RIVERA, ZYRENE MAY C.

OCTOBER 05, 2021

BSN- 2 MS. VIVIAN LAJARA

CHAPTER 6 NURSING CARE FOR THE FAMILY IN NEED OF

REPRODUCTIVE LIFE PLANNING
Reproductive life planning

 includes all the decisions an individual or couple make about

having children. These decisions usually include whether and
when to have children, how many children to have, and how they
are spaced. couples often need counseling about how to avoid
conception. Others need information on increasing fertility.
some couples need counseling because contraception has failed.
 It is important for the health of children that as many
pregnancies as possible be intended, because when a pregnancy is
unintended, the mother is less likely to seek prenatal care,
less likely to breast-feed, and less careful to protect the
fetus from harmful substances. A disproportionate share of the
women who bear children whose conception was unintended are
unmarried; such women are less apt to complete high school or
college and more likely to require public assistance and to live
in poverty than their peers who are not mothers. The child of
such a pregnancy is at greater risk of low birthweight, dying in
the first year, being abused, and not receiving sufficient
resources for healthy development (DHHS, 2000).
 Until the 1950s, contraceptive products (products to prevent
pregnancy) were not all that reliable or could not be easily
purchased. Today, people have numerous contraceptive choices,
which range in reliability and accessibility from fair to good.
Reproductive health has become so important that a number of
National Health Goals speak directly to this area of care

Abstinence

 the most effective way to protect against conception is to

abstain from sexual intercourse (abstinence). Abstinence has a
theoretical 0% failure rate and is also the most effective way to
prevent STIs.

Fertility Awareness Methods

 Fertility awareness methods rely on detecting when a woman is

capable of impregnation (fertile) and using periods of abstinence
or contraceptive use during that time (VandeVusse et al., 2003).
 Couples are then free to go without contraception during the rest
of the month.

Calendar (Rhythm) Method

 The calendar method requires a couple to abstain from coitus on

the days of a menstrual cycle when the woman is most likely to
conceive (3 or 4 days before until 3 or 4 days after ovulation).

Basal Body Temperature Method

 Just before the day of ovulation, a woman's basal body

temperature (BBT) falls about 0.50F. At the time of ovulation,
her BBT rises a full degree because of the influence of
progesterone. This higher level is then maintained for the rest
of her menstrual cycle. This pattern is the basis of the BBT
method of contraception.

Cervical Mucus (Billings) Method

 Another method to predict ovulation is to use the changes in

cervical mucus that occur naturally with ovulation. Before
ovulation each month, the cervical mucus is thick and does not
stretch when pulled between the thumb and finger. Just before
ovulation, mucus secretion increases. With ovulation (the peak
day), cervical mucus becomes copious, thin, watery, and
transparent. It feels slippery and stretches at least 1 inch
before the strand breaks, a property known as spinbarkeit.

Symptothermal Method

 symptotnermal method of birth control combines the cervical mucus

and methods. The woman takes her temperature daily, watching for
the rise in temperature that marks ovulation. She also analyzes
her cervical mucus daily.

Ovulation Awareness

 Yet another method to predict vulation is the use of an OTC

ovulation detection kit (Freundl et al., 2003). These kits detect
the midcycle surge of luteinizing hormone (LH) that can be
detected in urine 12 to 24 hours before ovulation.

Lactation Amenorrhea Method

 As long as a woman is breast-feeding an infant, there is some

natural suppression of ovulation. However, if the infant is
receiving a supplemental feeding, the use of lactation as an
 effective birth control method is questionable. Because women may
ovulate but not menstruate while breast-feeding, the woman may
still be fertile even if she has not had a period since
childbirth (Van der Wijden et al., 2005).

Coitus Interruptus

 Coitus interruptus is one of the oldest known methods of

contraception. The couple proceeds with coitus until the moment
of ejaculation. Then the man withdraws and spermatozoa are
emitted outside the vagina. Unfortunately, ejaculation may occur
before withdrawal is complete and, despite the care used, some
spermatozoa may be deposited in the vagina.

Oral Contraception

 commonly known as the pill or COCs (for combination oral

contraceptives), are composed of varying amounts of synthetic
estrogen combined with a small amount of synthetic progesterone
(progestin) (Peterson, 2003). The estrogen acts to suppress
follicle stimulating hormone (FSH) and LH, thereby suppressing
ovulation. The progesterone action complements that of estrogen
by causing a decrease in the permeability of cervical mucus,
thereby limiting sperm motility and access to ova. Progesterone
also interferes with tubal transport and endometrial
proliferation to such degrees that the possibility of
implantation is significantly decreased.

