community health nursing

1. FAMILY PLANNING
DIVYESH KANGAD
NURSING TUTOR
GNS - JUNAGADH

2. Family planning
• WHO expert committee of 1971 describes family
planning as follows:
• "Family planning refers to practices that help
individuals and couples to attain certain objectives".
To avoid unwanted births.
To regulate the interval between births.
To determine the number of children.
To control the time of birth to occur in relation with
ages of parents.
• Family planning is the term given for pre-pregnancy
planning and action to delay, prevent or actualize a
pregnancy.
FAMILY
PLANNING

3. Family planning…… Why ?
• Before discussing contraceptive methods, it is essential
to know what is family and why? Birth control or family
planning is synonymous?
• Birth control means "children by choice and not by
chance".
• Family planning means having only the number of
children you want and only when you want to have
them.
• The purpose of family planning is to limit the number of
children in the family and to delay or post-pone for some
time before having children.
• These can be used by newly married couples who want
to delay having children for two to three years.
DIVYESH
R.
KANGAD

4. Why…?
• There are a number of birth control methods available to
protect unwanted pregnancies, the risk of serious illness
or death resulting from pregnancy is far greater than the
risk involved in using any birth control method.
• Birth control measures eliminate the unnecessary need
for abortions. Abortions causes risk to the mother's life
and impair her chances of a healthy pregnancy later.
• This risk is compounded because many abortions are
done in secret by unskilled persons in unclean
surroundings causing infections and death. Sensible birth
control prevents this needless suffering and death.
FAMILY
PLANNING

5. Why…?
• There are a number of birth control methods available to
protect unwanted pregnancies, the risk of serious illness
or death resulting from pregnancy is far greater than the
risk involved in using any birth control method.
• Birth control measures eliminate the unnecessary need
for abortions. Abortions causes risk to the mother's life
and impair her chances of a healthy pregnancy later.
• This risk is compounded because many abortions are
done in secret by unskilled persons in unclean
surroundings causing infections and death. Sensible birth
control prevents this needless suffering and death.
DIVYESH
R.
KANGAD

6. Unplanned pregnancy
FAMILY
PLANNING

7. Healthy Timing and Spacing of
Pregnancy (HTSP):
• A woman considering using a family planning method
before trying to become pregnant should:
• Wait until the age of 20 years before she conceives for
the first time.
• Wait at least 24 months after childbirth to become
pregnant again(the recommended birth interval between
two births is minimum 36 months).
• Wait at least 6 months after miscarriage or abortion to
conceive again.
FAMILY
PLANNING

8. Objectives
To bring down birth rate, reduce population growth and improve quality
of life are the main objectives. To achieve these objectives national population
policies are set up.
These are:
• to raise the age of marriage from 15 to 18 years for girls and 18 to 21 years
for boys
• population education for all including school children
• women’s education
• promotion of all methods of contraception
• health programmes to cover all aspects of family welfare, particularly the
mother and children
• community participation in all aspects of implementation of the programme
• to create awareness about concept of small family norm which means two
children per couple in the family.
• to give information about methods of family planning to all eligible couples
• to ensure adequate supplies and facilities.

9. Use of contraceptives helps in
maintaining HTSP,
• Because pregnancy can occur as early as:
• 6 months postpartum, if woman is exclusively breastfeeding her
child
• 6 weeks postpartum, if woman is not exclusively breastfeeding
her child
• 4 weeks postpartum, if woman is not breastfeeding at all
• 10 days of first trimester abortion
• 4 weeks of second trimester abortion
• Pregnancy can occur even before resumption of menses after
childbirth/ abortion.
There are a number of family planning methods such as the
mechanical methods, chemical methods, biological methods,
hormonal methods, emergency contraceptive methods and
surgical methods.
DIVYESH
R.
KANGAD

10. Methods of Family planning
FAMILY
PLANNING

11. Temporary methods:
Natural methods
• Assistance
• Withdrawal methods
• Locational amenorrhea
method (LAM)
Biological methods
• Calendar methods
• Temperature methods
• Mucus and cervical
changes
Chemical methods
• Foams
• Vaginal tablets
• Gel, jelly and cream
• Films
FAMILY
PLANNING

12. Temporary methods:
Hormonal methods
• Combined oral
contraceptives (COCs)
• Progestin-only pills (POPs)
• Once a week pill
• Once a month pill
• Injectable contraceptives
• Emergency contraceptive
pills (ECPs)
• Sub dermal implants
• Implants
Mechanical method
• Male Condoms
• Female condoms
• Intra uterine devices
(IUDs)
• Diaphragm
• Female cap
• Lea’s shield
• Sponges
FAMILY
PLANNING

13. Permanent methods
Female sterilization
• Laparoscopy
• Mini lap
Male sterilization
• Vasectomy
• No scalpel vasectomy
DIVYESH
R.
KANGAD

14. FAMILY
PLANNING

15. Natural Family Planning Methods
• Natural family planning methods do not interfere with
person's health as these do not have side effects. The only
methods which are 100% effective are total abstinence,
removal of ovaries & castration. Other natural methods of F.P.
are not 100% effective.
 Abstinence:
 Withdrawal method:
 Locational Amenorrhea Method (LAM)
DIVYESH
R.
KANGAD

