Female Family

Planning
d r. A n o m S u a r d i k a
SpOG(K)
L/O/G/O

Family Planning Program

Objectives
Best Family 2015
Prosperous

Responsible

Healthy

Have Faith

Advanced

Ideal number of child

Independent

insightful
Harmonic

CONTRACEPTION

CONTRACEPTION
Contraception use is an effort to prevent pregnancy
Trustworthy
No significant adverse effect

IDEAL

The potency can be adjusted

Minimal disturbance when coitus

Forced Motivation unnecessary

Easy to do

IDEAL

Unexpensive, easy to accessed

Couple can tolerate the effect

Contraception Use
Delay pregnancy
Pil,
Mini IUD,
Simple
approach

Characteristic
High reversibility (no
child)
Relatively high
effectivity, itd
important because
failed contraceptive
means high risk
pregnancy

Making pregnancy rare

IUD,
Pill,
Inj,
Simple Approach,
Implant,
Permanent contraception

Stop fertility
Tubektomi / Vasektomi,
Implant,
IUD,
Inj,
Pill,
Simple approach

Characteristic

Characteristic

Enough Reversibility
Effective enough,
acceptor have option
to have more child .
can be use 3-4 years
Not interfere with
breastfeed

igh effectivity, because

failed contraceptive
means high risk
pregnancy to mother
& child
Low Reversibility
Long term effect
do not increase
complication or
existing disorder

What to consider before using a contraception

No

Consider

Pil

Injection

To delay pregnancy

Keep distance
between pregnancy
Stop pregnancy
probability
Protect from STD

5
6

7
8

9
10

IUD

Implant

Kondom

Spermisid

+
+
+

As substitute

Decrease sexual
quality
Need medical
assistance
If there any
complaint could
immediately
discontinued its use
High Effectivty

Low Cost for long

term effect

+
+

Natural

Tubectomy/vasec
tomy

+
+

NATURAL METHOD
Natural Method is a means of contraception that
used since long time ago and usually called
Traditional Contraception.
In 3 decade of Family planning in Indonesia this
Natural Contraception not recommended
because have low effectivity and 47% failure rate
Include in Natural way of contraception : Periodic
Abstineence and coitus interuptus

Periodic Abstinence
Prevent sexual intercourse when women
in fertile state
How to know fertile period of women
Measure of Basal temperature
Exist of cervix mucus discharge (Billings
method)
Calendar calculation (Ogino Knaus)

Periodic Abstinence
Advantages:
No need third party assistance.
Can be used to contraceptive and also planning for pregnancy .
Safe and inexpensive .
No need medical examination.
Alternatif method if couple can adapt to other contraception or refusal of contraceptive use
because beliefs
Doesnt affect breastfeeding and no hormonal adverse effect
Increase husband participation in family planning and as a way to intense communication of
marriage relationship
Its better than not using any contraception.
Disadvantages
Low Effectivity.
Need Commitment and discipline, because abstinence in long periode of time.
Can restrict spontaneous sexual activity and psychological stress in marriage.
Not appropriate for a wife with irregular menstrual cycles.
It took 6 to 12 menstrual cycle to determine the actual fertile period
Does not protect against sexually transmitted diseases including HIV/AIDS

Coitus Interuptus method

Coitus Interuptus, by immediately pull the
penis out of the vagina before ejaculation
This method need greater restraint and
control for man.The number of failure 1623 pregnancy every 100 woman per year

Coitus Interuptus method

Advantages:
Prevent pregnancy
Can be done everytime, without concern to fertile periode or not.
No cost.
doesnt need contraceptive tools.
Doesnt need medical examination
easily acceptable, secretive method between husband and wife, no advice needed.
Disadvantages:
Need strong self-control
Its possible there is a little fluid contains sperm shed and entered into the vagina so that
pregnancy can occur, even though it's been done before ejaculation
Reduce sexual pleasure and if one partner disagrees with it could cause tension in marriage.
Does not protect against sexually transmitted diseases including HIV/AIDS
Contraindications for men with premature ejaculation

