OB contraception

contraception
prevention of conception and can be accomplished by a variety of methods.
choices influenced by:
Economics
Convenience
Effectiveness
Side effects
Interference of spontaneity
Cultural/religious beliefs
Motivation
Nurses role
Have a basic understanding of what influences someone to choose one method of contraception over another.
Be able to perform a complete patient h&p to screen for risk factors.
Be familiar with the various methods of contraception including use, advantages, disadvantages, and efficacy.
Be able to provide accurate information in an unbiased manner related to each contraceptive method, including dispelling of any misconceptions patients might have.
Be able to provide non-judgmental support, taking into consideration the patient’s feelings and beliefs regarding contraception.
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Fertility Awareness Methods require discipline on
the part of the couple. can be used individually or in combination
Calendar Rhythm Method
A woman’s fertile period can extend from 4 days before to 3-4 days after ovulation.
Can be determined after accurately recording the length of menstrual cycles for 6 months.
Couple abstains from intercourse during the fertile period (usually day 10 thru day 17 of the woman’s cycle).
Ovulation usually occurs on day 14 +/- 2 days.
Basal Body Temperature (BBT) :
the lowest body temperature of a healthy person, taken immediately after waking and before getting out of bed (usually 36.2° – 36.3° C).
After ovulation, the BBT rises slightly and remains elevated for 2-4 days (0.4° – 0.8° C).
To prevent pregnancy, intercourse is avoided from the last day of the menses until after 3 days of elevated temperature.
Cervical Mucus Method:
requires that the woman recognize and interpret the characteristic cyclic changes in the amount and consistency of cervical mucus.
During ovulation cervical mucus increases becoming thin, watery, clear, slippery, and stretchy (Spinnbarkeit)
To prevent pregnancy, intercourse is avoided from the time mucous is present until 4 days after the end of this mucous.
Spermicides:
a physical barrier to sperm penetration that also has a chemical action on sperm (Nonoxynol-9).
placed deeply into the vagina in contact with the cervix before each incidence of intercourse. Effectiveness rate: 71%.
Male Condom
To prevent unintended pregnancy, it is essential that condoms be used correctly; effectiveness rate – 85%

The condom is applied prior to contact of the penis with the vagina.
A half-inch space is is left at the tip of the condom for sperm collection in order to prevent breakage.
Penis is withdrawn from the vagina while it is still erect and held in place to prevent slippage.

Female Condom
a vaginal sheath that has flexible rings at both ends; the closed end of the pouch is inserted into vagina against the cervix and the open ring covers the labia.

Requires prescription and professional fitting by healthcare provider

Should be replaced q 2 years and refitted after weight loss/gain or term delivery.

Effectiveness rate: 84%. Spermicide is placed inside the diaphragm and it is placed against the cervix and must remain there for a minimum of six hours after coitus.

Cervical Cap
similar to the diaphragm, but smaller in diameter, fits snugly around the base of the cervix

Must be left in place at least 6-8 hours after coitus but not more than 48 hours
No additional spermicide is needed for repeated acts of intercourse.
Effectiveness rate 75%.

Diaphragm
a shallow, dome shaped rubber device with a flexible rim that covers the cervix.
Cervical Sponge
small round sponge containing spermicide is placed next to the cervix

Provides 24 hour protection
Should be left in place for at least 6 hours but not more than 24-30 hours.

Birth Control
utilizing estrogens &/or progesterone.
Administered in several forms including oral, injectables, topicals, implants, and vaginal inserts.
Although often the most effective means of birth control, a variety of reasons are given for not using hormonal methods of contraception.

Irregular Bleeding
Nausea
Perceived weight gain
Mood Changes
Headache
Breast Tenderness

Contraindications to hormonal contraceptive methods
Coronary artery disease

Thrombophlebitis

Endometrial or breast cancer

Cerebral vascular accident

Pregnancy

Smoking increases risk especially in women over 35.
Reportable warning signs:
Abdominal pain
Chest pain or SOB
Headache
Eye problems
Severe leg pain
((ACHES))
Oral Contraceptives
Combined estrogen-progestin oral contraceptives

Biphasics – Ortho-Novum 10/11: delivers same amount of estrogen; level of progestin half way through cycle
Triphasics – Ortho-Novum 777, Ortho-Tri Cyclen: delivers 3 different doses of hormones throughout cycle
Extended cycle – Seasonale/Seasonique: delivers estrogen/progestin in active form for 84 days followed by 7-day inactive placebo; only four periods/year
Progestin-only oral contraception – MicroNor: less interference of milk production in breastfeeding mothers

