ANTERIOR ABDOMINAL WALL
EXTERNAL GENERATIVE ORGANS
INTERNAL GENERATIVE ORGANS
MUSCULOSKELETAL PELVIC ANATOMY
An understanding of female pelvic and lower abdominal wall anatomy is essential for obstetrical practice. Although consistent relationships between these structures are the norm, there may be marked variation in individual women. This is especially true for major blood vessels and nerves.
ANTERIOR ABDOMINAL WALL
Skin, Subcutaneous Layer, and Fascia
The anterior abdominal wall confines abdominal viscera, stretches to accommodate the expanding uterus, and provides surgical access to the internal reproductive organs. Thus, a comprehensive knowledge of its layered structure is required to surgically enter the peritoneal cavity.
Langer lines describe the orientation of dermal fibers within the skin. In the anterior abdominal wall, they are arranged transversely. As a result, vertical skin incisions sustain increased lateral tension and thus, in general, develop wider scars. In contrast, low transverse incisions, such as the Pfannenstiel, follow Langer lines and lead to superior cosmetic results.
The subcutaneous layer can be separated into a superficial, predominantly fatty layer—Camper fascia, and a deeper membranous layer—Scarpa fascia. Camper fascia continues onto the perineum to provide fatty substance to the mons pubis and labia majora and then to blend with the fat of the ischioanal fossa. Scarpa fascia continues inferiorly onto the perineum as Colles fascia (p. 22). As a result, perineal infection or hemorrhage superficial to Colles fascia has the ability to extend upward to involve the superficial layers of the abdominal wall.
Beneath the subcutaneous layer, the anterior abdominal wall muscles consist of the midline rectus abdominis and pyramidalis muscles as well as the external oblique, internal oblique, and transversus abdominis muscles, which extend across the entire wall (Fig. 2-1). The fibrous aponeuroses of these three latter muscles form the primary fascia of the anterior abdominal wall. These fuse in the midline at the linea alba, which normally measures 10 to 15 mm wide below the umbilicus (Beer, 2009). An abnormally wide separation may reflect diastasis recti or hernia.
FIGURE 2-1 Anterior abdominal wall anatomy. (From Corton, 2012, with permission.)
These three aponeuroses also invest the rectus abdominis muscle as the rectus sheath. 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 superficial to the rectus abdominis muscle, and only the thin transversalis fascia and peritoneum lie beneath the rectus (Loukas, 2008). This transition of rectus sheath composition can be seen best with a midline abdominal incision. Last, the paired small triangular pyramidalis muscles originate from the pubic crest, insert into the linea alba, and lie atop the rectus abdominis muscle but beneath the anterior rectus sheath.
FIGURE 2-2 Transverse sections of anterior abdominal wall above (A) and below (B) the arcuate line. (From Corton, 2012, with permission.)
The superficial epigastric, superficial circumflex iliac, and superficial external pudendal arteries arise from the femoral artery just below the inguinal ligament within the femoral triangle. These vessels supply the skin and subcutaneous layers of the anterior abdominal wall and mons pubis. Of surgical importance, the superficial epigastric vessels, from their origin, course diagonally toward the umbilicus. With a low transverse skin incision, these vessels can usually be identified at a depth halfway between the skin and the anterior rectus sheath, above Scarpa fascia, and several centimeters from the midline.
In contrast, 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. Of surgical relevance, the inferior epigastric vessels initially course lateral to, then posterior to the rectus abdominis muscles, which they supply. These vessels then pass ventral to the posterior rectus sheath and course between the sheath and the rectus muscles. Near the umbilicus, these vessels anastomose with the superior epigastric artery and veins, which are branches of the internal thoracic vessels. When a Maylard incision is used for cesarean delivery, the inferior epigastric artery may be lacerated lateral to the rectus belly during muscle transection. These vessels rarely may rupture following abdominal trauma and create a rectus sheath hematoma (Tolcher, 2010).
On each side of the lower anterior abdominal wall, Hesselbach triangle is the region bounded laterally by the inferior epigastric vessels, inferiorly by the inguinal ligament, and medially by the lateral border of the rectus muscle. Hernias that protrude through the abdominal wall in Hesselbach triangle are termed direct inguinal hernias. In contrast, indirect inguinal hernias do so through the deep inguinal ring, which lies lateral to this triangle, and then may exit out the superficial inguinal ring.
The anterior abdominal wall is innervated by intercostal nerves (T7–11), the subcostal nerve (T12), and the iliohypogastric and the ilioinguinal nerves (L1). Of these, the intercostal and subcostal nerves are anterior rami of the thoracic spinal nerves and run along the lateral and then anterior abdominal wall between the transversus abdominis and internal oblique muscles. This space is termed the transversus abdominis plane. Near the rectus abdominis lateral borders, these nerve branches pierce the posterior sheath, rectus muscle, and then anterior sheath to reach the skin. Thus, these nerve branches may be severed during a Pfannenstiel incision at the point in which the overlying anterior rectus sheath is separated from the rectus muscle.
In contrast, the iliohypogastric and ilioinguinal nerves originate from the anterior ramus of the first lumbar spinal nerve. They emerge lateral to the psoas muscle and travel retroperitoneally across the quadratus lumborum inferomedially toward the iliac crest. Near this crest, both nerves pierce the transversus abdominis muscle and course ventrally. At a site 2 to 3 cm medial to the anterior superior iliac spine, the nerves then pierce the internal oblique muscle and course superficial to it toward the midline (Whiteside, 2003). The iliohypogastric nerve perforates the external oblique aponeurosis near the lateral rectus border to provide sensation to the skin over the suprapubic area. The ilioinguinal nerve in its course medially travels through the inguinal canal and exits through the superficial inguinal ring, which forms by splitting of external abdominal oblique aponeurosis fibers. This nerve supplies the skin of the mons pubis, upper labia majora, and medial upper thigh.
The ilioinguinal and iliohypogastric nerves can be severed during a low transverse incision or entrapped during closure, especially if incisions extend beyond the lateral borders of the rectus muscle (Rahn, 2010). These nerves carry sensory information only, and injury leads to loss of sensation within the areas supplied. Rarely, however, chronic pain may develop.
The T10 dermatome approximates the level of the umbilicus. As discussed in Chapter 25 (p. 511), regional analgesia for cesarean delivery or for puerperal sterilization ideally blocks T10 through L1 levels. In addition, a transversus abdominis plane block can provide broad blockade to the nerves that traverse this plane and may be placed postcesarean to reduce analgesia requirements (Mishriky, 2012). There are also reports of rectus sheath block or ilioinguinal-iliohypogastric nerve block to decrease postoperative pain (Mei, 2011; Sviggum, 2012; Wolfson, 2012).
