Postpartum Contraception

Counseling
BROWN DEPT OF FAMILY
MEDICINE
MATERNAL CHILD HEALTH
WEB BASED MODULE
SERIES
ORIGINAL BY: ALLA GOLDBURT, PGY-2, 2013
EDITED BY: MARY BETH SUTTER PGY-3, 2013

Goal of Presentation
PART 1
What is different about contraception in
postpartum period?
When should we counsel?
PART 2
What are the options?
How do we use them?
Why do we recommend using them in this way?

What is different about contraception in postpartum

period?
Breastfeeding
Hypercoagulable state
Different contraceptive needs
Changes in libido
Interval between childen
Cultural/ religious issues

Breastfeeding Physiology
Pregnancy Stage 1

Prolactin -> breast growth, milk biosynthesis

Progesterone (and estrogen) -> antagonist for prolactin, inhibits
lactation

Birth Stage 2

Rapid withdrawal progesterone and estrogen> initiation of lactation

Suckling -> prolactin receptors , oxytocin release

Days 2-4 postpartum

High serum prolactin -> inhibits pulsatile GnRH -> prevents

ovulation
High local prolactin receptors -> continued lactogenic feedback

Breastfeeding and Hormonal Contr.

Nutritional research 1970s-1980s OCPs

Significant changes in concentration of total protein, milk

protein, and daily milk volume (Lonnerdal 1980)
Magnitude of changes w/in normal range, not of nutritional
importance to newborn (Kowetsawang 1987)

WHO Task Force (1984)

Prospective RCT of combined OCPs vs progesterone only pills

vs non-hormonal placebo pills
Milk volume: 41.9% decline in combined OCP group vs 12.0%
in progesterone only group vs 6.1% in non-hormonal controls
Comparable prevalence of initiation of partial bottle feeding
due to inadequate milk supply
No differences in growth of infants between treatment groups

Postpartum Hypercoagulable State

Physiology
Increase in coagulation factors and fibrinogen, resistance to
anticoagulant proteins C and S
Risk of VTE (Gherman 1999)
22-84x higher in first 6 weeks of postpartum period
greatest in first 21 days, after which risk sharply drops off

Postpartum libido
Libido decreases postpartum
Declining estrogen levels
May last up to a year
Breastfeeding
Contributes to decreased estrogen levels
Body Image
Fatigue
Physical Discomfort
Laceration or Episiotomy repair

Cultural considerations
Some cultures reinforce a one month or longer

period postpartum where intercourse is prohibited

No medical reason to not have intercourse as long as

bright red bleeding has stopped (usually within 10-14

days postpartum) and any incisions/lacerations have
healed)

Family planning needs?

Survey (Cwiak 2004) extremely important qualities

ANTEPARTUM: reliability, efficacy, and safety during breastfeeding

POSTPARTUM: ease of use, long-term protection, and no need
for monthly pharmacy trips
> 80% were using contraception prior to pregnancy, nearly
20% not satisfied with the method used.
> 40% thought intrauterine contraception seemed
somewhat or much better than their most recent method,
yet < 1% chose
Participants of study were mostly Caucasian, married, highly
educated and of higher income status

When should we counsel?

When do women initiate sexual activity postpartum?

(Ford 1998, Barret 2000)

Study at an urban university hospital

32-66% sexually active within first month
62-88% within second month

When should we counsel?

Is it happening as part of the standard discharge

discussion? (Glazer 2010)

77% (134 women) discussed contraception antepartum

87% (153 women) discussed postpartum
1/3 discussed IUDs with their doctor at any point

How effective are we at counseling?

NOT many great studies..
Effectiveness of prenatal counseling (Smith

2002)

Expert advice was compared to routine standard advice in

prenatal period in countries all over the world
Pregnancy rates at 1 year were not significantly different, even
when considering intention to become pregnant
Contraceptive practices differed significantly (those not
intending to get pregnant chose sterilization)

How effective are we at counseling?

Cochrane Review of effects of postpartum

interventions (Lopez 2002, 2010)

Counseling postpartum increased contraception use and

decreased unplanned pregnancies in 2/4 interventional trials

Interventions were more effective when further out from

hospital stay period and also when incorporated into home
visits

Part 2

What are the options? How do we use them?

