2. Definition
The contraceptive device provided to woman to
prevent unintended pregnancy following an
unprotected act of sexual intercourse is known as
emergency contraception.
The term is also preferred over post coital
contraceptives because it also implies that the
method is not for regular use.
3. Methods of emergency contraception
There are two main methods mainly available in
Nepal.
1.Oral contraceptive pills , both combined pills and
progestin only pills.
2.Intrauterine devices ;I e IUD
Several method can also be used within as short
time after unprotected intercourse . They are often
called ‘Morning after Pills’ .It is also appropriate to call
them secondary contraception.
5. Mechanism of action
The precise mode of action of emergency contraceptive
method is uncertain and may be related to the type of
emergency contraceptive and the time .It is used in a
woman’s menstrual cycle . It is thought to prevent
ovulation , fertilization and implantation . It cannot
disrupt an implanted pregnancy.
6. Indications
Contraceptive accident or misuse
Condom ruptures, slippage or misuse
Failed coitus interrupts
IUD expulsion
Unprotected intercourse prior to the effective time of
vasectomy
Miscalculation of the periodic abstinence method
Ready access is important because of the short time
period after unprotected intercourse during which
emergency contraception is likely to be effective.
7. Method of Emergency contraception
Method Timing Remarks Client Instruction
COCs (the
Yuzpe
method)
Should be
taken within 72
hours of
unprotected
sex and
repeated after
12 hours
o Effective (2%
become pregnant)
o Side effects
Nausea
Vomiting
Breast tenderness,
headache , dizziness
Irregular uterine
bleeding , spotting,
delayed menstrual
cycle.
If pregnancy is not
prevented , counsel
client for ANC
COCs low dose(30-
33mgEE)
Take 4 tablets within
72hours of
unprotected sex
12hours later
Take 4 more tablets
Total= 8 tablets
8. Cont….
Progestin
only pills
(POPs)
Should be
taken within
72 hours of
unprotected
sex and
repeated after
12 hours
Same side effect as with COCs
but significantly less severe
and nausea/vomiting is
minimal
-if pregnancy is not prevented
,counsel client for ANC.
POPs (750 mcg or 0.75 mg
LNG e. g, prostinor)
Take 1 tablet within 72
hours
12 hours later
Take 1 more tablet (Total
dose=1500 mcg of 1.5 mg
of levenorgestrel)
OR
POPs (0.075 mg
Norgestrel e.g, ovrette)
Take 20 tablets within 72
hours
12 hours later
Take 20 more tablets
(Total dose=3 mg of
norgestrel)
9. Cont…..
IUDs Should be
inserted within 5
days of
unprotected
intercourse
o Very
effective less
than 1 %
pregnant
o Few side
effects
o Provide long
term
contraception
as well
o Failure
increases with
longer interval
between
unprotected
intercourse &
insertion
o May not be
advisable for
young
nulliparous
clients
Counsel client
about post
insertion
bleeding, help
her understand
how to
distinguish this
from a
menstrual
period
10. Management of Nausea &Vomiting
Because of the high dose of estrogen in COCs ,nausea is a
common side effect . If accompanied by vomiting within 72
hours ,the effectiveness of COCs when used for emergency
contraception may decreased.
To minimize nausea and vomiting , advice the clients to
take each dose with food/taking the first dose at bed time.
Anti emetics can be used prophylactically but routine is
not recommended.
If vomiting occurs within 2 hours of taking the first or the
second dose, the clients may repeat the dose or consider
administering the dose vaginally.
11. Follow up care
Clients should be counseled to expect a menses within
3-4 weeks. If they have not had a menses they should
return to the clinic and a pregnancy test should be
performed. If the result is positive ,they should receive
counseling and referral for antenatal care.
12. Intrauterine Contraceptive Device
(IUCD)
The intrauterine device (IUD)has become one of the
most widely used and safest methods of
contraception available to women. It is based on the
principles of introducing foreign body in the uterus.
The original device was first used in 1909 which was
made up of silkworm gut. The IUD T cu 380 A was
recently approved for 12 years. The copper T 380 A is
shaped like a ‘T’ and has a copper notch stem and the
arms, with a total exposed copper area of 380 square
mm. It has white string at its base, which extends
through the cervix so that the IUD can be removed.
