Women’s Health

Family Planning and

Contraception

by
DR. dr. I Nyoman Bayu Mahendra, SpOG (K)
Goal of Family Planning
 To assist the clients with reproductive
decision making, enabling the client to
have control of the number of
pregnancies, spacing the time between
children, and to prevent pregnancy if
desired
Decision to use a
contraceptive
 May be made by the individual man or
woman or jointly as a couple
The Ideal Method Should Be
 Safe
 100% effective
 Free of SE
 Easily obtainable
 Affordable
 Acceptable to the user & sexual partner
 Free of effects on future pregnancies
Legal Issues related to Family
Planning and Contraception
 May vary from state to state concerning
minors,sterilization,and abortions.
 Informed consent-need to document
information provided and understanding of
client -the nurse should use (BRAIDED)when
counseling client on contraceptive methods
 decision about contraception should be
made voluntarily with informed consent
BRAIDED
 B- Benefits/Advantages
 R-Risks/Disadvantages
 A- Alternatives/Other methods available
 I-Inquiries/ Allow time for questions
 D-Decisions/opportunity to decide or change
mind
 E-Explanation/about method/how to use
 D-Documentation /everything taught
What to teach about each
method
 What it is, How it is used , or How it works?
 advantages
 disadvantages
 effectiveness
 side effects
 risks
 contraindications
 long term effects
Assessment
 Obtain a history to identify the client’s past
and current health status and potential
risks factors.
 Sexual history
 Reproductive health
 Future plans for childbearing
 Psychosocial data- lifestyle, motivation,
religious beliefs,cultural influences,
Assessment
 Financial factors
 these factors may affect the
selection,access,and use of aparticular
method
 Don’t assume anything….ask.
 Knowledge of and concern about
contraceptive methods need to be
determined to identify deficits and need
Assessment
 For accurate and additional information
 Identify actual or potential problems
from the assessment.
 Provide privacy for assessment and
discussion about contraceptive methods
Methods of Family Planning or
Contraception
 Natural methods-
 abstinence
 Coitus interruptus -(withdrawal)
 Fertility awareness methods-calendar
method,basal body temperature (BBT),
cervical mucus method, symptothermal
method
Methods of Family Planning
and Contraception
 Mechanical methods-
 Barrier methods-
 Condoms- Male/Female
 Diaphragm
 Spermicides
 Intrauterine device(IUD)
Methods of Family Planning
and Contraception
 Chemical Methods-
 Oral Contraceptives(birth control pills)
 Subdermal implants(Norplant)
 Long-acting progestin injections
 Postcoital contraception
 Surgical Methods-Vasectomy
 Tubal ligation
Natural methods
 Safe
 Situational methods requiring increased
self awareness
 Self control
 to be effective
Abstinence
 Compliance
 0 % failure rate
 Most effective way to prevent STD
Fertility Awareness Methods
 Based on an understanding of the
woman’s ovulation cycle and the timing
of sexual intercourse
 All methods attempt to identify the
female fertility and to avoid unprotected
intercourse during that time period
 Free,safe,and acceptable to couple’s
religious beliefs prohibit other methods
Female Reproductive Cycle
Fertility Awareness Methods
(Continue)
 Increases awareness of the woman’s body
 encourages communication
 can be used to prevent or plan a
pregnancy
 Requires extensive counseling and
education
 interfere with sexual spontaneity
 difficult with irregular cycles
 no protection for STI’s
Calendar method
 Rhythm method
 75 - 91% effective
 6 - 8 months period
 Shortest and longest cycles
 18 days from shortest cycle
 11 days from longest cycle
 Avoid sex during fertile period
Basal Body Temperature
 Based on the thermal shift in the
menstrual cycle
 75 - 97% effective
 drop prior to ovulation then raises 0.5 –
10F with ovulation
 Avoid intercourse when temperature
drops and for 3 days after.
Cervical mucus
 Ovulation or Billing’s Method
 Based on the cervical mucus changes that
occur during the menstrual cycle
 75 - 97% effective
 Cervical mucus changes in response to
levels of estrogen and progesterone
 Assess for amount, color, consistency, and
viscosity
Symptothermal Method
 Incorporates the assessment of multiple
indicators of ovulation - BBT, and
cervical mucus, increased libido,
abdominal bloating, mittelschmerz,
breast tenderness, pelvic tenderness,
pelvic or vulvar fullness, softer cervix
located higher in the vagina
 75 - 97% effective
Withdrawal – Coitus
Interruptus
 Male ejaculates outside vagina
 Sperm are contained in pre-ejaculatory
fluids
 Interfere with sexual satisfaction of
both partners
 **LEAST reliable method of
contraception
Mechanical Methods
 Male condom 86 - 97% effective
 Female condoms 79 - 95% effective
 Proper technique to apply
 Protection from pregnancy and Sexual
Transmitting Disease
 Water based lubricants
Male Condom
Applying Male Condom
Female condom
Diaphragm
 80 - 94% effective
 Dome shaped appliance made of rubber
with flexible rim that fits over cervix
 Used with spermicidal jelly or cream
 Physician will assess for size
 Reassessment after birth of baby or weight
loss or gain.
 Proper technique to apply
Diaphragm (Continue)
 Contraindications
 Allergy to latex or spermicide
 Recurrent UTI
 Inability to learn insertion technique
(mentally or physically challenged)
 Abnormalities of vaginal anatomy that
prevents a good fit or stable placement –
uterine prolapse, extreme retroversion
Diaphragm – Client Education
 Annual visits
 Needs to be refitted after significant
weight gain > 10 lbs, pelvic surgery, full
term delivery (after pregnancy should
wait about 12 weeks PP before using
the diaphragm)
Diaphragm – Client Education
(Continue)
 May be left in place up to 12 – 24 hrs
 Must be left in place 6 hrs after
intercourse
 May be inserted up to 2 hrs before
intercourse
 Must be fitted by MD or NP
Spermicides
 Chemical barrier to prevent pregnancy
by killing sperm or neutralizing vaginal
secretions
 74 - 94% effective
 Creams, jelly, melting suppositories,
foaming tablets, foam, and films
Intrauterine Device
 Progestasert & Paragard 380A
 Device inserted into uterus
 Mode of action
 Inhibits migration of sperm
 Speeds ovum transport
 Local inflammatory response in uterine
cavity- endotoxins are releases that destroys
sperm
 Cervical mucus
Intrauterine Device (Continue)
 Side Effects
 Increased Bleeding (anemia)
 Dysmenorrhea
 Pelvic Infections
 Ectopic Pregnancy
 Uterine perforation
Intrauterine Device (Continue)
 Contraindications
 Multiple sexual partners (risk for STD’s)
 Active, recent, or chronic pelvic infection
 Postpartum endometritis or septic abortion
 Pregnancy
 Endometrial or cervical malignancy
 Valvular heart disease
 Immunosuppression
Intrauterine Device – Client
Education
 Palpating string – check before
intercourse and after each period
 Inspect pads and tampons for an
expelled IUD
 Advise alternate contraception 1st
month after insertion
Intrauterine Device – Client
Education (Continue)
 Teach PAINS
 P – period late, abnormal spotting or
bleeding
 A – abdominal pain, pain with intercourse
 I – infection exposure, abnormal vaginal
discharge
 N – not feeling well, fever, chills
 S – string missing, shorter or longer
Intrauterine Device – Client
Education (Continue)
 Advise to wait 3 months after removal
before becoming pregnant – this
reduces the risk of ectopic pregnancy
Intrauterine Device

