Family planning lets people decide whether and when to have children. The nurse's role is client-centered counseling: present all suitable methods, respect the client's values and choice, screen for medical eligibility, and teach correct use. Coercion toward any method is unethical.

Two US tools guide practice

• US Medical Eligibility Criteria for Contraceptive Use (US MEC, 2024) — who can safely use each method, by medical condition
• US Selected Practice Recommendations (US SPR, 2024) — how to use methods: when to start, backup, missed doses, bleeding problems

US MEC categories

How methods work and typical-use failure rates (first year)

Long-acting reversible contraceptives (LARC — IUDs and implants) are the most effective reversible methods because they do not depend on daily action. Only condoms protect against STIs, including HIV.

• Reproductive goals, sexual activity, number of partners, STI risk, breastfeeding status, weeks since birth
• Menstrual history; possibility of current pregnancy — a provider can be reasonably certain the client is not pregnant if she has no symptoms of pregnancy and meets one of these: within 7 days after the start of normal menses; no intercourse since last normal menses; correct, consistent use of a reliable method; within 7 days after abortion or miscarriage; within 4 weeks postpartum; or fully or nearly fully breastfeeding, amenorrheic, and less than 6 months postpartum
• Medical history for MEC screening: blood pressure (measure before combined methods), smoking and age, migraine with aura, history of blood clots, clotting mutations, heart disease, stroke, liver disease, breast cancer, diabetes with vascular disease, lupus with antiphospholipid antibodies, current medications (enzyme inducers)
• A pelvic exam and Pap test are not required before starting most methods; a bimanual and speculum exam is needed for IUD placement, but a Pap test is not

• Blood pressure before combined hormonal contraception (CHC)
• Urine pregnancy test when pregnancy cannot be reasonably excluded (a negative test does not exclude very recent conception)
• STI testing (chlamydia, gonorrhea) per screening guidelines; can be done at the time of IUD placement — do not delay IUD placement for results in asymptomatic clients
• Semen analysis after vasectomy to confirm the absence of sperm

Combined hormonal contraception (estrogen + progestin): pill, patch, vaginal ring

• Benefits: regular lighter periods, less dysmenorrhea and acne, lower ovarian and endometrial cancer risk
• Adverse effects: nausea, breast tenderness, breakthrough bleeding; venous thromboembolism, stroke, myocardial infarction (estrogen-related); raised BP
• US MEC category 4 (do not use) — examples:
  • Age 35 or older and smoking 15 or more cigarettes/day (fewer than 15/day = category 3)
  • Migraine with aura (any age)
  • History of DVT/PE with higher recurrence risk, acute DVT/PE, known thrombogenic mutation
  • BP ≥ 160/100 mmHg (140–159/90–99 = category 3)
  • Ischemic heart disease, stroke, complicated valvular disease
  • Current breast cancer
  • Severe cirrhosis, hepatocellular adenoma or liver cancer
  • SLE with positive antiphospholipid antibodies; diabetes with vascular disease (category 3 or 4 depending on severity)
  • Postpartum under 21 days (breastfeeding or not); major surgery with prolonged immobilization
• Postpartum (US MEC 2024): not breastfeeding — 21–42 days: category 3 with other VTE risk factors, 2 without; breastfeeding — 21–29 days category 3, 30–42 days category 3 with VTE risk factors or 2 without, over 42 days category 2
• Drug interactions: rifampin/rifabutin, several anticonvulsants (carbamazepine, phenytoin, phenobarbital, primidone, topiramate, oxcarbazepine), some HIV drugs, and St. John's wort reduce effectiveness; CHC lowers lamotrigine levels. Most other antibiotics do not reduce effectiveness
• Patch: somewhat higher estrogen exposure; may be less effective at higher body weight (one brand is contraindicated with BMI ≥ 30)

Progestin-only methods

• Progestin-only pills: norethindrone or norgestrel must be taken at the same time daily (more than 3 hours late = missed); drospirenone pills allow a wider window. Irregular bleeding is common
• DMPA (depot medroxyprogesterone acetate) — 150 mg IM every 3 months (repeat injection can be given up to 15 weeks after the last one without backup)
  • Irregular bleeding then amenorrhea, weight gain in some users, delayed return of fertility (up to about 10–18 months)
  • Boxed warning: loss of bone mineral density — largely reversible after stopping; should not by itself prevent use; encourage calcium, vitamin D, and weight-bearing exercise
• Implant — single rod in the inner upper arm; FDA-approved for up to 5 years (2026); inserted and removed by trained clinicians (REMS-certified in the US); unpredictable bleeding is the main reason for removal
• Progestin-only methods are safe with most estrogen contraindications (e.g., smoking over 35, migraine with aura, history of VTE)

