Take Home Messages o Oestrogen-containing contraceptives are not recommended in the first three weeks postpartum because of the significantly higher risk of venous thromboembolism. o After six weeks, the benefits of low dose combined contraception appear to outweigh any proven or theoretical risks for the breastfeeding woman and her infant and there are no restrictions at all beyond six months. o The assumption that couples will not have resumed sexual activity by six weeks is erroneous, as Australian research suggests that at least 41% have done so. DR TERRI FORAN MB BS (Syd), MClin Ed (UNSW), FAChSHM Dr Terri Foran is a Sexual Health Physician with special interests in contraception, menopause issues and the management of sexually transmitted infections. She is presently engaged in clinical and research work at the Royal Hospital for Women in Sydney and also in clinical practice in an inner Sydney private practice. Terri is currently the monthly Women’s Health columnist for Australian Doctor Magazine, and has contributed to a 2011 Australian textbook on Sexual and Reproductive Health. This article describes the importance of postpartum contraception, dispels some of the myths and details the pros and cons of the various contraceptive options available in Australia. Postpartum Contraception www.healthed.com.au Page 1 Introduction I nitiation of contraception in the immediate post-partum period is a safe and cost-effective way of reducing the rates of both unintended pregnancy and early repeat deliveries. 1,2,3,4 However, contraception is often neglected in the hospital setting, given the understandable immediate focus on pregnancy and delivery. Traditionally, the discussion of contraception has been deferred until the six-week check, but this neglects the fact that ovulation can occur within twenty-five days of delivery in women who are not breastfeeding. 5 The assumption that couples will not have resumed sexual activity by six weeks is also erroneous, as Australian research suggests that at least 41% have done so! 6 The Natural Approach: Breastfeeding, Fertility Awareness and Barrier Methods Women who exclusively breastfeed, have not yet resumed menstruating and who are within six months of delivery have around a 2% risk of pregnancy. 7 However, should any one of these conditions alter, the contraceptive effect of breastfeeding plummets EXPERT MONOGRAPH ISSUE 5
Transcript
title sub title
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Take Home Messages
o Oestrogen-containing contraceptives are not
recommended in the first three weeks postpartum
because of the significantly higher risk of venous
thromboembolism.
o After six weeks, the benefits of low dose combined
contraception appear to outweigh any proven
or theoretical risks for the breastfeeding woman
and her infant and there are no restrictions at all
beyond six months.
o The assumption that couples will not have
resumed sexual activity by six weeks is erroneous,
as Australian research suggests that at least 41%
have done so.
DR TERRI FORAN MB BS (Syd), MClin Ed (UNSW), FAChSHM
Dr Terri Foran is a Sexual Health Physician with special interests in contraception, menopause issues and the
management of sexually transmitted infections. She is presently engaged in clinical and research work at
the Royal Hospital for Women in Sydney and also in clinical practice in an inner Sydney private practice. Terri
is currently the monthly Women’s Health columnist for Australian Doctor Magazine, and has contributed to
a 2011 Australian textbook on Sexual and Reproductive Health.
This article describes the importance of postpartum contraception, dispels some of the myths and details the pros and cons of the various contraceptive options available in Australia.
Postpartum Contraception
www.healthed.com.au Page 1
Introduction
Initiation of contraception in the immediate post-partum period is a safe and cost-effective way of reducing the rates of both unintended pregnancy and early repeat deliveries.1,2,3,4 However, contraception is often neglected in the hospital setting, given
the understandable immediate focus on pregnancy and delivery. Traditionally, the discussion of contraception has been deferred until the six-week check, but this neglects the fact that ovulation can occur within twenty-five days of delivery in women who are not breastfeeding.5 The assumption that couples will not have resumed sexual activity by six weeks is also erroneous, as Australian research suggests that at least 41% have done so!6
The Natural Approach: Breastfeeding, Fertility Awareness and Barrier Methods
Women who exclusively breastfeed, have not yet resumed menstruating and who are within six months of delivery have around a 2% risk of pregnancy.7 However, should any one of these conditions alter, the contraceptive effect of breastfeeding plummets
EXPERT MONOGRAPH ISSUE 5
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Hormonal Contraception Trouble-shooting Part One: The Overweight Woman
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Postpartum Contraception
and another method to avoid pregnancy must be considered. The postpartum period can be a difficult time to implement fertility awareness methods as menstrual cycles are disrupted. In addition to this, broken sleep, the presence of lochia and vaginal dryness can all make interpretation of the usual signs of fertility less reliable.
