NCMA217: CARE OF MOTHER AND CHILD AND ADOLESCENT (WELL CLIENT)

WEEK 3: MENSTRUATION
PROFESSOR: FRANCIS A. VASQUEZ, MAN, RN
1ST SEMESTER | A.Y 2023 – 2024 | TRANSCRIBER: RIZALYN RANGEL DIAVARRO

OUTLINE Menstrual Period

I. Menstruation
a. Menstrual Period vs Menstrual - days that a woman is menstruating
Cycle
b. Fertile Window
c. 4 Days of Menstrual Cycle Menstrual Cycle
d. Organs Involved
II. Conception - starts from the first day of the period to ovulation
III. Reproduction to the next first day of the next period
IV. Fetal Membranes - menstruation to ovulation (1st half of the cycle)
a. Umbilical Cord dominated by the hormone estrogen
b. Placenta - ovulation to menstruation (2nd half of the cycle)
V. Fetal Development dominated by the hormone progesterone
a. Milestones
b. Signs and Symptoms of Pregnancy
c. Assessment of Fetal Growth and
Development Thelarche
d. Fetal Movements - first or early sign of female secondary sex
VI. Ultrasound
development
a. Ultrasound Results
- breast development
VII. Amniocentesis
VIII. Discomforts of Pregnancy - comes after accelerated linear growth (growth
IX. Pregnancy: Psychological Adaptation spurt)
X. Prenatal Visit - Facility-Based
a. Components of PNV
XI. Pelvic Exam Sequence of Puberty in Girls
XII. Leopold’s Maneuver
XIII. Nutritional Requirements during 1. increase in height
Pregnancy 2. broadening of the hips
XIV. Exercise in Pregnancy 3. thelarche (breast development)
XV. Family Planning 4. adrenarche (appearance of pubic and axillary hair)
a. 2 Components 5. menarche (menstruation)
b. Methods of Contraception 6. ovulation (middle of the cycle)
i. Natural
ii. Artificial

MENSTRUATION
- periodic, cyclic discharge of blood from the uterus
(organ of menstruation)
- blood loss (30-80 cc, average of 60 or ¼ cup)
- iron loss (12-29 mg)

MENSTRUAL PERIOD vs MENSTRUAL CYCLE

 3-5 days; maximum of 7 days

 average of 28 days/cycle The day of ovulation based on the length of the cycle.
 ranges from 23-35 days; maximum of 40 days The length of the cycle affects the day of the ovulation.
 occurs during puberty, 9-17 y/o average of 12 y/o
 onset is menarche (usually occurs during puberty) For the nurse to accurately compute/determine the day of
the ovulation, she must deduct 2 weeks from end of the cycle.

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 You can add 14 days from the beginning of the cycle if the The first 2 days after the menstruation are the safest days
menstrual cycle is only 28 days. to have sex if the cycle is 28 days.
Ovulation will happen 2 weeks before menstruation. Having sex during the period is not always safe.
We can tell whether the menstrual cycle of a woman is It is possible to ovulate while having menstruation.
regular or irregular if the length of the cycle is constant
(same) for 6 months.
4 days of the Menstrual Cycle
Even though you are menstruating monthly but the length
of your cycle varies, you are considered as irregular. You
cannot use the calendar method of contraception.

FERTILE WINDOW
During the average woman's menstrual cycle there are six
days when intercourse can result in pregnancy.
This “fertile window” comprises the five days before
ovulation and the day of ovulation itself.
Just as the day of ovulation varies from cycle to cycle so
does the timing of the six fertile days.
 3rd - woman is menstruating so the level of estrogen
is low
Computation  13th - level of estrogen is high
 13th - level of progesterone is low
 14th - level of progesterone is high

 Deduct 5 days (lifespan of the sperm) from the day

of ovulation
During the first half of the menstrual cycle, the low level of
 Add 3 days (lifespan of the egg) from the day of estrogen on the 3rd day will stimulate/trigger the
ovulation hypothalamus to start the cycle by releasing FSHRF. FSHRF
will stimulate APG to release FSH which will cause maturation
of the egg cell/ovum. FSH will stimulate ovaries to release
estrogen which will convert Follicle to Graafian follicle (GF),
and estrogen will affect the uterus (thickening of
endometrium and myometrium).

