Womens Health 9

Chapter Nine Designing Your Reproductive Life Plan

Family Planning
Family Planning is more than a personal and family issue
It has health, social, and political implications
Women and children have been impacted by:
Governments
Religious bodies
Health care options
Political agendas
Women need access to a variety of reproductive options

Benefits of Family Planning
Contributes to decreasing poverty for women
Provides women more time to spend on education and job opportunities
Reduces the number of maternal and infant mortality
Reduces global population
Reduces the number of teens who give birth (unintended and premature births)
Provides adolescents with more opportunities to succeed in life

Reasons for Selecting a Birth Control Method
Availability of method
Prevent having children
Reduce STD risks
Religious doctrine
Decision-making process with partner
Health risks
Financial and emotional considerations for couples
User effectiveness rate

Birth Control Methods
Birth control methods are all strategies used to keep from having a baby and include the following:
Contraceptive methods
IUD’s
Emergency contraception
Abortion
Contraceptive choices are methods that prevent fertilization of the ovum such as:
Hormonal methods
Barrier methods
Sterilization
See Table 9.1 for comparisons of effectiveness and cost

Abstinence
Abstinence is the only sure method of birth control to prevent an unintended pregnancy or unwanted STIs
Teenagers can be sexually intimate without risking pregnancy or STIs
The latest trend is showing a decline in Abstinence-only programs
These programs are not supported by peer reviewed research for prevention of STIs, HIV/AIDS, and unplanned pregnancies
Furthermore, no research studies have shown abstinence only education to be consistently effective in delaying sexual activity in teens

Fertility Awareness Methods See illustration on next slide Offers no protection against sexually transmitted diseases or infections
Cycle-based method (calculating the unsafe days of ovulation)
Basal temperature (raise in body temperature could result in ovulation)
Mucus (evaluate consistency of vaginal discharge to predict ovulation)
Sympothermal (combines basal type and mucus together)
Withdrawal (not a contraceptive method) penis is withdrawn from the vagina before ejaculation
Natural Family Planning Methods

Fertility Awareness (See Figure 9.1)

Barrier Methods
Barrier methods prevent sperm from reaching the fallopian tubes, either by physical or chemical means
Barriers include the following:
Spermicides
Condoms
Diaphragms
Cervical caps
Barrier methods remain popular because of the protection they provide against HIV and other STIs

Barrier Methods, cont’d In a recent study, women who used a condom and N-9 gel had a 50% higher HIV infection rate vs. a condom and placebo gel
OTC products
Vaginal Spermicides

Barrier Methods, cont’d N/A Silicone cup with air valve that fits over the cervix and comes in 1 size Cervical Shield 84-97% user rate effective Soft rubber cap, must be fitted by health care professional, used with spermicide Diaphragm 87-98% user rate effective Thimble shaped device fits over the cervix Cervical Cap 78-88% user rate effective OTC product Female condom 98% user rate effective OTC product Condom with Spermicide 86-90% user rate effective OTC product Male Condom

Hormonal Contraceptives
Hormonal contraceptives are convenient, effective, and reversible
However, they provide no protection against HIV and other STI’s
They are solely intended to prevent pregnancy
The primary methods available are:
Oral contraceptives
Norplant
Injections i.e. Depo-Provera, Lunelle
Patch
Ring

Oral Contraceptives

Oral Contraceptives
Oral contraceptives are considered the second most popular form of birth control in the United States
Works by primarily inhibiting ovulation through suppressing FSH and LH
Types:
Combination pills that contain estrogen and progestin
Progestin only types (mini-pill)

Health Benefits of OC’s
Research suggests that Oral contraceptives provide the following benefits:
Protection against epithelial ovarian and endometrial cancer
Lowered risk for ectopic pregnancies and PID
Lighter and less painful menstrual flow
Decreases in iron deficiency anemia

Health Risks Associated with OC’s
Estrogen use is associated with the following side effects:
Nausea
Breast pain and soreness
Fluid retention
Progestin-only pills are associated with:
Increased irregular menstrual cycles
Vaginal bleeding
Other risks with OC’s include:
Blood clots
Strokes
Changes in bone density
Reproductive cancers

