OBSTETRICS

1.02 MATERNAL ANATOMY

CHRISTIANA DAMASO, MD |MARCH 31,2022

OUTLINE § Perineal infection or hemorrhage superficial to Colles

I. Anterior Abdomen III. Internal Generative fascia has the ability to extend upward
II. External Generative Organs • Thickness of subcutaneous layer depends on the
Organs IV. Musculoskeletal Pelvic abdominal girth of the patient and BMI
Anatomy • The fibrous aponeuroses of external oblique, internal
oblique, and transversus abdominis muscles form the
LEGENDS primary fascia of the anterior abdominal wall. These fuse in
Lecturer Book Presentation the midline at the Linea alba, which normally measures 10
to 15 mm wide below the umbilicus
o An abnormally wide separation may reflect diastasis recti
I. ANTERIOR ABDOMEN or hernia

• Confines abdominal viscera
• Stretches to accommodate the expanding uterus
• Provides surgical access to the internal reproductive
organs
A. Skin
• Langer Lines
® Describe the orientation of dermal fibers within the skin
® Arranged transversely in the anterior abdominal wall
§ Vertical skin incisions sustain increased lateral
tension and develop wider scars
o Not all patients develop wider scars
§ Depends on tension of patient’s skin and
retraction of sutures
o Incision: infraumbilical area to symphysis pubis
§ Low transverse incisions, such as the Pfannenstiel,
follow Langer lines and lead to superior cosmetic
results
o Bikini type incision & not prone to keloid formations
B. Subcutaneous Layer
• Camper Fascia
® Superficial, predominantly fatty layer
® Continues onto the perineum to provide fatty substance
to the mons pubis and labia majora and then to blend
with the fat of the ischioanal fossa
• Scarpa Fascia
® Deeper, more membranous layer
® Continues inferiorly onto the perineum as Colles fascia
C. Rectus Sheath
• Comprises the fibrous aponeuroses of the external oblique,
internal oblique, and transversus abdominis muscles
® If there are gynecological surgeries with cases of large
abdominal masses, extension of incision is up to
supraumbilical (at least 2-3 cm above the umbilicus,
depending on size of mass)
• Arcuate Line
® Demarcation line which divides the construction of the
rectus sheath
® Cephalad to this line
§ Aponeuroses invest the rectus abdominis bellies
above and below
® Caudal to this line
§ All aponeuroses lie anterior to the rectus abdominis
muscle and only the thin transversalis fascia and
peritoneum line beneath the rectus
• The paired small triangular pyramidalis muscles originate
from the pubic crest, insert into the Linea alba, and lie atop
the rectus abdominis muscle but beneath the anterior
rectus sheath.
D. Blood Supply
• Femoral Artery Branches
® Supply the skin and subcutaneous layers of the anterior
abdominal wall and mons pubis
a. Superficial Epigastric
b. Superficial Circumflex Iliac
c. External Pudendal Arteries
® Very important to identify in OBGYNE surgeries,
especially in laparoscopy.
® You need to identify these branches first before
making the incision to prevent injury to the vessels
which can result to hematoma
® In cases of Pfannenstiel incision, Superficial
Epigastric Artery is the most commonly transected
• External Iliac Artery Branches
® Supply the muscles and fascia of the anterior abdominal
wall
1. Deep Circumflex Iliac Vessels
2. Inferior "Deep" Epigastric Vessels
® Near the umbilicus, these vessels anastomose with
the superior epigastric artery and veins, which are
branches of the internal thoracic vessels.
® When a Maylard incision is used for CS, the inferior
epigastric artery may be lacerated lateral to the

