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Postpartum contraception

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Postpartum contraception

Scenario

Technician Vicky is talking to her friend Helen, who has popped in to the pharmacy with her newborn baby Zachary. “I tell you Vicky, I thought pregnancy was hard, but it was an absolute breeze compared to the labour. Zach’s amazing and I adore him, but I’m certainly not doing that again for a very long time! Mum says that I can’t get pregnant while I’m breastfeeding, but I don’t want to take any chances – and I do want Zach to start having the odd bottle – so I was thinking about starting back on the pill. What do you reckon?”

Answer

Lactational amenorrhoea – the absence of periods while a woman is breastfeeding her baby – is used by some women as a form of contraception, but it only lasts for a maximum of six months and relies on the woman entirely or almost fully breastfeeding (i.e. her baby is having breastmilk only, with very little formula or none at all) and she must experience no periods at all. Assuming all of these criteria are met, it is up to 98 per cent effective (i.e. more than two in every 100 women will fall pregnant using this method of contraception). Given that Helen is planning to start supplementing Zach’s breastfeeds with formula milk, she is sensible to be thinking about contraceptive alternatives to lactational amenorrhoea.

However, the combined oral contraceptive, which is what most people mean when they refer to ‘the pill’, contains oestrogen, which can reduce milk flow and so isn’t a suitable contraceptive given Helen’s plans to continue breastfeeding. If she prefers an oral contraceptive, the progestogenonly pill (POP), which is sometimes known as ‘the mini pill’, is a better option. If Helen decides that this is the best contraceptive method for her at the moment, she needs to start taking it before or when Zach is 21 days old.

If she starts a POP after this time, she needs to use additional precautions for the first seven days to avoid becoming pregnant. Helen should also be made aware that sex after childbirth can be a little uncomfortable due to bruising and hormonal changes that make the vagina drier than normal. Lubrication can make a huge difference, but if sex continues to be painful a couple of months after the birth, Helen should seek advice from her GP or ask the health visitor when she visits her local clinic to get Zach weighed.

The bigger picture

Given that Helen isn’t keen to fall pregnant any time soon, she may want to consider a longer-acting reversible contraceptive (LARC) such as the contraceptive injection, implant, intrauterine system (IUS) or intra-uterine device (IUD). All of these are fine to use when breastfeeding as they all contain progesterone only, with the exception of the IUD, which contains copper. The advantage of all of these methods of contraception is that Helen doesn’t really need to think about them once they are in place.

At a time when her life could be a little chaotic due to the round the clock demands of a newborn baby, not having to remember to take a tablet at a certain time each day can have its advantages. The implant, IUS and IUD can be taken out at the woman’s request, and normal fertility returns quickly. The injection offers less flexibility, and it can take several months for periods and fertility to return to normal, making it a less suitable method of contraception for someone who may want to try and become pregnant sooner than this.

Extend your learning

Given what this scenario talks about lactational amenorrhoea, why do you think it only lasts a maximum of six months? Check your understanding here.

Would you feel confident explaining the different forms of LARC to someone? Refresh your knowledge by clicking through the links at: FPA: Contraception Help

NICE has published guidance on LARC, including a useful section entitled “is it suitable for me?” Have a look at this here, so that you feel equipped to deal with the types of questions patients might ask.

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