CHAPTER 38. Gynecological and Reproductive Care
Laura Krieger
OBJECTIVES
After completion of this chapter, the reader will be able to:
1. Describe the anatomical and physiological aspects of the female reproductive organs and structures as they pertain to patients undergoing gynecological and reproductive diagnostic or operative procedures.
2. Identify assessment parameters for patients undergoing gynecological and reproductive operative or diagnostic procedures.
3. Define nursing priorities, concerns, and complications in each operative phase.
4. Define nursing care assessments, nursing diagnoses, nursing interventions, and expected patient outcomes.
5. List pertinent patient education and health maintenance tools.
I. OVERVIEW
A. Patients undergo gynecological operative or diagnostic procedures for:
1. Acute or chronic reasons
2. Elective or emergent reasons
B. Surgical interventions required for a variety of indications ranging from:
1. Simple diagnostic procedures
2. Radical excisions for malignancy
C. Nursing intervention strategies are discussed as they relate to specific diagnostic or operative situations.
II. ANATOMY AND PHYSIOLOGY
A. External genitalia (Figure 38-1)
1. Collectively called the vulva
2. Mons pubis
a. Mound of adipose tissue overlying symphysis pubis
b. Covered with pubic hair in the adult
3. Labia majora
a. Outer vulval lips
(1) Two rounded folds of adipose tissue
(2) Extend from the mons pubis to the perineum
(3) Covered with hair
(4) Protect perineum
(5) Contain large sebaceous glands that maintain lubrication
4. Labia minora
a. Inner vulval lips
b. Anterolateral medial parts
(1) Join to form prepuce and frenulum
(2) Folds of skin that cap the clitoris
c. Posterior union called the fourchette
5. Clitoris
a. Small, protuberant organ located beneath the arch of mons pubis
b. Composed of:
(1) Erectile tissue
(2) Venous cavernous spaces
(3) Specialized sensory corpuscles that are stimulated during coitus
c. Urethral opening is a slit below the clitoris.
d. Homologous to the male penis
6. Vestibule
a. Oval space bordered by:
(1) Clitoris
(2) Labia minora
(3) Fourchette
(a) Posterior junction of labia majora and labia minora
(b) Glands lubricate vestibule.
(4) Skene’s glands
(a) Open on both sides of urethral meatus
(b) Contain 6 to 31 ducts
(c) Known as paraurethral glands
(d) Becomes infected usually from organisms that cause sexually transmitted infections (STIs)
(5) Bartholin glands
(a) Open on both sides of vaginal meatus
(b) Can be palpated when enlarged
(c) Can become infected usually from organisms that cause STIs
b. Hymen: thin membrane partially covering vaginal orifice
c. Perineum
(1) Anteriorly bordered by top of labial fold
(2) Posteriorly bordered by anus
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| FIGURE 38-1 ▪ Midsagittal section of the female pelvis. (From Thibodeau GA, Patton KT: Anatomy & physiology, ed 6, St Louis, 2007, Mosby.) |
B. Internal structures (Figure 38-2)
1. Vagina
a. Occupies space between bladder and rectum
b. Connects uterus with vestibule
c. Lined with mucous membranes
d. Conduit for menstrual fluid discharge
e. Birth canal
2. Cervix
a. Narrow neck of uterus
b. Provides passageway between:
(1) Uterine cavity
(2) Vagina
3. Uterus
a. Hollow, pear-shaped muscular organ
b. Conceptus grows during pregnancy.
c. Uterine wall consists of:
(1) Inner mucosal lining (endometrium)
(a) Undergoes cyclic changes based on hormonal activity
(b) Facilitates and maintains pregnancy
(2) Middle muscular lining (myometrium)
(a) Interlaces uterine and ovarian arteries and veins
(b) During pregnancy, vasculature expands dramatically.
