PROMOTING MATERNAL
WELLNESS IN THE FAMILY
& COMMUNITY
Nursing 202
Elizabeth Hartman, RNC, MSN, CLC
Catherine Marin, MSN ©, RN, WHNP
Instructors,
Trends in Contemporary Childbirth
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Family-centered childbirth
Greater client choice: setting, caregiver, treatment/
management
Shorter hospital stays
Self-care movement: assume responsibility for one’s
own health
Culturally competent care
Community based or home care
Legal and Ethical Considerations
Legal Concerns:
• Scope of practice
• Standards of care
• Protection of clients’
rights
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Patient safety
Informed consent
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Emancipated minors
Refusal of treatment
Privacy/confidentiality
Ethical Concerns
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Maternal-fetal conflict
Abortion
Fetal rights
Fetal/stem cell research
Assisted reproductive
technology
Critical Thinking
The nurse manager is planning a presentation on ethical
issues in caring for the childbearing families. Which of
the following should the nurse manager include as an
example of maternal-fetal conflict?
A) A cesarean delivery of a breech fetus is court-ordered after
the client refuses.
B) A client chooses an abortion after her fetus is diagnosed
with a genetic anomaly.
C) A family of a child with leukemia requests cord blood
banking at this birth.
D) A 39-year-old nulliparous client undergoes therapeutic
insemination.
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Statistical Measurements of Maternal
and Child Health
Determine populations at risk, assess relationships between
factors, establish databases for specific populations,
evaluate success of care, etc.
• Birth rate: births per 1,000 pop.: 14
• Infant mortality rate: death in first 12 months of life, per
1,000 live births: 6.85
• Neonatal death rate: death rate of infants in first 28 days
of life: 4.7%
• Fetal death rate: death in utero at ≥ 20 wks gestation
• Perinatal death rate: sum of fetal and neonatal rates
• Maternal mortality rate: maternal deaths as direct result
of reproductive process, per 100,000 live births: 12
Family & Cultural Care
Chapter 2
• A group of people related by blood, marriage,
adoption, or residence in same household (US
Census Bureau)
• Family of orientation vs family of procreation
Trends Affecting the Family
• Employment Trends
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Dual-earner households
• Changes in marriage &
divorce rate
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Single parent families
Cohabitation
• Economic Trends
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Delayed childbearing
Intentional childlessness
• Increased role of grandparents
Duvall’s Family Life Cycles
(Age of Oldest Child Determines Stage, Table 2-1, pg 29)
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Stage 1: Beginning
families
Stage 2: Child-bearing
families
Stage 3: Families with
preschool children
Stage 4: Families with
school-aged children
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Stage 5: Families with
teenagers
Stage 6: Families
launching young adults
Stage 7: Middle-aged
parents
Stage 8: Retirement and
old age
Assessment of Families
(Friedman Family Assessment Tool, Fig. 2-7, pg. 34)
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Family Type & Stage
Structure and function
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Family roles
Level of functioning
Cultural associations
Religious affiliations
Support network
Communication patterns
Environmental considerations
Family Roles
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Nurturer
Provider
Decision-maker
Financial manager
Problem-solver
Health manager
Gatekeeper
Impact of Culture on Families,
Childbearing & Childrearing
Culture: A view of the world and traditions that a
specific social group uses and transmits to the
next generation
Ethnicity: Cultural group into which a person was
born
Cultural Values: Preferred ways of acting based on
traditions
Transcultural nursing: Nursing care that is guided by
cultural aspects and respects individual
differences
Family Planning
Chapter 5
Choosing a Method of Contraception
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Decision may be made individually or as a couple
Should be made voluntarily with full knowledge of
advantages, disadvantages, effectiveness, side effects,
contraindications & long-term effects
May be influenced by culture, religion, personality, cost,
effectiveness, availability, practicality (see Table 5-1, pg
90, Factors to Consider in Choosing Method)
• Consistency of use outweighs absolute reliability
of the method
Fertility Awareness-Based Methods
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Based on menstrual cycle
& identifying when
woman ovulates
Peak fertility is
approximately 5 days
