The organs of reproduction of women

The organs of reproduction of women are

classified as external or internal. The external
organs and the vagina serve for copulation ; the
internal organs provide for : ovulation , a site of
ovum fertilization , blastocyst transport ,
implantation , development and birth of the fetus.
There may be marked variation in anatomical
structure in a patient that is especially true for
major blood vessels and nerves.
External Generative Organs
External Generative Organs :
The pudenda or in other words the
external organs of generation are
commonly designated or indicate the
vulva, which includes all structures visible
externally from the pubis to the perineum,
that is: the mons pubis , labia majora and
minora, clitoris, hymen , vestibule ,
urethral opening and various vascular
structures.
Mons Pubis or mons veneris - is the fat -
filled cushon that lies over the interior surface
of the symphysis pubis. After puberty the mons
pubis’ skin is covered by curly hear that
forms the escutcheon . The distribution of pubic
hair is different in two sexes. In women it is
distribute in a triangular area . In men hair is
not well circumscribed. Hair grows in an
extended area toward the umbilicus and
downward and inward over the inner
surface of the thighs.
The second is labia Majora . Labia Majora are
two rounded folds of adipose tissue covered
with skin and are extended downward and
backward from the mons pubis. Among adult
women their structure vary in appearance
according to the amount of fat that is
contained within these very tissues.
Embryologically they are homologous with the
male scrotum. The round ligament terminate at
the upper borders of the labia majora. After
repeated childbearing they are less prominent
but in old age they begin to shrivel.
Generally these structures are 7-8 sm in length,
2-3 cm in width, 1-1.5 cm in thickness and
tepered at the lower extremities. In children
and nulliparous women labia majora lie in
close apposition and conceal the underlying
tissues. In multiparous women they may gape
widely .The labia majora continuous directly
with the mons pubis above and merge into the
perineum posteriorly where these structures are
join medially to form the posterior
commissure.
 Before puberty, the outer surface of labia is
similar to the adjacent skin but after puberty
they are covered with hair.
In nulliparous women , the inner surface is
moist and resembles a mucous membrane.
However in mutiparious ones the inner surface
becomes more skinlike and is not coverd with
hair. The labia majora are richly supplied with
sebaceous glands. Beneath the skin is a layer
of dense connective tissue that is rich in elastic
fibers and adipose tissue, but is almost void of
muscular elements.
Unlike the squamous epithelium of the
vagina and cervix there are epithelial
appendages in parts of the vulvar skin.
Beneath the skin is a mass of fat that
provides the bulk of the volume of the
labium. The very tissue is supllied with
a plexus of veins as a result of injury or
rupture to create a hematoma.
 Labia Minora - there are two flat reddish
folds of tissue that are visible when the
labia majora are separated. These
structures join at the upper extremity of the
vulva. The labia minora vary in size and
shape too. In nulliparous women they are
not visible behind the nonseparated labia
majora. In multiparous women the labia
minora projects stick out beyond the labia
majora.
Each labium minus is a thin fold of tissues and is
moist , reddish in appearance and similar to a
mucous membrane. These structures are covered
by stratified squamous epithelium in which lots
of papillae project. In the labia minora no hair
follicles but are many sebaceous follicles and a
few sweat glands too. The interior of the labial
folds include or comprise connective tissue with
many vessels and smooth muscular fibers and
are supplied with a variety of nerve endings that
are too sensitive.
 The labia minora’s tissues converge
superiorly and each is divided into two
lamellae. The lower pair of which fuses to
form the frenulum of the clitoris. The upper
pair merges to form the prepuce of the
clitoris. In nulliparous women the labia
minora extend to approach the midline as
low ridges of tissue to form the fourchette .
In mutiparous women the labia minora are
contiguous with the labia majora.
Clitoris is one of the erogenous organ of
women and the homologue of the penis
and is located near the superior extremity
of the vulva. This organ projects
downward between the branched
extremities of the labia minora. It is
converge to form the prepuce and
frenulum of the clitoris. The clitoris is
comprised of a glans, a body and two crura.
The glans is made up of spindleshaped cells. In the
body there are two corpora cavernosa . In the walls
there are smooth muscle fibers. The long , narrow
crura arise from the inferior surface of the
ischiopubic rami and fuse just below the middle of the
pubic arch to form the corpus. Clitoris rarely exceed
2 cm in length even in a state of erection. It is bent
sharply by traction exerted by the labia minora. The
free end of the clitoris is pointed down and up toward
the vaginal opening. The glans rarely exceed 0.5 cm
in diameter and covered by stratified squamous
epithelium that is supplied with sensitive nerve
ending. The vessels of the crectile clitoris are
connected with vestibular bulbs.
Vestibule is an almond-shaped area ,
enclosed by the labia minora laterally and
extends from the clitoris to the fourchette. It
is the functionally mature female structure of
the urogenital sinus of the embryo. In the
mature state is perforated by six openings:
the urethra, the vagina, the ducts of the
Bartholin glans or Skene ducts . The posterior
portion of the vestibule between the
fourchette and the vaginal opening is called
the fossa naivcularis and observed only in
nulliparous women.
As for the Bartholin glands , it is a pair of small
compound 0.5 -1 cm in diameter structures . Each of
them are situated beneath the vestibule on the sides of
the vaginal opening and they are the major vestibular
glands . They lie under the constrictor muscle of the
vagina and sometimes they are partially covered by the
vestibular bulbs. The gland dusts are 1.5 -2 cm long and
open on the sides of the vestibule outside the lateral
margin of the vaginal orifice. The small gland lumen
admits the finest of probes. During sexual arousal ,
mucoid material is secreted from these glands and may
harbor Neisseria gonorrhoeae or other bacteria that
may cause suppuration and a Batholin gland abscess.
Urethral Opening. The lower two thirds of the urethra
lies immediately about the anterior vaginal wall. The
urethral opening or meatus is in the middling of the
vestibule 1-1.5 cm below the pubic arch and a short
distance about the vaginal opening . The urethral
opening appears as a vertical slit and can be distended
to 4-5 mm in diameter. The paraurethral ducts known
as the Skene ducts- open in to the vestibule on the
both side of the urethra. Sometimes they open on the
posterior wall of the urethra just inside the meatus.
