Maternal Nursing - NCM 205 - PDF

MATERNAL NURSING NCM – Maternal And Child Health Nursing ` Ms. Ederlyn Maura Monzon-Delamide RN MAN Class Rules Week 1  Introduction Review the concept of person as an individual and as a member of the family The concept of family Tr...

MATERNAL NURSING NCM – Maternal And Child Health Nursing ` Ms. Ederlyn Maura Monzon-Delamide RN MAN Class Rules Week 1  Introduction Review the concept of person as an individual and as a member of the family The concept of family Trends and issues in MCH Ethico-legal aspect of maternal and child  Learning Objective Discuss framework of maternal health Examine the concept of family Understand Trends and issues in MCH Apply the knowledge of Ethico-legal aspect of maternal and child in practice Week 1  Framework for Maternal and Child Health Nursing Obstetrics - Care of woman during childbirth; derived from Greek word “obstare” (to keep watch) Pediatrics - derived from Greek word, “pais” (child)  Maternal and Child Health Goals and Standards These Global Health Goals are: End poverty and hunger. Achieve universal primary education. Promote gender equality and empower women. Reduce child mortality. Improve maternal health. Combat HIV/AIDS, malaria, and other diseases. Ensure environmental sustainability. Develop a global partnership for development Framework for Maternal and Child Health Nursing Health promotion Health maintenance Health restoration Health rehabilitation Definitions and Examples of Phases of Health Care  Measuring Maternal and Child Health Measuring what constitutes the area of maternal and child health is not as simple as defining whether clients are ill or well because individual clients and health care practitioners can maintain different perspectives on illness and wellness.  Common Statistical Terms Used to Report Maternal and Child Health Birth Rate The number of births per 1,000 population. Fertility Rate The number of pregnancies per 1,000 women of childbearing age. Fetal Death Rate The number of fetal deaths (over 500 g) per 1,000 live births. Neonatal Death Rate The number of deaths per 1,000 live births occurring at birth or in the first 28 days of life.  Common Statistical Terms Used to Report Maternal and Child Health Infant Mortality Rate The number of deaths per 1,000 live births occurring at birth or in the first 12 months of life. Perinatal death rate The number of deaths during the perinatal time period (beginning when a fetus reaches 500g, about week 20 of pregnancy, and ending about 4 to 6 weeks after birth);it is the sum of the fetal and neonatal rates. Maternal Mortality Rate The number of maternal deaths per 100,000 live births that occur as a direct result of the reproductive process.  Common Statistical Terms Used to Report Maternal and Child Health Child Mortality Rate the probability of dying between exact age one and age five, defined as the number of deaths of children age 1-4 years per 1,000 children surviving to age 12 months Childhood Morbidity Rate The number of deaths per 1,000 population in children aged 1 to 14 years.  LEGAL CONSIDERATIONS OF MATERNAL–CHILD PRACTICE ETHICAL CONSIDERATIONS OF PRACTICE Some of the most difficult ethical quandaries in health care today are those that involve children and their families. Examples include: Conception issues, especially those related to in vitro fertilization, embryo transfer, ownership of frozen oocytes or sperm, and surrogate motherhood Abortion, particularly partial-birth abortion Fetal rights versus rights of the mother Stem cell research Resuscitation (for how long should it be continued?) Number of procedures or degree of pain a child should be asked to endure to achieve a degree of better health Balance between modern technology and quality of life Difficulty maintaining confidentiality of records when there are multiple caregivers  The Concept of Family A family is defined by the U.S. Census Bureau (USCB, 2010) as “a group of people related by blood, marriage, or adoption living together.” This definition is workable for gathering comparative statistics but has limitations when assessing a family for its health concerns or support people available, because some families are made up of unrelated couples, and at points in life not all family members live together. Allender (2013) defines the family in a much broader  The Concept of Family Allender (2013) defines the family in a much broader context as “two or more people who live in the same household (usually), share a common emotional bond, and perform certain interrelated social tasks.” This is a better working definition for health care providers because it addresses the broad range of types of families apt to be encountered in health care settings.  The Concept of Family WORLD HEALTH ORGANIZTION (WHO) “______________________________”  Family Types Family of orientation (the family one is born into; or oneself, mother, father, and siblings, if any) Family of procreation (a family one establishes; or oneself, spouse or significant other, and children, if any)  Family Types The Dyad Family two people living together without children. The Cohabitation Family Cohabitation families are composed of couples, perhaps with children, who live together but remain unmarried. The Nuclear Family The traditional nuclear family is composed of a husband, wife, and children. In the past, it was the most common family structure seen worldwide.  Family Types The Polygamous Family Polygamy- a marriage with multiple wives or husbands. Polygyny- a family with one man and several wives. Polyandry- one wife with more than one husband. The Extended (Multigenerational) Family An extended family includes not only a nuclear family but also other family members such as grandmothers, grandfathers, aunts, uncles, cousins, and grandchildren  Family Types The Single-Parent Family someone who is unmarried, widowed, or divorced and not remarried. The Blended Family In a blended family (a remarriage or reconstituted family), a divorced or widowed person with children marries someone who also has children. The Gay or Lesbian Family Gay is the socially preferred term to describe men who have sex with men; lesbian is used to denote women who have sex with women. Gay couples or lesbian couples live together as partners for companionship, financial security, and sexual fulfillment, or form the same structure as a nuclear family.  Family Types The Foster Family Children whose parents can no longer care for them may be placed in a foster or substitute home by a child protection agency. The Adoptive Family Families of a great many types (nuclear, extended, cohabitation, blended, single parent, gay, and lesbian) adopt children today. No matter what the family structure, adopting not only brings unusual joy and fulfillment to a family but can also offer a number of challenges for both the adopting parents and the child as well as for any other children in the family  Developmental Stages Stage 1: Marriage Stage 2: The Early Childbearing Family Stage 3: The Family With a Preschool Child Stage 4: The Family With a School-Age Child Stage 5: The Family With an Adolescent Stage 6: The Launching Stage Family: The Family With a Young Adult Stage 7: The Family of Middle Years Stage 8: The Family in Retirement or Older Age  The Well Family Genogram is a diagram that details family structure and provides information about the family’s health history and the roles of various family members across several generations.  