Unit :7 Management of Normal Purperium
Physiological changes during purpureum period:
Purperium:
Puerperium means the period of 6 weeks (42 days) after child birth in which body tissues specially pelvic organs return to prepregnant stage both anatomically and physiologically is called perperium.
Duration:
The beginning of the puerperium is about 6 weeks after the placenta is expelled, and the uterus is almost nonpregnant in size.
The duration is roughly divided as follows:
Early:
Up to 7 days,
1) Physiological changes in reproductive system in periperium period:
(a) Involution of uterus:
Involution The process in which the bulky uterus progressively returns to its normal pre-pregnant state after delivery is called involution of uterus.
Anatomically Considerations
After the placenta is delivered, it heals into the endometrium of the placental site. After delivery, the uterus becomes firm and constricted with alternate hardening and softening.
The size of the uterus during pregnancy is approx.
Length: 20 cm, Width: 12 cm,
Thickness: 7.5 cm
As much as
And the weight of the uterus is about 900-1000 gm.
which,
Purperium period i.e. after 6 weeks of child birth the uterus returns to its pre-pregnant state i.e. the size of the uterus during the purperium period
Length: 7.5 cm, Width: 5 cm,
Thickness: 2.5 cm
As much as possible.
And the weight of the uterus is about 60 gm.
Reduction of the size and position of the uterus:
After labor the fundus is 5 cm below the umbilicus and 12 cm above the symphysis pubis.
After 24 hours it is at the level of the umbilicus. The uterus descends into the pelvic cavity at a rate of 1.25 cm/hr and is not palpated abdominally above the symphysis pubis after 10 days.
Consistency of the uterus:
Due to repeated strong myometrial contractions blood flow control towards the uterus becomes hard.Palpating its consistency should feel firm and round.If the fundus is soft, it is called a boggy uterus.Contractions are inadequate and blood loss is ongoing. suggests.
(b) Involution of cervix:
After delivery, the lower uterine segment and cervix remain loose, thin and stretched.
It may be oedematous, bruised and have small tears and lacerations. It takes a few weeks for the isthmus to return to normal shape and size.
Consistency of the first post partum day service remains normal until two fingers are admitted. Then at the end of the first week, the tip of the fingers remains as much as admitted. The evolution of the cervix is continuous for 3-4 months. But a parous cervix never gets the look of a non-parous cervix, the external os that first looked like a dimple looks like a slit.
(C) Vaginal canal:
A distensible vagina takes about 4 to 8 weeks to involute. After delivery, the vaginal canal appears swollen and smooth, gradually becoming small and firm but never of pre-pregnancy size, the introitus remains permanently large, and the hymen is lacerated. Represented in the form of nodular tags.
(d) Perineum:
The muscles of the perineum floor are stretched, swollen and bruised with an episiotomy scar.
(e) Broad ligaments and round ligaments:
Broad ligaments and round ligaments take some time to recover from stretching. Initially the ligaments are stretched but by the end of the periperium period the ligaments are back to their non-pregnant length.
(f) Pelvic floor and pelvic fascia:
The pelvic floor and pelvic fascia take a long time to involute from the stretching effect.
(f) Lokia:
During the first 15 days of the periperium period, the vaginal discharge called lochia comes from the uterine body, cervix, and vagina.
It contains blood vessels, decidual tissues, epithelial cells of vaginal mucus, bacteria, fragments of membranes and small clots.
Odair of Lokia
Odor (smell) of lokia is fishy.
Type of Lokia:
There are three types of lokia.
1) Lokia rubra,
2) Lokia cirrhosa,
3) Lokia Alba
1) Lokia Rubra :
Lokia rubra is the first phase of Lokia. Discharge which is red and bloody lasts for 1 to 4 days after child birth.
In the lokia rubra
blood,
Fital membrane, decidua,
Vernix caseosa and lanugo are present.
2) Lochia cirrhosa:
Lochia cirrhosa is the second phase of lochia.
Which is seen as yellowish pale or pale brownish color.
Lochia cirrhosa lasts for 5 to 9 days.
It has low amount of red blood cells but high amount of leukocytes.
Wound exudate,
survive mucus,
And microorganisms are found in it.
3) Lokia Alba:
Lokia Alba is the third phase of Lokia. It is usually pale white in color.
Lochia alba is observed for 10-14 days.
in it,
Excess decidual cells,
leukocytes,
mucus,
Cholestrin crystals,
Fatty and Glandular Epithelial Cells,
And microorganisms are found in it.
Amount:
The average amount of lochia is around 250 ml during the first 5 to 6 days.
Normal Duration:
The normal duration of lochia is up to three weeks, if it persists after three weeks, local license may be available.
Clinical Importance of Local Discharge:
Lochia provides information on the peripheral state of the mother, so assessment of lochia is important.
Odor (Smell): May be due to offensive infection.
Odair:
Scanty or absent may be due to infection.
Amount:
Scanty or absent may be due to infection.
Color:
Continuous red color Nokia may be due to subinvolution.
Duration:
If the lock is up to three weeks or longer then there may be a local licence.
(2) Breast and Lactose:
breast
Breasts are developed during pregnancy due to hormonal stimulus. Both feeding and non-feeding breasts secrete colostrum for a few days after delivery. Colostrum is the creamy yellow precursor of milk. In which the breast is soft and non-tender.
After three days, prolactin levels increase and breasts become firm and tender. When milk starts to secrete, the breast becomes distended, hard and warm due to increased blood flow, venous and lymphatic congestion, this is called physiological engorgement.
It lasts 24 to 48 hours and then resolves on its own. Milk production is stimulated by baby’s shaking. Breasts feel firm, full and tender until empty.
Lactation:
Lactation is the process of breast feeding which is based on interplay of hormones, instinctive reflexes, learned behavior of mother and newborn.
