Reproductive Life Planning

Reproductive Life Planning

n  Includes all the decisions an individual or couple make about having children.

n  If and when to have children

n  how many

n  how they are spaced

n  Counseling

n  how to avoid conception

n  increasing fertility

n  infertility

n  As many pregnancies as possible are intended.

n  Unintended pregnancies are less likely to:

n  seek prenatal care

n  to breast-feed

n  expose fetus to harmful substances

n  Greater risk of :

n  low birthweight

n  dying in the first year

n  being abused

n  not receiving resources for good health

n  Contraceptive products (products to prevent pregnancy) were not reliable or could not be easily purchased.

n  Today people have numerous choices.

n  They need to chose carefully:

n  know the advantages

n  disadvantages

n  side effects

n  other options

n  Consider:

n  Personal values

n  Ability to use correctly

n  How the method will affect sexual enjoyment

n  Financial factors

n  Status of a couple’s relationship

n  Prior experiences

n  Future plans

n  Nurses must educate the client

n  Nursing process:

n  Assessment- most important

n  nurse must focus on good communication

n  nursing diagnosis

n  Planning

n  goals

n  Implementation

n  counseling

n  Evaluation

Contraceptives

n  40 million women use some form of contraception

n  The ideal contraceptive should be:

n  safe

n  100% effective

n  free of side effects

n  easily obtainable

n  affordable

n  acceptable to both

n  free of effects on future pregnancies

n  Effectiveness of contraceptive measures

n  Abstinence - abstain from sexual intercourse

n  most effective way to protect against conception and prevent STD’s

n  difficult to comply

n  overlooked as an option

Natural Family Planning:

n  Involve no chemicals or foreign material being introduced into the body.

n  Religious belief

n  Natural belief

n  Effectiveness varies

n  No risk to the fetus

Fertility Awareness Methods:

n  Rely on detecting when the woman will be capable of impregnation (fertile) and using periods of abstinence or contraceptive use during that time.

n  Calculate the period based on a set formula, woman’s body temperature, consistency of cervical mucus, use of OTC ovulation kit

Calendar (Rhythm) Method:

n  requires a couple to abstain from coitus on the days of a menstrual cycle when the woman is most likely to conceive.

n  3-4 days before until 3-4 days after ovulation

n  Keep a diary of 6 menstrual cycles

n  To calculate “safe” days subtract 18 from the shortest cycle documented (1st fertile day)

n  Subtract 11 from the longest cycle ( last fertile day)

n  If she had 6 menstrual cycles ranging from 25-29 days her fertile period would be from the 7th day (25 minus 18)to the 18th day (29 minus 11)

n  Abstinence or use a contraceptive

n  Basal Body Temperature Method (BBT):

n  Just before ovulation the BBT falls about 1/2 degree

n  At ovulation the BBT rises 1 full degree because of the influence of progesterone

n  this higher level remains for the rest of the menstrual cycle

n  take temperature each morning before any activity

n  she notices a dip in temp followed by an increase; she has ovulated

n  She refrains from sex for the next 3 days

n  Sperm survives for at least 4 days in the reproductive tract so abstinence a few days before ovulation is recommended

n  Problems:

n  illness

n  changes in daily schedule

n  Cervical Mucus (Billing) Method:

n  Natural changes in cervical mucus with ovulation

n  Before ovulation:

n  cervical mucus is thick and does not stretch when pulled between the thumb and finger (spinnbarkeit)

n  mucus secretion increases

n  At ovulation: (peak day)

n  cervical mucus becomes:

n  copious, thin,watery, and transparent.

n  feels slippery, and stretches 1 inch before the strand breaks

n  breast tenderness

n  anterior tilt of the cervix

n  all days the mucus is copious and 3 days after the peak day are considered to be fertile days

n  abstain from sex

n  feel of vaginal secretions after sex is unreliable because of the seminal fluid

Symptothermal Method:

n  Combines the cervical mucus and BBT methods.

n  Temperature daily

n  Cervical mucus daily

n  more effective together

n  Ovulation Awareness:

n  Over the counter ovulation detection kit

n  detects the mid cycle surge of luteinizing hormone in urine 12 to 24 hours before ovulation

n  98-100% accurate in predicting ovulation

n  expensive

Lactation Amenorrhea Method:

n  women breast feeding an infant, there is some natural suppression of ovulation

n  not dependable because a women may ovulate but not menstruate while breast feeding

n  after 6 months of breast feeding advise her to choose another method of contraception

