Ag Nina Ian John “G” Rachel Mark Jocelle Edo Gienah Jho Kath Aynz Je Glad Nickie Ricobear

Teacher Dadang Niňa Arlene Vivs Paul F. Rico F. Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope Bien

S2 Lec 4: Family Planning by Dra. Teresita S. Cadiz-Brion SSeepptteem

mbbeerr 66,, 22001100
-if reaction persists, consider natural condoms (lambskin or gut)
*lahat po ng nakalagay sa box eh galing sa trans last year na tingin or another method
namin eh helpful naman sya kahit papano, the rest are all from Dra.’s „ -help client choose another method
ppt...:D -allergic reaction to spermicide:
-if symptoms persist after intercourse and no evidence of STD
-provide another spermicide
CONTRACEPTIVE METHODS
-a nonmedicated condom
-help client choose another method
1. Barrier methods
-Advantage
-MOA
-available over the counter
-physically prevents sperm for reaching the cervix
-easy to use and cheap
-destroys or makes spermatozoa immobile
-Causes of failure are
-intermittent use
A. Male condom
-ommision to use during coitus
-thin sheaths of rubber, vinyl or natural products placed on the penis
-having sex first then withdrawingto put on sheath
once it is erect
-breakage (rare)
-closed end has a reservoir at the tip to serve as the depository for
-Disadvantages
semen during the ejaculation
-reduces sensitivity of glans penis
-may be treated with a spermicide (usually nonoxynol-9) for added
-interferes with sexual spontaneity
protection
-allergy to latex
-MOA
-prevents access of sperm to female reproductive tract
B.Female condom
-prevents microorganisms (STDs) from passing
-thin sheath of polyurethane plastic with polyurethane rings at either end
Contraceptive benefits
-inserted into vagina before intercourse
-effective immediately
-soft, loose-fitting polyurethane sheath 7.8 cm in diameter and 17 cm in
-do not affect breastfeeding
length
-no method-related health risk
-has 2 diaphragm like flexible rings located at either end
-no systemic side effects
-closes end is inserted close to cervix and serves as an anchor while ring at
-widely available without prescription or medical assessment
the open end holds the device in place of the labia
necessary
-coated with silicone based lubricants
-inexpensive (short term)
-single use
-can be used as a backup to other methods
-can be used up to 8 hours before coitus
-Noncontraceptive benefits
-immediately effective but should be removed after intercourse before female
-promotes male involvement in family planning
stands up to avoid spillage
-only family planning method that offers protection against STDs
-MOA
(latex rubber and vinyl condoms only)
-prevents sperm from gaining access to female reproductive tract
-may prolong erection and time to ejaculation
-Contraceptive benefits
-may help prevent cervical cancer
-effective immediately
-Limitations
-controlled by the woman
-moderately effective (3/14 pregnancies per 100 women during the
-do not interfere with intercourse (may be inserted 8 hrs before)
first year)
-no method-related health risks
-effectiveness depends on willingness to follow instructions
-no systemic side effects
-user dependent (requires continued motivation and use in each
-no prescription or medical assessment necessary
with each act of intercourse)
-can be used as backup to other methods
-may reduce sensitivity of penis (makes maintenance of erection
-do not affect breast feeding
more difficult)
-Noncontraceptive benefits
-disposal of used condoms may be a problem
-may provide protection against STDs
-adequate storage must be available at client‟s home
-may help prevent cervical cancer
-supplies must be readily available before sexual intercourse
-Limitaitons
-ressuply must be available
-expensive(at this time)
-Side Effects
-moderately effective (5-21 pregnancies per 100 women during the first
-allergic reaction to condom or local irritation to penis:
year)
-ensure that condom is not medicated
-effectiveness as contraceptive depends on the willingness to follow
instructions

Page 1 of 10
 -user-dependent (require continued motivation and use with each act of D. Diaphragm
intercourse) -covers the cervix
-disposal of used condoms may be a problem -should be used with a spermicide
-adequate storage must be available at the client‟s home -left inplace for at least 8hrs after last coital act
-supplies must be readily available before intercourse begins
-resupply must be available 2. Combined Contraceptives

