MALE REPRODUCTIVE SYSTEM Andrology: Study of male reproductive system Primary Reproductive Function: The production and transport

of sperm through out of the genital tract into the female genital tract The Penis 1. It is elongated and cylindrical, consisting of a body (shaft) and a coneshaped end (gland). It lies in front of the scrotum. 2. Extremely vascular (blood supplied by a parallel system of internal and external pudendal arteries and veins. Blood to the cavernous sinuses is provided by branches of the penile artery.) Blood spaces fill and become distended during sexual excitement resulting in penile distension and stiffening termed erection. 3 columns of erectile tissue: The penile shaft has 3 longitudinal columns of erectile tissue: 1. Corpora Cavernosa (2 columns): lateral columns located on either side and in front of the urethra. 2. Corpus Spongiosum (1 column): posterior column which contains the urethra. The tip is expanded to form the glans penis. The skin at the end of the penis is folded back on itself above the glans penis to form the prepuce (foreskin), a movable double fold. Blood Supply: It is comprised of a parallel system of internal and external pudendal arteries and veins. Blood to the cavernous sinuses is provided by two branches of the penile artery.

Nerve Supply: The penis is inverted by the pudendal nerve. Sympathetic Fibers and Parasympathetic Fibers.

Function: It carries the urethra, path way for both urine and semen (serves both urinary and reproductive systems.)

Primary Function: Deposits sperm in the female vaginal for fertilization of the ovum.

Mechanism: Parasympathetic fibers from third and fourth sacral nerves, stimulation of the parasympathetic causes contraction of ischiocavernous muscle which prevents the return of venous blood from the cavernous sinuses. The blood vessels engorge, the penis becomes elongated, thickened, and stiff, which is a phenomenon called erection. If stimulation is intense, there is rhythmic contraction of penile muscle resulting in forceful and sudden expulsion of semen, a phenomenon which is called ejaculation.

Special Concerns: 1. Impotence: is the inability of the male to perform sexual intercourse due to absence or lack of ability to initiate and/or maintain erection. Types: 1. primary: rare 2. Secondary impotence: maybe due to organic cause such as: endocrine: diabetes Oral intake: alcohol Drugs (barbiturates, some anti-hypertensive drugs) Psychogenic causes (stress, depression, fatigue burn out, guilt) Situational impotence is when it occurs only in a particular conflict-or guilt-laden relationship.

Medical Treatment: Viagra, contra indicated on men who use nitric oxide donors? And nitrates in any form, in men with cardiovascular problems, and in those for whom sexual activity is inadvisable, not indicated for women.

Surgical treatment: Penile prosthesis: the implant of silicones into penile tissue restore erectile capability but has no impact on ejaculation, fertility, nor orgasm. Post-op problem: pain and edema are expected for 5 to 14 days and sexual activity may resume 6 to 8 weeks after surgery if there is no pain.

2. ejaculatory incompetence: a. premature ejaculation: may be a learned behavior from early hurried sexual experience or expression of interpersonal conflicts. The Scrotum Sac or pouch-like structure from root of penis suspended from the perineal region; formed of pigmented skin and has two compartments, one for each testis. 1. It is composed of skin and dartos muscles. 2. Sebaceous glands open directly onto scrotum secretions with distinct odor. 3. Contraction of dartos and cremasteric muscles shortens scrotum and draws it closer to the body, wrinkling its outer surface. 4. Degree of wrinkling a. Smooth in preterm, wrinkled in full term newborns b. Greatest wrinkling in young men and at cold temperature. c. Least wrinkling in older men and at warm temperature. 5. Nursing Implication: When education on testicular self-examination (TSE) emphasize that the best time for doing it is after a warm bath or shower when scrotum is soft and less wrinkled, one can palpate the testes.

Testicular Self-examination (TSE) a. Ideally performed monthly, after a warm shower or bath when scrotal skin is relaxed. b. Standing in front of a mirror, the man gently rolls each testicle between the thumb and fingers of both hands. c. Feel for the normal testes which are smooth, firm, and oval shaped. d. Most testicular cancers, the most common cancer in young men between 15 and 34, are found by men themselves or when doing TSE. Warning Signs that men should look for:

a. b. c. d. e.

Hard lump. Painless swelling, pain in a testicle or scrotum. Feeling of heaviness. Sudden collection of fluid in the scrotum. Dull ache in the lower abdomen or groin.

Function of scrotum: The scrotum contains the testes and the epididymis, the primary function of the scrotum is to protect the testes and the sperm by maintaining temperature lower than the body, because the testes are sensitive to touch, temperature, pressure, and pain, the scrotum protects the testes from potential harm.

Nursing Implication: 1. Assessment of the male newborn should include palpating the scrotum to detect if the testes have descended from the abdominal cavity. Spermatogenesis will not occur if the testes fail to descend because they will be subjected to body temperature; it is cooler in the scrotum. 2. To enhance spermatogenesis and have adequate number of viable sperm, avoid tight undergarment and pants and prolonged sitting. Testes: Two small (4.5cm to 6cm long, 2.5cm wide, 3cm thick), oval male gonads suspended in the scrotum, weighing 10 to 15 g.

Testicular functions: Secretion of male sex hormones (androgens) and site of spermatozoa production in the mature male.

1. Endocrine function: a. hypothalamus: Releasing factor is inhibiting Anterior Pituitary Gland (APG) b. Anterior Pituitary Gland: Secrets the gonadotropins (LH) luteinizing hormone - ICSH (interstitial cell-stimulating hormone) - Stimulates the testes

c. Testes interstitial cells of leydig are the cells stimulated by LH to synthesize testosterone from cholesterol. Most of the circulating testosterone is converted in the liver into 17ketosteriods, which are secreted in the urine. d. Testosterone hormone production is by the interstitial cells of leydig of the testes. Sperm production: 1. the primary spermatogonia, the primitive germ cell, are present at birth; with cells (diploid) 44XY. 2. after puberty, spermatogenesis is continuous and is completed in 72 hours. 3. spermatogenesis is the process by which male spermatogonia develop into mature spermatozoa. Sperm Types:

Androsperm Carries Y-sex chromosome Fast moving Smaller, weaker, short-lived Dies in acid

Gynosperm Carries X-sex chromosome slower bigger, stronger, long-lived acid-resistant

1. Sperm Parts: 1. Head where the nucleus is compacted, made up of chromosomal materials; the tip is covered by a cap called acrosome which is rich in enzymes to dissolve the covering of the ovum (zona pellucida) in order to penetrate it. 2. Body 3. Mobile tail used to propel the sperm along the spermatozoa leaving the testes are not fully motile, they continue to mature and acquire motility during their passage through the epididymis, which is the area for maturation of sperms and reservoir for mature sperms. 2. Life span: Sperms can survive in the female reproductive tract for up to 72 hours. However, it is believed to be healthy and higher fertile for only 24 hours (Silverstein 1980)

3. Development of sperm in the testes takes approximately 70 days, sperm remain in the epididymis for 12 to 26 days for maturation.

4. Sex determination the 2 chromosomes of the 23rd pair (either XX or XY) are called sex chromosome. a. Y, the smaller sex chromosome on the sperm, the Y chromosome carry only genes for maleness b. X, the larger sex chromosome in the sperm, for female c. The x chromosome carry several genes other than those for sexual traits. These other traits are called sex linked because they are controlled by the genes of X chromosome like hemophilia, blindness. d. Females have two X chromosomes (XX). e. Males have one X chromosome and one Y chromosome (XY). The father is responsible for the Y sex chromosome, which determines the male sex of the offspring.

Testosterone: the male reproductive hormone. 1. Gonadal development begins at 5 to 6 weeks gestations. Testicular differentiation and testosterone production begin at 7 weeks of gestation. This action of testosterone continues through out life, including the development of sperm (levels decrease as men age) 2. Responsible for production of sex drive and potency. 3. Develops secondary sex characteristics: a. Increase in height, size and number of muscles and bone growth cessation. b. Deepening of the voice. c. Growth of penis, testes, scrotum, seminal vesicles, prostate gland and genital duct system. d. Growth of hair on face, chest, axilla and pubis. 4. Together with FSH, testosterone stimulates sperm production.

The Ducts: The Highly Intricate Duct Systems of the Testis 1. Seminiferous tubules (seed-carrying tubules) a. Place of sperm production (spermatogenesis) b. There are up to three tubules in each lobule and between the tubules are interstitial cells which secret the male hormone testosterone. c. The tubule join to form a system of channels leading to the epididymis. 2. Epididymis a. Soft, cordlike, coma-shaped b. Located on the superior surface of the testes and travels down to the posterior aspect to the lower pole of the testis leading to the deferent duct (vas deferens) c. Head: attached to the top of the testis d. Tail: continuous with vas deferens. e. Strong House: for maturing spermatozoa. 3. Spermatic Chord a. Vas deferens carries the sperm to the ejaculatory duct; ligated in bilateral vasectomy, planning. b. Testicular blood vessels Testicular artery branch of abdominal aorta; supplies blood to the testis; scrotum and attachments.

Testicular vein drains in the same manner as the ovarian veins. The right testicular vein joins the inferior vena cava, but the left returns its blood to the left renal vein. c. Nerves the nerve supple is from the tenth and eleventh thoracic nerve. d. Lymphatic Vessels lymphatic drainage is to the lymph nodes around the aorta.

e. Vas Deferens joins ducts of seminal vesicles to become ejaculatory ducts small muscular ducts that carry the spermatozoa and the seminal fluid to the urethra.

Accessory Glands 1. Seminal vesicles: They are paired structures, or pouches situated posterior to the bladder. a. 5cm long and pyramid-shaped b. Secrete a viscous fluid, becomes part of the ejaculated. c. Contribute to nutrition and activation of sperms. Keep sperms alive and motile. 2. Prostate Gland: It is located below the bladder surrounds the urethra at the base of the bladder between the rectum and the symphysis pubis. a. 4cm long, 3 cm wide and 2 cm deep. b. Composed of columnar epithelium, a muscular layer and enclosed in a firm outer fibrous layer/capsule. c. Connected to urethra and ejaculatory ducts. d. Secrets a thin, lubricating milky fluid which enters the urethra, just below the prostate glands; secrete small amount of lubricating fluid. 3. Cowpers glands: Located on each side of the urethra, just below the prostate gland, secrete small amount of lubricating fluid.

Reproductive concerns: a. Infertility: inability to conceive after 1 year of unguarded, appropriately timed coitus. b. The subinfertility is the inability to achieve a pregnancy after one year of unprotected intercourse. c. The male must produce adequate quantity of mature, motile sperm, capable of surviving the hostile environment and the arduous trip to reach the egg cell. d. Male factor account for 35% to 40% pf infertility.

Special Concerns 1. Benign Prostatic Hypertrophy (BPH) a. Mild to moderate prostatic enlargement causing urethral compression resulting to urinary retention. b. Most common problem of the male reproductive system occurring in 50% of men over age 50, and 75% of men over age of 75 c. Early sign: decreased force and amount caliber of urinary stream. d. Diagnosis: elevated prostate-specific antigen (PSA) normal less than 4ng/ml Prostatic Cancer: a. Usually an adenocarcinoma (growth related to the presence of androgens) b. Cause: unknown c. Spreads from prostate to the seminal vesicles, urethral mucosa, bladder wall, external sphincter, and lymphatic systems. d. Diagnosis: elevated acid phosphatase (distant metastasis) and alkaline phosphatase (bone metastasis) Semen Analysis: Procedure: 1. Abstain form coitus/ejaculation for 2 to 3 days or at least 48 hours before collecting specimen. 2. Collect entire specimen/ejaculate obtained through masturbation in a clear/ dry container. 3. Keep the specimen at body temperature. 4. Deliver to the laboratory with in 30 to 45 mins or up to 60 mins. 5. Test may be repeated after 2-4 weeks because of the variability specimens; 2-3 specimens may be required over several months because spermatogenesis takes 2.5 months. Normal findings: 1. Volume 2-6 ml; pH: 7-8 2. Viscosity: liquefy within 30 minutes (20-30 minutes) 3. Sperm count: more than 20 millions/ml 4. Morphology: more than 50% mature and normal 5. Motility: more than 40% (or 50%) moving 6. Leucocytes: fewer than 1 million/ml

Factors to consider when cause of low sperm count seems idiopathic 1. Activities that increase scrotal heat: frequent hot tub use, frequent sauna, long periods of sitting (e.g. at a desk, car, bike) 2. Clothing that increase scrotal heat, tight-fitting clothing 3. Drug/ marijuana use and alcohol 4. Frequency of ejaculation 5. Sons of mother who took diethylstilbestrol (DES) while pregnant 6. Trauma/ surgery to the testes

FEMALE REPRODUCTIVE SYSTEM EXTERNAL GENITALIA:

1.

THE VULVA: the external genitalia a. Mons Veneris/ Mons Pubis: soft, rounded, fatty pad over the symphysis pubis i. Grows coarse hair after puberty that thins after menopause ii. Function: protects the symphysis pubis

b. The Labia Majora: known as the bigger lips i. Two folds of the skin with sparse hair on either side at the vaginal opening ii. With fat iii. Contains the bartholins glands iv. Function: protects the labia minora and vaginal os

c. Labia Minora: two thinner folds of delicate tissue within the labia majora, hairless

i. Anterior ends unite to form the prepuce ii. Posterior ends unite to form the fourchette iii. Function: protects and obscures the vestibule, urinary meatus and vaginal os

d. Glans Clitoris: a small body of highly erogenous and sensitive tissue protected by prepuce i. Measures less than 1 cm in width and 2 cm in length ii. Sensitive to touch, pressure and temperature iii. Secretes smegma iv. Primary site of sexual arousal, excitement, and orgasm. v. Primary significance in obstetrics: serves as guide to female catheterization vi. Site of Syphilitic chancre (in young women) and Leukoplakia (in mature women)

e. Openings of the Bartholins glands or Vulvoginal glands i. Two small, palpable glands situated between the vestibule on wither side of the vaginal orifice ii. Secrete alkaline mucus during coitus which makes vagina less acidic and more alkaline; thus secretion favors motility and viability of sperms particularly the Androsperms (carriers of the Ysex chromosomes), which die in acidic environment. iii. Site of cysts (Bartholins cyst), infection (Bartholinitis) and abscess formation (Bartholins abscess)

f. Openings of the skenes ducts or paraurethral glands: 2 small, palpable glands that open onto the posterior urethral wall. i. Common site of gonococci infection and other sexually transmitted diseases. ii. Function: secretes mucus to lubricate the vestibule

g. Urinary meatus: external opening of the urethra; the shortness of the urethra predisposes the female to recurrent urinary tract infection.

h. Hymen: thin mucus membrane i. Can be stretched or torn during physical activity, tampon insertion, vaginal examination or sexual intercourse. ii. Myrtiformes Caruncles are remnants of the hymen after childbirth iii. Imperforate hymen: congenital absence of the normal opening of the hymen which can be treated by surgical perforation iv. Function: protects the opening of the vagina; separates internal from external reproductive system

i. Perineum: is the area between the vagina and rectum which consists of fibromuscular tissue. Most of the support of the perineum is provided by: i. Pelvic diaphragms: this consist of the Levator ani muscles plus the coccygeous muscle posteriorly ii. Urogenital diaphragms: the urogenital diaphragm is compromised of the deep transverse perineal muscles, the constrictor of the urethra and the internal and external fascial coverings.

