INTRODUCTION TO MIDWIFERY.pdf

 Anatomy and Physiology of reproductive system, professionalism and Communication skills Demonstrate knowledge on the structure of female pelvis in relation to pregnancy and labour Describe the physiology of female pelvis in relation to pregnancy and labour Describe the structure and p...

 Anatomy and Physiology of reproductive system, professionalism and Communication skills Demonstrate knowledge on the structure of female pelvis in relation to pregnancy and labour Describe the physiology of female pelvis in relation to pregnancy and labour Describe the structure and physiology of female reproductive cycle Describe the structure and physiology of the breast Purpose The unit is designed to enable the learner, describe history of midwifery, anatomy and physiology of reproductive system. Expected Learning outcomes:-By the end of the unit the learner, will be able to: 1. Describe history of midwifery 2. Demonstrate knowledge on structure of the female reproductive system.  Explain fertilization process, growth and development of the foetus Demonstrate knowledge of the foetal head in relation to labour Course Content Definitions, history of midwifery; Kenya, Role of a midwife, Job description of a midwife, Legal aspects of midwifery. Anatomy and physiology of reproductive system and pregnancy: Structure of the female pelvis and reproductive organs, hormonal cycles, the male reproductive system, the breast.  Physiology of lactation; fertilization and early embryonic development, the placenta; foetal growth and development, foetal circulation, the skull, adaptation to extra-uterine life and foetal investigation. Physical, physiological changes in pregnancy, diagnosis of pregnancy. Instructional Resources: handouts, lecture notes, procedure manual, chalk board, Models, anatomy charts, text books, video/slide shows. Teaching and Instructional methodology: lecture, group discussion, self-directed learnin,simulation and Role play. Evaluation: Assignments, class presentations, CAT, End of block examination. Reference Materials Nolte, A.G., Copper, M.A., and Fraser, M.M., (2010). Myles Textbook for Midwives African (2 nd Edition). Toronto: Churchill Livingston.50. Nursing Council of Kenya. (2009). Procedure Manual for Nurses. Nairobi: NCK Douglas, C., and Rebeiro, G., (2012). Potter and Perry‘s Fundamentals of Nursing, (4th edition). St. Louis: Elsevier  Waugh, A., and Grant, A (2018) Ross and Wilson Anatomy and Physiology in Health and Illness. (1 3th Edition). London: Churchill Livingst This is a branch of medicine that deals with pregnancy, labour and care after birth. It’s a course that deals with care of a woman during the events which concern childbearing. i.e. the care of a woman before she conceives, during pregnancy(antepartum/antenatal) and in the period of adjustments after birth (post partum).  It’s a person who has been admitted to a midwifery education and has successfully completed the prescribed course of studies and acquired the required qualification to be registered (enrolled) and licenced legally to practice midwifery.  Gravidity is defined as the number of times that a woman has been pregnant. is the number of times that she has given birth to a fetus with a gestational age of 28 weeks or more, regardless of whether this resulted in stillbirth or a live birth. pertains to the time during pregnancy before the onset of labor  refers to the time during labour and child birth. : refers to the first 6 weeks after childbirth.  Midwifery is defined as the art of providing supportive care for women during their childbearing years. It remains the first holistic profession in the world in which “care” has always been a women- centered phenomenon.  Labor was perceived as a basically natural process.As women gave birth, they sought and received care from supportive others. At an unknown point in the cultural evolution, some experienced women became designated as the wise women to be in attendance at birth. Thus, the profession of midwifery began.  Since midwifery practice generally remained on an informal level, knowledge of this sophistication was not disseminated within the midwifery profession.The midwife had knowledge and skill in an area of life that was a mystery to most people. Since women had no access to formal education, it was widely assumed that the midwife's power must come from supernatural sources.  Traditionally, midwifery was an unregulated practice in which females took the initiative based on their societies needs. Before the twentieth century, child birth occurred most often in the home with the assitance of an experienced elderly woman whose training was obtained through an apprenticeship with an experienced grand mothers.  