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REPRODUCTION > Anatomy and embryology > Flashcards

Anatomy and embryology Flashcards

1
Q

What are the bones of the bony pelvis?

A

2 innominate bones
Sacrum
Coccyx

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2
Q

Each innominate bone is a fusion between which 3 bones?

A

Ilium

Ischium

Pubis

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3
Q

The iliac fossa is the part of the bony pelvis which is for attachment of which muscle?

A

iliacus muscle

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4
Q

The iliac crest extends between which two points?

A

ASIS and PSIS

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5
Q

The ischiopubic rams is part of which bone(s)?

A

It is a part of both the ischium and the pubis!

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6
Q

What type of joint is the hip joint?

A

Synovial joint

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7
Q

What type of joint is the pubis symphysis?

A

Secondary cartilaginous

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8
Q

The inguinal ligament attaches between which two landmarks?

A

ASIS and the pubic tubercle

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9
Q

The ischial spines are palpable on vaginal examination. Where can they be palpated?

A

Palpable about a finger breadth into the vagina at 4 o’clock and 8 o’clock positions

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10
Q

What are the two important ligaments of the pelvis and what are their attachments?

A

Sacrospinous ligament
Sacrum and ischial spine

Sacrotuberous ligament
Sacrum and ischial tuberosity

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11
Q

What is the function of the ligaments of the pelvis?

A

Ensure the inferior part of the sacrum is not pushed superiorly when weight is suddenly transferred vertically through the vertebral column

(e.g when jumping or in late pregnancy)

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12
Q

What are the bones/ bony features that make up the pelvic inlet?

A

Sacral promontory

Ilium

Superior pubic ramus

Pubic symphysis

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13
Q

What are the bones/ bony features that make up the pelvic outlet?

A

Pubic symphysis

Ischiopubic ramus

Ischial tuberosities

Sacrotuberous ligaments

Coccyx

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14
Q

Which structure forms the inferior part of the pelvic cavity?

A

Levator ani muscle

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15
Q

Describe the differences in the bony pelvis in males and females

A

The AP and transverse diameters of the female pelvis are larger at the pelvic inlet and outlet

Subpubic angle (pubic arch) is wider in females

Pelvic cavity is shallower in females

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16
Q

What does the term ‘moulding’ mean?

A

Describes the movement of one bone over another to allow the foetal head to pass through the pelvis during labour

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17
Q

How should the fetal skull ideally enter the pelvic cavity and why is this?

A

Foetus should enter the cavity facing either to the right or left (transverse direction)

*This is because in the fetal skull the occipitofrontal diameter is longest and in the pelvic inlet the transverse diameter is widest

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18
Q

What is meant by the term ‘station’?

A

The distance of the foetal head from the ischial spines

-ve number, means the head is superior
+ve number means the head is inferior

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19
Q

In what position should the baby ideally leave the pelvic cavity?

A

OA (occipitoanterior) position

During delivery the fetal head should be in extension

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20
Q

Describe how the fetal head changes position in the different stages of labour

A

At the pelvic inlet the fetal head should be transverse

As it descends through the pelvic cavity the fetal head should rotate and should be flexed

At the pelvic outlet the fetal head should ideally lie in the OA direction and extension of the head and neck should occur

After the head is delivered, it is manipulated into a transverse position to allow delivery of the shoulders

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21
Q

What is the vertebral level of the PSIS and what structure also ends at this level?

A

S2

Dura ends here

*NB spinal cord ends at L2

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22
Q

What group of muscles attaches to the ischial tuberosity?

A

Hamstrings

Back of the thigh

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23
Q

What structures pass through the obturator foramen?

A

Obturator nerve

Obturator artery

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24
Q

At what vertebral level is the iliac crest?

A

L4

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25
Q

What is the soft spot on the head of a newborn called?

A

Anterior fontanelle

the spot between the two frontal bones and the parietal bone

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26
Q

What structures are contained within the pelvic cavity?

A

Ovaries
Uterine tubes
Uterus
Superior part of the vagina

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27
Q

What structures are contained within the perineum?

A 
Inferior part of the vagina 
Perineal muscles 
Bartholin's glands 
Clitoris 
Labia 
(external genitalia)
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28
Q

The peritoneum forms which pouches in females?

A

Vesico-uterine

Recto-uterine (pouch of douglas)

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29
Q

Where does excess fluid collect within the peritoneal cavity in women?