(3) Outer serous layer (parietal peritoneum)
(a) Covers:
(i) All of the fundus
(ii) Part of the corpus
(iii) Not the cervix
d. Divided into fundus and cervix, which protrudes into vagina
e. Lining sheds (menstruation) in monthly cycle in the absence of:
(1) Fertilization
(2) Implantation of embryo
4. Fallopian tubes (uterine tubes)
a. Extend from sides of fundus
b. Terminate near ovaries
c. Carry ova to uterus
d. Facilitate movement of sperm toward ovaries
e. Move zygote (fertilized ovum) to uterus
5. Ovaries
a. Two almond-shaped organs
b. Attached to posterior surface of broad ligament
c. Produce:
(1) Ova
(2) Estrogen
(3) Progesterone
(4) Small amounts of androgen
d. Fully developed after puberty
e. Shrink after menopause
6. Ligaments of uterus
a. Wide fold of periosteum that holds the uterus in place
b. Eight in number
(1) Two cardinal ligaments
(a) Fibrous sheets that extend to lateral pelvic wall from:
(i) Cervix
(ii) Vagina
(b) Help prevent prolapse of uterus
(2) Two lateral or broad ligaments
(a) Attach uterus to either side of pelvic cavity
(b) Divide cavity into two portions
(i) Anterior part—bladder
(ii) Posterior part—rectum
(c) Keep uterus in position
(3) Two uterosacral ligaments
(a) Lie on either side of rectum
(b) Connect uterus to sacrum
(4) Two round ligaments
(a) Flattened bands between 10 and 12 cm in length
(b) Situated between layers of the broad ligaments
(i) In front of uterine tubes
(ii) Below uterine tubes
7. Peritoneal folds of uterus
a. One anterior
(1) Vesicouterine fold of periosteum
(2) Reflected onto bladder from front of uterus
b. One posterior
(1) Rectovaginal fold of periosteum
(2) Reflected from back of posterior fornix of vagina to front of rectum
8. Vasculature
a. External genital blood supply
(1) Vulva
(a) Blood supply
(i) External pudendal arteries
(ii) Internal pudendal arteries
(b) Venous drainage
(i) Internal pudendal veins
b. Internal genital organs
(1) Vagina
(a) Blood supply
(i) Uterine arteries
(ii) Vaginal arteries
(iii) Internal pudendal arteries
(b) Venous drainage
(i) Vaginal venous plexus
(ii) Uterine venous plexus
(2) Uterus
(a) Blood supply
(i) Uterine arteries
(b) Venous drainage
(i) Uterine venous plexus into internal iliac vein
(3) Ovaries and fallopian (uterine) tubes
(a) Blood supply
(i) Ovarian arteries from abdominal aorta
(ii) Uterine arteries from internal iliac artery
(b) Venous drainage
(i) Right ovarian vein into inferior vena cava
(ii) Left ovarian vein into left renal vein
(iii) Tubal veins drain into:
[a] Ovarian veins
[b] Uterine venous plexus
9. Nerves
a. Superior hypogastric plexus
(1) Carries sympathetic fibers
(2) Responsible for innervation of:
(a) Fundus uteri
(b) Cervix
(c) Vagina
b. Inferior hypogastric plexus
(1) Three portions representing viscera innervation
(a) Vesical plexus
(i) Bladder
(ii) Urethra
(b) Hemorrhoidal plexus
(i) Rectum
(c) Ureterovaginal plexus
(i) Uterus
(ii) Vagina
(iii) Clitoris
(iv) Vestibular bulbs
c. Iliohypogastric
(1) Innervates skin near iliac crest just above symphysis pubis
d. Ilioinguinal
(1) Sensory innervation
(a) Upper medial thigh
(b) Mons
(c) Labia majora
e. Genitofemoral
(1) Sensory innervation
(a) Anterior vulva
(b) Middle and upper anterior thigh
f. Posterior femoral cutaneous
(1) Sensory innervation
(a) Vulva
(b) Perineum
g. Pudendal
(1) Sensory innervation
(a) Perianal skin
(b) Vulva
(c) Perineum
(d) Clitoris
(e) Urethra
(f) Vaginal vestibule
(2) Motor innervation
(a) External anal sphincter
(b) Perineal muscles
(c) Urogenital diaphragm
10. Associated structures
a. Genitourinary
(1) Bladder
(2) Ureters
(3) Urethra
b. Sigmoid colon and rectum
c. Pelvic floor muscles
d. Lymph nodes
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| FIGURE 38-2 ▪ Uterus and uterine tubes. (From Thibodeau GA, Patton KT: Anatomy & physiology, ed 6, St Louis, 2007, Mosby.) |
III. PATHOPHYSIOLOGY
A. Congenital or anatomical abnormalities
1. Imperforate hymen
a. Completely closed hymen
2. Herniations
a. Abnormal bulging/pouching of organs/tissues
b. Cystocele
(1) Herniation of bladder
(2) Causes anterior vaginal wall to bulge downward
c. Rectocele
(1) Formed by protrusion of anterior rectal wall (posterior vaginal wall) into vagina
d. Enterocele
(1) Herniation of cud-de-sac of Douglas
(2) Contains loops of small intestine
e. Urethrocele
(1) Pouch-like protrusion of urethral wall
(2) Thickening of connective tissue around urethra
3. Uterine displacement
a. Abnormal position or shape of uterus
b. Prolapsed uterus
(1) Collapsed uterus into vaginal opening
4. Bicornuate uterus
a. Usually two separate “horns” that form the top of uterus
5. Septate uterus
a. Uterine cavity divided by a wall (septum)
b. Septum may extend only part of the way.
c. Septum may extend as far as the cervix.