Currently, midwifery is a profession that has a regulated scope of practice. Pregnancy and childbirth during the Paleolithic era were processes that required women to survive labor in a hard environmental lifestyle. Women supported themselves during birth based on knowledge and skills they gained from observing other mammals.  They prepared for labor by getting into a squatting position, cutting the umbilical cord, initiating breastfeeding, and creating a warm and safe environment for newborns.  Midwifery during the biblical era was a respected social practice performed by women of childbearing years. Their role focused on managing normal pregnancies and deliveries; they were skilled in vaginal examination, and in defining the gender of a fetus during breech presentations.Midwives during the biblical era initiated the use of birthing stool during  Biblical recognition of the functions of midwives included several verses recounting the experiences of two Hebrew midwives who refused to kill male infants in defiance of the King of Egypt (Exodus 1:15-22). Other verses in the Bible also make passing references to midwifery attendance at birth, implying that it was omnipresent (Genesis 35:17; 38:28).  Historians have found the practice of midwifery referred to in other papyri as well as in ancient Hindu records. Magic and witchcraft were practiced widely. A religious man, the Rabbi usually attended birth only to manage difficult cases; difficult delivery was seen as caused by witchcraft or black magic and it was believed that only the Rabbi could break this spell.  The Nursing Council of Kenya, a professional regulatory body that licenses nurses and midwives as private practitioners. The Kenya Medical Board, which licenses private clinics. The National Nurses Association, the professional and welfare association for nurses where individuals are members. Private Nurse  Members of the East, Central and Southern African College of Nursing (ECSACON), a regional nursing body that also includes members of the Association. ECSACON is the designated regional advisory body to the Conference of Ministers of Health in the Eastern, Central and Southern African Health Community.  To observe,examine and teach a woman during pregnancy, labour and puerperium. To care for the mother and the baby after delivery To act promptly and appropriately to save the life of the woman or the baby.examining and monitoring pregnant women.  Assessing care requirements and writing care plans. Undertaking antenatal care in hospitals, homes and GP practices. Carrying out screening tests. Providing information, emotional support and reassurance to women and their partners.  To promote and maintain the physical and psychological health of the pregnant woman in order to ensure birth of a normal healthy baby without any complications to either the mother or the baby To ensure a live healthy baby through fetal supervision  To prepare the mother through health messages for, lactation and subsequent care of the baby. To detect early and correct or treat appropriately and promptly any risk conditions(medical or obstetrical) that might interfere or endanger the health of the mother or fetus. To involve the husband and other members of the family in the care of the pregnant woman and that of the baby after birth.  This should govern the midwife behavior with women and partners or relatives Respect for life Respect for patient rights. Be respectful to others and polite Confidentiality- keep information given in trust by the patient secret To be calm, obedient and control their tempers. Respect to human dignity.  Trustful- the midwife should behave and act in a way that the client can believe in him/her all through the provision of care. Good communication to colleagues, team members, client and relatives. Punctuality- both on duty and taking actions because delays can cause irreversible damages.  Maintain own and others dignity through good moral behavior and respect for life. Exercise equity to all irrespective of their social background and status, religion, race or beliefs.  The principle of beneficence is the obligation of a midwife to act for the benefit of the patient and supports a number of moral rules to protect and defend the right of others, prevent harm, remove conditions that will cause harm, help persons with disabilities, and rescue persons in danger.  is the obligation of a midwife not to harm the mother. This simply stated principle supports several moral rules − do not kill, do not cause pain or suffering, do not incapacitate, do not cause offense, and do not deprive others of the goods of life.  