Two-thirds of couples resume sexual relations within the first postpartum month; 90% within the second month. Because ovulation may occur within 3–4 weeks and before the first menses, contraception should be initiated either immediately postpartum or within the first few weeks. Non-breast-feeding women Although there are theoretical concerns regarding postpartum hypercoaguability, there are no definitive clinical data that justify withholding combined contraceptives until four weeks postpartum although this is the recommendation indicated in product labeling. Progestin-only oral contraceptives and DMPA do not contain estrogen, and these methods may be safely initiated immediately postpartum. ACOG recommends DMPA and progestin-only pills be initiated at six weeks postpartum in lactating women and immediately postpartum in non-lactating women if desired. IUDs are less likely to be expelled if inserted immediately following the delivery of the placenta. If not inserted immediately they should be inserted at 6–8 weeks postpartum. Breast-feeding women60,61,62,63 Lactation provides an excellent and reliable contraceptive method for up to six months, with a failure rate of 0.5 to 1.5% for women who exclusively breast feed at least every four hours and experience an absence of menstrual bleeding. Pumping is not an effective substitute for suckling. Another contraceptive method should be initiated if any supplemental feedings are given to the infant, if the feeding frequency decreases, or when the baby reaches six months of age. Spermicides, condoms, and barrier methods are acceptable choices, although diaphragms should be fitted or refitted at approximately six weeks postpartum. A new size of FemCap may need to be prescribed. Fertility awareness methods may require closer scrutiny of physiological parameters. The basal body temperature may not be reliable in the setting of the normal sleep disruption of the newborn period. Progestin methods (Implanon, progestin-releasing IUS, DMPA (104 mg or 150 mg), and progestin-only pills) are recommended after 4–6 weeks postpartum, based largely upon theoretical concerns and animal studies. The World Health Organization recommends that COCs should be avoided in lactating women within the first six weeks postpartum and used with caution between six weeks and six months. Although the estrogen that is transmitted in breast milk has not been shown to be detrimental to the infant, it has been associated with decreased milk supply in some studies. Some lactating women may not be able to compensate with greater milk production. There are essentially no conclusive data in human mothers as to the clinically significant impact of either progestin compounds or combination contraceptives in breast milk on infants. ACOG on the other hand references studies that state the use of hormonal contraception in nourished breastfeeding women does not appear to compromise infant growth or development nor impair lactation. They advise COCs can be used once milk flow is well established. POPs and DMPA do not impair lactation and can be used “immediately.” Although small amounts of progestin are passed into the breast milk, no adverse infant effects have been documented. Product labeling for progestinonly pills recommends fully breastfeeding women begin tablets six weeks postpartum and partially breastfeeding women begin at three weeks. Use of DMPA immediately post partum does not appear to adversely affect lactation or infant development. ACOG recommends DMPA and progestin-only pills, be used at 6 weeks postpartum in lactating women and immediately postpartum in non-lactating women if desired. Postpartum sterilization, if chosen, should be performed after the infant’s first successful feed to minimize any impact of a delayed first feed on lactation; the mother should be allowed to nurse again in the recovery room. Alternatively, it can be performed at six weeks postpartum. Cigarette smokers Clinicians should prescribe combination hormonal contraceptive methods only cautiously, if at all, to women over the age of 35 years of age who smoke. Barrier methods, injectable progestin, subdermal implants or IUDs are preferred.
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