Reproductive Health Theoretical Book PDF 2024/2025

Reproductive Health Theoretical Book Prepared by All Members of Maternal & Neonatal Health Nursing Department 2024/2025  Maternal and Neonatal Health...

Reproductive Health Theoretical Book Prepared by All Members of Maternal & Neonatal Health Nursing Department 2024/2025  Maternal and Neonatal Health Nursing College Vision: ‫رؤية الكلية‬ ‫تسعى كلية التمريض جامعة الفيوم أن تكون مؤسسة تعليمية رائدة ومتفردة فى مجاالت التمريض والبحث العلمي وخدمة‬ .‫المجتمع على كافة المستويات المحلية واإلقليمية والدولية‬  College Vision the Faculty of Nursing at Fayoum University seeks to be a leading and unique educational institution in the fields of nursing, scientific research and community service at all local, regional and international levels. ‫رسالة الكلية‬ ‫ تلتزم كلية التمريض جامعة الفيوم بإعداد خريج متميز علميا ومهنيا وأخالقيا يكون قادرا على تقديم رعاية تمريضية‬ ‫تلبى احتياجات الفرد واألسرة والمجتمع وفقا لمعايير الجودة وأحدث التقنيات والتطورات العلمية‬, ‫متميزة وشاملة وآمنة‬ ‫ وعلى المشاركة في إنتاج البحوث العلمية التطبيقية القائمة على ا ألدلة والبراهين التي تسهم‬.‫العالمية في مجال التمريض‬ :‫ يتم ذلك‬.‫في تطوير المهنة وتحقيق التميز في مجاالت الرعاية التمريضية والبحث العلمي والمشاركة المجتمعية‬.‫من خالل برامج تعليمية مواكبة ألحدث التطورات العلمية العالمية تساهم في إثراء مجتمع‬  ‫المعرفة ودعم تنافسي ة الخريج من خالل التواصل مع المؤسسات الصحية اإلقليمية والدولي ة وتنمى لدى الطالب القدرة‬ . ‫على القيادة و اتخاذ القرارات والتنمية المستمرة للذات‬  College Mission The Faculty of Nursing at Fayoum University is committed to preparing a distinguished graduate scientifically, professionally, and morally, who is able to provide distinguished, comprehensive, and safe nursing care that meets the needs of the individual, family, and society in accordance with quality standards, the latest technologies, and international scientific developments in the field of nursing. Moreover, it encourages graduates to participate in the production of applied scientific research based on evidence and proof that contributes to the development of the profession and achieve excellence in the fields of nursing care, scientific research and community partnership. This will happen through educational programs keeping pace with the latest international scientific developments that contribute towards enriching the knowledge society and supporting the competitiveness of the graduate through communication with regional and international health institutions, and developing the student’s abilities of leadership, decision-making and continuous self-development. 1 0  ‫‪Maternal and Neonatal Health‬‬ ‫‪Nursing‬‬ ‫األهداف االستراتيجية‬ ‫‪‬‬ ‫تحديث وتطوير البرامج التعليمية بما يحقق المعايير األكاديمية القومية والعالمية‪.‬‬ ‫‪‬‬ ‫تبنى أنماط حديثة فى التعليم و التعلم والتقويم تستفيد من التكنولوجيا المتطورة‪.‬‬ ‫‪‬‬ ‫دعم منظومة البحث العلم ي لتنمية احتياجات المجتمع وإثراء المعرفة العلمية‪.‬‬ ‫‪‬‬ ‫نشر و دعم تطبيق منظومة القيم الحاكمة وأخالقيات المهنة والميثاق األخالقي للمجامعة‪.‬‬ ‫‪‬‬ ‫التحديث والتطوير المستمر للمنظومة اإلدارية بالكلية بما يتواءم مع المستحدثات التكنولوجية‪.‬‬ ‫‪‬‬ ‫تنمية الموارد البشرية بالكلية في المجاالت التعليمية والبحثية والتكنولوجية واإلدارية والمجتمعية‪.‬‬ ‫‪‬‬ ‫وضع استراتيجيات مبتكرة لجذب الطالب على المستويات المحلية واإلقليمية والدولية‪.‬‬ ‫‪‬‬ ‫دعم نظام توكيد الجودة بالكلية على كافة المستويات‪.‬‬ ‫‪‬‬ ‫تعظيم دور الكلية لتلبية احتياجات المجتمع‪.‬‬ ‫‪‬‬ ‫تطوير آليات المشاركة العلمية والبحثية على المستويات الم حلية واإلقليمية والدولية‪.‬‬ ‫‪‬‬ ‫التنمية المستمرة والذاتية لموارد الكلية‪.‬‬ ‫‪‬‬ ‫تبنى الفكر الديمقراطي واإلبداعي في حل المشكالت واتخاذ القرارات‪.‬‬ ‫‪‬‬ ‫‪1‬‬ ‫‪0‬‬  Maternal and Neonatal Health Nursing Strategic Objectives - Updating and developing educational programs to achieve national and international academic standards. - Adopting modern patterns in teaching, learning and assessment that benefit from advanced technology. - Supporting the scientific research system to develop the needs of society and enrich scientific knowledge. - Disseminate and support the application of the system of governing values, professional ethics, and the ethical charter for intercourse. - Modernization and continuous development of the College's administrative system in line with technological innovations - Developing the College's human resources in the educational, research, technological, administrative and societal fields. - Develop innovative strategies to attract students at the local, regional and international levels. - Supporting the quality assurance system in the College at all levels. - Maximizing the role of the College to meet the needs of the community. - Develop scientific and research partnership mechanisms at the local, regional and international levels. - Continuous and self-development of the College's resources. - Adopting democratic and creative thought in problem solving and decision-making 1 0  ‫‪Maternal and Neonatal Health‬‬ ‫‪Nursing‬‬ ‫جودة التعليم العالى (كلية التمريض – جامعة الفيوم)‬ ‫ان الجودة في التعليم الجامعي تشير إلى تضافر الجهود التي بذلها أعضاء هيئة التدريس والقيادات العلمية واإلدارية في المؤسسة‬ ‫التعليمية ( الكلية ) لتوجيه كافة الموارد والعمليات التعليمية لرفع مستوى الطالب بما يتناسب مع متطلبات المجتمع وحاجة سوق العمل‬ ‫‪ ,‬وإعداد طالب قادر على المنافسة محليا وإقليميا ودوليا ووسيلة مميزة لجذب الطالب الوافدين للكلية لذا أصبحت الجودة هي المحور‬ ‫وبما ان الطالب هو حجر الزاوية والمخرج النهائي لبرنامج االعتماد وجودة التعليم ‪.‬الرئيسي إلدارة وتميز الجامعات في المستقبل‬ ‫العالى وجب على كل طالب معرفة مجموعة هامة من المفاهيم ‪:‬‬ ‫‪:‬تعريف الجودة‬ ‫مجموعة الخصائص والسمات التي يجب توافرها في المنتج ( الطالب ) أو الخدمة بحيث تجعله يقوم بوظيفته على أكمل وجه ويرضى‬ ‫‪.‬الجهة المنتفعة‬ ‫الهيئة القومية لضمان جودة التعليم واالعتماد‬ ‫)‪National Authority for Quality Assurance and Accreditation of Education(NAQAA‬‬ ‫أنشأت الهيئة القومية لضمان جودة التعليم واالعتماد بالقانون رقم (‪ )82‬لسنة ‪ ,2006‬وتعد الهيئة القومية لضمان وهى‬ ‫الجهة المسئولة عن نشر ثقافة الجودة في المؤسسات التعليمية والمجتمع‪ ,‬وعن تنمية المعايير القومية التي تتواكب مع‬ ‫المعايير القياسية الدولية إلعادة هيكلة المؤسسات التعليمية وتحسين جودة عملياتها ومخرجاتها على النحو الذي يؤدي إلى‬ ‫كسب ثقة المجتمع فيها‪ ,‬وزيادة قدراتها التنافسية محليًا ودوليًا‪ ,‬وخدمة أغراض التنمية المستدامة في مصر‬ ‫مفهوم المعايير األكاديمية القومية لضمان جودة التعليم واالعتماد‬ ‫)‪(NARAS) (National Academic Reference Standard‬‬ ‫هي الحد األدنى من المتطلبات المتوقعة من المعرفة والمهارات الالزمة للوفاء بمتطلبات الشهادة األكاديمية في الجامعات‪.‬‬ ‫‪1‬‬ ‫‪0‬‬  ‫‪Maternal and Neonatal Health‬‬ ‫‪Nursing‬‬ ‫أهمية الجودة‪:‬‬ ‫‪.1‬ضبط وتطوير النظام االكاديمى و االدارى فى المؤسسة التعليمية ‪.‬‬ ‫‪.2‬توفير بيئة عادلة وامنه ترتقى بمستوى العملية التعليمية ‪.‬‬ ‫‪.3‬االرتقاء بمستوى الطالب فى جميع المجاالت ‪.‬‬ ‫‪.4‬تطوير المناهج والمقررات العلمية بشكل دورى بما يحقق احتياجات سوق العمل ويرفع من مستوى الطالب‪.‬‬ ‫‪.5‬تلقى وفحص شكاوى الطالب واإلقـالل منهـا ووضـع الحلول‪.‬‬ ‫‪.6‬زيادة الكفاءة التعليمية ورفع مستوى األداء للعاملين بالمؤسسة ‪.‬‬ ‫‪.7‬الوفاء بمتطلبات الطالب والمجتمع والوصول إلى رضاهم وفق النظام العام للمؤسسة التعليمية ‪.‬‬ ‫‪.8‬تمكين المؤسسة التعليمية من تحليل المشكالت بالطرق العلمية ‪.‬‬ ‫‪.9‬رفع مستوى الطالب تجاه المؤسسة التعليمية مـن خالل إبراز االلتزام بنظام الجودة ‪.‬‬ ‫الترابط والتكامل بين جميع القائمين بالتـدريس واإلداريـين في المؤسسة والعمل بروح الفريق ‪.‬‬ ‫‪.10‬‬ ‫‪.11‬تطبيق نظام الجودة يمنح المؤسسة التعليمية االحتـرام والتقدير المحلى والقدرة على المناقشة بين نظيراتها من المؤسسات‬ ‫المحلية واإلقليمية والدولية ‪.‬‬ ‫‪1‬‬ ‫‪0‬‬  Maternal and Neonatal Health Nursing Faculty: Nursing University: Fayoum Course Specifications Program(s) on which the course is given: Bachelor in nursing Major or minor element of programs: major (core course) Department offering the program: Maternal and Neonatal health Nursing Department offering the course: Maternal and Neonatal health Nursing, Faculty of nursing Fayoum University. Date of specification approval:……………………… 1 - Basic Information Code: Title: Academic year / Level: (3rdyear 1st term). Maternal and Total: Practical: Lecture:4 Neonatal 24hrs Hours: 60 hr 20hours/week hr/ week health / (15 week) Nursing week rd The course aiming at providing the 3 year students with 2- Overall aims of the course the necessary knowledge and understanding that enable them to provide quality nursing care for women in normal and abnormal conditions across life span as well as newborn within the framework of nursing process. 3 – Competency Areas: DOMAIN ١- PROFESSIONAL AND ETHICAL PRACTICE ١-١- COMPETENCY Demonstrate 1- Demonstrate formal and competence methods of education knowledge, understanding, responsibility in implementing educational activities to women in pregnancy , and accountability of the legal labor , postpartum area under the umbrella of responsibility and obligations for ethical nursing practice. accountability. 2-Apply interpersonal communication, value statements and ethics in caring for woman across life span for ethical decision making. 