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  1. 1. Nursing 246 Unit I: Women’s Health Care Needs –urethral/paraurethral glands Quick Review: A & P –Bartholin’s glands •Reproductive Development Genetic Males –female/male systems are fundamentally similar –produce sex cells/transport to locations where their •Other internal reproductive structures occurring through process of differentiation include: union can occur –sex cells - gametes - produced by gonads –vas deferens –epididymis Embryonic Development –seminal vesicle •Genetic sex determined at fertilization –ejaculatory duct •Male/female systems undifferentiated for 8 weeks –prostate/bulbourethral glands develop from urethra •Followed by period of rapid differentiation External Structures Ovaries & Testes •All males and females possess the same external genitals until the end of the 9th week •During 5th week of gestation, primitive gonad develops •Differentiation of external genitals is complete by the end •in males, the inner portion (medulla) develops into a testis of the 12th week and the outer portion (cortex) regresses •If fetal testosterone is not present, the external genitals are •in females, the cortex develops into an ovary, and the feminized medulla regresses Oogenesis •When external genitals are feminized, the phallus becomes the clitoris, the urogenital folds become the labia minora, and •Ovary produces oogonia the labioscrotal folds become the labia majora. •These are primitive egg cells which become primitive eggs •If fetal testosterone is present, the external genitals become masculine. The phallus lengthens and become the penis. called oocytes Fusion of urogenital folds becomes penile urethra, and the •No oocytes are formed after fetal development urethral meatus moves toward the glans •All the eggs available for maturation in a woman’s Female Reproductive System reproductive life are present at birth •External Genitals •About 150,000 oocytes are contained in the ovaries at birth –mons pubis •Each oocyte is contained a a small ovarian cavity called a –labia majora primitive follicle –labia minora •During the reproductive years, monthly an oocyte –clitoris undergoes cellular division & maturation becoming a fertilizable egg (ovum). Those left degenerate over time. –urethral meatus and opening of Skene’s glands Spermatogenesis –vaginal vestibule •Each testis produces male gametes (spermatozoa or sperm) –perineal body Mons Pubis through a process called spermatogenesis •This process does not occur until puberty •Mound of subcutaneous fatty tissue which covers the anterior portion of the symphysis pubis •See Figure 10-1 •Covered with pubic hair Genetic Females •Protects pelvic bones, especially during coitus Labia Majora •Other internal reproductive structures occurring through •Longitudinal raised folds of skin on either side of the process of differentiation include: vulvar cleft –fallopian tubes –vagina •Labia majora protect structures lying between them
  2. 2. •inner surface in women who have not had children is moist •It contains the introitus (vag opening), which is the border and looks like mucous membrane, but becomes more skinlike between the internal and external genitals and less prominent with each pregnancy •Hymen is the collar of tissue that surrounds the vaginal •Extensive venous network opening •varicosities may occur during pregnancy •At puberty, hymen becomes more full due to increasing estrogen levels •Hematomas are not uncommon after birth trauma or sexual •Old Wive’s Tale that the hymen covers the vaginal opening trauma and if intact, is a sign of virginity •Shares extensive lymphatic system with other structures of •Hymen surrounds, rather than covers the vaginal opening the vulva and can spread cancer quickly and can be broken not only through sex but other strenuous •some regional anesthesia blocks cause numbness activity, masturbation, menstruation, or use of tampons Labia Minora •Bartholin’s glands are located externally to the hymen at •Soft folds of skin within the labia majora that converge the base of the vestibule near the anus, forming the fourchette •They secrete a clear and thick mucus which enhances the •Has appearance of mucous membrane, shiny, moist, and viability and motility of the sperm deposited in the vaginal vestibule hairless •Rich in sebaceous glands, so sebaceous cysts common here •These ducts can harbor gonorrhea and other bacteria, making them a common place for suppuration and abcesses •Composed of erectile tissue and involuntary muscle tissue Perineal Body •Wedge-shaped mass of fibrous, muscular tissue found •Vulvovaginitis very irritating because lots of tactile nerve between the lower part of the vagina and the anal canal endings •The superficial area between the anus and vagina is called Labia minora increase in size at puberty and decrease the perineum after menopause due to changes in estrogen levels Clitoris •Many muscles meet here, allowing a remarkable amount of stretching •5-6 mm long and 6-8 mm across, located between the labia •This area thins during pushing until it is only a few cms minora