1|Williams Maternal Anatomy24th Ed
ANTERIOR ABDOMINAL WALL
I. Skin, Subcutaneous Layer and Fascia
 LANGER LINES
o Anterior Abdominal Wall- Transverse
 Vertical Incisions – wider scars
 Low Transverse Incision (Pfannenstiel) –
superior cosmetic results
o Subcutaneous Layer
 Camper Fascia-
 Superficial Fatty layer
 Mons Pubis and Labia Majora
 Blend with Ischioanal Fossa
 Scarpa Fascia
 Continues to the perineum as
COLLES FASCIA
o Perineal Infection or
hemorrhage superficial to this
can extend upward to involve
the superficial layers of the
abdominal wall
 Muscles
 Midline
 Rectus Abdominis, Pyramidalis
o Pyramidalis
 From the pubic crest inserts
into the linea alba and lie on
top of the rectus abdominis
beneath the anterior rectus
sheath
 Extends across the Entire Wall
 External Oblique, Internal Oblique
and Transversus Abdominis
o Fascia from these untie in the
midline to form the Linea Alba
o Wide separation can lead to
Diastasis Recti or hernia
o RECTUS SHEATH
 Above the rectus sheath,
aponeuroses is found on
both ventral and dorsal
surface
 Below the sheath, it is only
found on the VENTRAL part,
only the thin Transversalis
fascia and peritoneum lies
on the dorsal surface
II. Blood Supply
o Femoral Artery
 Superfical Epigastric
 Superficial Circumflex Iliac
 Superficial External Pudendal
 Supplies:
 Skin
 Subcutaneous Layers of the Anterior
Abdominal Wall
 Mons Pubis
o External Iliac Vessels
 Inferior Deep Epigastric
 Deep Circumflex Iliac
 Supplies:
 Muscles
 Fascia
o Internal Thoracic Vessels
 Superior Epigastric
 Maylard Incision, Inferior Epigastric
Artery may be lacerated lateral to the
rectus belly and can rupture following
abdominal trauma and create a rectus
sheath hematoma
o Hesselbach Triangle
 Lateral- Inferior Epigastric Vessels
 Inferior- Inguinal Ligament
 Medial- Lateral border of Rectus Muscle
 Hernia that protrudes through the
triangle- Direct Inguinal Hernia
 Hernia that protrudes through the
deep inguinal ring, lateral to the
triangle- Indirect Inguinal Area
III. Innervation
Both Intercostal
 Anterior Abdominal Wall and Subcostal are
o Intercostal nerves (T7-11) Anterior rami of
o Subcostal Nerve (T12) Thoracic Spinal
o Iliohypogastric& Ilioinguinal (L1)
 Transversus Abdominis Space- between
anterior abdominal wall and tyransversus
abdominis
 Intercostal and Subcostal can be severed
during pfannensteil incision.
 Iliohypogastric and ilioinguinial can be
severed during LTCS or entrapped during
closure
 2|Williams Maternal Anatomy24th Ed

