INFERTILITY CONTRACEPTION, ABORTION
INFERTILITY
LEARNING OBJECTIVES
List common causes of infertility.
Discuss the psychologic
impact of infertility.
Identify common diagnoses and treatments for
infertility.
Examine the various ethical and legal
considerations of assisted reproductive therapies for infertility.
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.
KEY TERMS AND DEFINITIONS
assisted reproductive therapies (ARTs) Treatments for infertility, including in vitro
fertilization procedures, embryo adoption, embryo hosting, and therapeutic
insemination
basal body temperature (BBT) Lowest body temperature of a healthy person
taken immediately after awakening and before getting out of bed
induced abortion Intentionally produced termination of
pregnancy
in vitro fertilization Fertilization in a culture dish or test tube
infertility Decreased
capacity to conceive
rhythm method Contraceptive method in which a woman abstains
from sexual intercourse during the ovulatory phase of
her menstrual cycle; calendar method semen analysis Examination
of semen specimen to determine liquefaction, volume, pH, sperm density, and
normal morphology
sterilization Process or act that renders a person unable to
produce children
therapeutic donor insemination (TDI) Introduction of donor semen by instrument
injection into thevagina or uterus for impregnation
vacuum aspiration Uterine aspiration method of early abortion
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.
INFERTILITY
the inability to conceive following
unprotected sexual intercourse year (age < 35) or 6 months (age >35)
Infertility is a serious medical
concern that affects quality of life and is a
problem for 10% to 15% of reproductive-age
couples (American Society for Reproductive Medicine [ASRM], 1999; G. Stewart, 1998b). The term infertility
implies subfertility, a prolonged time to
conceive, as opposed to sterility, which
means inability to conceive. Normally, a fertile couple has
approximately a 20% chance of conception in
each ovulatory cycle. Primary infertility applies to a woman who has never been pregnant; secondary
infertility applies to a woman who has
been pregnant in the past.
The prevalence of infertility is
relatively stable among the
overall population but increases with the age of the woman. For example, women older than age 40 have a 50% decreased fertility rate (G.
Stewart, 1998b). Probable causes of infertility include the trend toward
delaying pregnancy until
later in life, when fertility decreases naturally and the prevalence of
diseases such as endometriosis and ovulatory
dysfunction increases.
There is some controversy regarding whether there has been an increase
in male infertility, or whether male infertility is being more readily identified
because of improvements in diagnosis.
Diagnosis and treatment of infertility require considerable physical,
emotional, and financial investment over an
extended period. Men and women often perceive infertility differently,
with women having more stress from tests and
treatments, placing greater importance
on having children, being more accepting of indicated treatments, and wanting
children more than men (Stephen &
Chandra, 1998).
Factors Associated with Infertility
Many factors, both male and female,
contribute to normal fertility.
A normally developed reproductive tract in both the male and female partner is
essential. Normal functioning of
an intact hypothalamic-pituitary-gonadal axis supports gametogenesis—the
formation of sperm and ova.
Although sperm remain viable in the female's reproductive tract for 48 hours or more, probably only a
few retain fertilization
potential for more than 24 hours. Ova remain viable for approximately 24 hours, but the optimal time for fertilization may be no more
than 1 to 2 hours
(Cunningham et al., 2001). Thus timing of intercourse is critical.
After fertilization the conceptus
must travel down the patent
uterine tube to the uterus and implant within 7 to 10 days in a hormone-prepared endometrium.
The conceptus must develop normally, reach viability, and be born in good condition for extrauterine
life.
An alteration in one or more of these structures, functions, or processes results in some degree of
impaired fertility. In general, a
female factor such as ovulatory dysfunction or
a pelvic factor is responsible for infertility in approximately 50% of infertile couples (ASRM, 1999). A
male factor (sperm and semen abnormalities) is responsible for infertility in approximately 35% of couples.
Unexplained factors and causes
(e.g., coital techniques) related to both partners are responsible for infertility in approximately
15% of couples (Session et al, 1998; Stenchever et al., 2001).
