Maternal & Child Nursing Care Reproductive Anatomy andPhysiology CRISTINA MARIE M. MANZANO RN, RM, MAN
Learning Objectives Identify the structures and functions of the female and male reproductive systems. Summarize the actions of the hormones that affect reproductive functioning. Identify the two phases of the ovarian cycle and the changes that occur in each phase.
Describe the phases of the menstrual cycle, their dominant hormones, and the changes that occur in each phase. Discuss the significance of specific female reproductive structures during childbirth. Identify the functions of specific male reproductive structures for reproduction.
FIGURE 3–1 Sexual differentiation. A, At 7 weeks’ gestation, male and female genitalia are identical(undifferentiated). B and C, By 12 weeks’ gestation, noticeable differentiation begins to occur.D and E, Differentiation continues until birth but is almost complete at term.
FIGURE 3–2 Physiologic changes leading to onset of puberty. A, In females, and B, in males. Solid lines illustrate stimulation of hormone production, and broken lines illustrate inhibition. Through a neurotransmitter the central nervous system stimulates the hypothalamus, which in turn produces a gonadotropin-releasing factor that causes the anterior pituitary to produce gonadotropins (FSH or LH). These hormones stimulate specific structures in the gonads to secrete steroid hormones (estrogen, progesterone, or testosterone). The rise in pituitary hormone increases hypothalamus activity. Elevated steroid hormone levels stimulate the central nervous system and pituitary gland to inhibit hormone production.
Female Reproductive System External genitalia/vulva Mons pubis Labia majora Labia minora Clitoris Urethral meatus and opening of the paraurethral glands Vaginal vestibule Breasts: Accessories of the reproductive system
Schematic representation of a mature spermatozoon
Hormones Female Hormones Estrogen Progesterone Prostaglandin Male Hormones Testosterone is the most important sex hormone
Estrogen Controls development of female secondary sex characteristics Assists in the maturation of the ovarian follicles Causes endometrial mucosa to proliferate following menstruation Causes uterus to increase in size and weight
Female reproductive cycle: interrelationships of hormones with the four phases of the uterine cycle and the two phases of the ovarian cycle in an ideal 28-day cycle
Estrogen Increases myometrial contractility in both the uterus and fallopian tubes Increases uterine sensitivity to oxytocin Inhibits FSH production Stimulates LH production
Progesterone Decreases uterine motility and contractility Facilitates vaginal epithelium proliferation Secretion of thick viscous cervical mucus Increases breast glandular tissue in preparation for breast feeding
Prostaglandin Prostaglandin: Increases during follicular maturation Causes extrusion of the ovum
FIGURE 3–16 Various stages of development of the ovarian follicles.
Follicular Phase Hypothalamus secretes gonadotropin-releasing hormone (GnRH) GnRH stimulates the anterior pituitary gland to secrete the gonadotropic hormones, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) FSH is primarily responsible for the maturation of the ovarian follicle
Follicular Phase (cont’d) As the follicle matures, it secretes increasing amounts of estrogen Final maturation facilitated by LH The follicular phase ends with ovulation
Luteal Phase Release of ovum LH: Corpus luteum develops from ruptured follicle Secretion of progesterone increases Fertilized ovum able to implant into endometrium Secretion of human chorionic gonadotropin (hCG) Absence of fertilization Corpus luteum degenerates Decrease in estrogen and progesterone Increase in LH and FSH
Menstrual Phase Shedding of the endometrial lining Low estrogen levels
Proliferative Phase Enlargement of the endometrial glands Changes in cervical mucus Increasing estrogen levels
Secretory Phase Follows ovulation Influenced primarily by progesterone Increase in vascularity of the uterus Increase in myometrial glandular secretions
Ischemic Phase If fertilization does not occur, the ischemic phase begins The corpus luteum begins to degenerate Both estrogen and progesterone levels fall Escape of blood into the stromal cells of the endometrium
A FIGURE 3–12 Female pelvis. A, The false pelvis is a shallow cavity above the inlet; the true pelvis is adeeper portion of the cavity below the inlet.
B FIGURE 3–12 (continued) Female pelvis. A, The false pelvis is a shallow cavity above the inlet; the true pelvis is adeeper portion of the cavity below the inlet. B, The true pelvis consists of the inlet, cavity(midpelvis), and outlet.
