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Attention-Deficit/Hyperactivity Disorder

Attention-deficit hyperactivity disorder

Attention deficit hyperactivity disorder is the most commonly diagnosed mental disorder of children and teens and which can also continue to adulthood. Children with ADHD may be hyperactive and unable to control their impulses or they may have trouble paying attention

Attention deficit hyperactivity disorder (ADHD) is a brain disorder marked by an on-going pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning of development.

Inattention means a person wanders off task, lacks persistence, has difficulty sustaining focus and is disorganized and these problems are not due to defiance or lack of comprehension.

Hyperactivity means a person seems to move about constantly, including in situations in which it is not appropriate or excessively fidgets, taps, or talks.

Impulsivity means a person makes hasty actions that occur in the moment without first thinking about them and that may have high potential for harm or a desire for immediate rewards or inability to delay gratification. An impulsive person may be socially intrusive and excessively interrupt others to make important decisions without considering the long-term consequences.

This disorder is characterized by severe disruption of attention along with over activity more frequent and severe than is typical of children at a similar level of development. ADHD is thought to result from brain damage during birth. A child with ADHD cannot sit still or remain at one place for any length of time, is always on the go, fears no dangers, climbing and playing dangerously with house hold objects. The prevalence is much common in boys than girls

Aetiology

Biological influences

genetics; ADHD tends to run in families
biochemical theory; a deficit of dopamine and norepinephrine neurotransmitters has been attributed to cause over activity as seen in ADHD

Pre, Peri and postnatal factors

prenatal toxic exposure
prematurity
fetal distress
precipitated or prolonged labour
perinatal asphyxia
low Apgar scores
postnatal infections
CNS abnormalities resulting from trauma

Environmental influences

lead poisoning
food additives, colouring, preservatives and sugars

Psychosocial factors

prolonged emotional deprivation
stressful psychic events
disruption of family equilibrium

Risk factors

drug exposure in utero
birth complications
low birth weight
lead poisoning

Clinical features

sensitive to stimuli, easily upset by light, noises or environmental changes
more commonly active an sleeps little
short attention life span
failure to finish tasks
impulsivity
memory and thinking difficulties
specific learning disabilities

In school

answers only the first two questions and often blurts out answers before questions have been completed
unable to wait to be called on in school and may respond before everyone else
has difficulty awaiting in games or group situations
often loses things necessary for tasks or activities at school

Home

explosive or irritable
emotionally labile and easily set off to laughter or tears
unpredictable mood
impulsiveness and inability to delay gratification
often talks excessively
often engages in physically dangerous activities without considering possible consequences

Symptoms can also be grouped as follows;

Inattention symptoms

Overlook or miss details or make careless mistakes in schoolwork
Have problems sustaining attention in tasks or play including conversations, lectures or lengthy reading
Not seem to listen when spoken to directly
Not follow instructions and fail to finish school work or duties on work or start tasks but quickly lose focus and get easily side-tracked
Have problems organizing tasks and activities, such as what to do in sequence, keeping materials and belongings in order, having messy work and poor time management and failing to meet deadlines
Avoid or dislike tasks that require sustained mental effort, such as school work or homework.
Loose things necessary for tasks or activities such as school supplies, pencils, books, tools, eyeglasses, paperwork etc.
Be easily distracted by unrelated thoughts or stimuli
Be forgetful in daily activities like keeping appointments.

Hyperactivity-impulsivity symptoms

Leave seats in situations when staying seated is expected such as in classroom
Run or dash around or climb in situations where it is inappropriate or restless in teens
Be unable to play or engage in hobbies quietly
Be constantly in motion or ‘on the go’ or act if ‘driven by a motor’
Talking nonstop
Blurt out an answer before question has been completed, finish other peoples sentences or speak without waiting for a turn in conversation
Have trouble waiting for his or her turn
Interrupt or intrude on others, for example conversations, games or activities
Constant fidgeting
Acting without thinking
Little or no sense of danger

MANAGEMENT

Pharmacotherapy;

Medication do not offer permanent cure for ADH but may help someone with the condition to concentrate better, be less impulsive, fell calmer and learn to practice new skills. Drugs licensed for treatment of ADHD include;

Methylphenidate one tablet once a day
Lisdexamfetamine once capsule once a day
Dexamfetamine one tablet once or twice a day
Atomoxetine one capsule once or twice a day
Guanfacine one tablet once a day

tricyclic antidepressants
Antipsychotics
serotonin specific reuptake inhibitors

Psychological therapies

Psychotherapy especially behavioural therapy is very essential as it aims at a child changing their own behaviour. It might involve practical assistance such as help organizing tasks or completing schoolwork or working through emotionally difficult events
Cognitive behavioural therapy; here a therapist tries to change how a child thinks about the situation and in turn would change the behaviour
social skill training
family therapy

Nursing interventions

Children with ADHD need guidance and understanding from their parents, families, and teachers to reach their full potential and to succeed. For school age children, frustration, blame and anger may hinder recovery in other wards children need special help to overcome negative feeling and to develop new skills and attitudes.

Social skills training; this will help the child learn how to behave in social situations by learning how their behaviours affect others
Parenting skills training (behavioural parent management training) this teaches parents the skills to encourage and reward positive behaviours in their children. It helps parents learn how to use a system of rewards and consequences to change a child’s behaviour
Stress management techniques, these can benefit parents of children with ADHD by increasing their ability to deal with frustration so that they can respond calmly to their child’s behaviour
Support groups; these help parents and families connect with others who have similar problems and concerns. Groups often meet regularly to share frustration and successes to exchange information about recommended specialists and strategies and to talk with experts
Diet; sugar, food colourings and additives as well as caffeine should be excluded in the patients diet as they aggravate hyperactivity

Help the child with ADHD to stay organised and stay organised by;

Keeping a routine and a schedule. Keep the same routine every day from wake-up time to bedtime. Include times of homework, outdoor play and indoor activities. Write all changes on the schedule in advance as possible
Organizing everyday items; have a place for everything and keep everything in its place. This includes clothing, backpacks and toys
Using homework and notebook organizers. Stress to the child the importance of writing down assignments and bringing home necessary books
Being clear and consistent. Children with ADHD need consistent rules they can understand and follow
Giving praise or rewards when rules are followed. Children with ADHD often receive and expect criticism. Look for good behaviour and praise it.
Develop a trusting relationship with the child that conveys acceptance of the child separate from unacceptable behaviour
Ensure patient has a safe environment free from dangerous objects that can injure him due to random hyperactive movements
Keep the child in an environment that is free from distractions to help him comply on given tasks
Ensure child’s attention by calling his name and maintain an eye contact before giving instructions
Ask patient to repeat instructions before beginning the task
establish goals that allow the patient to complete part of the task, rewarding each step completion with a break for physical activity
Provide assistance on one-to-one basis beginning with simple concrete instructions
Gradually decrease the amount of assistance given to task performance while assuring patient that assistance is available if still needed
Offer recognition for successful attempts and positive reinforcement for attempts made
Provide quiet environment, self-contained classrooms an small group activities
Help the patient to learn how to take his turn, wait in line and follow rules
Provide information an materials related to the child’s disorder and effective parenting techniques
Explain and demonstrate positive parenting techniques to parents such as being vigilant in identifying the child’s behaviour and responding positively to that behaviour
Co-ordinate overall treatment plan with schools, child and family

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Standards of Care

Standards of Care In Mental Health

Standards of Care are a means for improving the quality care for mentally ill people.

They were enunciated by the American Nurses Association (ANA) in 1973.

Development of Code of Ethics

This is very important for a psychiatric nurse as she takes up independent roles in psychotherapy, behavior therapy, cognitive therapy, individual therapy, group therapy, maintains patient’s confidentiality, protects his rights and acts as patient’s advocate.

Legal Aspects in Psychiatric Nursing

The practice of psychiatric nursing is influenced by law, particularly initial concern for the rights of patients and the quality of care they receive.

The client’s right to refuse a particular treatment, protection from confinement, intentional torts, informed consent, confidentiality and Promotion of research in mental health nursing
The nurse contributes to nursing and the mental health field through innovations in theory and practice and participation in research.
Cost-effective nursing care. Studies need to be conducted to find out the viability in terms of cost involved in training a nurse and the quality of output in terms of nursing care rendered by her.
Focus of care. A psychiatric nurse has to focus care on certain target groups like the elderly, children, women, youth, mentally retarded and chronic mentally ill.
Record keeping are a few legal issues in which the nurse has to participate and gain quality knowledge.

STANDARDS OF MENTAL HEALTH NURSING

The purpose of Standards of Psychiatric and Mental Health Nursing practice is to fulfill the profession’s obligation to provide a means of improving the quality of care. The standards presented here are revision of the standards enunciated by the Division on Psychiatric and Mental Health Nursing Practice in 1973.

Professional Practice Standards

Standard I: Theory

The nurse applies appropriate theory that is scientifically sound as basis for decisions regarding nursing practice. Psychiatric and mental health nursing is characterized by the application of relevant theories to explain phenomena of concern to nurses and to provide a basis for intervention.

Standard II: Data Collection

The nurse continuously collects data that are comprehensive, accurate and systematic. Effective interviewing, behavioral observation, physical and mental health assessment enable the nurse to reach sound conclusions and plan appropriate interventions with the client.

Standard III: Diagnosis

The nurse utilizes nursing diagnosis and/or standard classification of mental disorders to express conclusions supported by recorded assessment data and current scientific premises.

Nursing logic basis for providing care rests on the recognition and identification of those actual or potential health problems that are within the scope of nursing practice.

Standard IV: Planning

The nurse develops a nursing care plan with specific goals and interventions delineating nursing actions unique to each client’s needs.

The nursing care plan is used to guide therapeutic intervention and effectively achieve the desired outcomes.

Standard V: Intervention

The nurse intervenes as guided by the nursing care plan to implement nursing actions that promote, maintain or restore physical and mental health, prevent illness and effect rehabilitation.

(a) Psychotherapeutic interventions

The nurse uses psychotherapeutic interventions to assist clients in regaining or improving their previous coping abilities and to prevent further disability.

(b) Health teaching

The nurse assists clients, families and groups to achieve satisfying and productive patterns of living through health teaching.

The nurse uses the activities of daily living in a goal directed way to foster adequate self-care and physical and mental well-being of clients.

(d) Somatic therapies

The nurse uses knowledge of somatic therapies and applies related clinical skills in working with clients.

(e) Therapeutic environment

The nurse provides structures and maintains a therapeutic environment in collaboration with the client and other health care providers.

Standard VI: Evaluation

The nurse evaluates client responses to nursing actions in order to revise the database, nursing diagnosis and nursing care plan.

Professional Performance Standards

Standard VII: Peer Review.

The nurse participates in peer review and other means of evaluation to assure quality of nursing care provided for clients.

Standard VIII: Interdisciplinary Collaboration

The nurse collaborates with other health care providers in assessing, planning, implementing and evaluating programs and other mental health activities.

Standard IX: Utilization of Community Health Systems

The nurse participates with other members of the community in assessing, planning, implementing and evaluating mental health services and community systems that include the promotion of the brand continuum of primary, secondary and tertiary prevention of mental illness.

Standard X: Research

The nurse contributes to nursing and the mental health field through innovations in theory and practice and participation in research.

Standards of Care Read More »

Law and Mental Illness

Law has relevance in nearly all aspects of nursing practice, but in no other area of nursing is the law more intimately involved than in psychiatric nursing.

This is because psychiatric clients may;

be placed on treatment against their own will
pose a risk to them selves
have been charged to have committed crime while legally insane
be un able or unwilling to consent to treatment
be incapable of fully understanding medical risks
require constant restraints for their safety or others
make threats to others
under go forensic evaluations that require nurses to testify in court

Forensic psychiatry

Forensic psychiatry is a branch of psychiatric nursing that deals with disorders of mind and their relationship with the legal principles.

It is also concerned with the assessment, investigations, diagnosis and treatment of mental disorders among three broad categories of individuals i.e.;

individuals who have are alleged to have committed an offence and face prosecution
convicted prisoners who develop mental illness in the course of serving their sentence
individuals who have not committed an offence but are at risk because of their mental capacity

Under existing mental health legislation in Uganda, its not expected that the primary health care provider will provide this service. its however advised that a PHC provider knows something about prisoners’ mental health needs for the purpose of early and appropriate referrals to centres where a psychiatrist or other mental health professionals are available.

The basic forensic psychiatry includes;

crime and psychiatric disorders
criminal responsibility
civil responsibility
laws relating to psychiatric disorders
admission procedures of patients in psychiatric hospital
civil rights of mentally ill
psychiatrists and court

Crime and psychiatric disorders

There is a close association between crime and psychiatric disorders like schizophrenia, affective disorders, epilepsy, drug dependency, personality disorders etc.

Mentally ill people may commit crime because;

they do not understand the implication of their behaviour
due to delusions and hallucinations
abnormal mental states like confusion or excitements
drug related violence

Instances when an individual facing prosecution may come to attention of a psychiatrist

when police notices signs of mental disorder in individual under their custody
when the judge observes signs of mental disorder
when relatives raise issue of mental disorder
when prisoner reports history of treatment for psychiatric disorder
when suspect pleads insane during court proceedings

Under any of the above, the magistrate may order assessment and observation of an individual to ascertain;

whether the individual is mentally disordered
the individual’s ability to stand trial if mentally disordered
whether the accused is criminally responsible for the offence he is charged with

Responsibilities of a psychiatrist in order to find answers for the above questions

hospitalize the accused for the purpose of observations and possible treatment or attend to matter as an out- patient case
take a full psychiatric history including history of previous episodes of illness and treatment
order an observation of patient by other nursing staff on dairy basis
conduct laboratory, psychological and social investigations
make a report to the magistrate who will then decide on the best course of action on the basis of a psychiatric report

Criminal responsibility

Criminal responsibility is a legal concept which refers to the extent to which an individual can be held liable for his or her offence.

According to section 84 of the Indian penal code act of 1860, “Nothing is an offence which is done by a person who, at a time of doing it, by reason of unsoundness of mind, is incapable of knowing the nature of act, or that he is doing what is either wrong or contrary to the law”.

A clinical test of responsibility may be used to determine whether an individual is responsible for an offence or not.

Criteria for criminal responsibility

Criteria for Criminal Responsibility[CCR]	SCORE
1. offence required careful planning
2. offence was unrelated to symptoms of mental disorder
3. identifiable motive for the crime was not a product of mental disorder
4. mental capacity at a time of crime was unimpaired or did not impair rational judgement
5. amnesia if present is incongruent with relevant key features of crime and mental state

Score each item 1 for a Yes response and 0 for No response. The maximum score is 5. A score of 3 and more indicates that the individual is probably responsible for an alleged crime.

Other criteria used to determine criminal responsibility

M’Naghten’s rule

This states that the individual at a time of the crime did not know the nature and quality of the act and if he did know what he was doing, he did not comprehend it to be wrong.

The Irresistible impulse act

According to this rule, a person may have known an act was illegal but as a result of mental impairment lost control of their actions.

The Durham test or Product rule

This states that an accused is not criminally responsible if his unlawful act was the product of mental disease or abnormality

American law institute

This states that a person is not responsible for criminal conduct if at time of such conduct, as a result of mental disease or defect he lacks adequate capacity either to appreciate the criminality of his conduct or to conform his conduct to requirements of the law

Ability to Stand Trial

An individual will not be expected to have an ability to stand trial under the following circumstances;

mentally ill with active signs of mental disorder
lacks ability to understand court proceedings

in cases of the above, the psychiatrist may recommend that the individual receives relevant treatment for the mental disorder and after full recovery, the individual may then stand trial. However in cases of severe psychotic illness like schizophrenia, the case might be disposed.

Convicted prisoner

In case a prisoner who is serving sentence falls ill, he or she may be referred to a mental hospital under magistrates court Act for assessment, observation and treatment. Unfortunately, under existing laws, such an individual will not be excused from serving his prison sentence on ground of mental illness otherwise he will be released at the end of a prison sentence.

Civil responsibilities of mentally ill person

Management of property

In case the court ascertain that a person is of unsound mind and incapable of managing his property, a manager is appointed by court of law to take care of his property which may include selling or disposal of property to settle debts or expenses.

Marriage

As per the Hindu marriage act 1995, marriage between any two individuals one of whom was of unsound mind at a time of marriage is considered null and void in the eyes of the law. Unsoundness of mind for a continuous period can be sighted as a ground for obtaining divorce. The other party can file divorce when unsoundness continues for a period of 2 years however divorce is granted with a precondition that one has to pay maintenance charges for the mentally ill.

Testamentary capacity

Testamentary capacity of the mental ability of a person is a precondition for making a valid will. The testator must be the major, free from coercion, understanding and displaying soundness of mind.

Right to vote

A person of unsound mind cannot contest for elections or exercise the privilege of voting.