o Openings:
EXTERNAL GENERATIVE ORGANS - Urethra
I. VULVA aka PUDENDA - Vagina
 Mons Pubis - 2 Bartholin Gland Ducts
o Aka Mons Veneris - 2 Skene (Paraurethral) Gland Ducts
o Fat filled o Fossa Navicularis- between the fourchette
o Hair forms the escutcheon and vagina; found ONLY in nulliparas
 Labia Majora o Urethral opening is below the pubic arch
o Homoloogue of Scrotum and above the vaginal opening
o Round ligaments terminate at the upper
boprders of the Labia majora
o No hair on the inner surface Glands Description/Function
o Apocrine, Eccrine and Sebaceous glands Bartholins - Aka Greater
are abundant Vestibular Gland
o Rich in elastic and adipose tissue - Inferior to the
vascular vestibular
 Labia Minora
bulb
o Homologue of ventral shaft of the penis
- 5’ and 7 ‘oclock on
o Divides into lamellae
the vestibule
o Fusion of lamella forms the frenulum of
the clitoris and the upper merge to form
Minor Vestibular Lined by simple mucin
the prepuce
secreting epithelium
o Also forms the fourchette
and open along the
o HART LINE hart line
- Medial- squamouse non keratinized Skene -open along the
epithelium (Paraurethral) inferior aspect of the
o No hair follicles, eccrine and apocrine urethra
glands Lie distally near the
o Numerous Sebaceous glands urethral meatus
 Clitoris -inflammation can
o Prinicipal female erogenous organ lead to urethral
o Homologue of Penis diverticulum
o Glans- stratified Squamous formation
o Body
- 2 corpora cavernosa II. VAGINA AND HYMEN
o Blood Supply  Hymen
- From Internal pudendal Artery o Elastic and Collagenous connective
 Deep Artery of Clitoris- Body Tissue
 Dorsal Artery of Clitoris- Glans o Non-keratinized Stratified Squamous
and Prepuce Epithelium
 Vestibule o Imperforate Hymen- accumulation of
o Fom urogenital membrane menstrual blood
o Almond shape o Pregnant Woman- thick and collagen
o Border: rich
- Lateral- hart Line o Hymeneal or Myrtiform caruncles-
- Medial- External Surface of Hymen Multipara women
- Anterior- Frenulum  Vagina
- Posterior- Fourchette
 3|Williams Maternal Anatomy24th Ed
o Musculomembranous tube that extends
into the uterus
o Separated from the bladder-
Vesicovaginal Septum
III. PERINEUM
 Diamond shaped
 Boundaries:
 Anterior- Pubic Symphysis
 Anterolateral-Ischiopubic Rami and Ischial
Tuberosities
 Posdterolateral- Sacrotuberous Ligaments
 Posterior- Coccyx
 Triangles
 Anterior Triangle
o Divided into 2 spaces by Perineal
Membrane
o Boundaries:
 Sup: Pubic Rami
 Lat: Ischial Tuberosities
 Post: Superficial Transverse
Perineal muscles
 Superficial
 Superficial: Colles Fascia
 Deep: Perineal Membrane
 Closed Compartment
 Contents: Bartholin Glands,
Vestibular Bulbs, Clitoral Bofy
and Crura, Pudendal Vessels
and nerve and the
Ischiocavernous,
Bulbocavernous and Superficial
Transverse Perineal Muscles
 Ischiocavernous Muscle- help
maintain clitoral erection
 Vestibular Bulb
 Coropora Spongiosa of the
Penis
 Terminate in the middle of
the vaginal opening
 Deep
 Continuous superiorly with
the pelvic cavity
 Contents: Urethra and
Vagina, Internal Pudendal
Artery, Compressor
Urethrae and
Urethrovaginal sphincter
muscles

