OB Module 6: Family Planning Flashcards
Nearly half of all pregnancies in the US are ___
unintended
Every year __% of women 15-44 yo who dont use birth control during vaginal intercourse become pregnany
85%
What are the most common forms of contraception in the US?
- Female Sterilization - 10.7 mil
- Oral Contraceptive Pills - 10.4 mil
- Male condoms - 7.9 mil
- Male Sterilization - 4.2 mil
Why is it interesting that the most common form of contraception is female sterilization by a large margin?
- There is a comparatively low rate of male sterilization
- This is due in part to women having to take ownership of the contraceptive use issue often
- It is an invasive procedure that opens the abdomen and uses anesthesia so there are hazards
OCs and BCPs
Oral Contraceptives and Birth Control Pills
Barrier Methods for contraception
condoms
diaphragms
contraceptive sponge
cervical cap
A shot or an implant like depo is what kind of contraceptive method?
Long Acting Hormonal Methods
IUD
Intrauterine Devices
What are the various contraceptives that one can use?
OCs and BCPs
Barrier methods
IUDs
Long Acting hormonal methods
spermicides
hormonal contraceptive patch
hormonal contraceptive vaginal ring
natural family planning
lactation amenorrhea method
surgical or procedural sterilization
emergency contraception
When is another name for emergency contraception
Plan B
What are the different types of contraceptive uses
Typical
Perfect
Typical Use
User effectiveness
the use of any given method by a typical couple
the typical user may not use the method with every act of intercourse or may not consistently or correctly use the product
Perfect Use
Theoretical Effectiveness
Method used consistently and correctly according to a specified set of rules or guidelines with very act of intercourse
statistics are based on the theory of perfect use
Rates of ___ use are lower than __ use
typical; perfect
Periodic abstinence like calendar, ovulation method, symptothermal, and post ovulation are what kind of contraception?
family planning
they have only typical use ratings rather than perfect
When is a pregnancy cap more effective
if it is a primiparous woman than a multiparous woman since the cervix will alter after L&D and the cap may not fit right
Why is withdrawal a bad method of contraception?
Pre ejaculate has sperm in it too in some amount
Pull out game weak regardless of what you do
Why does Nuvaring have only perfect use rates and not typical
it is put in and left in so there is not much typical use occurring
Why can male sterilization still have a failure rate?
Some guys are not good at going back until sperm levels hit zero while others do not always use protection in the meanwhile
Emergency contraception has the highest rate of prevention when…
it is started within 72 hours
the sooner started the higher the contraceptive success rate
Factors to Consider when Choosing a Contraceptive
She can be comfortable with
Her partner can be comfortable with
Is as effective as she needs for it to be effective
Is cost effective or low cost
Is easily hidden if need be
Prevents STD transmission if necessary
Separates the act of intercourse from contraception if needed
Allows for immediate use if spontaneity is an issue
May be easily reversible or permanent
What is one of the most cost effective contraceptives and why
IUD
the initial payoff is larger but you get protection for years
It ends up being a low cost in the long run but it must be aid upfront
It is also secretive and good for prevention in adolescents, abused women, and prevention of STDs
Factors to take into consideration while counseling regarding contraceptive choices?
Medical history and risk factors
effects an unwanted pregnancy would have at this point in the patients life
potential for multiple partners in reproductive life span especially in the next few years
patients comfort level touching her body and her lovers body
maturity level
frequency of intercourse
patients ability to understand instructions
patients access to the health care setting
methods used to date and her perceptions regarding these contraceptive methods as well
the patients weight
the patients ability to consistently use the method
If there is a need to prevent pregnancy and prevent STD transmission, what may the patient be advised to do?
Combine two methods to enhance pregnancy prevention but also prevent STD transmission
ex: Condoms and spermicidal foam or Condoms and OCs
What is important for the patient to know when starting a new method of contraception
that she is using the method on a trial basis and that if she finds that the method is not working well for her and her partner that she then needs to return for further counseling and a trial of another method
What should the provider do before the client leaves the clinic with a new barrier method of contraception
give clear and simple instructions on how to use the method
have the patient demonstrate the use of any barrier method before leaving the clinic setting as leaving something like a diaphragm in place could have risks
It will be important to __ __ with the patient how she will discuss contraception with her partner
role play
Why is it particularly important to act out discussion with a partner
this is especially important if the method will involve his cooperation or use at the time of sexual activity
How can cultural issues come into play when choosing a contraceptive
they can come into play regarding the mothers expectations for her daughter in contrast to the cultural norms in the culture they are now acclimating to
the cultural issues and this patients beliefs and values regarding health and the potential impact of chemicals introduced into the body effect her choices regarding birth control
How does the patients education level impact choosing a method of contraception? What does it not impact?
