SPUP AUXILIUM 2023

3. MUSCLES & Their Associated Fascias

I. LAYERS OF THE ABDOMINAL A. Uterus 4. TRANSVERSALIS FASCIA
WALL B. Ligaments
A. Subcutaneous Layer C. Ovaries
Contains the Extraperitoneal Fascia
B. Muscles D. Uterine Tubes 5. PARIETAL PERITONEUM
II. FEMALE GENERATIVE ORGANS V. ARTERIAL SUPPLY OF THE
A. Mons Pubis PELVIS
B. Labia Majora VI. VENOUS SUPPLY OF THE PELVIS
C. Labia Minora VII. NERVE SUPPLY OF THE PELVIS
D. Hymen VIII. LYMPH NODES
E. Clitoris IX. THE BONY PELVIS
F. Vestibule A. Pelvic Inlet
G. Female Urethra B. Midpelvis
III. FEMALE UROGENITAL TRIANGLE C. Pelvic Outlet
MUSCLES D. Caldwell-Moloy
IV. INTERNAL GENERATIVE Classification of the Pelvis
ORGANS X. REFERENCES

Separated into:
o SUPERFICIAL (FATTY) LAYER
a.k.a
continues onto the perineum to provide the
fatty substance to the mons pubis and labia
majora, and it blends with the fat of the
ischioanal fossa.
o DEEP (MEMBRANOUS) LAYER
a.k.a
continues inferiorly on the perineum where it is
called COLLES FASCIA
infection or hemorrhage to Colles Fascia
1. SKIN can extend upward to superficial layers of
Composed of imaginary surgical lines called the abdomen

o Any incision done against these lines will create NOTE!!

o This is the area in the perineum that is primarily

VERTICAL INCISIONS sustain increased composed of elastic fibers that eventually
lateral tension causing Wider scars bulges prior to delivery ( ). It
PFANNENSTIEL INCISION follow the indicates the presenting part of the baby
Langer lines leading to a Superior PERINEUM
Cosmetic Results o Area where episiotomy is done
o Obstetrically speaking, easiest way to do a o Allows more room/space for the presenting
Caesarean section is by making a MIDLINE part during normal delivery
INCISION Infraumbilical Midline Incision
It is has the easiest access to the uterus
especially if the reason for a Caesarean
Section is cause by Fetal or Maternal
Distress
o PFANNENSTIEL INCISION (SUPRAPUBIC
TRANSVERSE INCISION) used in non-imminent
deliveries like in cases of malpresentation (the
most common of which is Breech Presentation
in a newly gravid Patient)
2. SUPERFICIAL FASCIA

