C H A P T E R

C H A P T E R 2 6

Bereavement and loss in maternity care

The chapter aim s to:

• consider the meaning of bereavement and loss in maternity and childbearing

• contemplate the significance of bereavement and loss in maternity and childbearing

• discuss forms of loss

• draw on research evidence and other knowledge to review the care of those affected by loss.

Introduction

In 21st-century Western society, bereavement is closely linked with loss through death. In this chapter, to increase the relevance of these concepts, the focus is broadened to include other sources of grief that are likely to aﬀect midwifery care. In widening the topic, the original meaning of ‘bereavement’ is reﬂected, which implies plundering, robbing, snatching or otherwise removing traumatically and, crucially, without consent. This meaning may conﬂict with the other part of the title – ‘loss’ – which is also widely used in this context. But any inconsistency is fallacious because, although bereavement involves ‘taking’ in various ways, the unspoken hopes and expectations invested in that which is lost remain irretrievable.

In many ways, loss in childbearing is unique, which is due to the awful contrast between the sorrow of death and the mystical joy of a new life. Additionally, the cruel paradox of the ‘juxtaposition’ of birth and death aggravates responses (Howarth 2001: 435). We tend to assume that birth and death are separated by a lifetime; this means that the experience becomes incomprehensible when they are uniﬁed (Bourne 1968). Although any childbearing loss is unique, the uniqueness of both the individual's experience and the phenomenon itself must be contrasted with the frequency with which ‘lesser’ childbearing losses happen. Such lesser losses include the reduction of the parents' independence, the woman's loss of her special relationship with her fetus at birth, or the family loss of the expected idealized baby when they recognize that the actual baby is all too real (Atkinson 2006). Central to this chapter is the woman losing a baby and her care by the midwife. The midwife draws on theory which, as in any care, is

grounded in ﬁrm knowledge, such as research evidence. Such knowledge is utilized in skilled care to facilitate adjustment to these greater and lesser losses. Thus, as well as loss through death, other forms of childbearing-related loss are also considered.

Grief and loss

Grief, like death and other fundamentally important mafers, is a fact of life. All human beings invariably face grief in some form, possibly when young. Despite its universality, a woman in a higher income country experiencing childbearing loss may be too young to have previously encountered the grief of death. This is a further reason for the uniqueness of childbearing loss.

Attachment

Limited understanding of mother–baby afachment, or ‘bonding’, long prevented our recognition of the signiﬁcance of perinatal loss. The strength of the growing relationship between the woman and her fetus emerged in a research project involving bereaved mothers (Kennell et al 1970). This relationship develops with feeling movement and experiencing pregnancy, including investigations such as ultrasound scans. Ordinarily, afachment continues to develop beyond the birth (Bowlby 1997). Afachment during pregnancy means that, should the relationship not continue, it must be ended as with any parting. Thus, the reality of the mother–baby relationship needs to be recognized before the loss can be accepted. These processes are crucial for the initiation of healthy grieving.

Grief

Through grieving we adjust to more serious, and lesser, losses throughout life. Healthy grief means that we can move forward, although probably not directly, from the initial distraught hopelessness. We eventually achieve some degree of resolution, or perhaps integration, which permits ordinary functioning much of the time. Through grief we learn something about both ourselves and our resources (Vera 2003).

Grief has been viewed historically as apathetic passivity, but it is really a time when the bereaved person actively struggles with the emotional tasks facing her; the term ‘grief work’ summarizes this struggle (Engel 1961). The stages of grief through which the person works have been described in various ways, but Kübler-Ross's (1970) account is memorable. These stages (Box 26.1) are not necessarily negotiated in sequence; individual variations cause the person to move back and forth between them before reaching a degree of resolution.

Box 26.1

St a g e s o f g r ie f

• Shock and denial

• Increasing awareness

– Emotions: sorrow – guilt – anger

– Searching

– Bargaining

2 Realization

– Depression

– Apathy

– Bodily changes

3 Resolution

– Equanimity

– Anniversary reactions.

The initial response to loss comprises a defence mechanism protecting the individual from the full impact of the news or realization. This reaction comprises shock or denial, which insulates the bereaved person from the unbearably unthinkable reality. Facilitating coping with impending realization, this initial response allows some ‘breathing space’, during which the person marshals their emotional resources.

Denial soon becomes ineﬀective and awareness of the reality of loss dawns. Awareness brings powerful emotional reactions, together with physical manifestations. Sorrowful feelings emerge but, less acceptably, other emotions simultaneously overwhelm the bereaved person. These include guilt and dissatisfaction, as well as compulsive searching and, disconcertingly, anger. Realization dawns in waves as the bereaved person tries coping strategies to ‘bargain’ with herself to delay accepting the grim reality.

When such fruitless strategies are exhausted, the despair of full realization materializes, bringing apathy and poor concentration, together with bodily changes. At this point, the bereaved person may show anxiety and physical symptoms, like depression.

When the loss is eventually accepted, it starts to become integrated into the person's life (Walter 1999). As mentioned already, this is not straightforward and may involve slow progress and many setbacks, with oscillation and hesitation. Although the person may never ‘get over’ the loss, it should eventually be integrated. This ultimate degree of ‘resolution’ is recognizable in the bereaved person's contemplation with equanimity of the strengths, and weaknesses, of the lost person and relationship.

Significance

Healthy grieving mafers because it contributes to balance or homeostasis in the bereaved person's life. Grief helps people deal with the wounds inﬂicted by the greater and lesser losses of life. The hazards of being unable to grieve healthily have long been recognized in emotional terms, but there may be an association between perinatal loss and physical illness (Boyce et al 2002). This research suggested the woman's need for

support regardless of the nature of the loss or the extent to which it is recognized, or her grief sanctioned, by society.

Culture

A general picture of healthy grieving, and individual variation, common to people of diﬀerent ethnic backgrounds, has been described (Katbamna 2000). The manifestations of grief, and accompanying mourning rituals, vary hugely. These variations are inﬂuenced by many factors. Cecil (1996) shows the massive diﬀerences between ethnic groups in afitudes towards childbearing loss. A midwife may encounter diﬃculty understanding the diﬀerent afitudes to loss in cultures other than her own ( Mander 2006). Whether the midwife is able to work through such feelings, to support the woman with diﬀerent afitudes, is uncertain. Closely bound up with culture, and inﬂuencing mourning, are the grieving person's religious beliefs, or lack thereof. These aspects, however, are difficult to separate from social class and prevalent societal attitudes.

Despite huge variations in its manifestation, mourning has a universal underlying purpose. It establishes support for those closely aﬀected, by strengthening links between the people who remain. In perinatal loss the midwife initially provides this support. The midwife's role is to be with the woman when she begins to realize the extent of her loss and to prevent interference in the woman's healthy initiation of grieving.

Forms of loss

The terms ‘loss’ and ‘bereavement’ apply to a range of experiences, varying hugely in severity and eﬀects (Despelder and Strickland 2001). We must be careful, however, to avoid assumptions about the meaning of loss to a particular person. It is diﬃcult, even impossible, for anybody to understand the signiﬁcance of a pregnancy or a baby to someone else. This is because childbearing carries a vast range of profound feelings, including unspoken hopes and expectations based on personal and cultural values. We should accept that grief in childbearing, like pain, is what the person who is going through it says it is (McCaffery 1979).

Some situations in which we encounter grief are mentioned. Some situations of childbearing grief are not included here, while some situations listed here may not engender grief.

Perinatal loss

When loss in childbearing is mentioned, loss in the perinatal period comes quickly to mind, which includes the stillborn baby and the baby dying in the ﬁrst week. Afempts have been made to compare the severity of grief of loss at diﬀerent stages, perhaps to demonstrate that certain women deserve more sympathy. A classic study investigating severity, however, showed no signiﬁcant diﬀerences in the grief response between mothers losing a baby by miscarriage, stillbirth or neonatal death (Peppers and Knapp

1980). This study emphasized the crucial role of the developing mother–baby relationship – the understanding of which has facilitated changes in care.

Stillbirth

A retrospective Swedish study focused on the mother's long-term recovery from stillbirth. Rådestad and colleagues (1996a) compared the recovery of 380 women who had given birth to a stillborn baby with 379 women who birthed a healthy child. The 84% response rate shows the mothers' perception of the importance of this study. These researchers found that the mother recovered befer if she could decide how long to keep her baby with her aher the birth and if she could keep birth mementoes. The mother whose recovery was more diﬃcult was the one where the birth of the baby was delayed aher realization of fetal demise. Clearly, these ﬁndings have important implications for midwifery care (see section on The Mother, below). Additionally, the researchers discuss the ‘known’ stillbirth, when the mother knows before labour that her baby has died, previously termed ‘intrauterine death’ or ‘IUD’. Alternatively, the loss is unexpected. While avoiding comparisons, it is understandable that the mother aware of carrying a dead baby bears particular emotional burdens. These burdens, compounded by the baby's changing appearance, may impede her grieving.

Early neonatal death

Grieving a liveborn baby who dies may be facilitated by three factors. First, the mother has seen and held her real live baby; giving her genuine memories. Second, United Kingdom (UK) legislation requires the registration of both the birth and death of a baby dying neonatally, providing wrifen evidence of the baby's life. Third, staﬀ investment in the care of this dying baby increases the likelihood of eﬀective parental support (Singg 2003). Even for the mother whose preterm baby survives, though, there may still be elements of grief (Shah et al 2011).

Accidental loss in early pregnancy: miscarriage

Early pregnancy loss may be due to various pathological processes, such as ectopic pregnancy or spontaneous abortion. The word ‘abortion’ is befer avoided in this context, because it carries connotations of deliberate interference, which are unacceptable to a grieving mother. The term ‘miscarriage’ is preferable, to include all accidental losses. The grief of miscarriage has long been ignored, because of its frequency. This has been estimated to be about one-third of pregnancies, although the ﬁgure may be higher (Oakley et al 1990).

Understanding the woman's experience of miscarriage has been sought through qualitative research, which shows miscarriage to be far from an insigniﬁcant event, with some mothers so ill that they fear for their lives. Although mothers ﬁnd reassurance in the conception of the pregnancy that was lost, some come to doubt their fertility. As in other forms of loss, the mother ﬁnds diﬃculty in locating support and encounters comments denigrating her loss (Simmons et al 2006). It may be necessary to seek the

cause of a woman's miscarriage, especially if it happens repeatedly (Hyer et al 2004). Although miscarriage has been linked with stressful life events, Nelson et al (2003) found no link between psychosocial stress and miscarriage. Limited recognition of miscarriage is now being addressed, and women are encouraged to create their own rituals to assist grieving. Brin (2004) showed the helpful nature of a religious service, of photographs or of communicating sorrow through writing a poem or letter.

Infertility

Grief associated with involuntary infertility is less focused than when grieving for a particular person (Lau 2011). In this situation the couple grieve for the hopes and expectations integral to the conception of a baby. Realization of their infertility, and the associated grief, is aggravated by the widespread assumption that conception is easy, which is suﬃciently prevalent for the emphasis, in society generally and healthcare particularly, to be on preventing conception. Complex investigations and prolonged infertility treatment result in a ‘roller-coaster’ of hope and despair.

As with any grief, the couple in an infertile relationship grieve diﬀerently from each other, engendering tensions. Being told the diagnosis or cause of their infertility resolves some uncertainty, but raises other diﬃculties. These include one partner being ‘labelled’ infertile and, hence, ‘blamed’ for the couple's diﬃculty. A complex spiral of blame and recrimination may escalate to damage an already vulnerable relationship (Allen 2009). Clearly, counselling an infertile couple diﬀers markedly from counselling those bereaved through death.

