Return Visits Help Clients Continue
Clients are always welcome to return, for any reason—such as needing more supplies, seeking help with a question or problem, wanting an IUD or Norplant implants removed, or wanting to change methods for any reason. Returning clients deserve the same care and attention as new clients. Return visits are good times to ask if clients are satisfied with their family planning choices and to answer questions or solve problems. Listen carefully, especially if clients have concerns about side effects. Do not dismiss a client's concerns or take them lightly. Here are suggestions to help clients who have problems with their methods. If a client is not satisfied after treatment and counseling, help the client choose another method.
Low-Dose Combined Oral Contraceptives (The Pill)
Forgetting pills: Suggest taking each pill at the same time every day—each morning on waking, for example. Suggest that a family member help remind her. Urge the client to keep taking the pill even if she has any of the common side effects listed below. Skipping pills can make some side effects worse. In the first 3 months of use, mention that these side effects usually go away or become less after 3 months. Nausea (common, not a sign of serious illness): Suggest taking the pill at night or with food. Slight headaches (common; not a sign of serious illness): Suggest taking ibuprofen, aspirin, or paracetamol. Spotting or bleeding (common, not harmful, but may bother the client): Missing pills is sometimes the cause of spotting or bleeding between periods. Encourage her to take a pill every day. Common side effects lasting longer than 3 months that bother the client: Suggest a different low-dose combined oral contraceptive or a progestin-only pill. Or help the woman choose a different method. Amenorrhea (no menstural period) (Common; usually not a sign of pregnancy): She probably is not pregnant if: She has had even a little bleeding, or She has taken a pill each day, or She missed the 7-day break between 21-pill packs. But, if she has missed more than one active pill in a row, check for pregnancy (see Is She Pregnant? Ask Questions to Find Out). If she may be pregnant, tell her so, ask her to stop taking oral contraceptives, and give her condoms and/or spermicide to use until it is clear whether or not she is pregnant.
Condoms
Itching: Recommend a dry condom or one without spermicide; suggest water if lubricant is needed. If itching continues, examine the client for infection. If no infection and itching continues, help the client choose another method unless he or she is at risk for catching or transmitting an STD. If so, urge continuing condoms despite itching. Cannot use condoms consistently: Discuss ways to make condoms part of each sex act. Remind the client that condoms are the only method proved to prevent both pregnancy and STDs, including HIV/AIDS. Give the client plenty of condoms so that supply is not a concern. If problems continue, discuss other methods. The client with high STD risk should think about using condoms and another family planning method together.
Female Sterilization
Follow-up within 7 days after the procedure is strongly recommended. Infection:Clean site with soap and water or antiseptic. Give oral antibiotics for 7 days and check again. Abscess (pus present): Clean site with antiseptic. Incise, drain pus, and treat wound. Fever and chills may require hospitalization.
Vasectomy
Follow-up within 7 days after the procedure is strongly recommended. A man can come back any time after 3 months if he wants his semen checked to make sure the vasectomy is working. Pain: Check for blood clots in the scrotum. Small, uninfected clots require rest and pain-relief medication such as paracetamol. Large blood clots may need to be surgically drained. Infected clots require antibiotics and hospitalization. Infection: Clean site with soap and water or antiseptic. Give oral antibiotics for 7 days and check again. Abscess (pus present): Clean site with antiseptic. Incise, drain pus, and treat wound. Fever and chills may require hospitalization. Fear of impotence: Assure the man that vasectomy does not physically change sexual desire, function, or pleasure.
