5.4: Barrier Methods of Contraception

Learning Objectives

By the end of this section, you will be able to:

• Compare and contrast the risks, benefits, advantages, and disadvantages of barrier contraception methods
• Discuss population-focused use of barrier contraception methods

Preventing pregnancy using a barrier method blocks the passage of sperm through the reproductive tract, which prevents the sperm from reaching the egg for fertilization. Barrier methods of contraception are useful for those who cannot use hormonal contraception due to current or previous medical history or those not wanting hormonal birth control. Barrier methods offer a cost-effective and safe way to prevent pregnancy without having to meet with a health-care provider. These methods can be utilized as short-term options or as “backup” methods. Barrier methods include external and internal condoms, diaphragm, cervical cap, and the cervical sponge. Chemical methods can be used with barrier methods or as stand-alone contraception. These include contraceptive foam, suppositories, film, and creams.

Barrier and Chemical Methods of Contraception

Barrier method contraceptives are inserted or placed prior to acts of intercourse and in some cases can be left in place for hours after. They can be used in conjunction with nonoxynol-9, a spermicide approved for use in the United States. A spermicide is a foam, gel, suppository, film, or cream inserted into the vagina that can be used alone or can act as an adjunct therapy when used with barrier methods; it destroys sperm by disrupting the cell membrane (Xu et al., 2022). Before insertion or placement of any barrier method of contraception, the person should wash their hands with soap and water to prevent the transmission of any bacteria.

External Condom

External condoms are placed on a penis or sex toy, providing both contraception and STI protection. They have a 98 percent perfect use effectiveness rate compared to an 82 percent typical use effectiveness rate (Hatcher, 2018). For external condoms to be effective in preventing pregnancy and STIs, the person must use a new condom from start to finish during every sexual act or penetration. Condoms can be purchased in drug stores, grocery stores, and online and are even available for free in some clinics, bars, and clubs. External condoms are available in many different shapes, sizes, flavors, materials, and textures, depending on the individual’s and couple’s preference. This method of contraception is extremely cost-effective, ranging from free to approximately one dollar per condom. If a person is allergic to latex, condom options are available in lambskin, polyurethane, and polyisoprene (Hatcher, 2018).

Nurses can provide education to patients not to use oil-based lubricant with external condoms, as oil breaks down the latex, making the condom ineffective. Nurses also educate about the proper way to place condoms to improve their effectiveness. The person using the condom will need to squeeze all the air out of its reservoir tip to ensure that it is completely collapsed (Figure 5.3). Next, the person places the condom on the tip of the erect penis, rolling the condom down toward the base of the penis. When the penis is withdrawn from the vagina, the used condom should be removed immediately and discarded. Every time intercourse is desired, a new condom must be used. The nurse must educate the condom-using person that care should be taken to keep the condom on the penis during withdrawal from the vagina, ensuring no semen is spilled (CDC, 2022).

Figure 5.3 Placing an External Condom Nursing education about placing an external condom should be very specific. Patients need to know how to remove air from the reservoir tip, avoid spillage of semen, and dispose of external condoms appropriately. (credit: “How To Put On and Take Off a Male (External) Condom” by Center for Disease Control and Prevention/cdc.gov, Public Domain)

Internal Condom

An internal condom is a soft polyurethane sheath that is inserted into the vagina for contraception and STI protection. It contains a closed end that is inside the vagina and an open end with a larger ring that remains outside the vagina. Internal condoms work similarly to the external condom, except they are worn internally in the vagina. Both types of condoms keep sperm inside the condom and out of the vagina. Internal condoms have a perfect use rate of 95 percent, and a typical use rate of 79 percent (Hatcher, 2018). Like the external condom, a new internal condom needs to be used for every act of penetration. These condoms can be purchased at drug or convenience stores, online, or from clinics or health departments. While these condoms are not as cost-effective as external condoms, they are still minimally expensive at a price of around $2–$3 per condom (Planned Parenthood, n.d.-a).

The benefits of using this type of contraception are that it offers greater protection from STIs because the external ring provides a barrier protection to the labia, it requires no health-care provider visits, it can be used with oil-based lubricant, and it is made of non-latex nitrile and polyurethane (CDC, 2022; Hatcher, 2018). Placement of the internal condom takes practice. The nurse educates the person to squeeze the sides of the closed-end ring together firmly and position themselves as though they are inserting a tampon. They then slide the internal condom into the vagina as far as it will go, aiming for the cervix. The external ring lies outside the vagina, partially covering the external genitalia (CDC, 2022). Figure 5.4 demonstrates insertion of the internal condom.

