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Are most causes of maternal mortality treatable?

How many lives could be saved?
Most of the causes of maternal mortality are treatable or preventable with adequate healthcare including contraceptive services and up to 100,000 maternal deaths could be avoided if services were available.
What percentage of US pregs are unintended?

Of these, how many end in abortion?
Current statistics indicate that almost half of all U.S. pregnancies are unintended with 4 in 10 of these pregnancies being terminated by abortion
Disruptions in life due to unintended preg?
  • Education plans
  • Career goals
  • Financial hardship
  • Health issues
Amt saved for every $1 spent on famliy planning re: preg care and newborn care
For every $1 spent, an average $3 is saved on pregnancy-related care and care of newborns. Furthermore, without these publicly supported services an additional 1.3 million pregnancies would occur
What counseling should patients desiring contraception receive prior to choosing a method?

  • Types of available contraception

  • Protection against sexually transmitted infections(also commonly referred to as sexually transmitted diseases)

  • Risks and benefits associated with each

  • Proper use of each method

  • What to do if an error is made

  • Emergency contraception

  • Back-up methods and when to use them

  • How to go about changing methods

  • All patient questions and concerns should be addressed

Some factors that influence patient decisions re: family planning
  •  Cultural practices
  • Religious beliefs
  • Attitudes and personal preferences
  • Cost
  • Effectiveness
  • Misinformation
  • Practicality of the method
    • Convenience
    • Effect on spontaneity
  • Self-esteem

Reversible Methods of Contraception
  • Reversible Methods
    • Behavioral
    • Barrier
      • Mechanical
      • Chemical
    • Hormonal
    • Intrauterine Devices (IUD)
Permanent Contraception Methods
  • Permanent Methods (sterilization)
    • Non-surgical sterilization (Essure)
    • Bilateral Tubal Ligation (BTL)
    • Vasectomy
Clinical Interruption of Pregnancy
aka abortion
is the avoidance of sexual intercourse or any activity that may lead to conception. It is the only completely effective method for preventing pregnancy and the transmission of sexually transmitted infections but must be practiced 100% of the time to be 100% effective.
Coitus Interruptus (and failure rate)
is the withdrawal of the penis from the vagina prior to ejaculation. This method does not protect against sexually transmitted infections. Also, since pre-ejaculate can contain sperm, failure rate for this method is high (approx. 27%).
Calendar Method (and failure rate)
is based on the assumption that ovulation should occur around the 14th day after the onset of menses for women who have a 28 day cycle. To determine the fertile period, the menstrual cycle should be charted for 6 months. Abstinence is then practiced during the days that are believed to be fertile. This method has a high failure rate (approx. 25%) because many women do not have regular menstrual cycles and factors such as stress and illness can affect ovulation.
Basal Body Temperature
-what happens to womans BBT before and with ovulation?
consists of the woman charting her body temperature each morning before getting out of bed. BBT is the lowest body temperature of a healthy person. A woman's BBT may drop just before ovulation and then rise 0.4 degrees C (0.8 degrees F) with ovulation. This method used alone is not very effective because many factors can cause a fluctuation in body temperature and intercourse occurring the day prior to the increase in temperature is likely to result in pregnancy (due to the ability of sperm to survive for several days in the woman's reproductive tract). Point of interest: BBT may also be used by couples attempting to achieve pregnancy.
Cervical Mucus - Contraception
changes in amount and consistency in response to rising estrogen levels at the time of ovulation. The woman can assess her own cervical mucus for increased amount and "slippery-ness" as an indication of ovulation. To prevent pregnancy, the woman avoids intercourse until 4 days after the end of the slippery mucus.
Symptothermal Method
-combo of what?
is a combination of the calendar, BBT, and cervical mucus methods in addition to observing for other signs of ovulation such as weight gain, abdominal bloating, mittelschmerz, and increased labido. Sexual intercourse is avoided during this time period.
lower abdominal pain with ovulation
Lactation amennorhea (LAM)
occurs when a woman is lactating. The high prolactin levels associated with lactation suppress the secretion of gonadotropin-releasing hormone and luteinizing hormone that are responsible for ovulation. Women who breastfeed exclusively without giving any formula or other supplemental foods may experience amennorhea for the first six months or longer. However, because ovulation may occur before the woman realizes her menstrual cycle has begun again, additional forms of contraception are recommended.
barrier methods work by......