HORMONAL CONTRACEPTION
The principle of hormonal contraceptive is by replaced
normal production of the ovarian estrogen and
progesterone with hormonal contraceptive, then
ovulation can be prevented. Thickening cervical mucus
and made sperm cannot penetrate it. Also, by make
endometrium not receptive for ovum fertilization
Hormonal contraception, include:
Pill
Injection
Implant
IUD with progestin

Birth Control Pill

Combined estrogen and progestin hormones or
tablet containing progestin hormone only
Its effectiveness is very high. Theoretically, only
0,35 % failure rate but actually can reach 6 %
Birth-control pills classified into two types :
Combined OC pill, contain estrogen dan
progestin.
Mini pil, contain progestin only

Deifference of Combined OC with

Mini Pill
Combine OC pill :

Reduce Breast Milk volume

Control menstruation cycle more regular
3 option of estrogen dose:
High dose, with estrogen level > 50
mcg, its use is not recommended
because it may cause serious
complications. Ex: Ovostat birth control
pills
Middle dose, dengan with estrogen
level > 50 mcg. Acceptors generally
choose this birth-control pills, ex:
Marvelon, Microgynon 30, Nordette,
Femodene.
Low dose, with estrogen level < 30
mcg. This type is less favored because
it may cause spotting.

Mini Pill :

Do not reduce the volume of Brest milk,

making it suitable for breastfeeding women.
an be used for women who have
experienced side effects from Combined OC
Not suitable for a woman with history of
ectopic pregnancy, can increase risk
Take every day in exact same time without
any intervals free ( including during
menstruation ).
Most effective at 21 hours after. So, if
intercourse done at night, pills taken in the
morning
Sometimes followed by spotting or bleeding
resembling menstruation or could be no
menses at all. This can be a problem for
women that worry become pregnant
otherwise have menstruation.

Birth Control Pill (OC pill)

How to use
The pills are taken daily one pill at the same time continuously until it runs
out completely. There are several ways to start taking birth control pills, :
Begin on the first day of menstruation.
Starting on the fifth day of menstruation.
Starting in the first week after menstruation.
Start on current day, if certainly not pregnant.
Instructions if you forget to drink a pill:
Forgot to take 1 pill
Immediately drink a pill after recall, by directly taking 2 pills on the same
day, then return to the original schedule
Forgot to take 2 pill
When remember, soon to take 2 pills per day for 2 days and use a back-up
plan (such as the use of condoms).

Birth Control Pill (OC pill)

Advantages
Cheap and easy to use. If not suitable can be immediately discontinued its use.
Suitable for delaying the first pregnancy.
Reduce the use of menstrual pain
Usage of 4 years in a row is useful to prevent anemia, reduces the risk of ovarian
cancer, endometrial cancer and breast benign tumor.
Reduce the symptoms of menopause and the risk of osteoporosis.
Disadvantages:
Requires discipline to use it
Can reduce breast milk (pills containing estrogen).
The return of fertility is a bit late, it took 2 months after cessation of birth control pills.
Can increase the risk of chlamydial genital warts.
Not recommended for women over 40 years old because it would affect body
metabolism balance

Birth Control Pill (OC pill)

Adverse Effect:
Nausea and vomiting.
Dizziness/headache.
Pain/tense and increase in breasts size.
Increased appetite/weight changes in the 3 part of body (hips, buttocks,
thighs).
Feeling lethargic, weak, not excited in work.
Decrease In Breast Milk.
High blood pressure.
Acne.
Brown spots on the face.
Varicose Veins.
Vaginal Discharge.
Menstrual disorders

Birth Control Injection

From contained Hormon, Contraceptive Injection
can grouped in 2 types :
Contains the progesterone hormone with the
protection of 3 months.
Contain combination of estrogen and
progesterone hormone with 1-month
protection
Injections works by preventing the release of
ovum, thickening the cervical mucus, and
thinning the endometrium to make it unprepared
for pregnancy

