Couples who are enlightened usually decide on the number of children they want to have. This depends on the amount of money they have. The precautionary measures couples take to have the number of children they want is termed fertility control.
Three Methods are Available
- Termination of Pregnancy
There are various methods of contraception ranging from primitive to the most modern methods.
- Conventional Method
- Billings Method
- Rhythm or safe period
- Barrier Method
In abstinence, couples refuse to have sex until they desire a baby. This is the oldest method in practice. It is also the method of contraception approved by the Catholic Church, which is a dangerous period. The danger period is during ovulation. The majority of the woman ovulates on the 14th day of their cycle. The range however is from the 12th to the 16th day. Every woman has to find out the day she ovulates so that her danger period will be shorter.
The following signs donate ovulation
- A temperature rise occurs as soon as a woman ovulates.
- The cervical mucus is clear, copious and can be drawn out in the fine thread
- Slight abdominal pain.
It has been established that the egg lasts for between 24 hours and 36 hours while the sperm can live up to 48 hours. For a woman who ovulates on the 14th day of her cycle, it follows that the egg cannot live till the noon of the 16th day. It is evident too that if she has sex on the 12th day she will be pregnant since the sperm can live for about 48 hours. To avoid getting pregnant, such a woman must not have sex from the 11th day to the 17th day of her cycle. Barrier methods include condoms, cervical caps, and cervical diaphragms. They have the advantage of being cheap and readily available; need no prescription and prevent sexually transmitted diseases. The disadvantages, however, are that it can burst, maybe an error in the production and in the case of a condom can slip off the penis during intercourse.
B. Intrauterine Contraceptive Device (IUCD)
These are materials put directly to sit on the fundus of the uterus thereby preventing implantation. IUCD does not prevent fertilization but rather prevents implantation. Insertion is done immediately after menstruation to ensure she is not pregnant and the cervix is open which makes insertion easier.
Types: Two types are commonly used and are:-
- Lippes Loop. This is made of polythene and is radio-opaque. It can be left in situ in the uterus indefinitely Copper T (CU-T). This is made of the metal copper. The metal gives it some degree of efficiency. Its life span is three years and some last for more.
(A) Heavy period and of longer duration
(b) Increased vaginal discharge
(c) Increased tendency to pelvic inflammatory disease
(d) Ectopic pregnancy
Any woman with the following conditions should not use an intrauterine contraceptive device:
- Suspected pregnancy
- Past history of ectopic pregnancy
- Recurrent pelvic inflammatory disease
- Cancer of the genital tract.
- Recent abortion less than six months
- Severe dysmenorrhoea
These are tablets that contain the hormones oestrogen and progesterone. There are varieties of oral contraceptive pills. Some are combined, others are oestrogen-only pills and yet others are progesterone-only pills. They are taken daily. Information on their usage is written on each pack. Of importance to women of easy virtues is the post-coital pill. It is used after unprotected intercourse. It has to be taken within hours of the intercourse for it to be effective. An example of a postcoital pill is d-norgestrel.
They either thicken the cervical mucus making it hostile to sperm or make the endometrium atrophic and unreceptive to the fertilised ovum. The side effects of the oral contraceptive pill are:
(a) Headache and migraine.
(b) Breast symptoms such as enlargement and mastitis.
(c) Thrombo-embolic problems.
(d) Weight gain.
(e) Post-pill amenorrhoea
(1) Bleeding between periods.
(9) Skin problems such as acne and rashes.
The use of the oral contraceptive pills is contraindicated in the following conditions:
(2) Migraine headache
(4) Psychiatric illness
(5) Heart and liver diseases
(6) Peptic Ulcer
(7) Diabetes and sickle cell disease.
These are progesterone preparations given by injections. The two most popular ones in use in this environment are:
The dosage is 150mg ampoule every three months Should pregnancy occur when the IUCD is insitu there is a higher chance of abortion, prematurity, bleeding and infection. The patient is advised to remove the coil so that the pregnancy can continue, otherwise terminate the pregnancy. The side effects of the IUCD include:
- Noristerat: This is 200mg ampoule every two months.
The side effects of injectable contraceptives are:
(b)Irregular bleeding per vagina.
Contra-indications to Injectable Contraceptive are:
2. Irregular bleeding per vagina
3. Cancer of the genital tract
2. Sterilization: This is an irreversible form of surgical contraception
Female sterilization is more common and it consists of:
(A) Tubal Ligation:- This means tying the fallopian tubes
(B) Hysterectomy:- This is removing the uterus.
