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Definitions
Family Planning: Purposeful decision to conceive or to not conceive
Contraception: Purposeful pregnancy prevention.
Birth control: Device or practice used to decrease the likelihood of pregnancy.
There is a wide assortment of birth control options available.
Women may choose to use different contraceptive methods at various stages throughout their fertile years. It is important for nurses to understand all aspects of the many birth control methods, including reliability, relative cost of the method, any protection from sexually transmitted infections (STIs), the individual’s comfort level with the method, and the partner’s willingness to use a particular birth control method. This video discusses these factors.
Contraception can be considered effective family planning and its increased use is one of the most important public health accomplishments in the 20th century. Despite this advancement in both efficacy and availability of contraception, almost half of all pregnancies in the US are not planned.
When considering contraceptive choices, any method’s failure rate, theoretical effectiveness rate, and typical effectiveness rate should be considered. Contraceptive failure rate is the percentage of contraceptive users expected to have an unplanned pregnancy during the first year of use. Contraceptive effectiveness is measured by the theoretic effectiveness which is the rate of efficacy with perfect use. On the other hand, the typical effectiveness is the rate of efficacy with typical use (i.e., nonperfect). The most effective contraceptive methods are the long-acting, reversible contraceptive (LARC) methods.
Global Health Media Project (2022, April 6). Comparing Contraceptive Methods: https://globalhealthmedia.org/videos/comparing-contraceptive-methods-hw-english/
Client Assessment: Client assessment is key to selecting the most appropriate method of birth control for any individual. Assessment of the client begins with the following:
Client knowledge and partner commitment
Sexual history including frequency of intercourse, number of partners, willingness to participate in the selected method, and partner consensus
Comfort with genital touching
Identification of religious and cultural factors
Clinical history and plans for future fertility
Informed Consent: Informed consent is always required. Select the tabs to learn each letter of the acronym BRAIDED, or the seven basic components of consent that a patient must be made aware of.
B: benefits
R: risks
A: alternatives
I: inquiries: chance to ask questions
D: decisions
E: explanations
D: documentation
The following are factors affecting contraceptive method effectiveness:
Frequency of intercourse
Motivation to prevent pregnancy
Understanding of how to use method
Adherence to method
Provision of short- or long-term protection
Likelihood of pregnancy for the individual woman
Contraceptive Effectiveness
Contraceptive Effectiveness
Abstinence is the only method of contraception that is 100% effective against pregnancy and infection with a sexually transmitted infection (STI or STD). Long Acting Reversible Contraception (LARCs), implants or intrauterine devices (IUDs) are considered as effective as sterilization of a man by vasectomy or a female by a tubal ligation since the risk of misuse is very low; these are considered 98-99% effective. Hormonal options such as the pill, shot, patch, and ring have the next highest level, but must be use appropriately to reach maximum effectiveness; these are considered about 90% effective. The least reliable method of birth control are the nonhormonal and barrier methods remain the least reliable method of contraception with varying degrees of effectiveness; diaphragms are most effective of these methods followed by male condoms, female condoms, coitus interruptus (withdrawal), sponges, fertility awareness methods, and spermicide. These methods are about 70-85% effective. Male and female condoms are the methods that also protect against STIs, so it is encouraged for women who are at risk for acquiring one to use them even if they are using another type of contraception for birth control.
Centers for Disease Control (2016). Effectiveness of Contraceptive Methods: https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/pdf/usspr_slideset_2016.pdf
Types of Contraception/ Birth Control
Types of Contraception/ Birth Control
Bedsider.org (2023). All Birth Control Options: https://www.bedsider.org/birth-control
GeekyMedics (2023, July 31). Methods of Contraception: https://geekymedics.com/methods-of-contraception/
Non-hormonal Methods of Contraception
Non-hormonal Methods of Contraception
Fertility Awareness-Based Methods (Natural Family Planning)
Fertility Awareness-Based Methods (Natural Family Planning)
Bedsider.org (2023). Fertility Awareness Method: https://www.bedsider.org/birth-control/fertility_awareness
Fertility awareness-based (FAB) methods rely on avoiding intercourse during fertile periods (ovulation). Understanding the female ovulatory cycle is critical to this method’s success.
The infertile phase occurs before ovulation.
The fertile phase (ovulation) is 5 to 7 days 14 days before the next menstrual cycle, including several days before and during ovulation, and the day afterward.
The infertile phase occurs after ovulation.
The ovum can be fertilized no later than 12 to 24 hours after ovulation. Sperm can fertilize the ovum probably no longer than 24 to 48 hours after. One problem with FAB methods is that the exact time of ovulation cannot be predicted.
Calendar-based Methods:
Calendar-based Methods:
The calendar rhythm method is based on the number of days in each cycle, counting from the first day of menses. It works by recording the lengths of menstrual cycles for at least six months. The fertile period is estimated by subtracting 18 days from the length of the shortest cycle and 11 days from the length of the longest cycle.
When a nurse is working with a client who chooses a calendar-based method of contraception, it is important the woman’s knowledge about contraception and her sexual partner’s commitment to any particular method is assessed. Another form of assessment involves collecting data about the frequency of coitus, the number of sexual partners, the level of contraceptive involvement, her or her partner’s objections to any methods, and the woman’s level of comfort and willingness to touch her genitals and cervical mucus. While doing so, identify any misconceptions, as well as religious and cultural factors, and pay close attention to the woman’s verbal and nonverbal responses to hearing about the various available methods. Also consider the woman’s reproductive life plan. Finally, complete a history (including menstrual, contraceptive, and obstetric), physical examination (including pelvic examination), and laboratory tests (as needed for identifying the presence of STIs).
Global Health Media Project (2022, September 20). Calendar-based Methods: https://globalhealthmedia.org/videos/the-calendar-method/
Standard Days Methods:
The standard days method (SDM) is modified form of the calendar rhythm method that has a “fixed” number of days of fertility for each cycle (i.e., days 8 to 19). CycleBeads is a visual tool that aids in identifying fertile and nonfertile days of the menstrual cycle. The red bead marks the first day of the menstrual cycle and the white beads mark days that are likely to be fertile days.
