After.pdf

Women’s Health Associates
Obstetrics and Gynecology


Facts about the "Morning After Pill"
(Postcoital Hormonal Contraception)

WHAT IS IT? - The "morning after pill" is a birth control pill commonly called Ovral. When prescribed as a
"morning after pill" only four pills are used out of the packet and they must be started within 72 hours of
unprotected intercourse.
HOW IT WORKS - Two pills are taken within 72 hours of unprotected intercourse, then 12 hours later two more
pills are taken. Your next menstrual period should begin sometime within the next 2 to 3 weeks. When used in this
manner, the pills may keep the ovary from releasing an egg, prevent egg and sperm from joining and/or change the
lining of the uterus(womb) in such a way that if an egg is fertilized by a sperm, the fertilized egg may not attach
(implant) and develop into a pregnancy.

EFFECTIVENESS - The "morning after pill" is not 100% effective. Some pregnancies do occur because a
fertilized egg has already implanted, too much time has gone by between unprotected vaginal intercourse and taking
the pills, or due to a failure of the drug itself. You must return to the clinic in 3 weeks for an examination and
pregnancy test.

WHO CAN USE IT? - Not all women should be given the "morning after pill. The decision to prescribe this
drug must be based on complete and accurate information given by the patient about her past and present health, the
time of unprotected intercourse, a physical examination, and a highly sensitive pregnancy test. A few conditions rule
out the "morning after pill" entirely: having blood clots, inflammation of the veins, serious liver disease,
unexplained bleeding from the vagina, any suspicion of abnormal growth or cancer of the breast or reproductive
organs, or an already established pregnancy. In rare cases there is a slightly greater chance of developing certain
serious problems, such as blood clots, stroke and heart attack (women age 35 and older, who smoke heavily are at
greatest risk).
COMMON REACTIONS - The most noted common reactions are: nausea and/or vomiting, breast tenderness,
irregular bleeding and headaches.
POSSIBLE PROBLEMS - Some studies have shown that some offspring of women who take estrogen
hormones during pregnancy have birth defects of their reproductive systems. Symptoms to report to a doctor are:
chest or arm pain, shortness of breath, unusual swelling or pain in the legs, severe headaches, eye problems such as
blurred or double vision, pain in the abdomen, yellowing of the skin or eyes, severe depression.
If you are seeing a doctor, or see a doctor for any reason before you have a menstrual period, be sure to tell him/her
that you are taking or have taken the "morning after pill."
Informed Consent for Postcoital Hormonal Contraception
"Morning After Pill"

Examination and Treatment

Before you give your consent, be sure you understand both the pros and cons of using the postcoital contraception.
This form outlines the possible complications that can occur with use of these pills and the danger signs you should
watch for. If you have any questions as you read, we will be happy to discuss them, and you can change your mind
at any time prior to starting this method. Also, bear in mind that your consent is entirely voluntary.
Instructions to Patient:
Place your initials to the left of each statement to indicate that you have read, understand and agree with the
statement.
INITIALS
______ The "morning after pill" is a hormone or combination of hormones. ______ These pills are taken after having unprotected vaginal intercourse in the time of my menstrual cycle when I am most likely to get pregnant. This method is to be used as an emergency measure only and not as a main method of birth control. ______ The pills may keep the ovary from releasing an egg, prevent egg and sperm from Joining, and/or change the lining of the uterus (womb) in such a way that if an egg is fertilized by a sperm, the fertilized egg may not attach (implant) and develop into a pregnancy. The pills should be started within 72 hours after even a single act of unprotected vaginal intercourse. ______ Taking the "morning after pill" is a different use of these hormones than is usual and customary, and I understand that I will receive the FDA-approved information provided by the manufacturer of the pills. I understand it is my responsibility to read it and ask any questions I may have, and that the FDA has not approved this medication specifically for postcoital hormonal contraception. ______ Some studies have shown that some of the offspring of some women who take estrogen hormones during pregnancy have birth defects of their reproductive systems. I understand estrogen hormones are present in this method of treatment I am seeking, and if treatment fails I must accept this risk should I decide to continue the pregnancy. ______ I understand a sensitive urine pregnancy test and a pelvic exam will be done to try to rule out the presence of an already established pregnancy, and that the earlier the pregnancy test and pelvic exam, the greater the chance of error. The correctness of the results of the pregnancy test is not guaranteed whether positive or negative. I hereby release Women's Health Associates and its medical staff and employees from any and all liability arising out of or connected with this pregnancy test and particularly with regard to any errors in diagnosis based on this test. ______ As a result of taking the "morning after pill, " I may have a slightly greater chance than non-pill users of developing certain serious problems which may become fatal in rare cases, including: blood clots, stroke, heart attack (women age 35 and older are at greatest risk). ______ I understand use of these pills should not be used if I have had, or now have: blood clots, inflammation in the veins, serious liver disease, unexplained bleeding from the vagina, any suspicion of abnormal growth or cancer of the breast or reproductive organs, an already established pregnancy. ______ Some minor reactions to these pills may include: nausea and/or vomiting, breast tenderness, irregular ______ I understand if I see a doctor for any reason before I get my period, I should tell him/her that I have taken or are taking the "morning after pill." ______ I know to watch for the following danger signs and to report any of these symptoms to a clinician immediately: chest or arm pain, shortness of breath, unusual swelling or pain in the legs, severe headaches, eye problems such as blurred or double vision, pain in the abdomen, yellowing of the skin or eyes, severe depression. ______ I have received fact sheets containing information on the use, effectiveness, and medically recognized risks of the available birth control methods including oral contraceptives (birth control pills),intrauterine device (IUD), diaphragm, and other contraceptive methods, and understand a clinician is available to answer any questions I may have. ______ I understand if tests for sexually transmitted diseases are positive, reporting of certain positive results to public health agencies is required by law. ______ I know I should return to the clinic in 3 weeks for a check-up, and agree to accept responsibility for any additional and/or follow-up care that may not be available from Women's Health Associates. I have been told how to get medical care in case of an emergency. ______ I hereby give my permission to the employees of Women's Health Associates and others authorized by them to use information contained in my medical record for statistical purposes, with the understanding that confidentiality will be maintained. ______ No guarantee or assurance has been made to me as to the results which may be obtained if I use the "morning after pill. " I hereby request that a person authorized by Women's Health Associates perform a pregnancy test, examine and treat me, and provide the "morning after pill". I have given a complete and accurate history. The only unprotected intercourse since my last period started was during the past 72 hours, and my signature indicates I have chosen to use this hormonal method (The "morning after pill") of postcoital contraception. I witness the fact the patient received the above mentioned information and said she read and understood same.

Source: http://www.whadoctors.com/forms/MorningAfterPill.PDF