 Posterior Triangle
 Contains the Ischioanal fossae, anal
canal and anal canal sphincter complex.
 Pelvic Diaphragm
o Deep to the anterior and posterior
triangles
o Substatntial support to the pelvic
viscera
o Levator and and Coccygeus
 Levator: Pubococcygeous,
Puborectalis and Iliococcygeus
 Pubococcygeus: Pubovaginalis,
Puboperinealis and Puboanalis
o Most Commonly Damaged Muscle
during Childbirth: Pubovisceral
greater risk for POP or Urinary
Incontinence
 Perineal Body
 Fibromuscular mass
 Aka Central Tendon of the Perineum
 For Perineal support
 Superficial
 Structures that converge :
 Bulbocavernous
 Superficial Transverse Perineal
 EAS
 Deep
 Perineal Membrane
 Pubococcygeus muscle
 IAS
 Ischioanal Fossa
 Aka Ischiorectal Fossa
 Bulk of the Posterior Triangle
 Inmjury ot vessels in the posterior
triangle can lead to hematoma
formation in the ischioanal fossa
 Anal Canal
 Distal continuation of the rectum begins
ar the level of levator ani attachment to
the rectum and ends at the anal skin
o Upper: Columnar Epithelium
o Dentate or Pectinate Line: Simple
Stratified Squamous Epithelium
 Hemoorhoids
4|Williams Maternal Anatomy24th Ed
o External- distal to the pectinate
lines; stratified squamous
epithelium; painful
o Internal- above the dentate line,
covered in insensitive anorectal
mucosa; Painful only if it becomes
thrombosed or necrotic
 Anal Sphincter Complex
o Internal Anal Sphincter (IAS)
 Continuation of rectal circular
smooth muscle layer
 Parasympathetic fiber
 Superior, Middle and Inferior
Arteries
 Contributes the bulk of anal
canal resting pressure for fecal
continence
o External Anal Sphincter (EAS)
 Striated muscle ring
 Ant Attachment: Perineal Body
 Post. Attachment: Coccyx
 Maintains constant resting
contraction
 Inferior Rectal Artery- (Int.
Pudendal Art)
 PUDENDAL NERVE
 S2-S4 Ant. Rami
 Exits: Greater Sciatic Formaen
 Ischial Spines serves as landmark for
Pudendal Nerve Block
 Lies within the Alcock’s Canal splitting
of the obturator internus investing
fascia
INTERNAL GENERATIVE ORGANS
1. Uterus
 Situated between the bladder (ant) and
rectum (post)
 Entire posterior wall is covered by
serosa- VISCERAL PERITONEUM
 Lower portion of peritoneum Pouch
of Douglas
 Anterior wall is united to the posterior
wall Vesicouterine space
Dissection caudally within thespace lifts the
bladder off the lower uterine segment for
hysterectomy
 Pear Shaped
 Upper Triangle- Body or Corpous
Lower Cylindrical Shape- Cervix
Isthmus- union of the two parts; forms the
lower uterine segment during pregnancy
Uterine Cornu Origin of fallopian tube and
origin of round and uterovarian ligaments
Fundus- between the points of fallopian tube
insertion and the convex upper uterine
segment
Uterine Body- muscle
Pregnancy stimulates remarkable uterine
growth due to muscle fiber hypertrophy
Cervix
 Fusiform
 Upper boundary: Internal Os
o Level @ which peritoneum is
reflectd up onto the bladder
o Portio Supravaginalis- above
vagina’s attachment to the
cervix; covered by
peritoneum; wehere the
cardinal ligaments attach
o Portio Vagionalis- lower
cervical portion which
protrudes to the vagina
o Ectocervix- exterior to the
EOS- nonkeratinized
squamous epithelium
o Endocervis- single layer pof
mucin secreting columnar
epithelium
 Eversion- endocervix
moves out and onto the
ectocervix
o Chadwick Sign-blue tinit
o Goodell Sign- cervical edema
softening
o Hegar Sign- Isthmic softening
MYOMETRIUM
 SMOOTH MUSCLE BUNDLE
 Living Ligature- interlacing fibers
that surround myometrial vessels
and contract to compress these,
5|Williams Maternal Anatomy24th Ed
integral to hemostasis at the
placental site during the 3rd stage
of labor
 Body>cervix (10%); inner wall>ou
ter wall; Lateral wall> anterior
and posterior wall
ENDOMETRIUM
 Varies greatly throughout the
menstrual cycle
 Functionalis vs. basalis
LIGAMENTS
 Round
o Male Gubernaculum
o Extends lateral and
downward into the inguinal
canal
o Location of the Sampson
artery from the Uterine
Artery
 Broad
o Winglike structure
o Uterine vessels and ureter are
found in its base
o Divides the pelvic cavity into
anterior and posterior
compartments
o Suspensory Ligament of the
Ovary- from the peritoneum
that extends beneath the end
of the fallopian tube; contains
nerves and ovarian vessls
 Cardinal
o Aka Mackenrodt or
Transverse Cervical Ligament
o Thick base of the broad
ligament
 Uterosacral
o Forms the lateral boundaries
of the pouch of Douglas
 BLOOD SUPPLY and LYMPHATICS
 Uterine Artery
o Main branch of the IIA
enters the base of the broad
ligament
o Crosses over the ureter
o Spiral Arteries- supply
functionalis layer;
hormonally responsive
o Basal Arterie/Straight
Arteriesbasalis layer; not
hormonally sensitive
o Ovarian Branch Tubal and
Fundal branch to the
fallopian tube
 Ovarian Artery
o Direct branch of the aorta
o Enters the broad ligament
through the
infundibulopelvic ligament
o The uterus has dual blood
supply to prevent ischemia if
ligation of the uterine or IIA
 Veins
o Arcuate Veins from Uterine
Vein  IIV CIV
o Pampiniform plexus 
Ovarian vein
 Rt. Ovarian Vein IVC
 Lt. Ovarian Vein  Left
Renal Vein
 ANTERIOR DIVISION
o Pelvic Organs
o Perineum
 POSTERIOR DIVISION
o Buttock and Thigh
o Superior Gluteal, Lateral
Sacral and Iliolumbar
o Ligation distal to the
posterior division avoid
compromised blood flow to
these areas
 Endometrium Lymphatics
o Confined in the basalis layer
o LN from the cervix
Internal Iliac Nodes
o LN from Uterine Cornu:
 Internal Iliac Nodes
 From the Ovarian LN 
Paraaortic LN
 INNERVATION
o Predominantly Autonomic
 Sympathetic
6|Williams Maternal Anatomy24th Ed

