Family Planning and Contrceptives For Midwifery Students

Introduction to
Family Planning
By:- Abdusamed M. (MSc, PhD Candidate)

Learning Objectives
At the end of this session, the students will be able to:-
 Define family planning
 Differentiate family planning and contraceptives
 Discuss the rationale of family planning
 Describe the legal aspects contraceptives
 List different types of family planning methods
2
Definitions of Terms
 Family planning or birth control
 Is a means of promoting the health of women and families
 The use of various methods of fertility control that will help
couples to have the number of children they want and when
they want them in order to assure the well being of children
and the parents
 Is a part of a strategy to reduce the maternal, infant and child
morbidity and mortality
 Helps to determine the number of children or family size,
timing and spacing of child birth
3
 Can be either reversible or permanent (sterilization)
Definitions… Cont…
 Contraception – is temporary or permanent measures
designed to control pregnancy
 Family planning – includes both fertility inhibition

(contraception) and fertility stimulation
 Ideal contraception – is contraception which is widely

acceptable, inexpensive, simple to use, safe, highly effective
and requiring minimal motivation maintenance and
4 supervision
Indications for Birth Control
 To space their children or to limit their family size
 To avoid childbearing because of the effects of preexisting
illness on the pregnancy, such as severe diabetes or heart

disease
5
Rationale of Family Planning
 Demographic Rationale
 Reducing high fertility and slowing population growth
 To control potentially negative effects of rapid population
growth and high fertility on living standards of human being
 Health Rationale:
 High rates of infant, child, and maternal mortality as well as
abortion and its health consequences, were pressing health

problems
6
Rationale of… Cont…
 Benefits to women’s health:-
 Avoiding pregnancy at the extremes of maternal age
 Decreasing risks by decreasing parity
 Preventing high-risk pregnancies
 Prevention of unwanted pregnancy
 Improving health through non-contraceptive benefits
including prevention of STIs and reproductive cancers
7
Rationale of… Cont…
Family planning benefits children’s health
 Infants born at least 24 months after the previous
birth have lower mortality

 Better health
 More food and other resources available
 Greater opportunity for emotional support from
parents
 Better opportunity for education

8
Legal Aspects of Contraception
 Health care providers are obliged to provide all persons requesting
contraception with detailed information about
 Use of the method(s) and its benefits
 Risks and side effects
 So that the patient can make an informed choice relative to a particular
method
 Providers must be careful to avoid imposing their own religious or
moral views on their patients
 Documentation of the discussion with the patient is important both
clinically and legally in particular, when using methods that require

9 instrumentation or surgery (e.g. IUD, implants, and sterilization)
Factors to Consider
 Efficacy
 Convenience
 Duration of action
 Reversibility and time to return of fertility
 Effect on uterine bleeding
 Frequency of side effects and adverse events
 Affordability
 Protection against sexually transmitted diseases

10
Efficacy of Contraceptives
 Failure rate estimates are often separated into two
components
1. The perfect use failure rate :- the percentage of women
who conceive in the first year of use when they use the
method exactly as instructed
2. The typical failure rates:-
 When couples use the method in the real world are
significantly higher
 Are the most accurate ones to quote when counseling patients
 Reversible contraceptive methods are best grouped by efficacy
into three major groups-
1. The highly effective methods (typical failure rates <3%)
2. Very effective methods (typical failure rates 3% to 10%), and
11 3. All others
Methods of Contraception
Barrier Methods Traditional Methods
– Condoms  Coitus interruptus
– Diaphragms  Breastfeeding
– Cervical caps  Fertility awareness method
– Spermicides  Calendar method
Hormonal Methods  Symptothermal

 Cervical mucous (Billings)
– Pills
– Injectables
– Implants
IUCD
Permanent: Tubectomy & Vasectomy
12
Natural Family
Planning Methods

Learning Objectives
At the end of this session, the students will be able to:-
 List the natural family planning methods
 Describe the mechanism of action of natural family planning
methods
 Discuss the effectiveness of natural family planning methods
 Differentiates the advantages and disadvantages of natural
family planning methods
2
Traditional /Natural FP Methods
Coitus Interruptus
 Is withdrawal of the penis before ejaculation
 Results in deposition of the semen outside the female genital tract
 Demands sufficient self-control by the man so that withdrawal
precedes ejaculation
 Failure rate is higher than that of most methods
 Failure may result from:
 Escape of semen before orgasm; or

 The deposition of semen on the external female genitalia near the
vagina
3
Traditional Methods… Cont…
Post-coital Douche
 Washing the vulva with plain water, vinegar, and a number
of "feminine hygiene" products

 It f lushes the semen out of the vagina
 The additives to the water may possess some spermicidal
properties
 Nevertheless, sperm have been found within the cervical
mucus within 90 seconds after ejaculation
 Hence, the method is ineffective and unreliable

4
Natural Methods… Cont..
 Fertility Awareness Methods

 Implies that a woman knows how to tell when the fertile
time of her menstrual cycle starts and ends
 The fertile time is when she can become pregnant
 It is also called periodic abstinence or natural family planning
 A woman can use several ways, alone or in combination, to

tell when her fertile time begins and ends
 Divided into two broad categories:
1. Calendar based
2. Symptom based methods
5
1. The Calendar Method

 Predicts the day of ovulation by means of a formula based on
the menstrual pattern recorded over a period of several
months
 Ovulation ordinarily occurs 14 days before the 1st day of the
next menstrual period
 The fertile interval should be assumed to extend from at
least 3 days before ovulation to no less than 3 days after
ovulation
 Its success requires regular menstrual cycles
 The most commonly used method of periodic abstinence
 The least reliable, with failure rates as high as 35% in 1 year's use
6
Natural Methods… Cont…
 Rhythm Method
 The woman calculates the fertile days of her menstrual period
 Then, the couple avoids vaginal sex, or uses temporary
methods during the fertile time
 Does not protect from STIs including HIV
 Return of fertility after stopping the method is immediate
Mechanism of action (how does it work)
 Helps a woman know on which days of the menstrual cycle she
is fertile
 The couple prevents pregnancy by avoiding unprotected
vaginal sex during these fertile days
Effectiveness
 With consistent and correct use, about 91% effective
7
How to Use Rhythm Method
 Before relying on Rhythm method,
 The woman records the number of days in each menstrual
cycle for at least 6 months
 The first day of monthly bleeding is always counted as day 1

 Subtract 18 from her shortest recorded cycle  this tells
her the estimated first day of her fertile time
 Subtract 11 days from her longest recorded cycle  this

tells her the estimated last day of her fertile time
8
Standard Days Method (SDM)

 Is a calendar-based method
 Used by women who have regular cycles that are 26 – 32 days
long
 The woman calculates the fertile periods and avoids
unprotected vaginal sex or use temporary method
Mechanism of action (how does it work)
 Helps the woman know when she could potentially become
pregnant
 The couple prevents pregnancy by avoiding unprotected
vaginal sex during these fertile days
9
SDM …
 White beads days are days

when she can get pregnant
 Brown bead days are days
when pregnancy is unlikely
10
10
SDM …
11
11
SDM …
12
SDM …
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 2122 23 24 25 26 27 28 29
13
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Effectiveness
 About 5 pregnancies per 100 women in the first year of
consistent and correct use
How to Use Standard days Method
 A woman keeps track of the days of her menstrual cycle,
counting the first day of monthly bleeding as day 1
 Avoid unprotected sex on days 8–19
 The couple can have unprotected sex on all the other days of
the cycle
 Days 1 through 7 at the beginning of
the cycle and from day 20
until her next monthly bleeding begins
14
Natural Family Planning Methods cont..
Symptoms‐Based Methods
1. Cervical mucus method
2. Basal body temperature method
3. Symptom-thermal method
15
Symptoms‐based Methods… Cont…
 How to use.. SBM

