Final Mchn Slides1

Maternal and Child Health Nursing PART I

MARY LOURDES NACEL G. CELESTE, RN, MD

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Man as a Sexual being

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Sexuality an important dimension of development in human beings a link between humans, yet it is perhaps the least understood area in the development of man MARY LOURDES NACEL G. CELESTE, RN, MD

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Man as a Sexual being 

Although the sex of the child is determined genetically at the time of conception, the development of the child’s sexuality after birth is influenced by development in the physical, mental, emotional and socio-cultural areas of living; likewise, the level of maturity. MARY LOURDES NACEL G. CELESTE, RN, MD

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Man as a Sexual being 

Because of the complexity of human in his total development, parents and society and the helping profession have many times failed in their responsibility to counsel and guide the child through the years to adulthood. MARY LOURDES NACEL G. CELESTE, RN, MD

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Man as a Sexual being 

Human sexuality is in fact fundamental to life and has much a broader meaning than the physical act of sex alone.

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It can lead ultimately to either a sustained relationship with a mate or it can be sublimated through outlets having a social value. MARY LOURDES NACEL G. CELESTE, RN, MD

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Sex and Procreation 

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Sex is a biological need of human beings. Sexual response is one aspect of human reproduction.

MARY LOURDES NACEL G. CELESTE, RN, MD

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Sex and Procreation 

In as much as we are going to deal with human reproduction, and pregnancy later on, it is but proper that we understand the biological phase before pregnancy comes about. MARY LOURDES NACEL G. CELESTE, RN, MD

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Sexual Maturity 

may be defined as the capacity to form a stable relationship with the opposite sex which is physically and emotionally satisfying and in which sexual intercourse, forms the main though not the only mode of expression of love. MARY LOURDES NACEL G. CELESTE, RN, MD

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Sexual Health 

the integration of the somatic, emotional, intellectual and social aspects of sexual being in ways that are positively enriching and that enhance, personality, communication and love (World Health Organization) MARY LOURDES NACEL G. CELESTE, RN, MD

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This definition recognizes a number of factors: 

that sexuality in a person is one of the major determinants of the human personality The human is not a desexualized, neuter being. The human is a man or a woman with a combination of qualities that might be considered masculine or feminine, with instinctual drives and MARY LOURDES NACEL G. CELESTE, RN, MD desires rooted in his/ her sexuality that 10

This definition recognizes a number of factors: 

that sexual expression is a communication-expression in contrast, for example, to digestion and circulation which are restricted to the individual . Sexuality finds meaning and expression with other beings. MARY LOURDES NACEL G. CELESTE, RN, MD

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This definition recognizes a number of factors: 

that in its mature expression, sex can not be separated from love; that sexual expression should not be possible without an affectional basis of love

MARY LOURDES NACEL G. CELESTE, RN, MD

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Three Basic Elements of Sexual Health 

capacity to enjoy and control sexual and reproductive behavior in accordance with a social and personal ethic

MARY LOURDES NACEL G. CELESTE, RN, MD

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Three Basic Elements of Sexual Health 

freedom from fear, shame, guilt, false beliefs and other psychological factors inhibiting sexual response and impairing sexual relationship MARY LOURDES NACEL G. CELESTE, RN, MD

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Three Basic Elements of Sexual Health 

freedom from organic disorders, diseases and deficiencies that interfere with sexual and reproductive function

MARY LOURDES NACEL G. CELESTE, RN, MD

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In spite of the fact that biologically, the concept of sexuality cannot be dissociated from reproduction, there is no mention of reproduction in the definition of sexual health.

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While the definition does not exclude it, it may even be said to include it implicitly when it spells out communication and love, since reproduction is the eventual and natural result of love and sexual communication.

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This does not suggest though that sexual health is attained only when reproduction occurs but indicated that the capacity for reproduction MARY LOURDES NACEL G. CELESTE, RN, MD is an 16 important element of sexual health.

Sexual Normalcy 

the state wherein a person is within the average of sexual capacity, with expression within a framework of sexual meaning and/ or direction, and when he has a sense of well-being within that context MARY LOURDES NACEL G. CELESTE, RN, MD

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Four Elements of Sexual Normalcy 

There must be a congruence of the various components of sexual identity: anatomical, behavioral, chromosomal, hormonal.

MARY LOURDES NACEL G. CELESTE, RN, MD

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Four Elements of Sexual Normalcy 

There must be in the individual, emotional acceptance of sexuality, his gender, and the expression of that sexuality in his/ her personality and behavior.

MARY LOURDES NACEL G. CELESTE, RN, MD

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Four Elements of Sexual Normalcy 

There should be an understanding of the meaning and expression of sex and sexuality adequate for the sexual needs in life a specific community imposes on him, recognizing the fact that sexual mores and practices may vary from one community to another, and from time to time. MARY LOURDES NACEL G. CELESTE, RN, MD

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Four Elements of Sexual Normalcy 

There should be a capacity to adapt individual sexuality of societal requirements, particularly in terms of the right of others and of the community at large.

MARY LOURDES NACEL G. CELESTE, RN, MD

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Responsible Parenthood

The world responsibility may mean different things to different people. 

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Many people simply equate it with duties and so develop a negative attitude towards it. Since a duty is often seen as something imposed, people tend to shun responsibilities when they can. Other people equate responsibility with accountability. To them, the responsible man is someone who is willing to stand up and be accountable for whatever he says or does. Whether right or wrong, he is a responsible man, as long as he is willing to “face the music.” To other people, responsibility means commitment. A person is responsible if he is willing to take a definite stand on a given situation or question. The irresponsible person is “neither hot nor cold, but simply lukewarm.” Other people think of it as the capacity

and willingness to give the proper response to anything that confronts them. In this manner, they go to the original form of the word – response – ability.

MARY LOURDES NACEL G. CELESTE, RN, MD

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Responsible Parenthood 

A responsible person is a man or woman who is able and willing to give the proper response to the demands of a given situation.

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With specific reference to marriage and family life, the responsible spouse is one who gives the proper responses to the needs of his/ her spouse, as well as his own, and of their life together. Similarly, responsible parents give proper responses to ofRN, their children. MARYthe LOURDESneeds NACEL G. CELESTE, MD 23

Responsible Parenthood 

Although some people object to the idea, we tend to equate family planning with responsible parenthood. Family planning refers more specifically to the voluntary and positive action of a couple to plan and decide the number of children they want to have and when to have them. MARY LOURDES NACEL G. CELESTE, RN, MD

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Maternal and Child Health Nursing 

a conceptual approach to nursing care that views maternity and child health nursing as a continuum, not separate entities

MARY LOURDES NACEL G. CELESTE, RN, MD

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Maternal and Child Health Nursing 

Involves care of the woman and family throughout pregnancy and childbirth and the health promotion and illness care for the children and families MARY LOURDES NACEL G. CELESTE, RN, MD

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Goal of Maternal and Child Health Nursing 

Promotion and maintenance of optimal family health to ensure cycles of optimal childbearing and childrearing MARY LOURDES NACEL G. CELESTE, RN, MD

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Maternal and Child Health Nursing Range of Practice Preconceptual health care Care of women throughout pregnancy Care of children during perinatal period Care of children from birth through adolescence Care in all settings (birthing room, PICU and the home) MARY LOURDES NACEL G. CELESTE, RN, MD

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Philosophies of Maternal and Child Health Nursing    

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Family-centered Community-centered Research-oriented Nursing theory and evidence-based practice provide a foundation for nursing care MCH nurse: advocate to protect the rights of all family members including the fetus MARY LOURDES NACEL G. CELESTE, RN, MD

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Philosophies of Maternal and Child Health Nursing 

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Uses a high degree of independent nursing functions: teaching and counseling Promotes health Pregnancy or childhood illness can be stressful and can alter family life in both subtle and extensive ways MARY LOURDES NACEL G. CELESTE, RN, MD

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Philosophies of Maternal and Child Health Nursing 

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Personal, cultural and religious attitudes and beliefs influence the meaning of illness and its impact on the family. MCHN is a challenging role for the nurse and is a major factor in promoting high- level wellness in families. MARY LOURDES NACEL G. CELESTE, RN, MD

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Framework of Nursing Care: Four Phases of Health Care  Health promotion  Health

maintenance  Health restoration  Health rehabilitation

MARY LOURDES NACEL G. CELESTE, RN, MD

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Four Phases of Health Care  Health

promotion - educating clients to be aware of good health through teaching and role modeling MARY LOURDES NACEL G. CELESTE, RN, MD

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Four Phases of Health Care  Health

maintenance - intervening to maintain health when risk of illness is present

MARY LOURDES NACEL G. CELESTE, RN, MD

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Four Phases of Health Care  Health

restoration - promptly diagnosing and treating illness using interventions that will return client to wellness most rapidly MARY LOURDES NACEL G. CELESTE, RN, MD

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Four Phases of Health Care  Health

rehabilitation - preventing further complications from an illness; bringing ill client back to optimal state of wellness or helping client to accept inevitable death MARY LOURDES NACEL G. CELESTE, RN, MD

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The Nursing Process 

Applicable for all health care settings Assessment Nursing diagnosis Planning Implementation Evaluation MARY LOURDES NACEL G. CELESTE, RN, MD

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Evidence-Based Practice  Use

of research or controlled investigation of a problem in conjunction with clinical expertise as a foundation for action MARY LOURDES NACEL G. CELESTE, RN, MD

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Nursing Research Controlled investigation of

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problems that have implications for nursing practice Justification for implementing activities for outcomes Results in improved and costeffective patient care MARY LOURDES NACEL G. CELESTE, RN, MD

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Nursing Theories  How

nurses view clients  Goals of nursing care  Activities of nursing care

MARY LOURDES NACEL G. CELESTE, RN, MD

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Maternal and Child Health Nursing

MARY LOURDES NACEL G. CELESTE, RN, MD

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Maternal and Child Health Nursing  20th

century

Infant mortality rate >100 per 1,000  Today

6.9 per 1,000

MARY LOURDES NACEL G. CELESTE, RN, MD

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Trends in Maternal and Child Health Nursing Population

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Trends in Health Care Environment  Cost

Containment  Delegation

Right task for the situation Right person to complete the task Right communication concerning what is to be done Right evaluation that the task was completed MARY LOURDES NACEL G. CELESTE, RN, MD

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Trends in Health Care Environment  Alternative

styles

settings and

Home Hospitals Birthing centers

 Strengthening

the ambulatory care setting  Shortening hospital stays MARY LOURDES NACEL G. CELESTE, RN, MD

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Trends in Health Care Environment

Including the family in health care  Increased number of intensive care uni un  Regionalization of intensive care  Increased reliance on comprehensive care settings  Increased use of alternative treatment modalities 

MARY LOURDES NACEL G. CELESTE, RN, MD

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Trends in Health Care Environment Increased reliance on home care  Increased use of technology  Health care concerns and attitudes -Increasing concern regarding health care costs -Increasing emphasis on preventive care 

MARY LOURDES NACEL G. CELESTE, RN, MD

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Trends in Health Care Environment -Increasing emphasis on familycentered care -Increasing concern for quality of life -Increasing awareness of the individuality of clients -Empowerment of health care consumers MARY LOURDES NACEL G. CELESTE, RN, MD

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Advanced Practice Nursing  Nurse

practitioner

Women’s health Family Neonatal Pediatric

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Advanced Practice Nursing  Clinical

nurse specialists  Case manager  Nurse-midwife

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Legal Considerations

Protection of the rights of clients  Accountability for nursing care  Identifying and reporting suspected child abuse  Scope of practice (range of services and care that may be provided by RN)  Documentation 

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Ethical Considerations       

Conception issues Abortion Fetal rights Resuscitation Procedures Quality of life Research MARY LOURDES NACEL G. CELESTE, RN, MD

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The Childbearing and Childrearing Family and Community

Family Theory A

set of perspectives from the family’s point of view Helps nurses address important health issues of the childbearing and childrearing family MARY LOURDES NACEL G. CELESTE, RN, MD

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Nursing Process: Promotion of Family Health Assessment  Nursing Diagnosis  Outcome identification and planning  Implementation  Outcome evaluation 

MARY LOURDES NACEL G. CELESTE, RN, MD

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Nursing Diagnoses 

Generally relate to the family’s ability to handle stress and to provide a positive environment for individual growth and development

MARY LOURDES NACEL G. CELESTE, RN, MD

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Nursing Diagnoses: 

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Parental role conflict related to prolonged separation from child during long hospital stay Impaired parenting related to unplanned pregnancy Health-seeking behaviors related to birth of first child Ineffective family coping related to inability to adjust to child’s illness MARY LOURDES NACEL G. CELESTE, RN, MD

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Family 

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A group of people related by blood, marriage, or adoption living together (USCB 2005) Two or more people who live in the same household, share a common emotional bond and perform certain interrelated social tasks (Allender and Spradley) MARY LOURDES NACEL G. CELESTE, RN, MD

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Family 

How well a family works together and how well it can organize itself against potential threats depend on its structure (who its members consist of) and its function (the activities or roles family members carry out) MARY LOURDES NACEL G. CELESTE, RN, MD

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Family Types Family of orientation  Family of procreation  The dyad family  The nuclear family  The cohabitation family  The extended family 

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Family Types The single-parent family  The blended family  The communal family  The gay or lesbian family  The foster family  The adoptive family 

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Family Types 

Family of orientation: - the family one is born into

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Family of procreation: - a family one establishes

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Nuclear family: - family composed of husband, wife and children MARY LOURDES NACEL G. CELESTE, RN, MD

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Dyad family: - family consists of 2 people living together usually man and woman without children

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Single parent family: - family with one parent

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Cohabitation family: - composed of heterosexual couples who live together like a nuclear family but remain unmarried (may be temporary or lasting)

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Extended (multigenerational) family: -includes not only nuclear family but also other family members

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Blended family: - divorced or widowed person with childr marries someone who also has children MARY LOURDES NACEL G. CELESTE, RN, MD

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Communal family: - group of people who have chosen to live together as an extended family 

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•Gay or lesbian family: - homosexual union, individuals of the same sex live together as parents for companionship, financial security, and sexual fulfillment

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Foster family: - children whose parents can no longer care for them may be placed in a foster or substitute home by child protection agency; temporary arrangement MARY LOURDES NACEL G. CELESTE, RN, MD

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Adoptive family: - families who adopt children for various reasons:

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inability to have children biologically biological parents are unable to provide care and are willing to have their children adopted

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Methods of Adoption 

Agency  International adoption program  Private resources

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Family Functions and Roles  Passed

from one generation to the next  Changing and not well defined

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FAMILY ROLES AND FUNCTIONS: -WAGE EARNER -FINANCIAL MANAGER -PROBLEM SOLVER -DECISION MAKER -HEALTH MANAGER / NURTURER - GATE KEEPER MARY LOURDES NACEL G. CELESTE, RN, MD

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Changing patterns of family life: 

Factors : – Increased mobility of families – An increase in the number of families in which both parents work outside the house (dual-earner family) – An increase in the number of one-parent family – An increase in shared childrearing responsibilities MARY LOURDES NACEL G. CELESTE, RN, MD

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8 Essential Family Tasks  Physical

maintenance  Socialization of family members  Allocation of resources  Maintenance of order MARY LOURDES NACEL G. CELESTE, RN, MD

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8 Essential Family Tasks Division of labor  Reproduction, recruitment and release of family members  Placement of members into the larger society  Maintenance of motivation and morale 

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Family Life Cycles Stage 1: Marriage and the family  Stage 2: The early child-bearing family  Stage 3: The family with preschool children  Stage 4: The family with schoolaged children 

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Family Life Cycles Stage 5: The family with adolescent children  Stage 6: The launching center family  Stage 7: The family of middle years  Stage 8: The family in retirement or older age 

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Patterns of Family Life Mobility patterns  Poverty  Reduced government aid programs  The homeless family  Increasing number of one-parent families 

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Patterns of Family Life Increasing divorce rates  Decreasing family size  Dual-parent employment  Increased family responsibility for health monitoring  Increased abuse in families 

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Assessment of family structu and function: 

Tools : – Genogram-a diagram that details family structure, provide information about the family’s history and roles of various family member

MARY LOURDES NACEL G. CELESTE, RN, MD

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FAMILY GENOGRAM

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Family Structure  Well

family  Family in crisis Assessment:  Genogram  Family APGAR MARY LOURDES NACEL G. CELESTE, RN, MD

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Family as Part of a Community  Community

Geographical areas in which residents relate and interact among themselves

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Sociocultural Aspects of Maternal and Child Health Nursing

Ethnicity Cultural group into which a person was born

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Culture 

An organized structure that guides behavior into acceptable ways for that group

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Culture A view of the world and a set of traditions that a specific social group uses and transmits to the next generation MARY LOURDES NACEL G. CELESTE, RN, MD

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Cultural Values Preferred ways of acting based upon traditions  Norms/

Mores – usual customs MARY LOURDES NACEL G. CELESTE, RN, MD

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Taboos  Actions

that are not acceptable to a culture Murder Incest Cannibalism

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Transcultural Nursing

Nursing care that is guided by cultural aspects and respects individual differences

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Stereotyping Expecting a person to act in a characteristic way without regard to his or her individual characteristics MARY LOURDES NACEL G. CELESTE, RN, MD

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Assessing for Cultural Values

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Sociocultural Differences: Implications for Nursing

 Cultural

Concepts

Acculturation/ Assimilation – cultural expression is lost by taking on the customs of the dominant culture Ethnocentrism – belief that one’s own culture is superior to all others Cultural competence – the integration of cultural elements to enhance communication and work effectively with people MARY LOURDES NACEL G. CELESTE, RN, MD

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Sociocultural Differences: Implications for Nursing  People

bring cultural values and beliefs to nursing interactions, and these affect nursing and health care. MARY LOURDES NACEL G. CELESTE, RN, MD

