• Take/record client’s BP and weight
• Take/record client’s history (see p426)
• Use history checklist in Procedure Manual to assess suitability of chosen method
• Provide suitable method and ensure client understands fully how the method works and how any medicine for home use is to be taken
• Advise client on any potential problems with the chosen method and when to return immediately
• Manage any serious side-effects and complications
• Arrange for client to return for routine follow-up and for additional FP supplies
7.1 Condom (male) eg. Protector®, Engabu®
Indications
• Couples where one or both partners have HIV/AIDS even if using another FP method
• Couples needing an immediately effective method
• Couples waiting to rule out suspected pregnancy
• Protection against exposure to STIs including HIV/AIDS
• Where back-up method is needed when woman starting or forgotten to take oral contraceptives
• Where this is preferred FP method
Advantages
• Man plays role in FP
• Also protects against STI and HIV infection
Disadvantages
• Some men may have difficulty maintaining an erection with condom on
• May cause insensitivity of the penis
• Occasional sensitivity to latex or lubricants
Management
HC2
Ensure client understands correct use, storage and disposal
Supply at least 40 condoms
Advise client to return for more before they are finished
7.2 Condom (female) eg. Femidom®, Care®
A soft plastic prelubricated sheath with an inner and outer ring which is inserted into the vagina before intercourse
Indications
• As for 7.1 Condoms (male) above
• Women whose partners will not user the male condom
• Where there is allergy or sensitivity to condom latex
Advantages
• Woman plays active role in FP
• Can be inserted before intercourse and so does not interrupt sexual spontaneity
• Not dependent on male erection & does not require immediate withdrawal after ejaculation
• Protects against STI and HIV infection
• No special storage required
Disadvantages
• Requires special training and practice to use correctly
• New product with limited public awareness
Management
HC2
Ensure client understands correct use, storage and disposal
Supply at least 40 female condoms
Advise client to return for more before they are finished
7.3 Combined oral contraceptive pill (COC) eg. Lo-femenal®, Microgynon®, Eugynon®
Contains an oestrogen + a progestogen, the types and quantities of which may vary in different preparations
Indications
• Women <35 needing highly effective FP method
• Non-breastfeeding clients or breastfeeding clients after 6 months postpartum
• Clients with dysmenorrhoea
• Clients with heavy periods or ovulation pain
• Clients concerned by irregular menstrual cycles
Contraindications
• Diastolic BP >100
• Cardiac disease
• Thromboembolic disease
• Active liver disease
• Within 2 weeks of childbirth
• When major surgery planned within 4 weeks
• Unexplained abnormal vaginal bleeding
• Known/suspected cervical cancer
• Undiagnosed breast lumps or breast cancer
• Pregnancy (known or suspected)
Risk factors:
If any 2 of the following, recommend progrestogen-only or non-homonal FP method:
• Smoking (especially if >10 cigarettes/day)
• Age >35 years
• Diabetes
Disadvantages & common side-effects:
• Spotting, nausea & vomiting within first few months
• May cause headaches, weight gain
• Effectiveness dependent on regular daily dosage
• Suppresses lactation
• Drug interactions reduce effectiveness including:
- drugs which increase hepatic enzyme activity, eg. rifampicin (especially), carbamazepine, griseofulvin, nevirapine, phenytoin, phenobarbitone
- short courses of some broad spectrum antibiotics, eg. ampicillin, amoxicillin, doxycycline
An additional FP method must be used during course of treatment and for at least 7 days after completion
Complications & warning signs:
• Severe headaches + blurred vision
• Depression
• Acute severe abdominal pain
• Chest pain + dyspnoea
• Swelling or pain in calf muscle
Management:
HC2
Give 3 cycles of COC and explain carefully:
- how to take the tablets
- that strict compliance is essential
- what to do if doses are missed or there are side-effects or warning signs
If starting COC within 5 days of period:
Supply and show how to use back-up FP method
Ask client to return when <7 tablets remain in last cycle
7.4 Progestogen-only pill (POP) eg. Ovretteâ (also known as the ‘mini-pill’)
Indications:
• Breastfeeding clients after 3 weeks postpartum
• Women who cannot take COC but prefer to use pills
• Women >40 years
Contraindications:
• Breast or genital malignancy (known or suspected)
• Pregnancy (known or suspected)
• Undiagnosed vaginal bleeding
Disadvantages & common side-effects:
• Spotting, amenorrhoea
• Unpredictable irregular periods