Rights of psychiatric patients

Right to wear their own clothes
right to informed consent
right to habeas corpus
right to have individual storage space for their private use or right to privacy
right to keep and use their own personal possessions
right to spend some of their money for their own expenses
right to have reasonable access to all communication media like telephones
right to see visitors
right to treatment in the least restricted setting
right to hold civil service status or enter into legal contracts e.g marriage, personal last will etc
right to refuse treatment especially ECT
right to manage and dispose of property and execute wills

Aims of management in forensic work

diagnose to form a basis for treatment and recommendations to court
make report and submit to court
rehabilitate as part of management
promote acceptance of individual in his community
resettle individual back in community
promote after care following discharge from court and hospital

Legal responsibilities of a nurse

Psychiatric nurses are confronted on daily basis with the interface of legal issues as they attempt to balance the rights of the patient with the rights of the society. Nurses and other health care providers should never in any way violate the rights of the mentally ill.

Nurses should be aware of;

All the laws in the state in which they practice so as to protect herself from liability and patient from unnecessary detention and mistreat
patients’ rights
criminal and civil responsibilities of ill patients
legal documentation

In addition to knowing the above, the nurse should also;

protect patients’ rights
keep legal records safely
maintain confidentiality of patients information
take informed consent from patients of relatives for any procedure
explain based on the level of anxiety, span of attention and level of ability to decide

Nursing Malpractice

Malpractice involves failure of professionals to provide proper and competent care that is given by members of their profession, resulting in harm to the patient.

Common areas of liability in psychiatric service

patient committing suicide
misuse of psychoactive prescription drugs
failure to obtain consent
failure to report abuse
breach of confidentiality
failure to diagnose
inadequate monitoring of patients

Steps to avoid liability in Psychiatric nursing Services

reporting information to co-workers involved in patient care
clearly and accurately maintaining records
maintaining confidentiality of patients information
practice within the scope of state laws and nurse practice act
collaborate with colleagues to determine the best course of action
use established practice standards to guide decisions and action
always put patients’ rights and welfare first
develop effective interpersonal relationship with patients and family.
document all assessment data, treatment given, any interventions and evaluation of the patients response to care accurately and thoroughly.

To successfully argue a case of malpractice against a physician or psychiatric nurse;

The Patient must prove 3 conditions;

There is an established standard of care.
The physicians breached his/her responsibility to the plaintiff.
The physicians breach of responsibility caused injury or damage to the plaintiff.

Compensatory damages are awarded to the patient and reimbursed medical expenses, lost salary or physical suffering.

Punitive damages are awarded to the patient only in order to punish the doctor or nurse for gross negligence or carelessness.

Mental Treatment Act

LEGAL DOCUMENTS AND ADMISSION OF CIVIL PATIENTS.

Civil patients are admitted under the mental treatment act which was passed in 1964 in parliament to replace the mental treatment ordnance which was passed in 1938.

REASONS FOR PASSING THE MENTAL TREATMENT ACT

To safeguard the people with unsound mind from the public and vice vasa
To authorize the mental hospitals to detain, treat, and discharge the mentally ill patients.

There are four orders under which civil patients are admitted in mental hospitals. These ;

Urgency order
Temporary detention order
Reception order
Voluntary order

URGENCY ORDER

This is provided by sec 7 of MTA. It is for quick removal of the mentally ill from the public to the mental hospital. It is signed by any of the following;

A medical practitioner who is licensed eg registered nurse, dr, pco etc
A police officer not below the level of the assistant inspector of police.
A gazzetted chief eg a RDC,

This order remains in place for a period of 10 days. If the patient has not improved, another urgency order is signed. It is not renewed. If not cancelled after 10 days the patient has the right to sue the hospital for illegal detention.

TEMPORARY DETENTION ORDER

This is section 3 of MTA

This is the standard procedure for detaining the mentally ill patients in the mental hospital. The first and important thing is the information of the lunacy.

It can be made by any one at the ward, but in practice, it is made by the ward in charge.

This order remains in place for 14 days but can be renewed for another 14 days when it expires and cannot be renewed any further.

RECEPTION ORDER

This is section 5 of MTA

If the patient does not improve after renewing of the temporary detention order, a magistrate appoints 2 medical practitioners not related to the patient to dig out patent’s information pertaining his behavior and illness.

After the magistrate has received the medical reports, and is satisfied with the reports, he sign the order. This order remains in place for a period of 1 year. If the patient does not improve within one year, it can be renewed for another year, if still the patient has not improved, the order is renewed for 3 years, and will be renewed every 3 years.

Patients under this section are said to be satisfied and nor allowed to sign a will, vote, or stand as witness in court or marry.

VOLUNTARY ORDER

This not under the MTA but is usually legally accepted.

Here the patient comes to the hospital by himself and is directed to the medical superintendent or director who examines the patient and confirms he is mentally sick or not.

The patient will promise to abide by hospital rules and regulations.

If this patient feels he wants to leave the ward, he informs the ward in charge with in 72 hrs who in turn informs the ward doctor that will also inform the medical director or superintendent.

DISCHARGE OF CIVIL PATIENTS

Role of a nurse in discharge procedure

Identify the fitness of the patient and inform the ward doctor ( psychiatrist)
Provides feed back and information about patients discharge and seek patient’s opinion.
Make sure all the paper work and forms are ready, signed and copies sent to the records.
Ensure the patient hands over all the hospital property to the ward manager.
All necessary information especially regarding medications, follow up dates, should be made clear to the patient.
The nurse must bare in mind that the patient may be having mixed minds about staying in the hospital and going back to the community. And so must help the patient to coup.
Depending on circumstances, the patient’s community should be well prepared to receive and stay with the patient.
The nurse should at least escort the patient out of the ward or hospital compound.

Civil patients are discharged under the following sections in MTA

SEC 18; FOR RECOVERED PATIENTS

After the nurse has approved the fitness she informs the ward doctor who recommends the fitness and writes to the director reply and authorizes the doctor to discharge the patient on treatment. But in case the patient is on temporary detention or reception order, the magistrate if informed who then authorizes the discharge of the patient on treatment.

SEC 19; DISCHARGE OF A PATIENT UNDER THE CARE OF THE RELATIVES

If the relatives so wishes to take their patient, they should make a statement indicating that they are going to take care of the patient at home. If the patient becomes un manageable at home with in 28 days from the day of discharge, he/she can be re admitted using the previous order. But if 28 days have expired, then a new order is signed.

No drugs shall be provided unless they pay for it because it is a discharge against medical advice.

SEC 20; DISCHARGE FOR A PAYING PATIENT.

If the relatives think that they may not be able to pay the increasing costs of medical bills, they may request the medical suppretendant to discharge the patient. If the patient is still not yet well but relatives insists on discharge, the patient is discharged on a condition that if anything happens at home, the hospital will not be counted responsible. No medication is provided on discharge unless they pay for it.

SEC 21; DISCHARGE ON TRIAL LEAVE

The director of medical services authorizes the medical sup or ward Dr to discharge the patient an a trial leave for a specified period of time usually 28 days to return to the hospital for review. If the patient exceeds the 28 days given, then the patient if he /she is to be re admitted, afresh order must be signed.

SEC 22; DISCHARGE FOR ESCAPEE PATIENTS

If the patient escapes and does not return with in28days, the if brought back, he/she should not be re admitted unless a fresh order is signed. this section caters for for the safety of the hospital and management.

SEC 23; DISCHARGE OF A PERSON OF SOUND MIND;

If the person of a sound mind is detained against his will, the magistrate examines the person together with the psychiatrist and will direct the medical supretendant or ward doctor to immediately discharge the person.

SEC 36; TRANSFER OF PATIENTS

This section has 2 sub sections,

Transfer of a patient from one hospital to another within the same country. If the patient or relatives or doctor deems it necessary to transfer the patient this section will allow the transfer.
Transfer of a patient from one country to another. This section allows the transfer of a mental patient from one hospital to another hospital in a different country.

Sec 38; TRANSFER OF A FOREIGNER BACK TO THEIR OWN COUNTRY.

This provides the mandate to transfer a foreign mental patient back to his/her own country of origin.

ADMISSION AND DISCHARGE OF A CRIMINAL MENTAL PATIENT.

These are forensic patients. They can be classified into 2.

Remand patients
Class A, B and C patient.

REMAND PATIENTS (panel code act 106)

These are accused persons charged with an offence but are suspected to be of un sound mind while undergoing court proceedings .

They are taken to the mental hospital by the magistrate for ;

Observations
Investigations
Medical report as requested by the magistrate

ADMISSION OF A REMAND PATIENT.

They are brought to the mental hospital on a warrant of commitment on remand signed by the judge or a magistrate. With affixed date or open date to re appear in court.

FIXED DATE REMAND.

This is when the date of the accused to appear in court is specified. When the date reaches, the patient is sent to court accompanied by the medical report stating whether the patient is capable or incapable of pleading. If capable then he is straight away sentenced but if incapable then he/she is brought back to the hospital as class B patient.

OPEN DATE REMAND.

This is when the date of next hearing is not indicated on the warrant of commitment and when a need arises the patient is collected on a production warrant signed by the magistrate.

CLASS A PATIENT.

These are prisoners who develop mental disorders while serving their sentences in prison

ADMISSION OF CLASS A PATIENTS

They are transferred from prison to the mental hospital on the following orders.
Temporally detention order or reception order
Warrant of commitment indicating the offence committed
Warrant slip on which the expiring of the sentence is indicated’

DISCHARGE OF CLASS A PATIENT.

If the patient recovers when the sentence has not yet expired, he/she is taken back to the prison to finish his sentence on a production warrant signed by the magistrate.

If the sentence expires when the patient is in the hospital he will be discharged directly home under sec 18 of the MTA.

If the sentence expires when the patient is in the hospital and has not shown any signs of improvement he/she is called off from the register and transferred to a civil hospital on civil orders.

CLASS B PATIENTS

These are patients admitted from the court having been incapable of making their own defense and follow the court proceedings due to insanity.

They are admitted on in a mental hospital for observations and treatment on the following orders.

Warrant of detention of the accused person incapable of making a self defense signed by the minister of justice or attorney general.
Warrant of detention of accused person incapable of making a self defense signed by the magistrate or judge pending the minister’s order.

DISCHARGE OF CLASS B PATIENT

When the patient is able to plead, a psychiatrist makes a certificate of mental fitness which is taken to the director of public prosecutions who will arrange for the hearing in court.

After pleading, if the accused is found guilty, he/she is sentenced directly. But if found not guilty, due to reasons of insanity he is sent back to the mental hospital as class C patient.

CLASS C PATIENTS.

They are admitted from the court after pleading not guilty due to reasons of insanity. They are admitted on the following orders.

Warrant of detention signed by the judge or magistrate pending minister’s order
Minister’s order with a heading ORDER OF DETENTION of a person of un sound mind not found guilty due to reasons of insanity.

DISCHARGE OF CLASS C PATIENTS.

Depending on the ministers order the patient after recovery is discharged directly home unless otherwise ordered by the minister.

Law and Mental Illness Read More »

Resuscitation

Resuscitation of a Newborn

Resuscitation is a mean of restoring life to a baby from the state of asphyxia.

It is a single intervention of birth asphyxia (Devi, Upendra, and Bard, 2017). Resuscitation is helping a baby to breath.

The first 28 days of life is called neonatal period and incontrovertibly, it is the most vulnerable and high risk time in life because of the highest mortality and morbidity that occur in this period. The day of birth is the riskiest time to a baby (Sajjad, 2012; and WHO, 2015).

APAGAR SCORE

Aims of Management.

To initiate and/or restore respiration /breathing
To prevent infection
To prevent other complications
To Prevent hypothermia

Requirements

A pair of surgical gloves
Warm baby’s clothes.
Suction device e.g bulb syringe
Ventilation bag and mask (ambu bag)
Endotracheal tube to give oxygen direct to the lungs (size 1mm for full term or 0.5mm preterm babies)
laryngoscope
Nasal gastric tube
3 Gallipots
3 Receivers
Mothers chart
Tray containing a gallipot of wet swab, syringes.
Pediatric stethoscope
Strapping
Naso prongs (oxygen catheters)

Drugs

Naloxone hydrochloride 1mg ampoule 400mg/1ml
Adrenaline (Epinephrine) 1:1000
Normal saline 0.9%
Ringers lactate
Sodium bicarbonate 4.2%
Dextrose 10%
Vitamin K
Sterile water

Bed side

Resuscitation table
Timer (clock watch)
Light source
Oxygen source
Displayed chats for steps

Principles of Management.

Temperature regulation. Ensure adequate warmth for the baby to prevent hypothermia which leads to decreased metabolic which cause additional stress to the baby.
Ensure adequate oxygenation to the baby to prevent hypoxia by administration of oxygen and monitoring oxygen perfusion. An endotracheal tube should be inserted and oxygen administered
Prevention of hypoglycemia by regular monitoring blood glucose and if risk for hypoglycemia is identified administer dextrose as per prescription.

Steps for Resuscitation

TABCs of resuscitation

STEP 1

Dry the baby, wipe the baby’s mouth with gauze and remove any wet cloth.

STEP 2

Clear the air way by;

Suck blood or mucus from mouth using a bulb syringe or mucus extractor.
Position baby’s head in a neutral position with head extended.
Place a small towel under the shoulders to maintain the position.

STEP 3

Support breathing by;

Stand at the baby`s head, apply ambu-bag and a small mask to the baby’s face ensuring that the mask covers the face and mouth to form a seal.
Give five inflation breaths (each 2-3seconds duration).
Observe response by looking at the chest movements (chest rising) or increase in the heart rate. (if chest does not rise then reapply mask, reposition baby’s head, and suction.)
Continue ventilating at a rate of 30-40 breathes for a minute.
Circulation/External Cardiac Massage
Chest compression should be performed when the heart rate is less than 100b/m and falling inspite adequate ventilation
If no heart beats are recorded after one minute, do external compressions.
Wrap your palms around the baby`s chest, placing the thumbs / first finger over the lower part of the sternum.
Chest is compressed at rate of 100–120 times 1 minute at a ratio of 3 compressions to one ventilation
Use the thumb to gently compress the chest, depressing it ½ to ¾ inch each time.
If in 20 minutes the breathing is not established. Consider intubation.
When the infant has no spontaneous breathing then continuous positive pressure ventilation (CPPV) should be started with bag and mask.
The rate of chest compressions in one minute should be 90 along with 30 PPVs, (3:1), a total of 120 events.
If the heart rate is <60, despite of effective ventilation, chest compression and two intravenous doses of adrenaline (Epinephrine), the sodium bicarbonate 4.2% solution (0.5mmol/ml) can be administered using 2–4ml / kg (1-2mmol/ml) by slow intravenous.

Adrenaline (Epinephrine)

This is indicated if the heart rate is <60, despite 1 min of effective ventilation and chest compression. An initial dose of 0.1-0.3 ml/kg of 1:10,000 solution give i.v. repeated after 3 minutes for a further two doses.

10% dextrose

(Hypoglycemia is not usually a problem) 3mls/kg i.v via the umbilical vein to correct low blood sugar of <2.5mmol/L
Volume replacement
On rare occasions, bradycardia will not respond to volume expansion and bradycardia that does not respond to chest compressions or drugs is suggestive of hypovolemia–0.9% normal saline 10 ml /kg initially via the umbilical vein.

Naloxone hydrochloride

This is not an emergency drug parse it is a powerful anti-opioid drug used to reverse the effects of maternal narcotic drugs given towards the end of first stage of labour (Preceding 3hours.)
Dose 0.1–0.2 mg per kilogram body weight intramuscular.

Calcium gluconate

A dose of 100mg kg body weight and 150 adrenaline 0.1-0.5mg/kg 1 min given for severe bradycardia or cardiopulmonary arrest
Vitamin K–given prophylaxis against bleeding disorder.

Drugs

If there is no heart beat after 1 minute of breathing for the baby:
Inject 0.5 mls of 1;10,000 adrenaline solution intravenously or through the umbilical vein. Give 1 to 2 mls per kilogram body weight of 25% dextrose solution intravenously.
Continue to monitor response to resuscitation by using APGAR score.
- If the baby responds to resuscitation keep the baby warm and transfer to the special unit (NICU).
- If baby is breathing well, keep reassuring the mother
- If baby is breathing well, breast feeding should be encouraged. If no response discontinue resuscitation.

Resuscitation Read More »

Obstetric Anatomy Q & A

Obstetric Anatomy, Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period

Question 1

(a) Describe the vagina.

(b) Outline indications of vaginal examination.

(d) List contraindications of vaginal examination

SOLUTIONS.

A vagina is a muscular fibrous canal which forms the part of the internal female reproductive organs

Situation

It is a canal which extends from the vestibule below to the cervix above running in an upward and backward direction between the planes of the pelvic brim.

Shape

It is a potential tube which runs upwards and backwards with its walls in close contact but can be separated during coitus, menstruation, vaginal examination and child birth.

Size

The anterior wall measures 7.5cm

The posterior wall is longer and it measures 10cm.This is because the uterus enters the vagina at an angle of 90 degrees and bends forwards towards the anterior wall hence it encroaches on it

Structure

Gross structure

Superiorly; the upper end of the vagina is known as the vault, where the cervix protrudes into the vault it forms circular recess known as fournices.

