2EARLY DEVELOPMENT Male & Female organs produce sex cellstransport for unionSex Differentiation at 8 weeks of lifeOvary - produces oogonia at 10 weeks of fetal life; approximately 150,000 oocytes present at birthTestes - produces spermatoza at 7-8 weeks
7Layers of the Uterus Perimetrium Myometrium Endometrium outer layer composed of peritoneumMyometriuminner layer primarily in the fundus; longitudinal fibers; causes cervical effacement and power to express the babyEndometriuminnermost layer, produces endometrial milk, undergoes monthly regeneration
9Myometrium Muscular Layer - composed of 3 distinct layers Longitudinal fibers found mainly over the fundus; most involved with birth of fetusFibers interlaced with blood vessels in Figure 8 pattern; living ligature – helps stop bleedingCircular fibers concentrated around fallopian tubes and cervical os; helps keep cervix closed
11Internal Organs con. Isthmus Cervix Joins corpus to the cervix Site for lower C/SCervixComposed of fibrous connective tissueLength 2.5 to 3 cm (~1-2”)FunctionsPassage of menses and spermProduces mucus in response to cyclic hormonesFrequent site for uterine cancer
12Bottom of Cervix, Cells are taken from here for Pap Smear
13Uterine Ligaments Think which ligaments cause pain during pregnancy Broad ligament – stabilizes uterus, covers uterus anteriorly and posteriorlyRound ligament – helps keep uterus in place from the sides, pain on sides late in pregnancyOvarian ligament – anchors lower part of ovary, helps catch ovum in fimbriaeCardinal ligament – chief uterine support, prevents uterine collapseUterosacral ligament – support for uterus at level of the ischial spine, source of menstrual pain
14Figure 2–5b Interlacing of uterine muscle layers.
16Fallopian TubesFunctions – provide passageway for ovum into uterus, site for fertilizationFimbriae – most distal part, wavelike motion that pulls ovum into tubeAmpulla – site for fertilizationIsthmus - close to uterus, site for BTL
18Ovaries At birth, all ova are contained within immature follicles FunctionsOvulationProduce hormones
19Bony PelvisFunctions – to support and protect the internal organs of reproductionInnominate BonesIlium – upper prominence of hipIschium – under the ilium, ends in ischial tuberosity, serves as reference point for stationPubis – (2 separate bones) front of innominate, meets other to form symphysis pubisSacrum – 5 fused vertebrae, sacral promontoryCoccyx – (Tail bone) triangular bone last on vertebral column, moves backward in childbirth (Sometimes can get fx’d during childbirth)
20Figure 2–8 Pelvic bones with supporting ligaments.
21Pelvic Floor (Muscles) Designed to overcome force of gravityProvides stability and support for surrounding structures (Help body remain intact, until baby is ready for birth)Pelvic diaphragm – deep fascia, levator ani, and coccygeal musclesMuscles function as a whole, yet are able to move over one another – provides capacity for dilatation
22Figure 2–9 Muscles of the pelvic floor Figure 2–9 Muscles of the pelvic floor. (The puborectalis, pubovaginalis, and coccygeal muscles cannot be seen from this view.)
23Pelvic DivisionFalse Pelvis – portion above pelvic brim or inlet; serves to support pregnant uterus; helps direct presenting part into true pelvisTrue Pelvis – portion below linea terminalis; represents the bony limits of the birth canalPelvic inlet – upper border of true pelvisPelvic outlet – lower border of true pelvis
24Figure 2–10a Female pelvis Figure 2–10a Female pelvis. False pelvis is shallow cavity above the inlet; true pelvis is deeper portion of cavity below the inlet.
25Figure 2–10b True pelvis consists of inlet, cavity (midpelvis), and outlet.
26Figure 8–5a Manual measurement of inlet and outlet Figure 8–5a Manual measurement of inlet and outlet. Estimation of the diagonal conjugate, which extends from the lower border of the symphysis pubis to the sacral promontory.
27Figure 8–5b Estimation of the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum.
