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Continues onto the perineum to provide fatty substance to the mons pubis
and labia majora
Fibrous aponeuroses of these three latter muscles form the primary fascia
of the anterior abdominal wall.
Lie atop the rectus abdominis muscle but beneath the anterior rectus
sheath.
Blood Supply
Arise from the Femoral Artery just below the inguinal ligament within the
femoral triangle
a)
Superficial Epigastric
b) Superficial Circumflex Iliac
c)
Superficial External Pudendal
Supply the skin and subcutaneous layers of the anterior abdominal wall
and mons pubis.
Inferior Epigastric vessels initially course lateral to, then posterior to the
rectus abdominis muscles, which they supply.
Pass ventral to the posterior rectus sheath and course between the
sheath and the rectus muscles.
Near the umbilicus, anastomose with the Superior Epigastric Artery and
Veins, which are branches of the Internal Thoracic Vessels.
These vessels rarely may rupture following abdominal trauma and create
a rectus Sheath Hematoma
Hesselbach Triangle
Direct Inguinal Hernias: hernias that protrude through the abdominal wall
in Hesselbach triangle.
Rem Alfelor
Maternal Anatomy
Innervation
Anterior Abdominal Wall is innervated by
a)
Intercostal Nerves (T711)
b)
Subcostal Nerve (T12),
c)
Iliohypogastric and Ilioinguinal Nerves (L1)
Intercostal and Subcostal Nerves are Anterior Rami of the Thoracic Spinal
Nerves
Run lateral and then anterior abdominal wall between the transversus
abdominis and internal oblique muscles(Transversus Abdominis Plane)
Near the rectus abdominis lateral borders, these nerve branches pierce
the posterior sheath, rectus muscle, and then anterior sheath to reach the
skin.
Emerge lateral to the psoas muscle and travel across the quadratus
lumborum inferomedially toward the iliac crest.
Near this crest, both nerves pierce the transversus abdominis muscle and
course ventrally.
Perforates the external oblique aponeurosis near the lateral rectus border
to provide sensation to the skin over the suprapubic area.
Ilioinguinal Nerve
Course medially through the inguinal canal and exits through the
Superficial Inguinal Ring, which forms by splitting of external abdominal
oblique aponeurosis fibers.
Supplies the skin of the mons pubis, upper labia majora, and medial upper
thigh.
Ilioinguinal and Iliohypogastric Nerves can be severed during a low
transverse incision or entrapped during closure, 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.
Includes all structures visible externally from the symphysis pubis to the
perineal body.
Mons Pubis
S: continuous directly with the mons pubis and round ligaments terminate
at their upper borders.
P: taper and merge into the area overlying the perineal body to form the
Posterior Commissure.
Hair covers the labia majora outer surface but is absent on their inner
surface.
Beneath the skin is a dense connective tissue layer, which is nearly void
of muscular elements but is rich in elastic fibers and adipose tissue.
Mass of fat provides bulk to the labia majora
Supplied with a rich venous plexus
Each is a thin tissue fold that lies medial to each labium majus
Inferiorly extend to approach the midline as low ridges of tissue that join to
form the fourchette
Lack hair follicles, eccrine glands, and apocrine glands but many
sebaceous glands
Clitoris
Principal female erogenous organ
Erectile homologue of the penis.
Located beneath the prepuce, above the frenulum and urethra,
projects downward and inward toward the vaginal opening
Rarely exceeds 2 cm in length
Composed of
Rem Alfelor
Maternal Anatomy
a)
Glans
b)
Corpus or body
c)
Two crura
Glans
Richly innervated
Clitoral Body
Vestibule
An almond-shaped area
Enclosed by
L: Hart line, M: external surface of the hymen, A: clitoral frenulum,
P: fourchette
Fossa Navicularis
Posterior portion of the vestibule between the fourchette and the
vaginal opening
Usually observed only in nulliparas.
Paraurethral Glands
Collective arborization of glands whose multiple small ducts open
predominantly along the entire inferior aspect of the urethra.
Two Largest are called Skene Glands
Lower two thirds of the urethra lie immediately above the anterior vaginal
wall
1-1.5 cm below the pubic arch and short distance above the vaginal
opening.
Aperture of the intact hymen ranges in diameter from pinpoint to one that
admits one or even two fingertips.
Imperforate Hymen
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Over time, the hymen transforms into several nodules of various sizes,
termed Hymeneal or Myrtiform Caruncles.
Vagina
Posteriorly, between the lower portion of the vagina and the rectum
together form the Rectovaginal Septum.
Midportion of the vagina: lateral walls are attached to the pelvis by visceral
connective tissue.
