CONTRACEPTION AND ABORTION
Prepared by Ass. Prof. N. Petrenko, MD, PhD
Compare the different methods of contraception.
State the advantages and disadvantages of commonly used methods of contraception.
Explain the common nursing interventions that facilitate contraceptive use.
Recognize the various ethical, legal, cultural, and religious considerations of contraception.
The reproductive spectrum is the focus of this chapter, covering voluntary control of fertility, interruption of pregnancy, and impaired fertility. The nursing role in the care of women varies, depending on whether management of these fertility-related concerns is associated with assessment of needs, investigation of problems, or implementation of interventions.
Contraception is the voluntary prevention of pregnancy, having both individual and social implications. Today, couples choosing contraception must be informed about prevention of unintended pregnancy, as well as protection against sexually transmitted infections (STIs). Nurses can be instrumental in assisting couples in their decision-making process.
HISTORY of CONTRACEPTION
• 1850 B.C. Egyptians used crocodile dung mixed with honey as vaginal pessary
• China - quicksilver (mercury) was heated in oil and swallowed by women
• Persia - sponges soaked in quinine, iodine, carbolic acid (phenol) and alcohol were inserted in vagina before intercourse
• Arabs used pebbles, glass beads, buttons to put into uterus (as IUD)
• 6th century Greeks scooped out the seeds from half a pomegranate and used the skin of the fruit as a cervical cap
• Mid 1600’s - the Era of Condom used sheep intestine
• Soranus suggested that Greek women jump backward seven times after intercourse.
• European women used bees-wax to cap the cervix
• Charles Goodyear developed the first rubber condom in the 19th century
• 1870’s- vulcanized rubber was produced; rubber was washed and reused until it had cracks or tears
• Margaret Sanger, a socialist and feminist from New York City, created the term ‘birth control’.
• In 1950, Dr Gregory Pincus was asked to develop the ideal contraceptive.
• He derived the steroid compounds from the roots of the wild Mexican yam.
An oral birth control pill was tested on 6,000 women from Puerto Rico and Haiti.
– In 1960, the first oral contraceptive (Enovid-10) was launched in the US market.
– The ‘Pill’ heralded a revolution in birth control.
ACCORDING TO THE ALAN GUTTMACHER INSTITUTE
• 64% of the more than 60 million women aged 15–44 in the United States practice contraception.
• 31% of reproductive-age women do not need a method because:
– they are pregnant, postpartum, or trying to become pregnant; have never had intercourse; or are not sexually active.
• Thus, only 5–7% of women aged 15–44 in need of contraception are not using a method.
The 3 million women who use no contraceptive method account for almost:
• Half of unintended pregnancies (47%), whereas the 39 million contraceptive users account for 53%
• The majority of unintended pregnancies among contraceptive users result from inconsistent or incorrect use.
MAIN PRINCIPLES includes three general strategies:
– Prevent ovulation;
– Prevent fertilization (Keep sperm & oocyte away from each other)
– Prevent implantation.
A multidisciplinary approach may assist a woman in choosing and correctly using an appropriate contraceptive method. Nurses, nurse-midwives, nurse practitioners, and other advanced practice nurses and physicians have the knowledge and expertise to assist a woman in making decisions about contraception that will satisfy the woman's personal, social, cultural, and interpersonal needs.
Assessment and Nursing Diagnoses
The woman's knowledge about contraception and her sexual partner's commitment to any particular method are determined. Data are required about the frequency of coitus, number of sexual partners, the level of contraceptive involvement, and her or her partner's objections to any methods (see Guidelines/Guias box). The woman's level of comfort and willingness to touch her genitals and cervical mucus are assessed. Myths are identified, and religious and cultural factors are determined. The woman's verbal and nonverbal responses to hearing about the various available methods are carefully noted. An individual's reproductive life plan must be considered. A history (including menstrual, contraceptive, and obstetric), physical examination (including pelvic examination), and laboratory tests are usually completed.
Informed consent is a vital component in the education of the patient concerning contraception or sterilization. The nurse has the responsibility of documenting information provided and the understanding of that information by the patient. Using the acronym BRAIDED useful.
LEGAL TIP Informed Consent
B—Benefits: information about advantages and success rates
R—Risks: information about disadvantages and failure rates
A—Alternatives: information on other methods available
I—Inquiries: opportunity to ask questions
D—Decisions: opportunity to decide or change mind
E— Explanations: information about method and how it is used
D—Documentation: information given and patient's understanding
Nursing diagnoses related to contraception include the following:
• Risk for decisional conflict related to
- contraceptive alternatives
- partner's willingness to agree on contraceptive method
• Fear related to
- contraceptive method side effects
• Risk for infection related to
- being sexually active -use of certain contraceptive methods
- broken skin or mucous membrane secondary to surgery, IUD insertion, hormonal implant
• Risk for ineffective sexuality patterns related to
- fear of pregnancy
• Acute pain related to
- postoperative recovery after sterilization
• Spiritual distress related to
- discrepancy between religious or cultural beliefs and choice of contraception
Expected Outcomes of Care
The expected outcomes are determined and phrased in patient-centered terms and may include that the woman/ couple will do the following:
• Verbalize understanding about contraceptive methods.
• State comfort and satisfaction with the chosen method.
• Use the contraceptive method correctly.
• Experience no adverse sequelae as a result of the chosen method of contraception.
• Prevent unplanned pregnancy.
Plan of Care and Interventions
Unbiased patient teaching is fundamental to initiating and maintaining any form of contraception. A care provider relationship based on trust is an important factor in patient compliance. The nurse counters myths with facts, clarifies misinformation, and fills in gaps of knowledge. Various contraceptive techniques are used in North America. The ideal contraceptive should be safe, easily available, economical, acceptable, simple to use, and promptly reversible. Although no method may ever achieve all these objectives, impressive progress has been made.
Contraceptive failure rate refers to the percentage of contraceptive users expected to experience an accidental pregnancy during the first year, even when they use a method consistently and correctly. Contraceptive effectiveness in preventing pregnancy varies and depends on both the properties of the method and the characteristics of the user (Guest, 1998). Failure rates decrease over time either because a user gains experience and uses a method more appropriately or because the less effective users stop using the method.
Safety of a method depends on the patient's medical history, tobacco use, and age. Barrier methods offer some protection from STIs, and oral contraceptives may lower the incidence of ovarian and endometrial cancer, but increase the risk of thromboembolic problems.
Methods of Contraception
The following discussion of contraceptive methods provides the nurse with information needed for patient teaching. After implementing the appropriate teaching for contraceptive use, the nurse supervises return demonstrations and practice to assess patient understanding. The woman is given written instructions and phone numbers for questions. If the woman has difficulty understanding written instructions, she (and her partner, if available) is offered graphic material and a phone number to call as necessary or an offer to return for further instruction.
NATURAL FAMILY PLANNING METHODS
Coitus interruptus. Coitus interruptus (withdrawal) involves the male partner withdrawing the penis from the woman's vagina before he ejaculates. Although coitus interruptus has been criticized as being an ineffective method 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. The failure rate for users of withdrawal is approximately 19% (Kowal, 1998). Coitus interruptus does not protect against STIs or human immunodeficiency virus (HIV) infection.
Periodic abstinence. Periodic abstinence, or natural family planning (NFP), provides contraception by using methods that rely on avoidance of intercourse during fertile periods. NFP methods are the only contraceptive practices acceptable to the Roman Catholic Church. Fertility awareness is the combination of charting signs and symptoms of the menstrual cycle with the use of abstinence or other contraceptive methods during fertile periods. Signs and symptoms most commonly used are menstrual bleeding, cervical mucus, and basal body temperature (Jennings, Lamprecht, & Kowal, 1998).
