STANDARD OF CARE
considered heavy bleeding.
Standard I: Assessment
Standard II: Diagnosis
Standard III: Outcome Identification
Standard IV: Planning
Standard V: Implementation
Standard VI: Evaluation
MENSTRUATION
 Is the periodic discharge of blood and mucosal
tissue from the inner lining of the uterus
through the vagina.
 Episodic uterine bleeding in response to cyclic
hormonal changes
 Brings an ovum to maturity and renews uterine
tissue bed
MENSTRUAL CYCLE
 Is the monthly series of changes a woman's
body goes through in preparation for the
possibility of pregnancy.
 Periodic series of changes that recur in the
uterus and associated organs beginning at
puberty and ending at menopause
 Taken from the first day of menstruation to the
first day of the next menstruation
 Basis for menstrual cycle is 6-12 month
graphing.
Menarche – first menstrual period that occurs typically
at age 12 but may occur as early as 9 or as late as 17.
Thelarche – is the development of the breast buds that
occur at puberty.
Adrenarche – is the development of pubic & axillary hair
due to androgen stimulation
Characteristic of Menstrual Blood:
 Does not appear to clot
 Dark red as that of venous blood
 Offensiveness ( Fleshy stale odor)
Characteristics of the Menstrual cycle
 Interval between cycles: average 28 days; cycles
of 23 to 35 days not usual
 Duration of Menstrual flow average flow: 2-7
days ranges 1-9 days not normal
 Amount of menstrual flow: Difficult to estimate;
average 30 to 80 ml. per menstrual period;
saturating a pad in less than an hour is
Reproductive Hormones:
Gonodotropin-Releasing Hormone (GnRH)
 Stimulates release of FSH and LH initiating
puberty and sustaining menstrual cycle.
Follicle-stimulating Hormone (FSH)
 stimulate growth and maturation of graafian
follicle before ovulation
 thins the endometrium
Luteinizing Hormone (LH)
 stimulates final maturation of graafian follicle
 stimulates transformation of graafian follicle
into corpus luteum
 thickens the endometrium
Estrogen
 stimulates thickening of the endometrium;
causes suppression of FSH secretion
 responsible for the development of secondary
sex characteristics
 stimulates uterine contractions
 increases water content of uterus
Progesterone
 inhibits secretion of LH
 relaxes smooth muscles thereby decreases
contractions of uterus
 causes cervical secretion of thick mucus
 maintain thickness of endometrium
 allows pregnancy to be maintained = Hormone
of Pregnancy
 prepares breasts for lactation
Prolactin
 stimulates secretion of milk
Oxytocin
 stimulates uterine contractions during birth and
compress uterine blood vessels and control
bleeding
 stimulates let-down or milk-ejection reflex
during breastfeeding
The menstrual cycle can be divided into the following
parts:
1. Ovarian cycle
2. Uterine cycle
OVARIAN CYCLE
Phase 1: The Follicular phase
 Days 1 through 13
 It's called the follicular phase because growth or
maturation of the egg is taking place inside the
follicle, a small sac where the egg matures.
 Ovulation occurs around day 14 of the cycle
Phase 2: The Luteal phase
 Days 14 through 28
 Time of ovulation until the first day of
menstruation,
 It is a structure that grows in the ovary where a
mature egg was released at ovulation.
 The luteal phase has a more precise timeline
and usually is only 12-16 days from the day of
ovulation
OVULATION
 An egg (ovum) lives 12-24 hours after leaving
the ovary
 Normally only one egg is released each time of
ovulation
 Ovulation can be affected by stress, illness or
disruption of normal routines
 Some women may experience some light blood
spotting during ovulation
 Implantation of a fertilized egg normally takes
place 6-12 days after ovulation
 Each women is born with millions of immature
eggs that are awaiting ovulation to begin
 A menstrual period can occur even if ovulation
has not occurred
 Ovulation can occur even if a menstrual period
has not occurred
Some women can feel a bit of pain or aching, near the
ovaries during ovulation. This is called
"MITTLESCHMERZ"
 If an egg is not fertilized, it disintegrates and is
absorbed into the uterine lining
 Sperm can live in a woman's body up to 5 days
after intercourse, though more often 2 days.
 Pregnancy is most likely if intercourse occurs
anywhere from 3 days before ovulation until 2-3
days after ovulation.
UTERINE CYCLE
The Menstrual phase (bleeding phase)
 Days 1 to 4 (may last for 3 to 5 day)
 The terminal phase of the menstrual cycle
 Characterized by vaginal bleeding
 About 25 – 60 ml of blood equivalent to 0.4 -1.0
mg of iron lost each day of the cycle
The Secretory phase (luteal phase)
 Days 14 through 28
 Is the time after ovulation
 When an egg is not fertilized, the corpus luteum
gradually disappears, estrogen and
progesterone levels drop, and the thickened
uterine lining is shed.
The Proliferative phase (follicular phase)
 Days 5 through 14; last about 9 days
 The regenerative phase
 Is the time after menstruation and before the
next ovulation,
 The lining of the uterus increases rapidly in
thickness and the uterine glands multiply and
grow.
WHAT HAPPENS DURING MENSTRUAL CYCLE?
PITUITARY GLAND
 Follicle Stimulating Hormone (F.S.H.)
 Luteinizing Hormone (L.H.).
 OVARIES stores thousands of Follicles
 Ovarian follicles are the basic units of female
reproductive biology.
 They contain a single oocyte (immature ovum or
egg).
 These eggs/ova are developed only once every
menstrual cycle
Discomforts of Menstruation
 Breast tenderness and feeling of fullness
 Tendency towards fatigue
 Temperament and mood changes – because of
hormonal influence and decreased levels of
estrogen and progesterone
 Discomfort in pelvic area, lower back and legs
 Retained fluids and weight gain
Abnormalities of Menstruation