Latestation is particularly controlled by the hormones prolactin and oxytocin and is maintained by three factors:
1) Anatomical structure of mammary gland, development of alveoli, duct and nipple.
2) Initiation and maintenance of milk secretion.
3) Milk ejection or propulsion of milk from alveoli to nipple.
Physiology of Lactation:
Lactation
Lactation is the process of breastfeeding through which the mammary gland produces and releases milk to provide nourishment to the child. It occurs through a complex interplay of hormones. In it, prolactin and oxytocin work as important hormones for main lactation.
The establishment and maintenance of lactation is generally determined by three factors:
1) Anatomical structure of mammary gland like development of alveoli, ducts, and nipple.
2) Initiation and maintenance of milk secretion.
3) Ejection or propulsion of milk from the alveoli towards the nipple.
The main two hormones responsible for lactase are:
Prolactin and oxytocin work as important hormones for lactation.
1) Prolactin:
Prolactin hormone is secreted from the anterior pituitary gland.
It is the primary hormone for the stimulation of milk production (lactogenesis).
Estrogen and progesterone hormones are increased during pregnancy, these hormones prepare the breast for milk production but inhibit the production of lactase.
After the birth of a child, the level of estrogen and progesterone hormones decreases due to which the effect of prolactin hormone can be on the mammary gland and the secretion of milk increases.
2) Oxytocin:
Oxytocin is released from the posterior pituitary gland.
The release of oxytocin is crucial for milk ejection (the let-down reflex), which normally depends on the baby’s sucking and nipple stimulation.
Oxytocin is an important hormone for the contraction of the myoepithelial cells surrounding the alveoli (milk producing gland) causing milk to enter the duct from the alveoli and then from the duct to the nipple for best fitting.
•> Lactation is divided into four phases according to the physiological base.
1) Mammogenesis (preparation of breast),
2) Lactogenesis (synthesis and secretion of milk from breast alveoli),
3) Galactokinesis (ejection of milk),
4) Galactopoiesis
(Maintenance of Lactation)
1) Mammogenesis (Preparation of Breast):
In this stage, the ductal and lobuloalveolar system of the breast grows during pregnancy in which the breast is prepared for the secretion of milk.
2) Lactogenesis (synthesis and secretion of milk from breast alveoli):
Some secretory activity (colostrum) is present during pregnancy and increases after delivery.
Actually milk secretion starts on the third or fourth day postpartum, during this period the breast feels engorged, tense, tender and warm.
Despite the high prolactin level during pregnancy, due to the effect of steroid estrogen and progesterone hormone, the breast tissue does not respond to the prolactin hormone and milk secretion does not occur, but after delivery, as the estrogen and progesterone levels fall down (decrease), the prolactin hormone decreases its milk secretion activity. In the mammary gland, prolactin and glucocorticoid hormones are important in this stage.
Secretory activity is increased directly or indirectly by growth hormone, thyroxine and insulin.
3) Galactokinesis (ejection of milk):
Milk is not only ejected by the baby’s shaking but milk is ejected from the alveoli by a contractile mechanism.
Oxytocin hormone is the major galactokinetic (milk ejection) hormone.
Reflux is set up during the baby’s shaking.
Impulses from the nipple and areola then pass through the thoracic sensory and cause the synthesis of oxytocin in the hypothalamus and then reach the posterior pituitary gland to transport the oxytocin synthesized in the hypothalamus.
Oxytocin hormone is released from the posterior pituitary gland, which then causes contraction of the myoepithelial cells surrounding the alveoli (milk producing gland).
This process is called “milk ejection” or “milk let down reflex”.
Where milk is forced into the ampulla of the lactiferous duct, it is expelled either by the mother’s express or by the baby’s shuck.
A baby’s cry elicits a let-down reflex even without shaking.
The pressure of milk that builds up in the breast before the baby sucks is called “draft”. It is also produced by injecting oxytocin.
Breast engorgement occurs due to pain in the milk ejection reflex, breast engorgement if the ejection reflex is obstructed for more days after the start of milk secretion.
4) Galactopoiesis
(Maintenance of Lactation):
Prolactin is a single and important galactopolytic hormone.
Shaking is essential for effective and continuous lactation not only for the milk to come out of the gland but also for the release of prolactin.
Due to the pressure of milk in the breast, the production rate of milk decreases, so by periodic breast feeding, that pressure can be reduced and the secretion of milk is maintained.
A healthy mother produces 500-800 ml of milk to feed her baby.
Thus, according to this the physiology of lactation is divided into 4 phases
Milk Production:
A healthy mother produces 500 to 800 ml of milk to feed her baby.
(3) Cardiovascular Changes:
Blood volume
The increased blood volume during pregnancy decreases and the circulatory system returns to its prepregnancy state.
cardiac output
Excess water in the body is removed due to diuresis and diaphoresis from the body and the cardiac output comes to its normal range.
Hemoglobin and Hematocrit Level:
Due to blood loss during pregnancy, hemoglobin and hematocrit levels are initially low, but within a few weeks, the blood stabilizes in its normal range.
4) Respiratory function:
After delivery, abdominal pressure decreases and the diaphragm descends, thus lung expansion and ventilation improves, but there are no noticeable changes in respiratory rate.
(5) Endocrine Changes:
Hormone Shift:
Pregnancy related hormones are reduced such as estrogen, progesterone and human chorionic gonadotrophin (HCG) hormone.
The level of prolactin hormone is elevated to maintain breast feeding.
(6) Renal changes
Diuresis
Urine output increases due to which fluid accumulated in the body during pregnancy is excreted from the body.
Bladder function
The bladder regains its tone and function, although some temporary issues such as urinary retention or urinary incontinence occur.
