NURSING CARE OF

CLIENTS WITH
REPRODUCTIVE
HEALTH PROBLEMS
ADULT WOMEN

Mastitis
Infection of the breast usually caused by
Staphylococcus aureus
Risk factors: plugged ducts, untreated engorgement,
cracked nipples, missed feedings, excessive fatigue,
decreased resistance to infection
Common occurring in 5%10% of breastfeeding
women
Most common in first month
Recurrences occur in 8%19% of women and
commonly (25%) leads to lactation cessation

Reference 8, 44

Mastitis History and

Physical Exam
Fever, diffuse myalgias, flu-like symptoms, breast
pain
Wedge-shaped, tender, erythematous, usually
unilateral
Upper, outer quadrant most common

Mastitis Treatment
DO NOT stop breastfeeding on the affected side,
empty the breast
If mild, symptoms occur for less than 24 hours and
may attempt to resolve with frequent nursing or
pumping and supportive measures including bed rest,
fluids, analgesics
Antibiotic options include dicloxicillin 500 mg po qid;
cephalexin 500 mg po qid, or clindamycin 300 mg po
qid for 10 to 14 days
Observe carefully for signs of abscess formation

Reference 1, 20, 39

Endometriosis
Presence of endometrial tissue outside uterus (ectopic)
Found on ovaries, ligaments, colon, sometimes lungs

Responds to cyclic hormonal variations

Grows and secretes then degenerates, sheds and bleeds
What is the problem? (Where does it go?)

Blood irritating to tissues = inflammation and pain

Recurs w/ e/ cycle w/ eventual fibrous tissue
Causes adhesions and obstruction

Diagnosis confirmed w/ laparoscopy

Endometriosis
Infertility results from
Adhesions pulling uterus out of normal position
Blockage of fallopian tubes

chocolate cyst develops on ovary

Fibrous sac containing old brown blood

Primary manifestations
Dysmenorrhea
More severe e/ month

Painful intercourse if vagina and supporting ligaments affected by

adhesions

Endometriosis
Cause not established
Migration of endometrial tissue up thru tubes to peritoneal cavity during
menstruation, development from embryonic tissue at other sites, spread
thru blood or lymph, transplantation during surgery (C-section) all
possibilities

Treatment
Hormonal suppression of endometrial tissue
Surgical removal of endometrial tissue

Pregnancy and lactation delay further damage and alleviate

symptoms

Endometriosis

Pelvic Inflammatory Disease (PID)

Common infection of reproductive tract
Particularly fallopian tubes and ovaries

Includes:

Cervicitis (cervix)
Endometritis (uterus)
Salpingitis (fallopian tubes)
Oophoritis (ovaries)

Infection either cute or chronic

Short-term concerns: peritonitis, pelvic abscess
Long-term concerns: infertility, high risk of ectopic pregnancy

PIDPathophysiology
Usually originates as vaginitis or cervicitis
Often involves several causative bacteria

Uterus fallopian tube

Edema, fills w/ purulent exudate

Obstructs tube and restricts drainage into uterus
Exudate drips out of fimbriae onto ovaries and surrounding tissue
Peritoneal membrane attempts to localize but peritonitis may develop
Abscesses may form; life-threatening
Cause septic shock

Adhesions affect tubes and ovaries

Lead to infertility and ectopic pregnancies

PID

PIDEtiology
Arise from sexually transmitted diseases
Gonorrhea
Chlamydiosis

Prior episodes of vaginitis or cervicitis precedes development

Infection acute during or after menses
Endometrium more vulnerable

Can also result from IUD or other contaminated instrument

Can perforate wall and lead to inflammation and infection

PIDSigns and Symptoms

Lower abdominal pain (1st indication)
Sudden and severe or gradually increasing in intensity

Tenderness during pelvic exams

Purulent discharge at cervix
Dysuria
Fever and leukocytosis can occur
Depends on causative organism

PIDTreatment
Aggressive antibiotics
Cefoxitin, doxycycline

Recurrent infections common

Sex partners should be treated as well

Follow-up appt to ensure eradication

Benign Tumors: Ovarian Cysts

Variety of types
Follicular and corpus luteal cysts common
Develop unilaterally in both ruptured and unruptured follicles

Usually multiple fluid-filled sacs under serosa that covers ovary

May become large enough to cause discomfort, urinary retention,
or menstrual irreg
Bleeding if ruptures
Cause even more serious inflammation

Risk of torsion of the ovary

Ultrasound and laparoscopy to ID cyst

Ovarian Cysts

MANAGEMENT OF
ABORTION

Threatened Abortion

Conservative with bed rest and

reassurance till bleeding stops.
Sexual intercourse best avoided.
Follow up with ULTRASOUND-presence of
fetal cardiac activity predicts good
outcome in 95%of cases.
Hormone therapy -400mg natural
progesterone in 2divided doses orally or
vaginally on empirical basis.
Anti D if mother is Rh negative and
pregnancy is beyond 12 weeks.