No vaginal glands
Blood supply from each side forms anastomoses on the anterior and
posterior vaginal walls with contralateral corresponding vessels.
Lymphatics from the lower third, along with those of the vulva, drain
primarily into the Inguinal Lymph Nodes.
Middle third drain into the Internal Iliac Nodes
Upper third drain into the External, Internal, and Common Iliac
Nodes.
On the perineum, Colles fascia securely attaches L: pubic rami and fascia
lata of the thigh, I: superficial transverse perineal muscle and inferior
border of the perineal membrane, M: urethra, clitoris, and vagina.
Superficial space of the anterior triangle is a relatively closed compartment, and
expanding infection or hematoma within it may bulge yet remains contained.
L: ischiopubic ramus
A: clitoral crus
Constrict the vaginal lumen and aid release of secretions from the
Bartholin glands.
Contribute to clitoral erection by compressing the deep dorsal vein
of the clitoris.
Perineum
Diamond-shaped area between the thighs has boundaries that mirror those of
the bony pelvic outlet:
Rem Alfelor
Maternal Anatomy
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Deep Space of the Anterior Triangle
Space lies deep to the perineal membrane and extends up into the pelvis
Continuous superiorly with the pelvic cavity
Contains
a)
Portions of urethra and vagina
b)
Certain portions of internal pudendal artery branches,
c)
Compressor urethrae
d)
Urethrovaginal sphincter muscles
Comprise part of the striated urogenital sphincter complex.
Pelvic Diaphragm
Found deep to the anterior and posterior triangles
Broad muscular sling provides substantial support to the pelvic viscera.
Composed of
a)
Levator ani
b)
Coccygeus muscle.
c)
Levator ani
Composed of
1)
Pubococcygeus
2)
Puborectalis
3)
Iliococcygeus
Pubococcygeus Muscle
Include
1)
Pubovaginalis
2)
Puboperinealis
3)
Puboanalis
Insert into the vaginal, perineal body, and anus, respectively
Vaginal birth conveys significant risk for damage to the levator ani or to its
innervation
Consists of
a)
Internal anal sphincter
b)
External anal sphincter
c)
Puborectalis muscle
d)
Branches of the pudendal nerve and internal pudendal vessels
Ischioanal Fossae
Also known as Ischiorectal Fossae
two fat-filled wedge-shaped spaces
found on either side of the anal canal
comprise the bulk of the posterior triangle
Each fossa has skin as its superficial base
Deep apex is formed by the junction of the levator ani and obturator internus
muscle.
Other borders include:
Episiotomy infection or hematoma may extend from one fossa into the
other.
Begins at the level of levator ani attachment to the rectum and ends at the anal
skin.
4-5 cm length
Mucosa consists of
a)
Columnar epithelium (uppermost portion)
b)
Simple stratified squamous epithelium (begins at dentate or pectinate line
continues to the anal verge)
Aid complete closure of the canal and fecal continence when apposed.
Increasing uterine size, excessive straining, and hard stool create increased
pressure that ultimately leads to degeneration and subsequent laxity of the
cushions supportive connective tissue base.
External Hemorrhoids
Those that arise distal to the pectinate line.
Covered by stratified squamous epithelium
Receive sensory innervation from the Inferior Rectal Nerve.
Pain and a palpable mass are typical complaints.
Following resolution, a hemorrhoidal tag may remain composed of
redundant anal skin and fibrotic tissue.
Internal Hemorrhoids
Those that form above the dentate line
Covered by insensitive anorectal mucosa
May prolapse or bleed but rarely become painful unless they
undergo thrombosis or necrosis.
Contributes the bulk of anal canal resting pressure for fecal continence
and relaxes prior to defecation
Measures 3- 4 cm in length
Somatic motor fibers from the Inferior Rectal Branch of the Pudendal
Nerve supply innervation.
IAS and EAS may be involved in fourth-degree laceration during vaginal delivery
Anal Canal
Distal continuation of the rectum
Rem Alfelor
Maternal Anatomy
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Pudendal Nerve
Formed from the anterior rami of S24 spinal nerves
Courses between the piriformis and coccygeus muscles
Exits through the greater sciatic foramen
Reenters the lesser sciatic foramen to course along the obturator internus
muscle.
Lies within the pudendal canal (Alcock canal)
Rem Alfelor
Maternal Anatomy
Uterus
Nonpregnant uterus: situated in the pelvic cavity
Peritoneum in this area reflects forward onto the bladder dome to create
the Vesicouterine Pouch
Lower portion of the anterior uterine wall is united to the posterior wall of the
bladder by well-defined loose connective tissue layer (Vesicouterine Space)
Dissection caudally within this space lifts the bladder off the lower uterine
segment for hysterotomy and delivery
Pear shaped
Consists of two major but unequal parts.
a)
Body or Corpus
upper triangular portion
b) Cervix
Lower, cylindrical portion
Projects into the vagina
c)
Isthmus
Union site of these two
Special obstetrical significance because it forms the lower uterine
segment during pregnancy.
