Reproductive System - Male

Scope: Lecture Twenty-Five is the first of three lectures on the reproductive system. This lecture
examines the gross anatomy of the male reproductive system. The scrotum contains the testes, which
produce spermatozoa through the process of spermatogenesis. A series of tubules and ducts lead the
sperm and fluids into the epididymis, where the sperm matures and gains motility. From there, the
sperm passes through the vas deferens to the ejaculalory duct. The lecture also reviews the functions
of the prostate and Cowper's glands, the process of erection and ejaculation, and the composition of
the semen.

I. The major functions of the male reproductive system include the production, storage, and delivery of
spermatozoa and the production, storage, and release of male sex hormones.

II. Embryology

A. External sex organs

1. Five-week-old embryos have undifferentiated sex organs: the genital tubercule, the
glans, the urethral folds, the labioscrotal swelling, and the beginning of the perineum.

2. At 10 weeks, some differentiation has taken place in the glans and the urethral folds
and the perineum has connected to the anus.

3. Just before birth, the sex organs have completely differentiated.

4. In hypospadias, the urethra does not connect to the bladder. This is generally
surgically corrected at birth.

B. Internal sex organs

1. In the undifferentiated stage (5-10 weeks), the gonads, paramesonephric duct, and
mesonephric duct are not developed enough to determine sex.

2. The testes, epididymis, mesonephric duct (later the spermatocord), and prostate then
develop in the male. The mullerian duct degenerates in the male and eventually
develops into the fallopian tubes in the female.

3. Just before birth, the testes descend into the scrotum in the male and the prostate
develops. The sex organs descend in the female as well but remain internal.

C. Hermaphroditism is the development to some degree of both sets of sex organs; it is caused by
chromosomal abnormality.
III. Gross anatomy

A. Scrotum (”bag”)

1. The scrotum holds the testes.

2. The superficial fascia (dartos) under the skin can contract and wrinkle the scrotum,
drawing it nearer the body for warmth.

3. Sperm production is best at about 93 degree Fahrenheit below body temperature.

B. Testes (testicles)

1. The testes develop in the abdomen and descend into the scrotum through the inguinal
canal.

2. Failure to descend is called cryptorchidism.

a. This condition, if uncorrected, can lead to sterility.

b. It also increases chances of testicular cancer.

c. It can be corrected by hormone injection (human chorionic gonadotropins) or

surgery.

3. Spermatogenesis is the production of spermatozoa in seminiferous tubules, beginning at

puberty.

4. The spermatocord migrates from a retroperitoneal position down through the inguinal
canal to the testes. It contains the pampiniform plexus, the veins of which can swell and
suppress sperm production.

5. The cremaster is an involuntary muscle that pulls the testes closer to the body for
warmth.

C. Ducts

1. The flow of sperm and fluids goes from the seminiferous tubules (tortuous) to the
straight tubules.

2. Rete (network) testes receive fluid and sperm from the straight tubules.

D. Epididymis

1. Efferent ducts lead sperm into epididymis.

2. Sperm matures here for about 2 weeks.

3. Motility increases.

4. The epididymis contains smooth muscle to propel sperm along.

E. Vas deferens (ductus deferens)

 1. The vas deferens leads from the epididymis to the prostate.

2. It enters the inguinal canal and penetrates the peritoneal cavity at the inguinal ring.

3. Vas deferens ends in the ejaculatory duct.

F. Spermatogenesis consists of the following stages:

1. Leydig cells (interstitial endocrine cells) secrete testosterone.

2. Spermatogenic cells are the stem cells from which all other cells arise. They mature in
the basement membrane. They are 2N (or diploid; they have the chromosomes of
both the mother and father).

3. The spermatogonia (diploid) move upward and become the primary spermatocytes.

4. The primary spermatocytes divide into secondary spermatocytes (1N, or haploid; they
have only one set of chromosomes).

5. Spermatocytes develop into spermatids connected by the cytoplasmic bridge.

6. Spermatozoa (mature sperm cells; haploid) gradually move from the seminiferous
tubules to the duct lumen as they mature.

7. Spermatogenesis takes 2-3 months. Sertoli cells (sustentacular cells) nourish the
developing spermatozoa.

G. Chromosomes

1. There are 23 pairs of chromosomes.

2. Chromosome 23 has X and Y variants; these are the sex chromosomes.

3. Having three copies of chromosome 21 (trisomy 21) is commonly known as Down

syndrome.

4. Spermatogonium divide in a process called mitosis into daughter cells (diploid) and
primary spermatocytes (diploid).

5. DNA replication and random crossing over (between chromosome pairs) mix
chromosomal material to create a new set of chromosomes.

6. In meiosis, primary spermatocytes divide into secondary spermatocytes, each with only
one set of chromosomes (haploid).

7. Extra chromosomal material in cells always causes problems in embryo development.

H.
Sperm cells

1. The sperm cell head is pointed to penetrate the egg.

2. The nucleus contains one set of chromosomes.

3. The cell is also full of mitochondria.

4. The tail (flagellum) whips back and forth to propel the sperm out of the body.

5. Motility increases as sperm cells mature.

I. Seminal vesicles

1. The seminal vesicles secrete fluids that nurture and protect the spermatozoa.

2. The ultimate fluid coating, semen, neutralizes the acidity of the female vagina and
protects the sperm.

3. Prostaglandins increase sperm motility.

J. Ejaculatory duct

1. The ejaculatory duct is formed by the junction of the vas deferens and the seminal
vesicles.

2. It forces sperm out into the urethra during ejaculation.

K. Prostate gland

1. The prostate gland lies at the base of the bladder at the outlet for the urethra; it acts
like a hand-warming muff.

2. The ejaculatory duct enters the urethra in the prostate gland.

3. Its secretions help sperm motility and longevity.

L. Cowper's glands

1. Cowper's glands are paired just below the prostate.

2. They secrete a fluid to neutralize the acid environment of the urethra (which is acidic
to deter bacterial growth).

3. Mucous secretion buffers the sperm against injury during ejaculation.

M. Because individual sperm have little chance of survival, each ejaculation contains a million or
more spermatozoa. Also, no single sperm contains enough of the enzyme necessary to
penetrate the egg; thus, many sperm can pool this enzyme.

