Ncma 217 Lec

NCMA217: CARE OF MOTHER, CHILD & ADOLESCENT
PRELIMS REVIEWER: CU1 – CU5

Ms. Karla May G. Jamosmos – 1st SEMESTER A.Y. 2022 – 2023
Bachelor of Science in Nursing : Sec 2-YA-10
NCMA 217 LEC: Prelims Content • Considers the family as a whole and as partners
in care
CU1 Framework for maternal and child • Serves as an advocate to protect the rights of all
health nursing family members
CU2 a. Human Sexuality • Demonstrates a high degree of independent
b. Anatomy of the Male and Female nursing functions
Reproductive System • Promotes health and disease prevention
c. Physiology of Menstruation • Serves as resource person
d. Human Genetics • Respects personal, cultural and spiritual
CU3 Responsible parenthood attitudes and beliefs
CU4 Care of the Fetus • Encourages developmental stimulation of
CU5 a. Normal Diagnostic Laboratory children
Findings and Deviation • Assesses families for strengths and challenges
b. Normal Changes in Pregnancy • Encourages family bonding through rooming-in
CU1: FRAMEWORK FOR MATERNAL AND and family visits in maternal-child settings
CHILD HEALTH NURSING • Encourages early hospital discharge to create
• Obstetrics – Greek word helpful transition process
o Obstare – “to keep watch” • Encourages families to reach out to their
• Pediatric - Greek word community for support
o Pais – “child”
• Major Focus of MHCN FOUR PHASES OF HEALTH CARE
o Care of childbearing and childrearing families
Health Promotion Educating clients to be
aware of good health
through teaching and role
modeling
Health maintenance Intervening to maintain
health when risk of illness
is present
Health restoration Promptly diagnosing and

treating illness using
interventions that will
return client to wellness
most rapidly
Health rehabilitation Preventing further

complications from an
illness
Bringing an ill client back
• MCHN is continuum to an optimal state of
Primary Goal wellness or helping a
• Promotion and maintenance of optimal family client to accept inevitable
health to ensure cycles of optimal childbearing death
and childrearing. STANDARDS OF CARE AND MEASURE OF
MCHN Range of Practice QUALITY (WHO)
• Preconceptual health care • The framework contains eight domains of
• Care of women during three trimesters of quality of care that should be assessed,
pregnancy and the puerperium improved and monitored within the health
• Care of infants during the perinatal period system
• Care of children from birth through adolescence • Health facility teams can use the measures to
• Care in different settings such as birthing room, identify gaps in the quality of care and improve
PICU and the home. the provision and experience of care according
A MATERNAL AND CHILD HEALTH NURSE to the standards and quality statements
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• They are for use by health facility leaders, 5.1: All women and newborns have privacy around the
planners, managers and providers to assess time and labor and childbirth, and their confidentiality is
and monitor the availability of resources, respected.
performance, areas for improvement and the 5.2: No woman or newborn is subjected to mistreatment,
impact of interventions, leading to better such as physical, sexual or verbal abuse, discrimination,
quality. neglect, detainment, extortion or denial of services.
Standard 1: Every woman and newborn receives routine, 5.3: All women have informed choices in the services
evidence-based care and management of complications they receive, and the reasons for interventions or
during labor, childbirth and the early postnatal period outcomes are clearly explained.
according to WHO guidelines. Standard 6: Every woman and her family are provided
a: Women are assessed routinely on admission and with emotional support that is sensitive to their needs
during labor and childbirth are given timely, appropriate and strengthens the woman’s capability.
care. 6.1: Every woman is offered the option to experience
b: Newborns receive routine care immediately after labor and childbirth with the companion of her choice.
birth, 6.2: Every woman receives support to strengthen her
c: Mothers and newborns receive routine postnatal care. capability during childbirth.
1.2: Women with pre-eclampsia or eclampsia promptly Standard 7: For every woman and newborn, competent,
receive appropriate interventions, according to WHO motivated staff are consistently available to provide
guidelines. routine care and manage complications.
1.3: Women with postpartum hemorrhage promptly 7.1: Every woman and child has access at all times to at
receive appropriate interventions, according to WHO least one skilled birth attendant and support staff for
guidelines. routine care and management of complications.
Standard 2: The health information system enables use 7.2: The skilled birth attendants and support staff have
of data to ensure early, appropriate action appropriate competence and skills mix to meet the
2.1: Every woman and newborn has a complete, requirements of labor, childbirth and the early postnatal
accurate, standardized medical record during labor, period
childbirth and the early postnatal period. 7.3: Every health facility has managerial and clinical
2.2: Every health facility has a mechanism for data leadership that is collectively responsible for developing
collection, analysis and feedback as part of its activities and implementing appropriate policies and fosters an
for monitoring and improving performance around the environment that supports facility staff in continuous
time of childbirth to improve the care of every woman quality improvement
and newborn. Standard 8: The health facility has an appropriate
Standard 3: Every woman and newborn with condition(s) physical environment, with adequate water, sanitation
that cannot be dealt with effectively with the available and energy supplies, medicines, supplies and equipment
resources is appropriately referred. for routine maternal and newborn care and
3.1 Every woman and newborn is appropriately assessed management of complications
on admission, during labor and in the early postnatal 8.1: Water, energy, sanitation, hand hygiene and waste
period to determine whether referral is required and the disposal facilities are functional, reliable, safe and
decision to refer is made without delay. sufficient to meet the needs of staff, women and their
3.2: For every woman and newborn who requires families
referral, the referral follows a pre-established plan that 8.2: Areas for labor, childbirth and postnatal care are
can be implemented without delay at any time. designed, organized and maintained so that every
3.3: For every woman and newborn referred within or woman and newborn can be cared for
between health facilities, there is appropriate ADVANCED-PRACTICE ROLES FOR
information exchange and feedback to relevant health NURSES IN MATERNAL AND CHILD
care staff.
Standard 4: Communication with woman and their
HEALTH
I. CLINICAL NURSING SPECIALISTS
families is effective and responds to their needs and
preferences. • Are nurses prepared at the master’s or
4.1: All women and their families receive information doctorate degree level who are capable of
acting as consultants in there are of expertise,
about the care and have effective interactions with staff.
4.2: All women and their families experience coordinated as well as serving as role models, researchers
care, with clear, accurate information exchange between and the teachers of quality nursing care.
relevant health and social care professionals. • Neonatal nurse specialists
Standard 5: Women and newborns receive care with o Manage the care of infants at birth and in
respect and preservation of their dignity. intensive care settings
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o They provide home follow-up care to ensure the o Such a nurse plays a vital role in educating
newborn remains well women about their bodies and sharing with
them methods to prevent illness
o They care for women with illnesses such as
• Lactation consultants sexually transmitted infections, and offer
o Educate women about breastfeeding and information and counsel them about
support them while they learn how to do this reproductive life planning.
• Genetic nurse counselors • Neonatal Nurse Practitioner
o Consult with families about patterns of o is an advanced-practice role for nurses who are
inheritance and offer support to families with a skilled in the care of newborns, both well and ill
child who has inherited a genetic disorder o NNPs may work in level 1, level 2, or level 3
• Case manager newborn nurseries, neonatal follow-up clinics,
o A graduate-level nurse who supervises a group or physician groups.
of patients from the time they enter a health • Family Nurse Practitioner (FNP)
care setting until they are discharged from the o Is an advanced-practice role that provides
setting. health care not only to women and children but
o One that follows people both during an illness also to the family as a whole
and on their return to the community o In conjunction with a physician, an FNP can
o Case management can be a vastly satisfying provide prenatal care for a woman with an
nursing roles, because if the healthcare setting uncomplicated pregnancy. Certified Nurse-
is “seamless.” Midwife (CNM) is an individual educated in the
II. NURSE PRACTIONERS two disciplines of nursing and midwifery and
• Are nurses educated at the master’s or doctoral level. licensed
Recent advances in technology, research and o Plays an important role in assisting women with
knowledge have amplified the need for longer and pregnancy and childbearing. Either
more in-depth education for nurse practitioners as independently or in association with a
they play pivotal roles in today’s health care system physician, the nurse-midwife assumes full
• Has advanced study in the promotion of health and responsibility for the care and management of
prevention of illness in women. Such a nurse plays a women with uncomplicated pregnancies
vital role in educating women about their bodies and • Certified Nurse-Midwife (CNM)
sharing with them methods to prevent illness; in o Is an individual educated in the two disciplines
addition, they care for women with illnesses such as of nursing and midwifery and licensed.
sexually transmitted infections, and offer information o Plays and important role in assisting women
and counsel them about reproductive life planning with pregnancy and childbearing. Either
• Pediatric Nurse Practitioner (PNP) independently or in association with physician,
o is a nurse prepared with extensive skills in the nurse-midwife assumes full responsibility
physical assessment, interviewing, and well- for the care and management of women with
child counseling and care. In this role, a nurse uncomplicated pregnancies.
interviews parents as part of an extensive LEGAL CONSIDERATIONS OF MATERNAL-
health history and performs a physical CHILD PRACTICE
assessment of the child • Maternal and child health nursing carries some legal
o If the PNP determines that a child has a concerns that extend above and beyond other areas
common illness (such as iron deficiency of nursing, because care is often given to an “unseen
anemia), he or she orders the necessary client”—the fetus—or to clients who are not of legal
laboratory tests and prescribes appropriate age for giving consent for medical procedures. In
drugs for therapy addition, labor and birth of a neonate are considered
o If the PNP determines that the child has a major “normal” events, so the risks for a lawsuit are greater
illness (such as congenital subluxated hip, when problems arise (O’Grady et al., 2007)
kidney disease, heart disease), he or she • Nurses are legally responsible for protecting the rights
consults with an associated pediatrician; of their clients, including confidentiality, and are
together. accountable for the quality of their individual nursing
• Women’s Health Practitioner care and that of other health care team members
o Has advanced study in the promotion of health • Understanding the scope of practice and standards of
and prevention of illness in women care can help nurses practice within appropriate legal
parameters
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• Documentation is an essential for protecting a nurse more critically ill than ever before. Because care of
and justifying his or her actions women during pregnancy and of children during their
• Documentation is essential for protecting a nurse and developing years helps protect not only current health
justifying his or her actions but also the health of the next generation, maternal-
• Nurses need to be conscientious about obtaining child health nurses fill these expanded roles to a
informed consent for invasive procedures and unique and special degree
determining that pregnant women are aware of any PHILOSOPHY OF MATERNAL AND CHILD
risk to the fetus associated with a procedure or test HEALTH NURSING
• Adolescents who support themselves or who are • Maternal and child health nursing is family centered;
pregnant are termed “Emancipated minors” or assessment must include both family and individual
“mature minors” and have right to sign for their own assessment data
health care • Maternal and child health nursing is community
ETHICAL CONSIDERATIONS OF PRACTICE centered; the health of families depends on and
Some of the most difficult ethical quandaries in health influences the health of communities
care today are those that involve children and • Maternal and child health nursing is evidence based,
their families: because this is the means whereby critical knowledge
• Conception issues, especially those related to in vitro increases
fertilization, embryo transfer, ownership of • A maternal and child health nurse serves as an
frozen oocytes or sperm, cloning, stem cell research, and advocate to protect the rights of all family members,
surrogate mothers including the fetus
• Abortion, particularly partial-birth abortions • Maternal and child health nursing includes a high
• Fetal rights versus rights of the mother degree of independent nursing functions, because
• Use of fetal tissue for research teaching and counseling are major interventions
• Resuscitation (for how long should it be continued) • Promoting health and disease prevention are
• Number of procedures or degree of pain that a child important nursing roles because these protect the
should be asked to endure to achieve a degree of health of the next generation
better health • Maternal and child health nurses serve as important
• Balance between modern technology and quality of resources for families during childbearing and
life childrearing as these can be extremely stressful times
NURSING THEORY in a life cycle
• One of the requirements of a profession (together • Personal, cultural, and religious attitudes and beliefs
with other critical determinants, such as member-set influence the meaning and impact of childbearing and
standards, monitoring of practice quality, and childrearing on families
participation in research) is that the concentration of • Circumstances such as illness or pregnancy are
a discipline’s knowledge flows from a base of meaningful only in the context of a total life
established theory • Maternal and child health nursing is a challenging role
• Nursing theorists offer helpful ways to view clients so for nurses and a major factor in keeping families well
that nursing activities can best meet client needs—for and optimally functioning
example, by seeing a pregnant woman not simply as a GOALS OF MATERNAL AND CHILD
physical form but as a dynamic force with important HEALTH NURSING
psychosocial needs, or by viewing children as The primary goal of maternal and child health
extensions or active members of a family as well as nursing care can be stated simply as the promotion and
independent beings. Only with this broad theoretical maintenance of optimal family health to ensure cycles of
focus can nurses appreciate the significant effect on a optimal childbearing and childrearing
family of a child’s illness or of the introduction of a • The goals of maternal and child health nursing care
new member are necessarily broad because the scope of practice
• Another issue most nursing theorist’s address is how (the range of services and care that may be provided
nurses should be viewed or what the goals of nursing by a nurse based on state requirements) is so broad.
care should be. Extensive changes in the scope of The range of practice includes:
maternal and child health nursing have occurred as o Preconceptual health care
health promotion, or keeping parents and children o Care of women during three trimesters of
well, has become a greater priority pregnancy and the puerperium (the 6 weeks
• With health promotion as a major nursing goal, after childbirth, sometimes termed the fourth
teaching, counseling, supporting, and advocacy are trimester of pregnancy)
also common roles. Nurses care for clients who are
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o Care of infants during the perinatal period (6 o Perinatal period is the time period beginning
weeks before conception to 6 weeks after birth) when a fetus reaches 500g (about 20 weeks)
o Care of children from birth through adolescence and ending about 4 to 6 weeks after birth.
o Care in settings as varied as the birthing room, • Maternal mortality rate
the pediatric intensive care unit, and the home o Number of maternal deaths per 100.000 live
• In all settings and types of care, keeping the family at births that occur as a direct result of the
the center of care or considering the family as the reproductive process
primary unit of care is an essential goal. This is o Severe bleeding (mostly bleeding after
because the level of a family’s functioning affects the childbirth)
health status of its members o Infections (usually after childbirth)
• A healthy family, on the other hand, establishes an o High blood pressure during pregnancy (pre-
environment conducive to growth and health- eclampsia and eclampsia)
promoting behaviors that sustain family members o Complications from delivery
during crises. Similarly, the health of an individual and o Unsafe abortion Philippines maternal ratio was
his or her ability to function strongly influence the at level of 121 deaths per 100,000 live births in
health of family members and overall family 2017, down from 124 deaths per 100,000 live
functioning. For these reasons, a family-centered births previous year, this is a change of 2.42%
approach enables nurses to better understand • Infant mortality rate
individuals and their effect on others and, in turn, to o Number of deaths per 1000 live births occurring
provide holistic care at birth or in the first 12 months of life
STATISTICAL TERMS USED TO REPORT o Traditional standard used to compare the
MATERNAL AND CHILD HEALTH health care of a nation with that previous years
or of other countries
• Birth rate
o The infant mortality rate for Philippines in 2019
o Number of births per 1000 population
was 19.239 deaths per 1000 live births, a 2.16%
o The social structure, religious beliefs, economic
decline from 2018
prosperity and urbanization within each country
o The top three leading causes of infant mortality
are likely to affect birth rates
rate were Pneumonia (3.146; 14.3%), Bacterial
• Fertility Rate
sepsis of newborn (2,731; 12.4%) and
o Number of pregnancies per 1000 women of
Respiratory distress of newborn (2,347; 10.7%)
childrearing age
• Childhood mortality rate
o May be low in countries trouble by famine, war
o Number of deaths per 1000 population in
or disease
children, 1 to 14 years of age
• Fetal death rate
o Respiratory disorders (asthma and tuberculosis)
o Number of fetal deaths (weighing more 500g)
o Gastrointestinal disturbances, and
per 1000 live births
consequences of injuries
o May occur due to maternal factors such as
o Obesity
maternal disease, premature cervical dilatation
or maternal nutrition MILLENNIUM DEVELOPMENT GOALS
o Fetal factors such as fetal disease, chromosome 2000-2015
abnormality or poor placement attachment • In September 2000, leaders of 189 countries
o Important in evaluating the health of a nation gathered at the United Nations headquarters and
because it reflects the overall quality of signed the historic Millennium Declaration.
maternal health and prenatal care. • They committed to achieving a set of eight
• Neonatal death rate measurable goals that range from halving extreme
o Number of deaths per 1000 live births occurring poverty and hunger to promoting gender equality
at birth or in the first 28 days of life and reducing child mortality, by the target date of
o Reflects not only the quality of care available to 2015
women during pregnancy and childbirth but • Substantial progress has been made regarding the
also the quality of life to infants during the first MDGs. The world has already realized the first MDG
month of life of halving the extreme poverty rate by 2015.
• Perinatal death rate However, the achievements have been uneven
o Number of deaths per 1000 live births • The MDGs expired in 2015 and the discussion of a
occurring at birth or in the first 28 days of life post-2015 agenda continued
per 1000 live births • The focus is now on building a sustainable world
where environmental sustainability, social inclusion
and economic development are equally valued.
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SUSTAINABLE DEVELOPMENT GOALS • Is a multidimensional concept
(2015-2030) • It can be defined broadly by stating that
sexuality integrates the somatic (bodily),
emotional, intellectual and social aspects of
being a human sexual being.
• It involves the anatomy and physiology of the
human body as well as one’s attitudes and
feelings about oneself.
Biologic Gender
• Is the term used to denote chromosomal
sexual development
• Male (XY) or Female (XX)
Gender/Sexual identity
• Is the inner sense a person has of being male or
female
Gender Role
• The Rio+20 conference (the united nations
• Is the behavior a person conveys about being a
conference on sustainable development) in Rio de
male or female
Janeiro, June 2012, galvanized a process to develop a
new set of Sustainable Development Goals (SDGs)
COMPONENTS OF SEXUALITY
a. Reproductive Sexuality
which will carry on the momentum generated by the
MDGs and fit into a global development framework • Involves the biological aspects of
beyond 2015 conception and procreation
• In July 2014, the UN General Assembly Open Working • It includes the sexual response
Group (OWG) proposed a document containing 17 b. Gender Sexuality
goals to be put forward for the general assembly’s • Deals with the social and emotional aspects
approval in September 2015 of being a man or a woman
• This document set the ground for the new SDGs and c. Erotic Sexuality
the global development agenda spanning from 2015- • Refers to sexual love and arousing sexual desires
2030 TYPES OF SEXUAL ORIENTATION
• The sustainable development goals are the blueprint • Sexual gratification is experienced in several ways.
to achieve a better and more sustainable future for What is considered normal varies greatly among
all cultures, although general components of accepted
• They address the global challenges we face including sexual activity are that it is an activity of adults and
those related to poverty, inequality, climate change, privacy, consent and lack of force are included.
environmental degradation, peace and justice a. Heterosexuality
• The 17 goals are all interconnected and in order to • One who finds sexual fulfillment with a
leave no one behind, it is important that we achieve member of opposite gender
them all by 2030. b. Homosexuality
SDG 3: ENSURE HEALTHY LIVES AND PROMOTE • A person who finds sexual fulfillment with a
WELLBEING FOR ALL AT ALL AGES member of his or her own sex
The goals within a goal: Health targets for SDG 3 • Usually they prefer to be called as “gay” for
specific to MCHN men and “lesbian” for women
3.1 By 2030, reduce the global maternal mortality ratio • More recent terms are “men who have sex
to less than 70 per 100,000 live births. with men” (MWM) and “women who have
3.2 By 2030, end preventable deaths of newborns and sex with women” (WWW)
children under 5 years of age, with all countries aiming • Many young adults are worried about the
to reduce neonatal mortality to at least as low as 12 per stigma of being labeled homosexual
1000 live births and under-5 mortality to at least low as therefore they keep their identity secret
25 per 1000 live births. from heterosexual acquaintances.
