REPRODUCTIVE ANATOMY & PHYSIOLOGY

EARLY DEVELOPMENT

• Male & Female organs– produce sex cells– transport for union

• Sex Differentiation at 8 weeks of life– Ovary - produces oogonia at 10 weeks of fetal

life; approximately 150,000 oocytes present at birth

– Testes - produces spermatoza at 7-8 weeks

Reproductive Anatomy• External Organs

– Mons Pubis– Labia Majora– Labia Minora– Clitoris– Vaginal Vestibule

• Urethral meatus• Skene’s Glands• Hymen• Fourchete• Perineum

Figure 2–1 Female external genitals, longitudinal view.

Reproductive Anatomy con.

• Internal Organs– Vagina– Uterus

• Fundus• Corpus • Isthmus• Cervix

Figure 2–2 Female internal reproductive organs.

Layers of the Uterus

• Perimetrium– outer layer composed of peritoneum

• Myometrium – inner layer primarily in the fundus; longitudinal fibers;

causes cervical effacement and power to express the baby• Endometrium

– innermost layer, produces endometrial milk, undergoes monthly regeneration

Figure 2–4 Structures of the uterus.

Myometrium

• Muscular Layer - composed of 3 distinct layers– Longitudinal fibers found mainly over the fundus;

most involved with birth of fetus– Fibers interlaced with blood vessels in Figure 8

pattern; living ligature – helps stop bleeding– Circular fibers concentrated around fallopian

tubes and cervical os; helps keep cervix closed

Figure 2–5a Uterine muscle layers. Muscle fiber placement.

Internal Organs con.• Isthmus

– Joins corpus to the cervix– Site for lower C/S

• Cervix– Composed of fibrous connective tissue– Length 2.5 to 3 cm (~1-2”)– Functions

• Passage of menses and sperm• Produces mucus in response to cyclic hormones• Frequent site for uterine cancer

Bottom of Cervix, Cells are taken from here for Pap Smear

Uterine LigamentsThink which ligaments cause pain during pregnancy

• Broad ligament – stabilizes uterus, covers uterus anteriorly and posteriorly

• Round ligament – helps keep uterus in place from the sides, pain on sides late in pregnancy

• Ovarian ligament – anchors lower part of ovary, helps catch ovum in fimbriae

• Cardinal ligament – chief uterine support, prevents uterine collapse

• Uterosacral ligament – support for uterus at level of the ischial spine, source of menstrual pain

Figure 2–5b Interlacing of uterine muscle layers.

Figure 2–6 Uterine ligaments.

Fallopian Tubes

• Functions – provide passageway for ovum into uterus, site for fertilization

• Fimbriae – most distal part, wavelike motion that pulls ovum into tube

• Ampulla – site for fertilization• Isthmus - close to uterus, site for BTL

Figure 2–7 Fallopian tubes and ovaries.

Ovaries

• At birth, all ova are contained within immature follicles

• Functions1) Ovulation2) Produce hormones

Bony Pelvis• Functions – to support and protect the internal

organs of reproduction• Innominate Bones

– Ilium – upper prominence of hip– Ischium – under the ilium, ends in ischial tuberosity,

serves as reference point for station– Pubis – (2 separate bones) front of innominate, meets

other to form symphysis pubis• Sacrum – 5 fused vertebrae, sacral promontory• Coccyx – (Tail bone) triangular bone last on

vertebral column, moves backward in childbirth (Sometimes can get fx’d during childbirth)

Figure 2–8 Pelvic bones with supporting ligaments.

Pelvic Floor (Muscles)

• Designed to overcome force of gravity• Provides stability and support for surrounding

structures (Help body remain intact, until baby is ready for birth)

• Pelvic diaphragm – deep fascia, levator ani, and coccygeal muscles

• Muscles function as a whole, yet are able to move over one another – provides capacity for dilatation

Figure 2–9 Muscles of the pelvic floor. (The puborectalis, pubovaginalis, and coccygeal muscles cannot be seen from this view.)

Pelvic Division

• False Pelvis – portion above pelvic brim or inlet; serves to support pregnant uterus; helps direct presenting part into true pelvis

• True Pelvis – portion below linea terminalis; represents the bony limits of the birth canal

• Pelvic inlet – upper border of true pelvis• Pelvic outlet – lower border of true pelvis

Figure 2–10a Female pelvis. False pelvis is shallow cavity above the inlet; true pelvis is deeper portion of cavity below the inlet.

