Breastfeeding and Contraceptions Post Partum

Question 1

When is the earliest date ovulation can occur post partum?

Answer 1

The earliest date of ovulation in a non-breastfeeding woman is thought to be day 28 days postpartum. Therefore, contraception is required from day 21 onwards, as sperm can survive for up to 7 days. A woman who is exclusively breastfeeding will take longer to ovulate, however, contraception should still be advised if pregnancy is not desired.

Question 2

What type of emergency contraception should and shouldn’t be used 21 days post partum?

Answer 2

After day 21 postpartum, progesterone only emergency contraception (Levonelle and ellaOne) can be used in both breastfeeding and non-breastfeeding woman. The Cu-IUD should not be inserted before day 28 postpartum, due to the increased risk of uterine perforation if inserted before this time.

Question 3

When can the progesterone only pill be used post partum?

Answer 3

Women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.
after day 21 additional contraception should be used for the first 2 days. A small amount of progestogen enters breast milk but this is not harmful to the infant.

Question 4

When can the COCP be used post partum?

Answer 4

Absolutely contraindicated - UKMEC 4 - if breast feeding < 6 weeks post-partum. Note after this date the COC may reduce breast milk production in lactating mothers
In non-breast-feeding mother it may be started from day 21 - this will provide immediate contraception.

Question 5

When can the IUD or IUS be inserted?

Answer 5

The IUD or IUS can be inserted within 48 hours of childbirth or after 4 weeks.

Question 6

Can breastfeeding be used as contraception?

Answer 6

Prolactin release prevents ovulation by inhibiting the LH surge. On its own if a women is regularly and only breast feeding this is 98% effective up to 6 months postpartum. This can be combined with progesterone contraceptives after 21 days.

Disadvantages include no protection against STIs, requires no supplementary feeds and is not as reliable as medical contraceptives

Question 7

What hormones control and allow for breastfeeding after pregnancy?

Answer 7

High progesterone and oestrogen in pregnancy stimulates breast tissue growth, secretion is promoted by prolactin. Prolactin is secreted by anterior pituitary gland controlled by dopamine from the hypothalamus (inhibits). Factors promoting secretion of prolactin reduce dopamine secretion.

Oestrogen from the placenta stimulate the lactotrophs to undergo hyperplasia allowing the cell to produce large amounts of prolactin but they can’t yet secrete it. They need thyrotropin releasing hormone stimulating the release of prolactin. TRH also inhibits Dopamine by downregulating the number of dopamine receptors in the brain.

Question 8

What is the importance of suckling to produce a feed?

Answer 8

Suckling promotes pituitary prolactin secretion – potent neuro-endocrine reflex. Suckling during one feed promotes prolactin by inhibiting dopamine release which causes production of the next feed, which accumulates in alveoli and ducts so there must be sufficient suckling stimulus at each feed.

Question 9

How is coloustrum produced?

Answer 9

Colostrum is produced because of release of prolactin from the decidual cells in the endometrium, which is pumped into the amnion, into the umbilical cord, chorion and then out into maternal circulation.

Question 10

How is milk ejected out of the breast?

Answer 10

Babies do not suck milk out of the breast it is ejected by a let-down reflex. Myoepithelial cells surround alveoli and are contracted by oxytocin which is released from posterior pituitary when the breast is stimulated by suckling. Babies don’t suck – they can’t until they can walk.

Question 11

How is lactation maintained?

Answer 11

Maintenance of lactation is via a Neuro-endocrine reflex from suckling and expressing. Anticipation of feed, fondling and bonding with the baby inhibits dopamine release in the hypothalamus and so encourages prolactin release and stimulates oxytocin release causing smooth muscle contraction.

Question 12

What is colostrum made of?

Answer 12

Colostrum – thick yellow fluid produced from around 20weeks gestation. High concentration of IgA and rich in proteins that are important for gut maturation and maturation of the immune system of the infant. It is produced in small quantities following the delivery.

Question 13

What’s the importance of early skin to skin contact for breast feeding?

Answer 13

Skin to skin contact should begin as soon as possible following delivery. Early contact increases breast feeding within the first 2 hours after birth and increase duration of breastfeeding when compared with delay of 4 hours or more.

Question 14

Why is demand feeding important?

Answer 14

Demand feeding should be encouraged as it rapidly increases weight loss in the immediate post-partum period. It also helps to prevent engorgement and allows breast feeding to be established more easily.

Question 15

How should demand for feeding change over the first week after delivery?

