O B S T E T R I C S I

TOPIC # 1: Maternal Anatomy

Dr. Ivy Castro- Bello • September 09, 2020 • 1St Semester (Midterms)

LEGEND A. LAYERS OF THE ABDOMINAL WALL

Black:PPT•Blue:BOOK•Red:Audio
a. Skin
OUTLINE
i. Langer lines
I.ANTERIOR ABDOMINAL WALL  Arranged transversely
A. Layers  Dermal fiber within the skin
B. Blood Supply
C. Innervation
II. EXTERNAL GENERATIVE ORGANS
A. Vulva
B. Vagina
C. Perineum
III. PELVIC BONES
A. Divisions
B. Planes
C. Shapes
D. Innervations
IV. INTERNAL GENERATIVE ORGANS
A. Cervix
B. Uterus
C. Ovaries
D. Fallopian Tube
E. Ligaments Figure 2: Incision during Caesarean Section
V. CLINICAL CORRELATIONS
VI. MODULE
 Vertical skin incisions sustain greater lateral
tension and thus, in general develop wider
I: ANTERIOR ABDOMINAL WALL scars.
 Low transverse incisions, such as Pfannenstiel,
 Confines abdominal viscera follow Langer lines and lead to superior
 Stretches to accommodate the expanding uterus cosmetic results. Better cut as cosmetic
 Provides surgical access to the internal reproductive purposes but expensive
organs  Pfannenstiel or “Bikini cut”
 Site of incision during OB surgery
b. Subcutaneous Layer

i. Camper’s Fascia (Fatty Layer)

 “fatty campers”- thicker
 Superficial
 Fatty (Mons pubis & Labia majora)
 Blends with the fat of the ischioanal fossa

ii. Scarpa’s Fascia (Deep Membranous)

 Thinner
 Deeper
 Membranous
 Continues inferiorly onto the perineum as
Colles fascia
FIGURE 1 Transverse sections of anterior abdominal  Perineal infection or hemorrhage superficial to
wall above (A) and below (B) the arcuate line. (From Colles fascia has the ability to extend upward
Corton, 2012, with permission.) to involve the superficial layers of the
Abdominal wall

c. Anterior Abdominal Wall Muscles

 Beneath subcutaneous layer

Page 1 of 26 Transcribers: Agustin, DJ, Agustin, KVJ, Alimboyoguen,R, Aniscal, DS, Anog CJ, Anselmo, M
OBSTETRICS I: Maternal Anatomy

 Consist of the midline RECTUS ABDOMINIS and B. BLOOD SUPPLY OF THE ANTERIOR ABDOMINAL
PYRAMIDAL MUSCLES as well as the WALL
EXTERNAL OBLIQUE, INTERNAL OBLIQUE
and TRANSVERSUS ABDOMINIS MUSCLES
 Extend across the entire wall

d. Primary Fascia
 Formed from the fibrous aponeuroses of these
three latter muscles
 These fuse in the midline at the linea alba, which
normally measures 10-15 mm wide below the
umbilicus
 Abnormally wide separation may reflect distasis or
hernia.
 These three aponeuroses also invest the rectus
abdominis muscle at the rectus sheath
 Construction of this sheath varies above and
below a boundary-termed the arcuate line
 Cephalad to this border, the aponeuroses invest
the rectus abdominis bellies on both dorsal and
ventral surfaces
 Caudal to this line, all aponeuroses lie ventral or
superficial to the rectus abdominis muscle, and
only the thin transversalis fascia and peritoneum
Figure 3 Anterior abdominal wall anatomy.
lie beneath the rectus.
(From Corton, 2012, with permission.)
 Paired small triangular pyramidalis muscles
originate from the pubic crest
a. Femoral Artery Branches
 Supplies the skin and subcutaneous layer of
i. Rectus abdominis
the anterior abdominal wall and mons
pubis (all branches has superficial names in it,
therefore supplying superficial structures)

i. Superior (Superficial) Epigastric

-Of Surgical importance, from their origin,
course diagonally towards the umbilicus. With
a low transverse skin incision, these vessels
can usually be identifies at a depth halfway
between the skin and the anterior rectus
sheath, above scarpa fascia, and several
centimeters from the midline.

ii. Superficial Circumflex Iliac

iii. Superficial External Pudendal Arteries

b. External Iliac Artery Branches

 Supplies the muscles and fascia of the
 Rectus Sheath- fascia; surrounds the rectus anterior abdominal wall
abdominis *middle: LINEA ALBA
 Pyramidalis i. Inferior “deep” Epigastric Vessels
 Obliques -Of clinical relevance, the inferior epigastric
 Internal: upwards vessels initially course laterally to, then
 External: downwards posterior to the rectus abdominis muscles
which they supply.
ii. Transversus abdominis muscles - These vessels then pass ventral to the
 Extends across the entire wall and fuses midline posterior rectus sheath and course between
(Linea alba) the sheath and the rectus muscle. Near the
 Linea alba : white in the midline between rectus umbilicus, these vessels anastomose with the
muscles
Page 2 of 26 Transcribers: Agustin, DJ, Agustin, KVJ, Alimboyoguen, R, Aniscal, S, Anog, CJ, Anselmo, M
OBSTETRICS I: Maternal Anatomy
superior epigastric artery and veins, which are
branches of the internal thoracic vessels.
- When a Maylard Incision is used from cesarean
delivery, the inferior epigastric artery maybe
lacerated to the rectus belly during muscle
transection. These vessels rarely may rapture
following abdominal trauma and create a
rectus sheath hematoma.
ii. Deep Circumflex Iliac Vessels
Figure 4 Blood Supply of the abdominal wall
HESSELBACH’S Triangle)
- Hesselbach triangle is the region bounded laterally
by the inferior epigastric vessels, inferiorly by the
inguinal ligament, medially by the lateral border of the
rectus abdominis muscle
-Importance:
1. Direct Inguinal Hernias- protrude through the
abdominal.
2. Indirect Inguinal Hernias- Do so through the
deep inguinal ring which lies lateral to this triangle, and
then may exit out the superficial inguinal ring.
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C. INNERVATION OF THE ANTERIOR ABDOMINAL
WALL
a. T7 – T11 (Intercostal)
 Anterior rami of the thoracic spinal nerve
b. T12 (Subcostal)
 Anterior rami of the thoracic spinal nerve*
* Intercosal and Subcostal
 Run along lateral and then anterior abdominal
wall between the transversus abdominis
and internal oblique muscles
 The space is termed transversus
abdominus plane
 Near the rectus abdominis lateral borders,
these nerve branches pierce the posterior
sheath, rectus muscle, and then anterior
sheath to reach the skin
 Damage in Pfannensteil incision, where
anterior rectus sheath is separated from
rectus muscle.
c. L1 (Iliohypogastric & Ilioinguinal)
 Last 2 nerves pass 2-3 cm medial to the
Anterior Superior Iliac Spine , the nerves then
pierce the internal oblique muscle and course
superficial to it toward the midline
 From anterior ramus of the lumbar spinal
nerve
 Emerge lateral to the psoas muscle and travel
retroperitoneally across the quadratus
lumborum inferomedially toward the iliac
crest
 Both nerves pierce the transversus abdominis
muscle and course ventrally
 severed during low transverse incision
andentrapped during closure, especially if
incisions extend beyond the lateral borders of
rectus muscle.
 Carry sensory information only and injury
cause loss of sensation in areas supplied.
Chronic pain may developed
 T10 dermatome
- Level of umbilicus
- Regional analgesia (ceasarean
delivery or for puerperal sterilization)
o Blocks T10 through L1 levels
- Transversus abdominis plane
block – broad blockage to nerves that
transverse this plane.
*dermatomal level – very important during operation and
in caesarean we have to block T4 or nipple segment
i. Iliohypogastric
 Suprapubic
 Perforates the external oblique
aponeurosis near the lateral rectus border
Transcribers: Agustin, DJ, Agustin, KVJ, Alimboyoguen, R, Aniscal, S, Anog, CJ, Anselmo, M
OBSTETRICS I: Maternal Anatomy

