1.
Physiology of Menstruation
A menstrual cycle (a 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 responsible for the ova’s
growth should it be fertilized. It is the process that
allows for conception and implantation of a new life.
Because menarche 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. It is a poor introduction to sexuality and
womanhood for a girl to begin menstruation
unwarned and unprepared for the important internal
function it represents.
The length of menstrual cycles differs from woman to
woman, but the 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) is 4 to 6
days, although women may have periods as short as
2 days or as long as 7 days (MacKay, 2009).
Because there is such variation in length, frequency,
and amount of menstrual flow and such variation in
the onset of menarche, many women have questions
about what is considered normal. Contact with health
care personnel during a yearly health examination or
prenatal visit may be their first opportunity to ask
questions they have had for some time.
- Phases of Menstruation
First Phase of 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. This growth is
very rapid and increases the thickness of the
endometrium approximately eightfold. This increase
continues for the first half of the menstrual cycle
(from approximately day 5 to day 14). This half of a
menstrual cycle is termed interchangeably the
proliferative, estrogenic, follicular, or postmenstrual
phase.
FIGURE 5.13 (A) Plasma hormone concentrations in the normal female
reproductive cycle. (B) Ovarian events and uterine changes during the
menstrual cycle.
Second Phase of 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). The capillaries of the endometrium
increase in amount until the lining takes on the
appearance of rich, spongy velvet. This second
phase of the menstrual cycle is termed the
progestational, luteal, premenstrual, or secretory
phase.
Third Phase of Menstrual Cycle (Ischemic). If
fertilization does not occur, the corpus luteum in the
ovary begins to regress after 8 to 10 days. As it
regresses, the production of progesterone and
estrogen decreases. With the withdrawal of
progesterone stimulation, the endometrium of the
uterus begins to degenerate (at approximately day 24
or day 25 of the cycle). The capillaries rupture, with
minute hemorrhages, and the endometrium sloughs
off.
Fourth Phase of a Menstrual Cycle (Menses).
Menses, or the menstrual flow, is composed of:
• Blood from the ruptured capillaries
• Mucin from the glands
• Fragments of endometrial tissue
• The microscopic, atrophied, and unfertilized ovum
Menses is actually the end of an arbitrarily defined
menstrual cycle. 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.
- Cervical Changes
Cervix
The mucus of the uterine cervix, as well as the
uterine body, changes each month during the
menstrual cycle. During the first half of the cycle,
when hormone 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 is high, cervical mucus
becomes thin and copious. Sperm penetration and
survival at the time of ovulation in this thin mucus are
excellent. As progesterone becomes the major
influencing hormone during the second half of the
cycle, cervical mucus again becomes thick and
sperm survival is again poor.
Women can analyze cervical mucus changes to help
plan coitus to coincide with ovulation if they want to
increase their chance of becoming pregnant or plan
to avoid coitus at the time of ovulation to prevent
pregnancy (see Chapter 6).
Menopause is the cessation of menstrual cycles.
Perimenopausal is a term used to denote the period
during which menopausal changes occur.
Postmenopausal describes the time of life following
the final menses. The age range at which
menopause occurs is wide, between approximately
40 and 55 years of age with a mean age of 51.3.
The age at which menopause symptoms begin
appears to be genetically influenced or at least is not
associated with age of menarche. Women who
smoke tend to have earlier menopause (Baram &
Basson, 2007).
An older term to describe menopause was “change
of life,” because it marks the end of a woman’s ability
to bear children and the beginning of a new phase of
life. Such a role change can produce psychological
stress, although, through health teaching, nurses can
help a woman appreciate that her role in life is
greater than just bearing children; loss of uterine
function may make almost no change in her life; and,
for a woman with dysmenorrhea (painful
menstruation) or with no desire for more children,
menopause can be a welcome change. Menopause
can cause physiologic stress as ovaries are
a woman’s chief source of estrogen. When ovaries
begin to atrophy, reducing estrogen production, “hot
flashes,” vaginal dryness, or osteoporosis (lack of
bone mineral density [BMD]) occurs. Urinary
incontinence from lack of bladder support can also
occur (Freeman et al., 2007).
Hot flashes can be accompanied by heart
palpitations and can occur up to 20 to 30 episodes a
day; episodes commonly last for 3 to 5 minutes at a
time. An immediate aid in reducing this sudden
overheated feeling is to sip at a cold drink or use a
hand fan.
At one time, hormone replacement therapy (HR) was
prescribed extensively to decrease menopause
symptoms because it was believed that this therapy
reduced cardiovascular complications such as
atherosclerosis or heart attacks as well. HR is no
longer prescribed routinely as such therapy does not
appear to reduce cardiac risk or prevent osteoporosis
and may be associated with endometrial cancer,
cerebrovascular accidents (strokes), and perhaps
breast cancer (Gabriel-Sanchez, et al., 2009).
HR may be prescribed on a short-term basis (1 to 2
years) if a woman has symptoms so severe that they
interfere with her life plans but women should not
receive estrogen replacement therapy indefinitely
because of the possible adverse effects. Women who
notice excessive vaginal dryness can be advised to
use a lubricating jelly such as KY Jelly prior to sexual
relations. Other possibilities are application of
estrogen cream or insertion of a vaginal ring that
dispenses low-dose estrogen. Low-dose estrogen or
testosterone can also be prescribed to increase
sexual libido. Practicing Kegel’s exercises (see
Chapter 12) can help strengthen bladder supports
and reduce urinary incontinence.
Osteoporosis occurs in as many as 13% to 18% of
women over age 50. It is seen most frequently in
women who are Asian, have a low body weight, have
a positive family history, participate in few weight-
bearing exercises, have a low intake of calcium, are
cigarette smokers, have an early surgical
menopause, or take certain anticonvulsant
medications or corticosteroids. As calcium is
withdrawn from bones, women notice a decrease in
height and back pain from shortening of the vertebral
column. If they fall, they are more prone to fractures
than are younger women (Bessette et al., 2008).