At each superolateral margin of the body is a Uterine Cornu
Between the points of fallopian tube insertion is the convex upper uterine
segment (fundus)
Bulk of the uterine body is muscle
Inner surfaces of the anterior and posterior walls lie almost in contact
Multiparas: cervix is only a little more than a third of the total length.
Pregnancy stimulates remarkable uterine growth due to muscle
fiber hypertrophy
Uterine fundus, previously flattened convexity between tubal
insertions, now becomes dome shaped.
Round ligaments appear to insert at the junction of the middle and
upper thirds of the organ.
Fallopian tubes elongate, but the ovaries grossly appear
unchanged.
Cervix
Fusiform and open at each end by small apertures
a)
Internal Cervical Ora
b) External Cervical Ora
Proximally, the upper boundary of the cervix is the internal os, corresponds to
the level at which the peritoneum is reflected up onto the bladder
Portio Supravaginalis
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Myometrium and Endometrium
Most of the uterus is composed of
Myometrium
Anterior and posterior walls: more muscle than in the lateral walls.
During pregnancy, the upper myometrium undergoes marked hypertrophy, but
there is no significant change in cervical muscle content.
Uterine cavity is lined with Endometrium
Divided into
a)
Functionalis Layer
Important if pelvic adhesions limit tubal mobility and thus limit fimbria
visualization prior to tubal ligation.
Each extends laterally and downward into the inguinal canal, through
which it passes, to terminate in the upper portion of the labium majus.
Sampson Artery
Branch of the uterine artery
Runs within this ligament
Peritoneum that extends beneath the fimbriated end of the fallopian tube
toward the pelvic wall forms the.
Parametrium
Describe the connective tissues adjacent and lateral to the uterus
within the broad ligament.
Paracervical tissues are those adjacent to the cervix
Paracolpium
Tissue lateral to the vaginal walls.
Blood Supply
During pregnancy, there is marked hypertrophy of the uterine vasculature
Supplied principally from the Uterine and Ovarian Arteries
Uterine Artery
Broad Ligaments
Two wing like structures that extend from the lateral uterine margins to the
pelvic sidewalls.
Peritoneum
a)
Mesosalpinx: Overlies the fallopian tube
b) Mesoteres : Around the round ligament is the
c)
Mesovarium: Over the uteroovarian ligament
Rem Alfelor
Maternal Anatomy
Enters the base of the broad ligament and makes its way medially to the
side of the uterus.
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 or ligated during hysterectomy when the vessels are
clamped and ligated.
Once the uterine artery has reached the supravaginal portion of the
cervix, it divides
Cervicovaginal Artery
Supplies blood to the lower cervix and upper vagina
Main branch turns abruptly upward and extends as a highly
convoluted vessel that traverses along the lateral margin of the
uterus
Extends into the upper portion of the cervix,
Numerous other branches penetrate the body of the uterus to form
the Arcuate Arteries
Tubal branch
Makes its way through the mesosalpinx
Supplies part of the fallopian tube
Fundal branch
penetrates the uppermost uterus
Ovarian Artery
Ovarian hilum: divides into smaller branches that enter the ovary.
As the ovarian artery runs along the hilum, it also sends several branches
through the mesosalpinx to supply the fallopian tubes.
Main stem traverses the entire length of the broad ligament and makes its
way to the uterine cornu.
Forms an anastomosis with the ovarian branch of the uterine artery. Dual
uterine blood supply creates a vascular reserve to prevent uterine
ischemia if ligation of the uterine or internal iliac artery is performed to
control postpartum hemorrhage.
Uterine veins accompany their respective arteries.
Empties into the internal iliac vein and then the Common Iliac Vein.
Within the broad ligament, these veins form the large pampiniform plexus
that terminates in the Ovarian Vein.
Right Ovarian Vein empties into the Vena Cava
Left Ovarian Vein empties into the Left Renal Vein.
Blood supply to the pelvis is predominantly supplied from branches of the
Internal Iliac Artery.
Posterior Division
Lymphatics
Endometrium is abundantly supplied with lymphatic vessels that are confined
largely to the basalis layer.
After joining certain lymphatics from the ovarian region, terminates in the
Paraaortic Lymph Nodes.
Innervation
Peripheral nervous system is divided
a)
Somatic Division
Innervates skeletal muscle
b) Autonomic Division
Innervates smooth muscle, cardiac muscle, and glands.
