INTRODUCTION A.

DEFINITION OF MCN OBSTETRICS - branch of medicine that deals with medical management of pregnancy parturition (labor and delivery) and puerperium (6 week period following childbirth). OBSTETRIX - meaning midwife or the person who "standby" (obstare) a woman during childbirth. OBSTETRICAL, NURSING - used, before but with evolution of broader terms it become MCN. MATERNAL NEWBORN NURSING Focuses in: a. ) perinatal nursing b.) parental nursing c.) care of the growing family B. THE MATERNAL NEWBORN NURSE 1. She should be a BSN or RN. 2.Should have the experience of delivering a baby because of that, all the crisis, labor contractions, that a pregnant mother has. 3. Knows how to empathize with feeling of joy, pain, fear, threat, hope, achievement, disappointment, satisfaction and terror. C. NURSING THEORY OF MCN One of the requirements of a professor is that the concentration of knowledge flow from a theoretical base. 1. How is the person who is to be nursed to be viewed. 2. What are the grams of nursing care. 3. What are the activities of nursing care that will meet these goals. D. PHILOSOPHY OF MCN 1. Pregnancy is a stress stance because it is a maturational crisis. It alters family life in both subtle and extensive way. 2. Not only to, adults and children have the right to be healthy, a newborn has the right to be born healthy.

3. The maternal newborn nurse serves as an advocate to protect the right of the fetus as well as the woman and the family. 4. Pregnancy, labor and delivery puerperium are part of a continuum of a total life cycle. They are meaningful only in the context of a total life. 5. Personal and cultural, religious attitudes and beliefs influence the meaning of pregnancy for individuals and make each experience unique. 6. Maternal newborn nursing is family centered. The father of the child is as important as the mother. 7. Maternal-newborn nursing is research oriented, always trying to achieve optimal health for woman and then fetuses/newborns. 8. Maternal newborn nursing is commonly centered the health of an individual is dependent on the health of the country. 9. MCN utilizes a high degree of independent nursing functions because teaching and counseling are such frequent implementations. 10. Maternal newborn nursing is a challenging role for the professional nurse and is a major contribution to promotion of a high level wellness in families. II. R E V I E W O F ANATOMY AND P H Y S I O L O G Y MALE REPRODUCTIVE ORGANS External genital organs of the male include the testes (which are encased in the scrotal sac) and the penis. 1 . Scrotum. a rugated, skin-covered, muscular pouch suspended from the perineum. -supports the testes and help regulate the temperature of sperm. -in very cold weather, the scrotal muscle contracts to bring the testes closer to the body -in very hot weather, or in the presence of fever, the muscle relaxes, allowing the testes to fall away from the body, making the temperature of the testes as even as possible to promote the production and viability of sperm.

BLOOD SUPPLY: -external pudendal branches of the of he femoral artery -scrotal branches of the internal pudendal artery NERVE SUPPLY: -anterior surface: ilioinguinal nerves and genital branch of the genitofemoral nerve -posterior surface: branches of the perineal nerves and the posterior cutaneous nerves of the thigh 2. Testes. -two ovoid glands, 2 to 3 cm wide, that lie in the scrotum. -each is encased by a protective white fibrous capsule and is composed of a number of lobules, each lobule containing interstitial cells (Leydig's cells) and a seminiferous tubule. -Seminiferous tubules: produce spermatozoa. -Leydig's cells : responsible for production of testosterone. -testes first form in utero in the pelvic cavity. -descend, late in intrauterine life (about the 34th to 38th week) into the scrotal sac thats why many male preterm infants are born with undescended testes. -testicular descent does not occur as readily in extrauterine life as it does in utero. - normal testes feel firm, smooth, and egg-shaped BLOOD SUPPLY: -testicular artery: a branch of the abdominal aorta NERVE SUPPLY: -femoral branch of the genitofemoral nerve 3. Penis. -composed of three cylindrical masses of erectile tissue in the penis shaft: -two dorsally placed:corpus cavernosa -single corpus spongiosum on the ventral surface -distally, the corpus spongiosum expands to form the glans penis which covers the distal ends of the corpora cavernosa. -prepuce (foreskin): hoodlike fold of skin that covers the glans -the urethra passes through these layers of erectile tissue, so the penis serves as the outlet for both the urinary and the

reproductive tracts in men. -with sexual excitement, nitric oxide is released from the endothelium of blood vesselsdilation of blood vessels increase in blood flow to the arteries of the penis engorgement contraction of ischiocavernosus muscle at the base of the penis trapping of both venous and arterial blood in the three sections of erectile tissue distention and erection of the penis. BLOOD SUPPLY: - penile artery, a branch of the pudendal artery NERVE SUPPLY: -dorsal nerve of penis, terminal branch of pudendal nerve - pelvic plexuses -penile erection is stimulated by parasympathetic nerve innervation. Male Internal Structures 1. Epididymis . -the seminiferous tubule of each testis leads to a tightly coiled tube, the epididymis. -tightly coiled, approximately 20 ft long. -responsible for conducting sperm from the testis to vas deferens, the next step in the passage to the outside -responsible also for absorption of fluid and addition of substances to the seminal fluid to nourish the maturing sperm -because the epididymis is so narrow along its entire length, infection of the epididymis can easily lead to scarring of the lumen that prohibits passage of sperm beyond scarred point. -it takes at least 12 to 20 days for them to travel the length of the epididymis, -total of 64 days for them to reach maturation BLOOD SUPPLY: -testicular artery: a branch of the abdominal aorta 2. Vas Deferens (Ductus Deferens) -an additional hollow tube surrounded by arteries veins and protected by a thick fibrous coating. -carries sperm from the epididymis through the inguinal canal the abdominal cavity, where it ends at the seminal vesicles and the ejaculatory ducts.

-blood vessels and vas deferens together are referred to as the spermatic cord -varicocele, or a varicosity of the internal spermatic vein can contribute to male infertility by causing congestion with increased warmth in the testes (Johnson, 2003 -Vasectomy (severing of the vas deferens) is a popular means of male birth control. BLOOD SUPPLY: -artery to the vas deferens 3. Seminal Vesicles -are two convoluted pouches that lie along the lower portion of the posterior surface of the bladder and empty into the urethra by way of the ejaculatory ducts. -secretes viscous portion of the semen, which has a high of a basic sugar, protein, and prostaglandins and is alkaline. -sperm become increasingly motile with this added because it surrounds them with nutrients and a more favorable pH. BLOOD SUPPLY: -inferior vesical and middle rectal arteries 4. Ejaculatory Ducts -the two ejaculatory ducts pass through the prostate gland and join the seminal vesicles to the urethra. 5. Prostate Gland -chestnut-sized gland that lies just below the bladder -the urethra passes through the center of it, like the hole in a doughnut. -secretes a thin, alkaline fluid that when added to the secretion from the seminal vesicles and the accompanying sperm from the epididymis, this alkaline fluid further protects sperm from being immobilized by the naturally low pH level of the urethra. -in middle life, many men develop hypertrophy of the prostate which interferes with both fertility and urination 6. Bulbourethral Glands -two bulbourethral or Cowper's glands lie beside the prostate gland and empty by short ducts into the urethra.

-secrete an alkaline fluid that helps counteract the acid secretion of the urethra and ensure the safe passage of spermatozoa. -Semen, therefore, is derived from the prostate gland (60%), the seminal vesicles (30%), the epididymis (5%), and the bulbourethral glands (5%). 7. Urethra -a hollow tube leading from the base of the bladder, which, after passing through the shaft and glans of the penis continues to the outside through the shaft and glans of the penis. -approximately 8 inches (18 to 20 cm) long FEMALE REPRODUCTIVE ORGANS A. EXTERNAL GENITALIA The female external genitalia is collectively known as the vulva or pudendum. This includes the mons pubis, the labia majora and minora, the clitoris, the bulb of the vestibule and the vestibule of the vagina, the urethra, the ducts of the paraurethral glands (of Skene) and vestibular glands. l . Mons veneris (pubis) -rounded, soft, fullness over the symphysis pubis. -covered with course dark hair during functional years and thins after menopause because ovarian hormones decline. 2. Labia Majora -two fatty tissue containing folds of skin that extend downward from the mons veneris around the external vaginal opening or introitus terminating in the perineum. 3. Labia Minora -narrow folds of skin and fibro-areolar tissue extending from the clitoris to the fourchette. - Fourchette: line of convergence of the labia majora and minora, the structure that is sometimes cut (episiotomy) during childbirth to enlarge the vaginal opening. 4. Clitoris -homologous to the penis; is a short erectile organ fixed just beneath the arc of the pubis, slightly above the urethral meatus.

-highly sensitive to temperature, touch and pressure sensation that may stimulate sexual arousal. -serves as a landmark in locating the urethral meatus for female catheterization. 5. Bulbs of the Vestibule -paired elongated masses of erectile tissue located at the sides of the vaginal orifice -each valve is homologue of half of the bulb of the penis and the posterior part of the corpus spongiosum 6. Urethral meatus -a pink, reddened, slit like opening marks the terminal or distal urethra. 7. Paraurethral Glands (Skene's Glands) -are two very short tubular structures. -situated posteriolaterally just inside the urethral meatus. -acute gonorrhea or other vulvovaginal pathogens may cause infection of this glands. -dysuria and few drops of pustular fluid may be expressed for culture and sensitivity. 8. Hymen -partial, elastic but tough mucosa covered septum in vaginal patients. -when complete vaginal obstruction by imperforate hymen may be associated with menstrual pain, amenorrhea, lower abdominal fullness. -after coitus, instrumentation or vaginal delivery, residual tags of hymen remains are called CARUNCULAE MYRTIFORMS. 9. Perineum - composed of-several muscles: a. transverse b. bulbocavernous c. sphincter ani externus d. levator ani c. perineal -these muscles, are interwoven and superimposed on each other. -their movements make possible for full dilatation of the birth canal during emergency of the fetus mid closure following delivery.