Relinquishment for adoption

Although long accepted that relinquishment is followed by grief (Sorosky et al 1984), the view persists that, because relinquishment is voluntary, grief is unlikely. Each mother in the study conducted by Mander (1995) was clear that her relinquishment was deﬁnitely involuntary and she had no alternative to relinquishment. These mothers really were ‘bereaved’ in the original sense (see Introduction, above).

The grief of relinquishment diﬀers crucially from grief following death. First, aher relinquishment grief is delayed. This is partly because of the woman's lifestyle and partly because of the secrecy imposed on the woman who does not mother her baby as is usual. Secondly, the grief of relinquishment is not resolved in the short or medium term. This is because, ordinarily, acceptance of loss is crucial to resolving grief. Aher relinquishment, such acceptance is impossible due to the likelihood that the one who was relinquished will make contact when legally able. Being reunited with the relinquished one was fundamentally important to the mothers interviewed. ‘Rosa’s’ words reﬂect many mothers' hopes: ‘I’d be delighted if she would turn up on the doorstep’ (Mander 1995).

Termination of pregnancy (TOP)

Grief associated with termination of an uncomplicated pregnancy is problematic and for this reason it tends not to be included in the literature on grief. The experience of grief following TOP for fetal abnormality and of guilt following TOP do, however, tend to be recognized and accepted. In view of the frequency of TOP and the grief engendered, this deserves more attention.

TOP for fetal abnormality (TFA)

The package of investigations known as ‘prenatal diagnosis’ (see Chapter 11) may ultimately lead to the decision to undergo TFA. Although it may be assumed that the mother's reaction is solely one of relief at avoiding giving birth to a baby with a disability, Iles (1989) suggests reasons for a mother in this situation experiencing conflicting emotions that impede grieving:

• the pregnancy was probably wanted;

• the TFA is a serious event in both physiological and social terms;

• the reason for TFA may arouse guilty feelings;

• the recurrence risk may constitute a future threat;

• the woman's biological clock is ticking away;

• her failure to achieve a ‘normal’ outcome may engender guilt.

Interventions have been introduced to facilitate the grieving of the mother who has undergone TFA, which involve counselling and the creation of memories, as in other forms of child-bearing loss (see section on The Baby, below). A randomized controlled trial to study the eﬀectiveness of psychotherapeutic counselling in such mothers with no other risk factors was undertaken by Lilford et al (1994). This study suggested that bereavement counselling makes no diﬀerence to the diﬃculty or duration of grieving. Additionally, the researchers concluded that mothers afending for counselling would probably have resolved their grief more satisfactorily than the control group anyway.

TOP for other reasons

The non-recognition of grief associated with TOP may be because the mother whose pregnancy is ended may be considered ‘undeserving’ of the luxury of grief. Further, this may be aggravated by her being blamed for her situation. Research on the psychological sequelae of TOP has focused on the guilt of having decided to end the pregnancy, as opposed to grief reactions; it may be that this focus is associated with the acrimonious abortion debate that continues in some countries. Thus, the grief and depression, presenting as tearfulness, were thought normal aher termination of pregnancy (Wahlberg 2006). Perhaps these reactions could be prevented by counselling before, as well as after, the TOP.

The baby with a disability

For various reasons a baby may be born with a disability, which may or may not be

anticipated. Disabilities vary hugely in severity and their implications for the baby. The mother may have to adjust to the possibility of her baby dying, but many conditions permit the continuation of a healthy life.

The mother's reaction to a baby with a disability will involve some grief. This is particularly true if the condition was unexpected, as the mother must grieve for her expected baby before relating to her real baby. The mother may be shocked to ﬁnd herself thinking that her baby might be befer oﬀ not surviving ( Lewis and Bourne 1989). Although the mother may be reassured that such thoughts are not unique, she may still find it difficult to begin her grieving.

If a baby is born with an unexpected disability, the problem of breaking the news emerges. There are no easy answers to how this can be done to reduce the trauma, but clear, effective and honest communication is crucial (Farrell et al 2001).

The midwife's experience

The emotional reaction that may sometimes be experienced by the midwife may come as a surprise to her. Considering herself to be a professional person, she may be taken aback by the strength and complexity of her feelings when caring for a bereaved mother. This aspect has now begun to be addressed by research and to be opened up to debate (Kenworthy and Kirkham 2011; see Box 26.2).

Box 26.2

That sad day

This is a summary of feelings and thoughts when I discovered an intrauterine death at 41 weeks' gestation. The woman involved had been admifed for induction of labour and neither of us was prepared for this.

My heart sank when on initial palpation her abdomen felt cold and then the electronic fetal monitor did not detect the heart beat (I had just used the machine earlier). I knew, although it would be diﬃcult, that I had to try and prepare her. I stayed later to try and give some continuity of care and support for her and her husband. Aher the scan conﬁrmed the death I hugged her and her husband and cried with them. Aher this happened, I had a day oﬀ work with a severe migraine caused by stress. I felt very nervous and sick about going back to work, this was compounded when I discovered that the woman had been admifed to Intensive Care and was very ill. However, I did go back to work, visited the woman and sat holding her hand. We talked about her sadness and she said she had been worried about me leaving work late and wondered how I had coped gefing home and facing my two children. I couldn't believe that she was concerned about me! She remembered every word I had said to her and praised my honesty. I had told her before the scan that I was sure that the baby had not survived. Two weeks later I afended the funeral in order to seek closure and to demonstrate my sympathy and sadness for the parents.

I have been a midwife for over 12 years and this has NEVER happened to me before. The whole event was very traumatic and upsefing for me. Some colleagues told me not to be upset, cry and/or get involved, but this was ineﬀective advice. I was so determined that my experience should not be in vain that I wrote this reﬂective piece. In total I have experienced the loss of over nine friends and relatives including my parents when I was fairly young. However, nothing can prepare someone (even a professional) for discovering that a baby has died and having to prepare the parents for this. Without the love and support of my family, friends and colleagues I would not have coped. As healthcare professionals we should be empathic and display understanding towards our colleagues in similar situations.

As Rosemary Mander [2004b] writes in ‘When the professional gets personal’:

for professional staff who provide effective care, there is likely to be a personal cost. These are the ‘costs of caring’, which may be regarded as the negative side of engaging with patients and clients and with one's work.

The whole experience will have a huge eﬀect on my practice in various ways. I will encourage midwives to be honest with the clients. This will ensure that words are carefully chosen and also sensitively put, because they will be clearly remembered in years to come. I will not try to smooth over colleagues' feelings when they are involved in issues like this.

I am also going to liaise with the Local Supervising Authority to look at guidance for other midwives in situations like this. The success of the ‘Birth Aherthoughts Service’ within the Trust has led me to identify the need for a service for midwives dealing with bereavement and perhaps morbidity as well. Therefore, as a Supervisor of Midwives I aim to promote separate sessions for midwives – even if the midwife says she is unaﬀected. This will not be blame-based but will simply allow the members of staﬀ to come to terms with their emotions and feelings by helping them to move on in a positive way.

To summarize, writing about this episode has been a catharsis for me and hopefully my experience will have a positive outcome for other staﬀ who ﬁnd themselves in the same sad and extremely difficult situation, and therefore benefit the parents as well.

Source: Reproduced with the kind permission of The Pra ctising Midwife

Loss in healthy childbearing

It may be hard to understand that, even in uncomplicated, healthy childbearing, grief may still present as a feature.

The ‘inside baby’

The woman's grief may be because, despite obstetric technology, the mother is unable to

view her baby before birth. Inevitably the real baby diﬀers from the one whom she came to love during pregnancy. These diﬀerences may be minor, such as the amount of hair or crying behaviour. Lewis (1979) coined the term ‘inside baby’ to denote the one whom she came to love during pregnancy and who was perfect. The ‘outside baby’ is the real one, for whom she will care and who may have some imperfections, such as the wrong colour of hair. Clearly the mother may have moments of regret, during which she grieves the loss of her fantasy ‘inside’ baby, before being able to begin her relationship with her real baby.

The mother's birth experience

A further form of loss, over which the mother may need to grieve, is her loss of her anticipated birth experience. If she hoped for an uncomplicated birth, even some of the more common interventions may leave her feeling like a failure (Green and Baston 2003). Thus, in the same way as the woman may need to grieve her ‘inside baby’, even though all appears satisfactory, this disappointed mother has some grief work to complete.

Care

In considering the care that midwives provide in the event of loss, there are diﬃculties in deciding where to begin. Thus, I have organized this section by focusing ﬁrst on those who are involved or aﬀected and then on other crucial issues. From this material will emerge the principles of midwifery care. While recognizing the artiﬁciality of distinguishing care for the individuals involved in this complex situation, this approach helps us to consider the different needs among the people affected by the loss.

The baby

It is particularly hard to separate the care of the baby from the care of those who are grieving, because much of our care comprises the creation of memories of the baby, which will facilitate their grieving (Box 26.3). Midwives may think of the care of the baby before the birth by considering the cot in the labour room (Mander 2006). Although the cot's presence may cause the staﬀ some discomfort, it reminds everybody of the baby's reality. If possible, that is if the baby's demise is known in advance, the midwife discusses with the parents prior to the birth their contact with the baby. This contact takes any of a number of forms, beginning with just a sight of the wrapped baby. Contact with the baby has been said to resolve some of the confusion surrounding the birth; but the benefits of such care have also been called into question (Hughes et al 1999).

Box 26.3

C r e a t ing m e m o r ie s

• Midwifery activities

– Information-giving

– Arranging for/taking photographs*

– Cutting a lock of hair*

– Taking a footprint*

– Giving a cot card and/or name-band

• Parental activities

– Naming baby

– Seeing baby

– Holding baby

– Caring for baby: bathing – dressing

– Taking photographs

• Other activities

Writing in a book of remembrance Service/funeral/burial/cremation Tree planting

Writing a letter and/or poem

* Parents' informed consent will be needed.

The midwife faces the quandary of whether, and how much, she will encourage the mother to make contact with her baby, drawing on her understanding of its beneﬁcial eﬀect on grief (Mander 2006). This quandary is diﬃcult, but midwives tend to be overcautious in encouraging the mother to have contact. This was an important ﬁnding from a study of 380 mothers who had experienced perinatal loss (Rådestad et al 1996b). These researchers found that one-third of the mothers would have appreciated more encouragement to have contact with their babies.

The mother may choose to have considerable contact with her baby, perhaps keeping the baby with her for some time. During this time, the mother may wish to have her baby baptized which, as well as its religious signiﬁcance, emphasizes the baby's reality. This simple act, possibly undertaken by the midwife, additionally presents an opportunity to name the baby. The mother may also during this time have other opportunities to create memories of her experience; these include doing some of the things a mother ordinarily does for a baby, such as bathing and dressing him or her.

Irrespective of whether the mother chooses to have contact with her baby immediately, it is usual to collect certain mementoes at the time of the birth, such as a lock of hair, a footprint or photographs. If the mother chooses to have no contact at the birth she may later ask for these mementoes. Taking photographs of a suitable quality may present a challenge to the midwife who is not skilled in using a camera, causing dissatisfaction (Rådestad et al 1996b). Figure 26.1 shows the sensitive way in which a photograph may be used to help create memories of the birth.

[pic]

FIG. 26.1 Photograph showing a grieving mother cradling her baby, who has been named Baby Shane.

In the hope of preventing a future loss, the parents may be advised that the baby should have a post mortem examination. This raises diﬃcult issues for parents who consider that their baby has already suﬀered enough. In the UK there are guidelines providing information for the parents prior to seeking their consent for the post mortem. These guidelines aim to prevent certain abuses, which have previously caused anguish to bereaved parents (Dimond 2001; Royal College of Pathologists [RCP] 2000).

