Postpartum Contraception

Women can become fertile from 21 days after delivery so contraception is a important discussion for healthcare providers to have before a woman is discharged from maternity services. This is important for two reasons; firstly women are often so busy with their newborn to seek contraception advice after discharge, and a birth-to-conception time of less than 12 months leads to increased risk of premature delivery, low birth weight, small-for-gestational age babies and fetal mortality.

Term delivery

Long-acting reversible contraceptives (LARCs) are particularly recommended by guidelines as they can be inserted immediately after birth and are effective for years.

Type of contraception	Safe to start	Other notes
Lactational amenorrhoea	Immediately after delivery	Requires >85% feeds being breastfeeding, amenorrhea and within 6 months of delivery
Intrauterine (IUD and IUS)	Post-placental – within 10 minutes of delivery of the placenta Post-partum – within 48h of delivery Delayed – over 4 weeks after delivery	Contraindicated if risk of pelvic infection
Progesterone-only pill	Immediately after delivery	Safe in breastfeeding
Progesterone implant	Immediately after delivery	Safe in breastfeeding
Combined hormonal contraception	Breastfeeding – 6 weeks after delivery Non-breastfeeding – 3 weeks after delivery	Pregnancy-related considerations – HTN and UKMEC 2
Barrier contraception	Condoms immediately Diaphragm – wait 6 weeks	Delay in diaphragm due to changing uterine size
Female sterilisation	Delay advised	Delay advised due to increased risk of regret if done immediately If a woman has requested sterilisation during an elective C-section ensure consent is taken at least 2 weeks before
Male sterilisation	Immediately after delivery	Much safer and lower failure rates than female sterilisation
Fertility awareness method	Immediately after delivery	Hormonal changes due to pregnancy and lactation can make it harder to identify ovulation

 

If contraception is started before the 21-day mark then no additional precautions are required, whereas if it has been longer than this the standard precautions for each contraceptive method are needed. Women are advised to take a pregnancy test before starting contraception if it is over 3 weeks since delivery.

 

If a woman is not on contraception and has unprotected sex over 3 weeks she can safely be given ulipristal acetate or levonorgestrel as emergency contraception. The IUD is safe from 4 weeks after delivery. However, breastfeeding women should be advised to avoid feeding for one week if they take ulipristal acetate and should instead express and discard the milk.

 

Ectopic pregnancy, miscarriage or abortion

Fertility returns from 5 days after early pregnancy loss and women may quickly return to sexual activity so contraception advice is key if they don’t want another pregnancy. Similar to the 21-day window after term delivery, if contraception is started after this 5-day period additional precautions must be taken (2 days for progesterone-only pill, 7 days for all other methods).

All hormonal methods are safe immediately after uncomplicated abortion or miscarriage. Intrauterine devices should be avoided if there is a risk of infection. Additional considerations for each situation are listed below.

Abortion

• Depot – slightly higher risk of failed abortion if depot started when mifepristone is taken
• Women are advised to delay sterilisation due to increased risk of regret
• Medical attention should be sought in the case of an absent period as it may indicate a failed abortion, don’t assume it is due to hormonal contraception

Ectopic pregnancy

• Women who take methotrexate should wait 3 months before conceiving again

Miscarriage

• Combined hormonal contraception should be avoided in women with recurrent miscarriage until antiphospholipid syndrome is ruled out