BMD scans are helpful in diagnosis. To help prevent
osteoporosis, women should be sure to ingest 1200
mg calcium daily along with 400 to 800 IU of vitamin
D, in addition to beginning a program of weight-
bearing exercises such as walking or low-impact
aerobics. Calcitonin, a thyroid hormone that regulates
body calcium, may be prescribed as a nasal spray.
Other drugs commonly prescribed are selective
estrogen receptor modulators (SERMS) such as
Evista and bisphosphonates such as Fosamax that
regulate calcium by aiding bone reabsorption.
If a woman lives to be 80, she will spend a third of
her life postmenopausal. Women appreciate learning
the normal parameters of menopause so they
understand what will happen to them as changes
occur and to be able to continue to monitor their
health during this time.
2. Family Planning Methods/Contraception
Natural Family Planning and Fertility Awareness
The contraceptive approach of natural family planning
(also called periodic abstinence methods) involves no
introduction of chemical or foreign material into the body or
sustaining from sexual intercourse during a fertile period.
Many people hold religious beliefs that rule out the use of
birth control pills or devices; others simply prefer natural
methods because no expense or foreign substance is
involved; still others believe that a “natural” way of
planning pregnancies is simply best for them. The
effectiveness of these methods varies greatly from 25% to
85%, depending mainly on the couple’s ability to refrain
from having sexual relations on fertile days or days on
which the woman has the most likely chance to become
pregnant (Schorge et al., 2008). Fertility awareness
involves detecting when a woman is fertile so she can use
periods of abstinence during that time.
Methods
There are a variety of ways, or methods, to determine a
fertile period such as calculating the period based on a set
formula, measuring the woman’s body temperature,
observing the consistency of cervical mucus, using an
over-the-counter ovulation test kit, or using a combination
of these methods.
Abstinence. Abstinence, or refraining from sexual
relations, has a theoretical 0% failure rate and is also the
most effective way to prevent STIs. However, clients,
particularly adolescents, may find it difficult to adhere to
abstinence, or they may completely overlook it as an
option. Because it fails as an effective birth prevention
measure for so many people, use of no contraceptive has
a failure rate of 85% (Cunningham et al., 2008). In a
moment of passion, many otherwise responsible people
are unable to remain abstinent. Only 67% of women still
use the method after a year. Many sex education classes
advocate abstinence as the only contraceptive measure,
so adolescents who take these courses may know little
about other options. When discussing abstinence as a
contraceptive method, be sure to provide information not
only on the method but suggestions of ways to comply with
this method (Box 6.3). A worry is that adolescents who
make “abstinence pledges” to not have sexual intercourse
until they are married may “tune out” not only additional
information on contraception but on safer sex practices as
well. Then, if they break their pledge (about 50% do), that
could leave them more vulnerable to STIs and pregnancy
than others (Cherlin, 2008).
Calendar (Rhythm) Method. The calendar method
requires a couple to abstain from coitus (sexual relations)
on the days of a menstrual cycle when the woman is most
likely to conceive (3 or 4 days before until 3 or 4 days after
ovulation). To plan for this, the woman keeps a diary of six
menstrual cycles. To calculate “safe” days, she subtracts
18 from the shortest cycle documented. This number
represents her first fertile day. She subtracts 11 from her
longest cycle. This represents her last fertile day. If she
had six menstrual cycles ranging from 25 to 29 days, her
fertile period would be from the 7th day (25 minus 18) to
the 18th day (29 minus 11). To avoid pregnancy, she
would avoid coitus during those days (Fig. 6.1A).
Basal Body Temperature Method. Just before the day of
ovulation, a woman’s basal body temperature (BBT), or
the temperature of her body at rest, falls about 0.5° F. At
the time of ovulation, her BBT rises a full degree because
of the influence of progesterone. This higher level is then
maintained for the rest of her menstrual cycle. This pattern
is the basis of the BBT method of contraception.
To use this method, the woman takes her temperature
each morning immediately after waking either orally or with
an ear thermometer before she undertakes any activity;
this is her BBT. As soon as she notices a slight dip in
temperature followed by an increase, she knows that she
has ovulated. She refrains from having coitus for the next
3 days (the life of the discharged ovum). Because sperm
can survive for at least 4 days in the female reproductive
tract, it is usually recommended that the couple combine
this method with a calendar method, so that they abstain
for a few days before ovulation as well. The calendar
method has an ideal failure rate of 9%, a typical rate of
25% (MacKay, 2009).
Cervical Mucus Method. Yet another method to predict
ovulation is to use the changes in cervical mucus that
occur naturally with ovulation (Fig. 6.1B). Before ovulation
each month, the cervical mucus is thick and does not
stretch when pulled between the thumb and finger. Just
before ovulation, mucus secretion increases. With
ovulation (the peak day), cervical mucus becomes
copious, thin, watery, and transparent. It feels slippery and
stretches at least 1 inch before the strand breaks, a
property known as spinnbarkeit (see Chapter 5, Fig. 5.15).
In addition, breast tenderness and an anterior tilt to the
cervix occur. All the days on which cervical mucus is
copious, and for at least 1 day afterward, are considered to
be fertile days, or days on which the woman should
abstain from coitus to avoid conception (Germano &
Jennings, 2007).
Symptothermal Method. The symptothermal method of
birth control combines the cervical mucus and BBT
methods. The woman takes her temperature daily,
watching for the rise in temperature that marks ovulation.
She also analyzes her cervical mucus every day and
observes for other signs of ovulation such as
mittelschmertz (midcycle abdominal pain). The couple
must abstain from intercourse until 3 days after the rise in
temperature or the fourth day after the peak of mucus
change, because these are the woman’s fertile days. The
symptothermal method is more effective than either the
BBT or the cervical mucus method alone (ideal failure rate,
about 2%).
