Oxford Handbook of Midwifery (115 page)

Points to remember

for evidence of skin irritation or allergy, even though the patch is hypoallergenic, and ask her to return immediately if skin irritation should occur, but to continue to wear the patch until an alternative method of contraception is organized.

• A 24h telephone helpline
  
• Online support
  
• Text message reminder on patch change day.
  

  CHAPTER 22
  Contraception
  

  536‌‌
  

  Contraceptive vaginal ring
  

  • The ‘pill in a ring’ (Fig. 22.3) became available in the UK in 2009 and is designed as an alternative to taking a pill daily. Known as Nuvaring
    ^®
    in the UK.
    
  • It is a combination oestrogen and progesterone drug and can be given to any woman who is suitable for the combined pill.
    
  • Each ring lasts for 3 weeks, i.e. one ring per menstrual cycle, with a ring free week in the fourth week, during which a withdrawal bleed ‘period’ will occur.
    
  • The daily release of hormone is 15micrograms ethinylestradiol and 120micrograms etonorgestrel. Hormone release occurs continuously and the body does not store the drug. It is designed to inhibit ovulation.
    

    Using the ring
    

    She should:
    

  • Insert the vaginal ring on the first day of the next period or no sooner than day 21 after giving birth or having a second trimester abortion. After a first trimester abortion she can start immediately. Ask her to note the start day. This is the day that she will always insert a new ring.
    
  • Place the ring as high in the vagina as she can; a similar technique to
    inserting a tampon.
    
  • Leave the ring in position for 21 days. After the three completed weeks, tell her to then have a 7 day break, during which withdrawal bleeding will occur.
    
  • Remove the ring 3 weeks after insertion on the same day of the week at about the same time of day that it was inserted. Hook the index finger under the forward rim or hold the rim between the index and middle finger and pull it out.
    

    Points to remember
    

  • Remind her to check regularly that the ring is firmly in place.
    
  • If the ring is accidentally expelled and is left outside of the vagina for less than 3h, contraceptive efficacy is not reduced. Replace the ring in the vagina.
    
  • If the ring is out of the vagina for more than 3 continuous hours during weeks 1 and 2, contraceptive efficacy may be reduced. She should insert the ring as soon as she can. Additional contraception, usually in the form of the male condom, should be used for the next 7 days.
    
  • If the ring is out of the vagina for more than 3 continuous hours in week 3 she should discard that ring. She can at that point either:
    
    • Insert a new ring immediately for another 3 weeks
      

      or
      

    • Have a withdrawal bleed and insert a new ring no later than
      

      7 days from the time the previous ring was removed or expelled. Additional contraception, usually in the form of the male condom, should be used for the next 7 days.
      

      CONTRACEPTIVE VAGINAL RING
      

      537
      

Storage

54mm

4mm

Squeeze the ring between thumb and forefinger ready for insertion into vagina

Fig. 22.3
Vaginal ring.

Insert in an upwards and backwards motion into the posterior fornix

To remove, place the forefinger over the lower edge and pull gently

Copyright © fpa 2009 and reproduced by permission of the publisher.

CHAPTER 22
Contraception

538‌‌

Progesterone-only pill

Contents

• Tablets containing progesterone only.
  
• Dispensed in packs containing either 28 or 35 days’ pills, depending on brand.
  
• Designed to prevent implantation of the fertilized ovum, which, depending on personal beliefs about when life begins, may not be acceptable to all women. However, in long-term users of the POP, ovulation does become inhibited.
  

  The desogestrel pill, Cerazette
  ^®
  , licensed in the UK in 2002, has a different mode of action from standard POPs and is the first choice POP in women <40, who need highly effective contraception. It is designed to inhibit ovulation: in clinical trials ovulation was inhibited in 99% of cycles at 7 and 12 months after initiation and has been shown to be as effective as the combined pill.
  

  Indications
  

  There are a number of indications for the POP:
  

• The woman’s choice
  
• Breastfeeding: all POPs secrete a very small amount of progestogen
  to the infant, the equivalent of one POP in 2 years, which is much less
  

  than the progesterone level found in dried cow’s milk.
  ¹
  POPs do not
  

  interfere with lactation
  

• Hypertension
  
• Migraine (particularly focal migraine)
  
• Diabetes
  
• Obesity
  
• Older women, particularly smokers >35
  
• Side-effects of the combined pill
  
• Sickle-cell disease.
  

  When is it taken?
  

• Advise the woman to choose a time of day that is most convenient and best remembered. A useful tip to help her remember is to set an alarm on her mobile phone if she has one. Her partner or other close relative could be of help in reminding her, if she is liable to forget.
  
• Ideally, the woman should start the first pack on the first full day of menstrual bleeding. If this is done, there is no need for additional contraception in the first cycle.
  
• However, if the pill is started later than the second day of the cycle it is advisable to use condoms every time sexual intercourse occurs in the next 7 days. After that, the hormonal control will be established.
  

  This advice also applies when started postnatally in a non-breastfeeding woman who has not yet had her first period following birth.
  

• It is not started in the latter half of the menstrual cycle, because of the risk of pregnancy, even if full sexual intercourse has not occurred.
  

  PROGESTERONE-ONLY PILL
  

  539
  

  Missed pill