UNIT 15 FAMILY PLANNING

Prepared By
Samjhana Neupane
Family planning

Introduction:
 Family planning is the term given for pre-pregnancy planning
and action to delay, prevent or actualize a pregnancy.
 Family planning is to regulate the number and spacing of
children in a family through the practice of contraception or
other methods of birth control
 Definition:

 ‘A way of thinking and living that is adopted voluntarily upon

the basis of knowledge, attitudes and responsible decisions by
Individuals and couples, in order to promote the health and
welfare of the family group and thus contribute effectively to
the social development of a country”

-WHO (1971)
Definition............
 “Family planning allows individuals and couples to
anticipate and attain their desired number of children and the
spacing and timing of their births. It is achieved through use
of contraceptive methods and the treatment of involuntary
infertility.

WHO 2010
 Purpose of Family Planning
 To avoid unwanted births

 To bring about wanted births

 To regulate the interval between pregnancy

 To control the time at which births occurs in relation to age of

parents.
 To determine numbers of children in the family

 To decrease the maternal and child mortality and morbidity rate

Scope of family planning services
 The proper spacing and limitation of births

 Advice on sterility

 Education for parent hood

 Sex education

 Screening for pathological conditions related to the reproductive

system

 Genetic counselling
Scope of family planning services
 Premarital consultation and examination

 Carrying out pregnancy test

 Marriage counselling

 The preparation of couples for the arrival of their first child

 Providing services for unmarried mothers

 Teaching home economics and nutrition

 Providing adoption services

 Eligible couple:

 Eligible couple refers to a currently married couple wherein the

wife is in reproductive age (15-45 years).
 Target couples

 “Target couples” are the couples who have two to three living
children, and family planning was largely directed to such couples.

 The definition of target couples has been gradually enlarged to

include families with one child or even newly married couples with a
view to develop acceptance of the idea of family planning from the
earliest possible stage.
 Elements Of Family Planning
BENEFITS

To Mother

 Reduce the health risk

 Below 20y, and above 35 y. At risk of developing complications during

pregnancy.

 Physical strain of child bearing.

 Reduce number of maternal death.

 Reduce the risk of ovarian cysts.

Health Benefits to Children:
 Ensures better chance of survival at birth.

 Promote better childhood nutrition.

 Promote physical growth and development.

 Prevent birth defects

Health Benefits to Father:
 Allows father to keep a constant balance between their
physical, mental, social well –being.
 Increase father sense of respect because he is able to provide
the type of education and home environment.
Benefits to Whole Family Health:
 Benefits to Whole Family Health - help the family enjoy the
better kind of life.
 Also called CYP ( Couple years of protection) is a measure that
estimated the protection from pregnancy provided by contraceptive
methods during a one year period.
CONTRACEPTION:

 It is the voluntary prevention of pregnancy, a process with individual

and social implications. Contraception (birth control) prevents
pregnancy by interfering with the normal process of ovulation,
fertilization, and implantation. There are different kinds of birth control
that act at different points in the process
Characteristics of ideal contraceptive
 Safe

 Effective

 Acceptable

 Inexpensive

 Reversible

 Simple to administer

 Independent of coitus

 Longlasting to avoid frequent administration

 Require little/ no medical supervision

A

B
Temporary method :
 Used to postpone pregnancy or space births

Permanent method:
 Aim is to purposefully and permanently destroy the
reproductive capacity of an individual.
 Miscellaneous / Natural methods of contraception:

 These are the methods in which the woman assesses the

physiological signs and symptoms to determine ovulation
and hence determine the fertile period
 Technique using condom

 Before any sexual contact condom should be rolled into erect penis.

 If the condition does not have reservoir tip, about 1-2 cm should be
left at the tip of it.

 Penis should be withdrawal before losing the erection and holding

onto the condom base with the fingers so that it comes out without
slip of semen.

 Tie a knot in the condom before discarding

 Precaution for use

 Use new condom in each sexual contact.