BLOOD SUPPLY OF THE VULVA: -internal and external pudendal arteries on each side and a portion of the inferior rectus artery NERVE SUPPLY OF THE VULVA: -anterior: ilioinguinal nerves and genital branch of the genitofemoral nerve -posterior: branches of the perineal nerves and the posterior cutaneous nerves of the thigh B. INTERNAL STRUCTURES 1. Vagina - thin walled, partially compressed musculofascial tube lined by a glandular mucous, membrane characterized by transverse rugae. -it extends from the introitus to the cervix and measures about 10 cm. In length and 14 cm. width. Vagina is situated between bladder and rectum. -the acid medium (pH 4-5) of the vagina tends to inhibit the growth of the organism and this acidity is maintained by the action of DODERLEINS BACILLI (a normal bacterial flora of the vagina) FUNCTIONS: 1. Passageway for the sperm's entrance to the uterus. 2. For copulation. 3. Passageway for menses. BLOOD SUPPLY: 1. Descending branches of uterine artery (upper part) 2. Middle hemorrhoidal artery (middle part) 3. Internal pudendal artery (lower part) NERVE SUPPLY: -uterovaginal plexus -Pain fibers travel with the sacral parasympathetic fibers and enter through S2-S4 nerves (Pudendal nerve and Hemorrhoidal nerve) 2. Uterus - hollow muscular organ shaped like a flattened pear. -located inside the true pelvis between bladder (anterior) and

the rectum (posterior), the weight of a non-pregnant uterus is approximately 60 gals. -M EASUREMENT S: Cervix - 2.5 cm. in length and the same width. Corpus - 5 cm. in length and width. Thickness - 2.5 cm. Total length - 7.5 cm. PARTS OF THE UTERUS I. Cervix - neck or mouth of the uterus is divided into: a. External os - small, round distal opening to the vagina but after childbirth it is transverse slit. -its level is at the level of the ischial spines (an important relationship in estimating the level of the fetus in the birth canal b. Internal os the opening of the canal at the junction of the cervix and isthmus c. Cervical Canal - space between external os and internal os, cervical glands (Naboth) produce a mucous known as operculum, a cervical plug that prevents ascending infection. 2. Isthmus - a constricted area immediately above the cervix which distends and softens during, pregnancy (Hegar's Sign) to form the lower uterine segment. -1-2 mm in length in non-pregnant state -the portion of the uterus that is most commonly cut during cesarean birth 3. Corpus - the body of the uterus, uppermost part and forms the bulk of the organ 4. Fundus - top portion of the uterus; highly contractile portion. -portion of the uterus between the points of attachment of the fallopian tube LAYERS OF THE UTERUS: 1. Perimetrium - layer of the peritoneum which covers the uterus except at the sides because the broad ligaments arises from the sides of the uterus. 2. Myometrium - middle layer made up of muscles gild has a very great expansile properties.

-consists of three layers: inner circular fibers, a thick intermediate layer and fibers that form the figure of eight surrounding the blood vessels and by constricting them act as a living ligature. -they arc times more plentiful at the fundus. 3. Endometrium - inner lining of the uterus made up of columnar epithelium, glands which produce an alkaline secretions, stroma capable of regeneration following menstruation. It is a rich source of prostaglandin, richly supplied with blood about 1.5 mm. In thick. - after implantation the endometrium is known as DECIDUA and after delivery it shed -off known as LOCHIA. POSITION OF THE UTERUS: ANTEVERSION: a condition in which the fundus is tipped forward RETROVERSION: a condition in which the fundus is tipped back ANTEFLEXION: a condition in which the body of the uterus is bent sharply at the junction with the cervix RETROFLEXION: a condition in which the body is bent sharply back just above the cervix -any of this position prevents uterine prolapsed. - extreme abnormal flexion or version positions may interfere with fertility because they may block the deposition or migration of sperm LIGAMENTS 1. Broad ligaments - is a double-fold peritoneum extending outwards from the uterus attached to the side walls of the pelvis. - the low portion of the broad ligament if thickened and strengthened with fascia, fibrous tissue and muscle to form the most important uterine support transverse cervical ligament, if overstretched and damaged during labor will cause the uterus to sag downwards. 2. Round Ligaments - arises from the cornua of the uterus, in front and below the insertion of the fallopian tubes then joins the folds of the broad ligaments then passes thru the inguinal canal and finally to the labia majora.

- it has a little support, but maintains the normal position of the uterus (anteversion). 3. Utero-Sacral Ligaments - consist of folds of peritoneum extending backward from the sides of the isthmus and attached to the sacrum. FUNCTIONS: l. Organ of Reproduction 2. Organ of Menstruation 3. It nourishes and protects the fertilized ovum for 40 weeks. 4. It expels the products of conception. BLOOD SUPPLY: -Uterine and Ovarian arteries. NERVE SUPPLY: -Efferent nerves from T5-T10 spinal ganglia -Afferent nerves: join the hypogastric plexus and enter the spinal column at T11 and T12 3. Fallopian tubes -smooth, hollow tunnel that arise from each upper corner of the uterine body and extend outward and backward until it opens at its distal end, next to an ovary -approximately 10 cm. in length -conveys the ovum fro the ovaries to the uterus and provides a place for fertilization of the ovum by sperm Four parts: 1. Interstitial portion - the most proximal division that lies within the uterine wall and opens into the uterine cavity -about 1 cm in length, the lumen of the tube is only 1 mm in diameter 2. Isthmus -extremely narrow and is approximately 2 cm. in length -the portion that is cut or sealed in a tubal ligation or tubal sterilization procedure 3. Ampulla -longest portion of the tube and is approximately 5 cm. in length and has relatively thin walls

-fertilization of ovum occurs 4. Infundibulum - most distal segment approximately 2 cm. long -funnel shaped with a number of irregular processes, the fimbriae, projecting out from its margins that helps guide the ovum into the fallopian tube -one of the longest fimbriae being in contact with the ovary to collect the mature ovum - Fimbriae Ovarica. FUNCTIONS: 1. Organ of fertilization 2. Transport eggs, sperm and zygote to the uterus. BLOOD SUPPLY: -Uterine and Ovarian arteries NERVE SUPPLY: -Inferior hypogastric plexus 5. Ovaries -two almond shaped glands on the posterior surface of the broad ligaments - freely movable, smooth, firm and slightly flattened ovoids -measurements:4 cm. long and 1.5 cm. thick PARTS a. Medulla - a supporting framework of connective tissue, blood vessels and nerves. b. Cortex - important Functioning part and is composed of germinal epithelium, stroma cells and grafian follicle. FUNCTIONS: 1. Release the matured ovum monthly (ovulation) only one ovum is released every month. -it happens exactly 14 days previous to the first day of the next menstrual period or by subtracting 14 days from the usual menstrual cycle then account one on the first day of bleeding. 2. Produces Estrogen and Progesterone. BLOOD SUPPLY: -Ovarian artery NERVE SUPPLY: -Aortic plexus

RELATED STRUCTURES BREAST -considered as accessory organs of reproduction. -composed of glandular, fibrous and adipose tissue. -about 15-20 lobes on each breast and each lobe is divided into several lobules each of which contains numerous acini, the cells that produces milk. BLOOD SUPPLY: -Thoracic branch of the axillary, intercostal and internal thoracic arteries. NIPPLE -a small cylindrical body which projects slightly from the center of each breast and is composed of erectile tissue which responds to tactile stimulation. The tip of the nipple is perforated with 15-20 small opening - LACTIFEROUS DUCTS. COLOSTRUM: a thin yellowish fluid composed of colostrum corpuscles, watery fluid and fat globules. -contains more protein but less fat and sugar than matured milk. -continuous to be secreted until about 3rd day post-partum ESTROGEN AND PROGESTERONE - inhibits the release of prolactin from the anterior pituitary gland, thus lactation is suppressed. OXYTOCIN - hormone from the posterior pituitary gland that stimulate expression of milk from the lactating breast - LETDOWN REFLEXES. Sounds of the infant crying may produce it. Fright, pain or emotional stress may inhibit it. MALE AND FEMALE REPRODUCTIVE ORGAN HOMOLOGUES MALE FEMALE Glans penis Clitoris Floor of penile urethra Labia minora Scrotum Labia majora Testes Ovary Prostate gland Paraurethral (Skenes) glands Bulbourethral (Cowpers) glands Bartholins glands

Gubernaculum testis

Round ligament of ovary/uterus

PELVIS -serves to support and protect the reproductive and other pelvic organs -a bony ring formed by four united bones: Bones of the Pelvis: 1. Right and Left Innominate Bones (Flaring hip bones) -forms the anterior and lateral portion of the ring - each of which is made up of right and left pubic bones, ilium and ischium. a. ilium forms the upper and lateral portion, the flaring superior border forms the prominence of the hip (crest of the ilium) b. ischium: the inferior portion -ischial tuberosity- two projections at the lowest portion of the ischium upon which a person sits, markers to determine lower pelvic width -ischial spines-small projections that extend from the lateral aspects into the pelvic cavity, marks the midpoint of the pelvis c. pubis: the anterior portion -symphysis pubis-junction of the innominate bones at the front of the pelvis 2. Sacrum -forms the upper posterior portion of the pelvic ring - the wedge bone at the back of the pelvis. - SACRAL PROMINENCE :marked anterior projection where it touches the lower lumbar vertebrae; serves as the landmark for the pelvic measurements. 3. Coccyx -composed of five very small bones fused together located below the sacrum -Sacrococcygeal joint: the degree of movement permits the coccyx to be pressed backward, allowing more room for the fetal head as it passes through the bony pelvic ring at birth For obstetric purposes, the pelvis is further subdivided by an imaginary line, the linea terminalis drawn from the sacral prominence

at the back of the pelvis to the superior aspect of the symphysis pubis at the front of the pelvis into: 1. False Pelvis (superior half) - shallow upper part if the pelvis that supports the uterus during the late months of pregnancy - aids in directing the fetus into the true pelvis for birth 2. True pelvis (inferior half) - lower, smaller but deeper part of the pelvis that must be adequate for the delivery process. -lies below the linea terminalis. -is also known as the bony birth canal. Other terms: a. Inlet - entrance to the true pelvis - it is at the level of the linea terminalis and is marked by the sacral prominence in the back, the ilium on the sides and the superior aspect of the symphysis pubis in the front - its transverse diameter is wider than its anteroposterior diameter. Thus-: Transverse diameter = 13.5 cm Anteroposterior diameter = 11 cm. Right and Left oblique diameter = 13.75 cm b. Pelvic cavity - space between the inlet and outlet -curved not a straight passage -the curve slows and controls the speed of birth reducing sudden pressure changes in the fetal head which might rupture cerebral arteries -also compresses the chest of the fetus which helps to expel lung fluid and mucus preparing the lungs for good aeration after birth c. Outlet -inferior portion of the pelvis, bounded in the back by the coccyx, on the sides by the ischial tuberosities and in front by the inferior aspect of the symphysis pubis and the pubic arch. -its anteroposterior (AP) diameter is wider than its transverse diameter. Types/Variations of the Pelvis 1. Gynecoid -- "normal" female pelvis - Inlet is well rounded forward and back -most ideal for childbirth.

