NURP 501 Week Two Exam Review MASTERY GUIDE: Advanced Health Assessment, Clinical Diagnostics & Expert-Verified Q&A (Instant Download)

What does birth control need to be?

Safe, Effective, & Acceptable

What is Family Planning?

Planning the number and timing of children

*Discuss contraception and infertility

What is birth control?

The voluntary limitation of the number of children conceived.

*Discussed methods used

What is contraception?

Prevention of pregnancy

What is an unintended pregnancy?

An unwanted, mistimed, or unplanned pregnancy.

50% of pregnancies are unintended!

Of that 50%, 1/2 used contraception.

40% of unintended pregnancies are terminated

What does every women deserve with birth control?

A method of birth control that is:

Safe

convenient

cost effective

limited side effects

Need to select a method that best meets the patient's needs!

What education needs to be provided regarding BC methods?

There is no perfect method:

Safety

Effectiveness

Cost

Privacy issues

risk

benefits

Dispelling of myths

Must provide education on correct and consistent use!

Efficacy

Likelihood that conception will occur despite consistent and correct use

Effectiveness

Success of a method preventing pregnancy when used typically in practice

Contraceptive Counseling - Goals in Family Planning

Family Centered Care

Empowering women in their own health care

Promoting public health

Ensuring informed choices

***Women have the right to self determine method used!

*Provider must be aware of own feelings and biases

*Must consider a woman's culture, attitude, beliefs, and plans

Assessing feelings and priorities in Contraceptive Counseling

Need to assess:

Reproductive goals?

What characteristics are desired with contraception?

-Regulating menstrual cycle?

-Improving acne?

-No menstrual cycle?

***Patient centered counseling and education increases satisfaction and successful contraception management!

What is the safety and Medical Eligibility Criteria (MEC)?

CDC guidelines to be used when counseling women about contraceptive choices

Focuses on safety when initiating or continuing contraceptives when underlying medical conditions exist.

Categories of USMEC

1 - no restrictions

2 - advantages likely outweigh the risk

3 - Risk outweigh the benefits

4 - Unacceptable health risks!

Options for unintended pregnancies

1 - maintain the pregnancy & keep the infant

2 - maintain the pregnancy & consider adoption

3 - Terminate pregnancy

Counseling women with unintended pregnancy

Must recognize own beliefs and biases and not let them compromise patient's access to care and informed consent!

Ethical obligation to provide information on all options!

Every woman has the right to:

Make own health choices that meet her needs

access factual information

have financial resources to services that meet her needs

Adoption couseling

Inform on local and state programs (social and financial support)

Provide information on sources for help in creating an adoption plan (in collaboration with SW and adoption agency)

Familiarize yourself with local resources!

Encourage patient to initiate early prenatal care - vitamins and folic acid

Address any health risks!

Types of adoption

Open - birth mother and adoptive family are known to each other

Semi-open - Some identifying information is shared, and communication occurs at pre-arranged intervals

Closed - Birth records are sealed and all identities are concealed.

*All done via agency or attorney

Abortion Counsesling

*If your conscience does not permit abortion counseling then you need to facilitate in finding another provider who will offer the counseling.

Must include:

Discussion of method

Specific risks and benefits

Informed consent

Limits established by gestational age based on state law

Availability of trained providers and facilities

Pregnancy Termination

90 % occur in first trimester via pharmacologic or surgical intervention

Second and third trimester abortions have limited options and are more costly and higher risk

What is the most frequently used method of abortion in 1st trimester?

