Family Planning

Family Planning • • • • • •

The concept of enhancing the quality of families w/c includes: Regulating & spacing childbirth Helping subfertile couples beget children Counseling parents and would-be parents The privilege and the obligation of the (married) couple exclusively to decide w/ love when and how many children provided: the motive is justified and the means are moral. Involves personal decisions based on each individual’s background, experiences and sociocultural beliefs. It involves thorough planning to be certain that the method chosen is acceptable and can be used effectively.

Function of the Health Professional in Family Planning  To counsel, reassure, give information and allow an individual/couple to decide his/her/their course of action according to what he/she think is appropriate for them and in accordance to their own personal, societal, religious beliefs & values FAMILY PLANNING SERVICES  Temporary conception control • Methods used to prevent conception • Methods used to prevent ovulation • Methods used to prevent implantation  Sterilization/ Permanent conception control • Tubal Occlusion / Bilateral Tubal Ligation • Vasectomy or Vas Ligation (never advice a permanent method of planning)

METHODS USE TO PREVENT CONCEPTION Natural methods ( The only method accepted by the catholic church) Coitus interruptus (least effective method) • Oldest type of birth control practiced by man. • The premature withdrawal of the penis before ejaculation during sexual intercourse • Reliability is low because sperms are emitted in varying quantities in the normal lubricating fluid secreted throughout intercourse • Psychological disadvantage • Not accepted by the Catholic Church Coitus reservatus • Male does not reach orgasm and therefore no ejaculation occurs • Requires considerable control over the sexual urge Coitus interfemora – “ipit” (kaskas lang) Rhythmic abstinence • Identification of the periods of fertility and the periods of sterility in the menstrual cycle of a woman and the restriction of sexual intercourse to the sterile periods or the time when the pregnancy is unlikely because the woman is biologically unprepared to conceive. • Also known as “safe or infertile period” technique and “natural birth control” or NFP because there is nothing artificial used to prevent conception. • These methods are based on the ff. principles: • The human ovum is susceptible to fertilization for approx. 18-24 hours after ovulation

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The sperms deposited in the vagina are ordinarily capable of fertilizing the ovum for no more than 72 hours • Present methods of determining ovulation time are inexact and seldom sufficiently predictive (by at least 48 hours) so that in practice, it is necessary to avoid intercourse for a far longer period of time than 72 hours before ovulation and 24 hours after ovulation Calendar method • The use of mathematical calculations to predict the probable time of ovulation. “Ovulation most often takes place 14 days before the onset of the next menstruation.” • Ogino-knaus formula: 1. Determine the shortest and longest cycle ex. Shortest cycle = 28 days Longest cycle = 36 days 2. If the cycle is irregular, subtract 18 from the shortest and 11 from the longest ex. 28-18=10 ex. 25-18=7 36-11=25 29-11=18 3. The difference between the shortest cycle and 18 determines the earliest time when ovulation occur. 4. The difference between the longest cycle and 11 determines the last day when ovulation can occur 5. OVULATION CAN OCCUR ANYTIME IN BETWEEN. 6. In a regular 28 day cycle, abstinence should be observed from day 9 to day 17. (count 5 days before the earliest ovulation and 3 days after the last day) Basal Body Temperature • This relies on slight changes (0.3 to 0.6ºC) in basal body temp. that may occur just before ovulation • Pre-ovulatory temperature is low because of high estrogen levels • Post-ovulatory temp. rise is due to high progesterone • The temperature is taken every morning at the same time with the same thermometer just before arising and after at least 4-6 hours of continuous sleep. • 3 days of elevation indicate temperature change is due to ovulation • Abstinence should be observed 5 days before and 3 days after temperature rise. Billings or CERVICAL MUCUS METHOD • A particular type of cervical mucus felt by the woman at the vaginal opening is a signal of ovulation • Research shows this type of mucus appears necessary for conception. Without the mucus, sperm transport is impeded. •

This type of mucus is described as “clear and transluscent and about the consistency of raw egg white.”