Ovulation Detection. Still another method to predict
ovulation is by the use of an over-the-counter ovulation
detection kit. These kits detect the midcycle surge of
luteinizing hormone (LH) that can be detected in urine 12
to 24 hours before ovulation. Such kits are 98% to 100%
accurate in predicting ovulation. Although they are fairly
expensive, use of such a kit in place of cervical mucus
testing makes this form of natural family planning more
attractive to many women. Combining it with assessment
of cervical mucus is becoming the method of choice for
many families using natural family planning (Box 6.4).
Lactation Amenorrhea Method. As long as a woman is
breastfeeding an infant, there is some natural suppression
of ovulation. Because women may ovulate, however, but
not menstruate, a woman may still be fertile even if she
has not had a period since childbirth. If the infant is
receiving a supplemental feeding or not sucking well, the
use of lactation as an effective birth control method is
questionable (Van der Wijden, Brown, & Kleijnen, 2009).
As a rule, after 3 months of breastfeeding, the woman
should be advised to choose another method of
contraception (Burkman, 2007).
Coitus Interruptus. Coitus interruptus is one of the
oldest known methods of contraception. The couple
proceeds with coitus until the moment of ejaculation. Then
the man withdraws and spermatozoa are emitted outside
the vagina. Unfortunately, ejaculation may occur before
withdrawal is complete and, despite the care used, some
spermatozoa may be deposited in the vagina.
Furthermore, because there may be a few spermatozoa
present in preejaculation fluid, fertilization may occur even
if withdrawal seems controlled. For these reasons, coitus
interruptus is only about 75% effective (Stubblefield, Carr-
Ellis, & Kapp, 2007).
Postcoital Douching. Douching following intercourse, no
matter what solution is used, is ineffective as a
contraceptive measure as sperm may be present in
cervical mucus as quickly as 90 seconds after ejaculation.
Hormonal Contraception
Hormonal contraceptives are, as the name implies,
hormones that cause such fluctuations in a normal
menstrual cycle that ovulation does not occur. Hormonal
contraceptives may be administered orally, transdermally,
vaginally, by implantation, or through injection.
Oral Route
Oral contraceptives, commonly known as the pill, OCs (for
oral contraceptive), or COCs (for combination oral
contraceptives), are composed of varying amounts of
synthetic estrogen combined with a small amount of
synthetic progesterone (progestin). The estrogen acts to
suppress folliclestimulating hormone (FSH) and LH,
thereby suppressing ovulation. The progesterone action
complements that of estrogen by causing a decrease in
the permeability of cervical mucus, thereby limiting sperm
motility and access to ova. Progesterone also interferes
with tubal transport and endometrial proliferation to such
degrees that the possibility of implantation is significantly
decreased.
Mini-pills. Oral contraceptives containing only progestins
are popularly called mini-pills. The progesterone content
thickens cervical mucus and helps prevent sperm entry
into the uterine cervix. Ovulation may occur but, because
the endometrium does not develop fully, implantation will
not take place. Such a pill has advantages for the woman
who cannot take an estrogen- based pill because of the
danger of thrombophlebitis but who wants high-level
contraception assurance (they are as effective as
estrogen/progestin pills). They have the disadvantage of
causing more breakthrough bleeding than combination
pills. They are taken every day, even through the
menstrual flow. Because it does not interfere with milk
production, they may be taken during breastfeeding.
Emergency Postcoital Contraception. Several
regimens, often referred to as “morning-after pills,” are
available for emergency postcoital contraception (Godding,
2008). The high level of estrogen they contain apparently
interferes with the production of progesterone, thereby
prohibiting good implantation. The Yuzpe regimen consists
of the administration of two fixed-dose combination pills
(usually Ovral), taken within 72 hours after unprotected
intercourse. This is followed by two additional pills 12
hours later. This high dose of estrogen (200 mcg) almost
always causes nausea and vomiting. Pretreatment with an
antiemetic, such as 50 mg meclizine (Bonine), is usually
recommended to decrease the possibility of vomiting. If
vomiting should occur within 2 hours after administration,
the pills should be repeated.
A specially designed emergency contraceptive kit (Preven)
is a second method available for use after unprotected
intercourse, particularly after a sexual assault has
occurred. The kit consists of a urine pregnancy test to
determine whether pregnancy has occurred and four pills
that contain concentrations of estrogen/progestin (the first
two taken within 72 hours after intercourse and the next
two taken 12 hours later).
Transdermal contraception refers to patches that slowly
but continuously release a combination of estrogen and
progesterone (Fig. 6.3). Patches are applied each week for
3 weeks. No patch is applied the fourth week. During the
week on which the woman is patch free, a menstrual flow
will occur. After the patch-free week, a new cycle of 3
weeks on/1 week off begins again. The efficiency of
transdermal patches is equal to that of COCs, although
they may be less effective in women who weigh more than
90 kg (198 lb). Because they contain estrogen, they have
the same risk for thromboembolitic symptoms as COCs
(Cole et al., 2007).
Patches may be applied to one of following four areas:
upper outer arm, upper torso (front or back, excluding the
breasts), abdomen, or buttocks. They should not be placed
on any area where makeup, lotions, or creams will be
applied; at the waist where bending might loosen the
patch; or anywhere the skin is red or irritated or has an
open lesion.
Vaginal Insertion
A vaginal ring (NuvaRing) is a silicone ring that surrounds
the cervix and continually releases a combination of
estrogen and progesterone (Fig. 6.4). The ring was FDA
approved in 2001. It is inserted vaginally by the woman
and left in place for 3 weeks, then removed for 1 week
(Roumen, 2007). Menstrual bleeding occurs during the
ring-free week. The hormones released are absorbed
directly by the mucous membrane of the vagina, thereby
avoiding a “first pass” through the liver, as happens with
COCs; this is an advantage for women with liver disease.
