Prescribing Emergency Contraception in ED

We are faced by this issue on our day to day life in the EDs or Urgent Care centers, Hence the CEM has presented this as a part of our curriculum for the OSCE Exams. It not only tests, the examinee's skill in dealing with a sensitive issue but also assesses his knowledge and understanding of the legal ruling in treating minors.

Introduce
Ask Name, Age, and Occupation.
Ask name, and relationship of attendant.
I have been asked to attend to your problem and provide you with presciption, is it correct? But before I begin, I need to ask you a few questions, Is that Okay with you?
Sir/Mam (Attendant), Do you mind waiting out in the lobby, while I ask her few questions?
I want to ask for a nurse as a chaperone.
Ms. ABC, I would like to assure you that, I would provide you every help, but I need to ask certain questions before that. Some questions might be embarrassing, but these are routine questions we ask in such cases, and whatever discussion we have shall be kept confidential.
So, shall we proceed? How can I help you?

I Need an E pill. Okay, I need to know few things about your sexual activity before I prescribe you?

When it happened?
Consensual?
Did penetrative sex took place?
Age of the partner?
Planned or on impulse?
Alcohol or drug involved?
Any contraception used?

Menstrual history:
LMP, Regularity, any discharge, inter menstrual bleedings,

Obstetrics:
Is there any chance that you are pregnant?
Did you have any pregnancies/miscarriages/abortions in past?

Sexual history:
Active with this partner ONLY? Any other partner, now or in past?
Regularly use Contraceptives?
Any History of STDs in you? or in any partner?

Medical illness in past:
Porphyria, Liver disease, blood transfusion

Smoking, urinary complaints.

2 Options:

Levonorgestrel 1.5 mg PO stat
Effective within 72 hours
If vomitted in first three hours, retake it.

Copper IUD
effective within 5 days
Risk of Perforation, Pregnancy (ectopic), PID, Pain, Requires trained Professionals to insert.

Arrange Follow Up:
Counsel Safe Sex Practice
In 3 weeks with FP to ensure she is not pregnant
Urine B HCG if menses delayed by 5 days or abnormal (too less or heavy bleeding)
If heavy bleeding, or pain in abdomen or pelvis, return to ED



FRASER RULING (GILLICK COMPETENCE):

It Clarifies the legal position of treating children under 16 years without parental consent.

Criteria are:

1. Patient understands what has been proposed
2. She is encouraged to inform her parents but could not be persuaded to do so.
3. Prescribing treatment is in the best interest of the patient
4. The patient will begin or continue sexual activity with or without contraception.
5. Their physical and mental health may suffer if treatment is not provided