Contraceptive Procedure Consent

Preprocedure assessment and informed consent apply to every contraceptive procedure: implant insertion and removal, IUD insertion and removal, vasectomy and female sterilisation. The purpose is to confirm that the patient wants the procedure, is eligible, is not pregnant, has no condition that makes the procedure unsafe, and understands what will happen. A short, structured check on the day of the procedure prevents most serious errors.

Indications for a formal assessment. Any planned insertion, removal or surgical procedure, and any patient presenting with a complication from an earlier procedure.

Eligibility and pregnancy. Confirm the method is suitable using the focused history, and exclude pregnancy with the checklist or a test. For IUD insertion and sterilisation the threshold for excluding pregnancy is stricter.

Procedure-specific history.

• Implant: bleeding disorder or anticoagulant treatment, keloid or hypertrophic scarring, allergy to local anaesthetic or antiseptic, enzyme-inducing medicines.

• IUD: symptoms or signs of cervicitis or pelvic infection, unexplained bleeding, uterine anomaly or fibroids, previous failed insertion, cervical surgery, copper allergy or Wilson disease (copper IUD), recent delivery or abortion, breastfeeding.

• Sterilisation and vasectomy: age, parity, stability of the relationship, certainty that no more children are wanted, previous pelvic or abdominal surgery, anaesthetic risk.

• All procedures: fainting during previous procedures, latex allergy, current medicines, and HIV and hepatitis B status when known.

Examination. Blood pressure and pulse before any procedure. Inspect the arm before an implant, perform an abdominal examination followed by a bimanual and speculum examination before an IUD, and examine the scrotum before vasectomy.

Equipment and environment. A private room with a couch and good light; resuscitation equipment and emergency drugs within reach (adrenaline 1 mg in 1 mL ampoules, oxygen, bag-valve mask, intravenous access); sterile instruments; a trained assistant.

Consent discussion.

• Confirm the patient's identity, the planned method and, for an implant, the arm.

• Explain in plain language what the procedure is, how it is done, how long it takes, what it will feel like, the analgesia offered and the alternatives, including no procedure.

• State the benefits, the common effects and the risks that matter.

• Ask the patient to repeat the main points in her own words.

• Tell her she may stop the procedure at any time by saying so.

Risks to state.

• Implant: bruising and tenderness; infection in about 1 in 100 or fewer; rare deep insertion with nerve or vessel injury; expulsion; changes in bleeding pattern.

• IUD: cramping; expulsion in about 2 to 10 in 100 in the first year; perforation in about 1 in 1,000 or fewer (higher while breastfeeding and in the first weeks after delivery); infection in the first 20 days; ectopic pregnancy if the method fails.

• Sterilisation and vasectomy: failure, permanence, regret, and surgical and anaesthetic risk.

Recording consent. Written, signed consent is needed for sterilisation and vasectomy. For implants and IUDs record the consent in the notes or on a consent form, using the facility's usual practice. The patient may withdraw consent at any point and the procedure stops.

Pause before starting. Check aloud: right patient, right method and device, pregnancy excluded, eligibility confirmed, allergies checked, consent given, analgesia given, instruments sterile and device in date, assistant present, aftercare planned. Do not begin until every item is answered.

Preprocedure medicines. Ibuprofen 400 to 800 mg orally 30 to 60 minutes before IUD insertion when there is no contraindication. No routine antibiotic prophylaxis for IUD or implant insertion. The patient may eat and drink normally except before a sterilisation under general anaesthesia.

Problems found at assessment.

• Pregnancy found or suspected: do not proceed with an IUD or sterilisation; manage the pregnancy and give an interim method.

• Cervicitis or pelvic infection: delay IUD insertion, treat, and give condoms and another method meanwhile.

• Bleeding disorder or anticoagulant: avoid an implant if another method is suitable, or apply a prolonged pressure bandage; discuss significant coagulopathy with a specialist.

• Doubt, pressure from a partner or relative, or unclear consent: stop, offer time and a private interview, and give an interim method.

Vasovagal reaction. Pallor, sweating, slow pulse, nausea or fainting. Stop, lay the patient flat with the legs raised, loosen clothing, give oxygen if available, monitor pulse and blood pressure, and give atropine 0.5 mg intravenously only for persistent symptomatic bradycardia.

Anaphylaxis to local anaesthetic or antiseptic. Adrenaline 0.5 mg (0.5 mL of 1 in 1,000) intramuscularly into the anterolateral thigh, repeated after 5 minutes if needed; call for help; give oxygen and intravenous fluids; chlorphenamine 10 mg and hydrocortisone 200 mg intravenously as additional treatment.

Anxiety and distress. Slow down, explain each step, allow a support person and offer a pause.

Documentation. Record the assessment, consent, basis for excluding pregnancy, allergies, analgesia given, any problem and the name of the provider. Give the patient a card with the method, date, device batch where relevant and the date for removal or review.

Instructions. Give clear verbal and written warning signs and return instructions for the specific procedure, and give condoms.

Review. Arrange follow up that the procedure needs: implant site check, IUD review at 3 to 6 weeks, sterilisation or vasectomy wound check.

Special groups. Adolescents: assent and, where the law requires, guardian consent, with a private interview. Postpartum and postabortion patients: counsel and obtain consent before delivery or abortion, never during labour or acute distress. Patients with disability: adapted communication and supported decision making.

Referral and escalation. Refer when the procedure is beyond the provider's training, when examination suggests malignancy or a uterine anomaly, or when the patient needs specialist anaesthetic or surgical care.