FAMILY PLANNING

FAMILY PLANNING: It is a way of thinking and living adopted voluntarily, upon

basis of knowledge, attitudes and responsible decisions by individuals and couple
in other to promote the health of the family, group, and thus contributes
effectively to the social development of a country (WHO)
DEFINITION OF FAMILY PLANNING: It is a method of having children by choice
and not by chance. It is when a couple decides that they want to give space in
between their children or they have enough children that they desire, thereby use
some family planning method to avoid pregnancy.
Factors affecting acceptance of family planning:
 Traditions (e.g wife inheritance)
 Religion
 Place of male children
 Divorce
 Occupation
 Taboos, myths
 Expectation/ request of extended family
 Children as a source of pride
 Befitting burial
 Marriage (monogamy, polygamy)
 Poverty, ignorance and lack of awareness
 Misconceptions
 Spousal consent
Strategies for acceptance of family planning:
 Dispel rumours, myths, and taboos on family planning
 Educate on benefits of family planning
 Correct any misconception on family planning methods
 Increase access to services by bringing services closer to the people
(physical and through women friendly clinic schedule)
 Ensure that services are affordable; review and monitor standard of care
 Provide full and accurate family planning information and counselling in an
atmosphere that ensures privacy and confidentially
  Respect client rights: to express their own opinions, to receive safe
services, to be comfortable while receiving services, to be treated with
respect, and to adopt, switch or discontinue a contraceptive method.
 Make every effort to ensure that an appropriate contraceptive mix is
available at your facility (according to your national guide line) do not limit
choices.
 Counsel client about all available methods; assist client to choose the
contraceptive method of their choice.
 Institute innovative approaches to reach the often, unreached groups (e.g
adolescents, men, people in refugee camps)
 Promote community distribution and social marketing of family planning
services.
 Ensure a continuum of care for contraceptive acceptors by submitting your
supply needs to an effective logistics management system.
 Promote dual protection (protection against pregnancy and against sexually
transmitted infections). Make sure that your client know that a condom is
needed in addition to other family planning methods to protect them from
the possible transmission of HIV and sexually transmitted infections.
 Discuss post- partum contraceptive options during pregnancy.
 Counsel client that return of fertility is not entirely predictable, and
conception can occur before menstrual periods resume.
 In-general, providers of contraception- particularly long- acting methods-
should offer methods without pressure as part of wider menu.
Family planning methods: family planning method is any act or device use to
safely and effectively delay or prevent pregnancy for a specified duration or
period. The methods include the following:
1. Traditional methods
2. Natural methods
3. Artificial methods
4. Hormonal methods (oral, injectables and implants)
5. IUCD (techniques of insertion, maintenance and removal)
6. Barrier methods: (mechanical, chemical, methods of administration, mode
of action, advantages and disadvantages, effectiveness, side-effects,
 indication and contra-indications, major complications, client instruction,
referral of clients with major complications, associated problems and
managements)
7. Voluntary surgical contraception (bilateral tubal ligation and vasectomy).
Pre and post operative management.
8. Emergency contraceptive methods

TRADITIONAL METHODS OF FAMILY PLANNING

Traditional methods are those used from time immemorial by indigenous
populations.
Comon types:
1) Arm or waist band
2) Native rings
3) Wooden crafts (omolangidi)
4) Herbs
5) Scarifications
6) Pad locks
7) Omi oku (fluids from dead body /corps)
8) Potash powder solution
9) Blue powder solution
10) Feathers etc
Advantages of traditional method:
 Method were used even when modern methods were not available
 Support the believe system held by men
 Those not need a change in the behaviour
 Some methods e.g breast feeding and abstinences are effective and
beneficial to mother and baby.
Disadvantages of traditional method.
 The mechanisms of action are not clearly understood
 Effectiveness cannot be measured
 Some of the articles are injurious to the body e.g potassium powder and
blue powder solutions
  Some of the methods are irreversible, especially when there is a mistake
by the user.
 Some of the articles are difficult to get e.g leopard’s skin
 Some methods can only be operated by traditional medicine men
 The women that use the methods may be at the mercy of the traditional
medicine man.

NATURAL FAMILY PLANNING METHOD

Natural family planning is the use of fertility awareness and periodic abstinence to
avoid pregnancy. It does not require any kind of medication of device.
Natural family planning uses one or more of the following methods to determine
fertile and infertile periods in a woman’s menstrual cycle:
1. Fertility awareness-based methods (natural methods):
Fertility awareness- based methods on the ability to recognize certain physiologic
changes associated with ovulation. This enables the couple to recognize fertile
and infertile phases of the menstrual cycle. The couple can plan the time of inter
course according to their present pregnancy hence the methods are called fertility
awareness methods.
Examples of facility- based awareness methods:
a) Basal body temperature (BBT) method.
b) Calenda /rhythm method.
c) Cervical mucous method. (CMM) or Billing ovulation method.
d) SymPto-thermal method (STM)
Description of natural methods:
Basal body temperature method: instruct client to:
Take temperature in the morning before getting out of bed and before
eating or drinking anything or putting anything in the mouth.
Take temperature at the same time every morning, in the same way, either
orally, rectally or vaginally i.e
*orally for 5 minutes
 Hythm method
*rectally for 2 minutes
Record the readings at the level the mercury stops. If mercury stops in
between two readings take the lower reading as your temperature.
Record reading on a temperature chart and do these for 3-6 consecutive
months to determine the pattern of temperature rise.
Abstain from intercourse from the first day of your period until after the 3 rd
consecutive day of rise of body temperature.
Do not use this method if you are breast feeding (temperature may not rise
during this period)
Repeat instructions.

Calendar /Rhythm method: instruct client as follows:

 Record the first day of each menstrual cycle for 6-12 months
 Determine the beginning of the fertile period by subtracting 18 days from
the shortest cycle.
 Determine the end of the fertile period by subtracting 11 days from the
longest cycle.
 If your longest period is 31 days and the shortest is 23 days, your fertile
period is from the 5th to the 20th day of your cycle, i.e 16th day.
 Abstain from intercourse during this days every month
 If your period is irregular, do not use this method of contraception, use
spermicidal or other barrier method as well
 Repeat instruction.

The cervical mucus (billings) method:

Explain the following to the client: Billings method is based on changes that take
place in the quantity and quality of the cervical mucus during the menstrual cycle.
Prior to ovulation the mucus is thick. At ovulation the mucus becomes thin, clear,
plenty in amount and slippery. It is easily stretched out between the fingers, like
egg white. After ovulation it becomes thick again and dose not draw.
Instruct client to:
Abstain from intercourse during menstruation.
Feel the vaginal daily for mucus
Record findings daily on appropriate chart.
Have sexual intercourse during the ‘dry’ days when no mucus appears.
Abstain from intercourse once mucus appears and continue abstinence
until 4days after mucus has ceased to be felt
Do not douche, as this alters the nature of the cervical mucus.
Abstain from intercourse whenever there is inter menstrual bleeding.
Abstain on alternate days, during the learning phase, prior to onset of the
feeling or observation of mucus.
This is to reduce the confusion that may arise as a result of the presence of
seminar fluid.

Symptom-thermal method: This is a combination of the temperature, calendar

and cervical mucus methods to determine time of ovulation. Othe ovulation-
associated sign and symptoms such as breast tenderness, feeling of bloatedness,
mid-cycle pain, vagina spotting are also used in this method.
Instruct client to:
Avoid intercourse during the fertile period as determined by BBT or
calendar method, or when mucus is first noted, which ever comes first.

