FAMILY PLANNING

ISSA SULEIMAN
INTRODUCTION TO FAMILY
PLANNING
 Definition- family planning is a way of
thinking or adapted lifestyle by couples or
individuals who have attained sexual
maturity to voluntarily have the number of
children they can comfortably cater for their
basic needs based on the luxury the
individual or couple can afford.
 N.B it is a government policy where the
government provides contraceptives to those
who need them.
BIRTH CONTROL
 It is a method of limiting the number of

children to the desired number as stipulated

by the government of the day. Failure to
which, penalty is given. It is also a
government policy and contraceptives are
provided to those who need them, sometimes
by induction, force or persuasion, it is done
for political, social or economic reasons.
Potential clients for FP
 These are clients who are at risk of having

unplanned pregnancy- men & women of

reproductive age.
ESSENTIAL MESSAGES GIVEN TO F.P.
CLIENTS
I. Explain all available methods and
expected side effects.
II. Physical examination including breast with
self examination, pelvic- speculum &
bimanual after detailed history taking and
counseling.
III. Tailored counseling for informed choice.
Explaining about the method chosen.
IV. Giving instructions for method use.
V. Tell the importance of follow up visits.
identifying and teaching about common
infections found in FP clinics
VI. Identify and teach about common
infections found in FP clinics e.g.
◦ Bacterial-syphilis, Chancroid, Chlamydia etc
◦ Viral-HPB,HIV, genital warts
◦ Parasites-trichomonas, scabies, pediculus pubis
◦ Fungal- moniliasis, candidiasis etc.
Factors which lead clients to be FP
acceptors.
 IEC (Information, Education, Counseling)-

awareness has been created.

 Economic reasons- so as to be able to support

the family.
 Social reasons- to fit in a certain social class.
 Religious reason
 Belifs/value/ customs & taboos.
 Gender sensitivity- women feel they don’t

want to be misused.
 Health reasons
 Peer pressure
 Self esteem-maintain social status and
outlook
 Employment- employers don’t want to give
maternity leave.
 Couples own choice.
Advantages of FP
 To the individual -The mothers health

improves because she rests between

pregnancies
 The man has time to relax with his family

instead of spending most of his tine looking

after the woman in maternity & other
children left behind. He has fewer people to
look care for reducing his stress.
 The child born benefits from proper breast

feeding and proper parental care from both

parents since they have time for the child.
 Family members benefit from adequate
basic needs and they are able to socialize
since mother is not away in hospital ( mat) or
having pregnancy complications.
 The health and social status of the family is
good since parents have more time for
income generating activities.
 Community-the family is able to take part in
development activities & engage in social
groups to improve their general status.
 The families are able to mix with other people
in the community & learn development &
improvement activities.
 The nation- a healthy individual leads to a
healthy family, community and nation. A
government can be able to plan for its people
and the nation becomes economically stable.
Disadvantages
 The mother forgets her natural role of

parenting.
 There is an urge for another baby and regrets

the period of wanting especially if she compares

self with other women of the same status.
 The man feels hopeless and experiences a

feeling of reduced manhood.

 Family labor force is reduced, security is

interfered with and young children run errands.

 The community- major activities are
managed by expatriates as there less young
people to take over the work.
 To the nation- lot of funds will be spent

importing labor and caring for old people

and also money will be spent on research
on acceptance and awareness of FP.
PRINCIPLES OF FP
1. FP clients are not sick and rarely need
evaluation of their health but need help in
understanding their own reproductive health.
2. FP clients need simple clear information to
help them in informed choice decision making.
3. The success of FP continuity & effectiveness
depends on proper counseling & instruction on
methods use.
4. The client must know the needs which must
be meet or fulfilled by the service provider
e.g.- understanding own contraceptive needs.
Which are:
 ◦ Information about all available methods
◦ Information on the method chosen.
◦ Informed consent.
◦ Instruction on method use & continuity
5. The service provider must know his/her role in
order to meet the clients needs satisfactory e.g.
◦ History taking
◦ Interviewing
◦ Counseling
◦ Tailored counseling
◦ Physical examination
◦ Help client choose most suitable methods.
◦ Ensure informed consent
◦ Provide method chosen
◦ Give clients instructions for use, ensure safety,
continuity & follow up.
6. Clients using methods best suited to their
needs will be those clients most satisfied
and happy to continue practicing FP.
7. Service providers giving quality care to
their clients are happy to have a job
satisfaction.
Types of FP methods
 Natural
 Artificial
 Modern and traditional methods
Specificity of methods
 Short term artificial methods:
◦ Condoms
◦ Pills
 Long term artificial methods:
◦ Injectables
◦ Implants
◦ IUCD
 Long term permanent
◦ Vasectomy
◦ Bilateral tubal ligation.
PLANNING AN FP CLINIC
 The manager should have client-provider
concept. I.e.
◦ C-client
◦ O- oriented
◦ P-provide
◦ E-efficient
 The manager has to plan, implement according
to the clients needs based on the service
providers ability, qualification and experience.
 Supervision and evaluation should be done
continuously to see whether objectives are met
 Continuous supply of commodity should be
ensured.
 Infection control should be ensured.
 Integrated service concept should be

embraced.
 Policy of 1st come 1st service.
CONDUCTING AN FP CLINIC
1. Have all physical facilities & equipment &
supply.
2. Have trained personnel available using
proper personnel criteria.
3. Clients should be motivated to use the
services.
Attending FP clients
 These clients should be held in high esteem.
 Privacy and confidentiality should be

ensured.
 They should be attended within the shortest

time possible.
 Their needs are highly personal .
 No personal questions should be asked in

public.
 1st come 1st service principle should be

used.
 Ideal place for history taking, physical

examination and counseling should be

provided.
WHO CRITERIA FOR INITIATION
OF F.P. METHOD
CATEGORY ONE
 Men or women with no surgical or medical

condition which can make the method

ineffective or worsen the condition.-no
contraindication
CATEGORY TWO
 Men and women with surgical & medical

condition which can not be worsened by

methods used or make the method ineffective
e.g. hypertension, mild toxic goiter, mild
varicose veins. no contraindication but observe
CATEGORY 3
 Men & women with medical/surgical conditions

which can or may be worsened by methods

used or make method ineffective. E.g. DM, TB,
epilepsy, cardiac diseases, etc. Can give with
proper doctor’s follow up.- relative
contraindication.
CATEGORY 4
 Men/ women with medical/surgical conditions

