Naval Education and
Training Command
NAVEDTRA 10669-C
JUNE 1989
0502-LP-218-8100

Training Manual
(TRAMAN)
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Hospital Corpsman
3 & 2

 

 


Pages 3-49, 3-50, and 3-51

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Female Reproductive System
The female reproductive system (fig. 3-56) includes the ovaries, the fallopian (uterine tubes) the uterus, the vagina, the external genitalia (vulva), and the breasts (mammary glands), which are not illustrated but will be discussed.
External Genitalia
The external genital organs, referred to collectively as the vulva, include the mons pubis, labia majora, labia minora, clitoris, vestibule, Bartholin's glands, and hymen. The mons pubis is the pad of fatty tissue beneath the skin, anterior to the symphysis pubis. The labia majora are two folds of skin extending from the mons pubis anteriorly to the perineum (the region between the vaginal orifice and the anus). Within these two folds of skin are two smaller folds, called the labia minora, extending from the clitoris to either side of the vaginal orifice. The clitoris is a small body richly endowed with nerves, highly sensitive, and of significance in sexual stimulation. The clitoris becomes engorged with blood during sexual excitement, but , unlike its male counterpart, the penis, it does not become erect. It is located at the point where the two labia minora meet. The vestibule is the area between the labia minora into which the urethral and vaginal orifices open. The urinary meatus is the external urethral orifice situated inferior to the clitoris and superior to the vaginal orifice. The vaginal orifice is situated inferior to the urethra. The Bartholin's glands are the female counterparts of the Cowper's glands in the male. They consist of two small roundish bodies on either side of the vaginal opening. Each gland is connected with the vagina by means of long ducts and secretes a viscid, alkaline fluid lubricant between the labia minora and the hymen. Finally, the hymen is a fold of mucous membrane that extends across the lower part of the vagina. It is not a very reliable indicator of virginity.
Mammary Glands
The mammary glands, or breasts, are accessory organs of the female reproductive system. They develop during puberty under the influence of the hormones estrogen and progesterone. The breasts are responsible for the secretion of milk (lactation) for the nourishment of newborn infants.

Structurally the breasts resemble sweat glands. At the center is a nipple containing 15 to 20 depressions, into which ducts from the lobes of the gland empty. During pregnancy hormones secreted by the ovaries cause the glandular tissue to grow in preparation for lactation. After childbirth hormones secreted  by the anterior lobe of the pituitary gland stimulate production for 6 to 9 months.

Ovaries
The ovaries (female gonads) are two almond-shaped glands suspended by ligaments in the upper pelvic cavity, one on either side of the uterus, posterior and inferior to the fallopian tubes. Their prime function is to produce the ova and the female hormone estrogen and progesterone. Although these hormones are manufactured by the ovaries, their production is controlled by the anterior pituitary gland. These hormones play essential roles in the development of secondary sex characteristics, the reproductive cycle, gestation, and lactation.

The graafian follicles are microscopic pockets in the ovaries. Once a month, under hormonal influence, a follicle matures, ruptures, and expels its ovum into the uterus. Each ovary normally releases an ovum every 56 days, the right and left ovary alternately discharging an ovum every 28 days. The menstrual cycle in most women is therefore 28 days in length.

Fallopian Tubes
The fallopian (uterine) tubes are composed of internal mucous, middle muscular, and outer serous coats that are continuous with the layers of the uterus. They serve as ducts of the ovaries, providing a passageway to the uterus. These tubes are in contact with the ovaries, but are not continuous with them. Their funnel-shaped openings, called free openings, are fringed with fingerlike processes that pick up an ovum and draw it into the fallopian tubes, where it is transported to the uterus by peristalsis and gravity. Fertilization of an ovum normally takes place in the fallopian tubes.
Uterus
The uterus (womb) is a hollow, pear-shaped organ with thick, muscular walls. It is lined with a specialized epithelium, called endometrium, which undergoes partial destruction about every 28 days in the nonpregnant woman.

The uterus averages 7 cm in length and 5 cm in width. It has three opening: the openings of the fallopian tubes laterally and the opening into the vagina. The parts of the uterus are the body, which is the large upper portion, and the cervix, which is the smaller portion that projects into the upper part of the vagina. The cervical opening into the vagina is called the external os. The walls of the uterus are highly flexible and are composed of three layers that are continuous with the respective layers of the fallopian tubes.