The funeral serves a multiplicity of purposes, including a demonstration of general support as well as establishing the reality of the loss. A young woman with no experience of death may have diﬃculty imagining how such a ritual could ever be beneﬁcial. She may be helped, though, by being reminded how cemetery and crematorium staﬀ are sensitive to the need to provide a suitable ceremony and a congenial environment in which the child may subsequently be remembered. In some situations, such as early miscarriage, a funeral is inappropriate. The mother may ﬁnd that an impromptu service is helpful near the time of her loss or, later, she may create her own memorial by writing a lefer to her lost baby or planting a tree. The care of this mother is particularly important if and when she decides to embark on another pregnancy (Reid 2007; Armstrong et al 2009).

The mother

Much of the midwife's care of the grieving mother comprises helping her to make sense

of her mystifying experience. As mentioned already, the mother needs help to recognize that she has given birth, even though she no longer has her baby. Integral to this is assisting her realization that she is a mother, through midwifery care.

The mother may start to make sense of her loss by talking about it. Although this sounds simple enough, ‘opening up’ presents the mother with certain challenges. For example, she may be inexperienced and uncomfortable in talking about profound feelings. Further, she may have diﬃculty ﬁnding a suitable and willing listener precisely when she feels ready. The problem of her ﬁnding a listener was identiﬁed in a research project showing that senior hospital staﬀ appear too busy, and other staﬀ insuﬃciently experienced, for her to unburden herself. Family members, who might listen, have their own difficulties to face, making them less receptive to the mother's needs (Rajan 1994).

In a situation of loss, any of us may feel that our control over our lives is slipping away. Such feelings of losing control are exacerbated when the loss involves a physiological process such as childbearing, which many people achieve successfully and eﬀortlessly. Midwives should be able to help the mother to retain some degree of control. They can do this is by giving her accurate information about the choices open to her and on which she is able to base decisions. In this way, the midwife may be able to empower the woman and the two may form a partnership together.

The reality of the grieving mother's control over her care was the subject of research by Gohlish (1985). She interviewed 15 mothers of stillborn babies and asked them to identify the ‘nursing’ behaviours they considered most helpful. This study showed the importance to the grieving mother of assuming control over her environment. While the midwife may be keen to share many aspects of control in the form of decision-making with the grieving mother, there are some decisions that midwives consider unsuitable for the mother to make (Mander 1993). The suitable decisions include the contact that the mother has with her baby; whereas the unsuitable decisions may include the environment in which she is cared for during her hospital stay.

The support oﬀered to the woman was the subject of a systematic review, which found that there is lifle evidence to indicate the eﬀectiveness of psychological support at this time (Flenady and Wilson 2008). A randomized controlled trial by Forrest et al (1982) investigated the eﬀects of support following perinatal loss. The experimental group, comprising 25 bereaved mothers, received ideal supportive midwifery care together with counselling; the control group comprised another 25 bereaved mothers who received standard care. Unlike the more psychotherapeutically oriented study by Lilford et al (1994), Forrest et al (1982) found that the well-supported and counselled group recovered from their grief more quickly than the control group. Unfortunately, both studies had difficulty retaining contact with the grieving mothers.

The mother may ﬁnd helpful support in a number of people, who provide support on a more or less formal basis (Forrest et al 1982). Although we may assume that identifying support is easy, research by Rådestad et al (1996b) has shown that, like ﬁnding a suitable listener, locating support may be problematic for the mother. These researchers found that for just over one-quarter of bereaved mothers the support lasted for under 1 month; while for just over another quarter the support was non-existent.

Of particular signiﬁcance to midwives is the contribution of the lay support and self- help groups. Research by Mander (2006) showed that midwives are happy to recommend that a mother may ﬁnd a support group, such as the Stillbirth and Neonatal Death Society (SANDS), helpful. Unfortunately, lifle is known about their eﬀectiveness or the experiences of those who attend.

If the loss occurs while the woman is in hospital, her transfer home is crucially important, due to the likelihood of other agencies becoming involved. At this point good inter-agency communication ensures that the woman's healthy grieving is not jeopardized. In her large study, Moulder (1998) identiﬁed the quality of the help provided for the grieving mother by community agencies. She found that women experience very diﬀerent standards of care from the various professionals, such as health visitors, general practitioners, community midwives and counselling personnel. Similarly, the 6-week follow-up presents an opportunity, not only to check the woman's physical recovery, but also to discuss important outstanding issues. These include the couple's emotional recovery from their loss, the post mortem results (if relevant), any questions arising or remaining, as well as plans for the future. The research by Moulder (1998) found that this follow-up visit is ohen handled appropriately sensitively, in a suitable environment, with appropriate personnel present and adequate time to address mafers of concern. Unfortunately, though, some women's appointments were delayed and staff were condescending.

The family

The mother is clearly most intimately involved with, and aﬀected by, a perinatal loss. To a greater or lesser extent, those close by will share her grief. In this context, the chapter includes, as well as conventional family members, a range of non-blood and non-marital relationships.

The father

The eﬀect of the loss on the father may previously have been underestimated (Mander 2004a). This is partly because men tend to show their grief diﬀerently from women and partly because they are socialized into supporting their womenfolk, possibly at the cost of their own emotional well-being. Further, men are stereotypically unlikely to avail themselves of the therapeutic eﬀects of crying and articulating sorrow. Men's coping mechanisms also involve less healthy grieving strategies, including returning early to work and using potentially harmful substances such as nicotine or alcohol.

Possibly in association with their different patterns of grieving (Samuelsson et al 2001), the parental relationship is likely to change following perinatal loss. Whether the couple find their relationship strengthened or threatened is unpredictable.

Other family members

Perhaps because they are less closely involved, grandparents may be disproportionately adversely aﬀected by the loss, possibly due to their inability to protect their children (the

bereaved parents) from painful loss. Inevitably and additionally they experience their own sense of loss at the threat to the continuity of their family and what that means to them.

The eﬀects of perinatal loss on a sibling may be problematic because of uncertainty about the child's understanding of the event (Hayslip and Hansson 2003; Dyregrov 2008). This diﬃculty is compounded by the parents' diﬃculty in articulating their pain in a suitable form. The parents may seek to ‘solve’ these problems by ‘protecting’ their other child(ren) from the truth. They lifle know that ‘protection’ creates a pafern of unhealthy grieving, leaving a family legacy of dysfunctional relationships (Dyregrov 2008).

Whilst midwives ohen assume that family are best at supporting a grieving mother (Mander 1996), family responses may not always be healthy or helpful (Kissane and Bloch 1994).

The formal carers

The diﬃculty that staﬀ face in caring for a grieving mother has been linked with their personal reactions to the loss of a baby (Bourne 1968). This may be the reason for the historical neglect of such mothers in particular and this topic in general. Furthermore, loss of a baby represents all too clearly the failure of the healthcare system, and those who work in it, to ensure a successful outcome to the pregnancy. The fear of failure in turn engenders a cycle of avoidance, which perpetuates neglect of the mother.

This vicious cycle has been interrupted so that as the care of the mother has been changed, it is necessary to question whether the care of staﬀ has kept pace (Clarke and Mander 2006). The emotional costs of providing care are now being recognized (Kenworthy and Kirkham 2011). The devaluation of the emotional component of care is associated with increasing use of the medical model and contributes to the increasing recognition of ‘burnout’. The need for extra support is particularly important for less experienced staﬀ when providing care for grieving families (Mander 2000). The education of staﬀ for their counselling role is another solution, which is enhanced by supervision for the counsellors. The role of the midwife manager in creating a supportive environment for staﬀ in stressful situations should not be underestimated. The midwife may also be able to locate support in others alongside whom she works, such as the hospital minister or chaplain or her named Supervisor of Midwives. Additionally, there are helpful agencies which may be located within or outwith the healthcare system (see Useful Websites, below).

The involvement of staﬀ in the mother's grief raises some diﬃcult questions. First there is the helpfulness or otherwise of the midwife sharing the bereaved mother's tears. Although some midwives are prepared to cry alongside the mother, others feel that crying is ‘unprofessional’ and would not be comfortable shedding even a few tears. The midwives in Mander's (2006, 2009) research said that, generally, crying was not a problem; but any loss of control that impeded their ability to provide care must be avoided at all costs. Another diﬃcult decision is whether staﬀ should afend the baby's funeral. Some of the midwives interviewed found this helpful and they had not been

uncomfortable attending. In some circumstances, however, this might not apply.

Other aspects of care

Not least because of their eﬀect on grieving, other aspects of care assume greater importance.

Record-keeping and documentation

Record-keeping in this context becomes even more signiﬁcant. This is because communication is vital in ensuring consistent care, which will facilitate the mother's grieving. Although not ideal, it may be diﬃcult to avoid this care being provided by diﬀerent personnel. Thus, each midwife must be able to learn from the mother's records about decisions and actions already taken (Horsfall 2001).

The cremation or burial

The documents required for the ‘disposal’ of the baby diﬀer according to whether the baby was born before or aher 24 weeks' gestation (the current legal limit of viability in the UK), according to whether the baby was born alive or not, and according to where the baby was born. If the baby was pre-viable, there is no legal requirement for the baby to be buried or cremated. It is, however, essential to ensure that the baby's remains are removed according to the mother's wishes. If she decides not to participate in the removal of the baby's remains, they should still be removed sensitively (Royal College of Obstetricians and Gynaecologists [RCOG] 2006). A book of remembrance in the maternity unit is available to parents to record their names, their baby's details and thoughts about the baby.

For a baby born aher 24 weeks, burial or cremation may be arranged by the hospital, with the parents' permission, or by the parents. Cemeteries and churchyards are subject to individual regulation, but the local cemetery is likely to have a special plot for babies to be buried individually and a religious or other service may be available. There is also the possibility that the parents may erect a headstone, although the design may be subject to approval.

The statutory documentation is speciﬁc to each of the countries of the UK. Details of the registration requirements in each of the four countries of the UK are provided on the websites listed at the end of this chapter.

The mother's choices

If she loses her baby, as well as her grief work, the mother has certain choices. In terms of how the baby's body should be buried or cremated, the mother decides whether to arrange this privately or allow the hospital to organize it. The mother also needs to decide the extent to which she would like to be involved in planning the funeral, the blessing or the memorial ceremony. In some hospitals, services of remembrance are held on a regular basis, and bereaved parents choose whether to afend. As mentioned above,

the mother needs appropriate information to decide about the funeral and post mortem.

The death of a mother

A form of loss that happens even less frequently than the death of a baby is when the mother dies; this is usually known as maternal death. In the UK, the rate of maternal death is approximately 1 in 10,000 births (Lewis 2011: 48). This means that in a medium- sized maternity unit a mother is likely to die about once every 3 years.

Although the obstetric and epidemiological aspects of maternal death have been well addressed (Maclean and Neilson 2002; Edwards 2004; Lewis 2011), the more personal aspects tend to be avoided (Mander 2001a). There is, however, lifle understanding of the family's experience, or the life of the motherless child. Palliative care principles may be appropriately applied to the care of the childbearing woman with or dying from an incurable condition (Mander 2011). The care of this woman and the implications for her baby and the other family members are likely to become increasingly important as women choose to delay child-bearing into their mature years. This childbearing woman's care has yet to be subjected to serious research attention.

However, the experience of the midwife providing care around the time of the death of a mother has begun to be addressed (Mander 2001b, 2004b). This research shows the dire implications for the midwife of afending a mother who dies, to the extent that the experience assumes the proportions of a disaster. The midwife's desperate need for support may be met by midwifery colleagues who either shared her experience or have been through a similar one. The midwife's family also plays a fundamentally important role in supporting her (Mander 1999).