Ducts are about 0.5 mm in diameter and of variable
length.
Vaginal Opening and Hymen. The vaginal opening varies in
size and shape. In virgins it most often is hidden by the
overlapping labia minora, and when exposed it appears almost
fully closed by the membranous hymen. There are main
differences in shape and in consistency of the hymen that is
comprised of elastic and collagenous connective tissue. Both
outer and inner surfaces are covered by stratified squamous
epithelium. Connective tissue papillae are numerous on the
vaginal surface and at the free edge. There are no glandular or
muscular elements in the hymen and is not highly supplied
with nerve fibers. In the newborn the humen is too vascular and
redundant ; in pregnant the epithelium is thick and the tissue is
rich in glycogen; after menopause , the epithelium of the
hymen is thin and focal cornification may develop .
In adult virginal women the hymen is a
membrane of various thickness that surrounds
the vaginal opening more or less fully. Among
virginal women , the aperture of the hymen
varies in diameter from of a pinpoint to a
caliber that admits the tip of one or two fingers.
They hymenal opening generally is
crescentic / circular, but sometimes may be
cribriform, septate or fimbrated . The
fimbriated hymen in virginal women may be
indistinguishable from one that was penetrated
during intercourse.
As a rule the hymen is torn at several sited during the
first coitus, usually in the postcrior portion. The edges
of the torn tissue soon cicatrize and the hymen
becomes divided permanently into two or more
portions separated by narrow sulci. The size of rupture
varies with the structure of the hymen. It is believed
that hymen’s ruptures is accompanied by bleeding.
Rarely the hymenal membrane may be resistant and
incision of the tissue can be necessary before coitus can
be accomplished.
The changes in the hymen brought by coitus are
mostly of medicolegal importance and especially in
instances of alleged sexual assault.
 When nulliparous women are examined a few hours after an
attack, the finding of fresh hymenal lacerations, abrasions or
bleeding points on the hymen constitutes corroborative evidence
of recent vaginal penetration possibly by intercourse.
Actually many cases of pregnancy have been reported in
women with not ruptured hymen . Usually the changes
produced in the hymen by childbirth are readily recognizable.
After recovery from delivery several different size cicatrized
nodules are formed, the tissue remnants of the hymen .
A rare lesion imperforate hymen is a condition when the
vaginal orifice is occluded fully, causing retention of menstrual
discharge .
Vagina . A tubular , musculomembranous structure
that extend from the vulva to the uterus, interposed
interiorly and posteriorly between the urinary bladder
and the rectum is called the vagina. It has many
functions like : the excretory canal of the uterus throw
which uterine secretions and menstrual flow escape;
organ of copulation and part of the birth canal. The
upper portion of vagina arises from the mullerian
ducts . The lower portion is formed from the
urogenital sinus. Anteriorly it is in contact with the
bladder and urethra, from where is separted by
connective tissue or vesicovaginal septum. Posterior-
ly , between the lower portion of vagina and the
rectum there are similar tissues that form the
rectovagian septum .
The upper fourth of the vagina is
separated from the rectum by rectouterin
pouch or cul-de-sac of Douglas.
The anterior and posterior vaginal walls lie
in contact with a slight space that
intervenes between the lateral margins.
When not distended the vaginal canal on
transverse section is H-shaped. Vagina can
be distended markedly during childbirth .
The upper end of vagina vault is subdivided
into the anterior , posterior and two lateral
fornices by the uterine cervix. The depth of
posterior fornix is appreciably greater than the
anterior. The lateral has serious clinical
importance because the internal pelvic organs
usually can be palpated through the thin walls
of the fornices. Moreover , the posterior fornix
provides ready surgical access to the peritoneal
cavity. Vaginal length varies considerably; the
anterior and posterior vaginal walls are
respectively 6-8cm and 7-10 cm in length.
The vaginal mucosa consists of noncornified stratified
squamous epithelium. Beneath the epithelium there is
a thin fibromuscular coat, consisting of an inner
circular layer and an outer longitudinal layer of smooth
muscle. There is a thin layer of connective tissue that
overlies the mucosa and the muscularis. One is rich in
blood vessels, and one has a few small lymphoid
nodules. The mucosa and muscularis are attached very
loosely to the underlying connective tissue. Connective
tissue often referred to an perivaginal endopelvic
fascia .
Normally glands are not present in the vagina. In
parious women fragments of stratified epithelium are
occasionally embedded in the vaginal connective
tissue. These vaginal cysts are not glands, they are
remnants of mucosal tags that were buried during the
repair of vaginal lacerations after childbirth.
Occasionally , other cysts lined by columnar
epithelium and are derived from embryonic remnants.
From early in infancy until after menopause, there is
an amount of glycogen in the superficial cells of the
vaginal mucosa. By examination of exfoliated cells
can identify the various hormonal events of the ovarian
cycle.
In nonpregnant women the vagina is kept moist by an amount
of secretion from the uterus. During pregnancy, there is
copious acidic vaginal secretion, which consists of a curdlike
product of exfoliated epithelium and bacteria. The pH of the
vaginal secretion varies with the ovarian secreted hormones.
Before puberty, the pH of the secretions of the vagina varies
between 6.8-7.2 . In adult women it generally ranges from 4.0 to
5.0.
During pregnancy appears both qualitative and
quantitative changes in the microbial flora . In
80 % of women with normal flora before
pregnancy the flora remains normal. It is
reported, Lactobacillus species are isolated
during pregnancy. Probably anaerobic
organisms isolated from nonpregnant women
are not numerous during pregnancy. However,
during the postpartum period, anaerobic bacteria
increases dramatically and causes infection in
puerperal women.
The vagina has abundant vascular supply.
The upper third is supplied by the
cervicovaginal branches of the uterine arteries.
The middle third is supplied by the inferior
vesical arteries and the lower third is
supplied by the middle rectal and internal
pudendal arteries. Vaginal artery may branch
from the internal iliac artery where is an
extensive venous plexus that directly
surrounds the vagina. Vessels that follow the
course of the arteries , eventually empty into
the internal iliac veins.