o Continuous with the Perineum

 NOTE!!
Located beneath the Subcutaneous Tissue ANATOMICAL LAYERS OF THE ABDOMEN
Include encountered during general operational
o Midline Rectus Abdominis procedure
o Pyramidalis Muscles 1. Skin
o External oblique 2. Fat
o Internal oblique 3. Rectus Sheath
o Transversus abdominis muscles 4. Rectus Abdominis
Transversus abdominis muscles are not 5. Abdominal Peritoneum
during incision 6. Pelvic Peritoneum
by surgeons 7. Uterine Muscles
The Fibrous Aponeuroses of these three latter muscles
(External and Internal Oblique muscles, and Transversus
Abdominis muscles) form the primary fascia of the
anterior abdominal wall
o Fuse in the midline at the Linea Alba (10 15 mm
wide below the umbilicus)
This area is very important because during
pregnancy, the abdomen also adapts with the
growing uterus causing the fusion of these
muscles in the infraumbilical area to stretch.
This is the reason why, failure of doing a
good apposition after a Caesarean
section of all the structures incised, patient
may complain of an umbilical hernia
Or when in cases of normal delivery, and
patient failed to use a binder or failed to
do abdominal exercise causing retention
of the wide gap in the area of fusion, the
patient may complain of diastasis recti. Arteries that arise from the FEMORAL ARTERY below the
inguinal ligament within the femoral triangle:
o Superficial epigastric artery
The superficial epigastric vessels course
diagonally from the origin towards the
umbilicus
This orientation makes it surgically important to
obstetricians
o Superficial Circumflex Iliac Artery
o Superficial Pudendal Artery
These 3 arteries supply the skin and
subcutaneous layers of the anterior abdominal
wall and mons pubis
INFERIOR DEEP EPIGASTRIC VESSELS
o Branches of External Iliac Vessels
o Supply the anterior abdominal wall muscles and
fascia
o Course lateral to and posterior to the rectus
abdominis muscles
o Above the arcuate line, these vessels course
ventral to the posterior rectus sheath
o Near the umbilicus, the inferior epigastric vessels
anastomose with the superior epigastric artery and
vein (branches of INTERNAL THORACIC VESSELS)
o In Caesarean delivery, it may be lacerated lateral
The Pyramidalis Muscle is appreciated in Caesarean to the rectus belly during muscle transection
sections involving a Pfannenstiel incision, unlike during (MAYLARD INCISION).
Midline incision where it cannot be appreciated INTERCOSTAL NERVES (T7-11), SUBCOSTAL NERVE (T12),
(maliban na lang kung maganda ang abdominal and ILIOHYPOGASTRIC and the ILIOINGUINAL NERVES
anatomy ng patient). (both L1)
o Innervate the entire anterior abdominal wall
o The Iliohypogastric nerve perforates the external
oblique aponeurosis near the lateral rectus border
 to provide sensation to the skin over the suprapubic
area
o The Ilioinguinal nerve supplies the skin of the mons
pubis, upper labia majora, and medial upper thigh
Extends from the mons pubis anteriorly to unite
posteriorly at the midline
Covered with hair, have both sebaceous and sweat
glands, and apocrine glands
Homologous to scrotum in males

Also called Nymphae

2 small, red cutaneous folds between the labia majora
and vaginal orifice
Forms the fourchette posteriorly
Anteriorly, they divide at the clitoris to form the prepuce
(superiorly) and the frenulum (inferiorly).
The labia minora and the breasts are the parts of the
body rich with sebaceous glands without hair follicles.
Composed of dense connective tissue with erectile
and elastic fibers
Homologous to the penile urethra and skin of the penis
in males

NOTE!!
VULVA (Pudenda) In children and post-menopausal women = more
o Refer to all structures visible externally from the prominent si Labia Minora than majora
symphysis pubis to the perineal body. In women of reproductive age = more prominent si
o These include: Labia Majora than minora
Mons Pubis
Clitoris
Urinary Meatus Thin, usually perforated membrane at the entrance of
Labia Majora the vagina
Labia Minora Lined by stratified squamous epithelium, fibrous tissue
Hymen and blood vessels
Vestibule COITARCH first sexual intercourse
Vestibular Glands

Also called Mons Veneris

Rounded eminence that become hairy after puberty
o ESCUTCHEON
a.k.a Pubic Hair
Women: Triangular (inverted)
Men: Diamond
Fat-filled cushion directly anterior and superior to the
symphysis pubis

2 large, longitudinal cutaneous folds of adipose and

fibrous tissue (7-8cm in length, 2-3cm wide, and 1.5cm
thick) Short, cylindrical, erectile organ at the superior portion
of the vestibule
o 1.5 2cm in length, and 1cm wide
Has 2 crura attached at symphysis pubis; and body with
NOTE!! (photos above)
2 corpora cavernosa & erectile tissue
Dissection of perineum showing the different
Homologous to male penis
structures including the muscles, fascia, ligaments
Glans (partly hidden by the prepuce) is lined by nerve
and the bony portions of the pelvis.
endings
These structures are clinically important in
patients undergoing vaginal birth because there
Space between the labia minora (lowest part of the are structures located in this area that can be
urogenital sinus) traversed during a midline or mediolateral
o Apex = Clitoris episiotomy
o Floor = urethral opening, vagina, and ducts of the
greater vestibular glands