before ovulation until 3
days after
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Natural Family Planning
Calendar Rhythm
Method
Basal Body Temperature
Method
Cervical Mucus
(Billings) Method
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Advantages: safe, free,
acceptable to religious
beliefs
Disadvantages: require
extensive counseling to
learn, interfere with
spontaneity, require
couple to maintain
records for several
cycles, difficult with
irregular periods, may not
be as reliable
Barrier Methods
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Prevent transport of
sperm to ovum,
immobilize sperm, or kill
them. Often used with
spermicide (a chemical
barrier)
• Spermicide
• Condoms
• Diaphragm
• Cervical Cap
• Vaginal Sponge
• Intrauterine Devices
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Advantages: safe, effective if
used correctly, offer some
protection against infection
Disadvantages: require
motivation & cooperation,
may be used less consistently
Good: if hormonal methods
contraindicated, in early
postpartum/lactation, have
intercourse rarely/sporadically,
need backup method
Hormonal Contraceptives
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Combination EstrogenProgestin
Action: inhibit ovulation,
maintain atrophic
endometrium & maintain
thick cervical mucus
Modes:
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Combined oral
contraceptives (COC)
Patches
Vaginal Rings
Injections
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Advantages: safe, effective,
quickly reversible, reduce
PMS/pain with menses
Disadvantages: Must
remember to take, have many
side effects (Table 5-2, pg. 99)
Contraindicated: hx of
thrombophlebitis/
thromboembolic disease, liver
dx, CA, heavy smoking,
gallbladder dx, HTN, DM,
migraine with visual
disturbance, hyperlipidemia
ESTROGEN is the culprit
Progestin Only & Other Methods
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Long-Acting Progestin:
Depo-Provera,
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IM every 3 months
Suppresses ovulation,
can be used by nursing
moms
May take 9 mos for
fertility to return
Should not be used more
than 2 years--associated
with CA loss from bones
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Postcoital Emergency
Contraception--combo or
progestin only
Operative sterilization:
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Vasectomy
Tubal ligation
Nonoperative
sterilization: Essure
Abortion: surgical or
medical (mifepristone)
Critical Thinking
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Instructions concerning the use of a diaphragm should
include that it is an excellent method of contraception,
provided that the woman:
A) Removes it promptly following intercourse and then
douches.
B) Inserts it at least two hours prior to intercourse.
C) Does not use any spermicidal creams or jellies with it.
D) Leaves it in place for six hours following intercourse.
Sexually Transmitted Infection
(Summary Table 6-1, pg 113)
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Prevention:
• Education & counseling of at-risk people on safer sex
practices
• ID infected, asymptomatic and symptomatic notlikely-to-seek-treatment individuals
• Effective diagnosis & treatment
• Evaluation, treatment, counseling & education for
partners of people with STI
• Preexposure vaccination (Gardasil)
• Expedited partner therapy (infected person gets
prescription for partners, too)
Lower Genital Tract Infection (Vaginitis)
Symptoms: ↑vaginal discharge, vulvar irritation/pruritis,
external dysuria, foul odor
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Bacterial Vaginosis (BV)
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Thin, watery, white or gray, fishy smelling vaginal discharge
Predisposing Fx: frequent sex w/out condom, douching
Tx: Flagyl, Clindamycin
Associated with preterm labor and amniotic fluid infections
Candidiasis (yeast)
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Thick, white discharge, severe itching, dysuria/dyspareunia
Predisposing Fx: glycosuria, oral contraceptives, antibiotics,
pregnancy, DM, immunosuppressant drugs. (If recurrent, test for
diabetes, HIV)
Tx: local vaginal treatment with “azole” drugs or nystatin
cream, tablets or suppositories
Thrush in newborn
Trichomoniasis (trichomonas vaginalis)
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Often asymptomatic. Yellow-green, frothy, odorous
discharge & vulvar itching, dysuria, dyspareunia.
Tx: Flagyl until cured & avoid (avoid intercourse
alcohol)
Associated with premature rupture of membranes,
preterm birth, low birth weight and post-cesarean
infection
Usually, no fetal effects
Gonorrhea
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Often asymptomatic in women.
Purulent, greenish-yellow vaginal discharge, dysuria,
urinary frequency.
Often occurs with chlamydia.
Treat both partners.