3.7 By 2030, ensure universal access to sexual and c. Bisexuality
reproductive health-care services, including for family • People are bisexual if they achieve sexual
planning, information and education, and the satisfaction from both homosexual and
integration of reproductive health into national heterosexual relationship
strategies and programs. • Men who have sex with men or bisexual
CU2A: HUMAN SEXUALITY men may be at greater risk for HIV and STIs
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• Female partners of bisexual men need to be • Some parents of adolescents may need to
aware that they are also at increased risk be assured that an interest in this type of
for HIV and other STIs material is developmental and normal
d. Transexual or Transgender i. Fetishism
• Is an individual who, although one biologic • Sexual arousal resulting from the use of
gender, feels as is he or she should be of the certain objects or situations. Leather,
opposite gender rubber, shoes and feet are frequently
• Sex change operations (synthetic perceived to have erotic qualities.
vagina/penis) • The object of stimulation does not just
SEXUAL EXPRESSION enhance the experience, rather it becomes
a. Celibacy or sexual abstinence a focus of arousal and a person may come
• Abstinence from sexual activity to require the object or situation for
• Ability to concentrate on the means of stimulation
giving and receiving love other than DISORDER OF SEXUAL FUNCTIONING
through sexual expressions a. Erectile Dysfunction
• It is avowed state of certain religious orders • Formerly referred to as impotence
• It is a way of life for many adults and one • Inability to produce or maintain an erection
that is becoming fashionable among a long enough for vaginal penetration or
growing number of young adults partner satisfaction
• It is the main point of many high school sex b. Premature ejaculation
education classes • Ejaculation before penile contact
b. Transvestite • Can be unsatisfactory and frustrating to
• Individual who dresses to take on the role both partners
of the opposite sex • Can be psychological
• Can be heterosexual, homosexual or c. Failure to achieve orgasm
bisexual • Can be due to poor sexual technique
• Some transvestites are particularly married • Possible negative attitudes toward sexual
heterosexuals, may be under a great deal of relationships
strain to keep their lifestyle a secret from d. Vaginismus
friends and neighbors • Involuntary contraction of the muscles at
c. Voyeurism the outlet of the vagina when coitus is
• Sexual arousal by looking at another’s body attempted
• Almost all children and adolescent pass • This muscle contraction prohibits penile
through a stage when voyeurism is penetration
appealing e. Dyspareunia
d. Sadomasochism • Pain during coitus
• Involves inflicting pain (sadism) or receiving • Can be due to endometriosis
pain (masochism) to achieve sexual f. Inhibited sexual desire
satisfaction • Lack of desire for sexual relations, may be a
e. Masturbation concern of young or middle-aged adults
• Self-stimulation for erotic pleasure • Support or a caring sexual partner or relief
• Children between ages 2 to 6 years discover of the tension causing the stress allows a
masturbation as an enjoyable activity as return to sexual interest
they explore their bodies HUMAN SEXUAL RESPONSE
f. Exhibitionism • Sexuality has always been a part of human life
• Revealing one’s genitals in public but it is only in the past few decades that it has
g. Pedophiles been studied scientifically.
• Interested in sexual encounters with • One common findings of researchers has been
children that feelings and attitudes about sex vary
h. Erotic stimulation widely; the sexual experience is unique to each
• Is the use of visual materials such as individual, but sexual physiology
magazines or photographs for sexual a. Excitement
arousal • Occurs with physical and psychological
stimulation that causes parasympathetic nerve
stimulation. This leads to arterial dilation and
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venous constriction in the genital area. The CU2B: ANATOMY OF THE MALE AND
resulting increased blood supply leads to FEMALE REPRODUCTIVE SYSTEM
vasocongestion and increasing muscular REPRODUCTIVE DEVELOPMENT
tension
• In women, this vasocongestion causes the
clitoris to increase in size and mucoid fluid to
appear on vaginal walls as lubrication.
o The vagina widens in diameter and
increases in length
o The nipples become erect
• In men, penile erection occurs, as well as scrotal
thickening and elevation of testes
• In both sexes, there is an increase in heart and
respiratory rates and blood pressure
b. Plateau
• Reached before orgasm Intrauterine Development - The sex of an individual is
• In woman, the clitoris is drawn forward and determined at the moment of conception by the
retracts under the clitoral prepuce, the lower chromosome information supplied by the particular
part of the vagina becomes extremely ovum and sperm that joined to create the new life.
congested and there is increased nipple • Gonad – is a body organ that produces the cells
elevation necessary for reproduction (the ovary in females, the
• In men, the vasocongestion leads to distention testis in males).
of the penis. o At approximately week 5 of intrauterine life,
o Heart rate increases to 100 to 175 beats per primitive gonadal tissue is already formed
minute and respiratory rate to • In both sexes, two undifferentiated ducts, the
approximately 40 respirations per minute mesonephric (wolffian) in males and paramesonephric
c. Orgasm (müllerian) ducts in females, are present
• Occurs when stimulation proceeds through the • By week 7 or 8, in chromosomal males, this early
plateau stage to a point at which the body gonadal tissue differentiates into primitive testes and
suddenly discharges to a point at which the begins formation of testosterone. Under the influence
body suddenly discharges accumulated sexual of testosterone, the mesonephric duct begins to
tension develop into the male reproductive organs, and the
• A vigorous contraction of muscles in the pelvic paramesonephric duct regresses. If testosterone is
area expels or dissipate blood and fluid from the not present by week 10, the gonadal tissue
area of congestion. differentiates into ovaries, and the paramesonephric
o The average number of contractions at duct develops into female reproductive organs
intervals of 1 every 0.8 seconds • Pubertal Development - Puberty is the stage of life at
• In men, muscle contractions surrounding the which secondary sex changes begin
seminal vessels and prostate project semen into o These changes are stimulated when the
the proximal urethra. hypothalamus synthesizes and releases
o These contractions are followed gonadotropin-releasing hormone (GnRH),
immediately by three to seven propulsive which in turn triggers the anterior pituitary
ejaculatory contractions, occurring at the to begin the release of follicle-stimulating
same time interval as in the woman, which hormone (FSH) and luteinizing hormone
force semen from the penis (LH). FSH and LH initiate the production of
d. Resolution androgen and estrogen, which in turn initiate
• Is a 30-minute period during which the external secondary sex characteristics, the visible
and internal genital organs return to an signs of maturity.
unaroused state • Role of Androgen - Androgenic hormones are the
• For the male, a refractory period occurs during hormones responsible for muscular development,
which further orgasm is impossible physical growth, and the increase in sebaceous gland
• Women do not go through this refractory secretions that causes typical acne in both boys and
period, so it is possible for women who are girls. In males, androgenic hormones are produced by
interested and properly stimulated to have the adrenal cortex and the testes; in females, by the
additional orgasms immediately after the first adrenal cortex and the ovaries.
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• Role of Estrogen – When triggered at puberty by FSH, o Cowper’s glands
ovarian follicles in females begin to excrete a high ANATOMY AND PHYSIOLOGY OF THE
level of the hormone estrogen. This hormone is REPRODUCTIVE SYSTEM
actually not one substance but three compounds • The major function of the reproductive system
(estrone [E1], estradiol [E2], and estriol [E3]). is to ensure survival of the species. An individual
may live a long, healthy, and happy life without
SECONDARY SEX CHARACTERISTICS
producing offspring, but if the species is to
Adolescent sexual development is categorized into continue, at least some individuals must
stages (Tanner, 1990). There is wide variation in the time produce offspring.
required for adolescents to move through these • Within the context of producing offspring, the
developmental stages; however, the sequential order is reproductive system has four functions:
fairly constant. o To produce egg and sperm cells
In girls, pubertal changes typically are manifest as: o To transport and sustain these cells
• Growth Spurt o To nurture the developing offspring
• Increase in the transverse diameter of the o To produce hormones
pelvis Roles of androgens
• Breast development Androgenic hormones – responsible for muscular
• Growth of pubic hair development, physical growth and an increase in
• Onset of menstruation sebaceous gland secretions causing typical acne in both
• Growth of axillary hair boys and girls
- produce by adrenal cortex and testes (males)
• Vaginal secretions
Secondary sex characteristics of boys usually occur in the MALE REPRODUCTIVE SYSTEM
order of:
• Increase in weight
• Growth of testes
• Growth of face, axillary, and pubic hair
• Voice changes
• Penile growth
• Increase in height
• Spermatogenesis (production of sperm)
Estrogen – breasts grow, pubic hair grows, wide hips
develop
Testosterone – body hair grows, voice breaks, muscle
growth increases
Puberty – is the stage if life at which secondary sex Functions
changes begin • Production of gametes
o Usually starts in girls at 10-13 years old and o Male sex cells (sperm)
boys starts at 12-14 years old • Synthesis of androgens
o Is initiated by hypothalamic pituitary or o Male sex hormones (testosterone)
gonad complex • Delivery of sperm into the female reproductive
FEMALE AND MALE REPRODUCTIVE tract
HOMOLOGUES Male External Structures
• Female . Scrotum
o Clitoris glans • Loose pouch-like sac of skin that hangs behind
o Clitoral shaft the penis
o Labia majora • is a rugated, skin-covered, muscular pouch
o Ovaries suspended from the perineum.
o Skene’s glands • Contains testes, epididymis and the lower
o Bartholin’s glands portion of the spermatic cord
• Male • In very cold weather, the scrotal muscle
o Penile glans contracts to bring the testes closer to the body;
o Penile shaft • In very hot weather, or in the presence of fever,
o Scrotum the muscle relaxes, allowing the testes to fall
o Testes away from the body.
o Prostate
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• Functions: support the testes, helps regulate • Prepuce – also called the foreskin. Loose skin
the temperature of sperm through contraction attached to the shaft, allowing for expansion
and relaxation during erection. Retractable casing of skin that
b. Testes protects the nerve sensitive glans at birth
• are two ovoid glands, 2 to 3 cm wide, that lie in • Frenulum – ventral fold of tissue attaches the
the scrotum (walnut size). skin to the glans. Contains the urethra as well as
• Each testis is encased by a protective white 3 erectile bodies
fibrous capsule and is composed of several o 2 dorsal erectile tissues known as the
lobules, with each lobule containing interstitial corpora cavernosa
cells (Leydig’s cells) and a seminiferous tubule o 1 midventral tissue known as the
• Surrounded by 2 tunics corpus spongiosum
o Tunica vaginalis – derived from the § Surrounds penile urethra
parietal peritoneum § Expands distally to form the
o Tunica albuginea glans penis
• Seminiferous tubules produce spermatozoa
• Leydig’s cells – are responsible for the
production of testosterone
• Testes in a fetus first form in the pelvic cavity.
They descend, late in intrauterine life (about the
34th to 38th week), into the scrotal sac. Because
this descent occurs so late in pregnancy, many
male preterm infants are born with
undescended testes
• In most males, one testis is slightly larger than
the other and is suspended slightly lower in the
scrotum than the other (usually the left one).
Because of this, testes tend to slide past each
other more readily on sitting or muscular
activity, and there is less possibility of trauma to
them
• Spermatozoa do not survive at a temperature as
high as that of the body, however, so the
location of the testes outside the body, where
the temperature is approximately 1° F lower
than body temperature, provides protection for
sperm survival
c. Penis
• Tubular structure located above the scrotum,
composed of shaft and glans
• Soft and flaccid (2.5 inches to 4 inches)
• Erection – blood vessels in the shaft become
congested, penis become hard and erect (5.5 to
7 inches)
• The penis is composed of three cylindrical Sexual excitement
masses of erectile tissue in the penis shaft: • Nitric acid is released from the endothelium of
o two termed the corpus cavernosa, and blood vessels
a third termed the corpus spongiosum. • Result in engorgement or an increase in the
The urethra passes through these blood flow to the arteries of the penis
layers of erectile tissue, making the • The ischiocavernosus muscle at the penis base
penis serve as the outlet for both the then contracts
urinary and the reproductive tracts in • Trapping both venous and arterial blood in the
men. 3 sections of erectile tissue
• Glans – the distal end of the organ is bulging • Leading to distention and erection of the penis
sensitive ridge of tissue which has the external Male Internal Structures
urinary meatus at its tip a. Epididymis
• Corona – the proximal margin of the glans
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• the seminiferous tubule of each testis leads to a colliculus seminalis. During ejaculation, semen
tightly coiled tube, the epididymis, which is passes through the ducts and exits the body via
responsible for conducting sperm from the the penis
tubule to the vas deferens, the next step in the e. Prostate Glands
passage to the outside. • is a chestnut-sized gland that lies just below the
• Because each epididymis is so tightly coiled, its bladder. The urethra passes through the center
length is extremely deceptive: it is actually over of it, like the hole in a doughnut.
20 ft long. • The prostate gland secretes a thin, alkaline fluid.
• Some sperm are stored in the epididymis, and a When added to the secretion from the seminal
portion of the alkaline fluid that will surround vesicles and the accompanying sperm from the
sperm at maturity (semen, or seminal fluid that epididymis, this alkaline fluid further protects
contains a basic sugar and mucin, a form of sperm from being immobilized by the naturally
protein) is produced by the cells lining the low pH level of the urethra.
epididymis f. Bulbourethral Glands
• Sperm are immobile and incapable of • two bulbourethral or Cowper’s glands lie beside
fertilization as they pass or are stored at the the prostate gland and empty via short ducts
epididymis level into the urethra. Like the prostate gland and
• It takes at least 12 to 20 days for them to travel seminal vesicles, they secrete an alkaline fluid
the length of the epididymis and a total of 64 that helps counteract the acid secretion of the
days for them to reach maturity urethra and ensure the safe passage of
• Aspermia (absence of sperm) and oligospermia spermatozoa.
(20 million sperm/mL) are problems that do not g. Urethra
appear to respond immediately to therapy but • is a hollow tube leading from the base of the
rather only 2 months bladder, which, after passing through the
b. Vas Deferens (Ductus Deferens) prostate gland, continues to the outside
• is an additional hollow tube surrounded by through the shaft and glans of the penis.
arteries and veins and protected by a thick • It is approximately 8 in (18 to 20 cm) long
fibrous coating. • 3 sections
• It carries sperm from the epididymis through o Prostatic – within the prostate
the inguinal canal into the abdominal cavity, o Membranous – within the urogenital
where it ends at the seminal vesicles and the diaphragm
ejaculatory ducts. o Penile (spongy) – within the penis
• Sperm mature as they pass through the vas • Seminal Plasma – liquid produced by seminal
deferens. vesicles, prostate gland and cowper’s gland
• It Is believed that the vas deferens acts as o Aids in the transport of sperm
reservoir for sperm between ejaculation o Provides energizing nutrients for the
• Vasectomy – (severing of the vas deferens to sperm
prevent passage of sperm) is a popular means o contains form of sugar – fructose,
of male birth control mucous, salts, water, base buffers and
c. Seminal Vesicles coagulators to aid the sperm in their
• are two convoluted pouches that lie along the journey
lower portion of the posterior surface of the • Semen/Seminal fluid – thick, creamy white fluid
bladder and empty into the urethra by way of with the consistency of mucus or egg whites
the ejaculatory ducts. o Normal amount is 2mL – 6mL per
• These glands secrete a viscous alkaline liquid ejaculation
that has a high sugar, protein, and prostaglandin o fertile man will dispel 20-160 million
content. sperm per ejaculate
• Sperm become increasingly motile with this • Spermatozoon – is made up of a head and a tail
added fluid, because it surrounds them with o The head carries the male’s haploid
nutrients and a more favorable pH. number of chromosomes (23)
d. Ejaculatory Ducts o The part that enters the ovum at
• These are formed by the fusion of the vas fertilization
deferens and the seminal vesicles o The tail specialize in motility
• Causes the reflex action of ejaculation o Sperm maybe stored in the male
• They begin at the vas deferens, pass through the genital system for 42 days
prostate and empty into the urethra at the
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o Sperm can live only 2-3 days in the • It contains multitude of sebaceous and sweat
female genital tract once ejaculated glands
FEMALE REPRODUCTIVE SYSTEM d. Vestibule
• is the flattened, smooth surface inside the labia.
The openings to the bladder (the urethra) and
the uterus (the vagina) both arise from the
vestibule
e. Clitoris
• Is a small (approximately 1 to 2 cm), rounded
organ of erectile tissue at the forward junction
of the labia minora. It is covered by a fold of
skin, the prepuce.
is sensitive to touch and temperature and is the
center of sexual arousal and orgasm in a
woman.
• It is made up of erectile tissue which many large
and venous channels surrounded by large
• It produces the female egg cells necessary for amount of involuntary muscle tissue, the
production called the ova or oocytes ischiocarvernosa facilitate erection of the organ
• It is designed to transport the ova to the site of • Measure 5-6 mm long and 6-8mm across
fertilization • It has very rich blood and nerve supplies
• If fertilization does not take place, the system is • Functions: stimulate and elevate levels of
designed to menstruate sexual tension, serves as a landmark in locating
• It produces female sex hormone that maintain urethral opening during catheterization
the reproductive cycle f. Urethral meatus/urethral orifice
Female External Structures • Although not a true part, it is considered as part
a. Mons Veneris/Pubis of the reproductive system because of its
• is a pad of adipose tissue located over the closeness and relationship to the vulva
symphysis pubis, the pubic bone joint. It is g. Skene’s Glands (paraurethral glands)
covered by a triangle of coarse, curly hairs • are located just lateral to the urinary meatus,
• It contains many nerve ending that makes the one on each side. Their ducts open into the
mons pubis sensitive to touch and pressure urethra.
• Functions: is to protect the junction of the pubic h. Bartholin’s Glands (vulvovaginal glands)
bone from trauma • are located just lateral to the vaginal opening on
b. Labia Minora both sides. Their ducts open into the distal
• just posterior to the mons veneris spread two vagina.
hairless folds of connective tissue, the labia • Secretions from both of these glands help to
minora. Before menarche, these folds are fairly lubricate the external genitalia during coitus.
small; by childbearing age, they are firm and • The alkaline pH of their secretions helps to
full; after menopause, they atrophy and again improve sperm survival in the vagina.
become much smaller. i. Vaginal orifice/introitus
o It appears thin pale pink in color. When • Occupies the lower portion of the vestibules
stimulated, it turns to dark red or dark and varies considerably in size and shape
pink due to presence of blood vessels, • The vagina has an abundantly vascular supply
no hair; smooth in texture j. Fourchette
c. Labia Majora • is the ridge of tissue formed by the posterior
• are two folds of adipose tissue covered by loose joining of the two labia minora and the labia
connective tissue and epithelium that are majora. This is the structure that is sometimes
positioned lateral to the labia minora. Covered cut (episiotomy) during childbirth to enlarge the
by pubic hair, the labia majora serve as vaginal opening
protection for the external genitalia and the k. Perineum
distal urethra and vagina. • Located just posterior to the fourchette
• The outer lips separates downward from the • Is a muscular area, that’s easily stretched during
mons and meet again below the vagina introitus childbirth to allow enlargement of the vagina
and passage of the fetal head
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• Many exercises are aimed at making the • The fallopian tubes arise from each upper
perineal muscle more flexible to allow easier corner of the uterine body and extend outward
expansion during birth without tearing of this and backward until each opens at its distal end,
tissue (kegel’s, squatting and tailor-sitting) next to an ovary. Fallopian tubes are
l. Hymen approximately 10 cm long in a mature woman.
• is a tough but elastic semicircle of tissue that Their function is to convey the ovum from the
covers the opening to the vagina in childhood. It ovaries to the uterus and to provide a place for
is often torn during the time of first sexual fertilization of the ovum by sperm.
intercourse. However, because of the use of • It takes about 3 days for an egg to travel the
tampons and active sports participation, many length, but unfertilized eggs lives only 24 hours
girls who have not had sexual relations do not • Functions: site of fertilization, provide transport
have intact hymens at the time of their first for the ovum from the ovary to the uterus,
pelvic examination. serves as a warm, moist, nourishing
Female Internal Structures environment for the oum or zygote
a. Ovaries • Interstitial Portion – most proximal division
• The ovaries are approximately 4 cm long by 2 o Is that part of the tube that lies within
cm in diameter and approximately 1.5 cm thick, the uterine wall
or the size and shape of almonds. o This portion is only about 1 cm length;
• They are grayish white and appear pitted, or the lumen of the tube is only 1 mm in
with minute indentations on the surface. diameter at this point
• The function of the two ovaries (the female • Isthmus – next distal portion
gonads) is to produce, mature, and discharge o Is approximately 2 cm in length and like
ova (the egg cells). In the process, the ovaries the interstitial tube, is extremely
produce estrogen and progesterone and initiate narrow
and regulate menstrual cycles. o Is the portion of the tube that is cut or
• Ovarian function, therefore, is necessary for sealed in a tubal ligation or tubal
maturation and maintenance of secondary sex sterilization procedure
characteristics in females. • Ampulla – third and the longest portion of the
• At birth, each ovary contains approximately 2 tube
million immature ova (oocytes), which were o Is approximately 5cm in length
formed during the first 5 months of intrauterine o It is in this portion that fertilization of
life. an ovum usually occurs
• By age 7 years, only approximately 500,000 are • Infundibular – most distal segment of the tube
present in each ovary; by 22 years, there are o Is approximately 2 cm long and is
approximately 300,000; and by menopause, funnel shaped
none are left (all have either matured or o The rim of the funnel is covered by
atrophied). fimbria (small hairs) that help to guide
Three principal divisions the ovum into the fallopian tube
o Protective layer of surface epithelium • The wall of the fallopian tube is made up of 4
o Cortex, where the immature (primordial) layers:
oocytes mature into ova and large amounts of o Peritoneal (serous) – covers the tubes
estrogen and progesterone are produced o Subserous (adventitial) – contains the
o Central medulla, which contains the nerves, blood and nerve supply
blood vessels, lymphatic tissue, and some o Muscular – responsible for the
smooth muscle tissue peristaltic movement of the tube
Layers of ovaries o Mucosal – composed of ciliated and
o Tunica albuginea – dense and dull white and unciliated cells with the number of
serves as protective layer ciliated cells more abundant at the
o Cortex – main functional part because it fimbria
contains ova, graafian follicles, corpora lutea,
degenerated corpora lutea (corpora
albicantia)
o Medulla – central portion of the ovary is
composed of loose connective tissue
o Functions: ovulation, hormone production
b. Fallopian Tubes
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c. Uterus • External cervical os - distal opening to the
vagina. The level of the external os is at the level
of the ischial spines (an important relationship
in estimating the level of the fetus in the birth
canal
• Cervical mucosa has 3 functions
o Provide lubrication for the vaginal
canal
o Act as a bacteriostatic agent
o Provide an alkaline environment to
shelter deposited sperm from the
acidic vagina
• Secretory cells of the cervix produce about 20-
60 mL of mucus per day
• At the time of ovulation, the mucus becomes
• is a hollow, muscular, pear-shaped organ thinner and more alkaline
located in the lower pelvis, posterior to the • Mucus – provides for the energy needs of the
bladder and anterior to the rectum. sperm, protects sperm from the environment of
• It is approximately the size of an olive the vagina and protects them from phagocytes.
