Tools and Techniques

Basic Elements of a Clinical Protocol

Definition

This section describes the method.

Type

Many contraceptive methods have different types or brands.

Effectiveness

Most contraceptive methods have theoretical effectiveness (how effective they would be if they were perfectly used) and use effectiveness (how effective they actually are in practice).

Mode of Action

This is the physiological way in which the method prevents pregnancy.

Method of Use

This section discusses whether or not the method is related to intercourse; whether it is injected, inserted, or taken orally; and how often.

Indications

The medical, social, and cultural profile of the client indicates whether this is an appropriate method.

Contraindications

The cultural, social, and medical factors which make this an inappropriate method for a client. These are usually separated into absolute and relative contraindications. An absolute contraindication means that a particular method should never be provided when this condition is present. A relative contraindication means that the method should only be provided if there is no other alternative acceptable to the woman, and she should have more medical supervision than other users do.

Client History

The client history covers the relevant points to consider in the client's health assessment. For women, these usually include menstrual history, OB/GYN history, and any history related to contraindications for the method.

Physical Examination

This section lists the elements in the physical exam which are essential for providing this method.

Laboratory Test

Certain lab tests may e needed to rule out or confirm contraindications.

Time of Insertion or Initiation

Many methods can only be initiated at the beginning of menses or during menses. Some methods, like the combined pill, should not be initiated post-partum as they would interfere with breastfeeding.

Insertion Procedure (for IUDS and contraceptive implant only)

The protocols for these two methods are long, since sterile technique and proper placement are essential.

Complications and Side Effects

The protocol should indicate all possible complications or side effects, degree of risk, and method of management. This section is often extensive for modern clinical methods. Removal (for IUDs and contraceptive implant only): This section covers the reasons for removal (request, expiration, side effects), when it can be done, and method of removal.

Client Education

This section includes all relevant information that the client should understand before choosing the method so that the client knows when it is necessary to seek follow-up medical care, how to use the method properly, and what minor side effects to expect.

Follow-up

The level of medical supervision that is needed for users of each method, as well as when and how often check-ups should occur, are managerial and medical decisions.

Clinical Protocol Example: The IUD

Definition

The Intrauterine Device is a small contraceptive device inserted into the uterus.

Type

Some of the IUDs currently available are Lippes Loop, the Copper-T 380A and 200, the Copper-7, the Multiload, and the Progestasert-T

Effectiveness

The effectiveness of an IUD varies with type, and with the age and parity of the user. In general, the IUD has a theoretical effectiveness of 98 to 99 percent. Its use effectiveness is lower due to a 9.2 percent spontaneous expulsion rate.

Mode of Action

The exact mechanism by which the IUD prevents pregnancy is not known. It may affect sperm, ova, fertilization, or the endometrium. Recent observations indicate that the IUD affects the ovum before it reaches the uterus.

Method of Use

The IUD is unrelated to intercourse. It is inserted into the uterus. The Copper-T 380 must be withdrawn before the end of the fourth year.

Indications

The best candidate for an IUD is a woman who has had at least one child, who wants a method requiring minimal attention and unrelated to intercourse, and who has no contraindications. In an area where sexually transmitted diseases (STDs) are prevalent, the woman should be in a mutually monogamous relationship.

Contraindications

Absolute contraindications include active, recent, or recurrent pelvic infection, including gonorrhea, and pregnancy. Relative contraindications include undiagnosed, irregular or abnormal uterine bleeding; risk factors for pelvic inflammatory disease; and a history of ectopic pregnancy.

Client History

For IUD use, the history should coverwhether the client has had a child and if so, how many; whether the client has had any unusual uterine bleeding; whether the client has any STDs; whether the client has had any ectopic pregnancies; whether the client could be pregnant now.

Physical Examination

The examination should include a bi-manual pelvic exam and a speculum exam.

Laboratory Tests

Lab tests for the IUD might include hematocrit/hemoglobin, urine for glucose and protein, and screening for STDs.

Time of Insertion

An IUD can be inserted any time during a woman's menstrual cycle unless it is possible that she is pregnant, in which case it should be inserted at the time of the next menstrual flow.

Insertion Procedure

The clinical protocol for IUD insertion is too long to include here. Complications and

Side Effects

An example of a possible IUD side effect is pelvic inflammatory disease (PID), which has a 1 to 7 percent risk of occurring, depending on social factors. PID is treated by removing the IUD, initiating antibiotic treatment, and referring the client to a gynecologist, if possible.

Removal

The clinical protocol for IUD removal is too long to include here.

Client Education

Education about the IUD should include checking for the IUD string, what to do if the IUD is expelled, how to recognize signs of PID, watching for menstruation, what to do if abdominal pain occurs, and what minor side effects to expect.

Follow-Up

A typical IUD follow-up protocol calls for a check-up one month after insertion and then every 12 months until the device is no longer effective.