Two-Day Method:
The two-day method is based on the monitoring and recording of cervical secretions. Each day the woman asks herself the following:
“Did I note secretions today?” and “Did I note secretions yesterday?”
If yes, she should avoid coitus or use a backup method of birth control. If no, the probability of getting pregnant is very low.
Cervical Mucous Ovulation Detection Method:
The cervical mucus ovulation detection method requires recognition and interpretation of cyclic changes in the amount and consistency of cervical mucus that transforms prior to and during ovulation to facilitate and promote the viability and motility of sperm.
Cervical mucus changes throughout the menstrual cycle. Postmenstrual mucus is scant. Pre-ovulation mucus is cloudy, yellow or white, and sticky. Ovulation mucus is clear, wet, sticky, and slippery. Postovulation fertile mucus is thick, cloudy, and sticky. Postovulation, postfertile mucus is scant. Right before ovulation, the watery, thin, clear mucus becomes more abundant and thick. It feels similar to a lubricant and can be stretched 5+ cm between the thumb and forefinger. This quality of mucus is referred to as spinnbarkeit and its presence indicates the period of maximal fertility. Sperm deposited in this type of mucus can survive until ovulation occurs.
Assessment techniques include: good handwashing, observation beginning on the last day of menstrual flow, assessing cervical mucus several times a day for several cycles, obtaining mucus from the vaginal opening (reaching into the vagina to the cervix is unnecessary), and recording the findings on the same record on which the basal body temperature is entered.
Self-evaluation of cervical mucus can be both diagnostically accurate and useful. Whether or not a woman wants to use this method for contraception, self-evaluation alerts the couple to the reestablishment of ovulation while breastfeeding and after discontinuation of oral contraception. Noting anovulatory cycles at any time and at the beginning of menopause assists couples in planning a pregnancy.
Global Health Media Project (2022, March 5). The Secretion Method: https://globalhealthmedia.org/videos/the-secretion-method/
Basal Body Temperature:
The BBT method involves taking the body temperature of a healthy person after waking and before getting out of bed; in other words, when the body is fully at rest. This usually varies from 36.2°C to 36.3°C (97.16°F to 97.34°F) during menses and for approximately five to seven days afterward. Around the time of ovulation, a slight drop in temperature (approximately 0.5°C or 0.9°F) may occur in some women, but other women may have no decrease at all.
After ovulation, due to increased progesterone levels of the early luteal phase, the BBT increases slightly (approximately 0.4–0.8°C or 0.72–1.4°F). Before ovulation, 35.5°C to 36.6°C (96°F to 98°F) is normal in many women. The temperature remains on an elevated plateau until two to four days before menstruation. Then the BBT decreases to the low levels recorded during the previous cycle, unless pregnancy has occurred. In pregnant women the temperature remains elevated. If ovulation fails to occur, the pattern of lower body temperature continues throughout the cycle.
The fertile period is defined as the day of the first temperature drop, or the first elevation, through three consecutive days of elevated temperature. Abstinence begins the first day of menstrual bleeding and lasts through three consecutive days of sustained temperature rise (at least 0.2°C or 0.18°F).
Symptothermal Method:
The symptothermal method combines the BBT and cervical mucus methods with awareness of related signs and symptoms of the menstrual cycle. Signs and symptoms of the menstrual cycle that can be used with this method of contraception include: light spotting, slight cramping or pain on one side of the pelvis, breast tenderness, abdominal bloating, increased sex drive, and a heightened sense of smell, taste, or vision. Nurses are responsible for teaching the client cervical characteristics.
Biologic Marker Methods:
Home predictor test kits, such as the urine predictor test for ovulation, detects the sudden surge of luteinizing hormone (LH) that occurs approximately 12 to 24 hours before ovulation. Another method used is the Marquette Model which is cervical monitoring along with the ClearBlue Fertility Monitor.
Spermicides and Barrier Methods
Spermicides and Barrier Methods
Barrier contraceptives also offer protection against the spread of STIs such as HIV and herpes simplex virus (HSV). Spermicides create a chemical barrier against semen and inhibit the function of sperm to fertilize the ovum.
Spermicides:
Spermicides such as nonoxynol-9 (N-9) reduce sperm mobility. The spermicide should be inserted in the vagina so that it makes contact with the cervix. Spermicide should be inserted at least 15 minutes before (and no longer than 1 hour before) intercourse and reapplied for each additional act of intercourse, even if a barrier method is used.
Bedsider.org (2023). Spermicide as Birth Control: https://www.bedsider.org/birth-control/spermicide
Bedsider.org (2023). Condoms: https://www.bedsider.org/birth-control/condom
Male Condom:
The male condom is a thin sheath that covers the penis. It is applied before genital, oral, or anal contact and is removed when the penis is withdrawn from the partner’s orifice after ejaculation. Condoms provide a barrier to sperm and some STIs. They are made of either latex, polyurethane (strong, thin plastic), or natural membranes (animal tissue). Condoms lubricated with N-9 are not recommended for preventing STIs or HIV and do not increase protection against pregnancy. Latex condoms break down with oil-based lubricants.
"Unrolled Durex Condom" by Tomhannen, used under CC BY SA 2.0/Cropped from original
Female Condom (Internal Condom):
The female condom is a sheath that inserts into the vagina and is secured using flexible rings. It is applied before genital or oral contact and is removed after coitus is completed. It provides a barrier to sperm and some STIs. They are made of nitrile (a synthetic rubber) and lubricated.
Patients must be comfortable with touching their genitals for insertion and removal
"Illustration Demonstrating a Female Condom" by BruceBlaus, used under CC BY SA 4.0, Cropped from original
"Female Condom Use" by CDC , used under CC BY SA 2.0/Cropped from original
Bedsider.org (2023). Internal Condoms: https://www.bedsider.org/birth-control/internal_condom
Global Health Media Project (2022, February 13). The Female Consom: https://globalhealthmedia.org/videos/the-female-condom/
Bedsider.org (2023). Cervical Cap: https://www.bedsider.org/birth-control/cervical_cap
"Illustration of a Cervical Cap" by BruceBlaus , used under CC BYSA 4.0/Cropped from original
Cervical Cap:
The FemCap™ is the only type of cervical cap available in the United States. It fits snugly around the base of the cervix, close to the junction of the cervix and vaginal fornices. It should remain in place no less than six hours and not more than 48 hours at a time. The cap provides a physical barrier to sperm; spermicide inside the cap adds a chemical barrier. The cap must be checked before and after each act of intercourse. The cap requires refitting after any gynecologic surgery or birth, after any major weight losses or gains, or at least once a year.