2. LACTATIONAL AMENORRHEA METHOD (LAM): Exclusive breastfeeding can

be used as a method of contraception because it causes lactational
amenorrhea and anovulation. For it to be very effective, a client must have
adequate information and clear instructions as follows:
 Clarifies that she wishes to use the LAM as her contraceptives
method.
 Explain how LAM work to prevent pregnancy.
 Explain other available methods. Ask her questions about her past
and present breastfeeding practice.
  Ask client the following question and help her choose another
method of family planning if she answers ‘yes’ to any of these:
 Has client had a period since baby’s birth?
 Is the baby more than six month old?
 Does the baby sleep all through the night?
 Is the baby breastfeed less than 8 times a day?
 Has the baby started taking any other food or drinks?
If answer to all questions are NO, client may use LAM as a contraceptive method.
Find out how much client knows about the rules for using LAM as a
contraceptives method.
Instruct clients as follows:
 Breastfeed exclusively for the first 6 months
 Breast feed as often as child demands
 Refrain from given a pacifier (dummy)
 Allow a long time on the breast each time. (at least 15 minutes)
 The risk of pregnancy is similar whether or not twice).
 Give no other food, drink or water before 6 months of age
 Use another method of contraception, if for any reasons the breast milk
begins to fall, or breast feeding is interrupted or irregular.
 Return to the clinic if breastfeeding pattern changes or menses resumes.

Effectiveness of breast feeding as a contraceptive method.

The likelihood of pregnancy is lower during the first month after delivery, whether
or not a mother breast feed her child since she is usually amenorrheic during this
time.
It is important to note that after menstruation resumes, the risk of pregnancy is
similar whether or not a woman breast feeds. This suggests that the pregnancy
preventing properties of breast feeding are primarily limited to the amenorrheic
period.
Contraceptive effectiveness of breast feeding is enhanced by the following:
 More prolonged breast feeding
  More breastfeeding on demand (around the clock)
 More simultaneous use of abstinence during breast feeding.
The most effective contraceptive effects occurring during the first 6 months when
a woman is not supplementing the breast milk wit other types of food. It is the
frequency and duration of breastfeeding that most reduce the chance of
pregnancy and this is only achieved through exclusive breast feeding.
This method can be effective for woman who remain amenorrheic and whose
infants are less than 6 months old. After 6 months, effectiveness is not certain.

3. MODERN /ARTIFICIAL METHOD:

Coitus interruptus
Coitus interruptus (withdrawer method) is when the penis is withdrawn
from the vagina just before ejaculation.
Instruct client as follows:
- Withdraw penis from vagina just before ejaculation
- Wipe off any fluid at the tip of the penis before intercourse (pre-
sexual emissions may contain sperm).
- Withdraw the penis from vagina when ejaculation is about to occur
and make sure ejaculation occurs away from the entrance to the
vagina.
- Do not use this method if there is going to be repeated acts of
intercourse
- Do not use this method if your partner is not in full control of
ejaculation.
- In case of an accident (failure to withdraw completely before
ejaculation has taking place) use a quick acting spermicide such as
foaming tablet or jelly immediately, and emergency contraceptive
within 72 hours.
4. ABSTINENCE: This is a method of avoiding or refusing sexual intercourse.
 It is the only method the adolescent/ youths are encouraged to
adopt
 It is morally and culturally acceptable
  It is 100% effective in the prevention of pregnancy, STI, HIV, and
AIDS
 It bestows on young people a sense of self-worth.
ADVANTAGES OF NATURAL METHODS:
 No physical side effects
 No effect on breast feeding or breast milk
 Safe
 Helpful for planning or preventing pregnancy
 In-expensive
 Acceptable to many religious groups that oppose conventional methods
 Encourage couples to communicate about family planning and sexuality
 Educate people about woman’s fertility cycles
 No need of any drugs
DISADVANTAGES OF NATURAL METHODS:
 Abstinence may be difficult to some couples
 Require high motivation for success
 Restrict sexual spontaneity
 Not suitable for woman with irregular menses
 Require a long time of practice
 No protection against HIV/AIDs, STIs
 Difficult to use after child birth until menstrual cycle become regular again.
 Fever, vagina infection and bleeding after effective use of lactational
amenorrhea method (LAM)
 Predisposes to marital disputes.
INDICATIONS: This method can be used when:
 Client choice is influence by religious or other personal reasons
 Other methods are contra-indicated
 An in-expensive method is required.
 In-accessibility to medical care.
CONTR-INDICATIONS (client who can not use)
  It can not be used if there is no knowledgeable instruction to teach the
client.
 Client is no strongly motivated.
 Client is not comfortable touching her genitals.
 Client cannot understand or comprehend how to use the methods.
 Client whose menses are irregular (e.g. calendar method).
 There is alteration of cervical mucus e.g infections, erosions
 Immediate post-partum or post-abortion
 Partner does not cooperate

BARRIER METHODS OF CONTRACEPTION

This is the use of chemical action or mechanical obstruction to prevent
spermatozoa from entering the womb.
Description of types:
1) Chemical barrier methods
This is the use of spermicides. Spermicides are chemicals placed in the vagina to
immobilize, kill or destroy sperms.
- They can be used alone or in combination with mechanicals barriers
- They are placed in the vagina before intercourse.
Types of spermiciders;
- Spermicidal cream and jellies
- Foaming tablets e.g conceptrol or Neo-sampoon tablets
- Vaginal films
- Vagina suppositories
- Spermicidal foams-e.g Aeriosol foam.
Advantages:
Spermicides can be provided by non medical personnel or without prescription.
Convenient to use and are used only when a couple want to have sex.
- Serves as lubricant
 - Easy to apply
- Readily available
- Safe to use- 80% effective
- No systemic effect
- No effect on breast milk
- Relatively cheap
- Protect against some sexually transmitted infections (except those with
monoxynol-9)
- Can be used as a very good back up method when extra protection is
needed or in missed oral contraceptives pills.
- The tablets are easy to carry and can be used without an applicator
- Do not affect the woman’s menstrual cycle
- Can be used with condom or diaphragm to offer dual protection.
Disadvantages:
 Unacceptable to those who are opposed to touching their genitals
 Can be messy or course minor vagina or skin irritations or produce burning
sensations in clients or partners.
 Interrupt sex if not inserted prior to intercourse
 Can be difficult to hide from partners
 Some may melt in hot whether
 Not good for woman with allergy to ingredients of the spermicides
 Disadvantageous and risky to woman with cervical or vaginal lesion or with
high risk for HIV.
Explain to client on use as follow:
- Must be used with each act of intercourse
- Tablet must be inserted before intercourse
- Use indicated amount of the spermicide
- Place spermicide into the vagina as deeply as possible to cover the cervical
os
- Read and follow instruction for specific type regarding time for placement,
duration and effectiveness.
- Do not dough until at least 6 hours after the intercourse
Post -prescription instructions: Ask client to return to the clinic for re-supply of
spermicides and/ when she has any problem with the method.
Note:After 3-5 hours, foam dissolves and is discharged from the vaginal with
normal vagina secretion
2) Mechanical barrier methods
This act as physical barrier to agents that destroy or immobilize the spermatozoa
along the female genital tract.
Types of mechanical barrier methods:
Male type:
- condom
Female types:
- diaphragms
- condoms
- vault caps
- cervical caps
- sponges
- spermicidal foam
- spermicidal cream and jellies.
DIAPHRAGMS
This is a mechanical barrier form of contraception, mechanical non-natural
method of contraception. It is a dome-shaped rubber cup with flexible rim. It is
inserted into the vagina before intercourse so that the posterior rim rests in the
posterior fornix and anterior rim fits snugly behind the pelvic bone. The dome of
the diaphragm covers the cervix. It is best used with a spermicidal cream, which is
pour inside the dome, so that it is in contact with the cervix when the diaphragm
is in place.
types: There are forms according to the type of rim as follows:
 arcing spring
 flat spring
  coil spring
 wide seal rim
note: The diaphragm is very safe to use for most woman except for woman with
chronic bladder infections or frequent urinary tract infections.
advantage: it protects client against some sexually transmitted infections (STIs)
 can be won without discomfort
 can be fitted at any time (but post -partum mothers must wait for 6-12
weeks after delivery or mid-trimester abortion)
 it is effective, about 82% effectiveness rate.
 It is safe
 Can be won by client without discomfort
 It has no systemic effect
 Can b won up to 6 hours before intercourse to avoid interruption
 Does not affect the woman’s menstrual cycle.
 Use only when needed at intercourse
 No side effect for either of the partner
 Good for woman who have contraindications to other contraceptives.
disadvantage:
Not readily available in Nigeria
Require medical examination
Must be properly won and fitted
Must be used every time before intercourse and remove 6 hours later. (it
should not be left in the vagina for more than 24 hours after intercourse).
Can cause or increase the risk of urinary tract infection.
A different size may be required after child birth.
May be expensive for some clients
Needs special care and storage
Can be damage by excessive use or poor storage.
Diaphragm are unsuitable until involution is complete after delivery
It is only good for the woman with infrequent intercourse.
Disadvantageous and risky to woman with sensitivity or allergy to rubber
or spermicide, or woman with history of repeated urinary tract infection.
CONDOMS
The condom serves as mechanical barrier to the passage of sperms between
genital tracts of sexual partners.
Types:
 Male condom
 Female condom
Male condom: This Is a thin rubber sheath (a soft tube made of thin rubber) that
is worn over the erect penis before sexual intercourse. It acts as a barrier
preventing entrance of semen into the vagina. The male type are in 3 forms
according to their materials.
I. Latex rubber condoms
II. Synthetic materials condom (soft plastic)
III. Natural tissues condoms
Mechanism: it act as a mechanical barrier preventing pregnancy and reducing
transmission of STIs and HIV. It acts by preventing the entry of the sperm into the
vagina thus hunting the sperm from meeting the ovum. It also prevents direct
contraction of the penis and the vagina.
Advantages:
o In-expensive, relatively cheap
o Widely acceptable and available
o Does not require medical prescription
o Offers dual protection (prevents pregnancy and some STIs and HIV)
o It blocks the exchange of body fluids that may cause infection
o Promotes male involvement and partner participation in family planning
Side effect are rare
- Can be used when breastfeeding or immediately after birth.
Effectiveness: 99% effective
Disadvantage:
 Interrupt fore play
  Decrease sexual enjoyment for some couple
 Delay sensation as soon as it is worn on the penis
 A new condom must be worn with each act of intercourse
 May burst during intercourse or slip off a flaccid penis after ejaculation or
during withdrawal.
 Deteriorates if not properly stored.
 May course itching or rash (allergic reaction in some men).
Indications:
I. Anyone can use condoms if they are not allergic to rubber(latex)
II. Condoms can be used when:
- A temporary contraceptive is desired
- No other contraceptive methods are available or acceptable to the couple
- Multiple sexual partners are involved
- Protection against STI and HIV is required
- The male wants to share in the contraceptives responsibility
- Non-prescription type of contraceptives is desired.
- Sexual intercourse is not frequent
- A temporary contraceptive method is require between pregnancies or
before a first pregnancy
- Use as back up for some other methods
- If there are contraindication to use of IUCD and the hormonal contraceptive
in the partner on medical grounds.

