ANATOMY AND PHYSIOLOGY OF FEMALE REPRODUCTIVE ORGANS

FOR BSc. NURSING STUDENTS, 2013G.C

By :Kihinetu .G

I. Anatomy of the female pelvis

Session objectives
By the end of this session, students will be able to Define pelvis. List the functions of female pelvis Describe the bones, joints and ligaments of the pelvis Demonstrate pelvic bones, joints and ligaments.
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pelvis
The part of the trunk inferoposterior to the abdomen. The area of transition between the trunk and the lower limbs. Part of the appendicular skeleton of the lower limb. The space or compartment surrounded by the pelvic girdle(bony pelvis).
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Anatomy of the female pelvis

A knowledge of pelvic anatomy is a great
importance to the students of midwifery, for during birth the fetus has to traverse the relatively unyielding ring which it forms on its passage from the uterus to the vulva. The student should be competent enough to recognize a normal pelvis in order to recognize deviation from normal and to refer for better management.

Function of pelvis
Adapted for child bearing Allow movement of the body Permits the person to sit and stand Transmits the weight of the trunk to the leg Affords protection to pelvic organs and a lesser extent to the abdominal contents

Fun..
Provide attachment for the powerful muscles of locomotion and posture. Provide attachment for the erectile bodies of the external genitalia. Provide attachment for the muscles and membranes that assist in these functions by forming the pelvic floor and filling gaps that exist in or around it.
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The bones of the pelvis

It is composed of four bones
Two innominate or hip bones One sacrum One coccyx

Each innominate bone is formed by fusion of three bones

The ileum The ischium The pubic bone

The three bones fussed at acetabulum

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Fig. Pelvic bones

The ilium
Is the large flared out part of the innominate bone Is made up of a relatively flat of bone above and part of acetabulum below.

the superior, fan-shaped part of the hip bone

It has the following characteristics: The external aspect is gently curved and has a roughened surface to which are attached the gluteal muscles of the buttock. The greater part of the inner aspect is smooth and concave forming the iliac fosse. The ridge which surmount these two surface is known as iliac crest, which serves for the attachment of the muscles of the abdominal wall.
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iliac crest
The superior margin of ileum . the fourth lumbar vertebra. Used as a surface marking when performing lumbar puncture. Ends interiorly in a rounded anterior superior iliac spine and posterior in a sharp posterior superior iliac spine.
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The ilium
Anteriorly the crest ends in the anterior superior iliac spine, a bony prominence which can be palpated under the skin. Posteriorly iliac crest ends in the posterior superior iliac spine. Below the anterior superior iliac spine is an other bony prominence the anterior inferior iliac spine, while posteriorly, there is posterior inferior iliac spine. At its lower most part the ileum forms the upper two- fifths of the acetabulum, where it fuses with ischium and pubis.
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The ilium
Behind the acetabulum, the ileum forms the upper part of a large notch, the greater sciatic notch, through which pass the piriforms muscles and the nerves of the sacral plexus, on their way from the front of the sacrum in to the thigh. On the inner aspect of the bone, the iliac fossa is bounded below by a prominent ridge, which is the iliac part of the ilio pectineal line. Anteriorly the ilio pectineal line swells into a bony prominence, at the point where the ileum fuses with superior ramus of the pubis, to form the ilio-pectineal eminence. Posterior to the ilio pectineal line and above the greater sciatic notch, is a roughened area , where the ileum articulate with the sacrum to form the sacro -iliac 12 joint.

The ischium
The lowest constituent bones of the innominate bone Formed by the following parts; The head forms the lowest two-fifths of the acetabulum, where it fuses with the ileum and pubis. Below the acetabulum a thick buttress of bone pass down and terminates in ischial tuberosity the part which the weight of the body rest on when sitting.
Passing up wards and in ward from the ischial tuberosity a small shaft of the ischium becomes continuous with the inferior ramus of the pubis so forming the public arch.
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The ischium
The ischium forms the lower boundary of the large foramen, the obturator foramen or foramen ovale. On its internal aspect the ischium forms the side wall of the true pelvis. Protruding in wards from its posterior edge, about 5cm above the tuberosity, is a conspicuous projection known as the ischial spine which is use to estimate the station of fetal head. Lesser sciatic notch is situated between the ischial spine above and ischial tuberosity below.
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The pubis
The smallest of the three bones forming the innominate bone and form the lower one fifth of the acetabulum. The right and left pubic bones unite with each other anteriorly at the square shaped pubic bodies. They are fused by a pad of cartilage, the symphysis pubis. The upper surface of the body forms a crest, the pubic crest, which ends laterally in the 15 pubic tubercle.

The pubis
Extending upwards from each pubic body, the superior ramus unites with ilium at iliopectineal eminence. Below the body of the pubic, the inferior ramus passes down wards and out wards to join the ischium, so forming the upper part of pubic arch
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The sacrum
Is situated in the posterior part of the pelvis and consists of five fused sacral vertebrae. The anterior surface is smooth, and is concave from above down wards and slightly so from side to side forming the hollow of the sacrum. The sacral alae are the widened out wings of bone on each side of the 1st sacral vertebra. Promontory of the sacrum is the center point of the upper border of the 1st sacral vertebrae which with the base of the 5th lumbar vertebra, protrudes over the hollow of the sacrum.
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The sacrum
Sacral canal runs longitudinally through the center of the sacrum and opens at the level of the 5th sacral vertebra. The posterior surface for the sacrum is rough and irregular and serves for the attachment of the ligaments and muscles of the back. The sacrum articulates laterally with the ileum at sacroiliac joint and lower margin of it articulate with coccyx at sacro18 coccygeal joint.

The coccyx
Consists of four fused coccygeal vertebrae. It is triangular in shape with its base uppermost. The 1st coccygeal vertebra articulates with lower end of the sacrum at the sacro-coccygeal joint. The remaining three vertebrae mere rudimentary nodules of bone; they are smooth in their inner surface where they support the rectum, while their lowest most tip are attached to the external anal sphincter and ano-coccygeal body.
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Pelvic joints

There are four pelvic joints Two sacro-iliac joints One symphysis pubis One sacro-coccygeal joints

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1. The sacro Iliac joints

Are the strongest joint in the body. They join the sacrum to the ileum and thus connect the spine to the pelvis. Their main features are; The joint cavity is very small The articular surfaces are placed on the inner surface of the ileum above the greater sciatic notch and on the lateral aspect of the sacrum, extending for the 1st two sacral vertebrae.
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The sacro Iliac joints

The supporting ligaments pass from the sacrum and the fifth lumbar vertebrae to the ileum both anterior and posterior to the joint cavity. Movements at these joints occur under normal conditions but are very slight. They increase in range during pregnancy and labor when the ligaments become softened under the influence of the hormone relaxin.
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2. The symphysis pubis

Is formed at the junction of the pubic bones which are united by a pad of cartilages. It is reinforced by supporting ligaments which pass from one pubic bone to the other in front, behind, above and below the disc of cartilage.

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3. The sacro- coccygeal joint

Is situated between the lower border of the sacrum and the upper border of the coccyx. Slight back ward and forward movement of the coccyx on the lower end of the sacrum occur normally; the back ward movement is greatly increased during labor at the time of the actual birth of the head.
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The pelvic ligaments

Each of the pelvic joints held together by ligaments These are: pubic ligaments sacro-iliac ligament sacro-coccygeal ligaments

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The pelvic ligaments

Sacro- tuberous ligaments is a strong ligament passing from the posterior superior iliac spine and lateral borders of the sacrum and coccyx to the ischial tuberosity. It bridges across the greater and lesser sciatic notches The sacro- spinous ligament - passes from the side of the sacrum and coccyx across the greater sciatic notch to the ischial spine. It lies in front of the sacro27 tuberous ligament.

