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Puerperium & Contraception - OB/GYN MBBS Notes

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PART 1: THE PUERPERIUM

Definition

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Physiological Changes in the Puerperium

Uterine Involution

• Uterus weighs ~1000 g immediately postpartum; by 6 weeks returns to ~60 g (nonpregnant weight)
• After 5-7 days: firm and nontender, midway between symphysis pubis and umbilicus
• By 2 weeks: uterus is no longer palpable abdominally
• Involution occurs via apoptosis, atrophy, and extracellular matrix breakdown
• Afterpains (uterine contractions) are common and may require analgesia; worse in multiparous women and during breastfeeding (oxytocin release)

Lochia (Vaginal Discharge)

Cardiovascular

• Pulse rate drops in first 24 hours
• Temperature may be slightly elevated (<38°C in first 24 h is not pathological)
• Marked leukocytosis (up to 20,000/μL) in first 24 hours - normal
• Rapid diuresis occurs postpartum - urine may transiently contain protein and sugar
• Hematocrit is artificially elevated for a few days due to decreased intravascular volume

Bladder

• Urine retention and bladder overdistention must be monitored
• Rapid diuresis occurs especially when oxytocin is discontinued
• Woman must be encouraged to void; asymptomatic bladder overfilling must be prevented

Diet & Ambulation

• Regular diet may be offered as soon as desired after normal vaginal delivery
• Full ambulation encouraged ASAP
• Showers: encouraged; vaginal douching: prohibited

Bowel

• Laxatives may be needed
• If no bowel movement within 3 days, a mild cathartic may be given
• Episiotomy discomfort relieved with hot sitz baths and analgesia

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Uterine Management (First Hour)

• Mother observed for 1 hour after third stage; periodic uterine massage to maintain contraction
• If uterus does not stay contracted: Oxytocin - 10 units IM, or 10-30 U in 1000 mL IV fluid at 125-200 mL/hr for 1-2 hours
• Active management of labor (oxytocin before placenta delivery) reduces uterine atony and PPH

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Breast Engorgement & Lactation Suppression

• Painful engorgement occurs in early lactation
• For women not breastfeeding: suppress lactation with firm breast binding, restriction of oral fluids, followed by firm support
• Symptoms last 3-5 days with these measures

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Psychological Changes

Baby Blues

• Very common, self-limited
• Mild depression, tearfulness, anxiety, irritability, mood lability, fatigue
• Peak: 4-5 days after delivery
• Usually resolves by 10th postnatal day

Postpartum Depression

• Occurs in ~10% of childbearing women
• Onset: 24 hours to several months after delivery
• Features: lack of interest in infant, suicidal/homicidal ideation, hallucinations, psychotic behaviour
• Treatment: psychotherapy, pharmacotherapy (SSRIs - note caution regarding congenital heart anomalies if in pregnancy)
• Routine antenatal screening for history of depression recommended for all women

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Return of Menstruation & Ovulation

• Conception has been reported as early as 2 weeks postpartum
• Duration of anovulation in breastfeeding women depends on: frequency of feeds, duration of feeds, and proportion of supplemental feeds

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PART 2: CONTRACEPTION IN THE PUERPERIUM

Key Principle

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Lactational Amenorrhea Method (LAM)

1. Amenorrhea - no return of menstruation
2. Fully or nearly fully breastfeeding - frequent feeds; no periods >4-6 hours between feeds
3. Less than 6 months since delivery

Important caveat: The first ovulation occurs before the first menses, so reliance on absence of menstruation alone is unreliable. - Swanson's Family Medicine Review; Creasy & Resnik's MFM

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WHO Medical Eligibility Criteria (MEC) - Postpartum Timing

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Hormonal Contraception - Key Points

Combined Estrogen-Progestin Methods (COC, patch, ring)

• Previously contraindicated during lactation due to concern over milk quantity/quality
• Clinical studies show conflicting results regarding breastfeeding continuation with COC use
• Estrogen methods generally avoided before 6 weeks postpartum
• Oral contraceptives may be started at discharge (low-dose estrogen or progestin-only preferred)
• Berek & Novak's Gynecology; Textbook of Family Medicine 9e

Progestin-Only Methods (Mini-pill, DMPA, Implant)