thick (episiotomy area) •composed of erectile tissue Female Internal Reproductive Organs •glans is partially covered by a fold of skin called the •Vagina prepuce, or hood •Uterus •This area may be confused with the urinary meatus •Fallopian Tubes •Very rich blood and nerve supplies •Ovaries •Primary erogenous organ of women •These are target organs for estrogenic hormones and play a •secretes smegma, which along with other vulval secretions unique part in the reproductive cycle Vagina has a unique odor which may be sexually stimulating to a man •Muscular and membranous tube that connects the external genitals to the uterus •In some cultures, the clitoris is removed: “female •Also called birth canal, because the fetus must pass through circumcision” Urethral Meatus & Paraurethral Glands here during birth •Urethral meatus is located 1 - 2.5 cms below the clitoris •Cervix of the uterus projects into the upper part of the vagina •appears as puckered, slitlike opening •Upper portion of vagina called vaginal vault, with the area •May be difficult to visualize due to mucosal folds, blind around the cervix called the vaginal fornix •Walls of the vaginal vault are very thin, so many structures dimples, or wide variations in location can be palpated through them •Skene’s glands open into the posterior wall of the urethra –uterus and lubricate the vagina --- distended bladder Vaginal Vestibule –ovaries •Boat-shaped depression enclosed by labia majora and –appendix visible when they are separated –cecum
  3. 3. –colon •Body of uterus is freely movable; only the cervix is –ureters anchored laterally •Fornix allows pooling of semen •Position of uterus can vary, depending on: •Collection of large amount near cervix at or near time –woman’s posture ofovulation increases chances of becoming pregnant –number of children borne •Vaginal walls are covered in rugae, allowing this tissue to –bladder and rectal fullness stretch for delivery of a baby Rich blood supply is necessary –even respiratory patterns •Vaginal environment is normally acidic •Secretions provides a moist environment –Usually the uterus bends forward sharply (anteverted). This is normal. •Acidic environment maintained by a symbiotic relationship between lactic-acid producing bacilli and the vaginal •Uterus has 3 sets of supports: epithelial cells •Any interruption in this balancing act can destroy the self- –upper - broad and round ligaments cleaning action of the vagina –middle - cardinal, pubocervical, uterosacral •Interruption may be caused by antibiotic therapy, douching, –lower - pelvic muscular floor or use of vaginal sprays or deodorants •Acidic environment present only during reproductive years •Uterus is divided into two parts: and first few days of life •Corpus (body) - upper 2/3, composed mainly of a smooth •The vagina is divided into thirds for vascular and lymphatic muscle layer (myometrium) systems. There are many venous anastamoses. •Lower 1/3 is the cervix, or neck •Pudendal nerve supplies what relatively little somatic innervation there is to the lower third of the vagina. Vaginal •Isthmus - the slight constriction in the uterus that divides it sensation during coitus is minimal, as is vaginal pain during into these two unequal parts second stage of labor •Rounded uppermost portion of the body of the uterus is the •Vagina has the following functions: fundus –serve as passageway for sperm and for the fetus •It is in the area of the isthmus that the uterine lining during birth changes into the mucous membrane of the cervix –provide passage for menstrual blood flow from the •During pregnancy, the isthmus becomes the lower uterine uterine endometrium to the outside segment and does not contract (along with the cervix). This is –protect against infection from pathogenic organisms the site for cesarian births. Uterus •There are extensive blood and lymphatic supplies to the uterus •Numerous folk tales abound about the uterus •hollow, muscular, thick-walled organ shaped like an upside- •entirely innervated by the autonomic nervous system down pear, lying in the pelvic cavity between the base of the •Even hemiplegic women can have adequate uterine bladder and the rectum and above the vagina contractions •Uterus lies below the pelvic brim; the cervix about the level •Pain of uterine contractions is carried to the CNS by the of the ischial spines 11th and 12th thoracic nerve roots. •The mature uterus weighs 50-70 gms and is 6 - 8 cms long •Pain from the cervix and upper vagina passes through the ilioinguinal and pudendal nerves •uterine anomalies are thought to be congenital: •Motor fibers to the uterus arise from the 7th and 8th –bicornuate uterus (two-horned) thoracic vertebrae –didelphys uterus (double uterus) •Because the sensory and motor levels are separate, epidural anesthesia can be used during labor and birth –These two anomalies are associated with habitual abortion •Function of the uterus: •Both the urinary and reproductive systems develop from –provide a safe environment for fetal development the same urogenital fold in the embryo, anomalies in one –uterine lining is cyclically prepared by steroid system are frequently accompanied by anomalies in the other hormones for implantation of the embryo (nidation)
