REPRODUCTIVE HEALTH

INTRODUCTION

Reproductive Health is an integral aspect of health care which is content in the minimum

Health care package. Knowledge, skills and attitude of this course will help the learner to

manage and counsel clients with Health problems related to reproductive health.

DEFINITIONS:

Reproductive health is defined as a state of physical, mental, and social well-being not

merely in the absence of diseases or infirmity in all matters related to the functions and

processes of the reproductive system. In this state, people are able to have a satisfying safe

sex life and have the capability to reproduce. Men and women have the right to be informed

and have access to safe effective, affordable and acceptable methods of their choice for the

regulation of fertility as well as access to health care for pregnancy and childbirth.

Sexual health is a state of physical, emotional, mental and social well-being in relation to

sexuality; it is not merely the absence of disease, dysfunction or infirmity.

Sexual health requires a positive and respectful approach to sexuality and sexual

relationships, as well as the possibility of having pleasurable and safe sexual experiences, free

of coercion, discrimination and violence.

Importance of Reproductive Health

• Reproductive health is a human right stated in international law.

• Reproductive health plays an important role in morbidity, mortality and life expectancy.

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• Reproductive health problems are the leading cause of women’s ill health and mortality

worldwide.

COMPONENTS OF REPRODUCTIVE HEALTH

 Family planning: This is when an individual or a couple makes a voluntary or

informed decision on children to have, when to have children, the number of children

to have and the interval between children and use of the family planning method of

their choice to carry out these decisions.

 Adolescent reproductive Health: This involves ensuring that adolescents and young

people are given information and services they need to remain healthy by all

stakeholders at all levels.

Adolescents have special needs that must be addressed which include; education, recreation,

shelter, food and adequate income since their health is affected by both personal and external

conditions because the life styles acquired during adolescence have direct impact on current

and future health so timely interventions must be put in place to reduce health risks.

 Safe motherhood (Maternal and child health-MCH): Maternal health involves

issues related to the health of the mother during pregnancy, labor and after delivery

Child Health involves issues related to the health of the child before its born and through the

child`s first years of life.

 Sexually Transmitted infection, including HIV and AIDS: These are infections that

are usually or exclusively passed through sexual intercourse with an infected person.

Human Immune Deficiency Virus (HIV) is a retrovirus that infects T4 cells (CD4). The virus

causes a persistent lifelong infection that destroys these cells thus wearing down the immune

system resulting in HIV related diseases and AIDS.

AIDS (Acquired Immune deficiency syndrome)

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Specific group of diseases that indicate severe immunosuppression related to infection with

the HIV, AIDS is the late stage of HIV.

 Comprehensive abortion care: This involves prevention of abortion and the care

given to mothers with abortion as well as linking them to other reproductive health

services.

 Gender-Based issues

 Treatment and management of infertility

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SAFE MOTHERHOOD

Topic objectives

1) Define safe motherhood

2) Explain the pillars of safe motherhood

3) Describe the components of safe motherhood

4) Outline the role of the community, Husband, Midwife, and ministry of Health in safe

motherhood

Definition

Safe motherhood is a combined effort of all Health workers and the community in preventing

maternal / infant morbidity and mortality by early preparation of a girl child for conception,

provision of essential obstetric care during pregnancy, labour and puerperium.

OR

This is the prevention of maternal and infant morbidity and mortality by proper preparation

and care of the mothers before conception during pregnancy, labour and pueperium.

SAFEMOTHERHOOD stands for:

S-- Start early to prepare girl child for conception and delivery

A-- Avert harmful practices, culture and beliefs that endanger women during child birth. Like

Female genital mutilation, early marriages which can lead to injury, ill health physiological

stress and death.

F—Family planning practice which should be timely and accessible to all.

E-- Education of women (female literacy)

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M-- Manage all obstetrical cases by trained person considering EMOC

O-- Organize women group or support, community based Health care in:

 Sanitation

 Immunization

 Family planning

 Care during pregnancy, labour and puerperium

 Family death

T-- Train all health workers, TBA, CHW towards safe motherhood

H-- Health educate mothers and the community on danger signs of pregnancy, wellbeing of

mothers and baby

E-- Empowerment of women to reduce over dependency on men and encourage self-help

projects

R-- Remove barriers to safe motherhood

H--- Hear listen and help women to avoid barriers of safe motherhood, communicate to

adolescents

O-- Optimum care during pregnancy, labour and puerperium

O-- Obligatory health services to the mother

D-- Delivery should take place only in hospitals, maternity centre and by trained TBA.

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THE PILLARS OF SAFE MOTHERHOOD

1. 1st Pillar Family planning

This promotes safe motherhood by helping a woman to become pregnant at the right age, 18

and above for the first baby, right interval not less than two years, right number preferably

five children and below, not too late for the first baby 35years and 40 years for the last baby

Safe motherhood therefore is promoted by the by the four blocks: Not too early, too frequent,

too many and too late.

2. 2nd Pillar Antenatal care

Early and regular antenatal care- a minimum of four visits prevents maternal/ infant morbidity

and mortality by encouraging early detection of risk mothers complications of pregnancy,

early treatment and referral of difficult cases, correction of malpresentations, prevention and

treatment of STI and HIV all of which all put the pregnant woman at risk of complication and

death.

3. 3rd Pillar Clean, safe delivery

This promotes maternal/ infant health by preventing the five major causes of maternal

mortality namely, haemorrhage, sepsis, obstructed labour, abortion and pregnancy induced

hypertension. Clean safe delivery involves update knowledge of the health workers, training

and supervision of traditional birth attendants, equipping of all health units and maintenance

of such equipment, knowledge and application of life saving skills such as partograph,

manual removal of the placenta, vacuum extraction etc.

4. 4th Pillar Essential Obstetrical care

 All pregnant women are eligible for emergency obstetrical care including referral,

emergency treatment, antenatal care, clean and safe delivery, Family planning, Clean

and safe delivery, postnatal care, abortion care and care of a neonate and a sick new

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 born baby.Essential obstetric care is important in reducing maternal deaths. Essential

obstetric care is of two types:

That is:

i. Basic essential obstetric care

ii. Comprehensive essential obstetric care.

 Basic essential obstetric care (also called basic emergency obstetric care) at the health

centre level should include at least:

- Parentral antibiotics

- Parentral oxytoxic drugs

- Parenteral sedatives for eclampsia

- Manual removal of placenta

– Removal of retained products

- Assisted vaginal delivery

 Comprehensive essential obstetric services at district hospital (first referral level)

should include all of the above plus,

– Obstetric Surgery

– Anesthesia

– Blood transfusion

 Care during puerperium

 Post abortion care

 Care of a healthy new born baby.

 Care of a sick new born baby

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These two pillars were also added on the four above:

I. Post abortion care: This is the care offered to a woman after an abortion; it involves

prevention and management of complications as well as family planning consultation.

II. STI/HIV control: This involves voluntary counselling and testing of all expectant

mothers, prevention of mother to child transmission and early detection through

screening and treatment of STDs.

Components of safe motherhood

 Pre-conceptual Care

 Family Planning

 Prenatal Care – Antenatal Care

 Clean Safe delivery

 Essential Obstetric Care

 Care during the Puerperium

 Care of a health new born baby

 Post abortion Care

 Care of a sick new baby

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CONCEPTS OF SAFE MOTHERHOOD
 No woman or fetus/baby should die or be harmed by pregnancy or birth.

 Assurance of basic safe living as a girl and a woman in society.

 Respects the freedom to choose when and whether to have children and how many to

have.

 Availability, acceptability and easy access to health care services for a woman during

pregnancy, child birth, post-partum care, family planning for all couples and basic

gynecological needs.

 Requires involvement and commitment from each community and nation to fairly

allocate resources that promote health of all women and infant.

UGANDA SAFE MOTHERHOOD STRATEGIES/ACTIVITIES

1. Ensuring sustained political and community commitment to safe motherhood done by

training the health workers like in life saving skills.

2. Improving quality and accessibility of maternal health and obstetric care to the

community, make guidelines on how to refer cases or mothers with

complications/problems, how to manage emergencies; encourage community to form

helping associations like ‘munnomukabi’.

3. Develop human resources for safe motherhood by training midwives, doctors, nurses

with provision of training materials.

4. Ensuring access to family planning, HIV & STDs screening and encourage men to be

fully involved.

5. Strengthening, monitoring, evaluation and research of safe motherhood in health

systems.
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 6. Reducing social inequalities, comforting the status of women done by encouraging

women associations like poverty alleviation programmes, loan programmes

agricultural programmes.

MATERNAL MORBIDITY

This is general disability or permanent ill health of mothers due to complications of

pregnancy, labour and puerperium.

MATERNAL MORTALITY

This is death of mothers due to causes attributed to pregnancy labour and puerperium

CAUSES OF MATERNAL MORBIDITY AND MORTALITY

These are divided into three:

a) Direct or major or Obstetrical causes

b) Indirect causes

c) Other causes or predisposing factors.

A. DIRECT OR OBSTETRICAL CAUSES OF MATERNAL MORBIDITY AND

MORTALITY

(i) Haemorrhage

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As a result of Antepartum, post-partum haemorrhage, ruptured uterus due to delay to decide,

lack of transport, to health unit, mismanagement t or lack of facilities at the health unit.

(ii) Obstructed labour

Due to contracted pelvis, malpresentations, big baby. This condition is worsened by lack or

poor antenatal care and attendance, misuse of native medicines, mismanagement of first stage

of labour leading to maternal exhaustion, ruptured uterus, assisted deliveries, injuries and

postpartumHaemorrhage.

(iii) Pregnancy related hypertension

Pre eclampsia and eclampsia lead to intracranial damage and haemorrhage, blockage of the

airway, liver and renal damage, cardiac failure and suffocation especially during a fit. These

are major causes of maternal death and disability.

(iv) Abortion

Mismanaged or ‘back street’ (induced) abortions expose the mother to sepsis and injury to the

pelvic organs leading to Haemorrhage.

(v) Asepsis: Many mothers deliver from home or under un-hygienic conditions and by

unskilled personnel, leading to haemorrhageinfections (asepsis) and lack postpartum

care. Lack of medical personnel, medical services, and facilities also expose the

mother to infections.

B. INDIRECT CAUSES

These are mainly medical conditions, which complicate or are complicated by pregnancy,

labour and puerperium. These include HIV and AIDS, anemia, malaria, pneumonia,

Tuberculosis, renal diseases, diabetes mellitus, cardiac diseases and other medical diseases.

Conditions from which anybody else can die at the same time regardless of whether pregnant

or not e.g. accidents, burns, injuries, fighting, suicide, death during wars, social insecurity and

insurgencies.

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PREDISPOSING FACTORS TO MATERNAL MORBIDITY AND MORTALITY

 Before conception

 Preference of boys to girls the effect is abortion because they want

boys, poor feeding of the girl child leading to poor growth and

contracted pelvis.

 Denial of parental care / love leading to psychological trauma

 Lack of education leading to early conception and grand multiparity

 Restriction of specific foods from girls hence poor growth

 Heavy workload leading to contracted pelvis

 Poor diet due to lack of nutritional foods

 Violence against women e.g. sexual abuse, defilement, corporal

beating, incest, violation of women’s rights

 Low social economic status of women and dependency on men

 Early marriage

 Cultural beliefs and practices-female genital mutilation, bridal

inheritance

 During pregnancy

 Un wanted pregnancy –abortion with its complications

 Cultural beliefs affecting pregnancies- preventing them from particular

foods, misuse of native medicine, wrong ideas about antenatal clinics

 Lack of Antenatal care due to poverty, facilities, knowledge, medical

workers to provide the services, lack of integration of services.

 Poor handling of mothers

 Un treated diseases e.g. syphilis, anaemia

 Lack of transport, poor communication and insecurity

 Heavy workload during pregnancy

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  During labour

 Lack of proper care and delivery or in wrong places

 Lack of transport, insecurity delay of referral and delivery in wrong

places

 Lack of trained personnel

 Cultural beliefs and practices, misuse of native medicine

 During puerperium

 Cultural practices e.g. restriction of certain foods

 Mode of delivery

 Poor diet

 No rest

THE ROLE OF A MIDWIFE IN IMPLEMENTING SAFE MOTHERHOOD

Aims

(i) To educate the community

(ii) To educate the mothers

(iii) To provide care during pregnancy

(iv) To provide care during labour

(v) To provide care after delivery

At community level

i) Educate the community to value all children especially girls and to avoid

harmful practices e.g. female genital mutilation and their dangers to girls

before, during pregnancy and after delivery.

ii) Encourage parents to educate their children and proper nutrition including all

girls.

iii) Educate community on Educate community to provide transport to pregnant

women and support them.

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 iv) Educate the community to utilize the healthy facilities available – health

services.

v) Educate community to recognize danger signs especially those related to

pregnancy, labour, puerperium and refer them to health units.

vi) Advocate for the community to have the basic needs of life e.g. water, shelter

and to maintain good hygiene.

In the maternity centre and Hospital

Educate individuals and groups about safe motherhood activities

Provide quality service by identifying risk factors and manage, counsel for

appropriate service during antenatal, Intrapartum and post-partum period

Provide adolescent reproductive services.

Provide integrated reproductive health services

Ensure maternity unit / Hospital is well equipped with medicines and

equipment

Train and support traditional birth attendants

Maintain cooperation and coordination with fellow health workers

Maintain and submits reports to relevant authorities

Conducts operational research in regard to safe motherhood

During pregnancy

 Proper antenatal care

 Health educate about proper nutrition, rest and sleep and good hygiene

 Provide emergency obstetrical care

 Administer Tetanus Toxoid, haematenics like iron and folic acid which should be

administered before conception to prevent anomalies

 Discourage the use of native medicine especially during pregnancy

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  Avoid putting blame on themselves for their situations like frequent child bearing, but

advice on Family planning, reassurance and proper counseling.

During labour

 Provide clean and safe delivery places

 Monitor mothers in labour properly using a partograph, detecting problems early, and

proper referral system

 Prevent complications

BABY- Offer the needs of a baby

 Establishment of respiration and maintaining it

 Prevent hypothermia by keeping baby warm

 Immediate breast feeding

 Early immunization

 Prevent infections by applying sterile techniques when cutting the cord

 Prevent blindness

ROLE OF THE MOTHER IN SAFE MOTHER HOOD

i) Understand the importance of preparation for pregnancy.

ii) Use family planning services so as conceive when ready.

iii) Utilize the antenatal, Intranatal and postnatal services

iv) Involve themselves in self-help activities to avoid dependency on men

v) Eat nutritious foods and learn how to prepare a balanced diet as well as sources

and storage of foods

vi) Recognize danger signs of pregnancy

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vii) Avoid substance abuse

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THE ROLE OF THE HUSBAND IN SAFE MOTHERHOOD

They are divided into:

i. During pregnancy

ii. During labour/child birth

iii. After delivery

iv. In family planning

v. During child rearing

During pregnancy

Domestic work

There is need for the husband to understand and appreciate the discomfort, anxieties

and tiredness that pregnancy may cause in a mother.

Take over tiring tasks like working in the fields, lifting heavy loads, washing and

scrubbing floors to avoid heavy workload on a woman.

