Not all contraceptives are suitable immediately postpartum

CASE

On postpartum rounds, you visit a 21-year-old woman, G1P1, who has had gestational diabetes and, 12 hours earlier, had a spontaneous vaginal delivery.

You recall that, as part of prenatal care, you had several conversations with her about the risks and benefits of various contraceptive options postpartum. She didn’t select a method then, however.

Today, your patient asks about her options. She has two initial questions:

“What if I want to start taking a birth control pill right away—can I do that? And if I want an IUD, could you insert one for me before I go home?”

She adds that she plans on exclusively breastfeeding her baby for 6 months.

How should you answer this woman’s questions? See “Key guidance for responding to this patient”.

After delivery, ovulation can begin as soon as 25 days. Because unintended pregnancy and a short birth interval are associated with adverse health outcomes, it’s important that women who have delivered have a plan to start a contraceptive promptly.

Many important variables influence the selection of a contraceptive. In the postpartum interval, the impact of a contraceptive method on 1) the risk of deep venous thrombosis (DVT) and 2) breastfeeding are of particular importance, and should factor strongly into a woman’s choice.

For example, The US Centers for Disease Control and Prevention (CDC) has recommended that combined estrogen–progestin contraceptives (oral, vaginal ring, and patch) should not be used:

• within 21 days after delivery by women who are not breastfeeding
• until 42 days after delivery in women who are breastfeeding or who have an additional risk factor for DVT (age >35 years, previous DVT, thrombophilia, immobility, transfusion at delivery, body mass index ≥30, postpartum hemorrhage, cesarean delivery, preeclampsia, smoking).¹

Because so many postpartum women have one or more of these risk factors for DVT, combined estrogen–progestin contraceptives are not recommended for most women during the first 42 days after delivery. For women who want to start a contraceptive in the first 42 days after delivery, therefore, options of particular importance include:

• immediate post-delivery, post-placental placement of an intrauterine contraceptive
• progestin-only contraceptive
• condom
• sterilization.

OPTION: Immediate post-delivery, post-placental insertion of an intrauterine contraceptive

The US Food and Drug Administration has approved immediate placement of the copper intrauterine device (Paragard) after delivery of the placenta.

What is key is that you have 10 minutes after delivery of the placenta to insert an intrauterine contraceptive. Placing one of these devices after 10 minutes is associated with an increased rate of expulsion and is not recommended by experts.²

After vaginal delivery, an intrauterine contraceptive can be placed immediately after delivery of the placenta, but typically before any perineal repair,³ as follows:

• Administer oxytocin and perform fundal massage
• Assess the patient’s risk of significant postpartum hemorrhage; proceed if postpartum hemorrhage is determined to be unlikely
• Using a new pair of sterile gloves, grasp the anterior lip of the cervix with ring forceps
• Remove the copper IUD from the insertion tube and gently grasp the stem with ring or ovum forceps
• Place the device at the fundus, its arms parallel to the anterior and posterior walls of the uterus
• To help ensure that the device is properly positioned at the fundus, place an abdominal hand on the fundus to confirm that it, and the forceps, have reached the fundus before you release and remove the forceps (alternatively, use ultrasonography to guide fundal placement of the device⁴)
• Trim the strings with scissors at the level of the cervix (you can trim them further, as necessary, at the postpartum office visit).

The technique of insertion is modified after cesarean delivery: While the hysterotomy incision is open, grasp the device with ovum forceps and position it at the fundus. Guide the strings through the internal os into the vagina. Close the incision. Trim the strings after surgery is complete.

The main concern with immediate post-delivery insertion of an intrauterine contraceptive is an expulsion rate of 12% to 24%; compare this with the much lower expulsion rate associated with interval insertion of a copper IUD: between 3% and 10%.^5,6

Note: Results of one small study suggest that the levonorgestrel-releasing intrauterine system (Mirena) can also be placed immediately after delivery of the placenta.⁶

OPTION: Post-delivery progestin-only contraceptives

A major advantage of progestin-only contraceptives is that they have a minimal effect on the risk of DVT. In addition, unlike estrogen–progestin contraceptives, they do not inhibit production of breast milk. Estrogen–progestin contraceptives appear to both decrease the daily volume of milk and alter its composition by reducing the concentration of nitrogen, lactalbumin, lactoferrin, and lactose.