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Bushra's Contraception > Contraception After Pregnancy FSRH Jan - 2017 > Flashcards

Contraception After Pregnancy FSRH Jan - 2017 Flashcards

1
Q

contraceptive counselling for postnatal contraception-

What methods of contraception - clinical judgement (safe and appropriate methods)

A

Refer to

    • relevant current FSRH guidelines, including
    • UKMEC,
  • discuss: any medical or social factors that may be relevant to her choice of contraceptive method.
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2
Q

antenatal, after abortion & post GTD contraceptive

  • Effectiveness of contraceptive method
  • Information & counselling quality
  • Record keeping and obtaining valid consent
A
  • informed during pregnancy: effectiveness of different contraceptives,
  • superior effectiveness of LARC,
  • opportunity to discuss contraception.
  • not feel under pressure to choose a method.
  • person-centred approach.
  • information is timely, up-to-date and accurate.
  • Comprehensive, unbiased and accurate information
  • different languages and formats including audio-visual.
  • document: discussion and provision of contraception.
  • Valid consent must be obtained before providing women with their chosen method.
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3
Q

Contraception after Pregnancy, abortion

- Provision of contraception

A
  • Maternity services: IUC and progestogen-only methods, including IMP, injectable (POI) or pill (POP), before discharged from the service.
    _______________
  • Services able to offer all methods including LARC, before discharged from service.
  • sufficient numbers of staff able to provide IUC or IMP so can initiate them immediately (eligible). Only IMP after GTD
  • unable to provide chosen method, inform services where their chosen method can be accessed.
  • A temporary (bridging) method should be offered until the chosen method can be initiated.
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4
Q

Contraception after Pregnancy

Provision of continuing care and support

privacy and gender based violence

A

Clinicians should facilitate opportunities to discuss issues with woman in private without a partner, friend or relative being present.

  • Clinicians should know how to enquire about gender-based violence (GBV) and how to support women affected by GBV and abuse, including providing access to information and referral to specialist support.
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5
Q
  • When should contraception after childbirth be discussed/provided?
A

Maternity services: opportunities to discuss their fertility intentions, contraception and preconception planning.

  • Effective contraception: initiated by both breastfeeding and non-breastfeeding ASAP.
  • Maternity service:access to full range contraceptives, including most effective LARC methods, to start immediately after childbirth. (not limited to conditions pose a significant health risk during pregnancy and vulnerable groups ( young people) at risk of a short IPI or an unintended pregnancy.
  • Contraceptive counselling: antenatal period
  • Any contraceptive counselling: (general or specialist) in conjunction with easy access to, in immediate postpartum period.
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6
Q
  • When can contraception after childbirth be initiated?
A
  • choice initiated by 21 days after childbirth.
  • can be initiated immediately after childbirth.
  • insertion of IMP soon after childbirth & IUC at time of vaginal or CS delivery:
    • -convenient and
    • -highly acceptable.
    • -high continuation rates &
    • -reduced risk of unintended pregnancy.
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7
Q
  • How long should a woman wait before trying to conceive again?
A
  • advise: interpregnancy interval (IPI) of less than 12 months between childbirth associated with an increased risk of
  • – preterm birth,
  • – low birthweight and
  • – SGA babies.
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8
Q
  • Who should provide contraception to women after childbirth?
A 
Trained clinicians including 
1 - sexual & reproductive health (SRH) doctors & nurses, 
2 - obstetricians, 
3 - midwives, 
4 - nurses, 
5 - GPs and 
6 - health visitors
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9
Q

Contraception After Childbirth

  • Record keeping and obtaining valid consent
A
  • clearly document discussion & provision of contraception after childbirth.
  • Valid consent: must before providing chosen method.
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10
Q

Contraception After Childbirth, Medical eligibility

  • Which methods of contraception are safe to use after childbirth?
A
  • not required in the first 21 days

- most methods can be safely initiated immediately, with exception of CHC.

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11
Q

Contraception After Childbirth, Medical eligibility

  • Can women who develop medical problems during pregnancy safely use contraception after childbirth?
A
  • discuss: any personal characteristics or existing medical conditions, including that developed during pregnancy, which may affect her medical eligibility for contraceptive use.
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12
Q
  • emergency contraception EC after childbirth?
A

indicated for UPSI from 21 days after childbirth, but is not before this.
- Oral LNG-EC 1.5 mg and UPA-EC 30 mg safe
to use from 21 days after childbirth.
- Cu-IUD is safe to use for EC from 28 days after childbirth.