Tx: Antibiotics: cephalosporin plus azithromycin or
doxycycline for chlamydia co-infection.
Ophthalmia neonatorum which causes severe eye
infection and blindness in baby (prophylaxis with
erythromycin ointment)
Chlamydia
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Most common STI in U.S., especially adolescents/young
adults
Often asymptomatic. Thin or mucopurulent discharge,
friable (bleeds easily) cervix, burning & frequency of
urination & lower abdominal pain.
Causes urethritis in men--often diagnosed in women after
treatment of male partner.
Tx: Doxycycline or azithromycin
Associated with premature rupture of membranes, preterm
labor and endometriosis, pelvic inflammatory disease
(PID), infertility, ectopic pregnancy, ophthalmia
neonatorum & chlamydial pneumonia in baby
Prevention: annual screening of at-risk individuals & at
first prenatal visit
Herpes Simplex Virus
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Primary episode: herpes lesions, flulike symptoms,
genital pruritus or tingling. May recur at anytime.
Tx: No cure. Acyclovir, valcyclovir, famciclovir to
prevent recurrence & lessen symptoms (acyclovir in
pgncy only for severe infection)
Primary Infection during Pregnancy: severe
congenital anomalies, miscarriage (SAB), preterm
labor (PTL), intrauterine growth restriction (IUGR),
infection
If lesions present at time of labor, c-section to reduce
chance of transmission to baby
Syphilis (treponema pallidum)
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Early stage (primary): chancre (painless ulcer), slight
fever, weight loss, malaise.
Secondary symptoms: condylamata lata (wartlike
plaques), arthritis, enlargement of liver, spleen,
lymph nodes, chronic sore throat
Screening at first prenatal visit (VDRL or RPR)
Tx: penicillin. Before 16 wks prevents fetal
transmission.
Fetal effects: stillbirth, congenital anomalies, PTL &
IUGR
Human Papilloma Virus (genital warts)
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Over 120 types--most asymptomatic. Types 6 & 11--visible
genital warts. Soft, greyish-pink, cauliflower-like lesions.
Itching, bleed easily or be painful. Lesions may be in vagina or
on cervix & visible only by colposcopy. Subclinical dx made
by changes on Pap smear.
Tx: podofilox solution (not used in pregnancy) or imiquimod
cream for external lesions. Cryotherapy, trichloroacetic acid,
laser ablation.
Women with HPV need frequent Pap smears to monitor cervical
cell changes--associated with cervical & anorectal cancers.
Condoms to reduce transmission,
Gardasil vaccine (against 4 types which cause 90% of genital
warts & 70% of cervical cancer)
Teratogenic Maternal Infections
TORCH: cross placenta & cause fetal harm
• Toxoplasmosis: (raw meat, cat litter) associated with
CNS damage, retinal deformities
• Other infections (syphilis, Hep B, HIV, etc)
• Rubella: deafness, mental/motor challenges, cardiac
defects, cleft lip/palate
• Cytomegalovirus: severe neurological damage, eye
damage, chronic liver dx
• Herpes Simplex, Primary Infection: severe congenital
anomalies, SAB, PTL, IUGR, infection
Group B Streptococcal
 20-30% of pregnant women are carriers
 Leading infectious cause of neonatal sepsis/mortality
in 1970s
 Infects neonates causing pneumonia, sepsis,
respiratory distress and meningitis
 Maternal screening 35-37 wks,
 Antibiotics (Ampicillin, clindamycin or
erythromycin) during labor or ROM
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Other infections in pregnancy
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Table 20-8, pg 535
Hepatitis B or C
• Can infect neonates
• Hep B vaccine for baby
• Hepatitis B Immune Globulin (HBIG)
-if mom is positive (testing done at first
prenatal visit)
Lower Urinary Tract Infection
• Cystitis/Urethritis
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Risk factors: sex, use of diaphragm & spermicide,
delayed postcoital micturition, pregnancy & history
of UTI
Most common cause: e. coli
Dysuria, urgency & frequency, suprapubic or low
back pain, low-grade fever, hematuria
UA: ↑ leukocytes and bacteria
Tx: culture & sensitivity for causative pathogen &
appropriate antibiotic or other treatment.
