NCM 107 – Care of the Mother, Child and Adolescent

S.Y. 2023-2024 | 1st Semester | Preliminary Term

Module 3 – Reproductive Life Planning

Description
Reproductive life planning includes all the decisions an individual or couple make about
whether and when to have children, how many children to have and how they are spaced. This
module will provide the student an understanding of the different methods of reproductive life
planning and the advantages and disadvantages, and the risk factors associated with each. It will
also tackle how the couple can utilize the chosen method considering their religious, personal
and cultural beliefs.

Learning Outcomes
LO1 Integrate concepts of different methods of reproductive life planning and the advantages
and disadvantages, and the risk factors associated with each in the formulation and application
of appropriate nursing care during childbearing and childrearing years.
LO3 Assess clients for reproductive life planning needs
LO4 Formulate nursing diagnosis/es related to reproductive planning
LO5 Implement safe and quality nursing interventions related to reproductive planning.
LO6 Conduct individual/group health education activities such as educating adolescents about
the use of condoms as a safer practice as well as to prevent unintended pregnancy.
LO7 Evaluate with the client the health outcomes of nurse-client relationship.

Module Outline

I. Reproductive life planning

II. Commonly used birth control methods
III. Assessment for reproductive life planning needs
IV. Nursing Diagnoses Related to Reproductive Life Planning
V. Interventions Related to Reproductive Life Planning
VI. Evaluating Outcomes Related to Reproductive Life Planning

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 Module
I. Reproductive life planning Includes all decisions an individual or a couple make about
having children, including
1. If and when to have children
2. How many children to have?
3. The length of time between having children
Counseling may include the topics of avoiding conception, increasing fertility, and/or
what to do if contraception has failed.
An ideal contraceptive should be
a. Safe
o Effective
o Compatible with religious and cultural beliefs and personal preferences of user
and partner
o Free of bothersome side effects
o Convenient to use and easy to obtain.
o Affordable and needing few instructions for use.
o Free of effects on future pregnancies after discontinuation
II. Commonly Used Birth Control Methods
A. Natural Family Planning
Natural family planning methods, also called periodic abstinence methods, involve no
introduction of chemical or foreign material into the body. The effectiveness of these
methods varies greatly from a 2% ideal failure rate to about 25% failure rate, depending
mainly on the couple’s ability to refrain from having sexual relations on fertile days.
1. Abstinence

Abstinence has a theoretical 0% failure rate and is also the most effective way to prevent STIs.
Because it is difficult for many couples to adhere to abstinence, the method has a high failure
rate.

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 2. Lactation Amenorrhea Method (LAM)

When a woman is breastfeeding, there is a natural suppression of both ovulation and menses.
Lactation amenorrhea method is a safe birth control method with failure rate of about 1% to 5%
if:
a. An infant
1. under 6 months of age
2. Exclusive breastfeeding
3. No supplementary feedings
b. Menses have not returned.

3. Coitus interruptus

Coitus interruptus or withdrawal method is one of the oldest methods of contraception. The
couple proceeds with coitus until the moment of ejaculation. Then, the man withdraws, and
spermatozoa are emitted outside the vagina. Unfortunately, ejaculation may occur before
withdrawal is completed and, despite the caution used, some spermatozoa may be deposited in
the vagina. Furthermore, spermatozoa may be present in pre-ejaculation fluid, fertilization may
occur even if withdrawal seems controlled. For these reasons, coitus interruptus is only about
82% effective and can also lead to STIs.
4. Fertility Awareness Method
Fertility awareness methods rely on detecting when a woman will be fertile so she can use
periods of abstinence during that time. There are a variety of ways to determine a fertile period:
• Calendar
• Body temperature
• Consistency of cervical mucus

A fertile period exists from about 5 days before ovulation to 3 days after.
• Calendar (Rhythm) Method

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The calendar method requires the couple to abstain from coitus on the days of a menstrual cycle
when the woman is fertile. To plan for this, the woman keeps a diary of about six menstrual
cycles. To calculate for “safe” days, she subtracts 11 from her longest cycle and 18 from shortest
cycle. To avoid pregnancy, the couple should avoid coitus during these days
Example: menstrual cycle ranging from 25 to 29 days
Shortest cycle = 25 days – 18 days = 7
Longest cycle = 29 days – 11 days = 18
FERTILE PERIOD = 7th to 18th day of the menstrual cycle.
• Basal Body Temperature

Just before the day of ovulation, a woman’s basal body temperature (BBT) falls about 0.5oF. At
the time of ovulation, her BBT rises 1oF (0.2oC) because of the rise in progesterone (thermogenic
hormone) with ovulation. To use this method, the woman takes her temperature each morning
immediately after waking before she rises form bed or undertakes any activity; this is her BBT.
As soon as a woman notices a slight dip in temperature followed by an increase she knows she
has ovulated. She refrains from having coitus for the next three days.
A problem with assessing BBT for fertility awareness is that many factors can affect BBT. For
example, a temperature rise caused by illness, activity or warm environment could be mistaken
as the signal for ovulation.
• Cervical Mucus Method (Billing’s Method)

