Reproductive Health Nursing

Kea-Med University College, Debre Brehan Campus
Unit – One
Sexual & Reproductive health care
1. Advocating family health service
1.1 . Definition of terms
Family: - the smallest unit of a society or the building block of a society.
Family health: - the health confined to the health of a family.
Health (WHO definition): - is the state of complete physical, mental & social well being
and not merely the absence of disease or infirmity.
Reproductive health: - is the state of complete physical, mental & social well being and
not merely the absence of disease or infirmity, in all matters related to the reproductive
system, to its functions and process.
1.2 . Description of historical development and concepts of reproductive health

 It is helpful to understand the concept and to examine its origin.
 During 1960sUNFPA established with a mandate to raise awareness about population
problems and to assist developing countries in addressing them.
 At that time, the talk was (major issues) of “standing room only”, population booms,
demographic entrapment and scarcity of food, water and renewable resources.
 Concern about population growth, particularly in the developing world & among
technologies coincides with the increase in availability of technologies for reducing
fertility.
o The contraceptive pill became available during the 1960s along with;
 The IUD and long acting hormonal methods.
 In 1972, WHO established the special programme of research (HRP- Special program of
research development and research training in human reproduction), whose mandate was
focused on;
o Research into the development of new & improved methods of fertility regulation.
o Research on issues of safety & efficacy of existing methods (Pills and IUD).
 Modern contraceptive methods were seen as;
o Reliable independent of people’s ability to practice restrain.
o More effective than withdrawal, condoms or periodic abstinence.
o More over they held the promise of being able to prevent recourse to abortion or
infanticide.
 Population policies become widespread in developing countries during the 1970s and
1980s & were supported by UN agencies & a variety of NGOs like international planned
parenthood federation (IPPF) is perhaps the most well known.
 The dominant paradigm argued that rapid population growth would not only hinder
development, but was itself the cause of poverty & underdevelopment.
 The 1994 ICPD in Cairo has been marked as the key event in the history of reproductive
health followed by some important occurrences that made the world to think of other ways
of approach to reproductive health.
 The 3 elements of particular importance that brought paradigm shift that Cairo represents
& that has been reinforced in the recent special session of the “UN general assembly” are:-
a) Growing strength of the women’s movement & criticism of the over emphasis on the
control of female fertility & their sexuality.
b) The advent of HIV/AIDS pandemic, STDS became possible to talk about sex, sexual
relations outside marriage as well as with in it and about the sexuality of young
people.
c) Articulation of the concept of reproductive rights.
Reproductive Health Nursing Lecture Note for Third Year Nursing Student Prepared by Tesfa D. Page 1
E.g. the three rights in particular are;

i. The right of couples & individuals to decide freely and responsibly the
number and spacing of children to have information and means to do so.
ii. The right to attain the highest standard of sexual and reproductive health.
iii. The right to make decisions free of discrimination coercion or violence.
1.3 . Development of reproductive health
A. Before 1974 Alma – Ata conference.
 Basic health services in clinics & health centers.
B. Primary health care declaration, 1978.
 MCH services started with move emphasis on child survival.
 Family planning was the main focus for mothers.
C. Safe mother hood initiative in 1987.
- Emphasis on maternal health.
- Emphasis on reduction of maternal mortality.
D. Reproductive health, ICPD in 1994.
- Emphasis on quality of services.
- Emphasis on availability & accessibility.
- Emphasis on social injustice.
- Emphasis on individual woman’s needs & rights.
E. Millennium development goals and reproductive health in 2000.
- MDGS are directly or indirectly related to health.
o MDGS 4, 5 and 6 are directly related to health.
o While MDG 1, 2, 3 and 7 are indirectly related to health.
- World summit 2005, declared universal access to “RH”.
- Sexual & reproductive health is fundamental to the social and economic
development of communities and nations, and a key component of an equitable
society.
1.4 . Components of reproductive health
A) Quality family planning service.
B) Promoting safe motherhood (prenatal, delivery, postnatal, BF).
C) Prevention and treatment of infertility.
D) Prevention and management of complications of unsafe abortion.
E) Safe abortion services, where not against the law.
F) Treatment of reproductive tract infections, including STI.
G) Information and consoling of human sexually responsible parenthood & sexual and
reproductive health.
H) Active discouragement of harmful practices e.g. FGM.
I) Functional & accessible referral.
1.5 . The Target Groups for Reproductive Health Services

The following populations are groups of priority concern in reproductive health services.
These groups are:
• Women of childbearing age (15 – 49 years old).
• Adolescents (both male and female).
• Under five years old children.
1.6 . Advocating gender issues
- Gender: - refers to economic, social & cultural attributes & opportunities associated with
being male or female in a particular social at a particular point in time. It is learned and
changed through time.
- Sex: - refers to biological & physiological attributes of that identify a person as male or
female. It is innate behavior and can’t changed through time.
- Gender equality: - means equal treatment of women & men in laws and policies, and equal
access to resources & services within families, communities & society at large.
- Gender equity: - means fairness & justice in the distribution of benefits & responsibilities
between women & men.
- Gender stereotype: - refers to benefits that are so ingrained in our consciousness that many
of us think gender roles are natural & we don’t question them.
1.6.1 .Comparison of gender versus sex
Attributes Gender Sex Remark

Economic + -
Social + -
Cultural + -
Biological - +
Physiological - +
1.6.2 .Community perception about gender

1. Women give birth to babies, men do not. In many societies child rearing is the sole
responsibility of women.
2. In a case, when a child brought up as a girl learned that he was actually a boy, his school
marks improved dramatically Boys are intellectual than girls.
3. Sex is not as important for women as it is form men.
4. Women inherited property and men did not.
5. Division of labour (girls are expected to do more than boys; girls are expected to handle home
activities like making dishes, serving foods, cleanings). In a study of 224 cultures, there were
5 in which men did all the cooking and 36 in women did all the house building.
6. Dressing codes (girls and boys are expected to dress differently. Though it may vary across
cultures and societies.
7. Physical segregation of boys and girls (girls are told not to play with members of the opposite
sex, or not to get involved in any activity that will bring one into physical contact with people
of the opposite sex.
8. The kinds of games girls and boys play (girls are not encouraged to be involved in vigorous
physical activity and physical contact with each other; boys who do not engage in rough
physical games are thought to be ‘sissies’).
9. Emotional responses (girls and boys are expected to respond differently to the same stimulus;
while it is acceptable for girls to cry, and it is seen as a weakness in boys).
10. Intellectual responses (girls are not expected to take back or express their opinions while boys
are expected to respond and talk back).
All the above mentioned and the remaining perceptions of the community regarding
gender let a door to violence against women.
1.6.3 .Violence against women
 Violence against women is any act of gender based violence that results in, or is likely to
result in, physical, sexual, psychological harm or suffering to women, including of
liberty, whether occurring in public or private life.
 Globally, at least one is three women has experienced some form of gender – based abuse
during her lifetime.
 In addition to causing injury, violence increases women’s long term risk of a number of other
health problems, including;
o Chronic pain.
o Physical disability.
o Drug and alcohol abuse & depression.
o Unintended pregnancy.
o STI & Adverse pregnancy outcomes.
Gender violence throughout the life cycle of women
PHASE TYPE OF VIOLENCE
Pre - birth Sex selective abortion; battering during pregnancy (emotional and physical effects
on the woman; effects on birth outcome); coerced pregnancy.
Infancy Female infanticide; emotional and physical abuse; differential access to food and
medical care for girl infants.
Girlhood Child marriage; genital mutilation; sexual abuse by family members and
strangers; differential access to food and medical care; child prostitution
Adolescence Dating and courtship violence; economically coerced sex; sexual abuse in the
workplace; rape; sexual harassment; forced prostitution; trafficking in women
Reproductive age Abuse of women by intimate male partners; marital rape; dowry abuse and
murder; partner homicide; psychological abuse; sexual abuse in the workplace;
sexual harassment; rape; abuse of women with disabilities
Elderly Abuse of widows; elder abuse
Events triggering violence are;

Not obeying the man.
Arguing back.
Not having food ready on time.
Not caring adequately for the children/home.
Questioning the man about money or girl friends.
Going somewhere without the man’s permission.
Refusing the man sex.
The man suspecting the woman of infidelity.
1.6.4 .Prevention of violence
o Police & judicial reforms, legislatives initiatives, community mobilization to
encourage behavioral change.
o Empowering women & raising their status.
o Combating norms of violence.
o Reducing poverty and alcohol consumptions.
1.6.5 .Advocating on prevention of stigma & discrimination
 Stigma (stigmatization):- a process which we separate ourselves from other who remind us of;
 Illness
 Disfigurement
 Disability
 Death
 Shame
 Discrimination: - action or treatment based on stigma directed towards the stigmatized person or
people in employment, housing, medical care, education or social integration.
o The causes of stigma and discrimination are;

 Illness
 Disfigurement
 Disability
 Death
 Shame
o The consequences of stigma and discrimination are;
 Violence of human rights.
 Undermine prevention & care effort.
 Discourage from using services e.g. VCT.
o Measures to be taken to avoid stigma & discrimination are:-
 Community education.
 Comprehensive support.
 Inclusion of individuals who are stigmatized & discriminated.
 Alleviating current problem.
1.6.6 .Advocating on adolescent health
o Adolescents: - according to WHO, adolescents are those individuals who are found
between the age 10 and 19.
o The reason why we focus on adolescent health are:-
 Young people constitute a large & growing segment of the population
 68% of young population lives in less developed countries.
 Certain health problems (STI, HIV) are more prevalent in this age
group.
 Behaviors starting in adolescence frequently lead to health problems,
which may merge in later life.
 Future economic development depends on having increasing
proportion of reasonably well educated, healthy & economically
productive population.
o Adolescent health should focus on;

Education on:
 Their sexuality.
 On reproductive health challenges.
 Unwanted pregnancy.
 On STI, including HIV/AIDS.
 On FGM.
 On commercial sex activities.
 On sexual violence.
 On early marriage & its consequence.
 On the effects of unprotected sexual intercourse.
o The factors affecting RH in adolescents are;
 Age
 Marital status
 Gender norms
 Sexual status
 School status
 Child bearing status
 Rural/urban residence
 Peer pressure
 Culture/political condition
Unit–two
2.1. Assisting family planning need
2.1.1 Definition and concept of family planning
Family planning: - is defined as the use of various methods of fertility control that
will help individuals or couples to have the number of children they desire and at a
planned time interval in order to ascertain the well being of the children, parents and
community at large.
There fore;
 Family planning is what men and women use to prevent having unintended
pregnancies and too many children.
 FP makes it possible to reduce the risk that can place on the health of children
and women.
 Generally to avoid the 4 TOO’s
 Age at pregnancy: Too young/Too old.
 Number of pregnancies: Too many.
 Space of pregnancies: Too closely.
Family planning is considered to be part of the basic human rights of all individuals or
couples as it was endorsed by the international conference on population and development in
Cairo in 1994.
Family planning programs provide services that help people to achieve:-
 The number of children they desire.
 Reduce the risk of STI (especially condom).
 Improve the health of women & children by spacing birth.
To achieve the above objectives the service should offer;
 A wide range of contraceptives & counseling for well informed choice.
 Screening & follow up.
 Integrated services like prevention & treatment of STIs.
2.1.2. Explanation of benefit of family planning and factors affecting the
use of family planning service
 Family planning has the following benefits;
A) Demographic & economic benefit.
B) Health benefit for mothers & children.
C) Family planning benefits women & their societies.
A) Demographic benefit & economic importance
- Reducing high fertility & slowing population growth provided the dominant rational for
family planning programs in the 1960S.
- The rationale was based on concerns over the potentially negative effects on rapid population
growth and high fertility on living standards and human welfare, economic productivity,
natural resources, and the environment in developing world, but still surveys showed
substantial unmet need for family planning.
B) Health benefits of family planning
o During the 1980S, the public health consequences of high fertility for mothers & children are set
of concerns for international community especially for developing countries. High rates of
infant, child, and maternal mortality as well as abortion & its health consequences, were
pressing health problems in many developing nations and had also become of greater concern
for international development agencies.
o Simply by providing contraceptives to women who desire to use it, we can reduce maternal
deaths by as much as 1/3 because:
o Avoiding pregnancy at decreasing parity. If all women had five births or fewer, the
number of maternal deaths could drop by 26% world wide.
o Preventing high risk pregnancies (decrease MMR by ¼).
o Preventing unwanted pregnancies (reduces unnecessary risks).
C) Family planning benefits women & their societies
 Family planning reduces the health risks of women & gives them move control over their
reproductive lives. With better health & greater control over their lives, women can take
advantage of education, employment and civic opportunities. If couples have fewer children in
the future, the rate of population growth would decrease. As a result future demands or natural
resources such as water & fertile soil will be less.
2.1.3. Factors affecting the use of family planning service
1) Men’s attitude towards FP.
2) Women’s educational attainment.
3) Residence (urban versus rural).
4) Marital age
5) Religion
6) Proudness with the number of children they have.
7) Lack of information.
8) Lack of near by services.
9) Poor reporting on the demand and supply of the services.
10) Poor networking system among regional and woreda level.
11) Poor coordination among private and public stakeholders
2.1.4. Target groups for family planning
o The target groups for family planning are the following;
1) Women of child – bearing age (15 – 49 years old).
2) Adolescents (both sexes). They lack reliable information to make
responsible choice regarding their reproductive behavior, since they are
sexually active.
3) Under five children. They are the base for health adolescent and the health
of children & women is inseparable.
2.2. Teaching & counseling about family planning
 The main goal of FP is to improve the quality of life & reproductive health by empowering
individuals & couples to exercise their right to safe sexually, and to decide whether and when to
have children and how many to have. The other goal is to provide opportunities for people to
discuss their circumstances, needs & options to help clients make informed decisions about
contraception fertility and sexual health.
 Counseling is crucial.
 Through counseling providers help clients;
 Make their own choices.
 To be more satisfied.
 To use family planning more longer and successfully.
 Good counseling never takes too mach time.
2.2.1. Principles of counseling

1. Treat each client well.
 Be polite
 Respect every client
 Create a feeling of trust
 Be open to sensitive matters
2. Interact.
 The provider should listen
 Understands the clients
 Desire
 Situation
 Encourage the client to talk and ask
3. Tailor information to the client.
 Listen and give what information the client needs in language that the client
understands.
4. Avoid too much information.
 Give information to make informed choices
 Too much information makes it hard to remember
 The provider will spent much time and little time will be left for the client’s question,
concerns and opinions.
 Delivering too much information is called “information overload”.
5. Provide the method that the client wants.
 Help the client to make informed choice
 Respect the clients choices
 Start counseling from what the clients know before
 Check the client understands the method
 How it is used?
 The advantages and disadvantages
 Correct any mistaken ideas gently
 Make the client to consider other choices and compare them
 If there is no medical reason against it, clients should have the method what they want
 This makes them to use the method more longer
6. Help the clients understand and remember.
• Show sample family planning materials
• Encourage the client to handle them
• Show how they are used
• Explain flip charts pamphlets or posters if you have
• Check the clients understanding from time to time
• Give printed materials to the client to remind
2.2.2. Topics to be covered on family planning counseling

1. Effectiveness of the method.
• Because it is an important point for clients to make their choice.
• Tell them the effectiveness is also depends on the user.
2. Advantages and disadvantages.
• Tell the clients about the advantages and the disadvantages of the method what they
choose
3. Side effects and complications.
 Clients need to know the side effects of the method before they choose and start to use
 Clients who know the side effects of the method they choose will be more satisfied with
their choice
4. How to use?
 Demonstrate how to use the method.
 Cover instructions what clients can do to remember eg .a pill.
5. STD prevention.
• Family planning clients should know to use condoms if they might get STD even if they
are using another method
• Explain the ABC of safe behavior
6. When to return.
• If the client wants the supply
• If the client wants other information
• If the client wants to change the method
• If the client has seen the side effects or other signs or symptoms
• The client should be welcome at any time she comes
All the above point summarized by GATHER-steps. These are;
1) G – Greet the client
2) A – Ask the client about themselves
3) T – Tell the client about family planning methods
4) H – Help the client choose a method
5) E – Explain how to use a method
6) R – Return for follow up
A good counsellor
Understands and respects clients.
Earns the clients trust.
Understands benefits and limitations of methods.
Understands cultural and emotional factors that affect decision.
Encourages clients to ask questions.
Uses a non-judgemental approach.
Presents information in unbiased client sensitive manner.
Understands the effect of non - verbal communication.
Recognizes when s/he can not help and refers the client.
o Client assessment for family planning (Physical examination)
 Remember the client has;

 The right to decide whether or not to use FP.
 The freedom to choose method.
 The right to privacy and confidentiality.
 The right to refuse examination.
 In the process consider;
 Reproductive goals of the client.
 Personal factors (time, economic status etc).
 Accessibility and availability.
 The need for protection against STDS.
2.3. The examination done for client who came for family planning
A) Gynecological examination (breast examination)
- Self exam.
- By health care provider.
B) Medical examination
o Irregular bleeding.
o Pelvic infection.
o Vascular problem.
o Hypertension /heart disease.
o Personal /family history of diabetes or breast cancer.
2.4. Anatomy & physiology of female reproductive organs
Knowledge of female reproductive organs and glands is very important to understand the
mechanism of action of different family planning methods.
It also decreases misconception of family planning users about the effects of contraceptives on
their sexual activity.
Family planning users with knowledge of the reproductive system develop healthier attitude
towards normal sexuality.
Female reproductive organ can be divided into external and internal organs.
A. The external sex organs
1. Mons pubis (mons veneris):- this is a fatty pad tissue over the pubic bone. After puberty it
is covered with hair.
2. Labia majora (Outer Lips):- there are two folds of fat and arealor tissue, covered with skin
and pubic hair on the outer surface. They extend from the mons veneris to the perineum where
the two lips merge behind. It helps to protect the reproductive and urnary organ the lie
between them.
3. Labia minora (Inner lips):- are two thin skin folds lying between the labia majora.
Anteriorly they divide to enclose the clitoris. It is the sensitive part to touch. During sexual
arousal, they swell & darken in color. It contains clitoris and another fold called hood.
4. Clitoris:- It is a small rudimentary organ corresponding to the male penis located at the very
top of the inner lips. It is highly vascularized and most sensitive part of the female genitalia.
5. The urethral orifice:- the external opening of the urethra which lies about 2.5 cm posterior
to the clitoris.
6. The vaginal opening:- It is the entrance to the vagina and it is partially closed by the
hymen, a thin membrane which tears during sexual intercourse or during birth of the first
child.
7. Hymen:- thin membrane just inside the vaginal opening. Varies greatly in shape and size. In
a virgin, it may be stretched or torn during the first experience of sexual intercourse. Some
virgins may not have all intact hymen.
8. Perineum:- It is the triangular area, which is found posterior to labia minora and anterior to
the anus.
9. Bartholin's glands:- these are two small glands which open on either side of the vaginal
opening and lie in the posterior part of labia majora. They produce mucus during sexual
contact. Sometimes these glands become infected.
10. Skene’s gland:-found on either side of the urethral opening. Produce small amount of mucus
which lubricate the opening.
B. Female Internal Reproductive Organs consist of:
1. Vagina:- It is elastic, muscular passage, which lies between the vaginal opening and
cervix. It is about 10cm long. The vagina is the female organ of sexual intercourse. It is a
passage for fetal delivery and menstrual blood flow. It is capable of great exertion of seen
during child birth and sexual intercourse.
2. Cervix:- It is part of the uterus, which is situated at the lower end of the uterus protruding
into the upper vaginal canal. The opening of cervix is called the cervical os. The opening
has glands responsible for lubricating the vagina.
3. Uterus:- The uterus or womb is a hollow muscular pear shaped organ in the pelvis,
situated behind the bladder and in front of the rectum. It leans forward (anteversion), bends
forwards on itself (anteflexion). During pregnancy the uterus shelters, supports and
nourishes the growing fetus. It prepares for pregnancy each month; following pregnancy it
expels uterine contents. It has a size of lemon in non-pregnant state.
4. Fallopian Tubes (oviducts):- There are two fallopian tubes, which extend outward and
back from the top of each side of the uterus. The fallopian tubes are muscular channels of
about 10cm long with ciliated canal that helps in the movement of the ova from the ovary
to the uterus. Fertilization takes place in these tubes.
5. Ovaries:- There are two ovaries each of which is attached by ligaments to each side of the
uterus. They are the principal structures of the female reproductive system. Each ovary
produces thousands of follicles, these follicle produces female sex hormones known as
estrogen and progesterone, which are released into the blood stream and responsible to the
thickening as well as maintaining of the lining of the uterus in preparation for the
implantation of the fertilized egg. It is an almond shaped organ.
2.5. Mechanism of action of contraceptives
Generally the mechanism of action is by disturbing the natural physiology of the female
reproductive system.
Specifically the mechanism of action of contraceptives includes;
A) Preventing direct unit of spermatozoa and ovum.
E.g. Barrier methods of FP, Withdrawal, abstinence.
B) Chemical killing of the spermatozoa.
E.g. Spermicidal agents.
C) Thickening the cervical mucus.
E.g. COCP, POP.
D) Preventing/Suppressing ovulation.
E.g. Progestogen only method (injection), COCP, breast feeding.
E) Preventing implantation of the fertilized ovum.
E.g. IUCD.
2.6. Classification of female contraceptives
A. Base on origin of preparation.
o Natural. E.g. Breast feeding, Abstinence, Withdrawal /coitus interrupts/,
Calendar methods, cervical mucus /Billing’s methods/, Sympathothermal.
o Artificial. E.g.
 Barrier methods. E.g. diaphragm, Condom, Cervical cup and

