How to Choose a Contraceptive for Your Postpartum Patient

Q: What’s a vital aspect of the care we provide to postpartum patients?

A: Optimal timing of evaluation for contraception.

Good timing minimizes the likelihood that postpartum contraception will be initiated too early or too late to be effective.

The choice of a contraceptive method for a postpartum woman also requires a careful balancing act. On one side: the risks of contraception to the mother and her newborn. On the other: the risk for unintended pregnancy. Among the concerns that need to be addressed in contraceptive decision-making are:

• Whether the woman has resumed sexual intercourse

• Infant feeding practices

• Risk for venous thromboembolism (VTE)

• Logistics of various long-acting reversible contraceptives and tubal sterilization.

In this article, we outline the components of effective contraceptive counseling and decision-making. We also summarize recent recommendations from the CDC on the use of various contraceptive methods during the postpartum period.

FIRST: START AT THREE WEEKS
The traditional six-week postpartum visit was timed to take place after complete involution of the uterus following vaginal delivery. However, involution occurs too late to prevent unintended pregnancy because ovulation can—and often does—occur as early as the fourth postpartum week among nonbreastfeeding women.

In the past, when it was more common to fit a contraceptive diaphragm after pregnancy, six weeks may have been the best timing for the visit. Today, given the high safety and efficacy of modern contraceptive methods (even when initiated before complete involution), as well as the importance of safe birth spacing, the routine postpartum visit is more appropriately scheduled at three weeks for women who have had an uneventful delivery.

In some cases, of course, it may be appropriate to schedule a visit even earlier, depending on the medical needs of the mother (which may include staple removal after cesarean delivery, follow-up blood pressure assessment for patients who have gestational hypertension, etc). That said, the first postpartum visit should be routinely scheduled for no later than three weeks for healthy women who have had an uncomplicated delivery.¹

The data support this approach. In one study, 57% of women reported the resumption of intercourse by the sixth postpartum week.² A routine three-week postpartum visit instead of a visit at six weeks would reduce unmet contraceptive needs among this group of women.

HOW INFANT FEEDING PRACTICES COME INTO PLAY
Both the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics recommend six months of exclusive breastfeeding because of recognized health benefits for both the mother and her infant. Exclusive breastfeeding is also a requirement if a woman desires to use breastfeeding as a contraceptive method.

Healthy People 2010 is a set of US health objectives that includes goals for breastfeeding rates. Although the percentage of infants who were ever breastfed has reached the 75% target of Healthy People 2010, according to data from the National Health and Nutrition Examination Survey (NHANES), the percentage of infants who were breastfed at six months of age has changed only minimally.³ For Mexican-American infants, that rate is 40%, compared with 35% for non-Hispanic whites and 20% for non-Hispanic black infants.³ Rates of exclusive breastfeeding are even lower, highlighting the importance of early breastfeeding support and contraceptive guidance during the postpartum period—support and guidance that can be offered at a three-week postpartum visit.

EXTENT OF BREASTFEEDING TO BE ASSESSED
Full or nearly full breastfeeding should be encouraged, along with frequent feeding of the infant. In addition, the contraceptive effect of lactation during the first six months of breastfeeding should be emphasized (see sidebar on the lactational amenorrhea method [LAM] of contraception).
Keep in mind, however, that a substantial number of nursing mothers who are not breastfeeding exclusively will ovulate before the six-week postpartum visit. Data suggest that approximately 50% of all nonbreastfeeding women will ovulate before the six-week visit, with some ovulating as early as postpartum day 25.⁴

For this reason, you need to determine the extent of breastfeeding at the three-week visit to determine whether LAM is a contraceptive option for your patient. Full or nearly full breastfeeding means that the vast majority of feeding is breastfeeding and that breastfeeding is not replaced by any other kind of feeding. Frequent feeding means that the infant is breastfed when hungry, be it day or night, which implies at least one nighttime feeding. If evaluation at the three-week visit indicates that breastfeeding is no longer full or nearly full and frequent, another form of contraception should be initiated.⁵

For most women, the benefits of initiating a progestin-only or nonhormonal method of contraception at this time outweigh the risks, regardless of breastfeeding status, according to the CDC’s medical eligibility criteria for contraceptive use.⁶

HOW THE RISK FOR VTE AFFECTS THE CHOICE OF CONTRACEPTIVE
The hematologic changes of normal pregnancy shift coagulability and fibrinolytic systems toward a state of hypercoagulability. This physiologic process reduces the risk for puerperal hemorrhage; however, it also predisposes women to VTE during pregnancy and into the postpartum period. Studies assessing the risk for VTE in postpartum women indicate that it increases by a factor of 22 to 84 during the first six weeks, compared with the risk in nonpregnant, nonpostpartum women of reproductive age.⁷ This heightened risk is most pronounced immediately after delivery, declining rapidly over the first 21 days after delivery and returning to a near-baseline level by 42 days postpartum.

