1.

02 MATERNAL ANATOMY AND PHYSIOLOGY

Dr. Ryan B. Capitulo || June 23, 2015
OB
Transcribers: Almonte, Alonzo, Alparas, Alvarez, Alvero, Apolonio
Editors: Lavares

OUTLINE Maternal Anatomy

Maternal Anatomy: Maternal Physiology A. Vulva/Pudenda

A. Vulva/Pudenda A. Uterus
B. Vagina B. Cervix
C. Pelvis and Perineum C. Ovary
D. Pelvic floor D. Vulva and Vagina
E. Pelvic Organs E. Skin
F. Pelvic Ligaments F. Breast
G. Pelvic Arterial Blood G. Carbohydrate
Supply Metabolism
H. Pelvic Venous Drainage H. Blood
and Lymphatics I. Immunity
I. Pelvic Autonomic J. Heart
Nerves K. Lungs
J. Pelvic Bone L. GI Tract
M. Thyroid
N. Musculoskeletal

Legend:
Remember Previous Trans
Lecturer Book
(Exams) Trans Comm
    

References: Figure 1. External anatomy of the female reproductive organ

PPT and Recording
Moore et al. Clinically Oriented Anatomy, 6th ed.  Borders include all visible structures externally from pubis
symphysis to the perineal body
Notes: o Mons pubis
 The lecturer mentioned that there is no need to read anything o Labia majora and minora
else, except for two specific topics: Pelvic Arterial Blood Supply o Clitoris
and Pelvic Autonomic Nerves. The transcribers have already o Hymen vestibule
incorporated a summary of these topics. o Urethral opening
 The points emphasized by the lecturer are listed at the end of the o Bartholin’s glands and minor vestibular glands
transcription. Do not ignore. The transcribers have also done a o Skene glands
great job in placing the “” sign where the lecturer has  Labia majora
o Continuous directly with the mons pubis superiorly
emphasized an important point. 
o The round ligaments terminate at their upper borders
 Vestibule
o Perforated by six openings
 Urethra
 Vagina
 2 Bartholin gland ducts
 2 Skene gland ducts

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[OB] 1.02 MATERNAL ANATOMY AND PHYSIOLOGY – Dr. Ryan B. Capitulo
B. Vagina
 Perineum – diamond-shaped area between the inner thighs
which is bounded by:
o Symphysis pubis (anteriorly)
o Ischiopubic rami and ischial tuberosities
(anterolaterally)
o Sacrotuberous ligaments (posterolaterally)
o Coccyx (posteriorly)
 Should be able to visualize the diamond shaped area
especially when there are injuries after vaginal birth such as
perineal tear
 An arbitrary line joining the ischial tuberosities divides the
perineum into:
o anterior triangle (urogenital triangle)
o posterior triangle (anal triangle)
 Perineal membrane
o Important structure with a height of ~2cm and
width of ~1.5cm
o It provides one of the major supports of the pelvic
organs in the perineum

D. Pelvic Floor

Figure 2. Internal anatomy of the female reproductive organ

 Fornices (subdivided by the external portion of the cervix)

o Anterior
o 2 Lateral
o Posterior
 Aka Pouch of Douglas
 Provides surgical access to peritoneal
cavity
 Relationship to other structures
o Vesicovaginal septum
 Separates vagina from urethra
o Rectovaginal septum
 Separates vagina from rectum

C. Pelvis and Perineum

Figure 4. Pelvic Floor

 The pelvic floor or the pelvic diaphragm is composed of the

levator ani muscles, composed of three muscles:
o pubococcygeus (from the pubis to the coccyx)
o puborectalis (from the pubis, forms a sling around
the rectum and goes back to the other side of the
pubic symphysis)
o iliococcygeus (from ileum to coccyx)
 The levator ani muscles are the main support of the pelvic
organs.

