What is the principle behind Natural family planning method?

The basic priniciple is to determine the fertile periods of a woman using the physiologic signs and symptoms. 

What are the various types of NFP?

1. Basal Body Temperature (BBT)
2. Cervical Mucus Method / Billing's Ovulation Method
3. Sympto-Thermal Method
4. Lactational Amenorrhea Method (LAM)
5. Cycle Calculation Method / Calendar Method / Rhythm method 

What is the overall Actual Failure rate of NFP?

10-30% 

What are the indications as to when we can provide NFP?

• for women who do not wish to use other contraceptive methods because of health or religious or personal beliefs
• for women who want to use a less effective method of family planning

What are the advantages of NFP?

• Widely acceptable ; no known side effects
• Used either to delay or to achieve pregnancy
• Promotes self-awareness and knowledge of the human reproductive functions.
• Promotes shared responsibility between couples

What are the disadvantages of NFP?

• It requires commitment, cooperation, and open-communication between partners
• Requires daily record of signs and symptoms of fertility
• "Emotional stress" experienced by some couples due to the need to abstain from intercourse during certain days

What are the contraindications of NFP?

No absolute contraindications

What are the pre requisites before giving NFP?

• To get client history and physical examination is not strictly necessary.
• Client education is very important; it requires intensive training of both partners

 

What is the principle behind BASAL BODY TEMPERATURE (BBT)?

• during menses, a woman's BBT changes from a lower to a higher level
• before ovulation (estrogen dependent), the temperature pattern is at a lower level
• shortly before, during ovulation (progesterone dependent) the BBT rises

"THERMAL SHIFT"(TF)
• 0.4 - 1.0 deg Fahrenheit
• 0.05 - 0.2 deg Centigrade
Note :
• ovulation occurs 1 to 2 days before the "thermal shift" or on the day of the thermal shift
• ovulation can occur :
  - 1 day after the "thermal shift"
  - or rarely 3-6 days before the "thermal shift"

What are the important pointers to remember in BBT ? 

1. BBT pattern changes from a lower to a higher level during menses.
2. by monitoring her BBT, one can determine her infertile phase.
3. safest way to avoid pregnancy is to avoid intercourse all throughout the cycle until after BBT rises and remains high for 3 days.
4. The following affects BBT monitoring :

• sore throat
• colds and flu
• fever
• toothache
• vomiting
• diarrhea
• anxiety
• sunburn
• medications
• travel
• sleep disturbances
• alcoholic beverages

How do we use BBT?

1. Take temperature every morning upon waking up and before any activity.
2. If not possible, take the temperature about the same time everyday after at least three hours of undisturbed rest.
3. Take the temperature (under the tongue, in the vagina, or in the rectum). The temperature should be taken in the same manner/site throughout the cycle. Rectal and vaginal temperatures are usually higher than oral temperatures.
4. Leave the thermometer in place for five minutes.
5. Read and record the temperature immediately after taking it.
6. Record it on a chart by placing a dot in the center of the box that matches the temperature printed on the left side of the chart. Connect the dots marking the temperature on a daily basis so as to see the pattern.
7. Record any unusual event such as illness, worry or any changes in the lifestyles. 

What is COVER LINE?

It is the point of reference to determine the thermal shift due to ovulation.

This is determined by the following:

• identify the first 10 temperatures of the cycle
• disregard the temperatures for D1 - D5
• find the highest temperature from D6 - D10
• draw a horizontal line on the highest temp from D6 - D10. This is the coverline.

ABSOLUTE INFERTILE PHASE DAYS :
- From the rise in the temperature due to ovulation, wait for 3 consecutive days above the coverline.
- Intercourse is allowed from the 4th day of the thermal shift until the end of the cycle. This is infertile phase of the cycle.

 

-

What is the principle behind the CERVICAL MUCUS METHOD?

- uses the changes in the cervical mucus consistency as to predict ovulation and to determine when it has occurred.

1) After menses ends

• most women - no mucus
• vagina feels dry
• these are called dry days

2) After the dry days

• mucus - sticky, pasty or crumbly
• color - white or yellow
• vagina - still dry, little sticky
• these means that ovulation is coming, this is considered a fertile time

3) As ovulation gets nearer

• mucus - welt, increases in amount
• color - clearer

4) At the time of ovulation

• mucus - very wet, stretchy and slippery (raw egg white)
• vagina - feels very wet
• this will last for several days
• the last day of the wet and slippery mucus is called the peak day

5) After ovulation

• mucus - very sticky, and pasty, decreases in amount

INFERTILE PERIOD

• 4th day after the peak day and continues until menstruation begins

How do we use CERVICAL MUCUS METHOD?