N.
Penis

1. The penis functions as a conduit for urination and ejaculation of semen.

2. The main components of the shaft are:

a. Paired corpora cavernosa, which are spongy collections of pockets that fill with
blood during erection.

b. A single ventral corpus spongiosum.

c. The urethra runs through the corpus spongiosum.

d. Arteries, veins, and nerves.

e. Prepuce (foreskin); the need for circumcision is still hotly debated.

3. Erection

a. Arterial inflow increases

b. Venous outflow is decreased by pressure from arterial expansion.

c. Parasympathetic response causes erection from a large number of stimuli (sight,

sound, touch, imagination).

4. Ejaculation

a. Ejaculation is mediated by the sympathetic nervous system.

b. The urinary sphincter closes at the base of the bladder, preventing the flow of
semen into the bladder and urine into the ejaculate.

c. All accessory sexual organs (ductus deferens, seminal vesicles, prostate, and
ejaculatory ducts) contract their smooth muscles to expel semen.

d. The ischiocavernosus muscle at the base of the penis contracts.

5. Semen

a. Semen contains spermatozoa and seminal fluid from the accessory glands.
 b. Average volume is 1 teaspoon (5 ml), which contains about 100 million sperm
cells.

c. Seminal fluid is bacteriocidal and alkaline.

d. It clots initially, and then liquefies in 20 minutes.

e. Only one sperm is needed to fertilize the ovum.

6. Prostate pathology

a. Benign prostate hypertrophy (BPH) tends to close the urethra, causing a number
of urinary dysfunctions.

b. Transurethral resection of the prostate involves cutting the prostate into small
chunks removed through the urethra. This can cause ejaculation into the
bladder.

c. Cancerous prostates can be approached from the pubic bone or the penis and
removed, but both surgical approaches may cause postoperative problems.

Reproductive System - Female

Scope: This lecture reviews the female reproductive system. We begin by reviewing the anatomy of the
external female genitalia, the vagina, the uterus, the fallopian tubes, and the ovaries. Next we consider
the physiology of the menstrual cycle, fertilization, and early pregnancy. Finally, we examine the
anatomy and physiology of the breast, the various risk factors for breast cancer, and its treatments.

I. Genitalia

A. The vulva (volvere = "to wrap around") is also called the pudendum.

1. The prepuce covers the clitoris. Its analog in the male is the foreskin.

2. The clitoris is sensitive to stimulation. Its analog in the male is the glans.

3. Labia majora ("large lips")—-the analog in the male is the scrotal skin and hair.

4. The labia minora ("small lips") secrete oil.

5. The vestibule is located between the labia minora.

a. Hymen

b. Vaginal orifice

c. External urethral orifice

d. Skene's (paraurethral) glands secrete mucous. Their analog in the male

is the prostate.
 e. Bartholin's (greater vestibular) glands secrete mucous during
intercourse. Their analog in the male are the Cowper's glands.

B. The mons pubis is a deposition of fat that cushions the pubic bone.

C. The urinary bladder is a wholly extraperitoneal organ that resides in the vesico-uterine
pouch.

D. All female reproductive organs, however, are intraperitoneal.

E. The cervix is extraperitoneal (intra-vaginal) and provides easy clinical access to the
uterus for examination or removal.

F. The rectum and bladder are separated in the female by the uterus.

G. Fistulas can form between the bladder and vagina or the rectum and vagina, leading to
inflammation and infection.

H. The vermiform appendix lies almost directly above one ovary. Pelvic inflammatory
disease (tubo-ovarian abscess) causes infections of the tubes and ovaries that can be
confused with appendicitis.

I. The vagina is the conduit for spermatozoa during intercourse.

1. It functions as the birth canal during delivery.
2. It is a potential space, with great elasticity.
3. Its walls are composed of smooth muscle.
4. It has an acid environment to inhibit the growth of bacteria.
5. The cervix of the uterus protrudes into the vaginal vault.

J. The uterus is the conduit for sperm to reach the ovum in the fallopian tube.
1. It is the cradle for development of the fertilized ovum (zygote).
2. It has the following three anatomic sections:
a. Fundus—the superior portion.
b. Corpus— the body and midsection.
c. Cervix—the "neck" protruding into the vagina.
i. The cervical os is the opening of the cervix.
ii. There is a mucous plug in the opening except during the fertile
period.
 3. The endometrium is the lining of the uterus that covers the muscles.
4. The myometrium is the muscular lining of the uterus.
5. Uterine pathology
a. Uterine cancer is cancer of the endometrium.
b. Fibromas (leiomyomas) are benign tumors of the uterine wall that
cause problems because of their size.
c. Uterine prolapse is excessive downward movement of the uterus,
generally because of age.
d. Cervical cancer (human papilloma virus) is a common sexually
transmitted viral disease.

K. The fallopian tubes are the active conduit for the ovum to reach the uterus.
1. The fallopian tube is the site of fertilization of the ovum about 24 hours after
ovulation.
2. It has the following three anatomic parts:
a. Infundibulum—a fimbriated ("fingerlike") opening that swirls to suck
the ovum into the tube when expelled from the ovary into the
peritoneal cavity.
b. Ampulla—the mid-portion and widened part.
c. Isthmus—a narrowed portion leading to the uterus.
3. Smooth muscle and cilia propel the ovum distally.
4. The fertilized ovum spends about 1 week in the tube in transit.
5. In a scarred or damaged tube, pregnancy can take place in the tube (ectopic
pregnancy), which can lead to tubal rupture and life-threatening bleeding.

L. The ovaries bear all the precursor ova.

1. Primordial follicles develop into primary follicles that contain oocytes at various stages
of development.

2. Follicular cells nurture the developing oocyte (estrogen).

3. The graafian follicle is the mature follicle at the last stage of oocyte development from
which the mature ovum emerges.