28Pelvic Measurements Helps figure whether baby’s head can fit. Diagonal conjugate – extends from the subpubic angle to the middle of the sacral promontory; can be measured manually (with hand) during a pelvic examTake and substract 1.5cm to get Obstetric conjugate.Obstetric conjugate – extends from the middle of the sacral promontory to 1 cm below the pubic crest (Cannot be reached/measured manually)Conjugate vera – extends from the middle of the sacral promontory to the pubic crest
29Figure 2–11 Pelvic planes: coronal section and diameters of the bony pelvis.
30CDFigure 8–5 c & d Methods that may be used to check the manual estimation of anteroposterior measurements.
31Figure 8–6 Use of a closed fist to measure the outlet Figure 8–6 Use of a closed fist to measure the outlet. Most examiners know the distance between their first and last proximal knuckles. If they do not, they can use a measuring device.
32Pelvic Types Gynecoid – most common female, adequate Android – most common male, not adequateAnthropoid – usually adequatePlatypelloid – usually not adequate
33Figure 15–1 Comparison of Caldwell-Moloy pelvic types.
34Female Sex Hormones Estrogen Maturation of secondary sex characteristicsSecreted by the maturation of ovarian folliclesCause proliferation of endometrial mucosaCauses increase in size and weight; closure of long bonesIncreases myometrial and fallopian tube contractilityIncreases uterine sensitivity to oxytocinMaintains bone densityInhibits FSH production and stimulates LH productionMay increase libido
35Female Sex Hormones con. Progesterone “keeps everything quiet”; maintains pregnancyLH stimulates corpus luteum to secrete progesteroneDecreases motility and contractility of uterusProliferates vaginal epitheliumCauses cervix to secrete thick viscous mucusAnti-spermPrepares breast tissue for lactationThermogenic “heat producing”check temp to determine ovulation“Hormone of Pregnancy”
36Female Sex Hormones con. ProstaglandinsProduces by the endometrium “lining of the uterus”Differentiated by Roman letters and numbers or Greek numbersEssential for ovulation (help egg be expelled from the ovary)Causes expulsion of the ovumProduces progesterone withdrawalFacilitates tissue digestion to cause endometrial shedding
37Neurohormonal Basis of the Female Reproductive Cycle Causes menses cycle to occur Controlled by an interaction between the nervous and endocrine systems and their target tissues – hypothalamus, anterior pituitary, and ovaries
38NEUROHORMONAL BASIS OF THE FRC CNS --- HYPOTHALMUS RELEASES ----GnRF (FSHRH & LHRH) CAUSES ANTERIOR PITUITARY TO RELEASE FSH & LH ---- STIMULATES GONADS TO SECRETE HORMONES (ESTROGEN & PROGESTERONE)In males, LH induces secretion of testosterone.In females, LH working w/ FSH stimulate follicle growth in ovary to secrete estrogen.
39Ovarian Cycle Be able to know which cycle the woman is in 1st Part- Follicular Phase (Follicles- where the immature eggs are contained)Starts with day 1 menses; 1-14 days; may varymultiple follicles are maturing; one is selected; when mature, called a graafian follicle; surrounded by fluid …and becomes a cyst on the ovary.Comes close to surface of ovary, forms a blister, ovum pushed out of the follicle near the fimbria (ovulation)Pain at mid-cycle Mittelschmerz (may see blood spotting)Pulled into fallopian tube and travels to ampulla where fertilization can occur
40Ovarian Cycle con. 2nd Part- Luteal Phase Begins with ovulation (the second half of ovarian cycle)Corpus luteum develops from the ruptured follicleIf fertilized, the ovum implants into endometriumOvum secretes HCG to maintain corpus luteum; the corpus luteum secretes progesterone and estrogen (cause you have to have high levels of H to maintain preg)If no fertilization, degenerates in about a week and becomes the corpus albicansEstrogen and Progesterone decrease which stimulates FSH and LH to be released which will start whole cycle over again.14 days after ovulation, menses begins (this remains constant) A person can then predict ovulation.
41Figure 2–14 Various stages of development of the ovarian follicles.