EXTERNAL GENERATIVE ORGANS
Mons Pubis, Labia, and Clitoris
The pudenda—commonly designated the vulva—includes all structures visible externally from the symphysis pubis to the perineal body. This includes the mons pubis, labia majora and minora, clitoris, hymen, vestibule, urethral opening, greater vestibular or Bartholin glands, minor vestibular glands, and paraurethral glands (Fig. 2-3). The embryology of the external genitalia is discussed in Chapter 7 (p. 144), and its innervations and vascular support are described with the pudendal nerve (p. 24).
FIGURE 2-3 Vulvar structures and subcutaneous layer of the anterior perineal triangle. Note the continuity of Colles and Scarpa fasciae. Inset: Vestibule boundaries and openings onto the vestibule. (From Corton, 2012, with permission.)
The mons pubis, also called the mons veneris, is a fat-filled cushion overlying the symphysis pubis. After puberty, the mons pubis skin is covered by curly hair that forms the escutcheon. In women, hair is distributed in a triangle, whose base covers the upper margin of the symphysis pubis and whose tip ends at the clitoris. In men and some hirsute women, the escutcheon is not so well circumscribed and extends onto the anterior abdominal wall toward the umbilicus.
Embryologically, the labia majora are homologous with the male scrotum. Labia vary somewhat in appearance, principally according to the amount of fat they contain. They are 7 to 8 cm in length, 2 to 3 cm in depth, and 1 to 1.5 cm in thickness. They are continuous directly with the mons pubis superiorly, and the round ligaments terminate at their upper borders. Posteriorly, the labia majora taper and merge into the area overlying the perineal body to form the posterior commissure.
Hair covers the labia majora outer surface but is absent on their inner surface. In addition, apocrine, eccrine, and sebaceous glands are abundant. Beneath the skin, there is a dense connective tissue layer, which is nearly void of muscular elements but is rich in elastic fibers and adipose tissue. This mass of fat provides bulk to the labia majora and is supplied with a rich venous plexus. During pregnancy, this vasculature commonly develops varicosities, especially in parous women, from increased venous pressure created by the enlarging uterus. They appear as engorged tortuous veins or as small grapelike clusters, but they are typically asymptomatic.
Each labium minus is a thin tissue fold that lies medial to each labium majus. In males, its homologue forms the ventral shaft of the penis. The labia minora extend superiorly, where each divides into two lamellae. From each side, the lower lamellae fuse to form the frenulum of the clitoris, and the upper merge to form the prepuce. Inferiorly, the labia minora extend to approach the midline as low ridges of tissue that join to form the fourchette. The size of the labia minora varies greatly among individuals, with lengths from 2 to 10 cm and widths from 1 to 5 cm (Lloyd, 2005).
Structurally, the labia minora are composed of connective tissue with numerous vessels, elastin fibers, and very few smooth muscle fibers. They are supplied with many nerve endings and are extremely sensitive (Ginger, 2011a). The epithelia of the labia minora vary with location. Thinly keratinized stratified squamous epithelium covers the outer surface of each labium. On their inner surface, the lateral portion is covered by this same epithelium up to a demarcating line—Hart line. Medial to this line, each labium is covered by squamous epithelium that is nonkeratinized. The labia minora lack hair follicles, eccrine glands, and apocrine glands. However, there are many sebaceous glands (Wilkinson, 2011).
The clitoris is the principal female erogenous organ and is the erectile homologue of the penis. It is located beneath the prepuce, above the frenulum and urethra, and projects downward and inward toward the vaginal opening. The clitoris rarely exceeds 2 cm in length and is composed of a glans, a corpus or body, and two crura (Verkauf, 1992). The glans is usually less than 0.5 cm in diameter, is covered by stratified squamous epithelium, and is richly innervated. The clitoral body contains two corpora cavernosa. Extending from the clitoral body, each corpus cavernosum diverges laterally to form a long, narrow crus. Each crus lies along the inferior surface of its respective ischiopubic ramus and deep to the ischiocavernosus muscle. The clitoral blood supply stems from branches of the internal pudendal artery. Specifically, the deep artery of the clitoris supplies the clitoral body, whereas the dorsal artery of the clitoris supplies the glans and prepuce.
This is the functionally mature female structure derived from the embryonic urogenital membrane. In adult women, it is an almond-shaped area that is enclosed by Hart line laterally, the external surface of the hymen medially, the clitoral frenulum anteriorly, and the fourchette posteriorly. The vestibule usually is perforated by six openings: the urethra, the vagina, two Bartholin gland ducts, and at times, two ducts of the largest paraurethral glands—the Skene glands. The posterior portion of the vestibule between the fourchette and the vaginal opening is called the fossa navicularis. It is usually observed only in nulliparas.
The bilateral Bartholin glands, also termed greater vestibular glands, are major glands that measure 0.5 to 1 cm in diameter. On their respective side, each lies inferior to the vascular vestibular bulb and deep to the inferior end of the bulbocavernosus muscle. The duct from each measures 1.5 to 2 cm long and opens distal to the hymeneal ring—one at 5 and the other at 7 o’clock on the vestibule. Following trauma or infection, either duct may swell and obstruct to form a cyst or, if infected, an abscess. In contrast, the minor vestibular glands are shallow glands lined by simple mucin-secreting epithelium and open along Hart line.
The paraurethral glands are a collective arborization of glands whose multiple small ducts open predominantly along the entire inferior aspect of the urethra. The two largest are called Skene glands, and their ducts typically lie distally and near the urethral meatus. Clinically, inflammation and duct obstruction of any of the paraurethral glands can lead to urethral diverticulum formation.
The lower two thirds of the urethra lie immediately above the anterior vaginal wall. The urethral opening or meatus is in the midline of the vestibule, 1 to 1.5 cm below the pubic arch, and a short distance above the vaginal opening.
Vagina and Hymen
In adult women, the hymen is a membrane of varying thickness that surrounds the vaginal opening more or less completely. It is composed mainly of elastic and collagenous connective tissue, and both outer and inner surfaces are covered by nonkeratinized stratified squamous epithelium. The aperture of the intact hymen ranges in diameter from pinpoint to one that admits one or even two fingertips. Imperforate hymen is a rare malformation in which the vaginal orifice is occluded completely, causing retention of menstrual blood (Chap. 3, p. 38). As a rule, the hymen is torn at several sites during first coitus. However, identical tears may occur by other penetration, for example, by tampons used during menstruation. The edges of the torn tissue soon reepithelialize. In pregnant women, the hymeneal epithelium is thick and rich in glycogen. Changes produced in the hymen by childbirth are usually readily recognizable. For example, over time, the hymen transforms into several nodules of various sizes, termed hymeneal or myrtiform caruncles.
Proximal to the hymen, the vagina is a musculomembranous tube that extends to the uterus and is interposed lengthwise between the bladder and the rectum (Fig. 2-4). Anteriorly, the vagina is separated from the bladder and urethra by connective tissue—the vesicovaginal septum. 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 rectouterine pouch, also called the cul-de-sac or pouch of Douglas.
FIGURE 2-4 Vagina and surrounding anatomy. (From Corton, 2012, with permission.)
