14                                                   Family planning                                                   aft...
258   MATERNAL CARE14-2 Who requires family                           Step 1: Discussion of the patient’s futureplanning e...
FAMILY PLANNING AFTER PREGNANC Y      259If the contraceptive efficiency of the preferred      5. The condom.method is app...
260   MATERNAL CARETable 14-1: The efficacy of the various contraceptive methods for use after delivery                   ...
FAMILY PLANNING AFTER PREGNANC Y      261  available on a WHO website (www.who.int/                • Depression.  reproduc...
262   MATERNAL CAREthe prevention of pregnancy is a very important    2. Teenagers and patients with multiplegeneral healt...
FAMILY PLANNING AFTER PREGNANC Y      263puerperium for all patients who request                  CASE STUDY 1sterilisatio...
264   MATERNAL CARE5. What other advice must be given               appropriate. Oral contraceptives are onlyto a patient ...
FAMILY PLANNING AFTER PREGNANC Y     265oral contraceptive pills may reduce milk           2. When should the device be in...
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Maternal Care: Family planning after pregnancy


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Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

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Maternal Care: Family planning after pregnancy

  1. 1. 14 Family planning after pregnancyBefore you begin this unit, please take the CONTRACEPTIVEcorresponding test at the end of the book toassess your knowledge of the subject matter. You COUNSELLINGshould redo the test after you’ve worked throughthe unit, to evaluate what you have learned. 14-1 What is family planning? Family planning is far more than simply birth Objectives control, and aims at improving the quality of life for everybody. Family planning is an important part of primary healthcare and includes: When you have completed this unit you should be able to: 1. Promoting a caring and responsible • Explain the wider meaning of family attitude to sexual behaviour. 2. Ensuring that every child is wanted. planning. 3. Encouraging the planning and spacing • Give contraceptive counselling. of the number of children according to • List the efficiency, contraindications and a family’s home conditions and financial side effects of the various contraceptive income. methods. 4. Providing the highest quality of maternal • List the important health benefits of and child care. 5. Educating the community with regard contraception. to the disastrous effects of unchecked • Advise a postpartum patient on population growth on the environment. the most appropriate method of It is essential to obtain prior community contraception. acceptance of, and promote community participation in, any family planning programme if the programme is to succeed in that community.
  2. 2. 258 MATERNAL CARE14-2 Who requires family Step 1: Discussion of the patient’s futureplanning education? reproductive careerBecause family planning aims at improving Ideally a woman should consider and plan herthe quality of life for everybody, every person, family before her first pregnancy, just as shefemale or male, requires family planning would have considered her professional career.education. Such education should ideally start Unfortunately in practice this hardly everduring childhood and be given in the home by happens and many women only discuss theirthe parents. It is then continued at school and reproductive careers for the first time whenthroughout the rest of the individual’s life. they are already pregnant or after the birth of the infant.14-3 Who needs contraceptive counselling? When planning her family the woman (orEvery person who is sexually active, or preferably the couple) should decide on:who probably will soon become sexually 1. The number of children wanted.active, needs contraceptive counselling (i.e. 2. The time intervals between pregnanciesinformation and advice about birth control). as this will influence the method ofWhile the best time to advise a woman on contraception used.contraception is before the first coitus, the 3. The contraceptive method of choice whenantenatal and post-delivery periods are an the family is complete.excellent opportunity to provide contraceptivecounselling. Some patients will ask you for Very often the patient will be unable orcontraceptive advice. However, you will often unwilling to make these decisions immediatelyhave to first motivate a patient to accept after delivery. However, it is essential to discusscontraception before you can advise her about contraception with the patient so that she canan appropriate method of contraception. plan her family. This should be done together with her partner and, where appropriate, other members of her family or friends.14-4 How should you motivate a patientto accept contraception after delivery? Step 2: The patient’s choice of contraceptiveA good way to motivate a patient to accept methodcontraception is to discuss with her, or The patient should always be asked whichpreferably with both her and her partner, the contraceptive method she would prefer as thishealth and socio-economic effects further will obviously be the method with which she ischildren could have on her and the rest of the most likely to continue.family. Explain the immediate benefits of asmaller, well-spaced family. Step 3: Consideration of contraindications toIt is generally hopeless to try and promote the patient’s preferred methodcontraception by itself. To gain individual and You must decide whether the patient’s choicecommunity support, family planning must of a contraceptive method is suitable, takingbe seen as part of total primary healthcare. into consideration:A high perinatal or infant mortality rate in acommunity is likely to result in a rejection of 1. The effectiveness of each contraceptivecontraception. method. 2. The contraindications to each14-5 How should you give contraceptive method.contraceptive advice after delivery? 3. The side effects of each contraceptive method.There are five important steps which should be 4. The general health benefits of eachfollowed. contraceptive method.
