Your contraceptive needs often change when you have a child. You may now feel your family is complete, or you simply may want to postpone your next pregnancy because you do not want to have children too close together.
Furthermore, if you wish to breastfeed, you need to know what birth control choices are appropriate and what influence contraceptives might have on the quality and quantity of breast milk. If you want a reliable contraceptive, there are methods that are both effective and compatible with breastfeeding. Most of all, you should be aware that exclusive breastfeeding can be very effective birth control in itself.
Breastfeeding, or lactation, delays your body's return to its usual cycle of ovulation. This also means you do not menstruate, because your uterus does not prepare for a fertilized egg. Mothers who do not nurse generally resume ovulation (and menstruation) within the first 3 months after their delivery. For mothers who do breastfeed, however, ovulation can be delayed for many months, sometimes as long as a year, depending on how often they nurse their babies. In the United States, the average delay in ovulation seldom lasts more than 6 months, because most mothers begin giving supplemental feedings, such as juice or cereal, by that time.
USING THE LACTATIONAL AMENORRHEA METHOD FOR BIRTH CONTROL
The absence of menstruation because of breastfeeding is called lactational amenorrhea. When used deliberately to prevent pregnancy, it is referred to as the lactational amenorrhea method (LAM). LAM can be continued for some months after a birth and used as a natural—and very effective—method of contraception. If you only breastfeed your baby, have no signs of menstruation, and have not passed the six-month postpartum mark, your risk of pregnancy while relying on lactational amenorrhea is less than 2 percent.
LAM can be maintained by following simple rules:
1. The intervals between nursing should not be longer than 4 hours. Working women who want to use LAM for birth control will need to pump their breasts at least every 4 hours while away from their babies.
2. Most of the baby's nutrition should come from breastfeeding. There should be little or no other foods or liquids given.
3. Six months should not have passed since your baby was born. (Using LAM beyond 6 months currently is not recommended.)
4. You have had no vaginal bleeding since the first month after your child was born.
How long menstruation is delayed depends a great deal on how completely you breastfeed. As long as your baby is suckling at least every 4 hours, ovulation usually will be suppressed. Either suckling or the stimulation of the nipple while using the breast pump inhibits the production of the hormone that is necessary for the ovaries to function. Without it, there is no ovulation and no menstrual cycle.
When you begin to supplement your infant's diet with other foods or liquids, nursing will become less frequent, and ovulation will soon get under way. Any vaginal bleeding (beyond the first 4 weeks following childbirth) means lactational amenorrhea has ended, and you need another contraceptive. Many women begin using birth control as soon as they start giving supplemental foods, before they actually have any bleeding—because there is a risk that a fertile first ovulation will occur before any sign of menstruation.
It is a good idea to begin thinking about contraceptive methods before you actually need to use something. Since many couples resume sexual intercourse within weeks after childbirth, a woman who is not nursing or is only partially nursing should use birth control. If you are fully nursing, you will not need a contraceptive, but you should start planning which method will be best when you are no longer using LAM.
Although some women return to the birth control method they were using before they became pregnant, many others decide they need a more effective method or one more compatible with nursing. Many methods can be used safely when you have just given birth or are breastfeeding, but some are better than others.
Condoms pose no risk to either mother or child and offer protection against disease. Because a nursing mother's vagina is drier than normal, the use of a lubricated condom, a condom plus a spermicide, or a female condom will make this method more comfortable.
IN A NUTSHELL
BREASTFEEDING AND CONTRACEPTION
Breastfeeding can protect a woman against pregnancy for about 6 months after childbirth, if the baby is given no other food or milk and nurses often.
When you start giving your baby other food or milk, or if your periods begin, you must use birth control right away if you want to avoid another pregnancy.
If you want to use a contraceptive method while breastfeeding, some birth control methods are better than others. Good methods to use are condoms, diaphragms, the cervical cap, the IUD, and spermicides. If you have been using a diaphragm or cervical cap, you need to be refitted. The shape and size of your vagina and cervix may have changed.
Combined birth control pills are not recommended because the estrogen in the pills will decrease your milk supply. POPs may be used if you prefer pills to the methods above.
Whether or not you are breastfeeding, it is necessary to wait until the uterus has returned to its normal size and place and the cervix has closed before you are fitted for a diaphragm or cervical cap. If you have used either of these previously, you will need to be refitted, because the shape and size of your cervix and upper vagina may have changed.
