Maternal Health Nursing Part 1

MATERNAL HEALTH NURSING
Part I
Mary Lourdes Nacel G. Celeste, RN, MD
Requirements
• Textbook: Pilliterri ‘s Maternal and Child
Health Nursing – to be checked
• OB notebook
• DLP exercises
• Quizzes 20%
• Mastery Exams 30%
• Major Exams 40%
Reproductive and
Sexual Health
MLNG CELESTE, RN, MD 4

Reproductive Anatomy and Physiology
Male reproductive system

External structures
Scrotum
Testes
Penis

Male internal structures

Epididymis
Vas deferens
Seminal vesicles
Prostate gland
Bulbourethral glands
Urethra

• MALE REPRODUCTIVE SYSTEM

MALE REPRODUCTIVE SYSTEM: ANDROLOGY
A. External Structures
1. Penis: the male organ of copulation; a cylindrical shaft consisting
of:
a. corpora cavernosa -two lateral columns of erectile tissue
b. corpus spongiosum - encases the urethra
-The glans penis, a cone-shaped expansion of the corpus

spongiosum that is highly sensitive in males.
-Erection is stimulated by parasympathetic nerve
2. Scrotum: a pouch hanging below the penis that contains the

testes.
3. Testes: two solid ovoid organs 4-5 cm long and 2-3 cm wide,
divided into lobes containing
Seminiferous tubules -produce spermatozoa
Leydig cells - testosterone production

Parts of the Penis:
1.The glans penis, a cone-shaped expansion of

the corpus spongiosum that is highly sensitive
in males
2. Shaft or body
3. Prepuce or Foreskin – retractable skin

covering the glans & removed during
circumcision. Unretractable or tight foreskin is
called PHIMOSIS.
-Erection is stimulated by parasympathetic

nerve
MALE REPRODUCTIVE SYSTEM:
A. External Structures continued
SPERMATOZOA are produced by:

Hypothalamus Control by
GnRH (+/-) feedback
Anterior Pituitary gland
FSH / LH
Testes
FSH - release of Androgen Binding Protein (ABP) which
promotes SPERMATOGENESIS
LH - release of Testosterone.
“Spermatozoa do not survive at body temperature.

They usually survive at temperature 1°F lower
than body temperature”. Hence, testes are
suspended outside the body.
B. Internal Structures
1. Epididymis: serves as reservoir for sperm storage and

maturation. Approximately 20 ft. it takes 12-20 days for
the sperm to travel the length of Epididymis.
A total of 64 days before the sperm reach maturity.

Aspermia - absence of sperm
Oligospermia- if < 20 million sperm/ ml
2. Vas deferens: a duct extending from epididymis to the

ejaculatory duct and seminal vesicle, providing a
passageway for sperm. Sperm mature as they pass through.
Varicocele- varicosity of internal spermatic cord (may
contribute to infertility)
Vasectomy- severing vas deferens (male birth
control)
• Beginning in early adolescence, boys
need to learn testicular self-examination.
• Testes should feel firm, smooth, egg-
shaped.

B. Internal Structures continued
3. Seminal vesicles: are two convoluted pouches that lie
along the lower portion of the bladder and empty into the
urethra by the way of the ejaculatory ducts
4. Ejaculatory ducts: the canal formed by the union of the vas

deferens and the excretory duct of the seminal vesicle, which
enters the urethra at the prostate gland.
5. Prostate Gland: located just below the urinary bladder.

Secretes alkaline fluid and most of the seminal fluid.
6. Bulbourethral glands or Cowper’s Gland: adds alkaline

fluid to the semen.
7. Urethra: the passageway for both urine and semen, extending

from the bladder to the urethral meatus. (8 inches long)

SEMEN:
• Is a thick whitish fluid ejaculated by the male during orgasm,
contains spermatozoa and fructose-rich nutrients.
• During ejaculation, semen receives contributions of fluid from
Prostate gland (60%)
Seminal vesicle (30%)
Epididymis ( 5%)
Bulbourethral gland (5%)
• Average pH = 7.5
• The average amount of semen released during ejaculation is
2.5 -5 ml. It can live with in the female genital tract
for about 24 to 72 hours.
• 50-200 million/ml of ejaculation
• ave. of 400 million/ejaculation
• 90 seconds- cervix
• 5 minutes- end ofMLNGfallopian
CELESTE, tube
RN, MD 15
Spermatogenesis
Testes
Contain Leydig cells produces testosterone
Testosterone ALERT: it takes 64 days

for sperm to reach
maturity
Stimulates
APG secrete FSH & LH
stimulates seminiferous tubules to produce
spermatozoa
Sperm Pathway
• Testes ---produces sperms
• Epididymis conducts sperm to Vas deferens
• Seminal vesicles ( secretion of fructose & protein)
• Ejaculatory duct
• Urethra ( 8 inches) ( cowper’s gland secretes

alkaline fluid)
• OUT
Female reproductive system

External structures
Internal structures

EXTERNAL REPRODUCTIVE SYSTEM

FEMALE REPRODUCTIVE SYSTEM: GYNECOLOGY
A.External Structures
1. Mons pubis/ Mons veneris – pad of adipose tissues, which

lies over the symphysis pubis, which protects the surrounding
delicate tissue from trauma.
2. Labia majora – longitudal folds of pigmented skin extending

from the mons pubis to the perineum. Contains the Bartholin’s
gland that secretes yellowish mucus that acts as a lubricant
during sexual activity.
3. Labia minora – soft longitudal skin folds between the Labia

majora.
4. Glans clitoris – erectile tissue located at the upper end of

Labia minora; primary site of sexual arousal.
FEMALE REPRODUCTIVE SYSTEM:
A.External Structures continue
5. Vestibule – a narrow space seen when labia minora are

separated that also contains the vaginal introitus,
Bartholin’s gland and urethral meatus.
6. Urethral Meatus – small opening between the clitoris and

vaginal orifice for the purpose of urination.
7. Vaginal orifice/introitus/opening – external opening of

the vagina that contains the hymen.
8. Hymen – a membranous tissue ringing the vaginal introitus
9. Perineum – tissue between the anus and vagina. Site of

episiotomy
The external genitalia’s blood supply:

Arteries: a. pudendal artery b. RN,
MLNG CELESTE, inferior
MD rectus artery. 21
Vein: Pudendal vein
• FEMALE
INTERNAL
STRUCTURES
1. Ovaries
2. Fallopian tubes
3. Uterus
4. Vaginal canal

Female reproductive system
Internal structures

B. Internal Structures
1. Ovaries – female sex glands located on each side of the uterus

with two ovaries (4 x 2 x 1.5 cm thick).
Ovaries are formed with 3 principal divisions:

a. A protective layer of surface epithelium
b. The cortex filled with the ovarian and graafian follicle
c. The central medulla containing nerves, blood vessels,
lymphatic tissue and some smooth muscle tissue
Functions: -Ovulation (release of ovum) and Secretion of

hormones like estrogen and progesterone.
Estrogen- helps to prevent osteoporosis, and atherosclerosis

and potential risk for breast cancer/ endometrial cancer

Ovary
3 principal divisions:
a. protective layer of surface epithelium
b. The cortex filled with follicles
c. The central medulla containing nerves, blood vessels, lymphatic

tissue and some smooth muscle tissue
- Firm almond shaped

organ covered by the
peritoneum
2. Fallopian Tubes – 4 inches (10 cm) long from each side of the
fundus
Divided into four separate parts:
1. Intramural portion- most proximal (1 cm in length)
2. Isthmus portion- extremely narrow (2cm)

Important: tubal ligation
3. Ampulla- longest portion (5cm) and widest part

Function: site of fertilization
4. Infundibular portion- funnel- shaped with Fimbrae (2cm):

finger like projections.
Function: responsible for the transport of mature ovum from
ovary to uterus MLNG CELESTE, RN, MD 27
Fallopian Tube
4 parts
1. Infundibulum- funnel
shape, with fimbriae
2. Ampulla- wide middle

segment; usual site of
FERTILIZATION
3. Isthmus- narrowest part
•Bilateral ducts extend 4. Interstitial or

laterally from the uterus Intramural- embedded
in the uterine wall
•receive oocyte and
provide site for
fertilization MLNG CELESTE, RN, MD 28
B. Internal Structures continue
3. Uterus – hollow pear-shaped muscular organ.

Size: 3 inches long (5-7cm), 2 inches wide(5cm) and 1 inch thick
(3x2x1)
Wt: 60 gms. in non pregnant Location: lower pelvis
Parts: Corpus, Isthmus, and Cervix
Position: anteverted and anteflexed
Layers: perimetrium, myometrium and endometrium
Functions:
1. receives the ova to fallopian tube; place for implantation and
nourishment during fetal growth; furnishes protection to a growing
fetus
2. aids in labor and delivery
Cervix (2-5cm long)

Internal cervical os - an impt. relationship in estimating the
External cervical os level of dilatation of the fetus
in the birth canal before birth.
Uterus
• Pear-shaped organ with a
cavity
• receives the ova to
fallopian tube
• place for implantation
and nourishment during
fetal growth; furnish
protection to a growing
fetus
• aids in labor and
delivery

3 main parts
1. Fundus- rounded portion superiorly
2. Corpus or Body- major portion
3. Cervix- outlet which protrudes into vagina
• Isthmus- junction between the body and the cervix
• POSITION: Anteverted and Anteflexed
layers of uterine wall
1.endometrium (or mucosa) – inner layer
2.myometrium – thick, middle circular
layer (stratum vasculare)
3. epimetrium- superficial part
surrounded by the perimetrium

layers of the endometrium
1. Stratum Functionale
– Stratum compactum
– Stratum spongiosum
2. Stratum basale or germinativum

Uterus continue
Nerve Supply:
Efferent (motor) nerve- spinal ganglia (T5 to T10)
Afferent (sensory) nerve - hypogastric plexus (T-11 & T-12)
Impt: Controlling pain in labor ( Epidural anesthesia)
Uterine Ligaments:
1. Broad Ligaments – from the sides of uterus to pelvic walls
2. Round Ligaments – from sides of uterus to mons pubis.
3. Cardinal and uterosacral ligaments- provide middle support
4. Pelvic muscular floor ligaments- provide lower support

3. Vaginal Canal – 3-4 inch long dilatable canal between the bladder
and the rectum; contains rugae that permits stretching without
tearing.
Anterior Vaginal wall- 6-7 cm (anterior fornices)

Posterior Vaginal wall- 8-9 cm (posterior fornices)
Functions: 1. passageway for menstrual discharges

2. receives penis during intercourse and
3. serves as birth canal.
- lined with stratified squamous epithelium
- Bulbocavernosus: a circular muscle acts as voluntary sphincter

(Kegel exercises)
Blood supply to the vagina:

Arteries: vaginal artery branch of internal iliac artery
Vein: pudendal vein MLNG CELESTE, RN, MD 37
Vagina continued…
The external genitalia’s blood supply: mainly from the

a. pudendal artery and
b. a portion of inferior rectus artery.
Nerve supply: has both parasympathetic & sympathetic

(S-1 to S-3 levels)
Nerve supply of the anterior portion: (L1)

a. Ilio-inguinal nerves b. Genito-femoral nerves
Nerve supply of the posterior portion: (S3)
Pudendal nerves
“This is the reason why one type of anesthesia used for

childbirth is called Pudendal block.”