Inevitable Abortion
Immediate evacuation of pregnancy.
(If duration of pregnancy less than 12
weeks-suction evacuation and greater
than 12 weeks oxytocin infusion.)
Shock-resuscitation with i/v fluids and
blood transfusion.
Prophylactic antibodies and anti-D.

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Suction abortion

Incomplete Abortion

Resuscitation if patient is in shock and

evacuation by suction evacuation.
If the os is closed PGE1 tablets are kept
in vagina for ripening the cervix.
Prophylactic antibodies and anti D

Complete abortion

Conservative
Anti D not indicated if pregnancy is less
than 12 weeks and there was no
operative intervention.

Missed Abortion

Uterus evacuated as soon as possible. A

donor should be kept ready.
If uterine size is less than 12 weeks of
gestation PGE1 tablets kept in vagina
results in spontaneous expulsion without
the need of surgical intervention.
If more than 12 weeks, 6th or 12th hourly
PGE1 tablets used vaginally results in
spontaneous expulsion or extra amniotic
ethacridine acetate.
Anti D and antibiotics.

Septic Abortion

Police notification if a criminal abortion is

suspected.
Mild cases-broad spectrum antibiotics are
started and uterus evacuated.
Severe cases-maintenance of perfusion
and ventilation.
I/v infusion and CVP line is inserted
Blood transfusion
Oxygen given by nasal catheter.

Click icon to add picture

CVP line

Septic Abortion(cont..)

Antibiotics commenced after taking a

high vaginal swab.
Ampicillin,Gentamycin and
Metronidazole/third generation
cephalosporin like cefotaxime or
cefuroxime with metronidazole or
clindamycin.
Evacuation of uterus after infection is
controlled.

Recurrent Miscarriage

Due to cervical incompetence

Management is be cervical cerclage if there is

a well documented history otherwise serial
follow up is done with transvaginal
ultrasound for early signs of
incompetence.Cervical cerclage is usually
delayed upto 12-14 weeks so that
miscarriage due to other causes can be
eliminated.
Sonography is done to confirm live fetus and
if there is infection,it should be treated and
sexual intercourse should be avoided.
Contraindications-

Click icon to add picture

Cerclage

1.McDonalds Cerclage
Patient is in lithotomy position and cervix is
exposed with Sims speculum.The cervical lips
are held with sponge holding forceps and a purse
string suture with a non absorbable material like
black silk is taken all around the cervix.
Disadvantage suture may be below internal os.

Click icon to add picture

McDonalds cerclage

2.Modified Shirodkars cerclage.

Small transverse incision is made on
anterior lip of cervix at cervicovaginal
junction 2cm above the external
os.Bladder is then pushed up and a
suture of black silk or mersilene tape
is passed from anterior to posterior
aspect submucosally using Shirodkars
or any curve bodied needle.2 ends of
the suture are pulled and tied

Click icon to add picture

Shirodkars cerclage

3.Transabdominal cerclage
Done in cases of repeated failure of
vaginal approach and cervix is inaccessible
Disadvantage-Caesarean section
In case of miscarry cerclage has to be
removed at laparotomy.

Post operative care

Bed rest for 48 hours

Antibiotic cover
Avoid sexual intercourse
Cerclage is removed at 37 weeks or at
the onset of labour ,if not it can result in
rupture uterus.

Other cases of recurrent miscarriage

Chromosomal abnormalities-karyotyping of both

parents and prenatal diagnosis in the next
pregnancy.
Uterine factors-hysteroscopic resection in case of a
septum or division of the adhesion in Ashermans
syndrome. Myomectomy in case of fibroid.
APLA Syndrome-Combination of low dose aspirin
and low MW heparin as soon as pregnancy is
confirmed.Aspirin preconceptionally.
Inherited thrombophilia-Low dose aspirin and
heparin.