16. Abstinence:
Abstinence is not having any kind of sex i.e. Oral,
anal or vaginal and not engaging in any activity that puts
you or your partner in contact with either of your bodily
fluids such as semen, vaginal fluids, and blood.
• It is a way to postpone taking the
physical and emotional risks such as
pregnancy which one is not ready to
handle. With perfect use, abstinence is
effective in preventing pregnancy and
sexually transmitted disease.
• This method is useful as there are no
medical or hormonal side effects and it
doesn't cost anything.
Drawbacks
• It works if a person doesn’t engage in any kind of sex.
DIVYESH
R.
KANGAD

17. Withdrawal method:
• Coitus interrupts involves the withdrawal of the penis
from the vagina just before the ejaculation. This prevents
the semen from entering the women.
FAMILY
PLANNING

18. Locational Amenorrhea Method
(LAM):
It is a family planning method for breastfeeding
women. It provides natural protection against pregnancy
for up to 6 months. Breast feeding suppresses ovulation.
This method can be used by a woman who is Breast
feeding her baby day and night.
• The failure rate is 1-2%
during the first 6 months
after childbirth in exclusively
breastfeeding women. It
does not provide protection
against STDs.
DIVYESH
R.
KANGAD

19. Biological Methods
• It is well known that pregnancy is possible only in the certain period of a
menstrual cycle and therefore it is better to avoid sexual contacts during
that period. The woman is fertile for only 100 to 120 hours during a
month. This period is known as window fertility period.
• Avoiding sexual intimacy during window of fertility, pregnancy can be
avoided. If the window fertility can be determined with 100% accuracy,
the natural method of F.P. are nearly perfect birth control methods. To
determine the window of fertility, several methods are used such as:
 Calendar method.
 Temperature method.
 Mucus and cervical changes.
• One technique or a combination of techniques can be used to identify
the start and end of a woman's fertile period. These methods are
effective if the person is trained, counseled, motivated to avoid
unprotected intercourse for a week or more each month. The women
can immediately return to fertility on discontinuation.
DIVYESH
R.
KANGAD

20. Calendar Method:
• Women have to make a record of her periods for six
months. Each month, the number of days between the
starting of one period and the next one is recorded for
the last six months. The longest and shortest interval is
recorded between the periods.
• From the shortest interval subtract 18 days and subtract
11 from the longest interval between the starting periods.
The interval between these two values will be the phase
of ovulation. This has been illustrated with an example.
• A woman who has recorded 28 days as the shortest
interval and 30 days as the longest interval between the
periods, her period of ovulation will be calculated by:
FAMILY
PLANNING

21. Calendar Method:
From Shortest interval, Subtract 18
• 28-18=10 days
From Longest interval, Subtract 11
• 30-11-19 days
The phase of conception will be
• 10 to 19 days
The safe period will be:
• 1st Safe period - 1st to 9th day
• 2nd Safe period - 20th to 30th day
DIVYESH
R.
KANGAD

22. Temperature Method:
• This method helps the woman to know when they are ovulating
simply by checking the temperature every morning. In this, the
women has to take temperature every morning after waking from
at least five hours of undisturbed rest and before getting out of
bed.
• The same thermometer is used daily at the same time. A record of
temperature is kept and three successive higher average
temperature is identified which shows that ovulation has
occurred. This increase in temperature is about half degree Celsius
because of the influence of the hormone progesterone.
• It is also called basal body temperature method.
FAMILY
PLANNING

23. Temperature Method:
FAMILY
PLANNING

24. Mucus and cervical changes
Method:
• The mucus and cervical
changes occur during the
course of every month
because of fluctuation levels
of female hormone estrogen.
The mucus is thin,
transparent, watery and
yellowish before a few days of
ovulation. The mucus is
thicker, wet and thread like
and gives the moist feeling on
the date of ovulation.
FAMILY
PLANNING

25. Chemical Method
• Chemical methods have spermicidal effect i.e. kill the sperms
inside the vagina. Spermicides work by killing sperm or making
sperm unable to move towards the egg. Nonoxinol-9 is the
commonest spermicide which is used in these products.
• The spermicides are effective for about 45 to 60 minutes.
These are put into vagina before intercourse. In the case of
solid preparations, time must be given to dissolve before
having sex.
• Efficacy is improved if spermicides combination with
mechanical barrier methods such as a cervical cap,condom,
diaphragm The main types of chemical methods used are as
follows.
FAMILY
PLANNING

26. • Foams: These are in aerosol form which are used immediately
before sex and are inserted into the vagina with a special syringe,
e.g., Delfen
• Vaginal tablets: These are also known as pessaries. These are
inserted into vagina. Orthoformc. E.g.
• Gels, jellies and creams: These are mainly used for spreading onto
contraceptive caps before insertion. Durex Duragel (Gel), Gynol II
(jelly) and Ortho-Creme (cream).
• Films: Squares of contraceptive film which was put on the tip of
the penis before the start of intercourse. This is risky, and is not
recommended.
Advantages: Can be purchased from any pharmacy without prescription.
Disadvantages: These spermicidal products contain various fragrances,
colorings and other components. Men and women can become allergic to
these ingredients and can develop symptoms of allergy such as soreness,
swelling, redness and itching. It does not provide any protection against
HIV or other sex infections.
FAMILY
PLANNING