Contraceptive Inj.
Indication :
Cant use the other methods because of health reasons.
Want to get a long-term contraceptive protection.
Want to breastfeed, while in need to have birth controlled

Contraindication:
In Pregnancy, because it can cause a miscarriage.
Just had a baby, less than 2 months, because the hormone injection may
slow healing of placental site.
Suffering from severe depression.
Had breast cancer or cancer of the genitals.
Experience vaginal bleeding of unknown cause, it probably symptoms of
cancer

Contraceptive Inj.

Advantages:
High effectiveness with failure rate less than 1%.
Practical, selectively, and secure because repeated use after 3 months.
Does not affect breast milk.
Can decrease the possibility of anemia.
Not limited to age
Disadvantages:
Disruption of menstrual pattern. Acceptors are sometimes experienced a menstrual
irregularity, spotting or bleeding, even 50% of women are not have menstruation after
injection three times.
Cant stop immediately if there is a complaint and it took many months to restore its
fertility. Most women have to wait 4-5 months after stopping the injection.
Increased body weight up to 5 kg.
Acceptors should be returned to health provider to have repeated injecton

Contraceptive Inj.

Adverse Effect :
Menstruation delayed.
Weight gain.
Headache accompanied by
disturbances of vision.
Infection at injection site.
Lower abdominal pain.
Bleeding caused by injections.

Implant
These tools are planted by doctors or midwives under
the skin surface through a small incision in the arm with
in local anesthesia
Implants work by releasing levonorgestrel / progestins in
low speed and constant into the body for 2-5 years. The
progestin hormone will prevent ovulation, thicken
cervical mucose so inepenetrable by sperm, halt the
endometrial cycle so that the ovum that has been
fertilized cant infiltrate it

Implant

Ideal implant :
In the first week of menstruation (max 5-7 days after 1st day of
menstruation).
At 7 days postpartum.
Previously were pill acceptors, can substitute to implants
immediately after stop taking birth control pills.
For previous inj. acceptors, implants use in the last week before the
inj scheduled.
Previous implant acceptors, can immediately proceed with new
implants at the same time when the old implants removed. When
swelling does occur, the new implants can be used in the old place
or in the same place with a different direction, but can also be
attached in a different place

Implant
Advantages:

High effectiveness, the failure rate is theoretically only 0.2% and, practically only 1-3%.
Do not suppress the production of breast milk.
Practical and effective.
There is no forgotten factor
Help prevent anemia.
Can be used for clients that do not match with estrogen use.
Used in a prolonged period of between 2-5 years.
Fertile state back soon after cessation of use.

Disadvantages:

Should be done with minor operations by the doctor or midwife.

May change the menstrual pattern.
Sometimes irregular bleeding could happen.
Cant stop directly.
Implants may be seen under the skin.
The price is relatively expensive.
There is the possibility of headaches, mood swings, changes in libido, and increase weight loss

Implant

Reason for the removal of implants:

Pregnancy
Severe headache, dizzy with migraine that happened for the first time.
Disturbance of vision.
Pain usually followed by complaints such as pain around the breast and
chest.
Contraceptive protection period runs out

Adverse Effect
No Menstruation.
Severe,prolonged Bleeding
Implants were lost or not palpable.
Nausea, dizziness, anxiety, headaches followed by blurred vision

IUD Progesterone
This contraceptive IUD is same with others, it's just
copper on the rod contains hormones levonorgestrel /
progestasert
Brands of Progesterone-IUD :
Progestasert Alza-T shaped, contains 35 mg of the hormone
progesterone and barium sulfate, with the effectiveness is 18
months.
LNG-20, contains 46-60 mg of levonorgestrel, the effectiveness
is 5 years.