 Provide sensation to the skin over the  Tip: ends at the clitoris
suprapubic area  In men and some hirsute women, the escutcheon
is not so well circumscribed and extends onto the
ii. Ilioinguinal anterior abdominal wall towards the umbilicus.
 Mons Pubis
 Upper portion of the Labia Majora b. Labia Majora
 Medial upper thigh  Two large, longitudinal folds of adipose and
 Medially travels through the inguinal canal fibrous tissue
and exits through the superficial inguinal  Surface area: 7-8 x 2-3 cm, 1-1.5 cm thick
ring, which forms by splitting of external  Outer convex skin:
abdominal oblique aponeurosis fibers o Pigmented
o Covered with hair follicles
II. EXTERNAL GENERATIVE ORGANS  Inner surface skin:
 Mons pubis o Many sebaceous glands
 Labia majora o NO hair follicles
 Labia minora  Histology :
 Hymen o Sweat glands
 Clitoris o Sebaceous glands
 Bestibule o Apocrine glands – similar to breast and
 Urethra axillary areas
 Skene glands  Superiorly: continuous w/ mons pubis tapers &
 Bartholin glands merge medially at the perineal body = Posterior
 Vestibular glands Commissure
A. VULVA  Round ligaments terminate at its upper borders
 Also known as the pudenda  Abundant apocrine (with hair ie. armpit & groin),
 Receives innervation and vascular support from eccrine (sweat; open directly onto the surface of the
the pudendal nerve skin) and sebaceous glands
 a dense connective tissue layer is nearly void of
muscular elements but is rich in elastic fibers and
fat

c. Labia Minora/Nymphae
 Two small red cutaneous folds that are
situated b/n labia majora and vaginal
orifice.
 More delicate, shorter, and thinner
than L. majora.
 Anteriorly they divide at the clitoris to
form superiorly the Prepuce and
inferiorly the frenulum.
 Histology
o Dense connective tissue
Figure 5: Vulvar structures and subcutaneous layer of the o Erectile tissue and elastic
anterior perineal triangle. Note the continuity of Colles and fibers rather than adipose
Scarpa fasciae. tissue
Inset: Vestibule boundaries and openings onto the o Many sebaceous glands
vestibule. o Less cornified
(From Corton, 2012, with permission.) o NO hair follicles or sweat
glands
a. Mons pubis/ Mons Veneris  Size:
 Fat filled cushion overlying the symphysis pubis o Varied among women of
 ESCUTCHEON reproductive age
 Covered by curly hair after puberty o More prominent in children and
 Inverted triangle postmenstrual women
 For some women not triangular, some extending to  Thin fold of tissue medial to LM (2-
the thigh 10cm in L & 1- 5 cm in W)
 Base: covers upper margin of the symphysis pubis  Homology: Penile urethra and part of the

Page 4 of 26 Transcribers: Agustin, DJ, Agustin, KVJ, Alimboyoguen, R, Aniscal, S, Anog, CJ, Anselmo, M
OBSTETRICS I: Maternal Anatomy

skin in males’ penis M: external hymen

 TRIVIA!  Fossa navicularis
o L. minora and Breasts o Posterior portion of the vestibule between the
- Only areas rich in sebaceous fourchette and the vaginal opening
glands w/o hair follicles o Usually observed only in nulliparas
 No eccrine and apocrine glands o Cut during episiotomy during delivery
either midline or right Mediolateral
d. Hymen  Perforated by SIX opening:
 Membrane covering thickness that surrounds 1. Urethra
the vaginal opening more or less completely 2.Vagina
 Lined by non-keratinized 3.Bartholin gland ducts
stratified squamous epithelium - (Greater Vestibular ducts)
inner and outer layer 4.Skene’s glands (Paraurethral glands)
 Composition:
f. Urethral Opening or Meatus
o Elastic and collagenous
connective tissue  1-1.5cm below the pubic arch & short distance
above vaginal opening but in some, distance
 Pinpoint to admits 1 or 2 fingertips
varies
 Pregnant women: epithelium is thick
 Lower 2/3 of urethra above the anterior vaginal
and rich in glycogen
wall
 After NSD >nodule >hymenal or
myrtiform caruncle
g. Greater Vestibular glands
 Types:
 aka. Bartholin’s glands
- Annular, Separate, Cribriform, Parous
 Major glands ( 0.5-1 cm in diam )
 Can be lacerated during: 1st sexual contact,
tampon use, riding bicycle or horseback riding  Duct = 1.5-2cm long
 Opens hymeneal ring at 5 & 7 o’clock
 Following trauma or infection -Vaginal mass- there
is a Bartholin’s Duct Cyst due to infection or
trauma
 Procedure for reproductive age women:
-Marsupilization thru incision then leaving it open still
for reproductive use usually done
 Excision of cyst- removal of Bartholin’s gland
which is important for mucoid material
e. Vestibule  Duct swells and obstruct
✓ Bartholin cyst
✓ Bartholin abscess
 Lies inferior to the vascular vestibular bulb and
deep to the inferior end of the bulbocavernosus
muscle
 Secrete mucoid material at sexual arousal

h. Minor Vestibular glands

 Shallow glands lined by simple mucin-secreting
epithelium and open along Hart line.

i. Clitoris

 Functionally mature female structure

derived from EMBRYONIC UROGENITAL
MEMBRANE
 Almond shaped area enclosed by Hart line
laterally
 BOUNDARIES (take note this)
P: fourchette
A: clitoral frenulum
L: Hart line
Page 5 of 26 Transcribers: Agustin, DJ, Agustin, KVJ, Alimboyoguen, R, Aniscal, S, Anog, CJ, Anselmo, M
OBSTETRICS I: Maternal Anatomy

 Principal female erogenous organ  Lacks glands

 Homologous to penis  Midportion is attached to pelvis (pelvic bone to
 Covered by stratified squamous epithelium and maintain its shape) by visceral connective tissue
is richly innervated w/c blends into investing fascia of the levator ani,
 Location: beneath the prepuce, above creating the anterior and posterior lateral vaginal
the frenulum and urethra sulci thus giving the vagina an H shape in cross
 Projects downward and inward toward the section
vaginal opening  Extensive venous plexus - follows the course of
 Each crus lies along the inferior surface of arteries
its respective ischiopubic ramus and deep
to the ischiocavernosus muscle
 Parts:
a. Glans - >.5cm diameter, covered with stratified
squamous epithelium, richly innervated.
b.Corpus or body - contains 2 corpora cavernosa
c. Crus-lies along the inferior surface of its
respective ischiopubic ramus deep to the ischiocavernus
muscle