Vaginal canal
• Connects the cervix to the vestibule
• Fibromuscular walled tube lined with mucus and
covered with hymen
• hymen – vascular and tends to bleed when
ruptured
• The remnant of hymen is called CARUNCULAE
MYRTIFORMIS
• Bulbocavernosus: a circular muscle acts as
voluntary sphincter (Kegel exercises)
Function: organ of copulation and passageway of

menstrual flow and baby

Variations of Uterine Formation
NORMAL Bicornuate Septum- Double

UTERUS Uterus dividing
MLNG CELESTE, RN, MD uterus uterus
41
Uterine Deviations
 Bicornuate – oddly shaped horns at the junction
of the fallopian tubes
 Anteversion – fundus is tipped forward
 Retroversion – fundus is tipped back
 Anteflexion – body of the uterus is bent sharply
forward at the junction of the cervix
 Retroflexion – body of the uterus is bent sharply
back just above the cervix

Anteversion Anteflexion
Retroversion Retroflexion

Female internal structures
Vagina
Breasts
Pelvis

Analogous Structures
Female Male
Glans Clitoris Glans penis
Labia majora Scrotum
Vagina Penis
Ovaries Testes
Fallopian tubes Vas deferens
Skene’s glands Prostate glands
Bartholin’s glands Cowper’s glands
Ovum Spermatozoa

Mammary glands
- MODIFIED SWEAT GLAND
- glands consist of 20 individual compound
alveolar glands w/ separate openings
(lactiferous ducts) at nipple
- internally 15-25 lobes
- under effects of estrogen and progesterone for
development; prolactin for milk secretion;
oxytocin - milk ejection reflex

• HORMONES THAT INFLUENCE THE
MAMMARY GLANDS:
– ESTROGEN – STIMULATES THE
DEVELOPMENT OF THE DUCTILE
STRUCTURES OF THE BREST
– PROGESTERONE – STIMULATES THE
DEVELOPMENT OF THE ACINAR CELLS
– HUMAN PLACENTAL LACTOGEN –
PROMOTES BREAST DEVELOPMENT
DURING PREGNANCY
– OXYTOCIN – LET DOWN REFLEX
– PROLACTIN – STIMULATES MILK
PRODUCTION
Reproductive Development
 Intrauterine development
-sex of an individual is determined at the moment of
conception
 Gonad- body organ that produces sex cells (ovary,testis)
 Week 5: primitive gonadal tissue is formed

- Mesonephric (wolffian) and paramesonephric (mullerian) ducts are
present
 Week 7 or 8 - in choromosomal males: primitive testes;
formation of testosterone
 Week 10 - ovaries in females; oocytes formed
 Week 12 – external genitalia

REPRODUCTIVE AND SEXUAL HEALTH
PUBERTAL DEVELOPMENT:
Puberty is the stage of life at which the

secondary sex changes begin.
Girls- age 9 to 12 years
Theory: must reach a critical weight of approx.
95 lbs (43kgs) or develop a critical mass of fat
before the hypothalamus is triggered to
stimulate the anterior pituitary gland to begin
gonadotropic hormone formation.
Boys- age 12 to 14 years

The role of Androgen- hormones
responsible for :
1. Muscular development
2. Physical growth
3. Increase sebaceous gland secretion
(acne)
Androgen- produced by the adrenal cortex
and testes in the males; by the adrenal
cortex and the ovaries in the females
“Testosterone -1° androgenic hormone”

In girls, testosterone influences the development of
labia majora, clitoris, and axillary & pubic hair latter
termed as (adrenarche)
In males, it influences the development of testes,

scrotum, penis, prostate and seminal vesicle; the
appearance of pubic, axillary hair; facial hair;
laryngeal enlargement; voice change; maturation of
spermatozoa and closure of growth in long bones.

• Estrogen – excreted by the ovarian

follicles (3 compounds: estrone,
estradiol and estriol)
- Influences the development of the
uterus, fallopian tubes and vagina at
puberty; typical female fat distribution
and hair patterns; breast development
and end of growth of long bones

Secondary sex characteristics of boys occur
in the following order:
1. increase in weight
2. growth of testes
3. growth of face, axillary and pubic hair
4. voice changes
5. penile growth
6. increase in height
7. spermatogenesis

Secondary sex characteristics of girls occur in the
following order:
1. growth spurt
2. increase in the transverse diameter
of the pelvis
3. breast development (thelarche)
4. growth of pubic hair (adrenarche)
5. onset of menstruation (menarche 12.5 y/o
ave.)
-Ovulation occurs 1 – 2 years after menarche
6. growth of axillary hair (adrenarche)
7. vaginal secretion

Menstruation
Episodic uterine bleeding in
response to cyclic hormonal
changes
Brings an ovum to maturity and
renews uterine tissue bed

MENSTRUAL CYCLE / FEMALE REPRODUCTIVE
CYCLE
= EPISODIC UTERINE BLEEDING IN RESPONSE
TO HORMONAL CHANGES
= PERIODIC SERIES OF CHANGES THAT RECUR
IN THE UTERUS AND ASSOCIATED ORGANS
BEGINNING AT PUBERTY AND ENDING AT
MENOPAUSE
= TAKEN FROM THE FIRST DAY OF
MENSTRUATION TO THE FIRST DAY OF THE
NEXT MENSTRUATION
Basis for menstrual cycle is 6-12 month graphing.
Menarche – first menstrual period that occurs
typically at age 12 but may occur as early as 9 or as
late as 17.
Thelarche – is the development of the breast buds
that occur at puberty.
Adrenarche – is the development of pubic & axillary
hair due to androgen stimulation.
MENSTRUATION = PERIODIC, SLOUGHING OFF
OF THE ENDOMETRIUM WHICH OCCURS
EVERY 28 DAYS BUT COULD BE ANYWHERE
FROM 25 TO 35 DAYS & LASTS FOR 3-5
DAYS.
Characteristic of Menstrual Blood:
1. Does not appear to clot
2. Dark red as that of venous blood
3. Offensiveness ( Fleshy stale odor)
BODY STUCTURES INVOLVED IN
MENSTRUATION;
1. HYPOTHALAMUS – ultimate initiator of
menstrual cycle. Secretes GnRH. Releases
FSHRF during the first half of the cycle & LHRF
during the second half of the cycle.
2. ANTERIOR PITUITARY GLAND – releases the
gonadotropin hormones (GH) FSH & LH
3. OVARIES- site of ovulation & releases estrogen
& progesterone.
4. UTERUS – the organ from which menstrual
discharge is formed. The changes in the uterine
endometrium are due to ovarian hormones
PITUITARY HORMONES ( GONADOTROPIC
HORMONES) WHICH REGULATE
MENSTRUAL CYCLIC ACTIVITIES:
1. FOLLICLE STIMULATING HORMONE ( FSH)
2. LUTEINIZING HORMONE ( LH )
OVARIAN HORMONES WHICH REGULATE
MENSTRUAL CYCLE ACTIVITIES:
2. ESTROGEN – hormone of women; produced by
the graafian follicle
2. PROGESTERONE – hormone of mothers;
produced by the corpus luteum
• Diseases of the hypothalamus causing a
deficiency of this releasing factor can
result in delayed puberty. Diseases
causing early activation of the GnRH can
lead to abnormally early sexual
development or precocious puberty
Characteristics of Normal
Menstrual Cycles
• Beginning (menarche) – average of onset 12 -13 yrs;
average range 9 -17 years
• Interval between cycles – Average 28 days; cycles of 23
– 35 days not unusual
• Duration of menstrual flow – Average flow 2-7 days;
ranges 1-9 days not abnormal
• Amount of menstrual flow –difficult to estimate; average
30-80 ml
• Color of menstrual flow – dark red; combination of blood,
mucus and endometrial cells
• Odor- similar to that of marigolds