A

Pouch of douglas

because this is the most inferior part of the peritoneal cavity when in the anatomical position

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30
Q

How can fluid be rained from the pouch of douglas?

A

Culdocentesis

= Drainage via a needle passed through the posterior fornix of the vagina

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31
Q

What are the 3 layers of the wall of the uterus from outer to inner?

A

Perimetrium

Myometrium

Endometrium

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32
Q

Which layer of the uterus is shed during the menstrual cycle?

A

Endometrium

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33
Q

Where does implantation usually occur?

A

Body of the uterus

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34
Q

Why might uterine prolapse occur?

A

Weakness of the strong ligaments, endopelvic fascia and muscles of the pelvic floor

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35
Q

What junction must be sampled during a cervical smear?

A

The squamous columnar junction

transformation zone

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36
Q

The squamous columnar junction involves a transition between which types of epithelium?

A

Secretory columnar epithelium to squamous epithelium

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37
Q

Where does fertilisation usually occur?

A

Ampulla of the uterine tubes

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38
Q

What is Bilateral salpingo-oophrectomy?

A

Removal of both uterine tubes and ovaries

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39
Q

What is unilateral salpingectomy?

A

Removal of one of the uterine tubes

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40
Q

Where is there communication between the genital tract and the peritoneal cavity?

What is the clinical significance of this?

A

The fimbriae at the end of the uterine tubes open into the peritoneal cavity

Infection could pass between the two areas

  • PID can cause peritonitis
  • Ectopic pregnancy can develop in the peritoneal cavity
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41
Q

Where do the ovaries develop and what is their final position?

A

Develop on the posterior abdominal wall and move onto the lateral wall of the pelvis by the action of the round ligament of the uterus

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42
Q

What nerve supplies the levator ani muscle?

A

S3,4,5, sacral plexus

“Nerve to levator ani’

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43
Q

What kind of muscle is the levator ani?

A

Skeletal muscle - voluntary control

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44
Q

What is the function of levator ani?

A

Continual support for the pelvic organs by tonic contraction

Maintains faecal and urinary incontinence

Forms the roof of the perineum and the floor of the pelvis

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45
Q

Which nerve supplies the perineal muscles?

A

Pudendal nerve

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46
Q

What is the perineal body?

A

Bundle of tissues into which the perineal muscles attach

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47
Q

Where is the focal point which is important for pelvic floor strength?

A

Perineal body

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48
Q

Which gland is responsible for providing lubrication of the female genital tract?

A

Bartholins gland

greater vestibular gland

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49
Q

Why might a bartholin gland be enlarged?

A

Infection

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50
Q

The bed of the female breast extends from which bony structures/ areas?

A

Ribs 2-6, lateral border of the sternum, mid-axillary line

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51
Q

The bed of the breast lies on what tissues?

A

Bed of the breast lies on the deep fascia covering the pec major and the serrates anterior

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52
Q

Where is the retromammary space?

A

The space between the breast and underlying tissues (pec major and fascia)

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53
Q

Which ligaments are involved in attachment of the female breast?

A

Suspensory ligaments

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54
Q

Where does most lymph from the breast drain to?

A

Ipsilateral axillary lymph nodes and then to the supraclavicular nodes

NB lymph from the inner breast may drain to the contralateral side

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55
Q

Where does lymph form the lower inner breast quadrant drain to?

A

Abdominal lymph nodes

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56
Q

Why might lymphedema occur?

A

When axillary lymph nodes are removed (e.g for the treatment of breast cancer)

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57
Q

Which ligament of the uterus is formed form a double layer of peritoneum?

A

Broad ligament

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58
Q

Which ligament of the uterus is an embryological remnant?

A

Round ligament

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59
Q

Which uterine ligament contains the uterine tubes and the proximal part of the round ligament?

A

Broad ligament

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60
Q

What is the most common position of the uterus?

A

Anteverted

*cervix is tipped anteriorly relative to the axis of the vagina

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61
Q

What is the anti flexed position of the uterus?

A

Uterus is tipped anteriorly relative to the axis of the cervix

(the mass of the uterus lies over the bladder)

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62
Q

What is the retroverted position of the uterus?

A

Uterus is tipped posteriorly relative to the axis of the vagina

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63
Q

What is the retroflexed position of the uterus?