Conclusion

This chapter has shown that, for the midwife's care of the mother grieving a loss in childbearing to be of a suitably high standard, there needs to be a suitably strong knowledge base. Although obtaining such knowledge is not easy, it is only by obtaining and using it that midwives are able to give this mother and family the high standard of care which they deserve and need. In this way, the midwife facilitates healthy grieving in the mother, having avoided the impediments that interfere with or complicate her grief and prevent its resolution. In this most human of situations, midwives must remember that ‘being nice’ is not enough; they need to ensure that midwifery care is based on a ﬁrm knowledge base if the woman is to come to terms with her loss. Other, less widely recognized or discussed forms of loss in childbearing have also been addressed.

Male and female sterilization 585

Female sterilization 585

Male sterilization (vasectomy) 586

The future of contraception and sexual health services 586

Ongoing developments 586

References 587

Further reading 588

Useful websites/contacts 588

Contraception and sexual health are important considerations for women of childbearing age. There are numerous ways in which women can control their fertility, but the choice of contraception will depend on a multitude of factors, including: method of infant feeding, age, culture, religion, access to contraception and previous experience. Women with additional challenges such as physical, sensory or cognitive needs, or those who do not speak or read English, may need extra support and information to enable them to make informed decisions about postpartum contraception.

The chapter aim s to:

• provide up-to-date knowledge of all forms of contraception

• emphasize the role of the midwife in providing contraceptive information and advice for women in their care.

The role of the midwife

The midwife has a unique and pivotal role in discussing contraception and sexual health. The Nursing and Midwifery Council (NMC) in the United Kingdom (UK) states that one of the activities of a midwife is to provide sound family planning information and advice (NMC 2012). Midwives are encouraged to take on a wider public health role and are in a key position to create and use opportunities to enable women to express their needs in respect of choice of contraception.

The most appropriate time to discuss sexual health, resumption of sexual activity and contraception will, in some respect, be dependent on the individual woman. Some midwives may feel that any encounter with postnatal women, even soon aher giving birth, will capitalize on contraceptive and sexual health education opportunities. The

National Institute for Health and Clinical Excellence (NICE) (2006) recommends that contraception advice should be imparted within a week of the birth. Issues such as loss of libido, adjustment to motherhood, breastfeeding, discomfort of the perineum, vaginal dryness and body image may also inﬂuence choice and use of a particular method of contraception (Faculty of Sexual and Reproductive Healthcare Clinical Eﬀectiveness Unit [FSRH] 2009a). The use of a leaﬂet from the Family Planning Association (FPA) can be helpful as such leaﬂets are clear to understand in both text and illustration, and are in a variety of languages. The midwife should be familiar with the contraception and sexual health services available in the area in which she practises and know the system of referral to these specialist services.

For contraceptive methods discussed in this chapter, the eﬃcacy rate is given as a percentage. This rate does not reﬂect the fact that fertility decreases with age and may be suppressed during lactation, or that the success of a method is partially dependent on motivation, experience of using the method and the teaching received on its use. It is recognized that if 100 sexually active women do not use any contraception, 80–90 of them will become pregnant within a year (FPA 2012). Sexual intercourse following childbirth is a hitherto seldom discussed issue. McDonald and Brown (2013) found in their study of 1507 primigravidae that almost 60% of the women had not resumed intercourse six weeks following the birth. Discussions need to take place well before this time to ensure no unintended pregnancies occur. Some women may even appreciate information on contraception in the antenatal period, to give them plenty of time to decide which contraceptive method would be right for them. Partnership working between the new mother and midwife is essential and conversations regarding contraception should take place in a quiet, relaxed sefing, with the midwife having up-to-date knowledge on all methods available.

In the UK, all contraception is available free of charge from the National Health Service (NHS). This is diﬀerent in other parts of the world, with a range of charges for certain methods of contraception.

Hormonal contraceptive methods

The combined hormonal contraceptive pill

The combined oral contraceptive pill (COC or ‘the pill’) (Fig. 27.1) came as a breakthrough, in 1960, in terms of women being in a befer position to control their fertility. This method has subsequently proven to be both eﬀective and safe. The overall use varies greatly between countries but it is estimated to be used by approximately 1% of Japanese women who are married or in a union, 53% in Germany, 28% in the UK and 50% of women in Western Europe (Guillebaud and MacGregor 2013). In the UK, approximately 95% of women under the age of 30 have used oral contraceptives at some time. Around 100 million women rely on the pill worldwide (Guillebaud and MacGregor 2013).

[pic]

FIG. 27.1 The combined hormonal contraceptive choices.

The combined pill contains the synthetic steroid hormones oestrogen and progestogen. All COCs available in the UK contain ethinyl oestradiol, with the exception of Norinyl-l, which contains mestranol and Qlaira which contains estradiol valerate. There are a variety of COCs available containing diﬀerent progestogens. This accounts for subtle diﬀerences in their biological eﬀects and provides women with a wide choice. The most commonly used pills in the UK are monophasic pills, which deliver a constant dose of steroids throughout the packet. ‘Everyday’ pills contain 28 pills in each packet, 21 of which are active monophasic pills while the seven remaining pills contain no hormones (FPA 2012).

Also available are biphasic and triphasic pills, in which the dose of steroids administered varies in two or three phases throughout the packet to mimic the natural ﬂuctuations of the hormones during the menstrual cycle. These pills are less commonly used in the UK. A relatively new pill, called Qlaira, is licensed in the UK; it is a complex quadraphasic pill designed to give optimal cycle control. It is taken every day but has two placebo tablets.

The ﬁrst generation COC pills contained large doses of oestrogen and were associated with a high risk of deep vein thrombosis. They were replaced in the late 1960s with pills that had lower doses of oestrogen and progestogen. They were equally as eﬀective as the earlier pills, being much safer and befer tolerated. The progestogens in these second generation pills were norethisterone and levonorgestrel. The third generation pills,

which came along in the mid-1980s, contained a variety of new synthetic progestogens, that appeared to have befer eﬀects on serum lipid proﬁles. Among these were desogestrel and norgestimate, which were also less androgenic; gestodene, which was the most potent, achieving the best cycle control; and cyproterone acetate, which was anti- androgenic but licensed only as a treatment for acne. Drospirenone has been available from the late 1990s, with mild antimineralocorticoid activity to counteract oestrogen- induced water retention. It is also anti-androgenic.

Mode of action

Combined oral contraceptives work primarily by preventing ovulation. The ﬁrst seven active pills in a packet inhibit ovulation and the remaining pills maintain anovulation (FSRH 2011a).

Oestrogen and progestogen suppress follicle stimulating hormone (FSH) and luteinizing hormone (LH) production causing the ovaries to go into a resting state; the ovarian follicles do not mature and ovulation does not normally take place. Progestogen also causes the cervical mucus to thicken, making penetration by spermatozoa diﬃcult. The pill renders the endometrium unreceptive to implantation by the blastocyst. These actions provide additional contraception in the event of breakthrough ovulation occurring.

Efficacy

Provided that the pill is taken correctly and consistently, and that it is absorbed normally and interaction with other medication does not aﬀect its metabolism, its reliability with consistent perfect use is almost 100% (Guillebaud and MacGregor 2013).

Important considerations

The combined oral contraceptive pill is a reliable contraceptive, which is independent of sexual intercourse and has many advantages. Healthcare providers should manage consultations for contraceptive pills with due regard for the woman's personal context and contraception experience.

Additional beneﬁts of taking the COC pill, in the short term, are regular, lighter, less painful periods, possible reduction in premenstrual symptoms, reduction in acne, protection against pelvic inﬂammatory disease (PID) (because of the thickened cervical mucus), decreased incidence of ectopic pregnancy and reduced risk of benign breast disease. Taken long term, COC pills oﬀer protection against ovarian and endometrial cancers and reduction in the incidence of ovarian cysts and benign ovarian tumours (FSRH 2011a).

Use of the COC pill may lead to side-eﬀects such as irregular bleeding, headaches, nausea and breast tenderness; there is lifle evidence to support the association of weight increase, depression and COC use (FSRH 2011a). These eﬀects ohen diminish with continued use or may improve with a change of pill. A basic knowledge of the side- eﬀects afributable to the components of the COC pill is helpful when making decisions

about changing pills.

Oestrogen dominance in a pill may cause water retention, resulting in breast tenderness, mild headaches, elevated blood pressure and cyclical weight gain. It may also be responsible for nausea and vomiting, excessive vaginal secretion (leucorrhoea) and skin pigmentation similar to chloasma. The progestogens may lower mood and libido, provoke acne and seborrhoea and cause mastalgia.

The vast majority of women experience no adverse eﬀects. Every woman is unique in their biological response and also in their perception and tolerance of side-eﬀects. The metabolic eﬀects of the COC pill can occasionally result in major side-eﬀects. The risks of venous thromboembolism (VTE) with the COC pill, in absolute terms, show a rarity of VTE in women of reproductive age (see Table 27.1 ). The risk of VTE is higher in women with a Body Mass Index (BMI) over 30, heavy smokers, those with a previous history of deep vein thrombosis or a family history of venous thrombosis and those who are immobile.

Table 27.1

Risks of venous thromboembolism

|Risk of VTE per 10 000 woman years |

|Not using COC |4–5 |

|COC users (risk depends on type of COC) |9–10 |

|In pregnancy |29 |

|Immediate postpartum |300–400 |

Adapted from FSRH 2011a

Allan and Koppula (2012) concluded that the risks of VTE when comparing all COCs appear to be unclear, but if there are diﬀerences they are likely to be very small and similar, therefore, any of the COCs may be considered for prescription if this method has been chosen for contraception.

Some women may develop a signiﬁcantly high blood pressure, which could increase the potential for haemorrhagic stroke and myocardial infarction. Hypertension with a blood pressure (BP) between 141/91 mmHg and 159/94 mmHg is considered to be at a level of risk that outweighs the beneﬁts of using the COC. Hypertension with BP of 160/95 mmHg or higher poses an unacceptable health risk with COC use (FSRH 2011a).

Cigarefe smoking is known to potentiate most of the risks associated with COC pill use such as ischaemic and haemorrhagic stroke and myocardial infarction (FSRH 2011a).

The research surrounding the risk of developing breast cancer for COC users is largely contradictory, but it is widely acknowledged that there is a small increase in this risk (FPA 2012). Any excess risk of breast cancer associated with COC use declines in the ﬁrst ten years after discontinuing the pill.

Studies show a small increase in the relative risk of cervical cancer, which is associated with a long duration of use (Guillebaud and MacGregor 2013). However, the eﬀects of

confounding factors such as sexually transmifed infections (STI), non-use of barrier methods and a high number of sexual partners may distort an accurate understanding of the influence of the COC pill.

Contraindications to COC pill use are pregnancy, undiagnosed abnormal vaginal bleeding, history of arterial or venous thrombosis (or predisposing factors such as immobility), hypertension, focal migraines, current liver disease, trophoblastic disease (until serum human chorionic gonadotrophin [hCG] is no longer detectable), smoking (if the woman's age is over 35 years) and a BMI over 39. This is not an exhaustive list. As the pill is not suitable for everyone, women wishing to consider using this form of contraception should have a full history recorded and be fully informed and counselled regarding possible side-effects.

Using the COC pill

When initially commencing the pill, the very ﬁrst pill is usually taken on the ﬁrst day of the menstrual period (for postpartum use, see later). Starting on any day up to the ﬁhh day is just as eﬀective, provided the ﬁrst seven pills are taken correctly. If a 21-day pill has been prescribed, the contraceptive eﬀect is immediate, provided that the remainder of pills in the packet are taken correctly. If the pill is initially commenced on any day beyond the ﬁhh day of the cycle, additional contraception (such as a condom) should be used in conjunction with the pill for the ﬁrst seven days. It is recommended that Qlaira is taken on the ﬁrst day of the menstrual cycle, and if taken on any other day, additional contraception should be used for nine days. One pill is taken every day for 21 days, then no pills for the next seven days. Vaginal bleeding usually occurs within the seven day break, before the next packet of pills is commenced (FPA 2012).