  • breastfeed: limited evidence LNG-EC no adverse effects
    BUT express and discard milk for a week after UPA-EC.
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13
Q

Is additional contraception required after initiation of a method after childbirth?

A
  • additional contraceptive precautions (e.g. barrier method/abstinence) if hormonal contraception is started 21 days or more after childbirth.
  • Additional contraceptive precaution is not required if contraception is initiated immediately or within 21 days after childbirth.
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14
Q

Contraception After Childbirth

  • Does initiation of hormonal contraceptives affect breastfeeding outcomes or infant outcomes?
A
  • progestogen-only methods (LNG-IUS, IMP, POI and POP) have no adverse effects on lactation, infant growth or development.
  • wait until 6 weeks to initiating CHC.
  • limited evidence: effects of CHC use on breastfeeding. - better quality studies of early initiation of CHC found no adverse effects on either
  • – breastfeeding performance (duration of breastfeeding, exclusivity and timing of initiation of supplemental feeding) or
  • – on infant outcomes (growth, health & development).
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15
Q

Contraception After Childbirth

  • Can women who breastfeed effectively use lactational amenorrhoea method (LAM) as contraception?
A
  • < 6 months postpartum, amenorrhoeic and fully breastfeeding, LAM highly effective contraception.
  • Risk of pregnancy is increased
    1- If frequency of breastfeeding decreases
    – stopping night feeds,
    – starting or increasing supplementary feeding,
    – use of dummies/pacifiers,
    – expressing milk),
    2- when menstruation returns or
    3- when more than 6 months after childbirth.
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16
Q

Contraception After Childbirth

  • Intrauterine contraception (IUC)
A
  • immediately after birth (within 10 minutes of delivery of placenta) or within the first 48 hours after uncomplicated caesarean section or vaginal birth.
  • After 48 hours, insertion should be delayed until 28 days after childbirth.
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17
Q

Contraception After Childbirth

Methods which can be safely started at any time after childbirth including immediately after delivery.

A
  • IMP
  • Progestogen-only injectable (POI)
  • Progestogen-only pills (POP)
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18
Q

Contraception After Childbirth

- Combined hormonal contraception (CHC) & VTE

A 
- CHC should not be used if risk factors for VTE within
6 weeks of childbirth. (both breastfeeding/ not breastfeeding)
  -- immobility, 
  -- transfusion at delivery, 
  -- BMI ≥30 kg/m2, 
  -- PPH, 
  -- post-CS delivery, 
  -- pre-eclampsia or
  -- smoking.
  • Women who are not breastfeeding and are without additional risk factors for VTE should wait until 21 days after childbirth before initiating a CHC method.
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19
Q
  • Female sterilisation After Childbirth
A
  • safe option for permanent
  • both Filshie clips and modified Pomeroy technique are
    effective.
  • Filshie clip application is quicker to perform.
  • some LARC methods are as, or more, effective than
    female sterilisation and may confer non-contraceptive benefits.
  • not feel pressured into choosing LARC over female sterilisation.
  • Tubal occlusion ideally after some time following childbirth. Women who request at time of delivery should be advised of possible increased risk of regret.
  • written consent: CS +TL, obtained and documented at least 2 weeks in advance of a planned elective CS.
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20
Q

Contraception After Childbirth, abortion & GTD

  • Barrier methods
A
  • Male and female condoms: safe.

- diaphragm: wait at least 6 weeks after childbirth b/c size may change ( uterus returns to normal size.)

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21
Q

Contraception After Childbirth, abortion & GTD

  • Fertility awareness methods (FAM)
A
  • can be used
  • advise: detection of signs & symptoms of fertility and ovulation, difficult after childbirth & during breastfeeding.
22
Q
  • When should contraception after abortion be discussed/provided?
A
  • Choice of contraception initiated at time of abortion or soon after, as sexual activity and ovulation can resume very soon after abortion.
23
Q
  1. Contraception After Abortion
    - Discussion & provision of contraception after abortion
    - When can contraception be initiated after abortion?
A
  • chosen method initiated immediately (medical and surgical).
  • insertion of IUC at time of abortion is convenient and highly acceptable, high continuation rates and reduced risk for another unintended pregnancy.
  • insertion of progestogen-only implants (IMP) at time of abortion is convenient and highly acceptable to women. high continuation rates and a reduced risk for another unintended pregnancy.
24
Q
  1. Contraception After Abortion
    - Discussion & provision of contraception after abortion
    - Which contraceptive methods are most effective in preventing another abortion?
A

Clinicians should be aware that women who choose to commence LARC immediately
after abortion have a significantly reduced likelihood of undergoing another abortion
within 2 years, compared with women provided with medium-acting, short-acting or no
contraceptive methods.

