Family Planning Part 1 PDF

# Family Planning ## Definition of Key Terms - **Family Planning:** Involves cognitive decisions and behavioral practices that enable a woman to conceive a wanted pregnancy and avoid an unwanted or a badly timed pregnancy. - **Effectiveness:** The number of pregnancies per 100 women using a given...

# Family Planning ## Definition of Key Terms - **Family Planning:** Involves cognitive decisions and behavioral practices that enable a woman to conceive a wanted pregnancy and avoid an unwanted or a badly timed pregnancy. - **Effectiveness:** The number of pregnancies per 100 women using a given method per year. - **Highly / Very Effective:** 0-0.9 pregnancies per 100 women. - **Effective:** 1-9 pregnancies per 100 women. ## Scope of Family Planning Services 1. Counseling on family planning methods. 2. Distribution of family planning methods. 3. Monitoring users to ensure effective and safe use of methods. 4. Training of health personnel. 5. Managing infertility. 6. Genetic and premarital counseling. 7. Sexually transmitted disease screening and treatment. ## Types of Family Planning Methods 1. Hormonal Contraceptives 2. Spermicides & Barrier Methods 3. Intrauterine Device (IUD) 4. Emergency Contraceptive Method 5. Natural Contraceptives 6. Surgical Contraceptives (Voluntary Sterilization) ## Characteristics of an Ideal Contraceptive Method - Cheap, available, accessible, and easy to use. - No continuous medical supervision needed. - Safe and harmless (no adverse effects or complications). - 100% effective in preventing pregnancy. - Reversible (no fertility delay after discontinuation). - Does not interrupt sexual intercourse or reduce sexual sensation. - Long-acting (does not require continuous motivation). - Prevents sexually transmitted diseases. - Acceptable regarding culture and religion factors. ## Nursing Care Management for the Woman Choosing a Contraceptive Method ### Goal: Help women choose a suitable and acceptable contraceptive method for themselves and their partners. ### Initial / First Visit - Assess the couple (husband and wife) for contraindications to family planning methods by: - **History Taking:** - Socio-demographic data. - Drug abuse and habits (smoking). - Pre-existing medical conditions or surgical procedures. - Family history to determine genetic disease risks. - Menstrual and gynecological history. - Previous contraceptive use. - Personal interests and plans for future childbearing. - **Physical Examination:** - Complete physical examination (from head to toe) with special emphasis on the reproductive system. - Measure height, weight, body mass index, and vital signs, particularly blood pressure. - **Laboratory Investigations:** - Blood tests: CBC, blood type, clotting, liver function, hemoglobin, and glucose. - **Counseling on the Chosen Method:** - Provide detailed explanations and instructions about the chosen method. - Ensure the client understands the instructions. - Give the client the chosen method and a back-up option. - Inform the client about their next appointment schedule. ### Return / Follow-Up Visit - **Activities:** - Assess client feedback. - Renew supplies of the contraceptive method. - Answer client questions. - Encourage continued method use. - Repeat important instructions. - Monitor for, and manage possible side effects and complications. - Evaluate clinic success. ## Family Planning Methods (Contraceptive Methods) ### I. Hormonal Contraceptive Methods - **Definition:** A synthetic preparation of hormones (progesterone or estrogen and progesterone combination) is used to prevent pregnancy by suppressing ovulation. - **Types:** - **Combined Contraceptives (estrogen + progesterone):** - Combined oral contraceptive pills (COCs). - Combined injections. - Transdermal contraceptive patch. - Vaginal contraceptive ring. - **Progesterone Only Contraceptives:** - Progesterone only pills (mini pills/ POPs). - Progesterone only injections. - Contraceptive implant. - **Mechanism of Action:** - **Estrogen Hormone:** - Suppresses ovulation through central action on the hypothalamus, suppressing GnRH and the pituitary gland to suppress FSH and LH. - Accelerates fallopian tube motility so the ovum reaches the uterine cavity in time unsuitable for implantation. - Produces histological and biochemical changes in the endometrium that make the lining unfavorable