Welcome to the Postpartum Contraception Nursing Education Module

 

Choosing a contraceptive method after having a baby is an extremely important part of postpartum care. Nurses can help women achieve their reproductive life plan regarding the timing and spacing of their children through effective counseling on contraceptive methods. This module uses realistic patient scenarios as the framework for providing guidance on conducting patient-centered, non-directive contraceptive management counseling.

How to Use This Module 

Provide’s Nursing Education Curriculum is designed for a flipped classroom model to incorporate unintended pregnancy prevention and care into existing curricula.

Students are encouraged to complete the Pre-Assessment below and then work through the module. Definitions and Orienting Facts provide context for the Patient Situations, which are clinical scenarios designed to raise critical issues and questions to put unintended pregnancy prevention and care in the context of Postpartum Contraception. Students may complete the Recommended Reading at any time while going through the Patient Situations. Please complete the Post-Assessment after finishing the module.

Faculty are encouraged to open the Faculty Guide tab below to access teaching tips, exercises and handouts for incorporating module content into the classroom, and to learn more about obtaining a “Site Code” to download and access students’ Pre- and Post-Assessment data.

Pre- and Post-Assessments

Please complete the Pre- and Post-Assessments. A new window will open to a Survey Monkey Pre-Assessment and the window must remain open while you work with the module. Once you have completed the module you will return to the Survey Monkey window to complete the Post-Assessment. If your faculty requires completion of this module as a course requirement, please check with them about due dates and credit allocations.

Relevant UPPC Essential Competencies

Through a national Delphi study, Essential Competencies in Unintended Pregnancy Prevention and Care for Nursing Education (Hewitt, C. and Cappiello, J., 2015) 85 nursing experts in unintended pregnancy prevention and care reached consensus on 27 core educational competencies for nursing education which provide a framework for curricular development in an important area of nursing education. The following competencies are relevant to this nursing education module.

  1. Demonstrate knowledge of types of induced abortion methods, including risks and benefits, which are legally available in the U.S.
  2. Demonstrate understanding of how contraceptive methods work (e.g. hormonal methods, post‐partum and emergency contraception, lactational and fertility methods, IUD, barrier methods, sterilization), risks, benefits, alternatives, effectiveness, and eligibility.
  3. Demonstrate knowledge of current evidenced‐based guidelines for primary prevention of unintended pregnancy.
  4. Demonstrate proficiency in promoting sexual-health self-care practices.
  5. Demonstrate ability to confirm pregnancy and determine gestation age.

Learning Objectives

  • Describe postpartum contraception for lactating and non-lactating women
  • Analyze the health benefits of pregnancy spacing
  • Understand the various types of contraceptive methods and their mechanism of action
  • Demonstrate counseling options for unintended pregnancy prevention and management

Early Pregnancy Decision-Making:  Refers to the decision-making process that a woman engages in when faced with an unintended pregnancy. Pregnancy options include continuing the pregnancy with the intention to parent, continuing the pregnancy with the intention to adopt, or choosing abortion care.

Emergency Contraception:  A contraceptive method used after intercourse to prevent a pregnancy.

Induced or Therapeutic Abortion (commonly referred to as “abortion”):  An abortion that is brought about intentionally, also called a therapeutic abortion. Medical terminology refers to induced and spontaneous abortion (commonly referred to as a miscarriage).

Lactational Amenorrhea Method (LAM):  A natural, temporary method of contraception based on the concept that lactation postpones ovulation in the postpartum period. LAM can be up to 99% effective if the mother is breastfeeding exclusively with no supplementation, is not gone for long periods of the day or night between feedings, menses have not returned and baby is less than 6 months old.

Long-Acting Reversible Contraceptives:  LARCs refer to methods of contraception that can last for several years. Examples are intrauterine devices (which range from 3-10 years) or a hormonal implant called Nexplanon (3 years). Some people also consider the Depo-provera injection (which lasts for 3 months) to be a LARC.

Medication Abortion:  This method of early abortion is currently used up to 63 days of pregnancy in the U.S. The most commonly used regimen includes mifepristone (formerly known as RU486) followed by misoprostol. Generally a woman has an appointment with a provider for mifepristone after which she self-administers misoprostol in 1-3 days at home. Within a few hours, she has miscarriage with cramping and bleeding which ends the pregnancy.

Preconception Health:  This refers to the health of women and men during their reproductive years, which are the years they can have a child. It focuses on taking steps to protect the health of a baby they might have sometime in the future. The Center for Disease Control (CDC) offers detailed information to assist individuals in developing a reproductive life plan and to health care professionals to support this planning.

