fINAL MCHN Slides1

Maternal and Child
Health Nursing
PART I
MARY LOURDES NACEL G. CELESTE, RN, MD 1

Man as a Sexual being
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
 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.
 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.
 Human sexuality is in fact
fundamental to life and has
much a broader meaning than
the physical act of sex alone.
 It can lead ultimately to

either a sustained
relationship with a mate or it
can be sublimated through
outlets having a social value.
Sex and Procreation
 Sex is a biological need of
human beings.
 Sexual response is one aspect
of human reproduction.

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.

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.
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)
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
desires rooted in his/ her sexuality that 10
MARY LOURDES NACEL G. CELESTE, RN, MD
 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.
 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

Three Basic Elements of
Sexual Health
 capacity to enjoy and control

sexual and reproductive
behavior in accordance with a
social and personal ethic

Sexual Health
 freedom from fear, shame,

guilt, false beliefs and other
psychological factors
inhibiting sexual response
and impairing sexual
relationship

Sexual Health
 freedom from organic

disorders, diseases and
deficiencies that interfere
with sexual and reproductive
function

 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.
 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.
 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

Four Elements of Sexual
Normalcy
 There must be a congruence of

the various components of
sexual identity: anatomical,
behavioral, chromosomal,
hormonal.

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.

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.
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.

Responsible
Parenthood
The world responsibility may mean different things to different
people.

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.
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 MARYthe
LOURDESneeds ofRN, their
NACEL G. CELESTE, MD children.
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.
Maternal and Child Health
Nursing
 a conceptual approach to
nursing care that views
maternity and child health
nursing as a continuum, not
separate entities

Nursing
 Involves care of the woman

and family throughout
pregnancy and childbirth and
the health promotion and
illness care for the children
and families

Goal of Maternal and Child Health
Nursing
 Promotion and
maintenance of optimal
family health to ensure
cycles of optimal
childbearing and
childrearing
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)
Philosophies of Maternal
and Child Health Nursing
 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
Philosophies of Maternal
and Child Health Nursing
 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
Philosophies of
Maternal and Child
Health Nursing
 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.
Framework of Nursing
Care:
Four Phases of Health
Care
 Health promotion
 Health maintenance
 Health restoration
 Health rehabilitation

Care
 Healthpromotion
- educating clients to be
aware of good health
through teaching and role
modeling

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

Four Phases of Health Care
 Healthrestoration
- promptly diagnosing and
treating illness using
interventions that will
return client to wellness
most rapidly
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
The Nursing
Process
 Applicable for all health care
settings
Assessment
Nursing diagnosis
Planning
Implementation
Evaluation
Evidence-Based
Practice
 Useof research or
controlled investigation of
a problem in conjunction
with clinical expertise as a
foundation for action

Nursing
Research
Controlled investigation of

problems that have implications
for nursing practice
Justification for implementing
activities for outcomes
Results in improved and cost-
effective patient care

Nursing Theories
 How nurses view clients
 Goals of nursing care
 Activities of nursing care

Maternal and Child Health Nursing

Maternal and Child Health Nursing
 20th century
Infant mortality rate >100 per
1,000
 Today
6.9 per 1,000

Trends in Maternal and Child Health
Nursing Population

Trends in Health Care
Environment
 CostContainment
 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
Environment
 Alternative settings and

styles
Home
Hospitals
Birthing centers
 Strengthening the
ambulatory care setting
 Shortening hospital stays
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

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

Environment
-Increasing emphasis on family-

centered care
-Increasing concern for quality of
life
-Increasing awareness of the
individuality of clients
-Empowerment of health care
consumers
Advanced Practice Nursing
 Nurse practitioner
Women’s health
Family
Neonatal
Pediatric

Advanced Practice Nursing
 Clinical
nurse specialists
 Case manager
 Nurse-midwife

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
Ethical Considerations
 Conception issues
 Abortion
 Fetal rights
 Resuscitation
 Procedures
 Quality of life
 Research

The Childbearing
and Childrearing
Family and
Community
Family Theory
Aset of perspectives from
the family’s point of view
Helps nurses address
important health issues of
the childbearing and
childrearing family

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

planning
 Implementation
 Outcome evaluation

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

Nursing Diagnoses:
 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
Family
 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)

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)

