About emergency contraceptive and onjectabel contraceptive

1. By:- Michiale H. (BSc Mw, MSc Mw)
Lecturer, Department of Midwifery
Dire Dawa University CMHS
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Objectives
 Describe male and female condoms
 Explain the implication of dual use
 Demonstrate proper use of male and female cond
oms
 Describe spermicides and diaphragm

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Male Condoms
 Sheaths, or coverings, th
at fit over a man’s erect
penis.
 Known by many differen
t brand names – Hiwot T
rust, Sensation, French F
eelings, etc.
 Most are made of thin la
tex rubber.

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Male Condoms …
 As commonly used, about 15 pregnancies per 100 w
omen whose partners use male condoms over the f
irst year.
 When used correctly with every act of sex, about 2
pregnancies per 100 women whose partners use ma
le condoms over the first year.

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Male Condoms …
 Provides dual protection against STIs and unwante
d pregnancy
 Have no hormonal side effects.
 Can be used as a temporary or backup method.
 Can be used without seeing a health care provider.
 Available in health facilities, over the counter and i
n shops, kiosk, supermarkets, etc.

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Proper use of male Condom
 Use a new condom for each act of sex

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Proper use of male Condom …
 Before any physical contact, place the condom on t
he tip of the erect penis with the rolled side out

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Proper use of male Condom …
 Unroll the condom all the way to the base of th
e erect penis


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Proper use of male Condom …
 Immediately after ejaculation, hold the rim of the
condom in place and withdraw the penis while it is
still erect

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Proper use of male Condom …
 Dispose of the used condom safely

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Proper use of male Condom …
 Demonstration on proper use of male condom usi
ng penile model

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Female condom/Reality
 Poly urathane
 Has 2 flexible rings at the end
 15 cm in length and 7 cm in width
 It enables a woman to control its use to prevent pre
gnancy and STIs including HIV.

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Female condom …
 As commonly used, about 21 pregnancies per 100 w
omen using female condoms over the first year.
 When used correctly with every act of sex, about 5
pregnancies per 100 women using female condoms
over the first year.

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Proper use of female condom
 Use a new female condom for each act of sex
 Before any physical contact, insert the condom int
o the vagina
 Ensure that the penis enters the condom and stays
inside the condom
 After the man withdraws his penis, hold the outer
ring of the condom, twist to seal in fluids, and gen
tly pull it out of the vagina
 Dispose of the used condom safely

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Proper use of female condom ..

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Proper use of female condom ..

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Proper use of female condom …
 Show video on proper use of female condom.

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How women can negotiate condom
use with partner
 Emphasizing use of condoms for pregnancy preven
tion rather than STI protection.
 Appealing to concern for each other—for example:
“Many people in the community have HIV infectio
n, so we need to be careful.”
 Taking an uncompromising stance—for example: “
I cannot have sex with you unless you use a condo
m.”

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How women can negotiate condom
use with partner …
 Suggesting to try a female condom, if available.
 Some men prefer them to male condoms.
 For pregnant women, discussing the risks that STIs
pose to the health of the baby and stressing how co
ndoms can help protect the baby.
 Informing partner that she is unable to take other
methods of contraception for health reason

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Diaphragm
 Circular, rubber dome with flexible outer rim
 Covers the vaginal fornices & the cervix
 Shouldn't be removed for 6 hrs

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Diaphragm …
 As commonly used, about 16 pregnancies per 100 w
omen using the diaphragm with spermicide over the
first year
 the diaphragm or cap has been in place for 3 hours o
r more before you have sex

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Diaphragm…

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Cervical cap
 A bell-shaped rubber device that fits over th
e cervix

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Spermicides -Nonoxynol-9
 Jellies, creams, foams or supposit
ories
 As commonly used, about 29 pre
gnancies per 100 women using s
permicides over the first year
 Not recommended for clients wh
o
 Are at high risk for HIV infec
tion
 Have HIV infection
 Have AIDS

26.  Spermicides block the cervix (the opening to the
uterus) and slow sperm down to make it harder fo
r them to swim to an egg.
 must be placed in the vagina at least 10 to 15 minut
es before sex so they have enough time to dissolve
and spread.
 are effective for only 1 hour after they are inserted
 houldn't douche for at least 6 hours after a couple
has sex using spermicide as birth control.
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Oral Contraceptive Pills (
OCPs)

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Objectives
 Describe COCs, POPs and Injectables
 Explain effectiveness of COCs, POPs and Injectables
 Discuss characteristics of COCs, POPs and Injectables
 Describe when to start COCs, POPs and Injectables
 Discuss MEC, side effects and complications of COCs,
POPs and Injectables

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Combined oral contraceptives
 Contain estrogen and progesterone
 Pills that contain low doses of two hormones-a pr
ogestin and an estrogen.
 Work primarily by preventing the release of eggs fr
om the ovaries.
 Women who are infected with HIV, have AIDS, or a
re on ARV therapy can safely use COCs.

