Postpartum Contraception

by Veronica Gillispie, MD, FACOG

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    00:01 Now let's talk about postpartum contraception.

    00:05 So when we address postpartum contraception, the first thing we want to address is if our patient is breastfeeding or not.

    00:12 So this is a clinical pearl.

    00:14 For women that are breastfeeding, contraceptive options should be limited to progestin only or non-hormonal options.

    00:22 Options that contain estrogen can dry up the patient's breast milk.

    00:27 So let's look at those.

    00:28 And we're going these into reversible options and non reversible options.

    00:33 So for our reversible options, we'll start with natural family planning.

    00:37 Now prolactin increases during breastfeeding and this causes ovulation to cease.

    00:45 It's reliable about 98% if used correctly.

    00:49 Again this is also called rhythm method.

    00:52 Next is the barrier method.

    00:54 This is the use of condoms and/or spermicides.

    00:57 It used together and correctly, the effective rate is about 82%.

    01:04 Next is the progestin only birth control pill.

    01:06 So the progestin only or the mini-pill has to be taken at the same time everyday.

    01:13 It's most reliable when done that way.

    01:15 Long acting reversible contraceptives.

    01:20 LARC as they're often called provide contraception for an extended period of time.

    01:25 And there are several options.

    01:27 Let's go through those.

    01:29 So for our long acting reversible contraceptives or LARC as they are often called, let's start with the Copper IUC or intrauterine contraception.

    01:37 The Copper IUC is non-hormonal and it is the only non-hormonal IUC.

    01:43 It actually provides contraception, by providing a sterile environment that kills the sperm.

    01:48 And it's effective for 10 years.

    01:51 The progestin IUC's prevent pregnancy by also creating a sterile environment that kills the sperm.

    01:58 But because of the progestin, they increase cervical mucus to make it difficult for the sperm to enter the cervix.

    02:04 They also the make the endometrium thin and they can inhibit mortality of the fallopian tube.

    02:10 So there are three marketed progestin only IUC's.

    02:13 Mirena which has 52 milligrams of levonorgestrel and is effective for 5 years.

    02:18 Skyla which has 13.5 milligrams has a an effective wait of 3 years.

    02:24 And then the Loette has 52 milligrams of levonorgestrel and it is FDA indicated for 3 years of use.

    02:33 Moving on from our intrauterine contraceptives we have a progestin implant, this is known as nexplanon.

    02:39 The progestin only implants is placed underneath the skin, approximately 3 centimeters from the elbow crease.

    02:46 It has 68 milligrams of etonogestrel and is effective for 3 years.

    02:52 Next we have the progestin implant.

    02:56 This is medroxyprogesterone acetate.

    02:58 So this is an injection that's given every three months.

    03:02 With perfect use is it 99% effective as are all the other LARC's.

    03:07 The side effect of the medroxyprogesterone, however, include weight gain, hair loss and irregular cycles.

    03:14 Now, we've talked about our reversible methods, let's talk about our irreversible methods.

    03:23 So that would be a postpartum tubal ligation as one option.

    03:27 With postpartum tubal ligation, this can be performed immediately after delivery, during a cesarean section or up to 6 weeks after delivery.

    03:35 During that time the fallopian tube is either legated with a device or a portion of it is removed.

    03:42 We also have the hysteroscopic tubal ligation.

    03:47 Right now the only FDA device is the Essure procedure.

    03:50 Well this is recommended to be performed at least 6 weeks after delivery.

    03:55 A small camera is introduced into the cervix and the endometrium is visualized.

    04:00 You at that time can see the ostia or the tubal opening.

    04:03 A coil is placed in the tubal opening on each side.

    04:07 Because of fibres within the coil, this causes inflammation which will cause the tubes to scar down, causing blockage.

    04:15 The FDA indicates that an hsg or X-ray with dash should be done 12 weeks after the procedure to ensure that it's tubes are indeed occluded.

    04:26 This procedure can be done in the operating room or it can actually be done in the office under local anesthesia.

    04:35 So the next option is vasectomy.

    04:37 This procedure is performed for males.

    04:39 So let's take a case.

    04:43 Justine is a 20 year old gravida 3 para 0 female who presents for her postpartum visit.

    04:49 She is interested in discussing contraceptive options.

    04:54 She is breastfeeding but not consistently due to sore nipples.

    04:58 She thinks she has completed childbearing.

    05:00 What options would you say best fit her contraceptive needs? A. Barrier method.

    05:06 B. Oral contraceptives.

    05:08 C. Long Acting Reversible Contraceptive or D. Tubal ligation.

    05:13 The answer is C.

    05:15 A Long Acting Reversible Contraceptive.

    05:18 She already said that she thinks she may have completed child bearing.

    05:22 However, the young, the highest risk of regret is a young age.

    05:26 So we don't want to give her the option or we don't want to encourage the option of tubal ligation.

    05:32 Barrier method or contraceptive is not as effective because of self use.

    05:37 So in this case a long acting reversible contraceptive, would be the best option.

    About the Lecture

    The lecture Postpartum Contraception by Veronica Gillispie, MD, FACOG is from the course Postpartum Care. It contains the following chapters:

    • Postpartum Contraception
    • Non Reversible Contraceptives

    Included Quiz Questions

    1. 98% effective
    2. 82% effective
    3. 99% effective
    4. 60% effective
    5. 75% effective
    1. Copper intrauterine device
    2. Mirena intrauterine device
    3. An upper arm implantable device
    4. E-Sure (Hysteroscopic tubal ligation)
    5. Condom and spermicide combined
    1. A hysterosalpingogram should be done 12 weeks after the procedure to assure it has worked.
    2. It is a long acting reversible type of contraception.
    3. It should be performed within six weeks of delivery.
    4. It involves removing a portion of the fallopian tubes.
    5. Side effects include irregular menstrual cycles.
    1. Prolactin levels are increased, diminishing ovulation
    2. Prolactin levels are increased, increasing ovulation
    3. Prolactin levels do not have any effect on ovulation
    4. Prolactin levels are decreased, diminishing ovulation
    5. Prolactin levels are decreased, increasing ovulation
    1. Blocks the fallopian tubes with scared coils
    2. Creates a sterile environment that kills sperm
    3. Increases thickness of cervical mucous
    4. Thins the endometrial lining
    5. Decreases fallopian tube mobility
    1. 82%
    2. 65%
    3. 99%
    4. 95%
    5. 50%

    Author of lecture Postpartum Contraception

     Veronica Gillispie, MD, FACOG

    Veronica Gillispie, MD, FACOG

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