Client Assessment

By Mulualem S. (MSc)

1
Objectives
At the end of this session you will be able to:
Discuss the importance of history taking and
physical examination in FP
Describe specific information that need to be
extracted from the client
Classify selected procedures and tests for providing
FP methods
Understand how a provider be reasonable sure a
client is not pregnant
Describe the four categories of MECs
 Introduction
client assessment:
 It creates an environment where client-provider
communication is established and confidence is built.
 Unless specific problems are suspected, the safe provision of most
contraceptive methods does not require performing a physical,
pelvic or laboratory examination.
 Few physical examinations are absolutely necessary and few
laboratory examinations are mandatory before commencing some
of the contraceptive methods; IUCDs and VSC.

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History
Age
Parity, last delivery, last abortion, history of ectopic
pregnancy
Breastfeeding
Smoking
Sexual behavior: self, partner
 History …
 Present and past medical conditions
 STIs
 HIV status
 Pelvic surgery and infection
 Tuberculosis
 Hypertension and Diabetes
 CVS risk factors (smoking, obesity, hypertension, previous thrombo-
embolic phenomena)
 Migraine
 Viral hepatitis
History …
Medications the client is taking:
Antiretroviral drugs
Antibiotics
Anticonvulsants
Family history of cancers, cardiovascular diseases and
cerebro-vascular accidents
Physical examination
Blood pressure measurement – note systolic and diastolic
measurements
Obesity – height and weight
Pelvic examination
Pelvic examination is seldom necessary, except to rule out

pregnancy in women who are amenorrheic for more than 6

weeks from LMP and before the use of IUCD and female
sterilization.
 Laboratory examination
Only when indicated
 Hemoglobin
 Screening for STIs/HIV –VDRL, HIV test
How to be reasonably sure that a woman is not
pregnant
NO YES
Have you abstained from sexual intercourse since your last
monthly bleeding or delivery?
Have you been using a reliable contraceptive method correctly
and consistently?
Did your last monthly bleeding start within the past 7 days (or
within 12 days if the client is planning to use an IUCD)?
Have you had a baby in the last 4 weeks?

Have you had a miscarriage or abortion in the last 7 days (or

within 12 days if the client is planning to use an IUCD)?
Did you have a baby less than 6 months ago, if so, are you fully
or nearly fully breastfeeding, and had no monthly bleeding
since then?
How to be reasonably sure that a woman is
not pregnant …
If the client answered ‘yes‘ to at least one of the

questions, and she has no symptoms or signs of pregnancy,

she can start the method she has chosen

If the client answered ‗No‘ to all questions, pregnancy

cannot be ruled out. The client should wait for her next
monthly bleeding or use a pregnancy test.
 How to be reasonably sure that a woman is
not pregnant …
 Pregnancy test is not essential most of the time.

 It may be required in certain circumstances where:

 It is difficult to confirm an early pregnancy (6 weeks or less from the LMP); or

 The results of pelvic examination are doubtful (e.g., obese client).

 In these conditions, urine pregnancy test or ultrasound scan may be helpful, if

readily available and affordable.

 If pregnancy test is not available counsel the client to:

 Abstain from sexual intercourse or

 To use barrier methods until her menses return or pregnancy is confirmed.

 Procedures and tests for providing FP methods
 Class A: Essential and mandatory in all circumstances for safe and effective use

of the contraceptive method.

 Eg. PV for IUCD and female sterilization, STI risk assessment for IUCD

 Class B: Contributes substantially to safe and effective use.

 If the test or examination cannot be done, the risk of not performing it should

be weighed against the benefits of making the contraceptive method available.

 Eg. Hemoglobin for female sterilization

 Class C: Does not contribute substantially to safe and effective use of the

contraceptive method.
 Procedures and tests for providing FP
methods …
This classification apply to people who are presumed to be

healthy

For a person with a known medical condition or other

special condition, refer to the Medical Eligibility Criteria

for Contraceptives
 Medical Eligibility Criteria (MEC)
 It used to review who can and cannot safely use a contraceptive method.

 It offers guidance on the safety of using different methods for women

and men with specific reproductive and social characteristics or known

medical conditions.

 The recommendations are based on systematic reviews of available

clinical and epidemiological research.

 Improve both the quality of and the access to FP services for clients.

 To address and change misconceptions about who can and cannot safely
16
use contraception
 MECs Categories
 The conditions affecting eligibility for the use of
each method are classified under in to four
categories:
1. A condition for which there is no restriction for the use of
the contraceptive method.
2. A condition where the advantages of using the method
generally outweigh the theoretical or proven risks.
3. A condition where the theoretical or proven risks usually
outweigh the advantages of using the method.
4. A condition which represents an unacceptable health risk if
the contraceptive method is used.
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 MECs Categories…

18
 Categories for Sterilization

19
 Categories for Fertility awareness methods

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 Family Planning for People
with Special Needs

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 Objectives
By the end of this module, you will be able to:
 Describe the special considerations for clients with HIV
 Describe the special considerations for adolescents and
youth
 Express the special considerations in clients with
disability
 Understand the special considerations for survivors of
sexual violence

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 Family Planning
for
clients with HIV

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 Fertility intentions of clients with HIV
Fertility intentions of PLWH are varied
FP service providers should respect the right of PLWH and
help them to achieve their reproductive needs
Avoiding unwanted pregnancy in HIV positive women using
FP is one of the four prongs of preventing mother to child
transmission of HIV

Couples with HIV have a wide range of methods from

which to choose.
Dual Method Use
Use condoms to protect against HIV/STIs and another
method to prevent pregnancy.
Reduces:
 Risk of unintended pregnancy
 Transmission of HIV between partners
 Risk of acquiring or transmitting other STIs

Dual method use may not be easy to achieve.

 There are 5 dual protection strategies.
Strategy 1: Use a male or female condom correctly with every act of sex.
Strategy 2: Use condoms consistently and correctly plus another family
planning method.
Strategy 3: If both partners know they are not infected, use any family
planning method to prevent pregnancy and stay in a mutually faithful
relationship.
Strategy 4: Engage only in safer sexual intimacy that avoids intercourse
and otherwise prevents semen and vaginal fluids from coming in contact
with each other’s genitals.
Strategy 5: Delay or avoid sexual activity (either avoiding sex any time
that it might be risky or abstaining for a longer time).
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IUCD Use by Women with HIV