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Sociocultural Differences: Implications for Nursing Cultural aspects that are important to assess:  Assessment techniques  Use of conversational space  Time orientation  Work orientation  Family orientation MARY LOURDES NACEL G. CELESTE, RN, MD

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Sociocultural Differences: Implications for Nursing  Male

and female roles  Religion  Health beliefs  Nutrition practices  Pain Responses Pain threshold Pain tolerance MARY LOURDES NACEL G. CELESTE, RN, MD

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Reproductive and Sexual Health MARY LOURDES NACEL G. CELESTE, RN, MD

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Reproductive Development 

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Intrauterine development -sex of an individual is determined at the moment o conception Gonad- body organ that produces sex cells (ovary,testis)

 Week 5: primitive gonadal tissue is formed - Mesonephric (wolffian) and paramesonephric (mullerian) ducts are present  Week 7 or 8 - in choromosomal males: primitive testes; formation of testosterone  Week 10 - ovaries in females; oocytes formed  Week 12 – external genitalia MARY LOURDES NACEL G. CELESTE, RN, MD

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REPRODUCTIVE AND SEXUAL HEALTH

PUBERTAL DEVELOPMENT: Puberty is the stage of life at which the secondary sex changes begin. Girls- age 9 to 12 years Theory: must reach a critical weight of approx. 95 lbs (43kgs) or develop a critical mass of fat before the hypothalamus is triggered to stimulate the anterior pituitary gland to begin gonadotropic hormone formation. MARY LOURDES NACEL G. CELESTE, RN, MD

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REPRODUCTIVE AND SEXUAL HEALTH

Boys- age 12 to 14 years The role of Androgen- hormones responsible for : • Muscular development • Physical growth • Increase sebaceous gland secretion (acne) Androgen- produced by the adrenal cortex and testes in the males; by the adrenal cortex and the ovaries in the females MARY LOURDES NACEL G. CELESTE, RN, MD

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REPRODUCTIVE AND SEXUAL HEALTH

“Testosterone -1° androgenic hormone” In girls, testosterone influences the development of labia majora, clitoris, and axillary & pubic hair latter termed as (adrenarche) In males, it influences the development of testes, scrotum, penis, prostate and seminal vesicle; the appearance of pubic, axillary hair; facial hair; laryngeal enlargement; voice change; maturation of spermatozoa and closure of growth in long bones. MARY LOURDES NACEL G. CELESTE, RN, MD

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REPRODUCTIVE AND SEXUAL HEALTH

Estrogen – excreted by the ovarian follicles (3 compounds: estrone, estradiol and estriol) - Influences the development of the uterus, fallopian tubes and vagina at puberty; typical female fat distribution and hair patterns; breast development and end of growth of long bones 

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REPRODUCTIVE AND SEXUAL HEALTH

Secondary sex characteristics of boys occur in the following order: • increase in weight • growth of testes • growth of face, axillary and pubic hair • voice changes • penile growth • increase in height • spermatogenesis

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REPRODUCTIVE AND SEXUAL HEALTH Secondary sex characteristics of girls occur in the following order: 1. growth spurt 2. increase in the transverse diameter of the pelvis 3. breast development (thelarche) 4. growth of pubic hair (adrenarche) 5. onset of menstruation (menarche 12.5 y/o ave.) -Ovulation occurs 1 – 2 years after menarche 6. growth of axillary hair (adrenarche) 7. vaginal secretion

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Reproductive Anatomy and Physiology  Male

reproductive system External structures  Scrotum  Testes  Penis MARY LOURDES NACEL G. CELESTE, RN, MD

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Reproductive Anatomy and Physiology

Male internal structures  Epididymis  Vas

deferens  Seminal vesicles  Prostate gland  Bulbourethral glands  Urethra MARY LOURDES NACEL G. CELESTE, RN, MD

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MALE REPRODUCTIVE SYSTEM

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MALE REPRODUCTIVE SYSTEM: ANDROLOGY A. External Structures 1.

Penis: the male organ of copulation; a cylindrical shaft consisting of: a. corpora cavernosa -two lateral columns of erectile tissue b. corpus spongiosum - encases the urethra -The glans penis, a cone-shaped expansion of the corpus spongiosum that is highly sensitive in males.

-Erection is stimulated by parasympathetic nerve •

Scrotum: a pouch hanging below the penis that contains the testes.

3. Testes: two solid ovoid organs 4-5 cm long and 2-3 cm wide, divided into lobes containing Seminiferous tubules -produce spermatozoa MARY LOURDES NACEL G. CELESTE, RN, MD 112 Leydig cells - testosterone production

MALE REPRODUCTIVE SYSTEM: A. External Structures continued SPERMATOZOA are produced by: Hypothalamus Control by GnRH (+/-) feedback Anterior Pituitary gland FSH / LH Testes FSH - release of Androgen Binding Protein (ABP) which promotes SPERMATOGENESIS LH - release of Testosterone.

“Spermatozoa do not survive at body temperature. They usually survive at temperature 1°F lower than body temperature”. Hence, testes are MARYthe LOURDESbody. NACEL G. CELESTE, RN, MD 113 suspended outside

MALE REPRODUCTIVE SYSTEM: B. Internal Structures 1. Epididymis: serves as reservoir for sperm storage and maturation. Approximately 20 ft. it takes 12-20 days for the sperm to travel the length of Epididymis. A total of 64 days before the sperm reach maturity. Aspermia - absence of sperm Oligospermia- if < 20 million sperm/ ml “Treatment= 2 months”

2. Vas deferens: a duct extending from epididymis to the ejaculatory duct and seminal vesicle, providing a passageway for sperm. Sperm mature as they pass through. Varicocele- varicosity of internal spermatic cord (may contribute to infertility) Vasectomy- severing vas deferens (male birth control) MARY LOURDES NACEL G. CELESTE, RN, MD

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Beginning in early adolescence, boys need to learn testicular selfeamination. Testes should feel firm, smooth, egg-shaped.

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MALE REPRODUCTIVE SYSTEM: B. Internal Structures continued

3. Seminal vesicles: are two convoluted pouches that lie along the lower portion of the bladder and empty into the urethra by the way of the ejaculatory ducts

4. Ejaculatory ducts: the canal formed by the union of the vas deferens and the excretory duct of the seminal vesicle, which enters the urethra at the prostate gland. 5. Prostate Gland: located just below the urinary bladder. Secretes alkaline fluid and most of the seminal fluid. 6. Bulbourethral glands or Cowper’s Gland: adds alkaline fluid to the semen. 7. Urethra: the passageway for both urine and semen, extending from the bladder to the urethral meatus. (8 inches long) MARY LOURDES NACEL G. CELESTE, RN, MD

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MALE REPRODUCTIVE SYSTEM: B. Internal Structures continued SEMEN: • Is a thick whitish fluid ejaculated by the male during orgasm, contains spermatozoa and fructose-rich nutrients. • During ejaculation, semen receives contributions of fluid from Prostate gland (60%) Seminal vesicle (30%) Epididymis ( 5%) Bulbourethral gland (5%) • • • • • •

Average pH = 7.5 The average amount of semen released during ejaculation is 2.5 -5 ml. It can live with in the female genital tract for about 24 to 72 hours. 50-200 million/ml of ejaculation ave. of 400 million/ejaculation 90 seconds- cervix 5 minutes- end ofMARY fallopian LOURDES NACELtube G. CELESTE, RN, MD 117

Reproductive Anatomy and Physiology  Female

system

reproductive

External structures Internal structures

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EXTERNAL REPRODUCTIVE SYSTEM

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FEMALE REPRODUCTIVE SYSTEM: GYNECOLOGY A.External Structures •

Mons pubis/ Mons veneris – pad of adipose tissues, which lies over the symphysis pubis, which protects the surrounding delicate tissue from trauma.

•

Labia majora – longitudal folds of pigmented skin extending from the mons pubis to the perineum. Contains the Bartholin’s gland that secretes yellowish mucus that acts as a lubricant during sexual activity.

•

Labia minora – soft longitudal skin folds between the Labia majora.

•

Glans clitoris – erectile tissue located at the upper end of Labia minora; primary site of sexual arousal. MARY LOURDES NACEL G. CELESTE, RN, MD

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FEMALE REPRODUCTIVE SYSTEM: •External Structures continue 5. Vestibule – a narrow space seen when labia minora are separated that also contains the vaginal introitus, Bartholin’s gland and urethral meatus. 6. Urethral Meatus – small opening between the clitoris and vaginal orifice for the purpose of urination. 7. Vaginal orifice/introitus/opening – external opening of the vagina that contains the hymen. 8. Hymen – a membranous tissue ringing the vaginal introitus 9. Perineum – tissue between the anus and vagina. Site of episiotomy The external genitalia’s blood supply: MARY LOURDES NACEL G. CELESTE, RN,rectus MD Arteries: a. pudendal artery b. inferior artery. Vein: Pudendal vein

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Reproductive Anatomy and Physiology 

FEMALE INTERNAL STRUCTURES

1. Ovaries 2. Fallopian tubes 3. Uterus 4. Vaginal canal

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Female reproductive system Internal structures

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FEMALE REPRODUCTIVE SYSTEM: B. Internal Structures •

Ovaries – female sex glands located on each side of the uterus with two ovaries (4 x 2 x 1.5 cm thick). Ovaries are formed with 3 principal divisions: a. A protective layer of surface epithelium b. The cortex filled with the ovarian and graafian follicle c. The central medulla containing nerves, blood vessels, lymphatic tissue and some smooth muscle tissue Functions: -Ovulation (release of ovum) and Secretion of hormones like estrogen and progesterone. Estrogen- helps to prevent osteoporosis, and atherosclerosis and potential risk for breast cancer/ endometrial cancer

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Ovary 3 principal divisions:

-

b.

protective layer of surface epithelium

b.

The cortex filled with follicles

c. The central medulla containing nerves, blood vessels, Firm almond shaped lymphatic tissue and organ covered by some smooth muscle the peritoneum MARY LOURDES NACEL G. CELESTE, RN, MD 126 tissue

FEMALE REPRODUCTIVE SYSTEM: B. Internal Structures continued 2. Fallopian Tubes – 4 inches (10 cm) long from each side of the fundus Divided into four separate parts: 1. Intramural portion- most proximal (1 cm in length) 2. Isthmus portion- extremely narrow (2cm) Important: tubal ligation 3. Ampulla- longest portion (5cm) and widest part Function: site of fertilization 4. Infundibular portion- funnel- shaped with Fimbrae (2cm): finger like projections. Function: responsible for the transport of mature ovum from MARY LOURDES NACEL G. CELESTE, RN, MD 127 ovary to uterus

Fallopian Tube4 parts 2.

Infundibulum- funnel shape, with fimbriae

2. Ampulla- wide middle segment; usual site of FERTILIZATION

•Bilateral ducts extend laterally from the uterus •receive oocyte and provide site for

3. Isthmus- narrowest part

4. Interstitial or Intramuralembedded in the uterine wall MARY LOURDES NACEL G. CELESTE, RN, MD

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FEMALE REPRODUCTIVE SYSTEM: B. Internal Structures continue 3. Uterus – hollow pear-shaped muscular organ. Size: 3 inches long (5-7cm), 2 inches wide(5cm) and 1 inch thick (3x2x1) Wt: 60 gms. in non pregnant Location: lower pelvis Parts: Corpus, Isthmus, and Cervix Position: anteverted and anteflexed Layers: perimetrium, myometrium and endometrium Function: 1. to receive the ova to fallopian tube; place for implantation and nourishment during fetal growth; furnish protection to a growing fetus 2. aids in labor and delivery Cervix (2-5cm long) Internal cervical os External cervical os

-an impt. relationship in estimating the MARY LOURDES NACEL G. CELESTE, RN, MD 129 level of dilatation of the fetus in the birth canal before birth.

Uterus 







Pear-shaped organ with a cavity receives the ova to fallopian tube place for implantation and nourishment during fetal growth; furnish protection to a growing fetus aids in labor and delivery

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3 main parts 1. Fundus- rounded portion superiorly 2. Corpus or Body- major portion 3. Cervix- outlet which protrudes into vagina 



Isthmus- junction between the body and the cervix MARY LOURDES NACEL G. CELESTE, RN, MD 131 POSITION: Anteverted and Anteflexed

layers of uterine wall 1.endometrium (or mucosa) – inner layer 2.myometrium – thick, middle circular layer (stratum vasculare) 3. epimetrium- superficial part surrounded by the perimetrium MARY LOURDES NACEL G. CELESTE, RN, MD

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layers of the endometrium 1. Stratum Functionale – Stratum compactum – Stratum spongiosum

2. Stratum basale or germinativum

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FEMALE REPRODUCTIVE SYSTEM: Uterus continue Nerve Supply: Efferent (motor) nerve- spinal ganglia (T5 to T10) Afferent (sensory) nerve - hypogastric plexus (T-11 & T-12) Impt: Controlling pain in labor ( Epidural anesthesia) Uterine Ligaments: 1. Broad Ligaments – from the sides of uterus to pelvic walls 2. Round Ligaments – from sides of uterus to mons pubis. 3. Cardinal and uterosacral ligaments- provides middle support 4. Pelvic muscular floor ligaments- provide lower support

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FEMALE REPRODUCTIVE SYSTEM: 3. Vaginal Canal – 3-4 inch long dilatable canal between the bladder and the rectum; contains rugae that permits stretching without tearing. Anterior Vaginal wall- 6-7 cm (anterior fornices) Posterior Vaginal wall- 8-9 cm (posterior fornices) Function: 1. passageway for menstrual discharges 2. receives penis during intercourse and 3. serves as birth canal. - lined with stratified squamous epithelium - Bulbocavernosus: a circular muscle acts as voluntary sphincter (Kegel exercises) Blood supply to the vagina: Arteries: vaginal artery branch of internal iliac artery MARY LOURDES NACEL G. CELESTE, RN, MD Vein: pudendal vein

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FEMALE REPRODUCTIVE SYSTEM: Vagina continued… The external genitalia’s blood supply: mainly from the a. pudendal artery and b. a portion of inferior rectus artery. Nerve supply: has both parasympathetic & sympathetic (S-1 to S-3 levels) Nerve supply of the anterior portion: (L1) a. Ilio-inguinal nerves b. Genito-femoral nerves Nerve supply of the posterior portion: (S3) Pudendal nerves

“This is the reason why one type of anesthesia used for childbirth is called Pudendal block.” MARY LOURDES NACEL G. CELESTE, RN, MD

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Uterine Deviations    



Bicornuate – oddly shaped horns at the junction of the fallopian tubes Anteversion – fundus is tipped forward Retroversion – fundus is tipped back Anteflexion – body of the uterus is bent sharply forward at the junction of the cervix Retroflexion – body of the uterus is bent sharply back just above the cervix MARY LOURDES NACEL G. CELESTE, RN, MD

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Reproductive Anatomy and Physiology  Female

internal structures

Vagina Breasts Pelvis

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Vaginal canal     

Connects the cervix to the vestibule Fibromuscular walled tube lined with mucus and covered with hymen hymen – vascular and tends to bleed when ruptured The remnant of hymen is called CARUNCULAE MYRTIFORMIS Bulbocavernosus: a circular muscle acts as voluntary sphincter (Kegel exercises)

Function: organ of copulation and passageway ofMARY menstrual flow and baby LOURDES NACEL G. CELESTE, RN, MD

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Analogous Structures Female Glans Clitoris Labia majora Vagina Ovaries Fallopian tubes Skene’s glands Bartholin’s glands Ovum

Male Glans penis Scrotum Penis Testes Vas deferens Prostate glands Cowper’s glands Spermatozoa

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Mammary glands - MODIFIED SWEAT GLAND glands consist of 20 individual compound alveolar glands w/ separate openings (lactiferous ducts) at nipple - internally 15-25 lobes - under effects of estrogen and progesterone for development; prolactin for milk secretion; oxytocin milk ejection reflex -

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Menstruation  Episodic

uterine bleeding in response to cyclic hormonal changes  Brings an ovum to maturity and renews uterine tissue bed MARY LOURDES NACEL G. CELESTE, RN, MD

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Characteristics of Normal Menstrual Cycles     



Beginning (menarche) – average of onset 12 -13 yrs; average range 9 -17 years Interval between cycles – Average 28 days; cycles of 23 – 35 days not unusual Duration of menstrual flow – Average flow 2-7 days; ranges 1-9 days not abnormal Amount of menstrual flow –difficult to estimate; average 30-80 ml Color of menstrual flow – dark red; combination of blood, mucus and endometrial cells Odor- similar MARY to LOURDES thatNACEL of G.marigolds CELESTE, RN, MD 150

HORMONES 1. Estrogen - female secondary sexual characteristics, such as breast development, increased adipose tissue deposition, and increased vascularization of the skin, widening and lightening of pelvis MARY LOURDES NACEL G. CELESTE, RN, MD

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HORMONES 2. Progesterone - triggers uterine changes during the menstrual cycle

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FEMALE REPRODUCTIVE FUNCTIONS AND CYCLES OOCYTES • in utero - 5 to 7 million • at birth - 2 million • 7 yrs of age only 500,000/ovary • Reproductive age only - 400–500 oocytes • Menopause

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Uterine cycle 3 phases 2.Menstrual phase 3.Proliferative phase 4.Secretory phase

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Menstrual Phase  





Day 1- day 5 First day of bleeding is the first day of cycle Stratum functionale (compactum and spongiosum) are shed Around 60 ml average MARY LOURDES NACEL G. CELESTE, RN, MD

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Proliferative Phase  Days

5- day 14  Eptihelial cells of functionale multiply and form glands  Due to the influence of estrogen MARY LOURDES NACEL G. CELESTE, RN, MD

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Secretory Phase  



 

Day 15- day 28 Endometrium becomes thicker and glands secrete nutrients Uterus is prepared for implantation Due to progesterone If no fertilization constriction vessels menstruation MARY LOURDES NACEL G. CELESTE, RN, MD