Why do we recommend using them in this way?

The Menu
Non-Hormonal
Lactational amenorrhea
Condoms
Cervical Cap
Copper IUD
Ovulation Timing
Methods
Sterilization

Hormonal
Progestin only pill
Depomedroxyprogesterone
IUD (levonorgestrel)
Combined OCPs
Patch/Ring
Implant (etonogestrel)

Intro to WHO classification

Category Classification of recommendations

1. No restriction (method can be used)

2. Advantages generally outweigh theoretical or proven risks
3. Theoretical or proven risks usually outweigh the
advantages

4. Unacceptable health risk (method not to be used)

Lactational Amenorrhea
How it works
Continuous prolactin signaling inhibits ovulation
Ovulation can occur within 3 months even in exclusive
breastfeeders, as early as 3-6 weeks in women who are not
exclusively breastfeeding
Ovulation may precede menstruation
EBM
< 2% failure rate in women exclusively or mostly
breastfeeding (defeeding both night and day, infant less than 6
months old and receiving >90% nutrition from breastmilk,
ammenorheic) (WHO)

Lactational amenorrhea
ACOG

WHO (AAFP)

NONBr Feed

NOT recommended

NOT recommended

Br Feed

(No recommendation )

( No recommendation )

Lactational amenorrhea
Clinical judgment
Menstruation is unpredictable
How much/ how long is your patient going to breastfeed
Has your patient resumed sexual activity

Combination contraceptives- COCs, Nuvaring,

Orthoevra
How it works
Primarily inhibits ovulation
Changes cervical mucous
Some benefits for lighter periods, less acne, protective against
ovarian cancer
Efficacy- Perfect use: 0.6-0.8%, Actual use: 0.8-1%
EBM
Initiate 3 weeks postpartum for nonlactating women-risk of
pregnancy related thrombosis reduced to acceptable level at
this time (Gherman 1999)
Decreases median lactating period (WHO 1984)

Combination Contraceptives
ACOG

WHO /CDC

AAP

NONBr Feed

> 4 weeks

4: < 21 days
3: 21-42 days with risk
factors for VTE
2: 21-42 days w/o risk
factors for VTE
1: > 43 days

After 3-6 weeks

Br Feed

> 4 weeks, waiting

until breast feeding
well established

4: < 21 days
3: 21-42 days with risk
factors for VTE
2: 21-42 days w/o risk
factors for VTE
1: > 43 days

After 3- 6 weeks
Wait until infant
not relying
predominately on
breast milk

Combination contraception
Clinical Judgment
Consider time frame of initiation and your patients risk for
VTE
How established is your patients breastfeeding/ how
important is this to them
Consider ease of use and familiarity for mother for route (pill
vs patch vs ring)
Weight limit with the patch
Counsel on missed pills!

Missed pill algorithm

http://campushealth.unc.edu/sites/campushealth.unc.edu/files/Missed%20Pill%20Chart.pdf

Progesterone only methods: Minipill, DepoProvera, Mirena IUD, Implanon

How it works
Thickens cervical mucous
Causes atrophy of endometrium
Unpredictably prevents ovulation
EBM
Progesterone little effect on coagulation factors, BP, lipids
Has NOT been shown to effect milk quality significantly (Truitt
2003)
NO effect on infant growth and development (WHO 1994)
Early initiation had NO effect on short-term breastfeeding
patterns (Halderman 2003)

Mirena- Progesterone only IUD

Efficacy: 0.1% typical use
Expulsion rates?
Immediate postplacental insertion 10 minutes within delivery
of placenta
OR

Interval insertion 4-6 weeks postpartum

24-48 hour interval insertion is NOT recommended
Postplacental generally higher explusion rate ~7-15%
(Cochrane 2010)
Most recent RCT: Postplacental group 24% expulsion rate,
Interval group 4.4% expulsion rate (Chen 2009)
Technique?? Inserter vs ring forceps vs manual; US vs no US