Phases of Wetness/Dryness 1. Wet – menstruation 2. Dry – basic infertile pattern - sequence of dry days (or days of unchanging mucus) indicating low level of estrogen and present infertility - duration is invariable, could be days, weeks,months or zero (if cycle is short) 3. Wet – days of possible fertility

o -changing mucus; non-slippery at first later becoming slippery o -peak: last day of slippery mucus o -days 1-3 after the peak are part of fertile period 4. Dry – infertile days o -day 4 after the peak till the end of the cycle o -ends about 2 weeks after the peak Lactational Amenorrhea Method •

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LAM is based on scientific evidence that a woman is not fertile and unlikely to become pregnant during full lactation or exclusive breastfeeding. Full lactation describes breastfeeding when no regular supplemental feeding of any type is given (not even water) and the infant is feeding both day and night with little separation from the mother. LAM – lactation amenorrheal method – LAM provides maximum protection as long as: hormone that inhibits ovulation is prolactin. Menstruation has not resumed and • breast feeding- menstruation will come out Bottle feeds or regular food supplements are not introduced and 4 – 6 months • bottle fed 2 – 3 months Baby is less than 6 months of age.

Symptothermal method (combination of BBT & cervical. Best method )

Signs of Ovulation: • Mitlelschmerz • Spinbarkheit • Changes in vaginal mucus • Goodell’s sign • Mood changes • Breast tenderness • Increased levels of progesterone • Change in basal body temp.

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disadvantage of lam – might get pregnant

Successful use of natural methods to prevent pregnancy depends upon: • • •

The accuracy of the method in identifying the woman's actual fertile days A couple's ability to correctly identify the fertile time The couple's ability to follow the rules of the method they are using

Advantages of natural family planning method • Safe and has no side-effects • Inexpensive • Acceptable to religious affiliations that do not accept artificial methods of contraception • Helpful for planning pregnancy and avoiding pregnancy • Promotes communication about family planning and contraception between couples. Disadvantages • Involves long preparation and intensive recording before it can be used. • There is a need to abstain on certain days which may be inconvenient for the couple. • Not ideal to women with irregular cycles. • Not very reliable because of menstrual cycle variations that may occur anytime. • • • •

Test kits that measures the level of LH and predict ovulation are now available in USA and other countries. These kits detect the level of LH in the urine w/c surges 12-24 hours before ovulation. It is 98 to 100% effective. When a woman sees that her LH level is high, she should avoid coitus.

LOCAL BARRIER METHODS CONDOM • •

A thin stretchable rubber sheath worn over the penis by the man during intercourse. Pregnancy rate is 7-28%

Adv; gives highest protection against STD – female condom

Disadvantages: • Self-lubricated type breaks easily • Penis must be withdrawn from the vagina before \it becomes flaccid • Lessen sexual enjoyment by the male

Female Condoms How to use the female condoms

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Open the Female condom package carefully; tear at the notch on the top right of the package. Do not use scissors or a knife to open.

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The outer ring covers the area around the opening of the vagina. The inner ring is used for insertion and to help hold the sheath in place during intercourse

While holding the Female condom at the closed end, grasp the flexible inner ring and squeeze it with the thumb and second or middle finger so it becomes long and narrow

Choose a position that is comfortable for insertion – squat, raise one leg, sit or lie down.

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Gently insert the inner ring into the vagina. Feel the inner ring go up and move into place.

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Place, the index finger on the inside of the condom, and push the inner ring up as far as it will go. Be sure the sheath is not twisted. The outer ring should remain on the outside of the vagina.

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The female condom is now in place and ready for use with your partner.

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To remove the Female condom, twist the outer ring and gently pull the condom out

When you are ready, gently guide your partner’s penis into the condom's opening with your hand to make sure that it enters properly – be sure that the penis is not entering on the side, between the sheath and the vaginal wall.

Wrap the condom in the package or in tissue, and throw it in the garbage. Do not put it into the toilet.

