Planning the number of family members in terms of timing, number, and interval between children, mainly achieved through contraception. There are natural forms and artificial methods.
Natural Methods
- Abstinence: primarily countered by self-control.
- Strict: absolute abstinence from any form of intercourse.
- Regular: no vaginal intercourse, permitting other forms of intercourse.
- Lactational Amenorrhea Method (LAM): provides protection for 6 months after delivery when observing exclusive breastfeeding via maintenance of high estrogen levels, which inhibits the release of FSHRF, therefore inhibiting FSH, the hormone responsible for maturation of egg cells. (Breastfeeding → High Estrogen → Low FSHRH → Low FSH → Non-maturity of Egg Cells)
- Breastfeeding may be combined with pills when the 6 month period runs out.
- Fertility Awareness Method (FAM): the Father and Mother should both receive counselling for education about family planning.
- Calendar Method:
- Ask the patient if they are regular or irregular.
- If regular, ask the patient about the duration of their cycle. To get their window of fertility, deduct 14 from the length, then extend three days back and five days forward.
- 30 day duration → → 11th to 19th day after the onset of menstruation.
- If irregular, find the longest cycle and shortest cycle:
- The fertile window of the patient is bordered by these values; ex. a patient with 21 to 36 day cycles would have a fertile window of 3rd to 25th day after onset of menstruation.
- Cervical Mucus Test/Billing’s Test/Spinnbarkeit/Creighton’s Method:
- The cervical mucus is dry during periods of infertility, and wet during periods of fertility.
- ex. in a 28 day cycle, the mucus is dry on days 6 to 8, and 18 to 28.
- The characteristics of a fertile cervical mucus are: watery, abundant, thin, clear, elastic, and slippery.
- Cervical mucus is collected in the morning, observed after arising from the bed.
- Rub the mucus between the thumb and index, then attempt to stretch it. If it stretches 5 to 10 cm without breaking (and is therefore thin), the woman is likely fertile.
- Basal Body Temperature (BBT) Test: a woman’s BBT increases with high levels of progesterone. Temperature is taken before getting out of bed to avoid increasing BBT from activity and eating. Contraindicated in febrile women and those who are unable to obtain a thermometer. In a 28-day cycle with ovulation on the 14th day:
- 3rd: low estrogen; 13th: high estrogen
- 13th: low progesterone; a sudden decrease in temperature
- 14th: high progesterone; a sudden increase in temperature. Temperature shifts by 0.2C to 0.5C.
- ex. d11: 36.7 → d12: 36.7 → d13: 36.5 → d14: 37.0 → d15: 37.0 → d16: 37.0 → d17: decr.
- Symptothermal Method: a combination of CMT and BBT.
- 2-day Method: a replacement of the CMT for patients who are against collecting their cervical mucus. For the 2-day method, compare the cervical mucus for the past two days; if two consecutive days are dry (D), the woman is infertile. When a wet (W) period exists within a two day period, the woman may be fertile i.e. DD is okay, DW, and WD, and WW are not.
- Calendar Method:
Artificial Methods
- Hormonal: prevention of pregnancy through ovulation suppressants which act to prevent hypothalamic activity for FSHRF and LHRF by elevating hormone levels.
- Pills: hormone-containing oral supplements for synthetic hormones.
- Progestine Only Pills (POP): progesterone only pill, containing 21 tablets. The patients take the pills daily, then wait for seven days. After, on the 29th day, start a new pack.
- Allowed in breastfeeding.
- Combined Oral Contraceptive Pills (COC; COCP): a combination of progesterone and estrogen, given in 28 tablet parts. 21 are white (containing hormones), and 7 are brown (placebos). The best time to start taking the pills is during menstruation; first pill on the first day of menstruation.
- When taking the brown tablets, menstruation ensues, often on the second or third pill. The woman may also reject the brown pills. Instead, mark or dispose of them to not lose track.
- Not used in breastfeeding, as estrogen decreases milk production.
- Estrogen is a vasoconstrictor, and is therefore not used in hypertension, smokers, >35 years old, diabetics, heart disease, thrombolytic, and liver problems.
- Not used when pregnant.
- Danger Signs: (mn. JACHES)
- Jaundice, Abdominal Pain: from liver problems
- Chest Pain: heart disease
- Headache and Eye Problems: HTN
- Severe Leg Pain: Thromboembolytic Disease
- Forgetting/Skipping Doses:
- Forgot in the set time for the day: take the pill on the same day
- Forgot one day: take two pills the next day.
- Forgot two days: take two pills the next day, then two the day after that.
- Forgot three days: discard the pack.
