[OBSTETRICS A] MATERNAL ANATOMY: EXTERNAL AND INTERNAL GENERATIVE ORGANS

MATERNAL ANATOMY: EXTERNAL AND INTERNAL RECTUS SHEATH

GENERATIVE ORGANS Fibrous aponeuroses of the external oblique, internal
oblique, and transversus abdominis muscles join in the
ANTERIOR ABDOMINAL WALL midline
These fuse at the linea alba, which normally measures 10
to 15 mm wide below the umbilicus An abnormally wide
separation may reflect diastasis recti or hernia
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

Confines abdominal viscera

Stretches to accommodate the expanding uterus
Provides surgical access to the internal reproductive organs
A comprehensive knowledge of its layered structure is
required to surgically enter the peritoneal cavity

SKIN
Langer lines
- Describe the orientation of
dermal fibers
- In the abdomen: Transversely
arranged
- Vertical skin incisions BLOOD SUPPLY
o More tension, wider scars Femoral Artery Branches - supply the skin and
- Low transverse incisions subcutaneous layers of the anterior abdominal wall and
(Pfannenstiel) mons pubis
o Follow Langer lines; superior Superficial Epigastric
cosmetic results Superficial Circumflex Iliac
External Pudendal
SUBCUTANEOUS LAYER External Iliac Artery Branches - supply the muscles and
Campers fascia fascia of the anterior abdominal wall
Superficial Inferior "Deep" Epigastric Vessels
Predominantly fatty layer Deep Circumflex Iliac Vessels
Camper fascia continues onto the perineum Provide
fatty substance to the mons pubis and labia majora and HESSELBACH TRIANGLE
then to blend with fat of the ischioanal fossa Boundaries:
Scarpas fascia Inferiorly: Inguinal ligament
Deeper Medially: Lateral border of the rectus muscles
More membranous layer Laterally: Inferior epigastric vessels
Scarpa fascia continues inferiorly to the perineum as Colles Direct Hernias - involves the Hesselbach triangle
fascia Perineal infection of hemorrhage superficial to Indirect Hernias - involves the deep inguinal ring
Colles fascia has the ability to extend upward to involve
the superficial layers of the abdominal wall INNERVATION
These are not discrete layers but instead represent a Intercostal Nerves (T7-11)
continuum of the subcutaneous tissue layer. Subcostal Nerve (T12)
Iliohypogastric and Ilioinguinal Nerves (L1)
Iliohypogastric Nerve
- Skin over suprapubic area

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 [OBSTETRICS A] MATERNAL ANATOMY: EXTERNAL AND INTERNAL GENERATIVE ORGANS

