1. Maternal Child Health Nursing Module 1

2. Objectives – Day 1
Discuss the female reproductive system anatomy/physiology, disorders, medical treatment, nursing care.

3. Female Anatomy and Physiology
Female reproductive system
Ovaries-produce estrogen and progesterone – and eggs or ova
Fallopian tubes, sometimes called oviducts or uterine tubes - where fertilization takes place
Uterus-3 layers (endo-, myo-, peri- metrium) fundus, corpus, cervix
Vagina

5. Greater vestibular glands (Bartholin's) Vulva and perineum
Accessory Organs
In females
Oviducts
Uterus
Vagina
Greater vestibular glands (Bartholin's)
Vulva and perineum

6. Female reproductive system. The enlargement (right) shows ovulation.  

7. Female Anatomy and Physiology
External genitalia-mons pubis, labia majora/minora, clitoris, and vestibule (a recess which contains the opening to the urethra)
Accessory glands
Skene’s glands-similar to prostate gland
Bartholin’s glands-provide lubrication
Perineum
Mammary glands (breasts)

9. Female: superior inlet

10. Female: inferior outlet

13. Located in pelvic abdomen Held by ligaments
The Ovaries
Located in pelvic abdomen
Held by ligaments
Attached to uterus and body wall
Contain and release eggs during ovulation

15. Ovarian follicle (Graafian follicle) Holds ripening ova
The Ova and Ovulation
Ovarian follicle (Graafian follicle)
Holds ripening ova
Secretes estrogen
Ruptures to discharge egg cell (ovulation)
Oviduct (aka Fallopian Tube)
Tube that leads to uterus

16. The Corpus Luteum
Formed from remains of follicle after ovum is expelled
Secretes estrogen and progesterone
Usually shrinks and is replaced by scar tissue unless pregnancy initiated
Remains active during early pregnancy

17. The Oviducts: Fallopian Tubes
Extend from near ovary to uterus
Not directly connected to ovary
Fimbriae produce current that sweeps ova into oviduct
Cilia in tube lining and peristalsis of tube move ova

18. The Uterus Organ where fetus develops to maturity Myometrium
Muscular wall
Endometrium
Specialized epithelium lining
Corpus
Body
Cervix
Neck
Fundus
Supporting ligaments

19. The Cervix

20. The Vagina
Distal part of birth canal that opens to outside of body
Fornix
Posterior fornix
Cul-de-sac (rectouterine pouch or pouch of Douglas)
Hymen
Greater vestibular (Bartholin's) glands

21. Female reproductive system (sagittal section)
Female reproductive system (sagittal section). This view shows the relationship of the reproductive organs to each other and to other structures in the pelvic cavity.  

22. The Vulva and the Perineum
Vulva: external parts of female reproductive system
- Labia
- Clitoris
- Related structures
- Obstetrical perineum

23. The Menstrual Cycle
Controlled by pituitary hormones regulated by hypothalamus
Cyclic pattern
Regulated by hormonal feedback
Averages 28 days

24. Several follicles in ovary begin to develop
Beginning of the Cycle
Several follicles in ovary begin to develop
Increased production of estrogen
Thickens endometrium
Elongates uterine secretion glands
Inhibits release of FSH
Stimulates pituitary to release LH

25. Luteinizing Hormone (LH) surge in blood Causes ovulation
Transforms ruptured follicle into corpus luteum that produces estrogen and progesterone
Endometrium thickens
Glands and blood vessels increase in size
Follicle Stimulating Hormone (FSH) and LH are inhibited

26. If ovum is not fertilized, corpus luteum degenerates
The Menstrual Phase
If ovum is not fertilized, corpus luteum degenerates
Estrogen, progesterone levels decrease
Endometrium degenerates, produces menstrual flow
Endometrium begins to repair itself
FSH released from anterior pituitary

28. Normal ovarian function declines Follicles stop ripening
Menopause
Menstruation ceases
Normal ovarian function declines
Follicles stop ripening
No appreciable amounts of estrogen produced
Uterus, oviducts, vagina, vulva become somewhat atrophied
Vaginal mucosa becomes thinner, dryer, more sensitive

29. Increases breast cancer risk Increases thrombosis and embolism risk
Hormone Replacement Therapy
Combination of estrogen with synthetic progesterone prescribed to relieve menopause discomfort
Increases breast cancer risk
Increases thrombosis and embolism risk
Risks increase with duration of therapy

30. Common Diagnostic Tests
Laboratory Tests
Radiologic Tests
Surgical Tests
Other Tests

31. Reproductive Lab Tests
Triple or Quad screen
Cultures
HCG
Pap Smear
Serum Alkaline Phosphatase
Serum Calcium
Segmented Bacteriologic Localization Culture