Long-Acting Injectable Contraceptives
More than 2 weeks late for injection and sexually active: If the woman might be pregnant, check for pregnancy (see Is She Pregnant? Ask Questions to Find Out). Unless she is might be pregnant, give another injection if she wants it. Often late for injections: Discuss ways to remember her next injection, such as linking the date to a holiday or change of season. Give the woman condoms to use if she cannot come for an injection on time. Spotting or bleeding:Reassure her that this is normal and very common especially in the first few months. It is not harmful. If this bleeding continues and still bothers the client, encourage her to return and discuss other family planning methods. Amenorrhea (no menstrual bleeding): Reassure her that this is normal and common. It does not mean she is sterile, pregnant, or ill or that menstrual blood is building up. It does not mean she will be unable to get pregnant when she stops using family planning. If amenorrhea continues to bother the client, discuss other methods.
Norplant Implants
If a woman seems unhappy with her implants after discussion, always ask clearly whether or not she wants the implants removed, and do as she asks. Amenorrhea: Reassure her that this is normal. It does not mean she is sterile, pregnant, or ill or that menstrual blood is building up. It does not mean she will be unable to get pregnant when she stops using family planning. If amenorrhea continues to bother the client, remove the implants or refer for removal. Help her choose another method. Spotting and bleeding between periods: Reassure her that this is normal and very common, especially in the first 3 to 6 months. It is not harmful. Infection at insertion site: If no abscess (no pus present), do not remove capsules. Clean site with soap and water or antiseptic. Give oral antibiotics for 7 days and check again. If abscessed, clean site with antiseptic, drain pus, remove capsules, and treat wound. A new set of capsules can be inserted in the other arm, or help her choose another method if she prefers.
Intrauterine Device (IUD)
At the time of IUD insertion, plan a return visit for 3 to 6 weeks later. At that visit ask if the woman has noticed: Signs of infection (increasing or severe pain in lower abdomen, especially if also fever and/or bleeding between menstrual periods). Signs that the IUD is out of place (strings seem shorter, longer, or missing, or she feels something hard in her vagina or at the cervix). If either is suspected, arrange a pelvic examination. Irregular bleeding, prolonged or heavy bleeding: If signs of infection or other abnormality: Arrange pelvic exam and, if needed, appropriate care. If no signs of infection: Ask whether she wants to keep her IUD or to have it removed, and do as she wishes. If no infection and less than 3 months since insertion: Reassure the woman that changes in her menstrual bleeding are normal and will probably lessen over time. Encourage her to return if bleeding worsens. If no infection but very heavy bleeding more than 3 months since insertion: Check for signs of severe anemia—pale under fingernails and inside eyelids. If she is anemic, recommend IUD removal and give iron tablets for 3 months. Help her choose another method. Lower abdominal pain that suggests pelvic inflammatory disease (PID): Arrange for abdominal and pelvic exam. If symptoms suggest PID, treat as appropriate or refer for treatment. Generally, remove the IUD and help her choose another method. If another serious condition is found, such as ectopic pregnancy or pelvic mass, treat appropriately. Active STD infection: A woman can keep her IUD if her clinician approves, if she has been or can be successfully treated, and if she is not likely to get an STD again. Otherwise, ask her to consider other methods, and recommend condoms. Client's or her partner's high-risk sexual behavior: Ask the woman to consider other methods, and recommend condoms. Pregnancy less than 13 weeks: Best to remove the IUD.
Fertility Awareness-Based Methods Including Periodic Abstinence
Frustration and/or difficulty abstaining from sex: Discuss possible sexual interactions without vaginal intercourse that the couple can enjoy during the fertile time. If appropriate, suggest using condoms or spermicide instead of trying to avoid sex during the fertile time. If the problem cannot be resolved and leads to disputes, discuss whether another method would be better.
Vaginal Methods (Spermicides, Diaphragm, Cervical Cap)
Allergic reaction or sensitivity: Check for signs of infection (abnormal vaginal discharge, redness and/or swelling of the vagina, itching of the vulva). Treat or refer. If no infection, suggest a different spermicide. Too messy: Explain again how to insert spermicide, including the correct amount to use. If this continues to bother the client, help her choose another method.

GATHER Elements:	Greet	Ask	Tell	Help	Explain	Return	Charts	Contents