The effectiveness is equal to that of COCs. Fertility returns
immediately after discontinuing using the ring. Women
may need to make out a calendar that they post
conspicuously to remind themselves to remove and
replace the ring. Women may need to be encouraged to
use vaginal rings as introducing a ring vaginally may at
first seem more complicated than taking a pill every day
(Gilliam, Holmquist, & Berlin, 2007). Some women
experience vaginal discomfort, which makes a ring not a
desirable contraceptive for them. While rings do not need
to be removed for intercourse, if a woman senses that a
vaginal ring is in place, this could interfere with sexual
enjoyment.
Implantation
Five subdermal implants, rods the size of pencil lead are
embedded just under the skin on the inside of the upper
arm, once used extensively by U.S. women are no longer
available. One- or two-rod versions (Jadelle, Implanon)
have been approved by the FDA and will soon be available
and probably back in favor (Stubblefield, Carr-Ellis, &
Kapp, 2007). The rods contain etonogestrel, the metabolite
of desogestrel, the same progestin that is used in the
NuvaRing. Once embedded, the implants appear as
irregular lines on the skin, simulating small veins. Over the
next 3 to 5 years, the implants slowly release the hormone,
suppressing ovulation, stimulating thick cervical mucus,
and changing the endometrium so
that implantation is difficult.
The implants are inserted with the use of a local
anesthetic, during the menses or no later than day 7 of the
menstrual cycle, to be certain that the woman is not
pregnant at the time of insertion. They can be inserted
immediately after an elective termination of pregnancy or 6
weeks after the birth of a baby. The failure rate is less than
1% (Cunningham et al., 2008). At the end of 3 to 5 years,
the implants are removed under local anesthesia (a quick
minutes-only procedure). A disadvantage of the implant
method is its cost ($500 on average) and side effects such
as:
• Weight gain
• Irregular menstrual cycle such as spotting, breakthrough
bleeding, amenorrhea, or prolonged periods
• Depression
• Scarring at the insertion site
• Need for removal
A major advantage of this long-term reversible
contraceptive is that compliance issues associated with
COCs are eliminated. It also offers an effective and
reliable alternative to the estrogen-related side effects of
COCs. Sexual enjoyment is not inhibited, as may happen
with condoms, spermicides, diaphragms, and natural
family planning methods. Implants can be used during
breastfeeding without an effect on milk production. Also,
implants can be used safely in adolescents.
Injection
A single intramuscular injection of medroxyprogesterone
acetate (Depo-Provera [DMPA]), a progesterone, given
every 12 weeks inhibits ovulation, alters the endometrium,
and changes the cervical mucus (Box 6.8). The
effectiveness rate of this method is almost 100%, making it
an increasingly popular contraceptive method (Chrousos,
2008). Do not massage the injection site after
administration as you want the drug to absorb slowly from
the muscle. Because Depo- Provera contains only
progesterone, it can be used during breastfeeding.
Advantageous effects are reduction in ectopic pregnancy,
endometrial cancer, endometriosis, and, for unknown
reasons, reduction in the frequency of sickle cell crises
(Burkman, 2007). Potential side effects are similar to those
of subdermal implants: irregular menstrual cycle,
headache, weight gain, and depression. Depo-Provera
may impair glucose tolerance in women at risk for
diabetes. Because there also may be an increase in the
risk for osteoporosis from loss of bone mineral density,
advise women to include an adequate amount of calcium
in their diet (up to 1200 mg/day) and to engage in weight-
bearing exercise daily to minimize this risk, rules that are
good for all women. Depo-Provera is not routinely
prescribed to adolescents, to protect their bone mineral
density (Glasier, Yan, & Wellings, 2007).
Like subdermal implants, intramuscular injections have the
advantage of longer-term reliability without many of the
side effects and contraindications associated with COCs.
An advantage of intramuscular injections over implants is
that there is no visible sign that a birth control measure is
being used; this makes them attractive to adolescents
(Rickert et al., 2007). Two disadvantages are that a
woman must return to a health care provider for a new
injection every 4 to 12 weeks for the method to remain
reliable, and the return to fertility is often delayed by 6 to
12 months. A reminder system, such as a postcard mailed
by the prescribing agency, may be necessary to be certain
that women return on time for their next injection.
Alternative methods of administration, such as allowing
pharmacists to give the injections or selling them over the
counter so that women can inject themselves, are being
studied.
Intrauterine Devices
An intrauterine device (IUD) is a small plastic object that
is inserted into the uterus through the vagina
(Postlethwaite et al., 2007). IUDs became popular as a
method of birth control in the 1980s, and although still a
popular choice worldwide, IUDs are used by only a small
number of U.S. women. Few manufacturers continue to
provide them since several lawsuits were filed in
association with the increased incidence of pelvic
inflammatory disease (PID) in women using one particular
brand, now no longer available.
Although the insertion of foreign objects into the uterus for
contraceptive purposes dates back thousands of years
(ancient camel drivers used the technique on their
animals), the mechanism of action for the method is still
not fully understood. Originally, it was thought that the
presence of a foreign substance in the uterus interfered
with the ability of an ovum to develop as it traversed the
fallopian tube. Today, the IUD is thought to prevent
fertilization as well as creating a local sterile inflammatory
condition that prevents implantation. When copper is
added to the device, sperm mobility appears to be affected
as well. This decreases the possibility that sperm will
successfully cross the uterine space and reach the ovum.
An IUD must be fitted by a physician, nurse practitioner, or
nurse-midwife, who first performs a Pap test and pelvic
examination. The device is inserted before a woman has
had coitus after a menstrual flow, so the health care
provider can be assured that the woman is not pregnant at
the time of insertion.
Barrier Methods
Barrier methods are forms of birth control that work by
the placement of a chemical or other barrier between the
cervix and advancing sperm so that sperm cannot enter
the uterus or fallopian tubes and fertilize the ovum. A
major advantage of barrier methods is that they lack the
hormonal side effects associated with COCs. However,
compared with COCs, their failure rates are higher and
sexual enjoyment may be lessened.
