CATHERINE RAMOS MARIN, MSN/ED(C), WHCNP, RN

DEMOGRAPHICS

62% of women practice contraception 31% do not because they are not sexually

active, are infertile, are pregnant or trying to get pregnant

7% at risk of becoming pregnant, not using contraceptive

Half of all pregnancies are unintended 4 in 10 are terminated by abortion

CHOOSING A METHOD OF CONTRACEPTION 2 leading methods: pill for women <

30 y.o. and sterilization for women over 35

Made with full knowledge of advantages and disadvantages, effectiveness, side effects, contraindications and long term effects

Cultural practices, religious beliefs, personality, cost, practicality of method, and self-esteem

Consistency of use outweighs the reliability of the method chosen

CONTRACEPTION METHODS Abstinence: refrain from sexual intercourse

associated to just saying “no” most effective method abstinence during fertile periods can be used but

requires an understanding of the menstrual cycle eliminates the risk of sexually transmitted

infections if there is no genitalia contact Coitus Interruptus: withdrawal of the

entire penis from the vagina before ejaculation. significant means of fertility control in the

developing countries, effectiveness dependent on the man’s ability to

withdraw prior to ejaculation

CONTRACEPTION METHODS Lactational Amenorrhea: elevated prolactin levels

and decrease of gonadotropin- releasing hormone during lactation suppress ovulation, duration of suppression varies and is influenced by the

frequency and duration of breastfeeding Disadvantages: return to fertility is uncertain, should not

be used if the mother is HIV positive Calendar Method:

a woman records her menstrual cycle, calculates the fertile period based on the assumption that ovulation occurs roughly 14 days before the onset of the next menstrual cycle, and avoids intercourse during that time

Note: sperms are viable for 48 to 120 hr and ovum is viable for 24 hrs.

Most useful when used together with BBT or the cervical mucus method, inexpensive

CONTRACEPTION METHODS Basal Body Temperature: temperature will

drop prior to ovulation, increase a full degree at ovulation woman will take her oral temperature prior to

getting out of bed each morning to monitor ovulation,

inaccurate interpretation of temperature changes such as stress, fatigue, illness, alcohol, and warmth or coolness of sleeping environment

Billings Method (cervical mucus method): ovulation occurs 14 days prior to next menstruation, following ovulation, the cervical mucus becomes thick and sticky under the influence of estrogen and progesterone to allow sperm viability and motility mucus could stretch between fingers: greatest time

at ovulation…known as spinnbarkeit sign.

CONTRACEPTION METHODS Condoms: a flexible sheath worn on the penis during

intercourse to prevent semen from entering the uterus protects against sexually transmitted disease and involves the

male in the birth control method, those made of latex should not be worn by those who are

sensitive or allergic to latex, only water-soluble lubricants should be used to avoid condom

breakage. Diaphragm: dome-shaped cup with a flexible rim made of

latex or rubber that fits snuggly over the cervix with spermicidal cream or gel placed into the dome and around the rim female client has to be fitted with diaphragm properly by a

primary care provider must be refitted every two years or if there is a significant

change in weight (7 Kg), after full term pregnancy, or second term abortion

Disadvantages: inconvenient, requires reapplication of spermicidal gel/cream with each act of coitus to be effective

not recommended for those with history of Toxic Shock Syndrome (TSS) or frequent urinary infection

CONDOM AND DIAPHRAGM

CONTRACEPTION METHODS Combined oral contraceptives: hormonal contraception

containing estrogen and progestin which acts by suppressing ovulation, thickening of cervical mucus to block the semen, and altering the uterine deciduas to prevent implantation medication requires prescription and follow-up appointments, instruct clients the side effects and danger signs: chest pain,

shortness of breath, leg pain from a possible clot, headache, or eye problems from a CVA or hypertension

Meds can alleviate dysmennorhea by decreasing menstrual flow and menstrual cramps, reduces acne