|
Factors Affecting Female Fertility CONGENITAL OR DEVELOPMENTAL FACTORS Abnormal external genitals Absence of internal reproductive structures OVARIAN FACTORS Anovulation-primary Pituitary or hypothalamic hormone disorder Adrenal gland disorder Congenital adrenal hyperplasia Anovulation-secondary Disruption of hypothalamic-pituitary-ovarian axis Amenorrhea after discontinuing OCP Early menopause Increased prolactin levels TUBAL/PERITONEAL FACTORS Tubal motility reduced Absence of fimbriated end of tube Absence of a tube Inflammation within the tube Tubal adhesions UTERINE FACTORS Developmental anomalies Endometrial and myometrial
tumors Asherman syndrome (uterine adhesions or
scar tissue) |
Fig CONGENITAL OR
DEVELOPMENTAL ABNOMALIES
Fig CONGENITAL OR
DEVELOPMENTAL ABNOMALIES
Fig CONGENITAL OR
DEVELOPMENTAL ABNOMALIES
Fig CONGENITAL OR
DEVELOPMENTAL ABNOMALIES
Fig CONGENITAL OR
DEVELOPMENTAL ABNOMALIES
Fig CONGENITAL OR
DEVELOPMENTAL ABNOMALIES
Fig CONGENITAL OR
DEVELOPMENTAL ABNOMALIES
Fig CONGENITAL OR
DEVELOPMENTAL ABNOMALIES
Fig Adhesions
Fig Adhesions and hydrosalpinx
Fig UTERINE FIBROID
Fig UTERINE FIBROID
Fig UTERINE FIBROID
Fig UTERINE FIBROID
Fig ENDOMETRIAL POLIP
Fig ENDOMETRIAL POLIP
Fig ENDOMETRIAL POLIP
Fig ENDOMETRIAL CANCER
Fig ENDOMETRIAL
HYPERPLASY
Fig ENDOMETRIOSIS
Fig ASHERMAN SYNDROME
Fig ASHERMAN SYNDROME
|
Factors Affecting Male Fertility STRUCTURAL OR HORMONAL DISORDERS Undescended testes Hypospadias Varicocele Low testosterone levels Testicular damage caused by mumps OTHER FACTORS Endocrine disorders Genetic disorders Psychologic disorders Sexually transmitted infections Exposure to workplace hazards such as radiation or toxic substances Exposure of scrotum to high temperatures SUBSTANCE ABUSE Changes in sperm (Smoking, heroin, marijuana, amyl nitrate, butyl nitrate, ethyl chloride, methaqualone; Monoamine oxidase ) Decrease in sperm (Hypopituitarism, Debilitating or chronic disease, Trauma,
Gonadotropic inadequacy) Decrease in libido (Heroin, methadone, selective serotonin reuptake inhibitors, and barbiturates) Impotence (Alcohol, Antihypertensive medications) OBSTRUCTIVE LESIONS OF THE EPIDIDYMIS AND VAS DEFERENS NUTRITIONAL DEFICIENCIES |
FIG. ANDESCENDENS TESTES
FIG. HYPOSPADIAS
FIG. VARICOCELE
CARE MANAGEMENT
Assessment and Nursing Diagnoses
The nurse assists in the assessment by obtaining data relevant to fertility through interview and physical
examination. The database must include
information to determine whether infertility is primary or secondary.
Religious, cultural, and ethnic data are noted because they may place restrictions on tests and treatments.
Some of the data needed to
investigate impaired fertility are of a
sensitive, personal nature. Obtaining these data may be viewed as an invasion of privacy. The tests and examinations are occasionally painful and intrusive
and can take the romance out of
lovemaking. A high level of motivation
is needed to endure the investigation.
Because multiple factors involving
both partners are common, the
investigation of impaired fertility is conducted systematically and
simultaneously for both male and female partners. Both partners must be
interested in the solution
to the problem. The medical investigation requires time (3 to 4 months) and
considerable financial expense, and it causes emotional distress and strain on
the couple's interpersonal
relationship (Angard, 2000).
Assessment of female infertility
Investigation of impaired fertility
begins for the woman with a complete history and physical examination. The history explores the duration of infertility and past obstetric events and contains a detailed sexual history.
Medical and surgical conditions are evaluated. Exposure to reproductive hazards
in the home (e.g., mutagens such as plastic-vinyl chlorides, teratogens
such as alcohol, and emotional stresses) and workplace are explored.
A complete general physical examination is followed by a specific assessment of the reproductive tract.
Evidence of endocrine system
abnormalities is sought. Inadequate development
of secondary sex characteristics (e.g., inappropriate distribution of body fat and hair) may point to problems with the hypothalamic-pituitary-ovarian
axis or genetic aberrations (e.g.,
polycystic ovarian syndrome, Turner syndrome).
A woman may have an abnormal uterus
and tubes as a result of exposure to diethylstilbestrol (DES) in utero. Evidence
of past infection of the genitourinary system is sought. Bimanual examination of internal organs may reveal lack of mobility of the uterus
or abnormal contours of the
uterus and adnexa. Data from routine urine and blood
tests are obtained along with other diagnostic tests.
Diagnosis. The basic infertility survey of the woman involves evaluation of the cervix,
uterus, tubes, and peritoneum (Figs. 9, 10,
and 6-11); detection of ovulation; assessment
of immunologic compatibility; and evaluation of psychogenic factors (Angard, 1999). The
nurse can alleviate some of the anxiety associated with diagnostic testing by explaining to patients the timing and rationale
for each test (Table 3). Test findings that are favorable to fertility are summarized in
Fig. 9 Hysterosalpingography. Note contrast medium flows through intrauterine cannula
and out through the uterine
tubes.
Fig. 10 Laparoscopy.
Fig. 11 Vaginal ultrasonography. Major scanning planes of transducer. H, Horizontal; V, vertical.
