Family Planning lecture for B.Sc Nursing students

1. FAMILY PLANNING
Prepared by: Taniya Thapa
Lecturer, MN, WHD

3. DEFINITION…
• Family planning services are defined as
"educational, comprehensive medical or
social activities which enable individuals,
including minors, to determine freely the
number and spacing of their children and to
select the means by which this may be
achieved".

4. Introduction…
• Nursing plays a primary role in providing
education about contraceptive choices and
teaching about the use of different methods.

6. Family planning as basic human
right..
• Proclamation of International conference on
human rights (1968)
• Women’s rights convention (CEDAW)- 1979
• ICPD program of action
• World summit :keeping the promise (2010)

8. OBJECTIVES BY GoN
• To increase access to and utilization of quality FP services
which are safe, effective and acceptable to individuals and
couples.
(Special focus is given to increasing access to services in places
where the rural, poor, Dalit, other marginalized people and
those with high unmet need live.)
• To create an enabling environment for increasing access to
quality family planning services to men and women.
• To increase demand of family planning services by
implementing various behavior change communication
activities.

9. SCOPE OF FAMILY PLANNING
• Proper spacing and limitation of births
• Advice on sterility
• Education for parenthood
• Sex education
• Screening for pathological conditions related to
reproductive system
• Genetic counseling

10. SCOPE OF FAMILY PLANNING
• Premarital consultation and examination
• Carrying out pregnancy tests
• Preparation of couples for the arrival of their first child
• Providing services for unmarried mothers
• Teaching home economics and nutrition
• Providing adoption services

11. NEED FOR CHILD SPACING AND
FERTILITY CONTROL

12. • Family planning can reduce unmet need for
contraceptives and unintended pregnancy
which ultimately helps to:
- improve maternal and child health
- empowers women
• Economic growth
• Improvement in quality of
life………………………………………

13. BENEFITS OF FAMILY PLANNING
• Preventing pregnancy-related health risks in women
• Reducing infant mortality
• Helping to prevent HIV/AIDS
• Empowering people and enhancing education
• Reducing adolescent pregnancies
• Slowing population growth

14. TERMINOLOGIES:
• Contraceptive prevalence rate (CPR):
= No. of women using a modern FP method at a
given point of time/ Married women of
reproductive age (MWRA) X 100

15. TERMINOLOGIES:
• Couple years of protection:
= estimated protection provided by FP services
during a year based upon the volume of all
contraceptives sold or distributed to client
during that period.
= quantity of each method X conversion factor

16. Conversion factor accepted by MoH &
Population are:
• VSC= 13 CYP
• Norplant= 5 CYP
• IUCD= 8 CYP
• 13 pills cycle= 1 CYP
• 4 doses of depo= 1 CYP
• 150 condoms= 1 CYP

17. TERMINOLOGIES:
• Modern contraceptive methods:
= require supplies or clinical services including
- Male and female sterilization
- IUDs, Implants
- Injections, pills, male condoms
- spermicides and female condoms

18. TERMINOLOGIES:
• Current users: no of women or partner who
are estimated be using contraception method at
given point of time, that can be reported by
type of method, region, source or other
relevant variables
• Demand of FP: Desire of women or couple to
control future fertility ( Demand for limiting
and demand for spacing)

19. TERMINOLOGIES:
• Method mix: % distribution of contraception
users by method.
• Unmet need: Sexually active women not using
contraception but either desire no more
children or postpone next birth for at least 2
yrs

21. Added Targets and indicators related to
FP
• Target 5b: Achieve universal access to
reproductive health
- 5.3 CPR
- 5.4 Adolescent birth rate
- 5.5 Antenatal care coverage
- 5.6 Unmet need for family planning

22. Milestone in FP program in Nepal
• 1959: Family Planning Association of Nepal (FPAN)
established
• 1991: Developed first National Medical Standard on FP
• 1994: Family health division established under MoH
incorporated into national FP program
• 1997: Published first FP policy
• 1998: Published national RH strategy
• 2012: Published national FP strategy

23. National family planning strategy 2012
• Targets:
- Reduce TFR to 2.5 per women by 2015
- Increase CPR of all methods to 67% by 2015

24. FAMILY PLANNING BY GoN
• It is also considered as a component of reproductive
health package and essential health care services of :
Nepal Health Sector Program II (2010-2015)
National Family Planning Costed Implementation
Plan 2015-2021
Nepal Health Sector Strategy 2015-2020 (NHSS)
Government of Nepal’s commitments to FP2020.

25. FP STRATEGIES
• Increase access and availability of FP services:
- Expand IUCD and implant in all PHCs and HPs.
- Regular VSC round year in district hospitals and
selected PHCs
- VSC mobile outreach clinic
- Satellite clinic to expand long acting FP

26. FP STRATEGIES…
• Encourage FCHV in periphery
• Integration of FP with other health services
• Capacity development, trainings
• Public private partnership

27. FP STRATEGIES…
• Strengthen LMS
• Male participation in FP
• Effective multi behavioral change
communication
• Focussed FP program to meet unmet need

28. FP delivery system in Nepal
• Ward level: FCHV (condoms, OCP)
• PHC/ORC clinic: MCHW/VHW ( condoms, pills,
depo)
• HP/SHP: ANM, HA… ( all+ IUCD, Implant)
• PHC: MO… ( all + vasectomy)
• District hospital : All FP services and management of
complications

29. FP INDICATORS
• Total fertility rate

30. FP INDICATORS
• Contraceptive Prevalence Rate, Modern Methods
(mCPR)
•

31. FP INDICATORS
• Unmet need
• Demand satisfied for modern
contraception
• Adolescent use of contraceptive

32. FP INDICATORS
• Contraceptive method mix

33. FP INDICATORS
• Availability of contraceptive services

34. CURRENT STATUS IN FP IN
NEPAL
• Total Fertility Rate :
Currently, women in Nepal have an average of
2.3 children.
Since 1996, fertility has decreased from 4.6
children per woman to the current level.
This demonstrates a decline of 2.3 children
within two decades.

