Nursing 246 Unit I: Women’s Health Care Needs Genetic Males Quick Review: A & P
• Other internal reproductive structures occurring through • Reproductive Development process of differentiation include:
– female/male systems are fundamentally similar – vas deferens
– produce sex cells/transport to locations where their – epididymis union can occur
– seminal vesicle – sex cells - gametes - produced by gonads
– ejaculatory duct
Embryonic Development – prostate/bulbourethral glands develop from urethra
• Genetic sex determined at fertilization External Structures • Male/female systems undifferentiated for 8 weeks • All males and females possess the same external genitals • Followed by period of rapid differentiation until the end of the 9th week
• Differentiation of external genitals is complete by the Ovaries & Testes end of the 12th week • During 5th week of gestation, primitive gonad develops • If fetal testosterone is not present, the external genitals are feminized • in males, the inner portion (medulla) develops into a testis and the outer portion (cortex) regresses
• When external genitals are feminized, the phallus • in females, the cortex develops into an ovary, and the becomes the clitoris, the urogenital folds become the medulla regresses labia minora, and the labioscrotal folds become the labia majora. Oogenesis • If fetal testosterone is present, the external genitals • Ovary produces oogonia become masculine. The phallus lengthens and become the penis. Fusion of urogenital folds becomes penile • These are primitive egg cells which become primitive urethra, and the urethral meatus moves toward the glans eggs called oocytes Female Reproductive System • No oocytes are formed after fetal development
• External Genitals • All the eggs available for maturation in a woman’s reproductive life are present at birth – mons pubis
– labia majora • About 150,000 oocytes are contained in the ovaries at birth – labia minora • Each oocyte is contained a a small ovarian cavity called a – clitoris primitive follicle – urethral meatus and opening of Skene’s glands • During the reproductive years, monthly an oocyte – vaginal vestibule undergoes cellular division & maturation becoming a fertilizable egg (ovum). Those left degenerate over time. – perineal body Mons Pubis
Spermatogenesis • Mound of subcutaneous fatty tissue which covers the anterior portion of the symphysis pubis • Each testis produces male gametes (spermatozoa or sperm) through a process called spermatogenesis • Covered with pubic hair • This process does not occur until puberty • Protects pelvic bones, especially during coitus Labia Majora • See Figure 10-1
• Longitudinal raised folds of skin on either side of the Genetic Females vulvar cleft • Other internal reproductive structures occurring through • Labia majora protect structures lying between them process of differentiation include: • inner surface in women who have not had children is – fallopian tubes moist and looks like mucous membrane, but becomes more skinlike and less prominent with each pregnancy – vagina
• Extensive venous network – urethral/paraurethral glands
– Bartholin’s glands
• Old Wive’s Tale that the hymen covers the vaginal • varicosities may occur during pregnancy opening and if intact, is a sign of virginity • Hematomas are not uncommon after birth trauma or • Hymen surrounds, rather than covers the vaginal opening sexual trauma and can be broken not only through sex but other strenuous activity, masturbation, menstruation, or use of • Shares extensive lymphatic system with other structures tampons of the vulva and can spread cancer quickly
• Bartholin’s glands are located externally to the hymen at • some regional anesthesia blocks cause numbness the base of the vestibule Labia Minora
• They secrete a clear and thick mucus which enhances the • Soft folds of skin within the labia majora that converge viability and motility of the sperm deposited in the near the anus, forming the fourchette vaginal vestibule • Has appearance of mucous membrane, shiny, moist, and • These ducts can harbor gonorrhea and other bacteria, hairless making them a common place for suppuration and abcesses • Rich in sebaceous glands, so sebaceous cysts common here Perineal Body
• Wedge-shaped mass of fibrous, muscular tissue found • Composed of erectile tissue and involuntary muscle between the lower part of the vagina and the anal canal tissue • The superficial area between the anus and vagina is • Vulvovaginitis very irritating because lots of tactile called the perineum nerve endings • Many muscles meet here, allowing a remarkable amount Labia minora increase in size at puberty and decrease of stretching after menopause due to changes in estrogen levels • This area thins during pushing until it is only a few cms Clitoris thick (episiotomy area) • 5-6 mm long and 6-8 mm across, located between the Female Internal Reproductive Organs labia minora • Vagina • composed of erectile tissue • Uterus • glans is partially covered by a fold of skin called the • Fallopian Tubes prepuce, or hood
• Ovaries • This area may be confused with the urinary meatus • These are target organs for estrogenic hormones and play • Very rich blood and nerve supplies a unique part in the reproductive cycle • Primary erogenous organ of women Vagina
• Muscular and membranous tube that connects the • secretes smegma, which along with other vulval external genitals to the uterus secretions has a unique odor which may be sexually stimulating to a man • Also called birth canal, because the fetus must pass through here during birth • In some cultures, the clitoris is removed: “female circumcision” • Cervix of the uterus projects into the upper part of the Urethral Meatus & Paraurethral Glands vagina