Take care of other children

Psychological support

Provide encouragement and emotional support by not criticizing and making demands

on her.

Come along with mother to the antenatal clinic and learn pregnancy related conditions

to enable him help the mother more effectively, and understand what the mother is

going through especially danger signs of pregnancy.

Diet
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 Understand that good nutrition and medical care during pregnancy are important and

so provide them.

Finance

Provide whatever money is necessary for transport fees or medicine.

Arrange to have transport ready in case of any emergency during pregnancy and

postnatal.

During labour/child birth

Provide money, transport, and clothing etc.

Stay with the wife during labour to provide comfort and support.

After delivery

Adapt to a new person (baby) in his life and meet the baby’s increasing demands and

needs.

Give the mother and baby understanding, support, affection and help her in day today

activities

Contribute to having a happy family by ensuring that the mother is well fed and that

both the mother and baby receive medical care

Should be aware of danger signs that might necessitate seeking for medical help

In family planning

To ensure that the mother has fully recovered from the demands of pregnancy and

birth thus after 2 or more years after delivery and protect her from conception for at

least 2 years after birth of the last baby

Seek advice from the Doctor or family planning clinics about methods of

contraception with the mother.

Support and co-operate when using whatever method that was selected.

Should accept male family planning methods

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During child rearing

Protect and provide resources e.g. food, clothing shelter, school fees for the family

Participate in upbringing of the children

Involve the wife in decision making

Counsel and advice adolescents, discuss issues on puberty changes, career guidance

and marriage

Ensure that his daughters are given the same opportunity as sons in terms of education,

health care and other benefits like home and seasonal education

Be available at home for both wife and children for warmth

SAFE CHILD BIRTH

Every mother has a right to expect that her baby will be born alive and healthy, just as every

baby a right to live with a healthy mother. Therefore good maternal health care leads to a

good health baby. In addition, after delivery, the baby needs special care for survival and

healthy development.

CARE OF A NEW BORN MEANS

I. Clean and safe delivery

Injuries and infections during delivery can be prevented by avoiding prolonged labour.

II. Clean cutting and care of the cord

Using sterilized instruments for cutting the cord helps to prevent septicemia due to infection

of the cord, clean cord ligatures, hygienic cord care practices and avoidance of non- hygienic

traditional cord care practices like use of cow dung are essential in ensuring safety of the child

as regards to prevention of infections.

III. Establishing and maintaining breathing, resuscitation if necessary

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OBSTETRICAL EMERGENICES

Learning objectives

1. Definition of obstetrical emergencies

2. List of obstetrical emergencies

3. The role of a midwife in obstetrical emergencies

4. General management of obstetrical emergencies

5. Complications of obstetrical emergencies

6. Prevention of obstetrical emergency

Definition

This is a situation when the lives of the mother or baby or both are in danger of death or

complication and something must be done quickly to save their lives. There is need for the

midwife to take quick action in provision of emergency treatment and consideration of proper

referral system.

List of obstetrical emergency

1) Antepartum haemorrhage

2) Postpartum haemorrhage

3) Cord prolapse

4) Dystocia caused by fetal anomalies like fetal macrosomia (generalized fetal

enlargement)

5) Amniotic fluid embolism

6) Obstetric shock (Hypovolemic, Septic/ endotoxic cardiogenic)

7) Ruptured uterus

8) Intra partum haemorrhage

9) Obstructed labour

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 10) Severe pre-eclampsia

11) Eclampsia

12) Acute Inversion of the uterus

GENERAL MANAGEMENT OF OBSTETRICAL EMERGENCIES

PRINCIPLES APPLIED TO THIS MANAGEMENT

1. Readiness with everything used in management of obstetrical emergencies. These

include facilities such as;

Emergency tray containing the following

(i) Drugs i.e. Pitocin, Lasix, Hydrocortisone, Diazepam, Adrenaline,

Dexamethasone, Manitol, digoxin Vitamin K, Aminophylline, pethidine,

Morphine, Magnesium sulphate, potassium chloride, solutions such as normal

saline, Ringers lactate and dextrose, needles and syringes.

(ii) Ambubag, Oxygen- cylinder and any other facility needed for resuscitation.

(iii) Adequate staff.

NOTE

Atropine is used in poisoning cases, relaxes the smooth and respiratory muscles and dried the

mucus in Eclampsia

2. The midwife should be calm, quick and knowledgeable and should summon for help.

3. Start with the most urgent needs first for example – Arresting haemorrhage,

rehydration or delivery of the baby

4. Quick general history taking, Examination and investigations.

5. Apply the essential care systematically according to the emergency, such as delivery

manual removal of the placenta, resuscitation etc. Apply the nursing process

6. Reassure the mother and relatives.

7. Prepare for transport

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 8. Writing referral notes which include the following

 Personal history of the mother

 All what has been found on examination and investigations on admission

 General condition on arrival

 Treatment given plus obstetrical management

 Reason for referral

 Condition at referral

9. Inform the mother and the relatives about the situation

10. Transfer and escort the mother

11. Handover to the midwife in the Hospital

12. Come back to the facility with equipment.

THE ROLE OF A MIDWIFE IN OBSTETRICAL EMERGENCIES

AT COMMUNITY LEVEL

Health education

 Health education to the community about obstetrical emergencies and their role in

management and prevention.

 Educate, supervise and evaluate the traditional birth attendants in management given

to mothers during pregnancy, labour and puerperium.

 To create awareness on the available health facilities like Dispensaries, clinics, health

centres and hospitals

Antenatal care

 Encourage mothers to attend antenatal, intranatal, postnatal, Young child’s clinics and

Family planning.

 Advise them to follow all the four focused Antenatal visits.

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  Discourage harmful and beliefs which expose a girl child to early sex’ marriage as a

result of lack of education, boy preference.

 Husbands should take over tiring work/duties from their wives when pregnant to

relieve them psychologically

Finance

 The husbands should provide all finances needed for antenatal, labour and puerperium

 Advise women to start self- help projects not to depend on men all the time.

 Encourage the community to provide transport in case of obstetrical emergencies.

During pregnancy

Identify cases with high risk pregnancies which may end in obstetrical emergencies

Thorough history taking, examination and early investigations on every mother during

pregnancy.

Early preparation of mothers for labour and successful lactation

Prompt treatment of mothers with minor conditions such as morning sickness

Early referral of mothers with serious conditions for further management

Proper referral system

During labour

 Proper accepting of mothers in labour in form of a very warm welcome, reassurance

and counseling

 Proper history taking, examination and investigation on every mother in labour.

 Proper monitoring of mothers in labour by using a partograph.

 Early detection of danger signs. The midwife should summon for help in time.

 Avoid prolonged and exhausting labour by administering analgesics, avoiding early

pushing and reassurance, oral and IV fluids

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  Give timely episiotomy in malpresentations and positions to prevent extended tears

and haemorrhage.

 Use aseptic / infection prevention techniques throughout labour.

 Ensure proper management of 3rd stage of labour to prevent P.P.H

After delivery

 Carryout proper observations to the mother and baby in the 1st 2hours to prevent 4th

stage complications

 Health education of mothers about the need of

 Taking a well-balanced diet

 Breast feeding on demand

 Carrying out postnatal exercises

 Breast feeding on demand

 Maintaining personal and environmental hygiene

 Come back for review at postnatal Clinics after 6 weeks

 Attend family planning clinics

 Bringing the baby for immunization at Y.C.C

COMPLICATIONS OF OBSTETRICAL EMERGENCIES

Obstetrical emergencies expose the mother and the fetus to a high morbidity and mortality.

This becomes worse in case management is delayed or even wrong applied. There is lack of

facilities or poor knowledge. However the mother and the fetus may face the following

To the mother

 Haemorrhage as a result of A.P.H, P.P.H, and Intrapartum haemorrhage.

 Shock as a result of haemorrhage

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  Infections following delay in second stage and manual removal of the

placenta

 General ill health

 Anaemia puerperal psychosis

 Poor lactation

 Venous thrombosis

 Sterility

 Assisted deliveries and its complications

 Premature labour

 Low resistance to infections

 A.B.O incompatibility

 Amniotic fluid embolism

 Infertility as a result of infections and damage to reproductive system

 Marital breakdown

Complications of obstetrical emergencies to the baby

1. High neonatal and infant mortality and morbidity

2. Failure to shrive

3. Cerebral damage leading to; paralysis, disablement, Deafness, Dumbness, Blindness

4. Premature deliveries with their complications

5. Abortions (pregnancy wastage)

6. Mental retardation

7. Intra uterine growth retardation

8. Low resistance to infection

PAEDIATRIC EMERGENCIES

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Definition

These are conditions where the life of the baby is in danger of death or complications.

They are considered right from birth up to 5 years

Causes of Neonatal mortality and morbidity

 Asphyxia neonatorum

 Birth injuries

 Low birth weight

 Hypothermia

 Congenital abnormalities

 Sepsis, neonatal sepsis

 Infections like pneumonia,ARTI, Tetanus, Diarrhea, meningitis, septicemia

Causes of infant mortality and morbidity

 Measles

 Diarrhea

 URTI

 Malaria

 Malnutrition

LIST OF PAEDIATRIC EMERGENCIES AT BIRTH

1. Intra uterine hypoxia due to cord prolapse and A.P.H

2. Asphyxia

3. Obstruction of the air way

4. Cerebral damage

5. Hemorrhagic disease of a new born i.e. un ligatured cord

6. Hemolytic diseases

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 7. Injury to the internal organs

8. Bowel obstruction

9. Fetal abnormalities where the life of the baby is in danger e.g.

Ancephally,exomphalus, esophageal atresia

Congenital enlargement of the kidney, heart defects like tetralogy of fallots.

After birth

10. Severe jaundice to the danger of kernicterus

During one week

11. Severe congenital and acquired malaria during the 1st week

12. Anaemiadue to haemorrhagediseases of the new born

13. Neonatal tetanus and sepsis

As it grows

14. Swallowed objects and aspiration

15. Poisons

16. Insect bites

17. Falling

18. Burns Cuts

19. Fractures

Diagnosis is by:

-APGAR score at birth and continue monitoring and observing until baby is able to speak.

-History from the mother and peers

Management of these emergencies

Depends on the cause but consider the following

- Resuscitation

- Induce emesis if the substance taken is not acidic

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 - Give milk or a sweet drink

- Give oxygen

- Put on a drip(forced duiresis)

Complications

- Depends on the type of paediatric emergency

- Complications may happen temporarily orpermanentlyat birth or later

Health education of the public on paediatricemergencies, their cause and prevention

Prevention of paediatric emergencies

1. Since most of the maternal conditions lead to paediatric emergencies, neonatal / infant

mortality and morbidity. Therefore steps in preventing

Such emergency is the same way as for the mother.

2. Knowledge of life saving skills in paediatrice.g. resuscitation is essential.

HIGH RISK PREGNANCY

DEFINITION

High risk pregnancy is pregnancy that is likely to end up with complications, death of mother

or baby or bothand the mother must be cared for and or delivered in a well-equipped health

unit under Doctors supervision

Management of high risk pregnancy

- See management of obstetrical emergencies

- Some mothers with high risk pregnancy are cared for in the maternity centre

during pregnancy and referred at full term for delivery in the hospital, others are

referred on first contact

- Early detection and referral are very important.

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Prevention of High risk pregnancy

a) The role of a midwife, husband, and community in safe motherhood

b) The Midwife should be knowledgeable with right updates on how to deal with high

risk pregnancies

c) Equip her maternity centre and be able to deal with such cases efficiently

d) Make sure she can refer mothers in need and in time.

SOME HIGHRISKMOTHERS

(i) Young prime gravida aged 16 and below

(ii) Elderly prime gravida aged 35 and above

(iii) Multi gravida of 5 and above

(iv) Mothers who have had 3 or more miscarriages

(v) Mother with small stature 153cm and below, limping mothers.

(vi) Mothers with history of pelvic fractures

(vii) Confirmed Cephalo Pelvic Disproportion

(viii) Multiple pregnancy

(ix)Mothers with intra uterine fetal death

(x) Post-partum haemorrhage on previous delivery

(xi) Pre-eclampsia, eclampsia, and any mother with history of post eclampsia toxemia

(xii) Mother with underlying medical diseases like cardiac, renal diseases, essential

hypertension, Diabetes, Anemia, Asthma, Rhesus negatives

(xiii) Mothers with history of instrumental deliveries

(xiv) Mothers with history of mental illness

(xv) Mothers with premature deliveries.

(xvi) Mothers with history of 2 or more still births.

(xvii) Previous retained placenta

29
 FAMILY PLANNING

DEFINITION

This is the service which assists individuals or couples to make an informal decision on how

to space children, number of children desired and to regulate the time of conception so as to

have them when they themselves wish in order to maintain physical, social and economic

wellbeing.

OR

Family planning is the way an individual or couples decide for themselves when to start

having children, how many children to have, how to space them and when to stop having

children.

CONCEPTS OF FAMILY PLANNING

Counseling

30
This is an important pre-requisite for the initiation and continuation of family planning

methods. Service providers should be trained to provide counseling about family planning

methods.

Provision of contraceptives

Contraceptives should be given to clients in accordance with approved methods, specific

guidelines and by service providers who have been trained in provision of that method.

Follow up and referral system

All clients who choose a family planning method should be informed of the appropriate

follow up requirements and encouraged to return to the service provider should they have any

concern.

Record keeping

All family planning service providers should maintain adequate records to identify each

client, the type of contraception provided and special circumstances associated with its

provision as well as when to return next.

Supervision

It is an essential component of the program evaluation. It helps to ensure that the needs of the

client are being met and service delivery guidelines are being followed.

Logistics

Maintenance of an effective organization and supply system helps staff at service delivery

points. Clients should not wait for a long time before being served.

Quality care in quality family planning programmes

It covers availability, accessibility and affordability of all the family planning services. The

care should be personalized, clients should be treated with dignity and privacy should be
31
maintained. Clients should not wait for a long time before being served. Service delivery

points should provide at least all services during normal working hours and where possible

attend to the special needs of their clients/ population and adequate supply of contraceptives

and consumable supplies should be maintained. Supervision should be dynamic, working

together with staff to solve problems is essential in providing quality services.

BENEFITS OF FAMILY PLANNING

Family planning helps the individual or couples to live a healthy and useful life that

contributes to the development of the family, community and the nation.

To the family/couple

 Waiting to have children can allow young women and men time to complete their

education.

 It helps the mother to have enough time to recover from the effects of pregnancy,

labour and delivery.

 Enables the couple to plan further for the size of the family they can afford to care for.

 There is enough love for their partners and children

 Mothers and babies will be healthier, because risky pregnancies are avoided.

 Family planning can also help you and your partner enjoy sex more, because you are

not afraid of unwanted pregnancy.

 And some methods have other health benefits. For example, condoms can help protect

against the spread of sexually transmitted infections (STIs),

To the children

 Fewer children mean more food for each child.

 There is prolonged breastfeeding which protects them from childhood diseases like

malnutrition.

 It improves parental and child to child relationship.