Contraindications:
Allergic to (rubber)
Inability to sustain erection.
How to use
Pinch the nipple end as you roll the condom over the penis, living a small space at
the tip if there is no teat.
Instruct client that:
Condom should be worn over erect penis.
 Always keep a supply of condom at hand within easy rich for use at any
intercourse.
Keep away from light and sharp finger nails.
Put condoms on before any genital contact
If the condom has no teat, leave about 1.5cm of the condom free at the tip
If necessary, lubricate the outside of the condom with contraceptive jelly or
any water -soluble lubricant e.g k-y jelly, (Don’t use Vaseline or any
petroleum production as lubricant
After ejaculation, while the penis is still erect, hold the rim of the condom
firmly against the base of the penis during withdrawal.
Discard the condom after use in the toilet or burn/ bury it.
Don’t leave where children can find it and play with it.

- Female condom
This is a soft, plastic pouch. One end is closed. It has a flexible ring on both ends. It
is inserted into the vagina before intercourse.

Mechanism of action:
It lines the surface of the vagina and holds sperm. It prevents the sperm from
meeting the egg. It also blocks the exchange of body fluids that may be infected.
It also stops direct contact of the penis and vagina thus preventing pregnancy and
sexually transmitted infections including HIV.

Instruction to client on how to use

- Place the condom in the vagina before intercourse
- Hold the pouch with the larger open end hanging down. Use your thumb
and middle finger of one hand to squeeze the closed ring.
- Squeeze it into a narrow oval – insert the squeezed ring into the vagina
- Put the closed ring and pouch of female condom into the vagina
- Use the finger next to the thumb to push the ring and pouch up into the
vagina
 - The ring at the open end of the female condom should stay outside your
body
- It should rest against the outer lips of the vagina. The larger flexible ring is
smothered over the vulva
- Don’t twist the condom
- You may need to guide the penis into the female condom.

How to remove the condom?

- Take the female condom out soon after intercourse
- Take it out before standing up
- Squeeze and twist the outer ring. This will keep the sperm inside the pouch
- Gently pull and slide the pouch out of the vagina
- Dispose of the female condom carefully
- Put it in a latrine or bury it or wrap it in a paper and burn it.
- Do not re-use the condom.

Advantages
- Reverts effectiveness 79% - 95% pregnancy and protects against STIs
- Can be inserted in advance
- Does not interrupt sex
- No need to see a health care provider before using
- Side-effects are rare
- A woman controlled method
- Can be used if breast feeding
- Affords female control.
Disadvantages:
- Expensive
- Difficult to place in the vagina
- Women must touch the genitals
- Makes embarrassing noise during intercourse not readily available.
- Must be used during each act of sexual intercourse
- May cause itch or rash if allergic to poly urethane (plastic)
 - May decrease sensation during sexual intercourse.

Cervical Caps and Vaults:

These also resemble the diaphragm in shape and has similar mechanism of action.
The advantages, disadvantage, side effects and effectiveness rate are also the
same with diaphragm.

HORMONAL CONTRACEPTIVES
Definition:
Hormonal contraceptives are synthetic Oestrogen and/or progestogen
administered orally, parenterally or by implants

TYPES OF HORMONAL CONTRACEPTIVES

i. ORAL CONTRACEPTIVES

Types:
1. Combined pills – combined oral contraceptives pills (COCPs)
2. Progesterone (Progestin) Only pills (POPs) or Mini Pills

Mechanism of action of combined Oral Contraceptives Pills (COCPs)

COCPs acts mainly by:
- Suppressing ovulation
- Thickening cervical mucus thereby preventing sperm penetration
- Reducing sperm transport along the genital tract
- Making the endometrium unsuitable for implantation.
Benefits of combined oral contraceptives pills (COCPs)
Highly effective (0.1-0.8 pregnancies/100 women during the first year of use)
- Effective within 12 hours
- Does not interfere with intercourse
- Decreases menstrual flow thereby preventing/improving existing anaemia

Limitations of combined Oral Contraceptives Pills (COCPs)

- User-dependant
- Does not protect against STIs/HIV
- Sometimes delays return to fertility

Contra-indications to use of combined Oral Contraceptives pills (COCPs)

- Pregnancy.
- Unexplained vagina bleeding
- Breast feeding in the first six months
- Active liver disease
- History or presence of high blood pressure
- Migraine
- Poor compliance

Side-effects of combined Oral Contraceptives Pills (COCPs)

- Irregular bleeding.
- Amenorrhea
- Nausea and vomiting.

Progesterone Only (Mini) Pills (POPs)

Mechanism of action of progesterone Only (Mini) Pills (POPs).
As for combined Oral Contraceptives (COCs)

Benefits of Progesterone Only (Mini) Pills (POPs)

- As for Combined Oral Contraceptives (COCs) but in addition it can be used
by breast-feeding mothers
- Decreases sickle cell crisis

Limitations
- May provoke weight gain
- Must be taken at the same time everyday
- Cannot be used by clients with history of breast cancer and women who
cannot tolerate any changes in their menstrual pattern.

