Contraceptive Devices Diaphragms

Diaphragms have an arcing, coil, or flat spring with the latex brands and a wide-seal rim, arcing or coil spring with the silicone devices. The arcing spring diaphragm is used most often because it is easier to place in the posterior fornix without an introducer. When fitting a diaphragm, the size can be determined with a simple pelvic examination.

With the patient in a dorsal lithotomy position, the provider inserts the lubricated and gloved index and middle finger straight into the vagina to the posterior fornix. Once there, the spot where the inferior pubic arch impacts the index finger is noted. The fingers are withdrawn, and the distance from that point on the index finger to the end of the middle finger is noted; this is about the diameter of diaphragm needed. Diaphragms come in 5-mm increments from 60 to 90 mm, with 75 and 80 mm most common. The diaphragm is then inserted and size confirmed with placement posteriorly in the posterior fornix behind the cervix and anteriorly behind the pubic arch. Removal of the diaphragm can be accomplished by hooking the anterior rim with a finger and gently extracting. Women should be given an opportunity to remove and replace the diaphragm to confirm placement before use.

The diaphragm can be placed in the posterior vagina covering the cervix up to 6 hours before intercourse. Generally, women have used 5 mL of spermicide within the diaphragm at insertion, although a Cochrane review failed to prove its contribution to contraceptive effectiveness (Cook et al., 2003). Additional spermicide can be inserted in front of the diaphragm before each act of intercourse without dislodging the diaphragm. The diaphragm is removed at least 6 hours and not more than 24 hours after the last intercourse. An increased risk of urinary tract infections exists with diaphragm use and risk of toxic shock syndrome if the diaphragm is left in place more than 24 hours. The diaphragm size needs to be reestablished after a weight change of 10 to 15 pounds, pregnancy, or pelvic surgery. Failure rate for the diaphragm is 18% but may be better with perfect use.

Cervical Caps

Two brands of cervical caps are currently approved and marketed in the United States. Although neither requires specific fitting by a practitioner, both require a prescription for pharmacy or manufacturer dispensation. FemCap comes in three sizes and is ordered based on pregnancy history, whereas Lea's Shield comes in one size for all women with normal anatomy.

The FemCap is a silicone rubber nonhormonal intravaginal contraceptive (IVC). The smaller rim size (22 mm) is for women who have never been pregnant. The medium size (26 mm) is intended for women who have been pregnant, even for up to as little as 2 weeks with no vaginal delivery. The larger-diameter cap (30 mm) is for women who have had a full-term vaginal delivery. When in doubt of prior pregnancy, the 26-mm cap should be used. The patient places the cap over the cervix with up to % tsp of 2% nonoxynol-9 spermicide used around the outside groove at least 15 minutes before sexual arousal. Placement over the cervix is critical and accomplished best while squatting. Once in place, the cap should be pushed in opposition to the cervix for at least 10 seconds to ensure firm placement against the vaginal wall, because it does not fit snug against the cervix. Additional spermicide should be placed with each act of intercourse without removing the cap. Hooking a finger under the removal strap in a squatting position and withdrawing gently removes the cap. The cap must be removed at least 6 hours but not longer than 48 hours after the last act of intercourse. During a 6-month clinical trial for approval, the FemCap was 86.5% successful in preventing pregnancy (FemCap, 2010). The device is washed and dried thoroughly between uses.

Lea's Shield is a silicone rubber IVC placed vaginally at any time before intercourse. It is inserted with spermicide to the depth of the vagina, and any trapped air is vented through a one-way valve, creating a tight fit between the vaginal wall and the device. The Shield is removed using the incorporated removal loop with a finger more than 8 hours after intercourse. Women had an 8.7% chance of becoming pregnant within 6 months when using the Lea's Shield (Yama, 2010). The shield is cleaned with warm soapy water and dried for reuse.

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