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

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

Family Types
 Family of orientation:
- the family one is born into
 Family of procreation:
- a family one establishes

 Nuclear family:
- family composed of husband,
wife and children

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

 Single parent family:
- family with one
parent

 Cohabitation
family:
- composed of
heterosexual
couples who live
together like a
nuclear family
but remain
unmarried (may
be temporary or
lasting)
 Extended (multigenerational) family:
-includes not only nuclear family but
also other family members

Blended family:
- divorced or widowed person with childr
marries someone who also has
children
 Communal
family:
- group of people
who have chosen
to live together
as an extended
family

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

 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
 Adoptive family:
- families who
adopt children
for various
reasons:
 inability to have children

biologically
 biological parents are
unable to provide care
and are willing to have
their children adopted
Methods of
Adoption
 Agency
 International adoption
program
 Private resources

Family Functions and
Roles
 Passed from one
generation to the next
 Changing and not well
defined

 FAMILY ROLES AND FUNCTIONS:
-WAGE EARNER
-FINANCIAL MANAGER
-PROBLEM SOLVER
-DECISION MAKER
-HEALTH MANAGER /
NURTURER
- GATE KEEPER

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
8 Essential Family
Tasks
 Physical maintenance
 Socialization of family
members
 Allocation of resources
 Maintenance of order

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

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 school-
aged children
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
Patterns of Family Life
 Mobility patterns
 Poverty
 Reduced government aid

programs
 The homeless family
 Increasing number of one-parent

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

health monitoring
 Increased abuse in families

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

FAMILY GENOGRAM

Family Structure
 Wellfamily
 Family in crisis
Assessment:
 Genogram
 Family APGAR

Family as Part of a
Community
 Community
Geographical areas in which
residents relate and interact
among themselves

Sociocultural
Aspects of
Maternal and Child
Health Nursing
Ethnicity
Cultural group into
which a person
was born

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

Culture
A view of the world
and a set of traditions
that a specific social
group uses and
transmits to the next
generation
Cultural Values
Preferred ways of acting
based upon traditions
 Norms/
Mores – usual
customs

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

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

Stereotyping
Expecting a person to
act in a characteristic
way without regard to
his or her individual
characteristics

Assessing for Cultural Values

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
Sociocultural Differences:
 Peoplebring cultural
values and beliefs to
nursing interactions, and
these affect nursing and
health care.

Cultural aspects that are important
to assess:
 Assessment techniques
 Use of conversational space
 Time orientation
 Work orientation
 Family orientation

 Male and female roles
 Religion
 Health beliefs
 Nutrition practices
 Pain Responses
Pain threshold
Pain tolerance
Reproductive
and Sexual
Health
Reproductive Development
 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
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.
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
“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.
 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
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

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

Reproductive Anatomy and
Physiology
 Malereproductive
system
External structures
 Scrotum
 Testes
 Penis

Physiology
Male internal structures
 Epididymis
 Vas deferens
 Seminal vesicles
 Prostate gland
 Bulbourethral glands
 Urethra

 MALE REPRODUCTIVE SYSTEM

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
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
suspended outsideMARYthe
LOURDESbody.
NACEL G. CELESTE, RN, MD 113
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)
 Beginning in early adolescence,
boys need to learn testicular self-
eamination.
 Testes should feel firm, smooth,
egg-shaped.

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)

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
Physiology
 Female reproductive
system
External structures
Internal structures

EXTERNAL REPRODUCTIVE
SYSTEM

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.
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:

Arteries: a. pudendal artery b. inferior
MARY LOURDES NACEL G. CELESTE, RN,rectus
MD artery. 121
Vein: Pudendal vein

Physiology
 FEMALE
INTERNAL
STRUCTURES
1. Ovaries
2. Fallopian
tubes
3. Uterus
4. Vaginal MARY LOURDES NACEL G. CELESTE, RN, MD 123
canal
Female reproductive system
Internal structures