• Not as effective as COC
• Drug interactions: effectiveness reduced by drugs which increase hepatic enzyme activity (as for COC above, p431)
Management:
HC2
Give 3 cycles of POP: explain carefully how to take the tablets and what to do if doses are missed or there are side-effects
Supply and show how to use back-up FP method for first 14 days of first packet, eg. condoms or abstention from sex
Ask client to return 11 weeks after start of using POP - use the last pill packet to show when this will be
7.5 Injectable progestogen-only contraceptive
A slowly absorbed depot IM injection which provides contraceptive protection for 3 months (eg. Depo-Proveraâ)
Indications:
• Proven fertile women requiring long-term contraception
• Breastfeeding postpartum women
• Known/suspected HIV +ve women who need an effective FP method
• Women with sickle-cell disease
• Women who can’t use COC due to oestrogen content
• Women who don’t want more children but do not (yet) want voluntary surgical contraception
• Women awaiting surgical contraception
Contraindications:
• As for POP above plus
• Women without proven fertility unless have HIV/AIDS
Disadvantages & common side-effects:
• Amenorrhoea - often after 1st injection & after 9-12 months of use
• Can cause heavy prolonged vaginal bleeding during 1st 1-2 months after injection
• Weight gain
• Loss of libido, delayed return to fertility - up to 10 months after stopping injection
Complications & warning signs:
• Headaches
• Heavy vaginal bleeding
• Severe abdominal pain
• Excessive weight gain
Management:
HC3
medroxyprogesterone acetate depot injection 150mg deep IM into deltoid or buttock muscle - do not rub the area as this increases absorption and shortens depot effect
If given after day 1-7 of menstrual cycle:
Advise client:
- to abstain from sex or use a back-up FP method, eg. condoms, for the first 7 days after injection
- to return for the next dose on a specific date 12 weeks after the injection (if client returns >2-4 weeks later than the date advised, rule out pregnancy before giving the next dose)
- on likely side-effects
- to return promptly if there are any warning signs
7.6 Intrauterine device (IUD)
Easily reversible long-term non-hormonal FP method effective for up to 8 years which can be inserted as soon as 6 weeks postpartum (eg. Copper T380Aâ)
Indications
• Women in stable monogamous relationships wanting long-term contraception
• Breastfeeding mothers
• When hormonal FP methods are contraindicated
Contraindications
• Pregnancy (known or suspected)
• PID or history of this in last 3 months
• Undiagnosed abnormal uterine bleeding
• Women at risk of STIs (including HIV), eg. women with, or whose partners have, multiple sexual partners)
• Reduced immunity, eg. diabetes mellitus, HIV/AIDS
• Known or suspected cancer of pelvic organs
• Severe anaemia or heavy menstrual bleeding
Disadvantages & common side-effects
• Mild cramps during first 3-5 days after insertion
• Longer & heavier menstrual blood loss in 1st 3 months
• Vaginal discharge in first 3 months
• Spotting or bleeding between periods
• Increased cramping pains during menstruation
Complications & warning signs
• Lower abdominal pain
• Foul-smelling vaginal discharge
• Missed period
• Displaced IUD/missing strings
• Prolonged vaginal bleeding
• PID
Management
HC3
Insert the IUD closely following recommended procedures and explaining to the client as each step is undertaken
Carefully explain possible side-effects and what to do if they should arise
Advise client:
- to abstain from intercourse for 7 days after insertion
- to avoid douching
- not to have >1 sexual partner
- to check each sanitary pad before disposal to ensure the IUD has not been expelled, in which case to use an alternative FP method and return to the clinic
- how to check after menstruation is finished to ensure the IUD is still in place
- to report to the clinic promptly if: late period or pregnancy, abdominal pain during intercourse, exposure to STI, feeling unwell with chills/fever, shorter/longer/missing strings, feeling hard part of IUD in vagina or at cervix
- to use condoms if any risk of STIs including HIV
7.7 Progestogen-only sub-dermal implant
Flexible progestogen-releasing plastic rods surgically inserted under the skin of the woman’s upper arm which provide contraceptive protection for 5 years (eg. Norplantâ)
Indications
• Women wanting long-term highly-effective but not permanent contraception where alternative FP methods are inappropriate or undesirable
Contraindications
• As for POP (see p432)
Advantages
• Highly effective (1-3% failure rate)
• No delay in return to fertility after removal
• Long-acting
• Low user-responsibility