42Endometrial Cycle- 4 Phases 1) MenstruationCyclic uterine bleeding in response to hormones changes; begins 14 days after ovulationPartial shedding of the endometriumDischarge made up of blood, fluid, cervical and vaginal secretions, bacteria, leukocytes and cellular debris; dark red, distinctive odorMenarche- onset of menstruation; age 9-16Cycle lengths vary days; illness, fatigue, stress, anxiety, vigorous exercise can alter cycle
43Endometrial Cycle con. 2) Proliferative 3) Secretory 4) Ischemic Endometrium increases 6-8 fold, estrogen incr/peaks, cervical mucus becomes thin (to allow sperm to pass), BBT drops at ovulation then increases (Progesterone levels incr)3) SecretoryEstrogen decreases, progesterone dominates, vascularity of uterus increases, glands begin to secrete endometrial milk for fertilized ovum4) IschemicIf no fertilization, corpus luteum begins to degenerate; estrogen and progesterone levels fall; leads to tissue necrosis and small blood vessels rupture, arteries constrict decreasing blood supply to endometrium; tissue pale, menses begins
44Figure 2–13 Female reproductive cycle: interrelationships of hormones with the four phases of the uterine cycle and the two phases of the ovarian cycle in an ideal 28-day cycle.
46Three Pregnancy Periods Antepartum- from conception to the onset of laborIntrapartum- from the onset of labor to the first 1-4 hours after delivery of newborn and placentaPostpartum- refers to the 6 weeks after delivery of the newborn and placenta.
47PregnancyNine months of pregnancy are divided into three trimesters, each are three months long.All systems of a woman’s body are altered in some way during pregnancy.
48Changes of the Reproductive System Uterus - increases in capacity and size; requires one-sixth of maternal blood flow.Braxton Hicks - irregular contractions, usually painless, felt throughout pregnancy, can be confused with true labor later in pregnancyOvaries – stop ovulation; corpus luteum continues to produce hormones until 6-8 weeksUterus - increases in capacity from 10mls to 5L; this increase is primarily caused by an increase in size of cells in response to estrogen, as well as distension of the growing fetus; by the end of the pregnancy, the uterus and its contents require up to one-sixth of the total maternal blood flow. The uterine stretching causes braxton hicks contractions.Braxton Hicks contractions > irregular contractions, usually painless, felt throughout pregnancy, can be confused with true labor later in pregnancy
49Change in the Reproductive System Cervix - secretes mucus that forms a plugGoodell’s sign - softening of the cervixChadwick’s sign - bluish color of the cervix during pregnancyVagina - mucosa thickens and connective tissue relaxes; pH acidic favors yeastunder the influence of estrogen, the cervix secretes mucus that forms a plug at the opening of the endocervical canal to limit bacteria entering the uterus; increased blood flow to the cervix results in two signs:under the influence of estrogen, vaginal mucosa thickens and connective tissue relaxes; vaginal secretions thicken and increase in amount during pregnancy; the pH is acidic, 3.6 – Acidic pH favors growth of yeast organisms.
50Changes in the Reproductive System cont Breasts - increase in size and number of glandsColostrum - thin yellow secretion high in protein and immune propertiesBreasts > estrogen and progesterone cause the breasts to increase in size and to increase in the number of glands; colostrum is produced and may be expressed during the last trimester.Colostrum > a thin yellow secretion high in protein and immune properties
51Changes in the Cardiovascular System Cardiac output - increases 30-40%Pulse – increases bpmBP - decreases in the 1st and 2nd trimesters; 3rd trimester increases to pre-pregnant levelsVena cava syndrome – (Caution!) uterus compresses the vena cavaS/S: pallor, dizziness and clammy skinCardiac output increases 30 to 40% over nonpregnant output with an increase in pulse of beats/minute.Pulmonary and peripheral vascular resistance decreases 40 to 50%, lowering the BP throughout the first and second trimesters; in the third trimester, it begins to increase to pre-pregnant levels; postural hypotension may result as the pregnant uterus presses on pelvic and femoral vessels limiting blood return to the heartSupine hypotension syndrome or vena cava syndrome results as the gravid uterus compresses the vena cava resulting in decreased blood flow to the right atrium and a decrease in blood pressure.> S/S include pallor, dizziness and clammyskin> Problem can be prevented or treated bypositioning the woman on her left side with apillow under her right hip.