 Superior Hypogastric Plexus

(Presacral)
 T10-L2
 Sacaral promontory Rt. And
Lt Hypogastric Nerves
 Parasympathetic
 From S2 –S4
o Inferior Hypogastric Plexus
 3 Plexuses
o Vesical Plexus- bladder
o Middle Rectal- Rectum
o Uterovaginal Plexus-
Frankenhauser Plexus;
proximal FT, Uterus and
Upper Vagina
o Uterosacral
o Sensory Fibers
 Inferior Hypogastric Plexus
 T10-T12,L1
 Pelvic Splanchnic (S2-S4) cervix
and upper part of the birth canal
 2 Hypogastric Nerves (Sympathetic)
and 2 Pelvic Splanchnic Nerves
 S4-S5
2. Ovaries
 Ovarian Fossa of Waldeyer


3. Fallopian Tubes
7|Williams Maternal Anatomy24th Ed

PELVIS

 4 bones: Sacrum, Coccyx and 2 Innominate Characteristic Male Female

Bones Built Massive, Bony Slender,
o Innominate Bones: Ilium, Ischiuma Prominence Smooth, Light
dn Pubis bones
 Joints Shape Deep Funnel Flat Bowl
Brim Heart Shaped Circular or
Joints Types Elliptical
Symphysis Pubis Fibrocartilagenous Cavity Conical/Funnel Broad and
Sacroiliac Joint Synovial Round
Sacrocaoccygeal Joint Synovial Hinge Outlet Smaller Larger
“Great international Bodies, So Punctual”
False Pelvis True Pelvis Broad in Females
ABOVE the Pelvic Brim BELOW the Pelvic Brim
No Obstetric Bony canal which the Greater Scaitic Notch
Significance fetus passes at time of Ischial Tuberosities
labor Body of Pubis
Subpubic Angle (90-100°)
Preauricular Sulcus

Diameters of the Pelvis

Diameter Inlet Cavity Outlet  TRUE PELVIS
AP Obstetric 11.5cm 11.5-13.5cm o Pelvic Inlet
Conjugate-  Narrowest in APD and Widest on TD
10-10.5cm
 Plane of Pelvic Inlet is tilted forwards
True  Superior Straight
Conjugate-  55° Angle of Inclination (L5 and
11cm Plane of Inlet)
Diagonal
o Increase in the Angle of
Conjugate-
12cm Inclination (High Inclination)
Oblique 12cm can cause delayed engagement
Transverse 13-13.5cm Interspinous Intertuberous of the fetal head and descent
– 10cm -11cm of fetal head; favors
Occipitoposterior position
Longest Diameter of TD of Inlet and APD of ◊For the proper descent and engagement of
Pelvis Anatomic outlet fetal head, it is important that the uterine axis
Shortest Major Interspinous Diameter coincides with the axis of inlet
Diameter
Longest AP of Inlet Diagonal Conjugate o Pelvic Cavity
Shortest AP of Inlet Obstetric Conjugate  Boundaries:
Only AP measured Diagonal Conjugate  Above: Pelvic Brim
Clinically  Below: Plane of Least Pelvic
Critical Obstetric 10cms ( if obstetric Dimension
Conjugate conjugate <10cm  Ant: Symphysis Pubis
vaginal delivery is not  Post: Sacrum
possible
8|Williams Maternal Anatomy24th Ed