25
Q
  1. Contraception After Abortion
    - Medical eligibility
    - Which methods of contraception are safe to use after abortion?
A

Women should be advised that any method of contraception can be safely initiated
immediately after an uncomplicated abortion.
D IUC should not be inserted in the presence of postabortion sepsis.

26
Q
  • Is emergency contraception (EC) safe to use after abortion?
A
  • EC is indicated for UPSI from 5 days after abortion.
  • any method of EC can be safely used after an
    uncomplicated abortion.
27
Q
  • Is additional contraception required after initiation of a method after abortion?
A
  • additional contraceptive precautions (e.g. barrier
    methods/abstinence) are required if hormonal contraception is started 5 days or more after abortion.
    BUT
    not required if contraception is initiated immediately or within 5 days of abortion.
28
Q

Contraception After Abortion

  • Intrauterine contraception (IUC)
A
  • safely used after an uncomplicated abortion.
  • may benefit from reduced uterine bleeding when using LNG-IUS.
  • With medical abortion, IUC can be inserted any time after expulsion of pregnancy.
  • With surgical abortion, IUC can be inserted immediately after evacuation of uterine cavity.
29
Q

Contraception After Abortion

  • Progestogen-only contraception
A

Progestogen-only contraception can be safely started at any time, including immediately, after medical or surgical abortion.

  • Women should be advised that IMP can be safely initiated at the time of mifepristone administration.
  • Women should be advised that there may be a slightly higher risk of continuing pregnancy (failed abortion) if DMPA is initiated at the time of mifepristone administration.
  • Women should be advised that scant or absent bleeding should not be attributed to a hormonal method of contraception that has been initiated, but that it may be due to failed medical abortion. Under such circumstances, urgent medical review should be sought.
30
Q
  1. Contraception After Abortion
    - Method-specific consideration
    - Combined hormonal contraception (CHC)
A

Combined hormonal contraception (CHC) can be safely started immediately at any time after abortion.

31
Q

Contraception After Abortion

  • Female Sterilisation
A
  • safe option for permanent
  • some LARC methods are as, or more, effective than
    female sterilisation and may confer non-contraceptive benefits.
  • not feel pressured into choosing LARC over female sterilisation.
  • Tubal occlusion ideally after some time following childbirth. Women who request at time of delivery should be advised of possible increased failure rate & risk of regret.
  • written consent: same time as surgical abortion is taken and documented in advance of the abortion.
32
Q
  1. Contraception After Ectopic Pregnancy or Miscarriage
    - Discussion and provision of contraception after ectopic pregnancy or miscarriage
    - When should contraception be discussed/provided?
A
  • Services providing care to women with ectopic pregnancy or miscarriage should give them opportunities to discuss their fertility intentions, contraception and preconception planning.
  • Whenever contraceptive counselling is provided, care should be taken to ensure women
    do not feel under pressure to choose a method of contraception.
  • If a woman wishes to delay or prevent a further pregnancy, effective contraception should be initiated as soon as possible as sexual activity and ovulation may resume very soon after ectopic pregnancy or miscarriage.
  • A woman’s chosen method of contraception should ideally be initiated immediately after treatment for ectopic pregnancy or miscarriage.
  • Women should be informed about the effectiveness of the different contraceptive methods, including the superior effectiveness of LARC, when choosing an appropriate method to use after ectopic pregnancy or miscarriage.
  • Clinicians should adopt a person-centred approach when providing women with contraceptive counselling.
  • Clinicians who are giving advice to women about contraception after ectopic pregnancy or miscarriage should ensure that this information is timely, up-to-date and accurate.
33
Q
  1. Contraception After Ectopic Pregnancy or Miscarriage
    - Discussion and provision of contraception after ectopic pregnancy or miscarriage
    - How long should a woman wait before trying to conceive again after ectopic pregnancy or miscarriage?
A
  • Women who wish to conceive after miscarriage can be advised there is no need to delay as pregnancy outcomes after miscarriage are more favourable when conception occurs within 6 months of miscarriage compared with after 6 months.
  • Women who have been treated with methotrexate should be advised that effective contraception is recommended during and for at least 3 months after treatment in view of the teratogenic effects of this medication.
  • Women should be advised that effective contraception can be started on the day of methotrexate administration or surgical management of ectopic pregnancy.
34
Q
  1. Contraception After Ectopic Pregnancy or Miscarriage
    - Discussion and provision of contraception after ectopic pregnancy or miscarriage
    - Who should provide contraception after ectopic pregnancy or miscarriage?
A
  • Services involved in the care of women who have had an ectopic pregnancy or miscarriage should be able to offer all methods of contraception, including LARC, to
    women before they are discharged from the service.
  • Services should ensure that there are sufficient numbers of staff able to provide IUC or IMP so that women who choose these methods and are medically eligible can initiate them immediately after
    treatment.
  • Women who are unable to be provided with their chosen method of contraception should be informed about services where their chosen method can be accessed. A temporary (bridging) method should be offered until the chosen method can be initiated.
  • Services should have agreed pathways of care to local specialist contraceptive services [e.g. community sexual reproductive health (SRH) services] for women with complex medical conditions or needs which may require specialist contraceptive advice.
  • Services should have agreed pathways of care to local services for women who may
    require additional non-medical care and support.
35
Q
  1. Contraception After Ectopic Pregnancy or Miscarriage
    - Discussion and provision of contraception after ectopic pregnancy or miscarriage
    - Record keeping and obtaining valid consent
A

