Maternal Review PDF

DEFINITION OR TERMS - Members provide each other with support -Can change as a result of divorce, separation, single Obstetrics - is the field of study concentrated on parenthood, or remarriage. pr...

DEFINITION OR TERMS - Members provide each other with support -Can change as a result of divorce, separation, single Obstetrics - is the field of study concentrated on parenthood, or remarriage. pregnancy, childbirth, and the postpartum period. Extended or multigenerational family Gynecology - is the medical practice dealing with – Nuclear family plus other family members the health of the female reproductive systems Single-parent family (vagina, uterus and ovaries) and the breasts. – Can result from divorce, death of spouse, or a parent raising a child outside marriage HISTORY – Lacks the support of a nuclear family in times of PRIOR TO THE 18TH CENTURY crisis. BEFORE 18TH CENTURY Cohabitation family -the ancient Greek they have the interest to study – A heterosexual couple that lives together but isn’t the reproductive organs and sexual practice. married Soranus of Ephesus – May be together for the short-term or the long- -he is interested to study the abortion, contraceptive, term coitus interuption, birth complications. Blended family Ephraim McDowell – Has combined because of remarriage -perform the first surgery of the ovary (ovariotomy) – Can foster feelings of yours, mine, and ours among J. Marion Sims members -vesicovaginal fistula – Rivalry and jealousy may develop 19TH CENTURY – Help children become more adaptable to new -men are introduced situations. Communal family THE FAMILY AND FAMILY HEALTH – Group of people who have chosen to live together Family but may not be related by marriage - two or more people who may live in the same Gay or lesbian family household, share an emotional bond, and perform – May choose to include children in the family certain interrelated social tasks Group of people who Children may be adopted. may be united by blood, marriage, or adoption and Foster family have a common residence for part of their lives. – Provides care for children whose biological parents FAMILY DYNAMICS can no longer care for them – Usually a temporary Families can profoundly influence individual family arrangement. members. Adoptive family A new family member alters the family structure. –Any type of family can become an adoptive family – Family roles must be flexible enough to adjust to May result from an inability to have biological the changes that a pregnancy and a neonate bring. children. If a family member is ill or is going through a rough FUNCTIONS OF A FAMILY developmental period, this puts a tremendous strain –Distribute resources on the family –Socialize family members Family-centered care examines individual –Divide the labor circumstances from a family or community –Provide for basic physical needs standpoint. –Maintain order Family-centered care has become a focus of modern nursing practice. Reproduce, release, and recruit family members Place family members into society FAMILY TYPES Maintain motivation and morale  Nuclear family ASSESSMENT OF FAMILY STRUCTURE AND - The traditional family, with a wife, a husband, and FUNCTION children Family health can be assessed on a variety of levels - Members feel affection for each other and in varying degrees of detail.  The type of family data collected and the method EXTERNAL GENITALIA  of collection should match the way in which the assessment date will be used PENIS: General characteristics of family type and -  Serves as the external organ of reproduction functioning can be assessed using observation and general history questions. and as the external organ of urinary elimination. THE WELL FAMILY The genogram –A diagram that details family structure, provide information about the family’s history and the roles of various family member over time, usually through several generations. ANATOMY AND PHYSIOLOGY OF THE REPRODUCTIVE SYSTEM Both male and females produced specialized reproductive germ cells called GAMETES (sex cells) SCROTUM -Main function is to protect the testes from trauma and to regulate the temperature within MALE REPRODUCTIVE SYSTEM the testes (a process that is extremely The male reproductive anatomy consists of important to the production of healthy male external and internal reproductive organs. gametes). The purpose of the male reproductive tract is to allow for sexual intimacy and reproduction of 1 degrees celsius cooler than the body offspring, and to provide a conduit for urinary Supplied abundantly with sweat & sebaceous elimination. Dartos Layer cold env- it contracts to pull the testes closer to the body to get heat warm env- it relaxes to descend the testes away from the body to get heat. INTERNAL GENITALIA Testes – Are equivalent of the ovaries in the female. – Two oval organs, one within each scrotal sac. – Each testis is about 4.5 cm long, 2.5 cm wide and 3 cm thick, and is divided into lobes. -Tunica Vaginalis- (free movement of the testes.) -Tunica Albuginea – (200-300 lobules) – Serve two important functions: production of male sex hormones, and formation and maturation of spermatozoa. -Each lobe contains: Seminiferous tubules - produces sperm Epididymis - Are intricate network of coiled ducts of each testis that is 6 meters in length. -Maturation of sperm takes place Accessory Glands and Semen o Seminal vesicles - Are 2 fibromuscular pouches lying on the posterior aspect of the bladder. Ductal System SPERM PATHWAY TESTES O Vas deferens (Ductus deferens) ↓ - Muscular tube in which sperm begin their SPERM journey out of the man’s body. ↓ -Connects the epididymis and ejaculatory duct. EPIDIDYMIS o Ejaculatory ducts ↓ – 2 tubes about 2cm long, passing through