4. Graafian follicles rupture and release eggs into the fallopian tube. This can sometimes
also release drops of blood into the peritoneal cavity, causing mittelschmerz (abdominal
pain in the middle of the menstrual cycle) for a few hours.

5. Corpus luteum ("yellow body") remains after ovulation and is the source of estrogen,
progesterone, relaxin, and inhibin.

6. Corpus albicans ("white body") is the remains of degenerating follicle.

II.
Physiology of menstruation

A. The cycle begins with the first day of bleeding (menses = "month").

B. Menstruation occurs in three phases.

1. The menstrual phase lasts about 5 days.

a. Uterus: Mainly menstrual bleeding.

b. Ovaries: Several secondary follicles begin to mature in both ovaries.

2. The preovulatory phase has the most variable duration, between the end of
menstruation and ovulation.

a. Ovaries: Follicular phase. FSH (follicle-stimulating hormone) stimulates

continued growth of secondary follicles. Only one continues to develop
and becomes a graafian follicle. Migration to surface up to rupture of
follicle into peritoneum. LH (luteinizing hormone) increases at this time.

b. Uterus: Proliferative phase. Endometrium is repaired and arterial supply

increases under estrogen stimulation. Preparation for arrival of fertilized
ovum.

3. Ovulation

a. Ovaries: Rupture of graafian follicle and release of ovum. LH peaks just

prior to ovulation; home tests depend on this to predict ovulation 24
hours later.

b. Uterus: Secretory phase. First estrogen, then estrogen and

progesterone, continue to prepare the endometrium to receive the
fertilized ovum. Arterial supply is very rich.

4. The postovulatory phase lasts 14 days and is fairly consistent. Estrogen and
progesterone decline and cause ischemia to the endometrium, which dies and
sloughs off.

5. Birth control pills mimic pregnancy by maintaining high levels of estrogen and
progesterone, which signal the uterus not to release any eggs. This prevents
superfecundation (multiple fertilized eggs), which can lead to spontaneous
abortion in humans.

III. Physiology of fertilization and early pregnancy.

A. Fewer than 1% of the sperm reach the ovum.

 B. Fertilization occurs in the fallopian tube 12-24 hours after ovulation.

C. Conception

1. Sperm are viable for 48 hours after ejaculation.

2. The ovum is viable for 24 hours after ovulation.

3. The theoretical window for conception is 36 hours.

D. Cleavage of the fertilized egg produces a two-celled conceptum and then, by the
fourth day, the morula, which has hundreds of cells.

E. The blastocyst, a spear of cells with a hollow center, develops on the fifth day; by the
end of the first week of pregnancy, it has implanted itself into the uterine wall.

F. If the uterine wall is not ready for the blastocyst, the cell mass will be rejected through
a normal menstrual process (missed abortion).

G. The blastocyst and endometrium develop two-layer walls around the seventh day.

H. The implantation process continues to develop layers of tissue and a separate

circulatory system for the embryo.

I. The developing placenta grows a network of capillaries that will eventually exchange
blood between the mother and embryo.

J. In early development, the placenta exchanges only gases, nutrients, and waste
because of possible differences in blood type between the mother and embryo.

K. Toward the end of pregnancy, the placenta begins to age and can mix the different
blood types. If the blood types are incompatible, problems such as neonatal jaundice
can occur.

V. The breast is technically an organ of reproduction because of its role in nurturing the newborn.
A. The breasts are also called mammary glands.
B. They are actually modified sweat (apocrine) glands capable of secreting milk.
C. Anatomy
1. The basic structural unit is the lobule.
a. The lobule is composed of alveoli lined with secretory cells.
b. Several lobules make up a lobe.
c. There are 15 -20 lobes in each breast.
2. The lobes drain into ducts lined with epithelium. The duct system converges
into 6-8 terminal ducts in the nipple.
 3. Nipple
a. The nipple is surrounded by areola, which contains smooth muscles
that eject the milk.
b. Ducts empty through the nipple and areola.
4. The breast contains ligaments that support it and is divided into primarily
breast tissue and fat. The amount of fat increases as the body ages.
5. The male breast is similar to the female breast but lacks the ability to secrete
milk.
6. Men can get ductal breast cancer, whereas women get both lobular and ductal
cancers. Because of differences in hormones, the male-to-female breast
cancer ratio is approximately 1:100.

D. Physiology and pathology

1. Milk letdown (lactation)
a. Lactation is controlled by oxytocin from the posterior pituitary.
b. Prolactin, estrogen, and progesterone are involved in milk production.
2. Breast cancer
a. Breast cancer is the number-one cancer in women, but it is highly
curable if detected early.
b. It also occurs in men with a similar clinical course.

c. Prolonged exposure to estrogen is the primary cause of breast cancer.

Factors that cause prolonged exposure in women include:
i. Cancer in the opposite breast
ii. Nulliparity (no childbirths)
iii. Early menarche (early onset of menstruation)
iv. Late menopause
v. Family history, especially a first-degree relative with
premenopausal bilateral breast cancer. There is less danger in
the case of a first-degree relative with postmenopausal
unilateral breast cancer.
vi. Radiation
vii. Possibly, diet and obesity/animal fat intake (debated).
d. Treatment includes surgery, radiation, chemotherapy, or all of the
above.