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

Ovary
3 principal
divisions:
b. protective layer of
surface epithelium
b. The cortex filled with

follicles
c. The central medulla

containing nerves,
- Firm almond shaped blood vessels,
organ covered by lymphatic tissue and
the peritoneum some smooth muscle
tissue
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
ovary to uterus MARY LOURDES NACEL G. CELESTE, RN, MD 127
Fallopian Tube4 parts
2. Infundibulum- funnel
shape, with fimbriae
2. Ampulla- wide
middle segment;
usual site of
FERTILIZATION
3. Isthmus- narrowest
•Bilateral ducts part
extend laterally from
the uterus 4. Interstitial or
Intramural-
•receive oocyte and embedded in the
provide site for uterine
MARY LOURDES NACEL G. CELESTE, RN, MD wall 128
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 -an impt. relationship in estimating the
External cervical os level
MARY LOURDES NACEL of dilatation
G. CELESTE, RN, MD of the fetus
129
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

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
 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

layers of the
endometrium
1. Stratum Functionale
– Stratum compactum
– Stratum spongiosum
2. Stratum basale or germinativum

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

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
Vein: pudendal vein
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.”

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
Physiology
 Female internal structures
Vagina
Breasts
Pelvis

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 143
Analogous Structures
Female Male
Glans Clitoris Glans penis
Labia majora Scrotum
Vagina Penis
Ovaries Testes
Fallopian tubes Vas deferens
Skene’s glands Prostate glands
Bartholin’s glands Cowper’s glands
Ovum Spermatozoa

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
Menstruation
 Episodic uterine bleeding
in response to cyclic
hormonal changes
 Brings an ovum to maturity
and renews uterine tissue
bed
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

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

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
MARY LOURDES NACEL G. CELESTE, RN, MD - none 153
Uterine cycle
3 phases
2.Menstrual phase
3.Proliferative phase
4.Secretory phase

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

Proliferative Phase
 Days 5- day 14
 Eptihelial cells of
functionale multiply and
form glands
 Due to the influence of
estrogen
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
Ovarian cycle
3 phases
1. Pre-ovulatory : follicular
phase
2. Ovulatory phase
3. Post-ovulatory : Luteal
phase
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
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
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
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
3. Ovulatory phase
– Increased LH (surge); Increased
Estrogen
4. Post ovulatory/luteal Phase

– Increased Estrogen, increased
progesterone until corpus luteum
degenerates
‘

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)
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

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

Education

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

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
- 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)
C. PREMATURE MENOPAUSE:
- manifested by permanent
amenorrhea before 35 years of
age due to:
1.genetic predilection
2.ovarian failure due to auto-
immune reaction
Concerns
1. Loss of childbearing capacity
2. Loss of youth
3. Skin changes-related to estrogen deficiency
that has a role in collagen storage and
restoration
4. Depression-related to changes in
relationship w/ children, spouse and other
life events
5. Anxiety and irritability –”climacteric
syndrome”; psychocial
6. Loss of libido-related to
MARY LOURDES NACEL vaginal
G. CELESTE, RN, MD atrophy 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
11. Cardiovascular disease
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
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
MARY LOURDES male pattern
G. CELESTE, RN, MD distribution
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
 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

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

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
Treatment:
Intermittent progestin therapy

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

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

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 MARY LOURDES NACEL G. CELESTE, RN, MD 194
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
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
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

Etiology and Risk
Factors
- Caffeine
- Smoking
- Lack of exercise
- Improper diet
- Inadequate sleep
- Stress
Management:
supportive
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
Risk Factors
 Multiple sexual partners
 History of PID
 Early onset sexual activity
 Recent gyne procedure
 IUD

Manifestations
 pelvic pain – sharp and cramping
 Fever
 Excessive vaginal discharge
 Menorrhagia
 Metrorrhagia
 Urinary symptoms
 Cervical uterine tenderness with
movement
Diagnostics
 History and PE
 CBC
 Vaginal and endocervical culture
 VDRL
 Endometrial biopsy - endometritis
 Sonography – tubo-ovarian
abscess
 Laparoscopy - salpingitis
Management
 Antibiotics
 IV fluids/increase oral fluid
 Pain medications
 Remove IUD
 Evaluation of sexual partners

Sexuality and Sexual
Identity
 Terms
Biologic gender
Gender identity
Gender role

Identity
 Development of gender
identity
Infancy
Preschool
School-age
Adolescent

Identity
 Development of gender
identity
Young adult
Middle-aged adult
Older adult
Physically challenged

Human Sexual Response
 Sexual
response cycle
(Masters and Johnson)
Excitement
Plateau
Orgasm
Resolution
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
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
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
 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