  4. 4. –Once implanted, the embryo is protected until it is •Cervical canal appears rosy red and is lined with columnar expelled epithelium, containing mucus-secreting glands –uterine body never returns to pre-pregnant size •Most cervical CA begins at this squamocolumnar junction. –external cervical os changes from circular opening to Exact location varies with age. slit with irregular edges Uterine Corpus •Elasticity is chief characteristic of the cervix. •Made up of three layers: •Ability to stretch due to high fibrous and collagenous content of the supportive tissues and vast numbers of folds –outermost (serosal layer) - perimetrium •Cervical mucosa has three functions: –middle (muscular uterine layer) - myometrium –provide lubrication for vaginal canal –innermost (mucosal layer) - endometrium –act as a bateriostatic agent •Muscular middle layer is continuous with the muscle layer –provide alkaline environment to shelter deposited of the fallopian tubes and the vagina (also the ovarian, round, sperm from acidic vagina cardinal ligaments and to some extent the uterosacral ligaments) which explains common female complaint of Uterine Ligaments “pelvic aches and pains” •Uterine ligaments support/stabilize the various reproductive •Myometrium has 3 distinct layers of involuntary smooth organs muscles •Broad ligament - keeps the uterus centrally placed and –outer layer over the fundus are longitudinal muscles provides stability. Double layered and continuous with that work to expell the fetus during delivery abdominal peritoneum. Covers the uterus anteriorly and posteriorly and extends to enfold and stabilize the fallopian –middle layer is thick and made of interlacing fibers in tubes. Between the folds of the broad ligament are connective figure-8 patterns surrounding large blood vessels. Their tissue, invol muscle, blood and lymph vessels, and nerves. contraction produces a hemostatic action to stop Round ligaments keep the uterus in place. These arise from bleeding after birth the sides of the uterus. They extend outward and eventually –Inner muscle layer forms sphincters at the fallopian fuse with the tissue of the labia majora. These enlarge during pregnancy. During labor, these ligaments force the fetal tube sites and around the internal os. The internal os presenting part into the cervix. sphincter inhibits the expulsion of the fetus during pregnancy, but stretches during labor. The fallopian tube sphincters prevent menstrual blood fromflowing •Ovarian ligaments - anchor the lower section of the ovary to the cornua of the uterus. These contract and help the backward into the tubes from the uterus. fallopian tubes fimbriae to catch the ovum as it is released •These muscle layers also work together, causing uterine each month. contractions which are responsible for the dilatation of the •Cardinal ligaments - chief uterine supports, prevent uterine cervix and provide the major force for the passage of the prolapse and also support the upper vagina fetus through the pelvic and vaginal canal at birth. •infundibulopelvic ligments - suspends and supports the •Endometrium is composed of a single layer of columnar ovaries and contains the ovarian vessels and nerves epithelium, glands, and stroma. The endometrium undergoes •uterosacral ligaments - provide support for the uterus and monthly renewal and degeneration in the absence of cervix at the level of the ischial spines, they also contain pregnancy, from puberty to menopause. sensory nerve fibers that contribute to dysmenorrhea •Endometrium varies in thickness from 0.5mm to 5 mm. Fallopian Tubes •Glands of endometrium produce a watery, thin, alkaline •These arise from the side of the uterus and reach almost to secretion, keeping uterine cavity moist. This “endometrial the side of the pelvis, where they turn toward the milk” assists sperm as they travel to the fallopian tubes, but ovaries.These tubes link the peritoneal cavity with the uterus also nourishes the developing embryo prior to implantation. and vagina •Blood supply of endometrium is unique. There are coiled •Each fallopian tube can be divided into 3 sections: arteries and straighter arteries. The coiled arteries are more sensitive to cyclic hormonal control. This response allows for –isthmus part of the endometrial tissue to remain intact, while other endometrial tissue is shed during menstruation. Once –ampulla pregnancy occurs, the endometrium is not shed. The stromal –fimbria cells become the decidua of the pregnancy, are highly vascular and channel a rich blood supply to the endometrial •Isthmus is straight and narrow, with a thick muscular wall surface. and a 2-3mm lumen. It is the site of tugal ligation. Uterine Cervix •Ampulla - Curved, comprises the outer 2/3 of the tube. •Narrow neck of the uterus which is canal-like, and connects Fertilization usually occurs here. Ampulla ends at the the corpus of the uterus to the vagina fimbria. •Vaginal cervix appears pink and ends at the external os
