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Contraceptive Management

RNs who are CRNBC-certified in reproductive health — contraceptive management use the DSTs listed below to administer and/or dispense combined hormonal contraception and progestin-only hormonal contraception.

 Introduction to Contraceptive Management Certified Practice

About Contraceptive Management

Overview

Definitions and Abbreviations

Overview

Registered nurses who complete CRNBC certification in Contraceptive Management (CM) can independently provide (dispense and/or administer) hormonal contraception to eligible clients as set out in CRNBC-approved CM decision support tools (DSTs).

The CM certified practice assessment is based on a client's medical eligibility criteria and their desire for a reliable, reversible, coitally-independent method of contraception. Clients seeking or using hormonal contraception for a sole purpose other than contraception must be referred to a physician or nurse practitioner for an order or transfer of care.

The CM products included in the Competencies and DSTs for CM certified practice are:
Combined Hormonal Contraception (CHC):

  • combined hormonal oral contraceptive pills
  • transdermal contraceptive patch
  • transvaginal contraceptive ring

Progestin-Only Hormonal Contraception (POHC):

  • progestin-only oral contraceptive pills
  • progestin-only injectable contraception (DMPA, Depo-Provera)

The Decision Support Tools (DSTs) are evidenced-based documents used to guide the assessment, diagnosis and treatment of specific clinical problems or conditions. When DSTs are used to direct practice, they are used in conjunction with clinical judgment and available evidence. Nurses also consider client needs and preferences when using DSTs to make clinical decisions. Where there were gaps or inconsistencies in the evidence for contraceptive management (CM), expert opinion was obtained.

The DSTs for CM are based on specific medical eligibility criteria. Relative and absolute contraindications for hormonal contraception are from the U.S. Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 which was adapted from the World Health Organization's (WHO) Medical Eligibility Criteria for Contraceptive Use (4th ed.). The U.S. CDC resource provides recommendations specific to chronic diseases that are not acknowledged in the WHO resource. Additional details and Canadian recommendations were sourced from the Canadian Contraceptive Consensus by the Society of Obstetricians and Gynecologists (SOGC) of Canada.

Consultation or referral to a physician or nurse practitioner is required for all women whose condition or medical history places them in a Medical Eligibility Criteria Category 3 or 4 as per Appendix 2 in the Contraceptive Management: Assessment DST.

CM certified practice includes the following resources:

  • Competencies for Reproductive Health: Contraceptive Management
  • Decision Support Tools:
    • Contraceptive Management: Assessment
    • Combined Hormonal Contraception
    • Progestin-Only Hormonal Contraception

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Definitions and abbreviations

Abnormal Uterine Bleeding (AUB) – See Unexplained Vaginal Bleeding

ACHES – mnemonic that represents signs and symptoms of possible serious complications from hormonal contraception

  • Abdominal pain – (severe)
  • Chest pain – (severe) cough, shortness of breath
  • Headache – (severe) dizziness, weakness or numbness, new or worsening with or without aura
  • Eye problems – (vision loss or blurring), speech problems
  • Severe leg pain – (calf or thigh) swelling heat or tenderness

Break Through Bleeding (BTB) – vaginal bleeding that requires use of sanitary protection during the time of active hormonal contraception.

Combined hormonal contraception (CHC) – hormonal contraception that contains both estrogen and progestin

Continuous use – ongoing use of a CHC without a consistently planned hormone-free interval

Consult – conferring with a health care provider for information and direction without transferring care

DMPA – depot medroxyprogesterone acetate, brand name Depo-Provera™

EC – emergency contraception, 150mg levonorgestrel in a single oral dose if unprotected intercourse occurred in past 5 days, or copper IUD if unprotected intercourse occurred within the past 7 days

ECP – emergency contraceptive pill(s)

Extended use – using a CHC for two or more cycles without a hormone-free interval with a planned hormonal-free interval

Hormone Free Interval (HFI) – the interval in which a client using combined hormonal contraceptives takes either a placebo dose or ≤7 days off, this is typically the period of time in which the client will have a hormone withdrawal bleed (aka: menses).

Hormone Withdrawal Bleed – the vaginal bleeding that occurs when combined hormonal contraception is abruptly discontinued, not a “true” menses because ovulation has not occurred.

Low-dose combined hormonal contraception – CHCs containing less than 50mcg of ethinyl estradiol per day

Medical eligibility criteria (MEC) – WHO convened a working group of experts to develop medical eligibility criteria based on the latest clinical and epidemiological data. The U.S. Centers for Disease Control and Prevention adapted the WHO criteria and included additional recommendations specific to many chronic illnesses and diseases. In combination, these are evidence-based criteria for which to determine medical eligibility for contraceptive use.

  • Medical eligibility criteria category 1 – a condition for which there is no restriction for the use of the contraceptive method
  • Medical eligibility criteria category 2 – a condition for which the advantages of using the method generally outweigh the theoretical or proven risks
  • Medical eligibility criteria category 3 (Relative Contraindications) – a condition for which the theoretical or proven risks usually outweigh the advantages of using the method
  • Medical eligibility criteria Category 4 (Absolute Contraindications) – a condition that represents an unacceptable health risk if the contraceptive method is used

PID – Pelvic inflammatory disease

Progestin-only hormonal contraceptive (POHC) – hormonal contraception that contains only progestin and no estrogen

Referral – transferring care to another health care provider

Risk factors for VTE – Smoking and age ≥35 years; previous VTE, deep venous thrombosis and or pulmonary embolism; known thrombogenic mutations; peripartum cardiomyopathy; immobility; transfusion at delivery; BMI ≥30 kg/m2; postpartum hemorrhage; post-cesarean delivery; preeclampsia; strong family history consistent with inherited thrombophilia, such as unprovoked venous thromboembolism in a first degree relative or several first and second degree relatives under the age of 50. Unprovoked VTE includes VTE not associated with pregnancy, cancer, airline travel, surgery, obesity or immobilization.

Shortened hormone-free interval– occasionally or consistently shortening the hormone-free interval to less than seven days while using CHCs

Spotting – any bloody discharge that does not require sanitary protection

STI – sexually transmitted infection

Unexplained vaginal bleeding – any variation from the client’s normal menstrual cycle. Vaginal bleeding is abnormal when it is unexplained; there is change in the frequency of the menses, the duration of flow or the amount of blood loss or it occurs at an unexpected time of life (before age 10, during pregnancy or after menopause).

Venous thromboembolism (VTE) – deep vein thrombosis (DVT) and pulmonary embolism (PE) represent different manifestations of the same clinical entity, which is referred to as venous thromboembolism. VTE is a rare, but a potentially serious condition that usually involves a blood clot in the deep veins of the legs and or pelvis.

WHO – World Health Organization

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 Competencies

 Decision Support Tools (DSTs)

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