Coitus Interruptus:

n  One of the oldest methods of contraception

n  Couples proceed with coitus until the moment of ejaculation

n  the man withdraws and sperm is emitted outside the vagina

n  some sperm may be deposited in vagina

n  pre-ejaculation fluid may contain sperm

n  little protection against conception

Oral Contraceptives

n  Commonly known as the pill or OC’s

n  composed of varying amounts of synthetic estrogen combined with a small amount of synthetic progesterone.

n  Estrogen suppresses FSH and LH which suppresses ovulation

n  Progesterone complements estrogen by causing a decrease in permeability of cervical mucus which limits sperm motility and access to ova

n  interferes with endometrial proliferation

n  implantation is significantly decreased

n  Monophasic-provides fixed doses of both estrogen and progestin throughout the 21-day cycle

n  Biphasic-deliver a constant amount of estrogen throughout the cycle but an increased amount of progestin during the last 11 days

n  Triphasic-vary both estrogen and progestin content throughout the cycle

n  Closely mimics a natural cycle and reduces breakthrough bleeding (bleeding outside the normal menstrual flow)

n  Obtained by prescription after a pelvic exam and PAP smear

n  99.5% effective when used correctly

n  Noncontraceptive benefits:

n  Decreased incidences of:

n  dysmenorrhea, due to lack of ovulation

n  premenstrual dysphoric syndrome, because of increased progesterone levels

n  Iron deficiency anemia, due to reduced amount of menstrual flow

n  Acute pelvic inflammatory disease (PID) with resulting tubal scarring

n  Endometrial and ovarian cancer and ovarian cysts

n  Fibrocystic breast disease

n  Packaged in dispensers for 21 or 28 days

n  Take 1st pill on Sunday

n  Not effective for 7 days and another contraceptive should be used

n  Women who do not want to have a menstrual flow can eliminate them by beginning a new 21 day cycle of pills immediately after finishing the previous ones

n  For ovulation suppressants to be effective they must be taken consistently and conscientiously

n  Poisoning with increased blood clotting from high estrogen levels could result if a child accidentally ingests the pills

n  Side Effects and Contraindication

n  Nausea

n  Weight gain

n  Headache

n  Breast tenderness

n  Break through bleeding

n  Monilial vaginal infections

n  Mild hypertension

n  Depression

n  These side effects usually subside after a few months of use or may change routine or brand

n  Myocardial or thromboembolic complications

n  Chest pain (MI, PE)

n  SOB (PE)

n  Severe headaches (CVA)

n  Severe leg pain (thrombophlebitis)

n  Eye problems such as blurred vision (HNT, CVA)

n  Mothers that are breast feeding and using OC’s with a high level of estrogen may decrease the milk supply

n  OC’s interact with many drugs

n  Effects on sexual enjoyment:

n  Increases pleasure because they do not have to worry about pregnancy

n  Loss of interest for 18 months due to altered hormones in the body

n  Nausea

n  Effects on Pregnancy:

n  If pregnancy is suspected discontinue taking the pill

n  High levels of estrogen or progesterone might be tertogenic to the fetus

n  Adolescents girls should have an established menstrual cycle for 2 years before beginning Ocs

n  Discontinuing use:

n  May not be able to become pregnant for 1 to 2 months or possibly 6 to 8 months

n  Pituitary gland requires a recovery period to begin cyclic gonadotropin stimulation

n  Mini-Pills:

n  Ocs containing only progesterone

n  implantation will not take place

n  must be taken at the exactly same time every day

n  may use while breast feeding

n  Emergency Postcoital Contraception:

n  Yuzpe regimen usually Ovral

n  administration of two fixed dose combination pills

n  take within 72 hours of unprotected intercourse followed by 2 additional pill in 12 hours

n  high dose of estrogen (200mcg) will cause nausea and vomiting

n  pretreat with Meclizine 50 mg

n  Morning after pill-Preven

n  kit consists of urine pregnancy test and 4 pills that contain estrogen/progestin

n  Plan B - progestin only

n  contains 2 pills containing high doses of levonorgestrel

n  one pill taken immediately and one 12 hours later

n  has less nausea

n  RU 486

Subcutaneous Implants

n  Norplant consists of 6 nonbiodegradable Silastic implants

n  width of pencil lead

n  filled with levonorgestrel (synthetic progesterone)

n  embedded just under the skin on the inside of the upper arm

n  lasts 5 years, by slowly releasing the hormone

n  inserted using local anesthetic during the menses or no later than day7

n  Can be inserted 6 weeks after childbirth

n  Disadvantages:

n  cost $500

n  weight gain

n  irregular menstrual cycle, spotting, breakthrough bleeding, amenorrhea, prolonged periods