2. Anthropoid -transverse diameter is narrow , AP diameter is larger than normal. 3. Platypelloid - inlet -has a oval, AP diameter is shallow. 4. Android -- "male" pelvis. - inlet has a narrow, shallow posterior portion and pointed anterior portion. Measurements 1. External - suggestive only of pelvic size. a. Intercristal = distance between the middle points of the iliac crests. Average = 28 cm b. Interspinous = distance between the anterosuperior iliac spines. Average = 25 cm. c. lntertrochanteric = distance between ft trochanters of the femur. Average = 31 cm. d. External conjugate / Bandelocque's = the distance between the anterior aspect of the symphysis pubis and depression below L5. Average =18-20 cm. 2. Internal - gives the actual diameter of the inlet and outlet a. Diagonal conjugate: distance between sacral promontory and inferior margin of the symphysis pubis. Average =12.5 cm. b. True conjugate/ conjugate Vera : distance between the anterior surface of the sacral promontory and the superior margin of the symphysis pubis. -very important measurement because it is the diameter of the pelvic inlet. Average = 1 0 . 5 - 1 1 cm. c. Biischial diameter/tuberischli: transverse diameter of the pelvic outlet. -measured at the level of the anus. Average = 11 cm. Tanners Rating Scale of Sexual Maturity (see appendix) NEUROENDOCRINOLOGY OF REPRODUCTION OOGENESIS begins during the fetal stage of the female where the oogonia enters the process of meiosis and begins the 1

S phase. at the age of puberty, the hormone gonadotropinreleasing hormone (GnRH) is secreted by the hypothalamus which stimulates the anterior pituitary gland to release follicle stimulating hormone (FSH). FSH stimulates the follicle to begin growing and maturing. another hormone from the pituitary called luteinizing hormone (LH) stimulates the developing follicle to produce estrogen. maturation of a follicle involve the development of follicle cells and changes in the primary oocytes. it completes stage 1 of meiosis then secondary oocytes will develop the mature egg cell (ovum), and the remaining cell forms the functionless polar body that divides to two cells that degenerates. Secondary oocytes enter stage II of meiosis and stop at metaphase and the LH stimulates this development and secondary oocytes is called (ovum). mature follicles takes about 14 days and this is called Graafian Follicle. egg cell exist within a cavity called the antrum and is surrounded by supporting cells the corona radiata. after maturation, a surge of LH stimulates and release of the egg cell from the follicle which is ovulation and the mature egg cell is released into the pelvic cavity.

SPERMATOGENESIS before puberty the testes remain relatively simple and unchanged from the time of their initial development. interstitial cells are not particularly prominent during this period, and the seminiferous tubules lack a lumen and are not yet functional. At 12 to 14 years of age, the interstitial cells increase in number and size, a lumen develops in each seminiferous tubule, and sperm cell production begins. the seminiferous tubules contain two types of cells,

germ cells and sertoli cells. Sertoli cells are also sometimes referred to as sustentacular cells or nurse cells. Sertoli cells are large cells that extend from the periphery to the lumen of the seminiferous tubule o nourish the germ cells and probably produce, together with the cells of Leydig, a number of hormones such as androgens; estrogens, and inhibins. o form a blood-testes barrier, which isolates the sperm cells from the immune system. o barrier is necessary because, as the sperm cells develop, they form surface antigens that could stimulate an immune response, resulting in their destruction. Testosterone, produced by the cells of Leydig, passes into the Sertoli cells and binds to receptors. combination of testosterone with the receptors is required for the Sertoli cells to function normally. testosterone is converted to two other steroids in the Sertoli cells: dihydrotestosterone and estradiol. The Sertoli cells also secrete a protein called androgenbinding protein into the seminiferous tebule. Testosterone and dihydrotestosterone bind to the androgen-binding protein and are carried along with other secretions of the seminiferous tubule to the epididymis. estradiol and dihydrotestosterone may be the active hormones, that promote sperm cell formation. Scattered between the Sertoli cells are smaller germ cells from which sperm cells derived. The germ cells are arranged according to maturity from the periphery to the lumen of the seminiferous tubules. The most peripheral cells, adjacent to the basement membrane of the sem Some of the daughter cells produced from these mitotic divisions remain spermatogonia and continue to produce additional spermatogonia.

 The others divide through mitosis and differentiate to form primary spermatocytes. Meiosis begins when the primary spermatocytes divide. Primary spermatocytes pass through the first meiotic division to become two secondary spermatocytes. Each secondary spermatocyte undergoes a second meiotic division to produce two even smaller cells called spermatids. Each spermatid undergoes the last phase of spermatogenesis to form a sperm cell or spermatozoon. Each spermatid develop a head and a tail. The head contains chromosomes, and at the leading end it has a cap, the acrosome, which contains enzymes necessary for the sperm cell to penetrate the oocyte (female sex cell). The flagellum is similar to a cilium, and movement of microtubules past each other causes the tail to move and propel the sperm cell forward. The middle piece has large numbers of mitochondria, which produce the adenosine triphosphate necessary for microtubule movement. At the end of spermatogenesis, the developing sperm cells gather around the lumen of the seminiferous tubules with their heads directed toward the surrounding Sertoli cells and their tails directed toward the center of the lumen. Finally, sperm cells are released into the lumen of the seminiferous tubules. MITOSIS absolutely essential to life because it provides new cells for growth and for replacement of worn-out cells. Mitosis may take minutes or hours, depending upon the kind of cells and species of organisms a process of cell duplication, or reproduction, during which one cell gives rise to two genetically identical daughter cells. All cell of the body, except those that give rise to sex cells, divide by mitosis.

 Mitosis involves two steps: (1) the genetic material within a cell is replicated, or duplicated, and (2) the cell divides to form two daughter cells with the same amount and type of DNA as the parent cell. Strictly applied, the term mitosis is used to describe the duplication and distribution of chromosomes, the structures that carry the genetic information. Prior to the onset of mitosis, the chromosomes have replicated and the proteins that will form the mitotic spindle have been synthesized. PROPHASE Mitosis begins at prophase with the thickening and coiling of the chromosomes. The nucleolus, a rounded structure, shrinks and disappears. The end of prophase is marked by the beginning of the organization of a (group of fibres to form a spindle and the disintegration of the nuclear membrane. METAPHASE The chromosomes, each of which is a double structure consisting of duplicate chromatids, line up along the midline of the cell. ANAPHASE Each chromatid pair separates into two identical chromosomes that are pulled to opposite ends of the cell by the spindle fibres. TELOPHASE The chromosomes begin to decondense, the spindle breaks down, and the nuclear membranes and nucleoli re-form. The cytoplasm of the mother cell divides to form two daughter cells, each containing the same number and kind of chromosomes as the mother cell. INTERPHASE The stage, or phase, after the completion of mitosis by time of day, temperature, and chemicals.

MEIOSIS Also called Reduction Division, division of a germ cell involving two fissions of the nucleus and giving rise to four gametes, or sex cells, each possessing half the number of chromosomes of the original cell. Sperm cell development and Oocyte development involve meiosis. This kind of cell division occurs only in the gonads. Consists of two consecutive nuclear divisions without a second replication of the genetic material between the divisions. Four daughter cells are produced, and each has half as many chromosomes as the parent cell. The normal chromosome number in human cells is 46. This number is called a diploid or a 2n number of chromosomes. T The chromosomes consist of 23 pairs. Each pair of chromosomes is called a homologous pair. One chromosome of each homologous pair is from the male parent, and the other is from the female parent. The chromosomes of each homologous pair look alike, and they contain genes for the same traits. In sperm cells and oocytes the number of chromosomes is 23 called a haploid or n number of chromosomes. Each gamete contains one chromosome from each of the homologous pairs. Reduction of the number of chromosomes in sperm cells or oocytes to an n number is important. When a sperm cell and an oocyte fuse to form a fertilized egg, each provides an n number of chromosomes, which reestablishes a 2n number of chromosomes. If meiosis did not occur, each time fertilization occurred the number of chromosomes in the fertilized oocyte would double. The extra chromosomal material would be lethal to the developing offspring. The two divisions of meiosis are called meiosis I and

meiosis IL The stages of meiosis have the same names as these stages in mitosis, that is, prophase, metaphase, anaphase, and telophase DIFFERENCES BETWEEN MEIOSIS AND MITOSIS Before meiosis begins, all the deoxyribonucleic acid in the chromosomes is duplicated. At the beginning of meiosis each of the 46 chromosomes consist of two sister chromatids connected by a centromere. In prophase of meiosis I the chromosomes align with their homologous pairs near the middle of the cell a process is called synapsis. Because each chromosome consists of two chromatids, the pairing of the homologous chromosomes brings two chromatids of each chromosome close together, an arrangement called a tetrad. Occasionally part of a chromatid of one homologous chromosome breaks off and is exchanged with part of another chromatid from the other homologous chromosome of the tetrad. This exchange of genetic material is called crossing over which allows the exchange material between maternal and paternal chromosomes. During synapsis homologous pairs of chromosomes line up near the center of the cell undergoing meiosis. However, for each pair of homologous chromosomes, the side of the cell on which the maternal or paternal chromosome is located is random. The way the chromosomes align during synapsis results in the random assortment of maternal and paternal chromosomes in the daughter cells during meiosis. Crossing over and the random assortment of maternal and paternal chromosomes are responsible for the large degree of diversity in the genetic composition of sperm cells and oocytes produced by each individual.