INTERNAL GENITALIA
A.

VAGINA: vascular, tubular, musculomembranous structure that extends from the vulva to the uterus between the urinary bladder (anteriorly) and rectum (posteriorly).

a. Length: 3-4 inches Posterior wall: 10 cm long Anterior wall: 7.5 cm long because the cervix projects at the right angle into its upper part

b. Vault: the term for the upper end of the vagina i. Where the cervix projects into the vagina, the vault forms a circular recess described as four arches or fornices. ii. The posterior vaginal fornix is the largest fornix because the vagina is attached to the uterus at a higher level at the back than in front. iii. The anterior vaginal fornix lies in front of the cervix; the lateral fornices lie on wither side

c. Vaginal layers i. The inner lining is made of squamous epithelium. Beneath the epithelium lies a layer of vascular connective tissue. ii. The middle muscular layer is divided into: weak inner coat and strong outer coat of longitudinal fibers iii. The pelvis fascia surrounds the vagina forming a layer of connective tissue.

d. Rugae: transverse ridges of mucus membranes lining the vagina which allow it to stretch during sexual intercourse and childbirth.

e.

Vaginal reaction: acidic with pH 4-6 due to the presence of lactic acid formed by action of Lactobacilli (Dderlein's bacilli) on glycogen found in the squamous epithelium of the lining. These are normal inhabitants of the vagina that cause vaginal acidity to protect against pathologic bacteria

f. Functions i. Female organ of copulation ii. Excretory canal of the uterus through which uterine secretions and menstrual flow escape iii. Soft birth canal during labor

B.

UTERUS: hollow muscular, pear-shaped organ, covered partially by peritoneum or serosa. It lies between the base of the bladder anteriorly, and rectum posteriorly. It is 7.5 cm long, 5 cm wide, 2.5 cm in depth, and with each wall 1.25 cm thick. The lower third of the uterus is the cervix and measures 2.5 cm.

a. Uterine length i. Before puberty: from 2.5-3.5 cm ii. In adult nulliparous women: from 6-8 cm iii. In multiparous women: from 9-10 cm

b. Uterine weight i. Non-pregnant women: 60g ii. Pregnant, term: 1000g

c. Uterine parts i. Fundus: convex upper part between the positions of the fallopian tubes; the most contractile portion of the uterus during labor. ii. Corpus or body: upper, larger and triangular portion. iii. Cornua: the portion or point from where the oviducts or fallopian tubes emerge. iv. Isthmus: constricted area immediately above the cervix; the lower uterine segment; distends during pregnancy. v. Cervix: lower, smaller, cylindrical portion with internal os, cervical canal and external os.

d. 3 uterine layers i. Endometrium: the inner mucosal layer which undergoes constant changes in response to estrogen (proliferative phase) and

progesterone (secretory phase) during the menstrual cycle; during pregnancy, it becomes highly specialized and is termed, decidua. ii. Myometrium: is the middle muscular layer which serves as the living ligatures that control bleeding during the third stage of labor; responds to oxytoxic drugs. iii. Perimetrium: is the outer serosal layer formed by the peritoneum. It is continuous with the broad ligament son the sides of the uterus.

e. Position: the uterus is a partially mobile organ. As the body moves, it freely moves along the antero-posterior plane. i. When a non-pregnant woman stands erect, the uterus lies in an almost horizontal position. ii. It leans forward in a position known as, anteversion iii. It leans forward on itself with the fundus resting on the bladder known as, anteflexion iv. The normal anteversion and anteflexion of the uterus prevents uterine prolapsed. v. Abnormalities in uterine position a. Retroflexion: the bending back of the body/corpus of the uterus toward the cervix, resulting in a sharp angle at the point of bending b. Retroversion: the turning backward of the entire uterus in relation to the pelvic area

f. Uterine ligaments: the uterus is supported by the pelvic floor and maintained in position by several ligaments.

g. Uterine function: i. Broad ligaments: extend from the lateral margins of the uterus to the pelvic walls, thereby dividing the pelvic cavity into anterior and posterior compartments. The transverse cervical ligament, on the other hand, may cause the uterus to sag downwards when damaged.

ii. Round ligaments: arise from the cornua of the uterus, infront and below the insertion of each fallopian tubes. It passes in between the broad ligament and is inserted in each labia majora. The round ligaments have little value as a support but it helps the broad ligament keep the uterus in place, and also tend to maintain the anteverted position of the uterus. iii. Ovarian ligaments: arise from the cornua of the uterus but behind the uterine tubes. It passes down between the folds of the broad ligament to the ovaries. iv. Cardinal ligaments: the chief uterine supports. These ligaments fan out from the sides of the cervix to the side walls of the true pelvis. They are also called transverse cervical ligaments or Mackenrodts ligaments. v. Utero-sacral ligaments: pass backwards from the cervix to the sacrum and provide support for the uterus and cervix at the level of the ischial spines. vi. Pubocervical ligaments: pass forward from the cervix, under the bladder to the pubic bones.

h. Blood supply: derived principally from the two uterine and ovarian arteries. The uterine artery arises at the level of the cervix and is a branch of the internal iliac artery. The ovarian artery is a branch of the abdominal aorta, which supplies both the ovary and fallopian tubes before joining the uterine artery. The uterine blood supply is increased in pregnancy and decreased in puerperium.

i. Lymphatic drainage: abundant

j. Nerve supply: The pelvic autonomic system is the main nerve supply of the uterus, which consists of sympathetic (as the principal nerve supply) and parasympathetic nervous system.

C.

FALLOPIAN TUBES or OVIDUCTS: two muscular canals/tubes.

a. Length: 8-14 cm (average 10 cm) extending from the uterine cornua to a site near the ovaries, enveloped in the upper fold of the broad ligament.

b. They are covered by peritoneal folds that drape down below as broad ligaments and extend at the sides to form the infundibulopelvic ligaments.

c. The lumen is lined by ciliated mucus membrane called, ciliated cubical epithelium, which produces a current of lymph that facilitates movement of the ovum along the tube.

d. Tubal musculature: constantly contracts rhythmically at a rate that varies with hormonal changes of the ovarian cycles.

e. Tubal parts: i. The interstitium: a portion embodied within the uterine muscular wall, with a length of 1.25 cm and a lumen diameter of 1mm. ii. The isthmus: a narrow portion immediately after the uterus which extends to a length of 2.5 cm. iii. The ampulla: the passage widest portion with a length of 5 cm. it is the site of fertilization (conception) iv. The infundibulum: a funnel-shaped passage with fringed ends composed of fimbriae. The fimbria ovarica/ ovarian fimbria is an elongated fimbria that is connected to the ovary.

f. Tubal function i. Site of normal fertilization, most commonly in the ampullary portion. ii. Ducts through which an ova travels from the ovaries to the uterus.

g. Blood supply: uterine and ovarian arteries and drains

h. Lymphatic drainage: to the lumbar glands

i. Nerve supply: from the ovarian plexus

D.

OVARIES: two almond-shaped organs a. Size: 2.5-5 cm in length, i.5-3 breadth, .6-1.5 cm thick b. Weight: 6-10 g each c. Location: situated in the uppermost portion of the pelvic cavity, attached to the posterior surface or back of the broad ligament within the peritoneal cavity. d. Covering: single layer of cuboidal epithelial cells called, germinal epithelium. No peritoneal covering for the ovaries. e. Surface: smooth and dull-white in color through which glisten several small follicles. It is more corrugated and markedly convoluted in older women. i. Advantage of no covering: assists the mature ovum to erupt ii. Disadvantage of no covering: easier spreading of malignant cells from cancer of the ovaries f. Ovarian layers: i. Tunica Albuginea: dense and dull-white protective layer ii. Cortex: outer main functioning part a. Contains the ovarian follicles in different stages of development; ova, graafian follicles, corpora lutea, degenerated corpora lutea (corpora albicantia), and degenerated follicles held together by ovarian stroma. b. There are about 200,000 primordial follicles in the ovarian cortex at birth.

iii. Medulla: inner central part a. Completely surrounded by cortex

b. Composed of loose connective tissues and contain nerves, blood vessels and lymphatic vessels. The hilum where these vessels enter lies just where the ovary is attached to the broad ligament, called the mesovarium. The sympathetic and parasympathetic nerves follow the ovarian artery across the infundibulo-pelvic ligament to reach the ovary. The ovaries are insensitive unless they are distended and squeezed. Mittelschmerz: mid-cyclic pain caused by irritation of the peritoneum by blood or fluid escaping along with the released ovum during ovulation.

g. Ovarian functions i. Oogenesis It is the process of developing a mature ovum in the Graafian follicle. When the primordial follicles mature and become cystic, they are termed as Graafian follicle. The Ovum is situated at the end of a graafian follicle, encircled by a narrow perivitelline space. The ovum is surrounded by clump of cells called Discus Proligerus, which radiates outward to form the Corona Radiata. The very clear cells of the corona radiata are referred to as Zona Pellucida. The whole follicle is lined with Granulosa cells and contains follicular fluid. The outer coat of the follicle is the external limiting membrane. Around this lies the Theca, an area of compressed ovarian stroma. ii. Ovulation: monthly expulsion of a mature ovum from the graafian follicle into the pelvic cavity iii. Endocrine function: secretion of female hormones, estrogen and progesterone. Maturing follicles secrete estrogen, while corpus luteum secretes estrogen and primarily progesterone. Ovaries are the primary source of estrogen, while adrenal cortex serves are an extrglandular site of production. a. Estrogen: develops female secondary sex characteristics b. Progesterone: hormone of pregnancy. Its effects on the decidua allow pregnancy maintenance.

h. Blood supply: blood flows through the ovarian arteries and veins. The right ovarian vein joins the inferior vena cava, but the left return blood to the left renal vein.

i. Lymphatic drainage: to the lumbar glands

j. Nerve supply: from the ovarian plexus

E. ACCESSORY ORGANS The Mammary glands (breasts) A. Location: under the skin, over the Pectoralis Major muscles

B. Composition: fibrous, adipose and glandular tissues. Glandular tissues are arranged in about 15-25 lobes. a. Each lobe is made up of several lobules, which in turn are made up of a large bumber of alveoli with: i. Secreting cells (acinar cells) which produce milk; and ii. Excretory ducts which lead from each lobe to opening in the nipple composed of erectile tissue and muscle fibers which have a sphincter-like action in controlling flow of milk, the smooth muscle of the nipple causes erection of the nipple on contraction. b. The areola: pigmented area of skin surrounding the nipple.

C. Size: varies depending on the amount of adipose tissue rather than on the amount of glandular tissue. The breasts increase in size at puberty due to stimulation by female hormone estrogen. The size of the breast is not a significant factor in successful breast feeding.

D. Function: lactation or milk secretion for nourishment and maternal antibodies (IgA): source of pleasurable sexual sensation.

E. The arterial, venous, and lymphatic communicate medially with the internal mammary vessels and laterally with the axillary vessels. In cancer of the breast, metastasis follows the vascular supply both medially and laterally.

F. Maternal reflexes in breast feeding: a. Prolaction reflex (milk secretion reflex): high prolactin level stimulates the alveoli, particularly the acini cells. Milk are then stored in the breast tubules. i. High levels of estrogen and progesterone induce alveolar and duct growth as well as stimulating milk secretion. ii. In pregnancy, milk secretion is not stimulated because of low prolaction, as a result of high estrogen secretion by the placenta.

b. Letdown reflex (draught reflex): is oxytocin induced; the act of sucking a lactating breast stimulates the flow of milk. This freeflowing of milk is called letdown reflexes. It is also affected by maternal emotions. c. Milk ejection reflex: controls the expulsion of milk from the breast tubules. It is also under the influence of oxytocin secreted by the posterior pituitary gland (PPG).

Cancer of Breast It is often signaled by a change in skin texture, puckering, dimpling, nipple discharge, or a lump.

Best surviving tips: i. ii. Early detection by monthly Self-Breast Examination (BSE) Mammography and Ultrasonography

Reproductive concern: Female Infertility

A. The single most important factor in female infertility is aging. With increasing age, there is increased risk of spontaneous abortion, increased incidence of pelvic or tubal problems, and decreased fertility due to endocrine changes that begin 10 to 15 years before menopause. Couples over 35 years old should seek help if conception has not occurred within 6 months. B. Other cause of female infertility: failure to ovulate(40%), tubal or pelvic problems(40%), and unexplained/ unusual problems(20%) C. Infertility may be primary (no conception ever) or secondary (there has been a pregnancy, irregardless of the outcome) D. Evaluation of the female infertility: i. Post-coital test: evaluates cervical mucus to determine ability of sperms to travel within it. Preparation/teaching: Abstinence from coitus for 48 hours; coitus timed within 24 to 48 hours of ovulation. b. Cervical specimen obtained 2 to 8 hours after coitus. c. Normal findings: 5 to 10 morphologically normal sperm with linear motility in thin, clear, copious, acellular mucus with spinnbarkeit more than 8cm. Ultrasonography: use of sound waves to evaluate pelvic structures and monitor ovulation by identification of follicles and release of ova; may be abdominal or vaginal. Hysterosalpingography/hysterogram: an x-ray of the uterus and the fallopian tube done 2 to 5 days after menses or first 10 days of the cycle. a. Involves instillation of a radiopaque substance into the uterine cavity which fills the uterus, and the fallopian tubes, and spills into the peritoneal cavity. Safety alert: assess allergy to iodine, history of PID, pelvic mass. b. Positive effect: Pregnancy is frequently achieved within the first 3 cycles following the test due to flushing of tubal debris, breaking of adhesions and induction of peristalsis by the instillation of dye. A moderate discomfort/pain is referred from the peritoneum to the shoulder. a.

ii. iii.

iv. Laparoscopy: uses an endoscope to view the pelvic organs, usually done under general anesthesia. It may be abdominal or vaginal. a. The peritoneal cavity is distended with carbon dioxide gas, and pelvic organs are directly visualized. b. Woman may have discomfort/pain from organ displacement, and referred shoulders and chest pain caused by gas in the abdomen. c. May also be used to retrieve eggs for reproductive technology.

d. Usually done 6 to 8 months after hysterogram, when no other causes of infertility are found. Visualization is best when the procedure is done in early follicular stage of the cycle.