Disadvantages & common side-effects
• Irregular bleeding, spotting or heavy bleeding in first few months; amenorrhoea
• Possibility of local infection at insertion site
• Must be surgically inserted & removed by specially trained service provider
• May not be as effective in women >70kg
Warning signs (require urgent return to clinic)
• Heavy vaginal bleeding
• Severe chest pain
• Pus, bleeding or pain at insertion site on arm
Management
HC4
Insert the implant subdermally under the skin of the upper arm following recommended procedures
Carefully explain warning signs and need to return if they occur
Advise client to return:
- after 2 weeks: to examine implant site
- after 3 months: for first routine follow-up
- annually until implant removed: for routine follow-up
7.8 Natural FP: Cervical mucus method (CMM)
CMM is a fertility awareness-based method of FP which relies on the change in the nature of vaginal mucus during the menstrual cycle in order to detect the fertile time. During this time, the couple avoids pregnancy by changing sexual behaviour as follows:
• Abstaining from sexual intercourse: avoiding vaginal sex completely (also called periodic abstinence)
• Using withdrawal: taking the penis out of the vagina before ejaculation (also called coitus interruptus)
• Using barriers methods: eg. condoms
Guidance on correct use of the method is only available at centres with specially trained service providers
Management
HC4
Ensure client understands how the method works
Explain how to distinguish the different types of mucus
Show client how to complete the CMM chart
Carry out a practice/trial period of at least 3 cycles
Confirm that the chart is correctly filled
Advise client:
- to always use condoms as well as CMM if there is any risk of exposure to STIs/HIV
- to return on a specific follow-up date after one menstrual cycle
7.9 Natural FP: Lactational amenorrhoea method (LAM)
LAM relies on the suppression of ovulation through exclusive breastfeeding as a means of contraception. Guidance on correct use of the method is only available at centres with trained service providers
Management
HC4
Ensure client understands how the method works
Explain to client that:
- she must breastfeed her child on demand, on both breasts at least 10 times during day and night
- she must not give the child any solid foods or other liquids apart from breastmilk
Advise the client that LAM will no longer be an effective FP method:
- if the baby does not feed regularly on demand or
- if menstruation resumes and that she will then need to use another FP method
Advise the client:
- to use condoms as well as LAM if there is any risk of exposure to STIs/HIV
- to return after 3 months for a routine follow-up or earlier if she has any problem or wants to change to another FP method
7.10 Voluntary surgical contraception (VSC) for men: Vasectomy
This permanent FP method involves a minor operation carried out under local anaesthetic to cut and tie the two sperm-carrying tubes (vas deferens). It is only available at centres with specially trained service providers
Indications
• Fully aware, counselled clients who have voluntarily signed the consent form
• Males of couples:
- who have definitely reached their desired family size and want no more children
- where the woman cannot risk another pregnancy due to age or health problems
Management
HC4
Ensure client understands how the method works and that it is permanent, not reversible and highly effective
Explain to client that:
- vasectomy is not castration and sexual ability/activity is not affected
- the procedure is not immediately effective and that the client will need to use a condom for at least 15 ejaculations after the operation
After the operation, advise client:
- on wound care
- to return for routine follow-up after 7 days or earlier if there is fever, excessive swelling, pus or tenderness at the site of operation
7.11 Voluntary surgical contraception (VSC) for women: Tubal ligation
This permanent FP method involves a minor 15 minute operation carried out under local anaesthetic to cut and tie the two egg-carrying fallopian tubes. It is only available at centres with specially trained service providers
Indications
• As for 7.10 vasectomy (above) but for females
Management
HC4
Ensure client understands how the method works and that it is:
- permanent and irreversible
- highly & immediately effective
Explain to client that:
- there may be some discomfort/pain over the small wound for a few days
Advise client:
- on wound care
- to use condoms if there is any risk of exposure to STIs/HIV
- to return after 7 days for routine follow-up or earlier if there is fever, excessive swelling, pus or tenderness at the site of operation