Figure 3. Pelvis and Perineum

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[OB] 1.02 MATERNAL ANATOMY AND PHYSIOLOGY – Dr. Ryan B. Capitulo
E. Pelvic Organs F. Pelvic Ligaments

Figure 5. Internal Anatomy of Pelvis

 The internal female genitalia is composed of:

o Uterus
 The lower portion of the anterior uterine wall Figure. 6 Pelvic Ligaments
is united to the posterior wall of the bladder by
a well-defined loose layer of CT called the 1. Major Ligaments
vesico-uterine space  Cardinal Ligament/Transverse cervical
 During caesarean, the peritoneum of the ligament/Mackenrodt ligament
vesico-uterine pouch is sharply incised and the o It is the thick base of the broad ligament.
vesico-uterine space is entered o Connective tissue that provides support to the
o Fallopian tubes uterus by attaching the supra-vaginal portion of the
o Ovaries cervix to the pelvic side walls.
o Cervix o Medially, it is united firmly to the uterus and upper
 Ectocervix – exterior to the external os; vagina.
non-keratinized stratified squamous  Uterosacral Ligament
epithelium o Extends from an attachment posterolaterally in the
 Endocervix – single mucin-secreting supra-vaginal portion of the cervix to insert into the
columnar epithelium with glands; fascia over the sacrum
produces thick mucus during pregnancy o Covered by peritoneum, these ligaments form the
 Before childbirth, the external os is small, lateral boundaries of the pouch of Douglas
regular and oval. 2. Minor Ligaments
 After labor, orifice becomes a transverse
 Round ligament
slit which is divided into anterior and
o Originates below and anterior to the origin of the
posterior lips of cervix.
fallopian tube and terminate in the upper portion of
 Irregular, nodular or stellate cervix may
labia majora
be due to deep tears during delivery.
 Broad Ligament
 During pregnancy, the endocervical
o Two wing-like structures that extend from the
epithelium moves out and onto the
lateral uterine margins of the uterus to the pelvic
ectocervix (eversion). This may lead to
sidewalls
metaplasia or Nabothian cysts over time
 Stroma is composed of collagen, elastin,
and proteoglycans with little smooth
muscles.
 In early pregnancy, the cervix is vascular
and edematous. This produces an
ectocervical blue tint (Chadwick sign) and
isthmic softening characteristics (Hegar
sign).

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[OB] 1.02 MATERNAL ANATOMY AND PHYSIOLOGY – Dr. Ryan B. Capitulo
G.  Pelvic Arterial Blood Supply (MEMORIZE the divisions of the Vaginal branch: Anterior and
Internal Iliac Artery) posterior walls of the vagina,
Vaginal artery vestibular bulb, adjacent rectum
Inferior vesical branch: fundus of
urinary bladder
Uterus, ligaments of the uterus,
Uterine artery uterine tubes, ovary, cervix,
superior vagina
Lower part of rectum, upper part
Middle rectal artery
of anal canal
 The inferior vesical artery is also a part of the anterior division
of the internal iliac artery, but it is only found in males.

Table 2. Posterior Division of the Internal Iliac Artery -MEMORIZE

Branches Structures being supplied
Iliac branch: iliacus muscle and ilium
Iliolumbar artery
Lumbar branch: quadratus lumborum
and psoas major muscles
Spinal branch: Spinal meninges, roots of
sacral nerves
Lateral sacral artery
Other branches supply the erector
spinae muscles and skin overlying the
sacrum
Superior gluteal artery Piriformis, gluteal muscles, and tensor
fascia lata

