Contraceptive

College Of Health And Medical Science
School Of Nursing
Masters program in nursing
Course Title: Clinical Pharmacology (emphasis on maternal and newborn area)
Presentation on Contraceptive and analgesia and anaesthesia in obstetrics
Present by Abas Ahmed
To Mr. Jemal
Contraceptive
05/16/2024 Contraceptive by Abas.A 2

Objectives
At the end of this presentation participant will be able to:
 Identify & understand of the Contraceptions methods.
 Perceive the different contraceptive utilities available
 Classify them according to their site and mechanism of action
 Justify the existing hormonal contraceptives present
 Able to know about benefits of Contraception

Content
 Introduction
 Types of Contraception
 Hormonal contraceptives
 Combined Oral Contraceptives (COCs)
 Progestin Only Pills (POPs)
 Injectable contraceptives
 Contraceptive implant
 Barrier methods
05/16/2024
Emergency Contraceptives Contraceptive by Abas.A 4
Introduction
 Contraception also known as Birth control.
 Contraception is the use of medicines, devices, or surgery to prevent pregnancy.
 There are many different types. Some are reversible, while others are permanent.
 Some types can also help prevent sexually transmitted diseases (STDs).
Need of Contraception
To prevent unwanted pregnancies.
To regulate the timing of pregnancy
To regulate the interval between pregnancy

Types of Contraception
 Hormonal Methods
 Barrier Methods
 Emergency Contraception
 Fertility Awareness-Based Methods
 Permanent Methods of Birth Control

Hormonal contraceptives
 Hormonal contraceptives are systemic in nature, a progestron combined with
estrogen or progestron alone.
 These methods include:-
1. Oral contraceptives.
2. Progestin only injectables.
3. Contraceptive implants

Oral contraceptives
• Oral contraceptives Are pills that taken by mouth to prevent pregnancy.
1. Estrogen and progestin (combined oral contraceptives (COCs))
 Ethinyl estradiol/norethindrone
2. Progestin only (progestin-only pills (POPs). norethindrone
Indications
As a contraceptive; preventing pregnancy

Combined Oral Contraceptives (COCs)
Preparations of synthetic estrogen and progestron.
Highly effective in preventing pregnancy.
 Mechanism of Action
►Preventing ovulation by suppressing the release of gonadotrophins.
►Inhibit implantation by: ↓ endometrial proliferation → no ovum can be embedded + ↓
secretion & peristalsis in fallopian tubes → hinder transport
►Inhibit fertilization: ↑ viscosity of cervical secretion → no sperm pass

Progestins Used in Combination Oral Contraceptives
• First generation (ethynodiol diacetate, norethindrone) Lower risk of thrombosis than other
• Second generation (levonorgestrel, norgestrel) Greater risk of thrombosis than with fgps,
• Third generation (desogestrel, norgestimate) Greater risk of thrombosis than with fgps
• Fourth generation (dienogest, drospirenone)
 Greater risk of thrombosis than with other progestins
 For drospirenone only:risk of hyperkalemia

Estrogens Used in Combination Oral Contraceptives
Only three estrogens are employed: ethinyl estradiol, mestranol, and estradiol valerate.
Most combination OCs use ethinyl estradiol.
A older products use mestranol,
o w/h undergoes conversion to ethinyl estradiol in the body.
New product—Natazia—uses estradiol valerate,
o which undergoes conversion to estradiol in the body.

Combined Oral Contraceptives (COCs)….
COCs are available in packets of:
• a) 21 pills, a pill is taken for 21 days and a break for 7 days before starting a new packet
• b) 28 pills, where a hormonal pill is taken every day for 21 days and
 the break occurs when seven placebo pills are taken as the last pills in each packet.
Advantages (Contraceptive)
Highly effective (0.1 pregnancies per 100 women during the first year of use)
Effective immediately (after 24 hours) and Do not interfere with intercourse
Client can stop use any time they want to get pregnant

