Write to: Dr Seng Shay Way c/o Q&A Ask ObGyn, MotherNeeds, 141 Lentor Street, Singapore 786838, or fax us at 6456-0031, or email info@motherneeds.com with "Ask ObGyn" as your subject heading.
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Dr Seng Shay Way is a consultant obstetrician-gynaecologist at a private practice in Gleneagles Medical Centre. Dr Seng has been practicing and teaching for over 12 years.

In his spare time, Dr Seng enjoys photography and cooking.

Learn more about Dr Seng Shay Way.

Visit our Archives for ObGyn topics previously addressed.

Question 1:
Dear Dr Seng,

I would like to understand the possible risks involved in a third pregnancy. I had delivered my first two children via C-section due to pre-eclampsia. My blood pressure continues to remain relatively high after my two pregnancies at about 140/95; and is kept relatively under control with Apo-Aternol 25mg.

I am now 38 years old. Aside from the higher probability of having a child with down's syndrome or spina bifina, what other risks does a third pregnancy pose for me, considering my past pregnancy conditions?

Thank you.

Dinah Lee

Answer 1:
Dear Dinah,

There are several factors that would determine the risk of your next pregnancy.

Two previous caesarean section: as you had two previous caesarean section for delivery, you would need a third caesarean section for your third pregnancy, caesarean section comes with its own set of risks, like higher amount of blood loss, infection risk, general anaesthesia risk if GA is used;

Previous history of pre-eclampsia and current hypertension:

In general, the recurrence risk of preeclampsia in a woman whose previous pregnancy was complicated by preeclampsia near term is approximately 10%. If a woman had severe preeclampsia (including HELLP syndrome and/or eclampsia), she has 20% risk of developing preeclampsia sometime in her subsequent pregnancy. If a woman had HELLP syndrome or eclampsia, the recurrence risk of HELLP syndrome and eclampsia are 5% and 2%, respectively. The recurrence rate rises the earlier the disease manifested during the index pregnancy. If preeclampsia presents clinically before 30 weeks' gestation, the recurrence rate may be as high as 40%.

Pre-eclampsia can affect the fetus causing intra-uterine growth retardation, placental abruption, low amniotic fluid levels, and non reassuring fetal heart rate. For the mother the risk is hypertension, renal failure, fluids accumulating in the lungs, convulsions, clotting disorders.

Age: While advances in medical care can help women over age 35 have safer pregnancies than in the past, infertility and pregnancy complications for this age group are higher than for younger women. The risk of giving birth to a child with a birth defect does increase as the mother's age increases The traditional age at which a woman is considered to be at high risk for chromosomal abnormalities is 35. Approximately 1 in 1,400 babies born from women in their 20's have Down syndrome; it increases to about 1 in 100 babies born with Down syndrome from women in their 40s. Studies show that the risk of miscarriage (loss of a pregnancy before 20 weeks gestation) is 12% to 15% for women in their 20s and rises to about 25% for women at age 40. The increased incidence of chromosomal abnormalities contributes to this increased risk of miscarriage in older women. Chronic health problems, such as diabetes or high blood pressure, are more common in women in their 30s and 40s. Be sure to get these conditions under control before you become pregnant, since they pose risks to both you and your baby.

These are not trivial considerations and it would be prudent if you discuss this with your obstetrician first, it is also important to control your blood pressure, you may have to change the blood pressure medication to one that is safe for pregnancy prior to getting pregnant. Your obstetrician may also start you on aspirin therapy once you are pregnant.

All the best,

Dr Seng Shay Way

Question 2:
Dear Dr Seng,

I am currently breastfeeding my 10-month-old child. My husband and I are contemplating on whether we should have another baby, hence we have decided against going for a ligation or vasectomy.

Our current means of contraception is the withdrawal method paired with regular checks of the level of cervical mucus. If we rule out birth control pills as an option, what other forms of contraception would you recommend?

Thank you.

Abigail Cheng

Answer 2:
Dear Abigail,

Congratulations on your baby, it is also very encouraging to hear that you are breast feeding. It is also important to think about birth control options well before the time you become fertile again. For the nursing mother who wants to space her pregnancies, there are many birth control options to choose from. Each method offers advantages and disadvantages.

As long as the nursing mother is exclusively breastfeeding, (nursing frequently day and night with no supplemental feedings), the baby is younger than 6 months of age, and the mother has not started having periods, she is more than 98% protected against pregnancy. It is important to understand that as soon as there is a decline in breastfeeding, due to the baby eating supplemental feedings or nursing less often, the contraceptive protection decreases, and other methods should be considered. Fertility is most effectively suppressed when the baby goes no longer than four hours during the day and six hours at night between feedings. The pattern of breastfeeding is a key factor, but the mother's own body chemistry also has an influence. Some mothers nurse without supplements and still start having periods within the first few months of nursing. Others whose babies sleep through the night or have supplemental feedings will not have a period for twelve months or longer. Some women go as long as two years or more without menstruating. After the initial flow of lochia (the bleeding experienced for two to four weeks after birth) has stopped, nursing mothers will usually experience no vaginal bleeding for several months. Often, the first period occurs without ovulation. Many women refer to this as a "warning" period, and take it as a sign that they are fertile from that point on. Often light bleeding or spotting is the first indication of the return of fertility. Any bleeding or spotting that lasts more than a couple of days should be considered a sign that the mother is fertile again. It is not unusual for a mother to have irregular periods during the time she is nursing.

The first choice of birth control for nursing mothers is non-hormonal methods. This includes condom use, which has the advantages of being readily available, and having no effect on breastfeeding. Condoms can be very effective if used correctly. Condoms offer some protection against STDS (sexually transmitted diseases) and have no risks to the mother or child, but can be irritating to vaginal tissue and may require additional lubrication.

IUDs (intrauterine device) have no effect on breastfeeding, and are very effective. There is a possible risk of expulsion or uterine perforation if the device is not properly placed or is inserted before 6 weeks postpartum. Mirena is another new form of IUD, this is progestin delivering IUD. Good option for women who seek mid to long term contraception 3-5yrs.

If the nursing mother chooses to use a hormonal method of birth control, the second choice is progestin only methods, such as implanon (implants), mini-pills, or injectables (Depo-Provera).

Implanon is a progestin releasing implant that is inserted under the skin of the upper arm. It releases progestin continuously, preventing ovulation. It is a long lasting form of contraception of 3 yrs duration; some women may experience spotting and irregular menstrual bleeding.

Each Depo-Provera shot provides contraception for up to 12 weeks and is highly effective in preventing pregnancy. It may cause spotting between periods or other undesired side effects in some women.

Progestin-only pills have a higher rate of failure than combination pills. They must be taken at the same time each day to work. Even taking the mini-pill a few hours late could result in pregnancy. Because of this, some mothers use a barrier method as extra protection while taking the mini-pill. If the mini-pill is used, the mother should contact her doctor or midwife when the baby is weaned. At that time it may be best to switch to combination birth control pills.

All of these methods can be very effective, and may even increase milk volume. Although some of the progestin hormone may enter the breast milk, there is no evidence of adverse effects from the small amount of hormone that passes into the milk.

These are some of the common contraceptive methods used for breast feeding mothers, you would have to find one that suits your lifestyle and you are comfortable with. It would also be helpful if you can discuss this with your obstetrician who can further guide you on the choice.

All the best,

Dr Seng Shay Way

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