By the time of the recommended three-week postpartum visit, the period of highest VTE risk has passed. For women who are no longer breastfeeding, the benefits of all hormonal contraceptive methods, including those that contain estrogen, outweigh their risks, according to a newly released update to recommendations from the CDC (see Table 1).⁶ Although combined oral contraceptives are known to increase the risk for VTE by a factor of 3 to 7, data suggest that healthy women who do not have additional risk factors for VTE (eg, thrombophilia, obesity, smoking, or age 35 or older) can use them safely.⁶

The updated recommendations discourage use of estrogen-containing contraceptives before 21 days postpartum because they present an unacceptable level of risk (regardless of breastfeeding status). But they allow the use of combined hormonal contraceptives in otherwise healthy, breastfeeding women after 30 days postpartum. For women who have additional risk factors for VTE, the risks of combined hormonal contraceptives outweigh the benefits until 
six weeks postpartum, regardless of breastfeeding status.⁶

In contrast, progestin-only and nonhormonal contraceptive methods can be safely initiated by both breastfeeding and nonbreastfeeding women before 21 days postpartum, which means that women can begin using them before discharge from the hospital.

WHEN TO CONSIDER LARC OR STERILIZATION
Long-acting reversible contraceptives (LARC) are an important postpartum contraceptive option because they offer highly effective protection against pregnancy that can begin as soon as the placenta is delivered. LARC methods include contraceptive implants and intrauterine devices (IUDs).

According to the CDC’s medical eligibility criteria for contraceptive use, implants can be placed immediately after delivery of the placenta without restriction.⁸

The copper IUD can be placed within 10 minutes after delivery of the placenta without restriction. If this window is missed, the benefits of inserting the IUD still outweigh the risks. Because four weeks postpartum is another time when the copper IUD can be inserted without restriction, the three-week visit is a reasonable time to screen and schedule a patient for insertion.

The benefits of insertion of the levonorgestrel-releasing intrauterine system (LNG-IUS) are also believed to outweigh the risks before four weeks postpartum. Like the copper IUD, the LNG-IUS can be inserted without restriction at four weeks postpartum or later.

There is no need for a pelvic exam at the three-week postpartum visit among women who undergo immediate postplacental insertion of the copper IUD or LNG-IUS. In fact, women can delay the exam until involution is complete.

Sterilization is best after complete involution
Interval tubal sterilization by laparoscopic, bilateral tubal fulguration or hysteroscopic microinsert placement is one of the most effective ways to prevent pregnancy. Both methods are best performed after the completion of involution and the return of normal coagulation; scheduling can take place at the three-week postpartum visit.

Given the benefit of depot medroxyprogesterone acetate (DMPA) in endometrial suppression before hysteroscopic sterilization, it is reasonable to consider administering DMPA at the three-week postpartum visit in anticipation of surgery after involution is complete.

THE BOTTOM LINE
Since most contraceptive methods can be safely initiated at or shortly after a three-weeks’ postpartum visit, there is no longer any reason to time the routine postpartum visit to coincide with the completion of involution. For healthy women who have had an uneventful delivery, the routine postpartum visit should occur at three weeks.

REFERENCES
1. Speroff L, Mishell DR. The postpartum visit: it’s time for a change in order to optimally initiate contraception. Contraception. 2008;78(2): 90–98.

2. Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunct. 2005; 16(4):263–267.

3. McDowell MA, Wang C-Y, Kennedy-Stephenson J. Breastfeeding in the United States: Findings from the National Health and Nutrition Examination Surveys 1999–2006. NCHS Data Briefs. 2008;5:1–8.