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Ovarian cycle 3 phases 1. Pre-ovulatory : follicular phase 2. Ovulatory phase 3. Post-ovulatory : Luteal phase MARY LOURDES NACEL G. CELESTE, RN, MD

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Ovarian Cycle; preovulatory/follicular 





Variable in length: day 6- day 13 Dominant follicle matures and becomes graafian follicle with primary oocyte FSH increases initially then decreases because of estrogen increase MARY LOURDES NACEL G. CELESTE, RN, MD

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Ovarian cycle: Ovulatory phase  Day

14  Rupture of the graafian follicle releasing the secondary oocyte  Due to the LH surge  MITTELSCHMERZ- pain during rupture of follicle MARY LOURDES NACEL G. CELESTE, RN, MD

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OVARIAN cycle:

Post-ovulatory: luteal phase  

 



Day 15- day 28 MOST CONSTANT 14 days after ovulation Corpus luteum secretes Progesterone If no fertilization, corpus luteum will become corpus albicans then degenerate Decreased estrogen and progesterone production MARY LOURDES NACEL G. CELESTE, RN, MD

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Hormonal cycle 1. Menstrual phase – Decreased Estrogen, decreased progesterone, decreased FSH and decreased LH

2. Proliferative/Pre-ovulatory phase – Increased FSH and Estrogen in small amounts MARY LOURDES NACEL G. CELESTE, RN, MD

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3. Ovulatory phase – Increased LH (surge); Increased Estrogen

4. Post ovulatory/luteal Phase – Increased Estrogen, increased progesterone until corpus luteum degenerates MARY LOURDES NACEL G. CELESTE, RN, MD

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‘

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SUMMARY OF MENSTRUAL CYCLE - monthly changes in the uterine lining that lead to menstrual flow as the endometrium is shed STEPS: 4. Corpus luteum of previous cycle fades, progesterone decreases, FSH rises (proliferative phase) MARY LOURDES NACEL G. CELESTE, RN, MD

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SUMMARY OF MENSTRUAL CYCLE 2. FSH stimulates follicular growth and differentiation and stimulate Estrogen secretion 3. Estrogen stimulates endometrial growth and differentiation along w/ follicular growth

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4. Rising Estrogen levels exert a negative feedback on the pituitary gland and hypothalamus to decrease secretion of FSH 5. Dominant follicle is destined grow for ovulation MARY LOURDES NACEL G. CELESTE, RN, MD

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6. Sustained high Estrogen level cause the LH surge w/c triggers ovulation 24-36 hours later, progesterone production and shift to luteal/secretory phase 7. Estrogen level decreases until the midluteal phase when it rises d/t corpus luteum secretion MARY LOURDES NACEL G. CELESTE, RN, MD

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8. Progesterone also rises because of corpus luteum secretion; protein rich secretory products in glandular lumen (secretory phase) 9. If pregnancy does not occur, the corpus luteum degenerates, hormone levels decline, and the uterine lining disintegrates and shed (menstrual phase) *time from ovulation to the onset of the next menstrual period is usually MARY LOURDES NACEL G. CELESTE, RN, MD

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10. If fertilization and implantation occur, ovary continues producing progesterone and the endometrium remains intact to support embryo development and pregnancy.

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Education

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Menopause 

  

Cessation of menstruation for at least one year occurring at the age of 45-52 due to cessation of ovarian function Decreased estrogen and progesterone Genetically determined May occur earlier in smokers, nulliparous and patients who underwent hysterectomy MARY LOURDES NACEL G. CELESTE, RN, MD

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A. MENSTRUAL CYCLE CHANGES: - changes in menstrual cycle regularity - remaining follicles in both ovaries become less sensitive to GnRH stimulation which results to: 1.increase level of fsh 2.reduction in estrogen concentration

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-

the limited follicle maturation leads to either a decrease in cycle interval or lapses of cycles, with oligomenorrhea

B. CESSATION OF MENSES: - menses usually cease between Ages of 45 and 52 years, (reduced level of estrogen from the remaining follicles is no longer sufficient to induce endometrial proliferation / changes capable of producing visible menstruation) MARY LOURDES NACEL G. CELESTE, RN, MD

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C. PREMATURE MENOPAUSE: - manifested by permanent amenorrhea before 35 years of age due to: 1.genetic predilection 2.ovarian failure due to autoimmune reaction MARY LOURDES NACEL G. CELESTE, RN, MD

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Concerns 1. 2. 3.

4.

5.

6.

Loss of childbearing capacity Loss of youth Skin changes-related to estrogen deficiency that has a role in collagen storage and restoration Depression-related to changes in relationship w/ children, spouse and other life events Anxiety and irritability –”climacteric syndrome”; psychocial Loss of libido-related to vaginal atrophy MARY LOURDES NACEL G. CELESTE, RN, MD 180 secondary to decreased estrogen

7. Abnormal bleeding – irregular, heavy or prolonged related to to anovulatory cycles * rule out pregnancy, malignancies and polyps 8. Hot flashes/flushes – recurrent, transient flushing, sweating, palpitations, anxiety, chills 9. Urinary symptoms – dysuria, urgency and recurrent UTI 10. Difficulty in concentration and short term memory loss MARY LOURDES NACEL G. CELESTE, RN, MD 11. Cardiovascular disease

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TARGET ORGAN RESPONSE TO DECREASED ESTROGEN: 

VAGINA - becomes smaller and the size of the upper vagina diminishes - epithelium becomes pale, thin, and dry - labia minora has a pale , dry appearance; reduction in fat content of labia majora



Uterus - endometrial tissue become sparse, with numerous small petecchial hemorrhages, has MARY LOURDES NACEL G. CELESTE, RN, MD 182 atrophic appearance







Breast - general loss of turgor, form, fullness of the breast Bones - gradual loss of calcium, lading to osteoporosis, characterized by reduction in bone density and fracture Hair - with the loss of estrogen, there is relative decrease in circulating androgens; increase quantity of hair withNACEL male pattern distribution MARY LOURDES G. CELESTE, RN, MD 183

Sequelae of reduced estrogen: A. vasomotor symptoms: - Hot flash/ flush, is the hallmark of the menopausal woman - last for a few seconds or several minutes - more frequent and severe at night or during time of stress - coincides with a surge of luteinizing hormones MARY LOURDES NACEL G. CELESTE, RN, MD

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



Altered menstrual function: – Oligomenorrhea followed by amenorrhea – Amenorrhea for 6 to 12 months – If vaginal bleeding occurs after 12 months of amenorrhea, endometrial biopsy must be ruled out osteoporosis: – Main health hazard associated with menopause MARY LOURDES NACEL G. CELESTE, RN, MD

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menopausal syndrome: - Such as fatigue, headache, nervousness, loss of libido, insomia, depression, irritability, palpitation, muscle pain Atrophic changes: - atrophy of the vaginal mucosa leads to atrophic vaginitis, pruritus of vulvovaginal area, dyspareunia and stenosis - urethral changes - increased frequency of cystitis - vaginal, urethral and bladder symptoms 

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

Treatment: – Estrogen replacement therapy 

Advantages: – Eliminate hot flashes – Reversal of atrophic vaginitis, dyspareunia, affective symptoms – Prevention and treatment of osteoporosis – Prevention of cardiovascular disease – Retention of youthful skin MARY LOURDES NACEL G. CELESTE, RN, MD 187



disadvantages -can cause acute liver disease -Acute vascular thrombosis - seizure disorder -Hypertension -Migraine headache -Breast cancer -Endometrial cancer

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Sequelae of excess endogenous estrogen a. DUB (dysfunctional uterine bleeding) - during perimenopausal age, some women manifest estrogen excess *increased endogenous estrogen can result to: 1. increased level of precursor androgens in functional and nonfunctional endocrine tumors, stress and liver disease 2. increased direct secretion of estrogen from ovarian MARY tumors LOURDES NACEL G. CELESTE, RN, MD 189

Treatment: Intermittent progestin therapy

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EVALUATION: 2. Endometrial biopsy 3. Vaginal USG 4. Hysteroscopy MANAGEMENT  Hormonal therapy – low dose contraceptives  surgery

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Menstrual Disorders Dysmenorrhea Primary – due to prostaglandin excess or increased sensitivity to prostaglandin w/ no pathologic pelvic disorder Secondary – with underlying disease ie, PID (Pelvic inflammatory disease) Endometriosis, Adenomyosis, Uterine prolapse, Uterine myomas, Polyps MARY LOURDES NACEL G. CELESTE, RN, MD

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Pathophysiology  Prostaglandin myometrial contractions muscle spasm constricts blood vessels ischemia and pain

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Clinical Manifestations   Primary – within 1-2 yrs after menarche in conjunction with ovulatory cycles -   pain few hours before menses up to 72 hours thereafter -   Nausea and vomiting, diarrhea, syncope, headache, back pain 

Secondary – years after menarche - 1-2 wks prior to menses and persist few days after menstrual cessation 

Diagnosis History and PE

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Medical Management  1. combination OCP – inhibit ovulation,

decrease prostaglandin and uterine activity 2.promote exercise 3.administer prostaglandin synthesis inhibitors – ibuprofen, mefenamic acid

Nursing Management 1. Education and reassurance 2. adequate nutrition and rest 3. stress management MARY LOURDES NACEL G. CELESTE, RN, MD

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Menstrual cycle irregularities Oligomenorrhea – infrequent, irregular bleeding at intervals > 35 days Polymenorrhea – frequent, regular bleeding at intervals < 21 days Amenorrhea – cessation of menses x 6 months Menorrhagia – regular bleeding that is excessive in amount and duration > 5 days Metrorrhagia – irregular bleeding Menometrorrhagia – excessive prolonged bleeding at irregular intervals MARY LOURDES NACEL G. CELESTE, RN, MD

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PREMENSTRUAL SYNDROME - emotional and physical manifestations that occur cyclically before menstruation and regress thereafter - peak 30-40 yo - mood and behavioral changes - No specific hormone, treatment or markers - inherent to menstrual cycle MARY LOURDES NACEL G. CELESTE, RN, MD

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Etiology and Risk Factors -

Caffeine Smoking Lack of exercise Improper diet Inadequate sleep Stress

Management: supportive MARY LOURDES NACEL G. CELESTE, RN, MD

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Pelvic Inflammatory Disease 



Caused by microorganisms colonizing endocervix ascending to endometrium and fallopian tubes Due to sexually transmitted microorganisms ie Neisseria, Chlamydia, Haemophilus influenza, peptostreptococci MARY LOURDES NACEL G. CELESTE, RN, MD

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Risk Factors     

Multiple sexual partners History of PID Early onset sexual activity Recent gyne procedure IUD

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Manifestations       

pelvic pain – sharp and cramping Fever Excessive vaginal discharge Menorrhagia Metrorrhagia Urinary symptoms Cervical uterine tenderness with movement MARY LOURDES NACEL G. CELESTE, RN, MD

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Diagnostics      



History and PE CBC Vaginal and endocervical culture VDRL Endometrial biopsy - endometritis Sonography – tubo-ovarian abscess Laparoscopy - salpingitis MARY LOURDES NACEL G. CELESTE, RN, MD

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Management     

Antibiotics IV fluids/increase oral fluid Pain medications Remove IUD Evaluation of sexual partners

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Sexuality and Sexual Identity  Terms

Biologic gender Gender identity Gender role

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Sexuality and Sexual Identity  Development

identity

of gender

Infancy Preschool School-age Adolescent MARY LOURDES NACEL G. CELESTE, RN, MD

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Sexuality and Sexual Identity  Development

identity

of gender

Young adult Middle-aged adult Older adult Physically challenged MARY LOURDES NACEL G. CELESTE, RN, MD

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Human Sexual Response  Sexual

response cycle (Masters and Johnson)

Excitement Plateau Orgasm Resolution MARY LOURDES NACEL G. CELESTE, RN, MD

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Excitement  occurs with physical and psychological (sight, sound, emotion, thought) stimulation that causes parasympathetic nerve stimulation  Arterial dilation and venous congestion in the genital area  Vasocongestion:  clitoris in women increases in size, mucoid fluid appears in vaginal walls as lubrication, vagina widens/ increase in length, nipples become erect  In men, erection occurs; scrotal thickening, elevation of testes  Increase in PR, RR and BP MARY LOURDES NACEL G. CELESTE, RN, MD

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Plateau just before orgasm Women: clitoris is drawn forward and retracts under the clitoral prepuce; lower part of the vagina becomes extremely congested (formation of the orgasmic platform), increased nipple engorgement  Men: vasocongestion leads to full distention of the penis  HR increases to 100 to 175 beats per minute and RR to approximately 40 respirations per minute  

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Orgasm Occurs when stimulation proceeds through the plateau stage to a point at which the body suddenly discharges accumulated sexual tension  Vigorous contractions of muscles in the pelvic area expels or dissipates blood and fluid from the area of congestion 

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Shortest stage in the sexual response cycle  Usually experienced as intense pleasure affecting the whole body not just the pelvic area  Highly personal experience; vary greatly from person to person 

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Resolution 

 



Period during which the external and internal genital organs return to unaroused state Males: refractory period – during which further orgasm is impossible Females: no refractory period; may have additional orgasms immediately after the first Generally takes about 30 minutes MARY LOURDES NACEL G. CELESTE, RN, MD

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Sexual Orientation  Heterosexuality  Homosexuality  Bisexuality  Transsexuality

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Sexual Expression  Celibacy  Masturbation  Erotic

stimulation  Fetishism

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Sexual Expression  Transvestism  Voyeurism  Sadomasochism  Other

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Sexual Harassment  Unwanted,

repeated sexual advances, remarks or behavior toward another Offensive to recipient Interferes with job performance MARY LOURDES NACEL G. CELESTE, RN, MD

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Disorders of Sexual Functioning  Sexual

Desire Disorders

Inhibited sexual desire  Sexual

Arousal Disorders

Failure to achieve orgasm

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Disorders of Sexual Functioning  Orgasm

Disorders

Erectile dysfunction Premature ejaculation  Pain

Disorders  Vaginismus  Dyspareunia/Vestibulitis MARY LOURDES NACEL G. CELESTE, RN, MD

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Reproductive Life Planning

Reproductive Life Planning FAMILY PLANNING

Reproductive Life Planning 

Includes all decisions an individual or couple make about having children:

-

If and when to have children How many children to have How children are spaced Conception, fertility and counseling

-

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Responsible Parenthood 

A responsible person is a man or woman who is able and willing to give the proper response to the demands of a given situation.



With specific reference to marriage and family life, the responsible spouse is one who gives the proper responses to the needs of his/ her spouse, as well as his own, and of their life together. Similarly, responsible parents give proper responses to ofRN, their children. MARYthe LOURDESneeds NACEL G. CELESTE, MD 222

Responsible Parenthood 

Although some people object to the idea, we tend to equate family planning with responsible parenthood. Family planning refers more specifically to the voluntary and positive action of a couple to plan and decide the number of children they want to have and when to have them. MARY LOURDES NACEL G. CELESTE, RN, MD

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Responsible Parenthood The concept of family planning includes these elements: 

Responsibility of parents to themselves and to each other



Responsibility to their present and future children



Responsibility to their community and country

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Responsible Parenthood Purposes of Family Planning  improvement of health  promotion of human right to determine reproductive performance  relation of demographic change to economic development MARY LOURDES NACEL G. CELESTE, RN, MD

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Responsible Parenthood The ultimate goal of family planning is directed towards: 

Birth spacing, to allow the mothers time to rest and regain their health before the next pregnancy



Birth limitation, when the desired number of children is reached



Helping those who do not have children to have children MARY LOURDES NACEL G. CELESTE, RN, MD

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Responsible Parenthood Advantages of family planning  



 

To the mother: enables the mother to regain her health after the delivery gives mother enough time and opportunity to love and provide attention to her husband and children provides mother who has chronic illness enough time for treatment and recovery without further exposure to the physiologic burden of pregnancy prevents high risk pregnancy gives mother more time to herself, family and community MARY LOURDES NACEL G. CELESTE, RN, MD

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Responsible Parenthood To the children,the practice family planning will make them  Healthier  Happier  feel wanted and satisfied  secure MARY LOURDES NACEL G. CELESTE, RN, MD

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Responsible Parenthood To the fathers  lightens his burden and responsibility in supporting his family  enables him to give his children a good home, good education and better future  enables him to give his family a happy and contented life  gives him time for his personal advancement  provides a father who has chronic illness enough time for treatment and recovery from his illness MARY LOURDES NACEL G. CELESTE, RN, MD

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Responsible Parenthood To the family  gives the family members more opportunity to enjoy each other’s company with love and affection  enables the family to save some amount for improvement of standard of living, and for emergencies MARY LOURDES NACEL G. CELESTE, RN, MD

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Responsible Parenthood To the community  improves the economic and social status of the community  better job opportunities  health status will improve  extra resources in the community (less congestion, less pollution, potable water supply, etc)  members will have more time to socialize with each other; to participate in socio-civic activities MARY LOURDES NACEL G. CELESTE, RN, MD

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Contraceptive 

Any device used to prevent fertilization of an egg

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Considerations:        

Personal values Ability to use method correctly How method will affect sexual enjoyment Financial factors Status of couple’s relationship Prior experiences Future plans Contraindications MARY LOURDES NACEL G. CELESTE, RN, MD

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CONTRAINDICATIONS OF CONTRACEPTIVE USE

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Contraceptives 



40 million women in United States use some form of contraception 65% of women of childbearing age – ? PHILIPPINES

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Contraceptives 1. Abstinence  



0% failure rate Most effective method to prevent STDs Difficult to comply with

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Contraceptives 2. Natural Family Planning 



No chemical or foreign material into the body Failure rate of approximately 25%

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Contraceptives Fertility Awareness Methods  Calendar (rhythm) method  Basal body temperature  Cervical mucus (Billings) method  Symptothermal method  Ovulation awareness  Lactation amenorrhea method 

Coitus interruptus MARY LOURDES NACEL G. CELESTE, RN, MD

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Calendar/ Rhythm (Natural Family Planning) 

Action – periodic abstinence from intercourse during fertile period; based on the regularity of ovulation; variable effectiveness

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Calendar/ Rhythm (Natural Family Planning) 

Teaching – fertile period may be determined by a drop in the basal body temperature before and a slight rise aftre ovulation and/ or by a change in cervical mucus from thick, cloudy and sticky during nonfertile period to more abundant, clear, thin, stretchy and slippery as ovulation occurs MARY LOURDES NACEL G. CELESTE, RN, MD

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1. Calendar (rhythm) method 





Entails keeping a day-by-day record of your cycle for 6 consecutive months noting the onset of bleeding as day 1 and the last day before your next menstrual bleeding as the final day of your cycle This 6 month record will show you your longest and shortest cycles- from which you can calculate your FERTILE days MARY LOURDES NACEL G. CELESTE, RN, MD

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1. Calendar (rhythm) method

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1. Calendar (rhythm) method 



The first day of menstrual bleeding (day 1 of your period) counts as the first day of the cycle. Approximately 14 days (or 12 to 16 days) before the start of the next period, an egg will be released by one of the ovaries. MARY LOURDES NACEL G. CELESTE, RN, MD

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1. Calendar (rhythm) method 

While the egg from the woman lives for only around 24 hours, sperm from the man can survive for up to 3 days, possibly longer.