The Well Family Ecomap- aspect of family assessment is to document the “fit” of a family into their community.  Learning Activity Find out the latest Maternal Mortality and Morbidity in the Philippines  MATERNAL NURSING NCM 205 – Maternal And Child Health Nursing Ms. Ederlyn Maura Monzon-Delamide RN MAN Week 2  Reproductive and Sexual Health a. Concept of Unitive and Procreative Health b. Female and Male Reproductive System c. Human Sexuality d. Responsible Parenthood Concept of Unitive and Procreative Health Unitive Procreative Unitive and Procreative Aspect of Sexuality in Marriage A sexual relationship in marriage has 2 purposes 1. Strengthen the couple and allow them to express their love for each other in a powerful way ( UNITIVE) 2. Leads to the creation of new life. ( Procreative) REPRODUCTIVE DEVELOPMENT  The Female Reproductive System External Internal  Female Reproductive System EXTERNAL STRUCTURES (VULVA/PUDENDUM) A. MONS PUBIS OR MONS VENERIS  Pad of fat over the symphysis pubis. Hairless and smooth in childhood. It is covered by dark and curly hair called ESCUTCHEON after puberty. Hair pattern in triangular with base up. B. LABIA MAJORA  Lengthwise, two thick folds of fatty skin extending from the mons to the perineum that protects the labia minora, urinary meatus and vaginal mucosa.  Female Reproductive System C. LABIA MINORA  Thinner, lengthwise folds of hairless skin, encircling the clitoris anteriorly (prepuce) and unite posteriorly (fourchette). Below the prepuce is called frenulum. Highly sensitive to manipulation and trauma, the reason why it is often torn during delivery. D. VESTIBULE  Triangular space located between introitus, urethral meatus, Bartholin & Skene’s glands.  Female Reproductive System E. GLANS CLITORIS  Small erectile structure; contains nerve endings, sensitive to temperature and touch. It is the seat of sexual arousal and excitement in females. It is the most sensitive part of a woman’s body. It is also the structure that guides the nurse to the urinary meatus.  Female Reproductive System F. URETHRAL MEATUS  The external opening of the urethra. Slightly behind and to the side are the openings of the Skene’s glands (paraurethral glands); the secretions of which help to lubricate the external genitalia. The shortness of the female urethra makes women more susceptible to UTI than men. G. HYMEN  A tough but elastic semicircle of tissue that covers the opening to the vagina. The remnant of hymen is called carunculae myrtiformis.  Female Reproductive System H. VAGINAL ORIFICE/ INTROITUS  External opening of the vagina covered by the thin membrane (hymen) in virgins. Located lateral to the vaginal opening on both sides are the Bartholin’s glands (vulvovaginal glands). It lubricates the external vulva during coitus and the alkaline PH of their secretion helps to improve sperm survival in the vagina. The Grafenberg or G-Spot is a very sensitive area located at the inner anterior aspect of the vagina.  Female Reproductive System I. FOURCHETTE  Thin fold of tissue formed by merging of the labia majora and labia minora below the vaginal orifice. J. PERINEUM  Muscular skin covered area between vaginal opening and anus  Female Reproductive System INTERNAL STRUCTURES A. VAGINA  Hollow membranous & muscular canal, 3-4 inches long, dilatable, contains rugae (which permits considerable stretching without tearing). It is located in front of the rectum and behind the bladder. Passageway of menstruation Passageway of fetus Organ of copulation Semen depository  Female Reproductive System oRugae – transverse folds of skin in the vaginal wall that is absent in childhood, appear after puberty & disappears at menopause. oFornix – Fornices – the cervix projects to the vagina forming four recesses or depression around its upper portion called fornices: anterior fornix, lateral fornices, posterior fornix.  Female Reproductive System ** Doderlien’s Bacillus maintains the normal flora of the vagina, which makes the pH of vagina acidic, detrimental to the growth of pathologic bacteria. B. UTERUS  Hollow, muscular pear-shaped organ located in the pelvis, weighing 50-60g in non-pregnant woman. Held in place by broad ligaments. Abundant blood supply comes from uterine and ovarian arteries.  Female Reproductive System - During puberty, it increases in size and reaches its maximum size at 17 years. FUNCTIONS: 1. Organ of implantation (nidation) and menstruation 2. Receives the ova from the fallopian tune 3. Furnishes protection for a growing fetus  DIVISIONS OF THE UTERUS 1. CERVIX  Lower portion called the neck a. External cervical OS – distal opening to the vagina b. Cervical canal – the cavity c. Internal cervical OS – opening to the uterus 2. FUNDUS  Uppermost convex portion and can be palpated to determine uterine growth during pregnancy. To assess uterine contractions during labor & involution during the postpartum period. It is the most vascular portion Normal implantation site 3. CORPUS – body to the uterus which makes up 2/3 of the said organ. Houses the fetus during pregnancy. 4. CORNUA – the upper portion where the fallopian tubes are attached.  LAYERS OF THE UTERUS 1. PERIMETRIUM  The outermost layer, it is attached to the broad ligaments and offer added support to the uterus. 2. MYOMETRIUM  Middle layer, expels fetus during birth process then contracts around blood vessels to prevent hemorrhage (oxytocin site) 3. ENDOMETRIUM  Innermost layer; this layer undergo changes in response to the hormones at various phases of the menstrual cycle & during pregnancy; it consists of two layers:  LAYERS OF THE UTERUS Glandular layer – peels off during menstruation and thickens during the proliferative and secretory phase Basal layer – layer adjacent to the myometrium and gives rise to the new endometrium after menstruation and delivery.  UTERINE LIGAMENTS 1. BROAD LIGAMENTS – supports the sides of the uterus and assists in holding the uterus in its normal anteversion and anteflexion position.  UTERINE LIGAMENTS 2. CARDINAL LIGAMENT – lower portion of the broad ligament. It is the main support of the uterus. Damage to this ligament will result to uterine prolapse.  UTERINE LIGAMENTS 3. UTEROSACRAL LIGAMENT – connects uterus to the sacrum. 4. ANTERIOR LIGAMENT – provides support to the uterus in connection with the bladder. Overstretching of this ligament will lead to herniation of the bladder to the vagina (cystocele). 