EXAM 2: Module 12 Family Planning

Cervical mucus ovulation detection method

(most effective) -checks cervical mucus daily and at same time of day and documenting these -if it indicates ovulation is in place, avoid pregnancy or have pregnancy based of wants Requires that woman recognize and interpret cyclic changes in amount and consistency of cervical mucus—changes prior and during ovulation Requires women check quantity and character of mucus each day for months & evaluate for cloudiness, tackiness, and slipperiness to learn how mucus responds to ovulation Sex is safe w/o restriction beginning 4th day after last day of wet, clear, slippery mucus (indicate ovulation occurred 2-3 days before) Disadvantages: some find this method unacceptable if they are uncomfortable touching their genitals

How does an IUD work?

-adversely effects sperm motility and irritates the lining of the uterus and prevents anything form going up into the fallopian tube -low level irritation - so anyone who has inflammation problems is probably not a good candidate -must have a neg pregnancy test -hyperplasyia is contradiction -rule out STI's -make sure pt is consented

IUD Disadvantages

-menstrual like cramping post placing -many women experience no period after placement theoretically immediate return of fertility post IUD removal Disadvantages -increased risk of PID (pelvic inflammatory disease) -some body's will expel them -risk of infection -small risk of perforation -do not provide protection again STD's/STI's

Basal body temperature (BBT) method

-often combined with cervical mucus -changes in BBT -dip, and immediate spike indicating ovulation BBT—lowest body temp. of a healthy person after waking and before getting out of bed -Varies from 36.2-36.3° C during menses Fertile period—day of 1 st temp. drop, or 1 st elevation, through 3 consecutive days of elevated temp Abstinence begins 1 st day of menstrual bleeding and lasts through 3 consecutive days of sustained temp. rise (≥ 0.2° C) Thermal shift—Decrease and subsequent increase in temp. Glass mercury thermometer needs no batteries but is fragile and can break Digital thermometer requires batteries but may have a recall function and audible beep Disadvantages: Infection, fatigue, & lt; 3 hours of sleep, awakening late, anxiety, jet lag, alcohol taken evening before affect BBT; BBT alone is not reliable method of predicting

Discuss the role of the professional nurse in family planning

-our role as nurses are advocates and educators -provide and give info in a nonjudgemental way -provide info on a variety of diff methods so they can choose what is right for them -think about things from various perspectives -ask them what is your goal? (get pregnant, prevent pregnancy, let things happen on their own?) -get good assessment and family dynamics

Potential Pitfalls of using FABs

-restriction of sexual spontaneity -rigorous daily monitoring -required training -risk of pregnancy during prolonged training period -risk of pregnancy high on unsafe days

Symptothermal method

-two day method with symptoms with BBT method Combines BBT & cervical mucus methods w/ awareness of secondary phase-related S/S (increased libido, spotting, mittelschmerz, pelvic fullness/tenderness, vulvar tenderness) Calendar calculations and cervical mucus changes are used to estimate the onset of fertile period Changes in cervical mucus of BBT are used to estimate the end of fertile period

Advantages and Disadvantages of Cervical Cap

Advantage: Extended period of wear may be an added convenience; can be inserted hours before sex; requires less spermicide; no additional spermicide is required for repeated acts of sex Disadvantages: correct fitting requires time, effort, skill; woman must check cap's position before and after each act; bc of risk of TSS another form of borth control is recommended during menses and 6 weeks postpartum

IUD Advantages & Disadvantages

Advantages: long-term protection from pregnancy; immediate return to fertility when removed Disadvantages: increased risk of pelvic inflammatory disease, unintentional expulsion of device, infection, possible uterine perforation, no protection against STI

Oral Contraceptive 91-Day Regimen

Allows women to take COCs in 3-month cycles and have fewer menstrual periods Levonorgestrel/ethinyl estradiol contains estrogen and progestin and is taken in 3-month cycles of 12 weeks of active pills followed by 1 week of inactive pills (when withdrawal bleeding occurs)

Second-trimester abortion

Associated w/ more complications and costs than 1 st trimester abortion Dilation and evacuation (D&E) can be performed at any point up to 20 weeks Usually performed between 13-16weeks gestation Cervix requires more dilation bc products of conception are larger Osmotic dilators are inserted several hours or days before procedure, or misoprostol Procedure is similar to vaginal aspiration except a larger canula is used and other instruments may be needed to remove fetus and placenta Disadvantages: possible long-term harmful effects to cervix

Informed Consent: BRAIDED

B: benefits R: risks A: alternatives I: inquiries and questions D: decisions may change mind E: explanations D: documentation