The pelvic ligaments

The inguinal ligament (paupers ligament )-runs from the anterior superior iliac spine to the pubic tubercle forming the groin.

The sacro- tuberous ligament and sacrospinous ligaments cross the sciatic notch and form the posterior wall of the pelvic out let.

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The regions of the pelvis

The brim of the pelvis divides the pelvis into two parts, the false and true pelvis . The false pelvis lies above the pelvic brim and consists mainly of the iliac fosse. It has little importance in midwifery. The true pelvis included the pelvic brim and all the area that lies below- It consists of three constituent parts; The in let or brim of the pelvis The cavity The out let
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The pelvic brim

Is round except where the sacral promontory projects in to it. It appears heart shaped because of sutting sacral prominence. It is wider transversely than in the anterior-posterior dimension. It is marked by 8 fixed land marks
1. 2. 3. 4. The promontory of the sacrum The alae of the sacrum The sacro- iliac joint Ilio - pectineal line -(which is the edge formed at the inward
aspect of the ilium)
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The pelvic brim

5. Ilion- pectineal eminence-(the superior ramus of the
pubic bone meets the ilium)

6. Inner border of the superior ramus of pubic bone. 7. Upper inner border of the body of pubic bone 8. upper inner border of symphysis pubis

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The pelvic cavity

Extends from the in let above to the out let below. Formed by the hollow of the sacrum. The posterior wall is deeply concave and approximately 12cm in length. The anterior wall is formed by symphysis pubis and is approximately 4cm long. The lateral walls comprise the greater sciatic notch, the internal surface of a small portion of the ileum, the body of the ischium and the foramen ovale.
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The pelvic cavity

The plane of the cavity of the pelvis is an imaginary surface which extends from the mid point of the symphysis pubis in front to the junction of the 2nd and 3rd sacral vertebrae. Ischial spine marks the mid plane of the pelvis

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The pelvic out let

Two out let of the pelvis are described - the anatomical and the obstetrical. i) The anatomical out let It is diamond in shape . Is formed by the structures which mark the lower border of the pelvis- these are: The lower border of the symphysis pubis The pubic arch The inner border of the ischial tuberosity. The sacro tuberous ligament The tip of the coccyx.
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The pelvic out let

ii) The obstetrical out let is the constricted lower portion of the pelvis and not merely its lower bony border. It is the segment of the f the pelvis which lies between the anatomical outlet below and an artificial line above. Its land marks are: The lower border of the symphysis pubis The ischial spine The sacro-spinous ligament The lower border of the sacrum
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The Dimensions of the Normal pelvis

Diameters of the Brim
Anterior posterior diameters is a line from the sacral promontory to the upper border of the symphysis pubis.
When the line taken to the upper most point of the symphysis it is called the anatomical conjugate or conjugate Vera and it measures 12cm. The measurement from the promontory of the sacrum to inner most margin of the symphysis pubis is the obstetrical conjugate and measures 11cm.
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Dimensions.
The diagonal conjugate is measured anteriorposteriorly from the lower border of the symphysis pubis to sacral promontory and measures 12-13cm.

It may be estimated pervaginum as a part of pelvic assessment. The oblique diameter passes from the sacro-iliac joints to the opposite ilio- pectineal eminence. It measures12cm. The transverse diameters is a line between the points farther most a part on the ilio- pectineal lines and measures 13 cm. The sacro- cotyloid diameter is a line passing from the promontary of the sacrum to the ilio- pectineal eminence and it measures 9.5 cm on each side.
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Dimensions
The diameters of the cavity - The cavity is circular in shape and all diameter are equal in length. Anterior- posterior diameters posses from the mid point of symphysis pubis to the junction of the 2nd and 3rd sacral vertebrae and measures 12cm. The oblique diameter- pass obliquely in the plane of the cavity parallel to the oblique diameters of the brim. It measures 12cm. The Transverse diameter- passes in the plane of the cavity between the points far most apart in the lateral pelvic walls and measures 12cm.
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Dimensions
The diameters of out let

The anterior-posterior diameter passes from the lower border of the symphysis pubis to the sacrococcygeal joint and measures 13cm. There are two transverse diameters;
The 1st is a line passes between the two ischial spines. It measure 11 cm. The 2nd is a line passing between the inner borders of the two ischial tuberosities and measures 11cm

The oblique diameters is said to be between the

obturator foramen and the sacrospinous ligament. It measures 12cm
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Variations in pelvic shape

Features of normal female pelvis

Sacral promontory is not prominent or un reachable. Rounded brim The cavity is shallow with straight sides Smooth (blunt) ischial spines The sacrum is smoothly concave (curved) Wide sciatic notch. The pubic arch is round Sub pubic angle 900
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Types of pelvis
Based on the shape of the brim, there are four main groups of pelvis Gyneacoid Android Platypelloid Anthropoid
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Gynaecoid pelvis(50%)
It is the normal female type. Inlet is slightly transverse oval. Sacrum is wide with average concavity and inclination. Side walls are straight with blunt ischial spines. Sacro-sciatic notch is wide. Subpubic angle is 90-1000.
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Fig. Gynaecoid pelvis

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Android pelvis (20%):

It is a male type. Inlet is triangular or heart-shaped with anterior narrow apex. Side walls are converging (funnel pelvis) with projecting ischial spines. Sacro-sciatic notch is narrow. Subpubic angle is narrow <900.

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Fig .Android pelvis

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Anthropoid pelvis (25%)

It is ape-like type All anteroposterior diameters are long. All transverse diameters are short. Sacrum is long and narrow. Sacro-sciatic notch is wide. Subpubic angle is narrow.

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fig. Anthropoid pelvis

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Platypelloid pelvis (5%)

It is a flat female type. It has kidney shaped brim. All anteroposterior diameters are short. All transverse diameters are long. Sacro-sciatic notch is narrow. Subpubic angle is wide.

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Fig. platypelloid pelvis

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Others rare types of pelvis

Justo-minor pelvis
It is similar to Gynaecoid in shape but all diameters are equally reduced. Found in woman who is less than 1.5M tall. Face difficulties to deliver large baby .

Robert pelvis
Has no wings (alae) of the sacrum and there fore contracted in all diameters It is a type very rarely seen and is the result of congenital abnormality . Caesarean section is always necessary for delivery
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Naegeles pelvis It has one wing of the sacrum

This may be due to congenital abnormality but can be caused by injury .

Delivery by c/s is always indicated

Fig. Naegeles pelvis

fig. Roberts pelvis

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Gynaecoid

Anthropoid

Android

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The pelvic floor (pelvic diaphragm)

The pelvic floor is formed by the soft tissue which fill the outlet of the pelvis. The urethra, the vagina and the anal canal pass through it.