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 Graafian Follicle support. The level of estrogen progesterone will become low,
and the uterus will contract. The temporary capillaries will
- a follicle that contains high level of estrogen; it is
rupture, and the temporary lining of the endometrium is
where you can find maturing egg cells
slough off resulting to menstrual discharge.

Feedback Mechanism
MENSTRUATUON: ORGANS INVOLVED
- APG will stop producing FSH for the ovaries to also
stop producing estrogen in order to start producing
progesterone

During the second half of the menstrual cycle, the low level
of progesterone on the 13th day will stimulate/trigger the
hypothalamus to release LHRF. LHRF will stimulate APG to
release LH which will cause ovulation. LH will stimulate
ovaries to release progesterone which will convert Graafian
follicle (GF) into Corpus luteum (2 weeks lifespan), and
progesterone will affect the uterus (increase vascularity of
endometrium).

Different Glands that control the Menstrual Cycle

(Structural and Hormonal)

Corpus luteum  Hypothalamus - starts the menstrual cycle;

- structure that maintains pregnancy in its early produces Gonadotropin-Releasing Hormone (GnRH)
months GnRH has two kinds; Follicle Stimulating Hormone
- if positive fertilization occurs, its lifespan will extend Releasing Factor (FSHRF) and Luteinizing Hormone
from 2 weeks to 2 months Releasing Factor (LHRF)
- after 2 months, placenta will go out (endorsement  Anterior Pituitary Gland - stimulated by the
time) hypothalamus; releasing FSH and LH
 Ovaries - stimulated by the Anterior Pituitary
Gland; produces estrogen and progesterone
Progesterone  Uterus - affected by the ovaries

- no. 1 hormone produced by the placenta

CONCEPTION

After 9 months of pregnancy, pregnant woman will have

aging placenta (placental degeneration theory) and
progesterone deprivation theory, which will lead to labor and
delivery.
If there is no fertilization occurs, the lifespan of corpus
luteum will not extend because there is no pregnancy to

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 Ovum FETAL MEMBRANES
- female sex cell or gamete
- released through ovulation
- life span: 24 hours
- two layers: corona radiata and zona pellucida

Sperm Cells
- Parts: head, neck and tail
- Lifespan: 48 to 72 hours (3-5 days)
- Types:
a. gynosperm – large oval head – X – acidic
b. androsperm – small head – Y – alkaline 1. Chorionic – placenta
2. Amniotic – BOW and umbilical cord

REPRODUCTION
Amniotic Fluid
Volume: 500-1200ml; average is 1000ml
Composition: 99% H20, 1% solid particles; pH 7-7.25
Vernix, uric acid, urea, albumin, lecithin, sphyngomyelin LS
ratio
Appearance:
➢ clear and colorless – straw-colored
➢ if green: meconium – possible fetal distress
➢ if golden: bilirubin – Rh Incompatibility
➢ if gray: infection

THE UMBILICAL CORD (Funis)

Function: transport 02 and nutrients to fetus, unoxygenated
blood and water to placenta
Blood Vessels: AVA
Length: 50-55 cm
Insertion: center of the placenta
1. knots – increases perinatal loss

2. cord coil – nuchal cord

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 THE PLACENTA Second Month
- From chorionic villi and Decidua Basalis - sex differentiation starts
- Weight = 500gms at term; has 15 to 20 cotyledons - assumes human form
- Produces: estrogen, progesterone, HPL, HCG - presence of amniotic fluid
- FHR determination by Doppler
2 Sides
Third Month
1. Maternal – Duncan – periphery to center
2. Fetal – Schultz – center to pheriphery - renal system is functional
- sucking reflex is present
- placenta is fully developed and functional