for implantation. - **Progesterone Hormone:** - Makes cervical mucus thick and hostile to sperm. - Decelerates fallopian tube motility. - Thins the endometrium, making it non-receptive to the ovum. - Suppresses mid-cycle LH surge. - **A.1. Combined Oral Contraceptive Pills (COCs):** - **Hormonal Content:** Each pill contains estrogen and progesterone hormones. - **Effectiveness:** 99% effective when used correctly. - **Dosing Schedule:** - **21-Day Regimen:** One pill taken daily for 21 days, followed by a one-week pill-free period. - **28-Day Regimen:** One pill containing the hormones is taken daily for 21 days, followed by a placebo or iron tablet for 7 days. - **When to Start Taking the Pills:** - Menstrual Cycles: Within 5 days after the start of the menstrual cycle. - Postpartum: 6 months after childbirth or after stopping breastfeeding. - After Abortion: Within the first 7 days post-abortion. - **Advantages:** - **Contraceptive:** Available, cheap, doesn't interfere with intercourse, reversible, safe and very effective when used correctly, quick and easy to use, client controls its use. - **Non-Contraceptive:** Relieve menstrual tension, regulate menstruation, treat acne, reduce ovarian cyst formation, protect against ovarian and endometrial cancer, reduce the incidence of benign breast disease, decrease the incidence of pelvic inflammatory disease, and decrease the incidence of ectopic pregnancy. - **Disadvantages:** - Requires high memory and strong motivation. - Does not protect against sexually transmitted diseases. - Interferes with breastfeeding. - Requires continuous supplies. - **Contraindications:** - **Absolute:** History of thromboembolic disorders, cerebrovascular or coronary artery disease, breast cancer, gallbladder disease, estrogen-dependent tumors, liver diseases, smoking over 35 years, undiagnosed abnormal vaginal bleeding, pregnancy. - **Relative:** Hypertension or diabetes, migraine headaches, uterine fibroids, elective surgery, long leg casts or major injury to the lower leg and long-term immobilization, varicose vein. - **Side Effects and Complications:** - **Minor:** Nausea, vomiting, breast tenderness, fluid retention, headache, tiredness, sleepiness, amenorrhea, menstrual irregularities, reduction of breast milk volume, depression & atrophic vaginitis, acne, hirsutism, vaginal moniliasis. - **Major:** Atherosclerosis, thrombo-embolic disorders (stroke, myocardial infarction, DVT), hypertension, diabetes mellitus, gallbladder disease and liver tumors, teratogenicity. - **Danger Signs:** Severe abdominal pain, chest pain, headache, eye problems, swelling or pain in the calf or thigh, irregular or excessive vaginal bleeding. - **A.2. Combined Birth Control Injections:** - Consist of monthly injections of combined formulations containing estrogen and progestin. - **Example:** Mesocept (50 mg norethisterone enanthate and 5 mg estradiol valerate in oily solution). - **A.3. Birth Control Patch:** - A small square patch that delivers steady levels of hormones (150 ug progesterone and 20 ug estrogen) daily. - Replaced once a week for three weeks, followed by a patch-free week. - **A.4. Vaginal Contraceptive Ring:** - A soft and flexible ring inserted into the upper vagina that releases estrogen and progesterone hormones. - Left inside the vagina for 3 weeks, followed by a ring-free week. - **B. Progesterone Only Hormonal Contraceptives:** - **b.1. Progesterone Only Pills (Mini Pills / POPs):** - **Hormonal Content:** Contain low doses of progesterone. - **Effectiveness:** 97-98% effective in breastfeeding women and about 99% effective in non-breastfeeding women. - **Dosing Schedule:** One pill taken daily with no pill-free days/rest period between the pill packs. - **When to Start Taking the Pills:** - Menstrual Cycles: If the the first pill is taken on the first through fifth day of the menstrual cycle, the contraceptive effect is immediate. If the pill is started on any other day of the cycle, use additional contraception (like a condom) for the first two days. - Postpartum: 4-6 weeks after childbirth. - After Abortion: Within the first 7 days post-abortion. - **Advantages:** Used by breastfeeding mothers, no estrogen-related side effects, helps prevent pelvic inflammatory disease, benign breast disease and endometrial cancer. - **Disadvantages:** Less effective than COCs, can cause changes