Contraception After Delivery

Timing & Choices - Postpartum Planning

• Immediate Initiation (<48h):
  • Cu-IUD, LNG-IUD, Implants, Progestin-Only Pills (POPs).
  • Bilateral Tubal Ligation (BTL) if opted.
• Delayed Initiation:
  • Breastfeeding (BF) Women:
    • LAM: Up to 6 months (📌 Lactation-exclusive, Amenorrhea, baby <6 Months).
    • POPs, Implants, DMPA, IUDs (Cu/LNG): Anytime.
    • Combined Hormonal Contraceptives (CHCs): Generally after 6 weeks (WHO MEC 2); some wait 6 months.
  • Non-Breastfeeding (NBF) Women:
    • POPs, Implants, DMPA, IUDs: Anytime.
    • CHCs: From 3 weeks (WHO MEC 1 if no VTE risk); from 6 weeks (WHO MEC 2 if VTE risk factors present).
• Key Factors: Breastfeeding, WHO MEC for VTE risk, return to fertility desires.

⭐ LAM offers >98% protection if criteria (exclusive BF, amenorrhea, baby <6 months) are met.

Progestogen-Only Picks - Safe for Milk

• Key Advantage: No estrogen; no adverse effect on lactation or infant health. Preferred for breastfeeding.
• **Progestogen-Only Pills (POPs):
  • Norethindrone/LNG.
  • Thickens cervical mucus.
  • Start: Anytime postpartum. Strict daily intake. 📌 "POP on time!"
• **Depot Medroxyprogesterone Acetate (DMPA):
  • Inj. 150 mg IM q 3 months.
  • Inhibits ovulation.
  • Start: After 6 weeks (BF); anytime (Non-BF).
  • SE: Irregular bleeding, delayed fertility.
• **Implants (Etonogestrel):
  • Subdermal, 3-yr efficacy.
  • Inhibits ovulation.
  • Start: Anytime postpartum.
• **Levonorgestrel-IUS (LNG-IUS):
  • Intrauterine, 3-8 yr efficacy.
  • Local action: cervical mucus, endometrium.
  • Start: Post-placental or after 4-6 weeks.

⭐ Exam Favourite: LNG-IUS can significantly reduce menstrual blood loss, making it a good LARC option for women seeking lighter periods.

Combined Hormonal Contraceptives - Timing is Key

• Why delay CHCs?
  • ⚠️ ↑ VTE risk postpartum (peaks <3 weeks).
  • Potential ↓ milk supply if CHCs started <6 weeks in breastfeeding women.
• Key CHC Contraindications (Postpartum Focus):
  • Prior VTE, known thrombophilia.
  • Severe HTN (≥160/100 mmHg).
  • Smoker ≥35 yrs (≥15/day).
  • Migraine with aura.

⭐ Non-breastfeeding: CHCs are UKMEC Cat 4 (do not use) if <21 days postpartum due to high VTE risk.

Non-Hormonal & Permanent Methods - Barrier & Beyond

• Barrier Methods:
  • Condoms (male/female), diaphragms, cervical caps, spermicides.
  • Use: Anytime postpartum.
  • Efficacy: User-dependent.
• Copper IUD (e.g., CuT 380A):
  • Mechanism: Spermicidal, inhibits implantation.
  • Timing: Post-placental, within 48 hrs, or after 4-6 wks.
  • Duration: Up to 10 yrs.
  • 
• Lactational Amenorrhea Method (LAM):
  • Criteria:
    • Amenorrhea.
    • Exclusive breastfeeding (day & night).
    • Infant < 6 months old.
  • Efficacy: ~98% if all criteria strictly met.
• Permanent Methods (Sterilization):
  • Female (Tubal Ligation):
    • Timing: Postpartum (within 7 days or after 6 wks), interval.
  • Male (Vasectomy):
    • Requires backup contraception for ~3 months.
  • Highly effective; counsel re: irreversibility.

⭐ Copper IUD insertion is ideal immediately post-placentally or within 48 hours postpartum; alternatively, it can be done after 4-6 weeks.

High‑Yield Points - ⚡ Biggest Takeaways

• Progestin-only methods (POPs, implants, injectables) can start immediately postpartum.
• Combined hormonal contraceptives (CHCs): avoid for 3-6 weeks due to VTE risk; may affect lactation.
• IUDs (Cu-IUD, LNG-IUD): insert immediately (within 48h) or after 4 weeks postpartum.
• LAM: effective with exclusive breastfeeding, amenorrhea, infant < 6 months.
• Postpartum sterilization: permanent option, done at delivery or interval.
• Barrier methods: safe anytime; counsel on correct use for efficacy.