4. Jackson E, Glasier A. Return of ovulation and menses in postpartum, nonlactating women: a systematic review. Obstet Gynecol. 2011;117(3):657–662.

5. Kennedy K, Rivera R, McNeilly A. Consensus statement on the use of breastfeeding as a family planning method. Contraception. 1988; 39(5):477–496.

6. Centers for Disease Control and Prevention. Update to CDC’s US Medical Eligibility Criteria for Contraceptive Use, 2010: Revised recommendations for the use of contraceptive methods during the postpartum period. MMWR. 2011;60(26):878–883.

7. Jackson E, Curtis K, Gaffield M. Risk of venous thromboembolism during the postpartum period: a systematic review. Obstet Gynecol. 2011;117(3):691–703.

8. Centers for Disease Control and Prevention. US Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR. 2010;59(No. RR-4):1–86.

9. Kletzky OA, Marrs RP, Howard WF, McCormick W, Mishell DR Jr. Prolactin synthesis and release during pregnancy and puerperium. Am J Obstet Gynecol. 1980;136(4):545–550.

10. Labbok MH, Hight-Laukaran V, Peterson AE, Fletcher V, von Hertzen H, Van Look PF. Multicenter study of the Lactional Amenorrhea Method (LAM): I. Efficacy, duration, and implications for clinical application. Contraception. 1997;55(6):327–336.

11.  Valdes V, Labbok MH, Pugin E, Perez A. The efficacy of the Lactational Amenorrhea Method (LAM) among working women. Contraception. 2000;62(5):217–219.

Q: What’s a vital aspect of the care we provide to postpartum patients?

A: Optimal timing of evaluation for contraception.

Good timing minimizes the likelihood that postpartum contraception will be initiated too early or too late to be effective.

The choice of a contraceptive method for a postpartum woman also requires a careful balancing act. On one side: the risks of contraception to the mother and her newborn. On the other: the risk for unintended pregnancy. Among the concerns that need to be addressed in contraceptive decision-making are:

• Whether the woman has resumed sexual intercourse

• Infant feeding practices

• Risk for venous thromboembolism (VTE)

• Logistics of various long-acting reversible contraceptives and tubal sterilization.

In this article, we outline the components of effective contraceptive counseling and decision-making. We also summarize recent recommendations from the CDC on the use of various contraceptive methods during the postpartum period.

FIRST: START AT THREE WEEKS
The traditional six-week postpartum visit was timed to take place after complete involution of the uterus following vaginal delivery. However, involution occurs too late to prevent unintended pregnancy because ovulation can—and often does—occur as early as the fourth postpartum week among nonbreastfeeding women.

In the past, when it was more common to fit a contraceptive diaphragm after pregnancy, six weeks may have been the best timing for the visit. Today, given the high safety and efficacy of modern contraceptive methods (even when initiated before complete involution), as well as the importance of safe birth spacing, the routine postpartum visit is more appropriately scheduled at three weeks for women who have had an uneventful delivery.

In some cases, of course, it may be appropriate to schedule a visit even earlier, depending on the medical needs of the mother (which may include staple removal after cesarean delivery, follow-up blood pressure assessment for patients who have gestational hypertension, etc). That said, the first postpartum visit should be routinely scheduled for no later than three weeks for healthy women who have had an uncomplicated delivery.¹

The data support this approach. In one study, 57% of women reported the resumption of intercourse by the sixth postpartum week.² A routine three-week postpartum visit instead of a visit at six weeks would reduce unmet contraceptive needs among this group of women.

HOW INFANT FEEDING PRACTICES COME INTO PLAY
Both the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics recommend six months of exclusive breastfeeding because of recognized health benefits for both the mother and her infant. Exclusive breastfeeding is also a requirement if a woman desires to use breastfeeding as a contraceptive method.

Healthy People 2010 is a set of US health objectives that includes goals for breastfeeding rates. Although the percentage of infants who were ever breastfed has reached the 75% target of Healthy People 2010, according to data from the National Health and Nutrition Examination Survey (NHANES), the percentage of infants who were breastfed at six months of age has changed only minimally.³ For Mexican-American infants, that rate is 40%, compared with 35% for non-Hispanic whites and 20% for non-Hispanic black infants.³ Rates of exclusive breastfeeding are even lower, highlighting the importance of early breastfeeding support and contraceptive guidance during the postpartum period—support and guidance that can be offered at a three-week postpartum visit.