(7) Gastrointestinal Changes:
Bowel function
Bowel function takes some time to return to normal but the condition of constipation is seen due to reduction in its size.
Appetite in women becomes normal in some time but in some women bowel changes are seen for some time.
(8) Musculoskeletal Changes:
Abdominal muscles
The tone of the abdominal muscles regains within a short time while the pelvic floor muscles also return to normal within a short time but Kegel exercises are important in strengthening the pelvic floor muscles.
(9) Psychological Changes
Hormonal fluctuations, physical recovery, and the demands of newborn care impact emotional well-being. It also features common experience mood swings such as “baby blue”. And post partum depression is also seen in some women.
Thus, these types of physiological changes are seen in women during the post partum period.
: Management of Normal Purperium:
Postnatal Care of Mother: Postnatal care includes systemic examination of mother and baby along with appropriate advice to mother and newborn in the postnatal period.
Aim and Objectives:
To provide support to mother and family in new changes.
To provide early diagnosis and treatment for prevention of any complications in mother and infant.
To provide early referral services to mother and infant if required such as,
a) For support of breast feeding,
b) To provide counseling services in nutrition, complementary feeding and immunization.
C) To provide proper counseling about contraception.
Principles of Normal Purperium:
1) To restore the mother’s health status.
2) To prevent infection.
3) To promote lactase.
4) To increase mother’s acceptance of contraceptives.
The following principles should be kept in mind in perparium management to normalize the woman physically and emotionally, viz.
1) Preserving the mother’s health status.
2) Preventing infection.
3) Promotion of best feeding.
4) Provide care to the baby.
5) To promote and guide family planning.
6) Providing health education as needed.
Management of Normal Purpurium:
Immediate Attention:
Immediate Post Natal Care
After the expulsion of the placenta, the time up to one hour (1 hour) is called the fourth stage of labor in which the general condition of the patient and the behavior of the uterus are monitored.
Observation of Women
It contains vital sign of mother like,
temperature,
pulse,
Respiration,
And blood pressure is properly monitored if it is mildly elevated, usually due to fatigue and dehydration, and to check increased vital signs every 15 minutes for the next 1 to 2 hours until the patient is stable.
Then assess the condition of the uterus in which the uterus is firmly contracted and in mid line.
Rest and ambulation: It is beneficial to ambulate the patient immediately after delivery as the benefits include a feeling of well-being in the patient, reduced bladder complications and constipation, rapid involution of the uterus with subsequent uterine drainage and reduced embolism Normal delivery Then the patient can do a little bit of work.
Diet: The patient should be given a normal diet as per her wish. If the patient is lactating then a high calorie diet, adequate protein, fat, more fluid, minerals and vitamins should be given. If the mother is non lactating then a diet should be given as per the non pregnant state.
Bladder care: After delivery, the patient should be encouraged to pass urine according to his convenience. Many times, if the position of the patient is not proper or the patient cannot pass urine due to the pain of perineum injury, then proper privacy should be provided to the patient after urination. Anchorage and if the patient is unable to pass urine, then properly catheterization. Continuous catheterization until bladder tone is restored. Properly prevent the condition of infection and cystitis through bladder care.
Bowel Care: Early ambulation and proper diet reduces the problem of constipation. Adequate fiber containing food and fluid does not cause bowel problem and if required mild laxative should be provided to the patient like mild milk of magnesia 4-6 teaspoon. At bed time.
Slip: The patient needs both physical and mental rest so the patient should be provided with proper work and comfortable environment. Due to the patient taking an adequate amount of sleep, he gets physical and mental support. If the patient has painful piles, and engorged breast, then properly analgesic medicine should be provided.
The mother should advise the athlete to take 7-8 hours of sleep during night time and 1-2 hours of sleep during the day.
Care of the vulva and episiotomy wound: Clean the vulva and buttocks with saline, lotion, soap and water after delivery. Apply antiseptic ointment or lotion over episiotomy and provide sterile pad. Provide care after micturation and defecation every time. It will reduce the pain.
Many women find warm water sitz baths relaxing.
Care of breast: Wash and clean breast and nipple with water. Apply soap while taking bath. Provide frequent and short fittings to prevent nipple soreness.
Asepsis and Antiseptic: Maintain asepsis technique especially in the first week of purperium by using local antiseptic and dressing the wound. Nosocomial infections can be reduced by using clean bed linen and clothing, clean surrounding, and limiting visitors to a limited number.
Immunization: If Rh Negative, give Anti-D gamma globulin within 72 hours of delivery. If second dose of tetanus toxoid not taken in pregnancy, should be provided at discharge.
Postnatal Exercise:
Objectives of Postnatal Exercise:
Improving abdominal and perineum muscle tone.
Advising the mother to do daily routine activities in small amounts.
Attachment and Bonding:
After the birth of the baby, placing the baby on the mother’s abdomen, due to which bonding with the mother and proper skin-to-skin contact can take place, due to which the attachment of the mother and the baby can occur and the baby can be prevented from hypothermia.
Family Welfare:
India is the first country in the world to implement a family welfare program on a national basis by the government.Family welfare is also known as family planning program.This family planning program was included as an official program since 1952.
Definition: Family planning means planning the family size that is affordable by the parents and for the health and welfare of the family. Family planning is that which helps an individual or a couple to achieve the following objectives.
1) To avoid unwanted birth.
2)Get the wanted berth.
3) To maintain a gap between two pregnancies.
4) Appropriate use of contraception method.
Objectives of Family Welfare Programme
The National Family Welfare Program in India is a comprehensive set of initiatives aimed at improving family health and well-being.
Family welfare programs are designed to achieve various objectives to improve family life and societal health.
Here are the objectives of Family Welfare Programme.
