Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

1. 14
Family planning
after pregnancy
Before you begin this unit, please take the CONTRACEPTIVE
corresponding test at the end of the book to
assess your knowledge of the subject matter. You COUNSELLING
should redo the test after you’ve worked through
the unit, to evaluate what you have learned.
14-1 What is family planning?
Family planning is far more than simply birth
Objectives control, and aims at improving the quality of life
for everybody. Family planning is an important
part of primary healthcare and includes:
When you have completed this unit you
should be able to: 1. Promoting a caring and responsible
• Explain the wider meaning of family attitude to sexual behaviour.
2. Ensuring that every child is wanted.
planning.
3. Encouraging the planning and spacing
• Give contraceptive counselling. of the number of children according to
• List the efficiency, contraindications and a family’s home conditions and financial
side effects of the various contraceptive income.
methods. 4. Providing the highest quality of maternal
• List the important health benefits of and child care.
5. Educating the community with regard
contraception.
to the disastrous effects of unchecked
• Advise a postpartum patient on population growth on the environment.
the most appropriate method of
It is essential to obtain prior community
contraception.
acceptance of, and promote community
participation in, any family planning
programme if the programme is to succeed in
that community.

2. 258 MATERNAL CARE
14-2 Who requires family Step 1: Discussion of the patient’s future
planning education? reproductive career
Because family planning aims at improving Ideally a woman should consider and plan her
the quality of life for everybody, every person, family before her first pregnancy, just as she
female or male, requires family planning would have considered her professional career.
education. Such education should ideally start Unfortunately in practice this hardly ever
during childhood and be given in the home by happens and many women only discuss their
the parents. It is then continued at school and reproductive careers for the first time when
throughout the rest of the individual’s life. they are already pregnant or after the birth of
the infant.
14-3 Who needs contraceptive counselling? When planning her family the woman (or
Every person who is sexually active, or preferably the couple) should decide on:
who probably will soon become sexually 1. The number of children wanted.
active, needs contraceptive counselling (i.e. 2. The time intervals between pregnancies
information and advice about birth control). as this will influence the method of
While the best time to advise a woman on contraception used.
contraception is before the first coitus, the 3. The contraceptive method of choice when
antenatal and post-delivery periods are an the family is complete.
excellent opportunity to provide contraceptive
counselling. Some patients will ask you for Very often the patient will be unable or
contraceptive advice. However, you will often unwilling to make these decisions immediately
have to first motivate a patient to accept after delivery. However, it is essential to discuss
contraception before you can advise her about contraception with the patient so that she can
an appropriate method of contraception. plan her family. This should be done together
with her partner and, where appropriate, other
members of her family or friends.
14-4 How should you motivate a patient
to accept contraception after delivery?
Step 2: The patient’s choice of contraceptive
A good way to motivate a patient to accept method
contraception is to discuss with her, or
The patient should always be asked which
preferably with both her and her partner, the
contraceptive method she would prefer as this
health and socio-economic effects further
will obviously be the method with which she is
children could have on her and the rest of the
most likely to continue.
family. Explain the immediate benefits of a
smaller, well-spaced family.
Step 3: Consideration of contraindications to
It is generally hopeless to try and promote the patient’s preferred method
contraception by itself. To gain individual and
You must decide whether the patient’s choice
community support, family planning must
of a contraceptive method is suitable, taking
be seen as part of total primary healthcare.
into consideration:
A high perinatal or infant mortality rate in a
community is likely to result in a rejection of 1. The effectiveness of each contraceptive
contraception. method.
2. The contraindications to each
14-5 How should you give contraceptive method.
contraceptive advice after delivery? 3. The side effects of each contraceptive
method.
There are five important steps which should be 4. The general health benefits of each
followed. contraceptive method.