Management of common side effects

- Amenorrhoea
- Check for Pregnancy
- If intra-uterine pregnancy is present, counsel clients on options
- If ectopic, counsel and refer for appropriate treatment
- If irregular vaginal bleeding, examine to exclude pregnancy or any other
cause and treat appropriately.

User’s instruction on oral contraceptives

There are two types of packaging of COC i.e. 28 tablets pack and 21 tablets pack.
In a 28-tablets pack, the first 21 tablets are the hormonal preparations and have
the same colour while the last 7 are iron tablets (placebo) and often have
different colour.
Clients starts the first pack by commencing with the 21 similar tablets and
continues with the 7 different coloured tablets. The next pack is commenced the
very day after the last tablet without omitting any day whether menstruation has
commenced or not.
In the case of the 21 tablets pack, they are of same colour and client should be
informed to wait for seven days after taking the last tablet of the present pack
before commencing the next pack irrespective of whether menses has occurred
or not.

ii. INJECTABLE CONTRACEPTIVES

Definition:
These are long-acting hormonal contraceptives containing combined estrogen
and progestin or progestin only, and are given by intramuscular injection.

Types
Progestin Only
- Norethisterone Enanthate (Noristerat, NET-EN)
- Depot-medroxy-Progesterone Acetate (DMPA, Depo Provera)
- Cyclofem

Advantages
- Highly effective
- Long-acting
- Minimal client dependence
- Not related to sexual intercourse
- Culturally acceptable
- Decreases menstrual cramps
- Has less slowing effect on blood circulation
- Makes Sickle Cell crisis less frequent and less painful
- May increase blood haemoglobin level
 - May protect against ectopic pregnancy
- Offers privacy
- Reduces frequency of seizures in epileptic women
- No drug interaction

Disadvantages
- Requires frequent visits to the clinic (2-3 monthly intervals) or monthly
- May cause irregular bleeding
- Menses may cease for several months
- Return of fertility may be delayed
- May cause weight gain
- Does not protect against STI/HIV/AIDs
- May cause headache, breast-tenderness, moodiness, nausea, hair loss and
reduces libido.

Indication for use (Women who can use)

Suitable for women:
- Of all reproductive ages and particularly adolescents and the nulliparous.
- Who are breastfeeding
- Desiring hormonal contraception
- Who want to use a contraceptive method confidentially?
- In whom combined pills are contra-indicated.
- With sickle cell disease
- With estrogen related complications.
- Immediately after abortion or miscarriage.

Women who cannot use

- Existing malignancy of the breast or genital organs
- Abnormal uterine bleeding.
- Pregnancy
- Depression
 - History of stroke, heart attack or blood clot problems
- Hypertension (diastolic equal or more than 100mm Hg and systolic equal or
more than 160mmHg)
- History of liver disease or active liver disease.

Advantages of combined injectable contraceptives

- Highly effective (0.1-1.4 pregnancies per 100 women during the first year of
use)
- Effective immediately pelvic examination not required prior to use
- Long acting
- Convenient and easy to use
- Does not interfere with sexual intercourse
- Few side-effects
- Can be provided by trained non-medical personnel
- May protected against ectopic pregnancy
- Offers privacy.

Disadvantages:
- Requires frequent visits to the clinic (monthly)
- May cause changes in menstrual bleeding pattern (irregular bleeding/initial
spotting) in some women.
- Return to fertility may be delayed (usually not beyond 3 months)
- Does not protect against STI/HIV/AIDS and HPV.
- May cause headache, breast-tenderness (mild), moodiness, nausea, hair
loss (usually disappears after two or three injections)
- Effectiveness may be lowered when certain drugs for epilepsy (phenytoin
and barbiturates) or for tuberculosis (Rifampricin) are taken.

Indication for use (women who can use)

Suitable for women
- Of all reproductive ages and parity including nulliparous women.
 - Who want a highly effective method against pregnancy
- Who are breastfeeding (6months or more)
- Who are post-partum and not breastfeeding
- Who are post-abortion
- With anaemia.
- With Severe menstrual cramping
- With irregular menstrual cycles
- With history of ectopic pregnancy
- Who cannot remember to take their pill every day.

When to use
- Anytime it is reasonably certain that a woman is not pregnant
- 6 weeks after childbirth
- After miscarriage or abortion.
- Immediately after stopping another method.

When to initiate cyclofem

- Anytime during menstrual cycle when provider can be reasonably sure the
client is not pregnant
- Days one to seven (1-7 days) of the menstrual cycle
- Post-partum
 After 6 months if breastfeeding
 After 3 weeks if not breastfeeding
- Post-abortion (immediately or within 7days)

Client preparation
- Ensure privacy for the client and make her comfortable and relaxed.
- Find out what client knows about injectable and fill in any gaps in her
knowledge.
- Explain the advantages and disadvantages, side-effects and complications.
- Make sure she fully understands.
 - Explain that the drug is given by intramuscular injection every 3 months (12
weeks) for Depo-Provera or every 2 months (8 weeks) for Noristerat, and
month or 4 weeks for cyclofem.
- Explain that after discontinuing use, she may experience delay in return to
fertility.
- Obtain client history.
- Perform a complete physical examination.
- Perform a speculum examination and where available Pap Smear
- Give injection during the first 7 days of menstruation. If client begins after 7
days of menstrual period she should use a barrier method or avoid sex for
the next 48 hours.
- Follow normal procedure for giving intramuscular injection.

iii. CONTRACEPTIVE IMPLANTS

Description:
Implant are progestin-Only contraceptives inserted under the skin of a woman’s
upper arm through a minor surgical procedure.

Types
- Norplant: (6 soft plastic rods each containing 36mg levonorgestrel).
- Jadelle (2 silicon rods, contains 75 mg levonorgestral). This is an improved
version of norplant
- Uniplant (1 rod, contains progestin 3 – Ketodesogestrel).

Advantages
- Has long-lasting effect
 Norplant and jadelle – 5 years
 Uniplant – 1 year
 Implanon – 3years
 - Fertility return to previous level on removal of implant rods.
- No repeated visit to the clinic are required.
- Effective within 24 hours of insertion.
- May help prevent iron deficiency anaemia, ectopic pregnancy and
endometrial cancer.
- May make sickle cell crisis less frequent and less painful.
- Other advantages are as progestin-only pill (POPs)
Note: Insertion and removal for jadelle, Uniplant and Implanon are easier and
faster than Norplant because of the fewer rods, but the procedure is the same.

Disadvantages
- Spotting and irregular vaginal bleeding (60 – 70% of users).
- Amenorrhoea may occur (< 10% of users).
- Effectiveness may be lowered when taking certain drugs e.g anto T.B drugs
– Rifampicin.
- Insertion and removal involved minor surgical procedures and therefore
may be associated with bruising (dis-coloration of the arm) infection or
bleeding.
- Client cannot discontinue the method on her own (It has to be removed by
a trained health personnel).
- The otline of the rods may be visible under the skin of some women,
especially when the skin is stretched.
- Does not protect a woman from STI/HIV/AIDS.

Indications for implants

Suitable for women who:
- Want long-term contraception
- Want highly effective reversible contraception that does not require daily
acion
 - Are delaying the start of their family, have completed their family or do not
want children
- Require user-independent method
- Have completed their family sizes but are not yet decided on, or are not
suitable for sterilization
- Cannot use estrogens.

Women with the following can use with caution or under close monitoring:
- Diabetes mellitus without kidney disease.
- Blood clotting problems
- Raised blood pressure (diastolic of more than 90 hg or systolic above 140
mm Hg)
- Epilepsy.
- Gallbladder disease.
- Mental Depression
- Headaches
- Thyroid disease
- Liver Disease (jaundice, painful, or enlarged liver, viral hepatitis, tumour)
- Unexplained Vaginal Bleeding.
- History of blood Clot in the legs, lungs or eyes.
- Little tolerance for Menstrual Bleeding irregularities.