spermicidal.
 Intrauterine device (IUD).
 Hormonal methods. E.g. Pills, Implants, Injectable.
 Surgical methods. E.g. Tubal legation, Vasectomy.
B. Based on duration.
1. Temporary. E.g. Except tubal legation and vasectomy.
2. Permanent. E.g. Tubal legation, Vasectomy.
C. Based on sex of users.
1. Female. E.g. Except withdrawal and Vasectomy
2. Male. E.g. Condom (female), Vasectomy, Abstinence, Withdrawal /coitus
interrupts/.
D. Based on mechanism of action. See the above classification.
1. Natural methods/Fertility Awareness Method
A. Breast feeding (lactation amenorrhea) method
This method has been used traditionally for a long period of time. Women are less
fertile when lactating their babies. There is delay in ovulation during this time because
of hypophysial or hypothalamic stimuli from lactation. But the duration of suppression
of ovulation is quite variable. In a few cases ovulation returns before the first post
partum menstrual cycle and thus risk of pregnancy. Prolonged breast feeding may also
lead to malnutrition of the baby as it is not adequate to meet the baby’s requirements.
However, complementary methods such as condoms, diaphragms, or IUDs are
recommended.
A woman who uses LAM should be given specific instructions:
- Breastfeed often: ideally at least 8-10 times a day including at least once at
night. Daytime feeding should not be more than four hours apart and night time
not more than six hours apart. Encourage the infant to breastfeed enough.
- Breast feed properly: teach correct techniques.
- Supplemental foods should be started by the sixth month. At this time the
infant may breastfeed less and LAM may no longer be effective. Recommend
additional family planning method.
- Start another family planning method when:
• Her menstrual period returns
• She stops breastfeeding fully or nearly so
• Baby is six months old
• She no longer wants to rely on LAM for family planning
More effective for those mothers who are amenorric during breast feeding.
More effective for those who are continuously breast feeding (fully or nearly fully with
infrequent juice, milk, water feeding) for the first 6 months.
It has high failure rate (0.9-1.2%)- recent WHO study.
B. Abstinence
Means keeping oneself from sexual intercourse for a long period of time.
It is 100% effective, if properly implemented.
C. Withdrawal (coitus interrupts) method
Coitus interruptus is withdrawal of the penis from the vagina before ejaculation. Thus
the semen is deposited outside the female genital tract. It requires sufficient self
control by the man to withdraw before ejaculation and high level of motivation and
cooperation from both couples.
This method is less effective than other contraception. Failure may result from escape
of semen before ejaculation or deposition of the semen close to the vagina where the
sperm cells can swim up into the female genital tract.
This method is not advisable if pregnancy is contraindicated.
It has the highest failure rate, so it is not a method to be recommended.
D. Calendar method
 It is a personalized calendar calculation based on the length of a woman previous 6-12
menstrual cycles.
 The calendar or rhythm method is the most widely used of all periodic abstinence
technique.
Effectiveness
 It has a high failure rate (20-30%).
Indication
 It is more convenient to use these method than other periodic abstinence
technique in women who have reasonably regular cycle.
Contradiction
• When there is need for highly effective protection against pregnancy
• Inability to comply with sexual abstinence as required by the methods.
• Irregular cycles.
• Breast feeding
Advantage
 Doesn't require daily monitoring of fertility signs.
Disadvantage
• High failure rate.
• Difficult to use with irregular cycle.
• Needs long time to learn.
• Sexual abstinence.
Procedure
Instruction to the client
 While she is being trained she can use non hormonal contraceptive methods. Hormonal
methods alter the woman cycles.
•Record the number of days in 6-12 consecutive menstrual cycles.
•Record the first day of menstruation as the first day of the cycle.
•Calculate the first fertile day by subtracting 18/20 from the shortest cycle.
•i.e. First fertile day = shortest cycle – 18
•Calculate the last fertile day subtracting 11/10 from the longest cycle.
•i.e. Last fertile day = longest cycle – 11
•Avoid sexual intercourse during the fertile phase.
Example
The women's last 6 cycles were 28, 26, 29, 27, 29, and 27 days
Calculation Shortest cycle = 26
Longest cycle = 29
First day of the fertile phase = 26 - 18 = 8
Last day of the fertile phase = 29 - 11 = 18
 The fertile period of the women
th
is between 8 - 18 days so she should avoid sex in
this period starting from the 5 day of menstruation.
N.B. With regular cycles (every 28 days or close to it). Since ovulation occurs about
14days before the next period about 14 days before the next period is due, a woman
should count backward 14 days from her next period is expected, to calculate the day
she will ovulate.
• She should avoid sex from about 7 days before that day until about two days after.
Example:
The woman's regular cycle is 30 days.
Regular cycle 30 - 14 = 16
• First day of fertile phase 16 – 7 = 9
•The last day of fertile phase = 16 + 2 = 18
Therefore, she should avoid sex between the 9th and 18 th day of the cycle.
Follow up
Reason to return
• When she need to discuss her experience about the method.
• When woman's situation changes (had a baby or breast feeding or close to menopause).
• If the woman wants to stop the method or use another method.
E. Cervical mucus (Billing’s ) method
 The cervical mucus method is based on recognizing and interpreting cyclic changes in
cervical mucus that occur in response to changing estrogen levels. The fertile and infertile
period is determined by changes in the appearance and viscosity of the cervical mucus.
There is increased amount of slippery, mucus, which reaches peak just before ovulation.
This property is called Spinn Barkeit phenomenon. The fertile phase begins when stretchy
and slippery mucus is first noticed and ends four days after the last day of fertile mucus.
 User effectiveness is 15 – 20/100 women.
Indication
Similar to BBT method and if the woman are willing to touch her genitalia.
Advantage
Similar with BBT method
Disadvantage
• Requires several days of abstinence.
• Needs long duration of practice.
• Difficult to use in case of vaginal infection.
• Not appropriate for women with medical contra indications to pregnancy.
Procedure
Instruction to the client:
Checking and recording cervical mucus pattern.
1. Provide the client with a chart to record the mucus pattern.
2. Record the sensation of either dryness, moistness or wetness felt at the opening of the
vagina. Observe the mucus pattern at convenient time at least twice a day with the first in the
morning and the last check in the evening every other night (Alternate Dry Day Rule). This
will keep the client from confusing semen with cervical mucus.
3. Check for the presence of mucus by wiping the vagina with a paper tissue or by using a
finger.
4. Collect the mucus when present, on a paper tissue or at the finger tip.
5. Note the color as white, cloudy or clear and the physical characteristics as thin and
lubricate, thick and viscid.
6. Check for the elasticity by opening the paper tissue or the fingers on which their mucus has
been collected.
7. Record the daily changes in the mucus and sensation felt in the vagina in the chart at night.
8. Use symbols or letters for different changes, such as:
D - for dry
M - for mucus
P - Periodic bleeding
9. Mark the last day of the slippery mucus which is the peak by a cross (+. and the following
three day as 1, 2, 3. The peak can only be recognized retrospectively when the mucus is no
longer slippery and elastic.
10. If slippery mucus reappeared after the peak has been recorded disregard the previous
recording and record the second peak.
Timing of sexual intercourse Sexual intercourse is permitted:
- Immediately following menstruation until the first sign of mucus.
- On the evening of the fourth day after the peak symptom and until menstruation starts.
Sexual intercourse should be avoided:
- From the first day that the mucus is observed after menstruation until then end of the fourth
day after the peak symptom.
- At any time if the client has any doubt about the mucus pattern.
Factors affecting the mucus pattern
1. Vaginal or cervical infection.
2. Vaginal secretions due to sexual stimulation.
3. Decongestant drugs used for cold or sinusitis.
4. Physical or emotional stress.
5. Breast-feeding.
F. The Basal body temperature method (BBT)
The basal body temperature is based on the increase in body temperature that occurs shortly
after ovulation. The temperature rises by 0.2 - 0.4°c and remains high until the next period.
The couples are advised to refrain from sexual intercourse from the day she noticed the
temperature until three days after the fall of temperature.
Sexual intercourse can be done from the third day/night of temperature fall until the next
menstruation.
Indication
• If the women is reluctant to touch her genitals.
• If the couple are willing to abstain from sexual intercourse for long period of time.
• If the woman has irregular menstrual cycles.
Advantage
• No systemic or long term effect.
• Encourage discussion about family planning between the couples.
Disadvantage
• Requires several days of abstinence.
• Needs longer duration to practice.
• False interpretation in case of febrile condition.
• Special thermometer may be required.
Instruction to clients
• Taking the temperature at constant time.
• Use thermometer, which has a scale with a wider range (easy to read).
• Keep the thermometer near the bed within hands reach.
• Shake the thermometer to lower the mercury level at night before going to bed.
• Take the thermometer and measure the temperature immediately after waking up (before
going out of bed) for any activity.
N.B.
•Make sure that the thermometer reads below 35°c before use. If not shake the thermometer
again.
•The temperature should be measured at the same time each day during a particular cycle.
•If the woman is working on night shift measure the temperature during the day or in the
evening after at least 3 - 5 hours of rest at the same time of each day.
•The temperature can be measured by the oral, rectal or vaginal route (rectal and vaginal
route are more reliable).
•Always use the same route and the same thermometer throughout one menstrual cycle as
long as it functions.
Technique of Measuring
 Oral route: Place the bulb of thermometer under the tongue with lips closed for five
minutes.
 Rectal route: Use a rectal thermometer, smear a little petroleum jelly or kyjelley on the
bulb and insert the thermometer into the rectum for about 2.5 cm while lying down are on
side with knees drawn up. Keep the thermometer inside the rectum for three minutes.
 Vaginal route: Insert the thermometer gently in to the vagina for about 4.5 cm and leave
it for three minute.
N.B. After removing the thermometer, take the reading and record it on the chart.
Clean the thermometer using cool water and return to its usual storage place.
G. Symptothermal method
 Usually cervical mucus method plus basal body temperature method. And also calendar
method and cervical mucus method.
 It is the combination of calendar & temperature methods.
 The 1st day of abstinence is predicted by using calendar method (shortest cycle) and the
last day by temperature method.
2. Artificial method
A. Diaphragm
o A shallow, dome–shaped, circular rubber cup with flexible rim at the margin having a
diameter of 5-10cm.
o It requires medical person to measure the appropriate size.
o It has different size which is designed to fit behind the pubic bones, the lateral vaginal
wall & the posterior fornix.
o Placed in the vagina 3 hours before coitus and removed 6 – 8hrs after intercourse but
not more than 24 hours.
o Spermicidal jelly is applied to the inside & outside surface placement in the vaginal.
o It is inserted into the vagina to cover the cervix and upper vagina.
Mechanism of action
 The diaphragm prevents pregnancy by blocking entrance of sperms to the uterus. The
spermicides should be applied on both sides of the diaphragm and in inactivates or kills the
sperms.
 Another intercourse act requires addition of the spermicide.
Effectiveness
o The failure rate of the diaphragm is about 18%.
Indication
 The diaphragm should be provided to any woman who requests it after receiving appropriate
counseling and reaching informed decision.
 It is appropriate for a woman. Who:
- Wants her own method of contraception.

- Wishes to separate the time of application from the time of intercourse, and
- Can learn the insertion technique.
Contraindication
• Chronic cervicitis.
• Genital abnormalities, which make insertion difficult.
• History of toxic shock syndrome, and allergy to latex or spermicides.
Advantage
• Can be used as back up method.
• Can be stopped at any time.
• Appropriate for women who have infrequent intercourse.
• No effect on breast cancer risk.
• Easy to insert, and be used again, (reusable)
• No side effects of hormones.
Disadvantage
• Not good to use in the first 12 weeks post partum when the pelvic organs are
reorganizing.
• Not appropriate for those who are prone to urinary tract infections.
Complication/ side effects
• Urinary tract infection
• Vaginal lesion caused by diaphragm’s rim.
• Toxic shock syndrome.
• Local irritation caused by sensitivity or allergy.
• Partner or user discomfort.
• Vaginal discharge and odour (if left more than 24 hours).
Equipment Needed
• Sterile sample of diaphragms in range of sizes.
• Sterile jelly or boiled water to lubricate diaphragms during fitting.
• Non sterile gloves.
N.B. Samples of diaphragms should be disinfected for the next client.
Procedure
1. Select the appropriate size by doing vaginal examination:
 With the first and second fingers in the posterior fornix, the thumb of the examining hand is
placed against the first finger to mark where the first finger touches the pubic bone.
 The distance between the tip of the middle finger and the tip of the thumb is the diameter of
the diaphragm that should be first tried.
 A set of test diaphragms of various sizes is used and the next diaphragm is inserted and
checked by palpation.
 The largest diaphragm that fits comfortably should be selected. The woman does not feel the
diaphragm if it fits properly. A size 65, 70, or 75 will fit most women.
2. The patient should practice insertion and should be reexamined to confirm the proper position of
the device.
 The diaphragm can be inserted several hours prior to intercourse. If intercourse is repeated she
should add spermicides into the vagina without removing the diaphragm.
 The diaphragm should be left in place at least six hours after intercourse to allow
immobilization of sperm then, it is removed, washed with soap and water, allowed to dry, and
stored away from heat.
How to insert
1. Hold the diaphragm with the dome down, (like a cup).
2. Apply spermicidal cream or Jelly into the cup of the diaphragm and around the rim.
3. Press opposite side of the rim together, with the doom side towards the palm of the hand push
the diaphragm into the vagina as far as it goes.
4. With a finger touches the diaphragm to make sure it covers the cervix through the dome of the
diaphragm. The cervix feels like the tip of the nose.
How to remove
 The diaphragm should not be left for more than 24 hours (increase risk of toxic shock
syndromes).
1. Insert a finger into the vagina until the rim of the diaphragm is felt.
2. Gently slides a finger under the rim and pull the diaphragm down and out.
3. Note: Be careful not to tear the diaphragm with a finger nail.
4. Wash, check for holes, dry and store in a clean, dark and cool place if possible.
Follow up
1. Arrange a follow up visits in one to two weeks to re-check fit and usage.
2. Instruct the women to wear the diaphragm for at least 8 hours before the visit to check
fitness.
3. Encourage the client to return at any time for problems such as side effects, losses or
gains weight more than 5 kg., complains of discomfort.
B. Condom
 It is a pouch made up of polyurethane
 There are condoms for both males and females.
 The female condoms have two rings in the inner and outer.
 It is also effective to prevent STD.
C. Cervical cup
 Rubber cup with metallic rim designed to fit the cervix.
 These devices, also made of soft rubber, are an alternative to the diaphragm for some
women.
 The cup is much smaller than the diaphragm, does not contain a string in the rim and
covers only the cervix. Like diaphragm they also come in different sizes.
Mechanism of action
Act in a similar way to the diaphragm. They are used with spermicides.
They block the sperm from entering the uterus.
Effectiveness
The failure rate of cervical cap varies from 18% for nulipara to 36% for
multipara.
Indication
Similar to diaphragm
Contraindication and side effect
Advantage
Safe, women controlled.
Offer contraception when needed.
No side effects from hormones.
No effect on breast milk.
Can be stopped at any time.
Easy to use with little practice.
Disadvantage
High failure rate.
Less effective in parous women.
Not widely available.

Requires fitting by family planning provider.
Sometimes may be difficult to remove.
Cap should be washed after each use.
Procedure
Materials:
• Sterile samples of cervical caps usually size 22 and 25.
• Sterile jelly or boiled water.
• Non sterile gloves.
How to insert
1. The cervical size is estimated by inspection and palpation (using speculum)
2. Select the appropriate size.
3. The cap is 1/3 filled with spermicides.
4. The cap is inserted by compressing it through the finger and thumb and placing it through the
vagina, dome outward.
5. Push the cap gently upward to fit over the cervix. The dome indented with the examiners finger to
create suction against the cervix.
6. Check for evidence of suction after the cap has been in place for a minute or two by rotating the
cap.
N.B.: Muliparous women usually require a size 22 while parous women generally are fitted with a
size 25. The client should be instructed to check for dislodgment after intercourse.
How to Remove
1. The cap should be left at least six hours after intercourse (it should not be left for more than 48
hours).
2. Insert a finger into the vagina until the rim of the cap is felt.
3. Press on the cap rim until the seal against the cervix is broken, and then tilt the cervix.
4. Hook a finger around the rim and pull it side ways out of the vagina.
5. Wash, dry and store like that of diaphragm.
Follow up
D. Spermicidal
Spermicides are chemicals that inactivate and kill sperm. To a certain extent they also form a
barrier over the cervix. The different kinds of carriers for spermicides include creams, jellies
or gels, suppositories, foaming tablets and aerosol foams.
It involves putting spermicidal chemical /nonoxynol-9/ into the vaginal 10 – 15 minutes
before each sexual act.
Mechanism of Action
Inactivate and kill sperm. Usually used as a supplement to other barrier methods. They offer
protection against some STDs, but the effect against HIV has not been proved.
Effectiveness
When used alone, it is less effective than other alternative modern methods.
Failure rate is about 20%.
Indication
• To any individual who requested it.
• Appropriate for:
- Highly motivated individual to use it effectively,
- Women’s natural fertility is decreased by age and breast feeding, and
- wish to use spermicides in association with other barrier method.
Contraindication
o Allergy to spermicides.
Side effect / complication

o Allergy (skin irritation)
Advantages
• Some protection against STDs (bacterial).
• Easy to insert and can be used by any one.
• Serves as lubricant.
• No systemic effects of hormone.
• May protect against cervical cancer.
Disadvantages
 May interrupt sexual act (for tablets and suppository 5/10 - 15 minutes are needed for
dissolving.
 Must be used before each act of sexual intercourse.
 Causes more wetness for vagina for several hours after intercourse.
 Tablets may cause sensation of heat to the women or the partner.
 Irritation and discomfort with frequent use.
 Less effective (high failure rate) compared to other modern method.
Procedure
Instruction to the client on how to insert
1. Wash your hands.
2. Insert foam, jelly or cream deep into the vagina just before intercourse.
3. Foam, jelly or cream are inserted using applicator as follows:
• shake the can up and down to mix.
• fill the applicator.
• Place the applicator high up into the vagina then push in the plunger so that their foam, jell
or cream goes up into the vagina.
4. Wash the foam applicator with soap and water after use.
5. Keep a spare container of spermicides at home.
6. Tablets or suppositories are inserted:
- Wash your hands.
- using the middle and index finger push the tablet or suppository deep into
- The vagina 10 - 15 minutes before intercourse.
- withdraw the middle finger and push the tablet and suppository deeper with
- The index finger, until it touches the cervix.
- Wait at least six to eight hours after intercourse if douching is wanted.
Follow up
Remind the client to return to the clinic if side effects, dissatisfaction with the methods, symptoms of
STDs otherwise, she should return when more spermicide is needed.
The various preparations include:
 Aerosol foam.
 Creams.
 Foaming tablets.
 Contraceptive sponges.
o It is made up of polyurethane with N-9.
o It looks the shape of mushroom cap.
o It is only prepared for single use with a diameter of 2cm.
o Removed 6-8 hrs after intercourse.
o It less effective, but the most expensive.
E. Intrauterine contraceptive device /IUCD/
Intrauterine devices are small flexible devices made of metal and/or plastic that come in
different shapes and sizes and are inserted in the uterus through the cervix. The various shapes
include ring, loop, spiral, T shape, 7 shape and others. Some are coated with copper, and some
contain small amounts of the female hormone progesterone. Most IUDs have a short "tail" or
string that the women can feel by putting her fingers into her vagina. The most commonly
used type in most countries including Ethiopia is Copper-380A.
Long term reversible contraceptive methods (3-10 years).
There are two types of IUCD. These are
a. Non-medicated IUCD /loop/;
- They are inert.
- They are the 1st generation.
- Used nowadays.
- They are larger in size.
- The do not need regular replacement.
b. Medicated IUCD;
o They are bioactive.
o They are smallest in size.
o Needs regular replacement every 10 – 12 years.
o Contains either cupper or progesterone which increases their
effectiveness and to decrease the incidence of side effect.
o The currently used medicated IUCDS are:
a) Copper – (T380A): T-refers the shape of the equipment, 380-refers
the surface area of the instrument, A/Ag-refers the silver coated
under cupper.
- For 10 – 12yrs.
- 2 nd generation.
b) Progestasert:
- Replaced every year.
- 3rd generation.
Mechanism of Action
o The exact mechanism of action of IUDs is not completely understood but it is believed that –
sterile inflammatory reaction to the endometrium. However, evidences now indicates that the
IUD prevents pregnancy by a combination of mechanisms of action including:
•Inhibition of sperm migration in the upper female genitalia,
•Inhibition of ovum transport by altering tubal motility and formation of thick cervical
mucus,
•Inhibition of fertilization,
•Inhibition of implantation,
•Inhibition of ovulation.
Effectiveness
 Copper -T 380A has proved to be highly effective for at least 10 years with failure rate
of 2.6 per 100 women. The hormone coated (Levonorgestrel) releasing IUD lasts for
more than 5 years with low failure rate similar to those of the copper - T 380A.
The failure rate of IUDs tends to be lowered if:
• The IUD is medicated with copper and progesterone,
• The IUD has a larger surface area,
• The IUD has a low expulsion rate,
• Partial and complete expulsions are detected quickly,
• The IUD is inserted all the way to the top of the fundus,
• Used in older women.
Indication
 The IUD should be provided to any women who requests after receiving appropriate
counseling and reaching an informed decision and who has no contraindications to its
use.
Contraindication
• Active, recent or recurrent pelvic infection.
• Suspected or known pregnancy.
• Cancer of the uterus, cervix or ovaries.
• Congenital uterine abnormalities or benign tumor of the uterus (myoma).
• Undiagnosed abnormal uterine bleeding (AUB).
• Risk factors for exposure to STD's including HIV/AIDS.
• Risk factors for pelvic inflammatory diseases such as:
- post partum endometritis,
- Infection following abortion that occurred in the past three months,
- impaired response to infection,
- Diabetes /steroid treatment.
• History of ectopic pregnancy.
• Impaired coagulation response.
• Valvular heart disease.
Advantage
• Very little supervision or follow up.
• Highly effective with low failure rate.
• Doesn't reduce breast milk (can be used by breast feeding mother).
• Can be used to menopause
Disadvantage
• Not suitable for all women because of risk of increased infection
• Needs a trained health worker for the initial screening and insertion or removal.
• Does not protect against STDs, including HIV/AIDS.
• In about 0.1% of cases there is uterine perforation during insertion.
• May increase risk of PID (Pelvic inflammatory diseases).
• May come out of the uterus without the client knowing.
• Increases menstrual blood flow and cramps.
Side Effects and Complications
• Bleeding from the wombs and pain in the abdomen (abnormal uterine bleeding).
• Spotting between periods.
• IUD expulsion.
• Pregnancy including Ectopic.
• Infertility.
• PID (increased risk within the first four months).
• Uterine perforation.
• Anemia.
• Difficult removal of the IUD.
Explanation to the Client (Information and Counseling)

 All IUD clients must receive appropriate counseling for selecting and using the method. For
selecting the method, discuss the following points with each client in a language she
understands.
 Advantages and disadvantages, effectiveness, risks and benefits, side effects, procedures
of insertion and removal and cost.
 Alternative methods of family planning.
 The type of IUD to be inserted (show a sample) and proper time for its replacement.
 The importance of regular follow - up visits
Provision of IUD
Who can insert IUDs?
Doctors, midwives, nurses and other health professionals can insert IUDs, provided that they
have been properly trained.
Health Assessment before IUD insertion
The purpose of the health assessment is to determine the clients’ suitability for the use of the method.
i. History: History of diabetes, anemia, immune depression, STDs including HIV/AIDS, PID and risk
factors to STDs such as multiple sexual partners.
ii. Physical Examination: Speculum visualization of cervix, bimanual pelvic examination and other
examination as indicated by the medical history.
iii. Laboratory Tests: Are not routinely done but when indicated by medical history and physical
examination. Whenever possible and appropriate selected tests as part of reproductive health services
can be done including:
- Urine analysis for glucose and protein
- VDRL (syphilis screening)
- Hemoglobin or haematocrit
- Pap (cervical smear)
Timing of Insertion
i. If the client is not at risk of pregnancy: Insert an IUD any time during the menstrual cycle
especially at mid cycle because cervical opening is a little larger than usual.
ii. If the client is at risk of pregnancy: A pregnancy test should be done before inserting the
IUD or it should be inserted during the next menstrual period (with in five days of start of
mensus)
iii. If Post partum: Immediately following childbirth after the placenta has been expelled or
with in 1or 2 days after delivery (with in a week).
Note: It needs special training.
- Six to eight weeks post partum in exclusively breast-feeding women who have ammenorrhea, since
pregnancy is very unlikely.
iv. If Post abortion: Insert immediately after uncomplicated abortion. If infection is present
treat, provide alternative method and reconsider IUD insertion three months later.
Inserting the IUD
Minimum equipment requirements for IUD insertion
 sponge - holding forceps,
 tenaculum or Allis - chalmers forceps,
 pean artery forces, curved,
 speculum,
 uterine sound,
 iodine cup,
 pair of scissors,
Technique
The procedure should be done under aseptic technique.
1. Explain the procedure to the women
2. Perform a careful bimanual examination
3. Cleanse the vagina and cervix with bactericidal solution
4. Insert the speculum
5. Grasp the anterior lip of the cervix and expose with tenaculum.
6. The uterine cavity should be measured with uterine sound slowly and gently. Do not
attempt to insert the IUD into uterus, which sounds less than 6.5 cm.
7. Load the IUD into the inserter barrel under sterile condition.
8. Introduce the inserter barrel through the cervical canal in to the uterine fundus by applying
steady gentel traction on the tenaculum.
9. Insert the IUD in to the cavity of the uterus either by push technique or withdrawal
technique. The withdrawal technique is slightly preferred. Insertion should be done slowly and
without much force.
Note: Follow the instruction of each device according to the manufacturer.
Push technique: Plugging the inner plunger into the outer barrel.
Withdrawal technique: retracting the outer barrel over the plunger
10. Gently and slowly remove the inserter barrel from the cervical canal.
11. Clip the strings. Leave about 5cm; it is always possible to trim strings at a later date, and
you should be able to see the stings protruding from the cervical OS.
12. Remove the tenaculum and then the speculum.
13. Ask the client how she is feeling, reassure her that some cramping is normal and ask her to
remain in supine position for about 5 minutes and then help her to sit up. The recovery period
may be up to 20 or 30 minutes.
14. Offer or recommend analgesics for the first 24 - 48 hours after insertion.
Instruction to the client