Depo-Provera- Progesterone only injection

150 mg depo-medroxyprogesterone IM q 3 months
Efficacy- Perfect use 0.3%, Actual use 3%
Breastfeeding
NO effect on duration or frequency of lactation (Hannon, 1997)
NO effect on timing of introduction of formula (Hannon, 1997)
Theoretical load of progesterone to be metabolized by fetal
liver when given immediately postpartum
Considerations
Weight gain in already overweight patients
Up to 18 months lag in fertility
Reversible loss of bone density with prolonged use

Other progesterone only methods

Mini-pill (35 mcg Norethindrone)
Efficacy- Perfect use 0.3%, Actual use 3%
Needs to be taken precisely at same time every day
Implanon/Nexplanon (68mg etonorgestrol, 3 years)
Efficacy- Typical use 0.5%
Pilot studies showed no effect on breastfeeding
Same theoretical progesterone load concern as DepoProvera
Can be inserted any time postpartum prior to hospital d/c
Irregular bleeding most common reason for discontinuation

Progesterone only- all methods

ACOG

WHO

NONBr Feed

Anytime

1: Anytime

Br Feed

> 3 weeks if partially breast

feeding

1: Anytime

> 6 weeks if fully breast

feeding
MIRENA

2: < 10 minutes
2: 10 minutes to 4 weeks
1: after 4 weeks

Progesterone only
Clinical judgment
Concerns for newborn with progesterone crossing breastmilk

Potential effects on newborn brain, liver in animal studies

Timing of insertion for Mirena and expulsion risk

Benefits of Mirena for lighter periods or possible amenorrhea
Prolonged/irregular bleeding with Implanon
Ease of use for progesterone only pill that requires precise
timing
Weight gain with Depo-Provera

ParaGuard- Copper IUD

How it works
Copper ions interfere with sperm transport and implantation
Efficacy: Typical use 0.6%
EBM
Post placental insertion within 20 minutes manually
Interval insertion at 4-6 weeks postpartum
Postplacental vaginal birth expulsion rate at six months 6.7
times more (7-15%) vs interval (Kapp 2009, Cochrane 2010)
Postplacental c-section expulsion rate 0 - 10.6 % at six months
(Levi 2012, Celen 2011)
No effect on breastmilk production

Paraguard Copper IUD

ACOG
NONBr Feed

WHO
1: < 10 minutes after delivery
2: 10 minutes to 4 weeks after
delivery
1: > 4 weeks after delivery

Br Feed

1: < 10 minutes after delivery

2: 10 minutes to 4 weeks after
delivery
1: > 4 weeks after delivery

ParaGuard- Copper IUD

Clinical Judgment
Timing of insertion
Expulsion risk
Lasts 10 years!

Other methods
Sterilization (Tubal, Essure, Vasectomy) Tubal ligation can be done immediately after c-section, within
24-48 hours after vaginal delivery or at an interval of 4-6
weeks
Tubal ligation is effective immediately, no effect on breast
milk, costly/ not guaranteed reversal
Essure needs interval timing, no effect on breast milk, NOT
reversible
Efficacy- Typical use 0.5%
Condoms Can be used at any time, effective immediately, no effect on
breast milk, protects against STIs, actual use 15% failure rate

Plan B and Ella

How it works
Progesterone only: 1.5 mg levonorgestrel x 1 (Plan B one step) or

.75 mg levonorgestrel x 2 (Plan B)

Progesterone receptor modulator: Ulipristal acetate 30mg (Ella)
Both block ovulation and implantation
Both effective up to 12o hours, the sooner the more efficacious

EBM
No increased risk of VTEs for mom
No effect on breast milk
Clinical Judgment
Availability- give out prescriptions!

In summary
What is different about contraception in

postpartum period?
When should we counsel?
What are the options?
How do we use them?
Why do we recommend using them in this way?

Question 1
Which form of birth control (not including

abstinence) is most effective when used properly?

a) Mirena IUD
b) Progestin only pills
c) Combined pills
d) Depo-Provera

Question 1
Which form of birth control (not including

abstinence) is most effective when used properly?

a) Mirena IUD
b) Progestin only pills
c) Combined pills
d) Depo-Provera

Mirena IUD is the most effective with a failure rate of

0.1% per year.