Chemical Barriers
A spermicide is an agent that causes the death of
spermatozoa before they can enter the cervix. Such
agents are not only actively spermicidal but also change
the vaginal pH to a strong acid level, a condition not
conducive to sperm survival.
They do not protect against STIs. In addition to the general
benefits for barrier contraceptives, the advantages of
spermicides include:
• They may be purchased without a prescription or an
appointment with a health care provider, so they allow for
greater independence and lower costs.
• When used in conjunction with another contraceptive,
they increase the other method’s effectiveness.
• Various preparations are available, including gels,
creams, sponges, films, foams, and suppositories.
Mechanical Barriers
Mechanical barriers, such as a diaphragm, work by
blocking the entrance of sperm into the cervix. A
diaphragm is a circular rubber disk that is placed over the
cervix before intercourse (Fig. 6.7). A Lea’s Shield, made
of silicone rubber and bowl shaped, is a new design.
Although use of a spermicide is not required for
diaphragms, use of a spermicidal gel with a diaphragm
combines a barrier and a chemical method of
contraception. With this, the failure rate of the diaphragm
is as low as 6% (ideal) to 16% (typical use) (Cunningham
et al., 2008).
A diaphragm is prescribed and fitted initially by a
physician, nurse practitioner, or nurse-midwife to ensure a
correct fit. Because the shape of a woman’s cervix
changes with pregnancy, miscarriage, cervical surgery
(dilatation and curettage [D&C]), or elective termination of
pregnancy, teach women to return for a second fitting if
any of these circumstances occur. A woman should
also have the fit of the diaphragm checked if she gains
or loses more than 15 lb, because this could also
change her pelvic and vaginal contours. A diaphragm is
inserted into the vagina, after first coating the rim and
center portion with a spermicide gel, by sliding it along
the posterior wall and pressing it up against the cervix
so that it is held in place by the vaginal fornices. A
woman should check her diaphragm with a finger after
insertion to be certain that it is fitted well up over the
cervix; she can palpate the cervical os through the
diaphragm.
A diaphragm should remain in place for at least 6 hours
after coitus, because spermatozoa remain viable in the
vagina for that length of time. It may be left in place for
as long as 24 hours. If it is left in the vagina longer than
this, the stasis of fluid may cause cervical inflammation
(erosion) or urethral irritation. A diaphragm is removed
by inserting a finger into the vagina and loosening the
diaphragm by pressing against the anterior rim and then
withdrawing it vaginally. A Lea’s Shield has an attached
rubber loop to grasp for easy removal. After use, a
diaphragm should be washed in mild soap and water,
dried gently, and stored in its protective case. With this
care, a diaphragm will last for 2 to 3 years.
Cervical Caps
A cervical cap is yet another barrier method of
contraception. Caps are made of soft rubber, are shaped
like a thimble with a thin rim, and fit snugly over the uterine
cervix (Fig. 6.8). The failure rate is estimated to be as high
as 26% (ideal) to 32% (typical use) (MacKay, 2009). The
precautions for use are the same as for diaphragm use
except they can be kept in place longer.
Although popular in Europe, many women cannot use
cervical caps because their cervix is too short for the cap
to fit properly. Also, caps tend to dislodge more readily
than diaphragms during coitus. An advantage is that
cervical caps can remain in place longer than diaphragms,
because they do not put pressure on the vaginal walls or Vasectomy
urethra; however, this time period should not exceed 48 In a vasectomy, a small incision or puncture wound is
hours, to prevent cervical irritation. Cervical caps, like made on each side of the scrotum. The vas deferens at
diaphragms, must be fitted individually by a health care that point is then located, cut and tied, cauterized, or
provider. They include a small strap, which can be grasped plugged, blocking the passage of spermatozoa (Cook et
for easy removal. They are contraindicated in any woman al., 2009) (Fig. 6.11). Vasectomy can be done under local
who has: anesthesia in an ambulatory setting, such as a physician’s
• An abnormally short or long cervix office or a reproductive life planning clinic. The man
• A previous abnormal Pap smear experiences a small amount of local pain afterward, which
• A history of TSS can be managed by taking a mild analgesic and applying
• An allergy to latex or spermicide ice to the site. The procedure is 99.5% effective (MacKay,
• A history of pelvic inflammatory disease, cervicitis, or 2009). Spermatozoa that were present in the vas deferens
papillomavirus infection at the time of surgery can remain viable for as long as 6
• A history of cervical cancer months. Therefore, although the man can resume sexual
• An undiagnosed vaginal bleeding intercourse within 1 week, an additional birth control
method should be used until two negative sperm reports
have been obtained (proof that all sperm in the vas
deferens have been eliminated, usually requiring 10 to 20
ejaculations)

Male Condoms
A condom is a latex rubber or synthetic sheath that is
placed over the erect penis before coitus to trap sperm
(Fig. 6.9). Condoms have an ideal failure rate of 2% and a
typical failure rate of about 15%, because breakage or
spillage occurs in up to 15% of uses (Kaplan & Love-
Osborne, 2007). A major advantage of condoms is that
they are one of the few “male responsibility” birth control
measures available, and no health care visit or prescription
Tubal Ligation
is needed. Latex condoms have the additional potential of
Sterilization of women could include removal of the uterus
preventing the spread of STIs, and their use has become a
or ovaries (hysterectomy), but it usually refers to a minor
major part of the fight to prevent infection with human
surgical procedure, such as tubal ligation, where the
immunodeficiency virus (HIV). Recommend them for any
fallopian tubes are occluded by cautery, crushing,
partners who do not maintain a monogamous relationship.
clamping, or blocking, thereby preventing passage of both
Female Condoms
sperm and ova. A fimbriectomy, or removal of the fimbria
Condoms for females are latex sheaths made of
at the distal end of the tubes, is another possible but little
polyurethane and prelubricated with a spermicide. The
used technique. Tubal ligation has a 99.5% effectiveness
inner ring (closed end) covers the cervix, and the outer
rate (Cunningham et al., 2008). Although the reason is not
ring (open end) rests against the vaginal opening. The
clear, tubal ligation is associated with a decreased
sheath may be inserted any time before sexual activity
incidence of ovarian cancer.