 Most part of the lymphatics from the
lower third of vagina along with the vulva,
drain into the inguinal lymph nodes.
Those from the middle third drain into the
internal iliac nodes. According to some
reports the vaigna is devoid of any special
nerve endings / genital corpuscles. Free
nerve endings are found in the papillae.
The Perineum: Many structures make up the
perineum. Perineum is provided by the pelvic
and urogenital diaphragms. The pelvic
diaphragm consists of the levator ani muscles
plus the coccygeus muscles posteriorly and
fascial coverings of these muscles too. The
levator ani muscles form a broad muscular
sling. It begins from the posterior surface of
superior rami of pubis from the inner surface of
the ischial spine and between these two sites
from the obturator fascia.
The muscle fibers are inserted in several locations
around the vagina and rectum to form efficient
functional sphincters for each:
-into a raphe in the midline between the vagina and
rectum;
-into a midline raphe below the rectum;
-into the coccyx.
The urogenital diaphragm is positioned external to the
pelvic diaphragm in the triangular between the ischial
tuberosities and the symphysis pubis. The urogenital
diaphragm is comprised of deep transverse perineal
muscles - the constrictor of the urethra, and the
internal and external fascial coverings.
 The major blood supply to the
perineum is via the internal pudendal
artery and its branches . Branches of
the internal pudendal artery include
the inferior rectal artery and posterior
labial artery. The innervations of the
perineum is primarily via the
pudendal nerve and its branches. The
pudendal nerve originates from the S2,
S3, S4 portion of the spinal cord.
Perineal Body: The median raphe of the
levator ani, situates between anus and vagina.
It is strengthened by the central tendon of the
perineum on which converge
bulbocavernosus muscles , superficial transvers
perineal muscles, external anal sphincter.
These structures contributed to the perineal
body and provide support for the perineum ,
often are lacerated during delivery, unless an
adequate episiotomy is made.
Internal Generative organs
 Internal Generative organs
Uterus: The uterus is a muscular
organ that is partially covered by
peritoneum or serosa. The cavity of
uterus is lined by the endometrium .
During pregnancy, the uterus serves
for reception , implantation, retention
and nutrition of the conceptus, which
expels during labor.
Anatomical Relationships: The uterus of nonpregnant
woman is situated in the pelvic cavity between the
bladder anteriorly and the rectum posteriorly . Almost
the entire posterior wall of the uterus is covered by
serosa or peritoneum, the lower portion of which
forms the anterior boundary of the recto-uterine cul-de-
sac/ pouch of Douglas. Only the upper portion of the
anterior wall of the uterus is so covered . The lower
portion is united to the posterior wall of the bladder
by a well-defined , normally loose layer of connective
tissue.
Size and Shape : The uterus is a structure that resembles
a flattened pear in shape . It consists of two major but
unequal parts:1) an upper triangular protion, the body or
corpus; 2) a lower, cylindrical or fusiform portion, the
cervix , which projects into the vagina. The bodies
anterior surface of uterus is almost flat, but the posterior
surface is distinctly convex. The oviducts or fallopian
tubes emerge from the cornua of uterus at the junction of
the superior and lateral margins. The fundus is the
convex upper segment between the points of insertion of
the fallopian tubes. Laterally, the portion of uterus below
the insertion of the fallopian tubes is not covered
directly by peritoneum, it is the site of the attachments
of the broad ligaments.
The uterus varies in size, shape. Before puberty, the
organ varies in length from 2.5 to 3.5 cm. The uterus
of adult nulliparous women is from 6-8 cm in length.
In mulitparous ones is 9-10 cm, but uterus is different
in weight, averaging from 50-70 g. for the former, and
80g or more for the latter. The relationship between the
length of body of uterus and of the cervix varies widely.
In the premenarchal girl the body of the uterus is only
half as long as the cervix. In nulliparous women the
two are about equal in length. In multiparous women,
the cervix is only a little more than one third of the
total length of the organ.
The bulk of the body of the uterus without cervix is comprised
of muscle. The inner surface of uterus anterior and posterior
walls lie almost in contact ; the cavity between walls forms a
mere slit. The cervical canal is fusiform. It is open at each end
by small apertures, the internal os and the external os . On
frontal section the cavity of body of uterus is triangular.
Whereas that of the cervix is fusiform is shape. The margins of
parous uteri become concave instead of convex and the
triangular appearance of the uterine cavity is less pronounce.
After menopause the size of uterus decreases as a
consequence of atrophy of both the myometrium and
endometrium. The isthmus is of special obstetrical significance.
In pregnancy, it is essential for formation of the lower uterine
segment .
Uterus during pregnancy: During pregnancy the
uterus undergoes remarkable growth due to
hypertrophy of muscle fibers. Its size increases from
70 g in the nonpregnant, to about 1100 g at term. The
total volume averages about 5l. As growth
proceeds , the uterine fundus , a previously flattened
convexity between tubal insertions becomes dome-
shaped. The round ligaments appear to insert at the
junction of middle and upper thirds of the organ. The
fallopian tubes elongate , but ovaries grossly appear
unchanged.
Uterine Cervix: The cervix is the specialized portion of the
uterus that is below the isthmus. Anteriorly , the upper
boundary of the cervix, the internal os, corresponds
approximately to the level at which the peritoneum is reflected
upon the bladder.
The cervix is divided by attachment of vagina into vaginal and
supravaginal portions. The supravaginal segment on its
posterior surface is covered by peritoneum. Laterally, it is
attached to the cardinal ligaments and anteriorly, it is
separated from the overlying bladder by loose connective
tissue. The external os / the portio vaginalis is located at the
lower extremity of the vaginal portion of the cervix.
The external cervical os varies greatly in appearance. Before
childbirth , it is a small, regular, oval opening; after childbirth
the orifice is converted into a transverse slit that is divided so-
called anterior and posterior cervix lips. If the cervix was torn
deeply during delivery , it might heal and appear to be
irregular , nodular or stellate. These changes are main
characteristics to permit an examiner to ascertain with some
certainty whether a give woman has borne children by
vaginal delivery.