32
  Better education, jobs and health facilities.

 Reduction of child mortality and morbidity.

To the community

 Improved quality of life of the people as food, education and other opportunities are

available.

 It decreases the number of street children.

 There is less economic burden.

Why a variety of family planning methods?

 It enables promotion of the quality of care through enhancement of choice,

encouragement of continuity.

 Upholds clients’ rights that is enhancement of choice and safety

MISCONCEPTIONS ABOUT FAMILY PLANNING

 The Norplant moves around the mother’s body and breaks inside the body.

 The IUD travels from the womb to other parts of the body.

 Condoms will not fit properly they are either too big or small and can break easily.

Condoms decrease sexual pleasure.

 It is difficult to become pregnant after using family planning methods as the ovaries

are all destroyed.

 Some say hormones in family planning enter breast milk and harm the baby.

 The methods can cause cancer.

Note: Health workers should educate the public the public to reduce mis-conceptions.

33
ASSIGNMENT: EXPLAIN BARRIERS TO FAMILY PLANNING PROGRAMME

TYPES OF FAMILY PLANNING METHODS

There are approximately 4types of family planning methods available in Uganda

1. Temporal hormonal family planning methods

 Oral pills

i. Combined oral contraceptives(COCs)

ii. Progesterone/progestin only pills(POPs)

iii. Emergency pills

 Injectables

i. Depoprovera

ii. Noristerat

 Implants

i. Norplants

ii. Implanon (3 capsules)

iii. Jadelle (2capsules)

2. Temporal non hormonal family planning methods

i. Intra uterine device (IUD)

ii. Condoms

iii. Spermicide

iv. Diaphragm

v. Cervical cap

3. Temporal natural family planning methods

i. Lactation ammenorrhoea method (LAM)

ii. Calendar method

34
 iii. Coitus Interruptus (withdraw method)

iv. Cervical mucus method/Billing’s method (CMM)

v. Basal body temperature (BBT)

4. Permanent family planning methods/voluntary surgical contraceptives(VSC)

i. Tubligation

ii. Vasectomy

TEMPORAL HORMONAL FAMILY PLANNING METHODS

1. ORAL PILLS

COMBINED ORAL CONTRACEPTIVES (COCS)

These are pills that contain synthetic or artificial oestrogen and progesterone taken/swallowed

by a woman every day to prevent pregnancy.

Types of COCs

Duofem

These are 28 pills with 21 white pills which contain 0.03mg of oestogen, 0.3mg of norgestrel

(progesterone) and 7 brown pills containing ferrous femurrate.

Lo-feminal

It has 21 white pills containing 0.03mg of ethinylestrodiol (oestrogen), 0.3mg of norgestrel

(progesterone) and 7 brown pills containing ferrous femurrate.

Microgynon

35
It contains 21 hormonal pills with 0.03mg of oestrogen, 0.15mg of levenorgestrel and 7brown

pills containing ferrous femurrate.

Mechanism of action of COCs

 Suppresses ovulation

 Thickens cervical mucus preventing sperm penetration

 Prevents implantation by thickening the endometrium.

Effectiveness of COCs

They are 92-99% effective depending on the user.

Advantages of COCs

 Prevent pregnancy

 The do not interfere with sexual intercourse

 They are convenient and easy to use

 They can also be used as emergency contraceptives

 They reduce dysmenorrhoea

 They are easily reversible

 They are very effective if taken correctly

 It decreases menstrual flow and cause the menses to be regular and predictable.

Disadvantages of COCs

 Effectiveness depends on the client’s remembering to swallow daily so strong

motivation is needed.

 Requires regular and dependable supply

 It does not prevent STDs

 Effectiveness may be lowered when certain drugs are taken.

36
Side effects of COCs

 Nausea

 Headache

 Weight gain

 Spotting

 Depression

 Dizziness

 Mild breast tenderness

 Heart attacks

 Stroke

 DVT

 Liver malignancies

Who should use COCs?

 Women of any age

 Women who are breastfeeding a baby more than 6months old.

Who should not use COCs?

 Women who are pregnant.

 Women who are breastfeeding a baby less than 6 months old.

 Women over 35years of age who smoke cigarettes.

 Women with blood pressure higher than 150/100mmHg.

 Women with blood clot disorders of the legs

 Women who have a lump in their breast.

 Women who cannot remember to take a pill every day.

37
When can a woman start taking COCs

 Within the first 5days after the start of her menstrual bleeding.

 Any other time if it is reasonably certain she is not pregnant.

 Six months post partum if breast feeding.

 Immediately after abortion

 Three weeks delivery if not breast feeding.

PROGESTIN ONLY PILL (PILLS)/MINI-PILLS

These are pills which contain synthetic progesterone and are taken every day by a woman at

the same time of the day to prevent pregnancy.

Types of POPs

Microval

They are 35 pills each containing 0.03mg levonorgestrel.

Ovrette

These are 28 pills each containing 0.075mg norgestrel.

Soft sure

These are 28 pills each containing 0.075mg norgestrel.

Mechanism of action

 Thickens cervical mucus to block sperm and egg from meeting.

 Prevents ovulation.

 Changes endometrium, making implantation less likely.

Effectiveness
38
99% with correct and consistent use. In breast feeding women the POP is nearly 100%

effective.

Advantages

 Prevent pregnancy

 The do not interfere with sexual intercourse

 They are convenient and easy to use

 They can also be used as emergency contraceptives

 They reduce dysmenorrhoea

 They are easily reversible

 There is immediate return to fertility when stopped.

 They are very effective if taken correctly

 They do not affect breastfeeding.

Disadvantages

 Effectiveness may be lowered when certain drugs are taken like rifampcin, phenytoin.

 Requires regular and dependable supply

 It does not prevent STDs

 Forgetfulness increases failure

 Some weight gain or loss may occur

Who should use (indications?)

 Breastfeeding mother (6 weeks or more post partum) who needs contraception.

 Post abortion women may start immediately.

Who should not use POPs?

 Women who are /suspected to be pregnant.

39
  Women who are breastfeeding a baby less than 6 months old.

 Women over 35years of age who smoke cigarettes.

 Women with blood pressure higher than 150/100mmHg.

 Women with blood clot disorders of the legs

 Women who have a lump in their breast.

 Women who cannot remember to take a pill every day.

 Children with active viral hepatitis/liver cirrhosis or tumors

When can a woman start taking POPs?

 Within the first 5days after the start of her menstrual bleeding.

 Any other time if it is reasonably certain she is not pregnant.

 Six months post partum if breast feeding.

 Immediately after abortion

CLIENTS’ INSTRUCTION/INFORMATION

 If you start taking the pill, abstain from intercourse for the next 48hours or use another

method of family planning like condoms.

 Take pills daily at the same time.

 If she forgets to take her pill one day, take two pills the next day. If she forgets to take

her pill on more than one day, she might become pregnant. She should keep taking one

pill each day, but she should also use condoms until her next menses. Her menses will

probably begin sooner than usual. On the fourth day of her menses, she should start a

new packet of combined pills.

 Use a condom in addition in addition to the pill if you think there is a chance that you

or your partner is at risk of exposure to STIs and HIV.

40
  Return to the clinic for more pills before you have finished your last pack of pills, if

she experiences any problems like severe headches,delayed menstrual period after

several months, sever lower abdominal pain

EMERGENCY CONTRACEPTION

These are methods of contraception used by women to prevent unintended pregnancy

following unprotected sexual intercourse. However, this has to be done within 72hours

(3days).

Why emergency contraception?

Is the only method that prevents pregnancy after unprotected sexual intercourse like rape.

Mechanism of action

 Prevents implantation of the fertilized ovum (incase the ovum was already released

following the sexual intercourse)

 Delays ovulation incase the ovum had not been released yet following the intercourse.

When is emergency contraception needed?

 Within 72 hours following un protected sexual intercourse/without contraceptive

protection.

 Following rape/forced intercourse.

 When a condom breaks or slips off during intercourse.

 When the IUD has been displaced.

41
  When a woman has miscalculated her fertile period, when using natural family

planning.

 When a woman has forgotten to take oral contraceptives for 2 consecutive days

 When a woman is more than two weeks late for her Injectable contraceptive and has

had unprotected sexual intercourse.

Types/methods of emergency contraception

There are two methods of emergency contraception:

i. Emergency contraceptive pills

ii. Intra uterine device

1. Emergency contraceptive pills (ECP)/’morning after pills’

These are hormonal methods that can be used to prevent pregnancy following unprotected

sexual intercourse.

Types of emergency contraceptive pills

 Combined oral contraceptives like lo-feminal:

- Take immediately----- 4 pills

- After 12 hours-------- 4 pills

 Progestin only pills like Ovrette

- Take immediately----- 20 pills

- After 12 hours-------- 20pills

 Dedicated emergency contraceptive pills like Vikella, Postinor

- Take immediately----- 1 pill

- After 12 hours-------- 1 pill

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Characteristics of emergency contraceptive pills

 Safe, effective and easy to use by all women

 Should be started within 72hours (3days) following unprotected sexual intercourse

 Should not be used as a regular contraceptive method but rather used only in

emergency. This is because they are less effective and have more side effects than

other family planning methods.

 Will not work once a woman is pregnant

 They do not protect against STIs and HIV inclusive.

Side effects

 Nausea and vomiting

 Headache

 Spotting

 Vaginal bleeding

 Dizziness

 Fatigue

 Earlier onset of the next menstrual period/bleeding

2. INJECTABLES

These are injections containing hormones that protect a woman from pregnancy in 2-3 months

by stopping her ovary from releasing eggs.

Effectiveness

99-99.7%

Types

I. Depoprovera/injectaplan

43
It is a progestin only Injectable contraceptive composed of synthetic progestin called Depot-

medroxy progesterone acetate (DMPA). It is given intramuscularly in 150mg every 3months.

II. Noristerat

Commonly known as Norethindroneenanthate (NET-EN) is a progestin only Injectable

contraceptive method given intramuscularly in 200mg every 2months.

Mechanism of action

 Suppresses ovulation

 Thickens the cervical mucus thus preventing sperm penetration

 Changes the endometrium making implantation less likely

Advantages

 They do not interfere with intercourse

 It does not affect breast feeding

 They prevent pregnancy/conception.

 No supplies needed by the client

 It reduces menstrual cramps

 It does not require /need daily remembering

 They protect against endometrial cancer.

Disadvantages

 Reduction of libido

 Does not offer protection against STDs/HIV

 Some weight gain is common

 Causes changes in menstrual bleeding patterns like irregular bleeding/spotting or lack

of menstrual bleeding, excessive menstrual bleeding.

44
Who should use Injectables?

 Women of any child bearing age

 Women who donot want to take pills everyday

 Women with high, low or normal blood pressure

Who should not use contraceptive Injectables?

 Women confirmed or suspected to be pregnant

 Nulliparous women

 Women who have abnormal/un explained bleeding

 Women with current breast cancer since the progestin in the contraceptive can lead to

cancer progression.

When should a woman start contraceptive injection?

 Post partum period that is either on the day the baby is born or any time afterwards, so

long as she is not pregnant.

 Any other time, if it is reasonably certain that she is not pregnant

Side effects

Minor side effects Major side effects

Weight gain Migraine headache

Mild headache Jaundice

Breast tenderness Extremely heavy bleeding

Steps in giving the injection

 Describe to the client how the injection will be given, what to expect.

 Check expiry date on Depoprovera/Noristerat single dose vial.

45
  Wash hands thoroughly and dry them.

 Prepare the injection (always shake vial vigorously before drawing solution into

syringe).

 Clean skin above deltoid or gluteal muscle with antiseptic solution.

 Insert needle deep into muscle and aspirate solution.

 Inject Depoprovera/Noristerat.

 Apply pressure to injection site with cotton, but donot rub-this may speed up the

release of progestin and shorten period of efficacy.

 Discard used syringe and needle in a safety box.

 Wash hands thoroughly with soap and water and dry them.

Client instructions

 The first injection becomes effective within 24 hours of injection if given between

Day 1 to7 of the menstrual cycle. If given after day 7, you must use a back –up family

planning method for 24hours.

 Educate her about the side effects and how to handle them.

 Should return urgently to the clinic if she experiences:

- Delayed menstrual period after several months of regular cycles (this may be a sign of

pregnancy).

- Severe lower abdominal pain

- Heavy bleeding (twice as long as or twice as much as normal) or prolonged bleeding

(lasting more than 8days).

- Pus or bleeding at the injection site.

- Migraine headaches repeated very painful headaches or blurred vision.

46
Return to the clinic for the next injection every 12 weeks (for Depoprovera) or every 8 weeks

(for NET-EN).

3. IMPLANTS

These are small flexible plastic rods or capsules about the size of a match box that release

synthetic progestin (Levonorgestrel) which are inserted under the skin of a woman’s upper

arm to prevent pregnancy.

Type of implants

I. Jadelle – 2 rods effective for 5 years.

II. Implanon – 1 rod effective for 3 years

III. Norplant – 6 capsules, labeled for 5 years of use

Effectiveness

99 to 99.9%

Mechanism of action

 Thickening cervical mucus (this blocks sperm from meeting an egg).

 Inhibits ovulation

Advantages

 They do not interfere with intercourse

 It does not affect breast feeding

 They prevent pregnancy/conception.

 No supplies needed by the client

 It may decrease menstrual cramps

47
  It does not require /need daily remembering

 They protect against endometrial cancer

 Long term contraception achieved

 There is immediate return to fertility.

Disadvantages

 Does not offer protection against STDs/HIV

 Some weight gain/loss may occur.

 Causes changes in menstrual bleeding patterns like irregular bleeding/spotting or lack

of menstrual bleeding, excessive menstrual bleeding.

 Requires trained provider for insertion and removal. (provider -dependent)

 Its effectiveness may be lowered when certain drugs are taken for epilepsy or TB.

Who should use implants?

 Women of any child bearing age

 Women who do not want to take pills everyday

 Women with high, low or normal blood pressure

Who should not use implants?

 Women confirmed or suspected to be pregnant

 Women who have abnormal/un explained bleeding

 Women with current breast cancer since the progestin in the contraceptive can lead to

cancer progression.

 Breast feeding mothers less than 6weeks post partum.

When should a woman start implants?

 Any other time, if it is reasonably certain that she is not pregnant

48
  Breastfeeding mothers immediately after 6weeks post partum.

 After miscarriage or abortion with in the first 7days after the abortion or immediately.

Implanon insertion

Requirements/equipments for the implant insertion:

 An examination table/coach for the woman to lie on

 Sterile surgical drapes

 Sterile gloves

 Antiseptic solution

 Local anesthetic (lignocaine)

 Needles and syringe

 Sterile gauze,

 Adhesive bandage/Pressure bandage

 An applicator and its parts are shown below

Steps for insertion

 Have the woman lie on her back on the examination table with her non-dominant arm

flexed at the elbow and externally rotated so that her wrist is parallel to her ear or her

hand is positioned next to her head.

 Identify the insertion site, which is at the inner side of the non-dominant upper arm

about 8-10 cm (3-4 inches) above the medial epicondyle of the Humerus .The implant

should be inserted subdermally just under the skin to avoid the large blood vessels and

nerves that lie deeper in the subcutaneous tissue.