Upper Urinary Tract Infection
(Pyelonephritis)
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More common at end of pregnancy or early postpartum
During pregnancy: increased risk of preterm labor &
birth
Sudden onset: chills, high fever, costovertebral angle
tenderness or flank pain, nausea, vomiting, general
malaise. Frequency, urgency & burning with urination.
Urine culture: bacteremia, pyurea & presence of white
blood cell casts.
Tx: hospitalization, IV antibiotics, hydration, urinary
analgesics (pyridium), pain management, antipyretics.
Follow-up urine cultures.
Obesity in the USA
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Epidemic
Up 74% in last 10 years
300,000 deaths annually
50% of American women
16% of children 6-19
1 in 20 American women obese + diabetic
Multifactoral etiology
Obesity in the USA
Definitions
-Obesity: BMI >29kg/m3
-Overweight: BMI 25-29
Medical Complications of Obesity
• HTN
• Type 2 DM
• Cholecystits
• Gout
• Depression
• Kidney stones
• Incontinence
• Hyperlipidemia
• CAD
• Stroke
• Osteoarthritis
• Cancers: Endometrial, Colon, Breast
• Sleep Apnea
Surgical Complications
Anesthesia issues
Wound Dehiscence
DVT, PE
 Hemorrhage
Infection 10X more likely
Obesity in Pregnancy
• BMI >29
• Abdominal circumference > 40 inches
– Tape measure at iliac crests
• Morbid obesity >250#
• Massive obesity >300#
• Late Fetal Death
BMI < 20
BMI 20-25
BMI 25-30
BMI >30
=1%
=1.25%
=1.75%
=2.75%
Cnattingius, S, Bergstrom, R, Lipworth, L, Kramer, M. (1998). Prepregnancy weight and the risk of
adverse pregnancy outcome. New England Journal of Medicine; 338:147.
Obesity:
Fertility and Early Pregnancy
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Subfertility
– If PCOS consider metformin
• Spontaneous AB (RR 1.2)
– High androgen levels
– Insulin resistance
• Recurrent miscarriage (RR 3.5)
• Congenital malformations
– NTDs: OR 3.5
– Cardiac: OR up to 6.5!
– Omphalocele: OR 3.3
• Suboptimal U/S visualization
Violence Against Women
Chapter 9
• As many as 1 in 3 women will be abused
• From 1998 to 2002, 1/3 of female murder victims were
killed by an intimate partner or ex-partner
• Intimate partner violence results in nearly 2 million
injuries and 1300 deaths annually
• Initiatives by JCAHO, Healthy People 2010, and the
American Nurses Association have identified the goals of
increasing identification and prevention of violence against
women.
Patrick Stewart talks about Domestic Violence
Domestic Violence
• A pattern of coercive behavior and methods used to gain
and maintain power and control over another in an adult
intimate relationship
• Can include: Psychological, physical, or sexual abuse or
threats of physical or sexual violence
• Psychological abuse includes:
• Emotional abuse, Isolation, Obfuscation, Using others, Male
privilege, Economic abuse, Coercion threats and Intimidation.
• Typically begins slowly and subtly. The woman may not
recognize that she is in an abusive relationship.
Domestic Violence
• Contributing Factors:
• Childhood experiences, Male dominance in family,
Marital conflict, Unemployment/low socioeconomic
status, Traditional definitions of masculinity.
• The Cycle of Violence
• Tension-building phase (power & control)
• Acute battering incident: triggered by external event or
internal state. Unpredictable & destructive.
• Tranquil phase: “honeymoon period”. Promises never
to do it again.
Domestic Violence: Nursing Considerations
Universal screening of all female clients (Figure 9-2, Pg. 185)
• Private, safe place, confidentiality. Use calm, reassuring tone & watch
non-verbal cues.
– "Within the last year, have you been hit, slapped, kicked or otherwise
physically hurt by someone?"
– "Within the last year, has anyone forced you to have sexual activities?"
Know cues of abuse:
• *Hesitation in providing details about an injury; defensive injuries;
*delayed reporting of symptoms or injuries; *pattern of injury consistent
with abuse such as multiple injury sites, scars or evidence of old injuries
that have healed; *inappropriate explanation for injuries; *inappropriate
affect *vague complaints; *lack of eye contact; *signs of increased
anxiety in presence of batterer.
