Maternal anatomy

1. Anterior abdominal wall

• Skin
– Langer lines describe the orientation of dermal fibers
within the skin.
– anterior abdominal wallarranged transversely.
• vertical skin incisions  increased lateral tension & develop
wider scars.
• low transverse incisions (Pfannenstiel) follow Langer lines
superior cosmetic results.
– Pfannenstiel incision
 incision made transversely, & through the external
sheath of the recti muscles,1 inch above pubes, the
muscles being separated at midline in direction of their fibers.
• Subcutaneous layer
– superficial, predominantly fatty layerCamper
fascia,
– deeper, more membranous Scarpa fascia
• Rectus Sheath
– The fibrous aponeuroses of external oblique,
internal oblique, & transversus abdominis muscles
join in midline.
• Anterior abdominal wall muscles:
– M. Rectus abdominalis
– M. Pyramidalis
– M. External oblique
– M. Internal oblique
– M. Transversus abdominalis
 Femoral Artery Branches
• Femoral artery :
– superficial epigastric artery
– superficial circumflex iliac artery
– External pudendal artery
• supply skin & subcutaneous layers of anterior
abdominal wall & mons pubis.
• During low transverse skin incisionsuperficial
epigastric artery can be identified at a depth
halfway between skin & rectus fascia, several
centimeters from midline.
 External Iliac Artery Branches
• inferior “deep” epigastric artery
• deep circumflex iliac artery
• supply muscles & fascia of anterior abdominal
wall
 Hesselbach triangle
• is region in anterior abdominal wall bounded :
– Inferior : inguinal ligament
– Medial : lateral border of rectus muscles
– Lateral : inferior epigastric vessels.
• Direct hernias protrude through abdominal
wall in Hesselbach triangle
• Indirect hernias through deep inguinal ring
lying lateral to this triangle.
 Anterior Abdominal Wall Innervation
• anterior abdominal wall is innervated by
– intercostal nerves (T7-11)
– subcostal nerve (T12)
– iliohypogastric
– ilioinguinal nerves (L1).
• iliohypogastric nerve skin over the suprapubic area.
• ilioinguinal nerve  skin of the lower abdominal wall
& upper portion of the labia majora & medial portion
of the thigh through its inguinal branch.
• T10 dermatome  approximates level of umbilicus.
External generative organs
 MONS PUBIS (monsveneris)
• fat-filled cushion  lies over symphysis pubis
• pubertycovered by curly hair that forms
escutcheon
• adult women it is distributed in a triangular
area,the base of which is formed by upper
margin of the symphysis.
LABIA MAJORA
• Male homologuescrotum
• Merge posteriorly to form
the posterior commissure.
LABIA MINORA
• composed of connective
tissue with many vessels &
some smooth muscular fibers
• moist reddish (similar to
mucous membrane)
• supplied with many nerve
endings (extremely sensitive )
• 2 lamellae superiorly
– lower pair forms frenulum of
clitoris
– upper pair forms the prepuce
• Inferiorly forms the
fourchette.
CLITORIS
• Male homologue (penis)
• composed of : glans,corpus,
and two crura
• rarely > 2 cm in length.
• covered by stratified
squamous epithelium
richly supplied with nerve
ending principal female
erogenous organ
VESTIBULE
• almond-shaped,
boundaries:
– LateralHart line (batas
mukosa dan kulit)
– Medial  external surface of
hymen
– Anteriorly  frenulum
– Posteriorly  fourchette
• 6 openings:
– urethra
– vagina
– ducts of the Bartholinglands
(2)
– ducts of paraurethral
glands/skeneglands (2)
 Vestibular glands
Bartholin glands Paraurethral glands
• greater vestibular glands • Lies in the inferior aspect of
•  : 0.5 to 1 cm urethra
• ducts are 1.5 to 2 cm long • Skeneglands largest
and open distal to the • Minor vestibular glands 
hymenal ring at 5 & 7 shallow glands lined by
o'clock simple mucin-secreting
epithelium
 Vestibular Bulbs