Figure 2–10b True pelvis consists of inlet, cavity (midpelvis), and outlet.

Figure 8–5a Manual measurement of inlet and outlet. Estimation of the diagonal conjugate, which extends from the lower border of the symphysis pubis to the sacral promontory.

Figure 8–5b Estimation of the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum.

Pelvic MeasurementsHelps figure whether baby’s head can fit.

• Diagonal conjugate – extends from the subpubic angle to the middle of the sacral promontory; can be measured manually (with hand) during a pelvic exam– Take and substract 1.5cm to get Obstetric conjugate.

• Obstetric conjugate – extends from the middle of the sacral promontory to 1 cm below the pubic crest (Cannot be reached/measured manually)

• Conjugate vera – extends from the middle of the sacral promontory to the pubic crest

Figure 2–11 Pelvic planes: coronal section and diameters of the bony pelvis.

Figure 8–5 c & d Methods that may be used to check the manual estimation of anteroposterior measurements.

C

D

Figure 8–6 Use of a closed fist to measure the outlet. Most examiners know the distance between their first and last proximal knuckles. If they do not, they can use a measuring device.

Pelvic Types

• Gynecoid – most common female, adequate• Android – most common male, not adequate• Anthropoid – usually adequate• Platypelloid – usually not adequate

Figure 15–1 Comparison of Caldwell-Moloy pelvic types.

Female Sex Hormones• Estrogen

– Maturation of secondary sex characteristics– Secreted by the maturation of ovarian follicles– Cause proliferation of endometrial mucosa– Causes increase in size and weight; closure of long bones– Increases myometrial and fallopian tube contractility– Increases uterine sensitivity to oxytocin– Maintains bone density– Inhibits FSH production and stimulates LH production– May increase libido

Female Sex Hormones con.

• Progesterone “keeps everything quiet”; maintains pregnancy– LH stimulates corpus luteum to secrete progesterone– Decreases motility and contractility of uterus– Proliferates vaginal epithelium– Causes cervix to secrete thick viscous mucus

• Anti-sperm– Prepares breast tissue for lactation– Thermogenic “heat producing”

• check temp to determine ovulation– “Hormone of Pregnancy”

Female Sex Hormones con.

• Prostaglandins– Produces by the endometrium “lining of the uterus”– Differentiated by Roman letters and numbers or Greek

numbers– Essential for ovulation (help egg be expelled from the

ovary)– Causes expulsion of the ovum– Produces progesterone withdrawal– Facilitates tissue digestion to cause endometrial

shedding

Neurohormonal Basis of the Female Reproductive Cycle

Causes menses cycle to occur

• Controlled by an interaction between the nervous and endocrine systems and their target tissues – hypothalamus, anterior pituitary, and ovaries

NEUROHORMONAL BASIS OF THE FRC

• CNS --- HYPOTHALMUS RELEASES ----GnRF (FSHRH & LHRH) ------CAUSES ANTERIOR PITUITARY TO RELEASE FSH & LH ---- STIMULATES GONADS TO SECRETE HORMONES (ESTROGEN & PROGESTERONE)

• In males, LH induces secretion of testosterone. • In females, LH working w/ FSH stimulate follicle growth in

ovary to secrete estrogen.

Ovarian CycleBe able to know which cycle the woman is in

• 1st Part- Follicular Phase (Follicles- where the immature eggs are contained)– Starts with day 1 menses; 1-14 days; may vary– multiple follicles are maturing; one is selected; when mature,

called a graafian follicle; surrounded by fluid …and becomes a cyst on the ovary.

– Comes close to surface of ovary, forms a blister, ovum pushed out of the follicle near the fimbria (ovulation)

– Pain at mid-cycle Mittelschmerz (may see blood spotting)– Pulled into fallopian tube and travels to ampulla where

fertilization can occur

Ovarian Cycle con.• 2nd Part- Luteal Phase

– Begins with ovulation (the second half of ovarian cycle)– Corpus luteum develops from the ruptured follicle– If fertilized, the ovum implants into endometrium– Ovum secretes HCG to maintain corpus luteum; the corpus luteum

secretes progesterone and estrogen (cause you have to have high levels of H to maintain preg)

– If no fertilization, degenerates in about a week and becomes the corpus albicans

– Estrogen and Progesterone decrease which stimulates FSH and LH to be released which will start whole cycle over again.