The human ovum can be fertilized no later than 16 to 24 hours after ovulation. Motile sperm have been recovered from the uterus and the oviducts as long as 60 hours after coitus. However, their ability to fertilize the ovum probably lasts no longer than 24 to 48 hours. Pregnancy is unlikely to occur if a couple abstains from intercourse for 4 days before and for 3 or 4 days after ovulation (fertile period). Unprotected intercourse on the other days of the cycle (safe period) should not result in pregnancy. However, there are two principal problems with this method: the exact time of ovulation cannot be predicted accurately, and couples may find it difficult to exercise restraint for several days before and after ovulation. Women with irregular menstrual periods have the greatest risk of failure with this form of contraception. The typical failure rate is 25% during the first year of use (Jennings et al., 1998).
Rhythm method. Practice of the rhythm method (also known as the calendar rhythm method or menstrual cycle charting) is based on the number of days in each cycle counting from the first day of menses (Trent & Clark, 1997). With this method the fertile period is determined after accurately recording the lengths of menstrual cycles for 6 months. The beginning of the fertile period is estimated by subtracting 18 days from the length of the shortest cycle. The end of the fertile period is determined by subtracting 11 days from the length of the longest cycle. If the shortest cycle is 24 days and longest is 30 days, application of the formula is as follows:
Shortest cycle (24) - 18 = Day 6 Longest cycle (30) - 11 = Day 19
To prevent conception the couple would abstain during the fertile period-days 6 through 19. If the woman has very regular cycles of 28 days each, the formula indicates the fertile days to be as follows:
Shortest cycle (28) - 18 = Day 10 Longest cycle (28) - 11 = Day 17
To prevent pregnancy, the couple abstains from day 10 through 17 because ovulation occurs on day 14 plus or minus 2 days.
Basal body temperature method. The basal body temperature (BBT) is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2° to 36.3° C during menses and for about 5 to 7 days afterward (Fig. 6-1).
About the time of ovulation a slight drop in temperature (approximately 0.05° C) may be seen; after ovulation, in concert with the increasing progesterone levels of the early luteal phase of the cycle, the BBT rises slightly (approximately 0.2° to 0.4° C) (Speroff & Darney, 1996). The temperature remains on an elevated plateau until 2 to 4 days before menstruation. Then it drops to the low levels recorded during the previous cycle, unless pregnancy has occurred and the temperature remains elevated.
The drop and subsequent rise in temperature are referred to as the thermal shift. When the entire month's temperatures are recorded on a graph, the pattern described is more apparent. It is more difficult to perceive day-to-day variations without the entire picture. Infection, fatigue, less than 3 hours of sleep per night, awakening late, and anxiety may cause temperature fluctuations, altering the expected pattern. Jet lag, alcohol taken the evening before, or sleeping in a heated waterbed can also affect the BBT. Therefore the BBT alone is not a reliable method to predict ovulation (Jennings et al., 1998). To determine whether a rise in temperature is indeed the thermal shift, the woman must be aware of other signs of approaching ovulation while she continues to assess the BBT.
Most counselors advise the couple who wish to prevent conception to avoid unprotected intercourse from the day of the drop in the BBT and for 3 days of elevated temperature (Jennings et al., 1998) (see the Teaching Guidelines box).
Basal Body Temperature
Discuss BBT with the woman.
Show the woman a diagram depicting the phases of the menstrual cycle. Discuss the different hormones in the woman's body that are responsible for her menstrual cycle and ovulation. Leave time for questions. Show the woman a sample BBT graph (see Fig. 6-1) and the biphasic line seen in ovulatory cycles. Show the woman the BBT thermometer and how it is calibrated. Have the woman demonstrate taking and reading the thermometer and graphing the temperature while the nurse watches. Instruct the woman to write down on the chart any other activity that might affect her true BBT.
Cervical mucus method. The cervical mucus method (also called the Billings method and the Creighton model ovulation method) requires that the woman recognize and interpret the cyclic changes in the amount and consistency of cervical mucus that characterize her own unique pattern of changes (see Teaching Guidelines box). To ensure an accurate assessment of changes, the cervical mucus should be free from semen, contraceptive gels or foams, and blood or discharge from vaginal infections for at least one full cycle. Other factors that create difficulty in identifying mucus changes include douches and vaginal deodorants, being in the sexually aroused state (which thins the mucus), and taking medications such as antihistamines (which dry up the mucus).
Some women may find this method unacceptable if they are uncomfortable touching their genitals. Whether or not the individual wants to use this method for contraception, it is to the woman's advantage to learn to recognize mucus characteristics at ovulation (Barron & Daly, 2001).
Daily observation chart no 13 Month Mar-Apr.
Name ___________________________ Age 28
Address __________________________ Phone __________
City ________ State______________ Zip ____________
Previous cycle variation 26-29
Cycle variation based on 12 recorded cycles
This cycle: 35 days
Day of cycle
Day of month
Peak or last day
Notes: spotting, schedule changes, pains, moods, etc
Peak day refers to the last day of the fertile mucus before it begins to dry up.
Temperature: usual time 7.'00 a.m.
Oral X____ Rectal____ Vaginal
P = peak mucus
D = dryness on labia
W = wetness on labia
M = ordinary, no particular consistency
T = tacky
S = smooth, slippery, stretchy
C = clear
O = opaque
Y = yellow
Stretch in inches Quantity: 0, +, ++, +++
Cervix: • = closed O = open F =firm L = low S = soft H = high
Fig. 6-2 Example of a completed symptothermal chart.
Cervical Mucus Characteristics
SETTING THE STAGE
Show charts of menstrual cycle along with changes in the cervical mucus.
Have woman practice with raw egg white.
Supply her with a basal body temperature log and graph if she doesn't already have one.
Explain that assessment of cervical mucus characteristics is best when mucus is not mixed with semen, contraceptive jellies or foams, or discharge from infections. Douching should not be done before assessment.
CONTENT RELATED TO CERVICAL MUCUS
Explain to woman (couple) how cervical mucus changes throughout the menstrual cycle.
Right before ovulation, the watery, thin, clear mucus becomes more abundant and thick. It feels like a lubricant and can be stretched 5+ cm between the thumb and forefinger; this is called spinnbarkheit. This indicates the period of maximum fertility. Sperm deposited in this type of mucus can survive until ovulation occurs.
Stress that good handwashing is imperative to begin and end all self-assessment.
Start observation from last day of menstrual flow. Assess cervical mucus several times a day for several cycles. Mucus can be obtained from vaginal introitus; no need to reach into vagina to cervix. Record findings on the same record on which basal body temperature is entered.
Symptothermal method. The symptothermal method combines the BBT and cervical mucus methods with awareness of secondary, cycle phase-related symptoms. The woman gains fertility awareness as she learns the psychologic and physiologic symptoms that mark the phases of her cycle. Secondary symptoms include increased libido, mid-cycle spotting, mittelschmerz, pelvic fullness or tenderness, and vulvar fullness. The woman is taught to palpate the cervix to assess for changes indicating ovulation; that is, the os dilates slightly, the cervix softens and rises in the vagina, and cervical mucus is copious and slippery (Trent & Clark, 1997). The woman notes days on which coitus, changes in routine, illness, and so on have occurred (Fig. 6-2). Calendar calculations and cervical mucus changes are used to estimate the onset of the fertile period; changes in cervical mucus or the BBT are used to estimate its end.
