1
Chapter 3: Anatomy and physiology of the reproductive systems
Components of the Male and Female Reproductive System:
• Female:
▪ Reproductive cells: Eggs or Ova
▪ Organs for development of fetus: Uterus
• Male:
▪ Reproductive cells: Sperm
▪ Organ for deposit of the sperm: PenisFunction of the external female reproductive
organs:
• Collectively called the vulva
▪ Protects urethra and vaginal openings
▪ Highly sensitive to touch to increase females' pleasure during sexual arousal
External female reproductive organs:
• Components of the vulva:
▪ Mons pubis
▪ Labia Majora and
minora
▪ Clitoris
▪ Vestibular structures
▪ Perineum
Function of the labia and clitoris:
• Labia majora: contains
sweat and sebaceous
glands; protects the vaginal
opening
• Labia minora: highly vascular and abundant in nerve supply; lubricates the vulva and swells
with stimulation
• Clitoris: small cylindrical mass of erectile tissue and nerves; function is sexual stimulation
• Prepuce: hood-like covering over the clitoris; also, site of female circumcision practiced in
some cultures
Structure and Function of the Vestibule
• Vestibule: oval area enclosed by the labia minora laterally located inside the labia minora
and outside the hymen
• Opening into the vestibule: urethra from the urinary bladder, vagina, and two sets of glands
• Opening into the vagina: introitus
• Fourchette: half-moon area behind the opening
• Glands: Bartholin and Skene glands secrete mucus to keep the opening moist
Internal Female Reproductive Organs
• Vagina
• Uterus
• Cervix
• Fallopian tubes
2
• Ovaries
Layers of the Uterine Wall
• Endometrium
▪ Innermost layer
▪ Lines the uterine cavity in nonpregnant women
• Myometrium: muscular middle layer
▪ Makes up the major portion of the uterus
▪ Composed of smooth muscle linked by connective tissue
• Perimetrium
▪ Outer serosal layer
▪ Covers the body of the uterus
• Cervix: The lower part of the uterus
Breasts
• Accessory organs which are specialized for milk secretion after pregnancy
• Nipple
• Areola
• Lobes
• Alveolar and lactiferous glands
Female Sexual Response
• Sexual stimulation leading to vasocongestion
• Vaginal expansion and elongation
• Secretion of mucus by vestibular glands
• Estrogen (preservation of vascular function)
and testosterone (hormone of sexual desire
in women)
• Orgasm (zenith of stimulation)
• Rapid dissipation of vasocongestion and
muscle contraction
• Sexual cycle: desire, excitement, plateau,
orgasm, and resolution
Female Reproductive Cycle
• Ovarian cycle
• Endometrial cycle
• Hormonal regulation
• Cyclical breast changes
• Menstruation (absence of fertilization)
Menstruation
• Expulsion of inner uterine lining occurring monthly
• Marks the beginning and end of each menstrual cycle
• Menarche: establishment of menstruation in females
• Menopause: naturally occurring cessation of regular menstrual cycles
• Frequency variable: 21 to 36 days; average 28 days
Menstrual Cycle
3
•
Ovarian cycle
▪ Follicular phase (Day 1 through ovulation, approximately days 10 to 14)
▪ Ovulation (Day 14 of a 28-day Cycle)
▪ Luteal phase (Day 15 through day 28 of a 28-day cycle)
Endometrial Cycle
• Proliferative phase
• Secretory phase
• Ischemic phase
• Menstrual phase
Menstrual Cycle Hormones
• Gonadotropin-releasing hormone (GnRH)
• Follicle-stimulating hormone (FSH)
• Luteinizing hormone (LH)
• Estrogen
• Progesterone
• Prostaglandins
Menopause
• Peri menopause
▪ 2 to 8 years prior to menopause
▪ Vasomotor symptoms (hot flashes and night sweats) are the most common
complaints
▪ Several therapies can be considered to help.
• Menopause
▪ Universal and irreversible part of the overall aging process
▪ 1 year without a menstrual period
External male reproductive organs
• Penis
▪ Organ of copulation
▪ Outlet for urine and sperm
• Scrotum
▪ Sac surrounding and protecting testes
▪ Climate control system for testes
Internal male reproductive organs
• Testes
▪ Sperm production
▪ Testosterone synthesis
• Ductal system
▪ Vas deferent (sperm transport)
▪ Spermatic cord
▪ Urethra
• Accessory glands
▪ Seminal vesicles
▪ Prostate gland
4
▪
Bulbourethral glands
Chapter 5: Sexually Transmitted Infections
STIs
Factors Placing Teenagers at Risk for STI
• Females’ anatomy predisposing them to STIs (columnar epithelial cells sensitive to invasion),
Teenagers’ feelings of invincibility, Unprotected intercourse, Partnerships of limited
duration, Obstacles to using the health care system
Manifestations of Common STIs
• Chlamydia: may be asymptomatic, dysuria, urinary frequency, dyspareunia, cervical
discharge, endocervicitis, inflammations of the rectum and lining of the eye, can infect
throat
• Gonorrhea: may be asymptomatic, dysuria, urinary frequency, vaginal discharge,
dyspareunia, endocervicitis, arthritis, PID, rectal infection
• Genital herpes: blister-like genital lesions, dysuria, fever, headache, muscle aches, malaise
• Syphilis: disease is divided into four stages:
▪ Primary: chancre on place of bacteria entrance
▪ Secondary: maculopapular rash, sore throat, lymphadenopathy, flu-like symptoms
▪ Latent: no symptoms; can be infective first 1–2 years of latency, some will go on to
develop tertiary infections
▪ Tertiary: tumors of the skin, bones, and liver, CNS symptoms, CV symptoms; usually
not reversible
• Trichomoniasis: may be asymptomatic, dysuria, urinary frequency, vaginal discharge,
dyspareunia, irritation of genital area.
• Genital warts: wart-like lesions that are soft, moist, or flesh colored and appear on the vulva
and cervix and inside; also surrounding the vagina and anus, sometimes appear in
cauliflower-like clusters, and are either raised or flat, and small or large.
Open discussion
• Client's sexual habits, Appropriate anticipatory guidance, Methods to prevent recurring STIs.
Most common cause of vaginitis
• Candida: fungus
• Trichomonas: protozoan
• Gardnerella: bacterium
Vulvovaginal Candidiasis
➢ Nursing management
• Teaching preventative measures
▪ Cotton underwear
▪ Avoidance of irritants
▪ Good body hygiene
▪ Avoidance of douching or super-absorbent tampons
Bacterial Vaginosis
• Most prevalent cause of vaginal discharge
5
• 50%–75% women asymptomatic
• Risk factors: Multiple sex partners, Douching, Lack of Vaginal Lactobacilli
Chlamydia
• Most common bacterial STI in the United States; majority asymptomatic
• Cause: Chlamydia trachomatis (intracellular parasite)
• Therapeutic management
▪ Antibiotics (doxycycline, azithromycin)
▪ Combination regimen if gonorrhea also presents
▪ Screening
➢ Nursing assessment
• Risk factors: adolescence, multiple sex partners, new sex partner, sex without condom, oral
contraceptive use, pregnancy, history of another STI
• Manifestations: mucopurulent vaginal discharge, urethritis, bartholinitis, endometritis,
salpingitis, dysfunctional uterine bleeding
• Urine testing or swab specimen culture, immunofluorescence, EIA, or nucleic acid
amplification
Gonorrhea
• Second most reported infection in the United States
• Highly contagious and reportable to health departments
• Cause: aerobic gram-negative intracellular diplococcus
• Site of infection: columnar epithelium of endocervix
• Almost Exclusively transmitted via sexual activity
• Therapeutic management: antibiotic therapy (dual therapy)
➢ Nursing assessment
• Risk factors: low socioeconomic status, urban living, single status, inconsistent use of barrier
contraceptives, age <20 years, multiple sex partners
• Manifestations: most asymptomatic; abnormal vaginal discharge, dysuria, cervicitis,
abnormal vaginal bleeding, Bartholin abscess, PID
• Neonatal conjunctivitis if woman gives birth
Nursing Management: Chlamydia and Gonorrhea
➢ Nursing management:
• Treatment strategies, referrals, preventative measures, education and counseling, sexual
history, public education, safe sex practices
Genital herpes simplex
• Recurrent lifelong viral infection
• Transmission via contact with mucous membranes or breaks in skin with visible or nonvisible
lesions
• Kissing, sexual contact, and vaginal delivery
• Therapeutic management
▪ No cure
▪ Antiretroviral therapy to reduce or suppress symptoms, shedding, and recurrent
episodes
➢ Nursing assessment
6
•
•
•
Syphilis
•
•
•
Primary episode (most severe and prolonged): multiple painful vesicular lesions,
mucopurulent discharge, superinfection with candida, fever, chills, malaise, dysuria,
headache, genital irritation, inguinal tenderness, lymphadenopathy
Recurrent infection (more localized and quicker resolution): tingling, itching, pain, unilateral
genital lesions (more localized)
Diagnosis confirmed via viral culture of fluid from vesicle
Curable bacterial infection caused by spirochete, Treponema pallidum
Serious systemic disease
Therapeutic management
▪ Benzathine penicillin G IM
▪ Doxycycline if allergic to penicillin
▪ Reevaluation with serologic testing
➢ Nursing assessment
• Primary: chancre, painless bilateral adenopathy
• Secondary: flu-like symptoms, rash on trunk, palms, and soles, alopecia, adenopathy
• Latency: absence of manifestations, positive serology
• Tertiary: life-threatening heart disease, neurologic disease
• Tests: VDRL and RPR; FTA-ABS, TPPA, and TPHA
Nursing Management of Herpes and Syphilis
➢ Nursing management
• Education, Referral to support group, Coping skills, treatment options and rehab
Pelvic Inflammatory Disease
• Result of ascending polymicrobial infection of upper female reproductive tract, frequently
from untreated chlamydia or gonorrhea Complications.
