Intrapartum Care: Family planning after pregnancy

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Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning

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Intrapartum Care: Family planning after pregnancy

  1. 1. 8 Family planning after pregnancyBefore you begin this unit, please take the for everybody. Family planning is an importantcorresponding test at the end of the book to part of primary health care and includes:assess your knowledge of the subject matter. You 1. Promoting a caring and responsibleshould redo the test after you’ve worked through attitude to sexual behaviour.the unit, to evaluate what you have learned 2. Ensuring that every child is wanted. 3. Encouraging the planning and spacing Objectives of the number of children according to a family’s home conditions and financial income. When you have completed this unit you 4. Providing the highest quality of maternal should be able to: and child care. 5. Educating the community with regard • Give contraceptive counselling. to the disastrous effects of unchecked • List the efficiency, contraindications and population growth on the environment. side effects of the various contraceptive methods. 8-2 Who needs contraceptive counselling? • List the important health benefits of While the best time to advise a woman on contraception. contraception is before the first coitus, the • Advise a postpartum patient on antenatal and postdelivery periods provide an the most appropriate method of excellent opportunity to provide contraceptive contraception. counselling. Some patients will ask you for contraceptive advice. However, you will often have to first motivate a patient to accept contraception before you can advise her aboutCONTRACEPTIVE an appropriate method of contraception.COUNSELLING All women should be offered contraceptive counselling after delivery.8-1 What is family planning?Family planning is far more than simply birthcontrol, and aims at improving the quality of life
  2. 2. FAMILY PLANNING AFTER PREGNANC Y 1318-3 How should you motivate a patient with her husband and, where appropriate,to accept contraception after delivery? other members of her family or friends.A good way to motivate a patient to accept Step 2: The patient’s choice of a contraceptivecontraception is to discuss with her, or methodpreferably with both her and her partner, thehealth and socio-economic effects further The patient should always be asked whichchildren could have on her and the rest of the contraceptive method she would prefer as thisfamily. Explain the immediate benefits of a will obviously be the method with which she issmaller, well spaced family. most likely to continue.It is generally hopeless to try and promote Step 3: Consideration of contraindications to thecontraception by itself. To gain individual and patient’s preferred methodcommunity support, family planning mustbe seen as part of total primary health care. You must decide whether the patient’s choiceA high perinatal or infant mortality rate in a of a contraceptive method is suitable, takingcommunity is likely to result in a rejection of into consideration:contraception. 1. The effectiveness of each contraceptive method.8-4 How should you give contraceptive 2. The contraindications to eachadvice after delivery? contraceptive method.There are five important steps which should be 3. The side effects of each contraceptivefollowed: method. 4. The general health benefits of eachStep 1: Discussion of the patient’s future contraceptive method.reproductive career If the contraceptive efficiency of the preferredIdeally a woman should consider and plan method is appropriate, if there are noher family before her first pregnancy, just as contraindications to it, and if the patient isshe would have considered her professional prepared to accept the possible side effects,career. Unfortunately in practice this hardly then the method chosen by the patient shouldever happens and many women only discuss be used. Otherwise help her to choose thetheir reproductive careers for the first time most appropriate alternative method.when they are already pregnant or after thebirth of the infant. When planning her family Step 4: Selection of the most appropriatethe woman (or preferably the couple) should alternative method of contraceptiondecide on: The selection of the most suitable alternative1. The number of children wanted. method of contraception after delivery will2. The time intervals between pregnancies depend on a number of factors including the as this will influence the method of patient’s wishes, her age, the risk of side effects contraception used. and whether or not a very effective method of3. The contraceptive method of choice when contraception is required. the family is complete. Step 5: Counselling the patient once theVery often the patient will be unable or contraceptive method has been chosenunwilling to make these decisions immediatelyafter delivery. However, it is essential to discuss Virtually every contraceptive method has itscontraception with the patient so that she can own side effects. It is a most important partplan her family. This should be done together of contraceptive counselling to explain the possible side effects to the patient. Expert
