English - K4Health

Clinical Guidelines for Integrating Family Planning
into Postpartum and Postabortion Care
May 2008
Project Team
Compilation
Dr. Alaa El-Fikky
Professor of OB/GYN
Ain Shams University
Monitors
Dr. Nahla Abdel-Tawab
FRONTIERS Regional Advisor
Population Council
Dr. Ahmed Afifi
Project Coordinator
Population Council
Reviewers
Ministry of Health & Population
Dr. Esmat Mansour
Advisor to the Minister
Maternal & Child Health Sector
Dr. Abdallah Kadah
Undersecretary
Curative Care Sector
Dr. Khaled Nasr
Undersecretary
Maternal & Child Health Sector
Dr. Hassan El-Gibaly1
Director
Population & FP Sector
Dr. Atef El-Shitany
Manager
Population & FP Sector
Dr. Tarek El-Mahallawy
Assistant Manager
Curative Care Sector
Dr. Hassan Nabih
Head of Quality Unit
Population & FP Sector
Dr. Samia El-Shafie
Head of IEC Unit
Population & FP Sector
Medical / Nursing Schools
Dr. Ezzeldin Osman
Professor of OB/GYN
Mansoura University
Dr. Mourad Hassanein
Professor of OB/GYN
Al-Azhar University
Dr. Maali Guimei
Professor of Nursing
Alexandria University
TAKAMOL / Pathfinder Project
Dr. Nagwa Samir
Primary Health Care Team Leader
Dr. Ayman Sabry
Training Specialist
Dr. Mohamed Abou Gabal
Maternal Health Specialist
Regional Center for Training (RCT)
Dr. Osama Refaat
Deputy Executive Director
1
Dr. Bahaa Shawkat
Head of Training Unit
Dr. El-Gibaly was the Director of Population & FP Sector until March 2008
Table of Contents
Foreword ..............................................................................................................................1
Postpartum Care ...................................................................................................................2
Background .................................................................................................................2
Definitions relevant to postpartum care .....................................................................2
Components of postpartum care .................................................................................3
Principles of postpartum care.....................................................................................4
Clinical guidelines for immediate postpartum care at the hospital ............................4
Clinical guidelines for providing postpartum family planning services ...................10
Postabortion Care ...............................................................................................................18
Background ...............................................................................................................18
Elements of postabortion care ..................................................................................18
Clinical guidelines for management of postabortion women ...................................20
Clinical guidelines for postabortion family planning ...............................................25
References ..........................................................................................................................29
Annexes..............................................................................................................................31
Annex I: The World Health Organization Classification of practices in
postpartum care according to usefulness, effectiveness and harmfulness ................31
Annex II: Clinical guidelines for the establishment of exclusive breastfeeding .......34
Annex III: Clinical guidelines for Lactational Amenorrhea Method........................42
Annex IV: Clinical guidelines for postpartum IUD insertion ...................................45
Annex V: Clinical guidelines for giving the contraceptive injection ........................50
Annex VI: Clinical guidelines for inserting & removing implants ...........................52
Annex VII: Medical eligibility criteria for contraceptive use ...................................54
Foreword
In Egypt, an increasing number of women are having deliveries and abortions at
health care facilities (El-Zanaty & Way, 2006; Huntington et al., 1998). Provision of
family planning services to postpartum and postabortion women is essential in order
to prevent unplanned or closely spaced pregnancies. However, those services are
seldom provided because curative services and family planning services are
administratively and geographically separated from one another. The need for
providing an integrated service for postpartum and postabortion women can not be
overemphasized.
The present guidelines are aimed at presenting a comprehensive model for providing
postpartum and postabortion care with emphasis on family planning service
provision before discharge from hospital. This document, “Clinical Guidelines For
comprehensive Postpartum And Post Abortion Care” is developed to ensure the
provision of good quality evidence-based health care after pregnancy comes to an
end, whether after delivery, or after an abortion/miscarriage. The care described in
this document is routine care that should be provided to uncomplicated cases. For
management of complications the provider should refer to more specialized manuals.
Those guidelines bring together the best international evidence and local knowledge
necessary for decision-making about post partum and postabortion care. Using
clinical practice guidelines in managing health care improves outcomes, reduces
complications as well as costs of health care provision.
This document describes care that should be provided to postpartum / postabortion
women regardless of who the health care provider is. A companion document has
been developed in Arabic to explain tasks that are expected to be performed by the
attending nurse in providing postpartum / postabortion services. This document has
been reviewed by a panel of experts in the fields of Ob/Gyn, pediatrics, nursing, and
public health as well as senior officials at the Ministry of Health and Population.
This comprehensive model of postpartum postabortion care will be implemented in
fifty hospitals in five governorates in Egypt (Cairo, Alexandria, Dakahleya, Minya
and Assiut). We hope service providers and program managers will find those
guidelines useful in improving quality of care in those hospitals. Lessons learned from
implementing those guidelines will assist Ministry of Health and Population in
integrating family planning services within postpartum / postabortion services
nationwide and will contribute to reducing the incidence of unplanned and closely
spaced pregnancies and ultimately maternal and newborn mortality in Egypt.
1
Postpartum Care
Background
Labor is the long-awaited result of pregnancy, and the start of a new life. However, it
is also a critical time for the health of the mother and her newborn. Complications
may develop that, if not treated promptly and effectively, can lead to morbidity and
even mortality for one or both of them. In fact the majority of maternal deaths and
morbidities occur during the postpartum period, while early neonatal mortality
remains a challenge to the health care system in Egypt.
The postpartum period, or puerperium, starts after the delivery of the placenta and
includes the subsequent six weeks. The following are the three most important
maternal complications occurring during the postpartum period. Interestingly, all
three are preventable complications.

Postpartum hemorrhage is the single most important cause of maternal death
worldwide. It kills 150 000 women each year world wide (selected practice
recommendations for contraceptive use – Second edition. WHO publications
2005). In Egypt postpartum hemorrhage is implicated as the cause of death in
around 26% of maternal deaths (2003 Egyptian National Maternal Mortality
Screening program.Unpublished data).

Puerperal infections such as sepsis are still major causes of maternal mortality in
many developing countries. Prevention by ensuring cleanliness and hygiene at
delivery is obviously the best course of action.

Eclampsia is the third most important cause of maternal mortality worldwide. A
woman suffering from eclampsia or severe preeclampsia the first days postpartum
should be hospitalized and the treatment of choice is magnesium sulphate.
The newborn’s health and well-being can also be affected by a variety of conditions.
The most common causes of death and disability in the postnatal period include
prematurity, neonatal sepsis, respiratory infections, neonatal tetanus and cord
infections, congenital anomalies, and birth trauma or asphyxia.
Definitions relevant to postpartum care

Postpartum period: is the period beginning immediately after the birth of a child
and extending for six weeks. The period is also known as postnatal period or
puerperium. Biologically, it is the time after birth, a time in which the mother's
body, including hormone levels and uterus size, return to pre-pregnancy
conditions.

Postplacental duration: is within 10 minutes after expulsion of the placenta.

Postpartum before discharge (PPBD): is within 48 hours after delivery, before
hospital discharge. This document is concerned with care provided to postpartum
women before they are discharged from hospital, i.e. care in the immediate
postpartum period.

Extended postpartum period: the period extending from six weeks to one year
after delivery.
2

Lochia: is post-partum vaginal discharge, containing blood, mucus, and placental
tissue.
Components of Postpartum Care
Postpartum care should respond to the special needs of the mother and baby during
this special phase (see Table 1) and should include the prevention, early detection,
treatment of complications and disease, establishment of breastfeeding, providing
family planning services and providing counseling and information to women
regarding their health and that of the newborn.
Table (1): Special needs of the mother and newborn during the postpartum period
In the postpartum period, women need:
Information/counseling
- Care of the baby and breast feeding
- What happens to their bodies, including signs of possible problems
- Self care - hygiene and healing
- Sexual life
- Contraception
- Nutrition
Support:
- From health care providers
- From husband and family: emotional, psychological
Health care for suspected or manifested complications.
Time to care for the baby
Help with domestic tasks
Maternity leave
Social reintegration into her family and community
Protection from abuse/violence.
Women may fear:
- Inadequacy
- Loss of marital intimacy
- Isolation
- Constant responsibility of caring for the baby and others
In the postnatal period, newborn infants need:
Easy access to the mother
Appropriate feeding
Adequate environmental temperature
A safe environment
Parental care
Cleanliness
Observation of body signs by someone who cares and can take action if necessary
Access to health care for suspected or manifested complications
Nurturing, cuddling, stimulation
Protection from
- Disease
- Harmful practices
- Abuse/violence
Acceptance by family and society
Recognition (vital registration system)
3
Principles of Postpartum Care
The following principles guide the care of women after pregnancy, in the postpartum
period:
1. A documented, individualized postpartum care plan should be developed for each
woman, ideally in the antenatal period. If this plan is not developed during
antenatal care, it should be developed as soon as possible after delivery.
2. A proper postpartum plan should include:

Relevant factors from the antenatal period. Details of intra-partum and
immediate postnatal periods should also be included.

Details of the healthcare providers involved in care of the woman and that of
her newborn, including contact details

Future plans for the postnatal period, including plans for birth spacing and use
of contraception

Exclusive breast feeding for six months and proper complementary feeding
after six months
3. Before discharge from hospital and at follow-up visits the healthcare provider
should:

Ask the woman about her health and well-being and that of her baby. This
should include asking women about any physical health problems. Any
symptoms reported by the woman or identified through clinical observations
should be assessed.

Documentation of specific problems and further follow-up in the postpartum
care plan.

Fill out follow-up card: All women should receive a card indicating their
medical condition, the care they received during and after delivery as well as
plans for contraceptive use.

Counseling to continue exclusive breast feeding for six months and proper
weaning with continuation of breast feeding for up to 2 years.
Clinical Guidelines for Immediate Postpartum Care at the
Hospital
Physiologic manifestations of the postpartum period:
Clinical manifestations during the puerperium generally reflect reversal of the
physiologic changes that occurred during pregnancy. Health care providers should be
aware of those changes, and should understand that these mild and temporary changes
should not be confused with pathologic conditions.

Temperature may be slightly elevated (up to 38°C).

White Blood Cells (WBCs) increase during labor, marked leukocytosis (up to
20,000 to 30,000/μL) occurs in the 1st 24 hours postpartum; white blood cell
(WBC) count returns to normal within one week.
4

Vaginal discharge is grossly bloody (lochia rubra) for 3 to 4 days; over the next
10 to 12 days, it changes to pale brown (lochia serosa) and finally to yellowish
white (lochia alba). About 1 to 2 weeks after delivery, eschar from the placental
site sloughs off and bleeding occurs; bleeding is usually self-limited.

Total blood loss during the puerperium is about 250 ml;

Urine temporarily increases in volume and may contain protein and sugar.

Because blood volume is redistributed, Hematocrit may fluctuate, although it
tends to remain in the pre-pregnancy range if women do not hemorrhage.

Plasma fibrinogen remains elevated during the first week postpartum.