 Blood Supply
o Branches of the internal pudendal artery
a. Deep artery of clitoris
- Supplies the body
b. Dorsal artery of clitoris Figure 6: Vagina and surrounding anatomy. (From
-Supplies the glans & prepuce Corton, 2012, with permission.)
j. Paraurethral glands a. Lymphatics
 Collectively arbulization of glands whose multiple  UPPER 3RD External, Internal and common iliac
ducts open predominantly along the inferior aspect  MIDDLE 3RD Internal iliac nodes
of the urethra.
 LOWER 3RD Inguinal lymph nodes
 Skene’s glands – 2 largest paraurethral gland, lie
 * No vaginal glands; Lubrication is from
distally and near the urethral meatus
transudate from subepithelial capillary plexus
 Homologous to prostate gland (only capillary circulation)
 Urethral diverticulum formation
(obstruction or inflammation)- it is excised
b. Blood Supply
 G-spot. Epicenter for female ejaculation.
 abundant blood supply
B. VAGINA  PROXIMAL: Cervical branch of the uterine
 Musculomembranous tube that extends to the artery and by the vaginal artery
uterus and is interposed lengthwise between the - the latter may variably arise from uterine
bladder and the rectum or inferior vesical artery or directly from the
 ANTERIOR wall: 6-8 cm (shorter) internal iliac artery
 POSTERIOR wall: 7-10cm  POSTERIOR: Middle rectal artery
 Anteriorly separated from the bladder and the  DISTAL: Internal pudendal artery
urethra by a connective tissue: VESICOVAGINAL
SEPTUM
 Posteriorly, between the lower portion of vagina
and rectum similar tissues form the
RECTOVAGINAL SEPTUM
 The upper fourth of the vagina is separated from
the rectum by a rectouterine pouch, also called
the cul- de-sac or pouch of Douglas
 Non keratinized stratified squamous epithelium
and underlying lamina propria
 In premenopausal women
-Lining is thrown to numerous
thin transverse ridges, known as rugae,
lines the anterior and posterior walls
-Rugae contains erectile tissues
Page 6 of 26 Transcribers: Agustin, DJ, Agustin, KVJ, Alimboyoguen, R, Aniscal, S, Anog, CJ, Anselmo, M
OBSTETRICS I: Maternal Anatomy
C. PERINEUM
 Diamond shaped b/n thighs and has
boundaries that mirror those of bony
pelvic outlet.
o Pubic symphysis (anteriorly)
o Ischiopubic rami and ischial
tuberosities(anterolaterally)
o Secrotuberous
ligaments(posterolaterally)
o Coccyx( posteriorly)
 an arbitrary line joining the ischial
tuberosities divides into:
 Anterior: UROGENITALTRIANGLE
 Posterior triangle: ANAL TRIANGLE
 From each side, anastomoses on anterior
and posterior vaginal walls with contralateral
corresponding vessel
 From Internal Iliac which is a branch of
common iliac from aorta
 2 Branches of Internal Iliac:
- Anterior and posterior
* Due to increased vascularity during
pregnancy, vaginal secretions are notably
increased, this may be confused with
amniotic fluid leakage
a. Perineal Body/ Central Tendon of the Perineum
 Fibromuscular mass at midline (2cm tall
and wide and 1.5cm thick)
 Between anterior & posterior triangles
 Serves as the junction for several
structures and provides significant
perineal support.
 Bulbocavernous muscle, superficial
transverse perineal, and external anal
sphincter muscles
 incised by an episiotomy incision and
is torn with second-, third-, and fourth-
degree lacerations.
i. Anterior Triangle
 Bounded by the:
-Pubic Rami: Superiorly
-Laterally: Ischial Tuberosity
-Posteriorly: Transverse Perineal Muscle
 Divided into Superficial and Deep Space by
the perineal membrane
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 This membranous partition is a dense fibrous
sheet that was previously known as the
inferior fascia of the urogenital diaphragm.
 Perineal membrane attachment:
-Laterally: ischiooubic rami
-Medially: to the distal third of the urethra
and vagina
-Posteriorly: perineal body
-Anteriorly: arcuate ligament of the pubis
i. Superficial Space of the Anterior Triangle
 Colles Fascia is the continuation of the scarpa
fascia of the perineum
 Relatively closed compartment and expanding
infection or hematoma within it may bulge yet
remains contained.
 Superficial Pouch: Bartholin’s Glands,
Vestibular glands, clitoral body, crura,
branches of the pudendal vessels and nerve,
and the ischiocavernous, bulbocavernous,
and superficial transverse perineal muscles.
Figure 7: Superficial space of the anterior triangle
and posterior perineal triangle.
 Ischiocavernosus Muscle
 Attaches to :
Inferiorly: Medial aspect of the ischial
tuberosity
Laterally: Ischiopubic ramus
Anteriorly: Clitoral crus
 Maintain clitoral erection (for women) by
compressing the crus to obstruct venous
drainage
 Bulbocavernosus (Bulbospongiosus) Muscle
 Overlies:
- Vestibular bulbs
- Bartholin’s glands
 Attaches to:
-Anteriorly: Body of the clitoris
-Posteriorly: Perineal body
 Constrict the vaginal lumen
Transcribers: Agustin, DJ, Agustin, KVJ, Alimboyoguen, R, Aniscal, S, Anog, CJ, Anselmo, M
OBSTETRICS I: Maternal Anatomy
 Aid release of secretions from Bartholin
glands
 For clitoral erection by compressing the
deep dorsal vein of the clitoris
 Superficial Transverse Perineal Muscle
 Narrow strips of muscle
 Attaches to:
-Laterally: Ischial tuberosities
-Medially: Perineal body
 May contribute to the perineal body if
present
ii. Vestibular Bulbs
 Beneath the bulbocavernosus muscle
 Homologous to corpora spongiosa of the penis
 Almond shaped aggregations of veins are 3-4 cm
long, 1 to 2 cm wide and 0.5 to 1 cm
 The bulbs terminate inferiorly at approximately the
middle of the vaginal opening and extending
upward towards the clitoris.
 Their anterior extensions merge in the midline,
below the clitoral body
 During childbirth, veins in the vestibular bulbs may
be lacerated or even create a vulvar hematoma
enclosed within the superficial space of the
anterior angle
 Deep apex: junction of levator ani and obturator
internus muscle.
 Laterally : obturator internus muscle fascia and
ischial tuberosity
 Inferomedially: anal canal and Sphincter complex
 Superomedially: inferior fascia of the downwardly
sloping levator ani
 Posteriorly: Gluteus maximus muscle and
sacrotuberous ligaments
 Anteriorly: inferior border of the anterior triangle
(Remember these)
iii. Deep Space of the Anterior Triangle
 This space lies deep in the perineal membrane
and extends up into the pelvis
 In contrast to the superficial perineal space,
the deep is continuous superiorly with the
pelvic cavity
 It contains portions of the urethra and vagina,
certain portions of internal pudendal artery
branches, and the compressor urethra and
urethrovaginal sphincter muscles, which
comprise part of the striated urogenital
sphincter complex.
iv. Pelvic Diaphragm
 Important during childbirth during bearing down
and muscles are lacerated
 A broad muscular sling which supports the pelvic
viscera
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 Found deep to the anterior and posterior triangles,
this broad muscular sling provides substantial
support to the pelvic viscera
 Composed of:
 Levator ani
a. Pubococcygeus/ Pubovisceral
Subdivided based on points of insertion and
function:
① Pubovaginalis: insert into the vagina
② Puboperinealis: perineal body
③ Puboanalis muscle: anus
b. Puborectalis muscles
c Iliococcygeus muscles
 Coccygeus muscle
-Vaginal birth conveys significant risk for damage
to the levator ani or to its innervation
(pubovisceral muscle – more commonly)
-Of these muscles, pubovisceral muscle is
commonly damaged
- Evidence supports that these injuries may
predispose women to greater risk of pelvic organ
prolapse or urinary incontinence. For this reason,
current research efforts are aimed at minimizing
these injuries.
c. Posterior Triangle
 Ischioanal fossae- from camper’s fascia (from the
subcutaneous layer)
 Anal canal
 Branches of pudendal nerve
Internal pudendal vessels
 Anal sphincter complex - internal & external anal
sphincter and puborectalis
i. Ischioanal/Ischiorectal Fossae
 Two fat-filled wedge-shaped spaces found on
either side of the anal canal and comprise the bulk
of the posterior triangle
 Each fossa has skin as its superficial base
 Deep apex: formed by the junction of the levator
ani and obturator internus muscle
 Borders:
- Laterally: obturator internus muscle fascia and
ischial tuberosity
Transcribers: Agustin, DJ, Agustin, KVJ, Alimboyoguen, R, Aniscal, S, Anog, CJ, Anselmo, M
OBSTETRICS I: Maternal Anatomy
- Infero-medially: anal canal and sphincter
complex
- Superomedially: inferior fascia of the
downwardly sloping levator ani
- Posteriorly: gluteus maximus muscle and
sacrotuberous ligament
- Anteriorly: inferior border of the anterior
triangle
 Fat provides support to surrounding organs that
allows rectal distention during defecation and
vaginal stretching during delivery
 Injury to vessels in posterior triangle leads to
hematoma formation in ischioanal fossa, and
the potential for large accumulation in these
distensible spaces
 The two fossae communicate dorsally, behind
the anal canal. This can be especially because
an episiotomy infection or hematoma may
extend from one fossa into another
 You can see fats during delivery if the laceration
is deep (fourth degree laceration)
ii. Anal Canal
 Distal continuation of rectum
 Begins at level of levator ani attachment to the
rectum and ends at the anal skin
 4-5 cm length
 Lining:
 Uppermost: Columnar epithelium
 Lowermost: Simple Stratified Squamous
(dentate line)
 At the verge: Keratin, and skin adnexa join the
squamous epithelium
 Inner layer: anal mucosa, the internal anal
sphincter, and an intersphincter space that
contains continuation of the rectum’s smooth
muscle layer
 Outer Layer: Puborectalis muscle as it’s
cephalad component and the external anal
sphincter caudally.
 Anal cushions
 Three highly Vascularized submucosal
arteriovenous plexuses
 Aid in the complete closure of the canal and
fecal continence
 Hemorrhoids: venous engorgement within the
cushions
iii. Anal Sphincter Complex
 Provide fecal continence
 Two sphincters:
 External anal sphincter
 Internal anal sphincter
 Proximate to vagina may be torn during vaginal
delivery and can be repaired
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 Internal Anal Sphincter (IAS)
 Distal continuation of rectal circular smooth
muscle
 For fecal continence and relaxes prior to
defecation
 Supplied by the superior, middle, and inferior
rectal arteries
 Innervation: Pelvic splanchnic nerves
(parasympathetic fibers)
 3-4cm length, distal site overlaps the external
sphincter for 1-2 cm , Intersphincteric groove
and is palpable on digital rectal examination.
 Contributes the bulk of anal canal resting
pressure for fecal continence and relaxes prior
to defecation.
 External Anal Sphincter (EAS)
 Striated muscle ring that:
 Anteriorly: attaches to the perineal body
 Posteriorly: connects to the coccyx via the
anococcygeal ligament
 Innervation: Somatic motor fibers from the
inferior rectal branch of the pudendal nerve.
 Blood Supply: Inferior Rectal Artery which is
a branch of the internal pudendal artery
-Maintains a constant resting contraction to aid
continence, provides additional squeeze
pressure when continence is threatened, yet
relaxes for defecation.
Clinically, the IAS and EAS may be involved in
third to fourth degree lacerations during vaginal
delivery, and reunion of these rings is integral to
defect repair.
 Innervation (PUDENDAL NERVE)
 Anterior rami of S2-4 spinal nerves
 Courses between the piriformis and coccygeus
muscles and exits through the greater sciatic
foramen
 Lies within the Alcock canal (pudendal canal)
 Formed by splitting of the obturator internus
investing fascia
 Pudendal nerve block = ischial spine = landmark
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OBSTETRICS I: Maternal Anatomy

