Sexual Development/ Human Sexuality/ Contraception

Prepared by:Teresa Fisher, PBT, RN, BSNRevised & Presented by: Judy Carlyle,

MSN, RN

Family Planning Goal: to assist clients with reproductive

decision making, enabling the client to have control in preventing pregnancy, limiting the number of children, spacing the time between children, and voluntarily interrupting pregnancy as desired.

So Many options; which one to choose?????

Safe Easily available Economical Available Simple to use Promptly reversible

Nurses Role in Contraception

Foster safe environment for consultation

Provide correct education Distinguish myth from fact Clarify misinformation Fill in gaps of knowledge Provide visual samples Gain a complete history

History should include

Menstrual history Contraceptive history Contraceptive goal Obstetric history Medical history Familial history

Methods of Contraception

Natural Methods 1) Abstinence 2) Coitus interruptus Fertility awareness methods 1) Calendar method 2) Basal body temperature method 3) Cervical mucus method 4) Symptothermal method

Methods of Contraception

Spermicides & barrier methods

* condoms * diaphragm * cervical cap * cervical sponge Hormonal methods Emergency

contraception Intrauterine devices Sterilization

Abstinence

The practice of avoiding sexual intercourse

Advantages

Safe Free Available to all 100% effective in preventing

pregnancy & STIs Can be initiated at any time Encourages communication between

partners

Disadvantages

Both participants must practice self-control

Nursing Education

Teach alternative methods of obtaining sexual pleasure

Provide positive feedback to clients who desire and maintain abstinence

Coitus Interruptus

AKA withdrawal Male partner

withdraws penis prior to ejaculation

Effectiveness depends on man’s ability to withdraw prior to ejaculation

Advantages

Can be practiced at any time during the menstrual cycle

Free

Disadvantages One of the least reliable contraceptive

methods Only 80% effective Does not protect from STIs Some pre-ejaculatory fluid, which may

contain sperm, may escape from the penis during the excitement phase prior to ejaculation

At the peak of sexual excitement, exercising self-control may be difficult

Nursing Education

Before engaging in sexual intercourse, the male should urinate and wipe off the tip of the penis to decrease the potential of introducing sperm into the vagina

Conception may occur if pre-ejaculatory fluid containing sperm enters the vagina

A spermicide or post-coital contraceptive may be needed if the female partner is exposed to sperm

Fertility Awareness Methods

Calendar based methods

Symptoms based method

Biologic marker methods

Advantages

Free Safe Acceptable to couples whose religious

beliefs prohibit other methods, such as Roman Catholics

Increases awareness of the woman’s body

Encourages couple communication Can be used to prevent or plan a

pregnancy

Disadvantages

Requires extensive initial counseling and education

May interfere with sexual spontaneity May be difficult or impossible for

women with irregular menstrual cycles Used alone, they offer no protection

against sexually transmitted infection Less effective in actual use

Calendar Rhythm Method

Based on assumption that ovulation occurs 14 days prior to the next menses, sperm are viable for 5 days, and the ovum is capable of being fertilized for 24 hours

91% effective if used perfectly

Calendar rhythm method

Based on number of days in each cycle, counting from first day of menses

Beginning of fertile period is estimated by subtracting 18 days from length of shortest cycle in last 6 months

End of fertile period is determined by subtracting 11 days from length of longest cycle

Example of Calendar Rhythm Method

Shortest cycle 24 days 24-18 = 6th day

Longest cycle 30 days 30 -11 = 19th day

• To avoid conception the couple would abstain during the fertile period days 6-19

Lets Try One

You are educating a client on the contraceptive calendar rhythm method. When you ask her how long her cycles have been for the last 6 months, she explains that her cycle is consistently 28 days. What days should you tell her to abstain from sexual intercourse???

Let’s Work This Together

Shortest cycle 28 days 28 -18 = 10th day

Longest cycle 28 days 28 – 11 = 17th day

To avoid pregnancy the couple abstains from day 10-17.

