s-

".

MANUAL
of
~STANDARD OPERATING
PA~EDURES

,-.

".KEPAnED HY THE XATIOXAL FAlIllLY PLAXXING OFFICE

, FOR 'rHE USE OF THE FA1IIlLY PLA....O nXG CLiXICS
{'XDBR THE :mNISTRY OF HEALTH FAMILY
I - PLANKING PROGRAM
H24.45 r,

M31'
I,
1980
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DOH- CENTRAL LIBRARY

MANUAL
of
STANDARD OPERATING
.PROCEDURES

Departmentof Health - Library

111\llllllllllllll ~1 \1 ,
0933
H24.45 M31 1980 I Manual of standard operatingprocedu
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TABLE OF CONTENTS

I. CONDOMS, FOAM TABLETS AND CONTRACEPTIVE FOAM ... .... 1

A. Condoms . ..... .__. .._._ ..... .__. ' 2
B. Foam Tablets .. .._ _. ._. ..._.._._... . . . 2
C. Contraceptive Foam .__.. .._. 3
II. IUD __.. .._..__. _ 4
III. ORAL CONTRACEPTIVES . . .______________________ 7
IV. RHYTHM ... . : . . . . . 13

V. OTHERS
A. Common Gynecological Procedures . .. 13
1. Pregnancy Test (Planosec) . . .________ 16
2. PAP Smear ..__ . .__. . .._._. . .... .__. 19
,B. Diagnosis and Management of Common Gynecological Con-
ditions . .... .. ... ..__.... .. . .__. ...._.__ __ __ _ 20
1. Non-Specific Vaginitis : . . .__.. .__. 20
2. Monilial Vaginitis . . . "._.. .. ..__._.. .__ 20
3. Trichomonas Vaginitis . . . 21
4. Mixed Infection . .... 21

(
 GUIDELINES FOR CONDOMS, FOAM TABLETS
AND CONTRACEPTIVE FOAM

CONDOMS, FOAM TABLETS AND CONTRACEPTIVE FOAM

WHOM TO GIVE

1. Post-partum and post aborioi clients

a. After delivery, and/or completion of abortion, foam tablets or con-
traceptive foam (for females) or condoms (for males) may be
used as temporary contraceptive measures while waiting for regular
menstruation. A preferred method shoutd be prescribed I!!l soon
as regular menstruation occurs, or when condition of client allows
other acceptable method to be prescribed.

2. Other clients/acceptors
a. Acceptors who cannot tolerate the pills.
b. Acceptors who expelled the IUD and would require protection while
, for her' next menstruation, for a possible reinsertion.
waiting
c. Clients under treatment for cervicitis and other local inflammatory
conditions of the reproduetiveorgans before prescribing :the pre-
ferred method, e.g. IUD; pill, etc.
d. Clients whose husbands work in other places and return to thei,r
homes at irregular intervals.

GENERAL POLICY

1. Clients using the foam tablets, contraceptive (oamor condoms as a

temporary or' stop-gap contraceptive measure will be ~.onsidere!l as
new acceptors of the clinic provided that-s-they are til ;be p.r~cribed
or to be shifted to other reliable methods when menstruation occurs
or when client's physical condition already permits .the acceptance of
other methods.
2. The clients, who use either the foam tablets or contraceptive foam (for
females) or condoms (for husbands) as their preferred contraceptives,
must continue using these methO<ls and be willing toprovide themselves

[ 1]
 with additional resupply to maintain their future needs and require-
. ments. If, however, adequate supplies are available in the centers,
users of -condoms should be given twelve (12) pieces per month, on
a continuing basis, free of charge. Their follow-up visits should in-
dicate that they are continuing users 'of these methods.
.,

INSTRUCTIONS FOR THE USE OF CONDOMS, FOAM TABLETS

• . , AND CONTRACEPTIVE FOAM

A. CONDOMS

How to use
1. Test condorna. for any holes before using.
2.' Put condom on the. erect penis before inserting it into the vagina.
-. Be sure to leave about one-half (~) inch of air-free space at the tip
.to hold the ejaculate (semen).
3. Hold base of the condom 'to prevent it from slipping off before with-
drawing penis after ejaculation. Take care not to spill any semen
on the women's external genitalia.