n  hair loss

n  depression

n  scarring at the insertion site

n  need for removal

n  Return to fertility in 3 months after removal

n  Safe for adolescents

n  Does not effect breast milk production

Intramusculas Injections:

n  DMPA or Depo-Provera

n  single injection of medroxyprogesterone given every 12 weeks or Lunelle injections every 30 days to inhibit ovulation, alter endometrium and change cervical mucus

n  Effectiveness 100%

n  side effects are similar to SC implants

n  increase calcium to 1200mg/day

n  encourage wt. bearing exercise

n  no visible signs of birth control

n  may be used during breast feeding

n  must return to health care provider for new injection every 4 to 12 weeks

n  return to fertility in 6 to 12 months

Intrauterine Devices

n  IUD-small plastic object inserted into the uterus through the vagina.

n  Incidents of PID

n  Interferes with fertilization

n  with copper added, sperm mobility is effected

n  pelvic exam and PAP before fitted

n  effective from 1 to 8 years depending on type

n  must have 1 pregnancy before insertion

n  Check for string placement monthly

n  May experience spotting or uterine cramping for 2 to3 weeks -use additional contraceptive

n  High risk for PID, tubal pregnancy and toxic shock syndrome

n  fever, pain with intercourse, abdominal tenderness

n  Heavy menstrual flow

n  May be left in place during pregnancy

Barrier Methods

n  Placement of a chemical or other barrier between the cervix and advancing sperm so sperm can not enter the uterus or fallopian tubes and fertilize the ovum

n  Advantage- lacks hormonal side effects

n  Failure rate is high and sexual enjoyment may be lessened

n  Spermicidal agents:

n  cause death of sperm before entering the cervix

n  change vaginal pH to acidic level

n  Advantages

n  no Rx or physical exam

n  Independence and low cost

n  Helps prevent STDs

n  Used with another contraceptive will increase effectiveness

n  Preparations - gels, creams, films, foams and suppositories (nonoxynol-9)

n  use 1 hour before coitus

n  no douche for 6 hours

n  20% failure rate

n  Diaphragms:

n  Circular rubber disk placed over the cervix before intercourse

n  Used with a spermicidal gel

n  Must be fitted to cervix and refitted if wt. gain of > 15 lbs or changes in contours of pelvis or vagina

n  Disadvantages

n  UTIs, difficult to insert and may dislodge

n  2 hours prior and 6 hours after intercourse

n  Cervical Caps:

n  soft rubber cap shaped like a thimble and fits snugly over the uterine cervix

n  failure rate 8 to 18%

n  disadvantage-cervix to long or short, easily dislodged

n  Vaginal Rings:

n  NuvaRings-thin, flexible plastic ring about 2 “ across that contains estrogen and progestin

n  Inserted into the vagina and left in place for 21 days then remove for 7 days

n  New ring is inserted after menses

n  Condom:

n  Latex rubber or synthetic sheath that is placed over the erect penis before coitus

n  Failure rate is 2 to 12%

n  male responsibility

n  prevents the spread of STDs and HIV

n  Female Condoms:

n  Latex sheaths made of polyurethane and lubricated with nonoxynol-9

n  Inner ring (closed end) covers the cervix and the outer ring (open end) rests against the vaginal opening

n  one time use

n  protects against STDs

n  OTC, expensive, 15% failure rate

Surgical Methods

n  Vasectomy:

n  Surgical sterilization for males

n  A small incision made in each side of the scrotum

n  Vas deferens is cut and tied, cauterized, or plugged, blocking passage of the spermatozoa

n  Local anesthesia in ambulatory setting

n  99.9% effective

n  Tubal Ligation:

n  sterilization of women

n  hysterectomy-removal of uterus or ovaries

n  fallopian tubes are occluded by cautery, crushing, clamping, or blocking the tubes preventing passage of both sperm and ova

n  99.9% effective

n  laparoscopy - under general or local anesthesia

n  incision 1 cm. under umbilicus

n  Co2 is pumped into abdomen to lift the wall so the fallopian tube is visible

n  electrical current to coagulate tissue for 3 to 5 seconds or tube is clamped

n  may use metal or plastic clips or rubber rings which cause necrosis at site

n  women is discharged in few hours

n  may resume coitus in 2 to 3 days

n  may be done 4 to 6 hours after childbirth (usually 12 to 24 hours)

Elective Termination of Pregnancy

n  Procedure to deliberately end a pregnancy before fetal viability

n  Also referred to as therapeutic, medical or induced abortions