
Goal: to assist clients with reproductive
decision making, enabling the client to
have control in preventing pregnancy,
limiting the number of children, spacing the
time between children, and voluntarily
interrupting pregnancy as desired.
Safe
 Easily available
 Economical
 Available
 Simple to use
 Promptly reversible

Foster safe environment for consultation
 Provide correct education
 Distinguish myth from fact
 Clarify misinformation
 Fill in gaps of knowledge
 Provide visual samples
 Gain a complete history

Menstrual history
 Contraceptive history
 Contraceptive goal
 Obstetric history
 Medical history
 Familial history

Natural Methods
1) Abstinence
2) Coitus interruptus
 Fertility awareness methods
1) Calendar method
2) Basal body temperature method
3) Cervical mucus method
4) Symptothermal method






Spermicides & barrier
methods
* condoms
* diaphragm
* cervical cap
* cervical sponge
Hormonal methods
Emergency
contraception
Intrauterine devices
Sterilization

The practice of avoiding sexual
intercourse
Safe
 Free
 Available to all
 100% effective in preventing pregnancy
& STIs
 Can be initiated at any time
 Encourages communication between
partners


Both participants must practice selfcontrol

Teach alternative methods of obtaining
sexual pleasure

Provide positive feedback to clients who
desire and maintain abstinence
AKA withdrawal
 Male partner
withdraws penis prior
to ejaculation
 Effectiveness
depends on man’s
ability to withdraw
prior to ejaculation


Can be practiced at any time during the
menstrual cycle

Free
One of the least reliable contraceptive
methods
 Only 80% effective
 Does not protect from STIs
 Some pre-ejaculatory fluid, which may
contain sperm, may escape from the
penis during the excitement phase prior
to ejaculation
 At the peak of sexual excitement,
exercising self-control may be difficult

Before engaging in sexual intercourse,
the male should urinate and wipe off the
tip of the penis to decrease the potential
of introducing sperm into the vagina
 Conception may occur if preejaculatory fluid containing sperm enters
the vagina
 A spermicide or post-coital
contraceptive may be needed if the
female partner is exposed to sperm


Calendar based
methods

Symptoms based
method

Biologic marker
methods
Free
 Safe
 Acceptable to couples whose religious
beliefs prohibit other methods, such as
Roman Catholics
 Increases awareness of the woman’s
body
 Encourages couple communication
 Can be used to prevent or plan a
pregnancy

Requires extensive initial counseling and
education
 May interfere with sexual spontaneity
 May be difficult or impossible for women
with irregular menstrual cycles
 Used alone, they offer no protection
against sexually transmitted infection
 Less effective in actual use


Based on assumption that ovulation
occurs 14 days prior to the next menses,
sperm are viable for 5 days, and the
ovum is capable of being fertilized for 24
hours

91% effective if used perfectly
Based on number of days in each cycle,
counting from first day of menses
 Beginning of fertile period is estimated by
subtracting 18 days from length of
shortest cycle in last 6 months
 End of fertile period is determined by
subtracting 11 days from length of
longest cycle


Shortest cycle 24 days
24-18 = 6th day

Longest cycle 30 days
30 -11 = 19th day
•
To avoid conception the couple would
abstain during the fertile period days 619

You are educating a client on the
contraceptive calendar rhythm method.
When you ask her how long her cycles
have been for the last 6 months, she
explains that her cycle is consistently 28
days. What days should you tell her to
abstain from sexual intercourse???

Shortest cycle 28 days
28 -18 = 10th day

Longest cycle 28 days
28 – 11 = 17th day
To avoid pregnancy the couple abstains
from day 10-17.