the VAS DEFERENS prostate gland and join the prostatic urethra, ↓ carrying seminal fluid and spermatozoa to the SEMINAL VESICLES urethra. ↓ o Prostate gland EJACULATORY DUCT ↓ - is a walnut-sized structure located below the PROSTATE GLAND bladder, secretes an additional fluid that ↓ nourish the sperm and helps sperm move. URETHRA o Bulbourethral (Cowper’s) glands ↓ -Secrete an alkaline fluid that coats the last art EXPULSION FROM THE BODY of the urethra during ejaculation. -Enhancement of sperm motility -Nourishment of sperm FEMALE EXTERNAL GENITALIA - Protection of sperm Mons pubis -The alkaline fluid and sperm combination is a Labia majora thick, whitish secretion termed semen. Typical Labia minora ejaculate = 2-5 ml fluid. o Urethra Clitoris - Provides a common pathway for the flow of oBartholins glands (vulvovaginal glands) urine and semen 19-20 cm long. Excretory duct -a mucus-secreting gland, which plays a role in for urine & semen. vaginal lubrication. -Secretes a clear, thick, alkaline mucus that enhances the viability and motility of the sperm HORMONAL CONTROL OF MALE deposited in the vaginal vestibule. REPRODUCTIVE FUNCTIONS Hymen= is a thin but tough vascularized mucuos membrane Fourchette= is a ridge of tissue formed -Provides passage for the menstrual products posteriorly at her labia majora & minora; being from the uterine endometrium to the outside of cut to enlarge vaginal opening the body, Fossa navicularis= space between the - Protects against trauma from sexual fourchette & vaginal opening intercourse and infection from pathogenic G-spot (Grafenberg)= inner-anterior surface of organisms. the vagina. Uterus -The core of reproduction Perineum -Organ for menstruation - A band of fibrous, muscular tissue that - A hollow, muscular, thick-walled pear- extends from the posterior portion of the labia shaped organ. majora to the anus -Lies in the center of the pelvic cavity -Capable of great expansion during childbirth between the base of the bladder and the to allow for delivery of fetus. rectum and above the vagina. -Approximately 7.5 cm long by 5.0 cm wide and weighs 40 gm in a nonpregnant woman. LIGAMENTS: Cardinal / Transvers Cervical/ Mackenrodt INTERNAL GENITALIA Broad ligaments Round ligaments Vagina Uterosacral ligaments o Extends from the vulva to the uterus Anterior ligament o Often called the birth canal Posterior ligament o Bulbocavernous muscle o Kegel’s exercise DIFFERENT POSITION o Lactobacilli microbes -Anteversion o Vaginal vault -Retroversion o Rugae o Fornix -Anteflexion oCul-de-sacofDouglas -Retrofelxion o Three functions: “Isthmus”- lowering uterine segment -Serves as the passage for sperm and for the -thinnest during childbirth fetus during birth  Fallopian tubes (OVIDUCTS) o About 10 cm trumpet-shaped long o Extending from the sides of the uterus between the body and the fundus oThe end of each tube has finger-like projection called fimbriae. Functions to: Provide a site for fertilization (ampulla) Transport ovum from ovary to the uterus Provides nourishment to the ovum Divided into three sections: the isthmus, the ampulla, and the infundibulum. ACCESSORY ORGAN -Bony pelvis (refer to labor Process) - Breast (mammary glands) -pair of accessory glands of female reproduction responsible for lactation, located between the 2nd & 6th ribs; - externally covered by skin with darker colored nipple and areola containing Montgomery’s glands that lubricate the nipples. (Dr. William Fetherstone Montgomery) - Suspending the breasts are fibrous tissues, called Cooper’s ligaments. Ovaries (6-19gms) oThe breasts are composed of glandular, - Are two female gonads that are located on fibrous, and adipose tissue. either side of the uterus oThe glandular tissue(alveoli) is arranged in a Functions are: series of 15-24 lobes clustered around tiny Oogenesis – development & maturation of ducts. ovum. Biological functions: Ovulation - release of MATURE ovum from the -Provide nourishment and protective ovary. antibodies to infants. Hormone production – the ovaries are the main - Source of pleasurable sexual sensation. source of estrogen & progesterone in nonpregnant woman. 1. Lobes – 15 – 20 lobes found in each breast LAYERS: 2. Lobules – composed of clusters of acini cells - TUNICA ALBUGINEA – the outermost layer 3. Acini cells – milk secreting cells of the breasts -MEDULLA- lies at the center & consist of that are stimulated by prolactin hormone fibrous tissue, blood vessels and nerves 4. Lactiferous ducts – ducts that serves as -CORTEX – functional layer; it is the site for passageways of milk ovum formation and maturation; it contains 5. Lactiferous sinus - dilated portions of the primordial follicles, graafian follicles, corpus ducts behind the nipple that serve as reservoir luteum, and corpus albicans. of milk. The female internal reproductive organs Hormones that influence the Mammary glands  Estrogen- stimulates development of EXTERNAL GENITALIA: ductile structures of the breasts A. MONS PUBIS - Provides an adipose cushion  Progesterone - stimulates the over the anterior symphysis pubis - Protects the development of the acinar structures of pelvic bones the breasts B. LABIA MAJORA - Positioned lateral top of the  HPL - promotes breasts development labia minor - Covered by pubic hair during pregnancy C. LABIA MINOR - Consists of connective tissue,  Oxytocin “ let down reflex” – this elastic fibers, veins and sebaceous glands - hormone is inhibited by progesterone Protect the ext. genitalia and the distal urethra  Prolactin – stimulates milk production; and vagina - Unite to form the fourchette, the inhibited by estrogen. vaginal vestibule. D. CLITORIS - 1-2 cm in size - Located in the anterior position of the vulva - Covered by a fold of skin called the prepuce - Make up of erectile tissue, nerves and blood vessels E. VAGINAL VESTIBULE - Flattened smooth surface inside the labia - Openings to the bladder (urethra) and the uterus (vagina), both arise from the vestibule - Consists of the vaginal orifice, the hymen, the fourchette, Skene’s and Bartholin’s glands HYMEN - Is a thin but tough, vascularization mucous membrane - located at the vaginal orifice FOURCHETTE - Is the ridge of tissue formed by the post. joining of the two labia majora and labia minora - sometimes cut during vaginal birth (episiotomy) SKENE’S GLANDS (PARAURETHRAL GLANDS) - are located lateral to the urinary meatus on either side - help lubricate the ext genitalia 1. ENDOMETRIUM - Inner mucous membrane during intercourse layer that’s shed during menstruation BARTHOLIN’S GLANDS (VULVOVAGINAL 2. MYOMETRIUM – 3 interwoven layers of GLANDS) - Secrete mucus along with Skene’s smooth muscle, which are arranged in glands during sexual stimulation - alkaline ph of longitudinal, transverse, & oblique directions - Skene’s and Bartholin’s help improve sperm offers extreme strength to the uterus survival in the vagina 3. PERIMETRIUM - Outer layer that covers the F. PERINEAL. BODY / PERINEAL MUSCLE / body of the uterus and part of the cervix PERINEUM - Post. to the fourchette - Easily - Adds strength and support stretched during childbirth to allow C. UTERINE NERVE SUPPLY enlargement of the vagina. - Both afferent (sensory) & efferent (motor) G. URETHRAL MEATUS - Located 1-2.5cm below nerves the clitoris D. UTERINE BLOOD SUPPLY - Uterine arteries - The uterus also receives blood from the ovarian arteries E. UTERINE SUPPORT BROAD LIGAMENTS -2 fold of peritoneum that cover the front and back of the uterus and extend to the pelvic sides ROUND LIGAMENTS - 2 fibrous muscular cords that pass from the body of the uterus near the attachments of the Fallopian tubes F. VAGINA - Vascularized musculomembranous tube that extends from the external genitalia to the uterus - Functions as the organ of intercourse, INTERNAL GENITALIA: channeling sperm to the cervix A. UTERUS - Expands with pregnancy to function as birth Functions: - To receive the ovum from the canal Fallopian tube - Act as uterine excretory duct for menses and - To provide a place for the ovum to implant other secretions - To offer nourishment and protection to the G. FALLOPIAN TUBES growing fetus - Each is about 10cm /12 cm long 4 layers: - To expel the fetus when mature 4 Parts: Peritoneal 1. Body/corpus - uppermost portion Subserous 2. Fundus - between points of attachment Muscular of the fallopian tubes - produces peristaltic motions that conduct the 3. Isthmus - short segment between corpus ova the length of the tube and cervix - cut during cesarean birth Mucosal 4. Cervix - lowest part - the junction of the - act as lubricant to aid ova travel and also act as canal at the isthmus is the internal cervical nourishment for the fertilized egg; contains os - the distal opening into the vagina is the CHON, H2O, and salt external cervical os. B. UTERINE LAYERS 4 Portions: - Provide nourishment to the infant and Interstitial - proximal portion; 1 cm in length transfer maternal antibodies during Isthmus - next distal portion; 2 cm breastfeeding - Enhance sexual pleasure - is the portion of the tube that is cut - Blood supply: thoracic branches of axillary, or sealed in tubal ligation internal mammary and intercostal arteries. Ampulla - 3rd and longest portion of the tube; 5cm - fertilization of an ovum takes place Infundibular - 4th most distal of the tube - 2 cm long and funnel shaped - the rim of the funnel is covered by fimbriae (small hairs) that help guide the ova into the tube. H. OVARIES - 2 almond shaped glandular structures on either side of the uterus, below and behind the Fallopian tubes - Produce mature and discharge ova. 2. FEMALE PELVIS - Supports and protects the reproductive organs - Bones which compose the body pelvis: ILIUM, ISCHIUM, PUBIS, SACRUM, COCCYX RELATED STRUCTURES: FEMALE ACCESSORY GLANDS: 1. BREASTS /Mammary glands - Divided by connective tissue into approx 20 lobes - All the glands in each lobe produce milk by ACINI cells and deliver it to the nipple by FALSE PELVIS lactiferous duct - Supports the uterus during the late months - Nipple is surrounded by a darkly pigmented of pregnancy area of epithelium approx 4 cm – areola - Directs the fetus into the true pelvis - The areola appears rough due to many TRUE PELVIS sebaceous glands called MONTGOMERY’S Inlet- entrance to the true pelvis; upper ring of tubercles the bone.  Pelvic Cavity 4 STRUCTURES INVOLVED IN THE MENSTRUAL -space between the inlet and outlet CYCLE: Outlet 1. HYPOTHALAMUS - inferior portion of the pelvis - Releases LHRH / GnRH which initiates menstrual cycle For the fetus to be delivered vaginally, it must - Presence of estrogen represses the hormone be able to pass through the ring of the pelvic 2. PITUITARY GLAND bone and the opening must be sufficient, - Under the influence of LHRH, the anterior otherwise the fetus may have to be delivered lobe of the pituitary gland (adenohypophysis) via CS. produces 2 hormones that act on the ovaries to further influence the menstrual cycle: FSH - Responsible for maturation of the ovum LH - becomes most active at the midpoint of the cycle and is responsible for ovulation 3. OVARIES -Maturation of locates (4 million at present) - Ovulation; every month, one of the follicles is activated by FSH. At maturity, it is visible on the surface of the ovary as a clear water blister approximately 1/4 - 1/2 termed GRAAFIAN 4 TYPES OF FEMALE PELVIS FOLLICLE - The ovum is set free from the surface of the 1. GYNECOID ovary, a process termed OVULATION; ovulation 2. ANDROID occurs on approximately 14th day before the 3. PLATYPELLOID onset of the next cycle (subtract 14 days from 4. ANTHROPOID the length of the menstrual cycle) - The LH causes the ovary to produce LUTEINIZING, a bright yellow fluid, instead of follicular fluid. This yellow fluid fills the empty follicle, which is then termed CORPUS LUTEUM (yellow body). SIGNS OF OVULATION: - FSH levels rise, and steady levels of LH Mittleschmerz - slight discomfort in right / influence the ovary to secret estrogen left iliac region - Usually lasts about 4-5 days, but 1-10 days Spinnbarkeit - stretchable, clear vaginal / maybe normal for some women. cervical secretions Change in body temperature 1 degree Fahrenheit the day following ovulation due to the concentration of progesterone. 