Midterm Patho

QFO-8.
3-03-01
Rev. 0
COLLEGE OF _________________________ Revision : __

SURIGAO EDUCATION CENTER Department of _________________________ Effective: __
Km. 2, National Highway, 8400 Surigao City, Philippines Supersedes: __
Instructional Module
MWPC-102
Pathological Obstetrics w/ Family Planning and Care of Infants
Module Holder: Control Number:
Prepared by: Reviewed & Evaluated by: Validated by: Approved by:
_______________________ ____________________
_______________________ ____________________ ______________________ ____________________________
Faculty Member(s) Dep’t Review Committee Dean Vice President for Academic Affairs
Date: __________________ Date: _______________ Date: _________________ Date: _______________

SURIGAO EDUCATION CENTER
Km. 2, National Highway, 8400 Surigao City, Philippines
REVISION HISTORY
NO. DATE REVISION
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I. OVERVIEW OF THE MODULE

A. SEC INSTITUTIONAL VISION
Surigao Education Center envisions being a dynamic educational producing globally competitive through quality education
B. SEC INSTITUTIONAL MISSION

Surigao Education Center is committed to provide an assured level of quality education relevant and responsive to the needs of
the community anchored on the values of accountability, work ethics, pursuit of excellence, truth, cooperation and social
responsibility.
C. SEC INSTITUTIONAL GOALS
1. Strengthen the school’s internal controls, operational infrastructure and accountability.
2. Achieve a status of professional institute:
3. Sustainably strengthen the school’s medium and long term financial position to obtain and maintain fiscal stability.
4. Establish a significant research culture and publication.
5. Serve Caraga Region by promoting a culture of community service and engagement.
D. SEC INSTITUTIONAL OUTCOMES:
A graduate of Surigao Education Center can
1. Render services to the community imbued with values of accountability, work ethics, excellence, honestly cooperation and
social responsibility;
2. Implement practices on the preservation, restoration and improvement to the environment
3. Create and communicate a vision that inspires others to act or achieve a desired goal
4. Preserve and promote Filipino culture and love of country;
5. Demonstrate cultivation of knowledge and creative skills to excel in life’s chosen work
E. PROGRAM OUTCOMES:
The Diploma in Midwifery Program aims to produce a Midwife who is able to:
1. Provide necessary supervision, care, and advice to low-risk women during pregnancy, labor and puerperium.
2. Manage normal deliveries and care of newborn on her own responsibility.
3. Perform primary health services with the community (promotive and preventive care).
4. Counsel and educate women, family and community regarding family planning including preparation for parenthood.
5. Detect (abnormal conditions in mother and child: procure specialized assistance as necessary (consultation or referral).
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F. COURSE OUTCOMES:
At the end of the semester, the student will have acquired knowledge, skills and attitude in instituting nursing measures
including drug administration.
G. Course Map in ______________
Course Outcomes
Course Code Course Title Program Outcomes
CO1 CO2 …
MWPC-102 Pathological Obstetrics w/ Family 1. Render services to At the end of Detect
Planning and Care on Infants the community the semester, (abnormal
imbued with values the student conditions in
of accountability, will have mother and
work ethics, acquired child:
excellence, honestly knowledge, procure
cooperation and skills and specialized
social attitude in assistance
responsibility; instituting as
nursing necessary
measures (consultation
including drug or referral).
administration.
2. Implement practices
on the preservation,
restoration and
improvement to the
environment
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Legend: I – Introduced Concept/Principle

P – Practiced with Supervision
D – Demonstrated across different clinical setting with minimal supervision
H. Course Description:
The course provides the student with the basic/necessary knowledge, skills, and acceptable attitudes in the care of individuals
and families. It includes comfort measures applied to individual clients and drug administration.
I. Pre-requisite: J. Co-requisite:
K. Course Requirements:
Equipment, Materials, Chemicals, Teaching Aids to be used:
Office Supplies such as: Hospital Forms and Logbook
Equipment such as: Different types of drugs, vital signs set, physical assessment set, stethoscope, Non-mercurial BP apparatus,
splints, mannequin/dummy as models, etc.
Fixtures such as: chart rack, medicine and treatment cards rack
Audio Visual Equipment’s: mannequin, models, video, CD, etc.
Appliance such as: footstool, hospital linens etc.
II. Course Outline
Periodic Module Week Number of Hours

Topics
Schedule Number Number Lecture Laboratory
Prelim
Midterm I. Complications during labor and delivery 4 13.5hours
1. Power
1.1 dystocia
1.2 precipitate labor
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1.3 ruptured uterus

1.4 dysfunctional uterine contraction
2. Passageway
2.1 CPD
3. Passenger
3.1 prolapsed cord
3.2 cord coil
3.3 multiple pregnancy
3.4 abnormal presentation
II. Responsible parenthood and family planning
1. Population situation
1.2 world
1.3 philippines
2. Laws and legislation related to FP
II.1 PD 965
II.2 PD 79
II.3 PD 223
II.4 PD 6365
II.5 PD 69
II.6 PD 48
II.7 LOI 47
3. Roles and functions of the midwife
3.1 motivator
3.2 Counsellor
3.3 service provider
3.4 family planning manager
4. Human sexuality
4.1 biophysical profile
4.2 psycho-physiological
4.3 socio-cultural
5. Benefits of family planning
5.1 mother
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5.2 father
5.3 children
6. Client health assessment
6.1 importance of client health assessment
6.2 when to conduct health assessment
6.3 components of health assessment
7. Counseling
7.1 importance of counselling
7.2 principles of counselling
7.3 steps in counselling
7.4 skills in counselling
7.5 effective counselling
8. Factors affecting couples acceptance and non-acceptance of FP
9. Methods of family planning
9.1 FAB methods
9.2 Hormonal methods
9.3 Barrier methods
9.4 Permanent methods
10. Current trends of family planning
Prefinal
Final
TOTAL
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III. LEARNING PLAN
A. Week No. ____ Module No. ______ <Topic> Time Allocation: ____
COURSE INTENDED LEARNING LEARNING ASSESSMENT

REFERENCES
OUTCOMES OUTCOMES TASKS/ACTIVITIES TASKS
B. Learning Tasks/Activities (Lesson Proper)
I. Complications during labor and delivery

1. Powers
1.1 Dystocia- is a broad term referring to prolonged and difficult labor (any labor that lasts more than 24 hours) caused by an abnormality or a
combination of abnormalities in the essential factors of labor.
-Also known as difficult labor, abnormal labor, difficult childbirth, abnormal child birth, and dysfunctional labor.
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Types of Dystocia
1. Uterine dysfunction- Abnormalities of the powers

a. Hypotonic uterine dysfunction
b. Hypertonic uterine dysfunction
c. Inadequate secondary forces
2. Abnormalities with passageway
a. Pelvic dystocia
 Inlet dystocia
 Midpelvis dystocia
 Outlet dystocia
b. Soft tissue dystocia
 Placenta previa that partially or completely obstruction the birth canal
 Presence of tumors that obstruct the birth canal
3. Fetal dystocia- Abnormalities of the passenger
a. Malposition- persistent occiput posterior position
b. Breech presentation
c. Face
d. Brow
e. Shoulder
f. Multiple presentation
g. Macrosomia
h. Hydrocephalus
Diagnosis of abnormal labor:
1. Laboratory tests: no specific laboratory studies can be used to assess abnormal labor
2. Imaging Studies: X-ray pelvimetry and Computerized Tomography (CT) pelvimetry may be used to assess the maternal bony pelvis.
3. Other test:
a. The simplest test used to evaluate abnormal labor is to plot the patient’s labor progress (cervical dilatation vs duration in hour) on a labor curve.
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b. A second test used to address adequate is the review of uterine contraction pattern: duration, frequency, interval and intensity.
c. FHT assessment: The fetal heart tracing must be reassuring throughout the labor course.
4. Clinical pelvimetry: This examination is useful in assessing if the pelvis is adequate, borderline, or contracted.
1.2 Precipitate labor- is labor that occurs within 3 hours from onset of contraction to delivery of baby. Precipitate delivery is delivery that occurs without warning.
Precipitate labor disorders can be classified as:
1. Precipitate dilatation- when cervical dilatation is progressing at a rate of 5cm or more per hour in nulliparas and 10cm per hour or more in multiparas
2. Precipitate descent- when fetal descent is progressing at a rate of 5 cm per hour or more in nulliparas and 10cm per hour or more in multiparas
Predisposing factors:
1. Multiparity
2. Large pelvis
3. Lax unresisting maternal tissue
4. Small baby in good position
5. Induction of labor: amniotomy and oxytocin administration
6. Absence of painful sensation and thus a lack of awareness of vigorous labor
Complications
1. Maternal
 Laceration of birth canal and uterine rupture
 Postpartum hemorrhage
 Amniotic fluid embolism
2. Fetal
 Hypoxia
 Intracranial hemorrhage due to sudden change of pressure
 Erb- Duchenne palsy
 Premature separation of placenta
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 Injuries as a falling to the floor in unattended birth
Sign and Symptoms
 Patient complains of a sudden, intense urge to push

 Sudden increase of bloody flow
 Sudden bulging of the perineum
 Sudden crowning of the presenting part
Management
1. Anticipatory guidance for prevention:

 Adequate prenatal care for early detection of risk conditions
 Inform multiparous women that succeeding labors are usually shorter so they can make appropriate plans for rapid transportation to the hospital
when labor accurs.
 Warm women with the hx of precipitate labor that rapid labor and delivery may be happen again
2. If accelerated labor pattern occurs during oxytocin administration, stop infusion right away and turn woman in her side.
3. Call for help. Do not leave the patient alone.
4. If in a health care facility, obtain a sterile delivery pack which contains the equipment’s necessary for vaginal delivery. If not available, ask for the following
priority items:
 Sterile gloves are preferred as they help promote sepsis
 Towel/cloth to provides a friction surface for control of delivery of the fetal head
 Bulb syringe to aspirate amniotic fluid from the infant’s mouth
 cord clamps to clamp the umbilical cord
 scissors to cut the episiotomy/cord
 dry blanket/towel to wrap the infant after delivery
5. If the permits, wash hands and wear sterile gloves.
6. Pour betadine over the perineum if there is no more time to perform perineal preparation
7. Speak in calm tone using short sentences. Inform woman of what is happening. Tell the mother to pant or to push at your instructions to control the delivery
of the head and the body. Preferably, only one person should coach the mother in bearing down to prevent confusion.
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8. Never hold the baby back if rapid labor occurs such as making the woman lock her legs together or by pushing the baby’s head back into the vagina this can
result in fetal brain damage.
9. Ask women to pant and not to push when the head is already crowning to prevent rapid expulsion.
10. Practice Ritgen’s maneuver when delivering the head.
11. After the head is delivered, tell the woman to continue panting to give time to suction ambiotic fluid from the baby’s mouth.
12. Check for nuchal cord. Slip it over the head or down the shoulder if loose.
13. Apply gentle downward pressure on the head until the anterior shoulder delivers from under the pubic arch and becomes visible. Support the infant back and
neck. The infant’s gently pushed or lifted upward to facilitate delivery of the posterior shoulder. After the delivery of posterior shoulder, the infant body is
generally expelled rapidly.
14. Place the on mother’s abdomen with the head tilted downwards to facilitate the drainage of mucus and amniotic fluid from the upper airway. The pressure
of the infant’s body on the uterus will help stimulate uterine contractions while waiting for the birth of placenta. Suction secretions from the mouth and
nose. If the baby does not cry spontaneously, rub the back or soles of the feet briskly.
15. Dry and wrap the infant immediately to prevent heat loss. In an emergency setting, place wrapped infant in the mother’s arms to be held close to her body to
maintain warmth.
16. While waiting for placental delivery, place hand over the fundus to make sure it remains firm and check the infant frequently for regular respirations.
17. Do not try to hasten placental delivery by pulling on the cord or applying fundal pressure: these actions can tear the cord from the placenta or cause uterine
inversion. Observe for signs of placenta separation that usually occurs 5 to 10 minutes after delivery. When they appear, ask the mother to bear down only if
necessary. In many instances of rapid labor and delivery, the placenta slips down the birth canal spontaneously and is delivered without need of effort from
the mother.
18. After placental delivery, massage uterus to promote uterine contraction. Check placenta for completeness. Encourage the mother to breastfeed to stimulate
uterine contractions.
19. Determine one (1) and five (5) minutes APGAR scores. Check the baby for injury after birth. Examine the woman for lacerations.
20. If supplies are not available (forceps, cord clamp) do not cut cord using unsterile ordinary household/sewing/school scissors, blade or knife, or tie it with
sewing thread.
21. Transport mother and baby to the nearest health care facility. Continue monitoring maternal and fetal well-being during the transport.
1.3 Uterine Rupture- or the tearing of the muscles of the uterus occurs when the uterus can no longer withstand the strain placed upon it.
CAUSES Uterine Rupture:
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 Rupture of scar from previous CS

 Prolonged labor, obstructed labor, malposition and malpresentation
 Over-distention of the uterus, multiple gestation
 Injudicious use of oxytocin, forceps and vacuum extraction, internal version
 Precipitate labor and delivery
 Manual removal of the placenta
 External trauma- sharp or blunt
 Placenta increta or accrete
 Adenomyosis
 Gestational trophoblastic neoplasma
Signs and Symptoms of Uterine Rupture:
1. Impending uterine rupture is often manifested by a pathologic retraction ring in obstructed labor.
2. During the peak of a contraction, the woman complains of a sudden sharp tearing pain after which, relief is felt as the uterus loses the Capacity to contract or
if it still does, the contractions are too weak to cause much discomfort.
Types of Uterine Rupture
1. Complete Rupture: When the uterus ruptures, the woman experiences a sudden excruciating pain at the peak of a contraction, then contractions stop
altogether. Two swellings will be visible in the abdomen: the uterus and the extra-uterine fetus. Internal hemorrhage soon follows and vaginal bleeding may
or may not occur. Separation of the placenta from the uterus cuts off blood supply to the fetus resulting in fetal hypoxia and death.
2. Incomplete Rupture: Symptoms of incomplete rupture are localized tenderness and persistent pain over the abdomen. Contractions may still continue or
stop but no progress in cervical dilatation will be observed. Vaginal bleeding may or may not be present. Signs of maternal shock and fetal distress are
observed because of internal bleeding.
Management
1. Blood transfusion and administration of IVF to correct shock.
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2. Administer mask oxygen to the woman at 8L/m.

3. Expect emergency laparotomy to deliver the baby.
4. Provide emotional support. Inform woman of what is happening the procedures being done, answer questions as realistically as possible, do not give false
reassurances.
5. Post-Op Care (same as care after hysterectomy)
 Explain need to avoid driving for 3-6 weeks
 Explain need to avoid jogging, sexual intercourse, dancing and lifting heavy objects for 6-8 weeks.
1.4Uterine Dysfunction- may be caused by any or a combination of the following conditions: pelvic contraction, fetal malposition, over distention, and excessive
rigidity of the cervix.
The following are the two common types of uterine dysfunction.
HYPOTONIC UTERINE INERTIA (dysfunction) HYPERTONIC UTERINE INERTIA (dysfunction)
Onset: late onset usually in the active phase Onset: late usually in the latent phase
Contractions: weak, painless Contractions: strong ,painful
Tension not synchronous Uncoordinated, increase contactions, but

ineffective in bringing about further dilation
Treatment:enema, walking if not contraindicated, Treatment:sedation

amniotomy, oxytocin
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Causes of HYPOTONIC UTERINE INERTIA (dysfunction)
 Overdistention of the uterus- multiple pregnancy, hydramnious

 Malpresentation and malposition
 Pelvic bone contraction
 Unripe or rigid cervix
 Congenital abnormalities of the uterus
 Unknown causes
Complications:
 Maternal and fetal infection because cervix is dilated for a long time providing more time for microbial invasion and growth
 Postpartum hemorrhage because of prolonged labor making the uterus too exhausted to contract effectively in the postpartum period
 Fetal distress and death
 Maternal exhaustion
Management:
 Reevaluate pelvic size to rule out fetopelvic disproportion

 Vaginal delivery:
. Amniotomy if membranes are not yet ruptured
. Augmentation of labor by oxytocin administration
 If contracted pelvis is present, ceasarian section is the method of delivery
 Provide supportive nursing care
HYPERTONIC UTERINE INERTIA (dysfunction) Management:
 Evaluation of pelvic size. If pelvis is adequate, vaginal delivery will attempted.
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 Maintenance of fluid and electrolyte balance by infusion of IV fluids.

 Therapeutic rest: The woman is given analgesics (morphine) and sedatives (Phenobarbital) to promote rest. The woman usually awakens with normal
labor pattern.
 Keep bladder empty to provide more space for the passage of fetus
 Encourage side lying position to maximize blood flow to the placenta and fetus
 Watch for diaper signals: fetal distress, passage of meconium stained amniotic fluid.
2.Passageway
2.1 CPD- Cephalopelvic disproportion occurs when a baby’s head or body is too large to fit through the mother’s pelvis. It is believed that true CPD is rare, but many
cases of “failure to progress” during labor are given a diagnosis of CPD.
What causes CPD:
 Large baby due to:

- Hereditary factors
- Diabetes
- Postmaturity (still pregnant after the due date has passed)
- Multiparity (mot the first pregnancy)
 Abnormal fetal positions
 Small pelvis
 Abnormally shaped pelvis
Treatment for CPD:
- If it is severe and diagnosed early, a planned C-section is indicated. In other cases, CPD may be treated with a symphysiotomy (the surgical
division of public cartilage) or an emergency (-section after a trial labor.
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How is cephalopelvic disproportion (CPD) diagnosed?
 When there is failure to progress (but not all cases of prolonged labour are the result of CPD)
 Use of ultrasound to measure the size of the fetus in the womb is controversial
 Pelvimetry may identify cephalopelvic disproportion
3.Passenger
3.1Prolapsed cord- occurs when the cord passes out of the uterus ahead of the presenting part.
Causes:
 Polyhydramnios
 Long cord
 Malposition and malpresentation (shoulder and foot presentation)
 Prematurity
 Placenta previa
Signs and symptoms:
1. Cord protrudes from the vagina and palpation of cord in the vaginal canal/cervix during IE
2. Fetal distress
Management:
1. Prevention: Place woman in bedrest after membranes have ruptured.

2. Reduce pressure on the cord by:
 Place in Knee-chest or trendelenburg position, or place a folded towel under hips
 Put on sterile gloves and insert two fingers into the vagina then, push presenting part upward
3. If cord exposed to air, cover it with a saline moistened sterile compress.
4. Never replace the cord back into the vagina as this will result in cord kinking.
5. Administer mask oxygen until delivery is completed.
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6. Deliver the baby as soon as possible:

 Vaginal delivery if cervix is fully dilated without fetal distress
 Cesarean section if cervix is not yet completely dilated and if fetal distress is present
3.2Cord coil- a nuchal cord occurs when the umbilical cord becomes coiled around an infant’s neck, most often in a single coil but in some cases, multiple coil.
Fast facts on nuchal chord:
 The umbilical cord carries nutrients and oxygen to the fetus in the mother’s womb.
 A nuchal cord might interrupt blow flow, oxygen, and nutrients to the fetus and cause complications
 Fortunately, most nuchal cords will resolve before delivery.
 If there is concern about the cord’s enlargement, a baby may be delivered by cesarean
 Even in cases where they do not resolve, the potential for probles is low.
Causes of cord coil:- the main cause of a nuchal cord is excessive fetal movement.
Other medical reasons why cords may move around the neck of a fetus or may result in loose knots include:
 An abnormally long umbilical cord

 A weak cord structure
 Excessive amniotic fluid
 Having twins or multiples
3.3Abnormal presentation
1. Breech presentation- is defines as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix.
There are four types of breech: frank breech, complete breech, and double or single footling.
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Causes Breech:
 Uterine relaxation due to multiparity