TRANS VEGA, TALOSIG, CANAOAY, MATIAS, SALAGAN, VICENTE 1 of 10

1.02 Maternal Anatomy
rectus belly during muscle transection. These vessels
rarely may rupture following abdominal trauma and
create a rectus sheath hematoma
• Hesselbach Triangle
® On each side of the lower anterior abdominal wall, this is
the region bounded laterally by the inferior epigastric
vessels, inferiorly by the inguinal ligament, and medially
by the lateral border of the rectus muscle.
® Hernias that protrude through the abdominal wall in
Hesselbach triangle are termed direct inguinal hernias
E. Innervation
• The entire anterior abdominal wall is innervated by
® Abdominal extensions of the intercostal nerves (T7-11)
® Subcostal nerve (T12)
® Iliohypogastric and ilioinguinal nerves (L1)
• The Intercostal and Subcostal nerves
® Supply the Anterior rami of the thoracic spinal nerves
and run along the lateral and then anterior abdominal
wall between the transversus abdominis and internal
oblique muscles
® Transversus abdominis plane
§ Space between the transversus abdominis and
internal oblique muscles
§ Can be used for post-cesarean analgesia blockade
o Where we inject Lidocaine for post-cesarean
analgesia blockade because this is the most painful
area perceived by patient
• Iliohypogastric nerve
® Provides sensation to the skin over the suprapubic area
§ Because it perforates the external oblique
aponeurosis near the lateral rectus border
• Ilioinguinal nerve
® Supplies the skin of the lower abdominal wall and upper
portion of the labia majora and medial portion of the thigh
through its inguinal branch
® The ilioinguinal nerve in its course medially travels
through the inguinal canal and exits through the
superficial inguinal ring, which forms by splitting of
external abdominal oblique aponeurosis fibers.
• Iliohypogastric nerve and ilioinguinal nerve
® Originate from the anterior ramus of the first lumbar
spinal nerve
® These two nerves pass 2 to 3 cm medial to the anterior
superior iliac spine and course between the layers of the
rectus sheath
® These nerves can be entrapped during closure of low
transverse incisions, especially if incisions extend
beyond the lateral borders of the rectus muscle
® These nerves carry sensory information only, and injury
leads to loss of sensation within the areas supplied.
II. EXTERNAL GENERATIVE ORGANS
A. Pudenda
• Commonly designated the Vulva
• All structures visible externally from the pubis to the
perineal body
• Mons pubis, labia majora & minora, clitoris, hymen,
vestibule, urethral opening, greater vestibular or Bartholin
glands, minor vestibular glands & paraurethral glands
OBSTETRICS
B. Mons Pubis
• Aka mons veneris
• Fat-filled cushion overlies the symphysis pubis
• After puberty, the skin of the mons pubis is covered by curly
hair that forms the escutcheon
• Hair is distributed in a triangular area of the symphysis
® Male: diamond escutcheon
C. Labia Majora
• Homologous with the male scrotum
• Vary in appearance, principally according to the amount of
fat they contain
• 7 to 8 cm in length x 2 to 3 cm in depth x 1 to 1.5 cm in
thickness
• Outer surface of the labia majora is covered with hair and
the inner surface, it is absent
• Apocrine, eccrine, and sebaceous glands are abundant
• Beneath the skin, there is a dense connective tissue layer,
which is nearly void of muscular elements but is rich in
elastic fibers and adipose tissue
® Provides bulk to the labia majora and is supplied with a
rich venous plexus
• During pregnancy, this vasculature commonly develops
varicosities, especially in parous women, from increased
venous pressure created by the enlarging uterus.
® They appear as engorged tortuous veins or as small
grapelike clusters, but they are typically asymptomatic.
D. Labia Minora
• Thin fold of tissue
• Homologous with the ventral shaft of the penis
• Extend superiorly, where each divide into two lamellae:
® Lower pair fuses to form the frenulum of the clitoris
® Upper pair merges to form the prepuce
• Inferiorly, the labia minora extend to approach the midline
as low ridges of tissue that fuse to form the fourchette
® This is traversed during episiotomy
® Fourchette is only found posteriorly
• Structurally, the labia minora are composed of connective
tissue with numerous vessels, elastin fibers, and very few
smooth muscle fibers. They are supplied with many nerve
endings and are extremely sensitive
• The epithelia of the labia minora vary with location.
® Thinly keratinized stratified squamous epithelium covers
the outer surface of each labium.
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® On their inner surface, the lateral portion is covered by
this same epithelium up to a demarcating line—Hart line.
® Medial to this line, each labium is covered by squamous
epithelium that is nonkeratinized.
• The labia minora lack hair follicles, eccrine glands, and
apocrine glands. However, there are many sebaceous
glands
E. Clitoris
• Principal female erogenous organ
• Erectile homologue of the penis
• Located beneath the prepuce, above the frenulum and
urethra
• It projects downward between the branched extremities the
labia minora, and the free end points downward and inward
toward the vaginal opening
• Rarely exceeds 2 cm in length
® >2cm: clitoromegaly
• Composed of a glans, a corpus or body, and two crura
• Stratified squamous epithelium
• Glans
® Usually less than 0.5 cm in diameter
® Composed of spindle-shaped cells
• Clitoral body
® Contains two corpora cavernosa
® Diverges laterally to form a long, narrow crus
® Clitoral blood supply stems from branches of the internal
pudendal artery (specifically, deep artery of clitoris)
F. Vestibule
• Functionally mature female structure derived from the
embryonic urogenital membrane
• An almond-shaped area that is enclosed by
® Laterally: Hart line
® Medially: External surface of the hymen
® Anteriorly: Clitoral frenulum
® Posteriorly: Fourchette
• Perforated by six openings
® Urethra
® Vagina
® Two Bartholin gland ducts
® Two ducts of the largest paraurethral glands - Skene
glands
§ Bartholin and Skene glands are appreciated if they
are obstructed
§ If cyst is located on the lateral of Bartholin gland,
differential diagnosis can be Bartholin gland cyst or
Bartholin gland abscess
§ If cyst is somewhere near Skene gland, it can be a
urethral furuncle
• Greater Vestibular glands
® Aka Bartholin glands
® 0.5 to 1 cm in diameter
® Ducts are 1.5 to 2 cm long and open distal to the
hymenal ring at 5 and 7 o'clock on the vestibule
® Bartholin's cyst or abscess
§ Bartholin’s abscess, Patient is:
- Complaining of perineal/vulvar mass
- Tender, Painful, Erythematous
- If ruptured already: Pus draining from the mass
OBSTETRICS
§ Bartholin’s cyst
- Fluctuant mass
- Not tender
- Not responsive to antimicrobials or antibiotics
- Tx: Excision
• Paraurethral glands/Skene glands
® An arborization of glands whose ducts open
predominantly along the entire inferior aspect of the
urethra
® Inflammation and duct obstruction any of the
paraurethral glands can lead to urethral diverticulum
formation
• Urethral opening
® Midline of the vestibule, 1 to 1.5 cm below the pubic arch
® Short distance above the vaginal opening
• Vestibular bulbs
® Correspond to the corpus spongiosum of the penis
® Almond-shaped aggregations of veins lie beneath the
bulbocavernosus muscle on either side of the vestibule
® 3 to 4 long x1 to 2 cm wide x 0.5 to 1 cm thick
• Vaginal Opening and Hymen
® Membrane of varying thickness that surrounds the
vaginal opening
® Composed mainly of elastic and collagenous connective
tissue
® Both outer and inner surfaces are covered by stratified
squamous epithelium
® Imperforate hymen
§ A rare malformation in which the vaginal orifice is
occluded completely, causing retention of menstrual