Pelvic visceral innervation is predominantly autonomic
Further divided in Sympathetic and Parasympathetic
Components.
Sympathetic Innervation to pelvic viscera begins with the Superior
Hypogastric Plexus (Presacral Nerve)
At the level of the sacral promontory, divides into a Right and a Left
Hypogastric Nerve, which run downward along the pelvis side walls
Rem Alfelor
Maternal Anatomy
Parasympathetic Innervation
Axons exit as part of the anterior rami of the spinal nerves for those levels.
These combine on each side to form the pelvic splanchnic nerves (Nervi
Erigentes)
Blending of the two Hypogastric Nerves (sympathetic) and the two Pelvic
Splanchnic Nerves (parasympathetic) gives rise to the Inferior Hypogastric
Plexus (Pelvic Plexus)
From here, fibers of this plexus accompany internal iliac artery branches
to their respective pelvic viscera.
Inferior Hypogastric Plexus
Most afferent sensory fibers from the uterus ascend through the inferior
hypogastric plexus and enter the spinal cord via T10-T12 and L1 spinal
nerves
Transmit the painful stimuli of contractions to the central nervous
system
Sensory nerves from the cervix and upper part of the birth canal pass through
the pelvic splanchnic nerves to the second, third, and fourth sacral nerves.
Those from the lower portion of the birth canal pass primarily through the
Pudendal Nerve.
Originates from the lateral and upper posterior portion of the uterus
3-4 mm in diameter
Central portion
There are a large number of arteries and veins and small number of
smooth muscle fibers.
Supplied with both sympathetic and parasympathetic nerves.
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Others are derived from the plexus that surrounds the ovarian
branch of the uterine artery.
Parasympathetic input: Vagus Nerve
Sensory afferents follow the ovarian artery and enter at T10 spinal
cord level.
Fallopian Tubes
Called Oviducts
Serpentine tubes extend 8-14 cm from the uterine cornua
Anatomically classified along their length as an
a)
Interstitial Portion
b) Isthmus
c)
Ampulla
d) Infundibulum
Interstitial Portion
Most proximal
Narrow 2-3 Mm
5-8 mm
More lateral
Infundibulum
Myosalpinx
Smooth muscle
Arranged in an inner circular and an outer longitudinal layer.
In the distal tube, the two layers are less distinct and are replaced
near the fimbriated extremity by sparse interlacing muscular fibers.
Tubal musculature undergoes rhythmic contractions constantly, the
rate of which varies with cyclical ovarian hormonal changes.
Endosalpinx
Tubal mucosa
Single columnar epithelium composed of ciliated and secretory cells
resting on a sparse lamina propria
In close contact with the underlying myosalpinx.
Ciliated cells are most abundant at the fimbriated extremity, but
elsewhere, they are found in discrete patches
Mucosa is arranged in longitudinal folds that become progressively
more complex toward the fimbria
Ampulla: lumen is occupied almost completely by the arborescent mucosa
Current produced by the tubal cilia is such that the direction of flow is
toward the uterine cavity.
Nerve supply derives partly from the Ovarian Plexus and partly from the
Uterovaginal Plexus.
Maternal Anatomy
Pelvic Bones
Pelvis
S:linea terminalis
I: pelvic outlet
Straight line drawn from the promontory to the tip of the sacrum usually
measures 10 cm
Pelvic Joints
A: pelvic bones are joined together by the symphysis pubis.
Between the sacrum and the iliac portion of the innominate bones to form
the Sacroiliac Joints.
Pelvic Inlet
Also called the Superior Strait
Bounded:
P: promontory and alae of the sacrum
L: linea terminalis
A: horizontal pubic rami and the symphysis pubis.
Rem Alfelor
Maternal Anatomy
During labor, the degree of fetal head descent into the true pelvis may be
described by station, and the midpelvis and ischial spines serve to mark
zero station
Interspinous Diameter
10 cm or slightly greater
Usually the smallest pelvic diameter
Anteroposterior Diameter
Through the level of the ischial spines
Normally measures at least 11.5 cm
Pelvic Outlet
Anteroposterior
Transverse
Posterior sagittal
Unless there is significant pelvic bony disease, the pelvic outlet seldom
obstructs vaginal delivery.
Pelvic Shapes
Caldwell-Moloy anatomical classification of the pelvis based on shape, and its
concepts aid an understanding of labor mechanisms.
Greatest transverse diameter of the inlet and its division into anterior and
posterior segments are used to classify the pelvis as
a)
Gynecoid
b) Anthropoid
c)
Android
d) Platypelloid
Gynecoid pelvis with an android tendency means that the posterior pelvis
is gynecoid and the anterior pelvis is android shaped.
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