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Expanding Clinicians' Roles in Breastfeeding Support: Focus on Maternal & Infant Care Prenatally and During the Hospital Stay: Continuing Medical Education (CME) Online Tutorial

  • Section 1
  • Section 2
  • Section 3
  • Section 4
  • Section 5
  • References
  • Resources
  • Post Test
  • Results and Certificates

Section 4: Special Topics

Family Planning

During the last half of pregnancy and early postpartum visits, obstetricians will discuss family planning options with mothers, including any potential effects of choices on breastfeeding. When counseling nursing mothers, it is important to review the following key points to ensure effective family planning without negatively affecting breastfeeding.37

Hormonal Methods and IUDs

  • Mothers should avoid estrogen-progesterone contraceptives if at all possible until lactation is completed. Combination contraceptives can sometimes decrease milk supply and reduce lactation duration, especially when started early postpartum. The negative impact on the infant is more likely due to reduced milk supply and, therefore, reduced weight gain, rather than from exposure to contraceptive hormones.
  • Similar to oral contraceptive pills, other combination products such as etonogestgrel/ethinyl estradiol vaginal ring (NuvaRing™) and noreigestromin/ethinyl estradiol transdermal system (OrthoEvra™ patch) should be avoided while breastfeeding.
  • Progesterone-only oral contraceptives rarely reduce milk supply; however other considerations include that:
    • They should only be started in patients who have well-established lactation.
    • Giving a mother a dose of medroxyprogesterone (Depo-Provera™) immediately postpartum in the hospital is more likely to negatively impact breastfeeding success and duration. Mothers should wait until 6 weeks postpartum to receive the injection if possible. This should be balanced with her risk of conceiving a pregnancy in the early postpartum period, which for some women, may be very high. In addition, some women are at high risk for not returning for follow up care, thus, they may benefit from early initiation of contraception.
    • For emergency contraception, mothers should choose a progesterone-only option such as levonorgestrel (e.g., Plan B™, Next Choice™) over combination products such as levonorgestrel/ethinyl estradiol (e.g., Preven™
    • Emergency Contraception Kit); however, a one-time dose of any combination emergency contraception would not likely have a major impact on overall milk supply.
  • Intrauterine devices such as Mirena™ (Levonorgestrel), Nexplanon™ (Etonogestrel), and ParaGard™ (copper IUD) are acceptable contraceptive choices for nursing mothers; however, postplacental placement of a levonorgestrel intrauterine device compared with delayed placement of the device was associated with lower rates of exclusive breastfeeding at 3 months and 6 months.36

Lactational Amenorrhea Method (LAM)

LAM is the natural infertility a new mother experiences while amenorrheic and nursing her baby.51 A mother who meets all of the following three criteria has a low risk of pregnancy when using LAM as a family planning method:

  • her menses have not returned since delivery (bleeding or spotting during the first 56 days postpartum is not considered menstrual bleeding)
  • she is exclusively breastfeeding her baby day and night
  • her baby is less than six months of age

If any of these three conditions is not met, additional birth control is recommended. It is imperative that a mother understands that the return of menses requires additional contraception and that LAM, even under the three conditions listed above, is not 100% effective. The introduction of solid foods reduces the frequency of breastfeeding and therefore reduces the effectiveness of LAM. The risk of pregnancy varies according to feeding practice during the first six months:

  • Exclusive breastfeeding: 0.5%
  • Full breastfeeding (i.e., occasional food or liquids): 2%
  • Working mothers pumping milk at work: 5%
  • Previous
  • Breastfeeding in the NICU
  • Special Topics
  • Breastfeeding in the NICU
  • Ankyloglossia (Tongue Tie)
  • Additional Considerations and Breastfeeding

""Image courtesy of Lucia Jenkins

Health Resources in Action logo

Roger A. Edwards, ScD
Consultant
Massachusetts Department of Public Health
508-472-0406
rogeredwards2002@hotmail.com

Rachel Colchamiro, MPH, RD, LDN, CLC
Director of Nutrition Services
Nutrition Division
Massachusetts Department of Public Health
617-624-6153
rachel.colchamiro@state.ma.us

massachusetts department of health logo

Rachel Colchamiro, MPH, RD, LDN, CLC
Director of Nutrition Services
Nutrition Division
Massachusetts Department of Public Health
617-624-6153
rachel.colchamiro@state.ma.us

Ellen Tolan, RD, LDN, IBCLC
State Breastfeeding Coordinator
Nutrition Division
Massachusetts Department of Public Health
617-624-6128
ellen.tolan@state.ma.us

Julie Forgit, LDN, CLC
State WIC Breastfeeding Peer Counselor Program Coordinator
Nutrition Division
Massachusetts Department of Public Health
617-624-6139
julie.forgit@state.ma.us

american academy of pediatrics logo

Susan Browne, MD
Breastfeeding Coordinator
MA Chapter
American Academy of Pediatrics
978-685-0977
brnfaap@mac.com

Mary Foley, RN, BSN, IBCLC
Lactation Program Coordinator
Melrose-Wakefield Hospital
Hallmark Health System
791-507-1980
mfoley@hallmarkhealth.org

Lucia Jenkins, RN, IBCLC, RLC
Melrose-Wakefield Hospital
Hallmark Health System
791-507-1980
luciansla@aol.com

Melrose Wakefield Healthcare

Lauren E. Hanley, MD, FACOG, IBCLC
Assistant Professor of Obstectrics, Gynecology
and Reproductive Biology
Harvard University School of Medicine
Massachusetts General Hospital
617-724-2229
lehanley@partners.org

Mary Ellen Boisvert, MSN, CLC, CCE
Six Sigma Black Belt
University of Massachusetts Dartmouth
Assistant Clinical Professor, College of Nursing

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