1

Objectives:
After mastering the contents of this chapter, you should be able
to:
1) Know the Goals and Philosophy of Maternal and Child
Health Nursing
2) Describe anatomy and physiology pertinent to reproductive
and sexual health.
3) Assess a couple for anatomic and physiologic health and
readiness for childbearing.
4) Explain the physiology of the Menstrual Cycle and the
Fertilization Process.
5) Using the nursing process, plan nursing care that includes
the six competencies of Quality & Safety Education for
Nurses (QSEN): Patient-Centered Care, Teamwork &
Collaboration, Evidence-Based Practice (EBP), Quality
Improvement (QI), Safety, and Informatics.

2
Objectives:
After mastering the contents of this chapter, you should
be able to:
6) Implement nursing care related to reproductive and
sexual health, such as educating adolescents about
menstruation.
7) Evaluate expected outcomes for achievement and
effectiveness of care.
8) Integrate knowledge of preparation for childbearing
with the interplay of nursing process, the six
competencies of QSEN, and Family Nursing to
promote quality maternal and child health nursing
care.

3
 Primary Goal of
Maternal & Child Health Nursing
 Promotion and maintenance of optimal family
health to ensure cycles of optimal childbearing
and childrearing.

4
Scope of Practice:
 Preconceptual health care

 Care of women during 3 trimesters of pregnancy and

puerperium (6 wks. after childbirth)
 Care of infants during the perinatal period (6 wks.
before conception to 6 wks. after birth)
 Care of children from infancy through adolescence

 Care in settings as varied as the birthing room,

pediatric intensive care unit, and the home

5
Philosophy of Maternal & Child
Health Nursing
1. Maternal & Child Health Nursing is family-centered.

2. Maternal & Child Health Nursing is community-

centered.

3. Maternal & Child Health Nursing is research-

oriented.

4. Nursing theory and evidence-based practice provide

a foundation for nursing care.

6
 Philosophy of Maternal & Child
Health Nursing
5. A maternal & child health nurse serves as an
advocate to protect the rights of all family members,
including the fetus

6. Maternal & child health nursing uses a high degree

of independent nursing functions because teaching
and counseling are frequently required, and are the
major interventions.

7. Promoting health and disease prevention are

important nursing roles because these protect the
health of the next generation.
7
 Philosophy of Maternal & Child
Health Nursing
8. Maternal & Child Health nurses serve as important
resources for families during childbearing and
childrearing as these can be extremely stressful times
in a life cycle and can alter family life.

9. Personal, cultural, and religious attitudes

and beliefs influence the meaning and
impact of childbearing and childrearing
on families.

10. Maternal & Child Health Nursing is a challenging

role for the nurse and is a major factor in promoting
high-level wellness in families.
8
SAFE MOTHERHOOD PROGRAM
 The Philippines has committed to the Unites Nation’s
millennium declaration that translated into a roadmap
a set of goals that targets reduction of poverty, hunger,
and ill health.
 In the light of this government commitment, the
Department of Health is faced with a challenge: to
champion the cause of women and children towards
achieving Millennium Development Goals
(MDGs)MDGs 4 (reduce child mortality), 5 (improve
maternal health) and 6 (combat HIV/AIDS, malaria
and other diseases).

9
SAFE MOTHERHOOD PROGRAM
 Pregnancy and childbirth are among the leading
causes for death, disease and disability in women of
reproductive age in developing countries.
 The Philippine government commitment to the MDGs
is among others, a commitment to work towards the
reduction of maternal mortality ratios by three-
quarters and under five mortality by two-thirds by 2015
at all cost.

10
 Goal 3: Ensure healthy lives and
promote well-being for all at all ages
 Targets
 By 2030, reduce the global maternal mortality ratio to less
than 70 per 100,000 live births
 By 2030, end preventable deaths of newborns and children
under 5 years of age, with all countries aiming to reduce
neonatal mortality to at least as low as 12 per 1,000 live births
and under-5 mortality to at least as low as 25 per 1,000 live
births
 By 2030, reduce by one third premature mortality from non-
communicable diseases through prevention and treatment
and promote mental health and well-being
 By 2030, ensure universal access to sexual and
reproductive health-care services, including for family
planning, information and education, and the integration of
reproductive health into national strategies and programmes
11
FEMALE REPRODUCTIVE
ANATOMY

12
Female External Organs
1. Mons pubis or Mons Veneris
 An important landmark
in measuring fundic height
 Protects symphysis pubis from
trauma
 Covered with curly hair
(escutcheon)
 Growth of pubic hair is stimulated by
testosterone, while pattern of hair growth is
governed by estrogen.