36. OTHER RELATED STATUS
• The median age at first marriage for women
age 25- 49 is 17.9 years, compared to 21.7
years among men age 25-49.
• Women with no education marry 4.6 years
earlier than women with SLC and above
education (16.8 years versus 21.4 years).
• More than half (52%) of women are married
by age 18, compared to 1 in 5 men (19%).

37. OTHER RELATED STATUS
• In Nepal, 17% of adolescent women age 15-
19 are already mothers or pregnant with their
first child.
• Teenage fertility is higher in rural areas
(22%) than in urban areas (13%).
• Teenage pregnancy decreases with increased
education.

38. CURRENT USE OF FP
• More than half (53%) of married women age 15-
49 use any method of family planning.
• 43% use a modern method and 10% use a
traditional method.
• Female sterilization is the most popular modern
method (15%), followed by injectables (9%),
male sterilization (6%), the pill (5%), male
condom (4%), implants (3%), and the IUD (1%).

40. DEMAND FOR FAMILY PLANNING
(One who want to delay or stop
childbearing)
• Fifteen percent of married women want to delay childbearing
(delay first birth or space another birth) for at least two years.
• Additionally, 61% of married women do not want any more
children.
• The total demand for family planning among married women in
Nepal is 76%.
• The total demand for family planning includes both met and unmet
need.
• Met need is the contraceptive prevalence rate.
• In Nepal, 53% of married women use any family planning method.

41. UNMET NEED FOR FP
• Unmet need for family planning is defined as the
proportion of married women who want to delay or
stop childbearing but are not using family planning.
• One in four married women in Nepal have an unmet
need for family planning: 8% want to delay
childbearing, while 16% want to stop childbearing.
(Sustainable Development Goal (SDG) target for 2017 of
reducing the unmet need for family planning to less
than 22%.)

43. METHODS OF FAMILY
PLANNING
A. SPACING METHODS
1. Barrier methods
a. Physical methods
b. Chemical methods
c. Combined methods
2. Intra-uterine devices
3. Hormonal methods
4. Post-conceptional methods
5. Miscellaneous
B. TERMINAL METHODS
1. Male sterilization
2. Female sterilization

44. The Ideal Method Should Be
• Safe
• 100% effective
• Free of side effects
• Easily obtainable
• Affordable
• Acceptable to the user & sexual partner
• Free of effects on future pregnancies

45. Concerned question to be asked??
• Do you have children? Do you want (more)
children in the future?
• Do you want to prevent pregnancy now?
• Are you using a family planning method now?
• Have you used a family planning method before?
• Is there a method you would like to use? What is
it about that method that you like?

46. Concerned question to be asked??
• Are you or your partner breastfeeding an infant less
than 6 months old?
• Do you want to keep your method private from partner
or parents?
• Have you talked to your partner about using family
planning? Will he or she be helpful and supportive?
• Are you concerned about STIs or HIV/AIDS?
• Do you have any health problems?

51. Male condom
• Condom is the most widely known and used barrier ie
by the males around the world .
• It is a thin rubber sheath which is rolled over the erect
penis before having sex prevents entry of semen into
the vagina
• It must be held carefully when taking out the penis
from the vagina to prevent spilling of semen.
• It is available free of cost from urban to rural family
welfare centers.

52. Advantages
• They are easily available
• Safe and inexpensive
• Easy to use; do not require medical supervision
• No side effects
• Light, compact and disposable
• Provides protection not only against pregnancy but also
against STD

53. Disadvantages
• It may slip off or tear during coitus due to
incorrect use
• Interferes with sex sensation locally about which
some complain while others get used to it.
•
• The main limitation of condoms is that many men
do not use them regularly or carefully, even
when the risk of unwanted pregnancy or sexually
transmitted disease is high.

54. MODERN CONTRACEPTIVE
METHODS
Method Description
How it
works
Effectivene
ss to
prevent
pregnancy
Male
condoms
Sheaths or
coverings
that fit over
a man's
erect penis
Forms a
barrier to
prevent
sperm and
egg from
meeting
98% with
correct and
consistent
use
Also
protects
against
sexually
transmitted
infections,
including
HIV

57. Reality  : The Female Condom
The female condom is a lubricated polyurethane sheath, similar in appearance to a male condom. It is inserted into the
vagina. The closed end covers the cervix. Like the male condom, it is intended for one-time use and then discarded.
The sponge is inserted by the woman into the vagina and covers the cervix blocking sperm from entering the cervix.
The sponge also contains a spermicide that kills sperm. It is available without a prescription.

58. MODERN CONTRACEPTIVE
METHODS
Method Description How it works
Effectiveness to
prevent
pregnancy
Female condoms
Sheaths, or
linings, that fit
loosely inside a
woman's
vagina, made of
thin,
transparent,
soft plastic film
Forms a
barrier to
prevent sperm
and egg from
meeting
90% with
correct and
consistent use
Also protects
against sexually
transmitted
infections,
including HIV

60. Diaphragm
• The diaphragm is a vaginal barrier. Also known as "Dutch
cap", the diaphragm is a shallow cup made of synthetic
rubber or plastic material.
• It ranges in diameter from 5-10 cm (2-4 inches).
• It has a flexible rim made of spring or metal.
• It is important that a woman be fitted with a diaphragm of
the proper size.
• This means, for successful use, the vaginal tone must be
reasonable. Otherwise, in the case of a severe degree of
cystocele, the rim may slip down.

61. Diaphragm…
• The diaphragm is inserted before sexual intercourse and
must remain in place for not less than 6 hours after
sexual intercourse.
• A spermicidal jelly is always used along with the
diaphragm.
• The diaphragm holds the spermicide over the cervix.
• Failure rate for the diaphragm with spermicide vary
between 6 to 12 per 100 women.