Although cervical caps are selected by many women as a preferred method of birth control, some women are not good candidates for choosing the cervical cap.
The following factors must be considered:
Those with abnormal Papanicolaou (Pap) test results
Those who cannot be fitted properly with the existing capsizes
Those who find the insertion and removal of the device too difficult
Those with a history of toxic shock syndrome (TSS)
Those with vaginal or cervical infections
Those who experience allergic responses to latex or spermicide
Sponge:
The vaginal sponge is a small, round polyurethane sponge that contains N-9 spermicide and it is designed to fit over the cervix (one size fits all). The sponge must be moistened with water before it is inserted and provides protection for up to 24 hours and for repeated instances of sexual intercourse.
The sponge should be left in place for at least 6 hours after the last act of intercourse. Wearing it longer than 24 to 30 hours may create a risk for TSS.
"Diaphragm, Vaginal Contraceptive Sponges "by Ryan Soma, used under CC BY 2.0/Cropped from original
Bedsider.org (2023). Birth Control Sponge: https://www.bedsider.org/birth-control/sponge
Global Health Media Project (2022, February 18). The Caya Diaphragm: https://globalhealthmedia.org/videos/the-caya-diaphragm/
Bedsider.org (2023). Diaphragm Birth Control: https://www.bedsider.org/birth-control/diaphragm
Diaphragm:
A diaphragm is a latex or silicone device with a flexible rim that covers the cervix.
These include four types: coil spring, arcing spring, flat spring, and wide seal rim. Effectiveness is enhanced when used with spermicide.
The diaphragm requires annual gynecologic examination to assess the fit of the diaphragm. However, the Caya™ diaphragm has a "one size fits most" design and does not need to be fit by a provider.
The diaphragm should be inspected before every use, replaced every 2 years, and may need to be refitted for a 20% weight fluctuation, after any abdominal or pelvic surgery, and after every pregnancy.
It can be inserted up to 6 hours before intercourse. Prompt removal six to eight hours after intercourse, not using the diaphragm or cervical caps during menses, and learning and watching for danger signs of TSS are important when using a diaphragm. It must be left in place for at least 6 hours after the last intercourse. Instructions must be offered regarding the proper method of removal.
Other non-hormonal methods
Other non-hormonal methods
Coitus Interruptus (Withdrawal):
The first method we will discuss is coitus interruptus. Coitus interruptus (withdrawal) is when the penis is withdrawn prior to ejaculation. This method provides no protection against STIs or human immunodeficiency virus (HIV).
There are both advantages and disadvantages to the coitus interruptus method of contraception. Advantages lie in its immediate availability; there are no devices, costs, or chemical involvements. Disadvantages include the high probability of pregnancy with incorrect or inconsistent use.
Although coitus interruptus is one of the least effective methods of contraception, it is a good choice for couples who do not have another contraceptive available. Effectiveness is similar to barrier methods and depends on the man’s ability to withdraw his penis before ejaculation.
Bedsider.org (2023). Pull Out Method: https://www.bedsider.org/birth-control/withdrawal
Copper Intrauterine Device (IUD) (ParaGard™):
An IUD is a small T-shaped device with bendable arms for insertion through the cervix. Two strings hang from the base of the stem through the cervix and protrude into the vagina for the woman to feel for assurance that the device has not been dislodged.
The woman should have had a negative pregnancy test, treatment for dysplasia if present, cervical cultures to rule out STIs, and a consent form signed before IUD insertion.
The ParaGard™ IUD is made of radiopaque polyethylene and fine solid copper and is approved and effective for 10 years of use but may be effective for longer than 10 years. The copper primarily serves to cause an immune response creating an unreceptive setting for sperm and interferes with oocyte division and development of fertilizable ova
The woman should be taught to check for the presence of the IUD strings after menstruation to rule out expulsion of the device.
GeekyMedics (2019, January 6). Copper Coil Counseling - OSCE Guide: https://geekymedics.com/copper-coil-counselling-osce-guide/
"Intrauterine Device" by BruceBlaus, used under CC BY 3.0, cropped from original
Bedsider.org (2023). IUD Birth Control Options: https://www.bedsider.org/birth-control/iud
Lactational Amenorrhea (LAM):
The lactational amenorrhea method (LAM) can be a highly effective, temporary method of birth control. When the infant suckles at the mother’s breast, a surge of prolactin hormone is released, which inhibits estrogen production and suppresses ovulation and the return of menses. LAM works best if the mother is exclusively or almost exclusively breastfeeding, if the woman has not had a menstrual flow since giving birth, and if the infant is younger than 6 months of age.
Global Health Media Project (2022, March 9). The Breastfeeding Method: https://globalhealthmedia.org/videos/the-breastfeeding-method/
Contraceptive Gel:
Phexxi™ is a hormone free contraceptive gel available by prescription. It uses lactic acid, citric acid, and potassium bitartrate to alter the acidity of the vagina and create a hostile environment for sperm. It is inserted using a vaginal applicator and must be inserted one hour before intercourse. It also must be inserted prior to each episode of intercourse even if that is multiple times in one day. Used correctly, it is 93% effective against pregnancy. It does not protect against sexually transmitted infections.
Phexxi.com (2023). Hormone Free Birth Control - Phexxi: https://www.phexxi.com/
Hormonal Contraception
Hormonal Contraception
Hormonal contraception formulations include combined estrogen–progestin or progesterone only hormones. The medications are administered orally (pills), transdermally (patch), vaginally (ring), by implantation, by injection, and by intrauterine insertion (IUDs).