• Urethral meatus is located 1 - 2.5 cms below the clitoris • Upper portion of vagina called vaginal vault, with the area around the cervix called the vaginal fornix • appears as puckered, slitlike opening • Walls of the vaginal vault are very thin, so many structures can be palpated through them • May be difficult to visualize due to mucosal folds, blind dimples, or wide variations in location – uterus --- distended bladder • Skene’s glands open into the posterior wall of the urethra – ovaries and lubricate the vagina Vaginal Vestibule – appendix
– cecum • Boat-shaped depression enclosed by labia majora and visible when they are separated – colon
– ureters • It contains the introitus (vag opening), which is the border between the internal and external genitals • Fornix allows pooling of semen • Hymen is the collar of tissue that surrounds the vaginal • Collection of large amount near cervix at or near time opening ofovulation increases chances of becoming pregnant • At puberty, hymen becomes more full due to increasing • Vaginal walls are covered in rugae, allowing this tissue estrogen levels to stretch for delivery of a baby
Rich blood supply is necessary – Usually the uterus bends forward sharply • Vaginal environment is normally acidic (anteverted). This is normal.
• Secretions provides a moist environment • Uterus has 3 sets of supports: • Acidic environment maintained by a symbiotic – upper - broad and round ligaments relationship between lactic-acid producing bacilli and the vaginal epithelial cells – middle - cardinal, pubocervical, uterosacral • Any interruption in this balancing act can destroy the – lower - pelvic muscular floor self-cleaning action of the vagina
• Interruption may be caused by antibiotic therapy, • Uterus is divided into two parts: douching, or use of vaginal sprays or deodorants • Corpus (body) - upper 2/3, composed mainly of a smooth • Acidic environment present only during reproductive muscle layer (myometrium) years and first few days of life
• Lower 1/3 is the cervix, or neck • The vagina is divided into thirds for vascular and lymphatic systems. There are many venous anastamoses. • Isthmus - the slight constriction in the uterus that divides it into these two unequal parts • Pudendal nerve supplies what relatively little somatic innervation there is to the lower third of the vagina. • Rounded uppermost portion of the body of the uterus is Vaginal sensation during coitus is minimal, as is vaginal the fundus pain during second stage of labor • It is in the area of the isthmus that the uterine lining • Vagina has the following functions: changes into the mucous membrane of the cervix
– serve as passageway for sperm and for the fetus • During pregnancy, the isthmus becomes the lower during birth uterine segment and does not contract (along with the cervix). This is the site for cesarian births. – provide passage for menstrual blood flow from the uterine endometrium to the outside • There are extensive blood and lymphatic supplies to the – protect against infection from pathogenic organisms uterus • entirely innervated by the autonomic nervous system Uterus
• Numerous folk tales abound about the uterus • Even hemiplegic women can have adequate uterine contractions • hollow, muscular, thick-walled organ shaped like an upside-down pear, lying in the pelvic cavity between the • Pain of uterine contractions is carried to the CNS by the base of the bladder and the rectum and above the vagina 11th and 12th thoracic nerve roots. • Uterus lies below the pelvic brim; the cervix about the • Pain from the cervix and upper vagina passes through the level of the ischial spines ilioinguinal and pudendal nerves
• Motor fibers to the uterus arise from the 7th and 8th • The mature uterus weighs 50-70 gms and is 6 - 8 cms thoracic vertebrae long
• Because the sensory and motor levels are separate, • uterine anomalies are thought to be congenital: epidural anesthesia can be used during labor and birth – bicornuate uterus (two-horned) • Function of the uterus: – didelphys uterus (double uterus) – provide a safe environment for fetal development – These two anomalies are associated with habitual – uterine lining is cyclically prepared by steroid abortion hormones for implantation of the embryo (nidation) • Both the urinary and reproductive systems develop from – Once implanted, the embryo is protected until it is the same urogenital fold in the embryo, anomalies in one expelled system are frequently accompanied by anomalies in the – uterine body never returns to pre-pregnant size other – external cervical os changes from circular opening • Body of uterus is freely movable; only the cervix is to slit with irregular edges anchored laterally Uterine Corpus
• Position of uterus can vary, depending on: • Made up of three layers:
– woman’s posture – outermost (serosal layer) - perimetrium
– number of children borne – middle (muscular uterine layer) - myometrium
– bladder and rectal fullness – innermost (mucosal layer) - endometrium
– even respiratory patterns • Muscular middle layer is continuous with the muscle layer of the fallopian tubes and the vagina (also the ovarian, round, cardinal ligaments and to some extent the
