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The Position of the Uterus and Fetus at Term (1872)

Braune, Wilhelm (1831-1892): Die Lage des Uterus und Foetus am Ende der Schwangerschaft. (Leipzig: Verlag von Viet & Comp., 1872).

This sagittal section through the maternal anatomy shows the relative size and position of the fetus during pregnancy.

Note also the altered maternal anatomical relationships during the pregnancy.

Braune Image Links: Uterus and Fetus Position at Term | Section through Uterus and Fetus | Uterus without Fetus | Uterus and Fetus Position at Birth | Section through Uterus and Fetus at Birth | Uterus without Fetus at Birth | 17-18 C Anatomies

The body from which this preparation was made was quite recent, twenty-five years of age, in the last month of pregnancy, and received in the condition of rigor mortis. Beyond the constriction of the neck produced by the means of death (hanging) no abnormality existed. The condition of the genitals corresponded with an advanced stage of pregnancy, and were injected and succulent. The method of preparation was carried out in the usual manner.

Preparation Method

The foetus, which was divided in the section of the body, was subsequently restored to its original condition, so as to afford a representation of its former position in the uterus. I chiselled out the foetus and the liquor amnii from the left side of the body, and moistened the surface of the section of the uterus, and then froze it on the right side. The portion now lying in the right half of the uterus remained then for the purposes of representation as an untouched foetus. The left half of the uterus and its appendages, after the removal of the rest of the liquor amnii, was represented as empty. The foetus, which was in the second position of the head, was a well-formed female. The vulva were closed and the nails well developed. Its entire length was about twenty-three inches, its weight without the cord about six pounds. The cord was divided, and passed to the placenta between the head and right arm, the placenta being placed downwards and on the right side of the uterus. The child, as the plate shows, lay mostly in the right half of the uterus. In the section more than the right half of the head which was sawn obliquely, was removed. Moreover, the left arm and a portion of the right shoulder were divided longitudinally, and the forearm being placed at right angles with it, transversely, as well as a portion of the right leg, which extended towards the left side. The left knee was moreover grazed by the saw. The back and belly lay in the right half of the uterus, and the greater portion of the liquor amnii remained in the left. As the relations of this oblique section of the foetus offer points of no peculiar interest, I have refrained from reproducing the corresponding plate of the large atlas in this small edition.

The uterus is so folded over the symphysis that its anterior wall forms a kind of sac, indicating a condition of relaxation. The numerous large veins in its tissue are shown in the plate in the wall as simple strokes, their lumina becoming recognisable only when their walls were separated from each other; they appear patent, however, in the vaginal portion of the uterus and in the vagina itself. The vaginal portion of the uterus is proportionately deep, and for the most part lies in the left half of the body, the section having passed through its right half and opened merely the first portion of the cervix, as shown in Plate XXIX A. It was filled with viscid mucus and opened into the cavity of the uterus, about one fifth of an inch below the plane of section, so that its upper half could not be seen. The length of the vagina at this period of pregnancy makes it probable that the woman was not a primipara, notwithstanding that there were no cicatrices on the abdominal parietes, and the os internum was so narrow that only a very small sound could pass it. The number of veins met with in the right half of the vagina and their swollen condition is remarkable, and their lumina are peculiarly well seen in the left half of the preparation, Plate XXIX B. The falling in of the vaginal portion of the uterus is remarkable, considering the empty contracted condition of the bladder. The latter has slipped down bodily from the inner surface of the symphysis, and is so completely displaced that the course of the urethra has become bent at an angle. The external os lies in the hollow of the under border of the symphysis, although, according to Moreau, it corresponds at the end of pregnancy with the level of the upper border of the symphysis, and is still higher according to Schultze.