Unintended Pregnancy:  An unintended pregnancy is a pregnancy that is mistimed, unplanned, or unwanted at the time of conception.

  • According to the CDC, family planning is one of the 10 greatest public health achievements of the 20th century. Family planning methods have provided a means for women to delay a first pregnancy, achieve interconceptional birth spacing, and attain an ideal family size.
  • According to Finer and Zolna (2014) half of pregnancies among American women are unintended, and four in 10 of these are terminated by abortion. Given this statistic, a woman might not be aware of a pregnancy until fetal development has progressed into the vulnerable period (17-56 days after conception). During this period the fetus is vulnerable to developing birth defects such as neural tube defects, major brain anomalies, heart defects, limb deficiencies, and various ear and eye defects. Exposure to prescription drugs that are known to cause birth defects, or hazardous substances in the workplace or home can have detrimental effects.
  • The Guttmacher Institute reports that “the average American woman spends about five years pregnant, postpartum or trying to become pregnant, and three decades—more than three-quarters of her reproductive life—trying to avoid an unintended pregnancy.” Guttmacher’s Fact Sheet on Induced Abortion in the United States indicates the likelihood of having an abortion rises over the course of a lifetime: 1 in 10 women will have an abortion by age 20, and 1 in 3 will have an abortion by age 45.
  • The Guttmacher Institute also reports that births resulting from unintended or closely spaced pregnancies are associated with adverse maternal and child health outcomes such as delayed prenatal care, premature birth and negative physical and mental health effects for children.
  • Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. For three decades, Healthy People has established benchmarks and monitored progress to identify nationwide health improvement priorities. Healthy People strives to increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress. They provide measurable objectives and goals that are applicable at the national, state, and local levels as well as engaging multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge and identifies critical research, evaluation, and data collection needs.
  • Healthy People Goals for 2020 include improving pregnancy planning and spacing, and prevention of unintended pregnancy.
  • Healthy People Goals for 2020 support breastfeeding for all infants. The goal for 2020 is 82% of all new mothers will breastfeed for 3-6 months.

Each scenario described in this module is broken into sections to enable self-guided learning. Detailed information is provided on the patient and the setting in addition to the patient scenario that deals with the complex and often controversial nature of unintended pregnancy prevention and care.

Amelia’s Contraception (Patient Situation #1)

The Patient

Amelia is 29 years old and gave birth two months ago to a baby girl, Isabella. Life slowly settled into a routine with regular daytime and nighttime breastfeeding. Amelia is breastfeeding exclusively; when she is away from Isabella, Amelia will pump and leave a bottle of breast milk.

Amelia hasn’t been using a method of contraception yet because she assumes she is protected while nursing (lactational amenorrhea).

The Setting

A Family Planning Department in a large federally qualified community health center (FQHC) that provides comprehensive reproductive health services. A full range of FDA-approved contraceptives are available on site. Registered nurses conduct the initial intake session, which focuses on the patient’s reproductive life plan as well as providing counseling on various contraceptive methods.

What Happened

Two months after giving birth, Amelia resumed a sexual activity. Amelia missed her postpartum appointment and wants to re-schedule the visit, but life events keep getting in the way. Finally, at three months postpartum, Amelia is able to schedule an appointment and she wants to discuss her contraceptive options.

Risk of pregnancy in the postpartum period while breastfeeding
The timing of the six-week postpartum visit is largely based on historical practices and long-time beliefs that the uterus will return to a state by then conducive to a pelvic exam. It is also based on the outdated view that women do not resume sexual intercourse prior to six weeks. Speroff and Mishnell (2008) argue that it is time to change the timing of the postpartum visit to three weeks postpartum in order to appropriately assess women’s physical and social well-being and to provide contraception in a timely fashion prior to women resuming sexual intercourse to prevent unintended pregnancy.

In Speroff and Darney’s book A Clinical Guide for Contraception, the “Rule of Threes” states that with full breastfeeding, a contraceptive method should be used beginning in the third month and if not breastfeeding or partially breastfeeding, a contraceptive method should be used beginning in the third week. This is because the range of return to menses while breastfeeding varies widely from 2- 18 months postpartum. Exclusive or continuous breastfeeding generally delays the resumption of ovulation and menses. Hormonal shifts that sustain lactation prevent ovulation so pregnancy can be prevent pregnancy if the mother is breastfeeding exclusively, is not gone for long periods of day or night between feedings, menses have not returned, and the baby is less than 6 months old. Ovulation usually occurs about two weeks before the onset of the first menses postpartum and there is no certainty when menses and ovulation will begin.

