Issued: July 2013 Review date: July 2014
Medicine Standing Order Title Contraception by depo injection
Rationale: In a rural GP clinic there are times when an authorised prescriber is not available and in order for patients to access
care a registered nurse using standing orders is the best option.
Organisation/clinic: Church Street Surgery Opotiki
Scope: To enable registered nurse working in the clinic to provide depo contraception to female
patients over 12 years of age.
Medicine/s: Depo Medroxyprogesterone Acetate (Depo Provera)
Dosage instructions for each medicine 150 mg
Route of administration: Deep IM injection
Indication/circumstances for activating the standing order: First visit / repeat visit protocol for the
administration of Depo provera has been followed.
Precautions and exclusions that apply to this standing order: Any client who has any two
Category WHO 2 or one Category WHO 3 contra-indications (not including those
contra-indications authorised as exclusions by the issuer), is reviewed by the issuer
prior to the administration of the injection and the Standing Order is authorised, or
the client is offered an alternative method of contraception.
Refer following table
Category WHO 4 (Do not use) Category WHO 3 (Caution / counselling) Category WHO
2 (Broadly useable)
NOTE 1: WHO Classifications - as a working rule:
Two Category WHO 2 conditions = Category WHO 3
Category WHO 2 + Category WHO 2 (or WHO 3) = Category WHO 4
Persons authorised to administer the standing order:
Registered nurses
Competency/training requirements for the person(s) authorised to administer:
Prior to administering depo provera under this standing order the registered nurse is required to
undergo the in-house training on the policy, procedure and documentation requirements for this
standing order. In addition registered nurse may undertake Family Planning and Sexual health
training. A record of this training will be kept.
Countersigning and audit
Countersigning by the issuer is required within 7 days of use of this standing order
Definition of terms used in standing order: WHO – World Health Organisation
IM intra muscular
Additional information: Follow Best Practice Nursing guidelines as available via Medtech, see
attached protocol
Signed by issuer:
Name:
Date:
Title: medical practitioner
Signed by management:
Name:
Date:
Title:
Signed by nurses working with Standing Order
Name/s :
Date:
This Medicine Standing Order is not valid after the review date.
Contraindications
Table
Age
WHO 2
WHO 3
< 18 yrs and BMI ≥30kg/m2 (more likely to gain
weight)1
>45 years1,2,3
Cardiovascular disease BMI > 301
Multiple risk factors including: smoking,
hypertension, migraine with aura.
Controlled hyperlidaemia1,2
Current/past history of ischaemic heart disease
or CVA.
Hyperlipidaemia uncontrolled3
Diabetes
Without complications uk who
With complications (nephropathy, neuropathy,
retinopathy) 1,2
Hypertension
Systolic 140 – 159; diastolic 90 – 99
Systolic ≥ 160; Diastolic ≥ 100
History of hypertension - BP not
measured including in pregnancy)
Current controlled hypertension & BP
measured.
DVT/PE Risks
Known thrombogenic mutations.
Past DVT/PE.
Recent DVT/PE and established on
anticoagulants1,2
Major surgery with prolonged immobilisation.
Current DVT / PE3
WHO 4
Contraindications
Table
Migraines
WHO 2
With aura prior to commencing1
WHO 3
WHO 4
With Aura since commencing1,3
Without Aura since commencing
SLE
With severe thrombocytopenia with
continuation
With positive / unkown antiphospholipid
antibodies
On immunosuppressive treatment
With severe thrombocytopenia on initiation
Without any complication
Liver &
Gall Bladder Disease
Gall bladder disease – with/without treatment
Active liver disease + abnormal LFT’s3
Acute porphyria – history of attack3
Previous COC related cholestasis
Current severe liver impairment.
Active liver disease + normal LFT’s3
Past steroid associated cholestatic jaundice
Non-acute porphyria3
Breast Disease
Undiagnosed breast lump
Carrier of BRCA1 mutation2
Pregnancy /
Post Partum
Past Cancer - remission > 5 years
Current breast cancer
< 6 weeks post partum & BF1
Pregnancy
Vaginal Bleeding
Unacceptable menstrual irregularities3
suspicious bleeding pending investigation /
evaluation1,2
Bone Density
Risks
Prolonged use > 2 years.
Cortico steroid use long term
Ostopenia3
FH osteoporosis
Anorexia / bulimia – recovered with normal
menstruation3.