Division of the Pelvis False pelvis Part above the pelvic brim Serves to support the weight of the enlarged pregnant uterus Directs the presenting fetal part into the true pelvis Inlet: upper border of pelvis Pelvic cavity: Curved canal with a longer posterior than anterior wall Outlet: Pelvic outlet is at the lower border of the true pelvis
FIGURE 3–13 Pelvic planes: coronal section and diameters of the bony pelvis.
Male Reproductive Structures Penis Scrotum Testes; seminal fluid
Male Reproductive Structures Epididymis Vas deferens Urethra
Functions of Male Reproductive Structures Penis: Deposits sperm in the vagina for fertilization of the ovum Scrotum: Protects testes and sperm by maintaining a temperature lower than the body Testes Serve as a site for spermatogenesis Produce testosterone Seminal fluid: Transports viable and mobile sperm to female reproductive tract
Functions of Male Reproductive Structures Epididymis: Reservoir for maturing spermatozoa Vas deferens: Rapidly squeeze sperm from their storage sites into urethra Urethra: Passageway for both urine and semen
Assignment Complete the activities: “Female Reproductive System”and “Male Reproductive System” on the accompanying Student CD-ROM. View the animations on the CD-ROM on the female and male pelvis.
Learning Objectives Compare the difference between meiotic cellular division and mitotic cellular division. Compare the processes by which ova and sperm are produced. Describe the components of the process of fertilization.
Describe in order of increasing complexity the structures that form during the cellular multiplication anddifferentiation stages of intrauterine development.Describe the development, structure, and functions of the placenta and umbilical cord during intrauterine life Identify the differing processes by which fraternal (dizygotic) and identical (monozygotic) twins are formed Summarize the significant changes in growth and development of the fetus in utero at 4, 6, 12, 16, 20, 24, 28, 36, and 40 weeks’ gestation.
Mitosis Process of cellular division Results in daughter cells that are exact copies of the original cell Identical to parent cell and to each other Contain a full set of chromosomes or genetic material Refered to as diploid cells Somatic cells continue to reproduce and replace each other
Mitosis The cell undergoes several changes ending in cell division At the last phase of cell division, a furrow develops in the cell cytoplasm The parent cell divides into two daughter cells Each daughter cell has its own nucleus They are identical to the parent cell They have the same diploid number of chromosomes (46) and same genetic makeup as the cell from which they came
Meiosis Type of cell division that produces reproductive cells called gametes (sperm and ova) - each cell contains half genetic material of parent cell (haploid)
Meiosis (cont’d) Meiosis consists of two successive cell divisions First division: Chromosomes replicate Second division: Chromatids of each chromosome separate and move to opposite poles of each of the daughter cells Cellular division results in formation of four cells Each cell contains haploid number of chromosomes Daughter cells contain only half the DNA of normal somatic cell
FIGURE 7–1 Gametogenesis involves meiosis within the ovary and testis. A, During meiosis, eachoogonium produces a single haploid ovum once some cytoplasm moves into the polar bodies.B, Each spermatogonium produces four haploid spermatozoa.