Attempting to predict future events with
past data







A modified form of calendar rhythm
method
Has fixed number of days of fertility for each
cycle
Day 8 – 19
Cycle Beads (bracelet)
Is useful for women who have 26-32 day
cycle
Unreliable for others
12% failure rate

Based on monitoring and recording of
cervical secretions

Cervical mucus changes occur in
response to levels of estrogen and
progesterone

Spinnbarkeit – Watery thin, clear mucus becomes
more abundant and thick. Feels similar to a
lubricant and can be stretched 5+ cm between
the thumb and forefinger
Presence indicates period of maximal
fertility
Sperm deposited in this type of mucus
can survive until ovulation occurs

Cervical mucus that accompanies
ovulation is necessary for viability &
motility of sperm

Mucus alters pH by neutralizing acid
Contraceptive gels or foams
 Vaginal infection
 Douches
 Vaginal deodorant
 Medications (antihistamines dry up
mucus)
 Sexually aroused state thins mucus
 Uncomfortable touching genitals

Assess cervical mucus daily
 Avoid intercourse when first notices
cervical mucus becoming more clear,
elastic, and slippery and then for 4 days
 Instruct women on barriers to cervical
mucus assessment


BBT is lowest body temperature of a healthy
person taken immediately after waking and
before getting out of bed

BBT varies from 36.2-36.3 during menses and 5 7 days after

At time of ovulation there is a slight decrease in
temperature (fertile period)

After ovulation the BBT increases slightly and
remains until 2-4 days prior to menstruation

Fertile period is day of first temp drop or first
elevation through 3 days of elevated temp

Abstinence begins the first day of menstrual
bleeding and lasts through 3 consecutive days
of sustained temp rise
Temps are recorded on graph
97% effective if performed correctly

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

Infection
Fatigue
Less than 3 hours sleep per night
Awakening late
Anxiety
New thermometer
Jet lag
Alcohol
Antipyretic medications
Heated waterbed
Electric blanket
Calendar rhythm method
 Two day method
 BBT


Detects the sudden surge of luteinizing
hormone (LH) that occurs 12-24 hours
before ovulation

Test is not affected by illness, emotional
upset, or physical activity
Spermicide
 Male condom
 Female condom
 Diaphragm
 Cervical cap
 Contraceptive sponge
 Intrauterine device (IUD)





Serve as chemical barriers
against the sperm
Nonoxynol-9 (N-9) work by
reducing the sperm’s
mobility
Attacks sperm flagella and
body so they cannot
reach the cervical os
Use of N-9 too often could
increase transmission of
HIV by disrupting vaginal
mucosa
Foams
Tablets
Suppositories
Creams
Films
Gels
Preloaded single-dose applicators
Inserted high in vagina to reach cervix
Inserted 15 min – 1 hr before sexual
intercourse
 When used alone 94% effective









No prescription required
 May be used alone or with a diaphragm
or condom
 May add additional lubrication and
moisture
 Penis can remain in vagina following
ejaculation
 Safe for breast-feeding women
 Several choices

The spermicide may be irritating to one
or both clients
 Some forms may be perceived as messy
 May interfere with spontaneity







Apply spermicide inside vagina & close to
the cervix prior to inserting penis
Spermicides must be applied with each act
of sexual intercourse
Onset of spermicidal action varies
When used alone effectiveness lasts no
longer than 1 hour
Foams, creams, & gels are effective
immediately
Vaginal contraceptive film & suppositories
become effective 15 minutes after insertion
into vagina
Are made of latex, polyurethane, or
animal tissue
 Polyurethane is thinner and stronger than
latex
 Protects against pregnancy and some
STIs
 Latex condoms will break down with oilbased lubricants
 Only water-based or silicone lubricants
should be used

Males are able to participate in
contraception
 Sexual intercourse may be prolonged
 Condoms are available in a variety of
sizes & styles at low cost or free
 Partners can participate in placing the
condom to enhance enjoyment
 All condoms except those made of
natural skins offer protection against
pregnancy

Natural skin condoms (lamb cecum)
does not provide same protection
against STIs & HIV
 Contain small pores that could allow
passage of viruses such as hepatitis B,
HSV, & HIV

Penis must be erect before placing the
condom on
 To prevent spillage of semen, the male
must withdraw after ejaculating, while
the penis is still erect
 Condoms can rupture or leak
 Oil-based lubricants can decrease
effectiveness of condom

