Contraceptive Implants Postpartum and Breastfeeding

Implants are among the most effective options after childbirth because they can be inserted before discharge, need no further visits and do not reduce milk supply. Progestin passes into breast milk in small amounts, with no adverse effect on infant growth, health or development. Immediate postpartum insertion prevents the unplanned pregnancy that often occurs before the first postpartum visit.

Systems. Etonogestrel 68 mg single rod (3 years); levonorgestrel two 75 mg rods (5 years or 3 years by system).

Mechanism in the postpartum period. The progestin thickens cervical mucus and supports the ovulation suppression already present in the early puerperium.

Breast milk transfer. Infant exposure is a small fraction of the maternal dose. No effect has been shown on milk volume, duration of breastfeeding or infant growth.

Effectiveness. About 0.05 pregnancies per 100 women in the first year.

Return of ovulation. In non-breastfeeding women, ovulation may return from about 3 to 4 weeks postpartum. In breastfeeding women it is delayed but unpredictable once breastfeeding becomes partial.

Eligibility categories.

• Non-breastfeeding, any time postpartum: category 1.

• Breastfeeding, under 6 weeks postpartum: category 2.

• Breastfeeding, 6 weeks or more postpartum: category 1.

• Past hypertension in pregnancy with normal current blood pressure, and history of gestational diabetes: category 1.

• Current venous thromboembolism: category 3.

Assessment before discharge. Confirm the birth date, breastfeeding intention, mode of birth, postpartum haemorrhage, pre-eclampsia, current anticoagulation and history of breast cancer. No investigation is required.

Counselling in pregnancy. Discuss implants during antenatal care so the choice is made before labour. Document the chosen method in the antenatal record.

Counselling after birth. Explain that bleeding may be irregular or prolonged once lochia settles, that breastfeeding will not be affected, and that removal is available at any time. Explain that the lactational amenorrhoea method protects only while all three criteria are met, and that the implant gives protection that does not depend on breastfeeding pattern.

Special groups. Adolescent mothers have high rates of rapid repeat pregnancy and benefit from immediate insertion. Women living with HIV: category 1 for the infection; check for efavirenz. Women after caesarean birth can have the implant inserted before discharge.

Regimen lines.

• Etonogestrel 68 mg single rod: subdermal, inner non-dominant upper arm; insert immediately after birth or at any time thereafter; replace at 3 years.

• Levonorgestrel two 75 mg rods: subdermal in a V, inner upper arm; insert immediately after birth or at any time thereafter; replace at 5 years (5-year system) or 3 years (3-year system).

Start timing, non-breastfeeding.

• Under 21 days postpartum: insert now, no backup.

• 21 days or more and no menses: exclude pregnancy, insert, backup 7 days.

• Menses returned: insert within 7 days of the start of bleeding, no backup; otherwise, exclude pregnancy and use backup 7 days.

Start timing, breastfeeding.

• Immediately postpartum, before discharge: insert, no backup.

• Fully or nearly fully breastfeeding, amenorrhoeic, under 6 months: insert at any time, no backup.

• Amenorrhoeic, 6 months or more postpartum: exclude pregnancy, insert, backup 7 days.

• Menses returned: insert within 7 days of the start of bleeding, no backup; later, exclude pregnancy and use backup 7 days.

Postpartum care schedule. Insert within 48 hours of birth where possible. Offer again at the 1 to 2 week postnatal visit, at 4 weeks, and at 6 weeks, and with the infant's immunisation visits.

Transition from the lactational amenorrhoea method. Insert before the infant reaches 6 months, before menses return, or before breastfeeding becomes partial, whichever comes first.

Follow up. No routine visit. The card records the system, insertion date and removal date. Return for site problems or concerns.

Bleeding. After lochia, bleeding may be irregular or prolonged. Exclude retained products, endometritis and new pregnancy when bleeding is heavy, offensive or associated with fever or pain. For bothersome bleeding with no cause, ibuprofen 800 mg three times daily for 5 days is compatible with breastfeeding. Combined pills are not used for bleeding control in breastfeeding women under 6 months postpartum.

Tranexamic acid 500 mg three times daily for 5 days may be used for heavy bleeding if there is no thrombosis risk; it is compatible with breastfeeding but caution applies in the first weeks after birth because of the higher thrombotic risk.

Mood. Postpartum low mood and depression are common and are not contraindications. Assess for postpartum depression on its own merits.

Site problems. Haematoma and infection may be more likely after caesarean birth or in women with anaemia; manage infection with an oral antibiotic covering skin flora and review in 1 week.

Postpartum venous thromboembolism. If thrombosis develops after insertion, treat it; the implant may stay (category 3 for current thrombosis) while alternatives are discussed.

Red flags. Fever with offensive lochia, heavy bleeding, leg swelling, chest pain, severe headache with hypertension.

Referral and escalation. Refer postpartum sepsis, haemorrhage, suspected thrombosis and severe hypertension urgently.