C. Spermicide A. Combined Oral Contraceptives (COC)

-definition: chemicals (usually nonoxynol-9) that inactivate or kill sperm
-types: aerosols (foams); vaginal tablets, suppositories or dissolvable film; 1. Monophasic
cream -all 21 active pills contain the same amount of estrogen/progestin (E/P)
-MOA: causes the sperm cell membrane to break, which decreases sperm -21-day packs: 7 days w/out pills accompanied by bleeding
movement (motility and mobility) and their ability to fertilize egg -28 day packs: with 7 placebo tablets
-effect starts a few minutes after application, during of effectiveness is
usually 1 hrs (resupply when needed) 2. Biphasic
-antimicrobial against gonorrhoea and Chlamydia -21 active pills containing 2 diff. Estrogen/progestin combinations (eg.
-Selection 10/11)
-aerosols (foams) effective immediately after insertion -varied amounts of estrogen and progestin are used in 3 consecutive
-aerosols are recommended if spermicide is to be used as the only phases w/ a single cycle
contraceptive method -steroid levels are altered to reduce metabolic effects w/out reducing
-foaming vaginal tablets/suppositories are convenient to carry and store contraceptive efficacy
but require waiting 10-15mins after insertion before intercourse
-melting vaginal suppositories also require 10-a5mins after insertion -disadvantage: reduced effectiveness if taken out of order
before intercourse
-spermicidal jelly usually used only with diaphragms 3. Triphasic
-Contraceptive benefits -21 active pills contain 3 diff. Estrogen/progesterone combinations (eg.
-easy to use 6/5/10)
-effective immediately (foams and creams) -mode of activity:
-no method-related risks
-suppresses ovulation
-no systemic side effects
-reduces sperm transport
-no prescription or medical assessment necessary
-endometrial changes make implantation less likely
-can be used as backup to other methods
-progesterone slows peristalsis and increases secretion in oviducts
-do not affect breastfeeding
-if during the 7 pill days, there is no menstruation, do a pregnancy test
-Noncontraceptive benefits
-increases wetness (lubrication) during intercourse
-Contraceptive benefits:
-may protect against some STDs (HBV, HIV/AIDS)
-highly effective when taken daily (0.1-5 pregnancies per 100 women
-Limitations
during the first year of use)
-moderately effective (6-26 pregnancies per 100 women during first
-effective immediately if started by day 7 of menstrual cycle
year of use)
-pelvic examination not required to initiate use
-effectiveness as contraceptives depends on willingness to follow
-do not interfere with intercourse
instructions
-few side effects
-user-dependent (require continued motivation and use with each act of
-convenient and easy to use
intercourse)
-client can stop use
-user must wait 10-15mins after application before intercourse (vaginal
-can be provided by trained nonmedical staff
foaming tablets, suppositories and film)
-Noncontraceptive benefits:
-each application is effective for only 1-2hrs
-decreases menstrual flow (lighter, shorter periods) and blood loss (20
-supplies must be readily available before intercourse begins
ml vs 35 ml)
-resupply must be available
-decreases menstrual cramps
-Conditions Requiring Precaution (WHO Class 3)
-may improve anemia and prevent iron deficiency anemia in 50% of
-if a woman:
patients
-has age, parity or health problems that make pregnancy a high risk
-protects against ovarian and endometrial cancer
-has physical disabilities or finds it unpleasant to touch external
-decreases benign breast disease and ovarian cysts
genitalia
-prevents ectopic pregnancy
-has genital anomalies or other abnormalities (allergic to
-protects against some cases of PID
spermicides)
-improves bone mineral density
-does not want any inconvenience
-Ovarian Cancer Risk
-if a couple:
-40-80% decrease risk compared to nonusers
-needs a highly effective method of contraception
-protection:
-wants a method not related to intercourse
-begins by 1 yr of use
-is not willing to use correctly and with each act of intercourse
-increases w/ duration of use
Page 2 of 10
 -persists at least 10-15 yrs after COCs are stopped -Endometriosis
-is biologically possible -genital tract cancers (cervical, endometrial, ovarian)
-COCs and Breast Cancer -high blood pressure (<160/100)
-there is no overall measurable increase of breast CA risk except -pregnancy-related benign jaundice (cholestasis)
possibly among younger women -trophoblastic disease (benign or malignant)
-breast CA at a young age represents a very small proportion of all -When to Start
cases and may represent acceleration of preexisting breast CA or -any cycle when sure the client is not pregnant
detection bias -days 1-7 of menstrual cycle
-COC use may provide protection against post menopausal breast CA -postpartum:
-Limitations: -after 6 months ofusing LAM
-user-dependent (requires continued motivation and daily use, -after 3 weeks if not breastfeeding
forgetfulness increases method failure) -postabortion (immediately or within 7 days)
-some nausea, dizziness, mild breast tenderness, headaches or -Client Instructions
spotting may occur -take 1 pill daily preferably at the same time of day starting from
