Session 1: Introduction to Family Planning Methods TYPES OF FAMILY PLANNING METHODS AVAILABLE IN UGANDA 1. Hormonal contraceptive method a. Oral pills Combined Oral Contraceptives (COC) examples are; Lo-feminal, Microgynon and Pill Plan Progestin only Pills (POP) examples; Overette and Microval b. Injectables: - Depo Medroxy Progesterone Acetate (DMPA/Depo Provera) and Nerethisterone Enanthate (NET – EN) FPAU clinic only) c. Implants: -Norplant, Jadelle, Implanon 2. Intra-Uterine Device (IUD): - Copper T380A 3. Barrier Methods: - Condoms – female, male, Spermicides – foams, jellies, creams 4. Natural Family Planning: - Lactational Amenorrhoea Method (LAM) Fertility awareness methods, Moon beads 5. Voluntary Surgical Contraception (VSC) : -Tubal Ligation, and Vasectomy GUIDE FOR DESCRIBING FAMILY PLANNING METHODS What it is Effectiveness in preventing pregnancy including the user’s role Mechanism of action
Transcript
Session 1: Introduction to Family Planning Methods
TYPES OF FAMILY PLANNING METHODS AVAILABLE IN UGANDA
1. Hormonal contraceptive methoda. Oral pills
Combined Oral Contraceptives (COC) examples are; Lo-feminal, Microgynon and Pill Plan
Progestin only Pills (POP) examples; Overette and Microvalb. Injectables: - Depo Medroxy Progesterone Acetate (DMPA/Depo
5. Voluntary Surgical Contraception (VSC) : -Tubal Ligation, and Vasectomy
GUIDE FOR DESCRIBING FAMILY PLANNING METHODS
What it is Effectiveness in preventing pregnancy including the user’s role Mechanism of action Advantages and non contraceptive benefits Protection against STIs/HIV/AIDS Common side effects and disadvantages Who can use the method Who cannot use Signs of problems that require urgent medical attention
WHO Medical Eligibility Criteria for starting or continuing to use Family Planning methods
World Health Organization (WHO) has outlined the medical eligibility criteria for starting and using contraceptive methods. This criterion has been put in the following categories:
WHO Category 1
No restriction on contraceptive use. The client can use the contraceptive
WHO Category 2
Client can generally use the method. Advantages of using the method outweigh proven or theoretical risks. If a client chooses the method more than usual follow up is needed
WHO Category 3
Client should not use the method. Proven or theoretical risks outweigh advantages of using the method.
WHO Category 4
Client should not use the contraceptive. Client’s condition represents an unacceptable health risk if method is used.
Scenario I:A 42 year old woman with 2 children requests COCs. She has a history of diabetes which was first diagnosed when she was 18 years old.
1. Is this client a good candidate for receiving COCs during today’s visit?
2. Explain your reasons3. What course of action would you suggest next for client?
Scenario II:A 28 year old woman has 3 children. She and her husband consider their family complete, do not want any more children, and would like to use an effective contraceptive method. After counseling session woman decided that she wants to use DMPA. She is healthy, but for the past two months noticed light bleeding/spotting every time she had intercourse. She meant to go to the doctor, but didn’t get round to it.
1. Is this client a good candidate for receiving COCs during today’s visit?
2. Explain your reasons3. What course of action would you suggest next for client?Session 1.1. Description of FP Methods
1. Combined Oral Contraceptives
Description of COCsCombined oral contraceptives are pills that contain 2 hormones i.e. Synthetic estrogen and progestin. They are taken orally and daily to prevent pregnancy.
Currently Uganda has only low oestrogen dose COCs (30 mcg instead of 50mcg that was responsible for oestrogen related effects in the previous years). The COC used in this country come in 28 Day Pill Cycles with 21 Active or Hormonal Pills and 7 Placebos or Ferrous Femurate to allow for withdrawal bleeding.
Types: Lo-feminal and Microgynon are found in the public sector health facilities whereas Duofem (Pilplan) is found in the private sector.
Microgynon: Lo-Feminal: Duofem21 hormonal pills containing 0.03 mg of ethinyl estradiol and 0.15 mg Levonorgestrel and 7 brown pills containing Ferrous Femurate.
21 White pills containing 0.03 mg ethinylestradiol (estrogen) and Norgestrel (progestin) 0.3 mg and 7 brown pills containing Ferrous Femurate.
(Marketed as New Pilplan): 21 White pills containing 0.03 mg ethinyl estradiol (estrogen) and Norgestrel (progestin) 0.3 mg and 7 brown pills containing Ferrous Femurate.
NB. Please note that though all the COCs have same type and amount of oestrogen in them, they sometimes differ in the type and amount of progestin e.g. Microgynon has a different type of progestin which is (Levonorgestrel 0.15 mg) whereas Lofeminal and Duofem have (Norgestrel 0.3 mg) as the progestin. The significance is that sometimes you may have
to switch clients from one COC to another because the clients may respond differently to either. An example is a client may respond better to Microgynon than Lofeminal and Duofem.
Mechanism of action of COCsThe COC Pills prevent pregnancy by:
Suppressing ovulation Thickening the cervical mucus thus making sperm entry difficult
Effectiveness of COCsThe effectiveness of the method depends on user compliance. It is very effective when used properly; about 3 in 1,000 women (0.3%) who use COC correctly and consistently get pregnant in the first year of use. When pill taking mistakes are made among the real users, the failure rate may be as high as 8%; this means that 1 woman in 12 will become pregnant in the first year of life as the hormone-free interval is lengthened (Contraceptive Technology 18th Revised Edition)The failure rates decline as duration of use increases; and also as age of user increases; Failures may be due to:
o Client error;o Service provider not giving complete and/or correct information;o Drug interactionso Severe vomiting/diarrhoea;o Expired pills
The continuation rate among COC users is low (25 – 50% of women will stop the COC within one year), most will stop for non-medical reasons. In cultures where bleeding may exclude women from some family activities, break through bleeding/spotting can be major reason to stop the pill. If client does not have or use another (back-up) method, unintended pregnancy can result;
It is important to counsel and reassure about potential side effects, and that break-through bleeding/spotting will decrease after first 3 to 4 months or can be managed. The client should be cautioned not to stop taking the COC unless she has another method to use, or has access to ECP at hand/has the method on hand, and knows how to use it.