Function
Supports the weight of the abdominal and pelvic organs. Its muscles are responsible for the voluntary control of micturition, defecation and play a role in sexual inter course. Maintenance of intra- abdominal pressure. It influences the passive movement of the fetus through the birth canal.
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The muscles of the pelvic floor

Superficial pelvic floor muscles- includes

Transverses perinea muscles arises from

the inner surface of ischial tuberosity and passes transversely a cross the out let to meet its follow. Helps to fix the position of the perineal body and support the lower part of the vagina.
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Muscles
Bulbo-cavernous muscles arise from the
central point of the perineum and pass forwards around the vagina lying superficial to bartholins glands and the vestibular bulbs, and deep to the labia. They are inserted into the corpora cavernous of the clitoris in the upper part of the pubic arch. Its action is to diminish the size of the vaginal orifice and to cause engorgement of clitoris during sexual activity.
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Muscles
Ischio cavernous muscles pass from the
ischial tuberosity a long the pubic arch to the corpora cavernous of the clitoris. Their function is to cause engorgement of the clitoris.

External anal sphincter surrounds the anal

canal, lying below the internal sphincter and the levator ani. Anteriorly it enters in to the formation of the perineal body and posteriorly some of its fibers are attached 58 to the tip of the coccyx.

Muscles
The membranous sphincter of the urethra is
composed of muscle fibers passing above and below the urethra and attached to the pubic bones.

Deep pelvic floor muscles

Is composed of three pairs of muscles which together are known as the levator ani muscles. Each lavetor ani muscles consists of the following muscles.

Iliococcygeus muscles arise from the white

line of fascia on the inner aspect of each iliac bone 59

Muscles
Ischiococcygeus muscles
arise from the ischial spine and pass to the upper part of the coccyx and lower border of the sacrum, in front of the sacro-spinous ligament. It helps to stabilize the sacroiliac and sacro-coccygeal joints.

Pubococcygeus muscles- arises from the back of

the body of pubic bones. Its fibers sweep posteriorly below the bladder on either side of the urethra and the lowest third of the vagina, to enter the perineal body. The longest fibers gain insertions into ano-cocygeal body and the coccyx. They surround and support the urethra, vagina and rectum. It helps in controlling micturition and defection, as well as 60 normal sexual function.

Fig. Pelvic floor muscles and ligaments

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The perineal body

It is a fibro- muscular pyramid situated between the lowest third of the vagina in front, the anal canal behind, and the ischial tuberosities laterally. It is triangular in shape and each side of the triangle is approximately 3.5cm in length. Structurally it is composed of three layers of tissue; Outer covering of skin Superficial pelvic floor muscles Bulbo cavernous Transverse perinea Deep pelvic floor muscle-puboccygeus 62

 Is a combination of connective tissue, blood vessels and voluntary and involuntary muscle fibers. It lines the walls and floor of the pelvic cavity and fills the area between the organs, thus giving additional support. The fascia thickens to form pelvic ligaments. These are Two lateral ligaments extend from the white line of the of fascia to the lateral walls of the bladder . Two pubovesical ligaments extend from the neck of bladder to the inner surface of each pubic body. 63 They form part of the pubo-cervical ligaments.

Pelvic fascia

Pelvic fascia
Two pubovesical ligaments are attached to the inner surface of each pubic body; they run posteriorly and become attached to the neck of bladder, the vault of the vagina and the supra vaginal cervix. Transverse cervical ligaments (cardinal or mackenrodts) - are attached to the vaginal vault and supravaginal cervix. Run transversely across the pelvic floor and run out until they reach the white line of the fasciae. They are the strongest of the pelvic ligaments. 64

Pelvic fascia
Uterosacral ligaments are attached to the vaginal vault and supravaginal cervix. They pass posteriorly and attach to the lateral border of the 1st sacral body. Round ligaments arise anteriorly from just below the cornu of the uterus and fallopian tubes then take a V, shaped canal before inserting in to each labia major. The cardinal, uterosacral and round ligaments all contribute to the support of the uterus and maintenance of its position
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II. The anatomy of the female Genital Organs

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The anatomy of the female Genital Organs

External Genitalia Vulva is formed from the following
structures;

Mons pubis is a pad of fatty tissue situated

in front of the symphysis pubis. It is covered by skin and pubic hair which develop at the time of puberty and appears triangular in distribution. Purpose protect the junction of the pubic bone from trauma. 67

External Genitalia

Labia majora- are two large rounded

folds of fatty tissue covered by skin which meet anteriorly at the mons pubis. Posteriorly each labia majora fuses medially to for in the posterior commissure. Contains sebaceous glands, sweet glands and hair follicle.
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External Genitalia
Labia minora are two smaller folds of pink

skin lying longitudinally with the labia majora. The area they in close is known as the vestibule Anteriorly they divided in to two folds. The upper folds surround the clitoris and unite to form the prepuce. The two lower folds are attached to undersurface of the clitoris and are known as the frenulum. Posteriorly, the labia minora unite to form a thin fold of skin, the fourchette.
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External Genitalia

Clitoris:- is small extremely sensitive

erectile structure situated with in the folds of the prepuce and frenulum.
It is about 2.5 cm long and is composed of two corpora covernose. It consists of the glans, body and two crura. It is analogue to the penis in the male and highly vascularized
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External Genitalia
vestibules:- is a triangular space bounded
anteriorly by the clitoris, posterior by the fourchette and on either said by labia minus. There are four openings in to the vestibule. 1.The urethral meatus lies 2.5 cm below the clitoris. 2.The vaginal orifice (introitus) occupies the lower two thirds of the vestibule lying between the labia minora.
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Hymen-is a thin membrane which covers the

introitus in virgin.

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External Genitalia
3.The bartholins ducts and glands:- are situated in the superficial perineal pouch posterior to the vestibular bulb.
It secretes abundant alkaline mucus during sexual excitement which helps in lubrication. 4.Vestibuler bulb:- are bilateral masses of erectile tissues situated beneath the mucus membrane called vestibule. Each bulb lies on either side of the vaginal orifice deep to the labia majora and minora and anterior to bartholins glands.
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External Genitalia
Blood supply:- The vulva is supplied with blood from two main arteries The femoral artery in the upper part of the thigh. The internal pudendal arfery running along the pubic arch. The veins drain to corresponding veins. Lymphatic drainage: - some drainage in to the inguinal glands and some is in to the external iliac glands. Never supply:- is from the branches of pudendal nerve and the perineal nerve.
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Internal genitalia
The vagina
Is a tube (canal) which extends from the vulva to the uterine cervix. It is longer in posterior wall (9cm) than anterior (7cm). The vault of the vagina is divided in to four fornices by the projection of the cervix. Anterior Posterior Two lateral fornices The posterior for nix is the largest. The vaginal walls are pink in appearance and thrown in to small folds known as rugae.
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The vagina
Structures
Vaginal wall is composed of four layers. The layers from in to out wards are : 1. Mucus coat lined by stratified squamous epithelium. 2. Sub mucous layer 3. muscular layer inner circular and outer longitudinal 4. fibrous coat
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The vagina
Contents
There are no glands situated in the wall of the vagina. The vagina contains a small amount of fluid which is derived from two sources; Alkaline mucus which secrete from the glands of the cervix, The vaginal blood vessels which allow serous fluid to transude through the vaginal wall into its lumen. The vaginal fluid is acidic in reaction having a PH of about 4.5 during reproductive life.