B. FOAM TABLETS

When to insert
1. Ten '(10) to twenty (20) minutes before intercourse is started and
~he woman in. lying position.
2. If the woman has to get up before the act, use an additional tablet.
3. Insert a new tablet everytime intercourse is repeated.

How to insert'
1. Wash hand thoroughly.
2. Hold foam tablet between index finger and middle finger and insert
gradually into the vagina.
3:. Push tablet deep into thevaginal canal with forefinger.

To avoid failures
1. Use foam tablet, everytime there is intercourse, without neglect.
2: 'Inserttablet deep into the vaginal canal.
3. Avoid special positions during intercourse, The position where the
woman is lying on her back is most suitable.
4. After a tablet has already been inserted, don't get up or walk around.
If you must do so before intercourse, then reinsert a new tablet deep
into the vagina before intercourse is started.
6. Refrain from getting up immediately after intercourse and avoid douch-
ing for at least eight (8) hours after intercourse.

C. CONTRACEPTIVE FOAM
'-'
How to use
1. Shake the container well..
2. Load the applicator. Remove the pink cap and set the container
upright. Lift the plunger all the way to the top of the u,pplieator.
Press the applicator down over the valve in the top of the container
and the foam will rise in the barrel of the applicator. .. .
3. Dosage. Allow the foam to fill the applicator to the ridge which is
above the middle of the barrel.
4. Place the applicator into the vagina. Push the plunger back into the
applicator to deposit the foam. When the plunger is completely
pushed in, remove the applicator.
. .
6. Douching is not necessary. If a douche is desired fOr cleansing pur-
poses, wait at least six hours following sexual intercourse. Contra-
ceptive foam must be applied before physical contact, but not more
than one hour in advance. After the foam is inserted, no waiting is
necessary. It must be used each t~me physical contact is repeated.
How to clean applicator, Wash the applicator in warm soapy water,
(not in boiling water). The applicator can be taken apart for cleaning
by gently pulling the plunger out of the barrel.
CAUTION: Store your container of contraceptive foam of normal room
temperatures. Exposure to temperatures above 130°F. may' cause
product discoloration. Irritation of vagina Or penis may occur. If
it does, discontinue use and consult your physici!ln:
 GUIDELINES FOR INSERTION OF INTRA-UTERINE DEVICE
(IUD)

WHEN TO INSERT

1. Post-parucm. cases
Preferably from the 2nd to the 4th week, not later than six (6) weeks
after delivery. Insertion may also be done, as early as one (1) to two
(2) days after delivery, if desired.

2. Post-abortai cases
a. NON-SEPTIC-preferably on the 2nd or 3rd day after completion of
abortion. Insertion may also be done immediately after completion
of abortion.
b. SEPTIc-treat first the infection and insert only when infection has
been controlled, provided, an alternate method of contraception
like condom or foam tablet (See Guidelines on the Use of Condom
and Foam Tablet p. 1) is being used.

3. Non-pregnant (interval) cases

, ,
Preferably on the 4th-5th day of 'the menstrual cycle. In some ins-
tances it may be inserted any day after menstruation as long as the
mother is not pregnant, as determined by pelvic examination and/or
pregnancy test (See Guidelines on the Use of Agglutination Test for
Pregnancy p. 24).
A pelvic examination should be done, depth and direction of uterine
cavity determined by the use of hysterometer or sound; Do not force
insertion if there is resistance. Try dilating cervical canal by the
use of dilator if available or straight uterine forceps.
Use of tenaculum is recommended to straighten uterine cavity. Be
gentle.

FOLLOW-UPS

1. Schedule
a. 1st Revisit-1 month after insertion
b. 2nd Revisit-3 months after insertion

[4 ]
 c. 3rd Revisit-c-B months after insertion
d. 4th Revisit and succeeding revisits-1 year after insertion "and
yearly thereafter.