The cervix is composed predominantly of collagenous tissue ,
clastic tissue and blood vessels, and contains some smooth
muscle fibers. The transition from cervix’s primarily
collagenous tissue to the primarily muscular tissue of the body
of uterus generally abrupt may be gradual, and may extend
over as much as 10mm. The results of studies shown the
cervix are determined in large measure by the state of the
connective tissue. During pregnancy and labor the remarkable
ability of the cervix dilate is the result of dissociation of
collagen. They quantified the amount of muscles and
collagen in the tissue of the cervix of women. In the normal
cervix the proportion of muscle is about 10%, whereas in
women with an incompetent cervix sometimes the proportion
of muscle is appreciably greater.
• The mucosa of the cervical canal is composed of a single
layer of very high, columner epithelium that rests upon a thin
basement membrane. The oval nuclei are situated near the
base of the columnar cells. Their upper portion appears to be
rather clear because of content of mucus. These cells
supplied abundantly with cilia.
• There are numerous cervical glands. They extend from the
surface of the endocervical mucosa directly into the subjacent
connective tissue. There is no submucosa and these glands
furnish the thick , tenacious secretion of the cervical canal. If
the ducts of the cervixal glands are occluded, retention cysts-
known as Nabothian follicles /Nabothian cysts are formed.
Normally the squamous epithelium of the vaginal portion of
the cervix and the columnar epithelium of the cervical canal
form a sharp demarcation very near the external os that is ,
the squamo-columnar junction. In response to inflammation
or trauma, the stratified epithelium may extend gradually up
the cervical canal and come to line the lower third, or even
the lower half of the canal. This change is clearly shown in
multiparous women , where the lips of the cervix often are
averted. Uncommonly, two varieties of epithelium about on
the vaginal portion outside the external os , as in congenital
ectropion.
Body of the Uterus: The uterus body wall is composed of
serosal, muscular and mucosal layers. The serosal layer is
formed by peritoneum. It covers the uterus and to which it
is firmly adherent except at sites about the bladder and at the
lateral margins where the peritoneum is deflected to form the
broad ligaments.
Endometrium. The endometirum is the innermost portions of
uterus . It is mucosal layer that lines the uterine cavity in
nonpregnant women. It is a thin, pink , velvet-like
membrane , which is perforated by a large number of minute
openings ; these are the ostia of the uterine glands. During
the reproductive years because of the repetitive cyclical
changes the endometrium normally varies greatly in
thickness, and measures from 0.5mm to as much as 5mm.
The endometrium is comprised of surface epithelium, glands
and intergalndular mesenchymal tissue , in which are
numerous blood vessels.
The endometrial surface of epithelium is comprised of
a single layer of closely packed , high columnar
ciliated cells. During the endometrical cycle, the oval
nuclei are situated in the lower portions of the cells but
not near the base as in the endocervix. Cilia have been
demonstrated in endometrial cells of many mammals;
the ciliated cells are located in discrete patches, whereas
secretory activity appears to be limited to nonciliated
cell. The ciliary current in both the fallopian tubes and
the uterus is in the same direction and extends
downward from the fimbriated end of the tubes toward
the external os.
The tubular uterine glands are invaginations of
the epithelium. In the resting state they are
reminiscent of the fingers of a glove. The glands
extend through the entire thickness of the
endometrium to the myometrium penetrated in
a short distance. Histologically the inner glands
resemble the epithelium of the surface and are
lined by a single layer of columnar , partially
ciliated epithelium that rests upon a thin
basement membrane. The glands secrete a thin
alkaline fluid that serves to keep the uterine
cavity moist.
The connective tissue of endometrium, between the surface
epithelium and the myomethrium is a mesenchymal stroma.
Immediately after menstruation, the stroma is comprised of
closely packed cells with oval and spindle- shaped nuclei,
around which there is very little cytoplasm. When separated
by edema, the cells appear to be stellate with cytoplasmic
processes that branch to form anastomoses. These cells are
packed more closely around the glands and blood vessles.
Several days before menstruation , the stromal cells become
larger and more vesicular, like decidual cells, and at the same
time there is adiffuse leukocytic infiltration too.
The vascular architecture of the endometrium is important
phenomena of menstruation and pregnancy. Arterial blood is
transported to the uterus by uterine and ovarian arteries. As
the arterial branches penetrate the uterine wall obliquely
inward and reach its middle third, these vessels ramify in a
plane that is parallel to the surface; these vessels are named as
arcuate arteries . Radial branches extend from the arcuate
arteries at right angles toward the endometrium. The
endometrial arteries are comprised of coiled or spinal arteries
- continuation of radial and basal arteries, which branch from
the radial arteries at a sharp
angle.
The straight basal endometrial arteries are smaller in both,
caliber and length. than The coiled arteries are smaller in
both caliber and length than are the coiled vessels. These
vessels extend only into the basal layer the endometrium of at
most a short distance into the middle layer , and are not
responsive to hormonal action.
Myometrium: The myometrium , which makes up the
major portion of the uterus , is comprised of bundles
of smooth muscle that are united by connective
tissue in which there are many elastic fibers.
According to scientists the number of muscle fibers
of the uterus progressively diminishes caudally such
that in the cervix , muscle comprises only 10% of the
tissue mass. In the inner wall of the body of outer
layers; there is relatively more muscle that in the
outer layers; and in the anterior and posterior walls,
there is more muscle than in the lateral walls.
During pregnancy, they myometrium increases greatly
via hypertrophy with no significant change in the
muscle content of the cervix.
Ligaments of the Uterus: The broad , round, and uteroscral
ligaments extend from either side of the uterus. The broad
ligaments are comprised of two winglike structures that
extend from the lateral margins of the uterus to the pelvic
walls and thereby divide the pelviccavity into anterior and
posterior compartments. Each broad ligament consists of a
fold of peritoneum, and there are superior, lateral, inferior,
and medical margins. The inner two thirs of the superior
margin form the mesosaponx, to which the fallopian tubes
are attached .The outer third of the superior margin of the
broad ligament, which extends from the fimbriated end of the
oviduct to the pelvic wall, forms the infundibuloplvic
ligament [suspensory ligament of the ovary], through which
the ovarian vessels travers.