 Pudendal nerve leaves the Alcock canal to enter

the perineum and divides into:
 3 terminal branches:
 Dorsal nerve of the clitoris
- Supply the clitoral glans (runs between
ischiocavernosus muscle and perineal
membrane)
 Perineal nerves
- Runs superficial to the perineal membrane
divides into:
a.Posterior labial branches
- Anterior perineal triangle muscle
b. Muscular branches
- Labial skin
 Inferior Rectal Nerves
- Runs thru the ischioanal fossa
Supplies the:
o External anal sphincter
o Anal mucosa
o Perianal skin

 Internal Pudendal Artery – int.iliac artery

branch
- The major blood supply to the perineum
its branches mirror the divisions of the
pudendal nerve. Figure 10: Sagittal view of the pelvic bones

A. Two Divisions
 True/Smaller Pelvis: Lies below linea terminalis
 False/Greater Pelvis: Lies above linea pelvis

Figure 9: Pudendal nerve and vessels. (From Corton,

2012, with permission.

III. PELVIC BONES

 The pelvis is composed of four bones

 1 SACRUM
 1 COCCYX
 2 INNOMINATE BONES Figure 11: Anteroposterior of a normal female
 Each innominate bone is formed by the fusion of three pelvis.Anteroposterior (AP) and transverse (T)
bones (ILLIUM, ISCHUIM, and PUBIS) diameters of the pelvic inlet.
 Both innominate bones are joined to the sacrum at the
sacroiliac synchondroses and to one another at the
symphysis pubis.

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OBSTETRICS I: Maternal Anatomy

-It is composed and described using specific

landmarks
- 3 Anteroposterior
a. True conjugate: outer symphysis
pubis
b. Obstetrical conjugate – middle
c. Diagonal conjugate – inner and
ONLY clinically measured.

2. Transverse Diameter:
-Is constructed at right angles to the
obstetrical conjugate and and represents the
greatest distance between the linea
terminalis on either side
-It is usually intersects the obstetrical
B. Four Planes of the Pelvis pproximately 5 cm in front of the promontory
and measures approximately 13 cm
 SUPERIOR STRAIT: The plane of the
pelvic inlet
 INFERIOR STRAIT: The plane of the
pelvic outlet
 LEAST PELVIC DIMENSION: The plane
of the midpelvis
 The Plane of the Greatest Pelvis
Dimension: No obstetrical Significance

3. Interspinous Diameter
-Smallest Diameter (10 cm or slightly greater)
-The anteroposterior diameter through the
level of the ischial spines normally
measures at least 11.5 cm

a. Pelvic Inlet
 Also Known as the superior strait, the
superior plane of the true pelvis
 Bounded:
 Posteriorly: Promontory and alae
of the Sacrum
 Laterally: Linea Terminalis
 Anteriorly: Horizontal Pubic
Rami Figure 12: Adult female pelvis demonstrating the
 Symphysis Pubis (memorize interspinous diameter of the midpelvis. The
this) anteroposterior and transverse diameters of the pelvic
 4 diameters of the Pelvic Inlet: inlet are also shown.

1. Anteroposterior diameter: Three Anteroposterior of the Pelvis

-Distance between the sacral promontory and  Transverse diameter
the symphysis pubis  2 Oblique diameters
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OBSTETRICS I: Maternal Anatomy
b. Pelvic Outlet
 Diamond Shaped area if the pelvis
 Also known as the inferior strait
 Consist of two approximately triangular
areas whose boundaries mirror those of the
perineal triangle.
 Three Diameters of the Pelvic Outlet
 Anteroposterior Diameter
 Transverse (Intertuberous)
 Posterior Sagittal
Figure 13: Diameters of the pelvic outlet,
viewed from below.
C. Pelvis Shape
 Caldwell-Moloy Anatomical Classification of
Pelvis
 Based on shape: Looking specifically on the
greatest transverse diameter of the inlet,
anterior and posterior segments
 Aid an understanding of labor mechanisms
 Greatest transverse diameter of the inlet –
anterior & posterior segments
 Used to classify the pelvis as gynecoid,
anthropoid, android, or platypelloid.
 Posterior segment → type of pelvis (Shape)
 Anterior segment → tendency
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 Many pelvis are in shape, border-line types
which contain characteristics of each of these
four parent groups.
 First Term: Posterior Segment
 Second Term: Anterior Segment
 Significance:
- To know the position and axis of
descent of the head in relation to the
pelvic cavity at various levels
- Position of the head may vary
according to the shape of the segment
through which it descends.
Example:
1. Anthropoid-Gynecoid-boreder line type
between the anthropoid and gynecoid type
which is a long wide oval in shape
2. Gynecoid Flat-Normal Pelvis with a flat
tendency at the inlet
3. Anthropoid-Gynecoid or Gynecoid Flat:
Longitudinal narrow oval shape to a
transverse or flat shape
D. Pelvic Visceral Innervation
 The autonomic.portion (majority)is further
divided into sympathethic and parasympathetic
 Sympathetic innervation to pelvic viscera
begins with the superior hypogastric termed
the presacral nerve
 Beginning below the aortic bifurcation and
extending downward retroperitoneally, his
plexus is formed by sympathetic fibers arisng
from spinal T10 throught L2.
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OBSTETRICS I: Maternal Anatomy
 At the level of sacral promontory, this superior
hypogastric plexus divides into the right and
left hypogastric nerve down to pelvis walls
 In contrast, parasympathetic innervation to the
pelvic viiscera derives from neurons at spinal
levels S2 through S4. Their axons exit as part
of the anterior rami of Spinal nerves for those
levels. These combine on each side to form
the pelvic splanchnic nerves,
NERVIERIGENTES.
 Blending of 2 hypogastric nerves (sympathetic)
and 2 pelvic sphlanchnic nerves
(parasympathetic) gives rise to inferior
hypogastric plexus called pelvic plexus.
 This retroperitoneal plaque of nerves lies at S4
and S5 level. From here, fibers of this plexus
accompany internal iliac artery branches to
their respective pelvic viscera. Thus, the
inferior hypogastric plexus divides into 3
plexuses:
1. Vesical plexus – innervates
bladder and middle rectal travels to
rectum.
2. Uterovaginal Plexus
(Frankenhauser plexus) – proximal
fallopian tubes, uterus and upper
vagina.
- composed variably sized
ganglia.
3. Extensions of Inferior
hypogastric plexus- perineum along
the vagina and urethra to innervate
the clitoris and vestibular bulbs.
 Most afferent sensory fibers from the
uterus ascend through the inferioe
hypogastric plexus and enter the spinal
cord via T10 through T12 and L1 spinal
nerves.
 This sensory nerves from the cervix and
upper part of birth canal pass through
the pelvic sphlanchnic nerves to the
second, third and fourth sacral nerves.
Those from the lower portion of the birth
canal pass primarily to the pudental
nerve.
IV. INTERNAL GENERATIVE ORGANS
A. CERVIX
 Fusiform shape
 Upper cervical portion( portio Supravaginalis)
- Begins at internal os, which corresponds to the level
of which the peritoneum is reflected into the
bladder.
 Lower Cervical portion ( Portio Vaginalis)
- Protrudes in vagina
 Open at each end by small apertures- internal and
external cervical ora
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 Nullipara (before childbirth): Small, regular and
oval opening (A)
 Parous: slit-like (B)
 After labor ( Vaginal birth)
- Orifice is converted into transverse slit:
a. Anterior transverse slit
b. posterior transverse slit
 In some instances, multipara women (G3) have
inverted cervix
a. Ectocervix
 NKSS; portion of the cervix exterior to the external
os
b. Endocervix
 simple columnar
 SCJ: mc site of malignancy
 Cervical stroma
 Composed mainly of collagen, elastin, and
proteoglycans, but very little smooth muscle
 Chadwick bluish discoloration
 Increased vascularity during pregnancy as seen
using Speculum
 Goodell softening of the cervix (edema)
 During pregnancy (cervix is firm if the woman is not
pregnant)
 Hegar
 Isthmic softening; part of uterus
 Eversion Eversion
 during pregnancy, the endocervical epithelium
moves out to the ectocervix (physiological process)
B. UTERUS
 Pear shaped organ
 Two major but unequal parts:
o Upper, triangular
-the body or corpus
o Lower, cylindrical
- the cervix, w/c projects to vagina
 nonpregnant uterus
o pelvic cavity – b/n the bladder(anterior)
and rectum(posterior).
o Lower perineum – forms the boundary of
the rectouterinecul-de-sac or puch of
Douglas
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OBSTETRICS I: Maternal Anatomy