Figure 7. Blood Supply of Pelvis  Direct Branch of Abdominal Aorta

o Ovarian arteries
 Internal Iliac Artery - principal artery of pelvis  Supplies the ovaries
o Begins as common iliac artery and bifurcates into  Enters the broad ligament through the
the internal and external iliac artery at infundibulo-pelvic ligament
intervertebral disc between L5 and S1
o Ureter crosses common iliac artery distal to its H. Pelvic Venous Drainage and Lymphatics
bifurcation  Uterine veins
o Descends posteromedially into lesser pelvis medial o Accompany respective aa.
to the external iliac artery and obutrator nerve and o Arcuate veins unite to form the uterine vein
lateral to peritoneum  Empty into the internal iliac vein and then
o Two Divisions: anterior and posterior the common iliac vein
 Anterior Division of the Internal Iliac Artery- branches are  Ovarian veins
mainly visceral but also include parietal branches that pass to o Right empties into the vena cava
the thigh and buttocks o Left empties into the left renal vein
 Lymphatics
Table 1. Anterior Division of the Internal Iliac Artery -MEMORIZE
o Endometrium is abundantly supplied with
Branches Structures being supplied
lymphatic vessels that are confined largely to the
Pelvic diaphragm, piriformis, basalis layer
quadratus femoris, uppermost o Lymphatics from the cervix terminate mainly in the
Inferior gluteal artery
hamstrings, gluteus maximus, internal iliac nodes
sciatic nerve
Perineum (its main artery): skin
and muscles of anal triangle,
Internal pudendal artery
urogenital triangle, the erectile
bodies
Forms the medial umbilical
ligaments; gives rise to superior
vesical artery which supplies the
Umbilical artery
superior part of the urinary
bladder

Pelvic muscles, muscles of medial

compartment of the thigh, head
Obturator artery of the femur, nutrient artery to
ilium

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[OB] 1.02 MATERNAL ANATOMY AND PHYSIOLOGY – Dr. Ryan B. Capitulo
I.  Pelvic Autonomic Nerves (Know where the sympathetic J. Pelvic Bones
innervation of the pelvic organs will arise and where the
parasympathetic innervation would be derived)

Figure 9. Pelvic Bones

 The decision to make a caesarian section may depend on the

configuration of the pelvic bone.
 The pelvic bone is composed of three bones, which are
attached to the sacrum:
Figure 8. Pelvic innervation o Ilium
o Pubis
 Pelvic innervations - predominantly autonomic o Sacrum
o Sympathetic innervations to the pelvic viscera
begins with superior hypogastric plexus/presacral
plexus
 Formed by sympathetic fibers arising
from T10-L2
 At the level of sacral promontory it
divides into the right and left hypogastric
nerve
o Parasympathtic innervations derive from S2
through S4 neurons
 These combine on each side to form the
pelvic splanchnic nerve
o Inferior Hypogastric Plexus
 Combination of 2 hypogastric nerves
(sympathetic) and 2 pelvic splanchnic
nerves (parasympathetic)
o Splanchnic nerve (parasympathetic)
 Divides into 3 plexuses: vesical, Figure 10. Anteroposterior view of the pelvis
uterovaginal, and middle rectal
o Afferent sensory fibers from uterus  False pelvis
 Ascend through inferior hypogastric o Lies above the linea terminalis
plexus and enter spinal cord via T10-T12  Bounded posteriorly by the lumbar
and L1 vertebra
 Laterally by the iliac fossa
 Anteriorly by the lower portion of the
anterior abdominal wall
 True pelvis
o Lies below the linea terminalis
 Important in childbearing
 Bounded superiorly by the promontory
and alae of the sacrum, linea terminalis,
and upper margins of the pubic bones
 Inferiorly bounded by the pelvic outlet