According to the CDC’s U.S. Selected Practice Recommendations for Contraceptive Use, 2013, breastfeeding can be a highly effective form of contraception for women who are within 6 months postpartum, are fully or nearly fully breastfeeding, and are amenorrheic; the risk for pregnancy is less than 2%. A Cochrane review also concluded that women who are fully breastfeeding and remain amenorrheic, have a very small risk of pregnancy in the first six months postpartum. This web page on Breastfeeding (Lactational Amenorrhea Method) from Association of Reproductive Health Professionals (ARHP) includes a fact sheet and short video describing how lactational amenorrhea can be used for contraception. However, it is a temporary form of birth control, which means that once menses returns breastfeeding is no longer an effective contraceptive method.

If Amelia wants to space out her pregnancies, she will want to consider another contraceptive method.

During the intake portion of the visit, the nurse conducts a sexual history. Amelia wants to breastfeed and pump for at least six months, however, due to working full time she has decided to use formula during the day. Amelia and her husband continue to use lactational amenorrhea as a contraceptive method. Given Amelia’s history and based on office protocol, the nurse runs a pregnancy test.

The pregnancy test result is negative. Relieved, Amelia asks the nurse to provide information on birth control methods because she and her husband do not want another child right away. Amelia states that she has successfully used birth control pills in the past. When the nurse gently explores Amelia’s strategies for consistent, daily use of the pill without gaps, Amelia says that this aspect of pill use is sometimes challenging. She had missed pills but, from her perspective, was lucky because she had never experienced an unintended pregnancy.

What are Amelia’s contraceptive options?

After Amelia chooses a contraceptive method she is comfortable consistently using, she will continue to take a daily prenatal vitamin as she is nursing. At some point when Amelia no longer is nursing, she can transition to a multivitamin with at least 400mcg of folic acid.

What If…

This section offers a twist or a different perspective on “What Happened” to guide and encourage learners to tease apart various aspects of the Patient Situation.

Amelia wanted an IUD?
Many clinics will insert IUDs on the same day without scheduling another appointment. The advantage of this scheduling is that the IUD begins acting immediately to prevent unintended pregnancy. Amelia’s options for intrauterine devices in the U.S. include ParaGard®, which is a copper IUD the FDA has approved for up to 10 years, and Mirena®, a levonorgesterel releasing hormonal IUD which has been approved for up to 5 years. However, based on newer research finding, many clinicians are using ParaGard® for 12 years, and Mirena® for 7 years (off-label).

The U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 states that if there is no evidence of puerperal sepsis, the copper IUD can be inserted at any time postpartum, including immediately postpartum. The hormonal IUD (levonorgesterel) can be inserted at any time, including immediately postpartum if it is reasonably certain that the woman is not pregnant. IUD expulsion rates are somewhat higher when inserted within 28 days of birth compared to waiting until 4 weeks or later.

The presentation IUD’s – Dispelling the Myths from the Reproductive Health Access Project, uses case studies to present factual information about intrauterine devices and their mechanisms, compares different types, and side effects including non-contraceptive advantages.

LARC FIRST is a comprehensive website that not only provides information on long-acting reversible contraceptive methods, but also includes videos, counseling tips, training and preceptoring information, quality management, and patient resources.

Amelia were not breastfeeding?
According to Speroff and Darney’s “Rule of Threes” women who are not breastfeeding can begin using a contraceptive method in the third week postpartum. Jackson and Glasier (2011) examined evidence regarding the return to fertility among non-breastfeeding postpartum women and indicated that ovulation can occur as early as 25 days postpartum, although fertile ovulation likely will not occur until at least 42 days postpartum. In terms of hormonal contraception, the current evidence generally recommends waiting until 42 days postpartum to begin hormonal pills, patches or rings. In women who are less than 21 days postpartum, use of combined hormonal contraceptives represents an unacceptable health risk and should not be used (Category 4). In women who are 21 – 42 days postpartum and have risk factors for venous thromboemolism (VTE) in addition to being postpartum, the risks for combined hormonal contraceptives usually outweigh the advantages and should not be used (Category 3). In the absence of other risk factors for VTE, the advantages of combined hormonal contraceptives generally outweigh the risks and can be used (Category 2). In women who are less than 42 days postpartum, no restriction applies for combined hormonal contraceptives (Category 1).

For more specific information, read the July 2011 CDC update to the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: Revised Recommendations for the Use of Contraceptive Methods During the Postpartum Period.

The common clinical dilemma of providing effective contraceptive options counseling relates to working with women who have specific medical conditions. In 1996, the WHO published the first edition of the MEC to give evidence-based guidelines on the safety of contraceptive method use for women with specific medical conditions. The U.S. did not adopt the document until 2010 when the CDC adapted the MEC for use with the U.S. population. The USMEC adds six additional medical conditions:

  1. history of bariatric surgery
  2. peripartum cardiomyopathy
  3. rheumatoid arthritis
  4. endometrial hyperplasia
  5. inflammatory bowel disease
  6. solid organ transplant.