 During anaphase I the homologous pairs are separated to each side of the cell. As a consequence, when meiosis I is complete, each daughter cell has one chromosome from each of the homologous pairs. Each of the 23 chromosomes in each daughter cell consists of two chromatids joined by a centromere. It is during the first meiotic division that the chromosome number is reduced from a 2n number (46 chromosomes or 23 pairs) to an n number (23 chromosomes or one from each homologous pair). The first meiotic division is therefore called a reduction division. The second meiotic division is similar to mitosis. The chromosomes, each consisting of two chromatids, line up near the middle of the cell. Then the chromatids separate at the centromere, and each daughter cell receives one of the chromatids from each chromosome. When the centromere separates, each of the chromatids is called a chromosome. Consequently, each of the four daughter cells produced by meiosis contains 23 chromosomes. HYPOTHALAMIC-PITUITARY-OVARIAN/TESTICULAR AXIS Gonadotropin-Releasing Hormone The hypothalamic hormone that controls the gonadotropic function of the anterior pituitary Synthesized by highly specialized neurosecretory cells within the hypothalamus concentrated mainly in two areas: anterior hypothalamus and the medial basal hypothalamus The greatest number of GnRH-producing neurons are found in the arcuate nucleus of the medial basal hypothalamus Major route of transport of GnRH: tuberoinfundibular tract Secreted from the hypothalamus in a pulsatile manner Responsible for the release of FSH and LH GnRH secretion is regulated by: a. the stimulatory effect and inhibitory feedback effects of the ovarian steroid hormones estradiol and progesterone

b. the inhibitory feedback effects of the gonadotropins, FSH and LH c. inhibition of GnRH synthesis by GnRH itself d. several neurotransmitters Dopamine: inhibits the release of GnRH; Norepinephrine stimulates its release)and neuromodulators (-endorphin level is increased by estrogen and progesterone, thus a decreased frequency of GnRH pulses in the luteal phase; Prostaglandin E2 increases GnRH levels in the portal blood) GnRH stimulates the release synthesis, storage and release of both LH and FSH Gonadotropic hormones Involved mainly in ovarian functions Follicle Stimulating Hormone (FSH) Receptors for FSH exist primarily on the cell membrane of granulosa cells of the ovarian follicle Stimulates follicular growth Luteinizing Hormone Receptors for LH exist on the theca cells at all stages of the menstrual cycle and on the granulosa cells after the follicle matures as well as on the corpus luteum Main action: stimulates androgen synthesis by the theca cells and progesterone synthesis by the corpus luteum Also stimulates prostaglandin synthesis by intracellular production of cAMP Estrogen responsible for breast and uterine development. genital enlargement. softens connective tissue decreases HCL, and pepsin. antagonist to insulin (to make glucose available for the fetus) support fat deposition. sodium and water retention. vasodilation. increase production of melanin stimulating hormone

Progesterone development of decidua promotes relaxation of the uterine muscles favors fat deposition decreases gastric motility relaxes sphincters decreases smooth muscle tone (bladder, colon, ureter, veins, gallbladder) increases BBT Testosterone MENSTRUAL CYCLE Episodic uterine bleeding in response to cyclic hormonal changes Cyclic monthly changes in ovaries and endometrium in preparations for ovulation. Menstruation - monthly shedding off uterine lining in response to drop in estrogen and progesterone level. Purpose: to bring an ovum to maturity and renew a uterine tissue bed that will be responsible for its growth should it be fertilized. Fertilization and implantation regulated by the HYPOTHALAMUS AND ANTERIOR PITUITARY GLAND via feedback mechanism. MENARCHE first menstrual period in girls, may occur as early as 9 years old or as late as 17 years of age Normal Menstrual Cycle: 25-35 days, average of 28 days. Length/Duration: 4 to 6 days, as short as 2 days or as long as 7 days Average amount of blood loss 70 ml. Characteristic of normal menstrual cycle Characteristic Description Beginning (Menarche) Average age at onset, 1113 years; average range, 917 years Interval between cycles Average, 28 days. Cycles of 23-35 days not unusual

Duration of menstrual flow Amount of menstrual flow

Color of menstrual flow Odor

Average flow, 2-7 days; ranges of 1-9 days not abnormal Difficult to estimate; average 30-80 mL per menstrual period; saturating pad or tampon in less than an hour is heavy bleeding Dark red; a combination of blood, mucus and endometrial cells Similar to that of marigolds

HYPOTHALAMUS (GnRH) FSH ---- Anterior Pituitary Gland ----L.H. Graafian Follicle (Estrogen) --- OVARIES Corpus luteum (Progesterone) ENDOMETRIUM MENSTRUAL PROLIFERATIVE SECRETORY 1 - 1- 3 day 6 13 15 21 25 PROLIFERATIVE/FOLLICULAR/ESTROGENIC/POST MENSTRUAL OR PRE-OVULATORY PHASE. Immediately after a menstrual flow (occurs during the 4 or 5 days of a cycle), the endometrium of the lining of the uterus is very thin, approximately one cell layer in depth the serum level of estrogen is very low and this serves as stimulus for the hypothalamus to produce the follicle-stimulating hormone releasing factor. This factor stimulates anterior pituitary gland to produce the first hormone from the anterior pituitary glands.

 The FOLLICLE STIMULATING HORMONE (FSH) which will act on one primary follicle containing immature oocyte by stimulating it's growth. Growth of this follicle increases the amount of estrogen production, and once estrogen is present in this primary follicle it is now formed GRAFIAN FOLLICLE which contains the highest level of estrogen. This increasing estrogen will cause the endometrial cells to (proliferate) grow rapidly and thickens about eightfold This increase continues for the first half of the menstrual cycle (day 5-14) OVULATION On the 13th day of menstrual cycle; there is now a very low serum level of progesterone. This stimulates the hypothalamus to produce luteinizing hormone releasing factor. This factor is responsible for stimulating the anterior pituitary glands to produce the second APG hormone called luteinizing hormone, which in turn stimulate the ovary to produce progesterone. Now, the estrogen and progesterone are increased in amount, the already matured ovum is push to the surfaces of the ovary until on the next day (Day 14 of menstrual cycle) the graafian follicle ruptures releasing the ovum, a process termed OVULATION. Ex. Situation: The first day menstruation is July 15. Count 14 days backward that is her previous day of ovulation. It is taken by subtracting 14 from her usual cycle, then count the -first day of bleeding as day one. Menstrual Cycle - 28 days - 14, so her next ovulation is July 28. SIGNS AND SYMPTOMS OF OVULATION 1. Basal body temperature slightly increase 0.2-0.5 C on the day following ovulation preceded by sudden drop. 2. Cervical mucous under the influence of estrogen is favorable to spermatozoa. -Fern test: with high levels of estrogen, cervical mucus forms fernlike patterns when placed on a glass slide and

allowed to dry : caused by crystallization of sodium choride on mucus fibers known as arborization or ferning - Spinnbarkeit Test: with high levels of estrogen, the cervical mucus becomes thin and watery and can be stretched into long strands : can be done by stretching a mucus sample between thumb and finger or by smearing cervical mucus specimen on a slide and stretching the mucus between the slide an cover slip 3. Midmenstrual pain (Mittleschmers pain). 4. Breast tenderness (least dependable sign of ovulation). Ovulation is suppressed by pregnancy and oral contraception. SECRETORY OR PROGESTATIONAL OR LUTEAL OR POST-OVULATORY PHASE OF PREMENSTRUAL PHASE. After ovulation, the ruptured graafian follicle because it now contains large amounts of progesterone, giving it a yellowish appearance (yellow body) called CORPUS LUTEUM - which contains the highest level of progesterone . This hormone causes endometrial glands, capillaries increase in amount to make the uterus favorable for the implementation, by a fertilized ovum. Glands of the uterine endometrium become corkskew or twisted in appearance and dilated with quantities of glycogen and mucin. Capillaries increase in amount until the lining takes on the appearance of rich, spongy velvet ISCHEMIC PHASE If no fertilization takes place, the corpus luteum in the ovary begins to regress after 8-10 days Estrogen and progesterone decreases With withdrawal of progesterone, the thickened endometrium will slough off, capillaries rupture with minute hemorrhages Corpus luteum now become CORPUS ALBICANS (WHITE BODY).

MENSES The following products are discharged: -blood from ruptured capillaries -mucin from the glands -fragments of endometrial tissue -the microscopic, atrophied and unfertilized ovum Iron loss in typical menstrual flow: 11 mg FACTORS THAT lNFLUENCE THE ONSET OF MENARCHE: a. Nutrition b. Climate c. Heredity d. Diseases MENOPAUSE permanent cessation of menstrual flow between 40-55 years of age. Age of menarche and the age of menopause tend to be familial Women refer to this period as a change of life Can produce stress especially if it will result in osteoporosis and hot flushes HUMAN SEXUALITY Multidimensional phenomenon that includes feelings, attitudes and actions Encompasses and gives direction to a persons physical, emotional and social and intellectual responses throughout life refers to person's maleness or femaleness, it includes sexual feelings, attitudes and actions. Biologically inherited and culturally learned. Gives direction to totality of a person.

