2.1 Non-Hormonal Contraception Flashcards
Contraception
- Considered effective family planning
- Most important public health accomplishment of 20th century
- Almost half of all pregnancies in US are unplanned even with the advancements in availability and efficacy of contraceptions
Family Planning
- Purposeful decision to conceive or not
Contraception
- Purposeful pregnancy prevention
Birth Control
- Device or practice used to decrease likelihood of pregnancy
Assessment
- Assessment is what guides the appropriate method of birth control for an individual.
Assessment includes - Client Knowledge and Partner Commitment
- Sexual History (Frequency of intercourse, number of partners, willingness to participate in selected methods)
- Comfort with genital touching
- Identification of religious and cultural factors
- Clinical History and plan for future fertility
Informed Consent-
B - Benefits R - Risks A - Alternatives I - Inquiry D - Decision E - Explanations D - Documentation
Reason for Informed Consent (Contraception)
- Welfare of patient
- Respect for autonomy
- Sufficient information so patient can choose wisely
Contraceptive Rates
Failure Rate - Percentage of contraceptive users expected to have unplanned pregnancy in first year
Contraceptive Effectiveness
Theoretical - Efficacy with perfect use
Typical - Efficacy with typical use (non-perfect)
Long-Acting Reversible Contraceptives (LARC)
- These are the most effective contraceptive methods
Coitus Interruptus (withdrawal)
- Penis withdrawn prior to ejaculation
- No protection against HIV or STIs
Advantages
- Immediate availability, no devices, cost, or chemicals
Disadvantages
- Not effective
- Good choice for people who do not have other options
- Effectiveness depends on man’s ability to withdraw
Fertility Awareness-Base Methods (FAB)
Natural Family Planning
- Avoiding sex during fertile periods
- Understanding ovulation cycle is critical to success
- Pregnancy is only possible 12-24 hours after ovulation
- Sperm can fertilize the ovum between 24-48 hours after.
- The biggest issue is it is difficult to find exact ovulation time.
Advantages of FAB
- No chemicals
- Instant availability
- Increased involvement and intimacy with partner
- Follows religious/cultural traditions
- Used to establish fertile days for contraception in people who want pregnancy
Disadvantages of FAB
- Requires male partner support
- Lower typical effectiveness than other methods
- Decreased effectiveness in women with irregular cycles (adolescents)
- Decreased spontaneity of coitus (sex)
Calendar Based Method
- Record lengths of menstrual cycles for at least 6 months.
- Subtract 18 days from the length of shortest cycle
- Subtract 11 days from the length of longest cycle
Shortest Cycle - 24 days - 18 days = 6th day
Longest Cycle - 30 days - 11 days = 19th day
Abstain from sex days 6th - 19th
Calendar Based Method Assessment
- Knowledge about contraception
- Sexual partner commitment
- Frequency of coitus
- Number of partners
- Objections to any methods
- Level of comfort/willingness to touch genitals
- Complete history (menstrual, contraceptive, obstetric)
- Physical (including pelvic exam)
- Lab tests (Identifying STI’s)
Calendar Based Method Effectiveness
Factors of Effectiveness
- Frequency of intercourse
- Motivation to prevent pregnancy
- Understanding how to use method
- Adherence to method
- Provision of short or long term protection
- Likelihood of pregnancy for the individual woman
Standard Days Method (SDM)
- Similar to calendar based method but has fixed number of days of fertility for each cycle.
- Example is days 8-19
SYMPTOMS BASED METHODS
Two-Day Method
- Based on monitoring cervical secretions
- Women asks herself 2 questions
1. Did I note secretions today
2. Did I note secretions yesterday
If yes, avoid coitus or use backup birth control
If no, probability of getting pregnant is very low
Cervical Mucus Ovulation Detection Method
(Billings Method)
(Ovulation Method)
- Recognition and interpretation of cyclic changes in the amount and consistency of cervical mucus that transforms prior to and during ovulation to facilitate and promote the viability and motility of sperm.
Basal Body Temperature (BBT)
- Take temperature in morning before getting out of bed
- Usually 36.2-36.3 during menses and 5-7 days after
- Around the time of ovulation there is a slight drop in temperature for some women. (0.5-0.9)
- After ovulation, increased progesterone levels temperature increases slightly. (0.4-0.8)
- Temperature remains elevated until 2-4 days before menstruation.
