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MATERNAL ANATOMY

External and Internal


Generative Organs

FEU-NRMF
Department of Obstetrics and Gynecology
ANTERIOR ABDOMINAL WALL
confines abdominal
viscera
stretches to
accommodate the
expanding uterus
provides surgical
access to the
internal
reproductive
organs
ANTERIOR ABDOMINAL WALL
ANTERIOR ABDOMINAL WALL
Skin
LANGER LINES
describe the orientation of
dermal fibers
In the abdomen:
Transversely arranged
vertical skin incisions
more tension, wider scars
low transverse incisions
(Pfannenstiel)
follow Langer lines; superior
cosmetic results
Subcutaneous Layer
Campers fascia
Superficial
predominantly fatty layer
Scarpas fascia
Deeper
more membranous layer

These are not discrete layers


but instead represent a
continuum of the
subcutaneous tissue layer.
Rectus Sheath

fibrous aponeuroses of the external oblique,


internal oblique, and transversus abdominis
muscles join in the midline
Arcuate Line
Cephalad- aponeuroses
invest the rectus
abdominis bellies above
and below

Caudal- all aponeuroses


lie anterior to the rectus
abdominis muscle, and
only the thin transversalis
fascia and peritoneum lie
beneath.
Blood Supply
Blood Supply
A. Femoral Artery Branches arteries
supply the skin and subcutaneous layers of
the anterior abdominal wall and mons
pubis
superficial epigastric
superficial circumflex iliac
external pudendal

B. External Iliac Artery Branches - supply


the muscles and fascia of the anterior
abdominal wall
inferior "deep" epigastric vessels
deep circumflex iliac vessels-.
Hesselbach triangle
Boundaries:
Inferiorly:
inguinal ligament
Medially: lateral
border of the
rectus muscles
Laterally: inferior
epigastric vessels.
Hesselbach triangle
CLINICAL
SIGNIFICANCE:
Direct hernias-
involves the
Hesselbach
triangle
Indirect hernias-
involves the
deep inguinal
ring
Anterior Abdominal Wall
Innervation
Intercostal nerves (T7-11)
Subcostal nerve (T12)
Iliohypogastric nerve- skin over
suprapubic area
Ilioinguinal nerves (L1)-
skin of the lower abdominal
wall
upper portion of the labia
majora
medial portion of the thigh
T10 dermatome- approximates
the level of the umbilicus.
Clinical Significance
ILIOINGUINAL AND ILIOHYPOGASTRIC NERVES
can be entrapped during closure of low
transverse incisions, especially if incisions
extend beyond the lateral borders of the
rectus muscle

carry sensory information only, and injury


leads to loss of sensation within the areas
supplied.
EXTERNAL
GENERATIVE
ORGANS
EXTERNAL GENERATIVE ORGANS
PUDENDA or VULVA
includes all structures
visible externally from
the pubis to the
perineum:
Mons pubis
Labia majora and minora
Clitoris
Hymen
Vestibule
Urethral opening
Various glandular and
vascular structures
EXTERNAL GENERATIVE ORGANS
MONS PUBIS
Also called mons veneris
fat-filled cushion that lies
over the symphysis pubis
At puberty, covered by
curly hair that forms the
escutcheon
In adult women, it is
distributed in a
triangular area
Base: forms the upper
margin of the symphysis
pubis
EXTERNAL GENERATIVE ORGANS
LABIA MAJORA
Male homologue: scrotum
It is where the round ligaments
terminate (upper boarder)
Outer surface with hair while
inner surface without hairs
In children and nulliparous women -
close apposition
In multiparous women - gapes widely
continuous directly with the
mons pubis
Merge posteriorly to form the
posterior commissure.
EXTERNAL GENERATIVE ORGANS
LABIA MINORA
composed of connective tissue
with many vessels and some
smooth muscular fibers
moist and reddish, similar in
appearance to a mucous
membrane
extremely sensitive because its
supplied with many nerve endings
2 lamellae superiorly
lower pair: forms the frenulum
of the clitoris
upper pair: forms the prepuce
Inferiorly, it forms the fourchette.
EXTERNAL GENERATIVE ORGANS
LABIA MAJORA
Lining epithelium
Outer and Lateral portion of inner surface- stratified
squamous epithelium
Medial portion- non-keratinized squamous epithelium

