MATERNAL ANATOMY

2. Contents
Anterior Abdominal wall
External Generative Organs
Internal Generative Organs
Pelvic Anatomy

3. ANTERIOR ABDOMINAL WALL
 Anterior Abdominal wall stretches to accommodate
the expanding uterus & provide surgical access to the
internal reproductive organs, thus comprehensive
knowledge of it’s layered structure is required to
surgically enter the peritoneal cavity.
 The anterior abdominal wall extends from the xiphoid
process of the sternum and costal margins cranially to
the iliac crest and pubic bones caudally

4. • Skin
– Langer lines
• Subcutaneous Layer
– Camper’s fascia
– Scarpa’s fascia
• Primary fascia (aponeurosis)/rectus sheath
• Abdominal wall muscles
– Rectus abdominis
– Pyramidalis
– Obliques (Ext. & Int.)
– Tranversus abdominis
• Tranversalis fascia
• Extra peritoneal tissue
• Parietal layer of peritonuem
LAYERS OF THE ANTERIOR
ABDOMINAL WALL

6.  Skin
 Langer lines :
 These describes the
orientation of dermal fibers
within the skin. In Ant.
Abdominal wall they are
arranged transversely. As a
result of this, vertical skin
incisions sustain greater and
thus in general it develops
wider scars.
 In contrast, Low Transverse
incisions such as Pfannenstiel
incision follows larger lines
and lead to superior cosmetic
result.
LAYERS OF THE ANTERIOR
ABDOMINAL WALL

7.  Subcutaneous Layer
– Camper’s fascia (Superficial fatty layer)
– Scarpa’s fascia (Deeper membranous
layer)
 Camper’s Fascia : Continues on to the
perineum to provide fatty substance to
Mons pubis, Labia majora and then to
blend with the fat of Ischio – anal fossa.
 Scarpa’s Fascia : Continues inferiorly on to
perineum as Colles fascia.
LAYERS OF THE ANTERIOR
ABDOMINAL WALL

8.  Primary fascia (aponeurosis)/Rectus sheath – It is formed
by Fibrous aponeurosis of External Obliques, Internal
Obliques, Transverse abdominis, these fuse in the midline
at the Linea alba [Normal 10 – 15mm]
 These three aponeuroses also invest the Rectus abdominis
muscle .
 Rectus sheath construction is different above and below
the arcuate line
LAYERS OF THE ANTERIOR
ABDOMINAL WALL

10.  Abdominal wall muscles
– Rectus abdominis
– Pyramidalis
– External Oblique
– Internal Oblique
– Tranversus abdominis
LAYERS OF THE ANTERIOR
ABDOMINAL WALL

13. Blood Supply of the ANTERIOR
ABDOMINAL WALL
BRANCHES OF FEMORAL ARTERY
 Superficial Epigastric Artery
Superficial Circumflex Iliac Artery
 Superficial External Pudendal Artery
supplies Skin,
Subcutaneous layer &
Mons Pubis.
 Inferior Deep Epigastric Vessels : Branch of External
Iliac vessels – supplies Anterior Abdominal wall
muscles & Fascia
Lies above the Arcuate line between Posterior
Rectus sheath & Rectus Abdominis.

14. Near the umbilicus : Inferior epigastric vessels
anastomoses with Superior epigastric artery and
vein which are the branches of internal thoracic
vessels
Clinically when a Maylard incision is used for
cesarean delivery ,the inferior epigastric vessels
may be lacerated lateral to the rectus belly during
muscle transection .preventively ,identification
&surgical occlusion are preferrable

17. Nerve Supply of the ANTERIOR ABDOMINAL
WALL
 Inter coastal Nerve [ T7 – 11]
 Sub coastal Nerve [T12]
 Ilio hypogastric Nerve[L1]
 Ilio inguinal Nerve[L1]
Derived from Anterior Rami of
thoracic spinal nerves
 Intercoastal & Subcoastal nerves are the anterior rami spinal nerves, an
Intercoastal nerve extends ventrally between the Trasversus abdominis and
Internal oblique muscles.
 During this path, the nerve ives rise to Lateral & Anterior cutaneus branches – that
innervates the Ant. Abdominal wall.
 The space between Transversus abdominis & Internal obliques is known as –
TRANS ABDOMINIS PLANE. [Most widely used for Post C – section analgesia
blockade.]

18.  Ilio hypogastric and Ilio inguinal nerves supply
the suprapubic area ,lower abdomen,and mons
pubis.
These nerve fibres run between the layers of
rectus sheath lateral to rectus muscle and may be
entrapped during closure, especially if incisions
beyond the lateral borders of the rectus abdominis
muscle.
These nerves carry sensory information only, and
injury leads to loss of sensations within the areas
supplied. Chronic pain may develop in rare cases.

19.  The T10 dermatome
approximates the level of
the umbilicus.
 Analgesia to this level is
suitabe for labor & Vaginal
Birth.
 Regional analgesia for
Cesarean delivery or for
puerperal sterilization
ideally extends to T4.