I.

THE MENSTRUAL CYCLE MENSTRUAL CYCLE Series of rhythmic reproductive cycle A. From the onset of menstrual bleeding to the day before the next bleeding day. The first day of the cycle is the day on which menstruation begins. B. Characterized by changes in the ovaries and uterus

C.

Influenced by normal hormonal variation mediated by hypothalamus and anterior pituitary gland (APG) via feedback mechanism (negative feedback) Recurring cyclically beginning at puberty with the first menstruation called menarche and ceasing at menopause

D.

E. Duration varies and is highly individualized but the average cycle/mean cycle length is 28 days; normal range is 25 to 35 days per cycles; can be as short at 21 days or as long as 40 days. Only one interval is fairly constant (almost always 14 or 15 days): the time from ovulation to the beginning of menses (Marieb, 2002). F. Function of the cycle: preparation for the release of egg, fertilization and implantation

II.
A.

MENSTRUAL CYCLE HORMONAL CONTROL HYPOTHALAMIC HORMONES: secrete gonadotrophin-releasing (GnRF) or inhibiting factors (GnIF) that stimulate the pituitary gland to secrete or inhibit the secretion of corresponding gonadotrophins (Gn) ANTERIORPITUTARY (APG) HORMONES: Gonadotrophins (Gn) follicle stimulating hormone (FSH) and luteinizing hormone (LH)

B.

1. Follicle-stimulating Hormone (FSH)

a.

Secreted by the APG in response to the stimulation of the hypothalamic follicle stimulating hormone releasing hormone releasing factor (FSHRF) triggered by low blood levels of estrogen during the first half of the menstrual cycle. Estrogen is at its lowest by days 4 to 5 of the menstrual cycle.

b. Stimulates the development of primordial follicles (immature follicles) into Graafian follicle (mature follicles); FSH stimulates follicle cells to secrete estrogen

2. Luteinizing Hormone (LH) a. Also called interstitial-cell stimulating hormone b. Secreted by the APG in response to the stimulation of hypothalamic luteinizing hormone releasing factor (LHRF) triggered by low blood levels of progesterone c. Progesterone is lowest on the 13th day of the menstrual cycle.
d.

Because progesterone is responsible for rise in basal body temperature (BBT), the slight rise in BBT (day 14) that is preceded by a drop (day 13) is considered a significant sign of ovulation in the regular 28 day cycle.

C. OVARIAN HORMONES: ESTROGEN AND PROGESTERONE 1. Estrogen a. Secreted by the ovaries, adrenal cortex; secreted by placenta in pregnancy
b.

Responsible for the development of secondary sex characteristics and assists in maturation of ovarian follicles

c. Inhibits secretion of FSH (negative feedback) and stimulates secretion of LH (positive feedback)
d.

Responsible for the proliferative phase of the menstrual cycle Responsible for fertile cervical mucus Thin, clear, colorless

e.

 Stringy, stretchable Slippery, lubricative Produces fern-pattern when dry (positive ferning test) f. In pregnancy: increases vascularity, maintains the highly specialized endometrium called decidua, stimulates uterine muscles contraction, causes fatigue, and antagonizes insulin.

2. Progesterone
a.

Secreted by corpus luteum in non-pregnant state and in early part of pregnancy; secreted by the placenta as early as sixth week of pregnancy until parturition

b. Inhibits secretion of LH (negative feedback) c. Helps maintain the endometrium by facilitating secretory phase of the mentrual cycle - preparation for implantation, also called nidation d. Relaxes smooth muscles including the myometrial muscle of the uterus: Progesterone is the hormone that maintains pregnancy by maintaining decidua. A drop in progesterone in early pregnancy may lend to abortion. A drop in progesterone in late pregnancy before term may lead to premature labor. Progesterone drop at term is one of the theories of labor onset when smooth muscle relaxant progesterone drops at term, uterine muscles are easily stimulated to contract due to rising stimulants late in pregnancy particularly oxytocin and prostaglandin. e. Thermogenic - increases basal body temperature

f.

Has water retaining, antidiuretic action

g. Increases fibrinogen level, thus increases blood coagulability h. Decreases hemoglobin and hematocrit levels i. Responsible for infertile cervical mucus: Thick opaque Sticky, non-stretchable Produces non-fern-pattern when dry (negative ferning test) In pregnancy: maintains pregnancy, relaxes the uterus, and together with estrogen, human placental lactogen (HPL) and cortisol, antagonizes insulin

j.

D.

PROSTAGLANDIN: fatty acids recognized as hormone secreted by a lot of body organs including the endometrium of the uterus 1. Affects menstrual cycle 2. Stimulates uterine muscles to contract

III.
A.

MENSTRUAL CYCLE STAGES/PHASES MENSTRUAL PHASE or menstruation/BLEEDING PRASE (day 1 to 4) may last for 3 to 5 days; the terminal phase of the menstrual cycle 1. Characterized by vaginal bleeding as the uterine endometrium is shed down to the basal layer along with blood from the capillaries and with the unfertilized ovum. 2. Menstruation is periodic discharge of blood, mucus and cellular debris from the uterine mucosa and occurs at regular, cyclic and predictable intervals from menarche to menopause. 3. The menstrual period is the woman's period of absolute infertility. 4. Menarche is the first menstruation; occurs between 12 to 13 years; usually anovulatory, infertile, irregular.

5. Duration of menstruation: variable with usual duration of 3 to 5 days or up to 4 to 6 days. 6. Amount: 25 to 60 mL equivalent to about 0.4-1.0 mg of iron loss for every day of the: cycle.
7.

Menstrual blood is incoagulable because the blood, coagulated as it is shed, is promptly liquefied by fibrinolytic activity.

B.

FOLLICULAR or PROLIFERATIVE PHASE (days 5 to 14 ending in ovulation; lasts about 9 days). 1. Regenerative Phase is the first few days of the reformation or the endometrium. 2. Under the control of ESTROGEN (principally ESTRADIOL there is regrowth and thickening/proliferation of the endometrium up to 8 to10 fold. Proliferative changes level off at ovulation. 3. At the completion of the proliferative phase, the endometrium consists of three lavers:
a.

Basal layer: 1 mm thick, lowest most layer lying immediately above the myometrium; contains all the necessary rudimentary structures for building up new endometrium; never alters during the menstrual cycle Functional layer: 2.5 mm thick; middle layer, contains' tubular glands; constantly CHANGES according to the hormonal influences of the ovary Cuboidal ciliated epithelium layer: upper most layer; covers the functional layer; dips down to line the tubular glands Ovulation: present in the middle of the cycle: monthly growth and release of a mature, non - fertilized ovum from the ovary

b.

c.

 Usually happens in the middle of the menstrual cycle; 13 to 15 days or an average of 14 days prior to the next menstruation in regular cycles. Estrogen is high while progesterone is low Ovulation signs Breast tenderness Slight rise in BBT (0.3 to O.5C or 0.4 to (1.8F) during ovulation which is preceded by a slight drop (0.2F) 24 to 36 hour before. The most fertile time is 3 to 4 days before ovulation and 1 to 2 days after (Littleton & Engebretson, 2006). Positive Spinnbarkeit test (with stretchable mucus) Mirrelschrnerz (left or right lower quadrant pain corresponding to the rupture of the Graafian follicle)

Positive Ferning test Estimating Ovulation Time: Substract 14 days from the menstrual cycle length:
a.

4.

In a 28-day cycle, ovulation occurs on the 14th day counting from the first day of bleeding. In a 30-day cycle, ovulation occurs on the 16th day counting from the first day of bleeding.

b.

c. The period when the woman is most fertile is during ovulation time, the period of absolute fertility.
d.

In a 28-day cycle, periods of fertility is from 9 to 17 days and in a 30-day cycle, periods of fertility is from 11 to 19 days, during these periods, pregnancy, is likely to occur if the woman engages in unguarded coitus.

C.

LUTEAL or SECRETORY PHASE (15 to 28 days; lasts about 12 days)

1. Initiated by ovulation in response to a surge in LH that promotes the development of corpus luteum from the ruptured follicle, the yellow body that secretes high levels of progesterone and estrogen. 2. Progesterone stimulates the already proliferated endometrium causing the functional layer to become thicker (3.5 mm thick), more spongy, softer with glands becoming more tortuous as the endometrial capillaries get distended with blood in preparation for reception/implantation and nourishment of the fertilized ovum.
a.

If fertilization occurs, implantation follows 6 to 9 days or 7 to 10 days (average on 7 days) after fertilization. The corpus luteum lives longer and secretes progesterone and estrogen in early pregnancy later replaced by placenta

b. The usual life span of the corpus luteum is two weeks or 10 to 14 days.
c.

If fertilization does not occur, the yellow body corpus luteum functions only for about 7 to 8 days after ovulation then involutes to become a white body, the corpus albicans which persists up to 10 to 12 days after ovulation. This causes a drop in levels of estrogen and progesterone causing endometrial ischemic or premenstrual phase.

IV.

SPECIAL CONCERNS: MENSTRUAL PROBLEMS/DISORDERS

A. PREMENSTRUAL SYNDROME ("PMS" Syndrome) 1. 2. Complex physical signs and behavioral symptoms that occur during the second half of the menstrual cycle and that resolve with the onset of menses PMS SYMPTOMS (Chihal, 1982; Pariser et al.. 1985) a. Neurologic: migrane, vertigo, syncope b. Psychologic: lethargy. Irritability, depression, sleep disorders, tearfulness/crying spell, anxiety, hostility

c. Respiratory: asthma, coryza, hoarseness d. Gastrointestinal: nausea, vomiting, constipation, bloating, craving for sweets and salary foods e. Mammary: swelling, breast fullness and tenderness f. Urinary: oliguria, retention g. Dermatologic: acne 3. Nursing Counseling a. Diet Restrict food rich in sugar and salt Restrict food containing methylxanthines like chocolate and coffee Increased intake of complex carbohydrates and protein Increased frequency of meals Supplementation with B complex, particularly Vitamin B6. Magnesium zinc (Abraham, 1982; Schaumburg, 1984), Vitamin E supplementation to decrease for cravings b. Activity: aerobic exercises (fast walking jagging, dancing) c. Rest periods balanced with exercise
d.

Drug treatment as prescribed.

B.

AMENORRHEA: absence of menstruation

1.

Primary Amenorrhea: menarche has never occurred a. In order to diagnostic primary amenorrhea, it must first be ascertained that the client: has passed the age at which menarche normally occurs has not entered puberty by the expected time has undergone complete pubertal development without the onset of menses. b. Related to thyroid gland abnormalities, typically, hyperthyroidism may be first suspected when delayed sexual maturation and amenorrhea occur, even in the absence of other signs and symptoms.

c.

May also be due to other endocrine dysfunction or problems of the hypothalamus, pituitary gland, ovaries, and uterus; chronic illnesses associated with malnutrition or tissue hypoxygenation (DM, cystic fibrosis, inflamamatorv bowel disease, cyanotic congenital heart defect)

2.

Secondary Amenorrhea: cessation of menses for more than 3 months after regular menstrual cycles have been established

Assess first the last menstrual period. PREGNANCY is the most frequent cause of secondary amenorrhea so the first diagnosis to be considered is pregnancy. Also related to stress, malnutrition (anorexia nervosa is a factor to both primary and secondary amenorrhea), obesity and hormonal imbalance due to problems of ovarian, pituitary, thyroid or adrenal origin.

C.

DYSMENORRHEA: painful menstruation; usually corresponds to the secretory phase of the endometrium indicating that ovulation has occurred; absent when ovulation is suppressed (Kain & Hall, 2000) 1. Primary Dysmenorrhea: occurs in the absence of any underlying anatomic abnormality a. Found in those with higher prostaglandins (produced by endometrium) Symptomatic relief occurs when prostaglandin synthetase inhibitors are administered prior to a menstrual period or with the onset of menses. b. Also related to acute uterine anteflexion, retroflexion, and cervical stenosis c. Psychologic factors: has long been erroneously considered to be emotional in origin
d.

Treatment: 1) rest, heat application, 2) distraction, exercise, 3) hormonal therapy (Oral Contraceptive Pills), 4) non-steroidal anti-

inflammatory medication. and 5) analgesic especially prostaglandin inhibitors (Ibuprofen)

2.

Secondary Dysmenorrhea: occurs when there is an underlying structural abnormality of the cervix or uterus (malpositions), presence of a foreign body (lUD), Pelvic inflammatory disease (PID), endometriosis, or endometritis.

D.

METRORRHAGIA: abnormal bleeding between menses/periods or intercyclic bleeding 1. May be related to PID, uterine fibroids, corpus carcinoma, erosion, and cancer of the cervix.

E.

MENOMETRORRHAGIA: excessive or prolonged menstrual bleeding which may lead to or cause hypovolemia and anemia
1.

Excessive menstrual bleeding is most often secondary to anovulatory cycles that normally occur in the first year postmenarche. a. Without ovulation, the effect of estrogen on the endometrium is unopposed by progesterone, resulting in continued endometrial proliferation or eventual massive shedding; this could be dysfunctional uterine bleeding (DUB)
b.

Treatment of DUB is indicated only when blood loss is significant.

2. May be related to infection (PID), IUD use, uterine tumors, endocrine problems (endocrinopathies), complications of medications (anticoagulants, aspirin), blood dyscrasias (thrombocytopenia), pregnancy, spontaneous abortion, ectopic pregnancy, and endometriosis.
3.

Congenital coagulopathy Von Willebrand disease should be considered in an adolescent whose first menstrual period is excessive and with a finding of prolonged bleeding time. A characteristic of the disease is that it is a defect in plateler adhesiveness and lower than normal levels of factor VIII.

F.

MENORRHAGIA: excessive, profuse menstrual flow; may be caused by hormonal imbalance, infection, uterine tumors OLIGOMENORRHEA: infrequent menses

G.

H. I. J.

POLYMENORRHEA: too frequent menses HYPOMENORRHEA: abnormally short menstrual cycle HYPERMENORRHEA: abnormally long menstrual cycle NURSING IMPLEMENTATION: MENSTRUAL ABNORMALITIES/DISORDER

V.

A. Prompt referral for evaluation and diagnosis if with: 1. Excessive menstrual flow, intermenstrual or post-menopausal bleeding 2. Absence of menarche at age 17 3. Severe pre-menstrual tension syndrome (PMS) - anxiety, depression, irritahility, headache, nausea, abdominal bloating B. Promote relief of discomfort of dysmenorrheal 1. Rest 2. Mild sedatives 3. Leg lifts 4. External heat to lower abdomen 5. Hot drinks 6. Treatment as ordered: antiemetics and prostaglandin inhibitors C. Psychological support: initial-encourage verbalization of fears, anxieties, problems and related concerns; provide and protect privacy. VI.
A.