IUD Progesterone
Advantage : Reduce blood volume during menstruation.
Decreased up to 40% compared to before IUD use.
Disadvantage : Progesterone IUD is more expensive
than the IUD without hormones; its effectiveness is only
18 months; often cause spotting or bleeding in the
middle of the menstrual cycle; LNG-20 can cause
menstruation to cease; the risk of ectopic pregnancy is
higher.

NON-HORMONAL CONTRACEPTION
IUD (Intra Uterine Device)
Condom
Spermisid Vaginal (Birth Control Tissue)

IUD (Intra Uterine Device)

IUD works in various ways:
Affects the ovum movement, faster in the
salfing, so when the sperm meet ovum, the
uterus is not ready.
Prevents sperm to finding the ovum.
Interfere with fertilization by interrupt
endometrial infiltration.

IUD (Intra Uterine Device)

The right moment to use IUD
To range the pregnancy.
Immediately after the removal of previous IUD
8 weeks after giving birth.
Within 5 days after sexual intercourse without
contraception.
Any time, if the acceptor previously use pill,
injection, or implants.
At any time, if it is ascertained not pregnant.

IUD (Intra Uterine Device)

There are 2 versions of the most ideal time put an IUD:
Old version.
insertion of the IUD when in menstruation or immediately after menstruation (day 1 to
17), with reason:
- Uterus was open and tender.
- It was certainly not pregnant.
- Bleeding that occurs due to insertion can be stop simultaneously with normal
menstrual bleeding.

New Version
Insertion of the IUD can be done at any time when not pregnant, if:
To avoid the occurrence of pelvic infection which usually occurs at the time of
installation of the IUD. There were increased risk of infections in menstruation.
Cervical ostium effacement was same with the menstruation or during mid-cycle,
as long as acceptors not in tense state.
It is easier for acceptor to get service anytime.

IUD (Intra Uterine Device)

CONTRAINDICATION
o
o
o
o
o
o
o
o
o
o

Pregnant.
History of pelvic inflammatory disease, and genital diseases.
Risk of benign/malignant tumor on the genitals or in the uterus and the cervix, the
IUD can irritate the area.
The presence of congenital abnormalities of the uterus, IUD is difficult to insert.
Pain or bleeding during menstruation, IUD can aggravate the complaint.
Severe anemic because of the IUD tend to worsen menstrual bleeding.
Often have vagina bleeding with no known cause.
History of rheumatic heart disease or kidney as it can be at risk of complication
Copper allergy due to the IUD generally entwined by copper.
IUD is also not recommended if married couples aged less than 25 years old and
have not had any children; not the type who are loyal and have more than one sexual
partner; had a venereal disease.

IUD (Intra Uterine Device)

Advantages
Practical and safe for the long term, once shield inserted protect from pregnancy
up to 5-8 years.
Economical and relatively inexpensive compared to implants. Now IUD price
range between Rp. 150,000 - Rp. 300,000 (including insertion fee), but there are
also provided by the Government.
Independently controlled.
The return of fertility is high.
No Forgotten factor such as pills use.
Disadvantages
Must be inserted by a trained midwife or doctor.
If there are complaints, acceptors can not stop the use by themselves.
If the protection time run out, must be expelled by a doctor or midwife.
Does not protect against the transmission of sexually transmitted diseases,
including HIV/AIDS.

IUD (Intra Uterine Device)

Adverse Effect
Pain, Usually lower abdominal pain.
Bleeding, IUD increase menstrual bleed volume 20-50%. Menstrual time also
prolonged
IUD tail undetected.
Infection. IUD usage increased infection risk.
Ectopic Pregnancy, IUD disrupt attachment of embrio.
Pregnant. If IUD acceptor were pregnant, it can maintained . Theres 2 option for
doctor :
If IUD tail seen, IUD expelled. To prevent miscarriage (60% chance),
premature birth, dead fetus, or Low birth weight.
If IUD tail unseen, doctor let IUD intrauterine, with stric observation