• Do not affect milk quality or quantity - preferred hormonal methods during lactation
• Include: progestin-only oral pill, injectable DMPA (Depo-Provera), levonorgestrel implants
• Theoretical concern that exogenous progesterone may disrupt milk synthesis in the first 6 weeks - but limited data suggest they are safe
• This theoretical risk should be communicated to allow informed decision-making
• DMPA: 3-monthly injection, can be used in the postpartum period and while breastfeeding
• Creasy & Resnik's MFM; Berek & Novak's Gynecology

IUD Insertion Postpartum

• Copper IUD: excellent for nursing mothers, no hormonal effects
• LNG-IUD: one RCT raised concern about immediate postpartum insertion and breastfeeding performance; however, due to low circulating hormone levels (lower than implants), no adverse effect on breastfeeding is anticipated
• More studies needed for definitive recommendations on LNG-IUD timing

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Emergency Contraception (for completeness)

• Mechanism: inhibit or delay ovulation; EC is NOT an abortifacient
• Swanson's Family Medicine Review

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Rubella Immunisation Note

• Rubella vaccination postpartum mandates a delay of 3 months before next pregnancy
• Contraception is therefore required during this period

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Practical Summary for MBBS

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• Textbook of Family Medicine 9e (Textbook of Family Medicine)
• Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice
• Berek & Novak's Gynecology
• Swanson's Family Medicine Review

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Contraceptive Counselling - MBBS Notes

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1. Introduction & Aims of Counselling

• Prevent unintended pregnancy (globally ~49% of all pregnancies are unintended)
• Reduce abortion rates
• Match the patient with a method that maximises compliance and minimises side effects
• Provide STI protection advice alongside pregnancy prevention
• Respect patient autonomy and individual circumstances

1. Efficacy of each method (typical vs. perfect use)
2. Side effect profile of estrogen and progestin components
3. Patient-specific factors (age, parity, medical comorbidities, breastfeeding status, future fertility plans)

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2. Pre-Counselling Assessment

Obese women generally require higher doses of estrogen and progestin to achieve contraception without bleeding side effects. - Textbook of Family Medicine 9e

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3. Efficacy of Contraceptive Methods

Pearl Index & Typical Use Failure Rates

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4. Categories of Contraceptive Methods

4A. Combined Hormonal Contraceptives (CHC)

• Primary: Inhibit ovulation via suppression of the HPO axis (LH surge suppression)
• Secondary: Thicken cervical mucus (progestin), thin endometrium (progestin)

• Can start any day of cycle (Quick Start); if not within first 5 days of menses, use backup method for 7 days
• A 3-month trial is needed to assess response to any new hormonal regimen

• Pregnancy
• Breastfeeding <6 weeks postpartum
• Age >35 years + smoking ≥15 cigarettes/day
• History of VTE or current DVT/PE
• Ischaemic heart disease or stroke
• Migraine with aura (any age)
• Active viral hepatitis, liver cirrhosis, hepatocellular adenoma/carcinoma
• Uncontrolled hypertension (>160/100 mmHg)
• Diabetes with vascular complications
• Breast cancer (current or within past 5 years)

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Side Effects by Hormonal Component

• Bloating, fluid retention, cyclic weight gain, irritability
• DVT, pulmonary embolism, CVA, thromboembolic disease
• Nausea and vomiting
• Hypermenorrhoea, dysmenorrhoea, uterine fibroid growth
• Breast tenderness, cystic breast changes
• Chloasma (skin pigmentation)
• Cyclic headaches/migraine, visual changes

• Breakthrough bleeding early in cycle (days 1-9) or continuous spotting
• Atrophic vaginitis, absence of withdrawal bleeding
• Vasomotor symptoms

• Weight gain, depression, fatigue
• Elevated blood pressure
• Decreased libido
• Oily skin, acne (androgenic progestins)
• Late cycle breakthrough bleeding (days 10-21)

• Breakthrough bleeding later in cycle
• Dysmenorrhoea

Key counselling point: Most side effects from COCs can be managed by adjusting estrogen-to-progestin ratios rather than stopping the method entirely. - Textbook of Family Medicine 9e

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Managing Common OCP Side Effects

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4B. Progestin-Only Contraceptives

• Thicken cervical mucus (primary in POP)
• Inhibit ovulation (more consistent with DMPA and implant)
• Thin endometrium