32. More lab tests Rubella immunity HIV antibody
Tests for sexually transmitted diseases
Hepatitis B screen
Varicella zoster viral screen
TORCH panel
Group B strep

33. Lab tests (cont’d) Glucose challenge test
Platelet count, H&H, Rh antibody screen
Fetal fibronectin (fFN)
Lecithin-sphingomyelin ratio
Triple and Quad screens

34. Cultures
Cultures and ‘smears’ are collected from exudates of the breast, vagina, rectum and urethra
They can be used to examine and identify:
Infectious processes
Presence of abnormal cells
Hormonal changes
Spread the collected specimen on a slide with aseptic technique

35. Clean catch urine
Frequently used to measure protein, glucose, WBCs and other elements in urine
Have patient clean area around urethral opening with antiseptic wipe
Have patient void some urine, stop stream and void urine into specimen cup and then finish urinating
Nurse uses standard precautions

36. Human Chorionic Gonadotropin (HCG) in other contexts
Confirms pregnancy, threatened or incomplete abortion
Produced by embryo to prompt corpus luteum to increase estrogen and progesterone
Assists in the diagnostic of HCG – producing tumors, such as choriocarcinoma or hydatidiform moles

37. Papanicolaou (Pap) Test (Smear)
Used to screen for early detection of cervical cancer and/or infections (such as HPV)
Examines scrapings of secretions and cells taken from the cervix
Label slides with date and time of collection, LMP, and whether the woman is taking estrogens or BCP
Women should have yearly Pap smears beginning at age 21 or three years after first sexual intercourse every 2-3 years. More frequent exams may be required for high risk factors.

38. Radiology: Hysterosalpingogram
Study for visualizing the uterine cavity to confirm:
Tubal abnormalities (adhesions and occlusions)
The presence of foreign bodies
Congenital malformation and leiomyomas (fibroids)
Traumatic injuries

39. Hysterosalpingogram Lithotomy position
Insertion of speculum into the vagina
Cannula inserted through the speculum into cervical cavity
Contrast medium injected through the cannula
Uterus and oviducts then viewed by a fluoroscope and films taken

41. Radiology: Mammography
soft tissue of the breast
identification of various benign and neoplastic processes, especially those not palpable on exam
Mammograms should be performed yearly after age 40 (American Cancer Society). High-risk women should also get an annual breast MRI

42. Surgery: Breast Biopsy
Used to differentiate benign or malignant tumors
Needle biopsy ~ local anesthetic, biopsy taken from the breast. Pressure applied to site to stop bleeding.
Open biopsy ~ general or local anesthetic, incision into breast to expose suspicious tissue and then specimens obtained. Sutures and dressing applied to incision.

43. Surgery: D & C
Dilation and Curettage – scraping of material from the wall of a cavity or other surface; performed to remove tumors or other abnormal tissue for microscopic study
General anesthesia, the cervix is dilated, and the walls of the uterus scraped with a curette

44. Used for dilation of cervix
Modern speculum
Used for dilation of cervix

45. Surgery: Endometrial biopsy
Tissue collection: diagnosis of endometrial cancer and analysis for infertility studies.
Performed at time of menstruation, as cervix is partially dilated and cells are more easily obtained
Cervix is locally anesthetized, a curette (loop) is inserted and tissue is obtained

46. Surgery: Laparoscopy Visualizes abdominal cavity
Uterus, adnexa
small incision beneath the umbilicus
Foley Catheter inserted to keep bladder decompressed
General anesthesia
C02 to inflate abdomen
Gas, referred pain to shoulder

47. Nursing care: surgery Ensure urinary elimination
Foley catheter may be needed until patient able to void
Discharge instructions should include safety
No lifting more than 10 lbs until cleared by physician
Teach s/s infection, how to clear any drains and monitor dressings and sites

49. Colposcopy Mounted, lighted instrument exams cervix, vagina
Indications:
Follow-up of abnormal Pap
abnormal bleeding or pain during intercourse
sores on the vulva

51. Pelvic Exam Exam of the: Often done with a Pap test
vulva, vagina, uterus, rectum and pelvis, including the ovaries
masses or growths.
Often done with a Pap test
Insertion of one or two gloved fingers into the vagina, hand pressure to lower abdomen
slight discomfort or pressure normal

53. Patient Education for Pelvic Exam
No douching for at least 2-3 days prior
No sex for 24 hours prior to the exam
Try to schedule when not on period
Need empty bladder
Gown only, provide drape for modesty
Lithotomy position

55. Ultrasound Transducer: high-pitched sound waves
Moved over abdomen with aid of gel
Scan of fetus and uterine or abdominal structures form picture (sonogram) on monitor screen
Predictive for normal pregnancy or abnormalities
Nursing: educate about procedure and purpose, avoid making patient anxious

