Objectives
The primary objectives of assessing clients prior to providing family planning
services are to determine:
- that the client is not pregnant,
- whether any conditions requiring precaution exist for a particular method, and
- whether there are any special problems that require further assessment, treatment or
regular follow-up.
This usually can be accomplished by asking a few key questions. Unless specific
problems are identified, the safe provision of most contraceptive methods, except IUDs and
voluntary sterilization, does not require performing a physical or pelvic
examination.
Where resources are limited, requiring medical evaluation and/or laboratory testing
(e.g., blood sugar and hemoglobin) before providing modern contraceptive methods is not
justifiable. Where demand for family planning services is high, medical requirements that
are not essential to the provision of specific contraceptives act as a major
barrier to contraceptive choice and access to services. To enable clients to obtain the
contraceptive method of their choice, only those procedures that are essential and
mandatory for all clients in all settings should be required.
With the exception of condoms (and diaphragms to a lesser degree), no contraceptive
method provides protection against STDs (e.g., HBV, HIV/AIDS). All clients should be made
aware of the risks of GTI and STD transmission (see STDs and Family
Planning chapter for details on client screening).
How to be Reasonably
Sure a Client is not Pregnant
You can be reasonably sure a client is not pregnant if she has no signs or symptoms of
pregnancy (e.g., breast tenderness or nausea) and:
- has not had intercourse since her last menses; or
- has been correctly and consistently using another reliable contraceptive method; or
- is within the first 7 days after the start of her menses (days 1–7); or
- is within 4 weeks postpartum (for non-breastfeeding women); or
- is within the first 7 days postabortion; or
- is fully breastfeeding, less than 6 months postpartum and has had no menstrual bleeding.
When a woman is more than 6 months postpartum you can still be reasonably sure
she is not pregnant if she has:
- kept her breastfeeding frequency high,
- still had no menstrual bleeding (amenorrheic), and
- no clinical signs or symptoms of pregnancy.
Pelvic examination is seldom necessary, except to rule out pregnancy of
more than 6 weeks, measured from the last menstrual period (LMP).
Pregnancy testing is unnecessary except in cases where:
- it is difficult to confirm pregnancy (i.e., 6 weeks or less from the LMP); or
- the results of the pelvic examination are equivocal (e.g., the client is overweight,
making sizing the uterus difficult).
In these situations, a sensitive urine pregnancy test may be helpful, if readily
available and affordable. If pregnancy testing is not available, counsel the client
to use a temporary contraceptive method or abstain from intercourse until her menses occur
or pregnancy is confirmed.
Client Assessment
Checklist for Reversible Methods
For either checklist if the client answers "NO" to all questions, and
pregnancy is not suspected, the client may go directly for method-specific
counseling, pelvic examination (required for IUDs only) and provision of the
contraceptive. If the client answers "YES," however, she will need
further counseling and possible evaluation before making a final decision.
HORMONAL METHODS
CHECKLIST
(pills, injectables and implants) |
YES
|
NO |
| Breastfeeding baby less than 6 weeks olda,b |
|
|
| Bleeding/spotting between periods or after
intercourse |
|
|
| Jaundice (abnormal yellow skin or eyes) |
|
|
| Smoker over age 35b
|
|
|
| Diabetes |
|
|
| Severe headaches or blurred vision |
|
|
| Severe pain in calves, thighs or chest, or
swollen legs (edema)b |
|
|
| High blood pressure (history of)b |
|
|
| Heart attack, stroke or heart disease
(history of) |
|
|
| Breast cancer or suspicious (firm,
nontender or fixed) lump in the breast |
|
|
| Taking drugs for epilepsy (phenytoin and
barbiturates) or tuberculosis (rifampin)c |
|
|
a Combined estrogen/progestin contraceptives (COCs
and CICs) are the methods of last choice for breastfeeding women, especially in the first
6–8 weeks postpartum.
b Does not apply to progestin-only contraceptives (implants,
PICs and POPs).
c Does not apply to PICs.
IUD CHECKLIST |
YES |
NO |
| Client (or partner) has other sex partners |
|
|
| Sexually transmitted genital tract infection (GTI) or
other STD (e.g., HBV, HIV/AIDS) within the last 3 months |
|
|
| Pelvic infection (PID) in the last 3 months or past
ectopic pregnancy |
|
|
| Heavy menstrual bleeding (twice as long or
twice as much as normal)a |
|
|
| Prolonged menstrual bleeding (> 8 days)a |
|
|
| Severe menstrual cramping (dysmenorrhea)
requiring analgesics and/or bed resta |
|
|
| Bleeding/spotting between periods or after intercourse
|
|
|
| Symptomatic valvular heart diseaseb
|
|
|
a Does not apply to progestin-releasing IUDs.
b Give prophylactic antibiotics if not on long-term
antibiotics at the time of IUD insertion.
Client Assessment
Guidelines for Permanent Methods
Voluntary sterilization (VS) procedures, including minilaparotomy and laparoscopy,
generally can be provided safely in ambulatory health care facilities. The guidelines
presented in the following tables are intended for use in selecting healthy clients who
can have a VS procedure in an ambulatory health care facility. Not acceptable
indicates that the procedure probably should be performed in a facility where additional
assistance and backup services are available (e.g., more experienced physician). It does
not relate to the appropriateness of the client’s decision to undergo VS.
Female Voluntary Sterilization
Guidelines
CATEGORY
|
SELECTION
CRITERIA |
Acceptable |
Not Acceptable |
| General health (assessed by history and limited
physical examination) |
Normal history and no current symptomatic heart, lung
or kidney disease |
Uncontrolled diabetes or history of bleeding disorder;
current symptomatic heart, lung or kidney disease, etc. |
| Emotional state |
Calm |
Unresolved fear and anxiety |
| Blood pressure |
< 160/100 mm/Hg |
> 160/100 mm/Hg |
| Weight |
Maximum weight: 80 kg (176 lb) Minimum weight: 35 kg
(77 lb) |
> 80 kg
< 35 kg |
| Previous abdominal/pelvic surgery |
Cesarean sections—only if mobile abdominal scar
and normal pelvic examination |
Other abdominal surgery, fixed scar or abnormal pelvic
examination |
| Previous pelvic disease (PID, ectopic pregnancy) or
ruptured appendix |
No history and normal abdominal/pelvic examination |
Abnormal abdominal/pelvic examination |
| Anemia |
Hemoglobin > 7 g/dl |
Hemoglobin < 7 g/dl |
Male Voluntary Sterilization Guidelines
CATEGORY
|
SELECTION
CRITERIA |
Acceptable |
Not Acceptable |
| General health (assessed by history and limited
physical examination) |
Normal history and no current symptomatic heart, lung
or kidney disease |
Uncontrolled diabetes or history of bleeding disorder;
current symptomatic heart, lung or kidney disease, etc. |
| Emotional state |
Calm |
Unresolved fear or anxiety |
| Blood pressure |
< 160/100 mm/Hg |
> 160/100 mm/Hg |
| Scrotal/inguinal infection or abnormalities
(undescended testes, hernia) |
Normal examination |
Infection of scrotal or inguinal area, infection of
foreskin or anatomic abnormalities |
| Anemia |
Hemoglobin > 7 g/dl |
Hemoglobin < 7 g/dl |
 
|