  5. 5. Fimbria - funnel-like enlargement with many moving fingerlike projections reaching out to the ovary. The longest –medulla fimbria is actually attached to the ovary. •Tunica albugnea - dense, dull white, protective layer •Tubes are made up of four layers: •Cortex - main functional part, containing ova, graafian –peritoneal (serous) layer-covers the tubes follicles, ccorpora lutea, degenerated corpora lutea, and degenerated follicles –subserous (adventitial) layer-contains blood and nerve supply •Medulla is completely surrounded by the cortex and –muscular layer-responsible for peristaltic movement contains nerves, blood and lymphatic vessels. of the tube –mucous tissues-composed of ciliated and non-ciliated •Ovaries are the primary source of 2 important hormones: cells –Estrogens - associated with characteristics •Non-ciliated cells produce a rich serous fluid that nourishes contributing to femaleness. Ovaries secrete large amounts of estrogens, the adrenal cortex produces the ovum minute amts of estrogens in non-pregnant women •Constantly moving cilia propel the ovum toward the uterus. –Progesterone - hormone of pregnancy. Placenta main The ovum is large and this action is needed the assist the site for progesterone during pregnancy. Hormone also tube’s muscular layer peristalsis. prevents lactation during preg. •Malformation or malfunction of the tubes could result in infertility, ectopic pregnancy, or sterility. •Interplay between ovarian hormones and others, like FSH and LH is responsible for the cyclic changes that allow pregnancy to occur. Between the ages of 45 and 55, the •Tubal Transport System: woman’s ovaries secrete decreasing amounts of estrogen. Eventually, ovulatory activity ceases, and menopause occurs. –active fimbriae close to the ovary Bony Pelvis –peristalsis of tube created by muscular layer •2 unique functions: –ciliated currents beating toward the uterus –support and protect the pelvic contents –proximal contraction and distal relaxation of the tube –form the relatively fixed axis of the birth canal caused by different types of prostaglandins. Bony Structure •FTs have rich blood and lymph supply, and the unusual •Pelvis made up of four bones: ability to recover from inflammatory processes (survival of –two innominate bones the fittest!) –sacrum •Functions of the FT: –coccyx –provide transport for the ovum (3-4 days) –provide a site for fertilization –Pelvis resembles a bowl or basin. Its sides are the innominate bones, and its back is made up of the –serve as a warm, moist, nourishing environment for sacrum and coccyx. The bony pelvis is lined with the ovum or zygote fibrocartilage and held tightly together by ligaments. Ovaries The 4 bones join at the symphysis pubis, the two sacroiliac joints, and the sacrococcygeal joints. •2 almond-shaped glandular structures just below the pelvic •Innominate bones (hip bones) - made up of three separate brim, one on each side of the pelvic cavity bones: •Size varies accding to woman and stage of the menstrual –ilium cycle •Girls have smooth ovaries, but women of reproductive age –ischium have pitted ovaries, due to scarring from ovulation. –pubis –These bones fuse to form a circular cavity, the •There is no peritoneal covering for the ovaries. This allows acetabulum, which articulates with the femur. the mature ovum to erupt, but also allows easier spread of malignant cells from CA of the ovaries. •Ilium - broad, upper prominence of the hip •Three layers: •Iliac Crest - margin of the ilium –tunica albuginea •Ischial Spines - site of attachments for ligaments and muscles - juts into pelvic cavity and serves as a reference –cortex point to evaluate descent of the fetal head
  6. 6. •Ischium - the strongest bone, ends in a marked protuberance •Pubic arch has great importance because the baby must pass on which the weight of a seated body sits under it in birth. If arch is narrow, baby’s head may be pushed back toward the coccyx, making extension difficult. •Pubis - slightly bowed front portion of the innominate This is called outlet dystocia and may lead to a forceps or bone. Pubic bones meet to form the joint known as cesarian delivery. Shoulders of a large baby may also get symphysis pubis. Triangular space beneath it is known as the stuck under the pubic arch, making birth more difficult. pubic arch. Fetal head passes under this arch during delivery. Pelvic Types Hormones of pregnancy relax all these joints toward the end of pregnancy to aid in the birth process. •Four basic types of pelves: •Sacrum - Wedge-shaped bone formed by the fusion of five –gynecoid vertebrae. It contains a projection into the pelvic cavity known as the sacral promontory, which is another guide in –android determining pelvic measurements –anthropoid •The last small triangular bone on the vertebral column is the –platypelloid coccyx. It usually moves backward during labor to facilitate Gynecoid Pelvis birth. Pelvic Floor •Most common female pelvis. Inlet is rounded. Posterior •The pelvic floor is designed to overcome the force of segment is broad, deep, and roomy. Anterior