Justice is generally interpreted as fair, equitable, and appropriate treatment of persons. Truth-telling is a vital component in a physician-patient relationship; without this component, the physician loses the trust of the patient.  A patient has the right to respectful care given by competent workers. A patient has the right to know the names and the jobs of his or her caregivers. A patient has the right to privacy with respect to his or her medical condition.  A patient has the right to know what facility rules and regulations apply to his or her conduct as a patient. A patient has the right to have emergency procedures done without unnecessary delay. A patient has the right to good quality care and high professional standards that are continually maintained and reviewed.  A patient has the right to make informed decisions regarding his or her care and has the right to include family members in those decisions. A patient has the right to information from his or her doctor in order to make informed decisions about his or her care.  A patient has the right to have his or her medical records treated as confidential and read only by people with a need to know. A patient has the right to request amendments to and obtain information on disclosures of his or her health information, in accordance with law and regulation.  A patient has the right to refuse any drugs, treatment or procedures to the extent permitted by law after hearing the medical consequences of refusing the drug, treatment or procedure. A patient has the right to have help getting another doctor’s opinion at his or her request and expense.  A patient has the right to care without regard to race, color, religion, disability, sex, sexual orientation, national origin, or source of payment. A patient has the right to be given information in a manner that he or she can understand. A patient has the right to have information in the medical record explained to him or her.  A patient has the right not to be awakened by staff unless it is medically necessary. A patient has the right to be free from needless duplication of medical and nursing procedures. A patient has the right to treatment that avoids unnecessary discomfort.  A patient has the right to be transferred to another facility only after care and arrangements have been made and the patient has been given complete information about the hospital’s obligations under law. A patient has the right to a copy of his or her bills. A patient also has the right to have the bill explained. A patient has the right to request help in finding ways to pay his or her medical bills.  A patient has the right to have protective services contacted when he or she or the patient’s family members are concerned about safety. A patient has the right to be informed of his or her rights at the earliest possible time in the course of his or her treatment. C  A patient has the right to personal privacy and to receive care in a safe and secure setting. A patient has the right to be free from all forms of abuse or harassment. A patient has the right to be free from the use of seclusion and restraint. A patient has the right to pastoral care and other spiritual services.  A patient has the right to be involved in resolving dilemmas about care decisions. A patient has the right to have his or her complaints about care resolved. A patient has the right to be free from financial exploitation by the health care facility. The female reproductive system is divided into a) External organs or genitalia(vulva) b) Internal organs or genitalia A. Prepuce (Hood) of Clitoris B. Clitoris C. Opening of Urethra (urinary tract) D. Labia minora E. Labia majora F. Opening of Vagina H. Hyman tissue (residual) I. Opening of Anus The female external genitalia is composed of; Its composed of :- The mons pubis The labia majora The labia minora The vestibule The urethral opening/meatus The vagina opening/meatus The bartholin glands opening The paraurethral opening The clitoris  The mons pubis is a rounded fatty elevation located anterior to the symphysis pubis and lower pubic region. It consists mainly of a pad of fatty connective tissue deep to the skin. The amount of fat increases during puberty and decreases after menopause.  The mons pubis becomes covered with coarse pubic hairs during puberty, which also decrease after menopause. The typical female distribution of pubic hair has a horizontal superior limit across the pubic region.  