Ques. 1 What is contraception?
Ans. The word contraception means prevention of conception and any device which is used for purpose may be called a contraceptive.
In order that conception can occur following conditions must be fulfilled –
- The sexual union must occur at certain fertile periods of the women’s menstrual cycle when ovum is present in the fallopian tube. This period is about 4 to 5 days beginning 11th day from first day of the previous menstruation.
- There must be no impediment to the passage of the sperm from the vagina, through cervical and uterine cavity to the uterine orifice of the fallopian tube and then onward along the tube to meet the ova awaiting fertilization.
- The unfertilized ovem must be able to enter the fallopian tube from the peritoneal cavity, where it is discharged by the ovary.
- The fertilized ovum must be able to travel to the uterine cavity.
- The endometrium of the uterus, under the influence of complex hormonal activity must be ready to receive and accept the fertilized ovum.
- There must be sexual union between a man and a woman both of whom have reached the age of puberty and are within the reproductive period of their lives.
- The male partner must be able to deposit semen containing viable sperms in vagina.
Conception will be prevented if any one of above requirements is not fulfilled and interference with one or all of them is basis of contraception.
Ques. 2 What are contraceptives?
Ans. CONTRACEPTIVE – By definition it means all temporary and permanent measures which are applied for preventing pregnancy resulting from coitus is known as contraceptive.
Any woman seeking contraceptive advice should be examined and carefully instructed about kinds, advantage, disadvantages, and use of appropriate methods of contraception and alternatives.
Ques. 3 What is the classification of contraceptive methods?
Ans. CLASSIFICATION – (of Contraceptive methods) –
Physiological Methods – In physiological or natural methods of contraception no appliance or medicine is required and is related to the sex habit of couple or menstrual cycle of wife. Complete abstinence, etc. may be termed as physiological methods.
Total Abstinence is the only real certain way of preventing Conception.
Abstinence During Fertile Phase – This is Rhythm Method or the use of the Safe Period, Which depends upon avoidance of sexual intercourse during the probable dates of ovulation. In a 28th day cycle ovulation occurs on the 14th day of the cycle. Seldom, however, is menstrual cycle accurate to within an exact day and equally seldom is time of ovulation accurately restricted to the 14th day. Even with relatively regular 28th day menstrual cycle ovulation may occur anywhere between the 12th and 16th day. Because most women do not have completely regular cycles, as such, exact calculations of date of ovulation are by no means easy and the method is, therefore, often unreliable. Use of this method of contraception will result in approximately 25 pregnancies per 100 woman year.
Spermatozoa deposited in the female genital tract may survive for upto 3rd days, so that intercourse which occurs at any time from 9th day to 16th day could theoretically result in conception. The ovum itself may well live for 24 hours, so that intercourse between 9th and 17th day results in a theoretical possibility of pregnancy. The Safe Period is, therefore, calculated from first day of onset of menstruation until 8th day of the cycle and from 18th to onset of menstruation.
In absence of direct and practical methods of observation of the phenomenon of ovulation, women desirous of adopting Rhythm Method of contraception can follow one of three indirect methods. These are –
WITHDRAWAL OR COITUS INTERRUPTUS –Withdrawal of coitus interruptus means discharge of male semen outside female genital organ during the act of intercourse. It is a good method for contraception, if practiced properly, but requires cooperation and harmony sex partners.
Pregnancy rate is 35 per 100 woman year.
CALENDAR METHOD OF OGINO AND KNAUS – Due to rise in hormone level, secretion from the cervix of the uterus increases becomes clear and slippery like egg white. Before ovulation the cervix remains comparatively dry. This dry wet variation of probable date of ovulation. In initial state the attending physician observes change and later women herself can be taught to recognize it. During ovulation the progesterone level in the blood rises and it causes increase of basal body temperature. This phenomenon may be utilized to determine the exact day to ovulation for practicing the Rhythm method. Immediately before and after ovulation the oestrogen in the blood reaches peak level.
MECHANICAL METHODS OR BARRIER METHODS –
- Cervical Cap.
CHEMICAL METHODS –
- Foam Tablet.
MECHANICAL AND CHEMICAL METHOD –
- Jellies containing spermicidal chemicals.
- Medicated sponge.
MECHANICAL AND BIOLOGICAL METHODS –
Intra Uterine Device (Types)
- Copper T.
- Latex Leaf.
- OTA Ring.
- Intra uterine membrane.
- Antigen-F, etc.
- Lippe’s Loop.
- Dalkon Shield.
PHARMACEUTICAL (OR SYSTEMIC METHOD)
Oral (contraceptive) Pill.
SURGICAL METHOD (OR TERMINAL METHOD)
- Tubectomy (for female).
- Vasectomy (for male).