Advantages and non-contraceptive benefits of COCs Cause periods to be regular and predictable;
Reduces menstrual blood loss which prevents anaemia Reduces dysmenorrhoea and premenstrual tension Can be used an emergency contraception Are very effective if taken correctly Are easily reversible Are safe for most women Are independent of coitus Protect against ovarian and endometrial cancer, and PID Reduce risk of functional ovarian cysts, benign breast cysts, fibro-
adenoma, and ectopic pregnancy
Disadvantages and common side effects of COCs Effectiveness depends on client remembering to take pill everyday;
strong motivation needed to take pills correctly/daily; Require regular and dependable supply; Reduces breast milk, especially in the first 6 months after delivery and
is, therefore, not the most appropriate choice for lactating women (unless no other method is available and there is a high risk of getting pregnant);
Minor side effects which are common in first three months may include: spotting, amenorrhea, nausea, breast tenderness, headaches, weight gain, depression, and/or acne;
May cause circulatory complications though very rare. Increased risk is related to women over 35 who smoke and have other health problems.
Protection of COCs against STD/HIV infectionSome protection against pelvic inflammatory Disease (PID) but does not protect against other STIs, including HIV.
Who can use COC? All women of reproductive age who desire to use COCs Women with:
o anaemia, but the basic problem causing anemia must be evaluated and treated
o dysmenorrhoeao irregular cycleso history of ectopic pregnancieso Diabetics lasting less than 20 years or without evidence of
hypertension
o BP less than 160/100 mm Hgo trophoblastic disease (on treatment and follow –up)o Varicose veins or superficial thromophlebitiso Unexplained vaginal bleeding (although evaluation should be done
as soon as possible)o Benign ovarian tumours (including cysts)o Ovarian cancer awaiting definitive treatmento Thryoid diseaseo Benign breast diseaseo Depressive disorderso Undergoing treatment with the antibiotic griseofulvino Undergoing treatment with ARVs (although effectiveness may be
reduced)o STIs, including HIV/AIDS
If a client is taking ARVs which include Niverapine and wants to use COCs, it is important that she takes the pill daily at the same time otherwise she is likely to get pregnant.
Who should not use COC?The following contra-indicate administration of COC: Pregnancy (although there is known harm to the woman or the foetus if
COCs are accidentally used during pregnancy) Complications or side effects that a service provider is not capable of
handling: Breast feeding mothers less than 6 months Women due for major surgery within four weeks; Women with:
- history of current deep vein thrombosis;- Vascular disease;- Migraine with focal neurological symptoms;- Liver disease e.g. Hepatitis, cancer, cirrhosis- Jaundice - women with Active viral hepatitis
Women undergoing treatment with drugs that affect the liver enzymes (rifampicin and certain anticonvulsants such as phenytolin, carbamazipine, barbiturates, primidone, topiramate, oxcarbazepine)
Women with: History of all ischemic heart disease;
- Stroke or history of stroke;- Major surgery with prolonged immobilization;- Hypertension greater than 160/100 mmhg;- Known thrombogenic mutations (e.g. factor V leiden: prothrombin
mutation: Protein S. Protein C and antithrombin deficiencies) due to higher risk of thrombosis
History of:- Diabetes with vascular complications or diabetes of more than 20
years duration- Smoking more than 15 cigarettes a day whatever the age- Smoking when older than 35 years
Women judged to be forgetful or mentally retardedTo date there is no concrete evidence that oral contraceptives have any effect on the transmission of HIV or the course of AIDS once a person is infected
Signs of problems that require urgent medical attention Severe headaches with blurred vision Severe constant pain the chest with difficulty in breathing Acute abdominal pain Pain in the calf muscle Eyes or skin become unusually yellow COC signs that require urgent medical attention are rare in low-dose sub
– 50 mcg danger signs, and what to do if she should experience any one of these. Care should be taken by the provider to present these in a non-alarming way to the client. Providers should question for these at each follow up visit. Heavy smoking appears to be the most significant risk factor for development of major cardiovascular disease.
Progestin only contraceptives (POP, Injectables, Implants)For effectiveness of each method in preventing pregnancy and contributing factors, service providers during counseling clients, should emphasize the following to them: POPs are effective after swallowing for seven days and the effectiveness
is maintained by swallowing every day at the same time. Injectables are effective within 48hrs. specifically for DMPA,
effectiveness will last 12 weeks and NET EN for 8 weeksProviders are also reminded that the effectiveness of the contraceptive in particular injectables and implants depends on giving the injection
following the correct procedure and infection prevention protocols.
Implants:The new implants (Jadell and Implanol) are different from the Norplant Implants was effective within 48 hours and used for 5 years whereas the new ones and are effective for 3 years. The effectiveness depends on proper insertion under the skin (subdermally)The side effects are temporally and that they wear out (usually within 3 months) when the body gets used to the method. The side effects which are specific for each group (POP, Injectables, and Implants) are discussed in this handout.All contraceptives which contain only one hormone; Progestin are referred to as Progestin Only Contraceptives (POCs). In Uganda, the major types available include oral pills, injectables and implants:
Type of POC
Name Description
Oral pills Progestin Only Pills (POP)
The one found in the health units in Uganda is Overette. Overette contains Norgestrel 0.075mg and is supplied in 29 pill packs.
Each vial contains Medroxy Progesterone Acetate 150mg (DMPA). The common name is Depo Provera. It is marketed as Inject–Plan. It is found in the public sector health facilities.
NET– EN (Noristerat)
It is found in the private sector and supplied in 200mg vials.
Implants Implanon A single rod (capsule) which contains Etonorgestrel 68mg. within eight hours of after sub dermal insertion, etonogestrel levels are sufficient to provide contraceptive protection. A continuous release of etonogestrel is maintained for 3 years and within one week after removal, etonogestrel is no longer detectable in human serum.
Jadell consists of two (2) rods (capsule) and each rod contains Levonorgestrel 75mg
Norplant Implants
FP method which contains six (6) small plastic capsules that are inserted under the skin of the woman’s upper arm. Each capsule contains only progestin hormone and lasts for 5 years.