  3. 3. 132 INTRAPAR TUM CAREfamily planning advice must be sought if the Breastfeeding, spermicides alone, coitusdistrict hospital is unable to deal satisfactorily interruptus and the ‘safe period’ are all verywith the patient’s problem. If family planning unreliable. All women should know aboutmethod problems are not satisfactorily solved, postcoital contraception.the patient will probably stop using any formof contraception. Breastfeeding cannot be relied upon to provide postpartum contraception. After delivery the reproductive career of each patient must be discussed with her in order to 8-6 How effective are the various decide on the most appropriate method of family contraceptive methods? planning to be used. Contraceptive methods for use after delivery may be divided into very effective and less effective ones. Sterilisation, injectables, oralCONTRACEPTION contraceptives and intra-uterine contraceptiveAFTER DELIVERY devices are very effective. Condoms are less effective contraceptives. The effectiveness of a contraceptive method8-5 What contraceptive methods is given as an index which indicates thecan be offered after delivery? number of women who would be expected to1. Sterilisation. Either tubal ligation (tubal fall pregnant if 100 women used that method occlusion) or vasectomy. for one year. The ideal efficacy index is 0.2. Injectables (i.e. an intramuscular injection The higher the index, the less effective is the of depot progestogen). method of contraception. The efficacy of the3. Oral contraceptives. Either the combined various contraceptive methods for use after pill (containing both oestrogen and delivery is shown in table 8-1. progestogen) or a progestogen-only pill (the ‘minipill’). 8-7 How effective is postcoital4. An intra-uterine contraceptive device contraception? (IUCD). 1. Norlevo, E Gen-C or Ovral are effective5. The condom. within five days of unprotected sexualTable 8-1: The efficacy of the various contraceptive methods for use after delivery Contraceptive method Efficacy index Sterilisation: Vasectomy 0.05 Tubal ligation 0.5 Injectables: Depo-Provera/Petogen 0.2 Nur-Isterate 0.6 Oral contraceptives: Combined pill 0.3 Minipill 1.2 IUCD: Copper 0.5 Condom* Male 2-15 Female (Reality female condom) 5-15*The safety of condoms depends on the reliability with which they are used.
  4. 4. FAMILY PLANNING AFTER PREGNANC Y 133 intercourse, but are more reliable the • Oestrogen dependent malignancies earlier they are used. such as breast or uterine cancer.2. A copper intra-uterine contraceptive 4. Progestogen-only pill (minipill): device can be inserted within six days of • None. unprotected intercourse. 5. Intra-uterine contraceptive device:3. Postcoital methods should only be used in • A history of excessive menstruation. an emergency and not as a regular method • Anaemia. of contraception. • Multiple sex partners when the risk of4. If Norlevo is used, one tablet should be genital infection is high. taken as soon as possible after intercourse, • Pelvic inflammatory disease. followed by another one tablet after A menstrual abnormality is a contraindication exactly 12 hours. to any of the hormonal contraceptive methods5. If Ovral or E-Gen-C is used, two tablets (injectables, combined pill or progestogen-only are taken as soon as possible after pill) until the cause of the menstrual irregularity intercourse, followed by another two has been diagnosed. Thereafter, hormonal tablets exactly 12 hours later. contraception may often be used to correct theThe tablets for postcoital contraception menstrual irregularity. However, during theoften cause nausea and vomiting reduce puerperium a previous history of menstrualtheir effectiveness. These side effects are less irregularity before the pregnancy is not awith Norlevo which contains no oestrogen. contraindication to hormonal contraception.Therefore Norlevo is a more reliable method If a woman has a medical complication, thenand should be used if available. Norlevo as a a more detailed list of contraindications maysingle dose method will soon be available in be obtained from the standard reference booksSouth Africa. such as J Guillebaud, Contraception: Your questions answered. Fourth edition. London:8-8 What are the contraindications to Churchill Livingstone 2004 (a new edition isthe various contraceptive methods? expected soon).The following are the common or important The World Health Orgainsation (WHO)conditions where the various contraceptive medical eligibility criteria for contraceptive usemethods should not be used: is also available on a WHO website (www.who.1. Sterilisation: int/reproductive-health/publications/mec/). • Marital disharmony. • Psychological problems. 8-9 What are the major side effects of • Forced or hasty decision. the various contraceptive methods? • Gynaecological problem requiring Most contraceptive methods have side hysterectomy. effects. Some side effects are unacceptable to2. Injectables: a patient and will cause her to discontinue • Depression. the particular method. However, in many • Pregnancy planned within one year. instances side effects are mild or disappear3. Combined pills: with time. It is, therefore, very important • A history of venous thrombo- to counsel a patient carefully about the side embolism. effects of the various contraceptive methods, • Age 35 years or more with risk factors and to determine whether she would find any for cardiovascular disease such as of them unacceptable. At the same time the smoking. patient may be reassured that some side effects • Anyone of 50 or more years. will most likely become less or disappear after a few months’ use of the method.