HUMAN SEXUAL RESPONSE Stages of Sexual Responses PHASE MALE FEMALE

BOTH

1. EXCITEMENT -physical and psychological stimulation (sight, sound, emotion or thought) that causes parasymphatetic nerve stimulation -leads to arterial dilation and venous constriction in the genital area 2. PLATEAU

-penile erection -scrotal thickening and elevation of the testis -

-clitoris -increase in increase in size BP, HR and -appearance of RR mucoid fluid on vaginal walls as lubrication -vagina widens in diameter and increases in length

-full distention of the penis

3. ORGASM -occurs when stimulation proceeds through the plateau stage to a point at which the body suddenly discharges accumulated sexual tension -vigorous muscle

-muscle contraction surrounding the seminal vesicle and prostate project semen into the proximal urethra -followed immediately by

-clitoris is HR: 100 to drawn forward 175 bpm and retracts RR: 40 cpm under clitoral prepuce -lower part of vagina becomes extremely congested (formation of orgasmic platform) -increased nipple elevation -Average: 8-15 contractions at intervals of 0.8 seconds

contraction in pelvic area -vary greatly from person to person

4. RESOLUTION -period where external and genital organs return to an unaroused state

3 to 7 propulsive ejaculatory contractions occurring at the same time interval as the woman with force semen from the penis -occurs during which further orgasm is impossible

-do not undergo through this period -can have additional orgasm immediately after the first

INFLUENCE OF THE MENSTRUAL CYCLE -during the luteal phase of menstruation there said to be an increase in since there's vasocongestion in the woman's lower pelvis which makes her more ready for plateau and orgasm. INFLUENCE OF PREGNANCY 1 st Trimester - increase in urge for sex due to the physiologic changes to patient. 2nd Trimester - increase in libido due to vasocongestion in the lower pelvis and breast, increase in oxytocin. 3rd Trimester - increase in libido due to preoccupation and fear of labor and delivery. . PEAK SEXUAL RESPONSE male's sexual response is at peak during his late teen years. female's peak sexual response is on her late 30s because male are sexually oriented first than female. BIOLOGIC GENDER - chromosomal sexual development - male (XY) and female (XX)

GENDER/SEXUAL ID ENTITY - inner sense a person has of being a male or a female - sex a person thinks of himself - maybe the same or different from biologic gender -develops throughout the entire lifespan GENDER ROLE -male or female behavior a person exhibits - activities of a person undertakes - maybe the same or different from biologic gender or gender identity -culturally influenced -more interchangeable nowadays PRENATAL SEX DETERMINATION - starts @ 12 weeks of intrauterine life. - (+) Wolffian duct - male - (+) Mullerian duct - female * concepts, questions or inquiries about sex differs or vary with age. DEVELOPMENT OF GENDER IDENTITY Infant -female and male are treated differently by their parents - by the end of one year, babies differ in plays. Pre-schoolers - can distinguish between male and female as early as 2 years of age -by 3 or 4, can say what sex they are -have absorbed cultural expectations of the sex role -sex role modeling is reinforced through behavior toward and expectations of the child (room color and dcor) -social contacts between the child and significant others contribute to sexual identification and should be encouraged -Boy- Oedipus complex -Girl- Electra complex School Age

-spend play time imitating adult roles as a way of learning gender roles - influenced by school and by teachers dominance Adolescents - establishing as sense of identity begins -problem of final gender role identification surfaces again -maintain strong ties to their gender group -some choose a child of their own gender a few years older than themselves to use as their model of gender role behavior Young Adults -many young adults marry with a commitment to one sexual partner -others establish relationships that are less binding by legal definitions but equally binding in concern and support - Homosexuality or bisexuality may be overtly expressed for he first time Middle Age Adult -sexuality has achieved a degree of stability -a sense of masculinity and femininity and comfortable patterns of behavior have been established -increased security promotes greater intimacy in sexual and social relationships -both men and women reexamine life goals, careers, accomplishments, value systems, familial and social relationships which can negatively and positively affect an individuals gender identity and sexuality Older Adults -both sexes need to follow safer sex practices throughout life -males remain fertile and must continue to be responsible sex partners in terms of reproductive planning -older women may have less vaginal secretions due to decreased estrogen after menopause (use of water-soluble lubricant before sexual intercourse may enhance their comfort and enjoyment)

The Individual Who Is Physically Challenged -have the same desires and needs as others do -but can have difficulty with sexual identity and fulfillment due to the effects of their condition SEXUAL ORIENTATION Heterosexuality - one who finds sexual fulfillment with a member of the opposite gender Homosexuality -a person who finds sexual fulfillment with a member of his or her own sex -Gay: homosexual men -Lesbian: homosexual women Bisexuality -a person who achieves sexual satisfaction from both heterosexual and homosexual relationship Transsexuality -a transsexual or transgender person is an individual who, although of one biologic gender, feels as if he or she should be of the opposite gender -may have sex change operations so that they appear cosmetically as the sex they envision themselves to be SEX ROLES AND PARENTING - the kind of parenting a child receives affects the sex roles he/she assumes and eventually will adapt into this as his kind of parenting also. REPRODUCTIVE LIFE PLANNING The use of technologies -n reproductive life planning affects the sexual response of an individual. E.g. pills with its estrogen (excess) decreases one's libido. TYPES OF SEXUAL EXPRESSIONS Celibacy -abstinence from sexual activity -the avowed state of certain religious orders Masturbation - self stimulation for erotic pleasure.

- offers sexual release, which may be interpreted by the person as overall tension or anxiety relief -children 2-6 years of age discover it as an enjoyable activity as they explore their bodies and can use it as a means of falling sleep at night or at naptime -school-age children continue to use masturbation for enjoyment or to relieve tension but perform such activities in private Erotic Stimulation - use of visual materials such as magazines or photographs for sexual arousal - known to be as male phenomenon Fetishism -sexual arousal resulting from use of certain objects (leather, rubber, shoes) or situations -the object of stimulation becomes the focus of arousal Transvestism - a transvestite is an individual who dresses to take on the role of the opposite sex -can be homosexual, heterosexual or bisexual Voyeurism -obtaining sexual arousal by looking at another persons body Sadomasochism -involves inflicting pain (sadism) or receiving pain (masochism) to achieve sexual satisfaction -Autoerotic asphyxia: extreme practice of causing oxygen deficiency (usually by hanging) during masturbation with the goal of producing extreme sexual excitement Exhibitionism -revealing ones genitals in public Pedophilia -pedophiles are individuals who are interested in sexual encounters with children SEXUALITY PROBLEMS Physical Illness - presence of any illness of the person may likely affect response of patient. E.g. obese =(-) deep penetration Erectile Dysfunction/Impotence

- inability to achieve and maintain an erection; said to be psychological or due to drug dependence. Management: Surgical implants to aid erection. Psychological block -by sexual counseling. Premature Ejaculation - ejaculation prior to penile-vaginal contact before sexual partner's satisfaction. -female can't achieve orgasm due to (-) erection. - known to be psychological. Management: Serotogernic anti-depresssants Sexual counseling for both partners Vaginismus - involuntary contraction of the muscle at the outlet of the vagina when coitus is attempted. - sexual or psychological counseling reduces this response Dyspareunia - pain during coitus Vestibulitis - inflammation of the vestibule - can occur due to endometriosis, vaginal infection or hormonal changes (menopause) causing vaginal drying HEALTH PROMOTION IN THE ANTEPARTAL PERIOD Physiology of Conception FERTILIZATION: The Beginning of Pregnancy Also referred to as conception, impregnation or fecundation union of the sperm and ovum, usually occurs 1?-14 hours following ovulation within the outer 1/3 of the fallopian tube, the ampulla. SPERM - male gamete - functional life: 48-72 hours - 3-5 cc of semen in every ejaculation containing 50200 million spermatozoa/mL -average of 400 million/ejaculation

- process of maturation: SPERMATOGENESIS - number of chromosomes is 23 (22 are autosomes and one sex chromosome X or Y). -An X carrying sperm produces a baby boy (XY), thus, the father determines the sex of the baby -spermatozoa deposited in the vagina during intercourse reach the cervix within 80 seconds and the outer end of a fallopian tube within 5 minutes -spermatozoa move by means of their flagella (tails) toward an ovum -Capacitation: final process that sperm must undergo to be ready for fertilization, consists of changes in the plasma membrane of the sperm head, which reveal the sperm-binding receptor sites -all of spermatozoa that achieve capacitation reach the ovum and cluster around the protective layer of corona cells. -Hyaluronidase (a proteolytic enzyme) is released and dissolve the layer of cells protecting the ovum - Only one spermatozoon is able to penetrate the cell membrane of the ovum and once it penetrates, the cell membrane changes composition to become impervious to other spermatozoa OVUM - female gamete - 6 million follicles in the two gonads at 7th month of intrauterine life -about 2 million survive to reach neonatal life -Menarche: 400, 000 viable follicles - one ovum is released every month -age 40-44: 8000 primordial follicles left - process of maturation: OOGENESIS - life span after ovulation is 12-24 hrs. - number of chromosomes 23 (22 are autosomes and 1 sex chromosome X.) - ovum extruded from a graafian follicle is surrounded by a ring of mucopolysacharride fluid (zone pellucida) and a circle of cells (corona radiata)

-ovum is propelled into the fallopian tube by currents initiated by the fimbriae -combination of peristaltic action of the tube and movements of the tube cilia propel the ovum to the length of the tube 72 hours :the critical time span during which sexual relations must occur for fertilization to be successful (48 hrs before ovulation and 24 hrs afterward) ZYGOTE: the product of the union of ovum and sperm. - chromosomal material of the ovum and sperm fuse = 46 chromosomes IMPLANTATION Contact between the growing structure and the uterine endometrium which occurs approximately 8-10 days Once fertilization is complete, zygote travels into the uterine cavity for the next 3-4 days while undergoing changes through mitotic cell division or cleavage. The first cleavage begins at about 24 hours and continue to occur at a rate of one about every 22 hours Zygote subdivides into two daughter cells, four, eight and this form is called BLASTOMERE Blastomeres contains 16 daughter cells this form is called MORULA (from the Latin word, morus, meaning mulberry), with bumpy outside appearance Morula reaches the uterine cavity with about 50 daughter cells Morula continues to float freely in the uterine cavity for 3 or 4 more days Large cells will arrange themselves along the side (periphery) of the ball, leaving a fluid space surrounding an inner cell mass. This structure is called BLASTOCYST (the one that attaches to the uterine endometrium) Trophoblast cells: cells in the outer ring which will later form the placenta and membranes Embryoblast cells: inner cell mass that will form the embryo

