Postpartum Contraception

The earliest known time of ovulation is 27 days after delivery. Therefore no contraception is needed until 21 days postpartum.¹

According to NICE guidelines, contraceptive methods and advice about when to start them should be discussed with our patients within the first postpartum week.²

The following points should be covered in the consultation to enable the woman to make an informed choice about which contraceptive method she will use:

• What are her beliefs, attitudes and personal preferences about contraception? Are there cultural considerations?
• What are her contraceptive needs: Has she started to have sex again? Are there any sexual problems? What degree of efficacy is needed? Does she want another child soon?
• Has ovulation restarted: When was the baby delivered? Has menstruation recurred? This can affect the starting regime of the contraceptive chosen and also whether extra contraceptive measures are needed initially.
• What is the feeding method: Exclusively breastfeeding? Mixed breast and bottle feeds? Total bottle feeding? This is particularly important if she would like to use the Lactational Amenorrhoea Method or she wishes to use hormonal contraception.
• What is the pattern of breastfeeding: Frequency? Duration of feeds? Feeding on demand day and night? Again, important to elicit if the Lactational Amenorrhoea Method is an option.
• Social factors: e.g. return to full-time employment, this can influence feeding method and breast feeding frequency and therefore contraceptive choice.
• Medical problems: e.g. hypertension, venous thromboembolism, previous trophoblastic disease? Are there any contraindications to a particular contraceptive?³

The main differences in contraceptive methods available to breastfeeding and non-breastfeeding women are that

• Breastfeeding women can use the Lactational Amenorrhoea Method
• Breastfeeding women should not use the combined oral contraceptive pill (COCP)

1. The Lactational Amenorrhoea Method (LAM)

Over 98% effective in preventing pregnancy if a woman is

• Less than 6 months postpartum
• Amenorrhoeic (no vaginal bleeding after the first 56 days postpartum)
• Fully breastfeeding day and night³

The risk of pregnancy is increased if

• Breastfeeding decreases (particularly stopping night feeds)
• Menstruation recurs
• The woman is more than 6 months postpartum³

2. Progestogen-only Pills (POP) and implants

The World Health Organisation (WHO) recommends that progestogen-only methods should not be used in the first 6 weeks postpartum.⁴ However, in the UK, it is common practice that POPs and implants are used before 6 weeks postpartum because of evidence of no effect on breast milk volume and infant growth during this period.³

Starting regime for POP

• Can start up to day 21 postpartum without extra contraception needed
• If started after day 21, additional contraception is needed for 2 days and need to be sure woman not pregnant
• If regular menstrual cycles have returned, start POP up to and including day 5 of period without the need for extra barrier methods⁵

Starting regime for Etonogestrel implant

• Can be started 21-28 days after delivery
• If later than 28 days, extra barrier methods of contraception are needed for 7 days

3. Progestogen-only injectables

• If used before 6 weeks, this is outside their license
• May cause troublesome bleeding if used in early postpartum period
• Recommended that start at, or after, 6 weeks if breastfeeding
• Can be started within 5 days of delivery if not breastfeeding but may be risk of heavy, prolonged bleeding
• If started on or before day 21 postpartum, no extra precautions are needed

4. Levonorgestrel-releasing intrauterine system

• Can be inserted from 6 weeks postpartum regardless of feeding method
• If period already returned, insert at end of period or any time if no risk of pregnancy

5. Combined Oral Contraceptive Pills (COCP)

Breastfeeding women

• There are concerns about hormonal effects on quality and quantity of milk, passage of hormones to the infant and adverse effects on infant growth if COCPs are used in breastfeeding women before 6 months postpartum
• A recent systematic review of randomised controlled trials was carried out to look into the evidence for this
• The review provided reassurance that hormonal contraception does not have an adverse effect on infant growth or development⁶
• 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 unacceptable⁴
• If used in breastfeeding women before 6 months postpartum, use is outside the license

Non-breastfeeding women

• During pregnancy, changes in concentrations of coagulation factors may predispose to thrombosis
• After about 2 weeks postpartum, these changes have reversed in most women
• The earliest start date for the COCP should be 21 days but should be later if the woman is at increased risk of thrombosis, e.g. if had severe pregnancy-related hypertension, HEELP syndrome⁷
• If started later than 21 days, additional barrier methods of contraception are needed for 7 days

6. Intrauterine device

• No effect on breastmilk production⁸⁹
• 1 in 20 expulsion risk⁹
• Review 4-6 weeks after insertion or after the first period, then review once a year
• Teach woman to feel threads after each period

Timing of insertion

• Can be inserted within first 48 hours postpartum
• At this time there is high motivation, assurance that the woman is not pregnant and it is convenient.However, expulsion rates appear to be higher than with interval insertion. Early follow-up is suggested to identify this.¹⁰
• With insertion within the first 10 minutes post placental delivery, cumulative 1 year expulsion rates in one study were 12.3%.¹¹
• Otherwise, delay insertion until 4 weeks postpartum due to increased risk of uterine perforation.¹⁰, ⁴

7. Barrier methods

• Include condoms, diaphragms and cervical caps
• WHO recommends that diaphragm and cap use should be delayed until uterine involution is complete after 6 weeks postpartum⁴
• Always re-check size postpartum, they need to be fitted by a trained practitioner
• Condoms and spermicides can be used by breastfeeding women before and after 6 weeks postpartum
• Replace diaphragms and caps annually
• Re-check for size if woman gains/loses weight by 3kg

8. Fertility awareness methods

• WHO recommends that these methods are used with caution even when menstruation starts again because of possible delay in return to regular menstrual cycles⁴

9. Sterilization

• Royal College of Obstetricians and Gynaecologists guidance states that women should be made aware of increased regret and possible increased failure rate of sterilization immediately postpartum
• Male Sterilization should also be considered

10. Emergency contraception

• Not needed before day 21 postpartum
• Progestogen only Emergency Contraception can be used even if breastfeeding
• Can use IUD after 4 weeks postpartum

1. 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.¹²
2. Detailed advice about what to do if things go wrong should be discussed, preferably with written information to take away, e.g. missed pill advice, IUD expulsion advice etc.
3. A follow-up appointment should be booked.