blood
§ As a rule, the hymen is torn at several sites during first
coitus. However, identical tears may occur by other
penetration. The edges of the torn tissue soon re-
epithelialize.
§ You catch it at puberty and appears like a bulging
bluish membrane at the perineum
§ Tx: incision to drain the menstrual blood
(hymenotomy/hymenectomy)
® Hymenal caruncles
§ In pregnant women, the hymeneal epithelium is thick
and rich in glycogen
§ Changes produced in the hymen by childbirth are
usually readily recognizable - i.e. over time, the hymen
transforms into several nodules of various sizes,
termed hymeneal or myrtiform caruncles.
§ Known as hymenal tag and mostly made up of elastic
tissues
§ Lacerations that are healed
§ Evident if patient already had coitus or delivered
vaginally
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G. Vagina • There are no vaginal glands
® Instead, is lubricated by a transudate that originates from
the vaginal subepithelial capillary plexus and crosses the
permeable epithelial layer
• Due to increased vascularity during pregnancy, vaginal
secretions are notably increased which may be confused
with amniotic fluid leakage
® Increased vaginal secretion during pregnancy:
Leukorrhea
• Vascular supply
§ Cervical branch of the uterine artery & vaginal artery
- Supplies the proximal portion
§ Middle Rectal artery
- Supply Posterior vaginal wall
§ Internal pudendal artery
- Supply Distal walls
• Lymphatics
• Musculomembranous structure extends from the vulva to § Inguinal Lymph Nodes
the uterus – Where the lower third along with vulva drains
• Interposed anteriorly and posteriorly between the bladder § Internal Iliac Nodes
and the rectum – Where the middle third drains
• Upper portion arises from the Müllerian ducts § External, Internal and Common Iliac Nodes
• The lower portion is formed from the urogenital sinus – Where the upper third drains
• Vesicovaginal septum
® Connective tissue that separates the vagina form the H. Perineum
bladder and the urethra anteriorly • Diamond shaped area between the thighs
• Rectovaginal septum • Boundaries
® Tissue that form between the lower portion of the vagina ® Anterior: Pubic Symphysis
and the rectum ® Anterolateral: Ischiopubic rami and Ischial tuberosities
• Recto-uterine pouch or Cul-De- Sac of Douglas ® Posterolateral: Sacrotuberous ligaments
® Separates the upper fourth of the vagina from the rectum ® Posteriorly: Coccyx
® Smooth and flattened: No mass and no nodularity • 2 Triangle of the Perineum
® Clinical significance: where culdocentesis is done if i. Urogenital triangle or the Anterior triangle
we are considering ectopic pregnancy ii. Anal triangle or the Posterior triangle
§ Non clotting blood with a background of (+) PT:
(+) Ectopic pregnancy 1. Anterior Triangle
• Vaginal length varies considerably Boundaries
® Anterior wall: 6 to 8 cm ® Superior: Pubic rami
® Lateral: Ischial tuberosities
® Posterior wall: 7 to 10 cm
§ In internal/bimanual examination, index and middle ® Posterior: Superficial transverse perineal muscle
finger is used.
§ Measure the tip of the middle finger up to base of palm • Perineal Membrane
in cm to have appropriate reporting of size of vagina ® Known as the inferior fascia of the urogenital
• Upper end of the vaginal vault is subdivided into anterior, diaphragm
posterior, and two lateral fornices by the cervix. ® Divides superficial and deep spaces
® Important because the internal pelvic organs usually can ® Sheet of dense fibrous tissue
be palpated through the thin walls of these fornices. ® Attachment
® Posterior fornix provides surgical access to the § Lateral: Ischiopubic rami
peritoneal cavity. § Medial: Distal third of the urethra and vagina
• During a woman’s lifetime, the average woman may have § Posterior: Perineal body
shortening of her vagina by 0.8 cm § Anteriorly: Arcuate ligament of the pubis