Bedsider.org (2023). Birth Control Pills: https://www.bedsider.org/birth-control/the_pill
GeekyMedics (2018, October 23). Combined Oral Contraceptive Pill (COCP) Counseling: https://geekymedics.com/combined-oral-contraceptive-pill-counselling/
Global Health Media Project (2021, December 12). The Contraceptive Pill: https://globalhealthmedia.org/videos/the-contraceptive-pill/
Combined Estrogen/Progesterone Contraception
Combined Estrogen/Progesterone Contraception
Combined Oral Contraceptives (COC) aka Birth Control Pill:
Regular ingestion of combined oral contraceptive pills (COCs) suppresses the action of the hypothalamus and anterior pituitary, leading to insufficient secretion of FSH and LH; therefore, follicles do not mature and ovulation is inhibited. The maturation of the endometrium is altered, making it a less favorable site for implantation.
COCs also have a direct effect on the endometrium, so from one to four days after the last COC is taken, the endometrial tissue sloughs and bleeding occurs because of hormone withdrawal. COCs should be taken at the same time each day. The cervical mucus remains thick from the effect of the progestin. Monophasic pills provide fixed dosages of estrogen and progestin. Multiphasic pills alter the amount of progestin and sometimes the amount of estrogen within each cycle.
Advantages
Since taking the pill does not relate directly to the sexual act, the acceptability of the pill may be increased. Improvement in sexual response may occur once the possibility of pregnancy is not an issue. For some women, it is convenient to know when to expect the next menstrual flow.
The noncontraceptive health benefits of COCs include:
Regulation of menorrhagia and irregular cycles
Treatment of endometriosis
Reduced incidence of dysmenorrhea and premenstrual syndrome (PMS)
Oral contraceptives also offer protection against endometrial cancer and ovarian cancer
Improve hirsutism and acne
Protect against the development of functional ovarian cysts
Increase bone mass
Perimenopausal women can benefit from regular bleeding cycles, a regular hormonal pattern, and the noncontraceptive health benefits of oral contraceptives
Disadvantages
Since hormonal contraceptives have come into use, the amount of estrogen and pregestational agent contained in each tablet has been reduced considerably. This is important because adverse effects are, to a degree, dose-related.
Women must be screened for conditions that present absolute or relative contraindications to COC use.
Some women choose to not have a cycle for either a vacation, a period of a few months, or all year. This is accomplished by beginning a new pack of active pills instead of taking the placebo pills at the end of the month.
Global Health Media Project (2021, December 2). How to Take the Contraceptive Pill: https://globalhealthmedia.org/videos/how-to-take-the-contraceptive-pill/
Global Health Media Project (2021, December 9). Taking the Contraceptive Pill Continuously: https://globalhealthmedia.org/videos/taking-the-contraceptive-pill-continuously/
Bedsider.org (2023). Birth Control Patch: https://www.bedsider.org/birth-control/the_patch
"Birth Control Patch" by BruceBlaus, used under CC BY 3.0/Cropped from original
Transdermal Combined Contraception (patch):
Available by prescription only, the contraceptive transdermal patch delivers continuous levels of norelgestromin (progestin) and ethinylestradiol.
The patch can be applied to intact skin of the upper outer arm, upper torso (front and back, excluding the breasts), lower abdomen, or buttocks.
Application is on the same day once a week for 3 weeks, followed by a week without the patch.
Vaginal Combined Contraceptive Ring (Nuvaring™ or Annovera™):
Available only with a prescription. The vaginal contraceptive ring is a flexible ring worn in the vagina to deliver continuous levels of progestin and estrogen
One vaginal ring remains in the vagina for 3 weeks, followed by a week without the ring. The ring is inserted by the woman and does not have to be fitted. For women who desire to skip their menses, the Nuvaring™ can be replaced on the same day of each month without a period of time without the ring.
A new Nuvaring™ must be placed each month. The same Annovera™ has enough medication to be used for one year; it is washed with warm soapy water and placed in a clean container during the week it is out of the vagina.
Contraceptive rings can remain in place during intercourse. If it is removed, it should only be out for 2 hours.
The woman must be comfortable with touching her genitals for this method to be used.
"Vaginal Birth Control Device" by Sakky , used under CC BY 2.0/Cropped from original
Bedsider.org (2023). Vaginal Rings for Birth Control: https://www.bedsider.org/birth-control/the_ring
Progesterone Only Contraception
Progesterone Only Contraception
Progestin Only Pill (POP) aka Mini-pill:
Contain only progesterone and has 28 active pills in each pack without placebo pills.
Progestin only methods impair fertility by inhibiting ovulation, thickening the cervical mucus present, thinning the endometrium, and altering cilia in the uterine tubes.
Most POPs must be taken within an hour of the same time each day to remain effective. Slynd™ contains a type of progesterone (drosperinone) that gives more flexibility to the time it must be taken; it also has three placebo pills to help regulate the menstrual cycle.
In July 2023 the FDA approved over-the-counter distribution of progesterone only pills
GeekyMedics (2019, January 6). Progesterone-only Pill (POP) Counseling: https://geekymedics.com/progesterone-only-pill-pop-counselling-osce-guide/
Implantable Contraception (Nexplanon™):
Contraceptive implants consist of a nonbiodegradable flexible rod that is inserted under the skin of a woman’s arm.
These implants contain a progestin hormone and are effective for contraception for at least 3 years. They must be removed at the end of the recommended time.
Insertion and removal is an in-office surgical procedures including a local anesthetic, a small incision, and no sutures. The capsule is injected intradermally in the inner aspect of the nondominant upper arm. Implants will prevent ovulatory cycles and will thicken cervical mucus.
Advantages include reversibility and long-term continuous contraception that is not related to the frequency of coitus. Nexplanon™ can be inserted immediately following birth in breastfeeding women without affecting lactation.
Disadvantages include irregular menstrual bleeding as the most common side effect. Less common side effects include headaches, nervousness, nausea, skin changes, and vertigo. No STI protection is provided with the implant method, so condoms should be used for protection.
