Contraception Counseling OSCE - Emergency Contraception

Case Overview

• Age/Sex: 15-year-old female
• Occupation: Student (secondary school)
• Setting: Sexual health clinic / GP practice urgent appointment
• Chief complaint: "I want to discuss contraception"

Patient Script

Who I Am

I'm 15, still at school, and I live with my mum — I'm a bit nervous about being here.

What Brings Me In

I had sex the other day and the condom split — I want to know if there's anything I can do so I don't get pregnant.

My Story

I had sex with a boy from school 36 hours ago. We were using a condom but I felt it tear and then we stopped. I didn't tell anyone at first because I was scared. I got online and read about the "morning after pill" and wanted to come see someone to get it. My periods are usually about 28 days apart and my last period started 14 days ago. This was the first time I've had sex. I'm worried and embarrassed. I've had emergency contraception once before about a year ago after a different incident — I don't remember exactly what I took. I haven't taken any regular contraceptive tablet before and I don't have any medical problems. I haven't told my mum because I don't want her to be angry.

My Medical Background

• Past medical history: none significant
• Current medications: none (sometimes take paracetamol for headaches)
• Allergies: none known
• Sexual history: first sexual encounter was 36 hours ago; partner is about 19 years old; condom reportedly broke
• Contraception: none regularly used
• Last menstrual period: started 14 days ago; cycles usually 28 days, fairly regular
• Social: lives with mum, attends school, denies substance misuse; a bit of occasional vaping with friends (rare)
• Family history: non-contributory

What I Think & Worry About

• I think I might be pregnant and I'm really scared about that.
• I'm worried my mum will find out and be angry or upset with me.
• I'm worried about what will happen if I can't get emergency contraception.

If You Ask Me About Other Symptoms...

• Vaginal bleeding: No, I haven't bled since my last period two weeks ago.
• Abdominal pain: No severe pain, just a bit of anxiety/stomach butterflies.
• Vaginal discharge: No unusual discharge or smell.
• Fever/illness: No fever, feeling otherwise well.
• Prior testing for STIs: Never been tested.
• Experience of coercion/pressure: I felt pressured by him to have sex and was too embarrassed to refuse at the time; I felt a bit rushed.
• Previous pregnancy: No previous pregnancies.
• Medication use that might affect treatment: I took a course of antibiotics for a throat infection about 3 months ago (amoxicillin) — not currently taking anything.

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Clinical Summary

Examination

• General: Alert, anxious but cooperative teenage female
• Vitals: BP 110/70 mmHg; HR 78 bpm; RR 14/min; Temp 36.7°C
• Abdominal: Soft, non-tender, no guarding
• External genitalia: No visible trauma reported or noted on brief external inspection (no intimate exam performed unless clinically indicated and with consent)
• No vaginal bleeding or abnormal discharge reported

Investigations

• Urine pregnancy test (POC): Negative (hCG not detected) — note: may be negative early after conception
• STI NAAT (vaginal swab/urine) offered and sample taken: pending
• If indicated: Serum quantitative hCG: not yet performed (would be considered if presentation was later or pregnancy suspected)

Diagnosis

• Primary: Request for emergency contraception (appropriate time window for emergency contraception) — evidence: history of unprotected intercourse 36 hours ago, regular 28-day cycle with LMP 14 days ago, and current negative urine pregnancy test but early timing.

• Differentials / other considerations:

  • Early pregnancy from prior unrecognized exposure (less likely given timing and negative urine test, but cannot be completely excluded)
  • Sexually transmitted infection (no symptoms but testing indicated due to recent unprotected sex)
  • Sexual coercion/exploitation (possible given age difference between patient [15] and partner [~19] and patient's report of feeling pressured) — requires safeguarding assessment

Management

• Offer emergency contraception immediately:
  • Discuss options: levonorgestrel 1.5 mg oral single dose (effective if taken within 72 hours) OR ulipristal acetate 30 mg oral single dose (effective up to 120 hours; preferable if presenting closer to 120 hours) — either can be considered; ulipristal may be preferred if available and no contraindications.
  • Offer copper IUD insertion as most effective emergency contraception (effective up to 5 days after unprotected intercourse) if patient desires and if service available and patient consents.
• Do not delay provision of emergency contraception pending a pregnancy test; negative POC urine pregnancy test supports immediate treatment but is not required to proceed.
• Explain common side effects (nausea, irregular bleeding) and advise antiemetic if vomiting within 2 hours of taking pill; advise to use condoms until next period and consider follow-up pregnancy test if period is delayed by more than 2 weeks.
• Offer STI screening (NAAT for chlamydia/gonorrhoea, HIV/hepatitis testing as per local protocol) and provide condoms and safer sex counselling.
• Assess capacity and confidentiality: explain confidentiality of sexual health services for young people, but discuss limits (safeguarding) — because patient is 15 and reports partner is about 19 and that she felt pressured, institute a safeguarding assessment and follow local child protection procedures (involve senior clinician and safeguarding lead; consider involving social services if concerns of exploitation/coercion).
• Provide contraceptive counselling and offer initiation of a regular method (e.g., progestogen-only pill, implant, depot injection) with discussion of suitability and consent; plan follow-up for ongoing contraception and to review STI results.
• Document discussion thoroughly, obtain verbal consent for treatment and for any disclosure required under safeguarding rules.

Key Learning Points

• Emergency contraception should be offered promptly and not delayed for pregnancy test: levonorgestrel is effective up to 72 hours, ulipristal up to 120 hours, and a copper IUD is the most effective option up to 5 days after unprotected intercourse.

• With young people, always assess capacity and confidentiality, but be alert to safeguarding concerns (age disparity, coercion, or exploitation) and follow local child protection pathways when indicated.

• Offer STI screening and ongoing contraception counselling at the same visit; ensure clear safety-netting (when to seek review for severe pain, heavy bleeding, or missed period) and arrange appropriate follow-up.