NCM 101 Lecture Notes PRELIMS Handout 4 _____________________

TYPES OF SEXUAL ORIENTATION 1. HETEROSEXUALITY: one who finds sexual fulfillment with a member of the opposite sex. Because interest in the opposite sex and sexual relationships may begin as early as the beginning of puberty. (10-12 Yrs old.) , HC providers need to provide information on safe sex practices as early as this age for the information and the knowledge to be most helpful. 2. HOMOSEXUALITY: is finding sexual fulfillment wit a member of his/her own sex. Why homosexual gender identity develops is unknown, although most individuals who are homosexual report a realization that they are different even as early as before puberty. It is probably during their adolescence in seeking a sense of identity that they realize that the reason they feel different is because they are homosexual. It is important that health care providers be sensitive to their needs in this time of identity formation. There is a higher suicide risk found in gay and lesbian adolescents because of either fear of social stigma, or having the turmoil of identity confusion. 3. BISEXUALITY: people who are bisexual achieve sexual satisfaction from both homosexual and heterosexual relationships. Gay and bisexual men have a higher risk for acquiring STDs. The role of the HC provider is to ensure that sufficient information and knowledge about HIV and STDs are given. 4. TRANSSEXUALITY: a transsexual individual is one who, although of 1 biologic gender feels as if he/ she should be of the opposite gender. Such people may undergo sex change so they appear cosmetically as the sex they envision themselves to be. Although the person becomes capable of sexual intercourse in this new role, they are incapable of reproduction. STAGES OF FETAL DEVELOPMENT: fetal growth and development is divided into 3 periods: 1. pre- embryonic- 1st 2 weeks beginning with fertilization 2. embryonic- from weeks 3-8 3. fetal- from week 8 through birth

FERTILIZATION: the union of the ovum and the spermatozoon. Usually occurs in the distal third portion of the fallopian tube. life span of sperm cell- 48-72 hours life span of egg cell- 24-42 hours an ejaculation of semen averages 2.5ml of fluid containing 50-200million sperm cells per ml. at the time of ovulation, there is a decrease in the thickness of the cervical mucous making it easier to be penetrated by the sperm cell. Sperm cells deposited in the vagina during intercourse generally reach the cervix within 90 seconds and the outer end of the fallopian tube within 5 minutes after deposition. Sperm cells move by means of their flagella (tails) and with the help of uterine contractions through the cervix, the body of the uterus, to the fallopian tubes, and to the waiting ovum. A proteolytic enzyme (HYALURONIDASE) acts to dissolve the layer protecting the ovum, making it easier to penetrate. Immediately after the penetration of the sperm cell to the ovum, the chromosomal material of the sperm and the ovum fuse. The resulting structure is called the ZYGOTE. Fertilization depends on at least 3 factors: a. maturation of both the sperm and the ovum b. ability of the sperm to reach the ovum c. ability of the sperm to penetrate the ovum

IMPLANTATION: - Once fertilization is complete, the zygote migrates towards the body of the uterus. This usually takes 3-4 days. During this time, mitotic cell division/ cleavage begins. The 1st cleavage occurs about 24 hours. By the time the zygote reaches the body of the uterus, it already consists of 1650 cells. At this stage, because of its bumpy outward appearance, it is termed as the MORULLA (mulberry). - The morulla continues to multiply as it floats free in the uterine cavity for 3-4 more days. At this stage, the structure is called a BLASTOCYST. It is this structure that attaches to the endometrium of the uterus. - Implantation occurs approximately 8-10 days after fertilization. - Then these 3 stages follow: 1. The blastocyst brushes against the endometrium (apposition). 2. it attaches to the surface of the endometrium (adhesion)

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Ms. April Anne D. Balanon

NCM 101 Lecture Notes PRELIMS Handout 4 _____________________

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3. and then settles down into the soft folds of the endomentrium (invasion) The implantation point is usually high in the uterus, on the posterior surface. If the point of implantation is low in the uterus, the growing placenta may occlude the cervix, and may make the delivery of the fetus difficult (PLACENTA PREVIA) EMBRYONIC AND FETAL STRUCTURES