Disadvantage To Calendar Rhythm Method

Attempting to predict future events with past data

Standard Days Method A modified form of calendar rhythm

method Has fixed number of days of fertility for

each cycle Day 8 – 19 Cycle Beads (bracelet) Is useful for women who have 26-32 day

cycle Unreliable for others 12% failure rate

Cervical Mucus Method Based on monitoring and recording of

cervical secretions

Cervical mucus changes occur in response to levels of estrogen and progesterone

Spinnbarkeit – Watery thin, clear mucus becomes more abundant and thick. Feels similar to a lubricant and can be stretched 5+ cm between the thumb and forefinger

Spinnbarkeit

Presence indicates period of maximal fertility

Sperm deposited in this type of mucus can survive until ovulation occurs

Cervical Mucus in Relation to Conception

Cervical mucus that accompanies ovulation is necessary for viability & motility of sperm

Mucus alters pH by neutralizing acid

Barriers to Assessing Mucus Contraceptive gels or foams Vaginal infection Douches Vaginal deodorant Medications (antihistamines dry up

mucus) Sexually aroused state thins mucus Uncomfortable touching genitals

Education

Assess cervical mucus daily Avoid intercourse when first notices

cervical mucus becoming more clear, elastic, and slippery and then for 4 days

Instruct women on barriers to cervical mucus assessment

Basal Body Temperature Method

BBT is lowest body temperature of a healthy person taken immediately after waking and before getting out of bed

BBT varies from 36.2-36.3 during menses and 5 - 7 days after

At time of ovulation there is a slight decrease in temperature (fertile period)

After ovulation the BBT increases slightly and remains until 2-4 days prior to menstruation

Basal Body Temperature Method

Fertile period is day of first temp drop or first elevation through 3 days of elevated temp

Abstinence begins the first day of menstrual bleeding and lasts through 3 consecutive days of sustained temp rise

Basal Body Temperature Method

Temps are recorded on graph97% effective if performed correctly

Alterations in BBT Accuracy

Infection Fatigue Less than 3 hours sleep per night Awakening late Anxiety New thermometer Jet lag Alcohol Antipyretic medications Heated waterbed Electric blanket

Combination contraception

Calendar rhythm method Two day method BBT

Urine Ovulation Predictor Test

Detects the sudden surge of luteinizing hormone (LH) that occurs 12-24 hours before ovulation

Test is not affected by illness, emotional upset, or physical activity

Mechanical Methods of Contraception

Spermicide Male condom Female condom Diaphragm Cervical cap Contraceptive sponge Intrauterine device (IUD)

Spermicides

Serve as chemical barriers against the sperm

Nonoxynol-9 (N-9) work by reducing the sperm’s mobility

Attacks sperm flagella and body so they cannot reach the cervical os

Use of N-9 too often could increase transmission of HIV by disrupting vaginal mucosa

Intravaginal spermicides Foams Tablets Suppositories Creams Films Gels Preloaded single-dose applicators Inserted high in vagina to reach cervix Inserted 15 min – 1 hr before sexual

intercourse When used alone 94% effective

Advantages

No prescription required May be used alone or with a diaphragm

or condom May add additional lubrication and

moisture Penis can remain in vagina following

ejaculation Safe for breast-feeding women Several choices

Disadvantages

The spermicide may be irritating to one or both clients

Some forms may be perceived as messy

May interfere with spontaneity

Nursing Education

Apply spermicide inside vagina & close to the cervix prior to inserting penis

Spermicides must be applied with each act of sexual intercourse

Onset of spermicidal action varies When used alone effectiveness lasts no longer

than 1 hour Foams, creams, & gels are effective

immediately Vaginal contraceptive film & suppositories

become effective 15 minutes after insertion into vagina

Male Condoms Are made of latex, polyurethane, or

animal tissue Polyurethane is thinner and stronger

than latex Protects against pregnancy and some

STIs Latex condoms will break down with

oil-based lubricants Only water-based or silicone lubricants

should be used

Advantages Males are able to participate in

contraception Sexual intercourse may be prolonged Condoms are available in a variety of

sizes & styles at low cost or free Partners can participate in placing the

condom to enhance enjoyment All condoms except those made of

natural skins offer protection against pregnancy

Natural Skin Male Condoms Natural skin condoms (lamb cecum)

does not provide same protection against STIs & HIV

Contain small pores that could allow passage of viruses such as hepatitis B, HSV, & HIV