Normally, the anterior and posterior walls of the vaginal lumen lie in contact, with only a slight space intervening at the lateral margins. Vaginal length varies considerably, but commonly, the anterior wall measures 6 to 8 cm, whereas the posterior vaginal wall is 7 to 10 cm. The upper end of the vaginal vault is subdivided into anterior, posterior, and two lateral fornices by the cervix. These are of considerable clinical importance because the internal pelvic organs usually can be palpated through the thin walls of these fornices. Moreover, the posterior fornix provides surgical access to the peritoneal cavity.
At the midportion of the vagina, its lateral walls are attached to the pelvis by visceral connective tissue. These lateral attachments blend into investing fascia of the levator ani. In doing so, they create the anterior and posterior lateral vaginal sulci. These run the length of the vaginal sidewalls and give the vagina an H shape when viewed in cross section.
The vaginal lining is composed of nonkeratinized stratified squamous epithelium and underlying lamina propria. In premenopausal women, this lining is thrown into numerous thin transverse ridges, known as rugae, which line the anterior and posterior vaginal walls along their length. Deep to this, there is a muscular layer, which contains smooth muscle, collagen, and elastin. Beneath this muscularis lies an adventitial layer consisting of collagen and elastin (Weber, 1997).
There are no vaginal glands. Instead, the vagina is lubricated by a transudate that originates from the vaginal subepithelial capillary plexus and crosses the permeable epithelium (Kim, 2011). Due to increased vascularity during pregnancy, vaginal secretions are notably increased. At times, this may be confused with amnionic fluid leakage, and clinical differentiation of these two is described in Chapter 22 (p. 448).
After birth-related epithelial trauma and healing, fragments of stratified epithelium occasionally are embedded beneath the vaginal surface. Similar to its native tissue, this buried epithelium continues to shed degenerated cells and keratin. As a result, firm epidermal inclusion cysts, which are filled with keratin debris, may form and are a common vaginal cyst.
The vagina has an abundant vascular supply. The proximal portion is supplied by the cervical branch of the uterine artery and by the vaginal artery. The latter may variably arise from the uterine or inferior vesical or directly from the internal iliac artery. The middle rectal artery contributes supply to the posterior vaginal wall, whereas the distal walls receive contributions from the internal pudendal artery. At each level, blood supply from each side forms anastomoses on the anterior and posterior vaginal walls with contralateral corresponding vessels.
An extensive venous plexus immediately surrounds the vagina and follows the course of the arteries. Lymphatics from the lower third, along with those of the vulva, drain primarily into the inguinal lymph nodes. Those from the middle third drain into the internal iliac nodes, and those from the upper third drain into the external, internal, and common iliac nodes.
This diamond-shaped area between the thighs has boundaries that mirror those of the bony pelvic outlet: the pubic symphysis anteriorly, ischiopubic rami and ischial tuberosities anterolaterally, sacrotuberous ligaments posterolaterally, and coccyx posteriorly. An arbitrary line joining the ischial tuberosities divides the perineum into an anterior triangle, also called the urogenital triangle, and a posterior triangle, termed the anal triangle.
The perineal body is a fibromuscular mass found in the midline at the junction between these anterior and posterior triangles (Fig. 2-5). Also called the central tendon of the perineum, the perineal body measures 2 cm tall and wide and 1.5 cm thick. It serves as the junction for several structures and provides significant perineal support (Shafik, 2007; Woodman, 2002). Superficially, the bulbocavernosus, superficial transverse perineal, and external anal sphincter muscles converge on the central tendon. More deeply, the perineal membrane, portions of the pubococcygeus muscle, and internal anal sphincter contribute (Larson, 2010). The perineal body is incised by an episiotomy incision and is torn with second-, third-, and fourth-degree lacerations.
FIGURE 2-5 Superficial space of the anterior triangle and posterior perineal triangle. Structures on the left side of the image can be seen after removal of Colles fascia. Those on the right side are noted after removal of the superficial muscles of the anterior triangle. (From Corton, 2012, with permission.)
Superficial Space of the Anterior Triangle
This triangle is bounded by the pubic rami superiorly, the ischial tuberosities laterally, and the superficial transverse perineal muscles posteriorly. It is divided into superficial and deep spaces by the perineal membrane. This membranous partition is a dense fibrous sheet that was previously known as the inferior fascia of the urogenital diaphragm. The perineal membrane attaches laterally to the ischiopubic rami, medially to the distal third of the urethra and vagina, posteriorly to the perineal body, and anteriorly to the arcuate ligament of the pubis.
The superficial space of the anterior triangle is bounded deeply by the perineal membrane and superficially by Colles fascia. As noted earlier, Colles fascia is the continuation of Scarpa fascia onto the perineum. On the perineum, Colles fascia securely attaches laterally to the pubic rami and fascia lata of the thigh, inferiorly to the superficial transverse perineal muscle and inferior border of the perineal membrane, and medially to the urethra, clitoris, and vagina. As such, the superficial space of the anterior triangle is a relatively closed compartment, and expanding infection or hematoma within it may bulge yet remains contained.
This superficial pouch contains several important structures, which include the Bartholin glands, vestibular bulbs, clitoral body and crura, branches of the pudendal vessels and nerve, and the ischiocavernosus, bulbocavernosus, and superficial transverse perineal muscles. Of these muscles, the ischiocavernosus muscles each attach on their respective side to the medial aspect of the ischial tuberosity inferiorly and the ischiopubic ramus laterally. Anteriorly, each attaches to a clitoral crus and may help maintain clitoral erection by compressing the crus to obstruct venous drainage. The bilateral bulbocavernosus muscles overlie the vestibular bulbs and Bartholin glands. They attach to the body of the clitoris anteriorly and the perineal body posteriorly. The muscles constrict the vaginal lumen and aid release of secretions from the Bartholin glands. They also may contribute to clitoral erection by compressing the deep dorsal vein of the clitoris. The bulbocavernosus and ischiocavernosus muscles also pull the clitoris downward. Last, the superficial transverse perineal muscles are narrow strips that attach to the ischial tuberosities laterally and the perineal body medially. They may be attenuated or even absent, but when present, they contribute to the perineal body (Corton, 2012).
Embryologically, the vestibular bulbs correspond to the corpora spongiosa of the penis. These almond-shaped aggregations of veins are 3 to 4 cm long, 1 to 2 cm wide, and 0.5 to 1 cm thick and lie beneath the bulbocavernosus muscle on either side of the vestibule. The bulbs terminate inferiorly at approximately the middle of the vaginal opening and extend upward toward the clitoris. Their anterior extensions merge in the midline, below the clitoral body. During childbirth, veins in the vestibular bulbs may be lacerated or even rupture to create a vulvar hematoma enclosed within the superficial space of the anterior triangle.