Hart line- demarcation line between lateral and midline


portion

Contains sebaceous follicles, few sweat glands


Lack hair follicles, eccrine glands and apocrine glands
EXTERNAL GENERATIVE ORGANS
CLITORIS
Male homologue: penis
composed of a glans, a
corpus, and two crura
rarely exceeds 2 cm in
length.
covered by stratified
squamous epithelium that is
richly supplied with nerve
ending
principal female erogenous
organ
EXTERNAL GENERATIVE ORGANS
VESTIBULE
from embryonic
urogenital membrane
almond-shaped
BOUNDARIES:
Lateral- Hart line
Medial external
surface of hymen
Anteriorly- frenulum
Posteriorly- fourchette
EXTERNAL GENERATIVE ORGANS
VESTIBULE
6 openings:
urethra
vagina
ducts of the
Bartholin glands (2)
ducts of the
paraurethral
glands/skene glands
(2)
Vestibular Glands
BARTHOLINS GLANDS
greater vestibular glands
0.5 to 1 cm in diameter
lie inferior to the vestibular
bulbs and deep to the
inferior ends of the
bulbocavernosus muscle
ducts are 1.5 to 2 cm long
and open distal to the
hymenal ring at 5 & 7
o'clock
Vestibular Glands
BARTHOLINS GLANDS
CLINICAL SIGNIFICANCE:
Following trauma or
infection, either duct may
swell and obstruct to
form a cyst, or if infected,
an abscess
Vestibular Glands
PARAURETHRAL
GLANDS
Lies in the inferior
aspect of the urethra
Skene glands - largest
Minor vestibular
glands - are shallow
glands lined by simple
mucin-secreting
epithelium and open
along Hart line.
Vestibular Glands

PARAURETHRAL
GLANDS
CLINICAL SIGNIFICANCE:
Inflammation and
duct obstruction of
any of the
paraurethral glands
can lead to a urethral
diverticulum
formation.
Vestibular Bulbs
Male homologue: corpus Bulbocavernosus
muscle
spongiosum of the penis
almond-shaped, mainly
Vestibular bulb
composed of
aggregations of veins
3 to 4 cm long, 1 to 2 cm
wide, and 0.5 to 1 cm
thick
lie beneath the
bulbocavernosus muscle
on either side of the
vestibule.
Vestibular Bulbs

CLINICAL
SIGNIFICANCE:
During childbirth, the
vestibular bulbs may
be injured and may
even rupture to
create a vulvar
hematoma
VAGINAL OPENING AND HYMEN

Vaginal opening is
rimmed distally
by the hymen or
its remnants
VAGINAL OPENING AND HYMEN

HYMEN
Membrane
surrounding the
vaginal opening
Composed of elastic
and collagenous
connective tissue
Covered by stratified
squamous epithelium
VAGINAL OPENING AND HYMEN
The aperture of the hymen
varies.
Hymen is torn at several
sites during first coitus.
Identical tears may occur by
other penetration. The
edges of the torn hymen
soon reepithelialize
hymenal caruncle
Imperforate hymen
Rare lesion in which the
vaginal orifice is occluded
completely, causing retention
of menstrual blood
VAGINAL OPENING AND HYMEN
VAGINA
Musculo-membranous
structure
Extends from the vulva to the
uterus
interposed anteriorly and
posteriorly between the urinary
bladder and the rectum .
Lining epithelium: non-
keratinized stratified squamous
epithelium
no glands
abundant vascular supply
VAGINAL OPENING AND HYMEN
VAGINA
Embryology
upper portion - mllerian ducts
lower portion - urogenital sinus
VAGINAL OPENING AND HYMEN
VAGINA
Anteriorly, the vagina is separated
from the bladder and urethra by
connective called vesicovaginal
septum