Pregnancy
A. Fertilization
1. Conception (fertilization)
a. Definition: union of sperm and ovum
b. Conditions necessary for fertilization
1. Maturity of egg and sperm
2. Timing of deposit of sperm
a. Lifetime of ovum is 24 hours
b. Lifetime of sperm in the female genital tract is 72 hours
c. Ideal time for fertilization is 48 hours before to 24 hours after
ovulation
d. Menstruation begins approximately 14 days after ovulation
3. Climate of the female genital tract
a. Vaginal and cervical secretions are less acidic during ovulation
(sperm cannot survive in a highly acidic environment)
b. Cervical secretions are thinner during ovulation (sperm can
penetrate more easily)
c. Process of fertilization (7-10 days)
1. Ovulation occurs
2. Ovum travels to fallopian tube
3. Sperm travel to fallopian tube
4. One sperm penetrates the ovum
5. Zygote forms (fertilized egg)
6. Zygote migrates to uterus
7. Zygote implants in uterine wall
8. Progesterone and estrogen are secreted by the corpus luteum to
maintain the lining of the uterus and prevent menstruation until
placenta starts producing these hormones; (note: progesterone is a
thermogenic hormone that raises body temperature, an objective sign
that ovulation has occurred)

d. Placental development
1. Chorionic villi develop that secrete Human Chorionic Gonadotropin
(HCG). which stimulates production of estrogen and progesterone
from the corpus luteum (production of HCG begins on the day of
implantation and can be detected by the sixth day)
2. Chorionic villi burrow into endometrium, forming the placenta
3. The placenta secretes HCG, human placental lactogen (HPL), and (by
week three) estrogen and progesterone
e. Fetal membranes develop and surround the embryo, fetus
1. Amnion: inner membrane
2. Chorion: outer membrane
3. Umbilical cord
a. Two arteries carrying deoxygenated blood to placenta
b. One vein carrying oxygenated blood to fetus
 c. No pain receptors
d. Encased in Wharton’s jelly
e. Covered by chorionic membrane

f. Amniotic fluid
1. Production origins
a. Maternal serum during early pregnancy
b. Fetal urine in greater proportion during latter part of
pregnancy
c. Replaced every 3 hours
d. 800-1,200 ml at end of pregnancy
2. Functions
a. Protection from trauma and heat loss
b. Facilitates musculoskeletal development by allowing for
movement of the fetus
c. Facilitates symmetric growth and development
d. Source of oral fluid for fetus
g. Placental transfer of material to and from the fetus
1. Diffusion across membrane (for example: gases, water, electrolytes)
2. Active transport via enzyme activity (for example: glucose, amino
acids, calcium, iron)
3. Pinocytosis: minute particles engulfed and carried across the cell (for
example: fats)
4. Leakage: small defects in the chorionic villi cause slight mixing of
maternal and fetal blood cells
5. Nutrients and wastes are exchanged in the placenta, but the blood
does not intermingle

Let's start with Section 1, Review of Female Reproductive Nursing. In this section, we will review
fertilization and fetal development, signs of pregnancy, assessment of date of delivery, physiological
adaptations and discomfort of pregnancy, teratogenic effects on fetal development, emotional and
psychological adaptations of pregnancy, and prenatal care.

So let's start with Section 1, with Pregnancy. We're going to start down with process of fertilization. And
the progesterone and estrogen, it's important to remember some key things about the hormones that
are happening or the interactions and what they do. Remember that progesterone and estrogen are
secreted by the corpus luteum to maintain the lining of the uterus or our environment for that
baby. And they also prevent menstruation.

It's important to note that progesterone and estrogen rise and is a thermogenic hormone that raises
body temperature, which is an objective sign of ovulation. Along at that same time, we're also going to
start development of the placenta, which will take over that hormonal production later in
pregnancy. Key to placental development, parts of that is the chorionic villi.

What's important here is that the chorionic villi secrete human chorionic gonadotropin or
HCG. Production of HCG begins on the day of implantation and can be detected by the sixth day
following pregnancy. And so early diagnosis is possible as early as six to ten days after conception.
The fetal membranes and development around that embryo, there's an inner and outer membrane, the
amnion and the chorion. The main thing to remember here is the connection to the baby with the
umbilical cord. The key here, as you can see, I've made a little mnemonic here for you, AVA or Ava, to
remember the vessel structure of the cord as artery, vein, artery. Most likely you will see a question
where it's asking you to assess an umbilical cord to see that the structure is correct and you should have
three vessels, two arteries and one vein.

Amniotic fluid, another component that is important, is replaced every three hours through urination of
the fetus. He drinks the fluid, he urinates it back out, and at the end of pregnancy as much as 1,200 cc,
almost a liter of fluid, can be held within the uterine cavity. The amniotic fluid functions to prevent
trauma and heat loss. It acts as a movement medium for the fetus for musculoskeletal development,
symmetrical growth as well, and it's also, again, like I said, that source of oral fluid for the fetus. Also,
the placenta acts as a transfer of nutrients through diffusion, active transport, penocytosis, but there is
theoretically no blood mixture between the fetus and the mom. Even though through micro-leakages in
the chorionic villi, some slight mixing can occur, the blood circulations do not mix. They come very close
together at the chorionic villi, and then the nutrients, not the blood, transfer across for the baby.

B. Fetal Development

1. Pre-embryonic: first two weeks

2. Embryonic: three to seven weeks

3. Fetal: eight to 40 weeks

a. Full term: 38 to 42 weeks

b. Preterm: less than 38 weeks

c. Post-term: more than 42 weeks

C. Terminology

1. Gravida

1. Definition: number of times pregnant, including present pregnancy

2. Variations: primigravida, multigravida

2. Para

a. Definition: number of pregnancies delivered after the age of viability, whether

born alive or dead

b. Variations: nullipara, primipara, multipara

3. Five-digit system

a. G: gravida

b. T: term infants

c. P: preterm
 d. A: abortions

e. L: living
Now, with fetal development, some key things here, and I put these in a box to
remind you, I'm sure you're aware of this, that you want to remember what is
classified as preterm, full-term, and post-term.

The preterm infant, remember, is a gestation of less than 38 completed weeks, full-
term is 38 to 42 weeks, and then a post-term fetus is more than 42 weeks of
gestation.

Along with that, we need to look at some terminology that will classify the
obstetrical history of the patient. Again, you see here in your definition box, this is a
key component that you need to be aware of, the term gravida, the number of times
that the client has been pregnant. It means nothing more and nothing less, and
many times students want to add in more things to this, but the term gravida, or the
G, is going to be number of times pregnant.

The para, or the P, is the number of pregnancies delivered after the age of viability,
whether born dead or alive. Now, you can see that your five-digit system, this is a
valuable piece of obstetrical history and information that's used in this little five-digit
system. We talk about gravida, number of times pregnant, the number of term
infants, which is the T. P is preterm, A is abortions, and that includes spontaneous or
therapeutically induced, as well as the number of living children.

