General overview: During the reproductive years, the woman who is sexually active often faces the decision to postpone, prevent, or terminate a pregnancy. The nursing role focuses on assisting her to make an informed decision consistent with individual needs.

1. FAMILY PLANNING
1. Assessment:
1. Determine interest in and present knowledge of methods of family planning.
2. Identify factors affecting choice of method: cultural and religious objections, contraindications for individual methods, motivation/ability to follow chosen method successfully, financial considerations, and sexual orientations.
2. Analysis/nursing diagnosis: knowledge deficit regarding family planning methods/options.
3. Nursing care plan/implementation: Goal: health teaching to facilitate informed decision making, selection of option appropriate to individual needs, desires.
1. Describe, explain, discuss options available and appropriate to the woman. Include information on advantages and disadvantages of each option Table 4-1. Contraception and Table 4-2. Sterilization .
2. Demonstrate, as necessary, method selected.
3. Quick health teaching reminders for missed oral hormone preparations:
1. Woman should take one pill at the same time every day for 21 (or 28) days.
2. If woman misses one pill, she should take it as soon as she remembers it; she should then take the next one at the usual time.
3. If woman misses two or more pills in a row in the first 2 weeks of her cycle, she should take two pills for 2 days and use a backup method of contraception for the next 7 days.
4. If woman misses two pills in the third week, or three or more pills anytime:
1. A Sunday starter should keep taking pills until the next Sunday, then start a new pack that Sunday. She should use a backup method of contraception for the next 7 days.
2. A day 1 starter should throw out the rest of the pack and start a new pack that day. She should use a backup method of contraception for the next 7 days.
5. 28-day pill pack: If woman misses any of the seven pills that do not have any hormones, she should throw out the pills missed and keep taking one pill a day until the pack is empty. She does not need a backup method of contraception.
4. Alert woman to discontinue use of oral hormone contraceptive preparations and report any of the following signs of potential problems to the physician STAT: "ACHES"*
• A—Abdominal pain: possible problem with the liver or gallbladder.
• C—Chest pain or shortness of breath: possible clot within lungs or heart.
• H—Headaches (sudden or persistent): possibly caused by stroke (brain attack) or hypertension.
• E—Eye problems: possible vascular incident or hypertension.
• S—Severe leg pain: possible thromboembolic process.
5. Signs of potential problems related to IUD use: "PAINS"*
• P—Period (menstrual) late, abnormal spotting or bleeding.
• A—Abdominal pain, pain during coitus (dyspareunia).
• I—Infection, abnormal vaginal discharge.
• N—Not feeling well; fever or chills.
• S—String missing (nonpalpable on vaginal self-examination, or not seen on speculum examination).
6. Toxic Shock Syndrome(TSS)
1. Signs/symptoms:
1. Fever of sudden onset—over 102°F (38.9°C).
2. Hypotension—systolic pressure 90 mm Hg; orthostatic dizziness; disorientation.
3. Rash—diffuse, macular erythroderma (resembling sunburn).
4. Sore throat; severe nausea, vomiting.
5. Copious vaginal discharge.
2. Instructions for prevention:
1. General
1. Avoid use of tampons, cervical caps, and diaphragms during the postpartum period (6 weeks).
2. Do not use any of the above if you have a history of TSS.
3. Call physician if you experience sudden onset of a high fever, vomiting, diarrhea, or skin rash.
4. Insert clean tampons and contraceptive devices with clean hands.
5. Remove within prescribed time limits.
2. Tampons
1. Change tampons every 3 to 6 hours.
2. Do not use superabsorbent tampons.
3. For overnight protection, substitute other products such as sanitary napkins or minipads.
3. Diaphragm or cervical cap
1. Avoid use during your menstrual period.
2. Remove within 8 hours after intercourse (diaphragm must be removed no later than 24 hours; the cap, no later than 48 hours).
4. Evaluation/outcome criteria:
1. Woman avoids or achieves a pregnancy as desired.
2. Woman expresses comfort and satisfaction with method selected.
2. INFERTILITY
1. Definition: inability to conceive after 1 year of unprotected intercourse.
2. Pathophysiology: contributing factors—hormonal deficiencies, reproductive system disorders, congenital anomalies, male impotence, sexual knowledge deficit, debilitating disease.
3. Assessment:
1. History—general health, reproduction, social history.
2. Maternal diagnosis
1. Basal body temperature (BBT) (Figure 4-4. Basal Body Temperature Chart).
2. Endocrine studies.
3. Huhner test (postcoital).
4. Rubin's test (tubal patency).
5. Hysterosalpingogram (tubal patency).
3. Male diagnosis—history, physical examination, laboratory studies (e.g., semen analysis).
4. Analysis/nursing diagnosis: altered sexuality, altered family process related to infertility.
5. Nursing care plan/implementation:
1. Provide emotional support.
2. Explain testing procedures for diagnosis.
3. Assist with referral process.
6. Evaluation/outcome criteria:
1. The couple conceives, or,
2. If the couple does not conceive, they accept referral for help with adoption, other reproductive alternatives, or childlessness.
3. INTERRUPTION OF PREGNANCY—also known as elective, voluntary, or therapeutic abortion. Once the diagnosis of pregnancy and the length of gestation are established, the woman faces the decision to interrupt or to maintain the pregnancy (Table 4-3. Interruption of Pregnancy (Elective/Voluntary Abortion) ).