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The vagina
Relations
Anterior the bladder and the urethra Posterior lowest 2/3 perineal body -Middle third rectum -Upper third pouch of Douglas. Lateral upper 2/3 pelvic fascia at the base of the brood ligament. - Lowest third two levator ani muscles - bulbo-cavernosus muscles. Superior Uterine cervix Inferior hymen and the structures of the vulva
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The vagina
Blood supply Arterial supply from the vaginal, the uterine (descending branch), the middle haemorrodial, the inferior vesical and pedundial arteries The vain drains in a corresponding manner. Lymphatic drainage The lowest 2/3 drain to the horizontal inguinal groups along with those of the vulva. Upper 1/3 drain to the internal iliac and sacral glands. Nerve supply is from the sympathetic and pelvic splanchnics nerves 80

The vagina
Functions Entrance for spermatozoa Exit for menstrual flow and products of conception Helps to support the uterus Organs for sexual intercourse Helps to prevent infection
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The Uterus
Is a hollow, flattened, muscular peer shaped organ situated between the bladder and rectum in non pregnant state. It is normally anteverted and anteflaxed It measures 8cm in length 5cm width and 2-3 cm thick. Its weight is approximately 57gm.

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The Uterus
It consists of the following parts. Body or corpus Comprise the upper 2/3 of the uterus Lies between the isthmus and the opening of the fallopian tubes. Cervix Forms the lower third of the uterus and measures about 2.5 cm in length. It is conical in shape The cervix projects through the anterior wall of the vaginal which divides it in to an upper supra vaginal portion and lower vaginal portion.
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The Uterus
SUPRA VAGINAL CERVIX

lies out side

and above the vagina Superiorly it meets the border of the uterus at the isthmus. Is separated in front from the bladder by parametrium. Posteriorly it is covered by the peritoneum.
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The Uterus
INFRAVAGINAL CERVIX- is the part which projects in to the anterior vaginal wall between the anterior and posterior fornices. The internal os-opens in to the cavity of the uterus It dilates during labor. In competence of the cervix at this level results in spontaneous abortion. The external os opens in to the vagina at the lower end of the cervical canal. The cervical canal lies between the internal and external os It is fusiform in shape.
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The Uterus
FUNCTIONS OF THE CERVIX It helps to prevent infection entering the uterus. It dilates and withdraws during labor to enable vaginal delivery of the fetus and placenta.

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The Uterus
The funds- is the domed upper wall between
the insertions of the fallopian tubes. The cornu- are the upper outer angles of the uterus where the fallopian tubes join. The cavity- is a potential space between the anterior and posterior walls It is triangular in shape the base of the triangle being upper most. The isthmus- is a narrow area between the cavity and the cervix which is 7 mm long. It enlarges during pregnancy to form the lower 87 uterine segment.

The Uterus
STRUCTURES
1. The mucous membrane (tunica mucosa) Endometrium Forms a lining of ciliated epithelium on a base of connective tissue or stroma. The epithelial cells are cubical in shape and dip down to form glands which secrete alkaline mucus.

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The Uterus
The cervical endometrium is thinner than that of the body and is folded in to a pattern known as the arborvitae (tree of life), this assist the passage of the sperm. Here the epithelial cells are tall and columnar in shape.

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The Uterus
2.The muscular coat (tunica muscularis)Myometrium.

It is thick in the upper part of the uterus and is more sparse in the isthmus and cervix. Its fibers are outer longitudinal, middle interlacing oblique and inner circular. Its muscle fibers are embedded in collagen fibers which enable to stretch in the labor.
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The Uterus
3.The serous coat (tunica serosa)Perimetrium. Is derived from the peritoneum; it invests the fundus and the whole of the intestinal surface of the uterus, covers the vesical surface as only far as the junction of the body and cervix.

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The Uterus
The form, size and situation of the uterus vary at different periods of life and under different circumstances. In the fetus:- the uterus is contained in the abdominal cavity projecting beyond the superior aperture of the pelvis. The cervix is considerably larger than the body. At puberty- it is pyriform in shape and weights from 14 to 17 gm.
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The Uterus
In the adults- the position of the uterus
depends on the condition of the bladder and rectum. When the bladder is empty the entire uterus is directed forward and is at the same time bent on itself at the junction of the body and cervix, so that the body lies up on the bladder. as the bladder fills the uterus gradually becomes more and more erect until with a fully distended bladder the fundus may be directed back ward 93 toward the sacrum.

The Uterus
During menstruation:-the uterus is enlarged, more vascular, and its surface rounder; the external orifice is rounded, its labia swollen, and the lining membrane of the body thickened, softer, and of a darker color.

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The Uterus During pregnancy- the uterus becomes

enormously enraged. By 12th week of pregnancy it rises out of the pelvis and becomes abdominal organs, by 38th week it reaches the xiphisternum. It is not longer anteverted and anteflexed but it is becoming vertical. At full term the uterus is 30cm in length, 23 cm wide and 20cm thick. Its weight has increased from 57gm to 1000gm. 95

The Uterus
After parturition-the uterus nearly

regains its usual size, weighinig about 42gm; but the cavity is larger than in the virgins state, its vessels are tortuous, and its muscular layers are more defined; the external orifice is more marked, and its edges present one or more fissures.
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The Uterus
In old age - the uterus becomes

atrophied, and denser in texture, a more distinct separates the body and cervix. The internal orifice is frequently, and the external orifice occasionally, obliterated, while the lips almost entirely disappear.
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The Uterus
RELATIONS ANTERIOR uterovesical pouch and bladder. POSTERIOR- recto uterine pouch of Douglas and the rectum. LATERAL broad ligaments, the fallopian tubes and ovaries. SUPERIOR- the intestines INFERIOR the vagina. 98

The Uterus
UTERINE SUPPORTS (ligaments) Transverse cervical ligaments and (mackenrodts) Uterosacral ligaments Pubocervical ligaments Broad ligaments Pass from the sides of the uterus to the lateral walls of the pelvis. Together with the uterus it forms a septum across the female pelvis dividing the cavity in to two portions.
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The Uterus
Between the two layers of each broad ligament are contained; Uterine tube The round ligament of the uterus The ovary and its ligament The epoophoron and paraoophoron Connective tissue Unstriped muscular fibers Blood vessels and nerves Round ligaments
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The Uterus
BLOOD SUPPLY From the uterine artery, a branch of the hypo gastric artery. Veins drains to the corresponding manner. LYMPHATIC DRAINAGE- lymph is drained from uterine body to the internal illiac glands and also from the cervical area to many other pelvic lymph glands. Nerve supply -from autonomic nervous system, sympathetic and parasympathetic via sacral plexus 101

The Uterus
FUNCTION OF THE UTERUS To prepare a bed for the fertilized ovum. To nourish the fertilized ovum for the gestation period To expel the product of conception at full term. To involutes following child birth
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FALLOPIAN TUBES
Are paired structures which are attached with the lateral angle of uterine cavity. They run along the upper margin of the broad ligament and 10 cm in length. It has four portions 1.The interstitial portion- is 1.25 cm long and lies within the wall of the uterus. Its lumen is 1mm wide
103

FALLOPIAN TUBES
2.The isthmus is another narrow part which extends for 2.5 cm from the uterus. It acts as reservoir for spermatozoa because its temperatures is lower than other. 3.The ampulla- is the wider portion where fertilization usually occurs & it is 5 cm in length. 4.The infundibulum- is the funnel shaped fingered end which is composed of many processes know as fimbriae.
104

105

FALLOPIAN TUBES
RELATIONS

Anterior posterior and superior the peritoneal cavity and the intestine Lateral the side walls of the pelvis. Inferior the broad ligaments and ovaries. Medial the uterus.
106

FALLOPIAN TUBES
LAYERS OF THE TUBE It consists of three coats 1.The external or serous coat is the peritoneum. 2.Middle or muscular coat- consists of inner circular and outer longitudinal layer of smooth muscles which helps for peristaltic movement of the fallopian tube. 3.The internal or mucous coat-is line by columnar and ciliated epithelium. Beneath the lining is a layer of vascular connective tissue.
107

FALLOPIAN TUBES
SUPPORT - by the infundibulo pelvic ligaments. These ligaments are formed from folds of the broad ligament and run from the infundibulum of the tube to the side walls of the pelvis. Blood supply:- is via the uterine and ovarian arteries; venous return is by the corresponding veins. Lymphatic drainage- is in to the lumbar gland. NERVE SUPPLY is from the ovarian plexus.