The vagina is made up of four fournices that is to say; The anterior fornix which is smaller and fairly deep The 2 lateral fournices which are shallow

The posterior fornix which is the longest and deepest

The lower end of the vagina is narrow and inferiorly we find the vulva_hymen enclosing the vaginal opening only present in virgins. If hymen is ruptured it leaves tags of membranes referred to as carunculae mytiformes. Vaginal orifice is also called introitus.

Microscopic structure

It is made up of four layers;

Squamous epithelium arranged in folds known as rugae and makes the inner most layer of the vagina, the rugae increase the surface area and offer the vagina ability to stretch when need be for example during coitus and child
Vascular connective tissue layer which is rich in blood vessels, nerves and lymphatics and is found just beneath the epithelium.
Muscular layer. This is thin but a strong layer which is divided into two; the weak inner circular and strong outer longitudinal fibres.
The pelvic fascial which is made up of loose connective It forms the outer protective coat and is continuous with the pelvic fascia.

Blood supply (arterial)

The vagina is supplied by the branches of internal iliac artery which include vaginal artery and uterine artery

Venous drainage

By the corresponding veins ie branches of internal iliac veins which include vaginal veins and uterine veins.

Lymphatic drainage

Into the inguinal, the iliac and the sacro glands

Nerve supply

By the sympathetic and parasympathetic nerves which are branches from the lee Franken lanser plexus

Contents of the vagina

It doesn‘t contain any glands but its kept moist by cervical mucus and a transudation from the underlying blood vessels through the epithelium.

Its media is acidic (PH 3.8 to 4.5) and this is made possible by presence of lactic acid after action of doderleins bacilli on glycogen

Relationships of the vagina

Anteriorly

Below, the base of the bladder rests on the upper ½ of the vagina and the urethra is embedded in the lower ½.

Posteriorly

Pouch of Douglas above, the rectum medial and perineal body below Laterally

Pubococcygeous muscles below and pubic fascial containing the uterus above Inferiorly

The structure of the vulva Superiorly

The cervix and the fournices

Functions of the vagina

Exit from menstrual flow
Entrance for spermatozoa
Exit for products of conception
Supports the uterus
Prevents ascending infection due to acidic PH
For assessing the pelvis
Drug administration

PART B

Indications of vaginal examination

Indications can be divided into during pregnancy, labour and puerperium

During pregnancy

To confirm pregnancy using hegars, jacquemiers and osianders signs
To rule out abnormalities in genital organs g. polyps, cervical erosion and cancer of the cervix
To rule out causes of bleeding in early weeks

During labour

First stage of labour

To diagnose onset of labour
To determine progress of labour by finding out degree of cervical dilatation
To note state of membranes
To confirm presentation, position and engagement of head
To assess moulding
To exclude cord prolapse when membranes rupture
To note dilatation before giving a narcotic

Second stage of labour

To confirm second stage of labour
To note cause of delay in second stage of labour
To confirm presentation of second twin before rupturing membranes

Third stage of labour

To determine cause of postpartum haemorrhage
Incase of retained placenta, to detect cause of retained placenta and exclude construction ring
To detect condition of birth canal following child birth

During puerperium

To rule out cause of secondary PPH
At 6-8weeks after delivery, to detect if the reproductive organs have gone back to their pregravida state.

Information to note on vaginal examination

On inspection

State of the vulva, note any abnormal discharges like pus, blood, abnormal growths like warts, oedema and scars.

On examination

Note condition of the vagina

Normally the vaginal walls feel warm and moist and dilatable. If dry may be a sign of infection or obstruction.

State of the cervix

If thin, thick, whether soft or rigid and whether its well applied to the presenting part.

Note dilatation and cervical effacement.

State of the membranes

Whether intact or ruptured. If ruptured check colour and smell of liquor

Presentation and presenting part

Note level of presenting part in the pelvis

Confirm position by finding or palpating sutures and fontanelles and relate them to the maternal pelvis.

Note moulding.

Do internal pelvic assessment and note

-sacro promontary if protruding
-hollow of the sacrum if well curved
-sciatic notches if well rounded
-ischial spines if prominent
-sub pubic arch-if it accommodates 2 ½ to 3 fingers
-inter tuberous diameter if it accommodates 4 knuckles

Contraindications of vaginal examination

Ante partum haemorrhage
Threatened abortion
Elective caesarean section

a) Describe

b) Outline the formation of the

c) List variations of the placenta

SOLUTIONS

Describe Fertilization

Fertilization is the fusion of the male gamete (sperm) and female gamete (ovum)

Fertilization occurs when the female gamete fuse to form a zygote during the time of intercourse, about 300 million spermatozoa are deposited into the vagina.

Some sperms cannot survive the acidic media of the vaginal secretions so the weak ones die and only the strong ones survive.

The surviving sperms continue moving forwards this is made possible by the special arrangement of the mucus lining of the cervix (arborvitae) which prevents back flow of sperms.

Sperms continue their journey but still the weak ones continue to die off. Movement is slowed down by the presence of hair like projections called cilia and more eradication of weak sperms continues. And if ovulation had taken place within 48 hours and the ovum is still viable the two gametes will meet in the ampulla and fusion will take place hence fertilization.

b) Outline the Formation of the Placenta

Placenta is a vital organ of communication between the mother and the fetus.

It‘s a maternal-fetal organ which begins developing at implantation of the blastocyst and is delivered with the fetus at birth.

Formations of the placenta

Maternal surface

This is the surface next to the uterus

Its dark red in color due to presence of maternal blood and it has 18-20 lobes which are collections of chronic villi each cotyledon is separated from the other by tissues.

Fetal surface

This is the surface next to the fetus

It has a shiny surface due to presence of amniotic membrane

c). List variations of the placenta / abnormalities of the placenta

Succenturiate lobe

This occurs due to abnormalities in development and it is the most significant abnormality. The additional lobule separates from the main part of the placenta.

Circumvallated placenta

It is an opaque ring seen on the fetal surface of the placenta and this is due to doubling back of the chorion and amnion

Bi-partite placenta or bi-lobed placenta

This placenta has two complete and separate parts each with a branch of umbilical cord vessels which later join to form one cord.

Battledore insertion of the cord

In this the placentas cord is inserted at the edge/margin of the placenta and the placenta has an appearance of a table tennis bat in shape.

Velamentous insertion of the cord

The cord is inserted into the fetal membranes some distance away from the edge of the placenta.

The diagram below shows the different variations of the placenta discussed above.

a) Describe the non-pregnant

b) What changes take place in this organ during pregnancy?

Description of the non pregnant uterus

This is a hollow muscular pear /ovacado shaped

Situation

It is situated in the true pelvis between the urinary bladder and the

Size

It is 5cm, long 5cm wide, and 2.5cm thick so each wall is 1.25cm thick.

Position

The uterus is anteverted (bends forward) and anteflexed (bends on itself)

Shape

The uterus is pear shaped (avocado) with the upper part bigger than the lower part .

Description of the non pregnant uterus

Gross structure

This is made up of the following

The body.

This forms the upper part of the whole uterus.

Fundus

This is a raised area between the insertion of the uterine tubes.

Cornua

Upper outer angles of the uterus where the uterine tubes are inserted. This is made up of the following

Cavity

This is a potential space between the anterior and posterior uterine walls.

It is triangular in shape.

Isthmus

This is a narrow area between the body of the uterus and the cervix.

Cervix or neck

This forms other lower third of the whole uterus into the

Microscopic structure

Endometrium

this is a layer of ciliated mucus
It changes constantly with the menstrual cycle
It lines the uterine cavity and shades off during menstruation up to the basal
The cervical endometrium does not change during menstruations

Myometrium

Middle layer and is formed by different muscle fibres.
Longitudinal fibres ;mainly found in the upper part of the uterus .
Oblique muscle fibres ;mainly found in the fundus
Circular muscle fibres which are located at the cornua and they prevent contractions extending to the uterine tubes.
Some are found around the cervix which help in dilatation during labour.

Perimetrium

It is a serous membrane which is a continuation of the peritoneum
It covers the outer aspect of the uterus.
It bends upwards to form the uterovesco pouch anteriorly and the pouch of dauglous posterioly

Blood supply

By uterine arteries which are the branches of the internal iliac artery and they supply the lower ovarian arteries the branches of the abdominal aorta and supply the upper parts.

Nerve supply

By sympathetic and parasympathetic
Lymph drains into internal illiac glands

Supports

The uterus is supported by pelvic floor muscles and maintained in position by ligaments.
Transverse ligament
Utero sacral ligament
Pubo cervical ligament
Broad ligament
Round ligament and,
Ovarian ligament.

Relations of the Body of the Uterus

Anteriorly:The bladder and vesco-uterine pouch.
Posteriorly: The pouch of douglas
Laterally: The broad ligament on each side uterine tubes and ovaries.
Superiorly: intestines
Inferiorly :vagina

Functions of the uterus

It shades the endometrium during menstruation
To prepare a bed for the fertilized ovum
It shelters the fetus during pregnancy
It expels the products of conception at term
To involute following childbirth

(B) THE PHYSIOLOGICAL CHANGES THAT OCCUR IN UTERUS DURING PREGNANCY

Pregnancy

Is the growth and the development of a fertilized ovum from the time of conception until its expulsion. In normal pregnancy expulsion of the fetus takes place at term. Thus, 38-42 weeks of gestation with an average of 40 weeks.

Physiological changes that take place during and pregnancy are associated with and caused by the effects of specific hormones.
These are temporary adaptations of the body that helps to meet the demands of the fetus.

CHANGE IN THE UTERINE SIZE DURING PREGNANCY.

The body of the uterus

After conception, the body develops to provide a nutritive and a protective environment into which the fetus will grow and develop.

Size: 7.5x5x2.5- 30×23 x20 (cm)

Weight: changes from 60 to 1000gm

Uterine shape and situation.

The uterus changes to a globular shape to accommodate the growing fetus, increasing amounts of liquor and placental tissues.

The lowest part of the uterus elongates 3 times its original length during the first trimester, giving the appearance of a stalk below the globular segment. This is the beginning of the upper and lower uterine
By 12^th week of pregnancy, the uterus rises out of the pelvis and becomes upright. It is no longer anteverted and ante flexed. It is about the size of a grape fruit and may be palpated abdominally above the symphysis pubis.
By 16^th week, the conceptus has grown enough to put pressure on the isthmus, causing it to open out so that the uterus become more globular n shape.
By 20^th week of pregnancy, the uterus becomes spherical in shape and has a thicker, and more rounded fundus. As the uterus continues to rise in the abdomen, the uterine tubes, being ristricted by attachments to the broad ligaments, become progressively more At 20^th week the fundus of the uterus may be palpated at or just below the umblicus.

At 30^th week, the lower uterine segment can be It is the portion of the uterus above the internal os of the cervix. The fundus can be palpated midway between the umblicus and the xiphisternum.

The uterus reaches the level of the xisphisternum by the 38^th A reduction in fundal height , known as lightening, may occur at the end of pregnancy when the fetus sinks into the lower pole of the uterus.

Decidua

The decidua is the name given to the endometrium during pregnancy. Estrogen and progesterone produced by the corpus luteum, causes decidua to become thicker and richer and more vascular at the fundus and in the upper body of the uterus, which are the usual site for implantation.

The decidua provides a glycogen rich environment for the blastocyst until the placenta is formed.

Myometrium.

It is made up of smooth muscle fibres, held together by connective These muscle fibres grow up to 15 to 20 times their non pregnant length.
The hypertrophy and hyperplasia of the uterine muscle is due to the effect of estrogen and
The uterus continues to grow in this way for the first three months, after which the growth is related to the distension by the growing
The wall of the myometrium become thicker during the first few months of pregnancy, and as gestation advances, the walls become thinner owing to the gross enlargement of the uterus being only 5 cm thick or less at term.
These prelabor contractions are associated with the ―ripening of the cervix‖ and eventually becomes the contractions of labor as the effects of estrogen supersede those of progesterone e. progesterone normally suppresses myometrial activity.
During pregnancy, the muscle layers become more differentiated and organized and organized for their part in expelling the fetus.
The thickness of the upper uterine acts as a piston to force the fetus into the receptive, passive lower uterine segment.

Contractions of these muscles fibres is necessary to entrap and enmesh bleeding vessels and ligate them after the placenta is delivered.

The inner circular layer is thin and forms sphincters around the openings at the cornua, and around the lower uterine segment and

Blood vessels

The uterine blood vessels increase in diameter and new vessels develop under the influence of estrogen. the blood supply through the uterine and ovarian arteries increase to about 750mls per minute at term to keep pace with its growth and also to meet its needs of the functioning placenta.

The cervix

The cervix remains tightly closed during pregnancy , providing protection to the fetus and resistance to the pressure from above when the woman is in a standing up
The mucus secreted by the endo cervical cells become thicker and more viscous during The thicken mucus then forms a plug called the operculum, which provides protection from ascending infections.
Cervical vascularity increases during pregnancy, giving the cervix a bluish color if viewed through a speculum.
The cervix remains 5cm long throughout pregnancy.
In late pregnancy, softening or ripening of the cervix occurs making it more distensible. The muscles of the fundus enhance tension in the outer longitudinal layer of muscles of the cervix contributing to the process of effacement.

Obstetric Anatomy Q & A Read More »

Ectopic Pregnancy

ECTOPIC PREGNANCY

Ectopic pregnancy is a gestation that implants outside of the endometrial cavity.

Ectopic pregnancy is an implantation of a fertilized ovum outside the uterine cavity.

An ectopic pregnancy most often occurs in a fallopian tube. This type of ectopic pregnancy is called a tubal pregnancy.

An ectopic pregnancy is estimated to occur in 1 of every 80 spontaneously conceived pregnancies.

ANATOMICAL LOCATION OF ECTOPIC PREGNANCY

Tubal (99%)

Ectopic Pregnancy occurs anywhere in the fallopian tube.
The most common site is the ampulla.
Interstitial (cornual) pregnancies occur in the most proximal tubal segment, which runs through the uterine cornua. This type of ectopic pregnancy can grow to be quite large, and rupture may cause massive haemorrhage.

Ovarian (0.5%)

Ectopic Pregnancy occurs in the ovary.

Abdominal (less than 0.1%)

Ectopic Pregnancy occurs in the abdomen.
With possible adherence to the peritoneum, visceral surfaces, or omentum

Cervical (0.1%)

Ectopic Pregnancy occurs in the cervix.
A cervical ectopic, in which the pregnancy implants on the cervix itself, is very rare. Most cervical pregnancies will result in miscarriage. The risk of bleeding, either with spontaneous miscarriage, or for those which require surgical intervention, is much higher

Heterotopic Pregnancy

This is a very rare type of multiple pregnancy, in which one viable pregnancy develops within the uterus, and another fertilised egg is implanted elsewhere as an ectopic pregnancy.
It occurs in less than 1 in 30,000 naturally occurring pregnancies, and is slightly more common in couples who conceive through assisted conception.
Both intrauterine and ectopic pregnancies may occur concomitantly.

Caesarean Scar Pregnancy

Rarely, the ectopic pregnancy can be located at the site of the scar from a previous Caesarean section. This occurs in 1 in 1,800 pregnancies.

Cornual/Interstitial

Interstitial ectopic pregnancies are those which occur in the tissue of the Fallopian tube that lies within the muscular wall of the uterus.
It can be quite difficult to diagnose through ultrasound, and may need laparoscopic (keyhole) surgery to confirm the diagnosis.

Other less common sites of ectopic implantation are the ovary, or a rudimentary uterine horn. Rarely, an ectopic may be intraligamentous or in the peritoneal cavity

CAUSES AND RISK FACTORS FOR ECTOPIC PREGNANCY

The occurrence of ectopic pregnancy has been associated with abnormal function of the fallopian tubes. Normally, the tubes facilitate collection and transport of the oocyte and embryo into the uterus. The integrity of the fimbria, lumen, and ciliated mucosa appears to be important for transport. Conditions thought to prevent or retard migration of the fertilized ovum to the uterus increase the risk for an ectopic pregnancy.

Abnormal Function of Fallopian Tubes:

Normal function of the fallopian tubes, involving the integrity of fimbria, lumen, and ciliated mucosa, is crucial for the proper transport of the oocyte and embryo into the uterus.
Conditions hindering migration of the fertilized ovum to the uterus elevate the risk of ectopic pregnancy.

Pelvic Inflammatory Disease (PID):

Inflammation and scarring from PID affect intra and extra luminal structures, impairing normal tubal function.
Severe damage may result in complete tubal blockage and infertility.

Tubal Surgery and Related Procedures:

Tubal surgeries, bilateral tubal ligation, and tubal reanastomosis may lead to scarring, narrowing, or false passage formation.
Other pelvic and abdominal surgeries may cause peritubal adhesions, although not directly associated with ectopic pregnancy.

Chlamydia, Gonorrhea, Endometriosis, and Salpingitis:

Infections, especially Chlamydia and gonorrhoea, which causes PID, contribute to inflammation and scarring.
Conditions like endometriosis and salpingitis increase the risk of ectopic pregnancy.