WHO Eligibility Criteria

 IUCDs safe for majority
Category of women with HIV
Condition
Initiate Continue  Initiation not
recommended if woman
HIV-infected 2 2 has AIDS and is not on
ARVs
AIDS 3 2
(without ARVs)  Encourage dual method
use
ARV therapy 2 2
(clinically well)
Injectable Use by Women with HIV
 Women with HIV/AIDS can use
WHO Eligibility Criteria without restrictions
Condition Category  Encourage to receive injections on
time
HIV-
infected
1
 Dual method use should be
AIDS encouraged
1
ARV
Therapy
1
OCP Use by Women with HIV
Women with HIV/AIDS can use oral contraceptive pills
Women whose ARV regimen contains drug ritonavir or
ritonavir-boosted protease inhibitors should not be
recommended to use COCs or POPs
Spermicides Use by Women with HIV
Should not use spermicides if at high risk of HIV,
infected with HIV, or has AIDS.
Implant Use by Women with HIV

WHO Eligibility Criteria

 Women with HIV/AIDS can
use without restrictions
Condition Category
 Nevirapine reduces blood
HIV-
infected
1 progestin level by ~20%
AIDS
1  Dual method use should be
encouraged
ARV
Therapy
2
Condoms

For clients with HIV :

Condition Category Prevent STI and HIV transmission
Prevent acquisition of different
HIV-
infected
1 HIV strain
AIDS Should be used even when HIV
1 infection is controlled by ARVs-
ARV
Therapy
1
Sterilization Use by Clients with HIV
 No medical reasons to deny sterilization to clients with HIV

 Procedure may be delayed in event of acute HIV-related

infection

 If the client has STI, Cervicitis or PID delay female

sterilization until treated

 Delay vasectomy procedure if the client is currently ill with

AIDS-related illness

 Encourage condom use

LAM Use by Women with HIV
Advise that children can become infected
 Risk of acquisition through breast milk ~ 35-40%

Exclusive breastfeeding during first six months may

reduce risk of acquisition by infant compared to
mixed feeding.
Exclusive use of formula or other substitutes
eliminates risk of transmission through breast milk
(often not possible/ safe)
FAB Methods Use by Women with HIV
Can use without restrictions

Should be encouraged to use condoms

Summary of Contraceptive Choices for
clients with HIV
 With very limited exceptions, almost any
method of contraception can be used by
clients with HIV.
 Family Planning
FOR
Adolescents and youth

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 Family planning for adolescents
Definitions
 Adolescent embraces the age group 10-19 years
 Youth refer to the age group 15-24
 Young people 10-24
 In general, adolescents are eligible to use any
method of contraception and must have access to a
variety of contraceptive choices.
 Age alone does not constitute a medical reason for
denying any method to adolescents
Specific attributes of the different FP methods for
use by adolescents shall be discussed during
counseling
 FP services for youth
FP services need to be youth-friendly
Adolescents prefer RH services under one roof.
 All efforts shall be made to provide FP and other RH
services in youth centers.
IEC messages shall be gender and age-oriented and
recognize the special needs of adolescents.
Good counseling and support is particularly essential.
 Ensuring privacy and confidentiality is particularly
important
 FP services for youth …
Dual use of FP method should be included in counseling
sessions.
Youth that are sexually active should get information and
education on FP.
As casual and forced sex is more prevalent in youth provision
of ECPs and condoms to youth in advance is recommended.
 FAMILY PLANNING
for
DISABLED CLIENTS

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 FP service for disabled
Barrier methods like condom and diaphragm may be difficult
to use for mentally disabled
COCs may not be a preferred method for women with
impaired circulation or immobile extremities
Consider long acting methods for individuals with intellectual
or mental health disabilities who have difficulty remembering
to take daily medications.
Counseling and informed decision should involve parents, care
givers, supporter or guardian
 In the absence of these care takers, the provider decides on
method choice
Provider dependent methods shall be encouraged to ensure
efficacy.
 FAMILY PLANNING
FOR
SURVIVORS OF SEXUAL VIOLENCE

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 FP for survivors of sexual violence
 Unwanted pregnancy is one of the complications of
sexual violence
 Emergency contraceptive should be provided for all
survivors of rape who are at risk of pregnancy.

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 Clients with FGM
A. Women with FGM can use contraceptive methods safely
B. Use of some barrier methods (female condom, diaphragm,
cervical caps), IUCD may need defibulation of type III FGM.

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 Objectives
 Define emergency contraception (EC)
 Explain the indications for ECs used
 List the types of ECs
 State the proper use and effectiveness of Ecs
 Explain the side effects of ECs and their management

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48
 What is ECs?
 A type of contraception that is used as an emergency to
prevent unintended pregnancy following an unprotected
sexual intercourse.
 Sometimes referred to as the ―morning-after pill‖ or ―post-
coital contraception‖.

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 Types of ECs
 Emergency contraceptive pills (ECPs):
 COC or
 POP
 Copper-releasing IUCDs.

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 Who can use ECs?
 When no contraceptive has been used
 When there is a contraceptive accident/ misuse
 Condom rupture, slippage or misuse
 IUCD expulsion
 Three COC missed consecutively & late for DMPA injection by > 4 weeks
 POP contraceptive pill taken 3 or more hours late
 Failure of a spermicidal to melt before intercourse
 Failed coitus interruptus (withdrawal)
 Diaphragm dislodgement or early removal.
 Miscalculation of the safe period when using a fertility awareness based method.
 In case of Rape

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 Not eligible for EC
Client who is already pregnant

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 ECP regimen
1. Progesterone only pills
 Pills containing 0.75mg levonorgestrel such as
postinor-2, Optinor.
 1 pill as soon as possible after unprotected intercourse
followed by a same dose taken 12 hours later.
 Pill containing 1.5mg levonorgestrel:
 1 pill only as soon as possible after unprotected intercourse
 Pills containing 0.03mg levonorgestrel (microlute,
norgeston, ovrette)
 20 pills for the 1st & 2nd dose

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 ECP regimen …
2. Combined OCP/ Yuzpe's method
 High dose pills containing 50 µg of ethinyl
oestradiol & 0.25mg levonorgestrel (neogenon,
ovran, eugynon)
 1st dose: 2 pills as soon as possible after unprotected
with in 5 days
 2nd dose: 2 pills 12 hours later
 Low dose pills containing 30 µg ethinyl oestradiol
& 0.15 mg of levonorgestrel (microgynon, nordate,
lo/femenal)
 4 pills for the 1st & 2nd dose
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 How does EC work?
 Delay or inhibit ovulation
 Is the principal mechanism
 Prevent implantation
 Prevent transport of the sperm & ovum
* Emergency contraceptives are not effective once
implantation has occurred.
*ECPs do not interrupt or abort an established
pregnancy

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 Characteristics
Documented safety.
Reduces the need for abortions.
Reduces the risk of unwanted pregnancy.
Can be used by young adults, who may be less likely to prepare for a first
sexual encounter.
Provides a bridge to the practice of regular contraception..
Does not protect against transmission of STIs and AIDS.
Does not provide ongoing protection against pregnancy (ECPs).
May be used within 5 days of unprotected intercourse.
May change the time of the woman‘s next menstrual period or produce
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spotting.
 Safety and effectiveness
 Safety
 ECP are considered very safe
 In > 20 yrs no death or serious complication reported
 ECP is not associated with fetal malformation/ congenital defect
 ECP do not increase the possibility of ectopic pregnancy
 Effectiveness
 ECP reduce probability of becoming pregnant
 By 75% in case of COC &
 By 85% in case of POP

 Overall, ECPs are less effective than regular contraceptive methods.