HORMONES
1. Estrogen - female secondary

sexual characteristics, such as
breast development, increased
adipose tissue deposition, and
increased vascularization of the
skin, widening and lightening of
pelvis

HORMONES
2. Progesterone - triggers uterine

changes during the menstrual cycle

FEMALE REPRODUCTIVE
FUNCTIONS AND CYCLES
OOCYTES
• in utero - 5 to 7 million
• at birth - 2 million
• 7 yrs of age only - 500,000/ovary
• Reproductive age only - 400–500
oocytes
• Menopause - none

Uterine cycle
3 phases
1.Menstrual phase
2.Proliferative phase
3.Secretory phase

Menstrual Phase
• Day 1- day 5
• First day of bleeding is the first day of
cycle
• Stratum functionale (compactum and
spongiosum) are shed
• Around 60 ml average

Proliferative Phase
• Days 5- day 14
• Eptihelial cells of functionale
multiply and form glands
• Due to the influence of estrogen

Secretory Phase
• Day 15- day 28
• Endometrium becomes thicker and glands
secrete nutrients
• Uterus is prepared for implantation
• Due to progesterone
• If no fertilization constriction vessels
menstruation

Ovarian cycle
3 phases
1. Pre-ovulatory : follicular phase
2. Ovulatory phase
3. Post-ovulatory : Luteal phase

Ovarian Cycle;
preovulatory/follicular
• Variable in length: day 6- day 13
• Dominant follicle matures and
becomes graafian follicle with
primary oocyte
• FSH increases initially then
decreases because of estrogen
increase
Ovarian cycle: Ovulatory phase
• Day 14
• Rupture of the graafian follicle
releasing the secondary oocyte
• Due to the LH surge
• MITTELSCHMERZ- pain during
rupture of follicle

OVARIAN cycle:
Post-ovulatory: luteal phase
• Day 15- day 28
• MOST CONSTANT 14 days after ovulation
• Corpus luteum secretes Progesterone
• If no fertilization, corpus luteum will become
corpus albicans then degenerate
• Decreased estrogen and progesterone
production

Hormonal cycle
1. Menstrual phase
– Decreased Estrogen, decreased
progesterone, decreased FSH and decreased
LH
2. Proliferative/Pre-ovulatory phase
– Increased FSH and Estrogen in small
amounts

3. Ovulatory phase
– Increased LH (surge); Increased Estrogen
4. Post ovulatory/luteal Phase

– Increased Estrogen, increased progesterone
until corpus luteum degenerates

‘

SUMMARY OF MENSTRUAL
CYCLE
- monthly changes in the uterine lining that
lead to menstrual flow as the endometrium is
shed
STEPS:
1. Corpus luteum of previous cycle fades,
progesterone decreases, FSH rises
(proliferative phase)

SUMMARY OF MENSTRUAL
CYCLE
2. FSH stimulates follicular growth and
differentiation and stimulate Estrogen
secretion
3. Estrogen stimulates endometrial growth
and differentiation along w/ follicular
growth

4. Rising Estrogen levels exert a
negative feedback on the pituitary
gland and hypothalamus to decrease
secretion of FSH
5. Dominant follicle is destined grow

for ovulation

6. Sustained high Estrogen level
cause the LH surge w/c triggers
ovulation 24-36 hours later,
progesterone production and shift to
luteal/secretory phase
7. Estrogen level decreases until the

midluteal phase when it rises d/t
corpus luteum secretion
8. Progesterone also rises because of
corpus luteum secretion; protein rich
secretory products in glandular lumen
(secretory phase)
9. If pregnancy does not occur, the corpus

luteum degenerates, hormone levels
decline, and the uterine lining disintegrates
and shed (menstrual phase)
*time from ovulation to the onset of the next
menstrual period is usually constant (2
weeks)

10. If fertilization and implantation occur,
ovary continues producing progesterone
and the endometrium remains intact to
support embryo development and
pregnancy.

Education

Menopause
• Cessation of menstruation for at least one year
occurring at the age of 45-52 due to cessation of
ovarian function
• Decreased estrogen and progesterone
• Genetically determined
• May occur earlier in smokers, nulliparous and
patients who underwent hysterectomy

A. MENSTRUAL CYCLE CHANGES:
- changes in menstrual cycle regularity
- remaining follicles in both ovaries become
less sensitive to GnRH stimulation which
results to:
1.increased level of fsh
2.reduction in estrogen concentration

- the limited follicle maturation leads to either a decrease
in cycle interval or lapses of cycles, with oligomenorrhea
B. CESSATION OF MENSES:
- menses usually cease between Ages of 45 and 52
years,
(reduced level of estrogen from the remaining follicles is
no longer sufficient to induce endometrial proliferation /
changes capable of producing visible menstruation)

C. PREMATURE MENOPAUSE:
- manifested by permanent amenorrhea
before 35 years of age due to:
1.genetic predilection
2.ovarian failure due to auto- immune
reaction