Artificial Reproductive Techniques:

In-vitro fertilization and gamete intrafallopian transfer have been linked to an increased risk of ectopic pregnancy.
Retrograde embryo migration is considered a possible mechanism.

Delayed Fertilization:

Possible transmigration of the oocyte to the contralateral tube and slowed tubal transport can delay the passage of the morula to the endometrial cavity.

Chromosomal and Structural Anomalies of the Conceptus:

Anomalies in the chromosomes or structure of the conceptus may predispose individuals to ectopic pregnancy.

Developmental Abnormalities of the Tube:

Abnormalities like diverticula, accessory ostia, and hypoplasia in the tube can elevate the risk of ectopic pregnancy.
Exposure to diethylstilbestrol increases the risk four to five times.

RISK FACTORS FOR ECTOPIC PREGNANCY:

Increased Maternal Age: Advanced maternal age is identified as a risk factor for ectopic pregnancy.
History of Previous Ectopic Pregnancy: Individuals with a history of ectopic pregnancy have a 15% to 20% risk of recurrence in subsequent pregnancies, in either the same or opposite tube.
History of Infertility: Infertile couples exhibit an increased proportion of ectopic pregnancies compared to the total number of pregnancies, regardless of the cause of infertility.
Contraceptive Methods: Certain contraceptive methods carry a higher risk, including Progestasert IUD (15%), intrauterine devices (5%), and diaphragms. Oral contraceptives have a 1% risk, while intrauterine devices are highly effective at preventing intrauterine pregnancy, making any pregnancy in an IUD user more likely to be tubal.
Progestin-only Contraceptives: Users of progestin-only oral contraceptives and injectable progestins face an increased risk of ectopic pregnancy if pregnancy occurs, possibly due to altered tubal motility.
Peritubal Adhesions: Adhesions following post-abortal or puerperal infections, appendicitis, or endometriosis contribute to the risk of ectopic pregnancy.
Cigarette Smoking: Studies indicate that cigarette smoking causes tubal ciliary dysfunction, contributing to the risk of ectopic pregnancy.
Endometriosis: Endometriosis can make the uterus unsuitable for implantation, increasing the likelihood of ectopic pregnancy.

WHY AN ECTOPIC PREGNANCY HAPPENS?

Pathophysiology of an Ectopic Pregnancy.

Fertilization occurs at the usual distal third of the fallopian tube.
After the union, zygote begins to divide and grow.
However, due to an obstruction by several factors (see Risk Factors), the zygote cannot travel through the length of the tube.
It lodges on that constricted part and implantation takes place at that area instead of the uterus.

In a normal pregnancy, an egg is fertilized by sperm in one of the fallopian tube which connect the ovaries to the womb .The fertilized egg moves and implants itself into the womb lining endometrial ,where it grows and develops

So for an ectopic pregnancy, it occurs when a fertilized egg implants itself outside the womb.

CLINICAL PRESENTATION OF ECTOPIC PREGNANCY

An ectopic pregnancy does not cause noticeable symptoms and is only detected during routine pregnancy testing. However, most women do have symptoms and these usually become apparent between 5 to 14 weeks of gestation.

The Classic Triad of symptoms of ectopic pregnancy consists of

Amenorrhea,
Vaginal bleeding, and
Lower abdominal pain.

Acutely ruptured ectopic pregnancy.

This clinical scenario represents a surgical emergency. The patient who has experienced rupture of her ectopic pregnancy will most likely have:

On History Taking:

History of amenorrhoea 6 – 10 weeks.
Patient complains of a feeling of fainting, dizziness, thirst, light vaginal bleeding and pelvic pain.
Abdominal distension, Guarding and rebound tenderness.
Patient complains of acute abdominal pain localized in the iliac fossa which is colicky in nature.
She may also complain of ipsilateral shoulder pain from phrenic nerve irritation due to hemoperitoneum from the blood in her abdomen and it occurs in up to 25% of patients.

On Examination:

Signs of pregnancy are present.eg darkening of areolar.
Signs of shock e.g. cold clammy skin, rapid thread pulse, low blood pressure and low temperature
Patient is anxious and restless
Pallor of mucous membranes

On Palpation:

Abdominal tenderness especially on the affected side.
Abdominal muscles become rigid due to mother guarding against pain.
Abdominal distention due to presence of blood in the abdominal cavity.

On Vaginal Examination:

Amount of bleeding does not correspond to the mother’s condition.
Tenderness on movement of the cervix and a mass is felt in the lateral fornix.
Painful mass in the pouch of Douglas.
Dark brown blood on the examining finger.

DIAGNOSIS OF ECTOPIC PREGNANCY

Ultrasound Confirmation: Utilization of ultrasound imaging as a primary diagnostic tool(golden standard).

An ultrasound would reveal an empty uterus and free fluid (blood) in the peritoneal cavity. The diagnosis of ectopic pregnancy may be confirmed by the absence of intrauterine pregnancy (IUP) on ultrasound in a woman with a level of HCG sufficient to normal pregnancy, the absence of intrauterine pregnancy on ultrasound examination is diagnostic for ectopic pregnancy if the gestational age is known for certain or if the HCG level is >2500 IU per ml.
Cordocentesis(Percutaneous umbilical cord blood sampling) , Aspiration of fluid from the cul-de-sac for evidence of intra-abdominal bleeding. It is a technique by which a needle attached to a syringe is inserted transvaginally through the posterior vaginal fornix into the pouch of Douglas to detect any fluid within the peritoneal cavity.

Laparoscopy: Commonly performed surgical procedure for diagnosis. Follows symptoms of bleeding and a positive pregnancy test.
Positive Pregnancy Test: Presence of human chorionic gonadotropin (hCG) in the blood or urine.
Cullen’s Sign: Specific clinical manifestation suggesting a ruptured ectopic pregnancy. Periumbilical bruising due to blood tracking from the ruptured fallopian tube.

Magnetic Resonance Imaging. This is also another way to detect the presence of ectopic pregnancy and it is safer than undergoing a CT scan for pregnant women.
Hematocrit and Haemoglobin Levels: Routine blood tests to assess for signs of anaemia due to internal bleeding.

DIFFERENTIAL DIAGNOSIS OF ECTOPIC PREGNANCY.

Gynecologic problems

Threatened or incomplete abortion
Ruptured corpus luteum cyst
Endometriosis
Gestational trophoblastic diseases
Ruptured corpus luteal cyst
Dysfunctional uterine bleeding
Acute pelvic inflammatory disease
Adnexal torsion
Degenerating leiomyoma (especially in pregnancy)
Salpingitis

Non Gynecologic Problems

Acute appendicitis
Pyelonephritis
Pancreatitis

MANAGEMENT OF ECTOPIC PREGNANCY.

Management has two modalities:

Surgical approach.
Medical approach.

In maternity center

Aims

To prevent shock
To relieve pain
To reassure the patient

Admission: The patient is admitted temporarily in a gynecological ward in a well-made warm bed.
Histories: These are taken including personal, social, surgical, medical, obstetrical history, how the condition started etc
Examination: This is carried out from head to toe to rule out anaemia, dehydration, shocketc
Observation: Temperature, pulse, respiration and blood pressure are taken and recorded to assess functioning of vital organs. The foot of the bed should be raised to allow blood to move to vital centres.
Send for transport as soon as possible and inform the patient and relatives about the decision made and why it is necessary.

Treatment

Put up intravenous infusion of normal saline to prevent or treat shock.. This is to elevate low blood pressure.
Administer morphine or pethidine to relieve pain as prescribed.
Nursing care: The vulva is swabbed and a clean pad is applied.
Send the patient to hospital with a written note stating when the patient reported to the centre, condition on admission and at time leaving and treatment given.

In the Hospital

Aims:

To treat anaemia
To prevent or treat shock
To reassure the patient
To prevent complications

It is a gynaecological emergency, requiring swift action.

Management

Admission: Admit the patient to a well-ventilated room and a warm admission bed. Establish a good nurse-patient relationship.

Histories: Take comprehensive history, including personal data, presenting complaints, and obstetrical and medical history.

General Examination: Perform a head-to-toe examination to rule out anaemia, shock, dehydration, etc.

Observations: Monitor vital signs like temperature, pulse, respiration, and blood pressure. Inform the doctor about the patient.

Investigations: Conduct investigations as required by the doctor, including Hb, grouping and cross-match, ultrasound scan, and urinalysis.

Resuscitation:

Administer intravenous fluids (e.g., normal saline) and maintain a fluid balance chart.
Consider blood transfusion based on haemoglobin results.
Provide pain relief with analgesics like morphine as prescribed by the doctor.
The doctor will determine the operation.

Preparation for Theatre:

Explain the nature of the operation and obtain informed consent.
Reassure the patient to allay anxiety.
Inform theatre staff.
Pass an intravenous line for infusion.
Perform vulva swabbing to minimize infections.
Catheterization is done, and a fluid balance chart is started.
Pass a naso-gastric tube for aspiration of gastric contents or administer an anti-acid like magnesium trisilicate to alkalize stomach contents and prevent aspiration into the lungs.
Pre-medication is given, such as atropine to dry secretions.
Repeat vital observations and compare with baseline observations, recording all findings.
Compile clinical charts and notes, dress the patient in a gown, and transport her carefully to the theatre.
In the theatre, give a full report to the theatre nurse about the patient.
Book about 1-2 units of blood.

SURGICAL APPROACH

Surgical treatment of ectopic pregnancy has the advantage of taking care of the ectopic immediately. It is suitable for emergency care of ectopic pregnancy. It is critical to establish large-bore intravenous lines and to start fluid resuscitation.

Salpingectomy, the removal of the fallopian tube containing the ectopic pregnancy, is the treatment of choice in the following situations:

Future childbearing is not desired.
The tube is severely damaged.
Bleeding cannot be controlled.
The ectopic is in a fallopian tube where an ectopic occurred previously.

Linear salpingostomy, the removal of the gestation through a linear incision in the fallopian tube, may be performed if future fertility is desired.

This procedure is associated with a persistent ectopic pregnancy rate of 3% to 20%.
Therefore, serial quantitative HCG values must be followed to ensure resolution.

Operative laparoscopy may be performed to confirm the diagnosis of ectopic pregnancy and to remove the abnormal gestation via salpingectomy or salpingostomy. This method is used in hemodynamically stable patients. Advantages of this technique over laparotomy include:

Shorter hospital stay
Faster postoperative recovery
Better cosmetic result
Potentially shorter operative time

Laparotomy is reserved for hemodynamically unstable patients who require emergent surgery for a ruptured ectopic pregnancy. This method may also be appropriate when laparoscopy is contraindicated or technically challenging because of extensive adhesive disease from prior surgery.

Cornual resection, may be performed when an interstitial pregnancy occurs. The interstitial portion of the tube is removed via wedge resection into the uterine cornua. Cornual ectopic pregnancies have a higher failure rate with methotrexate and a surgical approach may be more effective.

Oophorectomy is indicated only when an ovarian ectopic pregnancy occurs and salvage of the affected ovary is not possible.

Post-Operative Care:

Post-operative Bed Preparation: Set up the bed with all necessary accessories ready to receive the patient.

Patient Transfer: Inform ward staff, and two qualified nurses go to the theatre to collect the patient. In theatre, receive a full report from the anaesthetist and theatre nurse in a recovery room, reporting the patient’s condition.

Confirm the Report:

Check airway, breathing, and circulation.
Take vital observations.
Observe the site of operation for bleeding.
Observe the catheter to see if it is draining well and in a good position.

Patient Transfer to Ward: After confirming, gently wheel the patient to the ward in a recumbent position with the head turned to one side, observing the airway.

On Ward: Lift the patient from the trolley carefully to a well-made post-operative bed near the nurse’s station for close observations.

Place the patient in a recumbent position with the head turned to one side for drainage of secretions and to prevent the falling back of the tongue.
Conduct observations and record vital signs (temperature, respiration, blood pressure, and pulse) every 1/4, 1/2, 1, 2 hours as per surgeon’s instructions. Adjust the duration based on patient stabilization. Continue observations until the patient is discharged.
Observe the site of operation for bleeding.
Observe the catheter for drainage, color, and the quantity of urine passed.
Maintain a fluid balance chart and balance it every 24 hours to rule out renal failure.
On regaining consciousness, welcome the patient from the theatre, sponge the face, change the theatre gown, conduct mouthwash to remove the anesthetic smell, and offer a pillow.

Fluid/Hydration:

Continue intravenous fluid (e.g., 0.9%) to replace lost fluids.
Observe IV infusion, including cannular site for swelling and drip rate; correct any issues.
Monitor fluid intake and output to avoid overhydration.
Stop IV fluids when bowel sounds are heard, and the patient can take by mouth.
Remove the cannula when necessary, e.g., if the patient has completed intravenous drugs.

Drug Therapy:

Administer prescribed strong analgesics (e.g., pethidine for 48 hours, then switch to mild analgesics like diclofenac 50-100mg tds).
Administer prescribed antibiotics (e.g., x-pen 2mu qid for 72 hours, then change to oral antibiotics if necessary, such as amoxyl 250-500mg tds for 5 days).
Monitor the patient for side effects of the drugs given.
Provide supportive drugs like ferrous and folic acid to prevent anemia.

Wound Care:

Observe the wound for bleeding and add more dressing if needed. Change the dressing if soiled and check for signs of infections.
Conduct daily wound dressing.
Remove stitches on the 7th and 8th day alternately.

Physiology:

Encourage the patient to do deep breathing exercises to prevent chest complications like hypostatic pneumonia.
Encourage passive exercises, such as limb movement, and later active exercises like walking around to prevent deep vein thrombosis.
Provide psychotherapy for continuous reassurance.

Diet:

Conduct a digestion test, and if positive with bowel sounds heard, start the patient on small sips of water.
Introduce soft foods according to tolerance, rich in proteins for tissue repair, roughages to prevent constipation, and carbohydrates for energy.
Note: The nasogastric tube is removed as long as the patient can take orally without any complaint.

Hygiene:

Conduct a bed bath on the first day of operation when the patient is still weak, and later assist her to the bathroom.
Conduct mouth care to prevent neglected mouth complaints like stomatitis, halitosis, etc.
Ensure that the patient’s clothing, bed linen, and the surrounding environment are clean.

Bowel and Bladder Care:

If urine is clear in 24-48 hours, remove the urethral catheter and encourage the patient to pass urine.
Encourage the patient to pass stool, offer privacy, and provide foods rich in roughages to prevent constipation.
In case of constipation and failed conservative measures, give purgatives such as bisacodyl 5-10mg o.d or nocte.

Rest and Sleep:

Keep the patient in a quiet, well-ventilated room.
Restrict visitors, avoid bright light to create a conducive environment for the patient to sleep and rest.

Advice on Discharge: When the patient is fit for discharge, advise on:

Having enough rest at home.
Avoiding heavy lifting to prevent straining the abdominal muscles.
Coming back for review on appointed dates.
Attending ANC clinics when pregnant.
Bringing the husband for treatment if the cause of ectopic pregnancy was PIDs.
Completing the prescribed medications.

In case of Unruptured Ectopic Pregnancy, Medical Approach can be used.

MEDICAL APPROACH

Methotrexate, a chemotherapeutic agent, has been used successfully to treat small, unruptured ectopic pregnancies. This approach has the advantage that it avoids surgery, but the patient must be counselled that it may take 3 to 4 weeks for the ectopic to resolve with methotrexate therapy. Early diagnosis is very paramount for successful management.

Mechanism of action

Methotrexate is a folic acid antagonist that interferes with DNA synthesis. Its action is principally directed at rapidly dividing cells, such as trophoblastic cells.
Once an ectopic pregnancy has been confirmed, 50 mg/m2 is administered intramuscularly in a single or multiple doses with folic acid.
Serial HCG levels are followed every 2 to 4 days after treatment until the HCG level starts to decrease. This is to ensure resolution of the pregnancy
If a 15% reduction is not achieved during the first week, or in subsequent weeks a plateau occurs, then an additional injection of Methotrexate is given or surgical exploration is advocated.
Decreased success has been noted with ectopic pregnancies of greater than 3.5 cm, with fetal cardiac activity, or with high HCG levels (greater than 5000).
After treatment failures, surgical management is usually necessary.
After an ectopic gestation, pregnancy should be avoided for at least 3 months to allow for the fallopian tube architecture to normalize.
Contraception should be provided

Side effects (approximately 5% of patients).

Mild gastrointestinal symptoms such as nausea, vomiting, diarrhoea, and stomatitis are typical.
Potential life-threatening complications include pneumonitis, thrombocytopenia, neutropenia, elevated liver function tests, and renal failure.

Contraindications,

Women who are breastfeeding
Immunodeficiency,
Liver disease, renal disease,
Blood disorders,
Peptic ulcer disease,
Active pulmonary disease should not receive methotrexate.