how many types?
contraception prevent pregnancy by stopping the sperm from reaching the ovum thus preventing conception. There are 2 different categories of barrier contraceptives: mechanical and chemical.
mechanical barriers and types
Mechanical barriers include devices such as the diaphragmcervical capcontraceptive sponge, and male and female condoms. Several of these methods contain latex and therefore are contraindicated for individuals with latex allergies.
-failure rate
diaphragm is a soft, latex dome surrounded by metal springs. It is used with a spermicide and inserted into the vagina to cover the cervix. It may be inserted up to 4 hours before intercourse and must be left in place for a minimum of 6 hours after. The woman must visit her healthcare provider to have the diaphragm fitted. The device should be replaced every 2 years and may need to be refitted if the woman gains or loses weight (of 20% or more) or following a term birth. The initial cost of purchasing the diaphragm may be high and the typical failure rate for this method is approximately 16-20%. The woman should be advised not to use oil based lubricants (such as petroleum jelly) because these can damage the diaphragm making it less reliable.
advantages and disadvantages of diaphragms

  • Advantages: Can be inserted several hours before intercourse and remain in place for 24 hours.

  • Disadvantages: Initial cost may be expensive and requires a healthcare provider for fitting. May be difficult for some women to insert and remove. There is an increased risk for toxic shock syndrome with this method of birth control.

cervical cap
-failure rate
The cervical cap is smaller than the diaphragm, covering only the cervix, and is held in place by suction. The cap of this silicone dome is filled approximately 1/3 full with spermicide- using caution not to apply spermicide to the rim as this may interfere with the seal between the cap and the cervix. The cap may be inserted up to 12 hours prior to intercourse and provides protection for 48 hours. It must remain in place for at least 6 hours following the last intercourse. Like the diaphragm, the cervical cap must be fitted by a healthcare professional. Failure rate for this method is approximately 16% fornulliparous women and 32% for parous women.
adv/disadv cerv cap

  • Advantages: Smaller than a diaphragm and less noticeable. Can be left in place for 48 hours.

  • Disadvantages: May be expensive and requires a healthcare provider for the initial fitting. This form of contraception also has an increased risk for toxic shock syndrome.

contraceptive sponge
The contraceptive sponge is a soft, concave device made of polyurethane. It prevents pregnancy for up to 24 hours by covering the cervix and releasing spermicide. It should be left in place for at least 6 hours following last intercourse and does not require additional spermicide application for repeated intercourse. The sponge should not be left in the vagina for more than 24-30 hours due to an increased risk for toxic shock syndrome.
adv/disadv contraceptive sponge

  • Advantages: Inexpensive and available over-the-counter. May be placed several hours prior to intercourse.

  • Disadvantages: May cause irritation and provides to protection from STI's.

male condom
Male Condom
The male condom provides a reliable source of contraception when used correctly and consistently. It is becoming increasing popular because it can offer contraception as well as some protection against sexually transmitted infections (STI's) such as human immunodeficiency virus (HIV).The condom should be applied to the erect penis, rolling it down from tip to shaft prior to sexual contact. A small space must be left at the end to allow room for ejaculate and prevent the condom from breaking at the time of ejaculation. A water soluble lubricant such as KY jelly may also be necessary to decrease the likelihood that the condom will break. The penis should be withdrawn from the vagina and the condom removed before the penis becomes flaccid. It may be necessary to hold the rim of the condom to prevent spillage of ejaculate when removing the penis from the vagina.
adv/disadv male condom

  • Advantages: Condoms are small, disposable, inexpensive and can be purchased over the counter. There are no side effects assuming the individual is not latex allergic. While most condoms are made of latex, condoms made of polyurethane and silicone are also available. All condoms except natural "skin" condoms, made of lamb's intestine, offer some protection against both pregnancy and STI's.

  • Disadvantages: Breakage, displacement, perineal or vaginal irritation, and dulled sensations are possible disadvantages. Exposure to heat may cause the condom to deteriorate and break more easily so condoms should be stored in a cool environment.

female condom

The female condom is a thin polyurethane sheath with a flexible ring at each end. The inner ring at the closed end of the condom is inserted into the vagina first and fits over the cervix similar to a diaphragm. The outer ring remains outside of the vagina and covers a portion of the woman's perineum and the base of the man's penis during intercourse. The condom may be inserted up to 8 hours prior to intercourse and is intended for one time use. The inner sheath is pre-lubricated but does not contain spermicide and is not intended to be used in conjunction with a male condom.

  • Advantages: Available over the counter. Covers part of the vulva so may provide some protection against STI's.