3. FAMILY PLANNING AFTER PREGNANC Y 259
If the contraceptive efficiency of the preferred 5. The condom.
method is appropriate, if there are no
Breastfeeding, spermicides alone, coitus
contraindications to it, and if the patient is
interruptus and the ‘safe period’ are all very
prepared to accept the possible side effects,
unreliable. All women should know about
then the method chosen by the patient should
postcoital contraception.
be used. Otherwise proceed to step 4.
Step 4: Selection of the most appropriate Breastfeeding cannot be relied upon to provide
alternative method of contraception postpartum contraception.
The selection of the most suitable alternative
method of contraception after delivery will 14-7 How effective are the various
depend on a number of factors including the contraceptive methods?
patient’s wishes, her age, the risk of side effects
and whether or not a very effective method of Contraceptive methods for use after delivery
contraception is required. may be divided into very effective and less
effective ones. Sterilisation, injectables, oral
Step 5: Counselling the patient once the contraceptives and intra-uterine contraceptive
contraceptive method has been chosen devices are very effective. Condoms are less
effective contraceptives.
Virtually every contraceptive method has its
own side effects. It is a most important part The effectiveness of a contraceptive method
of contraceptive counselling to explain the is given as an index which indicates the
possible side effects to the patient. Expert number of women who would be expected to
family planning advice must be sought if the fall pregnant if 100 women used that method
local clinic is unable to deal satisfactorily for one year. The ideal efficacy index is 0.
with the patient’s problem. If family planning The higher the index, the less effective is the
problems are not satisfactorily solved, the method of contraception. The efficacy of the
patient will probably stop using any form of various contraceptive methods for use after
contraception. delivery is shown in table 14-1.
14-8 How effective is postcoital
After delivery the reproductive career of each contraception?
patient must be discussed with her in order to
1. Norlevo, E Gen-C or Ovral are effective
decide on the most appropriate method of family
within five days of unprotected sexual
planning to be used.
intercourse, but are more reliable the
earlier they are used.
14-6 What contraceptive methods 2. A copper intra-uterine contraceptive
can be offered after delivery? device can be inserted within six days of
unprotected intercourse.
1. Sterilisation. Either tubal ligation (tubal
3. Postcoital methods should only be used in
occlusion) or vasectomy.
an emergency and not as a regular method
2. Injectables (i.e. an intramuscular injection
of contraception.
of depot progestogen).
4. If Norlevo is used, one tablet should be
3. Oral contraceptives. Either the combined
taken as soon as possible after intercourse,
pill (containing both oestrogen and
followed by another one tablet after
progestogen) or a progestogen-only pill
exactly 12 hours.
(the ‘minipill’).
5. If Ovral or E-Gen-C is used, two tablets
4. An intra-uterine contraceptive device
are taken as soon as possible after
(IUCD).

4. 260 MATERNAL CARE
Table 14-1: The efficacy of the various contraceptive methods for use after delivery
Contraceptive method Efficacy index
Sterilisation: Vasectomy 0.05
Tubal ligation 0.5
Injectables: Depo-Provera/Petogen 0.2
Nur-Isterate 0.6
Oral contraceptives: Combined pill 0.3
Minipill 1.2
IUCD: Copper 0.5
Condom:* Male 2-15
Female (Reality female condom) 5-15
*The safety of condoms depends on the reliability with which they are used.
intercourse, followed by another two • Age 35 years or more with risk factors
tablets exactly 12 hours later. for cardiovascular disease.
• Anyone of 50 or more years.
The tablets for postcoital contraception
• Oestrogen-dependent malignancies
often cause nausea and vomiting, which
such as breast or uterine cancer.
reduces their effectiveness. These side effects
4. Progestogen-only pill (minipill)
are less with levonorgestrel (Norlevo and
• None.
Escapelle)which contains no oestrogen.
5. Intra-uterine contraceptive device
Therefore levonorgestrel (Norlevo and
• A history of excessive menstruation.
Escapelle) is a more reliable method and
• Anaemia.
should be used if available. Norlevo and
• Multiple sex partners when the risk of
Escapelle as a single dose method is available
genital infection is high.
in South Africa.
• Pelvic inflammatory disease.
14-9 What are the contraindications to A menstrual abnormality is a contraindication
the various contraceptive methods? to any of the hormonal contraceptive methods
(injectables, combined pill or progestogen-
The following are the common or important only pill) until the cause of the menstrual
conditions where the various contraceptive irregularity has been diagnosed. Thereafter,
methods should not be used: hormonal contraception may often be used to
1. Sterilisation correct the menstrual irregularity. However,
• Marital disharmony. during the puerperium a previous history of
• Psychological problems. menstrual irregularity before the pregnancy
• Forced or hasty decision. is not a contraindication to hormonal
• Gynaecological problem requiring contraception.
hysterectomy.
2. Injectables NOTE If a woman has a medical complication,
then a more detailed list of contraindications may
• Depression.
be obtained from the standard reference books
• Pregnancy planned within one year.
such as J Guillebaud: Your questions answered. Fifth
3. Combined pills edition. London: Churchill Livingstone 2009.
• A history of venous thrombo-
embolism. The World Health Organisation (WHO) medical
eligibility criteria for contraceptive use is also