An induced abortion client calls the nurse to report postprocedural symptoms. Which condition is not an indication for the nurse to ask her to come into the office for care? A. Abdominal tenderness when pressure is applied B. Chills and a fever of 101°F C. Return of her period in less than 6 weeks D. Foul-smelling vaginal discharge

C

Contradictions for COC

Contraindications for COC use include a HX of: -thromboembolic disorders -cerebrovascular or coronary artery disease -breast cancer -gallbladder disease -jaundice with prior pill use -estrogen-dependent tumors -pregnancy -severe cirrhosis -liver tumor -lactation less than 6 weeks postpartum -smoking if older than 35 years -headaches with focal neurologic symptoms -surgery with prolonged immobilization or any -surgery on the legs -hypertension (140/90 mm Hg) -diabetes mellitus (of more than 20 years' duration) with vascular disease

Disadvantages / SE of OC

Contraindications: hx of thromboembolic disorders, smoking if older than 35, surgery w/ prolonged immobilization or on the legs, HTN, DM Serious adverse effects w/ estrogen and progesterone: stroke, MI, thromboembolism, HTN Common SE w/ estrogen: nausea, breast tenderness, fluid retention, chloasma SE of progestin: increased appetite, tiredness, depression, vaginal yeast infection, oily skin and scalp Most common SE: bleeding irregularities

Injectable Progestins

DO NOT MASSAGE AFTER ADMIN (we want it to slowly absorb) DMPA or Depo-Provera, 150 mg, is given IM; initiated during 1st 5 days of menstrual cycle and administered every 11-13 weeks Advantages: contraceptive effectiveness comparable to that of perfect use of COC's, long-lasting effects, injections only 4 times a year SE: decreased bone density, weight gain, irregular vaginal spotting, breast changes, no protection against STIs, return to fertility delayed as long as 18 months Failure rate: 6%

Transdermal Contraceptive system

Delivers continuous levels of progestin and estradiol; patch applied to intact skin on same day once a week for 3 weeks, followed by a week w/o patch (withdrawal bleeding) MOA, efficacy, contraindications, SE similar to COCs Typical failure rate: 9%

Disadvantages

Disadvantages: pain, bleeding, infection, postsurgical complications -Sterility is not immediate: some sperm will remain in proximal portions of sperm ducts; weeks to months are needed to clear the ducts of sperm so contraception is needed until sperm count in ejaculate on 2 consecutive tests is zero Failure rate: 0.15%

Symptoms-based methods

EX: Two-Day Method symptoms two days prior and two days after based on monitoring & recording of cervical secretions but doesnt analyze characteristics "Did I note secretions today and/or yesterday?" -If answer to either is "yes" she should avoid sex or use a back up method -If answer to both is "no" her chance of getting pregnant is low After 2 days w/o secretion the woman may resume unprotected sex Advantages: simpler to teach, learn, and use; effective alternative for low-literacy populations Typical failure rate: 24%

What is the cornerstone of the nursing care plan?

Education is the cornerstone of the nursing care plan and planned interventions

Oral Progestins (Minipill)

Failure rate: 1-10%; Effectiveness is increased if taken correctly Must be taken at same time every day; Users often complain of irregular vaginal bleeding

Cervical Cap

FemCap is the only type available in the US—fits snugly around the base of the cervix close to the junction of cervix and vaginal fornices Cap remain in place no less than 6 hours and not more than 48 hours; left 6 hours after Seal provides a physical barrier to sperm; spermicide inside cap adds a chemical barrier Failure rates: 16% (nulliparous) and 32% (multiparous)

Female Condom

Female condom is a vaginal sheath with flexible rings at both ends—closed end of pouch is inserted into vagina and anchored around cervix; open ring covers labia For single use and not used concurrently w/ male condom Typical failure rate: 21%

Female Sterilization

Female sterilization (bilateral tubal ligation [BTL]) may be done immediately after birth, w/ induced abortion, or as an interval procedure

Vaginal Contraceptive Ring

Flexible ring worm in vagina to deliver continuous levels of progestin and estradiol Remains in vagina for 3 weeks followed by a week w/o ring (withdrawal bleeding) Some experience vaginitis, leukorrhea, and vaginal discomfort MOA, efficacy, contraindications, SE similar to COCs Typical failure rate: 9%

Breastfeeding: Lactational amenorrhea method

Highly effective, temporary method of birth control When infant suckles at mom's breast, prolactin is released which inhibits estrogen production and suppresses ovulation and return of menses prolactin levels may change/drop if she can't pump all the time, or if baby starts sleeping through the night so ovulation hormones will spike back up if using this method she should use the cervical mucous check as well Typical failure rate: 1-2%