• Therapeutic management
▪ Empiric broad-spectrum antibiotics Oral fluids,Bed rest,Pain management
➢ Nursing assessment
• Risk factors
• Manifestations: lower abdominal tenderness, adnexal tenderness, cervical motion
tenderness,fever, dysmenorrhea, dysuria, dyspareunia
• Diagnosis: endometrial biopsy, transvaginal ultrasound, laparoscopic examination
➢ Nursing management
• Hydration, Analgesics, Education to prevent recurrence, Risk assessment, Sexual counseling
Human Papillomavirus
• Most common viral infection in the United States Genital warts or condylomas
➢ Nursing assessment
• Risk factors
• Manifestations: most asymptomatic; visible genital warts
• Pap smears; HPV test
• Therapeutic management
▪ Primary prevention via vaccine and education; treatment of lesions and warts;
secondary prevention via education
7
➢ Nursing management
• Teaching about prevention, Promotion of vaccines and screening tests, Education about link
between HPV and cervical cancer
Hepatitis A and B
• Hepatitis A spreads via GI tract
• Hepatitis B via saliva, blood, semen, menstrual blood, and vaginal secretions
• Therapeutic management: prevention through immunization
➢ Nursing assessment: hepatitis A manifestations; hepatitis B manifestations
➢ Nursing management: screening, vaccination
Ectoparasitic Infections
• Scabies: intensely pruritic dermatitis with lesions
• Pubic lice: pruritus with lice or nits
• Treatment: permethrin cream or lindane shampoo; decontamination of bedding and
clothing; treatment of family members and sexual partners
• Three-tiered approach: eradicate infestation, remove nits, prevent spread or recurrence
Education (see Teaching Guidelines 5.5)
Human Immunodeficiency Virus
• Transmission
• AIDS due to HIV infection
• Fetal and neonatal effects
• HIV and adolescents increasing; most exposed via sexual intercourse
• Manifestations: acute phase; asymptomatic with viral replication, immunosuppression with
opportunistic infections, AIDS
• Diagnosis
• Therapeutic management: ART (Antiretroviral therapy)
➢ Nursing management
• Education about drug therapy Compliance
• Prevention
• Care during pregnancy and childbirth
• Referrals
Preventing STIs
• Education about safer sex practices
• Behavior modification
• Contraception
Physiologic and Psychological Aspects
• Address psychosocial well-being upon diagnosis of any STI
• Occurs
▪ Races
▪ Ethnicities
▪ Classes and social levels
▪ More frequently in women
• Client education on effective prevention methods
8
➢ Nursing Management
• Vulvovaginal candidiasis, focusing on avoidance of sex and alcohol consumption
• Bacterial vaginosis, focusing on primary prevention and education
• Chlamydia and gonorrhea, focusing on education and counseling and treatment regimen
• Genital herpes simplex and syphilis, focusing on support, assistance with coping, and
education
• PID, focusing on drug therapy, hydration, pain relief, education, and sexual counseling
• HPV, focusing on preventive education, vaccination, and counseling
• Hepatitis A and B, focusing on screening and vaccines
• Scabies and lice, focusing on eradicating the infestation and preventing spread and
recurrence
• HIV, focusing on education, counseling, support, and compliance with therapy
Chapter 6: Disorders of the Breasts
Key terms
• Breast disorders
▪ Breast cancer
▪ Carcinoma
▪ Duct ectasia
▪ Fibroadenomas
▪ Fibrocystic breast changes
▪ Mastitis
• Treatments
▪ Breast-conserving surgery
▪ Chemotherapy
▪ Modified and simple mastectomy
• Diagnostic tests
▪ Breast self-examination
▪ Mammography
Summary of Benign
Fibrocystic Breast Changes
9
• Response of breast tissue to monthly estrogen and progesterone levels
• Most common breast disorder affecting women between ages 20 and 50
• Rare in postmenopausal women
• Therapeutic management: self-care; medications for severe cases
➢ Nursing assessment
• Lumpy tender breasts bilaterally occurring
• Primarily during week before menses
• Dull, aching fullness
• Possible clear to yellow nipple discharge
• Fibrosis or thickening early on; cyst formation in later stages; cysts usually mobile and
tender without skin retraction
• Mammography and ultrasound
➢ Nursing management
• Education about condition
• Self-care tips
• Monthly breast self-examination after menses for changes
Fibroadenomas
• Benign solid breast tumors
• Glandular and fibrous tissue usually occurring in women ages 15 to 25 years of age
• Treatment: “watchful waiting,” surgery, cryoablation
➢ Nursing assessment
• Firm, rubbery, well- circumscribed freely mobile nodules with or without tenderness
➢ Nursing management
• reevaluation in 6 months, monthly breast self-examination, and annual clinical breast
examination
Mastitis
• Definition: infection of connective tissue primarily in lactating or engorged women
• Types: lactational or non-lactational
• Therapeutic management: oral antibiotics, acetaminophen, warm compresses
➢ Nursing assessment
• risk factors; flu-like symptoms; warm, red, tender, swollen breast; cracked or abraded nipple
➢ Nursing management
• breast-feeding or continued emptying of breast; medications; proper infant positioning at
nipple; warm compresses; handwashing, supportive bra
Malignant Breast Disorder: Breast Cancer
• Most common cancer in women; much rarer in men
• Second leading cause of cancer deaths in American women
• Etiology: result of complex interaction of environment, genetic, and hormonal factors
• Pathophysiology: unregulated cell growth beginning in epithelial cells of mammary ducts
• Noninvasive (or in situ) or invasive (or infiltrating)
• Invasive ductal carcinoma most common
Risk Factors for Breast Cancer
10
•
Nonmodifiable: gender, aging, genetic mutations, history of ovarian or colon cancer,
increased breast density, family or personal history of breast cancer, race, previous
abnormal breast biopsy, exposure to chest radiation, previous breast radiation, early
menarche, or late menopause
• Modifiable: not having children or childbearing after age 30, postmenopausal use of
estrogens and progestins, failing to breast-feed for up to a year after pregnancy, alcohol use,
smoking, obesity and high-fat diet, sedentary lifestyle
Later Signs of Breast Cancer
• Continued and persistent changes in the breast
• Lump or thickening in one breast
• Persistent nipple irritation
• Unusual breast swelling or asymmetry
• Lump or swelling in the axilla
• Changes in skin color or texture
• Nipple retraction, tenderness, or discharge
Nursing Process for the Patient with Breast Cancer
➢ Assessment
• Often asymptomatic; changes in breast appearance or contour
• Clinical breast examination (see Box 6.1)
• Characteristics of mass (see Tables 6.1 and 6.5)
➢ Nursing diagnoses
• Disturbed body image, Fear, Deficient knowledge
➢ Nursing interventions
• Education, Emotional support
• Postoperative care
▪ Immediate postoperative care
▪ Pain management
▪ Affected arm care
▪ Wound care
▪ Mobility care
▪ Respiratory care
▪ Education
• Health promotion and disease prevention strategies
• Breast cancer screening
▪ Breast self-examination (Box 6.1)
▪ Clinical breast examination
▪ Mammography
• Nutrition
Teaching Topics for Breast Cancer Prevention
• Prevention
• Early detection
▪ Breast self-exam
▪ Clinical breast examination
11
▪ Mammography
• Screening
• Dispelling myths and fears
Changes to Assess During Breast Self-Exam
• Changes in shape, size, contour, or symmetry
• Skin discoloration or dimpling, bumps/lumps
• Sores or scaly skin
• Discharge or puckering of the nipple
Breast Augmentation
• Common surgical procedure involving implants
▪ Saline filled
▪ Location typically is sub glandular (over the pectoral muscle) or subpectoral (under the
muscle)
▪ Breast implants are not lifetime devices, but most are guaranteed for approximately 10
years
• Risks
▪ Capsular contracture, rippling, implant rupture, infection, or hematoma
Breast Self-Examination Techniques
• Patterns using a circular motion
▪ Spiral, Pie-shaped wedges, Up and down
• Types of palpation
▪ Light, Medium, Hard
Chapter 7: Benign Disorders of the Female Reproductive Tract
Benign Neoplasms
• Cervical, endocervical, and endometrial polyps
• Uterine leiomyomas (fibroids)
• Ovarian cysts
• Genital fistulas
• Bartholin’s cysts
Key Terms Related to Pelvic Support Disorders
• Pelvic organ prolapse
▪ Cystocele
▪ Rectocele
▪ Enterocele
▪ Uterine prolapse
• Support pessary
• May cause urinary incontinence
Pelvic Support Disorders