Pregnancy

A. Fertilization

1. Conception (fertilization)

a. Definition: union of sperm and ovum

b. Conditions necessary for fertilization

1. Maturity of egg and sperm

2. Timing of deposit of sperm

a. Lifetime of ovum is 24 hours

b. Lifetime of sperm in the female genital tract is 72 hours

c. Ideal time for fertilization is 48 hours before to 24 hours

after ovulation

d. Menstruation begins approximately 14 days after

ovulation

3. Climate of the female genital tract

a. Vaginal and cervical secretions are less acidic during

 ovulation (sperm cannot survive in a highly acidic
environment)

b. Cervical secretions are thinner during ovulation (sperm

can penetrate more easily)

c. Process of fertilization (7-10 days)

1. Ovulation occurs

2. Ovum travels to fallopian tube

3. Sperm travel to fallopian tube

4. One sperm penetrates the ovum

5. Zygote forms (fertilized egg)

6. Zygote migrates to uterus

7. Zygote implants in uterine wall

8. Progesterone and estrogen are secreted by the corpus luteum to

maintain the lining of the uterus and prevent menstruation until
placenta starts producing these hormones; (note: progesterone
is a thermogenic hormone that raises body temperature, an
objective sign that ovulation has occurred)

d. Placental development

1. Chorionic villi develop that secrete Human Chorionic

Gonadotropin (HCG). which stimulates production of estrogen
and progesterone from the corpus luteum (production of HCG
begins on the day of implantation and can be detected by the
sixth day)

2. Chorionic villi burrow into endometrium, forming the placenta

3. The placenta secretes HCG, human placental lactogen (HPL), and

(by week three) estrogen and progesterone

e. Fetal membranes develop and surround the embryo, fetus

1. Amnion: inner membrane

2. Chorion: outer membrane

3. Umbilical cord

a. Two arteries carrying deoxygenated blood to placenta

b. One vein carrying oxygenated blood to fetus

 c. No pain receptors

d. Encased in Wharton’s jelly

e. Covered by chorionic membrane

f. Amniotic fluid

1. Production origins

a. Maternal serum during early pregnancy

b. Fetal urine in greater proportion during latter part of

pregnancy

c. Replaced every 3 hours

d. 800-1,200 ml at end of pregnancy

2. Functions

a. Protection from trauma and heat loss

b. Facilitates musculoskeletal development by allowing for

movement of the fetus

c. Facilitates symmetric growth and development

d. Source of oral fluid for fetus

g. Placental transfer of material to and from the fetus

1. Diffusion across membrane (for example: gases, water,

electrolytes)

2. Active transport via enzyme activity (for example: glucose, amino

acids, calcium, iron)

3. Pinocytosis: minute particles engulfed and carried across the cell

(for example: fats)

4. Leakage: small defects in the chorionic villi cause slight mixing of

material and fetal blood cells

5. Nutrients and wastes are exchanged in the placenta, but the

blood does not intermingle

B. Fetal Development

1. Pre-embryonic: first two weeks

2. Embryonic: three to seven weeks

 3. Fetal: eight to 40 weeks

a. Full term: 38 to 42 weeks

b. Preterm: less than 38 weeks

c. Post-term: more than 42 weeks

C. Terminology

1. Gravida

1. Definition: number of times pregnant, including present pregnancy

2. Variations: primigravida, multigravida

2. Para

a. Definition: number of pregnancies delivered after the age of viability,

whether born alive or dead

b. Variations: nullipara, primipara, multipara

3. Five-digit system

a. G: gravida

b. T: term infants

c. P: preterm

d. A: abortions

e. L: living

Signs of Pregnancy

1. Presumptive (subjective)

a. Amenorrhea: missed periods

b. Nausea and vomiting: morning sickness, probably due to HCG; usually lasts about
3 months

c. Fatigue: first trimester

d. Urinary frequency: caused by enlarging uterus pressing on bladder

e. Breast changes: tenderness and tingling, nipples pronounced, full feeling,

increased size, areola darker

f. Quickening: mother’s perception of fetal movement around 16-18 weeks:

fluttering sensation
2. Probable (objective)

a. Chadwick's sign: bluish coloration of the mucous membranes of the cervix,

vagina, and vulva

b. Goodell's sign: softening of cervix; occurs beginning of the third month

c. Hegar's sign: softening of the isthmus of the uterus, between the body of the
uterus and cervix; occurs about the sixth week

d. Enlargement of abdomen: uterus just above symphysis at 8-10 weeks; at

umbilicus at 20-22 weeks

e. Braxton-Hicks contractions: painless contractions occurring at irregular periods

throughout pregnancy; felt most commonly after 28 weeks

f. Uterine souffle: soft blowing sound; blood flow to placenta same rate as maternal
pulse

g. Pregnancy test positive: HCG in serum and urine

h. Ballottement: can push fetus and feel it rebound

i. Pigmentation changes: increased pigmentation, chloasma, linea nigra, and striae

gravidarum

3. Positive

a. Fetal heartbeat: by Doppler at 8-10 weeks

b. Fetal movements: felt by examiner

c. Fetal outline: on sonogram

D. Assessment of Date of Delivery

1. Nagele's rule: first day of last menstrual period (LMP) minus three months plus
seven days; in most cases, add one year

2. Other parameters: fundal heights, quickening, sonograms

Now, the next section, which is talking about signs and symptoms of pregnancy, we want
to remember that there are some presumptive or subjective signs that will indicate that a client may
be pregnant when they present. But remember, subjective means that this is the things that the
patient tells us. These are not things that we can particularly see with our assessment parameters.
Also, they can also account for other things. So this is very presumptive.

Amenorrhea, nausea and vomiting, urinary frequency and fatigue, changes in the breast,
enlargement, sensitivity, and of course, quickening or the mother's perception of fetal movement.