 After 3 to 4 days of floating, the last residues of the corona radiata and and zona pellucida are shed by the growing structure Apposition : the process where the blastocyst brushes against the rich uterine endometrium Adhesion: blastocyst attaches to the surface of the endometrium Invasion: blastocyst settles down into the soft folds of the endometrium which allows it to burrow deeply and receive nourishment of glycogen and mucoprotein from the endometrial glands Implantation occurs in the upper part of the posterior wall of the uterus If low, it will occlude the cervix and make birth difficult (placenta previa) Once implanted, the zygote is an embryo and the endometrium, decidua DEVELOPMENT OF THE PRODUCTS OF CONCEPTION Embryonic and Fetal Structures DECIDUA Comprises three parts: a. decidua basalis part of the endometrium that lies directly under the growing embryo and forms the placenta. - the portion where the trophoblast cells are establishing communication with maternal blood vessels b. decidua capsularis - part of the endometrium that stretches or encapsulates the surface of the trophoblast c. decidua vera remaining portion of the uterine lining CHORIONIC VILLI After implantation, the trophoblastic layer of cells mature rapidly miniature villi or probing fingers that reach out from the single layer of cells into the uterine endometrium on the 11th to 12th day At term, almost 200 villi is formed Central core of loose connective tissue contains fetal

capillaries Outer layer, syncytiotrophoblast produces the placental hormones (human chorionic gonadotropin (hCG), human placental lactogn (hPL), estrogen and progesterone) Inner layer: cytotrophoblast (Langhans layer) is present as early a 12 days gestation and protects the growing embryo and fetus from infectious organisms e.g. spirochete of syphilis (disappears by 20th to 24th week) PLACENTA Latin for pancake which is descriptive of its size and appearance at term Arises out of the trophoblast tissue Develops from the union of the chorionic villi and decidua basalis Begins to form on the eight weeks of gestation From few identifiable cells to an organ 15 to 20 cm in diameter, 500 grams in weight and 2 to 3 cm in depth and has about 10 to 38 cotyledons separated by placental septa at term Generally located in the uterus anteriorly and posteriorly near the fundus Two Surfaces of the Placenta: 1. Maternal Surface - made up of chorionic villi arranged like meat lobe- called COTYLEDONS. - Bluish-red in color, rough, irregular in shape. 2. Fetal Surface - smooth, white and shiny and it can be seen branches of blood vessels and the insertion of the umbilical cord. - it is covered by two membranes: a.) Chorion: tough, opaque outer membrane. b.) Amnion - smooth, shiny, transparent inner membrane. -these two membranes are continued beyond its edge to form the sac that contains fluids. FUNCTIONS: 1. Nutritive - proteins, glucose, calcium and phosphorous, vitamins, electrolytes, irons, minerals are needed to the fetus for growth and development.

2. Respiratory - fetus obtains oxygen from the mother's hemoglobin by simple diffusion and gives off carbon dioxide into the maternal blood. 3. Excretory- removal of the waste products as a results of catabolic processes. 4. Endocrine - placenta produces hormones: a. Human Chorionic Gonadotropin - produced in the chorionic villi - the basis for the (+) pregnancy test - large amount between 7-10 weeks and remain in low - level after the 20th -week until term b. Progesterone - hormone of mothers - maintains the endometrial lining of the uterus - present in serum as early as 4th week of pregnancy, as a result of the continuation of the corpus luteum - reduces the contractility of uterine musculature during pregnancy preventing premature labor attributed to a change in electrolytes (potassium and calcium) c. Estrogen - primarily estriol - produced as the second product of the syncitial cells - contributes to the mothers mammary gland development in preparation for lactation - stimulates uterine growth to accommodate the developing fetus d. Human Placental Lactogen - both with growth-promoting and lactogenic (milkproducing) properties - produced by the placenta beginning as early as 6 th week of pregnancy, increasing to a peak level at term - promotes mammary gland growth in preparation for lactation - regulates maternal glucose, protein, and fat levels so that adequate amount is always available to the fetus -metabolic actions:

1. Lipolysis with an increase in the levels of free fatty acids (provides energy for maternal and fetal secretion) 2. Anti-insulin action, which leads to an increase in maternal insulin favoring protein utilization (ensures mobilizable source of amino acids for transport to the fetus) Placental functions depend almost entirely on the maternal circulation. The placental life span is measured by activity until term is approached, where the functions progressively decreases until delivery. The placental lines during the uterine contraction (braxton hicks contraction) not during relaxation. With uterine relaxation blood drains out of the placental sinusoids into the maternal circulation. Optimum circulation to the placenta and fetus is possible when the patient is lying on her left side. When in supine the pregnant uterus (third trimester), compresses the vena cava thus the venous return from the uterus and lower extremities is impeded. Placental Transfer -Maternal and fetal circulation for the first 12 weeks of gestation is separated only by two layers of cells from the placenta, syncytiotrophoblast (outer) and cytotiphoblast, (inner). - After the first 12 weeks of gestation, the cytotrophoblastic cells become fewer and widely separated so that during the second and third trimester of pregnancy only cone cell layer separates the two blood stream PLACENTAL BARRIER. Passage of materials to and from the fetus is affected by four mechanisms. 1. Diffusion of oxygen, carbon dioxide, anesthetic gases, water, electrolytes and other substances of low molecular weight. 2. Selective transfer often by enzyme action result in the passage of glucose, amino acids, calcium, iron and other substances of higher

molecular weight. 3.. Pinocytosis - a mechanism by which minute particles may be engulfed and carried across the cell including fat and proteins. 4. Leakage - as results of small defects in the trophoblast surface allows slightly mixing of maternal and fetal blood cells and plasma. AMNIOTIC MEMBRANES The chorionic villi on the medial surface of the trophoblast not involved in implantation gradually thin, leaving the medial surface of the structure smooth now called chorion laeve, or smooth chorion Smooth chorion eventually becomes the chorionic membrane, the outermost fetal membrane which offers support to the amniotic sac (sac that contains amniotic fluid) Amniotic membrane- second membrane lining the chorionic membrane which form beneath the chorion - produces amniotic fluid - also produces a phospholipids that initiates the formation of prostaglandins which can cause uterine contractions andmay be the trigger that initiates labor No nerve supply, thus, no pain is felt by mother or fetus when it ruptures AMNIOTIC FLUID clear-pale straw fluid in which the fetus from the earliest weeks of pregnancy and increases the nearing term. quantity is 500-1,500 ml and consist of 99% water also contains albumin, urea, uric acid, phospholipids (Lecithin=surfactant), sphyngomyelin, enzymes, fat, fructose, inorganic salts, epithelial cells, leukocytes, lanugo and bilirubin; pH=7.0. FUNCTIONS: 1. Protects the fetus from direct trauma by distributing

and equalizing any impact they may receive. 2. Separate the fetus from fetal membranes. 3. Allows freedom of fetal movement. 4. Facilitate growth and development. 5. Protects the fetus from the heat loss and maintain constant temperature. 6. Source of oral fluid. 7. Acts as an excretion or collection system. 8. Study of amniotic fluid provides knowledge concerning sex, state of health, maturity of the fetus and diseases. Polyhydramnios excessive amniotic fluid - amount of fluid is over 2 000 ml. or pockets of fluid larger than 8 cm. on ultrasound - tends to occur in women with diabetes (hyperglycemia causes fluid shift into amniotic space), fetus with gastro-esophageal atresia Oligohydramnios amniotic fluid amount less than 300 ml. - no pocket on ultrasound larger than 1 cm. - occurs in disturbance in kidney function Green-tinge = due to presence of meconium (first stool) and considered as a sign of fetal distress in cephalic presentation. Golden coloured - sometimes found in RH hemolytic disease. UMBILICAL CORD (FUNIS) Formed from the fetal membranes chorion and amnion and provides a circulatory pathway that connects the embryo to the chorionic villi of the placenta Extends from the fetal umbilicus to the fetal surface of the placenta. Composed of connective tissue intermingles with Wharton's jelly (gives the cord body and prevents pressure on the vein and arteries that pass through it) and the outer surface is covered with amnion.

 Transports oxygen and nutrients to the fetus and returns wastes products from the fetus to the placenta. Carries two arteries and one vein. Arteries carry unoxygenated blood from the fetus and vein carries oxygenated blood of the fetus. Average length is 53 cm in length and about 2 cm thick. Said to be short or if round the neck it prevents fetal descend or placenta maybe separated prematurely (abruptio placenta). A long cord may become wind around fetus or knot in the cord occur. Funic Souffle = high-pitched sound produced by the fetal blood in the cord. The rate is 120-160 (with FHT synchronous). Uterine Souffle = soft blowing sound produced by mother's blood flowing into the placenta, rate is 60-80 bpm. Synchronous to maternal pulse. Abnormalities 1. Battle dore insertion - cord is inserted into the very edge of the placenta. 2. Velamentous insertion - cord is inserted into the fetal membranes. FETAL MORPHOLOGICAL DEVELOPMENT Development of the fetus proceeds in acephalocaudal direction (head to toe) Fetal development follows the principle of induction meaning one tissue transmitting stimulus to an adjoining tissue to begin development. In some instances interference with induction may lead to congenital anomalies. 1. Ovum - the period of fertilization until primary villi appears approximately 12-14 days gestation (0-2 weeks) 2. Embryo - the period of ovum until embryo, 54-56 days of gestation (2-9 weeks)

- the period of rapid cell division and the most critical time for the development of the individual because all organs are being developed. -highly vulnerable to environmental agents: virus, radiation, infection. - Any interference during this time can result to congenital defects. - At the end of eight weeks of gestation, the embryo has developed into a recognizable human characteristics called as FETUS offspring. 3. Fetus - the period from the embryonic stage until pregnancy is terminated (9 weeks up to birth First Trimester - period of organogenesis Second Trimester - period of rapid increase in length Third Trimester - period of continuous growth and rapid development due to deposition subcutaneous fats. Primary Germ Layers At the time of implantation, the blastocyst has differentiated to a point at which two separate cavities appear in inner structure. 1. large amniotic cavity lined with a distinctive layer of cells, the ectoderm 2. smaller cavity, lined with entoderm cells Between the amniotic cavity and the yolk sac, a third layer of primary cells form, the mesoderm Germ Layer Ectoderm Body Portions Formed Central nervous system (brain and spinal cord) Peripheral nervous system Skin, hair, and nails Sebaceous glands Sense organs Mucous membrane of the anus, mouth and nose Tooth enamel Mammary glands