• IUD is effective immediately as a contraceptive method.
• Check for the IUD string because IUD can expel especially during the first 6 weeks after
insertion or during menstrual period.
• Methods to check:
- Wash hands first.
- Sit in squatting position and reach into the vagina with your two fingers, as far as you
can reach and feel the strings. Be careful not to dislodge the IUD by pulling on the
string.
- Wash your hands again.
How often to check
• Every week during the first month after insertion.
• After each menstrual period and mid way between periods.
• After any of the following symptoms:
- Cramping in the lower abdomen,
- Spotting between period,

- After intercourse and
- Painful intercourse
N.B. Advice the women to return to the clinic as soon as possible if she:
• sees the following danger signs:
P - Period late (pregnancy) abnormal spotting or bleeding,
A - Abnormal pain, pain with intercourse,
I - Infection exposure (such as Gonorrhea) abnormal discharge,
N - Not feeling well - fever, chills and
S - String missing, shorter or longer.
• Feels the hard part of the device in the vagina or cervix
• Expels the device
N.B. In the mean time she should use a non-hormonal method of contraception such as
condoms.
Follow up
Advice to visit a clinic for a routine follow up with in three months (not before the first
menstrual period). The purpose of the follow up is to check that the IUD has not been expelled
and there are no major complaints. There after a routine follow up is advisable every year.
Indications for removal of an IUD
 When the client makes a firm request.
 When there is a medical indication for removal such as: pregnancy, acute PID,
suspected perforation, persistent cramp after insertion, severe dysmenorrheal,
endometrial or cervical malignancy, and abnormal and excessive bleeding with
evidence of anemia.
 When the effective life span of the IUD expired (this applies for medicated IUDs).
 When the women reaches menopause (remove the IUD one year after the last period).
 Displacement of the IUCD.
 Missing threat.
 Suspected perforation.
 Persistent cramp after insertion.
N.B. When there is a complication, refer to the nearest hospital.
2.1. Hormonal contraception
Hormonal contraceptive could be either of the following;
1. Pills-Taken per oral.
a) Combined oral contraceptive (The pill or cops).
b) Progestin only pill (Mini pill or Pop).
2. Injectable contraceptives.
3. Implants.
2.1.1. Combined oral contraceptives pills
Mechanism of Action
Inhibits ovulation
Prevents implantation
Thickening cervical mucus
Reducing sperm transport
Effectiveness
When COC pills are used correctly and consistently, their pregnancy prevention rate is greater
than 99%.
Indications
COCs are best options for women who have some of the following characteristics:
• Nulliparous.
• Young, sexually active.
• Not at risk for STIs, including HIV.
• Desiring spontaneous intercourse.
• Non-lactating postpartum.
• Desiring a reversible method.
• Bothered by heavy or painful periods.
Contra-indications
Absolute;
 Proven or suspected pregnancy
 Undiagnosed abnormal uterine bleeding
 Coronary artery disease and history of stroke and thromboembolism
 Hydatidiform mole
 Current liver disease (Liver carcinoma, Hx of cholestatic jaundice during
pregnancy)
 BMI>30
 HTN
 Breast Ca.
 Angina.
 MI
 Hyperlipidemia
 Focal migraine
Relative;
 Obesity
 Varicosities
 Epilepsy bronchial asthma
 Depression mood fluctuation
 Smoking
 Age>35
 Lactating mothers who are in the first six months
Advantages
Highly effective
Safe: Low dose combined pills are very safe for almost all women;
Can be used at any age from adolescence to menopause;
Fertility returns soon after stopping;
No need to do anything at time of sexual intercourse;
Can be used as emergency contraceptive after unprotected sex;
Reduction of acne and hirsutism
Monthly periods are regular; lighter monthly bleeding and fewer days of bleeding;
milder and fewer menstrual cramps.
Reduction of risk of PID, benign breast disease, e.t.c.
Improvement of IDA.
Relief of menstrual disorder.
And other non-contraceptive advantages.
Disadvantages
 Challenge of daily compliance: not highly effective unless taken everyday. Difficult for some
women to remember everyday.
 New packate of pills must be at hand every 28 days.
 Not recommended for breast-feeding women because they affect quality and quantity of milk.
 In few women it may cause mood changes including depression, less interest in sex.
 Do not protect against sexually transmitted infections (STI's) including AIDS.
Side - effects
o The following side effects are common during the first three cycles, and then usually disappear:
Break through bleeding, nausea/vomiting, dizziness, breast tenderness/mastalgia, mild
headaches, weight gain/edema of the leg, fluid retention, depression, amenorrhea and problems
with vaginal infections (Pills change the environment of the vagina and make it easier for some
microorganisms to grow), Acne, Chloasma, Mild hirsutism, Mood change/depression, Post pill
amenorrhea, e.t.c.
Complications
- Cardiovascular disease (related to the estrogen component), breast cancer, cervical cancer and
liver cancer. Fortunately, serious complications are extremely rare with low – dose COCs.
Provision of COCs: Who can provide COCs?
- Doctors, Health Officers, Nurses, community health workers trained in the education and
counseling of clients can provide oral contraceptives depending on local regulations and
practices.
Starting COC pills
When to start?
This depends on women's situation. Is she:
• Having menstrual cycles
 Any of the first seven days after her menstrual bleeding starts if she is cycling
normally.
 Any other time if certain that she is not pregnant. And should avoid sex or also use
condoms or spermicide for the next seven days.
• Postpartum
 If breast-feeding: After she stops breast-feeding or 6 months after child birth (which –
ever comes first).
 If not breast-feeding: Three to six weeks after childbirth. No need to wait for menstrual
period to return to be certain that she is not pregnant. After six weeks, any time it is
reasonably certain that she is not pregnant. If not reasonably certain, she should avoid
sex or use condoms or spermicide until her first period starts.
•After miscarriage or Abortion
- In the first 7 days after first or second trimester miscarriage or abortion.
- Later any time it is reasonably certain that she is not pregnant.
Explain how to use the pill
a) Hand her a packet of the same pills that she will use, even if she will be getting her pills
elsewhere latter.
b) Show her:
- Which kind of pill packet are you giving her - 21 pills or 28 pills?
- How to take the first pill out of the packet.
- How to follow the directions or arrows in the packet to take the rest of the pills, one each day
(first the hormonal pills, then any reminder pills).
c) Give her instructions on: starting the first packet, starting the next packet, and what to do after
missing pills.
i. Starting the first packet:
→ See the description on the topic ‘when to start’
ii. Starting the next packet:
→ 28 - pill packet: When she finishes one packet she should take the first from the next packet on the
very next day.
→ 21 - pill packet: After she takes the last pill from one packet, she should wait 7 days and then take
the first pill from the next packet.
iii. What to do after missing pills:
Missing only one (white) hormonal pill:
1. Take the missed pill as soon as she remembers.
2. Take the next pill at the regular time. This may mean taking 2 pills on the same day or even 2 at
the same time.
3. Take the rest of the pills as usual, one each day
Missing two or more (white) hormonal pills in any 7 days?
1. Most important: For 7 days use condom, spermicide, or avoid sex.
2. Take one (white) hormonal pill at once.
3. Count how many (white) hormonal pills are left in the packet:
• Seven or more (white) hormonal pills left?
- take all the rest of the pills as usual on each day; or
• Fewer than seven (white) hormonal pills left?
- take the rkest of the (white) hormonal pills as usual.
- do not take any (brown) reminder pills. Throw them away.
- start a new pack on the next day after the last (white) hormonal pill. You may miss a period.
This is okay.
Missing one or more of any (brown) reminder pills?
1. Throw the missed pills away.
2. Take the rest of the pills as usual, one each day.
3. Start a new packet as usual the next day.
d) Ask her to repeat the most important instructions and show how she will take her pills using
the pill packet.
e) Inform the client about the following early warning signals for danger. They can be easily
remembered by the word "ACHES"
A - Abdominal pain (severe)
C - Chest pain (severe), cough or shortness of breath.
H - Headache (severe)
E - Eye problems (vision loss or blurring) or speech problems.
S - Severe leg pain (calf or thigh).
f) Ask her if she has any questions, fears, or concerns, and answer her concerns respectfully and
caringly.
N.B. Warn her to contact her health care provider immediately on feeling of the above problems.
Follow - up
During follow- up ask clients the following questions at any return visit:
- Ask if the client has any questions or anything to discuss.
- Ask the client about her experience with the method, whether she is satisfied and whether she
has any problems. Give her any information or help that she needs and invite her to return
again any time she has questions or concerns. If she has problems that cannot be resolved,
help her choose another method.
- Ask if she has had any health problems since her last visit (see the management section).
N.B. -COCPs contains 30-35 micro grams synthetic estrogens and 0.5-1mg of progesterone.
-90% of the user ovulate after 3 months of stopping taking the pills
2.1.2. Progestin only pill /mini pill or POPs/
The progestin - only pill (POP) is an oral hormonal contraceptive containing only
progesterone in a smaller dose than in the combined pill.
These pills contain only progesterone derivatives in very low dose.

The commonly used progestins are levonorgesterel 75/30 microgram, norethisterone 350
microgram, ethinodiol diacetate 500 microgram.
They have to be taken continuously with no hormone free interval.
They are useful for women in whom estrogen containing contraceptives are contraindicated.
Mechanism of action
- Thicken cervical mucous making it difficult for sperm to pass through;
- It acts on the hypothalamus and pituitary and suppresses the Leutenizing Hormone (LH)
surge responsible for ovulation. Ovulation is prevented in at least half of the cycles.
- It reduces development of the uterine lining and slows the movement of egg and sperm
through the fallopian tubes.
- Ovulation suppression is partial & occurs in 50%.
- Decaudalization of the endometrium.
Effectiveness
 POPs are generally less effective than COCs. If used correctly and consistently 5 in 1000
(0.5%-2%) women would become pregnant in the first year. In breast-feeding women
however, the POP is nearly 100% effective.
Indications
POPs may be particularly appropriate for women who wish to use oral hormonal contraception and
have any of the following characteristics:
• Cannot use or tolerate COCs.
• Is breast-feeding.
• Are diabetic.
• Are obese or thin.
• Have hypertension.
• Have migraine syndrome or have experienced focal migraine while using COCs.
• Have developed other estrogen - related complications while using COCs.
• Smoke cigarettes.
• In any age including adolescents and over 40.
• Have just had abortion or miscarriage.
• Have or not have children.
Advantages
 No estrogen side effects (like, thrombosis, change in lipid profile, adverse effects on lactation
& milk volumes
 Can be used by nursing mothers starting 6 weeks after childbirth.
 Women take one pill every day with no break. Easier to understand than 21 day combined
COCs.
 Can be very effective during breast-feeding.
 May help prevent: benign breast disease, endometrial and ovarian cancer and pelvic
inflammatory diseases.
 Can be prescribed – for lactating mother, for women with hypertension, thrombosis, diabetes,
epileptic, with fibroid and smokers.
Disadvantages
o Should be taken at about the same time to work best. For women who are not breast feeding,
even taking a pill more than a few hours late increase the risk of pregnancy, and missing 2 or
more pills increases the risk greatly.
o Lack of protection against STIs including HIV.
o Ectopic pregnancy is more likely among women who become pregnant as a result of minipill
failure than among women who use other oral contraceptives.
o Interaction with anticonvulsants (barbiturates).
o High failure rate compare to COCPs.

o Intermenstrual bleeding.
Side effects
• Menstrual cycle disturbances like break through bleeding, prolonged bleeding, spotting, and
amenorrhoea.
• Headache
• Acne
• Mood changes
Provision of POPs
• Who can provide POPs :( Same as for COCs)
Starting POPs
When to start? This depends on women's situation:
 Breast-feeding: as early as 6 weeks after childbirth.
 After child birth if not breast feeding: immediately on or any time in the first 4-6 weeks after
childbirth. No need to wait for her menstrual period to return.
 After miscarriage or abortion: immediately or in the first seven days after either first or second
trimester miscarriage or abortion.
 Having menstrual cycles:
o Any time it is reasonably certain that she is not pregnant.
o In the first 5 days of menstrual bleeding. The first day of menstrual bleeding may be
easiest to remember. No back - up method is needed for extra protection. If not starting
in the first five days of menstrual period back up method is needed or avoid sex for at
least the next 48 hours.
 When stopping another method:
o Immediately. No need to wait for a first period after using injectables.
Explain How to use the pill? Same as for COCs except the following.
a) Starting the next packet (28 or 35 pills of the same color packet):
When she finishes one packet, she should take the first pill from the next packet on the very next
day. All pills are active, hormonal pills. There is no wait between packets.
b) What to do after missing pills:
- Take most recent missed pill as soon as possible; it is only 3 hours to remember and to
take it. If it is greater than 4 hours take the pill on the same time and use additional
family planning methods for the next 7 days.
- Abstain or use back - up method for 48 hours to 7 days.
- Take next pill at regular time.
Follow - up
Same for COCs Except:
 If the client has developed breast cancer or active liver disease:
o do not provide POCs,
o refer for care,
o Help her choose a method without hormones.
 If she is taking medicines for seizures (phenytion, carbamazepine, barbiturates, or prinidone)
or rifampicin or griseofulvin:
o provide condoms or spermcide to use along with POCs;
o If she prefers, or if she is on long term treatment, help her choose another effective
method.
 If the client has developed any of the following conditions, manage it properly.
o Un-explained abnormal virginal bleeding.
o Bleeding that may suggest pregnancy or an underlined medical condition.
o Heart disease due to blocked arteries or stroke.

o Very bad headaches.
N.B. If the ladies have diarrhea and vomiting additional pill should be taken until 7 days.
2.1.3. Injectable contraceptives
They are long acting reversible contraceptives containing progesterone preparations.
They are administered intramuscularly.
The most common type of injectable contraceptive DMPA (depot medroxy Progesterone
acetate) also know as Depo – provera 150mg which is given every three months and 300mg
every six months. It contains a progestin, similar to the natural hormone that woman's body
makes.
Depo-Provera has a grace period of 2 – 4 weeks but NET – EN has no grace period.
There are other injectable contraceptives such as NET-EN (Norethisterone enanthate) 200mg
which is given every two months. Other monthly injectable contraceptives include cyclofem,
cycloprovera and mesigyna.
Mechanism of action of DMPA
 Mainly stops ovulation (release of eggs from ovaries).
 Also thickens cervical mucus, making it difficult for sperm to pass.
 Prevent implantation.
Effectiveness of DMPA
Very effective 0.3-1 pregnancies per 100 women in first year of use (one in every 333) when
injections are regularly spaced three months apart.
Indications for DMPA
DMPA injectable can be used in any circumstances by women who:
 Are breast feeding (starting as soon as 6 weeks after child birth)
 Smoke cigarettes.
 Have no children.
 Are any age, including adolescents and over 40.
 Are fat or thin.
 Have just had abortion or miscarriage.
 Also women with benign breast disease, headaches, high BP, iron deficiency anemia,
varicouse veins, vascular heart disease, irregular menstrual periods, malaria, schistosomiasis,
sickle cell disease, thyroid disease, uterine fibroids, epilepsy and tuberculosis can use DMPA
in any circumstances.
Advantages
 Long-term effective contraceptive.
 Private, no one can tell that a woman is using it.
 Does not interfere with sex.
 No daily pill taking.
 Allows some flexibility in return visits. Client can return from 2 to 4 weeks early (although
this is not ideal) and 2 weeks and perhaps up to 4 weeks late for next injection.
 Can be used at any age.
 Can be used by nursing mothers as soon as 6 weeks after childbirth.
 No estrogen side - effects.
 Helps prevent ectopic pregnancies.
 Helps to prevent endometrial cancer.
 Helps prevent uterine fibroids.
 May help prevent ovarian cancer.
 Acceptable by many clients.
Disadvantages
 Delayed return of fertility especially DMPA it takes 5-7 months for the return of menstruation.
 Requires another injection every 3 months.

 Does not protect against STIs including HIV/AIDS.
Side - effects
o Menstrual cycle disturbance:
o Light spotting or bleeding. Most common at first.
o Heavy bleeding can occur at first - Rare.
o Amenorrhea, normal, especially after first year of use.
o May cause weight gain (2kg), headaches, breast tenderness, moodiness, nausea, vomiting, hair
loss, less of sex drive and/or acne in some women.
Provision of DMPA
Who can provide DMPA?
Health workers who have been trained in administering injections.
Starting DMPA
It depends on woman's situation,
• Having menstrual cycles
- Any time it is reasonably certain that she is not pregnant.
- If starting during the first 7 days after menstrual bleeding starts, no back-up method is needed
for extra protection.
- If she is starting on or after day 8 of her menstrual period, she should use condoms or
spermicide or avoid sex for at least the next 48 hours. If possible give her condoms or
spermicide.
• Breast feeding
- As early as 6 weeks after childbirth.
- If menstrual periods have returned, she can start DMPA any time it is reasonably certain that
she is not pregnant.
• After childbirth if not breast-feeding.
- Immediately or at any time in the first 6 weeks after child birth.
- After 6 weeks any time it is reasonably certain that she is not pregnant.
• After miscarriage or abortion.
- Immediately or in the first 7 days after either first or second trimester miscarriage or
abortion.
- Later any time it is reasonably certain that she is not pregnant.
• When stopping another method.
- Immediately.
Explaining how to use
• Explain that she should receive injection of DMPA every 3 months.
• Explain to her that she has to come back any time she has questions or
• Problems or wants another method.
• Mention and explain the most common side - effects.
Giving the injection
a. Equipment and supplies needed:
• One dose of DMPA (150mg = 1mL)
• An antiseptic and cotton wool.
• A 2 or 5ml syringe and a 21 to 23 gauge IM needle. (All sterile).
b. Steps in giving the injection
• Wash hands and if possible wear clean gloves.
• Shake vial gently, wipe top of vial and stopper with antiseptic, and fill syringe with proper
dose (150gm).
• Clean the injection site.
• Insert the sterile needle deep in to the upper arm (deltoid muscle) or glutial muscle upper
outer quadrant. For DMPA the upper arm is more convenient.
• Do not massage the injection site. Explain that this could cause DMPA to be absorbed too
fast.
• Dispose needles and syringes as appropriate.
Proper handling of needles and syringes
• Use disposable needles and syringes if available.
• Dispose needles and syringes.
- Place used disposable needles and syringes in a puncture- proof container,
- Burn or bury the container when three - quarters full.
- Do not put disposable needles in trash. Do not re-cup, bend or break needles before disposal.
- Do not re-use disposable needles and syringes.
• Re-usable needles and syringes
- Use properly sterilized or high level disinfected re-usable needles and syringes if disposable
are not available.
- The needles and syringes must be sterilized or high level disinfected again after each use.
Follow-up
• Tell the client the name of the injection and the date when the next Injection is due.
• A follow-up review may be performed at any of the visits during which the client obtains a repeat
injection:
- Up-date the client's address and how to contact her.
- Assess the client's satisfaction with the method.
- Determine if the client has had any problems or side - effects and, if so, record them in the
clinical record.
- update the medical history; measure BP and weight and perform any other examination
indicated by the history.
- provide appropriate counseling and/or treatment as required.
- encourage the client to contact the clinic any time if she has any questions, complaints or
problems.
• Late repeat injections:
- If the client comes 2 weeks late after the allowable time for repeat injection; to make certain
she is not pregnant:
• take careful history;
• If indicated, perform a pregnancy test and/or a pelvic examination.
Management of side - effects / problems
If the client reports any of the common side - effects of DMPA:
- Do not underestimate the woman's concerns or take them lightly.
- If the woman is worried, reassure her that such side - effects are not usually dangerous or
signs of danger.
- If the women is not satisfied after treatment or counseling, help her choose another method if
she wishes.
2.1.4. IMPLANTS
They are a highly effective, long acting, reversible, low dose, soft, slender, silicon rubber
capsules progestin only contraceptive each containing 36mg of levonorgestrel which are
implanted intra-dermally in the inner side of 6-8cm above the elbow fold in the non-dominant
hand.
They serve for 3 – 5 years.
They are different type;
o Norplant;
 The former Norplant has 6 silastic/silicone rubber capsules each containing 36mg
of levonorgestrel, which is released by slow diffusion over a period of 5 years.
 Initially it releases 80µmg and latter on reduced to 3080µmg/day over the five
years.
 It has a size of 34mm by24mm.
 More recent preparation with two small rods.
o Jadelle;
 It is a set of two flexible cylindrical implant consisting of 75mg of progestin
levonorgestrel.
 Commonly available in Bangladish.
 The size is 43mm by 2.5mm.
 Serves for five years by maintaining the following daily releasing dose;
o For the 1 st months-100µg/day.
o For the next 12 months-40µg/day.
o For the following months-30µg/day.
o Implanon;
 It is an implant with a single capsule and gives services for3 years.
 It contains 60mg of ketodesogestrel which is released 6030µg/day.
 Have drug reaction with anti-TB drugs such as rifampcin and antiepileptic drugs
such as phenitoin, phobarbiton, and carbamazepine.
Mechanism of action:
• Norplant inhibits ovulation;
• Thickens cervical mucus making it difficult for sperm to pass through.
• Causes changes in the uterine lining.
Effectiveness
- Very effective - the failure rate in the first year is 0.1 - 0.2 pregnancies per hundred women.
After 5 years, the total (commutative) pregnancy rate is only 3.7 percent.
- Pregnancy rate is slightly higher among women weighing more than 70kgs.
Indications
Norplant implants are suitable method for most women of reproductive age, but they are particularly
indicated for women who:
• Want a long term contraceptive method,
• Desire a method that is not coital related,
• Prefer a method that neither is taken daily nor requires frequent supply,
• Have the number of children they want, but do not wish to be sterilized,
• Are considering sterilization, but are not yet ready to make a final decision,
• Should not use estrogen containing contraceptives,
• Have problems remembering to take oral contraceptives
Contraindication (Implanon)
 Undiagosed bleeding
 Severe liver disease
 Thrombosis
 Cancer
 BMI>35kg/m2 .
Advantages
• Very effective, even in heavier women,
• Long term protection, but reversible,
• No need to do anything at time of sexual intercourse,
• Increased sexual enjoyment because no need to worry about pregnancies,
• Nothing to remember. Requires no daily pill taking or repeated injections,
• No repeated clinic visits required,