MENOPAUSE DESCRIPTION: transitional phase for women marking the end of their reproductive abilities. Menopause is to the climacteric as menarche is to puberty (Olds et aI., 1988).

1. Change of life or climacteric period 2. Occurs between 45 to 50 years in 50% of women; can be from 35 to 60 years with an average of 53 years; not completed until 2 years since the last period. 3. Ovulation ceases 1 to 2 years prior to menopause with individual variation. B. CHARACTERISTICS
1.

Gradual cessation of menstruation: first menstruation becomes irregular and then it ceases altogether

2. Presence of physical symptoms due to a drop in estrogen: a. Hot flashes: A cluster of symptoms due to vasomotor disturbances related to hormonal changes and cessation of menses Characterized by heat arising on the chest and spreading to the neck and face (caused by vasodilation), sweating, occasional chills , dizzy spells, palpitations, weakness. b. Emotional changes as mood swings or emotional lability c. Sleep disturbances
d.

Tendency to obesity not because of a change in adipose deposits but rather due to increased caloric intake

e. Sexual drive may not be diminished; sexual activity and interest may improve as the need for contraception disappears. f. Atrophic changes in the vaginal vulva and urethra and in the trigonal area of the bladder The vaginal atrophy may result in discomfort during intercourse- dyspareunia - but may be overcome with a lubricating gel or saliva, the most common vaginal lubricant.

g. The breasts become pendulous and decrease in size and firmness.

h. Long-range physical changes may include osteoporosis associated with: low estrogen and androgen levels lack of physical exercise low dietary intake of calcium. Treatment: For relief of symptoms of menopause. treatments include: a. Estrogen replacement if there is no history of cancer in the family although this treatrr.ent is controversial

3.

Short-term, low dose estrogenic therapy for troublesome vasomotor disturbances (hot flashes) Sustained high-dose estrogen therapy has been reported to predispose women to reproductive tract cancer. Hormonal vagina creams/Lubricants (K-Y jelly) for painful coitus or dyspareunia

b. Vitamins B complex and E hot flashes and other symptoms c. Increased calcium and phosphorus intake for osteoporosis prevention d. Support system to provide emotional support

I.

FERTILIZATION AND FETAL DEVELOPMENT FERTILIZATION A. Fertilization is the union of mature egg cell (ovum) and sperm cell happening in the ampulla (outer third) of the fallopian tube resulting in a fertilized ovum known as the zygote. B. It is also termed conception, fecundation, and impregnation. C. The movement of the sperms caused by flagellar action is believed to maintain the sperms in suspension and to facilitate transport.

D. Each sperm reaches the site of fertilization in the ampulla of the fallopian tube shortly after ejaculation, often only within 5 minutes, but on average, a time of 4 to 6 hours seems more reasonable.
E.

Sperms must be in the genital tract 4 to 6 hours before they are able to fertilize an egg. It is during this period when the enzyme needed to dissolve the cement substance (hyaluronic acid that holds together the cells covering the ovum is activated. This enzyme is called hyaluronidase.

F. The sperm must undergo 2 processes before fertilization:

1.

Sperm Capacitation: the process by which the sperm become hyper mobile and there is a breakdown of the plasma membrane and exposes the acrosomal membrane/covering of the sperm head allowing the sperm to bind with the zona pellucid of the ovum (Speroff et al., 1999). Acrosomal Reaction: follows capacitation; the acrosomal covering of the head of the sperm contains hyaluronidase. So as millions of sperms surrounds the ovum, they deposit minute amounts of hyaluronidase in the corona radiata, the outer layer of the ovum, which allows the sperm head to penetrate the ovum (Olds et al., 1985).

2.

G.

As soon as the sperm penetrates the zona pellucid and makes contact with the vitelline membrane of the ovum, a cellular change occurs in the (ovum that inhibits other sperms to penetrate, This cellular change is mediated by release of materials from the cortical granules, organelles found just below the egg surface (Class, 1984) Fertilization occurs when the male pronucleus unites with the female pronucleus, thus the chromosome diploid number 46 is restored and a new cell the zygote is created with a new combination of genetic material which creates unique individual different from the parents and anyone else CLEAVAGE/MITOSIS

H.

II.
A.

ZYsGOTE: the cell that results from fertilization of the ovum by a spermatozoan. This cell undergoes mitosis which is the process of cell replication where each chromosome splits longitudinally to form a double-stranded structure. CLEAVAGE: series of mitotic cell division by the zygote

B.

C.

BLASTOMERES: daughter .cells arising from the mitotic cell division. of the zygote (2-cell, 4-cell, B-cell blastomeres) MORULA: solid ball of cells produced by 16 or so blastomeres; called the 'travelling' form because it is in this form when it migrates through the fallopian tube (oviduct) and reaches the uterine cavity about 3 to 4 days after ovulation (Cunningham, MacDonald & Gant, 1989) BLASTOCYST: a fluid-filled cavity that reaches the uterine cavity Over the next 3 to 4 days of development, a differentiation of cells as to their specific potencies occurs, the reorganization of the morula follows forming a blastocyst, this is the Stage when there is already a cavity in the morula called the blastocoele, and when it enters the uterine cavity. The cavity enlarges and pushes the morula cells into an outer layer of cells called the trophoblast, Along with this is an inner cell mass attached to one side of the blastocyst. The divisions and the reorganization have already consumed energy stores available in the zygote, such that it becomes necessary for the blastocyst to embed or implant in the uterine wall. This is necessary for it to obtain nourishment for its further development. IMPLANTATION

D.

E.

III.

A. Also called Nidation

B. C.

TIME: 6 to 9 days (average is 7 days) after fertilization SITE: upper fundal portion or upper one-third of the uterus; can be anterior (towards the mother's front) or posterior (towards the mother's back), Abnormal implantation sites are the fallopian tubes which leads to ectopic pregnancy and the lower uterine segment which causes placenta previa. At the time of implantation, the blastocyst is completely buried in the endometriun, While the blastocyst is the stage of implantation, its outer layer the trophoblast, is responsible for actual implantation (nidation): THE PLACENTA

D.

IV.

A. DIMENSION
1. 2.

Discoid: 15 to 20 cm in diameter and 2 to 3 cm in thickness Location: in the uterus, anteriorly or posteriorly near the fundus

3. Fetal Side: covered with amnion; beneath it the feral vessels course with the arteries passing over the veins, Amnion: 0.02 to 0.5 mm in thickness; a sac that engulfs the growing fetus, Amniotic fluid: clear fluid that collects within the amniotic cavity. 4. Maternal Side: divided into irregular lobes; consists of fibrous tissue with sparse vessels confined mainly to the base 5.Average weight at term - 500 gm 6.Feto-placental weight ratio, at term - 6:1 B. Placenta is formed by the union of the chorionic villi and decidua basalis. Decidua: The endometrium in pregnancy; thickens in pregnancy with depth of 5 to 10 mm. 1. Decidua Basalis: portion of decidua directly beneath the site of implantation, under the imbedded ovum 2. Decidua Capsularis: the portion overlying the developing ovum; separates ovum from the rest of the uterine cavity: most prominent by 2nd month
3.

Decidua Vera/ Desidua Parietalis: lines the remainder of the uterus. Initially, the decidua capsularis and decidua vera are separated by a space because the gestational sac does not fill the entire uterine cavity; by the fourth month, the growing sac fills the uterine cavity.

4. Layers of Decidua Basalis and Decidua Vera Zona Compacta: uppermost/ surface layer made up of compact cells
a.

Zona Spongiosum: middle, spongy layer; with glands and small blood vessels
b. c.

Zona Basalis: lowest most/ basal layer The zona basalis and zona spongiosum together form the functional layer (zona functionales). Implanrauon is up to the level of spongiosum. The zona basalis remains after delivery/ placental separation.

5.

Decidual Aging: Nitabuch's layer, a zone of fibrinoid degeneration, is where invading trophoblast meets the decidua. This layer is usually absent whenever the decidua is defective.

C.

PLACE TAL MATURITY: 12 weeks or 3 months; functions most effectively through 40 to 41 weeks; may be dysfunctional beyond 42 weeks. PLACENTAL FUNCTIONS: Varied
1.

D.

Nutritive: transports nutrients and water soluble vitamins of fetus a. Fluid/gas transport Diffusion: oxygen, carbon dioxide, water and electrolytes move from greater to lesser concentration Facilities transport: glucose Active transport: amino acid, calcium, iron Pinocytosis: fat, gamma globulin albumin Leakage allows fetal and maternal blood to mix slightly because of placenta defects; normally there is no mixture of fetal and maternal blood.

2. Excretory with the amniotic fluid as the medium of excretion 3. Respiratory organ of the fetus 4. The placenta acts as a protective barriers to some substances and organisms like heparin and bacteria:ineffective for virus, alcohol, nicorine, antibiotics, depressants and stimulants.

SOME PLACENTA/CORD ABNORMALTIES Placenta succenturiata One or small accessory lobes are developed in the membranes; of clinical significance because retention in the uterus after placenta expulsion may result in maternal hemorrhage. Placenta infarcts Fibrinoid degeneration of the trophoblast, calcification, and

Placenta bipartita Placenta tripartita Battledore placenta Velamentous insertion of cord / Placenta velamentosa Cord loops Cords torsion Cords knots

ischemic infarction; of diverse origin; most common placental lesion Placenta with 2 complete or almost complete lobes Placenta with 3 complete or almost complete lobes insertion of the cord at the placental margin Umbilical vessels separate in the membranes at a distance from the placenta margin which they reach surrounded only by a fold of amnion When cord coils around portions of the fetus, usually the neck (nuchal cord) Twisting of the cord resulting from fetal movements; when marked, may affect fetal circulation False knots: result from kinking of the vessels to accommodate to the length of the cord True knots: result from active movement of the fetus

5. Endocrine: secretes hormones estrogen, progesterone, human chorionic gunadotropin (HCG), and human placental lactogen (HPL), also called chorionic somatomammotropin (HCS)
a.

Estrogen and progesterone's major source or production after the first 2 months.

b. Human chorionic gonadotropin (HCG) Secreted as early as 8 to 10 days after fertilization; detected in serum as early as the time of implantation by the most sensitive pregnancy test. The radioimmunoassay (RIA); and detected in urine a day after expected mense by a pregnancy test Functions: prolongs the life of the corpus luteum; serves as basis for pregnancy tests The hormone found elevated in excessive vomiting Normal value: 400, 00 I.U/24 hours c. Human chorionic somatomammotropin (HCS) or Human Placental Lactogen (HPL) Secreted by third week after ovulation

V.
A.

Influences somatic cellular growth of the fetus; resembles the growth hormone The fetus principal diabetogenic factor as it is the major insulin antagonist, or glucose sparing hormone Prepares the breasts of the mother for lactation

THE UMBILICAL CORD/FUNIS LENGTH: 55 cm. 1 inch across at term

B. PARTS: 1. One left umbilical vein: carries oxygenated blood to the 2. Two umbilical arteries (left & right): carry deoxygenated blood from fetus to placenta 3. Whartons jelly, gelatinous substance
a.

b.

Whartons Jelly: Specialized connective tissue, an extension of the amnion: surrounds the umbilical cord to prevent cord compression The blood volume in the cord also helps prevent cord compression

C. The cord extends from the fetal surface of the placenta to the fetal umbilicus
D.

FUNCTION: to transport oxygen and nutrients to the fetus and to return metabolic wastes including carbon dioxide from the fetus to the placenta.

VI.

THE AMNIOTIC FLUID

A. Clear, straw-colored fluid in which the fetus floats

B.

ORIGIN: both fetal and maternal; amniotic epithelium maternal serum and in later part (10th week), fetal urine; constantly being replaced so there is no "dry labor" in premature rupture of the bag of water

C.

AMOUNT: .500 to 1,000 ml at term; polyhydramnios excessive amount of amniotic fluid, greater than 1,000 to 1,500 mL; oligohydramnios - amount less than 300 to 500 mL. REACTION: neutral to alkaline (pH 7 to 7.25) ABNORMAL COLORS: green-tinge in a. non-breech presentation is a sign of fetal distress; golden-colored fluid may be found in hemolytic disease.

D. E.

F. AMNIOTIC FLUID FUNCTIONS 1. Serves as a protective cushion/shock absorber 2. Separates fetus from membranes allowing symmetrical growth and free movement 3. Acts as a medium of excretion 4. Serves as fetal drink (If there is an abnormality in the deglutition center of the brain or if there is esophageal atresia that the fetus could not swallow, amniotic fluid accumulates (polyhydramnios). 5. Serves as a specimen for periodic diagnostic exams to determine fetal wellbeing or its absence 6. Maintains fetal temperature 7. Equalizes uterine pressure and prevents marked interference with placental circulation during labor

VII.

STAGES Of INTRAUTERINE DEVELOPMENT A. THE OVUM 1. 2. From fertilization to 2 weeks The period of pre-differentiation of organs

3.

When the' ovum is exposed to a teratogen, the all or none' law applies, meaning the ovum is damaged and is out in spontaneous abortion or it is not affected at all and continues to grow normally.

B. THE EMBRYO 1. From 2 weeks to 2 months 2. The period of organ differentiation (organogenesis). 3. Most Dangerous Period: A teratogen introduced at this stage may result in severe organ malformation and dysfunction. C. THE FETUS 1. From 8 weeks to birth 2. The period of post-differentiation of organs
3.

When exposed to a teratogen. a malformation is least likely to occur. If ever the fetus is affected, the effects will most likely be alteration in size or function.

VIII.
A.

THE EMBRYONIC GERM LAYERS ECTODERM: the outer layer; develops into: 1. Nervous system 2. Hair, nails: skin epidermis, sebaceous and sweat glands 3. Salivary glands, mucous membrane of mouth 4. Epithelium of nasal oral passages MESODERM: the middle layer; develops into: 1. Dermis 2. Cardiovascular system

B.

3. Reproductive system 4. Musculo-skeletal system 5. Urogenital system; except the bladder

C.

ENDODERM/ENTODERM: the inner layer; develops into: 1. Linings of gastrointestinal tract from pharynx to rectum 2. Liver, pancreas, thyroid, parathyroid 3. Respiratory tract 4. Bladder, thyroid, thymus (for immunity building)

IX.

