Monday, September 17, 2012

A Hodgepodge of How-Tos for Women Charting Postpartum

As I mentioned in my last post, you should check out 1flesh.org (to convince you if you're not already using NFP, and for some laughs if you already are) and iusenfp.com (for some instruction) if you want to read up on the awesomeness that is natural family planning.

In my last post, I talked about my personal experiences using natural family planning in the postpartum period, and while breastfeeding. Now that I'm having my third go-around, I'm brushing up on my rules and sharing some of my observations with you all. I think I might *actually* be good enough at it now to give general advice to other people.

Please note: I am not a doctor, and I am not an NFP instructor. I am not a member of the Couple-to-Couple League. In fact, I don't even follow one method (Creighton, Billings, symptothermal, or any other) according to the letter of the law. My only qualifications are that I used NFP successfully to delay my first pregnancy (two years) and my third, and I have spent an unusual amount of time looking at this website (http://www.fertilityuk.org) and charting my cycles (8 years). My second conception was an experiment in "let's see what happens if we fail to abstain reliably to prevent pregnancy." (The answer, if you are happily married as I am, is apparently a baby born about 10 months later. Who knew?). What this all means is that I've only used NFP reliably during one postpartum period of my life, and I am self-taught. So take my comments with a grain of salt, and if you want more information than your body and I can give you, call around to natural family planning instructors in your area!

One bit of good news is that, for women who are fortunate enough to use the most natural method of feeding their baby, breastfeeding does tend to inhibit fertility. This may only be true when babies are nursed frequently and exclusively, so if you want to take advantage of it, you should start getting snuggly with your baby...a lot.

The lack of menstruation that women experience during breastfeeding is evidence of the fact that fertility is inhibited while a woman is breastfeeding, since no menstruation frequently also means no ovulation. Women do occasionally ovulate prior to menstruation while breastfeeding, but they also frequently experience anovulatory menstrual cycles, even after their period comes back. So even after her first few periods, a breastfeeding woman may still not be ovulating. No ovulation, of course, = no baby.

But if you've been paying attention, you'll note that I'm using words like "frequently" and "occasionally." And of course, "occasionally" does not equal "never," so what it all boils down to is this. Some women can and do get pregnant while breastfeeding (that is, assuming they are enjoying marital relations on occasion). La Leche League doesn't teach women about tandem nursing for nothing. Women even can and do get pregnant before their period returns while breastfeeding (that is, assuming they are enjoying marital relations on occasion). So you could do what my husband and I did for our second conception - "let's see what happens if we don't try to not have a baby?" But if you have a serious need to avoid pregnancy, you'd better fire up your cervical-mucus-interpretation skills, even before that period comes back.

OK, so here's my instruction manual.

The bad news: Your signs will look different than they did before you got pregnant.

The good news: After taking 10 months off, you probably won't remember what your signs looked like before you got pregnant. So just consider it a friendly reintroduction to your amazing fertility!

If you used a certain NFP method before pregnancy, your instructor will likely have some rules for postpartum pregnancy prevention, too. Mucus will be the only way you can determine fertility accurately before you get your period back, because the postpartum time is one giant pre-ovulatory stage until you are regularly menstruating again, and mucus is the only way to tell when you move from pre-ovulatory to fertile stage. So get comfortable with the words "goopy," "sticky," "tacky," and "slippery," because you're going to be hearing them a lot! I think temperatures, cervical changes, and any other signs and symptoms you have could be useful to cross-check your mucus readings if you think ovulation has already occurred. But in any case, you can't get around the mucus.

The presence of fertile mucus is the only way you'll be able to tell that you might get pregnant. I believe Creighton teaches women certain wiping methods to check their mucus on toilet paper, Billings teaches women to take heed of the sensation at the vaginal opening, and others probably want you to pay attention if anything shows up in your underwear. For me, I use all of the above AND what I see on my fingers following cervical checks, because, as I mentioned, I'm apparently super-fertile, and I don't want to miss any sign or symptom of the beginning of fertility. I don't often rely on sensation alone to determine the beginning of my fertile period, because between postpartum urinary incontinence and sweat, sometimes I can't distinguish it from fertile mucus. But if I do feel a wet or slippery sensation, I sit up and pay closer attention to my underwear, toilet paper, and fingers following cervical checks. Fertile mucus disappears after ovulation.

If you use them, cervical checks should be done once per day. You won't be able to tell the difference between a fertile and an infertile cervix if you don't track changes, and changes can only be detected over multiple readings. Always wash your hands BEFORE the cervical check, so that you don't introduce any nasty bacteria to your lady-parts, which are very sensitive to the disruption.

A note about resuming cervical checks initially following birth. You may want to wait several weeks after birth before beginning them, because of lochia (which makes cervical checks messy), tearing (which makes cervical checks potentially painful and/or likely to cause and infection to the wound), and confusion (because the cervix takes a little while to resume its normal shape and position following birth). If you are breastfeeding exclusively and you begin cervical checks at 6 weeks postpartum, I think you can be safe in assuming that your first three cervical checks, before enjoying any marital relations, will give you a good baseline for "infertile cervix." Make sure you do these before you resume marital relations, because as I describe below, seminal fluid kind of messes with all your observations. Cervical checks will not be able to tell you when your fertile period has begun, but it can be a helpful tool to confirm that ovulation has already occurred if you are abstaining during your fertile period.