62. DIAPHRAGM
The diaphragm is a flexible rubber cup that is filled with
spermicide and self-inserted over the cervix prior to
intercourse. The device is left in place several hours after
intercourse. The diaphragm is a prescribed device fitted by a
health care professional and is more expensive than other
barrier methods, such as condoms

63. Advantages
• The primary advantage of the diaphragm is the
almost total absence of risks and medical
contraindications.

64. Disadvantages
• Initially physician or other trained person will be needed
to demonstrate the technique of inserting the diaphragm into
the vagina and to ensure a proper fit.
• After delivery, it can be used only after involution of the
uterus is completed
• Practice at insertion, privacy for this to be carried out and
facilities for washing and storing.
• If the diaphragm is left in the vagina for an extended period,
there is a remote possibility of a toxic shock syndrome,
which is a state of peripheral shock requiring resuscitation

67. Cervical Cap
The cervical cap is a flexible rubber cup-like device that is filled with
spermicide and self-inserted over the cervix prior to intercourse. The device
is left in place several hours after intercourse. The cap is a prescribed device
fitted by a health care professional and can be more expensive than other
barrier methods, such as condoms.

69. Vaginal sponge
• It is the sponge soaked in vinegar or olive oil, but it is
recently one has been commercially marketed in USA under
the trade name TODAY for the sole purpose of preventing
conception.
• It is a small polyurethane foam sponge measuring: 5 cm x
2.5 cm, saturated with the spermicide, nonoxynol-9.
• The sponge is far less effective than the diaphragm, but it is
better than nothing .
• The failure rate in parous women is between 20 to 40 per
100 women-years and in nulliparous women about 9 to 20
per 100 women-years .

70. CHEMICAL METHODS

72. CHEMICAL METHODS
• In the 1960s, before the advent of IUDs contraceptives,
spermicides (vaginal chemical contraceptives were
used widely. They comprise four categories :
a) Foams : foam tablets, foam aerosols
b) Creams, jellies and pastes - squeezed from a tube
c) Suppositories - inserted manually
d) Soluble films - C-film inserted manually

75. How it works???
• The commonly used modern spermicides are
"surface-active agents" which attach
themselves to spermatozoa and inhibit
oxygen uptake and kill sperms.

76. Disadvantages
• They have a high failure rate
• They must be used almost immediately before
intercourse and repeated before each sex act
• They must be introduced into those regions of the
vagina where sperms are likely to be deposited
• They may cause burning or irritation, besides,
messiness.

77. INTRAUTERINE DEVICES
• There are two
basic types of
IUD : non-
medicated and
medicated.
• Both are
usually made
of
polyethylene
or other
polymers.

79. IUD…
• The non-medicated or inert IUDs are often referred to
as first generation IUDs.
• The copper IUDs comprise the second
• The hormone-releasing IUDs the third generation
IUDs.
• The medicated IUDs were developed to reduce the
incidence of side-effects and to increase the
contraceptive effectiveness but more expensive and
must be changed after a certain time to maintain their
effectiveness.

81. FIRST GENERATION IUD:
LIPPLES LOOP
• Lippes Loop is double-S shaped device made of
polyethylene, a plastic material that is non-toxic, non-
tissue reactive and extremely durable.
• It contains a small amount of barium sulphate to allow
X-ray observation.
• The Loop has attached threads or "tail" made of fine
nylon, which project into the vagina after insertion.
• The tail can be easily felt and is a reassurance to the
user that the Loop is in its place.

83. FIRST GENERATION IUD:
LIPPLES LOOP…
• The tail also makes it easy to remove the Loop when
desired.
• The Lippes Loop exists in four sizes A,B,C, and D, the
latter being the largest.
• A larger sized device usually has a greater anti-
fertility effect and a lower expulsion rate but a higher
removal rate because of side-effects such as pain and
bleeding.
• The larger Loops (C and D) are more suitable for
multiparous women.

84. SECOND GENERATION IUDS
• Earlier devices .
- Copper -
- Copper 1 7 -200
• Newer devices :
- Variants of the T device
(i) TCu-220C
(ii) TCu-380Aor
- NovaT
- Multiload devices
(i) ML-Cu-250
(ii) ML-Cu-375

86. Advantages of copper devices:
• Low expulsion rate
• Lower incidence of side-effects, e.g., pain and
bleeding
• Easier to fit even in nulliparous women
• Better tolerated by nullipara
• Increased contraceptive effectiveness
• Effective as post-coital contraceptives, if inserted
within 3-5 days of unprotected-intercourse

87. THIRD GENERATION IUDS
• Based on still another principle, i.e., release of a
hormone - have become available on a limited scale.
• The most widely used hormonal device is
progestasert, which is a T-shaped device filled with
38 mg of progesterone, the natural hormone.

88. THIRD GENERATION IUDS…
• The hormone is released slowly in the uterus at
the rate of 65 mcg daily.
• It has a direct local effect on the uterine lining,
on the cervial mucus and possibly on the
sperms.
• Because the hormone supply is gradually
depleted, regular replacement of the device is
necessary.

89. MOA OF IUDS
• IUD causes a foreign-body reaction in the
uterus causing cellular and biochemical
changes in the endometrium and uterus.
• It is believed that these changes impair the
viability to the gamete and thus reduce its
chances of fertilization, rather than its
implantation.

92. Advantages:
• Simplicity, i.e.. no complex procedures are involved
in insertion: no hospitalization is required
• Insertion takes only a few minutes
• Once inserted IUD stays in place as long as required
• Inexpensive
• Contraceptive effect is reversible by removal of IUD

93. Advantages…:
• Virtually free of systemic metabolic side-
effects associated with hormonal pills
• Highest continuation rate
• There is no need for the continual motivation
required to take a pill daily or to use a barrier
method consistently; only a single act of
motivation is required

94. Contraindication: Absolute
• Suspected pregnancy
• Pelvic inflammatory disease
• Vaginal bleeding of undiagnosed aetiology
• Cancer of the cervix, uterus or adnexia and other
pelvic tumours
• Previous ectopic pregnancy

95. Contraindication: Relative
• Anaemia
• Menorrhagia
• History of PID since last pregnancy
• Purulent cervical discharge
• Distortions of the uterine cavity due to congenital
malformations, fibroids
• Unmotivated person

96. The ideal IUD candidate
- Who has borne at least one child
- Has no history of pelvic disease
- Has normal menstrual periods
- Is willing to check the IUD tail
- Has access to follow-up and treatment of potential
problems
- Is in a monogamous relationship.