Predictor test for ovulation. The predictor test for ovulation is a major addition to the periodic abstinence methods to help women who want to plan the time of their pregnancies and those who are trying to conceive. The predictor test for ovulation detects the sudden surge of luteinizing hormone (LH) that occurs approximately 12 to 24 hours before ovulation. Unlike BBT, the test is not affected by illness, emotional upset, or physical activity. Available for home use, a test kit contains sufficient material for several days' testing of urine during each cycle. A positive response indicative of an LH surge is noted by an easily readable color change. Directions for use of this home test kit vary with the manufacturer.
Barrier contraceptives are popular as a birth control method, and they also provide some protection against the spread of STIs. Chemical barriers such as nonoxynol-9 have been shown to slightly reduce the risk of gonorrhea and chlamydia (Cates & Raymond, 1998; Heath & Sulik, 1997) but may increase the transmission of HIV (Stephenson, 2000). Male and female condoms provide a mechanical barrier to STIs (F. Stewart, 1998).
Spermicides. A vaginal spermicide is a physical barrier to sperm penetration that also has a chemical action on sperm. Nonoxynol-9 is the most commonly used spermi-cidal chemical in the United States. Intravaginal spermicides are available without a prescription as aerosol foams, foaming tablets, suppositories, creams, films, gels, and sponges (Fig. 6-3). Preloaded, single-dose applicators small enough to be carried in a small purse are available. Sper-micides can be used by nursing mothers and as a backup method if the woman forgets her oral contraceptive. They can also increase effectiveness of other barrier methods. Spermicides must be placed deeply in the vagina in contact with the cervix before each incidence of intercourse. The maximum effectiveness of the spermicide is usually no longer than 1 hour. Typical failure rate in the first year of use is 26% (Trussell, 1998).
Condoms. The male condom is a thin, stretchable sheath that covers the penis (Fig. 6-4). Most condoms are made of latex rubber. In addition to providing a barrier for sperm, latex condoms also provide a barrier for STIs and HIV. Latex condoms break down with oil-based lubricants and should be used only with water-based lubricants. A small percentage of condoms are made from the intestinal cecum of lambs (natural skin). Natural skin condoms do not provide the same protection against STIs and HIV infection. Unlike latex condoms, natural skin condoms contain small pores that could allow passage of viruses such as hepatitis B, herpes simplex, and HIV. More recently, condom manufacturers have begun using polyurethane, which is thinner and stronger than latex. Unlike latex condoms, polyurethane condoms can be used with oil-based lubricants (e.g., petroleum jelly, suntan oil) (Warner & Hatcher, 1998). Research is being conducted to determine the effectiveness of polyurethane condoms to protect against STIs and HIV.
A functional difference in condom shape is the presence or absence of a sperm reservoir tip. To enhance vaginal stimulation, some condoms are contoured and rippled or have ribbed or roughened surfaces. Thinner construction increases heat transmission and sensitivity; a variety of colors increases their acceptability and attractiveness (Warner & Hatcher, 1998). A wet jelly or dry powder lubricates some condoms. Spermicide is added to the interior or exterior surfaces of some condoms. Typical failure rate for first year of use of the male condom is 14% (Warner & Hatcher, 1998).
For years, health care providers assumed that everyone knew how to use condoms, so proper instruction was not provided. To prevent unintended pregnancy and the spread of STIs, it is essential that condoms be used correctly. Instructions, such as those listed in Box 6-1, can be used for patient teaching.
Fig. 6-4 Mechanical barriers. A, Female condom. B, Types of male condoms. C, Diaphragm. D, Cervical cap. E, Contraceptive sponge.
NURSE ALERT All women should be questioned about the potential for latex allergy. Latex condom use is contraindicated for persons with latex sensitivity. Plastic or natural membrane condoms can be used for contraception; however, only plastic condoms should be recommended for prevention of STIs.
MECHANISM OF ACTION
Sheath is applied over the erect penis before insertion or loss of preejaculatory drops of semen. Used correctly, condoms prevent sperm from entering the cervix. Spermicide-coated condoms cause ejaculated sperm to be immobilized rapidly, thus increasing contraceptive effectiveness.
Typical users, 14%
Correct and consistent users, 3%
No side effects Readily available
Premalignant changes in cervix can be prevented or ameliorated in women whose partners use condoms Method of male nonsurgical contraception
Must interrupt lovemaking to apply sheath. Sensation may be altered.
If used improperly, spillage of sperm can result in pregnancy. Occasionally, condoms may tear during intercourse.
If a condom is used throughout the act of intercourse and there is no unprotected contact with female genitals, a latex rubber condom, which is impermeable to viruses, can act as a protective measure against STIs. The addition of nonoxynol-9 increases protection against transmission of STIs.
Teach man to do the following:
• Use a new condom (check expiration date) for each act of sexual intercourse or other acts between partners that involve contact with the penis.
Place condom after penis is erect and before intimate contact.
Place condom on head of penis (Fig. A) and unroll it all the way to the base (Fig. B).
Leave an empty space at the tip (Fig. A); remove any air remaining in the tip by gently pressing air out toward the base of the penis.
If a lubricant is desired, use water-based products such as K-Y lubricating jelly. Do not use petroleum-based products because they can cause the condom to break.
After ejaculation, carefully withdraw the still-erect penisfrom the vagina, holding onto condom rim; remove and discard the condom.
Store unused condoms in cool, dry place.
Do not use condoms that are sticky, brittle, or obviously damaged.
The vaginal sheath (female condom) is made of polyure-thane and has flexible rings at both ends (see Fig. 6-4, A). The closed end of the pouch is inserted into the vagina and is anchored around the cervix, and the open ring covers the labia. The female condom can be inserted up to 8 hours before intercourse and is intended for one-time use. Both women and men report that intercourse with the sheath is generally as satisfying as intercourse without the sheath. It comes in one size and is available over the counter. Typical failure rate is 21% in the first year of use (R Stewart, 1998).
Diaphragm. The vaginal diaphragm is a shallow, dome-shaped rubber device with a flexible wire rim that covers the cervix (see Fig. 6-4, C. There are three main styles of diaphragms, available in a wide range of diameers (50 to 95 mm). A diaphragm should be the largest size the woman can wear without her being aware of its presence. The device may need to be refitted after significant weight loss or weight gain (more than 22 to 33 kg), term birth, or second-trimester abortion; annual examinations are recommended (F. Stewart, 1998). Diaphragms differ in the inner construction of the circular rim. The four types of rims are flat spring, coil spring, arcing spring, and wide-seal rim.
The diaphragm is a mechanical barrier preventing the meeting of the sperm with the ovum. The diaphragm holds the spermicide in place against the cervix for the 6 hours it takes to destroy the sperm. Typical failure rate of the diaphragm alone is 20% in the first year of use. Effectiveness of the diaphragm can be increased when combined with a spermicide (F. Stewart, 1998). Because there are various types of diaphragms on the market, the nurse uses the package insert for teaching the woman how to use and care for the diaphragm (see Self-Care box).
Disadvantages include the reluctance of some women to insert and remove the diaphragm. A cold diaphragm and a cold gel temporarily reduce vaginal response to sexual stimulation if insertion of the diaphragm occurs immediately before intercourse. Some women or couples object to the messiness of the spermicide. Side effects may include irritation of tissues related to contact with spermicides and urethritis and recurrent cystitis caused by upward pressure of the diaphragm rim against the urethra (F. Stewart, 1998). This method is contraindicated for the woman with relaxation of her pelvic support (uterine prolapse) or a large cystocele. Women who have a latex allergy should not use diaphragms made of latex.
Toxic shock syndrome (TSS) is a potentially life-threatening system disorder that can occur in association with the use of the contraceptive diaphragm (F. Stewart, 1998). The nurse should instruct the woman about ways to reduce her risk for TSS. These measures include prompt removal 6 to 8 hours after intercourse, not using the diaphragm during menses, thorough handwashing before handling and removing the diaphragm, and learning and watching for danger signs of TSS.