Then we can also see probable signs, and these are objective findings, things that we would see on
 physical exam. Chadwick's sign, which is that bluish color of the mucous membranes around the
cervix and the vagina with speculum exam. Goodell's sign, which is a softening of that cervix, which
can be felt with manual exam. Enlargement of the abdomen, where the uterus is rising above the
symphus, usually at about 8 to 10 weeks, and then at the level of the umbilicus around 20 to 22
weeks. The presence of Braxton-Hicks contractions, which we can palpate, which are just those
painless contractions that are thought to be used to just condition the uterus in preparation for
labor and delivery. A positive pregnancy test, meaning that we have elevated levels of HCG, which
can also indicate other things, but most likely it is pregnancy. Ballotment, meaning that the fetus
head can be felt and pushed up and rebound back down into the cervix. And of course, the common
pigmentation changes that we can see, chloasma with that darkening of the facial skin. Lina nigra,
which is the dark line going vertically across the abdomen. And of course, striae gravidarum, or
those stretch marks.

And then the positive findings, these are just irrefutable signs that pregnancy does exist, that there
is a fetal heartbeat that we can audibly hear through Doppler, and we can hear that as early as 8 to
10 weeks. Fetal movements felt by the examiner. And then of course, we see the baby on
ultrasound.

Now, once the diagnosis of pregnancy has been made, the next question that's going to need to be
addressed, because no further teaching or anything else can probably be done until this question is
answered, is what is the date of delivery? When is the patient due? So to assess, to determine that,
of course you can use all these fancy-smancy wheels and they can give you these dates, but perhaps
you'll be in a situation where you won't have that equipment available to you. We can also figure it
using Nagel's Rule. And you'll recall, we take the first day of the last menstrual period, we subtract
three months, and then we add seven days. And remember, in most cases, you're going to be adding
a year. You're going to move into the next calendar year with your due date. Be real careful looking
at your questions as you see them on the NCLEX exam, that your options, that the year is
correct, not only the month and the date, but the year is correct.

ADAPTATIONS TO PREGNANCY

ADAPTATIONS TO PREGNANCY TRIMESTER INTERVENTIONS

G.I:

- Nausea/vomiting 1 - Small frequent meals; eat

crackers or dry toast before getting up
in the morning; eat dry meals; drink
liquids between meals

- Exercise; increase fluid and

- Constipation,flatulence and 2, 3
fiber in diet; stool softeners if
heartburn
recommended by physician
 - Use soft toothbrush for
dental care

- Bleeding gums 2, 3 - Avoid fatty foods

- Gallstones 2, 3 - Small frequent meals; avoid

spicy, fatty foods; no sodium
- Heartburn 2, 3
bicarbonate as antacid; antacids as
recommended by physician

Urinary Tract: 1, 3 - Void when first urge felt;

wear a pad if leaking
- Frequency during first and third 2, 3
trimester due to pressure on bladder - Increase fluid intake

- Glomerular filtration rate (GFR)

increases (glycosuria)

- Increase in urinary infections

Breasts: 1 - Wear good supportive bra

- Increase in size and nodularity, 1

striae
2
- Tenderness and tingling
2
- Hypertrophy of Montgomery
2, 3
tubercles

- Darkening of areola

- Colostrum secreted

Vagina: 1, 2, 3 - Report itching and burning

to physician
- Epithelium undergoes hypertrophy 1
and hyperplasia - Promote cleanliness by
bathing daily; avoid douching; avoid
- Increased vascularity
nylon undergarments
- Increased pH; good for growth of
Candida (thrush)

- Increase in discharge; leukorrhea is

common

Respiratory System:

- Increase in volume of up to 40-50%

between 16th and 34th week

- Diaphragm is pushed upward;

ribcage flares out; breathing changes from
abdominal to chest

- Increase in oxygen consumption by

15%

Now, physical discomforts of pregnancy, by and large, some of the most common ones that we
see, of course, the nausea and vomiting, which is characteristic of the first trimester, and you will see
questions about the patient complains of X, the patient complains of Y. What would you educate the
patient to do? What would you have them to do? And so, with nausea and vomiting in the first
trimester, of course, smaller frequent meals, eating crackers before they get out of bed, avoiding a lot of
heavy liquids between meals, that kind of thing.

Also, urinary tract is another one that's frequently seen on NCLEX about urinary frequency. We
see it in the first trimester, as the uterus is pressing onto the bladder when it hasn't risen up out of the
pelvis yet. And again, in the third trimester, once the baby's head is engaged back down in the pelvis. So,
it will come, it will go away a while, and it'll come back. But the most important thing is to void when the
urge hits, not to have urinary stasis to avoid urinary tract infection, wearing cotton underwear to avoid
urinary tract. A pad is appropriate if there's leaking or incontinence, especially in the last trimester.

And then with breast, in the first trimester, another likely question will be the assessment
finding or the complaint by the patient of enlarging breast size, tingling, pain at the breast. And the
intervention is to wear a good supportive bra to support those changes.

Adaptations within the vagina that you would need to be aware of. Remember that in all of the
trimesters, there's an increase in pH, which accentuates as a growth medium for bacteria. So, the
patient is more at risk for candida or yeast infection. So, to report any itching or burning to their
physician immediately for treatment. As well as, especially in the first trimester, changes in the epithelial
lining will cause an increase in vaginal discharge. So, frequent cleanliness, bathing with that cotton
underwear again. Douching is contraindicated in pregnancy. So, not to do that.

Then with adaptations to specific systems, if you wanna look at it from, not from a complaint
standpoint, but as the system changes, that would require probably anticipatory guidance or education
as the patient is seen throughout the pregnancy. The respiratory system will increase in its volume. And
as the uterus moves up, the diaphragm will be pushed up and the ribs will flare out, giving the patient a
barrel-chested appearance just as a COPD patient or emphysema patient. This is considered a normal
finding in a pregnant woman. Oxygen consumption, it does not change the lung capacity, it just moves
the shape. But the oxygen consumption does go up about 15%.