Aspiration -

Can be used up to 12 weeks gestation

Uses suction with hand held syringe - removes gestational sac

Performed in office

Takes about 15 minutes

Abortion - Dilation and Evacuation (D & E)

Utilized dilation, forceps, and suction

Dilation - with dilating rods or softening and ripening agents such as MISOPROSTOL or OSMOTIC DILATORS several hours before the procedure

-Laminera-seaweed rods that absorb moisture from cervix and expand (remove just prior to the procedure) ***commercially available sponges work the same way

DNC

dilation and curettage

Dilate cervic => scrape or curettage the uterus

Used up to 13 weeks gestation

Complications = heavy bleeding, cervical laceration, infection, continued pregnancy, uterine perforation, injury to surrounding organs, risk for retaining products which can lead to need for surgery

Medical Abortion

Mifepristone (Mifeprex) - to block progesterone receptor sites (required for normal implantation; prevents fertilization) => shedding of the endometrium & cervical softening

Misoprostol or Cytotec - Given orally or vaginally to ripen cervix and promote expulsion

Give Mifeprex then two days later give misoprostol

95-98 effectiveness when used

Medical abortion with methotrexate

Inhibits enzymes required for DNA synthesis and stops mitosis of dividing cells

Expulsion can take up to 2 weeks

Only 60-84 % effective

Induction of labor after 1st trimester

Prostaglandings + Misoprostol or oxytocin to stimulate uterine contractions

Non-hormonal methods of contraception

Coitus interruptus

Calendar rhythm methods

condoms

female condoms

Diaphragm or cap

***Controlled by use, inexpensive, no side effects, no prescription, used when sex is anticipated

***Some rely on biological processes such as breast feeding or menstrual cycle

What is the likelyhood of unintended pregnancy when not using any contraceptive method?

85%

What is risk of unintended pregnancy with a copper IUD?

<1%

What is the risk of unintended pregnancies when using spermicide alone?

28/100 unintended pregnancies

Abstinence

100 % effective

Unrealistic

Difficult in high pressure situations

Coitus Interruptus (withdrawal)

used b 5% of the population

Can be used with other methods

12/100 unintended pregnancies

pre-ejaculate can contain sperm!

Only 20-60% effective in adolescents.

Lactational Amernorrhea Method

Relies on physiologic changes associated with breastfeeding

Used in postpartum period

Increased prolactin inhibits the secretion of GnRH which of sets the HPO axis and prevents ovulation.

MUST EXCLUSIVELY BREASTFEED!!! - NO MORE THAN 4 HOURS IN BETWEEN FEEDINGS DURING THE DAY AND 6 HRS AT NIGHT!

Infant must be <6 months old and menses must not have returned.

If all conditions met = 98-99.5% effective

Fertility Awareness Methods

Requires women to ID fertile time during menstrual cycle and use abstinence or barrier method during this time.

*Approved by the Roman Catholic Church

*Used by <17% of the population

What biological events are fertility awareness methods based on?

1. ovulation - about 14 days post menses

2. lifespan of ovum - about 12-24 hours

3. sperm viability - about 3-5 days

MUST BE AWARE OF BIOLOGICAL SIGNS DURING CYCLE!

Rely's on both partners participation.

Effectiveness of Fertility-Awareness based methods

24 % non-effective rate! IT IS THE LEAST EFFECTIVE METHOD!

Highest likelihood of pregnancy occurs during the fertile window - 5 days before and 1 day after ovulation.

What is the most fertile window?

5 days before and 1 day after ovulation

Contraindications to Fertility Awareness Methods

Conditions that interrupt normal cycles

recent childbirth

Menarche

Perimenopause

breast feeding

inovulatory cycles

recent D/C of hormonal therapy

Instramenstrual bleeding

Vaginitis

infections

Difficulty assessing vaginal secretions

Rythm Method

1st - Record and count days in menstrual cycle x 6-12 months

2nd - determine the longest and shortest cycle

3rd - Identify 1st and last fertile days expected

***Abstain during fertile days

*** Must have regular cycles that last 26-32 days

Standard Calendar Day method

Can use beads to assist

Billings Ovulation Method

Looks at changes in mucus

ID physiological changes and characteristics that naturally occur due to changes in hormone levels.

Ovulation method

Fertile window - vulvar wetness, stickiness, elastic mucous

Increased estrogen = egg white consistency (Spinnbarkeit)

Fertile until 4 days after last identified Spinnkarkeit

Two day method

If secretions noted or have been seen in two days then can get pregnant!

Basal Body Temperature Method

Increase in progesterone from ovulation results in increase in BBT - Must check temp at the same time each day before getting out of bed

Increase in temp by 0.4 degrees

May be preceded by a dip

Fertile during three days of plateau or 5 days of progressive increase

Infertile days of decreased temp!

