MEDICATION-FREE CONTRACEPTION
• Natural Family Planning (NFP) is a contraceptive method that involves identifying the fertile time period and avoiding intercourse during that time every cycle.
It is the only method of contraception acceptable to the Roman Catholic Church.
• Fertility Awareness Methods (FAMs) identify the fertile time during the cycle and use abstinence or other con- traceptive methods during the fertile periods. These methods require motivation and considerable counseling to be used effectively. They may interfere with sexual spontaneity and require several months of symptom/
cycle charting before they may be used effectively.
Effectiveness
The effectiveness in preventing pregnancy depends on the exact method used, but it is generally around 75%
effective.
Optimizing Outcomes— When teaching about NFP and FAMs of contraception
The patient and her partner need to be fully committed to use these methods successfully. There are several varia- tions: (1) the calendar, or rhythm method in which the fertile days are calculated; (2) the standard days method in which color-coded strung beads are used to track infer- tile days; (3) the cervical mucus method (also called the
“ovulation detection method” or the “Billings method”) where the changes in cervical mucus are used to track fertile periods; (4) the basal body temperature (BBT) method in which body temperature changes are used to detect the fertile period (Fig. 6-2; Box 6-3); and the symptothermal method that combines the BBT and cervi- cal mucus methods and involves recording various symp- toms such as changes in cervical mucus, mittelschmerz (abdominal pain at midcycle), abdominal bloating, and the BBT to recognize signs of ovulation (Hatcher et al., 2005). The woman needs to realize that stress or illness can affect her cycle and cause a variation in the fertile days. These methods are not best suited for adolescents or couples who would be devastated by an unplanned pregnancy. Since the “natural” methods identify fertile periods, couples who are attempting to conceive may also wish to use them.
Ovulation predictor kits detect the surge in luteinizing hormone (LH) that occurs 24–36 hours before ovulation.
The kits vary in price and procedure but most are similar to home pregnancy tests and are performed on the wom- an’s urine. Intercourse can then be timed to avoid or achieve pregnancy.
COITUS INTERRUPTUS
Coitus interruptus or the “withdrawal method” involves the man withdrawing his penis from the vagina before ejac- ulation. However, ejaculation may occur before withdrawal is complete and spermatozoa may be present in the pre- ejaculation fl uid. Men with unpredictable or premature ejaculation have diffi culty using this method successfully.
Effectiveness
The typical effectiveness rate for this method is about 71%.
LACTATIONAL AMENORRHEA METHOD (BREASTFEEDING)
Breastfeeding can be a form of contraception, although it is used more effectively in underdeveloped countries where mothers breastfeed their infants exclusively. Some lactating mothers may ovulate but not menstruate. It is diffi cult to determine when fertility is restored. This
Box 6-3 Basal Body Temperature as an Indicator of Ovulation
During the preovulatory phase, the basal temperature is usually below 98°F (36.7°C). As ovulation approaches, estrogen production increases.
At its peak, estrogen may cause a slight drop, then a rise, in the basal temperature. Before ovulation, a surge in luteinizing hormone (LH) stimu- lates the production of progesterone. The LH surge causes a 0.5°F–1°F (0.3°C–0.6°C) rise in the basal temperature. These changes in the basal temperature create the biphasic pattern consistent with ovulation. Pro- gesterone, a thermogenic, or heat-producing hormone, maintains the temperature increase during the second half of the menstrual cycle.
Although the temperature elevation does not predict the exact day of ovulation, it does provide evidence of ovulation about one day after it has occurred. Release of the ovum probably occurs 24–36 hours before the fi rst temperature elevation.
1 2 3 4 5 6 78 9 10 11 12 13 14 15 16 17 18 19202122 23 24 25 26 27 281 2 3 4 5 6 7 6
4 2 99.0 8 6 4 2 98.0 8 6 4 2 97.0
Days of Menstrual Cycle
Temperature
Example line only 1234 SAFE
Menstruation Menstruation
SAFE DAYS Ovulation
(Not safe)
Figure 6-2 A basal body temperature chart.
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144 unit two The Process of Human Reproduction
method works best when the mother exclusively breast- feeds, has had no menstrual period since giving birth, and whose infant is younger than 6 months of age.
Effectiveness
When the above conditions are met, the effectiveness rate for this method is about 98% (Hatcher et al., 2005).