Mechanism of action of POCsAll POCs prevent pregnancy by mainly in two ways by thickening the cervical mucus within 24 hours making it difficult for sperm to enter the uterus and/or inhibiting ovulation
Method specific information:a) Progestin Only Pills (POP)
Effectiveness POPs are most effective when taken at the same time everyday.
Delaying to take the pill for only three hours may result in pregnancy if the woman has unprotected sexual intercourse in that time.
For breastfeeding women, POP is very effective when taken correctly because breastfeeding itself provides much protection against pregnancy. Only one (1) pregnancy may occur per 100 women in the first year of use.
POPs are also very effective when used correctly and consistently in both breastfeeding and non breastfeeding women. 0.5 pregnancies (1 in every 200 women) may occur in the first year of use.
POPs are also very effective when used correctly and consistently in both breastfeeding and non breastfeeding women. 0.5 pregnancies (1 in every 200 women) may occur in the first year of use.
Advantages and non contraceptive benefits Very effective if taken correctly Can be very effective during breastfeeding start 6 weeks after delivery Does not suppress lactation No estrogenic side effects Can take one pill of the same colour everyday with no break, so it is
easier to understand Suitable for those with hypertension or thromboembolic, cardiac, or
sickle cell disease Does not increase blood clotting Reduces the risk of:
o Benign breast diseaseo Endometrial and ovarian cancero Pelvic inflammatory disease
Common side effects and disadvantagesFor women who are not breastfeeding may have: Spotting or bleeding between periods Amenorrhea Mild headache Breast tenderness If not breastfeeding, even taking a pill a few hours late increases risk of
pregnancy Does not project against other STIs or HIV
b) Depo Provera (DMPA) and Noristerat
Effectiveness: Very effective – 0.3 pregnancies per 100 women in first year of use (1 in
every 33.3 women) when injections are given regularly, every 12 weeks. Pregnancy rates become higher for women who are late for an injection
or who miss an injection or if there are stock outs.
Advantages and non contraceptive benefits It is very effective Does not suppress lactation Client only has to remember the return date for subsequent injections
i.e. it is private; no one can know that the woman is on it Can be used at any age No estrogen side effects May reduce the frequency of epileptic and sickle cells crisis less frequent Helps to prevent ectopic pregnancies and iron deficiency anaemia
Disadvantages and common side effects The woman may experience the following changes in the menstrual
bleeding:o Spotting (most common at first)o Amenorrhea (normal after first year of use)o Heavy bleeding (rare)
Weight gain Delayed return of fertility, about 4 months longer wait for pregnancy
after stopping use Mild Headaches Breast tenderness Loss of libido Moodiness Nausea Acne or hair loss Requires injection every three months Does to protect against other STIs or HIV
c) ImplantsThere are so far 3 types of Implants in Uganda i.e. Norplant Implant, Implanol and Jadell.
General information on Implants: Effectiveness Implants are very effective, only 0.1 pregnancies
per 100 women (1 in every 1,000) may occur in the first year of use.
Pregnancy rates have been slightly higher among women weighing more than 70 kgs.
Advantages and non contraceptive benefits
Very effective even in heavier women Effective within 24 hours after insertion No delay in return to fertility after removal Long acting; needs replacement after three years No repeated clinic visits required Helps to prevent: iron deficiency, anaemia, ectopic
pregnancy, endometrial cancer Makes sickle cell crisis less frequent and less painful No effect on breast milk No oestrogen side effects Insertion involves only minor pain of anaesthesia
needle. Not painful if anaesthesia is given properly.Common side effects and disadvantages
Changes in menstrual bleeding:o Spottingo Heavy bleeding (rare)o Amenorrheao Minor surgical procedure required for insertion
and removal
o Discomfort in the arm after insertiono Does not protect against STIs including
HIV/AIDS While being on Implants, some women may
develop:o Weight gaino Headacheso Dizzinesso Breast tendernesso Moodinesso Nauseao Acne/skin rasho Change in appetiteo Hair loss or more hair growth on the faceo Client cannot start or stop using an implant on
her own; the capsules must be inserted and removed by a specially trained health care provider.
SESSION: 1.3. SCREENING CLIENTS FOR CONTRACEPTIVES USE
Purposes of screening clients for FP method useFP clients are screened so as to: To rule out contra-indications/precautions to FP method use To identify reproductive health problems and manage accordingly; To screen for STI and HIV; To gather baseline data for future reference; To follow up on problems To determine eligibility for method of choice, according to WHO criteria
Components of Screening clients for FPThe following procedures are carried out when screening clients for contraceptive use: History taking Screening to be reasonably sure that the client is not pregnant Screening for medical eligibility using method specific checklists Physical examination
Laboratory investigations Ultra sound (pelvic)
1. History taking
A. Reasons for taking history being: To get an understanding of the client’s general health status To find if there are reasons why a client should not use some methods To find out any problems that may need treatment of referral To find out any problems that may have come about as a result of
using a family planning method To make and keep a record of a client’s health history To find out if there is a need for a physical examination To decide what to talk more about during counseling
B. Types of histories at first visit: Name, age and address for identification of individual client and the Reproductive health risk factors.
Social history to find out: Drinking, smoking and eating habits that may affect contraceptive use.
Family history to find out: Close members of family suffered from diabetes mellitus, high blood pressure asthma and heart disease. Some of these conditions may be inherited and may affect contraceptive use.Medical history to find out: Whether client had suffered from or currently suffering from certain illness that may be a contra-indication to some contraceptive use.Surgical history: To find out whether client has had any operations or is planning to have an operation which may deter her from using certain contraceptive methods.Reproductive history: - To find out the number of children she is having, or planning to have, their health status, any problems encountered during previous pregnancies and delivery. This history will enable provider to:
Identify the at risk clients, educate about the risks of pregnancy and benefits of FP
To counsel client and assist her to choose an appropriate method whether to space or terminate reproductive life.
FAMILY PLANNING CLIENT CARD
Client Number.…………… Health unit ………………… Date ………………..
Name ……………………….. Occupation …………………. Address ………….
Age …………… L.M.P. …………….
