OUTLINE IN OBSTETRICS

CHAPTER 1: ANATOMY AND

PHYSIOLOGY

FEMALE EXTERNAL GENITALIA

The term VULVA or PUNEDA refers to
the entire female external genitalia.
Mons Pubis/ Mons Veneris –a pad of fat above
the symphisis pubis. The mons is richly supplied
with sebaceous glands. Hairless nad smooth in
childhood, it is covered by curly hair, called
escutcheon, after puberty. The hair pattern in
female is triangular with base up and in male,
diamond-shaped.
Labia Majora –are two thick folds of adipose
tissues originating from the mons and
Fossa Navicularis –it refers to the space
terminating in the perineum, its outer surface is
between the fourchette and vaginal introitus. It is
thick and covered by hair and its inner aspect is
usually obliterated during childbirth.
thin, smooth and moist. It unites anteriorly to
Vestibule –is a triangular space located between
form the anterior commissure and posteriorly to
the labia minora containing the following
form the posterior commissure. Its main
openings; vaginal introitus, urethral meatus,
function is to provide covering and protection to
Bartholin’s glands and Skene’s glands.
the external organs located under it. In
Bartholin’s Glands –also known as
nulliparous women it is in close apposition to
vulvovaginal gland, paravaginal gland and major
each other. It tends to gape wider after every
vestibular glands. A pair of glands located at
childbirth.
each inner side of the vagina that secretes
Labia Minora –are two thin folds of connective
alkaline mucus which helps to keep the vaginal
tissue that joins anteriorly to form the prepuce
introitus lubricated and enhance sperm survival.
and posteriorly to form the fourchette. The lower
Skene’s Glands –also known as paraurethral
border of the upper portion (below prepuce) is
and minor vestibular glands. A pair of glands
called frenulum. It is highly vascular, sensitive
situated at each inner side of the urethral meatus.
and richly supplied with sebaceous glands. In
The secretions of the Skene’s glands and
nulliparous women, the labia minora cover the
Bartholin’s glands increases with sexual
vaginal introitus, vestibule and urethra. Being
stimulation to lubricate anterior surface of the
very fragile, it is usually torn during vaginal
vagina.
delivery.
Vaginal Orifice –the external opening of the
Clitoris –is a highly sensitive and erectile tissue
vagina located just below the urethral meatus.
situated under the prepuce of the labia minora. It
The Grafenberg or G-spot is a very sensitive
is highly sensitive to touch and temperature. It is
area located at the inner anterior surface of the
composed of two erectile tissues called corposa
vagina.
cavernosa that are connected to the pubic bone.
Hymen –is a thin circular membrane made of
It is supplied with many sebaceous glands that
elastic tissu4e situated at the vaginal opening
produce a cheese-like secretion called smegma.
and which is torn during the first sexual
The clitoris is used as a guide in female
intercourse and childbirth. The hymen separates
catheterization. During sexual arousal, the
the female internal organs to the external organs.
ischiocavernous muscle surrounding it contracts
Imperforate hymen is a hymen that is completely
blocking blood flow resulting in clitorial
covering the vaginal introitus preventing the
congestion and erection.
passage of menstrual discharge and sexual
intercourse. Hymenotomy or hymenectomy is the
surgical incision of an imperforate hymen.
Urethral Meatus –the external opening of the
female urethra is located just below the clitoris,
the shortness of the female urethra makes
women more susceptible to urinary tract
infection (UTI) than men.
Blood Supply –blood supply to vulva is
provided by the pudendal artery and inferior
rectus artery. This rich blood supply facilitates
rapid healing during the postpartum period.
Nerve supply –the anterior portion nerve supply
is derived from the L1 (ilioinguinal and
genitofemoral nerve) and the posterior portion is
derived from S3 (pudendal nerve).
THE INTERNAL ORGANS
Vagina –is a hollow, membranous and muscular
canal about 8 to 12cm long located in front of
the rectum and behind the bladder. It is
composed of connective and elastic tissues, and
muscle fibers. Its surface is lined by stratified
squamous epithelium. Its upper portion is
separated from the rectum by the cul-de-sac of
Douglas. The external opening of the vagina is
surrounded by the bulbocavernous muscle.
When a woman performs Kegel’s exercise the
tone of this group of muscles is greatly
improved.
Functions:
1. Organ of copulation
2. Discharges menstrual flow
3. Birth canal
Rugae –they are transverse folds of skin in the
vaginal wall that is absent in childhood, appear
after puberty and disappears at menopause. It is
most numerous in nulliparous women and
lessens with each childbirth and advancing age.