Transcervical Sterilization

Hysteroscopic techniques can be used to inject occlusion agents into uterine tubes Essure device is inserted through the vagina and cervix and into fallopian tubes Works by stimulating the woman's own scar tissue formation to occlude the uterine tubes and prevent conception Advantage: nonhormonal form of contraception can be inserted during an office procedure w/o anesthesia Disadvantages: Not immediately effective—need to use another form of contraception until tubal blockage is proven; possible expulsion and perforation Pregnancy rate: 1.1%

ParaGard Copper T 380A

IUD ParaGard Copper T 380A has fine solid copper and is approved for 10 years; copper serves as a spermicide and inflames endometrium preventing fertilization Typical failure rate: 1%

Intrauterine Devices (IUD)

IUD is a small T-shaped device w/ bendable arms for insertion through cervix; inserted against the uterine fundus, arms open near fallopian tubes to maintain position of device and to adversely affect sperm motility and irritate lining of uterus Strings hang from base and protrude into vagina for assurance that device has not been dislodged

Mirena and Skyla

IUD's Mirena and Skyla release levonorgestrel effective up to 5 years (Mirena) and 3 years (Skyla) impair sperm motility, thicken cervical mucus, decrease lining of uterus Typical failure rate: 1%

Hormonal Methods—progestin-only contraceptives

Impair fertility by inhibiting ovulation, thickening and decreasing the amount of cervical mucus, thinning the endometrium, and altering cilia in uterine tubes given to someone who is breastfeeding

FABs Fertile Periods

Infertile phase—before and after ovulation fertile phase—5-7 days around middle of cycle; days before, during, and after ovulation egg can be fertilized no longer than 12-24 hours after ovulation

Future Trends

Lower-dose COCs are available in Europe Female barrier methods are being tested Two new IUDs and spermicidal microbicides are being evaluated Male hormonal methods are being investigated—hormonal injections, vas occlusion, ultrasonic massage, contraceptive vaccines, and etc.

Male Condoms

Male condom is a thin, stretchable sheath that covers the penis before sexual contact and removed when penis is withdrawn from partner after ejaculation Latex condoms offer better protection against pregnancy and provide a barrier to STI and HIV polyurethane condoms are as effective for STI prevention but more likely to slip or lose contour natural skin condoms don't provide same protection against STIs and HIV Condom must be discarded after each single use Typical failure rate for male condom: 18%

Fertility Awareness Based methods (FABs)

Natural family planning (NFP) Only contraceptive practices acceptable to the Roman Catholic Church Rely on avoidance of intercourse during fertile periods (charts menstrual cycle and cervical mucous change to determine ovulation) Combine charting menstrual cycle with abstinence or other contraceptive methods

Implantable Progestins

Nonbiodegradable flexible tubes or rods inserted under skin of a woman's arm; contains progestin and are effective for contraception for at least 3 years; must be removed at end Implants will prevent some, not all, ovulatory cycles and will thicken cervical mucus Advantages: reversibility and long-term continuous contraception not r/t frequency of sex SE: irregular bleeding (most common); HA, nervousness, nausea, skin changes, vertigo, no STI protection

Emergency Contraception

Plan B One-Step sold over the counter; anyone is allowed to buy it at the local pharmacy Other options for emergency contraception: high doses of oral estrogen or COCs and insertion of a copper IUD Emergency contraception (EC) should be taken ASAP but w/in 72 hours of unprotected intercourse, or birth control mishap to prevent unintended pregnancy Risk of pregnancy is reduced by 75% (estrogen-progestin) and 89% (progestin only) IUDs containing copper should be inserted w/in 5 days of unprotected sex Risk of pregnancy is reduced by 99%

Spermicides and barrier methods

Popular also as protective measures against spread of STIs Chemical barriers may reduce the risk of some STIs but are not effective against most STIs Frequent use of spermicides (N-9) may increase the transmission of HIV Male and female condoms provide a mechanical barrier to STIs and HIV

Induced Abortion

Purposeful interruption of pregnancy before 20 weeks of gestation -Elective -Therapeutic: pregnancy risk to mom's health or baby not compatible with life The numbers of abortions in the United States have decreased significantly from 2000 to 2009. Legal and moral issues Incidence: Abortion rates tend to be higher in women whose income is below the poverty level. Decision to have an abortion Rates of biologic complications after abortion tend to be low if aborts during 1st trimester AWHONN supports a nurse's right to choose whether to participate in abortion procedures