1. The decidua- after fertilization, implantation happens in the endometrium of the uterus. The
decidua, the layer that thickens in order to cushion the egg does not slide off but instead continues to grow in thickness. The decidua has 3 separate areas: a. decidua basalis- the part of the endometrium lying directly under the embryo b. decidua capsularis- the portion of the endometrium that stretches or encapsulates the trophoblast c. decidua vera- the remaining portion of the uterine lining

2. chorionic villi- once implantation is achieved, the trophoblastic layer of the cells of the
blastocyst begin to mature rapidly. As early as the 11th or 12th day, finger like projections or chorionic villi reach out from the single layer of cells into the uterine endometrium. - The outer layer of the chorionic villi develops into a separate hormone producing system producing the following: a. HCG (human chorionic gonadotropin) this is the 1st hormone to be produced. It can be found in maternal blood and urine as early as the time of the first missed menstrual period until about the 100th day of pregnancy. b. estrogen: primarily ESTRIOL contributes to the mothers mammary gland development in preparation for lactation and it also stimulates uterine growth to accommodate the developing fetus. c. progesterone: is essential to maintain the endometrial lining of the uterus during pregnancy. This hormone also appears to decrease contractility of the uterine muscles during pregnancy, thus preventing premature labor. d. Human placental lactogen: is a hormone with either growth promoting and lactogenic or milk producing properties. It is produced as early as the 6th week of pregnancy. It promotes mammary gland growth in preparation for lactation in the mother. It also serves to regulate maternal glucose, CHON, and fat levels so that adequate levels of these are always available to the fetus.

3. Placenta- the placenta (Latin for pancake) arises out of trophoblast tissue. It serves as the fetal
lungs, kidneys, gastrointestinal tract, and as a separate endocrine organ throughout pregnancy. A placenta weighs 400-600g.

4. Umbilical cord- functions to transport oxygen and nutrients to the growing fetus from the
placenta and to return the waste products of the fetus to the placenta. This is about 20-21 inches long and 2cm thick. The bulk of the cord is a gelatinous muccopolysaccharide called WHARTONs JELLY which gives the cord body and prevents pressure on the vein and arteries. The umbilical cord has no nerve supply

5. membranes and amniotic fluid- the amniotic membrane and the chorionic membrane cover the
fetal surface of the placenta and give that surface its typical shiny appearance. The amniotic membrane produces, and supports the amniotic fluid. A decrease in the amount of the amniotic fluid is termed as OLIGOHYDRAMINOS Normal amount of amniotic fluid is 800-1200ml. Amniotic fluid is slightly alkaline with a pH of about 7.2 The amniotic fluid is an important protective mechanism for the fetus: a. it shields against pressure or a blow to the mothers abdomen b. It protects the fetus from changes in temperature, because liquid changes temperature more slowly than air. c. It aids in muscular development because it allows free movement of the fetus d. It protects the umbilical cord from pressure, protecting fetal oxygenation. FETAL DEVELOPMENT MILESTONES: The length of the pregnancy is generally measured from the first day of the last menstrual period ( GESTATIONAL AGE )

end of the 4th gestational week

2

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Ms. April Anne D. Balanon

NCM 101 Lecture Notes PRELIMS Handout 4 _____________________

At the end of the 4th week of gestation, the human embryo is a rapidly growing formation of cells but does not resemble a human being just yet. length is 0.75 ti 1 cm weight is 400mg 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, comprising about 1/3 of the entire structure the back is bent so that the head almost touches the tip of the tail the rudimentary heart appears as a prominent bulge on the anterior surface arms and legs are bud like structures rudimentary eyes, ears, and nose are discernible

end of the 8th gestational week

length is 2.5 cm or 1 inch weight is 20g organogenesis is complete the heart with valves and a septum beats rhythmically facial features are discernible extremities have developed external genitalia are present but sex is not distinguishable by simple observation the primitive tail is regressing abdomen appears large as fetal intestines are growing rapidly sonogram shows a gestational sac

