Oxford Handbook of Midwifery (120 page)

Points to remember

CHAPTER 22
Contraception

558

• If a mother is not breastfeeding or is post-abortion, her risk of pregnancy, even in the first menstrual cycle, is real. We have all seen the woman who comes for her postnatal examination and is pregnant again!
  
• For the mother who is fully breastfeeding, day and night, the risk of pregnancy is minimal. If this woman chooses to use a female condom, although it is very well lubricated, she may need additional lubrication because of the very low oestrogen levels while breastfeeding.
  
• If one or more partners are sensitive or allergic to latex, this is a useful alternative.
  
• She may use additional spermicides to increase efficacy of the condom.
  
• Emphasize that the condom is a ‘once only’ use and should never be re-used.
  
• In the UK all contraception is free of charge and the midwife can offer the woman a supply of female condoms. Make sure you know where the local contraception and sexual health clinics are located, to be able to advise her on further supplies.
  
• Remind her to check that the condom she is purchasing has the nationally agreed quality mark, e.g. the British Kite mark or the European Community CE mark.
  

  

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  CHAPTER 22
  Contraception
  

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  Diaphragms and cervical caps
  

  Diaphragms (Fig. 22.7) and cervical caps fit into the vagina and cover the cervix, providing a barrier to sperm, thus preventing fertilization.
  

  Fitting and teaching of the method must be done by a doctor, nurse, or midwife trained and competent to do so. Accurate fitting is essential to their success in use.
  

  How are they used?
  

• Diaphragms, in particular, are simple to use, once taught by a doctor or nurse experienced in fitting and teaching use of this method.
  
• The diaphragm comes in sizes from 55mm to 100mm and careful measuring and fitting is important.
  
• It can be inserted well ahead of intercourse and need not affect spontaneity.
  
• If more than 3h have elapsed since spermicide was applied, it must be reapplied before intercourse, usually in the form of a spermicidal pessary.
  
• The spermicide should be reapplied before repeated acts of intercourse.
  
• 2
  It must be left in place for at least 6h after intercourse
  .
  

  Efficacy
  

• When used carefully and consistently, with spermicide, they have a 92–96% success rate.
  
• Typically the efficacy rate is 82–90%, with a spermicide.
  
• The failure rate depends on how effectively the woman uses the diaphragm or cervical cap.
  
• Age is relevant, as the woman aged 25 is generally more fertile than a woman aged 40+.
  

  Disadvantages
  

• Requires motivation and needs to be used carefully and consistently.
  
• Needs to be used with a spermicide cream or gel for maximum effectiveness. Some women find the additional spermicide messy and unacceptable.
  
• No protection against HIV.
  
• May increase the incidence of cystitis and urinary tract infection (particularly if the diaphragm is too big).
  
• The woman must be comfortable with handling and exploring her body.
  
• Psychosexual problems may become apparent during discussion and teaching diaphragm or cervical cap fitting.
  

  Advantages
  

• There is little reduction in sexual sensitivity.
  
• It may give some protection against cervical cancer and sexually transmitted diseases, if the cervix is covered.
  
• No hormones to take.
  
• It is under the control of the woman.
  

  Contraindications
  

• Poor vaginal muscle tone, bladder, or uterine prolapse
  

  

  Ensure the diaphragm completely covers the cervix
  

  

  To remove the diaphragm place the forefinger over the power edge and gently pull downwards
  

  Fig. 22.7
  The diaphragm.
  

  

  Copyright © fpa 2008 and reproduced by permission of the publisher.
  

Side-effects

Points to remember

DIAPHRAGMS AND CERVICAL CAPS

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CHAPTER 22
Contraception

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Fertility awareness (natural family planning)

• Fertility awareness methods are natural, requiring no medical intervention, but do require competent education in their use.
  
• Natural methods of family planning are widely and successfully used, particularly in certain religious groups.
  
• Natural fertility awareness methods involve observation of female body changes within the woman’s menstrual cycle, in order to detect ovulation, either to use as contraception or to achieve pregnancy in the fertile period.
  
• Many women/couples now want to utilize non-hormonal methods of contraception.
  
• There are four main methods of natural family planning and fertility awareness:
  
  • Temperature method
    
  • Calendar method
    
  • Cervical mucus method (Billing’s method)
    
  • A combination of the above, known as the symptothermal method, which is the most effective and preferable method (see Fig. 22.8).
    

    After pregnancy
    

    2 Because of the hormonal changes in pregnancy, it is important to remind the woman that this method should not be relied on until she has had at least three normal periods after abortion or birth. This is to ensure that her natural hormonal levels are back to normal.
    

    Changing from a hormonal method of contraception
    

    2 As above, she should wait until at least three normal periods after dis- continuing the hormonal method.
    

    Breastfeeding
    

• 2 This method cannot be used while a mother is breastfeeding, because of altered hormone levels (for further details, b see Lactational amenorrhoea method, p. 528).
  
• She should wait until she has ceased breastfeeding and had at least three normal periods.
  
• She may need additional contraception in the intervening period.
  

  Efficacy
  

• This depends on consistency and conscientiousness of method use.
  
• The efficacy rate varies from 80–90%.
  

  Disadvantages
  

• Cannot be used immediately after pregnancy.
  
• Requires motivation and conscientiousness in use.
  
• Requires observation and recording of daily body changes.
  
• Requires specialist teaching.
  
• Takes time to learn (typically 3–6 months).
  

  FERTILITY AWARENESS (NATURAL FAMILY PLANNING)
  

  563