Posteriorly, there are similar


tissues together that form the
rectovaginal septum between the
lower portion of the vagina and
the rectum

The upper fourth of the vaginal is


separated from the rectum by the
rectouterine pouch or culdesac of
Douglas
VAGINAL OPENING AND HYMEN
VAGINA
Length
Anterior: 6 8cm
Posterior: 7 10cm
Subdivided by the
cervix into fornices
anterior, posterior,
lateral
VAGINAL OPENING AND HYMEN
VAGINA
The fornices are
clinically important
because the internal
pelvic organs can be
palpated through
their thin walls
Posterior fornix
provides surgical
access to the
peritoneal cavity
VAGINAL OPENING AND HYMEN
VAGINA

BLOOD SUPPLY LYMPHATIC DRAINAGE

cervicovaginal
branches of uterine Externa, internal and
Upper Third
artery and vaginal common iliac nodes
artery
Middle third inferior vesical arteries Internal iliac nodes
middle rectal and
Lower third internal pudendal Inguinal nodes
arteries
PERINEUM
The diamond area between the thighs
Boundaries are same as those of the bony pelvic outlet
Anterior: Pubic symphysis
Posterior: Ischiopubic rami
Anterolateral: Ischial tuberosities
Posterolateral: Sacrotuberous ligaments
Posterior: Coccyx

Blood supply:
Internal pudendal artery (inferior rectal artery and posterior
labial artery)
Anterior triangle, also
called the urogenital
triangle

Posterior triangle, also


called the anal triangle

Ischial Tuberosities divides the perineum into an


anterior and posterior triangle
PERINEUM
ANTERIOR TRIANGLE
Also called Urogenital Triangle
Further subdivided into:
Superficial space closed compartment
Deep space continuous superiorly with the
pelvic cavity

Boundaries:
Superior: Pubic rami
Lateral: Ischial tuberosities
Posterior: Superficial transverse pernieal muscle
PERINEUM
PERINEUM
SUPERFICIAL SPACE OF THE ANTERIOR TRIANGLE
attached at the ischial tuberosity and crus
Ischiocavernosus of clitoris helps maintain clitoral erection
Overly the vestibular bulb and Bartholin
glands
Attached at the perineal body and the
clitoris
Bulbocavernosus Constrict the vaginal lumen and aid in the
release of secretions of the Bartholins
gland
Contributes to clitoral erection
Superficial transverse attach to the ischial tuberosities laterall
perineal muscles and the perineal body medially
PERINEUM
DEEPSPACE OF THE ANTERIOR
TRIANGLE