27. Mechanical Methods
• Mechanical contraceptives prevent the sperm and egg
from meeting. These are all devices that can be inserted
into the vagina to prevent ejaculated sperm from passing
through the cervix and entering the womb.
• There are a number of mechanical contraceptive methods
used as male condom, female condom, diaphragm, fem
cap. Lea-shield. Caps and diaphragms come in different
sizes to accommodate women of different shapes.
• These can be used with a spermicide to achieve the
effectiveness.
• There are another kind of mechanical device that does
allow the meeting of sperm and egg. These are
intrauterine devices.
FAMILY
PLANNING

28. Condoms:
• Condom is a sheath or covering, which is made of thin latex
rubber to fit over a man's erect penis. It collects the semen
and prevents the sperm from entering a woman's vagina.
• It is known by many different brand names and also called
rubbers, sheaths and skins. Condoms of different sizes,
shapes, colors and textures are available.
• Some condoms are coated with a dry lubricant or with
spermicide. It must be used correctly, if not used correctly,
they may risk causing pregnancy, getting STDs, or giving STDs
to their partners. There are chances of 3 pregnancies per 100
women even when used correctly.
FAMILY
PLANNING

29. Condoms:
Advantages:
• Cheap and easy to find at any drug-store without a prescription.
• Available free at family planning clinics and health centers
• Protect against pelvic inflammatory disease, chronic pain and
possibly cervical cancer in women as well as infertility in both
men and women.
• It is safe and has no hormonal side effects.
• It prevents STDs, HIV/AIDS and pregnancy when used correctly
during sexual intercourse.
• Can be used without seeing a health care provider first.
• No effect on breast milk and protect against infection in uterus.
• Men of all ages can use.
FAMILY
PLANNING

30. Condoms:
Disadvantages:
• Make the sex less enjoyable for either partner.
• Some people may feel embarrassed at time of
purchasing.
• For people who are allergic to latex condoms may
develop itching.
• Couple must take time to put the condom on the erect
penis before sex.
• It is difficult for some people to ask a partner to use, put
on, take off and throw away condoms.
FAMILY
PLANNING

31. Female condom:
• A thin polyurethane sheath, shaped like a sock with flexible rings in
at each end. The ring at the closed end holds the pouch in place
inside the vagina, while the ring at the open end remains outside
the vagina.
• The pouch collects semen and prevents it from entering the vagina.
There are chances that 21 out of 100 women with typical use and
five out of 100 women with perfect use will become pregnant in
one year
DIVYESH
R.
KANGAD

32. Female condom:
Advantages:
• Protects against STDs, including HIV.
• Can get it without a prescription.
• Can be inserted up to eight hours before having intercourse.
• If allergic to latex and one wants to use condoms, this is a
good alternative.
Disadvantages
• Outside ring can slide inside the vagina during intercourse.
• Awkward to use.
• Must be removed right after inter-course, before you stand up
to prevent semen leakage.
• Cannot be used simultaneously with male condom.
FAMILY
PLANNING

33. Diaphragm:
• A spermicide is used to coat the inside and outer edge of this
dome-shaped silicone or latex cup with a flexible rim. Then it is
inserted into the back of vagina so that it covers the cervix,
where it blocks sperm. It can be used in place up to six hours
before intercourse and can stay there for 24 hours.
FAMILY
PLANNING

34. Diaphragm:
• There are chances that 16 women pregnant out of 100 with
typical use and six women out of 100 with perfect use will
become in one year. There is need to use fresh spermicide
each time one have intercourse.
• It won't effectively protect against most STDs, including HIV,
and can increase the risk of urinary tract infections and toxic
shock syndrome. Oil-based lubricants should not be used as
they can damage the diaphragm. It is messy and clumsy to use
until one get use to it. It can be kept in place for six hours after
the last act of intercourse and then needs to be washed
thoroughly with soap and water.
FAMILY
PLANNING

35. Femcap:
• Twenty women out of 100 with typical use and nine women
out of 100 with perfect fem cap use will become pregnant in
one year. It can be worn for up to 48 hours.
• There is an attached strap which aids in removal. It do not
protect against STDs, including HIV. It must stay in place for six
hours after last act of intercourse. The disadvantage is that
some women or their partners may feel discomfort while
using FemCap. It should be washed thoroughly with soap and
water.
• Fem cap is a hat-shaped silicone
rubber cap. A spermicide is used
to coat the inside of this hat-
shaped silicone rubber cap.
Then she inserts it into the back
of her vagina so that it covers the
cervix, where it blocks sperm.
FAMILY
PLANNING

36. Lea's shield:
• It has to stay in place for eight hours after the last act of
intercourse it needs to be washed thoroughly with soap and
water. It has an attached strap which aids in removal.
Disadvantages:
• It does not protect against STDs, including HIV,
• Some feel discomfort while using the shield.
• It should be replaced every six months.
• Lea's shield is an oval shaped made up
of silicon rubber. A spermicide is used
to coat the inside of device. Then it is
inserted into the back of her vagina so
that it covers the cervix, where it
blocks sperm. It can be worn for up to
48 hours.
DIVYESH
R.
KANGAD

