repro anatomy Flashcards
bony pelvis made up of?
ileum features
ischium features
sacrotuberous + sacrospinous ligament
pubis features
significance of pubic tubercle?
attachment of inguinal ligament (ASIS to pubic tubercle)
pelvic inlet made up of?
pelvic outlet?
true vs false pelvis?
greater/false pelvis
true pevlis = once through pelvic inlet
palpable surface landmarks of the pelvis
x-ray of pelvic features
joints of the pelvis
ligaments of the pelvis
+ obturator membrane, ilofemoral, ischiofemoral, pubofemoral
which ligaments form the greater and lesser sciatic foramen?
sacrotuberous + sacrospinous
structures related to obturator foramen
life threatening complications of pelvic fracture?
haemorrhage!
* common iliac!!
damage to pelvic organs
remember - pelvis is a ring bone so likely to have multiple fractures
male vs female pelvis
AP and transverse diameters larger in female
subpubic ange (pubic arch) wider in female
pelvic cavity more shallow in female
bones of foetal skull
+ moulding?
vertex?
foetal descent through pelvis
pelvic inlet = wider transversely so foetal head + body is transverse
when descening foetal head should roatate + FLEX
pelvic outlet is wider AP so foetus ideally in OA position
during delivery foetal head should EXTEND
foetal station?
distance of foetal head from ischial spines
negative number = head superior to spines
positive number = head inferior to spines
again, foeal descent + position in pelvis
following delivery of head - foetal position?
what dictates whether structure in pelvis or perineum?
levator ani!
pelvis = above levator ani muscle
below = perineum
how do visceral afferents get from pelvic organs to CNS?
superior pelvic organs i.e. touching peritoneum
* visceral afferents run alongside sympathetic fibres
* enter spinal cord levels T11-L2
* pain is percieved as suprapubic
inferior pelvic organs i.e. not touching peritoneum
* visceral afferents run alongside parasympathetic fibres
* enter spinal cord levels S2, S3, S4
* pain percieved in perineum
how do visceral afferents travel from pelvic organs above perineum to CNS?
in perineum?
above levator ani = in the pelvis
* visceral afferents - parasympathetic S2, S3, S4
below levator ani = in perineum
* somatic sensory = pudenal nerve
* spinal levels S2, S3, S4
autonomic nerves of pelvis
sympathetics
* T11-L2
* superior hypogastric plexus
parasympathetics
* sacral outflow (S2, 3, 4)
* pelvic splanchnic nerves
if spinal level is S2, 3, 4, does pudendal nerve therefore contain parasympathetics?
NO - parasympathetic outflow is seperate
summary of pain - female
2 important spinal cord levels in pain from female repro system?
T11-L2
S2, 3, 4
epidural and spinal anaethetic injected?
spinal cord becomes cauda equina at level L2
so inject into L3-L4
what layers does epidural needle pass through
supraspinous ligament
interspinous ligament
ligamentum flavum
epidural space
what layers does spinal anaesthetic needle pass through
supraspinous ligament
interspinous ligament
ligamentum flavum
epidural space (fat + veins)
dura mater
arachnoid mater
subarachnoid space (contains CSF)
spinal vs epidural?
spinal much faster acting
but epidural much longer acting
important side effect spinal anaesthetic?
blockage of sympathetic fibres = vasodilation
HYPOTENSION
signs its working = skin red, flushed, reduced sweating
pudendal nerve branches
S2, 3, 4
pudendal nerve block used when?
landmark
used during labour for: forceps delivery, painful vaginal delivery, episiotomy, perineal suturing post-delivery
landmark = ischial spines 4+8 o’clock
episiotomy
what structures are nearby
ishioanal fossa
mediolateral incision most common
where is incisision made for LSCS + hysterectomy?
laparotomy?
LCS + hysterectomy = suprapubic
laparotomy = vertical midline incision
abdominal muscles + fascia
fascia that lies deep to transversus abdominus = transversalis fascia
external oblique attachments?
where does external oblique aponeurosis attach?
fibre direction?
attachments = ribs 5-12, iliac crest, pubic tubercle + linea alba
aponeurosis combines with internal oblique aponeurosis before inserting into linea alba
fibre direction = hands in pockets (same as external intercostals)
internal oblique attachments?
fibre direction?
ribs 10-12, thoracolumbar fascia, iliac crest, linea alba
(external oblique does not connect to thoracolumbar fascia, its open back hehe)
fibre direction = hands on chest (same as internal intercostals)
where is neurovascular plane abdominal muscles?
between transversus abdominus and internal oblique
transversus abdominus attachments?
ribs 11-12, thoracolumbar fascia (like internal oblique), iliac crest and linea alba
rectus abdominis divisions
linea alba formed from?
attachments
divisions = tendinous intersections divide into 3 or 4 smaller muscles
linea alba formed from abdominal wall aponeuroses
runs from xiphoid process to pubic symphysis
following abdominal surgery what muscle must be stitched?
rectus sheath
Arcuate line?
divides rectus sheath into ones that have only anterior part and ones that have anterior + posterior part (i.e. transversus abdominus switches to anterior)
found 1/3rd between umbilicus and pubic crest
internal surface of abdominal wall
transversalis fascia?
internal lining of abdominal wall
nerve supply to anterolaeral abdominal wall
blood supply to anterolateral abdominal wall
superior and inferior epigastric tucked into rectus abdominis :)
40 week symphyseal fundal height
40 weeks fundus lower than 36 weeks due to baby becoming engaged
are rectus muscles cut during LSCS?