The uterus involutes progressively; after 5 to 7 days, it is firm and no longer
tender, extending midway between the symphysis and umbilicus. By the second
week, it is no longer palpable abdominally. Contractions of the involuting uterus,
if painful (afterpains), may require analgesics.
Management of postpartum women in the hospital:
The proper administration of immediate post partum care is crucial for the prevention
and management of many life threatening maternal and neonatal complications.
Comprehensive postpartum care will decrease maternal and neonatal mortality and
will reduce unplanned or closely spaced pregnancies2.
(A)
Minimizing risk of complications

2
Risk of hemorrhage, infection, and pain:
o
The woman is typically observed for at least two hours after the third stage
of labor.
o
The uterus is massaged periodically to ensure that it contracts and remains
contracted, preventing excessive bleeding.
If the uterus does not remain contracted with massage alone, oxytocin
“SYNTOCINON” 10 units IM or a dilute oxytocin IV infusion (10 or 20
units/1000 mL of IV fluid) at 125 to 200 mL/h is given immediately
after delivery of the placenta.
The drug is continued until the uterus is firm; then it is decreased or
stopped.
Oxytocin should be given as an IV bolus very cautiously because severe
hypotension may occur, subsequently increasing cardiac output.
If general anesthesia was used for operative delivery (by forceps,
vacuum extractor, or cesarean section), the woman is monitored
(preferably in a recovery room) for 2 to 3 h after delivery.
For all women: Oxygen, type O-negative blood or blood tested for
compatibility, and IV fluids must be available during the recovery
period.
o
Avoid unnecessary manipulations and interventions as vaginal examinations
and urinary catheterization.
see Annex I : The WHO classification of practices in postpartum care
5


Risk of Eclampsia:
o
A minimum of one blood pressure measurement should be carried out and
documented within 6 hours of the birth.
o
Routine assessment of proteinuria is not recommended.
o
Women with severe or persistent headache should be evaluated and preeclampsia considered (emergency action).
o
If diastolic blood pressure is greater than 90 mm Hg, and there are no other
signs and symptoms of pre-eclampsia, measurement of blood pressure
should be repeated within 4 hours.
o
If diastolic blood pressure is greater than 90 mm Hg and accompanied by
another sign or symptom of pre-eclampsia, evaluate further (emergency
action).
o
If diastolic blood pressure is greater than 90 mm Hg and does not fall below
90 mm Hg within 4 hours, evaluate for pre-eclampsia (emergency action).
Risk of Thrombo-embolism:
o
Women should be encouraged to mobilize as soon as appropriate following
delivery.
o
Women with unilateral calf pain, redness, or swelling should be evaluated
for deep venous thrombosis (emergency action).
o
Women experiencing shortness of breath or chest pain should be evaluated
for pulmonary thrombo-embolism (emergency action).
o
Routine use of Homan's sign as a tool for evaluation of thrombo-embolism is
not recommended.
o
Obese women are at higher risk of thrombo-embolism and should receive
individualized care.
(B) Diet

A regular diet should be offered as soon as the woman requests food.
(C) Initiation of Breastfeeding

Early skin to skin contact of mother and baby and immediate initiation of
breast feeding no later than one hour of normal delivery and within 2-3 hours
of cesarean section helps mother-child bonding and allows for better breast
milk production and reduces breast engorgement.

No other fluids e.g. herbs, glucose, or sugar water should be given besides
colostrum to the baby (i.e. exclusive breast feeding).

Rooming- in throughout the hospital stay of mother and baby should be
encouraged, even at night

Educate the mother about the correct positioning of the baby at the breast.

Women should be educated about exclusive breast feeding.
6

If there is a medical contraindication to breastfeeding, firm support of the
breasts can suppress lactation; gravity stimulates the let-down reflex and
encourages milk flow. For many women, tight binding of the breasts, cold
packs, and analgesics followed by firm support effectively control temporary
symptoms while lactation is being suppressed3.
(D) Provision of family planning services
All postpartum women should receive family planning counseling before
discharge from hospital. Women who are interested in immediate initiation of
contraception should be offered a family planning method before discharge.
Women who were counseled during antenatal care and who had indicated a desire
for postpartum IUD insertion could have an IUD inserted at delivery
(postplacental IUD insertion). Other women could have an IUD inserted before
discharge or receive any other method depending on their needs (See clinical
guidelines for providing postpartum family planning services page 10).
(E) Exercise
When to start an exercise routine depends on the woman; its safety depends on
whether complications or disorders are present. Usually, exercises to strengthen
abdominal muscles can be started once the discomfort of delivery (vaginal or
cesarean) has subsided, typically within one day for women who deliver vaginally
and later for those who deliver by cesarean section. Sit-ups or curl-ups, (rising
from supine to semi-setting position), done in bed with the hips and knees flexed,
tighten only abdominal muscles, usually without causing backache.
(F) Personal hygiene and perineal care

If delivery was uncomplicated, showering and bathing are allowed.

Vaginal douching is prohibited in the early puerperium, until bleeding stops
completely and all wounds are healed. The practice of vaginal douching may
cause more harm than benefit, and should not be routinely recommended.

The vulva should be cleaned from front to back.

Immediately after delivery, ice packs may help reduce pain and edema at the
site of an episiotomy or repaired laceration; later, warm sitz baths several
times a day can be used4.

Commonly used analgesics include Aspirin 650 mg, Acetaminophen 650 mg,
and Ibuprofen 400 mg orally every 4 to 6 hours.

Urinary catheterization should be avoided, if possible.

Rapid diuresis may occur, especially when oxytocin is stopped.

Voiding must be encouraged and monitored to prevent asymptomatic bladder
overfilling.
3
See Annex II: Clinical guidelines for exclusive breast feeding.
A sitz bath (also called a hip bath) is a type of bath in which only the hips and buttocks are
soaked in water or saline solution.
4
7
(G) Bowel movement

Women are encouraged to defecate before leaving the hospital, although with
early discharge, this recommendation is often impractical.

Maintaining good bowel function can prevent or help relieve existing
hemorrhoids, which can be treated with warm sitz baths.
(H) Lab tests and immunization

A complete blood count (CBC) to verify that a woman is not anemic is
required only if peripartum blood loss was excessive.

Women seronegative for rubella should be vaccinated against rubella on the
day of discharge.

Women with Rh-negative blood, who have an infant with Rh-positive blood
and are not sensitized, should be given Rh0(D) immune globulin 300 μg IM, as
soon as possible (preferably within 72 hours of delivery) to prevent
sensitization.
(I) Emotional support
a. Transient depression (“baby blues”) is very common during the 1st week after
delivery.
b. Symptoms are typically mild and usually subside by 7 to 10 days.
c. Treatment is supportive care and reassurance.
d. Persistent symptoms, lack of interest in the infant, suicidal or homicidal
thoughts, hallucinations, delusions, or psychotic behavior may require
intensive counseling and antidepressants or antipsychotics.
e. Women with a preexisting mental disorder are at high risk of recurrence or
exacerbation during the puerperium and should be monitored closely.
Instructions before Discharge:
The mother and infant should be ideally discharged after at least 24 hours of delivery.
Postpartum counseling should take place at a private area to allow women to ask
questions and express their concerns freely. If this is not feasible, counseling could be
done by the women’s bed provided that privacy is ensured. It is advisable to involve
husbands of postpartum women in this counseling and in receiving instructions before
discharge.
The following instructions should be given to the woman before discharge from
hospital:
1. Women should be advised of the warning symptoms of potentially lifethreatening conditions, and to seek immediate health care if any of the following
symptoms occur:
8
Symptom
suggestive of
Symptom
Sudden and profuse blood loss or persistent increased blood loss
Faintness, dizziness, or palpitations/tachycardia
Postpartum
hemorrhage
Fever, shivering, abdominal pain, and/or offensive vaginal
discharge
Infection
Headaches accompanied by one or more of the following
symptoms within the first 72 hours after delivery:
 Visual disturbances
 Nausea, vomiting
Pre-eclampsia/
eclampsia
Unilateral calf pain, redness or swelling
Shortness of breath or chest pain
Thromboembolism
2. Breastfeeding: Women should be encouraged to maintain exclusive breast
feeding for six months and should be educated about effective breastfeeding
practices, as well as common breastfeeding problems and how to manage and to
continue breast feeding for two years and to start complementary feeding after six
months5.
3. Contraception: Women should be informed about the advantages of birth spacing
for at least two years before getting pregnant again and about different family
planning options. Women should also be given a choice of receiving a family
planning method in the Ob/Gyn ward before discharge from hospital or at a family
planning clinic within the first 40 days postpartum (See clinical guidelines for
providing postpartum family planning services page 10).
4. Diet: Women should be advised to eat a diet that is rich in proteins, and fluids in
order to enhance milk production.
5. Pain relief: Women should be advised that analgesics such as paracetamol and
acetaminophen are allowed up to 1000 mg per day. Higher doses of
acetaminophen and other drugs should be limited in breastfeeding women, as
drugs are secreted in breast milk.
6. Normal activities may be resumed as soon as the woman feels ready. Major
problems are rare, but a scheduled home visit or follow-up visit may be necessary
to prevent these problems.
7. Personal hygiene and perineal care if delivery was uncomplicated, showering
and bathing are allowed.
8. Intercourse may be resumed after cessation of bleeding and discharge, and as
soon as desired and comfortable to the woman. However, a delay in sexual
activity should be considered for women who need to heal a laceration or
episiotomy repair.
5
See Annex II: Clinical guidelines for exclusive breast feeding.
9
9. Home visits: Women should be informed that routine home visits during the first
week postpartum may be performed by staff from the health unit.
10. Follow-up visit: Women should be informed that they should make a follow up
visit to this hospital or to a health unit at six weeks postpartum (preferably before
the 40th day) and to come back to hospital if they feel any symptoms that worry
them.
Clinical Guidelines for Providing Postpartum Family
Planning Services
Background
Why offer immediate postpartum family planning services?

Postpartum women are at risk of an unintended pregnancy
On average non-breastfeeding women have their first ovulation 45 days after delivery,
i.e. they are at risk of getting pregnant by the sixth week postpartum if they resume
sexual relations by that time. For breastfeeding women, return of menses may be
delayed six months or longer but this is based on exclusive breastfeeding, which is not
the predominant practice in Egypt.

Postpartum women have an unmet need for family planning
Demographic and Health Survey data show that very few women (3%-8%) want another
child within two years after giving birth. Also, although 40 percent of women in the first
year postpartum intend to use a family planning method but very few of them do.

Postpartum do not receive adequate information on family planning
Research conducted by the FRONTIERS program of the Population Council has
shown that postpartum women do not see a need to make a follow up visit after
delivery (Abdel-Tawab et al., 2007). Also, data from Egypt Demographic and Health
Survey (El-Zanaty & Way, 2006) shows that only one quarter of women received any
advice on family planning during the time they were pregnant, at the time they
delivered or during the two months following delivery (El-Zanaty & Way, 2006).

Provision of family planning services in the immediate postpartum period is an
important opportunity that should not be missed (Stephenson & MacDonald,
2005).
There is evidence that providing postpartum family planning services before
discharge from hospital is associated with higher rates of family planning acceptance.
Some women may be more ready to accept a family planning method immediately
after delivery than afterwards. Use of family planning by women who do not wish to
become pregnant would help reduce unwanted and closely spaced pregnancies as well
as pregnancies at the extremes of reproductive age, when risk of maternal and infant
mortality is greatest. It is estimated that 25 to 40 percent of maternal deaths could be
averted if unplanned and unwanted pregnancies were prevented (Campbell and
Graham, 2006). Also, child deaths (under five mortality) could be reduced by 10
percent if birth intervals of less than two years were eliminated (Cleland et al., 2006).
10
When to provide postpartum family planning services?

Ideally, counseling for postpartum contraception should start during the antenatal
period, and should be an integral part of antenatal care.

Women who had no antenatal care and those who did not receive counseling
during the ante natal period, should be counseled for family planning in the
immediate post partum period, after their own and their baby’s condition has
stabilized. The provider should make sure that the mother is not in pain and that
her other concerns have been addressed e.g. breastfeeding the baby. It is
preferable to offer family planning counseling some time before discharge from
hospital so as to give the woman time to make a free decision and to consider
different contraceptive options.

Women who will have elective C-section could be counseled pre-operatively.
Who should provide family planning services to postpartum women?

Family planning services should be provided by the attending doctor and nurse in
the Ob/Gyn ward as well as social worker. All three providers should provide
family planning counseling to the woman and offer her a method if she is
interested in immediate initiation. In settings where family planning methods are
not available on the ward, the health provider should provide family planning
counseling and refer the woman either to the hospital family planning clinic (if
the women is interested in immediate initiation) or to a family planning clinic
near her residence.
Where should postpartum family planning services be offered?

It is important to designate some private space on the Ob/Gyn ward for
counseling of postpartum and postabortion women. The space could be an office
that is rarely used, a corner of an examination or a treatment room where the
provider and the woman can talk privately. It is also possible for the provider to
speak with the women in the delivery room once they feel well enough or next to
her bed if privacy can be insured.
Components of postpartum family planning counseling
The health care provider should follow the GATHER steps in counseling postpartum
women (and their husbands).

Greet: If you have not met the women before, introduce yourself politely by
name to her and ask the woman if she feels well enough to talk. If yes, go with
her to a place where she can talk privately. Ask her if she would like to include
her husband in the discussion. Research has shown that including husbands in
family planning counseling is associated with increased husband support and
increased use of contraception. If the woman does not feel well enough, make
arrangements to return to speak with her later and leave her some leaflets / fliers
about different contraceptive options for postpartum women.