2. Follow-up examination during revisits

a. Speculum Examination . . .
1. To determine presence or absence of the IUD thread or strings.
2. To visualize the cervix for erosions, bleeding, etc.
3. To detect any abnormal discharges.
b. Pelvic Examination for the following conditions:
1. IUD acceptors with amenorrhea, to rule out pregnancy.
2. Unusual vaginal bleeding, to determine source.
3. Suspected "translocation". .
L 4. Recheck examination after 6 months and yearly thereafter.
It is, however, recommended that pelvic examination be made a
routine procedure for all IUD follow-ups to the extent possible.
c. "PAP Smear:' when available and feasible for the following con
ditions: (See Guidelines on PAP SMEAR p. 28)
1. Cervicitis that do not respond to local treatment.
2. Extensive erosions.
3. Presence of growth.
4. Post-coital bleeding.

3. Advise cliente to return. to the clinic for the following reasons.

a. Thread or strings cannot be felt by the client.
b. IUD has been expelled, partially, completely or in fragments.
c. Unusual bleeding or any other complaints.

4. Refer all suspected cases of "translocation," fragmentations and other

unusual complications to either of the fOllowing:
a. Regional/Provincial Family Planning Coordinators
b. Regional Field Assistance Unit (MSS II)
c. Nearest Emergency or Provincial Hospitals

5. AmenoTrhea with IUD in place.

a. Do pregnancy test (See Guidelines on the Use of Agglutination
Test for Pregnancy p. 24)
1. If negative (-), give reassurance;
2. If positive (+), reassurance and close follow-up.

[5]
6. Symptomatic treatment may be prescribed for the follAJwing:
a. Analgesics or antispasmodic for mild lower abdominal cramps and
back pains after insertion.
b. Iron preparations for occasional vaginal spotting and heavy men-
struation.

It is understood, however, that even if clients are not seen in the

clinic for checlv-up, they are to be followed up clAJsely ILt their resi-
d(Jnce; or whereabouts noted; arul status duly recorded. Schedule
of revisits can be changed dependisu) upon individual circumstances
amd is left to the discretum. of the clinic physicia1l1l.

[6]
 GUIDELINES FOR THE USE OF ORAL CONTRACEPTIVES

1. For non-pregnamt (interval ccses) mothers

1.1. 28 pill packet-start initially on the first day of menstruation
one (1) tablet daily until consumed. Start a new or second
packet on the 29th day, with or without bleeding, everyday there-
after until client decides to start a new pregnancy.
1.2. 21 pill packet-start initially on the fifth day of menstruation one
(1) tablet daily until consumed. Rest for five (5) days and start
a new packet on the sixth day with or without bleeding and
monthly thereafter following the same schedule until client decides
to start a new pregnancy.

2. Post-parium cases
2.1. For non-nursing mothers-as early as twenty four (24) hours
after delivery, but not later than four (4) weeks.
2.2. For nursing mothers-preferably four (4) to six (6) months
after delivery; in the meantime, while mother is not yet on pills,
she should be protected by the use of foaming tablets or condom
for the husband (See SOP on the use of Condom and Foaming
Tablet p. 1). In some instances, it may also be given six (6)
weeks after delivery; however, when diminution of milk secretion
is noted while on pills, that mother may be shifted to IUD, pro-
vided there are no contraindications to IUD insertion. If IUD is
not advisable at this time, or is refused by the mother, protection
may be provided, by the use of foaming tablets for the wife or
condoms for the husband (See SOP on the Use of Condom and
Foaming Tablet p. 1).

3. Post-abortal cases
Within twenty four (24) hours to two (2) weeks after completion of
abortion.

4. Amenorrhea or missed mense.•

Ascertain that the mother is not pregnant by pelvic examination and!
or by pregnancy test such as Frog Test or Agglutination Test like
Planosec. (See Guidelines on the Use of Agglutination Test for
Pregnancy p, 24). .

