Professional Documents
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lactation
Chapter I
Contraceptive methods used
during lactation
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2- Intrauterine device.
3- Condoms.
- Calendar method.
- Symptothermal method.
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1. Amenorrhea:
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(1) Few suckling episodes per hour (less than 1 per hour) each lasting at
least 11 minutes OR
Efficacy:
If a woman has deviated only slightly from the fully or nearly fully
breastfeeding criterion, she should be re-counseled about appropriate
breastfeeding and may use LAM thereafter if she returns to nearly fully
breastfeeding. Small amounts of other food or liquid which do not replace
breastfeeds do not have a substantial effect on the woman's fertility.
However, lowered frequencies of breastfeeding and regular supplementation
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to the infant's diet are associated with an increased risk of menses return and
a higher probability that ovulation will precede that menses (Labbok, 2000).
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• After the first six months, when supplemental foods are introduced,
breastfeeding should precede supplemental feedings.
Mechanism of action:
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Extended LAM:
Conclusions:
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Effectiveness:
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IUDs for contraception worldwide, and its effectiveness rivals that of tubal
sterilization (Population Reports, 1995 & Peterson et al., 1996).
The first-year failure rate in typical IUD users is 6%. The lowest
expected / reported pregnancy rates in medicated IUDs are 1% and 0.5%
respectively, and among non-medicated IUDs the percentages are 2% and
3%, respectively. The rates may be lower for newest generation of copper
and progestin IUDs (Hatcher et al., 1998).
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IUDs with high copper content are the most cost-effective methods
currently available (Newton & Tacchi, 1990).
Mechanism of action:
IUDs have become widely used since their introduction, but their
specific contraceptive action is far from clear. The mode of action of the
IUD is important, since if the IUD is an abortifacient, it could have
important moral, religious, and ethical repercussions. However, it is
generally believed that all IUDs stimulate an inflammatory response in the
uterus (Newton & Tacchi, 1990).
Since this time, at least three reviews have suggested that the
contraceptive effects of the Cu IUD occur predominantly before
fertilization (Mishell, 1998 - Rivera et al., 1999).
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information for clinicians who work with patients who may object to forms
of birth control that act after fertilization (Spinnato, 1999).
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The fertilized ova in the oviducts of the IUD users are not found
explained by: Spermatozoa may not be able to reach to the site of
fertilization or they may not be able to penetrate the oocyst covering
(Morgenstien et al., 1996).
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IUDs. Although prefertilization effects are more prominent for the Cu IUD,
both prefertilization and postfertilization mechanisms of action contribute
significantly to the effectiveness of all types of IUD. Patients considering
use of the IUD should be made aware of the available data about its
mechanisms of action (Standford & Mikolajczyk, 2002).
Duration of use:
Types of IUDs:
There are four types of IUDs approved by the Food and Drug
Administration (FDA). Three of these IUDs release copper and one type
releases progesterone. In 1988, the copper T380A (CuT 380A) was first
marketed in the USA for consumer. This device has a T-shaped plastic frame
with a 300 mm² surface area on the vertical stem and a 40 mm² copper collar
on each horizontal arm for a total of 380 mm² of copper surface area (Paul
et al., 1997).
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Today, two IUDs are approved for use in the USA: a copper-
releasing device (ParaGard) and a hormone-re1easing device (Mirena). Both
IUDs have monofilament threads that minimize the risk for bacterial
transmission (Johnson, 2005).
Non-contraceptive benefits:
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Possible Contraindications:
a) Absolute Contraindications:
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(6) Risk factors for exposure to the human immunodeficiency virus (HIV)
(Varney et al., 2004).
IUD insertion:
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possibility, delay the IUD insertion until the next menstrual flow which
usually indicates that the woman is not pregnant (Petersen et al., 1991).
If labor and delivery were normal, the uterus is firm, and bleeding
has subsided, an IUD may be inserted. Manual post partum IUD insertion
immediately following delivery of the placenta is a safe, convenient
approach to birth control and carries no increased risk of infection,
perforation or bleeding. To minimize infection, use a sterile long-sleeved
glove (Hatcher et al., 1998).