Criteria for medical management of ectopic pregnancy

Criteria for receiving methotrexate(MTX) (Absolute indications)

Contraindications to medical therapy (Absolute contraindications)

Hemodynamically stable without active bleeding or signs of hemoperitoneum
Non Laparoscopic diagnosis
Patient desires future fertility
General anaesthesia poses a significant risk
Patient is able to return for follow-up care
No contraindications to MTX

Relative indications

Unruptured mass ≤3.5 cm at its greatest dimension
No fetal cardiac motion detected
Patients whose hCG level does not exceed a predetermined value (6000-15,000 mIU/Ml

Breastfeeding
Laboratory evidence of immunodeficiency
Alcoholism, alcoholic liver disease, or other chronic liver disease
Preexisting blood dyscrasias, such as bone marrow hypoplasia, leukopenia, thrombocytopenia or significant anaemia
Known sensitivity to MTX
Active pulmonary disease
Peptic ulcer disease Hepatic, renal, or hematologic dysfunction

Relative contraindications

Gestational sac =3.5 cm
Embryonic cardiac motion

COMPLICATIONS OF ECTOPIC PREGNANCY

The most common complication is rupture with internal haemorrhage which may lead to hypovolemic shock. Death from rupture is rare in women who have access to modern medical facilities.

Infertility
Recurrence
Severe haemorrhage leading to shock
Anaemia due to bleeding.
Infections following operation.
Adhesions due to scar formation during healing process.
Re-occurrence of another ectopic pregnancy.
Infertility if both tubes are affected.

Nursing Diagnosis

Risk for Deficient Fluid Volume related to bleeding from a ruptured ectopic pregnancy.
Fatigue related to early loss of pregnancy secondary to ectopic pregnancy.

Nursing Interventions

Upon arrival at the emergency room, place the woman flat in bed.
Assess the vital signs to establish baseline data and determine if the patient is under shock.
Maintain accurate intake and output to establish the patient’s renal function.

Evaluation

The goal of the evaluation is to ensure that maternal blood loss is replaced and the bleeding would stop.
The patient must maintain adequate fluid volume at a functional level as evidenced by normal urine output at 30-60mL/hr and a normal specific gravity between the ranges of 1.010 to 1.021.
Vital signs, especially the blood pressure and pulse rate, should be stable and within the normal range.
Patient must exhibit moist mucous membranes, good skin turgor, and adequate capillary refill.

Ectopic Pregnancy Read More »

Family Planning Counseling

Family Planning Counseling is a continuous process that you as health care provider, as a counselor provide to help clients and people in the community or health facility make and arrive at informed choices about the size of their family (i.e. the number of children they wish to have)

Counseling is a face to face communication that you have with your client or couple in order to help them arrive at involuntary and informed decisions.

Informed choice is defined as involuntary choice or decision based on the knowledge relevant to the choice or decision.

In order to allow people to make an informed choice about family planning, you must make them aware of all available methods and advantages and disadvantages plus side effects of each .

They should know how to use the chosen method safely and effectively as well as understanding possible side effects.

Aims of Counseling

The primary objective of counseling in the context of family planning is to help people decide the number of children they wish to have and when to have them.
To help clients choose voluntarily, the method that is personally and medically appropriate to them.
To ensure they understand how to use their chosen method correctly for safe and effective contraceptive protection
To clear rumors and misconceptions a client may have about family planning methods

Types of Family Planning Counseling.

There are varieties of approaches for different types of family planning counseling:

Individual counseling
Couple counseling
Group counseling and information sharing

Individual counseling

This is a counseling approach that involves only one client. it involves individual privacy and confidentiality during communication or counseling with you.

It is mostly important when dealing with confidential matters that relate to family planning and other reproductive health issues . E.g.in HIV couples, the woman wants to use family planning but the husband does not.

Couple counseling

Couples counseling refers to counseling sessions in which a woman and her partner are present in discussions with the provider.

However, it must be recognized that couples counseling requires special sensitivity and skills to deal with gender related issues.

Group counseling and information sharing

This is counseling approach involving a group of many people.

It is used when individual counseling is not possible or there are people in the village who are more comfortable in a group.

It is a cost effective of information sharing and answering general questions but people are not likely to share their more personal concerns with you in this situation.

General principles of counseling

Privacy-find a quiet place to talk
Take sufficient time
Maintain confidentiality
Conduct a discussion in a helpful atmosphere
Keep it simple-use words people in your village will understand
First things first –do not cause confusion by giving too much information
Say if again –repeat the most important instructions
Use available visual aids like posters and flip charts etc.

Characteristics of a good counselor

The most important characteristics of a good counselor are:

Respect the dignity of others
Respect the clients’ concerns and ideas
Be non-judgmental and open
Show that you are being an active listener
Be empathetic and caring
Be honest and sensitive

Overview of stages of counseling

General counseling

This is the first contact of family planning counseling .it involves counseling on general issues to address the client’s needs and concerns.

The counselor needs to talk about the following:

To give general information about family planning methods
To clear up any mistaken belief or myths about specific family planning methods
Give information on other sexual and reproductive health issues like; STD’s, HIV and infertility

All these will make the client arrive at the informed decision on the best contraceptive method to use.

Method-specific counseling

The information is given about the chosen method.

The following points are considered:

Examination for fitness (screening) (Blood pressure, weights, age and other health parameters)
Instruct on how and when to use given method
Tell the client when to return for follow-up and ask them to repeat what you have said on key information.

BRAIDED,

Family planning counseling the BRAIDED approach, the acronym BRAIDED can help to remember what to talk about when counseling clients on specific methods.

It stands for:

B-Benefits of the method

R-Risks of the method including consequences of the method failure

A-Alternative to method, including abstinence and no method

I-Inquiries about the method (Individual rights and responsibilities to ask)

D-Decision to withdraw from a method without a penalty

E-Explanation of the method chosen

D-Documentation of the session for your own records

Return follow-up

Follow-up counseling should always be arranged after the counseling process.

The aims;

To discuss and manage any problem and side effects related to the given contraceptive method
It gives the opportunity to encourage the continued use of the chosen method unless problems exist.
It helps to find out whether the client has other concerns and questions

Steps in family planning counseling GATHER approaches

The counseling process should follow a step-by –step process.

GATHER acronym will help you remember the 6 steps for family planning counseling.

G-Greet the client respectfully

A-Ask them about their family planning needs

T-Tell them about different contraceptive options and methods

H-Help them to make decisions about choices of methods

E-Explain and demonstrate how to use the methods

R-Return /Refer, schedule and carryout a return visit and follow-up

It is important to give more emphasis to the points during counseling steps

Greet the client

In the first case give your full attention to your client
Greet them in respective manner and introduce yourself to them often offering seats
Ask them how you can help them
Tell them that you will not tell others what they have told you.
If the counseling takes place in health facility you have to explain what will happen during the visit describing physical examinations and laboratory tests if necessary
Conduct counseling in a place where no one can overhear your conversation

Ask

Help them to talk about their needs, doubts, concerns, and any question they might have
If they are new ,use a standard check list or from your health management information system to write down their names, age ,marital status ,number of pregnancies ,number of births, number of living children ,current and past family planning use and basic medical history
Explain that you are asking them the information in order to help you provide appropriate care
Keep questions simple and brief, and look at them as you speak

Many people do not know diseases, ask specific questions, say<< have you had any headache in the past 2 weeks? or have you had any genital itching? Or do you experience any pain when urinating?>> do not say <<have you had any disease in the recent past?>>

If you have seen the client previously, ask if anything has changed since the last visit.

Tell

Tell them about family planning method
Tel them which methods available
Ask them which methods interest them and what they know about the method
Briefly, describe each method of interest and explain how it works, its advantages, disadvantages and possible side effects.

Help

Help them to choose a method of contraception, ask them about their plans and family situation, if they are uncertain about the future start with the present situation
Ask what the spouse /partner likes and wants to use
Ask if there is anything they cannot understand and repeat information when necessary
When the chosen method is not safe for them explain clearly why the method may not be appropriate and help them choose another method.
Check whether they have a clear decision and ask what method have you decided to use?

Explain

Explain how to use a method after it has been chosen
Give supply if appropriate
If the method cannot be given immediately, explain how, when and where it will be provided
For the method like voluntary sterilization the client will have to sign consent form .the form says that; they want the method, have been informed about it, and understand the consent form.
Explain how to use the method
Ask the client to repeat the instructions
Describe and possible side effects and warning signs and tell them what to do if they occur.
Ask them to repeat this information back to you
Give them printed material about the method to take home if it is available
Tell them when to come back for a follow-up visit and to comeback sooner if they wish, or if side effects or warning signs occur

Appoint a return visit follow-up at the follow-up visit

Ask the client if she is or they are still using a method or whether there have been any side effects or problems
Refer for treatment if severe side effects are present
Re assure the clients’ concerning minor side effects are not dangerous and suggest what can be done to relieve them

Rights of the client

Information : to learn about their reproductive health ,contraception and abortion options
Access : to obtain services regardless of religion, ethnicity, age, marital or economical status
Choice : to decide freely whether to use contraception and which method
Safety : to have a safe abortion and to practice safe, effective contraception
Privacy : to have a private environment during counseling process
Confidentiality : to be assured that any personal information will remain confidential
Dignity : to be treated with courtesy ,consideration and effectiveness
Comfort : to feel comfortable when receiving services
Continuity : to receive follow-up care and contraceptive services and supplies for as long as needed
Opinion : to express views on the service offered.

Factors influencing family planning counseling outcomes

Factor related to the health care provider

Effective communication
Technical knowledge and skills, attitudes and behaviors can influence in effectiveness of counseling process

Factors related to the client

Client’s level of knowledge and understanding, what they choose to do may also be affected by the extent to which they trust and respect a service provider.
Personnel situation (e.g. .if the spouse or another family member has a difference to them)
External programmatic factors
In most health facilities the space or rooms for provision of family planning is integrated with other reproductive health services .This can make it very difficult for you to find a place where privacy and confidentiality can be maintained .

Family Planning Counseling Read More »

Hormonal Contraceptive Methods

HORMONAL CONTRACEPTIVE METHODS

Hormonal family planning refers to the use of hormonal methods to prevent pregnancy.

Hormonal contraceptive refers to birth control methods that act on the endocrine system (hormones).

These methods involve the use of hormones, usually synthetic versions of those naturally produced by the body, to regulate a woman’s menstrual cycle and prevent ovulation (the release of an egg from the ovaries). By preventing ovulation, hormonal methods make it difficult for sperm to fertilize an egg and thus prevent pregnancy.

These include;

Oral contraceptive pills
Implants
Injectable contraceptive
Emergency contraceptive pills

Hormonal Methods:

i. Oral Pills:

Method	Description
Combined Oral Contraceptives	Pills containing both oestrogen and progestin hormones
Progesterone-Only Pills	Pills containing only progestin hormone
Emergency Contraceptive Pills	Pills taken after unprotected sex to prevent pregnancy

ii. Implants:

Method	Description
Implanon (1 Rod Capsule)	Subdermal contraceptive rod
Jadelle (2 Rod Capsules)	Subdermal contraceptive rods
Norplant (6 Rod Capsules)	Subdermal contraceptive rods

iii. Injectable Contraceptives:

Method	Description
Depo Provera	Injectable contraceptive administered every three months
Injector Plan	Injectable contraceptive
Sayana Press	Injectable contraceptive
Noristrate	Injectable contraceptive

iii. Emergency Contraceptives:

Emergency Contraceptive	Mechanism of Action
Lofemenal/Microgynon 4BD for 1 day (Low Dose COC)	Inhibits ovulation, thickens cervical mucus
Eugynon (High Dose COC) 2BD for 1 day	Inhibits ovulation, thickens cervical mucus
Regular POP (Ovrette/Microval) at Recommended Dose	Alters cervical mucus, inhibits sperm function
Levonorgestrel 2 stat	Delays ovulation, inhibits fertilization
Postinar 2 BD for 1 day	Alters cervical mucus, inhibits sperm function
Vikela/Levonelle-2/Norlevo Plan B	Delays ovulation, inhibits fertilization

Oral Contraceptive Pills

There are two main types of hormonal oral contraceptive formulations:

Combined hormonal contraceptive methods which contain both oestrogen and progestin thus, they are called combined oral contraceptives (COCs)
One which contains only progesterone or one of its synthetic analogues (Progestins) thus, it is called progestogen-only pills (POPs) method.

(i) Combined Oral Contraceptive Pills (COC)

Combined oral contraceptives contain both oestrogen and progesterone. It achieves effects of both hormones. Oestrogen suppresses ovulation and progesterone creates unfavourable conditions for egg transport and thickening of the cervical mucus to impair sperm entrance into the canal.

Examples

Lo-femenal
Pill Plan (Duofen)
Microgynon

Mechanism of Action:

Combined methods work by:

Suppressing ovulation (estrogenic effect)
Thickening cervical mucus, making it difficult for sperm to penetrate the uterus
Making the endometrium unsuitable for implantation of a fertilized egg (thin and atrophic due to constant progestogenic action)
Reducing sperm transport in the upper genital tract (fallopian tubes).

Effectiveness:

92 – 99.9% effective, depending on user compliance.
In very young women, typical effectiveness can be as high as 95.3%.
Failure rates decline with the duration of use and age of the user.
Failures may be due to method failure, client error, incomplete information from service providers, drug interactions, severe vomiting/diarrhoea, or expired pills.

Advantages:

Very effective if taken correctly.
Effective immediately.
Easily reversible.
Few side effects.
Convenient and easy to use.
Does not interfere with intercourse.
Causes regular and predictable periods.
May improve anemia.
Reduces dysmenorrhea and premenstrual tension.
Protects against ovarian and endometrial cancer, and some causes of PID.
Reduces the risk of ovarian cysts, benign breast disease, and ectopic pregnancy.
Can be provided by trained non-medical staff.

Disadvantages:

Effectiveness depends on daily pill intake, requiring strong motivation.
Increases chances of promiscuity.
Can cause Candida vulvitis and vaginitis.
May lead to thromboembolism and benign/malignant liver tumors.
Requires regular and dependable supply.
Reduces breast milk, especially in the first 6 months after delivery.
Not the most appropriate choice for lactating women unless no other method is available and there is a high risk of pregnancy.

Indications:

Women requiring a highly effective method.
Women wanting an easily reversible method.
Non-breastfeeding women or breastfeeding women after 6 months.
Women who are anaemic with heavy menstrual bleeding.
Women with a history of ectopic pregnancy.
Nulliparous women.
Women with a history of benign, functional ovarian cysts.
Women with a family history of ovarian cancer.
Women with menstrual cycle symptoms or irregular menstrual cycles.

Contraindications:

Absolute contraindications include cardiovascular diseases, liver disease, pregnancy, undiagnosed per vaginal bleeding, and oestrogen-dependent neoplasms.
Relative contraindications include obesity, varicosities, epilepsy, asthma, mood disorders, nursing mothers in the first 6 months, smoking, and gallbladder disease.

Side Effects:

Major side effects include hypertension, venous thromboembolism, and cholestatic jaundice.
Minor side effects can be due to oestrogen, progestin, or both, including nausea, vomiting, headache, leg cramps, weight gain, chloasma & acne, breakthrough bleeding, hypomenorrhea, amenorrhea, leucorrhea, and decreased libido.

Danger Signs of COCs:

Acute abnormal pain.
Severe headaches with blurred vision.
Pain in the chest with difficulty in breathing.
Pain in the calf muscles.

Indications for Withdraw:

Severe migraine.
Visual disturbance.
Sudden chest pain.
Severe cramps.
Excessive weight gain.
Severe depression.
Patient wanting pregnancy.
Awaiting major surgery.

Drug Interaction:

Decreases effectiveness of methyldopa, oral anticoagulants, and oral hypoglycemics.
Increases effectiveness of B blockers, corticosteroids, diazepam, aminophylline, and alcohol.
Other drugs that increase COC metabolism include phenobarbitone, antiepileptics (except sodium valproate and clozapine), rifampicin, griseofulvin, spironolactone, and ketoconazole.

WHO Medical Eligibility Criteria for Contraceptive Use.

Category 1: A condition for which there is no restriction for use of the contraceptive

Category 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks

Category 3: A condition where the theoretical or proven risk outweigh the advantages of using the method.

Category 4: A condition that represents unacceptable health risk if the contraceptive is used.

Who can use only if more appropriate methods are not available (WHO class3)

Women with high BP (greater than 160/100 but less than 180/110) and no vascular disease.
Women with symptomatic gall bladder disease.
Women age 35 yrs or older and light smokers (under 20 cigarettes a day)
Women taking drugs for epilepsy or anti-TB.
Women with unexplained vaginal bleeding (only if serious problem suspected)
Women who are fully b/feeding (6 wks to 6 months postpartum)
Women who are not b/feeding who are less than 3 weeks postpartum.
Women with h/o breast cancer and no current evidence of the disease.