 Keep extra supply at hand for emergency use.

 Condoms should not store in warm and humid place.

 If condom break, replace immediately.

 Effectiveness

 In perfect users: 98%

 In typical users: 86%

 Correct use of condoms worn by women
 Carefully remove the condom from its protective pouch. Use few drops
of the lubricant that comes with condom to make outer surface of the
condom moist & slick for easy insertion.

 To insert the condom, squat down, sit with your knees apart, or stand
with one foot on a stool or low chair. Hold the condom with the open
end hanging down, while holding the top ring of the pouch- the closed
end of the condom- squeeze the ring between your thumb and middle
finger
 Now place your index finger between your thumb and middle fingers. With
your fingers in this position, keep the top of the condom squeezed in a flat
oval. Use your other hand to spread the lips of your vagina and insert the
closed end of the pouch.

 Once you have inserted the closed end of the pouch, use your index finger
to push the pouch the rest of the way up into your vagina. Check to be
certain that the top of the ouch is up past your pubic bone– which you can
feel curving your index finger upward once it is a few inches the pouch up
to eight hours before you have intercourse.
 Make sure that the condom is not twisted inside your vagina. If it is, rove it,
add a drop or two of lubricant, and reinsert.

 If your partner inserts his penis underneath or alongside the pouch, ask him to
withdraw immediately. Remove the condom , discard it, and use a new pouch.

 After your partner ejaculate and withdraws, squeeze and twist the open end of
the pouch to keep the sperm inside. Pull out gently. Discard the used condom
in a trash can, not in the toilet. Do not use condom more than once, and do not
us it if your partner uses a condom– it will not stay in place.
 Every time when diaphragm is put into vagina,
spermicidal jelly should be used with it.
 Effectiveness:

 In perfect user: 94%

 Kamal chakki is an example of spermicidal vaginal
suppository which is available in Nepal and made from
menfegol spermicide.

 Technique of using spermicides

 Wash hand with soap and water before and after insertion
the spermicides
 Aerosol ( foams)
 Shake the container 20-30 times before using it.

 Place container in upright position and put applicator over valve. Press applicator to side
so it fills with foam.

 While lying down, insert applicator into the vagina until the tip is at or near the cervix.
Push plunger and release the foam. There is no need to wait for the foam to work. The
foam applicator should be washed with soap and warm water, rinsed and dried. Do not
share applicator with others.

 Keep an extra supply of foam on hand, especially if you cannot see whether the container
is empty.
Vaginal tablets, suppositories or dissolvable film:
 Remove vaginal tablet, suppository or film from package.

 While lying down, insert vaginal tablet, suppository or film high in

the vagina.

 Wait 10-15 minutes before having intercourse.

 The applicator should be washed with soap and warm water, rinsed
and dried. It can be taken apart for easier cleaning. Do not share
applicator with others.

 Keep an extra supply of vaginal tablets, suppositories or film on hand.

 Cream
 To insert contraceptive cream, squeeze into applicator until full. Insert the
applicator into the vagina until the tip is at or near the cervix. Push the
plunger and release the cream. There is no need to wait for the cream to
work.

 The applicator should be washed with soap and warm water, rinsed and
dried. It can be taken apart for easier cleaning. Do not share the applicator
with others.

 Keep an extra supply of cream on hand, especially if out cannot see whether
the container empty.
 Selection

 Aerosal (foams) effective immediately after insertion.

 Aerosols are recommended if spermicide is to be used as the only

contraceptive method.

 Foaming vaginal tablets and suppositories are convenient to carry and store
but require waiting 10-15 minutes after insertion before intercourse.

 Melting vaginal suppositories also require waiting 10-15 minutes after

insertion before intercourse.

 Spermicidal jellies usually used only with diaphragms.