Vaginal Diaphragm • A shallow,dome-shaped rubber device with a flexible wire rim that covers the cervix; maybe inserted several hours before intercourse and left in place for at least 6 hours after the last intercourse • Initially fitted by a health professional • Weight loss/gain of 15 lbs may require re-fitting • Inserted before intercourse with the woman in squatting or supine position, or with one leg elevated on a chair • May cause cervicitis if left in place for too long • Washed with mild soap & water, lasts for 2-3 years • 97% efficiency

Ht: 1.) proper hygiene 2.) check for holes before use 3.) must stay in place 6 – 8 hrs after sex 4.) must be refitted especially if without wt change 15 lbs 5.) spermicide – chem. Barrier ex. Foam (most effective), jellies, creams S/effect: Toxic shock syndrome Alerts: Should be kept in place for about 6 – 8 hours

Cervical Cap •

Comes in 2 types: presized (S-M-L) and custom fitted (a plastic cap fitted to conform to the individual woman’s cervix made after making a mold of cervix with non-toxic substance used to make contact lenses) • Contraindications: hx of TSS, PID, cervicitis, cervical Ca, vaginal bleeding, an allergy to latex/spermicide • most durable than diaphragm no need to apply spermicide C/I: abnormal pap smear

Advantages • • • • •

Can be inserted many hours before sex play. Easy to carry around, comfortable. Does not alter the menstrual cycle. Does not affect future fertility. May help you better know your body.

Disadvantages • • • • • •

Does not protect against HIV/AIDS. Requires a fitting in a clinic. Some women cannot be fitted. Can be difficult to insert or remove. Can be dislodged during intercourse. Possible allergic reactions.

Intravaginal contraceptives (spermicides)

Side-Effects of Spermicides • You or your partner may be allergic to materials in spermicide. This can cause genital irritation, rash, or itchiness. If this happens and your spermicide has nonoxynol-9, try a spermicide without this chemical. Advantages • Available without a prescription. • Lubrication may increase pleasure. • Use can be part of sex play. • Does not affect future fertility. Disadvantages • Does not protect against HIV/AIDS. • Must be readily available and used prior to penetration. • Can be messy. • Can have a bad taste during oral sex. • Possible genital irritation. • When used frequently spermicides may irritate the vagina making it easier to catch HIV/STI

PREVENTION OF OVULATION • Use of contraceptives: • Pills • Injectable • Implant Contraceptive pills • Estrogen & progesterone prevent pregnancy by inhibiting the hypothalamus and anterior pituitary so that ovulation does not occur. They also inhibit fertility by: 1. Altering the motility of the fallopian tubes 2. Inadequately developing the endometrium 3. Keeping cervical mucus unreceptive and unsupportive of sperm

Types of Pills • Combination pills – contain both progesterone & estrogen; taken from day 5 to day 25 of the menstrual cycle • Sequential 21 day pill- start 5th day of mens • 2 types of pills are taken: 28day pill- start 1st day of mens 1. Contains estrogen alone – taken from day 5-19 missed 1 pill – take 2 next day 2. Contains progestin-taken from day 20-25 • All-progestin (minipill) – taken everyday • Does not necessarily inhibit ovulation; prevents implantation of the zygote Client Instructions on taking CPs • Before starting CP, the woman must undergo physical examination, pelvic exam and Pap smear to rule out contraindications. CP should be prescribed by a physician. • Must be taken on a Sunday following menses and abortion or the first Sunday 2 weeks after delivery,she is to use condom on the first 7 days of pill taking. They should be taken at the same time everyday. • If she is taking 28 day pills, there is no rest day or interval. If she is taking a 21 day pill, she ends on a Saturday and begin a new pack on the next Sunday. Bleeding will occur around 4 days after stopping pills. If she expected bleeding did not come, she should consult the doctor before starting a new packet of pill. • Minor side effects: nausea, weight gain, headache, breast tenderness, breakthrough bleeding, yeast infections, mild hypertension, potential depression • If a woman forgets one pill, take one now and then the next on the regular schedule of pill taking. If two pills, take two pills now and two pills tomorrow and use back-up method for the next 7 days. If 3 pills, discard the remaining pack and start a new pack, use back-up method for the next 7 days. • OC users should have a check-up after 4 months then annual check-ups to have pelvic exam, breast exam and Papsmear. • Another contraceptive method should be used until a woman has had 2 regular menstruations or wait for three months after stopping taking OC before attempting pregnancy. There is usually a 1-2 month delay in the resumption of menstruation after discontinuing OC. • Folic acid deficiency is common in long term user so that it is advisable to take folic acid supplement • If used by adolescent, they should have a regular menstruation for at least two years before beginning OC use. Contraceptive pills • If accidentally taken by a child, side-effect is increased blood clotting, stimulate vomiting by giving child syrup of ipecac • Danger signs: if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If forgotten for two consecutive days, or more days, use • A- abdominal pain another method for the rest of the cycle and the start again. • C-chest pain and dyspnea • H- headache • E-eye problems • S- severe leg pain Implant (Norplant) •