• Safe in breastfeeding mothers (do not affect milk quality or quantity)
• Used when estrogen is contraindicated
• Can be used in postpartum period

Progestin-Only Pill (Mini-Pill)

• Must be taken at the same time each day (within 3-hour window)
• If >3 hours late: use backup contraception for 48 hours
• Suitable for breastfeeding women, older women (>35), smokers, women with migraines

DMPA (Depo-Provera) Injection

• 150 mg IM every 13 weeks (or SC every 12-14 weeks)
• Efficacy: 6 pregnancies per 100 women/year (typical use)
• Side effects: Menstrual irregularity (common; usually resolves), headaches, abdominal pain, average weight gain <2 kg/year
• Delayed return to fertility: 9-18 months after stopping - must counsel patients
• FDA black box warning (2004): Should not be used >2 consecutive years due to decreased bone mineral density (BMD); however, BMD substantially returns after discontinuation - this risk must be weighed against need for contraception
• Adequate calcium and vitamin D intake should be encouraged

Subdermal Implant (Nexplanon)

• Single rod inserted in upper arm; lasts 3 years
• Most effective reversible method (pregnancy <1%)
• 24% discontinuation at 2 years (lowest of all hormonal methods)
• Side effects: Irregular bleeding (common reason for discontinuation)

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4C. Intrauterine Devices (IUDs)

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4D. Barrier Methods

"Considering all contraceptive options except abstinence, male and female condoms offer the most protection against sexually transmitted infections." - Textbook of Family Medicine 9e

If a lubricant is desired: saline-based lubricants are safest (oil-based lubricants degrade latex condoms).

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4E. Fertility Awareness-Based Methods (FABM / Natural Family Planning)

• Highest failure rate of all purposeful methods (~24% typical use)
• Include: Calendar/rhythm method, Basal Body Temperature (BBT) method, Cervical mucus (Billings) method, Symptothermal method, Standard Days Method, TwoDay Method
• Standard Days Method and TwoDay Method are easiest to use and therefore more effective in practice
• Patient must abstain or use barrier methods on fertile days
• No exogenous hormones or devices - often chosen for religious or personal reasons

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4F. Permanent Sterilisation

• Should only be offered to patients who truly desire permanent contraception
• Reversal is difficult, expensive, and associated with complications (including ectopic pregnancy)
• Vasectomy is NOT associated with prostate cancer, cardiovascular disease, or sexual dysfunction

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4G. Emergency Contraception (EC)

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5. Contraception in Special Populations

Adolescents

• Highest rate of unintended pregnancy AND highest discontinuation rate with any method
• 24-month discontinuation rates: IUD 23% | Implant 31% | OCP 57% | Patch 60% | Ring 59% | DMPA 62%
• ACOG recommends LARCs (IUD or implant) as the most cost-effective choice for adolescents
• Estrogen and progestin doses may need adjustment through adolescent to perimenopausal years

Perimenopausal Women

• Use of hormonal contraceptives (except OCP in women >40) has significantly reduced death risk from hormone-related side effects
• OCPs (regardless of tobacco use) carry higher death risk in women >40 years

Women with Medical Conditions

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6. WHO Medical Eligibility Criteria (MEC) Categories

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7. Counselling Framework (GATHER Model)

• G - Greet the client respectfully
• A - Ask about needs, concerns, current method, medical history
• T - Tell about available options (efficacy, advantages, side effects)
• H - Help the client choose a suitable method
• E - Explain how to use the chosen method correctly
• R - Return/follow-up - arrange review at 3 months; address any concerns

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8. Counselling Points for Key Methods

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9. Key Summary Points for MBBS Exams

1. LARCs (IUDs + implants) are the most effective reversible contraceptives and most cost-effective over 5 years
2. Copper IUD is the most effective emergency contraceptive
3. Only condoms protect against STIs
4. Progestin-only methods are preferred in breastfeeding women
5. Combined hormonal methods are contraindicated in: migraine with aura, VTE history, age >35 + heavy smoking, <6 weeks postpartum breastfeeding
6. DMPA causes delayed return of fertility (9-18 months) - must counsel patients planning future pregnancy
7. EC is NOT an abortifacient - it prevents fertilisation/implantation; it does not terminate an established pregnancy
8. Fertility awareness methods have the highest typical-use failure rates
9. Spermicide (nonoxynol-9) alone is no longer recommended - it increases susceptibility to HPV and HIV
10. ICD-10 code Z30.0 = Encounter for general counselling and advice on contraception