97. Timing of insertion
• Almost anytime during a woman's
reproductive years (except during pregnancy)
• During menstruation or within 10 days of the
beginning of a menstrual period
• During the first week after delivery before
the woman leaves the hospital

98. Side effects and complication
• Bleeding
• Pain
• Pelvic infection
• Uterine perforation
• Ectopic pregnancy
• Expulsion
• Cancer and teratogenesis

99. HORMONAL
CONTRACEPTIVES

100. Types
A. Oral pills
1. Combined pill
2. Progestogen only pill (POP)
3. Post-coital pill
4. Once-a-month (long-acting) pill
5. Male pill
B. Depot (slow release) formulations
1. Injectables
2. Subcutaneous implants
3. Vaginal rings

102. 1. ORAL PILLS: COMBINED
• It contain no more than 30-35 mcg of a
synthetic oestrogen, and 0.5 to 1.0 mg of a
progestogen.
• The pill should be taken everyday at a fixed
time, preferably before going to bed at night.

103. 1. ORAL PILLS: COMBINED…
• The first course should be started strictly on
the 5th day of the menstrual period, as any
deviation in this respect may not prevent
pregnancy.
• If the user forgets to take a pill, she should
take it as soon as she remembers, and that she
should take the next day's pill at the usual
time.

104. 2. PROGESTOGEN-ONLY PILL
(POP)
• This pill is commonly referred to as
"minipiH" or "micropiH".
• It contains only progestogen, which is given
in small doses throughout the cycle.
• The commonly used progestogens are
norethisterone and levonorgestrel.

106. 2. PROGESTOGEN-ONLY PILL
(POP)…
• The progestogen-only pills never gained
widespread use because of poor cycle control
and an increased pregnancy rate.

107. 2. PROGESTOGEN-ONLY PILL
(POP)…
• However, could be prescribed to older
women for whom the combined pill is
contraindicated because of cardiovascular
risks.
• They may also be considered in young women
with risk factors for neoplasia.

108. 3.POST-COITAL
CONTRACEPTION
• It is recommended within 72 hours of an
unprotected intercourse. Two methods are
available :
(a) IUD : The simplest technique is to insert an
IUD. if acceptable, especially a copper device
within 5 days.
(b) Hormonal : More often a hormonal
method may be preferable. '

109. 3.POST-COITAL CONTRACEPTION…
• One tablet of 0.75 mg levonorgesterol within
72 hours of unprotected sex and the 2nd
tablet after 12 hours of 1st dose.
• Two oral contraceptive pills containing 50
meg of ethinyl estradiol within 72 hours after
intercourse, and the same dose after 12 hours.

110. 3.POST-COITAL CONTRACEPTION…
• Four oral contraceptive pills containing 30 or
35 meg of ethinyl estradiol within 72 hours
and 4 tablets after 12 hours.
• Mifepristone 10 mg once within 72 hours.

112. 4. ONCE-A-MONTH (LONG-
ACTING) PILL
• Quinestrol, a long-acting oestrogen is given
in combination with a short-acting
progestogen, have been disappointing .
• The pregnancy rate is too high to be
acceptable.
• In addition, bleeding tends to be irregular.

114. 5. MALE PILL
• Preventing spermatogenesis
• Interfering with sperm storage and
maturation
• Preventing sperm transport in the vas, and
• Affecting constituents of the seminal fluid.

115. MOA OF ORAL PILLS
• Prevent the release of the ovum from the ovary.
• This is achieved by blocking the pituitary secretion of
gonadotropin that is necessary for ovulation to occur.
• Progestogen-only preparations render the cervical
mucus thick and scanty and thereby inhibit sperm
penetration.
• Progestogens also inhibit tubal motility and delay the
transport of the sperm and of the ovum to the uterine
cavity

116. Effectiveness
• Taken according to the prescribed regimen,
oral contraceptives of the combined type are
almost 100 per cent effective in preventing
pregnancy

117. Adverse effects
• Cardiovascular effects
• Carcinogenesis
• Metabolic effects
• Other effects as liver disorders, ectopic
pregnancies etc

118. Contraindication:
• Absolute: Ca of breast and genitalia, liver
disease
• Special problems requiring medical
surveillance : Age over 40 years; smoking;
mild hypertension; chronic renal disease;
epilepsy; migraine; nursing mothers in the
first 6 months; diabetes mellitus; history of
infrequent bleeding, amenorrhoea, etc.

119. DEPOT FORMULATIONS
• Injectable contraceptives:
- DMPA (Depot-medrooxyprogesterone acetate)
- NET-EN
- DMPA-SC

121. DMPA
• Standard dose is an intramuscular injection of 150
mg every 3 months.
• It gives protection from pregnancy in 99 per cent
of women for at least 3 months.
• It exerts its contraceptive effect primarily by
suppression of ovulation.
• Also has an indirect effect on the endometrium
and direct action on the fallopian tubes and on
the production of cervical mucus.

122. DMPA…
• Safe, effective and acceptable
• It does not affect lactation.
• Acceptable during the postpartum
period as a means of spacing
pregnancies.

123. DMPA…
• Side-effects :
Weigh increase
Irregular menstrual bleeding
Prolonged infertility after its use

125. (Norethisterone enantate )NET-EN
• It is given intramuscularly in a dose of 200
mg every 60 days.
• Contraceptive action to include inhibition of
ovulation, and progestogenic on cervical
mucus.
• Failure rate has been reported as compared to
DMPA.