The Labia Majora The labia (L. large lips) are two symmetrical folds of skin, which provide protection for the urethral and vaginal orifices. These open into the vestibule of the vagina. Each labium majus, largely filled with subcutaneous fat, passes posteriorly from the mons pubis to about 2.5 cm from the anus.  They are situated on each side of the pudendal cleft, which is the slit between the labia majora into which the vestibule of the vagina opens. The labia majora meet anteriorly at the anterior labial commissure. They do not join posteriorly but a transverse bridge of skin called the posterior labial commissure passes between them.  The labia minora (L. small lips) are thin, delicate folds of fat-free hairless skin. They are located between the labia majora. The labia minora contain a core of spongy tissue with many small blood vessels but no fat.  The internal surface of each labium minus consists of thin skin and has the typical pink colour of a mucous membrane. It contains many sensory nerve endings. Sebaceous and sweat glands open on both of their surfaces. The labia minora enclose the vestibule of the vagina and lie on each side of the orifices of the urethra and vagina.  They meet just superior to the clitoris to form a fold of skin called the prepuce (clitoral hood). Posteriorly they fuse forming the fourchete  The vestibule is the space between the labia minora. The urethra, vagina, and ducts of the greater vestibular glands open into the vestibule.  This median aperture is located 2.5cm posterior to the clitoris and immediately anterior to the vaginal orifice. On each side of this orifice are the openings of the ducts of the paraurethral glands (Skene's glands).  This large opening is located inferior and posterior to the much smaller external urethral orifice. The size and appearance of the vaginal orifice varies with the condition of the hymen, a thin fold of mucous membrane that surrounds the vaginal orifice.  These glands are about 0.5 cm in diameter. They are located on each side of the vestibule of the vagina, posterolateral to the vaginal orifice. they secrete a small amount of lubricating mucus into the vestibule of the vagina during sexual arousal. Bartholin's glands are homologous with the bulbourethral glands in the male.  The clitoris is 2 to 3 cm in length. It is homologous with the glans of penis and is an erectile organ. Unlike the penis, the clitoris is not traversed by the urethra; therefore it has no corpus spongiosum.  The clitoris is located posterior to the anterior labial commissure, where the labia majora meet. It is usually hidden by the labia when it is flaccid. The clitoris, like the penis, it will enlarge upon tactile stimulation, but it does not lengthen significantly. It is highly sensitive and very important in the sexual arousal of a female.  The rich arterial supply to the vulva is from two external pudendal arteries and one internal pudendal artery on each side. The internal pudendal artery supplies the skin, sex organs, and the perineal muscles. The labial arteries are branches of the internal pudendal artery, as are the dorsal and deep arteries of the clitoris.  The labial veins are tributaries of the internal pudendal veins and venae comitantes of the internal pudendal artery.  The vulva contains a very rich network of lymphatic channels. Most lymph vessels pass to the superficial inguinal lymph nodes and deep inguinal nodes.  The nerves to the vulva are branches of: The ilioinguinal nerve; The genital branch of the genitofemoral nerve; The perineal branch of the femoral cutaneous nerve; And the perineal nerve.  This is a fibromascular tube covered with stratified squamous epithelium that connects the uterus and the vestibule. It is made of the following layers:- §Mucous coat lined with squamous epithelium §Submucous layer of loose areolar vascular tissue §Muscular layer  The inner membrane is thrown into convolutions called rugae that allows stretching The anterior wall is about 7.5 cm long and posterior wall 10 cm long. This is because the cervix projects into the vagina at an angle. It has no secretory glands but it is kept moist my cervical secretions  Although the cervical mucous is alkaline, the breakdown of glycogen by Doderlin bacilli (Lactobacillus acidophilus) into lactic acid maintain the vagina PH at 4.5.  