[7J
 NOTE: A very early pregnancy of four (4) to five (5) weeks may not
be detectable by either pelvic examination or pregnancy test.
In case of doubt, play on the safe side by having that mother
protected either by the use of foaming tablets or condoms for
the husband until menstruation occurs or pregnancy is confirmed.
How Long May Oral Contraceptives Be Used Continuously?
Oral contraceptives can be used continuously for several years depending
on the patient's response. However, at the end of 2-3 years continuous
use, it is advised to discontinue treatment. At this point, a rest period
of 4-6 weeks is recommended during which time observation can be made
to ascertain that the patient's ovaries will function normally and the
patient menstruates spontaneously. To protect the patient during the
"rest period", some other form of contraception is provided such as:
condoms, spermicidal tablets, jellies. and diaphragms, After this "rest
period" and no contraindications are found, the patient may safely resume
taking the pill. (Alicia de la Paz, 1973). Recent WHO studies states
that oral contraceptives can be used continuously for as long as 5 years
after which it is advised to be discontinued to prevent the occurence of
possible metabolic effects.

FOLLOW-UPS

I. Schedule'
a. First revisit to clinic-three (3) weeks after taking the pills to
get her replenishment on time; as many as three (3) packets may
be given during this visit.
Succeeding revisits may be scheduled every three (3) months.
thereafter.
In special situations, the physician, at his disc-retion, may issue
more than three (3) packets.
Examples:
1. Clients going on vacation for an indefinite period.
2. Clients living in far places where transportation facilities are
limited or expensive.
3. Other situations such as typhoons, flood, bad roads that inter-
fere with travel to and from the clinic.
b. Clients should be encouraged to report anytime for any abnormal
signs and symptoms even if they have no clinic appointments.

• When clients are scheduled to get their resupply of pills from established
'Barr-io Resupply Points, these follow-up schedules are to be discarded.

[8 ]
II. Subsequent medical check-ups should be done at least once a year or
p1'e!embly every six (6) months
a. Physical examination includes weight, blood pressure, palpation of
breast for presence of masses or lumps. Blood presssure and
weight of clients should be taken and recorded everytime clients
return for resupply.
b. Pelvic examination-speculum and bi-manual examination.
c. Pap smear should be done if indicated, available and feasible. (See
Guidelines on Pap Smear p. 28). Slides may be referred to your
respective Regional Health Laboratory.

WHAT TO DO WITH COMPLAINTS

I. Bleeding
Bleeding in the form of excessive/prolonged menses or intermenstrual
spotting deserves a thorough pelvic examination.
It can either be organic or hormonal in nature.
a. Speculum examination will show source of bleeding whether cervical
or uterine.
b. Internal examination will detect uterine enlargement or displace-
ment, tumors in adnexae (tubes and overies), and any. other pelvic
masses.
Clients who may complain of intermenstrual spotting during the
first three (3) months after starting the pills should be assured
that the condition is temporary and that spotting usually stops
after three (3) months. If spotting or breakthrough bleeding
persists and organic pathology has been ruled out, the estrogen
progestin content of the particular pill may explain the cause of
bleeding. (See Symptoms and Management of Oral Contraceptives
p. 16).
a. "Early bleeding"-refers to spotting or breakthrough bleeding
occuring anywhere from Day 1 to Day 14 of the menstrual
cycle. This indicates estrogen deficiency. .

RECOMMENDATIONS

1. Instruct clients to double the dose the following day of the

bleeding until 21st day. Clients must be given extra packet
of pills.

[9,]
 2. Resume old schedule on the 29th day, one tablet daily.
3. Above procedure may be repeated for two (2) to three
(3) cycles if bleeding recurs.
4. Should breakthrough bleeding persists, change the brand
of pills to Norinyl 1 + 80 or change method.
b. "Late bleeding"-refers to spotting or breakthrough bleeding
occurring anywhere from Day 15 of the menstrual cycle and
beyond. This indicates progestin deficiency.

RECOMMENDATIONS
(
1. Shift to a brand with a higher progestin potency. Ex-
ample: Ovral, Demulen, Femenal, Norinyl-2.0
2. Profuse uterine bleeding is rarely observed in combination
type of pills available in the centers. Should uterine bleed-
ing be profuse, refer to the nearest hospital.

II. Other symptoms

a. Headache, nausea, vomiting and pelvic heaviness should be treated
symptomatically.
b. For complaints of sodium and fluid retention-restrict sodium in-
take; diuretics may be prescribed for certain persistent cases.
Check blood pressure-if high, diuretics and/or hypotensives may
be given. If blood pressure remains elevated change method and
manage hypertension.