Contra-indications
1. Current cancer of the breast
Women with body weight over 70kg are at a slightly higher risk than
women below 70kg body weight for implants
2. Obese women (e.g over 80kg)

Equipment and materials

- One set of Implant Capsules
- Trocar and Cannula as supplied
 - Sterile gloves preferably devoid of talcum powder
- Antiseptic solution likeSavlon, Hibitane or Betadine
- Local Anaesthestic Agent like Xylocaine 1%
- Syring and needle
- Sterile Gauze/Cotton Wool
- Plaster
- Artery Forceps
- Scalpel and Blade (size 12) (optional)
- Examination Couch with Arm rest
- Disinfectant Solution –JIK
- Plastic Bowl.

Procedure
a. Client preparation
- Listen to the client’s concern and respond to her questions appropriately
- Give clear information about probable changes in the bleeding pattern
during the menstrual cycle.
- Describe the insertion and removal procedures and what the client should
expect during and afterwards to ensure client’s cooperation and relaxation.
- Review client assessment data to determine if the client is an appropriate
candidate for implants or if she any problems that should be monitored
more frequently while they are in place.
- Do general and pelvic examination.

[Link] for insertion of implant

- Instruct the client to lie on the couch with arm stretched out comfortably
- Support arm with arm rest
- Use proper infection prevention procedure
- Wash hands
- Clean the area of insertion with antiseptic solution: iodine (if available) and
finally with spirit
- Apply sterile drapes exposing the insertion area only (inside of the upper
arm)
 - Using the standard technique, insert the implant under the skin
- Cover the insertion point with sterile dressing gauze, and plaster
- Apply bandage if necessary
Note: The insertion and removal procedures are the same as for all implants

Post insertion care and instructions

- Observe the client in the clinic for 15 minutes for signs of fainting or
bleeding from insertion site

Instruct client to:

 keep the insertion area dry and clean for 5 days
 Avoid carrying heavy load or applying unusual pressure to the site
 Inform the doctor that she is using Norplant if there is need for other
medical treatment
Return to the clinic if any of the following danger signs are experienced:
 Feeling unwell
 Fever
 Severe abdominal pain
 Heavy vaginal bleeding
 Pus at site of insertion
 Capsules falling out, or peeping out

- Return to the clinic at any time to receive advice and medical attention and
if desires, to have the rods remove
- Return for removal at the appointed time
- Request the client to repeat all instructions
- Schedule follow-up visit as follows:
 1st visit – 3months
 2nd visit – 1 year
 3rd visit – 5 years
 - Answer any remaining client questions.

Follow-up counselling
- Check whether the client is satisfied with method
- Inquire about problems and respond to concerns about side effects
- Reassure the client that the rods can be removed at any time, if desired
- Review the warning signs that indicate the need to return to the clinic
- Remind the client of removal date.

Removing implant capsules

Equipment and Materials
- Sterilised surgical drapes
- Sterile syringe (5-10mls) and Needle (23G or 21G) to apply anaesthesia
- Sterile gloves
- Antiseptic Solution like Savlon, hibitiane or Betadine
- Local Anaesthetic agent e.g 1% Xylocaine
- Scalpel Blade Holder and Surgical Blade
- Artery Forceps (Mosquito) 2
- Examination couch with Arm Rest
- Sterile guaze and cotton swabs
- Disinfectant e.g JIK
- Plastic bowl.

Steps
- Position the client and prepare the area of procedure as for insertion of
implant.
- Raise the head of the examining table. The client will be more comfortable.
- Be sure you are comfortable. You may be more at ease sitting rather than
standing.
- Locate the implant by palpation, possibly marking the position.
 - Inject the local anaesthetic slowly under the proximal 1/3 of the implants. It
is recommended that you initially inject approximately 3cc of 1% Xylocaine.
Have an additional 3-5cc of xylocIaine available, which can be used for the
removal of each implant, if required.
- Make a 3-4mm incision with the scalpel blade also to the ends of the
implants. Do not make a large incision
- Rather than making the incision at exactly the same site as the location of
the incision used to insert the implant, you may wish to make the incision
as close as possible to the tip of all the implants. Some physicians use the
incision so as to avoid a second scar.
- If one implant is far from the other and cannot be reached, make a second
incision
- Throughout the procedure, ask the client if she feels any pain and provide
additional local anaesthetic as needed.
- With your finger, apply pressure to the distal end of each implant. Push the
implant towards the incision with the fingers
- With a sharp blade, a gauze pad, or mosquito forceps, remove the scar
tissue covering the implants (i.e. gently opening the tissue capsule around
the implant)
- When the tip of the implant is visible in the incision, grasp it with the
mosquito forceps.
- Remove the implant from the incision with the second forceps
- The removal of the implants should be performed very gently and will take
more time than the insertion.
- Explain that after discontinuing use, she may experience delay in return to
fertility.

Drugs that interfere with hormonal contraceptives.

These drugs induce liver enzymes which metabolize hormonal contraceptives. In
addition, some of the drugs reduce intestinal absorption of oral pills. These effects
reduce efficacy of hormonal contraceptives.
Lists of drugs:
Analgesics
- Phenacetin
- Pethidine

Antibiotics
- Tetracycline
- Amoxycillin
- Ampicillin
- Chloramphenicol
- Rifampicin

Anticonvulsants
- Phenytoin

Management of clients taking drugs that interact with hormonal contraceptives

1. Use a higher dose pill e.g. pills containing 50mcg ethnylestradiol
2. Use three packs of the 21 tablets oral pill continuously without skipping the
7-day rest period.
3. Use 1gm of vitamin C daily, which increases effectiveness by increasing
serum contraception.

Drugs enhanced by hormonal contraceptives

Anticoagulants, anti-depressants, anti-diabetic drugs and anti-hypertensive drugs
may be enhanced by hormonal contraceptives. Therefore, clients using any of
these drugs(s) need to be monitored closely for effects of interaction or be
advised to change to non-hormonal methods.
 INTRA-UTERINE CONTRACEPTIVE DEVICES (IUCDS)
Definition:
Intra-uterine devices (IUDs) or IUDs are small objects made from inert plastic
material (medicated or non-medicated) placed in the uterine cavity for
contraceptive purposes. The medication, which could be copper or progesterone,
increases the effectiveness of the plastic object.

Types of IUCDs
- Copper-releasing
- Progestin-releasing and
- Inert devices e.g. Lippes loop

Mechanism of action of IUCDs

- Interference with passage of sperm through uterine cavity.
- Forming a physical barrier to implantation
- Changing endometrial lining thus making it hostile to sperm (especially the
progesterone impregnated type).

Benefits of IUCDs
- Higher effectiveness
- Long acting
- Non-interference with intercourse
- Breast feeding friendly
- Immediate return to fertility on removal.

Indication for use of IUCDs

- Preference for IUDs
- Unsuitability for client for other methods
- Poor or lack of access to family planning facility
 - Poor compliance to use of other methods e.g. oral pills or barrier methods.
- Breast-feeding.

Limitation of IUCDs
- Mandatory screening for pelvic pathology especially genital tract infection
before insertion
- Requires trained providers
- Needs regular check on the strings
- May increase risk of PID especially in women prone to STIs
- May increase risk of ectopic pregnancy
- Presence of congenital uterine abnormalities.