37. Sponges:
• Sponges are the barrier devices to prevent pregnancy. The
sponges are soaked with vinegar or olive oil or contain
spermicide Vaginal Sponge TODAY is marketed in USA which is a
small polyurethane sponge (5cm x 2.5 cm) soaked with
nonoxynol-9.
FAMILY
PLANNING

38. Intra uterine device's:
• Grafeinberg made the first
modern contraceptive device
from silkworm gut in 1909. In
1931 this was later modified into
a silver ring. Then over the years
copper wire with a surface area of
200mm was added to the device.
The intrauterine devices are a T-
shaped piece of plastic. It is
placed in a woman's uterus to
prevent pregnancy.
DIVYESH
R.
KANGAD

39. Intra uterine device's:
IUDs help prevent fertilization by:
• Leucocytic infiltration of endometrium macrophages engulf the
fertilized-egg
• Interfere with the motilities and survival of sperms.
• Cu-T brings certain enzymatic changes in the endometrium which
makes endometrium not suitable for implantation of the fertilized
ovum.
• Creating the endometrium hostile.
• Increases the tubal motility causing early embedding of fertilized
ovum Before endometrium is ready.
FAMILY
PLANNING

40. Intra uterine device's:
• They are impregnated with barium sulphate so as to render
them radio-opaque. The best time for insertion an IUD is
during period or just after period, so as to sure that the
women are not pregnant.
• It is also easier to insert and the procedure of insertion is done
during a pelvic examination by a doctor or nurse. A short
string will hang down through the cervix into the back of
vagina. Once a month the IUD string should be checked with
the finger. If the string is not there, then the plastic part of the
IUD can be felt.
• In case, one suspects that the device is out, then call the clinic
right away. The IUD is best for women who are in long-term,
monogamous relationships.
DIVYESH
R.
KANGAD

41. Intra uterine device's:
• The most widely used IUDs are copper-bearing IUDs. Inert
(unmediated) and progestin-releasing IUDs(levonorgestrel or
progesterone) are less widely available. IUCDs stimulates the
endometrium to release leukocytes and prostaglandins. This
causes bizarre and irregular growth of the endometrium and
makes it hostile to the sperm.
• In this way, prevent pregnancy by making the endometrium
unreceptive to the fertilized ovum. So the action of IUD's is to
inhibit sperm migration in the upper female genital tract, inhibits
ovum transport and stimulates endometrial changes to prevent the
pregnancy.
• IUDs are suitable for breast feeding women. IUDs are a safe and
effective method of reversible, long-term contraception for most
women. The failure rate for copper IUDs is 0.6% to 0.8% and for
the levonorgestrel-IUD the failure rate is 0.1% during the first year
of typical use.
FAMILY
PLANNING

42. Types of IUD'S
There are two types of
intra uterine devices:
• Non medicated
• Medicated
FAMILY
PLANNING

43. Non Medicated intra uterine devices:
These are made of polyethylene or polymers and are
referred as 1st generation IUDs. First generation IUDS are the
inert IUDs made of plastic (lippes loop) or stainless steel
(Chinese ring).These come in different size and shape.
 These are:
 Lippe's Loop
 T-shaped
 Spirals
 Coils
 Rings
FAMILY
PLANNING

44. Medicated intra uterine devices:
The medicated or the bioactive IUDs release metal ions
as in copper or hormone such as progestrones. Depending upon
this, the medicated type of IUDs are of two types:
Second Generation IUDS
Third generation IUDS
FAMILY
PLANNING

45. Second Generation IUDs:
Second generation IUDs are copper bearing bioactive devices viz.,
CuT 380 A, CUT 200 B, Multi load (MLCu 250 and 375) and NovaT.
Advantages:
• They do not affect breastfeeding.
• Do not interfere with intercourse.
• Do not have hormonal side effects.
• No restrictions on use for women age 20 and over.
• Can be used safely throughout their reproductive years.
• Can return to fertility immediately upon removal.
• After insertion of an IUD, the follow up is required within two or three
months the date of insertion and thereafter once a year.
Disadvantages:
• Does not protect against STDs.
• Can cause infections of uterus or fallopian tubes.
• Have side effects
• Cannot be used in certain conditions such as PID, gonorrhea etc.
FAMILY
PLANNING

46. Second Generation IUDs:
It is contraindicated in:
• PID,
• More than one sexual partner
• An ectopic pregnancy in the past
• Undiagnosed, abnormal vaginal
bleeding
• An allergy to copper
• Pregnancy
• Postpartum sepsis, immediate
post-septic abortion
• Abnormal uterine bleeding
• Cervical cancer, endometrial
cancer, uterine fibroids
• Pelvic tuberculosis and STDs.
Complications:
• Immediate: The
complications such as
difficulty in insertion,
cramps, partial or
complete perforation
• Early complications: Early
complications such as
expulsion of Cu-T, spot-
ting, menorrhagia and
dysmenorrhea.
• Late Complications: These
include P.I.D, ectopic
Pregnancy and
menorrhagia
FAMILY
PLANNING

47. Side effects
• The most common side effects are:
• Alteration in normal menstrual - prolonged bleeding,
menorrhagia, uterine cramps, etc.
• Inter-menstrual spotting, bleeding, prolonged or
increased menstrual flow, especially during the first
several weeks following insertion.
• Cramps at the time of insertion usually last not more
than a few seconds. Some
• Women may experience residual cramps for hours or
even days, there-after.
DIVYESH
R.
KANGAD