126. • The initial injection of both DMPA and NET-EN
should be given during the first 5 days of the
menstrual period.
• Given by deep intramuscular injection into the
gluteus maximus.
• Injection site should never be massaged following
injections.

128. DMPA-SC 104 mg (85)
• It is injected under the skin rather than in the
muscle. It contains 104 mg of DMPA rather than
the 150 mg in the intramuscular formulation.
• Like the intramuscular formulation, DMPA-SC is
given at 3-month intervals.
• Patterns of bleeding changes and amount of
weight gain are similar.
• Given in the upper thigh or abdomen.

129. SIDE EFFECTS:
• Both DMPA and NET-EN have similar side
effects
• Unpredictable bleeding
• Amenorrhoea

130. CONTRAINDICATION
• Cancer of the breast
• All genital cancers
• Abnormal uterine bleeding
• Very high blood pressure systolic > 160 mm Hg or diastolic >
100)
• History of stroke or heart attack and current deep vein
thrombosis
• Woman breastfeeding a baby less than 6 weeks old should not
use progestin-only injectables

131. COMBINED INJECTABLE
CONTRACEPTIVES
• Contain a progestogen and an oestrogen
• Given at monthly intervals, plus or minus three days.
• Act mainly by suppression of ovulation. The cervical
mucus is affected, mainly by progestogen, and
becomes an obstacle to sperm penetration.
• Changes are also produced in endometrium which
makes it unfavourable for implantation if fertilization
occurs, which is extremely unlikely.
.

132. COMBINED INJECTABLE
CONTRACEPTIVES …
.
• The contraindications are :
Confirmed or suspected pregnancy
Thromboembolic disorders
Cerebrovascular or coronary artery disease
Diabetes with vascular complications.
• Combined injectables are not suitable for
women who are fully breast feeding until 6
months post -partum.

133. SUBDERMAL IMPLANTS
• Norplant for long-term contraception. It consists
of 6 silastic (silicone rubber) capsules containing
35 mg (each) of levonorgestrel .
• More recent devices comprise fabrication of
levonorgestrel into 2 small rods, Norplant (R)-2,
which are comparatively easier to insert and
remove.
• The silastic capsules or rods are implanted
beneath the skin of the forearm or upper arm.

138. SUBDERMAL IMPLANTS…
• Effective contraception is provided for over 5
years.
• The contraceptive effect of Norplant/ Implant is
reversible on removal of capsules.
• The main disadvantages are irregularities of
menstrual bleeding and surgical procedures
necessary to insert and remove implants.

141. VAGINAL RINGS
• Contains levonorgestrel
• Slowly absorbed through the vaginal mucosa,
permitting most of it to bypass the digestive
system and liver, and allowing a potentially
lower dose.
• The ring is worn in the vagina for 3 weeks of
the cycle and removed for the fourth

142. MISCELLANEOUS
1. Abstinence
2. Coitus interrupts
3. Safe period (rhythm method)
4. Natural method
5. Breast feeding
6. Birth control vaccine

143. 1. ABSTINENCE
• Sound in theory only
• Repression of a natural force
• May show temperamental changes and even
nervous breakdown.
• Hardly be considered as a method of
contraception to be advocated to the masses.

144. Coitus interrupts

145. 2. COITUS INTERRUPTS
• Male withdraws before ejaculation
• Prevent deposition of semen into the vagina.
• Some find it difficult to manage.
• Precoital secretion of the male may contain
sperm, and even a drop of semen is sufficient to
cause pregnancy

146. Coitus….
• Failure rate with this method may be as high
as 25 per cent.
• It is better than using no family planning
method at all.

149. 3.SAFE PERIOD (RHYTHM
METHOD)
• This is also known as the "calendar method"
first described by Ogino in 1930.
• The method is based on the fact that ovulation
occurs from 12 to 16 days before the onset of
menstruation .
• The days on which conception is likely to
occur are calculated as follows :

150. • The shortest cycle - 18 days = first day of the
fertile period.
• The longest cycle - 10 days =last day of the
fertile period.
• For example, if a woman's menstrual cycle varies
from 26 to 31 days, the fertile period during
which she should not have intercourse would be
from the 8th day to the 21st day of the menstrual
cycle.

151. .
• The drawbacks of the calendar method are :
(a) Irregular menstruation
(b) Possible for educated and responsible couples
(c) "programmed sex“ required
(d) Not applicable during the postnatal period
(e) High failure rate of 9 per 100 due to wrong
calculations, inability to follow calculations, irregular
use and "taking chances".

152. 4.NATURAL FP METHOD
• Basal body temperature method
• Cervical mucus method
• Symptothermic method

153. BBT
• Rise of BBT at the time of ovulation, as a
result of an increase in the production of
progesterone.
• The rise of temperature is very small, 0.3 to
0.5 degree C.
• Temperature is measured preferably before
getting out of bed in the morning.

156. BBT
• Reliable if intercourse is restricted to the post-
ovulatory infertile period, commencing 3 days
after the ovulatory temperature rise and
continuing up to the beginning of menstruation.
• The major drawback of this method is that
abstinence is necessary for the entire
preovulatory period. Therefore, few couples
now use the temperature method alone

157. CERVICAL MUCUS METHOD
• This is also known as "billings method" or "ovulation
method".
• This method is based on the observation of changes in the
characteristics of cervical mucus.
• At the time of ovulation, cervical mucus becomes watery
clear resembling raw egg white, smooth, slippery and
profuse.
• After ovulation, under the influence of progesterone, the
mucus thickens and lessens in quantity

159. CERVICAL MUCUS METHOD
• Use a tissue paper to wipe the inside of vagina to assess the
quantity and characteristics of mucus.
• To practice this method the woman should be able to
distinguish between different types of mucus.
• This method requires a high degree of motivation than most
other methods.

160. SYMPTOTHERMIC METHOD
• This method combines the temperature,
cervical mucus and calendar techniques for
identifying the fertile period.
• If the woman cannot clearly interpret one sign,
she can "double check" her interpretation with
another.
• Therefore, this method is more effective than the
"Billings method".