 Clean the insertion site with an antiseptic solution.

 Anesthetize the insertion area by injecting 2 mL of 1% lidocaine just under the skin
along the planned insertion tunnel).

49
 Remove the sterile pre-loaded disposable Implanon applicator carrying the implant

from its blister. Keep the Implanon needle and rod sterile. The applicator should not

be used if sterility is in question. If contamination occurs, use a new package of

Implanon with a new sterile applicator.

 Keep the shield on the needle and look for the Implanon rod, seen as a white cylinder

inside the needle tip.

 If you don't see the Implanon rod, tap the top of the needle shield against a firm

surface to bring the implant into the needle tip.

 Following visual confirmation, lower the Implanon rod back into the needle by

tapping it back into the needle tip. Then remove the needle shield, while holding the

applicator upright.

 Note that Implanon can fall out of the needle. Therefore, after you remove the needle

shield, keep the applicator in the upright position until the moment of insertion

 With your free hand, stretch the skin around the insertion site with thumb and index

finger

 At a slight angle (not greater than 20°), insert only the tip of the needle with the

beveled side up into the insertion site.

 Lower the applicator to a horizontal position. Lift the skin up with the tip of the

needle, but keep the needle in the subdermal connective tissue

 While "tenting" (lifting) the skin, gently insert the needle to its full length. Keep the

needle parallel to the surface of the skin during insertion

 If Implanon is placed too deeply, the removal process can be difficult or impossible. If

the needle is not inserted to its full length, the implant may protrude from the insertion

site and fall out.

 Break the seal of the applicator by pressing the obturator support

50
  Turn the obturator 90° in either direction with respect to the needle

 While holding the obturator fixed in place on the arm, fully retract the cannula

 Confirm that the implant has been inserted by checking the tip of the needle for the

absence of the implant. After insertion of the implant, the grooved tip of the obturator

will be visible inside the needle.

 Always verify the presence of the implant in the woman's arm immediately after

insertion by palpation. By palpating both ends of the implant, you should be able to

confirm the presence of the 4-cm rod

 Place a small adhesive bandage over the insertion site. Request that the woman palpate

the implant.

 Apply a pressure bandage with sterile gauze to minimize bruising. The woman may

remove the pressure bandage in 24 hours and the small bandage over the insertion site

in 3 to 5 days.

 Complete the user card and give it to the woman to keep. Also, complete the patient

chart label and affix it to the woman's medical record.

Implanon removal

The following equipment is needed for removal of the implant:

 An examination table for the woman to lie on

 Sterile surgical drapes

 Sterile gloves

 Antiseptic solution,

 Local anesthetic

 Needles, and syringe

 Sterile scalpel/surgical blade

 Sterile dissecting and artery forceps (straight and curved mosquito)

 Sterile gauze

51
 Adhesive bandage and pressure bandages

Procedure for implant/Implanon removal

 Explain the procedure to the client, reassure her and ensure correct positioning.

 Clean the site near for removal

 Administer a local anaesthetic under the skin of her arm to prevent pain during

implant removal.

 Push down the proximal end of the implant to stabilize it; a bulge may appear

indicating the distal end of the implant.

 Make a small incision in the skin on the inside of the upper arm, near the site

of insertion.

 Gently push the implant towards the incision until the tip is visible. Grasp the

implant with forceps (preferably curved mosquito forceps) and gently remove

the implant

 The provider closes the incision with an adhesive bandage and pressure

bandage may be placed over the adhesive bandage.

52
TEMPORAL NON- HORMONAL FAMILY PLANNING METHODS

53
 1. INTRA UTERINE DEVICE/INTRA UTERINE CONTRACEPTIVE
DEVICE(IUD/IUCD)
Definition

This is a small, flexible, T-shaped plastic frame inserted into a woman’s womb/uterus through
her vagina and cervix so as to prevent conception for 12years while in situ.

Effectiveness

Highly effective that is 96 to 99.5%.

Offers long term protection (at least 12 years).

Effective immediately

Types of IUDs

i. Copper bearing IUD (non hormonal):

 This contains copper sleeves or wire around it.
Mechanism of action

 Works primarily by causing a chemical reaction that damages sperm and ova before
they can meet.
 Decreases sperm motility and function
 Alters the uterine and tubal environment.
 Thickens the cervical mucus hindering sperm penetration.
 Interferes with the ability of the sperm to pass through the uterine cavity.

ii. Levonorgestrel IUD (hormonal) (mirena)

This is a T-shaped plastic device that steadily releases small amounts of Levonorgestrel. It is
also called Levonorgestrel releasing Intra Uterine system (LNS-IUS) o hormonal IUD
(prevents pregnancy for up to 5years)

Mechanism of action

 It works primarily by suppressing ovulation.

 Makes the endometrium unavailable for implantation to take place.
Advantages

 No hormonal side effects (for the copper T IUD)

 Prevents pregnancy
 Easily reversible/immediate return to fertility upon removal
 It does not interact with other medication.
 Increases sexual desires as there is no need to worry about pregnancy
 Long term contraceptive method.
Disadvantages

54
  Mild cramps during menstruation
 Long and heavy blood loss in the first 3months following insertion.
 Increased normal vaginal discharge which may be quite discomforting
 Spotting and bleeding in between periods
 It is only inserted by a trained provider
 Requires the mother to check its position regularly
 It does not protect against STDs/HIV
 May be expelled spontaneously
Who should use IUD?

 Any women of child bearing age.

 Breastfeeding mothers
 Clients who want long term contraceptive methods.
Who should not use?

 Pregnant women either suspected or confirmed

 Puerperal sepsis or post septic abortion
 Distorted uterine cavity
 Has current PID, gonorrhea or Chlamydia
 Has current purulent cervical discharge
 Unexplained vaginal bleeding
 Cervical or endometrial cancer
When should a woman be fitted with an IUD?

 Any time for as long as the client is not pregnant

 Immediate post partum/post abortion
 During menstruation
INSERTION OF THE IUD

Requirements

Sterile tray containing:

 Bowl of sterile swabs

 Bowl of antiseptic
 Cusco’s speculum
 Sponge holding forceps
 Tenaculum
 Uterine sound
 Scissor
 Sterile gloves
Other requirements

 Flash light/head lamp

 Dressing mackintosh and towel
55
Steps


Assess the client thoroughly for eligibility of the method

Position the client on the coach/examination table

Screen the bed

Wash hands and dry them

Explain the procedure to the client and tell her that she will experience some
discomfort
 Put a dressing mackintosh and towel beneath the client’s buttocks
 Swab the vulva
 Insert the speculum and swab/cleanse the cervix
 Put tenaculum on the cervix to stabilize it
 Insert the uterine sound to assess its length which will help in loading of the IUD
 Load the IUD in its sterile pack
 Adjust the IUD depth-gauge to indicate uterine depth
 Remove the IUD in it package, ensuring that it does not become contaminated
 Carefully insert the IUD until slight resistance is felt
 Release the IUD using the withdrawal technique
 Reposition the IUD by gently pushing the insertion tube
 Trim the IUD strings
 Remove thetenaculum, speculum and clears away.
Steps for IUD removal

 Explain the procedure to client, reassure and provide privacy

 Observe infection prevention
 The provider inserts a speculum to see the cervix and IUD strings
 Cleans the cervix and vagina with an antiseptic solution
 Use forceps to grasp the strings in the vaginal canal
 Pull the strings gently but firmly using controlled traction to remove the IUD
 Show the client the IUD
 Gently remove the speculum
 Leave the patient comfortable.

2. BARRIER METHODS OF FAMILY PLANNING

These are devices which prevent sperms from entering the uterus thus there will be no
fertilization. These include the following:

 Condoms
 Diaphragm
 Cervical cap
 Vaginal sponge
i. Condoms

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This is a thin rubber sheath. In the male it is worn on an erect penis before coitus. The female
type is larger and fits inside the woman’s vagina

Mechanism of action

 It prevents sperms from gaining access to the female reproductive tract

 It prevents micro organisms which cause STI and HIV /AIDS passing from one
partner to the other.
Effectiveness: It is very effective (88 – 99 %) if used properly.

Advantages

 They are easy to get and cheap so they are readily available in pharmacies, community
shops and health facilities around the country.
 No prescription or medical assessment is needed before using.
 Convenient when short term contraception is needed
 It can be used a s backup method for other methods
 It prevents cervical cancer, pregnancy and STIs, HIV/ AIDS. It is the only family
planning method that does so.
 It has quick action
 Does not affect breastfeeding
 Promotes male involvement in family planning
 It may prolong erection and delay ejaculation.
Disadvantages

 Effectiveness as contraception depends on willingness to follow instructions properly.

 User dependent i.e. needs continued motivation and user with each act of intercourse
 May reduce sensitivity of the penis
 Disposal of used condoms may be a problem
 Adequate and appropriate storage is needed by the user to maintain viability.
 Supplies must be readily available before starting intercourse
 Resupply must be available
 There is possibility of tearing or slipping off the penis.
 Some people are allergic to rubber and may react
Who should use the condom?

 Men who wish to participate actively in family planning

 Couples who need contraception immediately
 Couples needing temporally non hormonal method while waiting for another method
e.g. Norplant, IUD, voluntary surgical methods.
 Couples who do not have intercourse often
 Couples in which one partner has other sexual partners even if they are using another
method to prevent STIs
 Women / men at risk of STI, HIV / AIDS
 Women who are allergic to their partners’ sperms
57
Who should not use condom

 Men / women who are allergic to rubber

 Men who cannot maintain an erection
 Men who are not willing to use a condom consistently
 Couples / women who need a highly effective method against pregnancy
Client’s instructions

1. Keep unused condom properly in a cool dry place, properly sealed, out of
reach of children. Properly kept condoms can last for 3 years from the date of
manufacture.
2. Use the condoms properly as follows :
 Check the condom packet to confirm that it is intact and there are no
holes
 Check the expiry date to confirm condom is still viable
 Open the packet carefully and remove the condom. Don’t use sharp
instruments which may puncture the condom
 Unroll the condom on to the hard / erect penis all the way to the end of
the shaft. Leave a space for semen at the tip ( teat)
 Now you can have sex safely/
 Immediately after the man has ejaculated and while still stiff, he should
withdraw his penis from the vagina while holding the condom on. This
is to prevent spilling of the contents on to the woman’s genitals.
 Remove the condom carefully and make sure you do not contaminate
yourself and semen does not spill.
 If you intend to clean yourself using a cloth after intercourse make sure
each partner uses a different cloth.
 Wrap the used condom in a piece of paper and throw it into the pit
latrine or burn them
3. Make the condom more effective by doing the following :
 You can use spermicide in addition to the condom
 Use a condom once and discard well
 A new condom must be used for each new act of intercourse ( round)
 Never use petroleum jelly with condoms they can cause condoms to
break
ii. Diaphragm and cervical cap
These are shallow cups made of soft rubber. A woman inserts one into the vagina and over the
cervix purposely to prevent entry of sperms into the uterus.

How to use them

A woman should insert the diaphragm or cervical cap less than 2 hours before intercourse.
Before insertion she should apply spermicide jelly or cream on the inside aspect of the
diaphragm / cervical cap. After intercourse the diaphragm / cap must remain in place for at

58
least 6 hours but not more than 245 hours. After removing it is washed, rinsed, dried and kept
in a cool dry place to wait for next use.

Contraindications

 Women who are allergic to rubber

 Those who fail to fit diaphragm or cap
 Where there is no privacy
 Where there is lack of soap and water to wash the cap after use
Advantages

 It acts as one of the methods to prevent conception

 It prevents transmission of STIs
 It prevents damage of cervix
 Can be used for intercourse during menstruation
Complications

 Skin irritation
 Trauma due to poor insertion
 It can lead to moniliasis or trichomoniasis to chemical irritation to the cervix
 Bad smell coming from the vagina due to infection or poor cleaning of the appliance.
iii. Spermicide
Spermicide is a chemical (usually nonoxynol -9) that comes in form` of foam, cream, jelly,
foaming tablets or suppositories. It is inserted into the vagina before sexual intercourse to
avoid pregnancy by preventing sperm from meeting the ova.

Effectiveness: it is a moderately effective family planning method (79 – 97 %)

Advantages

 No prescription is needed
 Can be kept available at all times and is easy to use
 Can be used as a backup method for other methods
 It increases wetness / lubrication during intercourse
 It has no systemic side effects
 It does not affect breastfeeding
 It is effective immediately ( foams and creams )
Disadvantages

 It may interrupt sexual intercourse since it takes 10 – 30 minutes after insertion to

have sex safely
 Each round of sex use a different application
 They can cause Candida
 It is not highly effective
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  Some women / men are allergic to Spermicides so may develop irritation and
discomfort
 It causes more wetness of the vagina for several hours after sexual intercourse
 It gives no protection against HIV
 Its effectiveness as a contraception depends on willingness to follow instructions.
Mechanism of action

Causes sperm membrane to break which decreases sperm movement and their ability to
fertilize the ovum.

Who should use Spermicides?

 Women who prefer not to use hormonal methods or those who should not use them
 Women who are breastfeeding and need contraception
 Women who want protection from STIs and those whose partners will not use
condoms
 Couples needing a back up method
 Couples needing a temporally method while Waiting for another method
Who should not use

Couples / women who desire highly effective protection against pregnancy

Women with abnormal vaginal discharges
Women whose age and parity or health problems make pregnancy high risk
Women who are allergic to nonoxynol -9 or other chemicals in Spermicides
Women with abnormal; vaginal anatomy e.g. septum, Stenosis, prolapsed, double
cervix, that may interfere with appropriate placement or retention of Spermicides
 Women with disability that may prevent her from reaching her genitalia
NATURAL FAMILY PLANNING

Definition
This is when a couple voluntarily avoids sexual intercourse during the fertile phase of the
woman’s cycle in order to avoid pregnancy. Natural family planning is moderately effective
(80 – 91 %)

General advantages of natural family planning

 There are no method related health risks
 It is in expensive
 It promotes male involvement in family planning
 It improves knowledge of the reproductive system
 The couple may develop a closer relationship
 It can be used to avoid or achieve pregnancy

General disadvantages of natural family planning

 Its effectiveness depends on willingness and ability to follow instructions
 A lot of training is required to use the most effective types of NFP correctly
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  It requires abstinence during fertile phase to avoid conception
 It requires daily record keeping
 Vaginal infections can make some kinds of NFP difficult to use
 A basal thermometer is needed for some methods
 It gives no protection against STI / HIV
 It requires a trainer provider
 It is only moderately effective
Mechanism of action
For contraception intercourse is avoided during the phase of menstrual cycle when conception
is most likely to occur. For conception intercourse is planned for near the mid cycle (usually
day 10 – 15) when conception is most likely to occur.
Types
 Lactation ammenorrhoea method (LAM)
 Basal body temperature (BBT)
 Cervical mucus method (CMM) or Billing’s method
 Symptothermal ( BBT + CMM)
 Calendar method or safe days ( moon beads)
Who should use natural family planning?
 Women of any reproductive age and parity including nulliparous women
 Couples with religious or philosophical reasons for not using other methods
 Women who are unable to use other methods
 Couples willing to abstain from intercourse for more than 1 week in each cycle
 Couples willing and motivated to observe, record and interpret fertility signs daily
 Couples trying to achieve pregnancy

Who should not use natural family planning?