48. Cu-T 380A:
• It is a T-shaped device made up
of polyethylene holding 380mm
on exposed area of copper. The
copper wire wound around
weighs 176mg and the copper
sleeves on the horizontal arm
weigh 66.5mg. These are
available in pre-sterilized sealed
pouches. The shelf life of Cu-T
380A is 10 years.
FAMILY
PLANNING

49. When it
can be
inserted?
• Interval IUCD: Any time during
menstrual cycle/ after 6 weeks of
delivery/ after 12 days of completion of
abortion.
• Postpartum IUCD (PPIUCD): Within
48 hours of vaginal delivery/concurrent
with C Section
• Post-Abortion IUCD: within 12 days of
completion of abortion (surgical
abortion). In case of medical abortion,
the completion of abortion is
ascertained on12th day after the intake
of second pill or 15th day after intake of
first pill.
FAMILY
PLANNING

50. Cu-T 375:
• It is an intrauterine device with
flexible side- arms. It is made
with a combination of high-
density polyethylene, ethylene
vinyl acetate copolymer and
barium sulphate in a weight ratio
of 44/36/20. A copper wire with
99% purity is wound around the
stem, giving a total copper
surface area of 375 mm2. Self life
of cu-T 375 is five year
FAMILY
PLANNING

51. Third generation IUDS:
• Third generation IUDs are hormone-releasing. These are
medicated with steroids viz., progesterone -containing
progestasert and levonorgestrel containing levonova.
• Early efforts produced a progesterone-releasing device
progestasert (T shaped containing 38mg of progesterone).
• Daily the hormone was released slowly at the rate of 65 mcg.
The regular replacement was necessary because of depletion
of hormone progesterone from the device.
• This was available for a short time because of excessively
high ectopic pregnancy rates.
FAMILY
PLANNING

52. Continue…..
• About 20% - 60% of women within the first year of use
become amenorrhoic. After 8months half of users experience
no menstrual bleeding. But some experience occasional scanty
spotting. Oligomenorrhea and amenorrhea are common.
Frequent or prolonged light bleeding is a problem. The women
may suffer from dysmenorrhea. As complication ovarian cysts
can occur.
• Side effects of LNG-IUS are nausea, acne, lower abdominal
pain, mastalgia, back pain, headache, mood changes, vaginal
discharge. According to the World Health Organization (WHO),
IUDS should not be inserted until 4 weeks post-partum.

53. Mechanism of Action
• Both IUCD 380 A and IUCD 375 have the same mechanism of
action.
• Copper ions decrease sperm motility and function by altering
the uterine and tubal fluid environment, thus preventing
sperm from reaching the fallopian tubes and fertilizing the
egg.
• The device stimulates foreign body reaction in the
endometrium that releases macrophages and prevents
implantation
FAMILY
PLANNING

54. Contraceptive Effectiveness IUDs
• The IUCD is effective immediately after insertion and its
effectiveness is comparable to sterilization. The failure
(pregnancy) rate associated with IUCD is less than 1% in the
first year of use. This means less than 1 pregnancy per 100
women in the first year of use (6 to 8 pregnancies per 1000
women) (WHO Handbook on Family Planning, 2018).
FAMILY
PLANNING

55. IUCD as an Emergency Contraceptive
• The IUCD can also be used
to prevent pregnancy if
inserted up to 5 days after
unprotected intercourse.
IUCDs can reduce the risk of
pregnancy by 99.9%. Once
inserted for emergency
contraception, the IUCD can
be left in place to prevent
pregnancy for as long as the
woman wants, until the
IUCD remains effective.
FAMILY
PLANNING

56. Hormonal
Contraceptive
Methods

57. Hormonal Contraceptive Methods
• Hormonal methods are effective if used properly. Oral
contraceptive contain synthetic oestrogen (ethinyl estradiol
and mestranol) and progesterone (pregnanes,oestranes and
gonames).
DIVYESH
R.
KANGAD

58. Combined Oral
Contraceptive Pills (COCs) :
• Combined contraceptives contain low-doses of both synthetic
estrogen and progestin, like hormones produced by the body
to regulate the menstrual cycle. COCs inhibits ovulation
(primary mechanism) and thickens the cervical mucus and
change sperm transport (secondary mechanisms).
• Combined oral contraceptive pills (COCs) are available in strip
of 28 pills, (21 are hormonal (combination of Levonorgestrel
(0.15mg) + Ethinyl estradiol (30 micrograms). The pill must be
taken daily, without any break to avoid risk of pregnancy.
DIVYESH
R.
KANGAD

59. There are two types of
COCs pills which are commonly
used. These are:
• Mala -N: Available at all PHC's
and urban family welfare center.
• Mala- D: Available in market at
the cost of Rs 2/- per packet.
• Besides Mala-D, COCs have also
been allowed to market their
proprietary brand name such as
ECROZ, PEARL, MOTI, CHOICE,
APSARA & SUVIDA.
DIVYESH
R.
KANGAD