PAINS - Sings of Potential Complications with IUD's

P—period late, abnormal spotting or bleeding A—abdominal pain, pain w/ sex I—infection exposure, abnormal vaginal discharge N—not feeling well, fever, chills S—string missing; shorter or longer

Oral Contraceptives

Regular ingestion of combined oral contraceptive pills (COCs) suppresses the action of the hypothalamus and anterior pituitary, leading to insufficient secretion of FSH and LH; therefore, follicles do not mature and ovulation is inhibited Maturation of endometrium is altered—less favorable for implantation Cervical mucus remains thick—less suitable for sperm penetration To maintain adequate hormonal levels for contraception, COCs should be taken at same time every day

Tubal Reconstruction

Restoration of tubal continuity (reanastomosis) and function is feasible except after laparoscopic tubal electrocoagulation Reversal is costly, difficult, uncertain; success rate varies Risk of ectopic pregnancy after reversal is increased 1-7%

Diaphragms

Shallow dome-shaped device w/ a flexible rim that covers the cervix Diaphragm should be largest size woman can wear w/o being aware of presence Disadvantages: reluctance to insert and remove it; insertion right before sex temporarily reduces vaginal response to stimulation; some object to messiness of spermicide Toxic shock syndrome (TSS) can occur -Prevention: removal 6-8 hrs after sex, don't use during menses; watch for S/S Typical failure rate w/ spermicide: 12% (effectiveness is less w/o spermicide)

Setting the Stage of Cervical Mucus Characteristics

Show charts of menstrual cycle along with changes in the cervical mucus. Have the woman practice with raw egg white. Supply her with a basal body temperature log and graph if she does not already have one. Explain that assessment of cervical mucus characteristics is best when mucus is not mixed with semen, contraceptive jellies or foams, or discharge from infections. Tell her to refrain from douching before the assessment.

Assessment Techniques

Stress that good handwashing is imperative to begin and end all self-assessments. Start observation from last day of menstrual flow. Assess cervical mucus several times a day for several cycles. Mucus can be obtained from vaginal opening; reaching into the vagina to the cervix is unnecessary. Record the findings on the same record on which the basal body temperature is entered

Tubal Occlusion

Tubal ligation and electrocoagulation are permanent; use of bands or clips has the advantage of possible removal and return of tubal patency Laparoscopic approach or a minilaparatomy can be used (small incision below umbilicus)

Tubal Reconstruction - Male

Tubal reconstruction—microsurgery to reanastomose the sperm ducts can be accomplished successfully in 90% but fertility rate varies Rate of success decreases as time since procedure increases Vasectomy may result in permanent changes in testes that leave men unable to father children; antibodies develop against own sperm

Two methods used for scrotal entry

Two methods used for scrotal entry: -conventional (scalpel incision) -no-scalpel (small puncture) vasectomy Vas deferens is immobilized through the scrotum Techniques to occlude the vas deferens: ligation w/ sutures, division, cautery, application of clips, excision of a segment, fascial interposition

Contraceptive Sponge

Vaginal sponge that contains N-9 spermicide—designed to fit over cervix Sponge must be moistened before insertion; provides protection for 24 hours and for repeated acts of sex Wearing it longer than 24-36 hours may put woman at risk for TSS Typical failure rate: 24% (parous) and 12%(nulliparous)

What does a vasectomy NOT effect?

Vasectomy has no effect on ejaculation or volume of ejaculate endocrine production of testosterone continues, so secondary sex characteristics aren't affected sperm production continues but unable to leave epididymis and are lysed by immune system

Vasectomy

Vasectomy is the sealing, tying, or cutting of vas deferens so sperm can't travel from testes permanent method bc reversal is unsuccessful

ACHES

Warning signs to teach patients starting or taking COCs: A: Abdominal pain may indicate a problem with the liver or gallbladder. C: Chest pain or shortness of breath may indicate possible clot problem within the lungs or heart. H: Headaches (sudden or persistent) may be caused by cardiovascular accident or hypertension. E: Eye problems may indicate vascular accident or hypertension. S: Severe leg pain may indicate a thromboembolic process.