Make sure to educate on proper use
and fit
 Condom should be in place prior to any
penile penetration








Check expiration date on package
Avoid using oil-based lubricants
Put on condom by placing condom on the tip
of the erect penis, leaving enough room at tip
to collect sperm, then unroll condom from tip
of erect penis to base
After intercourse erect penis should be
withdrawn from vagina while holding rim of
condom to prevent leakage
Inspect used condom for tears or holes
Discard used condom in disposable waste
container
Do not flush in toilet

Thin, polyurethane sheath with flexible
rings at each end, which covers cervix,
lines vagina, and partially shields
perineum

95% effective with perfect use
May be inserted up to 8 hours prior to
intercourse
 Not made of latex
 Both partners are protected against STIs
 Available without prescription
 Use of lubricants will not decrease
effectiveness
 Breast-feeding women can safely use

May twist or slip during intercourse
 Improper removal results in risk of
ejaculate leaking
 Outer ring may irritate external genitalia
 High cost
 Noise produced with intercourse
 Altered sensation
 Initial insertion may be awkward

Insert closed end of condom into vagina
so ring fits loosely against cervix
 After intercourse, condom should be
removed before standing up by
squeezing and twisting outer ring to close
sheath while gently pulling out of vagina


A shallow dome-shaped latex or silicone
device with a flexible rim that covers
cervix.
Gives woman control
 Partner may insert diaphragm as part of
foreplay
 Diaphragm contains no hormones and is
safe for breast-feeding client
 Penis can remain inside vagina after
ejaculation

Must be fitted by healthcare provider
 Must be replaced every 2 years
 Refitting & replacement may be needed
following pregnancy or a 15 pound
weight gain or loss (20% weight
fluctuation)
 Difficulty with learning how to place
correctly
 Should not be used if client has UTI or TSS
or history of either

Available in many sizes
 Should be largest size woman can wear
without her being aware of its presence
 Most effective when used with
spermicide
 Annual gynecologic exam to assess fit
 Inspect device prior to each use

Hold diaphragm up to light source
 Carefully stretch at area of the rim, on all
sides
 Make sure there are no holes
 Sharp fingernails can puncture
diaphragm
 Can fill diaphragm with water to assess
for holes
 If diaphragm is puckered do not use

Can be inserted up to 6 hours prior to intercourse
 Hold diaphragm between thumb and fingers
 Dome can be up or down
 Insert inward and downward as far as it will go
 Do not use oil based products such as vaginal
lubricants b/c they weaken the rubber


Diaphragms are contraindicated
for women with pelvic relaxation,
uterine prolapse, or large
cystocele.

Not a good option for women with
poor vaginal muscle tone or
recurrent UTIs

Toxic shock syndrome TSS can
occur



Remove diaphragm within 6-8 hours after intercourse
Do not use diaphragm or cervical cap during menses
Watch for danger signs of TSS
* Sunburn type rash
* diarrhea
* dizziness
* faintness
* sudden high fever
* vomiting
* weakness
* sore throat
* aching muscles and joints
Should be inserted 6 hours prior to sexual
intercourse
 Should remain 6 hours after sexual
intercourse

Small thimble-shaped device
 Made of soft rubber
 Fits over cervix
 Held in place by suction
 Acts as barrier b/t sperm & cervix
 Effectiveness determined by
childbearing hx
 Nulliparous – 91% effective
 Parous = 74% effective






Three types
Advantages &
disadvantages same as
diaphragm
Should remain in place for at
least 6 hours and no more
than 48 hours after
intercourse
Provides a physical barrier to
sperm
Spermicide is inside the cap
Fits the same way as a diaphragm
 Requires less spermicide than the
diaphragm
 Can be inserted hours before sexual
intercourse without need for
additional spermicide
 Repeated acts of intercourse are
possible
 There is a potential risk of TSS







Small, round polyurethane
sponge that contains N-9
spermicide
Designed to fit over cervix
One size fits all
One side is concave
Other side has woven
polyester loop to be used for
removal of sponge
Before insertion, sponge must
be moistened with water
Provides protection for 24 hours
 Should be left in place for at least 6 hours
after last intercourse
 Wearing longer than 24 hours places
women at risk for TSS

