Ag Nina Ian John “G” Rachel Mark Jocelle Edo Gienah Jho Kath Aynz Je Glad Nickie Ricobear

Teacher Dadang Niňa Arlene Vivs Paul F. Rico F. Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope Bien

S2 Lec 4: Family Planning by Dra. Teresita S. Cadiz-Brion SSeepptteem

mbbeerr 66,, 22001100
o Who wish to participate actively in family planning
OUTLINE o With religious or philosophical reasons for not using other
I. Temporary Methods methods
a. Traditional o Who need contraception immediately
i. Coitus interruptus o Who need a temporary method while waiting another
b. Natural Family Planning (NFP) method
i. Cervical mucus o Who have intercourse infrequently
ii. Basal Body Temperature  Who may require additional counseling?
iii. Symptothermal method o Experience premature ejaculation
iv. Lactational amenorrhea (LAM) o Have difficulty withdrawing the penis from the vagina prior to
v. Calendar method ejaculation
vi. Standard Days Method o Have other physical or psychological conditions that may
c. Artificial affect timely withdrawal
i. Hormonal o Women whose age, parity or health problems make
1. Combined Oral preganancy high risk
Contraceptive o Women whose partner will not cooperate
2. Progestin Only Pills (POP) o Couples with poor communication or problems in their
3. Combined Injectable relationship
Contraceptive o Couples in which either partner has more than one sexual
ii. Intrauterine Devices (IUD) partner
iii. Barrier Methods
1. Male condom B. Natural Family Planning(NFP)
2. Female condom  MOA
3. Spermicide o For contraception
o Avoid intercourse during the fertile phase of the menstrual
FAMILY PLANNING cycle when conception is most likely
o Plan intercourse near mid-cycle (usually days 10-15) when
I.TEMPORARY METHODS conception is most likely
A. Traditional  Contraceptive benefits
1. Coitus Interruptus (withdrawal) o Can be used to prevent or achieve pregnancy
 A traditional method of family planning in which the man o No method-related health risks
completely removes his penis from the woman‟s vagina before o No systemic side effects
he ejaculates o Inexpensive
 Assumes that sperms do not enter the vagina and fertilization  Noncontraceptive benefits
is prevented o Improved knowledge of reproductive system
 Contraceptive benefits o Possible closer relationship between couple
o Effect immediately o Increased male involvement in family planning
o Does not affect breastfeeding  Limitations
o Can be used as a backup to other methods o Moderately effective (1-25 pregnancies per 100 women
o No method-related health risks during the first year of use)
o Always available o Effectiveness depends on willingness to follow instructions
o No cost involved o Considerable training required to use correctly
 Noncontraceptive benefits o Requires trained provider (nonmedical)
o Promotes male involvement in family planning o Requires abstinence during fertile phase to avoid conception
o Possible closer relationship of couple o Requires daily record keeping
 Limitations o Vaginal infections make cervical mucus difficult to interpret
o Effectiveness depends on willingness of couple to use o Basal thermometer needed for some methods
method with every act of intercourse (4-19 o Does not protect against STDs (HBV, HIV)
pregnancies/100 women during 1st year of use)  Who can use NFP?
o Effectiveness further decreased by sperm from recent Women/couples:
(<24 hours) ejaculation remaining in the penis (urethra) o Of any reproductive age/parity
o May diminish sexual pleasure o With religious or philosophical reasons for not using other
o Does not protect against STDs (HBV, HIV) methods
 Who can use withdrawal o Unable to use other methods
Men/couples:

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 o Willing to abstain from intercourse for more than 1 week  Disregard any temperatures that are abnormally high due to
each cycle fever or other disruptions
o Willing and motivated to observe, record and interpret  Draw a line 0.05-0.10C above the highest of these 10
fertility signs temperatures. This line is called the cover line or
 Additional counseling temperature line.
Women: 3. Symptothermal method
o Whose age, parity or health problems make pregnancy high  99% effective
risk  Fertile and infertile days identified based on
o Without established menstrual cycles (breastfeeding,  Changes in basal body temperature
immediately postabortion)  Slippery and transparent mucus in genital area
o With irregular menstrual cycles  Swelling, tenderness and sensitivity of breasts
o Whose partner will not cooperate during certain times in the  Dull lower abdominal pain (Mittlscherz)
cycle  Midcycle spotting(klein Regal)
o Who dislike touching their genitals  Client instruction
 Conditions requiring precautions  After menstrual bleeding stops, you may have intercourse
o Irregular menses on evenings of every other dry day during infertile days after
o Persistent vaginal discharge ovulation
o Breastfeeding  The fertile phase begins when wet vaginal sensations or any
mucus appears. Abstain from intercourse until fertile phase
1. Cervical Mucus ends
 Changes are due to estrogen and progesterone  Abstain from intercourse until both peak day and thermal
 Close to ovulation: discharge is slippery, lubricative, transparent shift rules have been applies
and watery  When these rules do not identify the same day the end of
 Peak day: spotting/days of bleeding(kleine regal) the fertile phase, always follow rule that identifies the
 After peak: dry until menstruation longest fertile phase
 G type mucus: hostile to sperm 4. Lactational amenorrhea (LAM)
 L type mucus: neutralizes vaginal acidity for sperm survival  MOA: irregular secretion of GnRH interferes with release of FSH
 Client instructions and LH
 As mucus may change during the day, observe it several  Contraceptive benefits
times throughout the day. Every night before going to bed,  Effective (1-2 pregnancies per 100 women during the first 6
determine the highest level of fertility and mark chart with months of use)
appropriate symbol  Effective immediately
 Abstain from sexual intercourse for at least 1 cycle so that  Does not interfere with sexual intercourse
you will know the mucus days. Avoid intercourse during your  No systemic side effects
menstrual period.  No medical supervision necessary
 During dry days after period, it is safe tohave intercourse  No supplies required/ no cost involved
every other night.  Noncontraceptive benefits
 As soon as any mucus or sensation of wetness appears,  For child
avoid intercourse or sexual contat  Passive immunization and protection from other
 Mark last day of clear, slippery, stretchy mucus with an X. infectious diseases
This is the peak day, the most fertile time  Best source of nutrition
 After the peak day, avoid intercourse for next 3 dry days and  Decreased exposure to contaminants in water, other
nights. These days are not safe. milk or formulas, or on utensils
 Beginning on the morning of the fourth dry day, it is safe to  For mother
have intercourse until your menstrual period begins again  decreased postpartum bleeding
2. Basal body temperature  Limitations
 No report on effectiveness  user-dependent (requires following instructions
 Temperature rises regarding breastfeeding practices)
 Before menses (due to progesterone, associated with  may be difficult to practice due to social circumstances
corpus luteum formation and ovulation)  highly effective only until menses return or up to 6
 After ovulation (due to progesterone) months
 Client instructions  does not protect against STD‟s (HBV, HIV)
 Take temperature at about the same time each  who can use LAM?
morning(before rising) and record temperature on chart  are fully or nearly breastfeeding
provided by NFP instructor.
 have not had return on menses
 Use temperatures recorded on chart for first 10 days of
 are less than 6 months postpartum
menstrual cycle to identify highest of “normal,lo”
5. calendar method
temperatures (i.e. daily temperatures charted in typical
 87% effective
pattern without any unusual conditions)
 client instructions