  5. 5. 134 INTRAPAR TUM CAREThe major side effects of the various • Perforation of the uterus is uncommon.contraceptive methods used after delivery are: • Ectopic pregnancy is not prevented. Progesterone containing intra-uterine1. Sterilisation: contraceptive devices (Mirena) have lesser Tubal ligation and vasectomy have no side effects and reduce menstrual blood medical side effects and, therefore, loss. These devices are expensive and not should be highly recommended during generally available in the public health counselling of patients who have completed sector. their families. Menstrual irregularities 6. Condom: are not a problem. However, about 5% of • Decreased sensation for both partners. women later regret sterilisation. • Not socially acceptable to everyone.2. Injectables: • Menstrual abnormalities, e.g. amenorrhoea, irregular menstruation If a couple have completed their family the or spotting. contraceptive method of choice is tubal ligation • Weight gain. or vasectomy. • Headaches. • Delayed return to fertility within a Additional contraceptive precautions must be year of stopping the method. There is taken when the contraceptive effectiveness of no evidence that fertility is reduced an oral contraceptive may be impaired, e.g. thereafter. diarrhoea or when taking antibiotics. There With Nur-Isterate there is a quicker is no medical reason for stopping a hormonal return to fertility, slightly less weight gain method periodically to ‘give the body a rest’. and a lower incidence of headaches and amenorrhoea than with Depo-Provera or Petogen. 8-10 What are the important health3. Combined pill: benefits of contraceptives? • Reduction of lactation. The main objective of all contraceptive • Menstrual abnormalities, e.g. spotting methods is to prevent pregnancy. In developing between periods. countries pregnancy is a major cause of • Nausea and vomiting. mortality and morbidity in women. Therefore, • Depression. the prevention of pregnancy is a very important • Fluid retention and breast tenderness. general health benefit of all contraceptives. • Chloasma (a brown mark on the face). • Headaches and migraine. Various methods of contraception have4. Progestogen-only pill: a number of additional health benefits. • Menstrual abnormalities, e.g. irregular Although these benefits are often important, menstruation. they are not generally appreciated by many • Headaches. patients and health-care workers: • Weight gain. 1. Injectables:5. Copper containing intra-uterine • Decrease in dysmenorrhoea. contraceptive device. • Less premenstrual tension. • Expulsion in 3–15 cases per 100 • Less iron deficiency anaemia due to women who use the device for one year. decreased menstrual flow. • Pain at insertion. • No effect on lactation. • Dysmenorrhoea. 2. Combined pill: • Menorrhagia (excessive and/or • Decrease in dysmenorrhoea. prolonged bleeding). • Decrease in menorrhagia (heavy and/or • Increase in pelvic inflammatory prolonged menstruation). disease.