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58
Side effects
 Nausea
 Most common
 More in COC user than POP users
 In about 43% of clients using combined ECPs and in 23% of women using
progestogen-only ECPs
 Usually does not last > 24 hrs
 Vomiting
 In 16% of women using COC & 6% of women using pops as ECP
 Management- if vomiting occurs with in 2 hours, the dose
should be repeated
NB. If the menstrual period is delayed for >1 week from the
expected date, consider the possibility of pregnancy
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Instructions to the client
 Explain the correct use of the method
 Advise that emergency contraception does not protect against STIs
including HIV.
 Counsel on regular contraception then after.
 Advise the client to drink milk or eat a snack with the pills to reduce
nausea.
 Advise her to use a barrier method until her next menstruation if she
has sexual intercourse.
 Explain that after the use of ECPs most women will have the next
menstrual period early or on time.
 If the menstrual period is delayed for more than 1 week the possibility
of pregnancy should be considered.

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Copper-Releasing IUDs
 A copper-releasing IUD can be used within 7 days of
unprotected intercourse as an EC.
 Failure rate: <1% of women become pregnant.
 Indications: in addition to those for ECPs
 The client is considering using an IUCD for continuous, long-term
contraception.

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62
 DEBRE BERHAN UNIVERSITY

DEPARMENT OF MIDEWIFERY

LONG ACTING FAMILY PLANNING

By: Mulualem S.(MSc)

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 Objectives
By the end of this module, you will be able to:
Describe long-acting FP methods (IUCDs and
implants).
Describe the characteristics of each of the long-acting
FP methods
Apply MECs for initiating use of long-acting FP
methods
Perform insertion and removal of the implants and
IUCD
Identify and manage S/e and/or complications of the
64 use of long-acting FP methods
 IMPLANTS

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 Overview of Implants
Hormonal implants are:-
 Thin, flexible, matchstick-sized rods made of soft plastic.
 The rods contain the hormone progestin (similar to the natural
hormone progesterone in a woman‘s body)
 Placed just under the skin of the upper arm. by a trained
provider.
 An excellent option for women at all phases of their
reproductive lives, to delay, space, or limit births.
 Provided easily in an outpatient setting.

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 Implants…
Type of implants:-
1. Norplant® (a six-capsule system no longer in production that was
labeled as effective for 7 years).
2. Jadelle®® (a two-rod system labeled as effective for five years),
3. ―Trust Implant(II)®‖ (Sino-Implant (II)®, a two-rod system labeled
as effective for four years)
4. Implanon Classic and Implanon NXT ® (one-rod systems labeled
as effective for three years)

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 Characteristics of implants
 Safe and highly effective family planning methods
 A good alternative option for women who can't use estrogen-
based contraceptives
 Provides continuous pregnancy prevention for 3- 5 years and
can be removed anytime
 Fertility rapidly reversible after removal
 Private and discreet family planning method
 Stable hormone levels released in to blood
 Safe for Breast feeding mother

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 Characteristics of implants…
 Safe and Convenient
 May cause irregular bleeding
 Does not protect from STIs
 High initial cost
 Require minor surgical procedure for removal
 Do not increase frequency of ectopic pregnancy

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 Characteristics of implants…
 Non-contraceptive health benefits include:-
Help prevent ectopic pregnancy,
Help protect against pelvic inflammatory disease

Help prevent iron deficiency anaemia

May prevent endometrial cancer

May reduce sickle crises in women with sickle cell anaemia.

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 Effectiveness:
 Hormonal implants are one of the most effective and long-
lasting methods, resulting in less than 1 pregnancy per 100
women using implants over the first year (5 per 10,000
women).
 NOTE: Implants start to lose effectiveness sooner for
heavier women. Among women who used Jadelle® implants and
who weighed 80 kg or more, the pregnancy rate was 6 per 100 in
the fifth year of use.These women should have their implants
replaced after 4 years.

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 Mechanism of action
 The primary mechanisms are:
 Increased viscosity of the cervical mucus making it harder for
sperm to swim through (effect starts within 48-72 hours after
insertion of implants)
 Inhibition of ovulation in about 50% of menstrual cycles
 The secondary mechanism that may add to the primary
contraceptive effects include:
 Suppression of endometrial growth so that it is less receptive to
implantation

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 Convenience:
 Implants can be quickly inserted (in less than 5 min.) and
removed (<10 min)
 They can be inserted at any time during a woman‘s menstrual
cycle as long as it is reasonably certain that she is not pregnant.
 No routine follow-up or other action by the client is needed
 Implants can be removed any time

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 Who Can Use Implants?
Nearly all women can use implants, including women who:
 Are any age
 Those who have or have not had children,
 Those who are married or unmarried.
 Is considering sterilization but not ready to make a final
decision
 Implants are suitable both for women who wish to space births
and for those who wish to limit births.
 Implants can be inserted in women who have just had an
abortion or a miscarriage, and
 Is postpartum, breastfeeding and not breastfeeding
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 Who Can Use Implants?...
 Those who smoke cigarette
 Are infected with HIV, whether or not on antiretroviral
therapy
 Prefers a long-acting method
 Those who Can‘t remember to take a pill every day

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 Side Effects:
 Changes in bleeding patterns are relatively common and
may vary throughout the duration of use, although many
bleeding disturbances diminish with continued use.
 Typical changes include lighter bleeding, fewer days of
bleeding, irregular bleeding that lasts more than eight days,
infrequent bleeding, and no monthly bleeding.
 About 1 out of 3 contraceptive implant users has no
periods after one year.
 Other side effects may include headaches, dizziness, breast
tenderness, mood change and weight change.

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 Drug interaction effect on implants’ effectiveness
A. Anti-Infective Agents and Anticonvulsants:
 Implants are not recommended for women who require
chronic use of drugs that are potent inducers of hepatic
enzymes because implants are likely to be less effective for
these women.
 Contraceptive effectiveness may be reduced when hormonal
contraceptives are co administered with some antibiotics, anti-
fungals, anticonvulsants, and other drugs that increase the
metabolism of contraceptive steroids.

77
 B. Anti-HIV Protease Inhibitors:
 Women with HIV who are on ARV therapy can safely use
implants. While there may be some decrease in blood level of
contraceptive hormones, it is not considered significant
enough to affect contraceptive efficacy of the implants.
 Counsel these women to use condoms along with
implants.