52Figure 7–1 Vena caval syndrome Figure 7–1 Vena caval syndrome. The gravid uterus compresses the vena cava when the woman is supine. This reduces the blood flow returning to the heart and may cause maternal hypotension.Caution for Vena cava syndrome!!! Keep head elevated or turn to one side.
53Cardiovascular System cont Blood (More volume, but blood is diluted)volume increases 45%RBCs increase 18 to 30%Plasma volume increases 50%Physiologic anemia – more dilutedBlood volume increases 45% over pre-pregnant levels. RBCs increase 18 to 30% depending on the degree of iron supplementation.Plasma volume increases 50%The greater increase in plasma over RBCs results in physiologic anemia with a decrease on hemoglobin (10-14 grams/dL) and hematocrit (32-42%) the drop in hematocrit is approximately 5 to 7%.
54Changes in the Respiratory System Growing uterus elevates the diaphragmIncreased 02 needsIncreased air volume exchangeNasal stuffiness and epistaxis from increased estrogen
55Changes of the Musculoskeletal System Teeth/gums – bleeding gums; oral hygiene important to prevent preterm laborRelaxation of the pelvic joints – “Waddling” gaitPhysiologic lordosis - lumbar spinal curvature increases compensating for weight of uterusDiastasis recti - separation of the rectus abdominal muscle
56Figure 7–3 Postural changes during pregnancy Figure 7–3 Postural changes during pregnancy. Note the increasing lordosis of the lumbosacral spine and the increasing curvature of the thoracic area.
57Changes of the Gastrointestinal System 1st trimester – Incr HCG causes N/VIncreased progesterone levels – causes decreased peristalsis reflux and constipation (Fiber and fluids important)Hemorrhoids - constipation and increased pressure on blood vessels in the rectum
58Changes of the Renal System Urinary frequencyGlomerular filtration - increases 50%Glycosuria – more prone to develop gestational diabetes.Changes of the Renal SystemIn the first trimester, the gravid uterus presses on the bladder causing urinary frequency; this is relieved in the second trimester because the uterus moves into the abdominal area, this returns in the third trimester as the presenting part presses on the bladder.Glomerular filtration increases 50% during the second trimester and remains elevated until delivery; the kidneys may not be able to reabsorb all of the glucose filtered resulting in glycosuria.Glycosuria, if present may indicate development of gestational diabetes.
59Changes in the Integumentary System Increased pigmentation - areola, nipples and vulvaChloasma - mask of pregnancyLinea nigra - darkly pigmented line from umbilicus to the pubic areaStriae gravidarum - stretch marksSweat and sebaceous gland activity increasesChanges in the Integumentary SystemIn response to increased levels of estrogen, some areas of the skin have an increase of pigmentationThis is seen primarily in areas with increased pigmentation such as the areola, nipples and vulvaChloasma > mask of pregnancy, is an increase in pigmentation on the forehead and around the eyes; it is seen most often in women of color and is aggravated by sun exposure.Linea nigra > is a darkly pigmented line that extends from the umbilicus to the pubic area.Striae gravidarum > or stretch marks, appear as reddish streaks on trunk and thighs; they result from the stretching of connective tissue caused by increased adrenal steroids; while these generally change to a shiny gray-white color after delivery, they do not disappear.Sweat and sebaceous gland activity increases during pregnancy.