4. UTERUS IST PHASE: PROLIFERATIVE / FOLLICULAR / ESTROGENIC / POSTMENSTRUAL - Day 5-14 / 6-13 - Estrogen increases, leasing to proliferation of endometrium and myometrium in preparation of possible implantation of a fertilized ovum - Follicle secretes estradiol - FSH stimulates Graafian follicle - FSH production decreases before ovulation (around day 14) 2ND PHASE: SECRETORY / LUTEAL / PROGESTATIONAL / PREMENSTRUAL - Day 14 - 25 - The corpus luteum forms under the influence of LH - Estrogen and progesterone production increase - The endometrium is prepared for implantation of fertilized ovum - Increase vascular supply (capillaries) HORMONES INVOLVED: 3rd PHASE: ISCHEMIC PHASE 1.GnRH (APG) - initiates the menstrual cycle - Approximately 24 /25 day of the cycle FSH - stimulate development of - Days 26 through 28 primordial follicles into Graafian follicles - Corpus luteum degenerates if conception LH - responsible for ovulation doesn’t occur 2. ESTROGEN - Estrogen and progesterone levels decline if - secondary sex characteristics conception doesn’t occur - Fertile cervical mucus - Arteries and capillaries constrict and - Maintains the endometrium endometrium become anemiccapillaries rupture - Stimulates uterine contraction with minute hemorrhages, and the 3. PROGESTERONE endometrium sloughs off - Prepares the endometrium 4TH PHASE: MENSTRUATED PHASE / MENSE - Relaxes the myometrium - The end of menstrual cycle - Increases basal body temperature - Comprise the 1st 5 days of the cycle - Infertile mucus - The 1st day is used to mark the beginning of a - Maintains pregnancy new menstrual cycle - 30-80ml of blood / 50-150ml - Estrogen and progesterone level decrease  FERTILIZATION CONCEPTION / IMPREGNATION / FECUNDATION - Union of ovum and spermatozoon - Fertilized egg is called ZYGOTE OVUM - from ovulation to fertilization ZYGOTE - from fertilization to implantation EMBRYO - from implantation to 5-8 weeks – SEX- Act of copulation / “coitus FETUS- From 5-8 weeks until term CONCEPTUS - developing embryo / fetus and SEXUAL RESPONSE CYCLE placental structures throughout pregnancy. 4 Stages of Sexual Response: 1. EXCITEMENT PHASE - Physical and psychological stimulus - Arterial dilatation and venous constriction in the genital area Physiological changes in woman: - clitoris increase in size - Lubrication - Vagina widens - Breast nipples become erect - Increase BP, HR, RR Physiological changes in - Functional life of a spermatozoa is about 48h, men: possibly as long as 72h - Erection - Ova about 24h possibly as long as 48h - Scrotal thickening - The ovum is surrounded by a ring of - Elevation of the testes mucopolysaccharide fluid (zona pellucida) and a - Increase BP, HR, RR circle of cells (corona radiata) - serve as 2. PLATEAU PHASE protection from injury. - Reached first before orgasm - Women: formation of orgasmic platform, increased nipple engorgement -Men: full distention of the penis 3. ORGASM PHASE - Discharge of accumulated sexual tension - shortest stage 4. RESOLUTION STAGE - External and internal organs return to their uncrossed state - Generally, takes 30 min  - Fertilization usually occur in the outer 3rd of After the spermatozoon penetrates the ovum, the Fallopian tube, its nucleus is released into the ovum, its tail the ampullae portion degenerates and its head enlarges and fuses with the nucleus of the ovum. This fusion - Normally, an ejaculation of semen averages provides the fertilized ovum, called a zygote 2.5 ml of fluid with 46 chromosomes containing 50 - 200 million spermatozoa per milliliter or an The spermatozoon and ovum each carried 23 average of 400 million / ejaculation chromosomes (22 autosomal and 1 sex chromosome) - Spermatozoa deposited in the vagina during intercourse generally, reach the cervix within 90 sec and the other end of the Fallopian tube within 5 min after deposition CAPACITATION - Final process that sperm must undergo to be ready for fertilization - The sperm move toward the ovum - Changes in the plasma membrane of the sperm head, reveals the sperm - binding receptor sites 3 SEPARATE FACTORS FOR FERTILIZATION TO OCCUR A. Maturation of both sperm and ovum B. Ability of sperm to reach the ovum C. Ability of the sperm to penetrate the zona pellucida and cell membrane and achieve fertilization IMPLANTATION - Occurs when the cellular wall of growing structure / zygote implants itself in the endometrium of the anterior or posterior fundal region, 8-9 days after fertilization after the HYALURONIDASE corona and zona pellucida degenerates - Proteolytic enzyme - After fertilization. It takes 3-4 days for the - Released by the spermatozoa and acts to zygote to reach to the body of the uterus (free dissolve the layer of cells protecting the ovum floating). During this time, mitosis cell division, or cleavage begins Normally, only one spermatozoon is able to - Day 2 - 1st cell division penetrate the cell membrane of the ovum. Once - Day 3 - morula; bumpy appearance; consists it penetrates the zona pellucida, the cell of 16-50 cells; body of the uterus; floats free in membrane becomes impervious to other the uterine cavity for 3-4 days. spermatozoa.  