which are worsened by method use or make

method use ineffective. DO NOT GIVE. E.g.
pregnancy, active liver disease, undiagnosed
vaginal bleeding, RH cancers. Absolute
contraindication.
PRE REQUISITE FOR PROVISION
OF FP
1. Counseling –FP , HIV/AIDS, VCT & PMTCT.
2. Provision of contraceptives-must be
knowledgeable in order to provide a
method to a client.
3. Follow up referral system- inform clients of
return dates and importance of follow up.
4. Record keeping- proper records must be
maintained on clients, distribution of
contraceptives. M.O.H. record keeping
guidelines.
5. Supervision- supervision should ensure that
guidelines are followed , needs of clients
are met. Facilitative supervision should be
encouraged.
6. Logistics- maintenance of proper logistic
system should be maintained (movements
of goods or commodities from different
areas to the point of use) stores,
warehouses e.t.c. Avoid overstocking &
under stocking. Adhere to proper storage &
handling.
7. Cost consideration- in terms of time, cost of
commodities
Recommended infection
control measures
 Consider every client & staff potentially
infectious
 Wash hands before and after procedure.
 Wear gloves when touching anything wet e.g.
broken skin, mucous membrane, blood & other
body fluids.
 Use safe practices e.g. not recapping needles
or bending them, passing sharp instruments
safely, proper disposal of medical waste.
 Isolating patients when secretions & excretion
can not be contained.
PHYSICAL EXAMINATION
OBJECTIVES-The aim is;
To determine the following;
 That the client is not pregnant
 That there are no conditions requiring

additional care.
 That there are no special problems that

require further assessment, treatment or

follow up.
 Do a general physical examination from

head to toe with special emphasis on the

following;
◦ Breast examination by inspection,
palpation & expression. Then teach her
self breast examination.
◦ Pelvic examination- do speculum, check
first then do a bimanual or digital exam,
then a pap smear if indicated.
METHODS OF FP.
A. HORMONAL METHODS
I. Combined oral contraceptives
II. Combined injectables
III. Progestin only pills
IV. Progestine only injections e.g Depo
V. Implants e.g. norplant, jadelle, implanon.

B. IUCDS
I. Copper T 380 A
II. Multiload MLCU 250 & 375
III. NOVA T
IV. Progestesert e.g. mirena
V. Gyane fix
C. BARRIERS METHODS
I. Male & female condoms
II. Spermicides-jellies, creams, tablets,
vaginal films/ foams.
III. Cervical cap
IV. vaginal sponge
V. Diaphragm
D. NATURAL FAMILY PLANNING
I. Billings ovulation method
II. Basal body temprature
III. Sympto thermal method
E. LAM (Lactation Amenorrhoea Method)
F. PERMANENT METHODS
I. Tubal ligation
◦ Mini-laparatomy
◦ laparascopy
II. vasectomy
BENEFITS OF FAMILY PLANNING.
TO INDIVIDUAL & FAMILY
a. Reduced incidences of poor health related
to pregnancy delivery and post partum.
b. Reduced incidences of abortion.
c. Allow adequate breastfeeding and
subsequent gradual weaning of each baby.
d. Adequate time for providing individual child
care and guidance.
e. Mother will be prepared psychologically,
economically and socially to provide care
for the family.
TO THE COMMUNITY AND NATION
a. Providing safe environment
b. Reducing overcrowding
c. Conservation of resources e.g. forest and
sanitary surrounding.
d. Advancing community development,
education, health, technology and
security.
e. Adequate health facilities and water
supply.
f. Employment opportunities and income
generating activities.
FACTORS THAT INFLUENCE
ACCEPTANCE AND CONTINUATION
OF FAMILY PLANNING.
1. Educational and status of women in the
society.
2. Knowledge of the family planning methods.
3. Men’s knowledge and involvement in family
planning.
4. Age at birth of the first child
5. Accessibility, availability, acceptability of the
method.
6. Knowledge of side effects and how to cope
with them.
6. Religious and cultural beliefs.
7. Political influence
8. Infrastructure
9. Skilled service providers
10. Myths rumors and misconception.
Barriers to family planning
 Unskilled service providers/health workers
 Lack of privacy
 Lack of confidentiality
 Language barrier
 Age difference (Generation gaps)
 Level of education
 Values, beliefs and attitudes
 Lack of male involvement
 Inequitable distribution of facilities
 Donor dependent FP programs
MEDICAL ELIGIBILITY
CRITERIA
CATEGORY 1
 A condition for which there is no restriction for
the use of contraceptive methods.
CATEGORY II
 A condition where the advantage of using the

method generally out weighs the theoretical or

proven risks.
CATEEGORY III
 A condition where the theoretical or proven risk

outweigh the advantages of using the methods.

CATEGORY IV
 A condition which represents an acceptable

health risk if the contraceptive method is used.

TYPES OF CLIENTS
1. Initiating client-a new client who is using a
certain family planning method for the
first time.
2. Continuing client -a client who has been
on a method and wishes to remain on it.
COUNSELING FOR INFORMED
CHOICE IN FAMILY PLANNING
Need of family planning provider

1. Explore our own attitudes and inhibitions which

may affect how we counsel our clients.
2. Remember that individuals use contraceptives
so that they can have sex without getting
pregnant or STDs. Therefore the health provider
needs to be able to discuss a clients sexual
habits and those of their partners.
3. Frank discussion of sexual practices is necessary
to help clients choose the method that will work
best for them and not be desirable.
STEPS IN COUNSELING
 Several approaches to counseling have been
used, including;
1. GATHER
 Greet, Ask, Tell, Help, Explain, Return.

2. REDI
 Rapport, Exploration, Decision making and

Implementation of decisions.
3. BCS+
 The balanced Counseling strategy plus. It

incorporates counseling, screening, and

services for STIs, including HIV, within routine
FP consultations.
In general, counseling can be divided into three
phases:
 Initial counseling on arrival. The provider

describes all methods and helps the client to

chose the method appropriate for him or her.
 Method specific counseling prior to and

immediately following service provision. The

provider instructs the client on using the method
and discusses common side effects with him or
her.
 Follow up counseling during the return visit.

The provider discusses with the client the use of

the method, the client’s satisfaction with the
method , and any problem that the client might
have experienced.
Within the context of HIV/AIDS, FP counseling
should address the following concerns;
 Whether the chosen FP method protects

against STIs, including HIV.

 Safety of the FP method when used by a

person living with HIV/AIDS.