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 MECs to use implants
CATEGORY -1: No restriction for use:
 Any age and parity
 Blood pressure (systolic 140-159 and diastolic 90-99)
 Ectopic pregnancy history
 Pre-eclampsia (history)
 Smoking (any age or amount)
 Surgery (without prolonged bed rest)
 Superficial venous thrombosis
 Valvular heart disease (symptomatic or asymptomatic)
 Depressive disorders.
 Non-migraines head ache.
 Acute or chronic hepatitis
 Mild (compensated) cirrhosis
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 MECs to use implants
CATEGORY -2: Benefits of the method outweigh the theoretical or
proven risks of the method
 Less than six weeks post-partum
 Systolic > 160 or diastolic > 100 mm Hg
 Diabetes with or without vascular complications
 Taking drugs for epilepsy or tuberculosis
 ARV therapy including NNRTIs and ritonavir-boosted protease
inhibitors
 Cervical intra epithelial neoplasia
 Gall bladder diseases
 History of deep venous thrombosis or pulmonary embolism (PE)
80  Current and history of ischemic heart disease or stroke
 MECs to use implants…
CATEGORY -3: A condition where the theoretical or proven risks
usually outweigh the advantages of using the method.
 Current or history Ischemic heart disease (continuation)
 Stroke
 Unexplained vaginal bleeding
 Migraine with aura
 Acute deep venous thrombosis (DVT) /Pulmonary embolism
 Severe cirrhosis
 Hepato-cellular adenoma
 Women with a history of breast cancer

81
 MECs to use implants…
CATEGORY -4: Because the combination of this method with
certain condition poses a health risk
 Current breast cancer
 Sever liver diseases

82
 Implants for women with HIV/AIDS:
 Women with HIV/AIDS who do not take antiretroviral
drugs (ARVs) can use implants without restrictions.
 Women with AIDS on ARV therapy generally can use
progestin-only implants but follow up may be required.
 Women with HIV who choose to use progestin-only implants
should be counseled about dual method use and consider
using condoms in addition to implants.

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 Timing of insertion
Implants may be inserted at any time during the menstrual
cycle when it is reasonably certain that the client is not
pregnant
The best times to insert implants are:
Early in her menstrual cycle (No need of backup method).
Any time after day 7 of the menstrual cycle (A backup method
should be used for the first 7 days).
Postpartum – immediately whether or not breastfeeding ( No
need for a backup method)
Post abortion – immediately or within the first 7 days

84
 Timing of insertion…
If the client is using another method of contraception and the
client wants to switch to implants Jadelle® or Implanon
 Natural Family Planning or Barrier methods – first 7 days of
the menstrual cycle
 COC – during the 7 days after the 21st pill has been taken
 POP – on the day the last pill in the pack is taken
 Injectable Hormone(s) – any time up to the time of the next
scheduled injection
 IUCD – anytime, but need to use a backup method
 Implant – at the same time the old implant rods are being
removed
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 Timing of implant removal
When is the time for implant removal?
 At any time during the menstrual cycle
 At 5 years of use for Jadelle®, 4 years use of Trust Implant
and 3 years of use for Implanon NXT
 Anytime client requests removal, after adequate counseling

86
 JADELLE and Trust Implant
 Jadelle® and Trust Implant are progestin-only hormonal
implants composed of 2 rods that offers an additional family
planning option to the existing menu of methods.
 Jadelle® and Trust Implant are packaged in sealed, sterile plastic
pouches containing 2 rods (150 mg of Lenovonorgestrel (LNG) )
preventing pregnancy for up to 5 years and four years
respectively.
 Highly effective ( less than 0.05 pregnancy /100 women per in
first year of use)
 NB: Both Jadelle® and Trust Implant are now provided with a sterile,
single-use disposable trocars
87
 JADELLE and Trust Implant
Jadelle Trust-implant

88
 Pre-insertion counseling for Jadelle®
Thorough counseling improves user satisfaction and
success with their chosen method.
 How it works,
 Its effectiveness,
 How it is inserted,
 Its characteristics,
 Common side effects (such bleeding changes),
 When to return for care
 Care of the site
 Ask the client to repeat information to ensure that she
understands and
 Answer any questions that the client may have
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  Demonstrate Jadelle Insertion
Using
Learning Guide For Jadelle®® Insertion

90
 Key points for successful insertions
 Select the arm the client uses less for insertion of the rods.
 Use recommended IP practices to avoid infections.
 Make sure that the rods are placed at least 8 cm above the elbow
fold, in the inner aspect of the arm.
 Insert the trocar with plunger in place through the incision at a
shallow angle, superficially and just beneath the skin. Never force
the trocar.
 To ensure sub dermal placement, the trocar should visibly raise
(tent) the skin at all times.
 Make sure the first rod is completely free of the trocar before
inserting the second one.

91
 Key points for successful insertions…
 After insertion, if a rod tip protrudes from or is too close to
the incision, it should be carefully repositioned in the correct
position (i.e., 5 mm from the incision).
 Do not remove the tip of the trocar from the incision until
both rods have been inserted and their position checked.
 The two rods should form an angle of about 15°.
 Draw the location of the rods in the client's record and write
a note if anything unusual happened during the insertion.

92
 Post insertion client instructions
Client Instructions for wound care key points:
1. Keep the insertion area dry and clean for at least 48 hours (2
days).
2. Leave the gauze pressure bandage in place for 48 hours.
3. Leave the smaller bandage/dressing under the gauze pressure
bandage in place until the incision heals (approximately 3-5 days).
4. Routine work can be done immediately but avoid bumping the
area, carry in heavy loads, or putting unusual pressure to the site.
5. After healing, the area can be touched and washed with normal
pressure.
6. If the incision site becomes inflamed (red with increased heat or
tenderness) or there is pus at the site, return to the clinic without
delay.
93
 Jadelle® implant removal procedures

Unlike insertion, removal of Jadelle® rods can be done at any

time in the menstrual cycle.
Correct insertion – with the Jadelle® rods placed sub-
dermally and properly spaced – makes the removal procedure
much easier.
Removal of Jadelle® takes approximately 5- 10 minutes when
the capsules have been placed correctly

94
 Pre-removal Steps:
1. Before removing the implants, discuss with the client her
reasons for removal and answer any questions she may have.
2. Explore with the client what her current reproductive goals
are. Does she want more children, is she spacing her
pregnancy? Does she want to continue with implants ?
3. Locate the rods first with ungloved fingers.
4. Tell the client to wash her entire arm with soap and water,
and rinse it thoroughly.