Fourth Month
- FHT by fetoscope
- sex differentiation is complete
- quickening for multipara
- Ig G transport from mother to fetus
- lanugo appearance begin

Fifth Month
- vernix appears
- FHT by stethoscope
- Quickening for primigravida

Sixth Month
- surfactant production begins
- Hears external sound

FETAL DEVELOPMENT Seventh Month

1. Pre-embryonic – 1st 14 days after fertilization - continued growth and development

2. Embryonic – 15 days to 2 months - Bone ossification
3. Fetal – 2 months to birth
Eighth Month
- subcutaneous fat is present
- iron transfer from mother to fetus
- lanugo disappears

Ninth Month
- testes descends in scrotum

SIGNS AND SYMPTOMS OF PREGNANCY

MILESTONES IN FETAL DEVELOPMENT Presumptive Signs
First Month  Amenorrhea
- heart functions as early as 16th day  Morning Sickness (4-6 weeks gestation)
- development- nervous system; maternal  Breast Changes
hypoglycemia  Quickening (16-20 weeks)

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  Chloasma (“mask of pregnancy”) FETAL MOVEMENTS (Kick Count/hr)
 Urinary Frequency
Quickening – 1st fetal movements

primigravida – 20 weeks
Probable Signs
multigravida – 16 weeks
 Enlarged Uterus Average: 16-20 weeks
12 weeks – above symphysis pubis
20 weeks – at umbilicus Peak: 28-38 weeks
 Hegar’s and Goodell’s Sign
Normal: 5-10-15 times/hr
 Chadwick’s Sign
 (+) Urinary Pregnancy Test
ULTRASOUND

Positive Signs Uses

 Ultrasound evidence  To diagnose pregnancy

after 6 weeks (between 8-12 weeks)  Confirm presence, size and location of the placenta
 FHT and amount of amniotic fluid
 Quickening felt by the examiner  Detect fetal abnormalities and defects
 Determine fetal position and presentation, fetal sex
 Determine fetal maturity by means of biparietal
ASSESSMENT OF FETAL GROWTH AND DEVELOPMENT
diameter, placental grading
McDonald’s Rule

 Fundic height measurement cm Preparation of the Client

 Fundic height in cm
 Full bladder
= AOG in weeks
 Drink a glass of water every 15 minutes 1 ½ hours
 Or FHt x 8/7 = AOG in weeks
prior to procedure (<20 wks)
 (2nd trimester and up)
 Do not void before the procedure

Ultrasound Results

 Biparietal diameter of 8.5cm or more

= fetal weight of 2,500 gms or more
= total age of 40 weeks or more

Bartholomew’s Rule

 5th month of pregnancy

= fundus at the level of the umbilicus
 Early 9th month
= below xyphoid process
 End of 9th month
= at 8th month level AMNIOCENTESIS
- Aspiration of amniotic fluid from pregnant uterus
- Done on 12th to 13th weeks of pregnancy

Preparations
1. Empty the bladder
2. Supine position

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3. One towel under the right buttock
4. Attach fetal and contraction monitor
5. Ultrasound to determine position and location of
fetus and placenta

Results

 Color – clear to pale straw

 Lecithin-Sphingomyelin Ratio

DISCOMFORTS OF PREGNANCY

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 COMPONENTS OF PNV
- Min. of 4 Check-ups (once per trimester & on the 9th
month)
- Demographic data
- Chief concern/ complaint
- Family profile
- Hx of past illness
- Hx of family illnesses
- Gynecologic history

PELVIC EXAM

 IE – internal examination of the vagina

 to determine probable signs of pregnancy:
o Chadwick’s
o Goodell’s
o Hegar’s
 Cardinal Rule before the pelvic exam:
o VOID- Dorsal recumbent position