 Interactions between contraceptive methods

and some drugs used in treatment for

HIV/AIDS, including ARVS & anti-TB drugs.
 Knowledge and guidance on dual protection

practices, with emphasis on the consistent and

correct use of condoms or abstinence as the
most effective means of protection
BARRIERS THAT HINDER COUNSELING
 Age difference
 Language difference
 Educational level
 Lack of privacy
 Lack of confidentiality
 In appropriate non- verbal behavior
 Judgmental attitude
 Religious differences
 Gender biasness
HORMONAL
CONTRACEPTIVES
 They contain synthetic hormones (i.e. a

combination of estrogen and progestin, or

progestin only) which work primarily by
preventing ovulation and making the
cervical too thick for sperm penetration.
 NB. Methods containing estrogen are not
advisable for women who are breastfeeding
because this method can suppress lactation.
 Progestin- only pills are ideal for
breastfeeding mothers, they are provided to
breastfeeding women from four weeks
postpartum.
 The following hormonal methods are commonly
available in Kenya
◦ Combined oral contraceptive pills (COCs)
◦ Progestin-only injecatables contraceptive ( DMPA, NET-
EN)
◦ Progestine- only contraceptive Implants (implanon,
Zarin)
◦ Hormone realsing intrauterine systems (LNG20-IUS)
◦ Emergency contraceptives
◦ Progestine only pills (POPs)
 The following are les commonly available in
Kenya.
◦ Combined injectable contraceptives
◦ Combined contaceptive (skin) patch (Evra)
◦ Combined vaginal contraceptive ring ( NuvaRing)
COMBINED ORAL CONTRACEPTIVE
PILLS
 They contain synthetic oestrogen and
progesterone, which are similar to the
natural hormones produced I the woman’s
body.
 Apart from contraception, COCs also have

other significant health benefits

Mechanism of action
Prevent release of eggs from the ovaries.
 Over the years, the amount of oestrogen
hormone has reduced to lower and safer
levels, which has decreased occurrence of
side effects.
 High dose contain 50 micrograms of

oestrogen
 Low dose pills contain 30-35 micrograms

of oestrogen( most commonly used in

Kenya)
 Ultra-low dose pills contain 20

micrograms ethinyl oestadiol.

COC’S available in the Kenyan Market
TYPES OF COCs
 The pill comes in packets of 21 or 28 tablet in the

28-pill packet, only the first 21 pills are active i.e.

they containhormones. The remaining 7 pills are
not active and usually contain iron.
The low dose pill comes in three types:
i. monophasic: each pill contains the same
amount of oestrogen and progestin. E.g.
microgynon, Lo-femenal, Nordette, Marvelon
and yasmin.
ii. Biphasic: the active pills contain two different
different dose combination of estrogen &
progestin . E.g. in a cycle of 21 active
pills, 10 may contain one combination, while 11
contain another. E.g. biphasil, ovanon and
normovlar.
 Triphasic : the active pills contain three
different dose combinations of oestrogen
and progestin. Out of a cycle of 21 active
pills, six may contain one combination, five
pills contain another combination, while 10
pills contain other combinations of the same
two hormones. E.g. Logynon and Trinordial.

N.B. biphasic and triphasic pills are not in

common use in Kenya.
ADVANTAGES OF COCs
A. Contraceptive benefits
a) They are highly effective. Are effective
immediately when started within the first
five days of the menstrual cycle.
b) They are safe for the majority of the
women
c) They are easy to use
d) Can be provided by trained non-clinical
service providers.
e) A pelvic exam is not required to initiate
use of COC’s.
B. Non contraceptive benefits
a) Reduction of menstrual flow (lighter,
shorter periods)
b) Decrease in in dysmenorrhoea
c) Reduction of symptoms of endometriosis
d) Improvement & prevention of anemia
e) Protection against ovarian and
endometrial cancer.
f) Possible protection from symptomatic
pelvic inflammatory disease
g) Treatment of acne & hirsutism.
 Limitations and side effects of coc’s
 COCs must be taken daily to he effective,

preferably at the same time each day.

Minor side effects include
◦ Nausea (more common in the first 3 months)
◦ Spotting or bleeding in between menstrual periods,
especially if a woman forgets to take her pills or takes
them late (more common in the first three months)
◦ Mild headaches
◦ Breast tenderness
◦ Slight weight gain
◦ Mood change
◦ Amenorrhea ( some women see amenorrhea as an
advantage)
Major side effects (or complications are
rare, but possible)
◦ Myocardial infarction
◦ Stroke
◦ Venous thrombosis or embolism or both.
Management of common side effects
 Nausea and vomiting
◦ asses for pregnancy
◦ Reassure the client that its is a common side
effect and that it may diminish in a few months.
◦ Advice client to take pills with meals or at
bedtime.
 Spotting
◦ Asses for pregnancy
◦ Reassure client its is harmless and common
especially during the first 3 months.
◦ Encourage client to take pills at the same time
each day.
◦ If it persists and unacceptable for the client
WHEN TO START
 A woman can start using COCs at any time

if its reasonably certain she is not pregnant.

If she begins using COCs within 5 days after
start of her monthly bleeding, she will not
need a back up contraceptive method.
If she begins using COCOs more than 5
days after the start of her monthly bleeding,
during the 7 days when she takes COCs she
should use a back up method i.e. condoms.
What to do in the case of missed
pill(s)
Pills missed Action and
consequences
One or two days missed or One or two days missed
started new pack one or two or started new pack one
late or two late

3 or more days in a row missed Take a pill as soon as

in the 1st or 2nd week or possible. Use a back up
started a new pack 3 or more method for the next 7
days late days, she can consider
ECPs
Pills missed Action and consequence
3 or more days in a row in the third week Take a pill as soon as possible, finish all
hormonal pills in the pack ( if 28 pill
pack are used, throw away the 7 non
hormonal pills) and start a new pack the
next day. Use back up method for the next
. Also if client had sex in the past 5 days,
she can consider use of ECPs

Sever e vomiting or diarrhoea If she vomits within 2 hours after

taking a pill, she should take
another pill from her pack as soon
as possible, then keep taking pills
usual.

If she has vomiting or diarrhoea

for more than 2 days, follow
instructions for one or two missed
pills, above.
PROGESTINE ONLY
PILLS(POPs)
 The contain only one hormone- progestin.
They do not suppress production of breast
milk.
Types of POPs
 Microlut
 Micronor
 Microval
 Ovrette
 Noriday
MECHANISM OF ACTION
 They thicken cervical mucus hence blocking

sperms from meeting an egg.

 Disrupt the menstrual cycle, including

preventing the release of eggs from ovaries

( Ovulation)
Advantages of POPs
 They are effective
 They are safe(no known health risk)
 Women return to fertility immediately upon

discontinuation.
 A pelvic examination is not required to

initiate use.
 They don’t affect milk production, safe for

breastfeeding women and their babies.

 Taking POPs doesn’t increase blood clotting.
Limitations
 They provide a slightly lower level of

contraceptive protection than COCs.

 They require strict daily pill taking,

preferably at the same time each day.