• An adolescent is closer to 17 years old before At other times, mucus becomes thick and can
the uterus reaches its adult size. With maturity, form a cervical plug which impedes passage of
a uterus is approximately 5 to 7 cm long, 5 cm pathogens
wide, and, in its widest upper part, 2.5 cm deep. Layers of Uterus
In a nonpregnant state, it weighs approximately • Perimetrium – a part of visceral peritoneum
60 g. • Myometrium – bulk of uterus.
• Functions: to receive the ovum from the o Three layers of muscle that contract
fallopian tube; provide a place for implantation under influence of oxytocin during
and nourishment; furnish protection to a labor
growing fetus; and, at maturity of the fetus, • Endometrium – highly vascular mucosa
expel it from a woman’s body. o Stratum functionalis – shed during
• Anatomically, the uterus consists of three menstruation
divisions: o Stratum basalis – deeper, permanent
o Body of the uterus – is the uppermost layer, gives rise to new stratum
part and forms the bulk of the organ. functionalis
During pregnancy, the body of the d. Vagina
uterus is the portion of the structure • passageway for sperm and menstrual flow
that expands to contain the growing • Receptacle for penis during intercourse
fetus. • Inferior portion of birth canal
o Fundus – the portion that can be • Capable of considerable distention (stretching)
palpated to measure uterine growth • Mucosa – is continuous with that of uterus and
and the force of uterine contraction consists of nonkeratinized stratified squamous
during labor epithelium
o Isthmus of the uterus – is a short
• Contains large stores of glycogen which
segment between the body and the
decomposes to organic acids
cervix. In the nonpregnant uterus, it is
• lower pH = less susceptible to infection and less
only 1 to 2 mm in length. It is the
hospitable to sperm
portion of the uterus that is most
commonly cut when a fetus is born by
a cesarean birth.
o Cervix – is the lowest portion of the
uterus. It represents approximately
one third of the total uterus size and is
approximately 2 to 5 cm long.
• Cervical canal – central activity
• Internal cervical os – junction of the canal at the
isthmus
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e. Breasts about 30-60 cc of blood, epithelial cells and
mucus are being discharged.
• About once a month, the uterus grows a new,
thickened lining (endometrium) that can hold a
fertilized egg. Once there is no fertilized egg to
start a pregnancy, the uterus sheds its lining
• The purpose of a menstrual cycle is to bring an
ovum to maturity and renew a uterine tissue
bed that will be responsible for the ova’s
growth should it be fertilized. It is the process
that allows for conception and implantation of
a new life.
• Form from ectodermic tissue early in utero. • The length of menstrual cycles differs from
They then remain in a halted stage of woman to woman, but the average length is 28
development until a rise in estrogen at puberty days (from the beginning of one menstrual
produces a marked increase in their size. The flow to the beginning of the next).
size increase occurs mainly because of an • It is not unusual for cycles to be as short as 23
increase of connective tissue plus deposition of days or as long as 35 days. The length of the
fat average menstrual flow (termed menses) is 4
• The glandular tissue of the breasts, necessary to 6 days, although women may have periods
for successful breastfeeding, remains as short as 2 days or as long as 7 days
undeveloped until a first pregnancy begins Physiology of Menstruation
• Milk glands of the breasts are divided by Four body structures are involved in the physiology of
connective tissue partitions into approximately the menstrual cycle: the hypothalamus, the pituitary
20 lobes.All of the glands in each lobe produces gland, the ovaries, and the uterus.
milk by acinar cells and deliver it to the nipple a. Hypothalamus
via a lactiferous duct • The release of GnRH (also called luteinizing
• Nipple hormone–releasing hormone, or LHRH) by the
o has approximately 20 small openings hypothalamus initiates the menstrual cycle.
through which milk is secreted. • GnRH is transmitted from the hypothalamus to
• Ampulla the anterior pituitary gland and signals the
o portion of the duct, located just gland to begin producing the gonadotropic
posterior to the nipple, serves as a hormones FSH and LH. Because production of
reservoir for milk before breastfeeding GnRH is cyclic, menstrual periods also cycle.
o is composed of smooth muscle that is b. Pituitary Gland
capable of erection on manual or • Under the influence of GnRH, the anterior lobe
sucking stimulation. On stimulation, it of the pituitary gland (the adenohypophysis)
transmits sensations to the posterior produces two hormones that act on the ovaries
pituitary gland to release oxytocin. to further influence the menstrual cycle:
• Oxytocin – acts to constrict milk gland cells and o FSH – a hormone that is active early in
push milk forward into the ducts that lead to the the cycle and is responsible for
nipple maturation of the ovum
• Areola – the skin surrounding the nipples, o LH – a hormone that becomes most
darkly pigmented and approximately 4 cm active at the midpoint of the cycle and
• Montgomery’s tubercles – area that appears is responsible for ovulation, or release
rough on the surface because it contains many of the mature egg cell from the ovary,
sebaceous glands and growth of the uterine lining
• Gynecomastia – increase in male breast size. during the second half of the
Most evident in obese boys. Normal change of menstrual cycle.
c. Ovary
puberty.
• As it grows, its cells produce a clear fluid
CU2C: PHYSIOLOGY OF MENSTRUATION (follicular fluid) that contains a high degree of
estrogen (mainly estradiol) and some
MENSTRUATION progesterone. At this stage of maturation, the
• monthly discharge of blood from the uterus small ovum (barely visible to the naked eye,
occurring form puberty to menopause wherein approximately the size of a printed period),
15
with its surrounding follicle membrane and Proliferative Phase: Days 5-14
fluid, is termed a graafian follicle. • The uterine lining increases rapidly in thickness
• After an upsurge of LH from the pituitary, and the uterine glands proliferate and grow
prostaglandins are released and the graafian Secretory Phase: Days 14 through 28
follicle ruptures. The ovum is set free from the • When an egg is not fertilized, the corpus
surface of the ovary, a process termed luteum gradually disappears, estrogen and
ovulation. It is swept into the open end of a progesterone levels drop, and the thickened
fallopian tube uterine lining is shed. This is menses.
d. Uterus Ovulation
• also illustrates uterine changes that occur Time of ovulation: An easy way to approximate the
monthly as a result of stimulation from the time of ovulation for women with regular cycles is to
hormones produced by the ovaries. subtract 16 from the number of the days in the cycle
Effects of Estrogen to the body and then add 4. This will calculate the span of days in
• Inhibits production of FHS. which ovulation is most likely to occur.
• Causes hypertrophy and hyperplasia of Signs & Symptoms of Ovulation
myometrium • Mittlelschmerz
• Stimulates the growth of ductile structures of o Abdominal tenderness on left/right iliac
the breast regions, brought about by peritoneal
• Increases quantity and pH of cervical mucus irritation due to blood coming out from the
causing it to become watery and can be to a graafian follicle
distance of 10-13 cm. (Spinnbarkeit test of • Spinnbarkeit
dilation) o Vaginal secretion is clear and transparent
Progesterone – is secreted mainly by the corpus luteum Antepartal Period
and works with estrogen to prepare the endometrium Ovum: from ovulation to fertilization
for implantation and mammary glands for lactation Zygote: from fertilization to implantation
o Decrease GI motility Embryo: from implantation to 5-8 weeks
o Increase permeability of kidney to lactose and Fetus: from 5-8 weeks until term
dextrose Conceptus: developing embryo or fetus and placental
o Responsible for the mood swings of the structure throughout pregnancy
mother
o Mammary gland development THE MENSTRUAL CYCLE
Effects of progesterone in the body
• Inhibits production of LH 1. On the third day of the menstrual cycle, serum
estrogen level is at lowest which stimulates the
• Facilitates transport of fertilized ovum through
hypothalamus to produce follicle stimulating hormone
the fallopian tubes
releasing factor (FSHRF)
• Causes fluid retention
2. FSHRF is responsible for stimulating the anterior
• Decreased hemoglobin and hematocrit levels
pituitary gland (APG) to produce the FSH which will act
• Increased basal body temperature after
on one immature oocyte inside. a primordial follicle,
ovulation because of the presence of
stimulating its growth.
progesterone
3. In view of the FSH, estrogen is now going to be
Ovarian Cycle produced in an increasing amount inside the follicle,
The Follicular Phase: Days 1 through 13 which is found in the ovary. Once estrogen is present,
• In response to follicle stimulating hormone the primordial follicle is now
(FSH) released from the pituitary gland in the termed Graafian follicle. The GF is the structure
brain, ultimately one egg matures therefore that contains high amounts of estrogen.
Ovulation: Day 14 4. Estrogen in the GF will cause the cells in the uterus to
• At about day 14, in response to a surge of proliferate (grow rapidly); increasing its thickness to
luteinizing hormone, the egg is released from about eight fold. This is called Proliferative/follicular
the ovary phase.
• The egg travels through the fallopian tube 5. On the 13th day of menstrual cycle, there is now a very
toward the uterus low level of progesterone in the blood. This stimulates
The Luteal Phase: Days 14 through 28 the hypothalamus to produce Luteinizing Hormone
• The remains of the follicle become the corpus releasing factor (LHRF).
luteum which releases progesterone 6. LHRF is responsible for stimulating the APG to produce
Uterine Cycle LH.
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7. The LH in turn, is responsible for stimulating the ovary
to produce progesterone. The increased amounts of
both estrogen and progesterone push the new mature
ovum to the surface of the ovary until the following day
(14th) the GF ruptures and releases the mature ovum.
8. Once ovulation has taken place, the GF which contains
increased amount of progesterone will turn to Corpus
Luteum which is yellow appearance.
9. Progesterone causes the gland of the uterine
endothelium to become corkscrew or twisted in
appearance. This is the hormone of pregnancy because
it prevents uterine contractions. Once the fertilized
ovum developed finger-like projections called
TROPHOBLAST around the blastocyst, the trophoblasts
are the ones that will implant high on the anterior or
posterior surface of the uterus. • Usually only one of a woman’s ova will reach
IMPORTANT: maturity each month. Once the mature ovum is
• Despite the variability of a woman’s cycle (23- released, fertilization must occur fairly quickly
35 days), ovulation occurs exactly 2 weeks because an ovum is capable of fertilization for only
before the next menstruation. The first 14 days 24 hours (48 hours at the most).
of the cycle is variable. Thus, ovulation occurs • After that time, it atrophies and becomes
not on the 14th day of the cycle but 14 days nonfunctional. Because the functional life of a
prior to the first day of the next menstrual cycle spermatozoon is also about 48 hours, possibly as
unless a pregnancy occurs long as 72 hours, the total critical time span during
• First day of the cycle is the first day of which sexual relations must occur for fertilization
menstruation and one menstrual cycle is from to be successful is about 72 hours (48 hours before
the first day of the menstrual period till the first ovulation plus 24 hours afterward).
day of the next cycle • As the ovum is extruded from the graafian follicle
of an ovary with ovulation, it is surrounded by a ring
of mucopolysaccharide fluid (the zona pellucida)
and a circle of cells (the corona radiata).
• The ovum and these surrounding cells (which
increase the bulk of the ovum and serve as
protective buffers against injury) are propelled into
a nearby fallopian tube by currents initiated by the
fimbriae—the fine, hairlike structures that line the
openings of the fallopian tubes. A combination of
peristaltic action of the tube and movements of the
tube cilia help propel the ovum along the length of
the tube.
• At the time of ovulation, there is a reduction in the
viscosity (thickness) of the cervical mucus, which
makes it easy for spermatozoa to penetrate it.
Sperm transport is so efficient close to ovulation
that spermatozoa deposited in the vagina generally
reach the cervix within 90 seconds and the outer
end of a fallopian tube within 5 minutes after
deposition.
• Spermatozoa move through the cervix and the
body of the uterus and into the fallopian tubes,
Fertilization: The Beginning of toward the waiting ovum by the combination of
Pregnancy movement by their flagella (tails) and uterine
Fertilization (also referred to as conception and contractions.
impregnation) – Is the union of an ovum and a • Capacitation – is a final process that sperm must
spermatozoon. This usually occurs in the outer third of a undergo to be ready for fertilization. This process,
fallopian tube, the ampullar portion which happens as the sperm move toward the
17
ovum, consists of changes in the plasma membrane • The blastocyst is able to invade the endometrium
of the sperm head, which reveal the sperm-binding because, as the trophoblast cells on the outside of
receptor sites. the structure touch the endometrium, they
• Hyaluronidase (a proteolytic enzyme) – is released produce proteolytic enzymes that dissolve any
by the spermatozoa and dissolves the layer of cells tissue they touch. This action allows the blastocyst
protecting the ovum. One reason that an to burrow deeply into the endometrium and
ejaculation contains such a large number of sperm receive some basic nourishment of glycogen and
is probably to provide sufficient enzymes to mucoprotein from the endometrial glands. As
dissolve the corona cells. Under ordinary invasion continues, the structure establishes an
circumstances, only one spermatozoon is able to effective communication network with the blood
penetrate the cell membrane of the ovum. Once it system of the endometrium
penetrates the cell, the cell membrane changes • Implantation or contact between the growing
composition to become impervious to other structure and the uterine endometrium occurs
spermatozoa. approximately 8 to 10 days after fertilization
• Immediately after penetration of the ovum, the • Apposition – the blastocyst brushes against the
chromosomal material of the ovum and rich uterine endometrium
spermatozoon fuse to form a zygote. • Adhesion – it attaches to the surface of the
• Because the spermatozoon and ovum each carried endometrium
23 chromosomes (22 autosomes and 1 sex • Invasion – the blastocyst settles down into its soft
chromosome), the fertilized ovum has 46 folds
chromosomes. • Once the zygote is implanted it is an embryo
• If an X-carrying spermatozoon entered the ovum,
the resulting child will have two X chromosomes
and will be female (XX)
• If a Y-carrying spermatozoon fertilized the ovum,
the resulting child will have an X and a Y
chromosome and will be male (XY)
Implantation
• Once fertilization is complete, a zygote migrates
over the next 3 to 4 days toward the body of the
uterus, aided by the currents initiated by the
muscular contractions of the fallopian tubes.
During this time, mitotic cell division, or cleavage,
begins.
• The first cleavage occurs at about 24 hours;
cleavage divisions continue to occur at a rate of
about one every 22 hours. By the time the zygote
reaches the body of the uterus, it consists of 16 to CU2D: HUMAN GENETICS
50 cells. At this stage, because of its bumpy Genetics – is the study of the ways such disorders occur.
outward appearance, it is termed a morula (from Genetic Disorders – are disorders resulting from a defect
the Latin word morus, meaning “mulberry” in the structure or number of genes or chromosomes.
• Large cells tend to collect at the periphery of the I. Nature of Inheritance
ball, leaving a fluid space surrounding an inner cell • Genes are the basic units of hereditary that
mass. At this stage, the structure becomes a determine both the physical and cognitive
blastocyst. It is this structure that attaches to the characteristics of people. Composed of segments of
uterine endometrium. The cells in the outer ring DNA, they are woven into strands in the nucleus of
are trophoblast cells. all body cells to form chromosomes.
• Implantation, or contact between the growing o A person’s phenotype refers to his or her
structure and the uterine endometrium, occurs outward appearance or the expression of the
approximately 8 to 10 days after fertilization. genes.
• The structure brushes against the rich uterine o A person’s genotype refers to his or her actual
endometrium (in the second [secretory] phase of gene composition.
the menstrual cycle), a process termed apposition. o A person’s genome is the complete set of genes
It attaches to the surface of the endometrium present which is about 50,000-100,000
(adhesion) and settles down into its soft folds II. Inheritance of the Disease
(invasion). A. Autosomal Dominant Inheritance
18
• With an autosomal dominant condition, either (a horizontal transmission pattern)
a person has two unhealthy genes or is 4. A known common ancestor between the parents
heterozygous, with the gene causing the sometimes exists. This explains how both male and
disease stronger than the corresponding female came to possess a like gene for the disorder
healthy recessive gene for the same trait.
• Examples of autosomal dominant disorders are:
o Huntington’s disease
o Facioscapulohumeral muscular
dystrophy, a form of Osteogenesis
imperfecta Marfan syndrome
In assessing family genograms for the incidence of
inherited
disorders, a number of common findings are usually
discovered when a dominantly inherited pattern is
present in the family:
1. One of the parents of a child with the
disorder also will have the disorder (a vertical
transmission picture) C. X-Linked Dominant Inheritance
2. The sex of the affected individual is There are about 300 known X-linked disorders. If the
unimportant in terms of inheritance gene is dominant, only one X chromosome with the trait
3. There is usually a history of the disorder in need be present for symptoms of the disorder to be
other family members manifested.
Family characteristics seen with this type of inheritance
include the following:
1. All individuals with the gene are affected
2. All female children of affected men are
affected; all male children of affected men are
unaffected
3. It appears in every generation
4. All children of homozygous affected women
are affected. 50% of the children of
heterozygous affected women are affected
B. Autosomal Recessive Inheritance

• More than 1,500 autosomal recessive disorders
have been identified. In contrast, to structural
disorders, these tend to be biochemical or
enzymatic.
• Examples include cystic fibrosis, adrenogenital
syndrome, albinism, Tay-Sachs disease,
galactosemia, phenylketonuria, limb-girdle
muscular dystrophy and Rh-factor
incompatibility
• When family genograms are assessed for the
incidence of inherited disease, situations D. X-Linked Recessive Inheritance
commonly discovered when a recessively The majority of X-linked inherited disorders are
inherited disease is present in the family include recessive,
the following: and inheritance of the gene from both parents is
1. Both parents of a child with the disorder are incompatible with life
clinically free of the disorder • Examples are Hemophilia A, color blindness,
2. The sex of the affected individual is unimportant Duchenne muscular dystrophy and fragile X
in terms of inheritance syndrome
3. The family history for the disorder is negative – When family genograms are assessed for inherited
that is no one can identify anyone else who had it disorders, the following findings usually are apparent if
19
an X-linked recessive inheritance disorder is present in the 4. Any individual who has an inborn error of
family: metabolism or chromosomal disorder
1. Only males in the family will have the 5. A consanguineous (closely related) couple
disorder 6. Any woman older than 35 years of age and
2. A history of girls dying at birth for unknown any man older than 45 of age
reasons often exists (females who had the 7. Couples of ethnic backgrounds in which
affected gene on both X chromosomes specific illnesses are known to occur
3. Sons of an affected man are unaffected Nursing Responsibilities
4. The parents of affected children do not have 1. Alerting a couple to what procedures they can expect
the disorder to undergo
2. Explaining how different genetic screening tests are
done and when they are usually offered
3. Supporting a couple during the wait for test results
4. Assisting couples in various clarifications, planning,
and decision making base on test results
ASSESSMENT FOR GENETIC DISORDERS
1. History
2. Physical Assessment
3. Diagnostic Testing
Karyotyping – is a visual presentation of the
chromosome pattern of an individual
Maternal Serum Screening
• Alpha-fetoprotein is a glycoprotein produced
E. Y-Linked Inheritance by the fetal liver that reaches a peak in
Although genes responsible for features such as height maternal serum between the 13th and 32nd
and tooth size are found on the Y chromosome, no week of pregnancy. The AFP level deviates
known disease genes are inherited by Y-chromosome from normal if a chromosomal or a spinal cord
transmission disorder is present.
Genetic Counseling • Chorionic Villi Sampling – a diagnostic
Anyone concerned about the possibility of transmitting technique that involves the retrieval and
a disease to his or her children should have access to analysis of chorionic villi for chromosome or
genetic counseling for advice on the inheritance of the DNA analysis
disease. • Amniocentesis – the withdrawal of amniotic
Purposes fluid through the abdominal wall for analysis at
1. Provide concrete, accurate information the 14th to 16th week of pregnancy
about inherited disorders Percutaneous Umbilical Blood Sampling (PUBS) or
2. Reassure people who are concerned that Cordocentesis – is the removal of blood from the fetal
their child may inherit a particular disorder umbilical cord at about 17th week of pregnancy using
that the disorder will not occur an amniocentesis technique
3. Allow people who are affected by inherited • Fetal Imaging – Computed tomography (CT),
disorders to make informed choices about Magnetic Resonance Imaging (MRI) and
future reproduction ultrasonography are all diagnostic tools used to
4. Educate people about inherited disorders assess a fetus for general size and structural
and the process of inheritance disorders of the internal organs, spine and
5. Offer support by skilled health care limbs.
professionals to people who are affected by • Fetoscopy – insertion of a fiberoptic fetoscope
genetic disorders through a small incision in the mother’s
The following are the couples most apt to benefit from abdomen
genetic counseling: into the uterus and membranes to visually
1. A couple who has a child with a congenital inspect the fetus for gross abnormalities
disorder or an inborn error of metabolism • Preimplantation Diagnosis – it may be possible
2. A couple whose close relatives have a child in the future for a fertilized ovum to be
with a genetic disorder including a congenital removed
disorder or inborn error of metabolism from the uterus by lavage before implantation
3. Any individual who is a known balanced and biopsied for DNA analysis
translocation carrier
20
Legal Responsibilities on Genetic Testing, modern contraceptives for all citizens, including
counseling and therapy impoverished communities, at government health
1. Participation by couples or individuals in genetic centers The law also mandates reproductive health
screening must be elective education in government schools and recognizes a
2. People desiring genetic screening must sign an woman’s right to post-abortion care as part of the right
informed consent for the procedure to reproductive healthcare.