Ask: Review the woman’s medical and reproductive history as documented in
her medical record. Ask her about her health, that of her baby, her reproductive
intentions, previous use of contraception and breastfeeding plans. Ask her what
she knows about family planning and if she prefers a particular method. A health
care provider should assess a woman's postpartum contraceptive needs by taking
11
into account her medical history, personal choice, sexual activity, breastfeeding
pattern, and medical and social factors. Listen to her needs and concerns and
correct any misinformation that the woman might have.

Tell: Tell the woman the following information during family planning counseling:
-
Birth spacing: It is advisable to postpone the next pregnancy for at least two
years to ensure best maternal and fetal outcomes. Women who get pregnant
within two years of a previous delivery have a higher risk of preterm birth,
perinatal mortality, infant mortality and maternal mortality. Women who had
a still birth may need special counseling preferably with their husband to help
them in delaying the next pregnancy for two years.
-
Effects of breastfeeding on ovulation and fertility: For non-lactating
women on average the first ovulation occurs within 45 days after delivery and
in some women ovulation occurs as early as 28 days postpartum. For lactating
women return of menses may be delayed for six months or longer if they are
practicing exclusive breastfeeding.
Women should be advised not to await the onset of menstruation before
starting contraception, as this might put them at risk of unintended pregnancy.
The fact that ovulation may precede the first menses by about 14 days should
be explained to postpartum women during counseling.
- Different family planning options: Tell the women briefly about various
family planning methods as appropriate, relating them to her particular
situation and needs. For each of those methods describe efficacy, effects on
breast milk and infant growth, when to start each method and possible sideeffects. Family planning methods are safe to use immediately postpartum,
depending on the woman’s medical condition and her breastfeeding intentions.
Use IEC materials such as flip chart, fliers or samples of family planning
methods.
- Initiation of contraception: A woman could receive a family planning
method in the Ob/Gyn ward before discharge, or at the hospital family
planning clinic (if FP methods are not available on the ward) or at a family
planning clinic near her residence within the first 40 days postpartum.

Help: The doctor should help the woman choose a method that meets her health,
social and psychological needs as well as her breastfeeding pattern. Women who
choose a method that can be initiated before discharge from hospital (e.g. post
partum IUD), should receive the method of their choice, together with
information and instructions from the health care provider. Women who choose
other methods e.g. progestin only pills, condoms … etc. could still receive those
methods and should be advised on the right time to start using them.

Explain: Explain to her in detail how to use the chosen method, how to become
comfortable using it, how and where to get supplies and how to deal with
common side-effects.

Referral: Refer the woman to the hospital family planning clinic or to a family
planning clinic near her residence for follow–up of the received method or to
obtain resupplies. Women should also be encouraged to visit the family planning
clinic if they experience any warning signs, if they want to discuss side-effects or
if they want to switch methods.
12
Family planning methods for postpartum women
A. BREASTFEEDING WOMEN
Table (2): Preferred contraceptive methods for breast feeding women
First Choice: Non-hormonal Methods:
1.
Lactational Amenorrhea Method (LAM)
2.
Intrauterine devices (IUDs)
3.
Diaphragm
4.
Male and Female Condoms
5.
Spermicides
6.
Natural Family Planning (NFP)
Alternative Choice: Progestin-only Methods
1.
Progestin-only Pills (POPs)
2.
Injectables (DMPA, NET-EN)
3.
Subdermal Implants
Less Preferred Choice: Combined Estrogen-Progestin Methods
1.
Combined Oral Contraceptives (COCs)
2.
Monthly injectables (Mesigyna, Cyclofem)
Non-hormonal Contraception
Lactational Amenorrhea Method (LAM)6

LAM is over 98% effective in preventing pregnancy, provided the following
three criteria are met:
1.
If baby is less than 6 months old, and
2.
Menses has not resumed. Menstruation is defined as any two consecutive
days of bleeding, even drops of blood, after two months postpartum.
3.
Baby is exclusively breastfed7, i.e. day and night and on demand with no
other fluids besides breast milk, not even water, with no longer than 4 hours
between two feeds during the day and 6 hours during the night.

Women using LAM should be advised that the risk of pregnancy increases if
breastfeeding decreases (particularly stopping night feeds), when menstruation
recurs, or when baby is older than 6 months postpartum.

Women choosing to use LAM for contraception should start immediately after
delivery.

Women using LAM should be advised to transition to another family planning
method before the end of 6 months postpartum.

Women using LAM should be advised on optimal breastfeeding behaviors that
may enhance effective use of LAM, namely:
6
7
See Annex III: Clinical guidelines for LAM.
See Annex II: Clinical guidelines for exclusive breast feeding.
13
1.
Allow the newborn to breastfeed as soon as possible after birth and to
remain with the mother for at least several hours following delivery.
2.
Breastfeed exclusively for the first six months: no water, other liquids or
solid foods.
3.
Position and attach the baby correctly at the breast.
4.
Breastfeed frequently whenever the baby is hungry, both day and night.
Daytime feedings should occur at intervals of no longer than four hours.
There should be at least one nighttime feeding at an interval of no longer
than six hours.
5.
Offer the second breast after the infant releases the first.
6.
Continue breastfeeding even if the mother or infant becomes ill.
7.
Avoid using bottles, pacifiers or other artificial nipples
8.
The lactating mother should eat a balanced diet and drink more than usual
(drink to thirst).
9.
Breastfeeding mothers may need family or social support for continued
exclusive breastfeeding for six months.
10.
After the first six months, when complementary foods are introduced, LAM
is no longer reliable and another family planning method should be used.
11.
Continue to breastfeed for up to two years.
Intrauterine Devices (IUD)

There are several points during the postpartum period when an IUD may be
inserted8:
1.
Post-placental insertion: Immediately after expulsion of the placenta,
preferably within 10 minutes after expulsion. Insertion can be done
manually or with forceps.
2.
Postpartum before discharge (PPBD) insertion: Within 48 hours after
delivery, before hospital discharge. Insertion is done only with forceps.
3.
Trans-cesarean insertion: During cesarean section, after the uterine cavity
has been explored manually, following delivery of the placenta. Insertion
can be done manually or with forceps.
4.
Delayed puerperal insertion: from one to four weeks after delivery.
Insertion is not recommended during this interval due to increased risk of
perforation and infection.
5.
Insertion at 4-6 weeks postpartum.

Inserting an IUD immediately after childbirth has advantages, most notably
convenience for the woman and prompt protection from unintended pregnancy.

Research evidence suggests that the immediate postpartum insertion of an IUD
(within 10 minutes of delivery) is generally safe and effective.
8
See Annex IV: Clinical guidelines for postpartum IUD insertion.
14

IUDs inserted within 10 minutes of placenta expulsion have a much lower
expulsion risk than those inserted later in the postpartum period, although the
expulsion is still higher than for interval insertions (about 42 days after child
birth). Early follow-up can identify spontaneous explusions.

IUDs have no effect on length of breastfeeding, infant growth, quantity of milk or
milk composition.

Similar expulsion rates of different types of IUDs.

No increased risk of pelvic infection occurs with postpartum IUD insertion.

The risk of uterine perforation for postpartum IUD insertion is low (not greater
than interval insertion i.e. 1 per 2000 insertions).
(Family Health International, 2006).
Barrier Methods, Spermicides, and Fertility Awareness Methods

Women and their husbands should be advised to abstain from sexual intercourse
until the all vaginal bleeding and discharge have stopped, and until any wounds,
injuries or abrasions have healed completely.

Condoms can be used during the post partum period as soon as bleeding stops
and the women feels comfortable with regards to resumption of sexual
intercourse.

Use of diaphragms and cervical caps should be delayed until uterine involution is
complete (from 6 weeks postpartum).

Fertility awareness methods are unreliable during the early postpartum period,
unless menstruation is regular and can be relied upon for calculation of the
“fertile period”.
Hormonal Contraception
Progestogen-Only Contraception

The use of progestogen-only methods when breastfeeding provides over 99%
efficacy; if correctly and consistently used.

The available research evidence indicates that progestin only contraception has
no proven effect on breast milk volume or on infant growth.

Irregular bleeding in the form of spotting associated with progestogen-only
methods is a common side effect, and does not indicate contraceptive failure.

The efficacy of Progestin only pills decreases in non-breast feeding women
compared to breast feeding women.

Starting Regimens
1. Progestogen-Only Pills (POPs)
A breastfeeding woman can start a POP at six weeks postpartum without the need
for additional contraceptive protection. The provider can give her PoPs before
discharge from hospital and advise her to start taking them at six weeks
postpartum.
15
2. Progestogen-Only Injectable
A breastfeeding woman could start depot medroxyprogesterone acetate (DMPA)
use at or after 6 weeks postpartum, as it may cause troublesome bleeding if used
before that time9.
Women who are at high risk of getting pregnant before 6 weeks postpartum and
who request DMPA contraception should be advised to delay the first injection
till breast feeding is properly established, usually by day 21 postpartum.
3. Progestogen-Only Implants
A breastfeeding woman could have a progestogen-only implant inserted by the
sixth week postpartum10.
4. Levonorgestrel-Releasing Intrauterine System (LNG-IUS)
Breastfeeding women may have a LNG-IUS inserted at 4 weeks postpartum.
Combined Hormonal Contraception

The use of combined oral contraception (COC) or monthly injectables in the first
6 weeks postpartum has an adverse effect on breast milk volume.

Breastfeeding women should be advised to avoid COC and monthly injectables
in the first 6 months postpartum.

Breastfeeding women should be advised that COC or monthly injectables can be
used without restriction from 6 months postpartum

If breastfeeding is established, COC or monthly injectables may be considered if
other contraceptive methods are contra-indicated.
B. NON BREASTFEEDING WOMEN

Women who will not breast feed for any reason need to know that they could
ovulate as early as 28 days postpartum and that they need to start using
contraception before then in order to protect themselves against an unplanned or
closely spaced pregnancy.