60. Who can not use COCs:
• Breastfeeding women: <6 months postpartum
• Non-breastfeeding: <3 weeks postpartum.
• Women who smoke: >15 cigarettes/day and are more than equal to 35
years old.
• Women with the following conditions:
• Deep vein thrombosis
• Heart disease, bleeding disorders
• Liver disease
• Recurrent migraine headaches
• Unexplained abnormal vaginal bleeding
• Breast cancer
• Currently taking anticonvulsants for epilepsy
• With advice of clinician, in case of following conditions:
• Women with hypertension (BP 140/90)
• Diabetes, (advanced or long standing), with vascular problems, or
• central nervous system, kidney, or visual disease

61. Missed pills…….?

62. Benefits of COCs:

63. Progestin-only pills (POPs):
• These are a monthly series of pills in which one pill is taken daily.
Progestin- only pills contain synthetic progestogens but no
oestrogen. These are commonly known by the name 'Mini Pill'.
These are the best oral contraceptives for breastfeeding women.
It must be taken at the same time every day as the hormone
dose is small and forgetting one day’s pill can cause the method
to be ineffective.
• It thickens cervical mucus to make it impenetrable for sperms. It
makes the endometrial lining thin which is not conducive to
implantation. These are better than COCs as these do not affect
lactation or increase BP and also do not cause headache. But the
failure rate is high as compared to COCs.
• These are Contraindications in certain conditions such as breast
cancer, liver cirrhosis, Benign or malignant liver tumors, history
of ischemic heart disease

64. Once a Week Pill:
• Once a week oral pill
called Saheli can also
be used to prevent
pregnancy. It is non-
steroidal and is
available in the
market at Rs. 1.50
per tablet.

65. Centchroman Pills (Chhaya)
• This is a non-hormonal, nonsteroidal, weekly pill which is suitable
for nearly all women including those who are unmarried and
have no children. It is available as 8 tablets per strip. For
initiation, the first pill is to be taken on the first day of period (as
indicated by the first day of menstrual bleeding), next pill three
days after. Therefore, one pill is taken twice a week for first three
months; Starting from fourth month, the pill is to be taken once a
week on the first pill day and should be continued on the weekly
schedule.

66. Once a month pill

67. Once a Month Pill
• Once-a-month administration of mifepristone if
administered at the early luteal phase is an
acceptable contraceptive option with minimal
side effects. Unfortunately, it is difficult to define
the correct timing.

68. Emergency Contraceptive Pills (ECPs)
• EC pills (Morning after pills or
Post coital pills) are hormonal
method of contraception which
a women uses to prevent
pregnancy after unprotected
intercourse.
• The agents used for EC are
Levonorgestrel only or combined
estrogen-progestin. ECPs inhibit
ovulation and cause changes in
the endometrium; it is
recommended that two tablets
(single dose) of levonorgestrel
should be given within 72 hours
of intercourse.

69. Emergency Contraceptive Pills (ECPs)
• These pills are useful for those women who had been subjected to
unprotected sex, slippage or bursting of condoms during sex or
sexual violence. These pills will also not work if woman is already
pregnant. Menstruation will not be started immediately.
• The next period may come a few days earlier or later than expected.
The pregnancy should be suspected, if the menstrual period is more
than one week later than expected or the menstrual period is
unusually scanty. The failure rate is 15% to 26%.
ECPs are of two types:
• Progestin-only: is more effective and have fewer side effects and
• Combined estrogen/progestin.
• Regular oral contraceptive pills can also be used for emergency
contraception

70. Injectable Contraceptives:
• The Injectable Contraceptives contain synthetic hormones
resembling the natural female hormones. When
administered (IM/SC) there is a slow release of hormone into
the blood stream and it provides protection from pregnancy
for a long duration of time to the client.
Types of Injectable Contraceptives
• Progestogen-only Injectable (POI) containing only synthetic
progesterone.
• They are of two types:
• Depot MedroxyProgesterone Acetate (MPA) - 3 monthly Injection.
• Norethisteroneenanthate (NET-EN) – - 2 monthly Injection.
• Combined Injectable Contraceptive (CIC): containing
estrogen (usually ethinylestradiol) and progesterone –
- 1 monthly injection

72. Contraceptive Benefits
• Safe, highly effective with long term contraceptive benefits.
• Convenient and easy to use (does not require daily routine or
additional supplies).
• Acts for 3 months with a grace period of 4 weeks.
• Completely reversible: 7-10 months from date of last injection
(average 4-6 months after 3 months effectivity of last injection is over).
• Does not interfere with sexual intercourse/pleasure.
• Suitable for breast feeding women (after 6 weeks postpartum) as it
does not affect quantity, quality and composition of breast milk.
• Provides immediate postpartum (in non-breastfeeding women) and
post-abortion contraception.
• May be used by women at any age or parity if they are at risk of
pregnancy
Non-contraceptive Benefits
• Improves anemia by reducing menstrual blood loss due to menstrual
changes
• Decreases benign breast disease and ovarian cyst.
• Helps prevent uterine tumors (fibroids).
• Protect against endometrial cancer and possibly ovarian cancer.
• Minimal drug interactions – no demonstrable interaction has been
found between MPA and antibiotics/enzyme-inducing drugs

73. Limitation
• MPA is an appropriate long acting contraceptive method
suitable in majority of the women, however it has some
limitations like
• It does not protect against STI/RTI and HIV infection.
• Once taken its action cannot be stopped immediately.
• It causes changes in the menstrual cycle and bleeding due to
its inevitable effect on a woman’s body hormones.
• It has to be repeated every three months to achieve desired
contraceptive effectiveness.
• Return of fertility takes 7-10 months from date of last injection
(Average 4-6 months after 3 months affectivity of last injection
is over).
• Cannot be given in few medical conditions/diseases