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1. Calendar (rhythm) method First unsafe day: subtract 18 from the number of days in your shortest cycle  Last unsafe day: subtract 11 from the number of days in your longest cycle  Ex: shortest: 26 – 18 = day 8 longest: 31 – 11 = day 20 UNSAFE PERIOD!! Days 8 -20 -avoid coitus or use a contraceptive 

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SHORTEST CYCLE 2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

2 6

2 7

2 8

2 9

25

26

1 18 DAYS

LONGEST CYCLE 2 3 4 5 6 7 8 9 1 1 0

1 1

1 2

1 3

1 4

1 5

1 6

1 7

1 8

1 9

2 0

2 1

2 2

2 3

2 4

2 5

3 0

3 1

11 DAYS

UNSAFE TIME 1

2

3

4

5

6

7

8

9

1 0

1 1

1 2

1 3

1 4

1 5

1 6

1 7

1 8

1 9

2 0

2 1

2 2

2 3

2 4

2 5

2 6

2 7

2 8

2 9

3 0

UNSAFE TIME

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3 1

2. Basal Body Temperature 





Involves taking the temperature every morning BEFORE the woman gets out of bed and recording it The temperature drops slightly 24 hours before ovulation, then rises to about half a degree higher than normal and remains thus for up to three days: UNSAFE period! Not a very efficient method unless combines with calendar and mucus methods MARY LOURDES NACEL G. CELESTE, RN, MD

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3. Cervical Mucus (Billings) Method 

Involves becoming aware of the normal changes in the cervical secretions that occur throughout your cycle by inserting the forefinger into the vagina first thing in the morning

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3. Cervical Mucus (Billings) Method 





A few days after menstrual bleeding: little secretion, vagina is dry Gradually, secretion increases and becomes thicker, cloudy white and sticky As ovulation approaches, this secretion or mucus becomes copious, clear, thin, less viscous, more liquid, slippery or stringy; as soon as this change begins and for 3 full days later: UNSAFE PERIOD!! MARY LOURDES NACEL G. CELESTE, RN, MD

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3. Cervical Changes  



Spinnbarkeit test Cervical mucus is thin, watery and can be stretched into long strands high level of estrogen: ovulation is about to occur

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3. Cervical Changes 





Ferning or arborization of cervical mucus At the height of estrogen stimulation just before ovulation Ferning- due to crystallization of sodium chloride on mucus fibers

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Symptothermal method 

Combines BBT and cervical mucus methods

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Ovulation awareness 



Use of over-the-counter OTC ovulation test kit which detects the midcycle LH (luteinizing hormone) surge in the urine 12 to 24 hours before ovulation 98 to 100% accurate

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Lactation amenorrhea method 





As long as a woman is breastfeeding an infant, there is some natural suppression of ovulation Not dependable- woman may be fertile even if she has not had a period since childbirth After 6 months, she should another method of contraception MARY LOURDES NACEL G. CELESTE, RN, MD

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Coitus interruptus  



Oldest method Couple proceeds with coitus until the moment of ejaculation, then the man withdraws and spermatozoa are emitted outside the vagina Offers little protection because ejaculation may occur before withdrawal is co mplete and despite the care used, spermatozoa may be deposited in the vagina MARY LOURDES NACEL G. CELESTE, RN, MD

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Contraceptives 3. Oral Contraceptives  Composed of varying amounts of estrogen combined with small amount of progesterone 99.5% effective

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3. Oral Contraceptives 



Estrogen suppresses FSH and LH, thereby suppressing ovulation Progesterone decreases the permeability of cervical mucus

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3. Oral Contraceptives 





Monophasic - Fixed doses of estrogen and progesterone ; 2128 day cycle Biphasic - Constant amount of estrogen with increased progesterone Triphasic - Varying levels of estrogen and progesterone MARY LOURDES NACEL G. CELESTE, RN, MD

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3. Oral Contraceptives Benefits of OC’s: DECREASED incidences of:  Dysmenorrhea  Premenstrual dysphoric syndrome  Iron deficiency anemia  Acute PID with tubal scarring  Endometrial and ovarian cancer and ovarian cysts  Fibrocystic breast disease MARY LOURDES NACEL G. CELESTE, RN, MD

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3. Oral Contraceptives Side Effects  Nausea  Weight gain  Headache  Breast tenderness  Breakthrough bleeding  Monilial vaginal infections  Mild hypertension  Depression MARY LOURDES NACEL G. CELESTE, RN, MD

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3. Oral Contraceptives Absolute Contraindications to OC’s  Breastfeeding  Family history of CVA or CAD  History of thromboembolic disease  History of liver disease  Undiagnosed vaginal bleeding MARY LOURDES NACEL G. CELESTE, RN, MD

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3. Oral Contraceptives Possible Contraindications to OC’s  Age 40+  Breast or reproductive tract malignancy  Diabetes Mellitus  Elevated cholesterol or triglycerides  High blood pressure  Mental depression

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

   

 

Migraine or other vascular type headaches Obesity Pregnancy Seizure disorders Sickle cell or other hemoglobinopathies Smoking Use of drug with interaction effect MARY LOURDES NACEL G. CELESTE, RN, MD

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Other Contraceptives 

  

Continuous or extended regimen pills Mini-pills Estrogen-progesterone patch Vaginal rings

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Estrogen-progesterone patch

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    

Highly effective, weekly hormonal birth control patch that’s worn on the skin Combination of estrogen and progestin Absorbed on the skin and then transferred into the bloodstream Can be worn on the upper outer arm, buttocks, upper torso or abdomen Worn for 1 week, replaced on the same day of the week for 3 consecutive weeks. No patch-4th week MARY LOURDES NACEL G. CELESTE, RN, MD

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Emergency Postcoital Contraceptives   

“Morning-after pills” High level of estrogen Must be initiated within 72 hours of unprotected intercourse

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4. Other Contraceptives

Subcutaneous implants (eg, Norplant)  6 nonbiodegradable Silastic implants with synthetic progesterone embedded under the skin on the inside of the upper arm  Slowly release the hormone over the next 5 years  Suppress ovulation, stimulating thick cervical mucus and changing the endometrium so implantation is difficult MARY LOURDES NACEL G. CELESTE, RN, MD

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4. Other Contraceptives Intramuscular injections -administered every 12 weeks Medroxyprogesterone (depoprovera) -100% effective 

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Contraceptives 1.       

INTRAUTERINE DEVICES T-shaped plastic device with copper With progesterone Mechanism of action not fully understood Must be fitted by physician, nurse practitioner or midwife Insertion performed in ambulatory setting after pelvic examination and pap smear Device is contained within uterus – string protrudes into vagina Effective for 5-7 years (mirena type) or 8 years (Copper T380) MARY LOURDES NACEL G. CELESTE, RN, MD

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INTRAUTERINE DEVICE

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5. INTRAUTERINE DEVICES Side Effects:  Spotting or uterine cramping  Increased risk for PID  Heavier menstrual flow  Dysmenorrhea 

Ectopic pregnancy

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6. Barrier Methods 

  

Vaginally inserted spermicidal products Diaphragms Cervical caps Condoms

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6. BARRIER METHODS 

SPERMICIDAL AGENT

goal: to kill the sperm before the sperm enters the cervix -Nonoxynol-9 -gel, creams, films,foams, suppositories

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6. BARRIER METHODS DIAPHRAGM -mechanically blocks sperm from entering the cervix -soft latex dome supported by a metal rim -can be inserted 2 hours before intercourse; removed at least 6 hours after coitus or within 24 hours -size must fit the individual -washable, may be used MARY LOURDES NACEL G. CELESTE, MD 276 forRN,2-3 years 

6. BARRIER METHODS 

CERVICAL CAP -similar to diaphragm but smaller -thimble-shaped rubber cap held onto the cervix by suction

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6. BARRIER METHODS MALE CONDOM

FEMALE CONDOM

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

MALE CONDOM Action – prevents the ejaculate and sperm from entering the vagina; help prevent venereal disease; effective if properly used; OTC



Teaching – apply to erect penis with room at the tip every time before vaginal penetration; use water-based lubricant, e.g., K-Y jelly, never petroleum-based lubricant; hold rim when withdrawing the penis from the vagina; if condom breaks, partner should use contraceptive foam or cream immediately MARY LOURDES NACEL G. CELESTE, RN, MD

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7. Surgical Methods 

Tubal Ligation -28% of all women in US -fallopian tubes are cut,tied/ cauterized to block passage of ova and sperm

ABDOMINAL INCISION MINILAPAROTOMY LAPAROSCOPY FOR TUBAL MARY LOURDES NACEL G. CELESTE, RN, MD STERILIZATION

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7. Surgical Methods Vasectomy - 11% of all men in US -incisions are made in the sides of scrotum; vas deferens is cut and tied, then plugged or cauterized -blocks passage of sperm -viable sperm for 6 months post op -reversible 95% MARY LOURDES NACEL G. CELESTE, RN, MD 281 

8. Elective Termination of Pregnancy

Procedure to deliberately end a pregnancy before fetal viability  Induced (mifepristone-progesterone antagonist; misoprostolprostaglandin analog  Medically induced D&C, D&E, saline induction, hysterotomy MARY LOURDES NACEL G. CELESTE, RN, MD

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The Infertile Couple

Infertility 

Inability to conceive a child or sustain a pregnancy to childbirth Pregnancy has not occurred after at least 1 year of engaging in unprotected sexual intercourse Affects 14% of couples desiring children MARY LOURDES NACEL G. CELESTE, RN, MD

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INFERTILITY Types of infertility: 



Primary infertility - refers to a couple who have never established a pregnancy Secondary infertility - refers to couple who have conceived previously but are currently unable to establish a subsequent pregnancy MARY LOURDES NACEL G. CELESTE, RN, MD

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

Incidence: – Approximately 10-14% of couples are infertile, using the criteria of at least 1 year of unprotected coitus – Approximately 15% of infertile couples have no identifiable cause of infertility

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Physiology of conception: 

Basic requirements for successful completion of reproductive process – Release of ova from the ovaries ( ovulation) on a regular cyclic basis – Production of an ejaculate containing an ample number of motile spermatozoa – Deposition of spermatozoa in the female reproductive tract, usually on or near the cervical os – Migration of the spermatozoa through the female reproductive tract to the fallopian tubes – Patency of the fallopian tube MARY LOURDES NACEL G. CELESTE, RN, MD

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– Normal intrauterine environment from the cervix to fallopian tube lumen to enable active movement of spermatozoa capable of fertilizing an ovum – Condition appropriate for fusion of gametes ( ovum and spermatozoa) with in the fallopian tube MARY LOURDES NACEL G. CELESTE, RN, MD

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Factors involved in infertility – – –

Spermatogenesis ( male factor) ovulation ( ovarian factor) mucus and sperm interaction ( cervical factor) – endometrial integrity and cavity size and shape (uterine factor) – oviduct patency and anatomic relationship to the ovary ( tubal factor) – Insemination ( the coital factor ) MARY LOURDES NACEL G. CELESTE, RN, MD

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Male Infertility Factors  Inadequate

sperm count  Obstruction or impaired sperm motility  Ejaculation problems

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

Male factor: Obstruction in seminiferous tubules , duct, or vessels preventing movement of spermatozoa  Qualitative or quantitative changes in the seminal fluid preventing sperm mobility (movement of sperm)  Development of autoimmunity that immobilizes sperm  Problem in ejaculation or deposition preventing spermatozoa from being MARY LOURDES NACEL G. CELESTE, RN, MD 291 placed close enough to the woman’s 

– Causes of inadequate sperm: Increase in body temperature  Chronic infection  Congenital anomalies  Varicocele  Trauma to the testes  Endocrine imbalances  Drug or excessive alcohol use  Environmental factor 

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–Obstruction or impaired sperm motility: – Mumps or orchitis – Anomalies of the penis – Extreme obesity

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– Ejaculation problem:  Psychological problem  Debilitating disease  Premature ejaculation

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semen analysis: – count: 20 million / ml or 50 million /ejaculation – volume: 2.5ml - 6 ml – Motility: >75% – Quality of motion: graded 1-4 (poor to excellent) – Morphology: more than 70% normal MARY LOURDES NACEL G. CELESTE, RN, MD

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Female Infertility Factors  Anovulation  Tubal

transport problems  Pelvic inflammatory disease  Uterine problems  Endometriosis MARY LOURDES NACEL G. CELESTE, RN, MD

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Common Sites 0f Endometriosis Formation

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Female Infertility Factors  Cervical

problems  Vaginal problems  Unexplained infertility

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

Ovarian factor: 

Anovulation- most common cause of infertility in women 1. genetic abnormality 2.hormonal imbalance 3. ovarian tumor 4. stress 5.decreased body weight MARY LOURDES NACEL G. CELESTE, RN, MD

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

Tubal factor: –



Pelvic inflammatory disease

Uterine factor: – – – –

Tumor ( fibroma) Congenitally deformed uterine cavity Endometriosis Inadequate endometrium formation MARY LOURDES NACEL G. CELESTE, RN, MD

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

Cervical factor: – Characteristic of cervical mucus – Infection/inflammation of cervix



Coital factor : – pH of the vagina: alkaline pH is optimum (8) – Presence of sperm-immobilizing/sperm agglutinating antibodies MARY LOURDES NACEL G. CELESTE, RN, MD

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Fertility Assessment  Health

history

General health Nutrition Alcohol, drug or tobacco use Congenital health problems Current illnesses MARY LOURDES NACEL G. CELESTE, RN, MD

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Fertility Assessment  Health

History

Menstrual history Contraceptive use Pregnancies or abortions

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Fertility Assessment  Physical

assessment

Secondary sex characteristics Genital abnormalities Breast and thyroid examination

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Fertility Assessment  Fertility

testing

Semen analysis Ovulation monitoring Tubal patency assessment

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Semen Analysis  Number

of sperm  Appearance of sperm  Motility of sperm  Sperm penetration

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Ovulation Monitoring  Record

basal body temperature  Ovulation by test strip Assesses upsurge of LH that occurs before ovulation

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Tubal Patency  Sonohysterography

Ultrasound to inspect uterus  Hysterosalpingography

Radiologic exam of fallopian tubes

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Advanced Surgical Procedures  Uterine

endometrial biopsy  Hysteroscopy  Laparoscopy

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Infertility evaluation: 

Male factor: Semen analysis  Post-coital test-mucus is examined microscopically between 2- 12hrs after coitus – Satisfactory test- many motile spermatozoa seen per high power field – Unsatisfactory result:  No spermatozoa are seen  Majority of spermatozoa are MARY LOURDES NACEL G. CELESTE, RN, MD 310 immotile 



Motility is characterized as shaking movement rather than forward movement  Hostile cervical mucus is present 

– Sperm antibodies: maybe measured in – Seminal plasma – Male serum – Female reproductive tract fluids – Female serum MARY LOURDES NACEL G. CELESTE, RN, MD

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– Test of fertilizing capacity of spermatozoa: 

 



Measurement of sperm acrosin-enzyme in sperm head that responsible for preliminary changes in the sperm zona-free hamster ovum penetration test Human ovum fertilization test

Coital factor: 





Taking history of coital frequency, pattern and technique Anatomic evaluation of the position of the cervix with relationship to the vagina Post coital testing MARY LOURDES NACEL G. CELESTE, RN, MD 312 MARY LOURDES NACEL G. CELESTE, RN, MD

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

Cervical factor: – Cervix is the first major barrier encountered by sperm after arrival in the female reproductive tract 1.Abnormalities in the cervix or the cervical mucus – Abnormal position of the cervix( prolapse or uterine retroversion – Chronic infection – Previous cervical surgery – Presence of sperm antibody in the cervical mucus MARY LOURDES NACEL G. CELESTE, RN, MD 313

2.mucus quality: - pH -bacteriologic culture for microorganism Uterine factor: * role of uterus in reproduction: - retention of the zygote after arrival from the fallopian tube - provision of suitable environment for implantation - protection of embryo /fetus from the external environment MARY LOURDES NACEL G. CELESTE, RN, MD 314 

– * evaluation of uterine factor: 

Endometrial sampling – Occurrence of ovulation when evidence of progesterone secretion is found on biopsy – duration of hormonal influence and defects in corpus luteum secretion of progesterone – Presence of infection MARY LOURDES NACEL G. CELESTE, RN, MD

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– Hysterography- visualize contour of the uterine cavity – Hysteroscopy –visualize uterine cavity to detect anomalous development, polyps or tumors