– 14 days after ovulation, menses begins (this remains constant) A person can then predict ovulation.

Figure 2–14 Various stages of development of the ovarian follicles.

Endometrial Cycle- 4 Phases• 1) Menstruation

– Cyclic uterine bleeding in response to hormones changes; begins 14 days after ovulation

– Partial shedding of the endometrium – Discharge made up of blood, fluid, cervical and vaginal

secretions, bacteria, leukocytes and cellular debris; dark red, distinctive odor

– Menarche- onset of menstruation; age 9-16– Cycle lengths vary 21- 36 days; illness, fatigue, stress,

anxiety, vigorous exercise can alter cycle

Endometrial Cycle con.• 2) Proliferative

– Endometrium increases 6-8 fold, estrogen incr/peaks, cervical mucus becomes thin (to allow sperm to pass), BBT drops at ovulation then increases (Progesterone levels incr)

• 3) Secretory– Estrogen decreases, progesterone dominates, vascularity of uterus

increases, glands begin to secrete endometrial milk for fertilized ovum• 4) Ischemic

– If no fertilization, corpus luteum begins to degenerate; estrogen and progesterone levels fall; leads to tissue necrosis and small blood vessels rupture, arteries constrict decreasing blood supply to endometrium; tissue pale, menses begins

Figure 2–13 Female reproductive cycle: interrelationships of hormones with the four phases of the uterine cycle and the two phases of the ovarian cycle in an ideal 28-day cycle.

Physical and Psychological Changes of Pregnancy

Three Pregnancy Periods

Antepartum- from conception to the onset of labor

Intrapartum- from the onset of labor to the first 1-4 hours after delivery of newborn and placenta

Postpartum- refers to the 6 weeks after delivery of the newborn and placenta.

Pregnancy

• Nine months of pregnancy are divided into three trimesters, each are three months long.

• All systems of a woman’s body are altered in some way during pregnancy.

Changes of the Reproductive System

• Uterus - increases in capacity and size; requires one-sixth of maternal blood flow.

• Braxton Hicks - irregular contractions, usually painless, felt throughout pregnancy, can be confused with true labor later in pregnancy

• Ovaries – stop ovulation; corpus luteum continues to produce hormones until 6-8 weeks

Change in the Reproductive System

• Cervix - secretes mucus that forms a plug – Goodell’s sign - softening of the cervix– Chadwick’s sign - bluish color of the cervix during pregnancy

• Vagina - mucosa thickens and connective tissue relaxes; pH acidic favors yeast

Changes in the Reproductive System cont

• Breasts - increase in size and number of glands

• Colostrum - thin yellow secretion high in protein and immune properties

Changes in the Cardiovascular System

• Cardiac output - increases 30-40% • Pulse – increases 10-15 bpm• BP - decreases in the 1st and 2nd trimesters;

3rd trimester increases to pre-pregnant levels • Vena cava syndrome – (Caution!) uterus

compresses the vena cava S/S: pallor, dizziness and clammy skin

Figure 7–1 Vena caval syndrome. The gravid uterus compresses the vena cava when the woman is supine. This reduces the blood flow returning to the heart and may cause maternal hypotension.

Caution for Vena cava syndrome!!! Keep head elevated or turn to one side.

Cardiovascular System cont

• Blood (More volume, but blood is diluted)

– volume increases 45% – RBCs increase 18 to 30% – Plasma volume increases 50%

• Physiologic anemia – more diluted

Changes in the Respiratory System

• Growing uterus elevates the diaphragm• Increased 02 needs• Increased air volume exchange• Nasal stuffiness and epistaxis from increased

estrogen

Changes of the Musculoskeletal System

• Teeth/gums – bleeding gums; oral hygiene important to prevent preterm labor

• Relaxation of the pelvic joints – “Waddling” gait • Physiologic lordosis - lumbar spinal curvature

increases compensating for weight of uterus • Diastasis recti - separation of the rectus abdominal

muscle

Figure 7–3 Postural changes during pregnancy. Note the increasing lordosis of the lumbosacral spine and the increasing curvature of the thoracic area.