it affects her ability to comprehend explanations regarding methods and anatomy with ease
but it does not insure her having a comfort level touching her own body or that of her lover in a sexual context
OTC Contraceptive Methods
Condoms
Female Condoms
Sponge
Contraceptive Film
Spermicide
Barrier Methods of Contraception
Condoms
Diaphragms
Contraceptive sponges
Cervical Caps
What is the major advantage of condom use
the additional barrier of STDs
they are often recommended for this use in addition to other methods for this very purpose
What is the rate of conception like with condoms?
Not great when condoms are used along
14% failure rate for typical use and 3% perfect use
more protection can be gleaned though when used with a spermicide foam, cream, jelly, suppository or film however.
Why has male condom use rose in recent years?
generally it is used more over the concern of AIDS or STDs
incidence increased in all ages but particularly in 20-24 year range and 25-29 year range
How does the Female Condom work
The same way as a male one - a barrier to sperm
Thin polyurethane acting as a sheath with 2 soft flexible rings at either end and is worn internally by the woman during coitus
Polyurethane covers one ring sitting against the cervix and acting as an anchor, the second is larger and remains outside the body and covers part of the peritoneum and labia
When can the female condom be inserted and when can it be removed?
it can be inserted as much as 8 hours prior to sex and should be removed immediately after sex
Never use a female condom with …
a male condom
Diaphragm
made of thin flexible silicone rubber and looks like a small dome or cup
Has a flexible ring around the edge
Inserted into the vagina prior to sexual intercourse
What should be used alongside the diaphragm and why?
Should be used with spermicidal cream or jelly to increase its effectiveness
A diaphragm needs what before use?
to be fitted by a health care provider
How often should the diaphragm be fitted and why
provider should be checking the fit every year in case the patient gained or lost weight, became pregnant, or gave birth as the diaphragm would likely no longer fit
How does the diaphragm work
by creating a barrier between sperm and the uterus
Where is the diaphragm placed
behind the pubic bone to completely cover the cervix
this prevents sperm deposited in intercourse from entering the cervix
any spermicide placed inside of the dome and around the rim of the diaphragm also helps kill any sperm that comes into contact with it
When can diaphragms be inserted and how often should spermicide be added?
Diaphragm can be put in 6 hours prior to intercourse
Spermicide will need to be added in the vagina every 2 hours or each time she has intercourse
How long can a diaphragm be left in and why
no more than 24 hours
if left longer there is risk for Toxic Shock Syndrome (TSS)
Advantages of using a diaphragm
easy to insert and remove
inexpensive and reusable
if inserted correctly, diaphragm cannot be felt by either partner
does not effect future fertility or the patients menstrual cycle
Disadvantages of the diaphragm
if left for longer than 24 hours you have TSS risk
continual use of spermicide can be irritating to the lining of the vagina and possibly increase risk of STD contraction
can increase the likelihood of bladder infections - because of push on urethra and urinary stasis that can occur as a result
does not protect against STDs - to do that she would need a condom everytime she has sex
How does the cervical cap work
like a diaphragm, it is a dome covering the cervix with a brim holding the cap in place tightly and a groove that can hold spermicidal jelly or cream
It prevents sperm from entering the uterus
however unlike the diaphragm, it is smaller and fits more tightly around the cervix when in place
What is a cervical cap made of?
silicone rubber
A cervical cap must be …
fitted by a health care provider
When does/can the cervical cap be inserted?