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

Sexual
Orientation
 Heterosexuality
 Homosexuality
 Bisexuality
 Transsexuality

Sexual Expression
 Celibacy
 Masturbation
 Erotic stimulation
 Fetishism

Sexual Expression
 Transvestism
 Voyeurism
 Sadomasochism
 Other

Sexual
Harassment
 Unwanted, repeated sexual
advances, remarks or
behavior toward another
Offensive to recipient
Interferes with job
performance
Disorders of Sexual
Functioning
 Sexual Desire Disorders
Inhibited sexual desire
 Sexual Arousal Disorders
Failure to achieve orgasm

Disorders of Sexual
Functioning
 Orgasm Disorders
Erectile dysfunction
Premature ejaculation
 PainDisorders
 Vaginismus
 Dyspareunia/Vestibulitis

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

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 MARYthe
LOURDESneeds ofRN, their
NACEL G. CELESTE, MD children.
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.
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

Responsible
Parenthood
Purposes of Family Planning
 improvement of health
 promotion of human right to
determine reproductive
performance
 relation of demographic
change to economic
development
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

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
To the children,the practice
family planning will make
them
 Healthier
 Happier
 feel wanted and satisfied
 secure

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
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

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
Contraceptive
 Any device used to prevent
fertilization of an egg

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
CONTRAINDICATIONS OF CONTRACEPTIVE USE

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

Contraceptives
1. Abstinence
 0% failure rate
 Most effective method to
prevent STDs
 Difficult to comply with

Contraceptives
2. Natural Family Planning

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

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

Calendar/ Rhythm
(Natural Family
Planning)
 Action – periodic abstinence from
intercourse during fertile period;
based on the regularity of
ovulation; variable effectiveness

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
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 241

 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.
 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.

 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

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 25 26
1
18 DAYS
LONGEST CYCLE
2 3 4 5 6 7 8 9 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3
1 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
11 DAYS
UNSAFE TIME
1 2 3 4 5 6 7 8 9 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3
0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
UNSAFE TIME

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
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

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!!
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
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
Symptothermal
method
 Combines BBT and cervical
mucus methods

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

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
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 255
Contraceptives
3. Oral Contraceptives
 Composed of varying amounts of
estrogen combined with small
amount of
progesterone
99.5% effective

 Estrogen
suppresses FSH
and LH, thereby
suppressing
ovulation
 Progesterone
decreases the
permeability of
cervical mucus
 Monophasic - Fixed doses of
estrogen and progesterone ; 21-
28 day cycle
 Biphasic - Constant amount of
estrogen with increased
progesterone
 Triphasic - Varying levels of
estrogen and progesterone
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

Side Effects
 Nausea
 Weight gain
 Headache
 Breast tenderness
 Breakthrough bleeding
 Monilial vaginal infections
 Mild hypertension
 Depression

Absolute Contraindications to OC’s

 Breastfeeding
 Family history of CVA or CAD
 History of thromboembolic
disease
 History of liver disease
 Undiagnosed vaginal bleeding

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

 Migraine or other vascular type
headaches
 Obesity
 Pregnancy
 Seizure disorders
 Sickle cell or other
hemoglobinopathies
 Smoking
 Use of drug with interaction effect
Other Contraceptives
 Continuous or extended regimen
pills
 Mini-pills
 Estrogen-progesterone patch
 Vaginal rings

Estrogen-progesterone
patch

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

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

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)
INTRAUTERINE DEVICE

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

6. Barrier Methods
 Vaginally inserted spermicidal
products
 Diaphragms
 Cervical caps
 Condoms

6. BARRIER METHODS
 SPERMICIDAL
AGENT
goal: to kill the
sperm before the
sperm enters the
cervix
-Nonoxynol-9
-gel, creams,
films,foams,
suppositories
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
forRN,2-3
MARY LOURDES NACEL G. CELESTE, MD years 276
6. BARRIER METHODS
 CERVICAL CAP
-similar to
diaphragm but
smaller
-thimble-shaped
rubber cap held
onto the cervix
by suction

6. BARRIER METHODS
MALE CONDOM FEMALE CONDOM

 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
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
STERILIZATION
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%
8. Elective
Termination of
Pregnancy
Procedure to deliberately end a
pregnancy before fetal viability
 Induced
(mifepristone-progesterone
antagonist; misoprostol-
prostaglandin analog
 Medically induced
D&C, D&E, saline induction,

hysterotomy
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
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
 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