In addition to being the focal point of the endometrial (menstrual) cycle, the uterus is the site of implantation, growth and development of the fertilized ovum. The muscular walls of the uterus produce powerful rhythmic contractions that are important in the expulsion of the fetus at birth.

Vagina
The vagina is a musculomembranous, collapsible tube capable of great distention. It is lined with mucous membrane that extends from the cervix to the vulva. The canal is about 7.5 cm long, and its lining membrane, which is greatly folded, is continuous with the inner lining of the uterus. The vagina is the organ that receives the male sperm during intercourse. It also forms the lower portion of the birth canal, stretching widely during delivery. In addition, it serves as an excretory duct for uterine secretions and menstrual flow.
Recurring Cycles
When females reach puberty, they begin to experience the two recurring female cycles, the ovarian and endometrial.

As previously mentioned, each ovary produces a mature ovum every 56 days. They expel their ova on an alternating basis, approximately one every 28 days. The length of this cycle may vary markedly from individual to individual and between cycles of the same individual. ON the first days of menstruation, several ova within the graafian follicles begin to mature, an normally one will be expelled 14 days before the next menstrual flow. This is the ovarian cycle.

The endometrial cycle centers around the periodic development and breakdown of the endometrial lining of the uterus. The first phase of the cycle is the menses, or menstruation. It begins when the endometrial lining starts to slough off from the walls of the uterus, and it is characterized by bleeding from the vagina. This is day 1 of the cycle, and this phase usually lasts through day 5. The time between the last day of the menses and ovulation is known as the postmenstrual phase. It lasts from day 6 through day 13 or 14 and is characterized b y proliferation of endometrial cells in the uterus, which develop under the influence of the hormone estrogen. Ovulation is the rupture of a graafian follicle with the release of a mature ovum into the fallopian tubes. It usually occurs on day 14 or 15 of the cycle. The postovulatory (premenstrual) phase is the time between ovulation and the onset of menses and normally lasts 14 days. During this phase the ovum travels through the fallopian tubes to the uterus. If the ovum becomes fertilized during this passage, it will become implanted in and nurtured by the newly developed endometrial lining. However, if fertilization does not take place, the lining deteriorates and eventually sloughs off, marking day 1 of the next cycle.

References
1. Anthony and Thibodeau: Text book of Anatomy & Physiology, ed 11. C.V. Mosby.

2. American Academy of Orthopaedic Surgeons: Emergency Care and Transportation of the Sick and Injured, ed 3.


Pages 4-89, 4-90

Emergency Childbirth
Every corpsman must  be prepared to handle the unexpected arrival of a new life into the world. If the corpsman is fortunate, a prepackaged sterile delivery pack will be available. This will contain all the equipment needed to delivery a normal baby. If the pack is not available, imaginative improvisation of clean alternatives will be needed.

When the corpsman is faced with an imminent childbirth, the first determination to be made is whether there will be time to transport the expectant mother to the hospital. To help make this determination, the corpsman should try to find out whether or not this will be the woman's first delivery (first deliveries usually take much longer than subsequent deliveries); how far apart the contractions are (if less than 3 minutes, delivery is approaching); whether or not a mother senses that she has to move her bowels (if so then the baby's head is well advanced down the birth canal); whether or not there is crowning (bulging) of the orifice (crowning indicates that the baby is ready to present itself); and how long it will take to get to the hospital. The corpsman must weigh the answers to these questions to decide if it will be safe to transport the patient to the hospital.

Prior to childbirth a corpsman must quickly "set the stage" to aid the event. the mother must not be allowed to go to the bathroom since the straining may precipitate the delivery in the worst possible location. Do not try to inhibit the natural process of childbirth by having the mother cross her legs. The mother should be lying back on a a sturdy table, bed, or stretch. A folded sheet or blanket should be place under her buttocks for absorption and comfort. Remove all clothing below the waist, bend the knees and move the thighs apart, and drape the woman with clean towels or sheets. The corpsman should then don sterile gloves or, if these are not available, rewash his or her hands.

In a normal delivery, your calm professional manner and sincere reassurance to the mother will go a long way towards alleviating her anxiety and making the delivery easier for everyone. Help the woman rest and relax as much as possible between contractions. During contraction, deep, open mouth breathing will relieve some pain and straining. As the child's head reaches the area of the rectum, its pressure will cause the mother to feel an urgent need to defecate. Reassurance that this is a natural feeling and a sign that the baby will soon be born will alleviate her apprehension.