- In pregnant women temperature remains elevated
- Fertile period is the day of first temperature drop, or the first elevation, through 3 consecutive days of elevation.
- Abstinence 1st day of menstrual bleeding and lasts 3 consecutive days of temperature rise
BBT - Thermal Shift
The decrease and subsequent increase in temperature due to progesterone.
- Infection, fatigue, lack of sleep, and anxiety may also cause temperature fluctuation.
Cervical Mucus
Postmenstrual - Scant (Insufficient)
Pre-Ovulation - Cloudy/Yellow/White/Sticky
Ovulation - Clear/Wet/Slippery
Post Ovulation Fertile - Thick/Cloudy/Sticky
Post Ovulation non-fertile - Scant (Insufficient)
Spinnbarkeit - Thick and can be stretched to 5+cm between thumb and forefinger. Indicates maximum fertility. (Sperm can survive in this mucus until ovulation)
Assessment for Cervical Mucus
- Hand Hygiene
- Observation begins on last day of menstrual flow
- Assess several times a day
- Obtain mucus from vaginal opening
- Record findings on same day BBT is entered
Hormones during Ovulation
Early Follicular Phase - Estrogen
Ovulation - Estrogen/Progesterone
Luteal Phase - Progesterone/estrogen
Symptothermal Method
- Combines BBT and Cervical Mucus methods with related signs of menstrual cycle. Signs/Symptoms - Light Spotting - Slight Cramping or Pain on one side - Breast Tenderness - Abdominal Bloating - Increased Sex Drive - Heightened Sense of Smell/Taste/Vision
Biological Marker Methods
- Kits that predict ovulation such as urine predictor test
- Detects surge of luteinizing hormone (LH) that occurs 12-24 hours before ovulation.
Spermicide and Barrier Methods
- Barriers offer protection against STI’s and HIV
- Spermicides create chemical barrier against semen and inhibit the function of sperm to fertilize ovum
Spermicides
- nonoxynol-9 (N-9) reduces sperm motility
- Inserted into vagina so that it makes contact with cervix.
- Inserted 15 minutes before (no longer than an hour) intercourse and re-applied during each act of intercourse even if barrier is used.
Marquette Method
- Uses cervical monitoring and ClearBlue Fertility Monitor to measure urinary estrogen and LH
Intrauterine Devices (IUD)
- T shaped device inserted through cervix
- Strings hang from the base and protrude into vagina so woman has assurance it has not been dislodged
- Women should not be pregnant, have dysplasia, cervical cultures to rule out STI’s, and consent form.
- Copper IUD can be used for 10+ years
- Women should be taught to check for presence of IUD strings after menstruation to rule out expulsion of device.
Advantages of IUD
- Long-term protection. (Ectopic pregnancy possible)
- Possible decrease in menstrual symptoms in people with fibroids (non-cancerous growths) or adenomyosis.
- Very effective and cost effective
- Insertion without time restrictions (some doctors prefer to insert during menstruation when cervix is dilated)
- Suitable for people with estrogen contraindications
- Immediate return to fertility when removed
Disadvantages of IUD
- Unintentional expulsion of device
- Increased risk of infection in the first month
- Increased bleeding for copper IUD
- Unpredictable bleeding patterns for LNG IUD
- Offers no protection against HIV or STI’s
How do IUD’s Work
- Impair semen mobility
- Thicken cervical mucus
- Decrease linings in uterus
- Has anovulatory effects (lack of ovulation)
- Uterine cramping and bleeding are usually decreased
- Irregular spotting is common in first few months
IUD Complication Signs
P - Period Late (abnormal spotting/bleeding)
A - Abdominal Pain (pain with intercourse)
I - Infection Exposure (Abnormal Vaginal Discharge)
N - Not Feeling Well (Fever/Chills)
S - String Missing (Shorter or Longer)
Sterilization
- Surgical procedures intended to make someone infertile
- Involves occlusion of passageways for ova and sperm
Women - Oviducts (uterine tubes) are occluded
Men - Sperm Ducts (Vas Deferens) are occluded
Only removal of ovaries (oophorectomy) or uterus (hysterectomy) will result in absolute infertility for women.