Figure 5.4 Placing an Internal Condom The person placing the internal condom uses their fingers to gently insert the closed-ring end of the internal condom into the vagina as far as possible, with the external ring left outside the vagina covering the labia. (credit: “The Right Way To Use A Female (Internal) Condom” by Center for Disease Control and Prevention/cdc.gov, Public Domain)

Life-Stage Context

Discussing Condoms with Teens

Exploration of sexual activity usually begins in the teen years. Nurses must know how to guide this special population. Nurses can discuss many topics, from sexuality to preventing STIs. Using direct and open language without judgment allows for the best educational opportunity with adolescents. Condoms come in both an external form, to be placed over a penis, and an internal form, to be used within a vagina or anus. They are not hard to use, but if you have never used one, it is worth talking about the differences and watching how they are properly placed. Follow this link to Planned Parenthood for teen-directed sex education.

Noncontraceptive Uses of Condoms

In addition to their contraceptive function, condoms offer protection from STIs. They do not provide 100 percent protection, but they are the most effective method for STI prevention. Condoms help prevent STIs by decreasing exposure to bodily fluids (WHO, 2023b). They cannot protect against infections occurring outside the coverage of the condom, such as genital warts or herpes (WHO, 2023b).

Contraceptive Gel

Contraceptive gel (Phexxi) contains lactic acid, citric acid, and potassium bitartrate and provides contraception by changing the pH of the vagina to a more acidic environment that inhibits sperm’s motility and ability to swim to the fallopian tube to fertilize an ovum (Steinberg & Lynch, 2021). Contraceptive gel is inserted into the vagina through an applicator immediately before or up to 1 hour before coitus. The ideal use effectiveness is 95.9 percent, with typical use efficacy of 89 percent (Steinberg & Lynch, 2021). Contraceptive gel, available by prescription only, is used by persons desiring nonhormonal contraception.

Diaphragm

A diaphragm is a dome-shaped silicone cup that is inserted into the vagina to cover the cervix, preventing sperm from reaching the egg (Figure 5.5). To work effectively, spermicide must be used with the diaphragm for each sexual penetration. Perfect use effectiveness for the diaphragm is 92 percent to 96 percent, and typical use effectiveness is 84 percent (Diaphragm, 2021). A diaphragm is a good option for people seeking a nonhormonal contraceptive method.

Figure 5.5 The Diaphragm The diaphragm is a dome-shaped silicone contraceptive barrier that is placed in the vagina and fits over the cervix, blocking sperm from reaching the egg. The diaphragm can be washed with mild soap and water, left to air dry, and placed back in its container until the next time it is needed. (CC BY 4.0; Rice University & OpenStax)

Diaphragms can be placed hours before sex with minimal side effects and left in for up to 24 hours. After 24 hours, the patient is at risk for urinary tract infections and toxic shock syndrome. Spermicide is used with the diaphragm, and morel spermicide should be added with each sexual penetration or if the diaphragm is in place longer than 3 hours (National Health Service, 2020). The diaphragm needs to be left in place for 6 to 8 hours. If removed earlier, the risk of pregnancy increases. Additionally, the patient needs to be comfortable with their body and with inserting fingers inside the vagina to place and remove the diaphragm. If they are not comfortable with that, this is likely not the right contraceptive method for them. The nurse also needs to assess the patient’s willingness to always carry the diaphragm and spermicide with them. People must see a clinician for sizing and proper fitting of a diaphragm.

Insertion of the diaphragm is much like insertion of the internal condom. Before inserting the diaphragm, the patient should inspect it for holes or imperfections that would allow semen to pass through. Next, a teaspoon of spermicide should be added to the inner part of the diaphragm. The patient then pinches the diaphragm together, being careful not to spill the spermicide, and inserts the diaphragm into the vagina, covering the cervix. After 6 hours or up to 24 hours, the patient puts an index finger inside the vagina, hooks the top rim of the diaphragm, and removes it. Proper care of the diaphragm includes washing with warm water and mild soap and allowing it to air dry. Persons should not use oil-based lubricants or vaginal medications while using the diaphragm, as these can alter its integrity. Periodically, persons should assess for perforations or loss of integrity by filling the diaphragm with water. Consider use of emergency contraception if the diaphragm is dislodged during sex or less than 6 hours post sex. It is recommended the person be refitted for a diaphragm after each pregnancy and a weight gain or loss of more than 7 pounds (National Health Service, 2020).