74. Return to Fertility
• MPA may cause a delay in the return of fertility. Since one
injection is effective for 3-4 months, the return of fertility takes 7-
10 months from date of last injection (average 4-6 months after 3
months effectivity of last injection is over). Studies have also
shown that ovulation/fertility return is not affected by duration of
MPA use or women’s age.
Initiation
• When to Start MPA Injection
• A MPA injection can be started any time if it is reasonably certain
that the woman is not pregnant (Annexure 1). A physical
examination is always an important part of good reproductive
health care but recent scientific studies have shown it is not
required for the provision of MPA. The following table highlights
different situations of women, when one can start the first dose
of MPA injection as an effective contraceptive method.

75. Sub-dermal Contraceptive Implant
(Single Rod)
• A Contraceptive Implant is a small flexible rod about the size
of a matchstick, placed under the skin of the upper arm of the
woman, using a pre-loaded sterile disposable applicator. It is a
long acting reversible hormonal contraceptive method
effective for 3 years after insertion. It is inserted by a trained
provider) at the designated health facilities.

76. Continue….
• Norplant should be inserted within 7 days of the onset of
menstrual bleeding or immediately after an abortion. The
implants are comfortable contraceptive methods. Norplants
are barely visible under the skin and if seen look like veins
without color. Two three month trial of an oral ontraceptive
containing levonorgestrel e.g Nordette, Ovrette is advised to
determine whether a woman can tolerate it or not and health
plans.
• It is particularly suited for women who are seeking continuous
contraception, want long term birth spacing, cannot use
contraceptives that contain estrogen. Women can become
pregnant when the implants are removed as the contraceptive
effect wears off quickly. After five years, norplant implants
should be removed as it becomes less effective. Before this
time it can be removed if the women wants. But it is difficult
to remove. So get it removed from an expert clinician.

77. Advantages:
• Effective even in heavier women.
• Provides long term pregnancy protection
• It is reversible as fertility returns almost immediately after the capsules
are removed.
• No change in quality and quantity of the breast milk so can be used by
nursing mothers starting six weeks after childbirth.
• Prevent pregnancy up to five years
• No estrogen side effects.
• No interference with sexual enjoyment
Disadvantages:
• Do not provide protection against sexually transmitted diseases.
• Cannot start or stop its use at her own as capsules must be inserted
and removed in by a specially trained practitioner.
• Discomfort for several hours to one day or several days in a few women
after insertion
• Removal is painful

78. THE PATCH (Ortho Evra)
• One patch is worn by the woman for seven days,
three weeks in a row, and then goes one seven-
day week without the patch. The patch releases
estrogen and progestin and works by preventing
ovulation, increasing cervical mucus to block
sperm and creating a thin uterine environment.
Disadvantages:
• Provides no protection against STDs, including
HIV.
• May cause local skin irritation or rash, vaginal
spotting, nausea, headaches, or moodiness.
• When worn, the patch may be difficult to hide.
• Smokers cannot use.

79. Permanent methods of
Family Planning
• Sterilization for men and women is a permanent method for
individuals who do not want any more children. With a
vasectomy, the vas deferens, which carry sperm from the
testes to the urethra of the penis, are cut.
• In a tubal ligation, the fallopian tubes, which carry the eggs
from the ovary to the uterus, are cut. Both methods are highly
effective (99.5% to 99.9%), safe, convenient, and performed in
a single procedure.
• These methods are not appropriate for anyone who may want
to have a child in the future. Because people so often change
their minds about having families, sterilization is usually
discouraged for people under 30 who have not had children.

80. Female Sterilization (Tubectomy)
• There are two common procedures for female sterilization as
described below.
Laparoscopy:
• A laparoscope is used for sterilization purpose. The abdomen is
inflated with carbon dioxide or nitrous oxide and laparoscope is
introduced to visualize the fallopian tubes. Then the clips are applied
to occlude the tubes. It is not advisable 6 weeks after delivery. The
client is kept under observation in hospital for 48 hours. Follow up is
required after 7-10 days and then 12-18 months. The laparoscopy
should not be done in:
Women having heart disease
Respiratory diseases
Diabetes
Hypertension
Hb not less than 8mg/dl

81. Laparoscopic tubule ligation

82. Mini lap:
• In this fallopian tubes are blocked which prevent the ovum
and sperm from uniting. It is a safe and simple surgical
procedure. It is done under local anesthesia and light
sedation. A small incision 2.5-3cm is made in the women’s
abdomen and the two fallopian tubes are blocked off or cut.
• Women can have female sterilization procedure anytime
immediately after child birth or within 7 days or immediately
after abortion.
• A women is sterile from the time the procedure is completed.
Only 1 pregnancy per 200 women have been recorded in the
first year after the procedure. Within 10 years, this figure
increasesto 1pregnancy per 55 women.

