OBSTETRICS MATERNAL ANATOMY:

1S-1 | CEU-SOM A & B External and Internal

Dr. Ronaldo Santos Generative Organs
OUTLINE
Hesselbach Triangle
I. ANTERIOR ABDOMINAL WALL  Boundaries:
II. EXTERNAL GENERATIVE ORGANS o Inferior: inguinal ligament
III. INTERNAL GENERATIVE ORGANS o Medial: lateral border of rectus muscles
IV . REFERENCES o Lateral: inferior epigastric vessels
 Clinical significance:
I. ANTERIOR ABDOMINAL WALL o Direct hernias – involve the Hesselbach triangle
 confines abdominal viscera o Indirect hernias – involve the deep inguinal ring
 stretches to accommodate the expanding uterus
 provides surgical access to the internal reproductive organs

Skin
 Langer lines – describe the orientation of dermal fibers
o in the abdomen, transversely arranged
o vertical skin incisions – more tension, w ider scars
o low transverse incisions (Pfannenstiel) – follow
Langer lines; superior cosmetic results

Subcutaneous layer
 Camper’s fascia
o superficial
o predominantly fatty layer
 Scarpa’s fascia
o deeper
o more membranous layer
 These are not discrete layers but instead represent a
continuum of the subcutaneous tissue layer Innervation:
 Intercostal nerves (T7-T11)
Rectus Sheath – fibrous aponeuroses of the external oblique, internal  Subcostal nerve (T12)
oblique, and transversus abdominis muscles join in the midline  Iliohypogastric nerve – skin over suprapubic area
 Ilioinguinal nerves (L1) – skin of the low er abdominal w all,
Arcuate line
upper portion of the labia majora, medial portion of the thigh
 Cephalad – aponeuroses invest the rectus abdmoninis bellies  T10 dermatome – approximates the level of the umbilicus
above and below
 Caudal – all aponeuroses lie anterior to the rectus abdominis Clinical Significance
muscle, and only the thin transversalis fascia and peritoneum  Ilioinguinal and iliohypogastric nerves
lie beneath o can be entrapped during closure of low transverse
incisions, especially if incisions extend beyond the
lateral borders of the rectus muscle
o carry sensory information only, and injury leads to
loss of sensation w ithin the areas supplied

II. EXTERNAL GENERATIVE ORGANS

PUDENDA or VULVA – includes all structures visible externally from

the pubis to the perineum: mons pubis, labia majora and minora, clitoris,
hymen, vestibule, urethral opening, and various glandular and vascular
structures

Blood Supply
 Branches of fem oral artery – supply the skin and
subcutaneous layers of the anterior abdominal w all and mons
pubis
o Superficial epigastric artery
o Superficial circumflex iliac artery
o External pudendal artery
 Branches of external iliac artery – supply the muscles and
fascia of the anterior abdominal w all
o Inferior deep epigastric vessels
o Deep circumflex iliac vessels kadiri ew w w

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 OBSTETRICS
1S-1 | CEU-SOM A & B
Dr. Ronaldo Santos
Mons Pubis
 also called m ons veneris
 fat-filled cushion that lies over the symphysis pubis
 at puberty, covered by curly hair that forms the escutcheon
 in adult w omen, it is distributed in a triangular area
 its base forms the upper margin of the symphysis pubis
Labia m ajora
 male homologue: scrotum
 it is w here the round ligament terminate (upper border)
 outer surface with hair w hile inner surface without hairs
o in children and nulliparous w omen – close
apposition
o in multiparous w omen – gapes w idely
 continuous directly w ith the mons pubis
 merge posteriorly to form the posterior commissure
Labia m inora
 composed of connective tissue w ith many vessels and some
smooth muscular fibers
 moist and reddish, similar in appearance to a mucous
membrane
 extremely sensitive because it is supplied w ith many nerve
endings
 2 lamellae superiorly
o Low er pair: forms the frenulum of the clitoris
o Upper pair: forms the prepuce
 inferiorly, it forms the fourchette
 lining epithelium
o Outer and lateral portion of inner surface –
stratified squamous epithelium
o Medial portion – non-keratinized squamous
epithelium
o Hart line – demarcation line betw een lateral and
medial portions
o contains sebaceous follicles, few sweat glands
o lacks hair follicles, eccrine glands, and apocrine
glands
Clitoris
 male homologue: penis
 composed of a glans, a corpus, and tw o crura
 rarely exceeds 2 cm in length
 covered by stratified squamous epithelium that is richly
supplied w ith nerve ending
 principal female erogenous organ
MATERNAL ANATOMY:
External and Internal
Generative Organs
o lie inferior to the vestibular bulbs and deep to the
inferior ends of the bulbocavernosus muscle
o ducts are 1.5 to 2 cm long and open distal to the
hymenal ring at 5 & 7 o’clock
o Clinical significance:
 Follow ing trauma or infection, either duct
may sw ell and obstruct to form a cyst, or
if infected, an abscess
 Paraurethral Glands
o lies in the inferior aspect of the urethra
o Skene glands – largest
o Minor vestibular glands – are shallow glands lined
by simple mucin-secreting epithelium and open
along Hart line
o Clinical significance:
 Inflammation and duct obstruction of any
of the paraurethral glands can lead to a
urethral diverticulum formation
Vestibular Bulbs
 male homologue: corpus spongiosum of the penis
 almond-shaped, mainly composed of aggregations of veins
o 3 to 4 cm long, 1 to 2 cm w ide, and 0.5 to 1 cm thick
 lie beneath the bulbocavernosus muscle on either side of the
vestibule
 Clinical significance:
o during childbirth, the vesibular bulbs may be injured
and may even rupture to create a vulvar
hem atoma
VAGINAL OPENING AND HYMEN
Vaginal opening
 rimmed distally by the hymen or its remnants
Hym en
 membrane surrounding the vaginal opening
 composed of elastic and collagenous connective tissue
 covered by stratified squamous epithelium
 the aperture of the hymen varies
 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
 Im perforate hymen – rare lesion in w hich the vaginal orifice
is occluded completely, causing retention of menstrual blood