Objectives of Family Welfare:
OBJECTIVES OF FAMILY WELFARE Improving the overall health and well-being of the family is a broad spectrum goal of family welfare.
The objectives of family welfare are as follows:
1) Promoting Re-productive Health:
Ensuring that families have access to reproductive health related services to maintain their reproductive health including,
Family planning, maternal and child health care, and prevention and management of reproductive tract infections. Their involvement takes place
2) Reducing Maternal Mortality Rate:
Maternal death and complications can be reduced by providing skilled care to the mother during pregnancy, child birth, and the postpartum period.
3) Reduce Infant and Child Mortality:
Child morbidity and mortality rate can be reduced by providing proper nutrition, immunization and proper health care services to infants and children.
4) Promoting Family Planning:
To encourage individuals or couples to use contrasitive methods to have space in pregnancy and to plan pregnancy according to choice.
5) Ensuring Safe Motherhood:
Promotion of safe child birth practices, prenatal care and postnatal care to improve maternal health outcomes.
6) Improving Nutrition and Hygiene:
Assessing malnutrition and promoting hygienic practices to improve the overall health and well-being of families.
7) Preventing and Management of Communicable Diseases:
Identify and treat infections affecting reproductive health such as sexually transmitted and other communicable diseases.
8) Social Support:
In social support, providing a social support system to families and mainly vulnerable populations such as single-parent, households, low-income families, and families with disabilities and long-term chronic illnesses. This support involves financial assistance, counseling services, and community-based support.
9) Promotion of Small Family Names:
To encourage families to voluntarily choose small family sizes to improve maternal and child health outcomes and overall family well-being.
10) Promotion of Spacing Method:
Advise to use contraceptives to space between pregnancies. Because of this, the healthier outcome of the mother and her child can be promoted.
11) Ensuring Access to Contraceptives:
Ensuring adequate contraceptive access to all ineligible couples to properly adopt family planning.
12) Prevention of Unwanted Birth:
Providing information and services to prevent unintended pregnancy, which can lead to better health of the mother and improvement in socio-economic outcomes for families.
13) Promotion of Planned Pregnancy:
Encouraging couples to plan and prepare for pregnancy so as to promote the health of both mother and child.
14) Promotion of Birth Spacing:
Advising families to keep adequate space between pregnancies so that overall well-being of mother and child can be maintained and complications due to close pregnancy can be reduced.
15) Age Appropriate Childbearing:
Advising families to plan an appropriate pregnancy at the same time can reduce complications due to early pregnancy or late pregnancy.
These objectives collectively aim to empower individuals and families to make informed choices about their reproductive health and family planning, thereby improving overall health outcomes and enhancing the quality of life for families.
Role of Nurse in Family Welfare Programme:
The role of a nurse in a family welfare program is diverse and multifaceted. Nurses play different roles in different settings of family welfare services. It generally depends on their post and their working capacity.
The role of the community health nurse (CHN) in family welfare services is important in promoting reproductive health, family planning and overall well-being in the community. Here are the key aspects of his role:
1) Survey work:
The nurse collects demographic facts through a survey.
It makes a list of house numbers and their locations in the community.
Pregnant Mothers, Ineligible Couples, by Nurse A Survey
Collects information on contraceptive users, children and children below school going age. Couples are then classified into high, medium and low priority.
To collect reviews about how many couples use contraceptives and how many people do not use them for the formation of further action plans.
2) Health Education:
To provide education about health and family planning to the individual, family, and community.
To make people aware about available family planning services.
Provide education and detailed information about different types of contraceptives to couples so that they can adopt them according to their choice.
Providing education to mothers or athletes to breastfeed their child up to one year because it works as a natural contractile.
To provide education about immunization, nutrition, first aid and personal and environmental hygiene in the community.
3) Coordinator and Provider of Family Welfare Services:
Provision of various types of contraceptives available to ineligible couples.
To arrange family planning clinics and camps to create awareness about people’s needs and available services.
To follow State Government and State Rules and Regulations and to provide direct services within legal and professional limits.
It coordinates the services of Gynecologists and other Family Welfare Services personnel.
5) Magnification function:
Encourages ineligible couples to adopt small family norms by using contraceptives.
Works to explain the need and importance of family planning.
Identify women who need medical termination of pregnancy and refer them to a doctor early.
Establishment of depots for adequate contraceptive supply and distribution in every village due to which adequate supply of contraceptives can be provided.
6) Administrative Role:
Fixing date and location of family planning clinics Arranging equipment, supplies and other resources in clinics.
Supervise and guide multipurpose health workers in clinics and distribute contraceptives and insert and remove IUDs.
To provide an assistant to the Medical Officer in conducting the clinic.
Organizing camps for family planning and assisting doctors in male-female and female sterilization operations.
Maintain aseptic technique during operation.
To provide follow up services to couples who have accepted the method of family planning.
Planning and evaluation of education programs.
7) Consultant:
Before starting any type of health care program in the community as a coordinator in family welfare services and as a direct care provider, it is important to consult them.
8) Counsellor:
The nurse counsels ineligible couples and target couples on different contraceptive methods and provides them the opportunity to choose the best suitable method for spacing.
9) Supervisory Role:
As a supervisor, the nurse working in the family welfare department encourages her staff to actively participate in the family welfare program.
As a supervisor, nurses organize in-service education programs for health workers, professionals, and nursing personnel.
10) Domiciliary Services:
Home visits are an important part of the family program. These services are provided by multipurpose health workers and health assistants.
wherein as Services,
To provide education and upbringing to illegible couples.
If using IUD and pills, provide advice for follow-up and provide education for follow-up in cases of vasectomy, tubectomy, medical termination of pregnancy (MTP).
Providing domiciliary care to antenatal, postnatal, newborn and toddler.