Symptothermal method

Looks at temp, cervical mucous, and cervical observation!

Following ovulation, the cervix is higher due to increased firmness and closed.

Male Condoms

Natural rubber latex OR polyurethane OR synthetic materials

Polyurethane - have longer shelf life and can be used with lubricants

Latex - less expensive and can be used with lubricants

PREVENT STI's!!!

Effectiveness of male condom

82 % effective or 18 % non-effective when used correctly

Risk of breakage or slippage!!!

Male condom disadvantages

Can tear or slip

Perceived reduced sensitivity and lack of spontaneity

Possible difficulty maintaining erection

Embarrassed to use or ask to be used.

Male controlled

Women exposed to risk of pregnancy

Can cause vaginal irritation (mostly latex)

Female Condom

Only one size available

does not require fitting

Can use lubricant and spermicide

one time use

Can be inserted 8 hrs prior to intercourse

Female Condom Effectiveness

79 % effective; 21% non-effective

Spermicidal Agents

Foam, cream, gel, film, suppository, sponge

Contains Nonoxynol-9 surfactant that destroys sperm cell membrane (52-150 mg)

Most ineffective!!!

SE: dermatitis, increased risk for STI, increased risk for HIV transmission

Women at high risk should not use!

Spermicide Effectiveness

72 % effective; 28% ineffective

Vaginal Sponge Effectiveness

76% effective in parous women

88% effective in nulliparous women

Vaginal Sponge and TSS

From staph or strep

Increased risk:

with recent childbirth

>24 hrs in place

Difficulty removing or fragmenting of sponge

2-3 days of mild symptoms: low backache, bodyaches, chills malaise => fever, erythematous rash, and hypotension

Diaphragm

Silicone or latex

use with spermicide

=provides a physical and chemical barrier

Must be fitted and requires prescription -

If weight gain >15 lbs, 2nd trimester abortion, or vaginal birth in past 6 weeks then must be refitted!

Can be inserted 6 hours prior to intercourse and must stay in place 6 hours after intercourse (no longer than 24 hours)

Effectiveness of Diaphragm

88 % effective (12 % non-effective)

SE of Diaphragm

UTI

Change in vaginal flora from spermicide

Improper fit can lead to abrasions

Risk for TSS - must remove before 24 hrs!!!

Category 3 if hx of TSS!

Cervical Cap "femcap"4

Looks like a sailors hat

use with spermicide

Requires prescription & only available at select pharmacies and planned parenthood

Can be inserted 42 hours prior to intercourse & must stay in place for 6 hours post intercourse

DO NOT USE WHILE MENSTRUATING!!!

Cervical cap sizes

22mm - nuligravida

26mm - nulipara

30mm - anyone with full term delivery

Cervical Cap Effectiveness

77% overall effective

86% effective for nuliparous women

INCREASES RISK FOR TSS!

Hormonal contraceptives

Contain synthetic steroid hormones that act centrally on pituitary function and steroidogenesis

-Supplement estrogen and/or progesterone

-Prevent ovulation and/or sperm transport

Exogenous estrogen in contraception

Stabilizes endometrium

Controls cycle

Prevents breakthrough bleeding

-Suppresses FSH and inhibits the development of a dominant follicle

#1 estrogen used in contraceptives

Ethinyl Estradiol

SE and risks with exogenous estrogen

SE: Headache and nausea

Risks: DVT or other thrombolytic events, breast cancer, and MI especially in smokers >35

Exogenous use of progesterone for contraception

Inhibits the release of LH which prevents the LH surge needed for ovulation

Thickens cervical mucosa and delays sperm transport

Progesterone SE and Risks

SE: Acne, PMS (swelling), breast tenderness, and transient mild depression

Progestin only contraceptives lack endometrial stabilization which increases the risk of irregular bleeding

Increased DVT risk with desogestrel and norgestimate

Long-Acting Reversible Contraceptives (LARC's)

IUD - copper

Implant

IUS - IUD that releases hormones

Can return to fertility within a few months after removed

Not depended on user action

Very effective!!!