EXTENT OF BREASTFEEDING TO BE ASSESSED
Full or nearly full breastfeeding should be encouraged, along with frequent feeding of the infant. In addition, the contraceptive effect of lactation during the first six months of breastfeeding should be emphasized (see sidebar on the lactational amenorrhea method [LAM] of contraception).
Keep in mind, however, that a substantial number of nursing mothers who are not breastfeeding exclusively will ovulate before the six-week postpartum visit. Data suggest that approximately 50% of all nonbreastfeeding women will ovulate before the six-week visit, with some ovulating as early as postpartum day 25.⁴

For this reason, you need to determine the extent of breastfeeding at the three-week visit to determine whether LAM is a contraceptive option for your patient. Full or nearly full breastfeeding means that the vast majority of feeding is breastfeeding and that breastfeeding is not replaced by any other kind of feeding. Frequent feeding means that the infant is breastfed when hungry, be it day or night, which implies at least one nighttime feeding. If evaluation at the three-week visit indicates that breastfeeding is no longer full or nearly full and frequent, another form of contraception should be initiated.⁵

For most women, the benefits of initiating a progestin-only or nonhormonal method of contraception at this time outweigh the risks, regardless of breastfeeding status, according to the CDC’s medical eligibility criteria for contraceptive use.⁶

HOW THE RISK FOR VTE AFFECTS THE CHOICE OF CONTRACEPTIVE
The hematologic changes of normal pregnancy shift coagulability and fibrinolytic systems toward a state of hypercoagulability. This physiologic process reduces the risk for puerperal hemorrhage; however, it also predisposes women to VTE during pregnancy and into the postpartum period. Studies assessing the risk for VTE in postpartum women indicate that it increases by a factor of 22 to 84 during the first six weeks, compared with the risk in nonpregnant, nonpostpartum women of reproductive age.⁷ This heightened risk is most pronounced immediately after delivery, declining rapidly over the first 21 days after delivery and returning to a near-baseline level by 42 days postpartum.

By the time of the recommended three-week postpartum visit, the period of highest VTE risk has passed. For women who are no longer breastfeeding, the benefits of all hormonal contraceptive methods, including those that contain estrogen, outweigh their risks, according to a newly released update to recommendations from the CDC (see Table 1).⁶ Although combined oral contraceptives are known to increase the risk for VTE by a factor of 3 to 7, data suggest that healthy women who do not have additional risk factors for VTE (eg, thrombophilia, obesity, smoking, or age 35 or older) can use them safely.⁶

The updated recommendations discourage use of estrogen-containing contraceptives before 21 days postpartum because they present an unacceptable level of risk (regardless of breastfeeding status). But they allow the use of combined hormonal contraceptives in otherwise healthy, breastfeeding women after 30 days postpartum. For women who have additional risk factors for VTE, the risks of combined hormonal contraceptives outweigh the benefits until 
six weeks postpartum, regardless of breastfeeding status.⁶

In contrast, progestin-only and nonhormonal contraceptive methods can be safely initiated by both breastfeeding and nonbreastfeeding women before 21 days postpartum, which means that women can begin using them before discharge from the hospital.

WHEN TO CONSIDER LARC OR STERILIZATION
Long-acting reversible contraceptives (LARC) are an important postpartum contraceptive option because they offer highly effective protection against pregnancy that can begin as soon as the placenta is delivered. LARC methods include contraceptive implants and intrauterine devices (IUDs).

According to the CDC’s medical eligibility criteria for contraceptive use, implants can be placed immediately after delivery of the placenta without restriction.⁸

The copper IUD can be placed within 10 minutes after delivery of the placenta without restriction. If this window is missed, the benefits of inserting the IUD still outweigh the risks. Because four weeks postpartum is another time when the copper IUD can be inserted without restriction, the three-week visit is a reasonable time to screen and schedule a patient for insertion.

The benefits of insertion of the levonorgestrel-releasing intrauterine system (LNG-IUS) are also believed to outweigh the risks before four weeks postpartum. Like the copper IUD, the LNG-IUS can be inserted without restriction at four weeks postpartum or later.

There is no need for a pelvic exam at the three-week postpartum visit among women who undergo immediate postplacental insertion of the copper IUD or LNG-IUS. In fact, women can delay the exam until involution is complete.