Women who will not breastfeed could use any family planning method so long as
they meet the medical eligibility criteria and follow the right time for initiation as
provided in table (3).
9
See Annex V: Clinical guidelines for giving contraceptive injection.
See Annex VI: Clinical guidelines for inserting & removing implants.
10
16
Table (3): Timing of method initiation by breast feeding and non-breast feeding women
Method
Breast Feeding women
Non-breast feeding
women
LAM
Immediately and could be
used for up to 6 months
postpartum
Inapplicable
IUD
Condoms/ Spermicides
Within 48 hours after delivery
Any time starting 4 weeks postpartum
After cessation of bleeding and discharge
and healing of all abrasions, wounds, and incisions
Progestin only pills
6 weeks postpartum
Immediately after delivery
Progestin only Injectable /
Implants
6 weeks postpartum
Immediately after delivery
Combined Estrogen progestin
pills / injectables
6 months postpartum
3 weeks postpartum
Natural family planning
Can begin once regular menses
returns, preferably six months onwards
LNG-IUS
4 weeks after giving birth
17
Postabortion Care
Background
Abortion is a major public health problem worldwide. It is estimated that at least 15%
of all pregnancies end in spontaneous abortion. On the otherhand, according to WHO
estimates, 70,000 women die each year as a result of complications following unsafe
abortion. Complications of abortion include hemorrhage, shock, sepsis, infertility and
other) Ministry of Health and Population & TAHSEEN / Catalyst Project 2005(.
Abortion also often poses an emotional trauma to women, especially if the lost
pregnancy was wanted.
In Egypt it is estimated that one in five cases admitted to the Ob/Gyn ward are for
treatment of a spontaneous or induced abortion (Huntington et al., 1998). More than
one third of those patients (37%) reported a previous miscarriage while 42 percent
reported an intention for using contraception soon after their discharge from hospital.
Elements of Postabortion Care
Comprehensive postabortion care (PAC) services should include both medical and
preventive healthcare. The key elements of postabortion care are (Postabortion Care
Consortium, 2002):
I.
Emergency Treatment for complications
WHO has identified the prompt treatment for complications of spontaneous or
unsafely induced abortion as an essential element of obstetric care that should be
available at every district-level hospital. Treatment of uncomplicated incomplete
abortions also can be provided at the primary care level or in family planning
clinics if manual vacuum aspiration (MVA) is available. The Essential Elements
of PAC model recognizes that high quality treatment also includes standard
infection prevention precautions, appropriate pain management, sensitive
interpersonal communication and adequate follow-up care.
II. Counseling
Counseling is an essential element of postabortion care because effective
counseling for women who are experiencing incomplete abortion and possible
complications should permeate every component of services from the first
contact between women and provider to the last contact and cover more than
family planning and contraception. The aim of counseling in postabortion care
is: (1)to solicit and affirm women’s feelings and provide emotional support
throughout the entire postabortion care visit; (2) ensure that women receive
appropriate answers to their questions or are otherwise provided with information
about medical conditions, test results, treatment and pain management options
and follow-up care, (3) help women clarify their thoughts about their pregnancy,
incomplete abortion, treatment, resumption of ovulation and reproductive
intentions; (4) listen and ask questions to help the provider better understand and
respond to other needs and concerns that could potentially impact their care, (5)
address other concerns women may have.
18
III. Postabortion Family Planning
Provision of family planning services is a central feature of postabortion care. A
woman’s fertility can return quickly after an abortion or miscarriage, as soon as
two weeks after. Also, recent WHO guidelines recommend a six month
interpregnancy interval following an abortion to ensure better maternal and fetal
outcomes. Although many postabortion women do not want to become pregnant
soon, very few of them receive family planning services before discharge from
hospital. This leaves those women at risk of another unintended pregnancy or a
closely spaced pregnancy.
Ensuring access to contraceptive methods for women who have undergone
abortion would help reduce an unwanted or closely spaced pregnancy as well as
injury and death from an unsafe abortion. Research has shown that providing
family planning services within PAC services benefits clients and programs.
Women are more likely to start using contraception if it is offered to them before
discharge from hospital. Providing family planning counseling and services on
the Ob/Gyn ward increases access to family planning information and informed
method choice which leads to improved long-term outcomes, savings to
programs, savings to clients and finally reduced incidence of unplanned
pregnancy and induced abortion.
IV. Links to Reproductive health and other Health Services
These include reproductive and other health services that are provided on-site at
the hospital where treatment of abortion has taken place or via referrals to other
accessible facilities. In many cases, PAC services are offered in facilities that
also provide other health services. It is important to reinforce the connections
among those services and establish mechanisms for ensuring that women who
need other health services are provided with those services. Reproductive and
other health services might include for example:
- Diagnosis and treatment of STIs.
- For women over age 30-35, it may be possible to offer cervical cancer or
breast cancer screening at the time of treatment or to provide referral to a
facility where screening is available.
- Women treated for spontaneous abortion may have special reproductive
healthcare needs, such as special follow-up for management of recurrent
spontaneous abortion (infertility) or advice before attempting to become
pregnant again or about prenatal care. She might also need referral to a
counselor or a social worker to help her deal with the psychological trauma of
the lost pregnancy.
- Screening for anemia and treatment and/or nutrition education.
V. Community and service provider partnerships:
To achieve universal local access to sustainable, high quality PAC and other
health services, community members and formally trained health care providers
must work in partnership. Examples of partnership include:
19
- Education to increase family planning and contraceptive use, thus preventing
unwanted and closely spaced pregnancies.
- Education about the risks and consequences of unsafe abortion
- Education about the signs and symptoms of obstetric emergencies such as
postabortion complications.
When providing postabortion care, the health provider should involve other
family members who accompany the woman at the hospital in education about
warning signs following abortion and importance of postabortion family
planning.
Clinical Guidelines for Management of Postabortion Women
1.
Initial screening



2.
Identification of abortion patients: any woman of reproductive age
experiencing at least two out of three of the following symptoms should be
considered as a possible abortion patient:
- Vaginal bleeding
- Cramping and/or lower abdominal pain
- A possible history of amenorrhea.
Quickly assess the patient for the following signs of shock:
- Rapid, weak pulse (rate 110 per minute or greater)
- Low blood pressure (hypotension); systolic less than 90 mmHg
- Pallor (inner eyelid conjunctiva, circumoral, or palms)
- Sweaty
- Fast breathing (respirations 30 per minute or greater at rest)
- Anxious, confused, or unconscious (diminished mental state).
If shock is suspected, immediately begin treatment.
Complete clinical assessment:
Several life-threatening conditions requiring immediate treatment may be present
at the same time. A complete clinical assessment is necessary to determine all
conditions that are present in order to decide the order in which to treat them:

History:
Ask about and record the following information:
- Amenorrhea - how long ago did she have her last menstrual period (LMP)
- Bleeding (duration and amount)
- Cramping (duration and severity)
- Abdominal or shoulder pain
- Drug allergies

General Examination:
- Check and record vital signs (temperature, pulse, respirations, blood
pressure)
- Note general health of woman (malnourished, anemic, general poor health)
20
- Examine lungs, heart, abdomen, extremities (In examining the abdomen first
check bowel sounds, then check to see if the abdomen is distended or rigid, if
there is rebound tenderness, abdominal masses, and presence, location, and
severity of pain)
- If a patient’s Rh status is routinely assessed in pregnancy, it should be done
during the clinical assessment in cases of abortion as well. If the patient is Rh
negative, give a dose of anti-D globulin within 48 hours of uterine
evacuation or of complete abortion.

3.
Pelvic Examination:
- Remove any visible products of conception from the vaginal canal or
cervical os
- Note if there is foul-smelling discharge
- Note the amount of bleeding and whether the cervix is open or closed to
determine the stage of abortion.
- Check for cervical lacerations
- Perform a bimanual exam:
- Estimate the size of the uterus
- Check for any pelvic masses
- Check for pelvic pain, note:
- Severity, location, and what causes the pain (at rest, with touch and pressure,
movement of the cervix)
Talking to the woman regarding her medical condition and the
treatment plan:
The patient needs information about her health condition and the MVA
procedure, or counseling. When talking with the patient, it is important to use
words that the woman understands so that she will understand the questions and
remember the information. The service provider should be able to address
particular needs for information or special concerns that a woman may have.
 Tell the woman (and her support person) what is going to be done, listen to
her and respond attentively to her questions and concerns.
 Provide continual emotional support and reassurance, as feasible.
 Give paracetamol 500 mg orally to the woman 30 minutes before procedure.
 Ask about allergies to antiseptics and anesthetics.
 Counseling before the procedure:
- Reassure and comfort the woman
- Obtain her consent for the operation
- Explain the benefits of local anesthesia (if manual vacuum aspiration will
be used)
- Explain what is going to happen during the procedure
- Answer her questions and fears
21
- Explain about the need to use family planning methods for at least 6 months
if she would like to get pregnant again or for longer if she does not want to
get pregnant again. Explain the possibility of immediate IUD insertion.
4.
Preparing for the procedures:





5.
Determine that required sterile or high-level disinfected instruments are
present.
Check that woman has recently emptied her bladder and washed her perineal
area.
Put on personal protective equipment.
Use antiseptic handrub or wash hands thoroughly and put on high-level
disinfected or sterile surgical gloves.
Arrange sterile or high-level disinfected instruments on sterile tray or in highlevel disinfected container.
Uterine evacuation techniques:
MVA is the preferred method of uterine evacuation to treat incomplete abortion
because relative to traditional treatment (D&C):
 The risk of complications is decreased,
 Access to services is increased, and
 The cost of postabortion services is reduced.
 Use of MVA offers the potential for earlier access to care, when
management is easier and serious complications less likely.
 Can be performed under local anesthesia (para cervical block).
Manual Vacuum Aspiration
Pre-procedure Tasks
- Explain each step of the procedure prior to performing it.
- Perform bimanual examination.
- Insert speculum.
- Swab cervix and vagina with antiseptic three times.
- Remove any products of conception (POC) from vagina and check for
any cervical tears.
MVA procedure
1. Put single-toothed tenaculum or vulsellum forceps on anterior lip of
cervix.
2. Administer paracervical block if cervical dilatation is needed.
3. Apply traction on cervix.
4. Dilate the cervix (if needed).
5. Insert the appropriate size cannula gently through the cervix into the
uterine cavity.
6. Attach the prepared syringe to the cannula.
22
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Evacuate contents of the uterus.
When signs of completion are present (i.e. gritty sensation, grasping of
cannula between anterior and posterior wall), withdraw cannula and
MVA syringe.
Empty contents of MVA syringe into a strainer, send specimen for
pathology if required.
Remove tenaculum or forceps and speculum.
Perform bimanual examination.
Inspect tissue removed from uterus to ensure complete evacuation.
Insert speculum and check for bleeding.
If uterus is still soft or bleeding persists, repeat steps 5–10.
Before removing gloves, dispose of waste materials in a leak-proof
container or plastic bag.
Flush MVA syringe and cannula with 0.5% chlorine solution and
submerge in solution for decontamination.
Needle and syringe should be disposed in puncture-proof container.
Remove gloves and discard them in a leak-proof container or plastic bag.
Use antiseptic handrub or wash hands thoroughly.
Check for bleeding and ensure cramping has decreased before discharge.
Counseling during the procedure
Supportive attention from staff can help reduce anxiety and lessen pain.
Talking with patients in a calm, relaxed manner helps focus attention away
from the procedure. The importance of staff (and providers) having these
special communication skills cannot be overestimated. Monitor the patient's
condition to be sure she is not experiencing undue discomfort or pain.
Throughout the procedure, health care providers should:
- Reassure the woman.
- Explain each step to the patient before it happens.
- Help her relax and so decrease her pain.
Dilatation and Curettage (D&C)
Dilatation and curettage should be used only if manual vacuum aspiration is
not available.

Provide emotional support and encouragement and give pethidine IM or
IV before the procedure. If necessary, use a paracervical block.

Administer oxytocin 10 units IM or ergometrine 0.2 mg IM before the
procedure to make the myometrium firmer and reduce the risk of
perforation.

Perform a bimanual pelvic examination to assess the size and position of
the uterus and the condition of the fornices.

Apply antiseptic solution to the vagina and cervix (especially the os).
23

Check the cervix for tears or protruding products of conception. If
products of conception are present in the vagina or cervix, remove them
using ring (or sponge) forceps.

Gently pass a uterine sound through the cervix to assess the length and
direction of the uterus.

Gently grasp the anterior lip of the cervix with a vulsellum or singletoothed tenaculum.
Note: With incomplete abortion, a ring (sponge) forceps is preferable
as it is less likely than the tenaculum to tear the cervix with traction
and does not require the use of lignocaine for placement.

If using a tenaculum to grasp the cervix, first inject 1 mL of 0.5%
lignocaine solution into the anterior lip of the cervix which has been
exposed by the speculum (the 10 o’clock and 2 o’clock position is usually
used).