Short-Acting Reversible Contraceptives

Contraceptive ring

The pill

Contraceptive injection

Contraceptive patch

Can contain estrogen and progesterone or progesterone only!

Highly effective

Easy to use

Reduces dysmenorrhea

Requires consistent and correct use

can be expensive

No protection from STI's

Most failure is user error

Hormonal Contraceptives decrease the risk of what?

Colon cancer

Endometrial cancer

Hirsutism

Osteoporosis

ovarian cancer

Can also decrease dysmenorrhea, heavy bleeding, menstrual migraines, and PMS!!!

CAn be used to treat fibroid bleeding, pelvic pain, endometriosis, and acne!

Drug interactions and cautions with hormonal contraceptives

Some drugs decrease contraceptive effect

Most interactions just cause breakthrough bleeding and not pregnancy

Caution if being treated for TB, seizure disorders, clotting disorders, HIV, or depression

Drugs that can interact

Rifampin, Tegretol, Dilantin, antifungal drugs, griseofulvin, St. Johns wort, OTC antacids.

Contraindications to estrogen

Heart disease

Coagulopathies

Breast cancer

pregnancy

Management for women starting hormonal contraceptives

#1 rule out pregnancy

2. No recent unprotected sex for the past two weeks

3. LMP within the last 5 days

4. Current use of another reliable method or discontinuation within the past 7 days

5. confirm method proposed is desired and likely to be used correctly

6. Assure that no contraindications exist

7. No likely drug interactions with the chosen method

Counseling for all methods should include

-review of warning signs

-Common side effects

-Effect on menstrual flow

-Non-contraceptive benefits

-Average time to return to fertility

-lack of protection from STI's

-Date and time for follow up appointments

-Health promotion screening activities as appropriate

Counseling women as they start hormonal contraceptives for SARC's

-When and how to initiate secondary protection for one week & back up methods

-Continuous, correct use of the method

-Common mistakes to avoid

-What to do in event of a missed dose

-Safe disposal

-Specific info on when to renew and costs

-Discussion of any questions.

Initiation of method

Must have reasonable assurance that she is not pregnant!

Quick start has improved satisfaction!!!

-must use back up method x7 days

There is also the Sunday start - 1st Sunday after menstruation

Primary reason for non-compliance or D/C

Menstrual irregularities

Educate that breakthrough bleeding may occur in 1st 3 months or longer with lower dose pills.

More common with progestin only methods!

SE associated with hormonal contraceptives

headaches

nausea - more common with oral agents ... recommend take before bedtime, avoid taking on an empty stomach, and ginger may help

Weight gain - adolescents and overweight women are at a higher risk with progestin only forms like Depo

If >5% over first 6 months then increased risk for continued weight gain (can be up to 40 lbs)

IF S/S of CVA then d/c and seek emergency care!

Combination Oral Contraceptives (COC's)

Wide variety with different side effect profiles

Depends on - hormonal dose, relative proportions of estrogen and progestin (Particular progestin component)

Monophasic

Biphasic

Multiphasic

Extended cycle

Effectiveness of oral contraceptives

91% effective (9% non-effective)

Monophasic COC's

Identical dose every day

21-24 pack including 4-7 placebo pills (4 placebo increase effectiveness and pt satisfaction)

Take one pill each day for 28 days then start a new pack

Multiphasic COC's

Biphasic or triphasic

Vary in amount of estrogen and or progestin provided weekly

Includes 4-7 placebos

Extended Cycle COC's

Taken for 3 consecutive months!

Sesonale includes 84 active pills and 7 placebos

will have withdraw bleeding or pseudo menstruation during placebo as with other COC's

COC's management plan

- determine any contraindications

- Review previous methods used

- Consider emergency contraceptive provisions

- PE, including BP and weight

- Consider cost

- Prescribe four to 6 cycles for new user with return visit

- Most ppl will resume normal ovulatory function within 90 days of d/c

- explain benefits of COC's and risks

- BEgin with lowest dose of estrogen to decrease risks and SE

- Discuss SE, what to do if missed a dose, adverse effects and warning signs!