3- Practice nursing in accordance with institutional/national policies to Protect woman rights regarding the respecting , privacy and dignity. DOMAIN ٢- HOLISTIC PATIENT-CENTERED CARE ٢-١- COMPETENCY Provide 1-Provide holistic nursing care that addresses the needs of holistic and evidence-based woman across life span and Mobilize the community resources nursing care in different practice through health education and Counseling. settings 2-Utilize the information magnitude of over population in Egypt in relation to family planning issue to determined needs/problems for woman and within the family planning 1 0  Maternal and Neonatal Health Nursing centers. DOMAIN ٣- MANAGING PEOPLE, WORK ENVIRONMENT AND QUALITY ٣-١- COMPETENCY Demonstrate 1-Show leadership and effective communication skills in effective managerial and leadership skills providing the universal precautions of infection control to in the provision of quality nursing care. provide safe and quality nursing care during normal pregnancy, childbearing and post natal period. 2-Plan and implement change conducive to the improvement of health care provision for female reproductive health during normal and abnormal condition ٣-٢- COMPETENCY Provide a safe 1-Apply leadership skills to recognize and manage risks to working environment that prevents provide maternity and neonatal care and safety and meets the harm for patients and workers. needs and interests of mothers during antenatal ,childbearing and postnatal periods. 2-Act to protect women from unsafe, illegal, or unethical care practices in different work settings. ٣-٣- COMPETENCY Review health care outcomes in the light of quality indicators and benchmarks to achieve 1- Implement standardized nursing care considering quality the ultimate goals of improving the improvement and safety for high risk women. quality of nursing care. DOMAIN ٤- INFORMATICS AND TECHNOLOGY ٤-١- COMPETENCY 1-Apply maternity information management tools to support safe Utilize information and technology to care and evaluate female reproductive health during normal underpin health care delivery, and abnormal condition. communicate, manage knowledge and 2-Use and evaluate information management technologies to support decision making for patient care. Identify the early complications that can occur during pregnancy, labor, and postpartum period and provide the holistic care ٤-٢- COMPETENCY Utilize 1-Apply communication technologies to form nursing process to information and communication enhance clinical nursing practice and support clinical decision technologies in the delivery of making to manage common problems during pregnancy, labor, patient/client care and puerperium DOMAIN ٥- INTER-PROFESSIONAL COMMUNICATION ٥-١- COMPETENCY Collaborate 1-Mobilize the community health care organizations and with colleagues and members of the resources through health education and Counseling. health care team to facilitate and And interdisciplinary communication. coordinate care provided for individuals, families and communities. 1 0  Maternal and Neonatal Health Nursing At the end of Maternal and Neonatal Health Nursing course the graduate should be able to: 1- Describe the anatomy & Physiology of female reproductive systems. 2- Explain the processes of fetal and placental development. 3- Identify the hormones that regulate menstruation 4- Describe the different phases of menstrual cycle. 5- Identify the important of preconception 6- Recognize signs and symptoms of pregnancy 7- Identify diagnostic techniques required to diagnose pregnancy. 8- Explain care required during antenatal, intra-natal and postnatal period Identify the critical diameter of female bony pelvis &fetal skull. 9- Identify the health deviation conditions encountering female reproductive health. 10- Identify the early complications that can occur during pregnancy, labor, and postpartum period. 11- Discuss family planning Methods 12- Develop nutritional guidelines for normal and abnormal conditions during the reproductive period 13- differentiate between the different contraceptive methods related to indication, contraindication, advantages, disadvantages, mode of action and their effectiveness 14- Perform abdominal examination for normal pregnant women 15- Sketch nursing care plan regarding pregnancy, labor, delivery and puerperium as well as newborn infant. 16- Perform uterine massage during post partum period 17- Develop self-learning skills 18- Monitor the progress of labor, assess uterine contraction and assess FHR utilizing electronic devices and plot the items of the partogram during labor 1 0  Maternal and Neonatal Health Nursing 4-Contents Topics No. of hours  Introduction of the course & scope of maternity 3 hrs.  Preconception care 2 hrs.  Anatomy and physiology of female reproductive system 4 hrs.  Anatomy and physiology of female reproductive system(bony pelvis).  Physiology of Menstruation. 3 hrs.  Physiological changes during pregnancy 3 hrs.  Diagnosis of pregnancy 2 hrs.  Antenatal Care 2 hrs.  Physiology of Labor 4 hrs.  Nursing Management during normal labor 3 hrs.  Physiological changes during postpartum 3 hrs. period  Nursing management of postpartum period 3 hrs.  Post partum complication 4 hrs.  Family Planning methods 3 hrs.  Concept of High risk pregnancy 2 hrs.  Bleeding in Early pregnancy Nursing 3 hrs. management of Bleeding in Early pregnancy  Nursing management of Bleeding in late 3 hrs. pregnancy& postpartum Bleeding o Nursing management of high risk pregnancy 2 hrs. (Diabetes M. during pregnancy) o Nursing management of high risk pregnancy (Heart disease during pregnancy). 2 hrs. o Nursing management of high risk pregnancy (Hypertensive disorders of pregnancy) 3hrs. o Revision 4hrs. Total 60 hour 1 0  Maternal and Neonatal Health Nursing Theory: 5– Teaching and  Lectures learning methods  Discussion.  Self reading  Brainstorming  Written assignments Clinical: -  Demonstration &remonstrations.( skill lab )  Clinical practice  Simulations  Collaborate learning team project  Not Applicable 6– Teaching and learning methods for students with limited capacity 1 0  Maternal and Neonatal Health Nursing Teaching and Learning Methods Competency areas Domain (1) Comp.        1 Domain 2 Comp      1.2 Comp     2.2 Comp    3.1 Comp   Domain 3    3.2 Comp      3.3 Domain 4 Comp         4.1 Comp      4.2 Domain 5 Comp      5.1 7- Student assessment methods a. Using assessment -Formative (ongoing evaluation) methods 1. Assignments: To assess the utilizing theoretical and empirical Knowledge from previous nursing courses to design nursing care plans for Management of individuals, families and groups. -Summative (Final evaluation) -Final written exam 1 0  Maternal and Neonatal Health Nursing b. Assessment schedule  Assessment 1 Quiz I 5th week  Assessment 2 Mid- term exam 9th week  Assessment 3 Quiz II 12th week  Assessment 4 Final written exam 15th week c. Weighting of assessments - Year work (80)  Mid-term theoretical exam 10 grades  Presentation 10 grades  Clinical Practice (ongoing) 60 grades - Final clinical exam 20 grades - Final oral exam 20 grades - Final term written exam 80 grades  Total 200 grades 8- List of references Essential books (Textbooks) 8.1- Essential books (text  Pillitteri, A. (2003): Maternal and child health nursing Fourth books) edition.  Philadelphia, Lippincott Williams & Wilkins.  Lowdermilk, D.L., Perry,S.E., and Bobak,l.,M. (1999): Pregnancy at risk:, Maternity Nursing. Fifth Edition, Philadelphia, Mosby.  Mardara,B.; (2009). Obstetric and pediatric pathophysiology (quick look nursing). 1st ed. Jones and Bartlett publishers.  Pillitteri,A.; (2010). Study guide accompany maternal & child health nursing: care of the childbearing &childbearing family. 1st ed. Lippincott Williams & wilkins.  Webb,C.; (2008). Reviewing research evidence for nursing practice: systematic reviews PB. 1st ed. B Blackwell publisher  Handouts 8.2- Course notes 8.2 - Periodicals, Web Sites … www.altavista.com etc(‫) دوريات علمية أو نشرات‬ www.midwivery.com 8.3- Suggested Books 1. Towle ,A.,M.,(2009). Maternity-newborn Nursing Care. 2nd ed. Pearsoon Prentice Hill Company. United States. 2. Orshan, S.A., (2008). Maternity Newborn &woman’s Health Nursing. 2nded. Wolters Kluwer. Lippincot Williams, Wilkins. New York. 3. Johnson, H.M.,(2009). Essential Reproduction.6th ed. Black well company. London. Head of the department: Assistance prof. Dr. Amal Sarhan Course coordinator: Dr.Asmaa Mohammad Signature Head of the department …………………………………….. 1 0  Maternal and Neonatal Health Nursing Table of content N Topic Page 1 Pre-Conception Care. 11 2 Anatomy and Physiology of Female Reproductive System. 22 3 Menstrual cycle. 41 Physiological changes of women’s body systems during 4 49 pregnancy. 5 Diagnosis of pregnancy. 62 6 Ante natal care. 70 7 Mechanism of normal labor. 83 8 Management of normal labor. 98 Physiological and psychological adaptations during 9 121 postpartum period. 