Oogenesis Process that produces the female gamete, called an ovum (egg), that begins to develop early in the fetal life of the female Ovaries begin to develop early in the fetal life of the female All ova that female will produce in her lifetime are present at birth - ovary gives rise to oogonial cells, which develop into oocytes During puberty: Mature primary oocyte continues through first meiotic division in ovary Haploid cells released at ovulalion
Oogenesis The first meiotic division Two cells of unequal size produced with same number of chromosomes One cell is secondary oocyte, other is minute polar body Secondary oocyte and polar body each contain 22 double-structured autosomal chromosomes and one double-structured sex chromosome (X) During puberty: Mature primary oocyte continues through first meiotic division in ovary
Spermatogenesis Production of the male gamete, or sperm, during puberty The spermatogonium (primordial germ cell) Begins with complete set of genetic material - diploid number of chromosomes Cell replicates before it enters first meiotic division Cell is now primary spermatocyte During second meiotic division, divide to form four spemiatids, each with haploid number of chromosomes
Spermatogenesis (cont’d) During the first meiotic division Spermatogonium forms two cells called secondary spermatocytes Each contains 22 double-structured autosomal chromosomes and either double-structured X sex chromosome or double-structured Y sex chromosome
Preparation for Fertilization Preparation is the first component of fertilization Ovum released into fallopian tube - viable for 24 hours Sperm deposited into vagina - viable for 48 to 72 hours (highly fertile for 24 hours) Sperm must undergo capacitation and acrosomal reaction Sperm penetration causes a chemical reaction that blocks more sperm penetration
Moment of Fertilization Sperm penetration causes chemical reaction that blocks more sperm penetration Sperm enters ovum, chemical signal prompts secondary oocyte to complete second meiotic division True moment of fertilization occurs as nuclei unite Chromosomes pair up to produce diploid zygote Each nucleus contains haploid number of chromosomes (23)
Moment of Fertilization (cont’d) Union restores diploid number (46) Zygote contains new combination of genetic material Sex of zygote determined at moment of fertilization Two chromosomes of twenty-third pair (sex chromosomes) - either XX or XY - determine sex of individual Females have two X chromosomes, males have an X and a Y chromosome
A FIGURE 7–2 Sperm penetration of an ovum. A, The sequential steps of oocyte penetration by a spermare depicted moving from top to bottom. B, Scanning electron micrograph of a human sperm surrounding a human ovum (750). The smaller spherical cells are granulosa cells of the corona radiata. Scanning electron micrograph used with permission from Nisson, L. (1990). A child is born. New York: Dell publishing.
B FIGURE 7–2(continued) Sperm penetration of an ovum. A, The sequential steps of oocyte penetration by a sperm are depicted moving from top to bottom. B, Scanning electron micrograph of a human spermsurrounding a human ovum (750). The smaller spherical cells are granulosa cells of the corona radiata. Scanning electron micrograph used with permission from Nisson, L. (1990). A child is born. New York: Dell publishing.(Photo Lennart Nilsson/Albert Bönniers Folag AB)
FIGURE 7–3 During ovulation the ovum leaves the ovary and enters the fallopian tube. Fertilizationgenerally occurs in the outer third of the fallopian tube. Subsequent changes in the fertilizedovum from conception to implantation are depicted.
Cell Multiplication Rapid mitotic division - cleavage Blastomeres grow to morula (solid ball of 12 to 16 cells) - solid ball of 12 to 16 cells Morula divides into solid mass (blastocyst); surrounded by outer layer of cells (trophoblast) Implantation; occurs in 7 to 10 days
Cell Differentiation 10 to 14 days (ectoderm, mesoderm, and endoderm) from which all tissues, organs, and organ systems develop Blastocyst differentiates into three primary germ layers (ectoderm, mesoderm, and endoderm) All tissues, organs, and organ systems develop from these primary germ cell layers Embryonic membranes form at implantation The chorion and the amnion
Derivation of Body Structures from Primary Cell Layers
Cell Differentiation Amniotic Fluid: Created when amnion and chorion grow and connect andform amniotic sac to produce fluid Yolk sac DeveIops as part of the blastocyst Produces primitive red blood cells Soon incorporated into the umbilical cord
FIGURE 7–4 Formation of primary germ layers. A, Implantation of a 7 1/2-day blastocyst in which thecells of the embryonic disc are separated from the amnion by a fluid-filled space. The erosion of the endometrium by the syncytiotrophoblast is ongoing. B, Implantation is completed by day 9, and extraembryonic mesoderm is beginning to from a discrete layer beneath the cytotrophoblast. C, By day 16 the embryo shows all three germ layers, a yolk sac, and an allantois (an out pouching of the yolk sac that forms the structural basis of the body stalk, or umbilical cord). The cytotrophoblast and associated mesoderm have become the chorion, and chorionic villi are developing.
Cell Differentiation Ectoderm Mesoderm Endoderm - differentiation of endoderm results in formation of epithelium lining respiratory and digestive tracts
FIGURE 7–5 Endoderm differentiates to form the epithelial lining of the digestive and respiratory tractsand associated glands.
FIGURE 7–6 Early development of primary embryonic membranes. At 4 1/2 weeks, the decidua capsularis (placental portion enclosing the embryo on the uterine surface) and decidua basalis (placental portion encompassing the elaborate chorionic villi and maternal endometrium) are well formed. The chorionic villi lie in blood-filled intervillous spaces within the endometrium. The amnion and yolk sac are well developed.
