Medical Termination of Pregnancy (MTP),sterilization and birth control

Content Questions

Q. Define and categorize abortion. Q. Enumerate the complications and sequele of abortions.Q. Describe the condition, person and place covered under MTP act 1971Q. Explain the male and female terminal methods of contraceptive procedures with their complicationsQ. Describe the various miscellaneous methods of birth control

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• Abortion = Termination of pregnancy before the foetus becomes viable.

Category:- Spontaneous: “ Natures method of birth control”- Induces: deliberately done legally or illegally

Abortion facts

• Out of 210 m pregnancies, 80 m are unintended• 2008: 21.6 m unsafe abortions causing 47,000 deaths• 14 unsafe abortions/ 1000 women (15-44 yrs)• Developing countries, its 16 per 1000 women

• India: ICMR study documented safe 6.1 and unsafe 13.5 per 1000 pregnancies

• 2/3rd takes place outside authorized health service

Complications and sequelae

Early complications:- Haemorrhage - Shock- Sepsis- Uterine perforation- Cervical injury- Thromboembolism - Anaesthetic and

psychiatric

Late sequelae - Infertility - Ectopic gestation- sed risk of

spontaneous abortion- Reduced birth weight

Medical termination of pregnancy act 1971

Coverage under MTP act 1971

1. Conditions under which preg can be terminated

2. Person/s who can perform

3. The place – terminations are performed

1. Conditions under which pregnancy can be terminated

Five- Medical: continuation might endanger mothers life- Eugenic: risk of the child being born handicap- Socio-economic: could lead to mothers health injury- Humanitarian: pregnancy is the result of rape- Failure of contraception: anguish caused by

unwanted pregnancy causing grave mental injury to the mother

Medical termination of pregnancy (MTP) act 1971 (contd.)

2. The Person/s who can perform abortion

• The act authorises only Registered Medical Practitioner having experience in Gynaec. and obs. (preg < 12 wks)

• 12wks – 20 wks: Opinion of two RMPs is necessary

Medical termination of pregnancy (MTP) act 1971 (contd.)

3. The place where abortion is performed

• NGOs may also take up – licence from dist. CMO

Medical termination of pregnancy (MTP) act 1971 (contd.)

Strategies of safe MTP centres and service providers

At community level:a. Spread awareness regarding availability of safe MTPb. Access to confidential counselling: train ANMs, AWW,

ASHAc. Provide post abortion care

At the facility level: d. To provide manual vaccum aspiration facilitye. Provide comprehensive & high quality services at FRUsf. Encourage private and NGO sectors to establish

Terminal methods

Sterilization Male Sterilization: 10-15% of sterilization in India though it is

simpler, safer & cheaper than female sterilization (85%)

Guidelines for sterilization1) Age of husband should not be <25 yrs or >50 yrs2) Age of wife should not be<20 yrs or >45 yrs3) Motivated couple must have 2 living children4) If the couple has 3 or more children the lower age limit of

couple can be relaxed by surgeon5) Acceptor declares having obtained consent of his/her spouse to

undergo sterilization

Female sterilization

• Postpartum/ at time of abortion

• 2 procedures: – Laparoscopy, – Mini-laparotomy (pomeroy)

Laparoscopic female sterilization

• Abdominal approach, specialized instrument called “laparoscope”

• Abdomen inflated with gas• Falope rings (clips) applied to occlude the tubes• Specialists availability ensured prior operation• Short operating time, short hospital stay, small scar

Complications: Puncture of large vesselsPatient selection: Not advisable postpartum for 6 wks

Minilaparotomy

• Modification of abdominal Tubectomy

• Simpler procedure requiring a smaller abdominal incision of only 2.5 – 3cm under LA

• Minilap/ Pomeroy technique

• Suitable technique at PHC for mass campaigns

• Suitable for post partum period.

Male sterilization (vasectomy)

• Simpler, faster, less expensive than tubectomy in terms of instruments, hospitalization and doctor’s training

• Cost wise ratio: 5 vasectomy to 1 tubal ligation

Procedure:• Acceptor is not immediately sterile after operation

usually until 30 ejaculations have taken place

• Remove at least 1 cm vas after clamping

Complications of male sterilization

• Operative : Pain, haematoma, wound infection (3%)

• Sperm granules (7mm)• Spontaneous recanalization• Autoimmune response• Psychological

Post – operative advice• Pt should be told that he is not sterile immediately after

operation, at least 30 ejaculations may be necessary before seminal examination is negative

• Use contraceptives until aspermia has been established

• Avoid taking bath for at least 24 hrs after operation• Wear T-bandage / scrotal support for 15 days• Avoid cycling/heavy wt. lifting for 15 days• To have stitch removed on 5th day after operation

No Scalpel Vasectomy (NSV)

• New technique that is safe, convenient & acceptable to males

• Accepted by NHFWP• Availability of this new technique at the

peripheral level will increase the acceptance of male sterilization

• Project is being funded by UNFPA

Miscellaneous methods of birth control

1) Abstinence 2) Coitus interruptus3) Safe period (rhythm method)

4) Natural methods: a) Basal body temperature method b) Cervical mucus method c) Symptothermic methodi. Breast-feedingii. Birth control vaccines

Safe period (Rhythm method)

• Calendar method• First day of fertile period:

Shortest cycle – 18 days• Last day of fertile period:

Longest cycle – 10 days• Eg

Safe period (contd.)

• Drawbacks:– Woman’s menstrual cycle is not regular– To be used by educated & responsible couples

with high degree of motivation– Compulsory abstinence of sexual intercourse for

nearly half of every month– Not applicable during post natal period– High failure rate: 9 per 100 HWY

• Complications:– Ectopic pregnancy– Embryonic abnormality

Natural family planning methods

a) Basal body temperature method (BBT) :– Rise of body temp by 0.3 – 0.5 degree C at the time of

ovulation – Intercourse restricted to post-ovulatory infertile period

b) Cervical mucus method– Billings method/ ovulation method– At the time of ovulation, cervical mucus becomes watery

clear resembling raw egg white, smooth, sleepery – After ovulation mucus thickens (progesterone)

c) Symptothermic method (combines temp. cervical and calender technique

Miscellaneous methods (Contd.)

• Breast feeding:– Lactational amenorrhoea

• Birth control vaccine– Prepared from B subunit of hCG– Research phase

Summary

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