The new guideline on Contraception after pregnancy has been released by Faculty of Sexual and Reproductive Healthcare, UK.This Guideline summary focuses specifically on those recommendations relating to the discussion and provision of contraception after pregnancy and childbirth.
Key Recommendations :
1.When can contraception after childbirth be initiated?
- The choice of contraceptive method should be initiated by 21 days after childbirth
- A woman’s chosen method of contraception can be initiated immediately after childbirth if desired and she is medically eligible
- Women should be advised that IUC and IMP can be inserted immediately after delivery
- Clinicians should be aware that insertion of IMP soon after childbirth is convenient and highly acceptable to women. This has been associated with high continuation rates and a reduced risk of unintended pregnancy
- Clinicians should be aware that insertion of IUC at the time of either vaginal or cesarean delivery is convenient and highly acceptable to women. This has been associated with high continuation rates and a reduced risk of unintended pregnancy
2.How long should a woman wait before trying to conceive again?
- Women should be advised that an IPI of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birthweight, and small for gestational age (SGA) babies
Which methods of contraception are safe to use after childbirth?
- Women should be advised that although contraception is not required in the first 21 days after childbirth, most methods can be safely initiated immediately, with the exception of combined hormonal contraception (CHC)
Can women who develop medical problems during pregnancy safely use contraception after childbirth?
- Clinicians should discuss with the woman any personal characteristics or existing medical conditions, including those that have developed during pregnancy, which may affect her medical eligibility for contraceptive use
Is emergency contraception (EC) safe to use after childbirth?
- Emergency contraception (EC) is indicated for women who have had unprotected sexual intercourse (UPSI) from 21 days after childbirth but is not required before this
- Oral EC levonorgestrel 1.5 mg (LNG-EC) and ulipristal acetate 30 mg (UPA-EC) are safe to use from 21 days after childbirth. The copper intrauterine device (Cu-IUD) is safe to use for EC from 28 days after childbirth
- Women who breastfeed should be informed that available limited evidence indicates that LNG-EC has no adverse effects on breastfeeding or on their infants
- Women who breastfeed should be advised not to breastfeed and to express and discard milk for a week after they have taken UPA-EC
Is additional contraception required after initiation of a method after childbirth?
- Women should be advised that additional contraceptive precautions (e.g. barrier method/abstinence) are required if hormonal contraception is started 21 days or more after childbirth. Additional contraceptive precaution is not required if contraception is initiated immediately or within 21 days after childbirth
4.Breastfeeding and contraception
Does initiation of hormonal contraceptives affect breastfeeding outcomes or infant outcomes?
- Women who are breastfeeding should be informed that the available evidence indicates that progestogen-only methods of contraception (LNG-IUS, IMP, POI and POP) have no adverse effects on lactation, infant growth or development
- Women who are breastfeeding should wait until 6 weeks after childbirth before initiating a CHC method
- Women who are breastfeeding should be informed that there is currently limited evidence regarding the effects of CHC use on breastfeeding. However, the better quality studies of early initiation of CHC found no adverse effects on either breastfeeding performance (duration of breastfeeding, exclusivity and timing of initiation of supplemental feeding) or on infant outcomes (growth, health and development)
Can women who breastfeed effectively use lactational amenorrhoea method (LAM) as contraception?
- Women may be advised that, if they are less than 6 months postpartum, amenorrhoeic and fully breastfeeding, the lactational amenorrhoea method (LAM) is a highly effective method of contraception
- Women using LAM should be advised that the risk of pregnancy is increased if the frequency of breastfeeding decreases (e.g. through stopping night feeds, starting or increasing supplementary feeding, use of dummies/pacifiers, expressing milk), when menstruation returns or when more than 6 months after childbirth
Intrauterine contraception (IUC)
- IUC can be safely inserted immediately after birth (within 10 minutes of delivery of the placenta) or within the first 48 hours after the uncomplicated cesarean section or vaginal birth. After 48 hours, insertion should be delayed until 28 days after childbirth
Progestogen-only implants (IMP)
- IMP can be safely started at any time after childbirth including immediately after delivery
Progestogen-only injectable (POI)
- POI can be started at any time after childbirth, including immediately after delivery
Progestogen-only pills (POP)
- POP can be started at any time after childbirth, including immediately after delivery
Combined hormonal contraception (CHC)
- All women should undergo a risk assessment for venous thromboembolism (VTE) postnatally. CHC should not be used by women who have risk factors for VTE within 6 weeks of childbirth. These include immobility, transfusion at delivery, body mass index (BMI) ≥30 kg/m2, postpartum hemorrhage, post-cesarean delivery, pre-eclampsia, or smoking. This applies to both women who are breastfeeding and not breastfeeding
- Women who are not breastfeeding and are without additional risk factors for VTE should wait until 21 days after childbirth before initiating a CHC method
- Female sterilisation is a safe option for permanent contraception after childbirth
- For sterilisation after childbirth, both Filshie clips and modified Pomeroy technique are effective. Filshie clip application is quicker to perform
- Women should be advised that some LARC methods are as, or more, effective than female sterilisation and may confer non-contraceptive benefits. However, women should not feel pressured into choosing LARC over female sterilisation
- Tubal occlusion should ideally be performed after some time has elapsed following childbirth. Women who request tubal occlusion to be performed at the time of a delivery should be advised of the possible increased risk of regret
- Clinicians should ensure that written consent to be sterilised at caesarean section is obtained and documented at least 2 weeks in advance of a planned elective caesarean section
- Male and female condoms can be safely used by women after childbirth
- Women choosing to use a diaphragm should be advised to wait at least 6 weeks after childbirth before having it fitted because the size of diaphragm required may change as the uterus returns to normal size
Fertility awareness methods (FAM)
- Fertility awareness methods (FAM) can be used by women after childbirth. However, women should be advised that because FAM relies on the detection of the signs and symptoms of fertility and ovulation, its use may be difficult after childbirth and during breastfeeding .
Please refer to the original guideline for a full list of recommendations, including those relating to contraception after abortion, ectopic pregnancy, miscarriage, or gestational trophoblastic disease available from…
Faculty of Sexual and Reproductive Healthcare –
Dr. Kamal Kant Kohli
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