Deep Space of the Anterior Triangle
This space lies deep to the perineal membrane and extends up into the pelvis (Fig. 2-6) (Mirilas, 2004). In contrast to the superficial perineal space, the deep space is continuous superiorly with the pelvic cavity (Corton, 2005). It contains portions of urethra and vagina, certain portions of internal pudendal artery branches, and the compressor urethrae and urethrovaginal sphincter muscles, which comprise part of the striated urogenital sphincter complex.
FIGURE 2-6 Deep space of the anterior triangle of the perineum. Structures on the right side of the image can be seen after removal of the perineal membrane. Also shown are structures that attach to the perineal body: bulbocavernosus, superficial transverse perineal, external anal sphincter, and puboperinealis muscles as well as the perineal membrane. (From Corton, 2012, with permission.)
Found deep to the anterior and posterior triangles, this broad muscular sling provides substantial support to the pelvic viscera. The pelvic diaphragm is composed of the levator ani and the coccygeus muscle. The levator ani is composed of the pubococcygeus, puborectalis, and iliococcygeus muscles. The pubococcygeus muscle is also termed the pubovisceral muscle and is subdivided based on points of insertion and function. These include the pubovaginalis, puboperinealis, and puboanalis muscles, which insert into the vaginal, perineal body, and anus, respectively (Kearney, 2004).
Vaginal birth conveys significant risk for damage to the levator ani or to its innervation (DeLancey, 2003; Weidner, 2006). Of these muscles, the pubovisceral muscle is more commonly damaged (Lien, 2004; Margulies, 2007). Evidence supports that these injuries may predispose women to greater risk of pelvic organ prolapse or urinary incontinence (DeLancey, 2007a,b; Rortveit, 2003). For this reason, current research efforts are aimed at minimizing these injuries.
This triangle contains the ischioanal fossae, anal canal, and anal sphincter complex, which consists of the internal anal sphincter, external anal sphincter, and puborectalis muscle. Branches of the pudendal nerve and internal pudendal vessels are also found within this triangle.
Ischioanal Fossae. Also known as ischiorectal fossae, these two fat-filled wedge-shaped spaces are found on either side of the anal canal and comprise the bulk of the posterior triangle (Fig. 2-7). Each fossa has skin as its superficial base, whereas its deep apex is formed by the junction of the levator ani and obturator internus muscle. Other borders include: laterally, the obturator internus muscle fascia and ischial tuberosity; inferomedially, the anal canal and sphincter complex; superomedially, the inferior fascia of the downwardly sloping levator ani; posteriorly, the gluteus maximus muscle and sacrotuberous ligament; and anteriorly, the inferior border of the anterior triangle.
FIGURE 2-7 Anal canal and ischioanal fossa. (From Corton, 2012, with permission.)
The fat found within each fossa provides support to surrounding organs yet allows rectal distention during defecation and vaginal stretching during delivery. Clinically, injury to vessels in the posterior triangle can lead to hematoma formation in the ischioanal fossa, and the potential for large accumulation in these easily distensible spaces. Moreover, the two fossae communicate dorsally, behind the anal canal. This can be especially important because an episiotomy infection or hematoma may extend from one fossa into the other.
Anal Canal. This distal continuation of the rectum begins at the level of levator ani attachment to the rectum and ends at the anal skin. Along this 4- to 5-cm length, the mucosa consists of columnar epithelium in the uppermost portion, but at the dentate or pectinate line, simple stratified squamous epithelium begins and continues to the anal verge. Here, keratin and skin adnexa join the squamous epithelium.
The anal canal has several lateral tissue layers. Inner layers include the anal mucosa, the internal anal sphincter, and an intersphincteric space that contains continuation of the rectum’s longitudinal smooth muscle layer. An outer layer contains the puborectalis muscle as its cephalad component and the external anal sphincter caudally.
Within the anal canal, three highly vascularized submucosal arteriovenous plexuses termed anal cushions aid complete closure of the canal and fecal continence when apposed. Increasing uterine size, excessive straining, and hard stool create increased pressure that ultimately leads to degeneration and subsequent laxity of the cushion’s supportive connective tissue base. These cushions then protrude into and downward through the anal canal. This leads to venous engorgement within the cushions—now termed hemorrhoids. Venous stasis results in inflammation, erosion of the cushion’s epithelium, and then bleeding.
External hemorrhoids are those that arise distal to the pectinate line. They are covered by stratified squamous epithelium and receive sensory innervation from the inferior rectal nerve. Accordingly, pain and a palpable mass are typical complaints. Following resolution, a hemorrhoidal tag may remain and is composed of redundant anal skin and fibrotic tissue. In contrast, internal hemorrhoids are those that form above the dentate line and are covered by insensitive anorectal mucosa. These may prolapse or bleed but rarely become painful unless they undergo thrombosis or necrosis.
Anal Sphincter Complex. Two sphincters surround the anal canal to provide fecal continence—the external and internal anal sphincters. Both lie proximate to the vagina, and one or both may be torn during vaginal delivery. The internal anal sphincter (IAS) is a distal continuation of the rectal circular smooth muscle layer. It receives predominantly parasympathetic fibers, which pass through the pelvic splanchnic nerves. Along its length, this sphincter is supplied by the superior, middle, and inferior rectal arteries. The IAS contributes the bulk of anal canal resting pressure for fecal continence and relaxes prior to defecation. The IAS measures 3 to 4 cm in length, and at its distal margin, it overlaps the external sphincter for 1 to 2 cm (DeLancey, 1997; Rociu, 2000). The distal site at which this overlap ends, called the intersphincteric groove, is palpable on digital examination.
In contrast, the external anal sphincter (EAS) is a striated muscle ring that anteriorly attaches to the perineal body and that posteriorly connects to the coccyx via the anococcygeal ligament. The EAS maintains a constant resting contraction to aid continence, provides additional squeeze pressure when continence is threatened, yet relaxes for defecation. Traditionally, the EAS has been described as three parts, which include the subcutaneous, superficial, and deep portions. However, many consider the deep portion to be composed fully or in part by the puborectalis muscle (Raizada, 2008). The external sphincter receives blood supply from the inferior rectal artery, which is a branch of the internal pudendal artery. Somatic motor fibers from the inferior rectal branch of the pudendal nerve supply innervation. Clinically, the IAS and EAS may be involved in fourth-degree laceration during vaginal delivery, and reunion of these rings is integral to defect repair (Chap. 27, p. 548).
This is formed from the anterior rami of S2–4 spinal nerves (Fig. 2-8). It courses between the piriformis and coccygeus muscles and exits through the greater sciatic foramen at a location posterior to the sacrospinous ligament and just medial to the ischial spine (Barber, 2002). Thus, when injecting local anesthetic for a pudendal nerve block, the ischial spine serves an identifiable landmark (Chap. 25, p. 508). The pudendal nerve then runs beneath the sacrospinous ligament and above the sacrotuberous ligament as it reenters the lesser sciatic foramen to course along the obturator internus muscle. Atop this muscle, the nerve lies within the pudendal canal, also known as Alcock canal, which is formed by splitting of the obturator internus investing fascia (Shafik, 1999). In general, the pudendal nerve is relatively fixed as it courses behind the sacrospinous ligament and within the pudendal canal. Accordingly, it may be at risk of stretch injury during downward displacement of the pelvic floor during childbirth (Lien, 2005).