5. POSTERIOR LIGAMENT – forms the cul-de-sac of Douglas. Damage to this ligament will lead to herniation of the rectum to the vagina (rectocele).  INTERNAL STRUCTURES C. FALLOPIAN TUBES/ OVIDUCTS/ UTERINE TUBES  Two slender muscular tubes which arises each of the upper corner of the uterine body and extend outward. Provides a place for fertilization (conception, fecundation, impregnation) of ova by the sperm.  PARTS OF THE FALLOPIAN TUBE 1. INTERSTITIAL – (1 cm) lies withing the uterine wall. It has the smallest lumen. 2. ISTHMUS – (2cm) portion cut or sealed during tubal ligation 3. AMPULLA – (5cm) longest portion. Exact site of fertilization (distal 3rd, outer 3rd) 4. INFUNDIBULUM – most distal portion; rim of the funnel is covered by fimbriae that helps guide the ova into the fallopian tube.  FUNCTION OF THE FALLOPIAN TUBE  Transport ovum from ovary to the uterus  Site of fertilization D. OVARIES  Almond shaped organs located on either side of the uterus. Before puberty, the ovaries are smooth, flat & ovoid organs, after ovulation, they assume a nodular and pitted appearance. FUNCTION: Responsible for the production, maturation and discharge of ova and secretion of estrogen and progesterone Organ of ovulation  LAYERS OF THE OVARY 1. TUNICA ALBUGINEA  The outermost protective layer surrounded by a single layer of cuboidal epithelium. 2. CORTEX  The functional layer which is the site of ovum formation and maturation. It contains the primordial follicles, graafian follicles, corpus luteum & corpus albicans.  Two months intrauterine = 600,000 oogonia 5 months intrauterine = 6,800,000 At birth = 2 million oocytes Prepuberty/ childhood = 300,000 to 400,000 36 years old = 30,000 to 40,000 Menopause = absent 3. MEDULLA  Layer which contains the blood vessels, lymphatics, nerves and muscle fibers.  THE MAMMARY GLANDS The female breasts are accessory organs of reproduction meant to provide the infant with the most ideal nourishment after birth. STRUCTURES: 1. LOBES – consists of 15-20 lobes found in each breast which are subdivided into lobules. 2. LOBULES – composed of clusters of acinar cells (responsible for milk production)  THE MAMMARY GLANDS 3. ACINAR CELLS – milk secreting cells that is stimulated by prolactin 4. LACTIFEROUS DUCTS – (milk reservoir) which opens to the nipple 5. AREOLA – dark pigmented part around the nipple 6. MONTGOMERY TUBERCLE – secretes fatty substance to lubricate nipples 7. NIPPLE – elevated part of the breasts containing 15-20 openings from the lactiferous ducts. 8. COOPERS LIGAMENT – provides support to the mammary gland.  PHYSIOLOGY OF MILK PRODUCTION ** The production of breast milk is not achieved during pregnancy because of the predominance of estrogen and progesterone. ** Immediately after the delivery of the placenta, there is a marked decrease of both estrogen and progesterone which serves as a stimulus for the APG (Anterior Pituitary Gland) to produce PROLACTIN. ** Prolactin acts on the acini cells to stimulate production of milk and are then stored in the lactiferous ducts  THE MAMMARY GLANDS ** As the infant sucks, the PPG (Posterior Pituitary Gland) is stimulated to release the hormone OXYTOCIN causing the collecting sinuses of the mammary glands to contract, forcing milk forward through the nipples called “LET DOWN REFLEX” or “MILK EJECTION REFLEX” PREGNANEDIOL – drug that suppresses milk formation Hormones that influences the Mammary Glands:  ESTROGEN – stimulates the development of the ductile structures of the breast  PROGESTERONE – stimulates the development of the acinar cells  HUMAN PLACETAL LACTOGEN – promotes breast development during pregnancy  OXYTOCIN – Let Down Reflex  PROLACTIN – stimulate milk production  MALE REPRODUCTIVE SYSTEM: ANDROLOGY Penis: the male organ of copulation; a cylindrical shaft consisting of Corpura cavernosa – two lateral columns of erectile tissue. Corpus spongiosum – encases the urethra  MALE REPRODUCTIVE SYSTEM: ANDROLOGY Parts of Penis : glans penis – a cone-shaped expansion of the corpus spongiosum that is highly sensitive in males Shaft or body Prepuce or foreskin- retractable skin covering the glans & removed during circumcision.  MALE REPRODUCTIVE SYSTEM: ANDROLOGY Parts of Penis : PHIMOSIS- Unretractable or tight foreskin Erection is stimulated by parasympathetic nerve. INTERNAL STRUCTURES: A. TESTES two ovoid shaped body that lie inside the scrotum encased by a protective white fibrous capsule and comprises a number of lobules. each lobules contains interstitial cells (Leydig’s Cells) and seminiferous tubules Seminiferous tubules produce spermatozoa Leydig’s cells produce the hormone testosterone.  FUNCTIONS OF THE TESTES: 1. SPERMATOGENESIS- process by which the spermatocytes are developed into mature spermatozoa 2. HORMONE PRODUCTION a. TESTOSTERONE- an androgen or masculinizing hormone responsible for growth and development of secondary sex characteristics. b. FSH (Follicle Stimulating Hormone) – causes rapid sperm production. c. ICSH (Interstitial Cell Stimulating Hormone) - stimulates Leydig’s cells to increase testosterone production. B. Internal Structure 1. Epididymis- serves as reservoir for sperm storage and maturation. Approximately 20 ft and it takes 12 – 20 days for the sperm to travel the length of epididymis. A total of 64 days before they reach maturity. (“Treatment = 2 months’) Aspermia – absence of sperm Oligospermia – if < 20 million sperm/ml 2. Vas deferens- a duct extending from epididymis to the ejaculatory duct and seminal vesicle, providing a passageway for sperm. Varicocele – varicosity of internal spermatic cord Vasectomy – (male birth control) 3. Seminal vesicle- are two convoluted pouches that lie along the lower portion of the bladder and empty into the urethra by the way of ejaculatory ducts 4. Ejaculatory duct: the canal formed by the union of the vas deferens and the excretory duct of the seminal vesicle, which enters the urethra at the prostate gland. 4. Prostate Gland: located just below the urinary bladder. Secretes alkaline and most of the seminal fluid. 5. Bulbourethral glands or Cowper’s Gland: adds alkaline fluid to the semen. Counterpart of the Bartholin’s glands in females. 4. Urethra: the passageway for both urine and semen, extending from the bladder to the urethral meatus. (8 inches long)  SEMINAL FLUID/ SEMEN - a grayish whitish substance containing spermatozoa and fructose rich substance - at the time of ejaculation, approximately 3 – 5 ml of semen is secreted with about 100 million spermatozoa per ml, or about 250 – 500 million spermatozoa at each ejaculation. If the sperm count drops to less than 20 million per ml of semen, the r5%)ate is considered infertile.  During ejaculation, semen receives contributions of fluid from: Prostate gland (60%), Seminal vesicle (30%), Epididymis (5%) and Bulbourethral gland (5%).  