13
Female External Organs

2. Labia Majora
 Are 2 thick folds of adipose
tissues originating from the
mons and terminating in the
perineum.
 Main function:
 to provide covering and protection to the
external organs located under it.

14
 Female External Organs
3. Labia Minora
 Are 2 thin folds of connective tissue that joins
anteriorly to form the prepuce and posteriorly
to form the fourchette.
 It is moist, highly vascular,
sensitive and richly supplied
with sebaceous glands.

15
Female External Organs

4. Clitoris
 Highly sensitive and
erectile tissue situated
under the prepuce of
the labia minora.
 Known as the “seat of a
woman’s sexual arousal and orgasm”.
 It is supplied with many sebaceous glands that
produce cheese-like secretion called smegma.

16
Female External Organs
5. Vestibule
 Triangular space between the labia minora
where the vaginal introitus , urethral
meatus , Bartholin’s glands and Skene’s
glands are located.

17
Female External Organs
6. Bartholin’s glands
 Also known as vulvovaginal glands,
paravaginal and major vestibular glands.
 Secretes mucus that helps to keep the
vaginal introitus lubricated.
 Its alkaline nature enhances sperm
survival.

18
Female External Organs
7. Skene’s glands
 A pair of glands also known as paraurethral
and minor vestibular glands.
 Situated at each inner side of the urethral
meatus.
 Secretions of the Skene’s and Bartholin’s
glands increases with sexual stimulation to
provide lubrication to the vagina thereby
facilitating coitus.
19
Female External Organs
8. Vaginal orifice
 Also known as introitus is the external opening of
the vagina located just below the urethral
meatus.
 The Grafenberg or G-spot is a very sensitive area
located at the inner anterior surface of the
vagina.
9. Hymen
 A thin, circular membrane made of elastic tissue
situated at the vaginal opening that separates the
female internal organs from the external organs.
20
Female External Organs
10.Urethral meatus
 Located just below the clitoris
11.Nerve supply
 The anterior portion’s nerve supply is
derived from the L1 (and the posterior
portion is derived from S3).
12.Blood supply
 Blood supply to the vulva is provided by the
pudendal artery and inferior rectus artery.
21
Female Internal Organs
1. Vagina
 A hollow, membranous and muscular canal, about 8 –
12 cm long, located in front of the rectum and behind
the bladder.
 It’s upper portion is separated from the rectum by
the cul-de-sac of Douglas.
 It’s surface is lined by stratified squamous
epithelium.
 The external opening of the vagina is encircled by the
vulvocavernosus muscle that acts as a voluntary
sphincter; Kegel’s exercise improves the tone of this
muscle. 22
Female Internal Organs
1. Vagina
 Innervation to the vagina is provided by the
uterovaginal plexus or Lee Franken Hauser plexus
and S1 – S3 nerves.

23
Female Internal Organs
1. Vagina
 Functions:
 Organ of copulation

 Discharges menstrual flow

 Birth canal

 Rugae
 Function is to allow the vaginal canal to stretch

during coitus and enlarge considerably during

delivery.

24
Female Internal Organs
1.Vagina
 Fornix
 The cervix projects into
the vagina forming four
recesses or depression
around the vagina’s upper
portion that are called fornices, and posterior
fornix (it is in this area that vaginal secretions
collect and semen pools.

25
Female Internal Organs
1.Vagina
 Vaginal pH
 Before puberty: vaginal pH is alkaline (6.8 – 7.2)
 After puberty: vaginal pH is acidic (4 – 5)
 With the advent of puberty, ovary begins to produce
increasing amounts of estrogen which stimulates mucus
production in the cervix.
 Cervix mucus is rich in glycogen; glycogen is converted to
lactic acid by Doderlein bacilli (a bacteria normally present in
the vagina, making the vaginal environment acidic); this low
vaginal pH helps control the growth of pathogenic
microorganisms that may cause vaginal infections.
26
Female Internal Organs
1.Vagina
 Blood supply
 Upper portion: supplied by the cervicovaginal
branch of uterine artery
 Middle portion: supplied by the inferior vesical
artery
 Lower portion: supplied by the rectal and
pudendal artery

27
Female Internal Organs
2. Uterus
 It is 2.5 – 3 inches long;
 1 inch thick, 2 inches wide
 weighs 50 – 70 gms.
 Functions:
 Organ of reproduction
 Organ of menstruation
 Contracts to expel the fetus during labor,
and to seal torn blood vessels after delivery
of the placenta. 28
Female Internal Organs
2. Uterus
 Parts:
 Fundus
(a)Most muscular area of the uterus

(b)Thickest & most contractile portion

(c)Palpation of its height is used to assess uterine

growth, and during the postpartum period to

assess for uterine involution.
(d)During labor, fundus is palpated to assess

uterine contractions and labor progress.

