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Anatomy of the female pelvis

and
vaginal birth

© Royal College of Obstetricians and Gynaecologists


Take a look at the bony pelvis you have been given.

View it from the front.

In the following slides, the bony landmarks will be described.

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External Pelvimetry

BICREST 28cm
BISPINOUS 24cm

ANTERO-POSTERIOR 20cm

INTERTROHANTERIAN 32cm

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Innominate bone
=
HIP BONE

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Sacrum

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Coccyx

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Sacroiliac joint

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Sacrococcygeal
joint

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Symphysis pubis

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Ischial spine

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Ileopectineal line

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Obturator foramen

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Pubic arch

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Sacral promontory

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Anterior foramina

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Now look at the pelvis from one side.

In the following slides, more landmarks will be shown.

You will also see how the pelvis is orientated when a woman
is standing up straight.

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Anterior superior
iliac spine

Symphysis pubis

Vertical plane

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HIP BONE

Ileum

Pubis
Ischium

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Acetabulum

Obturator foramen

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Look at the pelvis from the front again.

In the following slides, you will be shown a little more anatomy.

Look at the position of the sacrotuberous and sacrospinous ligaments.

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Sacrotuberous
ligament

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Sacrospinous
ligament

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Look at the pelvis from behind.

Look at the position of the sacrotuberous and sacrospinous ligaments.

These delineate the greater and lesser sciatic foraminae.

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Sacrospinous
ligament

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Sacrotuberous
ligament

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Greater sciatic
foramen

Lesser sciatic
foramen

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We are now going to add in blood vessels and nerves.

Look at the pelvis from the front again.

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© Royal College of Obstetricians and Gynaecologists
Common Iliac A

Internal Iliac A

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External Iliac A

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Common Iliac V

Internal Iliac V

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The Lumbosacral Plexus

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Sciatic nerve

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Pudendal nerve

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Obturator nerve

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Transobturator Tape in Treatment
of Stress Urinary Incontinence

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Look at the pelvis from the side.

We will look at the muscles and ligaments on the side wall of the pelvis.

You will see where the levator ani muscles originate.

You will also see the critical dimensions of the pelvis.

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Sacrotuberous
ligament

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Sacrospinous
ligament

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Obturator canal

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Obturator internus
Muscle
Covered by
Fascia

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Line of
attachment of
levator ani
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Critical pelvic
dimensions

Pelvic inlet

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Critical pelvic
dimensions

Pelvic midplane

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Critical pelvic
dimensions

Pelvic outlet

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The Pelvic Cavity
It is a segment the boundaries of which are:
• The roof of the plane of pelvic brim
• The floor is the plane of the least pelvic
dimension
• Amteriory the shorter symphysis pubis
• Posteriorly the longer sacrum

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The TRUE pelvis
The Pelvic Inlet (Brim)
Boundaries
• Sacral promontory
• Alae of the sacrum
• Sacroiliac joints
• Iliopectineal lines
• Iliopectineal eminences
• Upper border of the superior pubic rami
• Pubic tubercles
• Pubic crests
• Upper border of symphysis pubis

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Antero-posterior Diameters
• Anatomical antero-posterior diameter (TRUE
CONJUGATE) = 11 cm
– From the tip of the sacral promontory to the
upper border of the symphysis pubis
• Obstetric Conjugate = 10.5 cm
– From the tip of the sacral promontori to the
most bulgin part of SP which is about 1cm
below its upper border. The shortest AP
diameter
• Diagonal conjugate =12.5cm
– i.e 1.5 cm longer than the true conjugate.
From the tip of the sacral promontory to the
lower border of FP
• External conjugate =20cm
– From the depression below the last lumbar
spine to the upper anterior margin of the
symphysis pubis measured from outside by
the pelvimeter – no obstetrical importance
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Transverse Diameters

• Anatomical transverse diameter


=13cm
– Between the farthest two points on the
iliopectineal lines
– It lies 4 cm anterior to the promontory and 7
cm behind the symphysis Transverse 13.5cm

Conjugata vera
– It is the largest diameter in the pelvis Interspinous 10cm

= 10.5cm
• Obstetric transverse diameter
– It bisects the true conjugate and is slightly
shorter than the anatomical transverse
diameter

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Oblique Diameters

• Right oblique diameter = 12 cm


– From the right sacroiliac joint to the left
iliopectineal eminence

• Left oblique diametere = 12cm


– From the left sacroiliac joint to the right
iliopectineal eminence

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The Pelvic Outlet
• Anatomical Outlet
– Lower border of symphysis pubis
– Pubic arch
– Ischial tuberosities
– Sacrotuberous and sacrospinous ligaments
– Tip of coccys

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Female Male

Pelvic inlet

Pelvic outlet

Pelvic cavity

Pubic arch

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Pelvic types

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TYPE ONE
GYNAECOID PELVIS (50%)
1. Normal female type
2. Inlet is slightly transverse oval
3. Sacrum is wide with average concavity and
inclination
4. Side walls are straight with blunt ischial spines
5. Sacro-sciatic notch is wide
6. Suprapubic angle 90-100