Concerns
1. Loss of childbearing capacity
2. Loss of youth
3. Skin changes-related to estrogen deficiency that has a
role in collagen storage and restoration
4. Depression-related to changes in relationship w/
children, spouse and other life events
5. Anxiety and irritability –”climacteric syndrome”;
psychocial
6. Loss of libido-related to vaginal atrophy secondary to
decreased estrogen

7. Abnormal bleeding – irregular, heavy or prolonged
related to to anovulatory cycles
* rule out pregnancy, malignancies and polyps
8. Hot flashes/flushes – recurrent, transient flushing,
sweating, palpitations, anxiety, chills
9. Urinary symptoms – dysuria, urgency and
recurrent UTI
10. Difficulty in concentration and short term memory
loss
11. Cardiovascular disease
12. osteoporosis
TARGET ORGAN RESPONSE TO
DECREASED ESTROGEN:
• VAGINA
- becomes smaller and the size of the upper vagina
diminishes
- epithelium becomes pale, thin, and dry
- labia minora has a pale , dry appearance; reduction in
fat content of labia majora
• Uterus
- endometrial tissue become sparse, with numerous
small petecchial hemorrhages, has atrophic
appearance
- myometrium atrophies, uterus decreases in size
• Breast
- general loss of turgor, form, fullness of the breast
• Bones
- gradual loss of calcium, lading to osteoporosis,
characterized by reduction in bone density and fracture
• Hair
- with the loss of estrogen, there is relative decrease in
circulating androgens; increase quantity of hair with male
pattern distribution

Sequelae of reduced estrogen:
A. vasomotor symptoms:
- Hot flash/ flush, is the hallmark of the
menopausal woman
- last for a few seconds or several minutes
- more frequent and severe at night or during
time of stress
- coincides with a surge of luteinizing
hormones

• Altered menstrual function:
– Oligomenorrhea followed by amenorrhea
– Amenorrhea for 6 to 12 months
– If vaginal bleeding occurs after 12 months of
amenorrhea, endometrial biopsy must be ruled out
• osteoporosis:
– Main health hazard associated with menopause

• menopausal syndrome:
- Such as fatigue, headache, nervousness, loss of
libido, insomnia, depression, irritability, palpitation,
muscle pain
•Atrophic changes:
- atrophy of the vaginal mucosa leads to atrophic
vaginitis, pruritus of vulvovaginal area, dyspareunia
and stenosis
- urethral changes
- increased frequency of cystitis
- vaginal, urethral and bladder symptoms
• Treatment:
– Estrogen replacement therapy
• Advantages:
– Eliminate hot flashes
– Reversal of atrophic vaginitis, dyspareunia,
affective symptoms
– Prevention and treatment of osteoporosis
– Prevention of cardiovascular disease
– Retention of youthful skin

• disadvantages
-can cause acute liver disease
-Acute vascular thrombosis
- seizure disorder
-Hypertension
-Migraine headache
-Breast cancer
-Endometrial cancer

Sequelae of excess endogenous
estrogen
a. DUB (dysfunctional uterine bleeding)
- during perimenopausal age, some women manifest
estrogen excess
*increased endogenous estrogen can result to:
1. increased level of precursor androgens in
functional and nonfunctional endocrine tumors, stress
and liver disease
2. increased direct secretion of estrogen from ovarian
tumors
b. Endometrial neoplasia

Treatment:
Intermittent progestin therapy

EVALUATION:
1. Endometrial biopsy
2. Vaginal USG
3. Hysteroscopy
MANAGEMENT
• Hormonal therapy – low dose contraceptives
• surgery

Menstrual Disorders
Dysmenorrhea
Primary – due to prostaglandin excess or increased

sensitivity to prostaglandin w/ no pathologic pelvic
disorder
Secondary – with underlying disease

ie, PID (Pelvic inflammatory disease)
Endometriosis, Adenomyosis, Uterine prolapse, Uterine
myomas, Polyps

Pelvic Inflammatory Disease
• Caused by microorganisms colonizing

endocervix ascending to endometrium and
fallopian tubes
• Due to sexually transmitted
microorganisms ie Neisseria, Chlamydia,
Haemophilus influenza, peptostreptococci

Risk Factors
• Multiple sexual partners
• History of PID
• Early onset sexual activity
• Recent gyne procedure
• IUD

Manifestations
• pelvic pain – sharp and cramping
• Fever
• Excessive vaginal discharge
• Menorrhagia
• Metrorrhagia
• Urinary symptoms
• Cervical uterine tenderness with movement

Diagnostics
• History and PE
• CBC
• Vaginal and endocervical culture
• VDRL
• Endometrial biopsy - endometritis
• Sonography – tubo-ovarian abscess
• Laparoscopy - salpingitis

Management
• Antibiotics
• IV fluids/increase oral fluid
• Pain medications
• Remove IUD
• Evaluation of sexual partners

Dysmenorrhea
Pathophysiology
Prostaglandin myometrial contractions

muscle spasm constricts blood
vessels ischemia and pain

Clinical Manifestations

• Primary – within 1-2 yrs after menarche in conjunction with
ovulatory cycles
- pain few hours before menses up to 72 hours thereafter
- Nausea and vomiting, diarrhea, syncope, headache, back
pain
• Secondary – years after menarche
- 1-2 wks prior to menses and persist few days after
menstrual cessation
Diagnosis
History and PE

Medical Management
1. combination OCP – inhibit ovulation, decrease
prostaglandin and uterine activity
2.promote exercise
3.administer prostaglandin synthesis inhibitors – ibuprofen,
mefenamic acid
Nursing Management
1. Education and reassurance
2. adequate nutrition and rest
3. stress management

Menstrual cycle irregularities
Oligomenorrhea – infrequent, irregular bleeding at intervals

> 35 days
Polymenorrhea – frequent, regular bleeding at intervals
< 21 days
Amenorrhea – cessation of menses x 6 months
Menorrhagia – regular bleeding that is excessive in amount
and duration > 5 days
Metrorrhagia – irregular bleeding
Menometrorrhagia – excessive prolonged bleeding at
irregular intervals

PREMENSTRUAL SYNDROME
- emotional and physical manifestations that

occur cyclically before menstruation and regress
thereafter
- peak 30-40 yo
- mood and behavioral changes
- No specific hormone, treatment or markers
- inherent to menstrual cycle

Etiology and Risk Factors
- Caffeine
- Smoking
- Lack of exercise
- Improper diet
- Inadequate sleep
- Stress
Management:
supportive

Sexuality
• Includes feelings, attitudes and actions
• Has both biologic and cultural components
• Encompasses and gives direction to a person’s physical
emotional social, and intellectual responses throughout
life
• Each person is born a sexual being.
• Gender identity and gender role behavior evolve from
and usually conform to societal expectations within a
person’s culture.