• Includes pelvic organ prolapse and urinary and fecal incontinence
• Causes significant physical and psychological morbidity
• Weakness of connective tissue and muscular support of pelvic organs related to:
12
▪ Vaginal childbirth
▪ Advancing age
▪ Heavy work
▪ Poor nutrition
▪ Increasing body mass
Pelvic Organ Prolapse
• Types (see Figure 7.1):
▪ Cystocele
▪ Rectocele
▪ Enterocele
▪ Uterine prolapse
Stages of Pelvic Organ Prolapse
• Stage 0: No descent of pelvic structure during straining
• Stage I: Prolapsed descending organ is >1 cm above the hymenal ring
• Stage II: The prolapsed organ extends 1 cm below the hymenal ring
• Stage III: Prolapse extends 2 to 3 cm below the hymenal ring
• Stage IV: The vagina is completely everted or the prolapsed organ is >3 cm below the
hymenal ring
Therapeutic Management of Pelvic Organ Prolapse
• Kegel exercises
• Hormone replacement therapy
• Dietary and lifestyle modifications
• Pessaries (see Figure 7.2)
• Colpexin Sphere
• Surgery (anterior or posterior colporrhaphy; vaginal hysterectomy)
Pelvic Organ Prolapse: Nursing Assessment
• Health history
▪ Risk factors
▪ Clinical manifestations (usually asymptomatic): feeling of dragging, lump in vagina,
something “coming down” (see Box 7.1)
• Physical examination (pelvic exam for obvious protrusion; bladder function)
• Laboratory and diagnostic tests: urinalysis, urine culture, postvoid urine volume
Types of Urinary Incontinence
• Most common types: urge, stress, mixed
• Pathophysiology and etiology: interplay of bladder function, pelvic floor muscles, neural
control, and integrity of neural connections for voluntary control; contributing factors
13
Urge Incontinence vs. Stress Incontinence
Therapeutic Management of Urinary Incontinence
• Urge: bladder training, Kegel exercises, pessary ring, pharmacotherapy (anticholinergics);
surgery only if other methods fail
• Stress: weight loss, smoking cessation, avoidance of constipation, Kegel exercises, pessaries,
weighted vaginal cones, periurethral injection, medications (duloxetine), estrogen
replacement therapy, surgery
Urinary Incontinence: Nursing Assessment and Management
➢ Nursing assessment
• History, physical examination
• Laboratory tests (urinalysis and urine culture), and urodynamic testing
➢ Nursing management
• Discussion of treatment options
• Education about good bladder habits (see Teaching Guidelines 7.2)
• Support and encouragement
Reasons Clients Do not Talk about Bladder Control Issues
• Patient may feel UI is inevitable and not amenable to treatment
• Patient may feel the UI is a “normal” part of aging
• Female patient may feel that UI is part of being female and “accept it”
• Patient may consider UI a hygiene problem and not a medical condition
Polyps
• Benign growth; frequently result from infection
• Most common on cervix and in uterus
▪ cervical polyps appearing after menstruation
▪ endocervical polyps in multiparous women age 40 to 60
▪ endometrial polyps rare in women <20 years; peaking in fifth decade; gradually declining
after menopause
• Therapeutic management: removal via forceps, during hysteroscopy, or D&C; laser
vaporization
➢ Nursing assessment
• Endocervical polyps: cherry red
14
• Cervical polyps: grayish white
• Often asymptomatic
• Mild symptoms: abnormal vaginal bleeding or discharge
• Most frequently metrorrhagia with endometrial polyps
• Endometrial polyps detected via ultrasound or hysteroscopy
➢ Nursing management
• Explanation of condition
• Rationale for removal
• Follow-up care instructions
Uterine Fibroids
• Leiomyomas; benign growth
• Rapid growth during childbearing years due to estrogen dependency; shrink during
menopause
• Peak incidence around age 45
• Etiology
• Therapeutic management
▪ Medical: GnRH agonists, progestin antagonist, uterine artery embolization
▪ Surgical: myomectomy, laser surgery, hysterectomy (abdominal, vaginal, laparoscopic)
➢ Nursing assessment
• Health history; signs and symptoms
• Physical examination; ultrasound for confirmation
➢ Nursing management
• Preoperative teaching
• Aftercare (see Box 7.2)
Summary of Treatment Options for Uterine Fibroids
15
Genital Fistulas
• Common types
▪ vesicovaginal
▪ urethrovaginal
▪ rectovaginal
• Therapeutic management
▪ small fistulas: heal without treatment
▪ large fistulas: require surgical repair
➢ Nursing assessment
• history: common signs and symptoms related to type of fistula.
• physical examination: inspection and palpation
➢ Nursing management
• guidance and support
• explanation of treatment options
Bartholin Gland Cyst
• Blockage of one of the ducts of Bartholin gland; possible infection and abscess development
• Therapeutic management: conservative methods or surgery
➢ Nursing assessment
• health history; signs and symptoms (asymptomatic if cyst small; signs and symptoms of
infection); physical examination: protrusion of tender labial mass
➢ Nursing management: explanation, reassurance, support
Ovarian Cysts
• Types
▪ follicular
▪ corpus luteum
▪ theca-lutein
▪ polycystic ovary syndrome (PCOS)
• Therapeutic management
▪ benign versus solid ovarian malignancy; transvaginal ultrasound; laparoscopy; oral
contraceptives; analgesics
▪ PCOS: drug and nondrug therapy, lifestyle changes (see Box 7.3)
➢ Nursing assessment
• signs and symptoms of PCOS: hirsutism, alopecia, virilization, menstrual irregularity and
infertility, polycystic ovaries, obesity, insulin resistance, metabolic syndrome, cancer risks,
psychological impact, acne
• physical examination and laboratory and diagnostic tests: pelvic exam, pregnancy test to
rule out ectopic pregnancy, ultrasound
➢ Nursing management
• education about treatment options
• referral for surgery
• support and reassurance
• counseling and education for PCOS
16
Chapter 8: Cancers of the Female Reproductive Tract
Key Terms Related to Malignancies
• Cervical cancer
• Cervical dysplasia
• Endometrial cancer
• Human papillomavirus
• Ovarian cancer
• Vaginal cancer
• Vulvar cancer
Key Terms Related to Procedures or Diagnostic Testing for Cancers
• Colposcopy
• Cone biopsy
• Cryotherapy
• Papanicolaou (Pap) test
Risk Factors for Reproductive Cancer
• Early menarche
• Late menopause
• Sexually transmitted infections
• Use of hormonal agents
• Infertility
• Family history of cancer
• Lifestyle behaviors
Nursing Process Overview
• Initial reactions: fear and dread; two primary needs: information and emotional support
• Assessment
▪ Health history and physical examination
• Signs and symptoms
• Physical examination; review of systems,pelvic examination
▪ Laboratory and diagnostic testing (see Common Laboratory and Diagnostic Tests 8.1)
Nursing diagnosis (see Nursing Care Plan 8.1)
• Related interventions
▪ Educating to prevent cancer (see Teaching Guidelines 8.1)
▪ Teaching client about about diagnosis
▪ Providing emotional support
• Ensuring culturally competent care
• Supporting the pregnant woman with cancer
Warning Signs of Reproductive Tract Cancer
• Blood in a bowel movement
• Unusual vaginal discharge or chronic vulvar itching
• Persistent abdominal bloating or constipation
• Irregular vaginal bleeding
• Persistent low backache not related to standing
17
• Elevated or discolored vulvar lesions
• Bleeding after menopause
• Pain or bleeding after intercourse
Management of Cervical Cancer during Pregnancy: Variables
• Stage of the disease
• Nodal status
• Histologic subtype of the tumor
• Term of the pregnancy
• Whether the client wishes to continue her pregnancy
Ovarian Cancer
• Eighth most common cancer among women
• Most common in women between 55 and 75 years of age
• Extent of disease: most important variable for prognosis
• Pathophysiology: most cells originating from ovarian epithelium
• Screening and diagnosis
▪ TypicallynotdiagnoseduntilstageIIIorIV
▪ No adequate screening test
• Therapeutic management: dependent on stage and severity of disease
▪ Laparoscopyfordiagnosisandstaging
▪ Total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal biopsies,
omentectomy, and pelvic para-aortic lymph node sampling
▪ Chemotherapy recommended for all stages; possible radiation therapy
▪ Therapeutic management: dependent on stage and severity of disease
➢ Nursing assessment
• Vague complaints
• Early symptoms (bloating, early satiety, fatigue, vague abdominal pain, urinary frequency,
diarrhea, constipation, unexplained weight loss or gain)
• Late symptoms (anorexia, dyspepsia, ascites, palpable mass, pelvic pain, back pain)
• Risk factors.