161. 5. BREAST-FEEDING
• Field and laboratory investigations have confirmed the
traditional belief that lactation prolongs post part
amenorrhoea and provides some degree of protection
against pregnancy .
• No more than 5-10 per cent of women conceive during
lactational amenorrhoea, and even this risk exists only
during the month preceding the resumption of menstruation
.
• However, once menstruation returns continued lactation
no longer offers any protection against pregnancy

163. 6. BIRTH CONTROL VACCINE
• The most advanced research involves immunization with a vaccine
prepared from beta sub-unit : I human chorionic gonadotropin
(hCG), a hormone produced in early pregnancy.
• Immunization with hCG would block continuation of the
pregnancy.
• Antibodies appeared in about 4-6 weeks and reached maximum
after about 5 months and slowly declined reaching zero levels
after a period ranging from 6-11 months.
• The immunity can be boosted by a second injection.
• Two types of pregnancy vaccines employing variants of the beta
sub-unit of hCG are now about to go into in trial.

164. TERMINAL METHODS

165. VSC: INTRODUCTION
• VSC includes female and male sterilization
procedures that are intended to provide
permanent contraception.
• As such, special care must be taken to ensure
that every client makes a voluntary, informed
choice of the method.

166. • Particular attention must be given to counseling
in the case of
– young people,
– nulliparous women,
– men who are not yet fathers,
– clients with mental health problems,
including depressive conditions.

167. VSC….
• All clients must be carefully counseled about :
Intended permanence of the sterilization
Availability of alternative, long-term, highly
effective methods.

169. MALE STERILIZATION
• Single operation can be performed even in
primary health centres by trained doctors
under local anaesthesia.
• When carried out under strict aseptic
technique, it should have no risk of mortality.
• In vasectomy, it is customary to remove a
piece of vas at least 1 cm after clamping.

170. DEFINITION
• Surgical process of cutting the vas deferens in
order to stop the sperm from mixing with
semen, so that the semen is ejaculated
without sperm.
• Performed under a local anaesthesia
• Not synonymous with castration and does
not affect sexual ability.

171. DEFINITION...
• Has a failure rate of less than 1% in most
studies.
• Vasectomy does not become effective
immediately. It is important that clients use
condoms or another FP method for 3 months/
30 ejaculations after the operation to be
completely safe.

172. TECHNIQUES
• Scalpel vasectomy
• Non-scalpel vasectomy

173. Scalpel method…
• The ends are ligated and then folded back on
themselves and sutured into position, so that the
cut ends face away from each other.
• This will reduce the risk of recanalisation at a
later date.
• It is important to stress that the acceptor is not
immediately sterile after the operation, usually
until approximately 30 ejaculations have taken
place

179. Vasectomy for Men
• Simple surgical procedure
• Usually cannot be reversed.
• “Please consider carefully: Might you want more children in future?
What if you could no longer father children?”
• Ask about partner’s preferences or concerns.
• Can also consider female sterilization. Vasectomy is simpler and
safer to perform and slightly more effective.
• One of the most effective family planning methods.
• Not effective immediately. Must use condoms or partner must use
an effective method for 3 months after. “Would this be difficult?”
• For STI/HIV/AIDS protection, also use condoms.
“Would you like to know more about vasectomy, or talk about a different method?”
If client wants to know more about vasectomy,
go to next page.
Next Move:
• Check for concerns, rumours:
“What have you heard about vasectomy?”
Explain common myths:
• NOT castration. Can still have erections. Can still ejaculate.
• Does NOT affect masculinity. Does NOT make men more feminine.
V1
• Permanent. For men who
will not want more children.
• Very effective
• Very safe
• No effect on sexual ability
• No protection against STIs or
HIV/AIDS
About vasectomy:
• Works by keeping sperm out of semen. Tubes that carry sperm are
cut.
• During procedure man stays awake and gets injection to prevent
pain (local anaesthetic).
• Usually can go home in a few hours.
• May hurt for a few days.
Vasectomy
To discuss another method, go to a new
method tab or to Choosing Method tab.

180. When you can have vasectomy
But may need to wait if:
• Any problems with genitals such as
infection, swelling, injuries, lumps in
penis or scrotum
• Some other serious conditions or
infections
Most men can have
vasectomy at any time

181. Before you decide
Let’s discuss:
• Temporary methods are also available
• Vasectomy is a surgical procedure
• Has risks and benefits
• Prevents having any more children
• Permanent—decision should be
carefully considered
• You can decide against
procedure any time before surgery
Are you ready to choose this
method?
Want to know more about
the procedure?

182. The procedure
1. You will stay awake and get medication to
stop pain
2. Small opening made in scrotum
— not painful
3. Tubes that carry sperm are cut and tied
4. The opening is closed
5. Rest 15 to 30 minutes
What questions
do you have?
or 1 opening made here
Either 2
openings made
here
Afterwards:
• You should rest for 2 days
• Avoid heavy work for a few days
• Important! Use condoms for
next 3 months

183. Medical reasons to return
Come at once if:
•Swelling in first few hours after
surgery
•Fever in first 3 days
•Pus or bleeding from wound
•Pain, heat, redness of wound

184. Female Sterilization
• A surgical procedure
About female sterilization:
• Fallopian tubes that carry eggs to the womb are blocked or cut
and sealed (womb is left untouched).
• May hurt for a few days after.
• Usually woman not put to sleep but gets injection to prevent pain.
• Usually can go home in a few hours.
• Usually cannot be reversed.
• “Please consider carefully: might you want children in the
future?”
• Ask about partner’s preferences or concerns.
• Vasectomy might be another good choice. Vasectomy is simpler
and safer to perform and slightly more effective.
• One of the most effective family planning methods for women.
• Very rarely, pregnancy does occur.
• For STI/HIV/AIDS protection, also use condoms.
• Serious complications of surgery are rare (risk of anaesthesia,
need for further surgery).
“Do you want to know more about sterilization, or talk about a different method?”
If client wants to know more about
sterilization, go to next page.
Next Move:
• Permanent—for women who
will not want more children
• Very effective
• No long-term side-effects
• No protection against STIs
or HIV/AIDS
• Very safe
• Check for concerns, rumours:
“What have you heard about problems with sterilization?”
Use Appendix 10 to talk about myths about contraception.
• Explain that all women can have sterilization if they want, even
those with no children.
• Womb is NOT removed.
You will still have menstrual periods.
S1
Female
Sterilization
To discuss another method, go to a
new method tab or to Choosing
Method tab.