Each month before ovulation, the cervical mucus is thick and does not stretch when pulled
between the thumb and finger. Just before ovulation, mucus secretion increases. On the day of
ovulation (the peak day), it becomes copious, thin, watery, and transparent. It feels slippery (like
egg white) and stretches at least 1 inch before the strand breaks (spinnbarkeit). All the days on
which cervical mucus is copious, and for at least 3 to 4 days afterward, are considered to be fertile
days, or days on which the woman should abstain from coitus to avoid conception.
This method has a potentially high failure because of difficulty in interpreting mucus status,
therefore this method should be combined with a calendar method for best results.

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 • Symptothermal Method

The symptothermal method combines the cervical mucus and BBT method. The woman takes
her temperature daily, watching for the rise in temperature that marks ovulation such as
mittelschmerz or cervix feels softer than usual. The couple then abstain coitus until 3 days after
the rise in temperature or the fourth day after the peak of mucus change. The symptothermal
method, because it assesses more clues to ovulation, is more effective that either the BBT or
cervical mucus alone.
Natural family planning methods do not have side effects. If there is contraindication to their
use, it would be for couples who must prevent conception because their failure rate of all forms
is about 25%.
B. Barrier Methods of Contraception

Barrier methods are forms of birth control that place a chemical or latex barrier on the cervix and
advancing sperm so sperm cannot reach and fertilize an ovum.
1. Spermicides

A spermicide is an agent that causes the death of spermatozoa before they can enter the cervix.
It is a chemical barrier method and is often used in combination with other physical barrier
methods. Spermicides not only actively kill sperm but also change the vagina pH to a strong acid
level, a condition not conducive to sperm survival. They do not protect against STIs. Spermicidal
foam, cream, jelly, and suppository capsules are over the counter (OTC) contraceptives. They
have a failure rate of 21%. The use of other methods of family planning with spermicide increases
the contraceptive effectiveness.
Spermicides can cause local irritation in the vagina or on the penis. The irritation can cause tiny
cracks that provide portals of entry for infection.
2. Condoms

Male condoms are sheaths of thin latex, polyurethane, or natural membrane worn on the penis
during intercourse. Condoms collect semen before, during, and after ejaculation. They come in

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various styles, such as ribbed, lubricated, and colored, and with or without spermicide. They are
single-use, low-cost items that are available OTC. Latex condoms provide some protection from
STIs. Natural membrane condoms do not prevent the passage of viruses. To prevent condom
breakage, water-soluble lubricants should be used of the condom or vagina is dry.
Female condoms are essentially used for the same purpose as malt condoms. Two flexible rings,
one that fits into the vagina and one that remains outside, connected by a polyurethane sheath.
They are prelubricated, single-use items that are available OTC.
Side effects of and contraindications to condom use are rare. Either or the partners maybe
allergic to latex, in which case a polyurethane or natural membrane condom can be used
successfully. The failure rate is 18%.
3. Diaphragm and cervical cap

Diaphragms and cervical caps are rubber domes that fit over the cervix and are used with
spermicides to kill sperm that pass the mechanical barrier. A health care provider fits the
diaphragm and cervical cap. The woman must learn how to insert and remove the diaphragm or
cervical cap and to verify proper placement.
Before insertion, the woman should check either device for weak spots or pinholes by holding it
up to the light. Diaphragm or cervical cap is inserted before coitus and should be removed six
hours after sexual intercourse but not longer than 24 hours (Diaphragm) or 48 hours (Cervical
cap). The diaphragm must be refitted after each birth or after a weight change of 10 pounds or
more. The cap must be refitted yearly and after birth, abortion, or surgery.
User misplacement, especially of the small cervical cap, is a common reason for unintended
pregnancy. The typical failure rate is 12%.
Contraindications for Diaphragm include:
o history of toxic shock syndrome (TSS; a staphylococcal infection introduced
through the vagina
o allergy to rubber or spermicide
o history of recurrent UTI
o during menstrual period

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 Contraindications for Cervical cap
o abnormally short or long cervix
o abnormal Pap smear
o history of TSS
o history of latex or spermicide allergy
o history of cervicitis or cervical cancer
o undiagnosed vaginal bleeding

C. Hormonal Contraceptives
Hormonal contraceptives include one or more of these contraceptive effects:
• Prevent ovulation.
• Make the cervical mucus thick and resistant to sperm penetration.
• Make the uterine endometrium less hospitable if a fertilized ovum does
arrive.
1. Oral contraceptives

