THE PASSAGES

OBJECTIVES
• TO BE ABLE TO DIFFERENTIATE FALSE
FROM TRUE PELVIS AND THEIR
RESPECTIVE BOUNDARIES
• TO BE ABLE TO IDENTIFY THE PELVIC
INLET, MIDPLANE AND OUTLET
• TO BE ABLE TO KNOW THE CALDWELL
MOLOY CLASSIFICATION OF THE PELVIS
• TO BE ABLE TO FAMILIARIZE THE SOFT
PARTS OF THE PELVIS
 THE BONY PELVIS
• SACRUM
• COCCYX
• TWO INNOMINATE BONES
 FALSE PELVIS
• LIES ABOVE THE LINEA TERMINALIS
• HAS NO OBSTETRICAL SIGNIFICANCE
• BOUNDARIES:
– Posteriorly: lumbar vertebra
– Laterally: iliac fossa
– Anteriorly: lower portion of the anterior
abdominal wall
 TRUE PELVIS
• LIES BELOW THE LINEA TERMINALIS
• BOUNDARIES:
– Superiorly: Linea terminalis
– Posteriorly: Promontory and alae of the
sacrum
– Anteriorly: Upper margin of the pubic bones
– Inferiorly: Pelvic outlet
 PELVIC INLET (SUPERIOR
STRAIT)
• FOUR DIAMETERS:
– ANTEROPOSTERIOR DIAMETER OF THE
INLET
– TRANSVERSE DIAMETER OF THE INLET
– RIGHT AND LEFT OBLIQUE DIAMETERS
 ANTEROPOSTERIOR DIAMETER OF
THE INLET
• DIAGONAL CONJUGATE
• TRUE OR ANATOMIC CONJUGATE
• OBSTETRIC CONJUGATE
 DIAGONAL CONJUGATE
• DISTANCE BETWEEN THE LOWER
BORDER OF THE SYMPHYSIS PUBIS
• MEASURES 12 CMS
• THE ONLY DIAMETER THAT CAN BE
MEASURED CLINICALLY
 TRUE OR ANATOMIC
CONJUGATE
• THE DISTANCE BETWEEN THE
MIDPOINT OF THE SACRAL
PROMONTORY TO THE UPPER
MARGIN OF THE INNER BORDER OF
THE SP
• AVERAGES 11 CMS
• MEASURED INDIRECTLY BY
SUBTRACTING 1.2 CMS FROM THE
DIAGONAL CONJUGATE
THE OBSTETRIC CONJUGATE
• THE DISTANCE BETWEEN THE
MIDPOINT OF THE SACRAL
PROMONTORY TO THE INNER
SURFACE OF THE SYMPHYSIS PUBIS
• MEASURES 10 CMS
• OBTAINED BY SUBTRACTING 1.5-2
CMS FROM THE DIAGONAL
CONJUGATE
 TRANSVERSE DIAMETER OF THE
INLET
• DISTANCE BETWEEN THE 2 FARTHEST
POINTS OF THE PELVIC BRIM OVER
THE ILIOPECTINEAL LINE
• AVERAGES 13 CMS
 RIGHT AND LEFT OBLIQUE
DIAMETERS
• EXTEND FROM THE SACROILIAC
JOINTS TO THE OPPOSITE ILIOPUBIC
EMINENCE
• MEASURES 13 CMS
 PLANE OF THE GREATEST PELVIC
DIAMETER
• ROOMIEST PLANE OF THE PELVIS
• AP DIAMETER + TRANSVERSE DM:
12.5 CMS
• BOUNDARIES:
– Posteriorly: 2nd to 3rd sacral vertebrae
– Laterally: Ischial bones
– Anteriorly: Middle surface of the SP
 RIGHT AND LEFT OBLIQUE
DIAMETERS
• EXTEND FROM THE SACROILIAC
JOINTS TO THE OPPOSITE ILIOPUBIC
EMINENCE
• MEASURES 13 CMS
 PLANE OF THE MIDPELVIS
• EXTENDS FROM THE LOWER MARGIN
OF THE SYMHYSIS PUBIS THROUGH
THE LEVEL OF THE ISCHIAL SPINES
TO THE TIP OF THE SACRUM
• MEASURES 10.5 CMS
• CLINICAL ASSESSMENT NOT
POSSIBLE
 MIDPELVIC CONTRACTION
• PROMINENCE OF THE ISCHIAL
SPINES]
• PELVIC SIDEWALLS ARE
CONVERGENT
• CONCAVITY OF THE SACRUM IS
SHALLOW
• BI ISCHIAL DIAMETER OF THE OUTLET
<8 CMS
 PELVIC OUTLET
• BOUNDARIES:
– Anteriorly: Pubic arch
– Laterally: Ischiopubic rami, Ischial tuberosity,
sacrotuberous ligament
– Posteriorly: Tip of the coccyx
 PELVIC OUTLET
• MEASUREMENTS:
– AP Diameter: 9.5-11.5 cms
– Posterior sagittal DM: exceeds 7 cms
– Intertuberous DM: averages 11 cms
 HOW TO MEASURE THE
INTERTUBEROUS DIAMETER OF
THE OUTLET
• PLACE A CLOSED FIST AGAINST THE
PERINEUM AT THE LEVEL OF THE
TUBEROSITIES
• THOMS RULE: WHEN THE
TRANSVERSE + POSTERIOR SAGITTAL
DM IS > 15 CMS LONG, THE OUTLET IS
CONSIDERED ADEQUATE
CALDWELL MOLOY
CLASSIFICATION
 GYNECOID PELVIS
• This is the most suitable female pelvic
shape. It has round pelvic inlet and
shallow pelvic cavity with short ischial
spines.
• Engagement follows the usual mechanism
• No difficulty in delivery
 ANTHROPOID PELVIS
• Has oval shaped inlet with large anterio-
posterior diameter and comparatively
smaller transverse diameter.
• Has larger outlet.
• The diameters of inlet favors the
engagement of fetal head in occiput-
posterior position that may slow down the
progress of labor.
 ANTHROPOID PELVIS
• Engagment of the head has no difficulty
except that flexion is delayed
• If head engages in anterior position then
labor progress normally in most of the
cases.
• More incidence of face-to pubis delivery
 ANDROID PELVIS
• Has triangular or heart-shaped inlet and is
narrower from the front.
• It has prominent ishial spines and also has
narrower transverse outlet diameter.
 ANDROID PELVIS
• Engagment is delayed and difficult
• Difficult anterior rotation; chance of arrest
disorder common.
• Difficult delivery with increased chance of
perineal injuries
 PLATYPELLOID
• Platypelloid pelvis is has narrow anterio-
posterior diameter of pelvic inlet.
• The pelvic inlet is specifically oval
shaped.
• The pelvic cavity is usually shallow and
diameters of outlet are favorable for the
process of labor
 PLATYPELLOID PELVIS