Changes of the Gastrointestinal System

• 1st trimester – Incr HCG causes N/V• Increased progesterone levels – causes

decreased peristalsis reflux and constipation (Fiber and fluids important)

• Hemorrhoids - constipation and increased pressure on blood vessels in the rectum

Changes of the Renal System

• Urinary frequency • Glomerular filtration - increases 50%

• Glycosuria – more prone to develop gestational

diabetes.

Changes in the Integumentary System

• Increased pigmentation - areola, nipples and vulva

• Chloasma - mask of pregnancy

• Linea nigra - darkly pigmented line from umbilicus to the pubic area

• Striae gravidarum - stretch marks

• Sweat and sebaceous gland activity increases

Changes in the Endocrine System

• Metabolism - increases• Weight gain – Norm 3 to 5 pounds 1st

trimester; 1 pound/week 2nd and 3rd trimesters. (Avg 25-35lb incr throughout preg)

• Water retention - increased sex hormones and decreased serum protein

Endocrine System cont• Hormones

– Human chorionic gonadotropin (hCG)- Present only during preg, causes the N/V

– Human placental lactogen (hPL)- Maintainance of preg; is an insulin antagonist; it promotes lipolysis.

– Estrogen- incr growth of uterus and stimulates the breast for lactation.

– Progesterone “keeps uterus quiet” maintains the endometrium, decreased uterine contractility, and causes relaxation of smooth muscle.

– Relaxin- decreases uterine contractility, contributes to the softening of the cervix

– Postaglandins- some contract, some relax

Signs and Symptoms of Pregnancy

• 3 categories: presumptive, probable and positive.– 1) Presumptive – woman reports

• Amenorrhea • Nausea and vomiting• Fatigue• Urinary frequency• Breast changes- tender/darker• Quickening- From feeling the baby move

• Define: Quickening- the process of showing signs of life.• Define: Presumptive- signs of pregnancy, ex: morning sickness

Signs and Symptoms of Pregnancy

• 2) Probable - Noted by examiner– Goodell’s sign - softening of cervix– Chadwick’s sign - bluish color, cervix, vagina– Hegar’s sign - softening of lower uterine segment– Enlarged abdomen– Pigmentation changes– Stretch marks– Ballottement- A method of diagnosing pregnancy, in which

the uterus is pushed with a finger to feel whether a fetus moves away and returns again.

– Positive pregnancy test– Palpation of fetal outline

Figure 7–4 Hegar’s sign, a softening of the isthmus of the uterus, can be determined by the examiner during a vaginal examination.

Signs and Symptoms of Pregnancy

• 3) PositiveNoted by examiner - only caused by

pregnancy•Fetal heartbeat•Fetal movement palpable by the

examiner•Visualization of the fetus by ultrasound

Psychological Response of the Expectant Family to Pregnancy

• Turning point in a family’s life • Role changes• Financial changes• Fear and anxiety• Developmental tasks for mom and dad• Cultural values and beliefs

Maternal Reactions and Responses to Pregnancy

• 1st Trimester– Feelings of disbelief and ambivalence– Baby does not seem real– Focuses on herself and pregnancy– May experience early s/s of pregnancy– Introspective– Mood swings– Fantasize about miscarriage (Many women fear

miscarriage, usually w/in the 1st trimester)

Maternal Reactions and Responses to Pregnancy

• 2nd Trimester– Quickening - baby a real separate person.– Mom excited about pregnancy– Helps plan her future and child’s future– Experiences body image changes– Concern about partner’s support

Maternal Reactions and Responses to Pregnancy

• 3rd Trimester– Pride in pregnancy– Anxious about labor– Concern about baby’s health– Surge of energy close to delivery date

Rubin’s Maternal TasksWhat mom wants

• Ensuring safe passage for fetus• Seeking acceptance of fetus by others• Assumption of mother role• Learning to give of oneself on behalf of one’s

child

Paternal Psychological Responses to Pregnancy of Partner

• Pride in pregnancy– virility; Manly character; The ability to procreate

• Ambivalence- a state in which one experiences conflicting feelings (Ambi- “both”) Ex: concerns about readiness

• Stress • Concerns and fears • Couvades- may experience certain rituals during the

fatherhood transition. Also may experience certain pregnancy s/s felt by partner such as nausea, cravings and weight gain.

Other Family Members Reaction

• Sibling rivalry– Threat– Regression– Preparation – Include

• Grandparents– Increase support– Childrearing practices