Measures 1.5 in. (3.8cm) in length

Passes through the urogenital diaphragm, traverses the
sphincter urethrae to open below the clitoris in from of
the vagina
NOTE!! (photos above)
The perineum is divided by the SUPERFICIAL
TRANSVERSE PERINEAL MUSCLE (and associated
membranes) into 2 triangles:
o Anterior Triangle/Urogenital Triangle
Contains the vagina and other associated
orifices
o Posterior Triangle/Anal Triangle
Contains the Levator ani muscles
These muscles are the ones that hold the
reproductive organs intact
Give the inferior support of the perineal
organs
- Pag hindi intact, pwedeng
malaglag lahat ng mga organs na
nasa loob
- Clinically significant in cases of
prolapse uterus
NOTE!! (photo above)
The urethra is bounded by sphincters/muscles that
help control urination
o Clinically significant because in some women,
due to repeated vaginal birth and poor perineal
support, they complain of urinary incontinence
(like when urine leaks out when the patient
coughs).
NOTE!! (photo above)
Photo showing the proximity of the uterus and the
vagina with the bladder wall, and the rectum with the
vagina
NOTE!! (photo above)
The proximity of the female reproductive tract with
the bladder or the rectum can be clinically significant
because during difficult delivery, the rectum and
vagina may have a connection that feces may leak
out of your vagina
POSTERIOR CUL-DE-SAC (CUL-DE-SAC OF DOUGLAS)
o This is the area that is usually identified during an
ultrasound when entertaining an ectopic
pregnancy with rupture or bleeding
CULDOCENTESIS
o Procedure involving the poking of the posterior
vaginal wall to check the presence of non-
clotting blood in the pouch of Douglas in cases
of ruptured ectopic pregnancy.
o Not done anymore because of easy access of
the area via ultrasound.
The Pudendal Nerve is clinically important during a
vaginal delivery because this is the structure infused
with anesthesia during a Pudendal Block, para hindi
masakit sa mother ang mag-labor.
It is also important to take note that the area (where
the pudendal nerve is located) is actually associated
with abundant blood supply. Hence, it is important to
take proper precautions when performing a
pudendal block
 Three Layers of the Uterus:
1. External Serosal Layer
- Thin layer, covered firmly by visceral
peritoneum except anteriorly at the level of the
internal os of the cervix
- Not covered anteriorly by visceral peritoneum
because it is where you can find the
connection between the posterior portion of
the bladder and anterior portion of the uterus
2. Muscular Layer
- Wide middle layer with three indistinct layers of
smooth muscle:
Outer Longitudinal Layer
Contiguous with the muscle layer of
the oviduct and vagina
Middle Interlacing Layer
Oblique, spiral bundles of smooth
NOTE!! (photo above) muscle and venous plexuses
The uterus, fallopian tubes, ovaries, cervix, and upper Inner Longitudinal Layer
portion of the vagina came from the fusion of Muscular layer
Mullerian Ducts during embryogenesis 3. Endometrium
- Reddish mucus membrane (1-6mm thick)
- Contains Tubular Glands (Tall columnar
epithelium)
Thick-walled hollow muscular organ
- Composed of:
Parts of the Uterus:
inner stratum basale
o FUNDUS
The stratum basale is the one that
- Lies above the entrance of the uterine tubes
proliferates during the proliferative
o BODY
- Lies beneath the entrance of the uterine tubes phase of menstrual cycle
- Narrows below to become continuous with the outer stratum functionale
cervix composed of inner compact stratum
o CERVICAL CANAL and superficial spongy stratum
- Cavity of the cervix The stratum functionale is the one that
- INTERNAL OS cavity communicates with the sloughs off during menstruation.
uterine body