At the lateral margin of each braod ligament, the peritoneum
is reflected onto the side of the pelvis. The base of the broad
ligament, which is quite thick, is continuous with the
connective
tissue of the pelvic floor. The most dense portion- referred to
as the cardinal ligament , transverse cervical ligament /
Mackenrodt ligament - is composed of connective tissue that
medially is united firmly to the supravagianal portion of the
cervix. In the base of the broad ligament , the uterine vessels,
and the lower portion of the ureter are enclosed.
A vertical section through the uterine end of the broad
ligament is triangular and the uterine vessels are found
within its broad base. In its lower part it is widely attached to
the connective tissues that are adjacent to the cervix , that is,
the parametrium. The upper part is comproised of three fold
that nearly cover the oviduct , the utero-ovarian ligament and
the round ligament.
The round ligaments extend from lateral portion of uterus,
arising below anterior to that of the origin of the oviducts.
Each round ligament is located in a peritoneum fold . It
continuous with the broad ligament and extends outward and
downward to the inguinal canal, through which it passes to
terminate in the upper portion of the labium majus. In
nonpregnang women the round ligament varies from 3-5 mm
in diameter, and is comprised of smooth muscle cells.
It goes directly with those of the uterine wall and a certain
amount of connective tissue too. The round ligament
corresponds, embryologically, to the gubernaculums testis of
men. During pregnancy the round ligaments undergo
considerable hypertropy and increase appreciably in both
length and diameter.
Each uterosacral ligament extends from an attachment
posterolaterally to the supravaginal portion of the cervix to
encircle the rectum, and thence insert into the fascia over the
second and third sacral vertebrae. The uterosacral ligaments
are comprised of connective tisuue , smooth muscle and are
covered by peritoneum. These ligament form the lateral
boundaries of the rectouterine cul-de-sac / pouch of Douglas.
 Position: When a nonpregnant woman stands upright, the
body of the uterus often is almost horizontal , flexed anteriorly
with the fundus resting upon the bladder. The cervix is directed
backward toward the tip of the sacrum with the external os ,
approximately at the level of the ischial spines. The position
of the body of uterus is variable as a function of the degree of
distension of the bladder , rectum or both.
Normally the uterus is a partially mobile organ , the cervix
is anchored and the body of the uterus is free to move in the
anteroposterior plane. Posture and gravity are factors that
influence the position of the uterus. The posterior directed or
retroflexed uterus, with the fundus resting on the rectum that
is encountered in many women.
Blood Vessels: The uteres vascular supply is derived from the
uterine and ovarian arteries. The uterine artery, a main branch
of the internal iliac artery, enters the base of the broad
ligament and makes its way medially to the side of the uterus.
The supravaginal portion of the cervix, the uterine artery is
divided into two main branches. The smaller cervicovaginal
artery supplies blood to the lower portion of cervix and the
upper portion of the vagina. The main branch turns abruptly
upward and extends a highly convoluted vessel that traverses
along the
margin of the uterus.
A branch of considerable size extends to the upper portion of
the cervix and numerous other branches penetrate the body of
the uterus. Before the main branch of uterine artery riches the
oviduct, it divides into three terminal brances : fundal, tubal,
ovarian. The ovarian branch of the uterine artery
anastomoses with the terminal branch of the ovarian artery;
the tubal branch makes its way through the mesosalpinx and
supplies part of the oviduct; and the fundal branch is
distributed to the uppermost portion of the uterus. About 2
cm lateral to the cervix , the uterine artery crosses over the
ureter.
The uterine artery and uterine vein to the ureter at this point
has great surgical significance. During hysterectomy, the
ureter may be injured or ligated in the process of clamping and
ligating the uterine vessels. A major portion of the blood
supply to the pelvis is via the branches of internal iliac artery.
In the past , this was referred to as the hypogastric artery.
Other branches of anterior division of the internal iliac artery
include the umbilicval, middle and interior vesical , middle
rectal, obturator, internal pudendal middle hemorrhoidal,
vaginal and inferior gluteal arteries too. The branches of the
posterior division of the internal iliac artery include the lateral
sacral , superior gluteal, and iliolumbar arteries.
The ovarian artery- a direct branch of the aorta, enters the
broad ligament through the infundibulopelvic ligament . At
the ovarian hilum it is divided into a smaller branches that
enter the ovary. The main stem of the ovarian artery traverses
the entire length of the broad ligament very near the
mesosalpinx and makes its way to the upper portion of the
lateral margin of the uterus, where it anastomoses with the
ovarian branch of the uterine artery. There are numerous
additional communications among the arteries on both sides
of the uterus.
When the uterus is in a contracted state its numerous venous
lumens are collapsed; however in injected specimens the
greater part of the uterine wall appears to be occupied by
dilated venous sinuses. On either side , the arcuate veins unite
to form the uterine vein, which empties into the internal iliac
vein and thence into the common like vein.
Blood from the upper part of the uterus and blood from the
ovary and upper part of the broad ligament is collected by
several veins, within the broad ligament, form the large
pampiniform plexus- the vessels that terminate in the ovarian
vein. The right ovarian vein empties into the vena cava ,
whereas the left ovarian vein empties into the left renal vein.
During pregnangcy, there is marked hypertrophpy of the
blood supply to the uterus. This accommodates uteroplacental
blood flow estimated at 500-700 ml. per minute.
 Lymphatics: The endometrium is abundantly supplied with
lymphatics. True lymphatic vessels are confined largely to the
basal layer. The lymphatic of the underlying myometrium are
increased in number toward the serosal surface and form and
abundant lymphatic plexus just beneath it, especially on the
posterior wall. It forms the various segments of the uteres
drain into several sets of lymph nodes. Those from the cervix
terminate mainly in the hypogastric nodes, which are situated
near the bifurcation of the common iliac vessels. The
lymphatic from uterus body distributed to two groups of
nodes. One set of vessels drains
into the internal iliac nodes; the other set, after joining
certain lymphatic from the ovarian region terminates in the
periaortic lymph nodes.