NURSE ALERT Common signs of TSS in women who use a diaphragm or cervical cap as a contraceptive method include fever of sudden onset greater than 38.4° C, hypotension (systolic less than 90 mm Hg or orthostatic dizziness), and a rash.
Cervical cap. The cervical cap has a 22 to 31 mm soft, natural rubber dome with a firm but pliable rim (see Fig. 6-4, D). It fits snugly around the base of the cervix close to the junction of the cervix and vaginal fornices. The device is available in four sizes. It is recommended that the cap remain in place no less than 8 hours and not more than 48 hours at a time. It is left in place at least 6 hours after the last act of intercourse. The seal provides a physical barrier to sperm: spermicide inside the cap adds a chemical barrier. The extended period of wear may be an added convenience for women. Instructions for the actual insertion and use of the cervical cap closely resemble the instructions for the use of the contraceptive diaphragm. Some of the differences are that the cervical cap can be inserted hours before sexual intercourse without a need for additional spermicide later, no additional spermicide is required for repeated acts of intercourse when the cap is used, and the cervical cap requires less spermicide than the diaphragm when initially inserted.
Women who are not good candidates for wearing the cervical cap include those with abnormal Papanicolaou (Pap) test results, those who cannot be fitted properly with the existing cap sizes, those who find the insertion and removal of the device too difficult, those with a history of TSS, those with vaginal or cervical infections, and those who experience allergic responses to the latex cap or spermicide.
The angle of the uterus, the vaginal muscle tone, and the shape of the cervix may interfere with the cervical cap's ease of fitting and use. Correct fitting requires time, effort, and skill from both the woman and the clinician. The woman must check the cap's position before and after each act of intercourse (see Self-Care box).
Because of the potential risk of TSS associated with the use of the cervical cap, another form of birth control is recommended for use during menstrual bleeding and up to at least 6 weeks postpartum. The cap should be refitted after any gynecologic surgery or birth and after major weight losses or gains. Otherwise, the size should be checked at least once a year.
Patient Instructions for Self-Care
Use and Care of the Diaphragm
POSITIONS FOR INSERTION OF DIAPHRAGM
Squatting is the most commonly used position, and most women find it satisfactory.
Another position is to raise the left foot (if right hand is used for insertion) on a low stool and in a bending position insert the diaphragm.
Another practical method for diaphragm insertion is to sit far forward on the edge of a chair.
You may prefer to insert the diaphragm while in a semi-reclining position in bed.
INSPECTION OF DIAPHRAGM
Your diaphragm must be inspected carefully before each use. The best way to do this is as follows:
Hold the diaphragm up to a light source. Carefully stretch the diaphragm at the area of the rim, on all sides, to make sure there are no holes. Remember, it is possible to puncture the diaphragm with sharp fingernails. Another way to check for pinholes is to carefully fill the diaphragm with water. If there is any problem, it will be seen immediately.
If your diaphragm is puckered, especially near the rim, this could mean thin spots.
The diaphragm should not be used if you see any of the above; consult your health care provider.
PREPARATION OF DIAPHRAGM
Rinse off cornstarch. Your diaphragm must always be used with a spermicidal lubricant to be effective. Pregnancy cannot be prevented effectively by the diaphragm alone.
Always empty your bladder before inserting the diaphragm. Place about 2 teaspoonfuls of contraceptive jelly or contraceptive cream on the side of the diaphragm that will rest against the cervix (or whichever way you have been instructed). Spread it around to coat the surface and the rim. This aids in insertion and offers a more complete seal. Many women also spread some jelly or cream on the other side of the diaphragm (Fig. A).
INSERTION OF DIAPHRAGM
The diaphragm can be inserted as long as 6 hours before intercourse. Hold the diaphragm between your thumb and fingers. The dome can either be up or down, as directed by your health care provider. Place your index finger on the outer rim of the compressed diaphragm (Fig. B). Use the fingers of the other hand to spread the labia (lips of the vagina). This will assist in guiding the diaphragm into place
Insert the diaphragm into the vagina. Direct it inward and downward as far as it will go to space behind and below the cervix (Fig. C).
Tuck the front of the rim of the diaphragm behind the pubic bone so that the rubber hugs the front wall of the vagina (Fig. D).
Feel for your cervix through the diaphragm to be certain it is properly placed and securely covered by the rubber dome (Fig. E).
Regardless of the time of the month, you must use your diaphragm each and every time intercourse takes place. Your diaphragm must be left in place for at least 6 hours after the last intercourse. If you remove your diaphragm before the 6-hour period, your chance of becoming pregnant could be greatly increased. If you have repeated acts of intercourse, you need to add more sper-micide for each act of intercourse.
REMOVAL OF DIAPHRAGM
The only proper way to remove the diaphragm is to insert your forefinger up and over the top side of the diaphragm and slightly to the side.
Next, turn the palm of your hand downward and backward hooking the forefinger firmly on top of the inside of the upper rim of the diaphragm, breaking the suction.
Pull the diaphragm down and out. This avoids the possibility of tearing the diaphragm with the fingernails. You should not remove the diaphragm by trying to catch the rim from below the dome (Fig. F).
CARE OF DIAPHRAGM
When using a vaginal diaphragm, avoid using oil-based products, such as certain body lubricants, mineral oil, baby oil, vaginal lubricants, or vaginitis preparations. These products can weaken the rubber.
A little care means longer wear for your diaphragm. After each use the diaphragm should be washed in warm water and mild soap. Do not use detergent soaps, cold cream soaps, deodorant soaps, and soaps containing oil products, because they can weaken the rubber.
After washing, the diaphragm should be dried thoroughly. All water and moisture should be removed with a towel. The diaphragm should then be dusted with cornstarch. Scented talc, body powder, baby powder, and the like should not be used because they can weaken the rubber.
To clean the introducer (if one is used), wash with mild soap and warm water, rinse, and dry thoroughly. The diaphragm should be placed back in the plastic case for storage. It should not be stored near a radiator or heat source or exposed to light for an extended period.
Patient Instructions for Self-Care
Use of the Cervical Cap
Push cap up into vagina until it covers cervix
Press rim against cervix to create a seal.
To remove, push rim toward right or left hip to loosen from cervix and then withdraw
The woman can assume several positions to insert the cervical cap. See the four positions shown for inserting the diaphragm.
Contraceptive sponge. The vaginal sponge is a small, round, polyurethane sponge that contains nonoxynol-9 spermicide. It is designed to fit over the cervix (one size fits all). The side that is placed next to the cervix is concave for better fit. The opposite side has a woven polyester loop to be used for removal of the sponge.
The sponge must be moistened with water before it is inserted. It 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 longer than 24 to 30 hours may put the woman at risk for TSS (R Stewart, 1998).
More than 30 different oral contraceptive formulations are available in the United States today. General classes are described in Table 6-1. Because of the wide variety of preparations available, the woman and nurse need to read the package insert for information about specific products prescribed. Formulations include combined estrogen-progestin steroidal medications or progestin agents. The formulations are administered orally, subdermally, or by implantation.
Table 6-1 Hormonal contraception
ROUTE OF ADMINISTRATION
DURATION OF EFFECT
Combination estrogen and progestin (synthetic estrogens and progestins in varying doses and formulations)
Up to 5 years
Combined estrogen and progestin oral contracepves. Regular ingestion of combined oral contraceptive pills (OCPs) suppresses the action of the hypothalamus and anterior pituitary, leading to inappropriate secretion of follicle-stimulating hormone (FSH) and LH; ovulation is inhibited because ovarian follicles do not mature. Other contraceptive effects occur: maturation of the endometrium is altered, making it a less favorable site for implantation should ovulation and fertilization occur; and the cervical mucus remains thick as a result of the effect of the progestin and reduces the chance for sperm penetration.
