Postpartum contraception

Postpartum contraception and fertility

According to Faculty of Sexual and Reproductive Health (FSRH) guidelines , contraceptive methods and advice about when to start them should be discussed during the antenatal period and immediately after childbirth. 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, 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. Postpartum, a woman's contraceptive needs may have changed and discussions may occur regarding 'spacing' future pregnancies or preventing further pregnancies where a family is considered complete (sterilisation may be requested as a 'final' method, but alternatives should be raised). An interpregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of premature delivery, low birthweight and small for gestational age babies.¹

History taking

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

• Beliefs, attitudes and personal preferences. Establish whether there are cultural considerations.

• Contraceptive needs. Ask whether she has resumed sexual activity. Ask whether there are any new or ongoing sexual problems. Discuss what degree of efficacy is required: whether she wants another child soon or considers that her childbearing period has been completed.

• Whether ovulation may have restarted based on when the was 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 - until 2016 combined hormonal contraception was contra-indicated whilst breastfeeding. Further research has shown little evidence of adverse effect on mother or child, so breastfeeding between six weeks and six months postpartum is now a category 2 in the UK medical eligibility criteria (UKMEC) - ie benefits generally outweigh the risks.² A woman may wish to consider the lactational amenorrhoea method (LAM) but it is important to elicit the pattern of breastfeeding (frequency, duration of feeds, demand feeding) to determine whether or not this is an option.

• Social factors such as a return to full-time employment may influence feeding method and breastfeeding frequency and, therefore, contraceptive choice.

• Present or past medical problems, such as hypertension, personal or family history of venous thromboembolism (VTE), focal migraine or previous trophoblastic disease, which may dictate choices. Determine whether there are any contra-indications to a particular contraceptive. The UK Medical Eligibility Criteria (UKMEC) can be consulted for advice about specific conditions where caution should be taken.²

Postpartum contraception choices

The LAM

This is a method of avoiding pregnancy, based upon the natural postpartum infertility associated with fully breastfeeding: 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:

• Less than six months postpartum.

• Amenorrhoeic (no vaginal bleeding after the first 56 days postpartum).

• Fully breastfeeding day (at least four-hourly feeds) and night (at least six-hourly feeds).

The risk of pregnancy is increased if:

• Breastfeeding 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 six months postpartum.

POPs

Current eligibility criteria in the UK allow use of the progestogen-only contraceptive pill postpartum, in both breastfeeding and non-breastfeeding women.²

Starting regime for the POP³

• Commence up to day 21 postpartum without the need for extra contraception.

• If started after day 21, additional contraception is needed for two 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.

Implants

Current eligibility criteria in the UK allows use of the contraceptive implant postpartum, in both breastfeeding and non-breastfeeding women.

The etonogestrel implant (Nexplanon®) is currently the only one available in the UK.

Starting regime⁴

• Start from 21 days after delivery.

• If later than day 21, extra barrier methods of contraception are needed for seven days, unless the criteria for the lactational amenorrhoea method are also met.

Progestogen-only injectables

These are licensed for use only after six weeks postpartum. However, UK guidelines and eligibility criteria state the benefits may outweigh the risks of earlier use, and it may be started immediately postpartum.²

• If started on or before day 21 postpartum, no extra precautions are needed.

• If started after day 21, extra barrier methods of contraception are needed for 7 days, unless the criteria for the lactational amenorrhoea method are also met.

Combined hormonal contraceptives (CHCs)

These include the combined pill, the patch and the vaginal ring. For breastfeeding women:

• Previous concerns about hormonal effects on the quality and quantity of milk, passage of hormones to the infant and adverse effects on infant growth if COCs are used in breastfeeding women before 6 months postpartum have not been proven. This led to the UK Medical Eligibility Criteria (UKMEC) being changed in 2016 and some CHC methods are now licensed from 21 days postpartum.²

• Studies have not shown an adverse effect on infant growth or development.⁵

• CHC can now be used after six weeks postpartum in fully or almost-fully breastfeeding women.

For non-breastfeeding women:

• Pregnancy is a thrombophilic state; by about two weeks postpartum, these changes have reversed in most women.

• COC can be started from 21 days postpartum, assuming no other risk factors for VTE exist.⁶

• If started later than 21 days, additional barrier methods of contraception are needed for seven days (unless starting within the first five days of a menstrual period once cycles have returned, or where the criteria for the lactational amenorrhoea method are met).

IUCD and levonorgestrel-releasing IUS

• These have no effect on breast milk production.

• There is a 1 in 20 expulsion risk.⁷

• Teach the woman to feel threads after each period.

• Routine review at 3-6 weeks is no longer essential. The FSRH suggests that more emphasis is placed on making sure that women know how to feel their threads and when to come back for review - eg, if they cannot feel the threads or have any other concerns.⁷

Timing of insertion:

• FSRH guidance suggests that both the IUCD and IUS may be fitted from four weeks postpartum.⁷ The Mirena® IUS's product licence however specifies fitting from six weeks postpartum, but it is reasonable to fit from four weeks using the FSRH guidance.

• The risk of perforation is increased in women who are breastfeeding and may be increased for postpartum fittings.⁷

• Advantages to immediate insertion include high motivation, assurance that the woman is not pregnant, and convenience; however, this is balanced against increased risk of perforation compared with interval insertion after the immediate postpartum period. Cumulative one-year expulsion rates in one study were 12.3%.

Barrier methods

• These include condoms, diaphragms and cervical caps.

• Diaphragm and cap use should be delayed until uterine involution is complete after six weeks postpartum.⁸

• 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 - anecdotally it is becoming increasingly difficult to find a suitably trained practitioner, as use of the diaphragm falls and trained practitioners retire.

• Condoms and spermicides can be used safely by breastfeeding women.

Fertility awareness methods

• These methods should be used with caution, even after menstruation has resumed, because of possible delay in return to regular, ovulatory menstrual cycles.

• Only women who are already familiar with the method should practise it after four weeks postpartum and in advance of the return of their periods. It is not recommended for breastfeeding women.⁹ Women who intend to use fertility awareness should be advised of the annual failure rate of 24% with typical use, and offered an alternative.

Sterilisation

• Guidance from the FSRH states that regret is increased when sterilisation is performed at the time of caesarean section, compared to an interval sterilisation. They list a number of factors which are associated with regret and advise that these should be considered when counselling for sterilisation. They include age under 30 at the time of the procedure, not being in a relationship and having two or fewer children.¹⁰

• Female sterilisation can however 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 IUCD or IUS, implants and depot injections) should also be considered.

Emergency contraception

• Emergency contraception is not needed before day 21 postpartum.

• Progestogen-only emergency contraception can be used even if breastfeeding.

• The IUCD can be fitted for this indication, after four 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.¹¹

• Provide detailed advice about what to do if things go wrong, preferably with written information to take away - eg, missed pill advice, IUCD expulsion advice. Sending such advice by text message means that the woman has ongoing access to it (rather than a paper version which may be lost) and allows those whose first language is not English to use electronic means to translate it.

• A follow-up appointment should be arranged.