Watch for the presentation of the top of the head. Once it appears, take up your station at the foot of the bed and gently push against the head to keep it from popping out in a rush. Allow it to come out slowly. As more of the head appears, check to be sure that the umbilical cord is not wrapped around the neck. If it is, gently try to untangle it, or move one section over the baby's shoulder. If this is impossible, clamp in two places, 2 inches apart, and cut it. Once the chin emerges, use the bulb syringe from the pack to suction the nostrils and mouth while you support the head with one hand. Compress the bulb prior to placing it in the mouth or nose; otherwise, there will be a forceful aspiration into the lungs. The baby will now start a natural rotation to the left or right, away from the face down position. As this is occurring, keep the head in a a natural relationship with the back. The shoulders appear next, usually one at a time. From this point on, it is essential to remember that the baby is VERY slippery, and great care must be taken so that you do not drop it. The surface beneath the mother should extend at least 2 feet out from the buttocks to that the baby would not be hurt if it did slip out of your hands, and use the other to support its emerging body.

One the baby has been born, suction the nose and mouth again if breathing has not started. Wipe the face, nose and mouth clean with sterile gauze. Your reward will be the baby's hearty greeting to the world.

Clamp the umbilical cord as the pulsations cease. Use two clamps from the prepackages sterile delivery pack, 2 inches apart, with the first clamp 6 to 8 inches from the navel. Cut between the clamps. For safety, use gauze tape to tie the cord 1 inch from the clamp toward the navel. Secure the tie with a square knot. Wrap the child in a warm, sterile blanket and log the time of the child's arrival.

The placenta (afterbirth) will deliver itself in 10 to 20 minutes. This can be aided by massaging the mother lower abdomen. Do not pull on the placenta. Log the time of its delivery, and wrap it up for hospital analysis.

Place a small strip of tape (1/2 inch wide), folded and inscribed with the date, time of delivery, and mother's name, around the baby's wrist.

Complications in Childbirth
Breech Delivery
If the baby's legs and buttocks emerge first, follow the steps for a normal delivery, supporting the lower extremities with one hand. If the head does not emerge within 3 minutes, try to maintain an airway by gently pushing fingers into the vagina, pushing the vagina away from the face and opening the baby's mouth with one finger. Get medical aid immediately.
Prolapsed Cord
If the cord precedes the baby, protect it with moist, sterile wraps. If a physician cannot be reached soon, place the mother in an extreme shock position, give her oxygen if available, and gently move your gloved hand into the vagina to keep its walls and the baby from compressing the cord. Get medical aid immediately.
Excessive Bleeding
If bleeding is severe, treat the mother for shock and give her oxygen. Place sanitary napkins over the vaginal entrance and rush her to a hospital.
Limb Presentation
If a single limb presents itself first, get the mother immediately to a hospital.

 


Page 5-4

Sex
An individual is born either male or female and learns roles and responses associated with their gender through parental models, family relationships, and his or her specific society. As one enters into the world of providing health care services, it is necessary to learn and adopt new roles and responses regarding gender identification. As the number of females entering the military service increases, health care providers are increasingly being challenged to expand their function s in relation to caring for patients of the opposite sex. The health care provider who has developed sound moral principles and consciously strives to provide a service based on a firm ethical foundation has little to fear when providing care for an individual of either sex. However, the development of such a foundation requires diligent study, a commitment to growth, and an availability of professionally guided experiences. Throughout your career as a member of the Hospital Corps, you will be given opportunities and guidance to achieve a sound ethical background. Your only responsibility toward this growth is a desire and commitment to make yourself available and respond as a real professional.

Because of the increasing frequency with which hospital corpsmen are required to attend to persons of either sex, the following guidelines are presented to assist you in developing some decision-making judgments.

To ensure the protection of health care personnel from unjustified accusations, a witness should be present when a member of the opposite sex is being examined or treated. Whether this witness is a member of the same sex as the patient may be dictated by the availability of personnel. When you are caring for a patient, sensitivity to both verbal and nonverbal communication is paramount. A grin, a frown, or an expression of surprise may all be misinterpreted by the patient. Explanations and reassurances will go far in preventing misunderstanding of actions or intentions. Knowledge, empathy and mature judgement should guide the care provided to any patient; this is especially crucial when the care involves touching. As a member of the health care team, you are responsible for providing complete, quality care to all who need and seek your service. This care must  be provided in a manner compatible with your individual legal and technical limitations.