Effect on Sexual Enjoyment

 For the most part, not having to worry about pregnancy because
the contraceptive being used is so reliable makes sexual
relations more enjoyable for couples. Some women appear to lose
interest in coitus after taking the pill for about 18 months,
possibly because of the long-term effect of altered hormones in
their body

Effect on Pregnancy

 If a woman taking a COC suspects that she is pregnant, she should

discontinue taking the pill if she intends to continue the
pregnancy. High levels of estrogen or progesterone might be
teratogenic to a growing fetus, although the actual risk is now
thought to be no higher than normally occurs (23.3%) (Speroff &
Fritz, 2005).
Use by the Adolescent

 It is usually recommended that adolescent girls have well

established menstrual cycles for at least 2 years before you sent
beginning COCs. This reduces the chance that the COC will cause
permanent suppression of pituitary-regulating activity.

Discontinuing Use

 After a woman stops taking a COC, she may not be able to become
pregnant for 1 or 2 months, and possibly 6 to 8 months, because
the pituitary gland requires a recovery period to begin cyclic
gonadotropin stimulation again.

Continuous or Extended Regimen Pills

 Women may be prescribed extended programs for pills (91-day

regimens, or 84 days of pills followed by 7 days of placebo).
Although some women experience breakthrough bleeding, such
regimens limit menstrual periods to only four ümes a year and
provide effective birth control (Anderson & Hait, 2003).

Mini Pills

 Oral contraceptives containing only progesterone are popularly

called mini-pills. Without estrogen content, ovulation may occur
but, because the progestins have not allowed the endometrium to
develop fully, implantation will not take place.

Estrogen/Progesterone Patch

 Transdermal patches that slowly but continuously release a

combination of estrogen and progesterone were approved by the
U.S. Food and Drug Administration (FDA) in 2001 and reached the
market in 2002
 Patches are ap plied once a week for 3 weeks. During the week on
which the woman is patch free, a menstrual flow will occur. The
efficiency of transdermal patches is equal to that of COCs,
although they may be less effective in women who weigh more than
90 kg.

Vaginal Rings

 A vaginal ring (a silicone ring that surrounds the cervix and

continually releases a combination of estrogen and progesterone)
was also FDA approved in 2001
  The efficiency is 99.7%, equal to that of COCs. Fertility returns
immediately after removal of the ring (Peterson, 2003). Women may
need to make out a calendar that they post conspicuously to
remind themselves to remove and replace the ring.

Emergency Postcoital Contraception

 A number of regimens are available for emergency post. coital

contraception. These are often referred to morning-after pills. "
The high level of estrogen they stain apparently interferes with
the production of progesterone
 The Yuzpe regimen consists of the administration of two fixed-
dose combination pills (usually Ovral), taken within 72 hours
after unprotected intercourse (Croxatto et al., 2003).

Subcutaneous Implants

 Norplant consists of six nonbiodegradable Silastic implants,

about the width of a pencil lead, that are filled with
levonorgestrel (a synthetic progesterone) and embedded just under
the skin on the inside of the upper arm
 The implants are inserted with the use of a local anesthetic,
during the menses or no later than day 7 of the menstrual cycle,
to be certain that the woman is not pregnant at the time of
insertion. They can be inserted immediately after an abortion or
6 weeks after the birth of a baby.

Intramuscular Injections

 A single injection of medroxyprogesterone acetate (DepoProvera)

given every 12 weeks or injections of Lunelle (a synthetic
estrogen and progesterone) given every 30 days inhibit ovulation,
alter the endometrium, and change the cervical mucus
 Depo-Provera, because it contains only progesterone, can be used
during breast-feeding. Potential side effects are similar to
those of subcutaneous implants: irregular menstrual cycle,
headache, weight gain, and depression. Depo-Provera may impair
glucose tolerance in women at risk for diabetes.

Intrauterine Devices

 The intrauterine device (IUD) is a small plastic object that is

inserted into the uterus through the vagina. IUDs became popular
as a method of birth control in the 1980s but they are used by
only a small number of U.S.
Side Effects and Contraindications

 A woman with an IUD in place have a higher than usual risk for
PID, although the copper-wound devices may actually carry a lower
risk. Some women have a heavier than usual menstrual flow for 2
or 3 months and experience more dysmenorrhea than other women do.
Ibuprofen, a prostaglandin inhibitor, is helpful in relieving the
pain.

