Lee P. Shulman and Andrew M. Kaunitz
Table Of Contents
Lee P. Shulman, MD
Andrew M. Kaunitz, MD
INITIATING CONTRACEPTION FOR THE POSTPARTUM PATIENT
Despite recent data that demonstrate that the unintended pregnancy rate has declined in the United States, almost one half of all pregnancies remain unintended.1 Indeed, more than one half of these unintended pregnancies end in pregnancy termination,1 a sobering figure that underscores the critical need for those women who do not desire pregnancy to be aware of and have access to the various methods of safe and effective contraception. Many women who have recently given birth are highly motivated to initiate an effective contraceptive method. Accordingly, the puerperium presents an ideal and important opportunity to initiate effective contraception.
The high levels of emotion and stress that may be experienced intrapartum and immediately postpartum do not engender ideal circumstances for the initial consideration of a contraceptive method. Because contraception should be initiated soon after delivery for many women, discussion of a patient's needs and preferences should begin well before delivery, ideally in the third trimester.2 Multiple clinician-patient interactions during the antenatal period allow for clinicians to provide progressive contraceptive education while obtaining a broad perspective of a woman's lifestyle and sexual and contraceptive preferences and needs.
Deciding which contraceptive method to initiate following delivery is primarily based on whether the patient has decided to breastfeed and the extent to which she intends to do so. Assessing lactation status also helps to determine the proper timing of contraceptive initiation.3 This chapter provides a review of postpartum physiology as it pertains to postpartum contraception as well as the various issues that are involved in the choice of contraception following delivery.
Prolactin levels dramatically increase during pregnancy, stimulating breast growth and mammary gland development and acting as the principal hormone supporting lactation following delivery. Elevated levels of prolactin are also associated with ovulatory dysfunction and infertility; indeed, lactation plays an important role in delaying the return of ovulation following delivery. Evidence suggests that although high levels of prolactin work at central and ovarian sites to produce lactational amenorrhea and anovulation, the central action predominates. On weaning, prolactin levels return to normal, with ovulation returning within 14 to 30 days.4 Accordingly, breastfeeding has a critical and central role in the timing of the return of ovulation and thus fertility.5
Several studies have assessed the timing of postpartum resumption of ovulation in women who breastfeed. Scottish and Mexican studies of full, or nonsupplemental, breastfeeding women reported no ovulation in the initial 3 postpartum months.6,7 Fewer than 20% of Australian women had ovulated by the month 6 of nonsupplemental breastfeeding.8 In a U.S. study, the average time to first ovulation was 27 ± 2 weeks (range, 5–37 weeks).9 A recently published study of 72 nonsupplemental breastfeeding women found that ovulation invariably occurred later than 8 weeks postpartum.10
These studies serve to demonstrate that although breastfeeding is effective in preventing ovulation, it is not completely effective, especially later than 3 to 4 months postpartum. In addition, many women do not practice full, or nonsupplemental, breast-feeding (i.e. excluding the use of formula or foods). Accordingly, fluctuations in the length of lactational infertility are also affected by individual breastfeeding patterns.11 A proposed threshold for suppression of ovulation is at least five daily feedings totaling at least 65 minutes of suckling per day.12 Increased supplementation and decreased suckling time progressively weaken the associations among lactation, amenorrhea, and anovulation. Accordingly, back-up contraception may be required for women who are not nonsupplemental breastfeeders.5,13
In women who choose not to breastfeed, gonadotropin levels remain low during the first 2 to 3 weeks of the puerperium and return to normal during the third to fifth week, when prolactin levels also fall to normal levels.4 Among U.S. women, the average time to first ovulation among nonbreastfeeding women was 45 ± 3.8 days (range, 25–72 days). In addition, two thirds of breastfeeding and nonbreastfeeding women ovulated prior to their initial bleeding episode,9 demonstrating the importance of contraception consideration and initiation prior to the commencement of menstruation.
Postpartum Hypercoagulable State
Another important factor in choosing and initiating contraception following pregnancy completion is the persistence of a hypercoagulable state following the completion of a pregnancy. This results in an increased risk of venous thromboembolism for 2 weeks after childbirth.14 Accordingly, use of contraceptive methods that include estrogen is not recommended during this time period, because estrogen use could exacerbate the thromboembolic risk.15
Although the changing hormonal milieu of pregnancy may result in a less hypercoagulable state when a less-advanced gestation is terminated, a good rule to follow is to consider contraception within a postpartum framework once the pregnancy has progressed past the 20th gestational week.
