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POSTPARTUM CARE
Puerperium/Postpartum Period
- Refers to the six (6) weeks period after delivery of the placenta
- Time of maternal changes that are both
o Retrogressive (involution of uterus and vagina)
o Progressive (production of milk for lactation, restoration of normal menstrual cycle, and beginning parenting role)
*Involution- return of the reproductive organs to their pre-pregnant state (6 weeks)
Postpartum Care & Assessment (mnemonic: BUBBLE-HE)
BREASTS
UTERUS
BLADDER
BOWELS
LOCHIA
EPISIOTOMY
HOMANS SIGN
EMOTIONAL STATUS

A. IMMEDIATE NURSING CARE
1. Vital signs
Assess q 15 min x 4; then q 30 min x2; then q 4 hrs for the first 24 hrs (if stable) then q 8 hrs
BP should be WNL for patient
Pulse- 50-90 bpm
Temp- 98-100.4 degree F (36.6-38 degree C): normal for the 1
st
24 hrs due to DHN during labor
Resp- 16-24 bpm
o Increase in body temperature during the first 24 hours is not necessarily a sign of postpartum infection.
Any mother whose temperature reaches 38 degree C in any two consecutive 24 hrs period during
the first 10 postpartum days may suggest infection.
o Bradycardia (heart rate of 50-7- bpm) is common for (24-48 hrs) and persist 6-8 days postpartum.
Returns to non-pregnant rate by 3 months postpartum

2. Breast
Lacatation- formation of breast milk (BM); begins in a postpartal woman whether or not she plans to breast-feed.
o BM forms in response to decrease in estrogen and progesterone levels that follows delivery of the placenta
(which stimulates prolactin production)
Prolactin- hormone for production of breast milk
Oxytocin- hormone for excretion/ejection of milk
Colostrum is present at the time of delivery; BM is produced by the 3
rd
and 4
th
postpartum day; yellow sticky fluid;
more protein, less sugar, less fat than mature milk.
Engorgement_ the feeling of tension (heat or throbbing pain) in the breast as breast distention becomes marked
(fuller, larger, firmer); occurs on the 3
rd
-4
th
day
o Due to expanding veins and pressure of new breast milk contained with them
o There may be a slight elevation of body temperature during this time
o Congestion subsides in 1 or 2 days
In breast, prolactin stimulates alveolar cells to produce milk. Sucking of the newborn triggers a release of oxytocin
and contractility of the myoepithelial cells, which stimulate milk flow; this is known as the letdown reflex. The average
amount of milk produced in 24 hours increases with time:
o First week- 6-10 oz
o 1-4 weeks- 20 oz
o After 4 weeks- 30 oz
Mature milk
Foremilk-watery milk coming from full breast (low in fat, high in carbohydrates)
Hindmilk- creamy milk coming from a nearly empty breast
Amount of supply depends on how often the mother nurse or pumps ( the more the mother nurses, the more milk is
produced)
For those who choose not to breastfeed, lactation can be suppressed through:
o Use a well-fitting bra
o Avoid any type of nipple stimulation or heat to the breasts (such as warm/hot showers)
o May use ice packs or cold cabbages leaves to east breast discomfort until milk production ceases (it
generally takes 5-7 days)
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o Mild analgesics as prescribed

3. Uterus
After delivery of the newborn, involution of the uterus must occur; 2 main processes:
o Area where placenta is implanted is sealed off to prevent bleeding
o Uterus reduced to its pregestational size (grapefruit)
Firm, midline, reduced in its size
Soft & boggy, displaced (hemorrhage risk)
Few minutes after birth, fundus halfway between umbilicus and symphysis pubis
One hour later, rise to the level of umbilicus and it remains for the next 24 hours
First postpartal day (day 1)- one fingerbreadth below umbilicus
Day 2- 2 finngerbreadth below and so forth until day 10, it can no longer be palpated because it is already behind
symphysis pubis
At 10-14 postpartum days, the uterus cannot be palpated abdominally

o Subinvoluted Uterus
Uterus larger than normal and vaginal bleeding with clots. Since blood clots are good media for
bacteria; it is therefore as sign of puerperal sepsis
To encourage return of the uterus to its usual anteflexed position, PRONE and KNEE CHEST
positions are advised.
Fundal massage, ice pack over hypogastrium, IV oxytocin, nipple stimulation
(breastfeeding)

o Afterpains/afterbirth pains
Strong uterine contractions felt more particularly by multis, those who delivered larger babies or
twins and those who breastfeed. It is normal and rarely last for more than 3 days.
Menstruation
o If not breastfeeding- return in 6-8 weeks after birth
o If breastfeeding, in 3-4 months (lactational amenorrhea) or entire lactation period
Though does not guarantee that woman will not conceive because she may ovulate well before
menstruation returns