Total pregnancies: Live …… Still ……. Misc … Total ……. Living children ……
Last pregnancy: Live StillBirth …….. Birth ….. Abortion ….. Date …. Lactating ……
Delivered by/at …………………….. Returned for P.P check (yes/no) …………..
Previous contraception (Yes/No) if yes, name method ………………………………
Supplies given…………………………………………………………………………………
Immunization status dates for:
TT1 TT2 TT3 TT4 TT5
Initial assessment
Medical history ……………………………………………………………………………
Gynae history………………………………………………………………………………
Surgical history ……………………………………………………………………………
Physical exam (yes/no) …………………………………………………………………
Pelvic exam (yes/no) ………………………………………………………………………
Date L.M.P. BP WT Comments
Type of method
Quantity
Signs
Note: If you are using an exercise book at your facility rather than pre-printed Client Cards, format the client information in the exercise book in a similar way as the card shown above.
How to fill the family planning cardRefer to completed example on page 6.
Client number: - Get the client’s number from the family planning register and write in the space for “client no” Each client has his or her own client number. No two clients have the same client number.
Health unit: - Write the name of your health unit in the space provided
Date: - Enter the date when you are providing the client with the method for the first time.
Name: - Write both names of the client in full to avoid confusion for clients who may share names.
Occupation: -Write the client’s occupation in this space
Address: - Put the client’s address in this space, by parish or zone for easy contact tracing in case a home visit is necessary.Age: - Write the client’s age in years. Write the word “adult” in this space if the client does not know.
L.M.P. (Last Menstrual Period):- Write the date of the first (1st) day of the client’s last normal menstrual period. If she cannot remember the date, probe whether it was beginning, middle or end of the month. This is to rule out the possibility that the client may be pregnant and/or determine whether a back-up method is needed for a client who may wish to start a hormonal method.
Total pregnancies: - Write the number of children born alive in the “live” column, even if the child died afterwards. Enter number of children born dead (still births) under “still births” and enter miscarriages under “misc” Enter the total number of pregnancies under “total” and the number of client’s children who are still alive under “living children”If the total number of pregnancies seems to high, counsel the client on the risk/dangers posed by additional pregnancies. Note: if the client reports no pregnancies, skip to “previous conception”.
Last pregnancy ended in:Write “yes” or “no” where appropriate/suitable in the spaces provided for live birth (write “yes” even if the baby died immediately after birth); still birth, and abortion (a pregnancy which ended before 28 – weeks of pregnancy). Write the date that at the last pregnancy ended. Under “lactating” write “yes” if the client is still breastfeeding.Recall that some hormonal methods are not appropriate/suitable for women immediately after birth and/or while breastfeeding. Asking women this information can help you know if some methods may not be suitable for them at this particular time.
Delivered by/at: Ask the client who delivered her and where (e.g., TBA/at home, midwife/health unit) and enter her response in this space. This will help you talk with client about the importance of delivering at a health facility with a trained provider.
Returned for postpartum (PP) check: Ask the client if she attended a post-natal clinic following her last birth and if she was examined. Write “yes” or “no” as appropriate.This will help you talk with the client about the importance of seeing her health care provider for a post natal follow-up visit at 6-8 weeks post partum. You can also ensure that the baby is immunized, weighed and given a health card.
Previous contraception: Ask the client if she has ever used a modern family planning method and write “yes” or “no” in the space provided. If yes, ask the name of the method used and enter in the space provided. Also note how long the client used the method.Take a moment to ask some questions about the client’s experience with FP method(s) If the client has used a method before and stopped it to have a baby, it’s likely that she knows how to use that method and she may want to continue using it. If she stopped using it due to problems with the method or got pregnant while using the method, it may not be the best method for her.
Supplies given:- Ask the client the amount of contraceptives she received (e.g. how many cycles of pills or how many injections of Depo Provera she received) and enter the number in the space provided.
Immunization status dates: - Enter the month and year (e.g. 11/01) when the client received Tetanus Toxoid immunization under TT1 TT2 TT3
TT4 and TT5. Ask to see her TT card for confirmation. If she does not have the card, give TT1 and enter the month and year under TT1 but ask her to come with original card during her next visit. When she brings her original card, update the TT immunizations according to the card. Every woman should be immunized against tetanus five times. If the woman is not up-to-date, immunize her.
Initial assessment:
Medical historyAsk the clients for history of heart disease high blood pressure, liver disease, TB, weigh loss and diarrhoea which has lasted for more than one month, skin rash, sores all over the body, enlarged glands. Record the exact answer for what you asked. Do not write “Nil”Gynae (gynaecological) historyConfirm the date of the last month monthly period. Ask if the client has painful periods. Ask the questions related to STIs. number of sexual partners lower abdominal pain itchy vaginal discharge with a bad small sores swellings in the private parts pain when passing urine pain during of after sex bleeding after sex
Surgical historyAsk if the client has had any operation on the uterus e.g. Ca
Pregnancy Checklist: How to be reasonably sure a client is not pregnant
Ask the Client questions 1-6. As soon as the client answers YES to any question, stop, and follow the instructions.
NO
Did you have a baby less than 6 months ago, are you fully or nearly fully breastfeeding, and have you had no menstrual period since then?