3. Results must be interpreted correctly yet provided to • It mandates the government to adequately
the individuals as quickly as possible address the needs of Filipinos on responsible
4. The results must not be withheld from the individuals parenthood and reproductive health. The law
and must be given only to those persons directly aims to empower the Filipino people, especially
involved women and youth, through informed choice
5. After genetic counseling, persons must not be and age- and development- appropriate
coerced to undergo procedures such as abortion or education
sterilization. Responsible parenthood – is the will and ability of
Common Chromosomal Disorders Resulting parent(s) to respond to the needs and aspirations of the
In Physical Or Cognitive Developmental family and children. It is the shared responsibility
between parents to determine and achieve the desired
Disorders
number and timing of their children according to their
1. Trisomy 13 Syndrome – also called Patau syndrome
own aspirations. (RA 10354 Section 4v)
• is a chromosomal condition associated with
• These principles are based on the four (4) pillars
severe intellectual disability and physical
of Responsible Parenthood, Respect for Life,
abnormalities in many parts of the body.
Birth Spacing, and Informed Choice. Health
2. Trisomy 18 Syndrome – also called Edwards
services, including Reproductive Health
syndrome
services, are devolved by the Local Government
• is a chromosomal condition associated with
Code to the local government units (Philippine
abnormalities in many parts of the body.
Commission on Women, 2021
• Individuals with trisomy 18 often have slow
Reproductive life planning – Includes all the decisions an
growth
individual or couple make about whether and when to
before birth (intrauterine growth retardation)
have children, how many children to have, and how they
and a low birth weight.
are spaced
3. Cri-du-Chat Syndrome – also known as 5p- syndrome
Health teaching – is necessary because some couples
and cat cry syndrome
want counseling about how to avoid conception. Others
• is a rare genetic condition that is caused by the
need information on increasing fertility and their ability
deletion (a missing piece) of genetic material
to conceive. Others need counseling because
on the small arm (the p arm) of chromosome 5.
contraception has failed. It is important for the health of
4. Turner Syndrome
children that as many pregnancies as possible be
• is a chromosomal condition related to the X intended, because when a pregnancy is unintended or
chromosome that alters development in mistimed, both short-term and long-term consequences
females can result such as a woman being less likely to seek
• It is not usually inherited in families. prenatal care, being less likely to breastfeed, and
5. Klinefeiter Syndrome – also known as the XXY possibly being less careful to protect her fetus from
condition harmful substances.
• is a term used to describe males who • A disproportionate share of women who bear
have an extra X chromosome in most of their children whose conception was unintended are
cells. unmarried; such women are less apt to
6. Fragile X Syndrome (FXS) complete high school or college and more likely
• is a genetic disorder characterized by mild-to- to require public assistance and to live in
moderate intellectual disability poverty than are their peers who are not
7. Down Syndrome – referred to as Down's syndrome mothers.
or trisomy 21 • The child of such a pregnancy is at greater risk
• is a common genetic disorder that occurs when of low birth weight, dying in the first year, being
a person has three copies of chromosome 21 abused, and not receiving sufficient resources
CU3: RESPONSIBLE PARENTHOOD for healthy development
Responsible Parenthood and Reproductive Health Act Methods Of Contraception
of 2012, known as the RH Law – is a groundbreaking law Individuals or couples should choose a contraceptive
that guarantees universal and free access to nearly all method carefully, considering the advantages,
21
disadvantages, and side effects of the various options. or foreign material into the body or sustaining
Important things to consider when doing this are: from sexual intercourse during a fertile period
• Personal values Many people hold religious beliefs that rule out
• Ability to use a method correctly the use of birth control pills or devices; others
• How the method will affect sexual enjoyment simply prefer natural methods because no
• Financial factors expense or foreign substance is involved.
• Status of a couple’s relationship • The effectiveness of these methods varies
• Prior experiences greatly from 25% to 85%, depending mainly on
• Future plans the couple’s ability to refrain from having sexual
• As nurses’ roles are to educate couples on what relations on fertile days or days on which the
methods are available and how to use methods, woman has the most likely chance to become
understanding how various methods of pregnant.
contraception work and how they compare in • Fertility awareness involves detecting when a
terms of benefits and disadvantages is woman is fertile so she can use periods of
necessary for successful counseling. abstinence during that time.
• A major benefit of contraception that has Abstinence
occurred is that there are both fewer • Refraining from sexual relations, has a
adolescent pregnancies today and fewer theoretical 0% failure rate and is also the most
elective terminations of pregnancy than effective way to prevent STIs. However, clients,
formerly with information and the ability to particularly adolescents, may find it difficult to
discuss specific concerns, clients can be better adhere to abstinence, or they may completely
prepared to make the decisions that are right overlook it as an option.
for them • Because it fails as an effective birth prevention
• An ideal contraceptive should be: measure for so many people, use of no
o Safe contraceptive has a failure rate of 85%.
o One hundred percent effective • Many sex education classes advocate
o Compatible with religious and cultural abstinence as the only contraceptive measure,
beliefs and personal preferences of so adolescents who take these courses may
both the user and sexual partner know little about other options. When
o Free of side effects discussing abstinence as a contraceptive
o Convenient to use and easily method, be sure to provide information not
obtainable only on the method but suggestions of ways to
o Affordable and needing few comply with this method
instructions for effective use • Client education: Saying “no” to sexual
o Free of effects after discontinuation intercourse but can incorporate saying “yes” to
and on future pregnancies other gratifying sexual activities such as
Assessment Before Using a New affectionate touching, communication, holding
hands, kissing, massage and oral and manual
Method
stimulation
• VS, probably Pap smear, pregnancy test,
• Advantages
gonococcal and chlamydial screening, and
o Most effective method of birth control
perhaps hemoglobin for detection of anemia
o Abstinence during fertile periods
• Obstetric history, including STIs, past
(rhythm method) can be used but it
pregnancies, previous elective abortions, failure
requires understanding of the
of previously used methods, and compliance
menstrual cycle and fertility awareness
history with previously methods
o Can eliminate the risk of STIs if there is
• Subjective assessment of the patient’s desires,
no genitalia contact
needs, feelings, and understanding of
• Disadvantages: Requires self-control
conception
• Risk: If complete abstinence is maintained,
• Sexual practices, such as frequency, numbers of
there are no risks
partners, feelings about sex and body image
Calendar (Rhythm) Method
Natural Family Planning and Fertility
• The calendar method requires a couple to
Awareness abstain from coitus (sexual relations) on the
• The contraceptive approach of natural family days of a menstrual cycle when the woman is
planning (also called periodic abstinence most likely to conceive (3 or 4 days before until
methods) involves no introduction of chemical 3 or 4 days after ovulation).
22
• To plan for this, the woman keeps a diary of six Basal Body Temperature Method
menstrual cycles. To calculate “safe” days, she • Just before the day of ovulation, a woman’s
subtracts 18 from the shortest cycle basal body temperature has ovulated. She
documented. This number represents her first refrains from having coitus for the next 3 days
fertile day. She subtracts 11 from her longest (the life of the discharged ovum). Because
cycle. This represents her last fertile day. sperm can survive for at least 4 days in the
• If she had six menstrual cycles ranging from 25 female reproductive tract, it is usually
to 29 days, her fertile period would be from the recommended that the couple combine this
7th day (25 minus 18) to the 18th day (29 minus method with a calendar method, so that they
11). To avoid pregnancy, she would avoid coitus abstain for a few days before ovulation as well.
during those days The calendar method has an ideal failure rate of
• Client education: Accurately record the number 9%, a typical rate of 25% (MacKay, 2009)
of days in each cycle from the first day of • A problem with assessing BBT for fertility
menses for a period of at least six cycles. The awareness is that many factors, such as taking
start of the fertile period is figured by an antipyretic, can affect the BBT. Changes in
subtracting 18 days from the number of days in the woman’s daily schedule, such as starting an
the women’s shortest cycle. The end of fertile aerobic program, can also influence the BBT. A
period is established by subtracting 11 days woman who works nights should take her
from the number of days of the longest cycle. temperature after awakening from her longer
o Example: sleep period, no matter what the time of day
§ Shortest cycle, 26 – 18 = 8th • Client education: Measure oral temperature
day prior to getting out of bed each morning to
§ Longest cycle, 30 – 11 = 19th monitor ovulation. A woman who works nights
day should take her temp after awakening from her
§ Fertile periods is days through longest sleep period, no matter what time of
8 and 19 (refrain from the day. A slight dip in temp followed by an
intercourse during these days increase means she has ovulate. A woman must
to avoid conception refrain from having coitus for the next 3 days,
• Advantages: Most useful when combined with the possible life of the discharged ovum.
BBT or cervical mucus method. Inexpensive. • Advantages: Inexpensive. Convenient. No
• Disadvantages adverse effects.
o Not a very reliable technique • Disadvantages
o Does not protect against STI o Reliability can be influenced by stress,
o Requires accurate record keeping fatigue, illness, alcohol and warmth of
o Requires compliance regarding sleeping environment
abstinence during fertile periods o Does not protect against STIs.
• Risks: Various factors can affect and change • Risk: Risk of pregnancy
the time of ovulation and cause unpredictable Cervical Mucus Method
menstrual cycles. Risk of pregnancy. • Yet another method to predict ovulation is to
use the changes in cervical mucus that occur
naturally with ovulation. Before ovulation each
month, the cervical mucus is thick and does not
stretch when pulled between the thumb and
finger.
• Just before ovulation, mucus secretion
increases. With ovulation (the peak day),
cervical mucus becomes copious, thin, watery,
and transparent. It feels slippery and stretches
at least 1 inch before the strand breaks, a
property known as spinnbarkeit.
• All the days on which cervical mucus is copious,
and for at least 1 day afterward, are considered
to be fertile days, or days on which the woman
should abstain from coitus to avoid conception.
• A woman using this method must be
conscientious about assessing her vaginal
23
secretions every day, or she will miss the change is becoming the method of choice for many
in cervical secretions. The feel of vaginal families using natural family planning
secretions after sexual relations is unreliable, Marquette Model
because seminal fluid (the fluid containing • Combines the use of ovulation detection with
sperm from the male) has a watery, other signs of ovulation (cervical mucus, BBT,
postovulatory consistency and can be confused cervix position and softness) to avoid pregnancy
with ovulatory mucus. during a woman’s fertile period
• Client education Lactation Amenorrhea Method
o Good hand hygiene • As long as a woman is breastfeeding an infant,
o Begin examining mucus from the last there is some natural suppression of ovulation.
day of the menstrual cycle Because women may ovulate, however, but not
o Mucus is obtained from vaginal menstruate, a woman may still be fertile even if
introitus, it is not necessary to reach she has not had a period since childbirth.
into vagina to the cervix • If the infant is receiving a supplemental feeding
o Do not douche prior to assessment. or not sucking well, the use of lactation as an
• Advantages effective birth control method is questionable
o A woman can become knowledgeable • As a rule, after 3 months of breastfeeding, the
in recognizing her own mucus woman should be advised to choose another
characteristics at ovulation and self- method of contraception
ovulation can be very accurate Coitus Interruptus
• Disadvantages • is one of the oldest known methods of
o Some women are uncomfortable with contraception. The couple proceeds with coitus
touching their genitals until the moment of ejaculation. Then the man
o Does not protect against STIs. withdraws and spermatozoa are emitted
• Risk/Complications outside the vagina. Unfortunately, ejaculation
o Can be inaccurate if mucus is mixed may occur before withdrawal is complete and,
with semen, blood, contraceptive despite the care used, some spermatozoa may
foams or discharge from infections be deposited in the vagina. Furthermore,
o Risk for pregnancy. because there may be a few spermatozoa
Sympto-thermal Method present in pre ejaculation fluid, fertilization may
• Combines the cervical mucus and BBT methods. occur even if withdrawal seems controlled. For
The woman takes her temperature daily, these reasons, coitus interruptus is only about
watching for the rise in temperature that marks 75% effective.
ovulation. She also analyzes her cervical mucus Postcoital Douching
every day and observes for other signs of • Douching following intercourse, no matter what
ovulation such as mittelschmertz (midcycle solution is used, is ineffective as a contraceptive
abdominal pain). The couple must abstain from measure as sperm may be present in cervical
intercourse until 3 days after the rise in mucus as quickly as 90 seconds after
temperature or the fourth day after the peak of ejaculation.
mucus change, because these are the woman’s
fertile days. The symptothermal method is more
Hormonal Contraception
effective than either the BBT or the cervical • Hormones that cause such fluctuations in a
mucus method alone (ideal failure rate, about normal menstrual cycle that ovulation does not
2%) occur. Hormonal contraceptives may be
administered orally, transdermally, vaginally, by
Ovulation Detection
implantation, or through injection.
• Still another method to predict ovulation is by
Oral Route
the use of an over-the-counter ovulation
detection kit. These kits detect the midcycle • Composed of varying amounts of natural
estrogen or synthetic estrogen combined with a
surge of luteinizing hormone (LH) that can be
small amount of synthetic progesterone
detected in urine 12 to 24 hours before
ovulation. Such kits are 98% to 100% accurate in • The estrogen acts to suppress FSH and LH to
predicting ovulation. Although they are fairly suppress ovulation
expensive, use of such a kit in place of cervical • The progesterone action causes a decrease in
mucus testing makes this form of natural family the permeability of cervical mucus and so limits
planning more attractive to many women. sperm motility and access to ova
Combining it with assessment of cervical mucus
24
• Progesterone also interferes with tubal o Exacerbates conditions affected by
transport and endometrial proliferation to such fluid retention, migraine, epilepsy,
an extent the possibility of implantation is asthma, kidney or heart disease
significantly decreased o Adverse effects include headache,
Combined Oral Contraceptives nausea, breast tenderness and
• Hormonal contraception containing estrogen breakthrough bleeding
and progestin, which acts by suppressing Different types of COCs
ovulation thickening the cervical mucus to block • 21-day pills — Take one pill at the same time
semen and altering the uterine decidua to each day for 21 days. Wait 7 days before starting
prevent implantation a new pack. During the week you are not taking
• Client Education the pill, you will have your period
o Requires prescription and follow-up • 28-day pills — Take one pill at the same time
with the physician each day for 28 days. Depending on the brand,
o Requires consistent and proper use to the first 21 pills or the first 24 pills contain
be effective estrogen and progestin. The remaining pills may
o Side effects and danger signs including be estrogen-only pills; pills that contain a
chest pain, SOB, leg pain from a dietary supplement, such as iron, but no
possible clot, headache, eye problems hormones; or inactive pills (containing no
from a stroke and HPN hormones or supplements). During the days you
o In case of a missed dose: If one pill is are taking the hormone-free pills, you will have
missed, take as soon as possible. If two your period
or three pills are missed, follow the • 90-day pills — Take one pill at the same time
manufacturer’s instruction. Instruct on each day for 84 days. Depending on the brand,
the use of alternative forms of the last seven pills either contain no hormones
contraception or abstinence to or contain estrogen only. With both brands, you
prevent pregnancy until regular dosing will have your period on the last 7 days every 3
is resumed months
• Advantages • 365-day pills — Take one pill at the same time
o Highly effective if taken correctly and each day for a year. In time, your bleeding may
consistently become lighter and may even stop
o Non-contraceptive benefits Side Effects and Contraindications
§ Decreased menstrual blood • HX of thromboembolic disorders, stroke, heart
loss attack, CAD, GB disease, cirrhosis or liver tumor,
§ Decreased IDA headache with focal neurological symptoms,
§ Regulation of menorrhagia uncontrolled HPN, DM with vascular
and irregular cycles involvement,, breast or estrogen-related
§ Reduced incidence of cancers, pregnancy, lactating, less than 6 weeks
dysmenorrhea and postpartum or smoking
premenstrual symptoms • Effectiveness decreases when taking med that
§ Offers protection against affect liver enzymes, such as anticonvulsants
endometrial, ovarian and and some antibiotics
colon cancer • COCs are not routinely prescribed for women
§ Reduces the incidence of with a history of thromboembolic disease or a
benign breast disease family history of cerebral or cardiovascular
§ Improves acne accident, who are over 40 years of age, or who
§ Protect against the smoke because of the increased tendency
development of functional toward clotting as an effect of increased
ovarian cyst estrogen
• Disadvantages • COCs can interfere with glucose metabolism.
o Do not protect against STIs For this reason, women with diabetes mellitus
o Can increase the risk of or a history of liver disease, including hepatitis,
thromboembolism, stroke, heart are evaluated individually before COCs are
attack, HON, GB disease and liver prescribed
tumor • COCs may interact with several drugs such as
acetaminophen, anticoagulants, and some
anticonvulsants, reducing their therapeutic
25
effect so women may be advised to temporarily back, excluding the breasts), abdomen, or
change their method of birth control while buttocks. They should not be placed on any area
prescribed these drugs where makeup, lotions, or creams will be
Progestin-Only Pills applied; at the waist where bending might
• Provide same action as COCs loosen the patch; or anywhere the skin is red or
• Oral contraceptives containing only progestins irritated or has an open lesion.
are popularly called mini-pills. The • Patches can be worn in the shower, while
progesterone content thickens cervical mucus bathing, or while swimming. If a patch comes
and helps prevent sperm entry into the uterine loose, the woman should remove it and
cervix. Ovulation may occur but, because the immediately replace it with a new patch. No
endometrium does not develop fully, additional contraception is needed if the
implantation will not take place woman is sure the patch has been loose for less
• Client Education than 24 hours.
o Take the pill at the time daily Transdermal Contraceptive Patch
o The client can need another form of • Contains norelgestromin (progesterone) and
contraceptive during the first month of ethinyl estradiol, which is delivered at
use to prevent pregnancy continuous levels through the skin into SQ
• Advantages tissue
o Fewer SE than COCs • Client education
o Safe to take while breastfeeding o Apply the patch to dry skin overlying
• Disadvantages SQ tissue of the buttock, abdomen,
o Less effective in suppressing ovulation upper arm, or torso, excluding the
than COCs breast area
o Increased occurrence of ovarian cysts o Requires patch replacement once a
o No protection against STIs week
o Adverse effects include breakthrough, o Apply the patch the same day of the
irregular, vaginal bleeding, headache, week for 3 weeks with no application
nausea and breast tenderness on the fourth week
Risk/Contraindications • Advantages
• Effectiveness decreases when taking med that o Maintains consistent blood levels of
affect liver enzymes, such as anticonvulsants hormone
and some antibiotics o Avoids liver metabolism of the
• If a woman taking an estrogen/progestin medication because it is not absorbed
combination COC suspects that she is pregnant, in the GI tract
she should discontinue taking any more pills if o Decreases risk of forgetting daily pill
she intends to continue the pregnancy. High • Disadvantages
levels of estrogen or progesterone might be o Does not protect against STIs
teratogenic to a growing fetus o Same side effects as oral
• Contraindications: bariatric surgery, lupus, contraceptives
severe cirrhosis, liver tumors, current or past o Skin reaction can occur.
breast cancer • Risk/Possible Complications/Contraindications
Transdermal Route o Same as those of oral contraceptives
• Transdermal contraception refers to patches o Avoid applying the patch to skin rashes
that slowly but continuously release a or lesion
combination of estrogen and progesterone. o Less effective in women greater than
Patches are applied each week for 3 weeks. No 198 lbs
patch is applied the fourth week. During the Vaginal Insertion
week on which the woman is patch free, a • A (NuvaRing) is a silicone ring that surrounds the
menstrual flow will occur. After the patch-free cervix and continually releases a combination of
week, a new cycle of 3 weeks on/1 week off estrogen and progesterone
begins again. The efficiency of transdermal • Contains etonogestrel and ethinyl estradiol that
patches is equal to that of COCs, although they is delivered at continuous level vaginally
may be less effective in women who weigh • It is inserted vaginally by the woman and left in
more than 90 kg (198 lb). place for 3 weeks, then removed for 1 week.