Progestin-only pill (mini pill)

Lost dose single progestin used in women who want to use hormone-contraceptives but estrogen is contraindicated

Contains 0.35 mcg norethindrone and 0.75mcg of norgestrel

OK for breast feeding moms!

Decreased risk for thromboembolic issues

Progestin only pills management

regularity of the daily dose is unforgiving!!!

Must take pills in 24 hr intervals with +/- 3 hours or spotting will occur!

Irregular spotting is expected!

Transdermal Contraceptive Patch

6mg norelgestromin + 0.75 mg ethyl estradiol

Inhibits ovulation and changes cervical mucosa and endometrial lining!

Orthoevra- 3 layer polyester patch

-back layer - covering

-Middle layer - Drug layer

-Cover to be removed prior to use

How often do you apply the patch?

Every 7 days x 3 weeks then 1 week patch free

Effectiveness of the patch?

91% effective (9% noneffective)

If patient >198 lbs then increased risk for failure!

Partial detachment decreases effectiveness

Contraindications and SE of the patch

Contraindications -

Heart disease

coagulopathy

Breast cancer

SE:

Headache

Breast discomfort

Application site reactions - can cause permanent discoloration!

The patch management plan

Advise for weight less than 198 lbs

Prescribe for 4 months and follow up in three months

Discuss satisfaction and SE

Use only if untouched or unstuck

If more than 9 days elapsed without patch - unprotected!

Intravaginal Contraceptives "the ring"

Vinyl ring that provides a daily release of estrogen and progesterone

120 mcg ethogestrel and 15 mcg of ethanol estradiol daily

Inhibits ovulation, thickens cervical mucous, and effects endometrial lining.

Effectiveness of the ring

91 % effective if kept in place correctly!

Lower doses needed due to being released directly into the vagine!

How to use the ring

Insert monthly - lasts 21 days, remove x 7 days

ONE SIZE FITS ALL!

As long as it is in contact with the vaginal mucosa it is ok!

If out of vagina for <3 hours it is ok! If expelled for longer, use backup method!

Follow up in 3 months !

Contraindications and SE of the ring

Contraindications - same as other hormonal contraceptives

SE -

HA

Dysmenorrhea

Breast discomfort

Vaginal irritation

Other info on the ring

Store refrigerated

Can be stored outside of fridge x 4 months

Extreme temps should be avoided

can possibly be felt during sex

injectable contraceptives

Depo-Provera

Derivative of progesterone

Inhibits ovulation by preventing follicular maturation, thickens cervical mucosa, and induces endometrial atrophy

IM - 150 mg q12w

SQ-104 mg q12w

Effectiveness of Depo

94% (6% non-effective)

Depo-Provera key points

Return to fertility may be delayed

Irregular bleeding and spotting can occur and may be heavy in 1st few months

May have amenorrhea after 1st injection and 40-50% will have by 4-5 injection (after 1 year)

Can be administered anytime if not pregnant!!!]

If >7 days then use back up method

may receive anytime post partum if sexual activity has not occurred

Ovulation will occur 14 weeks post injection

DO NOT MASSAGE INJECTION SITE!!! May decrease effectiveness!!!

SE of Depo-Provera

HA

Reduction in bone density (reversible) from estrogen suppression

Changes in vaginal environment and cervical ectopy (increased risk of STI)

Nervousness

Decreased libido

Breast discomfort

Dizziness

Hairloss

Bloating/fluid retention

Decrease in glucose tolerance

Category 3 if HA with aura

Conditions may increase risk of osteoporosis including decreased BMI, decreased calcium, corticosteroid use, decreased vitamin D, family history, etc1

Depo counseling

Eat diet high in calcium with Vit D and multivitamin daily

Report - significant headaches, menorragia, depression, severe lower abdominal pain, indication of pregnancy

Subdermal implant

Subdermal implant

initiate 6 weeks post partum or during first 7 days of menstruation

Can cross into breast milk - do not use if lactating

Norplant - good x7 years

Nexplanon and implanon - 68 mg etonogestrel good for 3 years