-effectiveness my be lowered when certain drugs are taken day 1-7
can delay return to fertility -when 28-day pack is empty, immediately start taking pills from a new
-rare serious side effects possible pack
-ressuply must be readily and easily available -when 21-day pack is empty, wait 7 days and begin taking pills from a
-do not protect against STDs (HBV, HIV/AIDS) new pack
-Who Can Use COCs -if you vomit 30 min after taking the pill, take another pill or use a
-Women who are: backup method if you have sex during next 7 days
-of any reproductive age or parity -Common Side Effects:
-who are postpartum and are not breastfeeding (begins after 3rd -amenorrhea/bleeding/spotting
week) or who are breastfeeding (6 months or more postpartum) -nausea/ dizziness/ vomiting
-who are postabortion (start immediately or within 7days) -acne
-with anemia -high blood pressure
-with severe menstrual cramping -breast fullness or tenderness (mastalgia)
-with irregular menstrual cycles -chest pain (especially if it occurs with exercise)
-with a history of ectopic pregnancy -depression (mood change or loss of libido)
-Additional Counseling -headache
-women who cannot remember to take a pill everyday
-Contraindications (WHO Class 4) B. Combined Injectable Contraceptives (CICs)
-known or suspected pregnancy
-breastfeeding and <6 weeks postpartum 1.Cyclofem
-jaundice (symptomatic viral hepatitis or cirrhosis) -25mg depot-medroxyprogesterone acetate and 5mg estradiol
-currently with or previous history of ischemic heart disease or stroke cypionate injected (IM) once a month
-blood clotting disorders (deep vein thrombophlebitis or pulmonary 2. Mesigyna
embolus) 50 mg norethindrone enanthate and 5mg estradiol valerate injected
-age 35 years or older and smoking (IM) once a month
-has diabetes (>20 years duration)
-has high blood pressure (>180/110) -MOA: same as COC and POP + makes the endometrium shallow and
-has breast CA strophic with inactive glands
-has liver tumors -Contraceptive benefits
-has to undergo major surgery with prolonged bed rest -highly effective in long term contraception
-migraine -convenient, easy administration
-Conditions Requiring Precautions (WHO Class 3) -do not interfere with intercourse
-COCs are not recommended unless other methods not available or -not coitus dependent
acceptable if a woman: -Noncontraceptive benefit
-is <3 wks postpartum (even if not breast feeding) -protects against some causes of PID
-has unexplained vaginal bleeding (only if serious problem -Limitations
suspected) -changes in menstrual bleeding pattern
-has high blood pressure (>160/100 and <180/110) -irregular bleeding/spotting initially
-has history of breast CA -weight gain
-has symptomatic liver or gall bladder disease -delayed return to fertility for 7-9 months (on average) after
-is taking drugs for epilepsy (phenytoin or barbiturates) or discontinuation
tuberculosis (rifampin) -Contraindications
-Conditions in which there are No Restrictions: -known/ suspected pregnancy
-age as long as non smoker -breast ca
-DM (uncomplicated/ <20 yrs duration) -Initial injection
Page 3 of 10
 -days 1-7 of menstrual cycle  Known or suspected pregnancy
-Reinjection  Has unexplained vaginal bleeding (if serious problem suspected)
-DMPA – up to 4 weeks  Has breast cancer
-NET-EN – up to 2 weeks PICs: Conditions Requiring Precautions (WHO Class 3)
o PICs are not recommended unless other methods are not available or
acceptable if a woman:
PICs (sa ppt ni doc, PICs talaga ung nakalagay)
 Is breastfeeding (< 6 weeks postpartum)
 Has high blood pressure (> 180/ 110)
Types of PICs  Has ischemic heart disease ( current or history)
1.Depo-Provera (DMPA)  Has had stroke
-150mg of depot-medroxyprogesterone acetate given every 3months PICs: Conditions Requiring Precautions (WHO Class 3)
2.Noristerats (NET-EN) o PICs are not recommended unless other methods are not available or
-200mg of norethindrone enanthate given every 2 months acceptable if a woman:
 Is jaundiced ( symptomatic viral hepatitis or cirrhosis)
-MOA:  Has liver tumors (adenoma or hepatoma)
 Has diabetes (>20 years duration)
-suppress ovulation
PICs: Timing of Injection
-reduce sperm transport in fallopian tubes o Initial injection:
-change endometrium  Days 1 to 7 of the menstrual cycle
-thicken cervical mucus (prevent sperm penetration)  Anytime during the menstrual cycle when you can be
-Contraceptive benefits reasonably sure the client is not pregnant
-highly effective (0.3** pregnancies per 100 women during first year of  Postpartum:
use)  Immediately if not breastfeeding
-rapidly effective (24 hours) if started by day 7 of menstrual cycle  After 6 months if using LAM
-intermediate-term method (2 or 3 months protection per injection) o Initial injection:
-pelvic examination not required to begin use  Postabortion: immediately or within first 7 days
-do not interfere with intercourse o Reinjection:
**efficacy rate refers only to DMPA  DMPA: Up to 4 weeks early or late
-Noncontraceptive benefits  NET-EN: Up to 2 weeks early or late
-decrease ectopic pregnancy PICs: Side Effect Which May Require Management
-may decrease menstrual cramps  Amenorrhea (absence of vaginal bleeding or spotting)
-may decrease menstrual bleeding  Irregular or heavy bleeding
-may improve anemia  Headache