• Effective within 24 hours after insertion,
• Fertility returns almost immediately after capsules are removed,
• Can be used by nursing mothers starting 6 weeks after child birth,
• No estrogen side - effect,
• Help prevent iron - deficiency anemia, ectopic pregnancies, endometrial cancer,
• High continuation rate.
Disadvantages
 Client cannot start or stop use on her own. Capsules must be inserted and removed by
specially trained health care provider.
 Minor surgical procedures required to insert and remove capsules and may bother the
client.
 Discomfort for several hours to one day, perhaps for several days for some clients after
insertion. Removal is sometimes painful and often more difficult than insertion,
 Do not protect against STIs including HIV/AIDS,
 It is expensive,
 Local inflammation or infection at the site of implants,
 Norplant's effectiveness is lowered more significantly by anti seizure medicines and
refampicin than are other hormonal contraceptives.
Side - effects
Common side - effects include:
• Changes in menstrual bleeding including,
- Light spotting or bleeding between monthly periods (common);
- Prolonged bleeding;
- Ammenorrhea.
• Other minor side - effects include:
- Weight gain (a few women lose weight).
- Headaches.
- Nausea.
- Dizziness.
- Depression
- Acne or skin rash.
- Breast tenderness and/or discharge.
- Change in appetite.
- Enlargement of ovaries or ovarian cysts.
- Hair loss or more hair growth on the face.
Provision of Norplant
Who can provide Norplant?
Doctors, health officers, nurses, midwives and other health professionals who have been trained in
counseling and in insertion and removal procedures.
Starting Norplant Implants
This depends on woman's situation:
• Having menstrual cycles:
- Any time (on day one) it is reasonably certain that she is not pregnant;
- If started during the first seven days after menstrual bleeding no backup method is needed
for extra protection;
- If starting on or after day 8 of her menstrual (period, she should use condoms or spermicide
or avoid sex for at least 48 hours after insertion. If possible give her condoms or spermicide.
• Breast-feeding:
- As early as 6 weeks after childbirth.
- If menstrual periods have returned, she can start any time it is reasonably certain that she is
not pregnant.
• After child birth if not breast feeding:
- Immediately or at any time in the first 6 weeks after child birth. No need to wait for her
menstrual period to return.
- After 6 weeks, anytime it is reasonably certain that she is not pregnant.
• After miscarriage or abortion:
- Immediately or in the first 7 days after either first or second trimester miscarriage or
abortion.
- Later, any time it is reasonably certain that she is not pregnant.
• When stopping another method:
- Immediately.
Explain how to use Norplant implants
Explain to the client:
• To keep the insertion area dry for 4 days, she can take off the gauze after 2 days and the
adhesive bandage after 5 days.
• To remember that, after the anesthetic wears off, her arm may be sour for a few days. She
also may have swelling and bruising at the insertion site. This is not a cause for alarm.
• To return to the clinic or see a nurse or doctor if the capsules come out or if soreness in her
arm lasts more than a few days.
• About the most common side effects.
Insertion and removal of Norplant
Equipment for insertion of Norplant implant:
1 sponge - holding forceps.
1 iodine cup.
1 syringe and long needle.
1 scalpel with blade.
1 Norplant trocar and cannula
1 strapping tape
Insertion procedures:
• Use proper infection- prevention procedures,
• Use only local anesthesia;
• Make a small incision in the skin on the inside of the upper arm.
• Insert the capsules just under the skin. This makes the capsules easier to remove later.
• After all 6 capsules are inserted close the incision with an adhesive bandage. Stitches are not
needed. The insertion is covered with a dry cloth and warped with gauze.
Equipment for removal of Norplant implant:
1 sponge holding forceps.
1 iodine cup.
1 syringe and long needle.
1 scalpel with blade.
2 mosquito forceps.
1 strapping tape.
Removal Procedures
• Use proper infection - prevention procedures.
• Use only local anesthetic.
• Make a small incision about where the capsules were inserted.
• Use an instrument to help pull the capsules out.
• Close and bandage the incision, stitches are not needed.
N.B. If a woman wants to continue using Norplant implants, the new capsules are placed elsewhere in
the same arm or in the other arm.
Indications for removal
• User's firm request.
• Pregnancy (confirmed).
• Medical reasons; for example:
- Heavy menstrual bleeding.
- Symptoms of acute liver disease.
- Serious infection of insertion site not amenable to treatment with antibiotic and/or local
measures.
• Repeatedly occurring severe headache or migraine type headache occurring for the first time.
• At the end of 5 years after insertion.
Follow up
• The client should be seen within one month after insertion to check insertion site. Then at least
every year.
• Annual follow up:
- update the client's address and how to contact her.
- assess the client's satisfaction with the method.
- determine if the client has had any problems or side effects.
- update the medical history.
- perform physical examination including BP, breast examination (with instructions for self
examination), a bi-manual pelvic examination with a pap smear if this is due and possible.
- provide appropriate counseling and/or treatment as required.
- review with the client the warning signs and instructions given at the previous visit.
- encourage the client to contact the clinic any time if she has any questions, complaints or
problems.
Management of side - effects / problems
If the client reports any of the common side - effects of Norplant implants:
• Do not underestimate the woman’s concerns or take them lightly,
• If the woman is worried, reassure her that such side effects are not usually dangerous or
signs of danger.
• If the woman is not satisfied after treatment and counseling, ask her if she wants the
Norplant capsules removed. If so, remove the capsules or refer for removal even if her
problems with the Norplant implants would not harm her health. If she wants a new method,
help her choose one.
2.2. Surgical Methods (Surgical Sterilization)
 Sterilization is a permanent method of contraception done both for men and women.
 The method involves surgical procedures.
 It is permanent method of contraception.
 Consent for the operation should be signed & counseled.
2.2.2.1. Vasectomy
Vasectomy is done under local anesthesia through a small incision done in the upper aspects
of the scrotum.
Sutures or clips are put tightly around the vas and then excised.
The failure rate with this technique is estimated to be less than 0.2% (0.15%). Therefore,
proper counseling is important as fertility may never be attained again.
There is a fail chance of success of reversal anastomosis operation (50%).
The operation has no an immediate effect, rather it takes 2 – 3 months or 20 ejaculators before
the semen is free of spermatozoa because the semen is stored in the distal part of vasdeferens
for about 2-3months. During this month an other measure should be used.
The sperm production and hormone out put are not affected. The sperm produced are
destroyed by phagocytosis.
N.B.
 A person with eczema and scabies on the scrotal area are a temporary contraindication.
 If there is hydrocele and inguinal hernia, it should be treated first.
Post operative advice
- Antibiotic agent and analgesic agent.
- Restricting wt lifting, heavy work, and cycling.
- T-bandage for 2wks.
- Additional contraceptives should be used.
- Semen should be examined once a month. (if 2 results are shows a free semen from sperm-
sterile)
Complications
Immediate;
 Wound sepsis-scrotal cellulites/abscess.
 Scrotal hematoma.
Remote;
 Frigidity or impotency (psychological in origin).
 Sperm granuloma/sperm granules appear from 10-14 days after operation.
 Auto immune response.
 Spontaneous recanalization (0-6%)
Type
A. Non-scalpel.
B. Open-ended.
2.2.1.1. Tubal Sterilization
This is sterilization of women by surgical procedures on the fallopian tube.
Different techniques are used.
Proper pre-operative counseling is very important as this is a permanent contraception and that
the woman should not regret her decision.
Pain and menstrual disturbances are common complications after tubal ligation.
As this procedure requires surgical skill with facilities, it is usually done in hospitals.
Complications are infrequent, but bleeding, infection and allergic reactions may be
encountered.
The most popular method.
It can be done;
o 24 – 48 hours post partum for technical simplicity (hospitalization for both delivery
and operation.
o Post abortally (after 3 weeks).
o 3 months following delivery.
o During caesarean section.
Types of TL
A. Laparoscopic sterilization.
B. Mini-lap operation.
C. Vaginal tubaligation (through posterior colopotomy).
2.3. Emergency Contraception
2.3.1. Introduction
o Emergency contraception refers to the type of contraception that is used as an emergency
procedure to prevent unintended pregnancy following an unprotected act of sexual intercourse.
Mode of Action
o The precise mode of action of emergency contraceptive method is uncertain and may be
related to the type of emergency contraceptive and the time it is used in a woman's menstrual
cycle. It is thought to prevent ovulation, fertilization and/or implantation.
N.B. it is not a method of abortion.
Indication
o It is used in the following situations.
1. When no contraceptive has been used.
2. When there has been a contraceptive accident or misuse.
• Condom rupture, slippage or misuse,
• Diaphragm dislodgment or early removal,
• Failed coitus interrupts,
• Miscalculation of the periodic abstinence method, and
• IUD expulsion.
3. When the woman has been a victim of sexual assault.
2.3.2. Methods of emergency contraception
1. Emergency contraceptive regimen(ECP regimens)
2. Copper releasing IUDs
1. ECP regimens
I. Combined Pills
 Combined estrogen - progesterone pills, containing ethinyl estradiol and norgestrel
(Levonorgestrel) can be taken in a regimen known as Yuzp Emethod.
Prescription
If pills containing 50µgm ethinyl estradiol and 0.5mg norgestrel available:
• Two pills should be taken as the first dose as soon as convenient with in 72 hours after
unprotected intercourse. Second dose of two pills should be followed after 12 hours.
If pills containing 30µgm ethinyl estradiol and 0.3mg norgested
• Four pills should be taken as a first dose with in 72 hours after unprotected sex and another
four pills 12 hours later should be taken as a second dose
II. Progestin only pills
 A regimen that consists of levonorgestrel pill at least as effective as the YUZPE
method but with significantly lower incidence of side effect.
Prescription
If pills containing 0.75mg bevonorgestrel are available. One pills should be taken as a first
dose as soon as convenient within 72 hours after unprotected intercourse. Second dose of one
pill should be followed after 12 hours.
If pills containing 0.03mg levonorgestrel are available these may be taken. But require 20 pills
each dose.
Effectiveness
After a single act of unprotected sexual intercourse, about 2% of women become pregnant if
they use ECPs. But the chances of pregnancy are approximately four times greater when no
emergency contraceptive is used. If a woman used frequently, chance of becoming pregnant in
the long term would be much higher than if she used regular contraception.
Contraindication
• Pregnancy
• Suspected pregnancy
N.B. With known diagnosis of pregnancy and if pregnancy can not be ruled out with absolute
certainty it is not given.
Side-effects
- Nausea.
- Vomiting.
- Irregular uterine bleeding.

- Breast tenderness.
- Headache.
- Dizziness.
Follow up care
o No follow up should be required in relation to the use of emergency contraception.
Unless she has a delay in her, menstruation, suspects she may be pregnant or has other reasons
or concern.
2. Copper Releasing IUDs
 A copper releasing IUD can be used within five days of unprotected intercourse as an
emergency contraceptive.
Effectiveness
 Highly effective. After an act of unprotected sexual intercourse less than 1% of women
become pregnant if they use a copper releasing IUD as un emergency contraceptive.
Indication
In addition to the indication of all emergency contraception, IUDs are especially indicated:
• When more than 12 hours have elapsed after unprotected intercourse; thus ECPs can no
longer be used.
• When the client is considering using an IUD for continues long term contraception.
Contraindication
• Pregnancy
• Puerperal sepsis or post abortal sepsis with the last three months.
• Pelvic inflammatory diseases; current or within the last three months.
• STDs.
• Purulent cervicitis.
• Undiagnosed abnormal genital tract bleeding.
• Malignant gestational throphoblastic diseases.
• Known pelvic tuberculosis.
UNIT – THREE
3.1 Providing Antenatal Care (ANC )
3.1.1 Definition
Antenatal care is a care which is given for a pregnant mother form conception up to delivery
to meet both psychological & medical needs of pregnant mother with in the context of health
care delivery system.
3.1.2 Objective
 To have a safe normal delivery of a healthy mother and baby at term.
 To detect and treat complications during pregnancy.
 To help the mother be healthy during pregnancy.
 To advise the mother on ways of caring for herself during pregnancy.
 To promote breastfeeding.
 To give tetanus toxoid (TT) immunization.
 To advise the mother on ways of caring for the new born.
 To give health education on nutrition, breast-feeding, immunization, personal hygiene,
rest, recreation … etc.
 To care for pregnancy and to increase the number of births attended by trained health
workers.
Note: All mothers have to be encouraged to register for antenatal care as soon as they know they are
pregnant. ANC clinic can be held in a hospital, health center and private clinics and health post.
3.1.3 Frequency and timing of visit
There are two types of antenatal care visit recommendations. These are;
1) Traditional (Standard) western model
2) The new WHO ANC model
1. Traditional (Standard) western model:
 Recommends the 1st visit to take place as early as the 1st missed period. This
allows dating of pregnancy & design appropriate preventive and therapeutic
interventions.
 The subsequent visits are planned every 4 weeks until 28 weeks, every 2 weeks
between 28 – 36 weeks and every week after 36 weeks.
 More frequent visits are required for high risk mothers.
2. The new WHO ANC model recommends a maximum of 4 visits
 First visit takes place at 16wks or before.
 The 2 nd visit is planned between 24 – 28 weeks.
 The 3 rd visit at 32 weeks.
 The 4th visit at 36 – 38 weeks.
N.B. The initial visit takes 30 – 40 minutes & the other visits take around 20minutes each.
3.1.4. Components of ANC
- Risk screening
- Detection and management of associated diseases
- Efficient maintenance of maternal nutrition and health
- IEC related to safe delivery and early recognition and management of
complications including abortion.
3.1.5. Content of visits

 The content of antenatal visits for a normal pregnancy is described in three main categories:
 Assessment (history, physical examination and laboratory tests)

 Health promotion
 Care provision
3.1.6. The activities of new WHO ANC model
3.1.6.1. 1st visit
 History taking
o Identification;
 Name, Age, Address, e.t.c. (it varies depends up on the organization
set up)
o Family Hx
 Hx of Twins, Dm, HTN, PTB, psychiatric disorder, e.t.c.
o Surgical Hx
 Hx of C/S, blood transfusion, e.t.c.
o Medical Hx.
 For the presence of different medical disorder, like DM, HTN,
respiratory disorder, psychiatric disorder and other medical disorder.
o Past obstetrical Hx;
 Previous obstetric problems during pregnancy or delivery should be
given especial emphasis.
 It includes
 Ectopic pregnancy and recurrent spontaneous abortion (wks of
gestation and cause).
 Multiple pregnancy or preterm/post term.
 APH or PPH.
 Malpresentation.
 Intrauterine fetal death, still birth or early neonatal death.
 Birth weight of less than 2500 or greater than 4000 grams
 Operative delivery and cesarean section.
 Place of delivery and type of delivery.
 Congenital abnormalities.
 TT vaccine.
 Gravidity and parity.
 FP use.
 Puerperal infection.
o Present obstetric Hx.
 Short stature (< 150cm)
 Age less than 18 or greater than 40
 Gradndmultiparity
 Vaginal bleeding at any gestational age
 Uterine size to gestational age discrepancy (big or small for gestational
age)
 Premature rupture of membrane.
o Social/Personal Hx.
 Marital status, support, number of children, home condition,
occupation, planned or unplanned pregnancy and family or social
problems like FGM.
• Diagnose pregnancy – do pregnancy test if service is available.
 Physical Examination
• Weight (monthly in the first trimester and at any time in the second and third trimester,
height, blood pressure should be recorded.
• Mothers’ general condition and the size of the pelvis.
• Palpation: to detect fetal position, growth and development
• Auscultation: to detect fetal heartbeat.
 Laboratory Examination
• Laboratory examination of blood to test for anemia and to determine the blood group and
Rh, HIV, Hg level.
• VDRL test for syphilis is one of the important tests to be done irrespective of any
condition provided that the facilities are available. VDRL test is given emphasis because
syphilis has a grave impact on the fetus, and then on the new born.
• Stool: for ova and parasites
• Urine: for glucose, ketone bodies, proteins and microscopic examination, culture.
• Examination of urine is important to detect urinary infection or preeclampsia.
 Treatment
• Treat anemia with iron tablets
• Give advice to mothers not to discontinue the drug and about the side effects.
• Treat syphilis and other health problems such as malaria, intestinal parasites. Etc.
• Give vitamins to supplement the diet.
• Immunization: Tetanus Toxoid.
Protection: 2 doses of tetanus toxoid protect for 3 years, 3 doses for 5 years, 4 doses for 10
years and 5 doses for life.
• Educate the mother on danger signs of pregnancy
3.1.6.2. 2nd visit
•Measure blood pressure, if > or =140/90, then refer the patient to a higher institution
•Measure fundal height
•Calculate gestational age
•Give TT as indicated.
•Do Laboratory tests depending on the 1st visit or presence of current problems
•Screening for anemia, multiple gestation, preterm, diabetes, RH sensitization.
•Social support.
•Follow up on advice, care, and referral provided at previous visit.
o Activities in the 3rd visit and the 4th are the same with the second.
3.1.7. Screening of high risk mothers
Risk approach is a managerial tool for health services to identify people at risk as early as
possible and intervene in order to reduce the risk.
What is the basic concept behind this approach?
All women in reproductive age group are vulnerable to disease, death and disability. However, all
women are not equally vulnerable and this approach helps to identify mothers who are at a higher
risk than others with a lesser risk.
Purpose
The main objective of the at – risk approach is the optimal use of existing resources for the
benefit of the majority .It attempts to ensure a minimum of care for all while providing guidelines
for the diversion of limited resources to those who most need them. That means
• To care for all but to pay special attention to those in greatest need.
• The diversion of limited resources to those who most need them.
Detection of risk factors requires
• Knowledge of the characteristics associated with poor outcomes and
• The ability to recognize and measure them.

Criteria to identify high risk women
Identification of high- risk women can be based on two classifications
1. Relationships between the risk factor and adverse out come
- Causative or triggering - maternal malnutrition, LBW, placenta previa, congenital
malformation
- Contributory - grand multiparty can lead to transverse lie, prolapse of the cord
- Predictive or associative - previous foetal loss
2. Biological, medical, social condition
• Biological - Age, birth interval, weight gain
• Medical - diabetes, obstetric complication, pre eclampsia, health care utilization
• Social - work load, birth attendant, and economic status
Risk factors identifiable in ANC include:
• Age under 18 or above 35
• Primigravida
• Previous caesarean section, vacuum, forceps or destructive delivery
• Previous prenatal death, stillbirth
• Previous ante partum hemorrhage
• Previous post partum hemorrhage
• More than 6 pregnancies
• Multiple pregnancies
• Hydramnios
• Pre eclampsia and eclamsia
• Diabetes, cardiac problem, renal disease etc.
3.1.8. Clients risk groups
 The low risk group

 Patients with second, third or fourth normal pregnancy, the first pregnancy that was normal
and absence of the conditions mentioned below.
 The medium risk group

 Primigravidae
 Grand multiparae with normal pregnancy
 Patients with severe asthma, breathlessness or dyspnoea
 Patients with proteinuria plus one (+)
 Previous caesarean section cases
 Patients with breech and other mal presentation
 The high risk group
 Previous intrauterine foetal death
 Previous neonatal death, intrauterine foetal growth retardation
 Polyhdramnios
 Unsatisfactory maternal weight gain or low grade hypertension
 Sustained proteinuria (++ or more)
 Antepartum haemorrhage
 Multiple pregnancy
 Recurrent premature labour
 Medical conditions (cardiac diseases, diabetes mellitus)
 RH isoimmunization
 Post maturity
N.B. Pregnant mother with the above risk factors should be carefully screened and referred to the
nearby hospital
3.2. Providing safe delivery

 Delivery: - means child birth.
 Labor: - is function of the female by which the products of conception fetus, amniotic fluid,
placenta, and membranes are separated and expelled from the uterus through the vagina into
the outside world.
 Delivery is said to be safe if it is conducted in the area where essential delivery settings are
fulfilled and when delivery is completed with out any complication for both mother and
neonate.
 Trained health worker should attend mother and baby during labor and delivery. Delivery
should be conducted under hygienic conditions.
 The five basic factors in delivery care also known as ‘the five clean’ are:
o Clean hands
o Clean delivery surface
o Clean cutting of the cord
o Clean environment
o Clean perineum
3.2.1. Sign and symptoms of labor
o There are tow types of labor. These are;
1) True labor
2) False labor
1. True labor is characterized by the following;
o It is a continuous process in which progressive regular uterine contractions occur in the
expulsion of the products of conception from the uterus.
o It is painful.
2. False labor has also the following feature;
o It is painless irregular uterine contraction in the last 4 – 6 weeks of gestation and does
not result in cervical dilation.
Difference between true labor & false labor
False labor True labor
- Contraction occur at irregular interval - Contractions occur at regular interval
- With time, contraction stays the same - With time, constrictions increase with intensity
- Contraction disappear with analgesics - Contractions persist despite analgesics
- Lower abdominal and back pain present - Only lower abdominal discomfort present
- Can occur in the last trimester - Occurs when labor commences
- There is no cervical effacement and dilation - There is progressive cervical dilation and
effacement
- Occurs at night - Occurs at anytime
3.2.2. Stages of labor
o There are 4 stages of labor. These are

1) 1 st stage of labor
2) 2 nd stage of labor
3) 3 rd stage of labor
4) 4th stage of labor
1) first stage of labor
o It extends from the onset of regular uterine contraction/true labor/ to full dilation of cervix.
o It is further subdivided into latent phase (0-3cm dilatation of cx and slow ) and active phase
(3-10cm cx dilated and fast)
o It lasts 6 to 18 hours in a primigravida, and 2 to 10 hours in a multipara.
2) second stage of labor
o It extends from full cervical dilation to delivery of the fetus.
o It is characterized by more frequent & strong contraction.
o It takes 30 minutes to 3 hours in a primigravida (median-50 minutes), and 5 to 30 minutes in
the multipara (median-20 minutes). The median duration is slightly under 20 minutes in
multiparas, and just under 50 minutes for primigravidas.
3) third stage of labor
o It extends from the delivery of the fetus to the delivery of the placenta and membranes.
o Its duration is equal in multiparas & primiparas (5 – 30 minutes)
4) fourth stage of labor
o It extends from the delivery of the placenta & membrane to two/six hours post partum until
the postpartum condition of the patient has become stabilized.
3.2.3. Appropriate care in each stage of labor
o First stage of labor
o Keep the mother courage and morale (psychological assurance).
o Prevention of infection (enema, shower, minimize the frequency of V/E).
o Empty bladder.
o Diet (food and fluid should be restricted because of delayed gastric emptying time).
o Monitor fetal condition (FHB Q30 minutes for low risk and Q15 minutes for high risk
and assessing the nature of amniotic fluid).
o Monitor maternal condition (pulse rate measurement Q 30 minutes, BP and To Q 4hrs).
o Monitor the progress of labor (Uterine contraction-frequency, duration, and intensity).
o General care.
o Accurate charting of the observation.
o Second stage of labor – Position the mother in lateral recumbent/lithotomy
o Monitor vital sign more frequently (30min)
o Perform vaginal examination more frequently
o Clean any faces
o Deliver the fetus in control way
o Provide immediate neonatal care
o Clamp cord after 15 – 20seconds & cut
o Clear the airway
o Dry the baby & wrap with blanket
o Examine for gross malformation
o 3 rd stage of labor – determine the high & consistency of uterus
o Assess the degree of bleeding
o Remove the placenta
o 4 th stage of labor – The most critical stage where most maternal death occur
o Monitor maternal vital sign at least every 3 minutes
o Inspect vagina for bleeding & hematoma

3.3. Postpartum care
The postpartum period (also called puerperium) starts one hour after the birth of placenta and
ends six weeks after birth.
The first hour is considered to be part of childbirth, during which an immediate care of the
mother like assessing her condition, suturing and control of blood loss are undertaken. The
period of six weeks fits very well into cultural traditions in many countries including Ethiopia,
where often the first 40 days after birth are considered a time of convalescence to the mother
and her new born infant. By six weeks post partum the body of the woman has largely
returned to the non-pregnant state. The psychological and social adaptation of the mother, the
baby and the family to the new situation usually has attained a new balance.
The aims of care in the postpartum period are:
 Support of the mother and her family in the transition to a new family constellation, and
response to their needs.
 Prevention, early diagnosis and treatment of complications of mother and infant,
including the prevention of vertical transmission of diseases from mother to infant.
 Referral of mother and infant for specialist care when necessary
 Counseling on baby care
 Support of breastfeeding
 Counseling on maternal nutrition, and supplementation if necessary
 Counseling and service provision for contraception and the resumption of sexual activity
 Immunization of the infant.
 Provide information, screening and management of STDs.
3.3.1. Frequency and Timing
First type;
 First visit - First week postpartum.
 Second visit - Sixth week postpartum. However, all women should be assessed within 24
hours after delivery.
Second type; However, there have been recommendations with somewhat different and more
frequent schedule. An example is:
 First visit six hours after birth.
 Second visit 3 days after birth.
 Third visit 14 days after birth.
 Fourth visit 40 days after birth.
3.3.2. The Needs of Women in postpartum period
In the postpartum period, women need:
• Information/counseling on;
- Care of the baby and breast-feeding
- What happens to their bodies-including signs if possible?
Problems
- Self care –hygiene and healing
- Sexual life
- Contraception
- Nutrition
• Support form
- Health care providers
- Partner and family: emotional, psychological
• Health for suspected or manifest complications
• Time to care for the baby
• Help with domestic tasks
• Maternity leave
• Social reintegration into her family and community
• Protection from abuse/violence.
What should be checked? Postpartum bleeding, hypertension, puerperal infection, thromboembolic
disorders, complications related to the urinary system, the perineum and the vulva, establishment of
lactation, psychological problems and conditions. The postnatal period is a good time to discuss about
family planning.
Postpartum Assessment and Management
Asses for
6-12 hours 3-6 days 6 weeks
Blood loss Breast care Recovery