MISCELLANEOUS METHODS :
- Vaso vessel device (for male).
- Deporpvera (injection for woman).
Ques. 4 What are the general methods of contraception used by the male?
Ans. A brief description of some methods of contraception :
USED BY MALE –
Condom or Sheath – IN INDIA condom factory in Trivandrum produces the brand
“Nirod” which meets about 40% of requirement of the country.
Durapac and – Durex is London Rubber Co. product made in Madras. Sultan is U.S. made condom. In this method penis is completely covered by a rubber sheath, which may be of a very thin rubber (the condom), which is used only once, or a thicker rubber (washable sheath), which can be used repeatedly. A lubricant is advisable, and where highest degree of security is desired a spermicidal jelly or a soluble pessary is used in addition, giving further protection if sheath should slip or break. Skin condoms are costlier.
Method – For better safety. Condom is used along with chemical lubricant spermicide – preceptin gel to avoid tearing of condom. After ejaculation, condom is pulled out holding its rim over the penis before it becomes totally flaccid. One condom is rolled on erected penis in full length before coitus (foreskin retracted if uncircumcised) but not before ejaculation.
Advantage – In case of premature ejaculation, use of condom may be effective in prolonging the coitus by diminishing sensitivity. It is simple method and it is easy to use, there is no significant morbidity also any systemic effect. Acceptability – widely used throughout the world. The great advantage of condom is its availability and no medical supervision is required for its use. Apart from fertility control, other clinical use of condoms is as a preventive measure against venereal disease & reinfestation with vaginal trichomoniasis and moniliasis.
Disadvantages – Side effects – Rubber allergy to penis or vagina has been reported. Effectiveness – pregnancy rate varies from 6 to 10 per 100 women year.The use of sheath, however, can cause psychological disturbances sufficient to interfere with potency is some men, and many couples object to this method because of impairment of sensation or because of the inevitable interruption due to the adjustment of sheath.
Vasectomy - Vasectomy came up on Family Planning Programme in India since 1956. Vas occlusion was considered by English Surgeon, John Hunter in 1775 and Astley Cooper in 1830. It is clinically practice by Harry Sharp (U.S.A.) in 1899.
Method – The intervening portion of vas between ligatures is removed. Gauze dressing is placed on the wound and a suspensory bandage is worn by patient for a week. He is allowed to leave the clinic after resting for half an hour. He can take up his work on same day following vasectomy. Written consent is taken from man. He is clinically examined for his fitness. Scrotum is shaved. By palpating scrotum, the vas is isolated and fixed under the skin high up in the scrotum between thumb and index finger. The skin and dartos muscle are divided and thereafter sheath is divided to expose the vas. Vas is dissected out for a length of one and half inch by picking with an Allis forceps. The testicular end of exposed vas is securedly ligated with the silk followed by placing a ligature about an inch distally.
INDICATION OF VASECTOMY – The is indicated on healthy, psycho-sexually well adjusted man and explained that male hormonal balance, capacity of coitus and ejaculation are not affected by vasectomy.
- Causes little post-operative pain.
- In some cases reversible (if required).
- The volume of ejaculate and coitus itself remain unaltered by the operation.
- Possibility of unpleasant psychological consequences in the husband, including impotence.
- Following vasectomy the man is not immediately sterile, after three months following about one dozen ejaculation his semen becomes sterile.
- Side effects and complications 2 to 4 per 100 person year; haematoma, granuloma, infection, epididymitis, sperm antibodies may develop.
Ques. 5 What are the general methods of contraception used by the female?
Ans. USED BY THE FEMALE-
(A) Oral Contraceptive (pill) – This is hormone pill, combination of oestrogen when taken orally acts as most effective contraceptive at the present time. Dr. Rock, Dr. Garcia and Dr. Pincus from U.S.A. pioneered in clinical use of the pill as contraceptive in 1957. Thereafter its clinical use is increasing up to date throughout world.
DOSAGE – The various products of different commercial firm’s variations of progestogen and oestrogen. For contraceptive effect, course of pills are to be taken starting from 4th or 5th day of the mens. One pill is taken daily at fixed time preferably at bed time. On stoppage of course the drug withdrawal menstruation start by the next seven days. In every day formulation, 28 pills are provided of which 21 pills are hormone tablets and rest seven are inert or iron tablets.
INITIAL CHOICE OF HORMONAL PILL – Women who show progestogenic hormonal effects (scanty menses, dry vagina, acne, fullness of breasts) are prescribed low progestogenic pills. If one type of pill causes undesirable side effects, another preparation may prove to be less troublesome. Women who show more oestrogenic effects (viz. premenstrual tension, leucorrhoea, menorrhagia, fluid retention) prescribed strong progestogenic oral pills.