Anteriorly- the urethra and urinary bladder and urethra Posteriorly-Pouch of Douglas,rectum & perineal body. Laterally- upper 2/3 pelvic fascia and ureters, the lower 1/3 muscles of the pelvic floor Superiorly- uterus Inferiorly-the external genitalia  Arterial blood supply to the vagina is from the vaginal artery and a descending branch of uterine artery. Venous drainage is via corresponding veins. Lymphatic drainage is via the inguinal, internal iliac and sacral lymph nodes Inervation is from the Lee Frankehauser plexus 1. Allows the escape of menstrual flow 2. Receives the penis and sperms during copulation 3. Provides a passage way for the fetus during delivery  The uterus in non-pregnant state is a hollow, muscular pear-shaped organ situated in the cavity of true pelvis It is about 7.5cm long and 5cm wide and 2.5cm in depth. It lies behind the urinary bladder and in front of the rectum. The uterus leans forward(anteversion) and bends on itself(anteflexion) Its divided into 3 main parts:- a) The body b) The Isthmus c) The cervix  It’s the upper part which is about 5cm in length and forms the major part of the uterus. The rounder doom shaped part above the fallopian tubes is called the fundus, while the upper outer angles where the fallopian tubes join the uterus are known as the cornua The cavity is the triangular shaped space.  It’s the shortest segment of the uterus that lies between the body and the cervix. Its about 7mm in length.  It’s the lowest part of the uterus about 2.5cm long. It protrudes into the vagina with the upper ½ above the vagina being the supra-vaginal portion and the lower ½ the infra- vaginal portion. The internal OS is the narrow opening between the isthmus and the cervix and external OS is the portion that meets the vagina.  The uterus consist of three layers:- The endometrium The myometrium The perimetrium Endometrium It is the inner layer of mucus membrane formed by ciliated epithelium on a base of connective tissue. The epithelial cells are cubical in shape and dip down to form glands that secrete alkaline mucus  The cervical endometrium is thinner than that of the body of uterus and is folded into a pattern known as (tree of life) that is thought to aid the passage of sperms.  The middle muscular layer of uterus Thicker towards the fundus It fibers are arranged in all conceivable directions After delivery, these fibers act as ligatures of vessels to stop bleeding Perimetrium The outermost layer consisting of double serous membrane. Anteriorly, it covers the fundus and the body and then it is reflected over the urinary bladder to form vesico-uterine pouch  Posteriorly, the peritoneum extends over fundus, body and cervix and then reflected to the rectum forming recto-uterine pouch Laterally, it only covers the fundus.  Arterial supply- uterine arteries which are branches of internal iliac arteries Venous drainage is through the uterine veins that joins the internal iliac veins The lymph drains into the internal iliac and aortic lymph glands üThe pubocervical fascia – they pass forward from the transverse cervical ligament on the side of the bladder and attaches to the posterior surface the pubic bones üTransverse cervical ligaments(cardinal ligaments- extends from the sides of the cervix and vagina to the side walls of the pelvis 1. It receives a fertilized ovum from the fallopian tubes 2. It provides favorable environment for implantation and sheltering of embryo till delivery 3. It helps in expulsion of fetus, placenta and membranes during delivery 4.The cervix produces mucus which is essential and favorable for sperms survival and mobility  Stretch from the uterus to the ovaries and measure about 10cm in length. Range in width from about one inch at the end next to the ovary, to the diameter of a strand of thin spaghetti. The ends of the fallopian tubes lying next to the ovaries feather into ends called fimbria  Millions of tiny hair-like cilia line the fimbria and interior of the fallopian tubes. The cilia beat in waves hundreds of times a second catching the egg at ovulation and moving it through the tube to the uterine cavity. Fertilization typically occurs in the fallopian tube  Are the female gonads, equivalent to testis in males They produce the ova and female hormones They are about 3cm long, 2cm wide and 1cm thick  They are made of the medulla and the cortex Medulla is the central part consisting of fibrous tissue, blood vessels and nerves Cortex surrounds the medulla It is made of a framework of connective tissue(stroma) covered by germinal epithelium which contains follicles in their various stages of development.  