Dilatation is usually needed only in cases of missed abortion or when some
retained products of conception have remained in the uterus for several
days, if dilatation is required:
- Gently try to introduce the widest gauge curette;
- Use graduated dilators only if the curette will not pass. Begin with the
smallest dilator and end with the largest dilator that ensures adequate
dilatation (usually 10–12 mm)
- Take care not to tear the cervix or to create a false opening.
Note: The uterus is very soft in pregnancy and can be easily
injured during this procedure.
 Evacuate the contents of the uterus with ring forceps or a large curette.
 Gently curette the walls of the uterus until a grating sensation is felt.
 Perform a bimanual pelvic examination to check the size and firmness of
the uterus.
 Examine the evacuated material. Send material for histopathological
examination, if required.
6.
Post-Procedure Care
Patients need reassurance that everything is satisfactory. As the anxiety and stress
of the events leading up to the evacuation procedure begin to fade away, most
patients can begin to take in some new information (postoperative and follow-up
instructions). In addition, counseling for family planning and provision of
temporary contraceptive methods may be initiated prior to discharge in most
cases. The time of treatment for an incomplete abortion is seldom the best time
for women to make decisions about methods that are permanent or long lasting
but delay may make these women especially vulnerable to another unwanted
pregnancy. It is possible that some women may have made choices about longlasting or permanent methods before this event and they may be candidates for
24
these methods if their desire to proceed and their full understanding of the
procedures are confirmed.
 Counseling after the procedure
The topics that need to be addressed are:
- The need for rest
- The need for proper nutrition
- The return of her fertility within 2 weeks
- The need to use family planning methods for at least 6 months if she would
like to get pregnant again or for longer if she does not want to get pregnant
again.
- Provide family planning counseling and services (See clinical guidelines for
postabortion family planning page 25).
- The danger signs that make it necessary to come back
o
o
o
o
o
o
Prolonged cramping (more than a few days);
Prolonged bleeding (more than 2 weeks);
Bleeding more than normal menstrual bleeding;
Severe or increased pain;
Fever, chills or malaise;
Fainting.
- The date and importance of her follow up visit.
- Give paracetamol 500 mg by mouth as needed.
- Encourage the woman to eat, drink and walk about as she wishes.
- Offer other health services, if possible, including tetanus prophylaxis
- Discharge uncomplicated cases in 1–2 hours.
- To avoid infection she should not have sex until bleeding stops, i.e., about
5-7 days.
Clinical Guidelines for Postabortion Family Planning
Background
Postabortion family planning should be based on an individual assessment
of each woman’s situation e.g.:



Her personal characteristics (see table 4),
Clinical condition, and
The service delivery capabilities in the community where she lives.
Postabortion family planning services need to be initiated immediately because
ovulation may occur as early as 11 days following treatment of the incomplete
abortion and usually occurs before the first menstrual bleeding.
25
Counseling for postabortion contraception
Counseling for postabortion family planning should follow the same GATHER
guidelines mentioned earlier. In counseling postabortion patients the provider should
particularly pay attention to:
-
Approach the woman when she is already calm and recovering from the
procedure.
-
Be sensitive to the woman’s physical and emotional condition; forcing her to
listen when she is not ready is inappropriate.
-
The emotional condition of the woman should be taken into consideration.
Women who lost a wanted pregnancy may not be willing to talk about family
planning.
-
Flexibility about where counseling takes place: women may feel strong enough to
walk to a separate room, or may feel more comfortable remaining in bed and
being counseled while still in the recovery room.
-
It is advisable to include the husband in the counseling, if the woman prefers that.
-
Provide the woman with all the information and explanations that allow her to
make an informed choice.
-
Discuss previous use of contraception to identify possible reasons for
contraceptive failure.
-
Do not try to find out if the abortion was spontaneous or induced. Rather focus
on the woman’s pregnancy intentions.
-
Don’t be judgmental or blame the woman for having lost the pregnancy.
At a minimum, all women receiving postabortion care need counseling and
information to ensure that they understand:
-
They can become pregnant again before the next menses,
-
It is advisable to postpone pregnancy for at least six months following an
abortion to reduce the chances of low birth weight, premature birth and maternal
anemia.
-
There are safe contraceptive methods to prevent or delay pregnancy.
-
They could receive a family planning method in the Ob/Gyn ward before
discharge from hospital or at a family planning clinic near their residence within
two weeks from discharge.
-
To avoid infection she should not have sex until bleeding stops i.e. – about 5-7
days.
-
Information and counseling about all available methods, their characteristics,
effectiveness and side effects
-
Choices among methods (e.g., short- and long-term, hormonal and nonhormonal)
-
Assurance of contraceptive re-supply
-
Access to follow-up care
-
Information about the need for protection against STIs
26
Table (4): Individual Factors, Counseling Recommendations and Rationales in providing
postabortion family planning
If the woman...
Recommendations
Rationale
Does not want to
be pregnant
soon
 Consider all temporary methods
 Delaying the next
Is under stress
or in pain
 Consider all temporary methods. Do
Was using a
contraceptive
method when
she became
pregnant
 Assess why contraception failed and
 Method failure,
what problems the woman might
have had using a method effectively.
 Help the woman choose a method
that she will be able to use
effectively.
 Make sure she understands how to
use the method, get follow-up care
and resupply, discontinue use and
change methods.
unacceptability, ineffective
use or lack of access to
supplies may have led to
unwanted pregnancy.
 These factors may still be
present and may lead to
another unwanted
pregnancy.
Had stopped
using a method
 Assess why the woman stopped
 Unacceptability or lack of
pregnancy by at least 6
months diminishes the risks
for the next pregnancy
not encourage use of permanent
methods at this time. Provide referral
for continued contraceptive care.




using contraception (e.g., side
effects, lack of access to resupply,
etc.).
Help the woman choose a method
that she will be able to use
effectively.
Make sure she understands how to
use the method,
Get follow-up care and resupply,
discontinue use and
Change methods.
Has a husband
who is unwilling
to use condoms
or will prevent
use of another
method
 If the woman wishes, include her
Wants to become
pregnant soon
 Do not try to persuade her to accept
husband in counseling.
 Do not recommend methods that the
woman will not be able to use
effectively.
a method. But do explain that it may
be better to wait 6 months.
 Provide information or a referral if the
woman needs
 Other reproductive health services.
27
 Stress and pain interfere
with making free, informed
decisions.
 The time of treatment for
incomplete abortion is not a
good time for a woman to
make a permanent
decision.
access may have led to
unwanted pregnancy.
 These factors may still be
present and may lead to
another unwanted
pregnancy.
 In some instances, involving
the husband in counseling
will lead to his use of and
support for contraception.
 If the woman has had
repeated spontaneous
abortions, she may need to
be referred for infertility
treatment.
Postabortion family planning methods
As shown in table 5, all modern methods of contraception are appropriate for use after
treatment for abortion as long as:
 Provider screens the woman for the standard precautions for use of a particular
method using the WHO Medical eligibility criteria11.
 Provider provides adequate counseling and helps the woman choose a FP method
that meets her physical, emotional and reproductive needs.
Table (5): Contraceptive methods for postabortion use
Method
IUD
Timing after abortion
IUDs can be inserted immediately after first trimester
spontaneous or induced abortion if the uterus is not infected or
no injury to the genital tract is present and no severe bleeding
is present. If infection is suspected, delay insertion until the
infection has been resolved and use an interim method.
IUD insertion after second trimester abortion requires a
specifically trained provider.
11
12
13
COCs
Begin pill use immediately, preferably on the day of the
abortion even if the woman has injury to the genital tract. If the
woman is starting within 7 days of first or second trimester
abortion, no need for a back-up method.
Progestin-only pills
Same
Implants
Same
DMPA injectables
First injection can take place immediately after abortion in the
first or second trimester. If injection is taken within 7 days of
first or second trimester abortion no need for a backup
13
method .
Monthly injectables
Same
Non-fitted barrier
methods and
spermicides, e.g.
condom, foam tablets
Begin use as soon as intercourse is resumed
Diaphragm
Diaphragm can be fitted immediately after first trimester
abortion; after second trimester fitting should be delayed for
six weeks until involution is complete.
Fertility awareness
methods
Could be started once there is no infection related secretions
or bleeding due to injury to the genital tract. Calendar based
methods are not reliable until after the first postabortion
menses provided the woman is not having bleeding due to
injury to the genital tract.
12
See Annex VII: Medical eligibility criteria for contraceptive use.
See Annex VI: Clinical guidelines for inserting & removing implants.
See Annex V: Clinical guidelines for giving the contraceptive injection.
28
References
Abdel-Tawab, N. et al. 2006. “Helping Egyptian women achieve optimal birth
spacing intervals through maximizing opportunities in antenatal and postpartum care”.
FRONTIERS Research Update, no. 9. Cairo, Egypt: Population Council.
Abdel-Tawab, N. et al.1999. “Counseling the husbands of postabortion patients in
Egypt: Effects on husband involvement, patient recovery, and contraceptive use”. In
Huntington and N.Piet –Pelon (Eds.) Postabortion Care : Lessons from Operations
Research. New York: Population Council.
American Academy of Pediatrics. 2005. “Breastfeeding and the Use of Human Milk”.
(1997- revised Feb 2005) Pediatrics vol. 115 No. 2, pp. 496-506.
Benson, J. ; Leonard, A ; et al. 1992. Meeting Women’s Needs for Post-abortion
Family Planning: Framing the Questions. Carrboro, NC: Ipas.
El-Zanaty, F.&Way, Ann.2006. Egypt Demographic and Health Survey 2005. Cairo,
Egypt: Ministry of Health and Population, National Population Council, El-Zanaty
and Associates and ORC Macro.
EngenderHealth. 2003. Counseling the Postabortion Client: A Training Curriculum.
New York: EngenderHealth.
Faculty of Family Planning and Reproductive Health Care. 2004. “Contraceptive
choices for breastfeeding women”. Journal of Family Planning and Reproductive
Health Care, 30(3): 181-189.
Family Health International. 2006. Postpartum IUD insertion: What do we know?.
www.fhi.org/en/RH/pubs/factsheets/IUD_PP.htm
Huntington, Dale et al. 1997. “ Postabortion Caseload in Egyptian Hospitals: A
descriptive study”. International Family Planning Perspectives, 24(1): 25-31.
International Lactation Consultant Association. 2005. Clinical guidelines for the
establishment of exclusive breastfeeding. Raleigh (NC): International Lactation
Consultant Association (ILCA).
LINKAGES Project. 2001. Lactational Amenorrhea Method (LAM): Frequently
Asked Questions (FAQ). FAQ sheet 3. Washington, DC: Academy for Educational
Development.
Michigan Quality Improvement Consortium. 2006. Routine prenatal and postnatal
care. Southfield (MI): Michigan Quality Improvement Consortium.
Ministry of Health and Population & TAHSEEN/Catalyst Project.2005. Postabortion
Care Training Course for District and General Hospitals: Trainees Guide. Cairo:
Ministry of Health and Population.
Ministry of Health and Population & TAHSEEN/Catalyst Project.2005. Standards of
Practice For Integrated Maternal And Child Health And Reproductive Health
Services. Cairo: Ministry of Health and Population.
29
National Collaborating Centre for Primary Care . 2006 Jul. Postnatal care. Routine
postnatal care of women and their babies. London (England): Royal College of
General Practitioners .
Palada VA, Guise JM, Wathen CN. 2004 Mar 16. “Interventions to promote breastfeeding: Applying the evidence in clinical practice”. CMAJ. 170(6):976-8.
Postabortion Care Consortium Community Task Force. 2002. Essential Elements of
Postabortion Care: An Expanded and Updated Model. Postabortion Care Consortium.
Regional Center for Training in Family Planning and Reproductive Health. 2004.
Postpartum Care Handbook for Primary Health Care Physicans and Nurses. Cairo:
Regional Center for Training.
Registered Nurses Association of Ontario (RNAO). 2003. Breastfeeding Best Practice
Guidelines For Nurses. Toronto (ON): Registered Nurses Association of Ontario
(RNAO).
Salter, C.Johnston, H.B & Hengen, N. 1997. Care for Postabortion Complications:
Saving Women’s lives. Population Reports, Series L, No.10 Baltimore, Johns Hopkins
School of Public Health Population Information Program.
Setty, V. 2006. Better Breastfeeding, Healthier Lives. Population Reports, Series L,
No.14. Balimore, Johns Hopkins Bloomberg School of Public Health, The INFO
Project.
Singapore Ministry of Health. 2002. Management of breastfeeding for healthy fullterm infants. Singapore: Singapore Ministry of Health.
Solter, C., Miller,S. & Guitierrez, M. 2000. MVA for Treatment of Incomplete
Abortion. Water Town(MA): Pathfinder International.
Turner, K., T. McInerney and J. Herrick. 2004. Woman-centered Postabortion Care:
Trainer's Manual. Chapel Hill, NC: Ipas.
World Health Organization Department of Reproductive Health and Research
(WHO/RHR) and Johns Hopkins Bloomberg School of public Health/Center for
Communication Programs (CCP), INFO Project. 2007. Family Planning: A Global
Handbook for Providers. Baltimore and Geneva: CCP and WHO.
World Health Organization. 2005. Selected Practice Recommendations For
Contraceptive Use - Second edition. Geneva: WHO.
World Health Organization. 2004. Medical Eligibility Criteria For Contraceptive
Use, Third edition. Geneva: WHO.
World Health Organization. 2004. Unsafe Abortion Global And Regional Estimates
Of The Incidence Of Unsafe Abortion And Associated Mortality In 2003. Geneva:
WHO.
World Health Organization. 1998. Postpartum Care Of The Mother And Newborn: A
Practical Guide. Geneva: WHO.
30
Annexes
Annex I - The World Health Organization classification of
practices in postpartum care according to usefulness,
effectiveness and harmfulness
This annex classifies a number of practices common in postpartum care into four
categories, dependent on their usefulness, effectiveness and harmfulness.
CATEGORY A:
Practices which are demonstrably useful and should be encouraged






