INTRAUTERINE GROWTH AND DEVELOPMENT Development All systems in the rudimentary form Beginning formation of eyes, nose, GUT Heart chambers formed; heart beating (14 days) With arm and leg buds Head Large in proportion to the body Neuromuscular development some movements Rapid brain development External genitalia appear Placenta fully formed and functioning Kidneys develop: secrete urine Centers of ossification in most bones With sucking and swallowing Sex distinguishable FHT detected by ultrasound (1012 weeks) More human appearance Quickening-multigravida Meconium in bowels External genitalia obvious Scalp hair develops Formed eyes, nose, ears FHT by Doppler With vernix caseosa and downy

Age 4 weeks

8 Weeks

12 Weeks

16 Weeks

20 Weeks

24 Weeks

28 Weeks

32 Weeks

36 Weeks

40 Weeks

lanugo Quickening stronger, felt by Primigravida FHT audible using stethoscope Bones hardening Body well-proportioned Skin red and wrinkled Hearing established Eyebrows, eyelashes recognizable When born, may breathe, but usually doesnt Viable; immature if born at this time Surfactant production begins Body is less wrinkled With iron storage Nails appear Pupillary membrane has just disappeared from the eyes Subcutaneous fats begin to deposit Skin is smooth and pink More reflexes present With iron and calcium storage Good chance of survival if delivered Lecithin/sphyngoinyelin ratio 2:1 (L/S) Nails firm With definite sleep/wake pattern Lanugo disappearing Survival same as term Full term with good muscle tone and reflexes Little lanugo If male, testes in scrotum The age at time of EDC With other characteristic features Of the newborn

Drugs with ProvenTerarogenic Effects (Modified from Koren et al., 1998) Drugs Anticholinergic drugs Antithyroid drugs (Prophylthiouracil, Teratogenic Effects Neonatal meconium ileus Fetal & neonatal goiter,

methimazole) Cyclophosphamide Diethylstilbestrol Hypoglycemic drugs Methotrexate NSAIDs Phenytoin Psychoactive drugs (barbiturates, opiods, benzodiazepines) Tetracycline Thalidomide Warfarin (Coumadin)

hypothyroidism CNS malformation, secondary cancer Vaginal cancer, other genitourinary defects in male or female offspring Neonatal hypoglycemia CNS & limb malformations Constriction of ductus arteriosus, necrotizing enterocolitis Growth retardation, GNS defects Neonatal withdrawal syndrome when given in late pregnancy Teeth staining/defects, bone defects Limb defects/ shortening, internal organ defects Skeleton & CNS defects Heparin is the anticoagulant of choice in pregnancy; does not pass through placental barriers.

I.

ANTEPARTAL PERIOD The period of pregnancy or the period before labor is the antepartal period, also called prenatal period. The woman in this period is called the gravida.

II.

LENGTH Of PREGNANCY A. Days - 267 to 280 B. Calendar months 9 C. Weeks 40 D. Trimesters 3 E. Lunar months 10 It is best to express gestational age or length of pregnancy in weeks. At expected date of confinement (EDC), the fetus is 40 weeks old.

III.

TRIMESTERS OF PREGNANCY

A.

FIRST TRIMESTER: period of rapid organogenesis; teratogens like alcohol, drugs, virus, and radiation are highly damaging. SECOND TRIMESTER: most comfortable for the mother; with continued growth of the fetus. THIRD TRIMESTER: with rapid deposition of fats, iron and calcium; the period of most rapid fetal growth

B.

C.

IV.

PHYSIOLOGIC ADAPTATIONS IN PREGNANCY A. UTERUS 1. UTERUS SIZE is increased due to hyperthrophy of the existing muscles and connective tissues. ( No formation of new muscle fibers in pregnancy. Weight increases from 60g. ( non-pregnant ) to 1000g. (full term). 2. Uterine shape changes from GLOBULAR to OVAL. 3. New fibroelastic tissues are formed; this makes up stonger uterine walls. 4. Fundic height changes : 12th weeks level of symphysis pubis. 13th weeks rising from pelvic cavity;may be palpable just above the symphysis pubis. 14th weeks an abdominal content. 20th to 22th weeks at level of umbilicus. 30th weeks at xiphoid process level. 5. Increased vascularity to the pelvic region (estrogen effect)results : a. Hegars sign softening of lower uterine segment called the isthmus, easy compressibility of the uterus. b. Goodells sign softening of the cervix. c. Chadwicks sign : bluish or purplish discoloration of the cervix. 6. Braxton Hicks Contractions Intermittent irregular,painless,abdominal, and false labor contractions felt as abdominal muscle tightening by albout 4 months; more pronounced at 8 months. 7. Ballottment : Rebounding of fetal head against examining fingers by 4 to 5 months. 8. Secondary amenorrhea : due to the persistent of the corpus luteum. B. CERVIX shorter,thicker,more elastic. With edema and hyperplasia of the mucous lining, there is increased mucus production which make up the mucus plug (week 7 ). As it seals the cervix,it also prevents bacterial contamination of the uterine cavityIncreased vascularity causes to be soft : Goodells sign.

Vagina - thickened vagina mucosa results in Leukorrhea : Whitish, mucoid, non-foul smelling,non-pruritic vaginal secreations increases as estrogen levels increases; provides increase vaginal acidity, an added protection from bacterial invasion. Increased vascularity results to bluish discoloration: Chadwicks sign. D. Perineum - Increased in size, increased vasularization changes into deeper color. E. Ovaries Ovum production ceases. Corpus luteum takes over hormonal production task in early pregnancy. Placenta is the major endocrine organ in pregnancy. F. Breast Increased size and firmness, Tingling sensation in the nipples in 4 weeks , there is also breast tenderness. Enlargement of the areola, alveoli duct and alveoli system. Darkening of the areola and skin around it. Prominence of superficial veins. Colostrum ( 4 to 5 months ) : thin, watery, light yellow, high protein secretions. G. Endocrine Placenta secretes Human Chorionic Gonadotropin,estrogen,progesterone, and HPL ( human placental lactogen ) / HCS ( human chorionic somatomammotropin ). Thyroid Gland there are increased 25% metabolic rate activity but return to normal level at 6th week postpartum. The rest APG, Posterior ituitary Gland, Parathyroid Gland,Pancreas and Adrenal Cortex all as increases its works activities. H. Respiratory - Nose Increased vascularity ( estrogen effect) results most common in epistaxis,nasal stuffiness,hoarseness,Eustachean tube blockage causing temporary deafness or difficulty of hearing. Diaphragm rises by 1 inch at 36 to 38 weeks due to the growing fetus resulting in dyspnea which relieved by lightening. Lungs tendency to hyperventilate due to mothers need to blow off carbon dioxide transferred from fetus; and direct effect of progesterone on respiratory center. I. Circulatory system cardiac rate increased by 10 to 15 bpm/min. in the second and third trimesters. Cardiac output increases by 20 to 30% in the first and second trimesters to meet increase tissues demand. Vascularity increases ( estrogen effect) : causing dilatation of pelvic veins resulting in pelvic veins varicosities and leg varicosities. Fibrinogen level increases by 50% due to progesterone effect hence results in increased tendency to clotting high risk for thrombophlebitis. Homans sign if positive is a danger sign of deep vein thrombosis. Edema of the lower extremities is common in the last 6 weeks of pregnancy because of the pressure on the pelvic girdle. J. Hematologic Hemoglobin and hematocrit may drop by 10% in the second and third trimester may result to pseudoanemia/physiologic anemia. K. Gastrointestinal system increased acidity of saliva. No tooth loss in preagnancy. Increased vascularity resulys in soft and swollen gum/gingivitis; treatment dental hygiene. Cardiac sphincter relaxed
C.

L. M.

N.

results in esophageal reflux leading to heartburn or pyrosis felt behind the sternum. Slow motility results in slow digestion ( progesterone effect). Renal system Freqency of voiding increased in the first and third trimester because of uterine pressure on the urinary bladder. Integumentary system Chloasma dark patches on the checks,nose and neck. Mask of pregnancy due to increased melamocytestimulating hormones of pregnancy. Linea negra -_dark line from symphisis pubis upward to xyphoid process due to increased estrogen. Striae Gravidarum stretch marks, silvery streak. Palmar erythema reddened palm and vascular spider nevi ( facial) from increased vascularity due to elevated estrogen. Diaphoresis increased activity of the sweat and sebaceous glands due to increased metabolic rate. Musculo-skeletal increased estrogen,progesterone and relaxin relaxes the ligaments and joints. Stress on ligaments and muscles of the mid and lower spine results in backache. Lordosis from shift in the center of gravity during pregnancy results in backache and fatigue. Cramps (legs ) result from calcium and phosphorous imbalance, and pressure of the gravid uterus on nerve supplying the lower extremities. EMOTIONAL/PSYCHOSOCIAL ADAPTATIONS IN PREGNANCY

V.

A. FIRST TRIMESTER 1. Normal denial to confirmation of pregnancy

2.

Ambivalence about pregnancy child, and parenting

3. Mood swings or emotional labiliry 4. Focusing on the self B. SECOND TRIMESTER 1. Acceptance of the baby as distinct from self; enhanced by quickening which is "my baby is alive" to the layman 2. With fantasy and daydreaming 3. Introspective; evaluates marriage, career, in-laws 4. Most comfortable stage C. THIRD TRIMESTER

1. Fear/anxiety/dreams about labor, pain, mutilation, and death 2. Anxiety related to responsibilities 3. Preparation for birth: nesting behavior; role playing D. PSYCHOLOGIC TASKS OF PREGNANCY: Related to the psychosocial adaptations in pregnancy are the psychologic tasks of pregnancy: 1. 2. 3. Acceptance of pregnancy as a reality and incorporation of the fetus into the body image Preparation for physical separation from fetus (birth) Attainment of maternal role

E. NURSING IMPLEMENTATION The pregnancy woman should be encouraged to verbalize and express feelings, concerns, and discomforts. The nurse should validate normalcy of her feelings and reactions in order to provide psychological support. In addition, health teachings related to prevention and management of common discomforts of pregnancy should be provided. In the third trimester the is also recommended woman to attend prenatal classes. V. SIGNS OF PREGNANCY The changes in the various body systems give rise to the signs of pregnancy grouped into presumptive, probable, and positive signs. PRESUMPTIVE SIGNS: subjective; may be noticed by the woman but are not conclusive proof of pregnancy
1.

A.

Amenorrhea: first sign at 2 weeks from fertilization because of persistence of corpus luteum. Nausea and vomiting: are the most common forms of discomfort

2.

3.

Urinary frequency: is the most disturbing sign especially in the thid trimester Fatigue: estrogen-induced in early pregnancy Breast changes: tingling of nipples (4 weeks), darkening and enlargement of areola, enlargement of breasts, increased number of milk-secreting cells Skin changes: chloasma, linea nigra, striae gravidarum, diaphoresis Quickening: usually felt stronger at 20 weeks Leukorrhea: whitish-mucoid vaginal discharge due to estrogen

4. 5.

6.

7. 8.

9. Weight increase
B.

PROBABLE SIGNS: objective; as noticed or observed by healthcare provider but still not conclusive for pregnancy

1. Uterine enlargement causing abdominal enlargement 2. Goodell'.s sign: softening of the cervix 3. Hegar's sign: softening of lower uterus (isthmus) ~ compressibility of the uterus 4. Chadwick's sign: bluish discoloration of cervix, vagina and perineum 5. Braxton-Hicks contractions: painless, abdominal contractions; relieved by walking 6. Ballottement: rebound of fetus against examining fingers 7. Positive pregnancy test: due to presence and rising HCG in maternal blood and urine 8. Radioimmunoassay (RIA): test for the beta subunit of HCG ~ accurate as to be diagnostic of pregnancy (Kain & Hall, 2000).

C.

POSITIVE SIGNS: objective, emanate from the fetus; conclusive for pregnancy

1. FHT 2. Fetal outline (ultrasound) 3. Fetal parts (examiner's palpation) 4. Fetal skeleton (X-ray; not before 16 weeks)

DISCOMFORTS OFPREGNANCY AND RELIEF MEASURES Discomfort Relief Measures Morning sickness Eat dry crackers (carbohydrates) or toast. in the morning 30 minutes before getting up. Drink adequate fluids between meals. Avoid highly spicy, fatty foods. Eat small frequent meals; avoid overeating. Avoid fatty, highly seasoned foods. Heartburn Bend at the knees and NOT at the waist when picking things from the floor. Remain upright 3 to 4 hours after eating. Avoid taking sodium bicarbonate. Take aluminum-bearing antacids (Amphogel) as ordered. Flatulence Eat small frequent meals. Avoid gas-forming food. Frequency of Increase fluids to replace losses except at urination bedtime to present nocturia. Practice regular voiding. Practice frequent flushing: front to back. Report any burning sensation, dysuria, cloudy urine, or tea-colored urine. fatigue Have adequate rest and sleep (8 hrs. average night sleep) Avoid prolonged standing. Practice good body mechanics (posture). Report increasing fatigue with regular activities-a danger sign of heart disease Constipation Increase fluid intake (6 to 8 glasses of water per day). Increase roughage in the diet (daily fruits and vegetables). Regular exercise (best is walking) is recommended. Observe daily/regular bowel movement.

Hemorrhoids

Faintness/supine hypotensive syndrome / vena caval syndrome

Leg cramps

Varicose veins

Backache

Pedal edema

Shortness of breath

Drink warm water in the morning. Avoid constipation and other forms of straining. Promote com for : sitz bath, warm compresses Reinsert hemorrhoids, upon physician's recommendation. Avoid sudden changes in position. nd Avoid supine position in 2 to 3rd trimesters. Arise from a bed from a lateral position and gradually. Avoid staying in one position for a long time. Assume frequent left lateral positions in bed. Include adequate calcium in the diet; calciumphosphorus imbalance is the recognized most important cause of leg cramps. Avoid prolonged standing and sitting. Dorsiflex the foot while extending the leg; this hyperextends the involved muscle causing relief. No round garters around the abdominal and legs; avoid knee-high stockings. Wear supportive panty hose. Frequent elevation of legs and hips is advised. Maintain good posture. Wear flat shoes. Avoid prolonged standing. Pelvic rock exercise and tailor sitting are advised. Use supportive mattress. Wear maternity girdle in selected situation- as recommended. Assume left-lateral: position/elevation of legs frequently to promote venous return. Avoid prolonged standing. No round/constricting garters. Report swelling of hands and face. Maintain good posture. Avoid fatigue. Elevate head by several pillows in sleep, avoid supine position. Avoid constricting bra and other tight clothes. Report increasing dyspnea with minimal activity or dyspnea prior to 36 weeks (with normal pressure on the diaphragm).

VII. A.

PRENATAL MANAGEMENT FIRST VISIT: as soon as the mother missed a menstrual period when pregnancy is suspected.

