e m

Puerperium,

rs iu
Breastfeeding

r
ou o
C rat
& Family Planning
w o
ie M
ev S
R G

Alejandro R. San Pedro, MD.

Department of Obstetrics and Gynecology
PO

MCU-FDT Medical Foundation College of Medicine

 Presentation content

e m
1. Puerperium

rs iu
- involution and subinvolution

r
ou o
- afterpains & lochias

C rat
- puerperal complications
(late pph, infections - uterine,

w o
abdominal, perineal)
ie M
2. Breastfeeding
ev S
- benefits
R G

- contraindications
- breast engorgement & mastitis
PO

3. Family Planning
- postpartum and interval
- Long Acting Reversible Contraceptives
 Puerperium

e m
rs iu
• The time after

r
ou o
delivery when the

C rat
anatomical and
w o
ie M
physiological changes
ev S
of the woman return
R G
PO

to the non-pregnant
state.
 Involution

e m
rs iu
What is expected post

r
partum?

ou o
C rat
• Uterine size becomes small.

w o
• Endometrium regenerates
ie M
after delivery
ev S
• The basal layer of decidua
R G

remains intact and is the

PO

source of new
endometrium.
 Subinvolution

e m
If involution does not progress as

rs iu
expected, what happens?

r
ou o
• prolonged lochia,

C rat
• irregular or excessive uterine

w o
bleeding.
ie M
• Uterus is larger and softer than
ev S
expected.
R G

• May be due to infection or retained

PO

placental fragments.
• Give methylergometrine and
antibiotics for infection.
 Afterpains & Lochias

e m
• in multiparous women, uterus often

rs iu
r
contracts vigorously at interval

ou o
C rat
similar but milder than labor

w o
contractions.
ie M
• more pronounced as parity
ev S
R G

increases and during suckling.

PO

• lochia rubra, serosa, alba

 Puerperal complications
Late Post Partum Hemorrhage

e m
rs iu
- bleeding 24 hours to 12 weeks

r
ou o
postpartum.

C rat
- may be due to abnormal involution

w o
ie M
of placental site or retained placental
fragments.
ev S
R G

- managed with uterotonics.

PO

- avoid curettage, as primary treatment.

- antibiotics as needed.
 Puerperal Fever

e m
• Fever over 38 degrees Celsius after the first

rs iu
24 hours and lasting 2 days or more.

r
• Most persistent fevers are caused by genital

ou o
C rat
tract infection. Other causes are breast
engorgement, urinary tract infection,

w o
abdominal incisions, episiotomy & perineal
ie M
lacerations.
ev S
• Postpartum uterine infection or puerperal
R G

sepsis (metritis) – Risk factors are rupture

PO

of membranes, prolonged labor and multiple

cervical examinations and manual removal
of the placenta.
 Puerperal Fever

e m
• Pathogenesis of uterine infection in

rs iu
r
cesarean section is infected surgical

ou o
C rat
incision. For vaginal birth, it involves
the placental implantation site, decidua

w o
ie M
or cervicovaginal lacerations.
ev S
• Infections are polymicrobial
R G
PO
 Uterine infection (metritis)

e m
rs iu
• more common in cesarean delivery than in

r
vaginal. Risk factors are rupture of

ou o
C rat
membranes, prolonged labor and multiple
cervical examinations and manual removal

w o
of the placenta.
•
ie M
Pathogenesis of metritis following
ev S
cesarean section is an infected surgical
R G

incision. For vaginal birth, it involves the

PO

placental implantation site, decidua or

cervicovaginal lacerations.
 Role of Perioperative Antibiotics

e m
rs iu
Perioperative antimicrobial prophylaxis

r
ou o
at time of cesarean section has reduced

C rat
the rates of post operative pelvic and

w o
wound infection. Single dose ampicillin
ie M
or first generation cefalosporin.
ev S
R G
PO

ACOG 2011
 Postpartum blues

e m
• may have some degree of depressed

rs iu
r
mood a few days after delivery.

ou o
C rat
• Possible causes are emotional letdown,

w o
following the excitement and fears during
ie M
labor and delivery, fatigue, anxiety and
ev S
body image concerns.
R G

• Usually mild but if persistent or worsens,

PO

suicidal need urgent attention.