20. EXTERNAL GENERATIVE ORGANS
Vulva (Pudenda)
 Includes :
 Mons pubis
 Labia majora
 Labia minora
 Clitoris
 Vestibule
 Urethral opening
 Vaginal orifice
 Hymen
 Para urethral glands (skene’s
gland)
 Bartholin glands

21. MONS PUBIS :This is a triangular area anterior to the
pubic bones;
It is continuous with the abdominal wall above and with
labia below.
It is filled with adipose tissue and covered by hairy skin
:LABIA MAJORA:These are folds of fatty tissue covered
by skin that extend from the mons pubis to the perineum
to meet in front of the anus, forming the posterior
fourchette.
The skin on the lateral aspects of the labia majora is
pigmented and covered by hair .
The inner aspect is smooth and shiny and contains
apocrine, sweat & sebaceous glands .

22. EXTERNAL GENERATIVE ORGANS

23. LABIA MINORA:Labia minora are
folds of skin that lie medial to the labia
majora,encircling the urethral and
vaginal orificies.
Posteriorly they fuse with the posterior
fourchette but anteriorly they divide to
form hood /prepuce & a frenulum for
the clitoris

24. HART’S LINE:The outer side of L.Minora
is lined by keratinized squamous
epithelium.
The medial (inner)side of L.minora is lined
by non keratinized squamous epithelium.
The line which divides outer and inner side
of L.minora is called HART”S LINE

25. • Vulva (pudenda): includes all structures
visible externally from the symphysis pubis
to the perineal body.
EXTERNAL GENERATIVE ORGANS

26. CLITORIS
It is the main female erectile structure & is located
anterior to the urethral orifice between the anterior
folds of the labia minora.
It is the homologous of the penis in men
It is about 1.5-2cm in length.
• Parts :
– Glans – richly innervated
– Corpus
– (2) crura
EXTERNAL GENERATIVE ORGANS

27. VESTIBULE
It is an almond shaped area
enclosed by labia minora
laterally & extends from
clitoris to fourchette
Perforated By 6 Openings
– Urethra
– Vagina
– Bartholin gland ducts
– Skene glands
EXTERNAL GENERATIVE ORGANS

28. VESTIBULE
Boundaries
– P: fourchette
– A: clitoral frenulum
anteriorly
– L: Hart line laterally
– M: external surface of
hymen medially
Fossa navicularis
– posterior portion of
the vestibule
between the
fourchette and the
EXTERNAL GENERATIVE ORGANS

31. VESTIBULE
• Bartholin glands
– Greater vestibular glands
– Bartholin cyst
(obstructed)
– Bartholin abscess (if
infected)
• Paraurethral glands
• Skene glands – largest
• Inflammation, duct
obstruction –>
urethral diverticulum

32. BARTHOLIN GLAND
1)pea shaped gland
2)2 in number
3)located in superficial perineal pouch between
L.majora & L.minora at 4’o & 8’o clock postion .
4)These are homologous to cowper glands in
male .
5)Duct of the Bartholin gland open in the
vestibule outside the hymen i.e at the junction
of anterior 2/3rd & posterior 1/3rd .
6)If duct gets blocked ,it leads to Bartholin cyst .

33. BARTHOLIN’S CYST
POSTERIO-
LATERAL WALL
OF VAGINA
GARTNERS’ CYST
ANTERIO-
LATERAL OF
VAGINA

35. BARTHOLIN’S CYST :Intermittent
painless mass on vulva which is
aggravated by intercourse
MANAGEMENT:

38. HYMEN
It is a septum of mucous membrane which
usually gets ruptured during first
intercourse or during sternous exercise.
The hymen gets badly torn at parturition to
form different sized cicatrized nodules
known as hymenal tags

39. HYMEN

44. INTERNAL GENERATIVE ORGANS
• Vagina
• Cervix
• Uterus
• Ovaries
• Fallopian tubes

45. VAGINA

46.  Anterior vaginal wall : 6 to 8 cm
 Posterior vaginal wall : 7 to 10
cm
Lining : NKSS
VAGINA
 There are NO VAGINAL GLANDS.

48. VAGINA
BLOOD SUPPLY :
Cervical branch of Uterine artery} upper 1/3rd
Vaginal artery}middle 1/3rd
Middle rectal artery
Internal pudendal artery Lower 1/3rd

49. LYMPHATICS :
 Inguinal lymph nodes
 lower third, along with those of the vulva
 Internal iliac nodes
 middle third
 External, internal, and common iliac nodes
 upper third
NERVE SUPPLY
 Sympathetic from hypogastric plexus
 Parasympathetic from S2,3,4
VAGINA

50. Cervix
Small opening (nulli)
Slit-like (parous)
Ectocervix: NKSS epithelium
Endocervix: Simple Columnar ep.
SCJ is the mc site of
malignant
transformation
Eversion – during pregnancy
Composition: collagen,
elastin, proteoglycans,
very little SM

51. Uterus
NULLIGRAVID MULTIPAROUS
Weight 60kg Weighs more
Length 6-8cm 9-10cm
Fundus
and
cervix
Equal in
length
Cervix is only a
third of entire
Length