• Male homologuecorpus spongiosum of

penis
• almond-shaped, mainly composed of
aggregations of veins
• If injuredrupture vulvar hematoma
• Long :3-4 cm
• Wide : 1-2 cm
• Thick : 0,5-1 cm
 VAGINAL OPENING AND HYMEN
HYMEN
• elastic & collagenous connective tissue
• Lined by stratified squamous epithelium
• no glandular /muscular elements, & not richly
supplied with nerve fibers
• Appearance varies with age:
– Newbornvery vascular & redundant
– Pregnant  thick, rich in glycogen
– Menopause  thin, focal cornification may develop
 VAGINA

• Musculo-membranous structure
• Extends from vulva uterus
• Lining epitheliumnon-keratinized stratified
squamous epithelium
• no glands
• abundant vascular supply
 VAGINA
• Divided by a septum from urethra 8 rectum
• Anteriorlyvesicovaginal septum urinary bladder
• Posteriorly  Rectovaginal septum rectum
• upper fourth of the vagina is separated from the
rectum by the rectouterinepouch (cul-de-sac of
Douglas)
• Embryology :
– upper portionmüllerian ducts
– lower portion  urogenital sinus
• usual vaginal length:
– Anterior: 6 - 8 cm
– Posterior: 7- 10cm
 Vascular and Lymphatic Supply
• The proximal portion cervical branch of uterine
artery & vaginal artery.
• Posterior vaginal wall middle rectal artery
• Distal walls  internal pudendal artery
• Venous plexus surrounds vagina & follows course of
the arteries.
• Lymphatics from :
– lower third drain into the inguinal lymph nodes.
– middle third drain into the internal iliac nodes
– Upper third drain into the external, internal, & common
iliac nodes.
 Perineum
• Anterior triangle (urogenital triangle) bounded
by:
– Anterior : pubic rami
– Anterolateral : ischial tuberosities and ischial
tuberosities
– Posteriorolateral : sacrotuberous ligaments
– Posterior : os coccyx
• Vascular Internal pudendal artery:
– inferior rectal artery
– posterior labial artery
• Ischial Tuberosities divides perineum into
anterior and posterior triangle
 ANTERIOR TRIANGLE
(Urogenital Triangle)
• subdivided into:
– Superficial space closed compartment
– Deep space  continuous superiorly with pelvic
cavity
• Boundaries:
– Superior  Pubic rami
– Lateral  Ischial tuberosities
– Posterior  Superficial transverse pernieal muscle
SUPERFICIAL SPACE OF THE ANTERIOR
TRIANGLE
• Ischiocavernosus
– Helps maintain clitoral erection
• Bulbocavernosus
– constrict vaginal lumen & aid in release of
secretions of Bartholin’s gland
– Contributes to clitoral erection
• Superficial transverse pernineal muscles
– contributes to the perineal body
 DEEP SPACE OF THE ANTERIOR
TRIANGLE
• Compressor urethrae
• Urethrovaginal sphincter muscles
• External urethral sphincter
• Parts of urethra & vagina
• Branches of the internal pudendal artery
• Dorsal nerve
• Vein of clitoris
 POSTERIOR TRIANGLE
• Contains:
– Ischiorectal fossa
– Anal canal
– Anal sphincter complex
– Branches of the internal pudendal vessels
– Pudendal nerve
 Pudendal nerve
• Formed by : anterior rami of S2-S4
posteromedial to the ischial spines
• 3 Terminal branches:
– Dorsal nerve skin of clitoris
– Perineal nerve  muscles of anterior triangle &
labial skin
– Inferior rectal branch :
• external anal sphincter
• mucous membrane of the anal
• perianal skin
 Anus
• External anal sphincter (EAS)
– maintains a constant state of resting contraction
– Provides increased tone & strength when continence is
threatened
– Relaxes for defacation
• Internal anal sphincter (IAS)
– Primarily involved in 4th degree perineal laceration
• Anal cushion