Vestibule
 from embryonic urogenital membrane
 almond-shaped
 Boundaries:
o Lateral – Hart line
o Medial – external surface of hymen
o Anterior – frenulum
o Posterior – fourchette
 6 openings:
o Urethra
o Vagina
o Ducts of the Bartholin glands (2)
o Ducts of the paraurethral glands/Skene glands (2)

Vestibular Glands
 Bartholin’s glands
o greater vestibular glands
o 0.5 to 1 cm in diameter
saan dyan yung sa’yo char

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 OBSTETRICS MATERNAL ANATOMY:
1S-1 | CEU-SOM A & B External and Internal
Dr. Ronaldo Santos Generative Organs
Vagina PERINEUM
 musculo-membranous structure  the diamond area betw een the thighs
 extends from the vulva to the uterus  boundaries are same as those of the bony pelvic outlet
 interposed anteriorly and posteriorly betw een the urinary o Anterior: pubic symphysis
bladder and the rectum o Posterior: ischiopubic rami
 lining epithelium: non-keratinized stratified squamous o Anterolateral: ischial tuberosities
epithelium o Posterolateral: sacrotuberous ligaments
 no glands; abundant vascular supply o Posterior: coccyx
 Embryology:  blood supply:
o upper portion – m üllerian ducts o Internal pudendal artery (inferior rectal artery
o low er portion – urogenital sinus and posterior labial artery

Anterior Triangle – also called urogenital triangle

 Boundaries:  further subdivided into:
o Anteriorly, the vagina is separated from the bladder o Superficial space – closed compartment
and urethra by connective called – vesicovaginal o Deep space – continuous superiorly with the
septum pelvic cavity
o Posteriorly, there are similar tissues together that  boundaries:
form the rectovaginal septum between the lower o Superior: pubic rami
portion of the vagina and the rectum o Lateral: ischial tuberosities – divides the perineum
o The upper fourth of the vaginal is separated from into anterior and posterior triangle
the rectum by the rectouterine pouch or cul de o Posterior: superficial transverse perineal muscle
sac of Douglas
 Length: SUPERFICIAL SPACE OF THE ANTERIOR TRIANGLE
o Anterior: 6-8 cm • Attached at the ischial tuberosity
o Posterior: 7-10 cm attached at the ischial tuberosity and
 subdivided by the cervix into fornices – anterior, posterior, Ischiocavernosus crus of clitoris  helps maintain
lateral clitoral erection
 the fornices are clinically important because the internal pelvic
organs can be palpated through their thin w alls • Overly the vestibular bulb and
Bartholin glands
o posterior fornix provides surgical access to the
peritoneal cavity • Attached at the perineal body and
the clitoris
Bulbocavernosus
• Constrict the vaginal lumen and aid
in the release of secretions of the
Bartholin’s gland
• Contributes to clitoral erection
• Attached to the ischial tuberosities
Superficial transverse laterally and the perineal body
perineal m uscles medially