 General information
 It is important to use spermicide before each act of intercourse. ( reapply
for subsequent acts of intercourse)
 There is a 10-15 mins waiting interval after insertion of vaginal tablets,
suppositories or film. There is no waiting interval for aerosols (foams).
 It is important to follow the recommendations of the manufacturer for use
and storage of each product. ( example : shake aerosol foams before filling
applicator).
 Apply more spermicide if intercourse does not take place within 1-2 hours.
 It is important to place the spermicide high in the vagina so the cervix is
well covered.
Appropriate for
 Women who prefer not to use hormonal methods or should not use them.
( e.g., smokers over 35 yrs of age)

 Women who prefer not to or should not use IUDs.

 Women warning protection from STDs and whose partners will not use
condom.

 Women who are breastfeeding and need contraception.

 Couples needing a temporary method while awaiting another method.

 Couples needing a backup method.

 Methods characteristics or benefits
 Effective immediately ( foams & creams)

 Do not affect breastfeeding

 Can be used as backup to other methods.

 No method related health risks

 No systemic side effects

 Easy to use

 Increase wetness (lubrication) during intercourse.

 No prescription or medical assessment necessary

 DISAdvantages

 High failure rate

 Need to be used repeatedly

 Mild burning

 Irritating effect
 Combined methods

 Physical + chemical ( condom + form or suppository)

 The IUCD currently available in Nepal is the copper T 380A is
shaped like a T and has copper on the stem and the arms, with a
total exposed copper area of 380 square mm. it has a white string at
the base, which extends through the cervix so that the IUCD can be
removed .

 It can be left in place for 12 years.

Mechanism of action : copper T IUCD

 Primary mechanism is prevention of fertilization.

 Reduce motility and viability of sperm.

 Inhibit development of ova.

 Inhibition of implantation is a secondary mechanism

Advantages of copper devices
 Effectiveness is about 99%

 Easier to fit even in nulliparous women.

 Low expulsion rate

 Effective as post coital contraceptives or emergency contraception,

if inserted within 5 days of unprotected intercourse.

 Fertility return immediately after the removal of IUD

 Third generation IUDs
 Release of hormone have become available on a limited
scale.
 The most widely used hormonal devices is progestasert,
which is a T- shaped devices filled with 38 mg of
progesterone, the natural hormone. The hormone is
released slowly in the uterus at the rate of 65mcg daily.
 Mechanism of action third generation IUDs
 The physical presence of the IUD in the uterus, keep the sperm from moving
normally inside the uterus and fallopian tubes.

 IUD cause a foreign body reaction in the uterus causing cellular and
biochemical changes in the endometrium and uterine fluids, and it is believed
that these changes impairs the viability of the gamete and thus reduce its
chances of fertilization.

 Hormone releasing devices increases the viscosity of the cervical mucus and
there by prevent sperm from entering the cervix.
 The ideal IUD candidates
The planned parenthood federation of America (PPFA) has described the ideal
IUD candidates : as a women

 Who has borne at least one child.

 Has no history of pelvic disease.

 Has normal menstrual period.

 Is willing to check the IUD tails.

 Has access to follow up and treatment of potential problems.

 Is in a monogamous relationship
 Contraindication (Absolute)
 Suspected pregnancy

 PID

 Vaginal bleeding of undiagnosed etiology

 Cancer of cervix

 Previous ectopic pregnancy

Contraindication (Relative)
 Anaemia

 Menorrhagia

 Purulent cervical discharge

 Distortion of uterine cavity

 Unmotivated persons.
Special concern for return visit
 P= period late, abortion, spotting or bleeding

 A= Abdominal pain, pain with intercourse, severe cramping

 I= infection exposure

 N= Not feeling well, fever, chills, especially accompanied by lower

abdominal pain.

 S= String missing, shorter or longer or plastic tip of IUD

 Instructions to the clients of IUCD
 Regularly check the thread or tail to be sure that the IUD is in the uterus.

 If she fails to locate the threads consult health worker

 Visit health worker if any side effects such as fever, PID, Pain & bleeding

 If period is missed consult health worker.