PO]
 --- -- - - - - - - -

SYMPTOMS AND MANAGEMENT OF ORAL CONTRACEPTIVE COMPLICATIONS

ESTROGEN EXCESS PROGESTIN EXCESS

FLUID RETENTION I REPRODUCTIVE SYSTEM PROGESTATION AL ANDROGENIC

, ----------"------------------
SYMPTOM Headache Heavy menses Weight gain Hair loss
Dizziness Uterine enlargement Increased appetite Oily skin/acne
Nausea Fibroid growth Tiredness, depression Rash
Epigastric distress Increased cervical mucus Feeling weak Pruritis
Edema-bloating Cervical hypertrophy Breast discomfort Increased sex drive
Hypertension
MAN A G E- 1. Give contraceptive pills with less estrogen 1. Give contraceptive with less progestogen
MEN T .... content content
Example: Norinyl 1 + 50, Ortho-Novum 1 ' Example: Anovlar, Ovulen, Ortho-Novum 1
+ 50, Norlestrin, Demulen + 80, Norinyl 1 80 +
2. For hypertension-give hypotensive.
~

ESTROGEN DEFICIENCY PROGESTIN DEFICIENCY

SYMPTOM .___ Spotting or breakthrough bleeding early in the

Bleeding during the last five days of the men-
menstrual cycle. strual cycle.
Scanty menstrual flow or menstrual period. Heavy menstrual flow and clots
Uterine cramps
MAN A G E- 1. Give contraceptive pills with high estrogen 1. Give contraceptive pills with high progestin
MEN T content content
Example: Norinyl 1 + 80, Ortho-Novum 1 Example: Norlestrin 2.5 mg., Ovral, Demu-
+ 80 len, Femenal

l,;.1
 GUIDELINES FOR THE USE OF NORINYL 1 + 50
AND NORINYL 1 + 80

I. A. New pill acceptors should be started on Norinyl 1 + 50, a lower

dostute preparation.
B. Shifting from Norinyl 1 + 50 to Norinyl 1 +
80 would be in-
dicated under any of the following conditions:
1. Vaginal spotting or breakthrough bleeding occurring at anytime
during the first half of the cycle or before the fourteenth (14th)
day of the menstrual cycle.
2. Scanty menstrual cycle.
3. Amenorrhea or absence of menstruation «after ruling out
possibility of pregnancy).
4. Complaints of marked nervousness or irritability.

II. Old pill acceptors using other brands of pills Or shifters from other
contraceptive methods should also be started on Norinyl 1 +
50.
Should there be a need to prescribe a higher estrogen preparation,
i.e. from Norinyl 1 + 50 to Norinyl 1 +80, follow the same. guide- .
line as in Item 1 B.

.[.12 ]
 GUIDELINES ON RHYTHM

1. Clients desiring to use Rhythm as a contraceptive method should take

a record of their menstrual cycle for at least six (6) months. How-
ever, if client already knows her previous six (6) months' cycle, she
can be started on the method. The acceptor and her physician/
nurse/midwife calculate the onset/duration of her fertile period based
on the following assumptions-
a. ovulation occurs fourteen (14) -+- two days prior to onset of
next menstruation.
b. sperms remain viable for forty eight (48 i hours
c. ova remain viable for twenty four (24) hours

FERTILE PERIOD CAN BE DETERMINED

BY THE FOLLOWING METHODS

A. Calendar Method (Knause-Ojino Formula)

1. Analyze the client's menstrual cycle in a 6-month period and

determine the shortest and the longest cycles.
2. Subtract eighteen (18) days from the shortest cycle, and eleven
(11) days .from the longest cycle.
3. The differences obtained from the shortest and the longest cycles
represent the beginning and the end of the unsafe period re-
spectively. If, for example the woman's menstrual records
show that her shortest cycle is 25 and the longest cycle is 31
days, subtract 18 from 25 and 11 from 31. The difference is
7 and 20 respectively. Seven (7) is Day 7 and twenty (~O)
is Day 20 in the cycle. Day 7 js assumed to be the beginning
of the unsafe days up to Day 20, where the couple should avoid
unprotected intercourse in her succeeding menstrual cycles.
Days before Day 7 and after Day 20 are considered safe days
in the cycle.