Condom
Reason to choose Condom :
Inexpensive, without medical examination
Delay first pregnancy
Sexual intercourse not frequent
Couple have sexual transmitted disease .
Cant use other contraception method because health
reason.
As back-up for other contraceptive method
As emergency contraception
Want to have protection from pregnancy and STD
simultaneously

Condom
Advantage:
Easy, cheap, do not require prescriptions
Can prevent the transmission of sexually transmitted diseases.
Easy to carry everywhere

Disadvantages:
Sometimes disturb sexual comfort.
Should always change new condom every time after intercourse.
Easily torn if wearing it in a hurry.
The failure rate is quite high if too late to wear it

Spermisid Vaginal

Advantages & Disdavantages Spermisid Vagina :

Small and attractive, easy to carry.
Secure.
Can be used as backup or emergency contraception.
Suitable for menopausal couple because it lubricate the vagina.
Can do it yourself without a medical examination.
100% guaranteed return of fertility after usage stop.
The usage takes time.
If allergies, can cause itching or a feeling of heat on couples
should be worn over and over again for a consecutive intercourse.
Not all pharmacies provide this product

SIGNS OF DANGER IN THE USE OF

CONTRACEPTIVE
No.
1.

Sign
Severe abdominal pain

Pil
+
+

3.

Chest pain and shortness

of breath
Severe headache

4.

Increase in weight

5.

7.

Vaginal discharge and

foul odor
Vaginal bleeding or
blood clot
High fever, shivering

8.

Blurred vision, blind

9.

Severe lower extremities

pain
Delayed mesntruation/
become pregnant
Depression

2.

6.

10.
11.

IUD
+

Injection

Implant

+
+
+

+
+

+
+

PERMANENT
CONTRACEPTION
Vasectomy, i.e. tying, clog, or cutting channels
(vas deferens) so there were no longer sperm in
the semen.
Tubectomy, i.e., binding, clog, or cutting of tuba
falopi so can prohibit the fertilization.

Tubectomy
All acts of closing (cutting, binding,
mounting rings, blockages) on both
channel to the right and left ovarium, so
that the ovum cant pass through the
channel
The way it works: by inhibiting ovum
transfer to uterus and cant be fertilized by
sperm.

ESSURE
A MICROCOIL

Tubectomy

The proper time to do tubectomy

Not pregnant (absolute terms).
1-2 days after delivery or miscarriage.
3 months after giving birth and being not pregnant.
At the time of childbirth with sectio caesaria.
Advantages
Effectiveness undenied after the operation
Permanent.
There are no long term side effects.
Do not interfere with intercourse.

Disadvantages
Risk and adverse effect of surgery

Reference
Mansjoer, Arif. 2000. Kapita Selekta Kedokteran Jilid 1.
Edisi ke-3. Jakarta : Media Aesculapius.
Sarwisiyani, Dike, et al. 2004. Panduan Praktis Memilih
Kontrasepsi. Badan Koordinasi Keluarga Berencana
Kota Surabaya

IUD Insertion Skill

d r.L/O/G/O
Anom Suardika SpOG(K)

1. Consultation before insertion and client selection

Client selection (anamnesis carefully to make sure there is no health problems)

2.
3.
4.
5.
6.
7.
8.

LMP, long menstruation and menstrual bleeding patterns

Parity and last obstetric history
History of ectopic pregnancy
Great pains each menstruation
Multiple sexual partner
Cervical cancer
History of STD
Explain pelvic examination is necessary and give clients chance to asking
questions about the pelvic exam
Make sure the client is already emptying the bladder and wash genital area with
soap and water
Wash your hands with soap and water, dry it with a clean cloth.
Help the clients to get onto the examination bed
Palpate Abdomen area and check if there is pain, lumps or other abnormalities in
the suprapubic area
Wear a cloth cover on clients for a pelvic examination.
Set the direction of the light source to look at cervical