• Vaginal lining a. Superficial Space of the Anterior Triangle

® Composed of nonkeratinized stratified squamous ® Bounded deeply by the perineal membrane and
epithelium and underlying lamina propria superficially by ColIes fascia
® In premenopausal women, this lining is thrown into thin ® Closed compartment
transverse ridges, known as rugae ® Structures:
® Below the lamina propria is a muscular layer, which goes § Ischiocavernosus
smooth muscle, collagen, and elastin § Bulbocavernosus
® Beneath the muscularis lies and adventitial layer § Superficial transverse perineal muscles
consisting of collagen and elastin § Bartholin Glands

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§ Vestibular bulbs
§ Clitoral body and crura
§ Branches of the pudendal vessels and nerve
b. Deep Space of the Anterior Triangle
® Lies deep to the perineal membrane and extends up
into the pelvis
® Continuous superiorly with the pelvic cavity
® Structures:
§ Compressor urethrae and urethrovaginal sphincter
muscles (comprises the striated urogenital
sphincter complex)
§ External urethral sphincter
§ Parts of urethra and vagina
§ Branches of the internal pudendal artery
§ Dorsal nerve and vein of the clitoris
2. Posterior Triangle
® Structures:
§ Ischiorectal fossa
§ Anal canal
§ Anal sphincter complex (internal anal sphincter,
external anal sphincter, and puborectalis muscle)
§ Branches of the internal pudendal vessels and
pudendal nerve
• Ischiorectal or Ischioanal fossae
® Two fat-filled wedge-shaped spaces found on either
side of the anal canal and comprise the bulk of the
posterior triangle
® Provides support to the surrounding organs, yet
allow distension of the rectum during defecation
and stretching of the vagina during delivery
® Injury to vessels can lead to hematoma formation in
this fossa
OBSTETRICS
I. Anus
• Anal sphincter
® External and Internal anal sphincter
® 2 sphincters to provide fecal continence
® These 2 sphincters can be transected in median
episiotomy
a. External Sphincter
® Maintain a constant state of resting contraction
that provides increased tone and strength when
continence is threatened, and it relaxes for
defecation
§ Controls defecation process
® Supplied by the inferior rectal artery, branch of the
internal pudendal artery.
b. Internal Sphincter
® Contributes the bulk of anal canal resting pressure
for fecal continence and it relaxes prior to
defecation
® Supplied by the superior, middle, and inferior
rectal arteries.
• Anal Cushions
® 3 highly vascularized submucosal arteriovenous
plexuses
® Aid complete closure of the anal canal and fecal
continence when apposed
® Increasing uterine size, excessive straining, and hard
stools can increase venous engorgement within these
cushions to form hemorrhoids
§ External hemorrhoids arise distal to the pectinate
line, covered by stratified squamous epithelium and
receive sensory innervation from inferior rectal nerve
§ Internal hemorrhoids form above the dentate line and
are covered by insensitive anorectal mucosa.
J. Perineal Body
• Fibromuscular mass found in the midline at the junction
between anterior and posterior triangles
• Called the central tendon of the perineum
• Serves as the junction for several structures and provides
significant perineal support
• Bulbocavernosus, superficial transverse perineal, and
• external anal sphincter muscles converge here
• When incised by an episiotomy incision and is torn with 2nd,
3rd and 4th degree lacerations (median episiotomy)
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Function Potential Morbidity ® Round ligament now appears to insert at the junction of
• Anchors the anorectum • Episiotomy may injure the middle and upper thirds of the organ
• Anchors the vagina the perineal body ® Fallopian tubes elongate, but the ovaries grossly appear
• Helps maintain urinary ® If we do 3rd and 4th unchanged.
and fecal continence median episiotomy,
• Maintain the orgasmic it can injure perineal B. Cervix
platform body, but during • Fusiform and open at each end by small aperture - the
• Prevents expansion of episiorraphy, we can internal and external OS
the urogenital hiatus repair perineal body • Covered by peritoneum on its posterior surface
• Provides a physical layer by layer. • 2 Openings
barrier between the • Pudendal nerve injury 1. Internal Os
vagina and the rectum may be associated with ® Upper boundary of cervix
concurrent perineal body 2. External Os
injury ® Before childbirth, it is a small, regular, oval opening
® After vaginal childbirth, it is converted into
III. INTERNAL GENERATIVE ORGANS transverse slit
A. Uterus • 2 segments
• Portio supravaginalis
® The upper cervical segment that lies above the
vagina’s attachment to the cervix
2. Portio Vaginalis
® Lower cervical portion that protrudes into the vagina
• Ectocervix
® Portion of the cervix exterior to the external os
® Lined predominantly by nonkeratinized stratified
squamous epithelium
• Endocervical canal
® Covered by a single layer of mucin-secreting columnar
epithelium, which creates deep cleftlike infoldings or
“glands.”
• Chadwick sign: In early pregnancy, ­ vascularity within the
cervix stroma creates an ectocervical blue tint
• Goodell sign: Cervical edema leads to softening
• Non pregnant uterus • Hegar sign: isthmic softening
® Situated in the pelvic cavity between the bladder
anteriorly and the rectum posteriorly
® Almost the entire posterior uterine wall is covered by
serosa, that is, visceral peritoneum
® The lower portion of the anterior uterine wall is united to
the posterior wall of the bladder by a well-defined loose
connective tissue layer, the vesicouterine space
® The uterus averages 60 g and typically weighs more in
parous women
A. Nulliparous Cervix
® Pyriform or pear shape
® No vaginal delivery; Slit like opening
® Parts:
B. Multiparous Cervix
§ Upper triangular portion: Body or Corpus
® Multiple vaginal delivery; Fish mouth appearance
§ Lower cylindrical portion: Cervix, which project into the
vagina
C. Endometrium
§ Isthmus: Portion of the uterus between the internal
cervical OS and the endometrial cavity • Lines the uterine cavity in non-pregnant woman
o It is a special obstetrical significance because it • It is a thin, pink, velvet like membrane perforated by many
forms the lower uterine segment during pregnancy minute ostia of the uterine glands
• Normally varies greatly in thickness
• Pregnancy Induces Uterine Changes ® Divided into:
® Pregnancy stimulates remarkable uterine growth due to i. Functionalis layer: sloughed with menses
hypertrophy of the muscle fibers ii. Basalis layer: serves to regenerate the functionalis
® Uterine weights increase from 70 grams to layer following each menses.
approximately 1100 grams at term • During pregnancy, the endometrium is termed decidua.
® Total volume average about 5 liters • Composed of surface epithelium, glands, and interglandular
® Uterine Fundus, previously flattened convexity, mesenchymal tissue in which there are numerous blood
becomes a dome shaped vessels