When commencing the ‘Everyday’ (ED) COC pill, the active pills are taken ﬁrst. One pill is taken daily, with care to take the pills in the correct order. Vaginal bleeding will usually occur when the inactive pills are taken, which are usually denoted by a diﬀerent coloured section on the pill packet. If two or more pills have been missed, or the next pack of pills is two or more days late, the advice given in Fig. 27.2 should be followed. If a pill is forgofen from the beginning or end of a packet, the pill-free interval is lengthened and ovulation may be more likely to occur (FSRH 2011a). If a woman is concerned about a missed or late pill, she can contact the local contraception clinic or General Practitioner (GP) for reassurance or advice, as emergency contraception may be indicated (see later).

[pic]

FIG. 27.2 Missed pill rule (FSRH 2011b).

Other factors that may render the pill less eﬀective include interaction with other medication, vomiting within 2 hours of taking a pill and severe diarrhoea. Medications that may hinder the eﬀectiveness of the pill include liver-enzyme-inducing drugs such as rifampicin, some anticonvulsants and some herbal remedies, for example St John's wort. Aher absorption, synthetic oestrogen and progestogen are transported to the liver via the portal vein. Liver-enzyme-inducing drugs reduce the eﬃcacy of the pill by increasing the metabolism, and subsequent elimination of oestrogen and progestogen in the bile. Some newer antiepileptics are not enzyme inducers but the COC pill may reduce seizure control with lamotrigine.

Please note that additional precautions are no longer required when taking antibiotics (non-enzyme inducing) (FSRH 2011a).

The advice to be given in cases of an illness with severe vomiting and diarrhoea is to follow the missed pill rules. It is important that women are made aware of possible drug interactions and inform their medical practitioner/GP that the COC pill is being taken whenever other medications are prescribed.

Preconception considerations

It is useful to wait for one natural period aher discontinuing the pill before trying to conceive as dating the pregnancy can be more accurate and pre-pregnancy care can begin.

Postpartum considerations

The combined oral contraceptive pill reduces milk supply, particularly if lactation is not well established, and is therefore not recommended for use in the early months in lactating women. If the mother is bofle-feeding her baby, the COC pill may be commenced 21 days postpartum. This allows the high oestrogen levels of pregnancy to decrease before introducing the pill (Guillebaud and MacGregor 2013), thus reducing the risk of thromboembolism, but allowing the contraceptive eﬀect to be initiated before

ovulation resumes. Women who have experienced pregnancy-induced hypertension should be assessed on an individual basis with regard to recommencing COC use (Guillebaud and MacGregor 2013).

The COC pill can be commenced immediately following spontaneous miscarriage or therapeutic termination of pregnancy. Due to the risk of thromboembolism, the COC pill should be discontinued 4 weeks before major surgery and a progestogen-only method of contraception used. If this is not possible, then thromboprophylaxis and compression hosiery are advised. Women who have minor surgery do not need to discontinue taking the pill.

Further postpartum considerations for discussion with the mother may include whether remembering to take the pill will ﬁt into her current lifestyle and if she can easily access a clinic or doctor's surgery. Appropriate follow-up, including blood pressure assessments, should be conducted. Following the ﬁrst prescription, follow-up is usually at 3 months postpartum and thereafter it may be annually.

The combined hormone injectable (Lunelle)

Lunelle contains 25 mg medroxyprogesterone acetate and 5 mg estradiol cypionate. It is not yet licensed in the UK due to its poor uptake and subsequent withdrawal from the market in the United States of America (USA), but it is popular in South America and Asia (Guillebaud and MacGregor 2013). Lunelle is commenced on the ﬁrst day or within ﬁve days of a menstrual period, and given every 28–33 days. It is both eﬀective and reversible. Side-eﬀects include breakthrough bleeding and weight gain. The eﬃcacy is comparable with perfect use of the COC pill. Cyclofem and Mesigyna are similar monthly injections also available to women in many countries outside of the USA, mainly in South America and Asia.

The combined hormone patch

The combined hormone patch (EVRA) was licensed in the UK in 2003. One patch is used weekly for three weeks followed by one week patch-free. It is particularly suitable for women who are unable to tolerate oral medications and those with malabsorption syndrome. It releases 20 mg of ethinyl oestradiol and 150 mg of norelgestromin every 24 hours. Compliance and cycle control may be improved. The eﬃcacy of the combined hormone patch is comparable with the COC pill. The patch may be worn on most places on the body except the breasts. It is extremely sticky and should stay on during showering or swimming.

The FPA (2011a) suggest it may be used from day 21 in the postnatal period. However, if the mother is breastfeeding her baby, the patch should not be recommended as it will reduce breast milk production.

The combined hormone vaginal ring

The combined hormone vaginal ring (NuvaRing) is inserted into the vagina on the ﬁrst day of the menstrual cycle. If inserted at any other time additional contraception such as condoms should be used for seven days. It is then used continuously for three weeks followed by one week free of its use. It releases 15 mg of ethinyl oestradiol and 120 µg of etonogestrel per 24 hours. The NuvaRing appears to be acceptable to many women and well tolerated, with studies ﬁnding that compliance and cycle control are also remarkably good (Roumen et al 2006; Brucker et al 2008). The eﬃcacy of the NuvaRing is comparable with the COC pill.

The progestogen-only pills

Progestogen-only pills (POP) were introduced partly to avoid the side-eﬀects of oestrogen in the combined pill, as discussed earlier. They also oﬀer increased choice for women. Currently available in the UK are the older preparations, which contain norethisterone (Noriday, Micronor), etynodiol diacetate (Femulen) and levonorgestrel (Norgeston) and the new anovulant progestogen-only pills containing desogestrel (Cerazette). All have lower doses of progestogen compared with the COC pill.

Mode of action

The POP exerts its contraceptive eﬀects at diﬀerent levels. The cervical mucus is viscid, making it impenetrable to spermatozoa and the endometrium is modiﬁed to prevent implantation. The older POPs have been shown to suppress ovulation in up to 60% of women. The new POP Cerazefe is anovulant and also suppresses FSH and LH consistently such that it is effective in about 97% of women (FSRH 2008a).

Limitations to POP use include menstrual disturbances, encompassing unpredictable and quite ohen prolonged bleeding, oligomenorrhoea or amenorrhoea. Lifle is understood about the mechanism of erratic uterine bleeding, which most women experience to some degree. The menstrual disruption is the most common reason for discontinuation of progestogen-only methods. This indicates the need for careful explanation of the limitations to potential users.

An increased prevalence of functional ovarian cysts has been demonstrated in women using progestogen-only pills. These may sefle with continuation of use and will resolve if the POP is discontinued.

Contraindications to the use of progestogen-only-pills are pregnancy, undiagnosed abnormal vaginal bleeding, severe arterial disease and hydatidiform mole (until serum hCG is no longer detectable). The rate of ectopic pregnancy in women using the progestogen-only pill is no higher than in women using no contraception; however, the POP prevents uterine pregnancy more eﬀectively than tubal pregnancy. This is not a problem with the anovulant POP Cerazette.

Antibiotics do not adversely aﬀect progestogen-only methods of contraception but women should be advised to consult the doctor/GP regarding possible interactions if any other medications (especially enzyme inducers such as rifampicin) are prescribed.

Preconception considerations

There is no evidence of a teratogenic effect with the POP.

Postpartum considerations

Progestogen-only-pills may be commenced 21 days postpartum for contraception. These pills have no adverse eﬀect on lactation. Secretion of the hormone in breast milk and absorption by the neonate is minimal and does not aﬀect the short-term growth and development of infants. The POP can be used immediately following spontaneous miscarriage or therapeutic termination of pregnancy.

Using the POP

The POP is taken every day as there are no pill-free days and thus tablets are taken throughout the menstrual period. If the ﬁrst tablet is taken on the ﬁrst to ﬁhh day of the menstrual cycle, the contraceptive eﬀect is immediate. If the POP is started on any other day of the cycle then additional contraception, such as a condom, should be used for the first two days (FSRH 2008a).

If a pill is forgotten, the woman has only 3 hours in which to remember to take it. If the woman is over 3 hours late in taking a pill, she should continue taking her pills and use additional contraception for the next two days. However, with the anovulant POP Cerazette, the woman has up to 12 hours in which to remember to take the forgotten pill.

Following vomiting or severe diarrhoea, additional contraception should be used until two days aher the illness ceases. Women concerned about missed or late pills should be advised to contact their contraception and sexual health clinic or GP, as emergency contraception may be indicated (see later). The eﬀects of broad-spectrum antibiotics on the gut flora do not affect the action of the POP.

Efficacy

The eﬀectiveness of the older POP is dependent upon meticulous compliance. With perfect use, the POP is more than 99% effective (FSRH 2008a).

Long acting reversible contraception (LARC)

Contraceptives that are used daily or weekly sometimes fail because of non-adherence or incorrect use. A LARC is deﬁned by NICE (2005) as contraceptive methods that require administration less than once per menstrual cycle or month. These guidelines recommend giving women wider access to long acting reversible contraceptive (LARC) methods, as a feasible way to reduce unintended pregnancy (NICE 2005). Long acting reversible contraceptive methods are considered to be more reliable and cost-eﬀective than other methods.

Long acting reversible contraceptive methods include injectable progestogen contraceptives, intrauterine contraceptive devices (IUCD), intrauterine hormonal systems and subdermal contraceptive implants. These are all available in the UK but

usage remains low due to inadequate awareness of their availability and access as most GPs and practice nurses do not fit implants and intrauterine methods of contraception.

For a long acting method to be initiated, informed choice is crucial because only women who have realistic expectations may tolerate protracted side-eﬀects. The implants and intrauterine systems are expensive, therefore a reasonable continuation rate is pertinent.

Progestogen injections

The two contraceptive progestogen injections currently available in the UK are Depo- Provera, or depot medroxyprogesterone acetate (DMPA), and Noristerat (norethisterone enanthate). Both methods are given by deep intramuscular injection.

DMPA is the method of choice for many women, not simply those for whom other methods are contraindicated. Over 6 million women use this method in 130 countries worldwide, and in some countries, for example South Africa, it is the most commonly used reversible method. In the UK, less than 2% of women afending contraception clinics use injectables. The progestogen injections prevent ovulation, thicken cervical mucus and cause atrophy of the endometrium.

Depot medroxyprogesterone acetate

This is the most commonly used injectable and is given in a 150 mg dose at 12 week intervals. It is released slowly from the injection site into the circulation. DMPA is more than 99% eﬀective. Prolonged spofing, however, is a common side-eﬀect in the ﬁrst year but amenorrhoea ohen prevails in long-term use. Some DMPA users experience other side-eﬀects such as breast discomfort, nausea, vomiting, weight gain, seborrhoea, acne and mood swings. It is now recognized that amenorrhoea for more than two years with DMPA is associated with chronic low serum oestrogen and reduced bone density. All women choosing DMPA should be aware of this information. Teenagers, who will not have afained peak bone mass, should be advised to use other methods. The peak bone mass is afained around the age of 30 years. Women who have been amenorrhoeic for more than three years receiving DMPA should have their bone density assessed with dual X-ray absorptiometry (DEXA) scan. It may be reassuring to learn that reduced bone mineral density (BMD) when using DMPA does not progress indeﬁnitely but usually stabilizes aher about ﬁve years. The BMD returns to normal aher discontinuation (Scholes et al 2005).

Depot medroxyprogesterone acetate can oﬀer additional health beneﬁts for women with homozygous sickle cell haemoglobinopathy by reducing haemolytic and bone pain crises (Guillebaud and MacGregor 2013).

Aher discontinuation of DMPA, there may be a delay in the return of fertility for up to 18 months.