begins and then removed after ejaculation occurs. Like
The most common operation to achieve tubal ligation is
male condoms, they are intended for one-time use and
laparoscopy. After a menstrual flow and before ovulation,
offer protection against both conception and STIs (Fig.
an incision as small as 1 cm is made just under the
6.10). Female condoms can be purchased without a
woman’s umbilicus with the woman under general or local
prescription but are more expensive than male condoms.
anesthesia. A lighted laparoscope is inserted through the
Male and female condoms should not be used together.
incision. Carbon dioxide is then pumped into the incision to
The failure rate is somewhat greater than the failure rate
lift the abdominal wall upward and out of the line of vision.
for male condoms, 12% to 22%. Most failures occur
The surgeon locates the fallopian tubes by viewing the
because of incorrect or inconsistent use. Although female
field through a laparoscope. An electrical current to
condoms may reduce the risk of acquiring an HIV infection
coagulate tissue is then passed through the instrument for
by as much as 90%, they have not gained great popularity,
3 to 5 seconds, or the tubes are clamped by plastic, metal,
because of their bulk and difficulty in use (Burkman, 2007).
or rubber rings, then cut or filled with a silicone gel to seal
them (Fig. 6.12). The procedure provides immediate
contraception.

3. Naegele's Rule
An average pregnancy lasts 280 days from the first day of
the last menstrual period (LMP) or 266 days after
conception. Historically, an accurate LMP is the best
estimator to determine the due date. Naegele’s rule,
derived from a German obstetrician, subtracts 3 months
and adds 7 days to calculate the estimated due date
(EDD). It is prudent for the obstetrician to get a detailed
menstrual history, including duration, flow, previous
menstrual periods, and hormonal contraceptives.
4. Fertilization and Implantation
(Where does fertilization takes place?)
Fertilization occurs in the fallopian tubes
Many people think fertilization occurs in the uterus or
ovaries, but this isn’t true. Fertilization takes place in
the fallopian tubes, which connect the ovaries to the
uterus.
Fertilization happens when a sperm cell successfully
meets an egg cell in the fallopian tube. Once fertilization
takes place, this newly fertilized cell is called a zygote.
From here, the zygote will move down the fallopian tube
and into the uterus.
The zygote then burrows into the uterus lining. This is
called implantation. When the zygote implants, it’s called a
blastocyst. The uterus lining “feeds” the blastocyst, which
eventually grows into a fetus.
An exception to this rule would happen with in vitro
fertilization (IVF). In this case, eggs are fertilized in a lab.
If your fallopian tubes are blocked or missing, it’s still
possible to get pregnant via IVF, as fertilization will take
place outside your body. Once an embryo is fertilized
using this method, it’s transferred to the uterus.
Fertilization doesn’t always occur, even if you ovulate
Ovulation is when a mature egg is released from one of
your ovaries. If you ovulate and a sperm cell doesn’t
successfully fertilize the egg, the egg will simply move
down the fallopian tube, through the uterus, and out
through the vagina. You’ll menstruate about two weeks
later when the uterus lining is shed.
There are a number of reasons why fertilization might not
happen. This includes use of contraception and infertility. If
you’re having difficulty getting pregnant and have been
trying for over a year (or more than six months if over the
age of 35), speak to your healthcare provider.
A fraternal twin pregnancy occurs when two eggs are
released during ovulation, and both eggs are fertilized
Usually, only one egg is released during ovulation.
However, the ovaries sometimes release two eggs at
once. It’s possible for both eggs to be fertilized by two
different sperm cells. In this case, you might become
pregnant with twins.
These twins will be known as fraternal twins (also called
nonidentical twins). Because they come from two separate
egg cells and two separate sperm cells, they won’t have
the same DNA and might not look identical.
Fertility treatments like IVF can increase the likelihood
of multiple births, according to Cleveland Clinic. This is
because fertility treatments often involve transferring more
than one embryo to the uterus at a time to increase the
chances of pregnancy. Fertility drugs can also result in
more than one egg being released during ovulation.
An identical twin pregnancy occurs when the fertilized
egg splits
Sometimes, a single embryo splits after it’s been fertilized,
resulting in identical twins. Because both cells come from
the exact same egg cell and sperm cell, identical twins will
have the same DNA, the same sex, and a nearly identical
appearance.
The fertilized egg implants in the uterus
At the point of ovulation, the uterus wall is thick. Barring
any complications, the fertilized egg (embryo) should go
on to implant in the uterus by “sticking” to the thickened
uterus wall.
The American College of Obstetrics and Gynecology
(ACOG) considers someone pregnant only once the
embryo is successfully implanted against the uterine wall.
In other words, implantation marks the beginning of a
pregnancy.
The embryo, however, might not implant. Emergency
contraception, intrauterine devices (IUDs), and infertility
could prevent the embryo from implanting.
Emergency contraception pills and IUDs aren’t forms
of abortion
Standard oral contraception and emergency contraception
pills (“Plan B”) prevent ovulation. In the event that
ovulation has already occurred when you take Plan B,
the U.S. Food and Drug Administration Trusted
Source notes that it may prevent a fertilized egg from
implanting.
An IUD works by thickening cervical mucus. This can both
prevent ovulation and create an environment that kills or
immobilizes sperm, preventing the possibility of
fertilization.
Since you’re only considered pregnant by ACOG once
implantation happens, IUDs don’t end a pregnancy.
Rather, they prevent pregnancy from
happening. ACOG notes that IUDs and emergency
contraception aren’t forms of abortion, but contraception.
IUDs and emergency contraceptive pills are both
extremely effective forms of contraception. According to
the World Health OrganizationTrusted Source, both are 99
percent effective at avoiding pregnancy.