IUD Nursing Interventions

Woman should be taught to check for presence of IUD strings after menstruation; if pregnancy occurs w/ IUD in place, ultrasound should confirm its not ectopic

Advantages & Disadvantages of FABs

advantages: low to no cost; increased self reliance; absence of chemicals; instant availability; increased involvement and intimacy w/ partner; ability of couple to follow religious/cultural traditions disadvantages: exact time of ovulation can't be predicted accurately; couples find it hard to restrain several days before and after ovulation; difficulty w/ adherence to strict record-keeping; requirement of partner support; lower effectiveness; decreased effectiveness in women w/ irregular cycles; decreased spontaneity of coitus; no protection from STI and HIV effectiveness: failure rate of 24%

EC's in relation to Ovulation

ask when their last menstrual period was If taken before ovulation, EC prevents ovulation by inhibiting follicular development If taken after ovulation, there is little effect on ovarian hormone productions or endometrium

Breastfeeding & Progestin

be aware that you are increasing the risk of a thromobylitic episode if you are giving a pt this while breastfeeding

Ovulation mucus

clear, wet, sticky, slippery

Preovulation mucus

cloudy, yellow or white, sticky Right before ovulation, the watery, thin, clear mucus becomes more abundant and thick (Fig. A). It feels similar to a lubricant and can be stretched 5+ cm between the thumb and forefinger; this quality of mucus is called spinnbarkeit (Fig. B), and its presence indicates the period of maximal fertility. Sperm deposited in this type of mucus can survive until ovulation occurs

Advantages of OC

convenient to know when next menses; decreased menstrual blood loss and iron deficiency anemia; regulation of irregular cycles; reduced dysmenorrhea and PMS; protect against endometrial and ovarian cancer; improved acne

Spermicides

decrease motility (best used in conjunction with something else) Spermicides like nonoxynol-9 (N-9) work by reducing the sperm's mobility—attack the sperm flagella and body, preventing sperm from reaching cervical os Frequent use of N-9 or use of N-9 as a lubricant may increase transmission of HIV Women w/ high risk behaviors that increase likelihood of STIs are to avoid use spermicidal products w/ N-9 Failure Rate: 28%

Medical Abortion

medical abortion—available for use in US for up to 9 weeks after last menstrual period w/ any medical abortion, woman experience bleeding and cramping SE: N/V, diarrhea, HA, dizziness, fever, chills

Methotrexate

methotrexate is cytotoxic drug that blocks folic acid in fetal cells so they can't divide

methotrexate and misoprostol

methotrexate is given IM or PO and vaginal placement of misoprostol follow in 3-7 days

mifepristone and misoprostol

mifepristone 600 mg PO then 400 mcg PO of misoprostol 48 hrs later

Mifepristone

mifepristone binds to progesterone receptors and blocks the action of progesterone, which is needed to maintain pregnancy

Misoprostol

misoprostol acts directly on cervix to soften and dilate and on the uterine muscle to simulate contractions

Postovulation fertile mucus

thick, cloudy, sticky

Postmenstrual mucus

scant

Postovulation, postfertile mucus

scant

SAIE Nurse

sexual assault nurse examiner is trained in how to care for someone following a sexual assault how to appropriately get specimens and knows the legal chain in order to document it correctly

Standard days method

similar to calendar rhythm - I typically ovulate this day so I will avoid these days modified form of calendar rhythm method that has a "fixed" number of days of fertility for each cycle: days 8-19 (avoid unprotected sex during these days) useful to women whose cycles are regular and at 26 to 32 day intervals unreliable for those who have longer or shorter cycles, take hormonal contraception, IUDs, breastfeeding, recent pregnancy typical failure rate: 12%

Family Planning

the conscious decision on when to conceive throughout the reproductive years anyone engaging in sexual activity should be participating in this both individuals involved in as sexual relationship should have an opportunity to discuss this and identify what is important to them

Birth Control

the device or practice that decreases the risk of conceiving

Contraception

the intentional prevention of pregnancy during sexual intercourse

Aspiration

vacuum or suction curettage; cannula connected to suction is inserted into uterine cavity; products of conception are evacuated from uterus Bleeding after operation is about equal to heavy menstrual period; cramps are rarely severe excessive vaginal bleeding and infection are most common complications

Calendar rhythm method

where do you typically have a period and avoiding those times you may be ovulating (not everyone has a 28 day cycle and a lot can easily sway it) fertile period is determined after recording the lengths of menstrual cycles of 6 months beginning of fertile period: subtracting 18 days from length of shortest cycle end of fertile periods: subtracting 11 days from length of longest cycle to avoid conception the couple would abstain during the fertile period most useful as an adjunct to basal body temp. or cervical mucus method disadvantage: trying to predict future events w/ past data; unpredictability of cycle is not taken into consideration

Coitus interruptus (withdrawal)

—male partner withdrawing the penis from the vagina before ejaculation Advantages: good choice for couples who don't have another contraceptive available Disadvantages: Does not protect against STIs and HIV Effectiveness: similar to barrier methods and depends on man's ability to withdraw before ejaculation; One of the least effective methods Percentage of women who experience an unintended pregnancy of typical use: 22%