Some sections were eliminated, such as combined injectable contraceptives that are not available in the U.S. or advice that did not apply to U.S. women. For example, guidance for “blood pressure measurement unavailable” and “history of hypertension, where blood pressure cannot be evaluated” was removed, as these situations are unlikely in the United States. An easy-to-read, one page double sided, color coded summary chart is available in English and Spanish.

Colette’s Contraception (Patient Situation #2)

The Patient

Colette is 20 years old and gave birth eight weeks ago to a baby boy. At the time of discharge she was advised to call her midwifery office to discuss her options. Her vaginal soreness resolved, her bleeding stopped, and she resumed intercourse at six weeks postpartum, using lactational amenorrhea. She breastfed exclusively for the first 6 weeks and began supplementing with formula to ease her transition back to work.

See Colette’s Intake Form.

The Setting

A women’s health clinic that provides comprehensive reproductive health care and related preventative health services, including a full range of contraceptive options that are available on site. A sliding fee scale is available for patients in need of financial assistance.

What Happened

Colette scheduled a six-week postpartum visit, but she missed the appointment because she did not have transportation to the clinic. Colette was able to make another appointment and secure transportation at eight weeks postpartum. When she arrives, Colette tells the nurse that she became nervous about getting pregnant and used an over the counter pregnancy test at home. The test was positive. The nurse asks Colette how she feels about a pregnancy and Colette states that she is not ready to have another baby right now. The nurse then performs the urine pregnancy test and confirms the positive pregnancy test.

Giving pregnancy test results
When giving pregnancy test results it is important for nurses to understand that the results belong to the patient and it is the nurse’s responsibility to provide the results and what they mean without bias. Hearing the results of a pregnancy test can be a life changing moment; women may be delighted, regretful, anxious, and sometimes ambivalent about the being pregnant. Since it is difficult to predict how someone will feel when receiving the results, it is important not to congratulate the patient and allow time for the information to “sink in” before asking if she would like more information.

This presentation, Giving Pregnancy Test Results: A Primer for Nursing Students, from Provide serves as a guide for nursing students on giving pregnancy test results, identifying immediate health concerns, providing referrals, and an overview of laboratory pregnancy tests is provided. Recommendations are given on specific questions to ask and counseling language to use when providing negative and positive test results, and working with a patient who is ambivalent about the test results.

Since Colette has been breastfeeding and supplementing with formula, her periods returned but have been highly irregular. She does not know when she became pregnant.

How can the nurse confirm the pregnancy and determine length of pregnancy?
Health providers use the first day of the last menstrual period (LMP) to date pregnancies. One reason for not dating pregnancies from the day of conception is that most women find it difficult to know the exact date of conception and the first day of LMP is more typically known. Early pregnancy ultrasounds that use a crown rump measurement (which can generally be calculated only to 14 weeks) are the most accurate for assessing the gestational age of pregnancies.

Pregnancy wheels are commonly used to determine the due date or estimated date of confinement (EDC). Wheels are based on Nagel’s rule which estimates the EDC by adding one year, subtracting three months, and adding seven days to the first day of a woman’s LMP. The result is approximately 280 days (40 weeks) from the LMP. Wheels may vary by a day or two or it is easy for a health care provider to miss read a wheel by a day or two. Electronic calculation is considered more accurate.

There are several types of pregnancy tests. Immunometric tests, also known as ELISA or monoclonal antibody tests, have become the most common type of test, both at home and in clinical settings, because they are easy to use, non-invasive, highly sensitive and inexpensive. Results can be accurate as early as the time of the missed period. Some serum tests are accurate within 7-10 days of conception. It is rare to have false negatives, and even rarer to have false positive tests. However, it is important to understand that if a test is negative, it may not be a false negative but may simply be too early in pregnancy to be positive. If this is a concern, the test must be repeated in a few days to a week. The accuracy of test results is enhanced in very early pregnancy and first morning urine collection as a more concentrated specimen will have higher levels of hCG. Home pregnancy tests may have a decreased accuracy rates related to specimen collection techniques (e.g. residue in collecting container), errors in timing or errors in interpretation of the test. An older type of test, agglutination tests, are no longer common because monoclonal antibody tests provide positive results much earlier and at comparable cost, although the agglutination tests remain available for specific indications.