Induced abortion

THE MEDICAL TERMINATION OF PREGNANCY ACT, 1971

(Act No. 34 of 1971)

(10th August 1971)

An Act to provide for the termination of certain pregnancies by registered Medical Practitioners and for
matters connected therewith or incidental thereto.

Be it enacted by Parliament in the Twenty-second Year of the Republic of India as follows :-

1. Short title, extent and commencement

This Act may be called the Medical Termination of Pregnancy Act, 1971.

It extends to the whole of India except the State of Jammu and Kashmir.

It shall come into force on such date as the Central Government may, by notification in the Official
Gazette, appoint.

2. Definitions - In this Act, unless the context otherwise requires, -

guardian means a person having the care of the person of a minor or a lunatic;

lunatic has the meaning assigned to it in section 3 of the Indian Lunatic Act, 1912 ( 4 of 1912);

minor means a person who, under the provisions of the Indian Majority Act, 1875 ( 9 of 1875), is to

(d) registered medical practitioner means a medical practitioner who possesses any
recognized medical qualification as defined in clause (h) of section 2 of the Indian Medical
Council Act, 1956, (102 of 1956), whose name has been entered in a State Medical Register and
who has such experience or training in gynaecology and obstetrics as may be prescribed by
rules made under this Act.

Place where pregnancy may be terminated - No termination of pregnancy shall be made in accordance with this Act at
any place other than a hospital established or maintained by Government, or
a place for the time being approved for the purpose of this Act by Government.

Premenstrual Syndrome (PMS)

A cluster of symptoms that regularly occur several days
prior to onset of menstruation
More frequently in thirties and forties

Etiology
Cause is not clearly understood
Attributable to water retention, estrogen progesterone
imbalance, psychological factors or dietary deficiencies

Signs and Symptoms

Irritability
Sleeplessness
Fatigue
Depression
Headaches
Vertigo
Abdominal bloating or weight gain

Diagnostic Procedures
Keep a journal recording
Evaluation of estrogen and progesterone levels
Blood tests to rule out anemia

Treatment
A reduction of salt intake for 2 weeks prior to menses to
minimize water retention
Avoid coffee, nicotine, and alcohol
Proper diet and exercise and rest
Reduction of stress and relaxation techniques

Prognosis
Variable

Prevention
No known prevention

Endometriosis
Appearance and growth of endometrial tissue in areas
outside endometrium, the uterine cavitys lining
Misplaced endometrial tisse in pelvic area

Etiology
Cause is not known

Signs and Symptoms

Dysmenorrhea occurs, with pain in lower back and vagina

Diagnostic Procedures
Laparoscopy

Treatment
Hormone therapy
Surgery to include uterus, cervix, ovaries, and fallopian
tubes

Prognosis
Varies
Primary complication is infertility

Prevention
Use sanitary napkins rather than tampons

Pelvic Inflammatory Disease

Acute, or subacute, or a recurrent or chronic infection of the
fallopian tubes, ovaries, and adjacent tissues

Etiology
Parturition
Infections from N. gonorrhoeae, C. trachomatis,
Pseudomonas, and E. coli
Iatrogenic
Conization
Most common in young nulliparous women

Signs and Symptoms

Sudden pelvic pain

Purulent and foul-smelling vaginal discharge
Fever
Sexual dysfunction

Diagnostic Procedures
Ultrasonography used to identify a uterine mass

Treatment
Antibiotics
Surgery may be necessary to prevent septicemia

Prognosis
Good when treated early

Menopause
The cessation of menses and ovarian function
Decrease in estrogen levels
Not a disease

Etiology
Occurs naturally in women between ages 40 and 50

Signs and Symptoms

Menstrual irregularities
Decrease in flow
Hot flashes
Night sweats
Tachycardia
Loss of elasticity in skin
Reduction in size and firmness of breast

Diagnostic Procedures
Blood serum levels checked for increased production of
follicle-stimulating hormone (FSH) and luteinizing
hormone (LH)

Treatment
Hormonal replacement therapy if needed

Prognosis
Good

Prevention
Cannot be prevented but emotional swings occur

Uterine Prolapse

Prepared by: Cheng Chan Mara

Definition

Uterine Prolapse is the downward

displacement of the uterus into the vaginal canal
or a gradually descends of the uterus in the axis
of the vagina taking the vaginal wall with it.