• Physical examination
➢ Nursing management
• Promoting early detection: emphasis on not dismissing innocuous symptoms as “just a part
of aging”; bimanual pelvic exams and trans vaginal ultrasound.
• Educating client
• Risk reduction and health promotion.
• Treatment modalities, tests, and follow-up if diagnosed.
▪ Supportingclientandfamily
Endometrial Cancer
• Fourth most common gynecologic malignancy
• Pathophysiology
▪ Type I(most common): endometrial hyperplasia leads to carcinoma
▪ Type II: spontaneously appearing
• Screening and diagnosis
18
▪ Screening not routine
▪ Endometrial biopsy as procedure of choice for diagnosis; ultrasound
• Therapeutic management
▪ Surgery (hysterectomy and salpingo-oophorectomy)
▪ Adjunct therapy with radiation and chemotherapy for advanced disease
▪ Removal of tubes and ovaries
➢ Nursing assessment
• History: major initial symptom is abnormal painless vaginal bleeding
• Risk factors
• Physical examination, pelvic examination
• Trans vaginal ultrasound
➢ Nursing management
• Supportive listening
• Follow-up visits.
• Education about prevention and follow-up care
• Risk reduction(see Teaching Guidelines 8.2)
Cervical Cancer
• Incidence and mortality decreased due to Pap test
• Pathophysiology
▪ Changes in cellular lining at squamous–columnar junction (see Figure 8.4)
▪ Linkage to HPV
▪ Cervical dysplasia (precursor to cervical cancer)
• Screening and diagnosis
▪ Pap test (possible false-negative results)
▪ Recommendations for screening (seeTable8.2)
• Therapeutic management
▪ Dependent on severity and woman’s health history (see Box 8.2)
▪ Colposcopy
➢ Nursing assessment
• Risk factors; signs and symptoms: abnormal vaginal bleeding after sexual intercourse
• Physical examination: pelvic examination and Pap test (see Nursing Procedure 8.1)
• Further diagnostic testing
➢ Nursing management
• Primary prevention
▪ Education and HPV vaccine
• Secondary prevention
▪ Pap smear
• Tertiatry
▪ Treatment and support
Vaginal Cancer
• Rare cancer
• Pathophysiology
▪ Squamous cell (most common) usually in women over age 50
19
▪ Adenocarcinomas
• Therapeutic management: radiation, laser surgery, or both; possible radical surgery in
addition to radiation if extensive
➢ Nursing assessment
• Risk factors
• Signs and symptoms; usually asymptomatic
• Physical examination with biopsy of suspicious lesions
➢ Nursing management
• Emphasis on sexuality counseling
• Refer to support groups
Vulvar Cancer
• Most common in older women (mid-60s to 70s)
• Pathophysiology: primarily squamous cell carcinomas
• Screening and diagnosis
▪
Annual vulvar exams
▪ Biopsy of suspicious lesions (usually on labia majora)
• Therapeutic management: laser surgery, cryosurgery, or electrosurgical incision; radical
vulvectomy
➢ Nursing assessment
• Risk factors
• Persistent vulvar itching
➢ Nursing management
• Education: healthy lifestyle behavior, preventive measures
• Communication
• Information and support
Chapter 4: Common Gynecologic Issues
Common Menstrual Disorders
• Amenorrhea
• Dysmenorrhea
• Dysfunctional uterine bleeding
(DUB)
• Premenstrual syndrome (PMS)
• Premenstrual dysphoric disorder
(PMDD)
• Endometriosis
Common Women’s Reproductive Disorders
• Menstrual disorders
• Infertility
• Contraception
• Abortion
• Menopause
20
Amenorrhea
• Absence of menses during reproductive years
• Two types of primary amenorrhea
▪ Absence of menses by age 14 with absence of development of secondary sexual
characteristics
▪ Absence of menses by age 16 with normal development of secondary sexual
characteristics
• Secondary amenorrhea: the absence of regular menses for three cycles or irregular menses
for 6 months in women who have previously menstruated regularly
• Therapeutic management
▪ Primary involves the correction of any underlying disorders and estrogen replacement
therapy
▪ Secondary: cyclic progesterone, treatment of hyperprolactinemia, eating disorder,
obesity, hypothalamic failure, hypothyroidism
➢ Nursing assessment
• Tanner stages of breast development o Laboratory testing
➢ Nursing management
• Teaching Guidelines 4.2
Etiology and Types of Dysmenorrhea
• Painful menstruation
• Primary (spasmodic)
▪ Increased prostaglandin production (primary)
• Secondary (congestive)
▪ Pelvic or uterine pathology (secondary)
▪ Endometriosis most common cause of secondary dysmenorrhea
21
Nursing Management of Dysmenorrhea
➢ Nursing assessment
• Past medical history, sexual history,
menstrual history; bimanual pelvic
examination
• Manifestations: pain, nausea, vomiting,
diarrhea, fatigue, fever, headache,
dizziness; bloating, water retention, weight
gain, muscle aches, food cravings, breast
tenderness
• Client education
▪ Comfort measures: heat, lifestyle
changes, pain relief
▪ Teaching Guidelines 4.3
Abnormal Uterine Bleeding (AUB)
• Painless endometrial bleeding that is prolonged, excessive, and irregular and not
attributed to any underlying structural or systemic disease, not caused by pregnancy, a
tumor, or an infection
• Similar to and may overlap with other uterine bleeding disorders
• Occurs most often at beginning and end of reproductive years
• Etiology related to hormone disturbance
• Treatment involves treating the underlying cause
• Nursing management involves client education
• Therapeutic management: goal is to normalize the bleeding, correct the anemia, prevent,
or diagnose early cancer, and restore quality of life
▪ pharmacotherapy or insertion of a hormone-secreting intrauterine system
▪ surgical intervention: dilation and curettage (D&C), endometrial ablation, uterine artery
embolization, or hysterectomy
➢ Nursing assessment & Nursing management
• Nursing Care Plan 4.1
Premenstrual Syndrome (PMS)
• Wide range of recurrent symptoms occurring during the last half of the menstrual cycle
and resolving with the onset of menstruation
• More severe variant: premenstrual dysphoric disorder (PMDD)
▪ Etiology: unknown
• Therapeutic management
▪ Multidimensional approach
▪ Vitamin supplements, diet changes, exercise, lifestyle, medications
Categorizing Premenstrual Syndrome Symptoms
• Nursing assessment: irritability, tension, dysphoria (most prominent and consistent
symptoms)
▪ A: anxiety
22
▪ C: craving
▪ D: depression
▪ H: hydration
▪ O: other
• ACOG criteria
▪ Mood disorders: main symptoms of PMDD
Endometriosis
• Etiology: risk factors; exact cause unknown
• Condition in which bits of functioning endometrial tissue are located outside the
uterine cavity
• Therapeutic management
▪ surgery
▪ medication therapy
➢ Nursing assessment: infertility and pain; nonspecific pelvic tenderness; tender nodular
masses on uterosacral ligaments, posterior uterus, or posterior cul-de-sac
➢ Nursing management
• education
• healthy lifestyle habits
• support groups
Polycystic Ovary Syndrome (POCS)
• Etiology: exact cause unknown; can cause insulin resistance, obesity, family history.
• Condition in which a woman doesn’t ovulate and numerous small cysts (fluid-filled
sacs) form in the ovaries. These small cysts create an overproduction of androgens
(male sex hormones).
