Family Planning 1/29/09 Mechanical Methods of contraception

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Need to check for strings after menstrual period if cramping, spotting or pain Woman cannot stop use whenever she wants (provider-dependent) Increase menstrual bleeding and cramping during the first few months (copper releasing onl) May spontaneously be expelled Rarely (<1:000 cases) perforation of the uterus may occur during insertion Do not prevent all ectopic pregnancies (especially progestasert) May increase risk of PID and subsequent infertility in women at risk for STD (HBV, HIV/AIDS)

IUD Barrier Methods o o o o Condoms Spermicides Diaphragm and Cervical Cap Vaginal Sponge -

Intrauterine Devices (Intrauterine contraceptive devices) Types of Medicated IUD’s Copper releasing o o o Copper T 380A Nova T

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Who can use IUD’s? Women who want highly effective long term contraception Are breastfeeding Are postpartum and not breastfeeding Post abortion If at low risk for STD Cannot remember to take a pill every day Prefer not to use hormonal methods or should not use them Are in need of emergency contraception

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Progestin releasing o o o Progestasert LevoNova (LNG-2Q) Mirena

Contraceptive benefits of IUD Highly effective Immediately effective Long term method (up to 10 years protection with copper T 380A) Do not interfere with intercourse Immediate return to fertility upon removal Does not affect breastfeeding Decrease menstrual bleeding (progestin releasing only) Decrease ectopic pregnancy (Except progestasert) -

IUD’s: Who should not use Pregnant (or suspected) Has unexplained vaginal bleeding until the cause is determined and any serious problems are treated Has current, recurrent PID Has acute, purulent, pus-like discharge Has distorted uterine cavity Has malignant trophoblast disease Has pelvic TB Has genital tract CA Has an active genital tract infection (vaginitis, cervicitis)

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Non contraceptive benefits Reduces menstrual cramps (progestin – releasing only)

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IUD limitation When to insert an IUD Pelvic examination required and screening for sexually transmitted disease (STD) recommended before insertion Require trained provider for insertion and removal Anytime during the menstrual cycle when you can be reasonably sure the client is not pregnant Days 1-7 of the menstrual cycle

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Postpartum o Immediately following vaginal delivery, during the first 48h PP or after 4-6 weeks; after 6 months if using LAM

IUDs: Mgmt for vaginal bleeding problems Reassure client that menses generally are heavier with an IUD and bleeding/spotting may occur between periods, especially in the first few months Evaluate for other cause (s) and treat if necessary If no other cause (s) found, treat with NSAIDs (ibuprofen), 5-7 days Counsel on options and consider

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Post abortion - immediately or within the first 7 days Provided no evidence of pelvic infection

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IUD’s: Infection prevention recommendations

Mgmt of cramping and pain Pre insertion o o Insertion o Put new or high level disinfected gloves on both gloves Load IUD in sterile package Clean cervical os (and vagina) thoroughly two times with antiseptic Use “no touch” insertion technique If no other cause(s) found, consider treating with acetaminophen or ibuprofen daily with onset of menses Counsel on options and consider IUD removal if client requests. Wash hands before examining clients Wash genital area if hygiene is poor Evaluate other causes(s) and treat if necessary Reassure client that cramping and menstrual pain (dysmenorrhea) may occur with and IUD, especially in the first few months

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Indication for removal

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If the client desires At the end of effective life of the IUD (TCU 380A good for 10 years If change in sexual practices (high risk behavior), consider adding barrier method (condoms) or removal If treated for STD or documented pelvic infection Menopause

IUDs: Common side effects Copper releasing o o o o o Heavier menstrual bleeding Irregular or heavy vaginal bleeding

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Intermenstrual cramps Increased menstrual cramping or pain

MALE CONDOMS Vaginal discharge Thin sheaths of rubber, vinyl for natural products which may be treated with a spermicide for added protection They are placed on the penis once it is erect Condoms differ in such qualities as shape, color, lubrication, thickness, texture, and addition of spermicide (usually nonoxynol 9)

Progestin releasing o Amenorrhea or very light menstrual bleeding/ spotting

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IUD’s: General information Removal of the copper T380A is necessary after 10 years but may be done sooner if you wish Return to your provider if you o o o o Cannot feel the string Feel the hard part of the IUD Expel the IUD, or Miss a period

Types of male condoms Latex (rubber) Plalstic (vinyl) Natural (animal products)

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Contraceptive benefits Effective immediately Do no affect breastfeeding

Use condoms if at risk for STDs

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Can be used as back up to other method No method-related health risks No systemic side effects Widely available No prescriptions or medical assessment necessary Inexpensive (short term)

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No method-related health risks No systemic side effects No prescription or medical assessment necessary Controlled by the woman

Non-contraceptive benefits May provide protection against STD May help prevent cervical CA

Non contraceptive benefits Promote male involvement in family planning Only family planning method that provides protection against STDs (latex, rubber and vinyl condoms only) May prolong erection and time ejaculation

Limitations Expensive at this time Moderately effective Effectiveness as contraceptives depends on willingness to follow instructions User dependent (require continued motivation and use with each act of intercourse) Disposal of used condoms may be a problem Adequate storage must be available at the client’s home Supplies must be readily available before intercourse begins Resupply must be available

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May help prevent cervical CA -

Limitations Disposal of used condom may be a problem Adequate storage must be available at client’s home Supplies must be readily available before intercourse begins Resupply must be available

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Mgmt of common side effects Allergic reactions, although uncommon, can be uncomfortable and possibly dangerous o Allergic rxn to condom or local irritation to penis  Ensure that condom is not medicated If rxn persists, consider natural condoms (lambskin or gut) or another method) Help client to choose another method.