in menstrual patterns, requires high memory and strong motivation, does not protect against sexually transmitted diseases, requires continuous supplies. - **Indications:** Lactating women, women with contraindications for estrogen therapy. - **Contraindications:** Undiagnosed abnormal genital bleeding or irregular menstruation, pregnancy, history of reproductive cancer or ectopic pregnancy, women with breast cancer, chronic liver condition. - **Side Effects and Complications:** Irregular menstrual periods, ovarian cyst, acne, headache, dizziness, nausea and vomiting, ectopic pregnancy, mood changes, breast tenderness, reduction of libido. - **Danger Signs:** Severe abdominal pain, tenderness, or fainting (possibly due to an ovarian cyst or ectopic pregnancy), extremely heavy bleeding, severe headaches, skin or eyes become yellow. - **Missing Pills Regimen:** - **Less Than 3 Hours Late:** Take a pill as soon as you remember, take the next pill at the usual time, no extra precautions needed. - **More Than 3 Hours Late:** Take the pill as soon as you remember (take only one pill even if more than one was missed). Take the next pill at the usual time (this may mean taking two pills in one day). Use additional contraception (like condoms) for the next two days. Seek emergency contraception advice immediately if unprotected intercourse occurred in the past 7 days. - **Client Instructions:** - Explain how to take the pills: when to start the first pack, the number of pills per day, how to follow the arrows on the pack, and when to start the next pack. - Take the pills at approximately the same time each day, associate taking the pill with a routine activity (like brushing your teeth or eating breakfast). - Never share pills. - Take pills with food or at bedtime to reduce nausea, if you vomit within 2 hours of taking the pill, take another one. - Progesterone-only pills do not protect against STDs, use condoms in addition to the pill. - Discuss the missed pills regimen. - Be aware of danger signs and seek medical advice if needed. - Follow-up appointments: 3 months after the first prescription, then every 6-12 months. - **b.2. Progesterone Only Injections:** - **Hormonal Content:** A long-acting progesterone injection that is slowly released into the bloodstream (Depo-Provera, 150 mg depot medroxyprogesterone acetate). - **Effectiveness:** 97% effective. - **When to Start:** Menstrual cycles: within the first 7 days after onset of menstruation. Postpartum: 6 weeks after childbirth. Abortion: within 7 days after abortion. - **Advantages:** Long-acting, can be used at any age, suitable for breastfeeding mothers, no estrogen side effects or complications, helps prevent endometrial cancer, uterine fibroids, PID. - **Disadvantages:** May delay return of fertility up to 2 years after stopping injection, does not protect against STDs. - **Side Effects and Complications:** Weight gain, menstrual irregularities (spotting, heavy bleeding, amenorrhea), breast tenderness, abdominal bloating, acne, mood change, headache, dizziness, reduced libido. - **Client Instructions:** The injection is given in the upper arm (deltoid) or the gluteal muscles. Do not massage the injection site, women who use DMPA may lose significant bone mineral density, encourage women to consume calcium and exercise. - **Provide Clients with Written Reminders:** Type of injection, date of the next injection. - **Late for Injection:** - Less Than 4 Weeks Late: No need for a pregnancy test or backup method. - More Than 4 Weeks Late: Use backup method and emergency contraception if unprotected intercourse occurred in the past 5 days. - **b.3. Subdermal Contraceptive Implants:** - **Hormonal Content:** Consist of a small plastic implant (like a matchstick) that releases progesterone slowly and at a constant rate for a prolonged period of time. - **Effectiveness:** 98.5% to 99.5% effective. - **When to Insert:** Menstrual Cycles: Within the first 7 days after the start of the menstrual cycle. Postpartum: 6 weeks after childbirth. Abortion: Within 7 days after abortion. - **Types:** - **Norplant:** 6 capsules implanted, last for 5 years. - **Norplant 2:** 2 rods implanted, last for 3-4 years. - **Implanon:** Single rod implanted, last for 2-3 years. - **Advantages:** Can be used during lactation, long-acting but reversible, no need to take a daily pill. - **Disadvantages:** Not