Innervation. The nerve supply is derived from the sympathetic
nervous system and partly from the cerebrospian and
parasympathetic systems. The parasympathetic is on both side
of the pelvic nerve and is comprised of a few fibers derived
from the second , third and fourth sacral nerves. It loses its
identity in the cervical ganglion of Frankenhauser. The
sympathetic system goes the pelvis by way of internal iliac
plexus that arises from the aortic plexus just below the
promontory of the sacrum. After descending it enters the
outerovaginal plexus of Frankenhauser. It comprises various
size ganglia. Large ganglionic plate is situated on both side
of cervix and above the posterior fornix in front of the rectum.
Oviducts:
The oviducts or fallopian tubes vary from 8-14 cm in
length , are covered by peritoneum and their lumen is lined by
mucous membrane. Each tube is divided into a interstitial
portion, isthmus, ampulla and infundibulum. The interstitial
portion is embodied within the muscular wall of the uterus.
The isthmus / narrow portion of the tube that adjoins the
uterus passes into the wider, lateral portion or ampulla. The
infundibulum /fimbriated extremity is funnel-shaped opening
of the distal end of the fallopian tube. The oviduct waries in
thickness. The isthmus narrowest portion measures from 2-3
mm in diameter, and the widest portion of the ampulla
measures from 5-8 mm. The oviduct is surrounded
completely by peritoneum except at the attachment of the
mesosalpinx.
 The fimbriated end of the infundibulum opens into abdominal
cavity. The fimbria ovarica is considerably longer than the
other fimbriae. It forms a shallow gutter that approaches or
reaches the ovary. The fallopian tubes musculature is
arranged in 2 layers , an inner circular and an outer
longitudinal layer. In distal portion of oviduct 2 layers are less
distinct and near the fimbriated extremity, are replace by
interlacing network of muscular fibers. The tubal musculature
undergoes rhythmic contractions constantly and the rate
varies with the hormonal changes of the ovarian cycle. The
contractions frequency and intensity is reached during
transport of ova and are slow and weak during pregnancy.
The fallopian tube is lined by a single layer of columnar cells.
Some of them ciliated and others secretory. The ciliated ones
are most abundant at the fimbriated extremity. These sells are
found in discrete patched. There are differences in the
proportions of these two types of cells in different phases oh
ovarin cycle. There is no submucosa and the epithelium is in
close contact with the underlying muscle. In the tubal mucosa
, there are cyclical histological changes similar to , but less
stirking than the endometrium.
The postmenstrual phase is characterized by a low epithelium
that rapidly increases in height. During the follicular phase ,
cells are taller, ciliated elements are broad with nuclei near
the margin. Nonciliated cells are narrow with nuclei near the
base. During luteal phase the secretory cells enlarge. Project
beyond the ciliated cells and the nuclei are extruded. During
the menstrual phase these changes are even marked. Changes
in the fallopian tubes during pregnancy and in the
puerperium include the development of a low mucosa ,
plugging of the capillaries with leukocytes.
As soon as foreign bodies are introduced into the abdominal
cavities may eventually appear in the vagina. After these are
transported through the tubes and the cavity of the uterus.
Tubal peristalsis are important factor in transport of ovum. The
tubes are richly supplied with elastic tissue , blood vessels and
lymphatics. Sympathetic innervations of tubes is extensive.
Their role is poorly understood .
Diverticula may extend from the tube’s lumen into the
muscular wall and reach almost to the serosa. These
diverticula may serve a role of ectopic pregnancy.
 The Ovaries:
The ovaries are almond-shaped organs, functions are the
development and extrusion of ova and the synthesis and
secretion of steroid hormones. The ovaries vary considerable
in size . During childbearing years , they are 2.5-5cm in
length, 1.5-3cm in breadth and 0.6-1.5 cm in thickness. After
menopause, ovarian size diminishes highly. Ovaries are
situated in the upper part of pelvic cavity. They rest on the
lateral wall of the pelvis between the divergent external and
internal iliac vessels.
The ovary is attached to the broad ligament by the
mesovarium. The utero-ovarian ligament extends from the
lateral and posterior portion of the uterus beneath the tubal
insertion to the uterine. It is several santimeters long and 3-
4mm in diameter. It is covered by peritoneum and is made up
of muscle and connective tissue fibers . The suspensory
ligament of the ovary extends from the upper or tubal , pole
to pelvic wall and course the ovarian vessels and nerves.
The exterior surface of ovary varies in appearance with age.
In young women the organ is smooth, with a dull white
surface through which glisten several small, clear follicles.
As the woman grows older , the ovaries become more
corrugated . In elderly women the exterior surfaces may be
convoluted markedly.
The ovary’s general structure is studied best in cross sections
where two portions may be distinguished- the cortex and
medulla. The cortex or outer layer varies in thickness with
age and becomes thinner with years. The ova and graafian
follicles are located in layer. The cortex of the ovary is
composed of spindle-shaped connective tissue cells and fibers
among which are scatterd primordial and graafian follicles
that are in various stages of development. With ages the
follicles become less numerous. The outermost portion of
cortex is dull and within , is designated as the tunica
albuginea. On its surface there is a single layer of cuboidal
epithelium too .
 The medulla or central portion of the ovary is composed
of loose connective tissue that is continuous with the
mesovarium. There are lots of arteries and veins in the
medulla and a small number of smooth muscle fibers
that are continous in the suspensory ligament. The
muscle fibers may be functional in movements of the
ovary.
Both sympathetic and parasympathetic nerves are
supplied to the ovaries. The sympathetic nerves are
derived from ovarian plexus that accompanies the
ovarian vessels. A few are derived from the plexus that
surrounds the ovarian branch of the uterine artery. The
ovary is supplied with nonmyelinated nerve fibers which
for most part accompany the blood vessels.
Development of the Ovary: The developmental changes in
urogenital system have been displayed in ovaries from the
third gestatonal week after conception to maturity. At first
changes in the gonad are the same in both sexes. The earliest
sign of gonad appears on the ventral surface of the embryonic
kidney at a site between the eighth thoracic and fourth lumbar
segments at about 4 weeks . The coelomic epithelim is
thickened and clumps of cells to bud off into the underlying
mesenchyme. This coelomic epitheliumed area often is called
the
germinal epithelium.