Who should not use COCs (WHO Class 4)

Women with hypertension: blood pressure diastolic above 110 mm Hg. The health risk/benefit ratio is dependent upon the severity of the condition
Women with current or history of cardiac disease (heart disease or stroke). Among women with underlying vascular disease due to thrombosis, the increased risk of thrombosis with COCs should be avoided;
Women with thrombo-embolic disease (current and a history of or major surgery with prolonged immobilization). The increased risk of venous thromboembolism associated with COCs should have little impact on healthy women, but may have a big impact on women otherwise at risk for it;
Women within 2 weeks of child birth (Postnatal) and within 4 weeks or elective surgery;
Women with known or suspected cervical cancer. Theoretical concern that COC use may affect prognosis of the existing disease. In general, treatment of these conditions renders a woman sterile;
Women who are pregnant. As no method is indicated, any health risk is considered unacceptable. However, there is no known harm from COCs;
Women with undiagnosed breast lumps or breast cancer. Breast cancer is a hormonally sensitive tumor. The risk for progress of the condition may be increased among women with current or past history of breast cancer;
Women who are taking long-term drugs that could affect the pill’s efficacy. Commonly used liver enzyme inducers are likely to reduce the efficacy of COCs. Drugs which affect liver enzymes are the antibiotic rifampicin (note that other antibiotics will not affect pill efficacy), other drugs where another method should be used are: —griseofulvin, and anticonvulsants (such as phenytoin, carbamazepine, barbiturates, and primidone).
Women with severe headache (recurrent, including migraine with focal neurological symptoms). Focal neurological symptoms may be an indication for an increased risk of stroke( or cerebrovascular accident (CVA) is sudden damage to brain tissue caused either by a lack of blood supply or rupture of a blood vessel . The affected brain cells die and the parts of the body they control or receive sensory messages from ceaseto function.)
Women who are retarded or forgetful.
Women with sickle cell disease, as they have increased risk of thrombosis;
Women with trophoblast disease (current trophoblastic tumor)
Women who are to undergo major elective surgery with prolonged bed rest.

Client Information

Start between 1^st and 7^th day of monthly period
Take pills daily at the same time – at bed time if possible
Do not miss taking the pill any day
If you start after the 7^th day of monthly period; you need to use another FP method such condoms or to abstain from sex for one week.
Contraception is 7 days after initiation
You will have your monthly period when you are taking the brown pills. Do not stop taking the pills.

If a client misses, they should do the following:

If you miss one white pill, take it as soon as you remember, then continue normally.
If you miss 2 white or more days in a row; take two pills each day until all missed pills are taken and you are back on schedule. You must also use a condom for the next 7 days.
If you miss the brown pill, no worry. Just skip and continue
If you keep forgetting – may need to change method

ii) Progesterone Only Pills (POP)

Progestin-Only Pills are oral contraceptive pills which contain synthetic progestin and are taken orally every day at the same time of day to prevent pregnancy.

Mechanism of Action:

Reduces the frequency of ovulation.
Thickens cervical mucus, making it difficult for sperm to penetrate the uterus.
Partially inhibits ovulation.

Types of POPs available in Uganda:

Microval: 35 white pills, each containing 0.03 mg Levonorgestrel.
Ovrette: 28 yellow pills, each containing 0.075 mg Norgestrel.

Effectiveness:

Depends on user compliance.
Very effective if used correctly (83%-99%).
Crucial to take POPs at the same time every day, as effectiveness decreases even with a few hours’ delay.
In lactating women, POPs are nearly 100% effective, and they do not alter the quantity of milk.

Advantages of POPs:

Do not suppress lactation.
No estrogenic side effects.
Suitable for women with hypertension, thrombotic, cardiac, and sickle cell diseases.
Can be started at any time of the menstrual cycle and in the early postpartum period.
Decreased menstrual cramps.
Decreased amount of bleeding during periods.
Decreased severity of anaemia.
Do not increase blood clotting.
Some protection against pelvic inflammatory disease (progestins make cervical mucus thicker, reducing the likelihood of infection reaching the uterus and tubes).

Disadvantages of POPs:

Amenorrhea.
Must be taken at the same time every day.
Irregular periods, including spotting or bleeding between periods.
Prolonged or heavy vaginal bleeding.
For women who have had ectopic pregnancy, POPs do not prevent ectopic pregnancy as well as intrauterine pregnancy.
For women with a history of ovarian cysts, POPs do not protect against the development of future ovarian cysts.

Indications:

Women of any reproductive age or parity seeking pregnancy protection.
Breastfeeding women (6 weeks or more postpartum).
Post-abortion women (may start immediately).
Women who smoke.
Women with high blood pressure, blood clotting problems, or sickle cell disease.
Women unable to take Combined Oral Contraceptives (COCs) but want to take Pills.

Who should not use POPs (Class 3):

Women breastfeeding and less than 6 weeks postpartum.
Women with jaundice.
Women taking anti-epileptic and anti-TB medication.
Women with unexplained vaginal bleeding.
Women with breast cancer.
Women concerned about changes in their menstrual bleeding pattern.
Women unable to remember taking a pill every day (no more than 3 hours late).

Who should not use POPs (Class 4):

Women known or suspected to be pregnant.
Women who are known or suspected to be pregnant. POPs should not be initiated if a woman is pregnant. However, there is no known harm to mother or fetus if POPs are used during pregnancy;
Signs of problems from POPs warranting immediate return to clinic
Severe lower abdominal pain.
Heavy bleeding (twice as long and as much).
Migraine headaches, repeated very painful headaches, or blurred vision.

Signs of problems from POPs warranting immediate return to clinic:

Severe lower abdominal pain.
Heavy bleeding (twice as long and as much).
Migraine headaches, repeated very painful headaches, or blurred vision.

Client Instructions:

Start between the 1st and 7th day of the monthly period.
If started after the 1st day of bleeding, abstain from intercourse or use another method for the next 48 hours.
Take pills daily at the same time.
Do not miss taking the pill any day.
Return to the clinic for more pills before finishing the last pack.
Severe diarrhoea or vomiting reduces pill effectiveness. Use a backup method or abstain from sex while taking the pills and for 48 hours after.
If client misses taking pills:

If more than 3 hours late, take it as soon as remembered and the next pill at the usual time. Use a backup method or abstain for the next 48 hours.
If miss two or more days, take one as soon as remembered, continue as usual, and use a backup method or abstain for the next 48 hours.
If consistently forgetting, consider another method and seek counseling.

Contraindications:

Pregnancy: Progestin-Only Pills (POPs) should not be initiated if a woman is pregnant.
Unexplained vaginal bleeding: POPs are contraindicated in cases of unexplained vaginal bleeding, and immediate medical attention is advised to determine the cause.
Recent history of breast cancer: Women with a recent history of breast cancer are advised against using POPs due to potential hormonal interactions that could affect cancer progression.
Arterial diseases: Individuals with arterial diseases, such as a history of stroke or cardiovascular issues, should avoid POPs as they may pose additional risks to vascular health.
Thromboembolic diseases: Those with a history of thromboembolic diseases, involving blood clotting, are at an increased risk when using POPs, making it a contraindicated option.
Active hepatic diseases: Presence of active liver diseases is a contraindication, as POPs can impact liver function, and their use might exacerbate hepatic conditions.
Hypertension: Women with hypertension are advised against using POPs, as the hormonal components may contribute to increased blood pressure.

Side Effects:

Amenorrhea: Some women may experience amenorrhea (absence of menstruation) as a side effect of POPs, which is generally considered a normal response to hormonal changes.
Spotting: Spotting, or irregular bleeding between periods, can occur, and individuals should be aware that this is a common side effect that usually diminishes with time.
Prolonged or heavy bleeding: While some may experience prolonged or heavy bleeding, this side effect should be discussed with a healthcare provider to ensure it is not indicative of an underlying issue.
Lower abdominal pain: Lower abdominal pain may occur.
Weight gain or loss: Changes in weight, either gain or loss, may be observed.
Jaundice: Jaundice, characterized by yellowing of the skin or eyes, is a rare but serious side effect.
Nausea and vomiting: Nausea and vomiting may occur initially but often subside.
Headache with blurred vision: Headaches with blurred vision may be experienced.
Excessive hair growth: Some individuals may notice changes in hair growth patterns.
Breast fullness or tenderness: Breast fullness or tenderness is a common side effect that usually resolves over time.
High blood pressure: An increase in blood pressure may occur in some individuals

Implants

Implants are small, flexible rods or capsules that are inserted under the skin of a woman’s upper arm.

These implants release a steady, low dose of hormones (usually a progestin hormone) into the bloodstream over an extended period. The most common types of contraceptive implants include Implanon, Jadelle, and Norplant.

Implants are considered a reversible form of contraception, and their effectiveness is not dependent on user compliance once inserted. They are suitable for women who want a reliable, long-term birth control option without the need for daily or frequent intervention.

Types:

Implanon: A single rod capsule effective for 3 years.
Jadelle: Two rods of levornogestrel each 75mg capsules providing protection for 5 years.
Norplant: Consists of 6 rods each with 36mg levornogestrel capsules labelled for 5-7 years.

Modes of Action:

The hormonal release from these implants serves to prevent pregnancy by thickening the cervical mucus within 24 hours, hindering sperm entry into the uterus, inhibiting ovulation (the release of eggs from the ovaries), and altering the uterine lining to make it less receptive to a fertilized egg. Implants are highly effective and offer long-term contraception, ranging from three to seven years, depending on the specific type.

Insertion: Inner aspect of non dominant arm, 6 – 8 cm above elbow fold under local anesthesia. This is at day1, immediate after abortion or 3weeks postpartum.

Removal: Approximately 3 to 5 years

Advantages:

Very effective within 24 hours after insertion.
Easily reversible with no delay in returning to fertility after removal.
Reduces frequency and intensity of sickle cell crises.
Highly effective for long-term contraception.
Shares benefits with Depo Provera.

Common Side Effects and Disadvantages:

Changes in menstruation patterns.
Spotting.
Rare instances of heavy bleeding.
Amenorrhea.
Does not protect against STIs, including HIV/AIDS.
Discomfort in the hand after insertion.
Possible weight changes (overweight or weight loss).
Minor surgical procedure required for both insertion and removal.

Indications:

Breastfeeding post-partum mothers.
Adolescents.
Post-abortion contraception.
Women with sickle cell disease.
Women awaiting surgical contraception.
Women on treatment, e.g., ARVs.

Contraindications:

Serious problems with the heart or blood vessels.
Breast cancer history.
Liver diseases leading to jaundice.
Pregnancy.

Signs and Problems Requiring Medical Attention:

Soreness at the site of insertion.
Capsules coming out.
Severe headaches.
Heavy bleeding, exceeding the usual amount and duration.
Pregnancy.
Missed period after several regular cycles.

Injectable Contraceptives

Examples

Depo Provera (Depo Medroxyprogesterone acetate (DMPA), single dose of 150 mg I.M every 12 weeks. (Injecta Plan)
Sayana Press 104mg, 0.65ml Subcutaneously
Noristerat (Norethisterone) 200mg every 8 weeks for 24 weeks, then every 12 weeks.
Norigynon/Mesigyna (50 mg norethindrone enanthate plus 5 mg estradiol valerate) ; Both given monthly.

These contraceptives contain a single type of hormone, progestin.

Depo Provera

Depo Provera is a hormone used for contraception. It is given by injection and its effects will last for three months at a time.

Mode of Action

Inhibits ovulation.
Thickens cervical mucus, hindering sperm entry.
Thins the uterine lining, reducing chances of fertilized egg implantation.

Indications

Breastfeeding mothers after 6 weeks or immediately if not breastfeeding.
Women needing long-term contraception.
Known/suspected HIV-positive women.
Women with sickle cell disease.
Women unable to use COC due to oestrogen content.
Women awaiting surgical contraception.

Advantages

Very effective.
Does not suppress lactation.
Easy to remember return dates.
Private usage.
No oestrogen-related side effects.
Reduces sickle cell crisis frequency.
Non-interference with sex.

Disadvantages

Changes in menstrual bleeding.
Spotting (common in the first 3 months).
Amenorrhea (common after 1st injection and after 9-12 months).
Prolonged heavy vaginal bleeding.
Weight changes.
Irreversible injection.
Delayed return of fertility.
Loss of libido.
Does not protect against STIs/HIV/AIDS.

Management

Depo Provera 150mg deep IM into deltoid or buttock muscle.
No rubbing to avoid increased absorption.
Advise abstinence or backup FP method for the first 7 days after injection.
Return for the next dose 12 weeks after the injection.

Sayana Press

Sayana Press is a contraceptive injection that women can give to themselves to prevent pregnancy. It’s given under the skin, at the front upper thighs or abdomen. The injection releases medication that runs through your bloodstream over a period of 13 weeks.

Sayana press ® is a single-dose container with 104 mg Medroxyprogesterone acetate (MPA) in 0.65ml suspension (104mg) formulated for subcutaneous.
It is administered subcutaneously into the anterior thigh or abdomen or arm.
The efficacy of Sayana press depends on adherence to the recommended dosage schedule of administration.

Composition

Single-dose container with 104 mg Medroxyprogesterone acetate (MPA) in 0.65ml suspension.

Administration

Subcutaneously into the anterior thigh, abdomen, or arm

Mechanism of Action

Suppresses ovulation.
Renders endometrium unsuitable for implantation.
Increases cervical mucus viscosity, impeding sperm penetration.

Indications

Nearly all women can use it safely & effectively including women:-

Women whose partners have undergone vasectomy until vasectomy is effective.
Have or have not had children.
Any age including adolescents & women over 40 years old.
Have just had an abortion/miscarriage.
Breastfeeding women 6 weeks postpartum.
HIV infected whether or not on ART.

Advantages and Non contraceptive benefits.

New formulation for S/C injection.
30% low side effects compared to Depo-Provera.
Do not interfere with sex.
Private & no one else can tell that a woman is using it.
May help women gain weight.
Do not require daily action.
Prevents pregnancy.
Protects against endometrial cancer, uterine fibroids.
Reduces sickle cell crisis among women with sickle cell anaemia.
Protects against symptomatic PID & iron deficiency anaemia.

Disadvantages

Weight changes.
No protection against STIs/HIV/AIDS.
Delayed fertility return.
Potential side effects like hypersensitivity reactions, decreased/increased appetite, loss of libido, dizziness, headache, and more.

Problems that may need medical attention

Loss of bone mineral density.
Menstrual irregularities.
Thromboembolic disorders.
Anaphylaxis & anaphylactoid reactions.
Sudden partial or complete loss of vision.

Disadvantages & Side effects

Weight gain or loss
Does not protect against STI/HIV/AIDs
Delayed fertility return
Hypersensitivity reactions
Decreased/increased appetite
Loss of libido & irritability
Dizziness, headache & migraine
Thromboembolic disorders
Nausea & vomiting
Jaundice
Alopecia & urticaria
Loss of bone mineral density
Back & leg pains
Mood changes
Abdominal bloating & discomfort

Emergency Contraception / Post-Coital Contraception

Emergency contraception (EC) serves as a preventive measure for unintended pregnancies following unprotected sexual intercourse, condom rupture, missed pills, or sexual assault.

It should be regarded as an emergency measure and not as a routine contraceptive method. EC does not terminate pregnancy. It encompasses hormonal, anti-progestin, and other methods.

Types

Emergency Contraceptive Pills (ECP)
Progesterone-Only Pills Regimen

When to Start?

EC should be initiated within 3 -5 days or 72 -120 hours, with earlier administration being more effective, following unprotected sexual intercourse. Intrauterine contraceptive devices (IUCDs) with copper introduction, within a maximum period of 5 days, can prevent conception after accidental unprotected sexual exposure.

Mechanism of Action

Prevents implantation
Failure rate is about 1%
Effectiveness is over 99% in preventing pregnancy

NOTE:

Post-coital contraception is solely for emergency use and is not effective if used regularly, except for copper IUCDs.
Women seeking emergency contraception should also be counselled about regular contraceptive options, promoting consistent and correct usage.
Referral to relevant services, such as HIV counselling, testing, post-exposure prophylaxis (PEP), and treatment for sexually transmitted infections (STIs), is essential.
Specialized services for sexual and gender-based violence should also be considered.

Basic Steps of Client Care for ECP

Greet and introduce yourself.
Maintain a respectful attitude.
Ensure confidentiality of the discussion.
Explain different ECP options, including usage, side effects, and the need for referral or follow-up.
Encourage questions from the client.
Discuss regular contraception options.
Conduct counselling with active client involvement, reassurance of confidentiality, and in a private and supportive environment.

Examples of ECP:

Ethinyl estradiol 2.5mg b.d X 5/7
Conjugated oestrogen 15mg b.d X 5/7
Levonorgestrel 0.75mg stat and after 12 hours.
Mifepristone 600 mg stat – single dose.
Copper IUDs inserted within 5 days.
Others: Postinor, Microgynon, Eugynon.