Ilioinguinal Nerve LABIA MINORA

- Skin of the lower abdominal wall Male homologue: Ventral shaft of the penis
- Upper portion of the labia majora Composed of connective tissue with many vessels and
- Medial portion of the thigh some smooth muscular fibers
T10 dermatome - approximates the level of the umbilicus Moist and reddish, similar in appearance to a mucous
Clinical Significance membrane
The ilioinguinal and iliohypogastric nerves can be Extremely sensitive because its supplied with many nerve
entrapped during closure of low transverse incisions, endings
especially if incisions extend beyond the lateral borders of 2 lamellae superiorly
the rectus muscle - Lower pair: Forms the frenulum of the clitoris
These nerves carry sensory information only, and injury - Upper pair: Forms the prepuce
leads to loss of sensation within the areas supplied Inferiorly, it forms the fourchette
Lining epithelium
- Outer and lateral portion of inner surface - Stratified
EXTERNAL GENERATIVE ORGANS Squamous Epithelium
VULVA - Medial portion - Non-keratinized Squamous Epithelium
PUDENDA or VULVA Hart line - demarcation line between lateral and midline
Includes all structures visible externally from the pubis to portion
the perineum: Contains sebaceous follicles, few sweat glands
- Mons pubis Lack hair follicles, eccrine glands and apocrine glands
- Labia majora and
minora CLITORIS
- Clitoris Male
- Hymen homologue:
- Vestibule Penis
- Urethral opening Composed
- Various glandular of a glans, a
and vascular corpus, and
structures two crura
Greater vestibular or Bartholin glands Rarely
Minor vestibular glands exceeds 2
Paraurethral glands cm in length
Covered by stratified squamous epithelium that is richly
MONS PUBIS supplied with nerve ending
Also called mons veneris - Principal female erogenous organ
Fat-filled cushion that lies over the symphysis pubis
At puberty, covered by curly hair that forms the VESTIBULE
escutcheon From embryonic urogenital membrane
- In adult women, it is distributed in a triangular area Almond-shaped
o Base: forms the upper margin of the symphysis pubis Boundaries:
o Tip: ends at the clitoris - Lateral: Hart line
In men and some hirsute women, the escutcheon is not - Medial: External
so well circumscribed and extends onto the anterior surface of hymen
abdominal wall toward the umbilicus - Anteriorly: Frenulum
- Posteriorly:
LABIA MAJORA Fourchette
Male homologue: Scrotum 6 Openings:
It is where the round ligaments terminate (upper border) - Urethra
Outer surface with hair while inner surface without hairs - Vagina
- In children and nulliparous women - close apposition - Ducts of the Bartholin glands (2)
- In multiparous women - gapes widely - Ducts of the paraurethral glands/skene glands (2)
Continuous directly with the mons pubis Fossa Navicularis - posterior portion of the vestibule
Merge posteriorly to form the posterior commissure between the fourchette and the vaginal opening
Apocrine, eccrine, and sebaceous glands are abundant Usually observed only in nulliparas

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 [OBSTETRICS A] MATERNAL ANATOMY: EXTERNAL AND INTERNAL GENERATIVE ORGANS

VESTIBULAR GLANDS VAGINA

Bartholin Glands Musculo-membranous structure
- Greater vestibular glands Extends from the vulva to the uterus
- 0.5 to 1 cm in diameter Interposed anteriorly and posteriorly between the urinary
- Lie inferior to the vestibular bulbs and deep to the bladder and the rectum
inferior ends of the bulbocavernosus muscle Lining Epithelium: Non-keratinized stratified squamous
- Ducts are 1.5 to 2 cm long and open distal to the epithelium
hymenal ring at 5 & 7 o'clock No glands
Following trauma or infection, either duct may swell and Abundant vascular supply
obstruct to form a cyst or, if infected, an abscess Embryology:
Paraurethral Glands - Upper portion: Mllerian Ducts
- Lies in the inferior aspect of the urethra - Lower portion: Urogenital Sinus
- Skene Glands - largest Divided by a septum from the urethra and the rectum
- Minor Vestibular Glands - shallow glands lined by - Anteriorly: Vesicovaginal septum
simple mucin-secreting epithelium and open along Hart - Posteriorly: Rectovaginal septum
line Upper fourth of the vagina is separated from the rectum
Clinically, inflammation and duct obstruction of any by the rectouterine pouch (cul-de-sac of Douglas)
paraurethral glands can lead to urethral diverticulum Subdivided into the anterior, posterior, and two lateral
formation fornices by the uterine cervix
Usual vaginal length:
VESTIBULAR BULBS - Anterior: 6 to 8 cm
Male homologue: Corpus spongiosum of the penis - Posterior: 7 to 10cm
Almond-shaped, mainly composed of aggregations of Clinical Importance:
veins - Internal pelvic organs usually can be palpated through
3 to 4 cm long, 1 to 2 cm wide, and 0.5 to 1 cm thick their thin walls
Lie beneath the bulbocavernosus muscle on either side of - Posterior fornix provides surgical access to the
the vestibule peritoneal cavity
If injured, may rupture to create a vulvar hematoma
LYMPHATIC
BLOOD SUPPLY
VAGINA AND HYMEN DRAINAGE
HYMEN Upper Cervicovaginal branches
Iliac nodes
Elastic and collagenous connective tissue Third of uterine arteries
Lined by stratified squamous epithelium Middle
Inferior vesical arteries Internal iliac nodes
No glandular or muscular elements, and it is not richly Third
supplied with nerve fibers Lower Middle rectal and internal Inguinal lymph
Appearance varies with age: Third pudendal arteries nodes
- Newborn Very vascular and redundant
- Pregnant Thick and rich in glycogen PERINEUM
- Menopause Thin; focal cornification may develop PERINEUM
Appearance of the hymen cannot be used to determine Boundaries:
whether a woman has begun sexual activity