10 Management the fourth stage of labor (puerperium). 139 11 Family planning and counseling. 157 12 High risk concept. 172 13 Bleeding in early pregnancy. 176 14 Bleeding in late pregnancy. 191 15 Gestational diabetes mellitus. 203 16 Pregnancy induced hypertension nursing management. 210 17 Heart disease during pregnancy. 220 18 Nursing Management for Postpartum Complications. 231 19 Glossary. 258 1 0  Maternal and Neonatal Health Nursing Introduction The maternity nurse is a nursing professional, who provides care to expectant mothers before, during and after childbirth. Most of the maternity nurses focus on supporting women during the delivery process. They are working at the woman‘s side to monitor her and the fetus as well, besides encourage, educate and support them. Others may care for women who are experiencing complications before birth or provide postpartum care. The work of maternity nurses helps ensure a safe delivery and healthy start in an unpredictable and sometimes stressful work environment. Maternity nurses are experts at assessing and monitoring patients. Throughout the delivery period, they keep a close eye on the woman‘s blood pressure, fetal heartbeat, contraction patterns, and the vital signs. Based on their observations, the maternity nurses formulate and implement individualized care plans and communicate with other health team members including doctors, midwife or anesthetist as needed. They are committed to provide competent nursing care for pregnant women during labor, encourage and support mothers for starting breast feeding at delivery room, as well as provide natural measures for pain relive during labor in addition to support the woman in the process of delivery. Also, assist the obstetrician during labor process to provide immediate neonatal assessment and care, considering the infection prevention measures, as well as the ethical issues. 11  Maternal and Neonatal Health Nursing Pre-Conception Care Learning Objectives: By the end of this lecture, the nursing student will be able to: Explore the term of pre-conception care. - conception care. -conception care. ts of pre-conception care. -conception health. Outlines: Introduction. Definition of Pre-conception Care. -conception Care. -conception Care. -conception Care. -Conception Health. 11  Maternal and Neonatal Health Nursing Pre-Conception Care Introduction: A comprehensive program of pre-conception care involves a coordinated approach to medical and psycho-social support; that optimally begins before conception. Therefore, pre-conception care is considered an integral part of well women health care, because it permits identification of those conditions or risk factors; that could affect a future pregnancy or fetus and promotes early intervention. Definitions of Pre-conception period: It is a period before woman becomes pregnant. Definitions of Pre-conception Care: ▪ Pre-conception care is the provision of services directed towards the identification of medical and social problems prior to conception. OR ▪ Pre-conception care is the care that adds a different dimension to the usual primary care, as it focuses on the provision of prevention and intervention strategies designed to promote healthy pregnancy outcomes. Reasons for Pre-conception Care: ▪ Poor pregnancy outcomes continue to be at un-acceptable levels. ▪ Women enter pregnancy at Risk, which lead to adverse outcomes. 12  Maternal and Neonatal Health Nursing Paradigm/ Main Shift for Woman Health Concept From Anticipation and Management to Health Promotion and Prevention OR From Healthy Mothers& Healthy Babies to Healthy Women & Mothers and Healthy Babies Importance of Pre-conception Care: ▪ Reduce maternal and neonatal mortality. ▪ Prevent unintended pregnancies. ▪ Prevent complications during pregnancy and delivery. ▪ Prevent stillbirths, preterm birth and low birth weight. ▪ Prevent birth defects. ▪ Prevent neonatal infections. ▪ Prevent underweight. ▪ Prevent vertical transmission of HIV/STIs. 13  Maternal and Neonatal Health Nursing A. Risk Assessment: 1. Plan for future reproductive life. 2. Medical assessment. 3. Medication use. 4. Screening for Infectious Diseases. 5. Screen for Sexual Transmitted Diseases (STD. 6. Vaccination in the Pre-conception Period. 7. Genetic screening and family history. 8. Nutritional assessment. 9. Regular exercise. 10. Environmental risks. 11. Social assessment. 12. Laboratory test. 1. Plan for Future Reproductive Life: ▪ A set of personal goals about having (or not having) children based on personal values, resources and a plan to achieve those goals, which include: Do you want to have children? How many children would you like to have and when? 2. Medical Assessment: The following medical disorders are routinely checked: ▪ Anemia. ▪ Cardiac disease. 14  Maternal and Neonatal Health Nursing ▪ Diabetes mellitus. ▪ Autoimmune disease. ▪ Hypertension. ▪ Hyperthyroidism. ▪ Hypothyroidism. 3. Medication Use: ▪ The women may be advised about the drugs associated with adverse fetal effect and to refrain from self-medication and to consult the doctor about the safety and appropriateness of any medications required. The following drugs are to be avoided during pregnancy because of their teratogenic effect which include: Isotretinoin for acne may lead to congenital cardiac and CNS abnormalities. Oral hypoglycemia agents: diabetics planning a pregnancy should change over to insulin for glycemic control, because it is the most effective for fine-tuning blood glucose and it doesn‘t cross the placenta. Therefore, it is safe for the baby. 4. Screening for Infectious Diseases: ▪ Patient at risk for congenital rubella (German measles, viral infection) Hepatitis B and C. ▪ Cytomegalovirus- offered to cat –owner and those in business of handling raw meat. 5. Screen for Sexual Transmitted Diseases (STD): ▪ STD during pregnancy can lead to fetal death, physical, and developmental disabilities. ▪ Early screening and treatment can prevent these adverse birth outcomes. ▪ Women and their partners should be encouraged to be tested for STD regularly, including HIV, and if positive, receive treatment for the benefit of their own health and that of future pregnancies. 15  Maternal and Neonatal Health Nursing ▪ Some STD can be treated and some cannot. Steps can be taken to reduce the chance of passing on an infection from mother to fetus. ▪ Chlamydia and Gonorrhea (Treatable with antibiotics). ▪ Left untreated infections are associated with infertility, chronic pelvic pain and ectopic pregnancy. ▪ Treatment during pregnancy and the first six weeks of a fetus‘s life can improve protection from transmission to 99%. 6. Vaccination in the Pre-conception Period: The following immunizations are recommended for women at risk: a. Hepatitis A: ▪ Women at risk for hepatitis A virus (HAV) infection should receive a two-dose single antigen series, the interval between each dose is six months. b. Hepatitis B: ▪ Women at risk for hepatitis B virus (HBV) infection should receive the three-dose primary series, the interval between the 1st and 2nd dose is one to two months, while the interval between 2nd and 3rd dose is four to six months. Fetuses who acquire HBV prenatally are at very high risk of developing chronic HBV which can lead to chronic liver disease, cirrhosis and primary hepatocellular carcinoma in early adulthood. c. Measles, Mumps and Rubella (MMR): ▪ Women who have no history of previous immunization or lack laboratory evidence of rubella immunity should receive at least one dose of MMR vaccine. In addition to protecting individual women, MMR vaccine helps to prevent the occurrence of congenital rubella syndrome in newborns. As it is a live virus vaccine, women should be counseled to avoid pregnancy for four weeks after receiving the MMR vaccine. d. Varicella (Chickenpox): ▪ Women without a history of varicella infection should receive a total of two doses of varicella vaccine, four to eight weeks apart. 16  Maternal and Neonatal Health Nursing ▪ Fetus of women without a history of immunity may be at risk for congenital varicella syndrome and neonatal varicella infection. ▪ Women should be counseled to avoid pregnancy for four weeks after receiving the varicella vaccine 7. Genetic Screening and Family History: ▪ Some health problems can be passed through the genes of a mother or father to a baby. ▪ Genetic counseling: may help to reassure and help with making informed decisions about getting pregnant by determining the probability of certain conditions. Counseling could be suggested for women with. - - A history of genetic disorders due to family history. - Women with a personal risk of disease due to occupational exposure - Women with a history of multiple miscarriages. 