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
– 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

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 )

Male Infertility Factors
 Inadequate sperm count

 Obstruction or impaired
sperm motility
 Ejaculation problems

 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
MARY LOURDES from being
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

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

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

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

Female Infertility Factors
 Anovulation
 Tubal transport problems

 Pelvic inflammatory
disease
 Uterine problems
 Endometriosis
Common Sites 0f Endometriosis Formation

Female Infertility Factors
 Cervicalproblems
 Vaginal problems
 Unexplained infertility

 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

 Tubal factor:
– Pelvic inflammatory disease
 Uterine factor:
– Tumor ( fibroma)
– Congenitally deformed uterine
cavity
– Endometriosis
– Inadequate endometrium
formation
 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
Fertility
Assessment
 Health history
General health
Nutrition
Alcohol, drug or tobacco use
Congenital health problems
Current illnesses

Fertility
Assessment
 Health History
Menstrual history
Contraceptive use
Pregnancies or abortions

Fertility
Assessment
 Physical assessment
Secondary sex characteristics
Genital abnormalities
Breast and thyroid
examination

Fertility
Assessment
 Fertility testing
Semen analysis
Ovulation monitoring
Tubal patency assessment

Semen Analysis
 Number of sperm
 Appearance of sperm
 Motility of sperm
 Sperm penetration

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

Tubal Patency
 Sonohysterography
Ultrasound to inspect uterus
 Hysterosalpingography
Radiologic exam of fallopian
tubes

Advanced Surgical
Procedures
 Uterineendometrial biopsy
 Hysteroscopy
 Laparoscopy

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
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
– 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
312
 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
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
– * 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

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

 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

2. environmental function:
-fertilization of the ovum
-capacitation of spermatozoa
-early development and
segmentation of the fertilized
ovum

*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

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 320
 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
*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

 Corpus luteum production of progesterone-
must 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
 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

- 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
– 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 326
– 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
– 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

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
Infertility Management
 Correction of underlying problem

 Increasing sperm count and
motility
 Reducing the presence of
infection
 Hormone therapy
 Surgery

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

 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
MARY LOURDES or G.more ofMD them will
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
 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
ARTIFICIAL INSEMINATION

IN VITRO FERTILIZATION

Childbirth Alternatives
 Surrogate mothers
 Adoption
 Child-free living

Genetic Assessment
and Counseling
Facts
1 in 20 newborns has an
inherited genetic disorder
 Over 30% of pediatric
admissions are for genetic-
influenced disorders

Genetic Disorders
 Inheritedor genetic
disorders -disorders
that can be passed from
one generation to the next
 Genetics
-Study of why disorders occur
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
Normal Female
Karyotype
Mary Lourdes Nacel G. Celeste, R.N., M.D.

Normal Male
Karyotype

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
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)
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)
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
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)
Dominant and Recessive
Patterns
 Dominant genes – genes
which are expressed in
preference to others
 Recessive genes – genes
that are not dominant

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

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.

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

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.

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

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
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
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.
Autosomal dominant traits

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)
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

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
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
cells MARY LOURDES NACEL G. CELESTE, RN, MD 363
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
GROUP Disorder
Blacks/ African Sickle cell

Americans Anemia
Northern European Tay-Sachs
descendants of disease
Ashkenazic Jews
Caucasian/ Non- Cystic fibrosis
Hispanic
Mediterranean Thalassemia
descendants
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.
X-linked disorders
 Result from an altered gene on
the X chromosome
 May be dominant or recessive;
recessive is more common

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, R.N., M.D.