TERM BLOOD LYMPHATIC DEEP SPACE OF THE ANTERIOR TRIANGLE

SUPPLY DRAINAGE Deep to the perineal membrane and extends up continuous superiorly
Cervicovaginal External, internal and w ith the pelvic cavity
branches of uterine common iliac nodes
UPPER THIRD artery and vaginal Contains: compressor urethrae, urethrovaginal sphincter muslces,
artery external urethral sphincter, parts of urethra and vagina, branches of
internal pudendal artery, dorsal nerve and vein of the clitoris
MIDDLE Inferior vesical Internal iliac nodes
THIRD arteries Posterior Triangle – also called the anal triangle which contains the
Middle rectal and Inguinal nodes follow ing:
LOWER THIRD internal pudendal  Ischiorectal fossa
arteries o tw o fat filled w edge shaped spaces on either side of
the anal canal

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 OBSTETRICS MATERNAL ANATOMY:
1S-1 | CEU-SOM A & B External and Internal
Dr. Ronaldo Santos Generative Organs
o provide support to surrounding structures, yet allow o Bulbocavernosus muscle
distension of the rectum during defecation and o Superficial transverse perineal muscles
stretching of the vagina during delivery o External anal sphincter
o this continuity of the fossae across perineal  potential morbidity:
compartments allow s fluid, infection and o episiotomy may injure the perineal body
malignancy to spread o pudendal nerve injury may be associated with
 Anal canal and anal sphincter complex concurrent perineal body injury
o lie in the center of the fossae
 Branches of the internal pudendal vessels III. INTERNAL GENERATIVE ORGANS
 Pudendal nerve
o formed by the anterior rami of S2-S4 DEVELOPMENT OF THE INTERNAL GENERATIVE ORGANS
o lies posteromedial to the ischial spines
o 3 terminal branches:
 Dorsal nerve of the clitoris – supplies
the skin of the clitoris
 Perineal nerve – supplies the muscles of
the anterior triangle and labial skin
 Inferior rectal nerve – supplies the
external anal sphincter, anal canal’s
mucous membrane, and perineal skin

EMBRYOLOGICAL DEVELOPMENT

 fusion of the tw o müllerian (paramesonephric) ducts to form a

ANUS
External Anal Sphincters
 a ring of striated muscle attached to the perineal body
anteriorly and the coccyx posteriorly
 maintains the constant state of resting contraction
 receives blood supply from the inferior rectal artery
 motor fibers come from the inferior rectal branch of the
pudendal nerve
single canal begins at the level of the inguinal crest, that is,
the gubernaculum (primordium of the round ligament) – 5th
w eek of development
 upper ends of the müllerian ducts produce the oviducts and
the fused parts give rise to the uterus
 the vaginal canal is not patent throughout its entire length until
the sixth month of fetal life

Internal Anal Sphincter

 contributes the bulk of the anal canal resting pressure for fecal
continence
 formed by the distal continuation of the inner circular muscle
layer of the rectum and colon

Anal Cushion
 highly vascularized
 aids in fecal continence
 engorgement due to increased uterine size, excessive
straining and hard stools, can increase venous engorgement
w ithin these cushions to form hem orrhoids

Perineal Body
 anchors the anorectum; also anchors the vagina
 helps maintains urinary and fecal continence
 maintains the orgasmic platform
 prevents expansion of the urogenital hiatus
 provides a physical barrier betw een the vagina and rectum
 the structures that contribute to the perineal body are the ff:
o Median raphe of the levator ani
o Central tendon of the perineum

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 OBSTETRICS MATERNAL ANATOMY:
1S-1 | CEU-SOM A & B External and Internal
Dr. Ronaldo Santos Generative Organs
INTERNAL GENERATIVE ORGANS

 Layers of the uterus:

o Serosa (serosal layer)
• formed by the peritoneum that covers the
uterus
Cervix o Myom etrium (muscular layer)
 Internal cervical os • bundles of smooth muscle united by
o upper boundary; level at w hich the peritoneum is connective tissue in w hich there are
reflected up onto the bladder many elastic fibers
 Portio supravaginalis • relative more muscle in the inner w all
o covered by peritoneum on its posterior surface than the outer w all, and in the anterior
o attached to the cardinal ligaments laterally and posterior w alls than in the lateral
 Portio vaginalis w alls
 External cervical os before childbirth: small, oval opening • muscle fibers diminish caudally such that
 External cervical os after childbirth: transverse slit, giving rise the muscle comprises only 10% of the
to the anterior and posterior cervical lip tissue mass in the cervix
 Cervical stroma – compose mainly of collagen, elastin and • the interlacing myometrial fibers that
proteoglycan but very little smooth muscle surround the myometrial vessels are
 Ectocervix – nonkeratinized squamous epithelium integral to control of bleeding from the
 Endocervix – mucin-secreting columnar epithelium placental site during the third stage of
labor
o Endom etrium (mucosal layer)
• thin, pink, velvet-like membrane
perforated by a large number of minute
ostia of the uterine glands.
• histologically, its epithelium is single
layer of closely packed high columnar
cells than rests on a thin basement
membrane
• Uterine glands – invaginations of the
epithelieum that extend to the
myometrium
• Interglandular m esenchymal stroma –
varies remarkably throughout the ovarian
cycle, undergoes decidualization
follow ing ovulation
Uterus
 Thick- w alled, hollow , muscular organ
 Nulliparous: 6-8cm, fundus and cervix almost equal in length
 Multiparous: 9-10cm, cervix is 1/3 of the total length
 Entire posterior w all of the uterus is covered by serosa, or
peritoneum, the low er portion of w hich forms the anterior
boundary of the recto-uterine cul-de-sac or pouch of
Douglas.
 Blood supply:
o Uterine artery
o Ovarian artery
 Parts of uterus:
o Corpus or body
o Cervix
o Isthmus – between the internal cervical os and the
endometrial cavity; forms the lower uterine segment
during pregnancy
o Cornua – at the junction of the superior and lateral
margins
o Fundus – convex upper segment betw een the
points of insertion of the fallopian tubes

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 OBSTETRICS
1S-1 | CEU-SOM A & B
Dr. Ronaldo Santos
• Vascular architecture of Endometrium
 Uterine and ovarian arteries  arcuate arteries 
radial arteries  spiral/coiled arteries and
basal/straight arteries
 Spiral arteries – mid-portion and superficial third of
the endometrium, responsive to hormones
 Basal arteries – basal layer, not responsive to
hormones
Round Ligam ents
 extend from the lateral portion of the uterus
 arise below and anterior to the origin of the oviducts.
 terminate in the upper portion of the labium majus.
 Sampson artery runs w ithin this ligament.
 corresponds embryologically to the gubernaculum testis of
men
 clinically significant w hen doing puerperal tubal sterilization
Broad Ligam ents
 w ing-like structures from lateral margins to pelvic sidew all
 each consist of an anterior leaf and a posterior leaf
 drapes over structures extending from the cornu
 mesosalpinx, mesoteres, mesovarium, mesometrium
 suspensory ligament or infundibulopelvic ligament – from the
fimbriated end of the f allopian tube to the pelvic w all, where
ovarian vessels traverse
MATERNAL ANATOMY:
External and Internal
Generative Organs
Ovaries
 vary considerably in size.
o 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.
o After menopause, ovarian size diminishes
remarkably.
 rest in a slight depression on the lateral w all of the pelvis,
called ovarian fossa of Waldeyer between the divergent
external and internal iliac vessels
 attached to the broad ligament by the m esovarium
 the parts include the follow ing:
o Cortex – outer layer, contains oocytes and
developing follicles
o Medulla – central portion, composed of loose
connective tissue
 the ovaries are supplied w ith both sympathetic nerves from
the ovarian plexus and parasympathetic nerves

Cardinal Ligaments
 transverse cervical or Mackendrodt ligament
 thick base of the broad ligament that is continuous w ith the
connective tissue of the pelvic floor

Uterosacral Ligaments
 from its attachment posterolaterally to the supravaginal
portion of the cervix and inserts into the fascia over the sacrum Lym phatics
 form the lateral boundaries of the pouch of Douglas  Cervix – terminate mainly in the hypogastric nodes, which are
situated near the bifurcation of the common iliac vessels.
Fallopian Tubes  Body of the uterus – internal iliac nodes and periaortic lymph
 also called oviducts nodes
 vary in length from 8 to 14 cm.
 lumen is lined by mucous membrane
IV. REFERENCES
 its parts consist:
o interstitial portion
o isthmus  Lecture PPT of Dr. Santos
o ampulla  Clinical Anatomy by Regions, 9th Edition (Snell, 2011)
o infundibulum or fimbriated extremity – funnel-  YL1 Anatomy Trans (Tinio et al, 2018)
shaped opening at the distal
 tubal smooth muscle: inner circular and outer longitudinal,
undergo rhythmic contraction or peristalsis tow ard the uterine
cavity
 epithelium in close contact w ith muscle layer because there is
no submucosa
 epithelium – columnar cells (some ciliated, others secretory)

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