8. Nutritional Assessment: ▪ Eating well before becoming pregnant will help women meet the nutritional needs of a growing fetus during pregnancy and is required to make full evaluation for obesity/underweight and iron deficiency anemia. ▪ Healthy fetal development requires certain vitamins, minerals, and nutrients. ▪ Daily multivitamin and folic acid are needed during pregnancy. ▪ Folic acid supplement begins one month prior to conception, which greatly reduce incidence of neural tube defects such as: Spina Bifida: It is a developmental congenital disorder caused by the incomplete closing of the embryonic neural tube. Some vertebrae overlying the spinalbcord are not fully formed and remain unused and open. If the opening is large enough, this allows a portion of the spinal cord to protrude through the opening in the bones. There may not be a fluid-filled sac surrounding the spinal cord. 17  Maternal and Neonatal Health Nursing  Impact of Low Folate Levels on Reproductive Outcomes ▪ Increased incidence of neural tube defect. ▪ Anemia-mother and infant. ▪ Low birth weight. Impact of Diabetes on Reproductive Outcomes Pregnancy loss. Excess amniotic fluid. Cesarean Section (CS). Preterm labor. Increased risk of diabetes for baby. 9. Regular Exercise: The benefits of regular exercise before, during and after conception include: Healthier pregnancy. Faster and easier labor less need for induction. Returning to pre-pregnancy weight faster. Improved mood and sleep. Reduced weight gain during pregnancy. Fewer pregnancy discomforts such as backaches and swelling. 18  Maternal and Neonatal Health Nursing Control of gestational diabetes. Appropriate weight management. 10. Environmental Risks: ▪ Workplace Exposure (X-RAY). ▪ Certain workplace toxins have been associated with reduced fertility, still birth, miscarriage, low birth weight and birth defects. ▪ Environmental Exposure. 11. Social Assessment: ▪ Evaluation of the social and lifestyle history is necessary to identify behavior and exposure that may adversely affect future reproductive performance. ▪ Occupational hazards: exposure to ionizing radiation, heavy metals like lead and mercury. ▪ Substance abuse: alcohol and addicting substance. ▪ Excessive caffeine consumption. ▪ Domestic violence. ▪ Improper housing- lack of sanitation. ▪ Financial constraints. 12. Laboratory Test: ▪ Hemoglobin and hematocrit. ▪ ABO and Rh factor. ▪ Rubella antibody. ▪ Urine analysis. ▪ Pap smear for gonococcal / Chlamydia screen. ▪ VDRL test (venereal disease research laboratory) for syphilis. ▪ Hepatitis B and C screen. ▪ HIV. ▪ Thyroid screening. ▪ TORCH (Test for special group of infections), which include; Toxoplasmosis, Syphilis, Varicella, Rubella, Cytomegalovirus, Herpes simplex. 19  Maternal and Neonatal Health Nursing A. Intervention for the following Identified Risks: (will be discussed later). ▪ Diabetes. ▪ Hypertension. ▪ Cardiac. ▪ Anemia. ▪ Obesity. ▪ Hypothyroidism. ▪ Sexually transmitted infections B. Counseling Counseling should include the benefits of the following activities: ▪ Reducing weight before pregnancy if overweight. ▪ Increasing weight before pregnancy if underweight. ▪ Avoiding food additives. Preventing HIV infection. ▪ Determining the time of conception by an accurate menstrual history. ▪ Consuming Folic Acid. ▪ Maintaining good control of any pre-existing medical conditions. Goals for Improving Pre-Conception Health: ▪ Improve the knowledge, attitudes, and behaviors of men and women related to pre-conception health. ▪ Assure that all women of childbearing age receive preconception care services (i.e., evidence-based risk screening, health promotion and interventions), that will enable them to enter pregnancy in optimal health. ▪ Reduce risks indicated by a previous adverse pregnancy outcome through interventions during the inter-conception period, which can prevent or minimize health problems for women. ▪ Reduce the disparities in adverse pregnancy outcomes. 21  Maternal and Neonatal Health Nursing 21  Maternal and Neonatal Health Nursing Anatomy of Female Pelvis Introduction: Birth canal is composed of the mother‘s rigid bony pelvis and the soft tissue. The female bony pelvis is divided into a false and true pelvis separated by the pelvic brim. False pelvis (above the pelvic brim) has no obstetric importance. True pelvis (below the pelvic brim) concerned with child birth. 22  Maternal and Neonatal Health Nursing Pelvic bone Four pelvic Bones a- Innominate bone : 1- illium 2- ischium 3- pubic b- Sacrum c- Coccyx Functions of bony pelvis 1- Allow movement of the body, especially walking and running 2- Permits the person to sit and kneel 3- Transmits the weight of the trunk to the legs. 4- Acting as a bridge between the femurs, this makes it necessary for sacro-iliac Joint to be immensely strong and immobile 5- It affords protection to the pelvic organs and to a lesser extent, to the abdominal contents. Each innominate bone is composed of three parts: -Ilium: The large flared – out part. When the hand is placed on the hip it rests on the iliac crest which is the upper border. Ischium:- Is the thick lower part. It has a large prominence known as the ischial tuberosity on which the body rests when sitting. Behind and a little above the tuberosity is an inward projection, the ischial spine. -The pubic bone: Forms the anterior part. It has a body and Oar like projection, the superior ramus and inferior ramus. - The two pubic bones meet at the symphysis pubis and the two inferior rami form the pubic arch. - The innominate bone contains a deep cup to receive the head of the femur known as acetebulum. 2- Sacrum: Is a wedge – shaped bone consisting of five fused vertebra. The upper border of the first sacral vertebra just forward is known as sacral promontory. 23  Maternal and Neonatal Health Nursing The anterior surface of sacrum is concave and is referred to hallow of the sacrum. Laterally the sacrum extends into a wing or ala. 3- The Coccyx: The coccyx is a vestigial tail. It consists of four fused vertebra, forming a small triangular bone. 24  Maternal and Neonatal Health Nursing The Pelvic Joints: -One symphysis pubis: which is formed at the junction of the two pubic bones which are united by a pad of cartilage - -The sacro- illac Joints: are the strongest joints in the body. They join the sacrum to the ilium and thus connect the spine to the pelvis. -The sacrococcygeal Joint: is formed where the base of the coccyx articulates with the tip of the sacrum. Pelvic Ligaments: Each of the pelvic joints is held together by ligaments:  Interpubic ligaments at the symphysis pubis -  Sacro- iliac ligaments-  Sacrococcygeal ligaments  Sacrotuberous ligament runs from the sacrum to ischial tuberosity  Sacrospinous ligament. from the sacrum to the ischial spine- PELVIC MUSCLE Pelvic Floor It is formed by the soft tissues which fill the outlet of the pelvis. 25  Maternal and Neonatal Health Nursing Functions: 1- Pelvic floor supports the weight of the abdominal and pelvic organs. 2- Its muscles are responsible for the voluntary control of macturation and defecation. 3- It plays an important part in sexual intercourse. 4- During childbirth it influences the passive movements of the fetus through the birth canal and relaxes to allow its exit from the pelvis. The True Pelvis It is composed of inlet, cavity and outlet The true pelvis Is the bony canal through which the fetus must pass during birth. It has a brim, a cavity and outlet. 1- The pelvic brim: is round except where the sacral promontory and wings of the sacrum form its posterior border, the iliac bones its lateral borders and the pubic bones its anterior border. Fixed points on the pelvic brim (Landmarks): 1. Sacral promontory 2. Ala or wing 3. Sacro- iliac Joint 4. Iliopectineal line which is the edge formed at the inward aspect of the ilium 5. Iliopectineal eminence which is roughened area formed where the Superior arums of pubic bones meet the ilium 6. Superior arums of the pubic bone 7. Upper inner border of the body of the pubic bone 8. Upper inner border of the symphysis pubis 2- Pelvic Cavity: It extends from the brim above the outlet blow. The anterior wall is formed by the pubic bones and symphysis pubis and its depth is 4cm. The posterior wall is formed by the curve of the sacrum which is 12cm in length. It formed a curved canal It is circular in shape and although it is not possible to measure its diameters exactly, they are all considered to be 12 cm. 26  Maternal and Neonatal Health Nursing 3- The outlet: The anatomical outlet is formed by the lower border of each of the bone together with the Sacrotuberous ligament. The obstetrical outlet: is of great practical importance because it includes the narrow pelvic strait through which the fetus pass. It represents the space between the narrow pelvic strait and the anatomical outlet. Diamond shape. Diameters of the Pelvic Inlet The Anatomical Anteroposterior diameter True Conjugate (11cm) From the tip of the sacral promontory to the upper border of the symphysis pubis. Obstetric Conjugate (10.5cm) Extends from the tip of promontory to the most bulging point on the back of the symphysis. Diagonal Conjugate (12.5cm) a-Extends from lower border of the symphysis to the tip of the promontory B-TransverseDiameter Extends between the farthest points on the Iliopectineal lines. C-Oblique Diameter 1- Right and left oblique diameters (12 cm). Extends from the sacroiliac joint to the opposite Iliopectineal eminence. II- The Pelvic Cavity Bounded on each side:- It is bounded above by the pelvic brim, below by the plane of least pelvic dimensions, anteriorly by the symphysis pubis and posteriorly by the sacum. III- The Pelvic Outlet Bounded on each side: - 1- Anatomical outlet it is lozenge shaped bounded by Anteriorly: the lower border of the symphysis pubis. Posteriorly: the tip of the coccyx. Laterally: the pubic arch, ischial tuberosities and sacrotuberous ligament. 