FAMILY PLANNING PERMANENT METHOD - NURSING ASSIGNMENT

INTRODUCTION

        Family planning is not synonymous with birth which was felt to be too negative and restrictive. Family planning has been recognized as a basic human right by the United Nations in 1968. Family planning methods are classified in to two permanent and temporary methods.

DEFINITION

        According to WHO defined family planning as “a way of thinking and living that is adopted voluntarily, upon the basis of knowledge, attitudes and responsible decisions by individual and couples, in order to promote the health and welfare of the family group and thus contribute effectively to the social development of the country.

        Family planning refers to practices that help individual or couples to attain certain objectives;

a)    To avoid unwanted births

b)   To bring about wanted births

c)    To regulate the internals between pregnancies

d)   To control the time at which birth occur in relation to the ages of the parents

e)    To determine the number of children in the family

CONTRACEPTIVE METHODS

        Contraception is an important factor in many women’s lives, with needs varying according to the particular stage of the life continuum, and should also be viewed in the wides context of sexual and reproductive health.

        Contraception means preventing

a)    The union of the sperm and ovum

b)   Suppressing ovulation

c)    Interfering with implantation of the fertilized ovum in the uterus

        There is various contraceptive methods are based on these principles.

        The various contraceptive methods may be broadly divided in to

a)    Spacing methods (non-terminal)

b)   Terminal methods

CLASSIFICATION

1. Spacing Methods

a) For Men

        1. Condom

        2. Withdrawal

b) For Women

        1. Intrauterine devices

·        Copper T

2. Hormonal contraceptive

·        Oral pills

·        Injectables (DMPA, NET-EN)

·        Subdermal implants (Norplant)

3. Diaphragm

4. Foam tablets, jelly and cream

5. Rhythm Method (Safe Period)

2. Terminal Methods

a. For Males : Vasectomy

b. For Females: Tubectomy

TERMINAL METHODS (STERILIZATION)

        Permanent surgical contraception, also called voluntary sterilization, is a surgical method whereby the reproductive function of an individual male or female is purposefully and permanently destroyed. The operation done on male is vasectomy and that on the female is tubal occlusion, or tubectomy.

Couple Counseling

        Couple must be counseled adequately before any permanent procedure is undertaken. Individual procedure must be discussed in terms of benefits, risks, side effects, failure rate and reversibility.

Male Sterlization – Vasectomy

        It is a permanent sterilization operation done in the male where a segment of vas deferens of both the sides are resected and the cut ends are ligated.

Advantages

·        The operation technique is simple and can be performed by one with minimal training

·        The operation can be done as an outdoor procedure or in a mass camp even in remote villages

·        Complication immediate or late are few

·        Failure rate is minimal – 0.15 percent

·        The overall expenditure is minimal in terms of equipment, hospital stay and doctors training

Drawbacks

·        Additional contraceptive protection is needed for about 2-3 months following operations i.e. till the semen become free of sperm

·        Firdigity or importancy when occurs is mostly psychological

Selection of Candidates

·        Sexually active and psychologically adjusted husband having the desired numbers of children is an ideal one.

Technique

·        Written consent of the person is a must and the surgeon should be convinced about the family structure of the couple

·        Pre-medication is usually not necessary.

·        Local area is shaved and an antiseptic dressing is given with savlon

·        Full surgical asepsis has to be maintained during operation

·        The vas is palpated at the base of the scrotum and is lifted up by the thumb and index finger of the left hand

·        The area over the vas is infiltrated with 1 percent ligna caine (5-10 cc)

·        Small vertical incision ½” – ¾” is given over the vas

·        Dissecting the dastos muscle and cutting the sheath the vas is reached and is separated from the surrounding structure and lifted up by an Allis forceps

·        The vas is ligated at two places 1 cm a past by No. 00 chsomic catgut and the segment of the vas in between the ligatures is resected out

·        Heamostasis is secured and the skin is sutured by interrupted catgut

·        The same procedure is repeated on the other side

·        A scrotal suspensory bandage is worn

·        The patient is allowed to go home after ½ an hour

Advices

·        Antibiotic (Inj. Penditure LA 61M) is administered as a routine and an analgesic is prescribed

·        Heavy works or cycling is restricted for two weeks

·        Usually activities can be resumed forthwith

·        The patient should report back after 1 week or earlier if complication arises

·        Additional contraceptive should be used for 2-3 months

Precaution

·        The man does not become sterile soon after the operation, as the semen is stored in the distal past of the vas channels for a varying period of about 3 months

·        It requires about 20 ejacuations to empty the stored semen

·        Semen should be examined once a month and then again at two months and if the two consecutive semen analysis show an absence of spermatozoa , the man is declared as sterile

Complications

·        Immediate wound sepsis which may leads to scrotal cellulitis

o       Scrotal haematoma

·        Remote

o       Frigidity or impotency

o       Sperm granuloma

·        Increase in sperm agglutin in the circulation

·        Spontaneous recanalisation

No-Scalpel Vasectomy

·        It is performed under local anesthetic

·        Vas is grasped with a specially designed forceps

·        Stretched skin over the vas is punctured with the sharp pointed end of a forceps

·        Hole is increased and the vas is dissected out of the fascial sheath by using the tips of the forceps

·        Rest of the steps are as described above

·        No skin suturing is needed

Percutaneous Vas Occlusion

·        It is popular in China, is an effective and reversible method

·        Polyurethane elasto mere is injected in to the vas

·        It is solidifies and forms a plug and blocks the sperm passage

·        The plug can be removed under local anesthetic

Open Ended Vasectomy

·        The abdominal end of the resected vas is coagulated. The testicular end is lift open. This will prevent congestive epididymitis.