Combined Oral Contraceptives (COCs)…
Advantages (Noncontraceptive)
Decreased menstrual flow and may improve iron deficiency anemia
Decreased menstrual cramps and May lead to more regular menstrual cycles
Protects against ovarian, endometrial cancer and some causes of PID
Decreases benign breast disease and ovarian cysts and Prevents ectopic pregnancy
Disadvantages
User-dependent (require continued motivation and daily use)
Forgetfulness increases failure and Resupply must be available
Does not protect against GTIs or other STDs (e.g., HBV, HIV/AIDS)
Contra-indications
Pregnancy (known or suspected), Age 35 and smoker
Breast-feeding and fewer than 6-8 weeks postpartum
Unexplained vaginal bleeding (until evaluated), Active liver disease and Breast cancer
History of blood clotting problems, heart disease, stroke or high BP (>180/110)
Migraines and focal neurological symptoms or diabetes > 20 years.
Taking drugs like rifampin ,phenytoin and barbiturates

Adverse Effects
A. Estrogen Relate:
Nausea, breast tenderness, Headache and ↑ frequency of gall bladder disease.
↑ Skin Pigmentation and ↑ incidence of breast, vaginal & cervical cancer.
Cardiovascular (Thromboembolism and Hypertension) and Impair glucose
tolerance.
B. Progestin Related:
Nausea, vomiting, Headache, Fatigue, depression, Weight gain,
Menstrual irregularities, Hirsutism

05/16/2024
, masculinization and Ectopic pregnancy
Contraceptive by Abas.A 15
Interactions
Medications that cause contraceptive failure:
Antibiotics that interfere with normal GI flora → ↓absorption & ↓ enterohepatic

recycling → ↓ its bioavailability.
Microsomal Enzyme Inducers → ↑ catabolism of OC (Phenytoin , Phenobarbitone, Rifampin)
Medications that ↑ COC toxicity: (CYT P450 inhibitors)
• Microsomal Enzyme Inhibitors; ↓metabolism of OC→ ↑toxicity (Acetominophen,

Erythromycin,)
Medications of altered clearance (↓) by COC: ↑toxicity (warfarin, Cyclosporine, Theophyline.)

Client Instructions
Take 1 pill each day, preferably at the same time of day.
If vomit within 30 minutes of taking a pill, take another pill or use a backup method if
have sex during the next 7 days.
If forget to take a pill, take it as soon as you remember
If forget to take 2 or more pills, take 2 pills every day until back on schedule.
Use a backup method (e.g., condoms) or else do not have sex for 7 days.
Progestin Only Pills (POPs)
• The pill only contains progestin, no estrogen as norethindrone or desogestrel….
 Indications:- Are alternative when estrogen is contraindicated
(e.g during breast feeding, hypertension, cancer, smokers over the age of 35).
Mechanism of action
Increase cervical mucus, so no sperm penetration & therefore, no fertilization.
Make the endometrium thin → hard implantation

Progestin Only Pills (POPs)…
Advantages (Contraceptive)
Effective (0.5-10 pregnancies per 100 women during the first year of use)
Immediately effective (<24 hours) and Immediate return of fertility when stopped
Does not interfere with intercourse and affect breast-feeding
Advantages (Non Contraceptive)
May decrease menstrual cramps and benign breast disease
May decrease menstrual bleeding and may improve iron deficiency anemia
Protects against endometrial cancer and some causes of PID

Disadvantages :- Do not protect against GTIs or other STDs (e.g., HBV, HIV/AIDS)
Contra-indications
Pregnancy, and Taking drugs like rifampin ,phenytoin, and barbiturates
Cancer of the reproductive tract and breast, Undiagnosed genital tract bleeding.
ADRs
Nausea, vomiting, Headache, Fatigue, depression and Weight gain.
Menstrual irregularities, Hirsutism, masculinization, Ectopic pregnancy.

Client Instructions
Take 1 pill at the same time each day.
Take the first pill on the first day of your menstrual period.
Take all the pills in the pack. Start a new pack on the day after you take the last pill.
If vomit within 30 minutes of taking a pill,
• take another pill or use a backup method if sex during the next 48 hours.
If you take a pill more than 3 hours late, take it as soon as you remember.
• Use a backup method if you have sex during the next 48 hours.
If forget to take one or more pills, take the next pill when you remember.
• Use a backup method if you have sex during the next 48 hours.
Injectable contraceptives
 Systemic progestin preparations administered by intramuscular injection.
 The most common is Depo-Provera/DMPA, which given every 3 months.
 A second PIC is Noristerat, which is given every 2 months.
Mechanism of action
Thickens cervical mucus, preventing sperm penetration
Make the endometrium less favorable for implantation

Injectable contraceptives…
Adv:- Periods may be less painful, have no vaginal bleeding at all or very light bleeding.
Dis:- weight gain, headache, mood swings, breast tenderness, periods may become more
irregular, heavier, Shorter, lighter or stop altogether.
Contraindication:- pregnancy, active thrombophlebitis current or past history of
thromboembolic, malignancy of breast.

