After conception:
 Breast become swollen/tender
 Nipples are more sensitive/tingle
 Areola/nipple become darker by 12 weeks post conception

 Ductal, alveolar, and myoepithelial elements all undergo

marked hyperplasia. Ductal proliferation is
predominantly controlled by estrogen, but acinar
differentiation is a progesterone effect facilitated by
estrogen.
Pregnancy changes in the Breast
 Anatomic changes during the
intrapartum period
 Dilation of the cervix
 Thinning/effacement

 Descent of the fetal head into the vagina

 Dilation of the vagina as the fetal head descends
 Dilation of the introitus/vulva as the baby crowns

 Separation of the placenta after the baby is delivered

 Lengthening of the cord, bleeding

 Injury/stretching of nerves to pelvis

 Perineum/bladder (Pudendal & vesical plexes/hypogastric)
 Anatomic changes that occur
during the puerperium
 Involution (pelvic organs)
 Starts immediately post delivery of the placenta
 Lasts approximately 6 weeks
 Decrease in estrogen and progesterone aids in involution

 Breast Changes
 Post partum involution
 Uterus starts immediate involution.
 Contractions immediately decrease blood flow which
decreased blood loss and helps with involution
 Uterine muscles atrophy quickly at first and then continue
for 6 weeks
 Uterus weighs around 900 grams immediately PP – but only
50 – 60 grams at 6 weeks PP

 Vagina also involutes, but slower

 Tubes, ligaments and vulvar muscles also involute and

return to near pre delivery size
 Involution of Endometrium
 Endometrium necrosis and sloughs off

 Placental implantation site thrombosis over

 Basal layer is source of new endometrium

 Placental implantation site first shrinks in diameter,

then is exfoliated by undermining of site with new
endometrium
 Involution of Vagina
 Slower to involute (takes 4 to 8 weeks)

 Regains tone, but never back to virginal state

 Mucosa remains delicate for few weeks

 Rugae partially reappear at 3rd week PP

 Introitus also remains larger than virginal state

 Breast changes after delivery
 Mammary tissue becomes secretive with the abrupt
falling of estrogen and progesterone with delivery

 Lactogenesis requires 2-5 days (maturation of acinar

epithelium in breast)

 Once lactogenesis occurs completely, hormones

estrogen and progesterone have little effect on
production.
 References
 Netter, F., Atlas of Human Anatomy

 Williams Obstetrics, 23rd edition

 Gabbe, G.G., et al, Obstetrics Normal and Problem

Pregnancies. Fourth edition.

 www.healthcare.phillips.com