(C)Transcervical tubal occlusion
Male sterilization is by vasectomy. This is the ligation of the vas deferens
Complications of sterilization include:
4. Damage to visceral structures.
5. Depression and psychological problems
Termination of Pregnancy
(a) The pregnancy will involve risk to the life of the woman.
(b) There is a risk to the physical and mental health of the pregnant woman.
(c) There is a risk to the physical and mental health of the other children in the family
(d) The baby if born will suffer physical or mental abnormality or serious handicap.
The method of terminating the pregnancy depends on the gestational age.
1. Karman’s cannula and syringe
2. Suction current
Second and Third Trimester
Oxytocin infusion with artificial rupture of membrane (ARM)
Maternal Mortality And Perinatal Mortality
This refers to the number of women who die during childbirth or abortion. The maternal mortality rate is the number that dies per 1000. The rate is very high in developing countries due to
1. Haemorrhage, both antepartum and post-partum
3. Pre-eclampsia and eclampsia
4. Infections-puerperal and post abortal.
5. Obstructed labour of any aetiology
6. Cephalopelvic disproportion
7. Uterine rupture
8. Medical conditions in pregnancy such as Diabetes Mellitus, Sickle cell disease and anaemia.
9. Ectopic pregnancy
Despite attempts to reduce it the rate is still high. The reasons given for the high rate include:
(A) Poor obstetric care
(b) Low level of education
(c) Patient’s attitude towards antenatal care
(d) Failure of some clinics to diagnose it in time and
subsequently, take appropriate action.
(e) Lack of facilities in most hospitals.
How to reduce maternal mortality rate:
1. Good antenatal care.
2. Good and serviceable facilities in clinics.
3. Adequate nutrition.
4. Family planning services
5. Active management of infection and haemorrhage.
6. Blood bank services.
7. Community health education.
2. Perinatal Mortality
This is death occurring during pregnancy, labour and the first week of puerperium. It includes stillbirths and first-week deaths. Perinatal mortality is referred to as obstetrics death. The perinatal mortality rate is the number of obstetrics death per 1000 total births in a hospital or state or country. It is related to the social class and standard of obstetrics care.
1. Trauma such as prolonged labour, obstructed labour, ruptured uterus and cord prolapse.
2. Low birth weight
3. Antepartum haemorrhage
4. Pre-eclampsia and eclampsia
5. Idiopathic (cause is not known).
7. Maternal disease in pregnancy.
Bad obstetric care, low level of education and patient’s attitude toward medical care still keep the rate high. Poor facilities in hospitals and swarming of the health institution by quacks are also contributory to the high rate.
Prevention is for maternal mortality, Ectopic Pregnancy
This is pregnancy taking place outside the uterine cavity. The majority of it occurs in the fallopian tube. It is not certain what causes it but genital tract infections, surgery of the abdomen with adhesions; tubal diverticulum and IUCD are predisposing factors. Ectopic pregnancy tends to occur on the right side due to inflammation of the appendix which may cause partial blockage or adhesion of the right tube. The ectopic pregnancy starts developing in the tubes but since the muscles of the tube are not adapted for implantation, it cannot hold the fetus longer than six to eight weeks before it ruptures.
The clinical features are:
1. Secondary amenorrhoea for about six to eight weeks.
2. Sharp abdominal pain.
3. Bleeding per vagina.
4. Shoulder tip pain due to irritation of the diaphragm.
5. Dizziness which progress to fainting and collapse.
(a) Patient is in great pain
(b) Abdomen is tender with guarding, shifting dullness and fluid thrill.
(c) Vaginal examination shows bleeding per vagina and marked
cervical excitation tenderness.
Investigation done to confirm ectopic pregnancy is abdominal paracentesis. This yields non-clothing blood. An ultrasound scan also confirms it. In a few private hospitals and in all public hospitals the first thing to do is to take a patient’s blood for emergency grouping and cross-matching. In a dire emergency group O rhesus, negative blood can be given. However, in the majority of private hospitals, no Blood is required unless the patient is already anaemic. The management is emergency laparotomy. The ruptured tube is clamped and salpingectomy is performed with a peritoneal toilet. This is also done under outpatient anaesthesia with atropine, hyoscine, ketamine and diazepam. The nurse on duty should ask and be shown:
1 . The tube and site of the ectopic.
2. The opposite tube.
3. Both ovaries and told their state.
Preparation for sugary and postoperative management is the same as for the caesarean section outlined in the previous chapter. It should however be realised that a general pack rather than a caesarean section pack is used in the operation of ectopic pregnancy.