|INITIATING CONTRACEPTION FOR THE POSTPARTUM PATIENT|
After 2 weeks have passed since delivery and the issue of hypercoagulability is of less concern, lactation status becomes the central criteria for the type and timing of contraceptive initiation. Because of the aforementioned data concerning ovulatory return among lactating and nonlactating women, additional contraception is recommended for all women who do not desire to become pregnant. In this regard, the “Rule of Threes” offers a useful guide4:
For full breastfeeding women, contraception should begin in the third postpartum
Clinicians should be aware that women using dopamine agonists (e.g. bromocriptine) for lactation suppression may ovulate earlier and thus be at risk for pregnancy. For such women, contraception initiation should begin 2 weeks following delivery.4
Counseling is an integral part of the contraception process. Indeed, education concerning the efficacy and side-effects of the various hormonal, spermicidal, and barrier methods is an important determination regarding whether a woman will use her method consistently and correctly and obtain effective contraception. Counseling is not just to inform women about the various methods of contraception that are available; it should also be used to obtain information about the woman's lifestyle so that an appropriate contraceptive can be chosen. This should involve a frank discussion about personal health, sexuality, and the impact of specific contraceptives on health and lifestyle. Accordingly, this counseling should be individualized for each woman and include past experiences with contraception, personal medical history, sexuality, and desire for and timing of future childbearing, as well as thoughts and concerns regarding sexual practices following delivery.16,17 The optimal time for such counseling is during the third trimester; however, contraceptive counseling can be initiated prior to the pregnancy or as early as the initial prenatal visit, especially if permanent surgical contraceptive methods are being considered. Clinicians should endeavor to place women at ease in discussing the various issues concerning contraception at any time.5
To facilitate such counseling, the following section provides a review of the use of various contraceptive methods available to the postpartum woman. For a review of the actions and side-effects of each method, please refer to other chapters in this volume.
Lactation Amenorrhea Method
The lactation amenorrhea method (LAM) uses the anovulatory effect of breastfeeding to provide contraception for the postpartum woman. The Bellagio Consensus on the use of breastfeeding as a family planning method stated that “maximum birth spacing effect of breastfeeding is achieved when a mother `fully' or "near fully' breastfeeds and remains amenorrheic.”18 Indeed, only amenorrheic women who are nonsupplemental or nearly nonsupplemental breastfeeders are considered to have contraceptive protection equivalent to oral contraceptive use.
Supplemental feeding, menstruation, and the passage of more than 6 months after delivery increase the chance of ovulation and thus reduce the efficacy of lactation for contraception. Accordingly, LAM should not be considered for those women who are practicing supplemental breastfeeding; such women should be offered barrier, hormonal, or intrauterine methods of contraception after the third postpartum week.5 However, as ovulation has been documented to occur in nonsupplemental breastfeeding women prior to the sixth postpartum month,9,10 consideration of a supplementary contraceptive method (e.g., barrier, progestin only, intrauterine device) for nonsupplemental breastfeeding women is warranted in the third postpartum month.
Barrier methods of contraception include male and female condoms, the diaphragm, vaginal spermicidal jellies and inserts, and the cervical cap. Although some of these methods provide some protection against sexually transmitted disease (e.g. male or female condom), all barrier methods are associated with method and user failure rates higher than those with other reversible contraceptive methods.19
An important characteristic of all barrier methods is that they do not affect lactation. Accordingly, barrier methods are appropriate for all postpartum women considering contraception regardless of breastfeeding status. However, appropriate counseling regarding proper use and their relative lower contraceptive efficacy, even with correct use, must be provided prior to initiation.5,16
Condom, spermicidal agent, and vaginal sponge use can be initiated in the immediate postpartum period. Indeed, spermicidal agents and lubricated condoms may be helpful in facilitating comfortable intercourse for women who experience vaginal dryness or dyspareunia as result of breastfeeding or other causes. However, uterine involution plays an important role in the selection and initiation of other barrier methods, specifically the diaphragm and cervical cap. Parturition, regardless of route of delivery, causes considerable changes in the size, shape, and orientation of the cervix and vagina. Because these changes may alter prepregnancy anatomy, use of the diaphragm or cervical cap prescribed prepregnancy is not recommended in the postpartum period. Additionally, fitting new devices prior to complete involution of the uterus and healing of the vagina is difficult and is not recommended. Accordingly, consideration of diaphragm or cervical cap use is not warranted until at least 6 weeks postpartum, when women should present for a device fitting as well as complete contraception and device-oriented counseling.5
Combination Oral Contraceptives
Combination oral contraceptives (OCs) contain estrogen and progestin and can be offered to nonbreastfeeding women at or after 2 weeks postpartum, a time at which the hypercoagulable postpartum state has largely resolved.15,19,20 Combination OCs are not an optimal choice for women who breastfeed, because they decrease milk volume and quality.21