57. Vaginal ultrasound Vaginal ultrasound:
Transducer placed in vagina
Clearer imaging
Useful for obese patients to reduce amount of tissue between transducer and tissues to be scanned
Also useful early in pregnancy if clear resolution of young fetus necessary
Nursing care: explain procedure and expected result, provide modesty and comfort

58. Inflammatory: Mastitis
Breast infection
S. aureus or streptococci
Late pregnancy or lactation
Cracked nipple, infant infection
Obstructs milk flow
Tender, inflamed, engorged breast
Important to express milk or decrease production – keep breastfeeding
Nursing care: anti-infective, comfort measures, reassurance and education

59. Pelvic inflammatory disease (PID)
pathogenic invasion of the fallopian tubes and/or ovaries, as well as any vascular or supporting structures within the pelvis, except the uterus
Gonorrhea; streptococcus; staphylococcus; Chlamydia; tubercle bacilli
May cause adhesions or sterility
Fever and chills, severe abdominal pain, malaise, nausea, vomiting, purulent exudate
Nursing care: infection control, education

60. Inflammatory: Endometriosis
growth of endometrial tissue within pelvic cavity
ovarian hormones during menses cause bleeding and inflammation
adhesions, organ fusion, bladder dysfunction, or sterility

61. Inflammatory: Vaginitis
Simple: E. coli, staphylococcal, streptococcal, T. vaginalis, C. albicans, Gardnerella
Vaginal discharge, itching, burning
Obtain accurate history
Nursing care focus: rebalance acid/base, treat sexual partners, control/prevent infection

62. Inflammatory: cervicitis
Common reproductive disease
Caused by vaginal infection or STD
May follow lacerations from childbirth or abortion
S/S: backache, whitish exudate, menstrual irregularities
TX: anti-infective

63. Inflammatory: Toxic shock syndrome
S. aureus
Usually seen after superabsorbent tampon use
Overgrowth of bacteria releases toxins
Fever, vomiting, diarrhea, myalgia, hypotension, s/s septic shock, sore throat, H/A, red rash and desquamation, oliguria, elevated BUN

64. Nursing care: genital tract infection/inflammation
Assessment:
s/s infection
Response to treatment
Education
Cause
Prevention/control
How to use treatment

65. Benign neoplasms Fibrocystic breast: Cysts in mammary ducts
Increases risk for breast cancer
Often bilateral, multiple, soft, tender, moveable
Related to ovarian activity
Mammography, biopsy
Diet change, Danazol, vit. E

66. Benign neoplasms Ovarian cysts:
May arise from dermoid cells in uterus, cystic corpus luteum or Graafian follicle
May disturb menstrual cycle or cause slight vaginal bleeding, feeling “heavy”
Ovarian cystectomy
May be present in Polycystic Ovarian Syndrome (PCOS)

67. Breast cancers Breast cancer Unknown cause, hormonal influence
Small, solitary, irregular-shaped, firm, non-tender, and non-mobile tumor
Change in skin color, puckering or dimpling of tissue, nipple discharge, retraction of nipple, axillary tenderness
Radiation, chemotherapy and/or surgery most common treatments

68. Breast cancers
Risk factors: genetics, more than 2 alcoholic drinks/day, late or no childbirth, estrogen exposure, radiation during breast development
Nursing care: teach breast self exam, educate and support, assess acceptance and understanding of surgery/treatments
Lumpectomy
Mastectomy
Partial
Simple
Modified radical

69. Breast cancers Breast self-exam
Done 7-8 days after the last day of the menstrual cycle
Examine visually in mirror
Palpate in routine and systematic way, using circular motion
Include the axillae
Compress nipple and areola to check for discharge
Report changes to provider

70. Breast cancers Nursing care:
emotional and physical support of treatment side effects
pre/post operative care
Arm exercises after mastectomy to relieve edema
assessment of psychosocial adjustment to physical changes and illness

71. Cervical cancer Usually squamous cell carcinoma
Pap smears help detect preinvasive lesions; early stages “silent”
Linked to sexual risk factors, smoking, DES use in mom, multiple births, HPV
Leukorrhea, irregular vaginal bleeding, spotting, changes in vaginal exudate with disease progression
Surgical removal of area

72. Ovarian cancer Fourth most common cause of cancer death in women
High risk: infertile; anovulatory; nulliparous; habitual aborters; high-fat diet; exposure to industrial chemicals, close genetic relationship
> 5 years’ oral contraceptive use may decrease risk
Early S/S: Vague abdominal discomfort, flatulence; mild gastric disturbance

73. Nursing care: reproductive CA
Assessment: pain, function, psychosocial state, bleeding, V/S, pre/post operative status
Nursing care: pain management, referral, control bleeding, monitor vital signs and physical status, prepare for surgery and monitor post-operatively, report changes in baseline status