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D. Myometrium • Uterosacral ligament
• Composed of bundles of smooth muscle united by ® Originates with a posterolateral attachment to the
connective tissue in which there are many elastic fibers supravaginal portion of the cervix and inserts into the
• Interlacing myometrial fibers surround myometrial vessels fascia over the sacrum
and contract to compress these ® Composed of connective tissue, small bundles of
® Integral to hemostasis at the placental site during the vessels and nerves, and some smooth muscle
third stage of labor. • Round and broad ligaments provide no substantial uterine
• During pregnancy, the upper myometrium undergoes support, which contrasts with the cardinal and uterosacral
marked hypertrophy, but cervical muscle content does not ligaments.
change significantly
• Infundibulopelvic ligament
E. Ligaments ® Suspensory ligament of the ovary
® Peritoneum that extends beneath the fimbriated end of
the fallopian tube toward the pelvic wall forms
® Contains nerves and the ovarian vessels
® Pregnancy: these vessels, especially the venous
plexuses, are dramatically enlarged. Specifically, the
diameter of the ovarian vascular pedicle increases
from 0.9 cm to reach 2.6 cm at term

F. Blood Vessels
• Blood supply of the uterus
® Derived principally from the uterine and ovarian arteries
® Uterine Artery
§ Main branch of the internal iliac artery
§ Enters the base of the broad ligament and courses
medially to the lateral side of the uterus.
§ Approx. 2 cm lateral to the cervix, the uterine artery
crosses over the ureter.
- This proximity is of great surgical significance as
the ureter may be injured during hysterectomy
• Round ligament
§ Smaller cervicovaginal artery: supplies blood to the
® Each round ligament extends laterally and downward lower cervix and upper vagina
into the inguinal canal, through which it passes, to § Spiral artery: Supply the functionalis layer and has
terminate in the upper portion of the labium majus important role in menstruation
® Corresponds embryologically to the male gubernaculum ® Ovarian Artery
testis § Direct branch of the aorta
® This orientation can aid in fallopian tube identification § Enters the broad ligament through the
during puerperal sterilization infundibulopelvic ligament
® In nonpregnant women: composed of smooth muscle
bundles separated by fibrous tissue septa. • Blood supply to the pelvis
® Pregnancy: undergoes considerable hypertrophy and ® Predominantly supplied from branches of internal iliac
increase appreciably in both length and diameter. artery and organized into anterior and posterior division
® Sampson artery § Anterior division
§ Branch of uterine artery & runs within this ligament - Provides blood supply to the pelvic organs and
• Broad ligaments perineum
® 2 winglike structure that extends from the lateral uterine § Posterior division
margin to the pelvic sidewalls – Extend to the buttock and thigh and include the
® Divide the pelvic cavity into the anterior and posterior superior gluteal, lateral sacral, and iliolumbar
compartments arteries.
® Mesosalpinx: Peritoneum that overlies the fallopian tube
® Mesoteres: Around the round ligament G. Lymphatics
® Mesovarium: Over the uteroovarian ligament • Endometrium is abundantly supplied with lymphatic vessels
® The thick base of the broad ligament that are confined to the basalis layer
® Originate with the posterolateral attachment to the • Lymphatics from the cervix terminate mainly in the internal
supravaginal portion of the cervix and insert into fascia iliac nodes, which are situated near the bifurcation of the
over the sacrum. common iliac vessel
• Cardinal ligament • Lymphatics from the uterine corpus are distributed into two
® Transverse cervical ligament or Mackenrodt ligament groups of nodes.
® Thick base of the broad ligament ® One set of vessels drains into the internal iliac nodes.
® United firmly to the uterus and upper vagina ® Other set terminates in the para-aortic lymph node