(e)Ideal site for implantation of the zygote.
29
Female Internal Organs
2. Uterus
 Parts:
 Cornua
(a) Areas of the uterus at which the fallopian tubes are attached.
 Isthmus
(a) Upper third of the cervix which is very thin, becoming prominent
only near the end of pregnancy and during labor to form the
lower uterine segment together with the cervix.
 Corpus
(a) This is the body of the uterus which makes up 2/3 of the said
organ.
(b) It houses the fetus during pregnancy.

30
Female Internal Organs
2. Uterus
 Parts:
 Cervix
(a)Chiefly composed of elastic
and collagenous tissues,
10% muscle fibers
(b)Contains many sebaceous glands that secrete clear, viscid
and alkaline mucus.
(c) Parts of Cervix:
 Internal os: opens to the corpus

 Cervical canal: located between the internal and

external os
 External os: opens to vagina 31
Female Internal Organs
2. Uterus
 Layers of the uterus:
(a)Perimetrium:
outermost, serosal layer
attached to the broad ligaments.
(a)Myometrium:
the middle, muscular layer
responsible for uterine
contractions during labor.
(a)Endometrium: the innermost, ciliated, mucosal layer
containing numerous uterine glands that secrete a thin
alkaline fluid to keep the uterine cavity moist.
32
Female Internal Organs
2. Uterus
 Layers of the uterus:
c) Endometrium:
 Consists of 2 layers:
 Glandular layer

 Composed of columnar epithelium; this layer

peels off during menstruation and thickens

during the proliferative and secretory phase.
 Basal layer

 The layer adjacent to the myometrium and gives

rise to the new endometrium after menstruation

and delivery.
33
Female Internal Organs
2. Uterus
 Uterine Ligaments
(a)Cardinal/transverse – Cervical/Mackenrodt
ligaments (2)
 Lower portion of the broad ligaments.

 It is the main support of the uterus.

 Damage to this would result to uterine

prolapse.
(b)Broad ligaments/Peritoneal ligaments (2)
 It supports the sides of the uterus and

assists in holding the uterus in anteversion.

34
Female Internal Organs
2. Uterus
 Uterine Ligaments
c) Round ligaments (2)
Connect the uterus to the labia majora.
 During pregnancy, these ligaments hypertrophies and
gives stability to the uterus.
d)Uterosacral ligaments (2)
 These ligaments connect the supravaginal cervical
portion of the uterus to the 2nd and 3rd sacral
vertebra, passing on each side of the rectum.
 They help keep the uterus in its normal position by
maintaining traction on the cervix.
35
Female Internal Organs
2. Uterus
 Uterine Ligaments
e) Anterior ligament (1)
 Connects the anterior portion of the supravaginal
cervix to the posterior surface of the bladder.
 Overstretching of this ligament will cause the bladder
to “drop” and to herniate into the vagina (cystocele)

36
Female Internal Organs
2. Uterus
 Uterine Ligaments
f) Posterior ligament (1)
 Connects the posterior portion of the uterus to the
rectum.
 It forms a deep pouch called the Cul-de-sac of
Douglas, the lowest part of the abdominal cavity, so
that blood, pus, or other drainage of the abdominal
area tends to collect here.
 Damage to this ligament will lead to herniation of
rectum to the vagina (rectocele).
37
Female Internal Organs
2. Uterus
 Blood Supply
(a)Uterine artery
A branch of the internal iliac or hypogastric
artery which divided into 2 main branches:
 Cervicovaginal branch that supplies the upper
portion of vagina and lower portion of cervix.
 Main branch which divides into fundal, tubal
ovarian arteries
(b)Ovarian artery
 A direct branch of the aorta

38
Female Internal Organs
3. Fallopian tubes (Oviducts)
 Each tube is about
4 inches (10 cm) long
and ¼ inch in diameter.
 Blood supply is from ovarian artery
 Functions:
 Transport ovum from ovary to the uterus
 The site of fertilization
 Provides nourishment to the ovum during its
journey.