segment is well rounded. Has non-prominent ischial spines, straight and gravity exerted on the pelvic organs. parallel side walls, and a wide, deep sacral curve. Has a wide •Deep fascia, the levator ani and coccygeal muscles form the and round pubic arch. Capacity of outlet is adequate. Bones part of the pelvic floor known as the pelvic diaphragm. of medium structure and weight. Approx 50% of female •Levator ani muscle makes up most of the pelvic diaphragm. pelves are gynecoid. Android Pelvis Made up of 4 muscles: –iliococcygeus •Normal male pelvis is android, occasionally seen in females. Inlet is heart shaped. Posterior sagittal diameter is –pubococcygeus too short for birth. Posterior segment is shallow. Prominent –puborectalis ischial spines. All midpelvic diameters are reduced. Narrow, sharp, and deep pubic arch. Capacity of outlet is reduced. –pubovaginalis Bones are medium to heavy structure and weight. Approx Pelvic Division 20% of female pelves are android. Labor is not favorable. Descent is slow. Fetal head engages in oblique presentation •Pelvic cavity divided into the false pelvis and the true (asynclitism) with extreme molding. Arrest of labor is pelvis frequent, requiring difficult forceps manipulation, and the deep, narrow pubic arch may lead to extensive perineal •False pelvis - portion above pelvic brim and has the lacerations. Cesarian birth may be necessary. function of supporting the weight of the pregnant uterus and Anthropoid Pelvis directing the presenting part into the true pelvis below •Inlet is oval, with an adequate but short transposterior •True pelvis - portion that lies below the pelvic brim and diameter represents the bony limits of the birth canal. •The true pelvis is extremely important in childbearing •has variable ischial spines, straight side walls, narrow and long sacrum that incline backward. because its size and shape must be adequate for normal fetal passage during labor and at birth. The relationship of the fetal head to the true pelvic cavity is of critical importance. •Outlet adequate. •Consists of three parts: •Bones of medium weight and structure. –inlet •25% of female pelves are anthropoid. –pelvic cavity Platypelloid Pelvis –outlet •Flat, female pelvis •There are distinct measurements associated with each part that aid in evaluating pelvic adequacy for delivery. •all diameters are short and shallow •Pelvic Inlet - upper border of the true pelvis and is typically •variable ischial spines, parallel side walls, wide sacrum round in females. Measure: diagonal conjugate, obstetric with deep curve inward conjugate, and conjugate vera. •Pelvic Cavity - curved canal with longer posterior than •Outlet capacity inadequate anterior wall. •Pelvic Outlet - lower border of the true pelvis. Size of the •Bones are similar to gynecoid bones pelvic outlet can be determined by measurement of the transverse diameter. •5 % of female pelves are platypelloid. Breasts •Coccyx is pushed posteriorly during descent. Decreased mobility, large fetal head, and/or forceful birth can cause the •Mammary Glands - considered accessories of the coccyx to break. reproductive system, are specialized sebaceous glands
  7. 7. •Conical and symmetrically placed on either side of the chest •Cooper’s ligaments suspend the breasts •Left breast frequently larger than right •Breasts develop at slightly different levels in the pectoral region in different racial groups •Each mature breast has a nipple in the center which is composed of mainly erectile tissue. •The nipple becomes more rigid and prominent during the menstrual cycle, sexual excitement, pregnancy, and lactation •The nipple is surrounded by the heavily pigmented areola. Both nipple and areola are covered with small papillae called tubercles of Montgomery. These secrete a fatty substance that helps lubricate and protect the breasts while a baby nurses. •Composed of glandular, fibrous, and adipose tissue •Glandular tissue consists of acini, or alveoli which are arranged in a series of 15 to 24 lobes separated by adipose and fibrous tissue •Each lobe made up of grapelike clusters of alveoli around tiny ducts which are lined with cuboidal epethelium, which secretes the components of milk. Ducts from several lobules combine to form larger lactiferous ducts, which open on the nipple surface. Smooth muscle of the nipple causes erection of the nipple on contraction. •Cyclic hormonal control of the breast is complex: –estrogenic hormones stimulate growth and development of ductal epithelium –progesterone (w/estrogen) -acinar and lobular development during luteal phase of menstruation –adrenal corticosteroids, prolactin, somatotropin, and thyroxine also necessary for progesterone and estrogen to act •Arterial, venous, and lymphatic systems communicate medially with mamary vessels and laterally with axillary vessels. In CA of the breast, metastasis follows the vascular supply both medially and laterally. •What is the function of the breasts? •Provide nourishment and protective maternal antibodies to infants through the lactation process. Also a source of pleasurable sexual sensation.