Severe risk of osteoporosis 3
Medications
Warfarin3
Ovarian, Cervical,
Endometrial Diseases
Cervical cancer.
Benign/malignant trophoblastic disease until
HCG normal
Contraindications
Table
Miscellaneous
WHO 2
Past severe endogenous depression3
WHO 3
Other chronic systemic disease
WHO 4
Serious adverse reaction to COC (not
certainly related to oestrogen)3
Obesity3
Previous anaphylaxis to Depo Provera.
HIV/AIDS2
Hypersensitivity to component / constituent
(ie Methyl parabens excipient)3
First Visit / Repeat Visit Protocol
First visit:
1. Describe how Depo-provera works, failure rate, advantages/disadvantages.
2. Assess client suitability for Depo-provera and discuss risks and side effects
(especially with respect to bleeding and management of such). Bone density
issue
3. Check Medical History.
Absolute contraindications:
 -undiagnosed genital tract bleeding
 -possible pregnancy
 -hormone dependant cancer
 -active liver disease
 -allergy to progesterone
 -Eating disorder BMI < 18, need to discuss this with Dr
Possible (relative) contraindications – must see Dr.:



-history of depression, or currently treated for depression.
-Document if medication anti-depressants
-BMI 35 or over
4. Check BP and weight
5. Give first injection with menstrual period (advise condom use for 7 days if not
given between day 1 and day5). If requested at any other time do a preg
test, give the injection, advise client there are no known risks to fetus, have
another preg test in 3 weeks.
 Adrenaline 1/1000 must be on hand and nurse familiar with
management of anaphylaxis.
 Depo provera injection 150mg given intramuscular to upper outer
quadrant buttock
 Client must stay on premises for 20 min after injection
 Countersigning is to be completed by issuer (To be set for the doctor
on Medtech task)
Give notification of date of next injection - 12 weekly unless on an enzyme inducing drug in
which case then give 8 weekly.
Subsequent Visits
1. After the client has been on Depo Provera for 1 year a discussion concerning the
implication for bone density with long term use is to be discussed
2. BP and weight check 1st and 2nd visits then 6 monthly
3. Check for any possible side effects and client happy with method
4. Ensure the client is not overdue for injection (follow the Family Planning flow chart for
6 day overdue injections )
5. Exclude any contraindications
6. Notification of next injection
7. Enquire if needs STI check and/or smear.
depo provera checklist
Depo Provera checklist
For commencement or continued supply of Depo Provera
Describe how Depo Provera works
It prevents pregnancy by stopping the ovaries releasing an egg each month
Advantages
Disadvantages
Almost 100% effective
(Less than 1 woman out of 100 will get
pregnant each year).
- Almost all women can use Depo
Provera including women who cannot
use the combined contraceptive pill
- Convenient (lasts 12 weeks)
- No daily pill taking
- Doesn’t interfere with sexual
intercourse
- No one else needs to know you are
using it
- Antibiotics do not affect it
Absolute contraindications:
-
-undiagnosed genital tract bleeding
-severe depression, discuss with
psychiatrist
-
-possible pregnancy
-hormone dependant cancer
-active liver disease
-Eating Disorder BMI <18 discuss with Dr
-
Some women have irregular or no
periods
Some women have heavy or prolonged
bleeding
Weight gain (average 2 kilograms).
Mood changes –irritability, depression
Reduced sexual interest
Vaginal dryness
Headaches
Allergic reaction to the injection
Return to fertility (6months after
injection runs out to 2 years).
Possible (relative) contraindications –
-BMI 35 or over
Check
Administration
BP
-
Weight
History of allergies
-
Give first injection with menstrual
period (advise condom use for 7 days if
not given between day 1 and day 5). I
Depo-provera injection 150mg given
intramuscular to upper outer quadrant
buttock
Notification of next visit (date sticker),
can give up to 2 weeks late.
Safety
Subsequent visits
- Adrenaline 1/1000 must be on hand and
nurse familiar with management of
anaphylaxis.
- BP and weight check 1st and 2nd visits,
then 6 monthly
-The client must stay on the premises for
20 minutes after their injection.
- Check for possible side effects
-Must have 02 and adrenaline available
- After 1 year on Depo Provera a
discussion concerning the implication for
bone density is to be undertaken
- FP pamphlet on Depo Provera provided
Countersigning is to be completed by
issuer (To be set for the doctor on
Medtech task)
And discussed