Anatomy of Pelvic, Perineum, and Reproductive Organs (Clinical Oriented)

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Block C2 - Safe Motherhood & Neonates


Anatomy
Office:Anatomy Building.
Lab:Rear of Anatomy Building.
Work-plan:None.
Pre-test:5 questions, short-answer.
Post-test:None.
Lab Report:None.

Definitions[edit]

Fistula
an abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect. In other words, an abnormal hole between two spaces in the body.

Anatomy Notes[edit]

Pelvic Inlet[edit]

  1. Diameter anteroposterior
    • Conjugata vera anatomica
    • Conjugata vera obstetrica
    • Conjugata diagonalis
  2. Diameter transversa
  3. Diameter obliqua sinistra
  4. Diameter obliqua dextra

Pelvic Outlet[edit]

  1. Distansia interspinosa: narrowest part of birth canal.
  2. Diameter anteroposterior

Head of Baby[edit]

Cephalic presentations with different attitudes
Anthropometry of the baby's head
  1. Suboccipitobregamatic: ~9.5 cm (Vertex)
  2. Suboccipitofrontal: ~10.0 cm (Sinciput)
  3. Occipitofrontal: ~11.75 cm
  4. Occipitomentalis: 13.50 cm
  5. Mentovertical: ~13.8 cm (Brow)
  6. Submentobregmatic: ~9.5 cm (Face)
  7. Submentovertical: ~11.25 cm (Extended face)
  8. Biparietal diameter: ~9.5 cm, the transverse diameter of the head at the widest point.
  9. Bitemporal diameter: ~8.0 cm
  10. Bimastoid diameter: 7.5 cm

Joints and Ligaments[edit]

  1. Art. lumbosacralis
  2. Art. sacrococcygeum
  3. Art. sacroiliaca
  4. Lig. iliolumbale
  5. Lig. sacrotuberale
  6. Lig. sacrospinale
  7. Symphisis pubicum
  • Passive support of the uterus:
    1. Lig. teres uteri
    2. Lig. latum
    3. Lig. uterosacral
    4. Lig. cardinal uteri
  • Active support of the uterus:
    1. M. levator ani
      1. m. puborectal
      2. m. pubococcygeous
      3. m. ileococcygeous
    2. m. coccygeous

Innervation[edit]

  1. Plexus sacralis
    • N. pudendus (S2-S4)
    • N. ischiadicus (L4-S3)
    • N. gluteus superior (L4-S1)
    • N. gluteus inferior (L5-S2)
  2. Pelvic splanchnic nerves or nervi erigentes are splanchnic nerves that arise from sacral spinal nerves S2, S3, S4 to provide parasympathetic innervation to the hindgut.

Vascularization[edit]

  1. Ramus ovaricus arteriae uterinae: Terminal branch of uterine artery (with tubal branch) which runs through mesovarium supplying the ovaries.

Hodge planes and stations[edit]

Hodge planes
  1. Hodge plane III is equivalent to station 0.

Perineal lacerations[edit]

  • 1st degree: Vaginal mucous membrane.
  • 2nd degree: Fascia and muscles of perineum, except m. sphincter ani extrna.
  • 3rd degree: M. sphincter ani externa.
  • 4th degree: Rectal mucosa.

Prolapse[edit]

  • Stage system:
    • Stage 0: No prolapse.
    • Stage 1: Prolapse is still more than 1 cm above the hymen.
    • Stage 2: Prolapse descends so that it is within 1 cm of the hymen.
    • Stage 3: Prolapse extends 1 cm beyond the hymen but is within 2 cm of the total vaginal length.
    • Stage 4: Complete eversion.
  • Degree system:
    • 1st degree: To the upper vagina.
    • 2nd degree: To the introitus.
    • 3rd degree: Cervix is outside the introitus.
    • 4th degree: Uterus and cervix entirely outside the introitus.

Kegel exercises and pessary rings are used to avoid prolapse of pelvic organs.

Celes[edit]

Pelvic support problems
  1. Cystocele: Urinary bladder herniates into the vaginal cavity.
  2. Rectocele: Rectovaginal septum tears and the rectum herniates into the vaginal cavity.
  3. Enterocele: Small intestine and peritoneum herniate into the vaginal cavity.
  4. Urethrocele: Prolapse of the urethra into the vaginal cavity.

Celes are not fistulas, but may become fistulas. Different types of celes can happen at the same time.

Fistulas[edit]

Clinical Correlation[edit]

  • Celphalopelvic disproportion: Baby's head is too big or the mother's birth canal is too small.
  • Shoulder dystocia: After delivery of the head, the shoulder is stuck behind the pubic symphysis. The baby's chin presses against the walls of the perineum. McRoberts maneuver is used to widen the pelvis if shoulder dystocia occurs. Complications of shoulder dystocia include brachial plexopathy, Erb's palsy, and fracture of the clavicula.
  • Head trauma / Scalp hematoma:
    Scalp hematomas
    • Caput succedaneum: swelling involving subcutaneous bleeding.
    • Cephalhematoma: subperiosteal bleeding.
    • Subgaleal hematoma: bleeding between the skull periosteum and the scalp galea aponeurosis.

Procedures[edit]

  • Hysterosalpingography: radiologic procedure to investigate the shape of the uterine cavity and the shape and patency of the fallopian tubes.
  • Hysterectomy
  • Episiotomy
    1. Median
    2. Mediolateral
    3. Lateral
  • Laparoscopy: Less invasive and quicker recovery than open surgery.
  • Tubal ligation
    1. Pomeroy: twist, suture, and cut excess.
    2. Irving: cut from middle and proximal ends are sewn into the myometrium.
    3. Uchida: cut from middle and then reconnect ends.

Anesthesia[edit]

Spinal block
Pudendal block
  1. Spinal block (aka. Lumbar block)
    • Somantic, parasymphathetic, sympathetic.
    • Injected into the subarachnoid space between L3 and L4.
    • Patients cannot feel the contractions so a contraction monitor device is used.
    • Side-effect: headache.
  2. Pudendal block.
    • Somantic only.
    • S2-S4.
    • Injection site: Canalis Alcock near the ischial spine.
    • Pain relief for the vulva, 1/4 of the lower vagina, and perineum.
  3. Caudal epidural block
    • Parasympathetic and sympathetic
    • Through the hiatus sacralis.
    • Birth canal, pelvic floor, and most of the perineum ​​anesthetized. The inferior extremities are unaffected and uterine contractions can still be felt.

External Links[edit]

Videos[edit]

Slides[edit]