Deep to the perineal


membrane and extends up
continuous superiorly with the
pelvic cavity

Contains: compressor urethrae,


urethrovaginal sphincter
muslces, external urethral
sphincter, parts of urethra and
vagina, branches of internal
pudendal artery, dorsal nerve
and vein of the clitoris
PERINEUM
POSTERIOR TRIANGLE
Contains:
Ischiorectal fossa
Anal canal
Anal sphincter complex
Branches of the internal
pudendal vessels
Pudendal nerve
POSTERIOR TRIANGLE
PERINEUM
Ischiorectal fossae
Two fat filled wedge shaped
spaces on either side of the
anal canal
Provide support to
surrounding structures, yet
allow distension of the
rectum during defecation and
stretching of the vagina
during delivery
Anal canal and sphincter lie in
the center of the fossae.
This continuity of the fossae
across perineal
compartments allows fluid,
infection and malignancy to
spread.
PERINEUM
PUDENDAL NERVE
Formed by the anterior rami
of S2-S4
Lies posteromedial to the
ischial spines
PERINEUM
PUDENDAL NERVE
3 terminal branches:
Dorsal nerve of the
clitoris supplies the
skin of the clitoris
Perineal nerve
supplies the muscles
of the anterior triangle
and labial skin
Inferior rectal nerve
supplies the external
anal sphincter,
mucous membrane of
anal canal and the
perineal skin
Anus
EXTERNAL ANAL SPHINCTERS
A ring of striated muscle attached to the perineal body
anteriorly and the coccyx posteriorly
Maintains the constant state of resting contraction
Receives blood supply from the inferior rectal artery
Motor fibers come from the inferior rectal branch of the
pudendal nerve
Anus
INTERNAL ANAL
SPHINCTER
Contributes the bulk of
the anal canal resting
pressure for fecal
continence
Formed by the distal
continuation of the
inner circular muscle
layer of the rectum and
colon
ANAL CUSHION
Highly vascularized
Aids in fecal
continence
Engorgement due to
increased uterine
size, excessive
straining and hard
stools, can increase
venous engorgement
within these cushions
to form hemorrhoids
Perineal body
Structures that
contribute to the
perineal body:
Median raphe of the
levator ani
Central tendon of the
perineum
Bulbocavernosus m.
Superficial transverse
perineal m.
External anal sphincter
INTERNAL
GENERATIVE
ORGANS
Development of the internal
generative organs
Embryological development
Fusion of the two mllerian
(paramesonephric) ducts to
form a single canal begins at
the level of the inguinal
crest, that is, the
gubernaculum (primordium
of the round ligament) 5th
week of development

Upper ends of the mllerian


ducts produce the oviducts
and the fused parts give rise
to the uterus

The vaginal canal is not


patent throughout its entire
length until the sixth month
of fetal life
INTERNAL GENERATIVE ORGANS
Cervix
Internal cervical os
upper boundary; level
at which the
peritoneum is reflected
up onto the bladder
Portio supravaginalis
is covered by
peritoneum on its
posterior surface
attached to the cardinal
ligaments laterally
Portio vaginalis
INTERNAL GENERATIVE ORGANS
Cervix
External cervical os before
childbirth: small, oval opening
External cervical os after
childbirth: transverse slit,
giving rise to the anterior and
posterior cervical lip
Cervical stroma compose
mainly of collagen, elastin and
proteoglycan but very little
smooth muscle
Ectocervix nonkeratinized
squamous epithelium
Endocervix mucin-secreting
columnar epithelium
INTERNAL GENERATIVE ORGANS
Uterus
Thick- walled, hollow, muscular
organ
Nulliparous: 6- 8cm, fundus and
cervix almost equal in length
Multiparous: 9-10cm, cervix is
1/3 of the total length

Entire posterior wall of the uterus


is covered by serosa, or
peritoneum, the lower portion of
which forms the anterior
boundary of the recto-uterine cul-
de-sac, or pouch of Douglas.
Blood supply:
uterine artery
ovarian artery
INTERNAL GENERATIVE ORGANS
Uterus: Parts
Corpus or body
Cervix
Isthmus between the
internal cervical os and the
endometrial cavity; forms
the lower uterine segment
during pregnancy
Cornua at the junction of
the superior and lateral
margins
Fundus convex upper
segment between the points
of insertion of the fallopian
tubes
INTERNAL GENERATIVE ORGANS
Uterus
Layers:
serosa
muscular (myometrium)
mucosa (endometrium)