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Insertion Technique:
The arms of the IUD are to be folded into the insertion tube far
enough to retain them. The physician should stabilize the cervix during the
insertion of the IUD with a tenaculum. A sterile uterine sound should be
used to determine the depth of the uterine cavity. An adequate uterine depth
is 6-9 cm. An IUD should not be inserted if the depth of the uterus is less
than 6 cm. The physician should then insert the IUD into the uterus unti1l
the flange is against the cervical os. The clear inserter tube should be pulled
back on the insertion rod approximately 2 cm so that the arms can spread to
the T position. The physician should remove the insertion rod by holding the
insertion tube in place and then remove the insertion tube and tenaculum.
Finally, the threads emerging from the cervical os should be cut to a length
of 3 cm (Johnson, 2005).
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Various forms of treatment have been tried for the bleeding, but
none has proved entirely satisfactory. These include: ergotrate, ascorbic
acid, calcium, vitamins (especially vitamin K) and ferrous sulfate as well as
progesterone in the second half of the cycle (Treiman et al., 1995).
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(1) The device may have been expelled (check for pregnancy).
(2) The device may have rotated inside the uterus, pulling the threads up
with this movement. It would then have to be removed and a new IUD
inserted.
(3) The woman may be pregnant and the threads will have been pulled up
into the enlarged uterus (Varney, 2004).
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(6) Infertility:
The balance of evidence suggests that the use of an IUD does not
affect return to fertility (Hubacher et al., 2001).
1- Insertion:
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2- Prophylactic antibiotic:
3- Type of IUD:
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4- Age:
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In addition to new devices, the use of IUD may shift in the future to
include a wider range of users. Greater numbers of nulliparous women,
interested in reversible, long-term, highly effective contraception may
choose the device, especially if overly strict selection criteria are revised.
IUD also may be used increasingly in the future for non-contraceptive
purposes, such as treatment of menorrhagia and provision of endometrial
protection during estrogen replacement therapy (Grimes et al., 2004).
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POPs are taken every day with no pill free interval. The
effectiveness of POPs is greater when the normal bleeding pattern is most
disturbed. If ovulation is not suppressed, the POPs have no effect on the
cyclicity of bleeding, and menstrual bleeding occurs as it had before the
woman started POPs. POPs are generally less effective than combined oral
contraceptives (COCs) (Biswas et al., 2008).
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POPs have very low doses of progestin, lower than combined pills.
POPs prevent pregnancy in two main ways:
Advantages of POPs:
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Because women take the same type of pill every single day (same
color and hormone content), some women may find it easier to remember
(Hatcher et al., 1998).
Disadvantages:
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• Lactating women.
- Contraindications to use:
Danger Signs:
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■ Pill taken late: even if only 3 hours late use a backup contraceptive for the
next two days. Be careful to take minipills on time (Hatcher et al., 1998).
2) Norplant Implants
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Effectiveness:
Advantages:
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Disadvantages:
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• Have the number of children they want, but do not want to be sterilized at
this time.
• Want to be sterilized but do not meet the criteria required locally regarding
age and number of children.
• Are late in their reproductive years and whose clinicians would rather not
use an estrogen containing contraceptive.
Contraindications to use:
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3) Ectopic pregnancy:
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performance and the effect of its use during the first postpartum year on
breastfeeding performance and growth and health of the infants were studied
and compared to the findings in a parallel group who used an IUD in a
prospective, non-randomized study. This was carried out in Assiut, Egypt.
Two-hundred-forty fully breastfeeding mothers asking for initiation of
contraception early postpartum were assigned according to their choices into
either Uniplant (120 women) or IUD (CuT 380A) (120 women). The mother
and infant pairs were followed up at monthly intervals during the first three
months and at two-month intervals thereafter up until the first birthday of the
baby. No pregnancy occurred in the two groups. Amenorrhea was
significantly more prolonged in the Uniplant group than in the IUD group.
