FAMILY

PLANNING
By
Tiyas Kusumaningrum, S.Kep., Ns., M.Kep

Airlangga University-Faculty of Nursing-2018

 Background

• Human Rights declaration pasal 25:

“Everyone has the right to a standard of living
adequate for the health and wellbeing of himself
and of his family, including food, clothing, housing,
and medical care and necessary social services , and
the right to security in the event of unemployment,
sickness, disability , widowhood, old age or other
lack of live-hood in circumstances beyond his
control”
 Background
• International Conference on Population and
Development(ICPD) th 1994, Kairo:
“Reproductive health is a state of complete
physical, mental and social well-being in all matters
relating to the reproductive system, and to its
function and processes...... ”
• Indonesian Population Growth 2008= 1.175%
• Population Growth # Economic Growth
• Unwanted pregnancy rate
 Fungsi Pelayanan KB

• Mengatur waktu, jarak dan jumlah kehamilan

• Mencegah atau memperkecil kemungkinan seorang perempuan

hamil mengalami komplikasi yang membahayakan jiwa atau janin
selama kehamilan, persalinan dan nifas.

• Mencegah atau memperkecil terjadinya kematian pada seorang

perempuan yang mengalami komplikasi selama kehamilan,
persalinan dan nifas.
Airlangga University-Faculty of Nursing-2017
 Pelayanan KB di Fasilitas Kesehatan

FKTP meliputi:
• pelayanan konseling;
• kontrasepsi dasar (pil, suntik, IUD dan implant, kondom);
• Metode Operasi Pria (MOP)
• penanganan efek samping dan komplikasi ringan-sedang
akibat penggunaan kontrasepsi;
• merujuk pelayanan yang tidak dapat ditangani di FTKP

Airlangga University-Faculty of Nursing-2017

 Pelayanan KB di Fasilitas Kesehatan

FKRTL meliputi :
• pelayanan konseling;
• pelayanan kontrasepsi IUD dan implan
• Metode Operasi Wanita (MOW)
• Metode Operasi Pria (MOP).
Airlangga University-Faculty of Nursing-2017
Airlangga University-Faculty of Nursing-2017
Airlangga University-Faculty of Nursing-2017
Airlangga University-Faculty of Nursing-2017
 METHODS

• Ammenhorea Lactation Method (ALM)

• Fertility Awareness-based Methods (FAB)
• Barrier Methode
• Intra Uterine Device
• Intra Uterine Systems
• Hormonal Methode
• Tubal Ligation & Vasectomy
• Others
 ALM

• Available for women with baby under 6 month

• Prolactin >> GnRh release <<  LH <<  no
folicel stimulation  no ovulation  ammenorhea
• Conditions: intensive breastfeeding
• 5,2% failure of ALM  working women
• CI: mother with HIV, Hepatitis B without vaccine on
baby, active Tb, breast Ca on theraphy
 FAB

• Calendar
- track lenght of last 6 cycles
ovum hold for 24hr, sperm stays on uterine ±72hr, ovulation hapen in the middle of sicle.
- physical n psychology condition base
- failure rate >>

• Basal Body Temperature (BBT)

- assumtion body temperature decrease 12—24 hr pre-ovulation and increase couple days after
- morning measure same place
- physical n psychology condition base
• Billing Method/cervical mucous
- recognise spinnbarkeit mucous
- some women producing more mucous

• Sympto-thermal method
billing method + cervix consistency examination & sign of ovulation
(lower abdomen pain, hardnes in breast, emotional changes, etc)
 METODE BARIER

• Men Condom
• Women Condom
• Diafragm  combine with spermicidal
 Female Condom
Plastic sheath
with ring
at both ends

Outer ring Inner ring

Grasping female condom

for insertion
Insertion
• Diapraghm
Inserted up to 18 hours before intercourse and can be left
in for a total of 24 hours
• Condom
Combining condoms with spermicides raises effectiveness
levels to 99%
 Drawbacks

condom:
• Interruption of coitus
• Decreased sensation
 IUDs

• Efectiveness 5—10 years

• Insertion when menstruation time
• IUS (Intra Uterine System)
plus Mirena (levonorgestrel)20µg/day
 Mechanism of Action

• An IUD prevents sperm from meeting an egg.

