Postpartum contraception — structured SAQ (15 marks)

(a) The counselling conversation opener (2 marks)

One mark for the question, one for the rationale. ^[1]

• Open with "Do you think you might want to become pregnant again in the next year or two?" — a reproductive-intention question, not a closed "Do you want contraception?" which elicits a default "no".^[1]
• The rationale: it frames the whole conversation around her goals, opens the long-acting-versus-short-acting discussion, and is the single most evidence-based intervention in postpartum contraception counselling.
• Avoid coercion: present options, document her autonomous choice, and respect a decision to defer.

(b) Methods by WHO-MEC category in breastfeeding day 1 (5 marks)

One mark per method group correctly classified, with the category stated. ^[2]

Category 1 — start immediately, breastfeeding or not:^[2]

• Copper intrauterine device and levonorgestrel intrauterine system
• Etonogestrel subdermal implant
• Progestogen-only pill (levonorgestrel 30 µg or norethisterone 350 µg)
• Depot medroxyprogesterone acetate 150 mg IM every 12 weeks

Category 4 — do not start in breastfeeding under 6 weeks:^[2]

• Combined oral contraceptive pill, contraceptive patch, contraceptive ring (oestrogen-containing)

Category 2/3 — wait or use clinical judgement:^[2]

• Combined hormonal contraception becomes category 3 from 6 weeks to 6 months in breastfeeding, category 2 after 6 months.
• Diaphragm: refitted at 6 weeks once involution is complete.

(c) Immediate postpartum intrauterine device — the evidence (4 marks)

Two marks for the expulsion figure and the uptake argument; one for naming the Cochrane review; one for the counselling message. ^[1]

• The Cochrane review (Lopez and colleagues) found that immediate postpartum intrauterine device insertion is associated with higher expulsion rates than interval insertion — post-placental or within 48 hours typically 8 to 14 percent at vaginal birth and 4 to 10 percent at caesarean, compared with 3 to 5 percent for interval insertion.^[1]
• Despite the higher expulsion, net intrauterine device use at 6 months is greater with immediate insertion because uptake dramatically exceeds the interval path — many women who plan an interval insertion never attend the follow-up visit.
• The honest counselling message quotes both numbers: expulsion and net use. Quoting only expulsion denies her the method.
• A device that is expelled is replaced; a woman who never returns to clinic has no method.

(d) The LAM triad (2 marks)

One mark for the three criteria stated together; one for the failure rate and the trigger for switching. ^[3]

• The three criteria: (1) baby under 6 months, (2) fully or nearly fully breastfeeding (no supplements, no long intervals), (3) amenorrhoeic.^[1]
• Perfect-use failure rate is approximately 2 percent (98 percent effective) — but only with all three criteria met.
• LAM is no longer reliable when any one criterion is broken — supplementation, return of menses, or the baby reaching 6 months. Switch to a progestogen-only method, an intrauterine device, or an implant without stopping breastfeeding.

(e) Today's plan: insertion, consent, follow-up (2 marks)

One mark for the consent content; one for the follow-up plan. ^[1]

• Plan: immediate postpartum copper intrauterine device insertion is appropriate here — she is within 48 hours of an uncomplicated vaginal birth, has no chorioamnionitis, no active infection, and wishes to delay pregnancy for at least 3 years. A copper device lasts 10 years; a levonorgestrel device is an alternative if she wants lighter periods.^[3]
• Consent content: method efficacy, duration, the expulsion rate versus the net 6-month use benefit, the small risk of perforation, the alternative (implant, equally long-acting, slightly lower expulsion-equivalent burden), and the right to withdraw at any time.
• Follow-up: review at 4 to 6 weeks to check threads and confirm placement; sooner if pain, bleeding, or expulsion is reported. Document the method, insertion details, and review plan in the discharge letter to the general practitioner.