 Couples wanting a highly effective method since there is a high failure rate if
instructions are not followed properly.
 Women whose age, parity or health problems make pregnancy a high risk
 Women with irregular menstrual cycles cannot use calendar method
 Couples unwilling to limit intercourse to certain times in the cycle
 Women whose partners will not cooperate
 Couples with poor communication or problems in their relationship
 Couples in which either partner has more than one sexual partner because they are at
risk of STI and condom use will be more beneficial.
 Women with persistent vaginal discharge cannot use CMM since it will be difficult to
note the difference in the discharge which occurs in fertile days.
 Women who find it unpleasant to touch their genitalia to examine mucus

Lactation amenorrhoea method

LAM is a family planning method that relies on the temporally natural infertility in a woman
caused by exclusive and frequent breastfeeding in the first 6 months and before return of

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mother’s menstruation period. This is because the woman’s ovaries do not produce ova. The
method is highly effective (98 – 99%) in the first 6 months.

Physiology
During production of breast milk a hormone Prolactin is involved. This suppresses ovulation
so that if a woman breastfeeds on demand no ovum will be released. When the baby sucks on
the breast a message is sent to the pituitary gland to produce the hormone Prolactin.
This method is reliable until the mother resumes her menstruation after delivery. This is so
because menstruation is related to ovulation so the mother is no longer protected.
During the first 3 – 6 months if the mother is fully breastfeeding even it is less likely for her
to conceive since the ovary is not yet active. After 6 months this method is no longer
protective

Any factor that causes decrease in suckling can result in return of ovulation even before 6
months and thus decrease in breast milk. These factors may include:
 Use of pacifiers and supplementary feeds
 Reduction in number of feeds or increasing interval between feeds
 Maternal stress and illness or illness in the child.
This will lead to reduction in Prolactin levels and thus chances of ovulation

Mechanism of action: suppresses ovulation

This method is simple, has many advantages and can easily be understood. If well explained
in simple language which is easily understood the mother will be able to repeat back to you
what you told her. The following are points to stress:
 Conditions under which the method is effective
 Good breastfeeding practices and how to carry them out
 Conditions which indicate that the method is no longer protective and thus stop using
it and adapt another method to avoid pregnancy artificial methods which are
compatible with breastfeeding
 Condoms can be used together with LAM to prevent STIs

Advantages of LAM
 It is effective immediately
 Does not interfere with intercourse
 Has no systemic side effects
 No medical supervision is needed
 No supplies or costs are involved
 It is cheap, easy to use and always available
 Promotes bonding between mother and baby
 Decreases post partum bleeding
 Provides passive immunity to the baby
 It is the best source of nutrition for the baby
 Prevents infections to the baby since it is not exposed to contaminated water, milk,
formula and utensils.-
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Disadvantages of LAM
 Requires client to follow instructions regarding breastfeeding practices
 It may be difficult to practice due to social circumstances e.g. breastfeeding in public
 It is highly effective only before menstruation is resumed or up to 6 months after
delivery
 It gives no protection against STI
Who should use LAM?
 Women who are less than six months post partum, menses have not returned and are
exclusively breastfeeding. Exclusive breastfeed whenever baby desires (at least every
4 hours during day and at least every 6 hours during the night) and not to give the
baby any food or liquid other than breast milk.
Who should not use LAM?
 Women who have resumed menstruation
 Women whose baby does not feed at least every 4 hours during the day and every 6
hours at night
 Women who give their babies liquids and foods other than breast milk
 Women whose baby is over 6 months because this is when additional foods are started
and the amount of breast milk reduces so baby is not breastfeeding constantly.

Information on breastfeeding
1. Breastfeeding is good for the mother and the baby:
 It is cheap easy and readily available for the baby
 Breastfed babies have less diarrhea, fewer infections , are stronger and
healthier
 The mother who breastfeeds is less likely to bleed excessively after delivery or
develop cancer of the breast.
 Breastfeeding prevents short interval between pregnancy
2. Begin breastfeeding soon after birth and give baby only breast milk for the first 6
months. During this time the baby needs only breast milk but not cow’s milk, artificial
milk or water. These foods may expose child to infection especially if it is by bottle
feeding. The baby will need additional feeds when 6 months or older.
3. Successful breastfeeding can be achieved by
 Feed the baby very often and long enough to stimulate production of more
breast milk
 The more you breastfeed the more milk is produced
 Let the baby feed whenever it wants and for as long as he wants
 Suckling at night helps to keep up the milk supply
 Let the baby finish milk from one breast then offer the other one. Next time
begin with the one offered last
 If you will be away from baby for some hours express the breast milk and keep
in a clean place, well covered so that it can be fed to baby during your presence
by cup and spoon. Breast milk can stay good for 8 hour at room temperature.
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  It is not necessary to wash breasts before feeds so long as you maintain good
personal hygiene

Information to the client

1. Breastfeeding can be an effective method of family planning in the first 6 months but
follow the instructions carefully. (feed on demand and give no other feeds)
2. Breastfeeding is no longer effective if baby does not breastfeed exclusively, you have
resumed you menstruation, it is 6 months or more after you delivered even if you
periods have not returned.
3. There are other methods that can be used while breastfeeding e.g. non hormonal
methods, progestin only pill, Norplant, IUD
4. Use condoms in addition to breastfeeding to prevent STIs
Calendar method
Instructions to client
 You can determine your fertile days by monitoring the menstrual cycles
 Note length of each cycle for at least 6 months while abstaining or using another
method then calculate your fertile days as follows
 Subtract 11 from the number of days in your longest cycle; this is the last
fertile day of your cycle.
 Subtract 18 from days in your shortest cycle this shows the first fertile day in
you cycle e.g. Longest cycle is 30 days – 11 = 19. So day 19 is your last fertile
day. Shortest cycle is 26 – 18 = 8. This is the first fertile day. So your fertility
period starts from day 8 up to day 19.
 To avoid pregnancy abstain during those days but to achieve pregnancy have
intercourse during those days.

Basal body temperature

Information to client
 You can determine your fertility days by taking accurate measurements using a special
thermometer to detect a slight rise in your temperature
 Take your temperature at about the same time every morning before rising and record
on the chart provided
 Use the first recordings done in the first 10 days and determine your highest
temperature draw a line 0.1 degrees above the highest
tedddddddxxxxxxxxxxxxxxxxxxxxxmmperature ( cover line)
 Note when the temperature you plot is above the cover line
 The infertile phase starts on the third day when the temperature is above cover line
 For contraception abstain if temperature is above the line for 3 days.
 For conception have intercourse when the temperature is above the cover line within 3
days
 After infertile phase ( 3rd day when temperature is above cover line) you do not need
to take temperature and can have sex until commencement of the next menstruation
period then start taking and recording the temperature again.
Cervical mucus method
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Information to the client
 You can determine you fertile phase by observing your cervical mucus
 Observe the cervical mucus and record on the chart provided
 Record red or a star when there is bleeding
 Green or letter D to show dryness i.e. there is very little mucus. Dry days occur after
menstruation. There is no mucus and the vagina feels dry.
 Use letter M with a circle around it to show wet slippery fertile mucus. This fertile
mucus occurs when ovulation takes place so fertile days have started.
 Use as plain letter M or yellow color to show sticky white cloudy infertile mucus
 Peak day is the last day of slippery and wet mucus it indicates ovulation has just taken
place.
 Since mucus can change during the day observation is done several times throughout
the day. Every night before you go to bed determine your fertility level
 Abstain from intercourse during menstruation because for people with short cycles (21
days) these days are unsafe since ovulation can take place during menstruation.
 During the dry days you can have intercourse on alternative days to avoid confusing
semen with the fertile mucus
 As soon as any mucus or sensation of wetness occurs abstain from sex
 Mark the last day of clear slippery mucus with an X. this is the peak day and the most
fertile.
 After the peak day avoid intercourse for 3 days and nights the ovum, might be still
viable
 On the morning of the fourth day it is safe to have intercourse until menstruation
occurs
 If you want to become pregnant have sex during the fertile days when there is slippery
mucus.
Symptothermal
Client’s information
First give information of both temperature and cervical mucus methods.
 You can determine your fertile days by monitoring both temperature and cervical
mucus
 After menstruation stops you may have intercourse on alternative dry days.
 Fertile phase begins when wet mucus is seen so avoid sex until both peak day and rise
of temperature is over.
 If the methods do not identify corresponding days follow the one which identifies the
longest period

Follow up
For calendar method and body basal temperature no follow up is required but advise client to
return if she has a question or a problem
For cervical mucus and Symptothermal give follow up date after one menstrual; cycle
Tell the couple to bring the chart at the end of 3 cycles and then only if she has a problem.

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PARMANENT FAMILY PLANNING/ SURGICAL STERILIZATION

Definition

This is the family planning type where there is permanent contraception and is irreversible.

Types of surgical sterilization

 Vasectomy – for men

 Bi-lateral tubligation – for women

Effectiveness

99.9% effective

Who should have a surgical sterilization?

 Men and women who do not want more children

 Men and women who are too weak or too sick to have children.

Who should not have a surgical sterilization?

 Women who are pregnant

 Men and women who may/want more children

 Men and women whose partners oppose surgical sterilization.

How does surgical sterilization work?

Tubligation involves cutting and ligation/closure of the fallopian tubes through which ova

passes to the uterus and where fertilization takes place making it hard for the egg/ova to reach

the uterus. This prevents fertilization and implantation thus preventing pregnancy from

occurring.

Vasectomy involves closure of the vas deferens (sperm tubes) preventing the sperms from

joining the semen. Therefore the ejaculate during sex following vasectomy contains no

sperms. The man still has the sexual pleasure after the surgery but the semen will be sperm

less 3months after the surgery therefore it will be unable to fertilize the woman’s egg.

What to expect after surgical sterilization?

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  The couple may have sexual intercourse whenever they like and it will be as enjoyable

as before.

 The woman will not become pregnant again

 After vasectomy, the man’s semen will still contain some sperms for about 3months.

Therefore he should use condoms or his wife should receive a contraceptive method.

 It does not protect against other STD

SEXUALLY TRANSMITTED INFECTIONS

DEFINITION:

These are diseases caused by organisms that are passed through unprotected sexual

intercourse/activity with an infected partner.

STI is when the person is infected with the causative agent but has not yet shown any signs

and symptoms.

STD is when an infected person shows signs and symptoms of the infection.

Sexually transmitted diseases (STDs), or sexually transmitted infections (STIs), are generally

acquired by sexual contact. STDs can be transmitted during vaginal or other types of sexual

intercourse including oral and anal sex. The organisms that cause sexually transmitted

diseases may pass from person to person in blood, semen, or vaginal and other bodily fluids.

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Some such infections can also be transmitted non-sexually, such as from mother to infant

during pregnancy or childbirth, or through blood transfusions or shared needles.

CAUSES

The causative organisms behind STDs include:

 Viruses such as HIV virus, hepatitis B, herpes complex and human papilloma virus

(HPV).

 Bacteria such as gonorrhea, Chlamydia and syphilis.

WHO IS AT RISK?

Anybody who has engaged in unprotected sexual intercourse or contact is at risk of

transmitting an STD. However, the risk is higher in certain groups which include:

 Those with multiple sex partners

 Those who do not use condoms during sexual activities

 Drug abusers who tend to practice high-risk sexual behavior

GENERAL SYMPTOMS OF STDS

The symptoms of STDs vary with the type of infection but they commonly include:

 Abnormal discharge from the penis or vagina

 Itching around the genitalia

 Pain experienced during sexual intercourse or while urinating. The pain may be of a

stabbing or burning nature or a dull pain in the pelvic area.

 Sores which may be painless like Chancre sores or painful sores present around the

genital area, anus.

 Pain in or around the genitalia and/or anus.

 There may be blisters around the genital area that turn into scabs.
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  There may also be soft, flesh colored-warts around the genital area.

 General symptoms include fever, weakness, body and muscle aches and swollen

lymph nodes.

DIAGNOSIS AND TREATMENT

People who indulge in high-risk sexual behavior as well as those with STD symptoms need to

be checked for the presence of STDs. If not treated, these infections may have long-term

severe consequences and can also be passed onto partners of the infected individual. The

primary approach to treatment, which varies according to the type of infection, is preventing

further transmission of the infection and treating all the sexual partners involved.

EXAMPLES OF SOME OF THE SEXUALLY TRANSMITTED INFECTIONS (STIS)

ARE:

Bacterial

 Chancroid (Haemophilus ducreyi)

 Chlamydia (Chlamydia trachomatis)
 Gonorrhea (Neisseria gonorrhoeae)
 Syphilis (Treponema pallidum)

Viral

 Genital herpes (HSV)

 Genital warts (Condyloma acuminata) (HPV)
 Human immunodeficiency virus (HIV)
 Molluscum contagiosum (MCV)

Protozoal

 Trichomoniasis (Trichomonas vaginalis)

Parasitic

 Pubic lice (Pediculosis pubis)

 Scabies (Sarcoptes scabiei)
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Fungal

 Candidiasis (candida albicans)

MANAGEMENT OF EACH SEXUALLY TRANSMITTED INFECTION

1. GONORRHOEA

Cause: Neisseria gonorrhea.

Mainly invades the glandular and mucosal area of: Endocervix, Urethra, Bartholin’s gland

and duct, Rectum

Incubation period 2 to 7 days

Symptoms and signs

The female may harbor infection and transmit it without symptoms (60 to 80%)

-Purulent yellowish discharge from vagina

-Urethral discharge from glans penis

-Urethral discomfort (burning pain on micturition) presenting as painful micturition.

-Bartholin’s infection presenting as a tender swelling

-Infection may spread upwards

DIAGNOSIS

 History taking

 Physical Exam (milk penis, retract prepuce)

Investigations:

 Pus swab: Gram stain, C&S

 Urine analysis

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Treatment

 Ciprofloxacin 500mg single dose

 Doxycycline 100mg 12 hly x 7 days

 Erythromycin

 Co-trimoxazole

 Metronidazole

Complications

 Bartholin’s abscess

 Cervicitis

 Ophthalmianeonatorum

 PID

 Tubo ovarian abscess

 Pelvic abscess

 Ectopic pregnancy

2. CHLAMYDIA

Cause: Chlamydia trachomatis

Infect the cervix

Signs and symptoms

- Mucopurulent vaginal discharge due to cervicitis which is yellow or green in colour.

- Dysuria in some women and frequency of micturition.

- Asymptomatic in some women

Treatment

Tetracycline 500mg QID

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Doxycycline 100mg BID for 7 days

If TCL / Doxycycline are Contra-indicated

Give Erythromycin 500mg QID

3. LYMPHOGRANULOMA VENEREUM

Caused by chlamydia of L - serotypes.

Incubation period is 7 to 21 days.