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Tubal factor: - functions: 1.mechanical function- act to : -conveys recently ovulated ova into fallopian tube -permits spermatozoa to enter the oviduct -effects transfer of the blastocyst into the uterine cavity 

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2. environmental function:

-fertilization of the ovum -capacitation of spermatozoa -early development and segmentation of the fertilized ovum

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*Tests used to evaluate function of fallopian tubes: - determine patency ,location with respect to ovary and function c. Hysterosalpingography-enables visualization of the lumen and patency of fallopian tube

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b. Laparoscopy- direct visualization of fallopian tube in order to identify abnormalities in structure or location and detect peritubal adhesions c. Tubal insufflation- with carbon dioxide and manometric measurement of pressure( rarely used) MARY LOURDES NACEL G. CELESTE, RN, MD

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

Ovarian factor: -function: serve as repository for

oocytes, they release mature oocytes at regular interval throughout reproductive life - secrete steroid hormones that influence the structure and function of tissue in reproductive tract, promoting fertility MARY LOURDES NACEL G. CELESTE, RN, MD

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*documentation of ovulation: a. basal body temperature records demonstrate a 14 day elevation of basal temp.( progesterone-thermogenic effect) b. Blood progesterone level c. endometrial biopsy- secretory endometrial pattern

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 

Corpus luteum production of progesteronemust be sufficient Reasons for ovulatory defect: A. hypothalamic –pituitary insufficiency a. tumor or destructive lesion b. hyperprolactinemia due to pituitary adenoma B. thyroid disease C. adrenal disorders D. emotional disturbances E. metabolic and nutritional disorder F. excessive exercise MARY LOURDES NACEL G. CELESTE, RN, MD

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

Treatment : – Correction of male factor: a. Medical - correction of underlying deficiencies - artificial donor insemination b. surgical - reversal of sterilization - varicocele surgery c. assisted reproductive technologies 1. in vitro fertilization and embryo transfer MARY LOURDES NACEL G. CELESTE, RN, MD

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- removal of oocytes from the ovary, then placed on a dish together with the sperm 2. gamete intrafallopian tube transfer - ovum and spermatozoa are mixed together and immediately placed on fallopian tube 3. assisted fertilization is a technique of micromanipulation that thins the zona pellucida and inject sperm into the ovum in an effort to enhance fertilization MARY LOURDES NACEL G. CELESTE, RN, MD

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– Correction of coital factor: - psychotherapy - sexual therapy - artificial insemination – Correction of cervical factor: - low dose estrogen level - antibiotics - cervical or intrauterine artificial insemination -human gonadotropin - ivf/et MARY LOURDES NACEL G. CELESTE, RN, MD

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– Correction of uterine factor: - medical - antibiotic therapy for endometritis - surgical - myomectomy for myomata – Correction of tubal factor: 1. tubal anastomosis for reversal of sterilization 2. lysis of peritubal adhesions 3. IVF/ET when fallopian tubes are absent or irreparable MARY LOURDES NACEL G. CELESTE, RN, MD

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– Correction of ovarian factor: 1. induction of ovulation: - correction of underlying endocrine disorder - clomiphene citrate to correct hypothalamic function - human menopausal gonadotropin - bromocryptine for anovulation MARY LOURDES NACEL G. CELESTE, RN, MD

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2. correction of luteal phase – – – –

a. clomiphene citrate b. hCG human chorionic gonatrophin c.postovulatory progesterone supplementation d. human gonadotropin( fsh, lh)

Unexplained

fertility:

- IVF - GIFT - asssted fertilization MARY LOURDES NACEL G. CELESTE, RN, MD

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Infertility Management Correction of underlying problem  Increasing sperm count and motility  Reducing the presence of infection  Hormone therapy  Surgery 

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Assisted Reproductive Techniques Artificial insemination  In vitro fertilization  Gamete intrafallopian transfer  Zygote intrafallopian transfer  Surrogate embryo transfer  Preimplantation genetic diagnosis 

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

Artificial insemination – instillation of sperm into the female reproductive tract to aid conception



In vitro fertilization (IVF)– removing 1 or more mature oocytes from a woman’s ovary by laparoscopy and then fertilizing them by exposing them to sperm under laboratory conditions outside the woman’s body



Embryo Transfer (ET)– ova transfer; insertion of laboratory grown fertilized ovum into the wopman’s uterus approx. 40 hours after fertilization where 1 NACEL or G.more ofMD them will MARY LOURDES CELESTE, RN, 332 implant and grow



Gamete intrafallopian transfer (GIFT) – ova and sperm are instilled in the patent fallopian tube within a matter of hours without waiting fo rthe fertilization t o occur in the laboratory



Zygote intrafallopian transfer (ZIFT) – retrieval of oocytes, culture and insemination of oocytes in the laboratory; fertilized eggs are transferred in the patent fallopian tube within 24 hours MARY LOURDES NACEL G. CELESTE, RN, MD

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

Surrogate embryo transfer – oocyte from a donor is fertilized by the recipient woman’s male partner’s sperm and placed in the recipient’s uterus by ET or GIFT

Intravaginal culture  Blastomere analysis 

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ARTIFICIAL INSEMINATION

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IN VITRO FERTILIZATION

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Childbirth Alternatives  Surrogate

mothers

 Adoption  Child-free

living

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Genetic Assessment and Counseling

Facts 1

in 20 newborns has an inherited genetic disorder  Over 30% of pediatric admissions are for geneticinfluenced disorders MARY LOURDES NACEL G. CELESTE, RN, MD

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Genetic Disorders  Inherited

or genetic disorders -disorders that can be passed from one generation to the next

 Genetics

-Study of why disorders occur MARY LOURDES NACEL G. CELESTE, RN, MD

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Nature of Inheritance 

In humans, each cell, with the exception of the sperm and ovum, contains 46 chromosomes (44 autosomes and 2 sex chromosomes) in the nucleus



Each chromosome contains thousands of genes Sex chromosomes 46XX: female 46XY: male



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Normal Female Karyotype

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Normal Male Karyotype

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Nature of Inheritance 

Genes Basic units of heredity; structures responsible for hereditary characteristics  May or may not be expressed or passed to the next generation  According to Mendel’s Law, one gene for each hereditary property is received from each parent; one is dominant (expressed); one is recessive MARY LOURDES NACEL G. CELESTE, RN, MD

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Karyotype  Chromosomal pattern of a cell including genotype, number of chromosomes and normality or abnormality of the chromosomes Genotype  Actual gene composition  Sequence and combination of genes on a chromosome Phenotype  Outward appearance or observable expression of genes (hair color, eye color, body build, allergies) MARY LOURDES NACEL G. CELESTE, RN, MD

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Alleles  Pairs of genes located on the same site on paired chromosomes  Homozygous alleles (DD or dd)  Heterozygous alleles are two different alleles for the same trait (Dd) MARY LOURDES NACEL G. CELESTE, RN, MD

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CONGENITAL and GENETIC are not synonymous  Congenital - present at birth because of abnormal development in utero (teratology) 

Genetic – pertains to genes or chromosomes; some genetic disorders may be noticeable at birth and others may not appear for decades MARY LOURDES NACEL G. CELESTE, RN, MD

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Dominant and Recessive Patterns 

Homozygous - a person who has 2 like genes for a trait (eg, blue eyes: 1 from the mother and 1 from the father)



Heterozygous – if the genes differ (eg, 1 gene for blue eyes from the mother, 1 gene for brown eyes from the father) MARY LOURDES NACEL G. CELESTE, RN, MD

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Dominant and Recessive Patterns  Dominant

genes – genes which are expressed in preference to others

 Recessive

genes – genes that are not dominant MARY LOURDES NACEL G. CELESTE, RN, MD

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Homozygous dominant - an individual with 2 homozygous genes for a dominant trait  Homozygous recessive – an individual with 2 homozygous genes for a recessive trait 

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Their children have a 100% chance of being heterozygous for the trait. Phenotype – brown eyed (phenotype) ; but they will carry a recessive gene for blue eyes in their genotype.

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The child will have an equal chance of being brown eyed (50%) or blue eyed (50%).

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All the children will be brown- eyed. Chances are equal that their children will be homozygous dominant (50%) like the father or heterozygous (50%) like the mother.

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Both parents are heterozygous. 25% chance of their children being homozygous recessive (blueeyed), 50% chance of being heterozygous (brown eyed) and a 25% chance of being homozygous dominant (brown eyed).

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Inheritance of Disease 

 

Mendelian or Single gene disorders A. Autosomal disorders 1. Autosomal dominant disorders 2. Autosomal recessive disorders B. Sex – linked disorders 1. X-linked dominant inheritance 2. X-linked recessive inheritance Multifactorial inheritance Chromosomal aberrations or abnormalities MARY LOURDES NACEL G. CELESTE, RN, MD

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Autosomal disorders 





Occur in any chromosome pair other than the sex chromosomes Result from a single altered gene or a pair of altered genes on one of the first 22 pairs of autosomes Autosomal dominant or Autosomal recessive MARY LOURDES NACEL G. CELESTE, RN, MD

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Autosomal dominant traits 



Those in which the abnormal gene dominates the normal gene; thus, the condition is always demonstrated when the abnormal gene is present. The affected parent has a 50% CHANCE OF PASSING ON THE ABNORMAL GENE IN EACH PREGNANCY. MARY LOURDES NACEL G. CELESTE, RN, MD

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Autosomal dominant traits

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Autosomal dominant  

  

Osteogenesis imperfecta (bones are exceedingly brittle) Marfan syndrome (disorder of connective tissue; child is thinner and taller than normal; heart defects) Huntington’s disease Neurofibromatosis Achondroplasia (dwarfism) MARY LOURDES NACEL G. CELESTE, RN, MD

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Family pedigrees findings (Autosomal dominant ) 





1 of the parents of the child with the disorder also has the disorder The sex of the affected individual in unimportant in terms of inheritance History of the disorder in other family members MARY LOURDES NACEL G. CELESTE, RN, MD

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Autosomal recessive traits 





Require transmission of the abnormal gene from both parents for demonstration of the defect in the child Each child has a 50% CHANCE OF BEING A CARRIER OF THE DISORDER Almost all carriers are free from symptoms MARY LOURDES NACEL G. CELESTE, RN, MD

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Autosomal recessive  

-

-

Albinism Sickle cell anemia (chronic intensely painful episodes caused by obstruction of blood vessels by odd-shaped RBC’s; precipitated by dehydration, infection, exposure to cold, trauma, fatigue, lack of oxygen, strenuous physical activity) The primary nursing action in caring for an adolescent in sickle cell crisis is directed at maintaining adequate hydration the spleen usually becomes enlarged due to congestion and engorgement with sickled MARY LOURDES NACEL G. CELESTE, RN, MD 363 cells

Autosomal recessive 







Cystic fibrosis (multiple organ disease; the primary pathophysiologic mechanism in cystic fibrosis mucus buildup in the lungs and pancreas; steatorrhea; azotorrhea) Inborn errors of metabolism (disorders caused by the absence of or defect in enzymes that metabolize proteins, fats or carbohydrates) Phenylketonuria or PKU (phenylalanine hydroxylase) – brain damage and mental retardation Tay Sach’s disease (hexosaminidase)- child is attentive, passive and regresses in motor and social development MARY LOURDES NACEL G. CELESTE, RN, MD 364

GROUP

Disorder

Blacks/ African Americans Northern European descendants of Ashkenazic Jews Caucasian/ NonHispanic Mediterranean descendants

Sickle cell Anemia Tay-Sachs disease Cystic fibrosis Thalassemia

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Family pedigrees findings (Autosomal recessive) 

  

Both parents of a child with the disorder are clinically free of the disorder The sex of the affected individual in unimportant in terms of inheritance History of the disorder in the family is negative A known common ancestor between the parents sometimes exists. This is how both male and female have come to possess a like gene for the disorder. MARY LOURDES NACEL G. CELESTE, RN, MD

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X-linked disorders 



Result from an altered gene on the X chromosome May be dominant or recessive; recessive is more common

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Family pedigrees findings (X-linked dominant) 



 



All individuals with the gene are affected Female children of affected men are all affected; male children of affected men are unaffected It appears in every generation All children of homozygous affected women are affected. EXAMPLE: Hypophosphatemia MARY LOURDES NACEL G. CELESTE, RN, MD

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X- linked recessive  





More common Mother is the carrier of the disorder In female children, expression of the disease is blocked In male children, disease will be manifested MARY LOURDES NACEL G. CELESTE, RN, MD

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Family pedigrees findings (X-linked recessive)  





Only males will have the disorder A history of girls dying at birth for unknown reasons often exists Sons of an affected man are unaffected The parents of affected children do not have the disorder MARY LOURDES NACEL G. CELESTE, RN, MD

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X-linked recessive   

 

Hemophilia Color blindness Duchenne-type muscular dystrophy Christmas disease Fragile X syndrome MARY LOURDES NACEL G. CELESTE, RN, MD

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Multifactorial inheritance 





Abnormalities caused by multifactorial reasons which do not follow the mendelian laws of inheritance because more than a single gene is involved Environmental influences may be instrumental in determining whether the disorder is expressed Difficult to counsel parents regarding these disorders because their occurrence is unpredictable MARY LOURDES NACEL G. CELESTE, RN, MD

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Multifactorial inheritance       

Cleft lip or palate Neural tube disorders Mental illness Pyloric stenosis Hypertension Heart disease diabetes MARY LOURDES NACEL G. CELESTE, RN, MD

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Imprinting 

Differential expression of genetic material which allows researchers to identify whether the chromosomal material has come from the male or female parent

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Genetic marker 



Specific point on the chromosome that if present, marks the location of a missing or abnormal gene eg, cystic fibrosis - detected prenatally; gene marker on chromosome 7

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Chromosomal abnormalities 

    

Abnormality occurs not because of dominant or recessive genes but through a fault in the number or structure of chromosomes Nondisjunction abnormalities Deletion abnormalities Translocation abnormalities Mosaicism Isochoromosomes MARY LOURDES NACEL G. CELESTE, RN, MD

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



Mitosis is normal cell division, resulting in an exact copy of the parent cell. Meiosis is normal cell division of the ova and spermatozoon for procreation, resulting in 23 chromosomes (1 chromosome from from each os the 23 pairs)reduction division MARY LOURDES NACEL G. CELESTE, RN, MD

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1. Nondisjunction abnormalities 

 

Failure of 1 pair of chromosomes from either parent to separate during meiosis, usually resulting in 45 or 47 chromosomes in the offspring Monosomy – 45 chromosomes; most are incompatible with life Trisomy – 47 chromosomes - Down Syndrome MARY LOURDES NACEL G. CELESTE, RN, MD

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2. Deletion abnormalities 





Loss of a chromosome during cell division, producing varying effects in the offspring, depending on the type and amount of genetic material lost Part of chromosome breaks during cell division, causing the affected person to have the normal number of chromosomes +/- an extra portion of the chromosome Cri-du-chat syndrome MARY LOURDES NACEL G. CELESTE, RN, MD

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3. Translocation abnormalities 



Occur when the chromosome breaks; the parts may connect to another chromosome, or the genes may switch their order or spacing Down Syndrome, some cases

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4. Mosaicism 



Abnormal chromosomal division in the zygote resulting in 2 or more cell lines with different chromosomes Down syndrome (those with nearnormal intelligence), some cases

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5. Isochoromosomes 



If a chromosome accidentally divides by a horizontal separation and not by a vertical one, a new chromosome with mismatched long and short arms can result (isochromosome) Turner syndrome (45XO), some cases MARY LOURDES NACEL G. CELESTE, RN, MD

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Genetic Counseling  Purpose

Provide accurate information Provide reassurance Make informed choices Educate people about disorders Offer support MARY LOURDES NACEL G. CELESTE, RN, MD

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Nursing Responsibilities Alert couple to what procedures they can expect to undergo  Explain how genetic screening tests are done and when they are offered  Assess for signs and symptoms of genetic disorders  Offer support  Assist in value clarification  Educate on procedures and tests 

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Assessing for Genetic Disorders    



History Physical assessment Diagnostic testing Karyotyping – visual presentation of chromosomes (sample: peripheral venous blood; scraping of cells from buccal membrane) Barr body determination – if a child is born with ambiguous genitalia; scraping of cells from buccal membrane; stained and magnified; presence of nondominant X chromosome in the nucleus- Barr body MARY LOURDES NACEL G. CELESTE, RN, MD (chromosomally female)

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Assessing for Genetic Disorders AFP analysis - alpha fetoprotein (AFP) is a glycoprotein produced by the fetal liver - AFP level in the amniotic fluid or maternal serum will differentiate from normal if a chromosomal or a spinal cord disorder is present (eg, in mothers who have gestational diabetes; infants 10x risk of having a neural tube defect) - Serum test is done at 15th week of pregnancy; if result is abnormal, amniotic fluid will be assessed - elevated 3-5x in amniotic fluid secondary to leakage from open neural tube - low AFP, < 5% Down syndrome - maternal serum AFP has a false positive rate 30%; use of triple study (AFP, estriol and hCG) reduces false positive rate



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Assessing for Genetic Disorders Chorionic villi sampling  Retrieval and analysis of chorionic villi for chromosome analysis  Transcervical or transabdominal; may be done as early as 5 weeks, but more commonly done at 8-10 weeks of pregnancy  Risks: bleeding/ loss of pregnancy; limb reduction syndrome; infection  Diagnosis of Sickle cell disease, thalassemia MARY LOURDES NACEL G. CELESTE, RN, MD

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Chronic villi sampling

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Assessing for Genetic Disorders Amniocentesis Withdrawal

of amniotic fluid from the abdominal wall for analysis at 14th to 16th week of pregnancy May include karyotyping, analysis of AFP and acetylcholinesterase Used to diagnose potential genetic problems in the fetus (Down Syndrome), to estimate fetal lung maturity or to diagnose fetal hemolytic disease MARY LOURDES NACEL G. CELESTE, RN, MD

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Amniocentesis

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Assessing for Genetic Disorders 