Domestic Violence--Interventions
 Stress/Safety — "Do you feel safe in your relationship?”
 Afraid/Abused — "Have you ever been in a relationship
where you were threatened, hurt or afraid?”
 Friends/Family — "Are your friends or family aware that
you have been hurt? Could you tell them, would they be able to
give you support?“
 Emergency Plan — "Do you have a safe place to go and the
resources you need in an emergency?"
Domestic Violence--Interventions
• Do not tell abused woman what to do. Help her recognize
her options and resources and make her own decision.
• Self-Care Teaching:
• Women should have an exit or safety plan:
• Pack change of clothes, toilet articles, extra set of keys for
herself & kids to store at friend’s or neighbor’s house.
• Ask neighbor to call police if violence begins
• Have money, identification, and financial records on hand
• Plan where she will go and identify family & friends who can
help
• Have emergency, hotline, police, shelter numbers
Domestic Violence:
physical, sexual or emotional abuse
• Low birth weight 1.5 X more likely
• 3-fold higher risk of being victims of
attempted/completed homicide
• More likely to deliver by cesarean
• More hospitalizations for maternal complications
– kidney infection
– premature labor
– trauma due to falls or blows to the abdomen
Domestic Violence- Incidence
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1 in 12 pregnancies
Up to 20% in some studies
Often begins or escalates in pregnancy
Unintended pregnancy: 3 fold risk of abuse
More common than preeclampsia or gest diabetes
Infrequently screened for in office
Screening barriers
Human Reproduction
Reproductive System Chapter 10
• Intrauterine Development
• Week 5: primitive gonadal tissue
• Week 7 or 8: differentiation begins in males
• Primitive testes--testosterone
• Week 10: ovaries in females
• Fetal oogenesis: girls born with all their
eggs
• Week 12: external genitals visible
Puberty
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Hypothalamus: gonadotropin releasing hormone
(GnRH)
Anterior pituitary: follicle stimulating hormone (FSH) &
luteinizing hormone (LH)
Production of androgen (testosterone) and estrogen
hormones by gonads
Growth spurt & secondary sexual characteristics (1-2
years before)
Sudden surge of estrogen in females produces menarche:
first menstruation (9-15 years of age)
First nocturnal emission in males (10-17 years of age)
Internal Female Reproductive Organs
Vagina
• Hollow, musculomembranous canal that
extends from external vulva to uterus
• Walls contain folds/rugae--expandable
• Functions: a) passageway for sperm & fetus, b)
provides passage for menstrual blood flow, c)
protects against infection from pathogenic
organisms
• Acidic (pH 4-5) during reproductive years
Female Reproductive Organs:
Uterus
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Hollow, muscular, thick walled organ shaped like
upside-down pear, 6-8 cm long, 5 cm wide and 2.5
cm deep
Body (top, includes fundus), isthmus (between body
and cervix), cervix (lowest part)--2-5 cm long
3 layers of tissue: endometrium, myometrium,
perimetrium
After childbirth, the uterus never returns to its prepregnant size
Female Reproductive Structures
Fallopian Tubes
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Smooth hollow tunnel for movement of ova to uterus
Ampulla (longest segment) most common site of
fertilization
Lining of tubes composed of mucus membrane which
contain mucus-secreting and ciliated cells which
move ovum. Tubes also have muscular layer for
peristalsis.
Function-direct pathway that exists from the external
organs through the vagina to the uterus and tubes to
peritoneum so there is possibility of infection
(peritonitis).
Reproductive System
Ovaries
 2 almond-shaped glandular structures located
close to and on both sides of the uterus in the
lower abdomen
 Function:
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produce, mature & discharge ova;
secrete estrogen and progesterone;
initiate and regulate menstruation.
Female Reproductive Structures
Pelvis
• Supports and protects the reproductive and
other pelvic organs
• Divided into the false pelvis and true pelvis.
• False pelvis supports the uterus during the late
months of pregnancy and aids in directing the
fetus into the true pelvis for birth
• True pelvis most important for birth. Consists
of the inlet, pelvic cavity & outlet.