Norethisterone enanthate (NET-EN)

Marketed as Noristerat, this injectable contraceptive is given intramuscularly in a 200 mg

dose at 8 week intervals. It is used more commonly in Germany and many developing countries. Noristerat is more than 99% effective and its side-effects are similar to DMPA.

Using injectable progestogens

If the initial injection is given within the ﬁrst ﬁve days of the menstrual period (preferably days 1 to 3), the contraceptive eﬀect is immediate. If given at any other time, the practitioner must ensure that there is no likelihood of pregnancy already and advise that additional contraceptive cover is required for the next seven days (Guillebaud and MacGregor 2013).

Specific considerations

This method is irreversible from the time of action, therefore any side-eﬀects may be present until the injection wears oﬀ. The eﬃcacy of DMPA and NET-EN is not aﬀected by concurrent use of liver enzyme-inducing medications.

Preconception considerations

Injectable progestogen is not recommended as contraception for women who plan to conceive soon.

Postpartum considerations

Injectable progestogen contraceptives can be given prior to the 21st day postpartum, thus preventing the earliest ovulation; however, the woman must be warned about the increased risk of bleeding. It can be used by women who are breastfeeding their baby but delaying commencement until 6 weeks postpartum is ohen advised to ensure lactation is well established and reduce bleeding problems.

Subdermal contraceptive implants

Contraceptive implants have been used internationally for several years. Norplant was used in the UK from 1993 and replaced by Implanon from 1999. Nexplanon, however, replaced Implanon in 2010. The diﬀerences in the more recent implant are that the rod is radio-opaque, containing barium in order to locate it on X-ray if necessary, and it has a pre-loaded applicator which has been designed to reduce insertion errors.

Using implants

Implants are capsules containing progestogen, which are inserted under local anaesthetic into the inner aspect of the non-dominant upper arm (Fig. 27.3). The steroid is released into the circulation, producing a change in the cervical mucus which prevents spermatozoa penetration, disturbance of the maturation of the endometrium and suppression of ovulation.

[pic]

FIG. 27.3 Subdermal implant.

Norplant, which had six capsules containing levonorgestrel, has been replaced by Norplant 2 (also marketed as Jadelle), which has two capsules. Jadelle is eﬀective for 5 years and still available in many developing countries. Nexplanon and Implanon are single contraceptive rods containing 68 mg of etonogestrel. These single contraceptive rod devices should be inserted during the ﬁrst ﬁve days of the menstrual cycle and no additional contraceptive cover is required. Ovulation is suppressed within 24 hours. They are eﬀective for 3 years but can be removed at any time if the woman wishes. Aher removal, the serum is cleared of etonogestrel within 1 week and fertility is promptly regained.

Efficacy

Norplant is more than 99% eﬀective. Nexplanon and Implanon have practically zero failure rates if instructions are carefully followed (Guillebaud and MacGregor 2013). Reported implant failures are often due to interaction with enzyme-inducing medications used concurrently, failing to recognize that the implant has been incorrectly inserted and failing to recognize the woman is pregnant before the fitting.

Specific considerations

Irregular bleeding is the most common problem for women using subdermal contraceptive implants. Only 20–30% of users become amenorrhoeic, however headache, seborrhoea, acne and mood swings have also been reported as side-eﬀects. Insertion and removal require a minor surgical procedure, with accompanying risks of bleeding and infection. These aspects should be discussed prior to the woman making her decision. Counselling before ﬁfing and during use appears to be the only way to reduce premature discontinuation due to the side-effects.

Preconception considerations

The action of the implant is quickly reversible and ovulation can return within 21 days of removal in 94% of women (FSRH 2008b). This makes it suitable also for women wishing

to ‘space’ pregnancies.

Postpartum considerations

If the implant is inserted up to or at 21 days postpartum it is eﬀective immediately; however, if it is inserted aher the 21st day postpartum, additional contraception, such as a condom, should be used. The implant is safe for women who are breastfeeding their babies. The implant can also be inserted immediately aher miscarriages or induced terminations of pregnancy. No extra contraceptive precautions need to be taken.

Intrauterine contraceptive device (IUCD)

These devices are inserted into the uterus, as illustrated in Fig. 27.4. They contain copper, which increases contraceptive eﬃcacy. There seems to be an aversion for the use of IUCDs and progestogen-releasing intrauterine systems (IUS) in the UK, where only 6% of women use them (Guillebaud and MacGregor 2013). The IUCD is the most popular method in some countries and 150 million women worldwide use IUCDs, of which 60 million are in China.

[pic]

FIG. 27.4 Intrauterine contraceptive devices (IUDs). After insertion through the cervix, the framed devices assume the shape shown; the threads attached to it protrude into the vagina. (A) Copper- carrying device. (B) Frameless copper device. (C) Levonorgestrel-releasing system.

Mode of action

The IUCD creates an inflammatory response in the endometrium. Leucocytes are capable of destroying spermatozoa and ova. Gamete viability is also impaired by alteration of uterine and tubal ﬂuids. Copper aﬀects endometrial enzymes, glycogen metabolism and oestrogen uptake, thus rendering the endometrium hostile to implantation, consequently IUCDs are more than 99% effective (see Fig. 27.4A).

Using the IUCD

A copper IUCD can be inserted any time during the menstrual cycle if it is certain that the woman is not pregnant, or up to 5 days following the earliest estimated date of

ovulation: that is, day 19 in a 28-day cycle, when it will be eﬀective immediately. The woman may experience some discomfort during the procedure, which should be performed using aseptic techniques. Depending upon the type of IUCD used, it may be leh in place from 5–10 years and longer in some instances; e.g. if a woman aged 40 years or over has an IUCD ﬁfed, it may remain in place until one year aher the menopause, if this occurs aher the age of 50. Once in situ, the device requires no action of the user and it does not interfere with sexual intercourse. Women are usually taught to feel the threads attached to the IUCD on a regular basis as reassurance that it remains in place. A follow-up appointment in 3–6 weeks following insertion is recommended to assess for any infection, translocation or expulsion. Subsequently the woman requires further follow-up appointments only if she has any concerns. The traditional routine annual review is no longer recommended (NICE 2005).

Side-eﬀects of using the IUCD include menorrhagia, dysmenorrhoea, bacterial vaginosis and colonization by Actinomycetes-like organisms. When the lafer is reported in a routine cervical smear, the woman should be counselled about the options of either changing the IUCD or retaining it and being reviewed periodically to ensure there is no pelvic infection. Removal of the IUCD whenever desired is easy and painless, and fertility is promptly restored.

The suggestion that IUCDs promote pelvic inﬂammatory disease (PID) has been refuted. Clinical risk assessment for sexually transmifed infection (STI) is recommended (Guillebaud and MacGregor 2013). Routine or selective screening for chlamydia and gonorrhoea may be appropriate in some cases, where prompt treatment and contact tracing will be oﬀered. Intrauterine contraceptive devices are associated with a decreased risk of ectopic pregnancies because of their eﬀectiveness. However, in the unlikely event that a pregnancy should occur, the ratio of ectopic to intrauterine pregnancies is greater among women using IUCDs, as in general the device prevents more intrauterine pregnancies than ectopic pregnancies. Thus a woman who has an IUCD ﬁfed should be advised to seek early medical advice, should she suspect that she is pregnant.

If uterine pregnancy occurs, there is an increased risk of spontaneous miscarriage, therefore gentle removal of the device is preferred, to prevent infection and premature labour. If removal is not possible, it is reassuring to know there is no evidence of teratogenicity in the fetus.

A newer frameless device, GyneFix, as shown in Fig. 27.4(B), comprising six copper sleeves crimped onto a polypropylene monoﬁlament thread, is ﬁfed with one end embedded into the fundal myometrium of the uterus. This device is associated with lower expulsion rates and less dysmenorrhoea.

Progestogen-releasing intrauterine system (IUS)

The intrauterine system was developed to overcome some of the problems associated with conventional IUCDs and heavy menstrual bleeding. The progestogen-releasing intrauterine system in current use consists of a small plastic T-shaped frame carrying a Silastic sleeve loaded with 52 mg of levonorgestrel (see Fig. 27.4C). It is inserted into the

uterus and the steroid hormone is released steadily at 20 µg/day. The hormone prevents endometrial proliferation, thickens the cervical mucus and may suppress ovulation in some cycles. The frame, by inducing a sterile inﬂammatory reaction, may also contribute to the contraceptive eﬀect. The system is ﬁfed within the ﬁrst seven days of the menstrual period, when the contraceptive eﬀect is immediate. It is licensed for 5 years of use and is more than 99% eﬀective. A new frameless device containing progestogen has already been developed (Fibroplant-LNG) and has been trialled in several countries, including Belgium. In addition, a lower dose T-frame IUS called Femilis (Femilis Slim for nulliparae) have been developed with trials also being undertaken in Belgium regarding its use and eﬃcacy. It is not known, however, if these products will be introduced into the UK market in the near future.

Specific considerations

Irregular vaginal bleeding is common initially with the IUS, and then it gradually ceases. The uterine bleeding associated with the IUS is lighter than the menstrual period experienced when using a copper IUCD, with possible amenorrhoea in the long term. The failure rates of both intrauterine methods compare favourably with female sterilization.

Postpartum considerations

The IUS and copper IUCD have no adverse eﬀect on lactation. They can be inserted 4 weeks aher vaginal birth or Caesarean section (FSRH 2009b). Following miscarriage or induced termination of pregnancy, immediate insertion is safe.

Barrier methods of contraception (male and female methods)

Barrier methods of contraception prevent the sperm coming into contact with the oocyte. These methods include male and female condoms, caps and diaphragms which can be used in conjunction with spermicidal preparations to further increase their efficacy.

Some of the advantages of using condoms are that they are easily available at many outlets in the UK and using them does not require medical intervention. They oﬀer some protection against STIs (FPA 2011b ) and cervical cancer and can be used with another method of contraception. This is ohen called ‘double Dutch method’. One of the main disadvantages of using barrier methods of contraception is the possible interruption to sexual intercourse, which may be off-putting for some couples.

It is good practice to ensure that anyone choosing a barrier method is also aware of emergency contraception and how to access it, should it be required.

Male condom

Some 4.4 billion couples worldwide use the male condom (Fig. 27.5) for contraception, with 6 billion couples using it for Human Immunodeﬁciency Virus (HIV) prevention.

However, there are striking geographical diﬀerences. Japan accounts for more than one- quarter of all condom users in the world, being used by 75% of the contraception-using population. By contrast, and despite the substantial problem of HIV, the use of this method of contraception remains remarkably low in Africa, the Middle East and Latin America (Guillebaud and MacGregor 2013).

[pic]

FIG. 27.5 Male condom. Photograph K Jackson.

Guillebaud and MacGregor (2013) state that recent studies show approximately 25% of all couples in the UK use condoms but this may be occasional use or in addition to other methods. There are many varieties of condoms on the market, including latex, hypoallergenic and polyurethane. Polyurethane condoms are less sensitive to heat and humidity and not affected by oil-based lubricants (FPA 2011b).

Correct use of condoms is essential. Only condoms with a CE (European standard) mark should be used and the expiry date should be checked on the condom's package. Condoms should be stored away from extremes of heat, light and damp and care should be taken when handling the condom to prevent it from tearing. The condom is rolled on to the erect penis before any genital contact is made, as it is possible for some sperm to be present in the pre-ejaculate (Guillebaud and MacGregor 2013). About 1 cm of air-free space must be leh at the tip of the condom for the ejaculate, otherwise the condom may burst. Some condoms are designed with a teat end for this purpose. The penis should be withdrawn very soon aher ejaculation before it reduces in size and the condom becomes loose. The condom should be held in place during withdrawal of the erect penis so that it does not slip oﬀ. The condom should only be used once, and then disposed of in a waste

bin: it should not be flushed down the toilet.

Oil-based lubricants can damage rubber condoms but not polyurethane types. Water- based lubricants are not known to cause damage and are therefore recommended.