Contraceptive implant
Implant—The implant is a single, is inserted under the skin of a women’s upper arm.
• The rod contains a progestin that is released into the body over 3 years .
 Typical use failure rate: 0.1%. Subdermal etonogestrel implant [implanon]
Adv:- It comes with a few risks, such as infection & changes to the menstrual cycle.
Dis:- In the first 6-12 months, there is irregular bleeding (aka spotting).
Mechanisms of Action
Thickens cervical mucus, preventing sperm penetration
Make the endometrium less favorable for implantation
Reduces sperm transport in upper genital tract (fallopian tubes)

Barrier methods
 Used for prevention of pregnancy as well as certain sexually transmitted diseases.
 Barrier methods such as; Condoms, diaphragm, Sponges, spermicide, vaginal rings
Prevents sperm from entering the uterus.
Condom prevent STIs. If it’s used with spermicide, Condoms nearly 100% effective

Barrier methods...
Hormonal vaginal contraceptive ring
o The ring releases the hormones progestin and estrogen.
 Progesterone absorbed through vaginal mucosa.
 The ring is placed inside the vagina.
 The ring is wear for three weeks, take it out for the week the women have her period
 Typical use failure rate: 7%

Barrier methods...
Adv:- It may help premenstrual symptoms, period become lighter, more regular & less
painful, it isn’t affected by if the women is sick(vomiting) or having diarrhoea.
Dis:- Increased vaginally discharge, headache, nausea, breast tenderness and mood
change, may feel uncomfortable inserting or removing it from vagina.
Contraindication:- Age > 35 & smoke, stroke, heart attack, history of blood clots.

Emergency Contraceptives
• Used to prevent pregnancy after unprotected intercourse
• Emergency contraceptives not be used in place of family planning methods
• Used only in an emergency, for example
- In cases of rape
- A condom has broken
- An IUCD has come out of place (within 120 hours (5 days) of unprotected sex.)
- Pills are lost or forgotten
- Sex took place without contraception and the woman wants to avoid pregnancy.

Emergency Contraceptives…
Emergency contraceptive pills —
Levonorgestrel alone, Ulipristal acetate [ella] and Ethinyl estradiol/levonorgestrel
Women can take pills up to 72 hours (3 days) after unprotected sex.
Prevent fertilization & implantation by hypermotility of fallopian tube & uterus.
If fertilization & implantation occurred then it prevents implantation of blastocyst.
Contain 2 combined pills immediately followed by 2 pills after 12 hours.

ANALGESIA AND ANAESTHESIA IN OBSTETRICS

Objectives
At the end of this presentation participant will be able to:
Identify & understand of labor analgesia, regional and general anaesthesia
Analysis and apply technique for the epidural analgesia for painless delivery
Able to know indication, contraindication, benefits and complication of analgesia,
regional and general anaesthesia in labour & delivery.

Content
• Pain in labour &delivery
• Opioid analgesics
• Inhalational analgesia
• Regional anaesthesia
• General anaesthesia

Pain in Labour &Delivery
 Pain during labor from a combination of uterine contractions & cervical dilatation.
 During cesarean delivery incision is made around the T12 dermatome anesthesia is required
from the level of T4 to block the peritoneal discomfort.
 Labor pain is experienced by most women with satisfaction at the end of a success labor.