Bedsider.org (2023). Birth Control Implant (Nexplanon): https://www.bedsider.org/birth-control/implant
GeekyMedics (2019, February 28). Contraceptive Implant Counseling - OSCE Guide: https://geekymedics.com/contraceptive-implant-counselling-osce-guide/
Global Health Media Project (2021, December 13). The Implant: https://globalhealthmedia.org/videos/the-implant/
Injectable Contraception aka "The Shot" (Depo-Provera™):
Given as an intramuscular shot, it is considered to be a long-acting reversible contraceptive, (LARC). When administering an intramuscular injection of progestin, do not massage the site after the injection, because this action can hasten the absorption and shorten the period of effectiveness. It can also be given as a self-administered dose by the patient subcutaneously.
Advantages of Deop-Provera™ include: contraceptive effectiveness comparable to that of perfect use of COCs, long-lasting effects, requirement of injections only four times a year, and the improbability of lactation being impaired.
Side effects at the end of a year include: Possible decreased bone mineral density (therefore we do not give it to teenagers routinely), weight gain, irregular vaginal spotting, no protection against STIs (including HIV), return to fertility may be delayed as long as up to 10 months after discontinuing Depo-Provera™, and women who use Depo-Provera™ may lose bone mineral density no different than that seen in pregnancy and breastfeeding mothers
GeekyMedics (2019, January 6). Progesterone Depot Injection Counseling - OSCE Guide: https://geekymedics.com/progesterone-depot-injection-counselling-osce-guide/
Bedsider.org (2023). Birth Control Shot (Depo-Provera): https://www.bedsider.org/birth-control/the_shot
Progesterone Intrauterine Devices (Mirena™, Kyleena™, Skyla™, Liletta™):
Different than the Paragard described above, these IUDs contain the progesterone levonorgestrel. They are 99% effective and the most common LARC requested. The IUDs will differ slightly in size, dose, and length of time that they are effective:
Women usually choose this type of contraceptive for the convenience and length of time it is effective. It does not inhibit ovulation in all women; some users will still have a period, but the endometrial lining is thin and not hospitable for implantation of an embryo.
This method also increases cervical mucous which can also inhibit sperm from entering the uterus and is considered to have the added benefit of decreasing Pelvic Inflammatory Disease by blocking ascending sexually transmitted diseases. This method works locally in the uterus and women seem to have decreased side effects of other types of hormonal options which circulate through the body.
Bedsider.org (2023). IUD Birth Control Options: https://www.bedsider.org/birth-control/iud
Mirena IntraUterine System by Hic et nunc, used under CC BY 2.0/Cropped from original
GeekyMedics (2023, February 27). Intrauterine System (Mirena) Counseling - OSCE Guide: https://geekymedics.com/intrauterine-system-mirena-counselling-osce-guide/
Emergency Contraception
Emergency Contraception
Emergency contraception is used when other methods are not used, a condom breaks (or other barrier method was not used correctly), or another method was not used correctly (i.e. forgot to take a pill)
Levonorgestrel tablets (Plan B One-Step™) are the only EC method available without a prescription, found on store shelves, and sold without age restriction. They must be taken orally within 3 days of unprotected intercourse.
Ulipristal acetate, marketed as Ella™, is available by prescription from a health care provider and, in only eight states, it is available from a pharmacist without a prescription. It must be taken within 5 days of unprotected intercourse.
A High dose of COCs can be used by using a prescription of a pack of birth control pills. Dosing will depend on the dose of estrogen in the pills. Must be taken within 3 days of unprotected intercourse
Insertion of a copper or high dose progesterone IUD. They must be inserted within 5 days of unprotected intercourse and then provide reliable contraception for the client. The advantage of using an IUD is it continues to provide long-term highly-effective birth control for the client after insertion.
Bedsider.org (2023). Emergency Contraception: https://www.bedsider.org/birth-control/emergency_contraception
"Plan B One Step" by Bgtp, used under CC BY 3.0/Cropped from original
Global Health Media Project (2022, March 23). The Emergency Contraceptive Pill: https://globalhealthmedia.org/videos/the-emergency-contraceptive-pill-hw-english/
Sterilization
Sterilization
Sterilization refers to surgical procedures intended to render a person infertile. Most procedures involve the occlusion of the passageways for the ova and sperm. For the woman, the oviducts (uterine tubes) are occluded. For the man, the sperm ducts (vas deferens) are occluded. Only surgical removal of the ovaries (oophorectomy) or uterus (hysterectomy) or both will result in absolute sterility for the woman.
All states have strict regulations for informed consent around sterilization procedures.
Female Sterilization: Female sterilization (bilateral tubal ligation [BTL]) may be done immediately after birth (within 24 to 48 hours), concomitant with induced abortion, or as an interval procedure (during any phase of the menstrual cycle).
Often the current practice is to remove the entire fallopian tube to help protect against ovarian cancer. If only a part of the fallopian tube is removed, restoration of tubal continuity (anastomosis) and function is technically feasible except after laparoscopic tubal electrocoagulation. Sterilization reversal is costly, difficult (requiring microsurgery), and uncertain.
Male Sterilization: Vasectomy is surgical interruption of a man's vas deferens, which is responsible for transporting mature sperm to the urethra.
Microsurgery to reanastomose can be accomplished, but the pregnancy rates are 30 to 90%, depending on the procedure. The rate of success decreases as the time since the procedure increases.
Bedsider.org (2023). Sterilization as Birth Control: https://www.bedsider.org/birth-control/sterilization
Global Health Media Project (2022, March 17). The Tubal Ligation: https://globalhealthmedia.org/videos/the-tubal-ligation-hw-english/
Association of Professors of Gynecology and Obstetrics (2015, September 10). Topic 33: Family Planning: https://www.youtube.com/watch?index=24&list=PLy35JKgvOASnHHXni4mjXX9kwVA_YMDpq&v=IEffOROmkbQ
Global Health Media Project (2022, March 21). The Vasectomy: https://globalhealthmedia.org/videos/the-vasectomy-hw-english/
Abstinence
Abstinence
Bedsider.org (2023). "Not Right Now" - Abstinence and Outercourse: https://www.bedsider.org/birth-control/not_right_now
Abstinence is the only method that is 100% effective against pregnancy and STD prevention.