 Amenorrhea – absence of menstrual flow

 Dysmenorrhea – painful menstruation
 Oligomenorrhea – scanty menstruation
 Polymenorrhea – too frequent menstruation
 Menorrhagia -excessive menstrual bleeding
 Metrorrhagia – bleeding between periods of
less than 2 weeks
 Hypomenorrhea – abnormally short
menstruation
 Hypermenorrhea – abnormally long
menstruation
PLACENTA AND UMBILICAL CORD
PLACENTA is formed by the:
 chorionic villi at the base of the implanted
fertilized ovum and the decidua basalis
 endometrium at the side of implantation
Between days 6 and 14, implantation (the adhering of
the blastocyst to the wall of the uterus) occurs.
 The placenta also begins to form.
 At this stage, there are no more embryonic
stem cells.
By the 3rd week of pregnancy the placenta begins to
form in the uterus.
 The placenta is the connection between the
mother and the embryo which provides a
supply of oxygen and nutrients, while keeping
the mother and embryo’s blood supplies
separate.
Nutrients and oxygen are exchanged through diffusion.
The placenta is the embryo’s organ of respiration,
nourishment, and excretion.
PLACENTA
 Fully- functional by the 12th week
2 sides of placenta:
 maternal side which is irregular and is divided
into subdivisions called cotyledons-DUNCAN
 fetal side covered by amnion, so it is smooth
and shiny -SCHULTZ
UMBILICAL CORD
 a structure that connects the fetus to the
placenta.
 has 2 arteries and 1 vein
 2 arteries carry deoxygenated blood from the
fetus to the placenta
 1 vein carries oxygenated blood to the fetus,
along with nutrients, hormones etc.
In the fetal circulatory system, the umbilical vein
transports blood rich in O2 and nutrients from the
placenta to the fetal body.
Special Structures:
 Foramen Ovale
 Connects the left and right atria
 Bypassing fetal lungs
 Obliterated after birth to become fossa ovalis
 Umbilical Vein
 Brings oxygenated blood coming from the
placenta to the heart and liver
 Becomes ligamentum teres
Umbilical arteries
 Carry unoxygenated blood from the fetus to
placenta
 Become umbilical ligaments after birth
Ductus venosus
 Carry oxygenated blood from umbilical vein
to IVC
 Bypassing fetal liver
 Becomes ligamentum venosum after birth
Ductus arteriosus
 Carry oxygenated blood from pulmonary
artery to aorta
 Bypassing fetal lungs
FETAL CIRCULATION
1. Blood from the placenta is carried to the fetus by
the umbilical vein. About half of this enters the fetal
ductus venosus and is carried to the inferior vena
cava, while the other half enters the liver proper
from the inferior border of the liver. The branch of
the umbilical vein that supplies the right lobe of the
liver first joins with the portal vein.
2. The blood then moves to the right atrium of the
heart. In the fetus, there is an opening between the
right and left atrium (the foramen ovule), and most
of the blood flows through this hole directly into the
left atrium from the right atrium, thus bypassing
pulmonary circulation.
3. The continuation of this blood flow is into the left
ventricle, and from there it is pumped through the
aorta into the body. Some of the blood moves from
the aorta through the internal iliac arteries to the
umbilical arteries, and re-enters the placenta,
where carbon dioxide and other waste products
from the fetus are taken up and enter the maternal
circulation.
4. Some of the blood entering the right atrium does
not pass directly to the left atrium through the
foramen ovule, but enters the right ventricle and is
pumped into the pulmonary artery. In the fetus,
there is a special connection between the
pulmonary artery and the aorta, called the ductus
arteriosus, which directs most of this blood away
from the lungs
DEVELOPMENT OCCURS IN SYSTEMATIC MANNER
FROM HEAD TO TOE
FROM PROXIMAL TO DISTAL
FROM GENERAL TO SPECIFIC
or described in general term of TRIMESTER
 1st trimester - 12 weeks
 2nd trimester - 13 to 27 weeks
 3rd trimester - 28 to 40 weeks
EMBRYONIC STAGE
 Week 4 - (wt 0.4g, length is 4- 6mm), half the size of
a pea, brain differentiates, G.I. tract begins to form,
limbs buds appear
 Week 5 - cranial nerves present, muscles have
innervation ( L 6-8mm)
 Week 6 - fetal circulation established. Liver
produces red blood cells, CNS forms, primitive
kidney forms, lung buds present, cartilage forms,
primitive skeleton forms, muscles differentiate.
 Week 7 - eyelids form, palate and tongue form
stomach formed, diaphragm formed, arms and legs
move (L 22-28mm)
 Week 8 - resembles human being, eyes move to
face front, heart development complete, hands and
feet well formed; bone cells begin to replace
cartilage, all body organs have begun forming (wt-
2g, L 3cm,)
 By the end of the 8th week of pregnancy the
embryo is called a fetus and all of the major
structures are present
FETAL STAGE
 Week 9 - fingers and toenails form; eyelids fuse shut
 Week 10 - head growth slows, islets of langerhans
differentiated, bone marrow Forms, rbc produced;
bladder sac forms, kidneys make urine
o ( wt-14g,L 5-6cm C – H )
 Week 11 - tooth buds appear, liver secretes bile:
urinary system functions, insulin forms in pancreas
 Week 12 - lungs takes shape, palate fuses, heart
beat heard with Doppler, ossification established,
swallowing reflex present; external genitalia, male
or female distinguished
 Week 16 - meconium forms in bowels, scalp hair
appears, frequent fetal movement, skin thin and
pink ,sensitive to light, 200 ml of amniotic fluid
 Week 20 - myelination of spinal cord begins,
peristalsis begins, lanugo covers body; vernix
caseosa covers body, brown fat deposit begins,
swallows and sucks amniotic fluid, heart beat heard
by fetoscope, hands can grasp, regular schedule of
sucking , kicking and sleeping ( wt 435 g L
19cm)
 Week 24 - alveoli present in lungs/ begin
producing surfactant , eyes completely
o formed, eyelashes and eyebrows appear,
many reflexes appear, (+) chance of
survival if born
 Week 28 -subcutaneous fat deposits begin; lanugo
begins to disappears, nails appear, eyelids open
and close ; testes begin to descend
 Week 32 - more reflexes present, CNS direct
rhythmic breathing movement/ partially controls
body temperature, begins storing iron, calcium
phosphorus; ratio of lungs surfactant lecithin and
sphingomyelin is 1.2:2
 Week 36 - a few creases on soles of feet, skin less
wrinkled, fingernails reach fingertips, sleep-wake
cycle fairly definite, transfer of maternal antibodies
 Week 38 - L/S ratio 2:1
 Week 40 - lanugo only on shoulders and upper back;
creases cover sole, vernix mainly in folds of skin, ear
cartilage firm, less active, limited space, ready to be
born
System development
 All systems in the fetus begin forming by the
8th week
 Cardiovascular system – primitive heart begins
to beat on the 21st day following conception
,the 1st to function in the embryo;
 Congenital malformation may develop during
the 6th to 8th weeks
 ASSESSING FETAL WELL BEING TERATOGENS