Umbilical Cord Develops from amnion Body stalk attaches embryo to yolk sac, fuses with embryonic portion of placenta Provides pathway from chorionic villi to embryo Contains two arteries and one vein; surrounded by Wharton’s jelly to protect vessels Wharton’s jelly: Specialized connective tissue Protects blood vessels Function of umbilical cord: Provides circulatory pathway to embryo
Placenta Placental development Begins at third week of embryonic development Develops at site where embryo attaches to uterine wall Function: Metabolic and nutrient exchange between embryonic and maternal circulations Placenta has two parts Maternal Fetal
Placenta Maternal portion Consists of deciduas basalis and its circulation Surface appears red and flesh-like Fetal portion Consists of the chorionic villi and their circulation The fetal surface of the placenta is covered by the amnion Appears shiny and gray
FIGURE 7–8 Maternal side of placenta (Dirty Duncan).
FIGURE 7–9 Fetal side of placenta (Shiny Shultz).
FIGURE 7–10 Vascular arrangement of the placenta. Arrows indicate the direction of blood flow. Maternal blood flows through the uterine arteries to the intervillous spaces of the placenta and returnsthrough the uterine veins to maternal circulation. Fetal blood flows through the umbilical arteries into the villous capillaries of the placenta and returns through the umbilical vein to the fetal circulation.
FIGURE 7–11 Fetal circulation. Blood leaves the placenta and enters the fetus through the umbilicalvein. After circulating through the fetus, the blood returns to the placenta through the umbilical arteries. The ductus venosus, the foramen ovale, and the ductus arteriosus allow the blood to bypass the fetal liver and lungs.
Figure 7–7 A, Formation of fraternal twins. (Note separate placentas.) B, Formation of identical twins.
Figure 7–7 (continued) A, Formation of fraternal twins. (Note separate placentas.) B, Formation of identical twins.
Identical Twins Develop from single fertilized ovum Of same sex and have same genotype Identical twins usually have common placenta; monozygosity is not affected by environment, race, physical characteristics, or fertility Both fetus are same sex with same characteristics Single placenta
Identical Twins Number of amnions and chorions present - depends on timing of division Division within 3 days of fertilization; two embryos, two amnions, and two chorions will develop Division about 5 days after fertilization Two embryos develop with separate amniotic sacs Sacs will eventually be covered by a common chorion Monochorionic-diamniotic placenta
Identical Twins (cont’d) If amnion already developed, division approximately 7 to 13 days after fertilization Two embryos with common amniotic sac and common chorion Monochorionic-monoamniotic placenta Occurs about 1% of the time
Fraternal Twins Also referred to as dizygotic Arise from two separate ova fertilized by two separate spermatozoa Two placentas, two chorions, and two amnions Sometimes placentas fuse and appear to be one Fraternal twins No more similar to each other than singly bom siblings May be of same or different sex
FIGURE 7–12 The actual size of a human conceptus from fertilization to the early fetal stage. The embryonic stage begins in the third week after fertilization; the fetal stage begins in the ninthweek.
Fetus Growth and Development 4 weeks: 4–6 mm, brain formed from anterior neural tube, limb buds seen, heart beats, GI system begins 6 weeks: 12 mm, primitive skeletal shape, chambers in heart, respiratory system begins, ear formation begins
Fetus Growth and Development 12 weeks: 8 cm, ossification of skeleton begins, liver produces red cells, palate complete in mouth, skin pink, thyroid hormone present, insulin present in pancreas 16 weeks: 13.5 cm, teeth begin to form, meconium begins to collect in intestines, kidneys assume shape, hair present on scalp
FIGURE 7–13 The embryo at 5 weeks. The embryo has a marked C-shaped body and a rudimentary tail. Use with permission from Petit/Nestle/Science Source/Photo Researchers, Inc.
FIGURE 7–14 The embryo at 7 weeks. The head is rounded and nearly erect. The eyes have shifted forward and closer together, and the eyelids begin to form. Use with permission from Petit/Nestle/Science Source/Photo Researchers, Inc.