Percutaneous umbilical blood sampling - removal of blood from the umbilical cord using an amniocentesis technique - more rapid karyotyping



Sonography/ Fetal imaging – assess fetus for general size and structural disorders of the internal organs, spine and limbs - may be used concurrently with amniocentesis MARY LOURDES NACEL G. CELESTE, RN, MD

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Percutaneous umbilical blood sampling

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

Fetoscopy – insertion of a fiberoptic fetoscope through a small incision in the mother’s abdomen into the uterus and membranes to inspect the fetus for gross abnormalities - can be used to confirm sonography finding, remove skin cells for DNA analysis or perform surgery for a congenital defect



Preimplantation diagnosis – may be possible in the future - to remove the fertilized ovum from the uterus before implantation for biopsy or cell analysis MARY LOURDES NACEL G. CELESTE, RN, MD 396

Legal and Ethical Aspects Participation must be elective  Informed consent  Results must be interpreted correctly  Confidentiality must be maintained  Participation must be a free and individual decision 

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Common Chromosomal Disorders   

Detected at birth on physical examination Most common are nondisjunction syndrome Many of these disorders leave children cognitively challenged

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Common Chromosomal Disorders 1. Trisomy 13 syndrome (Patau syndrome) -

Children have extra chromosome 13 Severely cogitively challenged Incidence is low, .45 per 1,000 live births Midline body disorders present, microcephaly, with abnormalities of the forebrain and forehead Eyes are smaller than normal (microphthalmos) or absent Cleft lip and palate Low set ears Heart defects, VSD Abnormal genitalia MARY LOURDES NACEL G. CELESTE, RN, MD Most do not survive beyond early childhood 399

2. Trisomy 18 syndrome     

 

3 Number 18 chromosomes Severely cognitively challenged Incidence .23 per 1,000 live births Small for gestational age (SGA) Low set ears, small jaw, congenital heart defects, misshapen fingers and toes (Index deviates or crosses over other fingers) Soles of the feet are rounded not flat (rocker-bottom feet) Do not survive beyond early infancy MARY LOURDES NACEL G. CELESTE, RN, MD

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3. Cri-du-chat syndrome 







Result of a missing portion of chromosome 5 Abnormal cry – like a sound of a cat Small head, wide-set eyes, downward slant to the palpebral fissure of the eye Severely cognitively challenged MARY LOURDES NACEL G. CELESTE, RN, MD

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4. Turner syndrome - female with only 1 X chromosome        

   

Gonadal dysgenesis, 45XO Has only 1 functional X chromosome Short in stature Hairline at the nape is low set Neck may appear webbed and short May have edema of the hands and feet Congenital anomalies, eg, coarctation (stricture) of the aorta; kidney disorders Streak (small and nonfunctional) gonads; may have pubic hair in puberty, no other secondary characteristics Incidence is 1 per 10,000 live births On karyotyping, 1 X chromosome only (no Barr body present) Lack of fertility; learning disabilities; socioemotional MARY LOURDES NACEL G. CELESTE, RN, MD 402 problems Growth hormone may help achieve additional height;

5. Klinefelter syndrome

- male with an extra X chromosome  

  

Males with XXY chromosome pattern (47XXY) –may be revealed by karyotyping At puberty – poorly developed secondary characteristics; small testes that produce ineffective sperm- often infertile Usually of normal intelligence or have mental retardation Gynecomastia Incidence is about 1 per 1,000 MARY LOURDES NACEL G. CELESTE, RN, MD

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6. Fragile X syndrome         

X linked, 1 long arm of the X chromosome is defective 1 in 1,000 livebirths Most common cause of cognitive challenge in boys Before puberty – maladaptive behaviors: hyperactivity and autism Reduced intellectual functioning (speech and arithmetic) Large head, long face with a high forehead, prominent lower jaw, large protruding ears Hyperextensive joints, cardiac disorders After puberty – enlarged testicles; fertile Folic acid and phenothiazine may improve MARY LOURDES NACEL G. CELESTE, RN, MD symptoms of poor concentration and impulsivity; intellectual function cannot be

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7. Down syndrome (trisomy 21)    



Most frequent; 1 in 800 live births In pregnancy of women >35 years (1 in 100 live births); paternal age > 55 Diagnosis may be possible by sonography in utero Nose is broad and flat; epicanthal fold; palpebral fissure tends to slant upward; iris of the eyes may have white speck in it (Brushfield spots); tongue may be protruding; back of the head is flat; short neck; extra apd of fat at the base of the head; low-set ears; poor muscle tone;simian crease on palm Cognitively challenged; educable (IQ 50 – 70) to profound MR (IQ
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      

Prone to upper respiratory infections Congenital heart disease (atrioventricular defects) Stenosis/ atresia of the duodenum Strabismus; cataract disorders Acute lymphocytic leukemia Lifespan: 40 – 50 years Should be exposed to educational and play opportunities MARY LOURDES NACEL G. CELESTE, RN, MD

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The Growing Fetus

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Stages of Fetal Development During pregnancy, the fetus undergoes 3 major stages of development: PRE-EMBRYONIC PERIOD – fertilization to week 2 3. EMBRYONIC PERIOD – week 3 – week 8 3. FETAL PERIOD – week 8 to birth 2.

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Stages of Fetal Development  Fertilization

Beginning of pregnancy Union of the ovum and spermatozoon Usually occurs at the outer third of fallopian tube MARY LOURDES NACEL G. CELESTE, RN, MD

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Stages of Fetal Development  Implantation

Contact between growing structure and uterine endometrium Occurs 8-10 days after fertilization MARY LOURDES NACEL G. CELESTE, RN, MD

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Embryonic and Fetal Structures  Decidua  Chorionic

villi

 Placenta

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Embryonic and Fetal Structures  Endocrine

Function

Human Chorionic Gonadotropin Estrogen Progesterone Human Placental Lactogen MARY LOURDES NACEL G. CELESTE, RN, MD

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Embryonic and Fetal Structures  Umbilical

Cord

From fetal membranes Provides circulatory pathway Contains one vein and two arteries

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Embryonic and Fetal Structures  Amniotic

Membranes

Chorionic membrane Amniotic membrane

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Embryonic and Fetal Structures  Amniotic

Fluid

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Fetal System Development  Circulatory  Respiratory  Nervous  Endocrine  Digestive MARY LOURDES NACEL G. CELESTE, RN, MD

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Fetal System Development  Musculoskeletal  Reproductive  Urinary  Integumentary  Immune MARY LOURDES NACEL G. CELESTE, RN, MD

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Estimated Birth Date

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I. PREGNANCY - refers to condition of carrying an offspring within the body. - a form of reproduction that unites the cell of 2 individuals to form a unique new individual who embodies characteristics of both parents II. FERTILIZATION - union of ovum and spermatozoa - union generally occurs in the distal third of the fallopian tube MARY LOURDES NACEL G. CELESTE, RN, MD

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

Cells of the human body develop from chromosomes Normal human cell tissue contains 46 chromosomes-22 pairs of homologous autosomes (any chromosome other than sex chromosome) and one pair of sex chromosomes; one chromosome of each pair of chromosomes is received from the mother and the other one from the father  Sex determination occurs at the moment of conception as a result of the sex chromosome contributed by the male; an X-carrying sperm fertilizing the ovum produces a female (XX), a Ycarrying sperm produces a male (XY)  Aberration in the number of chromosomes result MARY LOURDES NACEL G. CELESTE, RN, MD 425 in abnormal offspring or spontaneous abortion 

Process of fertilization (conception) – only one sperm penetrates ovum  

Usually occurs in the outer third of the fallopian tube Implantation usually occurs in the upper part of the uterus about 7-10 d after fertilization when the developing zygote burrows into the endometrium, which has undergone changes to provide for its nourishment and is now called the deciduas MARY LOURDES NACEL G. CELESTE, RN, MD

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There are three groups of cells in the developing embryo: – Outer layer (ectoderm) – develops into the following structures; hair, nails, sebaceous glands, sweat glands, epithelium of nasal and oral passages -Middle layer (mesoderm) – – develops into the following structures: muscles, bones, sexual structures, heart, kidneys, teeth dentin – Inner layer (endoderm) – develops into the following: epithelium of digestive tract, respiratory tract, bladder MARY LOURDES NACEL G. CELESTE, RN, MD

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

Zygote- fertilized ovum



Cell division: - occurs as the zygote travels the fallopian tube to the uterus.it takes 3 to 4 days of cell division or mitosis for the zygote to become morula( resemble mulberry), this morula entering the uterus is now called a blastocyst

Blastocyst- differentiates into 1. inner mass of embryonic cell which becomes the EMBRYO 2. outer layer called the TROPHOBLAST, which is involved in implantation, hormone secretion, and membrane and MARY placental formation LOURDES NACEL G. CELESTE, RN, MD 428

III. IMPLANTATION - 7 days or 5 days after fertilization, the trophoblast burrows into the endometrium ( upper part of uterus), embedding the fertilized egg into the uterine lining decidua - what the endometrium is called after implantation MARY LOURDES NACEL G. CELESTE, RN, MD

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Formation of twins: 

Fraternal or dizygotic - 2 ova are being fertilized by 2 sperm, they are nonidentical, there are 2 amnion, 2 chorion, 2 placenta MARY LOURDES NACEL G. CELESTE, RN, MD

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Formation of twins: 

Identical or monozygotic twins: - one ovum is fertilized by one sperm and the inner cell mass of the blastocyst splits into 2 to form two embryos - maybe 2 males or 2 females, there are 2 amnion , one chorion and MARYone LOURDES NACEL G. CELESTE, RN, MD placenta

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





Chorion - outer fetal membrane, formed from the trophoblast ( maternal side of placenta) Amnion - originates in the blastocyst during early stages of development, expands as the fetus grows until it slightly adheres to the chorion ( fetal side of placenta) Amniotic sac - formed by 2 fetal membranes (chorion, amnion) MARY LOURDES NACEL G. CELESTE, RN, MD

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IV. AMNIOTIC FLUID - formed by the secretion of: 1. amniotic cells 2. lungs and skin of fetus 3. fetal urine - 98% water, but also contains glucose, protein, sodium, urea, creatinine, lanugo, vernix caseosa - slightly alkaline, replaced approximately every 3 hours - amniotic cells and the fetus urinating and swallowing regulate the secretion and reabsorption of the fluid MARY LOURDES NACEL G. CELESTE, RN, MD

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a. Functions of amniotic fluid:Never stagnant  Serves to protect fetus Shields against pressure  Protects from temperature changes  Protects umbilical cord 

1. equalizes the pressure around the fetus 2. cushion the fetus from external compression 3. provides constant temperature and fluid for the fetus to swallow 4. allows freedom of movement for the MARY LOURDES NACEL G. CELESTE, RN, MD fetus

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yolk sac - cavity in the blastocyst - forms primitive red blood cell until the liver is able to take over the process in about 6 weeks

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V. PLACENTA AND UMBILICAL CORD: placenta- formed by the : 1. chorionic villi at the base of the implanted fertilized ovum and the decidua basalis 2. endometrium at the side of implantation MARY LOURDES NACEL G. CELESTE, RN, MD

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Placenta - membranous vascular organ connecting the fetus to the mother, supplies the fetus with oxygen and food and transports waste product out of fetal system - development is stimulated by progesterone secreted by corpus luteum ( 3rd wk after fertilization) - fully functional by the 12th week MARY LOURDES NACEL G. CELESTE, RN, MD

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2 sides of placenta: 1.maternal side which is irregular and is divided into subdivisions called cotyledons 2. fetal side covered by amnion, so it is smooth and shiny

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Placental Circulation

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umbilical cord - a structure that connects the fetus to the placenta. - has 2 arteries and 1 vein (AVA) - 2 arteries carry deoxygenated blood from the fetus to the placenta - 1 vein carries oxygenated blood to the fetus, along with nutrients, hormones etc MARY LOURDES NACEL G. CELESTE, RN, MD

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Circulatory system of the mother and fetus are separate - maternal blood enters the intervillous spaces of the placenta - fetal blood is in the vessels of chorionic villi

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Function of placenta: 1.Transport: ( substances) a. by diffusion from an area of higher concentration to area of lower concentration ( oxygen, carbon dioxide, electrolytes, fat soluble vitamins, gases and drugs) b. facilitated diffusion uses carrier system to move molecules ( some glucose and oxygen) MARY LOURDES NACEL G. CELESTE, RN, MD

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c. active transport – allows molecules to move from lower concentration to area of higher concentration (amino acids, iron, calcium,iodine and water soluble vitamins) d.Pinocytosis - transfers larger molecules (albumins, globulins, antibodies, viruses) e. osmotic pressure and hydrostatic pressure Insulin, heparin IgM, and blood cell do not move across the placenta unless there is tear MARY LOURDES NACEL G. CELESTE, RN, MD

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2. Endocrine: secretes 5 hormones 1. hCG- basis of pregnancy test 2. human placental lactogen 3.estrogen. 4.progesterone 5.relaxin MARY LOURDES NACEL G. CELESTE, RN, MD

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HCG- secreted by trophoblast, during early pregnancy - prevents involution of corpus luteum, stimulates it to continue producing progesterone and estrogen for 11-12 weeks - 8 to 10 days after fertilization, hCG is present in maternal blood - few days from missed menses, (+) in urine MARY LOURDES NACEL G. CELESTE, RN, MD

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Human placental lactogen - makes sufficient amount of protein, glucose, and minerals - an insulin antagonist (maternal metabolism of glucose) - ensures that the mother’s body is prepared for lactation MARY LOURDES NACEL G. CELESTE, RN, MD

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Estrogen - stimulates development of uterine and breast tissues in the mother - increases vascularity and vasodilation in the villous capillaries

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Progesterone - after 11 weeks of pregnancy, placenta takes over the production of progesterone from the corpus luteum - it is a smooth muscle relaxant, prevents uterine contraction by decreasing its contractility - also maintains the endometrium relaxin - causes changes in collagen MARY LOURDES NACEL G. CELESTE, RN, MD

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3. Metabolic: - produces fatty acid, glycogen and cholesterol for fetal use and hormone production

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FETAL DEVELOPMENT: DIVIDED IN 3 STAGES: 1. PREEMBRYONIC OR GERMINAL STAGE: FIRST 14 DAYS AFTER FERTILIZATION 2.EMBRYONIC STAGE: -FROM THE BEGINNING OF 3RD WK(DAY 15) THROUGH WEEK 8 3. FETAL STAGE: -FROM WEEK 9 UNTIL 38 TO 40 WEEK MARY LOURDES NACEL G. CELESTE, RN, MD 452 FULLTERM

- DEVELOPMENT OCCUR IN SYSTEMATIC MANNER FROM HEAD TO TOE

from proximal to distal and from general to specific - or described in general term of trimester (1st trimester -12 wks, 2nd trimester-13 to 27 weeks, 3rd trimester-28 to 40 weeks) -

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Fetal development: - preembryonic or germinal stage: week 1 and 2 - rapid cell division and differentiation - germinal layers form -embryonic stage: week 3 - primitive nervous system, eyes, ears, rbc present, heart begins to beat day 21

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week 4 - (wt 0.4g, length is 46mm), half the size of a pea, brain differentiates, G.I. tract begins to form, limbs buds appear week 5 - cranial nerves present, muscles have innervation ( L 6-8mm) week 6 - fetal circulation established. liver produces red blood cells, cns forms, primitive kidney forms,lung buds present, cartilage forms, primitive skeleton forms, muscles differentiate MARY LOURDES NACEL G. CELESTE, RN, MD

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week 7 - eyelids form, palate and tongue form stomach formed, diaphragm formed, arms, legs move (L 22-28mm) week 8 - resembles human being, eyes move to face front, heart development complete, hands and feet well formed; bone cell begin replacing cartilage, all body organs have begun forming (wt-2g, L 3cm,) Fetal Stage week 9 - finger and toenails form - eyelids fuse shut MARY LOURDES NACEL G. CELESTE, RN, MD 456 week 10 - head grows slows, islets of

- bladder sac forms, kidneys make urine ( wt-14g,L 5-6cm C – H ) week 11 - tooth buds appear, liver secretes bile urinary system functions, insulin forms in pancreas week 12 - lungs takes shape, palate fuses, heart beat heard with Doppler, ossification established, swallowing reflex present external genitalia, male or female distinguishes week 16 - meconium forms in bowels, scalp hair appears, frequent fetal movement, skin thin and MARY LOURDES NACEL G. CELESTE, RN, MD 457 pink ,sensitive to light, 200 ml

week 20 - myelination of spinal cord begins, peristalsis begin, lanugo covers body vernix caseosa covers body, brown fats deposit begin , swallows and sucks amniotic fluid, heart beat heard by fetoscope, hands can grasp, regular schedule of sucking ,kicking, and sleeping( wt 435 g L 19cm,) week 24 - alveoli present in lungs, begin producing surfactant , eyes completely formed, eyelashes and eyebrow appear, many reflexes appear,(+) chance of survival if MARY LOURDES NACEL G. CELESTE, RN, MD 458 born

WEEK 28 -subcutaneous fat deposits begin, lanugo begin to disappears, nails appear, eyelid open and close testes begin to descend week 32 - more reflexes present, cns direct rhythmic breathing movement, cns partially controls body temperature, begin storing iron, calcium phosphorus, ratio of lungs surfactant lecithin and sphingomyelin is 1.2:2 week 36 - a few creases on soles of feet, skin less wrinkled, fingernail reached fingertips, sleep-wake cycle fairly definite,MARY transfer of 459 LOURDES NACEL G. CELESTE, RN, MD maternal antibodies

-creases cover sole, vernix mainly in folds of skin, ear cartilage firm, less active, limited space, ready to be born System development: -all system in the fetus begun forming by 8th week  cardiovascular system -primitive heart beginning to beat on the 21st day following conception ,the 1st to function in the embryo, congenital malformation develop during the 6th to 8th weeks MARY LOURDES NACEL G. CELESTE, RN, MD