An ectopic pregnancy is when the fertilized egg
implants outside the uterus
If the fertilized egg burrows somewhere else other than the
uterine lining, it’s called an ectopic pregnancy. About 90
percent of ectopic pregnancies occur when the embryo
implants in one of the fallopian tubes. It could also attach
to the cervix or abdominal cavity.
Ectopic pregnancies are medical emergencies that need
prompt treatment to prevent a tube rupture.
Pregnancy tests detect hCG in your urine or blood
After implantation occurs, the placenta forms. At this point,
your body will produce the hormone human chorionic
gonadotropin (hCG). According to Mayo Clinic, hCG levels
should double every two to three days in the early stages
of pregnancy.
Pregnancy tests work by detecting hCG in your body. You
can either test your urine, as with home pregnancy tests,
or test your blood via your healthcare provider. If you’re
testing your urine with a home pregnancy test, do the test
first thing in the morning, as that is when your urine is the
most concentrated. This will make it easier for the test to
measure your hCG levels.
Week 1 of your pregnancy is counted from the first
day of your last period, not from fertilization
The “gestational age” of a pregnancy is the duration of the
pregnancy. When you find out you’re pregnant, your doctor
or midwife might count the gestational age of your
pregnancy in increments of weeks. Most babies are born
in week 39 or 40.
Many people think that the gestational age begins at
fertilization, with “week 1” being the week you got
pregnant, but this isn’t the case. Week 1 is actually
retroactively counted from the first day of your last period.
Since ovulation usually occurs around 14 days after the
first day of your period, fertilization usually takes place in
“week 3” of pregnancy.
So, for the first two weeks of the gestational period, you’re
not actually pregnant at all.
From week 9 of pregnancy, the embryo is considered
a fetus
The difference between an embryo and a fetus is
gestational age. Until the end of week 8 of pregnancy, the
fertilized egg is called an embryo. In medical terms, it’s
considered a fetus from the beginning of week 9 onwards.
At this point, all major organs have begun to develop, and
the placenta is taking over many of the processes such as
hormone production.
(Where does implantation takes place?)
During fertilization, the sperm and egg unite in one of the
fallopian tubes to form a zygote. Then the zygote travels
down the fallopian tube, where it becomes a morula. Once
it reaches the uterus, the morula becomes a blastocyst.
The blastocyst then burrows into the uterine lining — a
process called implantation.
Implantation is a process that occurs after an embryo —
i.e., a fertilized egg — travels down the fallopian tube and
burrows deep into the lining of the uterus, where it will
remain until delivery.
While many consider fertilization to be the start of
pregnancy, successful implantation is another crucial
hurdle. Once the embryo is implanted, it starts releasing
hormones that prepare your body for baby, turning off your
period, building up the placenta and possibly making you
feel crampy and tired.
When does implantation occur?
Implantation occurs about eight to nine days after
fertilization, though it can happen as early as six days and
as late as 12 days after ovulation.
What are the signs and symptoms of implantation?
The signs and symptoms of implantation are your body's
way of welcoming you to pregnancy. While many women
don't feel anything during the process, others report some
symptoms, which can include:
Light bleeding
The difference between implantation symptoms and your
period can be confusing, especially because in both
instances, the blood is shed from the uterine lining. While
most women don't experience implantation bleeding, some
will, with approximately 15 to 25 percent of them
experiencing light, spotty blood. This blood usually starts
out pink and turns brown, and unlike your period, it won't
flow or contain clots. It should stop within a day or two.
Abdominal cramps
Many women don't have any symptoms of implantation,
but the subsequent hormonal shifts can cause cramps.
Implantation cramps should last only a day or so at most,
and you'll probably notice them around the time your
period is due.
5. Ectopic Pregnancy
Pregnancy begins with a fertilized egg. Normally, the
fertilized egg attaches to the lining of the uterus. An
ectopic pregnancy occurs when a fertilized egg
implants and grows outside the main cavity of the
uterus.
An ectopic pregnancy most often occurs in a fallopian
tube, which carries eggs from the ovaries to the
uterus. This type of ectopic pregnancy is called a
tubal pregnancy - the most common type of ectopic
pregnancy — happens when a fertilized egg gets
stuck on its way to the uterus, often because the
fallopian tube is damaged by inflammation or is
misshapen. Sometimes, an ectopic pregnancy occurs
in other areas of the body, such as the ovary,
abdominal cavity or the lower part of the uterus
(cervix), which connects to the vagina.
An ectopic pregnancy can't proceed
normally. The fertilized egg can't survive,
and the growing tissue may cause life-
threatening bleeding, if left untreated.
Symptoms
You may not notice any symptoms at first. However,
some women who have an ectopic pregnancy have
the usual early signs or symptoms of pregnancy — a
missed period, breast tenderness and nausea.
If you take a pregnancy test, the result will be
positive. Still, an ectopic pregnancy can't continue as
normal.
As the fertilized egg grows in the improper place,
signs and symptoms become more noticeable.
Early warning of ectopic pregnancy
Often, the first warning signs of an ectopic pregnancy
are light vaginal bleeding and pelvic pain.
If blood leaks from the fallopian tube, you may feel
shoulder pain or an urge to have a bowel movement.
Your specific symptoms depend on where the blood
collects and which nerves are irritated.
Emergency symptoms
If the fertilized egg continues to grow in the fallopian
tube, it can cause the tube to rupture. Heavy
bleeding inside the abdomen is likely. Symptoms of
this life-threatening event include extreme
lightheadedness, fainting and shock.
When to see a doctor
Seek emergency medical help if you have any signs
or symptoms of an ectopic pregnancy, including:
 Severe abdominal or pelvic pain
accompanied by vaginal bleeding
 Extreme lightheadedness or fainting
 Shoulder pain
- Risk Factors that causes ectopic pregnancy
Some things that make you more likely to have an
ectopic pregnancy are:
 Previous ectopic pregnancy. If you've had
this type of pregnancy before, you're more
likely to have another.