 Fetal abnormalities – hydrocephalus, anecephalus
 Hydramnios and oligohydramnios
 Congenital abnormalities of the uterus – bicornuate uterus
 Contracted pelvis
 Previous breech delivery
 Space occupying mass in the uterus that prevents the head from fitting into the lower portion such as placenta previa and fibroids
 Prematurity
 Multiple pregnancy
Complication of breech:
1. Prolapse cord because the breech does not fit well enough into the pelvic brim
2. Birth trauma: fracture of the skull, clavicle, humerus, intracranial hemorrhage, rupture of abdominal organs
3. Prolonged labor because the soft buttocks do not aid in cervical dilatation
4. Intrauterine anoxia
5. Fetal death
Management of breech:
1. Whenever a breech presentation is diagnosed late in pregnancy, the physician may attempt to rotate the fetus from breech to cephalic presentation by
external version.
2. Vaginal delivery
a. Vaginal delivery may be attempted if:
 There is no pelvic contraction
 The fetus is not too large – not more than 3,600grams
 There are personnel skilled in the delivery of breech
 Spontaneous labor occurs with progressive cervical dilatation and effacement ( add piper forcep to the delivery set-up)
b. Three general techniques of vaginal breech delivery:
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 Spontaneous breech delivery: the infant is born without traction or manipulation from the obstetrician
 Partial breech extraction: The infant is delivered spontaneously up to the umbilicus; the rest of the body is extracted.
 Total breech extraction: The entire body of the infant is extraction by the obstetrician.
c. The different maneuvers:
 Mauriceau Maneuver: First practiced by Mauriceau in 1721. Used to extract the head after delivery of the infant’s body.
 Prague maneuver: This technique is used when the back of the fetus fails to rotate to the anterior. This maneuver was first practiced by Kiwisch
(1846) in Prague.
 Bracht maneuver: Spontaneous delivery of the infant in breesch is achieved by the force of uterine contraction and moderate suprapubic pressure.
The baby is delivered spontaneously up to the umbilicus. The fetal body is, then, held against the mother’s symphisis pubis. Fetal suspension in this
position aided by strong uterine contraction and moderate suprapubic pressure can result in spontaneous delivery of the rest of the body.
 Pinard maneuver: A procedure involving intrauterine manipulation. The entire hand of the obstetrician is inserted into the vagina to convert frank
breech to footling breech.
 Abdominal recue: When the fully deflexed head is entrapped and cannot be delivered vaginally after the rest of the body has come out, the fetus is
replaced higher in the vagina and uterus. This is followed be cesarean section to deliver the fetus.
 Cliedotomy: Cutting of shoulder using scissors of dead fetus to facilitate delivery. This is also used in shoulder dystocia.
d. Management of vaginal breech delivery:
 Continuous assessment of the progress of labor: contractions, effacement, dilatation, station, presentation.
 Assessment of fetal condition: ultrasound to determine anomalies such as hydrocephalic, microcephaly and anencephaly.
 Continuous monitoring of fetal condition
 Additional nursing and medical personnel skilled in breech delivery and an obstetrical attendant to watch over the patient continuously and the
physician should be available anytime
 The decision regarding the method of delivery should be made as soon as possible after admission to avoid complications.
3. If it is not possible to deliver the fetus vaginally and to ensure safer route of delivery, sesarean delivery is employed.
2.Face presentation- occurs when the head is hyper extended and the chin (mentum) is the presenting part. On internal examination, the examining finger feels
the mouth, nose, molar bones and orbital ridges.
The mechanism of labor in face presentation is as follows: descent, internal rotation, flexion, extension, external rotation, expulsion.
Causes Face presentation:

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 Large fetus
 Lax uterus due to multiparity
 Occipitoposterior position because of the tendency of the fetus of extending the head instead of flexing it
Management of Face presentation:
1. If the chin is in anterior position (LMA or RMA), uterine contraction are strong, the head is small, shoulder have already entered the pelvis and there is no
pelvic contraction, vaginal delivery is possible but longer than usual. Forceps may be used to hasten the second stage
 The baby usually has a disfigured appearance after birth; the face is congested and bruised, often appearing purple and ecchymotic. Lip edema will
make sucking difficult

during the first two days. Reassure the mother that bruising and edema is a temporary result of delivery and will disappear within a few days.
 There is considerable molding with an increase in the diameter of the occipitomental.
2. If the chin is in posterior position (RMP, LMP) vaginal delivery may be impossible and dangerous if attempted because it can lead to transverse arrest.
Caesarean section is the delivery of choice when the chin is posterior.
3. Brow Presentation- is the most uncommon of all presentation. The causes are the same as those of face presentation. Brow presentation is commonly
unstable, it usually converts to face or vertex presentation. Babies born vaginally from brow presentation experience extreme facial edema, tell parents that
their babies’ unsightly appearance will disappear in a few days.
4. Shoulder Presentation- occurs when the fetus assumes a transverse or oblique lie. Shoulder presentation is suspected when upon palpation; the fetal head
occupies one side of the uterus and the buttocks, the other side. It can also be observed that the shape of the uterus is more horizontal than vertical.
Causes of Shoulder Presentation:
 Lax uterine and abdominal muscles due to multiparity is most common cause
 Fibroids and congenital abnormality of the uterus
 Preterm fetus, hydrocephalus
 Placenta previa
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Management of Shoulder Presentation:
1. External version before labor begins can be performed to rotate fetus in a deliverable position.
2. If version fails, the preferred method of delivery is caesarian section. Sometimes vaginal delivery is possible if the pelvic canal is large.
II. RESPONSIBLE PARENTHOOD AND FAMILY PLANNING
1.Population situation
1.1 world- 7.7 billion as of September 2019

1.2 Philippines – 108.12 million 2019
2. Laws and legislations related to FP
2.1 PD 965 – A decree requiring applicant for marriage license to receive instructions on family planning and responsible parenthood.
2.2 PD 79 – The law that created the Population Commission or POPCOM. This law was amended by Presidential No.16
Duties and Functions of POPCOM:
> To employ physician, nurses, and midwives to provide, dispense and administer all acceptable methods of contraception, provided nurses and midwives have been
trained and authorized by the POPCOM.
> To undertake projects, promote and publish information on the Philippine Population Program
> To utilize clinics, pharmacies and other commercial channels for the distribution of family planning information.
2.3 PD 223 – June 22,1973 created the Professional Regulation Commission (PRC) attached to the Office of the President (OP) for general direction and coordination.
Prescribing its power and function.
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2.4 RA No. 6365 – The national policy on population. This law created the Commission on Population or POPCOM
2.5 PD 69 - Limits the number of children to four for tax exemption
2.6 PD 48 – Limits maternity leave benefits to four children.
2.7 LOI 47- This law directs all schools of midwifery, social work, nursing, medicine and allied medical profession include family planning in their curricula.
2.7 RA No. 10354 – The Responsible Parenthood and Reproductive Health Act of 2012 Informally known as the Reproductive Health Law or RH Law, is a law in the
Philippines, which guarantees universal access to methods of contraception, fertility control, sexual education, and maternal care.
3. Roles and functions of the midwife FP
3.1 Motivator- (also known as promotion) includes all efforts to encourage people to practice family planning. It may be interpersonal or it may involve the mass
media. The messages should include a wide range of information on family planning and reproductive health concerns that can attract the interest of the general
public or a target audience. Motivational messages are made up of information emphasizing the benefits of a method being promoted. No special setting is required
for these activities.
Some examples of motivational messages:
1. billboard that promotes the use of specific brand of contraception

2. advertisement in a men’s magazine that promotes the use of condoms to prevent pregnancy and STI transmission.
3.2 Counselor- is a two-way communication process between the provider and the client. The goal of this communication is to assist the client in making a free and
informed decision about his or her fertility. This is done considering the client’s reproductive needs, living situation, opinions and feelings.
3.3 Service provider-who approved birth control methods, devices, and supplies ( e.g., birth control pills, injectable, or patches, condoms, diaphragms, IUDs)
3.4 Family planning manager- Play a crucial role in this global effort to overcome the obstacles preventing couples from having the number of children they want,
when they want them
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FAMILY PLANNING
BENEFITS TO MOTHER
 enables her to regain her health after delivery
 gives enough time and opportunity to love and provide attention to her husband and children.
 Gives more time for her family and own personal advancement.
 When suffering from an illness, gives enough time for treatment and recovery.
BENEFITS TO FATHER
 Lightens the burden and responsibility in supporting his family
 Enables him to give his children their basic needs ( food, shelter, education, and better future).
 Gives him time for his family and own personal advancement.
 When suffering from an illness, gives enough time for treatment and recovery.
BENEFITS TO CHILDREN
 Healthy mothers produce healthy children.
 Will get all the attention, security, love, and care they deserve.
FAMILY PLANNING ASSESSMENT
THE FP SERVICE FORM 1 IN CLIENT ASSESSMENT

LEARNING OBJECTIVES
At the end of the session, the participants will be able to:

1. Define client assessment.
2. Explain the purpose of client assessment in FP.
3. Describe the steps of FP client assessment.
4. Describe the FP Service Form 1 with its components.
5. Demonstrate use of the FP Service Form 1.
6. Explain guidelines on physical examination in FP service provision.
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7. Enumerate the steps in physical examination of FP clients.

8. Explain the purpose of laboratory examination in FP service provision.
CLIENT ASSESSMENT- is the very first stage in the provision of FP services to prospective FP method acceptor. It consists of
steps undertaken to determine the health status of a client particularly his/her eligibility for contraceptive use.
Date about the client’s health are gathered through medical history taking, physical examination, and needed laboratory examination which
are analysed to see if the client is in good health or needs further evaluation and management and / or referral.
It is a MUST that all clients who attend FP/RH clinics undergo assessment.
SPECIFIC STEPS IN CLIENT ASSESSMENT

The following are the steps in client assessment. Note that for each step, client comfort and privacy should always be considered.
1. Prepare the client

a. Greet her cordially and allow her to seat comfortably
b. Establish good rapport with the client
c. Establish the purpose of the visit
d. Explain to the client procedure to be performed (including physical and / or laboratory examinations, if needed.)
e. Encourage the client to ask questions openly.
2. Take and record client’s health history using the Family Planning Service Record Forms 1 (FP Form 1)
3. Discuss with the client the:
a. Findings based on the history
b. Need to perform further examination like physical and / or laboratory examination, if necessary
c. Need for referral for laboratory examinations or further management, if necessary.
d. Need and schedule of follow-up visit (s)
In assessing FP clients:
 Only those procedures that are essential as recommended by the WHO (Applicability of procedures and examinations for
contraceptive use) should be performed.
 Additional examinations (i.e., physical or laboratory) are performed to validate abnormal findings during client assessment.
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Example: It is not necessary to do a physical examination complete with a pelvic exam on a client requesting for a condom.
However, it there is a complaint of urethral discharge, a pelvic exam and collection of urethral discharge for smear should be
performed. In this case, the additional examinations are performed because of the signs of infections for determining his
suitability for using the condom.
CLIENT HISTORY-TAKING- is the process of gathering date by interviewing the client his/her past and present medical/ reproductive
health status.
Obtaining the client’s history during the initial visit is important in identifying his/her needs and factors or conditions that may affect his/her
suitability for using FP method(s). It is, therefore, the responsibility of the service provider to be able to elicit such information prior to the
provision of a method.
Client history-taking enables the service provider to:

1. Assess the client’s reproductive health status and identify the RH needs of the client.
2. Identify risk factors or areas for precaution in the use of an FP method.
3. Properly record and verify data gathered in FP Form 1.
FP Form 1
The FP Form 1 lists the possible illnesses relevant to possible FP method use. Family Planning visits are not due to illness, thus the
following items should be asked on the context of FP method use whether initial or follow up visits.
A. Personal Data
1. Complete name of client
2. For proper identification and documentation, take complete name of client including middle name. note that under the present
Family Code of the Philippines, an unmarried pregnant woman (this includes live-in partners) retains her maiden name.
3. Name of husband / partner/ guardian
 This is in cases of emergencies or for purpose of guardianship or consent.
4. Client’s age, sex, marital status, date and place of birth
5. Religion, occupation, average family monthly income
 To determine client’s preferences and practices
 To determine financial capacity for needed examinations, feasibility of using cheaper forms/methods
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6. Educational attainment
 To be able to adjust level of instruction and communication
 To determine ability to follow complicated instructions/precautions
7. Address
 To be able to determine if client can have good follow up or visit clients when necessary
 In cases of emergencies
B.MEDICAL HISTORY
This includes the following information:
 Past illness
 Accidents/ Injuries
 Allergies
 Immunizations
 Habits (Smoking, drinking, substance abuse, etc.)
C. FAMILY HISTORY
This includes the following information:
 Health status of immediate family members and living relatives
 Risk factor for heart disease and hypertension
D. REPRODUCTIVE HISTORY
1. Menstrual History
 Menarche – age of onset of menstruation
 LMP (Last Menstrual Period)- first day of last menstrual period, including the usual number of days of menstrual flow,
character of flow (scanty, moderate, or heavy), and accompanying symptoms
 PMP (Previous Menstrual Period)- first day of menstrual period prior to the mentioned LMP. This is important to establish
accuracy of mentioned LMP, and to establish regularity or irregularity of menstrual period.
 Usually, this is the best time to inform clients that “regularity” of menstrual flow is not based on the menstrual flow occurring
every same day or week of every month. Rather, it is based on the number of days between the two LMPs (first day of two
menstrual periods). The normal average interval number of days is 25-35 days.
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For example, it may happen that a woman with the following menstrual periods will appear to have very irregular memses but
is actually having her menses regularly.
- 2nd week of January (say, Jan.7 );