 The use of a particular fertility awareness method should be
delayed until the condition is evaluated or corrected
 Give the client another method to use until she can start the
symptoms-based method
 Mechanism of action
 Helps a woman know on what days she could become
pregnant
 And, the couple avoids unprotected vaginal sex during the
fertile days
 Effectiveness:
 With consistent and correct use 3 pregnancies per 100 women
will occur
16
The Cervical Mucus (Billings) Method

 Uses daily changes in cervical mucus secretions to predict
ovulation
 Starting several days before and until just after ovulation, the
mucus becomes thin and watery, whereas at other times the
mucus is thick and opaque
 Cervical secretions:
 Increases during fertile period
 She may feel just a little vaginal wetness
 Advantages:-
Relative simple
No requirement for charting
 Disadvantages
Difficulty in evaluating mucus in the presence of vaginal
17 infection
Cervical Mucus Method …
 Around the time of

ovulation cervical mucus
becomes profuse, thin
transparent, watery, and
slippery
 Avoid unprotected sex
when cervical secretions
begin to appear and until 4
days after the ‘peak mucus
day’.
18
How to Use Cervical Mucus Method cont..
 The woman checks every day for any cervical secretions on
fingers, underwear, or tissue paper or by sensation in or

around the vagina
 Avoid unprotected sex on days of heavy monthly bleeding:
Ovulation might occur
 Early in the cycle,

 During the last days of monthly bleeding, and
 Heavy bleeding could make mucus difficult to observe
19
How to Use Cervical Mucus Method cont..
 Resume unprotected sex until secretions begin: Between the
end of monthly bleeding and the start of secretions

 The couple can have unprotected sex, but not on 2 days in a
row
 Avoiding sex on the second day allows time for semen to
disappear and for cervical mucus to be observed
 It is recommended that they have sex in the evenings, after
the woman has been in an upright

20
The Basal Body Temperature (BBT) Method

 Relies on the woman’s ability to notice a slight increase in her
body temperature
 The elevation in the temperature is as a result of hormonal
changes that result in ovulation
 The vaginal or rectal temperature must be recorded upon
awakening in the morning before any physical activity is
undertaken
 After ovulation, BBT rises abruptly approximately 0.3–0.4
°C (0.5–0.7 °F) and remains at this plateau for the remainder
of the cycle
 The 3rd day after the onset of elevated temperature is
21
considered the end of the fertile period
BBT Methods… Cont…
22
BBT Methods… Cont…
 Mechanism of action
 Helps a woman to identify days when she could become
pregnant
 And, the couple avoids unprotected vaginal sex from the
first day of menstruation until 3 days after the woman’s
temperature has risen above her regular temperature
 Effectiveness
 With consistent and correct use 99% effective
 Characteristics
 Method does not protect from STIs including HIV
 Return of fertility after stopping the method is immediate
23
BBT Method… Cont…
How to Use BBT
 IMPORTANT: If a woman has a fever or other changes in
body temperature, the BBT method will be difficult to use
 Take body temperature daily :
 The woman takes her body temperature at the same time
each morning before she gets out of bed and before she eats
anything
 She records her temperature on a special graph
 She watches for her temperature to rise slightly—0.3° to
0.5°C—just after ovulation
 Avoid sex or use another method until 3 days after the
temperature rise
24
The Sympto-thermal Method
 If used properly, probably is the most effective of all the
periodic abstinence approaches
 It combines features of both the cervical mucus and the

temperature methods
 In addition, symptoms that may occur just prior to ovulation,
such as bloating and vulvar swelling, are used as adjuncts to
predict the likely occurrence of ovulation
 At least 20% of fertile women have enough variation in their
cycles that reliable prediction of the fertile period is
25 impossible
The Combined BBT and Calendar Method

 Uses features of the 2 methods to more accurately predict
the time of ovulation

 Failure rates of only 5 pregnancies per 100 couples per year
have been reported
26
Summary of effectiveness of Fertility
Awareness Methods
Method Pregnancies per 100 Women
Over the First Year
Calendar-based methods
Standard Days Method 5
Calendar rhythm method 9
Symptoms-based methods
BBT method 1
Cervical mucus/Ovulation 3
method
27
Lactational Amenorrhea (LAM):

 Can be a highly efficient method for breastfeeding women to
utilize physiology to space births

 A temporary family planning method based on the natural
effect of breastfeeding on fertility

 Requires 3 conditions; and all must be met:
1. The mother’s monthly bleeding has not returned
2. The baby is fully (i.e. exclusive breast-feeding) or nearly
fully (with some supplemental foods) breastfed and is
fed often, day and night
3. The baby is less than 6 months old
28
Mechanism of Action
 Prevents ovulation
 Frequent breastfeeding temporarily prevents the release of
the natural hormones that cause ovulation

 Suckling causes increased prolactin, which inhibits estrogen
production and ovulation
Effectiveness
 Depends on the user: Risk of pregnancy is greatest when a
woman cannot fully or nearly fully breastfeed her infant

 As commonly used, about 98% effective
29
Who can and can’t use LAM
 All breastfeeding women can safely use LAM
 The woman in the following circumstances may want to consider
other contraceptive methods:
 Has HIV infection including AIDS

 Is using certain medications during breastfeeding (including
mood altering drugs reserpine, ergotamine, anti-metabolites,
cyclosporine, and high doses of corticosteroids, bromocriptine,
radioactive drugs, lithium, and certain anticoagulants)
 The newborn has a condition that makes it difficult to breastfeed
 e.g. being small-for-date or premature or having deformities of the

mouth, jaw, or palate
30
LAM for Women with HIV
 Women who are infected with HIV or who have AIDS can use LAM
 Breastfeeding will not make their condition worse
 There is a chance that mothers with HIV will transmit HIV to their
infants through breastfeeding

 As breastfeeding is generally practiced, 10 to 20% of infants
breastfed by mothers with HIV will become infected with HIV

through breast milk
 Women taking antiretroviral (ARV) medications can use LAM
 ARV therapy during the 1st weeks of breastfeeding may reduce the
risk of HIV transmission

31
When can LAM be initiated?
 If the woman is within 6 months after childbirth:
 Start breastfeeding immediately (within one hour) or as

soon as possible after the baby is born
 In the first few days after childbirth, the yellowish f luid
produced by the mother’s breasts (colostrum) contains
substances very important to the baby’s health
 Any time if she has been fully or nearly fully
breastfeeding since birth and her monthly bleeding has
not returned
32
Barrier Methods of
Contraception
1
Objectives
 Describe male and female condoms
 Explain the implication of dual use
 Demonstrate proper use of male and female
condoms
 Describe spermicides and diaphragm
2
Condom
Types:-
 Male condom
 Female condom
 Textured condoms:- to provide extra sensations
 Ribbed condoms
 Anti-rape condom: worn by the female and designed to cause
pain to the attacker
 Store in a cool, dry place out of direct sunlight
 Don’t keep rubber (latex) condoms in a grove/thicket
compartment or other hot places for a long time
 Heat weakens latex and increases the chance that the
condom will break
3
Condom... Cont…
 Evolution of materials:
 Ancient (Lamb intestine)  Rubber: 1855  Latex: 1920
 Polyurethane: 1994

 
The first Male condom

in Egypt
4
Male Condom
 Made of natural, latex rubber and plastic materials
 Natural condoms
 Intestines and skins
 Barrier against sperm and bacteria
 Not effective against virus
 Allow transfer of body heat
 Rubber condoms
 Since the 19th Century
 Less permeable than natural condoms
 Reduce heat transfer
 Effective barrier even against HIV
 Plastic condoms
 Under development
 Good heat transfer
5
Male Condom… Cont…
 It is the only method recommended for prevention of all