STAGES OF FETAL DEVELOPMENT: 1. Pre-embryonic Period - Begins with fertilization and last a about 3 weeks - As the zygote passes through the Fallopian tube, it undergoes a series of mitosis divisions, or cleavage - Once formed, the zygote develops - Day 4 - Blastocyst; large cells collect at the into morula and then blastocyts eventually periphery of the ball, leaving a fluid space becoming attached to the endometrium surrounding an inner cell mass - this structure attaches to the uterine 2. Embryonic Period - Begins with the 4th week endometrium of gestation and ends with the 7th week (2wk - - the cells in the outer ring are known as 8 was) - Germ layers develop, giving rise to trophoblasts which will form into placenta and organ systems - The embryo is highly vulnerable membranes to injury from maternal drug use, certain - the inner cell mass (enclosed within the maternal infections and other factors trophoblast will form the embryo) 3. Fetal Period - Begins with the 8th week of gestation and continues until birth (9 weeks/2months-birth) - During this period, the embryo, now called a FETUS matures, enlarges and grows heavier -The head is disproportionately larger when compared its body - lacks subcutaneous fat - After implantation, the endometrium is called the DECIDUA - Once implanted, the zygote is called an EMBRYO EMBRYONIC AND FETAL STRUCTURES A. DECIDUA -refers to the endometrial lining during pregnancy 3 Separate layers: DECIDUA BASALIS - lies directly under the embryo; its where trophoblasts connect to the maternal blood vessels DECIDUA CAPSULARIS - Stretches over or forms a capsule over the trophoblast; enlarges as the embryo grows; eventually coming into contact & fusing at the opposite side of the uterine wall DECIDUA VERA/PARIETAL - remaining area of the endometrial lining.  C. PLACENTA - Latin for pancake - is formed by the union of chorionic villi and decidua basalis - Contains 15 - 2-/30 subdivisions called COTYLEDONS - Maturity: 12 weeks/3 months; functions most effectively through 40 - 41 weeks - Weighs 400- 600 gm; 1/6 of the weight of the baby; ENDOCRINE FUNCTIONS OF THE DECIDUA measures from 15-20cm in diameter and 2-3cm - Secretes PROLACTIN to promote lacatation in depth at term - Secretes RELAXIN, which relaxes the connective tissue of the symphysis pubis and 2 parts: pelvic ligaments; also promotes cervical dilation Maternal side - has a rough surface - Secretes PROSTAGLANDIN, important for Fetal side - shiny and gray mediating several physiologic functions MECHANISMS OF PLACENTA B. CHORIONIC VILLI A. SCHULTZ’ mechanism - Develops on the 11th / 12th day - fetal side goes out first - Miniature villi or probing fingers that reach - Most common; 80% of deliveries out from the single layer of cells into the uterine endometrium 2 layers: SYNCYTIOTROPHOBLAST / SYNCYTIAL LAYER - Produces HCG, somatomammotropin (HPL), estrogen and progesterone - Outer layer CYTOTROPHOBLAST / LANGHAN’S LAYER - Inner layer - Develops after fertilization - 12 days gestation - Functions in early pregnancy by protecting B. DUNCAN’s mechanism the growing embryo and fetus from certain - 20% infectious organisms. FUNCTIONS OF THE PLACENTA 1. Respiration, circulation  uterine growth to accommodate the developing fetus Progesterone - hormone of mothers - necessary to maintain the endometrial lining of the uterus during pregnancy - reduce the contractility of the uterine musculature during pregnancy, which prevents premature labor HPL / Human Chorionic Somatomammotropin - Growth promoting and lactogenic properties - Regulates maternal glucose, CHON, and fat levels D. UMBILICAL CORD - Originates from the amnion and chorion - Serves as the lifeline from the embryo to the placenta; provides circulatory pathway - Umbilical vein - About 53 - 55 cm (21inch) in length at - carries oxygenated blood term - 2 Umbilical arteries 3 Parts: - carry deoxygenated blood 1 vein - Foramen ovale 2 arteries - septal opening between the atria of the Wharton’s jelly - gelatinous substance that fetal heart helps prevent kinking of the cord in uterus - Ductus arteriosus - connects the (cord coiling / nuchal cord); gives the cord pulmonary artery to the aorta, allowing body and prevents pressure on the veins blood to shunt around the fetal lungs and arteries. - Ductus venous - carries oxygenated blood from the umbilical vein to the inferior vena cava bypassing the liver 2. Nutrition - supplies the fetus with CHO, H2O, fats, CHON, minerals and inorganic salts 3. Protection E. FETAL MEMBRANES & AMNIOTIC FLUID - transfers passive immunity via maternal - The chorionic villi on the medial surface of antibodies (IgG) the the trophoblast gradually thin and leave 4. Excretion the medial surface of the structure smooth - it carries end products of fetal metabolism - The smooth chorion eventually becomes to the maternal circulation for excretion the chorionic membrane, the outermost 5. Endocrine function fetal membrane. - produces hormones HCG - first hormone produces Estrogen - hormone of women - primarily Estriol - contributes to the mother’s mammary gland development - stimulates  EMBRYONIC AND FETAL STRUCTURES 1. Cardiovascular System - One of the 1st systems to become functional in intrauterine life - Single heart tube forming as early as the 16th day of life, beating as early as the 24th day - Heart beat may be heard with a Doppler as early as the 10th - 12th week of pregnancy; 16th - 20th week with a Stethoscope Chorion - outer wall of blastocyst - covering of the fetus 2. Respiratory System - holds the sac of amniotic fluid - 3rd week, respiratory and digestive tracts Amniotic / amniotic membrane