Indications

Unprotected sexual intercourse
Rape survivors
Contraceptive method failure
Missed contraceptive pills or injections
Delay in taking pills
Sexual assault or first-time intercourse

Contraindications

Pregnancy
After 120 hours or 5 days of unprotected sex

Emergency Contraceptive	Dosage	Mechanism of Action
Lofemenal/Microgynon 4BD for 1 day (Low Dose COC)	4 tablets once	Inhibits ovulation, thickens cervical mucus
Eugynon (High Dose COC) 2BD for 1 day	2 tablets twice	Inhibits ovulation, thickens cervical mucus
Regular POP (Ovrette/Microval) at Recommended Dose	As recommended	Alters cervical mucus, inhibits sperm function
Levonorgestrel 2 stat	2 tablets at once	Delays ovulation, inhibits fertilization
Postinar 2 BD for 1 day	2 tablets twice	Alters cervical mucus, inhibits sperm function
Vikela/Levonelle-2/Norlevo Plan B	As recommended	Delays ovulation, inhibits fertilization

NON HORMONAL METHODS click here

Hormonal Contraceptive Methods Read More »

Family Planning

FAMILY PLANNING

Family planning is defined as the practice of having children by choice and not by chance.

Family planning is defined as a process through which individuals, couples make an informed choice on how many children to have, when to have and how often to have so that each child born is expected and properly catered for in all ways.

Family planning policy does not discriminate against men; they also have great roles to play for the success of care.

Unplanned pregnancies constitute major public health problems .The United Nations International Children’s Emergency Fund (UNICEF) estimates that over 800,000 women worldwide die each year as a result of pregnancy and pregnancy-related causes and an additional 15 million women are severely disabled by pregnancy. Countries in which women utilize contraception have lower birth rates and the lowest rates of maternal mortality. Every method of birth control prescribed is safer than pregnancy.

Benefits/Importances of Family Planning

To the Mother

Physical and Mental Recovery: Allows the mother to recover physically and mentally from the effects of previous pregnancies.
Participation in Productive Activities: Offers ample time for a woman to actively participate in productive activities like farming and business.
Enhanced Social Bondage: Increases social bondage between the mother and her baby.
Reduced Maternal Mortality and Morbidity: Helps to reduce maternal mortality and morbidity due to pregnancy-related complications.
Promotion of Marital Happiness: Promotes a happy marital life and enjoyment between the couples without fear of unwanted pregnancy.
Preparation for Pregnancies: Family planning enables sexually active couples to prepare for pregnancies, optimizing fetal and maternal outcomes.
Avoidance of Unwanted Pregnancies: Family planning helps avoid unwanted pregnancies, reducing complications associated with childbirth.
Reduction of Maternal Complications: Reduces incidences of complications such as anaemia, poor maternal health, caesarean section, and maternal-child deaths.

To the Child

Emotional and Social Support: The child receives adequate emotional and social support, contributing to emotional maturity and stability.
Healthy Nutrition: Allows adequate nutrition for the baby in the womb, resulting in a healthy newborn.
Reduced Malnutrition: Reduces malnutrition by preventing early weaning and ensuring enough food for the child.
Fewer Infections: The child experiences fewer infections due to a strengthened immune system.
Love and Care for the Child: Enables families to concentrate on other income-generating activities, ensuring love and care for the child.
Ensuring Breastfeeding: Ensures adequate breastfeeding for the child, promoting child health.

To the Father

Reduced Domestic Violence: Family planning reduces domestic violence in a home.
Meeting Basic Needs: Enables the father to meet basic needs like food, medical care, etc.
Cost of Living Reduction: Reduces the cost of living in a home, allowing the father to invest in productive activities.
Preparation for Children: Assists couples in preparing for their children, ensuring they can provide love, care, and adequate support.
Protection Against STIs: Some family planning methods are protective against HIV and other sexually transmitted infections (STIs).

To the Community

Healthy and Productive Population: Family planning contributes to a healthy and productive population, enhancing community stability and harmony.
Reduced Overcrowding: Reduces overcrowding, maximizing available land for productivity.
Increased Socio-economic Development: Leads to increased socio-economic development within the community.
Prevention of Negative Behaviours: Reduces the presence of negative characters in the community, as parents have adequate time to provide for their children.
Improvement in Standards of Living: Family planning contributes to the improvement of standards of living within communities.

To the Nation

Control of Population Growth: Reduces the rapid population growth rate at a national level.
Reduced Dependence on Foreign Aids: Reduces the country’s dependence on foreign aids.
Improved Government Services: Enables the government to provide better social services and infrastructures like roads and health facilities.
Effective Resource Allocation: Facilitates easy budgeting for the people, as the number of resources to the population is manageable.
Population Growth Prediction: Helps predict population growth, allowing for better planning and resource allocation.

Components of Family Planning Services

Counselling: Counselling is an important need for the initiation and continuation of a family planning method. Service providers must undergo training to provide comprehensive counselling about all available family planning methods. Importantly, there should be no incentives or coercion to adopt family planning or a specific contraceptive method.
Provision of Contraceptives: Contraceptives should be provided to clients based on approved method-specific guidelines. Service providers delivering these methods must undergo training to ensure competency in their provision. This ensures that clients receive family planning services that align with their needs and preferences.
Follow-Up and Referral System: Clients choosing a family planning method should be informed about appropriate follow-up requirements. They should be encouraged to return to the service provider if they have any concerns or issues. The established referral system should be followed by service providers when making client referrals for further assistance.
Record Keeping: Family planning service providers are required to maintain comprehensive records. These records help identify each client, specify the type of contraception provided, and note any special circumstances associated with its provision. Effective record-keeping contributes to the overall management and evaluation of family planning programs.
Supervision: Supervision is an essential component of program evaluation. It ensures that client needs are met, and service delivery guidelines are adhered to. Supervisors act as team members who promote staff motivation, assist in problem-solving, and ensure the rights of both service providers and clients are observed throughout the delivery of family planning services.
Logistics: Maintenance of an effective organization and supply system is crucial to prevent both understocking and overstocking of family planning commodities. Staff at service delivery points must adhere to proper procedures for the storage and handling of contraceptives and other supplies to maintain the quality of services provided. This ensures that family planning services are consistently available and accessible to those in need.

Characteristics of an Ideal Family Planning Method

Effectiveness: A good family planning method should demonstrate high efficacy in preventing unintended pregnancies.
Minimal Side Effects: The method should have minimal or no adverse effects on the health and well-being of the individual using it.
Independence from Sexual Intercourse: The effectiveness of the method should not be relying on specific timing related to sexual activity.
User Autonomy: The method should empower individuals to manage their reproductive health without requiring constant supervision or intervention from health professionals.
Accessibility: It should be widely available, ensuring that individuals, regardless of geographic location or socioeconomic status, can access and utilize the method.
Ease of Distribution: The method should have a distribution system that allows for easy accessibility, ensuring convenience for users.
Affordability: Cost-effectiveness is crucial. A good family planning method should be affordable to a broad range of individuals, regardless of income.
Cultural and Religious Acceptance: The method should be culturally and religiously sensitive, respecting diverse beliefs and practices.
Reversibility: Individuals should have the option to discontinue the use of the method easily, with a quick return to fertility if desired.
Educational Support: The method should come with educational resources to ensure users are well-informed about its proper use, benefits, and any potential risks.
Long-Lasting: Ideally, the method should offer a duration of protection that aligns with the user’s family planning goals, whether short-term or long-term.
Compatibility with Health: The method should not compromise overall health, and individuals with specific health conditions should have suitable alternatives available.
Privacy and Confidentiality: The use of the method should be discreet, respecting the user’s privacy and maintaining confidentiality.
Community and Partner Support: It should encourage open communication and support from partners, families, and communities.
Research-Backed: The method’s safety and efficacy should be supported by scientific research and continuous monitoring.
Inclusivity: The method should be inclusive, addressing the diverse needs of different populations, including adolescents, women, and men.

Classification of family planning methods

There are 2 broad types of family planning:

Natural or Traditional or Non-hormonal methods.
Artificial or Hormonal methods.

Natural/Traditional Methods

Method	Description
Calendar/Rhythm	Tracking menstrual cycles for fertility awareness. This is the only method approved in the Roman Catholic Church
Basal Body Temperature	Monitoring temperature variations during the menstrual cycle
Cervical Mucus Method	Observing changes in cervical mucus for fertility awareness
Lactation Amenorrhea Methods	Reliance on breastfeeding as a natural contraceptive during postpartum period
Abstinence	Refraining from sexual activity
Withdrawal/Coitus Interruptus	Withdrawing the penis before ejaculation

Artificial Methods

a) Barrier Methods:

Method	Description
Spermicides	Chemical substances that kill sperm
Condoms	Barrier devices worn over the penis or inserted into the vagina to prevent sperm from reaching the egg
Intrauterine Contraceptive Devices (IUCDs)	Devices placed inside the uterus to prevent pregnancy
Diaphragm	Shallow, dome-shaped cup placed over the cervix with spermicide

b) Hormonal Methods:

i. Oral Pills:

Method	Description
Combined Oral Contraceptives	Pills containing both oestrogen and progestin hormones
Progesterone-Only Pills	Pills containing only progestin hormone
Emergency Contraceptive Pills	Pills taken after unprotected sex to prevent pregnancy

ii. Implants:

Method	Description
Implanon (1 Rod Capsule)	Subdermal contraceptive rod
Jadelle (2 Rod Capsules)	Subdermal contraceptive rods
Norplant (6 Rod Capsules)	Subdermal contraceptive rods

iii. Injectable Contraceptives:

Method	Description
Depo Provera	Injectable contraceptive administered every three months
Injector Plan	Injectable contraceptive
Sayana Press	Injectable contraceptive
Noristrate	Injectable contraceptive

c) Permanent Methods:

Method	Description
Tubal Ligation (Tubectomy) for Women	Surgical procedure to block or cut the fallopian tubes
Vasectomy for Men	Surgical procedure to block the vas deferens in the male reproductive system

NON-HORMONAL FAMILY PLANNING METHODS

They are so-called because they are not manufactured with hormone basis.

NATURAL NON-HORMONAL

These include:

Fertility awareness methods of family planning which involve identification of the fertile days of the menstrual cycle (when pregnancy is most likely to occur) and avoiding sexual intercourse (or using barrier methods ) during these days. The fertile days of the menstrual cycle can be determined by one of the following methods:

Calendar/Rhythm or Standard Days method, including cycle beads.
Basal Body Temperature
Cervical Mucus Method
Symptom- thermal ( a combination of cervical mucus and BBT methods).

Other Non Hormonal/traditional include;

Lactation Amenorrhea Methods
Periodic abstinence, abstaining from sexual intercourse during a woman’s fertile time.
Withdrawal/Coitus Interruptus

These methods, also known as fertility awareness methods, are based on understanding key physiological conditions related to reproduction, Such as;

Lifespan of Sperm and Ovum:

The lifespan of a sperm is approximately 3 – 5 days in the female reproductive tract.
The lifespan of an ovum (egg) is around 12- 24 hours.
Menstrual cycles can range between 23 to 35 days, but usually 28 days.

General Advantages:

Safety and Lack of Side Effects: FAMs are generally considered safe with minimal or no side effects.
Cost-Effectiveness: They are affordable, requiring no ongoing financial commitment.
Acceptability Across Groups: Often acceptable to individuals and religious groups opposing modern contraceptive methods.
Educational Benefits: These methods empower women with knowledge about their menstrual cycles and fertility.
Couples’ Control: Couples have direct involvement and control over the method, promoting shared responsibility.
Facilitates Pregnancy Planning: FAMs can be used for both family planning and to facilitate pregnancy when desired.
Non-Invasive: FAMs do not involve invasive procedures or the use of synthetic substances.
No Hormonal Interference: They do not interfere with hormonal balances, making them suitable for those sensitive to hormonal contraceptives.
Long-Term Relevance: Useful throughout a woman’s reproductive life, fostering awareness and informed decision-making.

General Disadvantages:

Learning Curve: Some methods require substantial education and learning before effective use.
Record Keeping: Users must maintain accurate records over several menstrual cycles for proper reference.
Challenges with Irregular Periods: Effectiveness diminishes when menstrual cycles are irregular.
Behavioural Adjustments: Requires adjustments to sexual behaviors during fertile periods.
Dependency on Partner Cooperation: Success depends on the level of cooperation between partners, which can be challenging.
Risk of Error: Inconsistencies in recording or misinterpretation may lead to unintentional pregnancies.
Limited Protection from STIs: FAMs provide no protection against sexually transmitted infections (STIs), including HIV/AIDS.
Intensive Monitoring: The method demands continuous and intensive monitoring, which may be burdensome for some users.

Indications:

Fertility awareness methods are suitable for any woman or couple who is willing and committed to observing, recording, and interpreting fertility signs on a daily basis. This includes:

Women who find other contraceptive methods unacceptable due to reasons such as religious beliefs.
Women who cannot use certain contraceptive methods for health reasons.
Couples who are open to abstaining from sexual intercourse (or using condoms) for more extended periods during each menstrual cycle.

Contraindications:

While there are no medical conditions that worsen with the use of fertility awareness methods, some conditions may make their application more challenging. In the presence of these conditions, the method may either be postponed or require specialized counselling to ensure correct utilization. These conditions include:

Breastfeeding, especially until the return of menstruation.
Less than three postpartum menstrual cycles.
Irregular vaginal bleeding.
Abnormal vaginal discharge.
Diseases that influence body temperature.

Barrier methods

Barrier methods work by preventing the passage of sperm into the female genital tract.

Female barrier methods include the diaphragm, cervical cap, FemCap, and the condom to both females and males and Spermicides

Condoms

A condom is a latex sheath put on an erect penis before coitus and worn during coitus.

Indications for Condom Use:

Men Engaging in Family Planning: Condoms are an excellent choice for men who wish to actively participate in family planning.
Sexually Active Adolescents: Adolescents engaging in sexual activity can benefit from the use of condoms as a reliable contraceptive and STI prevention method.
Infrequent Sexual Intercourse: Couples who engage in sexual intercourse infrequently may find condoms to be a practical and effective choice.
Casual Sexual Relationships: Individuals in casual sexual relationships where pregnancy is not desired can use condoms to prevent both unwanted pregnancies and sexually transmitted infections (STIs).
Back-Up Contraception: Couples waiting for another contraceptive method to become effective can use condoms as a reliable back-up method.
Temporary Contraception: Couples awaiting the initiation of another contraceptive method can use condoms as a temporary solution to prevent unintended pregnancies.

Mechanism of action of condom

Acts as a barrier, preventing sperm from entering the female genital tract.
For condoms that are coated with spermicide, the spermicide immobilizes and kills sperm.

Advantages of male and female condom

Effectiveness: When used correctly, condoms provide a high level of effectiveness (95 – 97%) in preventing pregnancy.
STI and HIV Prevention: Condoms are crucial in preventing the spread of sexually transmitted infections (STIs), including HIV.
Accessibility: Condoms are easy to obtain and can be distributed widely by Community Based Health Workers and the commercial sector.
Dual Purpose: They serve a dual purpose of family planning and STI/HIV prevention.
Potential Cervical Cancer Protection: There is a probable protective effect for women against the development of Intra-epithelial Neoplasm, i.e., cervical cancer.
Ease of Use: Condoms are easy to use, usually inexpensive, safe, effective, and portable.
Sexual Enhancement: They can help some men with premature ejaculation maintain an erection.
Convenient Short-Term Contraception: Condoms are convenient when short-term contraception is required.
Safety and Lack of Side Effects: Condoms are considered safe with minimal side effects.

Disadvantages:

Allergic Reactions: Some individuals may experience allergic reactions to latex or other materials used in condoms.
Sexual Enjoyment: Condoms may reduce the quality of sex for some individuals.
Male Partner Cooperation: Requires cooperation from the male partner for effective use.
Vulnerability to Damage: Can be damaged by exposure to oil-based lubricants, heat, humidity, or light.
Decreased Sensitivity: May decrease sensitivity for men, impacting the enjoyment of intercourse.
Slipping or Tearing: There is a small possibility of slipping or tearing during sexual intercourse.
Storage Requirements: Condoms can deteriorate if not properly stored, e.g., in too much heat, sunlight, or humidity.
Erection Challenges: Some men may struggle to maintain an erection with a condom on.

Spermicides

Vaginal spermicides come in the form of foam, cream, jelly, tablet or suppository and are inserted into the vagina just before sexual intercourse to prevent pregnancy.

Mechanism of action of spermicide

Inactivates and kills sperm;
Blocks the path of sperm to the uterus.

Effectiveness of spermicides

Fairly effective, depending on the user (79-97%);
If used with condom, effectiveness is 99%;
Effectiveness lasts only 30 to 40 minutes after insertion.

Advantages of spermicides

Over-the-Counter Availability: Spermicides can be obtained without a prescription, making them easily accessible.
Immediate Protection: Spermicides can be kept available for immediate use whenever needed, providing on-the-spot protection.
Additional Lubrication: Spermicides can offer additional lubrication during intercourse, enhancing comfort.
Enhanced Effectiveness with Condoms: When used in conjunction with condoms, spermicides can increase their overall effectiveness in preventing pregnancy.
Back-Up Option for Contraceptive Delays: Spermicides serve as a simple back-up option for women waiting to start oral contraceptives or have an IUD inserted. They are also useful for women who forget multiple contraceptive pills or run out of pills.
Emergency Use: In cases of a condom breakage, spermicides can be applied quickly as an emergency measure.