Good communication between partners is a key to success with this method.
Termination of Pregnancy
Termination of Pregnancy
Not all pregnancies are desired, and providers can determine if they will provide termination services or not. Referral of patients is often necessary; counseling can be done on pregnancy termination options prior to the referral if the practice desires. The type of termination will depend on the circumstances surrounding the pregnancy, the woman’s feelings about the pregnancy, and the gestational age of the fetus (each state’s laws will differ for what circumstances and gestational age terminations are allowed).
Medical Termination: Uses medications misoprostol and (possibly) mifepristone – available up to 9 weeks gestation
Aspiration: done in the office with a large syringe or in the operating room - known as a Dilation and Curettage (D&C) – done in the first trimester
Surgical Termination: known as a Dilation and Evacuation – done if in the second trimester
Association of Professors of Gynecology and Obstetrics (2015, September 12). Topic 34: Pregnancy Termination: https://www.youtube.com/watch?index=25&list=PLy35JKgvOASnHHXni4mjXX9kwVA_YMDpq&v=dwO0zkBXyLQ
Bedsider.org (2023). Find a Verified Abortion: https://www.bedsider.org/abortion
Let's Practice!: Contraception
Let's Practice!: Contraception
Answer the following questions about contraception to check your knowledge.
Answer the following questions about contraception to check your knowledge.
Photos by Reproductive Health Supplies Coalition on Unsplash
Assessment of a 16-year-old nulligravid client who visits the clinic and asks for information on contraceptives reveals a menstrual cycle of 28 days. The nurse formulates a nursing diagnosis of Deficient Knowledge related to ovulation and fertility management. Which of the following would be important to include in the teaching plan for the client?
Assessment of a 16-year-old nulligravid client who visits the clinic and asks for information on contraceptives reveals a menstrual cycle of 28 days. The nurse formulates a nursing diagnosis of Deficient Knowledge related to ovulation and fertility management. Which of the following would be important to include in the teaching plan for the client?
The ovum survives for 96 hours after ovulation, making conception possible during this time.
The basal body temperature falls at least 0.2°F after ovulation has occurred.
Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle.
Most women can tell they have ovulated because of severe pain and thick, scant cervical mucus.
Answer: 3
Ovulation usually occurs 14 days before the onset of the next menstrual cycle.
With a 28-day cycle, that is day 14. If she has a shorter or longer cycle, the time would be adjusted
Ovulation does not usually occur during menses, when the uterine lining is being shed.
The ovum usually survives for about 12 to 24 hours after ovulation, during which time conception is possible.
The basal body temperature rises 0.5° to 1.0°F when ovulation occurs.
Although some women experience some pelvic discomfort during ovulation (mittelschmerz), severe or unusual pain is rare.
After ovulation, the cervical mucus is thin and copious.
Which of the following instructions about activities during menstruation would the nurse include when counseling an adolescent who has just begun to menstruate?
Which of the following instructions about activities during menstruation would the nurse include when counseling an adolescent who has just begun to menstruate?
Take a mild analgesic if needed for menstrual pain.
Avoid cold foods if menstrual pain persists.
Stop exercise while menstruating.
Avoid sexual intercourse during menstruation.
Answer: 1
The nurse should instruct the client to take a mild analgesic, such as ibuprofen or naproxen, if menstrual pain or "cramps" are present.
The client should also eat foods rich in iron and should continue moderate exercise during menstruation, which increases abdominal tone.
Avoiding cold foods will not decrease dysmenorrhea.
Sexual intercourse is not prohibited during menstruation, but the male partner should wear a condom to prevent exposure to blood, prevent exposure to STIs, and prevent pregnancy.
Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for signs and symptoms of which of the following?
Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for signs and symptoms of which of the following?
Anemia
Hypertension
Dysmenorrhea
Acne Vulgaris
Answer: 2
Hypertension is a contraindication for using contraception with estrogen
Clients who have hypertension, thrombophlebitis, migraines, or a family history of cerebral or cardiovascular accident are poor candidates for combined oral contraceptives.
Women who smoke and are older than 35 years of age should be advised to use a different method.
Iron-deficiency anemia, dysmenorrhea, and acne are. not contraindications for the use of oral contraceptives. Use of oral contraceptives often improves facial acne
Oral contraceptives decrease the amount of menstrual flow and can be beneficial when used by clients with anemia.
Low-dose combined oral contraceptives prevent ovulation and may be effective in decreasing the severity of dysmenorrhea (painful menstruation) which is thought to be caused by the release of prostaglandins in response to tissue destruction during the ischemic phase of the menstrual cycle.
A 22-year-old nulligravid client tells the nurse that she and her husband have been considering using condoms for family planning. Which of the following instructions would the nurse include about the use of condoms as a method for family planning?
A 22-year-old nulligravid client tells the nurse that she and her husband have been considering using condoms for family planning. Which of the following instructions would the nurse include about the use of condoms as a method for family planning?
Using a spermicide with the condom offers added protection against pregnancy.
Natural skin condoms protect against sexually transmitted diseases
The typical failure rate for couples using condoms is about 25%.
Condom users frequently report penile gland sensitivity
Answer: 1
The typical failure rate of a condom is approximately 13%. Adding a spermicide can decrease this potential failure rate because it offers additional protection against pregnancy.
Natural skin condoms do not offer the same protection against sexually transmitted diseases caused by viruses as latex condoms do; natural skin (membrane) condoms do not prevent the passage of viruses.
Most condom users report decreased penile gland sensitivity.
Some users do report an allergic reaction (such as a rash) to latex, necessitating the use of a natural skin condom.
Which of the following would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a diaphragm for family planning?
Which of the following would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a diaphragm for family planning?
Douching with an acidic solution after intercourse is recommended.
Diaphragms should not be used if the client develops acute cervicitis.
The diaphragm should be washed in a weak solution of bleach and water
The diaphragm should be left in place for 2 hours after intercourse.
Answer: 2
Diaphragms should not be used if the client develops acute cervicitis, possibly aggravated by contact with the rubber of the diaphragm.
Diaphragm use may increase the incidence of urinary tract infections.
