5/26/2021 Kindu Y 1

UOG
School of Midwifery
Department of Clinical Midwifery
Maternity and Reproductive Health Nursing
By: Kindu Y.
Email:kinduyinges2010@gmail.com

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 The Puerperium
 The puerperium is the period of time encompassing the first few
weeks following birth.
 The duration:
o considered by most to be between 4 & 6 / 6-8 weeks

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 Puerperium Contd…
 Characterized by:
 Many Anatomic & Physiological changes
 Some mothers can have life threatening complications

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 Puerperium Cont’d…
 Some mothers can have life threatening complications like
o Uterine sub-involution
o Late PPH
o Puerperal fever
o Postpartal psychiatric disorders
o PP thyroiditis
o Obstetric neuropathies

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 Anatomic& Physiologic Changes
 Uterus
 Immediately after placental expulsion, fundus of the contracted uterus lies slightly below the
umbilicus.
 Anterior & posterior walls, each measure 4 to 5 cm thick
 Immediately postpartum, the uterus weighs approximately 1000 g
 Muscle cells shortening begins within 2 days & as a result the uterus begins to
involute.
 Immediate postpartum-1000gm slightly below umbilicus
 1 week- 12wks
 2week- in pelvis
 4th week- to prepregnant size

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  After Pains
 Pain from intermittent uterine contractions after delivery
 In primiparas, the uterus tends to remain tonically contracted following delivery.
 However, in multiparas, it often contracts vigorously at intervals and gives rise to after
pains, which are similar to but milder than the pain of labor contractions
 Common in multis and worsen with increasing parity
 Precipitated by suckling ( oxytocin)
 Usually decrease in intensity and become mild by third day

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  Endometrial Regeneration
 Within 2 or 3 days after delivery, the remaining decidua becomes differentiated into two layers.
 The superficial layer becomes necrotic & is sloughed in the lochia.
 The basal layer adjacent to the myometrium remains intact & is the source of new endometrium.
 Endometrial regeneration is rapid, except at the placental site
 Histological endometritis is part of the normal reparative process.
 Endometrial Regeneration starts about a week
 complete reepithialization in ~16 days
 At placental site, ~6th week post partum

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 Lochia
o Is post partal vaginal discharge resulting from sloughing of decidual tissue.
o Lochia is of variable quantity.
o Lochia can be of the following three types
– Rubra – Red
• blood, shreds of tissue, and decidua
• 1st few days ( 2-3 days)

– Serosa – Pale red

• serous to mucopurulent,
• From 3rd/4th day to~ the 10th day

– Alba- white/yellowish white

• admixture of leukocytes, thicker, mucoid,
• Scanty fluid + WBCs
• From ~10th day to the 4th- 8th week PP

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 Cervix
• Within 1 week
– Thickening
– Narrowing of the opening (~1cm)
– Formation of the Endo Cervical canal
• Complete healing & reepitheliztion takes 6-12wks
• External Os
– transverse slit as a result of laceration of the external os.
• Lower segment
– diminish to tiny isthmus in few weeks

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  Vagina
 Gradually diminishes in size but rarely returns to nulliparous
dimensions.
 Rugae begin to reappear by the third week but are not as
prominent as before.
 The hymen is represented by several small tags of tissue, which
scar to form the myrtiform caruncles.
 Vaginal epithelium begins to proliferate by 4 to 6 weeks, usually
coincidental with resumed ovarian estrogen production.
 Lacerations or stretching of the perineum during delivery may
result in relaxation of the vaginal outlet.
 Some damage to the pelvic floor may be inevitable,

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 CVS
• CO, PR, SV
– decline to non pregnant values by 10 days.
• Systemic vascular resistance steady increase after 02 days to reach
prepregnancy state.
• Heart
– Gradual reversal of structural changes ~1yr

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 Blood and body fluid
• During and after labor :
– Marked leukocytosis as high as 30,000/micl
• Hct
– no significant change ( if no severe bleeding)
• Coagulation factors
– high fibrinogen level persist for ~01 week

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 • Postpartum diuresis b/n 2nd & 5th days
• Blood volume
- Back to non Pregnant level in ~01week

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 Weight Loss
• Immediate Post partum loss of 5 to 6 kg
– uterine evacuation and normal blood loss,
• Further decrease of 2 to 3 kg through diuresis in 1-2weeks.
• Prepregnancy weight at ~ 6 months

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 Urinary Tract
 Immediately postpartum varying degrees of submucosal hemorrhage & edema is seen in the
bladder.
 Postpartum, the bladder has an increased capacity & a relative insensitivity to intravesical
pressure.
 Leading to over distension, incomplete emptying, and excessive residual.
 The dilated ureters & renal pelves return to their prepregnant state 2 to 8 weeks after delivery.
 Urinary tract infection is of concern because residual urine and bacteriuria in a traumatized
bladder, coupled with a dilated collecting system, are conducive to infection
 Elevated GFR and creatinine clearance
Return to their prepregnant state 2 to 8 weeks after delivery

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 Colostrum
 After delivery, the breasts begin to secrete colostrum, which is a deep lemon-yellow
liquid.
 It usually expressed by second postpartum day.
 Compared with mature milk, colostrum contains more minerals and amino acids.
 It has more protein, much of which is globulin, but less sugar & fat.
 Secretion persists for approximately 5 days, with gradual conversion to mature milk
during the ensuing 4 weeks.
 Colostrum contains antibodies, & its content of immunoglobulin A (IgA) offers the
newborn protection against enteric pathogens.

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 Reproductive Hormones
 HCG becomes negative within 11-16 days
 Prolactin level elevation
Non lactating until ~03 weeks
Lactating unti ~06 weeks ( continue to raise with episodes of breast feeding)
• GnRH- suppressed 20 to prolactin
• FSH, LH, E, P- very low in the 1st 1-2 weeks
• Reach the follicular phase level at ~3weeks Post Partum in non
lactating women

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 Ovulation
Anovulation in early puerperium
– 20 to elevated prolactin level
– Refractory gonads
Ovulation may commence in as early as 27 days
Non lactating woman
- 5-11wks Post Partum (average 7week)
Lactating women
- Generally delayed – often after 6mths
- Depends on frequency and intensity of breast feeding

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 Abnormal Puerperium
Common puerperal problems include
 PPH
 Hypertensive disorders
 Infections
 Thromboembolism
 Bladder problems
 Perineal discomfort
 Lactation failure
 Psychiatric disorders
 Pelvic pains
 Hemorrhoids
 Constipation
 Back aches

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 Uterine Subinvolution
• Arrest/retardation of uterine involution
• Cause
- Retained products of conception or
- Infections
• Manifestations
– UX Softer &larger than expected on bimanual exam
– Persistent lochia
– Excessive bleeding
• Treatment
- Methylergonovine 0.2 mg every 3 to 4 hours for 24 to 48 hours, but its
efficacy is questionable.
– Bacterial metritis (Chlamydia trachomatis causes third of cases ) responds to
oral antimicrobial therapy with Azithromycin or doxycycline therapy is
appropriate empirical therapy.

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 Late PPH
• Bleeding from 24 hrs – 12 weeks post partum
• Clinically worrisome uterine hemorrhage develops within 1 to 2 weeks in perhaps 1 % of women.

Causes
• Abnormal Placental site involution
• Retained placental fragment
- Usually the retained piece undergoes necrosis with deposition of
fibrin & may eventually form placental polyp.
- As the eschar of the polyp detaches from the myometrium, hemorrhage may be brisk (occurs
days 7-14, usually self limiting)
• Bleeding disorders (von Willebrand disease)
• Infection

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 Management of Late PPH
• Uterotonics
- for a stable patient, with empty uterus by ultrasound
- (oxytocin, methylergonovine, or a PG analog)
• Antimicrobials - if uterine infection is suspected
• Suction or sharp curettage for RPC indicated if
Large clots are seen in the uterine cavity.
Bleeding persists or
Recurs after medical management.

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 Puerperal Infections
 general term used to describe any bacterial infection of the genital
tract after delivery
 Puerperal Fever
- A temperature of 38.0°C (100.4°F) or higher—in the puerperium.
- Oral To > 38.0°C (100.4°F) on any 2 of the first 10 days after delivery,
exclusive of the first 24hrs

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 Puerperal Infections Contd…
• Of those febrile in the first 24 hrs of delivery Pelvic infection was
diagnosed subsequently in
– 20% of SVDs
– 70% of Cesarean deliveries

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 focuses of Puerperal Fever
1. Uterine Infection
– The most common
2. Urinary tract infection,
3. Lower genital tract infection,
4. Wound infections
5. Pulmonary infections,
6. Thrombophlebitis, and
7. Mastitis

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 Uterine Infection
Has different names
– Endometritis
– Endomyometritis
– Endoparametritis
– Metritis With Pelvic Cellulitis-more inclusive & preferred

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 Uterine Infection Cont…

• Risk factors of Metritis With  Young age & nulliparity

Pelvic Cellulitis  Induction
• Route of delivery
 Obesity
• CS > vaginal
• Is the single most significant risk  MSAF
factor  Bacterial colonization of
• Prolonged labor
lower GT
• ROM
 - Group B streptococcus
• Intrapartal chorioamnionitis
•
Chlamydia T, Mycoplasma ,
Multiple cervical examinations
•
Ureaplasma u,&
Internal fetal monitoring
• Manual removal of placenta
Gardnerella V.
• Multifetal gestation  Low socioeconomic status

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 Uterine Infection Cont…
Bacteriology
• common vaginal and cervical flora
• Polymicrobial
• Virulence is promoted by
– Polymicrobial infection  bacterial synergy
– Hematoma and
– Devitalized tissues
• Routine pretreatment genital tract cultures are of little clinical use and
add significant costs
• Routine blood cultures seldom modify care

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 Uterine Infection Cont…

Bacteria Commonly Responsible for Female Genital Infections

Aerobes

Gram-positive cocci—group A, B, and D streptococci, enterococcus, Staphylococcus aureus, Staphylococcus epidermidis

Gram-negative bacteria—Escherichia coli, Klebsiella,Proteus species

Gram-variable—Gardnerella vaginalis

Others

Mycoplasma and Chlamydia species, Neisseria gonorrhoeae

Anaerobes

Cocci—Peptostreptococcus and Peptococcus species

Others—Clostridium and Fusobacterium species Mobiluncus species

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 Uterine Infection Cont…
Clinical Features
• Fever – Commonly 38-39CO
– most important criterion for the dx of post partal metritis
• Chills that accompany fever suggest bacteremia
• Lower Abdominal pain
• Uterine tenderness
• Parametrial tenderness
• Offensive lochia
– Group A Strept infection-scanty odorless lochia
• Leukocytosis 15-30,000 – no significance

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 Uterine Infection Cont…
Treatment
• Mild disease – oral antimicrobials as outpatient
- 90% respond for Ampicillin + Gentamycin
• Moderate- severe disease-
- Admit
- IV antibiotics
- 90% respond in 48- 72 hrs
- Can be discharged after being afebrile at least for 24 hrs
- Further oral antimicrobial therapy is not needed

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 Prevention of Postpartum Infection of
1. Perioperative Antimicrobial Prophylaxis
• antimicrobial prophylaxis at the time of cesarean delivery has remarkably reduced the rate of
postoperative pelvic and wound infections.
• The observed benefit applies to both elective and nonelective cesarean delivery and also includes a
reduction in abdominal incisional infections
• Single-dose prophylaxis with Ampicillin(2gm Iv stat before skin incision ) or a first-generation
cephalosporin is ideal, and both are as effective as broad-spectrum agents or a multiple-dose
regimen

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  Persistent fever despite antibiotic treatment of metritis may be 20 to
1. Wound infection, dehiscence, abscess
2. Parametrial phlegmon
3. Pelvic abscess
4. Adnexal infections
5. Peritonitis
uterine incision necrosis and dehiscence ,ruptured ovarian/ parametrial abscess
6. Necrotizing fasciitis
7. Septic pelvic thrombophlebitis

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  Wound Infections
 When prophylactic antimicrobials are given the incidence of abdominal incisional infections following
cesarean delivery is <2 % .
 Wound infection is a common cause of persistent fever in women treated for metritis.
 Other risk factors for wound infections include obesity, diabetes, corticosteroid therapy,
immunosuppression, anemia, hypertension, and inadequate hemostasis with hematoma formation.
 Incisional abscesses that develop following cesarean delivery usually cause fever or are responsible for
its persistence beginning about the fourth day.
 Wound erythema and drainage are present .
 Treatment includes antimicrobials and surgical drainage, and wound care with careful inspection to
ensure that the fascia is intact.