Disadvantages and Side Effects:

Sexual Interruption: Some forms of spermicides, such as suppositories or foaming tablets, may require a waiting period of 10 minutes for dissolving before becoming effective, potentially interrupting sexual intercourse.
Application Before Each Act: Spermicides must be used before each act of sexual intercourse, requiring consistent and timely application.
Post-Intercourse Wetness: Spermicides may cause increased vaginal wetness for several hours after intercourse.
Sensitivity or Allergic Reactions: A few women may be sensitive or allergic to spermicides, leading to irritation and discomfort, especially with frequent use.
Lower Effectiveness Rates: Spermicides are generally less effective in preventing pregnancy compared to more modern methods such as IUDs and hormonal contraceptives.
Risk of Candida Vaginitis: Some women may develop Candida Vaginitis as a side effect of using spermicides.
Increased Infections: Spermicides can potentially increase the risk of urinary and yeast tract infections in women.
Messiness and Discomfort: Spermicides can be messy and may cause mild discomfort or minor allergic reactions in some individuals.

Vaginal Diaphragm

Diaphragm is a mechanical barrier placed between the vagina and cervical canal .They are designed to fit in the cul-de-sac and cover the cervix.

The contraceptive jelly or creams should be placed on the cervical side of the diaphragm before insertion because the device itself is ineffective. Again, this medication serves as lubricant for insertion of a device.

The device is inserted 6 hours prior to intercourse and should be left in place 6-24 hours after intercourse

Advantages

Easy to use
It offers some protection against STDs
Well used, it protects from conception with the failure rate as low as 6% of women per year of exposure.

Disadvantages

It require fitting by a well trained medical professional
Fitting may loose during intercourse
It cannot be effective in women with significant pelvic relaxation,a sharply retroverted or anteverted uterus or shortened vagina.

Side effects

Vagina irritation
Increased risk of urinary tract infection due to pressure of the rim against the urethra and alterations in the composition of vaginal normal flora.

Cervical Cap (CAP)

Cervical caps are small cuplike diaphragms placed over the cervix that are held in place by suction.

To provide a successful barrier against the sperms, they must be tightly fit over the cervix therefore, individualization is essential because of variability in cervical size.

It has few advantages because;

Unpleasant odour often develops after approximately 1 day of use
Dislodgment (as in diaphragm)
The cup should remain in place 1 or 2 days before intercourse and should be left in place for 8 -48 hours after intercourse.

Intrauterine Contraceptive Devices (IUCDs):

Intrauterine Contraceptive Devices, or IUCDs, are flexible plastic devices inserted into a woman’s uterus to prevent pregnancy, usually renewed every 3-5 years. These devices are often made of copper impregnated with gold, silver, and stainless steel.

Various Design Types:

Copper T 380A:

T-shaped device with copper on the stem and arms of the T.
Duration of effectiveness: 10 years.
Shelf life: 7 years.

Multiload 375:

Lasts for 5 years.

Mechanism of Action:

Renders the endometrium unsuitable for the implantation of a fertilized ovum.
Copper emits metal ions with spermicidal properties.

Advantages:

Very Effective: Provides high efficacy, ranging from 99-99.5%.
Immediate Effectiveness: Works instantly upon insertion.
Long-Term Method: Offers a long duration of effectiveness.
No Interference with Intercourse: Does not interfere with sexual activity.
Quick Return to Fertility: Fertility returns immediately upon removal.
Few Side Effects: Mild side effects compared to other methods.
No Client Supplies Needed: Does not require additional supplies by the client.

Disadvantages and Side Effects:

Mild Cramps: May experience mild cramps in the first 3-5 days post-insertion.
Menstrual Changes: Longer and heavier menstrual blood loss in the initial 3 months.
Increased Cramping Pain: Increased cramping pain during menstruation.
Provider-Dependent: Insertion and removal depend on a healthcare provider.
String Checks: Need to check for strings after menstruation.
Increased Bleeding: May experience increased bleeding in the first few months.
Spontaneous Expulsion: There is a possibility of spontaneous expulsion, especially in the first 6 months.
Uterine Perforation: Very rare, occurring in 1 out of 1000 cases.
Pelvic Inflammatory Diseases (PID): May increase the risk of PID.
Pain and Discomfort: Pain, especially with larger devices.
Menstrual Changes: Increased menstrual loss; intermenstrual spotting may occur.
Expulsion Risk: Higher risk of expulsion during the first 6 months, especially during menses.
Translocation Risk: Possibility of translocation to the peritoneal cavity or broad ligament.
Pregnancy Risks: May increase the risk of pregnancy and ectopic pregnancy.
No Protection Against STIs/HIV or Cancers: Does not provide protection against STIs, HIV, ovarian, endometrial, or cervical cancers.

IUCDs users who develop PID should be treated with the IUCD in place if they want to continue using it. If no improvement within 72 hours, remove it.

When to Insert an IUCD:

During or immediately after menstruation.
At a postnatal examination.
Immediately following delivery or any time within 46 hours after childbirth.
After termination of a pregnancy.
During the caesarean section.

Insertion of an Intrauterine Contraceptive Device (IUD): Procedure

Aseptic Technique: Implement aseptic techniques, including hand washing and wearing sterile gloves.
Device Preparation: Place the IUD in an introducer and plunger.
Straightening: The device straightens inside the introducer.
Visualization of Cervix: Insert a Cusco’s vaginal speculum to clearly visualize the cervix.
Cleaning: Clean the cervix and vaginal vault with sterile swabs.
Uterine Measurement: Measure the length of the uterus with a uterine sounder.
Introducer Insertion: Insert the introducer into the uterus through the cervix.
Plunger Action: Gently push the plunger to force the device out of the introducer into the uterus.
Device Lodging: In the uterus, the device resumes its original shape and lodges against the uterine walls.
String Placement: The two small strings attached to the device hang down through the cervical opening.
String Cutting: Cut the string with scissors to reduce the size, leaving approximately 3cm hanging out of the cervix.
Post-Insertion: After insertion, the client rests and can remain on the procedure table until ready to get dressed.
String Check: The woman can feel the strings in the vagina to ensure the device is in position.

Post-Insertion Instructions:

Backup Use: Use backup contraception for a minimum of 3 days.
Mild Pain: Slight pain may occur but usually does not require medication.
String Check: Check the string during menstruation to ensure it is in place; return if removed or dislodged.
Immediate Return for Discomfort: Return to the facility immediately in case of any discomfort.

Removing the IUDs:

Discussion with Client: Discuss side effects with the client and weigh the option of managing the problem or immediate removal.
Timing for Removal: Removal is simple and can be done any time of the month, with monthly bleeding making it easier.

Removal Procedure:

Explain the removal procedure to the client.
Ensure privacy and confidentiality.
Visualize cervix and UID strings with a vaginal speculum.
Clean cervix and vagina with antiseptic solution.
Instruct the client to relax and take slow breaths.
Gently pull the IUD strings until it comes completely out of the cervix.
Show the removed IUD to the client for assurance.
Thank the client for cooperating throughout the procedure.

Reasons for Missed Threads in IUDs:

Coiled thread inside.
Thread torn through.
Device expelled outside unnoticed by the client.
Device perforated the uterine wall and is lying in the peritoneal cavity.
Device pulled by the growing uterus in pregnancy.

Methods of Identification:

History taking (exclude pregnancy).
Ultrasonography.
Hysterectomy.
Hysteroscopy.
Straight x-ray.

Contraindications:

Pregnant women or those suspected to be.
Women with menorrhagia or abnormal bleeding.
Women with PID, current, or in the past 3 months.
Purulent per vaginal discharge, gonococcal, or chlamydial infection.
Malignant trophoblastic disease.
Pelvic tuberculosis.
Women with genital tract cancer.

Surgical methods

Male Vasectomy

Male vasectomy is a permanent operation in the male where a segment of vas deferens of both sides are resected and the cut ends are ligated.

Vasectomy is a voluntary surgical procedure for permanently terminating fertility in men.

Mode of Action

Blocking the vas deferens (ejaculatory duct) to prevent sperm presence in the ejaculate.

Indications

Men certain about achieving their desired family size, seeking a highly effective permanent contraceptive method, or whose partners face unacceptable pregnancy risks.

Contraindications

Vasectomy should be delayed in the case of local or systemic infections.

Benefits

Highly effective
Permanent
Simple surgery under local anesthesia
No further expense or concerns about conception
No long-term side effects
Does not interfere with sexual intercourse

Side Effects

Wound infection
Scrotal hematoma
Granuloma
Excessive swelling
Pain at incision sites

Explain to Clients

When to come back for follow-up visits
Common side effects of the method
What to do if there are changes in menstrual periods
How soon the method is effective
How to protect against STIs
How to care for the wound postoperatively

General Instructions to Clients Using Permanent Methods

Inform about follow-up visit schedules
Explain common side effects in simple language
Share warning signs or possible problems requiring medical attention
Guide regarding changes in menstrual periods
Emphasize the method’s lack of protection against HIV/AIDS and STIs, advocating for backup methods like condoms
Provide instructions on wound care postoperatively

Female -Tubal ligation

Female Tubal Ligation is the interruption of continuity of fallopian tubes.

Tubal ligation is a voluntary surgical procedure for permanently terminating fertility in women. It can be done by a mini-operation (laparatomy/laparoscopy).

Mode of Action

Blocking fallopian tubes by cutting, cautery, rings, or clips, preventing sperms from reaching the ovum.

Indications

Women certain about achieving desired family size, seeking a highly effective permanent contraceptive method, or facing unacceptable pregnancy risks. Family planning should be delayed in specific cases, such as pregnancy, postpartum complications, or certain health conditions.

Timing of the Tubal Ligation

Immediately after childbirth or within the first seven days (if chosen in advance)
Six weeks or more after childbirth
Immediately after abortion (if chosen in advance)
Any time, provided pregnancy is ruled out (between seven days and six weeks postpartum)
During cesarean section

Benefits

Highly effective
Immediate effectiveness
Permanent
Simple surgery under local anesthesia
No contraception-related concerns
No long-term side effects
Does not interfere with sexual intercourse

Disadvantage

Does not protect against STIs/AIDS
Irreversible

Side Effects

Wound infection
Post-operative fever
Rare bladder and intestinal injuries
Hematoma
Pain at the incision site
Superficial bleeding

Challenges associated with Tubal Ligation

Desire for more children after the operation
Excessive desire for reversal
Disagreement to sign the informed consent form
External pressures
Depression
Marital problems

General Complications

Obesity
Psychological upset
Chronic pelvic pain
Congestive dysmenorrhea
Menstrual abnormalities

General Advantages

Simple Surgical Procedure: The procedure is straightforward and uncomplicated.
Out-Patient Procedure: It can be performed as an outpatient procedure, avoiding the need for a hospital stay.
Few Complications: The surgery has a low incidence of complications.
Reversal Anastomosis: Reversal procedures, known as anastomosis, have a 50% chance of success.
Highly Effective: The failure rate is minimal, at 0.15%.
No Interference with Sexual Life: Vasectomy does not interfere with the sexual life of the individual.
Performed Under Anesthesia: The operation is conducted under anaesthesia, ensuring a painless experience.

General Disadvantages

Lack of Protection Against HIV and STDs: Vasectomy does not provide protection against HIV and sexually transmitted diseases (STDs).
Costly Reversal: Reversal procedures can be expensive.
Consent Requirements: Obtaining consent may involve important family members in decision-making.
Risk of Injury to Internal Organs: There is a potential risk of injury to internal organs during the procedure.
Anaesthesia Risks: The use of anaesthesia carries inherent risks.
Post-Surgical Complications: Possible complications include infection and bleeding.
Additional Contraception Required: Additional contraception is needed for about 2-3 months until semen becomes free of sperm.
Potential for Impotency: There is a rare risk of impotence.
Frigidity: Frigidity, especially sexual unresponsiveness in women and an inability to achieve orgasm during intercourse, may occur.
Stigma: Societal stigma may be associated with the decision to undergo vasectomy.

Important points to think about before the use of a permanent contraception

Because male and female sterilization are permanent methods of contraception, thorough counselling procedures must be followed to ensure that the client fully understands his or her choice and to minimize chances of regret.

Counselling: Thorough counselling sessions to ensure informed decision-making.
Reasons for Choosing Permanent Methods: Understand and evaluate the motivating factors behind the choice of permanent contraception.
Screening for Risk Indicators for Regret: Identify potential risk indicators such as:

Young age
Low parity
Single-parent status
Marital instability

Completion of Informed Consent Process: Ensure the individual fully comprehends the implications and consequences of the procedure.
Details of the Procedure: Provide comprehensive information about the surgical process involved in permanent contraception.
Possibility of Failure: Acknowledge the rare but existing possibility of the procedure not being 100% effective.
Positive Pregnancy Test Result: In case of a positive pregnancy test post-tubal ligation, rule out ectopic pregnancy.
Condom Use for STD Protection: Emphasize the continued need for condom use to safeguard against sexually transmitted diseases.

HORMONAL CONTRACEPTIVES (click here)

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Menstruation Disorders

MENSTRUATION DISORDERS

Menstrual disorders are abnormalities in menstruation during reproductive life.

Common disorders associated with menstruation are as follows;

Amenorrhoea
Dysmenorrhoea
Menorrhagia
Metrorrhagia
Polymenorrhagia (epimenorrhoea)
Dysfunctional uterine bleeding
Endometriosis

MENSTRUATION

Menstruation is defined as the periodic physiological discharge of blood from the uterus through the vagina.

The normal period of menstruation usually lasts 2-7 days with a total blood loss of

10 – 80 ml is considered normal.

The normal menstruation cycle has a length of 21-35 days.

THE MENSTRUATION CYCLE

The menstrual cycle is a sequence of physiological events that occur periodically (on average every 28 days) from puberty until menopause.

The events occur under the influence of hormones produced by pituitary glands(Follicle Stimulating Hormone – FSH and Luteinizing hormone – LH) and the ovaries (Progesterone & Oestrogen).

The menstrual cycle is divided into 3 phases namely:

Follicular phase
Ovulatory phase
Luteal phase

Follicular phase (proliferative phase)

This is marked by the beginning of menstruation.

Bleeding results from the decrease in the levels of oestrogen and progesterone from the luteal phase.
The reduction in oestrogen and progesterone leads to the shedding of the endometrium.
During this phase, Follicle stimulating hormone (FSH) from the anterior lobe of the pituitary gland rises to stimulate the growth of several ovarian follicles with each follicle containing an ovum.
Later, FSH levels reduce which leads to only one dominant follicle developing.
The dominant follicle then produces oestrogen hormone.

The Ovulatory phase

This begins with a sharp rise in the levels of LH and FSH.

The luteinizing hormone stimulates ovulation at about the 14th day of the menstrual cycle (between the 7th – 21st day depending on the cycle length).
The oestrogen levels reach a peak and progesterone levels begin to rise once the ovum has been released.
What is left behind of the dominant follicle after ovum release is referred to as the corpus luteum and it is the one that produces progesterone.

Luteal phase (Secretory phase)

Luteal phase usually occurs after ovulation.

During this phase, the endometrium begins to thicken in preparation for nourishment of an embryo in case fertilization takes place.
If fertilization doesn’t occur, the increasing levels of oestrogen and progesterone decrease the production of both luteinizing and follicle stimulating hormones.
Since the maintenance of corpus luteum depends on the luteinizing hormone, a decrease in its production causes the corpus luteum to atrophy leading to a reduction in the production of oestrogen and progesterone.
The thickened uterine lining then begins to slog off and menstruation begins.
And the follicular phase begins to complete the menstrual cycle.

Factors that may interfere with menstrual cycle thereby causing menstrual disorders

1. Physical conditions such as trauma, tumors, and diseases of the glands, ovaries, and uterus can impact the normal functioning of the reproductive system, potentially causing menstrual irregularities.

2. Debilitating diseases such as tuberculosis (TB) and HIV/AIDS can affect overall health, potentially disrupting the menstrual cycle.

3. Malnutrition can lead to hormonal imbalances, affecting the regularity of menstrual periods.

4. Dysfunctional uterine bleeding, which involves abnormal bleeding patterns, can be a contributing factor to menstrual disorders.

5. Age plays a role, as menstruation can be irregular in young girls after menarche (the first occurrence of menstruation).

6. Pregnancy naturally alters the menstrual cycle, and complications during pregnancy can lead to menstrual irregularities.

7. Certain drugs and exposure to X-rays, especially radiography, can impact hormone levels and disrupt the menstrual cycle.

8. Menopause, with its gradual onset, marks the end of the reproductive years and can cause significant changes in menstrual patterns.

9. The use of intrauterine contraceptives (IUCs) can also affect menstrual regularity in some women.

10. Extreme stress and worries, such as those experienced during times of war or conflict, can disrupt hormonal balance and impact the menstrual cycle.

11. Anxiety and mental health conditions can influence hormone levels, potentially leading to menstrual irregularities.

12. Environmental changes, such as transitioning to a new school or significant shifts in routine, can impact stress levels and, in turn, affect the menstrual cycle.

13. The stage of adolescence is a period of significant hormonal changes, and this transition can lead to menstrual irregularities as the body adjusts to these fluctuations.

AMENORRHOEA

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