Usually, prolapse is rated by degrees:

First-degree prolapse: the cervix rests in the

lower part of the vagina.

Second-degree prolapse: the cervix is at the
vaginal opening.
Third-degrees prolapse: the uterus protrudes
through the introitus.

First degree prolapse

Second degree prolapse

Third degree prolapse

Etiology

Stretching of muscle and fibrous tissue.

eg. Pregnancy and childbirth.
Increased intra-abdominal pressure as a result
of chronic coughing, lifting of heavy objects
and obesity, place pressure on the pelvic floor.
A constitutional predisposition to stretching of
the ligaments as a response presumably to
years in the erect position.
Menopause and ageing increase the risk of
prolapse. (The female hormone estrogen plays
an important role in maintaining the strength
of the pelvic floor).

Clinical Manifestation

Feeling like you are sitting on a small ball

Difficult or painful sexual intercourse
Frequent urination or a sudden urge to empty
the bladder
Low backache
Uterus and cervix that stick out through the
vaginal opening
Repeated bladder infections
Feeling of heaviness or pulling in the pelvis
Vaginal bleeding
Increased vaginal discharge

Treatment

Vaginal pessary:

This device fits inside your vagina and holds your

uterus in place. Used as temporary or permanent
treatment, vaginal pessaries come in many shapes
and sizes.

Treatment (cont.)

Surgery:
Several different types of surgery can be used
to treat a severe genital prolapse. These
procedures include:
surgery to repair the tissue that supports the
prolapsed organ
surgery to repair the tissue around the vagina
surgery to close the opening of the vagina
surgery to remove the womb (hysterectomy)

Collaborative Care

preventive measures:
Early visits to HC provider = early detection
Teach Kegels exercises during PP period
preoperative nursing care:
Thorough explanation of procedure, expectation and effect on future sexual f(x)
Laxative and cleansing edema (rectocele) independently, at home a day prior
procedure
Perineal shave prescribed also
Lithotomy position for surgery
postop nursing care:
Pt. is to void few hours after surgery; catheter if unable (after 6 hrs)

Infections of the Female

Reproductive Tract
Simple vaginitis
Etiology/pathophysiology
Common vaginal infection
Causative organisms: E. coli; staphylococcal; streptococcal; T. vaginalis; C.
albicans; Gardnerella

Clinical manifestations/assessment
Inflammation of the vagina
Yellow, white, or grayish white, curd-like discharge
Pruritus and vaginal burning

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 93

Infections of the Female

Reproductive Tract
Simple vaginitis (continued)
Medical management/nursing interventions
Douching
Vaginal suppositories, ointments, and creams

Organism-specific

Sitz baths
Abstain from sexual intercourse during treatment
Treat partner if necessary

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 94

Infections of the Female

Reproductive Tract
Cervicitis
Etiology/pathophysiology
Infection of the cervix

Clinical manifestations/assessment
Backache
Whitish exudate
Menstrual irregularities

Medical management/nursing interventions

Vaginal suppositories, ointments, and creams;
organism-specific

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 95

Disorders of the Female

Reproductive System
Vaginal fistula
Etiology/pathophysiology
Abnormal opening between the vagina and another organ

Clinical manifestations/assessment
Urine and/or feces being expelled from vagina

Medical management/nursing interventions

Oral or parenteral antibiotics
Diet: high protein; increase vitamin C
Surgery: Repair fistula; urinary or fecal diversion

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 96

Figure 12-10

(From Herbst, A.L., et al. [1998]. Comprehensive gynecology. [3 rd ed.]. St. Louis: Mosby.)

Types of fistulas that may develop in the vagina and uterus.

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 97

Disorders of the Female

Reproductive System
Cystocele and rectocele
Etiology/pathophysiology
Cystocele

Displacement of the bladder into the vagina

Rectocele

Rectum moves toward posterior vaginal wall

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Figure 12-12

(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)

A, Cystocele. B, Rectocele.
Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Disorders of the Female

Reproductive System
Cystocele and rectocele (continued)
Clinical manifestations/assessment
Cystocele

Urinary urgency, frequency, and incontinence; pelvic pressure

Rectocele

Constipation; rectal pressure; hemorrhoids

Medical management/nursing interventions

Surgical repair

Anteroposterior colporrhaphy; bladder suspension

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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