  3. 3. FAMILY PLANNING AFTER PREGNANC Y 259If the contraceptive efficiency of the preferred 5. The condom.method is appropriate, if there are no Breastfeeding, spermicides alone, coituscontraindications to it, and if the patient is interruptus and the ‘safe period’ are all veryprepared to accept the possible side effects, unreliable. All women should know aboutthen the method chosen by the patient should postcoital contraception.be used. Otherwise proceed to step 4.Step 4: Selection of the most appropriate Breastfeeding cannot be relied upon to providealternative method of contraception postpartum contraception.The selection of the most suitable alternativemethod of contraception after delivery will 14-7 How effective are the variousdepend on a number of factors including the contraceptive methods?patient’s wishes, her age, the risk of side effectsand whether or not a very effective method of Contraceptive methods for use after deliverycontraception is required. may be divided into very effective and less effective ones. Sterilisation, injectables, oralStep 5: Counselling the patient once the contraceptives and intra-uterine contraceptivecontraceptive method has been chosen devices are very effective. Condoms are less effective contraceptives.Virtually every contraceptive method has itsown side effects. It is a most important part The effectiveness of a contraceptive methodof contraceptive counselling to explain the is given as an index which indicates thepossible side effects to the patient. Expert number of women who would be expected tofamily planning advice must be sought if the fall pregnant if 100 women used that methodlocal clinic is unable to deal satisfactorily for one year. The ideal efficacy index is 0.with the patient’s problem. If family planning The higher the index, the less effective is theproblems are not satisfactorily solved, the method of contraception. The efficacy of thepatient will probably stop using any form of various contraceptive methods for use aftercontraception. delivery is shown in table 14-1. 14-8 How effective is postcoital After delivery the reproductive career of each contraception? patient must be discussed with her in order to 1. Norlevo, E Gen-C or Ovral are effective decide on the most appropriate method of family within five days of unprotected sexual planning to be used. intercourse, but are more reliable the earlier they are used.14-6 What contraceptive methods 2. A copper intra-uterine contraceptivecan be offered after delivery? device can be inserted within six days of unprotected intercourse.1. Sterilisation. Either tubal ligation (tubal 3. Postcoital methods should only be used in occlusion) or vasectomy. an emergency and not as a regular method2. Injectables (i.e. an intramuscular injection of contraception. of depot progestogen). 4. If Norlevo is used, one tablet should be3. Oral contraceptives. Either the combined taken as soon as possible after intercourse, pill (containing both oestrogen and followed by another one tablet after progestogen) or a progestogen-only pill exactly 12 hours. (the ‘minipill’). 5. If Ovral or E-Gen-C is used, two tablets4. An intra-uterine contraceptive device are taken as soon as possible after (IUCD).
  4. 4. 260 MATERNAL CARETable 14-1: 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. intercourse, followed by another two • Age 35 years or more with risk factors tablets exactly 12 hours later. for cardiovascular disease. • Anyone of 50 or more years.The tablets for postcoital contraception • Oestrogen-dependent malignanciesoften cause nausea and vomiting, which such as breast or uterine cancer.reduces their effectiveness. These side effects 4. Progestogen-only pill (minipill)are less with levonorgestrel (Norlevo and • None.Escapelle)which contains no oestrogen. 5. Intra-uterine contraceptive deviceTherefore levonorgestrel (Norlevo and • A history of excessive menstruation.Escapelle) is a more reliable method and • Anaemia.should be used if available. Norlevo and • Multiple sex partners when the risk ofEscapelle as a single dose method is available genital infection is high.in South Africa. • Pelvic inflammatory disease.14-9 What are the contraindications to A menstrual abnormality is a contraindicationthe various contraceptive methods? to any of the hormonal contraceptive methods (injectables, combined pill or progestogen-The following are the common or important only pill) until the cause of the menstrualconditions where the various contraceptive irregularity has been diagnosed. Thereafter,methods should not be used: hormonal contraception may often be used to1. Sterilisation correct the menstrual irregularity. However, • Marital disharmony. during the puerperium a previous history of • Psychological problems. menstrual irregularity before the pregnancy • Forced or hasty decision. is not a contraindication to hormonal • Gynaecological problem requiring contraception. hysterectomy.2. Injectables NOTE If a woman has a medical complication, then a more detailed list of contraindications may • Depression. be obtained from the standard reference books • Pregnancy planned within one year. such as J Guillebaud: Your questions answered. Fifth3. Combined pills edition. London: Churchill Livingstone 2009. • A history of venous thrombo- embolism. The World Health Organisation (WHO) medical eligibility criteria for contraceptive use is also