A

Uterus is tipped posteriorly relative to the axis of the cervix

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64
Q

What are the levels of the axillary lymph nodes?

A

Level I – inferior and lateral to pectoralis minor

Level II – deep to pectoralis minor

Level III – superior and medial to pectoralis minor

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65
Q

What is the clinical relevance of the internal thoracic artery supplying the female breast?

A

Breast cancer can enter the thoracic space and affect the thoracic spine

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66
Q

What are the boundaries of the pelvic inlet?

A

Symphysis pubis

iliopectineal lines

Sacral promontory

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67
Q

What are the boundaries of the pelvic outlet?

A

Pubic arch

Ischial tuberosities

Coccyx

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68
Q

Which nerve fibres are involved with structures in the pelvis?

A

Sympathetic, parasympathetic and visceral afferents

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69
Q

Which nerve fibres are involved with structures in the perineum?

A

Somatic motor and somatic sensory

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70
Q

Which nerve fibres transmit pain from the pelvic organs?

A

Visceral afferents

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71
Q

Which nerve transmits pain from the perineum?

A

Pudendal nerve

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72
Q

Describe how pain sensation is relayed differently from superior aspects and inferior aspects of pelvic organs

A

Superior aspect of pelvic organs / touching the peritoneum
Visceral afferent run alongside SYMPATHETICS
Enter spinal cord between levels T11-L2
Pain is perceived as suprapubic

Inferior aspect of pelvic organs / not touching peritoneum
Visceral afferents run alongside PARASYMPATHETICS
Enter spinal cord at levels S2, S3, S4

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73
Q

Where is pain from the inferior aspect of pelvic organs perceived?

A

Pain perceived in S2, S3, S4 dermatome (perineum)

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74
Q

Where is pain from the superior aspect of pelvic organs (touching the peritoneum) perceived?

A

Pain is perceived as suprapubic

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75
Q

Describe pain sensation from structures which cross from the pelvis to the perineum e.g urethra and vagina

A

Above the levator ani (in pelvis)
- Visceral afferents run alongside parasympathetics and enter the cord at S2,3,4

Below the levator ani (in the perineum)
- Somatic sensory in the pudendal nerve enters the cord at S2,3,4

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76
Q

Where do visceral afferents from the uterine tubes, uterus and ovaries enter the spinal cord?

A

T11-L2

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77
Q

Where do visceral afferents from the cervix and superior vagina enter the spinal cord?

A

S2-S4

78
Q

At what vertebral level does the spinal cord become the cauda equina?

A

L2

79
Q

At what vertebral level does the subarachnoid space end?

A

S2

80
Q

Where is anaesthetic injected in spinal and epidural anaesthesia?

A

L3-L4 region

anaesthetises the cauda equina

81
Q

Describe sympathetic outflow from the spinal cord

A

Sympathetics exit with T1-L2 spinal nerves

Travel to sympathetic chains

Pass into all spinal nerves

82
Q

What effect does spinal anaesthetic have on arterioles in the lower limbs?

A

Hypotension

Blocks sympathetic tone to all arterioles causing skin to be flushed, warm and have reduced sweating

83
Q

The pudendal nerve contains which branches of the sacral plexus?

A

S2,3,4

84
Q

Why may a pudendal nerve block be used?

A

To anaesthetise the majority of the perineum

For episiotomy incision, forceps use and perineal stitching post delivery

85
Q

Describe the course of the pudendal nerve

A

Exits pelvis through the greater sciatic foramen

Passess posterior to the sacrospinous ligament

re-enters pelvis through the lesser sciatic foramen

Travels in the pudendal canal and branches to supply the perineum

86
Q

What bony feature can be used as a landmark when administering pudendal nerve block?

A

Ischial spine

87
Q

What might occur as a result of pudendal nerve damage during labour?

A

Weakened pelvic floor and faecal incontinence

88
Q

Which muscles might be torn during labour?

A

Fibres within the levator ani (puborectalis) or external anal sphincter

89
Q

What is episiotomy?

A

Surgical incision of the perineum during labor to enlarge the opening for the baby to pass through

90
Q

In which area is the episiotomy incision made?

A

Ischioanal fossa

91
Q

Why is the incision in episiotomy more often oblique than median?

A

The median incision has a higher risk of involving the anal sphincter if further tearing occurs

92
Q

What are the different origins of the male and female duct systems?