Oral contraceptives, commonly known as pill, OCs (for oral contraceptive), or COCs (for
combination oral contraceptives), are composed of varying amounts of natural estrogen or
synthetic estrogen combined with small amounts of synthetic progesterone (progestin). The
estrogen acts to suppress follicle-stimulating hormone (FSH) and Luteinizing hormone (LH) to
suppress ovulation. The progesterone action causes a decrease in the permeability of cervical
mucus and so limits sperm motility and access to ova. Progesterone also interferes with tubal
transport and endometrial proliferation to such an extent the possibility of implantation is
decreased.
Combination oral contraceptives are available in 21-or 28- pill packs. If the woman has a 21-pill
pack, she takes one pill each day at the same time for 21 days and then stops for 7 days. The
woman who has a 28-day pack takes a pill each day; the last seven pills of the pack are inactive
(usually iron supplement) but help her maintain the habit of taking the pill each day.
Menstruation occurs during the 7-day period when either no pills or inactive pill are ingested.

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Because COCs are not effective for the first 7 days, advise women to use a second form of
contraception during the initial 7 days that they take pills.
Common side effects of OCs include nausea, headache, breast tenderness, weight gain, and
spotting between periods or amenorrhea. These effects generally decrease within a few months
and are seen less frequently with low dose of OCs.
Women with the following disorders should not take OCs or should take them with caution:
o Thromboembolic disorders (blood clots)
o Cerebrovascular accident or heart disease
o Breast cancer
o Smoking of more than 15 cigarettes a day for women older than 35 years
o Impaired liver function
o Confirmed or possible pregnancy
o Undiagnosed vaginal bleeding
o Diabetes mellitus
o Breastfeeding and less than 6 weeks postpartum

Some medications reduce the effectiveness of OCs include:

o Some antibiotics (ampicillin, tetracycline)
o Anticonvulsants
o Rifampin, barbiturates

The acronym ACHES can help a woman recall the warning signs to report when taking
OCs:
o Abdominal pain (severe)
o Chest pain, dyspnea, bloody sputum
o Headache (severe), weakness, or numbness of the extremities
o Eye problems (blurring, double vision, vision loss)
o Severe leg pain or swelling, speech disturbance

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 2. Hormone implants

A progestin-filled miniature rod no bigger than a matchstick, levonorgestrel implant (Nexplanon)

can be embedded just under the skin on the inside of the upper arm where it will slowly release
progestin over a period of 3 years. The implant suppresses ovulation, thickens cervical mucus,
and changes the endometrium lining, making the implantation difficult.
3. Intramuscular injection

A single intramuscular injection of depot medroxyprogesterone acetate or DMPA (Depo-

Provera), a progesterone given every 12 weeks (3 months). The effectiveness rate of this method
is almost 100%. The injection is made deep into major muscle before the fifth day after the
beginning of a menstrual flow. The woman should not massage the injection site after the
administration so the drug can be absorbed slowly form the muscle.
D. Intrauterine Device

An intrauterine device (IUD) is a small plastic device that is inserted into the uterus through the
vagina by a healthcare provider. IUDs can be either hormonal or non-hormonal. It prevents
fertilization and it creates a local sterile inflammatory reaction that prevents implantation. The
method has a failure rate of 0.1% and reversible, and no specific actions are required related to
intercourse. The hormonal IUD is usually replaced every 3 to 6 years.
Cramping and bleeding are likely to occur with insertion. Increased menstruation and
dysmenorrheal may occur, and these are common reasons that a woman decides to have the IUD
removed. The IUD does not protect against STIs.
The acronym PAINS can help a woman with IUD recall the warning signs to report:
o Period which late, heavy or prolonged
o Abdominal pain
o Increased body temperature (or any signs of infection)
o Noticeable vaginal discharge (foul-smelling)

E. Surgical method of reproductive planning

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Surgical methods of reproductive planning, often called sterilization, include tubal ligation for
women and vasectomy for men. Both have 99.5% effectiveness.
1. Vasectomy
In a vasectomy, a small puncture wound (referred to as “no-scalpel technique”) is made on the
scrotum. The vas deferens on each side are then pulled forward, cut and tied, cauterized, or
plugged, blocking the passage of spermatozoa. A vasectomy can be done under local anesthesia
in an ambulatory setting, such as in primary healthcare provider’s office or a reproductive life
planning clinic. Although the procedure is about 99.5% effective, spermatozoa, which were
present in the vas deferens at the time of surgery, can be viable for as long as 6 months.
Therefore, although the man can resume sexual intercourse 1 week, an additional birth control
method should be used until two negative sperm reports at about 6 and 10 weeks have been
obtained (proof all sperm in the vas deferens have been eliminated, usually requiring 10 to 20
ejaculations).
2. Tubal ligation