More than 30 different formulations
 Oral
 Transdermal
 Vaginal
 Injectable
 Emergency
 Intrauterine

AKA COCs
 Suppress the action of the hypothalamus
& anterior pituitary which leads to
insufficient secretion of FSH & LH
 Follicles do not mature
 Ovulation is inhibited
 Should be taken at
the same time each
day


Available in 21 day, 28 day, 91 day
packages

99.1% effective if used perfectly
Is initiated on the first Sunday after day
one of the menstrual cycle or after
childbirth or abortion
 Another form of contraception should be
used throughout the first week
 Taken the same time each day
 Almost 100% effective
 Almost all failures are a result of omission
of one or more pills during regimen

From 1-4 days after last
COC, the endometrium
soughs and bleeds
 Due to hormone
withdrawal
 Bleeding is less profuse
than normal menstruation
 May only last 2-3 days


If one pill is missed:
* take pill immediately
* begin regimen with time new pill
taken
* no alternate forms of
contraception is necessary

If two pills are missed
* Take one pill every day until Sunday
* Begin new pack on Sunday
* Do not take 2 pills at same time
* Use backup contraception for one
week








Does not effect sexual act
Improvement in sexual response may occur
once possibility of pregnancy is not an issue
Convenience of knowing when next
menstrual flow will occur
Decreased menstrual blood loss
Decreased iron-deficiency anemia
Regulation of irregular cycles
Reduced incidence of dysmenorrhea &
PMS
Return to fertility happens quickly
No protection against STIs
 Clients need to remember to take a pill
at the same time each day
 Clients with preexisting medical problems
may not be candidates for this method
 Effectiveness may be decreased with
certain medications
 May decrease effectiveness of insulin or
warfarin (coumadin)

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









thromboembolic disorders
cerebrovascular or coronary artery disease
breast cancer
Estrogen dependent neoplasms
Currently pregnant, lactation <6 weeks
postpartum
Smokes
>35 years old
Hypertension
DM with vascular disease
Surgery on legs
gallbladder disease










Nausea
Breast tenderness
Fluid retention
Chloasma (klo – as-mah)
Increased appetite
Tiredness
Depression
Breast tenderness
Hirsutism
Bleeding irregularities
Attributable to estrogen, progestin, or
both
 Stroke
 MI
 Thromboembolism
 Hypertension
 Gallbladder disease
 Liver tumors


The right product for a woman contains
the lowest dose or hormones that
prevents ovulation and that has the
fewest and least harmful side effects
phenytoin (Dilantin)
 topirimate (Topamax)
 ampicillin (Omnipen)
 tetracycline (Achromycin)
 penobarbital
 rifampin (Rifadin)
 Anti-HIV inhibitors
 St. John’s wort

A drop of blood or small brown smear
counts as a period
 All women taking oral contraceptives
should be aware of alternate methods of
contraception
 Assure woman knows that oral
contraceptives will not protect them
from STIs or HIV

Some women take COCs in 3 month
cycles
 Have fewer menstrual periods
 Seasonale

› Take 3 months of active pills followed by 1
week of inactive pills
› Menstrual period occur during 13th week
› If 13th week period does not occur, woman
should consider pregnancy
Small continuous levels of progesterone
and estrogen are released to suppress
ovulation
 Applied to intact skin of upper outer
arms, upper torso, lower abdomen &
buttocks

Patch requires only weekly application
 Patch stays on even when showering
and swimming

No protection against sexually
transmitted infections
 Not recommended for obese women, or
women with skin disorders
 Clients with preexisting medical diseases
may not be candidates for this method
 Medication precautions are same as oral
contraceptives

Do not apply to breasts
 Apply same day once a week for 3
weeks
 Followed by week without patch
 Failure rate < 8% in women weighing less
than 198 pounds