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H. Innervation • Uteroovarian Ligament
• Pelvic nerve supply is derived principally from the ® Originates from the upper posterolateral portion of the
sympathetic nervous system, but also partly from the uterus and extends to the uterine pole of the ovary.
cerebrospinal and parasympathetic system ® Made up of muscle and connective tissue and is covered
• Sympathetic by mesovarium
® Presacral nerve/Superior hypogastric plexus (T10 - L2) • Outer cortex
® At the level of sacral promontory, divides into a right and ® In young women, it is smooth with dull white surface
left hypogastric nerve ® Lined by single layer of cuboidal epithelium, the germinal
• Parasympathetic epithelium of Waldeyer.
® Anterior rami of S2 - S4 spinal nerves § This epithelium is supported by a connective tissue
o These forms the pelvic splanchnic nerves (Nervi condensation, the tunica albuginea
Erigentes) • Inner medulla
• Inferior hypogastric plexus/Pelvic Plexus ® Composed of loose connective tissue, numerous
® 2 hypogastric nerves (sympathetic) & 2 pelvic splanchnic arteries and veins, and a small amount of smooth muscle
nerves (parasympathetic) fibers.
® Lies at the S4 and S5 level • Attached to the broad ligament by the mesovarium
® 3 plexuses: • Supplied with both sympathetic and parasympathetic
§ Vesical plexus: Bladder nerves
§ Middle rectal plexus: Rectum
§ Uterovaginal (Frankenhäuser plexus): uterus, IV. MUSCULOSKELETAL PELVIC ANATOMY
proximal, fallopian tubes, and upper vagina A. Pelvic Bones
• Afferent sensory fibers • Four bones of
® Uterus: ascend through inferior hypogastric plexus and the pelvis:
enter SC via T10 - T12 & L1 ® Sacrum
o These transmit painful stimuli of contractions to CNS ® Coccyx
® Sensory nerves from cervix & upper vagina pass through ® Two
the pelvic splanchnic nerves to S2 – S4 innominate
® Lower vagina: pudendal nerve bones
• Each innominate
I. Fallopian Tubes bone is formed
• Also called oviducts by the fusion of
• Tubular extension from the uterine cornua three bones:
• Varies in length from 8 to 14 cm ® Ilium, Ischium,
• 4 Segments and Pubis
1. Interstitial portion
® Embodied within the uterine muscular wall • The innominate bones are joined to the sacrum at the
2. Isthmus sacroiliac synchondroses and to one another at the
® Narrowest part of the fallopian tube (2-3mm) symphysis pubis
3. Ampulla
® 5-8 mm B. True Pelvis and False Pelvis
4. Infundibulum • True pelvis
® Funnel-shaped fimbriated distal extremity of the ® Below this
tube, which opens into the abdominal cavity. anatomical
• Extrauterine segments: boundary
§ Mesosalpinx: Outermost; single-cell mesothelial layer and ® Important in
functioning as visceral peritoneum childbearing
§ Myosalpinx: Smooth muscles (inner circular, outer ® Obliquely
longitudal) truncated,
§ Endosalpinx (tubal mucosa): Single layer ciliated, bent cylinder
columnar epithelium with sparse lamina propria with its
• Tubal peristalsis created by the cilia & muscular layer greatest height
contractions is believed to be crucial factor in ovum posteriorly
transport. ® Boundaries:
§ Superior border: Promontory and alae of the sacrum,
J. Ovaries Linea terminalis & upper margins of the pubic bones
• Childbearing years: 2.5 to 5 cm in length, 1.5 to 3 cm in § Inferior margin: Pelvic outlet
breath and 0.6 to 1.5 cm in thickness § Anterior: Pubic bones, ascending superior rami of the
• Usually rests in the ovarian fossa of Waldeyer, which is a ischial bones and the obturator foramen
slight depression between the external and internal iliac § Posterior: Anterior surface of sacrum
vessels § Lateral limits: inner surface of the ischial bones and
sacrosciatic notches and ligaments

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1.02 Maternal Anatomy
® Adult woman: converged sidewalls
§ Extending from the middle of the posterior margin of
each ischium are the ischial spines
§ Great obstetrical importance because the distance
between them usually represents the shortest diameter
of the true pelvis
§ Landmark in assessing the level to which the
presenting part of the fetus has descended into the true
pelvis
§ Aid pudendal nerve block placement

• False pelvis
® Lies above the Linea terminalis
® Bounded posteriorly by the lumbar vertebra and laterally ® Obstetrical Conjugate
by the iliac fossa § AP diameter
® Boundaries: § Shortest distance between the promontory of the
§ Posterior: Lumbar vertebra sacrum and the symphysis pubis
§ Lateral: Iliac fossa § Predicts the adequacy of the pelvic inlet
§ Anterior: Lower portion of anterior abdominal wall § Measures 10 cm or more
§ Cannot be measured directly with the examiner’s
C. Pelvic Joints fingers
§ Estimated indirectly by subtracting 1.5 to 2 cm from the
• Symphysis pubis
Diagonal conjugate
® Anterior
® Consists of Fibrocartilage and superior and inferior pubic
® Diagonal Conjugate
ligament (arcuate ligament of the pubis)
• Sacroiliac joints
® Posterior
® Articulations between the sacrum and the iliac portion of
the innominate bones
• These joints in general have a limited degree of mobility
• During Pregnancy: Relaxation of the pelvic joint
§ Results from hormonal stimulation during pregnancy
§ Gliding of Sacroiliac joints