And with hormonal changes, thought to be brought on by the hormonal changes, nasal
stuffiness, perhaps nosebleeds, do occur, especially in the first trimester. So, a coolness
vaporizer, perhaps a decongestant prescribed by the physician would be appropriate, or a saline nose
spray would be okay.
 And then, of course, the diphtheria, this is a common complaint or occurrence, especially in the
last trimester, where posture is difficult to maintain, sleeping in an upright position, just more rest
periods, not exerting themselves overly a lot to decrease that diphtheria and that feeling of
breathlessness.

ADAPTATIONS TO PREGNANCY

ADAPTATIONS TO PREGNANCY TRIMESTER INTERVENTIONS

Respiratory System (continued)

- Stuffiness, epistaxis, and changes in voice
occur as a result of increase estrogen levels
1 - Cool moist air may help;
- Dyspnea
avoid over-the-counter decongestants
3 and sprays
- Proper posture; sleep with head
propped up

Skin:
- Areola darkens
- Abdominal striae, linea nigra
- Diaphoresis
- Chloasma; mask of pregnancy
2, 3 Daily bathing; powder
- Vascular spider nevi; chest, neck, arms,
and legs

Metabolism/Nutrition:
- Basal metabolic rate increased by 20%
- Water retention; edema

2, 3 - Elevate legs and feet when

sitting; avoid prolonged standing; do
not wear garters or clothing with
restrictive bands around the legs;
- Weight gain; 20-25 lbs recommended
avoid crossing legs at knees
- Adequate protein intake, especially for
teens
- Increase iron during last eight weeks
- Pica: craving for nonnutritive substance

2, 3 - Eat well-balanced diet

Perineum:
- Increased vascularity
- Venous congestion of the perineum

2, 3 - Kegal exercises

Cardiovascular:

- Cardiac output increases by 30%

- Blood volume progressively increases and
peaks around 30-40 weeks at 47% above
pre-pregnant state
- Plasma volume increases greater then RBC
and hemoglobin, resulting in "pseudo
anemia"
- Pulse rate increases by 10-15
beats/minute; BP drops slightly in second
trimester due to peripheral dilatation effects
of progesterone; returns to normal by third
trimester

ADAPTATIONS TO PREGNANCY

ADAPTATIONS TO PREGNANCY TRIMESTER INTERVENTIONS

Cardiovascular (continued)
- Varicose veins may develop

2, 3 Elevate legs; avoid standing

for long periods of time; avoid
constrictive clothing

Uterus:
- Growth is influenced by estrogen
- 500 - 1,000 fold increase in capacity
- Cervical secretions form mucus plug

Endocrine:
- Increase in size and activity of thyroid
- Increase in size and activity of anterior
lobe of pituitary
- Increase in size and activity of adrenal
cortex
- Increase in production of relaxin causes Pelvic rock; good body mechanics;
joint and back pain. supportive shoes
2, 3

Now, within the integumentary system, the skin, the areola, the line of nigra, all these
chloasma, all these pigment changes are relation to hormonal changes. And main thing is the patient
needs to be reassured that after pregnancy that these things will go away.

The only integumentary change that is not guaranteed to decrease or go away is

striagravidarum or stretch marks. They may decrease in intensity, but they may still be visually
perceptible.

Also with nutrition, remember that the metabolic rate is going to be going up because all of the
systems, all of the body systems are working overtime. Their demand has been increased for their work,
so they're going to need extra nutrition, extra metabolism going to keep all that functioning.

So weight gain of 20 to 25 pounds, that's going to be a key one. You'll see, just almost guarantee
it, what is appropriate weight gain during pregnancy. Or it may be presented that a patient has gained X
number of pounds and is this appropriate. So total weight gain of 20 to 25 pounds. With a high protein
diet, good adherence to using the food pyramid, good well-rounded diet is what we want.

Don't forget that pica, the craving for non-nutritive substances, we see that a lot in the second
and third trimester, should be addressed with telling the client not to do that and to be sure to eat a
well-balanced diet.

The cardiovascular system, this is also a very important area to be aware of the physiological
changes because this will impact changes with cardiac defects, pregnancy-induced hypertension that
we'll discuss later on.

But cardiac output increases about 30% during pregnancy and the blood volume, circulating
volume, will increase in pica around 30 weeks at almost 50% of an increase about pre-pregnancy
levels. That increase in volume is circulating volume. So it will give the laboratory findings of a pseudo-
anemia, meaning that it's hemodiluted is what has happened.

So we just want to be sure that the H and H remains at 10, 10 and 30 would be an appropriate
non-anemic level. And of course, pulse rate, because we're having to circulate extra volume, we have
increased oxygen needs that we're going to increase pulse rate by 10 to 15 beats a minute. And that the
blood pressure will drop initially because the vessels will vasodilate in preparation for that volume, but
the volume will not come as rapidly as the vasodilation. And so we will have an initial drop in blood
pressure and then it will come back to pre-pregnancy levels. We should not have an increase in blood
pressure. And this is brought on by changes by progesterone.

The uterus, that is our garden for this baby, our environment, our growing ground. And it's
highly influenced by estrogen and progesterone. It'll increase its capacity by 500 to 1,000 cc's of volume.

And then with endocrine, we're going to see increased activity of the thyroid, obviously. We
have a higher metabolic rate. Adrenal cortex, pituitary, everything is going to be put into overdrive, if
you will.

The other endocrine change that you'll see at two to the second and more so in the third
trimester is the production of relaxin, which causes joint and back pain. And this is where we would be
doing teaching about the pelvic rock, standing really nice and tall, low heeled shoes, those kind of
things.