  5. 5. FAMILY PLANNING AFTER PREGNANC Y 261 available on a WHO website (www.who.int/ • Depression. reproductive -health/publications/mec/). • Fluid retention and breast tenderness. • Chloasma (a brown mark on the face).14-10 What are the major side effects of • Headaches and migraine.the various contraceptive methods? 4. Progestogen-only pill • Menstrual abnormalities, e.g. irregularMost contraceptive methods have side menstruation.effects. Some side effects are unacceptable to • Headaches.a patient and will cause her to discontinue • Weight gain.the particular method. However, in many 5. Copper-containing intra-uterineinstances side effects are mild or disappear contraceptive devicewith time. It is, therefore, very important to • Expulsion in 3–15 cases per 100counsel a patient carefully about the side effects women who use the device for one year.of the various contraceptive methods, and to • Pain at insertion.determine whether she would find any of them • Dysmenorrhoea.unacceptable. At the same time the patient • Menorrhagia (excessive and/ormay be reassured that some side effects will prolonged bleeding).most likely become less or disappear after a few • Increase in pelvic inflammatorymonths’ use of the method. disease.The major side effects of the various • Perforation of the uterus is uncommon.contraceptive methods used after delivery are: • Ectopic pregnancy is not prevented. 6. 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 South Africa counselling of patients who have completed 7. Condom their families. Menstrual irregularities • Decreased sensation for both partners. are not a problem. However, about 5% of • Not socially acceptable to everyone. women later regret sterilisation.2. Injectables • Menstrual abnormalities, e.g. If a couple have completed their family the amenorrhoea, irregular menstruation contraceptive method of choice is tubal ligation or spotting. or vasectomy. • Weight gain. • Headaches. Additional contraceptive precautions must • Delayed return to fertility within a be taken when the effectiveness of an oral year of stopping the method. There is contraceptive may be impaired, e.g. diarrhoea no evidence that fertility is reduced or when taking antibiotics. There is no medical thereafter. reason for stopping a hormonal method With Nur-Isterate there is a quicker periodically to ‘give the body a rest’. return to fertility, slightly less weight gain and a lower incidence of headaches and amenorrhoea than with Depo-Provera or 14-11 What are the important health Petogen. benefits of contraceptives?3. Combined pill The main objective of all contraceptive • Reduction of lactation. methods is to prevent pregnancy. In developing • Menstrual abnormalities, e.g. spotting countries pregnancy is a major cause of between periods. mortality and morbidity in women. Therefore, • Nausea and vomiting.
  6. 6. 262 MATERNAL CAREthe prevention of pregnancy is a very important 2. Teenagers and patients with multiplegeneral health benefit of all contraceptives. sexual partners. • An injectable, as this is a reliable methodVarious methods of contraception have even with unreliable patients who mighta number of additional health benefits. forget to use another method.Although these benefits are often important, • Additional protection against HIVthey are not generally appreciated by many infection by using a condom ispatients and healthcare workers. essential. It is important to stress1. Injectables that the patient should only have • Decrease in dysmenorrhoea. intercourse with a partner who is • Less premenstrual tension. willing to use a condom. • Less iron-deficiency anaemia due to 3. HIV-positive patients decreased menstrual flow. • Condoms must be used in addition to • No effect on lactation. the appropriate contraceptive method2. Combined pill (dual contraception). • Decrease in dysmenorrhoea. 4. Patients whose families are complete • Decrease in menorrhagia (heavy and/or • Tubal ligation or vasectomy is the prolonged menstruation). logical choice. • Less iron-deficiency anaemia. • An injectable, e.g. Depo-Provera or • Less premenstrual tension. Petogen (12 weekly) or Nur-Isterate (8 • Fewer ovarian cysts. weekly). • Less benign breast disease. • A combined pill until 35 years of age if • Less endometrial and ovarian there are risk factors for cardiovascular carcinoma. disease, or until 50 years if these risk3. Progestogen-only pill factors are absent. • No effect on lactation. 5. Patients of 35 years or over without risk4. Condom factors for cardiovascular disease • Less risk of HIV infection and other • Tubal ligation or vasectomy is the sexually transmitted diseases. logical method. • Less pelvic inflammatory disease. • A combined pill until 50 years of age. • Less cervical intra-epithelial neoplasia. • An injectable until 50 years of age. • A progestogen-only pill until 50 years of age. The condom is the only contraceptive method • An intra-uterine contraceptive device that provides protection against HIV infection. until one year after the periods have stopped, i.e. when there is no further14-12 What is the most appropriate risk of pregnancy.method of contraception for 6. Patients of 35 years or over with riska patient after delivery? factors for cardiovascular disease • As above but no combination pill.The most suitable methods for the followinggroups of patients are:1. Lactating patients The puerperium is the most convenient time • An injectable, but not if a further for the patient to have a bilateral tubal ligation pregnancy is planned within the next performed. year. • A progestogen-only pill (minipill) for Every effort should be made to provide three months, then the combined pill. facilities for tubal ligation during the • An intra-uterine contraceptive device.