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
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
X-linked recessive
 Hemophilia
 Color blindness
 Duchenne-type muscular
dystrophy
 Christmas disease
 Fragile X syndrome

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
Multifactorial
inheritance
 Cleft lip or palate
 Neural tube disorders
 Mental illness
 Pyloric stenosis
 Hypertension
 Heart disease
 diabetes
Imprinting
 Differential expression of genetic
material which allows researchers
to identify whether the
chromosomal material has come
from the male or female parent

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

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
 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
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
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
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

4. Mosaicism
 Abnormal chromosomal division
in the zygote resulting in 2 or
more cell lines with different
chromosomes
 Down syndrome (those with near-
normal intelligence), some cases

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
Genetic
Counseling
 Purpose
Provide accurate information
Provide reassurance
Make informed choices
Educate people about
disorders
Offer support
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
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
(chromosomally female)
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
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,
thalassemiaMARY LOURDES NACEL G. CELESTE, RN, MD 390
Chronic villi sampling

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
Amniocentesis

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
Percutaneous
umbilical blood
sampling

 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
Common Chromosomal
Disorders
 Detected at birth on physical examination

 Most common are nondisjunction syndrome
 Many of these disorders leave children
cognitively challenged

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
- 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
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
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
problems MARY LOURDES NACEL G. CELESTE, RN, MD 402
 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
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
symptoms of poor concentration and
impulsivity; intellectual function cannot be

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<NACEL
MARY LOURDES 20)
G. CELESTE, RN, MD 405
 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
The Growing Fetus
Stages of Fetal
Development
During pregnancy, the fetus
undergoes 3 major stages of
development:
2. PRE-EMBRYONIC PERIOD –
fertilization to week 2
3. EMBRYONIC PERIOD –
week 3 – week 8
3. FETAL PERIOD – week 8 to birth
Stages of Fetal
Development
 Fertilization
Beginning of pregnancy
Union of the ovum and
spermatozoon
Usually occurs at the outer
third of fallopian tube

Stages of Fetal
Development
 Implantation
Contact between growing
structure and uterine
endometrium
Occurs 8-10 days after
fertilization

Embryonic and Fetal
Structures
 Decidua
 Chorionic villi
 Placenta

Embryonic and Fetal Structures
 Endocrine Function
Human Chorionic
Gonadotropin
Estrogen
Progesterone
Human Placental Lactogen

Embryonic and Fetal
Structures
 Umbilical Cord
From fetal membranes
Provides circulatory pathway
Contains one vein and two
arteries

Embryonic and Fetal
Structures
 Amniotic Membranes
Chorionic membrane
Amniotic membrane

Embryonic and Fetal
Structures
 Amniotic Fluid

Fetal System Development
 Circulatory
 Respiratory
 Nervous
 Endocrine
 Digestive

Fetal System
Development
 Musculoskeletal
 Reproductive
 Urinary
 Integumentary
 Immune

Estimated Birth
Date

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

 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 Y-
carrying sperm produces a male (XY)
 Aberration in the number of chromosomes result
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

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
 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 MARYplacental formation
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
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
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
placenta
 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)
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
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
fetus MARY LOURDES NACEL G. CELESTE, RN, MD 434
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

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
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
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

Placental Circulation

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

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

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)

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
2. Endocrine:
secretes 5 hormones
1. hCG- basis of pregnancy test
2. human placental lactogen
3.estrogen.
4.progesterone
5.relaxin
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
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

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

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

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

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)

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

week 4 - (wt 0.4g, length is 4-
6mm), 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
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
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
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
bornMARY LOURDES NACEL G. CELESTE, RN, MD 458
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
LOURDES NACEL G. CELESTE, RN, MD of 459
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
Fetal
Circulation

Fetal circulation:
oxygenated blood(placenta)
umbilical vein
liver ductus venosus
inferior vena cava
right atrium
foramen ovale( flap opening in the atrial septum

that allow only R-L movement of
blood)

 Continuation:
left atrium
left ventricle right ventricles( small

amount)
aorta pulmonary arteries

ductus arteriosus
supply the body aorta
supply blood to the body

 Continuation:
superior vena cava
right atrium
right ventricle
pulmonary arteries
( ductus arteriosus)
aorta
supply blood to the body

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
 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
conception
 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
MARY LOURDES encounters
NACEL G. CELESTE, RN, MD hypoxic 467
stress anal sphincter may
 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
- end of 12 th
week
MARY LOURDES skeletal
NACEL muscles begin468
G. CELESTE, RN, MD
involuntary movement( depend on volume

 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
ovaries develop inG.the
MARY LOURDES NACEL abdomen
CELESTE, RN, MD and 469
stay in the pelvic cavity