  6. 6. FAMILY PLANNING AFTER PREGNANC Y 135 • Less iron-deficiency anaemia. • A combined pill until 35 years of age if • Less premenstrual tension. there are risk factors for cardiovascular • Fewer ovarian cysts. disease, or until 50 years of age if these • Less benign breast disease. risk factors are absent. • Less endometrial and ovarian 4. Patients of 35 years or over without risk carcinoma. factors for cardiovascular disease:3. Progestogen-only pill: • Tubal ligation or vasectomy is the • No effect on lactation. logical method.4. Condom: • A combined pill until 50 years of age. • Less risk of HIV infection and other • An injectable until 50 years of age. sexually transmitted diseases. • A progestogen-only pill until 50 years • Less pelvic inflammatory disease. of age. • Less cervical intra-epithelial neoplasia. • An intra-uterine contraceptive device until one year after the periods have stopped, i.e. when there is no further The condom is the only contraceptive method risk of pregnancy. that provides protection against HIV infection. 5. Patients of 35 years or over with risk factors for cardiovascular disease:8-11 What is the most appropriate • as above but no combination pill.method of contraception fora woman after delivery? The puerperium is the most convenient timeThe most suitable methods for the following for the patient to have a bilateral tubal ligationgroups of women are: performed.1. Lactating patients: • An injectable, but not if a further Every effort should be made to provide pregnancy is planned within the next facilities for tubal ligation during the year. puerperium for all patients who request • A progestogen-only pill (minipill) for sterilisation after delivery. three months, then the combined pill. Remember that sperms may be present • An intra-uterine contraceptive device. in the ejaculate for up to three months2. Teenagers and patients with multiple following vasectomy. Therefore, an additional sexual partners. contraceptive method must be used during • An injectable, as this is a reliable method this time. even with unreliable patients who might forget to use another method. 8-12 What are the risk factors for • Additional protection against HIV cardiovascular disease in women infection by using a condom is taking the combined pill? essential. It is important to stress that the patient should only have The risk of cardiovascular disease increases intercourse with a partner who is markedly in women of 35 or more years of age willing to use a condom. who have one or more of the following risk3. Patients whose families are complete: factors: • Tubal ligation or vasectomy is the 1. Smoking logical choice. 2. Hypertension • An injectable, e.g. Depo-Provera or 3. Diabetes Petogen (12 weekly) or Nur-Isterate 4. Hypercholesterolaemia (eight-weekly). 5. A personal history of cardiovascular disease
  7. 7. 136 INTRAPAR TUM CARE contraceptive or an intra-uterine contraceptive Smoking is a risk factor for cardiovascular disease. device would be the next best choice.8-13 When should an intra- 3. If the patient accepts tubal ligation,uterine contraceptive device when should this be done?be inserted after delivery? The most convenient time for the patientIt should not be inserted before six weeks as and her family is the day after deliverythe uterine cavity would not yet have returned (postpartum sterilisation). Every effort shouldto its normal size. At six weeks or more after be made to provide facilities for postpartumdelivery there is the lowest risk of: sterilisation for all patients who request it.1. Pregnancy2. Expulsion 4. If the couple decides not to have a tubal ligation or vasectomy, how willPostpartum patients choosing this method must you determine whether an injectablebe discharged on an injectable contraceptive or an intra-uterine contraceptiveor progestogen-only pill until an intra-uterine device would be the best choice?contraceptive device has been inserted. Assessing the risk for pelvic inflammatoryInsertion of an intra-uterine contraceptive disease will determine which of the twodevice immediately after delivery may be methods to use. If the patient has a stableconsidered if it is thought likely that a patient relationship, an intra-uterine contraceptivewill not use another contraceptive methods and device may be more appropriate. However, ifwhere sterilisation is not appropriate. However, she or her husband (or boyfriend) has otherthe expulsion rate will be as high as 20%. sexual partners, an injectable contraceptive would be indicated.CASE STUDY 1 5. What other advice must be given to a patient at risk of sexuallyA 36-year-old patient has delivered her fourth transmitted infections?child in a district hospital. All her children arealive and well. She is a smoker but is otherwise The