5.7: Emergency Contraception

Learning Objectives

By the end of this section, you will be able to:

• Compare and contrast the available methods of emergency contraception
• Explain the education a nurse would provide to a patient seeking emergency contraception

If administered within a specific time after sexual intercourse, emergency contraception (EC) is a form of contraception that is effective in interrupting a pregnancy before it begins. A person may choose to use emergency contraception because of condomless sex, a sexual assault, a faulty contraceptive method such as broken condom, missed or late DMPA injection, missed combination oral contraception pills, or expired diaphragm use. Emergency contraception must be initiated within 72 hours of intercourse, or 120 hours if using ulipristal acetate (Ella), to be effective at preventing pregnancy (Dickey & Seymour, 2021). Taken within 72 hours, emergency contraception is between 85 percent and 99 percent effective according to research (Hatcher, 2018). Emergency contraception prevents pregnancy; it does not abort or remove a pregnancy.

Forms of Emergency Contraception

Forms of EC that will be discussed in this section include high-dose levonorgestrel and ethinyl estradiol (Yuzpe), high-dose levonorgestrel (Plan B; Plan B One-Step), ulipristal acetate (Ella), and the Paragard IUC. Ella, Yuzpe, and the IUC all require a visit with a health-care provider and a prescription; Plan B One-Step can be purchased without a prescription over the counter at most pharmacies (Dickey & Seymour, 2021). All clinicians who care for reproductive-age patients should have knowledge about EC; however, a recent study revealed that only 64 percent of clinicians in emergency departments knew about EC (ACOG, 2015).

Emergency contraception pills include Yuzpe regimen, Plan B/Plan B One-Step, and Ella (ACOG, 2015). Yuzpe is a combined progestin-estrogen pill that is available by prescription only and must be taken within 72 hours after intercourse. This method has many side effects such as cramping and nausea and is therefore no longer widely used (Gragnolati, 2022). Its mechanism of action is to prevent ovulation. Levonorgestrel EC (Plan B/Plan B One-Step) is a progesterone-only tablet that is available over the counter. The mechanism of action is to prevent ovulation and disrupt luteal function (Hatcher, 2018). It should be taken as soon as possible after unprotected intercourse but can be taken up to 72 hours after the act; however, effectiveness decreases each day during those 3 days (Hatcher, 2018). The newest form of EC in the United States is the progesterone agonist/antagonist pill known as Ella. Ella is a single pill containing 30 mg of ulipristal (progesterone agonist/antagonist), which prevents follicular rupture and delays proliferation of the endometrium if ovulation has occurred (Dickey & Seymour, 2021). Ella works best within 72 hours, but unlike the other EC pills, Ella can be effective up to 120 hours, and its effectiveness does not decrease during those 5 days (Dickey & Seymour, 2021).

Although not FDA approved for this indication, the most effective form of EC is insertion of a Paragard IUC. Research from clinical trials indicates that EC pills used within 24 hours prevent around 67 percent of pregnancies. In contrast, insertion of the copper intrauterine contraceptive Paragard prevents 99 percent of pregnancies if inserted within 120 hours of unprotected intercourse (Dickey & Seymour, 2021; Hatcher, 2018). The mechanism of action for the Paragard IUC is prevention of fertilization by affecting sperm viability and function, disrupting the endometrial environment, and preventing implantation (Hatcher, 2018).

Table 5.14 summarizes the pros, cons, and efficacy of different methods of EC.

Method	Pros	Cons	Typical Use Efficacy
Yuzpe (estrogen/progesterone)	Effective	Side effects of estrogen (ACHES), effective up to 72 hours	62%–85%
Ella (progesterone agonist/antagonist)	Effective, can be effective up to 120 hours	Must have a provider visit and a prescription	62%–85%
Plan B	Effective, available over the counter	Effective only up to 72 hours	62%–85%
Progesterone=only EC	Effective, single pill, over the counter	Effective up to 72 hours and moderately effective up to 5 days after	62%–85%
Copper IUC	Very effective, can be used for ongoing contraception, can be used up to 120 hours	Must see a provider to have it placed	99%