Sterilization of women could include removal of uterus or ovaries (hysterectomy), but it usually
refers to a minor surgical procedure, such as tubal ligation, where the fallopian tubes are
occluded by cautery, crushed, clamped, or blocked, and thereby preventing passage of both
sperm and ova. A fimbriectomy, or removal of the fibria at the distal end of the tubes is another
possible but little used technique. Three methods may be used:
a. A minilaparatomy uses an incision near the umbilicus in the immediate postpartum
period or just above the symphysis pubis at other times. The surgeon makes a tiny
incision, brings each tube through it, and ligates, and cuts the tube.
b. Laparoscopic surgery is similar, but the tubes are identified, and ligated tube called
laparoscope.
c. The traditional approach is performed during other abdominal surgery, usually a
cesarean birth.

III. Assessment for reproductive life planning needs

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 As a result of changing social values and lifestyles, many women are interested in
reproductive life planning and so are able to talk easily about types and methods today. Other
people are uncomfortable or not interested in using a planning method so may not voice their
interest in the subject independently. For this reason, at health assessments, ask clients if they
want more information or need any help with reproductive life planning as part of obtaining a
basic health history. Before people are begun on a new contraceptive, other information that
needs to be obtained is:

• A Pap smear, pregnancy test, gonococcal and chlamydial screening, perhaps

hemoglobin for detection of anemia or a mammogram to rule out breast disease
• Obstetric history, including sexually transmitted infections (STIs), past
pregnancies, previous elective abortions, failure of previously used methods,
and compliance record
• Subjective assessment of the client’s desires, needs, feelings, and understanding
of conception (teens, for example, may believe that they are too young to get
pregnant; many women in the immediate postpartum period may believe that
they cannot conceive immediately, especially if they are breastfeeding)
• Sexual practices, such as frequency, number of partners, feelings about sex and
body image, or latex allergy
IV. Nursing Diagnoses Related to Reproductive Life Planning
Because reproductive life planning touches so many facets of life, nursing diagnoses
can differ greatly depending on the circumstances.
Examples might include:
• Health-seeking behaviors regarding contraception options related to desire to
prevent pregnancy
• Deficient knowledge related to use of diaphragm
• Spiritual distress related to partner’s preferences for contraception
• Decisional conflict regarding choice of birth control because of health concerns

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 • Decisional conflict related to unwanted pregnancy
• Powerlessness related to failure of chosen contraceptive
• Ineffective sexuality pattern related to fear of pregnancy
• Risk for ineffective health maintenance related to lack of knowledge about natural
family planning method

V. Interventions Related to Reproductive Life Planning

When establishing expected outcomes for care in this area, be certain that they
are realistic for the individual. Women’s decisions are influenced by many factors; a
nurse’s role is to educate about contraceptives and support a woman about her
contraceptive decision. If a woman has a history of poor compliance with medication, for
instance, it might not be realistic for her to plan to take an oral contraceptive every day.
Be certain to be sensitive to a couple’s religious, cultural, and moral beliefs before
suggesting possible methods. It is equally important to explore your own beliefs and
values. This not only helps develop self-awareness of how these beliefs affect nursing
care, but it allows you to become more sensitive to the beliefs of others. Some couples
cannot make realistic plans about contraception because they are uninformed or
misinformed about the options. When counselling, be certain to emphasize safer sex
practices as well as contraceptive ones.

VI. Evaluating Outcomes Related to Reproductive Life Planning

Evaluation is important in reproductive life planning, because anything that causes
clients to discontinue or misuse a particular method will leave them at risk of pregnancy.
Reassess early (within 1 to 3 weeks) after a couple begins a new method of contraception,
to prevent such an occurrence. Evaluate not only whether a chosen method is effective
but whether the woman and her partner are satisfied with the method.
Examples of expected outcomes include:
• Client voices correct technique for using chosen method

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 • Client voices confidence in chosen method by next visit
• Client expresses satisfaction with chosen method at follow-up visit
• Client consistently uses chosen method without pregnancy for 1 years’
time

References
Flagg, J. (2018). Maternal and child health nursing: Care of the childbearing and childbearing
family (8thed.). Philadelphia, PA: WoltersKluwer.

Credits and Quality Assurance

Prepared: Recommending Approval:

MELANIE C. TAPNIO, MAN, RN, LPT Denmark D. Gabriel, MSN, RN, LPT
Assistant Professor Assistant Professor & Chairperson, Nursing Program

Reviewed by:
Approved by:
JENNY ROSE LEYNES-IGNACIO, EdD, MAN, RN
Assistant Professor & OBE Facilitator PRECIOUS JEAN M. MARQUEZ, PhD, MSN, RN
OIC Dean
School of Nursing and Allied Medical Sciences

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