FIGURE 2-8 Pudendal nerve and vessels. (From Corton, 2012, with permission.)
The pudendal nerve leaves this canal to enter the perineum and divides into three terminal branches. Of these, the dorsal nerve of the clitoris runs between the ischiocavernosus muscle and perineal membrane to supply the clitoral glans (Ginger, 2011b). The perineal nerve runs superficial to the perineal membrane (Montoya, 2011). It divides into posterior labial branches and muscular branches, which serve the labial skin and the anterior perineal triangle muscles, respectively. The inferior rectal branch runs through the ischioanal fossa to supply the external anal sphincter, the anal mucosa, and the perianal skin (Mahakkanukrauh, 2005). The major blood supply to the perineum is via the internal pudendal artery, and its branches mirror the divisions of the pudendal nerve.
INTERNAL GENERATIVE ORGANS
The nonpregnant uterus is situated in the pelvic cavity between the bladder anteriorly and the rectum posteriorly. Almost the entire posterior wall of the uterus is covered by serosa, that is, visceral peritoneum (Fig. 2-9). The lower portion of this peritoneum forms the anterior boundary of the rectouterine cul-de-sac, or pouch of Douglas. Only the upper portion of the anterior wall of the uterus is so covered. The peritoneum in this area reflects forward onto the bladder dome to create the vesicouterine pouch. The lower portion of the anterior uterine wall is united to the posterior wall of the bladder by a well-defined loose connective tissue layer—the vesicouterine space. Clinically, during cesarean delivery, the peritoneum of the vesicouterine pouch is sharply incised, and the vesicouterine space is entered. Dissection caudally within this space lifts the bladder off the lower uterine segment for hysterotomy and delivery (Chap. 30, p. 593).
FIGURE 2-9 Anterior (A), right lateral (B), and posterior (C) views of the uterus of an adult woman. a = fallopian tube; b = round ligament; c = uteroovarian ligament; Ur = ureter.
The uterus is pear shaped and consists of two major but unequal parts. There is an upper triangular portion—the body or corpus, and a lower, cylindrical portion—the cervix, which projects into the vagina. The isthmus is the union site of these two. It is of special obstetrical significance because it forms the lower uterine segment during pregnancy. At each superolateral margin of the body is a uterine cornu, from which a fallopian tube emerges. Also in this area are the origins of the round and uteroovarian ligaments. Between the points of fallopian tube insertion is the convex upper uterine segment termed the fundus.
The bulk of the uterine body, but not the cervix, is muscle. The inner surfaces of the anterior and posterior walls lie almost in contact, and the cavity between these walls forms a mere slit. The nulligravid uterus measures 6 to 8 cm in length compared with 9 to 10 cm in multiparous women. The uterus averages 60 g and typically weighs more in parous women (Langlois, 1970; Sheikhazadi, 2010). In nulligravidas, the fundus and cervix are approximately equal in length, but in multiparas, the cervix is only a little more than a third of the total length.
Pregnancy stimulates remarkable uterine growth due to muscle fiber hypertrophy. The uterine fundus, a previously flattened convexity between tubal insertions, now becomes dome shaped. Moreover, the round ligaments appear to insert at the junction of the middle and upper thirds of the organ. The fallopian tubes elongate, but the ovaries grossly appear unchanged.
The cervical portion of the uterus is fusiform and open at each end by small apertures—the internal and external cervical ora. Proximally, the upper boundary of the cervix is the internal os, which corresponds to the level at which the peritoneum is reflected up onto the bladder. The upper cervical segment—the portio supravaginalis, lies above the vagina’s attachment to the cervix (Fig. 2-10). It is covered by peritoneum on its posterior surface, the cardinal ligaments attach laterally, and it is separated from the overlying bladder by loose connective tissue. The lower cervical portion protrudes into the vagina as the portio vaginalis. Before childbirth, the external cervical os is a small, regular, oval opening. After labor, especially vaginal childbirth, the orifice is converted into a transverse slit that is divided such that there are the so-called anterior and posterior cervical lips. If torn deeply during labor or delivery, the cervix may heal in such a manner that it appears irregular, nodular, or stellate.
FIGURE 2-10 Uterus, adnexa, and associated anatomy. (From Corton, 2012, with permission.)
The portion of the cervix exterior to the external os is called the ectocervix and is lined predominantly by nonkeratinized stratified squamous epithelium. In contrast, the endocervical canal is covered by a single layer of mucin-secreting columnar epithelium, which creates deep cleftlike infoldings or “glands.” Commonly during pregnancy, the endocervical epithelium moves out and onto the ectocervix in a physiological process termed eversion (Chap. 4, p. 48).
The cervical stroma is composed mainly of collagen, elastin, and proteoglycans, but very little smooth muscle. Changes in the amount, composition, and orientation of these components lead to cervical ripening prior to labor onset. In early pregnancy, increased vascularity within the cervix stroma beneath the epithelium creates an ectocervical blue tint that is characteristic of Chadwick sign. Cervical edema leads to softening—Goodell sign, whereas isthmic softening is Hegar sign.
Myometrium and Endometrium
Most of the uterus is composed of myometrium, which is smooth muscle bundles united by connective tissue containing many elastic fibers. Interlacing myometrial fibers surround myometrial vessels and contract to compress these. As shown in Figure 2-11, this anatomy is integral to hemostasis at the placental site during the third stage of labor.
FIGURE 2-11 Smooth muscle fibers of the myometrium compress traversing blood vessels when contracted.
The number of myometrial muscle fibers varies by location (Schwalm, 1966). Levels progressively diminish caudally such that, in the cervix, muscle makes up only 10 percent of the tissue mass. In the uterine body inner wall, there is relatively more muscle than in outer layers. And, in the anterior and posterior walls, there is more muscle than in the lateral walls. During pregnancy, the upper myometrium undergoes marked hypertrophy, but there is no significant change in cervical muscle content.
The uterine cavity is lined with endometrium, which is composed of an overlying epithelium, invaginating glands, and a supportive, vascular stroma. As discussed in Chapter 5 (p. 84), the endometrium varies greatly throughout the menstrual cycle and during pregnancy. This layer is divided into a functionalis layer, which is sloughed with menses, and a basalis layer, which serves to regenerate the functionalis layer following each menses.