Pain Temperature/infection Anemia
BP Lochia Contraception
Advice/ Mood Problems
Warning signs
Unit four
4. Providing care for STIs & AIDS cases
4.1. Teaching on prevention of STIs /AIDS for vulnerable cases
4.1.1. Definition & overview of STIS
STI is an infection which is caused by sexual contracts and we call them infection, because most of
them do not have a full blown sign and symptoms and an individual may be infected by more than
one sexually transmitted disease at a time and one or two may be actively identified.
Sexually transmitted diseases (STDs) are spread primarily through sexual intercourse and can have
long term negative consequences including reproductive tract infections, infertility and stillbirths.
The worldwide incidence of STDs is high and increasing. The situation has worsened with the
emergence of the HIV epidemic. Although the incidence of some STDs has stabilized in parts of the
world, there have been increasing cases in many regions.
The social and economic disadvantages that women face make them vulnerable to STDs, including
HIV/AIDS as illustrated, for example, by their exposure to the high risk sexual behaviour of their
partners. The risk of transmission from infected men to women is greater than form infected women
to men, and many women are powerless to take steps to protect themselves.
More than 20 diseases including HIV are spread by sexual contact. Every day more than million
people are infected with a curable STD – an estimated 333 million cases worldwide each year. The
four most common STDs (excluding AIDS) are gonorrhoea, syphilis, chancroid (rare in developed
countries), chlamydia and trichomoniasis – are relatively easy to cure using antibiotics. However,
many people especially women who have STDs, may not have any symptoms and so do not know
that they need treatment. Every year over 200 million cases of gonorrhoea and over 50 million cases
of syphilis are known to occur globally. In large parts of the world STDs go unreported and untreated.
In Africa, chancroid and syphilis cause around 80% of genital ulceration and herpes around 10%.
Infertility in men due to STDs is estimated at around 20 - 40% in developing world. Pelvic
Inflammatory Diseases (PID) is found up to 8 - 10% of females. Ectopic pregnancy has an annual
incidence rate of 0.01 - 0.04% in those who had PID. Conjunctivitis and respiratory diseases are the
main causes of morbidity in neonates due to N. gonorrhoea and C. trachomitis infection in the mother.
In children congenital syphilis accounts for about 1.3% of mortalities and 20 - 25% of stillbirths are
also due to complications related to syphilis. GUD (Genital Ulcer Diseases) are more common in
Africa than in developed countries and since they also facilitate the spread of HIV, it is an indirect
explanation of the rapid spread of heterosexually transmitted HIV infection here.
4.1.2. Definition & overview of HIV/AIDS
HIV/AIDS is one of the sexually transmitted pandemic disease nowadays. It is caused by a virus
called HIV. It is transmitted by sexual intercourse, mater to – child (vertical transmission and by
blood and blood products.
The AIDS pandemic is a major concern in both developed and developing countries. Globally the
number of infected persons has been estimated between 30 and 40 million. About four fifths of the
infected persons live in developing countries where the infection is mostly transmitted by
heterosexual intercourse and the number of new cases is rising most rapidly in women. In 1980, an
estimated 80% of HIV infected people were men. By December 1998, of the estimated 32.2 million
HIV adults, 13.8 million are women, representing 40% of the total adult infected population. As a
consequence, a growing number of children are becoming orphans, themselves at high risk of illness
and death. The worst situation is observed in sub-Saharan. Statistical estimates show that there were
22.5 million adults and children living with AIDS (worldwide 33.4 million), newly infected with HIV
4 million ( worldwide 5.8 million), adult prevalence rate 8% ( worldwide 1.1%) and percent of HIV
positive adults who are women 50%.
According to ICPD, the objectives HIV/AIDS prevention and control are:
1. To prevent, reduce the spread of and minimize the impact of HIV infection; increase
awareness of the disastrous consequences of HIV infection and AIDS and associated fatal
diseases, at the individual, community and national levels, and of ways of preventing it; to
address the social, economic and racial inequities that increase vulnerability to the disease;
2. To ensure that HIV infected individuals have adequate medical care and are not
discriminated against; to provide counselling and other support for people infected with
HIV and to alleviate the suffering of people living with AIDS and that of their family
members, especially orphans ; to ensure that the individual rights and the confidentiality of
persons infected with HIV are respected; to ensure that sexual and reproductive health
programs address HIV infection and AIDS;
3. To intensify research on methods to control the HIV/AIDS pandemic and find an effective
treatment for the disease.
The Conference further recommended that:
Governments should assess the demographic and development impact of HIV infection and
AIDS and the pandemic should be controlled through multicultural approach that pays sufficient
attention to its socio-economic ramifications, including the heavy burden on health infrastructure and
household income, its negative income on labour force and productivity, and the increasing number of
orphaned children. Multisectoral national plans and strategies to deal with AIDS should be integrated
into population and development strategies. The socio economic factors underlying the spread of HIV
infection should be investigated and programs to address the problems faced by those left orphaned
by the AIDS pandemic should be developed.
Programs to reduce spread HIV infection should give high priority to information, education,
communication campaigns to raise awareness and emphasize behavioural change. Sex education and
information should be provided to not those infected and those not infected and especially to
adolescents. Health providers , including family planning providers need training in counselling on
sexually transmitted diseases and HIV infection, including the assessment and identification of high
risk behaviours needing special attention and services; training in the promotion of safe and
responsible sexual behaviour, including voluntary abstinence, and condom use; training in the
avoidance of contaminated equipment and blood products; and in the avoidance of sharing needles
among injecting drug users. Governments should develop guidelines and counselling services on
AIDS and STDs within the primary health care services. Wherever possible, reproductive health
programs should include facilities for the diagnosis and treatment of STDs including RTIs,
recognizing that many STDs increase the risk of HIV transmission. The links between the prevention
of HIV infection and the prevention and treatment of tuberculosis should be assured.
Governments should mobilize all segments of society to control the AIDS pandemic,
including non governmental organizations, religious leaders, the private sector, the media, schools
and health facilities. Mobilization at the family and community levels should be given priority.
Communities need to develop strategies that respond to local perceptions of the priority accorded to
the health issues associated with the spread of HIV and sexually transmitted diseases.
The international community should mobilize the human and financial resources required to
reduce the rate of HIV transmission. In particular, donor and research communities should support
and strengthen current efforts to find a vaccine and to develop women controlled methods, such as
vaginal microbicides, to prevent HIV infection. Increased support is also needed for the treatment and
care of HIV infected and AIDS patients. The coordination of activities, including the UN system, to
combat the AIDS pandemic should be enhanced. The international community should also mobilize
efforts in monitoring and evaluating the results of various efforts to search for new strategies.
Governments should develop policies and guidelines to protect the individual rights of and
eliminate discrimination against persons infected with HIV and their families. Services to detect HIV
infection should be strengthened, making sure that they ensure confidentiality. Responsible sexual
behaviour, including voluntary sexual abstinence, for the prevention of HIV infection should be
promoted and included in education and information programs. Condoms and drugs for the
prevention and treatment of STDs should be made widely available and affordable and should be
included in all essential drug lists. Effective action should be taken to further control the quality of
blood products and equipment decontamination.
4.1.3. Pregnancy, child birth and HIV/AIDS.
Several studies have reported that pregnancy accelerated the onset of AIDS in HIV infected pregnant
women. However, a few other studies did not suggest that effect and thus the influence of pregnancy
on the natural history of HIV under different circumstance has to be assessed using sound
methodologies. But there seems little disagreement about the fact that more HIV positive pregnant
women are faced with complications compared with HIV negative pregnant women.
The transmission of HIV infection via blood has special meaning for health workers attending
deliveries. Obstetric patients receive more blood transfusion than other patients and every effort
should be made to ensure safety of transfused blood. In addition, health workers have the
responsibility to make sure that every transfusion is clearly indicated. There should be clear
guidelines on transfusion requirements. Birth attendants are also exposed to relatively large amount of
blood during a delivery and should observe, as far as possible, universal precautions to protect
themselves from HIV infections. Although there have been many incidents of blood spillage
involving HIV, only a few incidents have been so far resulted in infection.
After the birth of a baby from an HIV infected mother, the health worker is faced with important
aspects of care such as breast feeding, contraception and child immunization.
Until recently WHO encouraged breastfeeding in areas where safe and effective use of alternatives is
not possible considering the protective, nutritional, psychological, child spacing etc benefits of
breastfeeding. The current estimate of HIV transmission through breastfeeding is about 14 – 15 %.
The tendency is to follow a more flexible approach towards breastfeeding substitutes based on
circumstances.
The possibility that there may be an interaction of oral contraceptives with HIV infection has caused
some concern among health professionals. Oral contraceptives induce subtle changes in the vaginal
and cervical epithelium and it was speculated that these changes may enhance susceptibility to HIV
infection. Well designed studies should address this issue. Intrauterine devices can also cause cervical
irritation providing a portal of entry for infections which could have serious consequences for HIV
infected women. Condoms have been shown to be impermeable to HIV in vitro and a reduction in
HIV transmission has been documented when condoms are used. In addition to other contraceptive
methods of choice, condoms should be used when prevention of HIV infection is required.
HIV infection that has not developed into clinical AIDS is not a contraindication for immunization
against six main childhood killer diseases that are prevented by EPI. Only eligible children with
clinical AIDS should not receive BCG. Such children should be immunized with all other EPI
antigens, unless there are other contraindications. Irrespective of HIV status, pregnant women should
receive tetanus toxoid as scheduled.
4.1.4. The Situation in Ethiopia
Ethiopia is one of the sub – Saharan countries that has been affected by AIDS. The HIV/ AIDS
epidemic has affected a large number of the urban population and continues to expand in to the rural
population. The HIV epidemic probably started at around 1984. The first two HIV positive sera were
reported for the mentioned year based on retrospective analysis of sera from blood donors and
patients. Adult HIV prevalence is estimated to have increased from 1% in 1997 to 7.4% in 1997.
AIDS is now one of the most important causes of mortality and morbidity in Ethiopia. By December,
1999 a total of 76,203 cases have been reported to the Ministry of Health which is a very gross
estimate the actual situation because of the following and other reasons:
 Some people never seek hospital care for AIDS
 The practice of recording and reporting of AIDS cases is often incomplete
 Some people with HIV infection may die of other diseases before they are even diagnosed
as having AIDS
 Most rural health facilities do not have the capacity to test HIV infection.
 Many people have poor access to health service units
As early as 1985 a national task force on HIV/AIDS was created in Ethiopia and in 1987 a department
of AIDs Control was established in 1987. A number of serosurveys across the country followed. With
the political and social changes that occurred soon the tasks of tackling the epidemic were more
devolved to the Regions. However, the epidemic grew and expanded relentlessly. As a result the
Government has endorsed a national HIV/AIDS policy in August 1998 and is in the process of
establishing a national HIV prevention and control council. The Ministry of Health and the Regional
Health Bureaux, in collaboration with stakeholders, have drafted multisectoral strategic five year
plans.
Systematic studies need to be conducted on the impact of the health sector and economy and social
impacts of AIDS in Ethiopia. Available data suggest that a sizeable proportion of orphans were shown
to have dropped out of school, faced abandonment and displacement. For the period 1997 – 2000 a
study estimated the cost of the cost of health care to be 32 – 49 million dollars in the low cost
scenario in addition to the cost of preventive services valued at 56 million US dollars. The indirect
cost (in terms of income loss due to premature deaths) was estimated to be equivalent to 23.42% of
the national income.
Seroprevalence of HIV infection in women and children in Ethiopia:
Several authors have criticised the accuracy of available data on HIV prevalence in Ethiopia, although
perhaps nobody doubts that the country has one of the highest prevalence in the world. The possibility
of over and underestimating by the two common ways of estimating prevalence among blood donors
and antenatal clinic attendees is obvious. According to surveys among blood donors in Addis Ababa
and Gondar the prevalence of HIV infection in women was found to be even higher than men,6.9% vs
6.4% and 11.5% vs 8.4% in Addis Ababa and Gondar respectively. HIV prevalence among ANC
attendees in the different hospitals situated in the main towns of the country has ranged from 14% -
20%. The picture in rural women is not known. So far there are no studies that are large enough to
describe the magnitude of mother to child transmission of HIV infection although it is generally
known that 90% of HIV/AIDS in children is acquired through mother to child transmission. One
study has crudely estimated vertical transmission to be between 29% - 47%.
4.1.5. Distinctive features of STD epidemiology
 STDs typically have long latent or incubation period before symptoms become apparent,
during which transmission occurs.
 Generic variation of STD causing organisms - difficulty of developing vaccine against them.
 Class of behaviour which is resistant to change underlies all of them.
 Many people in developing countries seek treatment out side the formal health system. E.g.: a
study on social features of STD patients in AA in 1990 showed that 80% of the patients came
a week after the onset of symptoms.
 Incomplete treatment may mask symptoms with out cure thus facilitating disease spread.
 Proper treatments for STDs are expensive.
 Sex is embarrassing to discuss
 Treatment is not always simple or effective
4.1.6. Vulnerable populations
o The vulnerable groups for STI & HIV/AIDS are:-
o Poor and homeless persons
o Pregnant adolescents
o Migrant workers
o Substance abusers
o Abused individuals
4.1.7. Risk factors for STD transmission
Behaviours affecting transmission: These include multiple sexual partners, partner who has
other partners, casual partners, recent change of partner.
Social factors;
o Failure to follow safe sex,
o Delay in getting treatment
o Not taking the full prescribed course
o Failure to bring in sexual partners for treatment
o urban residence, being single, and being young
o Increasing urbanization with disruption of traditional social structures, increased
mobility for economic reasons, poor medical facilities and high unemployment rates.
Biological factors
o Age, gender, circumcision. However, the actual distribution may or may not follow the
biological patterns as it may be governed by more strong social and behavioural
factors.
4.1.8. Public Health Significance of STDs
 The following data of DALYs give the share of STDs in total disease burden in a high
prevalence African city and the proportion of STDs. Measles 18%, Malaria 14%, 7 Infant
diseases 15%, HIV and STDs 22%, 5 Adult diseases 7%, gastroenteritis 9%, other diseases
14%. Breakdown of STD burden HIV 69%, Syphilis 18%, Chlamydia 10%, gonorrhoea 2%,
and Chancroid 1%.
Why are STD programs important for AIDS prevention and control?
 These programs have direct contact with patients at high risk of acquiring HIV infection.
 Health workers trained in STD management and control can offer some of the best expertise
needed in AIDS control program.
 Clinical studies suggest some STDs (GUDs including chancroid, syphilis, genital herpes and
chlamydial infections) may facilitate the spread of HIV and/or increasing the sexual partner's
susceptibility to HIV infection. Therefore, developing a more extensive STD control program
within PHC could slow the current rapid spread of HIV in many parts of the world.
 Monitoring the occurrence of STDs can provide useful indicators of the effectiveness or
ineffectiveness of AIDS control programs and/or significant modification of sexual behaviour.
Chancroid ulcers in HIV infected persons tend to be larger, more numerous and persist for
longer than usual. Herpes simplex infections cause severe genital, perianal and rectal ulcers.
Extensive genital ulceration due to Herpes simplex type II virus may be the first underlying
immune deficiency symptom. Late syphilis may develop within unusually short period of time.
On the other hand the prescience of STD that cause genital ulcer (open sores), may increase the
chance of HIV transmission during single coitus by as much as 50 times.
According to ICPD, the objective of Reproductive Health Programs should be to prevent, reduce the
incidence of, and provide treatment for STDs, including HIV/AIDS and the complications of STDs
such as infertility, with special actions to girls and women. The actions to be taken include:
o Reproductive health programs should increase their efforts to prevent, detect and treat STDs
and other reproductive tract infections (RTIs), especially at the primary health care level.
Special outreach efforts should be made to those who do not have access to (reproductive and
sexual health) care programs.
o All health care providers, including all family planning providers, should be given specialized
training in the prevention and detection of, and counselling on STDs, especially infections in
women and youth, including HIV/AIDS.
o Information, education and counselling for responsible sexual behaviour and effective
prevention of STDs and HIV should become integral components of all (reproductive and
sexual health) services.
o Promotion and reliable supply and distribution of high quality condoms should become
integral components of all (reproductive health) care services.
o All relevant international organizations, especially WHO, should significantly increase their
procurement.
o Governments and the international community should provide all means to reduce the spread
and the rate of transmission of HIV infection.
4.1.9. Strategies for reducing spread

1. Early diagnosis and treatment of patients.
2. Education of patients and the general public. In patient education remember the following
steps: Explain
 the STD and its treatment
 and discuss the patients risk level including
i. number of sexual partners
ii. sex with a new of different partner in the past few months
iii. exchange of sex for money, goods
iv. HIV infection
v. Other non sexual risky behaviour (skin piercing, blood transfusion, risk of
perinatal transmission, use of drugs, alcohol)
vi. partners sexual behaviour (other partners, STD, injecting drugs )
vii. Patient’s protective behaviour
 the need to change sexual behaviour help the patient decide to change his/her sex
behaviour
 barrier to changing behaviour
i. Gender – women often have little control over when, with whom, under what
circumstances they have sex.
ii. Cultural practices – age differences at marriage, wife inheritance, values of
family and community.
iii. Religion may contribute to adoption of safe sex practices. On the other hand it
may discourage open discussion about sexuality and protective measures.
 Changes the patient will make in their sexual behaviour
 The need to treat sexual partners
3. Condom provision and safe sex practices
4. Treatment and education of sexual partners
5. Targeting vulnerable groups
In cases of commercial sex workers, their ability to negotiate safer sex practices
depends on more than negotiating and sexual/condom use skills; they have to believe that
it is their right to work safely. Persistent education of people on the idea of assuming that
everybody could in fact be seropositive and individuals who can not abstain should have
this imprinted in their mind (voluntary behaviour modification mandatory). Peer education
by many sex workers have been observed in many places to promote the idea of safe sex
through condom use, as it also reaches many of the victims in the informal bars or those
invisible prostitutes. School sex education programs to address adolescent sexual health
issues and condom promotion.
4.1.10. Prevention and control of STDs
The objectives of STD prevention and care are to reduce the prevalence of STDs by
interrupting their transmission, reducing the duration of infection and preventing the
development of complications in those infected.
Primary prevention
Primary prevention, which is concerned with the entire community, curbs the acquisition
of infection and resulting illness. It can be promoted through health education, and
involves practices such as safer sex behavior, including the use of condoms, and
abstinence from sex. Primary prevention messages apply equally to HIV and other STDs.
Secondary prevention
Secondary prevention involves treating infected people. Except for HIV and the viral
STDs, treatment cures the disease and interrupts the chain of transmission by rendering the
patient non-infectious.
Ways of controlling and preventing STDs;
1. Case detection:
i. Screening: - testing apparently healthy volunteer individuals.
ii. Contact tracing:-sexual partners of diagnosed patient are identified, located,
investigated and treated.
iii. Cluster testing:-Patients are asked to name others persons of either sex who
move in the same socio-economic environment.
2. Case holding and treatment.
3. Epidemiological treatment:-administration of full dose of treatment to person waiting for
the lab result.
4. Personal prophylaxis: - contraception use (condom), washing the genitalia after intercourse.
4.1.11. Managements of STDs
4.1.11.1. Approaches to management of STDs
1. Drug treatment; the treatment of choice depends on the STD syndrome. WHO has recommended
a list of drugs. However, national recommendations can also be considered.
2. Educate the patient; Education is an important in STD case management. The objective of
educating a patient with STD is to help the patient resolve the current infection and prevent
future ones.
3. Partner management; The purpose of partner management is to treat as many of the patients
sexual partners as possible. For many [patients the news about partner management is
uncomfortable and indeed might cause far reaching consequences. Partner management must
comply with the principles of confidentiality and non compulsion. Patients should not be forced
to divulge information about partners, and their identity must not be disclosed to anyone outside
the health system. There are two approaches to contacting sexual partners:
 By the patient: known as patient referral.
 By service provider: known as provider referral.
Both approaches have advantages and disadvantages. Because of the expense of provider referral and
perceived threat to patient confidentiality, the more practical and workable approach is patient referral
which is the option recommended by WHO.
Advantages and Disadvantages of Patient and Provider Referral
5.1 5.2 Patient referral 5.3 Provider referral
5.4 Advantages 5.5 The patient has 5.6 If successful, able to

control over contact and treat
decisions – so both more partners
confidential and
voluntary
5.7 Disadvantages 5.8 Depends on 5.9 Depends on

willingness of willingness of
patient to refer patient to divulge
partners. Patient names. Cost, time
may require support and practical
from service problems of tracing
provider partners. Need for
extra, highly trained
outreach staff. May
be viewed by
patients as a threat to 4.1.11.2.
confidentiality.
assification of STDs management
4.1.11.2.1. Syndromic Diagnosis and Management of STDs