Sexuality and Sexual Identity
 Terms
 Biologic gender – denotes chromosomal
development: XX, XY
 Gender identity or sexual identity: inner sense a

person has of being male or female
 Gender role - behavior a person conveys about being

male or female (may or may not be the same as
biologic gender or gender identity)

Human Sexual Response
Sexual response cycle
(Masters and Johnson)
Excitement
Plateau
Orgasm
Resolution

Mechanisms involved in response to sexual stimulation:
1. Vasocongestion – the engorgement of blood

vessels and increased influx of blood into the tissues.
Congested tissues, because of its excess blood
content, become swollen, red and warm
2. Myotonia – increased muscles tension affecting

both smooth and skeletal muscles and occurs both
voluntarily and involuntarily

Excitement
 occurs with physical and psychological (sight,
sound, emotion, thought) stimulation that causes
parasympathetic nerve stimulation
 Arterial dilation and venous congestion in the
genital area
 Vasocongestion:
-clitoris in women increases in size, mucoid fluid
appears in vaginal walls as lubrication, vagina
widens/ increase in length, nipples become erect
 In men, erection occurs; scrotal thickening,
elevation of testes
 Increase in PR, RR and BP

Plateau
 just before orgasm
 Women: clitoris is drawn forward and retracts
under the clitoral prepuce; lower part of the
vagina becomes extremely congested (formation
of the orgasmic platform), increased nipple
engorgement
 Men: vasocongestion leads to full distention of
the penis
 HR increases to 100 to 175 beats per minute and
RR to approximately 40 respirations per minute

Orgasm
 Occurs when stimulation proceeds through
the plateau stage to a point at which the
body suddenly discharges accumulated
sexual tension
 Vigorous contractions of muscles in the
pelvic area expels or dissipates blood and
fluid from the area of congestion

 Shortest stage in the sexual response
cycle
 Usually experienced as intense pleasure
affecting the whole body not just the pelvic
area
 Highly personal experience; vary greatly
from person to person

Resolution
 Period during which the external and internal
genital organs return to unaroused state
 Males: refractory period – during which further
orgasm is impossible
 Females: no refractory period; may have
additional orgasms immediately after the first
 Generally takes about 30 minutes

Reproductive Life Planning
FAMILY PLANNING
• Includes all decisions an individual or couple
make about having children:
- If and when to have children
- How many children to have
- How children are spaced
- Conception, fertility and counseling

Responsible Parenthood
• A responsible person is a man or woman who is

able and willing to give the proper response to
the demands of a given situation.
• With specific reference to marriage and family

life, the responsible spouse is one who gives the
proper responses to the needs of his/ her
spouse, as well as his own, and of their life
together. Similarly, responsible parents give
proper responses to the needs of their children.

• Although some people object to the idea, we

tend to equate family planning with
responsible parenthood. Family planning
refers more specifically to the voluntary and
positive action of a couple to plan and decide
the number of children they want to have and
when to have them.

The concept of family planning includes these
elements:
• Responsibility of parents to themselves and to each

other
• Responsibility to their present and future children
• Responsibility to their community and country

Purposes of Family Planning
• improvement of health
• promotion of human right to determine
reproductive performance
• relation of demographic change to
economic development

The ultimate goal of family planning is directed
towards:
• Birth spacing, to allow the mothers time to rest and

regain their health before the next pregnancy
• Birth limitation, when the desired number of children

is reached
• Helping those who do not have children to have

children

Advantages of family planning
To the mother:
• enables the mother to regain her health after the
delivery
• gives mother enough time and opportunity to love
and provide attention to her husband and children
• provides mother who has chronic illness enough
time for treatment and recovery without further
exposure to the physiologic burden of pregnancy
• prevents high risk pregnancy
• gives mother more time to herself, family and
community

To the children, the practice of family
planning will make them
• Healthier
• Happier
• feel wanted and satisfied
• secure

To the fathers
• lightens his burden and responsibility in supporting
his family
• enables him to give his children a good home, good
education and better future
• enables him to give his family a happy and
contented life
• gives him time for his personal advancement
• provides a father who has chronic illness enough
time for treatment and recovery from his illness

To the family
• gives the family members more opportunity
to enjoy each other’s company with love and
affection
• enables the family to save some amount for
improvement of standard of living, and for
emergencies

To the community
• improves the economic and social status of the
community
• better job opportunities
• health status will improve
• extra resources in the community (less congestion,
less pollution, potable water supply, etc)
• members will have more time to socialize with each
other; to participate in socio-civic activities

Contraceptive
• Any device used to prevent fertilization of
an egg

Considerations:
• Personal values
• Ability to use method correctly
• How method will affect sexual enjoyment
• Financial factors
• Status of couple’s relationship
• Prior experiences
• Future plans
• Contraindications

CONTRAINDICATIONS OF CONTRACEPTIVE USE

Contraceptives
1. Abstinence
• 0% failure rate
• Most effective method to prevent STDs
• Difficult to comply with

Contraceptives
2. Natural Family Planning
• No chemical or foreign material into the
body
• Failure rate of approximately 25%

Contraceptives
Fertility Awareness Methods
• Calendar (rhythm) method
• Basal body temperature
• Cervical mucus (Billings) method
• Symptothermal method
• Ovulation awareness
• Lactation amenorrhea method
• Coitus interruptus

Calendar/ Rhythm (Natural
Family Planning)
• Action – periodic abstinence from

intercourse during fertile period; based
on the regularity of ovulation; variable
effectiveness

Calendar/ Rhythm (Natural
Family Planning)
• Teaching – fertile period may be
determined by a drop in the basal body
temperature before and a slight rise
after ovulation and/ or by a change in
cervical mucus from thick, cloudy and
sticky during nonfertile period to more
abundant, clear, thin, stretchy and
slippery as ovulation occurs

1. Calendar (rhythm) method
• Entails keeping a day-by-day record of your
cycle for 6 consecutive months
• noting the onset of bleeding as day 1 and the
last day before your next menstrual bleeding as
the final day of your cycle
• This 6 month record will show you your longest
and shortest cycles- from which you can
calculate your FERTILE days


• The first day of menstrual bleeding (day 1
of your period) counts as the first day of
the cycle.
• Approximately 14 days (or 12 to 16 days)
before the start of the next period, an egg
will be released by one of the ovaries.