Clinical Significance:
- Imperforate Hymen
o A rare lesion in
which the vaginal - Anterior: Pubic symphysis
orifice is occluded - Posterior: Ischiopubic rami
completely, - Anterolateral: Ischial tuberosities
causing retention - Posterolateral: Sacrotuberous ligaments
of menstrual blood - Posterior: Coccyx

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 [OBSTETRICS A] MATERNAL ANATOMY: EXTERNAL AND INTERNAL GENERATIVE ORGANS

Blood Supply: PUDENDAL NERVE

- Internal Pudendal Artery (inferior rectal artery and
posterior labial artery)
Ischial Tuberosities divides the perineum into an
anterior and posterior triangle

Formed by the anterior rami of S2-S4

ANTERIOR TRIANGLE Lies posteromedial to the ischial spines
Also called Urogenital Triangle 3 Terminal branches:
Further subdivided into: - Dorsal Nerve - supplies the skin of the clitoris
- Superficial Space: Closed compartment - Perineal Nerve - serves the muscles of the anterior
- Deep Space: Continuous superiorly with the pelvic triangle and labial skin
cavity - Inferior Rectal Branch - supplies the following:
Boundaries: o External anal sphincter
- Superior: Pubic rami o Mucous membrane of the anal
- Lateral: Ischial tuberosities o Perianal skin
- Posterior: Superficial transverse perineal muscle
ANUS
SUPERFICIAL SPACE OF THE ANTERIOR TRIANGLE
Ischiocavernosus Helps maintain clitoral
Muscles erection
Constrict the vaginal lumen
and aid in the release of
Bulbocavernosus
secretions of the Bartholins
Muscles
gland
Contributes to clitoral erection
Superficial Transverse Contributes to the perineal
Perineal Muscles body

DEEP SPACE OF THE ANTERIOR TRIANGLE

External Anal Sphincter (EAS)
Compressor urethrae
- Maintains a constant state of resting contraction
Urethrovaginal sphincter muscles
- Provides increased tone and strength when continence
External urethral sphincter
is threatened
Parts of urethra and vagina
- Relaxes for defacation
Branches of the internal pudendal artery
Internal Anal Sphincter (IAS)
Dorsal nerve
- Primarily involved in 4th degree perineal laceration
Vein of the clitoris
ANAL CUSHION
POSTERIOR TRIANGLE
Highly vascularized
Contains:
Aids in fecal continence
- Ischiorectal fossa
Engorgement due to
- Anal canal
increased uterine size,
- Anal sphincter complex
excessive straining and
Internal anal sphincter
hard stools, leads to
External anal sphincter
hemorrhoids
Puborectalis muscles
- Branches of the internal pudendal vessels
- Pudendal nerve