uterosacral ligaments) which explains common female Uterine Ligaments complaint of “pelvic aches and pains” • Uterine ligaments support/stabilize the various reproductive organs • Myometrium has 3 distinct layers of involuntary smooth muscles • Broad ligament - keeps the uterus centrally placed and provides stability. Double layered and continuous with – outer layer over the fundus are longitudinal muscles abdominal peritoneum. Covers the uterus anteriorly and that work to expell the fetus during delivery posteriorly and extends to enfold and stabilize the – middle layer is thick and made of interlacing fibers fallopian tubes. Between the folds of the broad ligament in figure-8 patterns surrounding large blood vessels. are connective tissue, invol muscle, blood and lymph Their contraction produces a hemostatic action to vessels, and nerves. stop bleeding after birth Round ligaments keep the uterus in place. These arise from the sides of the uterus. They extend outward and eventually – Inner muscle layer forms sphincters at the fallopian fuse with the tissue of the labia majora. These enlarge during tube sites and around the internal os. The internal os pregnancy. During labor, these ligaments force the fetal sphincter inhibits the expulsion of the fetus during presenting part into the cervix. pregnancy, but stretches during labor. The fallopian tube sphincters prevent menstrual blood • Ovarian ligaments - anchor the lower section of the fromflowing backward into the tubes from the ovary to the cornua of the uterus. These contract and help uterus. the fallopian tubes fimbriae to catch the ovum as it is released each month. • These muscle layers also work together, causing uterine contractions which are responsible for the dilatation of • Cardinal ligaments - chief uterine supports, prevent the cervix and provide the major force for the passage of uterine prolapse and also support the upper vagina the fetus through the pelvic and vaginal canal at birth. • infundibulopelvic ligments - suspends and supports the ovaries and contains the ovarian vessels and nerves • Endometrium is composed of a single layer of columnar epithelium, glands, and stroma. The endometrium • uterosacral ligaments - provide support for the uterus and undergoes monthly renewal and degeneration in the cervix at the level of the ischial spines, they also contain absence of pregnancy, from puberty to menopause. sensory nerve fibers that contribute to dysmenorrhea Fallopian Tubes • Endometrium varies in thickness from 0.5mm to 5 mm.
• These arise from the side of the uterus and reach almost • Glands of endometrium produce a watery, thin, alkaline to the side of the pelvis, where they turn toward the secretion, keeping uterine cavity moist. This ovaries.These tubes link the peritoneal cavity with the “endometrial milk” assists sperm as they travel to the uterus and vagina fallopian tubes, but also nourishes the developing embryo prior to implantation. • Each fallopian tube can be divided into 3 sections: • Blood supply of endometrium is unique. There are coiled – isthmus arteries and straighter arteries. The coiled arteries are more sensitive to cyclic hormonal control. This response – ampulla allows for part of the endometrial tissue to remain intact, – fimbria while other endometrial tissue is shed during menstruation. Once pregnancy occurs, the endometrium • Isthmus is straight and narrow, with a thick muscular is not shed. The stromal cells become the decidua of the wall and a 2-3mm lumen. It is the site of tugal ligation. pregnancy, are highly vascular and channel a rich blood • Ampulla - Curved, comprises the outer 2/3 of the tube. supply to the endometrial surface. Fertilization usually occurs here. Ampulla ends at the Uterine Cervix fimbria. • Narrow neck of the uterus which is canal-like, and Fimbria - funnel-like enlargement with many moving connects the corpus of the uterus to the vagina fingerlike projections reaching out to the ovary. The longest fimbria is actually attached to the ovary. • Vaginal cervix appears pink and ends at the external os
• Tubes are made up of four layers: • Cervical canal appears rosy red and is lined with columnar epithelium, containing mucus-secreting glands – peritoneal (serous) layer-covers the tubes • Most cervical CA begins at this squamocolumnar – subserous (adventitial) layer-contains blood and junction. Exact location varies with age. nerve supply
• Elasticity is chief characteristic of the cervix. – muscular layer-responsible for peristaltic movement of the tube • Ability to stretch due to high fibrous and collagenous content of the supportive tissues and vast numbers of – mucous tissues-composed of ciliated and non-folds ciliated cells
• Cervical mucosa has three functions: • Non-ciliated cells produce a rich serous fluid that – provide lubrication for vaginal canal nourishes the ovum
– act as a bateriostatic agent • Constantly moving cilia propel the ovum toward the uterus. The ovum is large and this action is needed the – provide alkaline environment to shelter deposited assist the tube’s muscular layer peristalsis. sperm from acidic vagina
the woman’s ovaries secrete decreasing amounts of • Malformation or malfunction of the tubes could result in estrogen. Eventually, ovulatory activity ceases, and infertility, ectopic pregnancy, or sterility. menopause occurs. Bony Pelvis
• Tubal Transport System: • 2 unique functions: – active fimbriae close to the ovary – support and protect the pelvic contents – peristalsis of tube created by muscular layer – form the relatively fixed axis of the birth canal Bony Structure – ciliated currents beating toward the uterus • Pelvis made up of four bones: – proximal contraction and distal relaxation of the – two innominate bones tube caused by different types of prostaglandins.
