Postpartum contraception

Contraception is not required in the first 21 days after childbirth
Nevertheless, with the exception of CHC, most methods can be safely initiated immediately after childbirth.
Additional contraceptive precaution (condoms or abstinence) is not required if contraception is started immediately or within 21 days after childbirth.

May be used Immediately after vaginal/caesarean delivery
May be used after 21 days postpartum (+ additional initial contraceptive precautions), No adverse effects on breast feeding:
LARCs: IMPLANT, LNG-IUS or Cu-IUD, DMPA
POP

Defer use of diaphragm till after 6 weeks postpartum
Diaphragm size may need to be adjusted according to uterine size involution and reversion to normal size

Postpartum use of CHC

May only be used after after 21 days postpartum if NOT breast feeding and NO additional risk factors for VTE (+ additional initial contraceptive precautions)
Otherwise, may only be used after 6 weeks postpartum, whether breast feeding or not (+ additional initial contraceptive precautions)

Emergency contraception options if UPSI occurs more than 21 days after childbirth

LNG-EC and UPA-EC are safe to use 21 days after childbirth
Cu-IUD is safe to use for EC from 28 days after childbirth
Avoid breast feeding for 1 week after using UPA-EC
No need to restrict breast feeding after using LNG-EC

Advice on inter-pregnancy interval

An inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birthweight and small for gestational age infants.

Lactational amenorrhea LAM method contraception requires fulfilment of:

• Fully breast feeding

• Amenorrhoea

• Less than 6 months postpartum

Immediately after abortion (no additional contraceptive precautions are required)

• LARCs: IMPLANT, LNG-IUS or Cu-IUD (assuming uncomplicated abortion and no post-abortion sepsis or pelvic sepsis), DMPA

• POP

• CHC

Additional contraceptive precautions (barrier or abstinence) are required only if hormonal contraception is started 5 days or more after abortion.

UPSI occurring 5 days after abortion, methotrexate administration, surgical treatment of ectopic pregnancy or GTD treatment

Emergency contraception is indicated.
Any method of EC may be used, however Cu-IUD is contraindicated in the presence of pelvic sepsis or GTD.
Oral EC is safe to use after treatment for GTD.

Methotrexate treatment of ectopic pregnancy

Contraception is recommended for at least 3 months after treatment in view of teratogenic effects of methotrexate.

Recurrent miscarriage

CHC should be avoided until antiphospholipid syndrome has been excluded

Contraception after gestational trophoblastic disease (GTD)

Avoid conception until GTD monitoring is complete.
Implant and DMPA are suitable options; avoid CHC, Cu-IUD and LNG-IUS.
Complete molar pregnancy: avoid pregnancy for 6m
Partial molar pregnancy: avoid pregnancy until two consecutive monthly HCG levels are normal
Chemotherapy for GTD: avoid pregnancy for 1 year after treatment