Advantages to OCs include:
98% Effective
Menstrual flow, regulation of menses
Incidence of PMS
Convenience of knowing when to expect menstrual flow
Disadvantages to OCs include:
Previously mentioned side effects and contraindications
Progestin-only OCs must be taken same time every day
Injectables – DepoProvera (depot medroxyprogesterone acetate) 150mg IM; Depo-subQ Provera 104mg SQ injection that is given during the 1st 5 days of the menstrual cycle w/99.7% effectiveness rate.
Must be administered every 11-13 weeks
Less likely to affect lactation
Side effects are comparable to those of OCs, in addition to â bone mineral density
Fertility may be delayed up to 18 months after discontinuance
Do not massage site after IM injection! (increases absorption rate)
Transdermal Patch – Ortho Evra: supplies continuous constant daily circulating levels of Estradiol (20mcg) and Norelgestromin (150mcg).
Applied weekly on the same day of each week for 3 weeks followed by a patch-free week.
Contraceptive effectiveness will be maintained for up to 2 days beyond the patch-free week if a new patch is not applied. Effectiveness = 95%, however less effective in women >198 pounds.
Side effects similar to those of OCs; á risk of serious cardiovascular side effects for those over 35 and who smoke.
Vaginal Ring – NuvaRing: a soft flexible, transparent ring that is inserted into the vagina and used for one cycle, which consists of 3 weeks of continuous use followed by one ring-free week.
Releases 120 mcg of Etonogestral and 15 mcg of Estadiol daily
Women can insert the ring themselves and it does not have to be fitted nor does it need any particular placement in the vagina.
Effectiveness = 94%
Side Effects
Headache
Vaginal discharge/vaginitis
Foreign body sensation
Ring expulsion
Coital discomfort
Implantible progestins – Implanon (etonogestrel): single implantable rod FDA approved in 2006 that is 99% effective.
Provides up to 3 years protection
Works by thickening cervical mucus, preventing ovulation, and changing the uterine lining
May not be as effective in overweight women
Requires replacement every 3 years
Side effects
Weight gain
Irregular infrequent bleeding
Breast pain
Acne
Vaginitis
Intrauterine Devices (IUD): an IUD (also known as an IUC-intrauterine contraceptive) is a small, T-shaped device inserted into the uterine cavity (Effectiveness 98%).
Loaded with either copper or a progestational agent.

ParaGard-T-380 – contains copper; damages sperm in transit to the uterine tubes and few sperm reach the ovum
Mirena – progesterone bearing IUD causes changes in cervical mucus and endometrial maturation

The effect is local and ovulation is not disrupted

IUD Advantages
pregnancy protection for 5-10 years, and immediate return to fertility upon removal of the device.
IUD Disadvantages
risk of pelvis inflammatory disease
bacterial vaginosis
uterine perforation
infection at time of insertion
Women using an IUD should be taught the signs of potential complications:
P = late period or abnormal bleeding
A = abdominal pain, pain with intercourse
I = infection, abnormal vaginal discharge
N = not feeling well, fever or chills
S = string missing; longer or shorter
Transabdominal sterilization Female:
surgical bilateral tying, cutting (ligation) or cauterization (electrocoagulation) of female fallopian tubes, or tubal occlusion through surgical application of bands or clips to fallopian tubes.
Transcervical sterilization Female:
hysteroscopic injection of occlusional implants into fallopian tubes that promote growth of scar tissue thus occluding tubes
Sterilization Advantages:
May be done on outpatient basis or immediately after delivery
One-time procedure
Failure rate <1%
Sterilization Disadvantages:
Permanent sterility w/traditional tubal ligation
Surgical procedure w/some discomfort afterwards
Difficult/expensive to reverse w/no guarantee of restored fertility
Vasectomy:
tying, cutting of male vas deferens interrupting sperm’s path from testes to penis
Vasectomy Advantages:
One-time procedure; permanent sterility
No effect on potency
Failure rate <1% Can be performed in physician's office
Vasectomy Disadvantages:
Some sperm may remain in proximal portions of ducts
Contraception needed until semen shows no sperm
Surgical procedure w/some discomfort afterwards
Difficult/expensive to reverse w/no guarantee of restored fertility
Coitus interruptus
full withdrawal of the penis prior to ejaculation
80% effective.
Arguably the oldest method of preventing pregnancy
Initial drops of semen contain greatest concentration of sperm and may escape into vagina before penis can be withdrawn
Lactational Amenorrhea Method
refers to the use of breastfeeding as a temporary method of contraception.

Not widely used in U.S.
May be 98% effective if certain criteria are met:
Infant is <6 months old Menstruation has not resumed Mother is exclusively (or nearly) breastfeeding Feeding interval < q4hrs during day/no > q6hrs during night
No bottle supplements

Emergency Contraception
Must be used ASAP, but within 3-5 days of unprotected intercourse.
No protection against HIV or STIs.
Uses high doses of OCPs to prevent ovulation or implantation.