ADVANTAGES OF EMERGENCY CONTRACEPTIVES:

 Well documented safety. Very safe and effective way of preventing an
unintended pregnancy after unprotected intercourse or contraceptive
accident, such as condom slipping or breaking.
 Relatively highly effective
 Virtually no medical condition, completely preclude the use of ECPs

INSERTION OF IUCD
Insertion of copper – T380A
Requirements:
- Angle poise lamp or touch light
- Sterile gloves
- Pack(s) of IUCD
- Cuscos vaginal speculum (various sizes).
- Vulsellium forcepts (Tenacullum)
- Sponge holding forceps.
 - Uterine sound
- IUCD retriever (e.g. hook or crochnet).
- Galipot containing antiseptic lotion e.g Savlon 1:100 or deltol 1:80
- Galipot containing sterile cotton wool swabs
- Receivers for used swabs and instruments.
- Surgical scissors (to cut IUCD strings)

Procedures for insertion of copper – t 380a

- Wash and dry hands
- Open copper – T wrapper carefully.
- Wear sterile gloves on both hands
- Swab the vulva
- Insert cuscos vaginal speculum
- Clamp the cervix at angles 10’ 0 clock and 2’0 clock with vulsellum forceps
(tenaculum).
- Sound the uterus as follow:
- While maintaining traction on the tenaculum, gently pass a uterine sound
into the uterine cavity until contact is made with the fundus.
- Measure the depth from the external os to the top of the fundus by
withdrawing the sound and looking at the level of blood on the sound or by
marking the level of the external os on the uterine sound with your index
finger.
- After sounding the uterus, load copper-T.
- Load copper-T as follow:

Step 1:
- Fold arms of T

Step 2:
- Insert arms of T into tube i.e. bend the horizontal arms of the device so that
the tips are forced into top of the inserter (tube)
 - Adjust the movable flange along the inserter so that the distance from the
tip equals the distance from the external os to the fundus as determined by
uterine sound.

Step 3:
- Insert into uterus. – introduce the loaded inserter through the cervical
canal and upwards until the flange rests in the external os. The tip of the
inserter should be at the uterine fundus.
Caution: Do not insert IUCD if depth is less than 6cm or greater than 10 cm as
uterus may be perforated or device improperly placed respectively

Step 4:
- Release the copper –T (the T arm) by holding the plunger and the
tenaculum steady with left hand and withdrawing the inserter (a little
about 1/2inch (2.5cm) with the right hand).
- This releases the arms of the T.

Step 5:
- Now push the plunger upwards until the resistance of the fundus is felt,
thus ensuring fundal placement

Step 6:
- Withdraw the plunger and inserter separately
- While holding the plunger stationary with the right hand withdraw the
inserter with left hand then withdrawal the plunger last.
Note: If the inserter and plunger are withdrawn together this will bring down the
inserted IUCD. Also note that the IUCD can be inserted either by withdrawal and
or push-in method i.e. with drawing the inserter first while holding on to the
plunger until it rests on the adjusted flange or by push-in method – this is done by
first pushing upwards the plunger while it rests on the adjusted flange or until
resistance is felt on the fundus. The push-in method is the commonest method of
insertion.
- In case of unsuccessful insertion, discard and take another pack.
- Trim the strings to a length of about 5cm.

Trans-caesarean insertion
- This is done during caesarean section

Post placental insertion of IUCD (PPIUD)

This is done immediately after expulsion of the planceta
Method is either by: Manual insertion or use of forceps (kelly’s forcep)
Note: The success and effectiveness of IUCD depend on high fundal placement of
the device.

Pre-discharge insertion
- Done within 48 hours after delivery while cervix is still open
- Insert IUCD with Kelly’s forcep or Ring forcep

Post-insertion care
- Ask client about pain, fainting attacks or any other discomfort
- Allow client to rest on the couch for a few minutes and then help her down
- Record findings and give 4 – 6 weeks appointment.

Post-insertion instructions
Inform client that there might be increased bleeding and/or cramping for a few
days and that these are normal.
Advice client as follows:
- Heavier menstrual bleeding, and possible bleeding between periods, is
common for the first 3 – 6 months after insertion.
- Avoid insertion of tampons, cotton wool, foam or toilet roll as these may
get entangled with the string causing the device to be dislodged or causing
infection. Therefore, the use of sanitary pads or clean cloth during
menstruation is recommended
- Inspect all sanitary pads as expulsion is common during menstruation
- Check for sting after each menstrual period
- Avoid multiple sexual partners as this would increase the risk of sexually
transmitted infection/HIV/AIDS
- Encourage the use of condom for dual protection
- Avoid intercourse in the first few days of insertion, while still bleeding.
- Report to the nearest family planning clinic if you notice any of the
following (ACRONYM “PAINS”)
P – period late or abnormal bleeding
A – Abnormal pain with intercourse
I – Infection exposure, such as gonorrhoea, abnormal discharges
N – Not feeling well, fever or chills
S – Strings missing, shorter or longer
- Check to see if string is in place during your fertile period, after any
episodes of lower abdominal pain and after menstruation

Follow-up
First visit (4-6 weeks after insertion)
- Ask client about health generally
- Ask about complaints
 - Ask about variations in her menstrual cycle. This should include
intermenstrual bleeding or spotting, excessive blood loss and painful
menstruation.
- Ask her when last she felt the strings of the device. (This is to ascertain that
client complies with instruction to check the strings).
- Carry out abdominal and pelvic examination. Inspect the cervix to confirm
presence of strings, if long, trim.
- Note any discharge, erosion, and cervicitis.
- Palpate for pelvic tenderness.
- Advise client on personal hygiene.

Schedule of subsequent follow-ups if no complaints

- Next visit is at 3 and 6 months
- Subsequently, yearly until she wishes to have the device removed or the
life span of the device expires
 Lippes Loop – Indefinite (now obsolete due to non-availability
and migration effect)
 Copper T – 200 – 3 years
 Copper T 380A - 10 years
 Multiload 250 -3years
 Multiload375 -8years

- Repeat the activities of first visit at each subsequent visit

- Encourage a pap smear every two years

Removal of intrauterine device

Indications for removal
- Client desires pregnancy
- Menopause no need for contraception
- Desires another method of contraception
- Life of IUD has expired
 - Accidental pregnancy
- Unusual bleeding or pain
- Pelvic inflammatory disease
- Genital tract malignancy
- Partial expulsion of the device
- Dyspareunia (painful intercourse)
- Cervical perforation
- Missing strings
- Allergy to the device (copper types)

When to remove IUCDS

- Remove IUCDs whenever a client insists on having it removed (but the best
time is during menses because cervix is slightly dilated, soft and removal is
less uncomfortable).

Procedure for removal

- Explain procedure to the client to ensure her cooperation and relaxation
- Ensure that client has emptied her bladder
- Place client in the dorsal position with the legs flexed at the hip and knees
- With sterile gloved hand, part the labia and gently pass a Cusco’s speculum.
- Visualise the cervix
- Clean the cervix and fornices with antiseptic solution
- Grasp the vaginal strings of the device near the external os with artery
forceps and apply gentle and steady traction to remove device
- Check that no part has broken off the device
- Show device to client
- Clean the cervix with an antiseptic solution
- Apply a perineal pad

Post removal instructions

- Explain to client slight Vaginal spotting may continue for a few days
 - If client wishes to use another method of contraception, counsel and/or
initiate accordingly

Difficulty in the removal of IUCDS

Trained doctors should do removal
If traction, (as described above) does not result in the removal of the device and
strings are still visible or snapped, proceed as follows:
- Probe the cervical canal with narrow artery forceps and attempt removal (if
this fails, device is probably embedded in endometrium)
- Explore the uterine cavity with alligator forceps, sharman’s curette or
retriever hook.
- If this fails, dilate the cervix with small dilators and attempt removal again
(cervical block may be necessary or give appropriate analgesics)
- X-ray or scan with ultrasound to exclude partial or complete extrusion
through uterine wall. If this is found, explore the uterine cavity under
general anesthesia and be prepared to remove a completely extruded IUD
by laparoscopy or laparotomy.

SIDE EFFECTS AND MANAGEMENT OF INTRA-UTERINE CONTRACEPTIVE DEVICES

Cramping:
1. If cramping is severe
- Exclude pelvic or ectopic pregnancy, remove IUCD and assist client choose
another method
2. Heavy or irregular vaginal bleeding
- If no pathology, reassure, counsel and follow-up
- If bleeding is heavy or there is anaemia
- Remove the IUCD and counsel client on other options

3. Vaginal Discharge or PID:

- If recurrent or persistent
 - Remove and treat infection appropriately
- Counsel on IUD and offer specific antibiotic therapy and counsel on other
options.

4. Amenorrhea:
- Check if IUD in-situ or intra-abdominal by scanning
- Institute appropriate treatment
- If IUD is not located it is possibly expelled
Note: In all situations, refer if in any doubt.