Disadvantages

Penis must be erect before placing the condom on

To prevent spillage of semen, the male must withdraw after ejaculating, while the penis is still erect

Condoms can rupture or leak Oil-based lubricants can decrease

effectiveness of condom

Use of the Male Condom

Make sure to educate on proper use and fit

Condom should be in place prior to any penile penetration

Client Education Check expiration date on package Avoid using oil-based lubricants Put on condom by placing condom on the tip of the

erect penis, leaving enough room at tip to collect sperm, then unroll condom from tip of erect penis to base

After intercourse erect penis should be withdrawn from vagina while holding rim of condom to prevent leakage

Inspect used condom for tears or holes Discard used condom in disposable waste container Do not flush in toilet

Female Condom Thin, polyurethane sheath with flexible

rings at each end, which covers cervix, lines vagina, and partially shields perineum

95% effective with perfect use

Female Condom

Insertion of Female Condom

Advantages

May be inserted up to 8 hours prior to intercourse

Not made of latex Both partners are protected against

STIs Available without prescription Use of lubricants will not decrease

effectiveness Breast-feeding women can safely use

Disadvantages

May twist or slip during intercourse Improper removal results in risk of

ejaculate leaking Outer ring may irritate external

genitalia High cost Noise produced with intercourse Altered sensation Initial insertion may be awkward

Client Education

Insert closed end of condom into vagina so ring fits loosely against cervix

After intercourse, condom should be removed before standing up by squeezing and twisting outer ring to close sheath while gently pulling out of vagina

Diaphragms

A shallow dome-shaped latex or silicone device with a flexible rim that covers cervix.

Advantages

Gives woman control Partner may insert diaphragm as part

of foreplay Diaphragm contains no hormones and

is safe for breast-feeding client Penis can remain inside vagina after

ejaculation

Disadvantages

Must be fitted by healthcare provider Must be replaced every 2 years Refitting & replacement may be

needed following pregnancy or a 15 pound weight gain or loss (20% weight fluctuation)

Difficulty with learning how to place correctly

Should not be used if client has UTI or TSS or history of either

Diaphragms

Available in many sizes Should be largest size woman can wear

without her being aware of its presence Most effective when used with

spermicide Annual gynecologic exam to assess fit Inspect device prior to each use

Inspecting Diaphragm Hold diaphragm up to light source Carefully stretch at area of the rim, on

all sides Make sure there are no holes Sharp fingernails can puncture

diaphragm Can fill diaphragm with water to

assess for holes If diaphragm is puckered do not use

Insertion of a Diaphragm Can be inserted up to 6 hours prior to intercourse Hold diaphragm between thumb and fingers Dome can be up or down Insert inward and downward as far as it will go Do not use oil based products such as vaginal

lubricants b/c they weaken the rubber

Disadvantages of Diaphragms

Diaphragms are contraindicated for women with pelvic relaxation,

uterine prolapse, or large cystocele.

Not a good option for women with poor vaginal muscle tone or recurrent UTIs

Toxic shock syndrome TSS can occur

Toxic Shock Syndrome Remove diaphragm within 6-8 hours after intercourse Do not use diaphragm or cervical cap during menses

Watch for danger signs of TSS * Sunburn type rash * diarrhea * dizziness * faintness * sudden high fever * vomiting * weakness * sore throat * aching muscles and joints

Client Education

Should be inserted 6 hours prior to sexual intercourse

Should remain 6 hours after sexual intercourse

Cervical Cap

Small thimble-shaped device Made of soft rubber Fits over cervix Held in place by suction Acts as barrier b/t sperm & cervix Effectiveness determined by

childbearing hx Nulliparous – 91% effective Parous = 74% effective

Cervical Cap

Three types Advantages & disadvantages

same as diaphragm Should remain in place for at

least 6 hours and no more than 48 hours after intercourse

Provides a physical barrier to sperm

Spermicide is inside the cap

Cervical Cap

Fits the same way as a diaphragm Requires less spermicide than the

diaphragm Can be inserted hours before sexual

intercourse without need for additional spermicide

Repeated acts of intercourse are possible

There is a potential risk of TSS

Cervical Cap

Contraceptive Sponge

Small, round polyurethane sponge that contains N-9 spermicide

Designed to fit over cervix One size fits all One side is concave Other side has woven

polyester loop to be used for removal of sponge

Before insertion, sponge must be moistened with water

Contraceptive Sponge Provides protection for 24 hours Should be left in place for at least 6

hours after last intercourse Wearing longer than 24 hours places

women at risk for TSS

Contraceptive Sponge

Hormonal Methods

More than 30 different formulations Oral Transdermal Vaginal Injectable Emergency Intrauterine