The level of the fundus corresponds nearly with the under border of the first lumbar vertebra; a more accurate definition cannot be given, as the highest point of the uterus was not included in the section, as it inclined more to the right side. This is almost the level given by Moreau, and according to the measurements of Schultze (' Wandtafeln,' taf. vi), it would appear to be the second lumbar vertebra. As the parts in the meanwhile began to thaw, a more accurate measurement in this particular could not be made.

The depth of the cavity of the uterus and its connections, and of the entire cavity of the abdomen, is less than is usually admitted. Notwithstanding the size of the foetus it is not improbable that the attitude of the body had some influence in this respect, and that lying horizontally on the back the uterus obtained a kind of fulcrum on the vertebral column, whilst in the upright position the yielding walls of the abdomen are pushed forwards. It is farther to be remembered that in dead bodies generally in consequence of the high position of the diaphragm, the depth of the cavity of the abdomen is less than during life.

In the present instance the distance of the lumbar vertebrae from the anterior wall of the abdomen was almost one third of the entire sagittal diameter of the body at its point of greatest distension ; whilst in the body which in Plate II is represented in the second month of pregnancy, the lumbar spine projects slightly beyond the middle of this diameter.

Finally, the vessels were in this case uninjected a circumstance which is to be taken into consideration in estimating the thickness of the walls of the uterus.

Abdomen

The cavity of the abdomen extended tolerably far up in comparison with its slight depth. The highest point of the diaphragm reached the level of the seventh dorsal vertebra, whilst in males, and unimpregnated females of middle age it would extend only as far as the ninth or tenth. The mass of the intestines was pushed downwards, and chiefly lodged in the left upper half of the abdominal cavity. The pyloric extremity of the stomach was bent at an acute angle backwards and to the left side, so that it was twice cut through. The upper horizontal portion of the duodenum was directed backwards. On the left half of the body the duodenum is contracted against the pylorus, and moreover shows the opening of the pancreatic and choledic ducts. Below the duodenum is the pancreas. The liver and spleen are not enlarged. The latter measured 5.5 inches long, 3.8 inches broad, and 2 inches thick. The duodenum and pyloric portion of the stomach had pushed the fundus uteri, which lay more to the right, together with the rest of the intestines over to the left side. The rectum, which was tolerably distended, bent round to its iliac flexure, towards the right side whilst yet in the pelvic cavity, so that this flexure is met with in the course of the section. Between the rectum the folds of which on the right side are so disposed that they might be taken for the valves of Kerkring in the plate and the uterus, is a coil of small intestine, the lowest portion of the ileum passing to the ascending colon, a disposition which does not usually happen with the impregnated uterus, but only in anteversion. In examining the limit of the peritoneum in the pelvis, it must not be confounded with the fascia, represented rather too thick, which passes down between the uterus, bladder, and rectum. The peritoneum is applied for only a short extent to the posterior wall of the vagina, and envelopes nearly half of the posterior wall of the contracted bladder, whilst the fascias, which enclose a loose, lax cellular tissue, pass forwards nearly to the internal orifice of the urethra, and posteriorly close to the end of the rectum.