patient must insist that her partner wearshealthy. She has never used contraception. a condom during sexual intercourse. This will reduce the risk of HIV infection.1. Should you counsel this patientabout contraception? CASE STUDY 2Yes. Every sexually active person needscontraceptive counselling. This patient in A 15-year-old primigravida had a normalparticular needs counselling as she is at an delivery the previous day in a district hospital.increased risk of maternal and perinatal She has never used contraception. Her mothercomplications, should she fall pregnant again, asks you for contraceptive advice for herbecause of her age and parity. daughter after delivery. The patient’s boyfriend has deserted her.2. Which contraceptive methods wouldbe appropriate for this patient? 1. Does this young teenager requireTubal ligation or vasectomy would be the contraceptive advice after delivery?most appropriate method of contraception if Yes, she will certainly need contraceptiveshe does not want further children. Should counselling and should start on a contraceptiveshe not want sterilisation, either an injectable
  8. 8. FAMILY PLANNING AFTER PREGNANC Y 137method before discharge from hospital. She 1. The patient says that she has usedneeds to learn sexual responsibility and must an injectable contraceptive for fivebe told where the nearest clinic to her home years before this pregnancy and wouldis for follow-up. She also needs to know about like to continue with this method.postcoital contraception. What would your advice be? Injectable contraception would not be2. Which contraceptive method would be appropriate as she plans her next pregnancymost the appropriate for this patient? within a year, and there may be a delayedAn injectable contraceptive would probably be return to fertility.the best method for her as she needs reliablecontraception for a long time. 2. If the patient insists on using an injectable contraceptive, which drug3. Why would she need a long would you advise her to use?term contraceptive? Any of the injectables can be used (DepoBecause she should only have her next child Provera/Petogen or Nur-Isterate) as there is nowhen she is much older and has a stable proven advantage of the one above the others.relationship. 3. Following further counselling, the4. If the patient prefers to use an oral patient decides on oral contraceptioncontraceptive, would you regard and is given a combined pill. Do youthis as an appropriate method agree with this management?of contraception for her? No. As she plans to breastfeed, she shouldNo. A method which she is more likely to be given a progestogen-only pill. Combineduse correctly and reliably would be more oral contraceptive pills may reduce milkappropriate. Oral contraceptives are only production while breastfeeding is beingreliable if taken every day. established. Progestogen-only pills have no effect on breastfeeding.5. The patient and her mother are worriedthat the long term effect of injectablecontraception could be harmful to a girl CASE STUDY 4of 15 years. What would be your advice? A married primipara from a rural area has justInjectable contraception is extremely safe and, been delivered in a district hospital. She has atherefore, is an appropriate method for long stable relationship with her husband and theyterm use. This method will not reduce her decide to have their next infant in five yearsfuture fertility. time. The patient would like to have an intra- uterine contraceptive device inserted.CASE STUDY 3 1. Is this an appropriate method for this patient?You have just delivered the first infant of ahealthy 32-year-old patient. In discussing Yes, as the risk of developing pelviccontraception with her, she mentions that she inflammatory disease is low.is planning to fall pregnant again within a yearafter she stops breastfeeding. She is a schoolteacher and would like to continue her careerafter having two children.
  9. 9. 138 INTRAPAR TUM CARE2. When should the device be inserted? 4. The patient asks if the intra-uterine contraceptive device could be insertedSix weeks or more after delivery as there is before she is discharged from hospital.an increased risk of expulsion if the device is Would this be appropriate management?inserted earlier. The expulsion rate and, therefore, the risk of3. Could the patient, in the contraceptive failure is much higher if themeantime, rely on breastfeeding device is inserted soon after delivery. Therefore,as a contraceptive method? it would be far better if she were to return six weeks later for insertion of the device.No. The risk of pregnancy is too high. Sheshould use reliable contraception, such asinjectable contraception or the progestogen-only pill, until the device is inserted.

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