 They don’t protect against STI’s, including

hepatitis B and HIV/AIDS. Therefore at risk

individuals should use a barrier method to
ensure protection against STI’s and
HIV/AIDS.
 They may lower effectiveness when certain

drugs are taken concurrently(e.g. certain

antiTBs, ARVs and anti-epileptic drugs.
Side effects
 Irregular spotting or bleeding, frequent or

infrequent bleeding, amenorrhea (less

common). Bleeding changes are common
but not harmful.
 Headaches, dizziness, nausea.
 Mood changes.
 Breast tenderness (although also common

with COCs).
Method prescription and use
 POPs can be given to a woman at any time

to start later. If pregnancy can not be ruled

out, a provider can give her pills to take
later, when her menses begin.
 Client should take one pill everyday at the

same time +/- 2 hours to avoid pregnancy

and minimize side effects.
 When ne pack is finished, client should

begin the next pack with no break in

between packs.
 An estimated 48 hours of POP use is usually
required to achieve the contraceptive effect
on cervical mucous.
 All clients can initiate use of POPs under the
following circumstances.
◦ If she is breast feeding and has not resumed her
menses, initiate any time between 4 weeks and 6
months after child birth.
◦ After child birth and she is not breast feeding,
initiate within the first four weeks (no back up
method needed) or any other time it is reasonably
certain that the client is not pregnant.
◦ If initiated after 4 weeks post partum, non
menstruating women and women whose menses
started >5 days should use backup
method( condom)or abstain for 2days.
◦ After miscarriage or abortion, initiate within the
first 5 days after an abortion, POPs can be
initiated without the need for backup protection.
After 5 days, a condom should be used as a
backup for 2 days.
◦ If client is having menstrual cycles, initiate any
time if it is reasonably certain that she is not
pregnant.
◦ if method is initiated within 5 days, a condom
should be used for the next 2 days.
PROBLEMS THAT MIGHT REQUIRE
SWITCHING METHODS
a) Unexplained vaginal bleeding
This condition requires evaluation,
diagnosis, and treatment as appropriate
b) Starting treatment with anti convulasnts,
rifapicin, rifabutin or ritonavir.
If these medications involve long term
treatment, a client may need help to chose
a different method. If treatment is short-
term, the client can use a backup method
along with POPs.
 Migrane headaches
 For migrane headaches without aura, a

client can continue using POPs if she so

wishes. If auras are present she should stop
taking POPs
d) Certain serious health conditions
 These include DVT, liver disease, ischemic

heart disease, breast cancer, or SLE with

positive antiphospholipid antibodies.
 If the condition worsens after client starts

using POPs, she should stop immediately.

The provider should help her choose a
method without hormones. Give her back
method till condition is evaluated. Refer her
for diagnosis and care if she is not already
under care.
e) Suspected pregnancy
 Assess the client for pregnancy, including

ectopic pregnancy. Inform the

Management of common side effects of POPs

Spotting
 Reassure client its common with POP use.
 If bleeding starts after several months of

normal or no monthly bleeding, or there

other reasons to suspect pregnancy ( if
client missed a pill) , asses for pregnancy or
other underlying conditions. Manage
condition or refer client to level.
Heavy or prolonged bleeding( twice as
much as usual or longer than eight
days)
 Reassure client that some POP user

experience this type of bleeding, but it is

generally not harmful.
 For the modest relief prescribe 800mg

ibuprofen TDS 5/7.

 If no relief, suggest another type of POP if

available or help choose another method.

Amenorrhoea
 If client is BF, reassure her that it is normal

not to have menses while BF.

 If client is not BF, reassure her that some
women stop having monthly periods while
taking POPs.
 If there are reasons to suspect pregnancy

(e.g client has missed pills), assess for

pregnancy. If client is pregnant, advice her
to stop using POPs and refer for antenatal
care. If not pregnant reassure her to
continue POPs.
Headache or dizziness
 Determine cause. If no cause is found,

counsel client and recommend common

pain killers.
 If headaches worsen while using POPs (e.g.
she develops migraines with aura), help
client select alternative method. Refer if
need be.
Abnormal suspicious vaginal bleeding
 Evaluate client by history and pelvic

examination (refer as necessary) including

VIA/VILI and pap smear. Treat or refer for
treatment as necessary.
Mood changes or nervousness
 Counsel client. If condition worsens, help

client select alternative methods.

Severe pain in lower abdomen
 R/O ectopic pregnancy, if it’s the case refer.
 What to do in the case of Missed pill(s)
Missed POP Suggested action
Client’s menses have returned Take one pill as soon as
and she misses one or more pills possible and continue
by more than 3 hours (or 12 hours taking the pills as usual,
in the case of 75g desogestral one each day.
containing pill), regardless of
whether or not she is breast Abstain from sex or use a
feeding back up method e.g.
condom for the next 2 days.
Client is Bf and is amenorrhoeic, Take 1 pill as soon as
and she misses one or more pills, possible and continue
by more than 3 hours ( or 12 taking the pills as usual,
hours in the case of 75mcg one each day.
desogestrel- containing pill ).
If she is <6 months post
partum, no back up method
is needed.
NOTE:
 Inconsistent or incorrect use of pills is a

major cause of unintended pregnancy. It is

important to ensure POPs are taken at
approximately the same time each day. An
estimated 48 hours of POP use is deemed
necessary to achieve the contraceptive
effects on cervical mucus.
EMERGENCY HORMONAL
CONTRACEPTIVES.
 Emergency contraception refers to the use of
certain contraceptive methods by women to
prevent pregnancy after unprotected sexual
intercourse.
 They must be taken within 120 hours of
intercourse, however, the sooner they are
taken the more effective they are.
 ECPs provide a second chance for preventing
pregnancy after unprotected sex, either
accidental or coerced sex or rape.
 EC should not be used on a regular basis
( from month to month) because it is less
effective than other methods.
Mechanism of action
 They prevent or delay ovulation
 Inhibit or slow down transportation of the

egg and sperm through the fallopian tubes

which prevents fertilization and
implantation.
TYPES OF ECPS AND DOSAGE
a) Combine oral contraceptives
◦ Eugynon ( 50mcg)- 2 tablets to be taken as soon as
possible after unprotected sex within 120 hours,
repeat the same dose in 12 hours. A total of 4 pills are
required.
◦ Microgynon (30 mcg)- 4 tablets to be taken as soon
as possible after unprotected sex within 120 hours
and a repeat dose in 12 hours. A total of 8 pills are
required.
b) Progestin only oral contraceptives
These dedicated ECPs contain the same progestin
hormone (levonorgesteral) as POPs, although in
higher doses. They are more effective than COCs
preventing up to 95% of unexpected pregnancies.
Available brands in Kenya are; Postinor 2, smart lady,
Ecee2, and Truston 2.
 The standard dose is as follows;
◦ One 750mcg levonorgestrel pill to be taken as
soon as possible after unprotected intercourse,
but within 120 hours. Repeat the same dose in
12hours. A total of 2 pills are required
◦ Two 750mcg levonorgestrol pills to be taken
as a single dose as soon as possible after
unprotected intercourse. This regimen is preferred
because it is easier to comply with the one- dose
regimen compared to the two dose regimen.
◦ Regular POPs may be used: 20 pills taken
within 120 hours after unprotected sex, repeat the
same dose in 12 hours. A total of 40 pills are
required.
Advantages and benefits of ECPs
 They provide emergence protection for about

75-95% of those at risk

 Can reduce unwanted pregnancies that lead to

child neglect, abandonment, and unsafe

abortions.
 They are an important element in post-rape

care.
 EC offers the following benefits

◦ It is safe, effective, and easy to use.