There were no significant differences in net continuation rates between the
two groups. There were no significant differences between the two groups in
the number of breastfeeding episodes, time of weaning, and the cumulative
rates of full and partial breastfeeding. There were no significant differences
between the two groups in infant weight, weight gain per day, or in infant
linear growth. There were no significant differences in the incidence of
important health problems affecting the infants of the two groups. However,
there were seven infant deaths; six of them were in the Uniplant group.
Uniplant implants can be offered as a new contraceptive option suitable for
nursing mothers (Abdel-Aleem et al., 1996).
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mothers, 50 each, were studied in parallel: the first used an IUD (Cu T380A)
and the second used either barrier or no contraception. There was no
difference in lactational performance among the three groups. The
increments in infant weight and height in the three groups were within the
normal range for Egyptian infants. However, the rates of weight and height
gain in the early postpartum months were slightly, but significantly, lower in
the NORPLANTR group than in the two control groups. However, by the
sixth postpartum month, there were no significant group differences in these
growth parameters (Population Reports, 1996).
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-Conclusion:
Danger signs:
■ Severe lower abdominal pain (ectopic pregnancy is rare but can occur).
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■ Arm pain.
■ Expulsion of an implant.
Advantages:
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continues effective protection for several weeks even if the user is late in
receiving the next injection. Because it is a long acting injectable, DMPA is
not related to sexual intercourse and offers privacy to the user since the
woman has no need to keep contraceptive supplies at home. Although some
women may find the prolonged amenorrhea a disadvantage, others find it
desirable (Hatcher et al., 2004).
Safety:
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adolescents (Cromer et al., 1996). This may suggest that DMPA may be less
desirable for young adolescents. The effect of DMPA on plasma lipids has
been inconsistent; in general, DMPA users appear to have reduced total
cholesterol and triglycerides, slight reduction in HDL cholesterol, and no
change or slight increase in LDL cholesterol, all of which are consistent with
a reduction in circulating estrogen levels. In some studies, the decrease in
HDL and increase in LDL are statistically significant, although the values
remain within normal ranges (Fahmy et al. 1991).
Such patients are at high risk for thrombosis regardless of the use
of DMPA. Women taking DMPA appear to experience a weight gain of 2 to
3 pounds more than nonusers over several years. Its use has not been
associated with teratogenesis. It is safe for use by lactating women and, as
with other progestin-only hormonal methods, appears to increase milk
production. DMPA has not been associated with affective disorders or mood
changes, although the data are limited (Westoff, 1996).
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Selecting DMPA:
■ Wants no more children but does not want to be or can not be sterilized.
■ Wants a safe, effective method for a short period of time before she is
sterilized for example, if she is a post-partum patient who is unable to
schedule tubal ligation for several months.
■ Has sickle cell disease and is not or good candidate for combined pills.
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Danger signs:
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a) The condom:
Effectiveness:
First year failure rates among typical users average about 12%.
Foam sometimes recommended for use in conjunction with condoms in an
effort to increase effectiveness (Berek, 2002).
Non-contraceptive benefits:
■ Condoms are relatively inexpensive and may even be obtained for free.
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■ Some women and men do not wish to have the penis in direct contact with
the vagina. The condom is an effective barrier that may make intercourse
more pleasurable if this concern exits.
■ Men who have difficulty maintaining an erection may find that the rim of
the condom may have a slight tourniquet effect, helping to maintain an
erection.
Contraindications:
• The male husband will not accept the respectability for birth control.
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b) Sponge:
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c) Diaphragm:
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d) Cervical Cap:
The cervical cap is a cup-shaped device that fits over the cervix and
is held in place, at least partially, by suction between its firm, flexible rim
and the surface of the cervix or upper vaginal wall. Caps currently being
used are made of soft rubber. They are not suitable for prolonged wear
because a strong odor appears after 36 to 48 hours of wear and because
there is a theoretical risk of toxic shock syndrome (Hatcher et al., 1998).