user-controlled, requires a minor surgical procedure to insert and remove, does not protect against STDs, infections at the site may occur. - **Indications, Contraindications & Side Effects:** Same as progesterone-only pills (POPs). - **Client Instructions:** Keep the area of insertion dry and out of the sun for the first week, bruising and slight bleeding is normal, avoid massaging or itching the site, if the area is red, hot or inflamed, see a doctor, return for a follow-up appointment after the first 5-7 days. - **Removal:** At the end of the implant's lifespan, when a pregnancy occurs, or if there are side effects. ### II. Spermicides and Barrier Methods - **A. Spermicides:** - **Description:** A chemical method that destroys sperm by disrupting the cell membrane. - **Types:** Cream, jelly, foam, vaginal film, or suppository. - **Effectiveness:** 20% failure rate when used alone, but more effective when used with barrier methods. - **Advantages:** Widely available, good backup method. - **Disadvantages:** Skin irritation, allergic reactions, does not protect against sexually transmitted diseases. - **Client Instructions:** Foam and creams inserted 10-15 minutes before intercourse, tablets and films inserted 15-30 minutes before intercourse. Reapply for every sexual act. Do not bathe or douche for 6 hours after intercourse. - **B. Barrier Methods:** - **Description:** Devices placed at the cervix or the male penis to prevent sperm from entering the uterus. - **Types:** - **Female:** - Diaphragm. - Cervical cap. - Vaginal sponge. - Female condom. - **Male:** - Male condom. - **Mechanism of Action:** Prevent the transport of sperm to the ovum, some barrier methods are used in conjunction with spermicides to further increase their efficacy. - **B.1. Diaphragm:** - **Description:** Shallow, dome-shaped device with a flexible rim that covers the cervix. - **B.2. Cervical Cap:** - **Description:** Cup-shaped device that fits over the cervix by suction. - **B.3. Vaginal Sponge:** - **Description:** Disposable, round-shaped, synthetic sponge containing spermicide. - **B.4. Female Condom:** - **Description:** Disposable, thin vaginal sheath with a flexible ring at each end. - **B.5. Male Condom:** - **Description:** Thin, stretchable sheath that covers the penis. - **Advantages of Condoms (Male and Female):** Inexpensive, readily available, no side effects (aside from latex allergies), reliable when used correctly. - **Disadvantages of Condoms (Male and Female):** May cause vaginal irritation, burning, and dulled sensations, may interrupt intercourse, improper use, displacement, and breakage can decrease effectiveness, increase pregnancy risk. - **Client Instructions:** Store condoms in cool dry places, examine condoms for tears before application or discarding, use a new condom for each act of intercourse, leave a small space at the end of the condom, do not use oil-based lubricants. - **Emergency Contraception:** Use a new condom if the existing condom breaks. ### III. Intrauterine Devices (IUDs) - **Description:** A small plastic device inserted into the uterine cavity that provides continuous contraceptive protection. - **Types:** - **Copper T380A (ParaGard):** Nonhormonal device containing copper, left in place for 5-10 years. - **Levonorgestrel-Releasing IUDs (Mirena and Skyla):** T-shaped frame contains progesterone, released gradually, Mirena lasts for 5 years and Skyla for 3 years. - **Mechanism of Action:** - **Copper IUD:** Prevents implantation by creating a local sterile inflammatory response in the endometrium, rendering the lining hostile to implantation, serves as a spermicide. - **Hormonal IUD:** Prevents implantation by thickening the cervical mucus, making the uterus impermeable to sperm, and may also suppress ovulation. - **Effectiveness:** More than 99% effective. - **Advantages:** Safe and reversible, provides long-term contraceptive protection, does not interfere with intercourse, immediate return to fertility when removed, no adverse effects on lactation. - **Disadvantages:** Offers no protection against HIV or sexually transmitted diseases. - **Indications:** Women who do not want to take oral contraceptives, women with medical problems that restrict the use of oral contraceptives, women who need long-acting methods. - **Contraindications:** Current pregnancy, current STDs or pelvic