39
Female Internal Organs
3. Fallopian tubes (Oviducts)
 Parts:
 Interstitial/Intramural
• Thick-walled,
• located inside the uterus;
• 1 cm long.
 Isthmus
• Narrowest portion
• About 1 cm long;
• Site of tubal ligation

40
Female Internal Organs
3. Fallopian tubes (Oviducts)

 Parts:
 Ampulla
(a)Middle portion
(b)widest part
(c) Site of fertilization

 Infundibulum
(a)The most distal portion
(b)Has fingerlike projections called fimbria

41
Female Internal Organs
4. Ovaries
 Almond shape glandular organ.
 Each weighs between 6-19 g;
 1.5 – 3 cm wide; 2 – 5 cm long.
 Functions:
 Responsible for development &
maturation of ovum (oogenesis)
 Ovulation
 Hormone production – main source of estrogen &
progesterone in non-pregnant women.

42
Female Internal Organs
5. Mammary glands
 External structures:
 Nipple
 Areola
 Montgomery tubercles
 Internal structures
 Lobes
(a)15 – 20 lobes are found in each breast that are divided
into several lobules.
 Lobules
(a)Composed of clusters of acini cells.

43
Female Internal Organs
5. Mammary glands
 Internal structures
 Acini cells
(a)These are the milk-secreting
cells of the breasts that are
stimulated by prolactin hormone.
 Lactiferous ducts
(a)Ducts that serve as
passageway of milk.
 Lactiferous sinus
(a)Dilated portion of the ducts located behind the nipple
that serve as reservoir of milk.
44
Female Internal Organs
5. Mammary glands
 Hormones that influence the Mammary Glands:
 Estrogen
 Stimulates development of the ductile structures of the

breast.
 Progesterone
 Stimulates the development of the acinar structures of
the breast
 Human placental lactogen
 Promotes breast development during pregnancy.

45
Female Internal Organs
5. Mammary glands
 Hormones that influence the Mammary Glands:
 Oxytocin
 Let-down reflex;

 Is inhibited by progesterone.

 Prolactin
 Stimulates milk production
 Is inhibited by estrogen.

46
47
48
Anatomy and Physiology of the
Reproductive System: The Male #1
 Andrology: study of the male reproductive system. The male
reproductive system consists of both external and internal
divisions
The Male External Organs
1.Penis
 Male organ of copulation and urination.
 Blood flow is controlled by ANS;
 Blood supply is provided by penile artery.
 The sympathetic nervous system inhibits penile
erection.

50
The Male External Organs
1.Penis
 The ischiocavernosus muscle at the base of
the penis, under stimulation of the
parasympathetic nervous system, then
contracts, trapping both venous and arterial
blood in the three sections of erectile
tissue.
 This leads to distention (and erection) of
the penis.

51
The Male External Organs
1.Penis
 Parts:
 Shaft or body
 Glans penis
Enlarged end which is
the most sensitive part.
 Prepuce or foreskin
A fold of retractable skin covering the glans, at
which it is removed during circumcision.
 Urethral meatus
A slit like opening located at the tip of the penis
which serves as passageway of both semen and
urine.
52
The Male External Organs
2. Scrotum
 Is a sac-like structure containing the testes that
hangs behind the penis.
 Is covered by sparse hair after puberty, wrinkled
and has a darker coloration than the rest of the
body.
 Has NO subcutaneous fat because the scrotum
must be kept cool.

53
The Male External Organs
2. Scrotum
 The skin of the scrotum is lined by fascia and a
smooth muscle layer, the Dartos.
 Contracts when environmental temperature is cold to
pull the testes closer to the body
 Relaxes when the environmental temperature is too
hot, causing the testes to descend away from the
body which lowers its temperature.
 If temperature is too warm or too cold,
spermatogenesis will not take place; testosterone
production will not be affected.

54
The Male Internal Organs
1.Testes

 Oval shaped
glandular organs.
 Descend in the scrotum
after 28 wks. gestation
 Temperature inside the
scrotum is 1°C (2-3°F) lower
than body temperature.
 Each testis is about 4 – 5 cm long.
55
The Male Internal Organs
1.Testes
 Functions:
 Hormone production:
 Testosterone stimulates spermatogenesis and is
responsible for the development of secondary male
characteristics.
 Beginning puberty, the hypothalamus secretes
gonadotropin releasing hormone (GnRH) which
stimulates the Leydig cells to release testosterone
and other androgens.