- requires the woman to observe what she feels and sees at her vulva and record

1) Begin checking the mucus - WHEN ?

• the menses ends or becomes lighter
• there is no prior sexual intercourse, and
• a woman is not sexually stimulated

2) Check the sensation of wetness and dryness while standing
3) Inspect underwear regularly for the presence of mucus
4) Wipe across the opening of the vagina with a piece of clean tissue paper, clean cloth or clean finger.
5) Using the middle/index finger and the thumb, test the consistency, the slipperiness, the stretchiness and the color of the mucus.

What is the principle behind SYMPTO-THERMAL METHOD (STM)?

• it is a combination of Basal body temperature (BBT) and Cervical mucus method as well as other signs that help identify her fertile time.

What are the "OVULATORY SIGNS" ?

• dull ache or sharp pain in the area of the ovary lasting from a few minutes to a day or two
• fluid retention (swelling of the hands and feet)
• increase or decrease in sexual desire
• slight bleeding for one or two days may occur (noted during ovulation)

AFTER OVULATION (BEFORE MENSES)

• oily skin and hair, pimples or increase in acne
• uterine cramps
• low back pains
• craving for sweets and/or salty foods
• breast tenderness
• increase or decrease in sexual feelings

How do we use STM?

The acceptor of this method is required to observe her BBT, cervical mucus and other and to record them in a chart. 

What are the rules to observe in STM?

1) Intercourse can occur during the first 5 days of the menstrual cycle if the peak day and thermal shift rules were applied
2) Menstruation days are relatively

• infertile days - average or long cycles
• fertile days - short cycles

3) After menses, intercourse can occur on the evening of every other dry day during the infertile days before ovulation
4) The first day a woman observes any type of mucus or when she begins to feel wet sensation, it is the beginning of the fertile phase.
5) Couples abstain from intercourse until the peak day rule and thermal shift rules have been applied whichever comes later.

What is the principle behind the LACTATIONAL AMENORRHEA METHOD (LAM)?

• it involves post-partum women
• effectiveness of breastfeeding as a contraceptive is brought about by the increased sucking frequency
• RETURN OF OVULATION :
       - MOST WELL BREASTFEEDING WOMEN - 4-12 and even up to 24 months
       - NON-BREASTFEEDING WOMEN - as early as 1-2 months after delivery

What are the forms of voluntary surgical forms of contraceptions (VSC)?

• FEMALE SURGICAL CONTRACEPTION (TUBAL LIGATION)
• MALE SURGICAL STERILIZATION (VASECTOMY)

FEMALE SURGICAL CONTRACEPTION (TUBAL LIGATION)

• ALMOST 100% EFFECTIVE
• involves the cutting ligation and tying of the fallopian tubes
• 2 TYPES : 1) MINI-LAPARATOMY; 2) LAPAROSCOPY
• OPERATIVE PROCEDURE : 10-20 MINUTES
• ANESTHESIA USED : LOCAL

1) MINI-LAPAROTOMY

• 3 cm abdominal incision
• above the symphysis pubis
• 2 types:
      a) interval minilaparotomy
      - 1st 7 days of menstrual cycle or anytime within the woman's cycle of pill intake or if she has an IUD
      - incision : above the symphysis pubis
      b) postpartum minilaparotomy
      - 1st 8 weeks after a normal delivery
      - incision : below the umbilicus/navel above the level of the fundus of the uterus

2) LAPAROSCOPY

• a 1-5 cm abdominal incision below the umbilicus
• a laparoscope is inserted
• uses electrocautery or fallopian rings or clips

What is the principle behind female VSC?

• blocking of the fallopian tubes

• prevents the union of the sperm and egg

What are the indications for TUBAL LIGATION?

• couples who have enough number of children they desire

• women who cannot practice any other family planning methods (religion, cultural, or personal beliefs)

• women whose child-bearing is dangerous (high risk)

What are the advantages of TUBAL LIGATION?

• inexpensive
• can be done on an out-patient basis
• easily performed
• does not affect the female hormonal balance
• does not lessen the couple's sexual desire and enjoyment
• decreases the maternal and child mortality and morbidity risks when done before or during the woman's high-risk period

What are the disadvantages of TUBAL LIGATION?