Advantages of taking OCPs are numerous. Taking the pill does not relate directly to the sexual act; this fact increases its acceptability to some women. Commonly there is an improvement in sexual response once the possibility of pregnancy is not an issue. For some women it is convenient to know when to expect the next menstrual flow. Oral contraceptives are considered to be a safe option for older, nonsmoking women until menopause. Perimenopausal women can benefit from regular bleeding cycles, a regular hormonal pattern, and the noncontraceptive health benefits of oral contraceptives (Hatcher & Guillebaud, 1998).
The noncontraceptive health benefits of combined oral contraceptives include decreased menstrual blood loss and decreased iron deficiency anemia, regulation of menorrhagia and irregular cycles, and lowered incidence of dysmenorrhea and premenstrual syndrome. Oral contraceptives also offer protection against endometrial adenocarcinoma and possibly ovarian cancer, reduce the incidence of benign breast disease, protect against the development of functional ovarian cysts and some types of pelvic inflammatory disease, and decrease the risk of ectopic pregnancy (Contraception Report, 1997; Hatcher & Guillebaud, 1998).
Women taking steroidal contraceptives are examined before the medication is prescribed and yearly thereafter. The examination includes medical and family history, weight, blood pressure, general physical and pelvic examination, and screening cervical cytologic analysis (Pap smear).
Use of oral hormonal contraceptives is usually initiated on one of the first 7 days of the menstrual cycle (day 1 of the cycle is the first day of menses). Women can start their use after childbirth or abortion. With a "Sunday start" pack, patients begin taking pills on the first Sunday after the start of their menstrual period. If contraceptives are to be started at any time other than during normal menses, or within 3 weeks after birth or abortion, another method of contraception should be used throughout the first week to avoid the risk of pregnancy (Hatcher & Guillebaud, 1998). Taken exactly as directed, the overall effectiveness rate is almost 100%. Almost all failures (i.e., pregnancy occurs) are caused by omission of one or more pills during the regimen.
There are also numerous disadvantages and side effects to taking OCPs. Women must be screened for conditions that present relative or absolute contraindications to combined oral contraceptive use. The World Health Organization recommends not providing combined OCPs to women with a history of thromboembolic disorders, cerebrovascular or coronary artery disease, breast cancer, estrogenic-dependent tumors, pregnancy, impaired liver function, liver tumor, lactation less than 6 weeks postpartum, smoking if older than 35 years of age (more than 20 cigarettes per day), headaches with focal neurologic symptoms, hypertension (blood pressure greater than 160/100 mm Hg), and diabetes mellitus (of more than 20 years' duration) with vascular disease (Hatcher & Guillebaud, 1998). Research findings on use of oral contraceptives and risk of breast cancer have been inconsistent (Furniss, 2000); investigation continues on this important concern.
Certain side effects of OCPs are attributable to estrogen, progestin, or both. Side effects of estrogen excess include nausea and vomiting, dizziness, edema, leg cramps, increase in breast size, chloasma (mask of pregnancy), visual changes, hypertension, and vascular headache. Side effects of estrogen deficiency include early spotting (days 1 to 14), hypomenorrhea, nervousness, and atrophic vaginitis leading to painful intercourse (dyspareunia). Side effects of progestin excess include increased appetite, tiredness, depression, breast tenderness, vaginal yeast infection, oily skin and scalp, hirsutism, and postpill amenorrhea. Side effects of progestin deficiency include late spotting and breakthrough bleeding (days 15 to 21), heavy flow with clots, and decreased breast size. One of the most common side effects is bleeding irregularities (Contraception Report, 1997; Hatcher & Guillebaud, 1998).
In the presence of side effects, especially those that are bothersome, a different product, a different drug content, or another method of contraception may be required. There is no way to predict the right dosage for any particular woman; trial and error is the main method for prescribing oral contraceptives, starting with the lowest possible estrogen dose.
Because of the wide variations in types of combined oral contraceptives, each woman must be clear about the unique dosage regimen for the preparation prescribed for her. Directions for care after missing one or two tablets also vary. If one or two tablets are missed, another form of contraception is usually recommended to be used until the required regimen is reestablished (Fig. 5).
The signs of potential complications associated with the use of oral contraceptives must be reviewed with the woman (see Signs of Potential Complications box).
Oral contraceptives do not protect a woman against STIs. A barrier method such as condoms should be used as well if protection is desired (Hatcher & Guillebaud, 1998).
SIGNS of POTENTIAL COMPLICATIONS
Before oral contraceptives are prescribed and periodically throughout hormone therapy the woman is alerted to stop taking the pill and to report any of the following symptoms to the health care provider immediately. The word aches helps in retention of this list:
A — Abdominal pain: may indicate a problem with the liver or gallbladder
C — Chest pain or shortness of breath: may indicate possible clot problem within lungs or heart
H — Headaches (sudden or persistent): may be caused by cardiovascular accident or hypertension
E — Eye problems: may indicate vascular accident or hypertension
S — Severe leg pain: may indicate a thromboembolic process
NURSE ALERT The effectiveness of oral contraceptives is decreased when the following medications are taken simultaneously (Hatcher & Guillebaud, 1998):
• Barbiturates (e.g., phenobarbital)
• Anticonvulsants (phenytoin sodium, carbamazepine, primidone)
• Antifungals (e.g., griseofulvin)
• Antibiotics (ampicillin, tetracycline, hfampin)
The use of oral contraceptives can decrease the effectiveness of several medications (e.g., oral hypo-glycemics, oral anticoagulants).
Combined contraceptives Injection
• 25 mg medroxyprogesterone acetate +5 mg estradiol cypionate
• Intramuscularly in the deltoid or gluteus maximus every 28 + 5 days
• Failure rate 3%
Combined contraceptives Transdermal contraceptive patch
• Releases 150 mg Norelgestromin and 20 mg Ethinyl Estradiol daily
• 4.5 cm square that can be worn
– lower abdomen, buttocks, upper outer arm
– upper torso (except breasts)
• 1 patch every week for 3 weeks, followed by a patch-free week
Combined contraceptives Vaginal Ring
• Etonogestrel + ethynyl estradiol
• Worn for 3 weeks + 1 week without ring
• Withdrawal bleeding occurs during “no ring” week
Progestin-only contraception. Progestin-only methods impair fertility by inhibiting ovulation, thickening and decreasing the amount of cervical mucus, and thinning the endometrium. Progestin-only contraceptives may be used by lactating women, although whether they are initiated within the first postpartum week or after breastfeeding is well established is still debated. Progestin-only users often complain of breakthrough vaginal bleeding. Depression, breast tenderness, and weight gain are experienced by some women. No STI protection is provided by these contraceptives (Hatcher, 1998).
Oral progestins (minipill). Progestin-only pills are less effective than combined OCPs. Failure rates for typical users is 5% (Hatcher, 1998). Because minipills contain such a low dose of progestin, the minipill must be taken at the same time each day to be most effective. Side effects are usually less than with OCPs, but if pregnancy occurs, it is more likely to be ectopic (Hatcher, 1998).
Injectable progestins. The advantages of medrox-yprogesterone (DMPA, Depo-Provera) include a contraceptive effectiveness comparable with combined oral contraceptives, long-lasting effects, required injections only four times a year, and lactation is not likely to be impaired. Disadvantages are prolonged amenorrhea or breakthrough uterine bleeding, and risk of allergic reactions. Long-term users may experience decreased bone density (Hatcher, 1998).