 IUD expulsion is uncommon, most expulsion occurs during menstruation so

she should check menstrual clothes or tampons, as well the toilet during
menstrual period & should insert another IUD
Management of side effects
specially of Heavy bleeding, lasting more than 3 months
 Examine for infection or fibroids

 Check for signs of anemia and treat if needed.

 Prescribe iron tablets 1 tab daily for 1-3 months & NSAIDS; ibuprofen 400
mg TDS for 5 days ( Prostaglandins make uterine/ menstrual bleeding
worse. NSAIDS decrease the production of prostaglandins and block the
body’s use of prostaglandins) or indomethacin 25mg BD for 5 days.

 Remove device
Oral Pills : Combined
 Combination : Estrogen and Progesterone

 In Nepal most common COCs are combined lower dose pills in

28days package. Available at all Government facility, contains
norgestrel ( progestin) 0.3 mg and ethinyl (estrogen) 0.03 mg in
each pill. The last 7 brown pills contain 75 mg ferrous fumarate
(iron) in each pill.
Mechanism of Action

 It inhibits ovulation by diminishing the secretion of gonadotrophins.

 It alters the viscosity of cervical mucus.

 3. Post- Coital Contraception

 “Morning after” is given within 72 hours of an unprotected intercourse.

Methods:

 IUD: The simplest technique is to insert it if acceptable, especially a

copper device within 5 days.

 Hormonal: More often this method is preferable. Levonorgestrel 0.75

mg tablet is used as one tablet within 72 hours of unprotected sex and
the second tablet after12 hours of first dose.
Effectiveness

 Less than one woman out of 100 will become

pregnant.
 Advantages
 Highly effective

 Easy to use & don’t interrupt sexual activity

 Risk of PID is halved

 Decrease risk of ovarian & uterine cancer

 Menstrual periods are regular and painless

 Decrease menstrual blood loss (50%), so reduces the risk of anemias.

 Protection against benign cystic breast disease & ovarian cyst.

 Disadvantages

 Failure rate is high if nit taken regularly

 Most common side effects with COCs are headache, breast tenderness,
feeling of sick, change in body wt & fluid retention. They can also cause
blot clits ( increase risk of CVS disease), changes in libido, depression
brown patches on skin.

 May increase the risk of Ca cervix & gall bladder

 Quantity of breast milk decrease

 Mild side effects: headaches, dizziness

 Contraindication
Absolute Relative
 Present or past history of  CVS disease: have family history of
thromboembolism blood or heart disease, HTN, varicose
 Ca breast & genital vein.

 Liver disease  Diabetes

 Hyperlipidemia, undiagnosed vaginal  Epilepsy

bleeding  Age above 40 years

 Severe migraine  Smokers (< 40 cigarettes/day)

 Heavy smoker (> 40cigarettes / day)  Chronic renal disease.

 Gall bladder disease

 DMPA (Depot- Medroxy Progesterone acetate),
Depoprovera
 DMPA contains the progestine hormone name “Depot-
Medroxy Progesterone acetate”. The brand name is
Depoprovera and commonly called “ Depo”.
 It is also called “ Sagini” in Nepal.
 Dose

 Single dose vial, each vial contains 150 mg of Depot-

Medroxy Progesterone acetate /ml for every 3 month.
 It is administered intramuscularly
 Mechanism of action

They prevent pregnancy by:

 Suppressing ovulation by suppressing the mid cycle LH peak.

 Making thin atrophic endometrium so ovum can not implant.

 Causing cervical mucus thick, which prevent sperm protection.

 Advantages
 Highly effective 99.7%

 Decrease anemia, PIVD and endometrial cancer

 Women lose less blood & have less menstrual cramping. Often after these
injections women stop periods. This safe.

 Nursing mother can receive depo provera injections. it’s best after baby is
6 wks old

 Reversible

 Rapidly effective (within 24 hrs)

 Disadvantages

 Depo. Injection can lead to very irregular periods.

