PocketGuide: Client Assessment

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PocketGuide for Family Planning Service Providers

Client Assessment

Introduction | How to Be Reasonably Sure a Client is Not Pregnant | Client Assessment Checklists | Using the Client Assessment Checklists for Reversible Methods

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 followup.

These 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 because:

The currently available low-dose¹ combined (estrogen and progestin) contraceptives, such as COCs and CICs, are quite safe. They are safer and have fewer serious side effects than older products and only rarely do they make existing medical problems worse.
Progestin-only implants, injectables and pills are free of estrogen-related effects and the amount of progestin delivered per day is lower than with COCs.

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 Pregnant²

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 a 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 nonbreastfeeding 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,
has still had no menstrual bleeding (amenorrheic), and
has no clinical signs or symptoms of pregnancy.

Pelvic examination is seldom necessary, except to rule out pregnancy of greater 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 (i.e., detects <50 mIU/ml of hCG) 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.²

Client Assessment Checklists

The following tables provide:

sample client assessment checklists for reversible methods (hormonals and IUDs),
guidelines for assessing the suitability of clients to have voluntary sterilization in ambulatory health care facilities, and
a summary of client assessment requirements for all methods.

Using the Client Assessment Checklists 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.

Note: Clients may not always have exact information about or recall the answers to the conditions listed in the Client Assessment Checklists. To be as certain as possible about the accuracy of information, it may be necessary to restate the question(s) in several different ways. Also, it is important to take into account any social, cultural or religious factors that might influence how the client responds.

The findings from the Client Assessment Checklist determine whether a physical examination is necessary (i.e., if the client answers “YES,” a brief physical examination or additional questions may be necessary).

¹ Low-dose combined contraceptives contain 30–35 ľg ethinyl estradiol.
² Adapted from: Technical Guidance Working Group 1994.

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