** Internal Rotation of the Fetal head occurs 013cms or 5 1/4in

when the BPD of the Fetal Skull occupies this when the head is
wide pelvic plane while the occiput is on the passing through the
pelvic floor at the plane of least pelvic introitus in the 2nd
dimension stage of labor

o Pelvic Outlet Transverse Intertuberous

 Midpelvis- Ischial Spine 11cm
 Plane of Least Pelvis Dimension Innerborders of ischial
 IR occurs at this level tuberosities
 Marks the beginning of forward Subpubic Angle 2 descending pubic
curve of the pelvic axis rami
 Most cases of Deep Transverse 85°
Arrest occur here WASTE SPACE of MORRIS
 Ischial Spines represent St.0 of the
head - 1cm from the midpoint of the inferior
 External Os lies at this level border of the symphysis pubis
 Landmark for Pudendal Block
 Interspinous Diameter- smallest pelvic PELVIC SHAPE
diameter and is important in cases of
Characteristic Gynecoid Android
obstructed labor
Intro Female Male
 Anatomical Pelvic Outlet
Type
 Lozenge Shape
Shape Oval Heart
 Boundaries
AP DIameter TD slightly TD >AP
o Symphysis Pubis
bigger than
o Pubic Arch
AP
o Ischial Tuberosities
Subpubic 90 <90
o Sacrotuberous Ligaments
Angle
o Sacrospinbous Ligaments
Outcome -No -Delayed
o Tip of Coccyx difficulty in Engagement
 Plane of Anatomical Outlet Engagement -Deep
 Anterior Sagittal Plane -MC Transverse
o Ant. Sagittal Diameter (6-7cm)- Position of Arrest
lower border of the pubic Head: Left -Persistent
symphysis to the center of Occiput Occiptoposterior
bituberous diameter Transverse Position
 Posterior Sagittal Plane or Left common
o Apex lies at the tip of the coccyx Occiput
o Posterior Sagittal Diameter (7.5- Anterior
10cm) from the tip of the Type of Normal Difficult
sacrum to the center of Delivery Instrumental
bituberous diameter Delivery
Diameters of Pelvic Outlet
AP Diameter Lower border of the Characteristic Anthropoid Platypelloid
symphysis pubis to tip Intro Ape Like Flat Pelvis; Least
of coccyx Pelvis Common
9|Williams Maternal Anatomy24th Ed

Variety de
Shape AP Oval Flat Bowl Mentovertical Partial / Brow
AP DIameter ONLY pelvis TD >>>APD Submentovertical Inc. / Face
in which Submentobregmatic Comp. / Face
APD >TD **Brow presentation always CS is done
Subpubic
Angle
Outcome -Diameter of -Head engages Engaging Diameters
Engagement in TD with Presentation AP Cms
is APD marked Vertex Suboccipitobregmatic 9.5
-Mc asynctitism Brow Mentovertical 14
Position: -Engaging Face Submento bregmatic 9.5
Occipito- diameter is Submentovertical 11.5
Posterior supersub
- parietal TYPES OF CONTRACTED PELVIS
Nonrotation diameter
is common (18.5cm) Type Etiology Feature
instead of usual Rachitic Rickets -Reniform
BPD (9.5) Shape of Inlet
Marked
Type of Face to -If head is able shortening of
Delivery Pubes to negotiate the APD w/o
inlet by means affecting TD
of asynclitism -Flat Sacrum
Normal labor -Widening of
otherwise CS TD of outlet
TRANSVERSE DIAMETER and arch
Triradiate Osteomalacia -Triradiate
“Miss Tina So Pretty” Severe Rickets shape of Inlet
M- biMastoid- 7.5cm in Adults -tuberosities
T- biTemporal-8cm are closer and
S- Super Subparietal Diameter- 8.5cm arch is
P- biParietal Diameter- 9.5cm narrower
-short sacrum
**APD of the skull are always bigger than TD with coccyx
** The longest APD of Fetal skull- pushed
Mentovertical- 14cm forward
The 2nd longest AP diameter is Naegeles Congenital One ALA is
Submentovertical/Occipitofrontal- 11.5cm Osteitis of SI jt absent
Mode of
Delivery: CS
AP Diameters of the Fetal Skull Roberts Both ala
Diameters Attitude Presentation absent
of the
Head
Suboccipitobregmatic Comp. Vertex
Suboccipitofrontal Inc.  Vertex
Occipitofrontal Marked Vertex
10 | W i l l i a m s M a t e r n a l A n a t o m y 2 4 t h E d