Douching after use of a diaphragm and intercourse is not recommended because pregnancy could occur.
The diaphragm should be inspected and washed with mild soap and water after each use.
A diaphragm should be left in place for at least 6 hours but no longer than 24 hours after intercourse.
More spermicidal jelly or cream should be used if intercourse is repeated during this period.
After being examined and fitted for a diaphragm, a 24-year-old client receives instructions about its use. Which of the following client statements indicates a need for further teaching?
After being examined and fitted for a diaphragm, a 24-year-old client receives instructions about its use. Which of the following client statements indicates a need for further teaching?
"I can continue to use the diaphragm for about 2 to 3 years if I keep it protected in the case."
"If I get pregnant, I will have to be refitted for another diaphragm after the delivery."
"Before inserting the diaphragm I should coat the rim with contraceptive jelly."
"If I gain or lose 20 pounds, I can still use the same diaphragm."
Answer: 4
Generally speaking, gaining or losing more than 15 pounds can change the pelvic and vaginal contours to such a degree that the diaphragm will no longer protect the client against pregnancy. However, the Caya diaphragm is a "one size fits all" appliance.
Diaphragms can be used for 2 to 3 years if it is cared for and well protected in its case.
Diaphragms should be refitted after pregnancy and delivery of a newborn because weight changes and physiologic changes of pregnancy can alter the pelvic and vaginal contours, thus affecting the fit and effectiveness of the diaphragm.
The client should use a spermicidal jelly or cream before inserting the diaphragm.
20-year-old woman desiring to use a cervical cap for family planning is instructed on its use. Which of the following client statements would indicate to the nurse that the client needs further instruction?
20-year-old woman desiring to use a cervical cap for family planning is instructed on its use. Which of the following client statements would indicate to the nurse that the client needs further instruction?
"Cervical caps can be left in place longer than a diaphragm."
"Using a cervical cap may increase the risk of irritation."
"Cervical caps usually fit better than a diaphragm."
"Many women are unable to use cervical caps."
Answer: 3
The client needs further instruction when she says that cervical caps fit better than the diaphragm.
Many women are unable to use cervical caps because their cervix is too short for the cap to fit the cervix properly.
A cervical cap may remain in place for up to 48 hours after intercourse, whereas it is recommended that a diaphragm be left in place for only 24 hours.
The cervical cap is associated with cervical irritation.
Which of the following would the nurse expect to include in the teaching plan for a 30-year-old multiparous client who will be using a Paragard ™ (non-hormonal) intrauterine device (IUD) for family planning?
Which of the following would the nurse expect to include in the teaching plan for a 30-year-old multiparous client who will be using a Paragard ™ (non-hormonal) intrauterine device (IUD) for family planning?
Amenorrhea is a common side effect of the Paragard IUD
The client needs to use additional protection for conception.
IUDs are more costly than other forms of contraception.
Severe cramping may occur when the IUD is inserted.
Answer: 4
Severe cramping often occurs as the device is passed through the internal cervical os during insertion
The insertion of the device is often done when the client is having her menses, because it is unlikely that she is pregnant at that time and the cervix is open. However, it can be inserted at any time of the month if it can be determined the patient is not pregnant.
Common side effects of non-hormonal IUDs are heavy menstrual bleeding and subsequent anemia, not amenorrhea. Progesterone IUDs may cause amenorrhea.
Uterine infection may occur if a client has an infection upon insertion.
There is an increase chance of ectopic pregnancy.
The IUD has an effectiveness rate of 98%. Therefore, additional protection is not necessary to prevent pregnancy.
IUDs generally are less costly than other forms of contraception because they do not require additional expense and are effective for many years.
Only one insertion is necessary, in comparison to daily doses of oral contraceptives or the need for spermicides in conjunction with diaphragm use.
A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which of the following statements would the nurse expect to include in the client's teaching plan?
A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which of the following statements would the nurse expect to include in the client's teaching plan?
About midway through the menstrual cycle, cervical mucus is thick and sticky.
During ovulation, the cervix remains dry without any mucus production.
As ovulation approaches, cervical mucus is abundant and clear.
Cervical mucus disappears immediately after ovulation, resuming with menses.
Answer: 3
Cervical mucus is always present. Changes in the cervical mucus are related to the influences of estrogen and progesterone.
During the luteal phase of the cycle, which occurs after ovulation, the cervical mucus is thick and sticky, making it difficult for sperm to pass.
As ovulation approaches, cervical mucus is abundant and clear, resembling raw egg white.
Ovulation generally occurs 14 days (plus or minus 2 days) before the beginning of menses.
A multigravida client will be using medroxyprogesterone acetate (DepoProvera ™) as a family planning method. After the nurse instructs the client about this method, which of the following client statements indicates effective teaching?
A multigravida client will be using medroxyprogesterone acetate (DepoProvera ™) as a family planning method. After the nurse instructs the client about this method, which of the following client statements indicates effective teaching?
"This method of family planning requires monthly injections."
"I should have my first injection during my menstrual cycle."
"One possible side effect is absence of a menstrual period.".
"This drug will be given by subcutaneous injections."
Answer: 3
With medroxyprogesterone acetate, irregular menstrual cycles and amenorrhea are common side effects initially.
Other side effects include weight gain, breakthrough bleeding, headaches, and depression.
This method requires deep intramuscular injections every 3 months.
The first injection should occur within 5 days after menses.
A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. The nurse should instruct the client to do which of the following?
A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. The nurse should instruct the client to do which of the following?
Check the cervical mucus to see if it is thick and sparse.
Take her temperature at the same time every morning.
Document ovulation when the temperature decreases at least 1°F.
Avoid coitus for 10 days after a slight rise in temperature.
Answer: 2
The basal body temperature method requires that the client take her temperature each morning before arising, preferably at the same time each day before eating or any other activity.
Just before the day of ovulation, the temperature falls by 0.5°F. At the time of ovulation, the temperature rises 0.4° to 0.8°F because of increased progesterone secretion in response to the luteinizing hormone.
The temperature remains higher for the rest of the menstrual cycle.
The client should keep a diary of about 6 months of menstrual cycles to calculate "safe" days.
