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3.0 Counseling for emergency contraception

3.1 GATHER approach

At the time of prescribing EC, the provider should follow the GATHER approach for counseling15. Ensuring confidentiality and privacy is crucial for all counseling sessions.

G - Greet - Greet the client. She should feel welcome. Build a rapport with client by greeting the client and making her feel comfortable.
A - Ask - Ask questions effectively in a friendly manner using words that client understands and listen patiently, without being judgmental. Identify client needs by asking relevant questions about personal, social, family, medical and reproductive health including reproductive tract infections, sexually-transmitted diseases, family planning goals and past/ current use of family planning methods.
T - Tell - Tell the relevant information to help her reach a decision and make an informed choice regarding method of EC and ongoing contraception method.
H - Help - Help the client to reach a decision and give other related information e.g. how to protect herself from STIs.
E - Explain - Explain about the method in detail including information that it protects against a ‘single act’, its efficacy, potential side-effects and the need for follow-up in case period is delayed by more than 7 days.
R - Return - Return for ongoing contraceptive method is advised and need for follow-up is emphasized if the period is delayed beyond 7 days.

 

3.2 Medical eligibility criteria

Table 6 Emergency Contraception Pill (ECP)
(including combined oral contraceptive pills and levonorgestrel contraceptive pills)16

 Condition Category New Evidence / Comments
Pregnancy N/A Although this method is not Indicated for a woman with a known or suspected pregnancy, there is no known harm to the woman, the course of her pregnancy, or the foetus if
ECPs are accidentally used.
Breastfeeding 1 The duration of use of ECPs is less than that of regular use
of COCs or POPs and thus would be expected to have less
clinical impact.

History of ectopic Pregnancy

1  
History of severe cardiovascular
complications
(Ischaemic heart disease, cerebrovascular attack, or other
thromboembolic conditions)
2 The duration of use of ECPs is less than that of regular use of COCs or POPs and thus would be expected to have less clinical impact.

Angina pectoris
2 The duration of use of ECPs is less than that of regular use of
COCs or POPs and thus would be expected to have less
clinical impact.
Migraine 2 The duration of use of ECPs is less than that of regular use of
COCs or POPs and thus would be expected to have less
clinical impact.
Severe liver disease
(including jaundice)
2 The duration of use of ECPs is less than that of regular use of
COCs or POPs and thus would be expected to have less
clinical impact.
Repeated ECP use Rape 1 Recurrent ECP use is an indication that the woman requires
further counseling on other contraceptive options. Frequently
-repeated ECP use may be harmful for women with
conditions classified as 2,3 or 4 for COC, CIC or POC use.
Rape 1 There are no restrictions for use of ECPs in case of rape.

 

3.3 Contraindications and precautions

There is no known medical contraindication to use of LNG as emergency contraception pill. ECP is not indicated in pregnancy.

WHO guidelines for medical eligibility criteria for ECP use put all conditions in category 1 or 2. Since the hormone exposure is for a very short duration, even when use of COC is contraindicated, ECP can be safely used. However, levonorgestrel only regimen is a better option in women with absolute contraindication to COC pill use.

Copper intra-uterine devices are most suitable for women in stable relationship but are contraindicated in some of the conditions such as:

unprotected sex in a non-monogamous relationship or with a newer partner

presence of active pelvic inflammatory disease or RTI

women at high risk for STI

immuno-compromised women

following sexual assault (the act is likely to put the woman to increased risk of STI)

nulliparous women

non-availability of trained personnel for insertion of CuT.

3.4 Follow-up

Women should be strongly advised to come for follow-up if the menses are delayed for more than one week from the expected date or if she has lower abdominal pain, heavy bleeding or is concerned and worried. If it is not practical to offer a designated follow-up appointment for everyone, the women should be advised to contact a family planning service provider in case there is

severe pain

abnormal bleeding or

subsequent period is unusually light, heavy, short or absent.

At the follow-up, details of the post-treatment menstrual period should be recorded to ensure that :

the treatment was successful. If pregnancy is suspected, a pelvic examination is recommended and a pregnancy test may sometimes be necessary. If pregnancy is diagnosed, it should be managed as any other unintended pregnancy.

the woman is using an effective method of contraception. Women provided with EC pills are counseled for use of regular contraception depending on individual preference. Women fitted with an IUD may wish to retain the device but should feel free to ask for its removal, if another method is preferred.

the woman is provided information on prevention of STIs and HIV/AIDS.

3.5 Initiating regular contraception after emergency conraception

Currently available methods of contraceptives should be explained. The client should be given an opportunity to choose a specific method, which can be started as per the following guidelines:

+ Barrier methods and spermicides

These can be initiated immediately following ECP use.

+ Oral contraceptives

The client may wait until the beginning of her menstrual cycle and then start a new pack according to the package instructions for the pill brand being used. She should be advised to use a barrier contraceptive method or abstain from
intercourse for the remainder of the current cycle. Alternatively, the client may start oral contraceptives on the day after she takes the ECP. She may begin a new pack of pills, or if she was using oral contraceptives before taking the ECP (i.e. the ECP was indicated because of missed pills), she may resume taking pills from the pack that she was previously using. She should use a barrier method for at least seven days after starting or restarting the oral contraceptive pills. She may have some irregular bleeding until the onset of menses.

+ Injectables

Initiate progestin-only injectables within 7 days after the beginning of the next menstrual cycle. Initiate combined injectables within 5 days after the beginning of the next menstrual cycle. The client should use a barrier contraceptive or abstain from intercourse for upto 7 days after she receives the injection.

+ Implants (Norplant)

Insert within 7 days after the beginning of next menstrual cycle. Use a back-up method or abstain from intercourse until the implants are inserted.

+ IUD

Insert during the next menstrual period. The client should use a barrier contraceptive or abstain from intercourse until the IUD is inserted.

If the client intends to use an IUD as a long term method and meets IUD screening criteria, emergency insertion of a copper-bearing IUD may be an alternative to ECP use.

+ Natural family planning

Natural family planning may be initiated after the normal menstrual period following ECP use. An alternative non-hormonal contraceptive method should be used in the interim period.

+ Female or male sterilization

Per form the operation only after informed consent can be ensured. It is not recommended that clients make this decision under the stressful conditions that often surround ECP use. Defer female sterilization until after the client’s menstrual period, to ensure that she is not pregnant. Use a back-up method or abstain from intercourse until the sterilization procedure is performed.


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