• it is a permanent procedure ; it is hard to reverse

• needs a trained surgeon to do it

• cannot be prescribe for those below 25 years or with less than 2 children

• psychological and emotional preparations needed

What are the various components to consider in the provision of tubal ligation ? 

1. SCREENING OF CLIENTS
   - pelvic infection, which should first to be treated before VSC
   - a systemic or localized infection
   - medical problems (heart disease, diabetes, bleeding tendencies)
   - obesity
   - pregnancy
   - previous surgery (adhesions)

2. COUNSELING
   - procedure is permanent
   - no effect on the sexual and other body functions
   - possible risk of failure

3. COMPLETE PHYSICAL AND PELVIC EXAM

4. LABORATORY EXAMS

5. INFORMED CONSENT FORMS
   - signed by the client
   - witnessed by her husband

What are the various rumors/misconceptions on tubal ligation (TL)?

• Tubal ligation results in the loss of sex drive.

• Tubal ligation stops menstruation and leads to premature menopause.

• Tubal ligation is not suited for women whose activities entail lifting of heavy objects or other strenuous activities.

What are the other information needed by patient on TL?

• Surgery is done on the 1st half of the cycle when she had no sexual contact, or within the first 3 days of delivery.

• After surgery,
      - 2 days rest is required
      - no sex or any hard work for 1 week
      - lower abdominal discomfort for a few days
      - wound care

What are the danger signs to watch out in TL?

• bleeding
• increasing abdominal pains
• fever

When is check up conducted after TL?

• 1st - after 1 week

• 2nd - after 1 month

• 3rd - after 3 or 6 months subsequent yearly check-up-Pap smear

MALE SURGICAL STERILIZATION (VASECTOMY)

• 1 cm skin incision made in the scrotal sac

• vas deferens is tied and cut

• failure rate : 1:1000 cases due to :
      - unprotected coitus before reproductive tract
      - spontaneous recanalization
      - occlusion of the wrong structure
      - undiagnosed duplication of the vas deferens

What is the principle behind vasectomy?

• disrupts the continuity of the vas deferens

• prevents the passage of the sperms

What are the indications of vasectomy?

• couples who have enough number of children they desire

• men whose wives cannot practice any other FP methods whether permanent or temporary

What are the contraindications of vasectomy?

• single, childless men

• unhappily married men

• men who are undecided as to whether they would still like more children

What are the advantages of VASECTOMY?

• convenient

• effective and reliable

• safe, simple and easy to perform

• does not affect male hormonal balance

• does not lessen the couple's sexual drive it may even enhance it

• inexpensive

What are the disadvantages of vasectomy?

• being permanent, it is hard to reverse

• it needs a trained doctor do it

• cannot be prescribed to those below 25 years and with less than 2 children

• emotional and psychological counseling required

What are the components in the provision of VASECTOMY ? 

1. SCREENING OF CLIENTS
   They should not have the following problems :
       - local skin infection or genital tract infection
       - hernias and other related pathology of the male genital tract

2. COUNSELING
   permanent nature of the procedure
   absence of effect on libido and other sexual failure
   risk of failure

3. COMPLETE HISTORY/PHYSICAL EXAM
   HISTORY WITH EMPHASIS ON THE FOLLOWING :
       - scrotal/inguinal operation
       - bleeding disorders
       - drug allergy
       - STDs
       - UTI
   PHYSICAL EXAM FOCUSES ON :
       - thick scrotal skin
       - scrotal mass
       - hernia
       - elephantiasis
       - varicose

4. INFORMED CONSENT FORM

What are the rumors/ misconceptions about VASECTOMY? 

1. Vasectomy is castration or "kapon"
2. Vasectomy results in the loss of male characteristics such as body hair, low pitch voice, sexual power, and ultimately, in impotence and homosexuality. 

What are the other things that clients need to know about vasectomy? 

1. Inform the client about the mechanism of action of the method as well as the technique of the operation
2. After surgery,

• client should return at home to rest for 2 days

• ice pack on the scrotum for at least 4 hours

• client may resume sexual intercourse, but he must use barrier methods (condoms)

• tubes will not clear of sperms until after 15-20 ejaculations

• wound care, he should not bathe the area for at least 2 days

What are the danger signs after vasectomy?

• bleeding

• pain/swelling of the scrotum

• fever within one month

When is check up after vasectomy done?

• 1ST - 1 WEEK AFTER

• 2ND - 1 MONTH AFTER

• SUBSEQUENT CHECK-UP WHEN NECESSARY

What are the essential points to consider in VSC?