95
 Key points for successful removals
1. An easy removal depends on correct insertion.
2. Palpate the area to identify the location of each rod and mark
the position of both rods with a pen.
3. Remove the rod that is nearer the point of the incision or closer
to the surface of the skin first.
4. Add incremental amounts of anesthetic only under the rod ends
5. If removal of either rod is difficult (i.e., both rods are not
removed in 30 minutes), it may be better to stop the procedure
or ask the client to return when the incision site is fully healed
(in about 4 to 6 weeks) and try again or refer to a more
experienced health care provider.
6. Finally, and most important, the health care provider should
work gently, carefully and patiently to avoid injuring the client's
arm.
96
 Side effects of Jadelle®
The most common side effect is that of changes in menstrual
bleeding patterns; including:
 First several months:
 Lighter bleeding and fewer days of bleeding or Irregular bleeding
that lasts more than 8 days or Infrequent bleeding or No monthly
bleeding
 After about one year:
 Lighter bleeding and fewer days of bleeding or Irregular bleeding
or Infrequent bleeding
 Other side effects of Jadelle® include:
 Headache, breast tenderness, weight gain, mood changes,
dizziness, abdominal pain (possibly due to the enlarged ovarian
97 follicle) and nausea.
 Complications
 Uncommon:
 Infection at insertion site (most infections occur within the first 2
months after insertion)
 Difficult removal (rare if properly inserted and the provider is
skilled at removal)
 Rare:
 Expulsion of implant (expulsions most often occur within the first
4 months after insertion)

98
 Implanon NXT
 Implanon NXT is a newer, single-rod progestin-only
contraceptive implant preloaded in a disposable applicator for
sub dermal use that offers a long-acting contraception.
 Implanon NXT is radiopaque and contains 15mg of barium
sulfate at the core of the rod which allows for its localization
X-ray and computerized tomography (CT) scan.
 It is a long-acting (for 3 years) single rod contraceptive implant
for sub dermal use containing 68 mg of etonogestrel.
 It is radio-opaque and must be removed after 3 years.

99
Pre-insertion counseling for Implanon NXT®
 Thorough counseling improves user satisfaction and success with their
chosen method. In a private setting, provide more detailed information
about Implanon NXT®
 How it works,
 Its effectiveness,
 How it is inserted,
 Its characteristics,
 Common side effects (such bleeding changes),
 When to return for care
 Care of the site
 Ask the client to repeat information to ensure that she understands and
100  Answer any questions that the client may have
 Post insertion client instructions
Client Instructions for wound care key points:
1. Keep the insertion area dry and clean for at least 48 hours (2 days).
2. Leave the gauze pressure bandage in place for 48 hours.
3. Leave the smaller bandage/dressing under the gauze pressure bandage
in place until the incision heals (approximately 3-5 days).
4. Bruising, swelling, or tenderness at the insertion site may occur for a
few days this is normal.
5. Routine work can be done immediately but avoid bumping the area,
carry in heavy loads, or putting unusual pressure to the site.
6. After healing, the area can be touched and washed with normal
pressure.
7. If the incision site becomes inflamed (red with increased heat or
tenderness) or there is pus at the site, return to the clinic without
delay.
101
  Demonstrate Jadelle Insertion
Using
Learning Guide For IMPLANON NXT® Insertion

102
 Implanon removal summary
1. The precise location of the implant is indicated on the user card.
2. Locate the implant by palpation and mark the distal end.
3. In case Implanon NXT cannot be palpated, it is strongly advised
to locate the implant by either ultrasound or magnetic resonance
imaging (MRI).
4. Apply iodine over the removal area.
5. Anaesthetize the arm with 1 ml of 1% lidocaine at the site of
incision, which is just below the distal end of the implant.
6. Make an incision of 2 mm in length in the longitudinal direction
of the arm at the distal end of the implant.
7. Gently push the implant towards the incision until the tip is
visible. Grasp the implant with a mosquito forceps and remove it.
103
 Implanon removal summary…

8. If the implant is encapsulated, an incision into the tissue sheath

should be made and the implant can then be removed with forceps.
9. If the tip of the implant is not visible, gently insert a forcep into
the incision and grasp the implant. With some second forceps
carefully dissect the tissue around the implant. The implant can then
be removed.
10. Close the incision with a butterfly closure.
11. Apply sterile gauze with a pressure bandage to prevent bruising.
12. There have been occasional reports of displacement of the
implant; usually this involves minor movement relative to the original
position. This may somewhat complicate removal.
104
 Intra-Uterine Contraceptive Devices

(IUCD)

105
 Characteristics of IUCD
 Highly effective, easy to insert and Safe for most women
 Easily reversible
 IUCDs can be safely used by breastfeeding women
 Good choice for women with contraindications for hormonal methods
 Long duration of use; Considered as ―Reversible permanent contraception
 Does not interact with medications
 Can be removed whenever the client chooses
 Does not protect against STIs/HIV
 It is trained-provider dependent.
 Economical or Cost-effective.
 Most IUCD users are very satisfied with their IUCD.
106
 Characteristics of IUCD...
 IUCDs can be a good choice for women who cannot use Combined
Oral Contraceptive (COC) or other hormonal methods.
 IUCDs can remain in for 5 to 12 years, depending on the type. The
latest scientific evidence shows that the Copper T 380A (Cu-T 380A) is
effective for at least 12 years.
 Note: IUCDs do not increase the risk of ectopic pregnancy.
 Good infection prevention practices are necessary during insertion
and removal to safeguard the health of the client.
 Despite the high rate of satisfaction among IUCD users,
misconceptions about the method have persisted.

107
 Type of IUCD
Common types of IUCDs available worldwide are:
 Copper - bearing, which include the Cu-T 380A, Cu-T
380A with safeload, Cu-T 200C, Multiload (MLCu 250 and
375), and the Nova T

 Medicated with a steroid hormone, such as the

levonorgestrel containing Mirena IUS (intrauterine system)

108
 Copper T 380 A (CuT 380 A)
 More than 25 million Cu-T 380 IUCDs have been distributed in
70 countries throughout the world. This model is made of plastic
(polyethylene) with barium sulphate (to detect the IUCD with X-
rays).
 The Cu-T 380A is T- shaped, with 314 mm of copper wire wound
around the vertical stem. Each of the two arms of the T has a
sleeve of copper measuring 33 mm.
 The bottom has a clear knotted string attached to it. The Cu-T
380A is inserted into the cavity of the uterus using the withdrawal
technique.
 It has a life span of twelve years, and the pregnancy rate is less
109
than one per 100 women years.
 Parts of IUCDs (cu T380A)

Arms (Rt./Lt.)

Copper sleeve
(33 mm×2=66 mm )
Stem

Copper wire
(314 mm )
String/Thread

Main frame: T shaped, flexible & containing barium sulfate

110
 Mechanism of Action IUCD
 The copper bearing IUCD‘s principal mechanism of action
(MOA) is to interfere with fertilization
 The IUCD creates a ―spermicidal environment.‖ This environment
becomes inhospitable to sperm cells. The sperms are killed or
damaged, so they cannot swim and reach the egg.
 The IUCDs which contain progesterone also cause the thickening
of cervical mucus, which stops the sperm from entering the
uterus.
 The IUCD‘s is not abortifacient.