Combined oral contraceptives (estrogen – progestin)

AKA COCs Suppress the action of the hypothalamus

& anterior pituitary which leads to insufficient secretion of FSH & LH

Follicles do not mature Ovulation is inhibited Should be taken at the same time each day

COC

Available in 21 day, 28 day, 91 day packages

99.1% effective if used perfectly

COC Regimen

Is initiated on the first Sunday after day one of the menstrual cycle or after childbirth or abortion

Another form of contraception should be used throughout the first week

Taken the same time each day Almost 100% effective Almost all failures are a result of omission

of one or more pills during regimen

COCs

From 1-4 days after last COC, the endometrium soughs and bleeds

Due to hormone withdrawal

Bleeding is less profuse than normal menstruation

May only last 2-3 days

What to do if COC is Missed

If one pill is missed: * take pill immediately * begin regimen with time new

pill taken * no alternate forms of contraception is necessary

What to do if COC is Missed

If two pills are missed * Take one pill every day until

Sunday * Begin new pack on Sunday * Do not take 2 pills at same time * Use backup contraception for one week

Advantages of COCs Does not effect sexual act Improvement in sexual response may occur

once possibility of pregnancy is not an issue

Convenience of knowing when next menstrual flow will occur

Decreased menstrual blood loss Decreased iron-deficiency anemia Regulation of irregular cycles Reduced incidence of dysmenorrhea & PMS Return to fertility happens quickly

Disadvantages

No protection against STIs Clients need to remember to take a pill

at the same time each day Clients with preexisting medical

problems may not be candidates for this method

Effectiveness may be decreased with certain medications

May decrease effectiveness of insulin or warfarin (coumadin)

Contraindications include HX. Of:

thromboembolic disorders cerebrovascular or coronary artery disease breast cancer Estrogen dependent neoplasms Currently pregnant, lactation <6 weeks

postpartum Smokes >35 years old Hypertension DM with vascular disease Surgery on legs gallbladder disease

Common Side Effects

Nausea Breast tenderness Fluid retention Chloasma (klo – as-mah) Increased appetite Tiredness Depression Breast tenderness Hirsutism Bleeding irregularities

Serious Adverse Effects

Attributable to estrogen, progestin, or both

Stroke MI Thromboembolism Hypertension Gallbladder disease Liver tumors

Finding the Right COC

The right product for a woman contains the lowest dose or hormones that prevents ovulation and that has the fewest and least harmful side effects

Effectiveness is Altered When Women also Take:

phenytoin (Dilantin) topirimate (Topamax) ampicillin (Omnipen) tetracycline (Achromycin) penobarbital rifampin (Rifadin) Anti-HIV inhibitors St. John’s wort

Nursing Considerations

A drop of blood or small brown smear counts as a period

All women taking oral contraceptives should be aware of alternate methods of contraception

Assure woman knows that oral contraceptives will not protect them from STIs or HIV

Oral Contraceptive 91-Day Regimen

Some women take COCs in 3 month cycles

Have fewer menstrual periods Seasonale

› Take 3 months of active pills followed by 1 week of inactive pills

› Menstrual period occur during 13th week› If 13th week period does not occur, woman

should consider pregnancy

Transdermal Contraceptive System

Small continuous levels of progesterone and estrogen are released to suppress ovulation

Applied to intact skin of upper outer arms, upper torso, lower abdomen & buttocks