Nonlactating women who wish to use OCs following delivery can be advised to begin their use on the first Sunday following the second week “anniversary” of their child's birth. This ensures that OC use will commence outside of the period of peak hypercoagulability while ensuring effective contraception prior to the onset of ovulation. However, clinicians should be aware that product labeling for all combination OCs advise deferment of initiation until the fourth postpartum week in nonbreastfeeding women.5
Progestin Only Methods
Because progestin only methods do not contain estrogen, they do not suppress lactation and thus can be used by postpartum women irrespective of breastfeeding status. Although all progestin only methods result in minute amounts of progestin being passed into the breast milk, this has not been shown to adversely effect infant growth or development, regardless of the type of progestin or infant gender.4
Progestin only contraceptives are an easy and effective method of contraception and are available by oral, injectable, and implantable routes. All three method types are associated with distinct sideeffects; accordingly, thorough counseling should be provided to all women considering these methods.16,19
Although several progestins are available as oral preparations worldwide, only norethindrone and norgestrel are available as progestin only pills in the United States. Because these contraceptive pills do not contain estrogen, progestin only pills (POPs), or “mini-pills,” may be used by women who breastfeed. Indeed, POPs may provide a moderate increase in milk production and have been shown to lead to longer breastfeeding.4 The combination of breastfeeding with an exogenous oral progestin thus provides a highly effective contraceptive option in this patient population. Current product labeling for the 0.35-μg norethindrone pill has been recently updated and now suggests that nonsupplemental breastfeeding women commence POPs at 6 weeks postpartum, and supplemental breastfeeding women can begin POPs at 3 weeks postpartum.5
POPs can also be used by nonbreastfeeding women. Current product labeling calls for nonbreastfeeding women to begin use of norethindrone mini-pills at 3 weeks postpartum. Consistent adherence to the mini-pill regimen (one pill each day at the same time of day) is essential to maintain adequate contraceptive protection and minimize side-effects, the most common of which is irregular vaginal bleeding. The contraceptive action of POPs is related to anovulation and cervical mucus thickening; McCann and Potter22 have reported that sex steroid levels and cervical mucus thickening are greatly reduced at 24 hours following administration. Accordingly, taking a POP tablet even several hours late may increase the risk of an escape ovulation and decrease cervical mucus thickening, thus increasing the risk of an unintended pregnancy.22 In contrast, taking a combination OC tablet a full day late does not significantly increase the risk of pregnancy as long as the missed pill is taken shortly after the next 24-hour period has commenced.4,15
DEPOT MEDROXYPROGESTERONE ACETATE.
Depot medroxyprogesterone acetate (DMPA) is an injectable progestin contraceptive that, similar to POPs, results in no adverse effect on lactation or infant growth and development despite the passage of small amounts into breast milk and minor effects on the composition of breast milk.21
Product labeling advises consideration of initiation within the first 5 days after delivery and by the third postpartum week if the woman is not breastfeeding and at the sixth postpartum week for nonsupplemental breastfeeding women. Given the lack of procoagulation and lactation impact,24,25 immediate postpartum use of DMPA in all postpartum women, regardless of lactation status, appears appropriate. The reason why DMPA and other progestin only methods are still recommended for initiation at the sixth postpartum week for nonsupplemental breastfeeding women is not because of any data contraindicating their use earlier in the postpartum period but rather because the manufacturers have not submitted data to the U.S. Food and Drug Administration (FDA) to support its use in the immediate postpartum period.4,15
Subdermal implants have little effect on lactation and infant development. In two Egyptian studies there was no difference in lactational performance between implant users and nonusers, and infant growth was normal for all groups.23,24 However, in one study, weight gain in the first 6 postpartum months for infants who were exclusively breastfed was slightly lower than that for those children who received supplemental feedings or who were not breastfed.23 Despite this reassuring information, more studies assessing the immediate postpartum use of subdermal implants and DMPA are needed.
As with DMPA, product labeling advises that insertion of implants be deferred until the sixth postpartum week in nonsupplemental breastfeeding women and by the third postpartum week in supplemental and nonbreastfeeding women. Two recent studies found that subdermal implants inserted in nonlactating women during the immediate postpartum period were effective and well tolerated.25,26 Accordingly, subdermal implants may be particularly appropriate for women who may have difficulties in returning for a postpartum visit or for women in whom compliance issues may preclude proper use of other reversible methods.16 In addition, subdermal implants and DMPA should be reserved for those women who desire relatively long-term contraception; those women who desire contraception for less than 18 to 24 months should consider other contraceptive options such as pills or barrier methods.