Symptoms and signs

 Inguinal lymphadenopathy - discharge sinuses

 Inguinal and rectal ulceration

 Anorectal lymphedema

 Painful defecation due to a rectovaginal fistula which is formed as a result of

 Stools may be blood – streaked

Treatment: Chemotherapy:

Doxycycline / TCL / Erythromycin for 21 days (Rpt)

Surgical

 Dilatation of stricture

 Abscess aspirated not excised

 Colostomy for severe stricture

Complications

 Perianal scarring

 Rectal stricture

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  Vulvar elephantiasis.

4. CHANCROID (soft chancre)

Cause- Haemophillus ducrey (Ducreyi’s bacillus).

Incubation period 3 – 5 days.

Symptoms

 Painful multiple genital ulcer on genital (soft and irregular)

 Discharge smelling and contagious

 Painful inguinal adenitis

Lab: culture of aspirates from the swollen inguinal lymph nodes.

TREATMENT

Local - sit bath

- wash with soap and water

- Aspiration of the inguinal lymph nodes

Antibiotics - Ceftriaxone 1gm stat.

- Co-trimoxazole 960mg BID for 7days

- Erythromycin Treatment

5. GRANULOMA INGUINALE (DONOVANOSIS)

Causative Organism: Calymmatobacerium granulomatis

Symptoms:

 Genital ulcer with mal-ordourous discharge.

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  Lymph nodes ulcerate.

Lab: smear/biopsy - giemsa stained - Donovan bodies

Treatment: TCL / Erythromycin / Doxycycline for3 weeks

6. HERPES GENITALIS

Caused by Herpes simplex virus (HSV) II.

HSV I cause Herpes labialis.

Symptoms:

 Occurs before 7days after exposure

 Small and extremely painful vesicles

 Virus is shed from the lesions until healing is complete

 Symptoms recur every after 3 – 4 weeks

Treatment:

 Oral Acyclovir 200mg 4hourly for 5 days

 Acyclovir creams 5% apply 4 hourly.

 Idoxuridine cream.

 Saline baths may also relieve pain

7. PAPILLOMA VIRUS HPV

Type 6, 11, 16, and 18 cause genital warts

Type 16 and 18 more associates with cervical cancer

NB: Cervical Cancer screening to be done

Incubation period 3 months

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Present as multiple pedunculated tumors in clusters involves vulvar and vaginal areas.

During pregnancy increases in size.

Treatment:

Small warts

- Podophyllin 10 - 25 % (wash after 4 – 6 hours) applied 2-3 times weekly

- surrounding skin to be protected with Vaseline

Large warts:

- Surgical excision with Diathermy

- Cryotherapy

- Laser therapy.

8. SYPHILIS

Causative Organism: Treponema pallidum

STAGES OF SYPHILIS

Primary syphilis:

 Painful papule in mucosa 8 – 10days

 After a week chancre solitary, non-tender indurated ulcer

 After 2-3 weeks LN enlarges rubbery, painless, discrete and mobile. Never suppurate

 Spirocheates may be seen on the microscope under dark ground illumination (from

lesion).

Secondary syphilis:

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  Occur 6-8 weeks after primary chancre

 Skin rashes

 Condylomata type of lesion - raised plaques

 Painless mucosal ulceration

 Cervical LN enlargement

 Spirocheates in moist areas

 Serological tests are positive

Tertiary syphilis:

Develops years after chancre have healed

 Gumatta formation - firm elastic tumors.

 Neurosyphilis

 Aneurysm of the aorta and large arteries

Syphilis and pregnancy - abortion - congenital syphilis

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LABORATORY INVESTIGATIONS

 VDRL

 TPHA

 RPR

Treatment

 Has NOT exhibit penicillin resistance

 Benzyl benzathine penicillin (Penadur) 2-4mu weekly 3 doses.

 Tetracycline or Erythromycin for 14 days

9. TRICHOMONIASIS
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Male asymptomatic

Mainly female are affected

Symptoms

 Yellowish froth and offensive vaginal discharge. Irritating

 Dyspareunia

 Reddened erythematous mucosa

Lab: Flagellated protozoa

Rx: Metronidazole 500mg TDS for 5/7 Tinidazole, secnidazole, ornidazole

ULCERATIVE INFECTIVE LESIONS:

1- Primary chancre of syphilis

2- Eroded papules or condylomatalata of secondary syphilis

3- Gummatous ulcers of tertiary syphilis

4- Chancroidal ulcers

5- Lymphogranulomavenereum

6- Granuloma Inguinale

7- Herpes genitatis

8- Scabies

DDx:

 Malignant Neoplasms

 Squamous cell Ca of vulva

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  Erosive vulvitis

 Herpes Zoster ( Shingles )

SYNDROMIC APPROACH TO DIAGNOSIS AND MANAGEMENT STIs/STDs

There are different approaches to STI diagnosis and management.

CLINICAL APPROACH

Identifying and treating a particular STI following signs and symptoms based on clinical

experience.

LABORATORY TESTING

Identifying and managing STI by considering causative organism identified by laboratory

tests.

SYNDROMIC APPROACH

Identifying and treating all possible causative organisms for a given group of symptoms and

signs (syndrome of STI)

RATIONALE OF SYNDROMIC APPROACH

 Most health units have no laboratory facilities, so it is difficult to differentiate disease

by causative organism.

 Most STI syndromes are caused by more than one organism so there is need to use

drug which can treat all.

 Even where laboratory exist results are not immediate and client is unlikely to return

for results and treatment.

 Mixed infections are common

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  Clinical picture may be influenced by self-medication and immunity thus general

treatment is therefore beneficial.

FACTORS TO CONSIDER IN ASSESSING ADVANTAGES AND DISADVANTAGES

OF ALL APPROACHES

 Accuracy of diagnosis

 Availability of resources

 Training of health workers

 Accessibility of services and client convenience

 Referrals

 Asymptomatic clients (especially women)

 Availability of drugs

STI SYNDROMES

Commonest

 Urethral discharge

 Abnormal vaginal/cervical discharge

 Genital ulcers

 Lower abdominal pain

 Enlarged groin lymph nodes (Bubo)

Others

 Painful scrotal swelling

 Bartholin’s abscess

 Conjunctivitis with pus in new born (opthalmianeonatorum)

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  Genital growth

 Inflammation of glans penis and prepuce (Balanitis)

 Acquired immunodeficiency syndrome

 Miscellaneous syndrome

SYNDROME CAUSATIVE DRUG OF CHOICE

ORGANISM/LIKELY

DIAGNOSIS

Cefixime 400mg + Doxycline

Urethral discharge  Gonorrhea 100mg b.d for 7 days. If partner

syndrome  Chlamydia pregnant instead of doxycline

 Non-gonococcal urethritis give erythromycin 500mg

6hourly for 7days.

If discharge persists doxycline +

flagyl 2g stat or ceftriaxone 1g

stat.

Abnormal vaginal  T.vaginalis Metronidazole 2g single dose +

discharge syndrome  Candida albicans Nystatin or fluconazole 200mg

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  Gardenellavaginalis once

If pregnant replace fluconazole

with clotrimazolepessaries 500mg

single dose (Flagyl is given only

after 3months of pregnancy).

If persists cefixime 400mg stat +

Doxycline if pregnant give

erythromycin.

Genital ulcers disease  Treponema pallidum Acyclovir 400mg tds for 7days. If

(GUD) syndrome  Haemophilusducreyi VDRL positive benzathine

 Herpes simplex penicillin 2.4mu intramuscular

single dose. If allergic to

 Granuloma inguinale
penicillin, erythromycin 500mg

6hourly for 14days.

If VDRL negative, ciprofloxacin

500mg b.d for 3days plus

benzathine. In pregnancy replace

ciprofloxacin with erythromycin.

Lower abdominal pain  Gonorrhea Cefixime 400mg od for 3days

syndrome/ PID  Chlamydia plus doxycycline 100mg for

 Anaerobic bacteria 2weeks plus metronidazole

400mg bd for 2weeks.

If no improvement ceftriaxone 1g

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 od for 3days

Enlarged lymphnodes  Chlamydia Doxycycline 100mg bd for

(BUBO)/ Inguinal  Haemophilusducreyi 2weeks. If pregnant erythromycin

swelling  Treponema pallidum 500mg qid for 2weeks. Do not

incise, aspirate every 2days if

persists repeat above dose.

Scrotal swelling/  NisseriaGonorrhoeae Cefixime 400mg stat

Bartholin’s abscess  Chlamydia +doxycycline 100mg bd for

7days. If pregnant erythromycin

500mg qid for 7days.

If persists repeat doxycycline.

If persists ceftriaxone 1g stat.

Conjunctivitis with pus  NisseriaGonorrhoeae Ceftriaxone 25mg/kg stat +

in new born  Chlamydia azithromycin syrup 20mg/kg/day

(opthalmianeonatorum orally for 3days

Genital swellings  Treponema pallidum Benzathine penicillin

(warts)  Human papilloma virus Podophylin 10-20% topically.

Balanitis in men  Candida albicans Fluconazole 200mg stat plus

 Chlamydia metronidazole 400mg bd for

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 7days

Miscellaneous  Scabies (sarcoptesscabie) Benzylbenzoate emulsion shave

 Pubic lice (phthinus pubis) and apply gamma benzene

hexachloride

COUNSEL AND EDUCATE ALL CLIENTS ON;

 Treatment compliance

 Condom use and provide condoms

 Partner management

 Offer HIV/VCT services and advice for medical circumcision

 Schedule a return visit

 Abstinence from sex until all symptoms have resolved and treatment completed

STEPS IN MANAGEMENT OF A CLIENT FOR STI

1. Greet client; offer a seat near you and away from hearing of others. Introduce yourself to

client. Tell client that whatever is discussed will be kept secret.

2. Ask purpose of visit: ask what she already knows about STI, correct any mis-

information and clarify rumors and mis conceptions.

3. Tell: client about STI generally including prevention.

4. Take history and carry out physical examination.

For male look for;

 Loss of pubic hair, presence of lice or scabies.

 Swelling or tenderness of scrotum

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  Inguinal lymphadenopathy

 Sores or swellings on shaft of penis

 Swellings or sores or inflammation of prepuce and glans penis

 Discharge from urethra.

For female;

Carry out general examination and perform pelvic examination.

5. Record findings and give client feedback of findings. Allow client to ask questions

and answer appropriately using visual aids.

6. Give specific drug/s according to syndromic approach. All stat doses must be given in

the clinic. Explain the instructions on how to take the drugs. Remind prevention of sti

and help client decide on how to prevent re-infection.

7. Provide condoms and teach proper use. Give partner notification card to client. Give

return date. Ask client to repeat instructions. Re-instruct if necessary and make sure

client understands.

8. Bid client fare well.

PURPOSE OF STI EDUCATION AND COUNSELLING

 Help client especially women recognize STI and come for early treatment.

 Make people aware of complications of STI.

 Encourage clients decide on how to prevent re-infection.

 Promote treatment compliance.

 Encourage follow up and reduce complications.

 Encourage partner notification.

 Promote condom use among people at risk.

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GENERAL STI EDUCATION MESSAGES

1. STIs are passed from one person to another through sexual intercourse. If a pregnant

woman has STI, it can harm the baby while in utero or at birth.

2. STI is a danger to health because;

 Makes easier to get infected with HIV

 If not treated properly can cause complications.

3. Most STIs can be cured;

 Seek early treatment as soon as you notice anything abnormal in the private parts.

 Seek treatment if your sexual partner has STI even if you do not have symptoms.

4. You can avoid STI by abstaining, stick to one partner, use condoms.

MESSAGES CONCERNING TREATMENT CONCERNING STI TREATMENT

1. Ensure infection does not reoccur

 Take all drugs as ordered even if symptoms disappear or you feel better.

 Make sure all your sexual partners are treated even if they have no symptoms.

 Avoid sex or use condoms during treatment.

 When cured practice safe sex.

2. If taking doxycycline do not take on empty stomach.

3. If taking metronidazole avoid alcohol up to 24hours after last dose

4. If using pessaries use even during menstruation.

5. If you develop itching vaginal discharges return to clinic for medication.

6. If pregnant, your drug may be different from that of your partner.

7. Do not share treatment.

RELATIONSHIP BETWEEN STI AND HIV/AIDS

1. They both have the same route of transmission.

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 2. They have the same predisposing factors.

3. Some of the STIs like HIV have no cure.

4. Some STIs develop in stages just like HIV for example syphilis.

5. May mask some signs and symptoms of HIV.

6. Some STIs may be transmitted through MTCT which is similar to HIV like syphilis,

hepatitis B, herpes,HPV.

WHY STIs ARE PUBLIC HEALTH PROBLEMS?

 Magnitude

 Complications

 Socio-economic consequences

 Cost effectiveness of intervention

 Infection and transmission

 Enhancement of HIV transmission.

 Stigmatization

CONTROL AND PREVENTION OF STIs/STDs

 Promotion of safer sex practices i.e. educate people about how to prevent spread of

STDs especially encouraging use of condoms and providing them.

 Providing good medical facilities for proper, early diagnosis and treatment of STDs.

 Promote contact tracing whereby health workers try to trace and treat all sexual

contacts of an infected person.

 Follow up clients who have been treated for re-examination to make sure that are

cured.

 Screening all sexually active individuals and those at high risk of acquiring STIs.

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  Circumcision may reduce the risk of cross infection.

ADOLESCENT REPRODUCTIVE HEALTH

DEFINITION OF TERMS

ADOLESCENT

WHO defines an adolescent as an individual aged between 10 -19years.This period is

characterized by physiological and psycho-social changes and growth.

YOUTH

Youths are those aged between 15-24 and the Uganda statute recognizes youths as those

individuals aged 18-30 years.

YOUNG PEOPLE

WHO defines young people as individual aged between 10-24 years however the Uganda

statute recognizes young people as those aged 18-30years.

RATIONALLE FOR ADOLESCENT REPRODUCTIVE HEALTH

 Adolescents form the largest proportion of the population that is approximately 52.7%

hence their health needs have to be addressed.

 Fertility among teenagers is increasing yet low contraceptive use resulting into

teenage/unwanted pregnancy.

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  Morbidity and mortality among adolescents accounts for a significant proportion of

maternal death that is 50%

 Abortion and its complications are common in this age group

 Substance abuse especially Tobacco and alcohol, this is common in street children and

secondary school students which all pose hazardous health problems.

 Harmful Traditional practices like early marriage, female genital mutilation, food

taboos and wife sharing which are deeply rooted in different cultures of various ethnic

groups.

Reproductive health rights of an adolescent

 The right to be responsible for all aspects of one’s sexuality.

 The right to information and education about sexual and reproductive health.

 The right to gender equality and equity.

 The right to receive reproductive health services as long as needed.

 The right to feel comfortable when receiving services.

 The right to choose freely one’s life/sexual partners.

 The right to celibacy.

 The right to refuse marriage.

 The right to say no to sex within marriage.

Reproductive health responsibilities of adolescents

 Inquire about available reproductive health services.

 Give your correct reproductive health history

 Share correct information about reproductive health.

 Make an informed choice on the services to receive.

 Consult your service provider in case of doubt or complaint

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  Follow instructions

 Use services correctly

Note: the service provider is therefore responsible for promoting adolescent reproductive

rights and responsibilities.