108

FALLOPIAN TUBES
FUNCTIONS

Propels the ovum towards the uterus. Receives the spermatozoa as they travel up wards Provides a site for fertilization Supplies the fertilized ovum with nutrition during its continued journey to the uterus.

109

THE OVARIES
Are two nodular bodies which produce ova and hormones estrogen and progesterone. POSITION They are attached to the back of the broad ligament within the peritoneal cavity Size 3 cm in length, 2 cm in width and about 1 cm in thickness and weight from about 6gm.
110

THE OVARIES
RELATIONS

Anterior the broad ligament. Posterior the intestine. Lateral the infudibulopelvic ligaments and the side walls of the pelvis. Superior the fallopian tubes. Medial the uterus and ovarian ligaments.

111

THE OVARIES
SUPPORTS From above by the ovarian ligament medially, and the infundibulo pelvic ligaments laterally. Attachment of ovary- infundibulo pelvic ligament to the pelvic wall. Ovarian ligament- to the uterus. Mesooverium to the broad ligament
112

THE OVARIES
Structures
The ovary is composed of medulla and cortex covered with germinal epithelium. The medulla- is the central portion and point of entry for blood vessels, lymphatic and nerves. The hilum where these vessels enter lies just where the ovary is attached to the broad ligament and this area is called the mesovarium. 113

THE OVARIES

The cortex- is the functioning part of the

ovary

It contains the ovarian follicles in different stage of development surrounded by stroma. The outer layer is formed of fibrous tissue known as tunica albuginea. Germinal epithelium lies over the tuinica albuginea.
114

THE OVARIES
Blood supply

Is from the ovarian arteries and drains by the ovarian veins. Lymphatic drainage- is to the lumbar glands. Nerve supply- is from the ovarian plexus.
115

III. Physiology of the female reproductive organs

116

III. Physiology of the female reproductive organs

Hormones and their function Hypothalamus produces a specific releasing and inhibitory hormones or factors which have effect on the production of pituitary hormones. 1.Gonadotrophin releasing hormones Concerned with the synthesis, storage and release of gonadotropin hormones (FSH and LH)
117

Hormones
2.Prolactin inhibitory factor/ hormones
3.Thyrotrophin releasing hormone

Stimulates the release of TSH

4.Corticotrophin releasing hormone

Stimulate the release of ACTH

5.Growth hormone releasing hormones

Stimulate the release of growth hormones.

118

Hormones
PITUITARY HORMONES

Anterior pituitary (Adenohypothesis) Gonadotropins hormones - FSH and LH. Prolactin hormones- milk production. Others hormones - TSH,ACTH,GH Posterior pituitary Oxytocin and ADH.

119

Hormones
Ovarian hormones 1.Estrogen - is produced by granulosa cells under the influence of FSH. Function (actions) Responsible for secondary sexual characteristics. Inhibition of FSH secretion from ovary (negative feedback mechanism). Growth of myomentrium, endometrium, alveoli and ducts of the breast. 120

Hormones
Myometrial stimulation (increase myometrial contractility). Promotion of female fat distribution. Stimulation of protein synthesis in the liver. Promotion of calcifications of the bone. Angiogenesis (new blood formation). Na and H20 retention by the kindney. Influences the production of cervical mucus and the structure of the vaginal epithelium.
121

Hormones
2.Progestrone-produced by the corpus luteum
under the influence of LH.

Actions Growth of ducts and lobules of the breast, inhibition of prolactin synthesis. Relaxation of smooth muscles of the uterus, blood vessels, GI and urinary tract. Secretary changes and decasualization of the endometrium.
122

Hormones
Vasodilatation. Termogenic (increase BBT). Hyperventilation (decrease concentration of co2 . 3.Androgens - produced by the theca interna cells. They are source for estrogen synthesis. 4.Inhibin and Relaxin
123

PUBERTY
Is the stage of life at which secondary sexual characteristics appear: It is marked by neuro-endocrine changes. Pulsative releases of GnRh seen at this time. Ovarian steroid hormones start to be secreted. The H-P-O axis becomes coordinated.

124

PUBERTY
Notable changes at this time are: Breast development. Marked physical growth. Increase in the transverse diameter of the pelvis. Growth of pubic and auxiliary hair. Menarche the 1st menses.
125

The menstrual cycle

is a periodic uterine bleeding in response to cyclic hormonal changes. It is hallmark of reproductive year.

Characteristics of normal menses

Interval 21-35 days Amount 30-80 ml Duration 1-8 days, average 5 days The blood is arterial (85%) oxygenated the rest 1015% is deoxygenated. Color dark red and non clotted in nature
126

The menstrual cycle

Physiology of

menstruation

Ovarian follicular development The number of oocytes are 6-7 million by 20 weeks of gestation. 1-2 million oocytes remain in the ovary at birth. At puberty only 300,000 oocytes remains. Only 400-500 will ultimately ovulate and they will end up at the time of menopause.
127

The menstrual cycle

PHASE OF OVARIAN CYCLE

1.Follicular phase:- hormonal feedback promote the development of single dominant follicle. Its average length is 10-14 days.

2. Luteal phase: - the time from

ovulation to the onset of the menses. Average length 14 days.

128

The menstrual cycle

Hormonal variation
At the beginning of each monthly menstrual cycle levels of gonadal steroids (progesterone and estrogen) are low and have been decreasing since the end of luteal phase of the previous cycle. Demise of corpusluteum results FSH level begin to rise. Causes growing of follicles from the ovary.
129

The menstrual cycle

Each growing follicies start to secrete estrogen hormone; this results uterine endometrial proliferation. Maximum estrogen level provides negative feedback on pituitary FSH secretion (which begins at midpoint of the follicular phase). Estrogen also stimulates LH production through the follicular phase.
130

The menstrual cycle

At the end of the follicular phase (just prior to ovulation) FSH induce LH receptors, then with LH stimulation secretion of progesterone will takes place. After sufficient degree of estrogenic stimulation the pituitary LH surge is triggered, this is the cause of ovulation then occurs 2436 hrs later.
131

The menstrual cycle

Estrogen level begin to rise again as result of corpusluteum secretion. Progesterone level rise after ovulation, it is a presumptive sign of ovulation has occurred. Both estrogen and progesterone level remain elevated till the demise of corpusluteum, then the next cycle will continue.
132