exists as a single - holds / lines amniotic fluid tube - inner fetal membrane - End of 4th week, a septum begins to - forms beneath the chorion divide the - also produces the fluid (amniotic fluid) esophagus from the trachea. At the same, Amniotic fluid - source is the fetal urine lung buds and amnion secretions appear on the trachea Characteristics: - Spontaneous respiratory movements - clear / yellowish begins as early as 3 - 800 - 1200 cc months - 7.2 pH - SURFACTANT, a phospholipid substance is Functions of amniotic fluid: formed and - Provides buoyancy and temperature excreted by the alveolar cells at about 24th control week. This - Prevents heat loss decreases alveolar surface tension on - Cushions the fetus expiration, - Facilitates symmetrical fetal growth preventing alveolar collapse - Provides a source of oral fluid - Provides a repository for fetal waste Surfactant has 2 components: - Helps open the cervix during birth - 35th weeks - lecithin and sphingomyelin - Ratio: 2:1 Problems of Amniotic Fluid: - With fetal lung movements, surfactant Oligohydramnios - lesser amount of mixes with amniotic amniotic fluid (300cc) Fluid Polyhydramnios- excessive amount of fluid (3000-5000cc) 3. Nervous System - Develops during 3rd and 4th week of life Embryonic Germ Layers: - Neural plate (thickened portion of - Ectoderm ectoderm) is apparent - Endoderm by 3rd week of gestation - Mesoderm - Brain waves can be detected on EEG by the 8th week - By 24th week, the ear is capable of - Fetus can be seen to move on ultrasound responding to sound; as early as 11th week the eye exhibits a pupillary reaction, 7. Reproductive System indicating sight is - Child’s sex is determined at the moment present. of conception - Can be determined as early as 8 weeks by chromosomal analysis - Gonads form at about 6th week - Testes first form into the scrotal sac late in intrauterine life at the 34th - 38th week 8. Urinary System - Rudimentary kidneys are present as early as the end of the 4th week - Urine is formed by the 12th week and is 4. Endocrine System excreted into the amniotic fluid by the 16th - They mature in intrauterine life week of gestation 5. Digestive System - At term, fetal urine is being excreted at - Separated from the respiratory tract at the rate of 500 ml/ day about 4th week 9. Immune System - MECONIUM forms in the intestines as - IgG maternal antibodies cross the early as the 16th placenta into the fetus primarily during the week. It consists of cellular wastes, bile, 3rd trimester of pregnancy, giving a fetus fats, mucoproteins, temporarily passive immunity against mucopolysaccharides, and portions of the diseases for which the mother has vernix caseosa antibodies - Meconium is black or dark green - The level of passive IgG immunoglobulins (obtaining its color from peaks at birth and then decreases over the bile pigment and sticky next 9 months. - Sucking and swallowing reflexes are not 10. Integumentary System mature until the - Skin covered by soft downy hairs (lanugo), fetus is about 32 weeks or the fetus weighs and a creamcheese like substances Vernix 1500 gm. Caseosa - secreted by sebaceous glands, important for lubrication, provide warmth, and keeping skin from macerating 6. Musculoskeletal System - Quickening - 1st fetal movements perceived by the mother 16th week- multiparous 20th week - primipara REPRODUCTIVE FUNCTION - Obesity: PUBERTY - Malnutrition and strenuous physical -Puberty is the time of life in which the activity individual becomes capable of sexual delay puberty. reproduction. -Puberty occurs on average between the MENSTRUATION ages of 10 and 14 years. -Periodic discharge from the vagina of blood, secretions, and shed mucous lining of the uterus (endometrium). MENSTRUAL CYCLE -varies from woman to woman Menstrual bleeding indicates the first day of the menstrual cycle, which lasts an average of 27–30 days, although ranges of 21–60 days have been recorded. -Average length of cycle is 28 days -Initiated by the release of gonadotropicreleasing hormone -The anterior pituitary gland produces two hormones that act on the ovaries to further influence menstrual cycle o Follicle stimulating – for maturation of ovum o Luteinizing hormone – for ovulation -The first day of menses marks the end of the cycle and the beginning of the cycle Thelarche: development of breast. - Iron loss is approx. 11 mg, women may Pubarche: development of pubic and need to take a daily iron supplement. axillary hair. Menarche: the first menstrual period1 The menstrual cycle has various Adrenarche: the onset of an increase in phases: the secretion of androgens; responsible for Menstrual phase (days 1 to5) the development of pubic/axillary hair, -On Day 1 of your cycle, the thickened body odor and acne (may occur before lining (endometrium) of the uterus puberty). begins to shed. You know this as menstrual bleeding from the vagina. A Factors that influence Puberty: normal menstrual period can last 4 to - Genetics factors: 50-80% variation in 6 days. pubertal Proliferative (follicular) phase (6 to 13 timing. days) - Environmental factors: Geographical -The follicular phase starts on the first day differences, psychosocial stresses, of menstruation and ends with ovulation. endocrine Prompted by the hypothalamus, the disruptors from pollutants, and exposure to pituitary gland releases follicle stimulating chemical and industrial compounds. hormone (FSH). This hormone stimulates  -Do not have refractory period - When properly stimulated it is possible to have an orgasm after the first o Male: A refractory period occurs, wherein further orgasm is impossible. FERTILIZATION: - The beginning of pregnancy - It is the union of the ovum and spermatozoon. -Occurs in the outer third of a fallopian