• Patches may be applied to one of following four Menstrual bleeding occurs during the ring-free
areas: upper outer arm, upper torso (front or
26
week. The hormones released are absorbed decreased bone density, and weight
directly by the mucous membrane of the vagina. gain
• Client education • Risks/Possible
o A clients inserts the ring vaginally Complications/Contraindications
o It stays there for 21 days. Then remove o Increased risk of ectopic pregnancy if
it and wait 7 days before inserting a pregnancy occurs
new ring o Contraindications include unexplained
o During the week the ring is not used, vaginal bleeding, lupus, severe
the patient will have her period cirrhosis, liver tumors, and breast
o To use the ring as a continuous-dose cancer
form of birth control, insert a new ring Injectable Progestin
every 21 days with no ring-free week in • Medroxyprogesterone is an IM or SQ injection
between given to a female client every 11 to 13 weeks
• Advantages • Client education
o Does not have to be fitted o Start of injections should be during the
o Decreases the risk of forgetting the pill first 5 days of a client’s menstrual cycle
• Disadvantages and every 11 to 13 weeks thereafter.
o Do not protect against STIs Injections in postpartum non-
o Same adverse effects as oral breastfeeding women should begin
contraceptives within 5 days following delivery. For
o Some clients report discomfort during breastfeeding women, injections
intercourse. The ring can be removed should start in the 6thweek
for up to 3 hours without postpartum
compromising its effectiveness. o Advise clients to keep follow-up
• Risks/Possible appointments
Complications/Contraindications o Maintain an adequate intake of
o Blood clots, HPN, stroke, heart attack calcium and vitamin D.
o Vaginal irritation, increased vaginal • Advantages
secretions, headache, weight gain, and o Very effective and requires only 4
nausea injections per year
Subdermal Hormone Implants o Does not impair lactation
• Also called implantable progestin o Possible absence of periods and
• Requires a minor sx procedure to subdermally decrease in bleeding
implant and remove a single rod containing o Decreased risk of uterine cancer if used
etonogestrel on the inner side of the upper long-term
aspect of the arm • Disadvantages
• Client education o Adverse effects include decrease in
o Avoid trauma to the implantation. bone mineral density, weight gain,
• Advantages increase in depression, and irregular
o Effective continuous contraception for vaginal bleeding
3 years o Does not protect against STIs
o Can be inserted immediately after o Return to fertility can be delayed as
abortion, miscarriage, childbirth, and long as up to 18 months after
while breastfeeding discontinuation.
o Reversible • Risks/Possible Complications
o Can be used by mothers who are o Avoid massaging the injection site to
breastfeeding after 4 weeks avoid accelerating medication
postpartum absorption, which will shorten the
• Disadvantages duration of its effectiveness
o Etonogestrel can cause irregular • Contraindications: breast cancer, evidence of
menstrual bleeding current cardiovascular disease, abnormal liver
o Does not protect against STIs function, liver tumors, and unexplained vaginal
o Adverse effects include irregular and bleeding.
unpredictable menstruation, mood Intrauterine Devices
changes, headache, acne, depression, • is a small plastic object that is inserted into the uterus
through the vagina
27
• A chemically active T-shaped device that is inserted wish to avoid some of the systemic hormonal
through the cervix and placed in the uterus by the side effects
provider. Releases a chemical substance that o They may create lighter or fewer periods
damages sperm in transit to the uterine tubes and • Teach women to regularly check after each
prevents fertilization menstrual flow, to make sure the IUD string is in
• A long-acting reversible contraceptive(LARC) along place, and to obtain a yearly pelvic examination
with implant. The copper-coated IUD prevents • Client education
pregnancy by not allowing the sperm to fertilize the o The device must be monitored monthly by
egg. It may also make it harder for a fertilized egg to clients after menstruation to ensure presence
implant in the uterus. An IUD coated with progestin of the small string that hangs from the device
works in a similar way, but also thickens the cervical into the upper part of the vagina to rule out
mucus and thins the uterine lining migration or expulsion of the device.
• IUDs became popular as a method of birth control in • Advantages
the 1980s, and although still a popular choice o Hormonal IUD effective for 3 to 5 years;
worldwide, IUDs are used by only a small number of copper IUD for 10 years
U.S. women. o Can be inserted immediately after abortion,
• Few manufacturers continue to provide them since miscarriage, childbirth, and while
several lawsuits were filed in association with the breastfeeding
increased incidence of pelvic inflammatory disease o Can be reverses with immediate return to
(PID) in women using one particular brand, now no fertility
longer available • Disadvantages
• Today, the IUD is thought to prevent fertilization as o Can increase risk of PID
well as creating a local sterile inflammatory condition o A client should report late or abnormal
that prevents implantation. When copper is added to spotting or bleeding, abdominal pain or pain
the device, sperm mobility appears to be affected as with intercourse, abnormal or foul-smelling
well. This decreases the possibility that sperm will vaginal discharge, fever, chills, a change in
successfully cross the uterine space and reach the string length, or if IUD cannot be located
ovum. o Does not protect against STIs
• An IUD must be fitted by a physician, nurse o Hormonal IUD: spotting, irregular bleeding,
practitioner, or nurse-midwife, who first performs a headache, nausea, depression, breast
Pap test and pelvic examination. The device is tenderness
inserted before a woman has had coitus after a o Copper IUD: increase in menstrual pain and
menstrual flow, so the health care provider can be bleeding
assured that the woman is not pregnant at the • Risks:
time of insertion o Best used by women in a monogamous
• The insertion procedure is performed in an relationship due to risks of STIs
ambulatory setting such as a physician’s office or a o Can cause irregular menstrual bleeding
reproductive planning clinic. The device is inserted in o Risk of bacterial vaginosis, uterine perforation,
a collapsed position, then enlarged to its final shape or uterine expulsion
in the uterus when the inserter is withdrawn. The o Must be removed in the event of pregnancy
woman may • Contraindications: Active pelvic infection, AUB,
feel a sharp cramp as the device is passed through severe uterine distortion, copper allergy
the internal cervical os, but she will not feel the IUD Side Effects and Contraindications
after it is in place. Properly fitted, such devices are • A woman may notice some spotting or uterine
contained wholly within the uterus, although the cramping the first 2 or 3 weeks after IUD insertion; as
attached long as this is present, she should use an additional
string protrudes through the cervix into the vagina form of contraception, such as vaginal foam
• IUDs have several advantages over other • Occasionally, a woman continues to have cramping
contraceptives. and spotting after insertion; in such instances, she is
o Only one insertion is necessary, so there is no likely to expel the device spontaneously. Women with
continuing expense IUDs in place should take active steps to avoid toxic
o The device does not require daily attention or shock syndrome (TSS; a staphylococcal infection from
interfere with sexual enjoyment the use of tampons), because infection might travel by
o It is appropriate for women who are at risk for the IUD string into the uterus to cause uterine
complications associated with COCs or who infection
28
• IUDs are not recommended for women with an • Film of glycerin – another form of spermicidal
increased risk of contracting STIs, such as those who protection impregnated with a spermicidal
have multiple sexual partners, because this agent that is folded and inserted vaginally
combination could lead to pelvic infection • On contact with vaginal secretions or precoital
• They also are not recommended for women who have penile emissions, the film dissolves and a
never been pregnant (their small uterus could be carbon dioxide foam forms to protect the
punctured with insertion) or who have a history of cervix against invading spermatozoa
having had PID. If PID is suspected, the device should Side Effects and Contraindications
be removed and the woman should receive antibiotic • Vaginally inserted spermicidal products are
therapy to treat the infection contraindicated in women with acute cervicitis,
• IUDs are also contraindicated in the woman whose because they might further irritate the cervix
uterus is distorted in shape (the device might • They are generally inappropriate for couples
perforate an abnormally shaped uterus) who must prevent conception (perhaps
• They are not advised for women with severe because the woman is taking a drug that would
dysmenorrhea (painful menstruation), menorrhagia be harmful to a fetus or the couple absolutely
(bleeding between menstrual periods), or a history of does not want the responsibility of children),
ectopic (tubal) pregnancy, because their use may because the overall failure rate of all forms of
increase the symptoms or incidence of these these products is about 20%
conditions • Women find the vaginal leakage after use of
• Women with valvular heart disease may be advised these products bothersome. Vaginal
against the use of an IUD because the suppositories, because of the cocoa butter or
increased risk of PID could lead to accompanying valve glycerin base, are the most bothersome in this
involvement from bacterial endocarditis. regard
Effect on Pregnancy Diaphragm
• If a woman with an IUD in place suspects that she is • A diaphragm is a circular rubber disk that is placed
pregnant, she should alert her primary health over
care provider. Although the IUD may be left in place the cervix before intercourse
during the pregnancy, it is usually removed • Although use of a spermicide is not required for
vaginally to prevent the possibility of infection or diaphragms, use of a spermicidal gel with a diaphragm
spontaneous miscarriage during the pregnancy. combines a barrier and a chemical method of
The woman should receive an early ultrasound to contraception. With this, the failure rate of the
document placement of the IUD. This can also diaphragm is as low as 6% (ideal) to 16% (typical use)
rule out ectopic pregnancy, which has an increased • A diaphragm is prescribed and fitted initially by a
incidence among IUD users who become physician, nurse practitioner, or nurse-midwife to
pregnant with the IUD in place ensure a correct fit. Because the shape of a woman’s
Barrier Methods cervix changes with pregnancy, miscarriage, cervical
Spermicide surgery (dilatation and curettage [D&C]), or elective
A spermicide is an agent that causes the death of termination of pregnancy, teach women to return for
spermatozoa before they can enter the cervix. Such a second fitting if any of these circumstances occur
agents are not only actively spermicidal but also change • A woman should also have the fit of the diaphragm
the vaginal pH to a strong acid level, a condition not checked if she gains or loses more than 15 lbs, because
conducive to sperm survival. this could also change her pelvic and vaginal contours.
• They do not protect against STIs • A diaphragm is inserted into the vagina, after first
• In addition to the general benefits for barrier coating the rim and center portion with a spermicide
contraceptives, the advantages of spermicides gel, by sliding it along the posterior wall and pressing
include: it up against the cervix so that it is held in place by the
o They may be purchased without a vaginal fornices.
prescription or an appointment with a • A woman should check her diaphragm with a finger
health care provider, so they allow for after
greater independence and lower costs insertion to be certain that it is fitted well up over the
o When used in conjunction with cervix; she can palpate the cervical os through the
another contraceptive, they increase diaphragm
the other method’s effectiveness • A diaphragm should remain in place for at least 6
o Various preparations are available, hours after coitus, because spermatozoa remain
including gels, creams, sponges, films, viable in the vagina for that length of time. It may be
foams, and suppositories. left in place for as long as 24 hours. If it is left in the
29
vagina longer than this, the stasis of fluid may cause • A condom is a latex rubber or synthetic sheath that
cervical inflammation (erosion) or urethral irritation is placed over the erect penis before coitus to trap
• After use, a diaphragm should be washed in mild soap sperm
and water, dried gently, and stored in its protective • Condoms have an ideal failure rate of 2% and a typical
case. With this care, a diaphragm will last for 2 to 3 failure rate of about 15%, because breakage or
years. spillage occurs in up to 15% of uses
Side Effects and Contraindications • A major advantage of condoms is that they are one of
• Diaphragms may not be effective if the uterus is the few “male responsibility” birth control measures
prolapsed, retroflexed, or anteflexed to such a available, and no health care visit or prescription is
degree that the cervix is also displaced in relation to needed
the vagina • Latex condoms have the additional potential of
• Intrusion on the vagina by a cystocele or rectocele, in preventing the spread of STIs, and their use has
which the walls of the vagina are displaced by bladder become a major part of the fight to prevent infection
or bowel, may make insertion of a diaphragm difficult with human immunodeficiency virus (HIV)
• Users of diaphragms may experience a higher • Recommend them for any partners who do not
number of urinary tract infections (UTIs) than maintain a monogamous relationship
nonusers, probably because of pressure on the Female Condoms
urethra • Condoms for females are latex sheaths made of
• Other contraindications include polyurethane and pre lubricated with a spermicide
o History of toxic shock syndrome (TSS; • The inner ring (closed end) covers the cervix, and the
staphylococcal infection introduced outer ring (open end) rests against the vaginal
through the vagina) opening
o Allergy to rubber or spermicides • The sheath may be inserted any time before sexual
o History of recurrent UTIs activity begins and then removed after ejaculation
Cervical Cap occurs. Like male condoms, they are intended for
• Caps are made of soft rubber, are shaped like a one-time use and offer protection against both
thimble conception and STIs
with a thin rim, and fit snugly over the uterine cervix • Male and female condoms should not be used
• The failure rate is estimated to be as high as 26% together
(ideal) • The failure rate is somewhat greater than the failure
to 32% (typical use). The precautions for use are the rate for male condoms, 12% to 22%. Most failures
same as for diaphragm use except they can be kept in occur because of incorrect or inconsistent use.
place longer Surgical Methods
• Many women cannot use cervical caps because their Vasectomy
cervix is too short for the cap to fit properly. Also, • In a vasectomy, a small incision or puncture wound is
caps tend to dislodge more readily than diaphragms made on each side of the scrotum
during coitus • The vas deferens at that point is then located, cut and
• An advantage is that cervical caps can remain in place tied, cauterized, or plugged, blocking the passage of
longer than diaphragms, because they do not put spermatozoa
pressure on the vaginal walls or urethra; however, • Vasectomy can be done under local anesthesia in an
this time period should not exceed 48 hours, to ambulatory setting, such as a physician’s office or a
prevent cervical irritation reproductive life planning clinic
• Cervical caps, like diaphragms, must be fitted • The man experiences a small amount of local pain
individually by a health care provider afterward, which can be managed by taking a mild
• They are contraindicated in any woman who has: analgesic and applying ice to the site
o An abnormally short or long cervix • The procedure is 99.5% effective
o A previous abnormal Pap smear • Spermatozoa that were present in the vas deferens at
o A history of TSS
the time of surgery can remain viable for as long as 6
o An allergy to latex or spermicide A
months
history of pelvic inflammatory
• Therefore, although the man can resume sexual
disease, cervicitis, or papillomavirus
intercourse within 1 week, an additional birth control
infection
method should be used until two negative sperm
o A history of cervical cancer
reports have been obtained (proof that all sperm in
o An undiagnosed vaginal bleeding
the vas deferens have been eliminated, usually
Male Condom requiring 10 to 20 ejaculations)
30
Tubal Ligation CU4: CARE OF THE FETUS
• Tubal ligation, where the fallopian tubes are occluded EMBRYONIC STRUCTURE
by cautery, crushing, clamping, or blocking, thereby A. The Decidua
preventing passage of both sperm and ova. • The corpus luteum in the ovary continues to function
• A fimbriectomy, or removal of the fimbria at the rather than atrophying under the influence of hCG
distal end of the tubes, is another possible but little secreted by the trophoblast cells
used technique • This hormone cause the uterine endometrium to
• Tubal ligation has a 99.5% effectiveness rate continue to grow in thickness and vascularity instead
• Although the reason is not clear, tubal ligation is of sloughing off
associated with a decreased incidence of ovarian • The endometrium is now called decidua (Latin word
cancer for “falling off”) because it will be discarded after child
• The most common operation to achieve tubal ligation birth
is laparoscopy • After fertilization, the corpus luteum in the ovary
• After a menstrual flow and before ovulation, an continues to function rather than atrophying, because
incision as small as 1 cm is made just under the of the influence of human chorionic gonadotropin
woman’s umbilicus with the woman under general or (hCG), a hormone secreted by the trophoblast cells.
local anesthesia This causes the uterine endometrium to continue to
• A lighted laparoscope is inserted through the incision. grow in thickness and vascularity, instead of sloughing
Carbon dioxide is then pumped into the incision to lift off as in a usual menstrual cycle
the abdominal wall upward and out of the line of • The endometrium is now termed the decidua (the
vision. Latin word for “falling off”), because it will be
• The surgeon locates the fallopian tubes by viewing the discarded after the birth of the child.
field through a laparoscope. Can also be done by • The decidua has three separate areas:
culdoscopy (a tube inserted through the posterior o Decidua basalis – the part of the endometrium
fornix of the vagina) or colpotomy (incision through that lies directly under the embryo (or the
the vagina), but the incidence of pelvic infection is portion
higher with these procedures and visualization is less where the trophoblast cells establish
• The woman is discharged from the hospital a few communication with maternal blood vessels)
hours after the procedure. She may notice abdominal o Decidua capsularis – the portion of the
bloating for the first 24 hours, until the carbon dioxide endometrium that stretches or encapsulates
infused at the beginning of the procedure is absorbed. the surface of the trophoblast
This can also cause sharp diaphragmatic or shoulder o Decidua vera – the remaining portion of the
pain if some of the carbon dioxide escapes under the uterine lining. As the embryo continues to
diaphragm and presses on ascending nerves grow, it
• A woman may return to having coitus as soon as 2 to pushes the decidua capsularis before it like a
3 days after the procedure blanket. Eventually, the embryo enlarges so
• Be certain that they understand. that tubal ligation, much
unlike a hysterectomy, does not affect the menstrual that this action brings the decidua capsularis
cycle, so they will still have a monthly menstrual flow into contact with the opposite uterine wall (the
• Be certain that women know to have no unprotected decidua vera). Here, the two decidua areas
coitus before a tubal ligation (sperm trapped in the fuse, which is why, at birth, the entire inner
tube could fertilize an ovum there and cause an surface
ectopic of the uterus is stripped away, leaving the
pregnancy) organ highly susceptible to hemorrhage and
infection
B. Chorionic Villi
• Once implantation is complete, the trophoblastic
layer of cells of the blastocyst begins to mature
rapidly. As early as the 11th or 12th day, miniature villi
that resemble probing fingers, termed chorionic villi,
reach out from the single layer of cells into the uterine
endometrium to begin formation of the placenta. At
term, almost 200 such villi will have formed
• All chorionic villi have a central core of connective
tissue and fetal capillaries. A double layer of
trophoblast cells surrounds these. The outer of the
31
two covering layers is the syncytiotrophoblast, or the
syncytial layer. This layer of cells produces various
placental hormones, such as hCG,
somatomammotropin (human placental lactogen
[hPL]), estrogen, and progesterone
• The middle layer, the cytotrophoblast or Langhans’
layer is present as early as 12 days’ gestation. It
appears to function early in pregnancy to protect the
growing embryo and fetus from certain infectious
organisms such as the spirochete of syphilis. This layer
of cells disappears, however, between the 20th and
24th weeks. This is why syphilis is not considered to
have a high potential for fetal damage early in
pregnancy, only after the point at which
cytotrophoblast cells are no longer present. The layer
appears to offer little protection against viral invasion
at any point.
• Protection for syphilis in early pregnancy
C. Placenta – latin for “pancake” which is descriptive of
its size and appearance at term o Bigger – circulation to the fetus may
o arises out of the continuing growth of be threatened because placenta was
trophoblast tissue. Its growth parallels that of forced to spread out in an unusual
the fetus, growing from a few identifiable cells manner to maintain adequate blood
at the beginning of pregnancy to an organ 15 to supply. In GDM, placenta may also be
20 cm in diameter and 2 to 3 cm in depth, larger because of excess fluid between
covering about half the surface area of the cells.
internal uterus at term • Circulation
o provides oxygen and nutrients to the growing o As early as the 12th day of pregnancy, maternal
fetus and removes waste products from the blood begins to collect in the intervillous spaces
baby’s blood of the uterine endometrium surrounding the
o no non-essential drugs during pregnancy, chorionic villi. By the third week, oxygen and
including alcohol (fetal alcohol spectrum other nutrients, such as glucose, amino acids,
disorder) fatty acids, minerals, vitamins, and water,
o Cotyledons – 30 or more partitions or septa. osmose from the maternal blood through the
This transmit fetal blood and allow exchange of cell
oxygen and nutrients with the maternal blood layers of the chorionic villi into the villi
o Braxton hicks contractions – starts at 12th capillaries. From there, nutrients are
week, aid in maintaining pressure in the transported to the
intervillous spaces by closing off the uterine developing embryo
veins momentarily with each contraction o Placental osmosis is so effective that all except
o Lying on the left side promotes uterine a few substances are able to cross from the
perfusion and placental circulation. This lifts mother into the fetus. Because almost all drugs
the uterus away from the inferior vena cava, are able to cross into the fetal circulation, it is
preventing blood from becoming trapped in important that a woman take no nonessential
the woman’s lower extremities drugs(including alcohol and nicotine) during
o Vena cava syndrome – placental circulation is pregnancy
reduced that supine hypotension can occur o For practical purposes, because the process of
o Placenta weighs 400 to 600g (1lb) at term osmosis is so effective, there is no
o Smaller – fetus may have been direct exchange of blood between the embryo
compromised, it suggests that and the mother during pregnancy. Because the
circulation to the fetus was outer chorionic villi layer is only one cell thick
inadequate after the third trimester minute breaks do
occur
and allow occasional fetal cells to cross into the
maternal bloodstream, as well as fetal
32
enzymes such as alpha-fetoprotein (AFP) from o Estrogen contributes to the woman’s mammary
the fetal liver gland development in preparation for lactation
o About 100 maternal uterine arteries supply the and stimulates uterine growth to accommodate
mature placenta. To provide enough the developing fetus
blood for exchange, the rate of uteroplacental o Produced as the second product of the syncytial
blood flow in pregnancy increases from about cells of the placenta
50 Progesterone – referred to as the “hormone of
mL/min at 10 weeks to 500 to 600 mL/min at mothers.” This is because, although estrogen influences
term. The woman’s heart rate, total cardiac a female appearance, progesterone is necessary to
output, and blood volume increase to supply maintain the endometrial lining of the uterus during
blood to the placenta pregnancy.
o Uterine perfusion, and thus placental o Hormones that maintains pregnancy
circulation, is most efficient when the woman o Present in the maternal serum as early as the 4th
lies week of pregnancy as a result of the corpus
on her left side. This position lifts the uterus luteum
away from the inferior vena cava, preventing o Level rises progressively during the remainder
blood from being trapped in the woman’s of the pregnancy
lower extremities. If the woman lies on her o Reduce contractility of the uterus, thus
back and the weight of the uterus compresses preventing premature labor
the vena cava, placental circulation can be so Human Placental Lactogen (hPL or Human Chorionic
sharply reduced that supine hypotension (very Somatomammotropin) – is a hormone with both growth-
low maternal blood pressure and poor uterine promoting and lactogenic (milk-producing) properties. It
circulation) occurs is produced by the placenta beginning as early as the
• Endocrine Function of the placenta sixth week of pregnancy, increasing to a peak level at
Aside from serving as the conduit for oxygen and term. It can be assayed in both maternal serum and
nutrients for the fetus, the syncytial (outer) layer of the urine. It
chorionic villi develops into a separate, important promotes mammary gland (breast) growth in
hormone-producing preparation for lactation in the mother. It also serves the
system important role of regulating maternal glucose, protein,
Human Chorionic Gonadotropin – The first placental and fat levels so that
hormone produced, hCG, can be found in maternal blood adequate amounts of these nutrients are always
and urine as early as the first missed menstrual period available to the fetus
(shortly after implantation has occurred) through about Placental Proteins – produces several plasma proteins.