Ovulation can occur within twenty-five days of delivery
in women who are not breastfeeding
Barrier contraception appeals to many couples, as it avoids the use of any exogenous hormones. Condoms have a typical failure rate of 15%,8 but with careful use and the decreased fertility associated with breastfeeding, most couples will have more success than this postpartum. The use of a diaphragm should be delayed until uterine involution has ended. The ‘one-size-fits-most’ CAYA® is now the only diaphragm now available in Australia. It has a typical failure rate of around 18%,9 but again, this rate is likely to be decreased during lactation. It is recommended that for maximum efficacy the CAYA® is always be used with its companion cellulose-based gel. If artificial lubricants are used, it is important to ensure that they are compatible with the barrier method chosen. This means only water-based lubricant can be used with latex condoms, though plastic condoms can be used with either oil-based or water-based products.
What about Combined Contraceptive Methods in the Postpartum Period?
Oestrogen-containing contraceptives are not recommended in the first three weeks postpartum because of the significantly higher risk of venous thromboembolism at this time.10 For breastfeeding women, this proviso against combined contraception extends until the infant is six weeks of age since oestrogen may impact on milk supply while feeding is being established. After six weeks, the benefits of low dose combined contraception appear to outweigh any proven or theoretical risks for the breastfeeding woman and her infant10 and there are no restrictions at all beyond six months. Mothers should be aware that with all hormonal methods of contraception, small amounts of hormone will be present in the breast milk. One recent systematic review found that no studies indicated an effect on infant growth or other infant health outcomes with the initiation of combined contraception beyond six weeks’ postpartum.11
What about Progestogen-only Methods in the Postpartum Period?
Systematic reviews of studies examining the effect of progestogen-only contraception on breastfeeding parameters (such as milk
quality and infant development) have never found any significant
adverse impact.12 Progestogen-only pills (POPs), also known as
minipills, have traditionally been the first choice for contraception
during lactation but it is no longer recommended that their
initiation be delayed until six weeks. One problem with POPs is
the requirement that they be taken within three hours of the usual
administration time. This can be difficult given the demands of
new motherhood.
Contraceptive implants may be easier to manage and may certainly
be used by all women in the immediate post-partum period,
whether they are breastfeeding or not. The Faculty of Sexual and
Reproductive Health Care in the United Kingdom also deems the
usable for most women immediately after delivery. The World Health
Organisation, however, suggests that the contraceptive injection be
delayed until six weeks’ postpartum, because of the higher initial
doses likely to be excreted in breast milk. In some countries, though
not Australia, breastfeeding women have access to a progesterone-
only vaginal ring which delivers 10mgs of progesterone per day.
Each ring provides contraceptive cover for three months and is
98.5% effective (provided the women breastfeeds more than four
times daily).13
What about Intrauterine Methods?
Intrauterine devices (IUDs), both copper and hormonal, offer
effective, immediate, long-term contraception and are rapidly
reversible. The copper IUD has the advantage of being not
only very effective but completely non-hormonal; this can be
an important consideration for some mothers. Placement of
an IUD within forty-eight hours of delivery (or at Caesarian) is
associated with an increase in risk of expulsion (12% to 24% as
opposed to approximately 4%).14,15,16 However, the risk of expulsion
significantly increases in the period from forty-eight hours to four
weeks’ postpartum; one study gave the rate of this complication as
70%.17 For that reason it is usually recommended that insertion be
delayed until four weeks’ postpartum.
What about Emergencies?
Emergency contraception is considered unnecessary if unprotected
intercourse occurs in the in the first twenty-one days postpartum.10
Until four weeks after the birth, complications such as an increased
risk of perforation and expulsion generally outweigh the benefits of
a copper IUD insertion as a means of emergency contraception.10
Both levonorgestrel and ulipristal emergency contraception can be
used by mothers safely from three weeks’ postpartum. However,
since breastmilk must be discarded for one week after taking
ulipristal, levonorgestrel emergency contraception is preferred in
breastfeeding mothers.10
Postpartum Contraception
www.healthed.com.au Page 3
What about Something More Permanent?
It is usually recommended that female tubal sterilisation be performed more than six weeks’ post-vaginal delivery, since tubal occlusion devices are more reliably placed at that time. However, if the woman has had an elective Caesarian, the procedure may be performed directly afterwards. One issue to be considered is that tubal occlusion failure rates rise over time.18 Although the failure rate in first year after surgery is one in two hundred and fifty, this rises to one in fifty-four by ten years’ postpartum. At best, sterilisation can only offer a younger woman a one in three hundred lifetime failure rate. Vasectomy is technically a much easier procedure, can be performed under twilight sedation only and has a much lower rate of serious complications when compared to tubal occlusion. The failure rate usually quoted for male sterilisation is around one to two per thousand.