52. ANGLE OF UTERUS also called as
CORNUA OF UTERUS
3structures are attached on
either side

53. FALLOPIAN TUBE
ROUND LIGAMENT
OVARIAN
LIGAMENT
FALLOPIAN TUBE
ROUND LIGAMENT
FALLOPIAN TUBE
OVARIAN
LIGAMENT
ANTERIOR
POSTERIOR
LATERAL
ANTERIOR
POSTERIOR
LATERAL
ANTERIOR
POSTERIOR
LATERAL

54. WHY IS IT IMPORTANT TO KNOW
RELATIONSHIPOF THESE
STRUCTURES
MC CAUSE of failure of female
sterilization is identificationof wrong
structure
Therefore; to prevent this wrong identification ,tube
should be identified by distal end

55. PERINEUM

60. ANATOMY OF THE ANTERIOR TRIANGLE

62. ANATOMY OF THE POSTERIOR TRIANGLE
ISCHIO RECTAL FOSSAE
 Two fat-filled wedge-shaped spaces
found on either side of the anal
canal (comprise the bulk of the
posterior triangle)
ANAL CANAL
distal continuation of the rectum:
 begins at the level of levator ani
attachment to the rectum and ends at
the anal skin (4 to 5-cm long)
 Anal cushion – aids in the complete
closure of canal and fecal continence
when apposed
 Lining (mucosa):
 columnar epithelium (upper)
 stratified squamous epithelium
(dentate line)
HEMORRHOIDS :
 External
 CC: pain (inferior rectal nerve)
 Internal
 CC: bleeding

63. The ANAL SPHINCTER Complex
Description Function Symptoms
EAS Striated muscle attaching to PB anteriorly
Provides squeeze pressure
responsible or maintaining fecal
continence when continence is threatened
25% resting pressure
Provides
emergency
control for liquid
stool and flatus
Fecal urgency
Urge
incontinence:
liquid & flatus
IAS Continuation of the rectal circular smooth Keeps anal canal Fecal soiling
muscle. (70-85% resting pressure) closed at rest, Incontinence
maintenance of fecal continence at rest continence of liquid of liquid
Receives parasympathetic nerve fibers stool & flatus stool and flatus

64. PERINEAL BODY
Central point of the perineum
it is a fibromuscular node

65. MNEMONIC
BELTS for support
BULBOSPONGIOSUS
EXTERNAL ANAL SPHINCTER
LEVATOR ANI
TRANSVERSE PERENEI-SUPERFICIAL &DEEP
SPINCTER URETHRAE

66. PELVIC DIAPHRAGM
• Broad muscular sling
that provides
substantial support to
the pelvic viscera
• composed of :
– Levator Ani*
 Pubococcygeus
 Puborectalis
 Iliococcygeus
– Coccygeus Muscle

69. PUDENDAL NERVE
• Anterior rami of S2-4
• Lies within the Alcock
canal
• 3 terminal branches:
– Dorsal nerve of
the clitoris
– Perineal nerve
• Posterior labial
branches
• Muscular branches
– Inferior rectal

71. Where does the
ROUNDligament terminate?
Labia Majora

72. Which ARTERY courses through the ROUND
ligament ?
Sampson Artery

73. Ligaments

74.  The broad ligaments
 Two wing like structures that extend from the lateral
uterine margins to the pelvic sidewalls.
 Peritoneum that folds over the fallopian tube
mesosalpinx, round ligament is the mesoteres
 Ovarian ligament is the mesovarium.
Ligaments

75. Ligaments

77. • CARDINAL LIGAMENT
– Transverse Cervical Ligament
– Mackenrodt ligament
• anchors medially to the uterus and
upper vagina.
• PARAMETRIUM is the connective tissues adjacent and
lateral to the uterus within the broad ligament.
• PARACERVICAL tissues are those adjacent to the cervix
• PARACOLPIUM is that tissue lateral to the vaginal walls.
Ligaments

78. PELVIC BLOOD SUPPLY

79. PELVIC BLOOD SUPPLY

82. Venous drainage
• The right ovarian vein empties into the vena cava
• Left ovarian vein empties into the left renal vein

83. Lymphatics
• Cervix : Internal iliac nodes
• Uterine corpus : internal iliac nodes, para – aortic lymph
nodes

85. Fallopian tubes (oviducts)
• 8–14 cm from the uterine cornua

86. Ovaries
 Rests at the ovarian fossa of Waldeyer.
 Sympathetic nerves : ovarian plexus (originates in the renal
plexus)
 Parasympathetic input : Vagus nerve
 Sensory afferents follow the ovarian artery and enter at T10

87. FEMALE REPRODUCTIVE TRACT
Lining Epithelium
Vulva Vagina Cervix Uterus FT Ovary
Stratified Stratified Ectocervix: Simple Simple Cuboidal
Squamous Squamous Stratified squamous Columnar Columnar
Keratinizing Non- Non-keratinizing Ciliated
Keratinizing Endocervix:
Simple columnar
Mucin-producing
?? Transformation zone: Squamo-columnar
Junction