- EXTERNAL OS cavity communicates with the
vagina
Normal positions of the Uterus:
o Anterversion forward bending of the uterus on
the long axis of the vagina
o Anteflexion forward bending of the uterus on
the cervix
Size of the uterus:
1. Nulliparous: 8cm long, 5cm wide, and weighs 40-
50g
2. Multiparous: 1.2cm larger and 20-30g heavier
1. SUSPENSORY LIGAMENT
a.k.a Infundibulo-Pelvic Ligament
lateral part of broad ligament
connects mesovarium to lateral pelvis
contains blood and lymphatic vessels
2. ROUND LIGAMENT
a. Round Ligament of the Ovary
Anlage of the upper gubernaculum
Extends from the medial margin of the ovary to
the lateral wall of the uterus
b. Round Ligament of the Uterus
It is the remains of the lower gubernaculum
QUESTION!! (photo above)
What artery is enclosed within the round ligament?
SAMPSON ARTERY
o Sampson artery is a branch of Uterine Artery
--take note, pwedeng ilabas ni doc sa exam
3. MESOVARIUM
Formed from the posterior part of the broad
ligament
Contains the anastomotic branches of the ovarian
and uterine ligaments, venous plexuses, and lateral
end of the ovarian ligament
It is technically a part of the broad ligament
4. BROAD LIGAMENT
Two winglike structures that extend from the lateral
uterine margins to the pelvic sidewalls
Has anterior and posterior leaves
NOTE!!
MESOSALPINX
Portion of the broad ligament just below the
fallopian tube
MESOVARIUM
Portion of the broad ligament just above the
ovaries
5. CARDINAL LIGAMENT
a.k.a Transverse Cervical Ligament or Mackenrodt
Ligament
it anchors medially to the uterus and upper vagina
thick base of the broad ligament
main ligament that supports the uterus and vagina
to stay in the midline
6. UTEROSACRAL LIGAMENT
Posterolateral attachment to the supravaginal
portion of the cervix
Inserts into the fascia over the sacrum
Composed of connective tissue, small bundles
of vessels and nerves, and smooth muscle
Forms the lateral boundaries of the pouch of
Douglas
NOTE!!
There are 2 associated pouches:
1. Vesicouterine Pouch
Anterior pouch bounded by the anterior
portion of the uterus and posterior part of the
bladder
2. Pouch of Douglas
Posterior pouch clinically important
landmark for detection of internal bleeding
Paired, light gray structure approximately almond-
shaped resting on the ovarian fossa at the lateral wall
of the pelvis bounded by external and internal iliac
arteries.
Attached to the back of the broad ligament by the
mesovarium
Hilum Structure where ovarian vessels enter the ovary
Covered by the germinal epithelium modified
portion of peritoneum
Beneath the epithelium is the tunica albuginea thin,
fibrous capsule
Has an outer cortex (where ovarian follicles are locate),
and an inner medulla
Reproductive years (1.5cm x 2.5cm x 4cm; and weighs
3-6g)
There are two uterine tubes
Each tube lies on the upper border of the broad
ligament (approximately 10-14cm long, and <1cm
external diameter).
Connects the peritoneal cavity in the region of the
ovary with the cavity of the uterus
Mucosal cells of the Oviducts:
1. Ciliated Epithelium Columnar cells, mostly at
the ovarian end of the tube, with 25% of
mucosal cells
2. Secretory Cells Columnar cells, 60% of
mucosal cells, mostly at the isthmic segment
3. Peg Cells narrow cells, located between
secretory and ciliated cells
 NOTE!!
Pelvic structures- supplied by the ABDOMINAL AORTA
From the abdominal aorta common iliac artery
bifurcates into internal and external iliac arteries
EXTERNAL ILIAC ARTERY
gives off branches that will supply almost all parts
from the buttocks down
INTERNAL ILIAC ARTERY
supplies the structures found in the pelvis and the
perineal area
divides into anterior and posterior division
**Take note of the branches of the Internal and External Iliac
arteries