Link to Learning

Bedsider is an online birth control support network for women ages 18 to 29. This website has information written in layperson’s terms. The nurse can log in to this website in the office while providing education to their patient. Then, this link can be provided on discharge papers to reinforce patient education when they leave.

Cervical Cap

Although similar to a diaphragm, a cervical cap is smaller and made to be a barrier only covering the cervix, blocking sperm from entering and fertilizing the egg (Figure 5.6). A visit to a health-care provider is required for correct fitting. Cervical caps are available in three sizes: small for nulliparous persons, medium for persons having had a cesarean birth or miscarriage, and large for persons who have had a full-term vaginal birth (Hatcher, 2018). As with the diaphragm, spermicide should be used in conjunction with the cervical cap to increase its effectiveness. The cervical cap is more effective for persons who have never had a vaginal birth. According to the National Health Service (2022), perfect use effectiveness for the cervical cap is 92 percent to 96 percent. According to the CDC (2023d), typical use effectiveness for the cervical cap is 83 percent.

Figure 5.6 The Cervical Cap The FemCap cervical cap is a firm piece of silicone that is inserted into the vagina and placed directly over the cervix. The cap is measured and fitted to the person using it to create a firm seal over the cervix to ensure no sperm reaches the uterus. (CC BY 4.0; Rice University & OpenStax)

The nurse should assess the person and provide education similar to that for the diaphragm. The benefit of the cervical cap over the diaphragm is that the cervical cap can be left in place for up to 48 hours (National Health Service, 2020). The cap is placed directly over the cervix instead of just inside the vagina. The cap creates suction on the cervix, and the person should check that the entire cervix is covered. To remove the cap, the dome of the cap is pressed to release the suction and remove the cap from the vagina. After use, the patient should wash the cervical cap with soap and water and allow it to dry.

Contraceptive Sponge

According to the Food and Drug Administration, the contraceptive sponge is a small, round sponge impregnated with 1,000 mg of spermicide called nonoxynol-9 (Today vaginal contraceptive-nonoxynol-9 sponge, 2018) (Figure 5.7). This contraceptive method is inserted into the vagina immediately before intercourse. The mechanism of action is three-fold: The sponge releases spermicide continuously while inserted in the vagina, acts as a barrier to the cervix when inserted, and traps and absorbs sperm. To use, the person wets the sponge with water, squeezing to make suds; folds the sponge with the dimple inside and the string on the outside; then inserts it into the vagina as deep as possible (Today vaginal contraceptive-nonoxynol-9 sponge, 2018). The contraceptive sponge works best for people who have not given birth. With perfect use, the sponge is 91 percent effective for nulliparous persons and 80 percent effective for parous persons; typical use is 88 percent for nulliparous persons and 76 percent for parous persons (Hatcher, 2018).

Figure 5.7 The Contraceptive Sponge The contraceptive sponge is a disposable circular sponge made of polyurethane foam that contains nonoxynol-9 spermicide. The spermicide is continuously released within the vagina while the sponge is in place, killing sperm while the sponge acts as a barrier to the cervix. (CC BY 4.0; Rice University & OpenStax)

Contraceptive sponges are effective for 24 hours but can remain in the vagina for up to 30 hours (Today vaginal contraceptive-nonoxynol-9 sponge). After 30 hours, the risk for vaginal infection and toxic shock syndrome increases (Today vaginal contraceptive-nonoxynol-9 sponge, 2018). Like the diaphragm, the sponge cannot be removed until 6 hours after the last act of intercourse; however, the sponge can be used with multiple acts of intercourse. The sponge cannot be reused and should be discarded after use. Sponges also require the patient to be comfortable with their body because they will need to insert fingers into the vagina to place the sponge and remove it.

Table 5.6 summarizes the information about barrier contraceptives presented in this chapter.