A

Male = mesonephric

Female= paramesonephric

93
Q

The testes descend to the scrotum under the control of what?

A

Gubernaculum

94
Q

What influence does the gonad (testi) have on gonadal and genital duct development?

A

Mullerian inhibiting substance from sertoli cells suppresses the paramesopnephric ducts

Testosterone stimulates the mesonephric ducts and causes the development of external genitalia

95
Q

How is the broad ligament of the uterus formed?

A

Fusion of the paramesonephric ducts

96
Q

What influence does the gonad (ovary) have on gonad and genital duct development?

A

Oestrogen stimulates the paramesonephric ducts and causes development of the external genitalia

97
Q

How does the pelvis differ between males and females?

A

The subpubic angle is more rounded in females, and more angular in males

The sacral promontory is more anterior in males

98
Q

Which nerves and vessels may be damaged as a result of pelvic trauma?

A

Iliac artery and vein

Lumbosacral plexus

99
Q

Define what is meant by the perineum?

A

The space that lies between the elevator ani muscle superiorly and the perineal skin inferiorly

100
Q

Why could a perianal abscess spread readily through the ischioanal fossa?

A

The Ischianal fossa is mostly made up of fat, with limited blood and lymphatics - this means there is minimal barrier to the spread of infection

101
Q

What clinical procedure in the female pelvis could damage the ureter?

A

Hysterectomy

102
Q

Where does lymph from the ovaries drain to?

A

Lumbar lymph nodes

103
Q

Why might uterine prolapse occur?

A

Weakened pelvic support

Increased abdominal pressure

104
Q

What is a cystocele?

A

Herniations of the bladder into the vagina

105
Q

What is a rectocele?

A

Herniations of the rectum into the vagina

106
Q

What is the main function of the fluid secreted by the prostate gland?

A

Activation of sperm

107
Q

What are the functions of the mucus secreted by the bulbourethral glands?

A

Lubrication of the female genital tract and neutralisation of the acidic environment of the female tract

108
Q

How can the position of the fatal head be identified during vaginal examination?

A

Midline suture of the skull

Fontanelles

  • Posterior fontanelle is triangular in shape
  • Anterior fontanelle is diamond in shape
109
Q

Why can forceps delivery cause Bell’s palsy?

A

The baby doesn’t have a mastoid process when it is born, therefore the facial nerve can be damaged causing Bell’s palsy

Identified on the baby by a droopy eye and poor sucking

110
Q

Erb’s and Klumpke’s palsy can both be caused at delivery, how is each caused?

A

Erb’s
*shoulder gets stuck behind the pubic symphysis

Klumpke’s
*tugging on the arm during birth

111
Q

What are the differences between Erb’s and Klumpke’s palsy?

A

Erb’s palsy

  • Waiter’s tip posture
  • C5,6

Klumpke’s palsy

  • Claw hand
  • C8, T1
112
Q

What other names are used to describe a lower segment caesarean section (LSCS) incision?

A

Suprapubic incision

Pfannestiel incision

Bikini lini incision

113
Q

What are the layers of the anrerolateral abdominal wall from outer to inner?

A 
Skin 
Fascia 
External oblique 
Internal oblique 
Transversus abdominus
114
Q

What is the linea alba?

A

The midline blending of aponeuroses

115
Q

The fibres of the external obliques run in the same direction as which muscle fibres?

A

Fibres of the external intercostals

116
Q

The fibres of the internal obliques run in the same direction as which muscle fibres?

A

Fibres of the internal intercostals

117
Q

Where does the linea alba extend between?

A

Runs from the xiphoid process to the pubic symphysis

118
Q

What is the risk of not stitching up the rectus sheath of linea alba sufficiently?

A

Incisional hernias

119
Q

What is the nerve supply to the anterolateral abdominal wall and what are the levels they supply?

A

Thoraoabdominal nerves (T7-T11)

Subcostal nerves (T12)

Iliohypogastric nerves (L1)

Ilioinguinal nerves (L1)

120
Q

Where do nerves travel in the anterolateral abdominal wall with reference to the different muscle layers?

A

Nerves travel in the plane between the internal oblique and the transverses abdominis

121
Q

What is the blood supply to the anterior abdominal wall?

A

Superior epigastric arteries

Inferior epigastric arteries

122
Q

What is the blood supply to the lateral abdominal wall?