There is no mucus for the first 3 or 4 days after menses, and then thick, sticky mucus begins to appear. As estrogen increases, the mucus changes to clear, slippery, and stretchy. This condition, termed spinnbarkeit, is present during ovulation. After ovulation, the mucus decreases in amount and becomes thick and sticky again until menses.
Because the ovum typically survives about 24 hours and sperm can survive up to 72 hours, couples must avoid coitus when the cervical mucus is copious and for about 3 to 4 days before and after ovulation to avoid a pregnancy.
Which statement is the most complete and accurate description of medical abortions?
Which statement is the most complete and accurate description of medical abortions?
They are performed only for maternal health
They can be achieved through surgical procedures or with drugs.
They are mostly performed in the second trimester.
They can be either elective or therapeutic.
Answer: 4
Medical abortions are performed through the use of medications (rather than surgical procedures).
They are mostly done in the first trimester, and they can be either elective (the woman's choice) or therapeutic (for reasons of maternal or fetal health).
June, an 18-year-old client, has come to Planned Parenthood for information on birth control methods and assistance with making her choice. She tells the nurse that she is planning to become sexually active with her boyfriend of 6 months and is worried about getting pregnant. She says, “I know I should know more about all of this, but I just don’t.”
STATE the most important nursing diagnosis that reflects Kathy’s concern.
OUTLINE the approach the nurse should use to help Kathy make an informed decision in choosing contraception that is right for her.
Knowledge deficit related to birth control options as evidenced by her stating "I know I should knjow more about all of this, but I just don't"
Describe the methods of birth control and discuss which methods are most desirable to her lifestyle
June plans to use combined oral contraceptive (COC) pills.
DESCRIBE the mode of action for this type of contraception.
LIST the advantages of using COC pills.
IDENTIFY the factors that, if present in June’s health history, would constitute absolute or relative contradictions to the use of oral contraception with estrogen and progesterone.
Using the acronym ACHES, IDENTIFY the signs and symptoms that would require June to stop taking the pill and notify her health care provider.
COC pills work by increasing the hormones estrogen and progesterone which stop the hypothalamic-pituitary axis. This will inhibit ovulation.
Advantages of COC pills are they are highly effective and easy to use
Migraine headaches with aura, hypertension, history of blood clots, smoking and over the age of 35 are all factors that would be absolute contraindications to using oral contraceptive pills
ACHES: Abdominal pain, Chest pain, Headaches (sudden onset, unrelieved with NSAIDS), Eye (Visual) changes, Stomach pain
Anita has just had a ParaGard T380A copper IUD inserted.
SPECIFY the instructions that the nurse should give Anita before she leaves the women’s health clinic after the insertion.
Call for significant pain (more than cramping), vaginal bleeding more than spotting, fever, malodorous vaginal discharge
It is normal to have increased cramping with menses for the first few months - she can take NSAIDs for this. She may also have increased menses initially. Both things should subside after about 3 months.
Judy (G6 P4-0-2-4) and Allen, both age 36 years, are contemplating sterilization now that their family is complete. They are seeking counseling regarding this decision.
DESCRIBE the approach a nurse should use in helping Judy and Allen to make the right decision.
Discuss their committment to permanent sterilization. Discuss the need for outpatient laproscopic surgery for tubal ligation and in-office procedure at a urology office for vasectomy.
Study Worksheets
Study Worksheets
worksheet Contraception and Infertility.pdfOther Resources
Other Resources
American College of Obstetricians and Gynecology (2014, June). Depot Medroxyprogesterone Acetate and Bone Effects. Committee Opinion Number 602. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/06/depot-medroxyprogesterone-acetate-and-bone-effects
American College of Obstetricians and Gynecologists (2015, September). Emergency Contraception. Practice Bulletin Number 152. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2015/09/emergency-contraception
American College of Obstetricians and Gynecologists (2017, November). Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Practice Bulletin Number 186. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/11/long-acting-reversible-contraception-implants-and-intrauterine-devices
American College of Obstetricians and Gynecologist (2020, October). Medication Abortion Up to 70 Days of Gestation. Practice Bulletin Number 225. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation
Ajmal, M.. Sunder, M., Akinbinu, R. (2022, July 15). Abortion. https://www.ncbi.nlm.nih.gov/books/NBK518961/
Bayer (2023). Skyla Information. https://www.skyla-us.com/
Bedsider Birth Control Support Network (2023). Birth Control: Find a Method That's Right for You. https://www.bedsider.org/birth-control
Centers for Disease Control and Prevention (2016). US Selected Practice Recommendations for Contraceptive Use. https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html
Centers for Disease Control and Prevention (2016). Contraception Resources from the CDC: 2016 U.S. Medical Eligibility Criteria for Contraceptive Use. https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/pdf/mec_slideset_2016.pdf
cdc contraception slides usspr_slideset_2016.pdfCenters for Disease Control and Prevention (2023, May 1). Contraception. https://www.cdc.gov/reproductivehealth/contraception/index.htm
Evofem Biosciences, Inc. (2023). Phexxi Information. https://www.phexxi.com/
FemCap, Inc. (2023). FemCap Information. https://femcap.com/new/
Food and Drug Administration (2023, July 13). FDA Approves First Nonprescription Daily Oral Contraceptive. https://www.fda.gov/news-events/press-announcements/fda-approves-first-nonprescription-daily-oral-contraceptive
Foundation Consumer Brands (2023). Plan B One-Step Information. https://www.planbonestep.com/
Medintim (2023). Caya Contoured Diaphragm. https://www.caya.us.com/
National Institutes of Health (2023). About Birth Control. https://www.nichd.nih.gov/health/topics/factsheets/contraception
National Institutes of Health (2023). Contraception and Birth Control. https://www.nichd.nih.gov/health/topics/contraception
Sohda, S., Kuzuki, K., Igari, I. (2017, November). Relationship Between the Menstrual Cycle and Timing of Ovulation Revealed by New Protocols: Analysis of Data from a Self-Tracking Health App. Journal of Medical Internet Research, 19(11). doi: 10.2196/jmir.7468
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