end of the 12th gestational week ( 1st trimester)

length is 7-9 cm weight is 45g nail beds are forming on hands and toes spontaneous movements are possible although are 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 outside appearance kidney secretion has begun, although urine may not be present yet in the amniotic fluid heart beat is audible by a Doppler

end of 16th gestational week

length is 10-17 cm weight is 55-120 g fetal heart sounds are audible with an ordinary stethoscope lanugo (fine hair on back and arms of the baby which serves as a source for insulation) is well formed liver and pancreas are functioning fetus actively swallows amniotic fluid, demonstrating an intact but uncoordinated swallowing reflex

end of 20th gestational week

length is 25 cm weight is around 223g spontaneous felt movements can be felt by the mother antibody production is possible hair forms including in eyebrows and hair on head meconium is present on upper intestine Brown fat begins to be formed behind the kidneys, the sternum, and the posterior neck. This aids in thermoregulation at birth fetal heart beat is strong enough to be heard through the abdomen with an ordinary stethoscope vernix caseosa begins to form. This is a cheesy white substance produced by the sebaceous glands. Definite sleep and activity patterns are distinguishable

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Ms. April Anne D. Balanon

NCM 101 Lecture Notes PRELIMS Handout 4 _____________________

end of 24th gestational week ( 2nd trimester)
length is 28-36cm weight is about 550g passive antibody transfer from mother to fetus probably begins as early as the 20th week of gestation 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 now open pupils are capable of reacting to light

end of the 28th gestational week

length is 35-38cm weight is about 1200g lung alveoli begin to mature and surfactant can be detected in the amniotic fluid testes begin to descend into the scrotal sac from the lower abdominal cavity in males the blood vessels of the retina are highly susceptible to damage from high o2 concentrations

end of the 32nd gestational week length is 38-43cm

weight is about 1600g subcutaneous fat begins to be deposited fetus is aware of the sounds outside the mothers body active moro reflex is present delivery position ( vertex or breech) may be assumed iron stores that provide iron during the time that the baby will ingest only milk after birth are beginning to develop fingernails grow and reach at the end of the fingertips

end of the 36th gestational week

length is 42-49cm Weight is 1900-2700g (5-6lbs.) body stores of iron, glycogen, calcium and carbohydrates are augmented Additional amounts of subcutaneous fats are deposited. Sole of the foot has only 1 or 2 creases compared to the full cris cross pattern that will be evident at term Amount of lanugo present begins to diminish Most babies will turn into a vertex position or head down presentation during this month

end of the 40th gestational week ( 3rd trimester)

length is 48-52cm weight is about 3000g (7-8lbs.) fetus kicks actively- hard enough to cause the mother some discomfort Fetal hemoglobin begins its conversion to adult hemoglobin. At birth, about 20% of hemoglobin will be adult in character vernix caseosa is fully formed finger nails extend over the fingertips creases on the soles of the feet cover at least 2/3 of the surface of the foot -in primiparas( 1st time mothers) the fetus often sinks into the birth canal during these last 2 weeks giving the mother a feeling that her load is being lightened.. This event is termed as LIGTENING. It is a fetal announcement that the 3rd trimester of pregnancy has ended and birth is at hand. PHYSIOLOGIC CHANGES IN PREGNANCY SKIN: As the uterus changes in size, the abdominal wall must stretch to accommodate it. This stretching can cause rupture and atrophy of small segments of the connective layer of the skin. This leads to pink or reddish streaks (STRIAE GRAVIDARUM) appearing on the sides of the abdominal wall and sometimes on the thighs.

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Ms. April Anne D. Balanon

NCM 101 Lecture Notes PRELIMS Handout 4 _____________________

The umbilicus is also stretched that it becomes obliterated and smooth because it has been pushed so far outward. Extra pigmentation also appears on the abdominal wall. A brown line (LINEA NIGRA) running from the umbilicus to the symphysis pubis may also be present. Darkened areas may also appear on the face particularly on the cheeks and across the nose ( MELASMA) or the mask of pregnancy All these are due to the melanocyte stimulating hormones secreted by the pituitary. This hormone level decreases after pregnancy and the once darkened areas again lighten. Vascular spiders are sometimes seen on the thighs of the woman during pregnancy. This is caused by an increase in the level of estrogen during pregnancy.