A

Intercostal and subcostal arteries

123
Q

Where is the blood supply to the anterolateral abdominal wall located with reference to the muscle layer?

A

Blood supply lies posterior to the rectus abdominus muscles

124
Q

The superior epigastric arteries which supply the anterior abdominal wall are a continuation of which artery?

A

Internal thoracic artery

125
Q

The inferior epigastric arteries which supply the anterior abdominal wall are a continuation of which artery?

A

External iliac artery

126
Q

The intercostal and subcostal arteries which supply the lateral abdominal wall are continuations of which artery?

A

Posterior intercostal arteries

127
Q

What are the layers cut through in a LSCS incision?

opening

A 
Skin and fascia 
Anterior rectus sheath 
Rectus abdominus
Fascia and peritoneum 
Uterine wall 
Amniotic sac
128
Q

What structure needs to be retracted during an LSCS incision?

A

The bladder

129
Q

What layers are stitched closed after a LSCS incision?

A

Uterine wall

Rectus sheath

Skin

130
Q

What layers are cut through for a laparotomy?

A

Skin and fascia

Line alba

Peritoneum

131
Q

What is a laparotomy?

A

A vertical midline incision into the abdominal cavity

132
Q

Why is healing not as good and the chance of infection increased with midline incisions such as laparotomy?

A

poor blood supply

linea alba is an aponeurosis and is avascular

133
Q

What is laparoscopy?

A

Small incisions made to allow access to the abdominal cavity

134
Q

If a lateral port is required for laparoscopy, which structure must be carefully avoided?

A

Inferior epigastric artery

135
Q

During laparoscopy, how can the position of the uterus be manipulated to allow for better viewing of the pelvic organs?

A

By grasping the cervix with forceps inserted through the vagina

136
Q

Where is the inferior epigastric artery located?

A

Emerges just medial to the deep inguinal ring

Passes superomedially posterior to the rectus abdominus

137
Q

What is an abdominal Vs a vaginal hysterectomy?

A

An abdominal hysterectomy is the removal of the uterus via an incision made in the abdominal wall

A vaginal hysterectomy is the removal of the uterus via the vagina

138
Q

What kind of incision is made for an abdominal hysterectomy?

A

Same incision as LSCS

139
Q

During hysterectomy, extreme care must be taken to not damage which structure?

A

Ureter

140
Q

Describe the relation of the ureter to the uterine artery

A

The ureter passes inferior to the uterine artery

141
Q

Which duct develops to form the vas deferens in males?

A

Mesopnephric duct

142
Q

Which duct develops to form the fornix of the vagina in females?

A

Paramesonephric duct

143
Q

What anatomical landmarks can be used for administration of a pudendal nerve block?

A

Ischial spines

144
Q

What 3 components make up the pelvic floor?

A

Pelvic diaphragm

Muscles of the perineal pouches

Perineal membrane

145
Q

What is the deepest layer of the pelvic floor?

A

Pelvic diaphragm

146
Q

The pelvic diaphragm consists of which two muscles?

A

Levator ani

Coccygeus

147
Q

The anterior gap between the medial borders of the pelvic diaphragm contains what?

A

urogenital hiatus

passage for urethra (♂ and ♀)

vagina (♀)

148
Q

What are the 3 parts of the levator ani?

A

Puborectalis

Pubococcygeus

Iliococcygeus

149
Q

What nerves innervate the levator ani?

A

Pudendal nerve and nerve to levator ani

150
Q

When does the elevator ani contract and relax?

A

Tonically contracted

Relaxes to allow urination and defecation

151
Q

What additional support is there for the pelvic organs other than the levator ani?

A

Endo-pelvic fascia

Pelvic ligaments

152
Q

Describe the location of the deep perineal pouch

A

Inferior to the levator ani and superior to the perineal membrane

153
Q

What structures are contained within the deep perineal pouch?

A

Contains part of the urethra

Vagina in females

Bulbourethral glands in male

Neurovascular bundle for penis/clitoris, extensions of the ischioanal fat pads and muscles

154
Q

What is the location and attachments of the perineal membrane?

A

Superficial to the deep perineal pouch

Attaches laterally to the pubic arch

Closes the urogenital triangle

155
Q

The perineal membrane has openings for what structures?