ANALOGOUS STRUCTURE FEMALE MALE Glans Clitoris Glans penis Labia majora Scrotum Vagina Penis Ovaries Testes Fallopian tubes Vas deferens Skene’s glands Prostate glands Bartholin’s glands Cowper’s glands Ovum Spermatozoa  PUBERTAL DEVELOPMENT PUBERTY – is the stage of life at which the secondary sex changes. - it is the stage when the reproductive organs becomes functional. Girls – age 9 to 12 years old Theory: must reach a critical weight of approx. 95 lbs. (43 kgs). Boys – age 12 to 14 years The role of Androgen: - hormone responsible for: 1. Muscular development 2. Physical growth 3. Increase sebaceous gland secretion (acne) “Testosterone - 1º androgenic hormone” In girls, testosterone influences the development of labia majora, clitoris, and axillary & public hair latter termed as adrenarche. SEQUENTIAL ORDER OF PUBERTAL CHANGES IN GIRLS GROWTH SPURT INCREASE IN THE TRANSVERSE DIAMETER OF THE PELVIS BREAST DEVELOPMENT (THELARCHE) GROWTH OF PUBCI HAIR ONSET OF MENSTRUATION (MENARCHE) GROWTH OF AXILLARY HAIR (ADRENARCHE) VAGINAL SECRETIONS SEQUENTIAL ORDER OF PUBERTAL CHANGES IN BOYS INCREASE IN WEIGHT GROWTH OF TESTES GROWTH OF FACE, AXILLARY & PUBIC HAIR VOICE CHANGES PENILE GROWTH INCREASE IN HEIGHT SPERMATOGENESIS  Atrophy of genitals gradually occurs. CLIMACTERIC PERIOD (AGE 50 Pubic hair thins YEARS) Penis becomes flabby  = episodic uterine bleeding in response to hormonal changes. MENSTRUAL CYCLE/ = periodic series of changes that recur in the FEMALE uterus and associated organs beginning at puberty and ending at menopause REPRODUCTIVE CYCLE = taken from the first day of menstruation to the first day of the next menstruation Basis for menstrual cycle is 6–12-month graphing. Menarche – first menstrual period that occurs typically at age 12 but may occur as early as 9 or as late as 17 Thelarche – is the development of the breast buds that occur at puberty Adrenarche – is the development of pubic & axillary hair due to androgen stimulation. MENSTRUATION – periodic sloughing off the endometrium which occurs every 28 days but could be anywhere from 25 to 35 days & lasts for 3-5 days. Characteristics of Menstrual Blood: 1. Does not appear to clot. 2. Dark red as that of venous blood. 3. Offensiveness (fishy stale odor)  BODY STRUCTURE INVOLVED IN MENSTRUATION 1. HYPOTHALAMUS – ultimate initiator of menstrual cycle. Secretes GnRH. Releases FSHRF during the first half of the cycle & LHRF during the second half of the cycle. 2. ANTERIOR PITUITARY GLAND – releases the gonadotropin hormone (GH) FSH & LH 3. OVARIES – site of ovulation and releases estrogen and progesterone 4. UTERUS – the organ from which the menstrual discharge is formed. The changes in the uterine endometrium are due to ovarian hormones.  FOLLICLE STIMULATING HORMONE (FSH) PITUITARY HORMONES WHICH REGULATE MENSTRUAL CYCLIC ACTIVITIES: LUTEINIZING HORMONE (LH) ESTROGEN – hormone of women; produced by the graafian follicle OVARIAN HORMONES WHICH REGULATE MENSTRUAL CYCLE ACTIVITIES: PROGESTERONE – hormone of mothers; produced by the corpus luteum  1. Assist with the maturation of the primary follicle 2. Causes thickening of the endometrium, stimulates growth of vagina and uterus 3. Responsible for the development of secondary sex characteristics (breast development) 4. Inhibits FSH production FUNCTIONS OF 5. Increases contractions of the myometrium ESTROGEN 6. Increases contractions of the fallopian tubes 7. Increases quantity and pH of cervical mucus causing it to become thin and watery and can be stretched toa distance of 10-13 cm (SPINBARKEIT TEST OF ELASTICITY) 8. Stimulates uterine contractions  FUNCTIONS OF ESTROGEN 1. Assist with the maturation of the primary follicle 2. Causes thickening of the endometrium, stimulates growth of vagina and uterus 3. Responsible for the development of secondary sex characteristics (breast development) 4. Inhibits FSH production 5. Increases contractions of the myometrium 6. Increases contractions of the fallopian tubes 7. Increases quantity and pH of cervical mucus causing it to become thin and watery and can be stretched toa distance of 10-13 cm (SPINBARKEIT TEST OF ELASTICITY) 8. Stimulates uterine contractions  FUNCTIONS OF PROGESTERONE Increases BBT (thermogenic effect) Prepares the endometrium for implantation by increasing glycogen. Arterial blood, secretory glands, amino acids and water. Maintains pregnancy by inhibiting uterine contractions. Inhibits the production of LH. Promotes growth of the acini cells of the breast. Causes secretory changes in the endometrium in preparation for implantation.  FUNCTIONS OF PUTUITARY HORMONES 1. FOLLICLE STIMULATING HORMONE (FSH) – STIMULATES THE DEVELOPMENT OF GRAAFIAN FOLLICLE AND OVUM - MAKES THE OVUM MATURE 2. LUTEINIZING HORMONE (LH) - STIMULATES OVULATION AND DEVELOPMENT OF CORPUS LUTEUM  PHASES OF MENSTRUAL CYCLE PROLIFERATIVE/ FOLLICULAR/ ESTROGENIC/ PREOVULATORY/ POST MENSTRUAL SECRETORY/ LUTEAL/ PROGESTATIONAL POST OVULATORY PREMENSTRUAL OR ISCHEMIC CYCLE MENSTRUAL PHASE  THE UTERINE CYCLE Consist of 3 phases: Menstrual phase Proliferative phase Secretory phase  UTERINE CYCLE: Menstrual Phase  Day 1 – day 5  First day of bleeding is the first day of cycle  Stratum functionale (compactum and spongiosum) is shed  Total blood loss during menses range from 30-80 ml. 60 ml average!  UTERINE CYCLE: Proliferative Phase (Estrogenic, follicular) Day 6 – day 14 of a 28-day cycle The very low estrogen level during menstruation stimulates hypothalamus to secrete FSHRF, which in turn stimulates the APG to secrete FSH Estrogen is lowest on the 3rd day and highest a day before ovulation  UTERINE CYCLE: Secretory Phase  Day 15 – day 28  Endometrium becomes thicker and glands secrete nutrients  Uterus is prepared for implantation  Due to progesterone  If no fertilization occurs → constriction of vessels → menstruation  ISCHEMIC PHASE  If fertilization does not occur, the corpus luteum shrivels as its life span is only 8-10 days from date of ovulation  OVARIAN CYCLE Consist of 3 phases: 1. Pre-ovulatory: Follicular phase 2. Ovulatory phase 3. Post-ovulatory: Luteal phase  OVARIAN CYCLE: Preovulatory/ Follicular  Variable in length: Day 6 – day 13  Dominant follicle matures and becomes graafian follicle with primary oocyte  FSH increases initially then decreases because of estrogen increase  OVARIAN CYCLE: Ovulatory Phase  Day 14  Rupture of the graafian follicle releasing the secondary oocyte  Due to LH surge  MITTELSCHMERZ – pain during rupture of follicle OVARIAN CYCLE: Post-ovulatory/ Luteal Phase  Day 15 – day 28  MOST CONSTANT 14 days after ovulation  Corpus luteum secretes Progesterone  If no fertilization, corpus luteum will become corpus albicans then degenerate  Decreased estrogen and progesterone  Signs of Ovulation 1. MITTLESCHMERZ – a certain degree of pain felt at the lower left or right iliac. 