The menstrual cycle

Phase of endometrial cycle
Because of the systemic effects of estrogen, the endometrium undergoes histologic cyclic changes that culminate in menstruation. The superficial 2/3 of the endometrium is called the decidua functionalis and is composed of stratum spongiosum superficial zone. The decidua basalis- is the deepest region of endometrial and doesnt undergo significant monthly proliferation. It is the source of endometrial regeneration after each menses.
133

The menstrual cycle

There are three phases in the endometrial cycle. 1.Menstrual phase:- start from day 1 and usually lasts 3 to 5 days. During this phase there is irregular sloughing of the superficial 2/3 of endometrium (decidua functionalis) accompanied by blood. Expulsion of the blood is aided by uterine contraction.
134

The menstrual cycle

2.Proliferate phase- starts near the end of the

menstrual phase the basal layer of the endometrium (decidua basalis) under the influence of estrogen; proliferate to regenerate the superficial layer that is shaded during menses. At the beginning of this phase endometrium is relatively thin (1-2mm)
135

The menstrual cycle

3.Secretary phase- extends from ovulation to the onset of the next menses. The proliferative endometrium, under the influence of progesterone is changed to secretary type. Glands becomes tortuous and exhibit secretary activity Stromal cells are separated by interstial endometrium The estrogen receptor cells decreases progressively because of the antagonistic effect of progesterone. As a result there is antagonism of estrogen induced DNA synthesis and cellular mitosis. 136

The menstrual cycle

At post ovulatory day 6-7 secretary activity of the glands is maximal and endometerium is optimally prepared for implantations of the balastocyst. Later on the endometrial layer become edematus and 2 days prior to menses there is a dramatic increment of polymorphonuclear lymphocytes leukocytic infiltration it heralds the collapse of the endometrial stroma and menses will start to flow. 137

The Menstrual Cycle

138

The menstrual cycle

Mechanism of Menstruation
In the absence of pregnancy, decreasing level of progesterone from the dying corpusluteum, results in dehydration of the stroma, as a result there is increased coiling of the spiral arteries, which supply the superficial layer of the endometrium

139

The menstrual cycle

Prostaglandin f2@-initiate uterine contraction. Decreases local uterine blood flow. Physical expel of the blood which result in menstruation.

140

IV. EMBRYOLOGY

141

IV. EMBRYOLOGY Is a science that deals with the origin and development of individual organism. FERTILIAZATION- is the union of the ovum and spermatozoa. Following ovulation as the ovum is extruded from the graafian follicle it is surrounded by a ring of mucoploysaccharide fluid (the zone pellucid) and a circle of cells (the corona radiate.) Fertilization usually takes place at the ampulla.
142

Mr.SPERM

Mrs. EGG
143

EMBRYOLOGY cont..
Immediately after penetration of the ovum the chromosomal material of the ovum and the spermatozoa fuse. The resulting structure is called a zygote. The occurrence of fertilization depends on: Maturation of both sperm and ovum. Ability of the sperm to reach the ovum Ability of the sperm to penetrate the zonapellucida and cell membrane and achieve fertilization. 144

Fertilization and the Events of the First 6 Days of Development

145

EMBRAYOLOGY cont..

IMPLANTATION- is a contact between

the blastocyst and the uterine endothelium. It occurs approximately 8 to 10 Days after fertilization. Once fertilization is complete the zygote migrates towards the body of the uterus aided by muscular contraction of the fallopian tubes.

146

EMBRYOLOGY cont..
It takes 3 to 4 days for the zygote to reach the body of the uterus. This time the zygote undergoes mitotic division and consists 16 to 50 cells and is termed as a morula. When fluid filled cavity appears in the morula a blastocyt is formed, these is after 3 or 4 days. The cells of a blastocyst are arranged in to layers the outer layer is called the trophoblast which eventually develops in to the placenta and membrane. The inner layer is called the embryoblast which later gives rise to the embryo 147 (fetus).

EMBRYOLOGY cont..
All tissue products of conception (embryo, fetus, fetal membranes and placenta) are called conceptus. On day 4 after fertilization the blastocyst enters in to the uterine cavity. By day 7 starts embedding it self in to the prepared endometrium which is now called the deciduas. This process is called implantation. Once implanted the zygote is an embryo (the period from the end of ovum stage until measurement reaches approximately 3cm, 54-56 days). Fetus- period end of embryo stage until birth.
148

EMBRYOLOGY cont..

First trimester (0-12 wks) Susceptible to teratogens. Heart function at 3-4 weeks. Eye formation at 4-5 weeks Arm and leg buds at 4-5 weeks Recognizable face at 8 weeks
149

EMBRYOLOGY cont..

Brain rapid grows. External genitalia at 8 weeks. Placenta formed at 12 weeks. Bone ossification at 12 weeks. Fetal circulation function properly at 8-12 weeks.
150

EMBRYOLOGY cont..
2nd trimester (13-27 weeks)
Less danger from teratogens after 12 week. Facial features formed at 16 week. Fetal heart beat heard by 16 to 20 week with fetoscope. Lanugo appears (hair over the body). Vernix present. Length 10 inches (2.5 cm), weight (05-0.6 Ib) (0.23-0.27 kg). Most organs become capable of functioning.
151

EMBRYOLOGY cont..

3rd trimester (28-42 weeks)

Iron stored. Surfactant production begins in increasing amount. Size; 15 inches, 2-3 pounds. Testes descend in to scrotum in male at 28-32 week. Calcium stored at 28-32 week.
152

EMBRYOLOGY cont..
Reflexes present at 28-32 week. Subcutaneous fat deposits at 36 week. Lanugo disappears from the body Average size 18-22 inch, 7.5-8.5 Ib at 38-40 weeks. Term is reached and birth is due at 38-40 weeks.

153

EMBRYOLOGY cont..

THE DECIDUA- is the endometrium after

implantation. It has three parts 1.The decidua basalis- the part of the endometrium lying directly under the embryo (the portion where the trophoblast cells establish communication with maternal blood vessels). 2.The decidua capsularis- the portion of endometrium that stretches or encapsulates the surface of the trophoblasts. 3.The decidua vera- the remaining portion of the uterine lining.
154

EMBRYOLOGY cont..

CHORIONIC VILLI
As early as the 11th or 12th day after conception the tropoblastic cells have sent out processes in to the endometrium. The outgrowths becomes finger like and termed chorionic villi. The chorionic villi have a central core of loose connective tissue surrounded by a double layer of trophoblastic cells. 155

THE PLACENTA
Is formed from the traphoblast and deciduas basalis. The placental barrier is formed by the syncitiotrophoblast, cytotrophoblast, the basement membrane and fetal vascular endothelial cells. The placenta on overage has a diameter of 18 cm, a thickness of 23 mm, a volume of 497ml, a weight of 508 grams and villous surface area of 15m2.
156

THE PLACENTA
It has two surfaces; maternal and fetal surface. The maternal surface is made of deciduas basalis and dark red in color. The fetal surface is smooth, white and is covered by amnion. The branching fetal vessels are visible under the amnion.

157

THE PLACENTA
FUNCTIONS OF PLACENTA

1.Respiration 2.Nutrition- food for the fetus derives from

the mothers diet and the placenta select those substance required by the fetus.

3.Stordge the placenta metabolites

glucose, stores it in the form of glycogen and reconverts it to glucose as required. It can also store iron and fat-soluble 158 vitamins.

THE PLACENTA 4.Excretion- co2 and bilirubin is

excreted through placenta.

5.Protection- placental barrier provides

protection against-certain bacteria, virus and maternal immunoglobins in case of Rh-isoimmunization.