- 1st week of February (feb. 2)
- Then again in February but in the last week ( feb. 28)
- Then in the 3rd week of March ( March 21)
2. OB History
Completing the OB score is one way of evaluating the obstetrics history of the client which provides information relevant to FP
method use (birth spacing and/or birth limiting). The OB score measures of gravidity (G), parity (P) of a woman. Gravidity (G)
refers to number of pregnancies borne by the mother, irrespective of the pregnancy outcome. Parity (P) refers to the number of
pregnancies reaching viability ( >20 weeks AOG). Other relevant information needed are:
 Full-term pregnancies
 Preterm pregnancies
 Abortions or miscarriages (ectopic / molar)
 Current living children
3. FP History
 FP method currently being used
- Duration of use
- Satisfaction with use
 FP method preciously used
- Duration of use
- Reason/s for discontinuation or shifting
 Reproductive goals / intent
- Desired number of children
- To limit or to space
4. Risk for Sexually-Transmitted Infections (STIs)
The following are reasons for assessing an FP client’s risk for STIs:
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 FP clients are sexually active people who need to know about factors which put them at risk for STIs.
 If the client is likely to get STIs, the client needs a supply of condoms and counselling about risks, symptoms, and treatment.
Counselling includes correct and consistent use of condoms.
 FP clients with a high individual risk for STSs may need to be referred to facilities providing STI services (i.e., counselling and
/ or treatment).
 IUD should not be provided to clients with high risks for STI.
A basic screening history for STI should be included in the history-taking which should include the following:
1. Presence of abnormal vaginal and or urethral discharge.

2. Abnormal vaginal bleeding with the last two menstrual periods
3. Pain or burning sensation during urination
4. History of genital tract problem such as vaginal discharge, ulcers or skin lesions around the genital area
5. Partner of client who have been treated for a genital tract problem in the last three months
6. More than one sex partner in the two months and / or their sex partner having other sex partner/s
When faced with clients who complain of side effects and complications, or who have reproductive concerns, the following information
should be obtained:
1. Present complaint or concern
2. Onset, nature, and duration of present complaint or concern
3. Accompanying symptoms and precipitating / aggravating factors
4. Measures or medications taken to relieve symptoms and precipitating / aggravating factors
5. Prior consult or medications
PHYSICAL EXAMINATION
Purpose of a Physical Examination
By evidence, a general physical examination is not necessary at all times in ensuring the SAFE USE of and FP method. The WHO
Applicability of procedures serves as a guide that will tell which of the procedures or examinations may be necessary.
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Physical examination when necessary will also help the FP service provider to:
- Confirm conditions suspected or noted during the client history-taking
- Evaluate the health of the client while uses an FP method to make sure she has not developed conditions which need
precautions to the use of the contraceptive method.
- Confirm complications from side effects which may have arisen from the use of an FP method;
These are only two appropriate timing for performing physical examination and the reasons for each.
Timing of Physical Examinations
 During the INITIAL visit to confirm medical conditions identified in history taking
 AS NEEDED or whatever there is an indication, complaint, or unusual symptom/s related to the use of an FP method.
There are basically four general steps in conducting a general physical examination:
1. Take vital signs
a. Blood Pressure
b. Pulse Rate
c. Respiratory Rate
d. Temperature
2. Prepare client
a. Making the client comfortable
b. If doing an internal exam: Asking client to void/empty bladder and wash perineum
c. Assuring privacy and confidentiality; and
d. Explaining the procedures or what is going to happen and why
3. Prepare needed instruments and supplies
a. Prepare the instruments and supplies ahead of the actual PE especially when there is no knowledgeable assistant around.
4. Conduct the physical examination
a. If the health provider is a male, the female client may request a companion during the conduct of the physical examination.
There are two golden rules to remember when conducting the physical examination :
a. Proceed from head to toe
b. Inspect first, palpate later.
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Others physical examination that may be done when necessary and these are;
Breast Examination: According to the applicability in WHO MEC a breast exam does not contribute to the safe and effective use of any
contraceptive method. However, in the light of providing quality reproductive health care, a breast examination can be done during initial
visit of new clients and yearly as part of a general check-up.
Abdominal Examination
1. Abdominal examination is done to check for tenderness, organ enlargements, or masses.
COUNSELING FOR FAMILY PLANNING
DEFINITION OF TERMS
Value- is a belief, idea, principle, or standard that is important and treasured by an individual. Values can be influenced by various factors
(i.e., education, culture, religion, and personal experiences). It influences an individual’s attitude and behaviour.
We acquire and change our values by the experiences we have. Therefore, we acquire new values and may change old ones as
influenced by the people we interact with, our education, age, marital status, health and economic status, number of children, and
sometimes by politics.
Values are strengthened by repetition and by making it a way of life. These enhance our personal growth and development, and as
affirmed by other people.
Examples of values are values that an individual put on honesty, integrity, honor , higher education, responsible parenthood.
People’s diverse experiences lead them to different conclusions and decisions. The counsellor must first be aware of his/her values
and understand that others have a right to their own values which they, too treasure. As such, the counsellor realizes that she/he should not
impose his/her own values on the client nor should these interfere with his/her responsibilities as a counsellor.
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Attitude is the observable, outward expression of one’s belief and value. Examples of attitudes are:
- Doing one’s best to be recognized.
- Doing the right thing at all times (for integrity)
- Caring for his/her children (for responsible parenting)
HOW CLIENT’S VALUES AFFECTS DECISION-MAKING
Values are important and may be considered an individual’s treasured possession. They are the principles that people use as a guide in
coping with stress in their everyday lives.
Different people may have similar or different values, depending on their experience, education, environment, social exposure, religion, and
culture. Values may change through the years but adequate information, exposure, experience, and education may help other people
develop desirable values. So that if an individual is given adequate and appropriate information about certain conditions, situation, or
practices regarding family planning.
The following are some common values that a family planning counsellor may encounter:
 Rural mothers still prefer bigger families, while urban woman are conditioned to have smaller families.
 When the availability of family planning methods is made public through mass media, there is increase in the number of
clients who go to the clinic for services.
 Due to high value on health, adverse rumours and misinformation are feared by most clients.
 Better quality means higher acceptance by clients of family planning services.
 Health workers advice plays a vital role in client choices. Health workers are typically their first contact. The majority of clients
decisions are affected to a great extent when a health worker promotes family planning. Clients are likely to make voluntary
decisions.
 Accessibility of service centre and the availability of a contraceptive method in a nearby clinic make clients more likely to avail
themselves of family planning services.
RESPONSIBILITY OF THE COUNSELOR IN CLIENT’S DECISION-MAKING
Clients have values, beliefs and experiences which shape their attitude towards family planning. It is the counsellor’s responsibility to help
clients examine their attitudes and values, and understand the reason for their choices to make it suitable to their values and priorities.
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FACTORS INFLUENCING FAMILY PLANNING DECISION-MAKING
These are some of the factors that influences clients in their FP decision-making:
 Age
 Marital status
 Number of children
 Health status
 Economic status
 Religious beliefs
 Relationship with spouse
 Fear of side effect
KEY LEARNING POINTS
 Understanding our own values can help us better understand and respect the values of the client.
 Reflecting on our own values can help us set limits so we do not influence our clients by sharing our own personal views.
 There are many factors that influence client’s decisions. We must remember that these are the same factors that affect OUR
decision-making but influence us in different ways.
1. Admit that you do not have a clear understanding of what the client is telling you.
2. Restate the client message as you understand it, asking the client if your interpretation is correct. Ask questions beginning with
phrases such as “Do you mean that…..”or” Are you saying…..”
3. Clients should not be made to feel they have been cut off or have failed to communicate. Therefore, do not use clarifying
excessively.
USING SIMPLE LANGUAGE
A large part of what a counsellor does is provide information’s so that the client has sufficient knowledge to make an informed decision
about his or her contraceptive options. The problem is that clients must get technical medical information about contraception methods, or
human anatomy, and reproductive physiology. As a result, one of the things that a counsellor must do is use simple language.
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THE G-A-T-H-E-R APPROACH TO FAMILY PLANNING COUNSELING
LEARNING OBJECTIVES
At the end of the session, the participants will be able to:
1. Explain the G-A-T-H-E-R approach to counselling.

2. Describe each step in the G-A-T-H-E-R approach counselling.
3. Use the approved counselling cue card/flipchart (if available) as an aid when counselling clients.
4. Explain the tasks of the counsellor for each of the G-A-T-H-E-R steps of counselling.
5. Explain the importance of each of the G-A-T-H-E-R steps of counselling.
6. Enumerate the task of the FP counsellor during each of the G-A-T-H-E-R steps of counselling.
7. Determine that the woman is not pregnant.
8. Assess client’s reproductive needs, risks for STI’s, status of relationship with partner, and knowledge on FP methods.
9. Use the FP Service Record (or any approved assessment of the client.
10. Use appropriate types of question (i.e., closed, open-ended, probing) during assessment of the client.
11. Describe available family planning (FP) methods based on client’s reproductive need.
12. Discuss appropriate FP methods in terms of:
 Mechanism of action
 Effectiveness
 Advantages and disadvantages
 Possible side effects
 Correct rumours and misconceptions
 Identify the reasons for clients return visits.
 Demonstrate counselling using the G-A-T-H-E-R approach.
NARRATIVE
A simplified concept in family planning counselling is G-A-T-H-E-R. the acronym stands for greet, ask/assess, tell, help, explain, and
return for follow-up or referral. This is merely a suggested guide of steps and topics to cover while the provider and client engage in an
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interactive two-way discussion of the client’s needs and risks. The steps help the client go through the process of learning, weighing
choices, making decisions and carrying out these decisions. In the role of helping the client choose a method, the counsellor uses a specific
set of skills and knowledge for each step.
G-A-T-H-E-R provides a useful framework, but this does not mean that it must be followed exactly or in sequential order during the
counselling session. Good counselling is flexible. The counselling process depends on the needs and situation of the client, so that the
length and the content of these steps vary.
G-A-T-H-E-R is an acronym which stands for the six steps of family planning counselling.
The acronym serves as a guide for the counsellor as she performs counselling.
Not all the steps are applied to all clients in the same way. Each individual client’s needs determine the counsellor’s level of emphasis of
each of the steps. Some clients may need a step repeated, while others may need only a brief exposure to a step.
G-A-T-H-E-R stands for
 G: Greet the client

