How to choose a contraceptive for your postpartum patient
An earlier follow-up visit is the first requisite. Also consider how soon your patient plans to resume intercourse, her risk of venous thromboembolism, and how extensively she intends to breastfeed.
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In contrast, progestin-only and nonhormonal contraceptive methods can be safely initiated by both breastfeeding and nonbreastfeeding women before 21 days postpartum, which means that women can begin using them before discharge from the hospital.
Updated recommendations for use of combined hormonal contraceptives during the postpartum period*
| Time since delivery | Recommendation | Clarification |
|---|---|---|
| Nonbreastfeeding women | ||
| <21 days | Combined hormonal contraception not recommended | Presents an unacceptable health risk |
| 21–42 days | Not recommended for women who have other risk factors for VTE (e.g., age ≥35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, BMI ≥30, postpartum hemorrhage, cesarean delivery, preeclampsia or smoking) Acceptable for women who do not have other risk factors for VTE | Theoretical or proven risks usually outweigh advantages in women who have risk factors for VTE Advantages generally outweigh the theoretical or proven risks in women who do not have other risk factors for VTE |
| >42 days | Recommended | No restrictions |
| Breastfeeding women | ||
| <21 days | Not recommended | Presents an unacceptable health risk |
| 21–29 days | Not recommended for women who have other risk factors for VTE (e.g., age ≥35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, BMI ≥30, postpartum hemorrhage, cesarean delivery, preeclampsia or smoking) Not recommended for women who do not have other risk factors for VTE | Theoretical or proven risks usually outweigh advantages |
| 30–42 days | Not recommended for women who have other risk factors for VTE (e.g., age ≥35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, BMI ≥30, postpartum hemorrhage, cesarean delivery, preeclampsia or smoking) Acceptable for women who do not have other risk factors for VTE | Theoretical or proven risks usually outweigh advantages in women who have risk factors for VTE Advantages generally outweigh the theoretical or proven risks in women who do not have other risk factors for VTE |
| >42 days | Acceptable | Advantages generally outweigh the theoretical or proven risks |
| VTE = venous thromboembolism, BMI = body mass index * Includes combined oral contraceptives, combined hormonal patch, and combined vaginal ring SOURCE: Adapted from CDC6 | ||
Long-acting reversible contraceptives (LARC) are an important postpartum contraceptive option because they offer highly effective protection against pregnancy that can begin as soon as the placenta is delivered. LARC methods include contraceptive implants and intrauterine devices (IUDs).
According to the CDC’s medical eligibility criteria for contraceptive use, contraceptive implants can be placed immediately after delivery of the placenta without restriction.8
The copper IUD can be placed within 10 minutes after delivery of the placenta without restriction. If this window is missed, the benefits of inserting the IUD still outweigh the risks. Because 4 weeks postpartum is another time when the copper IUD can be inserted without restriction, the 3-week visit is a reasonable time to screen and schedule a patient for insertion.
The benefits of insertion of the levonorgestrel-releasing intrauterine system (LNG-IUS) are also believed to outweigh the risks before 4 weeks postpartum. Like the copper IUD, the LNG-IUS can be inserted without restriction at 4 weeks postpartum or later.
There is no need for a pelvic exam at the 3-week postpartum visit among women who undergo immediate postplacental insertion of the copper IUD or LNG-IUS. In fact, women can delay the exam until involution is complete.
Sterilization is best after complete involution
Interval tubal sterilization by laparoscopic, bilateral tubal fulguration or hysteroscopic microinsert placement is one of the most effective ways to prevent pregnancy. Both methods are best performed after the completion of involution and the return of normal coagulation; scheduling can take place at the 3-week postpartum visit.
Given the benefit of depot medroxyprogesterone acetate (DMPA) in endometrial suppression before hysteroscopic sterilization, it is reasonable to consider administering DMPA at the 3-week postpartum visit in anticipation of surgery after involution is complete.
The bottom line
Because most contraceptive methods can be safely initiated at or shortly after a 3-weeks’ postpartum visit, there is no longer any reason to time the routine postpartum visit to coincide with the completion of involution. For healthy women who have had an uneventful delivery, the routine postpartum visit should occur at 3 weeks.
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