FIGURE 7–15 The fetus at 9 weeks. Every organ system and external structure is present. Use with permission from Nilsson, L. (1990). A child is born. New York: Dell Publishing.(Photo Lennart Nilsson/Albert Bönniers Folag AB)
FIGURE 7–16 The fetus at 14 weeks. During this period of rapid growth, the skin is so transparent that blood vessels are visible beneath it. More muscle tissue and body skeleton have developed,and they hold the fetus more erect. Use with permission from Nilsson, L. (1990). A child is born. New York: Dell Publishing.(Photo Lennart Nilsson/Albert Bönniers Folag AB)
FIGURE 7–17 The fetus at 20 weeks weighs 435 to 465 g and measures about 19 cm. Subcutaneousdeposits of brown fat make the skin a little less transparent. “Woolly” hair covers the head,and nails have developed on the fingers and toes. Use with permission from Nilsson, L. (1990). A child is born. New York: Dell Publishing.(Photo Lennart Nilsson/Albert Bönniers Folag AB)
Fetus Growth and Development 20 weeks: 19 cm, myelination of spinal cord begins, suck and swallow begins, lanugo covers body, vernix begins to protect the body 24 weeks: 23 cm, respiration and surfactant production begins, brain appears mature 28 weeks: 27 cm, nervous system begins regulation of some functions, adipose tissue accumulates; nails, eyebrows, and eyelids are present; eyes are open 36 weeks: 35 cm, earlobes soft with little cartilage, few sole creases
Fetus Growth and Development 40 weeks : 40 cm, adequate surfactant, vernix in skin folds and lanugo on shoulders, earlobes firm, sex apparent Weight about 3,000 to 3,600 g (6 lb., 10 oz. to 7 lb., 15 oz.) Varies in different ethnic groups Skin has a smooth, polished look Hair on head is coarse and about 1 inch long Body and extremities are plump
Fetal Development: What Parents Want to Know (cont’d)
Assignment Access the CD-ROM to view the cell division animation. Review the following animations:oogenesis, spermatogenesis, oogenesis and spermato-genesis compared, matching oogenesis and spermatogenesis. View and review all animations.
Anatomic and Physiologic Changes Respiratory system: Increasing levels of progesterone causes: Increased volume of air Decreased airway resistance Increased anteroposterior diameter Thoracic breathing occurs as uterus enlarges
Anatomic and Physiologic Changes Cardiovascular system: Increased levels of estrogen and progesterone Cardiac output and blood volume increases Increased size of uterus interferes with blood return from lower extremities Increased level of red cells to increase oxygen delivery to cells Clotting factors increase
Anatomic and Physiologic Changes GI system: Action of increasing levels of progesterone Delayed gastric emptying Decreased peristalsis GU system: Increased blood volume Glomerular filtration rate increases Renal tubular reabsorption increases
Anatomic and Physiologic Changes Skin and Hair: Increased skin pigmentation caused by increased estrogen and progesterone Musculoskeletal: Relaxation of joints caused by increased estrogen and progesterone Metabolism: Increased during pregnancy Demands of the growing fetus and its support system Weight Gain: Recommended 25 to 35 lb Overweight, recommended gain is 15 to 25lb. Underweight: Gain weight needed to reach ideal weight plus 25 to 35 lb
Anatomic and Physiologic Changes Endocrine System Thyroid Pituitary Adrenals Pancreas
Signs and Symptoms Uterus: Enlargement of abdomen Increased strength and elasticity: Allows uterus to contract Fetus expelled during labor Cervix: Mucous plug expelled as labor begins Increased vascularity may cause bleeding after vaginal exams Vagina: Acid pH increases chance of vaginal yeast infections Breasts: Increase in size causes soreness Colostrum may be present during the third trimester
Signs and Symptoms Respiratory system Increased size of uterus may cause shortness of breath Increased vascularity may cause nasal stuffiness and nosebleeds Cardiovascular system: Decreased blood return from lower extremities Varicose veins Hemorrhoids
Signs and Symptoms (cont’d) Pressure on vena cava by the enlarged uterus Dizziness Decreased blood pressure Skin and Hair: Increased skin pigmentation Causes linea nigra and chloasma
Signs and Symptoms (cont’d) GI system: Increased levels of estrogen cause: Nausea and vomiting Constipation Slow peristalsis and motility GU system: Increased urination caused by: Increasing size of uterus Pressure on bladder Increased blood volume and glomerular filtration
Signs and Symptoms (cont’d) Musculoskeletal: Action of estrogen and progesterone Relaxation of joints: Lordosis of lumbosacral spine
FIGURE 9–5 Approximate height of the fundus at various weeks of pregnancy.