YES
NO Have you abstained from sexual intercourse since your last menstrual period or delivery? YES
NO Have you had a baby in the last 4 weeks?YES
NO Did your last menstrual period start within the past 7 days YES
NO Have you had a miscarriage or abortion within the last 7 days? YES
NO Have you been using a reliable method of contraception consistently and correctly? YES
If the client answered NO to all of the questions, pregnancy cannot be ruled out. Client should await menses or use a pregnancy test
If the client answered YES to at least one of the questions and she is free of signs and symptoms of pregnancy, provide client with desired method
Session 1.4: Initiating clients on FP methods
Hormonal FP methods and intra uterine devises are initiated after proper screening and you are reasonably sure a client is not pregnant. To apply the WHO eligibility criteria in an easy way, the Ministry of Health has developed simple checklists. The checklists are based on WHO guidance and are designed to identify medical conditions and high risk behaviors that would prevent use of some contraceptive methods
When to initiate FP Methods
COC POP INJ. DEPO PROVERA
Norplant Condoms LAM
Any time in the cycle when certain the client is not pregnant
Any time in the cycle when certain the client is not pregnant
Postpartum period with Lactational
Any time in the cycle when certain the client is not pregnant
Within 6 -8 weeks post partum
Any time in the cycle when certain the client is not pregnant
Within 6 -8 weeks post partum
Any time of the cycle
As back up when starting COC or
- Missing
Immediately Post partum
OR Anytime before
first 4 weeks postpartum
After 6 months post partum with Lactational amenorrhea and pregnancy ruled out
Changing from Depo Provera, or POP even if having no periods
1 week after abortion
amenorrhea if client not pregnant
At 6-8 weeks postpartum
Changing from Depo Provera, or COC
Immediately Post partum or Post abortion
Immediately Post abortion
Switching from COC or POP
Immediately Post abortion
Switching from COC or POP
pills- Drug
interaction
(1st trimester)*
2 weeks post abortion (2nd trimester) or **post delivery and not breast feeding
* When method is started before ovulation occurs it increases protection against pregnancy by suppressing / preventing ovulation** Ovulation returns almost immediately post abortion:
- Within 2 weeks of first trimester abortion- Within 4 weeks of second trimester abortion or within 6 weeks of third trimester pregnancy
delivery or stillbirth
Handout: Checklist for Screening Clients who want to initiate use of DMPA or Depo Provera
To determine if the client is medically eligible to use DMPA, ask questions 1-7. As soon as the client answers YES to any question, stop and follow the instructions after question 7.
NO 1. Have you ever had a stroke, blood clot in your legs or lungs or a heart attack?
YES
NO 2. Have you ever been told you have breast cancer?
YES
NO 3. Do you have a serious liver disease or YES
jaundice (yellow eyes)?NO 4. Have you ever been told you have diabetes
(high sugar in your blood)?YES
NO 5. Have you ever been told you have high blood pressure?
YES
NO 6. Do you have bleeding between menstrual periods which is unusual for you or bleeding right after sexual intercourse (sex)?
YES
NO 7. Are you currently breastfeeding a child less than six weeks old?
YES
If the client answered NO to all of the questions 1-7, the client can use DMPA. Ensure that you ask questions to be reasonably sure that she is not pregnant
If the client answered YES to any of the questions 1-3, she is not a good candidate for DMPA. Counsel about other available methods or refer.
If the client answered YES to any of the questions 4-6, DMPA cannot be initiated without further evaluation. Evaluate or refer as appropriate, and give condoms to use in the meantime.
If the client answered YES to question 7, instruct her to return for DMPA as soon as possible after the baby is six weeks old.
Handout: Checklist for Screening Clients Who
MANAGING CLIENTS WITH BLEEDING PROBLEMS WHILE USING CONTRACEPTIVES
General Examination Check for Anaemia Check breast for signs of pregnancy Perform pelvic examination for:
o Abortion, if yes then refero Pregnancy, if yes then book ANCo Infections, if yes then give
antibioticso Uterine masses, if yes then refer
to MO
COC POP DEPO IUD
Spotting within 3 months R
eassure; or Give Microgynon or switch to Lo –femenal
hormonal method
Give Brufen 800 mgs tds X 5/7
Heavy bleeding POP: BD x 14 days Review in 14 days If no change, then
refer Brufen 800 mgs tds
5/7
Spotting Reassure If client worried,
give COC 1 pill/day X 7days
Heavy bleeding between 8 – 12 wks of 1st injection Give Depo
Provera Change return
dateHeavy bleeding at 3rd or later injection Give 1 cycle COC Give iron for 1
month Brufen 800mgs
tds X 5/7
Heavier period
ReassureSpotting within first 3 months ReassureInfection Give
antibiotics Remove IUD if
severe Counsel for
other methods
The common side effects of each FP method
Method Minor Side effects Rare Major side effects that require urgent medical attention
COC Most common in first 3 months- Nausea- Spotting or bleeding between
menstrual periods Light menstrual periods Occasional missed periods Mild headaches Breast tenderness Moodiness
Severe constant pain in chest, left arm or abdomen Severe headaches Eye problems-flashing lights or blurred vision Eyes or skin become unusually yellow (jaundice)
POP If not Breastfeeding Irregular periods Spotting or bleeding between periods Amenorrhea Mild headache Breast tenderness
Severe lower abdominal pain (may be sign of ectopic pregnancy)
Delayed period after several months of regular cycles may be sign of pregnancy
Repeated severe headaches if present may become worse on POPs
Depo-Provera (DMPA)
Changes in menstrual bleeding:- Spotting most common at first year. - Amenorrhea normal after firs year of
Repeated severe headaches Very heavy bleeding twice as much and twice as
long as you usually bleed when in your periods
use- Weight gain- Delayed return of fertility about 4
monthsOthers: Mild headaches Breast tenderness Moodiness Nausea Loss of libido Acne, hair loss
Depression Severe lower abdominal pain (may be sign of
ectopic pregnancy) Pus, prolonged pain and bleeding at injection site.
Norplant Change in menstrual bleeding- Spotting- Amenorrhea
Discomfort in the arm after insertion Some women have:- Weight gain- Headaches- Dizziness- Breast tenderness- Moodiness- Nausea- Acne/skin rash
Pain, heat, redness, severe soreness at insertion site
Capsules come out Severe headaches Very heavy bleeding-twice as much and twice as
long as you usually bleed when in your periods Severe abdominal pain (may be sign of ectopic
pregnancy) Missed menstrual periods after several cycles.
- Change in appetite- Hair loss or facial hair growth
IUD Mild cramps during the first few (3-5) days post insertion
Menstrual changes common in the first three months:- Longer and heavier menstrual
periods- Spotting - Increased cramping/pains during
menses
Severe abdominal cramps Heavy bleeding after 3 months of insertion Expulsion missing strings Missed menstrual periods Not feeling well, chills, fever and foul smelling
vaginal discharge
Female sterilization
Discomfort at incision site High fever (greater than 380C) Local anesthetic allergic reaction Severe abdominal pain/cramping Severe pain, heat, swelling or redness of the
wound Pus or bleeding from the wound Depression because of regret
Male sterilization
Discomfort at the incision site Minor swelling at incision site Minor bleeding
High fever (greater the380C) Bleeding or pus from the wound Pain, heat, swelling or redness of the wound Depression because of regret
Side Effects and complications
Side effects are the minor problems which are short lived and usually subside within two-three months, and complications are those problems which require urgent medical attention.