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TYPE THREE
ANDROID PELVIS (20%)

1. It is male type
2. Inlet is triangular or heart shaped with anterior
narrow apex
3. Side walls are converging (funnel pelvis) with
projecting ischial spines
4. Sacro-sciatic notch is narrow
5. Subpubic angle is narrow <90

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TYPE TWO
ANTHROPOID PELVIS (25%)

1. Ape-like type
2. All anteroposterior diameters are long
3. All transverse diameters are short
4. Sacrum is long and narrow
5. Sacro-sciatic notch is wide
6. Subpubic angle is narrow

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TYPE THREE
PLATYPELLOID PELVIS (5%)

1. It is a flat female type


2. All anteroposteror diameters are short
3. All trasnverse diameters are long
4. Sacro-sciatic notch is narrow
5. Subpubic angle is wide

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Look at the pelvis from the front again.

Imagine a ‘coronal’ plane through the middle of the pelvis.

You will see the rectum coming through the pelvis.

You will see where the levator ani muscles originate.

You will see which structures form the pelvic diaphragm.

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Peritoneum

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Subperitoneal
space

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Contains:
Pubocervical
Trans cervical
Sacrocervical
Ligaments

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Perineum
everything under
pelvic diaphragm © Royal College of Obstetricians and Gynaecologists
Ischiorectal fossae

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Now look at the pelvis from below.

Look at the layout of the bones and the ligaments.

They define the pelvic outlet.

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Obturator
membrane
Obturator canal

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Pubic arch Symphysis pubis

Inferior pubic
ramus

Ischial ramus

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Ischial tuberosity
Sacrotuberous
ligament

Sacrum / coccyx

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Pelvic outlet

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Urogenital
triangle

Anal triangle

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Here is the female abdomen and pelvis viewed from one side.

The structures shown should now be familiar to you.

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Peritoneum

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Sacrocervical
ligament
Pubocervical
ligament

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Pelvic diaphragm

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Urogenital
diaphragm

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Keep looking at the pelvis from below.

Imagine the anatomy above the pelvic diaphragm.

The following slides show the structures encountered as you descend


through the pelvis.

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Bladder
Above the

Cervix Pelvic diaphragm

Rectum

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Pubocervical
ligament Above the
Pelvic diaphragm

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Above the
Pelvic diaphragm
Transverse
cervical ligament

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Above the
Pelvic diaphragm

Sacrocervical
ligament

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Pelvic diaphragm

Levator ani:
Pubococcygeus
Iliococcygeus
Ischiococcygeus

Coccygeus

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Keep looking at the pelvis from below.

Imagine the anatomy as you descend below the pelvic diaphragm.

The following slides show the structures encountered as you continue to


descend through the pelvis.

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The UROGENITAL DIAPHRAGM layers

1. Superior urogenital fascia


2. Deep muscular layer of the urogenital diaphragm
• Deep transverse peroneal muscles
• External urethral sfincter muscle

3. Inferior urogenital fascia


4. Superficial muscular layer of the urogenital diaphragm
• Bulbospongious
• Ischiocavernous
• Superficial transverse

5. Structures in the superficial pouch (vestibular glands and their excretory cannals)
6. Perineal body

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Urogenital
diaphragm

1. Superior
layer of fascia

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Urogenital diaphragm

2. Deep muscular
layer
EXTERNAL
SPHINCTER
URETHRAE muscle

DEEP TRANSVERSE
peroneal muscles

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3. Inferior
layer of fascia
(Perineal
membrane)

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4. Muscles in
Superficial
pouch
Ischiocavernosus

Bulbospongiosus

Superficial transverse
peroneal muscles

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5. Structures in
Superficial pouch

Clitoris & crus

Bulb of vestibule

Vestibular glands

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6. Perineal body

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Keep looking at the pelvis from below.

You have now reached the most superficial level.

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Labium majus

Labium minus

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Mons pubis

Prepuce of clitoris

Vestibule

vagina

Fourchette

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Take your fetal skull and view it from above.

Note the near central position of the anterior fontanelle.

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parietal eminence
coronal sutures

frontal bones lambdoid sutures

occiput

anterior fontanelle

posterior fontanelle
sagittal suture

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The following slides will demonstrate the orientation of
the fetal skull as it passes through the pelvis in normal
labour.

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passenger

the head flexes as the uterus contracts


the head descends and engages in the pelvis
the leading part approaches the ischial spines
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passenger

the occiput starts to rotate anteriorly


the occiput reaches the pelvic floor (levator ani)
internal rotation continues to achieve an occipito-anterior position
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passenger

the occiput clears the symphysis pubis


the head extends to deliver
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passenger

the head sits on the maternal perineum

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passenger

the fetal head realigns itself with the fetal shoulders - restitution
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passenger

the shoulders contact the pelvic floor and rotate so that the bisacromial diameter lies
in an anteroposterior orientation
the head therefore continues to rotate - external rotation
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