Table 3 Tests for Impaired Fertility
|
TEST/EXAMINATION |
TIMING/(MENSTRUAL
CYCLE DAYS) |
RATIONALE |
|
Hysterosalpingogram |
7
to 10 |
Late follicular,
early proliferative phase; will not
disrupt a fertilized ovum; may open uterine tubes before time of ovulation |
|
Postcoital test |
1
to 2 days before ovulation |
Ovulatory late proliferative
phase; look for normal motile sperm in
cervical mucus |
|
Sperm
immobilization antigen-antibody reaction |
Variable,
ovulation |
Immunologic
test to determine sperm and cervical mucus
interaction |
|
Assessment
of cervical mucus |
Variable,
ovulation |
Cervical
mucus should have low viscosity, high spinnbarkeit |
|
Ultrasound diagnosis
of follicular collapse |
Ovulation |
Collapsed follicle is
seen after ovulation |
|
Serum
assay of plasma progesterone |
20
to 25 |
Midluteal midsecretory phase; check adequacy of corpus luteal production of progesterone |
|
Basal
body temperature |
Chart
entire cycle |
Elevation
occurs in response to progesterone,
documents ovulation |
|
Endometrial biopsy |
26
to 27 |
Late
luteal, late secretory
phase; check endometrial response to
progesterone and adequacy of luteal phase |
|
Sperm
penetration assay |
After 2 days but no
more than 1 week of abstinence |
Evaluation of ability
of sperm to penetrate an egg |
|
1. Follicular
development, ovulation, and luteal development are supportive of pregnancy: a. Basal
body temperature (presumptive evidence of ovulatory cycles) is biphasic, with
temperature elevation that
persists for 12 to 14 days before menstruation b. Cervical
mucus characteristics change appropriately during phases of menstrual cycle c.
Laparoscopic visualization of pelvic organs verifies follicular and luteal
development 2. The luteal phase is supportive of pregnancy: a. Levels of
plasma progesterone are adequate b. Findings from endometrial biopsy samples are consistent with day of cycle 3. Cervical
factors are receptive to sperm during expected a. Cervical os
is open b. Cervical mucus is clear, watery, abundant, and slippery and demonstrates good spinnbarkeit
and ar borization
(fern pattern) c. Cervical examination does not
reveal lesions or infections d. Postcoital test findings are satisfactory (adequate number of live, motile, normal sperm present in
cervical mucus) e. No immunity to sperm demonstrated 4. The
uterus and uterine tubes are supportive of pregnancy: a. Uterine and tubal patency are
documented by (1)Spillage of dye into peritoneal
cavity (2)Outlines of uterine and tubal
cavities of adequate size and shape, with
no abnormalities b. Laparoscopic examination verifies
normal development of internal
genitals and absence of adhesions,
infections, endometriosis, and other lesions 5. The male partner's
reproductive structures are normal: a. No evidence of developmental
anomalies of penis, testicular
atrophy, or varicocele (varicose veins on the
spermatic vein in the groin) b. No evidence of infection in
prostate, seminal vesicles, and
urethra c. Testes are more than 6. Semen is
supportive of pregnancy: a. Sperm (number per milliliter) are adequate in ejaculate b. Most sperm show normal morphology c. Most sperm are motile, forward
moving d. No autoimmunity exists e. Seminal fluid is normal |
Assessment of male infertility
The systematic investigation of
infertility in the male patient begins with a thorough history and physical
examination. Assessment of the male patient starts with noninvasive tests.
Semen analysis. The basic test for male infertility is the semen analysis. A complete semen analysis,
study of the effects of
cervical mucus on sperm forward motility and survival, and evaluation of the sperm's ability to
penetrate an ovum provide basic
information. Sperm counts vary
from day to day and are dependent on emotional and physical status and sexual activity. Therefore a
single analysis may be
inconclusive (Hargreave & Ghosh,
1998). Usually, several specimens taken at monthly intervals are evaluated (Trantham,
1996).
Semen is collected by ejaculation into a clean container or a plastic sheath that does not contain a spermicidal
agent. The specimen is usually
collected by masturbation following 2 to 5 days of abstinence from ejaculation.
The semen is taken to the laboratory
in a sealed container within 2 hours
of ejaculation. Exposure to excessive heat or cold is avoided. Normal values for semen characteristics are
given in
|
Liquefaction usually complete
within 10 to 20 minutes Semen
volume 2 to 5 ml (range of 1 to 7 ml) Semen pH 7.2 to 7.8 Sperm density 20 to 200 million cells/ml Normal morphology, > 60%
normal oval Motility
(important consideration in sperm evaluation), percentage of forward-moving sperm estimated with respect to abnormally motile
and nonmotile sperm > 50% Ovum penetration test (may be done if further evaluation necessary) Note: These values are not
absolute, only relative to final evaluation of the couple as a single
reproductive unit. |
Hormone analyses are done for
testosterone, gonadotropin, FSH, and LH. The sperm
penetration assay may be used to evaluate the ability of sperm to penetrate an egg. Because human oocytes are not readily available, hamster eggs have been used as a substitute to
evaluate sperm
penetration abilities (no actual fertilization occurs) (Hargreave & Ghosh, 1998). Testicular biopsy may be warranted.
Assessment of the couple
Postcoital test. The postcoital test (PCT),
also called the Sims-Huhner
test, is one method used to test for adequacy
of coital technique, cervical mucus, sperm, and degree of sperm
penetration through cervical mucus. The test is
performed within several hours after ejaculation of semen into the vagina. A
specimen of cervical mucus is obtained from the cervical os
and examined under a microscope. The
quality of mucus and the number of forward-moving sperm are noted. A PCT
with good mucus and motile sperm is associated with fertility (Hargreave & Ghosh, 1998).