”The SOAP process of managing side effects and complications of FP methodsThe SOAP processThe acronym SOAP is
S - SubjectiveO - ObjectiveA - AssessmentP - Plan
Subjective: Collect information on the situation from the client 9through history taking or counseling).
Objective: Collect information on the situation from physical examination, investigation and/or observation.
Assessment: Review subjective and objective information and make conclusion/diagnosis.
Plan: Determine strategy to resolve the situation (e.g. treatment, change of method, counseling or re-instruction) and tell the client of the plan. Remember to evaluate client’s understanding before he/she leaves and arrange for follow up visit.
Examples of SOAP Process applicationAMENORRHEASituation number 1: Client comes complaining of Amenorrhea for two months. She is at the end of the second packet of COCSubjective: Determine from the client if there has been any bleeding or spotting while taking the Pills:
Ask how client takes the Pills Ask client if taking any other drug e.g. Rifampicin for TB Ask the client about type of OCO (high or low dose) Ask the client about interruptions in pill administration (missing
pills, drug interaction and severe diarrhea or vomiting)
Ask the client about LNMP and other signs of pregnancyObjective: Based on the subjective findings:
Determine whether client is pregnant or not, by doing physical assessment, looking for: breast changes, uterine enlargement and softening and change of color of cervix;
Test urine for pregnancy if possible.Assessment: Based on subject and or objective information gathered above, the client is not pregnant;
Conclude that missed periods are caused by inadequate build up of Endometrium due to low dose of oral contraceptive
Plan: Inform the client about the findings and reassure her. Let her continue taking the pills and tell her to return if she
misses another period; If no low dose COC, let her continue or give her a higher estrogen
dose of COC or change FP method If not taking the “placebos” tell her the importance of taking the
brown Pills Evaluate understanding and give appointment date before she
leaves facility.Situation number 2: Client who comes complaining of amenorrhea
while on DMPASubjective:
Ask client about LNMP. Ask client when the injection was given. Ask client how many doses of DMP she has received so far. Ask client if she has been receiving the injections regularly or she
delayed to go for the previous dose (if it was not the first dose). More than 2 weeks late.
Ask for symptoms of pregnancy (e.g. morning sickness, tingling sensation in the breasts).
Ask if HIV positive and she is on long term ART which include Nevirapine (Triomune).
Objective: More than 2 weeks late for her injection and has been sexually
active or on long term ARV which include (Nevirapine) (Triomune). Determine whether client is pregnant or not
o Pregnancy test if available
o Physical assessment – looking for breast changes, uterine enlargement and softening and change of colour of cervix.
Assessment:Based on subjective and/or objective information gathered:
Conclude whether client is pregnant or not or you may not be sure.
If not pregnant conclude that the amenorrhea may have been a side effect of DMPA.
Plan: If not pregnant she can continue using DMPA if she prefers it. Reassure her that amenorrhea is normal DMPA users and not
harmful. She is not pregnant. Menstrual blood is not building up inside her uterus. Her uterus is not shading the inner lining so cannot bleed. Explain this can help to improve her health as she is not losing blood. This helps to prevent anaemia.
Reassure her that amenorrhea does not mean she cannot become pregnant after stopping DMPA (injection). It does not mean she has reached menopause early.
It client is 50 years or above, discontinue DMPA for 9 months to see if her period returns. Counsel for non-hormonal method (condom, Spermicide).
If from subjective history it is not easy to determine whether client is pregnant or not, discontinue DMPA, counsel client for a non-hormonal contraceptives or abstinence from sex for 7 days for pregnancy to be confirmed.
If confirmed pregnant, refer to ANC and re-assure that the injection will not harm the fetus.
HEAVY BLEEDINGSituation number 1: Client who comes complaining of heavy bleeding while on DMPASubjective:
Ask how long she has been bleeding. Ask if bleeding followed a period of amenorrhea. Ask whether bleeding is more than her usual menstrual
period. Ask if heavy bleeding started after she started using DMPA
or she had it before.
Ask if bleeding follows sexual intercourse.Objective:
Check for signs of aneamiao Paler mucous membranes of the conjunctiva, nail beds,
palms and tongueo Dizziness
Check pad if bleeding now. Perform pelvic examination (speculum and bimanual) to rule out
cancer of cervix, abortion and STI.Assessment:
Based on subjective and/or objective findings. Conclude if bleeding had become a health threat or not. Exclude other underlying medical/gynecological problems and anaemia.
Plan: Very heavy or prolonged bleeding/more than 8 days long or twice
as much as her menstrual period. If bleeding now stopped reassure client she can continue using
the method give the next injection. If bleeding persists give low dose of COC. One cycle or Repeat
injection of Depo-provera 150 mg if 8 weeks or more since the last injection and give new return date.
Give Ibuprofen 200mg three times a day for 7 days and give an appointment for evaluation within 14 days.
If the Client is very uncomfortable counsel for another method of choice.
Evaluate and treat any underlying medical condition or refer.
Situation number 2: Client who comes complaining of heavy bleeding while on NORPLANTSubjective:
Ask when implants were inserted. Ask when bleeding started. Ask if there was pain or redness occurred at the site of insertion. Ask if bleeding is accompanied with clots. Ask if she had similar bleeding before Norplant was inserted. Ask if she had a period of amenorrhea before the bleeding
started.
Ask if she had unexplained vaginal bleeding before she started using Norplant.
Ask when the LNMP was. Ask if pain, redness and heat occurred at the site of insertion. Ask if any implant was expelled. Ask for symptoms of pregnancy.
Objective: Rule out signs of pregnancy (uterine enlargement, breast changes
softening and change of colour of the cervix). Perform physical examination to rule out gynecological
conditions. Rule out anaemia. If bleeding present, check pads for amount of bleeding. Confirm presence of all the implants. Perform pelvic examination (speculum and bimanual) to rule out
cancer of the cervix, abortion and STI.Assessment:
Based on subjective and/or objective findingso If anaemia present, counsel on foods containing iron and
that she eats more of them.o Give iron supplements.