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• Textbook of Family Medicine 9e - Harper, Wilfing, Blanner (Chapter 26: Contraception)
• Berek & Novak's Gynecology
• Creasy & Resnik's Maternal-Fetal Medicine
• The Harriet Lane Handbook, 23rd edition
• Swanson's Family Medicine Review

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Sterilization - OB/GYN MBBS Notes

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1. Definition & Overview

• Female sterilization - various methods of tubal occlusion, ligation, or excision
• Male sterilization - vasectomy

• ~600,000 tubal occlusions per year (US)
• ~200,000 vasectomies per year (US)
• ~700,000 female sterilizations performed annually worldwide; about half are done within 48 hours postpartum
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry; Pfenninger & Fowler's Procedures for Primary Care

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2. Female Sterilization

2A. Approaches

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2B. Methods of Tubal Occlusion/Ligation

Surgical / Laparoscopic Methods

Hysteroscopic (Transcervical) Method

• Essure device: Microcoil inserted hysteroscopically into the tubal ostium under direct vision; causes fibrotic occlusion over 3 months
• Advantages: No incision, no anaesthesia, office-based, rapid recovery, high patient satisfaction (>97% would recommend)
• Requires a confirmatory imaging (HSG) at 3 months to confirm occlusion - use backup contraception until confirmed
• Note: Essure has been largely withdrawn from markets due to adverse event reports (nickel allergy, device migration, perforation)

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2C. Failure Rates by Method (10-Year Cumulative, per 1,000 procedures)

• Kaplan & Sadock's; Pfenninger & Fowler's

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2D. Advantages of Female Sterilization

• No impairment of sexual function or menstrual cycle
• No exogenous hormones - safe for women with contraindications to hormonal methods
• Can be performed in the immediate postpartum period (convenient)
• Not user-dependent - once done, no ongoing action required
• Total salpingectomy can reduce risk of ovarian cancer (especially BRCA1/2 carriers)
• Multiple observational studies show decreased incidence of ovarian cancer after tubal procedures

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2E. Disadvantages & Risks

• More complex procedure than vasectomy
• Surgical morbidity: infection, anaesthesia complications, vascular damage, visceral injury
• Potential for unintended laparotomy (~1/200) if laparoscopy fails
• Ectopic pregnancy risk: If sterilization fails, a significant proportion of failures are ectopic pregnancies
  • Ectopic risk: 7.3 per 1,000 procedures over 10 years
  • However, absolute ectopic risk is much lower than in non-contraceptive users
• Reversal is costly, difficult, and only rarely successful
• Regret: ~14% of patients express regret after sterilization

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2F. Hysterectomy as Sterilization

• Hysterectomy for sterilization alone is NOT indicated
• Associated with significantly more morbidity and mortality than any other female sterilization method

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3. Male Sterilization (Vasectomy)

Procedure

• Outpatient procedure performed under local anaesthesia
• Duration: approximately 20 minutes
• The vas deferens is identified, cut, ligated, coagulated, or occluded bilaterally

Techniques

• Conventional vasectomy: Small scrotal incision(s), vas deferens identified and cut
• No-scalpel vasectomy (NSV): A small puncture rather than incision; preferred - fewer complications

Post-Procedure

• Azoospermia takes 3-6 months to be confirmed (sperm may survive in the reproductive tract)
• Use backup contraception until semen analysis confirms azoospermia

Efficacy

• Failure rate: 0.15% in first year - the lowest of ANY permanent sterilization method
• Overall 10-year failure rate: 0.15-0.5%
• More effective than any female sterilization technique

Advantages Over Female Sterilization

• Safer (outpatient, local anaesthesia vs. general)
• More effective (lower failure rate)
• Less expensive
• Lower complication rate

Complications

• Infection
• Bleeding / scrotal haematoma
• Haematoma formation
• Sperm granuloma (inflammatory reaction to leaked sperm)
• Epididymitis
• Chronic scrotal pain (post-vasectomy pain syndrome) - uncommon

What Vasectomy Does NOT Cause (Dispelling Myths)