ABSTINENCE
Abstinence is the only contraceptive method with a 100%
effectiveness rate. If a couple chooses to be abstinent (refrain from vaginal intercourse), intimacy and sexuality may be expressed in many other ways. Abstinence requires commitment and self-control, but success with this method can lead to increased self-esteem and enhanced communi- cation about emotions and feelings. Abstinence can help adolescents learn negotiation skills (Hatcher et al., 2005).
BARRIER METHODS
Barrier methods are relatively inexpensive and some types can be used more than once. Although less effective than certain other forms of contraception, barrier methods have gained in popularity as a protective measure against the spread of STIs. If the woman is under 30 years of age, uses alcohol or recreational drugs, or has intercourse three or more times weekly, barrier methods are usually not as effective because of a decreased likelihood to use them consistently (Cates & Stewart, 2004).
Many women dislike barrier methods because they must be inserted or applied before intercourse. Most require a water-based lubricant and these should never be used with an oil-based lubricant (i.e., baby oil, petroleum jelly, vegeta- ble oil) or vaginal yeast cream as these products cause latex deterioration. Barrier methods have few side effects, although latex allergy may lead to life-threatening ana phylaxis. There is evidence that consistent use of latex condoms reduces the rate of HIV transmission, and both condoms and diaphragms can reduce the risk of cervical STIs (Hatcher et al., 2005).
Each of the barrier methods must be applied or inserted with clean hands. The key to success with these contraceptives is consistent and correct use, and the nurse must ensure that women know how to use their barrier method correctly and that they are satisfi ed with their choice.
Diaphragm
The diaphragm is a latex dome-shaped barrier device with a spring rim that resembles half a tennis ball. It is fi lled with spermicide and inserted up into the vagina to cover the cervix. Diaphragms are available in several sizes and types and must be fi tted by a trained health care professional.
Use of the diaphragm requires some planning ahead, so this method may not be the best choice for adolescents.
The diaphragm is inserted by the woman using her fi ngers or an inserter up to 6 hours before intercourse, and it must be fi lled with a spermicide applied inside and along the rim before insertion (Fig. 6-3). The diaphragm must remain in place for 6 hours after intercourse. If intercourse occurs again before 6 hours have elapsed, the diaphragm should be left undisturbed and another applicator-full of spermi- cide should be inserted into the vagina. The diaphragm should remain in place for 6 hours after the last act of intercourse. To ensure continued pro tection, the
diaphragm should be replaced every 2 years, and it may need to be refi tted after weight loss or weight gain, term birth or second trimester abortion (Hatcher et al., 2005).
SIDE EFFECTS. Other than occasional allergic reactions to the diaphragm or spermicide, there are no side effects from a well-fi tted device. There is an increased risk of uri- nary tract infections due to pressure of the diaphragm against the urethra, which may interfere with complete emptying of the bladder. Thus, women with a history of frequent urinary tract infections (UTIs) should avoid this method. The diaphragm should not be used during men- ses due to the risk of toxic shock syndrome (TSS), a rare, sometimes fatal disease caused by toxins produced by certain strains of the bacterium Staphylococcus aureus.
Women with pelvic relaxation syndrome or a large cysto- cele are not suitable candidates for the diaphragm.
EFFECTIVENESS. The effectiveness in preventing preg- nancy for typical use is 84% (Bachmann, 2007). For this reason, the diaphragm may not be the best choice for a woman who would consider pregnancy a disaster in her life or for a woman who feels uncomfortable touching her genital area. Since it is made of latex, the diaphragm is contraindicated in women with latex allergies.
Optimizing Outcomes— When teaching patients about use of the diaphragm
The diaphragm must be in the correct position for it to be comfortable and work effectively as a contraceptive.
The patient should practice insertion and removal of the diaphragm before leaving the clinic, and be instructed to return with it in place for a recheck of proper fi t 1 week later. Before each use, the diaphragm is carefully inspected for tears, holes, or damage. After removal, the device is cleaned with mild soap and water, dried thoroughly, and stored in its case in a cool place. Oil-based vaginal medi- cations or lubricants should never be used with the dia- phragm (Hatcher et al., 2005).
Cervical Cap
The cervical cap is a thimble-shaped latex device that fi ts fi rmly around the base of the cervix close to the junction of the cervix and vaginal fornices (Hatcher et al., 2005, Fig. 6-4). The device has a pliable rim and is available in Figure 6-3 Diaphragm insertion.