Question 2
What are ACOGs recommendations regarding the

initiation of Progestin only OCPs in a breastfeeding

woman?
a) Start on discharge
b) Wait one week
c) Wait 3 weeks
d) Wait 6 weeks

Question 2
What are ACOGs recommendations regarding the

initiation of Progestin only OCPs in a breastfeeding

woman?
a) Start on discharge
b) Wait one week
c) Wait 3 weeks
d) Wait 6 weeks
ACOG recommends waiting 3 weeks if not breastfeeding
and 6 weeks if breastfeeding, BUT, WHO says
anytime!

Question 3
Which method of birth control has the longest return

to fertility after discontinuation?

a) Vaginal ring
b) OCP
c) IUD
d) Depo-Provera
e) Lactational amenorrhea

Question 3
Which method of birth control has the longest return

to fertility after discontinuation?

a) Vaginal ring
b) OCP
c) IUD
d) Depo-Provera
e) Lactational amenorrhea

Depo- Provera can take up to 18 months for return to

fertility after stopping.

Question 4

Emergency contraception may be used in the breast feeding

mother

A) true
B) false

Question 4

Emergency contraception may be used in the breast feeding

mother
A) true
B) false

Yes! Breastfeeding mothers can absolutely use EC and

should be given a script before leaving the hospital.

Question 5

Depo-Provera in contraindicated for the breastfeeding mother

at hospital discharge

A) true
B) false

Question 5

Depo-Provera in contraindicated for the breastfeeding mother

at hospital discharge

A) true
B) false

Moms at high risk of getting pregnant again should be

offered Depo prior to leaving the hospital. WHO
recommends starting progesterone only
contraception anytime; while ACOG says wait 3 weeks
if not breastfeeding and 6 weeks if breastfeeding.

Question 6

It is recommended by ACOG that a woman wait 6 weeks

postpartum before having intercourse

A) true
B) false

Question 6

It is recommended by ACOG that a woman wait 6 weeks

postpartum before having intercourse

A) true
B) false

There is no medical reason to restrict sexual activity as

long as bright red bleeding has stopped (usually
within 10-14 days postpartum) and any incisions or
lacerations have healed)

Question 7
Your patient is a 17 yo G1 now P1, 2 days PP, who does not want to get

pregnant for at least 5 years. She currently has a new sexual partner.
She has never had and STD. She is breastfeeding. She weighs 223
pounds. She is now asking for your advice on which method to pick.
She would prefer a non-hormonal method. What are her most effective
choices for B.C.? (you may pick more than one)
a) No method
b) Lactational amenorrhea
c) Condoms
d) Depo-Provera
e) Mirena IUD
f) Paraguard IUD
g) Ring
h) Combined OCP
i) Progestin-only OCPs
j) EC

Question 7
Your patient is a 17 yo G1 now P1, 2 days PP, who does not want to get

pregnant for at least 5 years. She currently has a new sexual partner.
She has never had and STD. She is breastfeeding. She weighs 223
pounds. She is now asking for your advice on which method to pick.
She would prefer a non-hormonal method. What are her most effective
choices for B.C.? (you may pick more than one)

Lots of things are good for this patient- talk about your
thoughts with your senior/the entire MCH team!

In case of emergency
Online:
CDC.gov

Search US Medical Eligibility Criteria for Contraceptives

WHO.org
Search Medical Eligibility Criteria for Contraceptives
Working on Mobile App

Reproductiveaccess.org

Search Fact Sheets

Resources
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BJOG: An International Journal of Obstetrics & Gynaecology, 107: 186195.
Brownwell, et al. A Systematic Review of Early Postpartum Medroxyprogestrone Receipt and early
BreastfeedingCessation: Evaluating theMethodological Rigor of the Evidence. Breastfeeding Medicine. @012, 7, (1)
Celen, et al. Immediate postplacental insertion of an intrauterine contraception device after cesarian section.
Contracetpion. 2011,
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Chen BA Reeves MF, Hayes JL, Perriera LK, Creinin MD. Postplacental or delayed insertion of the levonorgestrel
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