◦ No medical examination or pregnancy tests are
necessary or required.
◦ It can be used at any time during the menstrual cycle.
◦ They are readily available.
Limitations and side effects
 They are only effective if used within 120

hours of unprotected sex.

 They are not to be used as a regular

method.
 They don’t protect against STIs, HIV, or AIDS
 They can cause nausea.
Method prescription and use
 EC pills should be started as soon as

possible, but within 120hours of

unprotected sex.
 The sooner they are used after unprotected

sex, the more effective they are in

preventing pregnancy.
MANAGEMENT OF COMMON SIDE EFFECTS.
Nausea and vomiting
 Women should be counseled (at the time of

ECP supply) about the possible occurrence of

nausea.
 For women using POPs or COCs as emergence

contraceptives, an anti-emetic may be used

before the pills are taken.
 If vomiting occurs within 2 hours, the woman

should repeat the previous ECP dose orally as

soon as possible.
 If she vomits again, give the dose vaginally,

placing the needed dose high up in the vagina.

Slight irregular bleeding
 Reassure women that this is not a sign of

pregnancy or other condition .

 Irregular bleeding due to ECPs is common and

will stop without treatment.

Change in timing of the next monthly
bleeding
 Explain that it is not unusual for the next

monthly bleeding to start a few days earlier or

later than expected.
 Asses for pregnancy if woman’s next monthly

bleeding is more than one week later than

expected.
Starting FP methods after EC
 contraceptive methods and when to begin

using them after EC.

METHOD WHEN TO START
Condoms Start immediately after EC;
use also for dual protection.
Oral contraceptive Start the next day after
pills (COCs POPs) second ECP dose or 1-7 days
after menses.
Injectables Start within the first 7 days
after the start of her next
IUCDs period ( 12 days for IUCD)
Implants
Voluntary
sterilization (VSC)
Fertility-
awareness
methods (FAM)
INJECTABLE HORMONAL
CONTRACEPTIVES
 They are injections containing long acting
synthetic hormones.
Types of POI injectables
a) Depo Provera- it is a three month interval
injection but it can be given 1 month earlier
or 2 weeks later. It contains Depot-
medroxyprogestrone acetate ( DMPA).
b) Noristerat – it is a 2 monthly injectable but
can be given 2 weeks earlier or 1 week later.
It contains Norethisterone enanthate-(NET-
EN).
Mechanism of action
 It causes thickening of cervical mucus

which decreases sperm penetration.

 Makes the lining of the uterus less thick in

blood, making implantation impossible.

 May inhibit ovulation.

Indications
 Women of reproductive age.
 Women of any parity including Nulliparaity

with established menses.

 Breastfeeding mothers after 6 weeks post

partum.
Contra-indications
 Pregnant women or those suspected to be

pregnant.
 Breast cancer or unexplained breast lump.
 Unexplained uterine/ vaginal bleeding for the

last three months.

 Women with BP >140/100.
 Women with DM complicated with vascular

diseases.
 Breastfeeding women <6 weeks post partum.
 Active liver disease
 Ischemic cardiovascular disease.
 Women who need a highly effective long
term protection against pregnancy.
 Immediate post partum for non breast

feeding women.
 Women who will not remember to take oral

pills daily.
 Post abortal clients.

Use with care with clients with the

following conditions
◦ Diabetes
◦ Hypertension
◦ Active liver tumor
◦ Impaired liver functions.
Non-contraceptive Health Benefits
 Amenorrhea, which might be beneficial for

women with (or at risk of) iron-deficiency

anemia.
 Decrease in sickle cell crises
 Reduction of symptoms of endometriosis
 Protection against endometrial cancer
 Protection against uterine fi broids
 Possible protection from symptomatic

pelvic inflammatory disease

 Possible prevention of ectopic pregnancy
Client instructions
 Its very effective for preventing pregnancy.
 If they are using depo they should visit

clinic 3 monthly, for NET-EN every 2

months.
 Note the following menstrual changes

◦ Less regular periods

◦ Spotting in between
◦ Amenorrhea
 When bleeding is of concern then she
should report to the client.
 Remind client to keep clinic appointment.
Limitations of Injectable Contraceptives
 Return of fertility may be delayed for about

four months or longer after discontinuation.

 They offer no protection against STIs,

including hepatitis B and HIV; individuals at

risk for these should use condoms in
addition to injectable contraceptives.
 This method is provider-based, so a woman

must go to a health care facility regularly.

Side Effects of Injectable Contraceptives
 Menstrual changes, such as:

◦ irregular bleeding
◦ heavy and prolonged bleeding
◦ light spotting or bleeding
◦ amenorrhea, especially after one year of use
 Weight gain
 Headache
 Dizziness
 Mood swings
 Abdominal bloating
 Decrease in sex drive
 MANAGEMENT OF SIDE EFFECTS
Spotting /light bleeding
 Reassure
 Assess for the other conditions/ infections.

Pregnancy-refer to ANC, gyaenacological

complications
 If STI continue with method while on

treatment. Counsel for abstinence/ condom

use.
 If condition progress and client is bothered,

stop/ change method or give COCs 1 tab for

7 days.
Amenorrhoea
 Require no treatment

 Reassure, normal in DMPA users not harmful and

she is not pregnant.

 Explain what may be causing the amenorrhea.

 Assess for pregnancy

 If she can not tolerate the amenorrhoea

discontinue method and help her choose another

method.
Headache/ Dizziness
 Mild treatment with analgesic and reassure check

BP if normal & headache persist, stop method and

refer for evaluation.
 If BP is> 140/90 help client chose another method.
When to Start
 A woman can start injectables at any time if it

is reasonably certain she is not pregnant.

 If she starts using an injectable within seven

days after the start of her monthly bleeding,

she will not need a back-up method.
 If she starts using an injectable more than

seven days after her monthly bleeding, she

should use a backup method for the first
seven days after injection.

 What to do when client misses an

appointment.
CONTRACEPTIVE IMPLANTS
 Contraceptive implants are small rods that
are inserted under the skin of a woman’s
upper arm to release the hormone
progestine slowly and prevent pregnancy.
 Types of implants

Device Design Hormone Duration of

effectivene
ss
Jadelle 2 rods Levinoestrel 5years
75mg/rod

implanon 1 rod Etonogestrel 3 years

l68mg/rod

Sino-implant (ZARIN) 2 rods Levinoestrel 4 years

75mg/rod (possibly 5)
Implanon
Jadelle
Advantages and Benefits of Using
Contraceptive Implants
Contraceptive Benefits
 Implants are highly effective and safe.
 Contraception is immediate if inserted

within the first seven days of menstrual

cycle, or within the first five days for
Implanon.
 There is no delay in return to fertility.
 They offer continuous, long-term protection
Non-contraceptive Health Benefits
 Implants do not affect breastfeeding.
 They reduce menstrual flow.
 They help prevent ectopic pregnancy (but

do not eliminate the risk altogether).