Exacerbates conditions affected by fluid retention such as migraine, epilepsy, asthma, kidney, or heart disease

Minipill: oral progestins that provide the same action as combined oral contraceptives, should take the pill at the same time daily to ensure

effectiveness, has fewer side effects, less effective in suppressing ovulation a pill, will need another form of birth control during the first month of use to prevent pregnancy, has fewer side effects, less effective in suppressing ovulation

ORAL CONTRACEPTIVE PILLS

CONTRACEPTION METHODS Emergency Oral Contraceptives- morning

after pill, taken within 72 hrs. after unprotected coitus a provider will recommend an OTC antiemetic to be

taken 1 hr prior to each dose to counteract the side effects of nausea that can occur with high doses of estrogen and progestin

provide client counseling, pill is not taken on a regular basis, not used when there is undiagnosed abnormal vaginal bleeding

Transdermal Contraceptive Patch: contains norelgestromin (progesterone) and ethinyl estradiol, which is delivered at continuous levels through the skin into the subcutaneous tissue apply on a subcutaneous tissue in areas of buttocks,

abdomen, upper arm, or torso excluding breast area

TRANSDERMAL CONTRACEPTIVE PATCH & EMERGENCY PILL

CONTRACEPTION METHODS Injectable progestins (Depo-Provera) : an

intramuscular injection given to a female client every 11 to 13 weeks start injection during the first 5 days of the client’s

menstrual cycle and every 11 to 13 weeks thereafter very effective and only requires four injections a year, does not impair lactation do not massage the area of injection following

administration to avoid accelerating medication absorption

Implantable progestin levonorgestrel (Norplant): requires a minor surgical procedure to subdermally implant or remove 6 Silastic capsules containing levonorgestrel on the inner aspect of the upper arm avoid trauma on the area of implantation effective continuous contraception for 5 years reversible can cause irregular menstrual bleeding

DEPO PROVERA AND NORPLANT

CONTRACEPTION METHODS Intrauterine Device (IUD): chemically active T-

shaped device inserted through the woman’s cervix and placed in the uterus by the primary care provider, releases a chemical substance that damages sperm in

transit to the uterine tubes and prevents fertilization device monitored monthly by the client after

menstruation to assure the presence of the small string that hangs from the device into the upper part of the vagina to rule out migration or expulsion of the device

can maintain effectiveness for 1 to 10 years, can increase the risks of pelvic inflammatory disease, uterine perforation, or ectopic pregnancy, there is a risk of bacterial vaginosis

Female sterilization (Bilateral tubal ligation): a surgical procedure requiring anesthesia that may be local or general permanent contraception, sexual function unaffected risk of ectopic pregnancy if pregnancy occur.

IUD & BTL

CONTRACEPTION METHODS Male sterilization

(vasectomy): a surgical procedure consisting of ligation and severance of the vas deferens, scrotal support needed after the

procedure sterility delayed until proximal

portion of the vas deferens is cleared of all the remaining sperm (approximately 20 ejaculations)

a permanent contraceptive method sexual function not impaired.

VASECTOMY

ELECTIVE TERMINATION (INDUCED ABORTION)

Procedure performed to end a pregnancy before viability

AKA therapeutic, medical, or induced abortions

A woman’s choice, should not be viewed as a method of contraception but as a remediation for failed contraception

LEGAL BACKGROUND

1973, US Supreme Court legalized abortion as long as the pregnancy is less than 12 weeks

Individual states can regulate second trimester termination and prohibition of third trimester termination that are not life-threatening

One half of unintended pregnancies end with elective termination (CDC, 2009).