 Breastfeeding

e m
rs iu
After delivery the breast

r
ou o
secretes colostrum can be

C rat
expressed on the second

w o
day. Intensity and duration
ie M
of lactation controlled by
ev S
repetitive nursing and
R G

emptying of milk from the

PO

breast.
 Human milk is ideal food for newborns.

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Advantages

rs iu
• Nutritional

r
ou o
• Immunological

C rat
• Developmental

w o
• economical.
ie M
Women who breastfeed:
ev S
•
R G

has a lower risk of breast and

PO

reproductive cancer
• less postpartum weight retention
• lower risk of coronary heart disease.
 Contraindication to breastfeeding

e m
• Those who take street drugs and who

rs iu
r
cannot control alcohol use

ou o
C rat
• Infants with galactosemia

w o
• Women with HIV infection
ie M
• With active, untreated tuberculosis
ev S
R G

• Undergoing breast cancer treatment

PO
 Breast engorgement

e m
• common in women who do not breastfeed.

rs iu
r
There is milk leakage and breast pain.

ou o
C rat
• No specific treatment.
• Support the breast with well-fitting

w o
ie M
brassiere or breast binder.
ev S
• Apply cool packs and oral analgesics.
R G

• Pharmacological and hormonal drugs are

PO

not recommended to suppress lactation.

 Mastitis

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- unilateral and marked

rs iu
engorgement usually precedes

r
ou o
inflammation.

C rat
- Sign & symptoms are chills, then

w o
fever and tachycardia. Severe
ie M
pain and the breast becomes
hard and red.
ev S
R G

- Common organism is
PO

staphyloccus aureus, bacteria

enters through the nipple at site
of fissure or abrasion.
 Mastitis

e m
rs iu
• Antibiotics are dicloxaxillin,

r
ou o
erythromycin and vancomycin.

C rat
• Continue breastfeeding. May do milk

w o
expression.
ie M
• Ten percent of women with mastitis
ev S
R G

may develop abscess which should be

PO

treated with incision and drainage.

 Presentation Outline

e m
 How do contraceptive

rs iu
r
methods work?

ou o
C rat
 WHO-MEC as guide in

w o
Contraceptive choices
ie M
Factors affecting choice
ev S
 Case scenarios
R G
PO

 Key points
 Effectiveness

e m
rs iu
Spermicides

r
ou o
Female condom

C rat
Standard Days Method
Male condom

w o
ie M
Oral contraceptives
DMPA
ev S
IUD (TCu-380A) Rate during perfect use
R G

Female sterilization
PO

Rate during typical use

Implants
0 5 10 15 20 25 30
Percentage of women pregnant in first year of use

Source: Center for Communication Program/JH Bloomberg School of Public Health and WHO, 2007.
 Contraceptive Benefits and Risks

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• Benefits often • SIDE EFFECTS:

rs iu
symptoms or
outweigh

r
ou o
conditions that pose
health risks

C rat
no significant health
risk

w o
ie M • COMPLICATIONS:
ev S
serious health
R G

problems or
PO

conditions
 e m
rs iu
How do the different

r
ou o
C rat
methods of contraception
w o
ie M
work?
ev S
R G
PO
 COC mechanism of action
(suppression of ovulation)

e m
rs iu
r
ou o
C rat
w o
ie M
ev S
R G
PO
Mechanism of action COCs
(thickens cervical mucus)

e m
rs iu
r
ou o
C rat
w o
ie M
ev S
R G
PO
 WHO Medical Eligibility Criteria

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Classification

rs iu
r
ou o
1 Use method in any circumstances

C rat
2 Generally use the method -

w o
ie M advantages outweigh risks
3 Usually not recommended unless more
ev S
appropriate methods are not available
R G
PO

