Woman Needing Emergency Contraception Four Days After Sex — Free SCA Practice Case

Character Overview: You are Mhairi Galbraith, a 28 year old lettings negotiator at a busy estate agency. You work long, target driven weeks and you rent a flat with your friend Pippa. You have been seeing Rafi, who works as a science technician at a secondary school, for about three months. You are usually careful and use condoms, but four nights ago, at about eleven o'clock at night, after a few drinks at his flat, you did not use one. You have counted it up and it is now about 90 hours, and it is roughly five in the afternoon. You only really took it in when Pippa asked how things were going and you panicked. You are cheerful and quick talking, a little embarrassed about the delay, and you want this sorted without fuss. You assume the morning after pill is the answer, and you would like a prescription sent to your chemist so you can collect it on the way home. You are not hiding anything, but you do not think of your herbal capsules as medicine, so you only mention them when asked about anything you buy or take yourself.

Opening Sentence: "Hi, doctor. I need the morning after pill, please. I had sex without a condom a few nights ago and I'd like to get it from my chemist, if you could send a prescription over."

History if Asked (Data Gathering Phase)

• ●When it happened: "Four nights ago, around eleven at night. It's about five now, so I make it ninety hours, give or take. I worked it out on my phone."
• ●What happened: "We'd had a few drinks at his flat and we just didn't use a condom. We always have before. It was vaginal sex, once. He didn't finish inside me, but I know that doesn't count for much."
• ●Why she is ringing now: "I was flat out at work and put it to the back of my mind. Then Pippa asked if I was sure I wasn't worried, and I went cold. I looked it up and one website said three days and another said five, so I thought I'd better ring."
• ●Other sex since or before: "No. Only that once, and no other unprotected sex this cycle."
• ●Periods: "Regular, every 28 days or so, five days long, moderate. My last one started 17 days ago. Nothing odd about it."
• ●Contraception: "None at the moment. I was on the combined pill but stopped it about fourteen months ago because it made me feel flat. We've just been using condoms."
• ●Pregnancy so far: "I haven't done a test. It's far too soon, isn't it?"
• ●Symptoms now: "No pain, no bleeding between periods, no discharge, no smell, nothing when I pass water. I feel fine physically."
• ●Taking tablets or anything bought: "Oh, the St John's wort. I buy it from the health food shop, two capsules every morning. I started about eight weeks ago because I've been feeling flat and tired. Pippa swears by it. It's only herbal, I didn't think it counted."

Ideas, Concerns, Expectations

Gating note: Mhairi does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks the best option is, what is worrying her, or what she was hoping for today.

• ●Ideas: She thinks the morning after pill is the only real option and that the chemist sells it to everyone, so it must be simple. She has heard the coil is for older women who have had children and that it is agony to have put in. "Isn't it just a tablet? I thought the coil was for people who've had kids. My friend's cousin said it was the worst pain of her life."
• ●Concerns: She is most worried about getting pregnant, because her promotion is being decided in about six weeks and the relationship is still new. She is also embarrassed that she left it so long. She fears the coil hurting, and about taking time off work for it. "I just can't be pregnant right now. And I feel stupid for waiting."
• ●Expectations: She expects a prescription for the tablet to be sent to her chemist so she can pick it up on the way home and not pay for it. "I rang so you could send it to the chemist. I'd rather not pay forty quid if the doctor can do it."

If Asked: Medical History and Medications

Gating note: Mhairi answers each of these plainly when the doctor asks about it.

• ●Other health problems: "Nothing. No asthma, no migraines, no blood clots, no operations. My periods are fine."
• ●Prescribed medicines: "None."
• ●Herbal or bought medicines: "Only the St John's wort. Nothing else, no vitamins, no antibiotics, nothing from a clinic."
• ●Allergies: "None."
• ●Mood: "A bit flat for a couple of months, mostly work pressure. I'm tired and I snap at people, but I sleep okay, I still enjoy my weekends and I have never had thoughts of harming myself. I haven't told anyone at the surgery."
• ●Pelvic problems: "I've never had a pelvic infection, an ectopic or any pelvic surgery. I've never been pregnant. I've never had a coil."
• ●Weight: "About fourteen stone. I'm five foot five, so I know I'm on the big side."
• ●Cervical screening and STI tests: "My smear was normal two years ago. I've never had a full sexual health check, just a chlamydia test years ago at uni, negative."