4. Bladder Elimination
Marked diuresis to eliminate excess fluid (as much as 2000-3000ml accumulates in the body during pregnancy)
o Urine output from 1500ml/day to as much as 3000ml/day 2
nd
-5
th
after birth
May complain of frequent urination in small amounts: explain that this is due to urinary retention with overflow
May have difficulty voiding because of abdominal pressure or trauma to the trigone of the bladder
Assess hypogastric area for overdistention of bladder:
o Palpation: hard or firm just above symphysis pubis
o Percussion: resonant
Voiding may be initiated by:
o Pouring warm and cool water alternately over the vulva
o Encourage the client to go to the comfort room
o Let her listen to the sound of running water
o If these measures fail, catheterization, done gently and aseptically, is the last resort on doctors order. (if
there is resistance to the catheter when it reaches the internal sphincter, ask patient to breathe through the
mouth while rotating the catheter before moving it inward again.)

5. Bowel Elimination
Full diet (unless GA)
Constipation: delayed bowel evacuation postpartally may be due to:
o Decrease muscle tone
o Lack of food and enema during labor
o Dehydration
o Fear of pain from perineal tenderness due to episiotomy, lacerations or hemorrhoids

6. Lochial discharge ( during the 1
st
3 weeks after delivery)- uterine discharge consisting of blood, deciduas, WBC, mucus and
some bacteria
It should approximate menstrual flow. It increases with activity and decreases with breastfeeding.
Types of lochia:
o Lochia rubra
Dark red in color within first 2-3 days
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Contains epithelial cells, erythrocytes, leukocytes, and deciduas and has a characteristic human
odor.
o Lochia serosa
Pinkish to brownish discharge
It is a serosanguineous discharge containing erythrocytes, leukocytes, cervical mucus and
microorganism
It has a strong odor
o Lochia alba
Almost colorless to creamy yellowish discharge occurring from 10 days to 3 weeks after delivery.
It contains leukocytes, deciduas, epithelial cells, fat, cervical mucus, cholesterol crystals and
bacteria
Odorless

7. Episiotomy/Perineum
Appears edematous and bruised after delivery caused by episiotomy (if performed) and some degree of laceration
Assess s/s of infection and inflammation:
o REEDA (redness, edema, ecchymosis, discharge, approximation of sutures)
Assess for lacerations:

o 1
st
degree- lacerations extend through the skin and superficial layers of the perineum

With mild burning or stinging with urination
First-degrees tears aren't severely painful and heal on their own within a few weeks.
To ease any discomfort during urination, pour warm water over your vulva as you're passing urine.

o 2
nd
degree- vaginal tears involve vaginal tissue and the perineal muscles the muscles between the vagina
and anus that help support the uterus, bladder and rectum.

Management:
o Second-degree tears typically require stitches and heal within a few weeks.
o Sit on a pillow or padded ring.
o Pour warm water over the vulva during urination, and rinse with a squeeze bottle afterward.
o Press a clean pad firmly against the wound when bearing down for a bowel movement.
o Cool the wound with an ice pack, or place a chilled witch hazel pad between a sanitary napkin
and the wound.
o Take pain relievers or stool softeners as recommended

o 3
rd
degree- vaginal tears involve the vaginal tissues, perineal muscles and the muscle that surrounds the
anus (anal sphincter).
These tears sometimes require repair in an operating room rather than the delivery room and might
take months to heal. Complications such as fecal incontinence and painful intercourse are possible.
To ease discomfort in the meantime:
Sit on a pillow or padded ring.
Pour warm water over your vulva as you're passing urine, and rinse yourself with a squeeze bottle
afterward. Press a clean pad firmly against the wound when you bear down for a bowel movement.
Cool the wound with an ice pack, or place a chilled witch hazel pad between a sanitary napkin and
the wound.
Take pain relievers or stool softeners as recommended by your health care provider.
o 4
th
degree- They involve the perineal muscles and anal sphincter as well as the tissue lining the rectum.
Fourth-degree vaginal tears are the most severe.
Require repair in an operating room rather than the delivery room
Might take months to heal.
Complications
o fecal incontinence
o painful intercourse.
Mangement:
o health care provider will evaluate recovery during postpartum checkup.
o (+) complications from a severe vaginal tear, might be referred to a urogynecologist, colorectal
surgeon or other specialist.
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Prevention of lacerations:
o Massage
o Warm compress
o Manual support (Ritgens maneuver)
o Birthing in a lateral position
To relieve pain:
o Sims position- minimizes strain on the suture line
o Perineal heat lamp or warm sitz baths twice a day- vasodilation increases blood supply and therefore,
promotes healing
o Apply ice or cold therapy to the episiotomy or laceration immediately after delivery to decrease edema and
provide anesthesia; thereafter apply moist or dry heat therapy to promote comfort and healing
o Application of topical analgesics or administration of mild oral analgesics as ordered.