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  monitor length or at least 6 menstrual cycle while abstaining or  highly effective when taken daily (0.1-5 pregnancies per
another contraceptive method 100 women during the first year of use)
 calculate when fertile days occur following the instructions below  effective immediately if started by day 7 of menstrual cycle
 subtract 18 from the shortest cycle (SC) (identifies the first fertile  pelvic examination no required to initiate use
day of the cycle), then 11 from the longest cycle (LC) (identifies  doesn‟t interfere w/ sexual intercourse
the last fertile day of the cycle)  few side effects
 your fertile period is calculated to be days 8 through 19 of the  convenient, easy to use
cycle (12 days of abstinence needed to avoid pregnancy)  patient can stop use
 example: SC = 27-20 = 7  can be provided by trained nonmedical staff
LC = 32-11 = 21  noncontraceptive benefits:
Days 7-21 are fertile days  decreases menstrual flow (lighter, shorter periods) and
blood loss (20 ml vs 35 ml)
6. Standard Days method  decreases menstrual cramps
 institute of reproductive health, Georgetown university school of  may improve anemia/prevent iron deficiency anemia (50%
medicine of pt)
 identifies days 8-19 of the cycle as fertile  protects against some cases of PID
 ideal for women with menstrual cycles between 25 and 32 days  prevents ectopic pregnancy
long  decreases benign breast disease and ovarian cysts
 avoids unplanned pregnancy by knowing which days are unsafe  protects against ovarian and endometrial cancer
 a client can use a color coded string of beads to help her keep  improves bone mineral density
track of where she is in her cycle and know when she is fertile  ovarian cancer risk
 who can use this method:  40-80% decrease risk compared to nonusers
 women w/ cycles between 26 and 32 days long  protection: begins by 1 yr of use
 couples who can avoid unprotected intercourse on days 8-  increases w/ duration of use
19  persists at least 10-15 yrs after COC‟c are stopped
 couples not at risk for STD‟s  is biologically possible
 COC‟s and breast cancer
C. Artificial  there is no overall measurable increase of breast CA risk
except possibly among younger women
1. Hormonal  breast CA at a young age represents a very small
proportion of pre existing breast ca or detection bias
A. Combined Oral Contraceptives (COC)  COC use may provide protection against post menopausal
breast cancer
1. Monophasic  limitations:
 all 21 active pills contain the same amount of estrogen/progestin  user-dependent (requires continued motivation and daily
(E/P) use, forgetfulness increases method failure)
 21-day packs: 7 days w/out pills accompanied by bleeding  some nausea, dizziness, mild breast tenderness,
 28 day packs: with 7 placebo tablets headaches or spotting may occur
 effectiveness my be lowered when certain drugs are taken
2. Biphasic  can delay return to fertility
 21 active pills containing 2 diff. Estrogen/progestin combinations  rare serious side effects possible
(eg. 10/11)  ressuply must be readily and easily available
 varied amounts of estrogen and progestin are used in 3  women who can use
consecutive phases w/ a single cycle  of any reproductive age/ parity
 steroid levels are altered to reduce metabolic effects w/out  postpartum and not breastfeeding (begins after 3rd week) or
reducing contraceptive efficacy who are breastfeeding (6 months or more postpartum)
 disadvantage: reduced effectiveness if taken out of order  postabortion (start immediately of 7 days)
 with anemia
3. Triphasic  with severe menstrual cramping
 21 active pills contain 3 diff. Estrogen/progesterone combinations  with irregular menstrual cycles
(eg. 6/5/510)  with a history of ectopic pregnancy
 mode of activity:  additional counselling
 suppresses ovulation  women who cannot remember to take pill everyday
 reduces sperm transport  contraindications (WHO class 4)
 endometrial changes make implantation less likely  known or suspected pregnancy
 progesterone slows peristalsis and increases secretion in  breastfeeding and <6 weeks postpartum
oviducts  jaundice (symptomatic viral hepatitis or cirrhosis)
 if during the 7 pill days, there is no menstruation, do a pregnancy  currently with or previous history of ischemic heart disease
test or stroke
 contraceptive benefits:

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  blood clotting disorders (deep vein thrombophlebitis or -started of first day of menstrual cycle and taken everyday w/outbreak
pulmonary embolus) whether menstruation occurs or not
 migraine -for breastfeeding women: start once lactation is established
 hypertension (>180/110) -intake regularity not important because peak of changes in cervical mucus
 known or suspected breast carcinoma brought by progestin occurs 3-4 hrs after pill ingestion
 hepatic adenomas or carcinomas -changes return to pretreatment level after 24 hrs
 >35 years old and smoker -if pill was missed, take missed pill as soon as remembered and take today‟s
 has diabetes (>20 years duration) pill on its regular time
 has to undergo major surgery w/ prolonged bed rest -if pill was missed in 3 hrs, use backup method for next 48 hrs
 conditions requiring precautions (WHO class 3)COCs are not -less effective than COC
recommended unless other methods not available or acceptable if -more menstrual irregularities and intermittent breakthrough bleeding
a woman: -limitations: forgetfulness
 is <3 wks postpartum (even if not breast feeding) -conditions requiring precautions (WHO class 3)
 has unexplained vaginal bleeding (only if serious problem COC‟s are not recommended unless other methods are not available or
suspected) acceptable if a woman:
 has high blood pressure (>160/100 and <180/110) -is breastfeeding (<6 weeks postpartum)
 has history of breast CA -has unexplained vaginal bleeding (only if serious problem is expected)
 has symptomatic liver or gall bladder disease -has breast cancer (current of history)
 is taking drugs for epilepsy (phenytoin or barbiturates) or -is jaundiced (active, symptomatic)
tuberculosis (rifampin)
 conditions in which there are no restrictions: C. Combined Injectable Contraceptive (CIC)
 age as long as non smoker Types:
 DM (uncomplicated/ <20 yrs duration) -noristeral- norethisterone enentatem (NET-EN)
 Endometriosis -Depo-povera – depot medoxyprogestreone acetate (DMPA) – given
 genital tract cancers (cervical, endometrial, ovarian) every 3 months
 high blood pressure (<160/100) -available:
 pregnancy-related benign jaundice (cholestasis) -cyclofem
 trophoblastic disease -25 mg DMPA and 5 mg estradiol cypionate IM 1x a month
 when to start -mesigyna
 any cycle when the patient is sure she is not pregnant -50 mg NET-EN and 5 mg estradiol valerate IM 1x a month
 days 1-7 of menstrual cycle -MOA same as COC and POP + makes the endometrium shallow and
 postpartum strophic with inactive glands
 after 6 months ofusing LAM -contraceptive benefits
 postabortion -highly effective in long term contraception
 client instructions -convenient, easy administration
 take 1 pill preferably at the same time of the day, from day -do not interfere with intercourse
1-7 -not coitus dependent
 when 28 day pack is empty, immediately start taking pills -noncontraceptive benefit
from a new pack -protects against some causes of PID
 when 21 pack is empty, wait 7 days and begin taking pills -limitations
from a new pack -changes in menstrual bleeding pattern
 if you vomit 30 min after taking the pills, take another pill or -irregular bleeding/spotting initially
use backup method if you have sex within the next 7 days -weight gain
 common side effect: -delayed return to fertility for 7-9 months (on average) after
 amenorrhea/bleeding/spotting discontinuation
 nausea/ dizziness/ vomiting -contraindications
 acne -known/ suspected pregnancy
 high blood pressure -breast ca
 breast fullness or tenderness (mastalgia) -initial injection
 headache -days 1-7 of menstrual cycle
 chest pain (especially if it occurs with exercise) -reinjection
 depression (mood change or loss of libido) -DMPA – up to 4 weeks
-NET-EN – up to 2 weeks
B.Progestin only pills (POP)
-also known as minipill 2.Intrauterine divices (IUD)
-has a small dose of progestin A. non medicated
-will not interfere with quality or production of breast milk -flexible polyethylene non absorbable material exemplified by once popularly
-for older women in late reproductive years used lippes loop\
-immediately reversible B.medicated
-MOA and contraindications same as those in COC -types