2. CERVICAL MUCUS METHOD OR BILLING’S METHOD – changes in cervical mucus secretions to clear, elastic & watery (most reliable sign) 3. SPINNBARKHEIT TEST – does not indicate the exact time of ovulation but signals that a woman is nearing ovulation. This sign is characterized by cervical mucus that is thin, watery and transparent, abundant and highly stretchable. When dried and viewed under a microscope, the mucus reveals a fern pattern. The fern pattern is due to elevated levels of sodium chloride. SPINBARKEIT TEST 4. CERVICAL CHANGES Ferning or arborization of cervical mucus At the height of estrogen stimulation just before ovulation Ferning – due to crystallization of sodium chloride on mucus fibers. 5. Basal Body Temperature Involves taking the temperature every morning BEFORE the woman gets out of bed ad records it. The temperature drops slightly 24 hours before ovulation, then rises to about half a degree higher than normal and remain thus for up to three (3) days: UNSAFE period! Increase of.3 to.6 degrees Celsius Not a very efficient method unless combined with calendar and mucus methods 6. Mood Changes 7. Breast Changes and Enlargement and Nipples Become Erect 8. Increased Libido  MENSTRUAL DISORDERS 1. DYSMENORRHEA – Painful Menstruation I. Primary Dysmenorrhea – no know or identified cause Symptoms includes nausea, vomiting, diarrhea, syncope, leg pain * Intervention: immediate relief is be sedatives & narcotics: Ibuprofen (Motrin), mefenamic acid (Ponstan), Naproxen sodium (Anaprox) II. Secondary Dysmenorrhea a. Pelvic Inflammatory Disease (PID) b. Endemetriosis – proliferation of endometrial tissues outside the uterus c. Adenomyosis – uterine and polyps d. Uterine prolapse e. Uterine myomas and polyps 2. AMMENORRHEA – absence of menses 3. OLIGOMENORRHEA – decreased menstrual flow 4. POLYMENORRHEA – too frequent menstruation occurring at intervals or less than three weeks 5. MENORRHAGIA – excessive menstrual bleeding 6. METRORRHAGIA – bleeding between periods; intercyclic bleeding 7. HYPOMENORRHEA – abnormally short menstruation 8. HYPERMENORRHEA - abnormally long menstruation  SEXUAL RESPONSE CYCLE 1. EXCITEMENT PHASE – occurs with physical, psychological (sight, sound, emotion or thought) stimulation that causes parasympathetic nerve stimulation vaginal lubrication occurs, arterial dilation and venous constriction in the genital area, overall muscle tension increases in men, erection increases, CR, RR, BP increases  SEXUAL RESPONSE CYCLE 2. PLATEAU PHASE – nipples become further engorged. In men Vaso congestion leads to full distention of the penis, flushing occurs “sex flush”, breathing becomes deeper, CR, RR & BP increase markedly. 3. ORGASMIC PHASE – shortest stage in the sexual response cycle, strong muscular contractions both voluntary and involuntary in many parts of the body, CR, RR doubles and BP increasing as much as 1/3 above normal. 4. RESOLUTION PHASE – generally takes approximately 30 minutes for both men and women, general muscle relaxation occurs, external and internal organs to unaroused state.  Responsible Parenthood Family Planning Method  Natural Family Planning Methods  Techniques including checking the body temperature or cervical mucus daily and recording menstrual cycles on a calendar to determine the days when the body is most fertile.  Effectiveness 81%  Accepted by religions and inexpensive  Artificial Family Planning Methods  Spermicides  Chemicals in the form of foams, creams, jellies or suppositories that are inserted into the vagina to kill the sperm before they can enter the uterus.  Typical effectiveness 70%  Available over the counter and can be used with other methods to improve effectiveness  Condoms  Male condom is a sheath of latex or animal tissue placed on erect penis  Female condom is a plastic sac with a ring on each end inserted into the vagina.  Both may be used with a spermicide  Birth Control Pills Prescription drugs that contains the female hormones (estrogen). One pill is taken daily to prevent ovaries from releasing eggs and thickens the cervical mucus to prevent sperm reaching egg.  Diaphragm Shallow latex cup with flexible rim inserted into vagina over cervix to prevent sperm from entering uterus with spermicide.  Intrauterine Device small device inserted by a health care professional into the uterus and prevents eggs from being fertilized and implanting in uterus.  Cervical Cap Thimble-shaped latex cap inserted into a vagina over cervix to prevent sperm from entering uterus used with spermicide.  Hormonal Injection (Depo-Provera) injection given by a health care professional in the arm or buttocks every 12 weeks to prevent ovaries from releasing an egg of thickened cervical mucus to keep sperm from reaching the egg.  Hormonal Implant (Norplant) Six small capsules inserted by a health care professional under the skin of the upper arm that deliver small amounts of hormone to prevent ovaries from releasing eggs.  Permanent Methods of Reproductive Life Planning  Tubal Ligation  surgical procedure to permanently block woman’s fallopian tubes to prevent eggs from reaching by sperm.  Permanent Methods of Reproductive Life Planning  Vasectomy  surgical procedure to permanently block the male’s vas deferens to prevent sperm from reaching eggs. Week 3  Care of the Mother and the Fetus during the Perinatal period Prenatal Care 6. Cognitive-Perceptual 1. Care of the mother 7. Self–Perception- Self- Concept 1. Signs of pregnancy 8. Role-Relationship 2. Planning and Intervention 9. Sexually based on Gordon’s 10. Coping Stress Tolerance Functional Pattern) 11. Value – Belief 1. Health Perception/ Health Management 2. Nutrition Metabolic 3. Evaluation 3. Elimination 4. Documentation 4. Activity Exercise 5. Sleep-Rest Signs of Pregnancy  Signs of Pregnancy Presumptive Signs Probable Signs Positive Signs  Presumptive Signs signs experienced by the woman herself; subjective least reliable indicators of pregnancy because any one of them can be caused by conditions other than pregnancy  Presumptive Signs Signs: Fatigue (12 wk) Breast tenderness (3 - 4 wk) Nausea & Vomiting (4 - 14 wk) Amenorrhea (4 wk) – most obvious Urinary frequency (6 - 12 wk) Hyperpigmentation of the skin (16 wk) Fetal movements (quickening; 16 - 20 wk) Uterine enlargement (7 - 12 wk) Breast Enlargement (6 wk)  Probable Signs signs that are apparent on physical examination by a health care professional although they suggest pregnancy and are more reliable than presumptive signs, they are still not 100% reliable in confirming pregnancy  Probable Signs Signs: Braxton Hicks contractions (16 - 28 wk) spontaneous, irregular, and painless contractions begin during first trimester continue throughout pregnancy, becoming especially noticeable during the last month, when they function to thin or efface the cervix before birth  Probable Signs Signs: Positive pregnancy test (4 - 12 wk) several pregnancy tests are available the tests vary in sensitivity, specificity, and accuracy and are influenced by the length of gestation, specimen concentration, presence of blood, and the presence of some drugs  Probable Signs Signs: Abdominal enlargement (14 wk) Ballottement (16 - 28 wk) the examiner pushes