 They protect against iron-deficiency

anemia.
 They help protect from symptomatic PID.
Limitations
 Contraceptive implants must be inserted

and removed by trained providers. This

requires a minor surgical procedure with
appropriate infection prevention practices.
Side Effects of Contraceptive Implants
 Common side effects of using implants

include menstrual changes, such as

irregular light spotting or bleeding,
prolonged bleeding, infrequent bleeding,
and amenorrhea.
Non-menstrual side effects include
headache, dizziness, nausea, breast
tenderness, mood changes, weight change,
and mild abdominal pain.
 Contraceptive implants do not protect

against STIs, including hepatitis B and HIV.

Individuals at risk should use condoms in
addition to the implants
 Instructions to Women
After Insertion
Counsel women to expect some soreness or bruising
(or both), after anesthetic wears off. This is common
and does not require treatment. She should be
counseled and given these instructions:
 Keep insertion area dry for four to five days.

 Remove the gauze bandage after one or two days,

but leave the adhesive plaster in place for an

additional five days.
 Return to the clinic if the rods come out or if

soreness develops after the removal of the adhesive

plaster.
 Return to the clinic if she experiences pain, heat,

pus, or redness at the insertion site, or if she sees a

rod come out.
 The service provider should emphasize that
implants must be removed by the due date,
and he should give her in writing the type of
implant she has, the date of insertion, and
the month and year when the implant will
need to be removed.
 The service provider should ensure that the

woman knows where to go in case of

problems with the implants.
Instructions for Clients Following Removal of
Implants
 After a client has had her implant removed,

she should be counseled and instructed as

follows:
 Keep removal area dry for four to five days.
 Remove the gauze bandage after one or

two days, but leave the adhesive plaster in

place for an additional five days.
 Return to the clinic if swelling and pain

develops after the removal of the adhesive

plaster.
 Management of side effects page 142
 Treatment for Light or Heavy Bleeding
If a woman experiences light or heavy bleeding
while using contraceptive implants, there are a
number of possible treatments:
• Treatment with NSAIDs
– Ibuprofen: 800 mg three times a day for fi ve days
– Mefenamic acid: 500 mg twice a day for fi ve days
• Hormonal management
– Low-dose COCs: 30 μg ethinylestradiol 150 μg
levonorgestrel a day for 21 days
– COCs: 50 μg ethinylestradiol 250 μg
levonorgestrel a day for 21 days
– Ethinylestradiol: 50 μg a day for 20 days
INTRAUTERINE CONTRACEPTIVE
DEVICES
 An IUCD is a flexible device that is inserted
into uteraine cavity by a trained service
provider. It is a safe and highly effective,
long-acting contraceptive method.
 Mechanism of action
 Sperm immobilisation
 Ova transportation
 Fertilization interferance
 Implantation prevention
 Types of IUCD
 Non hormonal

copper T e.g. 380A, 3805-12 years

multiiload- 375, cu 250-5 years
lippes loop- period indefinate
gynea fix-8 years
 Hormonal realsing IUCD

LNG-milena 5 years
Progestraset-5years
Copper T
ADVANTAGES AND BENEFI TS OF IUCDS
Contraceptive Benefits
 High effectiveness and safety
 Immediate effectiveness
 Long-acting protection
 Immediate return of fertility upon removal

of device
 Other Benefits
 IUCDs do not interfere with intercourse.

 Women who are breastfeeding can use IUCDs.

 IUCDs help prevent ectopic pregnancies.

 Women can use IUCDs immediately after

delivery to use LNG-IUS, breastfeeding women

should wait till our weeks postpartum).
 IUCDs, including the Cu-IUCDS, might help

protect from endometrial cancer.

 LNG-IUS do not increase bleeding as Cu-IUCDS

do; they may reduce menstrual bleeding or

cause amenorrhoea.
Indications, who should use

 Women of any reproductive age.

 Women of any parity including nuliparaity with
established menses.
 Women who desire highly effective long term
contraceptive.
 Women who are 4 weeks post partum or 48
hours postpartum.
 Women with ectropion ( cervical erosion).
 Women with DM uncomplicated
 Women following 1st trimester ectopic or
abortion as long as they are not septic.
Contraindication
 Known or suspected pregnancy.
 Women with puerperal sepsis.
 Undiagnosed vaginal bleeding.
 Women with pelvic cancers
 Women with current PID or purulent

cervicitis.
 Women likely to contract STIs especially

gonorrhea/ Chlamydia.
 Women with uterine fibroid distorting the

uterine cavity
 use with care for the following clients;
 Below 20 years of age
 Nulipara women
 Previous ectopic pregnancy
 Those whose partners are at high risk of STIs
 Women with severe dysmenorrhea
 Women in advanced stages of HIV/AIDS
 Those with vulvar heart disease complicated
 Those with heavy vaginal bleeding, prolonged

or not.
Warning signs(Danger signs)
 P-Late period
 A-Abdominal lower (lower)
 I-Infections
 N-Not feeling well
 S-Strings missing
When to initiate IUCD
 Can be inserted within 48 hours after

delivery.
 Day 1-7 after start of menses.
 4-6 weeks postpartum.
 When the client is changing from another

effective method.
 If pregnancy test is negative.
 The 1st 7 days following an abortion.
 When treasonably sure the client is not

pregnant.
 Trans-caesarean (i.e., following a caesarean
delivery): The IUCD can be inserted before
the uterus is sutured.
 Post-placental: The IUCD can be inserted

within 10 minutes after expulsion of the

placenta following a vaginal delivery.
Specific instruction to the client after
insertion of IUCD.
 Maintain hygiene

 Check strings 2-3 days after end of menses &

check for IUCD after changes of pad.

 Return date 2 months later then yearly

 Return date when the IUCD expires.

 They should not use tampons for periods

 Visit the clinic incase of danger signs.

 Visit the clinic if they want to switch methods.