Fetal heart rate A “teratogen” is any exposure that can cause harm to
Fetoscope an unborn or breastfeeding baby.
Doppler

 Daily fetal movements count (Fetal kick count) RISK

 Quickening- Movement felt by the mother.
BIRTH DEFECTS
 Occurs approx. 18 - 20 weeks of pregnancy.
 Peaks- 28 to 38 wks  3-5%
 The pregnant woman reports at least 10  will increase if expose to teratogens.
movements in 12 / hours.
 Absence of fetal movements precedes
MISCARRIAGE
intrauterine fetal death by 48 hours.
 25% Decreases to 10% on the eighth
week
 Rhythm Strip Testing record - assessing FHR for  Will increase upon teratogenic
whether a good baseline rate and both long- and exposure
short- term variability are present. Record FHR for
20 min.  Cigarette Smoking
 Nonstress Testing- measure the response of the  Miscarriage
FHR to fetal movement.  Stillbirth
 Ultrasonography- measure the response of the  low birth weight
sound waves againts solid object  premature birth
 Doppler Umbilical Velocity- measure the velocity at  Sudden Infant Death Syndrome (SIDS)
which red blood cells in the uterine and fetal vessel  possible increase in developmental delays
travel.  1% risk for cleft palate
 Placental Grading for maturity- placenta can be  and failure to thrive
graded by ultrasound based on the particular
amount of calcium deposited its presenting the
base.
 0 : between 12 and 24 weeks
 1 : 30 to 32 weeks
 2 : 36 weeks
 3 : 38 weeks (Because fetal lungd are apt to
be measure by 38 weeks, a grade 3 placenta
suggests that fetus is mature.

 Amniotic Fluid Volume- measure the the amount

of amniotic fluid to estimate fetal health. Between
28 and 40 weeks, the total pockets of amniotic
revealed by sonogram average 12 to 15 cm .
 Hydramnios- amount greater than 20 to 24
cm( excessive fluid , perhaps caused by inability of
the fetus to swallow)
 Oligohydramnios - amount of amniotic fluid less
than 5 to 6 cm . ( perhaps cause by poor perfusion
and kidney failure.