Its important function is to allow the vaginal
canal to stretch and enlarge during delivery.
Vaginal Column –longitudinal folds of skin in
the vaginal canal.
Vaginal Vault –upper end of the vagina.
Fornix/Fornices –the cervix projects to the
vagina forming four recesses or depression
around its upper portion called fornices; anterior
fornix, lateral fornices, posterior fornix. The
posterior (10cm) of the vagina is longer than the
anterior wall (7cm). the posterior fornix is the
deepest of the fornices, it is in this area that
vaginal secretions collect and semen pools.
Vaginal pH –vaginal pH before puberty is 6.8
to 7.2, which is alkaline. After puberty vaginal
pH goes down to 4-5, which is acidic. This is
because before puberty the young girls do not
have enough estrogen yet to stimulate cervical
mucus secretion but with the advent of puberty,
her ovary begins to produce estrogen which
stimulates mucus production in the cervix. This
mucus is rich in glycogen. The glycogen content
of vaginal mucus (which increases after puberty)
is converted to lactic acid by Doderlein bacilli (a
bacteria normally present in the vagina) making
the vaginal environment acidic- this helps
prevent the growth of pathogenic
microorganisms that can cause vaginal
infections.
Blood Supply –blood supply of the vagina is
derived from the vaginal artery that is a branch
of the uterine arteries. This rich blood supply
can cause massive hemorrhage if external
vaginal lacerations are not repaired. It also has
the advantage of facilitating rapid healing after
delivery.
 Upper portion –cervicovaginal branch of
uterine artery
 Middle portion –inferior vesical arteries
 Lower portion –rectal and pudendal
arteries
Its lymphatic drainage is via the inguinal,
internal iliac and sacral glands.
Nerve Supply –is provided by the uterovaginal
plexus or Lee Franken hauser plexus and S1 to
S3 nerves.
Uterus –is a hollow muscular canal resembling
an inverted pear which is situated in the true
pelvis. It is 2.5 to 3 inches long, an inch thick,
two inches wide and has a weight between 50-70
grams. In childhood, the cervix is larger than the
corpus. During puberty, it increases in size and
reaches its maximum size at 17 years. In
nulliparous women, the corpus and cervix are of
the same size. In multiparous, the corpus is
larger than the cervix. After delivery it do not
return to its pre-pregnant condition.
Functions of the uterus
1. Its cardinal function is as an organ of
reproduction
2. Organ of menstruation
3. Uterine contraction –to expel the fetus
during labor and to seal torn blood
vessels after delivery of the placenta
Parts of the uterus
1. Fundus –the uppermost convex portion
located between the insertion of the
fallopian tubes. The most contractile
portion. This is the portion that is
palpated to assess uterine growth during
pregnancy and involution during the
postpartum period. During labor, the
fundus is also palpated to assess uterine
contractions.
2. Cornua –the portion at which the
fallopian tubes are attached.
3. Isthmus –the upper third of cervix
which is very thin and which forms the
lower uterine segment during delivery.
4. Corpus –the body of the uterus which
makes up two-third of the said organ. It
houses the fetus during pregnancy.
5. Cervix –the neck of the uterus which is
about 2.5cm long and has a diameter of
2.5cm, too. It is chiefly composed of
elastic and collagenous tissues and only
10% muscle fibers. Women with
incompetent cervix have more muscle
fibers. The upper portion is lined by
mucous membrane similar to the uterus
and the lower portion is lined by
squamous epithelium similar to vagina.
The cervix contains many glands that
produce mucus at varying amounts in
response to different hormones. In
childhood the cervix is two times longer
than the cervix in puberty and
nulliparous women, the corpus is the
same as the cervix; in multiparous
women, the corpus is about 3x longer
than the cervix. The cervix contains
many sebaceous glands which secretes
clear viscid and alkaline mucus that
lubricates it and the vagina. Sometimes
these glands are occluded giving rise to
cyst-like structures called Nabothian
cysts. The parts of the cervix are:
a. Internal os –opens to corpus
b. Cervical canal –a spindle
shaped area which is actually a
continuation of the triangular
uterine cavity located between
the internal and external os
c. External os –opens to vagina
Layers of the Uterus
1. Perimetrium –the outermost secrosal
layer attached to the broad ligaments.
2. Myometrium –the middle muscular
layer responsible for uterine
contractions during labor.