6 tiny silicone rubber capsules or 2 rods containing progestin (evonorgestiel), surgically implanted under the skin of the upper arm; removed surgically in about 5 years or when the woman wishes to discontinue the method.

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disadvantage if keloid skin as soon as removed – can become pregnant

Advantages: • Long term reversible contraception • Do not interfere with coitus • Has no estrogen related side-effects • Can be used during breastfeeding • Can be used by adolescents • Rapid return of fertility w/c occurs 3 months after removal Disadvantages: • Expensive • Scarring at insertion site Contraindications: • Pregnancy • Desire to get pregnant within 2 years • Undiagnosed vaginal bleeding Injectable contraceptive (Depo-provera, Noristerat, etc.) • Synthetic progestin hormones injected into muscle: administered every 3 months - never massage injected site, it will shorten duration

They exert their contraceptive effect by inhibiting ovulation, altering cervical mucus and preventing endometrial growth. The woman does not menstruate with this contraception. It has the same advantages, disadv., and contraindications as implants. Disadvantages: • Fertility return is usually delayed by 6 months • Higher risk for osteoporosis so advise to increase calcium intake and engage in weight bearing exercise • Impair glucose tolerance in women at risk for DM Client instructions: • Advise client to have annual PE that includes breast exam,pelvic exam, and Papsmear • Report signs of leg pain or swelling, chest pain & dyspnea,tingling and numbness of extremities, loss of vision, severe headache, dizziness & fainting. Side-effects: 1. Thrombo-embolic disorders and other vascular problems including CVA & MI • Oral pills should be discontinued for 4-8 weeks before anticipated surgery 2. Alterations in metabolism,esp. of CHOs and B-vitamins (pyridoxine & folic acid) 3. Fetal effects after discontinuing the pill-evidence of increased of chromosomal changes 4. Amenorrhea after discontinuing the pill 5. Neoplastic disease (breast, liver-hepatocellular adenoma) 6. Hypertension 7. Adverse drug interactions

Estrogen deficiency & excess Estrogen excess • Nausea & vomiting • Dizziness • Edema • Leg cramps • Increase in breast size • Chloasma • Visual changes • Hypertension • vascular headache

Estrogen deficiency • Early spotting (days 1-14) • Hypomenorrhea • Nervousness • Atrophic vaginitis leading to painful intercourse

Progesterone deficiency & excess Progesterone excess • Increased appetite • Tiredness • Depression • Breast tenderness • Vaginal yeast infection • Oily skin and scalp • Hirsutism • Postpill amenorrhea

Progesterone deficiency • Late spotting and break-through bleeding (days 15-21) • Heavy flow with clots • Decreased breast size

Safety measures in the use of pills • Careful screening to detect women who are at risk of developing problems • Use of lowest possible dose for each women • Careful follow-up should be done every 6-12 months to detect problems —complete health assessment: should include history, PE, Pap smear & lab studies • Family history • Vascular accident (stroke) • DM • Breast Ca Contraindications: • Medical history • Hepatitis or hepatic insufficiency • Thrombo-embolic disease • Sickle-cell disease • Moderate/severe hypertension • Smoking more than 15 cigarettes a day • Psychic depression •

History of conditions that can be aggravated by fluid retention • Migraine • Convulsive d/o • Asthma • Cardiac & renal insufficiency

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PE findings  Pregnancy & Lactation  30 years old or older  Presence of hormonal-dependent tumors  Breast nodules  Fibrocystic disease  Abnormal mammogram  Varicose veins

