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. |