the 100th day of pregnancy. Because this is the hormone The function of these has not been well documented, but
analyzed by pregnancy tests, a false-negative result from it is thought that they may contribute to decreasing the
a pregnancy test may be obtained before or after this immunologic impact of the growing placenta through
period. The woman’s blood serum will be completely being part of the complement cascade
negative for hCG within 1 to 2 weeks after birth. Testing D. The Amniotic Membranes
for hCG after birth can be used as proof that placental
tissue is no longer
present. The production of hCG begins to decrease at
about 8th week of pregnancy
o The purpose of hCG is to act as a fail-safe
measure to ensure that the corpus luteum of
the ovary continues to produce progesterone
and estrogen. This is important because, if the
corpus luteum should fail and the level of
progesterone fall, the endometrial lining will
slough and the pregnancy will be lost. hCG also
may play a role in suppressing the maternal • Chorionic membrane – forms from the chorionic villi
immunologic response so that placental tissue on the medial surface of the trophoblast (do not touch
is not detected and rejected as a foreign the endometrium) gradually thins until it becomes the
substance outermost fetal membrane
Estrogen (primarily estriol) – is produced as a second • Amniotic membrane or amnion – forms beneath the
product of the syncytial cells of the placenta. Estrogen is chorion; a dual-walled sac with the chorion as the
often referred to as the “hormone of women.” outermost part and the amnion as the innermost
33
• Fused together and have no nerve supply; no pain Origin and development of Organ
when the “water breaks” systems
• Amniotic membrane produces and protects the Zygote: Totipotent stem cells – undifferentiated they
amniotic fluid. Produces a phospholipid that initiates have the potential to grow into any cell in the human
the formation of prostaglandin which may trigger the body
labor Embryo: Pluripotent stem cells – lose their ability to
E. The Amniotic Fluid become any bodycell and become specific
• Constantly formed and absorbed even if the amniotic Multipotent stem cells – so specific that they cannot be
membranes rupture before birth and the bulk is lost deterred to become a particular body organ
• Fetus continually swallows, absorbed from the fetal • Cephalocaudal development (head to tail)
intestine into the fetal bloodstream Primary Germ Layers
• Term – 800 to 1,200 ml At the time of implantation, a blastocyst already
• Hydramnios (Polyhydramnios)– more than 2,000 ml in has differentiated to a point at which two separate cavities
total or pockets of fluid larger than 8 cm on UTZ; cases appear in the inner structure:
of esophageal atresia, anencephaly, GDM
• Fetal urine add to the quantity of the amniotic fluid; a
disturbance of kidney function may cause
oligohydramnios
• Oligohydramnios – reduction in the amount of
amniotic fluid
• Amniotic fluid index must be at least 5 cm, vertical
pocket should be greater than 2 cm
• Purposes
o Protection against pressure or a blow to the 1. Amniotic cavity – large one, lined with a distinctive
mother’s abdomen layer of cells
2. Yolk sac – smaller cavity, lined with entoderm cells. In
o Protection from temperature changes humans, the yolk sac appears to supply nourishment only
o Aids in fetal muscular development until implantation. After that, its main purpose is to provide
o Protects the umbilical cord from pressure a
• Slightly alkaline, ph of 7.2 source of red blood cells until the embryo’s
• Differentiate from urine (pH of 5.0 to 5.5) hematopoietic system is mature enough to perform this
function (at about the 12th week of intrauterine life). The
E. The Umbilical Cord
yolk sac then atrophies and remains only as a thin white
• Formed from the fetal membranes, chorion and streak discernible in the cord at birth.
amnion • Between the amniotic cavity and the yolk sac, a third
• Connects the embryo to the chorionic villi of the layer of primary cells, the mesoderm, forms. The
placenta embryo will begin to develop at the point where the
• Transports oxygen and nutrients to the fetus and three cell layers
(ectoderm, entoderm, and mesoderm) meet, called the
returns waste products from the fetus to the placenta embryonic shield. Each of these germ layers of primary
• 53 cm long and about 2 cm thick at term tissue.
• Wharton Jelly – gelatinous mucopolysaccharide • Knowing the origins of body structures helps to
which gives the cord its body and prevents pressure explain why certain screening procedures are ordered
on the vein and arteries for newborns with congenital malformations. A
radiographic examination of the kidney, for example,
• AVA – one vein two arteries may be ordered for a child born with a heart defect. A
• Veins carries the oxygenated blood from the placenta child with a malformation of the urinary tract is often
to the fetus investigated for reproductive abnormalities as well. All
• Arteries carry the unoxygenated blood from the fetus organ systems are complete, at least in a rudimentary
to the placenta form, at 8 weeks’ gestation (the end of the embryonic
period). During this early time of organogenesis (organ
• Assessed at birth, 1 to 5% are born with only a single formation), the growing
vein and artery – 15 to 20% are associated with structure is most vulnerable to invasion by teratogens
chromosomal/congenital disorders of hearts and (any factor that adversely affects the fertilized ovum,
kidneys embryo, or fetus, such as cigarette smoking).
• Nuchal cord during delivery – remove coil before the Cardiovascular System
shoulders are delivered to avoid disruption of oxygen • One of the first systems to become functional in utero
supply to the fetus • Formed as early as 16th day of life and beats as early
as the 24th day.
• Cord clamping – no nerve supply • Chambers develops at 6th or 7th week, heart valves
• Unang yakap: Delayed cord clamping develop in 7th week
34
• FHT via Doppler as early as 10th to 12th week of blood is sent through the ductus venosus. This is also
pregnancy a shunt that lets highly oxygenated blood bypass the
• After 28th week when the sympathetic nervous system liver to the inferior vena cava and then to the right
matures, heart rate can be assessed at 110 to 160
beats/min
atrium of the heart
Circulation after birth • A small amount of this blood goes straight to the liver
1. Deoxygenated RBC from various parts of the body enter to give it the oxygen and nutrients it needs
inferior vena cava/superior vena cava • Waste products from the fetal blood are transferred
2. Blood cells flow into the right atrium and continue to the back across the placenta to the mother's blood
right ventricle • Ductus venosus carries freshly oxygenated blood to
3. Exit to the lungs via the pulmonary artery where blood
the fetal heart
cells are then oxygenated
4. Blood cells get oxygenated in the alveoli found in the Inside the fetal heart
capillaries of the lungs • Blood enters the right atrium. This is the chamber on
5. Oxygenated blood then enters the heart via pulmonary the upper right side of the heart. When the blood
vein enters the right atrium, most of it flows through the
6. Oxygenated blood cells move into the left atrium and foramen ovale into the left atrium
into the left ventricle
7. Red blood cells move into aorta from which they are • The foramen ovale keeps the oxygenated blood from
pumped to the rest of the body going straight to the lungs
• Blood then passes into the left ventricle. This is the
lower chamber of the heart. Blood then passes to the
aorta. This is the large artery coming from the heart
• From the aorta, blood is sent to the heart muscle itself
and to the brain and arms. After circulating there, the
blood returns to the right atrium of the heart through
the superior vena cava.
• The right atrium is more like a complicated pathway
and there is blood flowing in not one but 2 directions.
• About 2/3 of the blood will pass through the FO just
like it did on the first pass.
• The other 1/3 will pass into the right ventricle toward
the lungs.
• Foramen ovale bypasses the lungs. This shunt moves
blood from the right atrium of the heart to the left
atrium.
• Normally, the lungs are a low-pressure system, and it
is this way because this is how we receive the 02 to
breathe.
• In fetal circulation, the placenta is the lungs, and the
Fetal Circulation lungs only need enough 02 to make sure the tissue
• The mother (placenta) is doing the work that the stays viable.
baby’s lungs will do after birth. • The high-pressure system in fetal circulation helps to
• 3 shunts shunt blood away from the lungs to the aorta
o Ductus venosus • At the same time, the blood that does feed the lungs
o Foramen ovale enter the pulmonary artery and returns via the
o Ductus arteriosus pulmonary vein and empties into the left atria
• Foramen ovale – bypasses the lungs. This shunt • From the aorta, circulation is supplied to the lower
moves blood from the right atrium of the heart to the part of the fetal body
left atrium • Ductus arteriosus moves blood from the pulmonary
• Ductus arteriosus – moves blood from the pulmonary artery to the aorta
artery to the aorta • The blood in circulation from the lower extremities
• Ductus venosus – carries freshly oxygenated blood to enters the umbilical arteries and makes its way back
the fetal heart to the placenta for refueling
• Oxygen and nutrients from the mother's blood are • In the placenta, CO2 and waste products are released
sent across the placenta to the fetus. The enriched into the mother’s circulatory system and o2 and
blood flows through the umbilical vein to the liver nutrients from the mother's blood are released into
• The blood then reaches the inferior vena cava. This is the fetal blood and the cycle begins again
a major vein connected to the heart. Most of this
35
What happen to the 3 shunts after birth?
• The umbilical cord is clamped and the baby no longer
receives oxygen and nutrients from the mother. With
the first breaths of air, the lungs start to expand, and
the ductus arteriosus and the foramen ovale both
close. The baby's circulation and blood flow through
the heart now function like an adult's
• The ductus venosus closes due to changes in
intracardiac pressures and a decrease in endogenous
prostaglandins. Failure of the ductus venosus to close
may result in galactosemia, hypoxemia,
encephalopathy with hyperammonia, and hepatic
dysfunction.
• The ductus arteriosus normally closes within two or
three days. In premature infants, the connection often
takes longer to close. If the connection remains open,
it's referred to as a patent ductus arteriosus. The
abnormal opening causes too much blood to circulate
to the baby's lungs and heart
• The foramen ovale normally closes as blood pressure • At 35 weeks, lecithin becomes the chief
rises in the left side of the heart after birth. Once it is component by a ratio of 2:1
closed, the blood flows to the lungs to get oxygen • L/S ratio analysis via amniocentesis technique
before it enters the left side of the heart and gets is a primary test of fetal maturity
pumped to the rest of the body • Respiratory distress syndrome – severe
breathing disorder because of lack or immature
form of surfactant
• Any interference with the blood supply to the
fetus, such as placental insufficiency or
maternal HPN, may raise steroid levels in the
fetus and enhance surfactant development
• Betamethasone – administered to women in
preterm labor to facilitate fetal lung maturity
Nervous System
• Neural plate is apparent at 3rd week of
gestation. The top portion will form the CNS
(brain and spinal cord); neural crest will develop
Respiratory System into the PNS
• 3rd week – respiratory and the digestive tract • All parts of the brain form in utero, although
exists as a single tube none are completely mature at birth
• 4th week – septum divides the trachea and • By 24 weeks, the ear is capable of responding to
esophagus, lung buds appear sound and the eyes exhibit a pupillary reaction,
• Until the 7th week, diaphragm does not indicating sight is present
completely divide the thoracic cavity from the • Prone to insult during the early weeks of the
abdomen. embryonic period and can result in neural tube
• Diaphragmatic hernia – diaphragm fails to disorders such as meningocele
close completely • Folic acid – found in green leafy vegetables and
• Surfactant – formed and excreted by the preg vitamins
alveolar cells of the lungs beginning at approx. Endocrine System
24th week of pregnancy; decreases alveolar • Fetal pancreas produces insulin needed by the
surface tension on expiration, preventing fetus
alveolar collapse and improving the infant’s • Thyroid and parathyroid glands play vital roles
ability to maintain respirations in the outside in fetal metabolic function and calcium balance
environment at birth. • The fetal adrenal glands supply a precursor
• Lecithin and sphingomyelin necessary for estrogen synthesis by the
• Sphingomyelin – the chief component in the placenta
early weeks. Musculoskeletal System
36
• First 2 weeks of fetal life, cartilage prototypes • Undescended testes in preterm males
provide position and support to the fetus (cryptorchidism) – poor sperm production and
• 12 weeks – ossification of this cartilage into testicular cancer later in life
bones begins and continues into adulthood • Surgery
• A fetal movement can be seen as early as 11th Immune System
week in UTZ, although quickening can be felt by Immunoglobulin G maternal antibodies cross the
the mother until 16th to 20thweeks. This can be placenta into the fetus as early as the 20th week and
felt earlier in multigravida women. certainly by the 24th week of intrauterine life to give a
Digestive System fetus temporarypassive immunity against diseases for
• Meconium – early stool passed by a newborn which the mother has antibodies
soon after birth; collection of wastes, biles, fats, Integumentary System
mucoproteins accumulated in the intestines as • 36 weeks – subcutaneous fat begins to be
early as the 16th week; sticky in consistency deposited underneath the thin and almost
appears lack or dark green translucent skin
• Nursing responsibility: check if the NB has • Lanugo – soft downy hairs that serve as
passed meconium to rule out stricture insulation to preserve warmth in utero
(imperforate anus). • Vernix caseosa – cream cheese-like substance
• Vit K thru IM – given to NB to helps the blood to important for lubrication and for keeping the
clot and prevent serious bleeding skin for macerating in utero
• Sucking and swallowing reflexes are not mature • Both are still present at birth
until the fetus is approx. 32 weeks gestation MILESTONES OF FETAL GROWTH AND
• Liver is immature and cannot prevent the DEVELOPMENT
recreational drugs and alcohol from entering I. End of 4th Gestational Week
the fetal circulation At the end of the fourth week of gestation, the
• Hypoglycemia and hyperbilirubinemia – two human embryo is a group of rapidly growing cells but does
not yet resemble a human being
serious problems that can occur in the fetus 24 • Length: 0.75–1 cm
hours after birth • Weight: 400 mg
Urinary System • The spinal cord is formed and fused at the
• Urine formed by the 12thweek and is excreted midpoint
into the amniotic fluid by the 16thweek of • Lateral wings that will form the body are folded
gestation forward to fuse at the midline.
• The head folds forward and becomes
• Term – fetal urine is excreted at a rate of up to
prominent, representing about one-third of the
500 ml/day entire structure
• Oligohydramnios suggests fetal kidneys are not • The back is bent so that the head almost touches
secreting adequate urine and that there is a the tip of the tail
kidney, ureter, and bladder disorder • The rudimentary heart appears as a prominent
bulge on the anterior surface
• Arms and legs are budlike structures
• Rudimentary eyes, ears, and nose are
discernible
II. End of 8th Gestational Week
• Length: 2.5 cm (1 in)
• Weight: 20 g
• Organogenesis is complete
• The heart, with a septum and valves, is beating
rhythmically
• Facial features are definitely discernible
• Arms and legs have developed
• External genitalia are forming, but sex is not yet
distinguishable by simple observation
• The primitive tail is regressing
• The abdomen bulges forward because the fetal
Reproductive System intestine is growing so rapidly.
• The testes first form in the abdominal cavity and • An ultrasound shows a gestational sac,
diagnostic of pregnancy
do not descend in the scrotal sac until the 34th III. End of 12th Gestational Week (First Trimester)
to 38th week of intrauterine life • Length: 7–8 cm
• Weight: 45 g
• Nail beds are forming on fingers and toes
37
• Spontaneous movements are possible, although • Weight: 1200 g
they are usually too faint to be felt by the • Lung alveoli begin to mature, and surfactant can
mother be demonstrated in amniotic fluid
• Some reflexes, such as the Babinski reflex, are • Testes begin to descend into the scrotal sac from
present the lower abdominal cavity
• Bone ossification centers begin to form • The blood vessels of the retina are formed but
• Tooth buds are present thin and extremely susceptible to damage from
• Sex is distinguishable by outward appearance high oxygen concentrations (an important
• Urine secretion begins but may not yet be evident consideration when caring for preterm infants
in amniotic fluid who need oxygen)
• The heartbeat is audible through Doppler VIII. End of 32nd Gestational Week
technology • Length: 38–43 cm
IV. End of 16th Gestational Week • Weight: 1600 g
• Length: 10–17 cm • Subcutaneous fat begins to be deposited (the
• Weight: 55–120 g former stringy, “little old man” appearance is
• Fetal heart sounds are audible by an ordinary lost)
stethoscope • Fetus responds by movement to sounds outside
• Lanugo is well formed the mother’s body.
• Liver and pancreas are functioning • Active Moro reflex is present
• Fetus actively swallows amniotic fluid, • Iron stores, which provide iron for the time during
demonstrating an intact but uncoordinated which the neonate will ingest only milk after
swallowing reflex; urine is present in amniotic birth, are beginning to be developed
fluid. • Fingernails grow to reach the end of fingertips
• Sex can be determined by ultrasound. IX. End of 36th Gestational Week
V. End of 20th Gestational Week • Length: 42–48 cm
• Length: 25 cm • Weight: 1800–2700 g (5–6 lb)
• Weight: 223 g • Body stores of glycogen, iron, carbohydrate, and
• Spontaneous fetal movements can be sensed calcium are deposited
by the mother • Additional amounts of subcutaneous fat are
• Antibody production is possible deposited
• The hair forms on the head, extending to include • Sole of the foot has only one or two crisscross
eyebrows creases, compared with the full crisscross
• Meconium is present in the upper intestine pattern that will be evident at term
• Brown fat, a special fat that will aid in • Amount of lanugo begins to diminish
temperature regulation at birth, begins to be • Most babies turn into a vertex (head down)
formed presentation during this month.
behind the kidneys, sternum, and posterior neck X. End of 40th Gestational Week (Third Trimester)
• Vernix caseosa begins to form and cover the • Length: 48–52 cm (crown to rump, 35–37 cm)
skin • Weight: 3000 g (7–7.5 lb)
• Passive antibody transfer from mother to fetus • Fetus kicks actively, hard enough to cause the
begins mother considerable discomfort.
• Definite sleeping and activity patterns are • Fetal hemoglobin begins its conversion to adult
distinguishable (the fetus has developed hemoglobin. The conversion is so rapid that,
biorhythms at birth, about 20% of hemoglobin will be adult in
that will guide sleep/wake patterns throughout character
life) • Vernix caseosa is fully formed
VI. End of 24th Gestational Week (Second Trimester) • Fingernails extend over the fingertips
• Length: 28–36 cm • Creases on the soles of the feet cover at least
• Weight: 550 g two thirds of the surface
• Meconium is present as far as the rectum Preventing Fetal Exposure to
• Active production of lung surfactant begins
• Eyebrows and eyelashes become well defined
Teratogens
Teratogen – is any factor, chemical or physical, that
• Eyelids, previously fused since the 12th week,
adversely affects the fertilized ovum, embryo, or fetus. At
now open
one time, it was assumed that a fetus in utero was
• Pupils are capable of reacting to light
protected from chemical or physical injury by the presence
• When fetuses reach 24 weeks, or 601 g, they of the amniotic fluid and by the absence of any direct
have achieved a practical low-end age of placental exchange between mother and fetus. When
viability (earliest age at which fetuses could infants were born with disorders, it was attributed to the
survive if born at that time), if they are cared for
influence of fate, bad luck, or, in some cultures, evil spirits.
after birth in a modern intensive care facility Today, it is acknowledged that a fetus is extremely
• Hearing can be demonstrated by response to vulnerable to environmental injury
sudden sound
VII. End of 28th Gestational Week Effects of Teratogens on a Fetus
• Length: 35–38 cm • Several factors influence the amount of damage
a teratogen can cause. The strength of the
38
teratogen is one of these. For example, radiation 2. Rubella – usually causes only a mild rash and mild
is a known teratogen. In small amounts systemic illness in a woman, but the teratogenic
(everyone is exposed to some radiation every effects on a fetus can be devastating
day, such as from sun rays), it causes no • Fetal damage from maternal infection with
damage. However, in large doses (e.g., the rubella (German measles) includes hearing
amount of radiation necessary to treat cancer of impairment, cognitive and motor challenges,
the cervix), serious fetal defects or death can cataracts, cardiac defects (most commonly
occur patent ductus arteriosus and pulmonary
• The timing of the teratogenic insult makes a stenosis), intrauterine growth restriction (IUGR),
significant impact on damage done to the fetus. thrombocytopenic purpura, and dental and facial
If a teratogen is introduced before implantation, clefts, such as cleft lip and palate
either the zygote is destroyed or it appears • Typically, a rubella titer from a pregnant woman
unaffected. If the insult occurs when the main is obtained on the first prenatal visit. A titer
body systems are being formed (in the second to greater than 1:8 suggests immunity to rubella. A
eighth weeks of embryonic life), a fetus is very titer of less than 1:8 suggests that a woman is
vulnerable to injury. During the last trimester, the susceptible to viral invasion. A titer that is greatly
potential for harm again decreases because all increased over a previous reading or is initially
the organs of a fetus are formed and are merely extremely high suggests that a recent infection
maturing has occurred
• Two exceptions to the rule that deformities • A woman who is not immunized before
usually occur in early embryonic life are the pregnancy cannot be immunized during
effects caused by the organisms of syphilis and pregnancy because the vaccine uses a live virus
toxoplasmosis. These two infections can cause that would have effects similar to those occurring
abnormalities in organs that were originally with a subclinical case of rubella. After a rubella
formed normally immunization, a woman is advised not to become
• A third factor determining the effects of a pregnant for 3 months, until the rubella virus is no
teratogen is the teratogen’s affinity for specific longer active.