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 -coper-releasing -conditions requiring precautions (WHO class 3)
-copper T380A IUD are not recommended unless other methods are not available or
-nova T acceptable if a women has:
-multiload 375 -benign trophoblastic disease
-progestin-releasing -more than one sexual partner
-progestasert -a partner who has more than one sexual partner
-LevoNoa (LNG-20) -timing of insertion
-Mirena -any menstrual cycle when reasonably sure that the client is not
-MOA pregnant
-local inflammatory reaction (intensified by copper) destroys sperm -days 1 to 7 of menstrual cycle
-alters tubal and uterine transport to ovum and sperm -postpartum (immediately following delivery, during the first 48 hours
-thickened cervical mucus (due to progestin) postpartum or after 4 to 6 weeks, after 6 months if using LAM)
-inhibits sperm migration -postabortion (immediately or within the first 7 days) provided there is
-suppression of endometrium not evidence of pelvic infection
-destruction of prevention of implantation of ovum -side effects/ complications
-contraceptive benefits -maybe be spontaneously expelled
-highly effective (0.6-0.8 pregnancies per 100 women during the first -rarely, perforation of the uterus (<1/1000 cases) may occur during
year of use for copper T 380A) insertion
-effective immediately -may increase risk for ectopic pregnancies (especially progestasert)
-long-term method (upto 10 yrs of use for copper T 380A) -may increases risk of PID and subsequent infertility in women at risk
-does not interfere with intercourse for STD‟s (e.g HBV, HIV)
-does not affect breastfeeding -vaginal discharge
-few side effects -copper-releasing
-after follow up visit, client needs to return to clinic only if there are -irregular or heavy vaginal bleeding
problems -intermensrual cramps
-no supplies needed by client -increased menstrual bleeding and cramping/ pain during the first
-can be provided by trained non-physician few months
-immediate return to fertility on removal -progestin releasing
-inexpensive (copper T 380A) -amenorrhea or very light menstrual bleeding/ spotting
-noncontraceptive benefits -limitations
-decreases menstrual cramps (progestin releasing only) -pelvic examination is required
-decreases menstrual bleeding (progestin releasing only) -screening for STDs
-decreases ectopic pregnancy (except progestasert) -requires trained provider for insertion and removal
-effectiveness -need to check for strings after menstrual period if cramping, spotting or
-influence by shape, size and medication added pain
-also influenced by age parity of user -women cannot stop use whenever she wants (provider dependent)
-lower failure rates with -indications for removal
-copper/ progestin -if client desires that it should be removed
-larger surface area -at the end of he effective life of the IUS
-insertion upto fundus of uterus by health worker -TCu 3380A = 10 years
-who can use IUD‟s -change in sexual practices (high risk behaviour) consider adding
Women of any reproductive age/parity barrier method (condoms) or removal
-want highly effective, long term contraception -if being treated for STD or documented pelvic infection
-are postpartum, breast feeding or not -menopause
-are post abortion
-are at low risk for STDs 3. Barrier methods
-cannot remember to take pill daily -MOA
-prefer not to or cannot use hormones -physically prevents sperm for reaching the cervix
-are in need of emergency contraception -destroys or makes spermatozoa immobile
-contraindications (WHO class 4)
-known/suspected malignancy A. male condom
-has unexplained vaginal bleeding until the cause is determined and -thin sheaths of rubber, vinyl or natural products placed on the penis once its
any serious problems are treated erect
-has current or recent pelvic inflammatory disease (PID) -closed end has a reservoir at the tip to serve as the depository for semen
-has acute purulent (pus-like) discharge during the ejaculation
-has an active genital tract infection (eg. Vaginitis, cervicitis) -may be treated with a spermicide (usually menoxynol-S) for added
-has distorted uterine cavity protection
-has malignant trophoblastic disease -MOA
-has known pelvic TB -prevents access of sperm to female genital tract
-has genital tract cancer -prevents microorganisms (STDs) from passing