111
 Effectiveness….
 The IUCD is one of the most effective contraceptive methods
with effectiveness comparable to sterilization.
 Only 0.6 to 0.8 pregnancies per 100 women will occur over the
first year of IUCD use.
Continuation rates and client satisfaction
 Continuation rates are also high in IUCD users - higher than those
of most other reversible methods.
 Note: Continuation rates are not effectiveness rates, but do
represent user satisfaction with the method

112
 Effectiveness….
In this progression of effectiveness, where would you place
IUDs?

Implants
More Female Sterilization
effective
DMPA
COCs

Male Condoms
Standard Days Method
Female Condoms
Less
effective
Spermicides
113
 Crucial factors for safe IUCD use are:
 Careful screening and assessment
 Provider is competent in IUCD insertion and infection
prevention practices
 Careful and complete client counseling

114
 Who can use IUCD ?
 Has a healthy reproductive tract
 Wants to delay first pregnancy or space her children
 Appropriate for women that have completed childbearing and do
not want Voluntary Surgical Contraception
 Wants an effective method, but precaution(s) exists for hormonal
methods such as COCs
 Is breastfeeding (IUCDs do not affect lactation)
 Is immediately postpartum (from delivery of placenta to 48 hrs)
 Is immediately post abortion
 Has successfully used an IUCD in past (Users with positive past
experience tend to tolerate IUCDs well.)
115
 Medical Eligibility Criteria
 Certain conditions make the use of an IUCD unsuitable. For
women :
With pregnancy (known or suspected)

With unexplained vaginal bleeding

Who is post partum between 48hrs-4wks

With current pelvic infection (puerperal, post abortion, TB & STI)

With GTD or cervical/endometrial cancer

With uterine cavity distortion (myoma or congenital)

With AIDS cases (clinically not well)

116
 Client assessment For IUCD
 Once a client has made the decision to use an IUCD after
counseling on all methods, she needs to have IUCD method
specific counseling.
 Although IUCD is appropriate for most women, it may not be
appropriate for a few women.
 Careful screening is crucial for successful IUCD use.
 Before you can assure her that she can use IUCD, she needs to
have a limited history and physical exam in order to achieve the
following objectives:
 To screen for conditions which may preclude safe IUCD use
(medical eligibility).
 To identify other health or special problems.
117
 Client assessment For IUCD…
 Finally, you should perform a complete pelvic exam in order to:
 Determine position and size of uterus
 Rule out likelihood of pregnancy.
 Rule out presence of visible and/or palpable abnormalities,
including infections, masses, tumors, etc.
 If any of these are present, an IUCD should not be inserted
until the problem is investigated and resolved.
 Use pelvic bimanual and speculum exam
 Always use “Checklist for Screening Clients Who Want to
Initiate Use of the Cu- IUCD”

118
119
 Timing for IUCD insertion
1. There is no need to have menstrual bleeding in order
to have the IUCD inserted.
The IUCD can be inserted:
 At any time within the first 12 days after the start of
menstrual bleeding. No additional contraceptive protection is
needed.
 At any other time during the menstrual cycle, if it is reasonably
certain that she is not pregnant.
 Many health care providers prefer to insert during or very soon
after the menstrual period since there is little likelihood of
pregnancy at that time.
120
 Timing for IUCD insertion…
2. Switching from another method
 She can have the IUCD inserted immediately, if it is reasonably
certain that she is not pregnant. There is no need to wait for her
next menstrual period. No additional contraceptive protection
is needed.
3. Postpartum
 A woman can have an IUCD inserted immediately postpartum
(within 10 minutes) following delivery of the placenta, or
during or immediately after a cesarean section.
 It can also be inserted within the first 48 hours postpartum.
 Note: IUCD insertion immediately or within 48 hours
postpartum requires special training.
121
 Timing for IUCD insertion…
3. Immediately Post-abortion
 The IUCD may be inserted immediately post-abortion
(spontaneous or induced)-if the uterus is not infected-
during the first twelve days‘ post abortion, or anytime you can
be reasonably sure that the client is not pregnant.
 When there are signs of unsafe or unclean induced abortion,
signs of infection, or inability to rule out infection, do not insert
an IUCD.
 When there is hemorrhage: wait until hemorrhage is under
control
 Immediate post-abortion IUCD insertion after 16 weeks’
122 gestation requires special training of the provider.
 Timing for IUCD insertion…
5. For emergency contraception
 Within 7 days after unprotected sex.

123
 Timing for IUCD Removal
1. IUCD may be removed at any time during the menstrual
cycle.
2. Any time the client requests for any stated reason or for no
reason at all.
3. Evidence of uterine perforation.
4. Known or suspected pregnancy.
5. Partial expulsion - the old IUCD may be removed and
replaced with a new one.
6. Persistent side effects which client is not able to tolerate,
or other health problems such as severe bleeding with
evidence of worsening anemia.
7. When IUCD has been in utero for its effective life - a new
IUCD may be inserted immediately
124
BASIC PRINCIPLES FOR IUCD INSERTION
AND REMOVAL
Throughout insertion and removal, certain basic principles are to be
emphasized:
 Be gentle during the procedures to minimize discomfort and
emotional trauma to the client.
 Always use the no-touch technique throughout the insertion
procedure
A. The tip of the uterine sound that will be inserted through the cervix
should not touch anything that may contaminate it: hands, speculum,
vaginal wall, table top, etc.
B. The Cu T should be loaded using the no-touch technique, without
taking it out of the sterile package.
C. The loaded IUCD should not touch the vagina or any other part of
the body as it is inserted.
 The cervix and vagina should be thoroughly prepared with antiseptic.
125
126
 BASIC PRINCIPLES…
 Pelvic exam should be always done before inserting the
speculum for the IUCD insertion procedure to determine the
position of the uterus (in addition to screening for the signs for
infection).
 The uterine cavity should always be sounded to determine the
depth of the cavity.
 Set the depth gauge on the IUCD to the level measured by the
uterine sound.
 Insert the IUCD all the way to the fundus of the uterus by
withdrawal technique, as there is less risk of expulsion.

127
 BASIC PRINCIPLES…
Purpose of Sounding the Uterus
 To check for obstructions in the cervical canal.
 To measure the length from external cervical of to the uterine
fundus so that the blue depth gauge on the insertion tube (Cu-T
380A IUCD) can be set at the same distance.
Procedure for Sounding the Uterus
 Use no-touch (aseptic) technique throughout:
 Note: Before attempting to sound the uterus, a bimanual
examination should have been performed to rule out the possibility
of vaginal and cervical infection and to determine the size and
position of the uterus.