Sterilization is best after complete involution
Interval tubal sterilization by laparoscopic, bilateral tubal fulguration or hysteroscopic microinsert placement is one of the most effective ways to prevent pregnancy. Both methods are best performed after the completion of involution and the return of normal coagulation; scheduling can take place at the three-week postpartum visit.

Given the benefit of depot medroxyprogesterone acetate (DMPA) in endometrial suppression before hysteroscopic sterilization, it is reasonable to consider administering DMPA at the three-week postpartum visit in anticipation of surgery after involution is complete.

THE BOTTOM LINE
Since most contraceptive methods can be safely initiated at or shortly after a three-weeks’ postpartum visit, there is no longer any reason to time the routine postpartum visit to coincide with the completion of involution. For healthy women who have had an uneventful delivery, the routine postpartum visit should occur at three weeks.

REFERENCES
1. Speroff L, Mishell DR. The postpartum visit: it’s time for a change in order to optimally initiate contraception. Contraception. 2008;78(2): 90–98.

2. Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunct. 2005; 16(4):263–267.

3. McDowell MA, Wang C-Y, Kennedy-Stephenson J. Breastfeeding in the United States: Findings from the National Health and Nutrition Examination Surveys 1999–2006. NCHS Data Briefs. 2008;5:1–8.

4. Jackson E, Glasier A. Return of ovulation and menses in postpartum, nonlactating women: a systematic review. Obstet Gynecol. 2011;117(3):657–662.

5. Kennedy K, Rivera R, McNeilly A. Consensus statement on the use of breastfeeding as a family planning method. Contraception. 1988; 39(5):477–496.

6. Centers for Disease Control and Prevention. Update to CDC’s US Medical Eligibility Criteria for Contraceptive Use, 2010: Revised recommendations for the use of contraceptive methods during the postpartum period. MMWR. 2011;60(26):878–883.

7. Jackson E, Curtis K, Gaffield M. Risk of venous thromboembolism during the postpartum period: a systematic review. Obstet Gynecol. 2011;117(3):691–703.

8. Centers for Disease Control and Prevention. US Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR. 2010;59(No. RR-4):1–86.

9. Kletzky OA, Marrs RP, Howard WF, McCormick W, Mishell DR Jr. Prolactin synthesis and release during pregnancy and puerperium. Am J Obstet Gynecol. 1980;136(4):545–550.

10. Labbok MH, Hight-Laukaran V, Peterson AE, Fletcher V, von Hertzen H, Van Look PF. Multicenter study of the Lactional Amenorrhea Method (LAM): I. Efficacy, duration, and implications for clinical application. Contraception. 1997;55(6):327–336.

11.  Valdes V, Labbok MH, Pugin E, Perez A. The efficacy of the Lactational Amenorrhea Method (LAM) among working women. Contraception. 2000;62(5):217–219.

Q: What’s a vital aspect of the care we provide to postpartum patients?

A: Optimal timing of evaluation for contraception.

Good timing minimizes the likelihood that postpartum contraception will be initiated too early or too late to be effective.

The choice of a contraceptive method for a postpartum woman also requires a careful balancing act. On one side: the risks of contraception to the mother and her newborn. On the other: the risk for unintended pregnancy. Among the concerns that need to be addressed in contraceptive decision-making are:

• Whether the woman has resumed sexual intercourse

• Infant feeding practices

• Risk for venous thromboembolism (VTE)

• Logistics of various long-acting reversible contraceptives and tubal sterilization.

In this article, we outline the components of effective contraceptive counseling and decision-making. We also summarize recent recommendations from the CDC on the use of various contraceptive methods during the postpartum period.

FIRST: START AT THREE WEEKS
The traditional six-week postpartum visit was timed to take place after complete involution of the uterus following vaginal delivery. However, involution occurs too late to prevent unintended pregnancy because ovulation can—and often does—occur as early as the fourth postpartum week among nonbreastfeeding women.

In the past, when it was more common to fit a contraceptive diaphragm after pregnancy, six weeks may have been the best timing for the visit. Today, given the high safety and efficacy of modern contraceptive methods (even when initiated before complete involution), as well as the importance of safe birth spacing, the routine postpartum visit is more appropriately scheduled at three weeks for women who have had an uneventful delivery.