3. Endometrium –the innermost ciliated
mucosal layer containing numerous
uterine glands that secrete a thin alkaline
fluid to keep the uterine cavity moist.
This layer undergo changes in response
to the hormones at various phases of the
menstrual cycle and during pregnancy.
It consists of two layers:
a. Glandular layer –composed of
columnar epithelium, this layer
peels off during menstruation
and thickens during the
 proliferative and secretory Damage to this ligament will lead to
phase. herniation of rectum to the vagina, a
b. Basal layer –the layer adjacent condition called rectocele.
to the myometrium and gives
rise to the new endometrium Blood Supply
after menstruation and delivery. 1. Uterine artery –a branch of the internal
iliac or hypogastric artery which divides
Uterine Ligaments into two main branches: cervicovaginal
The different ligaments which support branch that supplies the upper portion of
the uterus permits it to move freely in the vagina and lower portion of cervix and
anteroposterior plane and to enlarge without the main branch which divides into
difficulty during labor. fundal, tubal and ovarian arteries.
1. Cardinal/Transverse-Cervical/ 2. Ovarian artery –a direct branch of the
Mackenrodt Ligaments –the lower aorta.
portion of the broad ligaments, it is the
main support of the uterus. Damage to
this ligament will result to uterine FALLOPIAN TUBES (OVIDUCTS)
prolapse. The oviducts are a pair of tube-like
2. Broad Ligaments/Peritoneal structures originating from the cornua of the
Ligament –originates from the sides of uterus with distal ends located near the ovaries.
the corpus and extends to the lateral Each tube is about four inches (10cm long) and
¼ inch in diameter. Its surfaced is lined by
pelvic walls, supports the sides of the
ciliated columnar epithelium. Rhythmic
uterus and assists in holding the uterus contractions of the fallopian tubes are strongest
in anteversion. The pampiniform plexus,
a collection of several veins is located
here. It has the following parts:
mesometrium, mesosalphinx,
mesovarium.
3. Round Ligament –connects uterus to
the labia majora. Gives stability to the
uterus.
4. Uterosacral Ligament –connects uterus
to sacrum.
5. Anterior Ligament –provides support
to the uterus in connection with the
bladder. Over stretching of this ligament
will lead to herniation of the bladder to
the vagina, a condition called cystocele.
at the time of ovulation and weakest during
6. Posterior Ligament –this ligament
pregnancy.
forms the cul-de-sac of Douglas.
Functions:
1. Transport ovum from ovary to the
uterus
2. The site of fertilization
 3. Provides nourishment to the ovum
during its journey
Parts of the Oviducts
1. Interstitial/Intramural –thick, walled,
located inside the uterus and is about
1cm long.
2. Isthmus –this is the narrowest portion
of the uterus and is about 1cm long. This
is the site of tubal ligation.
3. Ampulla –the middle portion and the
widest part. This is the site of
fertilization.
4. Infundibulum –the most distal portion.
It has fingerlike projections called
fimbria. The longest fimbria, called
fimbria ovarica is attached to the ovary
to guide the ovum to the oviduct during
ovulation.
Blood Supply –is derived from the ovarian
artery and drainage is via the ovarian and uterine
arteries.
OVARIES
The ovaries are almond-shape glandular
organs located on either side of the uterus.
Before puberty, the ovaries are smooth, flat and
ovoid organs. After several ovulation, they
assume a nodular and pitted appearance. Each
ovary weighs between 6 to 19g, 1.5 to 3cm wide
and 2 to 5cm long.
Functions
1. Oogenesis –for development and
maturation of ovum
2. Ovulation –release of ovum from the
ovary
3. Hormone production –it produce
estrogen and progesterone
Layers of the ovary
1. Tunica albuginea –the outermost
protective layer surrounded by a single
layer of cuboidal epithelium called
germinal layer of Waldeyer.
2. Cortex –the functional layer which is
the site of ovum formation and
maturation. It contains the primordial
follicles, Graafian follicles, corpus
luteum and corpus albicans. As the
follicles decreases in number after each
ovulation, this layer becomes thinner
with advancing age.
 Two months intrauterine -
600,000 oogonia
 5 months intrauterine -
6,800,000
 At birth -2million oocytes
 Prepuberty/childhood -300,000
to 400,000
 36 years old -30,000 to 40,000
 Menopause –absent
3. Medulla –the layer which contains
blood vessels, lymphatic, nerves and
muscle fibers. Blood supply is derived
from the ovarian artery. The left ovary
drains into the left renal vein and the
right into the inferior vena cava.