83. Advantages:
• Provides lifelong, safe and effective family planning.
• It does not affect the woman's ability to have sex.
• There are no side effects or health risks.
• Very effective.
Disadvantages:
• Injury to internal organs
• Risks are more with local anesthesia use. Reversal surgery is
difficult
• Pain can occur for several days after the operation.
• Infection or bleeding at the incision

84. Male Sterilization(Vasectomy)
• This is family planning method for men. In this method, the vas
deferens, the ejaculatory duct is blocked to prevent the sperms
from being released.
• It is a safe, simple and quick surgical procedure which can be
done in a clinic. A small opening in the man's scrotum is made
and both tubes vas deferens are closed off which carry sperm
from testicles.
• It is not castration. It does not affect the testes and sexual ability.
The man is not sterile till his ejaculations are sperm-free. He
becomes sterile after about 3 months or when 20 ejaculations
has been completed after the procedure, whichever comes first.
• The man is advised to wear T bandage 15 days and also not to lift
the heavy objects for 15 days. The man is asked to keep the site
clean and dry and stitches are removed on 5th day.

85. Advantages:
• It is a permanent method.
• It does not interferes the ability to have sex.
• It is very effective
• There are no long-term health risks.
Disadvantages:
• Uncomfortable for 2 to 3 days
• Bleeding or Blot clots or infection.
• Not immediately effective.
• Reversal surgery is difficult.

86. Vasectomy

87. No Scalpel Vasectomy(NSV)
• It is a safe minimally invasive procedure that reduces
complications occurring in conventional. This was developed
in 1974 in China by Dr. Shunqiang Li and introduced to the
western world in 1985.
• In India, the technique was introduced in 1992. It has
advantages such as no incision and no stitches are required.
This reduces the stress and anxiety leading up to the
procedure. The procedure is faster as it takes as it takes about
10 minutes to complete.. Even there are less chances of
infection or bleeding and is effective also.

88. No Scalpel Vasectomy(NSV)
• Most advance
• Painless
• Fast healing
• No complication

90. Role of nurse
in
Family planning

91. Community Level Interventions
• Support the frontline functionaries in identifying the level of health
facilities according to specific needs of the clients.
• Counseling on importance of appropriate age of marriage, delaying
conception after marriage, spacing and limiting methods.
• Ensure community- based distribution of contraceptives (including
Combined oral contraceptive pills (Mala N), Condoms (Nirodh),
Centchroman pills (Chhaya).
• Ensure provision of emergency contraceptive pills (Ezy pill), if required.
• Follow up with spacing contraceptive users for continuing use/switching
to other methods.
• Counseling and referral for adoption of long acting reversible
contraceptive methods (like injectable and IUCD) and limiting FP
methods.
• Ensure distribution of Pregnancy Testing Kit (Nishchay Kit) for early
detection of pregnancy and registration thereafter.
• Counseling on adoption of post abortion contraception.
• Counsel the women and family during ANC, early labour and PNC period
on importance of healthy timing and spacing of birth and encourage her
for adoption of postpartum contraception.

92. Facility level Intervention
• Update the eligible couple survey register by ASHA/ ANM.
Ensure that eligible clients requiring limiting options are
included in line listing by ASHA.
• Counsel the women on importance of healthy timing and
spacing of birth and encourage her for adoption of
postpartum contraception during ANC, early labour and PNC
period.
• Provision of short acting methods- condoms, oral
contraceptive pills (Mala N, Chhaya). Provision of emergency
contraception, if required.
• Install condom boxes at the health facility to promote condom
uptake and encourage male participation in family planning.
• Provision of long acting reversible contraceptive methods-
Injectable Contraceptives and interval IUCD.
• Provision for PPIUCD insertion if the facility is a delivery point.

93. Continue…….
• IUCD removal and its reporting (both interval and post pregnancy).
• Follow up, counseling, early management and referral (if required) for
side effects of contraceptives, if any.
• Ensuring continuity of contraceptive method and record method
switching, if any.
• Counseling and referral for adoption of limiting methods to couples
whose family size is complete. Conduct primary screening for Sterili
Sterilization at HWC, if warranted.
• Early detection of pregnancies through pregnancy testing kits (Nischay
Kit).
• Place indents and issue stocks through FP-LMIS and update the stock
position regularly.
• Counseling for adoption of post- abortion contraception.
• Support conduction of IEC/ BCC activities to promote awareness and
demand generation (Wall paintings, Display of contraceptive options,
folk plays, interpersonal communication etc.).
• Maintain proper records of services provided at the HWC and referrals

94. Role of Nurse in Family Planning
•
The community health nurse can educate the family and the eligible
couples on advantages of a planned family. To do this she should:
• Conduct survey to develop eligible couple list and use this for carrying out
family planning activities.
• Motivate couples to adopt family planning methods and arrange for facilities
to provide these methods.
• Offer follow-up services for mothers who have adopted FP methods and treat
side effects or minor complaints, if any.
• Train and supervise health workers, depot holders and maintain the record of
the services rendered through them.
• Involve voluntary health guides, women leaders and other voluntary
members; give them training, guidance and supplies.
• Encourage satisfied family planning acceptors to promote family planning.
• Give advice and refer if any couple needs infertility clinic services.
• Help women in availing facilities of Medical Termination of Pregnancy, if
required.
• Maintain records and reports.
• Communicate with individuals, groups and through mass media.
• Supervise dais and community level workers.
• Arrange incentives for members contributing towards achievement of targets.