NURSE ALERT When administering an intramuscular
injection of progestin (e.g., Depo-Provera), the site should not be massaged after the injection because this action can hasten the absorption and shorten the period of effectiveness.
Implantable progestins (Norplant). Norplant or Nor-plant-2 consists of two or six flexible, nonbiodegradable Silastic capsules. They contain progestin providing up to 5 years of contraception. Insertion and removal of the capsules are minor surgical procedures involving a local anesthetic, a small incision, and no sutures. The capsules are placed subdermally in the inner aspect of the upper arm (Fig. 6-6). The progestin prevents some, but not all, ovulatory cycles and thickens cervical mucus. The effectiveness is greater than 99% over 5 years. Other advantages include long-term continuous contraception not coitus related and reversibility. Irregular menstrual bleeding is the most common side effect. Other less common side effects include headaches, nervousness, nausea, skin changes, and vertigo. Ovarian cysts may develop but usually regress spontaneously (Hatcher, 1998).
Fig. 6-6 Norplant contraceptive system.
The nurse may be confronted with an ethical dilemma concerning enforced progestin injections or implants for a patient. There have been some judicial rulings for women convicted of child abuse to either obtain a Norplant device or face a jail term. Other women receiving public assistance for children may be told to receive the injection or implant or be faced with decreased or no payments. Some nurses may consider this punitive approach to be effective in preventing the birth of more children to unsuitable mothers; however, others strongly believe that forcing women to have such procedures is interfering with their constitutional rights.
Emergency contraception is used within 72 hours of unprotected intercourse to prevent pregnancy. High doses of combined OCPs are used to prevent ovulation or implantation. Recommended medication regimens for emergency contraception (combined estrogen-progestin) are presented in Table 6-2. A U.S. Food and Drug Administration (FDA)-approved emergency contraception kit (Preven) with the exact dosage and instructions for use is also available by prescription.
TABLE 6-2 Emergency Contraceptive Pill Dosages
FIRST DOSE (WITHIN 72 hr)
SECOND DOSE (12 hr LATER)
2 white tablets
2 white tablets
4 white tablets
4 white tablets
4 light orange tablets
4 light orange tablets
4 light orange tablets
4 light orange tablets
4 yellow tablets
4 yellow tablets
4 yellow tablets
4 yellow tablets
5 pink tablets
5 pink tablets
4 yellow tablets
4 yellow tablets
4 white tablets
4 white tablets
5 pink tablets
5 pink tablets
2 blue tablets
2 blue tablets
20 yellow tablets
20 yellow tablets
1 white tablets
1 white tablets
Source: American Pharmaceutical Association. (2000). Emergency contraception: The pharmacist's role. Washington, DC: APhA; Lindberg, C. (1997). Emergency contraception: The nurse's role in providing postcoital options. J Obstet Gynecol NeonatalNurs, 26 (2), 145-152; and Morris, B., & Young, C. (2000). Emergency contraception. Am J Nurs, 700(9), 46-48.
* Only product specifically marketed for emergency contraception.
+ Contains only progestin.
NURSE ALERT In most states a prescription from a licensed health care provider is needed to obtain emergency contraception. However, in some states, such as California and Washington, pharmacists may dispense emergency contraceptive pills without a prescription. Nurses should be familiar with the practices in their states.
There are no medical contraindications for emergency contraception except pregnancy (Van Look & Stewart, 1998). Emergency contraception is ineffective if the woman is pregnant. Effectiveness of emergency contraception is approximately 75% (Trussell, Rodriguez, & Ellertson, 1998).
Oral contraception for emergency contraception can be offered to a woman who has had unprotected sexual intercourse and requests treatment within 72 hours of that event. To minimize the side effect of nausea that occurs with high doses of estrogen and progestin, the woman can be advised to take an over-the-counter antiemetic 1 hour before each dose. If the woman does not begin menstruation within 21 days after taking the pills, she should be evaluated for pregnancy (Lindberg, 1997; Morris & Young, 2000). Abortion should be offered if the method fails (Van Look & Stewart, 1998).
Intrauterine devices containing copper provide another emergency contraception option. The intrauterine device should be inserted within 7 days of unprotected intercourse (Van Look & Stewart, 1998). This method is suggested only for women who wish to have the benefit of long-term contraception.
Progesterone is essential for maintaining pregnancy. Mifepristone (RU 486) is a progesterone antagonist that prevents implantation of a fertilized egg. It is most effective in early gestation, during the luteal phase, within 10 days of the expected onset of what would be the first missed period after conception. A dose of 600 mg of mifepristone within 24 hours of unprotected intercourse is usually effective in preventing pregnancy (Reifsnider, 1997).
Contraceptive counseling should be provided to all women requesting emergency contraception, including a discussion of modification of risky sexual behaviors to prevent STIs and unwanted pregnancy.
An intrauterine device (IUD) is a small, T-shaped device inserted into the uterine cavity. Medicated IUDs are loaded with either copper or a progestational agent (Fig. 6-7). These chemically active substances are released continuously, for example, copper-bearing devices for up to 10 years and progesterone devices for 1 year (G. Stewart, 1998a). IUDs are impregnated with barium sulfate for radiopacity. Evidence strongly supports a true contraceptive effect in preventing fertilization (Mishell, 1998). The copper-bearing IUD damages sperm in transit to the uterine tubes and few sperm reach the ovum, thus preventing fertilization (Speroff & Darney, 1996).
Fig. 6-7 Intrauterine devices (IUDs). A, Copper T-380A. B, Progesterone T (Progestasert). C, Levonorgestrel-releasing IUD.
The progesterone-bearing IUD causes progestin-related effects on cervical mucus and endometrial maturation (see Fig. 6-7). Because the effect is local, there is no disruption of the woman's ovulatory pattern. Copper-bearing IUDs have a lower failure rate than the progesterone-releasing IUDs. The typical failure rate of the IUD ranges from 0.1% to 2.0% (G. Stewart, 1998a).
The IUD offers constant contraception without the need to remember to take pills each day or engage in other manipulation before or between coital acts. If pregnancy can be excluded, an IUD may be placed at any time during the menstrual cycle. An IUD may be inserted immediately after childbirth or abortion (G. Stewart, 1998a).
The absence of interference with hormonal regulation of menstrual cycles makes the IUD more appropriate than hormonal contraception for heavy smokers, women older than 35, women who have hypertension, or those with a history of vascular disease or familial diabetes. Contraceptive effects of the IUD are reversible. When pregnancy is desired, the IUD may be removed by the health care provider.
The progesterone IUD offers two important noncontraceptive progesterone-related advantages: less blood loss during menstruation and decreased primary dysmenorrhea. The average blood loss is increased with the copper IUD.
IUD use is contraindicated in women with a history of pelvic inflammatory disease, known or suspected pregnancy, undiagnosed genital bleeding, suspected genital malignancy, or a distorted intrauterine cavity.
Disadvantages of IUD use include risk of pelvic inflammatory disease, especially within 3 months of insertion, and risk of bacterial vaginosis, uterine perforation, and infection at time of insertion. The IUD offers no protection against STIs. The IUD is not recommended for teenagers, but primarily for women who have had at least one child and who are involved in stable monogamous relationships (G. Stewart, 1998a).
The woman should be taught to check for the presence of the IUD thread after menstruation and at the time of ovulation, as well as before coitus, to rule out expulsion of the device. If pregnancy occurs with the IUD in place, the IUD should be removed immediately, if possible. Retention of the IUD during pregnancy increases the risk of septic miscarriage and ectopic pregnancy (G. Stewart, 1998a). Some women who are allergic to copper develop a rash, necessitating the removal of the copper-bearing IUD (see Signs of Potential Complications box).