There are several ligaments that extend from the uterine surface toward the pelvic sidewalls and include the round, broad, cardinal, and uterosacral ligaments (Figs. 2-9 and 2-12). The round ligament corresponds embryologically to the male gubernaculum testis (Acién, 2011). It originates somewhat below and anterior to the origin of the fallopian tubes. Clinically, this orientation can aid in fallopian tube identification during puerperal sterilization. This is important if pelvic adhesions limit tubal mobility and thus, limit fimbria visualization prior to tubal ligation. Each round ligament extends laterally and downward into the inguinal canal, through which it passes, to terminate in the upper portion of the labium majus. Sampson artery, a branch of the uterine artery, runs within this ligament. In nonpregnant women, the round ligament varies from 3 to 5 mm in diameter and is composed of smooth muscle bundles separated by fibrous tissue septa (Mahran, 1965). During pregnancy, these ligaments undergo considerable hypertrophy and increase appreciably in both length and diameter.
FIGURE 2-12 Pelvic viscera and their connective tissue support. (From Corton, 2012, with permission.)
The broad ligaments are two winglike structures that extend from the lateral uterine margins to the pelvic sidewalls. With vertical sectioning through this ligament proximate to the uterus, a triangular shape can be seen, and the uterine vessels and ureter are found at its base. The broad ligaments divide the pelvic cavity into anterior and posterior compartments. Each broad ligament consists of a fold of peritoneum termed the anterior and posterior leaves. This peritoneum drapes over structures extending from each cornu. Peritoneum that overlies the fallopian tube is termed the mesosalpinx, that around the round ligament is the mesoteres, and that over the uteroovarian ligament is the mesovarium. Peritoneum that extends beneath the fimbriated end of the fallopian tube toward the pelvic wall forms the infundibulopelvic ligament or suspensory ligament of the ovary. This contains nerves and the ovarian vessels, and during pregnancy, these vessels, especially the venous plexuses, are dramatically enlarged. Specifically, the diameter of the ovarian vascular pedicle increases from 0.9 cm to reach 2.6 cm at term (Hodgkinson, 1953).
The cardinal ligament—also called the transverse cervical ligament or Mackenrodt ligament—is the thick base of the broad ligament. Medially, it is united firmly to the uterus and upper vagina.
Each uterosacral ligament originates with a posterolateral attachment to the supravaginal portion of the cervix and inserts into the fascia over the sacrum, with some variations (Ramanah, 2012; Umek, 2004). These ligaments are composed of connective tissue, small bundles of vessels and nerves, and some smooth muscle. Covered by peritoneum, these ligaments form the lateral boundaries of the pouch of Douglas.
The term parametrium is used to describe the connective tissues adjacent and lateral to the uterus within the broad ligament. Paracervical tissues are those adjacent to the cervix, whereas paracolpium is that tissue lateral to the vaginal walls.
During pregnancy, there is marked hypertrophy of the uterine vasculature, which is supplied principally from the uterine and ovarian arteries (see Fig. 2-9). The uterine artery, a main branch of the internal iliac artery—previously called the hypogastric artery—enters the base of the broad ligament and makes its way medially to the side of the uterus. Approximately 2 cm lateral to the cervix, the uterine artery crosses over the ureter. This proximity is of great surgical significance as the ureter may be injured or ligated during hysterectomy when the vessels are clamped and ligated.
Once the uterine artery has reached the supravaginal portion of the cervix, it divides. The smaller cervicovaginal artery supplies blood to the lower cervix and upper vagina. The main branch turns abruptly upward and extends as a highly convoluted vessel that traverses along the lateral margin of the uterus. A branch of considerable size extends into the upper portion of the cervix, whereas numerous other branches penetrate the body of the uterus to form the arcuate arteries. These encircle the organ by coursing within the myometrium just beneath the serosal surface. These vessels from each side anastomose at the uterine midline. From the arcuate arteries, radial branches originate at right angles, traverse inward through the myometrium, enter the endometrium, and branch there to become basal arteries or coiled spiral arteries. The spiral arteries supply the functionalis layer. These vessels respond—especially by vasoconstriction and dilatation—to a number of hormones and thus serve an important role in menstruation. Also called the straight arteries, the basal arteries extend only into the basalis layer and are not responsive to hormonal influences.
Just before the main uterine artery vessel reaches the fallopian tube, it divides into three terminal branches. The ovarian branch of the uterine artery forms an anastomosis with the terminal branch of the ovarian artery; the tubal branch makes its way through the mesosalpinx and supplies part of the fallopian tube; and the fundal branch penetrates the uppermost uterus.
In addition to the uterine artery, the uterus receives blood supply from the ovarian artery. This artery is a direct branch of the aorta and enters the broad ligament through the infundibulopelvic ligament. At the ovarian hilum, it divides into smaller branches that enter the ovary. As the ovarian artery runs along the hilum, it also sends several branches through the mesosalpinx to supply the fallopian tubes. Its main stem, however, traverses the entire length of the broad ligament and makes its way to the uterine cornu. Here, it forms an anastomosis with the ovarian branch of the uterine artery. This dual uterine blood supply creates a vascular reserve to prevent uterine ischemia if ligation of the uterine or internal iliac artery is performed to control postpartum hemorrhage.
Uterine veins accompany their respective arteries. As such, the arcuate veins unite to form the uterine vein, which empties into the internal iliac vein and then the common iliac vein. Some of the blood from the upper uterus, the ovary, and the upper part of the broad ligament is collected by several veins. Within the broad ligament, these veins form the large pampiniform plexus that terminates in the ovarian vein. From here, the right ovarian vein empties into the vena cava, whereas the left ovarian vein empties into the left renal vein.
Blood supply to the pelvis is predominantly supplied from branches of the internal iliac artery. These branches are organized into anterior and posterior divisions, and subsequent branches are highly variable between individuals (Fig. 2-13). The anterior division provides blood supply to the pelvic organs and perineum and includes the inferior gluteal, internal pudendal, middle rectal, vaginal, uterine, and obturator arteries, as well as the umbilical artery and its continuation as the superior vesical artery. The posterior division branches extend to the buttock and thigh and include the superior gluteal, lateral sacral, and iliolumbar arteries. For this reason, during internal iliac artery ligation, many advocate ligation distal to the posterior division to avoid compromised blood flow to the areas supplied by this division (Bleich, 2007).
FIGURE 2-13 Pelvic arteries. (From Corton, 2012, with permission.)
The endometrium is abundantly supplied with lymphatic vessels that are confined largely to the basalis layer. The lymphatics of the underlying myometrium are increased in number toward the serosal surface and form an abundant lymphatic plexus just beneath it. Lymphatics from the cervix terminate mainly in the internal iliac nodes, which are situated near the bifurcation of the common iliac vessels. The lymphatics from the uterine corpus are distributed to two groups of nodes. One set of vessels drains into the internal iliac nodes. The other set, after joining certain lymphatics from the ovarian region, terminates in the paraaortic lymph nodes.
As a brief review, the peripheral nervous system is divided in a somatic division, which innervates skeletal muscle, and an autonomic division, which innervates smooth muscle, cardiac muscle, and glands. Pelvic visceral innervation is predominantly autonomic. The autonomic portion is further divided in sympathetic and parasympathetic components.
