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      <h1 id="top">3.3 Contraception</h1>
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            <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study C</h3>
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			Joanne is discharged early on day three and comes to see you for a 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?
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		<dl><dt><a href="topic_3-1.html"><cite>Topic 3.1: Early problems</cite></a></dt><dd class="topic-paragraph">There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.</dd></dl>
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			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?
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		<dl><dt><a href="topic_3-2.html"><cite>Topic 3.2: Risk of SIDS</cite></a></dt><dd class="topic-paragraph">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 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.</dd></dl>
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			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?
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		<dl><dt><a href="topic_3-3.html"><cite>Topic 3.3: Contraception</cite></a></dt><dd class="topic-paragraph">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.</dd></dl>
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			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?
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		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 <sup><a href="#note1">1</a></sup>.
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		Suckling of the infant inhibits maternal release of hypothalamic <abbr title="Gonadotropin Releasing Hormone">GnRH</abbr>, which controls the release of <abbr title="Luteinising Hormone">LH</abbr> and <abbr title="Follicle Stimulating Hormone">FSH</abbr> – 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<sup><a href="#note2">2</a></sup>. Once 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<sup><a href="#note2">2</a></sup>. When the suckling stimulus decreases, especially after the introduction of supplementary feeds or solids, <abbr title="Gonadotropin Releasing Hormone">GnRH</abbr> is released and ovulation occurs.
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		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:
		<ul><li>amenorrhoea (return of menses indicated by bleeding for two consecutive days, or a bleed like a menses after day 56);</li><li>exclusive or full breastfeeding  (no regular supplementation or solids; breastfeeding frequently on demand); and</li><li>less than six months postpartum.</li></ul>
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		When any of the three criteria are no longer applicable another method of contraception should be employed as pregnancy rates increase<sup><a href="#note3">3</a></sup>. The percentage of women whose menses return prior to six months varies considerably (26.569.5%)<sup><a href="#note4">4</a></sup>, 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 <abbr title="Lactational Amenorrhoea Method">LAM</abbr> 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<sup><a href="#note3">3</a></sup>.
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		Non-hormonal forms of contraception, such as condoms, diaphragms and some forms of <abbr title="Intrauterine Device">IUD</abbr>s, have little or no effect on lactation and are the methods of choice when another form of contraception in addition to, or instead of, <abbr title="Lactational Amenorrhoea Method">LAM</abbr> is required.
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		Studies of progesterone-only contraceptive methods (mini-pill, progesterone-containing <abbr title="Intrauterine Device">IUD</abbr>s, 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 lactogenesis II is triggered by a drop in progesterone levels.
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		Contraceptives containing oestrogen 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 (<sup><a href="#note1">1</a>,</sup><sup><a href="#note3">3</a></sup>).
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<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('x');</script>
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        <h3>Notes</h3>
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          <li id="note1"><a href="references.html#labb08" title="See full details">#</a> Labbok MH et al. (2005) Clinical protocol #13: Contraception during breastfeeding</li>
          <li id="note2"><a href="references.html#mcne01" title="See full details">#</a> McNeilly AS (2001) Neuroendocrine changes and fertility in breast-feeding women</li>
          <li id="note3"><a href="references.html#labb07" title="See full details">#</a> Labbok M (2007) Breastfeeding, Birth Spacing and Family Planning</li>
          <li id="note4"><a href="references.html#worl99" title="See full details">#</a>  (1999) World Health Organization task force on methods for the natural regluation of fertility</li>
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      <h1>Breastfeeding Essentials</h1>
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        <li>0.1 <a href="topic_0-1.html">Introduction</a></li>
        <li>1.0 <a href="topic_1-0.html">Case Study A (Joanne)</a><ol><li>1.1 <a href="topic_1-1.html">Discussing breastfeeding</a></li><li>1.2 <a href="topic_1-2.html">What information to give</a></li><li>1.3 <a href="topic_1-3.html">Effects of Breastfeeding alternatives</a></li><li>1.4 <a href="topic_1-4.html">Common breastfeeding concerns</a></li><li>1.5 <a href="topic_1-5.html">Breast examination</a></li><li>1.6 <a href="topic_1-6.html">Contraindications to breastfeeding</a></li><li>1.7 <a href="topic_1-7.html">Conditions related to lactation outcomes</a></li><li>1.8 <a href="topic_1-8.html">Medications</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Case Study B (Joanne)</a><ol><li>2.1 <a href="topic_2-1.html">Preparation Before Birth</a></li><li>2.2 <a href="topic_2-2.html">Birthing Factors that Affect Breastfeeding</a></li><li>2.3 <a href="topic_2-3.html">Management After Birth</a></li><li>2.4 <a href="topic_2-4.html">Poor Attachment</a></li><li>2.5 <a href="topic_2-5.html">Hypoglycaemia</a></li><li>2.6 <a href="topic_2-6.html">Relationship between Jaundice and Breastfeeding</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Case Study C (Joanne)</a><ol><li>3.1 <a href="topic_3-1.html">Early problems</a></li><li>3.2 <a href="topic_3-2.html">Risk of SIDS</a></li><li class="current">3.3 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_3-3.html">Contraception</a></li><li>3.4 <a href="topic_3-4.html">Milk composition</a></li><li>3.5 <a href="topic_3-5.html">Slowing of growth</a></li><li>3.6 <a href="topic_3-6.html">Introducing solids</a></li><li>3.7 <a href="topic_3-7.html">Weaning</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">Case Study D (Sally)</a><ol><li>4.1 <a href="topic_4-1.html">Initial assessment</a></li><li>4.2 <a href="topic_4-2.html">Milk production</a></li><li>4.3 <a href="topic_4-3.html">Causes of inadequate infant growth</a></li><li>4.4 <a href="topic_4-4.html">Increasing milk supply</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Case Study E (Anna)</a><ol><li>5.1 <a href="topic_5-1.html">Sore nipples</a></li><li>5.2 <a href="topic_5-2.html">Factors causing nipple damage</a></li><li>5.3 <a href="topic_5-3.html">General treatment for sore nipples</a></li><li>5.4 <a href="topic_5-4.html">Further causes of nipple pain</a></li><li>5.5 <a href="topic_5-5.html">Mastitis – diagnosis</a></li><li>5.6 <a href="topic_5-6.html">Mastitis – treatment and complications</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">In conclusion</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
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