Effect on Pregnancy

 If a woman with an IUD in place suspects that she is pregnant,

she should alert her primary health care Provider Although the
IUD may be left in place during the pregnancy, it is usually
removed vaginally to prevent the possibility of infection or
spontaneous abortion during the pregnancy. The woman should
receive an early sonogram to document placement of the IUD
(Schiesser et al., 2004). This can also rule out ectopic
pregnancy, which has an in. creased incidence among IUD users who
become pregnant with the IUD in place.

Use by the Adolescent

 IUDs are rarely prescribed for adolescents, because teens tend to

have variable sexual partners and no prior pregnancies, both
contraindications to IUD use.

Barrier Methods

 Barrier methods are forms of birth control that work by the

placement of a chemical or other barrier between the cervix and
advancing sperm so that sperm cannot enter the uterus or
fallopian tubes and fertilize the ovum. A major advantage of
barrier methods is that they lack the hormonal side effects
associated with COCs. However, compared with COCs, their failure
rates are higher and sexual enjoyment may be lessened.

Diaphragms

 A diaphragm is a circular rubber disk that is placed over the

cervix before intercourse; it forms a barricade against the
entrance of spermatozoa
 use of a spermicide is not required, use of a spermicidal gel
with a diaphragm combines a barrier and a chemical method of
 contraception. The failure rate of the diaphragm may be as low as
6% (ideal) to 16% (typical use) (Trussell, 2003).
 prescribed and fitted initially by a physician, nurse
practitioner, or nurse-midwife to ensure a correct fit.

Cervical Caps

 cervical cap is yet another barrier method of Contraception. Caps

are made of soft rubber, are shaped like a thimble, and fit
snugly over the uterine cervix
 Many women cannot use cervical caps because their cervix is too
short for the cap to fit properly. Also, caps tend to dislodge
more readily than diaphragms during coitus.

Female Condoms

 Condoms for females are latex sheaths made of polyurethane and

prelubricated with a spermicide. The inner ring (closed end)
covers the cervix, and the outer ring (open end) rests against
the vaginal opening. The sheath may be inserted any time before
sexual activity begins and then removed after ejaculation occurs.
Like male condoms, they are intended for one-time use and offer
protection against both conception and STIs.
 Female condoms can be purchased OTC but are more expensive than
male condoms. Male and female condoms should not be used
together. The failure rate in preliminary studies was somewhat
greater than the failure rate for male condoms, 5% to 21%

Surgical Methods of Reproductive Life Planning

 Surgical methods of reproductive life planning include

sterilization (tubal ligation for women and vasectomy for men).
About 28% of all women in the United States of childbearing age
choose a sterilization procedure to prevent unwanted pregnancy.
 Vasectomy is the contraceptive method of choice for about 11% of
men, making these two procedures the most frequently used methods
of contraception in the United States for couples older than 30
years of age (Peterson, 2003)

Vasectomy

 a small incisiön is made on each side of the scrotum. The vas

deferens at that point is then cut and tied, cauterized, or
plugged, blocking the passage of spermatozoa
 Vasectomy can be done under local anesthesia in an ambulatory
setting, such as a physician's office or a reproductive life
 planning clinic. The man experiences a small amount of local pain
afterward, which can be managed by taking a mild analgesic and
applying ice to the site. The procedure is 99.5% effective

THE COUPLE WITH A PHYSICAL OR COGNITIVE CHALLENGE

 A couple with a physical or cognitive challenge should be asked

at health care visits whether reproductive life plan. ning is a
concern. For example, a man who has unsteady coordination might
not have adequate hand coordination to place a condom
effectively. A woman with a similar Irandicap might have
difficulty inserting a diaphragm or vaginal ring, and a woman who
is cognitively challenged might not understand the need to take
COCs daily. For these reasons, subcutaneous implants or surgical
intervention may be the ideal contraceptive for many couples with
a disability (Zurawin & Paransky, 2003).

FUTURE TRENDS IN CONTRACEPTION

 Because estrogen is responsible for most of the side effects

associated with COCs, studies are being conducted using even
lower-dose estrogen pills. A progesterone-filled vaginal ring
that is permanently implanted is a possibility. A progesterone-
impregnated diaphragm and biodegradable implants that do not have
to be removed may be used in the future.

ELECTIVE TERMINATION OF PREGNANCY(INDUCED ABORTION)

 An elective termination of pregnancy is a procedure performed to

deliberately end a pregnancy before fetal viability. Such
procedures are also referred to as therapeutic, medical, or
induced abortions. Nurses employed in health care agencies where
induced abortions are performed are asked to assist with the
procedures as a part of their duties.