FIGURE 9–1 Vena caval syndrome. The gravid uterus compresses the vena cava when the woman issupine. This reduces the blood flow returning to the heart and may cause maternal hypotension.
FIGURE 9–3 Postural changes during pregnancy. Note the increasing lordosis of the lumbosacral spine and the increasing curvature of the thoracic area.
Changes of Pregnancy Subjective (presumptive) changes Amenorrhea Nausea and vomiting Fatigue Urinary frequency Breast changes Quickening
Differential Diagnosis of Pregnancy - Subjective Changes
Differential Diagnosis of Pregnancy - Subjective Changes
Changes of Pregnancy Objective (probable) changes Goodell’s and Chadwick’s sign Hegar’s and McDonald’s sign Enlargement of the abdomen Braxton Hicks contractions Uterine soufflé Skin pigmentation changes Pregnancy tests
FIGURE 9–4 Hegar’s sign, a softening of the isthmus of the uterus, can be determined by the examinerduring a vaginal examination.
Differential Diagnosis of Pregnancy - Objective Changes
Differential Diagnosis of Pregnancy - Objective Changes
Changes of Pregnancy Diagnostic (positive) changes Fetal heartbeat Fetal movement Visualization of the fetus
Pregnancy Tests Urine tests Hemagglutination-inhibition test (Pregnosticon R test) Latex agglutination test (Gravindex and Pregnosticon Slide tests) The first two are done on first early morning urine specimen Positive within 10 to 14 days after the first missed period Detect hCG during early pregnancy
Pregnancy Tests Serum tests -subunit radioimmunoassay: Positive a few days after presumed implantation Immunoradiometric assay (IRMA) (Neocept, Pregnosis); requires only about 30 minutes to perform Enzyme-linked immunosorbent assay (ELISA) (Model Sensichrome, Quest Confidot): Detects hCG levels as early as 7 to 9 days after ovulation and conception, 5 days before the first missed period Fluoroimmunoassay (FIA) (Opus hCG, Stratus hCG); takes about 2 to 3 hours to perform; used primarily to identify and follow hCG concentrations
Pregnancy Tests Over-the-Counter pregnancy tests Enzyme immunoassay tests Performed on urine Sensitive Detect even low levels of hCG Can detect a pregnancy as early as first day of missed period Negative result, test may be repeated 1 week if period has not occurred
Mother’s Emotional and Psychological Changes First trimester: Disbelief and ambivalence Second trimester: Quickening; helps mother to view fetus as separate from herself Third trimester: Anxiety about labor and birth; nesting (bursts of energy) occurs
Mother’s Emotional and Psychological Changes (cont’d) Rubin’s four tasks: Ensuring safe passage through pregnancy, labor, and birth Seeking acceptance of this child by others Seeking commitment and acceptance of herself as mother to infant Learning to give of oneself on behalf of one’s child
Father/Partner’s Emotional and Psychologic Changes First trimester May feel left out Disbelief May be confused by his partner’s mood changes Might resent the attention she receives Second trimester: Begins to decide which behaviors of own father he wants to imitate or discard Third trimester: Anxiety about labor and birth
Family’s Emotional and Psychologic Changes Siblings May view baby as threat to security of their relationships with parents Reaction depends on age of siblings Preparation for birth is essential Grandparents Usually supportive Excited about the birth May be unsure about how deeply to become involved
Cultural Assessment Determines Main beliefs Wishes Traditions of the family Values Behaviors about pregnancy and childbearing Helps to explore woman’s (or family’s) expectations of healthcare system Allows nurse to provide care that is appropriate and responsive to family needs
Cultural Factors Factors that will impact the family’s plans for the pregnancy Religious preferences Language Communication style Common etiquette practices Ethnic background Amount of affiliation with the ethnic group Patterns of decision making>
Assignment Draw the female internal reproductive anatomy. Label each organ, and list the changes that occur in each organ system(note book).
Learning Objectives Summarize the essential components of a prenatal history. Define common obstetric terminology found in the history of maternity clients. Identify factors related to the father’s health that are generally recorded on the prenatal record. Describe areas that should be evaluated as part of the initial assessment of psychosocial and cultural factors relatedto a woman’s pregnancy. Describe the normal physiologic changes one would expect to find when performing a physical assessment of apregnant woman.
Compare the methods most commonly used to determine the estimated date of birth.