VOLUNTARY SURGICAL CONTRACEPTION

Voluntary Surgical Contraception (VSC). Is a method that provides permanent
contraception through the occlusion or removal of some parts of the female/male
productive system; usually the tube in the female and the vas deferens in the
male
Clients for VSC require skilful counselling using the ACRONYM
B – benefits
R – risks
A – alternatives
I – information
D – decision to change
E – explanation
D – documentation.

Types of VSC
1. Bilateral tubal occlusion for women through
- Ligation by
 - Clip or ring application or by
- Diathermy application

2. Vasectomy for men.

Mechanism of action
VSC prevents the spermatozoa and the egg from coming together by blocking the
passage of sperm along the vas deference (vasectomy) or its transport along the
fallopian tubes (tubal occlusion)

Benefits of VSC
- High efficacy (0.1-0.15 pregnancies/100 women first year of usage)
- Relatively permanent
- Does not interfere with intercourse
- Does not affect breast feeding
- Allows male participation in family planning

Limitations of VSC
- Not easily reversible, so it needs effective counselling
- Client may regret later
- Risks and side effects of the surgical procedure
- Does not protect against genital tract infections (GTI)
- With vasectomy, effectiveness may be delayed for up to 3 months and
clients need to use back-up methods during intercourse.

Side effects/Complication of VSC

i. Wound Infection:
- Explain to client that this can be minimized by strictly observing infection
control methods
- Commence antibiotics and/or refer immediately.
 ii. Haematoma formation: may occur at site of operation e.g. if scrotal
support is not provided in vasectomy
iii. Drainage may be necessary by a competent hand.

Pre-operative management for voluntary surgical contraception

- Pre-operative preparation
- Counsel and obtain informed consent. Before any surgical permanent
method is performed (i.e. vasectomy or tubal ligation). Ask for reasons to
undertake the procedure and do not wish to bear more children. Tell client
the procedure is not reversible.
- Give appropriate information and counselling
- Obtain informed consent from client
- Confirm client willingness to proceed with sterilization procedure.
- Obtain pre-operative history a few days before or on the day of surgery.
- Examine client paying particular attention to the pubic area to exclude
aontra-indication
- Exclude all contra-indications to surgery e.g. large hydrocele bleeding
disorders or enlarged adnexia (female)

Immediate pre-operation care

Reassure the client and give pre-operative information and ensure the conscent
form is properly filed.
- Clean the site for operation-genital area with antiseptic lotion e.g Baladure
or chlorohexidure
- Drape the operative field
- Administer tranquilizer to calm client (if anxious)
- Anaesthesia e.g. 10cc syringe with 10% or 2% lignocaine without
epinephrine to ensure adequate relaxation of client.
- Place client in the dorsal position.
Post operation care
- Observe site for bleeding. If sedation has been used, monitor vital signs
every 15 minutes after surgery until stable.
- Clients who have undergone permanent surgical contraception may leave
the health facility after resting for 30 minutes or when comfortable to go.

Give post-operative instructions

(i) Tell client to maintain hygiene of the site.
(ii) What side-effects to expect e.g.
- Maintain hygiene of the site.
- Report any abnormality e.g. swelling, oozing of pus, bleeding or unbearable
pains.
- Can return home after full recovery from check-up to ensure that no
infection of other problem have occurred.
- What to do if complications occur, where to go for emergency care.
- When and where to return for a follow-up visit.
- Tell client that minor pains and brusing are to be expected and do not
require medical attention.
(iii) Explain possible complications to be reported such as fever, bleeding,
oozing from the site of operation, or if he/she experiences pain or
swelling.
(iv) Advise on rest at home the day after surgery
(v) Resume normal activities after one or two days
(vi) Avoid work or strenuous exercise for at least 48 hours to aid healing of
the wound.
(vii) Keep wound clean when bathing
(viii) Wash after three days
(ix) Can have sex as soon as it is comfortable or convenient but usually two
to three days after operation (for male) and two three weeks after the
operation (for female).
(x) Advise client and partner to use temporary contraceptive i.e. for female
dual protection method e.g. condom and spermicidal or other method
for 12 weeks or until after 20 ejaculations, before intercourse,
whichever comes first. Inform client that a small amount of pain is
 expected – use ice pack on site to relief pain, e.g. Protect with other
method until check-up for sterility e.g. use condom.

EMERGENCY CONTRACEPTIVES
Definition:
The term emergency contraception refers to methods used to prevent pregnancy
after or following unprotected sexual intercourse (either when no method was
used or the method failed at intercourse e.g. breakage of condom).
It is also known as “postcoital” and “morning-after” contraception.

Types of ECs
Several types in use around the world, include.
1. Various hormonal regimens e.g.
ORAL CONTRACEPTIVE PILLS such as:
- Combined oral contraception (COC)
- Progestin only pills (POP)
- The Yunzpe Regimen
- Levonorgestrel Regimen (POSTINOR)
- Mifepristone
- Danazol
- High Dose Estrogens

2. Copper intrauterine Devices (IUDS) copper containing e.g. post-coital

insertion of Cu-T.
- Antiprogestin (mifepristone)

Characteristics
 - All must be used within certain days of unprotected intercourse to prevent
pregnancy.
- Safe and relatively highly effective.
- Women are unaware of the existence of these methods and do not know
how to use them. By offering EC information and services to their clients, FP
programs can help wpmen to avoid unintended pregnancy.

Mechanism of action of Ecs

- Suppression of ovulation
- Sperm transport delay along the reproductive tract especially the cervical
mucus.
- Rendering endometrium unsuitable for fertilization and/or implantation.
ECPs prevent pregnancy by producing transient changes in:
- The ovary, by preventing ovulation (if administered in the first half of the
menstrual cycle)
- Altering the ovarian function (if administered after ovulation)
- Changes in the endometrium e.g. by making it unsuitable for implantation
of a fertilized ovum.

Indications:
Emergency contraception is indicated when a woman:
- Has been sexually assaulted;
- Has experienced condom breakage or slippage;
- Has neglected to use a method;
- Has engaged in unexpected sexual activity;
- Engages in sexual activity only infrequently;
- Does not want to use contraception on a regular basis out of fear of
discomfort or side effects;
- Had a failed coitus interrupts;
- Had ejaculation on external genitalia;
- Had a miscalculation of rhythm method;
 - Had her diaghgram inserted incorrectly, dislodged during intercourse or
removed too early;
- Had expulsion of an IUCD;
- Missed oral contraceptives.

Contral indications:
- Not ideal for women with multiple sexual partners.
- Not ideal for breast feeding women (Projestine – only ECPs preferable).

Effectiveness and safety:

Effectiveness:
- Relatively highly effective (99.1%).
- Risk of pregnancy = 1.9% for women on ECPs;
- With no ECPs, 7.2% would be pregnant during one menstrual cycle (ECPs
prevent about 3 out of 4 expected pregnancies).

Safety of ECPs
Considered very safe;
Virtually no medical conditions completely preclude the use ECPs;
No deaths or serious medical complications reported in more than 20 years;
Relatively small dose of hormones;
Short exposure to hormones;
No risk of fetal malformations or congenital defects;
Not ideal for breastfeeding women (Progestin-only ECPs preferred);
Overall risk of ectopic pregnancy probably reduced.

How to use ECs

 Women who are at risk of unwanted pregnancy should take:
- An initial dose of 100mcg of Ethinyl Estradiol (EE)
- 0.5 mg if Levonorgestrel (LNG). The same dose is repeated 12 hours later.
i.e. use as follow:
- COC -4 tablets (each containing 30mcg of ethinyloestralio) is taken within
72 hours of intercourse and 4 tablets repeated repeated 12 hours after the
first dose. Alternatively, 2 tabs of high dosage COC (50mcg ethinyl estradiol)
with 72 hours of intercourse and same dose repeated 2 hours later.
- Postinor-1 tablet (Postenor) containing 750mcg Levonorgestrel stat, or
packet of 20 tablets containing 75mcg of norgestrel is taken within 48 hours
of intercourse and dose repeated 12 hours later.