In many health institutioms excluding hospitals it is not possible to make an exact diagnosis of
each individual infection as special laboratory test are needed. However, even with out laboratory
tests, it is possible to make a fairly accurate diagnosis and offer the patient good treatment. A
number of RTIs produce similar symptoms and signs. The Syndromic approach is the most
effective way to treat persons with RTIs especially when no laboratory facilities are available. It
relies on the use of a clinical flow chart – a step by step standardised guide to decision making.
Once a syndrome has been identified, treatment can be provided against the majority of the
organisms responsible for the syndrome. The syndromic approach is well suited to resource poor
settings and enables health care workers to make diagnosis within a short time without special
skills and sophisticated laboratory tests.
Flow charts in use that manage the most common STD syndromes include the following
 Urethral discharge syndrome in man
 Epidymitis: a complication of untreated urethral syndrome
 Lower genital tract syndrome
 Pelvic inflammatory diseases
 Genital ulcer syndrome
Principles of Syndromic management
1) Many STIS can be identified & treated on the basis of signs and symptoms
2) Treatment covers several possible infections responsible for the syndrome
3) Syndromic management will reduce the cost of laboratory work up and extra visits to
health institutions
Its main features are:
 Classification of the main causative pathogens by the clinical syndromes they produce.
 Use of flow charts derived from this classification to manage a particular syndrome.
 Treatment for all important causes of the syndrome.
 Notification and treatment of sex partners.
 No expensive laboratory procedure required.
 Problem oriented (responds to patient’s symptoms).
 Highly sensitive & does not miss mixed infections.
 Treats the patient at first visit.
 Can be implemented at primary health care level.
 Provides opportunity & time for education &counseling.
Advantages:-
Saves time for patients.
Reduces laboratory expenses.
Limitation;
 Misses sub-clinical/asymptomatic infection
 Needs validation study
– Require prior research to determine the common causes of particular syndromes
 Needs training/acumen.
 Most STIs cause similar symptoms.
 Mixed infections are common &failure to treat may lead to serious complications.
 Drug resistance.
The man STI syndromes are:-
A. Genital ulcer
B. Urethral discharge
C. Vaginal discharge
D. Lower abdominal pain
E. Inguinal bubo
F. Scrotal swelling
G. Neonatal conjunctivitis
A. Genital Ulcer
Definition
A genital ulcer is defined as a loss of continuity of the skin of the genitalia. Genital ulcers may be
painful or painless and are frequently accompanied by inguinal lymphadenopathy.
Importance
Genital ulcers are a common cause of consultation in tropical countries and, depending on their cause,
may have serious consequences, such as late symptomatic syphilis, mutilating lesions and enhanced
transmission of HIV.
Etiology
Common STD agents producing genital ulcers are;
 Treponema pallidum- Syphilis
 Haemophilus ducreyi-Chancroid
 Calymmatobacterium granulomatis (Donovania granulomatis)-Granuloma inguinale
(donovanosis)
 C.trachomatis (L1,L2 & L3)-LGV
 Human (alpha) herpesvirus 1 or 2 (herpes simplex virus)-Herpes simplex
 Ulcers due to trauma can become infected by bacteria.
Subjective complaints
Patients usually complain of a sore or sores on the genitalia. Uncircumcised males may complain of
penile discharge or inability to retract the prepuce.
Objective findings
Physical examination: The number and characteristics of the lesions should be noted.
Examination of females may be difficult in some settings but should be performed whenever possible.
The presence of inguinal Lymph nodes should be noted.
Gloves should be worn for palpation.
Laboratory tests: Generally, diagnostic tests for this syndrome are not useful for initial treatment
decisions made at the peripheral level. Whenever available, serological test for syphilis can provide
additional information.
Diagnosis
Lesions of syphilis and chancroid vary in appearance and may be indistinguishable from one another.
If a shortage of drugs makes treatment for both chancroid and syphilis impossible, however, try to
distinguish between the two.
• Syphilis usually produces a single painless ulcer with firm borders that feel like the tip of the nose.
• Chancroid usually produces a soft, painful, easily bleeding ulcer with an irregularly shaped border.
In women the chancroid ulcer may not be painful, however. Alternatively, providers may treat for the
STD that is more common in the area.
Herpes ulcers with a secondary bacterial infection, however, may resemble syphilis and
chancroid ulcers.
Syphilis and chancroid may cause enlarged lymph nodes.
• In syphilis, lymph nodes are enlarged and firm but painless.
• In contrast, chancroid, like lymphogranuloma venerum (LGV), can cause enlarged and tender lymph
nodes that may burst and leak pus.
People with syphilis may not seek treatment until they have symptoms of secondary syphilis - rash,
hair loss, sore throat, malaise, headache, weight loss, fever, or swollen lymph nodes.
Donovanosis and LGV also cause genital ulcers. Donovanosis begins as nodules under the skin that
erupt and form usually painless, sharply defined lesions. The lesions of LGV are small papules or
shallow ulcers that look like herpes blisters and heal without treatment. LGV usually causes tender
inguinal buboes that may leak pus. These buboes are the usual reason that people seek treatment.
Patients may also have nonulcerative genital lesions caused by human papillomavirus (HPV) and
molluscum contagiosum. Human papillomavirus causes genital warts
(condylomata acuminata), which often look like a cauliflower. The lesions caused by
molluscum contagiosum are white, smooth pimples that contain a white, cheeselike substance.
Treatment
Make every effort to treat syphilis because it has serious sequelae.
Treatment for LGV is doxycycline, 100 mg orally, twice daily for 14 days; OR tetracycline,
500mg orally, four times daily for 14 days.
Treatment for Donovanosis is trimethoprim, 80mg/sulfamethoxazole, 400mg or a comparable
sulfonamide component, two tablets twice daily, orally for at least 14 days.
If a patient returns because a genital ulcer has not healed, HIV infection may be the reason. Refer the
patient for testing. In areas where both chancroid and syphilis are common, initial management
should be appropriate to both diseases. Knowledge of the relative frequencies of the different ulcer
diseases in the area is of crucial importance.
B. Urethral Discharge
Definition
In urethral discharge, exudate is present in the anterior urethra; the discharge is often accompanied by
dysuria or urethral discomfort.
Importance
Urethral discharge is the most common presenting complaint of men with STD.
Untreated urethritis may lead to epididymitis and complications such as infertility and urethral
stricture.
Etiology
In men with a history of sexual contact, urethral discharge is usually caused by Neisseria
gonorrhoea, Chlamydia trachomatis or Ureaplasma urealyticum, and rarely by other STD agents (e.g.,
Trichomonas vaginalis).
For practical purposes, STD - related urethritis is subdivided into; gonococcal urethritis, produced by
N.gonorrhoeae, and nongonococcal urethritis (NGU), usually caused by
C. Trachomatis or U. urealyticum. Gonococcal urethritis tends to produce more severe symptoms and
has a shorter incubation period (2-3 days) than NGU (1-3 weeks).
Consequently, some clinicians in areas with high gonococcal prevalence rely on the characteristics of
the urethral discharge to differentiate between gonorrhoea (abundant, purulent) and NGU (scanty to
moderate; white, mucoid, or serious). The quantity and appearance of the discharge can be used to
distinguish accurately between gonococcal and nongonococcal urethritis in about 75% of patients
who have not urinated recently; it can not, of course, be used to diagnose dual infections with
N.gonorrhoeae and C.trachomatis.
The vast majority of cases of urethritis in the developing world are caused by N.gonorrhoeae,
although the number of patients with concomitant C.trachomatis infection is increasing. In the
industrialized countries, NGU is more common than gonococcal urethritis.
Most patients complain of pus dripping from the penis and/or burning or pain on urination.
Objective findings
Physical examination: The appearance of the discharge may range from abundant and purulent to
scanty and mocoid. It may be necessary to “milk” the urethra in order to see the discharge, or to re-
examine after the patient has held urine for at least 3 hours.
Laboratory tests: Microscopic examination of a smear of urethral discharge stained with methylene
blue or safranin or by Gram’s method can be carried out immediately to detect gonococcal urethritis
(pus cells with characteristic intracellular diplococci). If properly performed, the sensitivity and
specificity of the stained smear of urethral exudates should be greater than 95% for gonococcal
urethratis. Concomitant nongonococcal infections will not be identified by this method.
Culture facilities for C.trachomatis, U.urealyticum, and other STD agents are usually not available at
the PHC level and even when available, will not aid in the initial decision to treat the patient, as there
is a delay of two or more days in obtaining the results. Cultures are important, however, when
isolation of the gonococcus is required, as when monitoring β-lactamase production and antimicrobial
susceptibility.
Diagnosis
Identify the origin of the discharge. Urethritis causes discharge from the meatus (the opening of the
penis). Un uncircumcised men discharge from the glans or foreskin may appear to come from the
meatuus.
If no discharge is visible, consider applying gentle pressure to the penis. It may be possible to observe
discharge by holding the head of the penis between the thumbs and gently rolling the thumbs up and
down. It may be necessary to milk the urethra: Start at the base of the penis. Place one finger or the
palm of the hand beneath the penis and one or two fingers on top at the base. Applying gentle
pressure, move the hands outward towards the tip of the penis. Repeat if necessary. If patients are
reluctant or afraid, they may milk the penis themselves.
If the patient urinated shortly before the examination, thus rinsing discharge from the urethra, the
discharge may not reappear for several hours.
Treatment
 Ciprofloxaciline 500 mg po stat or
 spectinomycine 2 grm Im stat plus
 doxycycline 100mg po bid for 07 days or
 Tetracycline 500 mg po TID for 07 days.
N.B.
 Use ery thromycine 500mg QID for 07 days for pregnant women & children
 Do not use ciprofloxacline, rather use spectinomycine.
C. Vaginal Discharge
Definition
STD-related vaginal discharges are abnormal in colour, odour and/or amount. The discharge may be
accompanied by pruritis, genital swelling, dysuria, or lower abdominal or back pain.
Importance
Although vaginal discharge is the most common gynaecological complaint of sexually active women,
not all vaginal discharges are abnormal or indicative of an STD.
Gonococcal or chlamydial infections can lead to pelvic inflammatory disease and complications of
infertility and ectopic pregnancy. Infants born to women with untreated
gonorrhoea or chlamydial infections may develop ophthalmia neonatorum if eye prophylaxis is not
provided at birth.
Etiology
Trichomonas vaginalis, Candida albicans, and a combination of Gardnerella vaginalis and vaginal
anaerobes (“bacterial vaginosis) cause vaginal discharge directly, while N.
gonorrhoeae and C.trachomatis do so indirectly via cervicitis and cervical discharge.
Extensive first-episode human (alpha) herpesvirus 1 or 2 (herpes simplex virus) infection may also
cause visible cervical, vaginal and vulval exudate. Careful history-taking should reveal whether a
vaginal discharge has been caused by a chemical vaginitis, due to topical self-medication or repeated
vaginal cleaning with abrasive substances.
Both the patient’s and the community’s perception of what constitutes “abonormal vaginal discharge”
may vary. In general, most women with this syndrome will complain of the soiling of undergarments,
excessive secretions, changes in colour and/or odour, itching, dysuria, dyspareunia, redness of the
vulval, and sometimes lower abdominal pain.
Pregnancy status should be determined by taking a careful menstrual history.
Objective findings
Clinical examination: A proper gynaecological examination requires an examination table, gloves,
and speculum. Inspect the vulva and introitus for discharge, rashes, erosions, ulcers and palpate the
lower abdomen. If an ulcer is present, consider genital ulcer. If palpation is painful, follow the
algorithm for lower abdominal pain. After introducing the speculum, determine the characteristics and
origin (vaginal, endocervical) of the discharge. Mucopurulent discharge exuding from the endocervix
often denotes infection with N. Gonorrhoeae and/ or C.Trachomtis. If indicated, perform a bimanual
pelvic examination to aid in the diagnosis of pregnancy and pelvic inflammatory disease.
If mobilization of the cervix elicits pain, consider lower abdominal pain.
Laboratory tests: Although desirable, culture facilities are usually not available at the PHC level.
Where a microscope is available, wet-mount microscopy may be useful in differentiating between
trichomoniasis, candidiasis, and “bacterial vaginosis” (KOH test, ratio of pus cells to epithelial cells,
and presence of “clue cells”). In general, Gram stains are not helpful in diagnosing gonorrhoea in
females.
Diagnosis
The perception of abnormal vaginal discharge depends on the patient. Common complaints are new
or increasing stains on underwear, a large volume of secretions, change in the color and consistency
of the discharge, a foul odor, itching and soreness, painful urination, or pain during intercourse.
Diagnosing an STD on the basis of the consistency of vaginal discharge may be difficult.
If a diagnosis can not be based on the consistency of the discharge, check the pH of the discharge if
possible. Normal vaginal fluid has a pH between 4.0 and 4.5. Bacterial vaginosis raises the pH above
4.5. In candidiasis the pH of the discharge is usually less than 4.5. Trichomoniasis discharge usually
has a pH greater than 5.0. Blood in vaginal secretions or pregnancy also may make the pH greater
than 4.5, however.
If the vaginal and vulva are inflamed, candidiasis or trichomoniasis may be the cause.
Bacterial vaginosis usually does not cause inflammation. Vulvar itching is also a symptom of
candidiasis and trichomoniasis. The origin of the discharge can help to identify the disease. Discharge
from the cervix indicates possible gonorrheal or chlamydial infection. Discharge from the vaginal
wall indicates trichomoniasis, candidiasis, or bacterial vaginosis. Trichomoniasis also can cause
urethral discharge. Identifying the origin of discharge in the vaginal may be difficult, however.
Wiping off the cervix with a swab can help. Discharge from the cervix may then be observed. Other
signs of cervical infection are redness and bleeding when the cervix is touched with a swab.
Treatment
 Ciprofloxacillin 500mg po stat or
 Spectinomycin 2grm IM stat plus
 Doxychclin 100mg po bid for 07 days or
 Metronidazole 500mg pot id for 07 days
Factors to be taken into account in selecting treatment include pregnancy status, patient discomfort,
and the most likely cause. Except in candidiasis and bactrial vaginosi, which are not usually sexually
transmitted, the regular sex partner should be included in the management of all cases. Suspicion of a
gonococcal or chlamydial infection warrants immediate treatment of the patient and her partner (s).
Pregnant women should not receive tetracycline.
Treat male partners of women with trichomoniasis with metronidazole, 2 g in one oral dose, or 400 -
500 mg orally, two times daily for seven days.
Metronidazole crosses the placenta and may slightly increase the risk of congenital malformation. It
should not be given to women in the first trimester of pregnancy. Since there are no other effective
treatments for trichomoniasis, metronidazole may be used during the second and third trimesters if
necessary.
Metronidazole passes into breast milk. Some think that breastfeeding women given the single 2g oral
dose should interrupt breastfeeding for 24 hours. Women may not need to stop breastfeeding,
however, because there is no evidence that metronidazole is harmful to babies, whereas disrupting
breastfeeding could be harmful.
D. Lower Abdominal Pain
Definition
Lower abdominal pain in women is often associated with pelvic inflammaory disease.
This is a diagnostically inexact term used to denote suspected or proven pelvic infections in women
(e.g., salpingitis, endometritis, parametritis, oophoritis, pelvic peritonitis) caused by microorganisms
which generally ascend from the lower genital tract to invade the endometrium, fallopian tubes,
ovaries and peritonitis.
Importance
Sexually transmitted pelvic infections are a major cause of infertility, ectopic pregnancy, and chronic
pain. Pelvic inflammatory disease is a common reason for admission to gynecological wards and
emergency rooms. Complications, such as tubo-ovarian abscess, require major surgical procedures
and may cause death.
Etiology
Common sexually transmitted pathogens that cause pelvic inflammatory disease are
N.gonorrhoeae, C.Trachomatis, and perhaps Mycoplasma hominis. Postpartum and post abortion
ascending infections, although usually related to lack of hygiene and poor obstetric care, may
occasionally be associated with gonococcal and/or chlamydial infections. The presence of intrauterine
devices (IUD) favors the development of pelvic inflammatory disease, particularly in the month
following insertion.
Mild to severe lower abdominal pain, which may first be noticed during or shortly after the menses
and which is sometimes associated with fever and/or other symptoms of vaginal discharge (excessive
secretions, changes in colour / or odour, itching, dysuria, dyspareunia, redness of the vulva, etc.)
Objective findings
Physical examination: The clinician should exclude medical-surgical emergencies (e.g., septic
abortion, intestinal obstruction, ruptured bowel, appendicitis and ectopic pregnancy) and evaluate for:
- lower abdominal tenderness,
- vaginal discharge,
- ulceration (also of external genitalia),
- presence of an IUD,
- open cervix, abortion tissue seen or felt,
- tenderness on cervical movement,
- adnexal tenderness and/or masses on bimanual examination,
- temperature > 38 ºC.
Laboratory tests: Direct wet-mount microscopy of a vaginal specimen is necessary.
The presence of pus cells in numbers exceeding those of the epithelial cells suggests infection of the
lower genital tract.
Diagnosis
Check for emergencies and refer immediately to a hospital if septic abortion, intestinal obstruction,
ruptured bowel, appendicitis, or ectopic pregnancy is suspected.
In addition to lower abdominal pain pelvic inflammatory disease can cause pain during intercourse or
urination, heavy or prolonged menstrual bleeding, pain during menses, nausea, and vomiting.
On speculum exam, an open cervix indicates pregnancy or abortion.
Look for signs of STDs- ulcers or vaginal discharge.
Ask the patient if she is using an IUD. Women using IUDs have a higher risk of pelvic inflammatory
disease than women using no contraception, particularly if the IUD was inserted recently.
Treatment
Out patient;
ciprofloxacillin 500mg po stat or
Spectinomycine 2grm Im stat plus
Doxycyclin 100mg po bid for 14day or
Metronidazole 500mg pot id for 14 day
In pt treatment;
o ciprofloxacilline 250 mg IM/IV/ or
o Spectinomycine 2grm bid stat plus (+)
o Doxyclchine 100mg po bid for 14 days +
o Metronidazole 500mg po t id for 14 days
o CAF 500mg IV qid
N.B - Give these drugs paranteraly for 48hrs until the fever is subsided, then change
to po medication.
E. Inguinal Bubo
Definition
An inguinl bubo is an enlargement of the lymph glands in the groin area.
Etiology
Except in the case of lymphogranuloma venerum caused by C. Trachomatis serovars
L1-L3 (chlamydial lymphogranuloma), a bubo is rarely the sole manifestation of an STD and is
usually found together with the etiologically elated genital ulcer. Nonsexually transmitted local or
systemic infections (e.g., infections of the lower limb can also cause inguinal adnopathy.
Most patients complain of pain and swelling in the groin although buboes can be painless. It is
important to find out how long there has been a problem and whether there was a preceding genital
ulceration.
Objective findings
Buboes can be unilateral or bilateral. Palpation may reveal pain or fluctuation. In males, care should
be taken to retract the prepuce to look for ulcers.
Treatment
 ciprofloxaciline 500mg po bid for 03days plus
 Doxycycline 100mg po bid for 14 days or

 Erythromcine 500 mg po qid for 14 days.
Management of patients with buboes is important because inadequate treatment can lead to rupture
with chronic fistulization and scarring. In a patient with inguinal bubo without accompanying genital
ulcer, tetracycline treatment should be given for 2 weeks. Fluctuant buboes require aspiration through
adjacent healthy skin. If buboes persist, the patient should be referred. In principle the same treatment
should be offered to sexual partners, taking into account local cultural and epidemiological factors as
well as the presumed causative organism.
F. Scrotal Swelling
Definition
Scrotal swelling can be caused by trauma, a tumour, torsion of the testis or epididymitis.
Inflammation of the epididymis is usually accompanied by pain, oedema anderythema and sometimes
by urethral discharge, dysuria, and/or frequency. The adjacent testis is often also inflamed (orchitis),
producing epididymo-orchitis
Importance
When not effectively treated, STD-related epidymitis may lead to infertility. Sudden onset
of unilateral swollen scrotum may be due to trauma or testicular torsion and requires immediate
referral.
Etiology
Causative sexually transmitted agents are C.Trachomatis, N.Gonorrhoeae, and very rarely Treponema
pallidum. Mycobacterium tuberculosis is a relatively common cause on some developing countries,
while Gram-negative bacilli, especially of the family
Enterobacteriaceae, and Pseudomonas aeruginosa are common causes in older men with complicated
urinary tract infections. Mumps virus is a causal agent in postpubertal males.
Epididymitis is a fairly common disease, although accurate incidence data are rarely available.
The patient presents with an acute onset of a painful swollen scrotum which is almost always
unilateral. In STD-related epididymitis, there is often either a recent history of urethral discharge or
such a discharge can be seen on physical examination. Sudden onset or a history of trauma or of
recurrent urinary tract infection may help to identify non-
STD-related causes.
Objective findings
Physical examination: This disease is usually unilaterl. The scrotum may appear red and oedematous
and is tender to palpation. Evidence of urethreal discharge should be sought.
Laboratory tests: when feasible, a stained smear of urethral exudate or examination of urinary
sediment of first-voided urine for white blood cells and bacteria may be helpful in determining
whether there is an infectious cause.
Treatment
 ciprofloxaciline 500mg po stat or
 Spectinomycine 2grm Im stat plus
 Poxy cycline 100mg po bid for 07 days or
 Tetracycline 500mg po qid for 07 days.
G. Ophthalmia Neonatorum/Neonatal Conjunctivitis

Definition
Ophthalmia neonatorum is defined as acute purulent conjunctivitis of the newborn in the first month
of life, usually contracted during birth from infectious genital discharge of the mother.
Importance
Ophthalmia neonatorum can lead to blindness, especially when caused by
N.Gonorrhoeae.
Etiology
The most important sexually transmitted causes of ophthalmia neonatorum are
N.Gonorrhoeae and C.trachomatis. The relative frequency of infections with the two
agents depends on their prevalence in pregnant women and on the use of eye
prophylaxis, which is effective against N.Gonorrhoeae but often not against
C.trachomatis. In developing countries, N.Gonorrhoeae accounts for about 20-75% and
C.trachomatis for 15-35% of cases brought to medical attention. Other common causes are
Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus spp and Pseudomonas spp. The
chemical conjunctivitis sometimes caused by 1% silver nitrate drops can be readily distinguished
from infectious conjunctivitis because the former develops within 24 hours and subsides without
treatment.
Epidemiology
In developing countries in Africa, the incidence of gonococcal ophthalmia neonatorum is estimated
between 5 and 50 per 1000 live births, while the incidence of chlamydial conjunctivitis, which gives
rise to fewer symptoms, is probably about the same. If the mother is infected at the time of vaginal
delivery, the risk of transmission to the eyes of the neonate is between 30% and 50% for both N.
Gonorrhoeae and C. trachomatis.
The mother presents her newborn baby because of redness and swelling of the eyelids or “sticky
eyes”, or because of discharge from the eye(s).
Objective findings
These include;
- discharge, which may be purulent,
- redness and swelling of the conjunctivae,
- oedema and redness of the eyelids
The use of a stained smear of conjunctival exudate to detect intracellular diplococci
provides a highly sensitive and specific method of diagnosing gonococcal ophthalmia.
Treatment
 ceftriaxone 125mg Im stat or
 Spectinomycine 25mg/kg Im stat plus
 Erythromycine 12.5mg/kg po qid for 14 days.
Severe conjunctivitis developing in the first week of life is most probably gonococcal in origin and
demands immediate treatment to prevent eye damage.
Conjunctivitis is also a marker of more generalized neonatal infection, necessitating combined
systemic and topical treatment.
If clinical assessment only is possible, all ophthalmia neonatorum should be managed as gonococcal,
and both eyes treated, even if only one eye appears affected. If a stained smear (methyline blue,
safranin or Gram) is made, the ophthalmia neonatorum can be classified as gonococcal or
nongonococcal.
Treatment of mother: The mother should be treated for gonorrhoea and /or chlamydial
(nongonococcal) infection.
Treatment of mother’s partner(s): The partner(s) should always be treated for
urethritis, and the genitals examined for discharge or other STD syndromes.
Prophylaxis of ophthalmia neonatorum
A policy of neonatal eye prophylaxis should be implemented and include the cleaning of the eyes
immediately after birth plus instillation of 1% silver nitrate eye drops or 1% tetracycline ointment.
Only where the incidence of ophthalmia neonatorum is negligible can such a policy be abandoned.
4.1.11.2.2. Etiologic management

 It is done after the identification of the exact causative agent by laboratory investigation.
Advantages:-
o Avoids over treatment/drug resisitance.
o Conforms to traditional clinical training.
o Satisfies patients who feel not properly attended to.
o Can be extended as screening for the asymptomatics.
Disadvantage:-
 Requires skilled personnel &consistent supplies
 Treatment does not begin until results are available
 It is time consuming & expensive
 Testing facilities are not available at primary level
 Some bacteria fastidious &difficult to culture (H.ducrey, C.trachomatis)
 Lab. results often not reliable
 Mixed infections often overlooked
 Miss-treated/untreated infections can lead to complications and continued transmission
Unit – five
5. Providing counseling
5.1. Providing counseling for HIV/AIDS
For providing effective counseling services on HIV/AIDS, one needs to undergo training on
counseling.
Main purposes:
 To modify behaviors, reduce the risk of infection and transmission and cope with some
problems of life.
 To encourage to take responsibility for preventing HIV infection,
 To enable clients cope best with whatever medical, emotional, social problems that may rise
from having HIV/ AIDS,
 To help in finding ways to support family relatives and friends in caring for their loved ones
and deal with the losses in terminal illness.
Counseling about AIDS is an essential part of prevention and control of STI & AIDS. Some of
the components of counseling are ;
1. Safer sex practice
- Consistent use of condom every time individual is having sex.
- Reducing the number of sex partners i.e. sex with uninfected monogamist is
safe.
- Massaging, rubbing, touching, dry kissing, hugging or masturbation instead of
intercourse.
- To be away from unsafe sexual practices, like “dry sex”.
- Not to have intercourse with partner having genital sore or discharge.
2. General access to quality condoms at affordable price.
3. Early treatment of STI
4. Education of sexual partners.
5. Screening of clinically asymptomatic patients
5.1.1. Explanation of VCCT (voluntary confidential counseling and testing)
 Voluntary confidential counseling is a confidential dialogue between the client and the
counselor aimed at creating an enabling environment for them to cope with stress and to make
personal decisions related to HIV/AIDS.
 Voluntary HIV counseling & testing (VCT) is the process by which an individual undergoes
counseling enabling him or her to make an informed choice about being test for HIV. This
process is also aimed at helping them to cope with stress and to make personal decision related
to HIV/AIDS.
 HIV testing, for a person being tested, has far reaching consequences beyond that of the
diagnosis. Although there are many benefits to knowing one’s HIV status, in communities
where HIV is perceived as a stigmatizing condition, there may be negative consequences of
testing. Consequently no one should be coerced into being tested but agree of their own free
will or voluntarily.
 In VCT, HIV testing should only be performed after the client has given informed consent.
 Confidential testing :- is HIV testing in which only the client and the health professionals
involved in the client’s direct care know that was performed and have access to the results.
Comparison between Health education and Counseling

Health Education Counseling
It is a one to many communication It is a one on one interaction involving
confidentiality, anonymity, privacy
One deals with issues is general One has to deal with personal issues of the
individual
One shares statistical information, data and Have to understand the individual to make an
analyses to show trends and dangers of impact on specific attitude and behavior
(i) Epidemics
(ii) (ii) Risky behavior.
The interaction is impersonal The interaction can be very emotional
5.1.2. Pre – test counseling