STD including HIV
 May protect the couples from cervical carcinoma
 Can help men with premature ejaculation
 May reduce sensation
 Can be used by everyone except for the rare person who is

allergic to latex
 Can be damaged by oil based lubricants, heat, humidity or
light
6
How Effective?
 Its effectiveness depends on the users
 Protection Against Pregnancy:
 As commonly used, about 15 pregnancies per 100 women whose
partners use male condoms over the first year
 When used correctly with every sex act, about 2 pregnancies
per 100 women whose partners use male condoms over the first
year
 Protection Against HIV and Other STIs:
 When used consistently and correctly, it prevents 80 – 95% of
HIV transmission that would have occurred without condoms
7
Side Effects, Health Benefits, and Health Risks
 Side Effects: None
 Health Benefits: Help protect against:
 Risks of pregnancy
 STIs, including HIV
 Conditions caused by STIs:

 Recurring pelvic inf lammatory disease and chronic pelvic
pain
 Cervical cancer
 Infertility (male and female)

8
Side Effects, Benefits, and Risks of… Cont…
 Health Risks
 Extremely rare allergic reaction (among people with latex
allergy)
 Additional advantages:
 No hormonal side effects
 Can be used as a temporary backup method
 Can be used without seeing a health care provider
 Sold in many places and generally easy to obtain
9
5 Basic Steps of Using a Male 1
Condom
1. Check the condom package 2
 Do not use if torn or damaged; or if it shows obvious
signs of deterioration, such as brittleness, stickiness, or
discoloration, regardless of their expiration date.
 Avoid using a condom past the expiration date;
 Tear open the package carefully. Don’t use fingernails, 3
teeth, or anything that could damage the condom.
2. Before any physical contact, place the condom on
the tip of the erect penis with the rolled side out
4
3. Unroll the condom all the way to the base of the
erect penis
4. Immediately after ejaculation, hold the rim in
place and withdraw the penis while it is still erect 5
5. Dispose of the used condom safely

10
 If condom breaks, slips off the penis, or is not used
appropriately;
 About 2% of condoms break or slip off completely during sex,
primarily if they are used incorrectly

 NB: Used properly, condoms seldom break
 Emergency contraceptive pills (ECPs) can help prevent
pregnancy
 He should tell his partner so that she can use ECPs
 Increase the chance of slipping
11
 If a client reports breaks or slips;

 Ask clients to show how they open the package and put the
condom on, using model or other item

 Correct any errors
 Ask if lubricants were used

 The wrong lubricant or too little lubricant can increase breakage
 Too much lubricant can cause the condom to slip off
 Ask when the man withdraws his penis
 Waiting too long to withdraw can break or slip off the condom
12
Little can be done to reduce the risk of STIs:-

 Washing the penis does not help
 Vaginal douching is not very effective in preventing
pregnancy,
 Vaginal douching can increases a woman’s risk of acquiring
STIs, including HIV, and pelvic inf lammatory disease
 If exposure to HIV is certain, treatment with ARV
medications (post-exposure prophylaxis)
 If exposure to STIs is certain, treat presumptively for those
STIs i.e. treat them if they were infected
13
 If the client has signs or symptoms of STIs, assess or refer
 New problems that may require switching methods

 Female partner is using miconazole or econazole (for
treatment of vaginal infections)
 The drugs can damage latex
 She should use other alternatives:- female condoms or plastic
male condoms, another contraceptive method, or abstain from
sex until treatment is completed
 Oral treatment recommended and will not harm condoms
 Severe allergy to latex condom

 Hives or rash over much of body, dizziness, difficulty
breathing, or loss of consciousness during or after condom use
14
Condom Breakage and Slippage

 Breakage= Condom develop hole or tear
 Slippage= Condom comes off the penis while it is still in
the vagina
 Causes for condom breakage or slippage

Opening package with teeth or sharp objects
Unrolling condom before putting it on
Having intercourse for more than 20 min
Having intense sexual intercourse
15
Female Condom
It is a tube made of thin, transparent, soft plastic film
(polyurethane) with a closed end, which fit loosely inside a
woman’s vagina
 Have f lexible rings at both ends
 One ring at the closed end helps to insert the condom
The ring at the open end holds part of the condom outside the
vagina
 Lubricated inside and out with a silicone-based lubricant
 Form a barrier that keeps sperm out of the vagina and keep
infections in semen, on the penis, or in the vagina from
infecting the other partner
16
Female Condom… Cont…
 Brief history
 Need for a wider choice of methods
 Need for a method that women can initiate and/or control
 Invented by Lasse Hessel, a Danish physician in the mid-
1980s
 Made up of strong loose-fitting polyurethane sheath
 17 cm long with a f lexible ring at each end
 Polyurethane
 Is a soft, thin plastic that is stronger than latex
 Conducts, heat so sex with the female condom can feel very
sensitive and natural
 Is odorless
 Is not tight or constricting
 Does not require a prescription or intervention by (health
professionals)
17
Medical Eligibility Criteria
 Any woman can use plastic female condoms
 No medical conditions prevent the use of this method
 When to start: Any time when the client wants
 Male and female condoms should not be used together
 This can cause friction that may lead to slipping or tearing of
the condoms
 Reuse of the female condom is not recommended
 Women can use the female condom during their monthly
bleeding
 The female condom can be used in any sexual position
 It is not used with spermicides
18
How Effective?
 Effectiveness depends on the user:
 Few pregnancies or infections occur due to incorrect use, slips,
or breaks
 Protection Against Pregnancy:
 As commonly used, about 21 pregnancies per 100 women
using female condoms over the first year
 When used correctly with every sex act, about 5 pregnancies
per 100 women over the first year
 Return of fertility after use of female condom is
stopped: No delay
 Protection Against HIV and Other STIs: Reduce the risk of
infection with STIs, including HIV, when used correctly with
19
every sex act
Client Satisfaction:
 Why some women say they like female condoms?
 Women can initiate their use
 Have a soft, moist texture that feels more natural during sex
 Protect against pregnancy and STIs, including HIV
 Outer ring provides added sexual stimulation for some women
 Can be used without seeing a health care provider
 Why some men say they like female condoms?

 Can be inserted ahead of time so do not interrupt sex
 Are not tight or constricting like male condoms
 Do not dull the sensation of sex like male condoms
 Do not have to be removed immediately after ejaculation
20
Side Effects, Health Benefits, and Health Risks
 Side Effects: None
 Health Benefits
 Help protect against:
 Risks of pregnancy
 STIs, including HIV
 Health Risks: None
Advantage
 Soft, loose-fitting plastic sheath.
 Physical barrier
 Protection from STIs/HIV and pregnancy
 Transfer heat
 Female controlled
21  Can be inserted 8 hours prior to sex
5 Basic Steps of Using a Female
Condom
1. Check the condom package: If possible, wash
your hands with mild soap and clean water
2. Before any physical contact, insert the
condom
 Can be inserted up to 8 hours before sex
 Choose a comfortable position —squat, raise one leg,
sit, or lie down
 About 2 to 3 centimeters of the condom and the outer
ring remain outside the vagina
3. Ensure that the penis enters the condom and
stays inside
 The man or woman should carefully guide the tip of
penis inside the condom
4. After the man withdraws his penis, hold the
outer ring of the condom, twist to seal in f luids,
and gently pull it out of the vagina
5. Dispose of the used condom safely
22
Advantages Disadvantages
 Female controlled  Difficult to insert
 Dual protection  Noise
 Can be inserted before  Too large- only one size
intercourse available
 No need to withdraw  Discomfort caused by
immediately rings
 Easy removal  Reduced pleasure
 Lubrication is possible  Penile misrouting
 No side effects of allergy  Uncomfortable in some
 Stronger & stores better than sexual positions
latex  Relatively expensive
23
 Breakage often is due to human error.