infection, acute cervicitis, distorted uterine cavity, uterine or cervical carcinoma, unexplained vaginal bleeding, severe immunocompromised state, nulliparous, a uterine cavity size of less than 6 or greater than 9 cm, copper allergy, severe anemia, heavy menses, and severe dysmenorrhea. - **Specific Contraindication for Progesterone IUD:** Uterine cavity size less than 6 or greater than 9 cm, history of ectopic pregnancy, diabetes. - **Time of Insertion:** A negative pregnancy test, cervical cultures, and consent form must be obtained before insertion. - **During Menstrual Cycle:** Can be inserted at any time if the woman is confirmed not to be pregnant. - **Vaginal Birth:** 4 to 6 weeks after delivery. - **Caesarean Section:** 4 to 6 weeks after delivery. - **Miscarriage or Induced Termination of Pregnancy:** Immediate insertion is safe. - **Emergency Contraception:** Copper IUD may be inserted up to 5 days after unprotected intercourse. - **Side Effects:** - **During Insertion:** Vasovagal response (rapid decrease in blood pressure), uterine perforation. - **After Insertion:** Increased bleeding and cramping, infection, accidental pregnancy, pelvic inflammatory disease. - **Time of Removal:** Easy and painless, fertility is restored quickly. - **Client Instructions:** Copper IUDs and hormonal IUDs are considered immediately effective. - **Immediately After Insertion:** Avoid inserting anything into the vagina for 48 hours. - **Cramping or Bleeding:** Expect cramping and bleeding for 2 to 6 weeks. - **String Check:** Check for the string once a week for the first month and then after each menstrual cycle. - **Follow-Up Appointments:** 3 to 6 weeks after insertion, then 3 months later. - **Warning Signs:** Period late, abdominal pain, pain with intercourse, abnormal vaginal discharge, fever, chills, missing string. - **Pregnancy:** If the woman becomes pregnant with an IUD in place, have an ultrasound to confirm that is not ectopic. The device should be removed to prevent infection, miscarriage, or preterm labor. ### IV. Emergency Contraception - **Description:** Methods of contraception used to prevent unwanted pregnancy after unprotected intercourse. - **Types:** - **Emergency Contraceptive Pills (ECPs):** - **Progesterone Only Pills (Levonorgestrel 0.75 mg):** Most commonly used emergency contraceptive. - **Combined Pills (100 µg of ethinyl estradiol and 1 mg of levonorgestrel):** - **Note:** The first dose should be taken as soon as possible after intercourse up to 72 hours, the second dose should be taken 12 hours later. - **Postcoital Insertion of Copper IUD:** Placed within 5 days after unprotected intercourse. - **Mode of Action:** Prevent pregnancy by delaying ovulation and/or preventing implantation of the fertilized ovum. - **Effectiveness:** 95% effective if taken within 24 hours. Reduces to 58% effectiveness by 72 hours. - **Indications:** Unprotected intercourse, rape, missed pills, late for progesterone injection, IUD displacement, condom breakage. - **Contraindications:** Pregnancy, contraindications for hormonal contraceptive methods or IUDs. - **Side Effects:** Nausea and vomiting for the first 24 hours, menstrual period may start a few days earlier or later than expected, headache, fatigue, dizziness, breast tenderness, abdominal pain. - **Note:** - Not effective once pregnancy has begun. - Will not disrupt an established pregnancy or cause abortion. - Can only be used once per menstrual cycle. - **Client Instructions:** - Explain how to take the prescribed pills and doses. - Advise the client not to take more pills than the regimen requires (this will increase the level of side effects, but will not increase the effectiveness of the treatment). - Describe common side effects and their management. - Nausea: Take pills with food at bedtime and give anti-emetic drug 30-60 minutes prior to taking the pills. - Vomiting: Within 2 hours of taking pills, may take another dose. - **Follow-Up:** - Use barrier methods or mechanical contraceptives until the next menstrual cycle. - Explain that light bleeding is common 1-2 days after taking ECPs. - Monitor for delayed periods (more than 1 week late), and perform a pregnancy test. - Follow-up again on the first day of their suspected period or within the following 5 days. # Obstetric & Gynecologic Nursing Department- Faculty of Nursing - Alexandria University