 A: Ask the client about herself, Assess her knowledge, needs and risks (including risks for sexually-transmitted infections
like HIV/AIDS)
 T: Tell the client about family planning methods based on her needs and knowledge
 H: Help the client choose of method
 E: Explain how to use the method
 R: Return for follow-up and Refer for services
THE “G” (GREET) STEP.
This step relates to how counsellor can help establish a relationship/rapport with the client during their first meeting. A good relationship
develops when both counsellor and client share common goals, is open and communicative, and respect and trust each other. This session
introduces the norms of counselling which sets the stage for a positive relationship.
The following are the tasks in the G step.
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 As soon as you meet the client, give her your full attention.
 Greet her politely, introduce yourself, and make her comfortable by offering her a seat.
 Ask her the reason for her visit and how you can help her.
 Assure her that anything that is discussed during the session will be kept confidential.
The “A” (Ask/Assess) step.
The A step which is the second step in the G-A-T-H-E-R technique asks clients about themselves and assess their reproductive needs
family planning knowledge, STI’s risks, and relation with partner.
The tasks of the “A” step are:
 Ask the client about self ( use FP form 1). This will include:
- General data
- Medical/ OB-Gyne History
- Physical examination
 Check if there are any existing medical conditions that will not warrant the use of a specific FP method.
 Assess the client’s reproductive need
- Ask client when she/he plans to have their next baby
- Client’s reproductive need can be classified into 3 categories
REPRODUCTIVE HEALTH
METHODS
Short Term (<3 yrs) Long Term (>3 yrs) Permanent (no more children)
Condom, LAM, FAB, Pills FAB, Pills, DMPA BTL, Vasectomy

DMPA, IUD IUD DMPA, IUD
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 Ask client’s knowledge and previous use of FP

- What do you know about FP?
- Have you used any method in the past? If yes, what method and for how long? Are you satisfied with the method? If no,
why?
- Correct any misconceptions if there are.
 Assess client’s STI risks
- Find out if the client knows or suspects that her / his partner may be engaging in sex with other partners or if the client
herself / himself might have other partners by asking indirect questions beginning with
 How is your relationship with your husband / wife / partner? Or ask:
 Have you or your partner ever been treated for STIs in the past?
 For a woman, ask:
- Do you have any of the following?
 Unusual discharge from your vagina?
 Itching or sores in or around your vagina?
 Pain or burning sensation
 For a man, ask:
- Do you have any of the following?
 Pain or burning sensation
 Open sores anywhere in your genital area?
 Pus coming from your penis?
 Swollen testicles in your penis?
 If answer is YES to any of the questions above, refer the client for treatment. Talk to the client about the use of condom.
 Assesses for Violence Against Women (VAW)- you may ask the following questions
- How is your relationship with your husband or partner?
- Does she know about your coming here in the clinic?
- Is he willing to cooperate or support you in using FP method?
For any indication of VAW , refer client to the nearest Women’s Crisis Centre.
 Assess the possibility of pregnancy. The provider can be reasonably sure that the woman is not pregnant if:
o Her menstrual period started within the last 7 days
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o She gave birth within the last 4 weeks

o She had an abortion or miscarriage within the last 7 days
o She gave birth within the last 6 months, is fully breastfeeding, and has not yet had a menstrual period
o She has not had sexual intercourse since her last menstrual period
o She uses a modern/ reliable family planning method correctly
Even if she has been using a family method correctly but her last menstrual period is more than 5 weeks ago and she
had sex, pregnancy cannot be ruled out. An exception is if she is using a progestin- only injectable.
 If not reasonably sure that the woman is not pregnant, the counsellor should ask her about signs of pregnancy.
Early Signs of pregnancy Later signs of pregnancy (more than 12 weeks from last
menses)
 Late menstrual periods  Larger breast
 Breast tenderness  Darker nipples
 Nausea  More vaginal discharge
 Vomiting  Enlarging abdomen
 Weight gain  Movements of the baby
 Always tired
 Mood changes
 Changed eating habits
 Urinating more often
 If the woman has had several of these signs, she may be pregnant.
 If the woman’s answer or the physical examinations cannot rule out pregnancy, she can either
 Have a pregnancy test; or
 Wait until her next menstrual period before starting a method that should not be given during pregnancy
 Assess the client’s condition using the FP Service Record to identify the health status of the client and abnormal conditions
he/she may have. Findings of this assessment may be looked up in the WHO Medical Eligibility Criteria to determine
suitability of the client for using the chosen method.
 Category 3 and 4 conditions indicate that the method cannot be provided.
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Revisit Clients
The following are the tasks for revisit clients during the “A” step:
 Ask if their situation has changed since their last visit
 Ask if reproductive needs have changed
 Ask them if they have new concerns
 Ask if they have any problems related to their method.
 Re assess STI/HIV risk and client’s relation with partner
THE “T” (TELL) STEP.
The counsellor tells a client about the family planning methods. A client who wants to use family planning should know the basic
information about the available methods before she decides to use one. What she needs to know depends on what her reproductive needs
are, which methods interest her, and what she already knows about these appropriate methods. These information should have been taken
during the precious ask/assess, (A step).
After providing the client with the information on FP methods appropriate to his/her reproductive needs, the client is then helped to make
voluntary, well-informed decisions. It is the counsellor’s role to help clients make sound decisions.
The tasks under the T step are:
 Tell the client about the FP methods in terms of:

 What the method is
 How each method works
 The advantages of each method
 The disadvantages of each method
 The possible side effects of each method
 Correct rumours and misconceptions the clients have.
 Use IEC materials such as samples of contaceptives, leaflets, table flipcharts, cue cards, etc.
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THE “H” (HELP) STEP.
The primary task of the H step is to help the clients make a decision on what FP method he / she would want to use. Other tasks include:
 Ask the clients if there is anything they did not understand; repeat information as needed.
 Ask client what additional information is needed to help her / him make a decision.
 Ask clients what method they heard about during the “tell” step that interests them the most.
 Determines client’s suitability for his / her chosen method using the specific MEC Checklist for the chosen FP method.
 Asks the clients how they think they will possible side effects of the chosen method.
 If the client decides not to use a method, tell the client about:
 Possibility of pregnancy
 Availability of pre-natal services
 Assure the client that they can return to see you at any given time should they decide to use a FP method.
THE “E” (EXPAIN) STEP.
After a thorough assessment of the client during the “A” step, telling the client about appropriate family planning methods during the “T”
step and helping the client to choose a method in the “H” step, the client finally chooses a method she can use. The counsellor then
provides the method and explain the “E” step, how to use the method.
The main tasks of the E step are the following:
 Explain to the client how to start and use the chosen FP method.
 Explain the warning signs of the chosen FP method and what to do and where to go should she experience any one of these
warning signs.
 Confirm client’s understanding of what has been said by asking her / him to repeat what you have said in client’s own words. Correct
misunderstandings.
 Provide the method, if appropriate and available.
 Give the clients informational materials on the method chosen.
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Revisit Clients
Ask clients to tell you how she/he uses the present method and the warning signs for the method.
Repeat instruction on how to use the method and / or the warning signs if what client said were incomplete or in correct.
THE “R” (REFER/REVISIT) STEP.
The “R” return/refer step of the GATHER is the final, equally important step of the counselling process. During this step, the counsellor can
potentially do two things: first, the counsellor may inform the client about when to return, for both routine and emergency follow-up; and
second, the counsellor may need to refer a client for evaluation of a medical problem or for a contraceptive method that is not available.
Routine and emergency follow-up are defined as:
 Routine follow-up is defined as a visit that the client makes to get supplies, or have a routine (or scheduled) check-up
 An emergency follow-up visit is when a client experiences a warning sign or complication. It this should occur, the client should seek
medical help immediately.
It is important to emphasis to the client that counselling does not end after she / he has made a decision in choosing a family planning
method. The support should be continuous to ensure client’s satisfaction and safely while using the chosen method.
Return / follow-up visits provide support to clients because it is an important opportunity to:
 Reinforce the decision clients have made to plan their family.

 Discuss any problems they are having with their chosen method. Clients concern complaints should never be dismissed but taken
seriously with a supportive attitude.
 Answer question they may have.
 Explore changes in their current health status or life situation which may indicate a need to switch to another contraceptive method
or to stop using any method.
The tasks of the R step are:
 Tell the client when and where to go for routine follow-up.

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 Schedule the next visit before client leaves.

 Assure that she should not hesitate to come back for any problems, specially warning signs.
 Refer client for methods and / or services you do not provide. Provide client with a referral note.
During return/ follow-up visits, the counsellor:
 Reviews the chart for the details of the health history.

 Asks the client how she feels with the method, assesses the nature of the problem and discusses possible solutions.
 If she is having any problems with the method, assesses the nature of the problem and discusses possible solutions.
 If the problem is a side-effect, assesses how severe it is and offers suggestions for managing it or refers the client for treatment.
 If the client is not using the method any more, asks why not (it may be due to problems related to misunderstanding, side-effects or
supply).
 If the client still wishes to continue using a contraceptive, answer her/his questions and provides information that will enable her/ him
to continue with a contraceptive of choice.
 If the client is still using the method, determines if it is being used correctly. Asks the client how she is using the method. Re-enforces
instructions on the correct use of the method, if necessary.
 Ensure that the client receives re-supplies and an appropriate examination, if necessary.
 Assists the client in selecting another contraceptive method if the client is not satisfied with a method, if her/ his situation has
changed, or if the method is no longer safe.
 If the client wishes to become a pregnant , helps her to stop her method and provides information on the return to fertility.
Emphasizes the importance of antenatal care which the midwife can provide.
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Fertility Awareness Based Method (FAB)
Posted under Health Guides. Updated 3 January 2019.
Key Facts
FAB is also known as natural family planning. Some women choose this method because of concerns about side
effects from other contraceptive methods such as birth control pills. Others may use the FAB method of contraception for religious or
cultural reasons. Whatever the reason, it takes a lot of practice to learn how to use this method correctly. Out of all the different methods of
birth control, this method is the least effective in preventing pregnancy.
What are the fertility awareness-based (FAB) methods of contraception?
FAB methods are a way to become aware of the time when you ovulate so that you can prevent pregnancy. Couples who are trying to
become pregnant can also use this method. When using this method to prevent pregnancy, sexual partners do not have sexual intercourse
during ovulation. Ovulation is the time during a woman’s menstrual cycle when she is most likely to become pregnant.
Out of 100 women using natural family planning
Typical use: 24 women become

pregnant
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Perfect use: 3-5 women become

pregnant
How do you practice the fertility awareness-based methods?

