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Postpartum Contraception
According to National Institute for Clinical Excellence (NICE) guidelines, contraceptive methods and advice about when to start them should be discussed within the first postpartum week, [1] and this is usually delivered by hospital or community midwives. Further discussion and provision of contraception is an integral part of the six-week postpartum GP check. There is great variation in the return to fertility and sexual activity following childbirth but the earliest known time of ovulation is 27 days after delivery. Therefore, no contraception is needed until 21 days postpartum, [2] which is nonetheless ahead of the six-week check. Advise all women that they may become fertile ahead of the return of their periods and should not delay the use of contraception if they do not wish to become pregnant again. The puerperium and lactation make particular demands on the safe choice of contraception there is an increased risk of venous thromboembolic disease in the few weeks following childbirth and breast-feeding is considered a contra-indication to the use of the combined oral contraceptive pill (COCP). Postpartum, a woman's contraceptive needs may have changed and discussions may occur regarding 'spacing' future pregnancies (very close intervals between babies are generally thought to increase risk to mother and future infants) or preventing further pregnancies where a family is considered complete (sterilisation may be requested as a 'final' method, but alternatives should be raised).

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 breastfeeding 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

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Contraceptive methods available to women postpartum Unrestricted methods Methods not usually recommended, or used with restriction Combined oral contraceptive pills (COCPs) Combined contraceptive patch Combined contraceptive vaginal ring Copper intrauterine device (IUD) and the intrauterine system (IUS) (unless fitted within 48 hours of birth, delay until after 4 weeks postpartum) Fertility awarenessbased methods Sterilisation - usually delayed until at least 6 weeks post delivery

Non breast-feeding women <21 days postpartum

Progestogen-only pill (POP) Progestogen-only injectables and implants Barrier methods

Non breast-feeding women 21 days postpartum

COCPs Combined contraceptive patch Combined contraceptive vaginal ring POP Progestogen-only injectables and implants Barrier methods Fertility awarenessbased methods in a previous user

Fertility awarenessbased methods should not be taught to a new user until after periods have restarted Sterilisation Copper IUD and the IUS (use within 48 hours or from 4 weeks after delivery)

Breast-feeding women <6 weeks postpartum

Lactational amenorrhoea method (LAM) (if fully or almost fully breastfeeding and amenorrhoeic) POP Progestogen-only implants Barrier methods

COCPs Combined contraceptive patch, and combined contraceptive vaginal ring Copper IUD and the IUS (unless fitted within 48 hours of delivery or after 4 weeks after delivery) Fertility awarenessbased methods - previous users can start from day 21, but a new user should delay learning to use the method until menses resume Sterilisation

Fully or almost fully

LAM (if amenorrhoeic) POP Progestogen-only injectables and implants Copper IUD and the IUS Fertility awareness-

COCPs Combined contraceptive patch, and combined contraceptive vaginal ring

breast-feeding women between 6 weeks and 6 months postpartum

Fertility awarenessbased methods - if previous user Barrier methods Sterilisation

Page 3 of 6 vaginal ring Fertility awarenessbased methods - a new user should delay learning to use the method until her periods start

Progestogen-only injectibles can generally be used where their advantages generally outweigh the risks POP Progestogen-only injectables and implants Copper IUD and IUS Fertility awarenessbased methods - if previous user or new learner if periods Not fully or almost fully have resumed breast-feeding women Barrier methods between 6 weeks and 6 Sterilisation months postpartum Can generally be used where benefits outweigh risks: COCPs Combined contraceptive patch COCPs Combined contraceptive patch POP Progestogen-only injectables and implants Copper IUDs and the IUS Fertility awareness based methods new user should delay learning to use the method until periods resume Barrier methods Sterilisation

Combined contraceptive vaginal ring - not recommended until baby is fully weaned

Breast-feeding women >6 months postpartum

Combined contraceptive vaginal ring - not recommended until baby is fully weaned LAM - inadequate contraception from 6 months postpartum

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)

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Fully breast-feeding day (at least four-hourly feeds) and night (at least six-hourly feeds) [3] The risk of pregnancy is increased if: 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 [3] 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. [3] 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. [6] 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.

Page 5 of 6 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. [7] 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. [8] [9] There is a 1 in 20 expulsion risk. [9] 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. [10] The Mirena IUS's product licence however specifies fitting from 6 weeks postpartum. [11] 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. [12] 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%. [13]

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. [14] 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.

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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. [15] 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.

Further reading & references

Amy JJ, Tripathi V; Contraception for women: an evidence based overview. BMJ. 2009 Aug 7;339:b2895. doi: 10.1136/bmj.b2895. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Postnatal care: Routine postnatal care of women and their babies, NICE Clinical Guideline (2006) Guillebaud J; Postpartum contraception. Unnecessary before three weeks. BMJ. 1993 Dec 11;307(6918):1560-1. Contraceptive choices for breastfeeding women, Faculty of Family Planning and Reproductive Health Care RCOG (2004) Van der Wijden C, Kleijnen J, Van den Berk T; Lactational amenorrhea for family planning. Cochrane Database Syst Rev. 2003;(4):CD001329. [abstract] Medical eligibility criteria for contraceptive use. World Health Organization, 2004 Truitt ST, Fraser AB, Grimes DA, et al; Hormonal contraception during lactation. systematic review of randomized controlled trials. Contraception. 2003 Oct;68(4):233-8. [abstract] Guillebaud J, Contraception. 3rd ed, Churchill Livingstone (1999) 124-127 Diaz S, Zepeda A, Maturana X, et al; Fertility regulation in nursing women. IX. Contraceptive performance, duration of lactation, infant growth, and bleeding patterns during use of progesterone vaginal rings, progestin-only pills, Norplant implants, and Copper T 380-A intrauterine devices. Contraception. 1997 Oct;56(4):223-32. [abstract] Penney G, Brechin S, de Souza A, et al; FFPRHC Guidance (January 2004). The copper intrauterine device as long-term contraception. J Fam Plann Reprod Health Care. 2004 Jan;30(1):29-41; quiz 42. [abstract] Long-acting reversible contraception, NICE Clinical guideline (October 2005); (the effective and appropriate use of long-acting reversible contraception) Summary of Product Characteristics (SPC) - Mirena; Summary of Product Characteristics (SPC) - Mirena (levonorgestrel intrauterine system), Schering Health Care Limited, electronic Medicines Compendium. Updated April 2009 Kapp N, Curtis KM; Intrauterine device insertion during the postpartum period: a systematic review. Contraception. 2009 Oct;80(4):327-36. Epub 2009 Aug 29. [abstract] Celen S, Moroy P, Sucak A, et al; Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices. Contraception. 2004 Apr;69(4):279-82. [abstract] Male and female sterilisation, Royal College of Obstetricians and Gynaecologists (2004) Johnson LK, Edelman A, Jensen J; Patient satisfaction and the impact of written material about postpartum contraceptive decisions.; Am J Obstet Gynecol. 2003 May;188(5):1202-4. Current Version: Hilary Cole Document ID: 2643 Version: 22 EMIS

Original Author: Dr Michelle Wright Last Checked: 20/04/2011

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