• An IUD may stop a fertilized egg from growing inside
the uterus.
• Prevents fertilization by creating a hostile environment
(a sterile inflammatory reaction) for sperm and for a
fertilized ovum
 Timing of Insertion of Intrauterine
Contraception
Timing Pros Cons
Scheduling;
Ensures patient
With menses interim
not pregnant
pregnancy
Convenience;
Must rule out
Midcycle anytime low rate of
pregnancy
expulsion
Emergency Convenience;
contraception pregnancy Pregnancy
(copper IUD) prevention
Alvarez PJ. Ginecol Obstet Mex. 1994.
O’Hanley K, et al. Contraception. 1992.
 The IUS: Mirena
• Mirena – releases 20 mcg levonorgestrel/day
• Failure rate very low: only 0.3% over 5 yrs
• Ectopic rate very low : 0.02%
• 5 years (as effective as CuT380 at 7 years)
• Not for EC
• STI protection relative, not for sex workers
• Good for women with heavy periods
• Expulsion rate as other framed devices
 Advantages of the IUD
• Provides long-term birth control.
• Cost effective.
• Can be removed when a woman would like to become
pregnant.
• Convenient - a woman does not need to remember it daily
or weekly.
 Side Effect

• Spotting, light bleeding, heavy or longer menstrual

periods are common in the first 3 – 6 months of IUD use
• Pelvic pain after insertion
 Contraindications

• Multiple sexual partners

• History of PID
• Immunocompromised (e.g., HIV, sickle cell disease)
• Known/suspected pregnancy
• Small uterus (<6 cm in length)
 Complications

• PID
• Uterine perforation
• Ectopic pregnancy
• Menorrhagia and metrorrhagia
• IUD expulsion
 Fertility Rates in Parous Women After
Discontinuation of Contraceptive

100
Pregnancies

80
(%)

IUC
60
OC

40 Diaphragm
Other methods
20

0
0 12 18 24 30 36 42
Months After Discontinuation
Based on data from Vessey MP, et al. Br Med J. 1983.
 HORMONAL

• Combination pills (estrogen & progesteron)

• Mini pills (progestin)
• Monthly injectable (estrogen & progesteron)
• Trimester injectable ( DMPA) progesteron
• Implant (etonogestrel)
• Transdermal administration (Evra)
• Transvaginal administration (vaginal-Nuva ring)
Norplant Implant
 Mechanism
• Estrogen suppresses follicle-stimulating hormone
(FSH) and therefore prevents follicular emergence.
• Progesterone suppresses the midcycle gonadotropin-
releasing hormone (GnRH) surge, which suppresses
luteinizing hormone (LH) and therefore prevents
ovulation.
• Causes thicker cervical mucus
• Causes decreased motility of fallopian tube
• Causes endometrial atrophy
 COCs Mechanism of Action:
Ovulation Suppression
Normal Menstrual Cycle Cycle Modified by COCs
Follicular ovulation Follicular
development development

Pituitary Pituitary
hormones hormones

LH
LH
LH
LH
FSH
FSH FSH
FSH

Natural ovarian Synthetic

hormones hormones
progestin
progestin
estrogen
estrogen
progesterone
progesterone
estrogen
estrogen

1 14 28 1 14 28
days of menstrual cycle days of active hormone-free
pill-taking interval

Adapted from: Senanayake and Potts, 1995.

 Benefits of Oral Contraceptives

• Decreases risk of ovarian cancer by 75%

• Decreases risk of endometrial cancer by 50%
• Decreases bleeding and dysmenorrhea
• Regulates menses
• Protects against pelvic inflammatory disease (PID)
(thicker mucus)
• Protects against fibrocystic change, ovarian cysts,
ectopic pregnancy, osteoporosis, acne
 Hormonal SE

 Fats deposit>>, increase body weight

 higher trombosites
 High blood pressure
 Amenorrhea
 Cloasm
 Headache
 Nausea
Nonbreastfeeding postpartum women should wait three
weeks before starting estrogen-containing contraceptives
because of the increased risk of thromboembolism
 Return to Fertility After
Stopping DMPA Use

Percent of Women Having Conceived

100

80

60
Oral Contraceptives (0=last pill taken)
40 IUD (0=device removed)
DMPA (0=15 weeks after last injection)
20

0
0 4 8 12 16 20 24
Months After Stopping Contraceptive
Source: Tieng, 1982.
 Contraindications of Oral
Contraceptives
• Thromboembolism
• Cerebrovascular accident (CVA) or coronary artery disease (CAD)
• Breast/endometrial cancer
• Cholestatic jaundice
• Undiagnosed vaginal bleeding
• Hepatic disease
• Known/suspected pregnancy
• Concomitant anticonvulsant therapy
• Some antibiotics
• Relative contraindications: Migraines, hypertension (HTN), lactation
 Taking the Pill