56
The Male Internal Organs
1.Testes
 Functions:
 Spermatogenesis
Production and maturation of sperm cell begins at
puberty and continue until old age in a continuous
manner.
Beginning puberty, the hypothalamus secretes
gonadotropin releasing hormone (GnRH) which
stimulates the anterior pituitary gland to release
FSH which in turn causes the cell division and
development of spermatogonia to sperm cells.

57
The Male Internal Organs
1.Testes
 Parts of testis:
 Seminiferous tubules
spermatogenesis takes place
The testes produce about
176 sperm cells a day
This tube leads to the tightly
coiled epididymis.
 Leydig or Interstitial cells
Produce testosterone
Found around the
seminiferous tubules.
 Sertoli cells or supporting cells
Plays a role in sperm transport.
58
The Male Internal Organs
2. Epididymis
 Long, coiled tube
approximately 20 feet
long and at which the
sperm travels for 12 –
20 days after it leaves
the testis.
 It takes about 64 days
for the sperm to
become mature.

59
The Male Internal Organs
3. Vas Deferens
 Forms the passageway
of the sperm cells from
the epididymis in the
testis to the urethra.
 It is surrounded by
arteries, veins and a
thick fibrous covering.

60
The Male Internal Organs
3. Vas Deferens
 The contractile power of this part of the duct
system propels the spermatozoa to the urethra
during ejaculation.
 At the end of the vas deferens , just before it joins
the seminal vesicles, there is a dilated portion
which functions as a storage area of sperm cells
before ejaculation.
 The presence of acidic secretions in this portion
causes the sperm not to be very motile.

61
The Male Internal Organs
4. Ejaculatory duct
 Passageway of the semen.
5. Seminal vesicle
 2 pouch-like organs consisting of many saclike
structures located next to the ductus deferens and lying
behind the bladder and in front of the rectum.
 Each vesicle is about 4 cm long, the thick, mucoid
secretion of the seminal vesicles is high in sugar &
protein and slightly alkaline in nature (7-8 pH), causing
sperm cells to become more motile once surrounded
by this nourishing fluid.
 Its secretions also contain prostaglandins, a substance
thought to cause contractions of the female
reproductive tract to help transport the sperm cells.
62
The Male Internal Organs
6. Prostate gland
 It secretes a thin,
milky alkaline fluid
that helps to
neutralize the acidic
nature of the male
urethra caused by the
urine that passes
through it enhancing
sperm survival.

63
The Male Internal Organs
7. Cowper’s/bulbourethral
gland
 2 small glands located
below the prostate.
 Secrete an alkaline
fluid that helps to
neutralize the acidic
nature of the urethra
and provides
additional lubrication
during intercourse.
64
The Male Internal Organs
8. Semen
 Is a mixture of secretions from the seminal vesicles,
prostate gland, Cowper’s gland, ejaculatory duct
and sperm cells.
 The seminal vesicles produce about 60% of the
fluid, the prostate gland 30%, the testes 5%, and
the bulbourethral glands 5%.
 Composition:
 Volume: 2 – 5 ml
 Sperm count: 100 million/ml
 pH: 7.2 – 7.4 (alkaline)
 high in basic sugar and protein, particularly mucin.

65
SPERM CELL

66
 Spermatozoa are the only human cells that
contain flagella. They are made up of three
basic parts: the head, the middle-piece, and
the tail.
1. Head
 The head is an oval-shaped structure, in which
size ranges from 5 to 8 µm.
1. Head
 The head consists of two parts:
1) Acrosome
 The size of this organelle is 40% to 70% of total sperm
head area, and is located at one end of the sperm cell.
 It contains proteolytic enzymes that help to destroy
the outer layer of the egg cell, thereby allowing the
sperm to enter into it easily.
1. Head
 The head consists of two parts:
2) Nucleus
 It contains all the 23 chromosomes of the sperm cell,
that is, half the genetic information that will have the
new organism.
 This is the only part of the sperm cell that enters into
the egg cell. For this reason, it is a key part of the
spermatozoon, as it is the one that unites with the
egg’s nucleus to form a 46-chromosome cell called
zygote.
HEAD OF SPERMATOZOA
2. Neck and middle-piece
 The neck and the middle piece are the parts that
can be found between the head and the tail.
 Function:
 is to connect both ends of the sperm cell.
2. Neck and middle-piece
 The neck contains millions of spirally arranged
mitochondria.
 Function:
 to provide the sperm with all the energy required by the
flagellum to allow it to swim in the female reproductive
tract.
3. Tail
 Sperm tail defects or alterations can lead to male fertility
problems, being asthenozoospermia the most frequent
one.
3. Tail
 The tail, also known as flagellum, is a long
structure.
 Main function:
 to allow sperm motility by means of a slithering,
snake-like movement.
 The length of the tail is about 50 µm, allowing a
swimming velocity of 3 millimeters per minute
approximately.
Puberty
 is the stage of life at which secondary sex changes
begin.
 In most girls, these changes are stimulated when the
hypothalamus synthesizes and releases gonadotropin-
releasing hormone (GnRH), which then triggers the
anterior pituitary to release follicle-stimulating
hormone (FSH) and luteinizing hormone (LH).