Providing referral services if anyone has post-operative complications. 11) Record Maintenance:
A nurse is responsible for maintaining all records in a family planning program such as,
illegible couple records,
Target Couple Records,
Intra uterine devices record,
Sterilization Operation Record,
Clinic and camp records,
Health Education Activity Record,
training record,
Medical records etc.
The nurse is responsible for preparing monthly reports and submitting them to the authorities.
12) Role in Research:
A community health nurse is a primary member of a multidisciplinary research team. Nurses have to cooperate and participate in research activities of family welfare services.
13) Evaluation Roll:
The nurse evaluates the work performed in the family welfare program and prepares its reports. On the basis of this evaluation any further changes are made in the implementation of the program and the desirable targets are achieved.
14) Collaborators:
A community health nurse works for the improvement of health care services by collaborating with health teachers and non-governmental organizations in the community.
Nurses work collaboratively with doctors, dispensers, vaccinators, train birth attendants, and lady health visitors to provide family welfare services in the community.
Community health nurses play a crucial role in helping individuals and families make informed decisions about their reproductive health, support healthy pregnancy and child birth, and contribute to the overall well-being of the community through effective family welfare programs.
: Contraception Method:
A contraceptive method is a method in which a woman can be prevented from unwanted pregnancy. Contraception means all measures, temporary or permanent, in which pregnancy caused by coitus can be prevented.
Characteristics of Ideal Contraceptive:
It is usually inexpensive.
Effective in preventing pregnancy.
It is generally safe for health and free from harmful effects.
It is usually simple and some contraceptive methods do not require the supervision of a doctor or medical personnel.
Some contraceptives are reversible, meaning they do not obstruct pregnancy when desired.
Types of Contraceptives:
A) Spacing Method/Temporary Contraception:
Barrier Method:
•Physical method.
•Chemical method.
•Combined method.
intrauterine device,
hormonal method,
Postconceptional method,
Miscellaneous
B) Terminal Method / Permanent Contraception:
Male sterilization (vasectomy),
Female sterilization (tubectomy).
A) Spacing Method/Temporary Contraception:
The temporary method is commonly used to postpone birth and to keep space between births.This method is used more by couples who do not desire more children or by couples who wish to have space between children. .
Barrier method: The barrier method prevents the connection of the sperm with the ovum. It is called the barrier method.
This barrier method prevents the deposition of sperm in the vagina and also prevents the penetration of sperm through the cervical canal, usually mechanical, chemical and combined methods are used.
Physical method: Includes male condom, female condom, diaphragm, vaginal sponge.
Chemical Method:
Creams : Delphine/Pharmatex
Jelly: Coromax, Wolper Paste.
Foamtablet: Aerosol foams, Chlorimine T, Contab.
Combination: It usually uses a combination of mechanical and chemical methods.
Combined method: It uses a combination of mechanical and chemical methods.
1)Male Condom: Male condom is a male barrier contraceptive derived from the Latin word “condom” invented by Dr. Condom. The latest condoms are available in different sizes. They are 160-180 mm length, 49-52 mm width and 0.04-0.07mm thickness. They are plain or titwada with tip for Simmen collection. It is available in different colors. in which,
Dry Type Ex: Nirodh (Government Supply) and Kohinoor,
Prelubricated type Ex: Durex, Kamasutra and or spermicidal ones Ex: Raksak etc are available.
It is an effective and widely used device that has no side effects and can also prevent pregnancy. Condoms prevent both male and female sexually transmitted diseases (STDs).
Advantages:
Inexpensive and no contractions and side effects.
Simple for disposable use and easy to carry.
It provides protection against sexually transmitted diseases (STD) and pelvic inflammatory disease (PID).
Reduces the incidence of tubal fertility and ectopic pregnancy.
Used when coitus is irregular and infrequent.
Prevents premature ejaculation.
Pills and IUCD are used when contraindicated.
Disadvantages:
Sleep or break occurs during coitus.
Sexual pleasure remains inadequate. Psychological disturbance remains.
Latex allergy can be created.
Female Condom: The female condom is a newly developed female barrier contraceptive that has the combined features of a diaphragm and a condom. They are made of synthetic latex or polyurethane. It is a similar structure in which the internal ring covers the cervix and the external ring is on the outside of the vagina. It is prelubricated by silicone and does not require spermicide.
Advantages:
It prevents STDs (Sexually Transmitted Diseases) more effectively than male condoms because some female condoms also cover part of the perineum.
As it is made of polyurethane, there is no allergic reaction.
Male condoms are more convenient than condoms because they have to be inserted precoitus and the chances of breakage are less.
Disadvantages:
are expensive.
Some women have difficulty with insertion.
Failure rate 5-21/100 women.
Vaginal diaphragm: This is an intravaginal device made of synthetic rubber, flexible metal, or plastic material. Its diameter is 5 to 10 cm. It has a flexible rim which is usually made of spring or metal. A medical or paramedical person is needed to measure its size. Its rim extends from the upper end of the posterior fornix to its lower end at the back of the symphysis pubis, completely covering the cervix. A minimum of 6 hours should be kept after the sexual act. Failure rate is 4-12/ 100 women.
Vaginal Sponge: This combined vaginal barrier contraceptive is a polyurethane sponge containing 1gm Nonoxonal-9 spermicidal. Its sap is like a mushroom cap. Its concave side covers the cervix in the upper vagina. Vaginal sponge is easy to use, it is moistened with water and inserted into the vagina, it remains effective for 24 hours. It releases 125 – 150 mg Nonoxonal in 24 hours.
Chemical method: It is also called spermy side because it kills the sperm thus preventing chemical contraceptive pregnancy.
Ex: Foam tablet, aerosol, cream, jelly, paste, suppository, soluble film etc. All these sperm are to be inserted deep into the vagina 15 minutes before the side coitus.