 Some women gain weight

 A person has to return clinic every 3 months for injection

 Depo. May lower estrogen level & cause bone loss.

 Health personals are need for injections

Timing of implantation

 Any time during menstrual cycle if it is reasonably certain

that she is not pregnant.
 Within the 7 days after the start of means

 Within 7 days of post abortion

 If appropriately using LAM

 Advantages

 Highly effective 99.7%

 Immediately effective within 24hrs of insertion

 Long term protection 5 years.

 Reversible

 Can be remove any time it for any reason

 Does not interfere with the lactation

 Protect against uterine cancer

 Immediate return of fertility after removal

 Disadvantages
 Menstrual irregularities and about 10% of users discontinue using of this
reason.

 Does not protect from STD/AIDS

 Client does not discontinue the method on her own wish

 Need small surgical procedure and medical person for insertion &
removal.
 Contraindication

 Suspected pregnancy

 Liver disease

 Breast cancer

 Unexplained uterine bleeding and blood clots.

 Client’s instruction
 Insertion area should be clean and dry with pressure dressing in place for
2 days & band aid for 5 days.

 Routine work can be done immediately but avoid straining the area for
few days.

 If sign of infection such as inflammation, pain at site & fever returned to

clinic.

 Follow up after 7 days for the check up of insertion site and should return
any time if warning sign is present.
 4. Post Contraceptive methods

 Menstrual regulations

 Menstrual induction

 Abortion
 Menstrual regulation

 It is done within 14 days of missed period when

pregnancy is doubted but it is not confirmed. In this the
uterine contents are evacuated. The procedure is very safe.
There is no legal restriction.
 Complication which can occur are:- local injury,
perforation of uterus, infection
 Menstrual induction

 This is done with in few days of missed period. It is done

by application of prostaglandin F2 under sedation. This
induces continuous contraction of uterus lasting for 7 min.
 it is followed by cyclic contraction which continues for
next 3-4 hours. This initiates bleeding which lasts for a
week or so
 Contraindications:

 History of allergy or hypersensitivity to these drugs

 Confirmed or suspected ectopic pregnancy

 IUD in place

 Chronic adrenal failure

 Hemorrhagic disorder

 Inherited porphyria

 If a patient does not have access to medical facilities to provide

emergency treatment of complications
 ABORTION

 Defined as “termination of pregnancy before the foetus becomes

viable”.
 This has been fixed at 28 weeks when the foetus weighs
approximately1000 g.
 Abortions types:

 Spontaneous

 Induced.

 Spontaneous may be considered as nature’s method of birth control.

 Induced abortions may be legal or illegal.

 Hazards of Abortion

A- Early Complications:
 Hemorrhage Shock Sepsis
 Uterine perforation
 Cervical injuries
 Anesthetic and psychiatric complications

B- Late Sequelae:
 Infertility
 Ectopic gestation
 Increased risk of spontaneous abortion
 Reduced birth weight
Conditions under which a pregnancy can be terminated:

 Medical

 Eugenic

 Humanitarian

 Socio-economic

 Failure of contraceptive devices

3. Rhythm Methods
Natural Family Planning Method

 A couple voluntarily avoids sexual intercourse during the

fertile phase of the woman’s cycle( time when the woman
can become pregnant) or has intercourse during fertile
phase to achieve pregnancy
Terminal methods
 VASECTOMY
 Vasectomy is sterilization of male. It is very simple and minor operation
which takes hardly 15-20 min.

 The operation involves a small cut on both sides of scrotum then a small
portion of vas deferens (about 1cm) on either side of the scrotum is cut and
ligated, folded back and sutured.