tissue. Lead and mercury, for example, attack • All pregnant women should avoid contact with
and disable nervous tissue. Thalidomide, a drug children with rashes. Infants who are born to
once used to relieve nausea in pregnancy, mothers who had rubella during pregnancy may
causes limb defects. Tetracycline, a common be capable of transmitting the disease for a
antibiotic, causes tooth enamel deficiencies and, time after birth. Because of this, an infant may be
possibly, long bone deformities. The rubella virus isolated from other newborns during the
can affect many organs: the eyes, ears, heart, newborn period
and brain are the four most commonly attacked 3. Cytomegalovirus (CMV) – a member of the herpes
Teratogenic Maternal Infections virus family, is another teratogen that can
1. Toxoplasmosis – a protozoan infection, is spread most cause extensive damage to a fetus while causing few
commonly through contact with uncooked meat, although symptoms in a woman
it may, also be contracted through handling cat stool in soil • It is transmitted from person to person by droplet
or cat litter infection such as occurs with sneezing
• As many as 1 in 900 pregnancies may be • If a woman acquires a primary CMV infection
affected by toxoplasmosis during pregnancy and the virus crosses the
• A woman experiences almost no symptoms of placenta, the infant may be born severely
the disease except for a few days of malaise neurologically challenged (hydrocephalus,
and posterior cervical lymphadenopathy. Even in microcephaly, spasticity) or with eye damage
light of these mild symptoms, (optic atrophy, chorioretinitis), hearing
• if the infection crosses the placenta, the infant impairment, or chronic liver disease. The child’s
may be born with central nervous system skin may be covered with large petechiae
damage, hydrocephalus, microcephaly, (“blueberry-muffin” lesions)
intracerebral calcification, and retinal deformities. • However, diagnosis in the mother or infant can
• Pre pregnancy serum analysis can be done to be established by the isolation of CMV
identify women who have never had the antibodies in blood serum
disease and so are susceptible (about 50% of • Unfortunately, there is no treatment for the
women) infection even if it presents in the mother with
• Instruct pregnant women to avoid undercooked enough symptoms to allow detection. Because
meat and also not to change a cat litter box there is no treatment or vaccine for the
or work in soil in an area where cats may disease, routine screening for CMV during
defecate to avoid exposure to the disease. pregnancy is not recommended
• If the diagnosis is established by serum analysis • Women can help prevent exposure by thorough
during pregnancy, therapy with handwashing before eating and avoiding
sulfonamides may be prescribed crowds of young children at daycare or nursery
• Pyrimethamine, an antiprotozoal agent, may setting
also be used. This drug is an antifolic acid drug, 4. Herpes Simplex Virus (Genital Herpes Infection)
so it is administered with caution early in • The first time a woman contracts a genital herpes
pregnancy to prevent reducing folic acid levels infection, systemic involvement occurs. The
virus spreads into the bloodstream (viremia) and
39
crosses the placenta to a fetus posing When this layer atrophies at about the 16th
substantial fetal risk to 18th week of pregnancy, however, the
• If the infection takes place in the first trimester, spirochete then can cross and cause
severe congenital anomalies or spontaneous extensive damage. If syphilis is detected and
miscarriage may occur treated with an antibiotic such as benzathine
• If the infection occurs during the second or third penicillin in the first trimester, a fetus is rarely
trimester, there is a high incidence of affected. If left untreated beyond the 18th
premature birth, intrauterine growth restriction, week of gestation, hearing impairment,
and continuing infection of the newborn at cognitive challenge, osteochondritis, and
birth. Unless recognized and treated, the fetal fetal death are possible
mortality and morbidity rates are as high as • For this reason, serologic screening (by
80% either a VDRL or a rapid plasma reagin test)
• If a woman has had herpes simplex virus type 1 should be done at a first prenatal visit; the
infections before the genital herpes invasion test may then be repeated again close to
or if the genital herpes (type 2) infection is a term (the 8th month) if exposure is a
recurrence, antibodies to the virus in her system concern. Even when a woman has been
prevent spread of the virus to a fetus across the treated with appropriate antibiotics, the
placent serum titer remains high for more than 200
• If genital lesions are present at the time of birth, days; an increasing titer, however, suggests
however, a fetus may contract the virus from that reinfection has occurred. In an infant
direct exposure during birth. For women with a born to a woman with syphilis, the serologic
history of genital herpes and existing genital test for syphilis may remain positive for up to
lesions, cesarean birth is often advised to reduce 3 months even though the disease was
the risk of this route of infection. This treated during pregnancy
awareness of the placental spread of herpes • The newborn with congenital syphilis may
simplex virus has increased the importance of have congenital anomalies, extreme rhinitis
obtaining information about exposure to genital (sniffles), and a characteristic syphilitic rash,
herpes or any painful perineal or vaginal lesions all of which identify the baby as high risk at
that might indicate this infection at prenatal visits. birth. When the baby’s primary teeth come
• Intravenous or oral acyclovir (Zovirax) can be in, they are oddly shaped (Hutchinson teeth)
administered to women during pregnancy. The B. Lyme Disease – a multisystem disease caused by
primary mechanism for protecting a fetus, the spirochete Borrelia burgdorferi, is spread by the
however, focuses on disease bite of a deer tick. The highest incidence occurs in the
prevention. Urging women to practice safe sex is summer and early fall. The largest outbreaks of the
important to lessen their exposure to this disease are found on the east coast of the United
and other sexually transmitted infections. States. After a tick bite, a typical skin rash, erythema
Advising adolescents to obtain a vaccine against chronicum migrans (large, macular lesions with a
HPV (Gardasil) should lessen the incidence of clear center), develops. Pain in large joints such as
genital herpes infection in the future. the knee may develop. Infection in pregnancy can
5. Other Viral Diseases result in spontaneous miscarriage or severe
• It is difficult to demonstrate other viral teratogens, congenital anomalies
but rubeola (measles), coxsackievirus, infectious • To spread the spirochete, the tick must be
parotitis (mumps), varicella (chickenpox), present on the body possibly as long as 24
poliomyelitis, influenza, and viral hepatitis all may hours. After returning home from an outing,
be teratogenic. therefore, a woman should inspect her body
• Parvovirus B19, the causative agent of carefully and immediately remove any ticks
erythema infectiosum (also called fifth disease), found. If she has any symptoms that suggest
a common viral disease in school age children, if Lyme disease or knows she has been bitten,
contracted during pregnancy, can cross the she should contact her primary health care
placenta and attack the red blood cells of a fetus. provider immediately
Infection with the virus during early pregnancy is • Treatment of Lyme disease for pregnant
associated with fetal death. If the infection occurs women differs from that for nonpregnant
late in pregnancy, the infant may be born with women. The drugs used for nonpregnant
severe anemia and congenital heart adults, tetracycline and doxycycline, cannot
disease be used during pregnancy because they
A. Syphilis – a sexually transmitted infection, is of cause tooth discoloration and, possibly,
great concern for the maternal–fetal population long-bone malformation in a fetus. A course
despite the availability of accurate screening tests of penicillin will be prescribed to reduce
and proven medical treatment, as it is symptoms in the pregnant woman
growing in incidence and places a fetus at risk for • Because the symptoms of Lyme disease are
intrauterine or congenital syphilis chronic but not dramatic (a migratory rash
• Early in pregnancy, when the and joint pain), women may not report them
cytotrophoblast layer of the chorionic villi is at a prenatal visit unless they are educated
still intact, the causative spirochete of about their importance and are asked at
syphilis, Treponema pallidum, cannot prenatal visits if such symptoms are present
cross the placenta and damage the fetus. 6. Potentially Teratogenic Vaccines
40
• Live virus vaccines, such as measles, HPV, • However, alcohol has now been firmly isolated as
mumps, rubella, and poliomyelitis (Sabin type), a direct teratogen. Fetuses cannot remove the
are contraindicated during pregnancy because breakdown products of alcohol from their body.
they may transmit the viral infection to a fetus The large buildup of this leads to vitamin B
(Rojas, Wood, & Blakemore, 2007). Care must deficiency and accompanying neurologic
be taken in routine immunization programs to damage
make sure that adolescents about to be • Women during pregnancy should be screened
vaccinated are not pregnant. Women who work for alcohol use because an infant born with fetal
in biologic laboratories where vaccines are alcohol syndrome (FAS) not only is small for
manufactured are well advised not to work with gestational age but can be cognitively challenged
live virus products during pregnancy • Women are best advised, therefore, to abstain
7. Teratogenic Drugs from alcohol completely. Be certain to ask about
• Many women, assuming that the rule of being binge drinking (consuming more than five alcohol
cautious with drugs during pregnancy applies drinks in an evening) as women may refer to this
only to prescription drugs, take over-the-counter as only “occasional drinking.” Refer women with
drugs or herbal supplements freely. Although not alcohol addiction to an alcohol treatment
all drugs cross the placenta (heparin, for program as early in pregnancy as possible to
example, does not because of its large molecular help them reduce their alcohol intake
size), most do. Also, even though most herbs are 9. Teratogenicity of Cigarettes
safe, ginseng, for example, used to improve • Cigarette smoking is associated with infertility in
general well-being, or senna, used to relieve women. Cigarette smoking by a pregnant woman
constipation, may not be safe has been shown to cause fetal growth restriction.
• Any drug or herbal supplement, under certain In addition, a fetus may be at greater risk for
circumstances, may be detrimental to fetal being stillborn and, after birth, may be at greater
welfare. Therefore, during pregnancy, women risk than others for sudden infant death
should not take any drug or supplement not syndrome. Low birth weight in infants of smoking
specifically prescribed or approved by their mothers results from vasoconstriction of the
physician or nurse-midwife uterine vessels, an effect of nicotine. This limits
• A woman of childbearing age and ability should the blood supply to a fetus
not take any drug other than one prescribed • Another contributory effect may be related to
by a physician or nurse-midwife to avoid inhaled carbon monoxide. Secondary smoke, or
exposure to a drug should she become pregnant inhaling the smoke of another person’s
• The use of recreational drugs during pregnancy cigarettes, may be as harmful as actually
puts a fetus at risk in two ways: the drug may smoking the cigarettes. All prenatal healthcare
have a direct teratogenic effect, and intravenous settings should be smoke-free environments for
drug use risks exposure to diseases such as this reason
HIV and hepatitis B • The best way to urge women to discontinue
• Narcotics such as meperidine (Demerol) and smoking is to educate them about the risks to
heroin have long been implicated as causing themselves and their fetus at a first prenatal visit.
intrauterine growth restriction (IUGR). The use of It may be effective to encourage women to sign
marijuana alone apparently does not, although a contract with a health care provider to try to
the long-term effects of marijuana during stop or to join a smoking-cessation program
pregnancy are still unstudied. Cocaine, 10. Radiation
particularly its crack form, is potentially harmful to • Rapidly growing cells are extremely vulnerable to
a fetus because it causes severe destruction by radiation. That makes radiation a
vasoconstriction in the mother, compromising potent teratogen to unborn children because of
placental blood flow and perhaps dislodging the their high proportion of rapidly growing cells.
placenta. Its use is associated with spontaneous Radiation produces a range of malformations
miscarriage, preterm labor, meconium staining, depending on the stage of development of the
and IUGR embryo or fetus and the strength and length of
• An area of recreational drug use that needs to be exposure. If the exposure occurs before
examined is that of inhalant abuse (“huffing”). implantation, the growing zygote apparently is
Substances frequently used as inhalants include killed. If the zygote is not killed, it survives
gasoline, butane lighter fluid Freon, glue, and apparently unharmed. The most damaging time
nitrous oxide for exposure and subsequent damage is from
8. Teratogenicity of Alcohol implantation to 6 weeks after conception (when
• Evidence over the years has shown that when many women are not yet aware that they are
women consume a large quantity of alcohol pregnant). The nervous system, brain, and retinal
during pregnancy, their babies show a high innervation are most affected
incidence of congenital deformities and cognitive • As a rule, therefore, all women of childbearing
impairment. It was assumed in the past that these age should be scheduled for pelvic x-ray
defects were the result of the mother’s poor examinations only in the first 10 days of a
nutritional status (drinking alcohol rather than menstrual cycle (when pregnancy is unlikely be-
eating food), not necessarily the direct result of cause ovulation has not yet occurred), except in
the alcohol. emergency situations. A serum pregnancy test
can be done on all women who have reason to
41
believe they might be pregnant before diagnostic • If Apr – Dec = -3 +7 +1
tests involving x-rays are scheduled MC DONALD’S RULE
CU5: CARE OF THE MOTHER DURING THE • Use to determine age of gestation in weeks using
PERINATAL PERIOD FUNDIC HEIGHT
PRENATAL CARE • FORMULA:
OBSTETRIC DATA AOG in WKS = FUNDIC HEIGHT x 8/7
• FORMULA:
• Gravida - Number of pregnancy regardless of AOG in MONTHS = FUNDIC HEIGHT x 2/7
duration as long as the mother becomes pregnant BARTHOLOMEW’S RULE
even abnormal Use to determine age of gestation by proper location of
• Para/Parity – number of viable pregnancy or the fundus at abdominal cavity
total number of pregnancies in which the fetus has • < 12 weeks = not palpable/pelvic cavity
reached the age of viability and subsequently
• 3 months = above symphysis
delivered whether dead or alive at birth
• 5 months = level of umbilicus
• Viability – ability of the fetus to live outside the
• 7 months = bet. Umbilicus and xyphoid
uterus at the earliest possible gestational age
• 9 months = touching/below xyphoid
• Primigravida – woman who is pregnant for the first
• 10 months = level of 9 months due to lightening;
time
about 4 cm
• Primipara – woman who has given birth to one child
past age of viability; woman who has completed
LEOPOLD’S MANEUVER
one pregnancy to age of viability and subsequently 1st MANEUVER: Purpose: to determine the fetal
presentation/lie through fundal palpation
delivered the fetus, whether alive or dead at birth
• If palpated a round, hard and movable – BREECH
• Multigravida – woman who has been pregnant
presentation
previously; 2 or more pregnancy
• If palpated round, soft and immovable -
• Grandmultigravida – woman who has had six or
more pregnancies HEAD/CEPHALIC presentation
2nd MANEUVER: Purpose: to determine the back of fetus
• Multipara - Woman who has carried two or more
to hear the fetal heart sound
pregnancies to viability; woman who has carried
• If smooth hard and resistant surface - FETAL BACK
two or more pregnancies of stage of viability and
subsequently born alive or dead • If angular nodulations - KNEES AND ELBOWS
• Nulligravida - Woman who has never been and is 3rd MANEUVER: Purpose: to determine the degree of
engagement by palpating the lower uterine segment
not currently pregnant
• Nullipara- woman who has not carried a pregnancy • If the presenting part is movable: NOT ENGAGED
beyond 20 weeks • If the presenting part is immovable: ENGAGED
• Grandmultipara - woman who has had 6 or more o HARD: HEAD
o SOFT, GLOBULAR, LARGE: BUTTOCKS
viable deliveries, whether, the fetuses were alive or
dead 4th MANEUVER: Purpose: to determine the fetal attitude
–relationship of fetus to each part or degree of flexion by
PRINCIPLES IN IDENTIFYING PARITY
grasping the lower quadrant of abdomen. It is done only
1. Number of pregnancies is counted and not the number
if the fetus is in cephalic presentation.
of fetuses
• Full Flexion if the fetal chin touches chest
2. Abortion is not included in parity count
3. Live birth or stillbirth is counted in parity count Psychological Changes of pregnancy
• Pregnancy is such a huge change in a woman’s
OB SCORING
life and brings about more psychological
T - Term: Number of full-term infants born 37 weeks
P - Pre-term: Number of preterm infants born 20 – 36 changes than any other life event beside
weeks puberty
A - Abortion: termination of pregnancy before the age • A woman’s attitude towards a pregnancy
of viability (less than 20 weeks) depends a great deal on psychological aspects:
L – Number of Currently Living Children such as:
M – Multiple Pregnancy o The environment in which she was raised
o The messages about pregnancy her family
NAGELE’S RULE
communicated to her as a child
• Use to determine expected date of delivery (EDD
o The society and culture in which she lives
or EDB). It is important to determine the mother’s
as an adult
LMP.
o Whether the pregnancy has come at a
• If Jan – March = +9 +7
good time in her life
42
1. Social Influences 2. Find a compromise that will assure a woman that these
2. Cultural Influences are not really harmful to a fetus but that still respects
3. Family Influences these beliefs
4. Individual Differences Family Influences
5. Partners Adaptation • The family in which woman raised can be influential
Social Influences to her beliefs about pregnancy
• Woman and her siblings were loved and seen as a
From the Past Today
pleasant outcome is more likely to have a positive
The pregnancy was conveyed Pregnancy is viewed as a attitude towards her pregnancy
as a 9-month long illness healthy span of time best • A woman who views mothering a positive activity is
shared with supportive more likely to be pleased when she becomes
partner and or family pregnant than one who does not value mothering
• Negative Influences - woman and her siblings were
The pregnant woman went The woman brings their
blamed for the breakup of a marriage or a
alone to a physician’s office for families for prenatal care
relationship
care visits as well as to watch
Individual Differences
the birth
• A woman’s ability to cope with or adapt to stress
At the time of birth, she was The woman chooses plays a major role in how she can resolve any
separated from her family what level of pain conflict and adapt:
management they want o To being a mother without needing mothering,
to use for labor and birth to loving a child as well as partner
o To becoming a mother for each new child
The woman was hospitalized
depends on her basic temperament on whether
in seclusion from visitors and They expect to breastfed
she adapts to new situations quickly or slowly,
even from the new baby for 1 their newborn
whether she face them with intensity or
week afterward so the
maintain a low-key approach, and whether she
newborn could be fed by had experience coping with change and stress
nurses o The extent to which a woman feels secure in her
The woman and her partner feel during pregnancy and relationship with the people around her
prepared to meet the challenges are: o Past experiences influence on how woman
related to them: perceive pregnancy as a positive or negative
a. Cultural background experience
b. Personal beliefs o To being concerned about her appearance
c. Experiences reported by friends and relatives o To being worry that pregnancy will rob her
d. Current plethora of information available financially and ruin her chances of job
Nurse’s Role promotion
1. Teaching the woman about their health care option Nurse’s Role
2. Continue to work with other health care provider to 1. Assessing and counselling pregnant woman
“demedicalize” childbirth 2. Fill the role of an attentive listener
Cultural influences Partner’s Adaptation
• Cultural beliefs and taboos can place restrictions on • The more emotionally attached a partner is to a
a woman’s behavior and activities regarding her pregnant woman, the closer the partner’s
pregnancy attachment is apt to be to the child
• During prenatal visits, ask the woman and her • Factors that affect the pregnant woman’s decision
partner if there is anything, they believe that making:
should or should not be done to make the o Cultural background
pregnancy successful and keep the fetus healthy o Past experience
• Examples: Beliefs o Relationships with the family members
o Lifting the arms over the head during Psychological Tasks of Pregnancy
pregnancy will cause the cord to twist 1. First Trimester: Accepting the Pregnancy
o Watching a lunar eclipse will cause a birth Task: Accepting the pregnancy - woman and partner
deformity both spend time recovering from shock of learning
Nurse’s Role: they are pregnant and concentrate on what it feels
1. Supporting these beliefs shows respect for the like to be pregnant. A common reaction is
individuality of a woman and her knowledge of good ambivalence, or feeling both pleased and not
health pleased about the pregnancy.