b. Uterine Cornu
 Superolateral margin of the body
From w/c fallopian tube emerges
 Origins of the round and uteroovarian ligaments
 During tubal ligation look for the fimbriae at the
edge because the round ligament does not have
fimbriae

Figure 14: Anterior (A), right lateral (B), and c. Fundus

posterior (C) views of the uterus of an adult woman. a =  Convex upper uterine segment between the
fallopian tube; b = round ligament; c = uteroovarian fallopian tube insertion
ligament; Ur = ureter.
 Vesicouterine space- lower anterior uterine wall is d. Muscle
united to the posterior wall of the bladder by a well
defined loose connective tissue.  Bulk of uterine body not cervix
Clinically:
e. INNER SURFACES OF THE ANTERIOR &
During ceasarean section. POSTERIOR WALLS
1. the peritoneum of the vesicouterine pouch is  Almost in contact
sharply incised
 Cavity forms a mere slit
2. Vesicouterine space is entered. – so we can
pushed down the bladder and prevent injury.
* **In pregnancy – remarkable uterine growth due to
muscle hypertrophy
Table 1: Comparison of Nulliparous and Multiparous  Uterine fundus – flat convex to dome shaped
Uterus  Round ligaments – insert at the junction of the
NULLIPAROUS MULTIPAROUS middle and upper thirds of the organ.
Size(l) 6- 8 cm 9-10cm  Fallopian tube – elongates
Weight 60 g ≥80 g  Ovaries – no change
Relationship Corpus = Cervix Corpus = 1/3 of
cervix

i. Myometrium
a. Isthmus  Most of uterus
 Union site of the two parts lower uterine segment  muscle bundles united by connective tissue
during pregnancy Uterine cornu(horn) – fallopian with elastic fibers
tube emerges  Interlacing muscle fibers surrounding
 Forms the lower uterine segment during pregnancy myometrial vessels ( vessels are ligated
 Boundaries: (Nonpregnant uterus) to prevent profuse bleeding)
 Sit in the pelvic cavity  integral to homeostais at the placental site during
 Anteriorly: Bladder the 3rd stage of labor (Placental Delivery)
 Posteriorly: Rectum  Responsible for contraction of uterus
 Visceral peritoneum – Serosa  Muscles fibers varies by location and diminish
 almost covers the posterior wall of the uterus caudally – cervix 10% of tissue mass
 Anterior boundary of rectouterine cul-de-sac/  Uterine body inner wall has more muscle than
Pouch of Douglas outer layers
 Formed from lower portion of peritoneum of  More muscle in lateral walls than anterior
post vaginal wall posterior walls.
 During pregnancy, upper myometrium
undergoes marked hypertrophy but no
significant change in cervical muscle content

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OBSTETRICS I: Maternal Anatomy
Figure 15: Smooth muscle fibers of the
myometrium compress traversing blood vessels when
contracted
ii.Endometrium
 Lines the uterine cavity, an overlying epithelium
with invaginating glands and vascular stroma
 Varies greatly throughout the menstrual cycle &
pregnancy and divided into:
- Functionalis Layer - sloughs off w/
menses
- Basalis Layer - regenerates following
menses
 Lymphatic Supply
- Endometrium is largely supplied with
lymphatic vessels that are largely to the
basalis layer
- The lymphatics of underlying endometrium
are increased in no. in serosal surface and
form an abundant lymphatic plexus just
beneath it.
*Lymphatic from the cervix – terminates at
internal iliac nodes, situated near
bifurcation of common iliac vessels
- Lymphatic from the uterine corpus
i. Drains in internal iliac nodes
ii. Other set after certain lymphatics from
ovarian region, ends in paraaortic
lymph nodes
 BLOOD SUPPLY
Page 15 of 26
 Principally from the uterine and ovarian arteries
 Internal Iliac Artery branches
1. UTERINE ARTERY
 Main branch of the internal iliac artery
 hypogastric artery
 Approximately 2 cm lateral to cervix
Figure 17: Pelvic arteries. (From Corton, 2012,
with permission.)
 Uterine artery crosses over the ureter
 Ureter may be injured or ligated during hysterectomy
 At the cervix divides into:
1. Smaller CERVICOVAGINAL ARTERY
 Supplies lower cervix & upper vagina
 Main branch penetrates the body of the uterus
forming the:
- Arcuate arteries at right angles
- Radial branches traverse inward through the
myometrium, entering the endometrium w/c
becomes:
iia. Basal arteries (STRAIGHT)
- basalis layer, does not respond to hormones
iib. Coiled spiral arteries
- supply functionalis layer and respond by
vasoconstriction and vasodilation;
- important role in menstruation
Transcribers: Agustin, DJ, Agustin, KVJ, Alimboyoguen, R, Aniscal, S, Anog, CJ, Anselmo, M
OBSTETRICS I: Maternal Anatomy

 Uterine artery pierces the uterus: a > Arcuate a. > b. Posterior Division
radial a. > basal or straight > Spiral (coiled) - extend to buttock and thigh and include the
 Encircling the organ by coursing w/in the superior gluteal, lateral sacral, and iliolumbar
myometrium beneath the serosa arteries.
 From each side anastomose at the uterine midline (you take note the 2 divisions)
branch of considerable size extends into the upper
portion
 Before the main uterine artery reaches the fallopian
tube, it divides to three terminal branches.

1. Ovarian branch of UA
 forms an anastomosis w/ terminal branch of
Ovarian Artery
 Supplies the ovaries

2. Tubal branch
 Mesosalpinx
 Supplying part of fallopian tube

3. Fundal branch
 Penetrates the uppermost uterus
  UTERUS – LYMPHATIC DRAINAGE

1. Myometrium
- Lymphatic Plexus
2. Cervix
- Internal Iliac Nodes
3. Body of the Uterus
- Internal Iliac Nodes
- Para-Aortic Nodes

 UTERUS – INNERVATION

-Sympathetic: Uterovaginal Plexus

Uterus Bladder
Of Frankenhauser
Upper vagina
Uterus – Venous Drainage - -Sensory – T11 to T12
Cervix Upper birth
 Uterine veins accompany their respective arteries -Sensory – S2 to S4
canal
 Arcuate veins unite forming uterine vein>Internal Lower birth canal -PUDENDAL NERVE
iliac vein> Common iliac vein
 Enters broad ligament through the
infundibulopelvic ligament, these veins form the  Pelvic visceral innervation is predominantly
large pampiniform plexus that terminates in the autonomic
ovarian vein  Autonomic portion is divided into sympathetic and
 Right ovarian vein> to vena cava parasympathetic
 Left ovarian vein>left renal vein  Sympathetic innervation to pelvic viscera
 Blood supply to the pelvis is predominantly supplied  Superior hypogastric plexus or presacral nerve -
from the branches of the internal iliac artery into from T10- L2.
 Parasympathetic innervation to the pelvic viscera
a. Anterior Division (S2 - S4)
- provides blood supply to pelvic organs  Blending the two hypogastric nerves (sympathetic)
and pelvic splanchnic nerves (parasympathetic)
and perineum and includes the inferior gluteal,
gives rise to the INFERIOR HYPOGASTRIC
internal pudental, middle rectal, vaginal, uterine
PLEXUS / PELVIC PLEXUS
and obturator arteries, as well as the umbilical
artery and its continuation as the superior vesical
artery.

