PELVIC MUSCULATURE AND PERINEUM

Objectives
At the end of this topic, you should be able to : 1. Name the muscle that make up the pelvic floor and perineum 2. Describe the muscle of the : - Levator ani muscle - Superficial perineal muscle - Perineum 3. State the functions of the pelvic floor muscle 4. Name the muscles that are cut when performing an episiotomy 5. Describe the changes of the pelvic floor during :- Pregnancy - Labour - pueperium

General description
Pelvic floor : Soft tissue Cover pelvic outlet Strong sheet of muscles Shaped like a hammock Perforated by urethra, vagina and anus

structures
Made up of 2 layers : 1. Deeper layer this is the levator ani muscles 2. Superficial layer this is the outer layer and is called the superficial perineal muscles

Levator ani muscles

The levator ani muscles are a pair of strong muscles about 3.5 mm in thickness. They consist of 3 pairs of muscles namely ; - Pubo-coccygeus - Ilio-coccygeus - Ischio-coccygeus

Pubo-coccygeus
This pair of muscles arise from the pubic bone infront, pass backwards and under the bladder, surround the urethra and vagina in a figure of 8 manner, pass through the perineal body and get inserted into coccyx.

Ilio-coccygeus
This pair of muscles arise from the white line of pelvic fascia on the ilium, then pass downwards and backwards and get inserted into the avo-coccygeal body and the coccyx

Ischio-coccygeus
This part of muscles arise from the ischial spines ( this sheet of muscle lie infront of the sacro-spinous ligament) pass backwards and get into coccyx and sacrum

Summarise
Pelvic floor 2 layers Deeper layer is levator ani Superficial layer is superficial perineal muscles Pubo-coccygeus from pubic bone to coccyx Ilio-coccygeus from the ilium to the coccyx also Ischio-coccygeus from ischial spines to coccyx and sacrum

Assessment
What is pelvic floor? Name the 3 structures that perforate the pelvic floor.? Name the 2 layers of muscles that make up the pelvic floor

Superficial perineal muscles

This muscle lies below the levator ani muscle. They consist of 4 small pairs of muscles. The muscles are : a. External sphincter of the naus b. Transverse perineal muscles c. Bulbo-carvenosus d. Ischio-carvenosus

Superficial perineal muscles

Description
External sphinter of the anus - This muscle surrounds the anus. Some longer fibres get inserted into the perineal body and some get attached to the coccyx - Function of this muscles : assist in the act of defaecation

Cont,
Transverse perineal muscles - They arise from both sides of the ischial tuberosities and meet at the centre of the perineal body Bulbo carvenosus - These muscle arise from the centre points of the perineum, surround the vagina and pass upwards and get inserted into the corpora carvenosa ( body of clitoris )

Cont,
Ischio-carvenosus - The muscles arise from the ischial tuberosities and they pass upwards along the inferior ramii and get inserted into the corpora carvenosa of the clitoris. - The triangular ligament fills the triangular space left behind.

Functions of the pelvic floor

Covers the pelvic outlet Supports the pelvic organs like the uterus, vagina, bladder and rectum Assists in the control of the intra-pelvic pressure during coughing, laughing and starining Assists in the act of defaecation and birth of the baby

Cont,
Blood supply Comes from the pudendal arteries Venous return Venous blood returns to the heart via the pudendal veins Lymphatic drainage - The lymph drains into the inguinal and external iliac glands.

The perineal body

It is a fibre-muscular structure situated between the lowest third of the vagina infront, the anal canal behind and the ischial tuberosity laterally Shape triangular Size 4 cm x 4 cm Function assist the head to rotate forward during the birth process

Muscle of the perineal body

Pubo-coccygeus Bulbo-carenosus Transverse perineal muscles External sphincter of the anus

Cont,
Blood supply to perineal body
- Comes from the pudendal arteries

Venous return
- Returns to the heart via the pudendal veins

Nerve supply - Pudendal nerves

Pelvic floor changes

Pregnancy - The muscle are softerned by the action of hormone relaxine and it allows the uterus to sink down thus creating a situation called lightening. Labour - In the 2nd stage as the baby descends, the pelvic floor muscle parts like a swing whereby the muscles are displaced upwards, backwards and laterally - The perineal body stretches to its full capacity as the mothers bears down to push out the babys head

Cont,
Pueperium - At the end of labour the pelvic floor becomes laxed because it has been stretched during labour and remains so up to the 3rd week of pueperium. It takes 6/52 for the muscle to regain back its tone. - By the end of the pueperium the muscles have regained back its tone but it will not return it to its pregravid tone. - Infection of the perineal wound may result in weakness of the muscles or scar tissue formation, weakness of the muscles may result in prolapse of pelvic organs

Complications that can occur to the pelvic floor

1. Labour a) Loss of muscle tone cause : the mother bears down prematurely or too long resulting in overstreching of the muscles. b) Tears of varying degrees 1 st degree tear ( 1 tear ) ( skin of the fourchetted is torn )

 2 nd degree tear ( 2 ) ( fourchette , perineal skin, perineal muscles,vaginal mucosa and the external anal sphincter are torn ) 3 rd degree tear ( 3 ) ( the fourchette, perineal skin,perineal muscles, vaginal mucosa and the external anal urethral area resulting in profuse bleeding ) c) Lacerations big or small around the clitoris and urethral area resulting in profuse bleeding

Causes of perineal tears

Rapid and sudden expulsion of the babys head Persistent occipito posterior position in which a larger diameter stretches the vagina Big babies Difficult forceps delivery Misapplied perineal support Poor technique in the delivery of the baby Rapid perineum Old scar tissue gave way

Prevention of tears and other injuries

1. Seek medical aid if labour is prolonged 2. Practise correct technique in the delivery of the baby by a) maintaining flexion on the head during crowning to prevent rapid expulsion of the babys head b) Instruct mother to pant when the head is crowned and allow the contraction to slowly expel the head 3. Do a timely episiotomy to enlarge the vaginal orifice 4. Wait till shoulders are in the antero-posterior diameter of outlet before delivering the shoulders. Deliver the anterior shoulder first then the posterior shoulder.

Effects of injuries to the pelvic floor

1. Loss of muscle tone if the lacerated muscle are not repaired 2. Infection will set in 3. Prolapse of pelvic organs due to weakness of the pelvic floor muscles

Changes during pueperium

The falling level of progesterone allows the muscles to regain back its tone This process of recovery is gradual. It is also aided by early ambulation, post partum exercises and avoidance of constipation If there is edema in the tissues of the perineum after the birth of the baby, the excess fluid will be reabsorbed by the third or fourth day of puerperium