– sacrum • FTs have rich blood and lymph supply, and the unusual – coccyx ability to recover from inflammatory processes (survival of the fittest!)
– Pelvis resembles a bowl or basin. Its sides are the • Functions of the FT: innominate bones, and its back is made up of the sacrum and coccyx. The bony pelvis is lined with – provide transport for the ovum (3-4 days) fibrocartilage and held tightly together by ligaments. – provide a site for fertilization The 4 bones join at the symphysis pubis, the two sacroiliac joints, and the sacrococcygeal joints. – serve as a warm, moist, nourishing environment for the ovum or zygote • Innominate bones (hip bones) - made up of three separate Ovaries bones:
• 2 almond-shaped glandular structures just below the – ilium pelvic brim, one on each side of the pelvic cavity – ischium • Size varies accding to woman and stage of the menstrual – pubis cycle
– These bones fuse to form a circular cavity, the • Girls have smooth ovaries, but women of reproductive acetabulum, which articulates with the femur. age have pitted ovaries, due to scarring from ovulation. • Ilium - broad, upper prominence of the hip
• Iliac Crest - margin of the ilium • There is no peritoneal covering for the ovaries. This allows the mature ovum to erupt, but also allows easier • Ischial Spines - site of attachments for ligaments and spread of malignant cells from CA of the ovaries. muscles - juts into pelvic cavity and serves as a reference point to evaluate descent of the fetal head • Three layers:
• Ischium - the strongest bone, ends in a marked – tunica albuginea protuberance on which the weight of a seated body sits – cortex • Pubis - slightly bowed front portion of the innominate – medulla bone. Pubic bones meet to form the joint known as symphysis pubis. Triangular space beneath it is known as • Tunica albugnea - dense, dull white, protective layer the pubic arch. Fetal head passes under this arch during delivery. Hormones of pregnancy relax all these joints • Cortex - main functional part, containing ova, graafian toward the end of pregnancy to aid in the birth process. follicles, ccorpora lutea, degenerated corpora lutea, and degenerated follicles • Sacrum - Wedge-shaped bone formed by the fusion of five vertebrae. It contains a projection into the pelvic • Medulla is completely surrounded by the cortex and cavity known as the sacral promontory, which is another contains nerves, blood and lymphatic vessels. guide in determining pelvic measurements • The last small triangular bone on the vertebral column is • Ovaries are the primary source of 2 important hormones: the coccyx. It usually moves backward during labor to facilitate birth. – Estrogens - associated with characteristics Pelvic Floor contributing to femaleness. Ovaries secrete large amounts of estrogens, the adrenal cortex produces • The pelvic floor is designed to overcome the force of minute amts of estrogens in non-pregnant women gravity exerted on the pelvic organs.
• Deep fascia, the levator ani and coccygeal muscles form – Progesterone - hormone of pregnancy. Placenta the part of the pelvic floor known as the pelvic main site for progesterone during pregnancy. diaphragm. Hormone also prevents lactation during preg. • Levator ani muscle makes up most of the pelvic diaphragm. Made up of 4 muscles: • Interplay between ovarian hormones and others, like – iliococcygeus FSH and LH is responsible for the cyclic changes that allow pregnancy to occur. Between the ages of 45 and 55, – pubococcygeus
Prominent ischial spines. All midpelvic diameters are – puborectalis reduced. Narrow, sharp, and deep pubic arch. Capacity of – pubovaginalis outlet is reduced. Bones are medium to heavy structure Pelvic Division and weight. Approx 20% of female pelves are android. Labor is not favorable. Descent is slow. Fetal head • Pelvic cavity divided into the false pelvis and the true engages in oblique presentation (asynclitism) with pelvis extreme molding. Arrest of labor is frequent, requiring difficult forceps manipulation, and the deep, narrow • False pelvis - portion above pelvic brim and has the pubic arch may lead to extensive perineal lacerations. function of supporting the weight of the pregnant uterus Cesarian birth may be necessary. and directing the presenting part into the true pelvis Anthropoid Pelvis below
• Inlet is oval, with an adequate but short transposterior • True pelvis - portion that lies below the pelvic brim and diameter represents the bony limits of the birth canal.