By 8 months of gestation the ovary has become a long,
narrow, lobulated structure and is attached to the body wall
along the line of the hilum by the mesovarium in which lies
the epoophoron. At that stage of development , the germinal
epithelium has been separated for the most part from the
cortex by a band of connective tissue (tunica albuginea).
 Microscopical Structure of Ovary: From the first stages of
development until after the menopause, the ovary undergoes
constant change. The number of oocytes at the onset of puterty
has been estimated variously [ at 200,000-400,000] . Because
only one ovum ordinarily is cast off during each ovarin cycle,
a few hundred ova suffice for puroses of reproduction.
In women are distinguished : interstitial, thecal and luteal
cells. The interstitial glandular elements are formed from
cells of the theca interna of degenerating or atretic follicles.
The thecal glandular cells are formed from the theca interna of
ripening follicles. The luteal cells are derived from the
granulose cells of ovulated follicles and from the
undifferentiated stroma that surround them.
There is a gradual decline from a mean of 439.000 oocytes in
girls under 15, to a mean of 34.000 in a women over the age of
36.
In the young girl the portion of the ovary is comprised of the
cortex, which is filled with large number of closely packed
primordial follicles. The central portion of the ovary is at the
most advanced stages of development. In young women the
cortex is relatively thinner but still contains a large number
of primordial follicles .
They are separated by bands of connective tissue cells where
are spindle-shaped or oval nuclei. Each primordial follicle
is comprised of an oocyte and its suurounding single layer of
epithelial cells, which are small and flattened, spindle-shaped
and sharply differentiated from smaller and spindly cells of
the surrounding stroma.
The oocyte is large , spherical cell in which is clear cytoplasm
and a relatively large nucleus . It is located near the center of
the ovum. In the nucleus is one large and several smaller
nucleoli and numerous masses of chromatin. The diameter of
oocytes in the ovaries of adult women averages 33 μm and
that of the nuclei 20 μm
The Normal Pelvis
The Normal Pelvis - is composed of four bones :
-the sacrum;
-the coccyx;
-2 innominate bones ,
which are formed from the fusion of the illium, ishium and
pubis. The innominate bones are joined to the sacrum at the
sacroiliac synchondroses and to one another at the symphysis
pubis. As for Sacrum it consists of 5 vertebrae fused together
to form a single wedge-shaped bone. It articulates laterally
with two iliac bones to form the sacroiliac joints. The sacral
promontory is the first sacral vertebrae and can be palpated
during a vaginal exam. It is important landmark for clinical
pelvimetry.
The Coccyx composed of four vertebrae fused together to form
a small triangular bone articulated with the base of the sacrum .
The Ischial spines are extend from the middle of the posterior
margin of each ischium.
There are four major pelvic shapes: gynecoid; android ;
platypelloid and anthropoid . These shapes are differentiated
based on the measurements of the pelvis. Gynecoid is the ideal
shape for vaginal delivery, having a round to slightly oval
pelvic inlet.
The size and shape of the pelvis are important in obstetrics. In
both women and men the pelvis forms the body ring through
which body weight is transmitted to the lower extremities . In
women it has a special form that adapts it to childbearing.
 Pelvic Anatomy: Obstetrical
Considerations :
The false pelvis lies above the linea terminalis
and the true pelvis below this anatomica
boundary. The false pelvis is bounded posteriorly
by the lumbar vertebrae and laterally by the iliac
fossae.
The true pelvis is important In childbearing. It
is bounded above by the promontory and alae of
the sacrum, the linea terminalis and the upper
margins of the pubic bones and below by the
pelvic outlet. The cavity of the true pelvis can be
described as an obliquely truncated, bent cylinder.
The walls of the true pelvis are partly bony and partly
ligamentous. In form the true pelvis is bounded by the
pubic bones, ascending superior rami of the ischial
bones and the obturator foramina. The sidewalls of the
true pelvis are converged. The ischial spines are of
great obstetrical importance because the distance
between them represents the shortest diameter of the
pelvic cavity . The ischial spines can be felt readily
by vaginal or rectal examination .
The sacrum forms the posterior wall of the pelvic
cavity. Normally the sacrum has a marked vertical and
less pronounced horizontal concavity.
Pelvic inclination: The normal position of
the pelvis in the standing woman , can be
reproduced by holding a skeletal specimen
with the incisures of the acetabula pointing
directly downward.
 Pelvic Joints

Sumphysis Pubis:
Anteriorly the pelvic bones are joined together by the
symphysis pubis. The structure consists of fibrocartilage and
the superior and inferior pubic ligaments; the latter is
frequently designated the arcuate ligament of the pubis . The
symphysis has a certain degree of mobility which increases
during pregnancy.
Sacroilic Joints: Posteriorly the pelvic bones are joined by the
articulations between the sacrum and the iliac portion of the
innominate bones .
Relaxation of the Pelvic Joints: During pregnancy relaxation of
these joints likely results from hormonal changes. Relaxation
of the symphysis pubis commenced in women in the first half
of pregnancy and increased during the last 3 months.
Regression of relaxation began immediately after parturition
and is completed within 3-5 months. During pregnancy
symphsis pubis increases in width and returns to normal soon
after delivery. The increase in the diameter of the pelvic
outlet occurs only if the sacrum is allowed to rotate
posteriorly.
There are four diameters of the pelvic inlet :
1. anteroposterior ; 2. transvers; 3. two obliques.
The anteroposterior diameter of the pelvic inlet is the true
conjugate . The shortest distance is the obstetrical conjugate
through which the head passes going down through the
pelvic inlet.
Normally , the obstetrical conjugate measures 10cm or more,
but may be considerably shortened in abnormal pelvis. The
transverse diameter is constructed at right angles to the
obstetrical conjugate and displays distance between the
linea terminalis on either side.
The obstetrical conjugate cannot be measured directly with
the examining fingers, so various instruments have been
designed for measurement. Measuring the distance from the
lower margin of the symphysis to promontory of the sacrum
is the diagonal conjugate.