Advantages

Patch requires only weekly application Patch stays on even when showering

and swimming

Disadvantages

No protection against sexually transmitted infections

Not recommended for obese women, or women with skin disorders

Clients with preexisting medical diseases may not be candidates for this method

Medication precautions are same as oral contraceptives

Client Education

Do not apply to breasts Apply same day once a week for 3

weeks Followed by week without patch Failure rate < 8% in women weighing

less than 198 pounds

Vaginal Contraceptive Ring

Available only with a prescription Flexible ring made of ethylene

vinyl Worn in the vagina to deliver

continuous levels of progesterone & estrogen

Worn for 3 weeks Followed by 1 week without ring Bleeding occurs during ring free

week

Advantages

Requires application only once every 4 weeks

Requires no special fitting Can safely be left in place during

exercise or intercourse

Disadvantages

Offers no protection against sexually transmitted infections

Clients with marked vaginal prolapse should be cautioned to check for expulsion

Med precautions are same as taking oral contraceptives

Vaginal ring insertion

Ring is inserted by woman Does not have to be fitted If woman or partner notices discomfort

during coitus, ring can be removed and still be effective up to 3 hours

Failure rate is < 8 %

Progestin-Only Contraceptives

Impair fertility by inhibiting ovulation, thickening and decreasing the amount of cervical mucus, thinning the endometrium, and altering cilia in the uterine tubes

Oral Injectable Implantable

Advantages

95.5% effective

May be used by: * lactating women * women with mild hypertension

Oral Progestin (Minipill)

Failure rate 1-10% Must be taken correctly to increase

effectiveness Must be taken at same time every day

Oral Progestin (minipill)

If client misses one pill * missed pill should be taken immediately * next pill taken at regular time * Additional method of

contraception through end of that cycle

Injectable Progestin

Depo-provera Given IM or subcutaneously

4 times a year Should be initiated during

first 5 days of menstrual cycle

Administered every 11-13 weeks

97.7% effective

Depo-provera

Blocks the luteinizing hormone surge Suppresses ovulation Thickens cervical mucus to prevent

penetration of sperm

Important Education

Subsequent dose must be given 80-90 days after previous dose for continuous contraceptive protection

Return of fertility may be delayed up to 1 year after stopping this method

Implantable Progestins

Norplant 6 Implants are inserted

under the skin of the woman’s arm

Effective up to 3 years Prevent ovulatory

cycles, thicken cervical mucus

Side Effects of Implantable Progestins

Irregular menstrual bleeding HA Nervousness Nausea Skin changes Vertigo

Advantages

Not user-dependent for effectiveness 99.95% effective Does not contain estrogen Effective within 24 hours Lasts up to 5 years

Disadvantages

Minor surgery for insertion & removal May be visible under skin Irregular or prolonged menses No protection against STI Slightly higher failure rates in women

>154 pounds in fifth year of use

Emergency Contraception

Plan B Available without a

prescription Is available in 1 or 2 dose

regimens Should be taken by women

as soon as possible within 120 hours of unprotected intercourse, or birth control mishap

Risk of pregnancy is reduced by 75% - 89%

Emergency Contraception

If taken before ovulation emergency contraception prevents ovulation by inhibiting follicular development

If taken after ovulation there is little effect on ovarian hormone production or endometrium

If woman does not begin menstruation within 21 days, she should be evaluated for pregnancy

Is ineffective if the woman is pregnant because the pills do not disturb an implanted pregnancy

Intrauterine Device

A small T-shaped device with bendable arms for insertion through the cervix into the uterus

Mirena – releases levonorgestrel gradually from a reservoir

Impairs sperm motility, thickens cervical mucus, decreases lining of uterus

Uterine cramping & bleeding is decreased Effective for 5 years

Mirena

Provider inserts against uterine fundus Arms open near fallopian tubes Adversely affect sperm motility &

irritate lining of uterus Failure rate < 1%

Mirena

2 strings hang from base of stem through cervix & protrude into vagina

Woman must have negative pregnancy test, cervical cultures to rule out STIs & consent form signed

Advantages to IUD (Mirena)

Long-term protection Highly effective Continuous protection Good option for women

who cannot use hormone contraception, breastfeeding, >35, or smoke

Immediate return to fertility when removed

Disadvantages to IUD

Has to be inserted by healthcare provider

Risk of PID Unintentional expulsion of device Infection Possible uterine perforation No protection against HIV or STIs

Nursing Considerations

Teach woman to check for strings once a week for first month then once a month after menstruation

Signs of Potential Complications with IUD

P – period late, abnormal A – abdominal pain; pain with

intercourse I – Infection exposure, abnormal vag d/c N – not feeling well, fever, chills S - string missing, shorter, longer