In some cases, of course, it may be appropriate to schedule a visit even earlier, depending on the medical needs of the mother (which may include staple removal after cesarean delivery, follow-up blood pressure assessment for patients who have gestational hypertension, etc). That said, the first postpartum visit should be routinely scheduled for no later than three weeks for healthy women who have had an uncomplicated delivery.¹

The data support this approach. In one study, 57% of women reported the resumption of intercourse by the sixth postpartum week.² A routine three-week postpartum visit instead of a visit at six weeks would reduce unmet contraceptive needs among this group of women.

HOW INFANT FEEDING PRACTICES COME INTO PLAY
Both the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics recommend six months of exclusive breastfeeding because of recognized health benefits for both the mother and her infant. Exclusive breastfeeding is also a requirement if a woman desires to use breastfeeding as a contraceptive method.

Healthy People 2010 is a set of US health objectives that includes goals for breastfeeding rates. Although the percentage of infants who were ever breastfed has reached the 75% target of Healthy People 2010, according to data from the National Health and Nutrition Examination Survey (NHANES), the percentage of infants who were breastfed at six months of age has changed only minimally.³ For Mexican-American infants, that rate is 40%, compared with 35% for non-Hispanic whites and 20% for non-Hispanic black infants.³ Rates of exclusive breastfeeding are even lower, highlighting the importance of early breastfeeding support and contraceptive guidance during the postpartum period—support and guidance that can be offered at a three-week postpartum visit.

EXTENT OF BREASTFEEDING TO BE ASSESSED
Full or nearly full breastfeeding should be encouraged, along with frequent feeding of the infant. In addition, the contraceptive effect of lactation during the first six months of breastfeeding should be emphasized (see sidebar on the lactational amenorrhea method [LAM] of contraception).
Keep in mind, however, that a substantial number of nursing mothers who are not breastfeeding exclusively will ovulate before the six-week postpartum visit. Data suggest that approximately 50% of all nonbreastfeeding women will ovulate before the six-week visit, with some ovulating as early as postpartum day 25.⁴

For this reason, you need to determine the extent of breastfeeding at the three-week visit to determine whether LAM is a contraceptive option for your patient. Full or nearly full breastfeeding means that the vast majority of feeding is breastfeeding and that breastfeeding is not replaced by any other kind of feeding. Frequent feeding means that the infant is breastfed when hungry, be it day or night, which implies at least one nighttime feeding. If evaluation at the three-week visit indicates that breastfeeding is no longer full or nearly full and frequent, another form of contraception should be initiated.⁵

For most women, the benefits of initiating a progestin-only or nonhormonal method of contraception at this time outweigh the risks, regardless of breastfeeding status, according to the CDC’s medical eligibility criteria for contraceptive use.⁶

HOW THE RISK FOR VTE AFFECTS THE CHOICE OF CONTRACEPTIVE
The hematologic changes of normal pregnancy shift coagulability and fibrinolytic systems toward a state of hypercoagulability. This physiologic process reduces the risk for puerperal hemorrhage; however, it also predisposes women to VTE during pregnancy and into the postpartum period. Studies assessing the risk for VTE in postpartum women indicate that it increases by a factor of 22 to 84 during the first six weeks, compared with the risk in nonpregnant, nonpostpartum women of reproductive age.⁷ This heightened risk is most pronounced immediately after delivery, declining rapidly over the first 21 days after delivery and returning to a near-baseline level by 42 days postpartum.

By the time of the recommended three-week postpartum visit, the period of highest VTE risk has passed. For women who are no longer breastfeeding, the benefits of all hormonal contraceptive methods, including those that contain estrogen, outweigh their risks, according to a newly released update to recommendations from the CDC (see Table 1).⁶ Although combined oral contraceptives are known to increase the risk for VTE by a factor of 3 to 7, data suggest that healthy women who do not have additional risk factors for VTE (eg, thrombophilia, obesity, smoking, or age 35 or older) can use them safely.⁶

The updated recommendations discourage use of estrogen-containing contraceptives before 21 days postpartum because they present an unacceptable level of risk (regardless of breastfeeding status). But they allow the use of combined hormonal contraceptives in otherwise healthy, breastfeeding women after 30 days postpartum. For women who have additional risk factors for VTE, the risks of combined hormonal contraceptives outweigh the benefits until 
six weeks postpartum, regardless of breastfeeding status.⁶

In contrast, progestin-only and nonhormonal contraceptive methods can be safely initiated by both breastfeeding and nonbreastfeeding women before 21 days postpartum, which means that women can begin using them before discharge from the hospital.