against the woman's cervix during a pelvic examination, and feels a rebound from the floating fetus Goodell's sign (5 wk) softening of the cervix due to vasocongestion  Probable Signs Signs: Chadwick's sign (6 - 8 wk) bluish-purple coloration of the vaginal mucosa and cervix caused by increased vascularization of the cervix Hegar's sign (6 - 12 wk) softening of the lower uterine segment or isthmus results in exaggerated uterine anteflexion during the early months of pregnancy - adds to urinary frequency  Presumptive Signs confirm that a fetus is growing in the uterus visualizing the fetus by ultrasound, palpating for fetal movements, and hearing a fetal heartbeat are all signs that make a pregnancy a certainty once pregnancy is confirmed, the health care professional will set up a schedule of prenatal visits to assess the woman and her fetus throughout the entire pregnancy assessment and education begins at the first visits and continues throughout the pregnancy  Positive Signs Signs: ultrasound verification of embryo or fetus (4 - 6 wk) fetal movement felt by experienced clinician (20 wk) auscultation of fetal heart tones via Doppler (10 - 12 wk)  Health Perception– Health Management Pattern Based on culture and life experiences women either view pregnancy as an illness, a natural health state or a combination of both. Healthy/natural Active participant in social circle/career Choose provider with similar view Prenatal care Illness perspective Withdraw from work/social obligations May make unhealthy pregnancy choices, deny pregnancy Copyright Copyright ©© 2014 2014 byby Mosby, Mosby, anan imprint imprint ofof Elsevier Elsevier Inc. Inc. 133  Nutritional-Metabolic Pattern Good nutrition is essential for proper growth/ development Maternal nutritional deficiencies Developmental and physiological disadvantages Due to pre-pregnancy nutrition/weight, finances, culture Recommendation Weight gain 25-35 lb (300 calories or more/day) Well-balanced diet 8-10 glasses water 70 g protein Increased vitamins/minerals (Fe 27 mg, folic acid 600 mcg) Fats/carbohydrates for energy needs Copyright Copyright ©© 2014 2014 byby Mosby, Mosby, anan imprint imprint ofof Elsevier Elsevier Inc. Inc. 134  Elimination Pattern Fetus Elimination through placenta Carbon dioxide Water Urea Pregnant woman Common discomforts of pregnancy owing to enlarging uterus and hormonal influences Urinary frequency, constipation, hemorrhoids Copyright Copyright ©© 2014 2014 byby Mosby, Mosby, anan imprint imprint ofof Elsevier Elsevier Inc. Inc. 135  Activity-Exercise Pattern Fetus Early pregnancy: Spontaneous movements reflexive Quickening: At 16 weeks Pregnant woman Need physical activity, at least 30 minutes/day of aerobic (walking/swimming) exercise Avoid high-risk sports Copyright Copyright ©© 2014 2014 byby Mosby, Mosby, anan imprint imprint ofof Elsevier Elsevier Inc. Inc. 136  Sleep-Rest Pattern Fetus Four cyclical states of activity: complete wakefulness, drowsy wakefulness, rapid eye movement sleep, and quiet sleep Increasing levels of quiet sleep and quiet alertness as fetus develops Pregnant woman Fatigue significant during pregnancy Rest periods during day and good night’s sleep needed Sleep interruptions (frequent urination, postural discomfort) common Copyright Copyright ©© 2014 2014 byby Mosby, Mosby, anan imprint imprint ofof Elsevier Elsevier Inc. Inc. 137  Cognitive-Perceptual Pattern Fetus Senses (vision, hearing, taste, smell, touch, proprioception, vestibular sense) function 25 weeks: Able to respond to sudden noise Pregnant woman Psychological and cognitive changes Emotional Progesterone affects mood—focus on child Increased sensitivity and analysis of experiences Increased mood swings/variability Transitioning process to motherhood—influenced by maternal/infant variables and context Copyright Copyright ©© 2014 2014 byby Mosby, Mosby, anan imprint imprint ofof Elsevier Elsevier Inc. Inc. 138  Cognitive-Perceptual Pattern (Cont.) Ensuring safe passage Decides prenatal care options; more protective of self/fetus Ensuring acceptance of the child Receptivity of partner, others Binding into her unknown child Complex; integrate fetus as part of self but also as separate being (fantasies/nesting) Learning to give of herself Examines meaning of giving, gifts for herself/baby Copyright Copyright ©© 2014 2014 byby Mosby, Mosby, anan imprint imprint ofof Elsevier Elsevier Inc. Inc. 139  Self-Perception– Self-Concept Pattern Acceptance of pregnant body image Ambivalence vs. acceptance vs. yearning for pre-pregnant state Influences in assuming maternal role Internal (personality, maturity level) External (societal, family) Copyright Copyright ©© 2014 2014 byby Mosby, Mosby, anan imprint imprint ofof Elsevier Elsevier Inc. Inc. 140  Roles-Relationships Pattern Pregnancy affects whole family Without partner Isolation; dependent on family Partner Possible resentment, financial stress, potential for abuse, concerns about role Children Changed relationship with mother, less attention from parents Extended family/expectant grandparents Reminded of own aging; feeling of resentment vs. new closeness Copyright Copyright ©© 2014 2014 byby Mosby, Mosby, anan imprint imprint ofof Elsevier Elsevier Inc. Inc. 141  Coping-Stress Tolerance Pattern Perception of stressors and coping for all life aspects affected Anxiety Greatest in first and third trimesters May decrease blood flow to uterus/fetus May be demonstrated through Psychosomatic complaints/behaviors Dreams/fantasies Smoking/substance abuse Stress-relieving strategies encouraged Copyright Copyright ©© 2014 2014 byby Mosby, Mosby, anan imprint imprint ofof Elsevier Elsevier Inc. Inc. 142  Values-Belief Pattern Fulfillment vs. fear of losing part of self Shifting in relationships Mother Friends Shifting in values Self Partner Influence/changing of spiritual values Finding meaning in pregnancy Spiritual influences on pregnancy care decisions Copyright Copyright ©© 2014 2014 byby Mosby, Mosby, anan imprint imprint ofof Elsevier Elsevier Inc. Inc. 143  MATERNAL NURSING NCM 205 – Maternal And Child Health Nursing Ms. Ederlyn Maura Monzon-Delamide RN MAN Week 4 Care of the Fetus  PRENATAL CARE (ANTEPARTUM CARE) Refers to the health care given to a woman & her family during pregnancy. The primary goal is to improve maximum health to expectant mothers & their babies. 3 PHASES 1. Pre-consultation = history taking, family, medical, OB history 2. Consultation = physical assessment 3. Post consultation = health teachings  COMPONENTS OF PRE-VISIT 1. PRE-CONSULTATION PHASE: History Taking PERSONAL DATA: AGE, SEX, CIVIL STATUS, WEIGHT, HEIGHT AGE: Under 17 Or above 35 (Greater risk if over 40) Pregnant adolescents have a higher incidence of prematurity , cephalopelvic disproportion, poor nutrition & inadequate antepartal care. Women over 35 years old are at risk for chromosomal disorders in infants ,PIH & Cesarian delivery.  