The eﬃcacy of the condom if used correctly is 98% but is dependent on experience and age of the user.

Female condom

The female condom consists of a polyurethane sheath that is inserted into the vagina (Fig. 27.6). The closed inner end is anchored in place by a polyurethane ring, while the outer edge lies ﬂat against the vulva. It is available free from contraception clinics and may be purchased from selected chemists. Great care has to be taken to ensure that the penis is inserted inside the polyurethane sheath and not incorrectly positioned between the condom and the vaginal wall.

[pic]

FIG. 27.6 Female condom. Image reproduced courtesy of Sciencephoto, with permission.

The eﬃcacy depends on age and experience of the user, as with the male condom; however, the FPA (2011b) states that if it is used correctly it is 95% effective.

Diaphragm

A diaphragm consists of a thin rubber dome with a metal circumference to help maintain its shape (Fig. 27.7). A range of types and sizes are available and, in the UK, diaphragms are individually ﬁfed at contraception clinics and some GP practices. Less than 1% of women use this method of contraception in the UK (Guillebaud and MacGregor 2013). It is not used widely in developing countries and Guillebaud and MacGregor (2013) believe

this may be due to the fact that the device requires medical fitting.

[pic]

FIG. 27.7 The diaphragm. Image reproduced courtesy of Sciencephoto, with permission.

When in place, the rim of the diaphragm should lie closely against the vaginal walls and rest between the posterior fornix and the symphysis pubis. Before insertion, a spermicide should be applied. Aher insertion, the woman has to check that her cervix is covered by the diaphragm (see Fig. 27.8). In order to preserve spontaneity during sexual intercourse, the diaphragm can be inserted every evening as a matter of routine.

[pic]

FIG. 27.8 The diaphragm in place.

If sexual intercourse occurs more than 3 hours aher insertion of the diaphragm, then additional spermicide is required. The diaphragm must be leh in place for at least 6 hours aher the last intercourse, to ensure any sperm cannot reach the cervix. Once

removed, the diaphragm should be washed with a mild soap, dried and inspected for any damage. A new diaphragm should be ﬁfed annually or following a loss or gain in weight of more than 3 kg.

Eﬃcacy depends on the age and experience of the user and the FPA (2010a) quote that it is between 92% and 96% effective if used according to their guidance.

Cultural beliefs may aﬀect use of this method, for example in Judaism, where it is viewed as unacceptable to use any method of contraception that prevents the sperm from reaching its intended goal (Jogee 2004).

Postnatal considerations

The size of diaphragm should be reassessed at the 6th week postpartum, when the vagina and pelvic ﬂoor muscles will have regained some of their tone and any tissue injury sustained from the birth will have healed.

Cervical and vault caps

Cervical and vault caps cover only the cervix, adhering to it by suction. They are made of rubber and look smaller in diameter than the diaphragm (Fig. 27.9). They require ﬁfing at a contraception clinic. Only one cervical cap, the FemCap, is now available in the UK (Guillebaud and MacGregor 2013).

[pic]

FIG. 27.9 The cervical/vault cap. Image reproduced courtesy of Sciencephoto, with permission.

Spermicidal products

Spermicidal agents have not been shown to increase eﬃcacy of condoms and because they can cause irritation to genitalia, may in fact increase the risk of HIV transmission. Use of Nonoxinol-9 lubricated condoms is no longer generally recommended. However, current advice is still to use this spermicide with the female barrier methods – diaphragms and caps – as this has been shown to be beneﬁcial (Guillebaud and MacGregor 2013). Up until recently, a range of spermicidal products were available for use in the UK. However, the only product now available is Gygel, a clear gel containing Nonoxinol-9. Spermicidal pessaries are no longer available in the UK. Foams and aerosols are yet to be introduced into the UK market, but may well be available in other countries (Guillebaud and MacGregor 2013).

Efficacy

General teaching in the UK is that spermicidal products are not eﬀective when used alone.

Emergency contraception

Emergency contraception is required when contraception has not been used before, or during sexual intercourse, used incorrectly or when there is perceived to have been a failure in the contraception used, e.g. a condom mishap such as breaking, tearing or coming off. There are three types of emergency contraception:

• emergency hormonal contraception (EHC)

• selective progesterone receptor modulator (SPRM)

• copper intra-uterine contraceptive device (IUCD).

Emergency hormonal contraception (EHC)

EHC is a progestogen preparation with the brand name Levonelle which consists of one pill containing 1.5 mg of levonorgestrel and is available in many countries throughout the world. In the UK it is free from sexual health clinics, walk-in centres, some accident and emergency departments and GP practices. Many health centres and clinics provide EHC free of charge through selected pharmacies in an eﬀort to reduce unwanted pregnancies. It can also be purchased over the counter from pharmacies.

This method works by delaying ovulation or preventing implantation of the fertilized oocyte, depending on the stage of ovulation. This method may be contraindicated if there has been more than one episode of unprotected sexual intercourse (UPSI) during the cycle, as the earlier sexual intercourse may already have resulted in a pregnancy. Very careful questioning by the practitioner needs to take place prior to supplying EHC to prevent an unfavourable outcome.

Nausea is uncommon with the progestogen-based pill but an additional pill may be required if the woman vomits within 2 hours of taking the medication. The next menstrual period may begin earlier or later than expected and it should be stressed that

contraception must be used until the next period commences. If the woman receives the EHC in a contraception clinic in the UK, she is always given an appointment to return to the clinic if menstruation does not commence on time, or is shorter or lighter than usual. If menstruation is more than 7 days late, a pregnancy test will be oﬀered. Any unusual lower abdominal pain must be investigated as this could be a sign of an ectopic pregnancy.

The eﬃcacy of EHC depends on how quickly the emergency contraception is commenced. If taken within 24 hours of unprotected sexual intercourse, it will prevent 95% of pregnancies. This gradually decreases to 58% by 72 hours (FPA 2011c ). There are very few contraindications to using this method but those health professionals administering Levonelle need to know about any other medication being used by the woman. Emergency hormonal contraception can be used more than once in each menstrual cycle, but it may disrupt the menstrual period pattern.

Selective progesterone receptor modulator (SPRM)

Ulipristal acetate with the brand name ellaOne is an emergency contraception that has been in use since 2009. In the UK ellaOne is free from sexual health clinics, walk-in centres, some accident and emergency departments and GP practices. It is given as a

30 mg oral dose which should be taken as soon as possible aher UPSI or failed contraception. The action of SPRM is thought to be due to inhibition or delay in ovulation and alteration of the endometrium (Brache et al 2010). EllaOne is licensed for up to 120 hours following an exposure of risk to pregnancy. Only one dose of ellaOne can be taken per menstrual cycle. As with EHC, careful questioning within a consultation is required to ensure that there has been no previous risk of pregnancy either within a previous or the current menstrual cycle.

Randomized controlled trials (RCTs) have shown that ellaOne is at least as eﬀective at preventing pregnancy as Levonelle, and pooled data demonstrate that ellaOne is more effective than EHC up to 120 hours following UPSI or failed contraception (FSRH 2011b).

Side-eﬀects include abdominal pain, menstrual disorders such as irregular vaginal bleeding, disruption to the menstrual cycle with most women reporting lengthening of their cycle by 3 days; however, some women report a shortening of their cycle. Drug interactions can occur with liver enzyme-inducers such as carbemazepine and drugs that increase gastric pH, such as antacids. Ulipristal binds to progesterone receptors and therefore may reduce the eﬃcacy of progesterone-containing contraceptives ( FSRH 2011b).

Women may be asked to return to the clinic in 3-4 weeks to have a pregnancy test, or if menstruation is more that 7 days late.

The copper intrauterine device (IUCD)

The IUCD is the most eﬀective method of emergency contraception, with a failure rate of less than 1%. Implantation of the fertilized oocyte is avoided if the IUCD is inserted

within 5 days of UPSI or earliest estimated date of ovulation. This provides the clinician a much longer time range in which to oﬀer emergency contraception. For example, in a regular 28-day cycle, the IUCD can be fitted up to day 19 of the cycle. It can then be left in place for use as a regular method of contraception, or removed during the next menstrual period.

Coitus interruptus

Technically coitus interruptus should not be considered a form of contraception as it potentially has a high failure rate. It involves withdrawal of the penis from the vagina prior to ejaculation, and couples should be made aware of emergency contraception. Many euphemisms are used when referring to this, such as ‘being careful’ or the ‘withdrawal method’. Andrews (2005) gives a rate of 90% eﬀectiveness as a contraceptive. Failure is due to the small amount of semen that may leak from the penis prior to ejaculation with the potential of penetrating the ovum. The success of this method depends on the man exercising a great amount of self-control and is based on trust and honesty. This method is used widely throughout the world by diﬀerent cultures and is the oldest form of contraception, being referred to in the Old Testament of the Bible.

Fertility awareness (natural family planning)

The study of fertility awareness, previously (and sometimes still) referred to as natural family planning, is a fascinating observation of the way in which the female body works to produce the optimum conditions for conception.

According to UK Medical Eligibility Criteria for Contraceptive Use (FSRH 2009b), Natural Family Planning includes all the methods of contraception based on the identiﬁcation of the fertile time in the menstrual cycle. The eﬀectiveness of these methods depends on accurately identifying the fertile time and modifying sexual behaviour. To avoid pregnancy, the couple can either abstain from sexual intercourse or use a barrier method of contraception during the fertile time. Natural methods are afractive to couples who do not wish to use hormonal or mechanical methods of contraception. The midwife can provide the appropriate FPA leaﬂet, signpost the couple to the local contraception clinic or ﬁnd local information on fertility awareness teachers and available education from the website: .

The method can also be used as a guide to women wishing to become pregnant, by concentrating sexual intercourse on the days they are most fertile. The fertile time lasts around 8–9 days of each menstrual cycle. The oocyte survives for up to 24 hours, however the FPA (2010b) suggest that a second oocyte could, occasionally, be released within 24 hours of the ﬁrst. In addition, the FPA (2010b) state that as a sperm can live inside a female body for up to 7 days, this means that should sexual intercourse occur 7 days before ovulation, a pregnancy could result.

Fertility awareness methods

Physiological signs of fertility are:

• cervical secretions (Billings or ovulation method)

• basal body (waking) temperature

• cervical palpation

• calendar calculation.

Cervical secretions

Following menstruation the vagina will become dry. As oestrogen levels rise, the ﬂuid and nutrient content of the secretions increases to facilitate sperm motility, consequently a sticky white, creamy or opaque secretion is noticed. As ovulation approaches the secretions become wefer, more transparent and slippery with the appearance of raw egg white that are capable of considerable stretching between the ﬁnger and thumb. The last day of the transparent slippery secretions is called the peak day, which coincides closely with ovulation. Following ovulation, the hormone progesterone causes the secretions to thicken forming a plug of mucus in the cervical canal, acting as a barrier to sperm. The secretions will then appear sticky and dry until the next menstrual period.

When practising this method of contraception, the cervical secretions are observed daily. The fertile time starts when secretions are ﬁrst noticed following menstruation and ends on the third morning aher the peak day. If the secretions are used as a single indicator of fertility, the presence of seminal ﬂuid can make observation diﬃcult. Changes in secretions will be aﬀected by seminal ﬂuid, menstrual blood, spermicidal products, vaginal infections and some medications (Guillebaud and MacGregor 2013).

Postpartum considerations

In the ﬁrst 6 months following childbirth, the majority of women who are fully breastfeeding will be able to rely on the lactational amenorrhoea method (LAM) for contraception. Women who wish to continue using natural methods of contraception should begin observing cervical secretions for the last two weeks before the LAM criteria will no longer apply (i.e. 5 months and 2 weeks postpartum), in order to establish their basic infertile pattern.

