MATERNAL ANATOMY Support by : William’s

book
 ANTERIOR ABDOMINAL WALL
Skin : Langer lines (orientation of dermal fibers arranged transversely)
Subcutan layer : superficial, predominantly fatty layer—Camper fascia, and a
deeper membranous layer—Scarpa fascia
Rectus sheath: aponeurosis of midline rectus abdominis and pyramidalis muscles
as well as the external oblique, internal oblique, and transversus abdominis
muscles .
the construction of this sheath varies above and below a boundary, termed the
arcuate line (Fig. 2-2). Cephalad to this border, the aponeuroses invest the rectus
abdominis bellies on both dorsal and ventral surfaces. Caudal to this line, all
aponeuroses lie ventral or super cial to the rectus abdominis muscle, and only the
thin transversalis fascia and peritoneum lie beneath the rectus
ANTERIOR ABDOMINAL WALL

FIGURE 2-1 Muscles and blood vessels of the anterior abdominal wall
BLOOD SUPPLY
the superficial epigastric, superficial circumflex iliac, and superficial
external pudendal arteries arise from the femoral artery : skin and
subcutaneous layers of the anterior abdominal wall and mons pubis

the inferior “deep” epigastric vessels and deep circumflex iliac vessels
are branches of the external iliac vessels. they supply the muscles and
fascia of the anterior abdominal wall.
 INNERVATION
intercostal nerves (T7-11)the subcostal nerve (T12):
 anterior rami of the thoracic spinal nerves
 run along the lateral and anterior abdominal wall between the transversus abdominis and internal
oblique muscles.
 branches pierce the posterior sheath, rectus muscle, and then anterior sheath to reach the skin ->
severed during a Pfannenstiel incision

the iliohypogastric  perforates the external oblique aponeurosis near the lateral
rectus border
 skin over the suprapubic area

ilioinguinal nerves (L1) medially travels through the inguinal canal, exits through the superficial
inguinal ring, which forms by splitting of external abdominal oblique aponeurosis fibers
 skin of the lower abdominal wall, upper portion of the labia majora

The T10 dermatome approximates the level of the umbilicus. regional analgesia for
cesarean delivery or for puerperal sterilization ideally blocks T10 through L1 levels
ORGAN GENITALIA EXTERNA
Vulva : includes all structures visible externally from the pubis to the
perineal body
 Mons Pubis
 Labia Mayora ~ man’s scrotum
 Labia Minora
 Clitoris
 Hymen
 Vestibule
 urethral opening
 greater vestibular or Bartholin glands,
 minor vestibular glands,
 paraurethral glands
mons pubis
 a fat-filled cushion overlying the symphysis pubis. After puberty, the mons pubis skin is
covered by curly hair that forms the escutcheon
 contains many sebaceous glands (oils) that serve as pillows during sex.
 the labia majora = male scrotum
 principally according to the amount of fat they contain. ey are 7 to 8 cm in length, 2 to 3 cm in depth, and 1 to
1.5 cm in thickness.
 Both of these lips at the bottom meet to form the perineum

labia minora: a long, narrow skin crease located inside the large lip
(labia majora) without hair extending down the clitoris and fused with
the fourchette, the lateral half portion and anterior labia usually
contain pigment, medial surface of the labia minora is the same as the
vaginal mucosa that is pink and wet
.
Clitoris It is an important part of the erectile external reproductive
apparatus, and is located near the superior tip of the vulva. This organ
contains many blood vessels and sensory nerve fibers so it is very sensitive
analogous to the male penis. The main function of the clitoris is to stimulate
and increase sexual tension.

VestibulumIs an outer reproduction tool that is shaped like a boat or oval,

lies between the labia minora, the clitoris and the fourchette. Vestibulum
consists of urethral estuaries, parauretra glands, vagina and paravagina
glands. The thin and slightly slimy vestibule surface is easily irritated by
chemicals, heat, and friction.
f. Perinium
is a skin-covered muscular region between the vaginal introitusand
anus. Perinium forms the base of the perinium body.
g. Bartholin's gland
Important glands in the vulva and vaginal areas are fragile and
easily torn. At the time of sex expenditure mucus increased.
Himen (hymen)Is a network that covers the vaginal opening is fragile
andeasily torn, the hymen is hollow so it becomes a channel of
mucuswhich in the uterus and blood during menstruation

