Medios de comunicación y cultura: un enfoque desde Raymond Williams

The Norplant implant system is a highly effective, long acting, reversible, low dose, progestin only contraceptive. It consists of a set of 6 small, soft, slender, silicon rubber capsules each containing 36mg of levonorgestrel.

Mechanism of action:

• Norplant inhibits ovulation;

• Thickens cervical mucus making it difficult for sperm to pass through. • Causes changes in the uterine lining.

Effectiveness

Very effective - the failure rate in the first year is 0.1 - 0.2 pregnancies per hundred women. After 5 years, the total (commutative) pregnancy rate is only 3.7 percent.

Pregnancy rate is slightly higher among women weighing more than 70kgs.

Indications

Norplant implants are suitable method for most women of reproductive age, but they are particularly indicated for women who:

• Want a long term contraceptive method, • Desire a method that is not coital related,

• Prefer a method that neither is taken daily nor requires frequent supply, • Have the number of children they want, but do not wish to be sterilized, • Are considering sterilization, but are not yet ready to make a final decision, • Should not use estrogen containing contraceptives,

• Have problems remembering to take oral contraceptives

Advantages

• Very effective, even in heavier women, • Long term protection, but reversible,

• No need to do anything at time of sexual intercourse,

• Increased sexual enjoyment because no need to worry about pregnancies, • Nothing to remember. Requires no daily pill taking or repeated injections, • No repeated clinic visits required,

• Effective within 24 hours after insertion,

• Fertility returns almost immediately after capsules are removed, • Can be used by nursing mothers starting 6 weeks after child birth, • No estrogen side - effect,

• Help prevent iron - deficiency anemia, ectopic pregnancies, endometrial cancer, • High continuation rate.

Disadvantages

• Discomfort for several hours to one day, perhaps for several days for some clients after insertion. Removal is sometimes painful and often more difficult than insertion,

• Do not protect against STIs including HIV/AIDS, • It is expensive,

• Local inflammation or infection at the site of implants,

• Norplant's effectiveness is lowered more significantly by anti seizure medicines and refampicin than are other hormonal contraceptives.

Side - effects

Common side - effects include:

• Changes in menstrual bleeding including,

- light spotting or bleeding between monthly periods (common); - prolonged bleeding;

- ammenorrhea.

• Other minor side - effects include:

- weight gain (a few women lose weight). - headaches.

- Nausea. - dizziness. - acne or skin rash.

- breast tenderness and/or discharge. - change in appetite.

- enlargement of ovaries or ovarian cysts. - hair loss or more hair growth on the face.

Provision of Norplant

Who can provide Norplant?

Doctors, health officers, nurses, midwives and other health professionals who have been trained in counseling and in insertion and removal procedures.

Medical eligibility checklist for Norplant:

Ask, listen and assess the client for the following conditions. If the answer is NO to all of the questions/conditions she can use Norplant implants if she wants.

Questions / Conditions Yes No - Breast feeding a baby less than 6 weeks old ______ ________ - Problems with blood vessels. ______ _________ - Jaundice, sever liver cirrhosis, liver infection or tumor ______ _________ - Have or ever had breast cancer. ______ _________ - Unusual vaginal bleeding. ______ _________ - Taking medicines for seizure. ______ _________ - Pregnancy. ______ _________

Starting Norplant Implants

This depends on woman's situation:

• Having menstrual cycles:

- Any time it is reasonably certain that she is not pregnant;

- If started during the first seven days after menstrual bleeding no backup method is needed for extra protection;

- If starting on or after day 8 of her menstrual (period, she should use condoms or spermicide or avoid sex for at least 48 hours after insertion. If possible give her condoms or spermcide.

• Breast-feeding:

- As early as 6 weeks after childbirth.

- If menstrual periods have returned, she can start any time it is reasonably certain that she is not pregnant.

• After child birth if not breast feeding:

- Immediately or at any time in the first 6 weeks after child birth. No need to wait for her menstrual period to return.

- After 6 weeks, anytime it is reasonably certain that she is not pregnant. • After miscarriage or abortion:

- Immediately or in the first 7 days after either first or second trimester miscarriage or abortion.

- Later, any time it is reasonably certain that she is not pregnant. • When stopping another method:

- immediately.

Explain how to use Norplant implants Explain to the client:

• To keep the insertion area dry for 4 days, she can take off the gauze after 2 days and the adhesive bandage after 5 days.

• To remember that, after the anesthetic wears off, her arm may be sour for a few days. She also may have swelling and bruising at the insertion site. This is not a cause for alarm.

• To return to the clinic or see a nurse or doctor if the capsules come out or if soreness in her arm lasts more than a few days.

• About the most common side effects.

Insertion and removal of Norplant

Equipment for insertion of Norplant implant:

1 sponge - holding forceps. 1 iodine cup.

1 syringe and long needle. 1 scalpel with blade.

Insertion procedures:

• Use proper infection- prevention procedures, • Use only local anesthesia;

• Make a small incision in the skin on the inside of the upper arm.

• Insert the capsules just under the skin. This makes the capsules easier to remove later.

• After all 6 capsules are inserted close the incision with an adhesive bandage. Stitches are not needed. The insertion is covered with a dry cloth and warped with gauze.

Equipment for removal of Norplant implant:

1 sponge holding forceps. 1 iodine cup.

1 syringe and long needle. 1 scalpel with blade. 2 mosquito forceps. 1 strapping tape.

Removal Procedures

• Use proper infection - prevention procedures. • Use only local anesthetic.

• Make a small incision about where the capsules were inserted. • Use an instrument to help pull the capsules out.

• Close and bandage the incision, stitches are not needed.

N.B. If a woman wants to continue using Norplant implants, the new capsules are

placed elsewhere in the same arm or in the other arm.

Indications for removal

• User's firm request. • Pregnancy (confirmed). • Medical reasons; for example:

- heavy menstrual bleeding.

- symptoms of acute liver disease.

- serious infection of insertion site not amenable to treatment with antibiotic and/or local measures.

• Repeatedly occurring severe headache or migraine type headache occurring for the first time.

• At the end of 5 years after insertion.

Follow up

• The client should be seen within one month after insertion to check insertion site. Then at least every year.

• Annual follow up:

- update the client's address and how to contact her. - assess the client's satisfaction with the method.

- update the medical history.

- perform physical examination including BP, breast examination (with

instructions for self examination), a bi-manual pelvic examination with a pap smear if this is due and possible.

- provide appropriate counseling and/or treatment as required.

- review with the client the warning signs and instructions given at the previous visit.

- encourage the client to contact the clinic any time if she has any questions, complaints or problems.

Management of side - effects / problems

If the client reports any of the common side - effects of Norplant implants: • Do not underestimate the woman’s concerns or take them lightly,

• If the woman is worried, reassure her that such side effects are not usually dangerous or signs of danger.

• If the woman is not satisfied after treatment and counseling, ask her if she wants the Norplant capsules removed. If so, remove the capsules or refer for removal even if her problems with the Norplant implants would not harm her health. If she wants a new method, help her choose one.