Careful supervision of urine production of the woman 8-12 hours postpartum.
Regular inspection of the perineum during the first week postpartum.
Strict hygienic measures in the care of infants and mothers by all caregivers.
Rooming-in throughout the hospital stay of mother and baby, also at night.
Psychosocial support of caregivers for postpartum women/couples.
Distinguishing healthy low birth weight infants from those at risk.
(Daily) observation of the infant during the first week of life
Strict hygiene in the care of the umbilical cord and the cord stump.
Measures to prevent hypothermia of the baby, immediately after birth.
Eye prophylaxis with silver nitrate or tetracycline ointment in all those
situations where close daily observation of the infant cannot be guaranteed.
Persons with a herpetic lesion on the lip or genitals should avoid contact with
newborn infants, or take the utmost hygienic measures.
Early skin-to-skin contact of mother and baby, within 1 hour of birth, and
early suckling of the baby.
Support of the mother in the correct positioning of the baby at the breast.
Encouraging breastfeeding on demand.
Informing all pregnant and postpartum women about the benefits and
management of breastfeeding.
Informing all pregnant and postpartum women about all contraceptive choices
in the postpartum period.
Reinforcing that non-hormonal methods (LAM, barrier methods and IUDs) are
the best options for lactating mothers.
Initiating progestogen-only methods after 6 weeks postpartum to breastfeeding
women, if this is the woman's choice.
Advising against the use of combined oral contraceptives in breastfeeding
women in the first 6 months after birth, or until weaning, whichever comes
first.
Introduction of an IUD either in the immediate (<2 days) postpartum or after
4-6 weeks, if this is the method chosen.
Advising mothers who are carriers of HIV not to breastfeed their babies, but
only if they can ensure the baby uninterrupted access to nutritionally adequate
breast milk substitutes that are safely prepared.
Measures should be taken to protect the caregiver against contact with
contaminated blood, by safe handling and disposal of sharp instruments, and
by protective clothing where appropriate.
31











BCG immunization of all infants as soon after birth as possible, in populations
at high risk of tuberculosis infection.
Tetanus vaccination of pregnant women in countries where most women of
childbearing age have not been immunized with tetanus toxoid.
Vaccination against poliomyelitis and against hepatitis B soon after birth.
Vaccination against diphtheria, pertussis and tetanus (DPT) to begin 6 weeks
after birth.
Rh-prophylaxis in Rh-negative women who gave birth to a Rh-positive infant.
Rubella vaccination postpartum in women known to be rubella negative.
Supplementation of pregnant women with protein and energy, especially
during the third trimester, and of lactating women, if the woman herself
suffers from malnutrition or if the population of the region has a high
prevalence of malnutrition.
Giving lactating mothers 200 000 IU of vitamin A orally (in capsules) in
endemically vitamin A deficient regions where fortification of food products is
not feasible, but only once, in the first month after delivery.
Measuring the hemoglobin of the woman in the first week after delivery and 6
weeks after delivery, and prescription of iron if necessary. Alternative:
prescription of iron to all postpartum women.
Daily assessment of the condition of mother and baby in the first week
postpartum.
Combined advice on breastfeeding and contraception in the first week
postpartum, and integrated counseling on both subjects in the first months.
CATEGORY B:
Practices which are clearly harmful or ineffective and should be eliminated













Routine use of oral ergometrine for newly-delivered women.
"Rooming-out" system of baby care in a hospital or maternity clinic.
Hormonal treatment of postpartum depression.
Phototherapy for neonatal jaundice in healthy term infants on the third or later
days after birth, for bilirubin values <300 mol/l.
Restricted mother-infant contact after birth.
Providing breastfed infants bottle supplements with water, glucose or formula
while breastfeeding is becoming established.
Limiting suckling time to 10 minutes on each breast or any other arbitrary
period.
Restricting the frequency of breastfeeds to once in 3 hours, or to any other
arbitrary period.
Giving free formula samples, bottles and teats to breastfeeding women.
Giving artificial teats and pacifiers to breastfed infants.
Lactation inhibition by estrogens or bromocriptine.
Prescription of hormonal contraceptives during the first 6 weeks postpartum to
breastfeeding mothers.
Separate counseling of the woman on breastfeeding and on contraception.
32
CATEGORY C:
Practices for which insufficient evidence exists to support a clear
recommendation and which should be used with caution while further research
clarifies the issue


Antibiotics in the early phase of puerperal mastitis.
Routine administration of vitamin K to all healthy newborns or to all
newborns that will be breastfed.
CATEGORY D:
Practices which are frequently used inappropriately





(Routine) use of ergometrine for newly delivered women.
Introduction of milk supplements to breastfed infants.
Prescription of combined oral contraceptives to breastfeeding women from 6
weeks to 6 months postpartum.
Sterilization postpartum in women who have not been adequately counseled
beforehand.
HIV testing without pretest counseling and without informed consent.
33
Annex II: Clinical guidelines for the establishment of
exclusive breastfeeding
The health care provider can significantly influence a mother's decision to breast-feed.
Prenatal support, hospital management and subsequent pediatric and maternal visits
are all-important components of breast-feeding promotion.
Prenatal encouragement increases breast-feeding rates and identifies potential
problem areas.
Effective breastfeeding practices should be taught to pregnant mothers during
antenatal care.
Management Strategies
1.
Facilitate breastfeeding within the first hour after birth and provide for
continuous skin-to-skin contact between mother and infant until after the first
feeding.
2.
Avoid routine procedures (uterine massage, counseling for postpartum
contraception) until after the first breast feeding.
3.
Assist the mother in achieving a comfortable position and effective latch
(attachment).
4.
Avoid giving the newborn any fluids besides colostrum or breast milk. Harmful
practices common in health care facilities include giving dextrose solution, sugarwater, caraway, fenugreek (helba) or other herbal fluids to the newborn.
5.
Observe for signs of effective positioning:
 Infant well supported and placed at the level of the mother's breast
6.
Observe infants for signs of effective latch:
 Wide opened mouth
 Flared lips (Curled outwards)
 Chin touching the breast
 Asymmetric latch (more areola visible above the baby's mouth)
7.
Observe infant for signs of milk transfer:
 Sustained rhythmic suckle/swallow/breathe pattern with periodic
pauses
 Audible swallowing
 Relaxed arms and hands
 Moist mouth
8.
Observe mother for signs of milk transfer:
 Breast softening while feeding
 Relaxation or drowsiness
 Thirst
 Uterine contractions during or after feeding
 Milk may leak from the opposite breast while feeding
 Nipple elongated but not pinched or abraded after feeding
34
9.
Keep the mother and newborn together during the entire postpartum stay.
 Conduct examinations and routine tests of the infant while the infant is
in the mother's room, in the mother's arms, or on the breast.
10. Teach mothers to recognize and respond to early infant feeding signals and
confirm that the baby is being fed on DEMAND, at least 8 times in each 24 hours
with a minimum of one night feed.
Early infant signals include:
 Sucking movements
 Sucking sounds
 Hand-to-mouth movements
 Rapid eye movements
 Soft cooing or sighing sounds
 Restlessness
Remember: Crying is a late feeding
interfere with effective breastfeeding.
signal
and
may
11. Confirm that the mother understands the physiology of milk production.
To facilitate milk production:

Breastfeed when the infant exhibits early feeding signals
(approximately every 1 to 3 hours).

Breastfeed on the first breast until the infant seems satisfied
(on average 15 to 20 minutes) before offering the second
breast.

Next time start with the other breast.
Note: Some infants are satisfied with one breast, while others
will breastfeed on both breasts at every feeding.
12. Confirm that mothers know how to wake a sleepy infant.
 Wake when early feeding signals are exhibited or at least 8 times in
each 24 hours.
Strategies to wake the infant include:

Remove any blankets.

Change the infant's diaper.

Place the infant skin-to-skin.

Massage the infant's back, abdomen, arms, and legs.
13. Avoid using pacifiers, artificial nipples, and supplements, unless medically
indicated. It is extremely important to avoid using a sugary solution (Dextrose
35
solution) as it causes gaseous distension to the newborn and interferes with
physiologic processes enhancing normal breast feeding.
14. Document the following to assess effective latch:
 Comfort of mother
 Condition of both breasts and nipples
 Shape of nipple on release
 Signs of milk transfer
 Number of feedings
 Number of urinations
 Number and character of bowel movements
 Daily weight gain/loss
15. Assess the mother and infant for signs of effective breastfeeding and intervene if
transfer of milk is inadequate.
Signs of effective breastfeeding in the infant include:

Weight loss less than 7 percent in the first 7 days

At least 3 bowel movements in each 24 hours after day 1 (The
first 24 hours after birth is day 1)

Seedy, yellow bowel movements by day 5

At least 6 urinations a day by day 4 with urine that is clear or
pale yellow

Satisfied and content after feedings

Audible swallowing during feedings

No weight loss after day 3

Weight gain by day 5

Back to birth weight by day 10
Signs of effective breastfeeding in the mother include:

Noticeable increase in firmness, weight, and size of breasts and
noticeable increase in milk volume and composition by day 5

Nipples show no evidence of damage

Breast fullness relieved by breastfeeding
If effective breastfeeding, as indicated by milk transfer, is not observed within
the first 12 hours:




Re-evaluate breastfeeding techniques.
Initiate milk expression using manual expression or a breast pump.
If medically indicated, initiate supplementation.
Delay discharge from care until effective breastfeeding has been
observed.
36


Refer to a health care professional with breastfeeding expertise.
Coordinate care with the infant's health care provider.
16. Identify maternal and infant risk factors that may impact the mother's or infant's
ability to breastfeed effectively and provide appropriate assistance and follow-up.
Infant risk factors include but are not limited to:















Birth interventions and/or trauma
Less than 38 weeks gestation
Inconsistent ability to maintain an effective latch
Ineffective suck
Persistent sleepiness or irritability
Long intervals between feedings
Hyperbilirubinemia or hypoglycemia
Small (SGA) or large (LGA) for gestational age or intrauterine growth
restriction (IUGR)
Tight frenulum (Tongue-tie)
Multiple birth
Neuromotor deficits
Chromosomal abnormalities (e.g., Down syndrome)
Oral anomalies (e.g., cleft lip/palate)
Acute or chronic illness (e.g., cardiac disease)
Use of pacifier or artificial (bottle) nipple
Maternal risk factors include but are not limited to:













Previous breastfeeding difficulty
Birth interventions
Separation from infant
Absence of prenatal breast changes
Damaged, cracked, or bleeding nipples
Unrelieved fullness or engorgement
Persistent breast pain
Mother's perception of insufficient milk
Acute or chronic disease
Medication use
Breast or nipple abnormality
Breast surgery or trauma
Hormonal disorders (e.g., polycystic ovarian syndrome)
17. Identify any maternal and infant contraindications to breastfeeding.
37
Maternal contraindications include:








Human immunodeficiency virus (HIV) seropositivity (provided
affordable, acceptable, safe, sufficient, sustainable, and feasible
quantities of human milk substitutes are available)
Human T-cell Leukemia Virus-1 (HTLV-1) seropositivity
Substance (drug) abuse
Chemotherapy
Radioactive isotope therapy (interrupt breastfeeding only until the
isotope has been eliminated from the mother's body)
Active tuberculosis (if only the mother is infected, isolate the mother
until treatment is initiated and the mother is no longer contagious; the
mother's expressed milk can be fed to her infant; if mother and infant
are infected, isolate them together)
Active varicella (if maternal rash develops within 5 days prior to birth
or 2 days after birth, isolate the mother until she is no longer
contagious; expressed milk can be fed to her infant; if both mother and
infant are infected, isolate them together)
Active herpes lesion(s) on breast (breastfeed on unaffected breast or
interrupt breastfeeding only until lesion[s] heal)
Infant contraindications include:

Galactosemia
Some conditions incorrectly identified as contraindications to
breastfeeding:

Maternal fever in the absence of a contraindication listed
above

Hepatitis B or C infection

Exposure to low-level environmental contaminants

Alcohol use (advise mothers to limit intake to an occasional
drink)

Tobacco use (advise mothers to stop smoking or if unable
to stop make every effort to avoid exposing infant to
second-hand smoke)