Intercourse is synchronized with
the expected time of ovulation (as
determined from evaluation of BBT, cervical mucus changes, and usual length of
menstrual cycle or use of an LH detection
kit to determine LH surge). It is performed
only in the absence of vaginal infection. Couples may experience some difficulty abstaining from
intercourse for 2 to 4 days before
expected ovulation and then having intercourse with ejaculation on schedule.
Sex on demand may strain the couple's interpersonal relationship. A problem may
arise if the expected day of ovulation occurs when facilities or the physician
is unavailable (e.g., over a weekend or holiday).
Examples of nursing diagnoses related to impaired fertility include the following:
|
• Anxiety
related to -unknown outcome of diagnostic
workup • Disturbed
body image or situational low self-esteem related to -impaired fertility • Risk
for ineffective individual/family coping related to - methods used in the
investigation of impaired fertility - alternatives to therapy:
child-free living or adoption • Interrupted
family processes related to -unmet expectations for pregnancy • Acute
pain related to -effects of diagnostic tests (or
surgery) • Ineffective
sexuality patterns related to -loss of libido secondary to
medically imposed restrictions • Deficient
knowledge related to - preconception risk factors - factors surrounding ovulation - factors surrounding fertility |
Expected Outcomes of Care
The expected outcomes are phrased
in patient-centered terms and may
include that the couple will do the following:
• Verbalize understanding of
the anatomy and physiology of the reproductive system.
• Verbalize understanding of
treatment for any abnormalities
identified through various tests and examinations (e.g., infections, blocked
uterine tubes, sperm allergy, varicocele) and be able to make an informed
decision about
treatment.
• Verbalize understanding of
their potential to conceive.
• Resolve guilt feelings and not
need to focus blame.
• Conceive or, failing to
conceive, decide on an alternative acceptable to both of them (e.g., child-free
living, adoption).
Plan of Care and Interventions
Psychosocial
Within the
Infertility is recognized as a major life stressor that can affect self-esteem; relations with the spouse,
family, and friends; and careers. Couples often
need assistance in separating their concepts
of success and failure related to treatment for infertility from
personal success and failure. Recognizing
the significance of infertility as a loss and resolving these feelings
are crucial to putting infertility into perspective, even if treatment is
successful (Boxer, 1996).
Psychologic responses to a diagnosis of
infertility may tax a
couple's giving and receiving of physical and sexual closeness. The prescriptions and proscriptions for
achieving conception may add tension to a
couple's sexual functioning. Couples may report decreased desire for
intercourse, orgasmic dysfunction, or midcycle
erectile disorders.
To be able to deal comfortably with
a couple's sexuality, nurses
must be comfortable with their own sexuality so that they can better help couples understand why the
private act of lovemaking must be shared with
health care professionals. Nurses need up-to-date factual knowledge about human sexual practices and must be (1) able
to accept the preferences and activities of others without being judgmental,
(2) skilled in interviewing and in therapeutic use of self, (3) sensitive to the nonverbal cues of others, and (4) knowledgeable regarding each couple's sociocultural and religious tenets (Johnson, 1996).
The support systems of the couple with impaired fertility must be
explored. This exploration should include persons
available to assist, their relationship to the couple,
their ages, their availability, and the cultural or religious support that is available.
If the couple conceives, nurses
need to be aware that the concerns
and problems of the previously infertile couple may not be over. Many couples are overjoyed with the
pregnancy; however, some are not. Some couples rearrange their lives, sense of self,
and personal goals within their acceptance of their infertile state. The couple
may feel that those who worked with them to identify and treat impaired fertility expect them to be happy with the pregnancy. The couple may be shocked to find that they themselves
feel resentment because the pregnancy, once a cherished dream, now necessitates another change in goals,
aspirations, and identities. The normal ambivalence toward pregnancy may be
perceived as reneging on the original choice to become parents. The couple
might choose to abort the pregnancy at this
time. Other couples worry about miscarriage. If the couple wishes to continue with the pregnancy, they
will need the care other expectant
couples need. A history of impaired fertility
is considered to be a risk factor for pregnancy.
If the couple does not conceive,
they are assessed regarding
their desire to be referred for help with adoption, therapeutic intrauterine
insemination, other reproductive alternatives, or choosing a child-free state.
The couple may find a list
of agencies, support groups, and other resources in their community helpful (see Resources at
end of chapter).
Nonmedical
Simple changes in lifestyle may be
effective in the treatment
of subfertile men. Only water-soluble lubricants should be used during intercourse
because many commonly used lubricants contain spermicides or have spermicidal
properties. High scrotal temperatures may be caused by daily hot tub bathing or
saunas in which the testes are kept
at temperatures too high for efficient spermatogenesis.
Treatment is available for women who have
immunologic reactions to sperm. The use of condoms
during genital intercourse for 6 to 12 months will reduce female antibody production in most women who have elevated antisperm antibody titers. After the serum reaction subsides,
condoms are used at all times except at the expected time of ovulation. Approximately one third of couples with this problem conceive by following this course of
action.