1. Decision-making stage:
1. Assessment:
1. Health history:
1. Determine woman's feelings about the pregnancy, reasons for considering abortion, level of maturity; if decision was already made before she came to clinic, how was decision made? Does she have a support system?
2. Identify factors influencing/complicating her decisions (religious beliefs, cultural mores, peer and family pressures).
3. Information needs.
2. Physical examination.
3. Laboratory tests: blood type, Rh, hemoglobin, hematocrit, urinalysis, pregnancy test, antibody titer, other tests dependent on her health status.
2. Analysis/nursing diagnosis:
1. Ineffective coping related to emotional conflicts associated with need for decision to continue/terminate pregnancy.
2. Altered family process related to intrafamily conflict associated with need for/decision to continue/terminate pregnancy.
3. Anticipatory grieving related to loss of pregnancy/child.
4. Altered self-concept, self-esteem disturbance related to possible guilt feelings associated with pregnancy/termination.
5. Knowledge deficit related to available options.
3. Nursing care plan/implementation:
1. Goal: emotional support to minimize impact on self-image and self-esteem.
1. Maintain accepting, nonjudgmental attitude.
2. Encourage verbalization of feelings, perceptions, and values.
3. Support woman's decision.
2. Goal: health teaching to facilitate informed decision making.
1. Explain and discuss available options as applicable (see Table 4-3. Interruption of Pregnancy (Elective/Voluntary Abortion) ).
2. Describe procedure selected and what to expect after procedure.
3. Goal: minimize impact on intrafamily relations, family process. Where applicable, encourage open communication between deciding partners.
4. Evaluation/outcome criteria:
1. Woman states she understands all information necessary to give consent.
2. Woman expresses comfort and satisfaction with the decision.
2. Preoperative period
1. Assessment:
1. Reassess woman's emotional and physical status and current feelings regarding decision.
2. Determine woman's current knowledge/understanding of authorization form, anticipated procedure, and consequences (informed consent).
3. Monitor woman's physiological and (if awake) psychological response to procedure.
2. Analysis/nursing diagnosis:
1. Anxiety/fear related to procedure, potential complications.
2. Knowledge deficit related to ongoing procedure, sights, sounds, and sensations experienced.
3. Nursing care plan/implementation:
1. Goal: provide opportunity to reconsider decision regarding termination of pregnancy.
1. Check to ensure all required permission (informed consent) forms have been signed/filed.
2. Refer to physician if woman is ambivalent or insecure in decision.
2. Goal: reduce anxiety/fear related to procedure.
1. Explain all anticipated preoperative, operative, and postoperative care.
2. Assist with procedure; if woman is awake, explain what is happening and what she may be experiencing.
3. Goal: emotional support to facilitate effective coping.
1. Encourage verbalization of feelings, fears, concerns.
2. Support woman's decision.
4. Evaluation/outcome criteria: woman does not experience physiological or psychological problems during procedure.
3. Postoperative period
1. Assessment:
1. Monitor physiological response to procedure (vital signs, blood loss, uterine cramping).
2. Determine psychological response (happy, relieved; guilt feelings, lowered self-esteem).
3. Determine desire for family planning information.
4. Determine need for Rh_o(D) immune globulin, rubella vaccination
2. Analysis/nursing diagnosis:
1. Pain related to procedure.
2. High risk for infection related to lack of knowledge of postabortal self-care.
3. Nursing care plan/implementation:
1. Goal: provide and explain postoperative care.
1. Administer intravenous (IV) fluids.
2. Administer medications prn for discomfort.
3. Administer oxytocic medications for uterine atony, prn.
4. If mother is Rh-negative, 8 or more weeks of gestation, and laboratory tests indicate no current sensitization (i.e., she is Coombs' negative):
1. Explain rationale for postabortion administration of Rh_o (D antigen) immune globulin (RhoGAM).
2. Administer RhoGAM, as ordered.
5. Provide and explain perineal care.
2. Goal: health teaching to facilitate active participation in own health maintenance, informed decision making, provide predischarge anticipatory guidance (also provide in written form with attention to woman's level of reading skill and understanding, and in her native language whenever possible):
1. Immediately report any cramping, excessive bleeding, signs of infection.
2. Provide name and telephone number of person to call if she has questions.
3. Schedule a postabortal checkup.
4. Discuss contraception, if woman indicates interest; or give her place and name to call for information later.
5. Discuss resumption of tampon use (3 days to 3 weeks as ordered) and sexual intercourse (1 to 3 weeks as ordered).
6. Discuss need to avoid douching.
4. Evaluation/outcome criteria:
1. Woman returns for postabortal appointment.
2. Woman suffers no adverse physical sequelae to the procedure.
3. Woman suffers no adverse psychological sequelae to the procedure.
4. Woman is successful in achieving her goal of either contraception or conception at the time she desires.
5. Postabortion psychological impact:
1. Majority—relieved and happy.
2. Small number (5% to 10%)—negative feelings, such as guilt or low self-esteem.

^* Source: Hatcher, R, et al: Contraceptive Technology, ed. 16. Irving, New York.