9. Use DTT disposable gloves

10. Adjust the placement of equipment and materials to be used in sterile
containers or DTT
11. Do an inspection on the external genital
12. Palpate skene's gland and bartholine, observed the presence of pain or
vaginal discharge.
13. Insert the vaginal speculum.
14. Do inspeculum examination:
* Check the presence of lesions or vaginal discharge
* Cervical inspection
15. Remove the speculum with caution and put back in place by not touching
other equipment that has not been used.
16. Do a bimanual exam:
* Make sure cervical movement Is free
* Specify the magnitude and position of the uterus
* make sure there is no pregnancy
* make sure there is no infection or tumor in the adnexa
17.Do rectovaginal examination (with indication)
* Difficult to determine size retroversion uterus
* Tumours in douglas cavity.
18. Clean gloves and dip it in a solution of chlorine 0.5% then reverse it and soak
it in a solution of chlorine

PRE INSERTION PROCEDURE

19. Explain process of IUD insertion and what will clients feel in the process.
Give chance to ask questions
20. Insert IUD in the steriel packaging
. Open half plastic lid and fold to the back
. Insert plunger into the inserter without touching the unsterile object
. Put package in flat surface
. Tuck carton measurement under the IUD
. Grasp both ends of the IUD and push the tube up to the base of the arm
insertor so that the arm will be folded up.
. After the sleeve folded until touching the tube insertor, pull the tube from
under the folds .
. Lift up a liitle of tube insertor, push and rotate the arm to insert the IUD that
already folded into a tube inserter

IUD INSERTION PROCEDURE

21. Use New Gloves
22. Use Speculum to see cervix.
23. Swab vagina and cervix with antiseptic solution 2-3 times.
24. Pinch cervix with tenaculum carefully.
25. Insert sondage with non touching technique
26. Determine Position and depth of uterus, the take out the sondage.
27. Determine Uterine cavity depth on inserter tube while still in its sterile package
(By shifting blue neck on the tube insertor, then open the plastic cover packing)
28. Lift IUD tube of its package without touching the unsterile surface careful not to
touch he plunger.
29. Hold IUD tube with blue neck in horizontal position(parallel with IUD). While
carefully Pull tenaculum, insert a tube insertor to uterus till the blue neck touch
cervix or to feel pressure.
30. Hold and retain tenaculum and plunger with one hand.
31. Remove the IUD inserter by using the withdrawal technique, to pull out until the
base of the plunger with insertor while hold the plunger.

IUD INSERTION PROCEDURE

32. Pull plunger, than Inserter tube inserted to cervix till the blue neck
touch cervix or felt pressure
33. Remove half of inserter tube and cut IUD tail
34. Remove all inserter tube, move to contaminated trash
35. Remove tenaculum carefully, soak it in a solution of chlorine 0,5%
36. Check cervix if theres any bleeding from former tenaculum pinch,
press with gauze during 30-40 seconds
37.Take out speculum carefully, soak in aqueous solution of chlorine
0,5%

POST INSERTION PROCEDURE

38. Soak all of the equipment that is already in use in a solution of
chlorine 0.5% for 10 minutes for decontamination.
39. Waste materials which are not in use anymore (gauze, disposable
gloves) are already in place to provide
40. Dip both hands are still using gloves into the aqueous chlorine 0.5%
impurities on clean gloves, go in reverse and soak it in a solution of
chlorine 0.5%
41. Wash hands with soap and water
42. Make sure that clients do not experience cramps and observed for 15
minutes before allowing the client to go home.

C O N S U LTATI O N A F T E R P R O C E D U R E
43. Teach clients how to check their own IUD tail
44. Explain to the client what to do when experiencing the side effects of
IUD
45. Notify when a client must come back to the clinic to control
46. Remind returning period. Period of usage Cu T 380 is 10 years
47. Reassure the client that he or she can come to the clinic at any time
when need a medical examination or consultation, or if wants to
remove the IUD
48. Ask client to repeating explanation that has been given.
49. Complete medical record and IUD card for a client.

Thank You
L/O/G/O