Available only with a
prescription
Flexible ring made of ethylene
vinyl
Worn in the vagina to deliver
continuous levels of
progesterone & estrogen
Worn for 3 weeks
Followed by 1 week without ring
Bleeding occurs during ring free
week
Requires application only once every 4
weeks
 Requires no special fitting
 Can safely be left in place during
exercise or intercourse

Offers no protection against sexually
transmitted infections
 Clients with marked vaginal prolapse
should be cautioned to check for
expulsion
 Med precautions are same as taking oral
contraceptives

Ring is inserted by woman
 Does not have to be fitted
 If woman or partner notices discomfort
during coitus, ring can be removed and
still be effective up to 3 hours
 Failure rate is < 8 %


Impair fertility by inhibiting ovulation,
thickening and decreasing the amount
of cervical mucus, thinning the
endometrium, and altering cilia in the
uterine tubes
Oral
 Injectable
 Implantable


95.5% effective

May be used by:
* lactating women
* women with mild hypertension
Failure rate 1-10%
 Must be taken correctly to increase
effectiveness
 Must be taken at same time every day


If client misses one pill
* missed pill should be taken
immediately
* next pill taken at regular time
* Additional method of contraception
through end of that cycle
Depo-provera
 Given IM or
subcutaneously 4 times a
year
 Should be initiated during
first 5 days of menstrual
cycle
 Administered every 11-13
weeks
 97.7% effective

Blocks the luteinizing hormone surge
 Suppresses ovulation
 Thickens cervical mucus to prevent
penetration of sperm


Subsequent dose must be given 80-90
days after previous dose for continuous
contraceptive protection

Return of fertility may be delayed up to 1
year after stopping this method
Norplant
 6 Implants are inserted
under the skin of the
woman’s arm
 Effective up to 3 years
 Prevent ovulatory cycles,
thicken cervical mucus

Irregular menstrual bleeding
 HA
 Nervousness
 Nausea
 Skin changes
 Vertigo

Not user-dependent for effectiveness
 99.95% effective
 Does not contain estrogen
 Effective within 24 hours
 Lasts up to 5 years

Minor surgery for insertion & removal
 May be visible under skin
 Irregular or prolonged menses
 No protection against STI
 Slightly higher failure rates in women
>154 pounds in fifth year of use






Plan B
Available without a
prescription
Is available in 1 or 2 dose
regimens
Should be taken by
women as soon as
possible within 120 hours of
unprotected intercourse,
or birth control mishap
Risk of pregnancy is
reduced by 75% - 89%

If taken before ovulation emergency contraception
prevents ovulation by inhibiting follicular
development

If taken after ovulation there is little effect on ovarian
hormone production or endometrium

If woman does not begin menstruation within 21
days, she should be evaluated for pregnancy

Is ineffective if the woman is pregnant because the
pills do not disturb an implanted pregnancy
A small T-shaped device with bendable
arms for insertion through the cervix into
the uterus
 Mirena – releases levonorgestrel
gradually from a reservoir
 Impairs sperm motility, thickens cervical
mucus, decreases lining of uterus
 Uterine cramping & bleeding is
decreased
 Effective for 5 years

Provider inserts against uterine fundus
 Arms open near fallopian tubes
 Adversely affect sperm motility & irritate
lining of uterus
 Failure rate < 1%


2 strings hang from base of
stem through cervix &
protrude into vagina

Woman must have
negative pregnancy test,
cervical cultures to rule out
STIs & consent form signed
Long-term protection
 Highly effective
 Continuous protection
 Good option for women
who cannot use hormone
contraception,
breastfeeding, >35, or
smoke
 Immediate return to
fertility when removed

Has to be inserted by healthcare
provider
 Risk of PID
 Unintentional expulsion of device
 Infection
 Possible uterine perforation
 No protection against HIV or STIs


Teach woman to check for strings once
a week for first month then once a
month after menstruation
P – period late, abnormal
 A – abdominal pain; pain with intercourse
 I – Infection exposure, abnormal vag d/c
 N – not feeling well, fever, chills
 S - string missing, shorter, longer