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COCs: Mechanisms of Action
Suppress ovulation
Change endometrium making
implantation less likely
Thicken cervical mucus
(preventing sperm
penetration)
Reduce sperm transport
in upper genital tract
(fallopian tubes)

32.  Oral contraceptives prevent fertilization. The combina
tion of estrogen and progestin prevents ovulation by pr
oviding negative feedback to the hypothalamic-pituita
ry gland and thickening the cervical mucus, which sto
ps sperm from entering the uterus.
 It is possible that combined oral contraception might a
lter the endometrium, but evidence is insufficient to s
how implantation is prevented by oral contraceptive us
e.
 Combined oral contraception does not disrupt an exist
ing pregnancy
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COCs …
 Instructions: Begin with:
 The onset of menses
 6 weeks after delivery if breast feeding
 After 3 weeks if not breast feeding
 Immediately or with in 7 days after abortion
 Packing of 28 tablets containing 21 hormonal tabs and 7 pla
cebo or iron

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How to Take COCs:
Schedule and Missed Pills
Schedule:
• Take one pill every day
• 21-day packs  7-day break
• 28-day packs  no break between packs
Missed pill:
Missed 1 or 2
active pills
• Take missed pill as soon as remembered
• Keep taking other pills on schedule
• No backup method needed
Source: WHO, 2004.
Quick start in COC

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How to Take COCs:
Missed Pills
Miss 3 or more
active pills or
start pack 3 or
more days late
• Take first missed pill as soon as you remember
• Continue daily pill taking as usual and use
backup method or abstain for next 7 days
• Count number of active pills remaining in pack
7 or more active
pills left in the pack
• Finish active pills
• Take hormone-free break
Fewer than 7 active
pills left in the pack
• Finish active pills
• Discard inactive pills
• Start new pack immediately
Source: WHO, 2004.

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Non contraceptive benefits of COCs …
 COCs decrease
 Benign breast disease
 Functional ovarian cyst
 Anemia
 PID
 Endometrial & ovarian Ca
 Dysmenorrhea
 Arthritis & osteoporosis
 Endometriosis
 Ectopic pregnancy

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Who Can Use COCs Without Restriction
 Adolescents
 Nulliparous women
 Postpartum ( more than 3 weeks, if not BF)
 Immediately post-abortion
 Women with varicose veins
 Any weight (including obese)

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Who Should Not Use COCs
 Women with:
 Pregnancy (but no proven negative effects on fetus i
f taken accidentally)
 < 6 weeks post partum if breast feeding
 Age > 35 and smoker
 SBP >160 & DBP >100
 DVT or pulmonary embolism
 Cardio vascular disease or increased risk of CV diseas
e
 Breast cancer
 Liver disease

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Who Should Not Use COCs …
 Women with:
 < 3 weeks post partum and not breast feeding
 6 weeks - 6 months post partum and breast feeding
 SBP 140-159 & DBP 90- 99
 Migraine head ache
 Woman taking rifampicin & phenytoin

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Side effects & complications of COCs
 Nausea weight gain, chloasma, dizziness, mood chan
ge, acne and mastalgia
 Thromboembolism
 Hypertension
 Benign liver tumor and jaundice
 Amenorrhea

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Concerns with COC
 Cardiovascular disease
 COCs may slightly increase the risk of heart attack, strok
e and thromboembolism
 Breast cancer: No strong evidence of increased risk
 Cervical cancer: Small increased risk
 Liver cancer
 COC use is associated with growth of hepatocellular ade
noma.
For most healthy women the health benefit exceeds the health ris
k

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Progesterone only pil
ls/ POPs
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Progesterone only pills/ POPs
 28 pill pack, 1 pill to be taken daily
 Extra contraceptive method required if taken 3 hours a
part

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Progesterone only pill /POP
 Mechanism:
 Thicken cervical mucus & endometrial change
 Instruction: 28 pill pack, 1 pill to be taken daily
 Characteristics:
 Contains no estrogen
 Doesn't affect breast feeding
 Slightly increased incidence of EP
 May cause irregular uterine bleeding
 Extra contraceptive method required if taken 3 hrs apart

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Injectables

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Injectables preparations
 Progesterone only
 Medroxy progesterone acetate/ Depo-provera 150 mg eve
ry 90 days IM
 Noristerat/NET-EN 200 mg every 2 months IM
 Uniject/Depo-subQ provera 104: SC(Subcutaneous) ever
y 3 months
 DMPA has a grace period of 4 weeks and delays fertility for a
n average of 9 months

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Injectables …
 Mechanism of action: Similar to OCPs
 Characteristics:
 Independent of coitus
 Independent of daily activity
 May cause irregular uterine bleeding
 May cause amenorrhea
 Delay in fertility after discontinuation
 Need for injection
 May cause weight change, headache, dizziness and fatigu
e