First, you’ll need to figure out when you are ovulating (when your ovaries release the egg each month). Women are fertile (can become
pregnant) 5 days before ovulation (when an egg is released) up to 24 hours after ovulation has happened. Sperm can live for up
to 5 days and the egg lives 24 hours. So even if you are not ovulating the day you have sexual intercourse, you can still get pregnant if
you start ovulating within 5 days because the sperm can still be alive. If you have ovulated (released an egg) and you have sex the next
day, you can get pregnant since the egg can still be fertilized. To avoid pregnancy you should NOT have sexual intercourse a few days
before and the day after you ovulate. Keep in mind that ovulation may be tricky to predict because teens often have irregular cycles.
What are the different FAB methods?
You can use one method or a few methods to find out when you are ovulating. These methods include:
 Checking your basal body temperature; taking your temperature first thing in the morning with a special thermometer before you get out of
bed and then charting it on a special form.
 Observing changes in your cervical mucus.
 Keeping track of levels of LH (a hormone that starts ovulation) by checking your urine with an ovulation kit.
 Using a handheld computer application that uses a calendar method that helps you keep track of your menstrual cycle and when you’re
ovulating. The calendar method is appropriate if your menstrual cycles are between 26-32 days. If your period comes less than every 26
days or more than every 32 days, this is not a good method for you.
Once you figure out when you are ovulating, you should NOT have sexual intercourse during your fertile time. The fertility awareness-based
methods can be tricky to figure out, but if you think using this method to prevent pregnancy is a good idea for you, talk to your health care
provider.
How effective are the fertility awareness-based methods (FAB)?
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If women use the FAB methods every time they have sexual intercourse and follow instructions perfectly every time (a woman has to figure
out when she is ovulating and does not have sexual intercourse during this time), it is 95% effective. This means that if 100 women use the
FAB methods all the time and always use them perfectly, and their cycles are always regular at least 5 women will become pregnant in a
year.
Perfect use hardly ever happens (especially with this method) so this method is typically only 76% effective. This means that if 100
women use the FAB methods, 24 women will become pregnant in a year. Failure rates can be high using the FAB methods if you have
irregular periods, which are more common in teens. The FAB methods do not protect against sexually transmitted infections- you must use
condoms.
Are there any problems with the fertility awareness-based method (FAB)?
The FAB method is not the best type of contraception, but it is considered “natural” and many religions approve it. The good thing is that
there are no side effects from the FAB method. However, the fertility awareness-based methods are not very reliable. Illness can change
your body temperature and vaginal infections can cause changes in the mucus of your cervix. With these changes, there’s a greater chance
that you can get pregnant.
Hormonal Methods of Family Planning

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These methods contain hormones, called estrogen and progestin, that are similar to the estrogen and progesterone a woman makes in her own body. Hormonal methods
include:

Pills, which a woman takes every day.
Injections, which are given every few months.
Implants, which are put into a woman’s arm and last for several
years.
IMPORTANT! Hormonal methods do not protect against STIs or HIV.
A woman controls hormonal methods and they can be used without a man knowing.
Hormonal methods work by preventing the woman’s ovaries from releasing an egg. The hormones also make the mucus at the opening of the womb very thick, which helps stop
the sperm from getting inside the womb.
Most birth control pills and some injections contain both estrogen and progestin. These are called ‘combination’ pills or injections. The two hormones work together to give
excellent protection against pregnancy. However, some women should not use pills or injections with estrogen for health reasons, or because they are breastfeeding (see Who
should not take combined pills).
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Progestin-only pills (also called mini-pills), implants, and some injections contain only one hormone—progestin. These methods are safer than combined pills or injections for
women who should not use estrogen, or are breastfeeding.
These women should avoid ANY kind of hormonal method:

Some medicines for seizures (“fits”), for tuberculosis (TB), or for HIV make hormonal methods less effective. A woman taking these medicines should use another family planning method or combine it with a
second method such as a condom or a diaphragm.
 Women who have breast cancer, or a hard lump in the breast. Hormonal methods do not cause cancer. But if a woman already has breast cancer, these methods can
make it worse.
 Women who might be pregnant or whose monthly bleeding is late.
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 Women who have abnormal bleeding from the vagina during the 3 months before starting hormonal methods. They should see a health worker to find out if there is a
serious problem.
Some hormonal methods are harmful for women with other health problems. Be sure to check each method to see if it is safe for you. If you have any of the health problems
mentioned and still wish to use a method, talk to a health worker who has been trained in hormonal methods of family planning.
Side effects of hormonal methods

Because hormonal methods contain the same chemicals that a woman’s body makes when she is pregnant, these things may happen during the first few months:
nausea headaches swelling of weight gain changes in

the breasts monthly
bleeding
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Side effects often get better after the first 2 or 3 weeks or months. If they do not, and they are annoying or worrying you, see a health worker. She may be able to help you
change the amount of the hormones in your method or to change methods. For more information about the specific side effects that are common with each hormonal method,
read the sections lower on this page.
The Pill
The pills will not prevent pregnancy immediately. So, during the first 7 days on pills, use condoms or some other backup method to avoid pregnancy.
If you must change to a lower dose pill, use a barrier method of family planning or do not have sex during the first month.
Combined pills (birth control pills with estrogen and progestin)

Birth control pills will protect you from pregnancy as long as you take one pill every day. There are many different brands of combined pills with different types of estrogen and
progestin in them and different amounts of each hormone. The most common combined pills are “low-dose” pills with 20, 30, or 35 micrograms (mcg) of estrogen. Low-dose pills
and minipills are different—lowdose pills have both estrogen and progestin, while the minipill has only progestin.
Combined pills are usually available at family planning clinics, health posts, pharmacies, and through health workers.
Once you start taking pills, you should try to stick with one brand (and if you can, buy several packets at once). If you must change brands, try to get another with the same
hormone names and strength. You will have fewer side effects and better protection.
Who should not take combined pills:

Some women have health problems that make it dangerous for them to use the pill. NEVER take the pill if you have any of the conditions listed above, or if you:
 have liver disease hepatitis, or yellow skin and eyes.

 have ever had signs of a stroke, paralysis, or heart disease.
 have ever had a blood clot in the veins of your legs, or in your lungs or brain. Varicose veins are usually not a problem, unless the veins are red and sore.
If you have any of the following health problems, try to use a method other than combined birth control pills. But if you cannot, it is still better to take the combined pill than to
become pregnant.
Try not to take combined pills if you:
 Smoke and are over 35 years old. You have a greater chance of having a stroke or heart attack if you take combined pills
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 Have diabetes or epilepsy. If you are taking medicine for seizures (“fits”), you will need to take a stronger (50 micrograms of estrogen) birth control pill. Get medical advice
from a health worker or doctor.
If you are bothered by any body changes after starting birth control pills. Talk to a health worker. She might suggest a different pill
 Have high blood pressure (more than 140/90). If you have ever been told you have high blood pressure or think you might have it, have your blood pressure checked by a
health worker. If you weigh too much, have frequent headaches, get out of breath easily, feel weak or dizzy often, or feel pain in the left shoulder or chest, you should be
tested for high blood pressure.
Common side effects of combined pills:

If your monthly bleeding does not come at the normal time and you have missed some pills, continue to take your pills but see a health worker to find out if you are pregnant.
 Irregular bleeding or spotting (bleeding at other times than your normal monthly bleeding). Combined pills often make your monthly bleeding shorter and lighter. It is also
normal to sometimes skip your monthly bleeding. This is the most common side effect of combined birth control pills. To reduce spotting, be extra careful to take the pill at
the same time every day. If the spotting continues, talk with a health worker to see if changing doses of progestin or estrogen will help.
If you are given a new medicine while on the pill, ask your health worker if you should use a barrier method or not have sex while taking the medicine. Some antibiotics and other medicines make the pill less
effective.
 Nausea, the feeling that you want to throw up, usually goes away after 1 or 2 months. If it bothers you, try taking the pills with food or at another time of day. Some women
find that taking the pill just before going to sleep at night helps.
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 Headaches. Mild headaches in the first few months are common. A mild pain medicine should help. If the headache is severe or comes with blurred eyesight, this could be
a serious warning sign, see below.
Warning signs for problems with combined pills:

STOP taking the pill and see a health worker if you:
 have severe headaches with blurred vision (migraines) that begin after you start taking the pill.
 feel weakness or numbness in your arms or legs.
 feel severe pain in your chest and shortness of breath.
 have severe pain in one leg.
 have severe pain in the abdomen.
If you have any of these problems, pregnancy can also be dangerous, so use another type of family planning such as condoms until you can see a health worker
trained in hormonal family planning methods.
How to take combined birth control pills:

The pill comes in packets of 21 or 28 tablets. If you have a 28-day packet, take one pill every day of the
month. As soon as you have finished one packet, begin taking pills from another packet. (The last 7 pills
in a 28-day packet are made of sugar. They have no hormones in them. These sugar pills help you to
remember to take a pill each day.)
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28-Day Pill Packet
If you have a 21-day packet, take a pill every day for 21 days, then wait 7 days before
beginning a new packet. Your monthly bleeding will usually happen during the days
you are not taking pills. But begin a new packet even if your monthly bleeding has not
come.
21-Day Pill Packet
With both 21-day and 28-day packets, take the first pill on the first day of your monthly bleeding. This way you will be protected right away. If it is after the first day, you can start taking a pill
on any of the first 7 days of your monthly cycle. But you will not be protected right away, so for the first 2 weeks you are taking the pill you should also use another family planning method or
not have sex.
You must take one pill every day, even if you do not have sex. Try to take your pill at the same time every day. It may help to remember that you will always start a new packet on the same
day of the week.
Forgetting to take pills:
= missed pill
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= take 2 pills
If you miss pills you could get pregnant.
If you forget 1 or 2 pills, take 1 pill as soon as you remember. Then take the next pill at the regular time. This may mean that you take 2 pills in one day.
If you forget to take 3 pills, 3 days in a row, take 1 pill right away. Then take 1 pill each day at the regular time.
If you are using a 28-day packet of pills, take only the hormone pills and skip the sugar pills, then start taking hormone pills from a new packet. If you are using a 21-day packet,
start a new packet as soon as you finish the one you are taking now. Use condoms (or do not have sex) until you have taken a pill for 7 days in a row.
If you forget to take more than 3 pills, stop taking the pills and wait for your next monthly bleeding. Use condoms (or do not have sex) for the rest of your cycle. Then start a new
packet.
Late or missed pills may cause some bleeding, like a very light monthly bleeding.
If you have trouble remembering to take pills, try taking a pill when you do a daily task, like preparing the evening meal. Or take the pill when you see the sun go down or before
you sleep. Keep the packet where you can see it every day. If you still forget to take your pills often (more than once a month), think about changing to a different method of
birth control. If you vomit within 3 hours after taking your pill or have severe diarrhea, your birth control pill will not stay in your body long enough to work well. Use condoms, or
do not have sex, until you are well and have taken a pill each day for 7 days.
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Stopping the pill:

If you want to change methods or get pregnant, stop taking the pills when you finish a packet. You can get pregnant right after you stop. Most women who stop taking pills
because they want to get pregnant will get pregnant sometime within the first year.
The Minipill or Progestin-only Pills
The minipill is safe

and effective during
breastfeeding.
If you forget a pill, use a barrier method (or do not have sex) for 7 days, AND keep taking your pills.
Because this pill contains no estrogen, it is safer for women who should avoid combined pills for health reasons or who have side effects from combined pills.
The minipill is very effective for most breastfeeding mothers who have not had monthly bleeding since giving birth. It is slightly less effective than combined pills for women who
are not breastfeeding and for women who are breastfeeding more than 6 months after giving birth. See the different brand names.
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The minipill is usually available at family planning clinics, health posts, pharmacies, and through health workers.
Women with any of the conditions listed above and women who are taking medicine for seizures should not take the minipill. The medicine makes the minipill less effective.
Common side effects of the minipill:
 irregular bleeding or spotting. This is the most common side effect. If it becomes a problem, taking ibuprofen may help stop spotting.
 no monthly bleeding. This is fairly common, but if you go more than 45 days without bleeding you may be pregnant. Keep taking your pills until you can see a health
worker to find out if you are pregnant.
 occasional headaches.
How to take the minipill:
 If you are not breastfeeding, or if you are breastfeeding and your monthly bleeding has started again, take the first pill on the first day of your monthly bleeding.
 If you are breastfeeding and have not had monthly bleeding, you can take the first pill any day from 6 weeks to 6 months after giving birth. You may not begin bleeding.
This is normal. After 6 months with no monthly bleeding, you can take the first pill any day, but also use a barrier method or do not have sex for the first 2 days.
 Take the pill at the same time every day. If you take the pill even a few hours late, or if you forget to take the pill for only one day, you can become pregnant.
 When you finish a packet, start your new packet the next day, even if you have not had any bleeding. Do not skip a day.
What to do if you miss a minipill:

Take it as soon as you remember. Take the next pill at the regular time, even if it means taking 2 pills in one day. Use a barrier method with the pill, or do not have sex for 2
days. You may have bleeding if you take your pill at a later time than usual.
Stopping the minipill:
You can stop taking the pill any time. You can get pregnant the day after you stop, so be sure to use another family planning method right away if you do not want to become
pregnant. If you can wait until the end of your cycle before stopping, your monthly bleeding will be more regular.
Implants (Jadelle, Implanon, Norplant)
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Implants are small, soft tubes that are placed under the skin on the inside of a woman’s arm. These tubes contain the hormone progestin and work like minipills. They prevent
pregnancy for 3 to 5 years, depending on the type of implant.
How to use implants:
A trained health worker makes a small cut in the skin to insert and remove the implants. This is usually done at a clinic or family planning center.
IMPORTANT! Before trying implants, be sure a health worker near you is trained and willing to remove the implants, in case you want them removed. It is harder to take
implants out than it is to put them in.
Implants can be used by women who are breastfeeding and others who have problems with estrogen. Women should not use implants if they have any of the conditions
described above, if they have heart disease, or if they want to become pregnant in the next few years. If you are taking medicines for seizures, you will need to use a backup
method, like a condom or a diaphragm, as well as the implants.
Common side effects of implants:

During the first months, the implants may cause irregular bleeding (in the middle of your monthly cycle) or more days of monthly bleeding. Or you may have no bleeding at all.
This does not mean that you are pregnant or that something is wrong. These changes will go away as your body becomes used to having more progestin. If this irregular
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bleeding causes problems for you, a health worker may have you take low-dose combined birth control pills along with the implants for a few months. You may also have
occasional headaches and the same side effects common with progestin-only injections.
Many women want their implants removed early because they do not like the side effects. The most common concern is irregular bleeding.
To stop using implants:

Implants can be removed at any time—though it can be hard to find a health worker who knows how to remove them. After removal, you can get pregnant right away, so use
another family planning method if you do not want to become pregnant.
Birth control injections
In this family planning method, a woman is given injections of hormones every 1 to 3 months, usually at a health center or family planning clinic, by someone who knows how.
The protection lasts until you need a new injection, and can be used without others knowing.
Progestin-only injections
Progestin-only injections, such as Depo Provera and Noristerat, contain only the hormone progestin. These are especially good for women who should not use estrogen. They
are given every 2 to 3 months.
Women should not begin progestin-only injections if they have any of the conditions listed above, if they are unable to get regular injections, or if they want to become pregnant
within the next year.
Common side effects of progestin-only injections:

Progestin-only injections almost always cause changes in the monthly bleeding. You may have light bleeding every day or every once in a while. You will probably stop having monthly bleeding by the end of the
first year. These changes are normal.
Because of the large doses of progestin given with each injection, women experience more changes in their monthly bleeding during the first few months than with other
hormonal methods.
Other common side effects are:
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 irregular bleeding or heavy spotting. If this is a problem, a health worker can give 2 cycles of a combined low-dose birth control pill to take along with the injections to
stop the spotting. Most irregular bleeding will stop after a few months.
 no monthly bleeding.
 weight gain.
Combined injections
Other injections, such as Cyclofem and Mesigyna, contain both estrogen and progestin. This type of injection is good for women who want to have regular monthly bleeding.
Combined injections are given every month, are more expensive than progestin-only injections, and are harder to find.
Women who should not take combined birth control pills or progestin-only injections should not take combined injections either. Do not begin combined injections while
breastfeeding until your baby is 6 months old or your monthly bleeding returns, whichever happens first.
Common side effects of combined injections:

Because the injection contains the same hormones as combined birth control pills, the same side effects are common.
How to use birth control injections:

It is best to get your first injection during your monthly bleeding. This way you know that you are not pregnant. You can start the injections anytime if you are breastfeeding and
have not started your monthly bleeding. The injection protects you against pregnancy immediately if it is given within 5 days after your monthly bleeding begins. If the injection
was given 6 or more days after the beginning of your monthly bleeding, you should use condoms or not have sex for the next 7 days. You must have an injection every 1, 2, or 3
months, depending on the kind of injection:
 Depo Provera: every 3 months

 Noristerat: every 2 months
 Cyclofem and Mesigyna: every month
Try not to be late getting injections. The injection becomes less effective the longer you wait. If you are late, use a barrier method, or do not have sexual intercourse for 7 days
after the injection.
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You are using Depo Provera, so you will need to come back in 3 months for your next injection.
To stop using injections:

You can stop having birth control injections any time you want. But after you stop, it can take a year or more to become pregnant and for your monthly bleeding to return to
normal. But it also may come back sooner. So if you do not want to become pregnant right away, you must use another family planning method during this time.
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Barrier methods of family planning

Barrier methods prevent pregnancy by blocking the sperm from reaching the egg. They do not change the way the woman’s or man’s body works, and they cause very few side
effects. Barrier methods are safe if a woman is breastfeeding. Most of these methods also protect against STIs, including HIV. When a woman wants to become pregnant, she
simply stops using the barrier method.
The most common barrier methods are the condom, condoms for women, the diaphragm, and spermicides.
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The condom
If a condom breaks or comes off the penis, the woman should put spermicide in her vagina immediately. If possible, use emergency family planning.
The condom is a narrow bag of thin rubber that the man wears on his penis during sex. Because the man’s semen stays in the bag, the sperm cannot enter the woman’s body.
Condoms are the best protection against STIs and HIV. They can be used alone or along with any other family planning method. Condoms can be bought at many pharmacies
and markets, and are often available at health posts and through AIDS prevention programs.
Be careful not to tear the condom as you open the package. Do not use a new condom if the package is torn or dried out, or if the condom is stiff or sticky. The condom will not
work.
The condom must be put on the man’s penis when it is hard, but before it touches the woman’s genitals. If he rubs his penis on the woman’s genitals or goes into her vagina, he
can make the woman pregnant or can give her an STI, even if he does not spill his sperm (ejaculate).
How to use a condom:
1. If the man is not circumcised, pull the foreskin back. Squeeze the tip 2. Keep squeezing the tip while unrolling the condom, until it covers all of the penis. The loose part at the end will hold
the man’s sperm. If you do not leave space for the sperm when it comes out, the condom is more likely to break.
of the condom and put it on the end of the hard penis.
3. After the man ejaculates, he should hold on to the rim of the 4. Take off the condom. Do not let sperm spill or 5. Tie the condom shut and dispose of it away from children and
condom and withdraw from the vagina while his penis is still hard. leak. animals.
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Lubricants
Lubricants make the vagina or the condom wet and slippery. They help keep condoms from breaking and can make sex safer and more enjoyable. Lubricants should be water
based, such as spit (saliva), or K-Y Jelly. Rub the lubricant on the sides of the condom after it is on the hard penis. A drop of lubricant inside the tip of a condom can also make
it feel better for the man. Do not use cooking oils, baby oil, mineral oil, petroleum gel, skin lotion, or butter. They can make the condom break easily.
A woman who is using another family planning method should also use condoms if she needs STI protection.
Remember:
 Use a condom every time you have sex.

 If possible, always use condoms made of latex. They give the best protection against HIV. Condoms made of sheepskin or lambskin may not protect against HIV.
 Keep condoms in a cool, dry place away from sunlight. Condoms from old or torn packages are more likely to break.
 Use a condom only once. A condom that has been used before is more likely to break.
 Keep condoms within reach. You are less likely to use them if you have to stop what you are doing to look for them.
More Information
encouraging your partner to use condoms
At first, many couples do not like to use condoms. But once they get used to it, they may even recognize benefits besides protecting against unwanted pregnancies and STIs.
For example, condoms can help some men last longer before they come.
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The condom for women (female condoms)