Ovaries receive blood supply via ovarian arteries and drains into corresponding veins Lymphatic drainage is into the lumbar glands Nerve supply- parasympathetic supply comes from the sacral outflow and sympathetic nerves from lumbar outflow  Divided into two phases that take place concurrently in the uterus and the ovaries. Both phases are under the influence of hormones - The ovarian cycle - The uterine cycle  The ovarian cycle starts on the first day of the The begins on the first day of the periods - which is the first day of bleeding. At this time, the levels of all the hormones - estrogen, progesterone , FSH and LH are at the baseline levels. Low level of estrogen stimulates the hypothalamus to release gonadotrophine hormone  The hypothalamus release Gonadotropin Releasing Hormone. GnTRH acts on the anterior pituitary gland to release Follicle Stimulating Hormone(FSH) FSH stimulates growth of about 20 Graafian follicles. They enlarges rapidly and produces hormone estrogen in the blood stream  At around the 10th day of the follicular phase, one of the follicles becomes distinctly larger than the others. It continues to grow, becoming larger and larger (‘dominant follicle’) to become mature, while the growth of the others are arrested. These eventually die out. The estrogen released by the follicles, acts on the endometrium of the uterus and stimulates it to proliferate.  The dominant follicle usually ruptures when it is about 18 – 20 mm in size and releases an ovum at about the 14-16th day of the menstrual cycle. This process is called ‘ovulation’. The follicular phase ends at this stage and the Luteal Phase begins.  As the levels of estrogen rises, they inhibit the production of FSH by anterior pituitary gland and instead LH is produced. As soon as the Graafian follicle ruptures and releases the ovum (‘ovulation’) the cells of the follicle itself undergoes certain changes. Fat globules get deposited in them, they grow larger, and they assume a yellowish color. These cells are called luteal cells and the follicle now  The cells of the corpus luteum are capable of producing the hormone ‘progesterone’ which, like estrogen, acts on the uterine. Hence this phase is also called the progestogenic phase. The level of progesterone reaches a peak at 22 – 26th day of the cycle. The changes in the uterine endometrium is dependent on the hormones secreted by the ovaries.  If pregnancy does not take place, the corpus luteum start to decrease in size and eventually atrophies The level progesterone falls in tandem with the activity of corpus luteum and when a critical level is reached, the endometrium is shed off. This signifies a begining of a new cycle  Describes the cyclic changes that takes place in the female uterus every month It is under the influence of ovarian hormones Consist of three phases a) Menstrual phase b) Proliferative phase c) Secretory phase  Involves the shedding of the endometrium. Menses consist of blood, endometrial cells, endometrial secretions and the unfertilized ovum It occurs when the levels of progesterone are low because it trophic effect on the endometrium is withdrawn.  It follows the mensturation and lasts until ovulation. It is under the influence of estrogen which stimulates proliferation of the endometrium The endometrium thickens, and become highly vascularized as the number of capillaries increase All this takes place to prepare the uterus for a possible implantation  When levels of estrogen reaches the peak, ovulation occurs and this stage comes to an end. Increased levels of estrogen stimulates the cervix to produce lubricative mucus that becomes watery towards ovulation  It follows ovulation and is under influence of progesterone hormone and to some extent estrogen Progesterone causes further thickening of the endometrium, the endometrial glands become more tortuous and endometrium becomes more vascular.  If fertilization does not occur, the corpus luteum degenerates and the levels of progesterone goes down With the withdrawal of the maintenance effects of progesterone, the endometrium eventually breaks down leading to menses  Structural romote formation of female secondary sex characteristics. stimulate endometrial growth Increase uterine growth Maintenance of vessels and skin Reduce bone reabsorption, increase bone formation  Increase hepatic production of binding proteins Coagulation- increase circulating level of factors 2,7,9,10, antithrombin III, plasminogen Increase platelet adhesiveness Lipid -increase HDL, triglyceride, fat depositition decrease LDL  Converts the endometrium to its secretory stage to prepare the uterus for implantation During implantation and gestation, progesterone appears to decrease the maternal immune response to allow for the acceptance of the pregnancy. Progesterone decreases contractility of the uterine smooth muscle  In addition progesterone inhibits lactation during pregnancy. The fetus metabolizes placental progesterone in the production of adrenal steroids. In the females Stimulates development of alveoli for milk production. Increases the body temp by 0.5°c  Consists of:- 2 testes 