IMPORTANCE OF COUNSELING :

• considering the method is permanent

• surgical procedure

NEUTRALITY IN COUNSELING

• one should not persuade or influence people to choose one method over the other

• one should assess clients' knowledge about the different FP methods

• one should give information they lack, help them apply the facts about FP to their own circumstances so that they can make their own well-considered, free and informed decisions.

What are the special considerations for VSC counseling? 

(PEOPLE WHO MAY LATER CHANGE THEIR MINDS)

• young couples

• couples with children

• couples with unstable union

• clients pressured by spouse to undergo VSC

• a client who has made a hasty decisions

• a client who has decided under stress (while under labor pains, immediately following delivery or abortion).

• a client whose future goals are limited to home and family

• a client with unrealistic expectations of VSC

What are the expectations about reversal ?

• sterilization reversals is not available in most places

• clients should be made to understand the chances of reversing the procedure is low

• the reversal is costly and involves complications (ectopic pregnancy)

• lengthy surgery

What are INTRA UTERINE DEVICEs (IUD)?

• a small device introduced to the uterus to prevent pregnancy

• two types :
      1) Lypes Loop
      - S-shaped with two strand tail
      - effectivity : 96-99%
      2) Copper T 380 A
      - T-shaped with a coil copper wrapped around its stem and arms
      - effectivity : 98-99%

What is the mechanism of action of IUD?

• directly preventing fertilization through biochemical changes

• interferes with the transport of sperm in the genital tract

• decreases the number of viable sperm

• speeds up the ovum transport through the fallopian tubes

What are the advantages of IUD use?

• no systemic effect
• easy to use
• less instructions to remember
• does not interfere with sexual intercourse
• not messy
• safely used during lactation
• can be used without other people knowing
• less expensive than pills

 

What are the disadvantages of IUD use?

• danger of expulsion

• must be inserted by a trained health worker

• temporary side effects : mild abdominal pain

What are CONDOMS?

• made of latex that fits over the erect penis

• effectivity : 98% (consistent and correct use)

What is the mechanism of action of condoms?

• prevents the contact between sperm and ovum

What are the advantages in using condoms?

• Encourages male participation in reproductive health.

• relatively inexpensive

• can be bought over the counter

• easy to use and carry

• used only when needed

• protection against HIV/AIDS and STD

• prevents cervical cancer

• prevents messy post - coital discharge of semen

What are the disadvantages of using condoms?

• loss of sexual arousal

• reduced sensitivity of man's penis

• allergic reactions

• breakage of condom when not correctly used

What is a DIAPHRAGM?

• small rubber cup that fits inside the vagina over the opening to the uterus

• three types :
      1) Flat-spring rim
      2) Coil-spring rim
      3) Arching-spring rim

• effectivity : as high as 98% as low as 80%

What is the mechanism of action of diaphragms?

• a device that holds the spermicidal cream

• barrier placed in the vagina covering the cervix

What are the advantages of diaphragm use?

• very few side effects

• used only when needed

• can be placed 2 hours before intercourse

• good for pregnant or breastfeeding women

What are the disadvantages of diaphragm use?

• allergy to rubber or spermicides

• foul-smelling vaginal discharge

• pelvic discomfort or pressure on the rectum or bladder

• vaginal ulceration

What are CERVICAL CAPS?

• cup-shaped device that fits over the cervix and is held in place at least partially by suction

• three types:
      1) Prentif cavity rim
      2) Dumas cup
      3) Vimule cap

• effectivity : as high as 90% and as low as 70%

What is the mechanism of action of cervical caps?

• prevents sperm from entering the uterus

• device to hold spermicidal cream against the cervix

What are the advantages of cervical cap use?

• can be left for more than 24 hours

• can be inserted many hours or even a day or two before intercourse

• needs only a small amount of spermicides

What are the disadvantage of cervical cap use?

• allergy to ingredients

• can cause pregnancy

What are ORAL CONTRACEPTIVES PILLS (OCP)?

• composed of synthetic hormones which prevents pregnancy when taken regularly

• three types:
      1) Combined Monophasic - contains synthetic estrogen progesterone in a fixed dosage, effectivity is 99.6%
      2) Combined Multiphasic - composed of progesterone and estrogen
      3) Progesterone - only pill, effectivity is 97%

What is the mechanism of action of OCPs? 

1.  Primary Action

• suppressing the release of gonadotrophin releasing hormone (GnRH)

• directly inhibiting release of follicle stimulating hormone (FSH) and lutenizing hormone (LH)

2. Secondary Action

• thickening of the cervical mucus

• inhibits follicle development in the ovary

• inhibits sperm penetration into the ovum

• inhibits ovum transport to the uterus

What are the advantages of OCP use?