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 Wound Dehiscence
• Disruption or dehiscence refers to separation of the fascial layer.
• Serious complication &requires relaparatomy
• There could concurrent fascial infection and tissue necrosis.
• Most disruptions manifested on about the fifth postoperative
day and are accompanied by a serosanguineous discharge

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 Necrotizing Fasciitis
o This uncommon, severe wound infection is associated with high mortality.
o In obstetrics, necrotizing fasciitis may involve abdominal incisions, or it may complicate episiotomy or other
perineal lacerations.
o There is significant tissue necrosis.
o Three risk factors of these—diabetes, obesity, & hypertension—are relatively common in pregnant women.
o Is polymicrobial infections of normal vaginal flora.
o In some cases, however, infection is caused by a single virulent bacterial species such as group A -hemolytic
streptococcus.
o Treatment
- broad-spectrum antibiotics along with prompt
- wide fascial debridement until healthy bleeding tissue is encountered .

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 Peritonitis
 It is unusual for peritonitis to develop following cesarean delivery.
 It is almost invariably preceded by metritis & uterine incisional necrosis and dehiscence.
 Other cases may be due to
- Inadvertent bowel injury at cesarean delivery
- Rupture of a parametrial or adnexal abscess.
- Rarely be encountered after vaginal delivery.
 Abdominal rigidity may not be prominent with puerperal peritonitis because of abdominal wall
laxity from pregnancy.
 Treatment: laparatomy.

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 Adnexal Infections
• An ovarian abscess rarely develops in the puerperium.
• These are presumably caused by bacterial invasion through a
rent in the ovarian capsule.
• The abscess is usually unilateral, and women typically present 1
to 2 weeks after delivery.
• Rupture is common and peritonitis may be severe.

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 Parametrial Phlegmon
o In some women in whom metritis develops following cesarean delivery, parametrial cellulitis is
intensive and forms an area of induration, or phlegmon, within the leaves of the broad ligament.
o Phlegmons are usually unilateral, & they frequently are limited to the parametrial area at the
base of the broad ligament.
o If the inflammatory reaction is more intense, cellulitis extends along natural lines of cleavage.
o The most common form of extension is laterally along the broad ligament, with a tendency to
extend to the pelvic sidewall.
o Occasionally, posterior extension may involve the rectovaginal septum, producing a firm mass
posterior to the cervix.
o Severe cellulitis of the uterine incision may lead to necrosis and separation. Extrusion of purulent
material commonly leads to peritonitis.

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 DX
– Palpable mass on bimanual & or rectovaginal exam
– MRI- parametrial edema
RX
– In most women with a phlegmon, clinical improvement follows continued
treatment with a broad-spectrum antimicrobial regimen.
– Typically, fever resolves in 5 to 7 days, but in some cases, it is longer.

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Left-sided parametrial phlegmon: cellulitis causes induration in the parametrium adjacent to the hysterotomy
incision.

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• Absorption of the induration may require several days to weeks.
• Surgery is reserved for women in whom uterine incisional
necrosis is suspected.
• In rare cases, uterine debridement and resuturing of the
incision are feasible .
• For most, hysterectomy and surgical debridement are needed
and are predictably difficult.

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 Septic Pelvic Thrombophlebitis
 This was a common complication in the preantibotic era.
 Puerperal infection may extend along venous routes and cause thrombosis
 Lymphangitis often coexists
 The ovarian become involved because they drain the upper uterus and therefore, the
placental implantation site
 Hematogenous extension of Pelvic infection thrombosis in pelvic veins
 Uterine Veins  ovarian veins ( particularly ROV )  Internal Iliac Vein Common Iliac Vein 
Inferior venacava
 Occurs in 1/3000 deliveries

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 Clinical manifestation
– Women with septic thrombophlebitis usually have clinical improvement of pelvic infection
with antimicrobial treatment, however, they continue to have fever.
– Although there occasionally is pain in one or both lower quadrants, patients are usually
asymptomatic except for chills
DX-
Clinical
Pelvic CT, MRI,
Rx.
– Continued the antibiotic already started.
– Anticoagulation has no proven efficacy

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Septic pelvic thrombophlebitis: uterine and parametrial infection
may extend to any pelvic vessel as well as the inferior vena cava. Septic pelvic thrombophlebitis: uterine and
The clot in the right common iliac vein extends from the uterine
and internal iliac veins and into the inferior vena cava. parametrial infection may extend to any pelvic
vessel as well as the inferior vena cava.
The ovarian vein septic thrombosis extends halfway to the vena
cava.

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 UTI
• Predisposing Factors
– Urinary stasis
– Catheterization,
– Prolonged labor
– Frequent pelvic examination
• In 3-4% post partum women
• Clinical
– Dysuria, frequency, urgency, and low-grade fever;
– Urinary retention, hematuria, pyuria
– Pyelonephritis-fever, chills, malaise,CVAT, Nausea & Vomiting
– UA- WBC, RBC, Bacteria
– E.coli- most common etiology (~75%)

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 UTI Treatment
• Antimicrobials specific against the isolated etiology
• Lower UTI- PO
– Nitrofurantoin
– Trimethoprim-sulfamethoxazole
– Cephalosporins (cephalexin, cephradine)
– Amoxicillin-Clavullinate
• Pyelonephritis – IV antibiotics
Eg .- Ceftriaxone 1 gm IV BID or
- Ampicilin 2gm IV QID + Gentamycin 1.5mg/Kg TID
• Response in 48 hrs, continue po medication for ~10 days

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 Milk Fever (congestive Mastitis)
• Breast engorgement + fever
– Low grade fever in the 1st few days pp
– Seldom lasts for > 24hr
– 15% of non breast feeding women
– Less severe& less common in breast feeding women
• RX-
– Ice packs, analgesics ,Tight Pressure (for non BF),
– milk expression after Breast feeding
– Pharmacologic suppression- not recommended
– Exclude other causes

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 Mastitis
• Mammary gland parenchyma infection
• Rare ~<1%
• Usually after 3rd-4th week post partum
• Invariably unilateral
• Marked engorgement followed by inflammation
– Hard, reddened, painful breast
– Chills, rigor, fever, tachycardia

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 Mastitis Contd.
• Etiology
– S. aureus, MERSA (Community & hospital acquierd)
– Coagulase negative S. aureus,
– Viridae streptococci
• Source – infant nose and throat
• Bacteria enter the breast through the nipple at the site of a fissure or small abrasion
• Treatment
– Milk expression and Continued BF
• Prevents stasis
– Empirically – Dicloxacilin, Cloxacillin/Erythromycin
– With milk culture & sensitivity
– Rx for 10-14 days

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 Breast Abscess
• In ~ 10 % of mastitis
Dx
– Palpable fluctuating mass ,
– Ultrasound
– No improvement in 48-72hrs of mastitis treatment
RX
– Incision and drainage, pack
– Ultrasound guided needle aspiration (80-90% success)
– Antibiotics

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 Galactocele
• Occasionally a milk duct becomes obstructed by inspissated
secretions, and milk may accumulate in one or more mammary
lobes.
• The amount is ordinarily limited, but an excess may form a
fluctuant mass—a galactocele—that may cause pressure
symptoms and have the appearance of an abscess.
• It may resolve spontaneously or require aspiration

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 Venous Thromboembolism (VTE)
Puerperium is - Hypercoagulable state
– High fibrinogen level, Vascular injury, Immobility
– Increased platelet activity
• Incidence 1 in 500 to 1in 2000 pregnancies
• Pulmonary Embolism in 25% untreated cases
DVT
– Commonly lower extremity veins- often left leg
– Ilio femoral and deep calf veins
– Isolated iliac vein

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 VTE Contd.
Risk factors
– Cesarean delivery
– Instrumental delivery
– Thrombophilias
• Early ambulation- protective
DX and treatment
Superficial vein thrombosis
– Supportive treatment-analgesia, elastic support, and rest.

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 Postpartum Thyroiditis
• Autoimmune (In ~10% )
• DM – increased risk
• Hypo/ Hyperthyroid features
• Evaluation- TFT
• RX
– Hypo – Thyroxine supplementation
– Hyper-- β-blockers, PTU
• Sequelae
– Permanent hypothyroidism (5-30% of PPT)

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 Psychiatric Disorders
1. Postpartum Blues
– Mild and transient mood disturbances-
– Affects 40-80% of post partum women
– Usually in the 1st 10 days
– Self limiting-
– Treatment  Reassurance, support

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 2. Postpartal Depression
• More protracted depressive mood,
• Usual onset >1month postpartum
• symptoms
• In~12-20% post partum women
DX ( DSM V Peripartal Depression)
– Suicidal /Homicidal ideation- psychiatric emergency
Rx:
• Psycohtherapy, antidepressants
• Recurrence ~25%

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 3. Post Partal Psychosis
 in 0.1-0.2% of all postpartum women;
• symptoms usual onset b/n 1st and 2nd week
• cannot be distinguished from other psychoses
– anxiety, restlessness,
– Manic paranoid thoughts or delusions.
– Abnormal reaction towards family members.
• Admission to a psychiatric clinic ;.

