Postpartum_Contraception_Flashcards (1)
When do women require contraception after giving birth?
After day 21.
When can postpartum women start the progestogen-only pill (POP)?
Postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.
What additional contraception is needed after day 21 with the POP?
Additional contraception should be used for the first 2 days.
Does progestogen in the POP affect breast milk?
A small amount of progestogen enters breast milk but this is not harmful to the infant.
What is the UKMEC classification for the combined oral contraceptive pill (COCP) if breastfeeding < 6 weeks post-partum?
Absolutely contraindicated - UKMEC 4.
What is the UKMEC classification for the COCP if breastfeeding 6 weeks - 6 months postpartum?
UKMEC 2.
What effect does the COCP have on breast milk production?
The COCP may reduce breast milk production in lactating mothers.
When should the COCP not be used postpartum?
Should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum.
What additional contraception is needed after day 21 with the COCP?
Additional contraception should be used for the first 7 days.
When can the intrauterine device or intrauterine system be inserted postpartum?
Within 48 hours of childbirth or after 4 weeks.
What is the effectiveness of the Lactational Amenorrhoea Method (LAM)?
LAM is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum.
What are the risks associated with an inter-pregnancy interval of less than 12 months?
An increased risk of preterm birth, low birth weight and small for gestational age babies.
summarise
Postpartum contraception
After giving birth, women require contraception after day 21.
Progestogen-only pill (POP)
the FSRH advise ‘postpartum 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
Combined oral contraceptive pill (COCP)
absolutely contraindicated - UKMEC 4 - if breastfeeding < 6 weeks post-partum
UKMEC 2 - if breastfeeding 6 weeks - 6 months postpartum*
the COCP may reduce breast milk production in lactating mothers
should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum
after day 21 additional contraception should be used for the first 7 days
The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.
Lactational amenorrhoea method (LAM)
is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum
An inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight and small for gestational age babies.
*this changed from UKMEC 3 in 2016
A 34-year-old woman presents to her GP for contraception advice three weeks after the delivery of her second child. She is currently breastfeeding. She has a body mass index of 28 kg/m^2. Her husband has a vasectomy booked for three months time.
What is the most appropriate contraception?
Combined oral contraceptive pill
Progesterone only pill
Intra-uterine coil
Intra-uterine progesterone-only system (Mirena)
Progesterone implant (Nexplanon)
Progesterone only pill
Her partner is due to receive a vasectomy in three months time, therefore a long-acting reversible contraceptive would not be a sensible choice.
With regards to short acting contraceptions, the puerperium and lactation make particular demands on the safe choice of contraception - there is an increased risk of venous thromboembolic disease in the few weeks following childbirth and breastfeeding is considered a contra-indication to the use of the combined oral contraceptive pill (COCP). Therefore, the progesterone only pill would be the most sensible choice of contraception.
Guidelines state that women should be advised that contraception is not required before Day 21 postpartum. Therefore, it would be sensible to not initiate the progesterone only pill until then.
In addition, guidelines also state that women may be advised that if they are <6 months postpartum, amenorrhoeic and fully breastfeeding, the lactational amenorrhoea method (LAM) is over 98% effective in preventing pregnancy. This would also be an option for the lady in this scenario to consider.
References
Postnatal Sexual and Reproductive Health. Faculty of Sexual and Reproductive Healthcare (Royal college of obstetricians and gynaecologists) (2009).
A 34-year-old woman has just given birth 24 hours ago. She states she is not planning on having any more children in the immediate future and would like to start a long-term contraceptive. She has a past medical history of heavy menstrual bleeding and is planning to exclusively breastfeed.
What is the most appropriate contraception for this patient?
Copper intrauterine device
Lactational amenorrhoea method
Levonorgestrel intrauterine system
Progestogen injection
Progestogen only pill
Levonorgestrel intrauterine system
The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks
Levonorgestrel intrauterine system is the correct answer. It is a long-acting contraceptive that will also help to prevent any future heavy menstrual bleeding. As the patient is within 48 hours of childbirth, it can be inserted immediately.
Copper intrauterine device is not the correct answer. While this is a long-acting contraceptive and the patient is within the correct time window to have it inserted, it often causes heavy menstrual bleeding. It should therefore be avoided in those with a history of heavy menstrual bleeding.
Lactational amenorrhoea method is not the correct answer. Although lactational amenorrhoea is an effective method of contraception for women who exclusively breastfeed, it is only effective up to 6 months post-partum.
Progestogen injection is not the correct answer. While these injections can be given at any stage following pregnancy, progestogen injections must be repeated every 10-12 weeks, and are suitable for this patient’s desire for a long-term contraceptive.
Progestogen only pill is not the correct answer. While this is safe to start at any stage post-partum, it is not a long-acting contraceptive. This option would be more suitable for women who are considering having further children in the near future, or if other contraceptive options are contra-indicated.