no they are pulled apart
layers cut during LSCS?
layers to stitch?
skin and fascia
rectus sheath (anterior)
rectus abdominus
fascia and peritoneum
retract bladder
uterine wall
amniotic sac
layers to stitch = uterine wall, rectus sheath, skin
laparotomy layers cut through?
layers to stitch closed
complications?
layers cut open = skin and fascia, linea alba, peritoneum
layers to stitch closed = peritoneum and linea alba, fascia + skin
complications = relatively bloodless so not as good for healing, dehiscence, hernia
laparoscopy incision?
lateral port?
sub-umbilical incision or lateral incision
lateral port = care must be taken to avoid the inferior epigastric artery
* branch of external iliac artery
* emerges medial to deep inguinal ring then goes superomedially posterior to rectus abdominus
how to locate deep inguinal ring
what artery is this important for
halfway between ASIS and pubic tubercle
inferior epigastric artery - place port lateral to deep inguinal ring to avoid
during hysterectomy care must be taken to?
differentiate ureter form uterine artery
* ureter passes inferiorly to artery (water under the bridge)
* ureter will often “vermiculate” when touched
female organs in pelvic cavity?
perineum?
peritoneum?
pouches?
peritoneum = floor of peritoneal cavity + roof of pelvic organs
forms pouches:
* vesico-uterine
* recto-uterine (pouch of Douglas) = most dependent part when upright
..
round ligament of uterus?
attachments?
contained within?
embryological remnant (gubernaculum)
attaches to lateral aspect of uterus
passes through deep inguinal ring to attach to superfical tissue of female peritoneum
proximal part contained within broad ligament
3 layers of uterus
implantation occurs?
perimetrium
myometrium
endometrium
implantation occurs in body of uterus
how is uterus held in position?
weakness of these supports?
uterosacral ligaments
endopelvic fascia (like bubble wrap)
muscles of pelvic floor (levator ani)
weakness of these supports can result in uterine prolapse
normal uterus position
+ common variation
fertilastion occurs where?
ampulla
uterine tubes open into?
test for patency?
peritoneal cavity (this is why STIs + PID can cause peritonitis)
test for patency = HSG (dye should spill into peritoneal cavity)
fornix?
anterior
posterior
2 lateral
ischial spine palpation?
4 + 8 o’clock positions
perineum?
divided into?
space between pelvic diaphragm and the skin
divided into 2 triangles: urogenital and anal
levator ani?
forms?
function?
innervation?
skeletal muscle - voluntary control
forms most of pelvic diaphragm
function = provides support for pelvic organs + contracts during increased abdominal pressure e.g. cough
innervation = nerve to levator ani (NOT pudendal) - S3, 4, 5
perineal body?
bundle of collagen and elastic tissue
attachment for perineal muscles
bartholins gland also called?
where is it found?
greater vestibular gland
(called Cowper’s glands in males)
…
breast quadrants
contents of axilla?
axillary node levels?
brachial plexus
axillary artery + axillary vein
axillary lymph nodes
level 1 = inferior and lateral to pectoralis minor
level 2 = deep to pectoralis minor
level 3 = superior and medial to pectoralis minor
pelvic floor made up of?
pelvic diaphragm
muscles of perineal pouches
perineal membrane
pelvic diaphragm?
made up of?
appearance?
deepest layer of pelvic floor
levator ani + coccygeus
has appearance of sling
levator ani attachments?
3 parts?
pubic nones, ischial spines, tendinous arch of levator ani
perineal body, coccyx
3 parts = iliococcygeus, pubococcygeus, puborectalis
pelvic ligaments?
uterosacral ligaments
transverse cervical (cardinal)
lateral ligament of bladder
lateral rectal ligaments
endopelvic fascia
deep perineal pouch found?
contents?
lies above perineal membrane
females = urethra, vagina, NVB to clitoris, ischioanal fat pads
males = urethra, bulbourethral glands (Cowper’s), NVB to penis, ishioanal fat pads
perineal membrane foundd?
what is it?
supericial to deep perineal pouch
thin sheet of tough fascia (has openings for urethra - and vagina in females)
…
superficial perineal pouch female?
lies superficial to perineal membrane
contains:
clitoris + crura - corpus cavernosum
bulbs of vestibule
muscles - bulbospongiosus, ischiocavernosus, superficial transvserse perineal (pudendal nerve)
greater vestibular glands - Bartholin’s
superficial perineal pouch male?
lies superficial to perineal membrane
contains:
bulb - corpus spongiosum
crura - corpus cavernosum
muscles - bulbospongiosus, ischiocavernosus, superficial transverse perineal (pudendal nerve)
spongy (penile) urethra
perineal body found females?
males?
females = posterior to vagina
males = anterior to rectum
..
injury to pelvic floor Ax?
pregnancy + childbirth
chronic constipation
obesity
heay lifting
chornic cough/sneeze
previous injury
menopause
urinary continence depends on?
external urethral sphincter
compressor urethrae
levator ani
uterine prolapse degree?
1st degree - cervix dropping into vagina
2nd degree - cervix dropping to opening of vagina
3rd degree - cervix is now outside of the vgina
4th degree - entire uterus outside of the vagina
Tx uterine prolapse?
risks?
sacrospinous fixation
risks = injury to pudenal and sciatic nerve
Surgical Tx incontinence?
trans-obturator approach
i.e. mesh through obrutator canal, creates sling around urethra
write up embryology
uterine anatomical variations
hypospadias
failure of fusion of urethral groove
external urethral opening lies in abnormal position along ventral aspect of penis