• Therapeutic management:
▪ planning to become pregnant - diet; activity; medication to stimulate
ovulation (Clomiphene citrate)
▪ not planning to become pregnant - diet; activity; hormonal contraception;
diabetes medications (Metformin)K
Infertility
• Primary or secondary
• Cultural expectations for reproduction
• Impact of culture, ethnicity, and religion on perceptions and management of infertility
• Multiple known and unknown factors affecting fertility
• Male and female risk factors
• Therapeutic management: drugs or surgery
Fertility Assessment
• Male factor assessment: semen analysis, sexual characteristics, external and internal
reproductive organ examination, digital prostate examination
• Female factor assessment: ovarian function, pelvic organs
• Laboratory and diagnostic testing: home ovulation predictor kits, clomiphene citrate
challenge test, hysterosalpingogram, laparoscopy
23
Selected treatment options for infertility
Nursing Management of Infertility
• Respect for couple
• Education, anticipatory guidance, stress
management, counseling
• Assistance in decision-making; advocacy
• Assistance with financial strategies
Contraception: Behavioral Methods
• Abstinence
• Fertility awareness
▪ Cervical mucus ovulation method
▪ Basal body temperature
▪ Symptothermal method
▪ Standard days method
• Withdrawal (coitus interruptus)
• Lactational amenorrhea method
Contraception: Barrier Methods
• Condoms
• Diaphragm
• Cervical cap
• Contraceptive sponge
Contraception: Hormonal Methods
• Oral contraceptives
• Injectable contraceptives
• Transdermal patches
• Vaginal rings
• Implantable contraceptives
• Intrauterine contraceptives
• Emergency contraception
Contraception: Sterilization
• Tubal ligation
▪ Sterilization for women
▪ A laparoscope is inserted; fallopian tubes are grasped and sealed
• Vasectomy
▪ Sterilization for men
▪ Usually performed under local anesthesia
▪ Involves cutting the vas deferens, which carries the sperm
Nursing Management of the Woman Choosing a Contraceptive Method
➢ Nursing assessment
24
• Medical history
• Family history
• OB/GYN history
• Personal history
• Diagnostic testing
• Physical examination
➢ Nursing interventions
• Client/couple participation in decision-making
• Client education
▪ Misconceptions
▪ Mechanism of action; advantages and disadvantages, danger signs to report
▪ Method failure and backup method
Abortion
• Surgical abortion
• Medical abortion
▪ Methotrexate followed by misoprostol
▪ Mifepristone followed by misoprostol
Impact of Menopause on the Body
• Brain: hot flashes; sleep, mood, and memory problems
Heart: lower levels of HDL; increased risk of CVD
• Bones: bone density loss; increased risk of osteoporosis
• Breasts: duct and gland tissue replaced by fat
• Genitourinary: vaginal dryness, stress incontinence, cystitis
• Gastrointestinal: less Ca+ absorbed; increased fractures
• Skin: skin dry, thin; collagen decreases
Menopausal Transition
➢ Nursing assessment
• Screening for osteoporosis, cardiovascular disease, and cancer risk
• Lifestyle to plan strategies to prevent chronic conditions
➢ Nursing management
• Health maintenance education; risk reduction
• Lifestyle modifications
• Stress management
Chapter 10: Fetal Development and Genetics
Time Span
• Ovum released from ovary
• Passes into open fallopian tube
• Starts journey downward toward the sperm for fertilization
25
Stages of Fetal Development
• Zygotic stage: fertilization of sperm and egg (conception)
• Blastocyst stage: zygote divides into a solid ball of cells and attaches to uterus
• Embryonic stage: end of second week through eighth week
▪ Basic structures of major body organs and main external features
• Fetal stage: differentiation and structures specialize by end of the eighth week until birth
Summary of Pre-embryonic Development
• Fertilization takes place in ampulla of fallopian tube (outer third)
• Union of sperm and ovum forms a zygote (46 chromosomes)
• Cleavage cell division continues to form a morula (mass of 16 cells). This reaches the uterine
cavity 72 hours after fertilization
• Inner cell mass is called blastocysts, which form embryo and amnion
• Outer cell mass is called trophoblasts, which form placenta and chorion. Chorionic villi are
fingerlike projections (cotyledons) which allow increased surface area of circulation to the
fetus
• Implantation occurs 7 to 10 days post conception into endometrium.
Embryonic Layers
• Ectoderm: forms the central nervous system, special senses, skin, and glands
• Mesoderm: forms skeletal, urinary, circulatory, and reproductive organs
• Endoderm: forms respiratory system, liver, pancreas, and digestive system
Functions of the Placenta
• Serving as the interface between the mother and fetus
• Making hormones to control the physiology of the mother to ensure fetus is supplied with
nutrients and oxygen needed for growth
• Protecting the fetus from immune attack by the mother
• Removing waste products from the fetus
• Inducing the mother to bring more food to the placenta
• Producing hormones that mature into fetal organs
• Grows until the 20th week of gestation and then it becomes thicker 2 sides (maternal-Dirty
Duncan, and fetal-Shinny Schultz)
• Uterine souffle-blood flow through placenta which is the maternal pulse
Hormones Produced by the Placenta
• hCG-maintains the endometrial lining of the uterus and increases in titers up to the 11th
week gestation. Also suppresses the immune system.
• Prolactin
• Human placental lactogen (hPL)-(modulates fetal and maternal metabolism and increases
maternal insulin resistance and very important with diabetic situations) or human choronic
somatomammotropin (hCS)
• Estrogen-causes the uterus to enlarge.
• Progesterone-the hormone of pregnancy. Decreases uterine contractility
• and suppresses the immune system.
• Relaxin-acts synergistically with progesterone to relax muscles and joints.
Umbilical Cord
26
•
•
•
•
•
•
Formed from the amnion
Lifeline from the mother to the growing embryo
Contains one large vein and two small arteries
Wharton jelly surrounds the vein and arteries to prevent compression
At term, the average umbilical cord is 22 in long and about 1 in wide
True knot, false knot, nucal cord, body cord can all be problems associated with umbilical
cord
Role of Amniotic Fluid
• Helps maintain a constant body temperature for the fetus
• Permits symmetric growth and development
• Cushions the fetus from trauma
• Allows the umbilical cord to be relatively free of compression
• Promotes fetal movement to enhance musculoskeletal development
• There can be problems with the fluid such as:
▪ oligohydramnios (too little an amount)
▪ polyhydramnios (too much of an amount)
Fetal Circulation
• Blood from the placenta to and through the fetus and then back to placenta (see Figure
10.9)
• Three shunts during fetal life:
▪ Ductus venosus: connects the umbilical vein to the inferior vena cava. This structure
closes with clamping of the cord and inhibition of blood flow through the umbilical vein.
▪ Ductus arteriosus: connects the mainpulmonary artery to the aorta. Constricts in
response to higher arterial oxygen levels that occur after the first few breaths.
▪ Foramen ovale: anatomic opening between the right and left atrium. With the first
breath, there is increased blood flow to the lungs causing increase pressure in the left
atrium which in turn causes the foramen ovale to close.
▪ By 8 weeks gestation fetal heart beat can be detected by sonogram.
▪ By 12 weeks gestation fetal heart beat can be detected by doppler.
Genetics and Advances in Genetic Knowledge
• Study of heredity and its variation
• Pharmacogenomics: study of genetic and genomic influences on pharmacodynamics and
pharmacotherapeutics
• Part of perinatal care for decades
• Genetic testing
• Gene therapy
Human Genome Project
• International 13-year effort started in 1990 to produce a comprehensive sequence of the
human genome
• Goal: map, sequence, and determine the function of all human genes
• Genome: a person’s genetic blueprint determining:
▪ Genotype: genes inherited from parents
27
▪ Phenotype: observed outward characteristics
Inheritance
• Genes: individual units of heredity of all traits
▪ Organized into long segments of deoxyribonucleic acid
▪ (DNA) that occupies a specific location on a chromosome
▪ Determination of a particular characteristic
▪ in an organism; physical and mental characteristics of humans
• A chromosome: long, continuous strands of DNA carrying genetic information
• Karyotype: pictorial analysis of number, form, and size of chromosomes
Karyotype
• Pictorial analysis of number, form, and size of an individual’s chromosomes
• Commonly uses white blood cells and fetal cells in amniotic fluid
• Chromosomes are numbered from largest to smallest, 1 to 22, with sex chromosomes
designated by X and Y
Patterns of Inheritance
• Mendelian or monogenic disorders
▪ Autosomal dominant inheritance o Autosomal recessive inheritance o X-linked
inheritance
• X-linked recessive inheritance
• X-linked dominant inheritance
• Multifactorial disorders
• Nontraditional inheritance
Autosomal Dominant Inherited Disorders
• Heterozygous gene pair (Affected individuals have an affected parent)
• Children have 50% chance of being affected
• Affects males and females
• Ex: familial tendencies (CA)
▪ Huntington’s Disease
Autosomal Recessive Inherited Disorders
• Homozygous mutation of same gene pair. Both genes of the pair are abnormal producing
the disease.