 Nausea/ dizziness/ vomiting
-protect against endometrial CA
 Weight gain or loss (change in appetite)
-decrease benign breast disease
PICs: Management of Amenorrhea
-decrease sickle cell crises  Give reassurance that this is a common, not serious side effect
-protect against some causes of PID  Evaluate for pregnancy, especially if amenorrhea occurs after
-Limitations period of regular menstrual cycles
-changes in mestrual bleeding pattern  If no problem found, do not attempt to induce bleeding with COCs
-irregular bleeding/spotting initially in most women PICs: Client Instructions
-weight gain (2kg) is common  Return to health clinic for an injection every 3 months (DMPA) or
every 2 months (NET-EN).
-if pregnancy does occur, more likely to be ectopic than in a non-user
 Changes in menstrual bleeding patterns (amenorrhea) are
-resupply must be available
common, especially following first 2 or 3 injections.
-must return for injections every 3mos(DMPA) or 2mos(NET-EN)  If using DMPA, return of fertility is temporarily delayed, but does
-delayed return to fertility for 7-9months (on average) after not decrease fertility in the long term.
discontinuation  If using DMPA, 50% of women will stop having any bleeding by
-Who can Use PICs end of first year of use.
-Women of any reproductive age/parity who:  PICs do not provide protection against STDs (HBV, HIV/AIDS).
-want an effective, reversible method PICs: Warning Signs
-are postpartum and not breastfeeding  Delayed menstrual period after several months of regular cycles
 Severe lower abdominal pain
-are breastfeeding (6weeks or more postpartum)
 Heavy bleeding
-are postabotion
 Pus or bleeding at injection site
-are smokers (any age, any amount)  Migraine (vascular) headaches, repeated very painful headaches
-do not mind irregular bleeding or amenorrhea or blurred vision
-have moderate to severe menstrual cramping
-take drugs for epilepsy or tuberculosis POPs (Progestin only Pills)
-have high blood pressure or blood clotting problems
-prefer not to or should not use estrogen Types of POPs
-cannot remember to take a pill everyday  35-pill pack: 300 g levonorgestrel or 350  g norethindrone
 28-pill pack: 75 g norgestrel
-prefer a method not related to intercourse
Progestin- only Pills Progestin content Amount (g)
PICs: Contraindications (WHO Class 4)
Page 4 of 10
 POPs: Who May Require Additional Counseling
Microlut‟ Levonorgestrel 300 o Women:
Micronor‟ Norethindrone 350  Who cannot remember to take a pill every day at the same time
Ovrette‟ Norgestrel 75  Who cannot tolerate any changes in their menstrual bleeding
pattern
POPs: Contraindications (WHO Class 4)
o POPs should not be used if the woman has:
 Known or suspected pregnancy
 Unexplained vaginal bleeding (if serious problem suspected)
 Diagnosed breast cancer
POPs: Conditions Requiring Precaution (WHO Class 3)
o POPs are not recommended unless other methods are not available or
acceptable if woman:
 Is breastfeeding (< 6 weeks postpartum)
 Has unexplained vaginal bleeding (only if serious problem
suspected)
 Has breast cancer (current or history)
 Is jaundiced (active, symptomatic)
 Taking drugs for epilepsy (phenytoin and barbiturates) or TB
(rifampin)
 Has severe cirrhosis
POPS: Contraceptive Benefits  Has liver tumors (adenoma/hepatoma)
 Effective when taken at the same time daily (0.05-5 pregnancies/  Has had a stroke
100 women during the first year of use)  Has current or history of ischemicheartdse
 Immediately effective (> 24 hours) POPs: Conditions for Which there are No Restrictions
 Pelvic exam not required prior to use  Blood pressure (< 180/ 110)
 Do not interfere with intercourse  DM (uncomplicated or (< 20 years duration)
 Do not affect breastfeeding  History of pre-eclampsia
 Immediate return of fertility when stopped  Smoking (any age, any amount)
 Few side effects  Surgery (w or w/o prolonged bed rest)
 Convenient and easy-to-use  Thromboembolic disorders
 Client can stop use  Valvular heart disease (symptomatic or asymptomatic)
 Can be provided by trained nonmedical staff POPs: When to Start
 Contain no estrogen  Day 1 of the menstrual cycle when sure the client is not pregnant
POPs: Noncontraceptive Benefits  Postpartum:
 May decrease menstrual cramps  after 6 months if using lactational
 May decrease menstrual bleeding amenorrhea method (LAM)
 May improve anemia  after 6 weeks if breastfeeding but not using LAM
 Protect against endometrial cancer  immediately or within 6 weeks if not breastfeeding
 Decrease benign breast disease  Postabortion (immediately)
 Decrease ectopic pregnancy POPs: Drug Interactions
 Protect against some causes of PID o Most interactions relate to increased liver metabolism of
POPs: Limitations levonorgestrel:
 Cause changes in menstrual bleeding pattern  Rifampin (tuberculosis)
 Some weight gain or loss may occur  Anti-epilepsy (seizures):
 Barbiturates, phenytoin, carbamezepine (but not valporic
 User- dependent (require continued motivation and daily use)
acid)
 Must be taken at the same time every day
 Griseofulvin (long-term use only)
 Forgetfulness increases method failure
POPs: Client Instructions
 Resupply must be available
 Take 1 pill at the same time each day
 Effectiveness may be lowered when certain drugs for epilepsy