• reduces dysmenorrhea

• regulates menstrual cycle

• reduces menstrual blood flow (useful to anemic women)

• decreases premenstrual syndrome

• preserves reproductive ability

• decreases risk of severe form of P.I.D.

• decreases risk of ectopic pregnancy

• decreases risk of ovarian & endometrial cancer

• decreases rate of benign breast disease

• decreases incidence of acne

• does not interrupt sex

• can be stopped anytime

What are the disadvantage of OCP use?

• supply of pills

• compliance

• minor side effects: nausea, headache, and breakthrough bleeding

What are the DANGER SIGNS OF PILL INTAKE? 

A - abdominal pains, gallbladder disease, blood clots, pancreatitis
C - chest pains, coughs, shortness of breath, blood clots in the lungs, heart attack
H - headaches, dizziness, weakness, numbness, stroke
E - eye problems, speech problems, stroke
S - severe leg pains, blood clots in legs

Other signs :

• depression, jaundice, breast lump

What are INJECTIBLES?

• are progestin-only, long acting contraceptives that provide protection from 2 to 3 months for each injection

• effectivity : 99.6%

• 2 most commonly used:
      1) DMPA or Depo-Provera
      2) Net or Norigest or Noristerat

What is the mechanism of action of injectables?

• inhibits ovulation

• thickens the cervical mucus

• less blood supply to the lining of the uterus

What are the advantages of injectable use?

• highly effective, long-lasting, and safe

• protection against endometrial and ovarian cancer

• no serious complications associated with estrogen containing pills

• does not interrupt sex

• most confidential method

• prolonged amenorrhea, beneficial to some women

• does not affect breastfeeding

What are the disadvantages of injectable use?

• breakthrough bleeding or spotting

• frequent amenorrhea

• delayed return of fertility (18 months)

• weight gain

• decrease libido, depression, headaches, dizziness, allergic reactions, heavy bleeding

What are INJECTABLE IMPLANT CONTRACEPTIVES?

• are progestin-only contraceptives implanted beneath the skin for long term use, ranging from 6 months to 5 years

• effectivity : 98.99%

• 3 types:
      1) Norplant - most widely used
      2) Biodegradable implants - Copronor
      3) Injectable microspher and micro-capsule

What are the advantages of implants?

• long lasting and highly effective

• continuous protection up to 5 years

• reversible

• contains no estrogen

• no pelvic examination is needed

What are the disadvantages of implant use?

• changes in menstrual pattern

• headaches

• weight gain

• dizziness

• severe lower abdominal pains

• arm pains or bleeding on insertions site

• heavy bleeding

What are VAGINAL RINGS?

• a levonorgestrel-impregnated ring that a woman can place in her vagina

• effectivity : 96.5%

What is the mechanism of action of vaginal rings?

• prevents ovulation by slowly releasing hormones

• thickens cervical mucus

What are the advantages of vaginal ring use?

• minimal client - physician contact
• can be self-administered
• easily removed in case of pregnancy
• fewer side effects than oral contraceptives
• does not affect breastfeeding
• decrease menstrual blood loss

What are the disadvantages of vaginal ring use?

• vaginal discharge

• vaginal irritation

• vaginal infection

What are VAGINAL SPERMICIDES?

• made of an inert base and a spermicidal agent

• effectivity : 95% when used consistently

• four types:
      1)tablet
      2)foam
      3)jelly
      4)suppositories

What is the mechanism of action of spermicides?

• spermicides

• inert base, act as a barrier to the movement of the sperm

What are the advantages of spermicides?

• used only when needed

• can be stopped anytime when pregnancy desired

• no systemic effect

• less to developed P.I.D.

• protection against STD

What are the disadvantages of vaginal spermicides?

• expensive

• messy to use

• allergic reaction to ingredients

• pregnancy

What is a VAGINAL SPONGE?

• a sustained release system for the spermicide

• effectivity : exceeds that of spermicides but lower than the use of diaphragm or condom

What is the mechanism of action of sponge?

• Absorbs semen

• blocks entrance to the cervical canal

What are the advantages of vaginal sponge use?

• easier to use

• less messy

• provides continuous protection for 24 hours

What are the disadvantages of vaginal sponge use?

• allergy

• vaginal dryness, soreness, itching

• not good choice for women with anatomical change