 Planes and Diameters of the Pelvis:
The pelvis has four imaginary planes:
1. the plane of the pelvic inlet (superior strait);
2. the plane of the pelvic outlet (inferior strait);
3. the plane of the mid pelvis (least pelvic dimensions);
4. the plane of greatest pelvic dimensions
Pelvic inlet : The pelvic inlet is bounded posteriorly by the
promontory of the sacrum, laterally by the linea terminalis
and anteriorly by the horizontal rami of the pubic bones and
symphysis pubis.
Midpelvis: The midpelvis is of importance following
engagement of the fetal head in obstructed labor. The
interspinous diameter 10cm is the smallest diameter of the
pelvis because it normally measures at least 11.5cm. The
posterior component between the sacrum and the line created
by the interspinous diameter is at least 4.5 cm.
Pelvic Outlet: The outlet of the pelvis consists of two
triangular areas. There is a line drawn between the two
ishial tuberosites. The apex of the posterior triangle is
at the tip of the sacrum. The anterior triangle is formed
by the area under the pubic arch.
 Caldwell -Moloy Classification:
A line drawn through the greatest transverse diameter of the
inlet divides it into anterior and posterior segments. The shapes
of segments are important determinants in classification. The
character of the posterior segment determines the type of
pelvis. Many pelves are mixed types.
Gynecoid Pelvis: With the gynecoid pelvis the posterior sagittal
diameter of the inlet is slightly shorter than the anterior
sagittal. The sides of the posterior segment are well rounded
and wide. The transverse diameter of the inlet is slightly greater.
The anteroposterior diameter of the inlet is slightly oval . The
sidewalls of the pelvis are straight , the spines are not
prominent, the pubic arch is wide and the transverse diameter at
the ischail spines is 10 cm. The sacrosciatic notch is well
rounded and never narrow.
Android Pelvis : With the android pelvis , the posterior sagittal
diameter at the inlet is shorter than the anterior sagittal. The
sides of the posterior segment are not rounded. The anterior
pelvis is narrow and triangular. The sidewalls are
convergent . The ischial spines are prominent and the
subpubic arch is narrowed . The bones are heavy, the
sacrosciatic notches are narrow and highly arched. The
sacrum is set forward in the pelvis and is straight with little
or no curvature. The posterior sagittal diameter is
decreased from inlet to outlet . The extreme android pelvis
presages a poor prognosis for vaginal delivery. When there
is a small android pelvis its increases stillbirth and difficult
forceps operations .
Anthropoid Pelvis is characterized by an anteroposterior
diameter of the inlet greater than the transverse. Anterior
segment is narrow and pointed. The sacrosciatic notches are
large and the sidewalls often are convergent. The sacrum has
6 segments and is straight, making the anthropoid pelvis
deeper. The ischial spines are likely to be prominent . The
subpubic arch is narrowed but well shaped.
Platypelloid Pelvis has a flattened gynecoid shape with a short
anteroposterior and wide transverse diameter. It is situated
in front of the sacrum. The angle of the anterior pelvis is very
wide . The pelvis shallow creating wide sacrosciatic notches .
The sacrum is well curved and rotated backward.
 Pelvic Size and its Clinical Estimation.
Pelvic inlet measurements:
Diagonal Conjugate : In many abnormal pelves the
anteroposterior diameter of the pelvic inlet is considerably
shortened. The measurement can be obtained only by
radiographic techniques. The distance from the sacral
promontory to the lower margin of the symphysis pubis can
be measured clinically. The most important is the diagonal
conjugate measurement . Every obstetrician should be
familiar with the technique of its measurement. To obtain
this measurement the patient is placed upon an examining
table with her knees drawn up and her feet supported by
stirrups. Patient should be brought to the edge of the bed
where a firm pillow should be placed beneath buttocks.
 The examiner introduces / puts two fingers into the vagina.
Before measuring the diagonal conjugate the mobility of the
coccyx is evaluated and the anterior surface of the sacrum is
palpated. The mobility of the coccyx is tested by palpating it
with the fingers in the vagina. Occasionally the mobility of
the coccyx and the anatomical features of the lower sacrum
may be defined by rectal examination. The index and the
second fingers are carried up and over the anterior surface of
the sacrum. By sharply depressing the wrist , the promontory
may be felt by the tip of the second finger as a projecting
bony margin. With the finger closely applied to the upper
sacrum , the vaginal hand is elevated until it contacts the
pubic arch, and the adjacent point of the index finger is
marked. Then hand is withdrawn and the distance between
the mark and the tip of the second finger is measured.
Engagement refers to the descent of the biparietal plane of the
fetal head to a level below that of the pelvic inlet. When
the biparieal or largest diameter of the normally flexed fetal
head has passed through the inlet, the head usually is
regarded as a phenomenon of labor. In nulliparas it occurs
during the last few weeks of pregnancy. With engagement
the fetal head serves as an internal pelvimeter to demonstrate
that the pelvic inlet is ample for that fetus. Whether the
head is engaged may be ascertained / clear up by rectal or
vaginal examination or by abdominal palpation. If the
head is not engaged , the examining fingers can easily
palpate the lower part of the head and will converge .
Fixation of the fetal head prevents its free movement in any
direction. Fixation is not necessarily synonymous with
engagement .
 Pelvic outlet measurements:
An important dimension of the pelvic outlet is the diameter
between the ischial tuberosities , called intertuberous
diameter.
A measurement over 8 cm is considered normal. The
measurement of the transverse diameter of the outlet can be
estimated by placing a closed fist against the perineum
between the ischial tuberosities , after first measuring the
width of the closed fist. Usually the closed fist is wider than
the 8 cm. The shape of the sup-pubic arch can be evaluated
at the same time by palpating the pubic rami from the sub-
pubic region toward the ischial tuberosities.
Medpelvis Estimation: Clinical estimation of midpelvis
capacity by any direct form of measurement is not possible.
If the ischial spines are quite prominent , the sidewalls are
felt to converge and the concavity of the sacrum is shallow.
The midpelvis can be measured precisely only by using
imaging studies.
THE END.