60Changes in the Endocrine System Metabolism - increasesWeight gain – Norm 3 to 5 pounds 1st trimester; 1 pound/week 2nd and 3rd trimesters. (Avg 25-35lb incr throughout preg)Water retention - increased sex hormones and decreased serum proteinWater retention occurs during pregnancy caused by increased sex hormones and decreased serum protein
61Endocrine System cont Hormones Human chorionic gonadotropin (hCG)- Present only during preg, causes the N/VHuman placental lactogen (hPL)- Maintainance of preg; is an insulin antagonist; it promotes lipolysis.Estrogen- incr growth of uterus and stimulates the breast for lactation.Progesterone “keeps uterus quiet” maintains the endometrium, decreased uterine contractility, and causes relaxation of smooth muscle.Relaxin- decreases uterine contractility, contributes to the softening of the cervixPostaglandins- some contract, some relaxHuman chorionic gonadotropin (hCG), stimulates progesterone and estrogen production; it is thought to support the pregnancy and cause nausea and vomiting in the first trimester.Human placental lactogen, hPL, is a insulin antagonist; it promotes lipolysis, resulting in increased amounts of circulating free fatty acids available for metabolic use.Estrogen stimulates uterine development to support fetal growth and stimulates the ductal system of the breast for lactation.Progesterone maintains the endometrium, decreased uterine contractility, stimulates development of breast, and causes relaxation of smooth muscle.Relaxin decreases uterine contractility, contributes to the softening of the cervix, and has long-term effects on collagen.Postaglandins are lipids that are found throughout the reproductive system, contribute to the decrease seen in the placental vascular system, and probably
62Signs and Symptoms of Pregnancy 3 categories: presumptive, probable and positive.1) Presumptive – woman reportsAmenorrheaNausea and vomitingFatigueUrinary frequencyBreast changes- tender/darkerQuickening- From feeling the baby moveDefine: Quickening- the process of showing signs of life.Define: Presumptive- signs of pregnancy, ex: morning sickness
63Signs and Symptoms of Pregnancy 2) Probable - Noted by examinerGoodell’s sign - softening of cervixChadwick’s sign - bluish color, cervix, vaginaHegar’s sign - softening of lower uterine segmentEnlarged abdomenPigmentation changesStretch marksBallottement- A method of diagnosing pregnancy, in which the uterus is pushed with a finger to feel whether a fetus moves away and returns again.Positive pregnancy testPalpation of fetal outline
64Figure 7–4 Hegar’s sign, a softening of the isthmus of the uterus, can be determined by the examiner during a vaginal examination.
65Signs and Symptoms of Pregnancy 3) PositiveNoted by examiner - only caused by pregnancyFetal heartbeatFetal movement palpable by the examinerVisualization of the fetus by ultrasound
66Psychological Response of the Expectant Family to Pregnancy Turning point in a family’s lifeRole changesFinancial changesFear and anxietyDevelopmental tasks for mom and dadCultural values and beliefs
67Maternal Reactions and Responses to Pregnancy 1st TrimesterFeelings of disbelief and ambivalenceBaby does not seem realFocuses on herself and pregnancyMay experience early s/s of pregnancyIntrospectiveMood swingsFantasize about miscarriage (Many women fear miscarriage, usually w/in the 1st trimester)
68Maternal Reactions and Responses to Pregnancy 2nd TrimesterQuickening - baby a real separate person.Mom excited about pregnancyHelps plan her future and child’s futureExperiences body image changesConcern about partner’s support
69Maternal Reactions and Responses to Pregnancy 3rd TrimesterPride in pregnancyAnxious about laborConcern about baby’s healthSurge of energy close to delivery date
70Rubin’s Maternal Tasks What mom wants Ensuring safe passage for fetusSeeking acceptance of fetus by othersAssumption of mother roleLearning to give of oneself on behalf of one’s child
71Paternal Psychological Responses to Pregnancy of Partner Pride in pregnancy– virility; Manly character; The ability to procreateAmbivalence- a state in which one experiences conflicting feelings (Ambi- “both”) Ex: concerns about readinessStressConcerns and fearsCouvades- may experience certain rituals during the fatherhood transition. Also may experience certain pregnancy s/s felt by partner such as nausea, cravings and weight gain.Pride in pregnancyAmbivalence - concerns about readiness for responsibilities of parenthoodStress - may feel pressure for added financial supportConcerns and fears > change in relationship, health of baby and partnerCouvades > may experience certain rituals during the fatherhood transition. Also may experience certain pregnancy s/s felt by partner such as nausea, cravings and weight gain.
72Other Family Members Reaction Sibling rivalryThreatRegressionPreparationIncludeGrandparentsIncrease supportChildrearing practices