B. SCHEDULE OF VISITS 1. Once a month up to first 32 weeks 2. Twice a month (every 2 weeks) from 32 to 36 weeks 3. Four times a month (every week) from 36 to 40 weeks In the presence of danger signals of pregnancy, the mother should be instructed to report promptly for evaluation. C. CONDUCT OF INITIAL VISIT 1. Baseline Data Collection a. To serve as basis for comparison with information gathered on subsequent visits b. To screen for high-risk factors ROLL-OVER TEST I. PROCEDURE A. Place mother on left-side lying position (left lateral recumbent, LLR). B. Check BP until stable, may take 10 to 15 minutes C. Roll to supine D. Check BP right away E. Wait 5 minutes F. Check BP again. Compare the first with the second diastolic reading

II.

INTERPRETATION A. Positive Result an increase in the diastolic pressure of values greater than 20 mm of mercury; woman at risk B. Negative Result An increase in the diastolic pressure of values less than 20 mm of mercury 2. Obstetrical History a. b. c. Menstrual history-menarche (onset, regularity, duration, frequency, character Last menstrual period (LMP), sexual history, methods of Past menstrual period (PMP): menstrual period before the last Medical and Surgical History - past illnesses and surgical procedures, current drugs used
4. 5.

contraception.

3.

Family History to detect illnesses or conditions Current Problems - activities of daily living, discomforts, danger signs a. Vital signs Temperature: slight rise because of increased progesterone and increased activity of the thyroid gland; not to reach 38C. CR: Plus 10 to 15 BPM RR: May tend to be rapid and deep (16/min., deeper) because of progesterone's influence on the respiratory center. Maximum increase under normal conditions: 24/min at rest.

6. Initial and Subsequent Visits

BP: Tends to be hypotensive with supine position: vena caval syndrome. Prevention: Elevated BP reading may indicate pregnancyinduced hypertension (PIH).

The roll-over test can be done in the first trimester for early detection of developing pregnancy-induced hypertension by 20 to 24 weeks.

b.

Weight is checked in every visit.

Total weight gain: 20 to 25 lb., with average of 24 lb.; upper limit: 25 to 35 lb. First trimester: 1 lb. per month which is 3 to 4 lb. total Second trimester: 0.9 to 1 lb. per week or about 10 to 12 lb. Third trimester: 0.5 to 1 lb. per week or about 8 to 11 lb. The patterns of weight gain are more important than the amount of weight gain Normal weight gain patterns contribute to health of mother and fetus Failure to gain weight is ominous sign. Weight is therefore a measure of health of a pregnant mother.

c.

Urine testing for albumin and sugar Sugar - ideally not more than 1+ Albumin negative

d.

Fetal growth and development assessment Fundal height. Requires emptying of the bladder for accurate results

Fetal heart tones/fetal heart rate Abdominal palpitation - Leopold's maneuver Quickening - first fetal movement, plus subsequent mobility

7. Obstetrical History a. Preceding pregnancies and perinatal outcome 4-Point System: Past pregnancies and perinatal outcomes (FPAL) F: number of full term births P: number of premature births A: number of abortions L: number of currently living children 5-Point System: the total number of pregnancies (G) is the first number (GFPAL) G: total number of pregnancies F: number of full term births P: number of premature births A: number of abortions L: number of currently living children b. Gravida: number of pregnancies regardless of duration and outcomes, including the present pregnancy

Gravida 1 (G) - pregnant for the first time; a primigravida had one pregnancy Multigravida - with two or more pregnancies Nulligravida - woman who is not pregnant now and has never been pregnant.

c. Parity: number of pregnancies carried to period of viability whether born dead or alive at birth (twins considered as one parity)

Primipara: a woman who has once delivered a fetus or fetuses who reached the stage of viability. Therefore, the completion of

pregnancy beyond the period of abortion means one parity. It also means, therefore, that an abortion is not included in the counting. Multipara: a woman who has completed two or more pregnancies to the stage of viability 8. Estimates in Pregnancy
a.

EDC/EDD: expected data of confinement/ expected date of delivery Naegele's Rule Formula: Add 7 days to the first day of the last menstrual period (LMP): subtract 3 calendar months then add 1 year Given LMP: May 20, 2008 5 3 + 20 7 2008 + 1

_________________________ 2 27 2009

Measures of AGE of Gestation ( AOG ) 1. LMP : last menstrual period. 2. Fundic height Bartholomews Rule of Fours- measures age of gestation by determining the position of the fundus in the abdominal cavity. 3. McDonalds Rule : requires fundic height measurement in cm. AOG in weeks : FH in cm x 8 / 7 ; AOG in months : FH in cm x 2 /7 . 4. Ultrasonography : measures biparietal diameter. A BPD of 9.5cm = mature fetus, usually attained at 36 weeks of gestation. 5. Date of Quickening : at 20 weeks 6. Identification of FHT : 7 8 weeks by Doppler ultrasound.

9. Complete Physical examination : include internal examination and bimanual examinations. Do Paps smear on the first visit. a. Internal examination ( IE ): detect early signs of pregnancy. Chadwicks sign, Goodells and Hegars sign.
b.

Important concern of physical examinations : Breasts look for breasts changes, adequacy of breasts for breast feeding, any abnormal signs. Abdomen Fundic height, Leopolds maneuvers : systematic abdominal palpitation to estimate fetal size, locate fetal back and parts and determine fetal position and presentation. Extremities discomforts : leg cramps, varicosities, pedal edema. Danger sign : Homans sign ( pain in the calf upon dorsiflexion of the toes; a sign of thrombophlebitis ). Laboratory Test : Blood studies : complete blood count ( CBC ) Blood typing, Rh factor determination. VDRL ( Syphilis ), Rubella antibody titer determination, Human Immunodeficiency virus ( HIV), Hepatitis screening. Urine Test - Urinalysis . Pelvic Lab Tests : collection of pelvic cultures ( paps smear, culture for gonorrhea , and Chlamydia ) .

c.

d. In all the necessary testing, prepare the client through the following steps : 1. Providing an explanation of the procedure 2. Physical preparations specific to the procedure 3. Provision of support to patient and spouse; encouraging verbalization of concerns 4. Monitoring of patient and fetus after procedure 5. Documentation as necessary

VIII.

MAJOR GOALS OF COMPREHENSIVE PRENATAL ASSESSMENT AND EVALUATION: A. Define the health status of the mother and fetus. B. Determine gestational age of the fetus: estimate date of confinement.

C. Initiate a nursing care-plan for continuing maternity care of both mother and fetus. D. Detect early any high-risk condition.

IX.

HYGIENE OF PREGNANCY

A. NUTRITION
1.

Always start with diet history when it comes to giving nutritional instruction to the mother.

2. Nutritional Profile should include the following: a. Pre-pregnant and current nutritional status
b.

Dietary habits: junk, empty-caloric foods, regularity of meals, peer pressure, adequacy of food/available finances, cultural and religious restrictions Pica: persistent ingestion of inedible substances (e.g. clay, dirt, starch, chalk), and/or substances of little nutritional value; a psychobehaviora disorder (Rainville, 1998). Effects are displacement of nutritious foods, interference with nutrient absorption, and anemia

c.

d. Mother's knowledge of nutritional needs and the daily recommended allowances e. Physical findings indicative of poor nutritional status such as: anemia, underweight/overweight states dull hair dry/scaly skin pale/dull mucus membrane/conjunctiva f. Factors/conditions requiring special attention such as young, adolescent mother primigravidity low pre-pregnant weight obesity

low socioeconomic status/economic deprivation pre-pregnant debilitating conditions vegetarians -lack essential protein and minerals; may need vitamin B 12 supplement successive pregnancies; short interval between pregnancies education - not so much what they know (may receive nutritional teaching) but how much they earn (spells adequate finances) to buy essential foods.

3. Nutrient Needs should include the following: a. Calories Non-pregnant requirement: 1,800 to 2,200 Kcal/day Additional caloric requirement per day 300 Kcal/day Usual daily caloric need in pregnancy: 2,100 - 2,500; never less than 1,800 Kcal/day Avoid 'empty' calories like soft drinks. b. Protein: body-building food: additional 30 g/day to ensure 74 to 76 g/day. Rich food sources include: milk, meat, fish, poultry, and eggs. c. Carbohydrates: sufficient intake is necessary for added energy needs; avoid 'empty' calories like soft drinks. d. Fiber: taken from fruits and vegetables to prevent constipation e. Fats: high-energy foods for absorption of vitamins A, D, E, and K. Avoid too much fat to prevent vomiting and heartburn. f. Essential Minerals and Vitamins Iron: Most important mineral that must be taken in supplementary amount 18 mg/day in non-pregnant state; supplementary in pregnancy 30 to 60mg/day

Sources: liver (best source) and other red meats, green leafy vegetables, egg yolk, cereals, dried fruits, and nuts

Needed to increase maternal RBC mass and for fetal liver storage in the third trimester. Intake of iron-fortified multi-vitamins to ensure essential levels best absorbed in acidic medium: take between meals and with vitamin C-rich juice may cause constipation; so there is also a need for increased fluid intake, fibers/roughage; regular ambulation will darken stools: explain this to the patient; can be used in evaluating compliance

Calcium Needed for maternal calcium and phosphorous metabolism and fetal bone and skeletal growth 1,200 mg/day, equivalent to 1 quart of milk a day (4 glasses) Sources: milk and milk products and broccoli (which carries the same amount of calcium as milk) Sodium: most abundant cation in extracellular fluid Needed in pregnancy for tissue growth and development Contained in most kinds of foods Should not be restricted without serious indications

Folic Acid

Needed to meet increased metabolic demands in pregnancy and for production of blood products Deficiency may cause fetal anomalies/neural defect and bleeding complications Sources: liver, dark green leafy vegetables

Vitamins: water-soluble vitamins (C and B) and fat-soluble vitamins (A, D, E, and K) Major Food Sources:

Vitamin C: citrus fruits and vegetables like broccoli, bell peppers, and tomatoes Vitamin B Group: legumes, beans, nuts, whole grain. oatmeal, pork, beef, fish, liver, organ meats, eggs, and green leafy vegetables

Vitamin A: milk and dairy products; dark green and dark yellow fruits and vegetables; eggs and liver Vitamin D: milk and foods fortified with vitamin D; egg yolk; fish Vitamin E: nuts, seeds, wheat germ, whole grain products, green leaf" vegetables, vegetable oils Vitamin K: meats, liver, cheese, tomatoes, peas, and egg yolk

4. Daily Food Needs/Servings Food Milk and milk products Meat and meat products Cereals/grain products Fruit/fruit juices Vegetables/ vegetable juices Number of Serving I quart a day (4 glasses/day) 3-4 servings 4-5 servings 3-4 servings (one serving of vitamin C-rich fruit/ juice included) 3-4 servings (included is 1 serving of dark green or yellow vegetable)

Fluid

4-6 glasses of water plus other fluids to equal 8 (8-10) cups/day

B. BATH 1. Daily bath if desired. 2. Avoid soaps on nipples: with drying effect. 3. Towel-dry breasts: increases integrity/toughness of nipples.
4.

Tub bath: may cause injuries from accidental slipping as pregnant women have difficulty maintaining balance. a. Usually contraindicated except when there is care in getting into and out of bathtub; nonskid rubber mat on bathtub floor helps to prevent falls. Douching: not needed to manage vaginal discharge (Leukorrhea is estrogen-induced.); daily bath will suffice

5.

C. CLOTHING 1. Loose, comfortable clothes, of cotton material for more comfort 2. No constrictions around breasts, abdomen, legs; no round garters 3. Flat-heeled shoes for comfort and balance 4. Support panty hose for varicosities (avoid knee-length stockings) 5. Supportive, cotton-lined brassiere 6. Maternity girdle as necessary D. SLEEP AND REST 1. Assess activities to identify need for rest and sleep. 2. Average number of hours of sleep is 8 hours; may need I to 2 hours of afternoon nap. In the second half of pregnancy, advise to avoid the supine position in bed. 3. Plan rest time during the day.

4. At work, get to stand and walk about for few minutes at last once in every 2 hours (If task requires prolong standing, there should be time to walk about and sit at interval). E. TRAVELING 1. Long distance travel by land needs stop-overs so pregnant women can get out of the car and walk. Seatbelts are needed.
2.

Traveling by air requires pressurized planes: in late pregnancy, airlines will require a medical certificate indicating fitness to travel by air.

3. Best time to travel is during the second trimester because: a. the pregnant woman is most comfortable b. the danger of abortion is not great. c. the threat of premature labor is at a minimum 4. Journeys close to term are discouraged. F. EXERCISES 1. Cleansing Breathing: deep relaxed breath, like a sigh. Can be practiced in pregnancy; used in labor to signal the beginning of uterine contractions 2. Pelvic Rock: The most important exercise for comfort during pregnancy. Purposes: a. increases flexibility of the lower back b. strengthens the abdominal muscles c. shifts center of gravity back to uterine spine d. relieves backache, improves posture and appearance ,in late pregnancy 3. Squatting/Tailor-sitting: strengthens perineal muscles; makes pelvic joints more pliable

4. Abdominal Breathing: utilizes the diaphragm primarily and not the chest muscles; helpful during the first half of labor, and, when used together with total relaxation, can carry women through most of the first stage.
5.

Kegel: improves the tone of pubococcygeal, perineal, vaginal and pelvic floor muscles. In uterine prolapse, cystocele and rectocele, this can be done every hour.

6. Panting: best for crowning period and actual delivery of the baby leaving the work to be accomplished by, the uterus. Only by panting can the mother be kept from pushing in the transition phase of labor; pushing should be in the second stage of labor EXCEPT during CROW ING.
7.

Nursing Considerations Related to Exercises in Pregnancy a. Regular exercises are needed. b. Not necessary to limit maternal exercises provided they are:

Usual, customary; no new exercises should be started in pregnancy. Do not cause maternal fatigue. Evidences support that women who are used to aerobic exercises before pregnancy should continue them during pregnancy provided fatigue is avoided.

With no risk for maternal and fetal injury.

c. Literature reports that regular exercise in pregnant women results to lower CS rate and length of hospitalization. d. Exercise in standing position (not supine) to prevent pressure on the inferior vena and against the diaphragm. e. Avoid excessive and strenuous exercises. Excessive exercises cause increased blood flow to muscles and bones, diminishing blood flow to uterus, placenta and therefore, fetus. This implies the possibility of fetal distress in severe exercise.

 Excessive exercises can cause increased body temperature; elevated temperature is theoretically teratogenic.

G. MARITAL RELATIONS/COITUS 1. Changes in normal sexual response are related to the physiologic changes of pregnancy (Alteneder & Hartzell, 1997): a. First Trimester: less interest in sex due to fatigue, nausea, or adaptation to pregnancy. b. Second Trimester: interest in sex may increase as this trimester is the most comfortable period. c. Third Trimester, near term: less interest due to the discomforts brought about by positional difficulty and abdominal size. 2. Generally no contraindications except in the presence of: a. premature rupture of membranes b. premature labor c. history of abortion, bleeding
d.

deeply engaged head in late pregnancy

e. incompetent cervix
3.