FEMALE STERILIZATION
- Bilateral Tubal Ligation (BTL)
- Can be done immediately after birth (24-48 hours) naturally with induced abortion or as an interval procedure during any phase of menstrual cycle
Tubal Occlusion
- Laparoscopic (abdominal) approach
- Minilaparotomy (pubic) approach
Electrocoagulation/Ligation - Permanent
Bands/Clips - Possible reversal of infertility
Transcervical Sterilization
- Hysteroscopic Technique (via cervix)
- Inject occlusion agents into uterine tubes.
- Interval sterilization method
Tubal Reconstruction
- Restoration of Tubal Continuity (re-anastomosis)
- Cannot be done after laparoscopic or electrocoagulation.
- Sterilization reversal is costly, difficult, and uncertain.
MALE STERILIZATION
Vasectomy
- Surgical interruption of vas deferens which is responsible for transporting sperm to urethra.
Tubal Reconstruction
- Re-anastomose can be done but pregnancy rates are 30-90% depending on procedure.
- Rate of success decreases as time from vasectomy increases.
Breast Feeding: Lactation Amenorrhea Method
- Can be highly effective temporary birth control
- When infant suckles on mother’s breast, prolactin is released which inhibits estrogen and suppresses ovulation.
- Works best when mother is exclusively breast feeding, has not had menstrual flow since birth, and infant is less than 6 months old.
Contraceptives Access
Options are limited in US and Canada because
- Lack of funding for research
- Governmental regulations
- Conflicting values of contraception
- High costs of liability coverage for contraception
Induced Abortion
- Purposeful interruption of pregnancy before 20 weeks of gestation.
Elective Abortion - At mother’s request
Therapeutic Abortion - Maternal/Fetal Health/Disease reasons
Factors Deciding Abortion
- Preservation of life/health of mother
- Genetic disorder of fetus
- Rape/incest
- Pregnant women’s request
Abortion complications
- Low if aborted during first trimester.
- No correlation between abortion and mental health issues
FIRST TRIMESTER ABORTION
- Less than 9 weeks of gestation
Aspiration (Vacuum)
- Most common procedure during 1st trimester
- Preformed under local anesthetic’s
- Bleeding/infection is most common complications
- Prophylactic Antibiotics Given
- Post abortion NSAID’s for pain
Aspiration Signs to Return To Hospital
- Fever greater than 38C
- Chills
- Heavy bleeding
- Foul smelling vaginal discharge
- Severe abdominal pain/cramping or backache
Medical Abortion
- Used up to 9 weeks after last menstrual period
- Methotrexate, misoprostol, mifepristone used to induce abortion
Methotrexate and Misoprostol
- Methotrexate given IM or PO
- Returns for vaginal displacement of Misoprostol
- Follow-up to confirm abortion is complete
- If not, vacuum or additional dose of Misoprostol
Mifepristone and Misoprostol
- Mifepristone given up to 70 days after last menstrual period
- 200mg by mouth
- Check back in 2 weeks to see if pregnancy is terminated
Side Effects of Medical Abortion
- Bleeding/Cramping
- N/V
- Diarrhea
- Headache
- Dizziness
- Fever
- Chills
Aspiration Preperation
- Bimanual exam before procedure
- Speculum inserted and cervix anesthetized
- Cervix dilated
- Cannula connected to suction inserted into uterus
Nursing Care for Aspiration
- Keep patient informed about each step
- Assess vitals
- Promote rest post procedure
- Monitor for post procedure bleeding
- Provide uterine massage if indicated
Discharge Information for Aspiration
- Fever greater than 38
- Chills
- Bleeding greater than 2 saturated pads in 2 hours or heavy bleeding lasting a few days
- Foul-smelling vaginal discharge
- Severe abdominal pain, cramping, backache
SECOND TRIMESTER ABORTION
- More complications and higher cost than 1st trimester
Dilation & Evacuation (D&E) is the main form
Dilation & Evacuation
- Preformed up to 20 weeks of gestation
- Most common between 13 and 16 weeks
- Cervix requires more dilation because products for conception are larger
- Similar to aspiration but larger cannula
- Possible long term effects to cervix