Analogous structure in the Male and Female
Reproductive System
Male Female
Spermatozoa Ovum
Glans penis Glans clitoris
Scrotum Labia majora
Penis Vagina
Testes Ovaries
Vas deferens Fallopian tubes
Prostate glands Skene’s glands
Cowper’s glands Bartholin’s glands
THE PELVIC FLOOR AND ITS MUSCLES
The perineal body is a collection of
muscles and fibrous tissue located between the
vagina and rectum. It provides main support to
the pelvic floor. The perineal body is a very
important structure as it is the point where the
bulbocavernous, superficial transverse muscle of
perineum, external sphincter ani and fibers of
the levator ani muscles unite. The perineal body
is often lacerated during childbirth.
The perineum is composed of the
muscles and fascia of the urogenital diaphragm
and pelvic diaphragm. The pelvic diaphragm is
composed of the following structures:
 1. The superficial perineal muscles which
is composed of:
a. Bulbocavernous muscles
extending from perineal body to
the vagina and clitoris and act
like a sphincter to the vagina
and urethra.
b. Ischiocavernous muscle which
pass from ischial tuberosities to
clitoris and provide transverse
support to the perineum.
c. External and sphincter
surrounding the anal orifice and
controls passage of feces and
flatus.
d. Sphincter of the urethra which
controls the flow of urine.
2. Levator ani msucles and its fascia is the
deep muscle layer stretching in the
pelvic cavity like a hammock.
a. Pubococcygeus muscle –the
deepest part of the pelvic
perineal body which passes
from the pubis to the coccyx. It
surrounds the urethra, vagina
and rectum. Damage to this
muscle will result to cystocele
and rectocele, and urinary stress
continence.
b. Iliococcygeus muscles
c. Ischiococcygeus muscles
THE MAMMARY GALNDS
The female breasts are accessory organs
of reproduction meant to provide the infant with
the most ideal nourishment after birth. They are
situated over the pectoralis major muscles,
between the second and sixth ribs. The breasts
are supported by the Cowper’s ligaments.
External Structures
1. Nipple or Mammary Papillae- located
at the center of the anterior surface of
each breast. It has 15-20 opening
connected to lactiferous ducts and in
which milk flows out.
2. Areola- the pigmented skin that
surrounds the nipple. Both nipple and
areola have pigmented and wrinkled
skin.
3. Montgomery tubercles- glands in the
areola that secrete an oily substance that
keeps the areola and nipple lubricated.
Internal Structures
1. Lobes- 15 to 20 lobes are found in each
breast that are divided into several
lobules
2. Lobules- composed of clusters of acini
cells
3. Acini cells- milk secreting cells that is
stimulated by prolactin
4. Lactiferous ducts- ducts that serve as
passageways of milk
5. Lactiferous sinus- dilated portions of
the ducts located behind the nipple that
serve as reservoir of milk.
Hormones that influence the mammary glands:
1. Estrogen- stimulates development of
the ductile structures of the breast
2. Progesterone- stimulates the
development of the acinar structures of
the breast
3. Human placental lactogen- promotes
breast development during pregnancy
4. Oxytocin- let-down reflex
5. Prolactin- stimulates milk production
THE MALE REPRODUCTIVE SYSTEM
EXTERNAL ORGANS
Penis- is composed of three longitudinal erectile
tissue: two corposa cavernosa and 1 corposa
spongiosum. Blood flow in the penis is
controlled by autonomic nervous system and
blood supply is provided by penile artery,
parasympathetic nervous system governs penile
erection while sympathetic nervous system
inhibits penile erection.
Functions: organ of copulation and of urination
Parts:
 Shaft or body
 Glans penis –the enlarged end which is
the most sensitive part

 Prepuce or foreskin –a fold retractable
skin covering the glans and which is
removed during circumcision.
Sometimes the prepuce is tootight so
that it interferes with the flow of urine, a
condition called phimosis.
 Urethral meatus –a slitlike opening
located at the tip of the penis which
serves as passageway of both semen and
urine.