Refer for any gynecological conditions identified or suspected.If no gynecological problem found, explain that the bleeding will stop when her body gets accustomed to the implants.
Plan: If client was not pregnant and wishes to continue using the
method offer one cycle of low dose combined oral contraceptives, or Ibuprofen 200 mgs thrice a day for 7 days.
Explain that Norplant implants usually change vaginal bleeding patterns, and this is not harmful and may subside.
Counsel on iron containing foods. Provide iron supplements. If client is uncomfortable and wishes to change the method,
remove the implants and counsel her for another method. Treat any underlying medical condition or refer.
MANAGEMENT OF SIDE EFFECTS OF PROGESTIN ONLY INJECTABLES
Note: For all the side effects listed, if the client is using DMPA, and wishes to continue using progestin only injectables, a change to NET-EN may improve the symptom.
Side Effects Investigation Steps Management1. Heavier menses and/or prolonged bleeding
Bleeding changes are the major reason for discontinuation of injectables. Listen carefully to these complaints
A. Determine what the woman’s concerns are (fear of underlying disease? Anaemia? Inconvenience? Social problem surrounding “menstrual” bleeding? Expense of sanitary supplies?)
A. For prolonged spotting or moderate bleeding (equivalent to normal menstruation but longer in duration), the first approach should be counseling and reassurance. It should be explained that in the absence of evidence for other diseases, irregular bleeding commonly occurs in the first few months of use of injectable progestin. Explain that the number of bleeding days decreases with months of injectable progestin use. Clarify that this is not “menstrual” bleeding (this distinction may be of social or religious importance to her).
B. Determine by history whether other conditions are likely (such as, tumors, pregnancy, abortion, PID and other gynecologic problems).
B. If suspected, abnormal conditions which cause prolonged or heavy bleeding should be evaluated and treated as appropriate.
C. Look for evidence of anaemia. Evaluate and address anaemia if indicated. (Bleeding severe enough to cause anaemia is rare).
C. Give nutritional advice (if indicated) on the need to increase intake of iron-containing foods.
D. Determine whether counseling and reassurance are sufficient to address the client’s concerns.
D. If counseling and reassurance are not sufficient for the woman and she wishes to continue the method, the following management approaches may be tried.- short term (for 7 t0 21 days) COCs or oestrogen, and/or- Ibuprofen (or similar non-steroidal anti-inflammatories other than aspirin). The does of ibuprofen administered is 800 mg x 3 x 5days give with food or after meals.Note: Non-steroidal anti-inflammatory drugs (e.g. ibuprofen) should be used instead of aspirin because aspirin promotes bleeding.
E. Determine whether the prolonged spotting or bleeding has responded to treatment to the client’s satisfaction.
E. Since both treatments listed in D., (above) all work differently, each may be tried:- Ibuprofen blocks prostaglandin synthesis and thus decreases uterine bleeding, and- COCs with estrogen rebuild the Endometrium and thus may stop bleeding,
Some prolonged or heavy bleeding may fail to be corrected and injections may need to be discontinued.
2. Extremely Heavy Bleeding (very uncommon with injectables)
A. Take history and perform a physical examination to evaluate pregnancy intrauterine, ectopic, recent abortion, fibroid or other tumors (such as leiomyomata).
A. Manage any underlying conditions according to local clinic guidelines and refer as appropriate.
B. Evaluate and address anaemia C. Give nutritional advice on the need to increase intake of iron-rich foods.
C. Determine whether the client wants high does oestrogen therapy to stop the bleeding.
C. Heavy bleeding (greater than normal menstruation) is uncommon; it can usually be controlled by the administration of increased does of oestrogen (which may be given as COCs). Follow clinic protocol. Some clinicians begin with COCs twice daily for seven days to stop unusually heavy bleeding; where available, higher does oestrogen may also be used. For heavy bleeding due only to injectable progestin use, do not perform uterine evacuation because if the bleeding is only due to the progestin only injectable, increased doses of oestrogen will stop it.
D. Determine if heavy bleeding has been corrected
D. Some women will require stopping the use of injectable progestin due to medical reasons for excessive bleeding or due to the client’s preference.
3. Amenorrhea which concerns the Client
A. Attempt to rule out pregnancy by menstrual history, symptoms, physical examination and, if available and affordable, by laboratory test. See handout on “How to Be Reasonably Sure a Woman is Not Pregnant”.
A. If the client is definitely pregnant, refer her according to her preference. If she intends to continue the pregnancy, stop injections. When pregnancy cannot be proven (but cannot be ruled out), reassure the client that there is no evidence that DMPA causes foetal damage, and permit her to continue DMPA, if she so chooses.
B. If there are no signs or symptoms of pregnancy, ask her what it is about the absent menses that worries the client.
B. Many women are worried they are pregnant, and may even note symptoms of pregnancy even when they are not pregnant. Others worry that, if they have no menses, something toxic is building up inside them, and tht they need to menstruate to clean out “bad blood”. Reassure the client she is not pregnant. Explain that over 90% of all women on progestin-only injectables have absent menses for at least 3 months. Explain that progestin-only injectables keep the lining of the uterus from building up: “Nothing toxic is building up that there is none to be shed now”. Explain this is a safe condition which lasts only as long as she uses the injectable progestins.
C. Determine if the client is still bothered by lack of menses despite reassurance.
C. Change to COCs if oestrogen related “condition” does not apply to the client. If she has conditions in which oestrogen should not be used, help her make an informed choice of a non-hormonal method.
4. Severe Lower Abdominal Pain
A. Take history and perform physical examination to rule out possible ectopic pregnancy, acute PID, ovarian tumor, appendicitis, ovarian cysts, twisted ovarian follicles, or ruptured liver tumor.
A. (1) If the client presents with any of these cases, provide immediate medical attention and refer as appropriate.
(2) If ovarian cysts are found, reassure the client that they are a normal and frequent occurrence. Most cysts disappear on their own, without surgery. To verify that the cyst is resolving, re-examine the client in 3 weeks or so, if possible.
B. Take history and perform the relevant physical examination (palpate the abdomen; with a glove on do a rectal examination to rule out constipation).