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 Obstetric Neuropathies
• Injury to branches of lumbosacral plexus by
– Fetal head
– Inappropriate legging
– Forceps
• Usually after prolonged 2nd stage of labor
– Crampy leg pain ( uni or bilateral)
– Variable degree of Sensory or motor deficit
– Foot drop
• Resolve in 2wks- 18 mths (median duration~~2mths)

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 Management of the Puerperium
Immediate postpartal care (Hospital Care)
– Vaginal bleeding, uterine contraction,
– Urinary retention
• encourage voiding, catheter
– Perineal discomfort
• look for hematoma
• Ice pack to reduce edema over episiotomy/laceration
– Help with breast feeding
– Encourage early ambulation
• Minimal bladder and bowel complaints, ↓TE risk

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 • Discharge
– within 24- 48hrs) for uncomplicated SVD
– 2-4 days for uncomplicated CS
Instruction on
– Normal/ physiologic changes
– Danger signs (fever, excessive vaginal bleeding, or leg pain, swelling, or
tenderness. Shortness of breath or chest pain, mood problems.)
– Diet , activity, perineal and breast care,

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 • Subsequent follow up Care
– 3-6days
• infections, postpartum depression, and problems with infant care and feeding,
coitus, contraceptive
– 6weeks PP
• Recovery, Anemia, contraception, complaints
– 6months
• General health, any morbidity

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 Postpartal Contraception
• Options
– LAM
– Barrier
– Hormonal
– IUDs
– Sterilization

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 • LAM
• Progestin only-POP, Implants, Injectable
– After 6weeks PP ACOG, WHO
• IUCD
– Both copper and LNG can be used
– Timing
• Post placental (~10min of placental delivery) increased risk of expulsion
• 4-6weeks postpartum(after complete involution)
• Female sterilization
– 24hrs - 07 days postpartum
– 6weeks postpartum

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 Thank you !

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 Family Planning
And Contraception

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 Session objectives
At the end of this session students are expected to:
 Define family planning
 Describe the origins of FP in Ethiopia
 Identify contraceptive method options
 State why to invest in family planning
 Apply appropriate counseling for contraceptive method choice
 Analyze the demand and unmet need of contraceptive in the country

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 DEFINITION

Family planning refers to an action taken by an individual couples to

have the desire number of children and spacing

 Is ability of individual or couples to decide when to have the children

 Family Planning is having the number of children you want when

you want them

Contraception refers to all measures, temporary or permanent ,

designed to prevent pregnancy

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 The Evolution of FP

 Modern birth control movement started in 1912

– Margaret Sanger, New York public health nurse

– She opened the 1st FP clinic in 1916

 FP has received growing attention beginning in the 1960s due to three

reasons:
• Serious of discussion by different people implication of rapid
population growth
• International conferences attended by country leaders

• Invention of two types of contraceptives (Pills and IUD)

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 History of family planning in Ethiopia

• Family planning in modern sense is recent development in

Ethiopia.
• History of modern family planning is related with establishment of
family guidance association of Ethiopia (FGAE)
• FGAE is non profit making and non government association that
was established in 1966.

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• FGAE
– FGAE established in 1966
– Initially operating in a room which was in the premises of St. Paul
Hospital
– Became the first organization to FP clinic in Ethiopia (1974)
– Became affiliate member of the International Planned Parenthood
Federation (IPPF) (1975)
– Still recently FGAE was the main provider of community and facility
based FP in Ethiopia
– Contraceptive use and advertisement was illegal
06/27/2021 kindu y 72
Challenges on FGAE:

The government did not give attention for population growth(the

population at that time was considered as small)

 Did not get support of Ethiopian people in general and religious

leaders in particular

06/27/2021 kindu y 73
By 1970,FGAE was recognized by international planned parent hood
federation(IPPF) and got some assistance to expand their service.

During this time wives could get contraceptive only after their
husband signed consent.

By 1975 FGAE was allowed to be registered as NGO and became a

full fledged member of IPPF i.e. start to get more regular assistance.

By this time F/p clinics of FGAE were opened in Asmara and Addis
Ababa.

06/27/2021 kindu y 74
By this year MOH and FGAE agreed to train nurse in family planning.

By this year Ethiopian government accept primary health care

including family planning.

By 1980 department of MCH/FP was established by regional health

bureau.

In 1982 Ethiopian government fully, for the first time, officially
allowed F/p service to be given by FGAE as part of national maternal
and child health program under the supervision of the MOH.

06/27/2021 kindu y 75
 Rationale of Family Planning
1. Demographic rationale

2. Health rationale

3. Human right rationale

06/27/2021 kindu y 76
1. The demographic rationale (1960s and 1970s)

 Concern of rapid population growth on economic productivity,

savings and investment, natural resources, and the environment

2. The health rationale (in the 1980s)

 The consequences of high fertility for maternal, infant, and child

mortality

3. The human rights rationale (in the 1990s)

 women’s rights, principally reproductive rights, and the reproductive

health of women and men. This is associated with ICPD, in 1994.
06/27/2021 kindu y 77
 Demographic rationale

•The predominant rationale for much of the late 1960s and 1970s

•Rapid population growth in 1940s and 1950s, resulting from the gap
between declining mortality and continuing high fertility

•Concerns about rapid population growth and high fertility

•Excessive population growth being a threat to food supplies and natural

resources.

06/27/2021 kindu y 78
FP programs were intended to contribute to:

 lower rates of population growth,

 improved living standards and human welfare, and

 lessened impact on natural resources and the environment by

helping to reduce high rates of fertility.

06/27/2021 kindu y 79
 2. Health rationale

 Became prominent during the 1980s; driven by the consequences of

high fertility for maternal, infant, and child mortality

 High maternal mortality was associated with a high number of

pregnancies, births, and abortions.

06/27/2021 kindu y 80
High rates of maternal, infant and child mortality required
attention (1980s)

1. Avoiding the extremes of maternal age (<15 ), >35 years)

 Older- Mal-presentations, uterine rupture, hemorrhage,
abnormal placentation…
 Young - Pregnancy induced hypertension, obstructed labor…
 F/P prevent from the health risks associated with pregnancy,
delivery and the postpartum period.

06/27/2021 kindu y 81
2. Decreasing risk by decreasing parity

Risk of maternal death is 1.5 to 3 times higher for women with 5 or

more children than for women with 2 or 3 children

3. Preventing high risk pregnancies (previous complications, chronic

diseases, anemia…)

4. Decreasing abortion risks (“every child is a wanted child”)

5. Non contraceptive benefits (Protection against STIs and

reproductive tract cancers)

06/27/2021 kindu y 82
 3. Human right rationale

• FP became the subject of international human rights when

the United Nations issued a statement on population on
Human Rights Day in December 1967.
• The Teheran Conference on Human Rights affirmed the
basic right of couples to decide on the number and spacing
of their children and helped to legitimize family planning.

06/27/2021 kindu y 83
• focus on women’s rights, principally reproductive rights,
and the reproductive health of women and men.

• Found strongest articulation at the ICPD

06/27/2021 kindu y 84
• UN on Human rights day December 1967
– “…that the great majority of parents desire to have the knowledge and
the means to plan their families; that the opportunity to decide the
number of and spacing of their children is a basic human right…”

• Teheran Conference on Human Rights 1968

– Affirmed the basic right of couples to decide on the number and
spacing of their children
• The 1994 ICPD has resulted major shift toward reproductive rights…

06/27/2021 kindu y 85
 Advantages of FP
• For women:
– Avoiding pregnancy at the extremes of maternal age

– Decreasing risk by decreasing parity

e.g. Risk of maternal death is 1.5 to 3x higher for women with 5 or
more children than for women with 2 or 3 children

– Preventing high risk pregnancies

– Decreasing abortion risks

– Non contraceptive benefits (Protection against STIs and

reproductive tract cancers)
06/27/2021 kindu y 86
 Global Maternal Death Burden

• Every day in 2017, approximately 810 women died from

preventable causes related to pregnancy and childbirth.
• Between 2000 and 2017, the maternal mortality ratio (MMR,
number of maternal deaths per 100,000 live births) dropped by
about 38% worldwide.
• 94% of all maternal deaths occur in low and lower middle-income
countries.
• Young adolescents (ages 10-14) face a higher risk of complications

and death as a result of pregnancy than other women.

06/27/2021 kindu y 87
 Causes of maternal death in Ethiopia
Systematic review with meta-analysis in Ethiopia (1990-2000):
1.Hemmorage -29.9%
2.Obstructed labour -22.34%
3.Hypertention -16.9%
4.Purperal sepsis-14.68%
5.Unsafe abortion -8.6%

06/27/2021 kindu y 88
Children:
Infant/child deaths are reduced by:
– Spacing births > 2 years apart
– Delaying births until after age 18
– Limiting family size to < 4 children

• Birth interval < 12 months = 70-80% increase in risk of

death for previous child

• Infants born to women < 18 years old are 24% more likely
to die in first month

06/27/2021 kindu y 89
Adolescents:
– Protection from early and unwanted pregnancy
– Prevention of unsafe abortions
– Protection from STDs (e.g. HIV/AIDS)
– Increased education opportunities
– Increased job possibilities
Men:
• Protection from STDs (e.g. HIV/AIDS)
• Less emotional and economic strain
• Improved quality of life

06/27/2021 kindu y 90
Family:
– Less emotional and economic strain

– More resources available for children

– Increased education opportunities for children

– Increased economic opportunities

– More energy for household activities
– More energy for personal development and community
activities
06/27/2021 kindu y 91
Community:
• Reduced strain on environmental resources (land, food,
water)
• Reduced strain on community resources (healthcare,
educational and social services)
• Greater participation by individuals in community affairs

06/27/2021 kindu y 92
 Family planning Counseling

06/27/2021 kindu y 93
 Learning objectives

Define counseling

State the purpose of counselling

Explain the principles of counselling

Describe the qualities of good counselling

Describe the skills required for counselling

Explain the steps in the counselling process

06/27/2021 kindu y 94
 COUNSELING IN FAMILY PLANNING

Counselling refers to a process of interaction, a two-way

communication between a skilled provider bounded by a code of ethics
and practice, and client/s.

It aims to create awareness of and to facilitate or confirm informed and

voluntary sexual and reproductive health decision making by the client.

It is a process, which helps a client to decide if she/he want to practice

family planning

It helps client to choose a method that is personally and medically

appropriate

06/27/2021 kindu y 95
 CONT…

Counselling helps client to understand how to use correctly

and consistently family planning methods.

It requires empathy, genuineness and the absence of any

moral or personal judgment.

06/27/2021 kindu y 96
 Client’s right

1. Information

2. Access to services

3. Informed choice

4. Safety of services

5. Privacy and confidentiality

6. Dignity, comfort, and expression of opinion

7. Continuity of care

06/27/2021 kindu y 97
 Purpose of Counselling

Give correct and comprehensive information

Help clients to make informed choices and decisions

Help clients with special problems or questions

06/27/2021 kindu y 98
 Principles of counselling

1) Engage in two-way communication with the client.

2) Leave the client the right to decide

3) Keep problems of client confidential

4) Tell the truth

5) Show empathy for the client’s needs

6) Master the subject matter

06/27/2021 kindu y 99
 Elements of good counselling

• Focus on the woman's needs and knowledge

• Actively listen and learn from her

• Engage in interactive discussion

• Utilize skilled ways of asking questions

• Explore situations and beliefs

• Do not be judgmental

• Build trust

06/27/2021 kindu y 100

 Elements of good counselling…

• Explore options together

• Facilitate problem-solving

• Make a plan of action together

• Encourage and reinforce actions

• Evaluate together your plan of action

06/27/2021 kindu y 101

 Counselling is Not !
 Solving a client’s problems

 Telling a client what to do or making decisions for client

 Judging, blaming, or lecturing a client

 Pressuring a client to use a specific method

 Interrogating a client

 Imposing your beliefs

 Lying to or misleading a client

06/27/2021 kindu y 102
 Tips for Successful Counselling

• Show respect for every client, and help each client feel at ease.