5. FAMILY PLANNING AFTER PREGNANC Y 261
available on a WHO website (www.who.int/ • Depression.
reproductive -health/publications/mec/). • Fluid retention and breast tenderness.
• Chloasma (a brown mark on the face).
14-10 What are the major side effects of • Headaches and migraine.
the various contraceptive methods? 4. Progestogen-only pill
• Menstrual abnormalities, e.g. irregular
Most contraceptive methods have side
menstruation.
effects. Some side effects are unacceptable to
• Headaches.
a patient and will cause her to discontinue
• Weight gain.
the particular method. However, in many
5. Copper-containing intra-uterine
instances side effects are mild or disappear
contraceptive device
with time. It is, therefore, very important to
• Expulsion in 3–15 cases per 100
counsel a patient carefully about the side effects
women who use the device for one year.
of the various contraceptive methods, and to
• Pain at insertion.
determine whether she would find any of them
• Dysmenorrhoea.
unacceptable. At the same time the patient
• Menorrhagia (excessive and/or
may be reassured that some side effects will
prolonged bleeding).
most likely become less or disappear after a few
• Increase in pelvic inflammatory
months’ use of the method.
disease.
The major side effects of the various • Perforation of the uterus is uncommon.
contraceptive methods used after delivery are: • Ectopic pregnancy is not prevented.
6. Progesterone-containing intra-uterine
1. Sterilisation
contraceptive devices (Mirena) have lesser
Tubal ligation and vasectomy have no
side effects and reduce menstrual blood
medical side-effects and, therefore,
loss. These devices are expensive and not
should be highly recommended during
generally available in South Africa
counselling of patients who have completed
7. Condom
their families. Menstrual irregularities
• Decreased sensation for both partners.
are not a problem. However, about 5% of
• Not socially acceptable to everyone.
women later regret sterilisation.
2. Injectables
• Menstrual abnormalities, e.g. If a couple have completed their family the
amenorrhoea, irregular menstruation contraceptive method of choice is tubal ligation
or spotting. or vasectomy.
• Weight gain.
• Headaches.
Additional contraceptive precautions must
• Delayed return to fertility within a
be taken when the effectiveness of an oral
year of stopping the method. There is
contraceptive may be impaired, e.g. diarrhoea
no evidence that fertility is reduced
or when taking antibiotics. There is no medical
thereafter.
reason for stopping a hormonal method
With Nur-Isterate there is a quicker
periodically to ‘give the body a rest’.
return to fertility, slightly less weight gain
and a lower incidence of headaches and
amenorrhoea than with Depo-Provera or 14-11 What are the important health
Petogen. benefits of contraceptives?
3. Combined pill The main objective of all contraceptive
• Reduction of lactation. methods is to prevent pregnancy. In developing
• Menstrual abnormalities, e.g. spotting countries pregnancy is a major cause of
between periods. mortality and morbidity in women. Therefore,
• Nausea and vomiting.