 IUCD doesn’t protect one against HIV and STIs

Side effects and management of side effects
1. Cramping
 Bimanual/speculum examination is done to rule

out the following:

◦ PID
◦ Partial expulsion of IUCD
◦ Perforation of uterus or cervix
 If no cause give analgesics
 If severe, remove IUCD
 If IUCD is too large replace with a smaller one
 If the shape is distorted or device is displaced,
remove and change to a new one.
 If IUCD has lasted 3 months examine for other
cause of cramping.
2. Amenorrhea
 Do pelvic & speculum exam, check for

strings. R/O pregnancy. If strings can be

seen, remove.
 If she is <13 weeks pregnant and the

strings can not be visualized, the devices

may have been expelled, refer for ANC with
a note telling the health providers IUCD may
be insitu.
3. Missing strings
 If client is aware that the IUCD fell out
◦ Rule out pregnancy
◦ Provide back up method
◦ Insert IUCD with next period if she wishes
 Do speculum exam & bimanual exam, check
for strings.
 If pregnant refer with information about the
IUCD
 If strings are not felt in the cervical canal,
give a barrier method until the next menses.
Check for strings after menses, they may
come down, reassure.
 Rule out perforation by referring to hospital
for u/s or x-ray. It may have come out
unnoticed. Insert another one or help client
make another choice.
4. Irregular or heavy vaginal bleeding
 Do speculum/ bi manual exam for cervical

pathology, ectopic or intrauterine pregnancy.

 If normal give Ferrous Sulphate 200 mg TDS

3/12. Give a return date.

 Check for anemia- if present and severe

remove IUCD and help client change to

another method
BARRIER METHODS OF
CONTRACEPTION.
 Barrier methods prevent the sperm from
gaining access to the upper reproductive
tract and making contact with the egg.
These methods include male and female
condoms, spermicides, diaphragms, and
cervical caps. Whereas condoms,
diaphragms, and cervical caps are
mechanical barriers, spermicides are
chemicals that interfere with the movement
of the sperm and its ability to fertilize the
egg.
Currently in Kenya, the use of diaphragms,
cervical caps, and spermicides is negligible.
In addition, scientific evidence has shown
that repeated and high-dose use of the
spermicide nonoxynol-9 might cause
vaginal and cervical irritation or abrasions,
which
could increase the risk of infection with HIV
MALE CONDOMS
 The male condom is a thin, latex rubber
sheath or covering, made to fit a man’s erect
penis. Some are coated with a lubricant or
spermicide. Condoms come in different sizes,
colours, and textures.
 As stated above, condoms help prevent both

pregnancy and some STIs, including HIV/AIDS.

 Condom types in the market include plain,

flavoured, coloured, and spermicide-added

condoms.
Advantages of male condoms
 Condoms offer contraception only when

needed.
 Condoms are easy to obtain and can be

used without seeing a health care provider.

Other benefits of using condoms include
the following:
 With consistent and proper use, they are

highly effective protection against STIs,

including HIV/AIDS.
 Condoms reduce the risk of cervical cancer.
 Condoms prevent premature ejaculation.
 Almost every man is eligible to use a
condom.
 Condoms are easy to use with a little

practice.
 There is no health risk associated with this

method.
 Condoms do not interfere with the act of

intercourse, as do the foaming tablets.

Limitations of condoms
 A new condom must be worn for each act of

sexual intercourse.
 Condoms have a higher failure rate if used

inconsistently or incorrectly.
 Condoms might reduce sensitivity.
 Condoms might cause itching for a few

people who are allergic to latex.

 Condoms are user-dependent.
 Condoms cannot be used with oil-based

lubricants.
 Condoms are affected by heat, light, and

humidity.
Men Who Should Use Male Condoms
• Men who wish to participate actively in FP
• Couples who need a back-up method (e.g., for
missed pills)
• Couples who have sex infrequently and who
do not need continual protection
• Couples who need temporary methods while
awaiting another method
• Couples who want protection from STI/HIV
– Those who are not using another method, or
– Those who are using another method for
pregnancy prevention, and are at a risk of
acquiring an STI or HIV/AIDS
(dual method use)
In the case of the male condom:
• After ejaculation and before completely
losing his erection, the man should hold the
rim of the condom to the base of the penis so
it will not slip off when he is pulling his penis
out of the woman’s vagina.
• He should take the condom off his penis
without spilling the semen on the vaginal
opening.
• The used condom can be thrown into a pit
latrine, burned, or buried. It should be kept
away from children. Condoms must not be
reused.
FEMALE CONDOM
The female condom is made of thin,
transparent soft plastic (polyurethane).
Advantages and Benefits
Contraceptive Benefits
• They are effective if used consistently and
correctly. The effectiveness of the female
condom is slightly less than the male
condom. The failure rate is about 5 percent
in perfect use, and 21 percent in typical use.
• They offer contraception only when needed.
• Condoms can be used without seeing a
health care provider.
Other Benefits
• With consistent and proper use, condoms
are highly effective protection against STIs,
including HIV/AIDS.
• They protect against PID.
• The woman can control this method.
• Almost every woman is eligible to use this
method.
• It can be inserted eight hours before an
anticipated sexual act.
• There is no need to see a health care
provider before use.
• Condoms are easy to use with a little
practice.
• No health risk is associated with the
method.
• Unlike latex rubber, there is no known
allergy to polyurethane, the material from
which female condoms are made.
Limitations of Female Condoms
• Condom must be inserted before sexual
intercourse (although they can be inserted
in advance—as much as eight hours).
• Female condoms are expensive.
• A condom can be used only once—it cannot
be reused.
Women Who Can Use the Female
Condom
 All women of reproductive age of any parity,

including nulliparous women, can use a

female condom. The female condom is
appropriate in many circumstances:
• Women who need to rule out possible
pregnancy before proceeding with another
method.
• Women who need a back-up method.
• Women who need temporary methods of
contraception.
• Post-abortion clients before initiating other
methods.
• Women who need dual protection if they
are using another method for pregnancy
prevention, but are at a risk of acquiring an
STI or HIV/AIDS (e.g., a woman who has
more than one partner, or a woman whose
partner has more than one partner).
Women Who Should Not Use a Condom
 A woman who has one or more conditions that

make pregnancy dangerous and needs a more

effective method of protection against
pregnancy may want to consider other, less
client-dependant, methods of contraception.
Disposal of Used Female Condoms
• At the end of intercourse, the woman should
hold the outside rim of the female condom, twist
it to seal in the fluids, and carefully pull out the
device without spilling semen.
• The used condom can be thrown into a pit
latrine, burned, or buried. It should be kept away
from children.
• Condoms must not be reused.
CERVICAL CAP, DIAPHRAM
& SPERMICIDES
 DEFINATION: Diaphragms and cervical caps
are made of soft latex and are inserted into the
vagina fitting over the cervix. They are used with
spermicides for better protection against
pregnancy.
 Spermicides are chemical substances which
immobilise/ kill the sperms. They are made of
Nonoxyol 9.
 Spermicides are less effective than majority of
modern contraceptives therefore spermicides
alone are not good, but added to other barrier
methods e.g. diaphragm, cervical caps enhance
the effectiveness.
Cervical caps and
diaphragms
Indications
 All women of reproductive age.

 Women of any parity including nulliparous.

 Women needing to rule out possible

pregnancy before proceeding with another

method.
 Women needing a backup method.

