ETHICS/EDUCATION
Postpartum contraception
Michelle Cooper
Sharon Cameron
Abstract
Fertility and sexual activity can resume shortly after childbirth there-
fore the early initiation of effective postpartum contraception is
important to prevent an unintended pregnancy. An inter-pregnancy
interval of at least 12 months is recommended to reduce the risk
of obstetric and neonatal complications. Most methods of contra-
ception can be safely initiated immediately after childbirth, including
the most effective long-acting methods such as the implant and in-
trauterine contraception. The antenatal period presents a unique op-
portunity to counsel women about the full range of contraceptive
options so that the method chosen by the woman can be initiated
after delivery. This reduces the need for additional postnatal visits
to discuss and provide contraception, which may be difficult for
mothers to attend. Maternity care providers are ideally placed to
deliver a postpartum contraceptive service and should receive
appropriate training to ensure knowledge and skills in this area are
maintained.
Keywords inter-pregnancy interval; long-acting reversible contra-
ception; postpartum contraception
Introduction
Improving access to postpartum contraception may reduce the
risk of unintended pregnancy, and allow women and couples to
control future pregnancy spacing. One in 13 women in the UK
experience a short inter-pregnancy interval e defined as less
than 12 months between delivery and conception. This is asso-
ciated with an increased risk of complications including preterm
delivery, fetal growth restriction and stillbirth. For women
intending vaginal birth after a caesarean section (VBAC), a
minimum 12-month interval is recommended to reduce the risk
of uterine rupture during labour.
Ovulation can return shortly after childbirth and at least 50%
of couples will resume sexual activity by six weeks. There is
therefore a potential risk of another pregnancy unless effective
contraception is started early, and this may be before the woman
attends her GP for a six-week postnatal check-up. The long-
acting reversible contraceptive (LARC) methods, such as intra-
uterine contraception (copper intrauterine device or
levonorgestrel-releasing system) and implant, are among the
most effective available (Table 1). However, to initiate one of
Michelle Cooper MBChB MRCOG MFSRH, University of Edinburgh/NHS
Lothian, Chalmers Sexual Health Centre, Edinburgh, UK. Conflicts of
interest: none declared.
Sharon Cameron MBChB MD FRCOG MFSRH, University of Edinburgh/
NHS Lothian, Chalmers Sexual Health Centre, Edinburgh, UK.
Conflicts of interest: none declared.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 28:6
these LARC methods postpartum, women have usually needed to
make additional visits to have them inserted by a contraceptive
provider. These visits may be difficult to attend and of low pri-
ority for new mothers.
Table 2 summarizes the current UK Medical Eligibility Criteria
(UKMEC) guidelines for contraceptive use in the postpartum
period. As most methods can be safely initiated from childbirth
onwards, it may be more convenient for women to commence
contraception earlier before sexual activity resumes. The ante-
natal period provides a unique opportunity for discussion about
reproductive intentions and postpartum contraception. Maternity
care providers are ideally placed to provide this service and can
support women in accessing their chosen method before
discharge from the birth unit.
Method-specific guidance
Intra-uterine contraception
Intrauterine methods include the levonorgestrel-releasing system
(LNG-IUS) and copper-bearing intrauterine device (Cu-IUD).
Postpartum intrauterine contraception (PPIUC) refers to the
immediate insertion of a LNG-IUS or Cu-IUD at the time of de-
livery, or shortly afterwards. This can be performed after de-
livery of the placenta at caesarean section, or anytime up to 48 h
after vaginal birth. PPIUC has been shown to be a safe and cost
effective procedure and is routine practice in many countries
worldwide.
During caesarean section the device is placed at the fundus
under direct vision (either manually or with an instrument) prior
to closure of the uterine incision, with untrimmed threads
directed towards the upper cervical canal. Postpartum vaginal
insertion can be performed manually or via long placental (Kel-
ly’s) forceps through the dilated cervix after placental delivery.
PPIUC insertion should be avoided in women where intrauterine
infection is suspected, or at those at an increased risk (e.g. pro-
longed rupture of membranes).
Women should be counselled about the method, insertion
procedure and follow-up arrangements. Discussion should
ideally take place during the antenatal period when a fully
informed decision can be made.
Immediate postpartum insertion carries a slightly higher risk
of device expulsion than insertion at an interval (4 or more
weeks later) and so a follow-up visit with a healthcare provider
for a thread check is recommended at 4e6 weeks. Following
intra-caesarean insertion, up to 50% of women may have non-
visible threads and an ultrasound scan is required to confirm
device placement. It is also possible for long threads to appear in
the vagina during uterine involution and women may need to
attend for thread trimming.
