Postpartum contraception (1162)

3.1 Available Methods

• Recommended options for discharge from maternity services are:
  • Progestogen-only Implant (IMP). Nexplanon^TM (Etononogestrel) 68mg subdermal implant licensed for 3 years.
  • Progestogen-only Injectable (POI). Depoprovera^TM (Medroxyprogesterone Acetate) 150mg IM every 13 weeks.
  • Progestogen-only Pill (POP). Cerelle^TM (Desogestrel) 75 micrograms daily.
  • Intrauterine Contraception (IUC). Provision of insertion of a coil at the time of a planned caesarean can be facilitated if the women has been appropriately counselled.
• Other methods to consider:
  • Barrier Methods of contraception should be made available within the postnatal wards. They have an important role in reducing the risk of sexually transmitted infections (STI).
  • Female Sterilisation at caesarean. This remains an option however due to the irreversible nature, the standard guidance regarding decision making should be followed.
  • Combined Hormonal Contraception (CHC). CHC is not available for supply on discharge, as it should not be started until at least day 21 or 6 weeks for breast feeding women and women with additional VTE risk factors. Where this is the woman’s preference, the immediate discharge letter should include appropriate information to facilitate a prescription by the GP.
  • Emergency Contraception (EC) This is available from community pharmacies or via Sandyford (for advice and appointments phone 0141 211 8130 The line is open Mondays to Fridays from 8.30am - 4.15pm, except public holidays).

3.2  UK Medical Eligibility Criteria for Contraceptive Use (UKMEC)

• When making a clinical decision on safety and appropriateness of a method of contraception, clinicians should refer to the relevant, up to date, FSRH guideline and the UK Medical Eligibility Criteria for Contraceptive Use (UKMEC). 
• The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) provides recommendations for the safety of different methods of contraception with regards to personal characteristics.
• Personal characteristics that should be considered:
  • Patient preference/ previous contraceptive experience.
  • Age/ BMI/ smoking status.
  • Medical conditions e.g. malignancy, migraine, congenital heart disease.
  • Pregnancy related complications e.g. pregnancy induced hypertension, obstetric cholestasis, gestational diabetes.
  • Family history including thromboembolic mutations and carriers of gene mutations that predispose to malignancy.
  • Gynaecological history including uterine anomaly, previous pelvic infection and gestational trophoblastic disease.

Table 1: Definition of UK Medical Eligibility Criteria for Contraception Use (UKMEC) categories⁹

• UKMEC provides recommendations regarding safety of a method of contraception but do not indicate the most appropriate method for a woman or take into account efficacy.
• Clinical judgement should be used when considering women with multiple co-morbidities.
• Women with complex medical conditions who may require more specialist contraceptive advice can be discussed with Sandyford Sexual Health staff via the Professional Helpline or via switchboard and asking to speak to the CSRH Consultant on Call.
• Women with pregnancy associated medical conditions are eligible for all methods of contraception as below:
  • Hypertension during pregnancy -  All methods UKMEC 1 except CHC UKMEC 2.
  • Obstetric cholestasis - All methods UKMEC 1 except CHC UKMEC 2.
  • Gestational diabetes - All methods UKMEC 1.
• To contact the Sandyford for advice, email ggc.sandyfordprofessionalsupport@nhs.scot

3.3 Effectiveness of Contraceptive Method

• During pregnancy women should be informed about the efficacy of different methods of contraception, including the superior efficacy of LARC methods.
• Rates of unintended pregnancy are higher for methods which are user dependent methods of contraception (barrier, oral contraceptive pills).
• Table 2 compares the typical and perfect use percentage of women who experience an unintended pregnancy during the first year of contraceptive use.

Table 2: Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use¹⁰ Long-acting reversible contraceptive methods are in bold. 

*  Includes combined oral contraception, transdermal patch and vaginal rings

3.4 Information Giving and Counselling 

• When should contraception be discussed?
  • Contraception counselling should be ideally be initiated at any time after the booking appointment. The contraception guidance leaflet should be provided by 32 weeks and a decision should be documented by 36 weeks on Badgernet.
  • Care should be taken to ensure that women are informed of all available methods and that she is not pressured to choose a method.
  • Women should be informed about the efficacy of different methods of contraception, including the superior efficacy of long-acting reversible contraception (LARC).
  • Postpartum contraception information can be found on the Sandyford website:

• Who should provide contraception to women after childbirth?
  • All staff involved in the care of pregnant women should offer the opportunity to discuss contraception. This information should be up-to-date and accurate.
  • Maternity services within GGC are able to provide all progestogen-only methods including implants, injectable and progestogen only pills before women are discharged from the service.
  • Please contact your area charge midwife for an up to date list of all staff trained in implant insertion.