During this postpartum time, our rules for avoiding pregnancy are thus:

RULE NUMBER ONE:

First of all, I think it's a good idea to wait the full 6 weeks following birth before resuming marital relations at all. You will be tired, you may have some tearing in your perineum, and it's just a good idea for your doctor to check out muscle tone and any scar tissue that has developed down there before you introduce a new...activity in the region. Not to mention any lochia/postpartum discharge. So I make that recommendation whether you are trying to avoid pregnancy or not. (P.S., I'm still not a doctor, but recommendations are recommendations.)

To avoid pregnancy, cease marital relations at the first sign of fertile mucus. The first days of ovulatory, fertile mucus are white and sticky, then they grow stretchier and stretchier, until the mucus is very clear and slippery right before and at ovulation. Additional tips for determining fertile mucus patterns, including illustrations, here.


RULE NUMBER ONE IN THE REAL WORLD:

So those are the general guidelines. Here are my observations about what happens in the real world, using myself as the one and only Example A (because no modest woman in her right mind goes around sharing these things in pub...oh, shoot):

Early mucus looks kind of like a yeast infection, but without the smell. If you suspect it might be a yeast infection and you have been doing your cervical checks, you will know you are infertile if it's smelly and your cervix is in the same spot, same firmness, and same opening.

Seminal fluid WILL mess with your observations if you don't know what to expect. If you are enjoying marital relations on occasion (which I also highly recommend for those who are happily married...still not a doctor, but recommendations are recommendations), you should see slippery "mucus" in the one, two, or three days following intercourse. It's actually seminal fluid, but there's no way to tell the difference, so to avoid pregnancy, you should wait for a few dry days before enjoying marital relations again.

In the absence of a yeast infection, and in the absence of seminal fluid, you may notice a pattern of infertile mucus on your fingers following cervical checks. One or two little bell-pepper-seed-sized clumps of white. I called them "vaginal boogers" in my last post. I promise, I am going to restrict talk of "vaginal boogers" to posts about natural family planning, lest I drive away all my readers (which I may have already done. Thank you if you've gotten this far.) This is more of an FYI, so you don't freak out and think that you are fertile ALL THE TIME simply because you are seeing a little bit of vaginal discharge every day. It may take some time for you to interpret this infertile discharge.

RULE NUMBER TWO:

If you are happily married but still trying to avoid pregnancy, wait for three days following the disappearance of fertility indicators to resume marital relations.

After you ovulate, your mucus will dry up. You should wait for a full three dry days before resuming marital relations to be confident of having entered the infertile state.

Enter, stage right, cervical checks. As I mentioned, the cervix is not terribly useful on the front end, because the presence of fertile mucus is a much more universal and easily-identifiable indication. BUT, if you are abstaining during your fertile period, cervical checks ARE useful for confirming that ovulation is complete and you have entered the infertile, post-ovulatory state. When you're infertile, the cervix is firm, high, and the opening is closed. As you approach the peak day of fertility, you will see mucus and you will notice your cervix begins to soften, drop, and open. After ovulation, your cervix will firm up, rise, and close immediately. Additional tips about cervical changes here. Again, wait for three days after the cervix firms up.

RULE NUMBER TWO IN THE REAL WORLD:


Oh, seminal fluid. Our dear friend AND bearer of much confusion. You who blur the lines between man and woman...

The cervix also changes in the presence of seminal fluid. In fact, just as seminal fluid resembles your most fertile mucus, seminal fluid will effect changes to your cervix that make it look like you are ovulating. This is owing to the prostaglandins in seminal fluid - which is incidentally the same thing that ripens your cervix for labor and why marital relations may induce labor in women who are pregnant. So your cervix, in the few days following marital relations, will be soft, low, and open, just like it is when you are ovulating. It will gradually rise, firm, and close up over a few days.

Since seminal fluid is so indistinguishable from your hyperfertile mucus, you should wait for three dry days following marital relations. That way the pre-ovulatory fertile mucus won't be masked by seminal fluid.

I note again that cervical checks are really only useful if you do them every day, because you won't know the difference between a firm and a soft cervix, or a high or a low cervix, unless you've been feeling it day after day and suddenly one day it feels different. Sometimes, in the first few months after delivery, you may feel your cervix get higher and lower depending on whether your rectum (which is right next door to the cervix) is full. This is because the muscles which hold your rectum in place are loose and stretched out following pregnancy and birth, and may permit some bulging in the rectum (which is, as I mentioned, right next door to your cervix).

Oh, wow, could this possibly involve any more bodily functions about which people do not normally speak in public? Probably not. But then again, I've never been shy to talk about these things, much to my husband's chagrin...

As I mentioned, you can't get around the mucus, and it's absolutely necessary to chart mucus to avoid pregnancy, but I really appreciate having a cross-check to mark the post-ovulatory period. It gives me peace of mind to know that my mucus observations and my cervix are telling me the same thing.


If there is a discrepancy between the disappearance of fertile mucus/return of dryness and the firming up of the cervix, choose whichever is more conservative. The discrepancy should only be a day or so (in my experience).

After the mucus dries up and the cervix firms up, you have entered the infertile, post-ovulatory state. If you are confident that ovulation has occurred based on mucus readings and cervix checks, after three dry days, marital relations carry a low risk of pregnancy (low as in, 0.5-8.0% percent low. By the way, that percentage of pregnancy prevention is at least comparable to some contraceptive methods, and  blows other contraceptive technologies right out of the water).


I assume you know how to do the "marital relations" part, since you did just have a baby, so I won't go into that in further detail.


Hope this is helpful to some of you who are trying to use natural family planning following the birth of a child, but would really like to plan your next conception carefully, like those of us Type I diabetics. Feel free to e-mail me with questions (beth dot g dot turner at gmail dot com). And do check out fertilityuk.org. I learned almost everything I know from that site, and I can't imagine you will come away from it without some useful tidbits.

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