• Encourage the client to explain needs, express concerns, and ask

questions.

• Be alert to related needs such as protection from sexually

transmitted infections including HIV, and support for condom use.

• Talk with the client in a private place, where no one else can hear.

• Assure the client of confidentiality— that you will not tell others
about your conversation or the client’s decisions.

06/27/2021 kindu y 103

 Tips for Successful Counselling

• Show respect for every client, and help each client feel at ease.

• Encourage the client to explain needs, express concerns, and ask

questions.

• Be alert to related needs such as protection from sexually

transmitted infections including HIV, and support for condom use.

• Talk with the client in a private place, where no one else can hear.

• Assure the client of confidentiality— that you will not tell others
about your conversation or the client’s decisions.

06/27/2021 kindu y 104

 What is Informed Choice?

All family planning clients have right to informed choice:

• Opportunity to freely choose among options

Based on access to

• Complete, accurate information about

all appropriate, available options

06/27/2021 Kindu Y. 105

Family Planning clients have right to freely choose

Whether to:

• Have children, and how many to have

• Use FP or not

• Be tested for STIs/ HIV

• Use condoms

• Talk with partner about condoms or FP

• Reveal their HIV status

06/27/2021 Kindu Y. 106

 Who are our clients?

• New clients who have no method in mind

• New clients with a method in mind

• Clients returning for resupply (satisfied clients)

• Clients returning with problems or a different need (such as dissatisfied

return clients)

• Most FP clients are either return clients (already using a method) or

new clients who have a method in mind.

06/27/2021 Kindu Y. 107

 Clients by population group

• Men, women

• Married, unmarried

• Adolescents

• Clients with high individual risk for STIs

• Clients living with HIV

06/27/2021 Kindu Y. 108

 Clients by fertility plan
• Delayers

• Spacers

• Limiters

• Want to get pregnant

06/27/2021 Kindu Y. 109

 Clients by timing of last pregnancy
• Postpartum

• Postabortion

• Interval

• Never pregnant

06/27/2021 Kindu Y. 110

 Counseling Steps in Family Planning counselling

REDI approach

R--Rapport building

E--Exploration

D--Decision making, and

I--Implementing the decision.

06/27/2021 Kindu Y. 111

 Counseling Steps in Family Planning…

Step one; Rapport building

Greet client with respect

 Make introductions

 Ensure confidentiality and privacy

Help the client to relax and feel comfortable

 Explain the need to discuss sensitive and personal issues

06/27/2021 Kindu Y. 112

 Cont…

Step two; Exploration

• Explore in depth the client’s reason for the visit

• Explore client’s future RH-related plans, current situation, and past experience

Explore client’s reproductive history and goals, while explaining healthy timing
and spacing of pregnancy (HTSP)

Explore client’s social context, circumstances, and relationships

Explore client’s history of STIs, including HIV

06/27/2021 Kindu Y. 113

 Cont…

• Assess the family planning experience/ knowledge and provide

information and discussion about FP, dual protection and HIV/STI
transmission.

• Focus discussion on the method(s) of interest to client: discuss the

client’s preferred method

• Rule out pregnancy

• Properly response to clients concerns and questions.

06/27/2021 Kindu Y. 114

 Cont…
Step three; Decision making

 Identify the decisions the client needs to confirm or make

Explore relevant options for each decision

Help the client weigh the benefits, disadvantages, and consequences of

each option

Encourage the client to make his or her own decision

06/27/2021 Kindu Y. 115

 Cont…

Step four; Implementing the decision.

Assist the client in making a concrete and specific plan for carrying out the decision(s)

Have the client develop skills to use his or her chosen method and condoms

Identify barriers that the client might face in implementing his or her decision

Develop strategies to overcome the barriers

Make a plan for follow-up and/or provide referrals as needed

06/27/2021 Kindu Y. 116

 Challenging moments in counseling

1. Client becomes silent

2. Client cries

3. Client refuses help

4. Client is uncomfortable with the provider (because of gender

difference, age difference)

5. Provider makes mistake

06/27/2021 Kindu Y. 117

 Managing side effects

• Always acknowledge the clients’ complaints

• Take clients’ complaints seriously

• Gain a full understanding of the complaint: Ask and listen!

• Inform and reassure

• Discuss and/or offer medical management as appropriate

• Determine whether the side effect will go away without treatment or

should be treated

06/27/2021 Kindu Y. 118

 Managing side effects cont’d

• Remind the client that he or she is always welcome to come back with
any concerns or questions

• Remind the client that he or she is always welcome to change methods

• Treat side effects or complications accordingly

• If the client is not satisfied with these options, offer the client the
option of switching to another method

06/27/2021 Kindu Y. 119

Client Assessment and Medical Eligibility for FP Use

06/27/2021 Kindu Y. 120

 Client Assessment
 History

The following information should be sought from clients that request FP services to
ensure safety and effectiveness before providing contraceptives.
• Age

• Parity, last delivery, last abortion, history of ectopic pregnancy

• Breast feeding

• Smoking status

• Sexual behavior: self, partner

06/27/2021 Kindu Y. 121

• STIs and HIV status

• Pelvic infection

• Tuberculosis

• Pelvic surgery

• Hypertension

• Diabetes

• CVS risk factors (smoking, obesity, hypertension, previous thrombo-embolic phenomena,

and high lipids)

• Migraine

• Viral hepatitis

• Gall bladder disease

06/27/2021 Kindu Y. 122
 Medications the client is taking:

• Antiretroviral drugs
• Rifampicin

• Antibiotics
• Antidepressants
• Anticonvulsants
 Family history of cancers, cardiovascular diseases and cerebro-vascular accidents

06/27/2021 Kindu Y. 123

 Physical examination

• Blood pressure measurement – note systolic and diastolic

measurements
• Obesity – height and weight
• Pelvic examination – Pelvic examination is seldom necessary, except
to rule out pregnancy in women who are amenorrheic for more than 6
weeks from last menstrual period and before the use of IUCD and
female sterilization.

06/27/2021 Kindu Y. 124

 Laboratory examinations (only when indicated)

 Hemoglobin test
 Screening for STIs/HIV – wet smear, gram stain, VDRL, HIV test
 Pregnancy test: Be reasonably sure that a woman is not pregnant

06/27/2021 Kindu Y. 125

 The US Medical Eligibility Criteria

• Deals with an evidence-based tool

• used to review who can and cannot safely use a contraceptive method
• Improve both the quality of and the access to family planning services
for clients
• was developed within the context of clients’ informed choices and
medical safety

06/27/2021 Kindu Y. 126

 US MEC
 Groups contraceptive methods in to 6 by their similarity
1) Combination hormonal contraceptives (CHC)
2) Progestin only pill (POP)
3) Depot medroxyprogesterone acetate (DMPA)
4) Implants
5) Levonorgestrel-realizing intrauterine system(LNG-IUS)
6) Copper intrauterine device (Cu-IUD)

06/27/2021 Kindu Y. 127

 US MEC
For a given health condition, each method is categorized 1 through 4
1. No restriction of method use
2. Method advantage overweigh risks
3. Method risks overweigh advantages
4. Method poses unacceptably high health risk

06/27/2021 Kindu Y. 128

 Contraceptive methods

Methods of Contraception

Temporary
Permanent methods( used for
methods( used for
limiting)
spacing)

 Natural methods
 Barrier methods
Female Male ale
 Combination hormonal
contraceptives
 Injectables
tubectomy vasectomy
 Implants
 Intrauterine devices

06/27/2021 Kindu Y. 129

 Pearl Index
Indicates effectiveness of a method or is an index of contraceptive failure

Expressed in terms of failure rate per hundred women-years of exposure- WHY

 The total accidental pregnancies in the numerator includes every conception what
ever outcome it has

 The factor 1200 is the number of months in 100 years

 The total months of exposure in the denominator is obtained by deducing from the
period under review of 10 months for all full term pxy and 4 months for an abortion.

06/27/2021 Kindu Y. 130

 Classification of Contraceptive Methods
Contraceptive methods are classified based on their effectiveness in to four tiers:
1) Top-tier or first-tier methods

 Most effective and easy to use

 Require minimal user motivation or intervention and have a typical-use pregnancy

rate <1/100 women during the first year of use

 Gives the longest duration of contraception

 Require the fewest number of return visits

 unintended pregnancy rate reduction may be better achieved by increasing their use
 Include:
o Male and female sterilization
o Intrauterine contraceptive devices
o Implants

06/27/2021 Kindu Y. 131

2) Second-tier methods

 include hormonal contracep­tives that are available as oral tablets,

intramuscular injections, transdermal patches, or transvaginal rings.

 typi­cal-use pregnancy rate of 4 to 7 per 100

3) Third-tier methods

 Include condoms for men and women,

withdrawal, and fertility awareness methods such as cycle beads

 The typical-use pregnancy rate is 13-24 /100

 Efficacy rises with consistent and correct use

06/27/2021 Kindu Y. 132
4) Fourth tier methods- include spermicidal preparations, which

have a typical-use failure rate of 28 /100

06/27/2021 Kindu Y. 133

 Table 2: contraceptive failure rates
during the first year of method use
in women in the united states

06/27/2021 Kindu Y. 134

 Contra
ceptive
metho
ds
arrang
ed by
effectiv
eness

06/27/2021 Kindu Y. 135

 U.S. Medical Eligibility Criteria for Use of Various Contraceptive Methods While Breastfeeding

Time reflects time from delivery.

06/27/2021 Kindu Y. 136

 Natural Family planning Methods
Is a method without any drugs or hormones in it.
1) Rhythm /calendar method
2) Basal body temperature method
3) Symptothermal method
4) Withdrawal/coitus interruptus method
5) Billings/cervical mucus method
 Basis:
 Avoiding sexual intercourse around the time of ovulation
 The time of ovulation can be judged on calendar and symptom basis

06/27/2021 Kindu Y. 137

 Natural Family planning Methods
1) Rhythm Method:
 Based on Ogino-Knaus theory, ovulation occurs on 14 ± 2 days in a
female with a regular 28 days cycle.
 Avoid sex between 12th and 16th day of cycle
 Fertilization span of the sperm is 48-72 hrs. and is 12-24 hrs. for ova
 Cycle day 8-18- Unsafe period
 25-35% failure rate
 Failure rate will be reduced to 10% if sex is avoided 7-21 days
 Thus, sex is safe only in the first 7 days of the menstrual cycle

06/27/2021 Kindu Y. 138

 Natural Family planning Methods

The rhythm/calendar method

06/27/2021 Kindu Y. 139

 Natural Family planning Methods
For irregular method:

 Safe period is shortest cycle -18 (give the first day of the fertile period ) to longest cycle
-11(gives the last day of the fertile period )

Advantages - low cost and no side effects

Drawbacks

 Difficult to predict safe period for irregular cycles

 Can only suited for educated and responsible couples with high motivation and
cooperation

 Not applicable for postnatal period

 Needs abstinence

 High failure rate – 9/100 WY

06/27/2021 Kindu Y. 140
 Natural Family planning Methods
2) Standard Days Method:

 Has simple rule and is easier than rhythm/calendar method

 Cylclebeads- help to track the estimated high and low fertility points
throughout the menstrual cycle

 Only be used by women whose cycles are always b/n 26 and 32 days

 Days 1-7 of the cycle are considered

 Days 8-19 are considered fertile

 From day 20, infertility is considered resumed

 Failure rate – 2/100 WY

06/27/2021 Kindu Y. 141
 CycleBeads

 During use, the red bead denotes men­ses onset, and the small black band is advanced for each day of the menstrual cycle.