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 [OBSTETRICS A] MATERNAL ANATOMY: EXTERNAL AND INTERNAL GENERATIVE ORGANS
INTERNAL GENERATIVE ORGANS
EMBRYOLOGICAL DEVELOPMENT OF THE UTERUS AND
OVIDUCTS
Fusion of the two mllerian ducts to form a single canal is
begun at the level of the inguinal crest, that is, the
gubernaculum (primordium of the round ligament)
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
5th week of embryonic development - uterus and tubes arise
from the mllerian ducts, which first appear near the upper
pole of the urogenital ridge
6th week of embryonic life - the growing tips of the two
mllerian ducts approach each other in the midline; they
reach the urogenital sinus 1 week later
CERVIX
Anteriorly, upper boundary Internal os
Supravaginal Segment
Covered by peritoneum on its posterior surface
Attached to the cardinal ligaments anteriorly, and it is
separated from the overlying bladder by loose connective
tissue
Lower vaginal portion Portio vaginalis
The mucosa is a single layer of very high ciliated columnar
epithelium that rests on a thin basement membrane
Glands furnish the thick, tenacious cervical secretions
If the ducts of the cervical glands are occluded, retention
cysts, known as nabothian cysts, are formed
UTERUS
Thick- walled, hollow, muscular organ
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
The bulk of the body of the uterus is composed of muscle
The cervical canal is fusiform and is open at each end by
small apertures, the internal os and the external os
Body of the Uterus:
Composed of serosal, muscular, and mucosal layers
The serosal layer is formed by the peritoneum that covers
the uterus
ENDOMETRIUM
Thin, pink, velvet-like membrane perforated by a large
number of minute ostia of the uterine glands
Histologically: Inner glands resemble the epithelium of
the surface and are lined by a single layer of columnar,
partially ciliated epithelium that rests on a thin basement
membrane
MYOMETRIUM
Makes up the bulk of the uterus
Bundles of smooth muscle united by connective tissue in
which there are many elastic fibers
The number of muscle fibers of the diminishes caudally
Musculature:
- Inner wall > Outer wall
- A and P walls > lateral walls
During pregnancy, the upper myometrium undergoes
marked hypertrophy, but there is no significant change in
cervical muscle content
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 [OBSTETRICS A] MATERNAL ANATOMY: EXTERNAL AND INTERNAL GENERATIVE ORGANS

BLOOD SUPPLY OF THE UTERUS 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

OVIDUCTS
Musculature
Inner circular and
outer longitudinal
layer
Lined by a single
layer of columnar
cells, some of them
UTERINE LIGAMENTS ciliated and others
BROAD LIGAMENT secretory
Made up of two wing-like structures that extend from the No submucosa
lateral margins of the uterus to the pelvic walls The epithelium is in close contact with the underlying
Divide the pelvic cavity into anterior and posterior muscle
compartments Tubal peristalsis is believed to be an extraordinarily
Upper part is made up of three folds that nearly cover the important factor in transport of the ovum
oviduct Supplied richly with elastic tissue, blood vessels, and
lymphatics
CARDINAL LIGAMENT Sympathetic innervation of the tubes is extensive, in
Transverse cervical ligament or the Mackenrodt ligament contrast to their parasympathetic innervation
Densest portion Diverticula may extend occasionally from the lumen of the
Composed of connective tissue that medially is united tube; may play a role in the development of ectopic
firmly to the supravaginal portion of the cervix pregnancy

ROUND LIGAMENTS OVARIES

Extend from the lateral portion of the uterus, arising The ovaries vary
below and anterior to the origin of the oviducts considerably in size
In non-pregnant women, the round ligament varies from During childbearing
3 to 5 mm in diameter years, they are
Composed of smooth muscle cells from 2.5 to 5 cm in
Corresponds embryologically to the gubernaculum testis length, 1.5 to 3 cm
of men in breadth, and 0.6
During pregnancy, undergo considerable hypertrophy and to 1.5 cm in
increase appreciably in both length and diameter thickness
After menopause, ovarian size diminishes remarkably
Attached to the broad ligament by the mesovarium
Utero-ovarian ligament extends from the lateral and
posterior portion of the uterus, just beneath the tubal
insertion, to the uterine pole of the ovary
It is covered by peritoneum and is made up of muscle and
connective tissue fibers
Infundibulopelvic or suspensory ligament of the ovary-
extends from the upper or tubal pole to the pelvic wall
Parts:
Cortex: Outer layer
Medulla: Central portion
Blood Supply:
The ovaries are supplied with both sympathetic and
parasympathetic nerves

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