METHOD – If a pill is missed, 2 pills must be taken next day, one in morning, and one at bed time. If three pills are forgotten, additional contraception is advised for cycle. The women must have medical check up by the doctor to exclude any contra-indication for pill taking. Pelvic examination is made and cervical smear is taken for examination; she is instructed to take pill one a day from 4th or 5th day of menstruation till course of 20/21/22 pills is finished.
In every formulation, hormone tablets are started from the day of onset of mean till 28 tablets are taken. Thereafter another course of 28 tablets are started.
On completion of course, menstruation is awaited and next course is started from the 4th or 5th day of menstruation.
Follow up – Doctor’s prescription is necessary for oral pills. The women under cover of oral pill contraception should be followed up by periodic checking of B.P., Cervical smear and blood sugar every six months.
- Does not interfere with coitus.
- It may produce some favourable. Side effects, e.g., regularization of menstrual rhythm and reduction in flow, relieves from spasmodic dysmenorrhoea, improve the skin, and acne may be relieved, general feel of well being due in part to relief from fear of pregnancy. In come cases, Libido – may be increased due to absence of fear of pregnancy.
- Nearly 100% effective.
- Contraindicated in patients with thrombo-embolic tendency, liver diseases, diabetes mellitus, large fibroid, hormone dependant breast cancer etc.
- Cessation after prolonged treatment may by followed by amenorrhoea.
- Requires proper instructions and should be followed up by periodic checking of blood pressure. Cervical smear and blood sugar preferably every 6 months.
- Recurrent cost.
- Not tolerated well by all women. It may produce some side effects, e.g., gastric upset with nausea, headache, break through bleeding, fluid retention and weight gain, depression, irritability, scanty mens, lumpy tender breasts, oedema etc,
Time of use (of pill) after delivery or M.T.P. –
- If the patient is feeding her baby from breasts, pill should be postponed for 6 months following delivery.
- Following abortion, pill can be started once all bleeding has stopped.
- If the patient is not feeding her baby from breasts, pill can be started on the 6th post-partum week or earlier.
Intra Uterine Device – In 1909 Dr. R. Richter, a German physician, first introduced an intra uterine device for contraception.
In 1965 the Govt. of India introduced Lippe’s Loop in the National Family Planning Programme on recommendation of the Indian Council of Medical Research. Many IUD’s of different shapes and size have been designed and introduced. Some of them commonly used are –
- Copper Seven.
- Latex Leaf.
- Ota Ring.
- Intrauterine membrane.
- Antigon F.
- Dalkon Shield.
Mode of Action – The most widely accepted theory, is that IUD’s interfere, in some manner with implantation of the fertilized ovum in the endometrium. It was further observed that presence of IUD in the uterine cavity changes the characteristics of uterine fluid content causing an inhospitable environment for the survival of fertilized ovum. The exact way in which I.U.D. prevents pregnancy is till not known. It was observed that extensive cellular infiltration occurs in endometrium around the point of contact with IUD and phagocyte engulfs and destroys many spermatozoa on their way to upper part or uterine cavity.
Selection of cases & time of insertion & follow-up visits – The patient should be visited during her next menstrual cycle, and menstrual history taken. Menstruation is usually heavier than normal. There can be some intermittent bleeding also. In case of bleeding patient may be assured that, over her next few cycles the menstruation is likely to become normal. Special care should be taken for selection of cases for IUD. Insertion is contra indicated in case of pregnancy, sub-acute pelvic inflammatory disease, dysmenorrhoea, uterine bleeding disorders, congenital malformation of uterus or in case of suspected malignancy of uterus.
In general, device may be inserted during the last few days of menstruation, as it will exclude any chance of pregnancy and cervix also remains soft for dilatation.
- Does not interfere with coitus.
- Not carcinogenic.
- One time method.
- 8. Reliable.
- Can be used for much population control.
- No reduction of fertility after its removel.
- Insertion of I.U.C.D. requires proper selection of patients.
- 3 to 5% of the patients become pregnant.
- Not suitable for all cases.
- Side effect, e.g., menorrhagia, pain (during insertion), infection, spontaneous expulsion etc.
Ques. 6 What is Vaginal Diaphragm?
Ans. This is a female contraceptive cap worn by the woman in her vagina and acts mechanical barrier. This was first described by Dr. Hasse (1882) from Germany.
This is made of rubber dome with a base made of either flat (or coiled steel spring.) They are available in sizes varying from 50 to 100 mm. diameters. Although it has no side effect yet the method suffers following disadvantage-
- Offensive smell is recorded by some on removal after 6-8 hours.
- Needs initial training for fitting. 5. Needs privacy for insertion and removal.
- Likely to fail of not properly used.