Teratogen

1. Definition: nongenetic factor producing malformations of the fetus; greatest effect on

those cells undergoing rapid growth, thus time is important

2. Types

a. Chemical agents (for example: insecticides)

b. Radiation

c. Drugs: for example: alcohol, tetracycline (Sumycin), chemotherapeutic agents,

phenytoin (Dilantin), narcotics, nicotine, megavitamins, warfarin (Coumadin),
lead, lithium, carbamazepine (Tegretol), and mercury

d. Bacteria and viruses

1. Syphilis

a. Spirochete does not cross placenta until after 18th week; treat as
soon as possible; can treat later since penicillin does not cross
placenta

b. Can cause late abortions, stillbirths, and congenitally infected

infants

2. Gonorrhea: causes injury to eyes at birth (ophthalmia neonatorum)

3. T.O.R.C.H.- severe effects on the fetus

a. Toxoplasmosis: protozoan contracted by ingesting raw meat or feces of infected

animal (for example: cats); pregnant women should not change cat litter boxes

b. Rubella: first trimester most serious; causes congenital heart problems, cataracts,
 hearing loss; clients cannot receive the rubella vaccine during pregnancy as it is a
live virus; if they receive the immunization in the post-partum period, they must
understand that they should not become pregnant for at least three months

c. Cytomegalovirus (CMV): member of the herpes family; causes congenital and

acquired infection; principal organs affected: liver, brain, and blood

d. Herpes simplex virus, Type 2 (HSV-2)

1. Transmitted to infant vaginally in intrauterine cavity or during delivery;

do not deliver vaginally if active lesions are present

2. Affects blood, brain, liver, lungs. CNS, eyes, skin

3. Perinatal mortality: 96%; 50% of survivors have neurological or visual

abnormalities

4. Chlamydia: causes conjunctivitis and pneumonia in the newborn

5. AIDS

a. Transmitted via breast milk

b. 30% chance of transmission in utero or during delivery

c. Treatment of mother with zidovudine (AZT) while pregnant can reduce chance of
transmission to fetus to approximately 8%

Emotional and Psychological Adaptations to Pregnancy

Development Tasks of Pregnancy

1. First trimester: accept the biological fact of pregnancy; it is common to feel ambivalent
early in pregnancy

2. Second trimester: accept growing fetus as a baby to be nurtured

3. Third trimester, prepare for the birth and parenting of the child

Now, teratogenic effects on fetal development, remember that a teratogen is a non-

genetic factor producing malformations of the fetus. These are going to be things that can be chemical,
radiation, drugs which is commonly seen, things like alcohol consumption, tetracycline, chemotherapy
agents, Dilantin, megavitamins which are very big now with holistic therapy, but megavitamins can do
this, lithium, tegratol, just any type of medication or substance should be considered a teratogen.

Also bacteria and viruses are teratogenic. For example, syphilis does not cross the placenta
really until after the 18th week, so we want to treat it as soon as we can. Later penicillin does not cross
the placenta, so earlier is better. With gonorrhea, that is a risk to baby for blindness. And then of course
the torch infections, toxoplasmosis, rubella, cytomegalovirus, and herpes, chlamydia.
 The main thing to remember here is with toxoplasmosis, we want to do education to avoid cat
feces, bird feces, and undercooked meat which are sources for toxoplasmosis. With rubella, we want to
determine early rubella immunity status, we will do a rubella titer. If the patient is not immune, when
will they be immunized? Remember they cannot be immunized with rubella because it is a live virus
until after delivery. And then they need to be sure not to become pregnant for at least three months
after immunization.

CMV or cytomegalovirus, remember it is part of that herpes family, can affect liver, brain, all
major organs. And then of course herpes simplex virus. The main thing here to remember is that
patients who have herpes simplex and have active lesions are not candidates for vaginal delivery. They
must be delivered by section. And of course with AIDS, key things here to remember is that it can be
transmitted by breast milk, so that is the population that we do not advise breastfeeding. It is
contraindicated, the one and only time that that would be contraindicated. There is a chance of
transmission during, in utero, but we have seen that that is greatly decreased and especially if the mom
is taking AZT.

So we move on now to talk about emotional and psychological adaptations to pregnancy. Look
at it from a developmental standpoint that each trimester has its own developmental needs or
stages. The first task of pregnancy in the first trimester is actually accepting the fact that the client is
pregnant. Ambivalence is a common finding in the first trimester, not to be considered pathological or
needing a psychiatric consult. It is considered a normal finding.

The second trimester is where the mom begins to accept the growing fetus as a person to be
nurtured. And then of course the third trimester, the focus shifts from that to preparing for birth and
parenting and safe passage for the baby.

Prenatal Care

A. Assessment

1. Complete history

2. Lab work: complete blood count (CBC), blood type and Rh, Rubella, VDRL/FTA-
ABS/RPR, hepatitis B surface antigen, HIV antibody (with client's consent), alpha
fetal protein (AFP)

3. Vital signs, weight, urine test for protein and glucose

4. Physical exam: fundal height, fetal heart rate (FHR), fetal activity

5. Internal exam

a. Adequate pelvic outlet, signs of pregnancy (First visit)

b. Cervical changes, especially in last weeks (for example: "ripe cervix")

c. Vaginal smear for Neisseria gonorrhea, chlamydia, group B strep, human

 papillomavirus (HPV) cultures, and pap test

6. Psychosocial assessment

B. Health Teaching

1. Nutrition

2. Discomforts

3. Danger signs (The nurse must be able to differentiate potential complications

from the normal discomforts or physical adaptations of pregnancy)

a. Bleeding

b. Rupture of membranes (ROM)

c. Contractions (Braxton-Hicks contractions usually go away when position

is changed)

d. Signs of pregnancy induced hypertension (P1H), toxemia

1. Edema of hands and face, sudden weight gain

2. Headache, blurred of vision, spots before eyes, dizziness

3. Decrease in urinary output

e. Burning on urination

f. Fever

g. Significant decrease in fetal activity

4. Childbirth education and alternative methods of birth

a. Read method (Grantly Dick-Read)

1. Natural childbirth

2. Abdominal breathing

3. Fear-tension-pain cycle

b. Lamaze method

1. Prepared childbirth

2. Labor coach

3. Chest breathing

c. Leboyer
 1. Birth without violence

2. Concerned with possible negative effect a traumatic birth can

have upon an infant

d. Birthing chairs

e. Alternate positions

f. Birthing rooms

g. Birthing centers

h. Delivery by midwife

i. Home births

5. Rest and exercise