OBSTETRICAL DATA MENSTRUAL HISTORY: Includes menarche, length & regularity of menses, interval between periods, amount of flow, dysmenorrhea TERMINOLOGIES: GRAVIDA – The number of pregnancies regardless of duration or outcome PARA – Past pregnancies resulting in viable fetus (20 weeks) whether born dead or alive. (Twins, triplets etc. Considered as one)  OBSTETRICAL DATA T = number of full term births P = number of premature births A = number of abortions L = number of living children  OBSTETRICAL DATA PRIMIGRAVIDA – A woman who is pregnant for the first time PRIMIPARA – A woman who has delivered a viable live or dead child MULTIGRAVIDA – A woman who has had 2 or ore pregnancies NULLIGRAVIDA – A woman who has never been & is not currently pregnant NULLIPARA – A woman who has never delivered a fetus that reached the age of viability. Such woman may or may not have been pregnant before MULTIPARA – A woman who has completed to or more pregnancies to the age of viability  Definition of Terms Term infant – an infant born between 38 and 42 weeks of gestation Preterm – an infant born before 38 weeks Post term – an infant born after 42 weeks Abortion – pregnancy that terminates before the period of viability (20 weeks) Live birth – a live birth is recorded when an infant born shows sign of life  Definition of Terms Stillbirth – infant born without signs of life Early Neonatal Death – death of newborn within 7 days after birth Late Neonatal Death – death of newborn between 7 to 29 days after birth Low birth weight – < 2500 grams Normal birth weight – 2500-4000 grams Large birth weight – > 4000 grams Parturient – a woman in labor Puerpera – a woman who just delivered (within six weeks after delivery)  CONSULTATION PHASE: Physical Assessment Initial Visit – Complete physical exam Breast exam – nipple formation using “pinch test” in which the areola is pinched gently and pushed in with the examiner’s thumb and forefinger; an everted or normal nipple protrude, an inverted nipple will look flat or turned inward, indicating potential difficulty with breastfeeding Pelvic exam – Pap smear; culture for gonorrhea and herpes if appropriate; smear for chlamydia; bimanual (palpation of reproductive organs between abdominal and vaginal hands) to establish uterine size, consistency, and contour; pelvic measurements Treatment of Disease – in malaria infested areas, all pregnant women shall be given prophylaxis in the form of CHLOROQUINE (150mg) 2 tablets per week during the entire weeks of pregnancy  CONSULTATION PHASE: Physical Assessment C. VITAL SIGNS = Temperature, pulse and respiratory rates are important especially during the initial phase of the prenatal visit. But certainly more important are the weight & blood pressure as baseline data to determine any significant increase  TT IMMUNIZATION: TT1 given anytime during pregnancy TT2 one month after tt1 (3 years protection) TT3 six months after tt2 (5 years protection) TTt4 one year after tt3 (10 years) TT5 one year after tt4 or next pregnancy (lifetime protection)  Important Estimates 1. NAEGELE’S RULE = CALCULATION OF EXPECTED DATE OF CONFINEMENT (EDC) FORMULA: Count back 3 months from the last day of the menstrual (LMP) PERIOD (LMP) Then add 7 days plus 1 year EXAMPLE: LMP APRIL 22, 1995 -3 +7 +1 JAN 29, 1996  Sample Activity 1. March 10, 2024 2. July 18, 2024 3. May 12, 2024 4. Dec 8, 2023 5. Jan 3 2025  Important Estimates 2. MCDONALD’S RULE = (Estimation of AOG in months & weeks by fundic height measurement) = FORMULA: FUNDIC HEIGHT IN CMS X 2/7 OR 8/7 EXAMPLE: FUNDIC HEIGHT IS 21 CMS 21 CMS X 2 = 42 42/7 = 6 (AOG IN MONTHS) 6 MONTHS X 4 = 24 (AOG IN WEEKS)  Important Estimates HAASE’S RULE = Estimation of fetal length RULE: During the first half of pregnancy, square the number of the month (ex. First lunar month: 1x1 = 1cm) During the second half of pregnancy, multiply the month by 5 (ex. 6th lunar month: 6x5 = 30cm) Formula: 1 to 5 months = months squared examples: 5 months x 5 = 25 cms length 8 months x 5 = 40 cms length  Important Estimates JOHNSON’S RULE = Estimation of weight in grams FORMULA: FUNDIC HEIGHT IN CM – N X K “K” IS CONSTANT, IT IS ALWAYS 155 “N” IS MINUS 11 IF PART IS NOT YET ENGAGED MINUS 12 IF PART IS ALREADY ENGAGED EXAMPLE: 21 CM, NOT ENGAGED 21 – 11 = 10 X 155 = 1,550 GMS  Important Estimates BARTHOLOMEW’S RULE = estimation of AOG by the relative position of the uterus in the abdominal activity By the 3rd lunar month, the fundus is palpable slightly above the symphysis pubis On the 5th lunar month, , the fundus is at the level of the umbilicus On the 9th lunar month, the fundus is Below the level of the xiphoid process  Health Assessment Fundal height and fetal heart sounds Pelvic exam External genitalia Internal genitalia Pap smear Vaginal inspection Exam of the pelvic organs Rectovaginal exam  The Appearance of the Cervix 1. NULLIGRAVIDA 2. AFTER CHILDBIRTH 3. AFTER MILD CERVICAL TEARING (Stellate)  Laboratory Screening Initially and at routine visits, urine dipstick for glucose, protein (pregnancy induced hypertension and UTI), CBC, rubella IgG antibody Maternal serum alpha-fetoprotein (AFP) at 16-18 weeks to identify risk of neural tube defect in fetus Glucose screening between 24-28 weeks to detect gestational diabetes Repeat CBC at 24-28 weeks Rh antibody titers for Rh woman at 24, 28, 32, and 40 weeks Ultrasound  Laboratory Tests Urinalysis -1. Collect urinary specimen by midstream or clean catch technique -2. Benedict’s test to detect glycosuria -3. Heat & acetic acid to detect proteinuria -4. Urinalysis in the first trimester is also performed to detect asymptomatic bacteuria. Bacteuria can lead to abortion early in pregnancy & can cause premature labor late in pregnancy  Laboratory Tests Blood Tests Hematocrit & Hemoglobin – count at initial clinic visit & repeated at 28-32 weeks to detect anemia. Normal Hemoglobin level is between 12-16 mg/dl Normal Hematocrit count is between 37-47%  Laboratory Tests VDRL and Kahn & Wassaerman test to detect Syphilis Gonorrhea Culture Rubella Antibody Titer – to detect degree of protection against German measles. A test result of 1:8 or less indicates that the mother is at risk of acquiring the infection during pregnancy. A titer more than 1:8 means that the mother has immunity against German measles  Fetal Development Ovum: 1. It Is The Female Sex Cell Or Female Gamete 2. Regularly Released By The Ovary By Ovulation 3. Only One Ovum Reaches Maturity Every Month. 4. Ovum Has 2 Layers Of Protective Covering: A Ring Of Fluid Called “Zona Pellucida” & A Circle Of Cells Called “Corona Radiata” = These Structures Increase The Bulk Of The Ovum Facilitating Its Migration To The Uterus.  Fetal Development Ovum Can Stay Viable And Is Capable Of Being Fertilized For 12-24 Hours After Ovulation But Can Live Up To 3-4 Days Only On Spermatozoon Is Able To Penetrate The Cell Embrane Of The Ovum After which The Ovum Becomes Impervious To Other Spermatozoa.  