SIGNS of POTENTIAL COMPLICATIONS
Intrauterine Devices (IUDs)
Signs of potential complications related to IUDs can be remembered in this manner (G. Stewart, 1998a):
P—Period late, abnormal spotting or bleeding
A — Abdominal pain, pain with coitus
I —Infection exposure, abnormal vaginal discharge
N— Not feeling well, fever or chills
S—String missing, shorter, or longer
Sterilization refers to surgical procedures intended to render the person infertile. Most procedures involve the occlusion of the passageways for the ova and sperm (Fig. 6-8). For the female, the uterine tubes are occluded; for the male, 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 other sterilization procedures have a small but definite failure rate; that is, pregnancy may result.
Vas deferens is severed and ligated in this area B
Fig. 6-8 Sterilization. A. Uterine tubes severed and ligated (tubal ligation). B. Sperm duct severed and ligated (vasectomy).
Female sterilization. Female sterilization may be done immediately after childbirth (within 24 to 48 hours), concomitantly with abortion, or as an interval procedure (during any phase of the menstrual cycle). Most sterilization procedures are performed immediately after a pregnancy, probably because of heightened motivation or increased practicality. Sterilization procedures can be safely done on an outpatient basis. The failure rate is 0.5% (Stewart & Carignan, 1998).
Tubal occlusion. The operation used commonly is the laparoscopic tubal fulguration (destruction of tissue by means of an electric current [electrocoagulation]). A mini-laparotomy may be used for tubal ligation or for the application of bands or clips (e.g., Hulka-Clemens). Fulguration and ligation are considered to be permanent methods. Use of the bands or clips has the theoretic advantage of possible removal and return of tubal patency. Transcervical approaches to inject occlusive material into the tubes are being investigated (Reifsnider, 1997).
Male sterilization. Vasectomy is the easiest and most commonly employed operation for male sterilization. Vasectomy can be carried out with local anesthesia and on an out-of-hospital basis. Small right and left incisions are made into the anterior aspect of the scrotum above and lateral to each testis over the spermatic cord (see Fig. 6-8, B). Each vas deferens is identified; ligated with fine, nonabsorbable sutures; and cut between the ligatures. Occasionally, the surgeon cauterizes the cut stumps of the sperm ducts. Many surgeons bury the cut ends into scrotal fascia to lessen the chance of reunion.
Sterility is not immediate. Some sperm will remain in the proximal portions of the sperm ducts after vasectomy. One week to several months are required to clear the ducts of sperm (i.e., after approximately 15 ejaculations). Therefore some form of contraception is needed until the sperm count in the ejaculate on two consecutive tests is down to zero (Cunningham et al., 2001). The failure rate is 0.15% (Stewart & Carignan, 1998).
Vasectomy has no effect on potency (ability to achieve and maintain erection) or volume of ejaculate. Endocrine production of testosterone continues, so secondary sex characteristics are not affected.
Tubal reconstruction. Restoration of uterine tubal continuity (reanastomosis) and function is technically feasible except after laparoscopic tubal fulguration. However, sterilization reversal is costly, requires microsurgery, and success rates vary with the extent of tubal destruction and removal. The incidence of successful pregnancy after reanastomosis is only approximately 15%. The risk of ectopic pregnancy is increased. Microsurgery to reanastomose the sperm ducts (restoration of tubal continuity) can be accomplished successfully in 81% to 98% of cases (i.e., sperm in the ejaculate); however, the fertility rate is much lower (16% to 79%) (Stewart & Carignan, 1998). The rate of success decreases as the time since the procedure increases.
Laws and regulations. All states have strict regulations for informed consent. Many states permit voluntary sterilization of any mature, rational woman without reference to her marital or pregnancy status. Although the partner's consent is not required by law, the woman is encouraged to discuss the situation with the partner, and health care providers may request the partner's consent. Sterilization of minors or mentally incompetent females is restricted by most states. The operation often requires the approval of a board of eugenicists or other court-appointed individuals.
The nurse plays an important role in assisting people with decision making and ensuring that all requirements for informed consent are met. The nurse also provides information about alternatives to sterilization, such as contraception.
Information must be given about what is entailed in various procedures, how much discomfort or pain can be expected, and what type of care is needed. Many individuals fear sterilization procedures because of the imagined effect on their sexual life. They need reassurance concerning the hormonal and psychologic basis for sexual function and the fact that uterine tube occlusion or vasectomy has no biologic sequelae in terms of sexual adequacy (Stewart & Cangnan, 1998).
Preoperative care depends on the procedure perormed, for example, laparoscopy, laparotomy for tubal occlusion, or vasectomy. General postoperative care includes recovery after anesthesia, vital signs, fluid and electrolyte balance (intake and output, laboratory values), prevention of or early identification and treatment for infection or hemorrhage, control of discomfort, and assessment of emotional response to the procedure and recovery. Discharge planning depends on the type of procedure performed. In general, the patient is given written instructions about observing for and reporting symptoms and signs of complications, the type of recovery to be expected, and the date and time for a follow-up appointment (see Self-Care box).
• If federal or state funds are used for sterilization, the person must be at least 21 years old.
• Informed consent must include an explanation of the risks, benefits, and alternatives; a statement that describes sterilization as a permanent, irreversible method of birth control; and a statement that mandates a 30-day waiting period between giving consent and the performance of the sterilization. Informed consent must be in the person's native language or an interpreter must be provided.
Patient Instructions for Self-Care
What to Expect After Tubal Ligation
You should expect no change in hormones and their influence.
Your menstrual period will be about the same as before the sterilization.
You may feel pain at ovulation.
The ovum disintegrates within the abdominal cavity.
It is highly unlikely that you will get pregnant.
You should not experience a change in sexual functioning; in fact, you may enjoy sexual relations more because you won't be concerned about getting pregnant.
Sterilization offers no protection against STIs; therefore you may need to use condoms.
Evaluation of the effectiveness of care of the woman using a contraceptive method is based on the previously stated outcomes.
& if contraception fails …
– Blocks progesterone receptors
– Uterus & anterior pituitary behave as if no progesterone present
– Endometrium sloughs.
Induced abortion is the purposeful interruption of pregnancy before 20 weeks of gestation (miscarriage is discussed in Chapter 23). If the abortion is performed at the woman's request, the term elective abortion is used; if performed for reasons of maternal or fetal health or disease, the term therapeutic abortion applies. Many factors contribute to a woman's decision to have an abortion. Indications include (1) preservation of the life or health of the mother, (2) genetic disorders of the fetus, (3) rape or incest, and (4) the pregnant woman's request. The control of birth, dealing as it does with human sexuality and the question of life and death, is one of the most emotional components of health care and was the most controversial social issue in the last half of the twentieth century (Soriano, 1998). Abortion as a surgical alternative to contraception is regulated in most countries (World Health Organization, 1995). These regulations exist to protect the mother from the complications of abortion.
Most women having abortions are Caucasian, younger than 24 years old, and unmarried (CDC, 1996). Sixty percent of women having abortions say they used a contraceptive, but it failed. The U.S. Supreme Court set aside previous antiabortion laws in January 1973, holding that first-trimester abortion is permissible inasmuch as the mortality rate from interruption of early gestation is now less than the mortality rate after normal term birth; 90% of abortions are performed at this point in pregnancy (Wallach & Zacur, 1995). Second-trimester abortion was left to the discretion of the individual states (Cates & Ellertson, 1998).
In the fall of 2000, the FDA approved the controversial abortion pill mifepristone, better known as RU 486, to be used in the first 7 weeks of pregnancy. Abortion rights supporters and foes both predict that the drug will have a major effect on abortion in the United States. It remains to be seen whether there will be continuing legislation to restrict its use and what changes will occur in use of other methods of abortion.