Changes in nutrition and habits may increase
fertility for both men
and women. For example, a well-balanced diet, exercise, decreased alcohol intake, not smoking
or abusing drugs, and stress
management may be effective.
Medical
Pharmacologic therapy for female infertility
is often directed at
treating ovulatory dysfunction either by stimulating ovulation or by enhancing ovulation so
that more oocytes mature. These medications include clomiphene citrate,
human menopausal gonadotropin (HMG), FSH, recombinant FSH, and human chorionic gonadotropin. Gonadotropin-releasing hormone (GnRH)
agonists, progesterone, and bromocriptine are also used (Angard,
1999; Leibowitz & Hoffman, 2000). Table 4 describes
common medications used for treating infertility. Thyroid-stimulating hormone (Synthroid)
is indicated if the woman has
hypothyroidism. Combined oral contraceptives, GnRH agonists, or danazol may be used to treat en-dometriosis
(Session et al., 1998).
Table 4 Medications Used in the
Treatment of Infertility
|
DRUG |
INDICATION |
MECHANISM OF ACTION |
DOSE |
SIDE EFFECTS |
|
Clomiphene citrate (Clomid,
Serophene) |
Ovulation induction, treatment of luteal-phase inadequacy |
Thought to bind to estrogen receptors in the
pituitary, blocking them from detecting estrogen |
Tablets, starting with 50 mg/day for 5 days, may
increase to 200 mg/day |
Causes hypothalamus to release more GnRH, stimulating release of FSH and LH |
|
Human menopausal gonadotropins
(Pergonal) |
Ovulation induction |
Pergonal, LH, and FSH in 1:1 ratio,
direct stimulation of ovarian follicle |
Intramuscular injections, dosage regimen variable |
Ovarian enlargement, ovarian hyperstimulation,
local irritation at injection site, multifetal
gestations |
|
Purified FSH (Metrodin) |
Treatment of polycystic ovarian disease |
Direct action on ovarian follicle |
Intramuscular injections, dosage regimen variable |
Ovarian enlargement, ovarian hyperstimulation,
local irritation at injection site multifetal
gestations |
|
Human chorionic gonadotropin
(hCG) (Profasi) |
Ovulation induction |
Direct action on ovarian follicle to stimulate
meiosis and rupture of the follicle |
2000-10,000 units intramuscularly |
Local irritation at injection site |
|
Danazol (Danocrine) |
Treatment of endometriosis |
Combination of estrogen and androgen suppresses
ovarian activity, eliminating stimulation to endometrial glands and stroma, with resultant shrinkage and disappearance |
100-800 mg/day for 6 mo |
Mild hirsutism, acne,
edema and weight gain, elevation of liver enzyme levels |
|
GnRH agonists (Synarel,
Lupron, Zoladex) |
Treatment of endometriosis, uterine fibroids |
Desensitization and downward regulation of GnRH receptors of pituitary. resulting in suppression of
LH, FSH, and ovarian function |
Synarel, 200 yitg
intranasally twice daily for 6 mo; Lupron, intramuscularly 375 mg every 28 days for 6 mo; Lupron, subcutaneously 0.1 mg daily for 6 mo |
Synarel, nasal irritation, nosebleeds; Synarel and Lupron, hot
flashes, vaginal dryness, myalgia and arthralgia, headaches, mild bone loss (usually reversible
within 12-18 mo after treatment) |
|
Progesterone(progesterone in oil, Progestoral) |
Treatment of luteal-phase
inadequacy |
Direct stimulation of endometrium |
Vaginal suppositories, 25-50 mg twice daily or 50 mg
every night; rectal suppositories, 12.25 mg every 12 hr; progesterone
capsules, 100 mg by mouth three times daily |
Breast tenderness, local irritation, headaches |
Adapted from Fogel,
C, & Woods, N. (Eds.) (1995).
Women's health care.
Drug therapy may be indicated for male
infertility. Problems with
the thyroid or adrenal glands are corrected with appropriate medications.
Infections are identified and treated
promptly with antimicrobials. FSH, HMG, and clomiphene may be used to stimulate spermatogenesis in males with hypogonadism
(Leibowitz & Hoffman, 2000).
The primary care provider is responsible for
informing patients fully about the prescribed medications. However, the nurse must be ready to answer patients'
questions and to confirm their understanding of the drug, its administration,
potential side effects, and expected outcomes. Because information varies with each drug, the nurse
needs to consult the medication
package inserts, pharmacology references, physician, and pharmacist as
necessary.
Surgical
A number of surgical procedures can be used to treat problems causing female infertility. Ovarian
tumors must be excised.
When possible, functional ovarian tissue is left intact. Scar tissue adhesions caused by chronic
infections may cover much or all of the ovary. These
adhesions usually
necessitate surgery to free and expose the ovary so that ovulation can occur.
Hysterosalpingography is useful for identification of tubal obstruction and also for the release of
blockage (see Fig. 9).
During laparoscopy, delicate adhesions may be divided and removed and endometrial implants may be destroyed by electrocoagulation
or laser (see Fig. 6-10). Laparotomy
and even microsurgery may be required to do extensive repair of the damaged tube. Prognosis
depends on the degree to which tubal
patency and function can be restored.
