postpartum family planning aims to prevent unintended pregnancy and closely spaced pregnancies after childbirth

Method

• Long acting reversible contraceptions (fit and forget) – most effective
  • IUD
  • Implant
• hormonal contraception
  • COCP – combined oral contraceptive pill
  • POCP- progestogen- only contraceptive pill
  • Depo provera injection
• barrier method
  • condoms – also protect against STI
  • internal condom –
• emergency contraception
  • emergency contraceptive pill
  • copper IUD – (recommended if weight >70kg)
• fertility awareness
  • calendar method
• permanent contraception – most effective
  • vasectomy
  • tubal ligation

Long acting reversible contraceptions

IUD – Intrauterine Device

• can start within 48 hours/ delayed after 4 weeks postpartum
• prevent pregnancy for 5-10 years
• eg; levonorgestrel – releasing IUD (Mirena) – up to 7 years
• failure rates ; 1 in 1000 (0.001)
• copper IUD does not interfere breastfeeding
• return of fertility: immediate
• side effect;
  • IUD may came out of uterus
  • infection
  • injury
  • hormonal IUD (mirena) cause spotting and irregular bleeding in first 3-6 months of use, headache, nausea, depression, breast tenderness
  • copper IUD increase menstrual pain and bleeding, intermenstrual bleeding. decrease within 1 year of use

Implants

• release progestin
• can start anytime
• prevent pregnancy for 3-5 years
• failure rates ; 1 in 1000 (0.001)
• return of fertility: immediate
• does not interfere breastfeeding
• side effect;
  • irregular menses, intermenstural bleeding
  • mood changes
  • headache
  • acne
  • depression

Permanent Contraception

Female Sterilisation

• can start within 7 days / after 6 weeks postpartum
• failure rates ; 2 in 1000 (0.002)

Vasectomy

• can start anytime
• failure rates ; 1 in 1000 (0.001)
• takes about 2 to 4 months for the semen to become totally free of sperm after a vasectomy. A couple must use another method of birth control or avoid sexual intercourse until a sperm count confirms that no sperm are present.

pros;

• permanent birth control
• no daily attention require
• does not affect sexual pleasure

cons;

• may regret
• require surgery
• may not be reversible

Hormonal contraception-

Progestogen – only injectable contraceptives (Depoprovera)

• prevent pregnancy for 8-12 weeks ( 3 months )
• can start anytime
• failure rates ; 3 in 100 (0.03)
• side effects: amenorrhea
• return of fertility: months
• does not interfere breastfeeding
• side effect;
  • bone loss
  • irregular menses
  • headache
  • slight weight gain

Progestogen – only pills (POP)

• contained progestin
• taken continuously every day without a break
• can start anytime
• failure rates; 9 in 100 (0.09)
• does not interfere breastfeeding
• must be taken at the exact same time each day. If you miss a pill by more than 3 hours, you will need to use a back-up method for the next 48 hours.
• benefit; reduce menstrual bleeding or stop period altogether
• side effect
  • headache
  • nausea
  • breast tenderness
  • increase risk of breast ca

Combined oral contraceptive (COC) pills

• contained progestin and estrogen
• taken daily for 21 days followed by 7 days break when withdrawal bleeding ( menstruation) occurs
• failure rates; 9 in 100 (0.09)
• other form of COC – patch, vaginal ring
• benefit;
  • regular, lighter, shorter menses
  • reduce cramps
  • improve acne
  • reduce menstrual migraine frequency
  • reduce unwanted hair growth
• if women not breastfeeding, may start after 3 weeks postpartum unless they have rick of VTE, in which should only start COC after 6 weeks postpartum
• side effect;
  • postpartum DVT
  • interfere with breastfeeding – should not be used by breastfeeding women until baby is 6 months old
  • risk of stroke and heart attacks ( not recommended in >35 years old, smoker, HPT, DM, stroke, breast ca)
  • breakthrough bleeding, headache, breast tenderness, nausea

Barrier method

spermicide

• prevent transmission of gonorrhea and chlamydia.
• It can be stored for long periods of time.
• It may be messy, cause mild discomfort or minor allergic reaction, and can lead to yeast infections.
• may cause vaginal irritation with frequent use

diaphragm

cervical cap

condoms

• can use anytime
• failure rates; 12 in 100 (0.12)
• protect against STD
• does not interfere breatsfeeding
• cons
  • not suitable for pt with allergy to latex
  • interrupt sexual activity and may reduce sensation

withdrawal

• can use anytime
• failure rates; 18 in 100 (0.18)
• does not interfere breatsfeeding

fertility awareness based methods (FAB)