Social History and Lifestyle Impact

• ●Work: Lettings negotiator. Her days are mostly viewings and phone calls, and she is rarely at her desk. She has a promotion decision in about six weeks. If asked about appointments, she says she is free tomorrow before ten in the morning or at lunchtime, and she could leave this evening if there is something urgent.
• ●Home: Rents a flat with Pippa. Pippa knows about the sex and the worry but nobody else does. Her parents live far away and she has not told them anything.
• ●Partner: Rafi is kind and says he had a sexual health check at the start of the year and was clear. She has not had one herself. She does not know whether he has had other partners.
• ●Alcohol, smoking and drugs: A couple of glasses of wine at weekends. Non smoker. No drugs.
• ●Travel: Drives to work and can drive anywhere in the city. A sexual health clinic or a coil appointment in a different building is not a problem for her.

If Asked: Associated Symptoms

Gating note: Mhairi answers these only when asked. Every one is negative unless stated.

• ●If asked about abdominal or pelvic pain, vaginal discharge, bleeding after sex or between periods, or pain during sex: "No, none of that."
• ●If asked about fever or feeling unwell: "No."
• ●If asked about low mood in more detail, hopelessness or thoughts of self harm: "I feel flat, not hopeless. I'd never hurt myself."
• ●If asked about whether the sex was consensual or whether anyone pressured her: "Totally consensual. Rafi's lovely. It was just the drink and the moment."
• ●If asked about breastfeeding, recent pregnancy or recent miscarriage: "No."

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that the chemist pill may not work well for her, or that it is past the usual window for it:
  • ●Reaction: Surprised. "But the chemist gives it out all the time. Isn't ninety hours still inside five days?" If told her weight and the St John's wort both matter: "It's herbal. How can a plant do anything to the pill?" She accepts it once it is explained that the capsules speed up the way the liver clears some hormones, and she asks what her options are.
• ●If the doctor recommends the copper coil as the most effective option:
  • ●Reaction: Uneasy. "A coil? Honestly I thought that was for older women. Does it hurt?" She wants plain answers about the pain, how long it takes and whether she can go back to work afterwards. She asks, "How long does it stay in? I don't want a baby for a good few years, but I might want one someday." She is reassured to hear it can be taken out at any time and that fertility returns afterwards.
• ●If the doctor says the coil must be fitted within a time limit, and arranges it:
  • ●Reaction: Anxious about the clock. "So how long have I got? What if I can't get an appointment in time?" She is relieved when given a clear plan: "I can do tomorrow morning before ten, or I could get to a clinic this evening." If told a back up tablet can be taken meanwhile or if the coil is not possible, she asks which one and whether it will actually work.
• ●If the doctor offers or discusses a tablet instead, because she declines the coil:
  • ●Reaction: Practical. "Which one, and will it definitely work? How likely am I to get pregnant if it fails?" If told no tablet is certain and that it is less reliable for her: "Right, so the coil really is the best bet. I think I'd rather try for that." She asks to be told what to do if she is sick after a tablet.
• ●If the doctor asks about long term contraception or the St John's wort:
  • ●Reaction: Open once it is raised. "If I have the coil, do I need the pill as well? And should I stop the St John's wort? It's the only thing helping with how I feel." If the doctor suggests reviewing her mood, she agrees: "I'd actually like that. I just didn't want to make a fuss."
• ●If the doctor discusses STI testing, a pregnancy test and safety netting:
  • ●Reaction: Willing but wants details. "Do I need the tests? Rafi says he's clear." If told the reasons: "Fine. Can that be done when I'm there for the coil?" About the pregnancy test: "How long do I wait, and what would make you worry?" If the safety netting is vague, such as "come back if there's a problem": "What kind of problem? What would I look out for?" She repeats back specific advice clearly.