SEDATIVES AND ANALGESICS
OPIOID ANALGESICS:
PETHIDINE
Mechanism of action:
Inhibits ascending pain pathways in CNS , increase pain threshold and alters pain perception.
spasmoanalgesic action during labour
Indications: Moderate to severe pain in labour, postoperative pain, abruption placentae.
Dose: Injectable preparations contains 50mg/ml can be administered SC, IM,IV.
Its dose is 50-100 mg IM combined with promethazine (adjunct to narcotic during labor.)
OPOID ANALGESICS
PETHIDINE…
• Contraindications:
Not be used IV within 2 hrs and IM within 3 hrs of expected time of delivery of the
baby, for fear of birth asphyxia.
It not be used in cases of preterm labour and When respiratory reserve of the mother is
reduced
• Side effects:
Maternal: Drowsiness, Dizziness, Confusion, Headache, Sedation, Nausea, Vomiting
Fetal: Respiratory depression, Asphyxia

OPOID ANALGESICS
FENTANYL
 Mechanism of action:->Inhibits ascending pathways in CNS,
->Increases pain threshold and alters pain perception.
 Indications: Moderate to severe pain in labour, and adjunct to general anaesthetic.
 Dose: 0.05 to 0.1 mg IM q1-2 hrs prn. Available in injectable form, 0.05 mg/ml.
 It is given Iv and by epidural, also available in oral, oromucosal and transdermal forms for analgesia.
 Side effects: Dizziness, Delirium, Euphoria, Nausea, Vomiting, Muscle rigidity,

OPOID ANALGESICS
Nalbuphine
At low doses, it has analgesic actions equal to those of morphine.
Dose: 10 and 20 mg/mL supplied in solution for IV, IM, and SC Q3-6H over 10-15 mts
Slows RR/sedative/analgesic in mother and causes respiratory depression in fetus
Morphine sulphate
Morphine is given through an IV or it can be injected under the skin or into muscle.
Pain relief takes effect within 5 - 30 minutes and lasts 4 - 6 hours.
Effective analgesic /cause pruritus and Slows labour contractions
Cause some respiratory depression in foetus

OPOID ANALGESICS
MEPERIDINE
Compared to morphine, analgesic effect is one tenth, but respiratory depression is
less
It is used 25–50 mg (1–3 mg/kg IM) or a PCA pump 15 mg every 10 minutes.
Repeated use or PCA in labor, infants may need naloxone at delivery.
Maximum placental transfer and neonatal

05/16/2024 Contraceptive bydepression
Abas.A occur 2–3 hours of use. 40
OPOID ANALGESICS
Tramadol
Synthetic opioid
IM: 100mg/10-30min (onset)/ 3-4 hrs (duration)
Moderate analgesia (effective in 1st stage)
Mild respiratory depression and High placental permeability
Side effects: nausea, vomiting, sedation, dry mouth, sweating

OPOID ANALGESICS
Remifentanil
Is a very short acting narcotic.
It is always given via patient controlled analgesia (PCA) into your iv.
Rapidly effective within 1 - 2 minutes but only lasts 5 minutes.
For this reason, in addition to self-administration, the PCA will be programmed to
provide a continuous background infusion of remifentanil.
Because this drug lasts a short time, it is less to affect the baby’s breathing at birth.
INHALATIONAL ANALGESIA
50% nitrous oxide + 50% oxygen (entonox )
It has very low anesthetic potency and It has very high analgesic potency
Mixture is stable at normal temperature
Delivered in cylinders placed in horizontal position( nitrous oxide is heavier than oxygen)
N2O limits the neuronal & synaptic transmission within the central nervous system
Administered with entonox apparatus

COMMONLY USED LOCAL ANESTHESIA IN OBSTETRICS

REGIONAL ANAESTHESIA
 Injects bupivocaine/tetracaine to block specific nerve
 Acts by blocking sodium & potassium transport
 Effect on newborn flaccidity, bradycardia, hypotension
 Woman is awake
 Do not depress uterine tone

Management of Labour Pain
Regional
o Epidural analgesia
 Most effective means of relieving pain during labour.
 Local anaesthetics, opioids or a combination injected into the epidural space.
 Few absolute contraindications
Allergy to injectate and Uncorrected maternal hypovolemia
Intracranial lesions with associated increased intracranial pressure
Local infection at the site of needle insertion
Coagulopathy and Recent anticoagulant administration

Management of Labour Pain
 Regional
o Combined spinal-epidural analgesia
• Injection of local anesthetic agent into the subarachnoid space and epidural space.
Significantly faster onset to effective analgesia, faster onset to sacral analgesia,
Decreased incidence of failed epidural analgesia
o Paracervical block
Can be used for the first stage of labour to relieve pain deals with cervical dilation.
Involves injection of local anaesthetic lateral to the cervix.
o Pudendal block: Injection of local anaesthetic into the bilateral vaginal wall
• Partially relieve pain associated with the second stage of labour.