Advantages:
It is easy to use.
Not too expensive and increases vaginal lubrication.
Disadvantages:
Deep in all the places where the form reaches and should be inserted before every sexual activity, the couple may experience irritation and burning sensation.
Combine method: When a barrier method is used with a chemical method, it is called a combine method, which usually provides double protection.
Intrauterine device
IUCD
IUCD (intrauterine contraceptive device)
Introduction
An intra-uterine device is a T-shaped small and flexible device that is inserted into the uterine cavity to prevent pregnancy.
Intrauterine devices (IUCDs) are a popular method of long-term contraception that has been involved in family welfare programs due to their effectiveness.
The use of the Grafenberg ring by Grafenberg in Germany in 1929 has led to the invention of many different types of devices which are mainly divided into two parts.
in which,
1) Copper IUCD
(Copper Tea)
Description:
Made of plastic and copper. Copper acts as spermicidal, and prevents fertilization.
Duration
Effective for 5-10 years, depending on the specific type.
Examples: Copper T 380A, Multiload 375.
2) Hormonal IUCD (LNG-IUD)
Description:
Made of plastic and releases levonorgestrel, which thickens cervical mucus, inhibits sperm, and thins the uterine lining.
Duration
Effective for 3-5 years.
Examples:
Mirena, Skyla, Liletta, Kaylina.
Intrauterine contraceptive device involves the following contraceptive devices.
1)lippes loop
2) CU T 200 B
3) CuT 380 A,
4) Multiload Cu 250,
5)Multiload 375,
6)progesttasert,
7) Levonorgestrel IUCD.
1) lippes loop:
Lipis loop is a first generation intrauterine device Lipis loop is formed from polyethylene. And it is of double S ( S ) shape and a nylon thread is attached to it which remains in the vagina, which helps to remove the loop from the intrauterine cavity. It is in four sizes ie,
Available in A,B,C & D.
Lipase loop is nontoxic, reliable and stable. It can also cause perforation of the uterine wall. It contains a small amount of barium5 present which makes it visible in x-rays but is not currently used.
2) CU T 200 B:
CU T 200 B is a widely used medicated device. In which a copper wire having a surface area of 215 sq mm is wound round the vertical stem of the device.
The stem of the T-shaped device is made of a polyethylene frame. It consists of a monofilament of polyethylene which is tied to the end of the vertical stem.
This device is removed after 4 years.
CuT 200 B has 200 sq mm surface wire containing 120 mg copper and is removed after 3 years.
3) CuT 380 A:
CuT 380 A It is Government Supply CuT 380 A. It consists of two solid copper slimes transverse arm with T shape device and copper wire on vertical stem.
The total surface area of copper is 380 Sq mm with 314 mm over the wire and 33 sq mm over each coppersleeve. It consists of monofilament white thread.
It remains effective for about 10 years.
4) Multiload Cu 250:
The device is available in a sterile packet with an applicator. It does not have an introducer or plunger available.
The device releases 60-100 µg of copper per day over a period of one year. The device has to be replaced after 3 years.
5)Multiload 375:
It has a surface area of 375 mm² copper wire around its vertical stem. Replacement is every 5 years
6)progesttasert:
A bioactive core containing microcrystals of progestatron (38 Mg) enclosed within a plastic wall releases approximately 65 µg of progesterone daily into the uterine cavity. Release from the depot continues for one year only. Thus, it should be replaced after one year.
7) Levonorgestrel IUCD:
This is a T-shaped device
A polydimethylsiloxane membrane around the stem acts as a reservoir of the steroid. The total dose of levonorgestrel is 52mg which is released at a rate of 20 µg/day. This device is replaced every 5 years.
•>Mechanism of Action
1) Hormonal IUD
Releases copper ions, creating an environment inaccessible to sperm. Prevents fertilization of eggs by sperm. Can prevent implantation if fertilization occurs.
2) Hormonal IUD
Releases levonorgestrel to thicken cervical mucus, preventing sperm from entering the uterus.
Suppresses endometrial growth, making the lining of the uterine cavity unsuitable for implantation. Partially suppresses ovulation in some females.
Benefits
Effective:
More than 99% effective in preventing pregnancy.
Long Lasting:
Works as a contraceptive for many years.
Reversible:
Fertilization returns quickly after removal.
Convenience:
Little maintenance is required after insertion.
Cost Effective:
It is economically viable.
Insertion and Removal
Insertion:
Performed by trained health care personnel. A pregnancy can usually be rolled out during the menstrual period or at any time.
In the procedure, the IUD is inserted into the uterine cavity through the cervix.
Removal
Can be done at any time by a healthcare provider.
Fertilization usually returns immediately after removal.
Common side effects
Camping pain during and after introduction.
Irregular building and sports especially during the first month.
Heavy menstrual bleeding.
Decreased or missed periods with a hormonal IUD.
Risk
Expulsion (the IUD coming out of the uterus).
Perforation (rarely, the IUD can puncture the wall of the uterus during insertion).
Infection (slightly increased risk of infection during the first few weeks after insertion).
Nursing Responsibility
Pre-Insurance Counselling
Explain to the patient the type of IUD device, its benefits and its side effects.
Ensuring that the patient fully understands the procedure, its effectiveness and duration.
Insertion Procedure
Assisting health care providers during the insertion period.
Ask the patient to take proper rest and provide reassurance.
If there is any kind of complication, it should be treated immediately.
Post insertion care
Provide education to the patient about the side effects of the intrauterine device properly.
Provide patient education about signs of complications such as pain fever, infection, severe discharge bleeding etc.
Advising the patient for proper follow up.
Thus, intrauterine devices (IUDs) are a popular method of long-term contraception.