Surgical removal of tumors or
fibroids involving the endometrium or uterus often improves the woman's chance of conceiving and maintaining the pregnancy to viability. Surgical treatment of uterine tumors
or maldevelopment that results in successful pregnancy usually requires birth
by cesarean surgery near term gestation to prevent
uterine rupture as a result of weakness of
the area of surgical healing.
Surgical procedures may also be
used for problems causing male infertility. Surgical
repair of varicocele has been relatively successful in increasing sperm counts but not
fertility rates.
Reproductive alternatives
Assisted
reproductive therapies. There have been
remarkable developments in
reproductive medicine. Assisted reproductive therapies (ARTs) have created ethical and legal
issues (
|
Risks of multiple gestation Possible need for multifetal
reduction Possible need for donor oocytes, sperm, or
embryos or gestational carrier (surrogate
mother) Freezing embryos for later use Possible risks of long-term
effects of medications and treatment
on women, children, and families |
|
LEGAL TiP Cryopreservation of Human Embryos Couples who have excess embryos
frozen for later transfer
must be fully informed before consenting to the procedure, to make decisions regarding the disposal of embryos in the event of
(1) death, (2) divorce, or (3) the decision that the couple no longer wants
the embryos at a
later time. |
|
|
|
Fig. 12 Gamete intrafallopian
transfer (GIFT). A, Through laparoscopy, a ripe follicle is located and fluid containing the egg is removed. B, The sperm and egg are
placed separately in the uterine tube, where
fertilization occurs.
TABLE 5 Assisted Reproductive Therapies (ARTs)
|
PROCEDURE |
DEFINITION |
INDICATIONS |
|
In vitro fertilization - embryo
transfer (IVF-ET) |
A woman's eggs are collected from
her ovaries, fertilized in the laboratory with sperm, and transferred to her
uterus after normal embryo development has occurred |
Tubal disease or blockage; severe
male infertility; endometriosis; unexplained infertility; cervical factor;
immunologic infertility |
|
Gamete intrafallopian
transfer (GIFT)
|
Oocytes are retrieved from the ovary, placed
in a catheter with washed motile sperm, and immediately transferred into the fimbriated end of the uterine tube. Fertilization occurs
in the uterine tube |
Same as for IVF-ET, except there
must be normal tubal anatomy, patency, and absence of previous tubal disease
in at least one uterine tube |
|
IVF-ET and GIFT with donor sperm |
This process is the same as
described above except in cases where the male partner's fertility is
severely compromised and donor sperm can be used; if donor sperm are used,
the woman must have indications for IVF-ET and GIFT. |
Severe male infertility; azoospermia; indications for IVF-ET or GIFT |
|
Zygote intrafallopian
transfer (ZIFT) |
This process is similar to
IVF-ET; after in vitro fertilization the ova are placed in one uterine tube
during the zygote stage. |
Same as for GIFT |
|
Donor oocyte |
Eggs are donated by an IVF
procedure, and the donated eggs are inseminated. The embryos are transferred
into the recipient's uterus, which is hormonally prepared with
estrogen/progesterone therapy. |
Early menopause; surgical removal
of ovaries; congenitally absent ovaries; autosomal
or sex-linked disorders; lack of fertilization in repeated IVF attempts
because of subtle oocyte abnormalities or defects
in oocyte/spermatozoa interaction |
|
Gestational carrier (embryo
host); surrogate mother |
A donated embryo is transferred
to the uterus of an infertile woman at the appropriate time (normal or
induced) of the menstrual cycle |
Infertility not resolved by less
aggressive forms of therapy; absence of ovaries; male partner is azoospermic or is severely compromised |
|
Donor embryo (embryo adoption) |
A couple undertakes an IVF cycle
and the embryo(s) is transferred to another woman's
uterus (the carrier) who has contracted with the couple to carry the baby to
term. The carrier has no genetic investment in the child. Surrogate
motherhood is a process by which a woman is inseminated with semen from the
infertile woman's partner and then carries the baby until birth. |
Congenital absence or surgical
removal of uterus; a reproductively impaired uterus. myomas,
uterine adhesions, or other congenital abnormalities; a medical condition
that might be life-threatening during pregnancy, such as diabetes,
immunologic problems, or severe heart, kidney, or liver disease |
|
Therapeutic donor insemination
(TDI) |
Donor sperm are used to
inseminate the female partner. |
Male partner is azoospermic or has a very low sperm count; couple has a
genetic defect; male partner has antisperm
antibodies |
|
Intracytoplasmic sperm injection (ICSI) |
Selection of one sperm cell that
is injected directly into the egg to achieve fertilization. Used with IVF-ET. |
Same as TDI |
|
Assisted hatching |
The zona
pellucida is penetrated chemically or manually to
create an opening for the dividing embryo to hatch and implant into uterine wall |
Recurrent miscarriages; to
improve implantation rate in women with previously unsuccessful IVF attempts;
advanced age |
Data from Angard, N.
(1999). Diagnosis
infertility. AWHONN Lifelines, 3(3), 22-29; Stenchever, M. et al. (2001).
Comprehensive gynecology (4th ed.).