• Once a day at the same time everyday

• Use condoms for first month
• Use condoms when on antibiotics
• Use condoms for 1 week if miss a pill or take one
late
• The pill offers no protection from STD’s
 Sterilization

• Tubal Ligation ( Tubectomy )

- pengikatan
- pemotongan
- Essure nickel titanium insertion on each tubal by
histeroscopy
• Vasectomy
note: use condom until 15 ejaculation
 ’BAND-AID’
STERILIZATION
Tempat dilaksanakannya
vasektomi

Figure 25.1a
VASECTOMY
 Complication

• Poststerility syndrome: Pelvic pain/dysmenorrhea,

menorrhagia, ovarian cyst
• Fistula formation: Uteroperitoneal fistulas can occur,
especially if the procedure is performed on the fallopian
tubes < 2 to 3 cm from the uterus.
 OTHER METHODS

• Coitus interuptus / withdrawl

• Spermisides  gel
• Vaginal douche
 Postpartum Contraceptive
Options
Delivery 3 weeks 6 weeks 6 months onward
All women
Condoms/spermicides
IUD
Diaphragm/cervical cap
Female sterilization

Breastfeeding women
Lactational Amenorrhea Method
Progestin-only methods/Natural Family Planning
Combined estrogen-progestin
Non-breastfeeding women
Progestin-only methods
Combined estrogen-progestin methods/Natural Family Planning

Male sterilization
 Screening & Counseling Goals
for Providers

Review contraceptive options with patients

Allow patients to hold contraceptive devices

Promote successful use of chosen method

more…
 Screening & Counseling Goals
for Providers (Continued)

Allow time for questions

Provide written materials in the appropriate language and

literacy level
 Considerations in Choice of
Contraceptive Methods

• Patient choice
• Effectiveness • Reversibility
• Side effects • Non-contraceptive benefits
• Convenience • Cost
• Duration of action and • Privacy
childbearing plans
The new
Mirena
Inserter
 Insertion Technique

Open package carefully

Ensure the slider is furthest away from fitter
Check IUS arms lie in a horizontal plane prior to loading

Practical tip
To make sure arms are horizontal,
align on a flat, sterile surface whilst
maintaining moderate pressure
Important to note when handling with the new inserter

• Hold the slider firmly with your

forefinger or thumb when pulling on
the system into the tube

• Tube bends easily after 4th mark

(cm scale) if forced too much
 

• Knobs at the end of arms close and

form a rounded end with a small gap
in between the knobs
 Insertion Technique
• Pull on threads to place IUS in
insertion tube
• Fix threads in cleft at the end of
shaft
• Set upper edge of flange at the
uterine sound measure

Practical tip
The measurement obtained from
sounding the uterus should correspond to the
distance from the end of the loaded inserter to
the edge of the flange nearest to the cervix
 Insertion Technique
• Mirena is now ready to be
inserted
• Hold the slider firmly with
the forefinger/ thumb in
furthermost position
• Move inserter gently into
uterus until flange is about
1.5 - 2 cm from cervix.
Gives sufficient space for
arms to open
 New Insertion Technique

• Holding inserter steady, release

arms by pulling slider back to
the mark
• Push inserter gently inwards
until flange touches cervix
• Mirena should now be in fundal
Practical tip
To ensure IUS is in fundal position, continue
position
to advance insertion tube until resistance is
met at fundus. The flange may be pushed along the
tube by the cervix. Since the arms are unfolded and
in absence of strong force, there should be no added
risk of perforation
New Insertion Technique
 Release the IUS by pulling
the slider back down all the way
 Remove the inserter from the
uterus
 Cut the threads to leave about
2cm visible outside the cervix

Practical tip
When removing inserter, make sure the threads
run freely through the tube and do not draw
the system from its fundal position
 References
 KEMENKES RI (2014) Pedoman Manajemen Pelayanan Keluarga
Berencana. , p.13.
 F. Gary Cunningham...[et al.](2005) Williams obstetrics/[edited by].
22nd ed
 Helen Varney Burst, Jan M. Kriebs, Carolyn L. Gegor(2004)
Varney’s midwifery– 4th ed.
 I.Youngkin, Ellis Quinn. II. Davis, Marcia Szmania(2004) WOMEN'S
HEALTH: A PRIMARY CARE CLINICAL GUIDE - 3rd Ed.
 Sylvia K. Rosevear(2002) Handbook of gynaecology management
 Varney, Helen.