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[OB] 1.02 MATERNAL ANATOMY AND PHYSIOLOGY – Dr. Ryan B. Capitulo
 Pelvic inlet
o Divided by the transverse line into posterior sagittal
area and the anterior sagittal area (Refer to figure
10)
o Posterior sagittal area
 Important during labor and delivery
because this is where most of the cardinal
fetal movements will occur as it traverses
the pelvis
 Cardinal movements are movements of
the head of the baby so that it can
traverse a very narrow passageway during
delivery.
 Needs to be roomy so the baby can pass
easily
Figure 11. Pelvic Diameters
 Four diameters of the pelvic inlet (Refer to figure 11)
o Anteroposterior- shortest distance between the
promontory of the sacrum and the symphysis pubis
o Transverse- constructed at right angles to the
obstetrical conjugate and represents the greatest
distance between the linea terminalis on either side
o 2 oblique
o Interspinous- important in engagement of fetal
head in obstructed labor; measured at the level of
ischial spine; perpendicular to obstetric conjugate
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Figure 12. Pelvic Types
 Four parent pelvic types of the Caldwell-Moloy classification:
o Gynecoid: P>A; best prognosis for vaginal birth;
found in 50% of females
o Android: P<A; usually found in males; worst
prognosis for vaginal birth
o Platypelloid: P=A; transverse diameter widest
among the 4 types
o Anthropoid: P<A; narrow, but has good
posterior sagittal diameter; vaginal delivery is still
possible
Maternal Physiology
 These are the changes that occur in a woman’s body in order to
accommodate the baby.
 The product of conception itself, the conceptus, is a foreign body.
It is a mixture of DNA from the mother and the father. Rejection of
the conceptus does not take place because of the physiologic
changes.
A. Uterus
 Most of the uterus is composed of myometrium
 Uterine enlargement due to stretching
 Marked hypertrophy (NOT hyperplasia) of muscle cells
during pregnancy
o Stimulated by estrogen and progesterone
o Does not occur entirely in response to mechanical
distention
o No significant change in cervical muscle content
(NOT hyperplasia)
 Near term, it becomes a muscular sac with thin, soft, readily
indentable walls which allows for the Leopold’s Maneuver to
be done (palpation of uterus to assess baby’s position)
 Uterine enlargement most marked at the fundus
 Braxton - Hicks Contractions
o “Practice contractions”
o Unpredictable, sporadic, irregular, non-rhythmic,
painless
o May increase to every 10-20 mins at term
o May cause discomfort and “false labor” in late
pregnancy
 Increase in uterine blood flow to 450 - 650 ml / min near
term for sufficient perfusion of the placenta, delivering
enough nutrients to the fetus
[OB] 1.02 MATERNAL ANATOMY AND PHYSIOLOGY – Dr. Ryan B. Capitulo
 Increase in maternal-placental blood flow due to o Increase mucosal thickness
vasodilation o Loosening of connective tissue
o Uterine artery enlarges; diameter doubles by 20 o Hypertrophy of smooth muscle cells
weeks AOG o Hypertrophy of papillae of vaginal mucosa
o Uterine veins distend, which allows the veins to
hold the blood in the uterus for a longer period, E. Skin
giving more contact time for the blood and the  Some parts of the skin darken
placenta, allowing maximal extraction of nutrients  Reversible
from the blood  Striae gravidarum
B. Cervix o Due to breakage of collagen fibers from expansion
 Pronounced softening and cyanosis due to increase in of abdominal skin
vascularity and edema o Initiates mid-pregnancy and onwards
 Hypertrophy and hyperplasia of cervical glands  excessive o Risk factors: weight gain, young maternal age,
vaginal discharge family history
 Rearrangement of collagen-rich connective tissue
o With the detection of pregnancy, collagen fibers
rearrange in a circular fashion to secure the cervical
opening
o During labor, these collagen fibbers rearrange in a
radial fashion (like an asterisk) to facilitate its
opening
 Eversion of proliferating endocervical glands producing even
more discharge
 Endocervical mucosal glands produce tenacious mucus that
obstructs the cervical canal producing a mucus plug – to
prevent ascending infection from the vagina to the uterus
 Bloody show: expulsion of mucus plug at the onset of labor
Figure 13. Striae gravidarum
 Consistency of cervical mucus changes during pregnancy
 Basal cells near squamo-columnar junction become
 Linea nigra
prominent in size, shape and staining qualities due to
o Hyperpigmentation of the linea alba
estrogen
o Decrease in cytoplasm and increase in nucleus like a
dysplastic cell

C. Ovary
 Corpus luteum of pregnancy functions up to 6-7 weeks to
secrete progesterone that maintains the pregnancy (pro-
gestational).
 The precursors of the placenta produce beta hCG,
the purpose of which is to act on the ovary to
prolong the life of the corpus luteum.
o After 7 weeks, the placenta takes over the Figure 14. Stria nigra (the brown line that crosses the umbilicus)
progesterone production
o Clinical importance: pregnant patients with ovarian  Chloasma/Melasma
cyst or ovarian neoplasm are not being operated to o Mask of pregnancy
remove the ovary very early, because the corpus o Skin hyper-pigmentation due to estrogen and
luteum may still be there producing progesterone. progesterone
Operation takes place at around 10-12 weeks of
pregnancy, when the placenta already functions to
produce progesterone.
 Diameter of ovarian vascular pedicle (vasodilatation) increase
during pregnancy from 0.9 cm to 2.6 cm
 Relaxin secreted by corpus luteum, decidua, placenta and
heart – remodels connective tissues of reproductive tract
and relaxes the joints