Complications. Other than the established risks associated with laparoscopy and general
anesthesia, few risks are associated with
IVF-ET, GIFT, and ZIFT. The more common transvagmal needle aspiration requires only local or intravenous analgesia. Congenital anomalies
occur no more frequently than among
naturally conceived embryos. Ectopic pregnancies do occur more often,
however, and these carry a significant maternal risk. There is no increase in maternal or perinatal
complications with TDI; the
same frequencies of anomalies (approximately 5%) and obstetric complications (between 5% and 10%) that
accompany natural insemination (through sexual intercourse) apply also to TDI.
Preimplantation genetic diagnosis. Preimplantation genetic
diagnosis (PGD) or testing (PGT) is a form of early genetic
testing designed to eliminate embryos with serious genetic defects before implantation through one of the ARTs and to prevent later termination of the pregnancy for
genetic reasons (Fasouliotis & Schenker, 1999). There are
more than 20 centers worldwide where PGD is being used clinically.
Experts caution that use of PGD could lead to
"new" eugenics (Draper & Chadwick, 1999; King, 1999). Couples need to be counseled about their options
and choices, as well as the implications of their choices, when genetic
analysis is considered (Jones, 2000).
Adoption. Couples may choose to build their
family by adopting children who are not
their own biologically. However, with
increased availability of birth control and abortion and increasing numbers of single mothers keeping their babies, the adoption of Caucasian infants is extremely limited.
Minority infants, infants with special needs, older children, and foreign adoptions are other options.
Couples who decide to adopt a child have decided that being a parent and having a child is more important
than the actual process of birthing the child. The birth process is a small aspect of having a baby and becoming a
parent. So much emphasis is placed on being pregnant and having a child composed of one's own genetic makeup that
the focus of the reason to have a child becomes cloudy. The question to be answered by couples who are considering
adoption is, "What is important
to you – that you become parents or go through
the experience of pregnancy and birth?"
Evaluation
Evaluation of the effectiveness of care of the couple experiencing impaired fertility is based on the
previously stated outcomes (see Plan
of Care).
PLAN OF CARE. Infertility
NURSING DIAGNOSIS Deficient knowledge related to the reproductive process with regard to conception as evidenced by patient questions
Expected Outcome
Patient and partner will verbalize understanding of the components of the reproductive process, common problems leading to infertility, usual
infertility testing, and the importance of completing testing in a timely
manner.
Nursing Interventions/Rationales
Assess patient's current level of
understanding of the factors
promoting conception to identify gaps or misconceptions in knowledge base.
Provide information in a supportive
manner regarding factors promoting conception including common factors leading
to infertility of either partner to raise patient's awareness and promote trust in caregiver.
Identify and describe the basic infertility tests and the rationale for
precise scheduling to enhance completion of the diagnostic phase of the infertility workup.
NURSING DIAGNOSIS Risk for ineffective individual/family coping related to
inability to conceive as
evidenced by patient and partner statements
Expected Outcome Patient and partner will identify situational stressors and positive coping methods
to deal with testing and unknown
outcomes.
Nursing Interventions/Rationales
Provide opportunities through
therapeutic communication
to discuss feelings and concerns to identify common feelings and perceived stressors.
Evaluate couple's support system,
including support of each other during this process, to identify any
barriers to effective coping.
Identify support groups and refer as needed to enhance coping by
sharing experiences with other couples experiencing
similar problems.
KEY POINTS
A variety of contraceptive methods
are available with various effectiveness rates, advantages, and disadvantages.
Nurses need to help couples choose
the contraceptive method or methods best suited to them.
Effective contraceptives are
available through both prescription and nonprescription sources.
A variety of techniques are
available to enhance the effectiveness of periodic abstinence in motivated
couples who prefer this natural method.
Hormonal contraception includes
both precoital and postcoital
prevention through various modalities and requires thorough patient education.
The most widely used emergency
contraceptive method is ingestion of large doses of estrogen and progestin oral
contraceptive pills taken in two doses, 12 hours apart.
The barrier methods of diaphragm
and cervical cap provide safe and effective contraception for women or couples
motivated to use them consistently and correctly.
Proper use of latex condoms
provides protection against STIs.
Tubal ligations and vasectomies are
permanent sterilization methods used by increasing numbers of women and men.
Elective abortion performed in the
first trimester is safer than an abortion performed in the second trimester.
The most common complications of
elective abortion include infection, retained products of conception, and
excessive vaginal bleeding.
Major psychologic
sequelae of elective abortion are rare.
Infertility is the inability to
conceive and carry a child to term gestation at a time the couple has chosen to
do so.
Infertility affects between 10% and
15% of otherwise healthy adults. Infertility increases in women older than 40
years.
In the
Common etiologic factors of
infertility include decreased sperm production, ovulation disorders, tubal
occlusion, and endometriosis. Reproductive alternatives for family building
include IVF-ET, GIFT, ZIFT, oocyte donation, embryo
donation, TDI, surrogate motherhood, and adoption.
CRITICAL THINKING EXERCISES
1. Explore the options in your
community for diagnosis, treatment alternatives, and support services for couples
experiencing infertility. Discuss your findings in a clinical conference,
including the ease or difficulty a couple would have in getting help with their
problem.
