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  • Title: Post-partum contraception.
    Author: Kennedy KI.
    Journal: Baillieres Clin Obstet Gynaecol; 1996 Apr; 10(1):25-41. PubMed ID: 8736720.
    Abstract:
    The choice of a post-partum contraceptive method depends on many factors, including the need for a temporary versus a permanent method, the infant feeding choice and the extent to which informed consent is made prior to delivery. For maximum protection, the non-breast-feeding woman should be protected from the fourth week post-partum, even if that means using a temporary method, such as condoms or spermicides, until her method of choice is procured. Combined oestrogen/progestin methods should be avoided by all women for 2-3 weeks to avoid elevating the risk of thromboembolism. Preparations containing oestrogen should be avoided altogether during lactation because they have been associated with a reduction in milk production. POPs, implants and injectables are appropriate regardless of infant feeding choice. They can be administered immediately post-partum in bottle-feeding women, but should ideally be postponed for 6 weeks in breast-feeding women. It is best to insert IUDs within 10 minutes of delivery of the placenta, in order to minimize the risk of IUD expulsion. Insertion immediately after expulsion of the placenta requires special training, and expulsion rates are reduced with the insertion experience of the practitioner. Breast-feeding is not associated with an increase in IUD expulsion or uterine perforation, and it is associated with fewer removals for bleeding or pain. Tubal sterilization is safe, convenient and cost-effective when performed immediately after delivery, but it requires extensive counselling and fully informed consent prior to the onset of labour to avoid potential regret over post-partum tubal ligation. If the procedure is performed immediately, any effect on the establishment of lactation may be minimized. LAM is a method that can only be used by breast-feeding women. It may prove to be a useful way to time the commencement of a second, less temporary contraceptive method. Natural family planning methods require a period of abstinence for the establishment and identification of the new symptoms of fertility. When LAM is used during this interval, the need for abstinence may be reduced significantly for breast-feeding women. Breast-feeding provides health benefits for the woman and her infant, as well as the best possible nutrition for the baby. The International Planned Parenthood Federation (1990) (among others) recommends that, 'As far as is practicable, all women should be advised and encouraged to breastfeed fully'. The infant feeding decision affects the choice of a contraceptive method, and this is an important reason for the woman's physician to be interested in her infant feeding choice. The alterations in both fertility and coital behavior associated with childbirth necessitate special consideration of postpartum contraception. To maximize the likelihood of success, both infant feeding and family planning decisions should be made during the pregnancy. The choice of a postpartum contraceptive method and the timing of its initiation depend on whether the woman is breast feeding. For normal non-breast-feeding women, the first ovulation occurs, on average, at 45 days postpartum, indicating the need for an effective (even if temporary) contraceptive method by four weeks after delivery. Condoms, spermicides, male and female sterilization, IUDs, progestin-only pills, injections, and implants are all appropriate options for postpartum women who are not breast feeding, and this article reviews the considerations associated with each of these methods. For breast feeding women, contraceptive methods can be organized into a hierarchy of clinical appropriateness: 1) non-hormonal methods that do not interfere with lactation, 2) progestin-only hormonal methods, and 3) hormonal methods. Included in the preferred (non-hormonal) category are the lactational amenorrhea method, postpartum tubal sterilization, IUDs, and barrier/spermicide methods. Combined estrogen-progestin formulations should be avoided by all women for at least three weeks postpartum to avoid elevating the risk of thromboembolism.
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