After Pregnancy

Post-Partum Contraception

What type of Contraceptive should I use after the birth of my baby?
Planning our families is so important these days for both health and financial reasons. It is helpful if you have considered the options available to you at each phase of your life. The Puerperium (the time after childbirth when the body returns to the normal non-pregnant state) is such a special time with so many demands upon the new mother that it is worth thinking about your options before the birth.
The American Centre for Disease Control and Prevention (CDC) has recently updated its guidelines for this. Ovulation can occur as early as 25 days postpartum among non-breastfeeding women, so it is important to start contraception in the very early postpartum period.

In the first six weeks after delivery, women have an increased risk of blood clots (venous thrombo-embolism, VTE) forming in their legs or pelvis. This is variously estimated as a 22 to 84 times increase in risk. It is worst in the first three weeks. Therefore, as we know that Combined Oral Contraceptive (COC) pills also increase the risk slightly, the CDC recommends that they are not used at this time. From 21 to 42 days after delivery, women with risk factors for VTE generally should not use combined hormonal contraceptives, but these are thought to be safe during this period for women without risk factors for VTE. Risk factors for VTE include age 35 years or older, previous VTE, thrombophilia, known thrombogenic mutations, immobility, transfusion at delivery, body mass index of at least 30 kg/m2, postpartum haemorrhage, peripartum cardiomyopathy, post caesarean delivery, preeclampsia, or smoking. After the six week period, your decision should be in the light of normal non-pregnant risks and benefits.

The advice regarding progestogen-only pills, depot medroxyprogesterone acetate injections, and implants) is unchanged. They may be started in the immediate post-partum period for women who are either breast-feeding or not. There is some suggestion that the hormones may hinder breast feeding if it is not well established.
Insertion of Intra-uterine Contraceptive Devices (IUCDs), including the levonorgestrel-releasing IUS and copper-bearing IUCD, immediately after delivery, is not associated with an increase in complications. Rates of IUCD expulsion are somewhat higher when they are inserted within 28 days of delivery, but continuation rates at 6 months are similar regardless of whether IUCD insertion takes place immediately postpartum or is delayed.
Barrier methods may be considered. A Sheath or Condom may be used at any time though one must bear in mind the dependence on proper usage for protection. However, as the birth canal is returning from a pregnant size and shape to a non-pregnant state, a Cap or Diaphragm should not be used. (changes occur even if a Caesarean Section is performed for delivery) As the return to “normal” does not return you to exactly the same as before your pregnancy, a cap or diaphragm which was perfect before the pregnancy may not fit afterwards and should be checked at your family planning clinic.

Circumcision of a Male Child

There is no medical reason to circumcise the Newborn. However there are many religious and social indications.
Probably the only indication for circumcision is infection under the prepuce (foreskin) leading to swelling and pain, closure over the end of the glans penis (phimosis) or behind the glans (paraphimosis). However, many societies have adopted the practice, ostensibly for reasons of hygiene.
I will generally perform circumcision at about 7 or 8 weeks after birth using the Hollister "Plastibell" circumcision device. This gives time for the Paediatrician to check the boy and confirm that all is progressing normally. One would not wish to proceed with circumcision if there were a developmental abnormality or if the child were jaundiced or otherwise unwell.

How is the operation done?

A small cut is made in the upper surface of the foreskin and the device inserted under the skin. A ligature is then tied tightly around the foreskin in a groove in the device. This causes the skin to shrivel and fall off releasing the device in seven or eight days.
At this age, no anaesthetic is required. I find that if the child is fed just after the procedure, any sign of distress disappears.

Are there any risks or complications?

Bleeding is very rare (other than a tiny amount from the foreskin itself) as the blood supply to the foreskin is on the underside of the penis and is not cut.
Infection is rare with normal ablutions.  No special cleaning is required. 
Scarring is usually minimal though there may be scarring of the shaft in some cases.
It is very important to notify the surgeon if

  • - There is unusual swelling
  • - The plastic ring has not fallen off within eight days
  • - The ring has slipped onto the shaft of the penis
  • - Healing does not proceed as described.

The operation commonly called “Female Circumcision” is a mutilation performed in certain countries and can produce dense scarring leading to difficulty in childbirth.  It should be brought to the attention of the Obstetrician early in any pregnancy.

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