6. 262 MATERNAL CARE
the prevention of pregnancy is a very important 2. Teenagers and patients with multiple
general health benefit of all contraceptives. sexual partners.
• An injectable, as this is a reliable method
Various methods of contraception have
even with unreliable patients who might
a number of additional health benefits.
forget to use another method.
Although these benefits are often important,
• Additional protection against HIV
they are not generally appreciated by many
infection by using a condom is
patients and healthcare workers.
essential. It is important to stress
1. Injectables that the patient should only have
• Decrease in dysmenorrhoea. intercourse with a partner who is
• Less premenstrual tension. willing to use a condom.
• Less iron-deficiency anaemia due to 3. HIV-positive patients
decreased menstrual flow. • Condoms must be used in addition to
• No effect on lactation. the appropriate contraceptive method
2. Combined pill (dual contraception).
• Decrease in dysmenorrhoea. 4. Patients whose families are complete
• Decrease in menorrhagia (heavy and/or • Tubal ligation or vasectomy is the
prolonged menstruation). logical choice.
• Less iron-deficiency anaemia. • An injectable, e.g. Depo-Provera or
• Less premenstrual tension. Petogen (12 weekly) or Nur-Isterate (8
• Fewer ovarian cysts. weekly).
• Less benign breast disease. • A combined pill until 35 years of age if
• Less endometrial and ovarian there are risk factors for cardiovascular
carcinoma. disease, or until 50 years if these risk
3. Progestogen-only pill factors are absent.
• No effect on lactation. 5. Patients of 35 years or over without risk
4. Condom factors for cardiovascular disease
• Less risk of HIV infection and other • Tubal ligation or vasectomy is the
sexually transmitted diseases. logical method.
• Less pelvic inflammatory disease. • A combined pill until 50 years of age.
• Less cervical intra-epithelial neoplasia. • An injectable until 50 years of age.
• A progestogen-only pill until 50 years
of age.
The condom is the only contraceptive method
• An intra-uterine contraceptive device
that provides protection against HIV infection. until one year after the periods have
stopped, i.e. when there is no further
14-12 What is the most appropriate risk of pregnancy.
method of contraception for 6. Patients of 35 years or over with risk
a patient after delivery? factors for cardiovascular disease
• As above but no combination pill.
The most suitable methods for the following
groups of patients are:
1. Lactating patients
The puerperium is the most convenient time
• An injectable, but not if a further for the patient to have a bilateral tubal ligation
pregnancy is planned within the next performed.
year.
• A progestogen-only pill (minipill) for Every effort should be made to provide
three months, then the combined pill. facilities for tubal ligation during the
• An intra-uterine contraceptive device.

7. FAMILY PLANNING AFTER PREGNANC Y 263
puerperium for all patients who request CASE STUDY 1
sterilisation after delivery.
Remember that sperms may be present You have delivered the fourth child of an
in the ejaculate for up to three months unbooked 36-year-old patient. All her
following vasectomy. Therefore, an additional children are alive and well. She is a smoker,
contraceptive method must be used during but is otherwise healthy. She has never used
this time. contraception.
14-13 What are the risk factors for 1. Should you counsel this patient
cardiovascular disease in women about contraception?
taking the combined pill?
Yes. Every sexually active person needs
The risk of cardiovascular disease increases contraceptive counselling. This patient in
markedly in women of 35 or more years of particular needs counselling as she is at an
age who have one or more of the following increased risk of maternal and perinatal
risk factors: complications, should she fall pregnant again,
because of her age and parity.
1. Smoking.
2. Hypertension.
3. Diabetes. 2. Which contraceptive methods would
4. Hypercholesterolaemia. be appropriate for this patient?
5. A personal history of cardiovascular Tubal ligation or vasectomy would be the
disease. most appropriate method of contraception if
she does not want further children. Should
Smoking is a risk factor for cardiovascular she not want sterilisation, either an injectable
contraceptive or an intra-uterine contraceptive
disease.
device would be the next best choice.
14-14 When should an intra- 3. If the patient accepts tubal ligation,
uterine contraceptive device when should this be done?
be inserted after delivery?
The most convenient time for the patient
It should not be inserted before six weeks as and her family is the day after delivery
the uterine cavity would not yet have returned (postpartum sterilisation). Every effort should
to its normal size. At six weeks or more after be made to provide facilities for postpartum
delivery there is the lowest risk of: sterilisation for all patients who request it.
1. Pregnancy.
2. Expulsion. 4. If the couple decides not to have a
tubal ligation or vasectomy, how will
Postpartum patients choosing this method must
you determine whether an injectable
be discharged on an injectable contraceptive
or an intra-uterine contraceptive
or progestogen-only pill until an intra-uterine
device would be the best choice?
contraceptive device has been inserted.
Assessing the risk for pelvic inflammatory
NOTE Insertion of an intra-uterine contraceptive disease will determine which of the two
device immediately after delivery may be methods to use. If the patient has a stable
considered if it is thought likely that a patient relationship, an intra-uterine contraceptive
will not use another contraceptive method and
device may be more appropriate. However, if
where sterilisation is not appropriate. However,
the expulsion rate will be as high as 15 to 20%.
she or her partner has other sexual partners, an
injectable contraceptive would be indicated.