SURGICAL INTERRUPTION OF PREGNANCY Widely used is vacuum curettage Major risks: perforation of uterus, laceration

of cervix, hemorrhage, infection Unwanted or unintended pregnancy, sexual

assault, lack of finances, maternal or fetal health

Assess for need for support and counseling, post procedure support

Provide information about the methods of abortion and associated risks, available alternatives to abortion, encourage verbalization of her feelings

Provide physical comfort and privacy Post-abortion check-ups and contraception

review

MEDICAL INTERRUPTION OF PREGNANCY RU 486 or mifepristone (Mifeprex) FDA

approved in 2000: to medically induce abortion during the first 7 weeks of pregnancy

Oral dose taken at the MDs office and then 1-3 days later she returns to MD, and takes an oral or vaginal dose of prostaglandin misoprostol- induce contractions that expel the embryo/fetus

INFERTILITY

Lack of conception despite unprotected sexual intercourse for at least 12 months

Sterility: an absolute factor preventing reproduction

Subfertility: difficulty conceiving because both partners have reduced fertility

Secondary infertility: unable to conceive after one or more pregnancies

16% of couples in their reproductive years bin the US are infertile

INFERTILITY

Male factor: 40% Female factor: 40% Unknown cause: 20% Professional intervention can

help: 65%

INITIAL INVESTIGATION Use the easiest and least intrusive infertility

testing first Gather data re: timing and length of

intercourse, signs of ovulation, comprehensive health history, obvious causes in infertility

40% of infertility is related to male factor, semen analysis is done first

Initiate preconception counseling Prenatal vitamins often the earliest

recommendation, plus folic acid supplemenation(400 mcg) to reduce incidence of neural tube defects like anencephaly and spina bifida

Discuss the risks associated with alcohol, tobacco, and medications

Discuss the importance of rubella and varicella immunity

WAYS TO IMPROVE FERTILITY Avoid douching and artificial lubricants that can

alter sperm mobility Promote retention of sperm (male superior

position, female remain recumbent at least 20-30 min)

Avoid leakage of sperm (elevate the woman’s hips with a pillow after intercourse for 20-30 min)

Maximize potential for fertilization (every other day during fertile period)

Avoid emphasizing conception to decrease anxiety and sexual dysfunction

Maintain adequate nutrition and reduce stress Seek counsel and advice from a valued friend or

family member Consider incorporating culturally appropriate

methods to enhance fertility

POSSIBLE CAUSES OF INFERTILITY (FEMALE)

1. Favorable cervical mucus

2. Clear passage b/w cervix and tubes

3. Patent tubes with normal motility

Cervicitis, cervical stenosis, use of coital lubricants, antisperm antibodies

Myomas, adhesions, adenomyosis, polyps, endometritis, cervical stenosis

Pelvic inflammatory disease, peritubal adhesions, IUD

POSSIBLE CAUSES OF INFERTILITY Ovulation and

release of ova

Endometrial preparation

Primary ovarian failure, polycystic ovarian disease, hypothyroidism, pituitary tumor, periovarian tumor, lactation

Anovulation, luteal phase defect, malformation, uterine infection

POSSIBLE CAUSES OF INFERTILITY (MALE)

1. Normal semen analysis

congenital defect in testicular development, mumps after adolescence, gonadal exposure to Xrays, chemotherapy, smoking, alcohol abuse, constrictive underclothing

POSSIBLE CAUSES OF INFERTILITY Unobstructed

genital tract

Normal genital tract secretions

Ejaculate deposited at the cervix

infections, tumors, vasectomy, strictures, trauma

Infections, autoimmunity to semen, tumors

Premature ejaculation, impotence, hypospadias, obesity

NORMAL SEMEN ANALYSIS

1. Volume2. pH3. Total sperm count

4. Motility

5. Normal forms

Greater than 2 ml 7 to 8 Greater than 20

million/ml 50% or greater forward

progression 30% or greater

http://www.youtube.com/watch?v=DINf2RbMAsw&feature=related

QUESTIONS

REFERENCE Davidson, London, & Ladewig. Maternal-newborn

nursing and women’s health cross the lifespan. 8th edition.

Pillitteri, A. Maternal and child health nursing. 6th edition.