Postpartum Contraception

Ovulation can return from about 3 to 4 weeks after birth in women who are not breastfeeding, and in breastfeeding women it returns unpredictably once feeding becomes partial. Short birth intervals raise the risk of preterm birth, low birth weight, maternal anaemia and neonatal death, so contraception is planned in pregnancy and provided before discharge or at the earliest postnatal contact. A method can be given in the first 48 hours after birth, at 1 to 2 weeks, at 4 to 6 weeks, and at immunisation visits.

Assessment. Confirm the date and mode of birth, breastfeeding intention and pattern, return of menses, blood pressure, haemorrhage, pre-eclampsia, sepsis, thrombosis risk factors (caesarean birth, age 35 years or more, BMI 30 kg/m2 or more, immobility, pre-eclampsia, postpartum haemorrhage, smoking, transfusion, family history), HIV status and medicines.

Reasonable certainty of non-pregnancy. Within 4 weeks postpartum; or fully or nearly fully breastfeeding, amenorrhoeic and under 6 months postpartum; or the usual criteria for non-pregnancy. A urine test is needed when none applies.

Effectiveness. Typical-use first-year pregnancies per 100 women: implants about 0.05, intrauterine devices 0.2 to 0.8, injectables 3, lactational amenorrhoea method 2 (for 6 months only), combined pills 8.

Eligibility by method and timing.

Conditions that delay an intrauterine device. Prolonged rupture of membranes, prolonged labour, puerperal sepsis, genital tract infection and uncontrolled haemorrhage. After 48 hours and before 4 weeks, insertion is not done.

Method comparison. Intrauterine devices and implants give the longest protection and can be provided before discharge. Injectables suit those who prefer a 3-monthly method after 6 weeks. Combined pills are the least suitable early postpartum because of thrombosis risk and effect on milk.

Interactions. Efavirenz, rifampicin and enzyme-inducing antiseizure medicines lower hormonal effect in the same way as at other times.

Regimen lines.

• Copper T 380A: inserted within 10 minutes of placental delivery, at caesarean before the uterus is closed, or within 48 hours; lifespan up to 12 years; no backup. If not inserted within 48 hours, wait until 4 weeks.

• Levonorgestrel 52 mg device: same timing; 5 years; no backup.

• Etonogestrel 68 mg rod or levonorgestrel two 75 mg rods: inserted immediately postpartum, or at any time if amenorrhoeic; backup 7 days only if 6 months or more postpartum in breastfeeding women; replace at 3, 5 or 3 years by system.

• DMPA 150 mg intramuscularly or 104 mg subcutaneously every 13 weeks, up to 4 weeks late; norethisterone enanthate 200 mg every 8 weeks, up to 2 weeks late; start timing by the table; backup 7 days if started after day 7 and menses have returned.

• Progestin-only pills: start by the table; backup 2 days if more than 5 days since bleeding started or after 3 weeks without menses.

• Combined pill 30 to 35 micrograms ethinylestradiol: from 21 days postpartum if not breastfeeding and without risk factors; backup 7 days if more than 5 days since bleeding began.

Switching from the lactational amenorrhoea method. Start another method before 6 months, before menses return, or before feeding becomes partial, whichever is first.

Follow up. Plan the method antenatally; review at the postnatal visit; check strings and expulsion at 3 to 6 weeks after intrauterine insertion.

Intrauterine device after birth. Expulsion is more frequent than after interval insertion, highest with insertion between 10 minutes and 48 hours; reinsert or offer another method. Perforation is rare.

Danger signs after insertion. Perforation, severe pain, heavy bleeding, hypovolaemic shock, fever, rigors and foul-smelling discharge.

Bleeding with progestin methods. Exclude retained products, endometritis and new pregnancy. Ibuprofen 800 mg three times daily for 5 days is compatible with breastfeeding. Combined pills are not used for bleeding control under 6 months in breastfeeding women.

Thrombosis. Unilateral leg swelling, chest pain or breathlessness needs urgent assessment and anticoagulation; combined methods are stopped.

Referral and escalation. Refer haemorrhage, sepsis, suspected perforation, suspected thrombosis, severe hypertension and suspected ectopic pregnancy urgently.