8. 264 MATERNAL CARE
5. What other advice must be given appropriate. Oral contraceptives are only
to a patient at risk of sexually reliable if taken every day.
transmitted infections?
The patient must insist that her partner wears 5. The patient and her mother are worried
a condom during sexual intercourse. This will that the long-term effect of injectable
reduce the risk of HIV infection. contraception could be harmful to a girl
of 15 years. What would be your advice?
Injectable contraception is extremely safe and,
CASE STUDY 2 therefore, is an appropriate method for long-
term use. This method will not reduce her
A 15-year-old primigravida had a normal future fertility.
delivery in a district hospital. She has never
used contraception. Her mother asks you for
contraceptive advice for her daughter after CASE STUDY 3
delivery. The patient’s boyfriend has deserted
her. You have just delivered the first infant of a
healthy 32-year-old patient. In discussing
1. Does this young teenager require contraception with her, she mentions that
contraceptive advice after delivery? she is planning to fall pregnant again within
a year after she stops breastfeeding. She is a
Yes, she will certainly need contraceptive
schoolteacher and would like to continue her
counselling and should start on a
career after having two children.
contraceptive method before discharge
from hospital. She needs to learn sexual
responsibility and must be told where the 1. The patient says that she has used
nearest family planning clinic to her home is an injectable contraceptive for five
for follow-up. She also needs to know about years before this pregnancy and would
postcoital contraception. like to continue with this method.
What would your advice be?
2. Which contraceptive method would be Injectable contraception would not be
most the appropriate for this patient? appropriate as she plans her next pregnancy
within a year, and there may be a delayed
An injectable contraceptive would probably be
return to fertility.
the best method for her as she needs reliable
contraception for a long time.
2. If the patient insists on using an
injectable contraceptive, which drug
3. Why would she need a long-
would you advise her to use?
term contraceptive?
Any of the injectables can be used (Depo-
Because she should only have her next child
Provera/Petogen or Nur-Isterate) as there is no
when she is fully grown up and able to take
proven advantages of the one above the others.
care of her children by herself.
3. Following further counselling, the
4. If the patient prefers to use an oral
patient decides on oral contraception
contraceptive, would you regard
and is given a combined pill. Do you
this as an appropriate method
agree with this management?
of contraception for her?
No. As she plans to breastfeed, she should
No. A method which she is more likely to
be given a progestogen-only pill. Combined
use correctly and reliably would be more

9. FAMILY PLANNING AFTER PREGNANC Y 265
oral contraceptive pills may reduce milk 2. When should the device be inserted?
production while breastfeeding is being
Six weeks or more after delivery, as there is
established. Progestogen-only pills have no
an increased risk of expulsion if the device is
effect on breastfeeding.
inserted earlier.
CASE STUDY 4 3. Could the patient, in the
meantime, rely on breast feeding
as a contraceptive method?
A married primipara from a rural area has just
been delivered in a district hospital. She has a No. The risk of pregnancy is too high. She
stable relationship with her husband and they should use reliable contraception, such as
decide to have their next infant in five years’ injectable contraception or the progestogen-
time. The patient would like to have an intra- only pill, until the device is inserted.
uterine contraceptive device inserted.
4. The patient asks if the intra-uterine
1. Is this an appropriate contraceptive device could be inserted
method for this patient? before she is discharged from hospital.
Would this be appropriate management?
Yes, as the risk of developing pelvic
inflammatory disease is low. The expulsion rate and, therefore, the risk of
contraceptive failure is much higher if the
device is inserted soon after delivery. Therefore,
it would be far better if she were to return six
weeks later for insertion of the device.