• 25% chance the child will have the disorder
• 25% chance the child will not have the disorder
• Child of 2 carrier parents has a 50% chance to carry the gene
• Ex: cystic fibrosis, PKU, galactosemia, sickle cell, Tay- Sach’s, metabolic disorders
X-Linked Inherited Disorders
• Gene mutation is on the X chromosome (males have a 50% chance of being affected)
• Females are the carriers
• Males do not pass on the trait
• Ex: hemophilia, muscular dystrophy, color blindness
X-linked Dominant Inheritance
• Affect both males and females, but may be seen more often in females
28
•
Affected mother will pass an X-linked dominant disease to, on average, half of her daughters
and half of her sons
• Ex: Xg blood group (severe hemolytic anemia), vitamin D resistant rickets, Rett's syndrome,
Fragile X syndrome
Multifactoral Inherited Disorders
• Combination of polygenic (several affected genes) and environmental factors
• Ex: cleft lip, congenital heart defects, neural tube defects, pyoric stenosis, hypertension,
diabetes, heart disease, cancer, mental illness
Chromosomal Abnormalities
• Numerical abnormalities
▪ Entire single added chromosome (Trisomy)
▪ Entire single chromosome missing (Monosomy)
▪ One or more added sets of chromosomes (Polyploidy)
• Structural abnormalities
▪ Cri du chat syndrome
▪ Part of a chromosome missing or added
▪ Rearrangements of material within the chromosomes o Two chromosomes that adhere
to each other
▪ Fragile X syndrome
• Sex chromosome abnormalities o Turner syndrome
Potential Misuse of Genetic Information
• Risk profiling
• Privacy and confidentiality breaches
• Workplace discrimination and access to health insurance
• Loss of autonomy
• Possible injustices with risk determination years before disorder occurs
Chromosomal Testing
• Family pedigree
• AFP (at 15-18 weeks) low AFP=Down’s Syndrome high AFP=NTD
• Amniocentesis
• CVS (at 10-12 weeks)
• Percutaneous Umbilical Blood Sampling (after 16 weeks)
• Fetal Nucal Translucency (at 10-14 weeks)
• Genetic Ultrasound (at 18 weeks)
• Triple or Quad Marker (at 16-18 weeks)
Genetic evaluation and counseling
• Genetic counseling: The process by which patients or relatives, at risk of an inherited
disorder, are advised of the consequences and nature of the disorder, the probability of
developing it, and the options open to them in management and family planning in order to
prevent, avoid, or ameliorate it (Lea, 2010).
• Variety of reasons an individual should be referred to genetic counseling (see Box 10.2)
• Ideal time: before conception
29
Nursing Roles and Responsibilities
• Beginning the preconception counseling process and referring for further genetic
information
• Taking a family history
• Scheduling genetic testing
• Explaining the purposes, risks/benefits of all screening and diagnostic tests
• Answering questions and addressing concerns
• Discussing costs, benefits, and risks of using health insurance, and potential risks of
discrimination
• Recognizing ethical, legal, and social issues
• Safeguarding privacy and confidentiality
• Monitoring emotional reactions after receiving information
• Providing emotional support
• Referring to appropriate support groups
• What are the options??
Chapter 11: Maternal Adaption During Pregnancy
Signs and symptoms of pregnancy
• Presumptive signs (subjective)
▪ Fatigue (12 weeks)
▪ Breast tenderness (3-4 weeks)
▪ Nausea and vomiting (4-14 weeks)
▪ Amenorrhea (4 weeks)
▪ Urinary frequency (6-12 weeks)
▪ Hyperpigmentation of skin (16 weeks)
▪ Fetal movements (quickening) (16-20 weeks)
▪ Uterine enlargement (7-12 weeks)
▪ Breast enlargement (6 weeks)
• Probable (objective) signs
▪ Braxton hicks contractions (16-28 weeks)
▪ Positive pregnancy test (4-12 weeks)
▪ Abdominal enlargement (14 weeks)
▪ Ballottement (16-28 weeks)
▪ Goodwills sign (5 weeks) softening of the cervix
▪ Chadwick’s sign (6-8 weeks) bluish-purple coloration of the vaginal mucosa and
cervix
▪ Hegars sign (6-12 weeks) softening of the lower uterine segment allowing for anti
flexion and movement of the uterus to accommodate growing size
• Positive signs
▪ Ultrasound verification of embryo or fetus (4-6 weeks)
▪ Fetal movement felt by experienced clinician (20 weeks)
▪ Auscultation of fetal heart tones via Doppler (10-12 weeks)
30
Select Pregnancy Tests
Reproductive system adaptations
• Uterus
• Increase in size to 20 times that of nonpregnant size
• Weight increases from 2 ounces to approximately 2 pounds at term
• Length, width, depth all increase
• Volume and overall capacity increases from 2 teaspoons to 1 gallon
• 1/6 of total maternal blood volume is contained within the vascular system of the uterus by
term
• Uterine growth occurs due to hyperplasia and hypertrophy of myometrial cells which
increase size of uterine cells not the number of cells
• Pear shape to ovoid shape; positive Hegar’s sign
• Enhanced uterine contractility; Braxton Hicks contractions
• Ascent into abdomen after first 3 months
• Fundal height by 20 weeks’ gestation at level of umbilicus; 20 cm; reliable determination of
gestational age until 36 weeks’ gestation
• Cervix
▪ Cervix Softening (Goodell’s sign) Increased vascularity causes the cervix to soften
▪ Mucous plug formation- Increased mucus forms to seal off the cervix from outside
bacteria
▪ Increased vascularization (Chadwick’s sign) Estrogen causes the cervix to become
congested with blood (hyperemic), resulting in a bluish color that extends to include
the vagina
▪ Ripening about 4 weeks before birth
• Vagina
▪ Increased vascularity with thickening
▪ Lengthening of vaginal vault
▪ Secretions more acidic, white, and thick; leukorrhea
• Ovaries
31
▪
▪
▪
•
Enlargement until 12th to 14th week of gestation
Cessation of ovulation during
pregnancy due to increase in estrogen
and progesterone which causes a
block in secretion of FSH and LH
Corpus Luteum persists til 12 weeks to
secrete progesterone until the
placenta takes over
Breasts
▪ Increase in size and modularity to
prepare for lactation; increase in
nipple size, becoming more erect and
pigmented
▪ Production of colostrum: antibody
rich, yellow fluid that can be expressed
after the 12th week; conversion to
mature milk after delivery
Gastrointestinal system adaptations
• Gums: hyperemic, swollen, and friable
• Ptyalism (excessive salivation) is a common condition of
• pregnant women
• Dental problems; gingivitis
• Decreased peristalsis and smooth muscle relaxation
• Constipation + increased venous pressure + pressure from uterus = hemorrhoids
• Slowed gastric emptying; heartburn; reflux of gastric contents common due to relaxation of
smooth muscles by progesterone
• Prolonged gallbladder emptying (increased risk of gall stones)
• Nausea and vomiting (morning sickness) is due to high hCG levels from 6 to 12 weeks
Cardiovascular system adaptations
• Increase in blood volume (50% above prepregnant levels)
• Increase in cardiac output; increased venous return; increased heart rate
• Slight decline in blood pressure until midpregnancy, then returning to prepregnancy levels
• Varicosities
• Postural hypotension or Vena Caval Syndrome
• Decreased blood flow to right atrium due to enlarging uterus
• Increase in number of RBCs; plasma volume > RBC leading to hemodilution (physiologic
anemia)
• Increase in iron demands, fibrin & plasma fibrinogen levels, and some clotting factors,
leading to hypercoagulable state
Respiratory System Adaptations
• Breathing more diaphragmatic than abdominal due to increase in diaphragmatic excursion,
chest circumference, and tidal volume
• Difficulty breathing
32
• Increase in oxygen consumption
• Congestion secondary to increased vascularity
• Epitaxis (due to estrogen) induces edema and congestion of nasal mucosa
Renal/Urinary System Adaptations
• Dilation of renal pelvis; elongation, widening, and increase in curve of ureters
• Increase in length and weight of kidneys
• Increase in GFR; increased urine flow and volume which can lead to glycosuria due to
kidney’s inability to reabsorb filtered glucose
• Increase in kidney activity with woman lying down; greater increase in later pregnancy with
woman lying on side
• 1st and 3rd trimester frequency
Musculoskeletal System Adaptations
• Softening and stretching of ligaments holding sacroiliac joints and pubis symphysis
• Postural changes: increased swayback and upper spine extension
• Forward shifting of center of gravity
• Increase in lumbosacral curve (lordosis); compensatory curve in cervicodorsal area