• Does NOT cause prostate cancer
• Does NOT cause cardiovascular disease
• Does NOT decrease libido
• Does NOT cause erectile dysfunction
• Does NOT cause decreased penile sensitivity
• Does NOT affect male sexual function
• Swanson's Family Medicine Review; Kaplan & Sadock's

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4. Comparison: Female vs. Male Sterilization

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5. Timing of Female Sterilization

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6. Pre-Procedure Counselling (ESSENTIAL)

1. Permanence - the procedure is intended to be irreversible
2. Failure rates - sterilization is not 100% effective; method-specific rates should be shared
3. Ectopic pregnancy risk - if method fails, there is a higher proportion of ectopic pregnancies
4. Regret - approximately 14% of patients express regret after sterilization
5. Risk factors for regret:
   • Young age (<30 at time of sterilization)
   • Race and ethnicity (higher regret rates in women of colour)
   • Performed during the postpartum period (emotions/fatigue)
   • Recent adverse pregnancy event
   • Sterilization to stabilise a marriage
   • Death of a child after sterilization
   • Remarriage after sterilization
6. Reversal - expensive, difficult, success depends on method used, age of partners, and time elapsed since sterilization
7. Alternatives - LARCs (IUDs and implants) are equally effective as sterilization and fully reversible; vasectomy is safer and more effective for couples
8. Autonomy - respect for individual reproductive autonomy is the primary guiding principle; age and parity alone should NOT be used as barriers to access

"In a well-informed and counselled patient, age and parity should not be barriers to accessing permanent sterilization." - Sabiston Textbook of Surgery

"Physicians should carefully counsel patients about the permanence of female sterilization, particularly in light of long-acting reversible contraceptive measures, which are as effective as permanent sterilization." - Sabiston Textbook of Surgery

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7. Consent

• Written informed consent is required
• For postpartum sterilization at caesarean section: consent must be obtained BEFORE labour begins (a woman in labour cannot give fully informed consent for sterilization)
• Most countries require a minimum waiting period between signing consent and procedure
• In some systems, partner consent is still (controversially) required - current medical ethics emphasises individual reproductive autonomy

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8. Reversal of Sterilization

Female Reversal (Tubal Anastomosis)

• Costly and rarely successful
• Success depends on:
  • Method used - clip methods (spring clip) most amenable to reversal; coagulation/excision methods least reversible
  • Length of remaining tube - need at least 4 cm of viable tube
  • Age of patient - younger age = higher success
  • Time elapsed since original procedure
• Even with reversal, risk of ectopic pregnancy is elevated

Male Reversal (Vasovasostomy)

• ~80% reversal possible technically
• However, live birth rates after reversal are lower, influenced by elapsed time and anti-sperm antibody formation

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9. Sterilization & Ovarian Cancer

• Total bilateral salpingectomy for sterilization provides a reduction in ovarian cancer risk (particularly epithelial ovarian cancer originating in the fimbriae)
• Increasingly preferred over partial salpingectomy or clipping
• Strongly recommended in women with BRCA1/2 mutations who desire sterilization
• Observational studies show decreased incidence of ovarian cancer after tubal procedures generally
• Sabiston Textbook of Surgery; Goldman-Cecil Medicine

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10. Key Points for MBBS Exams

1. Sterilization is the most common contraceptive method among married couples
2. Vasectomy is safer, more effective, cheaper, and has lower complications than female sterilization
3. Postpartum partial salpingectomy (Pomeroy) has the lowest failure rate of female methods (7.5/1,000 over 10 years)
4. Titanium spring clip has the highest failure rate but is most amenable to reversal
5. If female sterilization fails, the resultant pregnancy has a high chance of being ectopic
6. ~14% of patients regret sterilization; young age and postpartum timing are risk factors for regret
7. Hysterectomy should NOT be performed for sterilization alone - too much morbidity
8. Total salpingectomy is increasingly preferred as it reduces the risk of ovarian cancer
9. Post-vasectomy: backup contraception needed for 3-6 months until azoospermia confirmed
10. Vasectomy does NOT cause prostate cancer, cardiovascular disease, or sexual dysfunction
11. Consent for postpartum sterilization at LSCS must be obtained before labour

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• Sabiston Textbook of Surgery, 21st edition
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry
• Pfenninger & Fowler's Procedures for Primary Care, 3rd edition
• Goldman-Cecil Medicine, International Edition
• Swanson's Family Medicine Review