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Few4y efewfwfny - Chester County Intermediate Unit

Assisting in Obstetrics and Gynecology Chapter 41 Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1 Learning Objectives Define, spell, and pronounce the terms listed in the vocabulary. Apply critical thinking skills in performing patient

assessment and care. Identify the major organs of the female reproductive system and explain the primary function of each. Trace the ovum through the three phases of menstruation. Compare and contrast current contraceptive methods. Summarize menstrual disorders and conditions. Distinguish among different types of gynecological infections. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2 Learning Objectives

Differentiate between benign and malignant neoplasms of the female reproductive system. Prepare for and assist with the female examination, including a Papanicolaou (Pap) test. Demonstrate patient preparation for a cryosurgery procedure. Teach the patient how to perform breast self-examination. Compare the positional disorders of the pelvic region. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3 Learning Objectives

Summarize the process of pregnancy and parturition. Describe the common complications of pregnancy. Specify the signs, symptoms, and treatments of conditions related to menopause. Outline the medical assistants role in gynecological and reproductive examinations. Demonstrate how to assist with the prenatal examination. Distinguish among diagnostic tests that may be done to evaluate the female reproductive system. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4 The Female Reproductive System

External genitalia The female reproductive system is made up of the external genitalia: the vulva, labia majora, and labia minora. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5 Female External Genitalia A from Applegate EJ: The anatomy and physiology learning system, ed 3, Philadelphia, 2006, Saunders; B from Frazier MS, Drzymkowski JA: Essentials of human diseases and conditions, ed 3, Philadelphia, 2004, Saunders. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6 Internal Organs

The internal organs include: The vagina with rugae formation in the walls so it can expand when the baby is born The bottom of the uterus, the cervix, which must dilate and efface for vaginal birth The uterus with the internal lining, the endometrium, and middle lining, the myometrium The fallopian tubes, which extend from the fundus of the uterus and carry the fertilized egg back to the uterus The ovaries, which mature and excrete an egg or ovum Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7

Mechanism of Fertilization Sperm deposited in the vagina Swim up the cervical os, through the uterus, into the fallopian tubes 200600 million sperm are deposited, with about 100,000 surviving the acidic vagina Fertilization occurs when one sperm cell penetrates an egg Usually takes place in the distal third of the fallopian tube Zygote moves by peristalsis into the uterus, where it implants and the placenta forms

Human chorionic gonadotropin (HCG) in urine if pregnant Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8 Breast Tissue Hormones that control mammary glands: Estrogen, which affects size starting at puberty Progesterone, which develops duct system Prolactin, which stimulates milk production Oxytocin, which causes milk let-down from ducts

Nipple surrounded by pigmented areola Each breast contains lobes surrounded by adipose tissue Also contains mammary glands and milk ducts Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9 Normal Female Breast From Jarvis C: Physical examination and health assessment, ed 4, Philadelphia, 2004, Saunders. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10 Menstruation

Menarchefirst menstrual cycle. Average menstrual cycle lasts 28 days. In the follicular phase, hormones mature a graafian follicle, and an ovum is released while the endometrial wall is thickening. Ovum passes into the fallopian tube and moves toward the uterus. The rupture spot on the ovarythe corpus luteum secretes progesterone. In the luteal phase, extensive growth of the endometrium continues; if conception does not occur, the menstrual cycle begins with the breakdown of the endometrium and menstrual flow. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11

Contraception Refer to Table 41-1. Condoms are only moderately successful in preventing pregnancy but should be used consistently to prevent transmission of STDs. Factors to consider: Is it safe and effective? Does it conveniently match sexual habits? Is the patient at risk for serious side effects? Is it affordable?