Sterilization
Surgical methods of contraception provide a permanent option
for couples who have completed their family. Women consid-
ering sterilization during planned caesarean section should be
counselled at least 2 weeks in advance of the procedure. Dis-
cussion should include information about risks, failure rate and
available alternatives. Tubal occlusion using Filshie clips and
salpingectomy are suitable options for intra-caesarean steriliza-
tion. Salpingectomy offers a slightly lower failure rate, but
183 Ó 2018 Elsevier Ltd. All rights reserved.
 ETHICS/EDUCATION

operating time and blood loss may be higher. Female sterilization

Comparative efficacy of contraceptive methods is rarely performed immediately after a vaginal birth, therefore
expressed as percentage (%) of women experiencing an interim contraceptive method should be advised for women
unintended pregnancy within the first year of use (LARC considering this option in the longer term.
methods are highlighted)
Progestogen-only methods
Method Typical use Perfect use
All progestogen-only methods are safe to use in the immediate
(%) (%)
postpartum period. Women who are breastfeeding can be advised
Progestogen-only implant 0.05 0.05 that there is no evidence of an adverse effect on lactation or infant
Levonorgestrel-releasing intrauterine 0.2 0.2 outcomes. Options include the implant, injectable and pill.
system The implant available in the UK (NexplanonÒ) is a single rod
Copper intrauterine device 0.8 0.6 containing etonogestrel that inhibits ovulation and has a three-
Progestogen-only injectables 6 0.2 year duration. Irregular bleeding is a common side effect,
Vasectomy 0.15 0.1 affecting up to one in five women beyond the initial 6 months.
Female sterilization 0.5 0.5 However, this is no more likely to occur with immediate post-
Progestogen-only pills 9 0.3 partum initiation.
Combined hormonal contraception 9 0.3 The injectable progestogen available in the UK is depot
(pill, patch, vaginal ring) medroxyprogesterone acetate. This is available as an intramus-
Female diaphragm 12 6 cular (IM) preparation (150 mg DepoproveraÒ), and as a subcu-
Male condom 18 2 taneous (SC) micronized preparation (104 mg Sayana PressÒ)
Fertility awareness methods 24 0.4e5 licensed for self-administration. Both preparations inhibit
No method 85 85 ovulation and are administered every 13 weeks. Amenorrhoea is
common with both injectables, affecting up to 50% of women at
Table 1 12 months. Long term use may be associated with a small
reversible reduction in bone mineral density.
Progestogen-only pills (POP) are taken continuously and all
exert a contraceptive effect through changes in cervical mucus.
Newer desogestrel-containing POPs (e.g. Cerazette) also inhibit
ovulation, therefore increasing efficacy and providing a longer
administration window (12 h) compared to traditional POPs (3
Summary of UK Medical Eligibility Criteria for h). Bleeding patterns are variable, although up to 20% of women
Contraceptive Use (UKMEC) categories applicable to will experience amenorrhoea.
women after childbirth
Combined hormonal methods
Condition Cu-IUD LNG-IUS IMP DMPA POP CHC Combined hormonal contraceptives are available as oral pills,
transdermal patch and a vaginal ring. They contain oestrogen in
Postpartum e breastfeeding
combination with a progestogen, and inhibit ovulation. They are
a) 0 to <6 weeks See below 1 2 1 4
generally administered continuously for three weeks, followed
b) >6 weeks to <6 months 1 1 1 2
by a one week interval; although continuous pill-taking regimes
c) >6 months 1 1 1 1
are increasingly common and safe to use.
Postpartum e non-breastfeeding
These are the only methods that should not be used imme-
a) 0 to <3 weeks See below
diately after childbirth due to the increased risk of venous
With other risk factors 1 2 1 4
thromboembolism (VTE). As coagulation factors mostly
for VTE
normalize by three weeks, CHC may be commenced thereafter
Without other risk factors 1 2 1 3
provided no other VTE risk factors are present. Specific post-
b) 3 to <6 weeks
partum factors to consider include:
With other risk factors 1 2 1 3
 BMI >30
for VTE
 Smoking
Without other risk factors 1 1 1 2
 Immobility
c) >6 weeks 1 1 1 1
 Pre-eclampsia
Postpartum e breastfeeding/non-breastfeeding
 Postpartum haemorrhage
a) 0 to <48 h 1 1 See above
 Postpartum blood transfusion
b) 48 h to <4 weeks 3 3
 Operative delivery/Caesarean section
c) >4 weeks 1 1
Where VTE risk factors are present, women should delay CHC
d) Postpartum sepsis 4 4
initiation until six weeks. For breastfeeding women, CHC initia-
CU-IUD e copper intrauterine device, LNG-LUS e levonorgestrel intrauterine tion should be delayed until at least 6 weeks postpartum, due to
system, IMP e progestogen-only implant, DMPA e progestogen-only inject- theoretical concern about the impact on milk production.