In healthy, pregnant women, sexual intercourse usually does no harm. a. Like any other activity, avoid fatigue; exercise moderation and hygiene. b. Couple may need counseling regarding more comfortable positions. The traditional man on top position is uncomfortable for many couples. c. Suggested positions: side lying and the woman-on-top position.

H. EMPLOYMENT The pregnant woman may continue working provided the work, work area. and work conditions do not pose hazards TO the health of mother and fetus. 1. Safety and rest are the two most important considerations in deciding whether or not the pregnant woman should continue working. 2. Whether standing or sitting at work, the pregnant woman should be advised to stop and walk about every few hours to improve circulation of blood. 3. Adequate periods of rest should be provided during the workday. 4. Women with previous complications that are likely to be repetitive like SGA. Premature labor or abortions probably should minimize physical work. I. CARE OF THE TEETH Regular examination of the teeth and gums should be part of the prenatal general physical examination. Dental carries require prompt management in pregnancy. but major dental surgeries should be postponed for the postpartal period. Because of estrogen effect on vascularity, the gums of pregnant women are painful and swollen. Instruct on the use of soft-bristled toothbrush and gentle brushing.
2.

1.

The concept that dental caries are aggravated by pregnancy- is not supported by literature. There is no tooth loss secondary to pregnancy.

II.

S-A-D HABITS OF PREGNANCY Smoking. Pregnant women should not smoke. Women who smoke in pregnancy have smaller infants (SG/\) than those women who do not. The use of over five cigarettes per day in pregnancy doubles a woman's risk of delivering a low-birth infant (Lieberman et al., 1994). Prenatal tobacco exposure causes learning and attention problems in children but less consistently than does alcohol exposure (Streissguth et aI., 1997) a. Effects of tobacco use (Lieberman et aI., 1994): Increased risk of SGA Prematurity Infant mortality Spontaneous abortion Placenta previa/abruption placenta Premature rupture of membranes

1.

b. Causes of adverse effects of smoking

2.

Nicotine, a vasoconstrictor, cause reduced placental perfusion. The increase of carbon monoxide causes functional inactivation of maternal and fetal hemoglobin. Smokers have decreased plasma volume Smokers have reduced appetite, Resulting to decreased caloric intake.

Alcohol. Alcohol ingestion by pregnant women is likely to cause fetal abnormalities. Alcohol is the leading known teratogen in the Western world.

a. Effects of chronic alcoholism: fetal alcohol syndrome (FAS). Heavy use of alcohol (2 or more drinks/day) has 10% risk of producing FAS, characterized by:

retardation/delays: cognitive, motor, attention, and learning deficits (streissguth, Barr, Sampson, & Bookstein, 1997) mental retardation: associated with microcephaly, and seizure disorders (Littleton & Engebretson, 2006). Prenatal alcohol is the leading cause of mental retardation, surpassing down syndrome (Streissguth et al., 1997)

b.

craniofacial defects (FAS facies): flat mid face, wide nasal bridge, thin upper lip cardiovascular defects limb defects impaired fine and gross motor function

Since modern science has not determined what level of alcohol is safe for pregnancy women, it is best that pregnant women abstain from alcohol ingestion. Including the so-called "social drinking," as this can cause problems that persist into the child's teenage years and beyond (Streissguth et al., 1977).

3.

Caffeine: reduce intake of coffee, tea, colas, and cocoa to 300 mg of caffeine per day or no more than 2 to 3 servings per day (US FDA). Drugs should only be taken by pregnant women when prescribed by their physicians. Drugs prescribed in pregnancy should have benefits or advantages outweighing the risks. The best recommendation: no medication is taken during pregnancy unless absolutely necessary and prescribed.
a.

4.

Intake of illicit drugs in the first trimester can cause the most adverse fetal malformations because:

placental barrier is not yet fully developed; placenta is mature by 10 to 12 weeks of gestation.

rapid organogenesis takes place during this period and could therefore be altered.

b.

The so-called "hard" drugs may cause growth retardation and drug withdrawal which is associated with increased neonatal mortality. The most common harmful effect of heroin on the neonates is withdrawal (Richardson et al., 1996), or neonatal abstinence syndrome giving rise to a group of signs that include: Sneezing Irritability vomiting and diarrhea seizures

c.

Illegal drugs carry the risk of acquiring HIV and other STDs because women may trade sex for drugs and may provide sexual favors for money needed to acquire drugs (Henderson et a!., 1994). Herbal Supplements. Herbs, being natural, are not always safe because of lack of consistent potency in the active ingredient. For vomiting or morning sickness, a gram of ginger is effective and safe, but 20 times the stomach settling dose can trigger menstruation (Littleton & Engebretson, 2006).

d.

General rule for natural herbs must be approved and supervised by health care provider.

HIGH-RISK PREGNANCY A high-risk pregnancy is one in which the mother or fetus has a significant increased chance of harm, damage, injury, or disability (morbidity), and loss of life or death (mortality). I. RISK FACTORS A. DEMOGRAPHIC FACTORS

1.

Age: Under 16 or over 35 years old. Studies have shown that the optimal age for childbearing is between 20 and 30 years. Weight: Overweight or underweight before pregnancy

2.

3. Height: less than 5 feet SOCIOECONOMIC STATUS: There are many interrelated socioeconomic factors that place a fetus at greater risk including: 1. Inadequate finances
2.

B.

Overcrowding, poor standards of housing, poor hygiene

3. Nutritional deprivation 4. Severe social problems

5.

Unplanned and unprepared pregnancy, especially among adolescents

At the root of these problems are poverty and low educational status.

C. OBSTETRIC HISTORY
1. 2.

History of infertility or multiple gestation Grandmultiparity Previous loses: feral death, stillbirth, neonatal or perinatal deaths Previous operative OB: cesarean section, mid forceps delivery Previous abnormal labor: premature labor, or postmature labor prolonged labor Previous high-risk infant: low-birth-weight (LBW), macrosomic (LGA), with neurologic deficit, birth injury on malformation

3. Previous abortion or ectopic pregnancy

4. 5.

6. Previous uterine or cervical abnormality

7.

8.

9. Previous hydatidiform mole

D. CURRENT OB STATUS 1. Late or no prenatal care 2. Maternal anemia 3. Rh sensitization

4.

Antepartal bleeding: placenta previa and abrutio placenta

5. Pregnancy, induced hypertension 6. Multiple gestation 7. Premature or postmarure labor 8. Polyhydramnios

9. 10.

PROM Fetus inappropriately large or small; abnormality in tests for fetal well-being; abnormality in presentation

E. MATERNAL MEDICAL HISTORY/STATUS 1. Cardiac or pulmonary disease 2. Metabolic disease: diabetes, thyroid disease 3. Endocrine disorders: pituitary, adrenal
4.

Chronic renal disease: repeated UTI, bacteriurea

5. Chronic hypertension 6. Venereal and other infectious diseases

7.

Major congenital anomalies of the reproductive tract

8. Hemoglobinopathies 9. Seizure disorder 10. Malignancy 11. Major emotional disorders, mental retardation F. HABITS/HABITUATION
1.

Smoking during pregnancy

2. Regular alcohol intake 3. Drug use/abuse

II.

DIAGNOSTIC TESTS IN HIGH-RISK PREGNANCY/PRENATAL DETERMINATION Of FETAL STATUS A. ULTRASONOGRAPHY 1. Description A non-invasive diagnosis procedure utilizing high-frequency sound waves to detect intrabody structures. 2. Purposes a. In early pregnancy: to confirm pregnancy b. To detect the fetus's: Viability, growth Number (multiple pregnancy)

Position, presentation

Abnormalities (structural) Heart tones (FHT)

Age of gestation by determining the biparietal diameter of the fetal head

Most accurate at 12 to 24 weeks Biparietal diameter of 9.5 cm = mature fetus

c.

Detects placental location (placenta previa) or placental abnormality (H-mole) An important aid in high-risk procedures like the amniocentesis

d.

III.

COMPLICATIONS OF PREGNANCY A. PREGNANCY-INDUCED HYPERTENSION

1.

Description: a disorder characterized by three symptoms of hypertension, edema and proteinuria appearing after the 20th

to 24th week of pregnancy and disappearing 6 weeks after delivery

2.

Incidence: 7% to 10% of all pregnancies; one of the major causes or maternal and fetal/neonatal mortality

3. Real Cause; unknown

4.

Etiologic Factors
a.

Nulliparity with extremes of age: 17 years old and below or 35 years old and above Severe nutritional deficiency: low protein diet, low calories Coexisting conditions: diabetes mellitus, multiple pregnancy, polyhydramnios, chronic hypertension, and renal disease

b. c.

5. Assessment Finding Assessment findings result from generalized vasospasm and arteriolar vasoconstriction which cause increased peripheral resistance, decreased blood flow to tissues and hypertension. The reduced blood flow to tissues results in tissue ischemia and altered organ functioning affecting mostly the kidneys, brain and uterus. a. Kidneys

Renal vasospasm and decreased perfusion cause glomerular lesions and membrane damage resulting in disturbed functions.

Proteinuria, hypoproteinemia, altered a/g ratio, altered blood osmolarity, fluid shift from intravascular compartment to interstitial spaces causing edema Angiotensin release leads to further vasospasm and hypertension,

b. Brain

Cerebral arteriospasm and edema cause cerebral hypoxia and CNS irritability manifested in:

visual disturbances: double vision, blurring and dimness of vision hyperreflexia/hyperirritability convulsion coma

c. Uterus

Decreased placental perfusion causes SGA (small for gestational age babies) Generalized vasoconstriction and arteriospasm precipitates abruption placenta

6. 7.

Types: Preeclampsia (mild and severe) and eclampsia Nursing Plan and Implementation a. Prevention: Health Teachings

Well-balanced diet high in protein to increase blood osmolarity and prevent fluid shift to interstitial spaces.

Supplemental iron of 30 to 60 mg per day in the second and third trimester and continued UP to 2 to 3 months postpartum in lactating mothers Increased caloric intake by 10% in pregnancy Sodium restriction in pregnancy is harmful as it can decrease circulating volume and may result in fluid and electrolyte imbalance and elimination of vital nutrients.

Adequate rest and sleep in left lateral (Sim's) position Regular prenatal care with prompt reporting of danger signals such as:

visual disturbances severe, persistent headache and dizziness digital and periorbital edema

irritability epigastric pain

Monitoring own blood pressure during the periods between visits.

b. Treatments and Nursing Care

Maintain bedrest in left lateral recumbent (LLR):

to promote increase in tissue perfusion and induce diuresis to reduce risk of supine hypotension syndrome (SHS)

Provide high protein diet with moderate sodium; no total restriction of sodium

to replace protein losses. retain fluid in the intravascular compartment and reduce edema

Frequent monitoring : the room of the mother should be near the nurses' station maternal and fetal VS Mild Preeclampsia 140/90 or systolic increase of 30 mm Hg or more above the baseline; diastolic rise 15 mm Hg or more Severe Preeclampsia 160/110 or systolic increase at or above the 160 or more than 50 mm Hg over the baseline; diastolic rise greater than 110 mm Hg or more on two readings taken 6 hours apart after bed rest 3+ to 4+ or 5g/day or more generalized, severe facial puffiness, severe

Signs hypertension

Proteinuria Edema

1 + 1 g/day Generalized, confined to face (periorbital) and

fingers Weekly weight gain greater than 1 Ib./week

swelling of face Excessive weight gain 5 Ib./week or more Epigastric pain - due to edema or liver capsule Cerebral disturbances: Severe frontal headache Increased irritability Blurring of vision Hyperreflexia Severe dizziness Halo vision, blind sports Persistent vomiting Disorientation Present; output 400 mL or less in 4 hours Present Hypoproteinemia Hemoconcentration

Oliguria IUGD (Intra-uterine growth retardation Others

Absent; output above 500 mL in 24 hours Absent

Hypernatremia Eclampsia is associated with convulsions and coma. Severe headache and epigastric pain may mean oncoming convulsion. The first nursing action if the client complains of severe headache or epigastric is to CHECK BLOOD PRESSURE. The first objective sign of a convulsion is ROLLlNG OF THE EYEBALLS.

I & O - oliguria is a grave sign; diuresis is a good sign Daily weight/edema-daily weighing is to evaluate degree and distribution of edema Reflexes - particularly the deep tendon reflex (DTR) as this is the first to get lost with CNS depression secondary to drug magnesium sulfate toxicity. onset or progress of labor; signs of abruptio placenta

Administer drugs as ordered.

1.

Magnesium Sulfate prevents convulsion Care before administration

Check RR: 12 to 14 min. or more before giving the first dose of the drug; MgSO can depress the respiratory enter and smooth muscles for respiration. Check knee jerk reflex or the deep tendon reflex (DTR) before giving the second dose of the drug: if it is present or if the result is more than 1+, (it means the first dose (or previous dose) did not depress the CNS to toxic levels. Check blood pressure. Check antidote: 10% calcium gluconate. Procaine Hydrochloride can be mixed with magnesium sulfate to make it less irritating or painful; requires doctor's order

During: Divide the dose of the drug into the two buttocks; give DEEP 1M, Z-track After: Monitor BP, RR, DTR, I&O, and FHT

2.

Hydralazine (Apresoline): Monitor BP Diuretics: Rare; now considered inappropriate as it further decreases circulating volume resulting in decreased renal, cerebral and uteri ne perfusion

3. Diazepam (Valium): Monitor BP

4.

5. Blood volume expanders Prevent convulsion

Reduce environmental stimuli: place the patient in a semi-darkened and quiet room; restrict visitors; room should be near the nurses' station as the client needs frequent monitoring Monitor for signs of impending convulsion

Severe headache frontal Severe epigastric pain Sharp cry Fixed, unresponsive eyes Facial twitching Hyperreflexia Administer anticonvulsant as ordered: MAGNESIUM SULFATE Have ready emergency items: airway, catheterization set, IV fluids, emergency drugs

Provide care during convulsions.

Never leave a convulsing patient alone. Maintain a patent airway (this should be first priority): lateral position, gentle suctioning, provide oxygen as ordered. Promote safety/prevent injury (second priority): provide bedrails (right on admission); do not apply leather restraints (for this may cause fracture of long bones).

Reduce environmental stimuli: keep the patient alone in a quiet and dim room if possible, but if there is no vacant single room available, the patient can be with another patient who also needs quiet and restricted visitors (i.e., a postpartum cardiac patient) Monitor, record, report type of convulsion: duration, progress, resultant coma or bowel or bladder evacuation. Continue strict monitoring for 48 hours after delivery because convulsions may still occur in the post-partum.