it must be done just prior to intercourse
How much spermicide is applied to a cervical cap
about a half teaspoon will need to be applied on the groove
a small amount is also applied to the bowl and brim of the cap
How long can a cervical cap be left in place and how often is spermicide applied
Can be left in place for 48 hours
spermicide does not need to be reapplied every time the patient has sex
HOWEVER the cap must be left in place for at least 8 hours post intercourse
Advantages of a Cervical Cap
doesnt affect fertility or menstrual cycle
can be left in vagina for 48 hours
usually unnoticeable to both partners
requires less spermicides than the diaphragm which increases the pleasure of oral sex
Disadvantages of a Cervical Cap
must be prescribed by a health care provider
can be difficult to insert properly and may become dislodged during intercourse
unlike some other kinds of birth control it is not effective protection against STDS
Contraceptive Sponge
small disposable sponges made of polyurethane foam and are infused with spermicide
they work by blocking sperm from entering the uterus and also by absorbing and killing sperm
What must be done prior to use of a contraceptive sponge
it must be moistened before use with water so that it becomes foamy and then inserted into the vagina, positioned so it sits over the cervix
How is the contraceptive sponge similar and dissimilar to the diaphragm
like the diaphragm it can be worn for 12-24 hours
unlike the diaphragm it offers continuous protection during that time regardless of how often the patient is having sex
How long should the sponge be left in place after sex
it must be left for at least 6 hours before removal
There is risk for toxic shock syndrome with a contraceptive sponge if…
the sponge is left in for more than 30 hours
What are the failure rates like for contraceptive sponges
they can vary widely between 9% to 40% depending on whether or not the patient has had a child and whether or not she put the sponge in correctly
women who have given birth vaginally are much more likely to have this method fail
What is associated with the use of hormonal contraceptives
it is associated with increased risks of several cardiovascular conditions including MI, stroke, venous thromboembolism, DVT, retinal vein thrombosis and PE
Hormonal contraceptives should be used if a woman ___. Why?
Smokes
Smoking is associated with an increased risk of serious cardiovascular SE alongside hormonal contraceptive use
Women who are on hormonal contraceptives should be strongly advised not to smoke
How do Oral Contraceptives (BCP and OC) work
they work by suppressing ovulation by inducing a pseudo pregnant state
they thin the uterine lining and change the consistency of the mucus in a womans cervix making it harder for sperm to move into contact with an egg
What do all combination OCs contain and how does that compare to OCs from 20-30 years ago
all combination OCs contain 20-50 mcg of estrogen and that is 25% less than the OCs made 20-30 years ago
What are the 3 types of OCs
Combination Pill
Mini Pill
Emergency Contraceptive Pill
What is the most widely prescribed form of contraception
the combination pill (OC)
The combination pill contains ___ and ___
estrogen and progestin
(but different formulations have different doses so prescription is based on pt hx and may alter amounts)
How may formulations and doses of combination pills differ?
- Some require taking a constant dose of both medications (est and progest) for 21 days followed by a week of placebo tablets
- Others vary the dose of estrogen and/or progestin that a woman gets throughout her cycle, or adds 5 additional days of tables of estrogen at the end of the 21 day cycle
- some newer preps allow 3 months of continuous use
Advantages of OCs
safe simple and convenient
one of the most effective form of reversible birth control
perfect use - fewer than 1 pregnancy per 100 women if taken as directed
typical use - fewer than 8 pregnancies per 100 women
fewer menstrual cramps and lighter periods
Absolute Contraindications to Oral contraceptive Use
Hx of thrombophlebitis or clotting disorders
Cardiovascular or CAD
known or suspected breast cancer
known or suspected endometrial cancer
undiagnosed genital bleeding
cholestatic jaundice
impaired liver function
hepatic adenomas, cancers or tumors
known or suspected pregnancy
Type II Hyperlipidemia
factor 5 Leiden mutation
at age 35 if the patient is a smoker she needs to come off OCPs
What are some coincidental benefits of OCs other than preventing pregnancy
improved acne
protection against ovarian cysts and endometrial cancer
decreased premenstrual symptoms, depression, and HAs
decreased iron deficiency anemia related to heavy periods
decreased vaginal dryness and painful intercourse associated with the changes of peri menopause
Possible side effects of oral contraceptives
bleeding between periods
breast tenderness
HA
nausea
weight gain or weight loss
change in sexual desire
depression
mood changes
What is the acronym for potentially life threatening side effects from Ocs
ACHES
acronym used in teaching warning signs of a serious problem with pill use to patients
What does ACHES stand for
Abdominal pain
Chest pain
Headaches
Eye problems
Severe leg pain
What may abdominal pain after OC use indicate
blood clot in the pelvis or liver
benign liver tumor or gall bladder disease
What may chest pain after OC use indicate and what are some s/s
blood clot in lungs
heart attack
angina - heart pain
breast lumps
What may headaches after OC use indicate and what are some s/s
stroke
migraine headache with neurological problems including blurred vision, spots, zigzag lines, weakness, difficulty speaking
other headaches caused by pills
high BP
What may eye problems after OC use indicate and what are some s/s
stroke
blurred vision
double vision
loss of vision
migraine with neurological symptoms
blood clots in the eyes
change in the shape of the cornea ( contacts don’t fit)
What may severe leg pain after OC use indicate
inflammation and blood clots of a vein in the leg
What are some medicines that can decrease the efficacy of oral contraceptives
oral antibiotics
rifampin
dilantin
phenobarbital
st johns wart (OTC use often times)
What needs to be done if someone starts taking a medication that decreases OC efficacy?