75
Puberty
 FSH and LH are termed gonadotropin (gonad=
“ovary”; tropin = “growth”) hormones not only because
they begin the production of androgen and estrogen,
which in turn initiate secondary sex characteristics,
but also because they continue to cause the production
of eggs and influence menstrual cycles throughout
women’s lives (Eggers, Ohnesorg, & Sinclair, 2014).

76
 The Role of Androgen
 Androgenic hormones are the hormones
responsible for:
1) muscular development
2) physical growth
3) increase in sebaceous gland secretions
that cause typical acne in both boys and
girls during adolescence.
 In males, androgenic hormones are
produced by the adrenal cortex and the
testes and, in females, by the adrenal
cortex and the ovaries. 77
 The Role of Androgen in MALES
 The level of the primary androgenic hormone,
testosterone, is low in males until puberty
(between ages 12 and 14 years) when it rises to
influence pubertal changes in the testes, scrotum,
penis, prostate, and seminal vesicles;
 the appearance of male pubic, axillary, and facial
hair;
 laryngeal enlargement with its accompanying
voice change;
 maturation of spermatozoa; and
 closure of growth plates in long bones
(termed adrenarche).
78
 The Role of Androgen in GIRLS
 In girls, testosterone influences the
following:
1) enlargement of the labia majora and
clitoris
2) formation of axillary and pubic hair.

79
The Role of Estrogen
 When triggered at puberty by FSH, ovarian
follicles in females begin to excrete a high
level of the hormone estrogen.
 This increase influences the following:
 development of the uterus, fallopian tubes,
and vagina;
 typical female fat distribution;
 hair patterns; and
 breast development.

80
The Role of Estrogen
 It also closes the epiphyses of long bones in
girls the same way testosterone closes the
growth plate in boys.
 The beginning of breast development is
termed thelarche, which usually starts 1 to
2 years before menstruation.

81
 MENSTRUATION
 A menstrual cycle (the female reproductive cycle) is
episodic uterine bleeding in response to cyclic
hormonal changes.
 The purpose of a menstrual cycle is to bring an
ovum to maturity and renew a uterine tissue bed that
will be necessary for the ova’s growth should it be
fertilized.

82
 MENSTRUATION
 Menarche
 First menstruation
 May occur as early as 9 years of age
 It is good to include health teaching information on
menstruation to both school-age children and their
parents as early as fourth grade as part of routine
care.

83
 MENSTRUATION
 The length of menstrual cycles
 differs from woman to woman.
 average length is 28 days (from the beginning of one
menstrual flow to the beginning of the next).
 It is not unusual for cycles to be as short as 23 days or
as long as 35 days.
 The length of the average menstrual flow (termed
menses)
 4 to 6 days
 although women may have flows as short as 2 days or
as long as 9 days (Ledger, 2012).

84
 MENSTRUATION
Characteristic Description
Beginning (menarche) • Average age at onset, 12.4
years; average range, 9–17
years
Interval between cycles • Average, 28 days; cycles of
23–35 days not unusual
Duration of menstrual • Average flow, 4–6 days;
flow ranges of 2–9 days not
abnormal