 When the white beads are reached, abstinence is observed until brown beads begin again

06/27/2021 Kindu Y. 142

3) Cervical mucus method/Billing method:

 Based on observation of changes in the characteristics of cervical

mucus

 During ovulation - Watery, clear (resembling raw egg white) ,

smooth slippery, elastic on stretching between fingers (called
Spinnbarkeit), and profuse

 After ovulation- thick, scanty, loses elasticity, breaks on stretching

and called Tack- (progesterone dominance)

 Use tissue paper to wipe inside the vagina to characterize the mucus

06/27/2021 Kindu Y. 143

 Cervical mucus during Ovulation

06/27/2021 Kindu Y. 144

 Intercourse is safe during the dry days immediately after menses and
till the mucus is detected

 Abstain until the 4th day after the peak day

 Need high degree of motivation and knowledge of different

characteristics of the mucus

06/27/2021 Kindu Y. 145

 Billing Method

06/27/2021 Kindu Y. 146

4) Basal Body Temperature method

 Body temperature drops briefly & then rises 0.5 degree celsius following
ovulation due to thermogenic effect of progesterone and remains elevated
in the secretory phase.

 A rise in temperature persisting 3 days indicates that ovulation has

occurred.

 Safe period is from fourth day(1st day being the day of ovulation) to the
last day of the next period

 A chart of daily temperature readings must be kept for the method to be

effective
06/27/2021 Kindu Y. 147
5) Symptothermal method:
 Use of at least to indicators to identify the fertile period.
 The cervical mucus method and the basal body temperature method
are usually use in combination.

6) LAM

06/27/2021 Kindu Y. 148

6) LAM
 Basis
Frequent intense suckling

Prolactin released

Inhibits GnRH secretion

Downregulates LH and FSH release

Disrupts follicular development

Anovulation and amenorrhea

06/27/2021 Kindu Y. 149

Key point
3 prerequisites for LAM to insure effective contraception
1) Excusive breast feeding
2) Baby < 6 months
3) Amenorrheic/menses should not have resumed
 Failure rate – 5/WY

06/27/2021 Kindu Y. 150

Natural family planning methods are not suitable for women:

o With irregular cycles, cycles shorter than 21 days

o Adolescent, lactating, premenopausal

o Had cervical surgery

o With vaginal infection

o Have STD or PID in the last 3 months

o Had recent abortion

o Non cooperative husbands or couples who have casual sex

So What?
06/27/2021 Kindu Y. 151
 Reading Assignment
Withdrawal method
Barrier methods
spermicides

06/27/2021 Kindu Y. 152

 Oral contraceptive pills(COC)
Taken by mouth to prevent pregnancy
Types of oral contraceptive pills :
Combined Oral Contraceptives(COC)

 progestin only pill(POP)

06/27/2021 Kindu Y. 153

 Oral contraceptive pills(COC)
•Pills that contain low doses of two synthetic hormones-a progestin and an
estrogen

• Highly effective in preventing pregnancy

•How do they work?
Inhibit ovulation-main MOA
Thicken cervical mucus
Change endometrial lining(thing )
Alter tubal transport
Effectiveness
–Typical use (as commonly use) 6-8% pregnancy rate
–Perfect use - 0.1% pregnancy rate

06/27/2021 Kindu Y. 154

 Oral contraceptive pills(COC)
•Pills that contain low doses of two synthetic hormones-a progestin and an
estrogen

• Highly effective in preventing pregnancy

•How do they work?
Inhibit ovulation-main MOA
Thicken cervical mucus
Change endometrial lining(thing )
Alter tubal transport
Effectiveness
–Typical use (as commonly use) 6-8% pregnancy rate
–Perfect use - 0.1% pregnancy rate

06/27/2021 Kindu Y. 155

 Oral contraceptive pills(COC)

A. Extended-use COCs. Each of the three sequential cards of pills is taken. Placebo pills (peach) are found In the bottom
card.
B. 21n triphasic COCs. Active pills are taken for 3 weeks and are followed by seven placebo pills (green). With triphasic
pills, the combina­tion of estrogen and progestin varies with color changes, in this case, from white to blue to dark blue.
c. 24/4 monophasic COCs. Monophasic pills contain a constant dose of estrogen and proges­tin throughout the pill pack.
With 24/4 dosing regimens, the num­ber of placebo pills Is decreased to four.

06/27/2021 Kindu Y. 156

 Oral contraceptive pills(COC)

06/27/2021 Kindu Y. 157

 Oral contraceptive pills(COC)

Return of fertility after COCs are stopped: No delay

Protection against STIs: None

Advantages
– Safe, effective and reversible
– Can be used at any age (adolescence to menopause)

Potential health benefits

– Prevent/reduce iron deficiency anemia
– Reduce risk of Pelvic Inflammatory Disease
– Reduced risk of uterine/ovarian cancer

06/27/2021 Kindu Y. 158

 Non-Contraceptive Benefits of COC

06/27/2021 Kindu Y. 159

 Absolute contraindication to COC

06/27/2021 Kindu Y. 160

 Relative contraindication to COC

06/27/2021 Kindu Y. 161

Indications for withdrawal in COC
 Severe headache

 Visual disturbances

 Sudden chest pain

 Preoperatively (6 weeks)

 Severe cramp & pains in legs

 Excessive weight gain

 Severe depression
 Wanting pregnancy

06/27/2021 Kindu Y. 162

 …cont’d
Disadvantages
• Challenge daily compliance
• New packet of pill must be at hand every 28 days
• Do not protect STI
• Reduces milk supply - not recommended less than
6months postpartum

Health risks
• Increased risk of myocardial infarction, stroke, venous
thrombosis
• Equivocal evidence of increased risk of breast and cervical
cancer

06/27/2021 Kindu Y. 163

 Side Effects
• Changes in bleeding patterns

• Headaches

• Dizziness

• Nausea

• Breast tenderness

• Weight change

• Mood changes

• Acne

• Blood pressure increase

06/27/2021 Kindu Y. 164

When to Start

Having menstrual cycles

• within 5 days after the start menses

switching from an IUD, inject able and others give in

that day

fully breast feeding less than 6 months after giving birth:

• Give her COCs and tell her to start taking them 6

months after giving birth

06/27/2021 Kindu Y. 165

Fully breast feeding more than 6 months after giving birth:

• Menses has not returned, not pregnant. She will need a backup

• If her monthly bleeding has returned within 5 days menses

Partially breast feeding less than 6 weeks after giving birth :

• 6 weeks after giving birth if menses not return

• Within 5 days of menstruation if menses return

06/27/2021 Kindu Y. 166

 Not breast feeding less than 4 weeks after
giving birth
• She can take on days 21

More than 4 weeks after giving birth

• bleeding has not returned, not pregnant. She will need

a backup method

• bleeding has returned, she can start COCs as advised

for women having menstrual cycles

06/27/2021 Kindu Y. 167

 No monthly bleeding (not related to
childbirth or breastfeeding):
• any time it is reasonably certain she is not pregnant. She
will need backup method for the first 7 days of taking
pills.

After miscarriage or abortion:

 within 7 days after first or second-trimester miscarriage
 If it is more than 7 days after first- or second trimester
miscarriage, she is not pregnant. She will need a backup
method

06/27/2021 Kindu Y. 168

Effects of COC on organs
1) Hypothalamo-pitutary axis: levels of FSH & LH
remain low as in early proliferative phase
2) Ovary: remains quiescent with occasional ovulation
so that evidence of fibrosis & low level of
endogenous steroids
3) Endometrium (P): stromal edema, decidual reaction
& glandular exhaustion
4) Cervix (E+P): Increased glandular hyperplasia &
down growth of cervical epithelium (Ectopy)
5) Uterus (E): slightly enlarged
6) Vagina (P): cytohormonal study shows early luteal
phase

06/27/2021 Kindu Y. 169

 Effects of COC on organs Contd.
7) Liver: liver functions will be depressed
8) GIT: increased incidence of mesenteric
vein thrombosis & ulcerative colitis
9) Urinary: increased incidence of UTI
because of sexual activity
10)Thyroid gland: estrogen in OCs increases
circulating thyroid-binding globulin
affecting tests of thyroid function

06/27/2021 Kindu Y. 170

 Effect of COC on reproduction

 Ovulation returns in three months after withdrawal in 90% of cases

 No increased incidence of congenital anomalies

 Lactation: reduction in milk production &quality of milk

If given less than 6months postpartum period .

Missed pills :

Missed 1 or 2 pills?

• Take a hormonal pill as soon as possible.

• Little or no risk of pregnancy

06/27/2021 Kindu Y. 171

Missed pills cont..
Missed 3 or more pills in the first or second week?

• Take a hormonal pill as soon as possible.

• Use a backup method for the next 7 days.

• Also, if she had sex in the past 5 days, can

consider ECPs

06/27/2021 Kindu Y. 172

Missed 3 or more pills in the third week?

• Take a hormonal pill as soon as possible.

• Finish all hormonal pills in the pack.

• Throw away the 7 non hormonal pills in a 28-pill pack.

• Start a new pack the next day.

• Use a backup method for the next 7 days.

• Also, if she had sex in the past 5 days, can consider

ECPs

06/27/2021 Kindu Y. 173

Missed any non hormonal pills?

• Discard the missed non hormonal pill(s).

• Keep taking COCs, one each day.

• Start the new pack as usual

06/27/2021 Kindu Y. 174

Progestin-Only Pills (POPs)
 Pills that contain very low doses of a progestin
 Can be used throughout breastfeeding and by women
who cannot use methods with estrogen.

How do they work?

 cervical mucus thickening(4hrs-22hrs)

 decreased tubal motility

 disrupting menstrual cycle(in 60% of cases)

 prevention of endometrial growth

06/27/2021 Kindu Y. 175

POP Contd.
o A distinct disadvantage is that these contraceptives must be
taken at the same or nearly the same time daily.
o If a progestin-only pill is taken even 4 hours late, a back-
up form of contraception must be used for the next 48
hours.
o Also, their effectiveness is decreased by the medications
shown in Table on next slide .
o Women taking any of these medications should not use this
form of contraception.
o Finally, unlike combined oral contraceptives, the mini-pill
does not improve acne and may even worsen it in some
women.

06/27/2021 Kindu Y. 176

 …cont’d
Effectiveness:

Breastfeeding women:

• Typical use (as commonly use) - 1% pregnancy rate

• Perfect use -0.03% pregnancy rate

Not breastfeeding:

• Typical use (as commonly use) – 3%-10% pregnancy rate

• Perfect use -0.09% pregnancy rate

06/27/2021 Kindu Y. 177

 Cont…..