27  Maternal and Neonatal Health Nursing Diameters of the Pelvic Outlet I- Antero-posterior diameter Anatomical anteroposterior (11cm). From the lower border of the symphysis to the tip of the coccyx. Obstetrical anteroposterior (13cm). From the lower border of the symphysis to the tip of the sacrum. II- Transverse diameters a- Bituberous (11cm) Between the inner aspects of the ischial tuberosities. Diameters of the Pelvic anteroposterior Oblique transverse Inlet 11 12 13 Cavity 12 12 12 Outlet 13 12 11 PELVIC SHAPE 1- GYNECOID Typical female pelvis found in 50% of women, Rounded—slightly oval inlet Straight pelvic sidewalls with roomy pelvic cavity, Good sacral curve Ischial spines are not prominent, Pubic arch is wide 2- ANDROID Typical male pelvis found in 1/3 white women 1/6 non-white, Pelvic brim is heart shaped, Pelvis funnels from above downwards (convergent sidewalls).Narrow pubic arch and Prominent spines 3- ANTHROPOID 25% white women & 50% nonwhite, Pelvic brim APD > TD ,Long & narrow pelvic canal with long sacrum and Straight pelvic sidewalls 4- PLATYPELLOID 3% of women, Pelvic brim TD >>>APD Æ kidney shape and Sacral promontory pushed forwards. 28  Maternal and Neonatal Health Nursing Anatomy and Physiology of Female Reproductive System A. Soft Tissue Learning Objectives By the end of this lecture the nursing student will be able to: ▪ Describe the parts of external, internal organ of female reproductive system (FRS) and breast. ▪ Explain the function of the major external and internal organ of female reproductive system and breast. Outlines: A. External Organs (Vulva): ▪ Mons Pubis / Veneries. ▪ Labia Majora. ▪ Labia Minora. ▪ Clitoris. ▪ Vestibule. Urethral Orifice. Two Skene Glands. Vaginal Orifice. Bartholin's Glands. ▪ Perineum. B. Internal Organs: 1. Vagina. 2. Uterus. 3. Fallopian Tubes. 4. Ovaries. C. Breast. 29  Maternal and Neonatal Health Nursing A. External Organs: 1. Mons Veneris / Mons Pubis is Characterized by: -It is a pad of fat lying over the symphysis pubis covered with pubic hair from the time of puberty. -As a women ages, the amount of pubic hair and fatty tissue decrease. -The Mons is actually the anterior fusion of the Labia Majora. External Genitalia 2. Labia Majora (Greater lips) ▪ Are two folds of fat it covered with skin and pubic hair on the outer surface. ▪ They arise in the Mons pubis and merge into the perineum behind. 31  Maternal and Neonatal Health Nursing 3. Labia Minora (Lesser lips): ▪ These are two thin folds of skin lying between the labia Majora. ▪ Anteriorly, they divided to enclose the clitoris, and posteriorly they fuse, forming the fourchette. ▪ The glands in the labia minora serve to lubricate the vulva. 4. Clitoris: ▪ It is an erectile organ corresponding to male penis. ▪ It is rich with blood and nerve supply so, it is very sensitive and vascular and plays a role in the orgasm of sexual intercourse. ▪ The sebaceous glands of the clitoris secret a cheese like substance called smegma, which has an odor that is sexually exciting to the male. 5. Vestibule: ▪ It is extending anteriorly to the clitoris and posteriorly to the perineum. It contains six openings. a. Urethral Orifice. b. Two skene glands: They are found posteriorly on either sides of the urethra and secrete small amounts of mucous that serve lubrication. c. The Vaginal orifice: It is called the introitus of the vagina it is partially closed by the hymen, which is a thin membrane that tears during first sexual intercourse or during the birth of the first child. d. Two Bartholin’s Glands: They are two small glands open on either side of vaginal orifice, and they secrete mucous which lubricates vaginal opening during sexual intercourse. 31  Maternal and Neonatal Health Nursing Vestibule 6. Perineum: ▪ The perineum is the most posterior part of the external female reproductive organs. ▪ This external region is located between the vulva and the anus. ▪ It is made up of skin and muscle. ▪ The perineum can become lacerated or incised during childbirth and may need to be repaired with sutures. ▪ Incision of the perineum area to provide more space for the presenting part is called an episiotomy. 32  Maternal and Neonatal Health Nursing B. Internal Organs: 1. Vagina ▪ It is a canal connecting the uterus to vestibule. ▪ It lies between Urinary bladder and Urethra anteriorly and Rectum and canal posteriorly. ▪ Anterior wall 7.5cm and posterior wall 9 cm Vaginal Structure ▪ The posterior wall is 10 cm long whereas the anterior wall is only 8 cm ▪ It is composed of fibro-muscular tissue capable of great distension, lined by stratified squamous epithelium that is elevated into folds (rugae) ▪ These rugae permit great distension without damage. 33  Maternal and Neonatal Health Nursing ▪ Between puberty and menopause, estrogen helps glycogen deposition in the epithelial cells of the vagina and Doderlein‘s bacilli split glycogen into lactic acid giving the vagina its acidic reaction (Ph 4.5) that protect the vagina against infection by pathogenic organisms. 2. Uterus: ▪ It is a hollow, muscular and a pear-shaped organ. The lower third is called the cervix and it measures 2.5 cm in each direction. The weight of the uterus is 60- 70 gms. In non-pregnant women Functions: It shelters the fetus during pregnancy. It expels the uterine contents following pregnancy. Position: It is situated in the cavity of the true pelvis, behind the bladder and in front of the rectum. It leans forward that is known as (ante-version), and it bends forward on itself (ante-flexed). It measures as 7.5 long X 5 wide X 2.5 depths. Relations: Anterior: Bladder. Posterior: Rectum. Lateral: Broad ligaments, fallopian tubes & ovaries. Superior: Intestine. Inferior: Vagina. 34  Maternal and Neonatal Health Nursing Uterus Consists of the Following Parts: 1. Fundus: ▪ It is the domed upper wall between the insertions of the fallopian tubes. 2. Cornua: ▪ It is the upper outer angles of the uterus, where the fallopian tubes join. 3. Corpus or body: ▪ It makes up the upper 2/3 of the uterus and is the greater part of the uterus. 4. Cavity: ▪ It is a potential space between the anterior & posterior walls, it is a triangular shape. 5. Isthmus: ▪ It is the narrow area between the cavity and the cervix, it enlarges during pregnancy. 35  Maternal and Neonatal Health Nursing 6. Cervix: (Neck of the uterus): ▪ It protrudes into the vagina, the upper half being above the vagina is known as the supra-vaginal portion. While the lower, half is infravaginal portion. It has two OS: Structure of the Uterus: a. Endometrium: ▪ It forms a lining of the epithelium (mucous membrane) ▪ It is constantly changing in the thickness throughout menstrual cycle. ▪ It sheds during menstruation. b. Myometrium: ▪ It is the muscle coat, thick in the upper part of the uterus and thin in the isthmus and cervix. c. Perimetrium: ▪ It is the outer membrane of the uterus, which extend to the peritoneum. 3. Fallopian Tubes: Functions: Pushes the ovum towards the uterus. Receive the spermatozoa, as they travel upwards. Provides a site for fertilization. Supplies fertilized ovum with nutrition. 36  Maternal and Neonatal Health Nursing Position: They extend laterally from the cornua of the uterus toward the wall of the pelvis. They arch over the ovaries. The fringed ends lie near the ovaries in order to pick-up the ovum. Structure of Fallopian Tube Structure: It has four parts: 1. Interstitial Portion: ▪ It is 2.5 cm long, lies within the wall of the uterus. Its lumen is 1mm (the narrowest part). 2. Isthmus: ▪ It is another narrow part with thick muscle wall; it extends for 2.5 cm from the uterus. 37  Maternal and Neonatal Health Nursing 3. Ampullary: ▪ It is the widest portion where fertilization occurs, 5cm long. 4. Infundibulum: ▪ It is the funnel-shaped end that is composed of many processes known as fimbria. Layers of Fallopian Tubes ▪ The lining is a mucous membrane and in this lining are goblet cells, which produce a secretion, containing glycogen to nourish the ovum. ▪ Beneath the lining is a layer of vascular connective tissue. ▪ The muscle coat consists of smooth muscles that cause peristaltic movement of the fallopian tubes. 