PREVENTION OF IMPLANTATION IUD (Intra-Uterine Device)  An object made of plastic or non-reactive metal (nickel-chromium alloy) that fits inside the uterine cavity  Manufactured in several shapes (loop, coil, spiral)  Causes a chronic inflammatory response in the endometrium, discouraging implantation of a fertilized ovum  Conception may occur; if implantation takes place, it causes early abortion  Usually inserted during the menstrual phase  IUDs come with increased risk of ectopic pregnancy and perforation of the uterus and do not protect against sexually transmitted disease. IUDs are prescribed and placed by health care providers.

Types of IUD • Non-medicated 1. Lippes-Loop- available in 4 sizes (A-small to D-large); has been withdrawn from the market 2. Saf-T-coil – available in 2 sizes (small & large) • Medicated 1. Copper 7 (Cu 200) – copper has direct spermicidal effect; has been withdrawn from the market 2. Copper-T (T-Cu 200, tatum copper-bearing IUD) 3. Progestasert-T HT 1.) Check for string daily 2.) Monthly checkup 3.) Regular pap smear

primary indication for use of IUD - parity or # of children, if 1 kid only don’t use IUD

Contraindications of IUD • Any inflammatory condition or infection of the reproductive tract or PID • Abnormalities of the uterus • Severe dysmenorrhea • Uterine bleeding of unknown origin • Suspected pregnancy Complications / Adverse reactions • Syncope during insertion • Increased risk of PID w/c may result in • Sterility or infertility • Medical-surgical intervention for complications such as twisted ovary, bowel obstruction, unilateral tubo-ovarial abscess • Perforation of the uterus • Dysmenorrhea • Increased blood loss (anemia) • Ectopic pregnancy • expulsion IUD Danger Signs P eriod late (pregnancy suspected) Abnormal spotting or bleeding A bdominal pain or pain with intercourse I nfection (abnormal vaginal discharge) N ot feeling well, fever, chills S trings lost, shorter or longer

STERILIZATION/ PERMANENT CONCEPTION CONTROL Tubal Occlusion / Bilateral Tubal Ligation - Involves tying, cutting or cauterizing the fallopian tbes - Usually done immediately after delivery (within 24-48 hours) when the incidence of morbidity & failure are lowest - May also be done in any phase of the menstrual cycle methods: o Mini-laparotomy o Laparoscopy or “band-aid surgery” o Vaginal tubal sterilization

HT: avoid lifting heavy objects

Vasectomy / Vas ligation •

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Accomplished without entry into the abdominal cavity; twin incisions are made in the area where the scrotum joins the body, just over the vas deferens The tubes are tied and seperated; portions maybe excised Follow-up sperm counts maybe done after.

After vas ligation, the man is considered sterile: After 20 or more ejaculation, zero sperm count- safe 2 outstanding needs of couples who come to the fertility clinic 1. Education about reproduction & procedures used to evaluate fertility 2. Counseling to help them maximize their potential for conception Stages on evaluating infertile couples: 1. Complete physical assessment to rule out endocrine or emotional problems and disease entities 2. Evaluation of the reproductive capacity of the male • Semen analysis • Hormone analysis • Testicular biopsy • X-ray studies to identify blockage of sperm pathway 3. Evaluation of the reproductive capacity of the female • Ability to ovulate • Endometrial biopsy • Test for cervical mucus viscosity/analysis of cervical secretions • Patency of the fallopian tubes • Analysis of endometrial secretions Possible management: • Hormonal therapy • Surgical intervention for obstructive cases • Medical therapy for PID  Success of treatment depends on:  Ages of the couple  Continued interest  Cooperation

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Financial resources

Other Family Planning Services • Sex Education • It is a broad term used to describe education about human sexual anatomy, sexual reproduction, sexual intercourse, and other aspects of human sexual behavior. Common avenues for sex education are parents or caregivers, school programs, and public health campaigns. • Genetic Counselling • Helping people faced with a diagnosis of genetic disease to understand both the factual information about the disease and the effect it will have on their lives, so that they can reach their own decisions about the future. • Research