Develop an outline of the essential measurements that can be determined by clinical pelvimetry.
Delineate the possible causes of the danger signs of pregnancy.
Relate the components of the subsequent prenatal history and assessment to the progress of pregnancy.
Prenatal History Details of current pregnancy First day of last normal menstrual period (LMP) Presence of complications Attitude toward pregnancy Results of pregnancy tests, if completed Presence of discomforts since LMP Number of pregnancies and number of living children Number of abortions, spontaneous or induced
Prenatal History History of previous pregnancies Length of pregnancy Length of labor and birth Type of birth Type of anesthesia used (if any) Woman’s perception of the experience Complications associated with childbirth Neonatal complications
Prenatal History Gynecologic history Date of last Pap smear - any history of abnormal Pap smear Previous infections: Vaginal, cervical, tubal, or sexually transmitted Previous surgery Age at menarche and sexual history Regularity, frequency, and duration of menstrual flow History of dysmenorrhea and contraceptive history
Prenatal History Current medical history General health: Weight, nutrition, and regular exercise program Blood type and Rh factor, if known General health: Nutrition and regular exercise program Medications and use of herbal medication use during pregnancy Previous or present use of alcohol, tobacco, or caffeine Illicit drug use and drug allergies and other allergies
Prenatal History Current medical history Potential teratogenic insults to this pregnancy Presence of disease conditions such as diabetes Immunizations (especially rubella) Presence of any abnormal symptoms
Prenatal History Past medical history Childhood diseases Past treatment for any disease condition Surgical procedures Presence of bleeding disorders or tendencies (Has she received blood transfusions?)
Prenatal History Family medical history Presence of chronic or acute systemic diseases Complications associated with childbirth: Preeclampsia Occurrence of multiple births History of congenital diseases or deformities Occurrence of cesarean births and cause, if known
Prenatal History Religious preference and religious beliefs related to health care and birth: Prohibition against receiving blood products Dietary considerations or circumcision rites Practices that are important to maintain her spiritual well-being Practices in her culture or that of her partner that will influence care
Prenatal History Occupational history: Physical demands of present job Partner’s history: Genetic conditions and blood type Woman’s demographic information Age, educational level Ethnic background Socioeconomic status
Common Obstetric Terminology Gravida: Any pregnancy, regardless of duration, includes the current pregnancy Parity: Birth after 20 weeks’ gestation; infant may be born alive or dead
Common Obstetric Terminology (cont’d) TPAL T: Number of term infants born P: Number of preterm infants A: Number of pregnancies ending in either spontaneous or therapeutic abortion L: Number of currently living children
FIGURE 10–1 The TPAL approach provides detailed information about the woman’s pregnancy history.
Common Obstetric Terminology (cont’d) Gestation: Number of weeks since the first day of the last menstrual period Abortion: Birth occurring before the end of 20 weeks’ gestation Term: Normal duration of pregnancy (38 to 42 weeks’ gestation) Antepartum: Time between conception and the onset of labor Intrapartum: Period from the onset of true labor until the birth of the infant and placenta
Common Obstetric Terminology (cont’d) Postpartum: Time from birth until the woman’s body returns to prepregnant condition Preterm or premature labor: Labor that occurs after 20 weeks’ but before completion of 37 weeks’ gestation Nulligravida: Woman who has never been pregnant Primigravida: Woman pregnant for the first time
Common Obstetric Terminology (cont’d) Nullipara: Woman who has had no births at more than 20 weeks’ gestation Primipara: Woman who has had one birth at more than 20 weeks’ gestation Multipara: Woman who has had two or more births at more than 20 weeks’ gestation Stillbirth: Infant born dead after 20 weeks’ gestation Multigravida: Woman in second or any subsequent pregnancy
Father’s Information Existing medical conditions History of chronic illness - father or immediate family member Blood type and Rh factor Age Occupation Current use of recreational drugs
Father’s Information (cont’d) Present use of tobacco and alcohol Genetic disorders Educational level Methods by which he learns best Attitude toward the pregnancy
Cultural and Psychosocial Factors Language preference Religious preference Socioeconomic status Psychological status Educational needs Support system