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OBSTETRICS I: Maternal Anatomy

with ovarian vessels and originates in renal

C. OVARIES plexus.
 Rests at the ovarian fossa of Waldeyer.  Others from plexus that surrounds the ovarian
 Usually lie in the upper part of the pelvic cavity branch of the uterine artery.
and rest in a slight depression on the lateral wall of  Parasympathetic – vagus nerve
the pelvis -sensory afferents follow the ovarian artery and
enter T10 spinal cord
 Varies in size & position
 Childbearing years d. Ovarian artery
 Length: 2.5- 5 cm - Direct branch of aorta and enters the broad
 Breadth: 1.5-3 cm in breadth ligament through the infundibulopelvic ligament
 Thickness: 0.6-.5 cm - At the ovarian hilum, it divides into smallerbranches
 Between external and internal iliac vessels that enter the ovary
 Uteroovarian ligament originates from the lateral and - Its main stem, however transverses the netire
upper posterior portion of the uterus length of the broad ligament makes its way to
 3-4 mm in diameter uterine cornu
 Covered by peritoneum, Mesovarium - At uterine cornu, it forms an anastomosis with the
ovarian branch of the uterine artery

- Before menopause a normal ovary may be up to 5

cm in length
- Small physiologic cyst: 6- 7 cm
- Normal atrophic postmenopausal ovary: cant be
palpated
- Ovaries and surrounding peritoneum are not devoid
of pain and pressure receptors
- Not usual for women during routine pelvic
examination experience discomfort when normal
deliveries are palpated.

 Ovarian denervation operation

a. Cortex - Made to alleviate chronic pelvic pain
 Outermost portion - smooth dull white surface = - High incidence of cystic degeneration causing
TUNICA ALBUGINEA interruption of blood supply
 Beneath the epithelium are oocytes & developing
follicle  Ovary, ovarina fossa and ureter
- Close proximity: Emphasized in surgery; treat
severe endometriosis or PID (Pelvic Inflammatory
b. Medulla
disease) Identify the course of ureter in ureteral
 Central portion injury.
 Composed of loose connective tissue
 Arteries and veins and a number of smooth muscle D. FALLOPIAN TUBES / OVIDUCTS
fibers - Serpentine Tubes extend laterally 8-14cm from
uterine cornua.
- Supplied richly with elastic tissue, blood vessels,
lypmhatics
- Sympathetic innervation is extensive in contrast to
parasympathetic innervation
- Nerve supply are from ovarian plexus and
uterovaginal plexus
- Sensory afferent fibers ascent to T10 spinal cord
level.

c. Nerve Supply
 Parasympathetic and sympathetic nerves
 Sympathethic – from ovarian plexus accompanies
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OBSTETRICS I: Maternal Anatomy
Figure 18: The fallopian tube of an adult woman with
cross sectioned illustrations of the gross structure in
several portions: (A) isthmus, (B) ampulla, and (C)
infundibulum. Below these are photographs of
corresponding histological sections. (Photographs
contributed by Dr. Kelley S. Carrick.)
 Parts:
> Interstitial portion
-most proximal and embodied in uterine wall
> Isthmus
- narrow 2-3mm adjoins the uterus and widens
gradually
- Narrowest and Rupture of most Ectopic
>Ampulla
- 5-8mm
- occupied almost completely by arborescent
mucosa
- Longest and Ectopic pregnancy usually occurs
> Infundibulum
-Funnel shaped fimbriated end opens to
abdomen
- Ciliated cells - most abundant at fimbriated
- Tubal cilia - direction of flow is toward the
uterine cavity
 Tubal peristalsis = important factor in ovum
transport
 If peristalsis is not good, ectopic
pregnancy may happen
 In cross section, the extrauterine
fallopian tube contains a mesosalpinx,
myosalpinx, and endosalpinx.
 Nerve supply derives partly from the
ovarian plexus and partly from the
uterovaginal plexus
 Sensory afferent fibers ascend to T10
spinal cord levels
Clinical Correlation:
 Majority of ectopic pregnancy occurs in ampulla
(70%).
 The most catastrophic bleeding associated with
ectopic pregnancy occurs with the implantation
site is in the intramural ( interstitial) segment of
the tube
 ISTHMUS – preferred site to apply an occlusive
device, such as clip for female sterilization
because it’s the narrowest part.
Page 18 of 26
 Right oviduct and appendix are soft adjacent
 Wide mesosalpinx of the ampullary segment of
the tube allows torsionof tube which result to
ISCHEMIC ATROPHY of the ampullary segment.
 Paratubal or paraovarian cyst can reach 5 to 10
cm in and occasiomally are confused with ivarian
cyst before surgery
E. LIGAMENTS
 Female reproductive ligament are series of
structures that support the internal female
genitalia in the pelvis.
 Despite their sppellation, the round and broad
ligamentsprovide no substantial uterine
support, whch contrast with the cardinal and
utersacral ligament.
a .Round Ligament
 Composed of smooth muscle bundles
separated by fibrous tissues septa. (3-5cm)
 Can be source of pain during pregnancy due
to increased force of ligament by expanding
uterus
 Homologous to male gubernaculum testis
 From lat. portion of the uterus and support
uterus a little
 Below and anterior to origin of FT (fallopian
tube)
 Landmark during ligation or sterilization
 Important surgical landmark in making the
initial incision into the parietal peritoneum to
gain access to the retroperitoneal space.
 Direct visualization of the retroperitoneal
course of the ureter is an important step in
many pelvic operations, includind dissections
in women with endometriosis. Pelvic
inflammatory disease. Large adnexal
masses and pelvic malignancies.
 mportant of pelvic adhesions limit tubal
mobility and thus, hinder fimbria visualization
and tubal confirmation prior to ligation
 Each round ligament extends laterally &
downward to inguinal canal terminating in
upper portion of labium majora
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OBSTETRICS I: Maternal Anatomy

-Aid in fallopian tube ID during sterilization  Hysterectomy : need sturdy clmapps

especially if w/ pelvic adhesions and suture for transection and
-SAMPSON ARTERY branch of the ligation
uterine artery, runs within this ligament
* Ligated to prevent L. majora o Parametrium
hematoma - connective tissue adjacent and lateral
to the uterus w/in the broad ligament
b. Broad Ligament o Paracervical
- tissues are those adjacent to the cervix
o Paracolpium
- tissues lateral to the vaginal walls

d. Uterosacral
 From posterolateral to supravaginal portion of
cervix and inserts into the fascia over the sacrum
 Composed of connective tissue,small bundles of
vessels & nerves, and some smooth muscle
 Forms the lateral boundaries of the pouch of
Douglas


 2 wing-like structures (of uterus on both sides)
that extend from the lateral uterine margins to
the pelvic sidewalls
1. Mesosalpinx - Fallopian tube
2. Mesoteres - Round ligament
3. Mesovarium - Ovarian ligament
 Ovarian vascular pedicle
 Increase to 0.9- 2.6cm during pregnancy
 Important anatomic and where the following
can be found:Oviducts, ovarian and round
ligaments e. Infundibulopelvic ligament/Suspensory Ligament Of
The Ovary
 Ureters; ovarian and uterine arteries
and vein; parametral tissue
 Peritoneum that extends beneath the fimbriated end of
 Embryonic remnants of the
the fallopian tube toward the pelvic side wall
mesonephric duct
 Contains nerves and ovarian vessels esp venous
 Secondary two ligaments;
plexus, w/c enlarges during pregnancy (0.9 cm to 2.6
mesovarium and mesosalpinx
cm at term)
c. Cardinal Ligament