Is it reversible? Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12 Barrier Contraceptive Methods Relatively inexpensive and reversible but must be used each time the patient has intercourse Cervical capthimble-sized and fits over cervix; used with spermicide Can be inserted 12 hours before intercourse and can stay in place 72 hours Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13

Barrier Method: Diaphragm Diaphragmis used with spermicidal jelly or cream and fits around the cervix Check for holes before each use Leave in place 6 hours after intercourse Before repeated use add spermicide to the outside of the diaphragm Wash with soap and water and air dry Should be refitted if patient gains or loses 10 to 15 lb or has a baby Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

14 Hormonal Methods Complications Symptoms may indicate thrombus formation or possible stroke. Blood clots and strokes are most serious complications Patient education mnemonic: ACHES AAbdominal pain, new and severe CChest pain, new and severe HHeadaches, new or more frequent EEye problems, blurred or loss of vision SSevere leg pain

Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15 Hormonal Methods Oral contraceptives (OCPs) must be taken daily Suppress ovulation and atrophy the endometrium Most effective method if taken as ordered Contraindicated if history of thrombi; liver disease; CAD; diabetes; breast, liver, reproductive tract cancer; or sickle cell anemia, and in smokers over 35 years of age Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

16 Hormonal Methods Transdermal Patch Ortho Evra Slowly releases estrogen and progestin through the skin and into the bloodstream As effective as OCPs in women weighing less than 198 pounds Exposes patients to 60% more estrogen than OCPs May be at greater risk of side effects Cigarette smoking increases risk of serious cardiovascular

side effects, especially in patients over 35 years of age Patch changed weekly for 3 consecutive weeks, and go patch-free the fourth week Can bathe, shower, and swim while wearing the patch Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17 Hormonal Methods NuvaRing vaginal ring that is inserted into the vagina Slowly releases estrogen and progestin for 1 month 2 inches in diameter; inserted anywhere in the vagina

Side effects are similar to those of other hormonal contraceptives An additional method of birth control must be used for the rst week of use If the ring falls out, it should be rinsed with warm water and reinserted within 3 hours; if out more than 3 hours use another birth control method for 1 week Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18 Hormonal Contraceptive Methods Depo-ProveraIM injections every 12 weeks Menstrual irregularities common but go away after

two injections Compliance may be a problemmust get injection every 9 to 13 weeks May delay return of fertility Contraindicated with history of breast cancer or liver disease Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19 Intrauterine Device (IUD) T-shaped plastic frame with threads attached that is inserted into the uterus to prevent pregnancy Inhibits fertilization by blocking sperms journey to fallopian tubes; prevents embryo from implanting in

the uterine wall Two types of IUDs: ParaGard releases copper, which acts to slow sperm in the cervix; can remain in place as long as 10 years Mirena releases progestin, which decreases sperm mobility and prevents thickening of the endometrial wall during the menstrual cycle; must be replaced every 5 years Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20 Permanent Methods of Birth Control Malevasectomy; can be done in physician office setting

Femalebilateral tubal ligation More expensive procedure because it requires outpatient hospitalization and anesthesia More complications Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21 Menstrual Disorders Amenorrheano menstruation for a minimum of 6 months Oligomenorrheano menstruation from 35 days to 6 months; caused by hormonal imbalance, eating disorder, extreme exercise, stress

Failure to ovulate increases risk of endometrial cancer TreatmentOCPs artificially stimulate endometrial shedding Menorrhagiaexcessive menstrual bleeding longer than 7 days Metrorrhagiaspotting or bleeding between menstrual cycles Treat excessive bleeding with OCPs or D&C Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22 Endometriosis

Functional endometrial tissue found outside the uterus Located on fallopian tubes, bladder, intestines, peritoneum Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23 Endometriosis Gould BE: Pathophysiology for the health professions, ed 3, Philadelphia, 2006, Saunders. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 24 Endometriosis

Ectopic endometrial tissue responds to hormone changesproliferates, degenerates, and bleeds during the menstrual cycle Causes inflammation that recurs with each cycle, ultimately leading to adhesions and obstructions Symptomsdysmenorrhea, dyspareunia, contact pain, excessive menstrual flow, infertility Treatmentlaparoscopy, OCPs, Depo-Provera, Lupron, hysterectomy; pregnancy helps relieve symptoms Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 25 Gynecological Infections