B. For constipation, instruct on diet (plenty of roughage and water) and adequate exercise. Give milk of magnesium or other mild laxative.
5. High Blood Pressure
A. Re-check BP after the client has sat quietly for a few minutes. Use large adult cuff (if available) for women with large arms.
A. If systolic BP is 180 or higher, or diastolic BP is 110 or higher, give the next injection and refer the client urgently, as appropriate. If the BP is over110/90 give the injection and repeat BP on two or more occasions over the next 2 weeks. If BP remains over 160/90 refer the client for treatment. Injectable progestins probably have little effect (positive or negative) on blood pressure.
6. Dizziness or Nausea (rare with injectables)
A. According to clinic ability, rule out other causes, such as anaemia high or low blood pressure, low blood sugar, pregnancy, viral illnesses, malaria or neurological disease.
A. Refer or treat according to local clinic guide lies. Reassure client that it is not common for progestin only injectables to cause dizziness or Nausea. If client wants to continue the method, provide injection.
B. If no cause is found and dizziness or nausea is very slight.
B. If dizziness or nausea continues, and the client finds it unacceptable and attributes it to progestin only injectables, help the client make an informed choice of a non-hormonal method.
C. If no cause is found and dizziness or nausea is very severe.
C. Refer the client as appropriate. Help the client make an informed choice of a non-hormonal method.
7. Depression A. Ask about possible causes, for example, family financial or social problems.
A. Counsel accordingly and follow up during her next return visit.
B. If no other cause is found, ask the client if she thinks depression has worsened while using progestin-only injectables or is due to the method.
B. If the client thinks her depression has worsened while using progestin only injectables or is due to the method; help her make an informed choice of a non-hormonal method. If the progestin only injectable have not caused the depression to worsen or the client sees other causes, the progestin only injectables can be continued, but follow up on this matter during her next visit.
8. Significant Unwanted weight Gain
A. Interview the client, inquiring about eating habits promoting weight gain, or lack of exercise.
A. Weigh the client and compare with her weight at her first visit. If her weight gain is less than 2 kgs, reassure her that this is negligible. If the weight gain is more than 2 kgs, instruct her on diet and exercise.
B. Rule out weight gain due to pregnancy. B. If the client is pregnant, refer her according to her preference. If she intends to continue the pregnancy, do not give the next injection.
C. If the client denies poor eating habits, but complains of increased appetite and unacceptable weight gain without apparent cause.
C. If the weight gain is unacceptable, help the client make an informed choice of another method, including a low dose combined oral contraceptive (COC), progestin only pill (POP), or other acceptable method.
9. Headaches A. Determine whether she has purulent nasal discharge and tender-ness in sinus areas.
A. Refer for treatment of sinusitis if present; continue progestin-only injectables.
B. Ask whether she has ever had high blood pressure.
B. Regardless of history, check the blood pressure. If it is elevated, repeat BP. You may give progestin-only injectable if remainder of investigation is negative.
C. Ask the client whether her headaches have been worse since the injections began.
C. If headaches are definitely worse with progestin-only injectables, recommend that she switches to a reliable non-hormonal method.
D. Ask if she has had loss of speech, numbness, weakness or tingling or visual changes 9spots, patterns or blank areas in her field of vision) associated with the headaches. These symptoms may suggest severe migrane headaches. They are often referred to as “focal symptoms” See management of side effects in the “COCs” Chapter for details on diagnosis of headaches.
D. These symptoms may suggest threatened stroke (temporary inadequate blood flow to the brain). Promptly refer as appropriate. Be sure the client does not smoke (or help her stop smoking). Help the client make an informed choice of a reliable non-hormonal method.
In general, the risks of a progestin-only method outweigh the benefits for a woman who develops focal migraines while using progestin only methods. (Although, if no other methods are acceptable, offer POPs or progestin-only injectables, which are always far safer than pregnancy.
E. If there is no threatened stroke or sinus disease and the headaches are no worse on injectables, explore possible social, financial or physical causes or headaches.
E. Counsel accordingly; continue progestin-only injectables.
10. Acne (rarely associated
A. Ask how and how often she cleans her face; rule out inadequate hygiene and use of creams that block pores.
A. Recommend cleaning face daily with water. An astringent, like lemon, may also help. Avoid heavy creams and creams with lanolin or perfumes.
with injectables)
B. Ask if she is currently feeling stressed. B. Counsel as appropriate.C. Ask if the client believes her acne has worsened with use of progestin-only injectables.
C. Explain that a few women have noticed worsening of acne with progestin-only injectables. This problem usually does NOT occur with estrogen-containing COCs (50 micrograms of estrogen may be needed to improve acne).
11. Loss of Libido (sex drive)
A. Ask if this is due to other causes, such as, dry vagina, painful intercourse, or marriage problems.
A. Counsel or refer as appropriate.
B. If no other cause is found and if the client sees this as a problem due to progestin-only injectables
B. Do not repeat injection. Help the client make an informed choice of another method e.g. including COCs.
Session 5.2: Records and Reports
Meaning of records Written information collected and kept / stored to help service providers, health unit In- charges, supervisors, health sub- district In- charges, District health officers and Ministry of Health to plan effectively and improve services. OR Written information referred to as administrative memory
Purpose of keeping records / reports in FP / RH service delivery Monitor and evaluate client treatment and progress Provide information that can be used to improve the quality of services and increase the number
of clients Monitor and evaluate the activities at the health facility in relation to set targets:
o Number of clients both new and returning o Number of clients served per week, month and year o Family planning methods supplied by type o Number of clients who drop out o Budgets that are planned and set at the district and national level (based on actual service
use information) Ensure that ample methods and supplies are available and they are within recommended period
of use (not expired) To provide information for accountability of commodities received To provide solutions to critical management issues in an attempt to ensure quality service
delivery To report outputs of facilities to the district and in turn to national level To use the information for planning at both local and national levels to improve efficiency.
Tools used to collect records in FP clinic 1. Family planning client cards 2. Family planning register 3. Stock Control card (HMIS 015)4. Requisition and issue voucher (HMIS 017)
5. Health unit family planning summary form (Table 4 - HMIS)6. Record of stock outs (Table 9 - HMIS)7. Monthly summary form (HMIS 105)8. Women’s passport