43
The Woman ● Task: Accepting the baby - Woman and partner
• Accept the reality of the pregnancy, later will move through emotions such as narcissism and
come the task of accepting the baby, following introversion as they concentrate on what it will feel
their initial surprise women often experience like to be a parent. Roleplaying and increased
the feeling of ambivalence dreaming are common
• Ambivalence – refers to the interwoven feelings The Woman
of wanting and not wanting feelings which can ● Psychological task of a woman is to accept she is
be confusing to an ordinarily organized woman having a baby, a step up from accepting the
• Most women who were not happy about being pregnancy
pregnant at the beginning are able to change ● The change usually happens at quickening or the
their attitude towards their pregnancy by the first moment a woman feels fetal movement.
time they feel the child move inside ● Woman who carefully planned the pregnancy, this
• Woman often comment after such visit they feel moment of awareness may occur soon as she
“more pregnant” or it makes a first visit more recovers from the surprise of learning she has
than an ordinary one actually conceived
• Early diagnosis is important because the earlier ● She announces the news to her parents and hear
a woman realizes she is pregnant, the sooner them express their excitement and see a look of
she can begin to safeguard fetal health by pride on her partner’s face
discontinuing all drugs not prescribed or ● A good way to measure the level of a woman’s
approved by her health care provider. acceptance is to measure how well she follows
Health care plan: prenatal instructions
1. Routine sonogram – to assess for growth The Partner
anomalies and can be a major step in promoting ● A partner may become overly absorbed in work,
acceptance because women can see a beating striving to produce something concrete on the
heart or fetal outline or can learn the sex of their job that may limit the amount of time a partner
fetus. spends with family
2. First prenatal visits - hearing their pregnancy ● Some men have difficulty enjoying the pregnancy
officially diagnosed at a first prenatal visit is because they have been misinformed about
another step toward accepting a pregnancy sexuality, pregnancy, and women’s health
The Partner 3. Third trimester: Preparing for parenthood
• All partners are important and should be ● Task: Preparing for the baby and end of pregnancy
encouraged to play a continuing emotional - Woman and partner prepare clothing and sleeping
and supportive role in pregnancy arrangements for the baby but also grow impatient
• Accepting the pregnancy for a partner with pregnancy as they ready themselves for birth
means not only accepting the certainty of The Woman and Partner
the pregnancy and the reality of the child to • Couples begin “nest building” activities
come but also accepting the woman in her (Planning the infant’s sleeping arrangements,
changed state choosing a name for the infant, ensuring safe
• Partner may also experience feeling of passage) by learning about birth
ambivalence • Couples are usually interested in attending
• Partner may feel proud and happy at the prenatal classes and or classes on preparing
beginning of pregnancy for childbirth
• Soon begin to feel both overwhelmed with • Childbirth education class and or preparing
what the loss of salary will mean to the for parenthood can not only help a couple
family if the woman has to quit work accept but also expose them to other parents
• Feeling close to jealousy of the growing baby as a role models who can provide practical
who although not yet physically apparent, information about pregnancy a concern child
seems to be taking up a great deal of the care.
woman’s time and thought Assessing events that could contribute to difficulty
Health care plan: accepting Pregnancy:
• Prenatal visit or fetal testing – provide an 1. Pregnancy is unintended
outlet for both male and female partners to 2. Learning the pregnancy is a multiple, not a single
discuss concerns and offer parenting one
information. 3. Learning the fetus has developmental
2. Second Trimester: Accepting the Baby abnormality
44
4. Pregnancy is less than 1 year after the previous o Chadwick’s sign - color change of the vagina
one from pink to violet
5. Family has to relocate during pregnancy (Involves o Goodell’s sign – softening of the cervix
a need to find new support people o Hegar’s sign - softening of the lower uterine
6. The main family support person suffers a job loss segment
7. The woman’s relationships end because of o Sonographic evidence of gestational sac
partner’s infidelity o Braxton Hick’s contraction – periodic uterine
8. There is a major illness in self, partner, or a tightening
relative o Fetal outline felt by examiner through palpation
9. Complications of pregnancy occur (Hypertension) o Ballottement – the fetus can feel through
10. The woman has a series of developing bimanual examination
experiences (failure in school work) Laboratory Tests – blood serum and urine specimen to
Emotional responses that can cause concern in detect the presence of human chorionic gonadotrophin
Pregnancy (hCG)
● Emotional responses and common reactions helpful • Serum pregnancy test – hCG appear as early as
to caution a pregnant woman and her partners that 24 – 48 hrs. after implantation and reach a
the common changes may occur so they’re not measurable level about 50 unit/ml 7-9 days
alarmed if they appear: after conception
1. Grief • Urine sample – concentrated such as a first
2. Narcissism urine in the morning
3. Introversion versus Extroversion • Home Pregnancy Test -it takes 2-3 mins. to
4. Body image and Boundary complete and have a high degree of accuracy
5. Stress • Early prenatal care – is the best safeguard to
6. Depression ensure successful pregnancy.
The Confirmation of Pregnancy Positive Signs of Pregnancy
• A medical diagnosis of pregnancy serves to • Sonographic evidence of fetal outline - fetal
date when the birth will occur and helps outline can be seen and measure by sonogram
predict the existence of a high-risk status • Fetal movement felt by examiner
• Pregnancy was diagnosed on symptoms • Fetal heart audible – doppler ultrasound reveal
reported by a woman and the signs elicited heartbeat (10th – 12th week of gestation
by a health care provider Physiologic Changes of Pregnancy
Signs and symptoms of Pregnancy • They can categorize as local (confined to the
1. Presumptive Signs (Subjective Symptoms) - are reproductive organs or systemic affecting the
findings in connection with the body system in which entire body)
they occur and are experienced by the woman but 1. Reproductive System Changes
cannot be documented by an examiner a. Uterine Changes – increase the size of the uterus
o Breast changes – feelings of tenderness, to accommodate the growing fetus
fullness, tingling, enlargement and darkening • The uterus increases in length, depth, width,
of areola weight, wall thickness and volume
o Nausea and vomiting – on arising or when o Length – from 6.5 - 32 cm;
fatigue
o Width – from 4cm to 24 cm;
o Amenorrhea – absence of menstruation
o Weight - increases from 50g to
o Frequent urination – sense of having to void
1000g;
more often than usual o Depth- increases from 2.5 cm to 22
o Fatigue - general feeling of tiredness cm
o Uterine enlargement – uterus can be palpated o Uterine wall thickens from 1cm to
over symphysis pubis 2cms
o Quickening - fetal movement felt by woman o Volume – increases from 2 ml. to
o Linea Nigra – line of dark pigment forms on the more than1,000 ml can hold a total
abdomen of 4000g at term (7-lb (3.175
o Melasma – dark pigmentation forms on face g.) fetus, 1,000 ml amniotic fluid
o Striae Gravidarum - red streaks forms on
• Fundus height at various week of
abdomen
pregnancy
2. Probable Signs (Objective Symptoms) – are findings
o 20-22nd week – reaches the level of
and can verified by an examiner
the umbilicus
45
o 36th week – touches the xiphoid 4. Respiratory system
process • Shortness of breathing is common
o 38th week – fetal head settles into • Marked congestion or stuffiness – due to increase
the pelvis estrogen
5.Cardiovascular system
● 30-50% increase in the total cardiac volume
● Physiologic Anemia of pregnancy may occur
● Increases heart rate
● Palpitations is common
● Edema and varicosities of the lower extremities
6. Gastrointestinal system
● Slow emptying time of the stomach
● Nausea and vomiting
● Decreased pH of the saliva
● Hemorrhoids is common due to constipation,
pressure of the uterus, slow peristalsis
7. Urinary System
● Glomerular Filtration rate increases
• Hegar’s signs – extreme softening of the lower
● BUN and Plasma Creatinine decreases
uterine segment
● Renal threshold for sugar decreases
• Ballottement – the fetus can be felt to bounce or
● Frequent urination in 1st trimester, normalizes in
rise
2nd trimester, frequent urination in 3rd trimester
• Braxton Hick’s contraction 8. Muscular system
• Amenorrhea ● Calcium and Phosphorus needs are increased
b. Cervical changes – becomes more vascular and ● Gradual softening of the pelvic ligaments
edematous ● Wide separation of the symphysis pubis
• Goodell’s sign - softening of the cervix 9. Immune system
c. Vaginal Changes – increase vascularity of the ● IgG production decreases
vagina ● WBC simultaneously increases
• Chadwick’s sign -changes in color from light pink to RECOMMENDED WEIGHT GAIN DURING
a deep violet
PREGNANCY
d. Ovarian Changes – active production of estrogen
• A weight gain of 11.2 to 15.9 kg (25 to 35 lb) is
and progesterone
recommended as an average weight gain in
2. Breast changes
pregnancy
• Feeling of fullness, tingling or tenderness because of
• Weight gain in pregnancy occurs from both fetal
increased estrogen level
growth and accumulation of maternal stores and
• Breast size increase because of the growth in
occurs at approximately 0.4 kg (1 lb) per month
mammary alveoli and in fat deposit
during the rst trimester and then 0.4 kg (1 lb) per
• Areola of the nipple darkens and the diameter week during the last two trimesters (a trimester
increases from about 3.5 cm (1.5 inches) to 5cm or pattern of 3-12-12)
7 cm (2 or 3 inches)
• As a general rule, in the average woman, weight
3. Endocrine changes
gain is considered excessive if it is more than 3 kg
• Increased thyroid and parathyroid hormone
(6.6 lb) a month during the second and third
production
trimesters; it is less than usual if it is less than 1 kg
• Palmar erythema (2.2 lb) per month during the second and third
• Insulin production is decreased early during trimester
pregnancy and increases after the • Women can be assured that most of the weight
1st trimester gained with pregnancy will be lost afterward
• Prolactin, Melanocyte-stimulating hormone, and • To ensure adequate fetal nutrition, advise women
human growth hormone of the pituitary gland not to diet to lose weight during pregnancy
increase,
• Weight gain will be higher for a multiple pregnancy
ESTOGEN AND PROGESTERONE produced than for a single pregnancy. You can encourage
• Placenta as a transient endocrine organ women pregnant with multiple fetuses to gain at
• Colostrum can be expelled as early as 16 weeks least 1lb per week for a total of 40 to 45 lb
• Increase vascularity • Sudden increases in weight that suggest fluid
• Enlarge and protuberant nipples retention or polyhydramnios
46
(excessive Amniotic fluid) or a loss of weight that progesterone and no bleeding occurs, the woman
suggests illness should be carefully evaluated is pregnant
at prenatal visits 4. Ultrasound imaging – (Ultrasound scanning or
NORMAL DIAGNOSTIC AND LABORATORY Scanning) involves exposing a part of the body to high
FINDINGS frequency sound waves to produce pictures of the
A medical diagnosis of pregnancy serves to date when inside of the body
the birth will occur and also helps predict the existence • It is a popular and safe diagnostic tool in the
of high-risk status care of the pregnant woman and her fetus
• With advancements in science and technology, • It provides the physician, and other
pregnancy tests today are commercially available members of the health team the ability to
and can be performed by the trained personnel approach the developing fetus aa a separate
that are highly accurate and precise, if done with patient with an identifiable set of reflexes
the correct technique reactions to outside stimuli and activity
Pregnancy testing – relies on the detection of an patterns
antibody to the hormone humanchorionic gonadotropin • 7-11 wks. if the date of LMP is unknown,
(hCG) or a subunit in the urine or serum between 16-20 wks. gestation to verify fetal
• Human Chorionic Gonadotropin – the first structures and gender
placental hormone produced and can be found
Types of Pelvic Ultrasound
shortly after implantation
a. Abdominal or Transabdominal – with the woman in
Specimens:
supine position, thesonographer/radiologist applies the
1. Urine – test to yield accurate results and it should be
transducer on the lower abdomen
done 10 to 14 days after the missed menstrual period.
b. Vaginal or transvaginal – with the woman in lithotomy
This period guarantee level of hCG and prevents false
position, thesonographer/radiologist inserts into the
negative results.
vagina 2-3 inches of the vaginal transducer’s end with the
a. Gravindex and Pregnosticon - are
protective cover and lubricating gel
immunologic pregnancy test andapproximately 95%
Purpose:
accurate in diagnosing pregnancy and 98% accurate in
1. Diagnose pregnancy as early as 6 wks. Gestation.
determining the absence of pregnancy
2. Confirm the size, location of the placenta and
b. Radioimmunoassay – tests for the beta
amniotic fluid
subunit of hCG and considered to be so accurate as to
3. Discover complications of pregnancy
be diagnostic for pregnancy
4 . Establish if fetus is growing and no congenital
anomalies
Urine Tests: (hCG)
5. Predict maturity by measurement
• Collect first voided urine using clean, dry bottle
of biparietal diameter of the head
free of detergent or contamination
Ultrasonography
• Do not drink fluids from 8pm the night before to
1. Biparietal diameter – used to predict fetal maturity.
concentrate the urine
a. Measurement of fetal head (8.5 cm. or
• Refrain from taking any drug 24 hrs. before the
greater)
test
b. Weight. 2500 g (5.5 lb.)
• Label the specimen with the woman’s name,
2. Doppler Umbilical Velocimetry – measures the
date, and time of voiding
velocity at which RBC in the uterine and fetal vessels to
• Bring the specimen to the laboratory immediately assess blood flow
• Refrigerate urine specimen-if more than one hour 3. Placental grading for maturity – graded based on the
is pass before the specimen gets to the amount of calcium deposits present in the base of the
laboratory because room temperature is high placenta
enough to destroy hCG Placental grading for Grades:
2. Blood – with sensitive assays hCG can be detected in o 0 – between 12 and 24 wks.
maternal blood at 7 daysafter conception and are o 1 – 30 – 32 wks.
accurate close to 100% of the time. o 2 – 36 wks.
3. Progesterone Withdrawal test – a contraceptive pill o 3 – 38 wks. – suggest fetus is mature
is taken OD or TID (3xdays) 4. Amniotic fluid volume – the amount of amniotic fluid
• If menstruation occurs within 10-15 days, the present estimate fetalhealth
woman is not pregnant o 20-24 cm. – indicates Hydramnios
• If corpus luteum produces enough hormones o < 5-6 cm – Oligohydramnios
to neutralize the effect of withdrawn synthetic 5. Nuchal translucency – described the appearance of a
collection of fluidunder the skin behind fetal neck
47
6. Magnetic resonance Imaging (MRI) – can identify • The test requires the use of an ultrasound and the
structural anomalies orsoft tissue disorder electronic fetal monitor and the observation time
7. Lateral Pelvimetry – in suspected cephalopelvic takes about 30 minutes.
disproportion (CPD) with a danger sign of absence
of lightening in a primigravida in active labor
Indications for lateral Pelvimetry Suspected CPD
a. Previous difficult delivery
b. History of severe vitamin D and calcium deficiency in
childhood
c. History of pelvic or spine injury
d. Cases of severe scoliosis
8. Laboratory Assessment
o Urinalysis – tested for proteinuria, glycosuria, Five Parameters:
nitrates, pyuria 1. Fetal Reactivity
o Complete blood count 2. Fetal breathing movements
o Genetic screen (G6PD glucose6phosphate 3. Fetal body movements
dehydrogenase) 4. Fetal tone
o VDRL serologic test for syphilis 5. Amniotic fluid volume
o Blood typing (Rh factor) Results:
o Maternal serum a-fetoprotein – done between o 8 - 10 fetus is considered to be doing well
16-18 wks. of pregnancy o 6 – 7 is considered suspicious
o Combs test – determination of whether Rh o 4 - denotes a fetus probably in jeopardy
antibodies are present in an Rh (-) woman Biophysical Profile Scoring
o HIV screening 1. Fetal breathing - at least one episode of 30secs of
o Serum antibody titers for rubella, hepatitis, sustained breathing movement within 30mins
varicella 2. Fetal movement - at least 3 episodes of fetal limb or
o Blood Serum Studies trunk movement w/in 30mins
o Tuberculosis Screening (Mantoux Test) 3. Fetal tone - Observation must extend and then flex
Assessing Fetal Well-being extremities or spine at least once in 30 mins.
4. Fetal heart reactivity - 2 or more heart accelerations at
least 15 beats/min
5. Amniotic fluid volume - A range of amniotic fluid
between 5 and 25 cm must be present
Fetal Heartrate
Fetal heartrate sound
a. 10 – 11 wks. – ultrasound
b. 10 wks. – Doppler
Daily fetal Movement Count (Kicks Count)
a. 18 – 20 wks. – quickening felt by the mother
b. 28 – 38 wks. – 10 x / hr. peaks in intensity
1. Fetal Biophysical Profile Rhythm Strip testing – assessment of the fetal heart rate.
Indications: o Average FHR – 130 beats/ min.
1. Mother with gestational hypertension o Average fetal moves – twice every 10 mins. -
2. Fetus appears to be small or not growing causes heart rate to increase
properly Vibroacoustic Stimulation – for acoustic (sound)
3. Fetus is less active than normal (movement) stimulation acoustic stimulator applied to the
4. Too much or too little amniotic fluid mother’s abdomen to produce sharp sound (80 db.),
• Is a noninvasive method of assessing the startling and waking the fetus
general well being of the fetus and the 2. Amniocentesis
fetal assessment • Amnion for sac and kentesis for puncture.
• BPP may be used as early as 26-28 weeks for the Scheduled between the 14th and 16th week
surveillance of high risk pregnancy • Amniocentesis is the removal of fluid from the
amniotic cavity by needle puncture. An ultrasound
is performed first to determine the safe site where
the needle can be inserted
48
• During the procedure, the fetus is continuously • Less than 1% risk leading to excessive bleeding, or
monitored by ultrasound to ensure its wellbeing pregnancy loss
• Complications includes hemorrhage from the • Reportable s/sx:
penetration of the placenta, infection of the o Chills or fever (infection)
amniotic fluid and puncture of the fetus o Uterine contraction or vaginal bleeding
Purposes of Amniotic Fluid Analysis: (threatened miscarriage)
• Detection of fetal abnormalities early in pregnancy 4. AFP / Triple Screen
• To determine fetal lung maturity
• Lecithin/Sphingomyelin ratio
• Lung Profile
• Amniotic Fluid Bilirubin
• Rh incompatibility
• For detection of certain infections
• Detection of fetal abnormalities early in pregnancy
Nursing Care During Amniocentesis:
• Assist client to empty her bladder before the
procedure
• Place in supine position and drape properly
• Put rolled towel under right hip to tip body to the • This test involves measurement of AFP, estriol and
left and remove pressure of uterus on vena cava HCG in maternal serum at 15-20 weeks of gestation
• Instruct not to take a deep breath and hold it while to screen for fetal structural & chromosomal
the needle is being inserted as it will shift the uterus abnormalities alpha-feto protein is a substance
and needle may hit placenta or fetus produced by the liver that is present in amniotic
• Inform the patient that it is not painful because fluid and maternal serum
anesthesia will be applied at the insertion site. She • Estriol is initially tested. If the result is abnormal, the
may experience pressure sensation during the woman is next referred for ultrasound to confirm
insertion of the needle gestational age and to evaluate for neural tube
• Monitor FHT before, during and in 30 minutes after defects (NTD) and other structural abnormalities
the test • A low estriol, elevated HCG, and low AFP finding is
• Instruct patient to observe for: often associated with Trisomy 21 (Down syndrome)
o Infection • High in the maternal serum (MSAFP) if the fetus has
o Uterine cramping an open spinal or abdominal defect.
o Vaginal bleeding 5. Non Stress Test (NST)
3. Chorionic Villi Sampling (CVS) • is an assessment of fetal well-being that analyses
• Is a transcervical or transabdominal insertion of a the response of the fetal heart to fetal movement ●
needle into the fetal portion of the placenta, at the When the fetus has adequate oxygenation and
area of the chorion frondosum intact CNS, the are accelerations of FHR with fetal
• CVS is performed at 8-12 weeks gestation under movement
ultrasound guidance to ensure that the fetus is • The baby’s heart rate should accelerate, by 15 beats
unharmed. for at least 15 seconds, twice in a twenty minute
• Chorionic villi cells are examined to detect period. This is called a reactive NST and is a good
chromosome abnormalities such as Down sign that the fetus is healthy
syndrome and genetic disorders such as cystic
fibrosis
• Is a biopsy & analysis of chorionic villi for
chromosomal analysis done at 8 to 10 weeks of
pregnancy chorion cells are located by
ultrasound
• A thin catheter is inserted vaginally or needle
biopsy is inserted intravaginally or inserted
abdominally, and a number of chorionic cells are
removed chromosoneanalysis (genetic defect)
• Instruct client to report bleeding, infection or
leakage of fluid after procedure
• Some instances of limb reduction syndrome
49
• A reactive NST indicates intrauterine survival for one o The lowest point of the deceleration (nadir) occurs
week. The doctor may order a CST if the NST near the end of the contraction instead of at its
is nonreactive. The usual preparation is to feed the peak
mother with food or fluids before the test to o Occur with hypertonia or with abnormal uterine
stimulate fetal movements tone caused by administration of oxytocin
o Stop or slow the administration of oxytocin
o Change the position from supine to lateral to
relieve pressure from the Vena Cava
o Administer IVF or O2 as prescribed
o If late decelerations persist – prepare for possible
prompt birth of the infant
d. Variable Decelerations
• Decelerations that occur at unpredictable times in
relations to contractions
• Indicate compression of cord
• Cord prolapsed
• Fetus is lying on the cord
• Occurs more frequently: after rupture of
membranes
• Oligohydramnios
• U, V or W – shaped waves
6. Contraction Stress Test (CST) • Position: lateral or T-position
• assess the ability of the fetus to withstand the • Administer fluids and O2 as prescribed
stress of uterine contraction done during labor • If not relieved, amnioinfusion may be
• CST is a means of evaluating the respiratory prescribed
function of the placenta Interpretation of Results of CST:
• Induced or spontaneous contraction decrease • Positive : there is persistent late decelerations w/
transport of O2 to the fetus. A healthy fetus more than half the contractions; maybe
maintains a steady heart rate associated w/ minimal or absent variability. A
• If placental reserve is insufficient, fetal hypoxia and positive CST means that the fetus is no longer
decrease in FHR occur receiving adequate oxygen and needs to be
• Testing is initiated when 3 contractions in every 10 delivered
minutes are attained. The test takes about 60-90 • Negative : There is no late deceleration in a 10-
minutes to perform minute period and this means that it is safe for
Periodic changes the fetus to remain in utero for the next 7 days
a. Accelerations
o temporary normal increases in FHR caused by fetal
movement or compression of the umbilical vein
during contraction
b. Early Decelerations
o periodic decreases in FHR resulting from pressure
of the fetal head during contractions
o Beginning when the contractions begins and
ending when the contractions end (mirror image)
o Normal – late in labor
c. Late Decelerations
o delayed decelerations until 30 to 40 seconds after
the onset of a contraction and continue beyond
the end of the contraction
o Ominous pattern in labor
(uteroplacental insufficiency) or ↓ blood flow
through the intervillous spaces of the uterus
during contraction
50

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NCMA217: CARE OF MOTHER, CHILD & ADOLESCENT

PRELIMS REVIEWER: CU1 – CU5

Health restoration Promptly diagnosing and

Health rehabilitation Preventing further

B. Autosomal Recessive Inheritance

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