Cytomegalovirus (CMV) infection

Newborn illness such as gastroenteritis and chest
infections.
18. If medically indicated, provide additional nutrition using a method of
supplementation that is least likely to compromise the transition to exclusive
breastfeeding.
38
Guidelines for milk supplementation:





Use mother's own milk first.
Pasteurize the mother's milk if she is HIV positive14.
Breast milk substitute (formula) is the last choice.
Reassure mother that her infant will benefit from any amount of her
milk provided.
The selection of a human milk substitute should take into account any
family history of allergic disease.
19. Provide appropriate breastfeeding education materials.
20. Support exclusive breastfeeding during any illness or hospitalization of the
mother or the infant.
21. Comply with the International Code of Marketing of Breast-milk Substitutes and
subsequent World Health Assembly resolutions, and avoid distribution of infant
feeding product samples and advertisements for such products.
22. Include family members or significant others in breastfeeding education.
23. Teach mother about common problems that could interfere with exclusive breast
feeding
Management of common problems that can interfere with exclusive
breastfeeding.
Nipple pain:
 Many mothers report mild discomfort at the beginning of a feeding
when the infant latches onto the breast.
 All pain should be evaluated.
 Pain is often the result of ineffective positioning and latch.
 Consider other causes such as bacterial or fungal infection.
Engorgement (as opposed to normal fullness):





Normal fullness is relieved with frequent, effective breastfeeding.
Engorgement occurs in some mothers approximately 3 to 5 days after
birth (breasts can be painful and swollen).
Unrelieved swelling (engorgement) requires treatment.
Focus treatment on measures to reduce swelling and relieve pain,
including breast massage, hand expression or pumping, intermittent
compression (reverse pressure softening), application of cold and antiinflammatory medication.
Avoid the use of warm compresses on the breast unless the breasts are
leaking freely.
14
A simple and inexpensive home pasteurization method, involves boiling a pan of water,
removing it from the heat source, immediately placing a covered jar of breast milk in the water
and leaving it there for 20 minutes(Setty, 2006)
39
Perceived insufficient milk supply:





A mother may think that she has insufficient milk because her breasts
are soft after birth.
Milk volume increases within several days and is usually accompanied
by breast fullness.
In the second week of life, initial breast fullness decreases but this does
not signal a decrease in milk production.
Infants have recurring growth or appetite spurts, during which more
frequent feedings increase milk production and thus caloric intake.
If a fussy infant is having normal output and is gaining weight, low
milk supply is not the cause of fussiness.
Infant crying:


No crying should go unattended.
Crying may be a sign of hunger or a sign of distress - if the infant is
not exhibiting feeding signals, parents can try other comfort measures
before offering the breast.
Maternal diet:


Dietary restrictions are seldom necessary; few infants are affected by
foods eaten by the mother
The mother should eat a variety of foods and drink to satisfy thirst.
24. Confirm that mothers understand normal breastfed newborn/infant behaviors and
have realistic expectations regarding infant care and breastfeeding.
Frequency and duration of feedings:

It is important to allow breastfeeding on demand ( 8 to 12 feedings in
each 24 hours is typical); however, feeding frequency can vary.

Some infants will cluster-feed (feed every hour for 2 to 6 times and
then sleep for a longer period) and others will breastfeed every 2 to 3
hours day and night.

On average, infants will feed 15 to 20 minutes on each breast at a
feeding; some will feed longer and some are satisfied with only one
breast.

Sleepy infants need to be awakened for feedings until an appropriate
weight gain pattern is established.
Infant output:



At least 3 bowel movements each day with age appropriate color
changes (first bowel movement typically occurs within 8 hours of birth)
At least 6 urinations each 24 hours by day 4 with urine that is clear or
pale yellow (first urination typically occurs within 8 hours of birth)
Bowel movements change from black and sticky to yellow, soft, and
watery by day 4.
40
Infant weight loss/gain



Expect less than 7 percent weight loss the first week.
Expect return to birth weight by 10 days of age.
Expect weight gain of approximately 20 to 35 grams each day for the
first 3 months.
Breastfeeding and Maternal Medications
Breastfeeding contraindicated
Anticancer drugs (antimetabolites);
Radioactive substances (stop breastfeeding temporarily)
Continue breastfeeding
Side-effects possible, monitor baby for drowsiness.
Selected psychiatric drugs and anticonvulsants (see individual drug)
Use alternative drug if possible and Monitor baby for jaundice.
Chloramphenicol, tetracyclines, metronidazole, quinolone antibiotics (e.g.
ciprofloxacin) Sulfonamides, dapsone, sulfamethoxazole+trimethoprim
(cotrimoxazole) sulfadoxine+pyrimethamine (fansidar)
Use alternative drug (may inhibit lactation)
Estrogens, including estrogen-containing contraceptives, thiazide diuretics,
ergometrine
Safe in usual dosage but keep Monitoring baby
 Analgesics and antipyretics: short courses of paracetamol, acetylsalicylic acid,
ibuprofen.
 Occasional doses of morphine and pethidine.
 Antibiotics: ampicillin, amoxicillin, cloxacillin and other penicillins,
erythromycin.
 Antituberculosis drugs, anti-leprosy drugs (see dapsone above).
 Antimalarials (except mefloquine, Fansidar).
 Anthelminthics, antifungals.
 Bronchodilators (e.g. salbutamol), corticosteroids
 Antihistamines
 Antacids.
 Drugs for diabetes.
 Most antihypertensives.
 Digoxin
 Nutritional supplements of iodine, iron, vitamins.
41
Annex III: Clinical guidelines for Lactational Amenorrhea
Method (LAM)
Counseling
What is the Method?
Lactational amenorrhea method (LAM) is the use of breastfeeding as a way to prevent
pregnancy.
How does it work?
Stimulation of nipples by suckling releases a hormone (prolactin) that prevents the
release of an ovum from the ovary.
Expressing breast milk may not be as effective as suckling at the breast in suppressing
ovulation, and for this reason a woman who expresses her milk may not be able to
rely on LAM.
How effective is it?
When used correctly it can prevent pregnancy in over 98% of cases.
How is it used?

There are three important conditions for LAM to be effective, all three
conditions must be met:
- Breastfeeding should be practiced exclusively (no other liquid or food,
e.g. water, anise or caraway ) and on demand day and night (feeds should
be no more than 4 hours apart during the day and no more than 6 hours
apart during the night).
- Menstruation has not returned (menstruation is defined as any two
consecutive days of bleeding “even drops” after two months post partum).
- The baby is less than six months of age.
Note: if breastfeeding is supplemented by other feeding,
menstruation has occurred or the baby is older than six months, LAM
is no longer reliable for prevention of pregnancy and a proper method
should be used after consulting with the doctor.
Advantages



An effective method (provided the three requisites are present) that can be
used immediately after childbirth.
Breastfeeding is good for the baby and the mother.
Cheap.
Disadvantages


It may be difficult for some women to maintain the required breastfeeding
pattern.
Can only be used for the first six months after delivery.
42
Possible side effects
 None
Transition to another contraceptive method




Encouraging the mother to visit a family planning clinic as soon as possible,
preferably within the 40 days after delivery to discuss with the service
provider if she is the right candidate for LAM use.
A woman can switch to another method any time she wants while
using LAM as long as she is properly screened and meets the eligibility
criteria.
To continue preventing pregnancy, a woman must switch to another
method as soon as one of the 3 LAM criteria no longer applies i.e.
menses returned or baby is older than six months or not exclusively
breastfed.
The provider should help the woman choose a new method before she
needs it. If she will continue to breastfeed, she can choose from several
hormonal or non hormonal methods, depending on how much time has
passed since childbirth.
WHO Medical Eligibility Criteria for Using LAM
All breastfeeding women can safely use LAM, but a woman in the following
circumstances may want to consider other contraceptive methods:
 Women having HIV infection provided that affordable and safe
alternatives to breastfeeding are available.
 Women using certain medications during breastfeeding (including
ergotamine, mood altering drugs, reserpine, anti-metabolites,
cyclosporine, high doses of corticosteroids, bromocriptine, radioactive
drugs, lithium and certain anticoagulants ).
 The newborn has a condition that makes it difficult to breastfeed
(including being small for date, or premature and needing intensive
neonatal care, unable to digest food normally, or having deformities of
the mouth, jaw, or palate).
Clinical and technical procedures
There are no clinical or technical elements to note when recommending breastfeeding
as a contraceptive method. However this method presents a counseling challenge to
the provider.
 Using the approved medical record, take the client’s medical history.
- Specifically ask the client three questions:
o Are you exclusively breastfeeding (i.e. no other fluids/or food, breast
feeding on demand, day and night)?
o Is the baby less than six months?
o Are you still not menstruating (i.e. no two consecutive days of
bleeding/ spotting after the second month postpartum)?
- If the answer to all three questions is “Yes”, LAM is an
appropriate method of contraception. If the answer to any
question is “No”, the client needs to use another
contraceptive method.
43

Perform a physical examination that includes but is not limited to:
- Examining the nipple, especially for retraction and fissures.
- Giving breast self examination instructions.

Encourage the mother to establish exclusive breastfeeding through:
- Initiating breastfeeding within the first hour after birth.
- Do not give any fluids like water, anise, caraway, etc. beside breast milk.
- Ensure good positioning and proper attachment.
- Teach the mother to recognize and respond to early infant feeding signals.
- Confirm that the mother knows how to wake a sleepy infant.
- Avoid using pacifiers, artificial nipples, and supplements unless medically
indicated.
- Support exclusive breastfeeding during any illness or hospitalization of the
mother or the infant.
Follow-up procedure







The client should be seen for the routine six-week postpartum visit (preferably
before the 40th day post partum).
Encourage the client to come when she no longer breastfeeds fully, or starts
menstruating or if the baby is six months old.
It is possible to become pregnant while breastfeeding. If symptoms of
pregnancy occur, the client should return for evaluation.
The client must have a back up method available if one of the conditions asked
about in the three questions outlined above changes.
Encourage the client to return to the family planning clinic at any time if she
has any concern or any problem, e.g. (problems with breast feeding, or she
wants another method, or she thinks she might be pregnant).
Document visits and findings in medical record and woman’s health card.
Remember: women who are using LAM should be advised to go to a family
planning clinic before the end of the six month period in order to receive
another family planning method.
44
Annex IV: Clinical guidelines for postpartum IUD insertion
Screening women for postpartum IUD
Postpartum IUD insertion is not appropriate for women with the
following:







An active STD or are at risk for STDs
A history of recent or recurrent pelvic inflammatory disease (PID), indicating
risk of exposure to STDs
Known or strongly suspected cancer of the uterus.
Prolonged rupture of membranes (greater than 24 hours)
Fever or any other signs of abdominal or pelvic infection
Intrapartum or postpartum hemorrhage that continues after completely
emptying the uterus
Bleeding problems, such as disseminated intravascular coagulation caused by
eclampsia or preeclampsia
PPIUDs are not the method of first choice for women who:




