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3.3 Contraception

Key Points - Case Study C

Joanne is discharged early on day three and comes to see you for follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
Topic 3.1: Early problems
There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.
You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?
Topic 3.2: Risk of SIDS
It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or choose to bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.
Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?
Topic 3.3: Contraception
Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.
Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?

As long as Joanne remains amenorrhoeic and is fully or nearly fully breastfeeding, the chance of her becoming pregnant in the first six months postpartum is less than 2 percent – a similar failure rate to many other methods of contraception.1

Suckling of the infant inhibits maternal release of hypothalamic GnRH, which controls the release of LH and FSH – hormones necessary for the development and maturation of the ovarian follicle. This effect is dependent on the total sucking stimulus rather than the frequency or length of feeds.2Once follicular growth occurs, there also appears to be a feedback mechanism so that ovulation is inhibited, and if ovulation does occur before six months postpartum it is usually accompanied by an inadequate luteal phase, especially prior to the first menses.2When the suckling stimulus decreases, especially after the introduction of complementary feeds or solids, GnRH is released and ovulation occurs.

After extensive observational and controlled trials in both developed and developing countries, the conditions under which this suppression of fertility could be used as an effective form of contraception were codified in 1991. The resulting contraceptive method (Lactational Amenorrhoea Method) consists of three criteria:

When any of the three criteria are no longer applicable another method of contraception should be employed as pregnancy rates increase.3 Menses returns in approximately 20% of exclusively breastfeeding women piror to six months.4 The majority of these women do not ovulate before their first menses and most who do have a shor tor defective luteal phase. The percentage of breastfeeding women whose menses return prior to six months varies considerably (26.5-69.5%),5 perhaps reflecting different cultural expectations of the frequency and length of breastfeeds and the introduction of other fluids and foods.


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Further studies suggest that the pregnancy rate when LAM is continued for up to 12 months with the addition of solid foods is still quite small, although the incidence of an adequate luteal phase with ovulation before the first menses increases.3

Non-hormonal forms of contraception, such as condoms, diaphragms and some forms of IUDs, have little or no effect on lactation and are the methods of choice when another form of contraception in addition to, or instead of, LAM is required.6

Studies of progesterone-only contraceptive methods (mini-pill, progesterone-containing IUDs, depo or implants) used during lactation also show minimal effect on lactation, although some women report a reduction in milk supply. Therefore, these methods should be used cautiously in women who have, or are at risk of having, problems maintaining an adequate milk supply. There is also a theoretical risk of disturbing the initiation of lactation if progestogens are prescribed early in the postpartum period as secretory activation is triggered by a drop in progesterone levels.6

Contraceptives containing estrogen are known to cause a reduction in milk supply and should preferably not be used during lactation. If it is the most suitable contraceptive method for a woman, delaying its introduction until six months postpartum is recommended.3

Case Study Activity

Notes

  1. # Kennedy KI et al. (1989) Consensus statement on the use of breastfeeding as a family planning method.
  2. # McNeilly AS (2001) Neuroendocrine changes and fertility in breast-feeding women
  3. # Labbok M (2007) Breastfeeding, Birth Spacing and Family Planning
  4. # Kennedy KI et al. (1992) Contraceptive efficacy of lactational amenorrhoea.
  5. # (1999) World Health Organization task force on methods for the natural regluation of fertility
  6. # Brodribb W. (ed) (2012) Breastfeeding and contraception. IN: Breastfeeding Management in Australia