She will need to use some other form of contraception for a month period and then she can restart the pill administration in the next month
What is the percent of accidental pregnancies (failure) with progestin only OCs for perfect users
0.5%
What is the percent of accidental pregnancies (failure) with Combined estrogen and progesterone OTCs for perfect users
0.1%
What is the overall typical use failure rate of OCs
3%
Why are progestin only pills mostly used by breastfeeding mothers? What is the drawback?
There is a small error of dosing so it MUST be taken at the same time everyday not just everyday
However, it does not interfere with milk production and lactation
NuvaRing
Contraceptive Ring / “The Ring”
Reversible prescription method of birth control
Small flexible ring that is inserted into the vagina once a month
It releases synthetic estrogen and progestin to protect against pregnancy for one month
How long does the NuvaRinga stay in place
It is placed one a month and left ion place for 3 weeks and is removed for the remaining week
How do the NuvaRing hormones work at preventing pregnancy?
They primarily keep the ovaries from releasing an egg (prevent ovulation)
thickens cervical mucus which prevents the sperm from joining an egg
thins the lining of the uterus (in theory this could prevent pregnancy by interfering with the implantation of a fertilized egg)
OrthoEvra Patch
contraceptive patch
reversible prescription method of birth control
thin, beige, plastic patch that sticks to the skin of the buttocks, stomach, upper outer arm, or upper torso
it releases synthetic estrogen and progestin to protect against pregnancy for 1 month
How oftne is a new contraceptive patch placed and how long is on for ?
It is placed once a week for 3 weeks in a row with no patch on the fourth week of the month
Why has the contraceptive patch fallen out of favor
there are concerns recently about an increased risk for thrombophlebitis with the patch
Why does this fourth week of no use occur with a lot of hormonal contraceptives
to allow for menstruation
IUD
intrauterine devices
they are T shaped and made of plastic
some have copper wire coating while others release hormones
are long term dwelling
How are IUDs placed
they are inserted by an OBGYN provider in an outpatient clinic setting
ParaGard
Copper T 380A
an IUD containing copper
can be left in place for 12 years of use
Mirena
an IUD that continuously releases a small amount of the hormone progestin
it continues to be effective for 5 years
How do IUDs work
they prevent sperm from joining with an egg by impacting the way sperm move (the hormone in Mirena increase the IUD effectiveness)
It ends up thickening cervical mucus which provides a barrier that prevents sperm from entering the uterus
prevents some women’s ovaries from releasing eggs (Stops ovulation)
IUDs end up altering the lining of the uterus
How can a woman make sure an IUID is in place?
there is a string attached at the base of the T that hands gown through the cervix and into the vagina and a woman can feel it in her vagina
How is an IUD removed
using the string
IUD failure rate decreases…
by continuously being in place
What is one of the most effective reversible methods of birth control
IUDs
How many woman using ParaGard or Mirena out of 100 will become pregnant during the first year of typical use?
