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Family Planning

World’s population day: 11th July.
  1. Scope of family planning ­Q
    1. Spacing and limitation of births
    2. Advice on sterility
    3. Education on parenthood
    4. Sex education
    5. Screening for pathological conditions related to reproductive system
    6. Genetic counseling
    7. Pre-marital counseling and examination
    8. Marriage counseling
    9. Preparation for parenthood
    10. Services for unmarried mothers
    11. Pregnancy testing
    12. Education in home economics and nutrition
    13. Adoption services
  2. Approach to family planning in India ­
    1. Welfare approach - emphasizes the link between family planning and welfare services Educational approach - no compulsions in family planning.
    2. Cafeteria approach - information given to the beneficiaries so that they could take an informed decision.
  1. Important points
    1. Eligible couple: currently married & wife in reproductive age gp 15-45 yrs.
    2. In India 150-180 eligible couples per 1000 population.
    3. 20% of eligible couples in 15-24 years.
    4. Every yr 2.5 million are joining reproductive. age group.
    5. Target couple; who have 2-3 living children
      FP services directed to them
      Term not used currently
  2. Couple Protection Rate (CPR):
    1. percentage of eligible couples effectively protected against childbirth.
    2. In India CPR= 52%.
    3. 50-60% birth are 3rd order.
  1. Method of FP used by order
    1. Condom users: worldwide most common method of contraception Although condoms are the most commonly used method of contraception worldwide, its failure rate (ranging from 4 to 14 per HWY ) is very high if not used appropriately, which precludes its usefulness in a newly married couple.
      Condom failure rate 2-3 to 14 per 100 women year
      Chemical method: spermicidal jelly nonoxynol 9
      MOA:
      1. Surface-active agent attach to spermatozoa, inhibit oxygen uptake & kill Sperms.
      2. Used in combination with barrier method.
      3. Female condom also available in India (being marketed by the name of Femshield) but very expensive.
    2. Gossypol: male pill
    3. IUD:
      1. 1st generation: non medicated e.g Lippes loop( size A,B,C,D latter largest)
        • ​​high anti-fertility &lower expulsion
        • S/E pain & bleeding more
        • Failure rate: 3
        • Cu T 380A introduced in 2002 effective x 10 years
      2. 2nd generation:
        • ​​Cu IUD – Tcu 200 – Failure rate: 3
        • TCu – 380A – Failure rate: 0.5 – 0.8
      3. 3rd generation: Hormone releasing
        • Progestasert: 38 mg progesterone
        • Rate of release: 65 micro gm/day
        • Failure rate: 1.3 – 1.6
        • LNG-20 (Mirena) 20 micro gm levonorgestrel
        • Low preg rate= 0.2 per 100 women & less ectopic preg
​​
  1. ​​MOA: cellular & biochem changes in endomet.
    Impair viability of sperms
  2. C/I : Absolute:  pregnancy, PID, DUB, Ca Cx, ut, adenexa any pelvic tumour & previous ectopic pregnancy.
    Relative: Anemia, Menorrhagia, H/o P/d since last preg, Purulent Cervical disease, Distortion of uterus, cong. Anomalies, fibroid, unmotivated person.
  3. Change of IUDs:
    Cu IUDs – 3-5yrs, Progestasert – 1yr, CuT 200 – 4yrs, LNG IUD – 7-10yrs, CuT 380A – 10yrs (Replaces all other models w.e.f.2003, this is the IUD now supplied under the RCH program).
  4. Ideal Candidate:
    1. Who has  at least one living child
    2. No h/o PID
    3. No abnormal menstrual periods
    4. Willing to check IUD tail
    5. Monogamous relation
    6. Accessibility

Extra Edge
In 1985, the American college of Obstetricians & Gynaecologists stated that IUDs are “not recommended  for women who have not had children or who have multiple partners, because of the risk of PID and possible infertility.”

  1. Time of insertion: during menses or with in 10 days
    1. Post partum insertion- after delivery
    2. 6-8 wks after delivery (Post pueperal insertion)
    3. Also after 1st trimester abortion
  2. Follow up:
    1. after 1st menses period
    2. 3rd menstrual period
    3. 6mths – one yearly
  3. S/E
    1. Bleeding settles in 1-2 mths
    2. Pain disappears by 3 mths
    3. PID 2-8 times more risk
    4. Uterine perforation : 1:150- 1:9000
    5. Pregnancy : 1st year 3 %
    6. Ectopic pregnancy
    7. Expulsion: 12-20%
  1. OCPs
    1. Mala N
      1. Norgestrol 0.3 mg
      2. Ethinyl oestradiol 0.03 mg
      3. OCPs are by far the contraceptive of choice in a young newly married couple wherein the wife does not suffer from any of the contraindications.
      4. The single most significant benefit of the pill is its almost 100 % effectiveness in preventing pregnancy and thereby removing the anxiety about the risk of unplanned pregnancy.
      5. Another advantage of OCPs is that the contraceptive effect is fully reversible and nearly 98% of women conceive within 3 months of discontinuation of these pills which is most desirable in newly married couples.
    2. Mini pill: Progestrone only pill: Progesterone only pills are advocated usually in older women (age > 40 yrs), lactating women in the first 6 months of lactation or even in young women with risk of neoplasia. But these pills could not become very popular due to poor cycle control and risk of pregnancy and definitely not a contraceptive of choice in newly married couple.
    3. MOA of OCP:
      1. prevent release of ovum from ovary.
      2. Progesterone only preparations.
        • Thick & scanty cervical mucus.
        • Inhibit tubal motility.
      3. Preg. Rate less than 1
    4. Side effects
      1. CV effects
        • Carcinogenesis: increased risk of Ca Cx.
        • Metab Effects:
          1. increase BP& Lipids.
          2. blood clotting
          3.  increase Blood Glucose & Plasma Insulin
        • Liver disorder: hepato-cellular adenoma, GB dis.
        • Lactation decreases
        • Breast tenderness
        • Head & migraine
        • Bleeding disturbance
        • Wt gain
    5. ​​Non Contraceptive Benefits: protection from
      1. Benign breast disorder
      2. ovarian cyst
      3. iron def anemia
      4. PID
      5. ectopic pregnancy
      6. ovarian cancer.
 