 Transverse cervical ligament/

Mackenrodt
 Thick base of the broad ligament
 MAJOR support of cervix and uterus
 Anchors medially to the uterus and
upper vagina
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OBSTETRICS I: Maternal Anatomy
Reference: Cunninghamm F. (2018). Williams obstetrics.
New York: McGraw-Hill Medical 25th Edition
V: CLINICAL CORRELATIONS
A. External Genitalia
 The skin of the vulvar region is subject to both
local and general dermatologic conditions. The
intertriginous areas of the vulva remain moist, and
obese women are particularly susceptible to
chronic infection.
 The vulvar skin of a postmenopausal woman is
sensitive to topical cortisone and testosterone but
insensitive to topical estrogen.
a. Bartholin Duct
i. Bartholin Duct Cyst
- The most common large cystic structure
of the vulva.
- May become painful if the cyst develops
into an acute abscess.
- Chronic infections of the periurethral
glands may result in one or more urethral
diverticula. The most common symptoms
of a urethral diverticulum are similar to the
symptoms of a lower urinary tract
infection: urinary frequency, urgency, and
dysuria.
 Vulvar trauma such as straddle injuries frequently
results in large hematomas or profuse external
Page 20 of 26
hemorrhage. The richness of the vascular supply
and the absence of valves in vulvar veins
contribute to this complication.
 The abundant vascularity of the region promotes
rapid healing, with an associated low incidence of
wound infection in episiotomies or obstetric tears
of the vulva.
 The subcutaneous fatty tissue of the labia majora
and mons pubis are in continuity with the fatty
tissue of the anterior abdominal wall. Infections in
this space such as cellulites and necrotizing
fasciitis are poorly contained and may extend
cephalad in rapid fashion.
B. Internal Genitalia
a. Vagina
 Colpectomy, colporrhaphy, and colposcopy
are derived from kolpos (fold), the Greek
word for the vagina, or hysterectomy (Greek)
versus uterus (Latin).
 Clinicians should consider the H shape of the
vagina when they insert a speculum and
inspect the walls of the vagina.
 The posterior fornix is an important surgical
landmark, because it provides direct access
to the cul-de-sac of Douglas. The distal
course of the ureter is an essential
consideration in vaginal surgery.
 Ureteral injury can result from vaginally
placed sutures to obtain hemostasis with
vaginal lacerations. The anatomic proximity
and interrelationships of the vascular and
lymphatic networks of the bladder and vagina
are such that inflammation of one organ can
produce symptoms in the other.
i. Vaginitis
- Sometimes produces urinary tract
symptoms such as frequency and
dysuria.
ii. Gartner Duct CYST
- A cystic dilation of the embryonic
mesonephros is usually present on the
lateral wall of the vagina. However, in
the lower third of the vagina these cysts
are present anteriorly and may be
difficult to distinguish from a large
urethral diverticulum.
iii.Vaginal Vault Prolapse
- The anatomic relationship between the
long axis of the vagina and other pelvic
organs may be altered by pelvic
relaxation resulting primarily from the
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OBSTETRICS I: Maternal Anatomy

trauma of childbirth. Atrophy or an ectropion. This is a normal finding,

weakness of the endopelvic fascia and especially during pregnancy.
muscles surrounding the vagina may  As a woman ages, the transformation
result in the development of a cystocele, zone migrates higher up the
rectocele, or enterocele, all possibly endocervical canal.
contributing to a vaginal vault prolapse.
- One operations for vaginal vault ii. Endocervix
prolapse is fixation of the vaginal apex to  rich in free nerve endings.
the sacrospinous ligament. A rare
 Women experience a vasovagal
complication of this operation is massive
response during transcervical
hemorrhage, usually from the arterial or
instrumentation of the uterine cavity.
venous branches of the inferior gluteal
 Serial cardiac monitoring during
or pudendal vasculature.
insertion of intrauterine devices
- Vaginal lubrication occurs from a
demonstrates a reflex bradycardia in
transudate produced by engorgement of
some women.
the vascular plexuses that encircle the
vagina. This richness of vascularization iii. Exocervix
allows many drugs to readily enter the
systemic circulation when placed in the  The sensory innervation of the
vagina. Medications that are absorbed exocervix is not as concentrated or
vaginally go directly into the systemic sophisticated as that of the endocervix
circulation, bypassing the liver and its or external skin. Therefore usually the
metabolism on the first round through exocervix may be cauterized by either
the circulation. cold or heat without major discomfort
to the patient.
b. Cervix
 The major arterial supply to the cervix is iv. Lymph Mapping
located on the lateral cervical walls at the 3  Similar to other disease sites, sentinel
and 9 o’clock positions, respectively. lymph node (SLN) mapping and biopsy
Therefore a deep figure-of-eight suture for cervical cancer is replacing the
through the vaginal mucosa and cervical more traditional full
stroma at 3 and 9 o’clock helps to reduce lymphadenectomies in favor of fewer
blood loss during procedures such as cone complications, specifically
biopsy. lymphedema. Sentinel lymph node
 If the gynecologist is overzealous in placing mapping in cervical cancer was first
such a hemostatic suture high in the vaginal described in 1999 by Echt and
fornix, it is possible to compromise the course coworkers when they injected 13
of the distal ureter just before it enters the patients who had early stage cervical
bladder. cancer with a blue dye, lymphazurin,
and identified SLNs in 15% (Echt,
i.Transformation Zone 1999). This technique has been refined
 An important anatomic landmark for over the years and is now performed
clinicians. using near-infrared fluorescence
 Encompasses the transition from imaging and indocyanine green (ICG)
stratified squamous epithelium to with detection of SLNs in 85% to 90%
columnar epithelium. of cases.
 Most cervical dysplasia develops within
this transformation zone.
 The position of a woman’s
transformation zone, in relation to the
long axis of the cervix, depends on her
age and hormonal status.
 When the female is young the
transformation zone is located further
out on the cervical portio: this is called