• Waddle gait
• Possible separated symphysis pubis
Integumentary System Adaptations
• Hyperpigmentation; mask of pregnancy (facial melasma)
• Linea nigra
• Darkening areola
• Striae gravidarum (stretch marks)
• Varicosities
• Vascular spiders
• Palmar erythema
• Decline in hair growth and hair follicles rest causing hair thickness; increase in nail growth
Immune System Adaptations
• Decrease in IGG
• Decrease in leukocyte function
• Decrease resistance to infections
Endocrine System Adaptations
• Thyroid gland: slight enlargement; increased activity; increase in BMR
• Pituitary gland: enlargement; decrease in TSH, GH; inhibition of FSH & LH; increase in
prolactin especially after the placenta is delivered, Melatonin Stimulating Hormone (MSH)
increases; gradual increase in oxytocin with fetal maturation and increased gestation
• Pancreas; insulin resistance due to hPL and other hormones in 2nd half of pregnancy (see
Box 11.2). To overcome HPL resistance the mother produces more insulin. Insulin can not
cross the placenta. This can cause glucose intolerance in the fetus AND if insulin producing
cells are not adequate mother will develop glucose intolerance
• Adrenal glands: increase in cortisol and aldosterone secretion
• Prostaglandin secretion increases at term
33
• Placental secretion: hCG, hPL, relaxin, progesterone, estrogen (see Table 11.3)
Fundal height
• Indicates uterine size by measuring the top of the symphysis pubis to the top of the fundus
• Correlates with weeks of gestation between 20-30 weeks
▪ 20 weeks = 20 cm
▪ 24 weeks = 24 cm
▪ 30 weeks = 30 cm
▪ Lightening occurs after 36 weeks as fetus drops and descends or engages into the
pelvis
Nutritional Needs
• Direct effect of nutritional intake on fetal well-being and birth outcome
• Need for vitamin and mineral supplement daily (prenatal vitamins and iron supplements)
▪ Dietary recommendations
▪ Increase in protein, iron, folate, and calories
▪ Use of USDA’s Food Guide MyPlate (see Figure 11.5)
▪ Avoidance of some fish due to mercury content
Maternal Weight Gain
• Healthy weight BMI: 25 to 35 lb
▪ First trimester: 3.5to5lb
▪ Second and third trimesters: 1lb/wk
• BMI <19.8: 28 to 40 lb
▪ First trimester: 5lb
▪ Second and third trimesters: +1lb/wk
• BMI>25: 15 to 25
▪ First trimester: 2lb
▪ Second and third trimesters 2/3lb/wk
Nutrition Promotion
• SDA Food Guide MyyPlate
• Client education (see Teaching Guidelines11.1)
• Caloric intake of 300cal/day above normal1800-2200cal/day
• Special considerations
▪ Cultural variations
▪ Lactose intolerance
• Vegetarianism--lacto-ovo-vegetarian -lacto-vegetarians -vegans
• Pica
• Eating disorders
• Adolescents
Maternal Emotional Responses
• Ambivalence: initial response; no visible body change yet
• Introversion: turning in on oneself
• Acceptance: triggered by quickening in 2nd trimester
• Mood swings: from great joy to despair
34
• Changes in body image: the “picture” you have of your body and of yourself
Maternal Role Tasks
• Ensuring safe passage throughout pregnancy and birth
• Seeking acceptance of infant by others
• Seeking acceptance of self in maternal role to infant (“binding in”)
• Learning to give of oneself (see Box 11.4)
▪ 1st trimester: identifying what must be given up to assume new role
▪ 2nd trimester: identifying with infant, learning how to delay own desires
▪ 3rd trimester: questioning ability to become a good mother to infant (Rubin,
1984)
Pregnancy and Sexuality
• Numerous changes, possibly stressing sexual relationship
• Changes in sexual desire with each trimester
• Sexual health and link to self-image
Pregnancy and Partner
• Family-centered emphasis
• Partner’s reaction to pregnancy and changes
▪ Couvade syndrome- the partner’s unintentional development of physical
conditions the woman is experiencing
▪ Ambivalence
▪ Acceptance of roles (2nd trimester)
▪ Preparation for reality of new role (3rd trimester)
Pregnancy and Siblings
• Age-dependent reaction
• Sibling rivalry with introduction of new infant into family
• Sibling preparation imperative
Grandparents
• Depends upon their place in life and their lifestyle
• Are they retired, ill, working, going through menopause?
Chapter 12: Nursing management during pregnancy
Preconception care and diagnostic testing
• Aminocentesis
• Biophysical profile
• Chorionic villus sampling (CVS)
• Natural childbirth
• Perinatal education
• Preconception care
Goals of preconception care
• Promote the health and well-being of a woman and her partner before pregnancy
35
•
Identify and modify biomedical, behavioral, and social risks to a woman’s health or
pregnancy outcome through prevention and management intervention
Risk Factors for Adverse Pregnancy
• Isotretinoins
• Alcohol misuse
• Antiepileptic drugs
• Diabetes (preconception)
• Folic acid deficiency
• HIV/AIDS
• Hypothyroidism
• Maternal phenylketonuria
• Rubella seronegativity
• Obesity
• Oral anticoagulant
• STI
• Smoking
Preconception Care
• Immunization status
• Underlying medical conditions
• Reproductive health care practices
• Sexuality and sexual practices
• Nutrition
• Lifestyle practices
• Psychosocial issues
• Medication and drug use
• Support system
First Prenatal Visit
• Establishment of trusting relationship
• Focus on education for overall wellness
• Detection and prevention of potential problems
• Comprehensive health history, physical examination, and laboratory tests
Comprehensive Health History
• Reason for seeking care
▪ Suspicion of pregnancy
▪ Date of last menstrual period
▪ Signs and symptoms of pregnancy o Urine or blood test for hCG
• Past medical, surgical, and personal history (allergies, chronic illness, family history of illness,
social history, religious/cultural/spiritual beliefs, occupation, partner’s occupation)
• Woman’s reproductive history: menstrual, contraceptive, obstetric, and gynecologic history
Menstrual History #1
• Menstrual cycle
36
▪ Age at menarche
▪ Days in cycle
▪ Flow characteristics
▪ Discomforts
▪ Use of contraception
• Date of last menstrual period (LMP)
• Calculation of estimated or expected date of birth
(EDB) or delivery (EDD)
▪ Nagele’s rule
✓ Use first day of LNMP 11/21/07
✓ Subtract 3 months 8/21/07
✓ Add 7 days 8/28/07
✓ Add 1 year 8/28/08 = EDB
▪ Gestational or birth calculator or wheel
(see Figure 12.3)
▪ Ultrasound is the best method of dating a
pregnancy
Obstetric History
• Gravida: a pregnant woman
▪ Gravida I (primigravida): first pregnancy
▪ Gravida II (secundigravida): second pregnancy, etc.
• Para: a woman who has produced one or more viable offspring carrying a pregnancy 20
weeks or more
▪ Primipara: one birth after a pregnancy of at least 20 weeks (“primip”)
▪ Multipara: two or more pregnancies resulting in viable offspring (“multip”)
▪ Nullipara: no viable offspring; para 0
• Terminology
▪ G (gravida): the current pregnancy
▪ T(term births): the number of pregnancies ending >37 weeks’ gestation, at term
▪ P (preterm births): the number of preterm pregnancies ending >20 weeks or viability
but before completion of 37 weeks
▪ A (abortions): the number of pregnancies ending before 20 weeks or viability
▪ L (living children): numberofchildrencurrently living
Physical Examination
• Vital signs- baseline
• Head-to-toe assessment
▪ Head and neck
▪ Chest
▪ AbdomenandMcDonald’sruleifapplicable
• Abdomen, including fundal height if appropriate. After 20 weeks gestation fundus is at the
level of the umbilicus. The fundus rises 1 cm every week (McDonald’s Method)
▪ Extremities, calf pain, DVTs
• Pelvic examination
37
▪
▪
▪
▪
▪
Examinationofexternalandinternalgenitalia
Pap smear, gonorrhea, chlamydia, group beta strep screening
Bimanual examination: Goodell’s and Chadwich’s signs
Pelvic shape: gynecoid, android, anthropoid, platypelloid
Pelvic measurements: diagonal conjugate, true (obstetric) conjugate, and ischial
tuberosity
Pelvic Measurements
▪ Diagonal Conjugate- Distance between the anterior surface of the sacral prominence and
the anterior surface of the inferior margin of the symphysis pubis.
▪ True Conjugate or Obstetrical Conjugate- distance from the anterior surface of the sacral
prominence to the posterior surface of the inferior margin of the symphysis pubis (this is the
smallest diameter the fetus must pass through).
▪ Ischial Tuberosities- transverse diameter of the pelvic outlet. This measurement is made
outside of the pelvis at the lower aspects of the ischial tuberosities.