B. Thermometer Method

Clients will have to supply themselves with thermometer and

graphing papers.

[ 13 ]
 1. Clients must take their daily basal body temperature (BBT),
preferably at the same time, with the same thermometer and
through the same route consistently (orally, axillary, vaginally
or rectally) in the morning just after waking and before any
activity including eating, drinking, smoking or going to the
bathroom.
2. She must submit to the clinic, records of BBT taken for three
(3) to four (4) consecutive months for plotting and evaluation.
Physician/nurse/midwife will determine ovulation time as shown
by a slight drop in BBT followed by steady rise after twenty
four (24) to seventy two (72) hours. While waiting for the
couple to understand this method correctly, give temporarily,
condoms for the husband or foam tablets for the wife, (See
Guidelines in Condom.& Foam Tablets p. 1). Infections, tension,
irregular sleeping hours may cause elevation in BBT and there-
fore caution should be exercised in the interpretation of the
graph.
3. She must visit the clinic monthly for the first three (3) months
and every three (3) months thereafter, bringing with her
graphs of previous months, or at the discretion of the physi-
cian.

C. Billing's Method (Ovulation Method)

1. Many, but not all women, experience changes in cervical sec-
retion just before ovulation. The changes are--
a. Pre-ovulatory phase (usually day 1-11 of the menstrual cycle)
--cervical secretion is scanty, yellowish-white, viscous mucus
except during menstrual flow. '
b. Ovulatory phase (usually day 12-16 of the menstrual cycle)
--cervical secretion is similar to raw egg-white which can be
stretched into a thin strand of six (6) or more ems. long.
c. Post-Ovulatory phase (usually day 17-28 of the menstrual
cycle)--cervical secretion is scanty yellowish-white, viscous
mucus. The client may feel two (2) types of sensations in
a given cycle:
(a) dryness-during pre-and post-ovulatory phase
(b) wetness-during ovulatory phase.
2. Clients who experience this phenomenon can be taught to eva-
luate mucus changes and advised to avoid intercourse during
the ovulatory phase (period of wetness).
3. The occurrence of the change depends on whether ovulation is
early (short cycle) or late (long cycle). In short cycles, mucus'

[14 ]
 change begins early, that it may sometimes coincide with the
menstrual flow. In such cases, woman should be instructed to
restrict sexual relations just after the menstrual period. let
long cycles, mucus change begins later in the cycle. In such
cases, the woman should be advised to have sexual relations
after the ovulatory phase (period of wetness).

D. Groden's method
This method regulates menstrual cycle by taking hormonal tablets
on eleven (II) fixed days of the menstrual cycle with seven (7)
abstinence days.
I. Schedule
a. Count twenty eight (28) days from the first day of mem-
struation and mark all the calendar the following:
Day I-First day of menstruation
Day 14--0vulation day
Day 10-I6-Fertile days (unsafe period-? days)
Day 15-25-Hormonal tablet (pills) days
b. Abstain from sexual contact from Day 10--16 as indicated
in the calendar.
c. Take one (1) hormonal tablet daily preferably at night
time from Day 15-25. Additional protection such as foam
tablets for the wife or condoms for the husband should be
given if the couple cannot abstain from sexual relation during
the unsafe period.

[I. For reporting of rhythm acceptors, please be reminded that a client

shall be considered an acceptor ONLY if she has followed the phy-
sician'a/nurse'a/rnidwife's instructions whether for the calendar, the
thermometer, Billing's or Groden's methods, for a period of at least
three (3) months or until the physician/nurse/midwife is convinced
that the client understands the procedure and can follow instructions
correctly and religiously.