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Fetal Circulation

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Fetal circulation: oxygenated blood(placenta) umbilical vein liver

ductus venosus inferior vena cava right atrium

blood)

foramen ovale( flap opening in the atrial septum that allow only R-L movement of MARY LOURDES NACEL G. CELESTE, RN, MD

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Continuation: left atrium

amount)

left ventricle

aorta supply the body

right ventricles( small

pulmonary arteries ductus arteriosus aorta supply blood to the body

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Continuation: superior vena cava right atrium right ventricle pulmonary arteries ( ductus arteriosus) aorta supply blood to the body MARY LOURDES NACEL G. CELESTE, RN, MD

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Special Structures: Foramen Ovale Connects the left and right atrium Bypassing fetal lungs Obliterated after birth to become fossa ovalis Umbilical Vein Brings oxygenated blood coming from the placenta to the heart and liver Becomes ligamentum teres Umbilical arteries Carry unoxygenated blood from the fetus to placenta Become umbilical ligaments after birth Ductus venosus Carry oxygenated blood from umbilical vein to IVC Bypassing fetal liver Becomes ligamentum venosum after birth Ductus arteriosus Carry oxygenated blood from pulmonary artery to aorta Bypassing fetal lungs Becomes ligamentum arteriosum; closes after birth MARY LOURDES NACEL G. CELESTE, RN, MD

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Hematologic development: - day 14 , primitive blood cells are formed in the yolk sac. - fifth week of gestation before the fetal liver begins hematopoiesis - fetal hemoglobin ( Hgb F ) found only during gestation and early neonatal period, has great attraction for oxygen - blood type is genetically determined at MARY LOURDES NACEL G. CELESTE, RN, MD 466 conception

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Gastrointestinal system: - 4th week of gestation ,G.I.T. begins forming - 20th week fetus begin to swallowing amniotic fluid, but there is no coordination of the swallow and suck reflexes until about 34th week meconium - fecal material stored in the fetal intestine, begin to form about week 16 - if the fetus encounters hypoxic 467 MARY LOURDES NACEL G. CELESTE, RN, MD stress anal sphincter may

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Musculoskeletal system: - limb buds appear late in the 4rt week and development is complete by 8th week - growth by skeleton is determined by genetics and maternal supply of calcium and phosphorous - cartilage is noted about 5th week - ossification begins about 12th week but not completed until after puberty th - end of 12 week skeletal muscles begin468 MARY LOURDES NACEL G. CELESTE, RN, MD involuntary movement( depend on volume

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Genitourinary system: - kidneys begin forming about 3 weeks - 12th week begin to produce hypotonic urine ( all nephron are in the kidney at birth) Reproductive system: - testes seen on abdomen by 7 week, and begin to descend to the scrotum about 30 week MARY LOURDES NACEL CELESTE, RN, MD ovaries develop inG.the abdomen and stay in the pelvic cavity

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Integumentary sytem: - creases form on the palm, fingers, sole, during week 11,permanent design formed by week 17 - lanugo appears during week 20 and slowly dissappear - mammary glands develop during the 6th week Respiratory system: - lung buds forming during 6th week - bronchi forming by week 16 MARY LOURDES NACEL G. CELESTE, RN, MD

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-surfactant production begins between 20-24 - primitive lung formed by week 23 - surfactant production matures between week 35 and 37 Immunologic system: - between12-15th week immune capability begins to develop - fetus produces small amount of immunoglobulin IgA, IgG, and IgE MARY LOURDES NACEL G. CELESTE, RN, MD

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Assessment of Fetal Growth

Estimating fetal growth McDonald’s Rule – determining during midpregnancy, that the fetus is growing in utero by measuring the fundal (uterine) height - typically, the distance from the fundus to the symphysis in centimeters is equal to the week of gestation between the 20th and 31st weeks of pregnancy 

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Measure from the notch of the symphysis pubis to over the top of the uterine fundus as the woman lies supine  inaccurate during the 3rd trimester  Typical measurements - Over the symphysis pubis: 12 weeks - At the umbilicus: 20 wks - At the xiphoid process: 36 wks  Rises about 1cm per MARY LOURDES NACEL G. CELESTE, RN, MD week; after which it 473 

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Assessment of Fetal Growth

Assessing fetal well-being Fetal movement Fetal heart rate Ultrasound Nonstress Test Electrocardiograp hy MRI Amnioscopy Fetoscopy

Maternal serum alpha-fetoprotein Triple screening (AFP, estriol and hCG) Chorionic villi sampling Amniocentesis Percutaneous umbilical blood sampling

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Fetal movement 

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Fetal movement that can be felt by the mother : QUICKENING begins at approximately 18 – 20 weeks of pregnancy;peaks at 28-38 weeks Primigravid- quickening:20 weeks Multigravid- 16 weeks Ask the mother to observe fetal movement. A healthy fetus moves at least 10x a day. MARY LOURDES NACEL G. CELESTE, RN, MD

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Sandovsky method - mother is in a left lateral recumbent position; fetus normally moves a minimum of twice every 10 minutes or an average of 10 -12x an hour

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Cardiff method – Count to ten - records the time it takes for her to feel 10 fetal movements; usually within 60 minutes MARY LOURDES NACEL G. CELESTE, RN, MD

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Fetal heart rate 

FHR should be 120160 beats per minute

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Can be heard with a Doppler : 10 – 11th week of pregnancy

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Fetoscope: 18-20 weeks

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ANTENATAL FETAL TESTING

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Ultrasound

Response of sound waves against objects  Allows visualization of the uterine content  Transabdominal UTZ - full bladder - client lies on her back  Transvaginal UTZ - probe is inserted in the vagina - lithotomy position - RN, empty bladder 480 MARY LOURDES NACEL G. CELESTE, MD 

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Diagnose pregnancy as early as 6 weeks Confirm the presence, size and location of the placenta and amniotic fluid Establish that the fetus is growing and has no gross defects (eg, hydrocephalus, anencephaly, spinal cord, heart, kidney and bladder defects) Establish the presentation and position of the fetus (sex can be diagnosed) Predict maturity by measurement of the biparietal diameter (BPD) discover complications of pregnancy / fetal anomalies MARY LOURDES NACEL G. CELESTE, RN, MD

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Estimation of Fetal Age  Gestational sac – 5 – 6 weeks  Crown rump length – 7 – 14 weeks  Femoral length – 12 – 22 weeks  Biparietal Diameter 17 -26 weeks MARY LOURDES NACEL G. CELESTE, RN, MD

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Biophysical profile (BPS) 

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Assesses 4 to 6 parameters (fetal breathing movement, fetal movement, fetal tone, amniotic fluid volume, placental grading, and fetal heart reactivity/ reactive NST) Each item has a potential for scoring a 2; 12 highest possible score BPS 8 – 10: fetus is doing well BPS 4 – 6: fetus is in jeopardy MARY LOURDES NACEL G. CELESTE, RN, MD

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Nonstress Test 

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Measures the response of fetal heart rate to fetal movement Determines fetal wellbeing Performed to assess placental function and oxygenation MARY LOURDES NACEL G. CELESTE, RN, MD

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An external ultrasound transducer and the tocodynamometer are applied to the mother and a tracing of at least 20 minutes’ duration is obtained so that the FHR and the uterine activity can be observed. Obtain baseline blood pressure and monitor blood pressure frequently. Position mother in semi-fowler’s or sidelying position or left lateral position to avoid vena cava compression. The mother may be asked to press a button every time she feels fetal movement; the monitor records a mark at each point of fetal movement, which is used as a reference point to assess FHR response. MARY LOURDES NACEL G. CELESTE, RN, MD

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RESULTS OF NST:  REACTIVE NONSTRESS TEST:Normal/Negative - indicates a healthy fetus - requires 2 or more FHR accelerations of at least 15 beats per minute, lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period. 

NONREACTIVE NONSTRESS TEST: Abnormal -No accelerations or accelerations of less than 15 bpm or lasting than 15 seconds in duration occur in a 40 minute observation.

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UNSATISFACTORY – The result cannot be interpreted because of the poor quality of the FHR tracing. MARY LOURDES NACEL G. CELESTE, RN, MD

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Contraction Stress Test 

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Assesses placental oxygenation and function Determines fetal ability to tolerate labor and determines fetal well-being Fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. MARY LOURDES NACEL G. CELESTE, RN, MD

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External fetal monitor is applied to the mother, and a 20 to 30 minute baseline strip is recorded. The uterus is stimulated to contract by the administration of a dilute dose of oxytocin or by having the mother use nipple stimulation until 3 palpable contractions with a duration of 40 seconds or more in a 10 minute period have been achieved. Frequent maternal BP readings are done, and the mother is monitored closely while increasing doses of MARY LOURDES NACEL G. CELESTE, RN, MD

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RESULTS OF CST:  NEGATIVE CST/ NORMAL - no late or variable decelerations of FHR 

POSITIVE CST/ ABNORMAL - late or variable decelerations of FHR with 50% or more of the contractions in the absence of hyperstimulation of the uterus.

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EQUIVOCAL – with decelerations but with less than 50% of the contractions, or the uterine activity shows a hyperstimulated uterus.

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UNSATISFACTORY – adequate uterine contractions cannot be achieved, or the FHR tracing is not of sufficient quality for adequate interpretation. MARY LOURDES NACEL G. CELESTE, RN, MD

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5. Amniocentesis – amniotic fluid is aspirated by a needle inserted through the abdominal and uterine walls; indicated early in pregnancy (14-17 wk) to detect inborn errors of metabolism, chromosomal abnormalities, open NTD (neural tube defect); determine sex of fetus and sex-linked disorders after 28 wk; determine lung maturity 

Indicated for pregnant women 35 years and older; couples who already have had a child with a genetic disorder; one or both parents affected with a genetic disorder; mothers who are carriers for X-linked disorders MARY LOURDES NACEL G. CELESTE, RN, MD

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Prior to the procedure, the patient’s bladder should be emptied; ultrasonography (x-ray only if necessary) is used to avoid trauma from the needle

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Post procedure, monitor for signs and symptoms of hemorrhage, labor, premature separation of placenta, fetal distress, amniotic fluid embolism, infection, inadvertent injury to maternal intestines/bladder or fetus; RhoGam is indicated for MARY Rh-LOURDES mothers NACEL G. CELESTE, RN, MD 492

6. Chorionic villus sampling (CVS) – transcervical aspiration of chorionic villi that allows for first trimester (8-12 wk) diagnosing of genetic disorders comparable to amniocentesis (except for NTD); preprocedure: there should be full bladder; ultrasound is used as in amniocentesis; post procedure: precautions as for amniocentesis MARY LOURDES NACEL G. CELESTE, RN, MD

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7. Estriol levels – serial 24-h maternal urine samples or serum specimens to determine fetoplacental status; falling levels usually indicate deterioration MARY LOURDES NACEL G. CELESTE, RN, MD

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8. Percutaneous umbilical blood sampling (PUBS) – second- and third-trimester method to aspirate cord blood (location identified by ultrasound) to test for genetic conditions, chromosomal abnormalities, fetal infections, hemolytic or hematological disorders MARY LOURDES NACEL G. CELESTE, RN, MD

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9. Lecithin/ Sphingomyelin ratio (2:1) – important components of surfactant, a phosphoprotein that lowers surface tension of the lungs that facilitates extrauterine expiration MARY LOURDES NACEL G. CELESTE, RN, MD

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Psychological and Physiologic Changes of Pregnancy

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Diagnosis of Pregnancy Presumptive signs of pregnancy (subjective) – experienced        

by the woman; (+) suspicion of pregnancy, not proof, could easily indicate other conditions Amenorrhea Nausea/ vomiting Breast sensitivity and increased size/fullness Fatigue Quickening (maternal perception of fetal movement occurring between 16-20 weeks Abdominal (uterine) enlargement Skin pigmentation changes (melasma, chloasma, linea nigra, striae gravidarum) MARY LOURDES NACEL G. CELESTE, RN, MD 499 Frequent urination

Probable signs of pregnancy – objective, can be

documented by examiner; increased suspicion of pregnancy but still not the true Laboratory diagnostic  Serum testsproof (hCG)     

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Home pregnancy tests Chadwick’s sign (color change of the vagina from pink to violet)* - presumptive in some references Goodell’s sign - softening of the cervix Hegar’s sign - Softening of the lower uterine segment Ballotement -when LUS is tapped on a bimanual exam, fetus can be felt to rise against abdominal wall or rebound caused by the fetus floating away and returning back to its previous position Fetal outline or contour palpated by examiner Braxton hicks sign -periodic uterine tightening/ contractions occurs; painless palpable contractions occurring irregular interval and felt by the mother as sensation of tightness over her abdomen Sonographic evidence of gestational sac MARY LOURDES NACEL G. CELESTE, RN, MD 500 Uterine soufflé – a muffed swishing sound over the

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Pregnancy test - HCG (human chorionic gonadotropin) - Immunologic test that can detect HCG in woman’s urine by 2 wk after missed period; cannot measure the amount of HCG; false readings may occur inappropriate timing, handling error, or some medications MARY LOURDES NACEL G. CELESTE, RN, MD

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Positive signs of pregnancy - definite signs of pregnancy; not subjective data

Fetal heart separate from the mother’s (Doppler, auscultation) Fetal movements felt by examiner Visualization of fetus: fetal outline can be seen and measured by sonogram MARY LOURDES NACEL G. CELESTE, RN, MD

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Psychological Tasks Emotional responses  Ambivalence  Grief  Narcissism  Introversion vs extroversion  Body image and boundary  Stress  Couvade syndrome – men experience physical symptoms  Emotional lability  Changes in sexual desire  Changes in the expectant family

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MATERNAL ADAPTATIONS IN PREGNANCY A.Anatomical Uterus •changes in size, structure, and position to become a thin-walled, muscular abdominal organ capable of containing the fetus, placenta, and amniotic fluid •In the early months of pregnancy, growth is partly due to formation of new muscle fibers and enlargement of preexisting muscle fibers •After the first trimester, the increase in size is partly mechanical due to the pressure of the developing fetus •The full-term pregnant uterus and its MARY LOURDES NACEL G. CELESTE, RN, MD contents weigh about 12 lb

504

Location of the fundus: 12 weeks  at the level of the symphysis pubis 16 weekshalfway between symphysis pubis and umbilicus 20weeks  at the level of the umbilicus 24 weeks  two fingers above umbilicus 30 weeks  midway between umbilicus and xiphoid process 36 weeks  at the level of xiphoid process 40 weeks  two fingers below umbilicus, drops at 34 weeks level because of lightening MARY LOURDES NACEL G. CELESTE, RN, MD

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FUNDIC HEIGHT AT VARIOUS AGES OF GESTATION

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Contractility:  Being muscular, the uterus is a highly contractile organ.  Beginning on the first trimester, the uterus undergoes irregular contractions.  Late in pregnancy, these contractions, known as Braxton-Hicks, become more intense and frequent causing some discomfort on the pregnant woman.  It is the cause of false labor. MARY LOURDES NACEL G. CELESTE, RN, MD

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Cervix undergoes increased blood supply, edema, and hyperplasia of the cervical glands contributing to: – Softening (Goodell’s sign) about 6 wk – Increased friability (bleeds easily after Pap smear and intercourse) – Distention of cervical mucosa glands with mucus, creating a tenacious “mucous plug” that seals the endocervical canal and inhibiting the ascent of bacteria and other substances into the uterus MARY LOURDES NACEL G. CELESTE, RN, MD

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Vagina and external genital organs enlarge, soften, thicken, and develop blueviolet hue as a result of increased vasculature Vaginal secretions become alkaline, causing an increased risk of vaginitis Connective tissue loosens in preparation for labor and delivery A blue-violet color (Chadwick’s sign) about 6-8 wk MARY LOURDES NACEL G. CELESTE, RN, MD

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Isthmus During pregnancy, the isthmus softens and elongates up to 25 mm. It will later form the lower uterine segment, together with the cervix Hegar’s sign  softening of the lower uterine segment begins as early as 5 weeks gestation Ovaries No Graafian follicles develop and no ovulation occurs during pregnancy Corpus luteum of pregnancy  the corpus luteum is the chief source of hormone progesterone during the first 12 weeks of gestation. The corpus luteum also produces estrogen, relaxin, inhibin and sometimes MARY LOURDES NACEL G. CELESTE, RN, MD 510 oxytocin

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Breasts enlarge early in pregnancy, causing progressive feelings of heaviness, fullness, and tenderness; the nipple and areola become larger, darker in color; blood vessels enlarge and become prominent beneath the skin MARY LOURDES NACEL G. CELESTE, RN, MD

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Body mass changes with weight gain; total desirable weight gain in pregnancy (for average woman) is about 23-28 lb (11-13 kg); 3-4 lb (1.36-1.81 kg) during the first trimester, followed by an average of slightly less than one pound per week for the rest of the pregnancy 1st trimester: 3-4 lbs 2nd trimester: 12-14 lbs 3rd trimester: 8-12 lbs

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Skin Pink or reddish streaks (striae gravidarum) may occur on breasts, abdomen, buttocks, and/or thighs as a result of fat deposits, which cause stretching of the skin Increased pigmentation can occur on the face as blotchy brown areas on the forehead an cheeks (chloasma or “mask of pregnancy”) and on the abdomen as dark line from the symphysis pubis (linea nigra) Minute vascular spiders may occur The umbilicus is pushed outward, and by about the seventh month its depression disappears and becomes a darkened area on the abdominal wall Sweat and sebaceous glands are more active MARY LOURDES NACEL G. CELESTE, RN, MD

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Musculoskeletal Change in the center of gravity, decreased muscle tone, and increased weight-bearing cause in accelerated lumbosacral curve, which may lead to lower back pain and difficulty with locomotion Progesterone – produced relaxation and increased mobility of the pelvic joints may cause discomfort and difficulty in walking The vertical abdominal muscles may separate (diastasis recti) MARY LOURDES NACEL G. CELESTE, RN, MD