Minimum package for adolescent friendly Health services is;

 Education on sexuality, growth and development.

 Counseling services

 Life skill education

 Recreation services

Goal for promoting adolescent friendly health services

To increase availability and utilization of quality health services for young people with focus

on:

- Adolescent pregnancy/abortion

- HIV/AIDs prevention

- STD prevention and treatment

- Reduction of substance abuse

- Sexuality, growth and development

Where adolescent friendly health services should be provided?

- Home

- School

- Health facility

- Media

- Young groups, community based organizations and non-government organizations

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 - Key social gathering places

Minimum package for Adolescent friendly health services

 Education on sexuality, growth and development

 Counseling services

 Reproductive health services

 Life skills education

 Recreation services

Principles of delivery of adolescent health services

- Integrate into existing services

- Strengthen links through referrals

- Strengthen demand through participation of adolescents.

- Build socio-cultural values and practices that promote adolescent health and

development.

- Be sensitive to needs based on gender, age and vulnerability.

- Provide facts and options for adolescents not just don’ts.

- Mobilize political and financial support at all levels

- Monitor and provide supervision.

Adolescents with special needs

 Sexually abused

 Drug and substance abusers

 Mentally and physically challenged

 Adolescents who need pregnancy prevention

Adolescents with RH problems

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  STDs, HIV/AIDS

 Abortion

 Menstruation problems like excessive bleeding

 Problems related to growth and development

RELEVANT TOPICS TO BE COMMUNICATED TO/HEALTH EDUCATE

ADOLESCENTS

 Anatomy of the human reproductive health system

 Growth and development – changes that take place during adolescence in boys and

girls

 Sexuality

 Indulgence in early sexual relationships

 Family planning/contraception/pregnancy prevention

 Safer sex

 Sexual abuse

 Adolescent pregnancy and its consequences

 Sexually transmitted infections, HIV and AIDS

 Unsafe abortion

 Use of available health services

 Life skills

 Harmful cultural practices

- Female genital mutilation

- Boy child preference

- Widow inheritance

- Early marriages

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 - Prolonged funeral ceremonies

 Immunization

 Substance abuse

- Drugs like marijuana, jet fuel sniffing, opium

- Alcoholism

 Hygiene

 Nutrition

 Mental health

 Reproductive health cancers

 Reproductive health rights and responsibilities of adolescents

FACTORS THAT CAN PROMOTE EFFECTIVE COMMUNICATION BETWEEN

HEALTH WORKERS AND ADOLESCENTS

 Use common language

 Good interpersonal relationship between the health worker and adolescent

 Confidentiality/privacy

 Understanding

 Being appreciative

 Give adolescents respect

 Good counseling skills

 Appropriate message for adolescent

 Convenient time and venue i.e. they don’t want to mix with adults.

 Complete and accurate information

BARRIERS TO EFFECTIVE COMMUNICATION BETWEEN HEALTH WORKERS

AND ADOLESCENTS

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When an adolescent is face to face with a provider (or an adult staff member) she/he may feel:

 Shy about being in a clinic (especially RH) and about needing to discuss personal

matters

 Embarrassed that she/he is seeking RH care

 Worried that someone he/he knows might see her/him and tell the parents

 Inadequate to describe what is concerning her/him and ill-informed about RH matters

in general

 Anxious that she/he has a serious condition that has significant consequences (e.g.

STD, pregnancy)

 Intimidated by the medical facility and/or the many ‘authority figures’ in the facility

 Defensive about being the subject of the discussion or because she/he was referred

against her/his will.

 Resistant to receiving help because of overall rebelliousness or other reasons fostering

discomfort of fear.

WHY ADOLESCENTS NEED COUNSELLING

 To facilitate behavior change

 To promote decision-making. Sometimes emotional disturbances result from

adolescents’ failure to make crucial decisions in life

 To enable the adolescent deal with emotional issues like anxiety, depression,

frustrations and disappointments

 To enable the child feel good about himself/herself; accept his or her limitations and

build self-confidence

 To maximize the opportunity for the adolescent to pursue relevant developmental

tasks. The adolescents’ unused or unidentified potentials/skills will be identified in the

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 counseling process, and the adolescent will be helped to develop or improve on those

skills for personal growth and development.

 To improve interpersonal relationships so that the adolescent can function comfortably

and adaptively with others at home, school and the community in which the adolescent

lives.

 To provide social and psychological support to those who feel insecure, lonely,

depressed, etc

LIFE SKILLS

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Skills –ability to use knowledge to do something. Those skills needed by an individual to

operate effectively in society in an active way.

Life skills are skills needed by an individual to operate effectively in society in an active and

constructive way. OR personal and social skills required for young people to function

confidently and competently with themselves, with other people and within a wider

community.

Aims of life skills:

 For social help in taking positive health choices.

 To enable individuals make informed decisions.

 To enable one practice health behavior.

 For Recognition and avoiding risky behaviors.

 They also enable an individual develop the ability for adaptive and positive behavior

that enables individuals to deal effectively with the challenges and demands of

everyday life.

Types of life skills

1. THE SKILLS OF KNOWING AND LIVING WITH ONE’S SELF

 Self-awareness: There is need for young people to understand themselves first, their

potential, their feelings and emotions, their positions in life and society, their strengths

and weaknesses. They need to have a clear sense of their identity, where they come

from, and the culture into which they have been born and which has shaped them.

 Self- esteem: self-awareness leads to self- esteem as people become aware of their

capabilities and place in their community. It has been described as an “awareness of

the good in oneself.” It refers to how an individual feels about such personal aspects as

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 appearance, abilities and behavior and growth and the bias of their experience of being

competent and successful in what they attempt.

However, self-esteem is strongly influenced by an individual’s relationship with others.

Significant adults such as parents, family members and teachers, and one’s peers can help to

develop or destroy a person’s self esteem by the way in which they interact with him or her.

 Assertiveness: This means knowing what you want and why and being able to take

the necessary steps to achieve what you want within specific contexts. It can cover a

wide variety of different situations, from a girl rejecting sexual advances of a fellow

student or older men to children convincing their parents to continue with their

education to adolescents taking the lead in bringing people together for some

beneficial acts in community such as protecting or developing the environment.

 Coping with emotions: Emotions such as fear, love, anger, shyness, disgust, desire to

be accepted, are subjective and impulsive situations. That is why they can be very

unpredictable and often lead to actions which are not based on logical reasoning. They

can therefore easily lead people into behaviors they may later regret.

 Coping with stress: Stress is an inevitable part of life. Family problems, broken

relationships, examination pressures, death of a friend, family member are all

examples of situations that cause stress in people’s lives. In limited doses and when

one is able to cope with it, stress can be a positive factor since the pressure forces want

to focus on what one is doing and respond accordingly. However, stress can be a

destructive force in an individual’s life if it gets too big to handle. Therefore, young

people need to be able to recognize stress, its causes and effects and know how to deal

with it.

2. THE SKILLS OF KNOWING AND LIVING WITH OTHERS

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  Interpersonal relationships: Relationships are the essence of life. Relationships also

come in different shapes and sizes. As children grow up, they develop relationships:

 Significant adults in their lives such as parents, relatives, neighbors, teachers etc.

 Peers out of school

 People they meet in life, friends of their parents, the local leaders, shop keepers, health

workers etc.

Not everybody can be one’s friend but children need to know how to react appropriately in

relationship so that they can develop to their maximum potential in their environment.

 Friendship formation: level of peers, this is one of the most important aspect of

interpersonal relationships. An individual needs friends to share with, activities, hopes,

fears and ambitions. Friendship formation starts from the earliest stages of life but

children and adolescents need to understand how friendships are formed and to form

and develop these which will be of mutual benefit. They should be able to recognize

and if possible resist friendships that can lead them into dangerous or unnecessary risk

taking behavior such as taking alcohol or other drugs, stealing and dangerous sexual

behaviors.

 Empathy: This involves putting oneself in other people’s circumstances and finding

ways to lessen the burden by sharing with them rather than condemning or looking

down on (or even pitying which is another form of looking down on people) them for

whatever reason. Thus empathy also means supporting the person so that they can

make a decision and stand on their feet as soon as possible.

 Peer resistance: this means standing up for one’s values and beliefs in the face of

conflicting ideas or practices from peers. Friends or colleagues can come up with

unacceptable or dangerous suggestions and may put pressure on one to accept. One

needs to resist things they believe to be wrong and be able to defend one’s decision

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 even if it means being threatened with ridicule or exclusion from group membership.

With young people in particular, the pressure to be like other group members is great.

 Effective communication: Adolescents should be able to communicate effectively

with others. This includes skill of listening and understanding how others are

communicating as well as realizing how one communicates in different ways.

 Negotiation: This is very important in interpersonal relationships. It involves

assertiveness, empathy and interpersonal reactions and also ability to compromise on

issues without compromising one’s principles. It involves being able to cope with

potentially threatening or risky situations in interpersonal relations, including peer

pressure, state one’s position and build mutual understanding.

 Non -violent conflict resolution: this is connected to interpersonal relations,

negotiating skills and coping with emotions and stress. Conflicts are unavoidable and

sometimes necessary but the skill of non-violent conflict resolution ensures that such

conflicts do not become destructive. This can either involve a person resolving his/her

own conflict situations or assisting others to come to an understanding without

resorting to fighting.

3. THE SKILLS OF MAKING EFFECTIVE DECISIONS

These skills enable youths to analyze critically the environment in which they live and the

multiple messages that they come across.

 Critical thinking: when the people/youths are placed in unexpected or unfamiliar

situations where critical thinking is required to make an appropriate response.

 Creative thinking: this skill enables adolescents to come up with new things, new
ways of doing things, new ideas and as well as arrangements.

 Decision making: youths should be equipped with this skill so as to enable them

decide on the most appropriate measure especially in case of conflicting demands all

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 of which cannot be met at the same time. Therefore one must make a choice but at the

same time one must be aware of the possible consequences.

 Problem solving: This skill is related to decision making and needs many of the same

skills. It is only through practice in making decisions and solving problems that

children and adolescents can build the skill necessary to make the best choices in

whatever situation they are confronted with.

In conclusion, the above skills are transferable to many different situations and issues.

Linking these skills to the knowledge available will enable the Ugandan child and adolescent

to become a confident and competent individual, able to make his/her place in society.

How do life skills contribute to the individual development? /importance of life skills

development.

 They promote positive and adaptive personal characteristics and social behavior.

 They equip young people with coping strategies for dealing with behavior.

 They help to establish sources of social support within impersonal relationships.

 They enhance self-esteem, self-worth and self confidence

 They promote health giving behavior.

Benefits of life skills education

 Promotes health behaviors among people especially the youth.

 It addresses the needs of children especially in schools.

 They empower the individuals to promote their own health, that of others and of the

community.

 Improvement in mental health status of individuals through improvement in self-

esteem and self confidence.

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 SEXUALITY

This is an expression of who we are as human beings. It includes all the feelings thoughts, and

behaviors of being a male or female, being attractive, and being in love as well as in

relationship that includes intimacy.

Sexuality is more than sex while sex is part of sexuality.

Different aspects of sexuality

Sexuality involves many aspects of being human, including:

Gender roles these are norms established by society that tell individuals how to behave based

on their biological sex.

Sensuality: this is how our bodies derive pleasure. It is the part of sexuality which deals with

the five senses (touch, sight, sound, smell and taste). Any of these senses, when enjoyed, can

be sensual.

Body image the way we feel about our bodies. It is important to know that we are unique, the

way we look, we should be proud.

Relationships: Forming loving and caring relationships with a partner is part of sexuality

Love / affection: Love is an intense feeling of affection for another person. It is defined only

on individual basis e.g. the love one has for a grandparent is not the one for the partner.

Sexual Health: This includes sexual development, equitable and responsible relationship,

sexual fulfillment, freedom from illness, disease, disability, violence, and other harmful

practices related to sexuality.

SEXUAL AND SOCIAL DEVELOPMENT

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Many milestones in sexual and social development are reached generally at the same age

worldwide though may follow patterns that may vary from culture to culture.

Milestones in Male and Female sexual and social development

 Begins to have sexual responses. This begins before birth, a male fetus achieves

genital erections in uterus, and some males are even born with erections. Sexual

responses in females are also intact before birth.

 Explores one’s own genitals (masturbates ) for the first time

Occurs between ages 6months and 1year. As soon as babies can touch their genitals they

begin to explore their bodies.

 Shows an understanding of gender identity. Occurs by age 2. Children are

aware of their biological sex.

 Shows an understanding of genital roles. Occurs between ages 3 and 5. Children

begin to confirm to the society’s messages about how males and females should

act.

 Ask questions about where babies come from. Occurs between ages 3 and five.

 Begins to show romantic interest. Occurs by ages 5-12 though may vary by

culture. At this stage children show the first sign of sexual orientation ( sex

preference towards male and female)

 Shows the first physical signs of puberty (the transition from child hood to

maturation) Occurs by ages 8-10 this occurs slightly earlier for girls.

 Begins to produce sperms (boys) Occurs between ages 11 and 18. This milestone

depends in part on the child’s nutrition and may be delayed where nutrition is

severely compromised.

 Begins to menstruate (girls). Occurs between 9-16. This milestone depends much

on nutrition and it is delayed where nutrition is severely compromised.

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  Begins to engage in romantic activity. Occurs between ages 10-15. This

milestone depends heavily on cultural factors.

 Has sex for the first time. This varies greatly by culture. But mid to late

adolescence is fairly common across cultures.

 Gets married. Depends on culture, in some culture girls and boys marry at a

young age while in others, at older ages.

 Begins to bear children depending on the individual and communities. This is

determined by many factors when to have children and not.

 Experiences menopause and andropause /climacteric (decreased female and

male hormonal levels) around ages 50, some in late 30s and others in early 40s in

females and 45-65 years in males.

 Experience sexuality in later life /older adults. Those aged 50-60 can remain

sexually active to the end of their life though some related changes in sexuality

take place.

BUILDING HEALTHY RELATIONSHIPS

Relationship means a link/dealing/association

Friendship means relationship between people who know and like each other and behave in a

kind and pleasant way to one another.

Romantic relationship means a loving association between two people that is appealing to

the imagination and effects the emotion.

Sexual relationship is an intimate relationship that involves sex between people in love.

STEPS OFBUILDING HEALTHY RELATIONSHIP

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  Actual contact is made for a purpose of getting together

 Each person tries to think that the other wants her/him

 Each person learns to accept one another for who they truly are

 They disagree a few times and the comfort level is greater between the partners.

 They learn to complement each other in their strength and weakness.

 Build trust. Feelings of jealousy reduce.

HEALTHY WAYS OF ENDING A RELATIONSHIP

 Make a clear decision about whether to end the relationship or not

 Know that you will probably hurt someone and will feel sad yourself

 Once you have made a decision stick to it

 It is important to be truthful, but kind, about why you are ending the relationship.

 Pick an appropriate place and time to break.