Serum monoclonal antibody pregnancy testing are more than 99% accurate in diagnosing pregnancy. Beta HCG hormone can be measured quite accurately as a qualitative test (positive or negative) or as a quantitative test with a specific value of milli-international units per milliliters. Serial quantitative tests are repeated every 2 to 3 days in special conditions of pregnancy: to assess the viability of a pregnancy, to determine if a miscarriage is occurring or to diagnosis an ectopic pregnancy. Beta HCG testing is more expensive than urine testing and in most settings, must be ordered through a laboratory.

In their discussions about Colette’s reproductive life plan, she reaffirms that she does not want to have another baby right now. It is up to the nurse to provide non-directive, patient-centered options counseling for Colette to make a choice that feels right to her.

What are Colette’s options?
In this case, Colette has already expressed that she does not want to have another baby right now, so the nurse must be prepared to provide patient-centered, non-directive options counseling after delivering the pregnancy test results. Please see the Options Counseling Nursing Education Module for further information and skills building for options counseling.

Colette could decide to have an abortion, she could continue with the pregnancy, or she could make an adoption plan. Options Counseling for Unintended Pregnancy is a presentation from Provide’s ROE (Reproductive Options Education) Consortium designed to give nurses and APRNs information on attitude, skills, and knowledge needed to provide options counseling to patients who experience unintended pregnancy.

Colette has already indicated that she does not want to have another baby, so the she and the nurse discuss abortion. Since Colette is less than 10 weeks pregnant she can chose to have a medication abortion or an aspiration procedure. In the article Mifepristone for Medical Abortion: Exploring a New Option for Nurse Practitioners, Taylor and Hwag introduce Mifespristone and provide clinical considerations including a chart comparing regimens and a chart comparing medication abortion with vacuum aspiration.

Facts About Mifepristone (RU-486), a fact sheet from the National Abortion Federation (NAF), discusses medication abortion and defines Mifepristone, a medication that blocks the action of progesterone, discusses how it works, effectiveness as an abortifacent when combined with Misoprostol, possible side effects, and what women can expect when using it. Another fact sheet What is Medical Abortion? from NAF provides detailed information on the medications including how they work, how long they take, possible complications, and follow-up care for medication abortions.

In the article Care for Women Choosing Medication Abortion Taylor et al. discuss the nurse practitioner’s role in providing medication abortions and uses case studies to present counseling, complications and potential side effects, and confirming complete abortion.

In “Part 2 – Tools for Clarifying Our Values” of The Abortion Option from the National Abortion Federation there are exercises designed to help nurses critically examine factors that might influence their beliefs about parenting, adoption, and abortion and, for some, their desire to become involved in abortion care. There are tools for clarifying values related to abortion, views about the role of health care providers, and case studies are used to identify and examine potential biases. Please also visit the Professional Ethics Nursing Education Module for more information and values clarification related to the role of nurses in providing abortion care.

Colette decides to have a medication abortion. Because the site does not offer medication abortion, the nurse offers to make a referral to a facility where Colette can receive this health care. Colette wants to discuss the unintended pregnancy with her partner. She is certain that he will agree that they are not ready to have another baby at this point. Colette and the nurse make a plan to speak on the phone the next day.

The next morning Colette calls the nurse and requests a referral. Local clinics vary as to how quickly they can offer Colette an appointment for an early abortion using medication. The nurse is familiar with the resources in the community and knows which local facility can usually offer an appointment within 24 hours. The nurse is able to schedule an appointment for later that day.

Making abortion referrals
When a woman chooses to have an abortion, and if the health center cannot do the procedure on site, it is essential to provide her with a referral that will facilitate her getting the care she needs quickly. One major barrier to providing effective referrals is that clinicians are unaware of where abortion services are offered. In this case, the nurse is familiar with the local facilities and even knows which one will be able to schedule an appointment the soonest. This web page from the National Abortion Federation includes an interactive map that gives state-specific information on abortion services and clinic contact information for each state.

Another barrier to providing abortion care and/or referrals is nurses’ willingness to participate. A small qualitative study in 2004 showed that more than one third of physician respondents reported that they had to postpone abortion services due to a lack of nurses willing to assist (Kade et. al.,2004).

The culture of a work environment can have an impact on a nurse’s decisions to participate or not participate in the care of a patient. In some settings, the nurse who agrees to provide abortion care may experience negative comments from her/his colleagues. A 2008 review of the literature by Lipp on nurses who participate in abortion care reports that nurses who participate in abortion care, as well as those whose refused, had been criticized by their co-workers.

To provide high quality patient care, it is vitally important that nurses are either able to participate in the care of the patient or to provide effective referrals so the patient can receive the health care she needs as soon as possible.

The nurse schedules a follow-up visit for Colette in one week for an IUD insertion. In the meantime, Colette is worried about breastfeeding once she takes the medication.