 Complaints
Inner ring cause discomfort when the penis hit it
Bothersome movement during sex
Noisy if not lubricated
 Men are less enthusiastic
24
How women can negotiate condom use with
partner?
 Emphasizing use of condoms for pregnancy prevention rather
than STI protection
 Appealing to concern for each other ; E.g.: “Many people in the
community have HIV infection, so we need to be careful”
 Taking an uncompromising stance; E.g.: “I cannot have sex with
you unless you use a condom”
 Suggesting to try a female condom, if available; some men prefer
them than male condoms
 For pregnant women, discussing the risks that STIs pose to the
health of the baby and stressing how condoms can help protect
the baby
 Informing partner that she is unable to take other methods of
contraception for health reason
25
Contraceptive Pregnancy Rates
Annual Accidental pregnancy rates for consistent
and correct use
Female condom Male condom
5% 3%
26
Diaphragm
 Circular, rubber dome with f lexible outer rim
 Covers the vaginal fornices & the cervix
 Shouldn't be removed for 6 hrs
 As commonly used, about 16 pregnancies per 100 women
using the diaphragm with spermicides over the first year
27
27
Diaphragm…
28
28
Cervical cap
 A bell-shaped rubber device that fits over the cervix
29
29
Spermicides – Nonoxynol-9
 Jellies, creams, foams or suppositories
 As commonly used, about 29 pregnancies per 100
women using spermicides over the first year
 Not recommended for clients who
 Are at high risk for HIV infection
 Have HIV infection
 Have AIDS
30
30
Short-acting Hormonal
Contraceptives

Objectives
After the end of this session, the students will be able to;
 Describe COCs, POPs and Injectables
 Explain effectiveness of COCs, POPs and Injectables
 Discuss characteristics of COCs, POPs and Injectables
 Describe when to start COCs, POPs and Injectables
 Discuss MEC, side effects and complications of COCs, POPs
and Injectables
2
Oral Contraceptive
Pills (OCPs)
3
Combined Oral Contraceptives (COC)
 Contain estrogen and progesterone
 Pills that contain low doses of two hormones; i.e.
progestin and an estrogen
 Work primarily by preventing the release of eggs from
the ovaries
 Women who are infected with HIV, have AIDS, or are on
ARV therapy can safely use COCs
4
5
COCs: Mechanisms of Action
Suppress ovulation
Reduce sperm transport

in upper genital tract
(fallopian tubes)
Change endometrium making

implantation less likely
Thicken cervical mucus

(preventing sperm
penetration)
5 3
COCs… Cont…
 Instructions: Begin with:
 The onset of menses
 6 weeks after delivery if breast feeding
 After 3 weeks if not breast feeding
 Immediately or within 7 days post-abortion
 Packing of 28 tablets containing 21 hormonal tabs and 7
placebo or iron
6
6
7
How to Take COCs:

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

8
How to Take COCs:

Missed Pills
Miss 3 or more • Take first missed pill as soon as you remember
active pills or • Continue daily pill taking as usual and use
start pack 3 or backup method or abstain for next 7 days
more days late • Count number of active pills remaining in pack
7 or more active Fewer than 7 active

pills left in the pack pills left in the pack
• Finish active pills • Finish active pills

• Take hormone-free break • Discard inactive pills
• Start new pack immediately
Source: WHO, 2004.

 Non Contraceptive Benefits: COCs decrease
 Benign breast disease
 Functional ovarian cyst
 Anemia
 PID
 Endometrial & ovarian Ca
 Dysmenorrhea
 Arthritis & osteoporosis
 Endometriosis
 Ectopic pregnancy
9
9
 Side effects & complications of COCs
 Nausea weight gain, chloasma, dizziness, mood change, acne
and mastalgia
 Thromboembolism
 Hypertension
 Benign liver tumor and jaundice
 Amenorrhea
 Who Can Use COCs Without Restriction
 Adolescents
 Nulliparous women
 Postpartum ( more than 3 weeks, if not BF)
 Immediately post-abortion
 Women with varicose veins
 Any weight (including obese)
 Who Should Not Use COCs: Women with:
 Pregnancy (but no proven negative effects on fetus)
 < 6 weeks post partum if breast feeding
 < 3 weeks post partum and not breast feeding
 6 weeks - 6 months post partum and breast feeding
 Age > 35 and smoker
 SBP 140-159 & DBP 90- 99
 SBP >160 & DBP >100
 DVT or pulmonary embolism
 Cardio vascular disease or increased risk of CV disease
 Breast cancer
 Liver disease
 Migraine head ache
 Woman taking rifampicin & phenytoin
11
11
Concerns with COC
 Cardiovascular disease
 COCs may slightly increase the risk of heart attack, stroke and
thromboembolism
 Breast cancer: No strong evidence of increased risk
 Cervical cancer: Small increased risk
 Liver cancer
 COC use is associated with growth of hepatocellular adenoma
For most healthy women the health benefit exceeds the health
risk
12
Progesterone Only Pills/ POPs
 28 pill pack, 1 pill to be taken daily
 Extra contraceptive method required if taken 3 hours apart
 Mechanism:
 Thicken cervical mucus & endometrial change
 Instruction: 28 pill pack, 1 pill to be taken daily
 Characteristics:
 Contains no estrogen
 Doesn't affect breast feeding
 Slightly increased incidence of EP
 May cause irregular uterine bleeding
 Extra contraceptive method required if taken 3 hrs apart
13
Injectables
14
Injectables Preparations
Progesterone only
 Medroxy progesterone acetate/ Depo-Provera 150 mg every 90
days IM
 Noristerat/NET-EN 200 mg every 2 months IM
 Uniject/Depo-subQ provera 104: Subcutaneous every 3 months
Combined: Given monthly IM

 Cyclofem (Cycloprovera/ Lunelle )= Medroxyprogesterone
acetate 25mg plus estradiol cypionate 5mg
 Mesigyna = Norethisterone enantate 50mg plus estradiol
valerate 5mg
 DMPA has a grace period of 4 weeks and delays fertility for an
15 average of 9 months
Injectables… Cont…
 Mechanism of action: Similar to OCPs
 Characteristics:
 Independent of coitus
 Independent of daily activity
 May cause irregular uterine bleeding
 May cause amenorrhea
 Delay in fertility after discontinuation
 Need for injection
 May cause weight change, headache, dizziness and fatigue
16
16
Depo-Provera (Injectables)
 Injection of 150 mg DMPA q 3 mo
 Women of any age and parity can use it (MEC Cat. 1, age 18-45;
Cat. 2, other ages)
 Start first 7 days after LMP, or can use any time reasonably sure
woman not pregnant
 Usable immediate PP if not BF; or 6th wk PP if BF
 Usable immediately after abortion
17
Who should not use DMPA
 Women with:
 Pregnancy
 Breast cancer
 Un explained vaginal bleeding
18
18
Long-acting
Hormonal Family
Planning Methods
1

Objectives
At the end of this session, the students will be able to:
 List different types of long-acting family planning methods
 Discuss the types of Implants
 Describe the mechanism of action of Implants
 Explain the effectiveness of Implants
 Discuss the medical eligibility criteria of Implants
 Demonstrate the proper insertion and removal of Implants
94
Types of Long-acting Contraceptives
Sinoplant
Jadelle Implants
Implanon
IUCD
95
Implants Service Provision
 Implant is a progesterone only long-acting method
 Can be used for 3 – 7 years depending on the number of
implants
 Implants are matchstick sized f lexible progestin-filled
rods or capsules that are placed just under the skin of
the upper arm
 An excellent option for women at all phases of their
reproductive lives, to delay, space, or limit births
96
Implants… Cont…
Comparison of Sinoplant, Jadelle & Implanon