8. Homans sign/Legs
Relative inactivity/prolonged time in stirrups leads to stasis of blood and promotes clotting of blood in the lower
extremities
Assess s/s of DVT
o Redness, warmth, tenderness, Homans sign (pain upon dorsiflexion of foot)
o It is also important to note that a DVT may be present despite a negative Homans sign
Early ambulation
Avoid crossing of legs, constrictive clothings/undergarments


9. Emotions: Psychological Adaptation (Reva Rubin): ESSENTIAL CONCEPTS
The postpartum period represents a time to emotional stress for the new mother, made even more difficult by the
tremendous physiologic changes that occur
Factors influencing successful transition to parenthood during the postpartum period include:
o Response and support of family and friends
o Relationship of the birthing experience to expectations and aspirations
o Previous childbearing and childrearing experiences
o Cultural influences
Reva Rubin (1997) describes this period as occurring in three stages: taking-in, taking-hold and letting-go
o TAKING-IN PERIOD
Occurring 1-2 days after delivery, the new mother typically is passive and dependent
Energies are focused on bodily concerns
She may review her labor and delivery frequently
Uninterrupted sleep is important if the mother is to avoid the effects of sleep deprivation, which
include fatigue, irritability, and interference with normal restorative process
Additional nourishment may be needed because the mothers appetite unusually increased; poor
appetite may be a clue that the restorative process is not progressing normally
Encourage her to talk about the birth will her integrate it into her life experiences

o TAKING-HOLD PERIOD
2-4 days after delivery
Mother becomes concerned with her ability to parent successfully and accepts increasing
responsibilities for her newborn
Woman begins to initiate action; she prefer to get her own wash cloth and make her own decisions
Mother focuses on regaining control over her bodily functions: bowel and bladder function, strength
and endurance
The mother strives to master newborn care skills (holding, breastfeeding, or bottlefeeding, bathing
and diapering)
She may be sensitive to feelings of inadequacy
The nurse should take this into account when providing instructions and emotional
support,
Provide praises

o LETTING-GO PERIOD
Redefines her new role
Generally occurs after the new mother returns home. It involves a time of family reorganization
Mother assumes responsibility for newborn care; she must adapt to demands of the newborns
dependency and to her decreased autonomy, independence and social interaction
She gives up the fantasized image of her child and accepts the real one.
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ATTACHMENT
o Refers to the emotional connection between a patient and her infant
Behaviors indicating a positive attachment include:
Touching
Holding
Kissing
Cuddling
Talking and singing
Choosing the en face position
Expressing pride in the infant
Mal-attachment behaviors vary, but can include:
Refusing to look at the infant
Refusing to touch or hold the infant
Refusing to name the infant
Negative comments about the infant
Refusing to respond or responding negatively to infant cues ( crying, smiling)

POSTPARTUM BLUES
baby blues; normal part of postpartum experience but only for a few days
Tearfulness, irritability, sometimes insomnia
Causes: hormonal fluctuations, physical exhaustion, maternal role adjustment
o Reassure that this is normal
o Anticipatory guidance and individualized support from health care personnel are important to help the parents understand
o Keeping lines of communication open
o Allow her to make as many decision as possible can help give her sense of control over her life
o Allow her to verbalize her feelings and concerns
POSTPARTUM DEPRESSION
A serious & debilitating depression, occurring within first 9 months after delivery, often within the initial weeks or months
Sadness, crying, insomnia, decreased appetite, withdrawal and sometimes suicidal ideation or the desire to harm the infant
Somatic symptoms: headaches, diarrhea, constipation, severe anxiety, feeling as though they are jumping out of their skin and/or
just not feeling like themselves
Management:
o Assessment tools:
Edinburg Postnatal Depression Scale (EPDS)
Postpartum Depression Screening Scale (PDSS)
o Refer to doctor; counseling and medication
o Help patient and family to understand this condition and assist to explore spiritual aspect of care
Additional physiologic adaptations after delivery:
1. Cardiovascular system
30-50% increase in total cardiac volume during pregnancy will be reabsorbed into the general circulation within 5-10
minutes after placental delivery
Blood loss: vaginal birth- 300-500 ml; cesarean birth- 500-1000ml
Blood volume decrease to non-pregnant levels by fourth week after delivery
Hematocrit rises by the 3
rd
-7
th
postpartum day
WBC increases to 20000-30000/mm3
o Cannot be used as an indicator or signs of postpartum infection
o Part of bodys defense system against infection
o Aid to healing
Extensive activation of the clotting factors which encourages thromboembolization:
o Ambulation is done early 4-8hours after normal vaginal delivery
When ambulating the newly-delivered patient for the first time, the nurse should hold on to the patients
arm.
o Massage is contraindicated.
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All blood values are back to prenatal levels by the 3
rd
-4
th
week postpartum