Female condoms are larger than condoms made for men and are less likely to break. They work best when the man is on top and the woman is on the bottom during sex.
A female condom, which fits into the vagina and covers the outer lips of the vulva, can be put in the vagina any time before sex. It should be used only once, because it may
break if it is reused. But if you do not have any other condoms, you can clean it and reuse it up to 5 times. The female condom should not be used with a male condom.
The female condom is the most effective of the methods controlled by women in protecting against both pregnancy and STIs, including HIV. There are now 3 types of female
condom available. The newest are less expensive. The VA female condom fits more closely to the woman’s body, so it is more comfortable and makes less noise during sex.
Female condoms are available only in a few places now. But if enough people demand this method, more programs will make them available.
How to use the female condom:
1. Carefully open 2. Find the inner ring, which is at the closed end of the condom.
the packet.
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Outer ring
3. Squeeze the inner 4. Put the inner ring 5. Push the inner ring up into your vagina with your finger. The outer ring stays outside the vagina.
ring together. in the vagina.
6. When you have sex, guide the penis 7. Remove the female condom immediately after sex, before you stand up. Squeeze and twist the outer
through the outer ring. ring to keep the man’s sperm inside the pouch. Pull the pouch out gently, and then dispose of it out of
reach of children and animals.
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The Diaphragm
When a diaphragm is used correctly, it prevents pregnancy most of the time and may also give some protection against STIs.
The diaphragm is a shallow cup made of soft rubber or thin silicone that a woman wears in her vagina during sex. The diaphragm covers the cervix so that the man’s sperm
cannot get into her womb. The diaphragm should be used with spermicide. If you do not have spermicide, you can still use the diaphragm, but it may not work as well to prevent
pregnancy.
Diaphragms come in different sizes, and are available at some health posts and family planning clinics. A health worker who has been trained to do pelvic exams can examine
you and find the right size diaphragm.
Diaphragms can get holes, particularly after being used for more than a year. It is a good idea to check your diaphragm often. Replace it when the rubber gets dry or hard, or
when there is a hole in it.
You can put the diaphragm in just before you have sex or up to 6 hours before. If you have sex more than one time after you put the diaphragm in, put more spermicide in your
vagina each time before you have sex, without removing the diaphragm.
How to use a diaphragm:

1. If you have spermicide, squeeze it into the center. Then spread a little bit around 2. Squeeze the diaphragm in half. 3. Open the lips of your vagina with your other hand. Push the
the edge with your finger. diaphragm into your vagina. It works best if you push it
toward your back.
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4. Check the position of your diaphragm by putting one of your fingers inside your vagina and feeling for your cervix through
the rubber of the diaphragm. The cervix feels firm, like the end of your nose. The diaphragm must cover your cervix.
5. If the diaphragm is in the right place, you will not be able to feel it inside you. 6. Leave the diaphragm in place for at least 6 hours after sex.
You can leave the diaphragm in for up to 24 hours. It is OK to use the diaphragm during monthly bleeding, but you will need to remove it and clean it as often as you would
change a cloth or pad.
To remove the diaphragm:

Put your finger inside your vagina. Reach behind the front rim of the diaphragm and pull it down and out. Wash your diaphragm with soap and water, and dry it. Check the
diaphragm for holes by holding it up to the light. If there is even a tiny hole, get a new one. Store the diaphragm in a clean, dry place.
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Spermicide
Foam
Tablets
Cream or Jelly
(contraceptive foam, tablets, jelly, or cream)
Spermicide comes in many forms—foam, tablets, and cream or jelly—and is put into the vagina just before having sex. Spermicide kills the man’s sperm before it can get into
the womb.
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If used alone, spermicide is less effective than some other methods. But it is helpful when used as extra protection along with another method, like the diaphragm or condom.
Spermicides can be bought in many pharmacies and markets. Some women find that some types of spermicides cause itching or irritation inside the vagina.
Spermicides do not provide protection against any STI. Because spermicides can irritate the walls of the vagina, they may cause small cuts that allow HIV to pass more easily
into the blood.
When to insert spermicide:

Tablets or suppositories should be put in the vagina 10 to 15 minutes before having sex. Foam, jelly, or cream work best if they are put in the vagina just before having sex.
If more than one hour passes before having sex, add more spermicide. Add a new tablet, suppository, or applicator of foam, jelly, or cream each time you have sex.
How to insert spermicide:
1. Wash your hands with soap and water.
2. To use foam, shake the foam container rapidly, about 20 times. Then press the nozzle to fill the applicator.
To use jelly or cream, screw the spermicide tube onto the applicator. Fill the applicator by squeezing the spermicide tube.
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To use vaginal tablets, remove the wrapping and

wet them with water or spit on them. (DO NOT put the tablet in your mouth.)
3. Gently put the applicator or vaginal tablet into your vagina, as far back as it will go.
4. If you are using an applicator, press in the plunger all the way and then take out the empty applicator.
5. Rinse the applicator with clean water and soap.
6. Leave the spermicide in place for at least 6 hours after sex. Do not douche or wash the spermicide out. If cream drips out of your vagina, wear a pad, cotton or
clean cloth to protect your clothes.
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Permanent Methods of Family Planning

Sterilization (the operation for no more children)
There are operations that make it almost impossible for a man or a woman to have any children. Since these operations are permanent, they are only good for those women or
men who are certain that they do not want any more children.
To have one of these operations, you must go to a health center or hospital. The surgery is fast and safe, and does not cause side effects.
The operation for the man (Vasectomy)
The man's tubes are cut:
here
and here
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More Information
a man’s body
A vasectomy is a simple operation in which the tubes that carry the sperm from the testicles to the penis are cut. The man’s testicles are not cut. This operation can be done in
any health center where there is a trained health worker. It takes only a few minutes to do.
The operation does not change a man’s ability to have sex or to feel sexual pleasure. He still ejaculates semen but there are no sperm in the semen. The tubes may still
have sperm in them for as long as 12 weeks after the operation, so you need to use another method of family planning during that time.
The operation for the woman (Tubal Ligation)
The woman's tubes are cut:
here
and here
A tubal ligation is a slightly more difficult operation than a vasectomy, but it is still very safe. It takes about 30 minutes.
A trained health worker inserts a tool through the skin near the belly button to cut or tie the tubes that carry the eggs to the womb. It does not change a woman’s monthly
bleeding or her ability to have sex and sexual pleasure.
IMPORTANT! Sterilization does not protect against STIs, including HIV. So you will still need to think about ways to protect yourself from these infections.
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Bear in mind that especially for revisit clients, counselling should be conducted again, using the appropriate GATHER steps. The
tasks enumerated above may fall under the different steps of the GATHER Approach.
C. Suggested Readings/Videos (Optional but Highly Encouraged)
MYLES textbook for Midwives 15th ed. Churchill Livingstone
D.Assessment Tasks
Week 5 day 10- Quiz: Identification:

1. Labor lasting no longer than 3 hours
2. Type of presentation wherein one or both of the feet present
Week 6 day 11/12: Quiz: Identification:
1. Labor lasting no longer than 3 hours
2. Type of presentation wherein one or both of the feet present
Week 7 day 13/14: Quiz: 1. List down benefits of Family Planning to: mother, father, children
Week 8 day 15/16: Quiz: List down 3 advantages and 3 advantages of FAB methods.
Week 9 day 17: Midterm exam
IV. GENERAL REFERENCES (for the whole module)
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V. ASSESSMENT GUIDE AND STANDARD
1. The components which will serve as basis for class performance of a student shall be:
For Lecture Class:
a. Performance Task (PT) - 30%

b. Average Quiz (AQ) - 30%
c. Major Exam (ME) - 40%
1.1 Performance Task (PT

The criteria for Performance Task shall include but not limited to research output, class participation, report, return
demonstration, and assignment presentation. For laboratory classes, this shall include the group experiments, and the individual
question and answer.
The formula for computing the Performance Task for the period is:
Total Raw Scores

PT = X 100%
Total Perfect Scores
1.2 Average Quiz (AQ)

The criteria included in this component are short and long quizzes. Quizzes are given to the students to evaluate the knowledge
and skills acquired from the just concluded discussion and demonstration provided by the teacher. This may be given before the
end of the class or before the start of the next class meeting. Long quizzes are announced quizzes given to the students to
evaluate the knowledge and skills acquired from a chapter’s or a week’s coverage of discussion and demonstration.
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The formula for computing the Average Quiz for the period is:
AQ = Summation of Percentage of All Quizzes w/in the Exam

X 100%
Total Number of Quizzes w/in the period
1.3 Major Examination (ME)
The major examination refers to a long examination administered during Preliminary, Midterm, Semi-Final, and Final
Examination.
The formula for computing the Major Exam component is:
ME = Score
X 100%
Total Perfect Score
2. Computation of Prelim/Midterm/Pre-Final/Final Grade:

The formula for computing the Prelim Grade is:
Prelim Grade = (PT x 0.30) + (AQ x 0.30) + (ME x 0.40)
The same formula is used for computing the Midterm, Pre-Final, and Final Grade.
3. Computation of the Final Grade

The Final Grade is computed using the averaging system:
Prelim Grade + Midterm Grade + Pre-Final Grade +Final Grade

Average Final Grade =
4
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QFO-8.

COLLEGE OF _________________________ Revision : __

Pathological Obstetrics w/ Family Planning and Care of Infants

Module Holder: Control Number:

Date: __________________ Date: _______________ Date: _________________ Date: _______________

NO. DATE REVISION

I. OVERVIEW OF THE MODULE

B. SEC INSTITUTIONAL MISSION

G. Course Map in ______________

Legend: I – Introduced Concept/Principle

II. Course Outline

Periodic Module Week Number of Hours

1.3 ruptured uterus

III. LEARNING PLAN

COURSE INTENDED LEARNING LEARNING ASSESSMENT

B. Learning Tasks/Activities (Lesson Proper)

I. Complications during labor and delivery

1. Uterine dysfunction- Abnormalities of the powers

Diagnosis of abnormal labor:

Precipitate labor disorders can be classified as:

 Injuries as a falling to the floor in unattended birth

Sign and Symptoms

 Patient complains of a sudden, intense urge to push

1. Anticipatory guidance for prevention:

CAUSES Uterine Rupture:

 Rupture of scar from previous CS

Signs and Symptoms of Uterine Rupture:

Types of Uterine Rupture

1. Blood transfusion and administration of IVF to correct shock.

2. Administer mask oxygen to the woman at 8L/m.

The following are the two common types of uterine dysfunction.

HYPOTONIC UTERINE INERTIA (dysfunction) HYPERTONIC UTERINE INERTIA (dysfunction)

Contractions: weak, painless Contractions: strong ,painful

Tension not synchronous Uncoordinated, increase contactions, but

Treatment:enema, walking if not contraindicated, Treatment:sedation

Causes of HYPOTONIC UTERINE INERTIA (dysfunction)

 Overdistention of the uterus- multiple pregnancy, hydramnious

 Reevaluate pelvic size to rule out fetopelvic disproportion

HYPERTONIC UTERINE INERTIA (dysfunction) Management:

 Evaluation of pelvic size. If pelvis is adequate, vaginal delivery will attempted.

 Maintenance of fluid and electrolyte balance by infusion of IV fluids.

What causes CPD:

 Large baby due to:

Treatment for CPD:

How is cephalopelvic disproportion (CPD) diagnosed?

Signs and symptoms:

1. Prevention: Place woman in bedrest after membranes have ruptured.

6. Deliver the baby as soon as possible:

Fast facts on nuchal chord:

 An abnormally long umbilical cord

 Uterine relaxation due to multiparity

Causes Face presentation:

Management of Face presentation:

Causes of Shoulder Presentation:

Management of Shoulder Presentation:

II. RESPONSIBLE PARENTHOOD AND FAMILY PLANNING

1.1 world- 7.7 billion as of September 2019

2. Laws and legislations related to FP

COLLEGE OF _______________________ Revision :

Date: __________ Date: _ Date: _ Date: _____