185. When you can have sterilization
But may need to wait if:
Most women can have
sterilization at any time
• May be
pregnant
• Gave birth
between 1 and 6
weeks ago
• Infection or
other problem in
female organs
• Some other
serious health
conditions

186. Before you decide
Let’s discuss:
• Temporary methods are also available
• Sterilization is a surgical procedure
• Has risks and benefits
• Prevents having any more children
• Permanent—decision should be carefully
considered
• You can decide against procedure
any time before surgery Are you ready to choose
this method?
Want to know more about
the procedure?

187. The procedure
1. Medication helps you keep calm and
helps prevent pain
2. You stay awake
3. Small cut is made — not painful
4. Tubes are blocked or cut
5. Opening closed with stitches
6. Rest a few hours
What questions
do you have?
Small cut either
here
or
here
Afterwards:
• You should rest for 2 or 3 days
• Avoid heavy lifting for a week
• No sex for at least 1 week

188. Methods of Female Sterilization
Interval
• Laparoscopic
– Electrocoagulation
(Mono and Bi -Polar)
– Falope Ring
– Hulka Clip
– Filshie Tubal Ligation
System
• Hysteroscopy
– Essure
– Adiana
Post Partum/ Labor & Delivery
• Pomeroy
• Parkland
• Irving
• Uchida
• Filshie Tubal Ligation System

189. Procedure Timing Technique
Minilaparotomy • Post Partum
• Post Abortion
• Interval
• Mechanical Devices (Clips,
Rings)
• Tubal Ligation or Excision
Laparoscopy • Interval Only • Electrocoagulation
(Unipolar, Bipolar)
• Mechanical Devices (Clips,
Rings)
Laparotomy In conjunction with other
surgery (Cesarean section,
salpingectomy, ovarian
cystectomy, etc.)
• Mechanical Devices (Clips,
Rings)
• Tubal Ligation or Excision
Methods of Female Sterilization

190. Methods of Female Sterilization
Laparoscopic
• Complications
• Bowel Burn
• Bleeding
• Longer portion
of tube is
damaged
• Failures and
ectopic
pregnancy
• Transection is
frequent
Failure Rate: 7.5/1000 (.07-.75%)1
Monopolar Coagulation

191. Methods of Female Sterilization
Laparoscopic
• Introduced in 1973 by Jacques
Rioux
Benefits
• Most common method of
laparoscopic sterilization
• Burn several locations along the
tube
Complications
• Formation of uteroperitoneal
fistulas
• High rate of ectopic pregnancy
• Potential for bowel burns
• Reversals are potentially more
difficult due to the extent of tube
damage
1
Failure Rate:
24.8/10001 (.2-2.5%)
Bipolar Coagulation

192. Methods of Female Sterilization
Destruction of the Entire Fallopian Tube: “Three Burn” Technique

193. Methods of Female Sterilization
Laparoscopic
• Tubal occlusion accomplished
by placing a silicone band
around the tube in a similar
fashion to Pomeroy-technique
• Thicker tubes may be
problematic
• May not be suited for
postpartum
Complications
• Increased patient discomfort
during recovery – large area of
necrosis
Falope Ring (Yoon band)
Failure Rate: 17.7/10001 (1.8%)

194. Methods of Female Sterilization
Falope Ring/Yoon Band

195. Methods of Female Sterilization
Laparoscopic
• Tubal occlusion is
accomplished by placing
a spring clip (plastic
and gold plate) across
the fallopian tube
• Hulka clip has limited
tubal capacity
• Not magnetically inert
• Potential patient allergy
due to gold plate
Failure rates 36.5/1000 (3.7%) (Ectopic 8.5/1000)1
Hulka Clip

196. Methods of Female Sterilization
Hulka Clip

197. Methods of Female Sterilization
Hulka Clip

198. Laparoscopic and Minilapararotomy
• Tubal occlusion accomplished by
placing a titanium hinge clip lined
with silicone rubber across the
fallopian tube
• Large tubal capacity
• Magnetically inert (okay for MRI)
• Minimal post operative pain
• Designed for use interval and post
partum (post vaginal birth and at
the time of C-section)
Methods of Female Sterilization
Filshie® Tubal Ligation System
Failure rate of 2.7/1,000 (.27%)1,2

199. Methods of Female Sterilization
Filshie® Clip – Laparoscopy

200. Methods of Female Sterilization
Filshie® Clip – Laparoscopy

201. Methods of Female Sterilization
Hysteroscopic (Hospital and Office-based
procedure)
– PET fibers stimulate in-growth over
several weeks
– 86% Success Rate for 1st time
placements of micro-
– 3 months of alternative contraception
until HSG procedure confirms occlusion
– Not suitable for patients with known
allergies to contrast media or
hypersensitivity to nickel
– Irreversible
• ACOG does not
recommend concomitant
endometrial ablation
Essure®
Failure rate .26%1
(5 year rate)

202. Methods of Female Sterilization
Hysteroscopic (Hospital
and Office-based
procedure)
– Approved in 2009
– Catheter delivers low RF
energy for one minute then a
3.5 mm non-absorbable
silicone elastomer matrix is
placed in each tubal lumen
– 3 months of alternative
contraception until HSG
procedure confirms occlusion
Adiana®
Failure rate 1.8%1
(2 year rate)