Basal body temperature

A woman can calculate her ovulation by recording her temperature immediately on waking each day. Should the woman have arisen during the night, she must take at least

3 hours rest before recording her temperature. Aher ovulation, the hormone progesterone produced by the corpus luteum causes the temperature to rise by about 0.2

°C. The temperature remains at this higher level until the next menstrual period. The infertile phase of the menstrual cycle will begin on the third day aher the temperature rise has been observed. Andrews (2005) points out that the temperature can be aﬀected by infection, therefore care needs to be taken when interpreting temperature charts.

Postpartum considerations

A mother with the demands of a new baby may ﬁnd diﬃculty in recording her temperature at the same time every day. Consequently many women prefer to rely on examining cervical secretions, or combine noting secretions with cervical changes at this time.

Cervical palpation

Changes in the cervix throughout the menstrual cycle can be detected by daily palpation of the cervix by the woman or her partner. Aher menstruation the cervix is low, easy to reach, feels ﬁrm and dry and the os is closed. As ovulation approaches, the cervix shortens, sohens, sits higher in the vagina and the os dilates slightly under the inﬂuence of oestrogen.

Postpartum considerations

Hormonal changes in pregnancy take around 12 weeks to sefle postpartum. The cervix will not revert completely to its pre-pregnant state as the os will remain slightly dilated even in the infertile time.

Calendar calculation

The calendar method (see Fig. 27.10) is based on observation of the woman's past menstrual cycles. When commencing to use this method, the specialist practitioner and the woman should examine the previous six menstrual cycles (Andrews 2005). The shortest and longest cycles over the previous six months are used to identify the likely fertile time. The ﬁrst fertile day is calculated by subtracting 21 days from the end of the shortest menstrual cycle. In a 28-day cycle, this would be day 7. The last fertile day is calculated by subtracting 11 days from the end of the longest menstrual cycle. In a 28-day cycle, this would be day 17. Cycle length is constantly reassessed and appropriate calculations made. Guillebaud and MacGregor (2013) indicate that the calendar method is not suﬃciently reliable to be recommended as a single indicator of fertility, but is useful when combined with other indicators of fertility. Ovulation usually takes place 14 days before the ﬁrst day of the next menstrual period. Therefore a woman who has a 28- day cycle would ovulate on approximately day 14 of her cycle and a woman who has a 30- day cycle would ovulate on approximately day 16 of her cycle.

[pic]

FIG. 27.10 Natural family planning: The fertility awareness (rhythm) method. Diagram to illustrate rhythm method of contraception in a 28-day menstrual cycle.

Postpartum considerations

Calendar calculations must be recalculated once normal menstruation has recommenced.

Symptothermal method

This is a combination of temperature charting, observing cervical secretions and calendar calculation, with the option of observing cervical palpation in order to identify the most fertile time. Andrews (2005) also includes in this method the observation of ovulation pain or ‘mittelschmerz’ and cyclic changes such as breast tenderness. Use of more than one indicator increases the accuracy in identiﬁcation of the fertile time. When combining indicators, a couple should avoid sexual intercourse from the ﬁrst fertile day by calculation, or the ﬁrst change in the cervix until the third day of elevated temperature, provided all elevated temperatures occur after the peak day.

Fertility monitoring device

These hand-held computerized devices monitor luteinizing hormone (LH) and oestrone- 3-gluronide (a metabolite of oestradiol) through testing the urine. The most well known in the UK is the ‘Persona’ monitoring device which is about 94% eﬀective and will detect from the urine test when a woman is fertile, indicating this through a series of lights. A green light indicates the infertile phase and a red light indicates the fertile phase, therefore barrier methods must be used should sexual intercourse be contemplated. A yellow light indicates that the database requires more information and a further urine test is required.

Postnatal considerations

The fertility monitor is not recommended as a method of contraception during lactation. The manufacturers of the Persona recommend that a woman has had two normal menstruations with cycle lengths from 23 to 35 days before using the monitor at the beginning of the third period (Guillebaud and MacGregor 2013).

Lactational amenorrhoea method (LAM)

It is thought that the action of the infant suckling at the breast causes neural inputs to the hypothalamus. This results in the inhibition of gonadotrophin release from the anterior pituitary gland, leading to suppression of ovarian activity. The delay in return of postnatal fertility in lactating mothers varies greatly as it depends on paferns of breastfeeding, which are inﬂuenced by local culture and socioeconomic status. The time taken for the return of ovulation is directly related to sucking frequency and duration. The maintenance of night-feeds and the introduction of supplementary feeds also aﬀects the return of ovulation.

The lactational amenorrhoea method (LAM) is a very eﬀective method of contraception when used according to the Bellagio consensus statement (Guillebaud and

MacGregor 2013). Research data concludes that there is over 98% protection against pregnancy during the ﬁrst 6 months following birth if a woman is still amenorrhoeic and fully or almost fully breastfeeding her baby (FPA 2010b ). In order to conﬁrm that LAM remains eﬀective as a contraceptive method, the woman should be asked if three questions (as indicated in Fig. 27.11) still apply. Mothers who work outside the home can still be considered to be nearly fully breastfeeding, provided they stimulate their breasts by expressing breastmilk several times a day.

[pic]

FIG. 27.11 Natural contraception: lactational amenorrhoea method (LAM).

The LAM is not recommended for use aher 6 months following birth, because of the increased likelihood of ovulation. Studies throughout the world have been conducted on the eﬀectiveness of LAM as a contraceptive, conﬁrming a rate of over 98% protection against pregnancy (Labbok 2012), suggesting it is a viable option for some postnatal breastfeeding women.

Male and female sterilization

This is the choice of contraception for many couples once they have decided their family is complete. Sterilization should be viewed as permanent, although in a few cases reversal of the operation is requested. Couples requesting sterilization need thorough counselling to ensure that they have considered all eventualities, including possible changes in family circumstances. Although consent of a partner is not necessary, joint counselling of both partners is desirable. The procedure is available on the NHS for both sexes but waiting times can vary. There are no alterations to hormone production following sterilization in males or females and some couples ﬁnd the freedom from fear of pregnancy very liberating.

Female sterilization

An estimated 600 million women worldwide have undergone female sterilization (Guillebaud and MacGregor 2013). During the procedure (Fig. 27.12), the uterine tube is occluded using division and ligation, application of clips or rings, diathermy or laser

treatment.

[pic]

FIG. 27.12 Female sterilization.

The operation is performed under local or general anaesthetic. The procedure can be performed via a laparotomy, minilaparotomy or laparoscopy. It can also be performed vaginally using a hysteroscope. The procedure usually requires a day in hospital.

Women are advised to continue to use contraception for four weeks following the procedure, or in the case of hysteroscopic sterilization (Essure) contraception should continue for 3 months, aher which successful tubal blockage is conﬁrmed by hysterosalpingography (FPA 2010c ). The couple should be advised to seek medical help urgently if they suspect pregnancy following sterilization because of the increased risk of

ectopic pregnancy if the procedure is unsuccessful.

Postpartum considerations

Should sterilization occur around the time of birth, it is vital that the woman receives thorough counselling prior to the procedure to avoid any regret later on. Women are ohen advised to wait 6 weeks aher the birth before undergoing the procedure. The FRSH (2009a) suggest that if sterilization is going to be undertaken at the same time as an elective caesarean operation, then one week or more should be provided for counselling and decision-making before the procedure finally takes place.

Guillebaud and MacGregor (2013) suggest that a waiting period of 12 weeks is desirable to ensure that the couple will have no regrets over the sterilization.

The failure rate for female sterilization is 1 in 200 (FPA 2010c ). Reversal of the sterilization is not usually available though the NHS in the UK and can be diﬃcult and expensive to obtain privately. Women considering sterilization should be made aware of the availability of LARC methods, which are highly effective but reversible.

Male sterilization (vasectomy)

The procedure of male sterilization involves excision or removal of part of the vas deferens, which is the tube that carries sperm from the testes to the penis (Fig. 27.13). A small cut or puncture to the skin of the scrotum is made to gain easier access to the vas deferens. The tubes are cut and the ends closed by tying them or sealing them with diathermy. The wound on the scrotum will be very small and stitches are not usually required. In the UK the operation is carried out in an outpatients department or clinic sefing. It is usually completed under local anaesthetic and takes around 10–15 minutes. Men are advised to refrain from excessive physical activity for about one week and to avoid heavy lifting following the procedure (Andrews 2005).

[pic]

FIG. 27.13 Male sterilization (vasectomy).

It may take some time for sperm to be cleared from the vas deferens; it can take approximately 12 weeks aher the operation for this to occur. Consequently, the semen must be tested to conﬁrm that it no longer contains sperm and sometimes further tests are necessary to conﬁrm the absence of sperm. Sexual intercourse can take place during this period but contraception must be used until a negative sperm result is confirmed.

The failure rate of male sterilization is 1 in 2000 (FPA 2010c). Careful counselling needs to take place before the procedure is carried out. Reversal of vasectomy is not usually available through the NHS and Andrews (2005) quotes around a 50% success rate in achieving a pregnancy following successful reversal within 10 years of the procedure being undertaken.

The future of contraception and sexual health services

In the UK the government remains commifed to developing conﬁdential, non- judgemental, integrated sexual health services, including STI screening and treatment, contraception, termination of pregnancy, health promotion and prevention (HM Government 2010). A recent Department of Health (DH) publication, ‘A framework for sexual health improvement in England’ (DH 2013), sets out a clear strategy for tackling sexual health issues such as STIs and teenage pregnancy. However, current ﬁnancial challenges mean that the FSRH (2012) are concerned that budget cuts and changes to commissioning processes may compromise access to and quality of contraceptive and sexual health services for the forseeable future.

In response to the Social Exclusion Unit Report (DH 1999), many NHS Trusts now provide clinics and projects for young people, and improved access to contraceptive and sexual health services has led to a decrease in the conception rate of the under-18s. One of the speciﬁc targets of this report was to reduce the teenage pregnancy rate by 50% by 2010. The actual statistics showed a 13.3% decline in conceptions to the under-18s and 25% reduction in births in this same age group. Plans to decrease teenage conceptions further continue (DH 2010). With strict adherence to the Fraser guidelines (Guillebaud and MacGregor 2013), teenagers under the age of 16 can receive advice and treatment from a contraceptive and sexual health practitioner.

T h e NICE guidelines (2005) have emphasized the need to promote long acting reversible contraception (LARC). This recommendation will encourage more women to use a form of contraception that does not have to be remembered on a daily basis.

There is a trend in the UK for many women to have their children later in life and to have much smaller families. Throughout the world, couples will seek to ﬁnd new ways to limit their family size as the need to reduce population growth continues (Guillebaud and MacGregor 2013).

Ongoing developments

An extended regimen of combined contraceptive pills for 84 days, e.g. Seasonale, has been conﬁrmed to be safe. Seasonale is a COC pill that has the equivalent of Microgynon

30 but is packaged in four packets to be taken consecutively followed by a pre- determined pill-free interval (Guillebaud and MacGregor 2013). It is currently licensed in many countries, including the USA, and may be available in the UK soon. Other similar products include Seasonique. Alternative delivery systems reducing the need for daily pill-taking are being explored. Subcutaneous injections (depo-subQ) and chewable tablets are being developed for progestogens. Research into biodegradable implants (which would be particularly useful in low income countries) and the use of transdermal spray for the delivery of a potent progestogen is ongoing. The Population Council is considering research into proteomics and an immunological approach to contraception. Eﬀective methods for men are still problematic and the long-awaited male pill is still not imminent (Guillebaud and MacGregor 2013). Gene blockers (reducing sperm mobility), the male patch and heat-based methods are amongst those being developed. Long acting testosterone injections with implanted progestogens or semen blocking methods may be available in the future (Dorman and Bishai 2012).

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