Sinoplant Jadelle Implanon
 150 mg  150 mg  68 mg
levonorgestrel levonorgestrel etonogestrel
 2 rods  2 rods  1 rod
 Insertion: 2 min  Insertion: 2 min  Insertion: 1.1 min
 Removal: 4.9 min  Removal: 4.9 min  Removal: 2.6 min
 4 years  5 years  3 years
 Disposable  Autoclavable /  Pre-loaded /
disposable disposable
97
Implants… Cont…
Mechanism of Action
 Implants continually release a small amount of progestin
steadily into the blood
 The primary mechanisms are:
 Increases cervical mucus viscosity (within 48 – 72 Hrs)
 Inhibition of ovulation
 Alters endometrium, making it less conducive for

implantation
Effectiveness
<1 pregnancy per 100 women over the first year (5 per 10,000
women)
98
Implants… Cont…
Characteristics of Implants
 Are safe and easy to use/ convenient
 Highly effective long acting contraceptive method
 Not motivation dependent - No need for user compliance
 Rapidly reversible - no delay of fertility return after removal
 Do not increase frequency of ectopic pregnancy
 Stable hormone levels
 Contain no estrogen
 Safe for breast feeding mother (after 6 wks PP)
 May cause irregular bleeding
 Does not protect from STIs
 High initial cost
 Require minor surgical procedure for insertion /removal
99
Implants… Cont…
Who Can Use Implants?
 Suitable for nearly all women; including women who:
 Prefers a long-acting method
 Cannot remember to take a pill daily
 Is breastfeeding (starting 6 weeks postpartum)
 Cannot take estrogen-containing contraceptives
 Is post-abortal
 Has moderate to severe menstrual cramping
10
0
Implants… Cont…
Who can not use Implants ?
 Implants may not be appropriate for some women
 Use the WHO medical eligibility criteria
 Generally avoid in case of
 Serious liver disease
 Current DVT
 Unexplained vaginal bleeding
 Breast cancer (current or history)
10
1
Implants… Cont…
WHO Medical Eligibility Criteria Classification
Categories
Classification With clinical With limited
judgment clinical judgment
1 Use method in any Yes
circumstances
Use the method
2 Generally use:
advantages outweigh
risks
3 Generally do not use: No

risks outweigh
advantages Do not use the
4 Method not to be used
method
10
Implants… Cont…
Client Assessment
 Assess the client by taking history that:-
 Identifies the client’s reproductive goals
 Screens for precautions to the use of implants
 Depending on the client’s history, perform physical

examination
 Pelvic exam is not required for beginning Implant
 Pregnancy testing is unnecessary except in case where it is

difficult to rule out pregnancy
11
Implants… Cont…
Timing of Insertion: Times for insertion when changing
from another contraceptive
 Natural or barrier methods: before day 7 of cycle
 COC: within 7 days of last active pill
 Implant: when Implant is removed
 POP: on the day the last pill is taken
 Injectables: any time before next injection
Timing of Removal
 At anytime during the menstrual cycle
 At 5 years of use for Jadelle and 3 years for Implanon
 Anytime client requests removal, after adequate counseling

12
Jadelle®
10
5
Jadelle® Implant
 Introduction
 Two thin, f lexible rods to be inserted under the skin of upper
arm simultaneously
 Each rod contains 75mg levonorgestrel (LNG)
 Prevent pregnancy for up to 5years
 Packaged in a sealed, sterile plastic pouch
 Store away from excessive heat (>300º C) & moisture
 Currently provided with a sterile, single-use disposable trocar
 Effectiveness
 0.1 pregnancies per 100 women in the first year of use
10
6
Jadelle® … Cont…
Pre-insertion Counseling
 In a private setting, provide information on:-
 How it works,
 Its effectiveness,
 How it is inserted,
 Its characteristics,
 Common side effects, and
 When to return
 Care of the site
 Answer any questions that the client may have
10
7
Preparation
 Check that all instruments and supplies are ready:
 Examination table with arm support or side table
 Soap for washing the arm
 Marking or ballpoint pen
 Plastic template for marking the ’’V’’ shape position rods
 Set of two rods in the sterile pouch
 Equipments and other supplies
10
8
Equipments Needed for Insertion
Insertion Procedures
1. Confirm that informed consent is obtained
2. Check to be sure the client is eligible
3. Let her wash the entire non-dominant arm with soap and water
4. Locate the best insertion area (6 – 8cm above the elbow fold)
5. Mark “V” shape on the arm with an angle of about 15 degrees
6. Strictly use infection prevention practices
7. Use 2mL of local anesthetic (1% without epinephrine)
8. Hold the trocar at 45 degree angle with the bevel facing up
9. Do not remove the tip of the trocar form the incision until inserting
the second rod
10. Post insertion client instruction
18
Post-insertion Client Instructions
 Client instructions for wound care key points:
 Keep the insertion area dry & clean for at least 48 hrs
 Leave the upper gauze pressure bandage in place for 3 days
 Leave the smaller bandage in place for 5 days
 Bruising, swelling, or tenderness may occur for few days
 Routine work can be done immediately but avoid
 Bumping/hitting the area,
 Carrying heavy loads or
 Putting unusual pressure to the site
10
Post Insertion Instructions… Cont…
 Return to the health facility in case of:-
 Severe lower abdominal pain
 Heavy per-vaginal bleeding
 If the insertion site becomes red with increased heat and/or
tenderness
 If there is pus at the site
 Bleeding from insertion site
 Sign of expulsion
 Migraine headache
 For removal at the end of 5 years or anytime she decides to stop
the service
20
Removal Procedures
 Key points:
 An easy removal depends on correct insertion
 If the rods cannot be palpated or provider inexperienced in
removal, refer to a higher level facility

 Inject local anesthesia under the ends of the rods
 Remove first the rod that is closer
 If neither rod can be removed, stop the procedure, ask to return

when fully healed (4-6 weeks) and try again or refer
 If the client wants to continue using Jadelle, a new set can be

113 inserted at the time the current set is removed
Post-removal Procedure and Care:
 Press down on the incision with a gauze for a minute
 Bring the edges together & close with Band-aid/surgical tape
 Check for bleeding
 Document procedure in the client’s record
 Observe the client for 15-20 minutes
 Inform the client regarding wound care
 Give a return visit appointment, if needed
11
4
Implanon®
115
Implanon® Implant
 A single rod etonogestrel-containing reversible contraceptive
method
 40 mm in length and 2 mm in diameter
 One of the most effective methods: Over 3 years of use
 Less than 1 pregnancy per 100 women (1/1,000 women)
 Pre-loaded inserter
 Easier insertion and removal than Jadelle
 Store at 25°C (15°-30°C) and avoid direct sunlight
11
6
Implanon® … Cont…
117
Pre-insertion Counseling
 In a private setting, provide more detailed information
 How it works
 Its effectiveness
 How it is inserted
 Its characteristics
 Common side effects, and
 When to return
 Answer any questions that the client may have
11
8
Insertion Procedures
 Preparation and pre-insertion tasks are similar to that of
Jadelle®
 Insertion performed with a specially designed applicator
 Key points during:
 Ensure informed consent and eligibility for insertion
 Use 1mL of local anesthetic (1% without epinephrine)
11
9
Removal Procedures
 Mostly similar to that of Jadelle® removal
 Key points:
 Generally is easier and takes less time than that of Jadelle
 If the rod cannot be palpated or a provider inexperienced in
removal, refer to a higher level
 Slowly inject 2mL local anesthesia under the end of the rod
 Make a 2mm longitudinal incision at the distal end
 Follow infection prevention techniques
 Perform post-procedural tasks just the same as for Jadelle®
12
0
Implanon NXT®
Applicator
Implanon NXT®
 Sub-dermal, long-acting hormonal contraceptive, effective for
3 years
 Progesterone-only implant
 Preloaded in a disposable, sterile applicator
 It is radiopaque and bioequivalent to IMPLANON®
 Clinical trials with IMPLANON® in 17 countries, including the
U.S.A
 Clinical trials with Implanon NXT® in 6 countries
 Single use and disposable
 Provided only by health care providers authorized to carry out
these procedures
 Characterized by changes in menstrual bleeding pattern
12
2
Implanon NXT®... Cont...
Applicator design elements:

 Preloaded for single use only
 Cap-blocking mechanism with cap/lever
 Implant retained in needle before insertion
 Single-handed movement with slider
 Easy to use
 Needle partly visible
12
3
Insertion Procedure
 Remove the sterile preloaded disposable Implanon NXT®
applicator carrying the implant from the blister
 Hold the applicator just above the needle at the textured surface
area
 Remove the transparent protection cap from the needle which
contains the implant
 If the cap does not come off easily the applicator should not be
used and replaced by a new one
► You may see the white colored implant into
the tip of the needle
► Do not touch the purple slider until you
have fully inserted the needle
subcutaneously, as it will retract the needle
and release the implant from the applicator
Insertion... Cont...
► Stretch the skin around the insertion site with
thumb and index finger
► Puncture the skin with the tip of the needle
angled about 30°
► Carefully focus on the insertion site and the
movement of the needle
► Lower the applicator to a horizontal position
► While lifting the skin with the tip of the needle,
slide the needle to its full length
► You may feel slight resistance but do not exert
excessive force
► If the needle is not inserted to its full length,
the implant will not be inserted properly
► While keeping the applicator in the same position and the
needle inserted to its full length, unlock the purple slider by
pushing it slightly down
► Move the slider fully back until it stops, leaving the implant now
in its final sub-dermal position and locking the needle inside the
body of the applicator
► Remove the applicator
► Now the implant is in its final sub-dermal position
• Inserting the needle to its full length is crucial; failure to do so
will result in a partly visible implant protruding from the skin
• If partial protrusion occurs, discard the implant and reinsert a
new sterile implant using a new applicator
► Always verify the presence of the implant in the woman’s arm
immediately after insertion by palpation
► By palpating both ends of the implant, you should be able to
confirm the presence of the 4 cm rod
► A correctly inserted implant should be palpable
12
7
 Close the incision with a sterile strip
 Apply a sterile gauze with a pressure bandage to minimize bruising
 The woman may remove the pressure bandage after 24 hours and the
small bandage after 3 – 5 days
 Complete post-procedural tasks
 If the implant is not palpable, confirm its presence in the arm with
imaging techniques as soon as possible
 The woman must use a backup method of contraception until the
presence of the implant has been confirmed
12
8
Implants® … Cont…
Summary
 Implants are the results of advancement in contraceptive
options
 Offers women another choice
 Safe, highly effective, and rapidly reversible
 Can be used by most women
 Not user dependant
12
9
Intra-Uterine Contraceptive Devices
(IUCD)

Contents
 Overview of IUCDs
 Medical eligibility criteria for use of IUCDs
 Client assessment
 When to insert & remove an IUCD
 Insertion and removal procedures for IUCDs (Cu-
T380A)
2
World-wide Spread of IUD Use
Sub-Saharan Africa 0.4%
Oceania 0.01%
Developed Countries 5%
Latin America &
Caribbean 5%
Distribution of IUD
Near East &
Users by Region, 2005
North Africa 7%
Eastern Europe &

Central Asia 11%
China 60%
Other Asia 12%
large majorityU
ofsm
eadrriebdyIUm
D uo
serre
s wtoh
rldawn
ide1—
5600%m
, oirllion women worldwide of mar
ost 923million—live in China. The IUD is popular in a few other
Source: Salem, 2006.
Type of IUCD
1. Copper–bearing: includes
 Cu-T 380A, Cu-T 380A with safe load,
 Cu-T 200C,
 Multi-load (MLCu 250 and 375),
 Nova T Copper T-380A
2. Medicated: with a steroid hormone, such

as the levonorgestrel containing Mirena IUS
(intrauterine system)
LNG-IUS
4
Copper T 380A (CuT 380A):
 Shaped, with:-
 Polyethylene with barium sulfate
 314 mm of copper wire wound around the vertical stem
 Each of the two arms of the ‘T’ has a sleeve of copper
measuring 33 mm
 Duration 10 – 12 years
5
Parts of IUCDs (Cu T-380A)
Arms (Rt./Lt.)
Copper sleeve
(33mm×2=66mm2 )
Stem
Copper wire
(314mm2 )
String/Thread
Main frame: T shaped, flexible & containing barium sulfate

6
Mechanisms of Action
 Principal mechanism: Sterile foreign body reaction 
hostile environment  prevent or interfere fertilization by
affecting sperm motility
 Effect of progesterone: Thickening of cervical mucus
 Not abortificant
 Prevents fertilization by
 Impairing the viability of sperm and
 Interfering with movement of the sperm
7
Effectiveness of IUCDs
 Is one of the most effective contraceptive methods
 Efficacy – pregnancy rate < 1% woman years
 As typically used, 0.8 pregnancies per 100 women year in the
first year of use
 Continuation Rates and Client Satisfaction:
 Continuation rates are also high
 Approximately 70- 90% of women use their IUCDs for one year
after insertion
8
Effectiveness… Cont…
In this progression of effectiveness, where would you place
IUCDs?
Implants
More Female Sterilization
effective
IUCDs
DMPA
COCs
Male Condoms
Standard Days Method
Female Condoms
Less
effective
Spermicides
9
10
Effectiveness
Spermicides
Female condom
Diaphragm w/spermicides
Male condom
Oral contraceptives
DMPA
IUD (TCu-380A) Rate during perfect use
Female sterilization Rate during typical use

Implants
0 5 10 15 20 25 30
Percentage of women pregnant in first year of use
Source: CCP and WHO, 2007.

Characteristics of IUCDs
 Safe for most women
 Immediate effectiveness and reversible
 May be safely used by lactating and postpartum women
 Good choice for older women with COC precautions
 Long duration of use
 Considered as “reversible” permanent contraception
 Can be inserted on the day of visit

 Nothing is required during sexual intercourse
 Allows women privacy & control over their fertility
11
Characteristics of… Cont…
 Does not interact with medications
 Can be removed whenever the client wants
 Does not protect against STIs/HIV
 Trained provider needed to insert and remove
 Have some side effects
 Complications are rare, but may occur
12
Who Can Use IUCDs?
 Most women can use the Copper T IUCD safely, including
women who:
 Have or have not had children
 Are not married
 Are of any age
 Have just had an abortion or miscarriage (no infection)
 Are breastfeeding
 Have had PID
 Have vaginal infections
 Are infected with HIV or have AIDS and on ARVs
13
Who Cannot Use IUCDs?
 Use the WHO medical eligibility criteria for IUCD use
 Generally not appropriate for women:-
 With pregnancy (known or suspected)
 With unexplained vaginal bleeding
 Who is postpartum between 48hrs – 4wks
 With current pelvic infection (puerperal, post abortal, TB &
STI)
 With GTD or cervical/endometrial cancer
 With uterine cavity distortion (myoma or congenital)
 With AIDS cases (clinically not well)
14
WHO Medical Eligibility Criteria Classification
Categories
circumstances
Use the
2 Generally use:
advantages outweigh method
risks

risks outweigh
advantages Do not use the
method
4 Method not to be used
15
Who Can Initiate Copper IUCDs?
WHO Conditions
Category
Category 1 •≥20 years, cervical ectopy,
•Uterine fibroids without distortion of the
uterine cavity
•Irregular bleeding without heavy bleeding
Category 2 •Menarche to <20 years, Nulliparous,
•Heavy or prolonged bleeding,
•Severe dysmenorrhea,
•Anemia
16 Source: WHO, 2004; updated 2008.