The serosal layer is


formed by the
peritoneum that
covers the uterus
INTERNAL GENERATIVE ORGANS
Uterus: Myometrium
Bundles of smooth muscle united by
connective tissue in which there are many
elastic fibers
Relative more muscle in the inner wall
than the outer wall, and in the anterior
and posterior walls than in the lateral walls
Muscle fibers diminish caudally such that
the muscle comprises only 10% of the
tissue mass in the cervix
The interlacing myometrial fibers that
surround the myometrial vessels are
integral to control of bleeding from the
placental site during the third stage of
labor
INTERNAL GENERATIVE ORGANS
Uterus: Endometrium
thin, pink, velvet-like membrane perforated by a large
number of minute ostia of the uterine glands.
Histology
Epithelium - single layer of closely packed high
columnar cells than rests on a thin basement
membrane
Uterine glands invaginations of the epithelieum
that extend to the myometrium
Interglandular mesenchymal stroma varies
remarkably throughout the ovarian cycle, undergoes
decidualization following ovulation
INTERNAL GENERATIVE ORGANS
Uterus: Blood supply
INTERNAL GENERATIVE ORGANS
Uterus: Endometrium
Vascular architecture
Uterine and ovarian
arteries arcuate arteries
radial arteries
spiral/coiled arteries and
basal/straight arteries
Spiral arteries
midportion and superficial
third of the endometrium,
responsive to hormones
Basal arteries basal layer,
not responsive to
hormones
INTERNAL GENERATIVE ORGANS
ROUND LIGAMENTS
Extend from the lateral portion of
the uterus
Arise below and anterior to the
origin of the oviducts.
Terminate in the upper portion of
the labium majus.
Sampson artery runs within this
ligament.
Corresponds embryologically to
the gubernaculum testis of men
Clinically significant when doing
puerperal tubal sterilization
INTERNAL GENERATIVE ORGANS
BROAD LIGAMENTS
Winglike structures from
lateral margins to pelvic
sidewall
Each consist of an anterior
leaf and a posterior leaf
Drapes over structures
extending from the cornu
Mesosalpinx, mesoteres,
mesovarium, mesometrium
Suspensory ligament or
infundibulopelvic ligament
from the fimbriated end of
the fallopian tube to the
pelvic wall, where ovarian
vessels traverse
INTERNAL GENERATIVE ORGANS
CARDINAL LIGAMENTS
Transverse cervical or Mackendrodt ligament
Thick base of the broad ligament that is continuous
with the connective tissue of the pelvic floor
INTERNAL GENERATIVE ORGANS
UTEROSACRAL
LIGAMENTS
From its attachment
posterolaterally to
the supravaginal
portion of the cervix
and inserts into the
fascia over the
sacram
Form the lateral
boundaries of the
pouch of Douglas
INTERNAL GENERATIVE ORGANS

LYMPHATICS
Cervix
terminate mainly in the hypogastric nodes, which are
situated near the bifurcation of the common iliac vessels.
Body of the uterus
internal iliac nodes and periaortic lymph nodes
Blood Vessels
INTERNAL GENERATIVE ORGANS
FALLOPIAN TUBES
Also called oviducts
Vary in length from 8 to 14 cm.
lumen is lined by mucous
membrane.
PARTS
interstitial portion
isthmus
ampulla
infundibulum or fimbriated
extremity- funnel-shaped
opening at the distal
INTERNAL GENERATIVE ORGANS
FALLOPIAN TUBES
Tubal smooth muscle:
inner circular and outer
longitudinal, undergo
rhythmic contraction or
peristalsis toward the
uterine cavity
Epithelium in close
contact with muscle
layer because there is
no submucosa
Epithelium - columnar
cells (some ciliated,
others secretory)
INTERNAL GENERATIVE ORGANS
Ovaries
the ovaries vary considerably in
size.
During childbearing years, they are from
2.5 to 5 cm in length, 1.5 to 3 cm in
breadth, and 0.6 to 1.5 cm in thickness.
After menopause, ovarian size diminishes
remarkably.

Rest in a slight depression on


the lateral wall of the pelvis,
called ovarian fossa of Waldeyer
between the divergent external
and internal iliac vessels
Attached to the broad ligament
by the mesovarium.
INTERNAL GENERATIVE ORGANS
Ovaries
PARTS:
Cortex- outer layer, contains
oocytes and developing follicles
Medulla- central portion,
composed of loose connective
tissue

BLOOD SUPPLY
The ovaries are supplied with
both sympathetic nerves from
the ovarian plexus and
parasympathetic nerves.
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14,15 Blood
supply to the
uterus
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