Table 5.14 Comparing and Contrasting Methods of Emergency Contraception (Hatcher, 2018)

Nurse-Provided Education

Emergency contraception can be a very personal, private issue that some people are uncomfortable discussing. The nurse can discuss EC with patients in a way that helps the person feel empowered to make decisions, especially in a situation where they may have been victimized. Framing nurse education to ensure that the patient does not feel judged, devalued, or revictimized is important to building a healthy, trusting relationship. After explaining the use of EC, the nurse will discuss beginning a routine contraceptive method and ways to improve safe sex. The nurse will also screen for intimate partner violence (IPV) in the relationship. Establishing trust is vital for these conversations so that the patient can make effective, informed decisions. See Chapter 3 Health Promotion, Disease and Injury Prevention, and Well-Person Care for screening tools for IPV.

Real RN Stories

Nurse: Joy, RN, BSN
Clinical setting: Planned Parenthood
Geographic location: Plano, Texas

As an RN, I recently had a heartwarming interaction with a young patient who visited our clinic asking about emergency contraception. I could feel her anxiety and uncertainty as she voiced her concerns about what it would mean to get pregnant and how she felt about stopping or preventing a pregnancy. She was a college student and wanted to graduate before thinking about starting a family. I explained what emergency contraception options were available. I explained the morning after pill and the IUD and answered her questions. She wanted to know how each option worked and if it would affect her future chance of having children. As I explained more, I saw the relief in her eyes to know it would not cause problems getting pregnant in the future. She decided on the morning after pill and thanked me for all the education I provided. She told me no one had ever spent that much time with her at a clinic and she was so grateful for my kindness. I handed her additional resources and wished her luck with graduation. As she walked out the door, I couldn't help but feel proud of being a nurse and helping this person. It was a really amazing moment.

Warning Signs and When to Follow Up

Anytime a patient has unplanned, unprotected sexual intercourse and uses EC, the nurse will educate the person on warning signs that pregnancy has occurred or warning signs of complications from the EC. The risks are mostly short term, but they still warrant careful attention. No scheduled follow-up is required for a patient using EC unless menstruation is delayed by more than 1 week or if abdominal pain, irregular bleeding, or fever occurs, suggesting a possible ectopic pregnancy (ACOG, 2015). Side effects from use of EC include change in menstrual cycle, nausea and vomiting, fatigue, headaches and dizziness, and cramping (Hatcher, 2018).

ACHES

For EC containing estrogen and progesterone, such as Yuzpe, this is a one-time high dose of hormones. The nurse provides education about when to return to the office or the emergency department if the patient begins to feel any symptoms of ACHES (see Table 5.9). If the person experiences any of these symptoms, the nurse should advise them to call the office immediately or go to the emergency department to check for blood clots, stroke, and cardiovascular involvement.

Return of Regular Menses

A person using emergency contraception can expect their menstrual period to return around 7 to 10 days after the dose. If menstruation does not occur, the patient should take a pregnancy test to determine if the EC was effective. If a positive test is confirmed, the person should make an appointment to see their health-care provider immediately.

Sexually Transmitted Infections

When a patient presents to a nurse with concerns about possible pregnancy from unprotected intercourse, an assessment should be completed for exposure to sexually transmitted infections (STIs). For more about STIs, diagnostic tests, and treatment, see Chapter 7 Commonly Occurring Reproductive and Genitourinary System Infections.

Use of Contraception

Emergency contraception should not be used as a form of ongoing contraception. The nurse will have a conversation with the patient about what form of ongoing contraception will be used in the future. The nurse evaluates what occurred that caused unprotected intercourse to determine if the contraceptive method the patient was using failed and if a different method would give better protection. If the patient decides to choose a new method of contraception, COCs can be started after menstruation returns and pregnancy is ruled out. In the meantime, the nurse should recommend a barrier method for pregnancy prevention. Because EC works by delaying ovulation, persons need to be cautioned that pregnancy can occur in the same menstrual cycle (ACOG, 2015). By choosing the Paragard IUC for EC, the patient has the benefit of ongoing contraception being in place. The nurse will provide education about the PAINS warning signs discussed earlier in the chapter and educate the patient to call the office if any symptoms arise.