[ 15 ]
 GUIDELINES ON THE USE OF AGGLUTINATION TEST
FOR PREGNANCY (PLANOSEC)

What is Plamosec?
It is simple disposable test for pregnancy which requires no refrigeration.
It is stable at room temperature until the expiration date printed on the
pack. The test is based on the demonstration of human chorionic gona-
dotrophin (HCG) in the urine of a pregnant woman by means of an
immuno-chemical reaction (agglutination) between 'HCG and HCG anti-
bodies. The reagents found on the test card are the following;
1. Colorless dot contain antiserum to HCG
2. Greenish dot contain latex particles onto which HCG has been
absorbed

A positive (+) result is generally demonstrable from at least ten (10)

days after the last missed menstruation. However, a negative (-) re-
sult at this stage does not rule out pregnancy. In such' case the test
should be repeated a week later.

How to do the test

The test should be done under good lighting and away from sunlight, heat
and draughts. Although the use of the morning urine is strongly re-
commended, the urine sample can be collected anytime of the day. It is
advisable to perform the test shortly after collection the urine sample.
1. Remove the test card from the packet by tearing the envelope where
indicated.
The test card should be removed from packet just before its use.
2. Place the test. card on a flat surface.
3. Take one (1) spatula pipette between the thumb and index finger
and squeeze.
4. Dip the open end of the pipette in the urine and by relaxing the fingers,
draw up a column of urine of at least 1 em. without air bubble into
the pipette.
5. Hold the pipette upright, squeeze and place one (1) drop of urine
to be tested onto the colorless anti-serum dot.

[ 16 ]
 --- --,

6. Using the spatula of the pipette, mix the urine and antiserum and
rock the card gently for 50 seconds. In both instances, care should
be taken not to allow them to come in contact with the green latex
dot. N. B. Technique for correct rocking-Tilt the card so that
mixture flows siowly around without coming in contact with green
latex dot. •
7. Squeeze one (1) drop of distilled water from the dropper tube onto
the green latex dot.
8. Mix latex and water with the same spatula without allowing them
to come in contact with urine mixture.
9. Mix both solutions together using the same spatula and spread the
mixture inside the circle.
10. Rock the card gently for two (2) minutes.
11. Read the result under strong glow-free light.

Result
No AGGLUTINATION (mixture homogeneous) indicates a positive test
(pregnant)
AGGLUTINATION (mixture with clumping) indicates a negative test (not
pregnant)

LISTED BELOW ARE SOME OF THE FALSE TESTS

A. False negative
1. En-or in reading
2. Too early or too late in pregnancy
3. Urine too dilute
4. Urine stored too long at room temperature
5. Threatened abortion
6. Missed abortion
7. Ectopic pregnancy
8. Too much antiserum

B. False positive
1. Error in reading
2. Proteinuria
3. Hematuria
4. Premature menopause
5. Mixed epithelioma

[17 ]
 6. Undifferentiated lung cancer
7. Ovarian teratoma
8. Persistent corpus luteum cysts
9. Thyrotoxicosis
10. Tubo ovarian abscesses
11. Drugs:
Aldomet
Thorazine
Stelazine
Mellaril
Marijuana
Methadone
Oral contraceptive
Aspirin in large doses
12. Perimenopausal women
13. Detergent residue on glassware
14. Immediate post-partum period (should be negative by 10 day.
postpartum) .

[18 ]
 GUIDELINES FOR TAKING .PAP SMEAR

IMPORTANT POINTS TO REMEMBER WHEN TAKING

SPECIMEN FOR PAP SMEAR

1. Do not take smear during menstruation or when under local vaginal

treatment because specimen may not be. adequate/accurate for diag-
nosis. However, if patient has abnormal bleeding, PAP SMEAR can
also be taken.
2. Use non-lubricated gloves and speculum.

PROCEDURE

1. Have correctly labelled slides, wooden spatula, tongue depressor or

cotton tip applicator 'and flxativeready.
2. Wet speculum with sterile water and insert into the vaginal canal.
3. With wooden spatula, tongue depressor or cotton tip applicator, take
secretion from the vaginal pool and lateral ~ aginal wall.
4. Spread the secretion thinly in one ,(1) stroke on the labelled slide.
5. Repeat procedure Nos. 3 and 4 taking secretion from the squamo-
columnar junction of the cervical os. Scrape or swab firmly the cervical
os making,360 0 rotation.
6. Then fix the material immediately either with the use of spraynet or
solution of equal parts of ethel ether and 95 % ethyl alcohol or dena-
tured alcohol whichever ,is available.
7. After three (3) to four (4) hours of fixing, dry slides.
8. To pack slides, put match stick in between ends of two slides, with
smeared side facing each other, and wrap before sending to the nearest
laboratory for processing and interpretation.