Advantages:

• Side effects of estrogen will be eliminated

• No adverse effect on lactation

• No “on & off” regimen during taking

• Reduces risk of PID & endometrial cancer

• Return of fertility after POPs are stopped: No delay

• Protection against STIs: None

06/27/2021 Kindu Y. 178

 …cont’d
Side Effects
• Changes in bleeding patterns
• Headaches
• Dizziness
• Mood changes
• Breast tenderness
• Abdominal pain
• Nausea

06/27/2021 Kindu Y. 179

Medications That Contraindicate Progestin-Only Oral Contraceptive

Carbamazepine (Tegretol)
Felbamate
Oxcarbazepine
Phenobarbital
Phenytoin (Dilantin)
Primidone (Mysoline)
Rifabutin
Rifampicin (Rifampin)
Topiramate
Vigabatrin
Possibly ethosuximide, griseofulvin, and troglitazone

06/27/2021 Kindu Y. 180

Managing missed pill
If a woman is 3 or more hours late taking a
pill or misses one completely
• Take the most recent pill as soon as possible
• Use backup method for 48hrs
• Take the next pill at regular time

06/27/2021 Kindu Y. 181

Injectables contraceptives
Types
1 . Progesterone only Injectable
The most popular is Medroxy progesterone acetate (DMPA) or
depo Provera which is given for 3 months

Norethinodrone enanthate (NET-EN) which is given in a dose of

200 mg IM every 2 months. It acts in the same way as DMPA &
has the same problem.
2. Combined formulations
• A combination of Estrogen with progesterone
1. Mesigyna
• A combination of norwthidindrone ethanoate (50 mg) with estradil
valerate (5mg) given monthly
• has less bleeding problem
• effective

06/27/2021 Kindu Y. 182

Combined formulations …..
2. Cyclofem- 25 mg medroxy progesterone
acelate + 5mg estradol cypionate

• They come pre-loaded in a 5 syringe & put in a

suspension with the addition of 2.5 ml dextran
• Mixture must be shaken between injection & its
injected deep in to the Gluteal using Z track injected
technique & not massaged.

06/27/2021 Kindu Y. 183

 Common trade Duration of effect Active ingredients Name
names

Depo-Provera, 90 days 150 mg DMPA

Depo-Clinovir, medroxyprogesterone (progesto
others acetate in an aqueous gen-only)
microcrystalline
suspension

Noristerat, 60 days 200 mg NET-EN

Norigest, norethisterone progesto(
Doryxas, and enanthate )gen-only
others in an oily preparation

Mesigyna, 30 days mg norethisterone 50 Mesigyna

Norigynon enanthate and combine(
mg estradiol 5 )d
valerate

184 Kindu Y. 06/27/2021

 DEPO-PROVERA

Is the most common Injectable contraception

• It is an aqueous solution of suspended micro crystals

mechanism of action

• In addition to thickening cervical mucosa &

alternation of endometrial (making the endometrium
hostile to implantation, DMPA effectively block LH
surge & there fore ovulation does not occur.

06/27/2021 Kindu Y. 185

 DEPO-PROVERA
• Efficacy

• Some studies show the efficacy of DMPA is equal to

sterilization 1 out of 400 will becomes pregnant /year (0.3%)

• One of reason for high effectiveness is that its high dose provides
more than 3 months of Protection: - that is a women will have 2
weeks of “ Grace period ” during which she can be late for her
next dose but still be protected.

• Very effective – 0.3 pregnancies per 100 women

06/27/2021 Kindu Y. 186

 DEPO-PROVERA
advantages

 This method is not associated with compliance problem & forget

fullness.

 It’s long-term

 Private, no one can tell that the women is using it

 Safely used in lactating mother as soon as 6 weeks after birth

 No estrogen side effect therefore can be used in patients with heart

disease, sickle-cell anemia, age > 35 & smokers, seizure disorders
& Hypertension

06/27/2021 Kindu Y. 187

 Cont …

Allows some flexibility in return visits  clients

can return 3 months + 2-4 wks safely.

Non contraceptive benefits

 Prevent ectopic pregnancy  prevent uterine fibroids

 Low endometrial cancer  reduce menstrual flow & anemic

It’s Accepted by many clients

Can be used in prevention of heavy menstruation

06/27/2021 Kindu Y. 188

 DEPO-PROVERA

disadvantage
• The return to fertility may be delayed by 18
months 90% become pregnant following DMPA
• Injection itself is disadvantageous (said by some
women)
• Does not protect STI & HIV/AIDS

• Some women complaint about amenorrhea

06/27/2021 Kindu Y. 189

 DEPO-PROVERA
Indications
• Estrogen free contraception is needed

• Breast feeding women (at 6 wks)

• At least 1 year of birth spacing desired

• Sickle cell disease & seizure disorder

• Women at any age requiring highly effective long acting contraception

• Private (secrete) use is desired

• After abortion

06/27/2021 Kindu Y. 190

DEPO-PROVERA
absolute CI

• Pregnancy

• Undiagnosed DUB or unexplained vaginal bleeding

• Malignant disease of the breast

Relative CI
• Liver disease
• Severe cardiovascular disease (MI)
• Severe depression
• Rapid return of fertility desired

06/27/2021 Kindu Y. 191

 DEPO-PROVERA

SIDE EFFECTS

• There is no increased risk of any lethal complication

most common side effects are
• Heavy bleeding –rare

• Amenorrhea- common specially after 9-12 month

use  this 2 are common reasons for discontinuing
DMPA
• If bleeding persists a NSAIDs for a week e.g.
Indomethacin 25 mg po bid for 07 days may be given
06/27/2021 Kindu Y. 192
DEPO-PROVERA

• Break through bleeding

• If 1 & 3times can be managed by providing COCs for 1-2
months. Or 1.25 mg estrogen or 2mg estradiol can be given
for 07 days daily
• If anemia <5% HCT, a women can be switched to other
contraceptive or provide iron supplement

06/27/2021 Kindu Y. 193

 DEPO-PROVERA

Other problems

• Weight gain

• Abdominal pain

• Headache

• Anxiety

• Dizziness

• Frequent urination

• Depression

06/27/2021 Kindu Y. 194

 Emergency Contraceptive pills
EC promotion and use in the country would reduce
incidence of unwanted pregnancies, which otherwise
would have ended in unsafe abortion and its complications

• serve as a back up to other family planning methods

• According to a national survey on abortion conducted by

Ethiopian society of obstetrics and gynecology (ESOG)
abortion related mortality was 1,209 per 100,000 abortions

06/27/2021 Kindu Y. 195

 FP for adolescent
• Unwanted pregnancy is one of the major RH challenges faced by
adolescents in Ethiopia.

• 54% of pregnancies to girls under age 15 are unwanted compared to

37% for those ages 20-24.

 This indicates the need to refocus programs and prioritize

interventions tailored to adolescents under 15 years

06/27/2021 Kindu Y. 196

 Emergency Contraception (EC)

Definition: Emergency Contraception refers to

contraception methods that can be used by women
following unprotected intercourse or if the woman had a
contraceptive accident such as leakage or slippage of
condom to prevent an unwanted pregnancy

• EC should not be used as a regular family planning

method but should be used in an emergency as a back up 

06/27/2021 Kindu Y. 197

 Emergency Contraception (EC)
• post-coital contraception
• Risk of pregnancy following unprotected intercourse
around time of ovulation is 8%
• Indications:
1. Unprotected intercourse
2. Condom rupture
3. Missed pill
4. Sexual assault
5. Unplanned 1st time intercourse

06/27/2021 Kindu Y. 198

 Emergency Contraception (EC)
Options:

1.Combined Oral Contraceptive Pills (COCs): An increased

dose of combined oral contraceptives containing ethinyl
estradiol and levonorgestrel (Yuzupe’s regimen)
• 4 low dose tablets of COC followed by another dose 12 hours later

• 2 “standard dose” COC followed by another equal dose 12 hours later

1. Progesterone Only Pills (POPs): High dose Progesterone

Only Pills containing levonorgestrel(20 POP pills)

2. Intra-utérine Contraceptive Devices (progesterone

06/27/2021 Kindu Y. 199
contaning IUDs) up to 5 days
 Emergency Contraception (EC)
• Treatment with both regimens should not be delayed unnecessarily as efficacy
declines over time.
1. Combined oral contraceptive pills: Contain ethinyl estradiol and levonorgestrel or
comparable formulations.
This regimen is known as the Yuzpe’s method, and it has been used since the 70s. 
• When high dose pills containing 50mcg of ethinyl estradiol
and 0.25mg of levonorgestrel are available, two pills should
be taken as the first dose as soon as convenient, but not later
than 3 days (72 hours) after unprotected intercourse.

• Eg. Neyogynon
• The second two pills should follow 12 hours later.

06/27/2021 Kindu Y. 200

 Emergency Contraception (EC)
• When low dose pills containing 30 mcg ethinyl
estradiol and 0.15 mg of levonorgestrel are available,

• four pills should be taken as the first dose as soon as

convenient but not later than 3 days (72 hours) after
unprotected intercourse

• followed by another four pills 12 hours later

e.g. of this group Microginon, prudence, le-ofemenal etc

06/27/2021 Kindu Y. 201

 Emergency Contraception (EC)

2. Dedicated ECs
• When pills containing 0.75 mg of levonorgestrel are available,
one pill should be taken as the first dose as soon as convenient,
but not later than 3 days (72 hours) after unprotected intercourse
to be followed by another one pill 12 hours later
POPs (mini-pills)
• When pills containing 0.03 mg of levonorgestrel are available,
twenty (20) pills should be taken as the first dose as soon as
convenient but not later than 3 days (72 hours) after unprotected
intercourse to be followed by another 20 pills 12 hours later.

06/27/2021 Kindu Y. 202

 IUD
• Effective within 5 day un protective sex
• Effectiveness→ less than 1% failed
Contraindication
• Pregnancy
• Puerperal sepsis
• PID
• Undiagnosed AUB
• GTD

06/27/2021 Kindu Y. 203

 MOA
The precise mechanism is not known
• Studies have suggested that EC pills can:
• Delay or inhibit ovulation
• Prevent implantation by making the inner lining of the uterus
(endometrium) unsuitable for implantation
• Prevent transport of the sperm and ovum

The mechanism that is active in a particular case depends on the

time of the menstrual cycle when emergency contraceptives are
used

06/27/2021 Kindu Y. 204

Mechanism…
• ECPs do not interrupt or abort an established pregnancy

• They can only help in preventing unwanted pregnancy.

Once implantation (pregnancy) has occurred, ECPs are
not effective.

• ECPs, thus, do not cause any form of abortion or bring

about menstrual bleeding.

06/27/2021 Kindu Y. 205

 Eligible women for ECPs

• Clients who are not eligible for ECPs:

• Client already pregnant

• When an emergency contraceptive option other than ECPs should be

considered (e.g. clients seeking care later than 3 days)
• Upon arrival clients have to be screened to determine eligibility.