Candidiasisvaginal yeast infection Caused by antibiotics, OCPs, diabetes, AIDS, STDs Symptomsgenital irritation and pruritus; odorless white vaginal discharge Treatmentantifungal cream or suppository; Diflucan or Monistat Cervicitisinflammation of cervix from a pathogen Symptompurulent, white, foul smelling discharge Treatmentantibiotics Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

26 Gynecological Infections Bacterial vaginosis secondary bacterial infection of the vagina Signs and symptoms vaginal discharge, odor, pain, pruritus, or burning Vaginal infection may cause increased susceptibility to STDs including HIV Can lead to PID Associated with premature or low-birth-weight infants Treated with antibiotics Flagyl or Cleocin

Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 27 Gynecological Infections Pelvic inflammatory disease (PID)any acute or chronic infection of the reproductive system ascending from the vagina Chronic episodes can result in scarring of the fallopian tubes and formation of adhesions Responsible for a large percentage of cases of infertility in women because of adhesions in the fallopian tubes that prevent migration of the ovum through the tube Patient may be asymptomatic or may complain of purulent vaginal discharge, fever, malaise, dysuria, lower abdominal pain, bleeding, nausea, and vomiting Treated with broad-spectrum antibiotics Flagyl, Rocephin, Vibramycin

Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 28 STDs and Women Refer to Table 41-2 Chlamydia HSV-2 HPV Gonorrhea Syphilis

Trichomoniasis HIV Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 29 STDs: Human Papillomavirus (HPV) HPV causes genital warts Whether there are symptoms of wart development or not, the infection can lead to serious complications in women Typically rst diagnosed by abnormal Pap test results Positive Pap test followed by HPV DNA test to diagnose specic strain of HPV Approximately 10 HPV strains are linked to cervical

carcinoma If diagnosed with a carcinogenic strain, patient must have regular Pap testing, usually every 3 to 6 months, for early detection and treatment of precancerous and cancerous cells on the cervix Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 30 HPV Immunization Gardasil first vaccine designed to prevent diseases caused by specific strains of HPV including cervical cancer, precancerous genital lesions, and genital

warts Recommended for 11- and 12-year-old girls as well as those between the ages of 13 and 26 who have never been diagnosed with HPV Effective against the four HPV types that cause approximately 70% of cervical cancers and it can prevent 90% of genital warts outbreaks Administration three separate doses over 6 month period; costs between $300 and $500 Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 31 HIV and AIDS

Percentage of women and girls with HIV is declining but heterosexual exposure still accounts for 31% of HIV cases diagnosed each year HIV can be transmitted through the placenta Crucial that women are diagnosed either before pregnancy or as early in the pregnancy as possible Treatment with a three-part ZDV (zidovudine, AZT, or Retrovir) regimen decreases the risk of HIV infection in the fetus by almost 70% Treatment ZDV at 14 to 34 weeks; administered IV during labor and delivery; given to infant every 6 hours for 6 weeks after birth HIV-positive women should never breastfeed since the virus is present in breast milk Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 32

Benign Tumors Uterine fibroidscomposed of smooth muscle and fibrous connective tissue; cause menorrhagia; become smaller and calcify after menopause; hysterectomy may be indicated if bleeding is excessive Ovarian cystssacs of fluid or semisolid material that can occur in the follicle or the corpus luteum at any time between puberty and menopause; treated with OCPs or laparoscopy Polycystic ovary diseasehormonal problem causes cysts to develop over enlarged ovaries; results in anovulation, amenorrhea, hirsutism, increased risk of endometrial cancer; treated with OCPs Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

33 Fibrocystic Breast Disease Multiple palpable nodules in the breasts. Usually associated with pain and tenderness that fluctuate with the menstrual cycle. Over time cysts enlarge and connective tissue of the breast is replaced with dense and firm fibrous tissue. Caffeine and high fat diets aggravate symptoms. Makes diagnosis of cancerous breast masses more difficult. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