 The operation is done not affect the sexual characteristics and sex life in any
form. The sperms are produces but not ejaculated along with semen
 Effectiveness: 99%
 Timing of operation

 Healthy male client with no precaution should be offered

surgery as soon convenient for them.
 ADVANTAGES
 No incision

 No stitches

 Faster procedure

 Faster recovery

 Less chance of bleeding

 Less discomfort

 Highly effective 99%

 disadvantages

 Delay in effectiveness ( requires 3 months; at least 20-30

ejaculation)

 Does not protect from STDs/AIDS

 Difficult & very expensive to reverse (permanent)

 Risk & side effect of minor surgery.

 contraindication

 Hydrocele

 Inguinal hernia

 Filariasis

 Scar tissue

 Previous scrotal surgery

 Large varicocele
 complications

 Swelling & pain

 Blood clots

 Infection

 Epididymitis

 Autoimmunity to own sperm

 Spontaneous recanalization
 Preoperative preparation

 Measure Vital sign

 Take written consent

 Client should bath & wear clean, loose fitting clothing

 Ask to bring clean scrotal support clothes.

 Vasectomy client have not receive anesthesia so he can go home after 30 mins
 Postoperative advice
 Should wear scrotum support, keep the operation site dry & rest for
2days

 Instruct the client avoid sexual contact at least 3-5 days after
operation

 Use other contraceptives until aspermia has been established about 3

months or 20-30 ejaculation.

 Do not shower for 2 days

 Avoid cycling or lifting heavy weighs for 15days

 If scrotum is swollen and sore, keep him at rest, take paracetamol
and keep ice pack to minimize pain

 Can maintain sexual contact after 2-3 days if fell comfortable

 Seek health care professionals if bleeding, pus and fever occurs.

 TUBECTOMY
 It is sterilization of female.

 This is done by resecting a small part of fallopian tubes and ligate the
sected ends. The closing of tubes can also be done by using other
methods like closing the tubes with bands clips and electrocautery.

 The operation can be done through abdominal or vaginal approach.

 The most common abdominal procedure are laproscopy and

minilaprotomy.

 The tubectomy can be done after delivery, between delivery and after
abortion.
 Timing of procedure
 Any time in the menstrual cycle, if ensure the client is not pregnant

 After 6-8 wks of postpartum but, pregnancy should be ruled out

 For immediately postpartum procedure, minilaprotomy only should

be performed within 48 hrs of delivery

 6 wks after delivery

 Minilaprotomy

 This operation is done under local anesthesia.

 2-3 inch incision is done in the lower abdomen and the fallopian
tube are tying off and cutting out small piece of tube.

 After that the abdominal opening is closed. Client can be

discharged within 3-4 hours of operations.
Advantages
 Highly effective 99.5%

 Immediately effective

 Permanent

 Does not interfere to sexual intercourse

 Can be performed on as OPD basis

 Simple surgery usually done under local anesthesia

 It may be used postpartum tubal ligation

 Disadvantages
 Expensive than vasectomy

 Not reversible

 Does not protect STDs/ AIDS

 Risk and side effects of minor surgery

 Contraindication

 Pregnancy

 PID/ UTI

 Mass in the pelvis

 Diabetes

 Hypertension

 Respiratory problems

 Severe anemia

 Active TB

 Fibroid and abdominal surgery

 complications

 Light bleeding

 Pain and post operative fever

 Wound infection

 Injury to other organs

 Light headache and giddiness

 Laparoscopy
 After giving local anesthesia about 1 cm incision is made
under the umbilicus and then the laparoscopy instrument
is inserted to find out the fallopian tubes.
 Then the tubes are tied using small rubber rings
 Advantages
 Operation takes only 15 mins and only small scar is remain

 Highly effective 99%

 Immediately effective

 Permanent

 Does not interfere with sexual intercourse

 Can be performed on as OPD basis

 Simple surgery usually done under local anesthesia

 Disadvantages

 Expensive than vasectomy and minilap due to expensive equipment

 Not reversible

 Does not protect from STD/ AIDS

 Difficult to operate than minilap

 Insufflations of the abdomen can lead to complications such as gas

embolism, subcutaneous emphysema, respiratory and cardiac failure