Answer 15

Post delivery demand for feeds may be as low as 3 times a day and is not cause for concern. Demand should increase daily reaching a peak by day 5. Exclusively breast-fed infants should be breast fed 8 times a day, 6 during the day and 2 at night. Exclusive breastfeeding should continue for at least 6 months.

Question 16

What are the benefits of breastfeeding to the baby?

Answer 16

Colostrum increases baby’s immunity and breast milk contains maternal antibodies
Reduces diarrhoea disease and other GI disease
Omega 3 fatty acids aid visual development
Improved bonding
Part of the natural defence against UTIs in the infant
Helps prevent chest infections
Reduced incidence of atopic illness
Reduced risk of childhood leukaemias

Question 17

What are the benefits of breastfeeding to the mother?

Answer 17

Reduced risk of breast disease for the mother
Reduces risk of PPH and encourages uterine involution
Lactational amenorrhoea and full or nearly full breast-feeding for up to 6 months is 99% effective as contraception (this decreases at 12 months)
Amenorrhoea helpful for anaemia
Protective against premenopausal breast cancer, ovarian cancer and osteoporosis

Question 18

What recommendations are there for prescribing during breastfeeding?

Answer 18

Very few studies looking into this. Most drugs will end up in breast milk but the amount varies depending on bioavailability and half-life.

Generally, only prescribe drugs with a short half-life, low toxicity, ones that are commonly used in infants and with reduced bioavailability. Only prescribe drugs in pregnant women when it is absolutely necessary.

Question 19

Give some examples of common medications that are safe to use in breastfeeding

Answer 19

Heparin
Insulin
Aminoglycoside antibiotics and third generation cephalosporins
Omeprazole and lansoprazole 
Inhaled steroids 
Beta agonists

Question 20

Give some examples of drugs that are contraindicated in breastfeeding

Answer 20

Amiodarone
Chloramphenicol 
Ergotamine 
Methotrexate
Lithium
Tetracycline 
Fluoxetine
ACEi
Alcohol
Caffeine 
Cocaine and marijuana

Question 21

How should milk supply problems be managed?

Answer 21

Inadequate milk supply – uncommon and treated with adequate fluids, nutrition, secure and private environment, dopamine antagonists, thyrotropin releasing hormone and oxytocin.

Question 22

How should breast engorgement be managed?

Answer 22

Breast engorgement – usually occur due to limitations on feeding frequency and duration, problems with positioning of the baby. Allowing the baby unrestricted access to the breast is most effective treatment.

Question 23

How should sore or cracked nipples be managed?

Answer 23

Sore or crackled nipples – can be caused by incorrect attachment of the baby to the breast. May be necessary to rest the breast and express naturally until it has healed.

Question 24

Describe the clinical features of mastitis?

Answer 24

Swollen and red
Painful 
Tachycardia
Pyrexia
Aching
Flu like symptoms
Shivering and rigors

Question 25

How can mastitis be classified?

Answer 25

Non infective – caused by obstruction of milk drainage from one section of the breast due to: restriction of feeding, a badly positioned baby, blocked ducts and compression from fingers holding the breast or too small a bra. This will resolve when the obstruction is relieved by continuing to breast feed but with the correct position.

Infective – if non infective mastitis is not managed appropriately then it may become infected. S.Aureus is most commonly involved. Treated with Co amoxiclav or flucloxacillin. Breast feeding should be continued.

Question 26

What can happen if infective mastitis is not treated correctly?

Answer 26

Breast Abscess, treatment may be surgical drainage under unaesthetic. If very severe cases breast feeding may have to cease on the affected side.

Question 27

How should nipple candidiasis be treated?

Answer 27

Nipple candidiasis: treatment for nipple candidiasis whilst breastfeeding should involve miconazole cream for the mother and nystatin suspension for the baby.

Question 28

What is a galactocele and how can it be differentiated from a breast abscess?

Answer 28

Galactocele typically occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct. A build up of milk creates a cystic lesion in the breast. The lesion can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.

Question 29

What is Raynaud’s disease of the nipple?

Answer 29

In Raynaud’s disease of the nipple, pain is often intermittent and present during and immediately after feeding. Blanching of the nipple may be followed by cyanosis and/or erythema. Nipple pain resolves when nipples return to normal colour.

Question 30

How should Raynaud’s disease of the nipple be treated?

Answer 30

Options of treatment for Raynaud’s disease of the nipple include advice on minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking. If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).

Question 31

When does mastitis require antibiotics?

Answer 31

If systemically unwell
If nipple fissure present
If symptoms do not improve after 12-24 hours of effective milk removal
If culture indicates infection

The first-line antibiotic is flucloxacillin for 10-14 days