Who Shouldn’t Initiate Copper IUCDs?
WHO Conditions
Category
Category 3 •48 hours to <4 weeks postpartum,
•Ovarian cancer/if initiating use,
•High individual risk of STI/ if initiating use
Category 4 •Pregnancy,
•Unexplained vaginal bleeding (prior to
evaluation),
•Current PID or cervical infection,
endometrial or cervical cancer/if initiating
use
17
Source: WHO, 2004; updated 2008.
IUCD Use by Women with HIV
WHO Eligibility Criteria
Condition Category
•IUCDs safe for majority of
Initiate Continue women with HIV
HIV-infected 2 2
•Initiation not recommended if
AIDS 3 2 woman has AIDS and is not on
(without ARVs) ARVs
ARV therapy 2 2
(clinically well)
•Encourage dual method use
18 Source: WHO, 2004; updated 2008.

Client Assessment
 Careful screening is crucial for successful IUCD use
 Taking history: Client Assessment (History) Checklist
 Perform brief P/E and complete pelvic exam to:
 Determine position and size of uterus
 Rule out likelihood of pregnancy
 Rule out presence of infections, masses, tumors, etc.
 Use pelvic, bimanual and speculum exam checklist
 Checklist for Screening Clients Who Want to Initiate Use

of the Cu- IUCD
10
IUD Checklist
This set of
questions
identifies
women who
are not
pregnant.
This set of
questions
identifies
women who
should not use
IUDs
The provider uses

these questions
during the pelvic
exam to identify
any category 3
and 4 conditions
20
Timing of Insertion
A woman can start using IUCDs any time she
wants if it is reasonably certain that she is not
pregnant
 Optimal times for insertion are
 Within 12 days from onset of menstrual bleeding
 Immediately or within 12 days after abortion (if no infection
is present)
 If <48 hours or > 4 weeks postpartum
 Switching from another method
 For emergency contraception
21
Timing for IUCD Removal
 At any time during the menstrual cycle
 Anytime the client requests for any reason
 Evidence of uterine perforation
 Known or suspected pregnancy
 Partial expulsion- may be replaced with a new one
 Persistent side effects or other health problems
 When IUCD has been in utero for its effective life
 Severe pain or server bleeding with marked anemia
22
Pre-insertion Counseling for Cu T-380A
 Effective client-centered counseling is key to successful,
ongoing IUCD use and its effectiveness
 Explain the insertion/removal procedure
 Provide post-insertion instructions
 Explain length of protection and when to return for removal

or replacement
 Describe reasons to return for follow-up
23
Counseling about IUDs:
Correcting Misconceptions
 IUCDs:
 Rarely lead to PID
 Do not increase risk of STIs, including HIV
 Do not work by causing abortion
 Do not make women infertile
 Do not move to the heart or brain
 Do not cause birth defects
 Do not cause pain for woman or man during sex
 Significantly reduce risk of ectopic pregnancy
24
25
IUCD Insertion Procedure
Instruments and Supplies
 IUD in unopened, undamaged, sterile package
 Bivalve speculum
 Tenaculum
 Uterine sound
 Ring forceps
 Sharp scissors
 Narrow forceps (uterine dressing or sponge)
 Light source to visualize cervix

 Gloves (single use disposable, or HDL, or sterile)
 Bowl with antiseptic solution
 Chlorine solution, 0.5%
 Sterile gauze/cotton balls
 Drape/cloth to cover table and woman’s pelvic area
Insertion Procedure… Cont…
Preventing Infection during Insertion
 Follow proper infection-prevention procedures
 Use HLD or sterile instruments
 Use an unopened, sterile IUCD packaged with its inserter
 Load IUCD into the inserter while it is still in the sterile package
 Clean cervix with antiseptic before insertion
 Do not touch vaginal wall or speculum blades with sound or
inserter
 Pass sound and loaded IUD only once through cervical canal
27
IUD Insertion Procedure Overview
1. Conduct speculum and bimanual pelvic examination to:
— Screen for eligibility
— Determine the position of the uterus
2. Sound the uterus to determine depth
3. Load the IUD into inserter without taking it out of the sterile
package
4. Set the depth-gauge to sounded depth

5. Place the IUD into the uterus
6. Allow the woman to rest
28
Step 1: Perform Pelvic Exam
1. Conduct pelvic exam (speculum exam, then bimanual
exam)
2. Screen for medical eligibility:
 If no signs and symptoms of infection—proceed with
insertion
 If suspicious of infection—do not insert IUCD— diagnose /
treat as appropriate, then reassess for insertion
3. Assess position of uterus (tilted up or down) to determine
appropriate orientation of sound
29
Step 2: Sound the Uterus
1. Clean the cervix with an antiseptic solution
2. Apply a tenaculum to the cervix
3. Gently pull the tenaculum to align the uterus, cervical opening, and
vaginal canal
4. Insert the uterine sound into the vagina and through the cervical
opening
5. Advance the sound into the uterine cavity until a slight resistance is
felt
6. Slowly withdraw the sound and assess the level of mucus/blood to
determine the depth of the uterus (average depth is 6 to 8 cm)
30
Step 3: Load the Copper T IUCD
 Load the IUCD by folding its a
rms
and placing them inside the in
sertion
tube
 Do not load more than five minutes

before inserting the IUCD into the
uterus
 If IUD arms remain folded for more
than five minutes, they may not
return to their original shape when
released
31
Step 4: Set Depth-Gauge
Set the blue depth-gauge to the uterine depth as
measured by the sound:
Ensure that the distance between tip of IUCD and the inside
edge of depth-gauge is equal to depth of the uterus
32
Step 5: Insert IUCD into Vagina
 Gently grasp the tenaculum

(still in place from sounding
the uterus) and apply gentle
traction
 Insert the loaded IUCD,

without touching vaginal
walls or speculum blades
33
Step 6: Advance IUCD into Uterus
 Gently advance the loaded IUD into

the uterine cavity
 STOP when the blue depth-gauge

comes in contact with the cervix or
light resistance is felt
34
Step 7: Release Arms of Copper T
 Hold the tenaculum

and white plunger
rod stationary, while
partially withdrawing
the insertion tube
 This releases the arms

of the Copper T
35
Step 8: Gently Push Insertion Tube
 Gently push the

insertion tube until
you feel a slight
resistance
 This step ensures

placement high in the
uterus
36
Step 9: Remove Plunger Rod
 Remove the white plunger
rod, while holding the
insertion tube stationary
37
Step 10: Partially Withdraw Inserter
 Gently and slowly withdraw

the inserter tube from the
cervical canal until strings can
be seen protruding from the
cervical opening
38
Step 11: Cut IUCD Strings
 Use sharp Mayo scissors to

cut the IUCD strings at 3–4
cm from the cervical opening
If scissors are dull, the
strings may get caught in
blades
 Completely withdraw
insertion tube with cut ends
of strings inside
39
Step 12: Remove Tenaculum
 Gently remove the

tenaculum
 Observe the woman’s cervix
for bleeding
 If there is bleeding, hold
swab to site using clean
forceps
49
Step 13: Remove Speculum and
Decontaminate Instruments
 Gently remove the
speculum
 Place tenaculum and

speculum in a 0.5%
chlorine solution for 10
minutes for
decontamination
41
Step 14: Allow Woman to Rest
 Allow the woman to rest