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f) Female condom:
g) Spermicides:
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place so that no sperm can escape contact with the spermicidal ingredient.
For foaming product, the base also contributes a physical barrier to reduce
contact between semen and the cervix. The active spermicidal ingredient in
many modern products is nonoxynol-9, a potent surfactant that kills sperm
cells by destroying the cell membrane (Brueggemann, 1997).
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Contraindications:
■ Lack of trained personnel to fit the device and/or lack of clinical time to
provide instruction and use (for diaphragm and cap).
■ Lack of facilities such as clean water and soap necessary in caring for the
device (For the diaphragm and cap).
■ Full term delivery within the past 6 weeks, recent spontaneous or induced
abortion, or vaginal bleeding from any cause, including normal menstrual
flow (for the cap and sponges) (Hatcher et al., 1998).
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Side Effects:
3- Vaginal trauma:
4- Infection:
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Indications:
(9) Acne.
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For women who are planning to gradually wean their infant, use of
COCs may provide an easier transition to bottle-feeding. COCs should be
used with caution by women who are not able to obtain supplemental milk.
A decrease in milk volume can lead to earlier discontinuation of the
hormonal contraceptive in an attempt to increase milk quantity.
Supplementation is often needed, and then the woman ovulates again,
possibly resulting in an unintended pregnancy (Kelsey, 1996).
Advantages:
1) Effectiveness:
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low dose combined pills, some clinicians routinely recommend that women
reduce the pill-free interval from 7 days to 4-5 days (Hatcher et al., 1998).
2) Safety:
Pills are extremely safe for young women. It is safer to use the pills
than to deliver a baby, unless a woman is over 35 years of age and smokes
more than 35 cigarettes/day (Grimes, 1992).
COCs use produces strong and lasting reduced risk for endometrial
and ovarian cancer. In addition, protection has been found for women with
known hereditary ovarian cancer. Any past use of COCs conferred a 50%
reduction in ovarian cancer risk when women with this history who took
COCs were compared with their sisters as controls. Protection increased
with increasing duration of use (Narod et al., 1998).
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5) Ectopic Pregnancy:
6) Excellent reversibility:
Disadvantages:
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• Nausea during the first cycle of pills or during the first few pills of each
new package.
• Weight change.
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■ Headache:
■ Eye problems:
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■ Circulatory disorders:
Although healthy young non-smoker can take the pill with very
little risk of serious complications, other women do have an increased risk of
cardiovascular side effects:
(3) Women who have other health problems such as hypertension, diabetes
or history of heart or vascular diseases.
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■ Hypertension:
Possible contraindications:
- Absolute contraindications:
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(3) Coronary artery or ischemic heart disease (or history there of).
(4) Known or suspected estrogen dependent neoplasia (or history there of).
(6) Pregnancy.
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(15) Over 40 years old, accompanied by a second risk factors for the
development of cardiovascular disease (such as diabetes or hypertension).
(16) Over 35 years old and currently a heavy smoker (15 or more cigarettes
a day).
- Other considerations that may suggest that pills are not the ideal
contraception:
■ Lactation.
■ Congenital hyperbilirubinemia.
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Any one of these 5 symptoms may mean that you are in serious trouble:
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Contraindications:
Precautions:
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Contraindications:
• Lactating.
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• Contraceptive users.
• Ill with diseases that affect signs and symptoms of the menstrual cycle.
Disadvantages:
• Signs and symptoms differ from woman to woman and from cycle to cycle.
a) Calendar Method:
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d) Symptothermal Method:
e) Coitus Interrupts:
f) Abstinence:
Introduction:
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Efficacy:
Indications:
Contraindications:
• Freedom from the threat of STI and HIV infection if there is no exchange
of body fluids
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• No cost, unless condoms and dams are used (Black et al., 2004).
● Combined birth control pill regimen: 2 pills (oral) taken within 72 hours
of unprotected intercourse and 2 more pills taken 12 hours later (Hatcher et
al., 2004).
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