  • Disadvantages: Expensive, cumbersome and noisy.

chem barriers
A chemical barrier, in the form of a spermicide, actually kills sperm. These products come in various forms such as foams, gels, and suppositories and may be used in conjunction with other mechanical barriers such as diaphragms and condoms. They are generally effective for 1 hour and then must be reapplied prior to having intercourse again.
chem barriers adv/disadv(inc fail rate)

  • Available over the counter and require no prescription

  • Does not need to be taken daily such as with oral contraceptives

  • No systemic side effects

  • May provide some protection from STI's


  • 29% failure rate when used alone

  • May be messy and irritating

Combined Estrogen Progestin Contraception
Combined Estrogen-Progestin Contraception
Combined oral contraceptives (COC's) are commonly referred to as "The Pill." They are relatively safe, highly effective, and rapidly reversible. COC's work by inhibiting ovulation, thinning the uterine endometrium (thus making implantation of an embryo more difficult should conception occur), and thickening cervical mucus to make sperm transport more difficult. COC's are usually prescribed daily for 21 days then 7 days off. The woman will typically menstruate approximately 1-4 days following the last pill taken. Some companies offer a 28 day pack that contains 7 placebo pills so that the woman is taking a pill every day. Additionally, there is growing interest in extended oral contraceptives that allow the woman to only menstruate four times per year. Seasonale and Seasonique are FDA approved extended oral contraceptives. Both offer a 91-day pack that contains 84 active pills and 7 placebo pills during which time the woman has a period.
combined estrogen progestin ADVANTAGES
Advantages: Highly effective form of contraception when taken as prescribed. Many women experience relief from uncomfortable menstrual symptoms such as cramping, heavy menstrual flow and cycle regularity is improved. Additional benefits include: reduction in ectopic pregnancies, ovarian cancer, endometrial cancer, iron deficiency anemia, and benign breast disease.
combines estrogen progestin DISADVANTAGES
-include estrogen related side effects
-include progestin related side effect
Disadvantages: Does not provide protection from STI's. Side effects tend to be either estrogen or progestin related and are less likely with the lower dose pills that are currently being prescribed.

  • Estrogen related side effects: breast tenderness, cerebrovascular accidents, fluid retention, headache, hypertension, nausea, nervousness, irritability, thromboembolic complications such as thrombophlebitis or pulmonary embolism.

  • Progestin related side effects: acne, oily skin, breast tenderness, decreased libido, decreased high density lipoproteins (HDL's), increased low density lipoproteins (LDL's), depression, fatigue, hirsutism, increased appetite, weight gain, oligomenorrhea.


-overanbundance of hair
-a reduction in number of menstrual periods or menstrual flow 
combined estrogen-progestin contraception

Absolute Contraindications: Pregnancy, previous history of thrombophlebitis or thromboembolic disease, acute or chronic liver disease of cholestatic type with abnormal function, presence of estrogen-dependent carcinomas, undiagnosed uterine bleeding, heavy smoking, gallbladder disease, hypertension, diabetes, and hyperlipidemia.
is combined estro-progest therapy recommended for breastfeeding women?

why or why not?
* Not recommended for breastfeeding women because estrogen can cause a decrease in milk supply.
-method of action
The NuvaRing vaginal contraceptive ring is a form of low-dose, sustained release, hormonal contraceptive available as a flexible, soft ring that the woman inserts into her vagina. The ring is left in place for 3 weeks and then removed for 1 week at which time menstruation occurs. One size fits all women and the ring can be left in place during intercourse without causing discomfort for the woman or her partner. Replacement rings should be kept in the refrigerator to protect their integrity.
Ortho Evra Patch
-reliability (weight)
-method of action
Hormonal contraceptives can now be administered transdermally using a skin patch (Ortho Evra patch). The woman applies the patch weekly for 3 weeks, rotating sites. During the 4th week, no patch is worn and menstruation occurs. The contraceptive patch is very reliable for women weighing less than 198 pounds. It also has a better compliance rate than oral contraceptives because of the weekly versus daily dosing. Transdermal estrogen absorption is 60% greater than oral absorption which has lead to concerns that women using transdermal contraceptives may be at higher risk for serious side effects and complications. Preliminary research suggests that the incidence of venous thromboembolism is higher for women using the patch than those taking COC's (Memmel & Gilliam, 2008). Research continues; however, women with risk factors for thromboembolic conditions should carefully discuss the use of the patch with their healthcare provider.
progestin only contraception
Progestin-only pills are commonly known as the minipill. The minipill is taken once a day with no hormone free days. It is less effective than COC's and it is essential that the woman take the pill at the same time each day. Failure to due so may jeopardize the effectiveness of the pill. While the minipill may not be as effective at preventing ovulation as COC's, it causes thickening of the cervical mucus which prevents sperm penetration and causes the endometrial lining to become unfavorable for implantation.
progestin only contraception