  1. ​​​​A. C/I: absolute Q
    • Ca breast & genital
    • Previous or present H/O thrombo-embolism
    • Cardiac abnormality
    • Cong. Hyperlipidemia
    • Undiagnosed abnormal uterine bleeding
  2. B.  Relative:
    1. Age>40
    2. Smoking and age >35
    3. Mild HT
    4. Chronic renal disease
    5. Epilepsy
    6. Migraine
    7. Nursing mother in first 6 months
    8. DM, GB disease
    9. H/o infrequent bleeding
    10. Amenorrhoea
​​
  1. Check List:

i. A. Age above 40

ii. B. Above 35 and smoking

1). Seizures

1). Severe pain in calves or thigh

2). Symptomatic varicose veins in legs

2). Severe chest pain

3). Unusual shortness of breathe after

3). Severe headache & visual

      examination    

      disturbances

4). Lactating

4). Inter-menstrual bleeding

5). Amenorrhea

5.) Abnormal yellow skin

6). B P(>140 systolic)

6). Mass in breast

7). Swollen legs

 
  1. Injectables
    1. Prog. Only:
      • ​​DMPA(Depot- Medroxyprogesterone acetate) 150 mg x 3 mths
      • NET- EN(norethisterone enantate) 200mg x 2 mths​
Time of Injection : During first 5 days of periods I/M

S/E :

C/I :

1)   wt gain

1)   ca breast, genitals

2)   Intermittens bleeding

2)   Undiagnosed uterine bleeding

3)   Amenorrhea

3)   Suspected malig

  1. Combined inj: Cyclo fem
    • Cyclo Provera
    • Mesigyna
  2. Sub-dermal implant: Norplant for 5 yrs
    • ​​6 silastic capsules with 35 mg of levonorgestral each
    • beneath the skin of forearm or upper arm
  1. Post-coital contraception: Also known as Emergency Contraception
    Methods available
    1. IUCD: most effective if used within 72 hrs
    2. Hormonal: Yuzpe & Lancee: 4 tabs of std combined pill then 4 pills after 12 hrs
    3. Mifepristone (RU 486)
    4. E Pill (Latest addition in the RCH program)- 0.75 mg Tablet – 2 tablets to be taken 12 hrs apart.(marketed by the name of I pill).

Regimen

Timing of dose after intercourse

Reported efficacy

Remark

1. Combined pills

0-72

75%

4 stat 4 after 12 hrs

2.Cu IUDs

0-120 hrs

Failure rate < 1%

 

3. Mifepristone

0-120 hrs

85 -100 %

Single dose

4.Levonorgestreal 0.75 mgs

0- 72 hrs

75 -85

Two dose 12 hrs apart




 
  1. ​Surgical Method
    1. Non Scalpel Vasectomy
      1. This is a new method of male sterilization which is currently being actively promoted by the WHO. The procedure uses a fixation clamp which is used to grasp the vas deferens from outside the scrotal skin and a vas dissecting clamp which is used to make a puncture into the skin overlying the fixed vas. At the end of the procedure, sutures are not needed and the small puncture hole is covered by a small piece of gauze.
      2. This method is superior to conventional vasectomy because of:
        • ​​It eliminates the fear of a big surgical incision
        • It is much quicker to perform
        • It has fewer complications
    2. ​​Vasectomy: 100% effective
      • ​​Effective after 30 ejaculations
      1. Complication:
        • ​​Operative
        • Non Oprative
          1. Sperm granule
          2. Spontaneous re-canalization
          3. Auto immune response
    3. ​​​Lap ligation: conventional mini laprotomy for female sterilization is obsolete now, only lap ligation recommended by RCH program.
  2. Sterilization : Most Common Method of contraception in Delhi
    1. Female 85% and male 15%
    2. Averts 1.5-2.5 births per women.​
Guidelines:
  1. Age of husband 25-50 years.
  2. Age of wife 20-45 years
  3. 2 children
  4. Couple with 3 or more children lower limit of age can be relaxed
  5. Consent
​​
  1. Contraceptive Failure rate (per 1000 / year)
    1. ​​Combined pills 1-8
    2. Mini pills 3-10
    3. Injectable contraceptives <= 1
    4. Contraceptive implants 0 – 2
    5. IUD < 1
    6. Tubal ligation 0.2 – 1
    7. Vasectomy 0.15 – 1
    8. Condom 5 – 20
    9. Diaphragm 5 – 25
    10. Spermicidal jellies/creams 10 – 30
    11. Sexual abstinence 10 – 30
    12. Coitus interruptus 5 – 25




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