D. Plane and Diameter of the Pelvis

• The plane of the pelvic inlet: Superior strait
• The plane of the pelvic outlet: Inferior strait
• The plane of the mid-pelvis: Least pelvic dimension
• The plane of the greatest pelvic dimension: No obstetrical
significance

• Pelvic Inlet
® Superior strait; Superior plane of the true pelvis § Determine by measuring the distance from the lower
® Boundaries margin of the symphysis to the sacral promontory
§ Posterior: Promontory and alae of the sacrum, § Normal size of diagonal conjugate: Should not be less
§ Lateral: Linea terminalis than 12.5 cm
§ Anterior: Horizontal pubic rami and symphysis pubis § For example: If a mother has diagonal conjugate of 9
® Four diameters cm, you should suspect a degree of pelvic inlet
i. Anteroposterior (AP) contraction.
ii. Transverse o If this happens, the baby cannot descend into the
® Constructed at midpelvis and outlet anymore
right angles to o Patient can’t deliver vaginally and instead, CS shall
the obstetrical be done
conjugate and
represents the E. Midpelvis
greatest • Measured at the level of the ischial spines
distance • Also called the midplane or plane of least pelvic dimension
between the • Midpelvis and ischial spines serve to mark zero station
linea terminalis ® It is of particular importance following engagement of the
on either side fetal head in obstructed labor
iii. 2 Oblique diameters

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1.02 Maternal Anatomy
® For example: The fetal head already reach the level of
ischial spine but after 2 hours, it is still engaged in station
0. In this case, suspect that there might be mid pelvic
contraction
® For Midpelvis, you must assess the:
§ Pelvic Side walls: Convergent or Divergent
§ Ischial spines: Prominent or Not
§ Sacrosciatic notch: Shallow or Deep
® Midpelvis must have divergent pelvic side walls, non-
prominent ischial spines and deep Sacrosciatic notch
• The interspinous diameter is 10 cm or slightly greater and
is usually the smallest pelvic diameter.
• The anteroposterior diameter through the level of the
ischial spines normally measures at least 11.5 cm.
D. Pelvis Outlet
• Consists of two approximately triangular areas that are not
in the same plane
• Have a common base, which is a line drawn between the
two ischial tuberosities
• Landmarks:
§ Apex of Posterior or anal triangle: Tip of sacrum
§ Lateral boundaries: Sacrotuberous ligament and
Ischial tuberosities
• Anterior triangle formed by descending inferior rami of the
pubic bones
® These rami unite at an angle of 90o to 100o to form a
rounded arch under which the fetal head must pass.
• Unless the is significant pelvic bony disease, the pelvic
outlet seldom obstructs vaginal delivery.
• The four different pelvis shapes are:
1. Gynecoid
® This is the most common type of pelvis in female
® Generally considered to be the typical female pelvis
® Its overall shape is round, shallow, and open
® The configuration of the gynecoid pelvis would
intuitively seem suited for vaginal delivery
2. Android
® This type of pelvis bears more resemblance to the
male pelvis.
® It’s narrower than the gynecoid pelvis and is shaped
more like a heart or a wedge
3. Anthropoid
® An anthropoid pelvis is narrow and deep.
® Its shape is similar to an upright egg or oval
® Posterior diameter is shorter than anterior diameter
4. Platypelloid
® Also called a flat pelvis
® This is the least common type
® It’s wide but shallow, and it resembles an egg or oval
lying on its side
D. Muscular Support
• Pelvic Diaphragm
® Forms a broad muscular sling and provides substantial
support to the pelvic viscera
® Comprised of the levator ani and the Coccygeus muscle
• Levator Ani
® Composed of the pubococcygeus, puborectalis and
iliococcygeus muscles

D. Pelvis Shapes
• Anatomical classification of the pelvis is based on shape
• Specifically, the greatest transverse diameter of the inlet
and its division into anterior and posterior segments are
used to classify the pelvis
§ Posterior segment: Type of pelvis
§ Anterior segment: Tendency

REFERENCES
• Dra. Damaso’s PPT
• William’s Obstetrics 24th edition

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