D. Vulva and Vagina

 Increase vascularity and hyperemia with softening of the
underlying connective tissue of vulva
 Increase vascularity of vagina with violet discoloration Figure 15. Chloasma
(Chadwick Sign)
 Vaginal preparation for distention during labor and delivery:

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[OB] 1.02 MATERNAL ANATOMY AND PHYSIOLOGY – Dr. Ryan B. Capitulo
F. Breast
 Increased breast size
o Due to hyperplasia and hypertrophy of the glands
during pregnancy in preparation for breastfeeding
o Nipples increase in size and become more erectile
and pigmented
 The nipple should reach the pharynx of
the baby when breastfeeding
 Areola becomes more pigmented with many glands of
Montgomery
G. Carbohydrate metabolism
 Four hallmarks (MEMORIZE):
1. Mild fasting hypoglycemia
2. Postprandial hyperglycemia and hyperinsulinemia
3. Pregnancy-induced peripheral resistance to insulin
 Pregnancy is a diabetogenic event
4. State of accelerated starvation
 Placenta has no resistance to insulin.
Insulin will act on the placenta. And,
placenta will get all the glucose extracted
from the food.
 In pregnant women, the process of
postprandial hyperglycemia and release
of insulin happens very fast.
 Intake of food → postprandial
hyperglycemia → immediate rise in
insulin levels → resistance of woman’s
body to insulin → placenta uses all the
glucose → mild fasting hypoglycemia
 Advise the patient to take small frequent
feedings
H. Blood
 Increase in blood volume by 40-45%
o With vasodilatation, if the blood volume will not
increase, mother will have decreased preload:
peripheral pooling of the blood → decreased
preload → compensation by increasing heart
contractility → heart failure
o Done by induced resetting of osmotic threshold for
thirst and vasopressin causing water retention
 Functions of increased blood volume:
o Meet the demands of the uterus
o Protect mother and fetus against the deleterious
effects of hypovolemia impaired venous return (due
to dilatation and superior vena cava compression
by enlarging uterus)
o Safeguard mother from blood loss during delivery
 Increase of 15% in 1st trimester, rapid expansion in 2nd
trimester, plateaus in 3rd trimester
 Increase due to increase plasma and RBCs secondary to
increase erythropoietin
 Iron requirement in pregnancy is 1,000 mg
 Iron is the only mineral that has to be supplemented during
pregnancy
 Iron requirement in latter half of pregnancy not available
from body stores
 Iron in diet and iron mobilized from body stores are not
enough to meet demands of pregnancy
 Coagulation cascade is activated during pregnancy
(hypercoagulable) – pregnancy is a thrombogenic event
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 Increased risk for pulmonary embolism and deep
vein thrombosis
o Increased clotting factors and plasma fibrinogen
o Decreased platelet due to increase consumption
and hemodilution
o Decreased fibrinolytic activity
I. Immunity
 Suppression of immunological functions to accommodate the
foreign “semi-allogenic fetal graft”
o Pregnant woman is immunosuppressed BUT NOT
immunocompromised.
 Decreased humoral immunity
o Decrease in Th1 and Tc1 activity such that IL-2, IFN-
gamma and TNF-beta also decrease
o Th1 suppression needed in pregnancy
continuation.
o Th2 on the other hand is upregulated.
 Peak levels of IgA and IgG in cervical mucus to protect
against ascending infection
 Increase WBC count, granulocyte, CRP, ESR, plasma
globulins, C3 and C4
 The normal WBC count is 5,000-10,000/µL. In
pregnancy, normal levels can reach up to
16,000/µL.
J. Heart
 Heart and circulation undergo remarkable physiologic
adaptations during pregnancy
o Increased cardiac output
o Increased heart rate and stroke volume
o Decreased systemic and pulmonary vascular
resistance (due to vasodilatation)
o Increased plasma volume causing increased preload
o Decrease colloid osmotic pressure
 Adjust to the physiologic demands of the fetus while
maintaining cardiovascular integrity
K. Lungs
 Diaphragm rises 4 cm, increase transverse diameter of
thoracic cage, increase thoracic circumference
 As the uterus enlarges, diaphragm rises → lungs will
be decompensated
 Compensatory increase in tidal volume and minute
ventilatory volume
 Decrease functional residual capacity, residual volume and
total pulmonary resistance due to lung compression
L. GI Tract
 Stomach, intestines and appendix displaced by uterus
 Pyrosis or heartburn common due to decreased tone of
Lower esophageal sphincter (LES) and decreased
intraesophageal pressure
 Gums may become hyperemic and softened (which can lead
to gum bleeding)
 Decrease contractility of gallbladder
 Increase residual volume and increase cholesterol saturation
of gallbladder
[OB] 1.02 MATERNAL ANATOMY AND PHYSIOLOGY – Dr. Ryan B. Capitulo
M. Thyroid 3. A pregnant patient, 32 weeks AOG complains of mild
 Increase in thyroid binding globulin (TBG) due to estrogen abdominal discomfort characterized as tightening of the
 TBG binds T4. Thus, the thyroid gland compensates by abdomen around 3-5 times a day. These contractions are
producing more of the hormone. called:
 Decreased availability of iodide for maternal thyroid due to a. Braxton-Hicks
b. Hypotonic
increased renal excretion
c. Tetanic
 Total T4 sharply increase at 6-9 weeks then plateaus at 18
d. True labor
weeks
4. A pregnant woman would seem to be always hungry due to
 Total T3 markedly increase at 18 weeks then plateaus
this hallmark of gestational carbohydrate metabolism
o Clinical significance: In considering thyroid
a. Accelerated starvation
comorbidity (i.e. hypothyroidism or
b. Hypoinsulinemia
hyperthyroidism) in a pregnant patient, levels of
c. Insulin
free T4 and TSH should be considered. Do not
d. Sensitivity
simply request for serum T4 levels. Total T4 serum
e. Postprandial hypoglycemia
levels will be naturally increased since high amount
5. Which laboratory test should be requested for a pregnant
of T4 is bound to increased amount of TBG.
woman suspected of having Grave’s Disease?
a. Free T4
N. Musculoskeletal
b. Free TSH
c. Total T4
d. Total TS