WHEN TO CONSIDER LARC OR STERILIZATION
Long-acting reversible contraceptives (LARC) are an important postpartum contraceptive option because they offer highly effective protection against pregnancy that can begin as soon as the placenta is delivered. LARC methods include contraceptive implants and intrauterine devices (IUDs).

According to the CDC’s medical eligibility criteria for contraceptive use, implants can be placed immediately after delivery of the placenta without restriction.⁸

The copper IUD can be placed within 10 minutes after delivery of the placenta without restriction. If this window is missed, the benefits of inserting the IUD still outweigh the risks. Because four weeks postpartum is another time when the copper IUD can be inserted without restriction, the three-week visit is a reasonable time to screen and schedule a patient for insertion.

The benefits of insertion of the levonorgestrel-releasing intrauterine system (LNG-IUS) are also believed to outweigh the risks before four weeks postpartum. Like the copper IUD, the LNG-IUS can be inserted without restriction at four weeks postpartum or later.

There is no need for a pelvic exam at the three-week postpartum visit among women who undergo immediate postplacental insertion of the copper IUD or LNG-IUS. In fact, women can delay the exam until involution is complete.

Sterilization is best after complete involution
Interval tubal sterilization by laparoscopic, bilateral tubal fulguration or hysteroscopic microinsert placement is one of the most effective ways to prevent pregnancy. Both methods are best performed after the completion of involution and the return of normal coagulation; scheduling can take place at the three-week postpartum visit.

Given the benefit of depot medroxyprogesterone acetate (DMPA) in endometrial suppression before hysteroscopic sterilization, it is reasonable to consider administering DMPA at the three-week postpartum visit in anticipation of surgery after involution is complete.

THE BOTTOM LINE
Since most contraceptive methods can be safely initiated at or shortly after a three-weeks’ postpartum visit, there is no longer any reason to time the routine postpartum visit to coincide with the completion of involution. For healthy women who have had an uneventful delivery, the routine postpartum visit should occur at three weeks.

REFERENCES
1. Speroff L, Mishell DR. The postpartum visit: it’s time for a change in order to optimally initiate contraception. Contraception. 2008;78(2): 90–98.

2. Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunct. 2005; 16(4):263–267.

3. McDowell MA, Wang C-Y, Kennedy-Stephenson J. Breastfeeding in the United States: Findings from the National Health and Nutrition Examination Surveys 1999–2006. NCHS Data Briefs. 2008;5:1–8.

4. Jackson E, Glasier A. Return of ovulation and menses in postpartum, nonlactating women: a systematic review. Obstet Gynecol. 2011;117(3):657–662.

5. Kennedy K, Rivera R, McNeilly A. Consensus statement on the use of breastfeeding as a family planning method. Contraception. 1988; 39(5):477–496.

6. Centers for Disease Control and Prevention. Update to CDC’s US Medical Eligibility Criteria for Contraceptive Use, 2010: Revised recommendations for the use of contraceptive methods during the postpartum period. MMWR. 2011;60(26):878–883.

7. Jackson E, Curtis K, Gaffield M. Risk of venous thromboembolism during the postpartum period: a systematic review. Obstet Gynecol. 2011;117(3):691–703.

8. Centers for Disease Control and Prevention. US Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR. 2010;59(No. RR-4):1–86.

9. Kletzky OA, Marrs RP, Howard WF, McCormick W, Mishell DR Jr. Prolactin synthesis and release during pregnancy and puerperium. Am J Obstet Gynecol. 1980;136(4):545–550.

10. Labbok MH, Hight-Laukaran V, Peterson AE, Fletcher V, von Hertzen H, Van Look PF. Multicenter study of the Lactional Amenorrhea Method (LAM): I. Efficacy, duration, and implications for clinical application. Contraception. 1997;55(6):327–336.

11.  Valdes V, Labbok MH, Pugin E, Perez A. The efficacy of the Lactational Amenorrhea Method (LAM) among working women. Contraception. 2000;62(5):217–219.