• can use anytime
• failure rates; 24 in 100 (0.24)
• not recommended post partum until women have regular menses for 3-4 cycles

Lactational amenorrhea method (LAM)

temporary method of birth control based on the natural way the body prevents ovulation when a woman is breastfeeding. It requires exclusive, frequent breastfeeding. The time between feedings should not be longer than 4 hours during the day or 6 hours at night. LAM may not be practical for many women.

emergency contraception

• levonorgestrel (LNG) emergency contraception can be used anytime postpartum regardless of whether or not a woman is breastfeeding
• high dose ethinyl estradiol either alone or in combination with progestogen (COCP) should not be used post partum due to risk of VTE
• emergency IUD is most effective method

PROCEDURE

1. PATIENT PUT IN SUPINE POSITION.
2. ABDOMEN CLEANED AND DRAPED.
3. PFANNESTIAL INCISION MADE AND ABDOMEN OPENED IN LAYERS
4. UV FOLD IDENTIFIED AND SEPARATED
5. BLADDER PUSHED AWAY CAUDALLY AND RETRACTED INFERIORLY WITH DOYAN’S RETRACTOR.
6. TRANSVERSE INCISION MADE AT LOWER SEGMENT OF UTERUS.
7. INCISION EXTENDED WITH BLUNT DISSECTION
8. AMNIOTOMY DONE AND BABY DELIVERED
9. PLACENTA AND MEMBRANES DELIVERED VIA CCT.
10. UTERUS CLOSED IN 2 LAYERS WITH VICRYL 1-0
11. FALLOPIAN TUBES AND OVARIES NORMAL
12. HAEMOSTASIS SECURED.
13. SWAB AND INSTRUMENT COUNTS WERE CORRECT.
14. RECTUS SHEATH WAS CLOSED WITH VICRYL 1.
15. SKIN WAS CLOSED VICRYL 2-0.
16. VAGINAL TOILET DONE AND BLOOD CLOTS EVACUATED.

POST OPERATIVE MANAGEMENT

1. TRANSFER OUT TO WARD ONCE PATIENT STABLE.
2. ALLOW ORALLY
3. LIE IN SUPINE POSITION FOR 6 HOURS (SPINAL)
4. BP/ PR MONITORING 1/4HOURLY UNTIL STABLE
5. CBD FOR ONE DAY
6. STRICT PAD CHARTING.
7. IVD 5 PINTS OF NSD5% / 24 H UNTIL PATIENT TAKING ORALLY WELL
8. CONTINUE ANALGESIA AS ORDERED BY ANESTHETIST. EG: SERVE SUP VOLTAREN 75MG BD. START FIRST DOSE 6 HOURS POST OP
9. SC HEPARIN 5000U BD TILL AMBULATING WELL
10. IV CEFOBID 1G BD + IV METRONIDAZSOLE 500MG TDS X 24 HOURS
11. WI DAY 2.
12. STO NOT REQUIRED
13. MODE OF DELIVERY NEXT PREGNANCY: TOS/LSCS
14. FBC DAY 2
15. IV PITOCIN 40U FOR 6H

Post Caesarian-section REVIEW

Age/race Para 1, Post ELLSCS 2 hours for breech presentation 

ANC: Breech presentation with oligohydromnios 

Intra operative findings: from op notes 

Progress: 
Patient complains of minimal pain at the op site 
Otherwise: No dizziness/headache, No SOB/chest pain No palpitations, No calf tenderness 

Unable to move legs, sensations intact 
Urine output: 400cc from the OT 
Pad: 3/4 soaked since from the OT 

Clinical: 
alert and conscious, pink, hydration fair 
not tachypneic, not tachycardic, vitals stable and afebrile 

Lungs: clear with equal air entry bilaterally 
CVS: DRNM 
PA: soft with minimal tenderness at the op site uterus well contracted at 20 weeks dressing minimally soaked 

Plan: To continue post op plan  

credit to : Ampang HO guide

Click to access ogobook1.pdf