tube (ampullar portion) -After ovulation, the ovum is extruded and is surrounded by a ring of mucopolysaccharide (the zona pellucida), and a circle of cells (zona radiata) -Sperm undergoes capacitation (Changes in the FERTILIZATION & IMPLANTATION plasma membrane of the sperm head) The blastocyst has already -A proteolytic enzyme (hyaluronidase) dissolves differentiated to two separate cavities: the layer of cells protecting the ovum. the amniotic cavity and the smaller -Once a sperm penetrates, the egg cell cavity (yolk sac – which supply outer membrane becomes impenetrable nutrients and blood only until middle -Immediately after penetration, fusion of implantation). chromosomal material of the ovum and sperm - Between the amniotic occurs, the resultant structure is called ZYGOTE cavity and yolk sac, a third layer, which gives rise to three germ layers: Factors affecting fertilization: Ectoderm, Mesoderm, and the o Maturation of both sperm and ovum Endoderm. o Ability of the sperm to penetrate o the zygote needs support from accessory The trophoblasts produce structures e.g., placenta proteolytic enzymes that dissolve the tissue of the endometrium that they touch -The woman may experience small amount of vaginal spotting due to implantation – it is important to assure the woman. EMBRYONIC AND FETAL STRUCTURES The Decidua Endometrium continues to grow in thickness and vascularity, now termed Decidua. Decidua has three separate areas: o Deciduas basalis o Decidua capsularis o Decidua vera  Chorionic Villi - Weighs approximately 450 to 600 g. -Chorionic villi (finger-like) rise from o Functions: a transport mechanism between the trophoblastic layer. the mother and the fetus, from the 3rd month Layers: of pregnancy until birth. o Central core has double layers of connective tissues: HCG: Human chorionic Gonadotropin - Network of capillaries -First hormone found in the maternal blood and O Outer – syncytiotrophoblast: urine o Inner core layer (Langhan’s) o Functions to sustain the corpus luteum at the - Protects the growing embryo from beginning of pregnancy certain infectious organisms such as -And also prevents the mother from rejecting spirochete of syphilis the fetus as a foreign body. - Disappears between 20-24 weeks AOG HPL: Human Placental Lactogin -Promotes mammary gland growth in preparation for lactation - Regulates metabolism for fetal growth -Provides a rich blood supply to the deciduas and placenta - Stimulates uterine growth to accommodate the growing fetus -Contribute to the mammary gland development for lactation. Progesterone: -Helps maintain the nutrient-rich Chorion and amnion- are not fused but lie in a endometrial lining close contact with each other, together they -Maintains uterine integrity (smooth make up the fetal membranes. muscle relaxation) Amnion o Is a thick fibrous lining, made up of several layers, that helps to protect the fetus o Produces the amniotic fluid Chorion o Is a second layer surrounding the amnion THE AMNIOTIC MEMBRANE The Placenta Umbilical cord -A flat disk-shaped structure formed from - Is formed from the amnion and chorion chorion, chorionic villi, and adjacent decidua serving as the circulatory pathway basalis -Is 21 inches long and with blood flow - Contains 15 to 20 cotyledons velocity of 350 ml/min - Has two arteries and 1 vein wrapped in Wharton’s jelly - Amniotic fluid - Is produced by the fetal membrane, amnion - Serves five main function: o for physical protection o Temperature regulation o Provides unrestricted movement and aids in symmetrical movement o Provides as medium that allows for fetal evaluation o It is a fluid source that the fetus drinks and urinates FETAL CIRCULATION STRUCTURES FETAL CIRCULATION -The three flowcharts below illustrate fetal blood circulation. The o Arteries -carry deoxygenated blood Fetal Circulatory System Overview: from the fetus to the placenta Oxygenated blood from the Placenta enters o Foramen ovale -serves as the the fetus septal opening between the atria of through the UMBILICAL VEIN the fetal heart Most of the newly oxygenated blood bypasses the liver Ductus arteriosus connects via the DUCTUS VENOSUS and combines with the pulmonary artery to the DEOXYGENATED BLOOD in the INFERIOR VENA aorta, allowing blood to shunt CAVA around the fetal lungs Blood then joins deoxygenated blood from the Ductus venosous carries SUPERIOR VENA CAVA and empties into the oxygenated blood from the right atrium umbilical vein to the inferior Since pressure in the right atrium is larger vena cava bypassing the liver. than the pressure in the left atrium, most blood will be shunted through the FORAMEN OVALE Some blood does travel from the right atrium to the right ventricle through the pulmonary trunk but most blood bypasses the pulmonary arteries and moves directly to the aorta via the DUCTUS ARTERIOSUS  Deoxygenated blood returns to the placenta via the UMBILICAL ARTERIES originating from the internal iliacs near the bladder POSTNATAL CIRCULATORY SYSTEM CHANGES: -With the FIRST BREATH, increased alveolar O2 pressure causes vasodilation in the pulmonary vessels -Obstetrical clamping induces spontaneous constriction and change of the UMBILICAL VEIN to LIGAMENTUM TERES and UMBILICAL ARTERIES to MEDIAL UMBILICAL LIGAMENTS -Within 10 – 15 hrs after birth, the DUCTUS ARTERIOSUS ECTODERM - the outermost of the constrict and will become the LIGAMENTUM three primary germ layers of the ARTERIOSUS embryo; from it are derived the -Increased LEFT ATRIAL pressure and epidermis and epidermic tissues such decreased RIGHT as nails, hair, and glands of the skin; ATRIAL pressure causes the FORAMEN OVALE to the nervous system; external sense close and become organs such as the eye and ear; and the FOSSA OVALIS the mucous membranes