128
 IUD Insertion Procedure:
Step 1: Perform Pelvic Exam
Conduct pelvic exam (speculum exam , then bimanual exam)
Screen for medical eligibility:
 If no signs and symptoms of infection—proceed with
insertion
 If suspicious of infection—do not insert IUD—
diagnose/treat as appropriate, then reassess for insertion
Assess position of uterus (tilted up or down) to determine
appropriate orientation of sound

129
 Step 2: Sound the Uterus
 Clean the cervix with an antiseptic solution.
 Apply a tenaculum to the cervix.
 Gently pull the tenaculum to align the uterus, cervical
opening, and vaginal canal.
 Insert the uterine sound into the vagina and through the
cervical opening.
 Advance the sound into the uterine cavity until a slight
resistance is felt.
 Slowly withdraw the sound and assess the level of
mucus/blood to determine the depth of the uterus (average
depth is 6 to 9 cm).
130
 Step 3: Load the Copper T
Load the IUD by folding its
arms and placing them inside
the insertion tube.
Do not load more than five
minutes before inserting the
IUD into the uterus.
 If IUD arms remain folded
for more than five minutes,
they may not return to their
original shape when released.
131
 Step 4: Set Depth-Gauge
Set the blue depth-gauge to the uterine depth as
measured by the sound:
• Ensure that the distance between tip of IUD and the
inside edge of depth-gauge is equal to depth of the
uterus.

132
 Step 5: Insert IUD into Vagina
 Gently grasp the tenaculum (still in
place from sounding the uterus) and
apply gentle traction
 Insert the loaded IUCD, without
touching vaginal walls or speculum
blades

133
 Step 6: Advance IUD into Uterus

 Gently advance the loaded IUD into the uterine cavity.

 STOP when the blue depth-gauge comes in contact with the
cervix or light resistance is felt.

134
 Step 7: Release Arms of Copper T

 Hold the tenaculum and

white plunger rod
stationary, while partially
withdrawing the insertion
tube.
 This releases the arms of
the Copper T.

135
 Step 8: Gently Push Insertion Tube
 Gently push the insertion
tube until you feel a
slight resistance.
 This step ensures
placement high in the
uterus

136
 Step 9: Remove Plunger Rod

 Remove the white

plunger rod, while
holding the insertion
tube stationary.

137
 Step 10: Partially Withdraw Inserter

 Gently and slowly withdraw

the inserter tube from the
cervical canal until strings
can be seen protruding from
the cervical opening.

138
 Step 11: Cut IUD Strings

 Use sharp Mayo scissors to cut

the IUD strings at 3–4 cm from
the cervical opening
 If scissors are dull, IUD strings
may get caught in blades.
 Completely withdraw insertion
tube with cut ends of strings
inside

139
 Step 12: Remove Tenaculum
Gently remove the tenaculum
Observe the woman‘s cervix
for bleeding
If there is bleeding, hold swab
to site using clean forceps

140
 Step 13: Remove Speculum and
Decontaminate Instruments
 Gently remove the
speculum
 Place tenaculum and
speculum in a 0.5%
chlorine solution for 10
minutes for
decontamination.

141
 Step 14: Allow Woman to Rest

Allow the woman to rest

Begin post-insertion tasks
Provide post-insertion
instructions

142
 POST-INSERTION
Immediate Post-insertion care and client instruction
 Long-term success, as defined by satisfied clients and high
continuation rates
 Most clients will not experience problems following IUCD
insertion. When they do occur, however, immediate problems
may include:
 Syncope (fainting), rarely
 Nausea
 Mild to moderate lower abdominal pain (cramping)

143
 POST-INSERTION…
 Telling a client about common IUCD side effects, as well as what
to do if certain problems occur, promotes continued use. In
particular, she should know:
1. What kind of IUCD she has and when it needs to be
replaced: Following insertion, the effective life of the Cu-T
380A IUCD is 12 years. The provider should give her a card
with the date of insertion and the IUCD‘s effective life.
2. The IUCD provides no protection against HIV or other
STIs:
3. When to come back for a checkup: A follow-up visit after
her first monthly bleeding or 3 to 6 weeks after IUD insertion is
recommended.
4. Health risks with IUCDs:

144
 POST-INSERTION…
 IUCDs, although extremely effective, may fail, even if they are
correctly in place. If a woman who has an IUCD thinks she
is pregnant, she should go to the clinic as soon as
possible for a checkup.
 If she is pregnant:
 Explain the risks of pregnancy with an IUCD in place. Early
removal of the IUD reduces these risks, although the removal
procedure itself involves a small risk of miscarriage.
 Explain that she should return at once if she develops any signs of
miscarriage or septic miscarriage (vaginal bleeding, cramping,
pain, abnormal vaginal discharge, or fever).
 If she chooses to keep the IUCD, her pregnancy should be
followed closely.
145
 POST-INSERTION…
5. How can she tell if she has one of these health
problems? A woman with an IUCD should come to the clinic as
soon as possible if any of the following occur:
 Late period with pregnancy symptoms (nausea, breast
tenderness, etc.);
 Persistent or crampy lower abdominal pain, especially if
accompanied by nausea, fever, or chills (these symptoms suggest
possible pelvic infection);
 Strings missing or the plastic tip of the IUCD can be felt when
checking for the strings.
6. How soon after insertion is the IUCD effective? It is
146 effective immediately, and
 POST-INSERTION…
7. Should the client check to see if the IUCD has
remained in place?
 In the past, providers were expected to counsel women
about checking the IUCD strings to make sure the IUCD
remained in place.
 The thinking on this issue has shifted and now providers do
not require women to do that. But, it is important to remind
women that if they suspect that their IUCD has come out
return to the clinic immediately.
 Advise the woman to check her menstrual pad or cloth, as
well as the toilet or latrine during menstruation during her
first several periods following IUCD insertion and look for
an IUCD that may have fallen out.
147
 POST-INSERTION…
She should return to the provider if she feels any of the
following, which suggest that the IUCD is being expelled:
 Cramping in the lower part of the abdomen,
 Persistent spotting between periods or after intercourse,
 Pain after intercourse or if her husband or partner
experiences discomfort during sex, or
 If the hard part of the IUCD is felt in the vagina or if she
notices the the string becomes longer, shorter, or
disappeared.

148
 POST-INSERTION…
8. What to do if there are changes in her menstrual
periods:
 For most women, the first few periods will be heavier, last
longer, and involve more cramping. This is not harmful.
 However, if the bleeding lasts twice as long as usual or if she
uses twice as many pads, cloths, or tampons, she should see a
health care provider.