4. The Ovaries Layers of the Ovary Functions: Ovaries are responsible for production of ova. Secretion of female sex hormones progesterone and estrogen. 38  Maternal and Neonatal Health Nursing Position: Ovaries are attached to the back of the broad ligaments within the peritoneal cavity. Structure: ▪ Medulla: It is the supporting framework, which is made of fibrous tissue, ovarian blood vessels, lymphatic and nerves transfer through it. ▪ Cortex: It is the functioning part of the ovary contains the ovarian follicles in different stages of development. C. Breasts: Structure as the following: Two mammary glands or Breasts. Accessory organs of the FRS. Secrete milk following pregnancy. Over lie the pectorals major muscles and extend from the 2nd to the 6th ribs and from the sternum to the axilla. Each breast has a nipple located near the tip, surrounded by a circular area of pigmented skin called the areola. Anatomy of the Breast 39  Maternal and Neonatal Health Nursing During Pregnancy: ▪ The breasts may double in size during pregnancy, this is attributed to secretion of the placental estrogen and progesterone hormone, which stimulate the development of the mammary glands and lead to increase in the size of the breast. Following Childbirth and the Expulsion of the Placenta: ▪ Levels of placental hormones (progesterone and lactogen) fall rapidly and the action of prolactin (milk-producing hormone) is no longer inhibited. Prolactin Hormone: ▪ Stimulates the production of milk, within a few days after childbirth; it starts with a dark yellow fluid called colostrum. Colostrum: ▪ Contains more minerals and protein. ▪ Less sugar and fat than mature breast milk. ▪ Its secretion may continue for approximately a week after childbirth, with a gradual conversion/ change to mature milk. 61  Maternal and Neonatal Health Nursing Physiology of menstruation 61  Maternal and Neonatal Health Nursing Learning Objectives: - By the end of this lecture, each nursing student will able to:  Define menstrual cycle.  Enumerate characteristics of normal menstruation.  List abnormalities of menstrual cycle.  Discuss physiology of menstrual cycle.  Enumerate hygienic care during menstruation Outlines: -  Introduction.  Definition of menstrual cycle.  Characteristics of normal menstruation.  Abnormalities of menstrual cycle.  Physiology of menstrual cycle.  Hygienic Care during menstruation. Introduction — The female reproductive cycle is a general term encompassing the ovarian cycle, the endometrial cycle, the hormonal changes that regulate them, and the cyclical changes in the breasts. The hypothalamus pituitary gland, ovaries, and endometrium are all involved in the cyclic changes that help to prepare the body for fertilization. Absence of fertilization results in menstruation, the monthly shedding of the uterine lining. Menstruation (shedding of the endometrium) marks the beginning and end of the monthly cycle. Menopause is the naturally occurring cessation of regular menstrual cycles. Definition: Menstrual cycle means cyclic uterine bleeding caused by shedding of progestational endometrium it occurs between menarche and menopause. OR Episodic uterine bleeding in response to cyclic hormonal changes. Characteristics of normal menstruation:  Cycle length: 21 to 35 days with an average 28 days.  Duration of flow: 3 to 7 days with an average 5 days.  Menarche :( The start of menstruation in females) 10-16 years. Average 13 years.  Amount of flow: 30:80 ml. 61  Maternal and Neonatal Health Nursing  Normally menstrual blood doesn’t coagulate as a result of secretion of fibrinolysin enzyme (plasmin) secreted by the endometrium. The menstrual blood is not clotted unless bleeding is excessive. Clotting first occurs in the uterine cavity, the clot is dissolved by fibrinolytic enzyme produced by the endometrium at menstruation. If the bleeding is excessive, the amount of fibrinolysin available is insufficient and so clots are expelled in menstrual flow.  Menstrual molimina refers to mild symptoms of 7-10 days before menstruation relieved once menstruation occurs exaggerated condition called (premenstrual syndrome). Symptoms of premenstrual syndrome (PMS).  Cramps  Tender breasts  Bloating  Mood swings  Irritability  Headaches  Tiredness  Low back pain. Abnormalities of menstrual cycle:  Periods that occurs less than 21 days or more than 35 days apart.  Not having a period for three months.  Menstrual flow that’s lighter (less than 30 ml) or much heavier (less than 80 ml).  Period of bleeding that lasts less than 3 days or longer than seven days.  Periods that is accompanied by severe pain, cramping, nausea or vomiting.  Bleeding or spotting that happens between periods. Physiology of Menstrual Cycle Four body structures are involved in the physiology of the menstrual cycle:  The hypothalamus.  The pituitary gland.  The ovaries.  The uterus. 61  Maternal and Neonatal Health Nursing 1. The Hypothalamus: ▪ Gonadotropin Releasing Hormones (GnRH) is transmitted from the hypothalamus to the anterior pituitary gland. ▪ GnRH stimulates the gland to begin producing Follicular Stimulated Hormone (FSH) and luteinizing Hormone (LH). 2. The Pituitary Gland: The anterior lobe of the pituitary gland (the adeno- hypophysis) produces two hormones: a. FSH: A hormone that is active early in the cycle (1-14 day) and is responsible for maturation of the ovum. b. LH: A hormone that becomes most active at the midpoint of the cycle and is responsible for ovulation or release of the mature egg cell from the ovary and growth of the uterine lining during the second half of the menstrual cycle. 1- Ovarian Cycle: Cyclical changes in the ovaries occur in response to two anterior pituitary hormones: Follicle-stimulating hormone (FSH) and Luteinizing hormone (LH). The 61  Maternal and Neonatal Health Nursing changes that occur in the ovary during each cycle can be divided into three phases, these phases run in parallel with the phases of the uterine cycle and together comprise the menstrual cycle. 1) Follicular phase (day 1-13) 2) Ovulatory phase (day 14) 3) The luteal phase (day 15-28). Follicular Phase:  It begins with the first day of menstruation and ends about 14 days later until ovulation when the mature egg (Graafian follicle) is released from the ovary.  It is called the follicular phase because growth or maturation of the egg is taking place inside the follicle.  The follicular phase is controlled by FSH, which is responsible for the growth of several primary follicle only one follicle on one of the ovaries reaches maturity (graafian follicle) which secretes estrogen. 61  Maternal and Neonatal Health Nursing 2-Ovulatory phase:  It occurs around the day 14 of the menstrual cycle. Ovulation is the outward expulsion of a mature ovum from a ruptured graafian follicle into peritoneal cavity, where it is picked up by the fimbriated end of the tube, in response to a surge of luteinizing hormone (LH) that occurs just before the egg is released from the ovary. 3-Luteal phase:  After the follicle ruptures as it releases the egg, it closes and forms a corpus luteum. LH continues to rise in amount and acts on the follicle cells of the ovary. It influences the follicle cells to produce progesterone and estrogen, whereas the follicular fluid was high in estrogen with some progesterone.  If conception (fertilization by a spermatozoon) occurs as the ovum proceeds down a fallopian tube and the fertilized ovum implants on the endometrial of the uterus, the corpus luteum remains throughout the major portion of the pregnancy (approximately 16 to 20 weeks). 61  Maternal and Neonatal Health Nursing  If conception does not occur, the unfertilized ovum atrophies after 4 or 5days from ovulation (at the day 18-19 of the cycle), and the corpus luteum (called a “false” corpus luteum) remains for only 8 to 10 days after ovulation (at the day 22-24 of the cycle). As the corpus luteum regresses gradually replaced by white a corpus albicans (white body). Hormones are secreted at peak levels during a typical 28-day menstrual cycle Uterine Cycle:( Endometrial Cycle):  The uterine cycle refers to the changes that are found in the uterine lining of the uterus. These changes come about in response to the ovarian hormones estrogen and progesterone. There are four phases to this cycle: proliferative, secretory, ischemic and menstrual. Proliferative Phase:  It extends from the day 6 to the day 14 (i.e. from the end of bleeding to ovulation) changes are caused by estrogen produced by growing ovarian follicles.  The endometrium undergoes proliferation above the basal layer, the uterine glands elongate and become tortuous and the endometrial thickness reaches 3-4 mm. Secretory Phase:  It begins with ovulation and ends with menstruation. It is under the effect of estrogen and progesterone secreted by corpus luteum. The uterine glands become larger, more tortuous and full of secretions, to nourish the fertilized ovum. The endometrium increases in thickness to about 6-8 mm (edematous and congested with blood), just before menstruation.  