• However, ECPs should not be delayed or withheld in order to

carry out screening procedures such as pelvic exam

06/27/2021 Kindu Y. 206

 Indications for the use of ECPs:

• When no contraceptive has been used

• When there is a contraceptive accident or misuse
• Condom rupture, slippage or misuse, and IUCD expulsion
• Two OCPs missed consecutively, and late for DMPA
injection by two weeks or more
• Failure of a spermicidal tablet or film to melt before
intercourse
• Failed coitus interruptus (withdrawal)
• Failure to abstain on a fertile day of the cycle in a woman
who uses the calendar method
• In case of sexual assault

06/27/2021 Kindu Y. 207

 Safety and effectiveness
ECs are considered very safe:
• In more than 20 years no deaths or serious medical
complications have been reported

• The COCs used as EC pills have not been associated with

fetal malformations or congenital defects in the event if EC
fails to prevent pregnancy.
• Available data suggest the ECPs do not increase the
possibility that a pregnancy following use will be ectopic.

06/27/2021 Kindu Y. 208

 Safety and effectiveness…
ECs are fairly effective in preventing pregnancy from unprotected sexual intercourse

• It is estimated that if 100 women have unprotected sexual intercourse

during the second or third week of their menstrual cycle, 8 would
become pregnant

• If the same 100 women use combined oral pills as ECs, instead of 8
women only 2 would become pregnant

• If the same 100 women used progestin-only ECs, instead of 8 women

only 1 would become pregnant

• These suggest ECs could reduce the probability of becoming pregnant

from unprotected sexual intercourse by roughly 75 % in the case of
COCs, and 85 % in the case of POPs

06/27/2021 Kindu Y. 209

 Side effects of ECs and their management

• The following are common side effects of ECPs:

• Nausea: It is the most common in ECPs, but COC user

experience more nausea than POP users. It usually does
not last more than 24 hours

• Management of nausea: Take the pill with food or at

bedtime to reduce nausea. A woman who has previously
experienced nausea while using hormonal methods
including ECPs could need prophylactic anti-emetic.

06/27/2021 Kindu Y. 210

 Side effects of ECs and their management
• Vomiting: Occurs in 20% of women using COCs and 5% of women using POPs as
ECs
• Management of vomiting: If vomiting occurs within 2
hours, the dose should be repeated
-Irregular vaginal bleeding or spotting: Some women may
experience irregular vaginal bleeding or spotting following
ECs
-Management: Inform women that ECPs do not bring menses
immediately a common misconception among ECP users. If
the menstrual period is delayed for more than two weeks
from the expected date, the possibility of pregnancy should
be considered and a pregnancy test should be done.

• If you cannot provide the test, refer to facilities where the

service can be provided.
06/27/2021 Kindu Y. 211
Side effects of ECs and their management
• Other problems: Breast tenderness, headache,
dizziness and fatigue, do not generally last more
than 24 hours

• Management: Aspirin or another non-

prescription pain reliever can be used to reduce
the discomfort of headaches and breast
tenderness

06/27/2021 Kindu Y. 212

Overview of implants
Objectives
At the end of this session students, will be able to:
Describe hormonal contraceptive implants as a
safe and effective LARCM
Discuss the drug interaction effect on it’s
effectiveness
Discuss the characteristics of each implant
contraceptive

06/27/2021 Kindu Y. 213

Implants cont.…
Implants are matchstick sized rods flexible
progestin-filled rods or capsules that are placed just
under the skin of the upper arm

WHO,2003

06/27/2021 Kindu Y. 214

 Types of implants
• Many types of implants:
• Norplant: 6 capsules, labeled for 5 years of use
• Jadelle: 2 rods, lasts 5 years
• 75 mg of levonorgestrel
• Implanon: 1 rod, lasts 3 years
• 68 mg of etonogestrel
• Sino- implant: 2 rods, lasts 4 years

06/27/2021 Kindu Y. 215

 Mechanism of action of implants
• Implants continually release a small amount of
progestin steadily into the blood.

• The primary mechanisms are:

• Increased cervical mucus viscosity (within 48-72 hrs).

• Inhibition of ovulation- in about 50% of menstrual cycles.

• Alters endometrium, making it less conducive for

implantation

06/27/2021 Kindu Y. 216

 Safety and effectiveness of implants
• Are one of the most effective and long-lasting
methods
• <1 preg. per 100 women over the first year (5 per
10,000 women).
• A small risk of pregnancy remains beyond the first year.
• Start to lose effectiveness sooner for heavier women
• No delay in return of fertility after removal
• No protection against sexually transmitted
infections
• Do not increase frequency of ectopic pregnancy.

06/27/2021 Kindu Y. 217

 Drug interaction effect on implants effectiveness
• Contraceptive effectiveness may be reduced
when co- administered with some:-
• Antibiotics,
• Anti-fungals,
• Anticonvulsants, and
• Anti-HIV Protease Inhibitors:
• Other drugs that increase the liver metabolism
of contraceptive steroids.

06/27/2021 Kindu Y. 218

 Category 3 Conditions
Breast feeding≤6wk  Severe cirrhosis
Acute DVT/PE (decompensated)
Current & hx of ischemic heart Hepatoma
disease Hepatocellular adenoma
Stroke Rifampicin , refabutin
+ve antiphosphlipid ab. Anticonvulsant therapy
Migraine with aura Retonavir boosted protease
Past hx breast ca. & no evidence inhibitor
of current disease for 5 years NB - current breast cancer is
Category 4 condition

06/27/2021 Kindu Y. 219

 When to start use implants
• Having menses
within 7days after the start(5days for implanon)
no backup
 if >7days → R/O pregnancy + backup for
7days
• Switching from IUD → insert immediately
• Switching from hormonal contraceptive → if
she was using correctly & consistently start
immediately & no need of backup

06/27/2021 Kindu Y. 220

 Cont…
• Fully or near fully breastfeeding
o < 6months →delay at least until 6wk

o > 6monts & no menses → R/O pregnancy + backup

• Partially breast feeding

o < 6wk →delay until 6wk

o > 6wk & no menses → R/O pregnancy + backup

• Non breastfeeding
o < 4wk → start anytime

o > 4wk & no menses →R/O pregnancy + backup

06/27/2021 Kindu Y. 221

 Cont…
• No monthly bleeding unrelated to
breastfeeding or pregnancy → R/O
pregnancy + backup

• After miscarriage or abortion

if with in 7days no need of backup
>7days → R/O pregnancy + backup

• After ECPs insert within 7days after the start

of menses or anytime after R/O pregnancy

06/27/2021 Kindu Y. 222

 Implants Contd.
o1) Norplant:
o This system provides levonorgestrel in six silastic
containers that are implanted sub dermally.
o six rod for five years with each rod containing 38 mg of
levonorgestrel releasing initially 85ug/day and later
30ug/day over five years.
o Mechanism of action and advantages are similar to
DMPA.
o Efficacy is comparable to COC with failure of 0.1 HWY
• The manufacturer stopped distributing the system in
2002

06/27/2021 Kindu Y. 223

Implant…
2.Implanon
• A single rod etonogestrel-containing, reversible,
implant
• 40 mm in length and 2 mm in diameter
• the most effective methods for preventing
pregnancy for 3 years .
• Less than 1 preg. Per 100 women (1/1,000 women)
• Pre-loaded inserter
• Easier insertion and removal
• Store at 25°C (15°-30°C) and avoid direct sunlight.

06/27/2021 Kindu Y. 224

 Pre insertion Counseling for Implanon
• In a private setting, provide more detailed
information
• How it works,
• Its effectiveness,
• How it is inserted,
• Its characteristics,
• Common side effects, and
• When to return
• Answer any questions that the client may have

06/27/2021 Kindu Y. 225

 Implanon insertion procedures
-Confirm that informed consent is obtained.
• Check to be sure the client is eligible.
• Let her wash the entire arm with soap & water
or iodine .
• Locate the best insertion area (8cm above the
elbow fold).
• Strictly use infection prevention practices.
• Use 1ml of local anesthetic (1% without
epinephrine).

06/27/2021 Kindu Y. 226

 Post insertion client instructions
•  Client Instructions for Wound Care key points:
• Keep the insertion area dry & clean for at least 48
hrs.
• Leave the gauze pressure bandage in place for 48
hours
• Leave the smaller bandage in place for 3-5 days).
• Bruising, swelling, or tenderness may occur for
few days.
• Routine work can be done immediately but
• Avoid bumping the area, carrying heavy loads or
putting unusual pressure to the site.

06/27/2021 Kindu Y. 227

 Post insertion client instructions; contd…
• Return to the health facility in case of:-
• Severe lower abdominal pain (ectopic pregnancy?)
• Heavy bleeding
• If the insertion site becomes red with increased
heat and/or tenderness, or if there is pus at the site,
• Bleeding at insertion site
• Expulsion
• Migraine headache
• For removal at the end of 3 years or anytime she
decides to stop using.

06/27/2021 Kindu Y. 228

 Implanon removal procedures
• Key points:
• An easy removal depends on correct insertion;
• If the rods cannot be palpated a provider
inexperienced in removal should NOT begin the
procedure- refer.
• Inject local anesthesia under the ends of the implant
• Remove the implant if it is palpable .
• If the rod can’t be removed, stop the procedure, ask
to return when fully healed (4-6 wks) and try again
or refer
• If the client wants to continue using Implanon , a
new set can be inserted at the time the current set is
removed.

06/27/2021 Kindu Y. 229

Side effects and complications

Side Effects Complications

• Changes in bleeding • Procedure site
patterns
• lighter and fewer days of problems (early)
bleeding, irregular bleeding, • Bleeding /
infrequent bleeding & no hematoma,
monthly bleeding.
• Headaches, • Expulsion,
• Breast tenderness, • Infection /cellulites /
• Mood changes, abscess
• Nausea, wt gaine
• All of which usually
decrease over time.

06/27/2021 Kindu Y. 230

 Implant cont..
3) Jadelle
2 rods
Effective 5 years to prevent pregnancy
1-yr failure: 0.05% (1 in 20,000); 5-yr failure
1.1%
Effectiveness vary based on wt. for Jadelle
& Norplant(>80kg used for 4yrs)
Effectiveness decreases from year to year
No delay of fertility after removal

06/27/2021 Kindu Y. 231

 Implants cont..
Jadelle….
• Pre insertion counselling
• Insertion procedures The
• Post insertion client instructions same as
Implano
• Jadelle removal procedures n
• Side effects and complication
o Except Jadelle has two rods and used 2ml
of lidocaine for insertion and removal

06/27/2021 Kindu Y. 232

 Implants cont ..
4.sino-implant
• Sino-implant is a two-rod system
• with the same amount (150 mg) of levonegstrol
• same mechanism of action as Jadelle
• but provides 4 years of contraception.
• Sino-implant is manufactured in China
• approved for use by 20 countries in Asia and
Africa, in 2012
• Like other implants placed subdermally on the inner
arm approximately 8 cm from the elbow
• have similar removal steps

06/27/2021 Kindu Y. 233

 INTRA UTERINE CONTRACEPTIVE DEVICE -
IUCD
IUCD is a safe, easy to use, reversible,
effective method of child spacing for couples
who are at low risk for STIs/HIV
Careful screening and counseling are essential
for successful use of an IUCD
IUCD can be used safely by breast-feeding
women
Different IUCD can remain in from 5 -10 yrs
Menstrual period may be heavier & longer,
esp. for the 1st few months