Clinicians should clearly document the discussion and provision of contraception. Valid consent must be obtained before providing women with their chosen method of contraception.

36
Q
  1. Contraception After Ectopic Pregnancy or Miscarriage
    - Medical eligibility
    - Which contraceptive methods are safe to use after ectopic pregnancy or miscarriage?
A
  • Clinicians should refer to the method-specific recommendations for abortion which may be extrapolated for use after ectopic pregnancy or miscarriage.
  • Women should be advised that any method of contraception can be safely initiated immediately after methotrexate administration or surgical treatment of ectopic pregnancy.
  • Women should be advised that any method of contraception can be safely initiated immediately after treatment for miscarriage.
  • IUC can be inserted after miscarriage as soon as expulsion has occurred at surgery or after medical or expectant management.
  • IUC should not be inserted in the presence of sepsis after ectopic pregnancy or miscarriage.
37
Q
  1. Contraception After Ectopic Pregnancy or Miscarriage
    - Medical eligibility
    - Is emergency contraception (EC) safe to use after ectopic pregnancy or miscarriage?
A
  • EC is indicated if UPSI takes place more than 5 days after methotrexate administration or surgical treatment of ectopic pregnancy.
  • Women should be advised that any method of EC can be safely used after ectopic pregnancy or miscarriage.
38
Q
  1. Contraception After Ectopic Pregnancy or Miscarriage
    - Medical eligibility
    - Is additional contraception required after initiation of a method after ectopic pregnancy or
    miscarriage?
A
  • Women should be advised that additional contraceptive precautions (e.g. barrier methods /abstinence) are required if hormonal contraception is started 5 days or more after miscarriage. Additional contraceptive precaution is not required if contraception is initiated immediately or within 5 days of miscarriage.
  • Women should be advised that additional contraceptive precautions (e.g. barrier methods /abstinence) are required if hormonal contraception is started 5 days or more after surgical treatment or administration of methotrexate for ectopic pregnancy.
  • Additional contraceptive precaution is not required if contraception is initiated immediately or within 5 days of treatment of ectopic pregnancy.
39
Q
  • What are the implications of recurrent miscarriage on contraceptive choice?
A
  • recurrent early miscarriage (REM) should be investigated for any underlying causes.
  • However, investigations should not lead to delay in initiation of a contraceptive method if the woman does not wish to become pregnant.
  • CHC should be avoided by women with REM until APS has been excluded.
40
Q
  1. Contraception After Ectopic Pregnancy or Miscarriage
    - Specific issues
    - Is there any method associated with a risk of another ectopic pregnancy?
A
  • Women should be advised that the absolute risk of ectopic pregnancy when contraception is used is extremely small and that the risk of pregnancy is lowest with LARC.
  • Women should be advised to seek medical advice if they suspect they may be pregnant and have symptoms suggestive of ectopic pregnancy, even while using contraception.
  • Women who have had an ectopic pregnancy should be advised that the IUC is one of the most effective methods of contraception and so the absolute risk of any pregnancy including ectopic pregnancy is extremely low.
  • Women should be informed that if pregnancy occurs with an IUC in situ, there is an increased risk of ectopic pregnancy and therefore the location of the pregnancy should be confirmed by ultrasound as soon as possible.
41
Q
  1. Contraception After GTD
    - Discussion and provision of contraception after GTD
    - When should contraception be discussed/provided?
A
  • Services that provide care to women who have/had gestational trophoblastic disease (GTD) should give them opportunities to discuss their fertility intentions, contraception and preconception planning.
  • Whenever contraceptive counselling is provided, care should be taken to ensure women do not feel under pressure to choose a method of contraception.
  • Women should be advised to avoid subsequent pregnancy until GTD monitoring is complete. Effective contraception should be started as soon as possible as sexual activity and fertility may resume very soon after GTD.
42
Q
  1. Contraception After GTD
    - Discussion and provision of contraception after GTD
    - Are fertility and pregnancy outcomes affected after GTD?
A