i. FourchetteIt is a thin, thin, transverse tissue fold, located at the lower

end of the labia majora and labia minora. In the midline is under the
vaginal orifice. A small basin and a naval fossa lies between the
fourchette and the hymen.
ORGAN GENITALIA EXTERNA (3)
Bulbus Vestibuli: correspond to the corpus spongiosum of the penis.
These are almond-shaped aggregations of veins, 3 to 4 cm long, 1 to
2 cm wide, and 0.5 to 1 cm thick, which lie beneath the
bulbocavernosus muscle on either side of the vestibule.
Vagina dan Hymen
FIGURE 2-2 External female reproductive organs.
VAGINA
musculomembranous structure extends from the vulva to the uterus and
is interposed anteriorly and posteriorly between the bladder and the
rectum
The upper portion arises from the müllerian ducts, and the lower
portion is formed from the urogenital sinus
Anteriorly, the vagina is separated from the bladder and urethra by
connective tissue—the vesicovaginal septum
 VAGINA
Posteriorly, between the lower portion of the vagina and
the rectum, there are similar tissues that together form
the rectovaginal septum.
The upper fourth of the vagina is separated from the
rectum by the recto-uterine pouch, also called the cul-de-
sac of Douglas.
Vaginal length varies considerably, but commonly, the
anterior and posterior vaginal walls are, respectively, 6
to 8 cm and 7 to 10 cm in length
VAGINA
Histologi : The vaginal lining is composed of nonkeratinized stratified
squamous epithelium and underlying lamina propria. Below this there
is a muscular layer, which consists of smooth muscle, collagen, and
elastin
PEMBULUH DARAH DAN SISTEM LIMFATIK
VAGINA
The proximal portion  cervical branch of the uterine
artery and by the vaginal artery.
posterior vaginal wall The middle rectal artery
the distal walls  internal pudendal artery.
Lymphatics from the lower third inguinal lymph
nodes.
middle third internal iliac nodes
Upper third  external, internal, and common iliac
nodes.
FIGURE 2-3 Uterine and vaginal blood supply. The origin of the vaginal artery varies
and may arise from the uterine, inferior vesical, or internal iliac artery.
PERINEUM
•Margins : the pubic symphysis anteriorly, ischiopubic rami and ischial
tuberosities anterolaterally, sacrotuberous ligaments posterolaterally, and
coccyx posteriorly.
•Trigonum Anterior:
- Superficial Space of the Anterior Triangle.
several important structures : the ischiocavernosus,
bulbocavernosus, and superficial transverse perineal muscles;
Bartholin glands; vestibular bulbs; clitoral body and crura; and
branches of the pudendal vessels and nerve
- Deep Space of the Anterior Triangle.
contains the compressor urethrae and urethrovaginal
sphincter muscles, external urethral sphincter, parts of urethra
and vagina, branches of the internal pudendal artery, and the dorsal
nerve and vein of the clitoris
PERINEUM
•Trigonum Posterior :
- contains the ischiorectal fossa, anal canal, anal sphincter
complex, and branches of the internal pudendal vessels and
pudendal nerve
- Ischiorectal Fossae.
 PUDENDAL NERVE AND VESSELS
•The pudendal nerve the anterior rami of the second through
fourth sacral nerves
- The dorsal nerve of the clitoris  the skin of the clitoris.
- The perineal nerve  muscles of the anterior
triangle and labial skin.
- The inferior rectal branch  the external anal
sphincter, the mucous membrane of the anal canal, and
the perianal skin
•The major blood supply to the perineum is via the internal
pudendal artery and its branches. These include the inferior rectal
artery and posterior labial artery.
FIGURE 2-4 Perineal anatomy. Anterior and posterior triangles are defined by a line drawn
between the ischial tuberosities. The superficial space of the anterior triangle and its
contents are shown above this line.
FIGURE 2-5 Perineal anatomy. Anterior and posterior triangles are shown. Within the anterior
triangle, the contents of the deep space are shown on the image’s right, whereas those of the
superficial space are on the left.
ANUS
•External Anal Sphincter (EAS).
It maintains a constant state of resting contraction that provides
increased tone and strength when continence is threatened, and it
relaxes for defecation
•Internal Anal Sphincter (IAS).
the IAS may be involved in fourth-degree lacerations
 ANUS

FIGURE 2-6 Anatomy of the anorectum, drawn to show relations of the internal anal sphincter,
the external anal sphincter, and the levator ani muscles. The boundaries of the ischiorectal fossa
are shown. The ischiorectal fossa is bounded deeply by the inferior fascia of the levator ani
muscles, superficially by the perineal skin, anterolaterally by the fascia of the obturator internus
muscles and ischial tuberosities, posterolaterally by the gluteus maximus muscles and
sacrotuberous ligament, and medially by the anal canal and sphincter complex.
PERINEAL BODY
The median raphe of the levator ani, between the anus and the
vagina, is reinforced by the central tendon of the perineum. The
bulbocavernosus, superficial transverse perineal, and external anal
sphincter muscles also converge on the central tendon.
The perineal body is incised by an episiotomy incision and is torn with
second-, third-, and fourth-degree lacerations
 PERINEAL BODY
TABLE 2-1. Perineal Body

Function

Anchors the anorectum

Anchors the vagina

Helps maintains urinary and fecal continence

Maintains the orgasmic platform

Prevents expansion of the urogenital hiatus

Provides a physical barrier between the vagina and

rectum

Potential Morbidity

Episiotomy may injure the perineal body

Pudendal nerve injury may be associated with concurrent

perineal body injury

Adapted from Woodman and Graney (2002).