149
 POST-INSERTION…
9. When to have the IUCD removed: The IUCD should be
removed
 If the client desires,
 If the client wants to get pregnant,
 If she experiences persistent side effects or other health problems
which she is not willing to tolerate
 At the end of the effective life of the IUCD. The Cu-T 380A
should be removed after 12 years.
10. Follow-up care
 A follow-up visit after her first monthly bleeding or 3 to 6 weeks
after IUCD insertion is recommended.
150
 Follow-up care
At the first regular check-up: Post-Insertion Follow-Up Visit
(3 to 6 Weeks)
 Ask how the client is doing with the method and whether she is
satisfied.
 Inquire about problems, questions, side effects or complications;
 Answer the client‘s questions or concerns; and
 Perform a speculum and bimanual exam to See the strings,
 Check for vaginal/cervical discharge or cervicitis suggestive of a
STI, and
 Check for uterine and adnexal tenderness or other signs of
infection.
151
 Advise client to return immediately if:
She thinks she is pregnant
She has persistent severe abdominal pain, fever or unusual
vaginal discharge
She or her partner feels pain/discomfort during
intercourse
She has sudden change in her menstrual periods
She has irregular bleeding or pain every cycle
She wishes to have the device removed
She cannot feel the IUCD‘s threads/ strings

152
152
 Side effects and complications of IUCD
Most side effects and other health problems associated with the use
of IUCDs (CU-T 380A) are not serious and can handle by the
provider or some may need referral to a specialist.
Side effects may include:
 Cramping.
 Changes in menstrual bleeding patterns are the most common
side effects.

153
 Side effects and complications….
Complications may include:
 Syncope/bradycardia, vasovagal episode during insertion
(fainting, becoming dizzy, or lowered heart rate during
insertion).
 Possible anemia.
 Missing strings.
 Expulsion of IUCD
 Pelvic inflammatory disease.
 Suspected uterine perforation.
 Suspected pregnancy, including ectopic pregnancy

154
 Permanent Methods of FP

155 By: Mulualem S.(MSc)

 Objective
By the end of this module, you will be able to:
Explain Permanent family planning methods
Identify the characteristics of Permanent family planning
methods (female & male sterilization)
 Describe the Effectiveness Permanent family planning
methods

156
 Introduction
 Permanent FP methods, also called voluntary surgical
contraception, Sterilization (Bilateral Tubal Ligation and
Vasectomy)
 currently most widely used contraception method in the
world.
 It account for nearly half of all contraceptive use worldwide
 The most effective, popular and well-established
contraceptive method
 The preferred options available for men and women who
desire no more children.
 The need for continued contraceptive supplies is eliminated
157
 Female Sterilization

158
Mechanism of Action

By blocking the fallopian tubes (tying and

cutting, rings, clips or electro cautery), sperm
is prevented from reaching ova and causing
fertilization.

159
Characteristics
Highly effective
 0.5 pregnancies per 100 women during first year of use
Safe
Permanent: Ideal for those desiring no more children
Does not interfere with intercourse
No need for partner compliance
Quick recovery
Simple surgery usually performed under local anesthesia and as
an out patient
No long-term side effects
 No change in sexual function
Cost-effective
160
Characteristics …
Takes effect immediately
Requires trained service providers
Short-term discomfort and pain following procedure
Potential risk of complications, especially if general anesthesia
is used
Must be considered permanent (success of reversal cannot be
guaranteed)
Client may regret later (age < 35)
Expense at time of procedure
Does not protect against STIs (e.g. HBV, HIV)
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Effectiveness
Spermicides
Female condom
Diaphragm w/spermicides
Male condom
Oral contraceptives
DMPA
IUD (TCu-380A) Rate during perfect use
Female sterilization
Rate during typical use
Implants
0 5 10 15 20 25 30
Percentage of women pregnant in first year of use

Source: CCP and WHO, 2007.

 Who can use BTL
Who want highly effective, permanent protection
against pregnancy
Who are certain that they have achieved their desired
family size
Who understand and consent to procedure

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Conditions warranting delay of surgery
 -Pregnancy and postpartum (7-28 days)
 - Severe preeclampsia or eclampsia
 - Prolonged rupture of membranes
 - Severe antepartum or postpartum hemorrhage
 - Severe trauma to the genital tract
 - Deep venous thrombosis or pulmonary embolism
 - Major surgery with prolonged immobilization
 - Post abortion sepsis or puerperal sepsis

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 Conditions warranting delay of surgery …
 - Unexplained vaginal bleeding
 - Malignant gestational trophoblastic disease
 - Cervical, endometrial or ovarian cancer
 - PID
 - Abdominal skin infection or other infection
 - Acute bronchitis or pneumonia
 - As an emergency (without previous counseling)

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 Complications
Procedural complications
 Bleeding or hemorrhage
 Infection
 Anesthesia-related complications
 Trauma – tears or perforations to abdominal organs
Ectopic pregnancy
 But the risk is lower than for non-sterilized women
Failure

 Risk of failure (pregnancy) ~ 2% at 10 years;)

 Risk varies by method and age and is higher in younger

166 women
 Procedure
Mini-laparotomy
 3-5cm incision is made in the abdomen
 Laparoscopy
 A laparoscope is inserted into the abdomen
through a 1-cm incision
 Laparotomy / Cesarean section

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 Mini-laparotomy procedure incision sites
(a) Supra-pubic—appropriate for (b) Sub-umbilical—appropriate for
interval & post-abortion procedures postpartum procedures

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Bilateral tubal ligation …
 Non scalpel vasectomy

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 NSV Characteristics
 Highly effective (comparable to FS, implants and IUDs)
 Not effective immediately —backup contraception for 3 months after the
procedure
 Failure (pregnancy rate) is 0.2% to 0.4%

 Doesn‘t protect from HIV/AIDS

 Very safe; few restrictions

 Regret :
 Some times in young age, marital instability and decision made under
pressure
 To minimize regret careful counseling is critical.

 Complication is rare, occurs in <1% of NSV

 Pain, infection and bleeding

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 Conditions requiring delay for NSV
 Local infection
 Active systemic infection
 Inflamed tip of the penis, testicles and sperm ducts
 Active scrotal infection

172
NSV procedure
 Small puncture; vas deferens pulled through
skin
 Procedure takes 15 minute or less

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 Counseling for permanent methods
It should address about :
Post procedure sexual function or pain
Correct myths e.g NSV is not castration, it does not
make weak
It is permanent: difficult to reverse
Does not protect STI/HIV
NSV is not effective immediately
Informed consent

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Summary:
 FS is
 Widely used form of contraception in the world
 No medical condition absolutely restricts a person's eligibility for FS

 NSV is
 A very safe, convenient, highly effective, and simple surgery
 Highly effective (comparable to vasectomy, implants, IUDs) and safe means
of contraception

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 Thank you
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