 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
-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
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
 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
week; after which it 473
Assessment of Fetal Growth
Assessing fetal well-being
Fetal movement Maternal serum
alpha-fetoprotein
Fetal heart rate
Triple screening
Ultrasound (AFP, estriol and
Nonstress Test hCG)
Electrocardiograp Chorionic villi
sampling
hy
Amniocentesis
MRI Percutaneous
Amnioscopy umbilical blood
Fetoscopy sampling
Fetal movement
 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 476
 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
 Cardiff method – Count to ten

- records the time it takes for her to
feel 10 fetal movements; usually
within 60 minutes
Fetal heart rate
 FHR should be 120-
160
beats per minute
 Can be heard with a

Doppler : 10 – 11th
week of pregnancy
 Fetoscope: 18-20
weeks
ANTENATAL FETAL TESTING

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,
MARY LOURDES NACEL G. CELESTE, empty
MD bladder 480
 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
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

Biophysical profile
(BPS)
 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
Nonstress Test
 Measures the
response of fetal
heart rate to fetal
movement
 Determines fetal well-
being
 Performed to assess
placental function
and oxygenation
 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 side-
lying 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.
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.
 UNSATISFACTORY – The result cannot be interpreted

because of the poor quality of the FHR tracing.
Contraction Stress
Test
 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.
 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
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.
 EQUIVOCAL – with decelerations but with less than

50% of the contractions, or the uterine activity
shows a hyperstimulated uterus.
 UNSATISFACTORY – adequate uterine contractions

cannot be achieved, or the FHR tracing is not of
sufficient quality for adequate interpretation.

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
 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
 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
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
7. Estriol levels
– serial 24-h maternal urine

samples or serum specimens
to determine fetoplacental
status; falling levels usually
indicate deterioration

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

Psychological and
Physiologic
Changes of
Pregnancy
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)
 Frequent urination
Probable signs of
pregnancy – objective, can be
documented by examiner; increased
suspicion of pregnancy but still not the
true Laboratory
 Serum diagnostic testsproof
(hCG)
 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
MARY LOURDES sac
 Uterine soufflé – a muffed swishing sound over the
 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
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
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

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
MARY LOURDES NACEL and
G. CELESTE, RN, MD its 504
contents weigh about 12 lb

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
FUNDIC HEIGHT AT VARIOUS AGES OF GESTATION

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.
 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
Vagina and external genital organs
enlarge, soften, thicken, and develop blue-
violet 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

 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
oxytocin MARY LOURDES NACEL G. CELESTE, RN, MD 510
 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 511
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

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

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

 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

 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 intra-
abdominal pressure of the
enlarged uterus toward the end of
the pregnancy)
 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

 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
 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
expansionMARY LOURDES NACEL G. CELESTE, RN, MD 524
 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 525
 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

 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

 Second trimester
 ACCEPTING THE BABY
 -usually increased maternal
feelings of physical and emotional
well-being; mother is often
described as self-absorbed and
introverted

 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
 Paternal reactions – may
parallel those of mother; some
may experience physical
symptoms of pregnancy
(couvades syndrome)
 Adaptation of siblings – age
and experience related

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

Health Promotion During Pregnancy
 Preconceptual visit
Health history
Pelvic exam
Pap test
Labs

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

PRENATAL
ASSESSMENT
A. VERIFYING PREGNANCY
 Signs and Symptoms
Presumptive
Probable
Positive
 Pregnancy Test
B. Estimated Date of Delivery/ Confinement

EDD/ EDC
Measure Fundic Height
C. Health
Assessment
 Initial
 History of
interview family illness
Health history  Gynecologic
 Demographic history
data  Obstetric
 Chief concern history
 Family profile  Review of
 History of past systems
illnesses
Health Assessment
 Initial
interview
Support
person’s role
Physical exam
 Baseline
height/weight,
vital signs
 Assessment of
systems
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
pregnancy MARY LOURDES NACEL G. CELESTE, RN, MD 541
 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
 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

 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)
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
adequacy of diet, vitamin supplements
LOURDES NACEL G. CELESTE, RN, MD
2. Interim History
 Frequency, intensity, and
management of discomforts of
pregnancy
 Abnormal signs and symptoms or
risk factors
 Changes in emotional, financial,
marital status
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
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
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,
32, and 40 wkMARY LOURDES NACEL G. CELESTE, RN, MD 549
 ultrasound
Assessment of
systems
 General  Neck
appearance and  Lymph nodes
mental status
 Head and scalp  Heart
 Eyes  Lungs
 Nose  Back
 Ears
 Rectum
 Sinuses
 Mouth, teeth and  Extremities and
throat skin
Health Assessment
 Fundal height and fetal heart sounds
 Pelvic exam
External genitalia
Internal genitalia
 Pap smear
 Vaginal inspection
 Exam of pelvic organs
 Rectovaginal exam