Combination OCPs (estrogen/progestin) can be used in two divided doses.
2-4 tablets w/in 72 hrs of unprotected sex followed by additional 2-4 tablets 12 hrs later
Plan B (0.75 mg Levonorgestrel): only FDA-approved product in U.S.
1 tablet w/in 72 hrs of unprotected sex followed by additional 1 tablet 12 hrs later

¯ chances of pregnancy by 89% when taken correctly
Does not affect an existing pregnancy

When discussing various methods of contraception with a patient, what should the nurse do to promote a productive discussion?
Discuss contraceptive options only when the patient’s partner is present.
Discuss use, effectiveness, and side effects of different methods.
Instruct the patient in the best method she should use.
Avoid discussing sterilization as a form of birth control.
Discuss use, effectiveness, and side effects of different methods.
Nurse’s role is to provide education regarding different contraceptive methods including advantages/disadvantages, and support the woman/couple in her/their choice.
When using fertility awareness as a form of birth control, a woman must monitor herself for signs that ovulation is occurring. Which sign is associated with ovulation?
An increase in the amount of cervical mucus.
Drop in the basal body temperature (BBT).
An increase in the thickness of cervical mucus.
Reduction in the level of luteinizing hormone (LH).
An increase in the amount of cervical mucus.
Cervical mucus increases during ovulation to aid sperm in traveling to fallopian tubes; basal body temperature increases as does the level of leutinizing hormone during ovulation
When providing teaching on the use of the cervical cap, the nurse should include which of the following instructions?
Continue to use the cap during menstrual periods.
Spermicide should not be used with the cervical cap.
Leave the cap in place for 72 hours after the last act of intercourse.
Women with a history of toxic shock syndrome should another form of contraception
Women with a history of toxic shock syndrome should another form of contraception.
A history of toxic shock syndrome is a contraindication to the use of the cervical cap; use of the cap during the menstrual period prohibits the flow of menses; the cap should be left in place for no more than 6-8 hours after the last act of intercourse; spermacide should be inserted into cap prior to insertion into the vagina.
Correct use of a male condom requires which of the following actions?
Using each condom for multiple acts of coitus.
Removing the penis from the vagina, while it is still erect, holding the rim of the condom in place.
Condoms can be placed on a flaccid penis.
Utilizing lubricants including petroleum based products such as Vaseline.
Removing the erect penis from the vagina, while holding the rim of the condom in place
A new condom should be used for each act of intercourse; condoms are applied just before intercourse over an erect penis; petroleum based lubricants can cause deterioration of condoms.
The nurse is providing patient teaching on oral contraceptives. Teaching has been effective when the patient makes which statement?
“I should not smoke the first month I’m taking this medication so I don’t develop a reaction to it”.
“If I forget a pill I have to start a new pack the next day”.
“Taking oral contraceptives will protect me from STIs (sexually transmitted infections)”.
“Weight gain and breakthrough bleeding are possible side effects I may experience”.
“Weight gain and breakthrough bleeding are possible side effects I may experience”.
Smoking is contraindicated at any time when taking oral contraceptives; if a pill is forgotten it should be taken ASAP when remembered; oral contraceptives do not protect against STIs.
When using the transdermal contraceptive patch patients should be aware of which piece of information?
The patch can be applied to any area of the body.
The patient can expect little to no side effects from this contraceptive method.
This method of birth control has been found less effective in women with obesity.
The patch can be worn for three months before changing.
This method of birth control has been found less effective in women with obesity.
Studies show this form of contraception to be less effective in women who weigh >190 lbs; the patch should not be applied to breasts; side effects are comparable to other forms of hormonal contraception; patch should be changed each month, rotating sites
Which statement best describes Implanon?
It is a series of hormone impregnated rods that are inserted into a woman’s upper arm.
It is an implantable contraceptive that is effective for 3 years.
It works by thinning out the cervical mucus, inhibiting the movement of sperm.
In addition to its contraceptive properties, it protects against HIV.
It is an implantable contraceptive that is effective for 3 years.
It is a single implantable rod that works by thickening the cervical mucus, and does not protect against STIs or HIV
What instructions should be given to the patient receiving DepoProvera? Choose all that apply.
The use of this birth control method does not protect against sexually transmitted diseases.
Women using this method of contraception may have side effects including weight gain and irregular bleeding
Women using this method should see their healthcare provider once a month.
This method of birth control requires the user to check for string placement monthly.
A & B
Women who use DepoProvera should see their healthcare provider every 3 months; DepoProvera is an injectable contraceptive; there are no strings involved w/its use.
A woman with a history of pelvic inflammatory disease (PID) would be counseled against using which form of birth control.
Oral contraceptive pills (OCP)
Intrauterine device (IUD)
Injectable hormones (DepoProvera)
Transdermal patch (Ortho Evra)
IUD
There is a higher risk of infection in women w/history of PID or STIs who use an intrauterine device (IUD) as a method of contraception
Plan B is a method of birth control that can be used on a regular basis.
True
False
False
Emergency contraceptives are not as effective as regularly prescribed OCs if used on a regular basis.
Initially, another form of birth control should be used following a vasectomy.
True
False
True
Some sperm may remain in proximal portions of ducts; an alternative contraceptive is needed until semen shows no sperm.

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