6. Tubal incompetency: a blockage of one or both fallopian tubes
a. Complete
b. Partial
B. Endocrine (hormonal) dysfunction
1. Abundant, low, or no secretions of necessary reproductive hormones
2. Endometriosis (growth of endometrial tissue outside the endometrium)
3. Dysfunctional uterine bleeding
4. Stein-Leventhal syndrome (polycystic ovary syndrome)
C. Growths and neoplasms
1. Cysts (closed sack or pouch with definite walls that contains fluid, semifluid, or solid material)
a. Bartholin
b. Ovarian
2. Uterine fibroids, myomatas, or leiomyomas—tumors containing muscle tissues
3. Carcinomas (malignant tumor growth in epithelial tissue)
a. Vulvar
b. Cervical
c. Uterine
d. Ovarian
4. Polyps (benign tumors with pediclea). Removed if possibility that it will become malignant
a. Prone to bleeding (hemorrhage)
b. Cervical
c. Uterine
5. Condylomata (wartlike growths of the skin)
a. External genitalia
b. Anal region
D. Infections and inflammatory processes
1. Pelvic inflammatory disease (PID)
a. Affects abdominal organs
b. May result in infertility
2. Abscesses (encapsulated infective material)
a. Perineal region
b. Abdominal organs
3. Fistulas (abnormal connection or passageway between two epithelium-lined organs)
a. Urethrovaginal
b. Rectovaginal
E. Pregnancy related (see Chapter 39)
1. Abortion
a. Incomplete
(1) Abortion in which parts of products of conception have been retained in uterus
b. Missed
(1) Abortion in which fetus has died before twentieth completed week of gestation
(2) Products of conception retained in uterus for 8 weeks or longer
c. Therapeutic
(1) Abortion performed when mental or physical health of mother is endangered by continuation of pregnancy
2. Incompetent cervix
3. Ectopic pregnancy (pregnancy occurring outside uterine cavity)
a. Commonly occurs in fallopian tube
b. Life-threatening if ruptured
(1) Hemorrhage
(2) Loss of fallopian tube and/or ovary
4. Hydatidiform mole—degenerative process in chorionic villi that gives rise to:
a. Multiple cysts
b. Rapid growth of uterus
c. Possible hemorrhage
d. Surgical removal by laparotomy
IV. DIAGNOSTIC/PREOPERATIVE EVALUATION
A. Physical examination of external genitalia
1. Pelvic
a. Inspection of external genitalia and pubic hair to assess sexual maturity
2. Labia
a. Gently spread the labia majora and minora and inspect area.
b. Area should be free from moisture and free from lesions.
c. May detect a normal discharge that should be:
(1) Odorless
(2) Nonirritating to the mucosa
3. Vestibule
a. Inspect the area around Bartholin’s and Skene’s glands.
b. Check for:
(1) Swelling
(2) Redness
(3) Lesions
(4) Discharge
(5) Unusual odor
c. Inspect the vaginal opening, noting whether hymen:
(1) Intact
(2) Perforated
4. External genitalia
a. Spread labia with one hand and palpate with the other.
b. Labia should feel soft.
c. Note swelling, hardness, or tenderness.
d. If mass or lesion detected:
(1) Palpate it to determine its size, shape, and consistency.
B. Physical examination of internal genitalia
1. Speculum examination of vagina and cervix
2. Obtain a specimen for a Papanicolaou’s test (Pap smear).
a. Detection and diagnosis of malignant and premalignant conditions
(1) Vagina
(2) Cervix
(3) Endometrium
b. Obtain wet preparation.
(1) Yeast infection
(2) Bacterial infection
(3) Trichomonas
c. Cultures for STIs
(1) Gonorrhea
(2) Chlamydia
3. Palpating the internal genitalia
a. Note tenderness or nodularity in vaginal wall.
b. Bulging of vaginal walls during “bearing down” may indicate:
(1) Cystocele
(2) Rectocele
4. Bimanual palpation of uterus and ovaries
a. Performed by advanced practitioners
b. Allows evaluation of:
(1) Rectovaginal area
(2) Posterior part of uterus and pelvic cavity
(3) Rectum
(4) Feel the edges of the cervix and lower posterior wall of the uterus.
C. Subjective data
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1. Characteristics (Box 38-1)
a. Menstrual history
b. Onset of menses
c. Length of cycles
d. Regularity of cycles
e. Duration, amount, and content of flow
f. Date of last menstrual cycle
g. Contraceptive use or absence
BOX 38-1
DEFINITIONS
Gravidity: pregnancies, full-term deliveries, preterm deliveries
Menarche: beginning of menstrual function
Amenorrhea: absence or abnormal stoppage of menses
Oligomenorrhea: infrequent menstrual flow occurring at intervals of 35 to 180 days
Menorrhagia: hypermenorrhea
Menometrorrhagia: excessive uterine bleeding occurring both during menses and at irregular intervals
Terminations: spontaneous, elective
2. Sexual activity, sexual partners
3. Virilizing features