If pregnancy does not occur ,the corpus luteum degenerates at the day 22-24 of the cycle thus secretion of estrogen and progesterone will stop and leads to break down and shedding of the lining (endometriun), called menstruation. 61  Maternal and Neonatal Health Nursing  If pregnancy occurs, the corpus luteum continues to develop and function till 4-5 months of pregnancy, where the placenta takes its function. The ovary will not select another follicle for ripening and no menstrual cycle will occur. Ischemic Phase:  On days 27 and 28, estrogen and progesterone levels fall because the corpus luteum is no longer producing them.  Without these hormones to maintain the blood vessel network, the uterine lining becomes ischemic. Menstrual Phase: (The destructive phase): during which the superficial functional layer of the endometrium separates leaving the basal layer from which regeneration of the endometrium starts. 61  Maternal and Neonatal Health Nursing Hormonal control of the menstrual cycle: - Hypothalamus secretes GnRH ↓ Anterior pituitary secretes LH and FSH ↓ Graafian follicle stimulated ↓ Ovaries release estrogen ↓ High estrogen levels inhibit FSH secretion, stimulate LH production ↓ LH makes mature follicle burst: ovulation ↓ LH makes corpus luteum secrete progesterone ↓ Progesterone inhibits LH secretion ↓ Decreased LH and FSH levels ↓ Corpus luteum atrophies, stops making progesterone ↓ Decreased estrogen and progesterone levels stimulate GnRH secretion 61  Maternal and Neonatal Health Nursing Hygienic Care during menstruation:  Take a shower at least once a day.  Change pads or tampons regularly to prevent infections - it is advisable to change a sanitary pad once every six hours, for a tampon, it is every two hours.  Use clean cotton underwear and change it every day.  Do not use soaps or vaginal hygiene products to wash the genital area. Instead, clean the vaginal area using warm water regularly, after each use of toilet and even after urination. Washing the vagina with an intimate wash can kill the good bacteria making way for infections.  Always keep the vaginal area dry after every wash, else it might cause irritation. Also, keep the area between the legs dry. Use antiseptic powder to help keep the area dry - preferably before wearing the pad and after washing the vagina.  Always wash or wipe the genitals from front to back. This is important because cleaning in the opposite direction can make way for bacteria from the anus to the vagina and urethral opening, leading to infection.  Wash hands with warm water and soap after toilet or changing pad/tampon.  Never flush used sanitary pad and tampons down the toilet as they can clog plumbing and cause the toilet to overflow. Discard them properly and throw them in the dustbin to prevent the spread of infections.  Wear comfortable, loose clothing, rather than jeans or tight-fitting during periods. This will ensure air flow around the sensitive areas as well as prevent sweating to a large extent. 61  Maternal and Neonatal Health Nursing Physiological Changes during Pregnancy 61  Maternal and Neonatal Health Nursing Learning Objectives: By the end of this lecture, each nursing student will able to: 1. Explain the new terms related physiological changes during pregnancy. 2. Identify the changes that take place within the woman's reproductive system during pregnancy. 3. Discuss the woman's general body systems adaptation to pregnancy. 4. Determine the level of weight gain during pregnancy. 5. Explore the role of the maternity nurse when giving advice to these women. Outlines:  Introduction.  Definitions.  Woman's systems adaptation to pregnancy: A. Reproductive System Adaptations (Changes): 1. Uterus. 2. Cervix. 3. Vagina. 4. Ovaries. 5. Breasts. B. General Body Systems Adaptations (Changes): 1. Gastrointestinal. 2. Cardio vascular. 3. Respiratory. 4. Renal/Urinary. 5. Musculoskeletal. 6. Integumentary. C. Weight Gain. Introduction: Every system of a woman’s body gets changes during pregnancy to accommodate the needs of the growing fetus, which starting rapidly. The physical changes of pregnancy can be uncomfortable, although every woman reacts uniquely. Definition: The changes that take place in the maternal organ systems in response to pregnancy to accommodate the pregnancy and to prepare the women for labor. Definitions of other related terms: 61  Maternal and Neonatal Health Nursing  Hagar's Sign: It is the softening of the isthmus of the uterus, the area between the cervix and body of the uterus, which occur at 6 to 8 weeks of pregnancy.  Goodell’s Sign: It is softening of the cervix.  Chadwick’s Sign: Is the bluish discoloration of the mucous membranes of the cervix, vagina and vulva due to vasocongestion of the pelvic vessels.  Cervical Ripening: It is softening, effacement and increased distension of cervix during the 1ststage of labor.  Leucorrhea: Increased the vaginal discharge under the effect of pregnancy hormones.  Ptyalism: It is excessive secretion of salivary gland under effect of pregnancy hormones.  Gingivitis: It is inflammation of the gum under effect of pregnancy hormones.  Pyrosis (heart burn): It is heart burn commonly occurred during pregnancy during the 2nd & 3rd trimester due to the gravid uterus is pushing the stomach up ward and the regurgitation of stomach occurred due to progesterone making relaxation to the cardiac sphincter of the stomach so the pregnant may feel it.  Lina- nigra: Normal dark line of pigmentation extended longitudinally on the center of the abdomen from the umbilicus to the pubis.  Striae-Gravidarum: Striae-gravidarum or stretch marks are irregular reddish lines, which appear on the abdomen, breasts and buttocks  Lightening: Defined as sensation of decreased abdominal distension during the later weeks of pregnancy following the decent of the fetal head into the pelvic inlet. Changes are due to alterations in:  Hormonal Production  Circulation  Metabolism 61  Maternal and Neonatal Health Nursing A. Reproductive System Adaptations: The significant changes occur throughout the woman’s body during pregnancy to accommodate the growing fetus during her body. Many changes have a protective role for maternal homeostasis and are essential to meet the demands of both the mother and the fetus. Many adaptations are reversible after the woman gives birth, but some persist for life. 1. The Uterus:  During the first few months of pregnancy, estrogen stimulates uterine growth and the uterus undergoing a great increase in size, weight, length, width, depth, volume and overall capacity throughout pregnancy.  The weight of the uterus increases from 70 gm. to about 1100 gm. at term.  Its capacity increases from 10 ml to 5000 ml. or more at term.  Uterine growth occurs as a result of both hyperplasia (increase in number of cells) and hypertrophy (increase in size of cells) of the myometrium cells, which don't increase much in number but increase in size.  Blood vessels elongate, enlarge, dilate and sprout new branches to support and nourish the growing muscle tissue. Also the increase in uterine weight is associated with a large increase in uterine blood flow, which are necessary to nourish the uterine muscle and accommodate the growing fetus.  Changes in the uterus occurring during the first 6 to 8 weeks of gestation which produce some of the typical findings; including a positive Hagar's sign (softening and compressibility of the lower uterine segment), which results in exaggerated uterine ante-flexion during the early months of pregnancy, which leading to urinary frequency.  As the uterus grows, it presses on the urinary bladder and causes the increased frequency of urination experienced during early pregnancy. 61  Maternal and Neonatal Health Nursing Urinary Frequency:  It occurs in the 1st trimester due to increase the size of gravid uterus, which make compression over the bladder.  In the 3rd trimester, it occurs due to lightening and engagement of the presenting part in the pelvic.  The uterus starts as a pear-shaped organ, which becomes ovoid (oval shaped) due to length increases over width.  The uterus remains in the pelvic cavity for the first 3 months of pregnancy, later it progressively ascends into the abdomen.  It will slightly be above the symphysis pubis at 12th week of gestation.  At 22 weeks of gestation the fundus or top of the uterus is at the level of the midline of umbilicus and measures 22 cm. A measurement of the height of the fundus in cm corresponds to the number of gestational weeks (checked by Maneuver).  The fundus reaches its highest level at the xiphoid process at approximately 36wks. As result, the gravid uterus pushes against the diaphragm, where many women experience shortness of breath.  