QUESTION!!
Most common part of the uterine tube where
fertilization occurs:
Ampulla

NOTE!!
SUPERIOR VESICAL ARTERY
supplies the superior portion of the vesical (bladder)
INFERIOR VESICAL ARTERY
supplies the inferior portion of the bladder
BLOOD SUPPLY OF THE PELVIS:
1. Common iliac artery
2. External iliac artery
3. Internal iliac artery
4. Superior rectal artery
5. Ovarian artery
6. Median sacral artery
 NOTE!!
There are different veins na di masyadong
kapareho ng artery most especially in the renal
area.

-hayst na ol favorite

VEINS:
1. External iliac vein
2. Internal iliac vein
3. Superior rectal vein
4. Ovarian vein
5. Medial sacral vein
 TWO PARTS divided by the pelvic brim (sacral
promontory) posteriorly, iliopectineal lines laterally and
symphysis pubis anteriorly
1. FALSE PELVIS greater pelvis (above the
iliopectineal line)
2. TRUE PELVIS lesser pelvis

NOTE!!
The importance of knowing the blood and nerve supply is to
prevent accidental dissection of the vessels.

TRUE PELVIS bowl-shaped structure

1. PELVIC INLET sacral promontory (posteriorly),
iliopectineal lines (laterally), symphysis pubis
(anteriorly)
2. PELVIC OUTLET (inferior portion) coccyx
(posteriorly), ischial tuberosities, sacrotuberous and
sacrospinous ligaments(laterally), pubic arch
(anteriorly)
PELVIC JOINTS
1. Sacroiliac joints
2. Symphysis pubis
3. Sacrococcygeal joints
FOUR IMAGINARY PLANES OF THE PELVIS:
1. The plane of the pelvic inlet superior strait
2. The plane of the pelvic outlet inferior strait
NOTE!! 3. The plane of the midpelvis the least pelvic
Lymph nodes are important in cases of carcinomas because dimensions
these are the structures involved in metastasis. 4. The plane of the greatest pelvic dimension of no
obstetrical significance
NOTE!!
These planes are important in clinical obstetrics
FOUR PARTS because these are the areas where you
o 2 hip bones articulated anteriorly by the symphysis determine if the pelvis is adequate for normal
pubis and with the sacrum at the sacroiliac joints delivery.
o Sacrum MIDPELVIC CONTRACTION
o Coccyx least dimension of which the fetal head
should descend
subjected to C-section
 a.k.a SUPERIOR STRAIT
Superior plane of the true pelvis
Bounded posteriorly (promontory and alae of the
sacrum), laterally (linea terminalis), and anteriorly
(horizontal pubic rami and the symphysis pubis)
Fetal head descent/head engagement
NOTE!!
ENGAGED/DESCENT pumasok na si biparietal
diameter ng fetal head sa inlet
Measured at the level of the ischial spines (also called
the midplane or plane of the least pelvic dimension)
During labor, degree of the fetal head descent into the
true pelvis is described by station
Midpelvis and ischial spines serve to mark zero station
Interspinous diameter is 10cm or slightly greater
(smallest pelvic diameter)
AP diameter through the level of the ischial spines
(approx. 11.5 cm)
Has two approximately triangular areas whose
boundaries mirror those of the perineal triangle with a
common base, which is a line drawn between the two
ischial tuberosities
Apex of the posterior triangle (tip of the sacrum) and
the lateral boundaries (sacrotuberous ligaments and
ischial tuberosities)

POSTERIOR SEGMENT determines the type of pelvis

ANTERIOR SEGMENT determines the tendency
GYNECOID PELVIS most common and most suited for
normal delivery
Note: sometimes not true because it will depend on the
position and presentation of the baby

NOTE!!
DIAGONAL CONJUGATE one that can be
measured during internal examination

1. Dr. Villarosa Lecture

2. Previous ppts
3. Sidenotes