Post coital contraception

Background

During the week these patients can be referred to their local GP or pharmacist. Please remember that particularly young teenagers may feel very scared, vulnerable and embarrassed. It may have taken all their courage to come to see you. Therefore, take them seriously. With young teenagers it is very important to talk about family planning and offer sexual health advice. Very often they have not got a clue what they are doing! All patients need sensitive and compassionate counselling. Special categories may need additional or specialised help, e.g. those after rape, incest, first time sex and people with learning difficulties.

Assessment & counselling

• Take a careful menstrual history
• Note time of unprotected intercourse and time this in relation to the day of the cycle
• Find out if there have been any other unprotected intercourse earlier in the cycle
• Enquire about the method of contraception that has been used. Stress the need for total honesty here
• Assess and discuss the risk of pregnancy - is any treatment indicated
  • One mid-cycle exposure - risk - 10% to 30% at other times less than 10%
  • Significant risk days 7 to 17 over 28 day cycle (must be correct for cycle length)
  • Remember that the decision to treat depends on many circumstances including the woman's level of anxiety
• Check the patient's medical history relevant to emergency contraception, e.g. personal history of thromboembolism, history of focal migraines, history of recent sexual transmitted disease/infection and concurrent medication. In general examination check the blood pressure
• Discuss family planning in general. This is particularly important in young people. Treat them as equals doing an adult activity. Do not talk down to them. You may need to promise confidentiality from GP and/or parents in very young patients in order to get their trust
• Explain precisely about the morning after pill, including the instruction of when it should be taken
• Emphasis that if they do not have a period they must have a pregnancy test
• Ensure that they organise a follow-up visit either with the GP or Family Planning Clinic
• If they are very young and they have come with a friend and not told their parents, encourage them at some point to do so. It is worth explaining that should the morning after pill fail and they need to consider an abortion, they will need a lot of support from people who trust them. Honesty is therefore the best policy. Explain that we MUST inform their GP of the prescription given and encourage them to attend their GP
• Prescribe the morning after pill
• Finally ensure that they have leaflets about emergency contraception and family planning to take away with them

Confidentiality

Confidentially may only be broken when the health, safety or welfare of the patient or others would otherwise be at a grave risk. If a request for contraception is made by a person under 16 years, confidentiality should be respected whether contraception is prescribed or not. 

If a healthcare professional is convinced that it is essential, her or she may disclose relevant information to an appropriate person or authority. In such cases, consent should be sought before any information is disclosed.

Consent

There may be rare cases when a healthcare professional believes that a young person is being exploited or abused or is in some danger of so being. In such cases child protection protocols should be followed.

Morning after pill

Levonelle - 2 = ( levonorgestrel 750 mcg 2 tablets)

MAP Contraindications

You should NOT take Levonelle 2 if

• possibility of established pregnancy (any unprotected sex within current cycle and over 72 hours ago)
• allergy to levonorgestrel
• significant problems with progestagen-only pill in past
• acute porphyria
• history of breast cancer
• severe hypertension
• complicated diabetes
• ischaemic heart disease
• stroke
• any new long-term medication
• under 16 and nurse not satisfied she is "Gillick competent"
• last saw clinic doctor over 2 years ago, or no valid prescription

MAP Treatment

750mg should be started within 72 hrs of unprotected sex and repeated after 12 hours.

Maximum of once per menstrual cycle

Follow-up : to be arranged if no / light menstrual period follows treatment.

Advise to see a doctor if severe abdominal pain occurs (possible ectopic)