Intrauterine devices

• Copper IUD — hormone-free; up to 10 years; may cause heavier, more painful periods
• LNG IUD — 52-mg devices up to 8 years; smaller devices 3–5 years; lighter periods, often amenorrhea
• Risks: expulsion (highest soon after placement and with immediate postplacental insertion), rare uterine perforation at placement, slightly higher PID risk only in the first ~20 days after insertion. If pregnancy occurs with an IUD in place, a higher proportion are ectopic — rule out ectopic
• Category 4: current pregnancy, current PID or purulent cervicitis, unexplained vaginal bleeding before evaluation, puerperal sepsis, some uterine distortions, cervical or endometrial cancer awaiting treatment
• Suitable for adolescents and nulliparous clients (category 2 for age under 20)

Barrier and behavioral methods

• Male condom: use a new one for every act, put on before any genital contact; use water- or silicone-based lubricants with latex (oil-based products weaken latex); polyurethane for latex allergy
• Diaphragm with spermicide: leave in at least 6 hours after intercourse, no longer than 24 hours (toxic shock syndrome risk)
• Spermicide (nonoxynol-9): frequent use irritates mucosa and may increase HIV transmission — not advised for those at high HIV risk
• Fertility-awareness methods: calendar/Standard Days (cycles 26–32 days; avoid unprotected intercourse on days 8–19), cervical mucus, BBT, symptothermal
• Lactational amenorrhea method (LAM): over 98% effective only if all three apply — fully or nearly fully breastfeeding, no return of menses, less than 6 months postpartum

Emergency contraception (EC)

• IUD within 5 days — copper IUD or LNG 52-mg IUD (US SPR 2024) — most effective EC; continues as ongoing contraception
• Ulipristal acetate 30 mg orally within 5 days (prescription only in the US) — more effective than levonorgestrel on days 3–5 and at higher body weight; wait 5 days before starting or resuming hormonal contraception (use backup or abstain) because progestin reduces its effect
• Levonorgestrel 1.5 mg orally as soon as possible, best within 72 hours; less effective with BMI ≥ 30
• EC pills delay ovulation; they do not end an established pregnancy. If no period within 3 weeks, take a pregnancy test

Permanent methods

• Tubal sterilization — effective immediately; bilateral salpingectomy (removing the tubes) is increasingly preferred because it also lowers ovarian cancer risk. Regret is more common when done at a young age
• Vasectomy — not immediately effective; use another method until a semen analysis (about 8–16 weeks later) confirms no sperm

Listed in priority order.

1. Screen for contraindications that create serious risk (VTE history, migraine with aura, smoking over 35, uncontrolled hypertension, pregnancy)
2. Rule out pregnancy reasonably before starting; use "quick start" (same-day start) whenever reasonably certain not pregnant
3. Backup contraception after starting (US SPR)
   • CHC: 7 days unless started within 5 days of menses onset
   • Traditional progestin-only pill: 2 days
   • DMPA: 7 days unless within 7 days of menses onset; implant and LNG IUD: 7 days unless within 5 or 7 days of menses onset respectively
   • Copper IUD: no backup needed
4. Procedure care (IUD/implant): consent, pain management, observe for vasovagal reaction after IUD placement; pressure dressing on implant site
5. Counseling: unbiased information on effectiveness, side effects (especially bleeding changes), STI protection, and how to stop the method

• Warning signs for combined methods (ACHES): Abdominal pain, Chest pain or shortness of breath, Headache (severe) or neurologic changes, Eye problems (vision loss or blurring), Severe leg pain or swelling — seek care immediately
• Missed combined pills (US SPR):
  • One missed (fewer than 48 hours since a pill should have been taken): take it now, continue as usual; no backup needed
  • Two or more missed (48 hours or more): take the most recent missed pill now, discard others, continue daily, use backup for 7 consecutive days; if missed in the last hormonal week, skip the hormone-free week; consider EC if missed in week 1 with unprotected sex
• IUD warning signs (PAINS): Period late or abnormal bleeding, Abdominal pain or pain with intercourse, Infection exposure or abnormal discharge, Not feeling well, fever or chills, Strings missing, shorter, or longer
• Stop smoking, especially with estrogen methods
• DMPA: return every 3 months; calcium and vitamin D; fertility may take up to a year or more to return
• Condoms for STI protection with every method ("dual protection")
• EC can be kept at home in advance

• LARC (implant, IUDs) = most effective reversible methods; only condoms prevent STIs
• US MEC category 4 = do not use; e.g., CHC with smoking ≥ 15/day at age ≥ 35, migraine with aura, VTE history, BP ≥ 160/100, current breast cancer, under 21 days postpartum
• ACHES = estrogen warning signs; PAINS = IUD warning signs
• Two or more missed combined pills → take one now, backup 7 days
• Rifampin and enzyme-inducing anticonvulsants reduce hormonal effectiveness
• DMPA: every 3 months, bone density boxed warning, delayed return of fertility
• IUD (copper or LNG 52-mg) within 5 days = most effective EC; ulipristal within 5 days; levonorgestrel within 72 hours
• Diaphragm: leave in 6 hours after, no more than 24 hours total
• LAM: exclusive breastfeeding + amenorrhea + under 6 months
• Vasectomy is not immediately effective — backup until semen analysis shows no sperm