Spermicides have not been shown to have an effect on breastfeeding, even though extremely small amounts of nonoxynol-9 may be absorbed into your bloodstream. Since vaginal dryness is common during nursing, some women find that spermicides, used alone or with a barrier contraceptive, make intercourse more comfortable.
IUDs are very suitable for nursing women, because they are convenient, effective, and safe. Neither the progesterone released from the Progestasert nor the copper of the ParaGard affects breast milk or the baby. The risk of the IUD being expelled by the uterus is reduced if it is inserted after the uterus has returned to normal size, about 6 weeks after the birth. There seems to be less discomfort when IUD insertion takes place during the breastfeeding months.
WHAT IS EXCLUSIVE BREASTFEEDING?
If you wish to use breastfeeding as a means of birth control, you must be nursing exclusively or almost exclusively, which is:
• nursing frequently, whenever the baby is hungry, both day and night;
• not offering the baby a bottle, pacifier, or other nipple substitute; and
• not supplementing breast milk with other sources of nourishment, such as juice or cow's milk.
When any of these criteria is not being met, it means that you are no longer exclusively (or almost exclusively) breastfeeding, and you cannot rely on LAM for birth control. When you start to give your baby other foods, or have to stop nursing for some reason (and do not want another child right away) you will need to start using some other form of contraception. Furthermore, any vaginal bleeding after the first month postpartum is also an indication that you should begin to use another method.
If you want this baby to be your last child, and have arranged to have a tubal occlusion immediately after you give birth, a local anesthetic is recommended because it is much less disruptive to breastfeeding than general anesthesia. A local anesthetic is preferred at this time because general anesthesia and any heavy sedation are associated with reduced milk production for as long as 2 weeks. Anesthetic drugs show up in the breast milk and appear to interfere with the establishment of a good sucking response, which can cause problems with breastfeeding.
If this permanent form of contraception has been carefully considered beforehand, immediately after childbirth is a good time to have the procedure, because the uterus and fallopian tubes are high in the abdomen and are easier for the surgeon to reach. This means the incision can be very small, the tubes need little manipulation, and the uterus does not have to be pushed up with an instrument.
Vasectomy is always an excellent method if no more children are wanted, because of its effectiveness and lower cost. However, counseling is especially important if a couple is making this decision shortly before or after the birth of a child.
Although progestin-only methods—Depo-Provera, progestin-only pills, and Norplant—are safe, they are not the methods of first choice for breastfeeding women, because the hormones do show up in breastmilk. No negative effects, however, have been documented so far among children exposed to these hormones as breastfed infants. Progestins do not negatively affect milk production or an infant's growth and health.
Nevertheless, starting a progestin-only method while nursing should be delayed until at least 6 weeks after the birth, for these reasons: (1) There is no risk of ovulating during these weeks. (2) This delay avoids exposing the newborn to hormones at the time when the baby theoretically might be more sensitive to them.
Combined oral contraceptives are not recommended if you are breastfeeding. The estrogen in the combined pill decreases the milk supply which usually leads to an earlier use of supplemental feeding and an early end to nursing. You can use progestin-only pills for the first 6 months and then switch to the combined pill, which is more forgiving if you do not use it perfectly.
Fertility awareness methods often are not recommended after childbirth and during nursing. Basal body temperature patterns generally are erratic and cannot be used to predict ovulation. Cervical mucus patterns also may vary during this period and changes in mucus are much harder to detect. However, a recent study demonstrated that the symptothermal method can be used successfully—by women who were experienced in using it—to identify most of their fertile days (which were verified by hormone measurements). However, abstinence was necessary 25 to 50 percent of the time. It should be noted that these women were not new users of this method, and they were supported by their partners and by trained fertility awareness counselors.
In general, barrier methods are the best complements to nursing, because they have no impact on the infant and their reliability is enhanced by the contraceptive effect of breastfeeding.
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The first trimester is very important for the mother and the baby. For most women it is common to find out about their pregnancy after they have missed their menstrual cycle. Since, not all women note their menstrual cycle and dates of intercourse, it may cause slight confusion about the exact date of conception. That is why most women find out that they are pregnant only after one month of pregnancy.