 HIV counseling should be offered before doing an HIV test. Ideally the counselor should
assist the client to identify her/his risk of acquiring HIV and prepare the client for taking the
test.
 The Purpose of Pretest Counseling is to:
 Enable people take informed decision on whether they want to be tested or not
 Assess a person’s ability to cope with the results of a test and act responsibly
 Pre-test counseling helps the person to:
 Obtain accurate information on HIV/AIDS
 Change behavior to prevent the transmission
 Consider possible implications of test results
 Make informed decisions whether to have or not the test
 Who should be offered pre-test counseling?
• All persons who undergo HIV testing
• Someone’s blood is drawn for testing (survey or donation)
 As part of the pre – test assessment, the counselor should ascertain the client’s understanding
of HIV transmission and the meaning of the antibody result by:
- Discuss the client’s understanding of the risk for HIV.
- Discuss what the virus is and how it is transmitted.
- Ensure that the client understands the risks & benefits of knowing his/her HIV
infection status
- Emphasis should be given to religion & culture
- Discuss what the test result mean.
- Negative result:- it means that the person is either non – infected or recently infected that the test
could not detect the infection. In the later case, the person could be in the “Window period”.
During this period, which may last up to 6 months after the initial infection, the person is infected
with HIV and can infect other, but will have a negative test and possibly no physical complaints.
- Positive result:- It mean that the person is infected with HIV and can transmit to others.
- Discuss the need for retest
- Discuss the client’s plan to cope while waiting for the result.
- Discuss the client’s plan to cope while waiting for the result.
- Explore with the client support systems that may be available.
- Ensure that the client understands what will happen in the post – test
counseling session.
- Discuss risk reduction options /strategies.
5.1.3. Post – test counseling

Post – test counseling should always be offered. The main goal of this counseling is to help the clients
understand their test results & initiate adaptation to their sero positive or sero- negative status. For
post – test counseling, the counselor should therefore:-
- Assure the client that the test results & any other information he/she provides
will remain confidential.
- Provides HIV positive results only by personal contact assuring a confidential
test results.
- Interpret the results for the client based on his/her risk of infection.
- Ensure the client understands what the results mean and address immediate
emotional concerns.
- Reinforce the plan for reducing risk considering the client’s HIV status.
- Discuss with the client the need to appropriately disclose HIV status.
- Assess & refer the client for additional medical &/or social services of
appropriate.
The purposes of post-test counseling are
 To provide emotional support to help the person cope with the news, i.e., help the person on
how to plan to live with HIV, how to avoid further risk of HIV infection.
 To provide more information about HIV and AIDS.
 To discuss prevention of infection.
Counseling after a negative result
- Introduction
- Check whether the person understands the meaning of the result. Discuss on what a negative
result could mean.
- Discuss measures that a person can take to prevent possibility of infection with HIV in future.
- Discuss any other immediate concerns the person may raise.
- Inform the person that counseling is available in future too.
Counseling after a positive result or Diagnosis of AIDS
 Introduction – be very sensitive
 Give the result clearly and simply – acknowledge shock, offer and provide support, encourage
hope
 Give time to let the person consider the result – silence and non verbal caring, empathy,
support
 Let the person talk about how s/he feels about the test result
 Discuss any immediate concerns the person may arise
 Arrange to see the person again soon
Issues in Post-test counseling
 Providing information
 Coping with the news (psychological adjustment)
 Prevention
 Who to tell?
 Discuss (Revise) the main ways of HIV transmission. It is also important to discuss
commonly held mistaken views about HIV transmission.
 Find out how much the person understands about HIV/AIDS and what the results mean to
him.
 Discussion on measures to live with the virus.
 Measures that prevent transmission of the disease.
Follow up (on going) counseling
Follow up counseling is offered to a person after pre and post test counseling to help the person try to
live positively with HIV infection and cope with any problems s/he may face.
The aims of offering ongoing counseling

• Empower people with HIV to maintain control over their lives
• Develop healthy coping skills
Some of the Psychological and Social Reactions to HIV Testing
The reactions usually occur among persons who are subjected for testing for HIV are Shock, stress,
anxiety, anger, denial, fear of illness, fear of desertion, isolation, depression, suicide, resentment at
changes in living partners, self-blame, and loss of self esteem
Special Problems in HIV Counseling
• HIV infection in one sexual partner but not in the other.
• HIV infections in childless couples
• HIV infection in a pregnant woman
• Parents with AIDS or severe HIV infection
An HIV test does not tell whether you have AIDS. It only determines whether you have been
infected with the virus.
Interpreting test results:
HIV Positive Test Result means
There is definite HIV infection if there are other obvious signs of immunedeficiency.
There is likely HIV infection and a confirmatory test should be done.
The person is able to spread the HIV during sex, through his/her blood, or during
pregnancy, childbirth and breast feeding.
The HIV positive test result does not mean:
That the person has developed the AIDS stage of HIV disease
That the person will definitely develop AIDS. However, most HIV positive people
(95%) will develop AIDS within 7-10 years from the time of the infection (not from
the time of the test!).
It does not reveal the stage of the disease.
It cannot determine when the person acquired the HIV infection.
HIV negative test result means
 The patient does not have HIV infection, unless the test is done during the “window
period”.
 It may be falsely negative if the test is done within the first 6-12 weeks after HIV
infection. If the test is done within the first 6-12 weeks after possible HIV exposure,
then the test should be repeated after a total period of 12 weeks after the possible HIV
exposure.
 Laboratory error
Principles of Nursing care for PLWHA
The health personnel should advise the caretakers/The patient himself/herself of AIDS patients to
provide the following care at home:
1. General hygienic measures – personal hygiene, house keeping (handling contaminated soiled
materials)
2. Nutrition of the patient – provide good nutrition (proper balanced diet)
3. Treatment of opportunistic infections
4. Physical therapy – physical exercises and massages
5. Various types of support to be provided – social, spiritual, emotional, psychological and material
support
6. Measures on the sexual behavior of the patients – information and education to promote
responsible or safe sexual behavior to prevent the spread
5.2. Providing counseling for STIs

 Reduction in conventional STI could result in reduction of HIV incidence. Effective STI
prevention & control program should be a component of HIV prevention program.
 The aim of counseling on STI;
- Interrupting transmission
- Prevent development of complications &
- Reducing the risk of transmitting and acquiring HIV – infection.
 Issues/topics discussed are;
o What is STIs?
o Burden/Impact of STIs
o Vulnerable groups
o Epidemiology
o Risk factors
o Manifestations
o Management
o Prevention
The methods of STI infection prevention are:
- Contact tracing
- Condom utilization
- Safer sexual behavior
5.3. Providing post abortion counseling
5.3.1. Definition of Abortion
Abortion: - is the termination or initiation of termination of pregnancy before reaching
viability (before 20/24 weeks or < 500gms according to WHO in UK or before 28 weeks of
gestation or less than 1kg fetal weight in Ethiopia and India. It can be spontaneous where
termination is not provoked deliberately or induced when there is a deliberate interference
with the pregnancy for the sake of terminating it. Most abortion occurs in the
N.B. There is no clear/constant definition of abortion. The definition depends on the specific type
of abortion.
5.3.2. Classifications of abortion
1. Spontaneous/Miscarriage
A. Threatened.
B. Inevitable
C. Incomplete
D. Complete
E. Missed
F. Septic
2. Induced
A. Legal/MTP
B. Clandestine/Criminal
A. Threatened Abortion
Characteristics;
 Scanty vaginal bleeding
 Alive fetus
 Intact membrane
 Closed cervix
 Variable abdominal pain
 Ux is soft, non-tender, and with the expected size of expected date
 The out come can be viability/expulsion of the fetus.
Mgx;
 Bed rest.
 Lab. investigation (for identification of the cause).
 Evacuation after antibiotic prophylaxis administration.
 Monitoring the progress.
B. Inevitable Abortion
Characteristics;
 Heavy profuse vaginal bleeding >3days.
 Fetus alive
 Ruptured membrane
 Cx dilated >3cm.
 Severe rhythmical abdominal pain >7days.
 Ux size is less than expected date.
Mgx;
- Ergometrine injection (0.5mg IV/IM)
- Oxytocin 20IU IV.
- Analgesic agent
- Reasurance
C. Incomplete Abortion
Characteristics;
 Some fetal part passed and some part retained.
 Cxal Os open.
 Severe abdominal pain.
Mgx;
o Evacuation
o Ergommetrine 0.5mg IM/IV.
D. Complete Abortion
Characteristics;
Complete expulsion of conceptus, placenta and membranes.
No abdominal pain.
Ux contracted.
Mgx;
No medical intervention is required except assurance.
E. Missed abortion
Characteristics;
 Embryo dies (death occurs before 8wks but mother fails to detect it)
 Placenta viable
 Sac retained (fetus retained in uterus >2months of demise)
 Uterus small and firm
Mgx;
• Evacuation
o D and C in first trimester.
• Prostaglandin IM in second trimester.
F. Septic Abortion
It is characterized by infection of one of the above type of abortion.
 According to WHO, unsafe abortion is characterized by;
o Lack of skilled providers
o Lack of safe techniques
o Lack of sanitary facilities
 Unsafe abortion is the commonest cause of maternal mortality accounting for up to 32% of all
maternal deaths in Ethiopia.
 Abortion is more than a medical issue, or an ethical issue, or a legal issue. It is above all a
human issue, involving women and men as individuals, as couples and as a member of the
society.
5.3.3. Causes of abortion
The most common causes of abortion are:
o Non – use of contraception
o Contraceptive failure
o Sexual coercion or rape
o Lack of control over contraception
o Abandonment or unstable relationship
o Mental or physical health problems
o Severe malformation of the fetus
o Financial constraints
5.3.4. Complication of abortion
- The complication of abortion could be acute or chronic
o The acute complications of abortion are:
 Incomplete abortion
 Sepsis
 Hemorrhage
 Uterine perforation
 Bowel injury
o Chronic /long term/ complication of abortion are
 Chronic pelvic pain
 PID
 Tubal blockage and secondary infertility
 Entopic pregnancy
 Increased risk of spontaneous abortion or premature delivery in subsequent pregnancies.
 These complications can limit women’s productivity inside and outside the home, constrain
their ability to care for children and adversely affect sexual life.
5.3.5. Postabortal contraception
- The most common postabortal contraceptive methods are
1. Postabortal tubal ligator
2. Post abortal IUCD insertion
3. Post abortal hormonal contraceptive
- All the above abortal contraceptive methods most be provided after adequate counseling.
Especially, if the method chosen is postabortal tubal ligation, an informed consent is
mandatory
N.B.
• Natural family planning - are not recommended until a regular menstrual pattern returns.
• Do not insert IUD until risk of infection is ruled out; until serious genital injury is healed and
until acute anemia improves.
• Spermicide foams, diaphragm or cervical cap - do not use until cervical injury is healed.
• Delay starting injectable until acute anemia improves.
Unit six
6. Providing nutritional health care
6.1. Providing prenatal nutrition
 During pregnancy, a woman must eat adequately to supply nutrients to the fetus, so it can
grow, as well as to support her own nutrition. Adequate protein may prevent complication of
pregnancy (preterm birth). Adequate vegetables and vitamin intake give a pregnant mother to
improve her immunity and to prevent micronutrient deficiency.
6.1.1. Gestational weight gain recommendation
 A weight gain of 11.2 – 15.9kg is recommended weight gain now a day in a pregnant woman.
If a woman is at high risk for nutritional defects, a more precise estimation of adequate weigh
gain can be calculated by computing body mass index. (BMI)
BMT = weight in kg
Square height in meter
BMT = under weight  < 18.5
- Normal  18.5 – 24.9
- Over weight  25 – 29.9
- Obese  > 30
N.B. A pregnant women gains 2kg weight in the 1st 20weeks and 0.4kg/week after 20weeks.
Daily nutritional requirements

- A 50 kg woman requires an average of;
Non pregnant Late pregnancy Lactation
Calories = 2200 2200 + 300 = 2500 2200 + 700 = 2900
 The demand of energy is for

1. Basic physiologic process – Respiration, digestion, circulation
- Maintenance of body temperature
- Growth and repair (2/3 of the total )
2. Every day activity – walking, speech, eating, (17%)
3. Work (Moderately working) 10%
4. Specific dynamic action of food – metabolism is stimulated by taxing of food
(7%)
- During pregnancy, the energy requirements for basic physiologic process and specific
dynamic action of food will increase due to the increased energy requirement due to demands
of the foetus, the placenta, the uterus and breast as meet by the increased food in take.
- During lactation, due to daily production of 500 ml milk containing lactose, fat and protein
and additional activity an additional 700 calorie are required per day.
Daily energy need of an average woman (50 kg) (non – pregnant)
Protein - 200 calories 9%
Fat - 450 calories 20%
Carbohydrate - 1580 calories 71%
Daily requirements
Non Late Lactation
Pregnant Pregnancy 50gm +
Protein 50 gm 50mg + 20 – 70mg
(1gm/kg/wt) 10 – 60gm
Fat 50gm 50gm 60gm
(1gm/kg/wt)
Carbohydrate 400gm 460gm 550gm
Components of nutritional health for pregnant woman and daily nutritional requirements
1. Calories:- the recommended daily requirement intake is 2500K cal. Even obese women
should never consume < 2500K calories
- The easiest method for determining is, if a woman, calorie intake is adequate,
assessing the weight she is gaining.
2. Protein:- The daily requirement intake is 44 – 60g
- The sources are meat, fish, togurt, egg & milk
3. Vitamine;
- Daily intake of most of the vitamins is needs to be increase during pregnancy.
- Particularly water soluble B Vitamins; folate and VB 12 are essential.
- Vit –A:-daily requirement is 800g
- The sources are butter, egg yolk, milk, green vegetable and liver.
- It prevents from night blindness & keep mucus membrane firm to prevent
infection.
- Vit – D – The daily requirement is 5g
 It is sources are egg, cheese, milk & butter,
 It maintains Ca2+ and phosphorus level in the body to the
formation of bone and teetch.
- Vit E – Its daily requirement is 15mg
 Its sources are fresh green vegetables and vegetable oils.
 Its function are protect immature infant from anemia an retinal
distraction from oxygen exposure.
- Vit C – its daily requirement is 85mg
 The sources are citrus fruit, tomatoes, orange juice
 They are used for metabolic functioning, tissue integrity formation
of intestinal connective tissue and strength of blood vessels.
- Folic acid – Its daily requirement is 600g
 The sources are dark green vegetables, kidney and liver.
 It is used to prevent metabolic anaemia
- Niacin – Its daily requirement is 17mg
 The sources are meat, cereals, peas, beans & other legumes.
 They are used to prevent pellagra.
- Riboflavin – Its daily requirement is 1.6mg
 The sources are milk, meat, fish, egg & green vegetable
- Thiamine: Its daily requirement is 1.4mg
 The sources are pork, whole grain & cereals,
- Vit – B12 – Its daily requirement is 2.62g.
 The sources are meat & dairy product
 It is used for proper functioning of bone marrow and intestinal tract.
- Vit B6 – Its daily requirement is 5mg
 The sources are grain, cereals, meat & milk
 It is used for the metabolism of amino acid & glycogen
4. Minerals:-
- Calcium – The daily requirement is too mg
 The sources are milk & cheese
 Its function is skeleton & teeth formation
- Phosphorus:- Its daily requirement is 175mg
 The source & function are the same to Ca2+
- Iodine – its daily requirement is 350mg
 The sources are leaf green vegetables, meat and egg yolk
 If is used for the formation of hemoglobin

- Zinc – its daily requirement is 15mg
 The sources are meat, egg & sea foods
 It is used for growth of bone & skin
- Fluoride – its daily requirement is 3mg
 The source is water
 Its use is for tooth growth
- Sodium chloride – total requirement during pregnancy = 5 – 10gm.
Sources – common salt
- Milk
- All types of diet
Over load – may cause oedema and raised blood pressure.
- Sodium only – daily requirement is 500 mg.
- Iodine – daily requirement = 0.05 mg
- - Source common salt, sea food.
- Iron – daily iron requirement during pregnancy is increased to 30 – 40 mg.
o Source – All animal food. Eg. Meat, liver, egg
o Vegetables – peas, fruits, green leaves.
5. Water
- Daily requirement – is 2.5 litre
- 1 ml water is required for every calorie food intake.
6.2. Nutritional problem
A) Protein energy malnutrition (PEM)
The most common form of malnutrition is associated with diarrhea, as well as inadequate diet in
young children. The complication mental apathy. The server malnutrition (Marasmus and
kwashiorkor) contributes a high mortality & morbidity rate of under five children.
- Kwashiorkor:- the most acute form of malnutrition is generally found in
children of 6 – 24 months who has had an excessive carbohydrate diet
containing relatively little protein.
- Clinical features are – edema
- Enlarged liver
- Loss of weight
- Coldness of extremities
- Depigmentation of skin & hair
Marasmus:- This condition is seen in children whose weight is below normal for their length /height.
- It is described as the state of starvation
- A general deficiency of protein & energy occurred reading to severe wasting of
subcutaneous fat and muscle tissue.
- The clinical manifestations of marasmus are
o Appears old man face
o Emaciated 1mgs
o Hungered & eager to eat when offered.
Treatment of severe PEM
Severe malnutrition children need admission.
The admission criteria for (6 month-18years) are:-
1. Weight for height less than 70%
2. Bilateral pitting edema
3. MUAC less than 11cm
 If one, two or all the above criteria are fulfilled, then the child must be admitted in
hospital.
Admission criteria for >18 years are;

 BMI<16kg/m2.
 Bilateral edema in the absence of other causes.
 MUAC<18cm.
- The treatment of severe malnutrition has its own phase.
- Phase – 1 – feed the child 6 – 8 times per day by mouth or NG – tube- F100 for marasmic
 F75 for kwashiorkor
o Monitor – weight daily
 Body temperature twice daily
 Stool, vomiting dehydration, respiration rate, liver size each day
 MUAC each week
 Height after 21 days
o Vit A – 100,000IU on day 1,2 & 14 po for those who are 6 months – 12 months.
 200,000 IV on day 1,2, & 14 po for those who are 1yr (>8kg) or
more.
o Folic acid 5mg single dose
o Vit D – 600,000 IV IM single dose
o Antibiotics during phase 1 + 4 days
 1st line drugs – Amoxicillin 20mg/kg/d Tid
 2nd line drugs – CAF 25mg/kg/d quid O2
o CAF 25mg/kg/d
o Measle vaccination if not given, for these  9 months
Transition Phase:- go to this phase, if there is good appetites and edema starts to subsided and no
other medical problem and also no IV line & NG – tube.
- In this phase, we have to continue feeding and antibiotic treatment for 4 days. The diet is
F100, not F75.
- Phase – 2 – medical treatment is not completed
- The criteria to pass transition phase to phase – 2 are
o Good appetite
o Edema should be subsided (from ++ to + )
- Feed the child by F100 atienlt 5 times per day.
- The discharge criteria are
o 1N/H  85% & MUAC  12cm
o BMI  17.5
o No edema at 10th day
o Parent education has been completed
o Immunization is updated
6.3. Providing postnatal nutritional health
- What is the need to study?
 Because – The energy requirement on the first year of life is high
 Babies can’t eat ordinary adult food or say how they feel after the feed.
 They are more prone to diseases.
 For the first 4-6 mouths of life, the infant should be fed either by breast feeding or with
formula based cow’s milk-modified to make its composition suitable for infants.
 The sero-status of the mother and the living or social status of the new born family may
determine the feeding schedule to be followed after delivery or on the first four to six months
of life.
‘There is no better nutrition for healthy infants at term and during early months of life than
breast feeding.’
- Vitamins
o The B vitamins are needed in increased amounts to meet extra demands of energy
metabolism and tissue development.
o Folate deficiency exists among adolescent girls, increases the risk of neural tube defect
in babies born to teenage mothers.
 A breast feeding mothers will gradually loss weight even if she chooses a well balanced diet
with nutrient – dense food and even with increased intake. Foods with strong flavors may after
the flavor of breast milk for the baby. It is very important to drink plenty of water. She should
take care of taking some antibiotics like TTC which has an adverse effect of an growth and
development of bone for the baby if the breast feeding mother takes this antibiotics. For those
women who are not breast feeding will loss their weight at a slow & steady pace. Any further
specific questions should be directed to words the mother by a physician or dietitian.
Infant nutritional health care
Specific nutrients are essential for optimal growth & development of an infant. A full term
infant requires 115 – 130Kcal/kg/day for the 1 st months of life. This can easily obtained from
breast milk or formula. By 3 – 6 months of age, an infant calorie requirement decreases to 100
– 110Kcal/kg/day.
Nutrients essential for growth includes lipid, protein, carbohydrate water, salt, minerals and
vitamin.
Exclusive breast feeding
- It is feeding the infant only breast milk for the 1 st 6months. Breast milk is the
best food for the infants as it provides all the nutrients in correct amounts that
an infant needs to satisfy hunger and thirst.
Proper position during breast feeding care:-
- The mother must be comfortable
- Hold the baby’s face at the level of the breast.
- The babies, stomach should be against the mother’s belly.
- The mother should hold her breast with her finger in a “C” shape manner, but
not in scissor – shape
- Touch the baby’s lower lip with the nipple, then the baby opens his mouth
widely, then quickly put the breast in baby’s mouth.
- Check that there should be more areola in the upper part than the lower lip.
- The signs of proper attachment are
- The baby’s nose & chin touches the breast
- The baby’s mouth is widely open
- Lower lips are turned out
- Advantage of breast milk for the infant
- Save infant’s life
- Whole food for the infant
- Promote adequate growth & development
- Contains an antibodies
- Is always ready & at right temperature
- Is easy to digest & easily absorbed
- Protects against allergy
- Contains enough water
- Helps bone & tooth development
- Increases mother – to – child bond.
- Advantage of breast milk for the mother:-
- Helps for F/P for the 1 st 6 months
- Facilitates placental expulsion if given early.
- Reduce risk of haemorrhage after delivery