06/27/2021 Kindu Y. 234

 Types of IUCD

 Inert- Lippes loop

 Medicated- contain progesterone
1. Progestasert - Contains 38mg of natural
progesterone & supplies 65µg/d into the uterine
cavity for 1 yr
2. Levonorgestrel (Mirena)- Contains 52mg of
LN, releases 20µg of LNg daily, & serves for 5
yrs
 Copper bearing- are copper coated :- Cu T
380A, Multi- load 250, Multi-load 375, Nova T,
Cu T 200 & 220

06/27/2021 Kindu Y. 235

 Types of IUCD

A. Copper­containing device
B. Levonorgestrel-releasing device.

06/27/2021 Kindu Y. 236

 Cu T380A
Also called ParaGard
Widely available
Used for 10 yrs
Very effective, 0.8 pregnancy/100 women
year
Coated with Cu bracelets = 33+33+314mm²
Polyethylene with barium sulfate for X-
ray

06/27/2021 Kindu Y. 237

 Mechanism of Action
Change in cervical mucus that inhibit sperm transport

Chronic inflammatory changes of the endometrium

and f/tubes

 Have spermicidal effects and inhibit fertilization and

implantation

Thinning and glandular atrophy of the endometrium

which inhibits implantation

06/27/2021 Kindu Y. 238

 Advantages Disadvantages
• Highly effective and very
• Side effects, including
safe
cramping and increased or
• Does not interfere with prolonged bleeding
intercourse
• Rare complications include
• Easy to use
perforation & PID
• Long-acting
• Method failure can lead to
• Easily reversible ectopic pregnancy
• Quick return to fertility
• Insertion and removal
• No systemic effects require trained provider
• No STI/HIV protection

06/27/2021 Kindu Y. 239

 Indications/eligible
Healthy reproductive tract –no infection, cancer, or anomaly
Mutually faithful sexual relationship
Completed child bearing
Wants a long term reversible method
Who has precautions for other methods
Breast feeding women
Immediately postpartum (with in 48hrs delivery)
N.B. An IUD may be provided to young, nulliparous
women after thorough consideration

06/27/2021 Kindu Y. 240

 Contraindications

Pregnancy or suspicions of pregnancy

Uterine abnormalities –myoma, didelphic uterus
Acute PID or Hx of PID in the past 3 months
Endometritis/septic abortion
Pelvic malignancies
Undiagnosed AUB
Untreated acute cervicitis or vaginitis
Wilson’s disease(hepatolenticular degeneration)
Immuno-compromised –Leukemia, AIDS, IV drug users

06/27/2021 Kindu Y. 241

 Contraindications To IUCD use

06/27/2021 Kindu Y. 242

 Contraindications To IUCD use

06/27/2021 Kindu Y. 243

 Timing for IUCD insertion

1.Anytime of menstrual cycle, after ruling out pregnancy

2. Postpartum

- Post placental IUCD:- within 10min of placental

delivery, during C/S

- Within 48hrs of delivery

- As early as 4wks postpartum

3. Immediately after safe abortion

06/27/2021 Kindu Y. 244

 Expulsion rates for interval and postpartum
insertions
Timing of insertion Expulsion rate
Interval (more than 4wks after Low(3% for skilled inserters )
delivery)
Immediate postpartum (within Slightly higher (up to 9.5%)
10 minutes)

Early postpartum (b/n Moderately higher(up to 37%)

10minutes and 48hrs)

Data on expulsion rates for late postpartum insertions (48 hrs to 4weeks )
are limited .but not recommended to IUCD insertion in this period due to
increased risk of uterine perforation .

06/27/2021 Kindu Y. 245

 Timing for IUCD removal
• Anytime the client requests

• Evidence of IUD perforation

• Pregnancy occurs

• Partial expulsion

• PID, AUB with anemia, severe pain

• Client at risk for STIs

• IUD has been used for effective period

• Woman has reached menopause

06/27/2021 Kindu Y. 246

 Follow-up schedule (after insertion)
1. There should be one follow-up visit approximately 3-6wks after
insertion

2. warning signs clients should report

• Late period
• Prolonged or excessive abnormal spotting or
bleeding
• Abdominal pain or pain during intercourse
• Abnormal vaginal discharge, pelvic pain , esp.
with fever
• String missing or string seems shorter or longer
3. Client could check for strings: with clean fingers & after each menses

06/27/2021 Kindu Y. 247

 Side Effects and Complications
o Cramping
o Irregular or heavy bleeding
o Syncope due to vaso-vagal episode during insertion
o Missing strings
o Amenorrhea
o Expulsion
o Pelvic infection
o Suspected uterine perforation
o Ectopic pregnancy if failed

06/27/2021 Kindu Y. 248

 Cont…
Cramping
Is common in the 1st 24-48hrs
If there is mild cramping give NSAID
severe cramping & no cause found, remove IUD
Pregnancy occurred
Rule out ectopic pregnancy
If intrauterine:- miscarriage & infection are quite likely
- 1st trimester pregnancy  remove the IUD if strings
are visible
- In 2nd trimester pregnancy or the strings are not visible,
leave the IUD in situ

06/27/2021 Kindu Y. 249

 Cont…
 Missing strings
 Perform speculum & bimanual exams
-String may be high up in the vagina or cervix
-Probe cervical canal with sterile cotton swab-stick
 If the string is not found, rule out pregnancy
 If there is no pregnancy, do ultrasound or abdominal X-ray to rule
out perforation
 IUD located intrauterine remove it with forceps
 If perforation- laparatomy for Cu IUD, but inert IUD may be left in
situ
 Developed PID
 Remove the IUD and treat for PID

06/27/2021 Kindu Y. 250

 Sterilization

1. Male (vasectomy)

2. Female (tubal-ligation)

06/27/2021 Kindu Y. 251

 Sterilization

 A surgical method where by the reproductive function of an

individual male or female is purposefully & permanently
destroyed

 Vasectomy in male and tubal occlusion in female

 Couple need to be adequately informed before any permanent

procedure

 Inform on individual procedure in terms of benefit, risks, side

effects, failure rate & reversibility

06/27/2021 Kindu Y. 252

 Vasectomy
Segment of vas deferens of both sides are resected and
cut ends are ligated

Advantages:

1. Simple

2. Out patient procedure

3. Few immediate & late complications

4. Failure rate is low (0.15%)

5. Minimal expenditures

06/27/2021 Kindu Y. 253

 Vasectomy…
Drawbacks:
1. Additional contraceptive needed for the first
2-3 months
2. Frigidity/impotence, most often psychological

Candidates:
1. Sexually active, psychological prepared &
completed fertility
2. No eczema or scabies around scrotal region
3. Correct hernia &/or hydrocele before
06/27/2021 vasectomy Kindu Y. 254
 complications
1. Immediate:

 Wound sepsis

 Scrotal hematoma

2.Late:

 Frigidity/impotence

 Sperm granuloma

 Increase in sperm agglutinin in secretions

 Spontaneous recanalization

06/27/2021 Kindu Y. 255

 Female sterilization
• Occlusion of both fallopian tubes in some form

• Most popular method of terminal contraception world wide

• Indications:

1. Family planning purposes

2. Socioeconomic after having the desired number of children

3. Medico-surgical indications (therapeutic)

06/27/2021 Kindu Y. 256

 Female Sterilization: Prevalence

 Most widely used modern method in world, in “less-

developed” regions, and industrial countries, including U.S.

 Worldwide, over 210 million couples use FS (Female

Sterilization)

 FS 12% of modern contraceptive use overall in East Africa;

more than 5% of modern use in West Africa

  

06/27/2021 Kindu Y. 257

 Female sterilization
 Time of operation: puerperium, interval or concurrent with medical
termination

 Ligation could be abdominal, vaginal or laparoscopic

 Different surgical types: e.g. Pomeroy’s technique

06/27/2021 Kindu Y. 258

Myths/misconception
• Does not make women weak

• Does not cause chronic back or abdominal pain

• Does not involve removal of a woman’s uterus

• Does not cause hormonal imbalances

• Does not cause heavier bleeding or irregular bleeding or

otherwise change women’s menstrual cycles

• Does not cause any changes in weight, appetite, or appearance

• Does not change women’s sexual behaviour or sex drive

06/27/2021 Kindu Y. 259

 Tubal ligation-complications…
• Immediate: related to anesthesia & the procedure it self

• Remote:

1. General: occasional obesity & psychological upset

2. Gynecological: congestive syndrome, hypo menorrhea & pelvic pain

 Pelvic pain, menorrhagia along with cystic ovaries constitute

“Post Ligation Syndrome”

 Alteration in libido

 Overall failure rate is 0.7%

06/27/2021 Kindu Y. 260

 POSTPARTUM AND POSTABORTION
Family Planning

06/27/2021 Kindu Y. 261

Objectives

At the end of this session students will be able to:

 Describe options for post abortion and post partum FP

06/27/2021 Kindu Y. 262

Unmet need for PP FP
• Only 3-8% of post partum woman want pregnancy with in 2 years

• Only 40% of post partum woman use FP

• After a live birth, the recommended interval before attempting the

next pregnancy is at least 24 months.

06/27/2021 Kindu Y. 263

PP FP counselling

• Timing of counseling could be at any of the following

visits:
• Preconceptional

• During antenatal care

• During the latent phase of labor

• Early in the postparum period

• During late postpartum period

06/27/2021 Kindu Y. 264

 Breast-feeding- Contraception
• Breast-feeding (Lactational amenorrhea method/ LAM)can only be considered
as a method of contraception if

• The women is amenorrheic

• Wtihin the first 6 months postpartum and

• Exclusively breast-feeding

• Even in women who are breast-feeding properly

• 12% will ovulate within the first 6 months and

• 2% will get pregnant

265

06/27/2021 Kindu Y. 265

 Unsafe Abortion Contraception

• Globally, approximately 500,000 maternal deaths each year

• Nearly 70,000 are from unsafe abortion

• A way to end unsafe abortion is through contraception

266

06/27/2021 Kindu Y. 266

Post-abortion FP

• Timing of counseling
• When the woman feels well enough
• Before or after treatment for abortion

• Safe methods to prevent pregnancy are available

• Most contraceptive methods can be used
immediately following abortion
• Inform the client that she could become pregnant
again within 10 days if not using contraception

06/27/2021 Kindu Y. 267

 Cont…
• Provide or inform how she could obtain
contraceptive services
• After abortion, the recommended minimum
interval to next pregnancy is at least six months
• In order to reduce risks of adverse maternal and perinatal
outcomes

06/27/2021 Kindu Y. 268

 Post abortion FP Methods

• Uncomplicated abortion:
• Uterine Size up to 12 Wks: All methods can be
used
• Uterine Size Greater > 12 Wks
• Most methods can be used immediately, IUCD can
also generally be used (Category 2)

269

06/27/2021 Kindu Y. 269

Take home message
 A woman could become pregnant again
within 10 days following abortion
 Safe methods to prevent pregnancy are
available after abortion & delivery
 For PP FP counseling should preferably
be during ANC

06/27/2021 Kindu Y. 270

• Abortion with Complications:
• Infection or genital trauma
• Delay female sterilization and IUD insertion

• Severe bleeding:
• Sterilization should be delayed

06/27/2021 Kindu Y. 271

 THANK YOU!

06/27/2021 Kindu Y. 272