85
 MENSTRUATION
Characteristic Description
Amount • Difficult to estimate;
• Average 30–80 ml per
menstrual period;
• Saturating a pad or tampon in
less than 1 hr is heavy bleeding
Color • Dark red;
• A combination of blood,
mucus, and endometrial
cells
Odor • Similar to marigolds
86
 The Physiology of
Menstruation
 Four body structures are involved:
1. hypothalamus
2. Anterior pituitary gland
3. ovaries
4. uterus.
 For a menstrual cycle to be complete, all four
organs must contribute their part;
 inactivity of any part results in an incomplete or
ineffective cycle
87
 The Physiology of
Menstruation
1. The Hypothalamus
 Release of the GnRH (also called luteinizing
hormone–releasing hormone [LHRH]) from the
hypothalamus initiates the menstrual cycle.
 GnRH then stimulates the pituitary gland to send
the gonadotropic hormone to the ovaries to
produce estrogen.
 When the level of estrogen rises, release of GnRH
is repressed and no further menstrual cycles will
occur.
88
 The Physiology of
Menstruation
2. The Anterior lobe of the Pituitary Gland (the
adenohypophysis)
 Under the influence of GnRH, produces two
hormones:
1) FSH, a hormone active early in the cycle that is
responsible for maturation of the ovum
2) LH, a hormone that becomes most active at the
midpoint of the cycle and is responsible for ovulation,
or release of the mature egg cell from the ovary.
 It also stimulates growth of the uterine lining during
the second half of the menstrual cycle.
89
 The Physiology of
Menstruation
3. The Ovaries
 Every month during the fertile period of a
woman’s life (from menarche to menopause),
one of the ovary’s oocytes is activated by FSH to
begin to grow and mature.
 As the oocyte grows, its cells produce a clear
fluid (follicular fluid) that contains a high degree
of estrogen and some progesterone.
 As the follicle surrounding the oocyte grows, it is
propelled toward the surface of the ovary.
90
 The Physiology of
Menstruation
3. The Ovaries
 At full maturity, the follicle is visible on the
surface of the ovary as a clear water blister
approximately 0.25 to 0.5 in. across.
 At this stage of maturation, the small ovum
(barely visible to the naked eye, about the
size of a printed period) with its surrounding
follicular membrane and fluid is termed a
graafian follicle.

91
 The Physiology of
Menstruation
3. The Ovaries
 By day 14 or the midpoint of a typical 28-day
cycle, the ovum has divided by mitotic division into
two separate bodies:
1) a primary oocyte, which contains the bulk of the
cytoplasm, and
2) a secondary oocyte, which contains so little
cytoplasm that it is not functional.
 The structure also has accomplished its meiotic
division, reducing its number of chromosomes to
the haploid (having only one member of a pair)
number of 23.
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 The Physiology of
Menstruation
3. The Ovaries
 After an upsurge of LH from the pituitary at about
day 14, prostaglandins are released and the
graafian follicle ruptures.
 The ovum is set free from the surface of the ovary,
a process termed ovulation. It is swept into the
open end of a fallopian tube.
 It is important to teach women that ovulation does
not necessarily occur on the 14th day of their
cycle;
 it occurs 14 days before the end of their cycle.
93
 The Physiology of
Menstruation
3. The Ovaries
 If their menstrual cycle is only 20 days long,
for example, their day of ovulation would be
day 6 (14 days before the end of the cycle).
 If their cycle is 44 days long, ovulation would
occur on day 30, not at the halfway point—
day 22.

94
 The Physiology of
Menstruation
3. The Ovaries
 After the ovum and the follicular fluid have been
discharged from the ovary, the cells of the follicle
remain in the form of a hollow, empty pit.
 The FSH has done its work at this point and now
decreases in amount.
 The second pituitary hormone, LH, continues to
rise in amount and directs the follicle cells left
behind in the ovary to produce lutein, a bright-
yellow fluid high in progesterone.
 With lutein production, the follicle is renamed a
corpus luteum (yellow body).
95
 The Physiology of
Menstruation
3. The Ovaries
 The basal body temperature of a woman drops
slightly (by 0.5° to 1°F) just before the day of
ovulation because of the extremely low level of
progesterone that is present at that time.
 It rises by 1°F on the day after ovulation because
of the concentration of progesterone, which is
thermogenic.
 The woman’s temperature remains at this
elevated level until approximately day 24 of the
menstrual cycle, when the progesterone level
again decreases (Huether & McCance, 2012).
96
 The Physiology of
Menstruation
3. The Ovaries
 If conception (fertilization by a spermatozoon) occurs
as the ovum proceeds down a fallopian tube and the
fertilized ovum implants on the endometrium of the
uterus, the corpus luteum remains throughout the
major portion of the pregnancy (to about 16 to 20
weeks).
 If conception does not occur, the unfertilized ovum
atrophies after 4 or 5 days, and the corpus luteum
(now called a “false” corpus luteum) remains for only 8
to 10 days.
 As the corpus luteum regresses, it is gradually
replaced by white fibrous tissue, and the resulting
structure is termed a corpus albicans (white body).
97
 The Physiology of
Menstruation
3. The Uterus
 Uterine changes that occur monthly as a result of
stimulation from the estrogen and progesterone
produced by the ovaries.