 Take first pill on first day of your menstrual period.
(phenytoin and barbiturates) or tuberculosis (rifampin) are taken
 If you POPs after the first day of your menstrual period, but before
 Do not protect against STD‟s (HBV, HIV/AIDS)
the seventh day, use a backup method for the next 48 hours.
Who Can Use POPs
 Take all pills in pack. Start a new pack on the day after you take
o Women:
last pill.
 Of any reproductive age/parity
 If you vomit within 30 minutes of taking pill, take another pill or
 Who want effective protection against pregnancy
use a backup method if you have sex during next 48 hours
 Who are postpartum breastfeeding (6 weeks or more postpartum)
 If you take a pill more than 3 hours late, take it as soon as you
or not
remember. Use a backup method if you have sex during the next
 Who are postabortion
48 hours.
 Who have blood pressure < 180/110, blood clotting problems or
 If you forget to take 1 or more pills, you should take the next pill
sickle cell disease when you remember. Use a backup method if you have sex
 With moderate to severe menstrual cramping during the next 48 hours
 Who smoke (any age, any amount)  If you miss 2 or more menstrual periods, you should go to the
 Who prefer not to or should not use estrogen clinic to check to see if you are pregnant. Do not stop taking pills
 Who want a progestin-only IUDs unless you know you are pregnant
Page 5 of 10
o Point out some important general information  Immediate return to fertility on removal
 Changes in menstrual bleeding patterns are common, esp. during  Inexpensive (Copper T380A)
first 2-3 cycles. They are often temporary and rarely a risk to IUDs: Noncontraceptive Benefits
health  Decrease menstrual cramps (progestin-releasing only.
 Other minor side effects may include weight gain, mild headaches  Decrease menstrual bleeding (progestin-releasing only)
and breast tenderness. These symptoms are not dangerous and  Decrease ectopic pregnancy (except Progestasert)
gradually disappear. IUDs: Limitations
 Certain drugs (rifampin and most anti epilepsy drugs) may reduce  Pelvic examinations required and screening for STDs
effectiveness of POPs. Tell your provider if you start any new recommended before insertion
drugs.  Require trained provider for insertion and removal
 Use a condom if at risk for STDs (e.g., HBV, HIV/AIDS).  Need to check for strings after menstrual period if cramping,
POPs: Warning Signs spotting or pain
o Return to clinic if any of the following occur:  Woman cannot stop use whenever she wants (provider-
 Delayed menstrual period after several months of regular cycles dependent)
(may be sign of pregnancy) IUDs: Side effects/ Complications
 Severe lower abdominal pain  Increase menstrual bleeding and cramping during the first few
 Heavy or prolonged bleeding months (Copper-releasing only)
 Migraine headaches  May be spontaneously expelled
 Rarely (, 1/1000 cases), Perforation of the uterus may occur
Intrauterine Devices (IUDs) Around the World during insertion
 May increase risk for ectopic pregnancies (especially
100 million users worldwide Progestasert)
 May increase risk of PID and subsequent infertility in women at
Intrauterine Devices (IUDs): risk for STDs (e.g., HBV, HIV/AIDS)
Non-medicated Who Can Use IUDs
o Lippes Loop o Women of any reproductive age/parity who:
 Want highly-effective, long term contraception
Types of Medicated IUDs
 Are postpartum breastfeeding or not
o Copper- releasing:
 Are postabortion
 Copper T3801
 Nove T  Are at low risk for STDs
 Multiload 375  Cannot remember to take a pill daily
o Progestin- releasing  Prefer not or cannot use harmones
 Progestasert  Are in need of emergency contraception
 Levo Nova (LNG-20) IUDs: Contraindictions (WHO Class 4)
 Mirena  Known or suspected pregnancy
IUDs: Contraceptive  As unexplained vaginal bleeding until the cause is determined
and any serious problems are treated
 Has current, recent PID
 Has acute purulent (pus-like) discharge
 Has an active genital tract infection (e.g., vaginitis, cervicitis)
 Has distorted uterine cavity
 Has malignant trophoblastic disease
 Has known pelvic TB
 Has genital tract cancer
IUDs: Conditions Requiring Precautions (WHO Class 3)
o IUDs are not recommended unless other methods are not available or
acceptable if a woman has:
 Benign trophoblastic disease
Benefits  More than one sexual partner
IUDs: Contraceptive Benefits  A partner who has more than one sexual partner
 Highly effective (0.6-0.8) pregnancies per 100 women during the When to Insert an IUD
first year of use for copper T380A)  Any menstrual cycle when reasonably sure that the clients is not
 Effective immediately pregnant
 Long-term method (up to 10 years protection with Copper T380A)  Days 1 to 7 of the menstrual cycle
 Do not interfere with intercourse  Postpartum (immediately following delivery, during the first 48
hours postpartum or after 4 to 6 weeks; after 6 months if using
 Do not affect breastfeeding
LAM)
 Few side effects
 Postabortion (immediately or within the first 7 days) provided no
 After follow-up visit, client needs to return to clinic only if problems
evidence of pelvic infection
 No supplies needed by client
 Can be provided by trained non-physician