Can Colette continue to breastfeed if she has a medication abortion?
According to TOXNET of the U.S. National Library of Medicine limited information indicates that breastfeeding need not be interrupted after a single dose of mifepristone. Mispoprostol is a prostaglandin E1 analogue, and prostaglandin E1 along with other prostaglandins, appear normally in colostrum and milk. Because of the extremely low levels of misoprostol in breastmilk, amounts ingested by the infant are trivial and would not be expected to cause any adverse effects in breastfed infants. No special precautions are required.

What If...

This section offers a twist or a different perspective on “What Happened” to guide and encourage learners to tease apart various aspects of the Patient Situation.

What if Colette missed her postpartum visit altogether and found out she was four months pregnant?
The nurse can provide Colette with information and nonjudgmental options counseling whereby she explains the benefits and risks to having an abortion procedure (dilation and evacuation), continuing with the pregnancy, or making an adoption plan. Truly non-directive options counseling can be difficult because of one’s own beliefs, especially when there is a strong feeling that we know what the best option would be for a woman. In Options Counseling: Techniques for Caring for Women with Unintended Pregnancies Singer provides guidance for clinicians to examine their own beliefs and values to improve their skills in providing nonjudgmental and nondirective options counseling for women experiencing unplanned pregnancy.

Regardless of the nurse’s beliefs or opinion on how the couple should proceed, non-directive options counseling is an essential component to quality patient care. Please see the Options Counseling Nursing Education Module for further information and skills building for options counseling. In addition, Options Counseling for Unintended Pregnancy is a presentation from Provide’s ROE (Reproductive Options Education) Consortium that was designed to give nurses and APRNs information on attitude, skills, and knowledge needed to provide options counseling to patients who experience unintended pregnancy.

Contraceptive Methods and Abortion

U.S. Selected Practice Recommendations for Contraceptive Use, 2013
These recommendations are designed as a companion guide to the MEC and are intended to help nurses and other health-care providers address issues related to use of contraceptives, including how to help a woman initiate use of a contraceptive method, which examinations and tests are needed before initiating use of a contraceptive method, what regular follow-up is needed, and how to address problems that often arise during use, including missed pills and side effects such as unscheduled bleeding. The document is based on the World Health Association’s (WHO) global health guide to contraception. Although many of the recommendations are the same as those provided by the WHO, they have been adapted to be more specific to U.S. practices or have been modified because of new evidence.

Method Match
This interactive website from the Association of Reproductive Health Professionals (ARHP) provides fact sheets on different methods of contraception that includes information on efficacy, how each method works, benefits and contraindications to each.

IUD’s – Dispelling the Myths
This presentation from the Reproductive Health Access Project uses case studies to present factual information about intrauterine devices and their mechanisms by comparing different types of IUDs and side effects including non-contraceptive advantages.

Extended Use of the Intrauterine Device: A Literature Review and Recommendations for Clinical Practice (Wu, J.P. and Pickle, S., 2014)
This literature review concludes that there are multiple IUDs that can be used effectively to prevent unintended pregnancy beyond their manufacturer-approved timeframe. There is good evidence to support extended use of copper IUDs and levonorgestrel intrauterine system 7 years. The authors found no data to support use of the LNG-IUS 13.5 mg (Skyla®) beyond 3 years. Creinin responds to this article in a letter to the editor that recommendations for extended use of levonorgestrel IUD is premature.

Breastfeeding (Lactational Amenorrhea Method)
This web page from Association of Reproductive Health Professionals (ARHP) includes a fact sheet and short video describing how lactational amenorrhea can be used for contraception.

Recent Changes in Pregnancy and Lactation Labeling: Retirement of Risk Categories (Ramoz, L.L. and Patel-Shori, N.M., 2014)
This article provides a review and summarizes the FDA’s new pregnancy and lactation labeling rule replaces the five categories previously used.  The new rule is being implemented in response to decades of criticism in effort to improve the risk versus benefit of drugs used by pregnant and nursing mothers.

Emergency Contraception and Medication Abortion: What’s the Difference?
This one-page chart from the Society of Teachers of Family Medicine (STFM) provides a comparison of emergency contraception and medication abortion (Mifepristone/RU-486).

Emergency Contraception: Dispelling the Myths
This presentation from the Society of Teachers of Family Medicine (STFM) introduces emergency contraception using data, case studies, and providing information on mechanisms of action and contraindications.

First Trimester Abortion: A Comparison of Procedures
This chart from the National Abortion Federation shows a side-by-side comparison of three types of abortion procedures and how they work as well as advantages and disadvantages to each.