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B.Physiological   

Hormonal Placental Estrogen – enlargement of uterus, breasts, genitals; growth of glandular tissue, ducts, alveoli, and nipples of breasts; fat deposition; increased elasticity of connective tissue; altered thyroid function; altered nutrient metabolism; sodium and water retention by kidneys; hypercoagulability of blood; vascular changes MARY LOURDES NACEL G. CELESTE, RN, MD

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Progesterone – development of decidua; decreased contractility of the uterus; decreased gastric motility (sphincters relaxed); increased sensitivity to CO2 in respiratory center; decreased tone of smooth muscle; development of secretory portions of lobular-alveolar system in breasts; sodium excretion MARY LOURDES NACEL G. CELESTE, RN, MD

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Human chorionic somatomammotropin and human placental lactogen; anabolic effect; insulin antagonist

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Pituitary gland Anterior lobe secretes prolactin hormone after delivery of the placenta Posterior lobe secretes oxytocin during labor and lactation

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Blood total blood volume in body increases during pregnancy by about 30%; normal blood pressure is maintained by peripheral vasodilatation RBC production increases; WBC count increases; clotting factors increase while fibrolytic activity decreases Hemoglobin and hematocrit levels decrease slightly in response to hemodilution (increased plasma content); hemoglobin <10 g/dL or hematocrit <35% may indicate MARY LOURDES NACEL G. CELESTE, RN, MD

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The increased blood volume creates the need for the heart to pump more blood through the aorta (about 50% more blood per minute) resulting increased heart rate; occasional palpitations (possibly due to sympathetic nervous imbalance in the early months of pregnancy or to intraabdominal pressure of the enlarged uterus toward the end of the pregnancy) MARY LOURDES NACEL G. CELESTE, RN, MD

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Respiration in the later months of pregnancy, the enlarged uterus causes the diaphragm to be displaced upward, putting pressure on the lungs and causing shortness of breath MARY LOURDES NACEL G. CELESTE, RN, MD

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Digestion Nausea and vomiting may occur in the first trimester; vomiting that is excessive or persists beyond this time (hyperemesis gravidarum) may require medical management; appetite usually improves as pregnancy advances Progesterone – induced relaxation of smooth muscle tone, reduction in total acidity of gastric juices, and pressure from the growing uterus may cause heartburn, flatulence, and constipation MARY LOURDES NACEL G. CELESTE, RN, MD

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Aversion or cravings for certain foods or unusual substances (e.g., pica) may occur Carbohydrate metabolism is profoundly affected to meet growth and development needs of fetus and the metabolic needs of mother to support tissue expansion MARY LOURDES NACEL G. CELESTE, RN, MD

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The first half of pregnancy -Maternal glucose is moved across the placenta by active transport; causing maternal glucose levels to fall slightly; her pancreas responds by decreasing production of insulin -Maternal insulin does not cross the placenta -By 8 wk the fetus’s own insulin production is consistent with the amount of glucose received from the mother MARY LOURDES NACEL G. CELESTE, RN, MD

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The second half of pregnancy – the placental hormones impede the mother’s ability to utilize insulin; the resulting demand for added insulin can be met by a normally functioning pancreas

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Urinary system Urinary output is increased and has a low specific gravity; possible tendency to excrete glucose; reabsorption of sodium and decreased water output (latter half of pregnancy) is a compensatory mechanism to maintain increased blood volume Ureters become dilated (especially the right ureter) due to the pressure of the enlarged uterus; the dilated ureters are unable to propel urine as efficiently, resulting in stasis of urine and possible urinary tract infection Bladder – urinary frequency may occur early in pregnancy and later again when “lightening” occurs as a result of increased pressure on the bladder from the enlarged uterus MARY LOURDES NACEL G. CELESTE, RN, MD 527

C. Psychological 



First trimester –ACCEPTING THE PREGNANCY - maternal ambivalence, even in planned pregnancy, is usual; there may be some anticipation and concern related to fears and fantasies about the pregnancy

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  

Second trimester ACCEPTING THE BABY -usually increased maternal feelings of physical and emotional well-being; mother is often described as self-absorbed and introverted MARY LOURDES NACEL G. CELESTE, RN, MD

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



Third trimester –PREPARING FOR PARENTHOOD - possible new fears related to labor and delivery and fantasies about the appearance of the baby; feelings of awkwardness, clumsiness, and decreased femininity related to changes in body image MARY LOURDES NACEL G. CELESTE, RN, MD

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



Paternal reactions – may parallel those of mother; some may experience physical symptoms of pregnancy (couvades syndrome) Adaptation of siblings – age and experience related MARY LOURDES NACEL G. CELESTE, RN, MD

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Assessing Fetal and Maternal Health: Prenatal Care Mary Lourdes Nacel G.

Health Promotion During Pregnancy  Preconceptual

visit

Health history Pelvic exam Pap test Labs

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Health Promotion During Pregnancy 

Choosing a health care provider Provides care throughout pregnancy and birth Initiate prenatal care early Nurse’s role  Educate  Listen  Counsel

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PRENATAL ASSESSMENT A. 



VERIFYING PREGNANCY Signs and Symptoms Presumptive Probable Positive Pregnancy Test

B. Estimated Date of Delivery/ Confinement EDD/ EDC Measure Fundic Height MARY LOURDES NACEL G. CELESTE, RN, MD

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C. Health Assessment  Initial

interview Health history  Demographic

data  Chief concern  Family profile  History of past illnesses

 History

of family illness  Gynecologic history  Obstetric history  Review of systems

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Health Assessment  Initial

interview Support person’s role Physical exam  Baseline

height/weight, vital signs  Assessment of systems

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History 

1. Initial visit

a. Obstetrical history (TPAL) 







Gravida – the total number of pregnancies regardless of duration (includes present pregnancy) Nulligravida – a woman who has never been pregnant Primigravida – a woman who is pregnant for the first time Multigravida – a woman who has two or more MARY LOURDES NACEL G. CELESTE, RN, MD 541 pregnancy



  

Para – number of past pregnancies that have gone beyond the period of viability (capability of the fetus to survive the outside of the uterus; currently considered any time after 20-wk gestation), regardless of the number of fetuses or whether the infant was born alive or dead Nullipara – a woman who has never delivered a fetus that reached the age of viability Primipara – a woman who has completed one pregnancy to viability Multipara – a woman who has completed two or more pregnancy to the age of viability MARY LOURDES NACEL G. CELESTE, RN, MD

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









Term infant – an infant born between 38 and 42 weeks of gestation Preterm – an infant born before 38 weeks Post term – an infant born after 42 weeks Abortion – pregnancy that terminates before the period of viability (20 wks) Live birth – a live birth is recorded when an infant born shows sign of life MARY LOURDES NACEL G. CELESTE, RN, MD

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





 

Low birth weight – < 2500 grams Normal Birth weight – 2500 – 4000 grams Large birth weight - > 4000 grams Parturient – a woman in labor Puerpera – a woman who just delivered (within six weeks after delivery) MARY LOURDES NACEL G. CELESTE, RN, MD

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Health factors that may influence course of pregnancy – Past/concurrent illnesses, surgeries, medications (possible teratogens) – Reproductive factors, e.g., menstrual pattern of problems, contraception, infections – Personal, social, cultural, marital, sexual, environmental, educational, past and present occupational, drugs (including alcohol), cigarette smoking, caffeine (coffee, tea, colas), exercise factors – Nutritional – prepregnancy weight (may indicate long-term malnutrition and depleted nutrient stores), recent weight gain or lossMARY(may denote at-risk situation),545 LOURDES NACEL G. CELESTE, RN, MD adequacy of diet, vitamin supplements

2. Interim History  Frequency, intensity, and management of discomforts of pregnancy  Abnormal signs and symptoms or risk factors  Changes in emotional, financial, marital status MARY LOURDES NACEL G. CELESTE, RN, MD

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D. Physical assessment 1. Initial visit – complete physical exam 



Breast exam – nipple formation using “pinch test” in which the areola is pinched gently and pushed in with the examiner’s thumb and forefinger; an everted or normal nipple protrude, an inverted nipple will look flat or turned inward, indicating potential difficulty with breastfeeding Pelvic exam – Pap smear; culture for gonorrhea and herpes if appropriate; smear for chlamydia; bimanual (palpation of reproductive organs between abdominal and vaginal hands) to establish uterine size, consistency, and contour; pelvic measurements MARY LOURDES NACEL G. CELESTE, RN, MD

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Routine visits  every 4 weeks until 32 weeks  then every 2 weeks until 36 weeks  weekly until delivery - to monitor vital signs, weight, fetal heart tones, fundal height and outline MARY LOURDES NACEL G. CELESTE, RN, MD

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Laboratory screening 

 

   

Initially and at routine visits, urine dipstick for glucose, protein (pregnancy induced hypertension and UTI), CBC, rubella IgG antibody Repeat GC culture late third trimester (more often if indicated) Maternal serum alpha-fetoprotein (AFP) at 16-18 wk to identify risk of neural tube defect in fetus Glucose screening between 24-28 wk to detect gestational diabetes Repeat CBC at 24 –28 wk Rh antibody titers for Rh woman at 24, 28, 549 32, and 40 wkMARY LOURDES NACEL G. CELESTE, RN, MD ultrasound

Assessment of systems  General appearance and mental status  Head and scalp  Eyes  Nose  Ears  Sinuses  Mouth, teeth and throat

 Neck  Lymph nodes  Heart  Lungs  Back  Rectum  Extremities and skin

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Health Assessment  

Fundal height and fetal heart sounds Pelvic exam External genitalia Internal genitalia  Pap smear  Vaginal inspection  Exam of pelvic organs  Rectovaginal exam

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THE APPEARANCE OF THE CERVIX

1. NULLIGRAVID

2. AFTER CHILDBIRTH

3. AFTER MILD CERVICALTEARING (Stellate)

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Health Assessment  Estimating

pelvic size

Type Measurements  Diagonal

conjugate  True conjugate or conjugate vera  Ischial tuberosity diameter MARY LOURDES NACEL G. CELESTE, RN, MD

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Passage

(maternal) – size and type of pelvis, ability of the cervix to efface and dilate, and distensibility of vagina and introitus 

Pelvis – the bony ring through which the fetus passes during labor and delivery; consists of four united bones (two hip or innominate bones, the sacrum, and the coccyx) between the trunk and thighs



Measurements – may be obtained by internal and external pelvic examination (using pelvimeter), x-ray pelvimetry (used rarely in pregnancy and only late in third trimester or in labor), and ultrasound MARY LOURDES NACEL G. CELESTE, RN, MD

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Pelvic types:   





a. Gynecoid – classic female pelvis inlet, well rounded (oval); ideal for delivery - most ideal for childbirth (50% of women) b. Android – resembling a male pelvis, narrow and heart-shaped; usually requires cesarean section or difficult forceps delivery (20% of women) c. Platypelloid – flat, broad pelvis; usually not adequate for vaginal delivery (5% of women) d. Anthropoid – similar to pelvis of anthropoid ape; long, deep, and narrow; MARY LOURDES NACEL G. CELESTE, RN, MD 556 usually adequate for vaginal delivery (25% of

TYPES OF PELVIS

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

PELVIS: provides protection to the organs found within the pelvic cavity  provides attachment to muscles, fascia and ligaments  supports the uterus during pregnancy  serves as birth canal 

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Division of the pelvis: b. False  upper flaring portion of the ilia  provides support to the uterus during pregnancy  to direct the fetus to the true pelvis during labor b. True forms the passageway of the fetus during labor MARY LOURDES NACEL G. CELESTE, RN, MD

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  

Consists of the following parts: 1. Inlet/ pelvic brim – entrance to true pelvis AP diameters: – Diagonal Conjugate = 12.5 cm – Obstetric Conjugate = 11 cm (Substract 1-1.5cm from diagonal conjugate) – True Conjugate/ Conjugate Vera = 11.5 cm (or 10.5 – 11cm) (Substract 1-1.5 cm (or 1.2-2cm) from diagonal conjugate)

 

Transverse diameter = 13.5 cm Right and left oblique diameter = 12.75 cm MARY LOURDES NACEL G. CELESTE, RN, MD

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DIAGONAL CONJUGATE 

 



The distance between (the anterior surface of) the sacral promontory of the sacrum and (the anerior surface of the inferior margin of) the symphysis pubis Measured clinically Most useful measurement for estimating the pelvic size (AP diameter of pelvic inlet) >12.5 cm adequate for birth MARY LOURDES NACEL G. CELESTE, RN, MD

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Measurement of Diagonal Conjugate

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Obstetric conjugate 





Shortest anteroposterior diameter between the sacral promontory and the symphysis pubis Can only be measured radiographically Normal > 10 cm

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

2. Pelvic canal - situated between inlet and outlet -Interspinous (smallest diameter of pelvic)= 10 cm -AP diameter at level of ischial spines = 11.5 cm -Posterior sagittal diameter = 4.5 cm

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

3. Outlet –most important diameter of the outlet is its transverse diameter or Bi-ischial diameter =11.5 cm



AP diameter = 9.5 to 11.5 cm Posterior sagittal diameter = 7.5 cm



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LEOPOLD’S MANEUVER 







systematic method of observation and palpation to determine fetal position -woman empties her bladder; lies supine with her knees flexed slightly -examiner warms hands to avoid contraction of abdominal muscles -gentle but firm touch MARY LOURDES NACEL G. CELESTE, RN, MD

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LEOPOLDS MANEUVER  





First Maneuver Palpation of the Uterine Fundus Will usually indicate the fetal part situated in the fundus; usually a fetal head; infrequently a fetal breech. Place hands on either side of the fundal area so that the fingers of both hands almost touch each other (face the woman's head). A somewhat hard and roundish shape, which when moved back and forth between the finger pads, also moves the entire fetus usually indicates a fetal breech. Press gently and firmly with finger pads. A very hard round well-defined shape that can be moved back and forth (balloted) usually indicates a fetal head. MARY LOURDES NACEL G. CELESTE, RN, MD

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First Maneuver

Palpation of the Uterine Fundus

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Second Maneuver Determines small parts and back of fetus along the sides of maternal abdomen     

Lateral Palpation of the Uterus Examiner faces woman's head Palpate with one hand on each side of abdomen Palpate fetus between two hands Assess on which side is the fetal back or spine and which side has small parts or extremities

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



Generally provides information regarding the location of the fetal back and the fetal small parts consisting of arms and legs. Hands should alternately apply pressure against the opposite hand. Directing alternating pressure against each hand is the technique. Alternating hands using firm resistance while the other hand gently and firmly applies pressure and rotates in a circular fashion. This technique can be used up and down the entire length of the uterus. MARY LOURDES NACEL G. CELESTE, RN, MD

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Second Maneuver Determines small parts and back of fetus along the sides of maternal abdomen

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Third Maneuver (Lower uterine segment or uterine pole)    

Face the woman's head and spread your hands widely apart. Grasp the uterine contents just above the symphysis pubis (firmly but gently). Hold presenting part between index finger and thumb. Assess for cephalic versus Breech Presentation Move the fetal presenting part gently back and forth in your hand Fetal head will shift more easily back and forth Fetal breech will move the whole body.

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



The 3rd Leopold's Maneuver (Pawlick's grip) will provide either initial information or confirm prior data gained from the previous steps of Leopold's maneuvers. Anchoring the uterine fundus with the non-dominant hand assist in identifying the location of the fetal back and small parts. MARY LOURDES NACEL G. CELESTE, RN, MD

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Third Maneuver (Lower uterine segment or uterine pole)

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Fourth Maneuver (pelvic palpation of the uterus - assess the presenting part) 

 



Provides information about the presenting part: breech or head, attitude (flexion or extension), and station (level of descent of the presenting part). Examiner faces woman's feet . Place hands on either side of the lower abdomen with finger pads at the lower uterine pole (bikini line) and thumbs directed toward the umbilicus. Carefully move fingers of each hand towards each other in a downward and inward manner using gentle pressure. MARY LOURDES NACEL G. CELESTE, RN, MD

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 

The nurse's thumbs should point towards the woman's umbilicus. If there is a head palpated in the pelvis, the fetal presentation is referred to as a cephalic or vertex presentation. Assess if a prominence on one side of the abdomen can be palpated higher than a prominence on the other side.  The first prominence felt indicates the sinciput (forehead) of the infant and is on the same side as the fetal small parts.  Therefore, the sinciput is on the side opposite the fetal back.  The prominence felt further down the pelvis is the fetal occiput back of the head) and is on the same MARY LOURDES NACEL G. CELESTE, RN, MD 580 side as the fetal back.

Fourth Maneuver (pelvic palpation of the uterus - assess the presenting part)

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LEOPOLD’S MANEUVER 1st What is at the uterine fundus? MANEUVER Head is more firm, hard and round that moves independently of the body. Breech is less well defined that moves only in conjunction with the body. nd 2 Where is the fetal back? MANEUVER Fetal back is smooth, hard, resistant surface. Knees and elbows of fetus feel with a number of angular nodulation. rd 3 What is at the inlet of the pelvis? MANEVER By grasping the lower portion of the abdomen (just above the symphisis pubis. Not engaged (not firmly settled in the pelvis) if the presenting part moves upward so an examiner’s hands can be pressed together. th 4 What is the fetal attitude? (degree of flexion) MANEUVER Fingers on both sides of the uterus (2 inches above inguinal ligaments) pressing down and inwards. The fingers of the hand that do not meet obstruction above the ligament palpates the fetal brow. Good attitude if brow corresponds to the side (2nd maneuver) that contained the elbows and knees. Poor attitude if examining fingers will meet an obstruction on the same side as fetal back (hyperextended head). Also palpates infant’s anteroposterior position. If brow is very MARY LOURDES NACEL G. CELESTE, RN, MD easily palpated, fetus is at posterior position (occiput pointing towards woman’s back).

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