When the diaphragm is the chosen method of contraception, patient education is key to compliance and effectiveness. An extended visit with the physician or a nurse may be required for a woman to learn proper insertion, removal, and care of the diaphragm. Methods of covering the cervix to prevent entry of sperm have been used for centuries. The Chinese employed disks made of oiled silk paper, while Europeans tried linen cloths and wax wafers.
Honey, pepper, and even animal dung were tried as spermicides or diaphragms. With the availability of oral contraceptive pills, use of the diaphragm has declined steadily over the past 40 years. The diaphragm may be the preferred method of contraception in women with contraindications to the use of oral contraceptive pills and women who do not wish to use an intrauterine device. Because the diaphragm is such a user-dependent form of contraception, reported rates for its effectiveness in preventing pregnancy range from 70 to 99 percent.
When patients are properly trained and use the diaphragm consistently i. Over the same period, approximately 85 pregnancies will occur if no form of contraception is used. Clinical practice has established the need for concurrent use of a spermicide with the diaphragm, although a recent Cochrane review noted that studies have failed to prove or disprove the contraceptive contribution of the spermicide.
The Centers for Disease Control and Prevention currently recommends that women at high risk for HIV infection not use nonoxynol—9 spermicides. Diaphragm users can combine contraceptive methods and theoretically achieve higher rates of effectiveness. For example, additional protection may be achieved through concurrent use of male condoms and a diaphragm with spermicide throughout the month. Some advantages of the diaphragm over other forms of contraception are listed in Table 1.
Notably, women who use the diaphragm typically are older, monogamous, more highly educated, and generally at lower risk for STDs compared with women who use other contraceptive methods or no form of contraception.
Diaphragm use allows greater sexual spontaneity and more sexual sensation than male condom use. Compared with OCPs, the diaphragm is safer for use in women with medical conditions and in women older than 35 years who smoke.
The diaphragm is an easily reversible method of contraception, unlike tubal ligation or vasectomy. Diaphragm use requires one annual physician visit, compared with multiple visits for injectable hormonal contraceptive use.
Information from references 1 and 7 through 9. One reported disadvantage of diaphragm use is an increased rate of urinary tract infections. Women with poor vaginal tone, a shallow vaginal shelf, rectocele, or cystocele may not be able to use the device effectively. A weight change of more than 6. Use of a diaphragm is contraindicated in women with hypersensitivity to latex unless the wide seal rim diaphragm is used or a history of toxic shock syndrome.
Diaphragms are made of latex or silicone. Types of diaphragms include the latex arcing spring, coil spring, and flat spring, and the silicone wide seal rim 15 Figure 1. The firmer rim of the arching spring diaphragm makes it the easiest type to insert. The diaphragm folds at two hinged points, forming an arc for insertion.
The firm rim is easier to place in the posterior fornix. This diaphragm may be the best one to use in women with decreased pelvic tone, rectocele, or cystocele. The coil spring diaphragm has a soft flexible rim that does not form an arc when folded. This diaphragm may be used in women with average vaginal muscle tone.
It can be inserted with a diaphragm introducer tool. The flat spring diaphragm is similar to the coil spring device but has a thinner, more delicate rim. Like the coil spring diaphragm, it can be inserted with a diaphragm introducer tool. The flat spring diaphragm may be used in women with firm vaginal muscle tone.
For women with hypersensitivity to latex, a silicone option is available. The wide seal rim diaphragm comes in an arcing spring style or a coil spring style. This silicone diaphragm is not available in pharmacies but must be ordered from the manufacturer.
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Thus, in cases of prior surgery or infection with resultant adhesion formation, this may not be a very useful technique. Palpation can also be used to check for ascites see below. First warm your hands by rubbing them together before placing them on the patient. The pads and tips the most sensitive areas of the index, middle, and ring fingers are the examining surfaces used to locate the edges of the liver and spleen as well as the deeper structures.
You may use either your right hand alone or both hands, with the left resting on top of the right. Examine each quadrant separately, imagining what structures lie beneath your hands and what you might expect to feel. What can you expect to feel?
In general, don't be discouraged if you are unable to identify anything. Remember that the body is designed to protect critically important organs e. It is, for the most part, during pathologic states that these organs become identifiable to the careful examiner. However, you will not be able to recognize abnormal until you become comfortable identifying variants of normal, a theme common to the examination of any part of the body. It is therefore important to practice all of these maneuvers on every patient that you examine.
Ask the patient or an observer to place their hand so that it is oriented longitudinally over the center of the abdomen. They should press firmly so that the subcutaneous tissue and fat do not jiggle. Place your right hand on the left side of the abdomen and your left hand opposite, so that both are equidistant from the umbillicus. Now, firmly tap on the abdomen with your right hand while your left remains against the abdominal wall. If there is a lot of ascites present, you may be able to feel a fluid wave generated in the ascites by the tapping maneuver strike against the abdominal wall under your left hand.
This test is quite subjective and it can be difficult to say with assurance whether you have truly felt a wave-like impulse. The abdominal examination, like all other aspects of the physical, is not done randomly. Every maneuver has a purpose. Think about what you're expecting to see, hear, or feel. Use information that you've gathered during earlier parts of the exam and apply it in a rational fashion to the rest of your evaluation. If, for example, a certain area of the abdomen was tympanitic during percussion, feel the same region and assure yourself that there is nothing solid in this location.
Go back and repeat maneuvers to either confirm or refute your suspicions. In the event that a patient presents complaining of pain in any region of the abdomen, have them first localize the affected area, if possible with a single finger, pointing you towards the cause of the problem.
Then, examine each of the other abdominal quadrants first before turning your attention to the area in question. This should help to keep the patient as relaxed as possible and limit voluntary and involuntary guarding i.
Make sure you glance at the patient's face while examining a suspected tender area. This can be particularly revealing when evaluating otherwise stoic individuals i. The goal, of course, is to obtain relevant information while generating a minimal amount of discomfort. Chronic liver disease usually results from years of inflamation, which ultimately leads to fibrosis and decline in function.
The multi-colored areas of the lung model identify precise anatomic segments of the various lobes, which cannot be appreciated on examination. Main lobes are outlined in black. Palpation plays a relatively minor role in the examination of the normal chest as the structure of interest the lung is covered by the ribs and therefore not palpable.
Specific situations where it may be helpful include:. In general, fremitus is a pretty subtle finding and should not be thought of as the primary means of identifying either consolidation or pleural fluid. It can, however, lend supporting evidence if other findings see below suggest the presence of either of these processes. This technique makes use of the fact that striking a surface which covers an air-filled structure e.
If the normal, air-filled tissue has been displaced by fluid e. Alternatively, processes that lead to chronic e. Initially, you will find that this skill is a bit awkward to perform. Allow your hand to swing freely at the wrist, hammering your finger onto the target at the bottom of the down stroke.
A stiff wrist forces you to push your finger into the target which will not elicit the correct sound. In addition, it takes a while to develop an ear for what is resonant and what is not. A few things to remember:. Practice percussion! Try finding your own stomach bubble, which should be around the left costal margin.
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