Postpartum contraception

Question 1

What contraceptive options are available?

Answer 1

• Lactational amennorhea
• Barrier methods
• COCP
• POP
• Depo-provera
• Implant
• CuT380 or mirena IUD
• Sterilisation
• Natural methods - i.e. monitoring for ovulation and abstinence

Question 2

How does LAM work?

Answer 2

• Regular lactation inhibits the normal pulsatile release of LH causing anovulation and amenorrhea.

Question 3

What is the effectiveness of LAM (%)? What does effective LAM require?

Answer 3

• 98% when breast feeding criteria are met - as below:
• Exclusive breast feeding day and night
• Amenorrhoea for > 56 days post partum
• Less than 6 months postpartum

Question 4

How long can LAM be relied upon if adequate breast feeding levels maintained?

Answer 4

• 6 months

Question 5

What are the specific risks of COCP in the postnatal period?

Answer 5

• Increased risk of VTE postnatally (particularly in higher risk groups)
• Can be transferred in breast milk
• Within first 6 weeks postnatally some evidence of slower infant weight gain

Question 6

When can COCP be started postnatally and what is the advice?

Answer 6

• In otherwise low risk women - after 21 days
• If additional risks for VTE (obesity, HTN, DM, operative delivery etc) - after 6 weeks
• If breast feeding - after 6 weeks

NB. if started >21 days after delivery, alternative contraception should be used for 7 days

Question 7

When can an IUD be placed postnatally?

Answer 7

• Immediate placement - 10mins after delivery of placenta to 48 hours postpartum
• Interval placement - > 4 weeks postpartum

NB. ‘ early placement’ i.e after 48 hours and before 4 weeks has the highest rate of expulsion - up to 30%

Question 8

What is the risk of expulsion of IUD when placed immediately postpartum (after 10 mins of placental delivery) versus interval placement (after >4 weeks postpartum)?

Answer 8

• Immediate placement = 1/10
• interval placement = 1/20

BUT at 6 months ongoing use is comparable between groups.

Question 9

Why are natural approaches not recommended in the postnatal period?

Answer 9

Because it’s a stupid method of contraception!!

• Ovulation may occur prior to first period so difficult to anticipate
• Ovulation can be erratic postpartum
• The usual signs and symptoms of ovulation can be missed in symptoms and fatigue postnatally