 Begin post-insertion
tasks
 Provide post-insertion
instructions
42
Post Insertion Client Instructions
 Proper client instruction promotes continued use; in
particular, she should know
 Type of IUCD inserted
 When to be removed/replaced
 That IUCD provides no protection against HIV or other STIs
 When to come back for a check up
 Health risks of IUCDs
 Symptoms of health problems
 How soon IUCD effective
43
Post Insertion Instructions… Cont…
 Advise client to return immediately if:
 She thinks she is pregnant
 She has persistent severe abdominal pain, fever or unusual
vaginal discharge
 She or her partner feels pain/discomfort during intercourse
 She has sudden change in her menstrual periods
 She has irregular bleeding or pain every cycle
 She wishes to have the device removed
 She cannot feel the IUCD’s threads/ strings
44
Follow-up after IUCD Insertion
 A follow-up visit after her first monthly bleeding or 3 to 6
weeks after IUCD insertion is recommended
 This allows for:
 The exclusion of infection
 Assessment of bleeding patterns
 Assessment of client and partner satisfaction
 Opportunity to reinforce the issue of condom use
 NB: No woman should be denied an IUCD, however,

because follow-up would be difficult or not possible
45
Basic Principles for IUCD Insertion
and Removal
 Be gentle during the procedures
 Use No-touch technique
 The Cu-T should be loaded using the ‘no-touch’ technique,
inside the package
 The cervix and vagina should be thoroughly prepared with
antiseptic solution (Betadine or Povidone Iodine)
 Sound uterus to confirm the position & depth of cavity
 Use withdrawal technique
46
Summary
IUDs are:
 Safe, effective, convenient, reversible, long lasting,
cost-effective, easy to use, and appropriate for the
majority of women
Providers can ensure safety by:
 Informative counseling
 Careful screening
 Appropriate infection prevention
practices
 Proper follow-up
47
Objectives
 Explain the concept of medical eligibility criteria
 Describe the four categories of medical eligibility criteria
 Explain categories for female sterilization and fertility awareness
Methods
 Demonstrate how to use the MEC table
Medical Eligibility Criteria for
Contraceptive Use (MEC)
 Covers 19 contraceptive methods, 120
medical conditions
 Over 1700 recommendations on who
can use various contraceptive methods
 Gives guidance to providers for clients
with medical problems or other special
conditions
3
Purpose of the Medical Eligibility Criteria
(MEC)
 To base guidelines for family planning practices on the best available
evidence
 To address and change misconceptions about who can and cannot
safely use contraception
 To reduce medical policy and practice barriers (i.e., unjustified by
the evidence)
 To improve quality, access and use of family planning services
4
What Is Answered by WHO’s MEC?
In the presence of a given individual characteristic or
medical condition,
Can a particular contraceptive method be used?
5
Categories:
 The conditions affecting eligibility for the use of each
method are classified under in to four categories:
1. A condition for which there is no restriction for the use of the
contraceptive method.
2. A condition where the advantages of using the method generally
outweigh the theoretical or proven risks.
3. A condition where the theoretical or proven risks usually outweigh the
advantages of using the method.
4. A condition which represents an unacceptable health risk if the
contraceptive method is used.
6
WHO Medical Eligibility Criteria
Classification Categories
circumstances
Use the method
2 Generally use: Yes
advantages outweigh risks Use the method
risks outweigh advantages Do not use the method
4 Method not to be used No

Do not use the method
7
8
Initiation versus continuation
 The MEC addressed the medical evidence for the initiation and
continuation of use of all methods evaluated.
 Continuation criteria is clinically relevant whenever a woman develops
the condition while she is using the method.
 Differences for initiation and continuation are noted as 'I=Initiation'
and 'C=Continuation'.
9
WHO Eligibility Criteria: Examples
Medical Condition/ Contraceptive Category
Characteristic Method
Uterine fibroids COCs 1
Nulliparous IUD 2
Breast feeding DMPA 3

and < 6 weeks PP
current Implants 4
breast cancer
10
Exercise
Method Condition Category
IUD 24 years old woman, with 2 children
COC 30 years old woman, with varicose veins
IUD A client using an IUD finds out that she is

HIV+
Jadelle 40 years old women, five living children
presenting with vaginal bleeding
DMPA For a client with BP of 150/90 mmHg
COC For a client with goiter

Categories for Sterilization
Accept (A) • There is no medical reason to deny sterilization to
a person with this condition.
Caution (C)  The procedure is normally conducted in a routine
setting, but with extra preparation and
precautions.
Delay (D)  The procedure is delayed until the condition is
evaluated and/or corrected.
Special (S)  The procedure should be undertaken in a setting
with an experienced surgeon and staff, equipment
needed to provide general anaesthesia, and other
back-up medical support
Categories for Fertility awareness methods
Accept  There is no medical reason to deny the particular
(A) FAB method to a woman in this circumstance.
Caution  The method is normally provided in a routine
(C) setting, but with extra preparation and
precautions.
 Special counseling may be needed to ensure
correct use of the method by a woman in this
circumstance.
Delay  Use of this method should be delayed until the
(D) condition is evaluated or corrected.
NA • Not applicable
Thank You
All!

Family Planning and Contrceptives For Midwifery Students

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Introduction to

By:- Abdusamed M. (MSc, PhD Candidate)

 Differentiate family planning and contraceptives

 Discuss the rationale of family planning

 Describe the legal aspects contraceptives

 List different types of family planning methods

 Family planning – includes both fertility inhibition

 Ideal contraception – is contraception which is widely

 To avoid childbearing because of the effects of preexisting

illness on the pregnancy, such as severe diabetes or heart

 Reducing high fertility and slowing population growth

 To control potentially negative effects of rapid population

growth and high fertility on living standards of human being

 High rates of infant, child, and maternal mortality as well as

abortion and its health consequences, were pressing health

 Benefits to women’s health:-

 Avoiding pregnancy at the extremes of maternal age

 Decreasing risks by decreasing parity

 Preventing high-risk pregnancies

 Prevention of unwanted pregnancy

 Improving health through non-contraceptive benefits

including prevention of STIs and reproductive cancers

Family planning benefits children’s health

 Infants born at least 24 months after the previous

birth have lower mortality

 More food and other resources available

 Greater opportunity for emotional support from

 Better opportunity for education

contraception with detailed information about

 Use of the method(s) and its benefits

 Risks and side effects

 So that the patient can make an informed choice relative to a particular

 Providers must be careful to avoid imposing their own religious or

moral views on their patients

 Documentation of the discussion with the patient is important both

clinically and legally in particular, when using methods that require

 Reversibility and time to return of fertility

 Effect on uterine bleeding

 Frequency of side effects and adverse events

 Protection against sexually transmitted diseases

Hormonal Methods  Symptothermal

By:- Abdusamed M. (MSc, PhD Candidate)

 Describe the mechanism of action of natural family planning

 Differentiates the advantages and disadvantages of natural

family planning methods

 Results in deposition of the semen outside the female genital tract

 Demands sufficient self-control by the man so that withdrawal

 Failure rate is higher than that of most methods

 Failure may result from:

 Escape of semen before orgasm; or

 Washing the vulva with plain water, vinegar, and a number

of "feminine hygiene" products

 The additives to the water may possess some spermicidal

mucus within 90 seconds after ejaculation

 Hence, the method is ineffective and unreliable

 Fertility Awareness Methods

 It is also called periodic abstinence or natural family planning

 A woman can use several ways, alone or in combination, to