74. Normal menses - review Sign of puberty
Body becomes capable of supporting a pregnancy
Occurs from 9-17 years of age; average is 12 ½
Cycle varies from days; average 28
Flow lasts from 1-8 days; average 3-5
Flow amount mL; average 35 mL

75. Normal menses- review Menopause Normal decline in female fertility
Average age 51
Atrophy of the vulva, vaginal dryness, loss of skin turgor and elasticity, shrinkage of reproductive structures
Fertility may remain as long as there is ovulation of any pattern

76. Menstrual disorders Dysmenorrhea Amenorrhea Polymenorrhea
Oligomenorrhea
Menorrhagia
Metrorrhagia

77. Menstrual disorders (cont’d)
abnormal uterine bleeding
premenstrual syndrome

78. dysmenorrhea Pain during menses that interrupts daily life activities
Primary: not related to disease, usually starts when ovulation established (<20 years old), often declines/disappears with pregnancy or by late 20s
Secondary: r/t disease (PID, endometriosis, etc), usually >20 years old

79. dysmenorrhea
Endocrine imbalance, increased prostaglandins, or chronic illness, fatigue and anemia
Diagnostics: pelvic exam, laparoscopy, D&C, hysterosalpingography
Nursing care depends upon causative factors: post-operative or procedural; supportive nutrition and symptom suppression

80. amenorrhea Primary: delayed onset of menses by 17 or 18
Causes – congenital defect
Secondary - menarche occurred but has ceased
Causes – pregnancy, frequent, vigorous exercise, or emotional disorders, anorexia

81. amenorrhea No menstrual flow for at least three months
number of periods missed and drugs/medications
Diagnostic: Pelvic exam, blood, urine, and hormone analysis, assessment of presence of tumors, Pap test

82. Menorrhagia A form of abnormal menstrual bleeding
Excessive menstrual flow
Younger women: endocrine disturbance
Older women: inflammation or tumors
Pad or tampon count

83. Premenstrual syndrome
30%-50% women ages 25-45
Unrelated to ovulation
Probably r/t neuroendocrine events in anterior pituitary gland
Possibly caused by estrogen/progesterone imbalances, B6 or magnesium deficiency
7-10 days before menses
Diagnosed after other disorders ruled out

84. Premenstrual syndrome
Treatment: symptom suppression; physical, emotional, nutrition support. May include medicines (anxiolytics, antidepressants), alternative therapies, exercise, B6/calcium/magnesium supplements, avoidance of triggers (caffeine, alcohol, nicotine), self-care and stress minimization

85. Structural disorders Fistulas Cystocele Urethrocele Rectocle
Prolapsed uterus
Relaxed pelvic muscles

86. Vaginal fistulas Abnormal opening between vagina and
Urethra
Bladder
rectum
Results from cancer, radiation, weakened tissues from pregnancy, surgery, necrosis in drastically prolonged labor

87. Cystocele
Displacement of the bladder into the vagina r/t childbearing, multiple births, cervical tears
Urinary urgency, frequency, and incontinence; fatigue; pelvic pressure
Treatment: bladder suspension
Nursing care: teaching, care r/t urinary flow, post-surgical care

88. Prolapsed uterus
Prolapse of the uterus through the pelvic floor and vaginal opening
Rated as first, second, or third degree
Stress incontinence, bowel/bladder problems, protrusion of cervix/vaginal walls into perineum

89. Prolapsed uterus

90. Nursing care: structural disorder
Assess for pain, bleeding, vital signs, urine or feces retention, elimination pattern, H&P, protrusion of tissues
Comfort, tissue protection, control bleeding, monitor vital signs, pre/post operative care, monitor I&O, report changes from normal baseline

91. Infertility
The inability to conceive after 1 year of sexual intercourse without birth control
Primary: no history of conception
Secondary: inability to conceive after hx conception
Factors: age, impaired sperm/ova production, interruption in reproductive system preventing fertilization

92. Infertility: factors Men: most fertile in teens and early 20s
Women: most fertile ages 20-29, decreases ages and ends with menopause
Female infertility most often due to history of infections or inflammatory disorders of reproductive system

93. Infertility: testing
Male infertility in 40% cases and testing simpler, so man may be tested first
Semen analysis
Endocrine imbalance
Underlying systemic issues
Women’s testing:
Ovulation
function of reproductive organs

94. Infertility: treatment
Hormone therapy to induce/support ovulation (Clomid, Pergonal, Parlodel)
Surgery for blocked structures
Support of cervical mucus quality by treating inflammation (cauterization) or giving estrogens
Reducing physical, psychological stressors to support efforts

95. Infertility: treatment
Intrauterine insemination with partner or donor sperm
In-vitro fertilization
Artificial Reproductive Therapies