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Depo-Provera (Injectable)
 Injection of 150 mg DMPA q 3 mo
 Women of any age and parity can use it (MEC Cat. 1, a
ge 18-45; Cat. 2, other ages)
 Start first 7 days after LMP, or can use any time reason
ably sure woman not pregnant
 Usable immediate PP if not BF; or 6th wk PP if BF
 Usable immediately after abortion

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Who should not use DMPA
 Women with:
 Pregnancy
 Breast cancer
 Un explained vaginal bleeding

50. Assignment
 WHO Medical eligibility criteria for contraceptive use
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What is EC?
 A type of contraception that is used as an emergency
to prevent unintended pregnancy following an unpro
tected sexual intercourse.
 Sometimes referred to as the “morning-after pill” or “
post-coital contraception”.

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Types of EC
 Emergency contraceptive pills (ECPs):
 COC or
 POP
 Copper-releasing IUDs.

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Who can use EC?
 When no contraceptive has been used
 When there is a contraceptive accident/ misuse
 Condom rupture, slippage or misuse
 IUCD expulsion
 Three COC missed consecutively & late for DMPA injection by
> 4 weeks
 POP contraceptive pill taken 3 or more hours late
 Failure of a spermicidal to melt before intercourse
 Failed coitus interruptus (withdrawal)
 Diaphragm dislodgement or early removal.
 Miscalculation of the safe period when using a fertility awareness ba
sed method.
 In case of Rape

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Not eligible for EC
 Client who is already pregnant

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ECP regimen
Progesterone only pills
 Pills containing 0.75mg levonorgestrel such as postino
r-2, Optinor.
 1 pill as soon as possible after unprotected intercourse follow
ed by a same dose taken 12 hours later.
 Pill containing 1.5mg levonorgestrel:
 1 pill only as soon as possible after unprotected intercourse
 Pills containing 0.03mg levonorgestrel (microlute, nor
geston, ovrette)
 20 pills for the 1st & 2nd dose
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How does EC work?
 Delay or inhibit ovulation
 Is the principal mechanism
 Prevent implantation
 Prevent transport of the sperm & ovum
* Emergency contraceptives are not effective once im
plantation has occurred.
*ECPs do not interrupt or abort an established preg
nancy

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Safety and effectiveness
 Safety
 ECP are considered very safe
 In > 20 yrs no death or serious complication reported
 ECP is not associated with fetal malformation/ congenit
al defect
 ECP do not increase the possibility of ectopic pregnancy
 Effectiveness
 ECP reduce probability of becoming pregnant
 By 75% in case of COC &
 By 85% in case of POP
 Most effective if taken within 3 days (or 72 hours).

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Side effects
 Nausea
 Most common
 More in COC user than POP users
 In about 50% of clients using combined ECPs and in 20% of w
omen using progestogen-only ECPs
 Usually does not last > 24 hrs
 Management:
 Take the pill with food/ at bed time
 Prophylactic anti -emetic may be considered in women who had
nausea in previous ECP use

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Side effects …
 Vomiting
 In 20% of women using COC &
 In 5% of women using pops as ECP
 Management- if vomiting occurs with in 2 hours, the do
se should be repeated
 Irregular vaginal bleeding or spotting
 Inform that ECP do not bring menses immediately
 If the menstrual period is delayed for >1 week from the
expected date, consider the possibility of pregnancy
 Breast tenderness, headache, dizziness & fatigue
 Management: pain reliever

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Instructions to the client
 Explain the correct use of the method
 Advise that emergency contraception does not protect against
STIs including HIV.
 Counsel on regular contraception then after.
 Advise the client to drink milk or eat a snack with the pills to r
educe nausea.
 Advise her to use a barrier method until her next menstruatio
n if she has sexual intercourse.
 Explain that after the use of ECPs most women will have the n
ext menstrual period early or on time.
 If the menstrual period is delayed for more than 1 week the po
ssibility of pregnancy should be considered.

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Follow-up care
 If the client adopted a method of contraception for regular u
se no follow-up should be required in relation to the use of EC
 During the follow-up contact discuss suitable contraceptive
options
 Oral contraception can be started the day after ECP is taken.
 Injectables, implants and IUCD can be given within 7 days o
f the beginning of the next menstrual cycle.
 In case of failure of ECP
 If the client decides to continue the pregnancy, reassure her th
at there is no risk of teratogenic effect following ECP.

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Copper-Releasing IUDs
 A copper-releasing IUD can be used within 5 days of un
protected intercourse as an EC.
 Failure rate: <1% of women become pregnant.
 Indications: in addition to those for ECPs
 The client is considering using an IUD for continuous, lo
ng-term contraception.

67. Quiz
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