203. Postpartum
– Pomeroy
– Parkland
– Irving
– Uchida
– Filshie® Tubal Ligation System
Methods of Female Sterilization

204. Methods of Female Sterilization
Developed in 1930 by Ralph
Hayword Pomeroy
– Incision – suprapubic and
subumbilical (PP)
– Isthmic portion is ligated twice
with 0 or 2-0 plain catgut suture
– Segment is then excised
– Inspect for hemostasis and the
presence of the tubal lumen
Benefits
– Easy technique
– Highly effective
– Relatively inexpensive
(excluding lab costs for
pathology)
Complications
– Infection and bleeding
– Potential ectopic pregnancy
Pomeroy Technique
Tied
Cut
Final result
Failure Rate: 7.5/1000

205. Methods of Female Sterilization
Introduced in the 1900s
• Isthmic portion of tube is
segmented and ligated at two
points
• An avascular area in the
mesosalpinx is opened
• 0 or 2-0 plain catgut passed
through the opening
• Proximal and distal ligated
and segment excised
Parkland Technique
Failure rate not reported1

206. Methods of Female Sterilization
Benefits
• Designed to reduces
natural tube re-attachment
• Good success rates
• Few complications
• Inexpensive to perform (if
no pathology)
Complications
• Ectopic pregnancies,
infection, bleeding
• Time required to perform
procedure properly
Parkland Technique (continued)
Failure rate not reported1

207. Methods of Female Sterilization
Method published in 1924
• Was developed for sterilization
at C/S
• Bury the proximal tubal stump
within the myometrium
• Original description – distal
tube buried in the broad
ligament
Benefits
• Used in conjunction with
cesarean delivery
Complications
• Moderate level of difficulty to
perform
• Pomeroy and Parkland are
quicker
1. Sterilization. The University of Kentucky Department of OB-GYN Women’s Health Curriculum.
Irving Technique
Failure rate: 1/10001

208. Methods of Female Sterilization
Introduced by Hajime Uchida in the
1940s
• Most complex method
• Inject saline into the subserosal layer
2 cm distal to the cornua
• Incise serosa to free a 2 to 3 cm
segment
• Ligate proximal and distal end of
freed tube
• Proximal tube “dunked,” distal is
“exteriorized” and serosa is then
closed
Benefits
• Can be performed immediately
postpartum
Complications
• Moderate level of difficulty to
perform
• Pomeroy and Parkland are quicker
Failure rate: more than 20,000 cases
performed by Uchida personally without a
failure 1
Uchida Technique

209. Methods of Female Sterilization
Filshie® Tubal Ligation System
Failure rate range: 0-1.15% *

210. Methods of Female Sterilization
Filshie® Clip: Postpartum Sterilization (Mini-laparotomy)

211. Methods of Female Sterilization
Filshie® Clip: Postpartum Sterilization (Cesarean)

212. Methods of Female Sterilization
Postpartum: Filshie® in place

213. Other Considerations
• All surgical tubal occlusion
procedures are considered to be
permanent female sterilization
methods.
– Changes in lifestyles and life
situations among some women
has led to instances of regret
after sterilization regardless of
the method used.
• The application of the Filshie®
clip in tubal ligation results in
an avascular necrotic segment
of the fallopian tube of about 4
mm.
– The result is complete tubal
occlusion with minimal tubal
damage.
Reversibility

214. Medical reasons to return
In first week, come at once if:
At any time in the future, come at once if:
• High fever • Pus or
bleeding
from wound
• Pain, heat,
swelling,
redness of
wound
• Steady or
worsening
pain, cramps,
tenderness in
belly
• Fainting
or very
dizzy
• Pain or
tenderness
in belly, or
fainting
• You think
you may be
pregnant

215. The ABHIBADAN
Approach
The word "ABHIBADAB"
represents one step in
counseling. There are five
steps to remember:

216. STEP 1: “A”
“A” refers to
ABHIBADAN, i.e. to
Greet

217. STEP 2: "Bhi"
• STEP 2: "Bhi" refers to
"Bhina na thani sodpuch
garne," i.e. Asking without
discrimination

218. STEP 3: "Ba"
• STEP 3: "Ba" refers to
"Baadha hataune," i.e. To
deal with problems and
concerns

219. STEP 4: "D"
•STEP 4: "D" refers to
"Dutta Chitta bhai
sahyog garne," i.e. Help
Whole-Heartedly

220. STEP 5: "N"
• STEP 5: "N" refers to
"Namaskar gardai punnah
Auna Anurodh garne," i.e. Bid
Goodbye and request to come
again

221. Focus on the needs of the client
• Informed voluntary choice
• Empowerment
• Confidentiality
PRINCIPLE OF COUNSELING

222. 222
Informed choice
• Informed choice is the process used by an
individual to make his/her own decision about
family planning methods. Informed choice is
based on fully understanding the necessary and
complete information including risks/benefits,
potential side effects, mode of action, etc. An
informed choice must be made in a stress-free
environment and without pressure, coercion or
incentives from others.

223. 223
Principles of Informed Choice
• Clients have the right and ability to make their own
decisions
• Clients are individuals with different reproductive needs
and circumstances
• Decisions should be based on information about the risks
and benefits side effects of all available options
• Options must be available
• The information given must be reliable, timely and
understandable
• The decision must be made free of stress, pressure,
coercion or incentives

224. 224
Importance of Informed Choice
• Human right
• Medically ethical
• A part of reproductive health policies
• A part of providing quality services
• Improved client satisfaction
• More effective use of method
• Satisfied clients are the best “promoters”

225. 225
Informed Consent
• “It is important to keep in mind that
Informed Consent is not a signature,
but a process of communication and
interaction.
”Federation of International Gynecologist & Obstetrician
(FIGO,1996)

226. 226
Rights of the clients
• Right to information
• Right to Access
• Right of choice
• Right to safety
• Right to privacy
 Right to confidentiality
 Right to dignity
 Right to comfort
 Right to continuity
 Right to opinion