Sterilization

Refers to surgical procedures intended to render a person infertile

Involves the occlusion of the passageways for the ova & sperm

Woman – uterine tubes are occluded Men – vas deferens are occluded Only a hysterectomy or oopherectomy

guarantees absolute sterility in women

Tubal Ligation

Fallopian tubes are accessed through two small incisions into the abdomen and visualized using a laparoscope

They are cut, tied, cauterized, or banded to block passage of sperm & prevent ovum from becoming fertilized

96-99% effective

Tubal ligation

Takes 20-30 minutes Performed under general or local

anesthesia Pain for several days Avoid tub baths for 48 hours Avoid driving, lifting, & strenuous

activity for 1 week

Tubal Ligation

Health care provider must be certain woman is not pregnant

½ are performed immediately after pregnancy

Advantages

Permanent and effective in preventing pregnancy

May be performed at any time Immediately after childbirth is optimal

b/c uterus is enlarged and fallopian tubes are easily identifiable

Sexual function and spontaneity are not affected

Disadvantages

Requires outpatient surgery Potential complications such as infection &

bleeding If pregnancy does occur risk for ectopic

pregnancy is increased Reversal of procedure is not always possible Sterilization offers no protection from STIs May feel pain at ovulation The ovum disintegrates within the

abdominal cavity

Male Sterilization

AKA vasectomy Sealing, tying, or cutting vas deferens Sperm cannot travel from testes to

penis Done on outpatient basis Permanent method of sterilization Reversal is generally unsuccessful

Advantages

99.85% effective Recovery time is short Simpler, safer, and more effective than

female sterilization Complications are rare Sexual function is not affected Cost effective Convenient

Disadvantages

Very unlikely that it can be reversed

Potential complications include adverse infection, bleeding, sperm granuloma or spontaneous re-anastomosis of vas deferens

Vasectomy

Ice packs applied to scrotum intermittently for a few hours after surgery

Scrotal support Moderate inactivity for 2 days Suture removed 5-7 days postop Sexual intercourse resumed as desired

Considerations

Sterility is not immediate Some sperm remain in proximal

portions of sperm ducts Takes 1 week to several months to

clear ducts of sperm Alternate contraception should be

utilized until 2 sperm counts come back as zero

Vasectomy

Vasectomy

Sexual Function

Explain to male that ability to achieve and maintain erection or volume of ejaculate is not altered

Sperm production continues but are unable to leave epididymis

Laws & Regulations

Informed consent Always!!! Voluntary sterilization of any mature,

rational woman without reference to marital or pregnancy status

Partner’s consent is not required Partners are encouraged to discuss

situation with each other Health care provider may request consent Sterilization of minors is restricted

Laws & Regualtions if Using Federal Funds

Person must be 21 years old

Irreversible method of birth control and a statement that mandates a 30-day waiting period between giving consent and the sterilization

Induced Abortion

Purposeful interruption of pregnancy before 20 weeks of gestation

Elective abortion - is done at woman’s request

Therapeutic abortion – performed for reasons of maternal or fetal health or disease

Indications for woman’s decision to have an

abortion Preservation of life & health of mother Genetic disorders of fetus Rape or incest Pregnant woman’s request

Rowe VS Wade

Abortion is now regulated Prior to 1970 was not legal January 1973 Supreme court legalized

abortion

Trimester approach

First trimester abortion is permissible Different states have different laws

regarding second trimester abortions Third trimester abortions are limited &

may be prohibited by state regulations unless it interferes with life or health or pregnant woman

Attempted Abortion Bans

In 2006 several states introduced bills to ban abortions

US supreme court will decide the future of abortions

Hospitals maintained by Roman Catholics forbid abortion & sterilization

Incidence of Abortions

In 2006 there were 846,181 abortions Most are unmarried Caucasian women

b/t 20-29 years

Nurses Right

Association of Women’s Health, Obstetric & Neonatal Nurses (AWHONN, 200) supports a nurse’s right to chose to participate or not in abortion procedures in keeping with his or her “personal, moral, ethical, or religious beliefs.

Nurse have a professional obligation to inform their employers at time of employment of attitudes & beliefs that may interfere with job function