Copper IUD
Cervical Cap
 Barrier method; soft rubber dome with a
flexible rim
 Shaped like a thimble
 Filled with spermicide
 Inserted prior to intercourse & should be
left in place at least 8 hours
 Should not be worn longer than 24 hours
Cervical Cap (Continue)
 Client should have Follow Up 3 months
then annually
Cervical Cap – Client
Education
 Practice insertion & removal
 Cap should not be worn during periods
 Cleaning – mild soap & water
 Check for tears
 Do not use petroleum products
 Schedule RTC 3 months
 Should be refitted after delivery, gyn surgery,
significant weight gain / loss
Oral Contraceptives
“The Pill”
 Prevents ovulation; mimics the
hormonal state of pregnancy
 Increased estrogen  Diminishes
hypothalamic effect on GnRH  Inhibits
the release of FSH / LH  NO OVULATION
OCCURS
 Progestin
 Affects cervical mucus & endometrial lining
Oral Contraceptives
“The Pill” (Continue)
 Monophasic
 Provides fixed doses of both estrogen and
progestin throughout the 21 day cycle
 Triphasic
 Vary both estrogen / progestin throughout
the cycle
 Mimics woman’s natural hormonal pattern
Oral Contraceptives
Client Education
 Missed pills
 Drugs (barbiturates, griseofulvin,
isoniazide, penicillin, tetracycline)
decreases the effectiveness of the pill
 Avoid if Breast Feeding until milk supply
is well established
 Discontinue if pregnancy occurs
Oral Contraceptives
Client Education (Continue)
 Adolescent girls should have well
established menstrual periods (2 years)
prior to starting the pill
 When to start pills
 1st Sunday after beginning period; after
childbirth Sunday 2 weeks post delivery;
post Ab – 1st Sunday after procedure
Emergency Contraception
 “morning after pill”
 75 - 85% effectiveness rate
 Combination estrogen/progestin
 Progestin only
 89% effective
 Can be taken immediately and up to 72 hrs
 Taken 2 doses; 2nd dose taken 12 hrs first
 Major Side Effect – Nausea
Emergency Contraception
(Continue)
 Emergency method-not to be used on a
frequent or regular basis
 reduces pregnancy rates by 75-85%
 oral contraceptives-MAP (morning after
pill)
 insertion of IUD
 abortions
Subdermal implant (Norplant)
 Consist of 6 silastic capsules containing
levonorgestrel (35 mg progestin)
 98.5-99.5% effective
 Inserted upper arm
 5 years
Norplant Implants (Continue)
 Effective within 24 hours after insertion