A

Urethra

Vagina in females

156
Q

What structure provides the last passive support for the pelvic organs

A

Perineal membrane and perineal body

157
Q

Which structures are involved in maintaining *urinary continence?

A

External urethral sphincter

Compressor urethrae

Levator ani

158
Q

Which structure is involved in maintaining *faecal continence? How does it do this?

A

Puborectalis

Tonic contraction of puborectalis bends the anorectum anteriorly
Active contraction maintains continence after rectal filling

159
Q

Where us the superficial perineal pouch located?

A

Below the perineal membrane

160
Q

What muscle covers the bulb of the penis in males and contracts to stimulate ejaculation?

A

Bublospongiosus

161
Q

What muscle covers the vestibular bulb in females?

A

Bulbospongiosus

162
Q

What are the two main muscles associated with the superficial perineal pouch in males and females?

A

Bulbospongiosus

and

Ischiocavernosus

163
Q

Describe the different types of vaginal prolapse

A

Herniation of urethra/ bladder/ rectum/ rectouterine pouch

Cystocele/ rectocele/ enterocele

Presents as a lump in the vaginal wall

164
Q

What are the different types of uterine prolapse and how does it present?

A

1st 2nd or 3rd degree

Dragging sensation, feeling of a ‘lump’ and urinary incontinence

165
Q

What is sacrospinous fixation used for?

A

To repair cervical/ vault descent

166
Q

There is risk of damage to which nerves with sacrospinous fixation?

A

Pudendal and sciatic nerves

167
Q

What is the normal size of an adult testis?

A

12-25 mls

168
Q

What procedures are performed during LSCS to minimise the risk of damage to the bladder?

A

Catheterisation (decreases bladder volume)

Incision is made 2cm above the pubic symphysis to avoid the bladder

Retract is used to move the bladder out the way

169
Q

The inferior epigastric artery is a branch of which artery?

A

External iliac artery

170
Q

Describe what happens during an erection

A

Parasympathetic control

Penis engorges with blood

Contraction of muscles pushes blood into the penis

Arteries are in the centre, veins are on the outside, so the veins get squished preventing blood from leaving the penis

171
Q

Describe what happens during ejaculation

A

Sympathetic control

Constriction of blood vessels allow for the passage of semen

172
Q

What is the most suitable female pelvic shape?

A

gynaecoid pelvis

173
Q

What is the anthropoid pelvic shape?

A

Oval shaped inlet with large AP diameter and smaller transverse diameter

174
Q

What is the android pelvic shape?

A

Triangular/ heart-shaped inlet

175
Q

What lies deep too the tendinous arch of the levator ani?

A

The ishioanal fossa

176
Q

From which vessel do the majority of the arteries of the pelvis and perineum arise from?

A

Internal iliac artery

177
Q

Which vessel does the gonadal artery arise from?

A

L2 abdominal aorta

178
Q

Which vessel does the superior rectal artery arise from?

A

It is a continuation of the inferior mesenteric artery

179
Q

The medial umbilical ligament (fold) is the remnant of which structure?

A

Umbilical artery

180
Q

The inferior vesical artery is only present in males. Which vessel is it replaced by in females?

A

Vaginal artery

181
Q

The median umbilical fold (NB different to the medial umbilical fold) is the remnant of which structure?

A

The urachus

182
Q

The lateral umbilical fold is the remnant of what?

A

Internal iliac artery of the fetus

183
Q

Most of the arteries to the male perineum come from the internal pudendal artery. The anterior scrotal artery is an exception to this - it is a branch of which artery?

A

External iliac artery

184
Q

Blood supply to the ovary comes from an anastomosis of which two vessels?

A

Ovarian artery and the uterine artery

185
Q

Sacral veins are valveless. What is the significance of this?

A

Spread of infection and metastases

186
Q

Describe the venous drainage of the pelvis

A

Mainly to the internal iliac vein

Some drainage via the superior rectal vein into the hepatic portal system

Some drainage via the lateral sacral veins into the internal vertebral venous plexus

187
Q

What are the nerve roots of the obturator nerve?

A

L2,3,4

188
Q

Superficial pelvic viscera drain to which lymph nodes?

A

External iliac nodes

189
Q

Inferior pelvic viscera drain to which lymph nodes?

A

Internal iliac nodes

190
Q

Superficial perineum drains to which lymph nodes?

A

Superficial inguinal nodes

REPRODUCTION (12 decks)

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