34 Cervical Cancer Cervical cancer Asymptomatic at first; advanced stages abnormal bleeding Almost all cervical carcinomas are caused by the human papillomavirus Early diagnosis of cervical cellular changes is possible with a Pap smear First stage of cervical cancer is asymptomatic Invasive stage abnormal vaginal bleeding and persistent

discharge as well as bleeding and pain during intercourse American Cancer Society recommends all sexually active women and those over the age of 18 yearshave annual Pap smears Average age at diagnosis dropping because of HPV infections Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 35 Fibrocystic Breast Disease Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 36 Pap Smear

Physician obtains cervical smear with a Cytobrush or small wooden spatula that is inserted and rotated in the cervical canal to obtain endocervical cells for cytology ThinPrep Pap Test collection device rinsed into a vial containing a preservative solution The laboratory lters the sample and creates a slide with a thin layer of cervical cells that is examined by a pathologist for abnormalities Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 37 Pap Smear Results Classied into five categories inflammation or STDs can cause abnormal changes

negative or normal atypical squamous cells abnormal with low-grade squamous lesions abnormal with high-grade lesions (precancerous) carcinoma cells in cervical cells, so the physician will decide how to manage abnormal results based on other diagnostic studies. If abnormal cells are seen, the pathologist grades cervical changes using cervical intraepithelial neoplasia (CIN) system of I to III, depending on the degree of cellular dysplasia Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

38 Classification of Cervical Cancer Stage 0: Carcinoma in situ Stage I: Carcinoma of the cervix with no adnexal involvement Stage II: Carcinoma of the cervix that has not spread into the pelvic wall or vagina Stage III: Carcinoma of the cervix that has spread into the lower part of the vagina; may be blocking the ureters Stage IV: carcinoma of the cervix that has spread to

nearby organs such as the bladder or rectum with involvement of structures outside the pelvic area Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 39 Colposcopy Colposcopy is the visual examination of the vagina and the cervical surfaces through the use of a colposcope Colposcope is a microscope with a light source and a magnifying lens that can be used during a vaginal examination to locate and evaluate abnormal cells and detect cancer of the cervix in its early stages

Can examine tissue from which an abnormal Pap smear was taken Monitor areas of the cervix in which malignant lesions have been removed Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 40 Colposcope Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 41 Conization or LEEP Procedures Conization removes a cone-shaped wedge of cervical tissue for either treatment or further analysis

Loop electrosurgical excision procedure (LEEP) less invasive inject local anesthetic into the cervix and insert a wire loop through the vagina high-frequency electrical current running through the wire is used to remove abnormal tissue from both the cervix and the endocervical canal can be used as a diagnostic tool to collect biopsy samples and as a treatment to remove abnormal tissue Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 42 Cryosurgery

Cryosurgery application of freezing temperatures to treat chronic cervicitis and cervical ulcers Freezing causes cellular necrosis; in approximately 1 month dead cells are replaced with healthy cells Probe is placed against problem area on the cervix and liquid nitrogen is applied for 3 or 4 minutes Patient may experience some pain for 30 minutes or so after the procedure and a slight watery discharge for up to a week Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 43 DES

DES synthetic estrogen prescribed from 1938 to 1971 to prevent miscarriages and premature births Potential health risks from the DES exposure include: Women prescribed DES have an increased risk for breast cancer DES daughters have an increased risk of cancer of the vagina and cervix, reproductive tract structural abnormalities, pregnancy complications, and infertility Men exposed to DES in utero have an increased risk for noncancerous cysts in the epididymis Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

44 Endometrial Cancer Endometrial cancer Irregular vaginal bleeding and leukorrhea Increased frequency in postmenopausal women, no children, early menarche, late menopause Diagnosed with endometrial biopsy Treatmenthysterectomy, radiation, chemotherapy Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 45