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chapter 6 Human Sexuality and Fertility 145
four sizes. It is somewhat more diffi cult to use than the diaphragm because it must be placed exactly over the cer- vix where it is held in place by suction. The seal provides a physical barrier to sperm and the spermicide placed inside the cap provides a chemical barrier. Women who choose the cervical cap should practice insertion and removal after the fi tting and return in 1 week with the cap inserted to check for proper placement.
Nursing Insight—
When counseling patients about the cervical capCertain women are not suitable candidates for the cervical cap.
Patients who have a history of toxic shock syndrome, pelvic infl ammatory disease (PID), cervicitis, papillomavirus infec- tion, a previous abnormal Pap smear or cervical cancer, and undiagnosed vaginal bleeding should choose another contra- ceptive method. Also, women who have an abnormally short or long cervix may not be able to use a cervical cap satisfactorily.
SIDE EFFECTS. There is evidence that the cervical cap can cause cervical irritation and erosion and it is not recom- mended for women who are at high risk for HIV (Hatcher et al., 2005). Because the device is made of latex, it is contraindicated in women with latex allergies. Since the cervical cap is associated with a high failure rate, women who choose this method should also be given emergency contraception pills.
EFFECTIVENESS. With typical use, the FemCap cervical cap is about 74% effective in preventing pregnancy (Trussell, 2004), so it may not be the best choice for the woman who would consider a pregnancy to be a disaster in her life. It is not as effective for contraception in women who have had a pregnancy (Bachmann, 2007).
Since proper use of the cervical cap requires planning ahead and strong motivation, it may not be the best con- traceptive method for adolescents.
Optimizing Outcomes— When teaching patients about use of the cervical cap
Before insertion, approximately one-third of the cap is fi lled with spermicide. Taking care not to spill the spermicide, the woman inserts the cap into the vagina and places it
directly over the cervix. The woman is taught to use her fi nger to trace around the rim of the cap to make certain the entire cervix is covered. The cervical cap can be inserted up to 6 hours before intercourse and should remain in place for 6 hours after the last intercourse. No additional spermi- cide is necessary with repeated intercourse. The cap should never remain in place longer than 48 hours and it should never be used during menses or when a vaginal infection is present. To remove the cap, the woman pushes against the rim with her fi nger to dislodge it from the cervix, gently hooks her fi nger over the rim and removes it. The cap is then washed with mild soap and water. The cap should be dried thoroughly and stored in a cool, dry place. Oil-based vaginal medications or lubricants should never be used with the cervical cap (Hatcher et al., 2005).
Be sure to— Inquire about latex allergy
Before dispensing diaphragms, cervical caps, or male con- doms, ask all patients about a personal or partner history of allergy to latex. Use of latex contraceptive devices is contraindicated in patients with latex sensitivity.
Condoms
Condoms are generally considered to be a male contra- ceptive device although the female condom (vaginal sheath) is also available. Male condoms may be made of latex rubber, polyurethane, or natural membranes. Latex male condoms are widely recognized for their role in preventing HIV infection and sexually transmitted infec- tions (STIs). Natural skin condoms do not offer protec- tion against HIV and STIs because they contain small pores that may permit the passage of viruses including HIV, hepatitis B, and herpes simplex. Although previous recommendations included combining condom use with the spermicide nonoxynol-9, recent data suggest that the spermicidal coating does not provide additional pro- tection from pregnancy or STIs (Nelson & Le, 2007).
Also, frequent use of condoms coated with nonoxynol-9 may increase the transmission of HIV and can cause genital lesions (Centers for Disease Control and Preven- tion [CDC], 2007; Warner, Hatcher, & Steiner, 2004).
Condoms are non-reusable and act as a mechanical bar- rier between the female and male genitalia.
MALE CONDOMS. Male condoms are one of the oldest known methods of contraception. When used correctly, male condoms are placed over the erect penis before any genital, oral, or anal contact. Condoms are inexpensive, require no prescription, and are available in a variety sizes, shapes, and colors. To prevent pregnancy and the spread of STIs, they must be used correctly at every act of intercourse.
SIDE EFFECTS. Condoms may cause an anaphylactic reaction in patients who are allergic to latex. Individuals with latex allergies must choose condoms made of other materials.