  7. 7. FAMILY PLANNING AFTER PREGNANC Y 263puerperium for all patients who request CASE STUDY 1sterilisation after delivery.Remember that sperms may be present You have delivered the fourth child of anin the ejaculate for up to three months unbooked 36-year-old patient. All herfollowing vasectomy. Therefore, an additional children are alive and well. She is a smoker,contraceptive method must be used during but is otherwise healthy. She has never usedthis time. contraception.14-13 What are the risk factors for 1. Should you counsel this patientcardiovascular disease in women about contraception?taking the combined pill? Yes. Every sexually active person needsThe risk of cardiovascular disease increases contraceptive counselling. This patient inmarkedly in women of 35 or more years of particular needs counselling as she is at anage who have one or more of the following increased risk of maternal and perinatalrisk factors: complications, should she fall pregnant again, because of her age and parity.1. Smoking.2. Hypertension.3. Diabetes. 2. Which contraceptive methods would4. Hypercholesterolaemia. be appropriate for this patient?5. A personal history of cardiovascular Tubal ligation or vasectomy would be the disease. most appropriate method of contraception if she does not want further children. Should Smoking is a risk factor for cardiovascular she not want sterilisation, either an injectable contraceptive or an intra-uterine contraceptive disease. device would be the next best choice.14-14 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. Pregnancy.2. 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 inflammatory NOTE Insertion of an intra-uterine contraceptive disease will determine which of the two device immediately after delivery may be methods to use. If the patient has a stable considered if it is thought likely that a patient relationship, an intra-uterine contraceptive will not use another contraceptive method and device may be more appropriate. However, if where sterilisation is not appropriate. However, the expulsion rate will be as high as 15 to 20%. she or her partner has other sexual partners, an injectable contraceptive would be indicated.
  8. 8. 264 MATERNAL CARE5. What other advice must be given appropriate. Oral contraceptives are onlyto a patient at risk of sexually reliable if taken every day.transmitted infections?The patient must insist that her partner wears 5. The patient and her mother are worrieda condom during sexual intercourse. This will that the long-term effect of injectablereduce the risk of HIV infection. contraception could be harmful to a girl of 15 years. What would be your advice? Injectable contraception is extremely safe and,CASE STUDY 2 therefore, is an appropriate method for long- term use. This method will not reduce herA 15-year-old primigravida had a normal future fertility.delivery in a district hospital. She has neverused contraception. Her mother asks you forcontraceptive advice for her daughter after CASE STUDY 3delivery. The patient’s boyfriend has desertedher. You have just delivered the first infant of a healthy 32-year-old patient. In discussing1. Does this young teenager require contraception with her, she mentions thatcontraceptive advice after delivery? she is planning to fall pregnant again within a year after she stops breastfeeding. She is aYes, she will certainly need contraceptive schoolteacher and would like to continue hercounselling and should start on a career after having two children.contraceptive method before dischargefrom hospital. She needs to learn sexualresponsibility and must be told where the 1. The patient says that she has usednearest family planning clinic to her home is an injectable contraceptive for fivefor follow-up. She also needs to know about years before this pregnancy and wouldpostcoital contraception. like to continue with this method. What would your advice be?2. Which contraceptive method would be Injectable contraception would not bemost the appropriate for this patient? appropriate as she plans her next pregnancy 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 (Depo-Because she should only have her next child Provera/Petogen or Nur-Isterate) as there is nowhen she is fully grown up and able to take proven advantages of the one above the others.care of her children by herself. 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
  9. 9. FAMILY PLANNING AFTER PREGNANC Y 265oral contraceptive pills may reduce milk 2. When should the device be inserted?production while breastfeeding is being Six weeks or more after delivery, as there isestablished. Progestogen-only pills have no an increased risk of expulsion if the device iseffect on breastfeeding. inserted earlier.CASE STUDY 4 3. Could the patient, in the meantime, rely on breast feeding as a contraceptive method?A married primipara from a rural area has justbeen delivered in a district hospital. She has a No. The risk of pregnancy is too high. Shestable relationship with her husband and they should use reliable contraception, such asdecide to have their next infant in five years’ injectable contraception or the progestogen-time. The patient would like to have an intra- only pill, until the device is inserted.uterine contraceptive device inserted. 4. The patient asks if the intra-uterine1. Is this an appropriate contraceptive device could be insertedmethod for this patient? before she is discharged from hospital. Would this be appropriate management?Yes, as the risk of developing pelvicinflammatory disease is low. The expulsion rate and, therefore, the risk of contraceptive failure is much higher if the device is inserted soon after delivery. Therefore, it would be far better if she were to return six weeks later for insertion of the device.