Postnatal sexual and reproductive health

Faculty of Sexual and Reproductive Healthcare


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Postnatal well-being

  • Health professionals should create opportunities for women and/or their partners to raise issues relating to postnatal sexual problems, body image and mental well-being, and should know where to refer if appropriate
  • Health professionals should allow opportunities for time alone with women in the antenatal and postnatal period, and should know how and where to access information and support for individuals affected by domestic violence

Assessment of contraceptive needs

  • Health professionals should find opportunities during both the antenatal and postnatal period to discuss all methods of contraception
  • Health professionals should assess a woman’s postpartum contraceptive needs by taking account of her personal beliefs/preferences, cultural practices, sexual activity, breastfeeding pattern, menstruation, medical and social factors

Postnatal contraception

  • The benefits of long-acting reversible contraception (LARC) methods in terms of efficacy should be highlighted to all postpartum women

Considerations for breastfeeding women

  • Women can be informed that available evidence suggests that use of progestogen-only contraception while breastfeeding does not affect breast milk volume
  • Women can be informed that there is currently insufficient evidence to prove whether or not combined hormonal contraception (CHC) affects breast milk volume
  • Women can be informed that progestogen-only contraception has been shown to have no effect on infant growth
  • Women may be advised that if they are <6 months postpartum, amenorrhoeic and fully breastfeeding, the lactational amenorrhoea method (LAM) is over 98% effective in preventing pregnancy
  • Women using LAM should be advised that the risk of pregnancy is increased if the frequency of breastfeeding decreases (stopping night feeds, supplementary feeding, use of pacifiers), when menstruation returns or when >6 months postpartum

How to advise women on starting specific methods postpartum

  • Women can be advised that contraception is not required before day 21 postpartum
  • If starting a hormonal method on or before day 21 there is no need for additional contraception
  • If starting a hormonal method after day 21, clinicians should be reasonably sure that the woman is not pregnant or at risk of pregnancy (see Criteria for excluding pregnancy), and should advise that she avoids sex or uses additional contraception for the first 7 days of use (2 days for the progestogen-only pill [POP]), unless fully meeting LAM criteria
  • CHC should not be commenced before day 21 due to the increased risk of thrombosis
  • Non-breastfeeding women may start CHC from day 21 postpartum
  • Breastfeeding women should avoid CHC in the first 6 weeks postpartum as there is insufficient evidence to prove the safety of CHC use while establishing breastfeeding
  • Use of CHC between 6 weeks and 6 months should not be recommended in fully breastfeeding women unless other methods are not acceptable or available. In partially or token breastfeeding women the benefits of CHC use may outweigh the risks
  • Postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum
  • Non-breastfeeding women can start a progestogen-only injectable method at any time postpartum
  • Breastfeeding women should not start a progestogen-only injectable method before day 21 unless the risk of subsequent pregnancy is high
  • Women should be advised that troublesome bleeding can occur with use of depot medroxyprogesterone acetate (DMPA) in the early puerperium
  • If more convenient, breastfeeding and non-breastfeeding women can choose to have a progestogen-only implant inserted before day 21, although this is outside the product licence for the 68 mg etonogestrel implant
  • Unless a copper-bearing intrauterine device (Cu-IUD) can be inserted within the first 48 hours postpartum (breastfeeding and non-breastfeeding women), insertion should be delayed until day 28 onwards. No additional contraception is required
  • A levonorgestrel-releasing intrauterine system (LNG-IUS) can be inserted from day 28 postpartum (breastfeeding and non-breastfeeding women). Women should avoid sex or use additional contraception for 7 days after insertion unless fully meeting LAM criteria
  • Women who choose a diaphragm or cervical cap should be advised to wait at least 6 weeks postpartum before attending for assessment of size requirement
  • Women and men considering sterilisation should be informed of the permanence of the procedure; about the risks, benefits and failure rates associated with sterilisation; and about other methods of contraception including LARC
  • Women can be advised that unprotected sexual intercourse or contraceptive failure before day 21 postpartum is not an indication for emergency contraception
  • Women can be advised that progestogen-only emergency contraception can be used from day 21 onwards and the emergency Cu-IUD from day 28 onwards

Criteria for excluding pregnancy

  • Clinicians can be ‘reasonably certain’ that a woman is not pregnant if any of the following criteria are met:
    • she has not had intercourse since last normal menses
    • she has been correctly and consistently using a reliable method of contraception
    • she is within 7 days of the onset of normal menses*
    • she is within 4 weeks postpartum for non-lactating women*
    • she is fully or nearly fully breastfeeding, amenorrhoeic, and less than 6 months postpartum

* Although the woman is not currently pregnant she may be at risk of pregnancy if she has had unprotected sexual intercourse up to 7 days prior to starting the LNG-IUS or traditional POP as these methods do not reliably suppress ovulation and have a delayed inhibitory effect on implantation

References

full guidelines available from…
Faculty of Sexual & Reproductive Healthcare
http://www.fsrh.org

FFPRHC guidance: Postnatal Sexual and Reproductive Health (September 2009)
First included: Feb 10.


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