Laboratory Tests
• Urinalysis
• Complete blood count
• Blood typing
• Rh factor
• Rubella titer
• Hepatitis B surface antigen
• HIV, VDRL/RPR/syphillus testing
• HCG titers if pregnant
• Cervical smears
• Ultrasound- can confirm placement of the pregnancy, gestational age, and growth and
development
Follow up visits
• Visit schedule
▪ 4 weeks up to 28 weeks
38
▪ Every 2 weeks from 29 to 36 weeks
▪ Every week from 37 weeks to birth
• Assessments
▪ Weight and BP compared to baseline values
▪ Urine testing for protein, glucose, ketones, and nitrates
▪ Fundal height
▪ Quickening/fetal movement to determine well being (16-20 weeks mom does a fetal
kick count)
▪ Fetal heart rate should range between 120-160 bpm
• Teaching: danger signs
• GCT/GTT assessment at 24-28 weeks
• Rhogam and indirect coombs test if indicated at 28 weeks
• GBS culture at 37-40 weeks
• Leopoldo maneuvers
Assessment of Fetal Well-Being #1
• Ultrasonography (see Figure 12.6)
• Doppler flow studies
• Alpha-fetoprotein analysis
• Marker screening tests
• Nuchal translucency screening
• Amniocentesis (see Figure 12.7)
• Chorionic villus sampling (CVS)
• Percutaneous umbilical blood sampling (PUBS)
• Nonstress test
• Contraction stress test
• Biophysical profile
Ultrasonography
• First Trimester
• Second trimester
• Third trimester
• Transvaginally
• Transabdominally
Doppler Flow Studies (Umbilical Velocimetry)
• Done between 8 – 16 weeks
• Measures blood flow through the umbilical vessels
▪ assesses placental perfusion
▪ done under ultrasound
▪ this test can show if the fetus is getting enough oxygen and nutrients
Alpha-Fetal Protein Analysis
• Done as early as 13 weeks
• Elevated levels significant for neural tube defects
• Decreased levels significant for Down’s Syndrome
39
Marker screening tests
• Done between 16-18 weeks
• Quad marker (AFP, conjugated estriole, hCG, inhibin A)
Nuchal Translucency Screening
• Done between 11 to 14 weeks when the base of the neck is still transparent
• Fetuses who have an extra chromosome may have more fluid at the base of their necks, a
spot known as the nuchal fold, making their necks larger
• Fluid can be measured on a sonogram
• It screens for Down syndrome (trisomy 21) and other disorders that are caused by extra
copies of chromosomes (trisomy 13, trisomy 18), as well as congenital heart defects.
Amniocentesis
• Can be done in 2nd or 3rd trimesters for different reasons. 2nd trimester-genetic
abnormalities
• 3rd trimester- lung maturity (Lecithin- Sphingomyelin ratio of 1:2)
• Risks and NI involved
Chorionic Villus Sampling
• Done at 10-12 weeks
• Detect chromosomal abnormalities but not NTD
Percutaneous Umbilical Blood Sampling
• Done after 16 weeks
• Testing for genetic abnormalities, blood
• incompatibilities, hemoglobinopathies
Non-Stress Test
• Measures utero-placental function
• Reactive= 2 accelerations of FHR above baseline of at least 15 BPM for 15 seconds with fetal
movements over a 20-minute period
Contraction Stress Test (Oxytocin Challenge Test)
• 3 contractions are needed in a 10-minute period determines FHR response to stress
(contractions)
Biophysical Profile
• In-depth ultrasound
• 5 components
▪ Body movements-three times or more within 30 minutes
▪ Fetal tone-moves limb from a bent to extended position and back to a bent position
▪ Fetal breathing-once for 30 seconds or more within 30 minutes
▪ Amniotic fluid volume
▪ NST
• Score 0-2 for each category
First Trimester Discomforts
• Urinary frequency or incontinence (see Teaching Guidelines 12.1)
• Fatigue
• Nausea and vomiting
• Breast tenderness
40
• Constipation
• Nasal stuffiness, bleeding gums, epistaxis
• Cravings
• Leukorrhea
First Trimester Teaching
• Get rest
• Eat dry crackers upon rising and small frequent meals
• Increase fiber, fluids
• Cool mist humidifier
• Substitute edible foods for pica cravings
• Use of cotton underwear
• Keep perineum clean
• Avoid douching and tampons
Danger Signs in the First Trimester
• Spotting
• Bleeding
• Painful urination
• Fever
• Lower abdominal pain
• Dizziness and shoulder pain
Second Trimester Discomforts
• Backache
• Varicosities of the vulva and legs
• Hemorrhoids
• Flatulence with bloating
Second Trimester Teaching
• Backache- pelvic tilt or rock
• Leg cramps- stretch muscles, elevate legs
• Varicosities- elevate legs for lower leg varicosities, ice packs to perineum for vulva
varicosities.
• Hemorrhoids- increase fiber, fluids
▪ -topical anesthetic
▪ -avoid prolonged standing or sitting
• Flatulance and bloating- avoid gassy foods
▪ -increase fiber, fluids, exercise
Danger Signs in the Second Trimester
• Contractions
• Calf pain
• Gush of fluid
• Absent fetal movements
Third Trimester Discomforts
• Return of first trimester discomforts
41
• Shortness of breath and dyspnea
• Heartburn and indigestion
• Dependent edema
• Braxton Hicks contractions
Third Trimester Teaching
• SOB- raise HOB, use pillows, LLP
• Constipation- increase fiber, fluids, exercise
• Heartburn/Indigestion- avoid gassy, fatty, spicy foods
▪ - avoid lying down after eating
• Dependent edema- elevate legs
▪ - increase fluids
▪ - report any edema of the face
• Braxton-Hick’s Contractions
Danger Signs in the Third Trimester
• Sudden weight gain
• Peri-orbital or facial edema
• Upper abdominal pain
• Headache
• Visual disturbances
• Decreased or absent fetal movements
• Contractions prior to due date
Nursing Management to Promote Self-Care
• Personal hygiene
• Avoidance of saunas and hot tubs
• Perineal care
• Dental care
• Breast care
• Clothing
• Exercise (see Teaching Guidelines 12.2)
• Sleep and rest
• Sexual activity and sexuality
• Employment (see Teaching Guidelines 12.3)
• Travel (see Teaching Guidelines 12.4)
• Immunizations and medications (see Box 12.5) (only killed viruses can be given and all
medications are harmful in pregnancy-category A meds are the only safe meds)
Preparation for Labor, Birth, and Parenthood #1
• Perinatal education
• Childbirth education
▪ Lamaze (psycho prophylactic) method: focus on breathing and relaxation techniques
▪ Bradley (partner-coached childbirth) method: focus on exercises and slow, controlled
abdominal breathing.
42
▪
•
•
•
•
•
•
•
•
•
•
•
•
Lamaze
•
•
•
•
Dick-Read (natural childbirth) method: focus on fear reduction via knowledge and
abdominal breathing techniques
Options for birth setting
▪ Hospitals: deliveryroom, birthing suite
▪ Birthcenters
▪ Homebirth
Options for care providers
▪ Obstetrician
▪ Midwife
▪ Doula
Think about which pediatrician to use
Feeding choices
▪ Breast-feeding: advantages and disadvantages
▪ Bottle-feeding: advantages and disadvantages
▪ Teaching
Final preparation for labor and birth
Referrals to support groups such as La Leche League, Parents of Multiples, etc.
Think about circumcision
Birth plan
Teach about S/S of labor, what to do when in labor, what to pack for the hospital
Prepare siblings- sibling classes
Prepare for the newborn- purchase equipment, choose name, newborn clothes, diapers,
bottles, thermometer
Prepare self- nursing bra, nursing clothes, educate self
Paced breathing-cleansing breath at the beginning and end of each contraction
Slow paced breathing- slow breathing at 6-8 breaths per minute
Modified paced breathing- upper chest breathing where inhalation and exhalation are equal
Patterned-paced breathing- 4 inhalations to 1 exhalation or 6 inhalations to 1 exhalation in a
pattern
• *** Remember each breathing pattern starts and ends with a deep cleansing breath
Bradley Method
• Exercises of slow controlled abdominal breathing
• The woman is conditioned to work with her body using breath control and deep abdominal
pelvic breathing to promote relaxation
Dick-Read Method
• Abdominal breathing during contractions
• Knowledge of childbirth and breathing techniques are essential for pain relief
Age Related
• Over 35(advanced maternal age)
• Women are having babies later in life due to technology, attention to careers
• This population is at risk for chronic health conditions as well as:
43
▪
GDM, HTN, PTL, PT births, multiples, genetic disorders, placenta previa, IUGR, spon
abortions, low APGAR scores, surgical births
➢ Nursing interventions:
• identify health risks at preconception visit, address lifestyle issues (smoking, drinking,
nutrition, weight, sleep, stress, drug use), genetic testing , psychosocially with new maternal
role
• Adolescents
▪ lack of information, skills, and resources to make informed choices
▪ high risk behavior- it won’t happen to me
▪ HCP must be able to make a connection and communicate
▪ they are not ready for the emotional, psychological, or financial responsibilities This
population is at risk for:
o PT births, LBW, child abuse, neglect, poverty, death, malnutrition
Nursing interventions:
• put aside own convictions and create a trusting relationship, stress maternal well-being is
significant for the fetus, monitor weight gain, nutrition, sleep, rest, identify pregnancy options,
support systems, continuation of education, career/job counseling, ancillary and financial
support