Legal TIP Induced Abortion
It is important for nurses to know the laws regarding abortion in their state of practice before they offer abortion counseling or nursing care to a woman choosing an abortion. Many states enforce a mandatory delay or state-directed counseling before a woman may legally obtain an abortion.
Rates of biologic complications after abortions (e.g., ectopic pregnancy, infection, hemorrhage) tend to be low, especially if the woman aborts during the first trimester (Speroff & Darney, 1996). Psychologic sequelae of induced abortion are uncommon and may be related to circum stances and support systems surrounding the pregnant woman, such as the attitudes reflected by friends, family, and health care workers. It must be remembered that the woman facing an abortion is pregnant and may exhibit the emotional responses shared by all pregnant women, including postbirth depression (Williams, 2000).
Nurses often struggle with the same values and moral convictions as those of the pregnant woman. The conflicts and doubts of the nurse can be readily communicated to women who are already anxious and overly sensitive. Health care professionals need assistance to identify and come to terms with their own feelings. It is not uncommon for confusion to arise as beliefs are challenged by the reality of care. Nurses whose religious or moral beliefs do not support abortion have the right to refuse such an assignment. In reality, reassignment is usually an option so that the abortion patient receives the needed care.
Methods for performing early abortion include vacuum aspiration, medical methods (mifepristone with prostaglandin), and methotrexate with misoprostol.
Vacuum aspiration (curettage) is the most common procedure in the first trimester, with about 97% of all procedures being performed by suction curettage. Very early abortions (menstrual extraction, endometrial aspiration) can be done with a small flexible plastic cannula without cervical dilation or anesthesia. The insertion of a small laminaria tent (cone of dried seaweed that swells as it absorbs moisture and dilates the cervix) retained by a vaginal tampon for 4 to 24 hours will usually facilitate the purposeful interruption of a first-trimester pregnancy greater than 8 weeks of gestation by dilating the cervix atraumatically (Wallach & Zacur, 1995). On removal of the moist, expanded laminaria tent the cervix will have dilated two or three times its original diameter. Rarely will further mechanical dilation of the cervix be required. The insertion of an adequate-sized aspiration cannula (8.5 to 10.5 mm) is almost always possible. Cervical laceration and bleeding are reduced by the use of laminaria. A disadvantage is the delay necessary and the need for an additional visit to the physician's office or clinic. Prostaglandin gel may also be used to soften the cervix (Cunningham et al., 2001).
Aspiration abortion is usually performed under local anesthesia in the physician's office, the clinic, or the hospital. The suction procedure for performing an early elective abortion (ideal time is 8 to 12 weeks since the last menstrual period) usually requires less than 5 minutes. During the procedure the nurse or physician keeps the woman informed about what to expect next (e.g., menstrual-like cramping, sounds of the suction machine). The nurse assesses the woman's vital signs. The aspirated uterine contents must be carefully inspected to ascertain whether all fetal parts and adequate placental tissue have been evacuated. After the abortion the woman rests on the table until she is ready to stand. Then she remains in the recovery area or waiting room for 1 to 3 hours for detection of excessive cramping or bleeding; then she is discharged.
Bleeding after the operation is normally about the equivalent of a heavy menstrual period, and cramps are rarely severe. Excessive vaginal bleeding and infection, such as endometritis or salpingitis, are the most common complications of elective abortion. Retained products of conception are the primary cause of vaginal bleeding. Evacuation of the uterus, uterine massage, and administration of oxytocin or methylergonovine (Methergine) or both may be necessary (Cates & Ellertson, 1998). Prophylactic antibiotics to decrease the risk of infection are commonly prescribed (Sawaya et al., 1996).
Postabortal instructions differ among health care providers (e.g., tampons should not be used for at least 3 days or should be avoided for up to 3 weeks, and resumption of sexual intercourse may be permitted within 1 week or discouraged for 3 weeks). The woman may shower daily. Instruction is given to watch for excessive bleeding (more than one large pad per hour for 4 hours), cramps, or fever and to avoid douches of any type. The woman may expect her menstrual period to resume 4 to 6 weeks from the day of the procedure. The nurse offers information about the birth control method the woman prefers, if this has not been done previously during the counseling interview that usually precedes the decision to have an abortion. The woman must be strongly encouraged to return for her follow-up visit so that complications can be detected and an acceptable contraceptive method prescribed. A pregnancy test may also be performed to determine whether the pregnancy was successfully terminated (Stenchever et al., 2001).
Methotrexate and misoprostol
Methotrexate is a cytotoxic drug that causes early abortion by blocking folic acid in fetal cells so that they cannot divide. There is no standard protocol, but the drug is usually given intramuscularly followed by vaginal placement of misoprostol (prostaglandin analog). If abortion does not occur, an additional dose of misoprostol is given or vacuum aspiration is performed (Carbonell et al., 1998). Women commonly experience nausea and vomiting and cramping after the misoprostol insertion.
Mifephstone and misoprostol
Mifepristone (RU 486) (Mifeprex) can be taken up to 7 weeks after the beginning of the last menstrual period. Mifepristone works by binding to progesterone receptors and blocking the action of progesterone, which is necessary for maintaining pregnancy. The woman takes 600 mg of mifepristone; 3 days later she returns to the office and takes 400 mg of misoprostol (unless abortion has already occurred and been confirmed). Cramping and bleeding are the main side effects, but nausea and vomiting and headache also can occur. Two weeks after the administration of mifepristone, the woman must return to the office for a clinical examination or ultrasound to confirm that the pregnancy has been terminated. In approximately 5% of cases, the drugs do not work and surgical abortion is needed (Christin-Maitre et al., 2000).
Second-trimester abortion is associated with more complications and costs than first-trimester abortions. Dilation and evacuation, induction of uterine contractions, and major operations are the methods used.
Dilation and evacuation
Dilation and evacuation (D&E) can be performed up to 20 weeks of gestation (Cates & Ellertson, 1998). It is the predominant method of abortion used beyond the first trimester. The cervix requires more dilation because the products of conception are larger. Often, laminaria are inserted several hours or several days before the procedure. Nursing care includes monitoring vital signs, providing emotional support, administering analgesics, and postoperative monitoring. Disadvantages of D&E may include possible long-term harmful effects on the cervix.
Hypertonic and uterotonic ag&nts
Hypertonic solutions (e.g., saline, urea) injected directly into the uterus and uterotonic agents (e.g., misoprostol, dinoprostone) account for less than 1% of all abortions because other methods are safer and easier to use.
The woman will need help exploring the meaning of the various alternatives and consequences to herself and her significant others. It is often difficult for a woman to express her true feelings (e.g., what abortion means to her now and in the future and what support or regret her friends and peers may demonstrate). A calm, matter-of-fact approach on the part of the nurse can be helpful (e.g., "Yes, I know you are pregnant. I am here to help. Let's talk about alternatives."). Listening to what the woman has to say and encouraging her to speak are essential. Neutral responses such as "Oh," "Uh-huh," and "Umm" and nonverbal encouragement such as nodding, maintaining eye contact, and use of touch are helpful in setting an open, accepting environment. Clarifying, restating, and reflecting statements; open-ended questions; and feedback are communication techniques that can be used to maintain a realistic focus on the situation and bring the woman's problems into the open. Once a decision has been made, the woman must be assured of continued support. Information about what is entailed in various procedures, how much discomfort or pain can be expected, and what type of care is needed must be given. If family or friends cannot be involved, scheduling time for nursing personnel to give the necessary support is an essential component of the care plan.