- Progestine Only Pills (POP): progesterone only pill, containing 21 tablets. The patients take the pills daily, then wait for seven days. After, on the 29th day, start a new pack.
- Injectable: Defoprovera, a progesterone-based injectable received during menstruation. It provides protection for three months.
- Do not massage the injection site as this hastens its absorption rate, shortening the duration of protection. Only press on the injection site.
- There will be no menstruation during this period.
- Implant: Implanon, a 99.98% effective method; the most protection. It is progesterone-based, and provides protection for three years.
- A large number of women remove their implant due to associated weight gain.
- There will be no menstruation during this period.
- Patch: Orthoevra; three patches that last 7 days (21 days total) then cessation for 7
- Patches are applied on the arm or thigh; highly muscular areas.
- Pills: hormone-containing oral supplements for synthetic hormones.
- Barrier: prevents the sperm from entering into different parts of the reproductive system. The condoms and CC/D are latex.
- Condom: prevents entrance into the vaginal canal.
- Protects against HIV/AIDS, Gonorrhea, but NOT genital warts, herpes, and pediculosis.
- Cervical Cap/Diaphragm: prevents entrance into the cervical canal. These are combined with spermicide to have improved effectivity.
- The use of a condom is contraindicated, as friction may damage both contraceptives. The woman is no longer protected from STDs.
- After ejaculation, the cervical cap is not to be manipulated or removed 6 to 8 hours after ejaculation, but not to be retained for more than 24 hours. If maintained for longer, Toxic Shock Syndrome results, often caused by E. coli and Staphylococcus aureus resulting in diarrhea and respiratory infection respectively.
- IUD: prevents entrance into the fallopian tubes. The most common form is the Copper T IUD, inserted during menstruation to ensure the woman is not pregnant. This IUD may stay within the uterus for 10 years.
- The most common problem with IUDs is the displacement or expulsion of the IUD, often presenting as pain.
- An IUD, if placed before pregnancy, may coexist with a pregnancy.
- Condom: prevents entrance into the vaginal canal.
- Chemical; Spermicides: only 80% effective; the least effective.
- Tablet
- Foam
- Gel
- Spray
- Sponge, a combination of barrier and chemical
- Surgical
- Vasectomy:
- Protection against STDs is present, but not all forms e.g. warts and genital herpes.
- Bilateral Tubal Ligation (BTL):
- Vs. IUD:
- Menstruation is maintained in both.
- Ovulation is maintained in both.
- Protection against pregnancy is present in both, and both also fail to protect against STDs.
- BTLs are permanent. IUDs are temporary.
- Both are done during menstruation.
- Vs. IUD:
- BRAIDED Counselling:
- Benefits: e.g. BTL is hassle-free.
- Risks: minor surgeries introduce risk for bleeding and infection, both manageable.
- Alternative methods
- Inquiries/concerns
- Declining is respected
- Explanation of procedure, ideally from the physician
- Documentation: informed consent forms for the surgery and sterilization
- Vasectomy:
Labor Induction/Augmentation
Labor may be induced, most often for post term babies via the use of oxytocic drugs. Augmentation of labor enhances labor in the cases of hypotonic contractions; prolonged labor. To determine the readiness of the woman for induction or augmentation, Bishop scoring is used.
Bishop Scoring
The lowest score is 0, and the highest score is 13 (3, 3, 3, 2, 2). A score of 8 or above permits for induction/augmentation. Lower than 8, the doctor is not allowed to induce/augment labor.
| Criteria | 0 | 1 | 2 | 3 |
|---|---|---|---|---|
| Cervical Dilatation | 0 | 1-2 | 3-4 | 5-6 |
| Cervical Effacement | 0% to 30% | 40% to 50% | 60% to 70% | 80% or greater |
| Fetal Station | -3 | -2 | -1 to 0 | +1 to +2 |
| Cervical Consistency | Firm | Medium | Soft | --- |
| Cervical Position | Posterior | Middle | Anterior | --- |
- Determining Consistency: Firm (like tip of nose), Medium (like earlobe), Soft (like lips)
- The medicine used to “ripen” the cervix (induce Goodell’s sign) is a prostaglandin gel.
- If ineffective, Cytotec is used: a scored tablet with 100 mcg, usually administered as 1/4th of a tablet (25 mcg)
- If dilatation remains slow, a Laminaria Tent may be used. It is a dried, sterile, cone-shaped seaweed inserted into the cervix, where it absorbs cervical mucus and expands, facilitating dilatation.
- Determining Position: Posteriorly Positioned (cervix pointing to anus), Middle (straight), Anteriorly Positioned (cervix pointing to clitoris)