of the mouth -The DUCTUS VENOSUS also constricts and and anus. will become the MESODERM - it is derived the connective LIGAMENTUM VENOSUM tissue, bone, cartilage, muscle, blood and blood vessels, lymphatics, lymphoid organs, Placental circulation notochord, pleura, pericardium, peritoneum, The uterine arteries supply the uterus kidneys, and gonads. with maternal blood ENDODERM - the innermost of the The blood is carried to the intervillous three primary germ layers of the spaces then around the chorionic villi, embryo; from it are derived the where oxygen and nutrients are epithelium of the pharynx, respiratory transferred by diffusion and active tract (except the nose), digestive transport across a thin membrane into the tract, bladder, and urethra fetal circulation. Fetal wastes diffuse into the maternal bloodstream Estimated Date of Delivery / EDC - Expected 2. Bartholomew’s Rule of Fours Date of Confinement - Measures age of gestation by determining the position of 1. NAGELE’s Rule. the fundus in the abdominal cavity - Count back 3 calendar months from the 1st day of LMP then add 7 days. - e.g. Oct 5 , - =. 7. 12 July 12 First three months = +9 +7 2. DATE OF QUICKENING Primigravida: - Date of quickening + 4 months and 20 days = EDC Normal length of pregnancy: Multigravida: Days - 267 - 280 - Date of quickening + 5 months and 4 days = Weeks - 40 - 41 weeks EDC Lunar months - 10 Calendar months - 9 AGE OF GESTATION Trimesters – 3 1. MC DONALD’S rule - uses fundal height to determine duration of ASSESSMENT FETAL WELL-BEING pregnancy 1. FETAL MOVEMENT - Measurement is made from the notch of the - Also called quickening; described as light woman’s symphysis pubis to over the top of the fluttering uterine fundus as the woman lies supine - Typically follows a consistent pattern, usually - Typically, the distance form the fundus to on the average of at least 10x / day symphysis - Ask the mother to lie in a left recumbent pubis in centimeters is equal to the week of position after a meal and record how many fetal gestation between 20th - 31st week movements she feels - FH x 8/7 = AOG over the next hour (SANDOVSKY method); a - Mc Donald’s rule becomes inaccurate during fetus usually moves a minimum of 2 x every 10 the min or an average of 10 3rd trimester of pregnancy - 12 times an hour - CARDIFF method - the time interval it takes for the mother to feel 10 fetal movements; usually this occurs within 60 min 2. FETAL HEART SOUNDS / RATE - Heart rate should be 120 - 160 beats/min throughout pregnancy A. RHYTHM STRIP TESTING - Assessment of the FHR in terms of baseline and long and short variability - BASELINE - refers to the average rate of the O2 supply and the physiologic stress of an fetal heartbeat per minute oxytocin -induced contractions before true labor - SHORT-TERM VARIABILITY / BEAT-TO-BEAT begins VARIABILITYsmall changes in rate that occur - IV oxytocin is administered, usually starting at from second to second 0.5mU/min at 15-20 min intervals until three - LONG-TERM VARIABILITY - the differences in high quality uterine heart rate that occur over the 20-minute time contractions are obtained within 10 minutes period - Can be used at 32 - 34 week gestation - Rhythm strip requires the mother to remain in D. NIPPLE STIMULATION STRESS TEST (breast a fixed position for 20 minutes self-stimulation) - Carries the risk of hyper stimulation or embarrassment because it can’t be controlled if there’s hyper stimulation - May require nipple rolling or application of warm washcloths to one nipple - Induces contractions by activating sensory receptors in the areola, triggering the release of oxytocin by the posterior pituitary gland - Exhibits the same reactive pattern as the reactive NST result and the same pattern as the abnormal OCT result 3. BIOPHYSICAL PROFILE - Assesses several variable B. NON-STRESS TEST (NST) Fetal breathing movements - Measures the response of the FHR to fetal Fetal body movements movement Fetal muscle tone - The woman pushes a button attached to the Fetal amniotic fluid volume monitor whenever she feels the fetus move Fetal heart rate reactivity - Fetal movement typically results in an increase Placental grade in FHR of about 15 beats/min - Each variable is scored as 0 - 2, with 0 - This increase should be sustained for about 15 indicating abnormal finding and 2 indicating a seconds and turn to baseline or average when normal finding; some institutions use a scoring fetus quiets down system of 0, 1 and 2; total score is then - Absence of an increase in FHR with movement calculated is highly suggestive of fetal hypoperfusion / fetal - This profile is commonly referred to as the hypoxia FETAL APGAR SCORE because scoring is similar - Non-stress test is usually done for 10-20 to that of the Neonatal APGAR Score minute (20-40) - Can detect CNS depression - The test is REACTIVE if two accelerations of 4. ULTRASOUND FHR (15 beats or more) lasting for 15 seconds - Provides immediate results without potential occur after movement within the chosen time harm to the period. NON-REACTIVE if no accelerations occur fetus or the mother with the fetal movements. - Non-invasive and painless Provides info about fetal presence, size, C. STRESS TEST / CONTRACTION STRESS TEST / position, and presentation, placental location, OXYTOCIN CHALLENGE TEST (OCT) amniotic fluid and gestational maturity via - Method of evaluating fetal ability to withstand biparietal measurements decrease - Evidence of normal fetal growth or possible defects or malformations, fetal death, malpresentations, placental abnormalities, multiple gestation and hydra nips oroligohydramnios - It is helpful if the mother has a full bladder at the time of the procedure - May also be done by an intravaginal technique