• While the egg from the woman lives for
only around 24 hours, sperm from the man
can survive for up to 3 days, possibly
longer.

• First unsafe day: subtract 18 from the number
of days in your shortest cycle
• Last unsafe day: subtract 11 from the number
of days in your longest cycle
• Ex: shortest: 26 – 18 = day 8
longest: 31 – 11 = day 20
UNSAFE PERIOD!! Days 8 -20
-avoid coitus or use a contraceptive

SHORTEST CYCLE
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
1
18 DAYS
LONGEST CYCLE
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1
11 DAYS
UNSAFE TIME
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
UNSAFE TIME

2. Basal Body Temperature
• Involves taking the temperature every morning
BEFORE the woman gets out of bed and
recording it
• The temperature drops slightly 24 hours before
ovulation, then rises to about half a degree
higher than normal and remains thus for up to
three days: UNSAFE period!
• Not a very efficient method unless combined
with calendar and mucus methods

3. Cervical Mucus
(Billings) Method
• Involves becoming aware of the normal
changes in the cervical secretions that
occur throughout your cycle by inserting
the forefinger into the vagina first thing in
the morning

3. Cervical Mucus
(Billings) Method
• A few days after menstrual bleeding: little
secretion, vagina is dry
• Gradually, secretion increases and becomes
thicker, cloudy white and sticky
• As ovulation approaches, this secretion or
mucus becomes copious, clear, thin, less
viscous, more liquid, slippery or stringy; as soon
as this change begins and for 3 full days later:
UNSAFE PERIOD!!

3. Cervical Changes
• Spinnbarkeit test
• Cervical mucus
is thin, watery
and can be
stretched into
long strands
• high level of
estrogen:
ovulation is about
3. Cervical Changes
• Ferning or
arborization of
cervical mucus
• At the height of
estrogen
stimulation just
before ovulation
• Ferning- due to
crystallization of
sodium chloride 171
MLNG CELESTE, RN, MD
Symptothermal method
• Combines BBT and cervical mucus
methods

Ovulation awareness
• Use of over-the-counter OTC ovulation
test kit which detects the midcycle LH
(luteinizing hormone) surge in the urine 12
to 24 hours before ovulation
• 98 to 100% accurate

Lactation amenorrhea method
• As long as a woman is breastfeeding an
infant, there is some natural suppression
of ovulation
• Not dependable- woman may be fertile
even if she has not had a period since
childbirth
• After 6 months, she should another
method of contraception

Coitus interruptus
• Oldest method
• Couple proceeds with coitus until the moment of
ejaculation, then the man withdraws and
spermatozoa are emitted outside the vagina
• Offers little protection because ejaculation may
occur before withdrawal is complete and despite
the care used, spermatozoa may be deposited
in the vagina

Contraceptives
3. Oral Contraceptives
• Composed of varying amounts of
estrogen combined with small amount
of progesterone
99.5% effective

• Estrogen
suppresses FSH
and LH, thereby
suppressing
ovulation
• Progesterone
decreases the
permeability of
cervical mucus
• Monophasic - Fixed doses of estrogen and
progesterone ; 21-28 day cycle
• Biphasic - Constant amount of estrogen
with increased progesterone
• Triphasic - Varying levels of estrogen and
progesterone

Benefits of OC’s:
DECREASED incidences of:
• Dysmenorrhea
• Premenstrual dysphoric syndrome
• Iron deficiency anemia
• Acute PID with tubal scarring
• Endometrial and ovarian cancer and ovarian
cysts
• Fibrocystic breast disease

Side Effects
• Nausea
• Weight gain
• Headache
• Breast tenderness
• Breakthrough bleeding
• Monilial vaginal infections
• Mild hypertension
• Depression

Absolute Contraindications to OC’s
• Breastfeeding
• Family history of CVA or CAD
• History of thromboembolic disease
• History of liver disease
• Undiagnosed vaginal bleeding

Possible Contraindications to OC’s
• Age 40+
• Breast or reproductive tract malignancy
• Diabetes Mellitus
• Elevated cholesterol or triglycerides
• High blood pressure
• Mental depression

• Migraine or other vascular type headaches
• Obesity
• Pregnancy
• Seizure disorders
• Sickle cell or other hemoglobinopathies
• Smoking
• Use of drug with interaction effect

Other Contraceptives
• Continuous or extended regimen pills
• Mini-pills
• Estrogen-progesterone patch
• Vaginal rings

Estrogen-progesterone patch

• Highly effective, weekly hormonal birth control
patch that’s worn on the skin
• Combination of estrogen and progestin
• Absorbed on the skin and then transferred into
the bloodstream
• Can be worn on the upper outer arm, buttocks,
upper torso or abdomen
• Worn for 1 week, replaced on the same day of
the week for 3 consecutive weeks. No patch-4th
week

Emergency Postcoital Contraceptives
• “Morning-after pills”
• High level of estrogen
• Must be initiated within 72 hours of
unprotected intercourse

4. Other Contraceptives
Subcutaneous implants (eg, Norplant)

• 6 nonbiodegradable Silastic implants with synthetic
progesterone embedded under the skin on the inside
of the upper arm
• Slowly release the hormone over the next 5 years
• Suppress ovulation, stimulating thick cervical mucus
and changing the endometrium so implantation is
difficult