One or fewer
How many women will get pregnant with perfect IUD use
fewer than one
the risk of pregnancy’s decreases even more with continued use
___ is the most popular form of reversible birth control in the world with __ ___ women using them
IUDs; 85+ million
Advantages of IUDs
may improve sex life as there is nothing to place before, and some state they feel more free to be spontaneous since they do not have to worry
ability to become pregnant can return quickly when use is stopped
a very private method of birth control - no packaging or evidence of use that might embarrass some users
IUDs are a good choice for what kinds of women
ones that want a long term birth control method
ones that are breastfeeding
ones that cannot or do not want to use a hormonal method
Contraindications to IUD use
pregnancy
cervical cancer that isnt treated
cancer of the uterus
pelvic tuberculosis
allergy to copper (ParaGard only)
Wilson’s Disease (ParaGard only)
Severe liver disease (Mirena only)
Breast cancer (Mirena Only)\
unexplained vaginal bleeding
pelvic infection following childbirth or an abortion in the last 3 months
past or current sexually transmitted infections or other pelvic infections
Wilson’s Disease
inability for the body to clear copper
cannot use a copper based IUD like ParaGard with this disease
Depoprovera and Lunelle
2 contraceptive shots
sometimes called DMPA for Depoprovera
DMPA can prevent pregnancy for how long
13 weeks
Lunelle prevents pregnancy for how long
a month
How does Depoprovera and Lunelle work
they primarily prevent the ovaries from releasing an egg (ovulation)
it thickens cervical mucus to prevent sperm from reaching the egg
alters the lining of the uterus, which in theory, may prevent implantation of a fertilized egg
___ is one of the most effective reversible methods of birth control with only 3 out of 1000 women who use it correctly and consistently getting pregnant during the first year of use
Depoprovera
__ in 100 women will become pregnant with typical use of Depoprovera
3 in 100
Why does Depoprovera have a typical use rating if it is a shot
it only lasts consistently for 13 weeks and some may not return for a follow up shot
What is important to educate regarding the use of Depoprovera
it can impede ovulation in some women for up to 18 months so it is not a good short term use method if they eventually want to have a baby
What are common side effects of Depoprovera and Lunelle
decreased menstrual flow
weight gain
Implanon
an implantable method of birth control
similar to norplant but it is one rod instead of five that is matchstick in size
it is placed under the skin on the inner side of the upper arm and releases a low steady dose of progestin to prevent pregnancy
Implanon is __% effective in preventing pregnancy when implanted properly
99%
How long can Implanon be left in place and when can it be removed
it can be left in place for up to 3 years and removed at any time
What are some side effects of Implanon
irregular menstrual bleeding and spotting - it may stop menstruation all together
acne
headaches
breast tenderness
weight changes
increased risk of blood clots, particularly in women who smoke, like other hormonal contraceptives
Why is it important to mention potential cessation of menstruation to those with Implanon
some take comfort in having a period as reassurance they are no pregnant so they should know
Female Sterilization
“Tubal Ligation”
Segment is cut from both fallopian tubes and the ends of the tubes are then burned, tied, or clamped
Female sterilization has a very high rate of efficacy for contraception, but what is one problem?
due to how vascular the area is and how prone it is to healing, there is a high failure rate if the procedure is done immediately after a delivery
What are some surgical risks for tubal ligation
infection
uterine
perforation
those who had tubes tied and then become pregnant are more likely to have an ectopic pregnancy
also menstrual cycle disturbances and gynecological problems can occur with having tubes tied
Vasectomy
simple procedure involving severing the vas deferens in a man
it can be done in a doctors office and is considered a permanent form of contraception
it usually takes less than 30 minutes and local anesthesia is given to make it less painful
What are common side effects or complications of a vasectomy
swelling
bruising
most common complication: infection
How long does it take after a vasectomy until a man is actually sterile
several months - 15 to 20 ejaculates
they will need to go in for periodic checks during the months following the vasectomy to evaluate the level of sperm in the ejaculate
Emergency Contraception (EC)`
“morning after pill” or “Plan B”
can prevent pregnancy AFTER unprotected vaginal intercourse
How soon must EC be started after unprotected intercourse?
within 120 hours (5 days)
however the sooner it is started the better with a 75-89% effectiveness rate when done within 72 hours
How does EC work
contains hormones found in birth control pills and prevents pregnancy by stopping ovulation or fertilization
theoretically it can also prevent implantation but it has not been proven scientifically
Will EC cause abortion or affect an existing pregnancy
No, however a woman should not use EC if pregnant
How can family planning affect average income per capita?
smaller families share income among fewer people allowing higher average income per capita
a family of a certain size may be below poverty line, but with one less member they may rise above the poverty threshold
Why can family planning help lower maternal mortality and morbidity
fewer pregnancies lead to lower maternal mortality and morbidity and often to more education and economic opportunities for women
a mothers death and disability can drive a family into poverty since her ability to earn income can lead the family out of poverty
What is the global perspective of family planning
high fertility undermines the education of children, especially girls
larger families have less to invest in the education of each child
early pregnancy interrupts young women’s schooling and in large families mothers often remove daughters from school to help care for siblings
less education typically implies increased poverty for the family as well as the inter generational transmission of poverty