CARDIOVASCULAR: Blood loss at a normal vaginal delivery is about 300-400ml whereas blood loss from a caesarean birth is much higher at about 800-1000ml. almost all women need iron supplements during pregnancy because of the following reasons: a. women have a comparatively low iron storage of less than 500mg because of their monthly menstrual loss b. The fetus requires about 350-400mg of iron in order to grow. c. Iron absorption may be decreased during pregnancy as a result of decreased gastric acidity, so additional iron is prescribed during pregnancy to prevent anemia. Women should also increase their intake of folic acid (spinach, asparagus, and legumes) to help reduce the risk for neural tube defects in the fetus. To handle the increase in blood volume, a womans cardiac output increases. The hart rate increases by 10 beats per minute During the 3rd trimester, blood flow to the lower extremities is impaired because of the pressure of the expanding uterus to the arteries and veins of the lower extremities, which slows the circulation to the area. This leads to edema, and varicosities to the rectum, vulva, and legs. Despite the increase in blood volume in pregnancy (HYPERVOLEMIA) the blood pressure does not normally rise because of the increased heart action. When a woman lies supine, the weight of the uterus presses on the vena cava obstructing the blood flow from the lower extremities. This results to a decreased blood flow to the heart and in turn HYPOTENSION. This is dangerous because it can lead to fetal HYPOXIA. ( Intervention: L side Lying)

RESPIRATORY:
Most women would complain of DOB or shortness of breath as the pregnancy progresses. Because as the uterus enlarges, pressure is put on the diaphragm, and ultimately on the lungs. Breathing rate also becomes more rapid during pregnancy (18-20 breaths per min.) The mother may also complain of stuffiness or congestion of the nasopharynx. This is normal because of the increase in the levels of estrogen.

BREAST:

Breast changes may be one of the first physiologic changes a woman will feel during pregnancy because of the change in the levels of estrogen and progesterone. A feeling of fullness, tingling, or tenderness in the breast may be felt because of the increased levels of estrogen. As pregnancy progresses, breast size also increases because of the hyperplasia of the mammary alveoli The areola also darkens in color and its diameter increases from about 3.5cm to 5/ 7.5cm The sebaceous glands of the areola ( MONTGOMERYS TUBERCLES) enlarge. The secretions from these help prevent the nipples from cracking and drying. By the 16th week of pregnancy, COLOSTRUM or the thin high protein fluid that is the precursor of breast milk can be expelled from the nipples.

URINARY: alterations in fluid retention, and renal, ureter, and bladder function Urinary frequency is also noted to change. During the 1st trimester, and during the last 2 weeks of pregnancy to a rate of 10-12 time of voiding per day.

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Ms. April Anne D. Balanon

NCM 101 Lecture Notes PRELIMS Handout 4 _____________________

Changes in the urinary system result from the following: a. effects of estrogen and progesterone activity b. compression of the bladder and ureters by the growing uterus c. increase blood volume d. postural influences Fluid retention is also seen during pregnancy. This brings about edema especially in the lower extremities. Water is retained during pregnancy to aid in the increase in blood volume and to serve as a ready source of nutrients for the fetus.