Other Forms of Hormonal Contraceptives
Yasmin (contains synthetic progestin, drospirenone)
Transdermal Patch (skin patch containing progestin/estrogen)
NuvaRing (vaginal insert containing progestin/estrogen)
Lunelle (monthly hormone injection)
Implanon (progestin-only subdermal implant)
Depo-Provera (progestin injection once every 3 months)

Emergency Contraception
In 1998, the FDA approved the first combination pill (Preven)
A year later, a progestin pill was developed (Plan B)
ECP’s reduce the risk of pregnancies by delaying or inhibiting ovulation when taken within 120 hours of unprotected intercourse
Effective rates improve when taken earlier vs. later
ECP’s do not induce a medical abortion or affect the developing pre-embryos or embyros
Emergency IUP insertion is also considered a choice within 5 days of Unprotected intercourse and reduces pregnancy risk by 99.9%

Contraindications for Hormonal Methods
If woman is pregnant
Active liver disease
Heart problems
Breast cancer
diabetes
Hypertension
Migraine headaches
Epilepsy
History of blood clotting

Intrauterine Devices
The WHO and the AMA have called the IUD one of the safest, most effective and least expensive reversible methods of birth control available
Past history with a faulty brand (Dalkon Shield, 1974) contributed to its lack of popularity in the U.S. as well as its stigma of being associated with abortion and PID’s
The method works by reducing the amount and ability of sperm to reach the egg
Other forms of IUD’s contain hormones, which allows the female to wear the IUD longer compared to others

Sterilization
Vasectomy – separation of the vas deferens
Tubal ligation – separation of the fallopian tubes

Maternal Mortality
Maternal mortality is defined as the death of a woman while pregnant
They are divided into direct and indirect obstetrical deaths
Direct: account for 80% of deaths and results from complications such as incorrect treatment, labor, pregnancy, or omissions, commonly due to hemorrhage
Indirect: result from previous existing diseases or diseases caused by the physiological complications of pregnancy e.g. anemia
The best mechanism to prevent maternal deaths is to improve the status of women

Infant Mortality
Infant mortality is defined as the deaths of infants under 1 year while neonatal mortality is under 28 days
Race and education are important indicators for infant mortality
The primary causes for neonatal and infant mortality are:
Congenital anomalies
Pre-term/low birth weight
SIDS
Respiratory Distress
Complications of Pregnancy

Pre-Pregnancy Planning
Non-drug use
Nutritional planning
Exercise
Time lapse of one menstrual cycle between contraceptive use and conception
Immunizations
Folic acid supplements
Quit smoking
Avoid alcohol beverages
Avoid OTC drugs
Avoid mega-dosing on nutritional supplements
Pre-pregnancy planning encompasses the following:

Conception
Pregnancy begins with the union of the female egg and the male spermatozoa
A one cell zygote is formed, containing characteristics of both parents
The fallopian tubes provide the environment where cell division begins
After 3 days, the fertilized ovum is transported to the uterus
Once the chorionic villi cover the ovum, hCG (human chorionic gonadotropin) supports the endometrial growth

Amnion
The amnion surrounds the embryo before it starts to evolve
The amnion cavity is a fluid filled space between the amnion and the embryo
It keeps the fetus at an even temperature, cushions, and provides nourishment
By the 4 th month, it can be sampled (amniocentesis) for possible genetic abnormalities

Placenta
This is formed during the 3 rd month
The function is to supply food to the fetus and connects to the fetus through the umbilical cord
The placenta does the following tasks:
Transfer gases and nutrients
Excretes waste
Transport heat
Produces various proteins and hormones
Brings maternal and fetal blood close together but are completely separate

Early Signs of Pregnancy
A missed period
A light period or spotting
Tender, swollen breasts
Fatigue
Upset stomach
Vomiting
Feeling bloated
Frequent urination
Most home pregnancy tests measure Human Chorionic Gonadotropin (hCG) to determine whether you are truly pregnant. Most tests are accurate.

Fetal Development Table 9.2 (First Trimester)
The heart beings to beat
Bones have appeared-head, arms, fingers, legs, and toes
The major organs and nervous systems are formed
The placenta is formed
Hair is starting to grow
20 buds for future teeth have appeared

Fetal Development Table 9.2 (Second Trimester)
The fetus grows quickly from now until birth
The organs are developing further
Eyebrows and fingernails form
The skin is wrinkled and covered with fine hair
The fetus moves, kicks, sleeps and wakes, swallows, can hear, and can pass urine
By the end of this time, the fetus is 11-14 inches long and weighs about 2-2.5 lbs.