3.5 Provision of Contraception

• All appropriate methods of contraception should be available to women before they are discharged from the service.
• Sufficient numbers of staff should be trained to provide implants to ensure that women who are medically eligible can initiate these immediately after pregnancy. Up to date records of staff trained in implant are available from all charge midwives.
• Effective contraception should be initiated in breastfeeding and non-breastfeeding women as soon as possible as sexual activity and ovulation may resume soon after delivery. It is estimated that approximately 50% of women are sexually active 6 weeks following delivery.⁸
• In non-exclusively breast feeding women this need is present after 21 days following delivery over 24 weeks.
• Women should be advised that although contraception is not required in the first 21 days after delivery, most methods are safe to initiate immediately, with the exception of combined hormonal contraception (CHC).
• Contraceptive need is present within 5 days following miscarriage, ectopic pregnancy and abortion.
• If methotrexate is required for management of ectopic pregnancy or pregnancy of unknown location, women are recommended not to conceive within 3 months following the first dose.

 3.6 Record Keeping and Obtaining Valid Consent 

• Staff should clearly document the discussion and provision of contraception.
• The contraception plan should be clearly documented in BadgerNet under “Contraception”. Once a method has been selected, an alert should be added to her notes to ensure that this is provided prior to discharge.

4.1  Suitable Methods of Contraception after Childbirth

Women can be advised that although contraception is not required until day 21 postnatal, most methods (with the exception of combined hormonal contraception) can be safely initiated immediately.  

* Adapted from UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) categories applicable to women after childbirth 

4.2 Breastfeeding and Contraception

• Women should be informed that the available evidence indicates that progestogen-only methods of contraception have no adverse effects on lactation or infants.
• If a woman is breastfeeding, she should wait until 6 weeks postnatal before initiating a CHC method.
• There is limited evidence about the effect of CHC on breastfeeding. Studies looking at early initiation of CHC found no adverse effects on either breastfeeding performance or infant outcomes.

4.3 Lactation amenorrhoea method (LAM)

• LAM is a highly effective method of contraception (less than 2% failure rate) if all of the following three criteria are fulfilled:
  • Less than 6 months postpartum,
  • Amenorrhoeic,
  • Fully breastfeeding.
• Efficacy is reduced if the frequency of breastfeeding reduces (eg: increasing intervals between breastfeeding of >4 hours during the day and >6 hours at night, use of a dummy, increasing supplementary feeding or expressing milk), when menstruation returns or if over 6 months since childbirth.

4.4 Additional Contraception

• If contraception is started immediately postpartum or within 21 days of childbirth additional contraceptive precautions (Eg: barrier method/abstinence) are not required.
• However additional contraception precautions (Eg: barrier method/abstinence) are required if hormonal contraception is started 21 days or more after childbirth. Number of days of additional contraceptive precautions is dependent on the method of contraception started. See below table.

4.5 Emergency Contraception (EC) after Childbirth 

• EC is indicated if a woman has had unprotected sexual intercourse from day 21 after childbirth. It is not required prior to this.
• Oral EC, Levonorgesterel 1.5mg (LNG-EC) and Ulipristal Acetate 30mg (UPA-EC) are safe to use from 21 days after childbirth.
• If a woman is breastfeeding she should be informed that the limited available evidence indicates that LNG-EC has no adverse effect on breastfeeding.
• If a woman is breastfeeding she should be advised to express and discard milk for one week after taking UPA-EC.
• The Copper Intrauterine Device (Cu-IUD) can be safely inserted for EC from 28 days after childbirth.

5.1 Intrauterine Contraception (IUC)

• IUC can be safely inserted immediately after birth or within the first 48 hours after an uncomplicated caesarean or vaginal birth. After 48 hours, insertion should be delayed until 28 days after birth.
  • Vaginal Birth – See attached Standard Operating Procedure entitled “Insertion of Post-Placental Intrauterine Contraception Following Vaginal Birth” for details regarding: eligibility, insertion technique, documentation and training.
  • Caesarean Birth – See attached Standard Operating Procedure entitled “Pathway for Women having Intra-uterine Contraception (IUC) fitted during Planned Caesarean Birth (PCB)” for further information regarding documentation and referral to Sandyford for follow up.
• Clinicians should clearly document the type of device inserted in BadgerNet (e.g. hormonal: Levosert^TM, Mirena^TM or non-hormonal: T-safe Cu 380A QL or TT380).
• There is no evidence of increased risk of uterine perforation if IUC is inserted immediately after delivery of the placenta or within 48hours of delivery, compared with delayed insertion (after 4 weeks).
• There is no increased risk of infection.
• The insertion of IUC immediately after childbirth is associated with higher rates of expulsion but also higher continuation rates 6-12 months postpartum regardless of type of IUC or mode of birth. Expulsion is most likely to occur within the first 3 months after insertion.
  • Caesarean Birth – Expulsion rate – Immediate insertion 10% vs Interval insertion 5%.
  • Vaginal Birth – Expulsion rate – Immediate insertion 24% vs Interval insertion 4.4%.