2. Reproductive system (Vagina)
Smooth and swollen with poor tone after delivery
Rugae reappears by 3-4 postpartum weeks
Diameter is greater than normal. Hymen is permanently torn.
The estrogen index returns in 6-10 weeks.
Vaginal dryness and painful intercourse (dyspareunia) may be noted during the postpartum period due to decreased
estrogen levels.

3. Integumentary system
Mask of pregnancy (chloasma) usually disappears, while stretch marks (striae gravidarum) and linea negra fade but
generally do not disappear

4. Endocrine system
Estrogen and progesterone level decreases as soon as the placenta is no longer present
HPL and HCG are almost negligible by 24 hours
FSH remains low for about 12 days and begins to rise as new menstrual cycle is initiated. Menstruation return in
approximately 6-8 weeks; ovulation cam return within 4 weeks.

5. Musculoskeletal system
Relaxin is the hormone responsible for the relaxation of the pelvic ligaments and joints during pregnancy. After delivery,
relaxin level subsides and the pelvic ligaments and joints return to their pre pregnant state. However, the joints of the feet
remain altered and many patients notice a permanent increase in shoe size.
Abdominal wall is weakened and the muscle tone of the abdomen is diminished after pregnancy. Some patients have a
separation between the abdominal wall muscles, called diastasis recti. This separation can often be corrected with certain
abdominal exercises (sit ups) performed during the postpartum period.

6. Urinary changes
Extensive diuresis begins to take place almost immediately after birth to rid the body of fluid
Increases the daily output a postpartal woman from a 1500- 3000 ml/day during the 2
nd
-5
th
day after birth
Contain more nitrogen than normal (due to breakdown of protein in a portion of uterine muscle)
Urinary retention as a result of decreased bladder tone and emptying can lead to urinary tract infections

PATIENT TEACHING: Self-care guidelines to the mother
Instruct the client on sitting properly to relieve pain (squeeze the buttocks together and contract pelvic floor muscles
before sitting)
Instruct to wear perineal pads loosely and to lie in sims position
Demonstrate how to clean the perineum after each voiding and defecation (wiping form front to back), washing the hands
and applying a perineal pad from front to back
Teach the importance of adequate fluid intake, exercise, proper diet and a regular defecation time
Instruct to avoid garters or constricting clothing that can impair circulation
Encourage client to shower as soon as she can ambulate and to take tub baths if desired after two weeks. Recommended
daily shower to promote comfort and a sense of well-being/
Provide adequate dietary fiber and fluids to promote bowel movements; if necessary administer stool softeners, laxatives,
suppositories or enema
Demonstrate newborn care and safery measures
Recommended exercise:
o Kegels and abdominal breathing on postpartum day one
o Chin-to-chest on postpartum day 2 to tighten and firm up abdominal muscles
o Knee-to-abdomen when perineum has healed, to strengthen abdominal and gluteal muscles
Sexual activity
o Resume by the 3
rd
-4
th
week postpartum
o Bleeding has stopped
o Episiorrhaphy has healed ( usually 1 week after delivery)
o Lochia has turned to alba.
o Decreased physiologic reactions to sexual stimulation are expected for the 1
st
3 months postpartum because of
hormonal changes and emotional factors.
o She should be protected against subsequent pregnancy by observing a method of contraception, except the
PILLS.
Postpartum checkup- 4-6 weeks after birth. Woman should return to her physician for an examination (visit is important
to ensure that involution is complete and reproductive planning is desired and may be discussed further.)