Ovarian Cancer Ovarian cancer Leading cause of gynecological-related deaths Asymptomatic until metastasis has occurred in 71% of patients Asymptomatic until tumor is large enough to put pressure on nearby structures; symptoms include vague abdominal discomfort, bloating, urinary urgency, weight loss, and general malaise Diagnosis combination of pelvic examination; cancer antigen (CA)-125 blood test that identies a protein found in abnormally high levels in women with ovarian cancer; and a pelvic or transvaginal ultrasound to evaluate the size and

shape of the ovaries; ultimate diagnosis is based on a positive biopsy Treatment complete hysterectomy (removal of the uterus, fallopian tubes, and ovaries), radiation, and chemotherapy Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 46 Breast Cancer Breast cancer One in every eight U.S. women has lifetime risk Predisposing factors family history, early menarche, late menopause, first pregnancy after 30 years or no pregnancy, ERT, obesity, high-fat diet, smoking Symptoms palpable breast mass that is rm and immovable, breast pain, tissue thickening, nipple retraction or dimpling, nipple discharge, and axillary lymphadenopathy Diagnosis clinical breast examination, SBE, mammogram, and MRI for high-risk women; needle

biopsy, stereotactic procedure Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 47 Inflammatory Breast Cancer Rare aggressive type; causes sudden onset of discoloration and warmth in the affected breast, with edema, dimpling of the skin, enlarged axillary lymph nodes, and pain Easily confused with breast infection Cancer cells rapidly spread and block lymph vessels in

the skin causing the sudden onset of symptoms Diagnosed by an excisional biopsy Typically diagnosed as Stage II cancer has spread to local lymph nodes; one-third of patients diagnosed with Stage IV carcinoma where metastasis has already occurred Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 48 Breast Cancer Treatment Dependent on type of carcinoma and its staging Extent of tissue surgically removed varies:

Lumpectomy mass plus surrounding area of normal tissue Partial mastectomy more advanced cases; remove tumor and tissue surrounding it, part of chest muscle, axillary lymph nodes Complete mastectomy entire breast, chest muscle, and axillary lymph nodes removed Removal of multiple axillary lymph nodes greatly increases risk of developing lymphedema of the arm Sentinel lymph node inject blue dye near tumor, lymph vessels carry it toward the lymph nodes, rst node to turn blue is removed for pathological testing; if it is cancer-free there is very little chance the breast tumor has metastasized Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 49 Pelvic Positional Disorders

Cystoceleprotrusion of bladder into anterior wall of the vagina; bladder becomes angled and urinary retention is common with frequent cystitis and UTIs. Rectoceleprotrusion of rectum into posterior wall of the vagina. Uterine prolapsecervix has dropped into the vaginal area; may progress to include drooping uterus to cervix protruding from the vaginal opening. Structural abnormalities can be corrected with surgery. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 50 Pelvic Floor Muscle Exercises

Kegel exercises help strengthen pelvic floor muscles and are done to prevent or treat pelvic organ prolapse and incontinence. Contract the muscles that make up the pelvic floor by visualizing that you are stopping the flow of urine mid-stream. Hold the contraction to the count of three and slowly relax for a count of three. Repeat the exercise until you are performing 10 to 15 contractions in a set, with up to three sets throughout the day. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 51 Pregnancy

Pregnancy occurs when the ovum and sperm meet in the fallopian tube and a zygote is formed. The zygote implants in the uterine wall and the placenta begins to form, which provides hormonal support for the pregnancy. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 52 Embryo The fetus is surrounded by an amniotic sac and floats in amniotic fluid. The fetus oxygen and nutrient needs are met by maternal blood that passes through the placenta to the umbilical cord, and waste material passes out along the same path. The embryonic period ends at 12 weeks, when all tissues and organs have developed.

Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 53 Fetus During the remainder of the pregnancy, the organs mature and begin to function, and the fetus grows First trimester from the LMP through the 14th week; multiple physical and psychological changes for the woman and is a crucial time for fetal organ development Second trimester 15th to 28th week; uterus above the umbilicus; quickening occurs

Third trimester 28th week through delivery; rapid fetal growth; baby gains close to 1 lb/week Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 54 Stages of Labor From Applegate EJ: The anatomy and physiology learning system, ed 3, Philadelphia, 2006, Saunders. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 55 Parturition Labor is divided into three stages:

Stage I: From the onset of labor through complete dilation and effacement of the cervix Stage II: From complete dilation and effacement of the cervix through the birth of the fetus Stage III: From the birth of the fetus through the expulsion of the placenta Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 56 Complications Complications of pregnancy begin with fertility

problems and the potential loss of the pregnancy from different types of abortions (miscarriages). Ectopic pregnancy occurs outside the uterus; most occur in the fallopian tube. Placental abnormalities pose a threat to the well-being of the fetus. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 57 Types of Miscarriages

Spontaneousabortions that do not have an identiable cause Completecomplete expulsion of both fetus and placenta without any medical intervention Incompleteexpulsion of only parts of the fetus and placenta; D&C must be done to remove remaining pieces, or mother will continue to bleed Missedfetus dies in utero and must be removed surgically Threatenedcervical bleeding but no dilation occurs; pregnancy continues uninterrupted Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 58 Placental Problems

In placenta previa, the placenta covers the cervical os; in abruptio placenta, the placenta breaks away from the uterine wall. Both cause maternal hemorrhage, threaten fetal oxygen supply, and require cesarean birth to protect the fetus and mother. From Frazier MS, Drzymkowski JA, Daty SJ: Essentials of human diseases and conditions, ed 3, Philadelphia, 2004, Saunders. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 59 Placenta and Exchange of Nutrients From Applegate EJ: The anatomy and physiology learning system, ed 3, Philadelphia, 2006, Saunders. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 60

Maternal Disorders: Gestational Diabetes Mellitus (GDM) Impaired glucose tolerance that develops during pregnancy Risk factors over 30 years of age; family history of diabetes mellitus; BMI more than 25 before pregnancy; and certain racial groups, including blacks, Hispanics, and Native Americans ACOG recommends all pregnant patients be screened at 24 to 28 weeks gestation using a 50-g, 1-hour glucose challenge test Must regularly monitor blood glucose levels Treatment diet, exercise, and oral hypoglycemics, or insulin Prognosis typically goes away after infants birth but women are at greater risk for developing type 2 diabetes later in life

Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 61 Maternal Disorders: Gestational Hypertension 10% to 15% of women develop hypertension during the second half of pregnancy If hypertension is accompanied by proteinuria after 20 weeks of pregnancy, patient is diagnosed with preeclampsia or toxemia Signs and symptoms hypertension with protein or albumin in

the urine, uremia, altered liver function, and reduced platelet count Birth of the baby will cure preeclampsia, with blood pressure returning to normal within a few days of delivery Complications severe headaches, vision disturbances, oliguria, and convulsions either before or during labor; may require emergency C-section to prevent serious maternal complications Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 62 Menopause Menopausepermanent ending of menstruation because ovarian function stops; diagnosed 12 months after last menstrual period

Perimenopausebegins when hormone-related changes start to appear and lasts until the final menses; ovulating but the uneven rise and fall of estrogen and progesterone may cause symptoms Some women have few or no symptoms; others have hot flashes, concentration problems, mood swings, irritability, migraines, vaginal dryness, urinary incontinence, dry skin, and sleep disorders Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 63 Menopause Treatment The physician may prescribe low-dose oral contraceptives or hormone-replacement therapy; soy products or supplements; vitamin E; vitamin B6; restriction of caffeine and spicy foods; a low-fat diet high in calcium; and regular weight-bearing exercise.

Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 64 Critical Thinking Application Rose Conrad, a 53-year-old patient of Dr. Beck, calls because she read recently that the hormone replacement therapy she has been taking for 3 years may be dangerous. Dr. Beck has reviewed her case and agrees that if she is concerned she can stop taking the medication; however, she recommends that Mrs. Conrad try some alternative therapies. What suggestions might Dr. Beck make for nonpharmaceutical treatment of perimenopausal symptoms? Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 65

MA Role Gather complete gynecological history Preparing the patient for the examination Equipping the room Making sure supplies are available and properly prepared Assisting with the examination Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 66 MA Role

Positioning and draping the patient Assisting with the Pap smear or any other procedure Providing support and understanding for the patient Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 67 Gynecological History

Age at menarche Regularity of menstrual cycle; amount and duration; history of menstrual disturbances and their treatment Any indicators of infection including vaginal discharge, pelvic pain, and urinary difficulties Breast abnormalities and date of last mammogram Date of last Pap test Sexual history; STD history Number of pregnancies and live births Date of LMP Lifestyle factors, including diet, exercise, smoking, alcohol use, and so on Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 68

Prenatal Examination Prenatal visit includes: vital signs, weight, and urinalysis prepare patient and supplies needed for pelvic measurements, perform serologic tests, and prepare for laboratory tests physician assesses heart, lung, and thyroid function and performs a physical examination OB examination includes palpation of the mothers abdomen, measurement of the height of the uterus, and a pelvic

examination Follow-up visits: the medical assistant collects a urine specimen for urinalysis, weighs the patient, measures BP, and answers questions about diet and health habits Doppler picks up fetal heart tones between 9 and 12 weeks of pregnancy Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 69 Prenatal Tests

Hematocrit and hemoglobin levels to check for anemia Blood type and Rh with antibody screening for possible Rh incompatibility Rubella titer rubella infection during pregnancy can cause multiple birth defects including deafness, vision disorders, and mental retardation Syphilis screening if the result is positive, antibiotic treatment to protect fetus from congenital syphilis Hepatitis B screening virus can be passed to the fetus in utero HIV screening suggested treatment of mother will greatly reduce risk of transmission to fetus Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 70 Prenatal Tests

Pap smear to check for abnormal cervical cells Gonorrhea and chlamydia cultures to prevent newborn infections Urinalysis for presence of protein, WBCs, or glucose Group B streptococcus vaginal culture mother treated with antibiotics to prevent fetal exposure during vaginal birth NST to evaluate fetal heart rate mother attached to fetal monitor; check for accelerations in fetal heart rate with movement Stress test or oxytocin challenge test (OCT) if the NST is abnormal; small amount of oxytocin administered IV while mother is on a fetal monitor to see how the fetus will respond to the normal stresses of labor Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

71 Diagnostic Tests Diagnostic tests for the female reproductive system include: ultrasonography to determine the number of fetuses, age and sex of the fetus, fetal abnormalities, and position of the placenta chorionic villi sampling or amniocentesis to perform genetic testing for anomalies or inherited disorders alpha-fetoprotein (AFP) blood tests to diagnose neural tube defects Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

72 Diagnostic Tests Mammography provides an x-ray image of the breast tissue to identify abnormal masses that would otherwise be undetected with a breast-palpation examination. Colposcopy procedures visualize abnormal cervical tissue for evaluation or biopsy. Cryosurgery treats cervical ulcers or cervicitis. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 73 Patient Education A woman who is planning a pregnancy or who

has just found out she is pregnant may benefit from some guidelines for healthy living. These include: nutrition limitation of alcohol smoking cessation medicine STD screening Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 74 Patient Education

One of the integral roles of the medical assistant in the OB/GYN practice is reinforcing the physicians patient education efforts. Betsy stays up to date on current contraceptive practices by attending local AAMA workshops and regional conferences. Betsy recognizes that she must continue to learn about new practices and recent research to help deliver the best possible care to the women in Dr. Becks practice. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 75 Recognizing Victims of Abuse

Know what to look for multiple injuries at different sites; victim may be frightened, anxious, or passive; history of accidents Know what to ask all female patients should be asked if they are in an abusive relationship Know what to say and do victim may begin to believe that she deserves to be mistreated and needs unconditional and nonjudgmental emotional support from the healthcare worker; encourage her to develop a plan of action for when the next violent episode occurs Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 76

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