Starting the Discussion about Postpartum Contraception
The ideal time to initiate the discussion of postpartum contraceptive needs is while the patient is still pregnant. It is important to provide the women or the couple with an evidence-based discussion of their various options and to provide prescriptions in advance, if appropriate. On a practical note, if her choice is an implant or an IUD, taking this to the hospital prior to the birth maximises the chances of insertion before discharge. Lastly, extol the virtues of ‘bridging’ – a pill or contraceptive injection might not be the ultimate contraceptive choice, but can provide an excellent stop-gap measure until a woman’s long-term method can be arranged.
Further reading
FSRH Clinical Effectiveness Unit. UK medical eligibility criteria for contraceptive use 2016. Faculty of Sexual and Reproductive Healthcare. 2016 Jul. Available online at: http://ukmec.pagelizard.com/2016
Declaration
Dr Terri Foran was commissioned by Healthed for this article. The ideas, opinions and information presented are solely those of the author. The advertiser does not necessarily endorse or support the views expressed in this article.
The author’s competing interests statement can be viewed at www.healthed.com.au/monographs.
References
1. Mwalwanda CS, Black KI. Immediate post-partum initiation of intrauterine contraception and implants: a review of the safety and guidelines for use. Aust NZ J Obstet Gynaecol. 2013 Aug; 53(4): 331-337
3. Washington CI, Jamshidi R, Thung SF, Nayeri UA, Caughey AB, Werner EF. Timing of postpartum intrauterine device placement: a cost-effectiveness analysis. Fertil Steril. 2015 Jan; 103(1): 131-137
4. Han L, Teal SB, Sheeder J, Tocce K. Preventing repeat pregnancy in adolescents: is immediate postpartum insertion of the contraceptive implant cost effective? Am J Obstet Gynecol. 2014 Jul; 211(1): 24.e 1-7
5. Jackson E, Glasier A. Return of ovulation and menses in postpartum nonlactating women: a systematic review. Obstet Gynecol. 2011 Mar; 117(3): 657-662
6. McDonald EA, Brown SJ. Does method of birth make a difference to when women resume sex after childbirth? BJOG. 2013 Jun; 120(7): 823-830
Video Resources
Important Advice for Women about IUCDs by Dr Terri Foran
Hormonal Contraception – Ask The Expert by Dr Terri Foran
Watch the full lectures on the Healthed website. Visit www.healthed.com.au/video
7. The Lancet. Breastfeeding as a Family Planning Method. Lancet. 1988 Nov; 2(8621): 1204-5
8. Trussell J. Contraceptive failure in the United States. Contraception. 2004 Aug; 70(2): 89-96
9. FSRH Clinical Effectiveness Unit. New product review from the Clinical Effectiveness Unit: one size contraceptive diaphragm (Caya) August 2014. Faculty of Sexual and Reproductive Healthcare. 2014 Aug. Available online at: https://www.fsrh.org/documents/cec-ceu-newproductreview-caya-aug-2014/
10. FSRH Clinical Effectiveness Unit. UK medical eligibility criteria for contraceptive use 2016. Faculty of Sexual and Reproductive Healthcare. 2016 Jul. Available online at: http://ukmec.pagelizard.com/2016
11. Tepper NK, Phillips SJ, Kapp N, Gaffield ME, Curtis KM. Combined hormonal contraceptive use among breastfeeding women: an updated systematic review. Contraception. 2016 Sep; 94(3): 262-274
12. Kapp N, Curtis K, Nanda K. Progestogen-only contraceptive use among breastfeeding women: a systematic review. Contraception. 2010 Jul; 82(1): 17-37
13. Sivin I, Diaz S, Croxatto HB, Miranda P, Shaaban M, Sayed EH, et al. Contraceptives for lactating women: a comparative trial of a progesterone-releasing vaginal ring and the copper T 380A IUD. Contraception. 1997 Apr; 55(4): 225-232
14. Chen BA, Reeves MF, Hayes JL, Hohmann HL, Perriera LK, Creinin MD. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2010 Nov; 116(5): 1079–1087
15. Celen S, Moroy P, Sucak A, Aktulay A, Danisman N. Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices. Contraception. 2004 Apr; 69(4): 279–282
16. Celen S, Sucak A, Yildiz Y, Danisman N. Immediate postplacental insertion of an intrauterine contraceptive device during caesarean section. Contraception. 2011 Sep; 84(3): 240-243
17. Eroglu K, Akkuzu G, Vural G, Dilbaz B, Akin A, Taskin L, et al. Comparison of efficacy and complications of IUD insertion in immediate postplacental/early postpartum period with interval period: 1 year follow-up. Contraception. 2006 Nov; 74(5): 376-381
18. Hillis SD, Marchbanks PA, Tylor LR, Peterson HB. Tubal sterilization and long-term risk of hysterectomy: Findings from the United States Collaborative Review of Sterilization. Obstet Gynecol. 1997 Apr; 89(4): 609-14