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BREASTFEEDING
Feed newborn per demand (breastfeeding or bottle-feeding) or at least every two hours and intervals should not exceed 5
hours
If breastfeeding
o From birth to at least 2 years and should continue as long as the mother and child wish
o Exclusive breastfeeding until 6 months of age (when solid are gradually introduced)
o Correct latching on ( to prevent nipple sores and allow baby to get enough milk)
Large part of the breast and areola need to enter the babys mouth
Nipple should be at the back of the babys throat with the babys tongue lying flat in its mouth
o 10-20 minutes each breast
o Cradling position
Storage of expressed breast milk
o Hard sided containers with airtight seals

Place of storage Temperature Maximum storage time
In a room 25 degree C 6-8 hours
Insulated thermal bag with ice packs Up to 24 hours
In a refrigerator 4 degree C Up to 5 days
Freezer compartment inside a refrigerator -15 degree C 2 weeks
A combined refrigerator and freezer with separate
doors
-18 degree C 3-6 months
Chest or upright manual defrost deep freezer -20 degree C 6-12 months
Oral contraceptives are contraindicated in lactating mothers because they contain estrogen and progesterone derivatives,
thereby decreasing milk supply

BREAST CARE:
Wash breast daily at bath or shower time
Soap or alcohol should never be used on the breast as they tend to dry and crack the nipples and cause sore nipples
Wash hands before and after every feeding
Insert clean OS squares or piece of cloth in the brassiere to absorb moisture when there is considerable breast discharges.
Engorgement management:
o Nurse often (not going more than 3 hours without nursing and not skipping night feedings)
o Well-fitted bra
o Warm compress/shower
o Chilled cabbage leaves (placed on breast with nipple exposed)
o Acetaminophen or ibuprofen for pain
o Pumping or manually expressing breast milk

Reproductive Life Planning
Includes all decisions an individual or couple make about having children:
o If and when to have children
o How many children to have
o How children are spaced
o Conception, fertility and counseling
A responsible person is a man or woman who is able and willing to give the proper response to the demands of a given
situation.
With specific reference to marriage and family life, the responsible spouse is one who gives the proper responses to
the needs of his/ her spouse, as well as his own, and of their life together. Similarly, responsible parents give proper
responses to the needs of their children.
Responsible Parenthood
Although some people object to the idea, we tend to equate family planning with responsible parenthood.
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Family planning refers more specifically to the voluntary and positive action of a couple to plan and decide the number
of children they want to have and when to have them. is the conscious process by which a couple decides on the
number and spacing of children and the timing of births.
The concept of family planning includes these elements:
o Responsibility of parents to themselves and to each other
o Responsibility to their present and future children
o Responsibility to their community and country
o Responsible Parenthood
Purposes of Family Planning
o improvement of health
o promotion of human right to determine reproductive performance
o relation of demographic change to economic development
The ultimate goal of family planning is directed towards:
o Birth spacing, to allow the mothers time to rest and regain their health before the next pregnancy
o Birth limitation, when the desired number of children is reached
o Helping those who do not have children to have children
The overall goal of nursing intervention in family planning is to improve general maternal, neonatal and family health.
Preconception Planning an ideal that is not always realized offers couple an opportunity to enhance the probability of
having a healthy newborn. It involves examining the health history and physical health of both partners and providing
appropriate instruction relative to physical, psychological an financial preparation for pregnancy and childbirth.

Contraception is the voluntary prevention of pregnancy. The decision to practice contraception has individual and social
implications. Any device used to prevent fertilization of an egg

Factors to consider when choosing the appropriate contraceptive method:
Religious orientation
Social and cultural values
Medical contraindications
Psychological contraindications
Individual sexual expression
Cost
Availability of bathroom facilities and privacy
Partners support and willingness to cooperate
Personal lifestyle

Abstinence the most effective way to protect against conception. This has 0% failure rate. Also, this is the most effective way to prevent
STDs.