Advantages: Avoids the side effects caused by estrogen and are beneficial for women who cannot take estrogen. *Can be taken while breastfeeding with little effect on milk supply.
Disadvantages: Side effects caused by progesterone (see above). Break through bleeding is common and the risk of pregnancy is greater than with COC's.
*It is important to note that with either COC's or Progestin-only contraception, missed doses may reduce effectiveness. The woman should follow instructions from her healthcare provider if missed doses occur. Also, certain medications (for instance some anti-seizure medications) may interact with these oral contraceptives and reduce their effectiveness making the possibility of an unplanned pregnancy more likely (see pg. 846-847 of your course textbook for more information).
depo provera
Depo Provera is a long acting progesterone that provides highly effective birth control for three months after a single injection. Depo Provera acts primarily by suppressing ovulation. It is more effective than the minipill because it contains levels of progesterone high enough to block the surge of lutenizing hormone thus suppressing ovulation. It also thickens cervical mucus.
depo provera



special concerns
AdvantagesCan be taken by breastfeeding mothers because it does not contain estrogen. Safe, convenient, reliable, and inexpensive.
Disadvantages: Menstrual irregularities, headache, weight gain, breast tenderness, depression. Return of fertility may be delayed for an average of 9 months.
Special concerns: At one time, use of Depo Provera for longer than 2 years was not recommended. Prolonged use has been associated with calcium loss from the bones that was believed to be irreversible even after discontinuation. However, the findings of more recent studies indicate that after approximately 2 1/2 years following discontinuation of Depo Provera, bone density in these women is similar to that of women who have never used Depo Provera (Hatcher, et al. 2007).
Implanon is a single capsule implant, inserted under the skin of the arm, that is effective for 3 years. It prevents conception by inhibiting ovulation and thickening cervical mucus. Side effects are consistent with other types of progestin contraceptives.

Emergency Postcoital Contraception (EC)
Emergency Postcoital Contraception (EC)
Often referred to as the "morning after pill," EC is indicated when a woman is concerned she may have conceived following unprotected intercourse, contraceptive failure, or rape. The name "morning after pill" is actually rather misleading because the woman takes the first dose as soon after intercourse as possible. This method is most effective if taken within 72 hours of intercourse, but may be used as long as 120 hours after. Emergency contraception taken within 72 hours of a single act of intercourse can reduce the risk of pregnancy by 89% (Office of Population Research & Association of Reproductive Health Professionals, 2007). Plan B, a progestin-only (levonorgestrel) pill, is the only medication currently available in the U.S. that is marketed specifically for EC. In 2005, Plan B was approved by the FDA for over-the-counter purchase to women 17 years and older. A prescription for women younger than 17 years is still required.
An intrauterine device (IUD) is a safe and effective method of contraception. This device is inserted into the uterus by a qualified healthcare professional and can be left in place for an extended period of time. It was once believed that IUD's worked by preventing implantation after conception had occurred. However, it is now known that this is inaccurate. IUD's actually trigger a spermicidal type reaction in the body thus preventing fertilization. They also cause an inflammatory effect on the endometrium.
two types of IUD
Two types of IUD's are now available in the U.S. The copper T380A (Paraguard) does not contain hormones, is highly effective, and can be left in place for 10 years. This type of IUD is ideal for women that can not take hormone containing contraceptives. The levonorgestrel-releasing intrauterine system (Mirena) is a small, T-shaped IUD that releases levonorgestrel gradually. While the Mirena does contain hormones, it is otherwise similar to the copper IUD and may be left in place for 5 years. Additionally, after 3 months of use, bleeding and length of menstruation are reduced and some women experience amennorhea.
IUD placement and teaching
The IUD is inserted into the uterus with its string or tails protruding through the cervix into the vagina. After insertion, the clinician should educate the woman to check for the presence of the strings once a week for the first month and then after each menses to be certain the IUD has not fallen out. The woman should also be told that it is normal to have some cramping and intermittent bleeding for the first 2-6 weeks after insertion of the IUD. Her first few menses may be irregular. Follow-up examination is recommended 4-8 weeks after placement.
Essure is a relatively new method of permanent sterilization that requires no surgical incision. With the use of hysteroscopy, stainless steel microinserts are placed in the woman's ovarian tubes stimulating the growth of local scar tissue resulting in blockage of the tubes. At 3 months post-procedure, complete blockage occurs in 96% of women and at 6 months this number increases to 100%. Essure avoids the need for surgery but does require the clinician to have specialized training to insert the device. Additionally, the woman will need to undergo a hysterosalpinogram (HSG) 3 months following the procedure to confirm that the ovarian tubes have been effectively blocked. A back-up contraceptive method should be used until after the HSG confirms blockage of the tubes.
IUD adv/disadv
Advantages: High rate of effectiveness, continuous contraceptive protection, and relatively inexpensive.
Disadvantages: Possible discomfort to the wearer, increased bleeding during menses for users of the copper IUD, increased risk for pelvic infection for approximately 3 weeks following insertion, perforation of the uterus during placement, light intermenstrual bleeding for users of the levonorgestrel-releasing IUD, dysmenorrhea, and expulsion of the device.
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