– highly vascularized
– aids in fecal continence
– engorgement due to  uterine size, excessive straining &
hard stoolshemorrhoids
 INTERNAL GENERATIVE ORGANS
Cervix
• Supravaginal segment
– covered by peritoneum on its posterior surface
– attached to cardinal ligaments anteriorly,
– separated from the overlying bladder by loose
connective tissue.
• Lower vaginal portion  portio vaginalis.
• mucosa  single layer of ciliated columnar
epithelium on a thin basement membrane
• Glands furnish  thick, tenacious cervical
secretions.
• If the ducts of cervical glands are occluded
retention cysts (nabothian cysts)
 Uterus
• Thick-walled, hollow, muscular organ
• posterior wall of uterus is covered by serosa,
or peritoneum,
• lower portion forms the anterior boundary of
recto-uterine cul-de-sac (pouch of Douglas)
• Blood supply:
– uterine artery
– ovarian artery
• Body of the Uterus
– composed of serosal, muscular, & mucosal layers.
– serosal layer is formed by peritoneum that covers
the uterus.
• Endometrium
– thin, pink, velvet-like membrane perforated by a
large number of minute ostiaof the uterine glands
– Histologically
• inner glands  epithelium of surface and are lined by
single layer of columnar, partially ciliated epithelium
that rests on a thin basement membrane.
 Myometrium
• bundles of smooth muscle united by connective
tissue in which there are many elastic
fibersnumber of muscle fibers of diminishes
caudally
• musculature:
– Inner >> outer wall
– A and P walls >> lateral walls
• During pregnancyupper myometrium
undergoes hypertrophy, but there is no t change
in cervical muscle content.
Vascularisation
 UTERINE LIGAMENTS
BROAD LIGAMENT
• made up of 2 wing-like structuresextend
from lateral margins of uterus to pelvic walls.
• divide pelvic cavity into anterior & posterior
compartments.
• upper part is made up of 3 folds that nearly
cover the oviduct
 UTERINE LIGAMENTS
CARDINAL LIGAMENT
• transverse cervical ligament/Mackenrodt
ligament
• densest portion
• composed of connective tissue medially is
united firmly to supravaginal portion of
cervix.
 UTERINE LIGAMENTS
ROUND LIGAMENTS
• extend from lateral portion of uterus, arising
below & anterior to origin of oviducts.
• Non pregnant women  : 3-5 mm
• composed of smooth muscle cells.
• corresponds embryologically to gubernaculum
testis of men
• During pregnancy hypertrophy &  in both
length & diameter.
 Lymphatics
• Cervix terminate hypogastric nodes, which
• body of uterus  internal iliac nodes and
periaortic lymph nodes
 Oviducts (fallopian tubes)
• Length: 8-14 cm.
• lumen is lined by mucous membrane.
• PARTS
– interstitial portion
– isthmus
– ampulla
– Infundibulum or fimbriated extremity-funnel-
shaped opening at the distal
 Oviducts (fallopian tubes)
• Musculatureinner circular & outer
longitudinal layer.
• Lined by a single layer of columnar cells, some
ciliated & others secretory.
• No submucosa
• Tubal peristalsis  important factor in
transport of the ovum
 Ovaries
• childbearing years:
– Length : 2.5 - 5 cm
– Breadth : 1.5 - 3 cm
– Thickness : 0.6 - 1.5 cm
• menopause, ovarian size diminishes
remarkably.
• attached to the broad ligament by the
mesovarium.
 Ovaries
• utero-ovarian ligament
– from lateral & posterior portion of uterus, just
beneath the tubal insertion, to uterine pole of
ovary.
• infundibulopelvicor suspensory ligament
– extends from upper or tubal pole to pelvic wall
• Konjugata vera (true conjugate) : 11cm
• Diameter transversa = 12,5-13 cm
• Diameter oblik= 13 cm