I. Natural Family Planning Method this involve no chemical or foreign material being introduced into the body. The effectiveness of
these methods varies greatly, depending mainly on the couples ability to retain from having sex on fertile days. Failure rates usually range
from 10% to 20%, although theoretical failure rate is as low as 1% or 2%. If pregnancy should occur, the continued use of these methods
poses no risk to the fetus.
A. Calendar (Rhythm) Method This requires a couple to abstain from coitus on the days of a menstrual cycle when the woman
is most likely to conceive (3 or 4 days before until 3 or 4 days after ovulation).
B. Basal Body Temperature Method (BBT) The basis of this method is that just before the day of ovulation, a womans BBT
falls about half a degree. At the time of ovulation, her BBT rises a full degree because of the influence of progesterone. This higher level is
then maintained for the rest of the menstrual cycle.
C. Cervical Mucus (Billings) Method Before ovulation each month, the cervical mucus is thick and does not stretch when pulled
between the thumb and finger (known as spinnbarkeit). Just before ovulation, mucus secretion increases. With ovulation (the peak day),
cervical mucus becomes copious, thin, watery and transparent. It feels slippery and stretches at least 1 inch before the strand beaks. In
addition, breast tenderness and an anterior tilt to the cervix occur. All the days the mucus is copious and the 3 days after the peak day are
considered to be fertile days, or days the woman should abstain from sex to avoid conception.
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D. Symptothermal Method The symptothermal method of birth control combines the cervical mucus and BBT methods. The
woman takes her temperature daily, watching for the rise is temperature that marks ovulation. She also analyzes her cervical mucus daily.
The couple must abstain from intercourse until 3 days after the rise in temperature or the fourth day after the peak of mucus change
because these are the womans fertile days. The symptothermal method is more effective than either the BBT or cervical mucus method
alone.
E. Ovulation Awareness This is another method to predict ovulation with the use of over-the-counter ovulation detection kit.
These kits detect the midcycle surge of luteinizing hormone that can be detected in urine 12 to 24 hours before ovulation. Such kits are
about 98% to 100% accurate in predicting ovulation. Although fairly expensive, using such kit in place of cervical mucus testing makes this
form of natural family planning more attractive to many women.
F. Lactation Amenorrhea Method (LAM) As long as a woman is breast-feeding an infant, there is some natural suppression of
ovulation. However, the use of lactation as a birth control method is not dependable. Because women may ovulate but not menstruate while
breastfeeding, the woman may still be fertile even if she has not had a period since childbirth. After 6 months of breast feeding, the woman
should be advised to choose another method of contraception.
G. Coitus Interruptus It is one of the oldest known methods ofcontraception. The couple proceeds with coitus until the moment
of ejaculation. The man withdraws and spermatozoa are emitted outside the vagina. Unfortunately, ejaculation may occur before withdrawal
is complete and, despite the care used, some spermatozoa may be deposited in the vagina. Because there maybe a few spermatozoa in
pre-ejaculation fluid, even though withdrawal seems controlled, fertilization may occur. For these reason, coitus interruptus offers little
protection against conception.

II. Barrier Methods are forms of birth control that works by the placement of a chemical or another barrier between the cervix and
advancing sperm so sperm cannot enter the uterus or fallopian tubes and fertilize the ovum.
A. Spermicides Spermicidal agents cause the death of spermatozoa before they can enter the cervix. Vaginal jelly, cream,
suppository, or foam preparations interfere with sperm viability and prevent sperm from entering the cervix. Nonoxynol-9, the active
chemical ingredient, destroys the sperm cell membrane. Pregnancy rates among typical users range from 5% to 50%. Advantages are that
they are available without prescription, are useful when other methods are inappropriate or contraindicated, and have few or no side
effects. They also may provide moderate protection (up to 25%) against some STDs, including gonorrhea and Chlamydia. Disadvantages
are that they have a lower effectiveness than other methods, may irritate tissues (most products contain alum), and are esthetically
unpleasant. One dose of most spermicides is effective for 1 hour.If a longer time has passed, a new application of spermicide is required.
B. Female condom (vaginal pouch) This is a long polyurethane sheath that inserts manually into the vagina with a flexible
internal ring forming the cervical barrier and a wide outer ring extending to cover the perineum; it is lubricated with spermicide (nonoxynol-
9). It can be inserted up to 8 hours before intercourse and is available over counter (OTC). It is about 80% effective. Advantages are that it
protects against STDs and conception, allows the woman to control protection, is inexpensive for single use, and is disposable.
Disadvantages are that it is esthetically unappealing, requires dexterity, is expensive for frequent use, may cause sensitivity to sheath
material, and decreases spontaneity.
C. Male condom This is a rubber sheath that fits over the erect penis and prevents sperm from entering the vagina. The condom
is about 86% effective. Advantages are that it helps prevent conception and transmission of STDs (thereby preserving fertility), is available
OTC, and has no side effects. In addition, the condom helps men maintain erections longer, prevents premature ejaculation, prevents sperm
allergies, and is easily and discreetly carried by men and women. Disadvantages are that it may decrease spontaneity and sensation, and
should be used with vaginal jelly if the condom or vagina is dry. Male condoms cannot be used in cases of latex allergy in the man or the
woman. There are natural (animal skin) condoms available, but they are expensive and do not protect against most STDs.
D. Cervical cap This is a small rubber or plastic dome that fits snugly over the cervix. Effectiveness depends on parity. In parous
women, effectiveness is about 60%; in nulliparous women, effectiveness is about 80%. The advantage is that it provides continuous
protection for 48 hours, no matter how many times intercourse occurs. Additional spermicide is not necessary for repeated acts of
intercourse. Disadvantages are that it may dislodge, must be filled with spermicide, must be fitted individually by a health care provider,
and may not be used if the woman has anatomic abnormalities or an allergy to plastic, rubber, or spermicide. Wear for longer than 48 hours
is not recommended because of the risk of toxic shock syndrome. Side effects include trauma to the cervix or vagina, pelvic infection,
cervicitis, and abnormal Pap test results. Odor problems may occur with prolonged use.
E. Diaphragm This is a flexible ring covered with a dome-shaped rubber cap that inserts into the vagina and covers the
cervix. The posterior rim rests on the posterior fornix and the anterior rims fits snugly behind the pubic bone. It is used with spermicide in
the dome and around the rim, is applied no more than 2 hours before intercourse, and is left in place for 6 hours after coitus, but no longer
than 12 ( and never more than 24). Additional spermicide must be applied for repeated intercourse. Effectiveness is about 80% with typical
use. Advantages are that it is reusable and inexpensive with use over several years. Disadvantages are that it requires dexterity to insert, it
must be fitted individually, it must be refitted after childbirth or after a weight loss of 15 lb or more.Wear for longer than 24 hours is not
recommended because of the risk of toxic shock syndrome. Side effects include toxic shock syndrome, cystitis, cramps or rectal pressure,
and allergy to spermicide or rubber.
F. Intrauterine device (IUD) This is a flexible device inserted into the uterine cavity. It alters tubal and uterine transport of
sperm so that fertilization does not occur. Estimates of effectiveness vary between 93% (typical effectiveness) and 97% (maximal
effectiveness). Advantages are that it is inexpensive for long-term use, is reversible, has no systemic side effects, may be used in lactating
women, and requires no attention other than checking that it is in place (by feeling for the attached string in the vaginal canal). An ideal
candidate for an IUD is a parous woman in a mutually monogamous relationship. Disadvantages are that there are possibly serious side
effects. The device is available only through a health care provider and cannot be used if the woman has an active or chronic pelvic
infection, postpartum infection, endometrial hyperplasia or carcinoma, or uterine abnormalities. It should not be used by women who have
an increased risk of STDs and women with multiple sexual partners. Side effects include dysmenorrheal, increased menstrual flow, spotting
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between periods, uterine infection or perforation, and pregnancy. Danger signs to report to the health care provider include late or missed
menstrual period, severe abdominal pain, fever and chills, foul vaginal discharge, and spotting, bleeding, or heavy menstrual
periods. Spontaneous expulsions occur in 2% to 10% of users in the first year.