Thorax

The thoracic cavity appears shallow, in consequence of the high position of the diaphragm, but, on the other hand, very wide in the antero-posterior diameter, as may be seen by comparing this preparation with the section of the female subject in Plate II. But on the strength of this, an enlargement of the base of the thorax during pregnancy is not necessarily to be inferred, as measurements for comparison are wanting before and after it. Although it may appear plausible to explain the unvarying size of the spirometer during pregnancy, by the fact that the diminution of the thoracic space dependent on the rising of the diaphragm is compensated for by the traction of the abdominal muscles acting over the uterus like a pulley, the anatomical relations in this respect are not yet determined. Gerhard found, by measurements on living bodies, that in forty-two females in advanced pregnancy the diaphragm was in thirty-six cases in a normal position, in five it was deeper, and only in one higher. Dorn in his measurements by means of the cyrtometer on living females in advanced pregnancy and in lying-in women, found that in most cases the bases of the thorax had a greater breadth during pregnancy than after delivery, but, on the other hand, its depth was less from before backwards. When the uterus was empty this relation was reversed, the thorax collapsed on both sides, the transverse diameter decreased, and the vertical diameter increased (' Bericht iiber die Naturforchenversammlung zu Griessen,' 1865, p. 225). In the cavity of the thorax, in consequence of the scoliosis of the spine, the section deviated to the right of the middle line, so that traversing the lumina of the superior and inferior venae cavae, the right auricle and root of lung are met with, consequently the relation of the openings of both veins into the heart are clearly seen. The inferior vena cava, which receives the hepatic vein just before its entrance into the heart, comes from behind into the right auricle, whilst the superior vena cava opens considerably further forwards. The axes, therefore, of the cavaa form an angle, which, owing to the convexity of the septum auriculorum, is rounded off. The eminence, behind which lies the left auricle, is the tuberculum Loweri. On the right half of the body is noticed the external wall of the right auricle, whilst on the left a view is obtained of the left ventricle, in front of the entrance to which is still a small portion of the rudimentary Eustachian valve. This valve limits the posterior portion of the right auricle, in which is still to be seen the original position of the foramen ovale. In the anterior portion of the auricle, to which the superior cava tends, the bulbus aortaa forms a flattish protuberance. The aorta itself is not seen entirely, a portion of it only being exposed. It rises in front of the superior vena cava, and then disappears below the left innominate vein. The section of the lung seen in Plate XXIX is that of the right.

The soft parts of the neck are considerably dislocated towards the left side, owing to the hypertrophied thyroid body. The trachea lies so far over to the left side that only a small portion of the thyroid cartilage is met with.

The brain was divided through its right half, the radiation of the fibres of the right corpus callosum being thus shown. Beneath it is the descending cornu of the right lateral ventricle with the pes hippocampi. Beneath the dura mater, in the right half of the preparation, a portion of the Gasserian ganglion and some fibres of the fifth nerve are seen.

The relations of the skeleton, however, are of the greatest importance. I had therefore, after all. the plates were drawn, the halves of the skeleton macerated, and the parts as accurately as possible adjusted with regard to each other, as represented in the adjoining woodcut. It presents a slightly scoliosed pelvis, with a like condition of the spine. It shows moreover that the deviation of the line of section from the middle line was not so considerable as the plate might suggest. The section passed through the pelvis, as near as possible in the middle line, externally and to the right of the lumbar vertebrge, meeting the dorsal at their articulation with the ribs, and passing again in the cervical region to the middle of the spinal column, and subsequently again to the right in the skull. Beyond the scoliosed condition of the spine there was nothing worthy of remark, except that there were two cervical ribs, one complete on the right side, and a rudimentary one on the left side of the seventh cervical vertebra. There were seven cervical vertebrse, but only eleven dorsal and five lumbar. There was a rudimentary process from the fifth lumbar which was attached to the upper portion of the sacrum. The measurements of the pelvis in inches were as follows : The conjugata vera 3.8 in. (the conjugata at the narrowest points being 3.7) ; the right sacro-cotyloid 2.8 in. ; the left sacro-cotyloid 3.2 in. ; the transverse diameter 5*8 in. ; the left oblique diameter, 5.08 in., and the right oblique diameter 5.6 inches. The sacrum was 4.5 in. deep and 4.8 in. broad.

Skeleton

The question arises whether, in a weak obliquely contracted pelvis, showing such a variation, child-birth be possible without surgical aid.

Detailed description of this Plate XXIX A, XXIX B, and XXX | Uterus and Fetus Position at Term - original version

Reference

Braune W. An atlas of topographical anatomy after plane sections of frozen bodies. (1877) Trans. by Edward Bellamy. Philadelphia: Lindsay and Blakiston.

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Cite this page: Hill, M.A. (2024, April 18) Embryology BrauneB1.jpg. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/File:BrauneB1.jpg

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