FEMALE STERILIZATION

Occlusion of the follopion tubes in some form is the underlying principle to achieve female sterilization. It is the most popular method of terminal contraception all over the world.

Indication

·        Family planning purposes

·        Socio-economic

·        Medico surgical indications (therapeutic)

Time of Operation

·        During puerperium: The operation can be done 24-48 hours following delivery. The chief advantage is technical simplicity

·        Interval: The operation is done beyond 5 months following delivery or abortion

·        The ideal time of operation is following the menstrual period in the proliferative phase.

·        Concurrent with MTP

Methods of Female Sterilization

        Occlusion by resection of a segment of both the falloplan tubes is the widely accepted procedure

Tubectomy

        It is an operation where resection of a segment of both the fallopian tubes is done to achieve permanent sterilization. The approach may be:

·        Abdominal

·        Vaginal

Abdominal

        Conventional (Lapasotomy): Steps

·        Anesthesia: In mass camp, local anesthesia is preferable

·        Incision: In pupesal cases

·        Delivery of the tube: The tube is identified by the simbrial end and mesosalpinx containing utero – ovasian anastomotic vessels

Techniques

·        A loop is made by holding the tube by an allis forceps in such a way that the major part of the loopis consists mainly of is thmus and past of the ampallary part of the tube

·        Through an a vascular area in the mesosalpime, a needle thread no. ‘0’ chromic catgut is passed and both the limbs of the loop are firmly tied together.

·        1.5 cm of the segment of the loop distal to the ligature is excised

·        Tube is so exercised as to leave behind about 1.5 cm of intact tube adjacent to uterus

·        Segment of the loop removed is to be inspected to be sure that the wall has not been partially re selected and to send it for histology.

Advantages

·        Safe, easy and very effective in spite of the simplicity  of the technique

·        The failure rate is 0.1-0.4 percent

·        Cut ends become independently sealed off and retract widely from each other

MINILAPROTOMY (MINI LAP)

        When the tubeclomy is done through a small abdominal incision along with some device, the procedure is called mini-lap.

Steps

·        Anaesthesis: Always under local anesthesia

·        Plan of incision: It is as same as that of the conventional method but the incision should be ½” -3/4”

·        Specially designed retractor may be introduced after the abdomen is opened

·        The uterus is elevated in to one side

·        Appropriate technique of tubectomy is performed on one side and then repeated on the other side

·        Periotoneum is closed by purse string sutuse. The patient is discharged within 24-48 hours

Vaginal Ligation

        Tubectomy through the vaginal route may be done along with vaginal plastic operation or in isolation when done in isolation, the approach to the tube is through posterior colpotomy.

Complications

        Heamorrhage, broad ligament haematoma and rarely rectal injury. Dyspareumia

Advantages

·        Short hospital stay

LAPROSCOPIC STERILIZATION

        Laproscopy is the commonly employed method of endoscopic sterilization. It should not be done within 6 weeks following delivery

·        The tubes are occluded by silastic ring devised by fallope or by filshie clip is made of titanium lined with silicone rubber

·         4 mm of the tube is destroyed

·        Failure rate is 0.1 percent

Principle Steps: (Single Puncture Techqnique)

Premediation;

        Pethidine hydrochloride 75-100 mg with phenergan 25mg and atropine sulphate 0-65 mg

Local Anaesthesia:

        Taking usual a septic precautions about 10 ml of 1 percent lignocaine hydrochloride is to be infiltrated at the puncture site.

Position of the patient

        Litho to my position

Producing pneumoperitoneum

        A small skin incision (1.25 cm) is made just below the umbilicus. The needle is introduced through the incision with 45⁰ angulation into the peritomial cavity.

Introduction of the Trocar and Laperscope with Ring Loaded Applicator:

·        Two silastic rings are loaded one after the other on the applicator with the help of a load or and pusher

·        The trocar with canula is introduced through the incision previously made with a twisting movement

·        The tracur is removed and the laproscope together with ring applicator is inserted through the canula

·        The ring loaded applicator approaches one side of the tube and grasps of the junction of the proximal and middle third of the tube

·        A loop of the tube (2.5 cm) is lifted up, drawn into the cylinder of the applicator and the ring is slipped into the base of the loop under direct vision

Removal of the Laproscope

·        After viewing that the ring are properly placed in position, the tubal loops looking white and there is no intraperitoneal bleeding

·        The laproscope is removed

·        The abdominal wound is sutured by a single chromic catgut ruture

CONCLUSION

        Contraception is an important factor in many women’s lives, with needs varying according to the particular stage of the life continuum, and should also be viewed in the wider context of sexual and reproductive health. It has been argued that control of their own fertility is the largest single factor affecting the independence of women.

BIBLIOGRAPHY

·        A Text Book of Myles for Midwives

14^th Edition, Page No.687-688

·        A Text Book of Community Health Nursing

20^th Edition, Page No.437-439

·        A Text Book of Obstetrics Including Perinatology and Contraception

17^th Edition, Page No.554-558.