2 epididymis 2 vas deferens 2 seminal vesicles 1 prostate gland 1 cowper’s gland 1 penis  A deeply pigmented pouch made of skin that lies below the symphysis pubis and behind the penis. It is made of connective tissue, fibrous tissue and smooth muscles It is divided into two compartments, each containing a testis, epididymis and testicular end of a spermatic cord. It main function is to maintain testicular temperatures below the core body temperatures  They are the male reproductive glands, equivalent to ovaries in females Each is about 4 cm long, 2.5cm wide and 3 cm thick. They are suspended in the scrotum by the spermatic cords. They are surrounded by three layers of tissues:-  Tunica vaginalis(outer)- which originates from abdominal and pelvic peritoneum Tunica albuginea(middle)- fibrous covering and the outer layer derived from the septum that divides the scrotum Tunica vasculosa(inner)- consist of connective tissues and capillary network.  Each testis is made up of about 200-300 lobules Each lobule has between 1-4 convoluted loops composed of germinal epithelium, called seminiferous tubules Between the tubules are cells interstitial cells of Leydig which produces hormone testosterone.  The tubules combine at the upper pole to form a single tubule, the epididymis which leaves the scrotum as the deferent duct in the spermatic cord Blood and lymphatic vessels pass to the testes through the spermatic cord.  They are two, one on each side. They consist of one testicular artery, one testicular vein, 1 deferent duct, nerves and lymph vessels within a sheath of fibrous connective tissue and smooth muscles. It serves to suspended the testes The vas deferens passes through the inguinal canal and ascends medially towards the posterior wall of bladder.  They join with ducts from seminal vesicles which together form the ejaculatory duct.  Are two fibromascular pouches lined with columnar epithelium in the posterior aspect of bladder. Produce 60% of alkaline semen including fructose to provide energy for sperm.  Are two tubes about 2cm long formed from the union of deferent duct and seminal vesicles They pass through the prostate gland and join the prostatic urethra. It carries the spermatic fluid and spermatozoa to the urethra.  Lies in the pelvic cavity in front of rectum and behind the symphysis pubis, surrounding the first part of urethra It consist of an outer fibrous covering, a layer of smooth muscle and glandular tissue Produces up to 1/3 of the semen & includes nutrients & enzymes to activate sperm  A small gland just below the prostate gland. Secretes mucous & alkaline buffers to neutralize acidic conditions of urethra.  It is a tubular passage about 19-20 cm long It consist of three parts:- Prostatic urethra- from the urethral orifice of bladder through the prostate gland. Membranous urethra- shortest and narrowest part extending from the prostate gland to the bulb of the penis Spongiose urethra- lies within the penis and terminates at external urethra orifice.  Formed by erectile tissue and involuntary muscles. The erectile tissue is supported by fibrous tissue and covered by skin. It is highly vascular The penis has two lateral columns of tissues made of corpora carvenosa and a medial column, the corpus spongiosum that contains the urethra At the tip, it is expanded into a triangular structure known as glans penis.  Glans penis is well supplied by autonomic and somatic nerves. Parasympathetic stimulation leads to engorgement with blood and erection of penis  Unlike in females, male reproductive hormones are not produced in cyclical fashion. Follicle stimulating hormone is produced by the anterior pituitary gland under the influence of gonadotropin releasing hormone It causes spermatogenesis in seminiferous tubules  Luteinizing hormone is also produced by anterior pituitary gland and is carried through blood stream to the testis. It stimulates the interstitial cells(leydig) to produce the hormone testosterone, the chief male sexual hormone  Produced by the interstitial cells It Is responsible for development of male secondary characteristics. Deepening of voice Maturation of genitalia Growth of hair on the pubis, axilla, face and chest  Spermatogenesis begins at puberty and continues throughout adult life. It is stimulated by changes in pituitary gland secretion when it starts releasing follicle stimulating hormone. The mature sperms are stored in the epididymis and released during ejaculation. At each ejaculation, between 2-4mls of semen is released, each ml containing about 100million sperms  The bony pelvis is a basin-like structure which connects the vertebral column with the lower limbs. For the fetus to pass through the birth canal, it means that the pelvis must be adequate.  