. . -' "

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....
 GUIDELINES FOR DIAGNOSIS AND MANAGEMENT
OF COMMON GYNECOLOGICAL CONDITIONS

1. NON-SPECIFIC VAGINITIS

a. DIAGNOSIS-

1. Itchiness at the genital area.

2. Pain on urination may be present.
3. Thick or watery, foul, yellowish to gray-green vaginal discharge.

b. MANAGEMENT-
1. Both male and female are infected in most cases, so that simulta-
neous treatment of both partners is important.
2. Either of the following may be used-
a. Local treatment with either Furacin as vaginal suppositories or
cream, triple sulfa vaginal tablets (Sultrin) for ten (10)-4ifteen
(15) days. .
b. Tetracycline therapy for partners, 1 tablet (250 mg) three times
daily orally for 7-10 days.
c. Terramycin vaginal tablet-l tablet inserted high in the vagina
for 10-15' days.

c. INSTRUCTION
1. Complete the course of treatment.
2. Use condoms until treatment is completed and symptoms are no
longer present.

2. MONILIAL VAGINITIS

a. DIAGNOSIS-

1. Itchiness at the genital area.

2. Redness of the external genitalia and sometimes the upper thighs.
8. Thick, white, cheesy-like discharge.

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 b. MANAGEMENT-
1. Vinegar douche-s-mixture of two (2) tbsp. white vinegar and one
I (1) liter lukewarm water. .
2. Mycostatin vaginal tablet daily at bedtime for fifteen (15) days.

c. INSTRUCTIONS-
1. Complete the course of treatment.
2. Test for diabetes if with recurrent monilial infection. Manage dia-
betes if present.
3. Wear cotton underwears and avoid tight underwear.

3. TRICHOMONAS INFECTION
•
a. DIAGNOSIS-

1. Itchiness at the genital area.

2. Pain on urination maybe present both in husband and wife.
3. Thin, frothy, fishy, greenish-yellow vaginal discharge.

b. MANAGEMENT-

1. Fasigyn 500 mg. oral preparation

a: Single dose-i-four (4) tablets taken at one time after meal.
b. Husband and wife should be treated with the same dose simul-
taneously.

4. MIXED INFECTION

a. DIAGNOSIS-

1. Itchiness at the genital area.

2. Whitish-yellowish, mucoid, vaginal discharge

b. MANAGEMENT-

1. Vaginal douche-s-either Potassium Permanganate (KMNO') 1 :1000

dilution in 1 liter of lukewarm water until the mixture is deep pink
or light purple in color or 1 tbsp. Betadine Antiseptic solution in 1
liter of lukewarm water. (Check if there is allergy to iodine before
using.)
Department of Health _lIbrary
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 2. Either of the following may be used-
a. Floraquin vaginal tablets-one (1) tablet inserted in the vagina,
morning and evening for two. (2) to four (4) weeks depending
upon the severity of infection.
b. Vagimycin vaginal tablet--one (1) tablet placed high in the
vagina daily for 14 consecutive days.
c. Pimafucin vaginal tablet--one (1) tablet inserted in the vagina
at bedtime for 20 consecutive days.

REFERENCES
DICKEY, R.P. "The Cause and Management of Symptoms Associated with
Oral Contraceptives Use," March, 1973
- - - - - - Managing Ccmtraceptive Pill Patients, April, 1977
HATCHER, R.A. et al, Contmcepiiue Technology, 1978--1979, 9th Revised
Edition
NOVAK, E.R. et al, Textbook of Gynecology, 9th Edition, 1975
PRITCHARD, J.A., et al. William Obstetrics, 15th Edition, 1976

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Department of Health· Llbmry

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H24.45 M31 1980/ Manuel of standard operating procedu