Formulations and dose required for emergency contraception.

Formulation Common Brand Tablets per Doses Timing of
names dose Required Administration
EE 50 mcg + Neogynon, Noral, 2 2 First dose within 72
LNG 0.25 mg Nordiol, Ovidon, hours of unprotected
or EE 50 mcg Ovran sex; second dose 12
+ NG 0.50 mg Eugynon 50, Ovral hours later.
EE 30 mcg + Microgynon 30, 4 2 First dose within 72
LNG 0.15 mg Nordette, hours of unprotected
or EE 30 mcg Rigevidon sex, second dose 12
+ NG 0.30 mg 4 2 hours later
Lo/Femenal, Ovral
L
LNG 0.75 mg Postinor 1 2 First dose within 72
hours of unprotected
sex; second dose 12
hours later
LNG 0.03 mg Microlut, 20 2 First dose within 72
Or Norgeston hours of unprotected
NG 0.075 mg Microval 20 2 sex, second dose 12
Ovrette hours later.
FF = ethinvl estradiol LNG = levonorgestrel NG = norgestrel
Note: it should not be used as regular oral contraceptive.

- IUDs – copper containing, such as CuT380 is inserted within 4-5days of

unprotected Intercourse.
- Antiprogestin: 600mg of mifepristone (RU 486) is taken orally within 72
hours of unprotected intercourse.
- As soon as after unprotected intercourse as possible within 72 hours.
- Women must be informed in advance that ECP services exist
- IUCD as emergency contraceptive
The IUD can in certain cases be used as an alternative to hormonal methods of
emergency contraception. A metal-analysis of 19 students of post coital
insertion of IUDs revealed a failure rate of 0.1%, which suggests that this
method may be 15 times more effective than the Yuzpee regimen. An IUD can
be inserted up to the estimated time of implantation, which is around five days
after ovulation (or five days after unprotected intercourse if the day of
ovulation is difficult to estimate); thus IUDs can be used 48 hours later than
hormonal methods. The IUD is effective as soon as it is inserted, and therefore
gives immediate protection for subsequent acts of intercourse in the same
cycle. It also provides up to 10 years of subsequent acts of intercourse in the
same cycle. It also provides up to 10 years of subsequent contraceptive
protection. No studies have reported side-effects or morbidity after insertion
of an IUD for emergency contraception.

Advantages of ECPs
- Well-documented safety. Very safe and effective way of preventing an
unintended pregnancy after unprotected intercourse or contraceptive
accident, such as condom slipping or breaking.
- Relatively highly effective
- Virtually no medical condition, completely preclude the use of ECPs.
- No deaths or serious medical complication reported in more than 20 years
- No risk of foetal malformations or congenital defects.
- Relatively small dose of hormones, short exposure to hormones
 - Drug exposure and side effects are of short duration
- Readily available
- Convenient and easy to use
- Multiple contraceptive mechanism: prevent ovulation and implantation
- Reduce the need for abortions
- Appropriate for young adults who may have unplanned sex
- Can provide a bridge to the practice of regular contraception.
- Overall risk of etopic pregnancy probably reduced
- Safe and effective if used within 72 hours of intercourse or 5 days with
regards to IUCDs
- Indeed. Emergency contraception has been describe as “one of the best
kept secrets in family planning”.

Disadvantages
- Women are unaware of the existence of this method and do not know how
to use them
- ECPs are neither suitable nor effective as a regular method of birth control.
- Do not protect against transmission of STDs and HIV;
- Do not provide ongoing protection against pregnancy;
- Should be used within 3 days of unprotected intercourse for highest
efficacy;
- May produce nausea and somethings vomiting;
- May alter date of next menstrual cycle;
- Less cost-effective than regular contraception;
- Could result in increased pregnancy risk if used too frequently.
- ECPs are not effective once implantation of a fertilized ovum has occurred.
- ECPs cannot be used to disrupt an established pregnancy.
- ECPs are neither suitable nor effective as a regular method of birth control
Side effects
- May cause severe nausea and/or vomiting.
- Nausea
Typical occurs in 50% of women using ECPs
Does not last more than 24 hours
 - Vomiting
Also occurs in 30% of women (Some studies report low levels)
- Irregular bleeding or spotting;
- Breast tenderness;
- Headache;
- Dizziness
- Cycle disturbance: irregular bleeding may occur during the treatment cycle.
Next menstrual bleeding may be early or late.

Benefits of ECs
- Unplanned and unprotected intercourse such as rape and incest.
- Broken condom
- Leakage from condom

Family planning methods for specific groups

1. Breast feeding mother:
Nursing mother:
The contraceptive chosen for a nursing mother after delivery should not be the
one that interferes with the mother’s ability to produce breast milk in sufficient
quantity. Contraceptives given at 6 weeks post-partum are less likely to interfere
with breast feeding because lactation has already been fully established by time.

Nursing mothers can choose any these methods:

(i) Abstinence if practiced properly it is 100% effective in preventing
pregnancy.
(ii) Barrier methods e.g. condoms or diaphragms.
(iii) Spermicides such as foaming tablets, creams/Jellies
(iv) Barrier methods e.g. condoms or diaphragms.
(v) Oral Contraceptive pills (OCP), preferably Mini Pills Combined Oral
Contraceptive Pills (COC-pill) with oestrogen content of 30 – 35 mcg (low
 dose pills) are good contraceptive choice for breast feeding mothers
provide they are given after lactation has fully been established e.g.
Exduton
(vi) Depo-Provera 150mg (injection)
(vii) Tubal-ligation for women who do not want to have more children.

Instructions for the breast feeding mother

1. Breast feed exclusively: The most effective contraceptive method for
nursing mothers
2. Practice more simultaneously use of abstinence during breast feeding
3. Ask your clinician for nutritional advice, anti-malarial pills and vitamins.

Points to note: Breast feeding on demand, day and night with short internals
between feeds if you plan to rely on breast feeding to prevent pregnancy.

2. Dual protection for HIV clients e..g. Condom

Every woman treated for abortion complication needs to know three facts:
i. She could become pregnant again right away
ii. She can delay or prevent another pregnancy by using family planning
method
iii. Her health care provider can help her get and use family planning
method most methods can be started right away she can choose from
any of the following:
- IUCD (copper or/levonorgestrel)
- Cervical cap or diaphragm
- Condoms e.g. female condom.
- Pills (Progrestine-only)
- Injectables (progresine only)
- Nor-plant, implants
- Spermicides.
 - Wait until a normal menstrual pattern returns before using natural family
planning (NFP e.g Rhythm, Periodoc Abstinence).

After treatment of second trimester abortion: surgical technique for female

sterilization must account for the account for the position of the fallopian tubes.
IUCD expulsion rates may be higher than usual.

3. Family planning method for specific medical conditions:

Current pelvic infection or risk that an infection is developing:
(i) For female sterilization or IUCD insertion, wait until infection is resolved
or rule out lacerations.
(ii) Injury to the genital tract for female sterilization or IUCD insertion worn
until the injury has healed.
(iii) Use of diaphragm, cervical cap or spermicides may be limited by injuries
to the vagina or cervix
(iv) Severe anaemia from blood loss: For female sterilization, consider the
risk of further blood loss.
(v) If the woman cannot begin using her preferred method right away, give
information about emergency contraception and make sure she has a
method she can use right away
(vi) Counsel on dual protection.

4. Family planning methods for adolescents/young people

Abstinence:
This is total avoidance of sexual intercourse and is the best for unmarried
adolescents.

Method:
Apply assertive skills e.g. in assertiveness, say ‘No’ maintain self-control etc
Benefits:
Full protection against pregnancy and STIs including HIV

Disadvantages:
Not all can practice it
- Use condom if you must sex

Condoms:
Types
Male and female condoms: Male condom is worn on erect penis before
intercourse, female condom is inserted into the vagina before sexual intercourse.