ORGAN REPRODUKSI INTERNA

FIGURE 2-8 Vertical section through the uterine end of the right
broad ligament. (Used with permission from Jennifer
UTERUS
Between the bladder anteriorly and the rectum posteriorly.
Almost the entire posterior wall of the uterus is covered by serosa, that
is visceral peritoneum.
The lower portion of this peritoneumforms the anterior boundary of
the recto-uterine cul-de-sac, or pouch of Douglas.
UTERUS
the upper portion of the anterior wall the vesicouterine pouch.
The lower portion of the anterior uterine wall  vesicouterine space.
pyriform or pear-shaped
UTERUS
body or corpus, and a lower, cylindrical portion—the cervix, which
projects into the vagina.
The isthmus is that portion of the uterus between the internal cervical
os and the endometrial cavity
The fallopian tubes, also called oviducts
The fundus
 UTERUS
The uterus of adult nulliparous womenmeasures 6 to 8 cm in length as
compared with 9 to 10 cm in multiparous women. In nonparous women, the
uterus averages 50 to 70 g, whereas in parous women it averages 80 g or
more
In nulliparous women, the fundus and cervix are approximately equal length,
but in multiparous women, the cervix is only a little more than 1/3 of the total
length
CERVIX
The upper segment of the cervix—the portio supravaginalis
Covered by peritoneum on its posterior surface,
the cardinal ligaments attach laterally
separated from lower vaginal portion of the cervix  portio vaginalis
LIGAMENTS
Round Ligament
Broad Ligament
infundibulopelvic ligament or suspensory ligament of the ovary,
cardinal ligament—also called the transverse cervical ligament
orMackenrodt ligament
FIGURE 2-15 Blood supply to the left ovary, left fallopian tube, and left side of the uterus. The
ovarian and uterine vessels anastomose freely. Note the uterine artery and vein crossing over
the ureter that lies immediately adjacent to the cervix. (Used with permission from Jennifer
Hulsey.)
FIGURE 2-16 Pelvic blood supply.
 TUBA FALOPII

FIGURE 2-17 The fallopian tube of an adult woman with cross-sectioned illustrations of the
gross structure in several portions: (A) isthmus, (B) ampulla, and (C) infundibulum. (Used
with permission from Dr. Kelley S. Carrick.)
FIGURE 2-17 These are photographs of corresponding histological sections.
(Used with permission from Dr. Kelley S. Carrick.)
OVARIES
During childbearing years  from 2.5 to 5 cm in length, 1.5 to 3 cm
in breadth, and 0.6 to 1.5 cm in thickness.
The cortex contains oocytes and developing follicles.
The medulla is the central portion, which is composed of loose
connective tissue, a large number of arteries and veins in the medulla
and a small number of smooth muscle fibers.
MUSCULOSKELETAL PELVIC ANATOMY
Pelvic Bones

FIGURE 2-18 Sagittal view of pelvic bones

PELVIC BONE
The pelvis is composed of four bones: the sacrum, coccyx, and two
innominate bones.
Each innominate bone is formed by the fusion of the ilium, ischium, and
pubis
The false pelvis lies above the linea terminalis
The true pelvis below this anatomical boundary, The true pelvis is the
portion important in childbearing
THE TRUE PELVIS
The posterior boundary is the anterior surface of the sacrum
the lateral limits are formed by the inner surface of the ischial bones
and the sacrosciatic notches and ligaments.
In front, the true pelvis is bounded by the pubic bones, the ascending
superior rami of the ischial bones, and the obturator foramen.
THE TRUE PELVIS
The ischial spines are of great obstetrical importance because the
distance between them usually represents the shortest diameter of the
pelvic cavity, as valuable landmarks in assessing the level to which the
presenting part of the fetus has descended into the true pelvis
PELVIC JOINTS
Symphysis Pubis
Sacroiliac Joints
FIGURE 2-19 Anteroposterior view of a normal female pelvis. Anteroposterior
(AP) and transverse (T) diameters of the pelvic inlet are illustrated
PLANES AND DIAMETERS OF THE PELVIS

The pelvis is described as having four imaginary

planes:
1. The plane of the pelvic inlet—the superior strait.
2. The plane of the pelvic outlet—the inferior strait.
3. The plane of the midpelvis—the least pelvic
dimensions.
4. The plane of greatest pelvic dimension—of no
obstetrical significance.
PELVIC INLET
MIDPELVIS
The midpelvis is measured at the level of the ischial spines
important following engagement of the fetal head in obstructed labor.
The interspinous diameter, 10 cm or slightly greater, is usually the
smallest pelvic diameter.
The anteroposterior diameter through the level of the ischial spines
normally measures at least 11.5 cm.
PELVIC OUTLET
PELVIC SHAPES
OTOT-OTOT DASAR PELVIS