Care for Women Choosing Medication Abortion (Taylor, D., et al., 2004)
This article addresses the nurse practitioner’s role in providing medication abortions, details the pharmacology involved, and uses case studies to present counseling, complications and potential sides effects, and confirming complete abortion.

What is Medical Abortion?
This fact sheet from the National Abortion Federation defines and provides details of medication abortions, including how the medications work, how long they take, possible complications, and follow-up care.

Mifepristone for Medical Abortion: Exploring a New Option for Nurse Practitioners (Taylor, D., et al., 2004)
This article introduces Mifespristone, commonly referred to as RU-486, provides clinical considerations including a chart comparing regimens and a chart comparing medical abortion with vacuum aspiration.

Facts About Mifepristone (RU-486)
This fact sheet from the National Abortion Federation defines Mifepristone—a medication that blocks the action of progesterone—discusses how Mifepristone works, effectiveness as an abortifacient when combined with Misoprostol, possible side effects, and what women can expect when using it.

Patient-centered Counseling

Options Counseling for Unintended Pregnancy
This presentation from Provide’s ROE (Reproductive Options Education) Consortium was designed to give nurses and APRNs information on attitude, skills, and knowledge needed to provide options counseling to patients who experience unintended pregnancy.

The Counseling Session
This video from LARC FIRST is available in English and in Spanish, and provides a demonstration of high quality, non-directive counseling on contraception options.

Patient-centered Contraception
This presentation from the Reproductive Health Access Project uses case studies to determine the most appropriate contraceptive methods for different patients, detailing the risks, benefits, mechanisms of action, and other clinical considerations for each case.

National Abortion Federation 2015 Clinical Policy Guidelines
These evidence-based guidelines and standards on abortion care from the National Abortion Federation include clinical practices on patient care, counseling, and different types of abortions. These guidelines are revised annually and are based on rigorous review of medical literature and known patient outcomes to support and educate providers on the most current information, standards, and recommendations.

Pregnancy Testing and Options Counseling

Giving Pregnancy Test Results: A Primer for Nursing Students
This presentation from Provide serves as a guide for nursing students on giving pregnancy test results, identifying immediate health concerns, providing referrals, and gives an overview of laboratory pregnancy tests. Recommendations are given on specific questions to ask and counseling language to use when providing negative and positive test results, and working with a patient who is ambivalent about the test results.

Clinical Training Curriculum in Abortion Practice, 2nd Edition
Module 1, “Pregnancy Verification and Estimation of Gestational Age”, of this evidence-based curriculum from the National Abortion Federation details interpreting HcG results and ultrasound dating, determining gestational age based on last menstrual period, and determining the location of pregnancy.

Early Abortion Training Workbook
Chapter 3, “Evaluation Before Uterine Aspiration”, of this workbook from Training in Early Abortion for Comprehensive Healthcare (TEACH) discusses all types of pregnancy testing, includes a chart with methods and tips for dating ultrasounds, recommended lab tests, and evaluation for ectopic pregnancy. This is an extensive comprehensive resource on abortion care with recommendations and guidance on issues ranging from confidentiality and consent procedures to medications and pain management for different abortions procedures.

Preconception and Interconception Care

Get the Facts: Health Benefits of Using Contraception to Plan, Avoid or Space Pregnancy
This document, written as a collaboration by several health care groups, provides an overview of the health advantages of birth spacing.

Birth Spacing and Risk of Adverse Perinatal Outcomes: A Meta-analysis (Conde-Agudelo, A., et al., 2006)
This meta analysis of 11 births worldwide suggests that birth spacing less than 18 months is associated with an increased risk of adverse perinatal outcomes.

The Postpartum Visit: It’s Time for a Change in Order to Optimally Initiate Contraception (Speroff, L. and Mishnell, D., 2008)
The authors argue that it is time to change the timing of the postpartum visit to three weeks postpartum in order to appropriately assess women’s physical and social well-being and to provide contraception in a timely fashion prior to women resuming sexual intercourse to prevent unintended pregnancy.

Preconception Care Clinical Toolkit
This extensive, interactive website was designed to help primary care providers and their practices incorporate preconception health into the routine care of women of childbearing age. The toolkit includes clinical guidance, patient resources, talking points, risk reduction strategies, and reproductive life planning assessments.

LactMed
This is a very useful tool for nurses who work with lactating women. The LactMed® database contains information on drugs and other chemicals to which breastfeeding mothers may be exposed. It includes information on the levels of such substances in breast milk and infant blood, and the possible adverse effects in the nursing infant. Suggested therapeutic alternatives to those drugs are provided, where appropriate. All data are derived from the scientific literature, are fully referenced and are updated monthly by a peer review panel. LactMed has a downloadable free app.