Sympathetic innervation to pelvic viscera begins with the superior hypogastric plexus, also termed the presacral nerve (Fig. 2-14). Beginning below the aortic bifurcation and extending downward retroperitoneally, this plexus is formed by sympathetic fibers arising from spinal levels T10 through L2. At the level of the sacral promontory, this superior hypogastric plexus divides into a right and a left hypogastric nerve, which run downward along the pelvis side walls (Açar, 2012; Moszkowicz, 2011).
FIGURE 2-14 Pelvic innervation. (From Corton, 2012, with permission.)
In contrast, parasympathetic innervation to the pelvic viscera derives from neurons at spinal levels S2 through S4. Their axons exit as part of the anterior rami of the spinal nerves for those levels. These combine on each side to form the pelvic splanchnic nerves, also termed nervi erigentes.
Blending of the two hypogastric nerves (sympathetic) and the two pelvic splanchnic nerves (parasympathetic) gives rise to the inferior hypogastric plexus, also termed the pelvic plexus. This retroperitoneal plaque of nerves lies at the S4 and S5 level (Spackman, 2007). From here, fibers of this plexus accompany internal iliac artery branches to their respective pelvic viscera. Thus, the inferior hypogastric plexus divides into three plexuses. The vesical plexus innervates the bladder and the middle rectal travels to the rectum, whereas the uterovaginal plexus, also termed Frankenhäuser plexus, reaches the proximal fallopian tubes, uterus, and upper vagina. Extensions of the inferior hypogastric plexus also reach the perineum along the vagina and urethra to innervate the clitoris and vestibular bulbs (Montoya, 2011). Of these, the uterovaginal plexus is composed of variably sized ganglia, but particularly of a large ganglionic plate that is situated on either side of the cervix, proximate to the uterosacral and cardinal ligaments (Ramanah, 2012).
Most afferent sensory fibers from the uterus ascend through the inferior hypogastric plexus and enter the spinal cord via T10 through T12 and L1 spinal nerves. These transmit the painful stimuli of contractions to the central nervous system. The sensory nerves from the cervix and upper part of the birth canal pass through the pelvic splanchnic nerves to the second, third, and fourth sacral nerves. Those from the lower portion of the birth canal pass primarily through the pudendal nerve. As described earlier (p. 24), anesthetic blocks used in labor and delivery target this innervation.
Compared with each other, as well as between women, the ovaries differ considerably in size. During childbearing years, they measure 2.5 to 5 cm in length, 1.5 to 3 cm in breadth, and 0.6 to 1.5 cm in thickness. Their position also varies, but they usually lie in the upper part of the pelvic cavity and rest in a slight depression on the lateral wall of the pelvis. This ovarian fossa of Waldeyer is between the divergent external and internal iliac vessels.
The uteroovarian ligament originates from the lateral and upper posterior portion of the uterus, just beneath the tubal insertion level, and extends to the uterine pole of the ovary. Usually, this ligament is a few centimeters long and 3 to 4 mm in diameter. It is made up of muscle and connective tissue and is covered by peritoneum—the mesovarium. As described on page 28, blood supply traverses to and from the ovary through this double-layered mesovarium to enter the ovarian hilum.
The ovary consists of a cortex and medulla. In young women, the outermost portion of the cortex is smooth, has a dull white surface, and is designated the tunica albuginea. On its surface, there is a single layer of cuboidal epithelium, the germinal epithelium of Waldeyer. Beneath this epithelium, the cortex contains oocytes and developing follicles. The medulla is the central portion, which is composed of loose connective tissue. There are a large number of arteries and veins in the medulla and a small number of smooth muscle fibers.
The ovaries are supplied with both sympathetic and parasympathetic nerves. The sympathetic nerves are derived primarily from the ovarian plexus that accompanies the ovarian vessels and originates in the renal plexus. Others are derived from the plexus that surrounds the ovarian branch of the uterine artery. Parasympathetic input is from the vagus nerve. Sensory afferents follow the ovarian artery and enter at T10 spinal cord level.
Also called oviducts, these serpentine tubes extend 8 to 14 cm from the uterine cornua and are anatomically classified along their length as an interstitial portion, isthmus, ampulla, and infundibulum (Fig. 2-15). Most proximal, the interstitial portion is embodied within the uterine muscular wall. Next, the narrow 2- to 3-mm isthmus adjoins the uterus and widens gradually into the 5- to 8-mm, more lateral ampulla. Last, the infundibulum is the funnel-shaped fimbriated distal extremity of the tube, which opens into the abdominal cavity. The latter three extrauterine portions are covered by the mesosalpinx at the superior margin of the broad ligament.
FIGURE 2-15 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. Below these are photographs of corresponding histological sections. (Photographs contributed by Dr. Kelley S. Carrick.)
In cross section, the extrauterine fallopian tube contains a mesosalpinx, myosalpinx, and endosalpinx. The outer of these, the mesosalpinx, is a single-cell mesothelial layer functioning as visceral peritoneum. In the myosalpinx, smooth muscle is arranged in an inner circular and an outer longitudinal layer. In the distal tube, the two layers are less distinct and are replaced near the fimbriated extremity by sparse interlacing muscular fibers. The tubal musculature undergoes rhythmic contractions constantly, the rate of which varies with cyclical ovarian hormonal changes.
The tubal mucosa or endosalpinx is a single columnar epithelium composed of ciliated and secretory cells resting on a sparse lamina propria. It is in close contact with the underlying myosalpinx. The ciliated cells are most abundant at the fimbriated extremity, but elsewhere, they are found in discrete patches. There also are differences in the proportions of these two cell types in the different ovarian cycle phases. The mucosa is arranged in longitudinal folds that become progressively more complex toward the fimbria. In the ampulla, the lumen is occupied almost completely by the arborescent mucosa. The current produced by the tubal cilia is such that the direction of flow is toward the uterine cavity. Tubal peristalsis created by cilia and muscular layer contraction is believed to be an important factor in ovum transport (Croxatto, 2002).
The tubes are supplied richly with elastic tissue, blood vessels, and lymphatics. Sympathetic innervation of the tubes is extensive, in contrast to their parasympathetic innervation. This nerve supply derives partly from the ovarian plexus and partly from the uterovaginal plexus. Sensory afferent fibers ascend to T10 spinal cord levels.
MUSCULOSKELETAL PELVIC ANATOMY
The pelvis is composed of four bones—the sacrum, coccyx, and two innominate bones. Each innominate bone is formed by the fusion of three bones—the ilium, ischium, and pubis (Fig. 2-16). Both innominate bones are joined to the sacrum at the sacroiliac synchondroses and to one another at the symphysis pubis.
FIGURE 2-16 Sagittal view of the pelvic bones.
The pelvis is conceptually divided into false and true components. The false pelvis lies above the linea terminalis, and the true pelvis is below this anatomical boundary (Fig. 2-17). The false pelvis is bounded posteriorly by the lumbar vertebra and laterally by the iliac fossa. In front, the boundary is formed by the lower portion of the anterior abdominal wall.