SPERM CELL has 3 parts: head that contain chromatin materials; neck or mid piece that provide energy and tail that is responsible for its motility. spermatozoa deposited in the vagina reaches the waiting egg in the fallopian tube in about 5 minutes the functional life of a spermatozoa is 48-72 hrs (or 3 to 4 days after ejaculation) but can stay alive in the vagina for 5-7 days  Sperm Cell 2 Kinds of Sperm Cell 1. GYNOSPERM – X CARRYING SPERM CELL. It has a large oval head, lesser in number than androsperm & thrive better in acidic environment. 2. ANDROSPERM – Y CARRYING CELL. It has a small head and thrive better in alkaline environment.  INSEMINATION Deposition of the sperm in the female internal organs which occurs during sexual intercourse. Although millions of sperm are deposited in the vagina, only a few reach the uterus because many of them are immobilized by the acidic vaginal environment. Fertilization (Conception, Fecundation, Impregnation)  It is the union of A mature egg and A sperm & the product is called A conceptus or zygote  It occurs at the distal 3rd of the fallopian tube – the ampulla  Before fertilization can happen, two things must occur: 1. Ovulation 2. Insemination  when the sperm reaches the uterus, it removes the protective covering, a process called “CAPACITATION”, the outer covering at the head of the sperm cell disappears and tiny holes appear on it. when it meets the ovum in the fallopian tube, it secretes the enzymes HYALURONIDASE through the holes in its head which dissolves the outermost overing of the egg cell, the corona radiata (a process called “ACROSOME REACTION.”) when radiata is dissolved, the sperm will again secrete another enzyme called ACROSIN to dissolve a portion of the pellucida & will enter the ovum.  once the sperm cell has entered the ovum & their nucleus has fused together, fertilization is completed. the plasma membrane of the ovum will undergo structural changes to prevent POLYSPERMY (or other sperm cell entering the ovum) the hereditary traits & characteristics of a person are found in the cell’s nucleus in the form of chromosomes. Each strands of chromosome is made up of thousands of genes that are composed of protein substances called deoxyribose nucleic acid (DNA) & ribonucleic acid (RNA)  Reproductive cells, during gametogenesis divide by MEIOSIS (HAPLOID NUMBER OF DAUGHTER CELLS) Therefore they contain only 23 chromosomes. = 22 pairs of autosomes = 1 pair of sex chromosomes  Body Cells Or Somatic Cells Have 46 Chromosomes Because They Divide Via Mitosis Sperms Have 24 Chromosomes = 22 Autosomes & 1 Sex Chromosome Or 1 Y Sex Chromosome The Union Of An X Carrying Sperm (Gynosperm) & A Mature Ovum Results In A Baby Girl (Xx) The Union Of A Y Carrying Sperm (Androsperm) & A Mature Ovum Results In A Baby Boy (Xy) Only Fathers Can Determine The Sex Of Their Children Sex Of A Child Is Determined At The Time Of Fertilization  ZYGOTE Is The First Cell Formed From The Fertilization Of Sperm & Ovum It Contains 46 Chromosomes: 44 Autosomes & Either XX Chromosomes If The Offspring Is A Female, Or XY Chromosome, If The Offspring Is A Male. It Journeys From The Fallopian Tube To The Uterus For 3-5 Days 16 Hours After Fertilization, It Undergoes Its First Cell Division, “Blastomere”  When there are already 16 or more blastomeres, the zygote is termed “morula” (morus – mulberry) When it reaches the uterus it is transformed into a “blastocyst” – a ball like structure composed of inner cell mass called embryonic disc or blastocele & an outer layer of rapidly developing cells called trophoblasts or trophoderm. Fluid fills the spaces found within the cells.  The trophoderm layer gives rise to the placenta, fetal membranes, umbilical cord and amniotic fluid. The important functions of the trophoblasts are to: 1. Absorb nutrients from the endometrium 2. Secrete a hormone called “human chorionic gonadotropin” necessary in prolonging the life of the corpus luteum.  Hcg First hormone to appear in pregnancy which serves as the basis for pregnancy testing 8 – 10 days after fertilization, hcg is present in the maternal blood Few days after missed menses (+) in the urine  The blastocele or embryonic disc gives rise to the three primary germ layers: Ectoderm Mesoderm Endoder  TROPHOBLASTS OR THE OUTER CELLS: At about 3 weeks, the trophoblast cells differentiate into two distinct layers: 1. Cytotrophoblast or langhan’s layer - Inner layer that protects the fetus against syphilis until the 2nd trimester. 2. Syncytiotrophopblast or synctial layer - Outer layer that produces hormones hcg (human chorionic gonadtoropin), hpl (human placental lactogen), estrogen and progesterone  IMPLANTATION / NIDATION  The blastocyst remains free floating in the uterine cavity for 3-5 days & implants in the endometrium 6-7 days after fertilization.  As it attaches itself to the wall of the uterus, its trophoblast cells release enzymes allowing it to burrow deep into the endometrium resulting in rupture of vessels & bleeding at the implantation site. “Implantation bleeding”  DECIDUA After Implantation, the Endometrium is now referred to as the Decidua. Layers: Decidua Basalis – Layer where implantation takes place. It will later on form the maternal side of the placenta. Decidua Capsularis – Layer which encloses, envelopes the blastocyst 7 becomes the bag of water. Decidua Vera – Remaining layer  MEMBRANES This encloses the fetus & at amniotic fluid. It also protects the fetus against ascending bacterial infection. Once the integrity of the membranes are destroyed, the woman is prone to develop infection. 1. Chorionic membrane – (outer membrane) - Together with the decidua basalis, it gives rise to the placenta. It contains 15-20 cotyledons 2. Amniotic Membrane – (inner fetal membrane) - It is a smooth, thin, tough & translucent membrane directly enclosing the fetus & the amniotic fluid. It is continuous with the umbilical cord and cover the fetal surface of the placenta and umbilical cord. - Amnion and chorion does not contain nerve endings  AMNIOTIC FLUID Formed by the secretion of amniotic cells, fetal lung, skin and urine 500 ML TO 1200 ML AT TERM; AVERAGE IS 1000 ML; replaced approximately every 3 hours 99% water & 1% solid particles containing albumin, urea, uric acid, creatinine, lecithin, sphingomyelin, bilirubin & vernix caseosa. Amniotic fluid volume increases during pregnancy & peaks approximately 2 weeks before EDC  Functions of Amniotic Fluid 1. Protects the fetus from trauma, blows & pressure 2. Allows freedom of movement which permits symmetrical growth & development 3. Maintains a constant temperature 4. Source of oral fluid intrauterine. 5. Aids in diagnosis of maternal & fetal complications 6. Aids in fetal descent during labor by provding lubrication in the birth canal.  AMNIOTIC FLUID AMOUNT ABNORMALITIES Fetus contributes to the fluid through urine excretion and absorbs from it by swallowing Hydramnios or polydydramnios (>2000 ml) – mostly seen in diabetic mothers. Oligohydramnios (