Hormonal Method:
Steroidal contraceptives:
A) Oral: It is commonly known as Pills.
B) Injectable: It is mainly provided through injection.
C) Newer Sustain Release System
A) Oral Pills:
Combine Peels:
Mala N (norethisterone acetate + ethinylestradiol).
Mala D( D Norgestrel + Ethinylestradiol).
Mini Pills: These contain only progestin, i.e. norethisterone + levonorgestrel.
Combine Pills: It contains 28 tablets in a packet to complete the menstrual cycle. 21 tablets contain a combination of estrogen and progesterone while 7 tablets contain iron and vitamins. Common estrogens include Ethinyl Estradiol, 30 mg and Progesterone Norethisterone 1 mg, DL Norgestrel, Levonorgestrel, Ethanodiol Diacetate, Linestranol etc. It can be started during the day in the first 5 days of the menstrual cycle. It has to be taken daily till night time for 21 days. The second packet is to be started after 7 days regardless of whether the menstrual cycle starts or stops.
MALA-N is free of charge by the government in the family planning program. It contains 30 mg of estrogen and 1.0 mg of thyrothysterone.
POP (Progesterone-Only Pills): These are called micropills or minipills. It is to be taken during the throwout menstruation cycle. It contains only progestogen. It has not become very popular due to its high failure rate. It is generally used more in older women for whom the combined pill is contraindicated.
Postcoital Contraception: Postcoital contraception is to be taken within 72 hours of unprotected intercourse usually using two methods namely,
1) IUD,
2) Hormonal
1) IUD: This is the simplest technique in which the copper device is usually removed within 5 days.
2) Hormonal: Hormonal method is preferable. Levonorgestrel 0.75 Tablet is advised as emergency contraception.
One tablet of levonorgestrel 0.75 mg is given within 72 hours and another tablet 12 hours after the first dose.
or two oral contraception pills containing 50 mcg ethinylestradiol
Within 72 hours after coitus act and the same dose is repeated after 2 hours.
or four oral contraception pills containing 30-35 mcg ethinyl-estradiol
It is advised to take four tablets within 72 hours and 12 hours later.
Long Acting Pills (once a month): These are long acting estrogens Ex: Quenestrol which are provided in combination with short acting progestogen but are not recommended due to high pregnancy rate.
Nonsteroidal Weekly Oral Pills:
This medicine is famous as the brand name of Saheli. It has less side effects like nausea, vomiting, weight gain, dizziness, etc. The name of this tablet is “Santcroman” and it is to be taken once in a week.
Mode of Action of Combine Pills: As for the mechanism of action of Combine Pills, this medicine prevents the release of ovum from the ovary which normally blocks the secretions like gonadotrophin required for the release of ovum. Progesterone makes the cervical mucus thick and scanty, which can prevent sperm penetration. Progesterone also inhibits tubal maturation and transport of ovum and sperm into the uterine cavity.
Advantages:
It is easy to use.
Inexpensive and easily available.
The safety rate is high.
Menstrual cycle remains regular.
Chances of breast cancer are reduced.
Disadvantages:) Not used in patients with cardiovascular disease.
Weight gain.
High blood pressure occurs.
Not suitable after the age of 40 years.
Its side effects include breast tenderness, pain, headache, irregularity in bleeding.
Other problems like liver disease, reduced lactation, sometimes ectopic pregnancy can also occur.
B) Injectable Contraception:
Injectable contraception includes two types:
1) Long acting progestins:
1) Depot- Medroxy Progesterone Acetate (DMPA) – 150 mg every 3 months.
2) Norethisterone enanthate ( NET – EN) – 200 mg every 2 months.
2) Combined injectable:
DMPA 25 mg + estradiol cypionate 5mg (Cyclophem)- monthly.
NET – EN 50 mg + Estradiol valerate 5mg (Mesigyana)- monthly.
1) Long acting progestins:
1) Depot-medroxyprogesterone acetate (DMPA) – 150 mg intramuscular injection is provided every 3 months.
It usually provides protection for up to three months of pregnancy.
1) It suppresses ovulation.
2) It has an indirect effect in the endometrium.
3) It decreases the size of fallopian tubes.
All these mechanisms of action can prevent pregnancy.
Timing: Within 7 days of menstrual cycle, immediately after abortion, and MTP, within 7 days postpartum, 6 weeks postpartum in breast feeding patients.
2) Norethisterone Enanthate ( NET – EN): – 200 mg every 2 months.
This injectable usually provides protection from pregnancy for up to two months.
Advantage:
Highly effective,
Provides long-term protection from pregnancy.
Does not interfere with sexual activity.
Can be used in any age.
Endometrium cancer and uterine fibroids are reduced.
Side-effects:
Irregular menstrual bleeding.
Amenorrhea.
Weight gain.
Breast tenderness.
Nozia.
Hair loss.
Contraindication:
Hypertension.
Cardiovascular disease.
Breast cancer.
2) Combined injectable:
DMPA 25 mg + estradiol cypionate 5mg (Cyclophem)- monthly.
NET – EN 50 mg + Estradiol valerate 5mg (Mesigyana)- monthly.
Combined injectable usually contains estrogen and progesterone which is usually taken every month which can be plus or minus 3 days.
Sustain Release System:
Norplant:
The Norplant 2 rod system, which contains two silastic rods totaling 140 mg of levonorgestrel, is implanted in a woman’s arm through a minor surgical technique with a failure rate of 0.5 per hundred women. It usually works for 5 years after which it is removed by a minor surgical technique.
Biodegradable implant: It delivers progesterone and dissolves slowly so it does not need to be removed.
Silastic Vaginal Ring: Progesterone is slowly released from the ring and is slowly absorbed into the vaginal happy thallium the woman can insert and remove herself. It remains effective for 12 months.