Method	Pros	Cons	Perfect Use Efficacy (% successful pregnancy prevention)	Typical Use Efficacy (% successful pregnancy prevention)
External condom	Cost-effective, protects against STIs, nonhormonal	Must be used with every sexual penetration	98	82
Internal condom	Cost-effective, protects against STIs, protects the labia from STI exposure, non-latex, nonhormonal	More difficult to place than external condom; must be used with every sexual penetration	95	79
Diaphragm with spermicide	Reusable, nonhormonal	Requires a health-care provider visit and a prescription, must fit properly and be in place both before and after intercourse for a set amount of time	94	83
Cervical cap with spermicide	Reusable, nonhormonal	Requires a health-care provider visit and a prescription, must fit properly, can be left in place for 48 hours	95	83
Contraceptive sponge	Nonhormonal; does not require a health-care provider visit or prescription, can be left in for 30 hours	Not as effective for parous persons and can be associated with infections (Cleveland Clinical Professionals, 2022)	Nulliparous: 91 Parous: 80	Nulliparous: 88 Parous: 76

Table 5.6 Comparing and Contrasting Barrier Methods of Contraception (CDC, 2022; Hatcher, 2018)

Populations for Whom Barrier Methods Are the Best Contraception

Some populations benefit from using barrier methods because they are safer than using hormonal contraception, cheaper than some other methods, and do not require a prescription. They can be a good choice for those in committed monogamous relationships in which the partner is supportive of the method of contraception even though it takes time and adherence to placement and removal. Breast-feeding persons are good candidates for barrier methods because estrogen-containing contraceptives can decrease milk supply. Persons who smoke, especially those over 35 years, are at increased risk for blood clots and should not use estrogen-containing contraceptives. Persons who are considering pregnancy can use a barrier method and not affect their menstrual cycle or ability to conceive. They are a good short-term contraceptive that has no impact on return of normal menstrual cycles.

Populations for Whom Barrier Methods Are Not the Best Primary Contraception

For several reasons, a barrier protection may not be the right contraceptive choice. To effectively use a barrier method as primary contraception, the person should fully understand how to use the product, including insertion, placement, and removal. Certain populations may not find barrier protection the best choice due to their age, the ways in which they explore their sexuality, and their sexual health needs.

Adolescents

Adolescents ages 10 to 19 who are exploring their sexual relationships may need more contraceptive management than a barrier method alone. The preceding barrier contraceptive devices discussed are great adjunctive choices to add to their contraceptive management plans, but most of the barrier methods covered in this chapter have lower effectiveness rates and require more responsibility for use. Using a barrier method as a primary method of contraception comes with the responsibility of remembering to use it every time from start to finish, following the education that was provided by the nurse regarding use of spermicide, and removing the barrier within the correct time frame to avoid pregnancy, infection, or toxic shock syndrome. Toxic shock syndrome is an illness that causes fever, hypotension, rash, and organ damage that was originally associated with the use of highly absorbent tampons; the organism causing the illness is most often Staphylococcus aureus or Streptococcus pyogenes (Ross & Shoff, 2023). Persons with a history of toxic shock syndrome should not use diaphragms, cervical caps, or the contraceptive sponge. It is recommended that adolescents be advised to use contraceptive methods that have high efficacy and high adherence rates, which barrier methods lack (ACOG, 2022a). Through shared decision making, the nurse can assist the adolescent to choose a highly effective method of contraception used in conjunction with a barrier method to provide protection against STIs.

LGBTQIA+ Patients

For patients who are LGBTQIA+, the barrier method may be appropriate for some, but not for others. For transgender patients, this may be a perfect method of contraception for those who cannot or do not want to choose hormonal methods that may interfere with hormone therapy. Others in the LGBTQIA+ population may prefer the barrier method because it is convenient, cheap, easy, and effective. Lesbians typically do not use barrier methods of contraception unless one of them is transgender. As with any patient, the nurse should complete a full sexual history with LGBTQIA+ patients to identify contraceptive and STI protection needs.

Life-Stage Context

Teaching Consent in Adolescents

Young people are learning about their bodies, their sexuality, and their sexual boundaries. Adolescents must be taught what touch is and is not acceptable. This a learning process that can be aided by parents, counselors, and nurses. At times, a person is unaware of a boundary until it is passed and does not feel appropriate. Adolescents must be taught they have a right to say “stop” or “no” when someone crosses that boundary.

During clinic visits, it is important to screen all patients for intimate partner violence and unwanted sex and to discuss consent and boundaries.

The best way to address consent is to define what consent is: Consent is agreement. If something sexual occurred that the patient did not want to occur, then that is sexual assault. After defining the topic, leave space for the patient to initiate conversation or ask questions. The most common questions that teens may have are: What if I didn’t say no? What if I’m in a relationship with this person? What if I had been drinking? What if I changed my mind? What does it mean if there wasn’t any violence?

How the patient perceives the experience is entirely their own perception and story. Allow them to tell their story and connect them to supportive resources.

(Bedsider, 2023)