SECTION ONE • Fundamentals 1 Clinical pelvic anatomy Introduction 1 Anatomical points for obstetric analgesia 3 Obstetric anatomy 1 Gynaecological anatomy 5 The pelvic organs during pregnancy 1 Anatomy of the lower urinary tract 13 the necks of the femora tends to compress the pelvis Introduction from the sides, reducing the transverse diameters of this part of the pelvis (Fig. 1.1). At an intermediate level, opposite A thorough understanding of pelvic anatomy is essential for the third segment of the sacrum, the canal retains a circular clinical practice. Not only does it facilitate an understanding cross-section. With this picture in mind, the ‘average’ of the process of labour, it also allows an appreciation of diameters of the pelvis at brim, cavity, and outlet levels can the mechanisms of sexual function and reproduction, and be readily understood (Table 1.1). establishes a background to the understanding of gynae- The distortions from a circular cross-section, however, cological pathology. Congenital abnormalities are discussed are very modest. If, in circumstances of malnutrition or in Chapter 3. metabolic bone disease, the consolidation of bone is impaired, more gross distortion of the pelvic shape is liable to occur, and labour is likely to involve mechanical difficulty. Obstetric anatomy This is termed cephalopelvic disproportion. The changing cross-sectional shape of the true pelvis at different levels The bony pelvis – transverse oval at the brim and anteroposterior oval at the outlet – usually determines a fundamental feature of The girdle of bones formed by the sacrum and the two labour, i.e. that the ovoid fetal head enters the brim with its innominate bones has several important functions (Fig. 1.1). longer (anteroposterior) diameter in a transverse or oblique It supports the weight of the upper body, and transmits the position, but rotates during descent to bring the longer head stresses of weight bearing to the lower limbs via the acetabu- diameter into the longer anteroposterior diameter of the lae. It provides firm attachments for the supporting tissues outlet before the time of birth. This rotation is necessary of the pelvic floor, including the sphincters of the lower bowel because of the relatively large size of the human fetal head and bladder, and it forms the bony margins of the birth canal, at term, which reflects the unique size and development of accommodating the passage of the fetus during labour. the fetal brain. The birth canal is bounded by the true pelvis, i.e. that In most affluent countries, marked pelvic deformation part of the bony girdle which lies below the pelvic brim – the is rare. Pelvimetry using X-rays, computed tomography lower parts of the two innominate bones and the sacrum. or magnetic resonance imaging scans can be used to These bones are bound together at the sacroiliac joints, measure the pelvic diameters but is of limited clinical and at the symphysis pubis anteriorly. The brim is outlined value in predicting the likelihood of a successful vaginal by the promontory of the sacrum, the sacral alae, the ilio- delivery. Mechanical difficulty in labour is assessed by pectineal lines and the symphysis. The pelvic outlet is close observation of the progress of dilatation of the cervix, bounded by bone and ligament including the tip of the and of descent, assessed by both abdominal and vaginal sacrum, the sacrotuberous ligaments, the ischial tuberosities examination. and the subpubic arch (of rounded ‘Norman’ shape) formed by the fused rami of the ischial and pubic bones. In the erect posture the pelvic brim is inclined at an angle of 65–70° The pelvic organs during pregnancy to the horizontal. Because of the curvature of the sacrum, the axis of the pelvis (the pathway of descent of the fetal The uterus head in labour) is a J-shaped curve (Fig. 1.2). The change in the cross-sectional shape of the birth canal The uterus is a remarkable organ, composed largely of at different levels is fundamentally important in understanding smooth muscle (the myometrium), which increases in weight the mechanics of labour. The canal can be envisaged initially during pregnancy from about 40 g to around 1000 g as the as a sector of a curved cylinder of about 12 cm diameter myometrial muscle fibres undergo both hyperplasia and (Fig. 1.2). The stresses of weight bearing at the brim level hypertrophy (Fig. 1.3). It provides a ‘protected’ implantation in the average woman tend to flatten the inlet a little, reducing site for the genetically ‘foreign’ fertilized ovum, accom- the anteroposterior diameter but increasing the transverse modates the developing fetus as it grows and, finally, expels diameter. In the lower pelvis, the counterpressure through it into the outside world during labour. 