• The level of the ischial spines marks the
midplane or midpoint of the pelvis
Pelvic Types
• Gynecoid: 50%. Adequate dimensions for birth
• Android: Male type. 20%. Inadequate outlet
dimensions for birth. C-section may be required.
• Anthropoid: 25%. Adequate dimensions for birth.
• Platypelloid: 5%. Outlet may be inadequate
(anterior-posterior dimension). May need c-section.
A
C
B
D
Female Reproductive Structures
Breasts
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glandular, fibrous & adipose tissue.
Milk glands of the breasts divided into 15-24 lobes
separated by adipose & fibrous tissue. All glands produce
milk.
• Nipple--erectile tissue. Surrounded by areola. Tubercles
of Montgomery secrete lubricant when baby suckles.
• Suckling --stimulation of
1) the anterior pituitary which releases prolactin to produce
milk and
2) the posterior pituitary which releases oxytocin for milk
ejection.
Menstrual Cycle
• Approx. 28 day cycle, 2-8 days of bleeding, average blood
loss: 25-60 mL.
• Starts with 1st day of period
2 cycles: ovarian and uterine
• Ovaries: Sensitive to lutenizing hormone (LH) &
follicle stimulating hormone (FSH)
• Follicular & luteal phases
• stimulation/maturation/ovulation
• Uterus: Sensitive to estrogen & progesterone
• Menstrual, proliferative & secretory ischemic phases
Ovaries---Follicular Phase
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Hypothalamus releases gonadotropin-releasing hormone
(GnRH) through the portal system to the anterior
pituitary system to trigger release of FSH & LH
FSH stimulates growth of egg follicle
Estrogen is produced after increase in LH
Surge in LH triggers ovulation
Follicle ruptures and releases an ovum into the
peritoneal cavity
http://youtube.com/watch?v=QkY7Xowg8Bw
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OVARIAN CYCLE
UTERINE CYCLE
Ovaries---Luteal Phase
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Begins with ovulation. Ends with the onset of menses.
Corpus luteum (the follicle after ovulation) produces
estrogen and progesterone
↑ estrogen & progesterone inhibit secretion of FSH and
LH (suppressing new follicular growth) &
prepares/maintains endometrium of uterus
If no fertilization, corpus luteum degenerates (8-10 days
after ovulation) ↓ estrogen and progesterone levels
When estrogen and progesterone decrease, the
endometrium breaks down and menstruation begins.
Key Points of Menstrual Cycle
• Menstrual Phase is 2 to 8 days of bleeding
• Body temperature drops slightly then rises (0.5-1
degree) around ovulation
• When FSH rises it means the beginning of a new
cycle
• LH surge stimulates ovulation and development
of corpus luteum
• *Ovulation 14 DAYS before next menses
Key Points of Menstrual Cycle
(Continued)
• Follicle is replaced by corpus luteum
• Corpus luteum secretes progesterone and estrogen
• Progesterone (“pro-gestation”) prepares
endometrium for pregnancy
• With no fertilization, corpus luteum degenerates-progesterone & estrogen fall and menstruation
and cycle begin again
Critical Thinking
The nurse is reviewing documentation of a 15year-old girl who reported that she has no pubic
or axillary hair and has not yet experienced
growth of her breasts. The nurse should explain to
the client she probably lacks which hormone?
A)Testosterone
B) Progesterone
C) Estrogen
D)Prolactin
Critical Thinking
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A woman telephones the clinic to say that it has been six weeks
since her last menstrual period, but that her home pregnancy
test was negative today. She asks, "Do you think I could be
pregnant?" After determining that the test was performed
correctly, what would be the nurse's best reply?
A) "You might be. If you haven't started your period in one
week, you should repeat the test and call the clinic again."
B) "You may have an ectopic pregnancy. You should be seen by
a doctor in the next few days."
C) "You probably are. There are a lot of false-negative results
with these tests."
D) "Probably not. These tests rarely give a false-negative result."
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Critical Thinking
• A woman is experiencing mittelschmerz and
increased vaginal discharge. Her temperature has
increased by 0.6° C (1.0° F) for the past 36 hours.
This most likely indicates that:
A) Menstruation is about to begin.
B) Ovulation will occur soon.
C) Ovulation has occurred.
D) She is pregnant and will not menstruate.
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