ABDOMINAL WALL AND GIT: As the uterus continues to grow in size, it displaces the stomach and intestines towards the back of the abdomen. This pushing pressure may cause a decrease in the peristaltic movement leading to heartburn, constipation, and flatulence. Because blood is also drawn to the uterus, decreased blood supply to the gastrointestinal tract is decreased and may cause a decrease in the gastric motility. This is caused by RELAXIN, a hormone produced by the ovaries. Progesterone also has an effect on smooth muscles (intestines) making them less active. Morning sickness can be noticed at the time HCG and progesterone levels begin to rise... This may be also attributed to the decrease in glucose levels of the mother because the growing fetus utilizes great quantities of glucose as it develops. Heartburn results from the reflux of the stomach contents into the esophagus as a result of the upward pushing of the uterus to the stomach Because of RELAXIN, which relaxes the esophageal sphincter, heartburn may also be felt There may also be increased saliva formation (HYPERPTYALISM) because of the increased levels of estrogen. SKELETAL Calcium and phosphorous needs are increased during pregnancy because the fetal skeleton must be built There is gradual softening of the pelvic ligaments to facilitate the passage of the baby during birth Wide separation of the symphysis pubis as much as 3-4mm by the 32nd week of pregnancy may occur, making the woman walk with difficulty. The woman also changes her center of gravity because of the weight of the fetus, to make ambulation easier. (LORDOSIS) REPRODUCTIVE Uterus length grows from approximately 6.5-32cm depth increases from 2.5-22cm width expands from 4-24cm weight increases from60-1000g Cervix softens during pregnancy turns from pale pink to violet blue in color a tenacious lining of mucous fills the cervical canal ( OPERCULUM) which acts to seal out bacteria during pregnancy and help protect the fetus from infection Vagina changes in color from light pink to dark violet Ovary no production of FSH and LH so ovulation does not occur ENDOCRINE: Placenta production of high levels of HCG, estrogen, progesterone, and relaxin Pituitary Gland increase levels of growth hormones, and melanocyte stimulating hormones- causing skin pigment changes Late in pregnancy, the posterior pituitary hormone produces OXYTOCIN which will later be needed during labor. Adrenal Glands Increase production of aldosterone and corticosteroids which aid in the suppression of inflammatory reaction- so the womans body would not reject the fetus growing in her womb.

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Ms. April Anne D. Balanon

NCM 101 Lecture Notes PRELIMS Handout 4 _____________________

Also helps regulate glucose metabolism in the mother DANGER SIGNS OF PREGNANCY:

1. VAGINAL BLEEDING- a woman should report vaginal bleeding no matter how slight, because a
lot of the serious bleeding complications arise from slight spotting. The nurse should ask the woman how she discovered her spotting. It could be possible that bleeding from hemorrhoids could be misinterpreted as spotting. Assessment is very important to rule out if the spotting needs further evaluation or not. PERSISTENT VOMITING- 1x or 2x of vomiting per day is not uncommon during the 1 st trimester. However. Persistent and frequent vomiting is not normal. (HYPER EMESSIS GRAVIDARUM) vomiting past the 12th week of pregnancy is not normal. This is dangerous because it depletes the fetus of its nutritional supply. CHILLS AND FEVER- this may be indicative of an intrauterine infection and should be checked immediately SUDDEN ESCAPE OF FLUID FROM THE VAGINA- may indicate premature rupture of membranes. This may cause the uterine cavity to be open to infxn, so it becomes a threat to both mother and baby. This may also cause the umbilical cord to prolapse (out from the uterus and into the vaginal canal) if the cord is compressed by the fetal head, this may create immediate danger to both. ABDOMINAL or CHEST PAINS- abdominal pain may be indicative of an ectopic pregnancy, separation of the placenta, or preterm labor. Chest pains may be indicative of pulmonary embolus, which may follow a complication such as thrombophlebitis. Severe chest or abdominal pain should therefore prompt immediate assessment and intervention. PREGNANCY INDUCED HYPERTENSION- (PIH) this situation needs immediate assessment and requires that the mother be monitored throughout her pregnancy so as not to endanger the life or the life of the baby. signs of PIH include the following: a. rapid wt. gain ( over 2lbs per week in the 2nd trimester) b. swelling of the face and fingers c. flashes of light or dots before the eyes d. dimness or burring of vision e. severe continuous headache f. decrease in urine output

2.

3. 4.
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5.

6.

7. INCREASE OR DECEASE IN FETAL MOVEMENT- A fetus normally moves more or less the same
amount everyday. An unusual increase or decrease in this movement suggests either that the fetus responds to the need for oxygen, or the fetus is in distress.

GreywolfRed
Ms. April Anne D. Balanon