4 Method not to be used-

Condition represents an unacceptable risk

Medical Eligibility Criteria For Contraceptive Use. Fourth Edition. WHO, 2009
How to be reasonably sure the woman
is not pregnant

e m
there is no sign & symptoms of pregnancy and…..

rs iu
– Menstrual period started within the

r
ou o
last 7 days

C rat
– Gave birth within the last 4 weeks

w o
– Had an abortion within the last 7 days
ie M
– Gave birth within the last 6 months,
ev S
R G

is fully breastfeeding & amenorrheic

PO

– Has not had coitus since LMP

– Uses a modern/reliable family planning
method correctly
 Case 1- Postpartum FP

e m
 28 years old G4P4,

rs iu
informal urban

r
settler.

ou o
C rat
 wants to practice
family planning.

w o
ie M
 Date of last delivery
ev S
was three months
R G

ago.
PO

 Currently
breastfeeding.
 Case 1- Postpartum hormonal contraceptives

e m
Which among the following

rs iu
statements is correct?

r
ou o
1. COCs should not be used

C rat
during lactation (WHO 4).

w o
2. If not breastfeeding,
ie M
COCs can be started one
ev S
week post-childbirth.
R G

3. Among breastfeeding
PO

postpartum women, the

baby may have problems
metabolizing DMPA.
Case 1- Postpartum hormonal contraceptives

e m
The 28 years old G4P4, housewife
returned for ff-up.

rs iu
She is now on her fourth month

r
ou o
postpartum and still using LAM.
However, she must return to

C rat
work and wants an additional FP
protection. What are her options?

w o
ie M
1. Can COCs be safely used in
addition to LAM?
ev S
2. Progestin only contraceptives
R G

(POPs or DMPA) can also be

added to LAM?
PO

3. The copper IUD can be

inserted now.
4. She can undergo BTL.
 Case 2 - Drug interactions

e m
The women is 26 years

rs iu
old G2P2, with two sons.

r
ou o
 wants to space her

C rat
pregnancies.

w o
 diagnosed with
ie M
pulmonary tuberculosis
ev S
a month ago.
R G

 Previous user of COCs

PO

prior to her
pregnancies.
 Case 2 - Drug interactions

e m
Which among the

rs iu
following drugs is

r
ou o
known to interact with

C rat
hormonal

w o
contraceptives?
ie M
1. Streptomycin
ev S
R G

2. Rifampicin
PO

3. Pyrazinamide
4. Isoniazid
 Case 2 - Drug interactions & Options

e m
Which among the following

rs iu
can be done to lessen

r
contraceptive failure in

ou o
women taking Rifampicin?

C rat
1. Use the higher COCs dose

w o
(50 micrograms EE)
2. ie M
Shift to POPs
ev S
3. Eliminate the Pill Free
R G

Interval (PFI)
PO

4. Shift to non-hormonal
Long Acting Reversible
Contraceptives (LARC)
 Case 3- “I will shift to the IUD”

e m
 The 26 years old G2P2,

rs iu
with pulmonary

r
tuberculosis now wants to

ou o
C rat
try the IUD but wants to be
clarified on concerns like:

w o
ie M
“I heard that the IUD
predisposes to pelvic
ev S
infections & ectopic
R G

pregnancy”.
PO
 Case 3 – Copper IUDs & ectopics

e m
Which among the following

rs iu
statements is correct?

r
1. The overall risk of ectopic

ou o
C rat
pregnancies is decreased
with the use of copper

w o
IUDs.
ie M
2. The risks of ectopic
ev S
pregnancies are higher
R G

among IUD conceptions.