 Women needing temporary method of

contraception.
 Post abortal clients before initiating more

appropriate method.
 Women with sickle cell, DM, HT, breast

feeding & women.

Who should not use
 Women who desire highly effective

protection against pregnancy.

 Women who dislike touching their genitals
 Women with vaginitis.
 Couples allergic to spermicides or latex
 Women with abnormalities or poor vaginal

muscle tone.
 Women with toxic shock syndrome.
Benefits
Contraceptives
 Effective immediately
 Do not affect breast feeding

Non contraceptive
 Woman controlled method
 Can be use by almost every woman
 No need to see health care provider
 May Protect against STI/HIV/AIDS; however

can’t be fully relied for protection.

Limitations
 Requires initial fitting by a trained provider.
 Efficacy is improved if diaphragm is used

together with spermicides

 Water & soap are needed to wash

diaphragm.
 Has to be inserted before sexual

intercourse.
SPERMICIDES
Benefits
 It is a safe contraceptive method if used

with another barrier method.

 It reduces chances of STIs
 Can be purchased over the counter.
 The male partner need not be involved in

the decision of the use of spermicide

 They can be used as lubricants during

intercourse
Limitations
 Irritation of the vulvo-vaginal & penile skin.
 Common dislike & unpleasant feeling by the

female using the spermicide.

 Increased incidence of candidiasis.
VOLUNTARY SURGICAL
CONTRACEPTION.
 Voluntary Surgical Contraception (VSC)
includes female and male
sterilisation procedures that are intended to
provide permanent
contraception.
 As such, special care must be taken to

assure that every client who chooses this

method does so voluntarily and is fully
informed about the permanence of this
method and the availability of alternative,
long-acting, highly effective methods.
 Caution must be taken when the following
individuals choose permanent methods:
◦ nulliparous women;
◦ youth;
◦ men who have not fathered a child;
◦ persons with mental health problems,
including depressive disorders.
The following categories are used for
recommending VSC
 Accept (Category A): There is no medical

reason to deny
sterilisation to a person with this condition.
 Caution (Category C): The procedure is

normally conducted in a routine setting, but

with extra preparation and precautions.
 Delay (Category D): The procedure is

delayed until the

condition is evaluated and corrected if need be.
Alternative temporary methods of
contraception should be provided.
 Special (Category S):
The procedure should be undertaken in
a setting with an experienced surgeon and
staff, equipment needed to provide general
anaesthesia, and other back-up medical
support. For these conditions, the provider
must be able to decide on the most
appropriate procedure and anaesthesia
regimen. Alternative temporary methods of
contraception
FEMALE VOLUNTARY SURGICAL
CONTRACEPTION.
DEFINATION:
Female voluntary surgical contraception,
also referred to as female sterilisation or
tubal ligation (TL), is a minor surgical
operation that involves cutting and tying
the fallopian tubes in order to prevent the
sperm from fertilising the ovum that was
released from the ovary, and reaching the
uterine cavity. In Kenya
Types of TL
There are several ways to perform a TL:
• Minilaparotomy
(postpartum,postabortion,43 or interval)
• Laparoscopic tubal ligation (interval)
• In conjunction with a caesarean section or
other abdominal surgery.
Advantages of TL
 Contraceptive Benefits

TL is a highly effective, immediate, and safe

form of contraception that offers the
following benefits:
• TL does not change sexual function and
does not interfere with intercourse.
• TL is permanent.
• TL has few known side effects (see
“Limitations and Side Effects of TL”).
• TL does not affect breastfeeding.
Other Benefits
 Women who have TLs have a decreased risk

of getting ovarian cancer and have a possible

decreased risk of PID.
 Limitations and Side Effects of TL

• TL is generally irreversible—the success of

reversal surgery cannot be guaranteed.
• Side effects include:
– Minimal risks and side effects of anaesthesia
– Risks associated with surgical procedures
– Some pain for several days after the
procedure
• In rare cases when pregnancy occurs, it is
more likely to be ectopic (although overall,
female sterilisation greatly reduces the risk
for ectopic pregnancy compared to women
who use no contraception)
• TL is not provided at all SDPs (service
delivery points).
• Only a trained provider can perform the
procedure.
• TL does not protect against STIs, including
HIV/AIDS and hepatitis B
 Management of common side effects
Side effects Suggested actions
Pain at incision site Determine presence of
infection and treat; if
no infection, reassure
and provide analgesics.

Wound infection, fever If skin is infected, clean,

dress, and treat with
antibiotics; if abscess is
present, incise and
drain; treat with
antibiotics for 7-10 days.

hematoma Apply warm, moist

packs on site, observe
for a
few days; if increasing,
evacuate.
Side effect Suggested action
More serious injuries e.g. bladder Give appropriate management or
or bowel injury refer for competent care in a
hospital.
Women Who Should Not Use TL
Providers should not perform TL on certain
women:
• Women who are uncertain of their desire for
future fertility
• Women who cannot withstand surgery
• Women or girls who do not give voluntary
informed consent
BILATERAL TUBAL
LIGATION
MALE VOLUNTARY SURGICAL
CONTRACEPTION
 Definition: Vasectomy, or male sterilization, is
the surgical process of cutting and tying the vas
deferens in order to prevent spermatozoa from
mixing with semen.
 Consequently, when ejaculation occurs, the

semen will not have any sperms. The operation is

performed under a local anesthesia, and it is one
of the most effective methods of contraception.
Types of Vasectomy
 There are scalpel and non-scalpel vasectomy

techniques.
Advantages and Benefits of Vasectomy
• The procedure is highly effective and safe.
• There is no change in sexual function—the
procedure does not interfere with sexual
intercourse.
• It is permanent.
 Limitations and Risks

• The procedure is virtually irreversible (i.e.,

success of reversal surgery cannot be
guaranteed).
• There are minimal risks and side effects of
local anaesthesia.
• There are risks associated with surgical
procedures.
• A vasectomy does not protect against STIs,
including HIV/ AIDS.
• Only a trained provider can offer a
vasectomy.
• There is a delay in effectiveness after the
procedure has been performed.
Men Who Should Not Have Vasectomies
 Vasectomies are not the appropriate choice

for every man. Men who should not have

vasectomies include the following:
• Clients who are uncertain of their desire for
future fertility.
• Clients who cannot withstand surgery.
• Clients who do not or cannot give voluntary
informed consent.
 Management of side effects of
vasectomy.
Side effects Management
Infection Treat with antibiotics for
7-10 days, may require
hospitalization
Abscess Incise and drain the
abscess following
infection-prevention
procedures.

Ensure proper wound

care.

Treat with antibiotics for

7-10 days.
Occasionally,
hospitalization might be
required for
more aggressive
treatment (IV antibiotics).
Assignment
 Read and write short notes on:
◦ Natural Family planning
◦ Lactational Amenorrhea Method