Between 38 to 40 weeks fundal height drops as the fetal head begins to descend and engage into the pelvis which is termed lightening. 61  Maternal and Neonatal Health Nursing  For the woman who is pregnant for the first time, lightening usually occurs approximately 2 weeks before the onset of labor, while the woman who is experiencing her second or subsequent pregnancy, it usually occurs at the onset of labor.  Although, breathing becomes easier because of this descent, the pressure on the urinary bladder now increases and women experience urinary frequency again. 2. The Cervix:  Between 6th and 8th weeks of gestation, the cervix begins to soften (Goodell’s sign) due to vaso-congestion.  The softening of the endo-cervical glands increases which produce more cervical mucus. Under the influence of progesterone, a thick mucus plug is formed that blocks the cervical Os and protects the opening from bacterial invasion.  At the same time, increased vascularization of the cervix causes Chadwick’s sign (bluish discoloration).  Cervical ripening (increased softening and effacement) begins about 4th week before birth. 3. The Vagina:  During pregnancy, there is an increased vascularity due to the influences of estrogen, resulting in pelvic congestion and hypertrophy of the vagina as preparation for the distention needed for birth. 61  Maternal and Neonatal Health Nursing  The vaginal secretions during pregnancy become white, thick and more acidic as a result of increasing glycogen under the effect of estrogen hormone.  Most of women experience an increase in a whitish vaginal discharge called leucorrhea, this is normal except when it is accompanied by itching and irritation.  Candida albicans and monilial vaginitis may occur. 4. The Ovaries:  The increased blood supply to the ovaries causes them to enlarge until approximately the 12th to 14th week of gestation.  Ovulation stops during pregnancy because of the elevated levels of estrogen and progesterone, which block secretion of follicle stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary gland.  The ovaries are very active in hormone production to support the pregnancy until about 6 th to 7th week of gestation, when the corpus luteum regresses and the placenta takes over the major production of progesterone.  Corpus luteum (yellow) will change to corpus albicans (white) after degeneration. 5. The Breasts:  The breasts increase in fullness, which become tender and grow larger throughout pregnancy under the influence of estrogen and progesterone.  The breasts become vascular and veins become visible under the skin.  The nipples become larger and more erect.  Both the nipples and the areola become deeply pigmented and tubercles of Montgomery (sebaceous glands) become prominent. These sebaceous glands keep the nipples lubricated for breastfeeding.  Colostrum is creamy, yellowish breast milk, can be secreted by the third trimester.  This breast milk provides nourishment for the neonate during the first few days after birth. The Breasts Changes during Pregnancy 61  Maternal and Neonatal Health Nursing B. General Body System Adaptations: In addition to changes in the reproductive system, the pregnant woman also experiences changes in every other body system as a response to the growing fetus. 1. Gastrointestinal (GI) System:  During pregnancy, the gums become congested, swollen and tend to bleed easily. These changes are influenced by estrogen and increased proliferation of blood vessels to the mouth.  Some pregnant women complain from excessive salivation (ptyalism), which may let them be more nauseated.  Some pregnant women with poor oral hygiene may develop calculus and debris; which increase deposits on the gum and cause gingivitis, as well as increase in dental caries.  Elevated progesterone levels cause smooth muscle relaxation, which results in delayed gastric emptying and decreased peristalsis.  Transition time of food throughout the GI tract may be so much slower, that lead to more reabsorbed water than normal, leading to bloating and constipation.  Constipation can also result from low-fiber food choices, reduced fluid intake, using iron supplements, decreased peristalsis movement and intestinal displacement secondary to a growing uterus.  Constipation, increased venous pressure and gravid uterus pressure contribute to the formation of hemorrhoids.  The slowed gastric emptying combined with relaxation of the cardiac sphincter allows reflux, which causes heartburn (pyrosis).  Heartburn seems to be a universal minor discomfort for pregnant women. It is caused by regurgitation of the stomach contents into the upper esophagus and may be associated with the generalized relaxation of the entire digestive system.  Nausea and vomiting known as morning sickness, occurs for about 50% to 80% among pregnant women. 61  Maternal and Neonatal Health Nursing  Although, morning sickness occurs most often in the morning, the nauseated feeling can last all day in some women. The highest incidence of morning sickness is between 6th to 12th weeks of gestation. It may be due to the high levels of Human Chorionic Gonadotropin (HCG) hormone or estrogens hormone or reduced stomach activity, as well as lowered motility of the digestive tract. Changes in Gastrointestinal System during Pregnancy Citied in https://www.google.com 2. Cardiovascular System:  Blood Volume:  Blood Volume:  Blood volume increases by approximately 1.500 ml, or 50% above non-pregnant levels, which is considered burden for a pregnant woman with heart disease and can cause maternal death.  It begins at weeks 10th to 12th and its peaks reach at weeks 32nd to 34th, and decreases slightly at week 40th.  This increase in blood volume is needed to provide adequate hydration of fetal and maternal tissues. Also, to supply blood to nourish the enlarging uterus and to compensate blood loss at birth and during postpartum.  This increase is also necessary to meet the increased mother's metabolic rate and to meet the needs of other organs, especially the woman’s kidneys, which excrete waste products for herself and fetus.  Cardiac Output and Heart Rate:  First, it increases from 30% to 50% over the non-pregnant rate by the end of 32nd week of gestation. Also, it increases only about 20% at 40 week of gestation.  Heart rate increases from 10 - 15 beat/minute during 14th and 20th weeks of gestation and then persists to term. 61  Maternal and Neonatal Health Nursing  There is slight hypertrophy or enlargement of the heart during pregnancy. This is probably to accommodate the increase in blood volume and cardiac output.  Positioning of the heart is changing and displaced upward due to pushing of diagram leading to secondary murmur, which is common in 2nd & 3rd trimester. Changes in Heart Position during Pregnancy  Blood Pressure:  Blood pressure (BP) especially the diastolic pressure declines slightly during pregnancy as a result of peripheral vaso-dilation caused by progesterone.  During the first trimester, BP Typically remains at the pre-pregnancy level, whenever during second trimester; the BP decreases 5 to 10 mmHg and later returns to the first trimester level.  Orthostatic hypotension is occurring due to pressure of gravid uterus on the inferior vena- cava, which leads to decreases venous return BP. Blood Pressure Changes during Pregnancy Citied in https://www.google.com  Blood Components:  The number of RBCs increases by 25% to 33% than non-pregnant level throughout pregnancy (depending on the level of iron). This increase is necessary to transport the additional oxygen required during pregnancy.  Plasma volume is increased as a result of hormonal factors and sodium and water retention due to aldosterone hormone.  Because the increase in plasma exceeds the increase of RBC production, normal hemoglobin and hematocrit values decrease.  This state of hemo-dilution is referred as physiologic anemia in pregnancy.  Both fibrin and plasma fibrinogen levels increase along with various blood-clotting factors. These factors make pregnancy a hyper-coagulable state to prevent abortion. 61  Maternal and Neonatal Health Nursing  These changes coupled with venous stasis secondary to venous pooling, which occurs during late pregnancy after long periods of upright standing with the pressure exerted by the uterus on the large pelvic veins.  These changes contribute to slowed venous return, pooling and dependent edema, which increased woman’s risk for venous thrombosis. Blood Changes during Pregnancy Citied in https://www.google.com 3. Respiratory System:  During the pregnancy, the amount of space available to house the lungs decreases as the uterus puts pressure on the diaphragm and causes it to shift upward by 4 cm above its usual position.  The growing uterus changes the size and shape of the thoracic cavity, but diaphragmatic curve increases. Also, chest circumference increases by 2 to 3 inch and the transverse diameter increases by one inch.  A pregnant woman breathes faster and more deeply becaus