1 2 Fundamentals False False pelvis pelvis Amnion Placenta Chorion True Parietal Basal pelvis Now fused decidua decidua Fig. 1.1 The ‘true’ and ‘false’ pelvis. Fig. 1.3 The uterus and developing fetus at 12 weeks’ gestation. dilatation and thinning, forming the lower segment of the uterus. It is through this thinned area that the uterine wall is incised during caesarean section. The uterine arteries, branches of the anterior division of the internal iliac arteries, become tortuous and coiled within the uterine wall (Fig. 1.4). Innervation of the uterus is derived from both sympathetic and parasympathetic systems, and the functional significance of the motor pathways is incom- pletely understood. Drugs that stimulate alpha-adrenergic receptors activate the myometrium, whereas beta-adrenergic drugs have an inhibitory effect, and both beta-agonists and alpha-antagonists have been used in attempts to inhibit premature labour. Afferent fibres from the cervix enter the spinal cord via the pelvic splanchnic (parasympathetic) nerves (S2,3,4). Pain stimuli during labour from the fundus and body of the uterus travel via the hypogastric (sympathetic) Fig. 1.2 The birth canal resembles a curved cylinder. plexus, and enter the spinal cord at the level of the lower thoracic segments. Table 1.1 Average pelvic diameters The cervix Diameter Level Direction Size (cm) This becomes more vascular and softens in early pregnancy. The mucous secretion from the endocervical glands becomes Inlet Anteroposterior 11.5 thick and tenacious, forming a mechanical barrier to ascend- Transverse 13 ing infection. In late pregnancy the cervix ‘ripens’ – the Cavity All diameters 12 dense mesh of collagen fibres loosens, as fluid is taken up Outlet Anteroposterior 12.5 by the hydrophilic mucopolysaccharides that occupy the Transverse intertuberous 11 interstices between the collagen bundles. This allows the Interspinous 10.5 cervix to become shorter as its upper part expands. Whereas the body of the uterus is formed from a thick Additional changes layer of plain muscle, the cervix, which communicates with the upper vagina, is largely composed of denser collagenous The ligaments of the sacroiliac and symphyseal joints become tissue. This forms a rigid collar, retaining the fetus in utero more extensible under the influence of pregnancy hormones. as the myometrium hypertrophies and stretches. The As a result, the pelvic girdle has more ‘give’ during labour. junctional area between the body and cervix is known as The increased mobility of the joints may result in backache the isthmus, which, in late pregnancy and labour, undergoes or symphyseal pain. Clinical pelvic anatomy 3 Ovary Ovarian artery Ascending branch Ureter uterine artery (from aorta) Uterine artery Descending branch (from internal iliac) uterine artery Fig. 1.4 The blood supply of the uterus, fallopian tube and ovary (posterior view). The urinary tract in pregnancy instrumental delivery, and because their integrity is vital for visceral muscular support and for sphincter function. Frequency of micturition is often noticed in early pregnancy. These nerves, which innervate the vulva and perineum, As pregnancy advances, the ureters become dilated, probably are derived from the second, third and fourth sacral roots due to the relaxing effect of progesterone on the smooth (see Fig. 1.2). On each side the nerve passes behind the muscle wall, but also in part due to the mechanical effects sacrospinous ligament close to the tip of the ischial spine of the gravid uterus. The urinary tract is therefore more and re-enters the pelvis, along with the pudendal blood vulnerable to ascending infection (acute pyelonephritis) in vessels, in the pudendal canal. After giving off an inferior comparison to non-pregnancy. rectal branch, they divide into the perineal nerves and the dorsal nerves of the clitoris. Motor fibres of the pudendal nerve supply the levator ani, the superficial and deep The perineum perineal muscles, and the voluntary urethral sphincter. This term usually refers to the area of skin between the Sensory fibres innervate the central areas of the vulva and vaginal orifice and the anus. The underlying musculature at perineum. The peripheral skin areas are supplied by branches the outlet of the pelvis, surrounding the lower vagina and of the ilioinguinal nerve, the genitofemoral nerve and the the anal canal, is important in the maintenance of bowel posterior femoral cutaneous nerve (Fig. 1.6). The pudendal and urinary continence, and in sexual response. The muscles nerve can be blocked by an injection of local anaesthetic intermesh to form a firm pyramidal support, the perineal just below the tip of the ischial spine, as described body, between the lower third of the posterior vaginal wall in Fig. 30.13. and the anal canal (Fig. 1.5). The tissues of the perineal body are often markedly stretched during the expulsive second stage of labour and may be torn as the head is Spinal block delivered. Injury to the anal sphincters may lead to impaired The spinal cord ends at the level of L1–2. A spinal injection anal continence of faeces and/or flatus.