159

THE PLACENTA

6.Endocrine function- placenta

secretes certain hormones:
Human chorionic gonadotropin (HCG)- the first hormone to be produced. Produced by the cytotrophoblastic layer of chorionic villi.
160

THE PLACENTA
Its purpose is to act as fail-safe measure to ensure that the corpus luteum of the ovary continues to produce progesterone and estrogen. Forms the basis for pregnancy test. Estrogens is produced as a 2nd product of the syncitial cells of the placenta. It contributes to the mothers mammary gland development in preparation for lactation and stimulates the uterus to growth to accommodate 161 the developing fetus.

THE PLACENTA
Progesterone- maintain endometrial
lining of the uterus during pregnancy. It reduces contractility of the uterine musculature during pregnancy which prevents abortion and premature labor.

162

THE PLACENTA
Human placental lactogen (HPL) (chorionic somatomamotropin): Is produce by placental trophoblasts (as early as 3rd week) and detected in serum by 4th week after ovulation. Its main action is resetting of CHO and fat metabolism of mother so as to ensure adequate supply of glucose and energy to the fetus.
163

THE PLACENTA
Other action includes. Gluconeogenesis inhibition. Inhibitions of peripheral uptake of cellular glucose and insulin hyper insulinism maintain maternal blood glucose level. Increase uptake of amino acid and ketones by placenta.
164

THE PLACENTA
ANATOMICAL VARATION OF THE PLECENTA AND CORD 1.Succenturiata lobe of placenta A small extra lobe is present, separate from the main placenta and joined to it by blood vessels which run through the membrane. Danger the small lobe may be retained in the utero after delivery and if it is not removed it may lead to hemorrhage and infection. Identification- on inspection the placenta will appear torn at edge or torn bold vessels may extend beyond the edge of the placenta.
165

THE PLACENTA
2.Circumvallate placenta- in this situation an opaque ring is seen on the fetal surface. It is formed by a doubling back of the chorion and amnion.

3.Bipartite placenta- two completed and

separate lobes are present each with a cord leaving it. The bipartite cord joins a short distance from the two parts of the placenta. Danger- the extra lobe may be retained during 166 delivery.

THE PLACENTA
4.A tripartite placenta is similar to bipartite but with three distinct lobes. 5.Battledore insertion of the cord- the cord is attached at the very edge of the placenta Danger- likely it is detached up on applying traction during active management of 3rd stage of labor. 6.Velamentous insertion of the cord- it is inserted in to the membrane some distance from the edge of the placenta. The umbilical vessels run through the membranous from the cord to the placenta. Danger- the vessels may tear with cervical 167 dilatation and would result in sudden blood loss.

THE UMBILICAL CORD (FUNIS)

Connects the placenta to the fetus. It has average length of 50 cm (range 30-100 cm) and diameter of 0.8-2 cm. It contains two umbilical arteries, one umbilical veins and Whartons jelly (jelly like substance which surrounds the blood vessels).
168

THE UMBILICAL CORD

FUNCTIONS

To transport oxygen and nutrients from placenta to the fetus. To return waste products from the fetus to the placenta Allows fetal mobility.
169

THE MEMBRANES AND AMMIOTIC FLUID

The membranes (sac) it has two layers: 1.Chorion - is the smooth opaque outer most fetal
membrane. Purpose support the sac that contains amniotic fluid.

2.Amnion is the inner membranes which is

smooth, strong and transparent. It lines the chorion and could always be detached from it to the insertion the umbilical cord.
170

THE MEMBRANES AND AMMIOTIC FLUID

Its function are:

Offers support to amniotic fluids. It produce the amniotic fluids. It produce phospholipids that initiates the formation of prostaglandins.
171

THE MEMBRANES AND AMMIOTIC FLUID

AMNIOTIC FLUID Is a clear fluid in which through the fetus floats and is also called liquor amnion. It is present in the sac from the early months. The normal amount is from 500cc-1500cc. It is alkaline in reaction and has 99% of water. The remaining 1% contains; mineral salt, urea from the fetal urine in late pregnancy, trace of protein, fat, CHO, enzymes, lanugo, bile pigments, placental hormones.
172

THE MEMBRANES AND AMMIOTIC FLUID

ORIGION is from amnion.

Maternal vessels in the decidua. Fetal vessels in the placenta. Fetal urine. APPEARANCE: Its normal color is clear fluid. Meconium stained- sign of fetal distress except in cases of breech presentation. Golden- sign of hemolytic disease. Milky appearance because of vernix caseosa.
173

THE MEMBRANES AND AMMIOTIC FLUID

FUNCTIONS: Allows the fetus free movement. Enables fetal limbs to develop and move without being compressed by each other, the fetal trunk or the walls of the uterus. Equalizes intra uterine pressure and acts as a shock absorber. Stablises intrauterine temperature.
174

ORIGIN AND DEVELOPMENT OF ORGAN SYSTEM

From the beginning of the fetal growth, development proceeds in a cephalo- caudal (head to tall) direction. PRIMARY GERM LAYERS the three germ layers which are formed during embryonic stage are: 1. Mesoderm Forms supporting structures of the body (connective tissue, cartilage, muscle, bone and tendons). Upper portion if urinary system; reproductive system, heart; circulatory system and blood cells.
175

ORIGIN AND DEVELOPMENT OF ORGAN SYSTEM

2.Endoderm Forms mucous membranes and glands (lining of the GIT, respiratory tract, tonsils, parathyroid, thyroid, thymus gland). 3.Ectoderm Forms the nervous system, skin, hair and nails, sense organs and mucous membranes of the mouth and anus.
176

177

UTERINE MALFORMATION
Various types of structural abnormality can result from failure of fusion of the mullerian ducts. Double uterus and double vagina- develop when there is complete failure of fusion of the duct. A single vagina with a double uterus- is the result of fusion at the lower end of the ducts only.
178

UTERINE MALFORMATION
A bicornuate uterus (one with two horns)- is the result of incomplete fusion at the upper portion of the urogenital area. Unicornuate uterus -with one horn. Agenesis- complete absence of the uterus and vagina Imperforate hymen.

179

UTERINE MALFORMATION
EFFECTS OF THE UTERINE ABNORMALITY

Abortion Premature labor abnormal lie of the fetus Poor uterine contraction Obstructed labor
180

V. Fetal circulation
181

V. Fetal circulation
As the placenta acts as the intermiditary organ of transfer between the mother and fetus, fetal circulation differs from that required for extra uterine existence. The fetus receives oxygen through the placenta because the lungs do not function as organs of respiration in the uterus. To meet this situation the fetal circulation contains certain special vessels that shunt the blood around the lungs, with only a small amount circulating through them for nutrition. 182

Fetal circulation cont..

The following functions occur. The umbilical vein transports blood rich in oxygen and nutrients from the placenta to the fetal body. This vein travels along the anterior abdominal wall of the fetus to the liver and at the porta hepatis, the umbilical vein divides in to two branches. About of the blood passes in to the liver and the rest enters a shunting vessel called the ductus venosus that by passes the liver. The ducts venosus travels a short distance and joins the inferior vena cava
183

184

Fetal circulation cont..