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OBSTETRICS I: Maternal Anatomy
c. Uterus
i. Hysterectomy
-Removal of the uterus which is
derived from the Greek word hystera,
meaning womb.
ii. Primary Dysmenorrhea
- Symptoms are treated successfully in
most women by prostaglandin
synthetase inhibition. Usually a
woman’s pain is controlled by oral
medication. However, it is possible to
alleviate uterine pain by cutting the
sensory nerves that accompany the
sympathetic nerves. This operation is
termed a presacral neurectomy. During
the operation, the gynecologist must
be careful to avoid injuring the ureters
and also careful to control hemorrhage
from vessels in the retroperitoneal
space.
iii. Position of the Fundus
- In some women the uterus is
anteflexed or anteverted, whereas in
others the normal position is retroflexed
or retroverted. In the 1930s and 1940s,
a retroflexed uterus was believed to be
one of the primary causes of pelvic pain.
- To alleviate this condition, many
women underwent an anterior uterine
suspension. Modern gynecologists have
abandoned the suspension operation as
a treatment for pelvic pain.
iv. Arterial Blood Supply
- enters the uterus on its lateral
margins. This relationship allows
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morcellation of an enlarged uterus to
facilitate removal of multiple myomas
without appreciably increasing blood
loss during vaginal hysterectomy.
v. Methods of Transcervical Female
Sterilization
- designed to occlude the tubal ostia at
the uterine cornua
- effective and commonly used.
- Prior to the application of this
method, procedures that blindly
injected caustic solutions into the
uterine cornua had a high failure rate.
Individual differences in the size and
shape of the uterine cavity and
muscular spasm of this region are the
primary reasons that sufficient
amounts of the caustic chemicals did
not reach the fallopian tubes in up to
20% of patients.
vi. Lymph Mapping
- Similar to the lymphatic drainage of
the cervix, the lymphatic drainage of
the uterus has also been studied.
Sentinel lymph nodes can also be
found on either side of the
pelvis/paraaortic areas in 85% to
90% of cases using near-infrared
fluorescence imaging and
indocyanine green (ICG)
d. Oviducts
i. Ectopic Pregnancy
-The majority of ectopic pregnancies
occur in the oviduct.
-The acute abdominal and pelvic pain
that women with an ectopic pregnancy
experience is believed to be caused by
hemorrhage.
-The most catastrophic bleeding
associated with ectopic pregnancy
occurs when the implantation site is in
the intramural segment of the tube.
-The isthmic segment of the oviduct is
the preferred site to apply an occlusive
device, such as a clip, for female
sterilization.
-The right oviduct and appendix are
often adjacent. Clinically it may be
difficult to differentiate inflammation of
the tube from acute appendicitis.
OBSTETRICS I: Maternal Anatomy
ii. Accessory Tubal Ostia
- Discovered frequently and always
connect with the lumen of the tube.
- These accessory ostia are usually
found in the ampullary portion of the
tube.
- The wide mesosalpinx of the ampullary
segment of the tube allows torsion of
the tube, which occasionally results in
ischemic atrophy of the ampullary
segment.
iii. Paratubal Or Paraovarian Cysts
- Can reach 5 to 10 cm in diameter and
occasionally are confused with ovarian
cysts before surgery.
iv. Obstruction
- Although a definitive anatomic
sphincter has not been identified at the
uterotubal junction, a temporary
physiologic obstruction has been
identified during
hysterosalpingography.
- Sometimes clinicians may alleviate this
temporary obstruction by giving the
patient intravenous sedation, a ligaments.
paracervical block, or intravenous
glucagon.
e. Ovaries
i. Size
- The size of the “normal” ovary during
the reproductive years and the
postmenopausal period is important in
clinical practice.
- Before menopause a normal ovary
may be up to 5 cm in length. Thus a
small physiologic cyst may cause an
ovary to be 6 to 7 cm in diameter.
- In contrast, the normal atrophic
postmenopausal ovary usually cannot
be palpated during pelvic examination.
It is important to emphasize that the
ovaries and surrounding peritoneum
are not devoid of pain and pressure
receptors. Therefore it is not unusual
for a woman during a routine pelvic
examination to experience discomfort
when normal ovaries are palpated
bimanually.
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ii. Operations/Surgery
- Attempts have been made to alleviate
chronic pelvic pain by performing an
ovarian denervation operation by
cutting and ligating the
infundibulopelvic ligaments. This
operation has been abandoned
because of the high incidence of cystic
degeneration of the ovaries, which
resulted from the interruption of their
primary blood supply that was
associated with the neurectomy
procedure.
- Prophylactic oophorectomy is
performed at the time of pelvic
operations in many peri- and
postmenopausal women. Sometimes
bilateral oophorectomy is technically
more difficult when associated with a
vaginal procedure in contrast to an
abdominal or laparoscopic
hysterectomy.
- Vaginal removal of the ovaries may be
facilitated by identifying the anatomic
landmarks, similar to the abdominal
approach, and separately clamping the
round ligaments and infundibulopelvic
C. External iliac artery and its branches
- Do not supply blood directly to the pelvic
viscera, an important landmark for
surgical anatomy.
- Gives rise to the obturator artery in 15%
to 20% of women.
- Also gives rise to the inferior epigastric
artery. (inferior epigastric artery should be
avoided when performing laparoscopic
operative procedures)
- Obese women are particularly susceptible
to chronic infection of vulva, the vulvar
skin of a postmenopausal woman is
sensitive to topical cortisone and
testosterone but insensitive to topical
estrogen. The most common large cystic
structure of the vulva is a Bartholin duct
cyst. This condition may become painful if
the cyst develops into an acute abscess.
D. Pelvic lymphatics
- Is important for the gynecologic oncologist
who is surgically determining the extent of
spread of a pelvic malignancy.
a. Pelvic hemorrhage
- A venous bleeding, is the most acute
complication of a lymph node dissection.
OBSTETRICS I: Maternal Anatomy
b. Profuse hemorrhage
- Causes hypogastric artery ligation in
female. Because of the extensive
collateral circulation, this operation does
not produce hypoxia of the pelvic viscera
but reduces hemorrhage by decreasing
the arterial pulse pressure.
c. Intractable pelvic hemorrhage
- It is necessary to supplement the effects
of bilateral hypogastric artery ligation.
Ligation of the terminal end of the ovarian
artery (utero-ovarian ligament) preserves
the direct blood supply to the ovaries and
minimizes the fear of subsequent cystic
degeneration of the ovaries that may
occur after ligation of the vessels in the
infundibulopelvic ligaments.
d. Congenital arteriovenous (A-V)
- A rare condition of malformation in the
female pelvis. Most of these are treated
with preoperative embolism and
subsequent operative ligation. One of the
treatments for repetitive embolization
arising from thrombosis is the placement
of a vascular umbrella into the inferior
vena cava. Collateral circulation exists
between the portal venous system of the
gastrointestinal tract and the systemic
venous circulation through anastomosis in
the pelvis, especially in the hemorrhoidal
plexus.
E. Posterior fibers of the levator ani muscles
- Encircle the rectum at its junction with the
anal canal, thereby producing an abrupt
angle that reinforces fecal continence.
a. Surgical repair of a displacement or
tear of the rectovaginal fascia and
levator ani muscles
- Resulting from childbirth is important
during posterior colporrhaphy.
- Vaginal delivery sometimes results in
dysfunction of the anal sphincter.
b. Round ligament
- An important surgical landmark in making
the initial incision into the parietal
peritoneum to gain access to the
retroperitoneal space.
- A cyst of the Nuck canal may be confused
with an indirect inguinal hernia.
c. During Pelvic surgery
- Traction on the uterus makes the
uterosacral and cardinal ligaments more
prominent. There is a free space
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approximately 2 to 4 cm below the
superior edge of the broad ligament. In
this free space there are no blood
vessels, and the two sides of the broad
ligament are in close proximity.
- Gynecologic surgeons utilize this area to
facilitate clamping of the anastomosis
between the uterine and ovarian arteries.
F. During abdominal hysterectomy
- Femoral nerve may be compromised by
pressure from the lateral blade of a self-
retaining retractor in the area adjacent to
where the femoral nerve penetrates the
psoas muscle.
a. During vaginal surgery
- Femoral nerve may be injured from
exaggerated hyperflexion of the legs in
the lithotomy position, because
hyperflexion produces stretching and
compression of the femoral nerve as it
coursesunder the inguinal ligament.
- (Because of the low density of nerve
endings in the upper two thirds of the
vagina, women are sometimes unable to
determine the presence of a foreign body
in this area. This explains how a
“forgotten tampon” may remain unnoticed
for several days in the upper part of the
vagina until its presence results in a
symptomatic discharge, abnormal
bleeding, or odor.)
b. Fallopian tube
- One of the most sensitive of the pelvic
organs when crushed, cut, or distended, a
fact that is appreciated in performing tubal
ligations with the patient under local
anesthesia.
c. Anatomic proximity of the ureters,
urinary bladder, and rectum to the
female reproductive organs
- Is a major consideration in most
gynecologic operations.
*Two of the classic ways to differentiate a
ureter from a pelvic vessel
- Visualization of peristalsis after stimulation
by a surgical instrument and
- visualization of Auerbach plexuses, which
are numerous, wavy, small vessels that
anastomose over the surface of the
ureter.
***Injury to the ureter or bladder during
urethropexy operations for genuine stress
incontinence is common. Therefore many
surgeons routinely inject indigo carmine
and either open the bladder or perform
cystoscopy near the end of the operative
Transcribers: Agustin, DJ, Agustin, KVJ, Alimboyoguen, R, Aniscal, S, Anog, CJ, Anselmo, M
OBSTETRICS I: Maternal Anatomy

procedure. The urinary bladder, if properly

drained, will heal rapidly after a surgical
insult if the blood supply to the bladder
wall is not compromised. This capacity
allows the gynecologist to use suprapubic
cystostomy tube without fear of fistula
formation.

Defective connective Tissue

 periurethral connective tissue
 pubourethral ligaments
 pubococcygeus muscles
one of the most common causes of
female urinary incontinence.

d. Parametria and cul-de-sac of Douglas

- Are important anatomic landmarks in
advanced pelvic infection and neoplasia.
- Occasionally the cul-de-sac of Douglas is
obliteratedby the inflammatory process
associated with either endometriosisor
advanced malignancy.

VI: MODULE
Table 1: External Generative Organs

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OBSTETRICS I: Maternal Anatomy

Table 2: Internal Generative Organs

Table 3: Layers of Anterior Abdominal Wall

References:

-Ivy Castro-Bello, MD, FPOGS, Module on Maternal

Anatomy for 2nd Year Student, UNP,
-Comprehensive Gynecology, 7th Edition
Williams Obstetrics, 25th Edition
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