able, POP e progestogen-only pill, CHC e combined hormonal contraception.
Although limited, currently available evidence does indicate a
Table 2 link with adverse infant outcomes.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 28:6 184 Ó 2018 Elsevier Ltd. All rights reserved.
 ETHICS/EDUCATION
Barrier methods
Condoms can be initiated any time postpartum. However,
women should delay use of female barrier methods such as the
diaphragm and cervical cap until at least six weeks after child-
birth (when uterine involution is complete) and attend a provider
to reassess size of the device required.
Fertility awareness methods
These methods rely on physiological indicators of ovulation (e.g.
menstrual pattern, basal temperature, cervical mucus) to identify
fertile times of the cycle. Mobile applications e.g. Natural CyclesÒ
are available to support users in identifying their fertile days, and
avoiding unprotected intercourse. However, as many of these
indicators are less reliable in the postpartum period, the use of
this method for contraception should be delayed until regular
menstruation resumes.
Breastfeeding and contraception
Breastfeeding may be contraceptive if the criteria for the Lacta-
tional Amenorrhoea Method (LAM) are met:
 Exclusively breastfeeding
 Amenorrhoea
 Less than 6 months postpartum
In this situation the method is 98% effective. However, efficacy
may be reduced if breastfeeding frequency declines or bleeding
resumes. Transition to another method by six months should be
ensured if other contraception has not been concomitantly used.
All progestogen-only contraceptives are safe for use by
breastfeeding women as there is no evidence to suggest a detri-
mental effect on milk production or infant outcomes. Combined-
hormonal contraceptives should be avoided in breastfeeding
women for the first six weeks postpartum due to theoretical
concerns on breastfeeding at this time.
Conclusion
Most of the currently available contraceptive methods are safe
for use during the postpartum period, and many can be initiated
immediately after childbirth. Improving access to effective
contraception within maternity care can overcome many of the
barriers women face in accessing this thereafter. As well as
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 28:6
providing holistic care, this may reduce the subsequent risk of
unintended pregnancy and a short inter-pregnancy interval with
its associated risks. Training should be provided to maternity
care providers in techniques such as PPIUC and implant insertion
to ensure the full range of options are available to women before
they leave the birth unit. A
FURTHER READING
Cameron ST, Craig A, Sim J, et al. Feasibility and acceptability of
introducing routine antenatal contraceptive counselling and provi-
sion of contraception after delivery: the APPLES pilot evaluation.
BJOG 2017 Dec; 123: 46e7.
Faculty of Sexual & Reproductive Healthcare (FSRH). Contraception
after pregnancy guideline, January 2017.
Faculty of Sexual & Reproductive Healthcare (FSRH). UK medical
eligibility criteria for contraceptive use (UKMEC), 2016.
Royal College of Obstetricians & Gynaecologist (RCOG). Best practice
paper in postpartum family planning (Best practice paper No. 1).
London: RCOG; 2015.
Sonalkar S, Kapp N. Intrauterine device insertion in the postpartum
period: a systematic review. Eur J Contracept Reprod Health Care
2015 Jan 2; 20: 4e18.
Practice points
C Contraception should be commenced shortly after childbirth to
reduce the risks of unintended pregnancy and a short inter-
pregnancy interval.
C All progestogen-only and intrauterine methods can be initiated
immediately after childbirth in suitable women.
C Postpartum intrauterine contraception (PPIUC) can be provided at
either caesarean section or within 48 h of vaginal birth.
C A VTE risk assessment should be performed prior to CHC initiation
e which should be delayed in women who are medically eligible
for this method until at least 3 weeks postpartum (6 weeks if
breastfeeding).
C Breastfeeding women can be reassured that there are no adverse
effects associated with progestogen-only contraceptives.
185 Ó 2018 Elsevier Ltd. All rights reserved.