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Advantage -contraceptive benefits
-available over the counter -effective immediately
-easy to use and cheap -controlled by women
-causes of failure are -does not interfere with intercourse
-intermittent use -can be left inserted for 8 hrs
-ommision to use during coitus -no method related health risks
-having sex first then withdrawingto put on sheath -no systemic side effects
-breakage (rare) -no prescription or medical assessment necessary
-disadvantages -can be used as a backup to other methods
-reduces sensitivity of glans penis -does not affect breast feeding
-interferes with sexual spontaneity -noncontraceptive benefits
-allergy to latex -may provide protection against STDs
-contraceptive benefits -may help prevent cervical cancer
-effective immediately -limitaitons
-does not affect breastfeeding -expensive
-can be used as a backup for other methods -moderately effective (5-21 pregnancies per 100 women during the first
-inexpensive (short term) year)
-widely available without prescription or medical assessment -effectiveness of the contraceptives depends on the willingness to
-no systemic side effects follow instructions
-noncontraceptive benefits -disposal of used condoms may be a problem
-promotes male involvement in family planning -adequate storage must be available at the clients home
-may help prevent cervical cancer -supplies must be readily available before intercourse begins
-may prolong erection and time of ejaculation -resupply must be available
-only family planning method that offers protection to STDs
-limitations C. Spermicide
-moderately effective (3/4 pregnancies per 100 women during the first -definition: chemicals (usually nonoxynol-9) that inactivate or kill sperm
year) -MOA: causes the sperm cell membrane to break, which decreases sperm
-effectiveness depends on willingness to follow instructions movement (motility and mobility) and their ability to fertilize egg
-disposal of used condoms may be a problem -effect starts a few minutes after application, during of effectiveness is
-reduces sensitivity of penis (makes maintenance of erection more usually 1 hrs (resupply when needed)
difficult) -antimicrobial against gonorrhoea and Chlamydia
-user dependent (requires continued motivation and use in each with -selection
each act of intercourse)
-adequate storage must be available at clients home STERILIZATION – permanent method of contraception
-ressuply must be available - voluntary surgical transaction
-supplies must be readily available before sexual intercourse Female-tubal ligation
-side effects Male- vasectomy
-allergic reaction or local irritation of the penis
-ensure that condom is not medicated Surgical approach
-if reaction persists, consider natural condoms (lambskin or gut) a. Minilaparotomy
or another method b. Culpotomy
„ -allergic reaction to spermicide c. Culdoscopy
-if symptoms persist after intercourse and no signs of STDs
-provide another spermicide IRVING PROCEDURE
-a nonmedicated condom - Medial out end of oviduct is cut
-help client choose another method - Oviduct in myometrium
Pomeroy procedure
B.Female condom Parkland procedure
-soft, loose-fitting polyurethane sheath 7.8 cm in diameter and 17 cm in mid-segment separated from mesosalphynx
length Madeiner procedure
-has 2 diaphragm like flexible rings located at either end Crushed ->ligate -> w/o resection
-closes end is inserted close to cervix and serves as an anchor while ring at Kroener procedure
the open end holds the device in place of the labia Fimbria cut
-coated with silicone based lubricants
-single use Last trans Brought to you by: OBwan – Kenobi
-can be used up to 8 hours before coitus (RPE-JCF-PF-SAH)
-immediately effective but should be removed after intercourse before female “with OBwan – Kenobi, everyone can OB”
stands up to avoid spillage
-MOA You think OBwan will leave you? Think again....Let the
-prevents microorganism from entering the genital track walking begin!

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