Q: What’s a vital aspect of the care we provide to postpartum patients?
A: Optimal timing of evaluation for contraception.
Good timing minimizes the likelihood that postpartum contraception will be initiated too early or too late to be effective.
The choice of a contraceptive method for a postpartum woman also requires a careful balancing act. On one side: the risks of contraception to the mother and her newborn. On the other: the risk for unintended pregnancy. Among the concerns that need to be addressed in contraceptive decision-making are:
• Whether the woman has resumed sexual intercourse
• Infant feeding practices
• Risk for venous thromboembolism (VTE)
• Logistics of various long-acting reversible contraceptives and tubal sterilization.
In this article, we outline the components of effective contraceptive counseling and decision-making. We also summarize recent recommendations from the CDC on the use of various contraceptive methods during the postpartum period.
FIRST: START AT THREE WEEKS
The traditional six-week postpartum visit was timed to take place after complete involution of the uterus following vaginal delivery. However, involution occurs too late to prevent unintended pregnancy because ovulation can—and often does—occur as early as the fourth postpartum week among nonbreastfeeding women.
In the past, when it was more common to fit a contraceptive diaphragm after pregnancy, six weeks may have been the best timing for the visit. Today, given the high safety and efficacy of modern contraceptive methods (even when initiated before complete involution), as well as the importance of safe birth spacing, the routine postpartum visit is more appropriately scheduled at three weeks for women who have had an uneventful delivery.
In some cases, of course, it may be appropriate to schedule a visit even earlier, depending on the medical needs of the mother (which may include staple removal after cesarean delivery, follow-up blood pressure assessment for patients who have gestational hypertension, etc). That said, the first postpartum visit should be routinely scheduled for no later than three weeks for healthy women who have had an uncomplicated delivery.1
The data support this approach. In one study, 57% of women reported the resumption of intercourse by the sixth postpartum week.2 A routine three-week postpartum visit instead of a visit at six weeks would reduce unmet contraceptive needs among this group of women.
HOW INFANT FEEDING PRACTICES COME INTO PLAY
Both the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics recommend six months of exclusive breastfeeding because of recognized health benefits for both the mother and her infant. Exclusive breastfeeding is also a requirement if a woman desires to use breastfeeding as a contraceptive method.
Healthy People 2010 is a set of US health objectives that includes goals for breastfeeding rates. Although the percentage of infants who were ever breastfed has reached the 75% target of Healthy People 2010, according to data from the National Health and Nutrition Examination Survey (NHANES), the percentage of infants who were breastfed at six months of age has changed only minimally.3 For Mexican-American infants, that rate is 40%, compared with 35% for non-Hispanic whites and 20% for non-Hispanic black infants.3 Rates of exclusive breastfeeding are even lower, highlighting the importance of early breastfeeding support and contraceptive guidance during the postpartum period—support and guidance that can be offered at a three-week postpartum visit.
EXTENT OF BREASTFEEDING TO BE ASSESSED
Full or nearly full breastfeeding should be encouraged, along with frequent feeding of the infant. In addition, the contraceptive effect of lactation during the first six months of breastfeeding should be emphasized (see sidebar on the lactational amenorrhea method [LAM] of contraception). Keep in mind, however, that a substantial number of nursing mothers who are not breastfeeding exclusively will ovulate before the six-week postpartum visit. Data suggest that approximately 50% of all nonbreastfeeding women will ovulate before the six-week visit, with some ovulating as early as postpartum day 25.4
For this reason, you need to determine the extent of breastfeeding at the three-week visit to determine whether LAM is a contraceptive option for your patient. Full or nearly full breastfeeding means that the vast majority of feeding is breastfeeding and that breastfeeding is not replaced by any other kind of feeding. Frequent feeding means that the infant is breastfed when hungry, be it day or night, which implies at least one nighttime feeding. If evaluation at the three-week visit indicates that breastfeeding is no longer full or nearly full and frequent, another form of contraception should be initiated.5
For most women, the benefits of initiating a progestin-only or nonhormonal method of contraception at this time outweigh the risks, regardless of breastfeeding status, according to the CDC’s medical eligibility criteria for contraceptive use.6