Transmits the weight of the body from the spinal column to the lower limbs It contains and protects the pelvic organs Provides attachment for the abdominal muscles and pelvic floor muscles It allows the passage of fetus during labor It allows the person to sit and kneel.  It is formed by four bones Two innominate bones One sacrum One coccyx Innominate bones Also referred to as hip bones They are two in number, each made of three fused bones. The ilium Ischium Pubic bones The three bones articulate with each other at the acetabulum.  It forms the flared out superior part of the pelvis The anterior surface is concave and called the iliac fossa The upper border is called the iliac crest In front of the iliac crest is a bony prominence called anterior superior iliac spine and below this, anterior inferior iliac spine.  On the posterior aspect are two corresponding spines, the posterior superior and posterior inferior iliac spines The iliac bones on each side articulate with the sacrum at a joint called sacro-iliac joint  It is the thick, lower bone posteriorly It has a large prominence, the ischial tuberosity which we sit on Posterior inward projection above the tuberosity are known as the ischial spines  Forms the anterior part of the pelvis It has a body, and two projections, the superior and inferior ramus. The inferior rami form the pubic arch The space between the rami and ischium is known as the obturator foramen On the lower border of the innominate bone are found two curves, the greater and lesser sciatic notches  It is a wedge shaped bone It is made of five fused vertebral bones The upper boarder of the first sacral vertebra is pushed forwards and is known as the sacral promontory The concave anterior surface is called the hollow of the sacrum  On the sides, the sacrum extends into a wing or ala. Four pairs of foramina pierce the sacrum, allowing the nerves to pass through them to supply the pelvic organs  It is a triangular bone formed by four fused coccyx üTwo sacro-iliac joints- the strongest joints in the body, where the sacrum articulate with the ilium. Strain due to pregnancy on the ligaments of these joints lead to back pains üSymphysis pubis joint- this is the joint between the pubic bones. It widens in late pregnancy causing pain while walking. In severe case, it can cause pelvic dysfunction üSacro-coccygeal joint- found where the sacrum articulates with the coccyx. It allows for the coccyx to be displaced posteriorly during labor. Each pelvic joint is held together by ligaments that strengthen it.  Inter pubic ligaments found at the symphysis pubis Sacro-iliac ligaments attach the sacrum and the ilium Sacrococcygeal ligaments are found at the sacro-coccygeal joint Sacro tuberous ligaments attach the sacrum and ischial tuberosities  Sacrospinous ligaments connect the sacrum and the posterior ischial spines  The bony pelvis is divided into two parts: False pelvis True pelvis False pelvis It is the part above the brim formed by the flared out part of iliac bones. it is bordered by the iliac crest and the 5th lumbar vertebra. It is of little obstetrical significance  It is the curved bony canal that the fetus pass through during labor It is divided into:- The brim The cavity The outlet True pelvis is of obstetrical importance  In females, it is rounded except where the sacral promontory projects in it It borders are:- Posteriorly, sacral promontory and the wings of sacrum Laterally- iliac bones Anteriorly- pubic bones The brim has important fixed points known as the landmarks of the brim Sacral promontory Sacral ala or wings Sacro-iliac joint Iliopectineal line Iliopectineal eminence Superior ramus of the pubic bone  Upper inner boarder of the body of pubic bone Upper inner boarder of the symphysis  Extends from the pelvic brim above to the outlet below Its anterior wall is formed by symphysis pubis and is about 4cm long. The posterior wall is formed by the curve of sacrum and is about 12cm long. The lateral border is formed by the wall of the pelvis which is covered by obturator internus muscle.  It is diamond shaped. Anteriorly- pubic arch Laterally- ischial tuberosities Posteriorly- coccyx and sacral tuberous ligaments  Antero -posterior diameters: Anatomical antero-posterior diameter (true conjugate) = 12cm from the tip of the sacral promontory to the upper border of the symphysis pubis.  from the tip of the sacral promontory to the most bulging point on the back of symphysis pubis which is about 1 cm below its upper border. It is the shortest antero-posterior diameter.