Clinicians should reassure women with GTD that fertility and pregnancy outcomes are favourable after GTD, including after chemotherapy for GTN. However, there is an increased risk of GTD in subsequent pregnancy.

43
Q
  • How long should a woman wait after GTD before trying to conceive?
A
  • After complete molar pregnancy, avoid subsequent
    pregnancy for at least 6 months to allow hCG
    monitoring for ongoing GTD.
  • After partial molar pregnancy, avoid pregnancy until two consecutive monthly hCG levels are normal.
  • After chemotherapy: avoid pregnancy for 1 year after treatment is complete.
44
Q
  • Which contraceptive methods are safe to use after GTD?
A
  • most methods of contraception can be safely used after treatment for GTD and can be started immediately after uterine evacuation, with exception of IUC.
  • IUC not inserted in women with persistently elevated hCG levels or malignant disease.
  • IUC should not normally be inserted until hCG levels have normalised but may be considered on specialist advice with insertion in a specialist setting for women with decreasing hCG levels following discussion with a GTD centre
45
Q
  • Is emergency contraception (EC) safe to use after GTD?
A
  • EC indicated if UPSI from 5 days after treatment for GTD.
  • oral EC is safe after treatment for GTD.
  • Insertion of Cu-IUD for EC may be considered in a specialist setting for women with decreasing hCG levels following discussion with a GTD centre.
46
Q
  • Is additional contraception required after initiation of a contraceptive method after GTD?
A
  • advised that additional contraceptive precautions (e.g. barrier methods/abstinence) are required if hormonal contraception is started 5 days or more after treatment for GTD.
  • Additional contraceptive precaution is not required if contraception is initiated immediately or within 5 days of treatment for GTD.
47
Q

Contraception After GTD

  • Intrauterine Contraception (IUC)
A
  • IUC not until hCG levels have normalised after GTD.
  • Cu-IUD as EC may be considered in a specialist setting with decreasing hCG levels following discussion with a GTD centre.
  • IUC at surgical evacuation where GTD is suspected but not confirmed, on individual case basis based upon – individual woman’s risk for GTD,
    • clinical findings and her
    • preference for IUC insertion at this time.
48
Q

Contraception After GTD

  • Hormonal contraception
A

Hormonal contraception can be started immediately after uterine evacuation for GTD.

49
Q

Contraception After GTD

  • Female sterilisation
A
  • Female sterilisation is a safe for permanent
  • some LARC methods are as, or more, effective than female sterilisation and non-contraceptive benefits.
  • women should not feel pressured into choosing LARC over female sterilisation.
  • Tubal occlusion ideally after some time after surgical evacuation for GTD. If request then advise possible increased failure rate and risk of regret.
50
Q
  • Is there any contraceptive method associated with a risk of GTD in subsequent pregnancies?
A
  • no evidence that use of any contraceptive method after GTD increases risk of GTD in subsequent pregnancy.
51
Q

Contraception after Pregnancy, abortion and GTD

  • Provision of contraception

Pathways

A
  • Maternity services should have agreed pathways of care to local specialist contraceptive services (e.g. community SRH services) for women with complex medical conditions or needs which may require specialist contraceptive advice.
  • Maternity services should have agreed pathways of care to local services for women who may require additional non-medical care and support. eg GBV
52
Q

Contraception After Pregnancy, abortion & GTD

  • Female sterilisation, difference in consent
A
  • Tubal occlusion ideally after some time following childbirth. Women who request at time of delivery should be advised of possible increased risk of regret.
  • written consent: CS +TL, obtained and documented at least 2 weeks in advance of a planned elective CS.
  • written consent: same time as surgical abortion is taken and documented in advance of the abortion.
  • Tubal occlusion ideally after some time after surgical evacuation for GTD. If request then advise possible increased failure rate and risk of regret.

Bushra's Contraception (21 decks)

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