EFFECTIVENESS. With typical use, male condoms are about 85% effective in preventing pregnancy.
Figure 6-4 Cervical cap insertion.
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146 unit two The Process of Human Reproduction
Optimizing Outcomes— When teaching patients about use of the male condom
It is important to choose and use the correct size of condom.
The condom is rolled onto the erect penis and should fi t snugly. The reservoir tip should be left unobstructed or extra space at the end (of a condom with no reservoir tip) should be provided for collection of the semen. Care must be taken not to tear the condom or spill its contents during removal. When possible, patients should practice placing a condom on a penile model to enhance understanding of the proper technique. Immediately after intercourse, the man should hold the condom at the base of the penis and with- draw the penis while still erect, then check the condom for the presence of tears after removal. Expiration dates should be checked often and out-of-date condoms discarded. Con- doms should always be stored in a cool, dry place and latex condoms only used with water-based lubricants (Nelson &
Le, 2007).
FEMALE CONDOMS. Made of polyurethane in a “one size fi ts all,” the female condom or vaginal sheath (Fig. 6-5) is less widely used than the male condom. The female condom resembles a sheath with a ring on each end: the closed end is inserted into the vagina and anchored around the cervix; the open end is placed at the vaginal introitus. Although no prescription is needed, female condoms are often diffi cult to fi nd, and they are more expensive than male condoms. Because they contain no latex, female condoms are safe for use in individuals with latex allergies.
Optimizing Outcomes— When teaching patients about use of the female condom
Female condoms cannot be used at the same time as male condoms. The man must carefully direct his penis into the condom to keep from inserting it between the condom and the vaginal wall. The female condom can be used during oral sex. Some individuals complain that female condoms generate “noise” during intercourse, but lubricant seems to help alleviate this problem.
Spermicides
Spermicides are available in the form of gels, creams, fi lms, and suppositories. All are inserted into the vagina or used with diaphragms or cervical caps. Spermicidal condoms are no longer recommended for use. Spermicides act as chemi- cal barriers that cause death of the spermatozoa before they can enter the cervix. Although spermicides can be messy, the lubrication afforded by the spermicide-based methods may improve sexual satisfaction for both partners.
Women who are at risk for HIV should not use spermi- cides as their only method of birth control (Hatcher et al., 2005). Since spermicidal suppositories and fi lms require 15 minutes to become effective, women who feel they can- not comply with this time constraint may wish to use a spermicidal foam, cream, or gel instead. Because of the low effectiveness rates associated with spermicides, the woman who believes that pregnancy would be personally disas- trous may wish to choose another contraceptive method.
SIDE EFFECTS. Spermicides should not be used in women with acute cervicitis because of the potential for further cervical irritation. Rarely, topical irritation may develop from contact with spermicides. When this occurs, the product should be discontinued and another contracep- tive method selected.
EFFECTIVENESS. The typical use effectiveness of spermi- cides in preventing pregnancy is 71%.
Optimizing Outcomes— When teaching patients about the use of spermicides
The woman should wash her hands before inserting any spermicide. Spermicides are most effective when used with a diaphragm or cervical cap. Most contraceptive fi lms and suppositories require a period of 15 minutes to elapse after insertion to become effective and they should be inserted no longer than one hour before intercourse. The spermi- cide should be inserted deep into the vagina so that it makes contact with the cervix. Although douching is never recommended, it should be avoided for 6 hours after inter- course to avoid washing the spermicide away (Hatcher et al., 2004). Douching in and of itself is not a reliable form of birth control.
Contraceptive Sponge
The contraceptive sponge was recently returned to the U.S. market. It is a soft, round disposable polyurethane device that fi ts over the cervix (one size fi ts all). The sponge is permeated with the spermicide nonoxynol-9.
One side is concave to enhance fi t over the cervix; the other side contains a woven polyester loop to facilitate removal.
SIDE EFFECTS. The contraceptive sponge is contrain- dicated in women who are allergic to the spermicide nonoxynol-9. The sponge should not be left in place for more than 30 hours (which includes the 6-hour waiting period after the last act of intercourse) due to the risk of toxic shock syndrome. It should not be used during men- struation or immediately after abortion or childbirth or if a woman has a history of toxic shock syndrome.
Figure 6-5 Insertion of a female condom.
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