Mesoderm

Ectoderm

Supporting structures of the body (connective tissue, bones, cartilage, muscle, ligaments and tendons) Dentn of teeth Upper portion of the urinary system (kidneys and ureters) Reproductive system Heart Circulatory system Blood cells Lymph vessels Lining of pericardial, pleura and peritoneal cavities Lining of the gastrointestinal tract, respiratory tract, tonsils, parathyroid, thyroid, thymus glands Lower urinary system (bladder and urethra)

Development of the Major Body Systems All organs are complete at least in a rudimentary form at 8 weeks gestation. It is during this time of organogenesis that the growing structures are highly susceptible to invasion of teratogens ,(any factor that adversely affects the fertilized ovum, embryo and fetus). Cardiovascular System one of the first system to become functional in intrauterine life. begins to form 16 days of life and to beat as early as 24 days. using a doppler systems, the fetal heart beat maybe heard as early as 10 weeks of pregnancy although accuracy is on the 20th weeks of pregnancy. the heart rate of the fetus is affected by oxygen level, body activity and circulatory blood volume. FHR = 120-160 bpm. Fetal Circulation - established as early as 3rd week of intrauterine life, wherein fetal blood has begun to accept

nutrient from the chorionic villi from maternal circulation. - During intrauterine life the fetus gets oxygen not from the lungs but at the placenta and that includes the exertion of carbon dioxide. - Blood goes to the lungs for supply not for oxygenation. - Blood from the placenta is highly oxygenated and enters the fetus through the umbilical vein (oxygenated blood) ductus venosus to supply the fetal liver inferior vena cavaright atriuma. via foramen ovale left atrium left ventricle aorta b. via tricuspid valve right ventricle pulmonary artery ductus arteriosus descending aorta umbilical arteries (deoxygenated blood) umbilical cordplacental villi where oxygenation takes place Fetal hemoglobin is 17.1 gm/100 ml. as compared to adults 11 gm/100 ml Fetal hematocrit 53% compare to adult 45%. The change from fetal to adult hemoglobin begins before birth and accelerates following birth. Respiratory System Third week of life, the respiratory and the digestive tract exist as a single tube. By this end of 4th week, a septum begins to divide the esophagus and trachea and lung buds appear on the trachea. 7th week- diaphragm completely divides the thoracic cavity from the abdomen If diaphragm fails to close completely the stomach, spleen, liver or intestines may enter the thoracic cavity a condition called DIAPHRAGMATIC HERNIA compromising the lungs and displacing the heart. Alveoli begin to form between 24th-28th weeks are supplied Both alveoli and capillaries must be developed before exchange of gas can occur in the fetal lungs 3 months gestation: Spontaneous respiratory practice movements begin and continues throughout pregnancy 24th week pregnancy surfactant are being excreted by

the alveolar cells. Surfactant is a phospholipids substance that decreases alveolar surface tension on the expiration. - prevents alveolar from collapsing (atelectasis) on expiration. - Surfactant has two components: Lecithin and Sphingomyelin, before 35 weeks. - Sphingomyelin is a chief component at about 35 weeks, there is a surge in the production of lecithin which become the chief component in a ratio of 2:1. - Analysis of the Lecithin / Sphyngomyelin ratio by amniocentesis technique is one of the primary test of fetal lung maturity. - Lack of a surfactant or a reverse L/S ratio is a sign of fetal lung immaturity and a factor in the development of Respiratory Distress syndrome (RDS) formerly known as hyaline membrane disease. Nervous System During 3rd and 4th weeks of life, active formation of the nervous system and sense organs begin 3rd week of gestation: neural plate (thickened portion of ectoderm) is apparent Top portion of neural plate differentiates into neural tube (will form the brain and spinal cord) and neural crest (develop into peripheral nervous system) Eye and ear develop as projections of the neural tube 8th week: Brain waves detected on EEG 24 weeks: ear is capable of responding to sound; eyes exhibit papillary reaction (indicates that sight is present) All parts of the brain (cerebrum, cerebellum, pons and medulla oblongata) form in utero but not completely mature at birth Growth proceeds rapidly during the first year and continues until 5 or 6 years of age Endocrine System Fetal adrenal glands supply a precursor for estrogen synthesis by the placenta

 Fetal pancreas produces insulin needed by the fetus (insulin does not cross the placenta from the mother to the fetus) Thyroid and parathyroid glands play vital roles in metabolic function and calcium balance Digestive System 4th week: digestive tract separates from respiratory tract Initially solid, tubes canalize (hollow) to become patent Endothelial cells proliferate and occlude the lumens requiring recanalization (failure of 1st or 2nd canalization = atresia or stenosis) Until 6th week: rapid intestinal growth, abdomen too small for the intestines : portion of the intestine guided by the vitelline membrane (part of the yolk sac) is pushed into the base of the umbilical cord and remains until the 10 th week th 10 week: intestine returns to the abdominal cavity rotating 180 degrees : Failure to rotate=volvulus of the intestine :Omphalocoele=any intestinal coils remains outside the abdomen : Gastroschisis= original midline fusion that occurred in early stage is incomplete : Meckels diverticulum= failure of vitelline duct to atrophy after return of intestines th 16 week : Meconium (collection of cellular wastes, bile, fats, mucoproteins, mucopolysacharrides and portion of the vernix caseosa) forms in the intestine GI tract is sterile at birth Vitamin K is low due to absence of bacteria that synthetizes Vit K Sucking and swallowing reflex mature at about 32 weeks or if fetus weighs 1500 g. 36 weeks: secretion of enzymes for carbohydrate and protein digestion reaches maturity Amylase (for digestion of complex starches) mature by 3 months after birth

 Most, lipase not yet developed Liver active but still immature throughout gestation (acts as a filter between the incoming blood and the fetal circulation and a deposit site for fetal stores of iron and glycogen, does not prevent recreational drugs or alcohol ingested by the mother from entering the fetal circulation) Immaturity of liver can possibly lead to hypoglycemia and hyperbilirubinemia 24 hours after birth Muskuloskaletal System 2 weeks: cartilage prototypes provide support and position 12th week: ossification of bone tissue begins continues until adulthood Carpals, tarsals, and sternal bones do not ossify until birth is imminent Fetus moves on ultrasonography by 11th week Mother feels the movement (Quickening) by 20 weeks Reproductive System 6th week: gonads and ovaries form 8 weeks: sex can be determined by chromosomal analysis Testes first form in the abdominal cavity and descends into the scrotal sac by 34th to 38th week gestational age Cryptorchidism: undescended testis Urinary System 4th week: rudimentary kidneys are present 12th week: urine is formed 16th week: urine is excreted into the amniotic fluid at 500 ml/day Loop of Henle not fully differentiated until birth Glomerular filtration and concentration are not efficient at birth (kidneys not yet mature even by birth) Patent urachus: open lumen between the urinary bladder and umbilicus fails to close (persistent drainage of a clear, acid pH fluid from the umbilicus) Integumentary System

 Skin appears thin and almost translucent until 36 weeks where subcutaneous fat deposition begins Skin covered by soft downy hairs (lanugo), and a cream cheeselike substance (vernix caseosa) which is important for lubrication and keeping the skin from macerating in utero Immune System IgG cross the placenta by third trimester giving the fetus a passive immunity against diseases for which the mother has antibodies (poliomyelitis, rubella, rubella, diphtheria, tetanus, infectious parotitis, hepatitis B and pertussis) Level of IgG peaks at birth and decreases over the next 8 months IgA and IgM cannot cross the placenta, their presence in a newborn is a proof that the fetus has been exposed to a disease Length: 0.75 to 1 cm Weight: 400 mg The spinal cord is formed and fused at the midpoint. Lateral wings that will form the body are folded forward to fuse at the midline. Head folds forward and becomes prominent, representing about one third of the entire structure. The back is bent so that the head almost touches the tipof the tail. The rudimentary heart appears as a prominent bulge on the anterior surface. Arms and legs are budlike structures. Rudimentary eyes, ears, and nose are discernible. End of 8th Gestatlonal Week Length: 2.5 cm (1 in) Weight: 20 g Organogenesis is complete. The heart, with a septum and valves, is beating rhythmically. Facial features are definitely discernible. Arms and legs have developed. External genitalia are present, but sex is not distinguishable by simple

observation. The primitive tail is regressing. Abdomen appears large because the fetal intestine is growing rapidly. Sonogram shows a gestational sac, diagnostic of pregnancy End of 12th Gestational Week (First Trimester) Length: 7 to 8 cm Weight: 45 g Nail beds are forming on fingers and toes. Spontaneous movements are possible, although they are usually too faint to be felt by the mother. Some reflexes, such as the Babinski reflex, are present. Bone ossification centers are forming. Tooth buds are present. Sex is distinguishable by outward appearance. Kidney secretion has begun, although urine may not yet be evident in amniotic fluid. Heartbeat is audible through Doppler technology. End of 16th Gestational Week Length: 10 to 17 cm Weight: 55 to 120 g Fetal heart sounds are audible with an ordinary stethoscope. Lanugo (the fine, downy hair on the back and arms of newborns, which apparently serves as a source of insulation for body heat) is well formed. Liver and pancreas are functioning. Fetus actively swallows amniotic fluid, demonstrating an intact but uncoordinated swallowing reflex; urine is present in amniotic fluid. Sex can be determined by ultrasonography. End of 20th Gestational Week Length: 25 cm Weight: 223 g Spontaneous fetal movements can be sensed by the mother.