98
The Physiology of Menstruation

99
The Physiology of Menstruation

100
 The Physiology of Menstruation
1. The First Phase of the Menstrual Cycle
(Proliferative)
 Immediately after a menstrual flow (which occurs
during the first 4 or 5 days of a cycle)
 the endometrium, or lining of the uterus, is very thin,
approximately one cell layer in depth.
 As the ovary begins to produce estrogen (in the
follicular fluid, under the direction of the pituitary
FSH), the endometrium begins to proliferate so rapidly
the thickness of the endometrium increases as much
as eightfold from day 5 to day 14.
 ALSO CALLED the proliferative, estrogenic, follicular,
or postmenstrual phase.

101
 The Physiology of Menstruation
2. The Second Phase of the Menstrual Cycle
(Secretory)
 After ovulation, the formation of progesterone in the
corpus luteum (under the direction of LH) causes the
glands of the uterine endometrium to become
corkscrew or twisted in appearance and dilated with
quantities of glycogen (an elementary sugar) and
mucin (a protein).
 It takes on the appearance of rich, spongy velvet.
 Is termed the progestational, luteal, premenstrual, or
secretory phase.

102
 The Physiology of Menstruation
3. The Third Phase of the Menstrual Cycle
(Ischemic)
 If fertilization does not occur, the corpus luteum in the
ovary begins to regress after 8 to 10 days, and
therefore, the production of progesterone decreases.
 With the withdrawal of progesterone, the endometrium
of the uterus begins to degenerate (at about day 24 or
day 25 of the cycle).
 The capillaries rupture, with minute hemorrhages, and
the endometrium sloughs off.

103
 The Physiology of Menstruation
4. The Fourth Phase of the Menstrual Cycle
(Menses)
 Menses, or a menstrual flow, is composed of
1) a mixture of blood from the ruptured capillaries;
2) mucin;
3) fragments of endometrial tissue; and
4) the microscopic, atrophied, and unfertilized ovum.
 Because it is the only external marker of the cycle,
however, the first day of menstrual flow is used to
mark the beginning day of a new menstrual cycle.

104
 The Physiology of Menstruation
4. The Fourth Phase of the Menstrual Cycle
(Menses)
 Contrary to common belief, a menstrual flow contains
only 30 to 80 ml of blood;
 if it seems to be more, it is because of the
accompanying mucus and endometrial shreds.
 The iron loss in a typical menstrual flow is
approximately 11 mg.
 This is enough loss that many adolescent women could
benefit from a daily iron supplement to prevent iron
depletion during their menstruating years (Bitzer, Sultan,
Creatsas, et al., 2014).

105
Menstrual Cycle
Hypothalamus

GnRH or LHRH

Anterior Pituitary Gland

106
 FSH & LH

Promotes growth of Prostaglandins are

follicle released

In estrogen (estradiol) Graafian follicle ruptures

and some progesterone
Ovulation
Endometrial tissue build-
up (Proliferative Phase) Follicle becomes FSH
Corpus luteum
(Luteal Phase)
107
 LH continues to

Corpus Luteum produce Lutein

Lutein is high in Progesterone (& some estrogen)

Stimulates glands of Temp. by 1F on the

endometrium to secrete day after ovulation
mucin & glycogen

Capillaries in endometrium
in amount

108
 Endometrium becomes softer
Unfertilized ovum Fertilization
atrophies after 4 – 5 days
Corpus Luteum remains
Corpus luteum becomes 16 – 20 wks.
Corpus Albicans
hCG stimulates corpus
Estrogen & Progesterone luteum to secrete
estrogen & progesterone
Ischemic Phase
Progesterone reduce
menstruation frequency of uterine
contractions
109
Cervical Changes
 The mucus of the uterine cervix also changes in
structure and consistency each month during a
menstrual cycle.
 At the beginning of each cycle, when estrogen
secretion from the ovary is low
 cervical mucus is thick and scant.
 Sperm survival in this type of mucus is poor.
 At the time of ovulation, when the estrogen level
has risen to a high point:
 cervical mucus becomes thin, stretchy (spinnbarkeit),
and copious.
110
Cervical Changes
 Spinnbarkeit

111
Cervical Changes
 Spinnbarkeit
 Sperm penetration and survival in this thin mucus are
both excellent.
 The second half of the cycle
 progesterone becomes the major influencing hormone
 cervical mucus again thickens
 sperm survival is again poor.
 During ovulation
 the body of the cervix is softer
 the cervical os is slightly open

112
Cervical Changes
 A ferning pattern of cervical mucus occurs with high
estrogen levels.

113