- Usually required another agent, e.g., spermicidal jelly.
Tubal Ligation Procedures - Tubal ligation, partial excision or total salpingectomy, by abdominal route is the commonest sterilizing method for women. Post partum sterilization and tubal ligation by vaginal route are also performed both under local and general anaesthesia. Female sterilization involves cutting of blocking of both fallopian tubes so that ovum released each month, by the ovary, cannot meet with and be fertilized by sperm.
Side Effects – The morbidity and mortality rate after female sterilization by application of modern techniques, has been reduced to almost Zero. Morbidity due to infection, still occur when operations are performed in mass camps. Psychological disturbances in some cases have been need due to fear. It can be prevented by proper assurance before operation and at follow up. Some sterilized women reported tendency to obesity and diminished sex urge. No change in female physiology is associated with tubal ligation or occlusion. The ovarian and menstrual cycle remain uncharged after such operation and the mature, but unfertilized ovum is lost in peritoneum.
Spermicidal Creams and Jellies –
- Simple to use.
- Reliable when used along with some mechanical barrier, e.g., Condom etc.
- Some women may complain of excessive white discharge per vagina.
- Unreliable when used alone.
Used by both partners – Rhythm Method – Although this method is widely practical, yet it is unreliable at pregnancy rate is about 30/100 woman year. This method is also unaesthetic, as coitus is dictated by calendar rather than by desire.
A through medical examination as possible should be made before prescribing the pill, as consistent with facilities available. Most women, even when illiterate, find no difficulty in following regimen if instruction are given properly. When several preparations are available with different dosage schedules of oestrogen in combination pill, p beginning should be made with a low dose pill.] Undoubtedly, Oral Contraceptives are the most effective and widely accepted contraceptives now available. The side effects being mild and infrequent the numbers of drop outs are also fewer than with users of other methods. Contra-indications for use of oral pill are few, but in some cases, caution must be exercised before prescribing the pill.
Ques. 7 What do you mean by M.C.H. or Mother & Child Health programme ? Discuss its main objectives and components.
Ans. Every expectant mother needs care right from time she becomes pregnant to the postnatal stage for the protection of health of mother & the new born baby. The child bearing imposes a great strain & it is & it is important that health supervision for the mother & the new born babies are well arranged by the society. Mother is the most significant phase in the life of a woman and pregnancy is a vital event in her life. Along with pleasure it brings the need of special health and welfare services for mother. The protection of the health of the mother & her child is important for building a healthy nation. The pregnancy is a physiological process but mother may suffer from morbid condition due to pregnancy. More than half of children born do not reach 15 years of age & ‘infant mortality’ is about 100 per 1000 live births per year.
The term M.C.H. refer to primitive, prevention, curative and rehabilitative health care for mothers and children. It includes the sub-area of maternal health, family planning, handicapped children, adolescence, and health aspects of care of children in special settings such as day care. The principle object of M.C.H. services is life long health. The specific objects of M.C.H. are –
- Promotion of reproductive health ;
- Promotion of the physical and psychological development of the child and adolescent within the family.
- Reduction of maternal. Perinatal, infant and childhood mortality and morbidity;
Main components of M.C.H. –
- Safe delivery services.
- Postnatal care.
- Infant care and toddler care.
- Antenatal care
Five Point M.C.H. Programme – This programme includes of immunization of the infant against T.B., diphtheria, tetanus, whooping cough and poliomyelitis. In india, this programme undertaken, as a part of National Family Welfare Programme.
Ques. 8 What instructions will you give to a mother? Regarding feeding of an infant?
Ans. Advice for feeding of an infant – When child is 7 or 8 months old, semi-solid cereals should be given. When child is 12 to 18 months age, the weaning should be complete. At the end of 18 months, a child can digest all foods. Mother’s milk so allowed gives full protection to child. Breast Feeding : Breast milk is the ideal for the infant/baby upto age of 6 months and then the baby should be gradually weaned. When child is of 6 months age, one breast feed should be missed and replaced by cow’s milk.
TIME INTERVAL FOR FEEDING – Average a child requires feeding every 3 hourly. There should not be a fixed and rigid time schedule for feeding child. Feeding should be done whenever the child demands the feed, i.e., hunger crying.
AMOUNT OF MILK – In terms of calories a healthy baby needs about 50 kcal of calories per pound of body weight. A healthy baby requires milk at rate of 2.5 ounces per pound of body weight per day.
ARTIFICIAL FEEDING – Cow, buffalo, goat milk, condensed milk, powder milk etc. are available; cow’s milk is best substitute for mother’s milk. If cow milk is diluted with some water and a little sugar is added, we get a mixture which is a good substitute for breast milk. The main indication for artificial feeding is failure of breast milk, and / or prolonged illness of mother.