Perineal infiltration
Used for episiotomy/perineal tear repair
Lignocaine 10-20mls 2% solution infiltrated into the site of episiotomy.
Not recommended for patients on epidural or combined epidural.
Paracervical block
Given prior to Manual Vacuum Aspiration
Performed with the patient on modified lithotomy position.
Infiltrate 5-10 ml of bupivacaine 0.125 – 0.25% without epinephrine on each side.

GENERAL ANAESTHESIA
 General Anesthesia means being completely asleep or unconscious.
 Never preferred for labour and may necessary in emergencies (vaginal deliveries and C/S).
 The main risk for the mother with general anesthesia is vomiting
 Induction of anaesthesia is done with the injection of thiopentone sodium 200-250 mg as a

2.5 % solution IV, followed by refrigerated suxamethonium 100 mg.
 Thiopental sodium+ N2O+O2
 Anaesthesia is maintained with 50% no2 , 50% oxygen and a trace of halothane.
 Relaxation is maintained with muscle relaxant [ vecuronium 4 mg or atracurium 25 mg].

THANKS –YOU
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College Of Health And Medical Science

Presentation on Contraceptive and analgesia and anaesthesia in obstetrics

Present by Abas Ahmed

05/16/2024 Contraceptive by Abas.A 2

At the end of this presentation participant will be able to:

 Identify & understand of the Contraceptions methods.

 Perceive the different contraceptive utilities available

 Classify them according to their site and mechanism of action

 Justify the existing hormonal contraceptives present

 Able to know about benefits of Contraception

05/16/2024 Contraceptive by Abas.A 3

 Combined Oral Contraceptives (COCs)

 Progestin Only Pills (POPs)

 Contraception also known as Birth control.

 Contraception is the use of medicines, devices, or surgery to prevent pregnancy.

To prevent unwanted pregnancies.

To regulate the timing of pregnancy

To regulate the interval between pregnancy

 Fertility Awareness-Based Methods

 Permanent Methods of Birth Control

05/16/2024 Contraceptive by Abas.A 6

 Hormonal contraceptives are systemic in nature, a progestron combined with

estrogen or progestron alone.

 These methods include:-

1. Oral contraceptives.

2. Progestin only injectables.

3. Contraceptive implants

05/16/2024 Contraceptive by Abas.A 7

• Oral contraceptives Are pills that taken by mouth to prevent pregnancy.

1. Estrogen and progestin (combined oral contraceptives (COCs))

2. Progestin only (progestin-only pills (POPs). norethindrone

As a contraceptive; preventing pregnancy

05/16/2024 Contraceptive by Abas.A 8

Preparations of synthetic estrogen and progestron.

Highly effective in preventing pregnancy.

►Preventing ovulation by suppressing the release of gonadotrophins.

►Inhibit implantation by: ↓ endometrial proliferation → no ovum can be embedded + ↓

secretion & peristalsis in fallopian tubes → hinder transport

►Inhibit fertilization: ↑ viscosity of cervical secretion → no sperm pass

• Fourth generation (dienogest, drospirenone)

 Greater risk of thrombosis than with other progestins

 For drospirenone only:risk of hyperkalemia

Most combination OCs use ethinyl estradiol.

A older products use mestranol,

o w/h undergoes conversion to ethinyl estradiol in the body.

New product—Natazia—uses estradiol valerate,

o which undergoes conversion to estradiol in the body.

05/16/2024 Contraceptive by Abas.A 11

COCs are available in packets of:

Effective immediately (after 24 hours) and Do not interfere with intercourse

05/16/2024 Contraceptive by Abas.A 12

Decreased menstrual flow and may improve iron deficiency anemia

Protects against ovarian, endometrial cancer and some causes of PID

User-dependent (require continued motivation and daily use)

Forgetfulness increases failure and Resupply must be available

Pregnancy (known or suspected), Age 35 and smoker

Breast-feeding and fewer than 6-8 weeks postpartum

History of blood clotting problems, heart disease, stroke or high BP (>180/110)

Migraines and focal neurological symptoms or diabetes > 20 years.