Medically Induced Abortion

 Mifepristone (a progesterone antagonist) is a compound that

blocks the effect of progesterone, preventing implantation of the
fertilized ovum and therefore causing abortion. The compound is
taken as a single oral dose of 600 mg any time within 49 days of
gestational age. RhoDnegative women should receive Rho(D) immune
globulin at the time the mifepristone is administered.
surgically Induced Abortion Procedures

 Elective surgical abortions involve a number of techniques,

depending on the gestational age at the time the abortion is
performed.

Menstrual Extraction

 Menstrual extraction or suction evacuation is the simplest type

of surgical abortion procedure (Grimes, 2003). It is performed on
an ambulatory basis 5 to 7 weeks after the last menstrual period.
The woman voids, and her perineum is washed with an antiseptic
(shaving is unnecessary). A speculum is then introduced
vaginally, the cervix is stabilized by a tenaculum, and a narrow
polyethylene catheter is introduced through the vagina into the
cervix and uterus

Dilatation and Curettage

 If the gestational age of the pregnant is less than 13 weeks a

dilatation and curettage (D&C) procedure may be used. This
procedure is usually done in an ambulatory setting using a
paracervical anesthetic block. A paracervical block does not
eliminate pain but limits what the woman experiences to cramping
and a feeling of pressure at her cervix.

Dilatation and Vacuum Extraction

 Most second-trimester abortions (those between 12 and 16 weeks)

are done by dilatation and vacuum extraction (D&E), which can be
cither an inpatient or an ambulatory procedure. In some centers,
dilatation of the cervix is begun the day before the procedure by
administration of oral misoprostol or insertion of a laminaria
tent (seaweed that has been dried and sterilized) into the cervix
under sterile conditions. In a moist body part such as the
cervix, the seaweed begins to absorb fluid and swell in size.

Prostaglandin or Saline Induction

 Prostaglandin or saline induction is used if a pregnancy is

between 16 and 24 weeks (see Fig. 5.14D), as an in. patient or
ambulatory procedure. The preferred method is to use
prostaglandin F2-alpha by injection or prostaglandin E2 by
suppository. This causes cervical dilation and uterine cramping,
which expels the products of conception (Trupin, 2003).
 The woman is admitted to a same-day surgery unit and has oral
misoprostol or vaginal laminaria inserted to help prepare the
 cervix for dilatation. The prostaglandin is then administered.
Labor, which follows the administration of the prostaglandin by
several hours, may be shortened by administration of a dilute
intravenous solution of oxytocin. Because the products of
conception are small, the actual delivery causes only a momentary
stinging pain as the perineum is stretched.

Hysterotomy

 If the gestational age for a pregnancy is more than 16 to 18

weeks, a hysterotomy, or removal of the fetus by surgical
intervention similar to a cesarean birth, may be performed.
Surgery is necessary at this point, because the uterus becomes
resistant to the effect of oxytocin as it reaches this phase of
pregnancy and may not respond to saline induction, even with the
assistance of oxytocin. Furthermore, the chance is great at this
gestational age, because the uterus is so enlarged, that it will
not respond and contract afterward, leading to hemorrhage.

Partial Birth Abortion

 was a surgical technique formerly used during the last 3 months

of pregnancy if the fetus had been discovered to have a
congenital anomaly that would be incompatible with life or would
result in a severely compromised child (e.g., encephalocele, high
meningocele). Labor was induced by a combination of oxytocin and
cervical ripening. The fetus was turned so that the breech
presented to the birth canal A clamp was then inserted into the
base of the fetal skull, the head contents were destroyed, and
the head was collapsed and then delivered. "Partial birth
abortion" is no longer legal in the United States. A cesarean
birth or vaginal delivery of the preterm infant is scheduled
instead (McCarthy, 2003).

Isoimmunization

 Whenever a placenta is dislodged, either by spontaneous delivery

or by surgical or medical intervention at any point in pregnancy,
blood from the placental Villi (the fetal blood) enter the
maternal circulation. This has implications for the Rh-negative
woman.
 Enough Rh-positive blood may enter her circulation to cause
isoimmunization, the production by her immunologic system of
antibodies against Rh-positive blood. If her next child should
have Rh-positive blood, those antibodies would attempt to destroy
the red blood cells of that infant during the months in utero.
Psychological Aspects/ Termination of Pregnancy

 Women of all ages, married or unmarried, with or without

children, request induced abortions. The usual profile of a
woman who is having such a procedure is young, unmarried, with
no previous live births, and undergoing the procedure for the
first time to end an unwanted pregnancy.
 A few women express sadness and guilt after abortion. These
women may need to be referred for professional counseling so
they can integrate and accept this event in their lives
(Harris, 2004).