 Inflammation or infection. Sexually
transmitted infections, such as gonorrhea or
chlamydia, can cause inflammation in the
tubes and other nearby organs, and increase
your risk of an ectopic pregnancy.
 Fertility treatments. Some research
suggests that women who have in vitro
fertilization (IVF) or similar treatments are
more likely to have an ectopic pregnancy.
Infertility itself may also raise your risk.
 Tubal surgery. Surgery to correct a closed or
damaged fallopian tube can increase the risk
of an ectopic pregnancy.
 Choice of birth control. The chance of
getting pregnant while using an intrauterine
device (IUD) is rare. However, if you do get
pregnant with an IUD in place, it's more likely
to be ectopic. Tubal ligation, a permanent
method of birth control commonly known as
"having your tubes tied," also raises your risk,
if you become pregnant after this procedure.
  Smoking. Cigarette smoking just before you
get pregnant can increase the risk of an
ectopic pregnancy. The more you smoke, the
greater the risk.
- Different types of ectopic pregnancy
Tubal pregnancy
A tubal pregnancy occurs when the egg has
implanted in the fallopian tube. This is the most
common type of ectopic pregnancy and the majority
of ectopic pregnancies are tubal pregnancies. The
type of tubal pregnancy can be further classified
according to where inside the fallopian tube the
pregnancy becomes established.
 A pregnancy grows in the fimbrial end in
around five percent of all cases.
 A pregnancy grows in the ampullary section in
around 80% of all cases.
 A pregnancy in the isthmus of the fallopian
tube is seen in around 12% of all cases.
Increased vasculature in this area means
hemorrhage is more likely to occur and
mortality of the pregnancy is therefore more
likely.
 A pregnancy in the cornual and interstitial part
of the fallopian tube is seen in around two
percent of cases and again is more likely to
lead to mortality of the pregnancy due to
increased vasculature in this area.
Non-tubal ectopic pregnancy
Nearly two percent of all ectopic pregnancies
become established in other areas including the
ovary, the cervix or the intra-abdominal region.
Heterotopic pregnancy
In some rare cases, one fertilized egg implants inside
the uterus and another implants outside of the
structure. The ectopic pregnancy is often discovered
before the intrauterine pregnancy, mainly due to the
painful nature of ectopic pregnancy. If human
chorionic gonadotropin levels continue to rise after
the ectopic pregnancy has been removed, the
pregnancy inside the womb may still be viable.
- Management
Therapeutic Management
Some ectopic pregnancies spontaneously end before
they rupture and are reabsorbed over the next few
days, requiring no treatment. It is difficult to predict
when this will happen, so when an ectopic pregnancy
is revealed by an early ultrasound, some action is
taken. An unruptured ectopic pregnancy can be
treated medically by the oral administration of
methotrexate followed by leucovorin (Hajenius et al.,
2009). Methotrexate, a folic acid antagonist
chemotherapeutic agent, attacks and destroys fast-
growing cells. Because trophoblast and zygote
growth is so rapid, the drug is drawn to the site of the
ectopic pregnancy (see Chapter 53 for a general
discussion of chemotherapy agents of this type).
Women are treated until a negative hCG titer is
achieved. A hysterosalpingogram or ultrasound is
usually performed after the chemotherapy to assess
whether the tube is fully patent. Mifepristone, an
abortifacient, is also effective at causing sloughing of
the tubal implantation site. The advantage of these
therapies is that the tube is left intact, with no surgical
scarring that could cause a second ectopic
implantation.
If an ectopic pregnancy ruptures, it is an emergency
situation (Stevens & Gilbert-Cohen, 2007). Keep in
mind the amount of blood evident is a poor estimate
of the actual blood loss. A blood sample needs to be
drawn immediately for hemoglobin level, typing and
cross-matching, and possibly hCG level for
immediate pregnancy testing, if pregnancy has not
yet been confirmed. Intravenous fluid using a large-
gauge catheter to restore intravascular volume is
begun. Blood then can be administered through this
same line when matched.
The therapy for a ruptured ectopic pregnancy is
laparoscopy to ligate the bleeding vessels and to
remove or repair the damaged fallopian tube. A
rough suture line on a fallopian tube may lead to
another tubal pregnancy, so either the tube will be
removed or suturing on the tube is done with
microsurgical technique.
If a tube is removed, a woman is theoretically only
50% fertile, because every other month, when she
ovulates from the ovary next to the removed tube,
sperm cannot reach the ovum on that side. However,
this is not a reliable contraceptive measure.
Research in rabbits has shown that translocation of
ova can occur—that is, an ovum released from the
right ovary can pass through the pelvic cavity to the
opposite (left) fallopian tube and become fertilized,
and vice versa.
As with miscarriage, women with Rh-negative blood
should receive Rh (D) immune globulin (RhIG) after
an ectopic pregnancy for isoimmunization protection
in future childbearing.
6. Principles of Blood Transfusion
- Nursing interventions
- Reactions
- Adverse effect (and when it happened, as a
nurse what will you do?)
7. Rh Isoimmunization
- (Sino ang nagkakaroon ng isommunization,
anong klaseng buntis, ano dugo ng bata?)
- (ano dapat mong gawin as a nurse)
8. Embryonic and Fetal Structures
- decidua
- chorionic villi (sampli)
- placenta ( diff. functions, importance in
pregnancy)
- amniotic membranes
- amniotic fluids (problems if kulang – what
does it mean ano yung sakit, and also if sobra –
ano ang sakit?)
- umbilical cord (functions)
9. Esophageal Atresia (pediatric complications)
10. McDonald's Rule
12. Bartholomew's Rule of Fourths
13. Assessment of Fetal Well-Being
- Fetal Heart Rate ( common question is the
normal range)
- Daily Fetal Movement (paano natin na
iinstruct ang mother)
- Ultrasound (ano ang mga nakikita sa
ultrasound, purpose)
- Placental Grading for Maturity
- Biophysical profile (5 components)
- Maternal Seram