Intrauterine Devices (IUDs)
Intrauterine devices (IUDs) are an appropriate choice of contraception for postpartum women regardless of lactation status because IUDs do not affect systemic sex steroid levels. Insertion of IUDs in breastfeeding women is associated with less pain at the time of insertion and with lower removal rates for subsequent pain and bleeding compared with nonbreastfeeding women.27
Two IUDs are currently available in the United States: a progesterone-containing device and a copper-containing device. Copper IUDs can be safely inserted at 4 to 8 weeks postpartum without an increase in postinsertion adverse outcomes (e.g. perforation, expulsion) compared with insertion more than 8 weeks postpartum.28 The Copper T 380A can be inserted immediately postpartum, although some studies have demonstrated a higher rate of expulsion compared with insertions performed at or after 6 weeks postpartum.29 Product labeling for both IUD types calls for insertion to be performed only when uterine involution has been confirmed.5
Approximately 1 million sterilization procedures are performed each year in the United States; the ratio of tubal ligation to vasectomy is about 2:1. Immediate postpartum sterilization accounts for approximately one third of tubal sterilization procedures performed in the United States.19 However, sterilizations performed at this time are associated with a higher rate of regret than those not associated with a pregnancy, highlighting the importance of counseling in the contraceptive/sterilization process.30 Indeed, women must be aware that postpartum sterilization leads to a permanent state of infertility; if there is any consideration of childbearing in the future, women should not be encouraged to consider reversal procedures or assisted reproductive technologies but rather be counseled about the availability of reversible contraceptive options.16
The Pomeroy technique is the most widely used sterilization method when the procedure is performed in the immediate postpartum period.19 Many centers also utilize clips and rings to ligate the fallopian tubes; now that the Filshie clip has been approved for use in the United States, clinicians may begin to use this novel and popular device for postpartum sterilization.31
Counseling is a central and critical part of the contraceptive process, because the eventual efficacy of contraception relates to whether the patient has been counseled about the proper use, expected side-effects, and short-term and long-term implications of the method chosen. For those clinicians who care for postpartum women, an understanding of postpartum physiology and the effects of sex steroids on coagulation and lactation is required to provide the safest and most reliable method to all postpartum women, regardless of lactational status. Indeed, lactation and uterine involution status provide the main guidelines for choosing the preferred method and determining when to initiate its use. Because counseling occupies such an important role in the contraceptive process, it should be initiated during the antenatal period so that decisions can be made outside of the immediate postpartum period, a time fraught with excitement and anxiety for women and their families and not necessarily amenable to reasoned deliberation about such an important personal medical decision.
In general, contraception is not needed prior to 3 weeks postpartum in women who are not breastfeeding or prior to 3 months in nonsupplemental breastfeeding women. Barrier methods can be used by all women at any time following delivery without regard to the woman's lactation status; however, these methods are associated with relatively high user and method failure rates. IUDs can likewise be used by postpartum women regardless of lactation status. Although IUDs are associated with very low failure rates and are an excellent method for women who may be affected by compliance issues, product labeling calls for delay of insertion until after completion of uterine involution.
Combination OCs are not an optimal method for nonsupplemental breastfeeding women, because the estrogen in the OCs may have a negative impact on lactation. If a breastfeeding woman desires hormonal contraception, progestin only methods are appropriate for consideration. Although product labeling information advises initiation of progestin only methods no earlier than 6 weeks postpartum, immediate postpartum initiation appears safe for mother and infant.
Combination OCs can be initiated 3 weeks postdelivery in nonbreastfeeding women. Earlier initiation is contraindicated because of the procoagulant effect of the estrogen and its possible adverse effect on maternal health during the immediate postpartum period, a time characterized by hypercoagulability. For women who desire immediate postpartum hormonal contraception, consideration of progestin only methods is warranted. Regardless of the type of contraception chosen by the nonbreastfeeding woman, initiation of use should occur by the third postpartum week, whether or not the woman has experienced menstruation.
Sterilization provides permanent and effective contraception for postpartum women. Counseling regarding postpartum sterilization should occur during or before the antenatal period and should include consideration of future childbearing desires, surgical risks, contraceptive efficacy, and alternative contraceptive methods. Some states have strict rules concerning the timing of obtaining sterilization consents and require the counseling to be performed well in advance of delivery. With the wide availability of safe and reliable reversible methods, sterilization should be reserved only for those women who are resolute in their desire to permanently terminate their fertility.
21. WHO Task Force on Oral Contraceptives, Special Programme of Research, Development, and Research Training in Human Reproduction. Effects of hormonal contraceptives on breast milk composition and infant growth. Stud Fam Plann 1988;19:361.
24. Shabaan MM. Contraception with progestogens and progesterone during lactation. J Ster Biochem Molec Biol 1991;40:705.