Page 6 of 10
  Decreased postpartum bleeding
LAM: Limitations
 User-dependent (requires following instructions regarding
breastfeeding practices)
 May be difficult to practice due to social circumstances
 Highly effective only until menses return or up to 6 months
 Does not protect against STDs (e.g., HBV, HIV/AIDS)
Who Can Use Lam
o Women who:
 Are fully or nearly fully breastfeeding
 Have not had return of menses
 Are less than 6 months postpartum1

NATURAL FAMILY PLANNING (NFP)

Methods of NFP
IUDS: Common Side Effects
 Vaginal discharge
 Copper-releasing:  Calendar Method
 Heavier menstrual bleeding  Basal Body Temperature (BBT)
 Irregular or heavy vaginal bleeding  Cervical Mucus Method (Billings)
 Intermenstrual cramps  Symptothermal (BBT + cervical mucus)
 Increased menstrual cramping or pain  Standard Days Method
 Progestin-releasing:
 Amenorrhea or very light menstrual bleeding/ spotting
IUDs: Indications for Removal NFP: Mechanism of Action
 If the client desires removal
 At the end of effective life of the ID  For contraception:
 TCu 380A= 10 years  Avoid intercourse during the fertile phase of the
 Change in sexual practices (high risk behavior), consider adding barrier menstrual cycle when conception is most likely.
method (condoms) or removal.  For conception:
 If being treated for STD or documented pelvic infection.  Plan intercourse near mid-cycle (usually days 10-15)
 Menopause when conception is most likely.
Lactational Amenorrhea Method (LAM)
NFP: Contraceptive Benefits

 Can be used to prevent or achieve pregnancy

 No method-related health risks
 No systemic side effects
 Inexpensive

NFP: Noncontraceptive Benefits

 Improved knowledge of reproductive system

 Possible closer relationship between couple
 Increased male involvement in family planning

NFP: Limitations
LAM: Contraceptive Benefits
 Effective (1-2 pregnancies per 100 women during first 6 months of
 Moderately effective (1-25 pregnancies per 100 women during the
use)
 Effective immediately first year of use)
 Does not interfere with sexual intercourse  Effectiveness depends on willingness to follow instructions
 No systematic side effects  Considerable training required to use correctly
 No medical supervision necessary  Requires trained provider (nonmedical)
 No supplies required/ No cost involved  Requires abstinence during fertile phase to avoid conception
LAM: Noncontraceptive Benefits  Requires daily record keeping
 For child:  Vaginal infections make cervical mucus difficult to interpret
 Passive immunization and protection from other infectious  Basal thermometer needed for some methods
diseases
 Does not protect against STDs (HBV, HIV/AIDS)
 Best source of nutrition
 Decreased exposure to contaminants in water, other milk of
formulas, or on utensils Who Can Use NFP?
 For mother: Women/couples:

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  Of any reproductive age or parity  Use temperatures recorded on chart for first 10 days of menstrual
 With religious or philosophical reasons for not using other cycle to identify highest of “normal, low” temperatures (i.e., daily
methods temperatures charted in typical pattern without any unusual
 Unable to use other methods conditions).
 Willing to abstain from intercourse for more than 1 week each  Disregard any temperatures that are abnormally high due to fever
cycle or other disruptions.
 Willing and motivated to observe, record and interpret fertility  Draw a line 0.05-0.1 °C above highest of these 10 temperatures.
signs This line is called the cover line or temperature line.
NFP: Additional Counseling
Client Instructions for Billings Method
Women:
 Whose age, parity or health problems make pregnancy a high risk  As mucus may change during the day, observe it several times
 Without established menstrual cycles throughout the day. Every night before going to bed, determine
(breastfeeding, immediately postabortion) highest level of fertility and mark chart with appropriate symbol.
 With irregular menstrual cycles (calendar method only)  Abstain from sexual intercourse for at least 1 cycle so that you will
 Whose partner will not cooperate during certain times in the cycle know the mucus days. Avoid intercourse during your menstrual
 Who dislike touching their genitals period.
 During dry days after period, it is safe to have intercourse every
NFP: Conditions Requiring Precautions other night.
 As soon as any mucus or sensation of wetness appears, avoid
 Irregular menses intercourse or sexual contact.
 Persistent vaginal discharge  Mark last day of clear, slippery, stretchy mucus with an X. This is
 Breastfeeding the peak day, the most fertile time.
 After the peak day, avoid intercourse for next 3 dry days and
Client Instructions for Calendar Method nights. These days are not safe.
 Beginning on the morning of the fourth dry day, it is safe to have
 Monitor length of at least 6 menstrual cycles while abstaining or intercourse until your menstrual period begins again.
using another contraceptive method. Then calculate when fertile
days occur following the instructions below. Client Instructions for Symptothermal Method
 From number of days in longest cycle, subtract 11. This identifies
the last fertile day of cycle.  After menstrual bleeding stops, you may have intercourse on
 From number of days in shortest cycle, subtract 18. This identifies evening of every other dry day during infertile days before
the first fertile day of your cycle. ovulation.
 Your fertile period is calculated to be days 8 through 19 of cycle  The fertile phase begins when wet vaginal sensations or any
(12 days of abstinence needed to avoid pregnancy). Abstain from mucus appears. Abstain from intercourse until fertile phase ends.
sexual intercourse during fertile days.  Abstain from intercourse until both peak day and thermal shift
rules have been applied.
Basal Body Temperature (BBT) Chart  When these rules do not identify the same day as end of fertile
phase, always follow rule that identifies the longest fertile phase.