Have severe anemia (hemoglobin less than 9, hematocrit less than 28).
Have an abnormal Pap smear for which treatment is imminent or other signs
of genital cancer.
Have conditions that increase the risk of infection, such as HIV/AIDS or
poorly controlled diabetes. However, women with HIV/AIDS who are under
retroviral therapy and controlled diabetic women may have an IUD
Do not have access to a health facility for follow-up care.
Counseling for postpartum IUD
 Women who choose to have an immediate post-placental IUD for contraception,
should have a special referral card indicating that they had been counseled during
antenatal care and that they have requested a PPIUD.
 The provider should still obtain the woman’s informed consent before
postplacental IUD insertion even if she has a card indicating that she had been
counseled during antenatal care and that she wants an IUD inserted immediately
after delivery.
 Women who were not counseled during antenatal care are not good candidates for
having a post-placental IUD insertion but they could have a Post partum before
discharge IUD insertion if they receive proper counseling after delivery. It is
preferable to include husbands in the counseling for PPBD IUD insertion, as their
support is crucial for family planning acceptance and continuation.
 Women who will have a post partum before discharge IUD insertion (PPBD),
should be counseled after delivery and after they had begun breast feeding their
newborn. Women with health risks during the immediate postpartum period are
not good candidates for counseling for PPBD.
45
 Counseling should not be attempted during any phase of labor, even women in
latent phase of labor should not be counseled for contraception. Focus should be
on maternal and fetal wellbeing during labor.
 Specific counseling points before having a PPIUD:
o Ask the woman what she already knows about IUDs.
o Tell her what kind of IUD she will receive. Show her either a sample or
picture of the IUD so that she can see how it looks and how large it is.
o Explain that the copper T IUD will prevent pregnancy for up to 10 years.
o Assure her that the IUD has no effect on breast milk.
o Tell her that she may resume sexual intercourse as soon as bleeding and
discharge stop and when all abrasions, wounds and incisions have healed.
o Explain that within a few weeks, the IUD strings will probably be felt in the
vagina.
o Tell her that the doctor will shorten the strings during the follow-up visit if
they are troublesome.
o Discuss with the woman the possibility that the IUD may be expelled,
especially during the first few weeks or months after insertion. Early followup may identify spontaneously expulsion.
o Instruct the client that she may find the IUD if it is expelled. She should then
come immediately to the hospital FP clinic or the nearest FP clinic to her
residence for insertion of another IUD.
o Explain to the woman that if the IUD is expelled during her postpartum
hospital stay, a second insertion can be done while she is in the hospital,
provided the woman is willing and that 48 hours have not passed since
delivery. Otherwise, the IUD can be replaced at the 4 - 6 week postpartum
visit, or later.
 Checking for the IUD strings. Tell the woman that after 6 weeks postpartum she
should:
o Wash her hands, using soap if possible. This helps to reduce the chance of
infection.
o Sit in a squatting position, or stand with one foot up on a step or ledge.
o Gently insert her finger into her vagina and feel for the cervix, which feels
firm, like the tip of the nose.
o Feel for the strings, but do not pull the strings as that could move the IUD or
cause it to come out.
o Tell the woman that she should do this at least once a month, after her
menstrual period, but should not check for the strings until after six weeks
postpartum.
 Explain the troublesome symptoms of IUDs:
o Tell the client that once menstruation returns, she may experience more
cramping and heavier bleeding during her periods, longer periods, or spotting
or bleeding between periods.
o These side effects usually go away after a few months of IUD use.
46
Equipment and supplies
Postpartum family planning services require minimal additional equipment and
supplies. One of the major advantages of postpartum family planning services is that
they do not require a separate clinical infrastructure or staff.
Once postpartum family planning education and services become a routine part of the
activities conducted at a maternity care center, they are easily sustainable and
institutionalized.
Post-placental insertion and insertion at cesarean section are done in the delivery area,
a clean procedure or examination room is needed, with an exam table and adequate
light.
Table (4): Instruments and supplies needed for PPIUD insertion
Manual
Forceps
Cesarean Section
Gloves
Gloves
Gloves
Sterile IUD
Sterile IUD
Sterile IUD
Antiseptic solutions and Gauze
Antiseptic solutions and
Gauze
Speculum or retractor
Speculum or retractor
Optional: one ring forceps
Two ring forceps / Kelly’s
forceps
Insertion techniques
(A) Manual
The manual method of insertion is appropriate when performed within ten minutes
of expulsion of the placenta. Manual insertion requires no special instruments, but
may be less comfortable for the client than insertion with ring forceps.
The steps are as follows:
 After determining that the entire placenta has been expelled, massage the
uterus until it becomes firm and bleeding subsides.
 Examine the cervix for injury using a retractor or speculum, if necessary.
 Wearing sterile gloves, insert the IUD by gripping it between the index and
middle fingers. Place the IUD strings in the palm of the hand.
 Use the opposite hand to firmly stabilize the uterus externally (hand on
abdomen).
 Place the IUD at the top (fundus) of the uterine cavity. It may be necessary
to grasp the cervix with a ring forceps to facilitate insertion.
 Gently remove the hand from the uterine cavity.
Note: Inspect the vagina. If the IUD strings are visible, the IUD is
placed too low and should be reinserted.
47
(B) Ring forceps
Post placental and PPBD (within 48 hours) IUD placement requires a long forceps
to achieve fundal placement. A 12 inch (30.6 cm) curved ring forceps without box
lock is suitable. The standard straight 9 inch (24 cm) sponge forceps is not long
enough to allow fundal placement in most women.
The insertion steps are as follows:
 Determine that the entire placenta has been expelled (if insertion is
immediately post-placental).
 Massage the uterus until it becomes firm and bleeding subsides.
 Examine the cervix for injury using a retractor or speculum, if necessary.
 Grasp the IUD with the 12 inch (30.6 cm) ring forceps, holding it at a
slight angle.
 Grasp the anterior cervix with a second ring forceps (9 inch, 24 cm).
 Hold the cervix and keep it in view while introducing the IUD through the
cervix into the lower uterus.
 Release the hand that is holding the cervix with the second ring forceps and
move it to the lower abdomen.
 Stabilize the uterus externally with firm pressure on the abdomen.
 Advance the IUD to the top (fundus) of the uterine cavity.
 Confirm fundal placement with both the abdominal hand and the ring
forceps inserting the IUD.
 After releasing the IUD, gently remove the ring forceps.
 Inspect the vagina. If the IUD strings are visible, the IUD is placed too low
and should be reinserted.
(C) Trans-cesarean section
The steps are as follows (after delivery of the placenta and after controlling the
bleeding from the uterine incision):
 Massage the uterus until bleeding subsides.
 Place the IUD at the top (fundus) of the uterine cavity manually or with
ring forceps.
 Before closing the uterine incision, place the strings in the lower uterine
segment.
 Do not try to place the strings through the cervix, as this is an unnecessary
step.
48
Post-insertion IUD instructions
It is important to give the PPIUD client clear instructions to help her use this method
safely, effectively, and with satisfaction. Instructions should be given both and in
writing.
Specific counseling points for postpartum IUD after insertion
 The first follow-up visit for PPIUD clients is usually done at a four or sixweek postpartum checkup. Thereafter, an annual pelvic exam is
recommended. The follow-up visit could be done at the hospital family
planning clinic or another FP clinic near her residence.
 The client should receive a card indicating that she had a PPIUD inserted,
the type of IUD inserted and the date of insertion.
 Emphasize that the client should go to a family planning clinic if the
strings seem to have become shorter or longer than when previously
checked or if they seem to be missing and she can no longer feel them.
 Explain the troublesome symptoms of IUDs:
o Tell the woman that she may or may not get her menses while
breastfeeding. But once menstruation returns, she may experience
more cramping and heavier bleeding during her periods, longer
periods, or spotting or bleeding between periods.
o These side effects usually go away after a few months of IUD use.
 Describe the warning sings for potential complications:
o Late period or other signs of pregnancy;
o Bleeding or spotting between periods or after intercourse;
o Unusual discharge from the vagina beyond six weeks postpartum;
o Missing, shorter, or longer strings;
o Feeling the IUD when checking for the strings, or if the IUD is
expelled.
 Tell the woman to go to the family planning clinic if a problem occurs or if
she has any problems or concerns about the IUD.
 Assure the client that she can have the IUD removed if she changes her
mind about the method. Tell her that she should not try to remove the IUD
herself.
 Give the woman written instructions. If she has difficulty reading, ask her
to identify someone in her family or neighborhood who can read the
instructions to her.
49
Annex V: Clinical Guidelines for giving the contraceptive
injection
1. Obtain one dose of
injectable, needle and
syringe
2. Wash

DMPA: 150 mg for injections into the muscle
(intramuscular injection). NET-EN: 200 mg for
injections into the muscle.

If possible, use single-dose vials. Check
expiration date. If using an open multidose vial,
check that the vial is not leaking.

DMPA: A 2 ml syringe and a 21–23 gauge
intramuscular needle.

NET-EN: A 2 or 5 ml syringe and a 19-gauge
intramuscular needle. A narrower needle
(21–23 gauge) also can be used.

For each injection use a disposable auto-disable
syringe and needle from a new, sealed package
(within expiration date and not damaged), if
available.

Wash hands with soap and water.

If injection site is dirty, wash it with soap and
water.

No need to wipe site with antiseptic.

DMPA: Gently shake the vial.

NET-EN: Shaking the vial is not necessary. In
winter or if vial is cold, it is important to warm
the vial before giving the injection.

No need to wipe top of vial with antiseptic.

Pierce top of vial with sterile needle and fill
syringe with proper dose.
3. Prepare vial
4. Fill syringe
50

Insert sterile needle deep into the hip
(ventrogluteal muscle), the upper arm (deltoid
muscle), or the buttocks (gluteal muscle, upper
outer portion), whichever the woman prefers.
Inject the contents of the syringe.

Do not massage injection site.

Do not recap, bend, or break needles before
disposal.

Place in a puncture-proof sharps container.

Do not reuse disposable syringes and needles.
They are meant to be destroyed after a single use.
Because of their shape, they are very difficult to
disinfect. Therefore, reuse might transmit
diseases such as HIV and hepatitis.

If reusable syringe and needle are used, they
must be sterilized again after each use
5. Inject formula
6. Dispose of disposable
syringes and needles safely
51
Annex VI: Clinical guidelines for inserting & removing
implants
Explaining the insertion procedure for Implanon
A woman who has chosen implants needs to know what will happen during insertion.
The following description can help explain the procedure to her. Learning to insert
and remove implants requires training and practice under direct supervision.
Therefore, this description provides a summary and not detailed instructions.
Inserting implants usually takes only a few minutes but can sometimes take longer,
depending on the skill of the provider. Related complications are rare and also depend
on the skill of the provider. (Implanon is inserted with a specially made applicator
similar to a syringe. It does not require an incision.)
2. The woman receives an injection of
local anesthetic under the skin of her arm
to prevent pain while the implants are
being inserted. This injection may sting.
She stays fully awake throughout the
procedure.
1. The provider uses proper infectionprevention procedures.
4. The provider inserts the implants just
under the skin. The woman may feel
some pressure or tugging
3. The provider makes a small incision
in the skin on the inside of the upper
arm.
5. After all implants are inserted, the provider closes
the incision with an adhesive bandage. Stitches are
not needed. The incision is covered with a dry cloth
and the arm is wrapped with gauze.
52
Removal of implants
IMPORTANT: Providers must not refuse or delay when a woman asks to have her
implants removed, whatever her reason, whether it is personal or medical. All staff
must understand and agree that the woman must not be pressured or forced to
continue using implants.
Explaining the removal procedure
A woman needs to know what will happen during removal. The following description
can help explain the procedure to her. The same removal procedure is used for all
types of implants.
1. The provider uses proper infection-prevention procedures.
2. The woman receives an injection of local anesthetic under the skin of her arm to
prevent pain during implant removal. This injection may sting. She stays fully
awake throughout the procedure.
3. The health care provider makes a small incision in the skin on
the inside of the upper arm, near the site of insertion.
4. The provider uses an instrument to pull out each implant. A
woman may feel tugging, slight pain, or soreness during the
procedure and for a few days after.
5. The provider closes the incision with an adhesive bandage. Stitches are not needed.
An elastic bandage may be placed over the adhesive bandage to apply gentle
pressure for 2 or 3 days and keep down swelling.
If a woman wants new implants, they are placed above or below the site of the
previous implants or in the other arm.
53
Annex VII
54
55
56
57
58
59
60
61
62
63
64
The Population Council conducts research
worldwide to improve policies, programs, and
products in three areas: HIV and AIDs; poverty,
gender, and youth; and reproductive health.
The Frontiers in Reproductive Health Program
(FRONTIERS) applies systematic research
techniques to improve delivery of family planning
and reproductive health services and influence
related policies. FRONTIERS is funded by the
U.S. Agency for International Development
(USAID) and led by the Population Council in
collaboration with Family Health International
Photos on cover page courtesy of:
TAKAMOL / Pathfinder Project
Communication for Health Living Project (CHL)
Those guidelines are made possible by the generous support of the American people
through the United States Agency for International Development (USAID) under the
terms of Cooperative Agreement No. HRN-A-00-98-00012-00.
The contents are the responsibility of the FRONTIERS Program and do not necessarily
reflect the views of USAID or the United States Government.
FOR MORE INFORMATION, PLEASE CONTACT:
FRONTIERS IN REPRODUCTIVE HEALTH PROGRAM
59 Misr-Helwan Agricultural Road, Maadi, Cairo
Tel.: 2 02 2525 5965 / 7 / 8 , Fax: 2 02 525 5962
e-mail: frontiers@pccairo.org, website: www.popcouncil.org/frontiers