Contraception Counselling and Initiation Note

Contraception Counseling and Initiation Note Consultation Context and Patient Goals: Patient is a 28-year-old female presenting for contraception counselling. She is in a stable, monogamous relationship and desires long-term, highly effective contraception. She is not planning pregnancy for at least 3-5 years. She is 12 weeks postpartum after an uncomplicated vaginal delivery. Medical and Sexual Health History: Menstrual history: Regular cycles, 28-day intervals, moderate flow, lasting 5 days. No history of dysmenorrhea or menorrhagia. Last menstrual period was 10 months ago due to pregnancy. No history of STIs. Previous contraception use includes combined oral contraceptive pills (COCPs) for 5 years, discontinued prior to conception. Experienced mild nausea initially with COCPs but tolerated well long-term. No known contraindications to hormonal contraception (e.g., no history of DVT/PE, migraine with aura, uncontrolled hypertension). Options Discussed and Counseling Provided: Discussed various contraceptive methods including: Long-Acting Reversible Contraception (LARC) – specifically intrauterine devices (IUDs) (both hormonal and copper) and contraceptive implants; Combined Oral Contraceptive Pills (COCPs); Progestogen-only pills (POPs); and barrier methods (condoms). Detailed the risks and benefits of each method, including effectiveness rates, common side effects, and mechanism of action. Emphasised LARC methods for their high effectiveness and convenience. Discussed potential side effects of hormonal IUDs (e.g., irregular bleeding, amenorrhea) and copper IUDs (e.g., heavier periods, increased cramping). Patient expressed interest in a hormonal IUD due to its efficacy and potential for lighter periods. Eligibility for hormonal contraception was confirmed based on her medical history. Chosen Method and Initiation Details: Patient has chosen the Levonorgestrel Intrauterine System (Mirena). Informed consent was obtained for insertion. The procedure is scheduled for 1 November 2024, at 10:00 AM, in the clinic. Patient advised to take ibuprofen 600mg one hour prior to the appointment. Prescribed a 7-day course of Doxycycline 100mg twice daily to start 2 days prior to insertion for infection prophylaxis. Follow-up appointment scheduled for 6 weeks post-insertion to check IUD placement and address any concerns. Advice and Safety Information: Advised to use condoms as a backup method for the first 7 days post-insertion, as full protection from the IUD begins after this period. Provided information on expected bleeding patterns post-insertion (irregular spotting/light bleeding for several months, potentially leading to amenorrhea). Counselled on symptoms requiring immediate medical advice: severe abdominal pain, fever, unusual or foul-smelling vaginal discharge, heavy bleeding, or missing strings.