LEOPOLD’S MANEUVER

 To determine:
1 - Lie
2 - Back
3 - Presentation
4 – Attitude

PREGNANCY: PSYCHOLOGICAL ADAPTATION

First Trimester
- Acceptance of pregnancy

Second Trimester NUTRITIONAL REQUIREMENTS DURING PREGNANCY

- Acceptance of the fetus as a separate individual  Calorie: 2,300-2,500

 CHON: 60 gms
 Vitamin A: 10,000 iu
Third Trimester
 Folic Acid: 400 mcg
- Acceptance of motherhood  Calcium: 1,200 mg
 Phosphorus: 700 mg
 Iron: 60 mg
PRENATAL VISIT- FACILITY -BASED  Elemental Iodine: 1 cap of 250 mg/preg

 First prenatal visit – establish baseline data

 Objective: To decrease maternal & neonatal EXERCISE IN PREGNANCY
morbidity & mortality rates
1. Walking
2. Tailor Sitting – to make perineum supple
3. Squatting – strengthens pelvic floor muscle

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4. Pelvic floor contractions (Kegel’s Exercise) NATURAL METHOD
5. Pelvic rocking – relieves back pain
 Abstinence
 Lactation Amenorrhea Method (LAM)
FAMILY PLANNING  Fertility Awareness Method (FAM) - father and
mother must cooperate with one another
- is the use of a range of methods of fertility o Calendar Method, Cervical Mucus Test
regulation in order to: o Basal Body Temperature Test and
Symtothermal Method, 2-day method
1. Avoid unwanted births/pregnancy  Coitus Interruptus (Withdrawal) - not recommended
2. Bring about wanted births/pregnancy by the DOH
3. Regulate the number of children born
*2 to 3 is the recommended number of children for CONCEPT: No use of any chemical, mechanical, hormonal and
couple. surgical means of preventing pregnancy.
4. Regulate intervals between pregnancies/birth
spacing
*3 to 5 years is the recommended interval for Abstinence
pregnancy
- refraining from vaginal sexual intercourse - different
5. Control time at which birth occurs (perfect timing)
from STRICT ABSTINENCE (no any form of sexual
contact)

2 COMPONENTS Advantages: acceptable, 100% effective, no cost

Planning the Pregnancy (prerequisites) Disadvantages: loss of self-control - difficult to maintain

 Proper nutrition and exercise

*Follic acid intake (400 mcg)
Lactation Amenorrhea Method (LAM)
 Lifestyle changes
Remember: Smoking can cause SGA baby - Use of this method requires regular and fulltime
 Alcohol can cause cognitive impaired baby breast feeding
 Medical History Taking and Checkup is important o Effective during the first 6 months post-
 Genetic counselling partum
o No ovulation and no menstruation
o Not effective after 6 months
Preventing Pregnancy o After 6 months, woman may ovulate but
without menstruation
 Contraceptive methods are used
 Always remember that there is always a possibility
for the method of contraception to fail thus BARRIER METHOD
pregnancy may occur.
 Condom - male and female
 Cervical Cap
METHODS OF CONTRACEPTION  Diaphragm
Natural  IUD - Intrauterine Device

 Standard Days Method (SDM)/Calendar

 Cervical Mucus Test (CMT)/Billing's test/Creighton's Intrauterine Device
Method/Spinnbarkeit
 Basal Body Temperature
 Abstinence
 2-day method
 Lactational Ammenorrhea Method/LAM
 Symptothermal Method (combination of CMT & BBT)

Artificial
 Copper Bearing IUD ex. Copper T
 Barrier, Chemical, Hormonal, Surgical

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 Progesterone Bearing IUD ex. Progestin T

HORMONAL METHOD

 Oral Pills - Combined Oral Contraceptives (COCP) -

contains estrogen and progesterone
 Progestin Only Pill (POP) - contains progesterone
 Injectable Depo Provera and Lunelle - progesterone
based
 Patch - Ortho Evra - progesterone based
 Implants - Norplant and Implanon (progesterone
based)
 Vaginal Ring - contains estrogen

STERILIZATION

 Vasectomy
 Tubal Ligation

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