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Gardner, Gray & ORahilly AnatomyTwinsTripletsFemale Pelvic and Perineal AnatomyPart 1 Musculoskeletal ElementsAudrone R. Biknevicius, Ph.D.Ohio University Heritage College of Osteopathic Medicine Athens1OUTLINE

Pelvic skeleton

Pelvic musculature

Organization of perineum (muscles, fascia)Snell Clinical Anatomy for Medical Students

0Pelvic inletSacral promontory, ileopectineal line, superior pubic symphysisSeparates greater (false) and lesser (true) pelvesPelvic outletCoccyx, ischial tuberosities, inferior pubic symphysisSeparates pelvic cavity from perineum3Most pelvic organs actually reside in the true pelvis

Curved red line is the path of baby. Starts at pelvic inlet and to pelvic outlet.Snell Clinical Anatomy for Medical Students

0Obstetric conjugate = Anterioposterior diameter of pelvic inlet

www.brooksidepress.org Diagonal conjugate Inferior pubic symphysis to sacral promontory~ 1.5-2 cm greater than obstetric conjugate

4Diagonal conjugate allows palpation.

Gardner, Gray & ORahilly AnatomyRotation of Babys Head During LaborLong axis (AP) of babys head coincides with median plane of mothers pelvisLong axis (AP) of babys head coincides with transverse diameter of pelvic inlet5Babys head longer front to back but the pelvic inlet is opposite.

PELVIC LIGAMENTS THAT STABILIZE PELVIC JOINTSPubic ligamentsSacrococcygeal ligaments Sacroiliac ligamentSacrotuberous ligamentSacrospinous ligamenthttp://oac.med.jhmi.edu/weblec/0

Inguinalligament

Pubic ligaments6A lot of bony structure in passage of the kid. The give is determined by the laxity of the ligaments. http://hal.bim.msu.edu/RPelvis/Biomechanics/start.html

Sacral Flexion Sacral Extension (Nutation Counternutation)0

Nutation. Means to Nod7Joint Mobility During ChildbirthEstrogen, progesterone & relaxinfrom ovaries & placenta

Relax ligaments

Increase mobility of joints

Increase effective size of:pelvic inlet (& diagonal conjugate)pelvic outlet

Snell Clinical Anatomy for Medical StudentsRotation of babys head during stage 2 of labor aligns head with greatest dimensions of the mothers pelvisHormones are secreted systemically. Towards end of pregnancy some womans teeth can even become loose form lax aveolar ligaments.

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Pelvic Diaphragm:1. Levator ani mm. Puborectalis m. Pubococcygeus m. Iliococcygeus m.

2. Coccygeus m.

Motor: Sacral spinal nn. Midline lateral view of pelvic girdle and muscular contentsNote obturator externus and piriformis mm.ttp://oac.med.jhmi.edu/weblec/0PELVIC FLOOR MUSCLESStriated mm. with a visceral function9Thinking about pelvic floor think pelvic diaphram.

Its form by two muscle in pair on right and left side.

TENDINOUS ARCH Thickened fascia of obturator internus m. Serves as attachment for most of levator ani mm.http://oac.med.jhmi.edu/weblec/0

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PELVIC DIAPHRAGM(Levator ani & Coccygeus mm.)Superior view of pelvic girdle and pelvic diaphragmhttp://oac.med.jhmi.edu/weblec/011Tendonus arch is thickened part of obturator internus.

Illiococcygenous largely comes off the tendonus arch

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Pelvicdiaphragm

Adapted from http://oac.med.jhmi.edu/weblec/PERINEUMITIschiopubic ramusIschiopubic ramusSacrotuberous ligamentSacrotuberous ligamentUG TriangleAnal TriangleSacrum & CoccyxIT12Perineum is diamond shaped structure. Made of two triangles. These two triangles are not coplanar. Look at picture on the bottom left.PERINEAL ROOF0

Inferior viewModified from http://oac.med.jhmi.edu/weblec/ Levator hiatus(genital hiatus)130

Modified from http://oac.med.jhmi.edu/weblec/ Pelvic diaphragm (roof)Fatty layer of the superficial perineal fascia(fat in ischioanal fossa)SkinAnal triangle(inferior/superficial)(superior/deep)PERINEUM ANAL TRIANGLEThe internal and external spincters are part of anal canl. Not really part of anal triangle. 14

http://oac.med.jhmi.edu/weblec/Deep perineal mm.Superficial perineal mm.PERINEUM UROGENITAL TRIANGLE150Pelvic diaphragm (perineal roof and pelvic floor)Deep Perineal FasciaSuperficial perineal mm.Colles fascia (membranous layer)SuperficialperinealfasciaFatty layer of superficial fasciaSkinUG Triangle/Perineum(inferior/superficial)(superior/deep)Superior fascia of UG diaphragmPerineal Membrane (Inferior fascia of UG diaphragm)UrogenitaldiaphragmPERINEUM UROGENITAL TRIANGLEDeep perineal mm. 16UROGENITAL TRIANGLEPelvic diaphragm (roof)Deep perineal mm. Superficial perineal mm.Fatty layer of superficial fasciaSkinhttp://oac.med.jhmi.edu/weblec/

17UROGENITAL TRIANGLEPelvic diaphragm (roof)Deep perineal mm. Superficial perineal mm.Fatty layer of superficial fasciaSkinhttp://oac.med.jhmi.edu/weblec/

Superficial transverse perineal m.Perineal membrane**PERINEAL BODY**Central tendon of perineumCommon attachment: Bulbospongiosus mm. Transverse perineal mm. Sphincter urethrae mm. Internal & external anal sphincter mm.0

Bulbospongiosus m.www.aafp.org Sphincter urethrae m.19Many of the muscles that she refeerred to have common attachemnt called the perineal body. What attaches here? Bulbus spongiousus. Transverse eprineal superficial and depe. Spincter urethrea. Internal and external anal sphincters.

Very important space to help us stabilze.

Superifical Perineal mm.Underlying Erectile TissuesBulbospongiosus mm.Bulbs of the vestibuleIschiocavernosus mm.Corpora cavernosaDeep perineal fasciaSuperficial perinal fascia (Colles & fatty layers)20Bulbospoingiosus lies over the bulbs of the vestibule.