Fetal Development Table 9.2 (Third Trimester)
The fetus kicks and stretches, but as it gets bigger it has less room to move
Fine body hair disappears
Bones harden, but bones of the head are soft and flexible for delivery
The fetus usually settles in a good position for birth
At 40 weeks, the fetus will be full term. It is about 20 inches long and weighs 6-9 pounds

Pre-natal Care (First initial visit)
Discussion of maternal nutritional needs, exercise, and drug use
History of maternal, paternal, and family
Physical exam including ht./wt. and blood pressure
Exam of the reproductive organs
Estimation of the due date
Blood, urine ,and pap tests

Pre-natal Care (subsequent visits)
Physical exam including ht./wt. and blood pressure
Fetal heartbeat, growth, and position
Urine test for protein and sugar
Possible ultrasound, chorionic villus sampling, maternal serum screening, amniocentesis, anon stress test, a contraction stress test and a biophysical profile
Weekly prenatal checkup are recommended after week 36

Labor Signs
Braxton Hicks contractions increasing in frequency and intensity
Lightening occurs
Amniotic sac ruptures
The 3 stages of labor are:
Uterine contractions 15-20 mins. w/ “bloody show” with full cervix dilation
Crowning of the fetus’ head to fetal expulsion
Placental separation and expulsion

Birthing Options
Midwives
Doulas
In-Hospital Deliveries
Birth Centers
Birthing Positions

Breast-feeding
Breast-feeding has prevented nearly 6 million infant deaths each year world-wide
Advantages are:
Inexpensive
Better nutritional quality
Ability to act as a birth control measure to limit fertility
Reducing ovarian and premenopausal breast cancer
Contains colostrum (initial milk produced by the mother) which helps fight infections

Potential Problems During Pregnancy
Ectopic Pregnancy
Tubal pregnancy
Occurs due to narrowing of the fallopian tubes
Can cause infertility and mortality
Hypertensive disorders
Preeclampsia-elevated blood pressure due to edema and/or proteinuria
Eclampsia-same as above except it progresses to convulsions and/or coma

Infertility
Health providers should determine the cause of having difficulty conceiving
Primary infertility is the inability of a woman to become pregnant within a year of having unprotected intercourse
Secondary infertility is the inability to carry the pregnancy to full term
The most common reasons for primary infertility in women are failure to ovulate or a damaged uterus or fallopian tube while men have low sperm or abnormal counts

Assisted Reproductive Technology (ART)
In vitro fertilization (IVF)
GIFT (gamete intrafallopian transfer)
ZIFT (zygote intrafallopian transfer)
ICSI (intercytoplasmic sperm injection)
The majority of these procedures are IVF (75%)
69% were performed on women aged 30-39
The remainder were common among women aged 40 years or older

Other Procedures Used to Promote Motherhood
Donor eggs
Vasovasotomy
Artificial Insemination
Surrogacy
Somatic stem cells

Abortion – Termination of a Pregnancy
First Trimester Procedures
Menstrual extraction – withdraw endometrial tissue during the 4 th -6 th week
Vacuum aspiration – 6 th -9 th week procedure performed the most by dilating the cervix and removing uterine contents
D&C (Dilation & Curettage) - performed during 9 th -14 th week; dilation of cervix and scraping the wall of the uterine
RU486 (Mifepristone) – blocks the action of progesterone and doesn’t allow implantation to occur

Abortion – Termination of a Pregnancy, cont’d
Second Trimester Procedures
D&C (Dilation & Curettage) - performed during 13 th -15 th week; cervix is dilated and contents are removed by suction
Hypertonic Saline procedure – 16 th week procedure where saline is administered and the uterus is caused to expel contents
Prostaglandin procedure – hormones cause contractions to expel uterine contents

Adoption
Adoption is an alternative to assisted reproduction or abortion
Adoptions can be ‘open ‘ or ‘closed’`
Couples who are making the decision have a variety of issues to consider
Services can vary from matching children and adoptive parents to educational and support services throughout the parenting years
See FYI: Facts on Adoption

Chapter Nine Designing Your Reproductive Life Plan

Womens Health 9

by amoeba1945 on Dec 28, 2008

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