FIGURE 2-17 Anteroposterior view of a normal female pelvis. Anteroposterior (AP) and transverse (T) diameters of the pelvic inlet are illustrated.
The true pelvis is the portion important in childbearing and can be described as an obliquely truncated, bent cylinder with its greatest height posteriorly. The linea terminalis serves as the superior border, whereas the pelvic outlet is the inferior margin. The posterior boundary is the anterior surface of the sacrum, and 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, by the ascending superior rami of the ischial bones, and by the obturator foramina.
The sidewalls of the true pelvis of an adult woman converge somewhat. Extending from the middle of the posterior margin of each ischium are the ischial spines. These are of great obstetrical importance because the distance between them usually represents the shortest diameter of the true pelvis. They also serve as valuable landmarks in assessing the level to which the presenting part of the fetus has descended into the true pelvis (Chap. 22, p. 449). Last, as described earlier, these aid pudendal nerve block placement.
The sacrum forms the posterior wall of the true pelvis. Its upper anterior margin corresponds to the promontory that may be felt during bimanual pelvic examination in women with a small pelvis. It can provide a landmark for clinical pelvimetry. Normally, the sacrum has a marked vertical and a less pronounced horizontal concavity, which in abnormal pelves may undergo important variations. A straight line drawn from the promontory to the tip of the sacrum usually measures 10 cm, whereas the distance along the concavity averages 12 cm.
Anteriorly, the pelvic bones are joined together by the symphysis pubis. This structure consists of fibrocartilage and the superior and inferior pubic ligaments. The latter ligament is frequently designated the arcuate ligament of the pubis. Posteriorly, the pelvic bones are joined by articulations between the sacrum and the iliac portion of the innominate bones to form the sacroiliac joints.
These joints in general have a limited degree of mobility. However, during pregnancy, there is remarkable relaxation of these joints at term, caused by upward gliding of the sacroiliac joint (Borell, 1957). The displacement, which is greatest in the dorsal lithotomy position, may increase the diameter of the outlet by 1.5 to 2.0 cm. This is the main justification for placing a woman in this position for a vaginal delivery. But this pelvic outlet diameter increase occurs only if the sacrum is allowed to rotate posteriorly. Thus, it will not occur if the sacrum is forced anteriorly by the weight of the maternal pelvis against the delivery table or bed (Russell, 1969, 1982). Sacroiliac joint mobility is also the likely reason that the McRoberts maneuver often is successful in releasing an obstructed shoulder in a case of shoulder dystocia (Chap. 27, p. 541). These changes have also been attributed to the success of the modified squatting position to hasten second-stage labor (Gardosi, 1989). The squatting position may increase the interspinous diameter and the pelvic outlet diameter (Russell, 1969, 1982). These latter observations are unconfirmed, but this position is assumed for birth in many societies.
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.
Also called the superior strait, the pelvic inlet is also the superior plane of the true pelvis. As noted earlier, it is bounded posteriorly by the promontory and alae of the sacrum, laterally by the linea terminalis, and anteriorly by the horizontal pubic rami and the symphysis pubis. During labor, fetal head engagement is defined by the fetal head’s biparietal diameter passing through this plane. To aid this passage, the inlet of the female pelvis—compared with the male pelvis—typically is more nearly round than ovoid. Caldwell (1934) identified a nearly round or gynecoid pelvic inlet in approximately half of white women.
Four diameters of the pelvic inlet are usually described: anteroposterior, transverse, and two oblique diameters. Of these, distinct anteroposterior diameters have been described using specific landmarks. Most cephalad, the anteroposterior diameter, termed the true conjugate, extends from the uppermost margin of the symphysis pubis to the sacral promontory. The clinically important obstetrical conjugate is the shortest distance between the sacral promontory and the symphysis pubis. Normally, this measures 10 cm or more, but unfortunately, it cannot be measured directly with examining fingers. Thus, for clinical purposes, the obstetrical conjugate is estimated indirectly by subtracting 1.5 to 2 cm from the diagonal conjugate, which is determined by measuring the distance from the lowest margin of the symphysis to the sacral promontory (Fig. 2-18).
FIGURE 2-18 Vaginal examination to determine the diagonal conjugate. P = sacral promontory; S = symphysis pubis.
The transverse diameter is constructed at right angles to the obstetrical conjugate and represents the greatest distance between the linea terminalis on either side. It usually intersects the obstetrical conjugate at a point approximately 5 cm in front of the promontory and measures approximately 13 cm. Each of the two oblique diameters extends from one sacroiliac synchondrosis to the contralateral iliopubic eminence. Each eminence is a minor elevation that marks the union site of the ilium and pubis. These oblique diameters average less than 13 cm.
Midpelvis and Pelvic Outlet
The midpelvis is measured at the level of the ischial spines, also called the midplane or plane of least pelvic dimensions (Fig. 2-19). During labor, the degree of fetal head descent into the true pelvis may be described by station, and the midpelvis and ischial spines serve to mark zero station. The interspinous diameter is 10 cm or slightly greater, is usually the smallest pelvic diameter, and, in cases of obstructed labor, is particularly important. The anteroposterior diameter through the level of the ischial spines normally measures at least 11.5 cm.
FIGURE 2-19 Adult female pelvis demonstrating the interspinous diameter of the midpelvis. The anteroposterior and transverse diameters of the pelvic inlet are also shown.
The pelvic outlet consists of two approximately triangular areas whose boundaries mirror those of the perineal triangle described earlier (p. 21). They have a common base, which is a line drawn between the two ischial tuberosities. The apex of the posterior triangle is the tip of the sacrum, and the lateral boundaries are the sacrotuberous ligaments and the ischial tuberosities. The anterior triangle is formed by the descending inferior rami of the pubic bones. These rami unite at an angle of 90 to 100 degrees to form a rounded arch under which the fetal head must pass. Clinically, three diameters of the pelvic outlet usually are described—the anteroposterior, transverse, and posterior sagittal. Unless there is significant pelvic bony disease, the pelvic outlet seldom obstructs vaginal delivery.
The Caldwell-Moloy (1933, 1934) anatomical classification of the pelvis is based on shape, and its concepts aid an understanding of labor mechanisms. Specifically, the greatest transverse diameter of the inlet and its division into anterior and posterior segments are used to classify the pelvis as gynecoid, anthropoid, android, or platypelloid. The posterior segment determines the type of pelvis, whereas the anterior segment determines the tendency. These are both determined because many pelves are not pure but are mixed types. For example, a gynecoid pelvis with an android tendency means that the posterior pelvis is gynecoid and the anterior pelvis is android shaped.
From viewing the four basic types in Figure 2-20, the configuration of the gynecoid pelvis would intuitively seem suited for delivery of most fetuses. Indeed, Caldwell (1939) reported that the gynecoid pelvis was found in almost half of women.
FIGURE 2-20 The four parent pelvic types of the Caldwell–Moloy classification. A line passing through the widest transverse diameter divides the inlets into posterior (P) and anterior (A) segments.
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