III. Pharmacologic methods are reversible and contraceptive steroids are now formulated in pills, patches, intravaginal rings,
subdermal implants and injections.
A. Oral contraceptives Combined estrogen and progesterone preparation in tablet form inhibits the release of FSH, LH, and an
ovum. The tablets are taken daily and are available in numerous hormone combinations (and as a progesterone-only preparation. Biphasic
and triphasic contraceptives closely mirror normal hormonal fluctuations of the menstrual cycle. They are about 97% effective. Advantages
are that they are among the most reliable contraceptive methods and are convenient to use. In addition, they are protective against ovarian
and endometrial cancer, benign breast disease, ovarian cysts, ectopic pregnancy, pelvic inflammatory disease (PID), and anemia. Oral
contraceptives also tend to decrease menstrual cramps and pain. Disadvantages are that they should not be used by women who smoke;
women with a history of thrombophlebitis, circulatory disease, varicosities, diabetes, estrogen-dependent carcinomas, and liver disease; or
by women who are older than 35 years of age. Reassessment and reevaluation are essential every 6 months. No protection is conferred
against STDs. Side effects include breakthrough bleeding, nausea, vomiting, susceptibility to vaginal infections, thrombus formation, edema,
weight gain, irritability, and missed periods. Danger signs indicating complications include abdominal pain, chest pain or shortness of
breath, headaches, blurred or loss of vision, or leg pain in the calf or thigh.
B. Minipills These contraceptive pills contain progestin but no estrogen. A pill must be taken each day and preferably at the
same time each day to achieve maximal effectiveness. The use of minipills results in a thin atrophic endometrium and a thick cervical
mucous, which inhibits permeability of sperm. Minipills do not suppress ovulation consistently; 40% of women will ovulate normally. Typical
user failure rate is 3%. Advantages are that it may be used immediately postpartum if the client is not breast feeding and 6 weeks
postpartum if she exclusively breastfeeding; it is highly effective when combined with breast feeding; it has no estrogen side effects; there
is an immediate return to fertility when discontinued; and there is a decreased risk of PID and iron-deficiency anemia. Disadvantages
include irregular bleeding, increased risk of functional ovarian cysts, increased risk of ectopic pregnancy (if pregnancy does occur), and it
must be taken at the same time each day. There is no data to suggest that minipills increase the risk of cardiovascular disease or
malignancy.
C. Subdermal implants Six, soft, Silastic rods filled with synthetic progesterone are implanted into the womans arm. The
progesterone leaks into the bloodstream, inhibiting ovulation, making cervical mucus hostile to sperm and inhibiting implantation in the
endometrium. The implants are known as Norplant. Estimates of effectiveness vary from 0.04% failure to 99% effective within 24 hours
(dropping to 96% effective after 5 years). Advantages are that they are long acting (effective for up to 5 years), not coitus dependent,
reversible, inexpensive over the life of the drug, and require little attention other than health care visits for problems or scheduled health
maintenance. Production of thick cervical mucous confers a protective effect against PID. Disadvantages are that they require surgical
insertion through a half-inch incision on the inside surface of the nondominant arm.They may be difficult to remove and should not be used
by a woman who has active thrombophlebitis, unexplained bleeding, active liver disease or tumor, or known or suspected breast cancer.
Side effects include tenderness and bruising at the insertion site, irregular bleeding, headaches, acne, weight change, and breast
tenderness. Signs of reportable complications include infection, bleeding, or pain at the insertion site; subdermal rod breaking through the
skin; heavy vaginal bleeding; severe abdominal pain; and sudden menstrual irregularity after a regular cycle has been established. Any
pregnancy that does occur is likely to be ectopic.
D. Subcutaneous injections Medroxyprogesterone (DMPA or Depo-Provera) is an intramuscular injection given every 3 months
that works like subdermal implants. Effectiveness is similar to subdermal implants. Advantages are that it is highly effective and requires
little attention except for returning to the health care provider for injection every 3 months. Also, it may be used by breast-feeding women.
Disadvantages are similar to those for subdermal implants. In addition, the risk for breast cancer and osteoporosis may be increased, and
there may be a delayed return to fertility (up to 18 months) and a decrease in bone density (reversible). Side effects are similar to those for
subdermal implants, primarily spotting, headache, and weight gain. DMPA is likely cause amenorrhea, particularly after the first year.