4. Other Contraceptives
• Intramuscular injections
-administered every 12 weeks
Medroxyprogesterone (depo-provera)
-100% effective

Contraceptives
5. INTRAUTERINE DEVICES
• T-shaped plastic device with copper
• With progesterone
• Mechanism of action not fully understood
• Must be fitted by physician, nurse practitioner or
midwife
• Insertion performed in ambulatory setting after pelvic
examination and pap smear
• Device is contained within uterus – string protrudes into
vagina
• Effective for 5-7 years (mirena type) or 8 years (Copper
T380)

INTRAUTERINE DEVICE

5. INTRAUTERINE DEVICES
Side Effects:
• Spotting or uterine cramping
• Increased risk for PID
• Heavier menstrual flow
• Dysmenorrhea
• Ectopic pregnancy

6. Barrier Methods
• Vaginally inserted spermicidal products
• Diaphragms
• Cervical caps
• Condoms

6. BARRIER METHODS
• SPERMICIDAL AGENT
goal: to kill the sperm
before the sperm
enters the cervix
-Nonoxynol-9
-gel, creams,
films,foams,
suppositories

6. BARRIER METHODS
• DIAPHRAGM
-mechanically blocks sperm
from entering the cervix
-soft latex dome supported by
a metal rim
-can be inserted 2 hours
before intercourse; removed
at least 6 hours after coitus
or within 24 hours
-size must fit the individual
-washable, may be used for
2-3 years

6. BARRIER METHODS
• CERVICAL CAP
-similar to
diaphragm but
smaller
-thimble-shaped
rubber cap held
onto the cervix by
suction

6. BARRIER METHODS
MALE CONDOM FEMALE

CONDOM

• MALE CONDOM
Action – prevents the ejaculate and sperm from entering
the vagina; help prevent venereal disease; effective if
properly used; OTC
• Teaching – apply to erect penis with room at the tip every

time before vaginal penetration; use water-based
lubricant, e.g., K-Y jelly, never petroleum-based
lubricant; hold rim when withdrawing the penis from the
vagina; if condom breaks, partner should use
contraceptive foam or cream immediately

7. Surgical Methods
• Tubal Ligation
-28% of all women
in US
-fallopian tubes are
cut,tied/ cauterized
to block passage of
ova and sperm
ABDOMINAL INCISION
MINILAPAROTOMY
LAPAROSCOPY
FOR TUBAL
STERILIZATION

7. Surgical Methods
• Vasectomy
- 11% of all men in US
-incisions are made in
the sides of scrotum;
vas deferens is cut and
tied, then plugged or
cauterized
-blocks passage of
sperm
-viable sperm for 6
months post op
-reversible 95%

8. Elective Termination of
Pregnancy
Procedure to deliberately end a pregnancy
before fetal viability
• Induced
(mifepristone-progesterone antagonist;
misoprostol-prostaglandin analog
• Medically induced
D&C, D&E, saline induction, hysterotomy

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MATERNAL HEALTH NURSING

MLNG CELESTE, RN, MD 4

Male reproductive system

MLNG CELESTE, RN, MD 5

Male internal structures

MLNG CELESTE, RN, MD 6

MLNG CELESTE, RN, MD 7

-The glans penis, a cone-shaped expansion of the corpus

-Erection is stimulated by parasympathetic nerve

2. Scrotum: a pouch hanging below the penis that contains the

MLNG CELESTE, RN, MD 8

1.The glans penis, a cone-shaped expansion of

3. Prepuce or Foreskin – retractable skin

-Erection is stimulated by parasympathetic

SPERMATOZOA are produced by:

“Spermatozoa do not survive at body temperature.

1. Epididymis: serves as reservoir for sperm storage and

A total of 64 days before the sperm reach maturity.

2. Vas deferens: a duct extending from epididymis to the

MLNG CELESTE, RN, MD 13

4. Ejaculatory ducts: the canal formed by the union of the vas

5. Prostate Gland: located just below the urinary bladder.

6. Bulbourethral glands or Cowper’s Gland: adds alkaline

7. Urethra: the passageway for both urine and semen, extending

MLNG CELESTE, RN, MD 14

Contain Leydig cells produces testosterone

Testosterone ALERT: it takes 64 days

• Epididymis conducts sperm to Vas deferens

• Seminal vesicles ( secretion of fructose & protein)

• Urethra ( 8 inches) ( cowper’s gland secretes

Female reproductive system

MLNG CELESTE, RN, MD 18

MLNG CELESTE, RN, MD 19

1. Mons pubis/ Mons veneris – pad of adipose tissues, which

2. Labia majora – longitudal folds of pigmented skin extending

3. Labia minora – soft longitudal skin folds between the Labia

4. Glans clitoris – erectile tissue located at the upper end of

5. Vestibule – a narrow space seen when labia minora are

6. Urethral Meatus – small opening between the clitoris and

7. Vaginal orifice/introitus/opening – external opening of

8. Hymen – a membranous tissue ringing the vaginal introitus

9. Perineum – tissue between the anus and vagina. Site of

The external genitalia’s blood supply:

MLNG CELESTE, RN, MD 23

MLNG CELESTE, RN, MD 24

1. Ovaries – female sex glands located on each side of the uterus

Ovaries are formed with 3 principal divisions:

Functions: -Ovulation (release of ovum) and Secretion of

Estrogen- helps to prevent osteoporosis, and atherosclerosis

MLNG CELESTE, RN, MD 25

c. The central medulla containing nerves, blood vessels, lymphatic

- Firm almond shaped

Divided into four separate parts:

1. Intramural portion- most proximal (1 cm in length)

2. Isthmus portion- extremely narrow (2cm)

3. Ampulla- longest portion (5cm) and widest part

4. Infundibular portion- funnel- shaped with Fimbrae (2cm):

2. Ampulla- wide middle

3. Isthmus- narrowest part

•Bilateral ducts extend 4. Interstitial or

3. Uterus – hollow pear-shaped muscular organ.

Cervix (2-5cm long)

MLNG CELESTE, RN, MD 30

MLNG CELESTE, RN, MD 32