 Mode of action: suppress ovulation,

thicken cervical mucus, creates a thin
atrophic endometrium, causes more
rapid tubal transport of ovum
Norplant Implants (Continue)
 Does not suppress lactation
 Side Effects
 Menstrual irregularities
 Amenorrhea after a few months
 Abdominal pain
 H/A
 Hair growth / hair loss
Norplant Implants (Continue)
 Contraindications
 Liver Disease
 Pregnancy
 Unexplained vaginal bleeding
 Breast CA
 Thrombophlebitis
Depo- Provera (DMPA)
 Long-acting progestin that blocks LH
surge, suppresses ovulation and
thickens cervical mucus
 97.7% effective
 Repeat every 80-90 days
 Contraception begins immediately and
last for 3 months
 Usually will not have period after 1 year
of use
Depo- Provera (continue)
 Dose 150 mg single dose vial
 IM – Do Not massage (hastens
absorption and shortens the period of
effectiveness
 Given with 5 days of onset of period
 Within 5 days from delivery
Depo- Provera (continue)
 Contraception begins immediately and
last for 3 months

 Instruct client to F/U for injection 2

weeks before 3 months is up

 Usually will not have period after 1 year

of use
Depo- Provera (continue)
 Side effects and contraindications same
as Norplant
 99.7 percent effective
 ***May be used during lactation
 Women who plan to get pregnant
within 6 – 9 months suggest another
method
Breast Feeding
 Prolongs anovulation for a certain
period of time, but is not always
effective and ovulation may return
before menstruation reoccurs and
PREGNANCY may result

 Not an absolutely reliable method

Vasectomy
 Male sterilization
 Vasdeferens is resected through small
incision in the scrotum resulting in
blockage of the passage of the sperm
 Health care provider must do in clinic,office
or hospital
 Sperm count to check for sterility
 99.5%effective
Tubal ligation
 Surgical procedure done in hospital
cuts, tied ,or cauterized the fallopian
tubes preventing sperm from fertilizing
ovum
 99.2 - 99.6% effective