Try not to blame your partner for the break

CONSEQUENCES OF ADOLESCENTS ENGAGING IN SEX

FACTORS LEADING TO ADOLESCENTS ENGAGING IN SEX

I. Lack of knowledge on outcomes of sexual activity

II. Sexual abuse i.e. defilement, rape, incest.

III. Poverty

IV. Lack of life skills e.g. assertiveness, self awareness, negotiation skills, decision

making.

V. Alcohol and drug abuse

VI. Peer pressure

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VII. Environmental social settings; poor housing, slums, influence of electronic and print

media, rapid urbanization.

VIII. Lack of recreational activities.

IX. Insecurity

X. Civil strife like financial

XI. Revenge

CONSEQUENCES OF ADOLESCENTS ENGAGING IN SEX

1. PREGNANCY: This may result into:

 Complications of teenage pregnancies

 Induced abortions and its consequences

 Premature child birth

 Damaged baby

 Poor parenting

 Difficult and often assisted deliveries

 VVF

2. sexually transmitted diseases/ HIV/AIDs

3. infertility

4. cancer of the cervix

5. Emotional consequences like; anxiety, depression, guilt/self condemnation, shame,

fear.

6. Social consequences; like dropping out of school, stigmatization, forced marriage,

stunted growth for adolescent mother and reduced employment chances and low social

status.

MEASURES TO PREVENT ADOLESCENTS ENGAGING IN SEX

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  Promotion of positive cultural practices.

 Advocating for virginity/abstinence

 Life skills promotion.

ROLE OF HEALTH WORKERS IN MANAGING ADOLESCENTS WHO ENGAGE

IN UNPROTECTED SEX.

 Sensitizing the community on consequences of adolescent sex.

 Promotion of recreation activities for adolescents

 Encouraging parents to discuss sex issues with adolescents

 Counseling

 Treat consequences

 Supply condoms and contraceptives.

ADOLESCENT PREGNANCY

DEFINITION

This is pregnancy that occurs between the ages of 10-19 years.

SIGNIFICANCE OF ADOLESCENT PREGNANCY/ WHY STUDY ADOLESCENT

PREGNANCY

i) Pregnancy during adolescence is a big concern because during this time the

adolescent is;

 Still young and growing and needs a lot of food to grow.

 Jobless and not established therefore poor and dependent.

 Psychologically and physical immature and needs parental and social support which is

negatively interrupted.

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 ii) Adolescent pregnancy creates a negative social response and may result into lack

of support.

iii) The pregnant adolescent is usually discontinued from school therefore her socio-

economic status is lowered.

iv) Adolescents lack basic reproductive health information and therefore do not make

appropriate timely decisions.

v) Sometimes the men/boys responsible for the pregnancy deny it which

psychologically affects the girls.

FACTORS THAT LEAD TO TEENAGE PREGNANCY

 Cultural beliefs and practices

 Peer pressure

 Exposure to risky situations

 Sexual abuse

 Inadequate information on sexuality and reproductive health

 Experimentation on sex by teenagers

 Lack of parental guidance and control.

NEEDS OF A PREGNANT ADOLESCENT

1. Counseling and support

 Effective communication and counseling (information)

- The implication of being pregnant

- What to expect during pregnancy, labour and post-natal care.

 Health services: antenatal care, delivery and post-natal care.

- All pregnant adolescents must attend ANC and must be assisted during delivery by a

trained health provider in a health unit that provides emergency obstetric care.

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 2. Nutrition

An adolescent girl is still growing therefore needs adequate nutritious food to make her baby
grow appropriately. Usually and adolescent finds herself in an unfriendly environment,
socially, economically and otherwise, therefore it becomes difficult for her to meet the needs
of the baby and herself. A pregnant adolescent needs food rich in iron, calcium, protein, folic
acid, carbohydrates and vitamins.

3. Health services ; antenatal care delivery and post-natal care

All pregnant adolescents should attend antenatal care for early detection of high risk factors
and appropriate care including immunization.

Plan with the health worker where to deliver and what is needed for the mother and baby.

COMMON CONSEQUENCES OF ADOLESCENT PREGNANCY

Adolescent pregnancy whether planned or unplanned, wanted or unwanted may end up with
adverse effects. It may result into undesirable economic, social and medical outcomes.

Social economic:

 Stigmatization by fellow students, teachers and parents.

 Poor image according to community outlook that is: it is not accepted generally in
most communities.
 The partner may deny responsibility
 Lack of capacity to make decisions
 Inability to take on the responsibilities of parenthood
 Psychological impact of being rejected and denied support by family, society, and
peers and sent away from home and/or school is a big trauma and should be avoided.
Medical complications of adolescent pregnancy

 Abortions which are commonly unsafe.

 Exaggerated disorders of pregnancy.
 Risk for complications in pregnancy like pregnancy induced hypertension.
 Obstructed labour
 Tears
 Breastfeeding problems like failure to breast-feed
 Post-partum infections
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  Inability to look after the baby
 Puerperal psychosis
STRATEGIES FOR PREVENTING ADOLESCENT PREGNANCY

 Educating the community and adolescents on the consequences of adolescent

pregnancy.
 Empowering adolescents with life skills
 Encouraging abstinence by promoting cultures that advocate for virginity
- Sensitizing the community on consequences of adolescent sex.
- Promoting activities to occupy minds of adolescents e.g. drama, games.
 Promoting use of contraceptives among adolescents.
 Keeping adolescents busy with other activities as this will promote abstinence
 Avail or access family planning services
 Promote complete and accurate information on sexuality, development and
consequences.
 Provide physical, emotional and financial support to adolescents
 Provide information on dangers of ‘’too early pregnancies’’ to adolescents and adults.

DISADVANTAGED AND VULNERABLE GROUPS OF ADOLESCENTS

DEFINITIONS

Disadvantaged:

These are adolescents who are in unfavorable conditions that stand in their way of success or
progress.

Vulnerable

This is liable to be harmed- not protected against attacks/risks.

Handicapped

Anything likely to lessen one’s chance of success in life.

VULNERABILITIES OF ADOLESCENTS
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Physical vulnerabilities

- Adolescence is a time of rapid growth and development creating the need for a
nutritious and adequate diet.
- Adolescents often have poor eating habits.
- Poor health in infancy and childhood, often resulting from impoverished conditions,
can persist into adolescence and beyond.
- Repeated and untreated infections and parasitic diseases, frequent diarrhea and
respiratory diseases, malnutrition, defects and disabilities can contribute to
compromised physical and psychological development.
- Some young women may have undergone female genital mutilation which can result
in significant physical and/or emotional difficulties, especially in sexual and
reproductive matters.
Emotional vulnerabilities

- Mental health problems can increase during adolescence because of hormonal and
other physical changes of puberty, along with changes in adolescents’ social
environment.
- Lack of assertiveness and good communication skills rendering the adolescents unable
to articulate their needs and withstand the pressure /coercion from their peers or adults
- Unequal power dynamics between adolescents and adults since adults often view
adolescents as children.
- Lack of maturity to make good, rational decisions.
Socio-economic vulnerabilities

- Adolescents’ need for money often increases while they have little access to money or
gainful employment.
- Poverty and economic hardships can increase health risks owing to poor sanitation,
lack of clean water, inability to afford health care and medications.
- Disadvantaged adolescents are at great risk for substance abuse and may feel forced to
resort to working in hazardous situations, including commercial sex work.
- Adolescents may marry very young to escape poverty but may find themselves in
another difficult and challenging situation.
CATEGORIES OF THE DISADVANTAGED AND VULNERABLE GROUPS OF
ADOLESCENTS

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 I. Street children
II. Out of school adolescents
III. Incarcerated adolescents: these are adolescents confined either in prisons or centres as
a result of care and protection beyond parental control or committing crimes. (These
centres include; naguru remand home, kampiringisa and fort portal).
IV. Disabled adolescents: these include; adolescents with mental disabilities, congenital
defects, physical disabilities.
V. Adolescents in war zones
VI. Adolescents orphans.
DIFFERENT INTERVENTIONS TO ADDRESS SPECIFIC NEEDS OF
DISADVANTAGED ADOLESCENTS

There are several interventions that are in place to assist such a group by NGOs and
governments. Such interventions include those having;

Street outreach

This may involve making contact with children identifying their needs and problems
counseling and referring appropriately. Many NGOs are involved in this programme.

Drop in centres

A drop in centre is a form of a rehabilitation place where children come to a place to receive
treatment, counseling, shelter, assistance, meal and form of literacy and resettlement. Children
here are free to come and go. Social workers can give attention to immediate help. In
Kampala, NGOs like Friends of Children and Tiger Club offer such facilities.

Institutions

These are remedial services where children are completely taken away from the streets for
rehabilitation. Such centres provide vocational skills and other educational activities. Africa
foundation and Bring Children from the streets organizations are examples of those
institutions.

Community

These are service providers for street children who rehabilitate them in their communities.
The communities where children are found are mobilized to identify problems and solutions
for children such as Katwe, Kisenyi, and Bwaise- Kalerwe. The project is mainly organized
by Uganda Youth Development Link (UYDEL).
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 SEXUAL AND GENDER BASED VIOLENCE

DEFINITION

Gender-based violence is violence against women based on women’s subordinate status in

society. It includes any act or threat by men or male dominated institutions that inflict

physical, sexual, or psychological harm on a woman or girl because of their gender. In most

cultures, traditional beliefs, norms and social institutions legitimize and therefore perpetuate

violence against women.

Gender violence occurs in both the ‘public’ and ‘private’ spheres. Such violence not only

occurs in the family and in the general community, but is sometimes also perpetuated by the

state through policies or the actions of agents of the state such as the police, military or

immigration authorities. Gender-based violence happens in all societies, across all social

classes, with women particularly at risk from men they know.

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TYPES OF GENDER-BASED VIOLENCE

1. Overt physical abuse (includes battering, sexual assault, at home or in the workplace) .

2. Psychological abuse (includes deprivation of liberty, forced marriage, sexual

harassment, at home or in the workplace)

3. Deprivation of resources needed for physical and psychological well-being (including

health care, nutrition, education, means of livelihood)

4. Treatment of women as commodities (includes trafficking in women and girls for

sexual exploitation)

SITES OF GENDER-BASED VIOLENCE

1. Family is one of the primary sites of gender violence. It prepares its members

for social life; forms gender stereotypes and perceptions of division of labor

between the sexes. However it is the arena where physical abuses (spousal

battering, sexual assault, sexual abuse) and/or psychological abuses occur.

(Domestic violence can also take such forms as confinement, forced marriage

of woman arranged by her family without her consent, threats, insults and

neglect; overt control of a woman’s sexuality through either forced pregnancy

or forced abortion.) Because violence within the family and household takes

place in the home, it is often seen as a ‘private’ issue and information about it

is lacking. Community/Society w as a group sharing common social, cultural,

religious or ethnic belonging, it perpetuates existing family structure and

power inequalities in family and society.

2. Workplace can also be a site of violence. Either in governmental service or in

a business company, women are vulnerable to sexual aggression (harassment,

intimidation) and commercialized violence (trafficking for sexual

exploitation).

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 3. State legitimizes power inequalities in family and society and perpetuates

gender based violence through enactment of discriminatory laws and policies

or through the discriminatory application of the law. It is responsible for

tolerance of gender violence on an unofficial level (i.e. in the family and in the

community). To the extent that it is the State’s recognized role to sanction

certain norms that protect individual life and dignity and maintain collective

peace, it is the State’s obligation to develop and implement measures that

redress gender violence.

FEMALE GENITAL MUTILATION

DEFINITION

These are procedures involving partial or total removal of the external female genital organs.
It also involves other injuries to the female genital organs whether for cultural or non
therapeutic reasons.

TYPES

1. Excision of the prepuce:

The covering of the clitoris is removed sometimes with part of the clitoris
2. Excision of the clitoris:
Sometimes with partial or total removal of labia minor. The raw areas may be sutured
together
3. Excision of part or all of the external genitalia and narrowing of the vaginal orifice by
stitching (infibulations) .The labia minora and majora are cut away and edges stitched
together.
4. Pricking, piercing or incising the clitoris/labia. Cauterization of the clitoris and other
tissues around the vagina. Herbs, corrosive substances are put in the vagina to cause
inflammation or bleeding and later narrowing of the orifice.
These procedures are irreversible and their effects last for a lifetime.

HOW IT IS DONE
Female genital mutilation is often carried out by traditional practitioners in dirty surroundings
using crude, unsterile equipments and dirty hands. The procedure is carried out by force and
without pain relief. Risk of cross infection and bleeding is very high.
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AGE WHEN IT IS DONE
This depends on customs and the community but can be done at any of the following periods
 Infancy
 Childhood
 Adolescence
 Adults as initiation
 Before marriage
BELIEFS WHY IT IS DONE

1. Religious beliefs
2. Initiation into adulthood
3. Cleanliness (female genitalia is dirty)
4. Female genitalia is shame full
5. The clitoris threatens the penis
6. To control promiscuity and preserve virginity
7. Discourage infidelity in marriage
8. To control women i.e. mother fear that their daughters will not get husbands
9. Those who perform the cutting fear to lose source of income and power.
MIDWIFE/NURSE’S ROLE

To convince women that female genital mutilation is harmful and dangerous
Work with community to find ways of changing the practice
Replace circumcision with initiation rites to mark important occasions e.g. transition
into womanhood.
 Educate community on human rights
 Create awareness of complications
 Protect young girls from this trauma by advocacy.
COMPLICATIONS

IMMEDIATE

1.Haemorrhage from cut blood vessels

2.Severe pain
3.Shock which may be due to bleeding or pain
4.Urine retention due to pain
5.Injury to the surrounding tissues. Infections e.g. tetanus, bacterial infections,
septicaemia and HIV due to shared dirty instruments and poor hygiene
6. Death due to shock or haemorrhage
LONG TERM

1. Delayed wound healing and localized infection

2. Excessive scar formation which may result into keloids
3. Pelvic infection
4. Cyst and abscess formation

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 5. Neuromata : cut and trapped nerve endings can cause severe pain
6. Psychological trauma such as flash backs, anxiety, depression and lack of trust in the
family
7. Vaginal narrowing or closure which can lead to impaired or total obstruction to
menstrual flow resulting in pain and infection.
8. Recurrent urinary tract infections and renal diseases.
9. Lack of sensation and inability to enjoy sex
10. Painful coitus ((dysparaenuia). A man may be unable to penetrate the introitus on first
intercourse and may use a knife or any sharp object to open the scar tissue.
11. Infertility due to infections
12. Obstructed labour due to scarring of the genital tract which may lead to ruptured
uterus.
13. Vaginal fistula
14. Perineal tears due to scar tissue which cannot stretch (button holing)
15. Still birth
CARE OF A PREGNANT WOMAN WHO UNDERWENT FEMALE GENITAL
MUTILATION

 During antenatal find out the extent of cutting

 Defibulation may be done during second trimester so that by the time the mother goes
into labour the area is healed. Sometimes it can be done during labour.
 Anterior midline incision if scarred tissue is extensive or tight. This should be done
with care since it may expose the clitoris and urethra and risk of injury.
 Give a generous Medio- lateral episiotomy.
 After delivery repair all the tears and cuts but do not re - infibulate

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