History taking

In order for a woman to make an informed choice about her future contraceptive method, discuss:

• Beliefs, attitudes and personal preferences - are there cultural considerations?
• Contraceptive needs - has she resumed sexual activity yet? Are there any new or ongoing sexual problems? What degree of efficacy is required: does she want another child soon or has childbearing been completed?
• Whether ovulation may have restarted based on when was the baby delivered, method of feeding and recurrence of menstruation. This can affect the starting regime of the contraceptive chosen and also whether extra contraceptive measures are needed initially.
• Feeding methods - the COCP is contra-indicated whilst breast-feeding. A woman may wish to consider the Lactational Amenorrhoea Method (LAM) but it is important to elicit the pattern of breast-feeding (frequency, duration of feeds, demand feeding) to determine whether or not this is an option.
• Social factors such as return to full-time employment may influence feeding method and breast-feeding frequency and, therefore, contraceptive choice.
• Present or past medical problems, such as as hypertension, venous thromboembolism (VTE) or previous trophoblastic disease, which may dictate choices. Determine whether there are any contra-indications to a particular contraceptive.^[3] 

Contraceptive choices

The LAM

This is a method of avoiding pregnancy based upon the natural postpartum infertility associated with fully breast-feeding: suckling an infant reduces the release of gonadotrophins, which suppress ovulation but, as suckling reduces, ovulation returns. It is over 98% effective in preventing pregnancy if a woman is:^[4]

• Less than 6 months postpartum
• Amenorrhoeic (no vaginal bleeding after the first 56 days postpartum)
• Fully breast-feeding day (at least four-hourly feeds) and night (at least six-hourly feeds)

The risk of pregnancy is increased if:^[3] 

• Breast-feeding decreases, particularly stopping night feeds, or with the introduction of formula or solids and where pumping rather than nursing occurs
• Menstruation resumes
• The woman is more than 6 months postpartum

However, much of the efficacy data are based upon women living in non-industrialised countries.

POPs and implants

The World Health Organisation (WHO) recommends that progestogen-only methods should not be used in the first 6 weeks postpartum.^[5] However, in the UK, it is common practice that POPs and implants are used before 6 weeks postpartum because there is no evidence of effect on breast milk volume and infant growth during this period.^[6]

Starting regime for POP:

• Commence up to day 21 postpartum without the need for extra contraception.
• If started after day 21, additional contraception is needed for 2 days and need to exclude pregnancy.
• If regular menstrual cycles have returned, start POP up to and including day 5 of period without the need for extra barrier methods.

Starting regime for etonogestrel implant:

• Start 21-28 days after delivery.
• If later than this, extra barrier methods of contraception are needed for 7 days.

Progestogen-only injectables

These are licensed for use only after 6 weeks post-partum:

• It is recommended that injections start at, or after, 6 weeks if breast-feeding.
• They can be started within 5 days of delivery, provided the woman is not breast-feeding but this may risk heavy or prolonged bleeding.
• If started on or before day 21 postpartum, no extra precautions are needed

COCPs

For breast-feeding women:

• There are concerns about hormonal effects on the quality and quantity of milk, passage of hormones to the infant and adverse effects on infant growth if COCPs are used in breast-feeding women before 6 months postpartum.
• A recent systematic review did not show an adverse effect on infant growth or development.^[7]
• However, WHO recommends that COCPs should not be used in the first 6 weeks postpartum and should only be used between 6 weeks and 6 months if other, more appropriate methods, are unacceptable.^[5]
• Use in breast-feeding women before 6 months postpartum is outside product license.

For non-breast-feeding women:

• Pregnancy is a thrombophilic state; by about 2 weeks postpartum, these changes have reversed in most women.
• The earliest start date for the COCP should be 21 days postpartum but later if the woman is at increased risk of thrombosis; for example, following severe pregnancy-related hypertension or H aemolytic anaemia, E levated L iver enzymes and L ow P latelet count (HELLP) syndrome.^[8]
• If started later than 21 days, additional barrier methods of contraception are needed for 7 days.

IUD and levonorgestrel-releasing IUS

For the IUD:

• This has no effect on breastmilk production.^[9][10]
• There is a 1 in 20 expulsion risk.^[10]
• Review 4-6 weeks after insertion or after the first period, then annually.
• Teach woman to feel threads after each period.

Timing of insertion:

• NICE guidance suggests that both the IUD and IUS may be fitted from 4 weeks postpartum.^[11] The Mirena® IUS's product licence however specifies fitting from 6 weeks postpartum.^[12]
• A recent systematic review suggests that there is no increased risk of complications of insertion in the postpartum period compared with outside of it. However, risk of expulsion is greater with delayed compared with immediate (<10 minutes following delivery of the placenta) insertion and with immediate compared with interval insertion.^[13]
• Advantages to immediate insertion include high motivation, assurance that the woman is not pregnant, and convenience; however, this is balanced against increased risk of expulsion compared with interval insertion after the immediate postpartum period. Cumulative 1 year expulsion rates in one study were 12.3%.^[14]

Barrier methods

• These include condoms, diaphragms and cervical caps.
• WHO recommends that diaphragm and cap use should be delayed until uterine involution is complete after 6 weeks postpartum.^[5]
• Always re-check size postpartum as this may have changed from the pre-pregnant state. Any change in weight of 3 kg or more should prompt a review of fit. Diaphragms and caps should be fitted by a trained practitioner and replaced on an annual basis.
• Condoms and spermicides can be used safely by breast-feeding women.

Fertility awareness methods

• WHO recommends that these methods be used with caution, even after menstruation has resumed, because of possible delay in return to regular, ovulatory menstrual cycles.^[5]
• Only women who are already familiar with the method should practise it after 3 weeks postpartum and in advance of the return of their periods.

Sterilisation

• Royal College of Obstetricians and Gynaecologists' guidance states that women should be made aware of increased regret and possible increased failure rate of sterilisation immediately postpartum and, ideally, sterilisation should follow at an appropriate interval after childbirth.^[15]
• Female sterilisation can be performed at the time of Caesarean section provided there has been appropriate counselling and consent antenatally.
• Male sterilisation and other effective, but reversible, methods (such as the IUD or IUS, implants and depot injections) should also be considered.

Emergency contraception

• This is not needed before day 21 postpartum.
• Progestogen-only emergency contraception can be used even if breast-feeding.
• The IUD can be fitted for this indication, after 4 weeks postpartum.

Follow-up

Regardless of the contraceptive choice made:

• Written information about contraceptive choices should be provided. This has been shown to increase a woman's ability to make an informed decision about birth control postpartum.^[16]
• Provide detailed advice about what to do if things go wrong, preferably with written information to take away, eg missed pill advice, IUD expulsion advice.
• A follow-up appointment should be arranged.