Postpartum contraception — structured oral station (12 minutes)

Opening prompt — "How do you begin the conversation?"

Model response: ^[1]

• "I would open with a reproductive-intention question, not a method question: 'Do you think you might want to become pregnant again in the next year or two?' That frames the whole conversation around her goals."^[1]
• "Then I would take a brief focused history: feeding intention (she is breastfeeding, which gates combined hormonal contraception), obstetric and medical history (provoked VTE in her first pregnancy, body mass index 38), medications, and sexual health risk."

Examiner is listening for: the opener, the risk-tier framing, and the recognition that combined hormonal contraception is contraindicated here.^[1]

Probe 1 — "She has read that the implant can reduce milk supply. What do you tell her?"

• "The Cochrane review of hormonal contraception in lactation concluded that the evidence on progestogen-only methods and breast milk composition is low to very low quality, and no high-quality trial has shown clinically important harm. The most recent non-inferiority randomised trial by Krashin and colleagues found that immediate etonogestrel implant placement was non-inferior to delayed placement on breastfeeding continuation."^[3]
• "So I would reassure her that the implant is safe in breastfeeding from day 1, WHO-MEC category 1, and offer it today."^[2]

Probe 2 — "She is worried the intrauterine device will fall out. What do you say?"

• "Her concern is reasonable. The Cochrane review found that immediate postpartum intrauterine device insertion is associated with higher expulsion rates than interval insertion — post-placental at vaginal birth typically 8 to 14 percent versus 3 to 5 percent for interval insertion."^[1]
• "However, 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. I would quote her both numbers honestly."^[1]
• "An intrauterine device that is expelled is simply replaced; a woman who never returns to clinic has no method. Given her body mass index and prior VTE, the implant is an equally long-acting alternative with no expulsion equivalent, and I would offer either."

Probe 3 — "What about combined hormonal contraception? She used the pill before."

• "Combined hormonal contraception is contraindicated here. With a prior VTE and a body mass index of 38 in the early puerperium, she is WHO-MEC category 4 — the venous thromboembolism risk is unacceptable. This holds whether or not she is breastfeeding under 6 weeks."^[2]
• "I would explain this clearly and offer the implant or the intrauterine device as the safer, more effective alternative."

Probe 4 — "She says she definitely does not want any more children. Can you sterilise her today?"

This is a communication, ethics and reproductive-justice probe. Demonstrate it out loud: ^[1]

• "I would explore her certainty, her partner's involvement if relevant, and the alternative of a long-acting reversible method that gives her the same protection with reversibility. The implant and intrauterine devices have continuation and effectiveness comparable to sterilisation in real-world use."^[1]
• "I would not consent her today. Permanent contraception consent should be obtained outside the emotional and physical stress of labour and the early puerperium, with a documented cooling-off period and counselling content that includes alternative methods, regret rates, and irreversibility."
• "Given her clinical context, she has a strong VTE contraindication to oestrogen — but the reversible methods address that fully. Permanent contraception would be appropriate if her decision is settled, after appropriate counselling and a separate consent visit."

Probe 5 — "She asks how she will know if the device has fallen out."

• "I would teach her to check the threads once a month after each period or at a regular reminder. Lost threads, pain, or a partner reporting feeling the device during intercourse are reasons to come back sooner."
• "At the routine 4-to-6-week review I would confirm threads are visible; if not, I would arrange a pelvic ultrasound to locate the device and exclude perforation or expulsion."^[1]

Probe 6 — "Her sister is Aboriginal and is also on the ward. How does your counselling differ?"

• "It does not differ in the methods offered — every woman deserves the same evidence-based options. It differs in the framing: I would be explicit about offering, not pushing, and acknowledge the historical weight of coerced sterilisation and contraceptive pressure on Aboriginal and Torres Strait Islander women in ANZ."
• "I would involve an Aboriginal health worker, use community-controlled services where available, and document her autonomous choice. Reproductive justice is a clinical skill, not an add-on."^[1]