2. Visit a clinic that provides
family planning services in your area.
a. Are there differences in fee
schedules for women with and without insurance? Are local, state, or federal
funds available for these family planning services?
b. Are the hours of service
sufficient to meet the needs of patients? How long are typical waits to be seen
during a scheduled appointment?
c. What is the nurse's role in the
clinic? What other health care professionals are present and what are their
roles? Is there any collaboration among these care providers?
d. Make suggestions for changes in
the way care is provided that increase efficacy and patient satisfaction.
3. You are working in a health
department clinic. A 16-year-old, unmarried woman who has missed one menstrual
period comes in requesting information about options for an unwanted pregnancy.
a. Examine your values about
teenage pregnancy. Explore your beliefs about options for an unwanted
pregnancy. How might these values and beliefs affect your ability to provide
information about options in a nonjudgmental manner?
b. What patient information do you
need to know before counseling a woman about her options?
c. What information is needed by
the pregnant woman in making a decision about her unwanted pregnancy?
d. What are the laws in your state
related to abortion, informed consent, and treatment of minors?
e. Select one option for this
hypothetical patient and justify your choice.
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
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
•
•
•
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
•
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
–
In 1960, the first oral contraceptive (Enovid-10) was launched in the
–
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
•
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.
CARE MANAGEMENT
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
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).
|
TEACHING GUIDELINES 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
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 ____________
Year 2003
Previous cycle variation
26-29
Cycle variation
based on 12 recorded cycles
This cycle: 35 days
Apr.
Day
of cycle
Menstruation
Coitus
record
Day
of month
Disturbances
Mucus
Peak or
last day
Cervix
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
Key
Mucus:
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.
|
TEACHING GUIDELINES 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. ASSESSMENT TECHNIQUE 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 methods
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
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
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.
|
Male
Condoms 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. FAILURE RATE Typical users, 14% Correct and consistent users, 3% ADVANTAGES Safe 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 DISADVANTAGES 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. STI PROTECTION 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. NURSING CONSIDERATIONS 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. |
FEMALE
CONDOM
The vaginal sheath (female condom) is made of polyure-thane and has flexible
rings at both ends (see Fig. 6-
Diaphragm. The vaginal diaphragm is a shallow,
dome-shaped rubber device with a flexible
wire rim that covers the cervix (see
Fig. 6-
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
Cervical cap. The cervical cap has a 22 to
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 Squatting is the most
commonly used position, and most women find it satisfactory.
Leg-up Method 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.
Chair Method Another practical method for diaphragm insertion is to sit far
forward on the edge of a chair.
Reclining 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).
GENERAL INFORMATION 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).
Hormonal methods
More than 30 different oral contraceptive
formulations are available in the
Table 6-1 Hormonal contraception
|
COMPOSITION |
ROUTE OF ADMINISTRATION |
DURATION OF EFFECT |
|
Combination
estrogen and progestin (synthetic estrogens and progestins
in varying doses and formulations) |
Oral |
24 hours |
|
Progestin
only |
|
|
|
Norethindrone, norgestrel |
Oral |
24 hours |
|
Medroxyprogesterone acetate |
Intramuscular injection |
3 months |
|
Levonorgestrel |
Subdermal implant |
Up to 5 years |
|
Progesterone |
Intrauterine device |
1 year |
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
•
Lunelle
•
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
•
–
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.
Ethical
Considerations
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.
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-
TABLE 6-2 Emergency Contraceptive
Pill Dosages
|
TRADE NAMES |
FIRST
DOSE (WITHIN 72
hr) |
SECOND DOSE (12 hr LATER) |
|
Ovral |
2
white tablets |
2
white tablets |
|
Lo/Ovral |
4 white tablets |
4 white tablets |
|
Nordette |
4 light orange
tablets |
4 light orange
tablets |
|
Levlen |
4 light orange
tablets |
4 light orange
tablets |
|
Triphasil |
4 yellow tablets |
4 yellow tablets |
|
Tri-Levlen |
4 yellow tablets |
4 yellow tablets |
|
Alesse |
5
pink tablets |
5
pink tablets |
|
Trivora |
4 yellow tablets |
4 yellow tablets |
|
Levora |
4 white tablets |
4 white tablets |
|
Levlite |
5
pink tablets |
5
pink tablets |
|
Preven* |
2
blue tablets |
2
blue tablets |
|
Ovrette+ |
20 yellow tablets |
20 yellow tablets |
|
Plan B+ |
1 white tablets |
1 white tablets |
Source: American Pharmaceutical Association.
(2000). Emergency contraception: The pharmacist's role.
* 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
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.
Intrauterine device
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
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).
LEGAL TIP
Sterilization
• 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
Evaluation of the effectiveness of care of the
woman using a contraceptive method is based on the previously stated outcomes.
& if contraception fails …
•
RU-486
–
Blocks progesterone receptors
–
Uterus & anterior pituitary behave as if
no progesterone present
–
Endometrium sloughs.
ABORTION
INDUCED ABORTION
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
|
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.
First-Trimester
Abortion
Methods for performing early abortion include
vacuum aspiration, medical methods (mifepristone with
prostaglandin), and methotrexate with misoprostol.
Vacuum aspiration
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
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
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.
Nursing
Considerations
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.