15. Generation of IUD
First generation IUDs : Non-medicated or inert IUDs usually
made of polyethylene or polymers. E g. loops, spiral, coils
,rings e t c
Second generation IUDs: Comprise of copper in IUDs. It was
found that metallic copper had a strong anti-fertility effect. E
g. copper-7, copper T-200.
Newer devices – copper T -220c
Copper T -380
Multi load devices
Third generation IUDs: based on principle of release of a
hormone. The most widely used hormonal device is
progestesert , which is a ‘T’ shaped device filled with
progesterone. The hormone is released slowly at the rate of 65
mcg daily.
16. Mechanism of Action
The exact mechanism of action is still unclear. The
most studies have suggested that they are:
Prevent implantation of developing embryo in the
uterus by acting foreign body.
Decrease the number of sperm reaching the fallopian
tube and inactivating them.
Ionized copper has local anti-fertility effect by
preventing implantation through enzymatic
interference.
Prevent fertilization.
17. Effectiveness
The effectiveness of IUDs is 99.2%. The failure rate is
only 0.1-2 H.W.Y.
*How soon after insertion of the IUD is effective
The IUD is effective immediately and the client can
have sex as soon as she wants .She should be told
there might be some bleeding ,spotting or cramping
during the first few weeks after insertion .
*Return of fertility.
18. Indication
Has one or more children
Is breast feeding and need contraception
Has no history of pelvic diseases
Has successfully used an IUD in the past
Is at low risk of contracting a sexually transmitted
diseases(STD)
Post abortion clients who do not have evidence of
infection
Prefers a method who provides highly effective, long
term contraception but does not want a permanent
method at this time.
19. Timing of insertion
It can be inserted at any time during the menstrual
cycle , if it is certain that the woman is not pregnant
.The best time to insert the device is at the end of the
menstrual cycle or 5th to 7th days of the menstrual
cycle.
Post abortion :Immediately for first trimester
abortion and provided there is no evidence of
infection . For 2nd trimester abortion ,after the
involution of uterus (6-8weeks)
21. Side effects &its management
Amenorrhea Provide counseling and advice the
client
Irregular bleeding with or without s/s of
pregnancy
Refer to appropriate for complete
evaluation
Cramping • Treat accordingly and remove if
indicated
• If no cause is found replace with new
IUD
Missing string Check for pregnancy and replace with
other
Vaginal discharge Obtain accurate history which facilitates
diagnosis and treatment
22. Contraindications
Absolute
Suspected pregnancy
Pelvic inflammatory diseases
Undiagnosed vaginal bleeding
Cancer of cervix , uterus and pelvic tumor
• Strong relative
Pelvic infection risk factors
Post partum endometriosis
Acute cervicitis
Recurrent pelvic infections
Multiple sexual partner
• Other relative
Anemia
Menorrhagia
Allergy to copper
Within six week following c s
23. Advantages
Highly effective
Long term protection up to 12 years
Immediate return to fertility after removal
Few side effects
Does not interfere with intercourse
Suitable for breast feeding women
Inexpensive
Highly continuation rate
24. Disadvantages
May increase the risk of PID
Required trained person to remove
Needs to check string after every menstruation
The client cannot discontinue on her own
25. Follow up care
Normally the clients should return to the IUD
provider after the first post insertion menses (4-6)
weeks but not later than 3 months for their first
checkup. The routine follow up are:
1st –After 1 week
2nd –First menses
3rd – After 2 months
4th –After 6 months
5th –After 12 months
26. RH protocol for COPPER -T
RH protocol Client desires IUCD
Assess if pregnant
no yes
Advice for ANC
History
Menstrual history
Recent or current PID
Valvular heart disease
Multiple partner
Vaginal bleeding or discharge
Exam
Heart
Vaginal bleeding or discharge
Investigation
Hemoglobin
Urine analysis
normal abnormal
Insert IUCD
Instruct client
Check string
Warning signs
Follow up
Ensure to
remove after
12yrs
Ask if she can
feel string
If not
appropriate
counsel the
client for
alternative
method &
Manage
identified
health
problem
Client with an STD can use IUCD
after the disease is treated