• has variable ischial spines, straight side walls, narrow • The true pelvis is extremely important in childbearing and long sacrum that incline backward. because its size and shape must be adequate for normal fetal passage during labor and at birth. The relationship • Outlet adequate. of the fetal head to the true pelvic cavity is of critical importance. • Bones of medium weight and structure. • Consists of three parts: • 25% of female pelves are anthropoid. – inlet Platypelloid Pelvis – pelvic cavity • Flat, female pelvis – outlet
• There are distinct measurements associated with each • all diameters are short and shallow part that aid in evaluating pelvic adequacy for delivery. • variable ischial spines, parallel side walls, wide sacrum • Pelvic Inlet - upper border of the true pelvis and is with deep curve inward typically round in females. Measure: diagonal conjugate, obstetric conjugate, and conjugate vera. • Outlet capacity inadequate • Pelvic Cavity - curved canal with longer posterior than • Bones are similar to gynecoid bones anterior wall.
• Pelvic Outlet - lower border of the true pelvis. Size of the • 5 % of female pelves are platypelloid. pelvic outlet can be determined by measurement of the Breasts transverse diameter. • Mammary Glands - considered accessories of the • Coccyx is pushed posteriorly during descent. Decreased reproductive system, are specialized sebaceous glands mobility, large fetal head, and/or forceful birth can cause • Conical and symmetrically placed on either side of the the coccyx to break. chest • Pubic arch has great importance because the baby must pass under it in birth. If arch is narrow, baby’s head may • Cooper’s ligaments suspend the breasts\ be pushed back toward the coccyx, making extension • Left breast frequently larger than right difficult. This is called outlet dystocia and may lead to a forceps or cesarian delivery. Shoulders of a large baby • Breasts develop at slightly different levels in the pectoral may also get stuck under the pubic arch, making birth region in different racial groups more difficult. • Each mature breast has a nipple in the center which is Pelvic Types composed of mainly erectile tissue. • Four basic types of pelves: • The nipple becomes more rigid and prominent during the menstrual cycle, sexual excitement, pregnancy, and – gynecoid lactation – android • The nipple is surrounded by the heavily pigmented areola. Both nipple and areola are covered with small papillae – anthropoid called tubercles of Montgomery. These secrete a fatty – platypelloid substance that helps lubricate and protect the breasts Gynecoid Pelvis while a baby nurses. • Most common female pelvis. Inlet is rounded. Posterior • Composed of glandular, fibrous, and adipose tissue segment is broad, deep, and roomy. Anterior segment is • Glandular tissue consists of acini, or alveoli which are well rounded. Has non-prominent ischial spines, straight arranged in a series of 15 to 24 lobes separated by and parallel side walls, and a wide, deep sacral curve. adipose and fibrous tissue Has a wide and round pubic arch. Capacity of outlet is • Each lobe made up of grapelike clusters of alveoli adequate. Bones of medium structure and weight. around tiny ducts which are lined with cuboidal Approx 50% of female pelves are gynecoid. epethelium, which secretes the components of milk. Android Pelvis Ducts from several lobules combine to form larger lactiferous • Normal male pelvis is android, occasionally seen in ducts, which open on the nipple surface. Smooth muscle of females. Inlet is heart shaped. Posterior sagittal diameter the nipple causes erection of the nipple on contraction. is too short for birth. Posterior segment is shallow.
• Cyclic hormonal control of the breast is complex:
– estrogenic hormones stimulate growth and development of ductal epithelium
– progesterone (w/estrogen) -acinar and lobular development during luteal phase of menstruation
– adrenal corticosteroids, prolactin, somatotropin, and thyroxine also necessary for progesterone and estrogen to act
• Arterial, venous, and lymphatic systems communicate medially with mamary vessels and laterally with axillary vessels. In CA of the breast, metastasis follows the vascular supply both medially and laterally. • What is the function of the breasts?
• Provide nourishment and protective maternal antibodies to infants through the lactation process. Also a source of pleasurable sexual sensation.