Cultural and Psychosocial Factors (cont’d) Determine food preferences Determine significant people to client - assess degree of involvement of those people Assess family functioning Level of involvement Stability of living conditions Be aware of the practices of various cultural groups
Normal Physiological Changes Pulse may increase by 10 beats per minute Respiration may be increased and thoracic breathing predominant Temperature and blood pressure within normal limits Weight varies: Should be proportional to the gestational age of the fetus Nose: Nasal stuffiness Chest and lungs: Transverse diameter greater than anterior-posterior diameter
Normal Physiological Changes (cont’d) Skin: Linea nigra Striae gravidarum Melasma Spider nevi Mouth: Gingival hypertrophy Neck: Slight hyperplasia of thyroid in the third trimester - small, nontender nodes
Normal Physiological Changes (cont’d) Breasts Increasing size Pigmentation of nipples and areola Tubercles of Montgomery enlarge Colostrum appears in third trimester
Normal Physiological Changes (cont’d) Abdomen Progressive enlargement Fetal heart rate heard at approximately 12 weeks’ gestation Extremities: Possible edema late in pregnancy Spine: Lumbar spinal curve may be accentuated Pelvic area: Vagina without significant discharge
Normal Physiological Changes (cont’d) Cervix closed Uterus shows progressive growth Laboratory tests Physiologic anemia may occur (decrease in hemoglobin and hematocrit) Small degree of glycosuria may occur
Commonly Used Methods Nägele’s rule Begin with the first day of the LMP Subtract 3 months, and add 7 days Physical Examination - fundal height: Measurement of uterine size Ultrasound: Method used to measure fetal parts Crown-to-rump measurements Biparietal diameter (BPD) measurements
FIGURE 10–2 The EDB wheel can be used to calculate the due date. To use it, place the “last mensesbegan” arrow on the date of the woman’s LMP. Then read the EDB at the arrow labeled 40. Inthis case the LMP is September 8, and the EDB is June 17.
FIGURE 10–3 A cross-sectional view of fetal position when McDonald’s method is used to assess fundalheight.
FIGURE 10–4 Listening to the fetal heartbeat with a Doppler device.
Pelvic Measurements Pelvic inlet Diagonal conjugate Measure at least 11.5 cm Obstetric conjugate - 10 cm or more
A FIGURE 10–5 Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, whichextends from the lower border of the symphysis pubis to the sacral promontory. B, Estimationof the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior measurements.
B FIGURE 10–5 (continued) Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, whichextends from the lower border of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior measurements.
C D FIGURE 10–5 (continued) Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, whichextends from the lower border of the symphysis pubis to the sacral promontory. B, Estimationof the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior measurements.
Pelvic Measurements Pelvic outlet Anteroposterior diameter Should be 9.5 to 11.3 cm Transverse diameter should be 8 to 10 cm
FIGURE 10–6 Use of a closed fist to measure the outlet. Most examiners know the distance between their first and last proximal knuckles. If they do not, they can use a measuring device.
Signs of Infection or Cancer Elevation in vital signs Urine with elevated white blood cells High white blood cell count in the blood Lesions in the genital area Excessive malodorous vaginal discharge Positive tests for sexually transmitted infections
Signs of Infection or Cancer Tender, hard fixed nodes in the neck Abnormal lung sounds Breast lumps Nipple discharge Redness and tenderness of breast tissue
Signs of Anemia or Cardiopulmonary Problems Pale mucous membranes Skin pallor Signs of nutrition deficiency Low hemoglobin and hematocrit levels Elevations in blood pressure Edema More than expected weight gain
Signs of Cardiopulmonary Problems Abnormal lung sounds Increased respiratory rate Abnormal heart rhythm Extra heart sounds
Other Danger Signs Less than expected weight gain Petechiae or bruises Inflamed gingival tissue Enlarged thyroid Abdominal tenderness or mass Lack of peripheral pulses
Other Danger Signs Failure to detect fetal heart rate Abnormal spinal curves Hyperactive reflexes Below normal pelvic measurements Hemorrhoids
Subsequent Prenatal Assessment Prenatal visits Every 4 weeks for the first 28 weeks’ gestation Every 2 weeks until 36 weeks’ gestation After week 36, every week until childbirth
Subsequent Prenatal Assessment Assessments during prenatal visits Vital signs and weight Edema Uterine size and fetal heartbeat Urinalysis Blood tests for AFP, glucose Vaginal swab for group B strep Expected psychological stage of pregnancy