PO

3. A past ectopic pregnancy

is a contraindication for
copper IUD use (MEC 4)
 Case 3 – Copper IUDs & ectopics
Annual Ectopics Ratio

e m
Pregnanci
es

rs iu
Scenario: 1 ectopic

r
ou o
pregnancy per 100

C rat
pregnancies

w o
Assuming zero infertility 1000 10 1:100
ie M
in 1000 with no
contraception
ev S
If same 1000 women use 10 1 1:10
R G

the Copper IUD with a

PO

first year failure rate of

1/100
Reduction 990 9
Adapted from Guillebaud Contraception 5th edition
 Case 3 – Copper IUDs & PID

e m
Which among the following

rs iu
statements is correct?

r
1. PID risk was higher during

ou o
the first 20 days after

C rat
insertion than later.

w o
2. PID rates relates to the
ie M
background rate of STIs
(the lower the rate of STIs, the
ev S
lower the rate of PID).
R G

3. A past history of STIs is a

PO

contraindication for
insertion of the Copper
IUD (MEC 4).
 Case 3- “Regarding Copper IUD”

e m
Which among the following

rs iu
statements is correct?

r
 The IUD should only be

ou o
C rat
inserted during
menstruation.

w o
 A tight cervix can be
ie M
softened with misoprostol.
ev S
 Uterine fibroid is WHO-MEC
R G

Category 4.
PO

 Antibiotics should be
routinely given on IUD
insertions.
Case 5- “Young girls & contraception”

e m
The 17 years old, G1P1

rs iu
consulted because she

r
wants to space her

ou o
pregnancy.

C rat
Which of the following

w o
choices is appropriate?
 COCs
ie M
ev S
 DMPA
R G

 Copper IUD
PO

 Cervical mucus
method
Case 6 - “Older women & contraception”

e m
The 42 years old, G1P1

rs iu
consulted because she

r
wants and effective method

ou o
C rat
of FP but does not want BTL.
Which among the following

w o
ie M
are acceptable choices?
ev S
1. Copper IUD
R G

2. Intra Uterine System

PO

3. COCs
4. DMPA
 Case scenario 7

e m
 25 years old G3P3,

rs iu
nonsmoker

r
ou o
 User of DMPA for 6

C rat
months

w o
ie M
 She has concerns
about the side effects
ev S
R G

of DMPA, i.e. spotting

PO

and bone density

loss.
 Case scenario 7

e m
Which among the following

rs iu
statements regarding DMPA use

r
is correct?

ou o
C rat
1. Bone loss is reversible after
discontinuation.

w o
ie M
2. Smoking is a known factor in
reducing bone density.
ev S
R G

3. DMPA is WHO-MEC 2 for

PO

adolescents.
4. No excess on limb or
vertebral fractures in long
term DMPA users.
Case 8 - “Overweight & contraception”

e m
 30 years old G2P2, non-

rs iu
smoker, normal BP

r
ou o
 BMI of 31.

C rat
 Wants to space pregnancy

w o
 Currently uses condom and
ie M
interested in COCs.
ev S
??? Anxious on relation
R G

of BMI & contraceptive

PO

effectiveness of COCs?
 Case 9 - “Missing the COCs”

e m
When is the “danger

rs iu
time” likely to develop

r
ou o
“skip ovulation” if the

C rat
woman misses taking the
COC pill for two days in a

w o
row? ie M
ev S
1. On days 13 & 14 of the
R G

pill cycle.
PO

2. On days 1 & 2 of a 28-

day pill cycle.
 PO
R G
ev S
ie M
w o
C rat
ou o
r
rs iu
e m
 Case 10 - “Limiting pregnancies”

e m
A 22 years old G1P1, wants

rs iu
to undergo BTL against the

r
husband’s wishes.

ou o
C rat
Consider the ff. challenges:

w o
1. I will do the BTL.
ie M
2. I will offer her LARC.
ev S
3. I will refuse to do BTL
R G

on account of her age &

PO

parity.
 Case 10 - “Limiting pregnancies”

e m
On further inquiry, this 22

rs iu
years old G1P1, asthmatic

r
ou o
with a BMI of 29.

C rat
If you decide to do BTL,

w o
what is her WHO-MEC
ie M
Category?:
ev S
R G

1. A accept
PO

2. C caution

3. D delay
 PO
R G
ev S
ie M
w o
C rat
ou o
r
rs iu
WHO-MEC Wheel

e m
 PO
R G
ev S
ie M
w o
C rat
ou o
r
rs iu
e m