Oxford Handbook of Midwifery (117 page)

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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

BOOK: Oxford Handbook of Midwifery
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  • When changing from another form of hormonal contraception to another it is important that there is planned change. Remind the
    woman to use condoms as additional protection for the first 7 days
    following insertion.
    Follow-up
  • Apart from a check of the insertion site to ensure there is no infection, it is not necessary to make a follow-up appointment.
  • Give the woman the card that comes in the implant packaging which tells her the date of insertion and the date for removal.
  • It is only necessary for her to return if there are any problems.
    Suitable for
  • Most women across the age range.
  • Women who cannot take oestrogen or who have oestrogen-related side-effects.
  • Diabetics, although possible adjustment of insulin dose may be required.
  • Women weighing more than 70kg, but it may have reduced efficacy, particularly in the third year. In this case, the implant may be changed sooner than 3 years.
  • Breastfeeding women, although a tiny amount of hormone may get into breast milk.
  • Hypertensive women, as there is no adverse effect on blood pressure.
  • Older women and smokers, who are at risk of cardiovascular incidents with oestrogen.
  • Blood levels of hormone are steady, rather than fluctuating, as with injectable or oral POP.
  • Absence of high-dose progesterone effects, as occur with Depo-Provera
    ®
    .
    CHAPTER 22
    Contraception
    544
    Side-effects
    • Disturbance of menstrual bleeding pattern:
      • 25% of women experience some change, with irregular cycles, inter menstrual bleeding, spotting, or prolonged bleeding in the first
        6 months
      • 80% of problems settle without further management
      • 35% have normal cycles and no problems in the first 6 months
      • 20% become amenorrhoeic
      • Bleeding problems are the most common reason for early removal.
    • Other possible effects:
      • Acne
      • Headaches
      • Abdominal pain
      • Weight gain
      • Breast pain
      • Dizziness
      • Mood swings
      • Hair loss.
    • Functional ovarian cysts:
      • These are usually asymptomatic and managed conservatively
      • They will resolve on removal of the implant.
        •
        Ectopic pregnancy: rare in implant users.
        Return of fertility
    • Plasma levels of etonogestrel are too low to measure 48h after removal and normal ovulatory cycles return within the first month after removal.
    • The subsequent conception rate is comparable with that of women not using contraception, and you can, therefore, reassure women that the implant alone will not adversely affect their future fertility.
      Drug interactions
    • Antibiotics, except rifampicin and griseofulvin, do not affect effectiveness.
    • Anti-epileptic treatment may reduce efficacy slightly. Advise additional consistent condom use.
      Metabolic effects
    • Minimal effects on carbohydrate metabolism, LFTs, blood coagulation, immunoglobulins, and serum cortisol levels have been reported.
    • Lipoprotein levels: there should be a small fall in total triglycerides and cholesterol. High-density lipoprotein (HDL)/cholesterol ratio is unchanged or improved.
    • These minimal metabolic effects make this a very suitable form of contraception for almost all women.
      This page intentionally left blank
      CHAPTER 22
      Contraception
      546‌‌
      Injectables
      Content
    • The most common injectable contraceptive in use is Depo-Provera
      ®
      (depot medroxyprogesterone acetate) 150mg, given every 12 weeks, but the interval may be extended up to 14 weeks.
      1
    • Noristerat
      ®
      (norethisterone oenanthate) 200mg, given by intramuscular injection every 8 weeks. Noristerat
      ®
      is oily and must be warmed to near body temperature prior to administration. Normally, only used for those women who have persistent vaginal bleeding problems with Depo-Provera
      ®
      and who wish to continue to use an injectable method.
      Method of administration
    • For both drugs the first dose should be given in the first 5 days of the menstrual cycle.
    • For maximum effect injection should be on day 1.
    • If given later than day 2, it is important to advise the woman to use extra barrier precautions for the next 7 days, if sexual intercourse occurs.
    • Depo-Provera
      ®
      is given by deep intramuscular injection into the
      gluteus muscle of the buttock, in the upper outer quadrant. It is important that the injection site is not rubbed afterwards, as this will accelerate breakdown of the drug and make it less effective.
      After giving birth
    • Normally given no sooner than 21 days after childbirth, to avoid prolonged or heavy bleeding, but can be given within 5 days of birth if not breastfeeding.
    • Ideally wait 6 weeks before injection in a breastfeeding mother, if she chooses additional hormonal contraception. By this time the infant’s enzyme system will be more fully developed and able to effectively metabolize any of the drug transmitted in the breast milk.
      After abortion
    • First trimester: can be given immediately.
    • Second trimester: ideally wait 2 weeks.
      Return of fertility
    • 2 After the last dose, return of fertility is commonly delayed (median 9 months) and the woman should be told this clearly.
    • There is no evidence that injectable contraceptives cause permanent infertility.
    • Over 80% of women are expected to conceive within 15 months of their last injection.
      Benefits
      The injectable progesterone-only method offers effective short- or long- term contraception.
    • 0–1 failure per 100 woman years.
    • Non-intercourse related.
      INJECTABLES
      547
  • May be used in spite of a previous history of thrombosis.
  • Ideal for women awaiting surgery, including sterilization.
  • 2 Women whose partners are awaiting vasectomy and postoperative confirmation of clear sperm count. It is important to stress the need to continue with effective contraception until the sperm count is clear or for 6 months after vasectomy.
  • Studies show no adverse effect on blood pressure.
  • Positively beneficial in women with endometriosis, epilepsy, sickle-cell anaemia, and pelvic inflammatory disease.
  • Women being immunized against rubella.
  • Minimal metabolic effects.
    Effects
  • Suppression of ovulation.
  • Amenorrhoea usual within 6 months.
  • Not reversible for duration of the injection.
  • Injectables are safer than combined oral contraceptives.
  • Delay in return of fertility (median 9 months).
    Side-effects
    Irregular bleeding
  • This is the most common side-effect, usually in the first 3-month cycle.
  • It usually resolves with second injection, which may be given early (not
    less than 4 weeks after the previous dose).
  • May require added oestrogen, for example ethinylestradiol 20–30micrograms (usually given in combined oral contraception form) up to 21 days (i.e. one menstrual cycle). If the woman has a past history of thrombosis or focal migraine, this may be given as a natural oestrogen, for example Premarin
    ®
    1.25mg for up to 21 days.

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