• Engagement is difficult
• Anterior rotation usually occurs late in the
perineum
• No difficulty in delivery
 IMAGING STUDIES OF THE
PELVIS
• INDICATIONS
– Previous pelvic injury or disease
– Fetus in breech presentation when vaginal
delivery is anticipated
SOFT PARTS OF THE PELVIS
• LEVATOR ANI MUSCLES
– Pubococcygeus
– Iliococcygeus
– Ischiococcygeus

– MUSCLE + FASCIAL COVERING =

PELVIC DIAPHRAGM
 PELVIC DIAPHRAGM
• HIATUS
– Hiatus urogenitalis – transmits the urethra and
vagina
– Hiatus rectalis – transmits the rectum
 PELVIC DIAPHRAGM
• NERVE SUPPLY
– 4TH Sacral nerve
– Inferior Rectal nerve
– Perineal branch of the Pudendal Nerve
 PELVIC DIAPHRAGM
• ACTIONS
– SUPPORT THE PELVIC ORGANS
– CONTROL THE EXTERNAL ANAL
SPHINCTER THROUGH THE
PUBORECTALIS
– STABILIZE THE SACROILIAC AND
SACROCOCCYGEAL JOINTS THROUGH
THE ISCHIOCOCCYGEUS
 UROGENITAL TRIANGLE
• OBSTETRICALLY IMPORTANT

• PIERCED BY THE TERMINAL

PORTIONS OF THE VAGINA &
URETHRA
UROGENITAL TRIANGLE POUCHES

• SUPERFICIAL POUCH
– Formed by the Colle’s fascia and perineal
membrane
– Contents:
• Bulbospongiosus muscle
• Ischiocavernosus muscle
• Bartholin’s glands
UROGENITAL TRIANGLE POUCHES

• DEEP PERINEAL POUCH

– Formed by the inferior and superior layers of
the urogenital diaphragm
– Contents:
• Deep transverse perineal muscles
• Sphincter urethrae
 ANAL TRIANGLE
• CONTENTS
– Terminal part of the rectum
– External anal sphincter
– Anococcygeal body
– Ischiorectal fossae
 PERINEAL BODY
• PYRAMID SHAPED
• LOCATED BETWEEN THE VAGINA AND
THE ANAL OPENING
• MEASURES 4 X 4 CMS
• AREA THAT IS CUT DURING
EPISIOTOMOY