 Antibody production is possible. Hair forms, extending to include eyebrows and hair on the head. Meconium is present in the upper intestine. Brown fat, a special fat that will aid in temperature regulation at birth, begins to be formed behind the kidneys, sternum, and posterior neck. Vernix caseosa, which serves as a protective skin covering during intrauterine life, begins to form. Definite sleeping and activity patterns are distinguishable (the fetus has developed biorhythms that will grade sleep/wake patterns throughout life). End of 24th Gestational Week (Second Trimester) Length: 28 to 36 cm Weight: 550 g Passive antibody transfer from mother to fetus probably begins as early as the 20th week of gestation, certainly by the 24th week. Infants born before antibody transfer has taken place have no natural immunity and need more than the usual protection against infectious disease in the newborn period until the infant's own store of immunoglobulins can build up. Meconium is present as far as the rectum. Active production of lung surfactant begins. Eyebrows and eyelashes are well defined. Eyelids, previously fused since the 12th week, are open. Pupils are capable of reacting to light. When fetuses reach 24 weeks, or 601 g, they have achieved a practical low-end age of viability if they are cared for after birth in a modern intensive care facility Hearing can be demonstrated by response to sudden sound. End of 28th Gestational Week Length: 35 to 38 cm Weight: 1,200 g Lung alveoli begin to mature, and surfactant can demonstrated in amniotic fluid. Testes begin to descend into the scrotal sac from lower abdominal cavity. The blood vessels of the retina are thin and e susceptible to damage

from high oxygen concentration (an important consideration when caring for preterm infants who need oxygen). End of 32nd Gestational Week Length: 38 to 43 cm Weight: 1,600 g Subcutaneous fat begins to be deposited (the former stringy, "little old man" appearance is lost). Fetus responds by movement to sounds outside the mother's body. " Active Moro reflex is present. Birth position (vertex or breech) may be assumed. Iron stores, which provide iron for the time during which neonate ingests only milk after birth, are beginning to be developed. Fingernails grow to reach the end of fingertips. End of 36th Gestational Week Length: 42 to 48 cm Weight: 1, 800 to 2,700 g(5 to 61b) Body stores of glycogen, iron, carbohydrate, and calcium are deposited. Additional amounts of subcutaneous fat are deposited. Sole of the foot has only one or two crisscross creases, compared with the full crisscross pattern that will be evident at term. Amount of lanugo begins to diminish. Most babies turn into a vertex or head-down presentation during this month. End of 40th Gestational Week (Third Trimester) Length: 48 to 52 cm (crown to rump, 35 to 37 cm) Weight: 3.000 g (7 to 7.5 lb) Fetus kicks actively, hard enough to cause the mother considerable discomfort. Fetal hemoglobin begins its conversion to adult hemoglobin. The conversion is so rapid that, at birth, about 20% of hemoglobin is adult in character. Vernix caseosa is fully formed. Fingernails extend over the fingertips.

 Creases on the soles of the feet cover at least two thirds of the surface. In primiparas (women having their first baby), the fetus into the birth canal during the last 2 weeks, giving her a feeling that the load she is carrying is less. This event, termed lightening, is a fetal announcement that the third trimester of pregnancy has ended and birth is at hand. MATERNAL ADAPTATIONS TO PREGNANCY 1. Enable her to provide oxygen and nutrient for the growing fetus and additional nutrients for her own increased metabolism during pregnancy-, 2. Prepare her body for labor and delivery and lactation. PHYSIOLOGICAL CHANGES OF PREGNANCY A. Local changes involving the reproductive tract, skin and breast. 1. UTERUS . increase in the size = length 6.5 cm.- 32 cm. Depth increases from 2.5-22 cm. Width expands from 4 cm.-24 cm. Weight increases from 50 to 1,000 g. Early in pregnancy, uterine wall hypertrophies and thickens to about 2 cm. toward the end of pregnancy, the wall thins to become supple and only about 0.5 cm. thick. Volume of uterus increases from about 2 mL to more than 1,000 mL Can hold a 7-lb (3, 175 g) fetus plus 1, 000 mL of amniotic fluid for a total of 4, 000 g Great uterine growth is due to the formation of new muscle fibers in the myometrium but principally to the stretching of existing muscle fibers Muscle fibers become 2 to 7 times longer from the nonpregnant state End of the 12th week: fundus is palpable above the symphysis pubis 20th week: fundus is at level of umbilicus 36th week: fundus touches the xiphoid process and makes

breathing difficult. Fundus of uterus may be pushed slightly to the right side because of the larger bulk of the sigmoid colon on the left Increase uterine size pushes the intestines to the side of the abdomen, elevates the diaphragm and liver and compresses the stomach and puts pressure on the bladder. Uterus is more anteflexed, larger and softer to touch 6th week:lower uterine segment becomes so soft and can be felt as thin as tissue paper on bimanual examination (Hegars sign) 12th week: uterine contractions begin, becoming stronger and harder as pregnancy advances felt as hardness or tightening across the abdomen (Braxton-Hicks contractions) which serves as warm-up exercises for labor and increases placental perfusion 16-20th week: (+) ballottement 20-24th week: uterine becomes thi and fetal outline is palpated Two weeks before the term in primigravida, the fetal head settles into the pelvis preparatory for delivery and this settling is known as lightening then breathing becomes easier but there is resurgence of frequent urination. In multipara, lightening is not predictable usually experienced when labor begins Uterine blood flow increases during pregnancy as placenta needs more and more blood volume for perfusion from 1520 mL/min to 500 to 75- mL/min with 75% of blood volume going to the placenta. Amenorrhea (absence of menstruation) due to suppression of FSH by rising estrogen levels

2. VAGINA Increases vascularity in early pregnancy change the color of the vagina from the light pink to deep violet = CHADWICK' S SIGN. Increased estrogen level causes hypertrophy of the vaginal epithelium and underlying and enriched by glycogen

 Connective tissue attachment loosensin preparation for distention at birth. Increased activity of the epithelial cell result in white vaginal discharge throughout pregnancy = LEUKORRHEA. pH falls from >7 to 4 or 5 due to increase lactic acid content by the action of Lactobacillus acidophilus which renders the viagina resistant to bacterial invasion but favor the growth of fungus (Candida albicans) resulting to candidiasis or moniliasis manifested by: 1. Itchiness with burning sensation of the vulva. 2. Cream cheese like vaginal discharge. TREATMENT: Anti-fungal medication, Nystatin (Mycostatin) -Candidal infection is manifested as thrush in the infant. 3. OVARIES Ovulation stops due to lack of activity of FSH and LH On the surface of the ovary, the corpus luteum continues to increase in size until about the 16th week of pregnancy when the placenta takes over as the chief provider of progesterone and estrogen. Corpus luteum then regresses in size and become indistinct 4. BREAST Feeling of fullness, tingling or tenderness due to high estrogen levels Increase in size due to hyperplasia of the mammary alveoli and fat deposits Areola darkens and diameter increases from 3.5 cm to 5 or 7 cm Darkening of skin surrounding the areola forming a secondary areola Vascularity increases (blue veins become prominent over the surface of the breast Montgomery tubercles (sebaceous glands of areola) enlarge and become protruberant 16th week: colostrums can be expelled from the nipples B. Systemic 1. INTEGUMENTARY SYSTEM

 The abdominal wall stretches to accommodate the uterus which causes rupture and atrophy of small segments of connective layer of the skin resulting to a pink or reddish streak on one side of the abdomen and on the thighs = STRIAE GRAVIDARUM This lightens and becomes silvery white in color = LINEA ALBICANTES At times the abdominal wall can not stretch enough and the rectus muscle separate = DIASTASIS RECTI (appears as a bluish groove at the site of separation after pregnancy). Umbilicus becomes obliterated and smooth or protrudes at the center of the abdominal wall LINEA NIGRA: Brown black line maybe present running from the umbilicus to the symphysis pubis separating the abdomen into right and left hemisphere MELASMA OR CHLOASMA (Mask of pregnancy): Dark brown areas in the face (cheeks and across the nose) due to increased pigmentation caused by melanocyte- stimulating hormone (MSH) secreted by the pituitary VASCULAR SPIDER: Small fiery red branching spots seen particularly on the thighs due to increased level of estrogen 2. RESPIRATORY SYSTEM Marked congestion or stuffiness of the nasopharynx due to increased estrogen levels Epistaxis may occur due to marked congestion of nasopharynx Diaphragm displaced 4 cm upward due to the enlarging uterus which causes acute sensation of shortness of breath late in pregnancy Vital capacity (maximum volume exhaled after maximum inspiration) remains the same Residual volume decreases up to 20% Tidal volume (the volume of air inspired) increases up to 40% Total oxygen consumption increases by as much as 20% PCO2 level decreases due to the action of progesterone allowing CO2 to cross readily from the fetus to the mother Increased ventilation (mild hyperventilation) occurs to blow off excess CO2 early in pregnancy

Slight increase in serum pH slightly increases the binding capacity of maternal hemoglobin and raises PO2 from 92 mmHg to 106 mmHg allowing good placental exchange Respiratory Changes During Pregnancy Vital Capacity No change Tidal volume Increased by 30-40% Respiratory rate Increased by 1 or 2 per minute Residual volume Decreased by 20% Plasma PCO2 Decreased to about 27-32 mmHg Plasma pH Increased to 7.40-7.45 Plasma PO2 Increased to 104-108 mmHg Respiratory minute volume Increased by 40% Expiratory reserve Decreased by 20%

3. TEMPERATURE slightly increases due to secretion of progesterone at 16 weeks, temperature decreases to normal 4. CARDIOVASCULAR SYSTEM Blood Volume Increase of about 30-50% to compensate for the blood loss at birth (NSD: 300-400 mL; CS: 800-1, 000 mL) Occurs gradually from the end of 1 st trimester, peaks at 28 th and 32nd week and continues throughout the 3 rd trimester The increase is mainly composed of plasma causing a drop in hemoglobin and hematocrit values = Pseudoanemia early in pregnancy The body compensates by producing more red blood cells by second trimester Effects are: 1. Systolic murmurs due to decrease blood viscosity. 2. Increase work load of the heart resulting to easy fatigability and shortness of breath. 3. Slightly increased in the size of the heart. Iron needs Fetal growth requires a total of 350 to 400 mg of iron

 Increase in maternal RBC mass require an additional 400 mg Total need: 800 mg Due to decreased iron stores (500 mg) and decreased iron absorption as a result of decreased gastric acidity, additional iron id required to prevent true anemia (Hgb concentration < 11.5 g/100 mL or Hct < 30%) Folic acid requirement also increases to prevent megalohemoglobinemia (large, non functioning RBC) and neural tube disorders in the fetus Foods high in folic acid: spinach, asparagus, legumes Heart To compensate for the blood volume, heart rate increases by about 10 bpm and cardiac output by 25 to 50% Heart is shifted to a more transverse position as the diaphragm is pushed upward (make it appear larger on CXR) Palpitation due to sympathetic nervous system stimulation and increase thoracic pressure caused by pressure of the uterus to the diaphragm