Contraceptive patch: The combined estrogen+progesterone patch is to be applied to the abdomen, buttocks, thighs, and upper outer thighs, and upper back. A new patch has to be applied on that website.
: Post conception contraception
Emergency Contraception: Emergency contraception is contraception used as an emergency procedure to prevent pregnancy after unprotected intercourse. This method is effective, safe and simple.
Yuzpe Method: This involves the use of combined oral contraceptive pills, two pills as soon as possible and two pills given 12 hours after the first dose.
Progesterone Only Pills: Levonogestrel 0.75 mg 2 doses provided two hours apart are equally effective as a single dose of 1.5 mg.
IUCD: IUCD has to be inserted within 5 days of intercos.
Antiprogesterone: Mifepristone (RU-486) 600 mg single dose provided within 72 hours of unprotected intercourse.
Miscellaneous:
Natural Family Planning Method:
Total Abstinence:
It completely involves coitus act no abstinence.
Coitus Interruption: It involves the withdrawal of the penis from the penis during sexual activity before ejaculation.
Lateral Amenorrhea Method (LAM): It has less chance of conception in women who breastfeed for 6 months after child birth.
Method Based on Fertility Awareness:
Calendar or Rhythm Method:
Record the days of the previous six menstrual cycles and subtract 18 days from the last cycle (28 – 18 = 10) which is the day of her first fertile period. Then subtract 11 days from the lowest cycle and that is the last day of the fertile period (31-11= 21). Avoid sexual intercourse during this period.
Basal Body Temperature Method (BBT): Monitoring temperature every morning before waking up from bed Temperature increases by 0.3°C – 0.4°C due to effect of progesterone After temperature increase three days until fertilization period no end Coitus activity to avoid
Cervical Mucus Method (Billing Method): During ovulation the mucus is watery, clear, smooth and slippery. Thus, doing coitus activity during ovulation and up to three days after ovulation.
Symptothermic Method: In this method, a combination of basal body temperature (BBT) + cervical mucus method + calendar method is used to prevent conception.
Sterilization/ Permanent Contraception:
Permanent surgical contraception also called voluntary sterilization is a surgical method in which the reproductive function of an individual male or female is purposefully and permanently destroyed.
such as,
1)Male Sterilization: Vasectomy,
2) Female Sterilization: Tubectomy
1)Male Sterilization: Vasectomy: This is a permanent stylization operation performed in the male in which both sides of the vas deferens are resected and its ends are cut and ligated.
Advantages:
It has a simple operation technique and few complications.
It can also be operated in camps and villages as an outdoor procedure.
Failure rate is 0.15% and success chance of reversal anastomosis operation is 50%.
Equipment, hospital stay, doctor training all costs are minimal.
Disadvantages:
Additional contraception is required for 2-3 months after the operation until the semen is sperm free.
Frigidity or impotence occurs which is mostly psychological.
Non Scalpel Vasectomy (NSV): This operation is provided under local anesthesia in which the vas is caught with specially designed forceps, then the stretched skin over the vas is punctured with the sharp point of the forceps without using a scalpel and then the vas is dissected, there is no need for sutures and the time is also less, there is a fast recovery, but the skill of the surgeon is much more required.
Female Sterilization/ Tubectomy:
Tubectomy is a method of permanent sterilization performed in females. It involves cutting the fallopian tubes and then ligation to block the passage of the ovum.
Time of Operation:
Postpartum Sterilization: Tubectomy can be done 24-48 months after delivery if the patient is healthy.
Internal Sterilization: When the operation is performed at any time other than child birth and abortion, it is called internal sterilization.
Traditional tubectomy: This method is also known as abdominal tubectomy. This method is usually performed under general anesthesia or spinal anesthesia in which an incision is made in the lower abdominal area and then the fallopian tubes are cut and tied or clamped. The abdominal lining is then closed. This usually works as a permanent contraceptive that blocks the passage of the ovum, which usually requires five to six days of hospitalization and sutures on the 5th day after the operation. Then it can be removed.
Post operative advice:
Heavy weight should not be lifted for 6 weeks.
Avoid heavy work for three months.
Sexual activity can be resumed 4 weeks after the operation.
Minilap operation: This is a minor form of abdominal tubectomy usually performed under local anesthesia in which a 2.5 to 3 cm incision is made in the lower abdominal area and then parts of the fallopian tubes are cut and clamped and The abdominal layer is then sutured again.This method is a very safe and effective method.This procedure can generally be performed at the Primary Health Center (PHC) level and also in the campaign.This procedure acts as a good technique for postpartum sterilization. .
Advantage:
This technique is generally suitable for post partum sterilization.
This procedure is usually less traumatic than an abdominal tubectomy.
It usually has fewer complications.
Laparoscopic Sterilization: This laparoscopic sterilization technique is a very popular procedure of female sterilization in which the fallopian tubes are blocked or a rubber ring is placed in the fallopian tubes so that the ovum cannot reach the uterus before inserting a laparoscope into it. The abdomen is expanded with carbon dioxide, nitrous oxide, or air, then the laparoscope is inserted through the abdomen and the tube is visualized. After the tube is visualized, the fallopian tube is placed or a clip is applied to the fallopian tube. Due to which the tube is blocked then the laparoscope is removed and the lining of the abdomen is sutured and closed.
Advantage:
The incision is very small and the scar is also small.
It requires less time for operation.
This is a less expensive procedure.
Complications are minimal.
Hospital stay is short usually up to 48 hours.
Disadvantage:
It is not usually performed in the postpartum patient.
It is not suitable for patients who have medical disc order like heart disease, respiratory disease, diabetes and hypertension.
Complications:
pain,
stretching,
Irregular menstrual cycle,
Local infection.