Making Effective Referrals

Referrals for Unintended Pregnancy: A Curriculum for Health and Social Service Providers
This curriculum from Provide includes six modules with training tips, materials, role plays, and other exercises to support health care and social service professionals to provide effective referrals for high quality abortion care.

Referral-making in the Current Landscape of Abortion Access (Zurek, M., et al., 2014)
This article highlights the increasing importance of providing effective referrals for abortion care as clinic closures further limit women’s access to these services.

National Abortion Federation Find a Provider
This web page from the National Abortion Federation includes an interactive map that gives state-specific information on abortion services and clinic contact information for each state.

Find a Nurse Practitioner
This resource from the American Association of Nurse Practitioners uses an interactive map to help a consumer find a nurse practitioner in their geographic area.

Best Practices and Recommendations

Referral-making in the Current Landscape of Abortion Access (Zurek et al., 2014)
This article highlights the increasing importance of providing effective referrals for abortion care as clinic closures further limit women’s access to these services.

Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs
This set of guidelines for the provision of quality family planning and related preventive health services in primary care settings was released as a CDC Morbidity and Mortality Weekly Report (MMWR) in April 2014. The report details recommendations for the provision of contraceptive services, pregnancy testing and counseling, including effective options counseling.

Caring for Women with Unintended Pregnancies (Simmonds, K. and Likis, F.E., 2011)
This article highlights the nurse’s professional responsibilities in providing care to women with unintended pregnancies which includes appropriate assessment, options counseling, referrals and care coordination, and prevention efforts.

The Postpartum Visit: It’s Time for a Change in Order to Optimally Initiate Contraception (Speroff, L., and Mishnell, D., 2008)
The authors argue that it is time to change the timing of the postpartum visit to three weeks postpartum in order to appropriately assess women’s physical and social well-being and to provide contraception in a timely fashion prior to women resuming sexual intercourse to prevent unintended pregnancy.

This module frames contraceptive options and unintended pregnancy prevention in the context of maternity and postpartum care. Nurses working with women who are about to give birth, or who come for a postpartum visit have an opportunity to support patients to develop and achieve their reproductive life plan through patient-centered contraceptive management and options counseling.

These modules are designed to use with a flipped classroom model in which students are directed to complete the module as homework, including the Pre- and Post-Assessments. Once students have completed the module in its entirety, including the recommended reading, faculty can use the Teaching Tips document and materials from the Exercises and Handouts section below to integrate concepts from the module into the classroom or group setting.

Teaching Tips

Exercises and Handouts

These materials can be used to enhance classroom learning. The Teaching Tips document provides recommendations on how to incorporate these materials into a classroom or group setting.

Contraception Counseling: Provider Tips and Patient Questions: This handout from CORE (Curricula Organizer for Reproductive Health Education) identifies specific questions for providers to consider and use when supporting patients in choosing a contraception that is best for them.

Preconception Care Clinical Toolkit: Use the reproductive life planning assessments and talking points from this toolkit for in-class activities.

WHY Refer: Use materials in Module 1 of Referrals for Unintended Pregnancy: A Curriculum for Health and Social Service Providers from Provide to highlight the importance of appropriate referrals, present a simple model for effective referral-making, and help providers identify their personal values.

HOW to Refer: Use materials in Module 2 of Referrals for Unintended Pregnancy: A Curriculum for Health and Social Service Providers from Provide to present referrals as part of services provision, identify general barriers to accessing abortion care, and demonstrate best practices for referrals.

Postpartum Contraception In-Class Presentation

For a more traditional approach to classroom learning, content from the Postpartum Contraception online module was used to develop this 15 – 20 minute presentation. Faculty can use this presentation in the classroom as a substitute for students completing the module independently. The Teaching Tips document and exercises and handouts that are provided as part of the module can be used to supplement this presentation and incorporate student participation in class.

Accessing Student Pre- and Post-Assessment Data

Pre- and Post-Assessments are designed to measure students’ satisfaction with the module as well as what they have learned. To be able to complete the Assessments students will need to enter a “Site Code” prior to working through the online module. Faculty will use this Site Code to download and review students’ Pre- and Post-Assessment data. To obtain a Site Code your institution must e-mail Provide. In the text of the email, please include your name (as instructor), the name of the institution, and the module(s) for which you would like to access data. Provide will send you 1) a Site Code for your students to enter at the beginning of the assessment, 2) a web link to access the results from each module, and 3) an “answer key” to help grade your students’ responses. You may also assign a unique Student Code to each student that you would like to assess on an individual basis. Students must enter the correct Site Code for faculty to be able to access their data.

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