Ecclesiastes 3:13
And people should eat and drink and enjoy the fruits of
their labor, for these are gifts from God.

Kasagutan: BCAAA…

IMPORTANT POINTS:
Figure 16. Musculoskeletal changes in pregnancy
 Anterior angulation of the cervical region
 Hyperkyphosis of the upper thoracic region to compensate
for weight and for the shift of the center of gravity
 Accentuated lumbar lordosis
 Hyperextension of the knees and flattening of the foot arches
 Levator ani
 Major Ligaments
 Pelvic Arterial Blood Supply: Divisions of the Internal Iliac
Artery
 Autonomic Innervations: Sympathetic and Parasympathetic
derivations
 “Vasodilatation” – When in doubt, whatever mechanism is
being described in the question, answer this according to the
lecturer. But still read the questions carefully.
 Bloody show: expulsion of the mucus plug
 Carbohydrate Metabolism in Maternal Physiology: Memorize
the 4 Hallmarks. Some questions will be derived from this.
 Thyroid Gland in Maternal Physiology: the effect of increased
TBG

Mini Quiz
1. Which of these pelvic ligaments provide the main support to
the uterus?
a. Broad
b. Cardinal
c. Infundibulopelvic
d. Round
2. Which of the following changes characterize the smooth
muscle cells of the uterus during pregnancy?
a. Atrophy
b. Hyperplasia
c. Hypertrophy
d. Neoplasia
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