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Who can use female condoms Women o Who prefer not to use hormonal methods or cannot use them (smokers, over 35yo) Who prefer not to use IUD Breastfeeding and need contraception Who want protection from STD and whose partners will not use condoms.

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Couples o o Who need contraception immediately Who need a temporary method awaiting another method (implants, IUD, voluntary sterilization) Who need a back up method Who have intercourse infrequently In which either partner has more than one sexual partner (at high risk for STD, including HBV and HIV/AIDS) even if using another method.

FEMALE CONDOMS Thin sheath of polyurethane plastic with polyurethane rings at either end. They are inserted into the vagina before intercourse

Contraceptive benefits Effective immediately Do not affect breastfeeding Do not interfere with intercourse (may be inserted up to 8h before) Can be used as back up to other methods

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Mgmt of problems

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Diminished sexual pleasure o If reduced sensitivity is not acceptable, help client choose another method

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Act as a barrier that keeps sperm from entering the uterus

How to use Wash hands Fill the cap 1/3 full of spermicidal gel Squeeze the sides of the cap together and put it all the way into the vagina and unto the cervix to form a strong suction When fitted, doctor will teach patient how to do this correctly Must leave it in place for at least 6h after last sexual intercourse No need to add extra spermicidal gel with each intercourse It is recommended to leave it in place no more than 48h To remove the cap, push the rim away the cervix

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Condom breaks or breakage suspected (before intercourse) o Check condom for a hole or demonstrable leak. Discard and use new condom

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Condom breaks or slips off during intercourse o Consider using a method of emergency contraception

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Client instructions Use a new condom every time you have intercourse The female condom can be inserted up to 8h before intercourse Wash hands with soap and water Remove the condom from the package. Do not use teeth, knife, scissors, or other sharp utensils to open package Hold the condom with the open end down Use the thumb and middle finger to squeeze the flexible ring at the closed end into a narrow oval With your other hand spread the lips of vagina Insert the ring and sheath into the vagina Use your index finger to push the ring as far as possible into the vagina Insert a finger into the condom until it touches the bottom of the ring Push the ring up past the public bone Make sure the outer ring and part of the sheath are outside the vagina over the vulva

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Proper use Take good care of cap by washing gently with warm water and mild soap Rinse well, pat dry, dust with cornstarch and put cap back into case Check the cap for holes or weak spots before using it If using extra lubricants during sex. Be sure that they are water based like KY liquid o Oil based lubricants like Vaseline or lotion can weaken the rubber and make it crack or tear.

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Potential risk Wearing a cap for longer than 48h is not recommended because of possible risk of TSS Some women who use the cap may be more likely to have abnormal cells on their pap smear

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CERVICAL CAP Danger signs A thimble shaped rubber (latex) cup that fits snugly over the cervix It is usually used with a small amount of special gel that contains a spermicide The woman inserts the cap and spermicide together into vagina to cover the cervix o o Cap comes in 4 sizes Each woman must be fitted for her cap by a trained doctor or health provider Sudden high fever Vomiting, diarrhea Dizziness, faintness, weakness Sore throat, aching muscles and joints Rash (sunburn like)

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Vaginal sponge, how does it stay in place It is held in place by the vaginal muscles

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In addition, the indentation (the dimple) helps position the today sponge properly and keeps it in place directly over the cervix

How long can you leave it 30 h, includes multiple acts of intercourse If intercourse takes place on or near the 24th hour, the today sponge should only be left in place for 6h afterwards, completing the 30h maximum

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Mechanism of action Works as a delivery system for spermicide. By continuously releasing spermicide throughout the vagina it will kill sperm on contact Additionally, the today sponge provides contraceptive protection by trapping and absorbing sperm It covers the cervix and thereby

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Who can use it Any woman comfortable using tampons or other vaginal contraceptives should be able to use the today sponge Vaginal contraceptives, such as the today sponge, are indicated for women for whom the pill may be unacceptable.

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Who should not use it? Menstruating Woman and partner have sensitivity to o o o Sulfa drugs The spermicide, nonoxynol Polyurethane

A woman with a vaginal abnormality With vaginal infection Woman with hx of TSS Woman who had a vaginal delivery (within 8 weeks), miscarriage, or other termination of pregnancy and has not been examined by physician Woman who cannot risk any chance of pregnancy whatsoever

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