Refers to surgical procedures intended
to render a person infertile
 Involves the occlusion of the
passageways for the ova & sperm
 Woman – uterine tubes are occluded
 Men – vas deferens are occluded
 Only a hysterectomy or oopherectomy
guarantees absolute sterility in women

Fallopian tubes are
accessed through two
small incisions into the
abdomen and visualized
using a laparoscope
 They are cut, tied,
cauterized, or banded
to block passage of
sperm & prevent ovum
from becoming fertilized
 96-99% effective

Takes 20-30 minutes
 Performed under general or local
anesthesia
 Pain for several days
 Avoid tub baths for 48 hours
 Avoid driving, lifting, & strenuous activity
for 1 week


Health care provider must be certain
woman is not pregnant

½ are performed immediately after
pregnancy
Permanent and effective in preventing
pregnancy
 May be performed at any time
 Immediately after childbirth is optimal
b/c uterus is enlarged and fallopian
tubes are easily identifiable
 Sexual function and spontaneity are not
affected


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




Requires outpatient surgery
Potential complications such as infection &
bleeding
If pregnancy does occur risk for ectopic
pregnancy is increased
Reversal of procedure is not always possible
Sterilization offers no protection from STIs
May feel pain at ovulation
The ovum disintegrates within the
abdominal cavity
AKA vasectomy
 Sealing, tying, or cutting vas deferens
 Sperm cannot travel from testes to penis
 Done on outpatient basis
 Permanent method of sterilization
 Reversal is generally unsuccessful

99.85% effective
 Recovery time is short
 Simpler, safer, and more effective than
female sterilization
 Complications are rare
 Sexual function is not affected
 Cost effective
 Convenient


Very unlikely that it can be reversed

Potential complications include adverse
infection, bleeding, sperm granuloma or
spontaneous re-anastomosis of vas
deferens
Ice packs applied to scrotum
intermittently for a few hours after surgery
 Scrotal support
 Moderate inactivity for 2 days
 Suture removed 5-7 days postop
 Sexual intercourse resumed as desired

Sterility is not immediate
 Some sperm remain in proximal portions
of sperm ducts
 Takes 1 week to several months to clear
ducts of sperm
 Alternate contraception should be
utilized until 2 sperm counts come back
as zero


Explain to male that ability to achieve
and maintain erection or volume of
ejaculate is not altered

Sperm production continues but are
unable to leave epididymis






Informed consent Always!!!
Voluntary sterilization of any mature,
rational woman without reference to
marital or pregnancy status
Partner’s consent is not required
Partners are encouraged to discuss
situation with each other
Health care provider may request consent
Sterilization of minors is restricted

Person must be 21 years old

Irreversible method of birth control and a
statement that mandates a 30-day
waiting period between giving consent
and the sterilization
Purposeful interruption of pregnancy
before 20 weeks of gestation
 Elective abortion - is done at woman’s
request
 Therapeutic abortion – performed for
reasons of maternal or fetal health or
disease

Preservation of life & health of mother
 Genetic disorders of fetus
 Rape or incest
 Pregnant woman’s request

Abortion is now regulated
 Prior to 1970 was not legal
 January 1973 Supreme court legalized
abortion

First trimester abortion is permissible
 Different states have different laws
regarding second trimester abortions
 Third trimester abortions are limited &
may be prohibited by state regulations
unless it interferes with life or health or
pregnant woman

In 2006 several states introduced bills to
ban abortions
 US supreme court will decide the future
of abortions
 Hospitals maintained by Roman
Catholics forbid abortion & sterilization

In 2006 there were 846,181 abortions
 Most are unmarried Caucasian women
b/t 20-29 years


Association of Women’s Health, Obstetric &
Neonatal Nurses (AWHONN, 200) supports a
nurse’s right to chose to participate or not
in abortion procedures in keeping with his
or her “personal, moral, ethical, or religious
beliefs.

Nurse have a professional obligation to
inform their employers at time of
employment of attitudes & beliefs that may
interfere with job function