Types of Spontaneous Abortion: Clinical Signs and Symptoms Types Bleeding Abdominal Cramps May or may not Inevitable Complete Moderate Small to negative Incomplete Severe (bleeds Severe the most) be present Moderate Open Moderate Close or partially open Open with tissue in Missed None to severe None No incoaguloparhy FHT with Habitual: 3 or more consecutiv ultrasound May represent signs of any of the above; usually detected in the threatened phase; cervical closure (McDonald surgery and Shirodkar-Barter surgery) may be employed. cervix None None Complete placenta with fetus Fetal or, incomplete placental tissue None No No No No Cervical Dilation None Tissue Passage None Fever No

Threatened Slight

e Septic

Mild to severe

Severe

Close or

Possibly,

Yes

open with foul or without discharge tissue

Nursing Care for Clients with Abortion THREATENED ABORTION INEVITABLE ABORTION Advise on complete bedrest for 24 to 48 hours Teach to save all blood clots passed and perineal pads used Advise prompt reporting to the hospital if bleeding persists or increases Prevention of abortion: Avoid coitus or orgasm especially around normal time of menstrual period. Save or monitor clots, pads or tissues for correct diagnosis. Monitor VS, blood loss, I & O, change in status and signs of infection and refer any deviation. Institute measures to treat shock as necessary: Replace blood, plasma, and fluids as ordered. Prepare for surgery. Provide psychological support Be non-judgmental Encourage verbalization of fears, frustrations, and concerns.

 Reduce anxiety; offer your presence, calm and non-judgmental reassuring ways. Allow the patient to cry; reassure crying is healthy. Prevent isoimmunization: administer RhoGAM as ordered if: Mother is Rh negative: abortus is Rh positive. Coombs' test result is negative (No isoimmunization yet No antibodies formed yet) Observe client for 48 to 72 hours: provide psychological and physical supported care.

B. ABORTION Termination of pregnancy before the age of viability usually before 20 to 24 weeks Causes of Spontaneous Abortion
a. b.

1.

Defective ovum/congenital defects the most common cause Unknown causes - second leading cause

c. Maternal factors viral infection malnutrition trauma (physical and mental) congenital defects of the reproductive tract incompetent cervix - most common cause of habitual abortion

hormonal - decreased progesterone production increased temperature as in febrile conditions Systemic diseases in the mother - DM, thyroid dysfunction, severe anemia Environmental hazards

Rh incompatibility

2. Types of Abortion
a. b.

Spontaneous - without medical or mechanical intervention Induced - with medical or mechanical intervention

3. Signs of Abortion
a.

Vaginal bleeding or spotting, mild to severe Passage of tissues or products of conception Signs related to blood loss/shock: pallor, tachycardia, tachypnea, cold clammy skin, restlessness, oliguria, air hunger, and hypotension

b. Uterine/abdominal cramps
c. d.

4. Treatment a. Surgery: dilatation/suction curettage b. Antibiotics: specially for septic type c. Blood, plasma, fluid replacement
d.

Habitual abortion: determine etiology; treatment of underlying causes; cerclage operation/cervical closure for incompetent cervix:

McDonald surgery: temporary closure of the cervix; requires stitch removal set at the time of labor. Shirodkar-Barter surgery: permanent suturing of the cervix; delivery by cesarean section.

e.

Blood tests: BT, Rh factor, Coombs' test serum fibrinogen, clotting time, platelet

C. ECTOPIC PREGNANCY This is a condition where pregnancy develops outside of the uterine cavity.

1. Predisposing Factors
a. b.

Fallopian tube narrowing or constriction PID: pelvic inflammatory disease salpingitis, endometriosis

c. Puerperal and postpartal sepsis d. Surgery of the fallopian tubes

e.

Congenital anomalies of the fallopian tubes IUD usage: intrauterine device prevents pregnancy by preventing normal implantation

f. Adhesions, spasm, rumors

g.

2. Types (dependent on the site of implantation)

a.

Tubal: MOST COMMON: TYPE; found in 90 to 95% of cases ~ tubal rupture occurs before 12 weeks

b. Cervical c. Abdominal d. Ovarian 3. Assessment Findings

a.

Amenorrhea or abnormal menstrual period/spotting - most common sign Early signs of pregnancy: tubal rupture signs - sudden, acute low abdominal pain radiating to the shoulder Kehrs sign (referred shoulder pain) or neck pain

b.

c. Nausea and vomiting

d.

Bluish navel (Cullen's sign) because of blood in the peritoneal cavity Rectal pressure because of blood in the cul-de-sac Positive pregnancy test in many women (50%) Sign of shock/circulatory collapse

e. f.

g. Sharp localized pain when cervix is touched

h.

4. Laboratory Findings a. Low hemoglobin in and hematocrit

b.

Low HCG (normal value at its peak: 400, 000 I.O./24 hours

c. Elevated WBC 5. Diagnosis

a.

Pelvic ultrasonography - no embryonic sac in the uterine cavity Culdocentesis - aspiration of non-clotting blood from the cul-de-sac of Douglas (positive tubal rupture) Laparoscopy - not common; requires direct visualization Serial testing of HCG beta-subunit offers 100% accurate result

b.

c. d.

6. Treatment
a. b.

Surgical removal of ruptured tube: SALPINGECTOMY Management of profound shock if ruptured: blood replacement

c. Antibiotics 7. Complications a. Hemorrhage b. Infection

c.

Rh sensitization. RhoGAM prevents isoimmunization: given to Rh negative mother with Rh position ectopic pregnancy with a negative Coombs test

8.

Nursing Implimentation a. Carry out an ongoing assessment for shock. b. Implement promptly shock treatment

c. Infuse D5LRS for plasma administration, blood transfusion or drug administration ( use isotonic saline to flush tube first before BT ) as ordered. d. Position on modified Trendelenburg. e. Monitor VS, bleedeing, I & O. f. Provide physical and psychological support pre-operative and post-operative. Anticipate grief. Anticipate possible guilt responses. Anticipate fear related to potential disturbances in childbearing capacity in the future. HYDATIDIFORM MOLE This is a benign neoplasm of the chorion. The chorion fails to develop into a full term placenta, and instead degenerates and become fluid-filled vesicles. . 1. Incidence : common in the orient and in people of low socioeconomic 2.Cause : unknown 3. Risk Factor : Increased or decreased maternal age ; Low socioeconomic status ; low protein diet ; History of abortion and clomiphene / Clomid therapy. 4. Assessment Findings a. Brownish or reddish, intermittent or profuse vaginal bleeding by 12 weeks. b. Expulsion, spontaneous, of molar cyst usually occurs between the 16th to 18th weeks of pregnancy. c. Rapid uterine enlargement inconsistent with the age of gestation. d. Symtoms of PIH before 20 weeks. e. Excessive nausea and vomiting because of excessive HCG ( 1 to 2 Million IU/L/24 hrs. ) f. Positive pregnancy test. g. No fetal signs heart tones, parts, movements.

status.

h. Abdominal pain. 5. Diagnosis a. Passage of vesicles first sign that aids diagnosis b. Triad signs : Big uterus . Vaginal bleeding : brownish and intermittent. HCG greater than 1 million ( N.V. : 400,000 IU/L/24 hrs. ) c. Ultrasound no fetal sac, no fetal parts. d. Flat plate of the abdomen done after 15 weeks- no fetal skeleton. 6. Prognosis : 80% remission after D & C ; may progress to cancer of the chorion : choriocarcinoma. 7. Treatment a. Evacuation by D & C or hysterectomy if no spontaneous evacuation. b. Hysterectomy if above 45 yrs old and no future pregnancy is desired or with increased chorionic gonadotropin levels after D & C. c. HCG titer monitoring for one year. Serum Beta HCG . no pregnancy for one year ( Use contraception ), because signs of pregnancy can mask early signs of choriocarcinoma. d. Medical replacement : blood, fluid , plasma. e. Chemotherapy for malignancy : Methotrexate is the drug of choice. f. Chest X ray to detect early lung metastasis. 8. Complications a. Choriocarcinoma : most dreaded complication. b. Hemorrhage ; most serious during the early treatment phase. c. Uterine perforation d. Infection 9. Nursing Implementation a. Advise bedrest b. Monitor VS, blood loss, molar tissue passage.I & O. c. Maintain fluid and electrolyte balance, plasma, and blood volume through replacements as ordered.

d. Prepare for D & C, hysterotomy or hysterectomy as indicated. e. Provide psychological support : anticipate Fear related to potential development of cancer. Disturbances in self esteem for carrying an abnormal pregnancy. f. Prepare for discharge : emphasize the need for follow up HCG determination for one year: Reinforce instructions on NO PREGNANCY FOR ONE YEAR, give instructions relted to contraceptions. PLACENTA PREVIA Premature separation of abnormally low implanted placenta. 1. Incidence ; Most common cause of bleeding in the third trimester ; occurs in 1:150 to 200 pregnancy. 2. Risk Factors : a. Multiparity : the single most important factor. b. Decreased vascularityin the upper uterine segment as in scarring and tumors. c. Increased age above 35 years d. Multiple pregnancy. 3. Types/ Degree of Placenta Previa I. Low lying Placenta at the lower third of the uterus ; does not cover the internal os. 2. Marginal : may be considered a low-lying type Placenta lies over the margins of internal os. 3. Partial Placenta partly covers the internal os. 4. Complete or Total : Placenta totally covers the internal os 4. Assessment Findings a. painless vaginal bleeding ( fresh ) , bright red, in the third trimester/ 7th month. b. Uterus soft/flaccid ; intermittent hardening if in labor. c. Intermitent Pain if it happens in labor secondary

to uterine contractions d. B leeding may be slight or profuse which may come after an activity, Coitus or internal examination. 5, Diagnosis ; ultrasonography give 95% accurate result - detects site of placenta. 6. Treatment a. Watchful waiting : expectant management , conservative if : the mother is not in labor. Fetus is premature, stable, and not in distress: Bleeding is not severe. b. Amniotomy : artificial rupture of the bag of water causes the fetal head to descend causing mechanical pressure at placenta site controlling bleeding. c. Double setup ( one set for vaginal delivery and another for classical CS ; prepared for I.E. in suspected placenta previa in the following conditions. 1. Term gestation 2, Mother in labor and progressing well 3. Mother and fetus are stable. If the woman is not in labor or in shock. And/ or the fetus is distressed, only one set-up is to be prepared, an emergency CLASSICAL cesarean section set-up. d. DELIVERY ; If conditions for watchful waiting are absent ; 1. Vaginal delivery if birth canal is not obstructed. 2. Cesarean section if placenta placement prevents vaginal birth. In previa, CLASSICAL CS is indicated as the LOWER uterine segment is occupied by the placenta. Future pregnancies will then be terminated by another CS because the presence of a classical scar is contraindication to vaginal delivery ; it is the leading cause of uterine rupture. 7. Complications ; HEMORRHAGE, PREMATURITY, OBSTRUCTION OF BIRTH CANAL. 8. Nursing Implimentation

a. Maintain bedrest left lateral recumbent with a head pillow. b. DO NOT PERFORM AN I.E. or vaginal examination. c. Careful assessment; VS, bleeding, onset/progress of labor, FHT. d. Prepare client for diagnostic ultrasonography. e. Institute shock measures as necessary. Initially, bleeding in previa is rarely life-threatening but may become profuse with internal examination. f. Provide psychological and physical comfort. g. Prepare for conservative management, double set-up or a classical cesarean section. h. Observe for bleeding after delivery ; the lower uterine segment, the site of placental detachment, is not as contractile as the upper fundal portion. ABRUPTIO PLACENTA A complication of late pregnancy or labor characterized by premature partial or complete separation of a normally implanted placenta. Also termed accidental hemorrhage and ablation placenta. 1. Incidence : second leading cause of bleeding in the third trimester; occurs in 1:300 pregnancies. 2. Predisposing factors a..Maternal hypertension : PIH, renal disease b. Sudden uterine decompression as in multiple pregnancy and polyhydramnios. c.Advance age d.Multiparity e.Short umbilical cord f.Trauma; fibrin defects.

3. Types of Abruptio Placenta TYPE I Concealed,covert,or central type ; the classic type Placenta separate at the center causing blood to accumulate behind the placenta. External bleeding not evident. SIGNS OF SHOCK NOT PROPORTIONAL TO THE AMOUNT OF EXTERNAL BLEEDING. TYPE II Marginal, overt , or external bleeding type Placenta separates at the margins. Bleeding is external, usually proportional to the amount of internal bleeding. Maybe complete or incomplete depending on the degree of detachment. 4. Assessment Findings aPainful vaginal bleeding in the third trimester b. Rigid, boardlike, and painful abdomen c. Enlarge uterus due to concealed bleeding; Signs of shock not proportional to the degree of external bleeding ( Classic type ). d. If in labor : titanic contractions with the absence of altering contraction and relaxation of the uterus. 5. Diagnosis a. Clinical diagnosis signs and symptoms b. Ultrasound detect the retroplacental bleeding c. Clotting studies reveal DIC, clotting defects. The thromboplastin from retroplacental clot enters maternal circulation and consumes maternal free fibrinogen resulting in : DIC ( dessiminated intravascular coagulation ); small fibrin clots in circulation. Hypofibrinogenemia : decrease normal fibrinogen results in absence of normal blood coagulation. 6. Complications a. Hemorrhagic shock

b. Couvelaire uterus : Bleeding behind the placenta may cause some of the blood to enter the uterine musculature causing the uterine muscles not to contract well once the placent is delivered. c. Disseminated intravascular coagulation ( DIC ) d. CVA cerebrovascular accident from : DIC , hypertension c. Hypofibrinogenemia d. Renal failure e. Infection h. Prematurity, fetal distress/demise (IUFD ) 7. Nursing Implementation a. Maintain bedrest , Left lateral recumbent ( LLR) b. Careful monitoring : Maternal VS, FHT, Labor onset/progress. I & O measurements, oliguria/anuria. Uterine pain. Bleeding ( not proportional to degree of shock ) c. Administer intravenous fluid, plasma, or blood as ordered. d. Prepare for diagnostic examinations explain results. e. Provide psychological support prepare for all examinations, explain what is happening, and inform/explain results. f. Prepare for emergency birth either per vagina or CS g. Observe for ASSOCIATED PROBLEMS AFTER DELIVERY. Poorly contracting uterus ( Couvelaire Uterus ) causing post partum hemorrhage. Disseminated intravascular coagulation ( DIC ) resulting in hemorrhage and possibly CVA. Hypofibrinogenemia causing postpartal hemorrhage. Prematurity, neonatal distress causing neonatal morbidity and mortality.