STANDARD DAYS METHOD

INSTITUE OF REPRODUCTIVE HEALTH, GEORGETOWN
Infertile UNIVERSITY SCHOOL OF MEDICINE

Characteristics
 Natural
Cover Line  Simple
 Low cost
 Effective

The so-called Standard Days Method

Client Instructions for BBT Method
 Identifies days 8-19 of the cycle as fertile
Thermal Shift Rule:  Is for women with menstrual cycles between 26 and 32 days long
 Avoid unplanned pregnancy by knowing which days unsafe
 Take temperature at about same time each morning (before  A client can use a color-coded string of beads to help her keep
rising) and record temperature on chart provided by NFP track of where she is in her cycle and know when she is fertile.
instructor.
Who Can Use This Method?
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  Women with cycles between 26 and 32 days long
 Couples who can avoid unprotected intercourse on day 8-19
 Couples not at risk of STDs
Withdrawal (Coitus Interruptus)
 A traditional method of family planning in which the man
completely removes his penis from the woman‟s vagina before he
ejaculates
 Assume that sperms do not enter the vagina and fertilization is
prevented
Withdrawal: Contraceptive Benefits
 Effective immediately
 Does not affect breastfeeding
 Can be used as backup to other methods
 No method-related health risks
 Always available
 No cost involved
Withdrawal: Noncontraceptive Benefits
 Promotes male involvement in family planning
 Possible closer relationship for couple
Withdrawal: Limitations
 Effectiveness depends on willingness of couple to use method
with every act of intercourse (4-191 pregnancies/100 women
during the first year of use)
 Effectiveness further decreased by sperm from a recent (< 24
hours) ejaculation remaining in the penis (urethra)
 May diminish sexual pleasure
 Does not protect against STDs (HBV, HIV/AIDS)
Who Can Use Withdrawal
Men/couples:
 Who wish to participate actively in family planning
 With religious or philosophical reasons for not using other
methods
 Who need contraception immediately
 Who need a temporary method while awaiting another method
 Who need a backup method
 Who have intercourse infrequently
Withdrawal: Who May Require Additional Counseling
Men who:
 Experience premature ejaculation
 Have difficulty withdrawing the penis from the vagina prior to
ejaculation
 Have other physical or psychological conditions that may affect
timely withdrawal
 Women whose age, parity or health problems make pregnancy a
high risk
 Women whose partner will not cooperate
 Couples with poor communication or problems in their relationship
 Couples in which either partner has more than one sexual partner
VOLUNTARY SURGICAL CONTRACEPTION FOR WOMEN
Tubal Occlusion: Most Popular Contraceptive Method Globally
Types of Tubal Occlusion
 Postpartum
 Minilaparotomy (Infraumbilical)
 Interval
 Minilaparotomy
 Laparoscopy
Tubal Occlusion: Client Issues
 The client should make the decision for sterilization voluntarily.
 The client has the right to change her mind anytime prior to the
procedure.
 The client should understand that voluntary sterilization (VS) is a
permanent (not easily reversible) method.
 No incentives should be given to clients to accept VS.
 A standard consent form must be signed by the client before the
VS procedure.
 Spousal consent is not required- not in the Phil.
Tubal Occlusion: Mechanism of Action
By blocking the fallopian tubes (tying and cutting, rings, clips or
electrocautery), sperm are prevented from reaching ova and causing
fertilization
Tubal Occlusion: Contraceptive Benefits
 Highly effective (0.51 pregnancies per 100 women during first
year of use)
 Effective immediately and is permanent
 Does not interfere with intercourse
 Good for client if pregnancy would pose a serious health risk
 Simple surgery,may be done under LA
 No long-term side effects
 No change in sexual function (no effect on hormone production by
ovaries)
Tubal Occlusion: Noncontraceptive Benefits
 Does not interfere with breastfeeding
 Decreased risk of ovarian cancer
Tubal Occlusion: Decreased
Risk of Ovarian Cancer
 39% decrease in risk compared to clients without tubal occlusion
 Decrease in risk does not depend upon method of sterilization
 Risk remains low 25 years after surgery
Tubal Occlusion: Limitations
 Must be considered permanent (reversal cannot be guaranteed)
 Client may regret later (age < 35)
 Small risk of complications
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  Short-term discomfort and pain  Gas or air embolism
 Requires trained physician (gyne or surgeon for laparoscopy)  Vasovagal attack
 Increased risk of ectopic pregnancy
 Does not protect against STDs (HBV, HIV/AIDS) Tubal Occlusion: Immediate Postoperative Complications
 Pain at infection site
Who Can Use Tubal Occlusion?  Superficial bleeding (skin edges or subcutaneously)
Women:  Postoperative fever
 Who are age > 22 and < 45  Wound infection
 Who want permanent contraception  Gas embolism with laparoscopy (very rare)
 For whom pregnancy would pose a serious health risk  Hematoma (subcutaneous)
 Who are postpartum/postabortion When to Perform Tubal Occlusion Procedure
 Who are breastfeeding (within 48 hours or after 6 weeks)  Anytime during the menstrual cycle when reasonably sure the
 Who are certain they have achieved their desired family size client is not pregnant
 Who understand and voluntarily consent  Days 6–13 of menses (proliferative phase preferred)
Tubal Occlusion: Who May Require Additional Counseling  Postpartum: Within 2 days or after 6 weeks -If delivered at home
Women: w/o sepsis and immunized (tetanus toxoid), can be performed
 Who cannot withstand surgery under antibiotic cover
 Who are uncertain of their desire for future fertility  Postabortion: immediately or within 7 days, w/o evidence of pelvic
 Who do not give voluntary, informed consent infection
Tubal Occlusion: Conditions
Requiring Precautions (WHO Class 3) Tubal Occlusion: Anesthesia
 Unexplained vaginal bleeding (until evaluated)  Local anesthesia of choice
 Acute pelvic infection  General–only in select cases
 Acute systemic infection (e.g., cold, flu, gastroenteritis, viral  obese
hepatitis)  associated (documented) pelvic pathology
 Anemia (Hb < 7 g/dl)  allergy to local anesthesia
 Abdominal skin infection  medical problems
 Cancer of the genital tract
 Deep venous thrombosis POSTPARTUM CONTRACEPTION
Providing Postpartum Contraception
“Appropriate precautions include delay of procedure until condition  Encourage full breastfeeding for all postpartum women
improves or resolves”  Do not discontinue breastfeeding to begin use of a contraceptive
method
Tubal Occlusion: Conditions Requiring an Experienced Clinician  Contraceptive methods used by breastfeeding women should not
 Diabetes adversely affect breastfeeding or the health of the infant
 Symptomatic heart disease
 High BP(> 160/100 or with vascular dse) IRVING PROCEDURE
 Coagulation (clotting) disorders - Medial out end of oviduct is cut
 Overweight (> 80 kg/176 lb if H/W ratio not normal) - Oviduct in myometrium
 Abdominal or umbilical hernia Pomeroy procedure
 Multiple lower abdominal incisions/scars Parkland procedure
mid-segment separated from mesosalphynx
Complications of Madeiner procedure
Laparoscopic Sterilization Crushed ->ligate -> w/o resection
Short-term Kroener procedure
 Occur in less than 1% of all procedures Fimbria cut
 Directly related to surgical expertise
Long-term
 Decreased long-term effectiveness Last trans Brought to you by: OBwan – Kenobi
(RPE-JCF-PF-SAH)
Tubal Occlusion: Intra-operative Complications “with OBwan – Kenobi, everyone can OB”
Minilaparotomy and Laparoscopy:
 Uterine perforation You think OBwan will leave you? Think again....Let the
 Bleeding from mesosalpinx walking begin!
 Convulsion and toxic reactions to local anesthesia
 Injury to urinary bladder
 Respiratory depression or arrest
 Injury to intra-abdominal viscera
Laparoscopy (primarily):
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