Sandyford have agreed to provide follow up. Women will be telephoned by the Sandyford team to arrange.

• All women should be provided with a written information leaflet after insertion of their IUC. This is available in maternity theatres, all postnatal wards and can also be accessed via the following link : https://www.sandyford.scot/sexual-health-services/contraception/intrauterine-contraception-coils/

5.2 Progestogen-only Implant (IMP)

• Insertion of the implant immediately after childbirth is currently out with its product licence, however, studies have shown that insertion at this time is safe and highly acceptable to women. Therefore the FSRH are supportive its use immediately postpartum.
• All women should be supplied with the patient information leaflet “Advice following insertion of a contraceptive implant leaflet”. This is available in all postnatal wards and can also be accessed via the following link :
  https://www.sandyford.scot/media/3804/317849_1_0-advice-following-insertion-of-acontraceptive-implant-leaflet-final.pdf

5.3 Progestogen-only Injectable (POI)

• POI can be started at any time after childbirth, including immediately after.
• There is theoretical concern that the use of DMPA may be associated with an increased risk of VTE compared to other progestogen-only methods. The progestogen only injection is therefore classified as UKMEC 2 for use by women in the first 6 weeks after childbirth.
• There are two available preparations:
  • Depo- Provera^TM – administered intramuscularly.
  • Sanya Press^TM – administered subcutaneously.

NB: Only Depo-Provera^TM is available on postnatal wards in GG+C at present.

5.4 Progestogen-only Pill (POP)

• POP can be started at any time after childbirth, including immediately after delivery.
• Desogestrel 75 micogram tablets – Cerelle^TM is available on postnatal wards in GG+C.

5.5 Combined Hormonal Contraception (CHC)

• All women should undergo a VTE risk assessment postnatally. CHC should not be used by women who have risk factors for VTE until 6 weeks postnatal (UKMEC 4). This applies to both women who are breastfeeding and not breastfeeding.
• Women who are not breastfeeding and are without any additional risk factors for VTE should wait until 21 days after childbirth before initiating a CHC.
• In women who are breast feeding it is recommended that commencing a CHC should be delayed until 6 weeks postpartum to allow breastfeeding to establish.
• Combined hormonal contraception should not be supplied on discharge, however, if desired a bridging method of contraception should be considered.

5.6 Female Sterilisation

• Female sterilisation is a safe and permanent option for contraception after childbirth.
• Both Filshie^TM clips and modified Pomeroy technique are effective.
• Women should be made aware that some LARC methods are as, or more effective than female sterilisation and may also offer non-contraceptive benefits.
• Women who opt for tubal occlusion should be made aware that they need to seek medical advice in the event of a pregnancy as they will be more likely to have an ectopic pregnancy.
• Women requesting sterilisation at the time of caesarean birth should be advised of the possible increased risk of regret compared to interval sterilisation.
• Written consent for sterilisation at caesarean birth should be obtained and documented at least 2 weeks prior to the planned caesarean birth.

5.7 Male Sterilisation

• Vasectomy should be discussed with all people requesting sterilisation. Individuals should be informed that some LARC methods are as effective as sterilisation and may offer some non-contraceptive benefits.
• They should be advised that vasectomy is associated with a lower failure rate, is quicker and associated with less morbidity than laparoscopic sterilisation.¹¹
• A negative ejaculate specimen is required to confirm that a vasectomy is effective. This can take up to 12 months and it is important that women are counselled about their on-going need for contraception during this time.
• An appointment to discuss a vasectomy can be made at Sandyford Central and does not require GP referral.

5.8 Barrier Methods

• Male and female condoms can be safely used by women after childbirth.
• If using a diaphragm, women should be advised to wait at least 6 weeks after childbirth before fitting as the size required may change as the uterus involutes.

5.9 Fertility Awareness Methods (FAM)

• Can be used after childbirth.
• Women should be advised that as FAM relies of the detection of signs and symptoms of ovulation its use may be difficult after childbirth and when breastfeeding.

1. Contraception Choices 
2. NHS Choices - Contraception
3. Family Planning - Contraception after having your baby https://www.fpa.org.uk/sites/default/files/contraception-after-having-baby-yourguide.pdf
4. Sandyford - Your guide to contraception after a baby.
5. Sandyford Professional Page – Postpartum contraception. 
6. Patient information leaflets
   1. Implants https://www.sandyford.scot/media/3804/317849_1_0-advicefollowing-insertion-of-a-contraceptive-implant-leaflet-pdf
   2. Intrauterine Contraception https://www.sandyford.scot/media/3805/316553_1_0-advice-following-intrauterine-contraception-fitting-at-the-time-of-birth-final-pdf