IV. Sterilization is considered a permanent method of contraception. In certain cases, sterilization can be reversed, but this is not
guaranteed. For this reason, sterilization is meant for men and women who do not intend to have children in the future.
A. Vasectomy Surgical ligation of the vas deferens terminates sperm passage through the vas completely after residual sperm
clear the male reproductive tract. It is almost 100% effective (nurses should point out the finality of the procedure). Advantages are that it
is highly effective and usually permanent. Disadvantages are that it requires surgery and may be irreversible. Reversal success rates vary;
anatomic success is 40% to 90%; clinical success is 18% to 60%. There is no protection against STDs.
B. Tubal ligation The fallopian tubes are surgically ligated or cauterized either through minilaparotomy or laparoscopy. It is almost
100% effective (nurses should stress the finality of the procedure). Advantages are that it is highly effective and usually permanent. May be
performed immediately postpartum. Disadvantages are that it is an invasive procedure and may be irreversible. Tubal reconstruction has a
50% to 70% successful reversal rate; however, there is a high risk of ectopic pregnancy after reversal. In addition, no protection is
conferred against STDs.







11

CONTRACEPTIVE FAILURE RATES:
Type of
Contraceptive
Failure
Rate (%)
Advantages Disadvantages
None 85 No motivation necessary Highly unreliable
Spermicides 21
No major health risk; no
prescription necessary
Unaesthetic to some; must be properly inserted
Periodic Abstinence 20
No costs; acceptable to
Roman Catholic Church
Requires high motivation and periods of abstinence
Withdrawal 18 No cost Requires Motivation
Cervical Cap 18
Can use for several days if
desired
May be difficult to insert; can irritate cervix
Diaphragm 18
No major health risks; easy to
use
Insertion may be difficult
Female Condom 15 Protection against STDs Insertion may be difficult
Male Condom 12
Protects against STDs; male
responsibility; no prescription
necessary
Requires interruption of sexual activity
IUD 3
No memory or motivation
needed
Cramping, bleeding; expulsion possible; possible risk of PID
Pill 3 Coitus independent Continual cost; possible side effects
Injectable
progesterone
0.3
Coitus independent;
dependable for 4 to 12 weeks
Continual cost; continual injections
Implanted
progesterone
0.04
Coitus independent;
dependable for 5 years
Initial cost; appearance on arm
Female sterilization 0.4 Permanent and highly reliable Initial cost; irreversible
Male sterilization 0.1 Permanent and highly reliable Initial cost; irreversible