- Prevent breast engorgement
- Reduces the mother work load
- It is economical
- Disadvantages of breast feeding
- Transmission of micro – organisms, HIV, CMV
- Inconvenience for a working mothers’
- Deficient in Vit k
6.4. Weaning
 Weaning is a process of expanding the diet of the infant to include foods & drinks other than
breast milk. The best age for start weaning is at 6months.
o If possible, the diet should be porridge
o Add protein rich foods, animal /plant
o Offer fruits & vegetables daily
o Pay attention for consistency of food. It should be mushy, not watery.
 Formula feeding:- commercial formulas are designed to substitute breast milk as closely as
possible in terms of protein, fat, carbohydrate, mineral & vitamin content.
Calculating a formula
1. Total fluid requirement is 160 – 200ml/kg/day
2. Protein requirement is 2.2mg/kg/day
3. Calorie requirement is 100 – 120mg/kg/day
Adolescent nutritional health
Adolescents are at risk for nutritional problems. They often have a low dietary intake of certain
vitamins & minerals. Determining nutritional need depends on the rate of growth and physical
activity.
The nutritional requirements of adolescent male is greater than female owing to their large body size
& prolong growth period.
Calorie & protein requirement
Age in year Calories /kg Protein (gm)/kg
Boys 11 – 14 60 1
15 – 18 42 0.9
19 – 22 41 0.8
Females 11 – 14 48 1
15 – 18 38 0.8
19 – 22 38 0.8
- Why?
- Because it is the second life time, other than infancy, that the human body shows a great
development.
o The weight of adolescent increases rapidly
o The height of adolescent increases
o An increase physiological charges
 Males become muscular and females begin menses.
- Energy requirements
o High amount of energy is required
o Girls require fewer calories than boys based on their smaller body size and body
composition.
- Protein
o An increased amount of protein is required to support the pubertal changes
o Girls require – 46 gm/day.
o Boys require – 52 gm/day.
- Minerals
o The calcium requirement for all a adolescents rises to 1300 mg/day to meet the
demands of bone development
o Poor bone mineralization in adolescents increases Vulnerability to bone fracture at
later ages.
o The beginning of the menses and consequent iron losses in the adolescent girl
predispose her to iron deficiency anaemia.
Basic Principles for the Preparation of Safe Food for Infants and Young Children
(WHO, 1996, 10 p.)
Adapted from Golden Rules for Safe Food Preparation in Health surveillance and management
procedures for food-handling personnel: report of a WHO consultation. Geneva, World Health
Organization,1989 (WHO Technical Report Series, No. 785).
Designed by WHO GRAPHICS
Cook Food Thoroughly
MANY raw foods, notably poultry, raw milk and vegetables, are very often contaminated with
disease-causing organisms. Thorough cooking will kill these organisms. For this purpose, all parts of
the food must become steaming hot, which means they must reach a minimum temperature of 70°C.
Avoid Storing Cooked Food
PREPARE food for infants and young children freshly, and give it to them immediately after
preparation when it is cool enough to eat. Foods prepared for infants and young children should
preferably not be stored at all. If this is impossible, food could be stored only for the next meal, but
kept cool (at temperatures below 10°C) or hot (at temperatures near or above 60°C). Before
consuming stored food, it should be reheated thoroughly. Again, this means that all parts of the food
must reach at least 70°C.
Avoid Contact Between Raw Foodstuffs And Cooked Foods
COOKED food can become contaminated through even the slightest contact with raw food. This
cross-contamination can be direct, as, for example, when raw food comes into contact with cooked
food. It can also be indirect and subtle: for example, through hands, flies, utensils or unclean surfaces.
Thus, hands should be washed after handling high-risk foods, e.g. poultry. Similarly, utensils used for
raw foods should be carefully washed before they are used again for cooked food. The addition of any
new ingredient to cooked food may again introduce pathogenic organisms. In this case, food needs to
be thoroughly cooked again.
Wash Fruits And Vegetables
FRUITS and vegetables, particularly if they are given to infants in raw form, must be washed
carefully with safe water. If possible, vegetables and fruits should be peeled. In situations when these
foods are likely to be heavily contaminated, for example when untreated waste water is used for
irrigation or untreated nightsoil is used for soil fertilization, fruits and vegetables which cannot be
peeled should be thoroughly cooked before they are given to infants.
Use Safe Water
SAFE water is just as important in preparing food for infants and young children as it is for drinking.
Water used in preparing food should be boiled, unless the food to which the water is added has
subsequently to be cooked (e.g., rice, potatoes). Remember that ice made with unsafe water will also
be unsafe.
Wash Hands Repeatedly
WASH hands thoroughly before you start preparing or serving food and after every interruption -
especially if you have changed the baby, used the toilet, or been in contact with animals. It should be
remembered that household animals often harbour germs that can pass from hands to food.
Avoid Feeding Infants With A Bottle
USE a cup to give drinks and liquid foods to children. It is usually difficult to get bottles and teats
completely clean. Cups, spoons, dishes and utensils used for preparing and feeding infants should be
washed right after use. This will facilitate their thorough cleaning. If bottles and teats must be used,
they should be thoroughly washed and boiled after every use.
Protect Foods From Insects, Rodents And Other Animals
ANIMALS frequently carry pathogenic organisms and are potential sources of contamination of
food.
Store Non-Perishable Foodstuffs In A Safe Place
KEEP pesticides, disinfecting agents or other toxic chemicals in labelled containers and separate
from foodstuffs. To protect against rodents and insects, non-perishable foodstuffs should be stored in
closed containers. Containers which have previously held toxic chemicals should not be used for
storing foodstuffs.
Keep All Food Preparation Premises Meticulously Clean

SURFACES used for food preparation must be kept absolutely clean in order to avoid food
contamination. Scraps of food and crumbs are potential reservoirs of germs and can attract insects and
animals. Garbage should be kept in safe, covered places and be disposed of quickly.
Back Cover
The World Health Organization estimates that every year some 1500 million episodes of diarrhoea
occur worldwide occur worldwide in children under the age of five, and over 3 million die as a result.
Diarrhoeal diseases are also a major underlying factor in malnutrition.
Up to 70% of diarrhoeal diseases episodes may be food borne and transmitted through food
contaminated during operation.
Unit seven
7. Public education services
7.1. School health service
Objectives – to assess health condition of the student
- To assess learning ability of a student
- To treat mild to moderate health problems
- To give service for hand caped students
- To give health education & information
- To promote positive health among school children
- To provide healthy environment
Aspects of school health service
- Health appraisal of school children & school personal
- Prevention of communicable disease
- Healthy school environment
- First aid & emergency care
- Dental care
The most import aspect of school health program is health education. The goal of health education
should be to bring about desirable behavioral changes on health knowledge, attitude & practice. It
should cover
– Personal hygiene
– Environmental health
– Family life education
– Nutritional life education
Major components of school health service
- Hygiene
- Nutrition
- First aid
- Communicable disease
- Family life /sexually/ education
- Adolescent pregnancy /health
- Environmental protection including routine use of toilet, hand washing before
& after using toilet, proper waste disposal.
- Health promotion
- Health education
- Routine examination of common eye problems, I/P & management.
- Accidental control (injury, burn, traffic, snake bite)
- Common activities include:-
- Physical examination
- Medical inspection (eye, ear, skin)
- Assessment of hand coped children
- Nutritional assessment
- Immunization
- Control of infection
- Health education
- Training of first aid
- Sanitary campaign
- Supplementary diet provision
- Formation of club (first aid, HIV/IDS)
7.2. Prevention substance abuse

Substance abuse overview
People abuse substance such as drugs, alcohol and tobacco for varied & complicated reason. But it’s
clear that our society plays a significant cost. The toll for this abuse can be seen in some hospitals &
emergency departments through direct damage to health by substance abuse & its link to physical
trauma. Jails & prisons tally daily the strong connection between crime & drug dependence and
abuse. Although use of some drugs such as cocaine has declined, use of other drugs such as heroin &
“club drugs” has increased.
Finding effective treatment for & prevention of substance abuse has been difficult. Through
research, we now have a better understanding of the behavior. Studies have at children &
adolescents offer the best chance to club abuse nationally.
Abused substances produce some form of intoxication that alters judgment, perception, attention or
physical control. Many substances can bring a withdrawal effect caused by cessation or reduction in
the amount of the substance used. Withdrawal effect can range from mild anxiety to seizure and
hallucination. Drug overdose may cause death. Nearly all these drugs also can produce a phenomenan
known as tolerance where you must use a large amount of the drug to produce the some level of
intoxication.
Tobacco:- People cite many reasons for using tobacco, including pleasure, improve performance &
vigilance, relief of depression, substance in cigarettes is nicoting. But cigarette smoke
contains thousands of other chemicals that damage health. Hazards include heart disease,
lung cancer & emphysema, PUD, and stroke. Withdrawal, symptoms of smoking include
anxiety, hunger, sleep disturbances and depression. Smoking is responsible for nearly a
half million deaths each year. Tobacco use costs an estimate $ 100, billion a year, nainly in
direct and indirect health care cost.
Alcohol:- although many people have a drink as a “pick me up”. Alcohol actually depresses brain.
Alcohol ressnes tour inhibitions, slurs speech and decreases muscle control & co –
ordination and may lead to alcoholism.
Withdrawal from alcohol can cause anxiety, irregular health beat tremor, seizures, and hallucination.
In its severest form, and withdrawal combined with malnutrition can lead to a life threatening
condition called “delirium tremens (DT). Alcohol is the most common cause of liver failure in USA.
The drug can cause heart enlargement & cancer of the esophagus, pancreas and stomach. In addition
to its health effect, officials associate alcohol with nearly half of all fatal motor vehicle accidents.
Marijuana:- also known as grass, pot, weed, hard. Marijuana which comes from the plant cannabis
sativa, is the most commonly used ideal illegal drug in the USA. The active ingredient associated with
intoxication. Marijuana resin, called hashish, contains an even higher concentration of THC. The drug
is usually smoked, but it can also be eaten. Its smoke irritates your lungs more & contains more
cancer – causing chemicals than tobacco. Common effects of marijuana use include pleasure,
relaxation & impaired co – ordination & memory often the 1st illegal drug people use, marijuana is
associated with increased risk of progressing to more powerful and dangerous drugs such as cocaine
& heroin. The risk of progressing to cocaine is 104 times higher if you have smoked marijuana at
least once than if you never smoked marijuana. Withdrawal can be intense & can include vomiting,
abdominal cramps, diarrhea, confusion, ache and sweating. Overdose may result in death from
decreased breathing. Because heroin is usually injected, often with dirty needles, use of the drug can
trigger other health complications including destruction of heart valves, HIV/AIDS, infections tetanus
& botulism.
- Methamphetamine:- a powerful stimulant that increases alertness, decreased appetite, and gives a
sensation of pleasure. The drug can be injected, snorted (chew) or eaten. It sharges many of the
same toxic effects as cocaine heart attacks, dangerously high blood pressure & stroke.
Withdrawal often causes depression, abdominal cramp & increased appetite. Other long term
effects include paranoa, hallucinations, weight loss, destruction of teeth and heart damage.
- Rohypnol:- also called roofies, roche. This is another sedative that can be taken used as a date
rape drug. Effects include low B/P, dizziness, abdominal cramps, confusion and impaired
memory.
- Ketamine:- also called special K, K. This is an anesthetic drug that can be taken orally or
injected. Ketamine (ketalor) can impair memory & attention. Higher doses can cause amnesia,
paranoa and hallucinations, depression and difficulty of breathing.
Causes of substance abuse
Use & abuse of substance such as cigarette, alcohol & illegal drugs may begin in child hood or the
teen years. Certain risk factors may increase some one’s likelihood to abuse substance. Factors within
a family that influence a child’s early development have been shown to be related to increased risk of
drug abuse.
- Chaotic home environment
- Ineffective parenting
- Lack of nurturing & parental attachment
- Factors related to a child’s socialization outside the family may also increase risk of drug abuse.
- Inappropriately aggressive or shy behavior in the class
- Poor social coping skills
- Poor school performance
- Association with a deviant peer group
- Perception of approval of drug use behavior
Substance abuse symptoms
Friends & family may be among the 1st to recognize the signs of substance abuse. Early recognition
may increases chances for successful treatment. The signs are:
- Giving past activities such as sport, homework, hanging out with new friends.
- Decline grades
- Aggressiveness & irritability
- Forgetfulness
- Disappearing money & valuables
- Feeling rundown, hopeless, depressed or even suicidal,
- Sounding selfish & not caring abut other
- Use of room deodorizers & incense
- Paraphrenia such as baggies, small boxes & rolling paper
- Getting drunk or high or drugs on a regular basis
- Lying, particularly about how many alcohol or dug he/she is using.
- Avoid friends or family
Substance abuse treatment
- Medical – nicotine patches & methadone to control withdrawal effect & drug
cravings.
- Behavioral – by proper counseling
Unit Eight
8.1. Harmful tradition
A) Female genital mutilation (FGM)
Defn:- FGM is the removal of part of the female genitalia. Reasons given by circumcisers & those
who believe in FGM are
1. Preserving virginity:- if
2. Increase fertility
3. Ritualistic reasons: FGM is viewed a step towards being initiates into adulthood.
4. For cleanliness:- the clitorises, labia majora & labia minora are wrongly assumed to
produce secretion which brings offensive smells and wetness, which causes
contamination.
5. Prevention form promiscuity
6. Prevention of death from the newborn:- there is a belief that uncircumcised, clitorises
touch the head of the baby during delivery would die.
7. For longer male sexual preference:- there is also a fear that if the uncircumcised
clitorises comes in contact with penis during intercourse it can excite the man & cause
early ejaculation.
- The operation includes:-
- Type – I – excision of the prepuce with or without part or all of the clitorises.
- Type – II – excision of clitoris with partial or total excision of the labia minora.
- Type – III – excision of part or all of the external genitalila (infibulations)
- The complications of FGM are:-
- Early – pain - Late – Scar formation
o Hemorrhage - Frigidity – painful
o Shock - Dysmenorrheal – painful
o Urinary retention - PID
o Infection - HIV/AIDS
o Septicemia
o Tetanus
- We can prevent FGF by:-
o Education
o Creating alternative employment for these who lives by circumcising
skill.
o Community involvement in the prevention
B) Rape
Defn:- it is a non – consensual oral, anal, or vaginal fenestration obtained by threat of bodily harm or
when the victim is incapable of giving consent.
Impacts of rape
1. Rape trauma syndrome:- emotional & physical effect a woman undergoes following a rape
or attempted rape.
2. STD
Causes of rape
1. Victim precipitated:- the view that the rape is the result of a woman “asking do it.
2. The product of gender role socialization in our culture
- Men use sex to demonstrate their power over women.
3. Psychopathology of a rapist.
4. Social disorganization
Measures of prevention of rape
A. Avoiding situation in which there is high risk of rape
- Set sexual limits:- no one has the right to force you so say, “don’t touch me.”
- Decide early if you would like to have intercourse

- Don’t give mixed message; be clear, say yes or no.
- Be forceful & firm
- Be aware that alcohol & drugs are often related to data rape
- Be careful when you invite someone to your home or you are invited to your
date’s home.
B. Knowing some defense technique
C. Change the attitude that contributes to rape
C) Marriage by abduction
It is gross violation of woman’s rights. In some cases the girl shows willing & ready to proceed with
the marriage. In this case the consequences are less grave. When the girl objects fight against the
abductors, she can be severely hurt & even get killed.
The reasons for marriage by abduction are
- Refusal or anticipated refusal of consent by parents or a girl.
- Avoid excessive wedding ceremony
- Ease the economic burden of the conventional bride price.
- Difference of ethnic origin or economic status
- Harmful effects of marriage by abduction:-
- Battering
- Conflict created by families
- Unhappy, unstable & loveless marriage
- Psychological stress on the girl
- Large cost for conflict resettlement
- School discontinuation
D) Sexual harassment
Defn:- It is unwanted, repeated sexual advances, remarks, or behavior towards another that is
offensive to the recipient & interferences with job performance. It may cause long or short term
psychological impacts like emotional distress, interpersonal conflict & impaired intimacy & sexual
functioning.
Sexual harassment can occur in a variety of circumstances. Often, but not always, the harassers are in
a position of power or authority over the victim.
- Forms of harassment relationships include:-
o Harasser can be anyone, client, co – worker, teacher, professor, student,
friend or stronger.
o Victim can be male or female.
o Harasser does not have to be of the some sex.
E) Early marriage
It is a common practice in Ethiopia, particularly in rural areas, in the age of 10 – 15years old. At this
age, preadolescent girls are not ready physically & psychologically for intercourse, childbirth &
childrearing.
- Some of the reasons for early marriage are:-
o Parents desire to see the marriage of their daughter
o Strengthen the family or business tie between the two parents.
o Avoiding the possibility of not getting marriage or becoming not eligible
for marriage.
o Avoid premarital sex or loss of virginity and its consequence.
- Harmful effects of early marriage are
o Psychological effect
o Prolonged & obstructed labor, pre eclampsia
o Hemorrhage & shock at delivery
o Stillbirth
o Loveless marriage often ending in divorce
o Measures to be take to minimize & eliminate harmful traditional practices
are
- Educate the community & the leader by using acceptable and effecting
methods.
- Provide legal support
- Use friendly health facilities to deal with problems associated with early
marriage.
- Endeavor to educate practitioners of harmful traditional practices about danger
of this practices.
- Imposing punishments on such practitioners if they persist with the practice.
Sexuality /reproductive health rights
- RH is a state of complete, physical, mental, social wellbeing & not merely
the absence of disease or infirmity in all matters related to reproductive system
& its function.
- Reproductive rights are human rights that are already recognized in national
law, international human right documents and other consensus documents.
These rights are:-
o The right to live – no women’s life should be at risk by reasons of
pregnancy.
o The right to equality & to be free from all forms of discrimination in
one’s reproductive & sexual life.
o The right to liberty & security of the person (FGM)
o The right to privacy
o The right to freedom of thought
o The right to information & education
o The right to choose whether or not to marry & to found and plan a family.
o The right to decide whether or when to have children
o The right to the benefits of scientific progress.
o The right to freedom of assembly & political participation.
o The right to free from torture & ill treatment, protection from violence,
sexual exploitation & abuse.
Sexuality is the degree to which a person is exhibiting experience maleness or femaleness physically,
mentally, emotionality as well as attitude towards sex.
Sexually includes knowledge of – menarche
- virginity
- age of incitation
- masturbation
- premarital sex & marital life
It also means sexual pressure
- Special attention should be given in material distribution of ANC, PNC, FP,
Nutritional educational & immunization for adolescents and children because
they are the future hopes for the continuing of this generation.
Addressing special health problems of adolescents
The healths problems occur during adolescents are
- STI, including HIV/AIDS
- Pregnancy & related problems
- Deficiency diseases.
- Psychological problems related to rape, harassment, etc.
Unit Nine
9.1. Providing normal delivery at home
- Home delivery service is a practice which is usually practiced by TBA’s & family doctors and
now a day by health extension workers which have now been recognized as sound.
The importance of normal delivery at home are:-
o Removal of placenta
o Allowing the presence of a relative during deliveries
o Encouraging walking around during labor
o Allowing delivers in free position including squatting & other position
o Placing the baby immediately at the mother’s break
- The special precaution at home delivery is the 5 – cleans
1. Clean environment
2. Clean delivery surface
3. Clean hands
4. Clean perineum
5. Clean cord cutting
9.2. Providing new born care at home level
The following interventions for newborn care recommended by the WHO technical working groups
on essential newborn care.
1. Cleanliness:- this refers to the “cleans” during delivery
2. Thermal protection:- prevention & management of neonatal hypothermia during the
stabilization period in the 1 st G – 12 hours any time is the environmental temperature is low
and thermal protection is inadequate.
The principle of preventing hypothermia in new born are:-
- A warm room for delivery
- Immediate drying of the baby following delivery
- Wrapping the baby in a dry warm cloth
- Giving the baby to its mother as soon as possible
3. Hyperthermia – Temperature above 37.50c in new born is considered as hyperthermia. They
develop hyperthermia if they are exposed to an environment that is to warm. The baby may
become irritated, breaths fast; have hot, dry, skin & flushed face.
The infant should be removed from the source of heat & undressed to allow the body to cool.
- The signs of hypothermia, hyperthermia & infection are similar. If any abnormal signs persists
after the above measures, the infant should be referred to a health facility where appropriate
care is available.
- Initiation of breathing, resuscitation:- if the neonat is not breathing or breaths poorly, active
resuscitation should be undertaken. Basic resuscitation equipments & skills should be
available for every birth.
The principles of resuscitation are:-
o Aspiration of the mouth & nostrils
o End ventilation with positive pressure
Positive ventilation of the neonat with a self inflating bag and music using additional oxygen is a
common method for managing birth asphyxia.
When additional O2 is not available, mouth – to – mouth ventilation can be effective for initiating
breathing in newborn with mild to moderate asphyxia.
- Early & exclusive breast feeling:- the important factor in establishing and maintaining breast
feeding after birth are:-
o Giving the 1 st feeding with in one hour of birth
o Correct positioning of the newborn to allow good attachment to the breat.
o Frequent feeds
o Avoid after supplements
o Psychosocial support for breast feeding mother
- Eye care:- prevention & management of ophtalmia neonatrum
o Ophtalmia neonatorum is defined as conjunctivitis with discharge occurring during the
1st two weeks of life. Infection by N. gonorrhea & C. trachomatis are the two main
causes.
o Complications are more severe & appear more rapid in gonococcal ophtalmia.
o Eye prophylaxis involves:-
 Cleaning the eye immediately after birth
 Apply 1% TIC ointment or 1% silver nitrate if TTC eye ointment is not available
with in 1 st after birth. In some cases, the above prophylaxis may fail & decisions
towards using antibacterial ointment based on local epidemiological evolutions.
Immunization: BCG should be given as soon after birth as possible in all population at risk of
tuberculosis infection.
o A single dose of OPV at birth or in the 1 st tow weeks after birth is recommended to
increase early protection.
9.3. Care of preterm & low birth weight new born
Because of their reduced weight & lack of fat as a source of energy and insulation. They are at
increased risk of hypothermia and poor growth. Therefore, the most important elements of care are
good thermal protection & breast feeding.
Skin – to – skin contact with the mother will provide the necessary warmth and permit frequent breast
feeding. If the baby does not have difficulty of breathing and can be breastfed, it should remain with
the mother.
Common new born diseases
The common new born diseases are:-
- Birth asphyxia
- Hypoxia
- Isclemic encephalopathy
- Intracranial haemorrhage
- Meningitis
- Seps.s
- Pneumonia
- Neonatal tetanus
- Omphalitis
- Conjunctivitis ophtalmia
- Skin infections
- Diarrhea
- Hyperbillirumemia
- Hypothermia
- Hyperthermia
9.4. Early detection of newborn illness at home
Mother & families need to know the danger signs of newborn illnesses, where to got for treatment &
why they must respond quickly if the danger sign occurs.
The following are the danger signs that should be recognized by mothers, other family members and
health workers.
- Respiratory – laboured fast breathing
o Grunting
o Cough
- Behavioral – convulsions
o Lethargic
o Floppiness
o Stiffness, rigidly lock jaw
- Feeding – poor sucking, especially who was previously sucking well

- Skin color – yellow
- Skin abnormality – pustules
o Rash
- Cord – redness
o Bleeding
o Pus
- Eye – redness
o Swelling
o Pus
9.5. Physical assessment of newborn
Just after birth, health personal or birth attendants should assess the following:-
1. Gross congenital malformation
- Imperforate anus
- Talpus
- Esophageal stricture
- Cleft lip
- Cleft pallet
- Microcephaly
- Microophtalmia, etc

Reproductive Health Nursing

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Reproductive Health Nursing

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Kea-Med University College, Debre Brehan Campus

1.2 . Description of historical development and concepts of reproductive health

E.g. the three rights in particular are;

1.5 . The Target Groups for Reproductive Health Services

1.6.1 .Comparison of gender versus sex

Attributes Gender Sex Remark

1.6.2 .Community perception about gender

Events triggering violence are;

o The causes of stigma and discrimination are;

2.2.1. Principles of counseling

2.2.2. Topics to be covered on family planning counseling

o Client assessment for family planning (Physical examination)

 Remember the client has;

 Barrier methods. E.g. diaphragm, Condom, Cervical cup and

- Wants her own method of contraception.

Not widely available.

Side effect / complication

Explanation to the Client (Information and Counseling)

Instruction to the client

- Spotting between period,

These pills contain only progesterone derivatives in very low dose.

o High failure rate compare to COCPs.

o Heart disease due to blocked arteries or stroke.

 Requires another injection every 3 months.

• No repeated clinic visits required,

- Irregular uterine bleeding.

3.1.5. Content of visits

 Assessment (history, physical examination and laboratory tests)

• The ability to recognize and measure them.

 The low risk group

 The medium risk group

3.2. Providing safe delivery

o There are 4 stages of labor. These are

o Inspect vagina for bleeding & hematoma

Blood loss Breast care Recovery

4.1.9. Strategies for reducing spread

5.1 5.2 Patient referral 5.3 Provider referral

5.4 Advantages 5.5 The patient has 5.6 If successful, able to

5.7 Disadvantages 5.8 Depends on 5.9 Depends on

assification of STDs management

4.1.11.2.1. Syndromic Diagnosis and Management of STDs

 Doxycycline 100mg po bid for 14 days or

G. Ophthalmia Neonatorum/Neonatal Conjunctivitis

4.1.11.2.2. Etiologic management

Comparison between Health education and Counseling

5.1.2. Pre – test counseling

5.1.3. Post – test counseling

The aims of offering ongoing counseling

5.2. Providing counseling for STIs

Daily nutritional requirements

 The demand of energy is for

 If is used for the formation of hemoglobin

Admission criteria for >18 years are;

- Reduce risk of haemorrhage after delivery

Keep All Food Preparation Premises Meticulously Clean

7.2. Prevention substance abuse

- Decide early if you would like to have intercourse

- Feeding – poor sucking, especially who was previously sucking well

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