THE APPEARANCE OF THE CERVIX
1. NULLIGRAVID 2. AFTER CHILDBIRTH 3. AFTER MILD CERVICALTEARING (Stellate)

Health Assessment
 Estimating pelvic size
Type
Measurements
 Diagonal conjugate
 True conjugate or conjugate vera
 Ischial tuberosity diameter

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
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;
usually adequate for vaginal delivery (25% of
TYPES OF PELVIS

 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

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
 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
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
Measurement of Diagonal Conjugate

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

 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

 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

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

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.

First Maneuver
Palpation of the Uterine
Fundus

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

 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.

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

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.

 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.

Third Maneuver
(Lower uterine segment or uterine
pole)

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.
 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
side as the fetal back.
Fourth Maneuver
(pelvic palpation of the uterus
- assess the presenting part)

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
easily palpated, fetus is at posterior position (occiput pointing
towards woman’s back).

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Maternal and Child

MARY LOURDES NACEL G. CELESTE, RN, MD 1

 Although the sex of the child

 It can lead ultimately to

MARY LOURDES NACEL G. CELESTE, RN, MD 6

MARY LOURDES NACEL G. CELESTE, RN, MD 7

MARY LOURDES NACEL G. CELESTE, RN, MD 12

 capacity to enjoy and control

MARY LOURDES NACEL G. CELESTE, RN, MD 13

 freedom from fear, shame,

MARY LOURDES NACEL G. CELESTE, RN, MD 14

 freedom from organic

MARY LOURDES NACEL G. CELESTE, RN, MD 15

 While the definition does not exclude it,

 This does not suggest though that sexual

important element of sexual health.

MARY LOURDES NACEL G. CELESTE, RN, MD 17

 There must be a congruence of

MARY LOURDES NACEL G. CELESTE, RN, MD 18

 There must be in the

MARY LOURDES NACEL G. CELESTE, RN, MD 19

 There should be a capacity to

MARY LOURDES NACEL G. CELESTE, RN, MD 21

 With specific reference to marriage and

 Although some people object to

MARY LOURDES NACEL G. CELESTE, RN, MD 25

 Involves care of the woman

MARY LOURDES NACEL G. CELESTE, RN, MD 26

MARY LOURDES NACEL G. CELESTE, RN, MD 32

MARY LOURDES NACEL G. CELESTE, RN, MD 33

MARY LOURDES NACEL G. CELESTE, RN, MD 34

MARY LOURDES NACEL G. CELESTE, RN, MD 38

MARY LOURDES NACEL G. CELESTE, RN, MD 39

 Activities of nursing care

MARY LOURDES NACEL G. CELESTE, RN, MD 40

MARY LOURDES NACEL G. CELESTE, RN, MD 41

MARY LOURDES NACEL G. CELESTE, RN, MD 42

MARY LOURDES NACEL G. CELESTE, RN, MD 43

 Alternative settings and

MARY LOURDES NACEL G. CELESTE, RN, MD 46

 Increased reliance on home care

MARY LOURDES NACEL G. CELESTE, RN, MD 47

-Increasing emphasis on family-

MARY LOURDES NACEL G. CELESTE, RN, MD 49

MARY LOURDES NACEL G. CELESTE, RN, MD 50

 Identifying and reporting

MARY LOURDES NACEL G. CELESTE, RN, MD 52

MARY LOURDES NACEL G. CELESTE, RN, MD 54

 Outcome identification and

MARY LOURDES NACEL G. CELESTE, RN, MD 55

MARY LOURDES NACEL G. CELESTE, RN, MD 56

MARY LOURDES NACEL G. CELESTE, RN, MD 58

MARY LOURDES NACEL G. CELESTE, RN, MD 59

 The dyad family

 The nuclear family

 The cohabitation family

 The extended family

MARY LOURDES NACEL G. CELESTE, RN, MD 60

 The communal family

 The gay or lesbian family

 The foster family

 The adoptive family