Scrotum- is a saclike structure containing the
testes that hangs behind the penis. It is covered
by sparse hair after puberty, with a darker
coloration than the rest of the body and with a
wrinkled appearance. The scrotum is supplied
abundantly by sweat and sebaceous glands. The
skin of the scrotum is lined by fascia and a
smooth muscle layer, the Dartos, which
contracts when environmental temperature is
cold pulling the testes closer to the body in order
to absorb more heat. When temperature is above
normal such as when the wheather is warm or
during exercise, the Dartos layer relaxes so that
the testes descend away from the body which
lower their temperature. This way, the scrotum
enables the etstes to maintain a constant
temperature. If the temperature is too war or too
cold, spermatogenesis will not take place. the
scrotum has no subcutaneous fat because the
testes must be kept cool. The cremaster muscle
of the testes also raises the testes in the scrotum
when the inner side of the thigh is stimulated by
a scratch or massage.
INTERNAL ORGANS
Testes- the two testes are oval shaped glandular
organs lying within the abdominal cavity in
early fetal life and descend to the scrotum after
28 weeks gestation. It is important for the testes
to descend into the scrotum because
spermatogenesis cannot take place at body
temperature. The temperature inside the scrotum
is 1’C lower than body temperature. If the testes
will not descend in the scrotum, sperm
production will not take place but testosterone
production will continue. Each testis is covered
by a sac of serous membrane, the tunica
vaginalis. The sac allows the testes free
movement within the scrotum to avoid injury.
Inflammation of tunica vaginalis causes
accumulation of fluid within it, a condition
called hydrocele. The tunica albuginea is a
fibrous covering which divides the testis into
200 to 300 lobules. The tunica vasculosa is an
inner layer of connective tissue which contains
blood vessels. Each testis is about 4 to 5cm long,
contains about 250 lobules. The lobules contain
seminiferous tubules in which sperm cells
develop. Connective tissue called Leydig cells or
interstitial cells which produce testosterone
surround the seminiferous tubules.
Functions:
 Hormone production –the testes produce
the hormone testosterone which is
responsible for the development of
secondary male characteristics and
stimulates spermatogenesis.
 Spermatogenesis –production and
maturation of sperm cell begins at
puberty and continue until old age.
Oogenesis, on the other hand, starts at
early fetal life and ends at menopause.
Parts:
 Seminiferous tubules –a long coiled tube
where spermatogenesis takes place, the
testes produce about sperm cells a day
 Leydig/interstitial cells –produce
testosterone, they are found around the
seminiferous tubules.
 Sertoli cells –supporting ells which
plays a role in sperm transport.
Epididymis- a long coiled tube approximately
20 feet long, at which the sperm travels for 12 to
20 days after it leaves the testis. It is in this area
where the sperm attains its motility and
maturity. The spermatic cord, the structure
which suspends the testes, is composed of 5ml, each milliliter containing about 100 million
epididymis, blood vessels, lymphatic and nerves. sperm cells. A sperm count below 20 million is
Vas deferens- the contractile power of tis part considered abnormal, this usually result sterility.
of the duct system propels the spermatozoa to
the urethra during ejaculation. The presence of
acidic secretions in this portion causes the sperm
not to be very motile. At the end of the vas
deferens, just before it joins the seminal
vesicles, there is a dilated portion which
functions as a storage area of sperm cells before
ejaculation. The vas deferens is the part of the
duct system cut during vasectomy.

Ejaculatory Duct- connects the seminal

vesicles to the urethra.

Accessory organs:
Seminal vesicle- are two pouch like organs
consisting of many saclike structures located
next to the ductus deferens and lying behind the
bladder and in front of the rectum. Each vesicle
is about 4cm long. The thick, mucoid secretion
of the seminal vesicles has a low pH and
contains nutrients that nourish the sperms. Its
secretions also contain prostaglandin that is
thought to cause contractions of the female
reproductive tract to help transport the sperm
cells.
Prostate gland- a walnut-shaped (conical) body
lying below the bladder surrounding the urethra
and the two ejaculatory ducts which secretes a
thin milky alkaline fluid that enters the urethra
to neutralize the acidic secretions of the testes,
seminal vesicles and vagina and also to nourish
the sperm cell.
Cowper’s/ Bulbourethral gland- two small
glands located below the prostate that secrete an
alkaline fluid before ejaculation which help
neutralize the acidic nature of urethra and
provides lubrication during intercourse.
Seminal fluid/semen- is a mixture of secretions
from the seminal vesicles, prostate gland,
Cowper’s gland, ejaculatory duct and sperm
cells. Emission is the discharge of semen from
the urethra. Ejaculation is the forceful expulsion
of semen from the urethra caused by contraction
of muscles in the penis such as what happens
during male orgasm. The seminal vesicles
produce about 60% of the fluid, the prostate
gland 30%, the testes 5% and the bulbourethral
glands 5%. The normal volume of semen is 2 to