There, the oxygenated blood from the placenta is mixed with deoxygenated blood from the lower parts of the fetal body. This blood continues through the vena cava to the right atrium. As the blood relatively high in oxygen enters the left atrium of the fetal heart, a large proportion of it is shunted directly in to the left atrium through an opening in the artial septum called the foramen ovale. The more highly oxygenated blood that enters the left atrium through the foramen ovale is mixed with a small amount of deoxygenated blood 185 returning from the pulmonary veins. This mixture

Fetal circulation cont..

Some of this blood reaches the myocardium by means of the coronary arteries and some reaches the tissues of the brain through the carotid arteries The rest of the blood entering the right atrium as well as the large proportion of the deoxygenated blood entering from the superior vena cava, passes in to the right ventricle and out through the pulmonary artery.
186

Fetal circulation cont..

Enough blood reaches the lung tissues to sustain them. Most of the blood in the pulmonary artery bypasses the lungs by entering the ductus arterious which connects the pulmonary artery to the descending portion of the aortic arch. Some of the blood carried by the descending aorta leads to the various parts in the lower regions of the body The rest of the blood passes in to the umbilical arteries which branch from the internal iliac arteries and lead to the placenta.
187

VI. The fetal skull

Is a bony box like cavity which contains and protects the delicate brain. It is the most important part of the fetus because;
It contain the delicate brain It is the least compressible part of the fetus. It is the most difficult part to deliver whether it comes first or last. It is the largest part of fetus.
188

The fetal skull

Division
The fetal skull is divided into three parts: The vault is the large dome shaped part above the imaginary line drown from below the occipital protuberance to the orbital ridges. The face - area extending from the orbital ridges to the junction of the chin and neck. The base - is composed of bones which are firmly united to protect the vital centers in the medulla. 189

The fetal skull

Bones of the vault
There are five main bones in the vault of the fetal skull.

One occipital bones lies at the back of the

head and forms the region of the occiput. Its ossification center is known as occipital protuberance. It is roughly triangular in shape. In its lower part it forms the margins of the foramen magnum.

190

The fetal skull

Two parietal bones lie on either side of the
skull. The ossification center of each bone is called partial eminence. They are the largest of the cranial bones. Roughly square in shape and curves as they lie over the parietal lobes of the brain.

Two frontal bones form the

forehead or

sinciput. Their ossification centers are named frontal eminence or frontal bosses. Fuse in to a single bone by 8 years 191

The fetal skull

Sutures
Is an area of membrane between the skull bones where ossification has not been completed. Overlap during the process of moulding at the time of birth.

Types of sutures Lambdoidal suture separate the occipital bone from the two parietal
bones. It is shaped like the Greek letter Lambda

Sagital suture- runs between the two parietal bones and runs
from the anterior fontanel in front to the posterior fontanel behind.

Frontal sutures- runs between the frontal bones, extending from

the root of nose below, to the anterior fontanelle above.

Coronal suture- separate frontal bones parietal bones, passing

from one temple to the other.
192

The fetal skull

Fontanels
Are areas where two or more suture meet. There are 6 fontanels, but only two are of great obstetrical importance. The anterior fontanel or bregma :-is formed where the sagital, coronal and frontal sutures meet. It is diamond in shape. It is much longer than posterior fontanel. Pulsation of cerebral vessels can be felt through 193 it.

The fetal skull

Posterior fontanel

occurs at the junction of the lambdoidal and sagital sutures. It is very small and triangular in shape It is normally closes by 6 weeks of age
194

195

The fetal skull

The Regions of the skull
Vertex is bounded by the anterior and posterior fontanels and parietal eminences Occiput lies between the foramen magnum and posterior fontanel.

Sinciput (brow) extends from the anterior fontanel

and coronal suture to the orbital ridge

Face extends from the orbital ridges and the root

of the nose to the junctions of the chin and neck. The point between the eye brow in known as the 196

The fetal skull

Land marks of the fetal skull Occipput Vertex Sinciput Posterior fontanel (Lambda) Glabella Mentum (chin) Anterior fontanel (Bregma) Occipital protuberance
197

Diameters of the fetal skull

Transverse Diameters
Biparietal diameter- between the parietal eminenences and measures 9.5cm Engagement occur as this diameter pass through the plane of the brim. Bi- temporal diameter runs between the two extremities of the coronal sutures and is 8.2cm in length. Bi-acromial diameter extends between the acromial processes of the scapulae, and measures 11.5cm. Bi- trochenteric diameter runs between the greater trochanters of the femur, and measures 9cm in 198 length.

The fetal skull

The fetal skull

Anteroposterior or longitudinal diameters
Subocipitobregmatic- measured from below the occiput to the bregma. It measures 9.5cm. Suboccipito frontal measured from below occipital protuberance to the center of the frontal sutures, and measures 10cm. Occipito frontal measured between the occiput and the glabella. It is 11.5 cm in length Mento-vertical measured from the point of the chin to the highest point on the vertex slightly nearer to posterior fontanel then anterior, and it measures 13.5cm. 199

The fetal skull

Submento vertical measured from the point where the chin joins the neck to the highest point on the vertex. It is 11.5 cm in length Submentobregmatic - measure from the point where the chin joins the neck to the center of the bregma and measures 9.5 cm
200

The fetal skull

The scalp tissue
There are five layers of scalp tissue : Skin containing hairs, (outer covering) Subcutaneous tissue Muscle layer containing the tendon of Galea Connective tissue a loose layer Periosteum which coves the skull bones
201

The fetal skull

Two conditions involving these tissue can arise during labor and both cause a swelling on the infants head.

1.Caput succedaneum is an
edematous swelling of the subcutaneous tissues of the fetal skull. It occurs in early rupture of membranes in the 1st stage of labor, because there is no bag of fore waters to take the pressure of dilating cervix off the fetal 202 head.

The fetal skull

Characteristics It is present at birth Occurs on the part of the head which lies over the inter as It may lie over a suture line It pits on pressure It disappears with in 24 - 48hrs No treatment required unless it is 203 excessive

The fetal skull

2.Cephelo hematoma this swelling is due

to bleeding between the skull bone and periosteum which covers it. The bleeding occurs because of friction between the skull bones and the periosteum. Characteristics It is not present at birth, but appears 2-3 days after wards . The swellings is limited by the periosteum and can there fore only occur over the bone , although it may be bilateral . It can not lie over a suture.
204

The fetal skull

The head is usually red- and bruised in appearance. It takes 6 weeks to disappear completely . Treatment is only required of the hematoma increase in size over a number of days. RX- vit. K, injection to raise the prothrombin level and assist clotting .
205

The fetal skull

Moulding
Is the change which takes place in the shape of the fetal skull as pass through the birth canal. As the head descends through the pelvis in response to the down ward pressure of uterine contractions, so the skull bones over up each other. Molding takes place gradually with out being prolonged, the cerebral membranes and blood vessels are not likely to be demaged .
206

The fetal skull

The dangerous types of molding are :

Excessive molding
Occurs when labor is prolonged or where the skull bones are not completely ossified ( as in prematurity ). Upward molding Occurs when the baby delivers in the persistent occipito posterior position and the after coming head of the breech passes through the pelvis. It can result in intracranial hemorrhage . 207

The fetal skull

Rapid molding
Occurs in a precipitate delivery, and during the delivery of the head of breach presentation. Results from rapid compression and decompression of the head which can rupture of the cerebral membrane . The infant is subjected to severe molding will suffer some degree of asphyxia at birth as a result of intracranial compression, thus they should be seen by pediatrician and get vit .K 208 (0.5-mg/kg).

209