[CG] Covid 19 Pandemic Post Partum Contraception Clinical Guideline

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1. Purpose/Scope of Guideline

Based on the Faculty of Sexual & Reproductive Healthcare (FSRH) clinical guideline “Contraception after Pregnancy” 2017. 1

For use within NHS Greater Glasgow and Clyde (GGC) by medical and midwifery staff involved in the care of women during and after pregnancy. A LearnPro on Postnatal Contraception is also available.

This guideline will be used throughout Women and Children’s services to support decision making and ensure that all women are provided the best advice and access to contraception after pregnancy in the context of social distancing in the current pandemic situation.

The recommendations within this guideline are intended to guide clinical practice but are not intended to serve alone as a standard of care or to replace clinical judgement in the management of individual women.

Key areas of focus

  • When should contraception be discussed?
  • Who should provide contraception to women after childbirth?
  • Which contraception method is most effective?
  • When can contraception after childbirth be initiated?
  • Which method of contraception is safe to use?
  • Method specific considerations

2. Background

There are numerous studies that have shown that unintended pregnancy occurs within a year of a previous pregnancy.2,3 4 5

There is evidence that a short inter-pregnancy interval (less than 12 months) leads to poorer neonatal outcomes 6

The World Health Organisation (WHO) recommends an interval of 24 months after childbirth.

Pregnancy is a unique opportunity to discuss contraception choices and reproductive intentions with women due to continued contact with healthcare services.

In the context of the pandemic we aim to recommend the most practical options based on the following assumptions.

  • recommendation of social distancing (patients are less likely to seek contraception as it may be perceived as a non urgent requirement)
  • reduced GP appointment availability
  • very limited Sexual Health clinic availability

3. Discussion and provision of contraception after pregnancy

When making a clinical decision on safety and appropriateness of a method of contraception, clinicians should refer to the relevant, up to date, FSRH guideline and the UK Medical Eligibility Criteria for Contraceptive Use (UKMEC).

Factors for Midwives and Obstetricians to consider:

  • Patient preference
  • Previous contraceptive experience, failures and side effects
  • Age, BMI, smoking
  • Medical conditions including malignancy
  • Pregnancy related complication e.g. hypertension
  • Family history including thromboembolic mutations and carriers of gene mutation that predispose to malignancy
  • Gynae history including uterine anomaly, previous pelvic infection and gestational trophoblastic disease

3.1 UKMEC

The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) provides recommendations for the safety of different methods of contraception with regards to personal characteristics.

Table 1: Definition of UK Medical Eligibility Criteria for Contraception Use (UKMEC) categories9

UKMEC

Definition

UKMEC 1

A condition for which there is no restriction for the use of the method

UKMEC 2

A condition where the advantages of using the method generally outweigh the theoretical or proven risks

UKMEC 3

A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/or referral to a specialist contraception provider. Use of the method is usually not recommended unless other more appropriate methods are not available or acceptable

UKMEC 4

A condition which represents an unacceptable health risk if the method is used

Please refer to the current version of UKMEC via www.fsrh.org/standards-and-guidance/documents/ukmec-2016/

  • UKMEC provides recommendations regarding safety of a method of contraception but do not indicate the most appropriate method for a woman or take into account efficacy. Clinical judgement should be used when considering women with multiple co-morbidities. Women with complex medical conditions who may require more specialist contraceptive advice can be discussed with Sandyford Sexual Health staff via the Professional Helpline or via switchboard and asking to speak to the CSRH Consultant on Call.
  • Women with pregnancy associated medical conditions are eligible for all methods of contraception as below
    Hypertension during pregnancy All methods UKMEC 1 except CHC UKMEC 2
    Obstetric cholestasis All methods UKMEC 1 except CHC UKMEC 2
    Gestational diabetes All methods UKMEC 1

3.2 Available methods within GG&C are listed below

Recommended options for discharge from maternity services during the pandemic are:

  • Progestogen-only implant (IMP)
    Nexplanon (Etononogestrel) 68mg subdermal implant licensed for 3 years
  • Progestogen-only injectable (POI)
    Depoprovera (Medroxyprogesterone Acetate 150mg IM every 12 weeks)
  • Progestogen-only pill (POP)
    Cerelle 75 micrograms daily

Other methods to consider:

  • Barrier methods of contraception should be made available within the postnatal wards. They have an important role in reducing the risk of sexually transmitted infections (STI).
  • Female sterilisation at caesarean section. This remains an option however due to the irreversible nature, the standard guidance regarding decision making should be followed.
  • Combined hormonal contraception (CHC). We do not plan to this supply on discharge, as it should not be started until at least day 21 and 6 weeks for breast feeding women and women with VTE risk factors. Where this is the patient preference, the immediate discharge letter should include appropriate information to facilitate prescription by the GP.
  • Intrauterine Contraception (IUC). We have been providing this at caesarean section as part of a pilot at the PRMH. There is a significantly higher expulsion rate compared to interval insertion and since follow up at sexual health service is currently not available, the reliability of this method cannot be recommended. Where the patient declines alternatives and has been appropriately counselled, it may be provided.
  • Emergency Contraception (EC). This is available from community pharmacies or via Sandyford (for advice and appointments phone 0141 211 8130 The line is open Mondays to Fridays from 8.30am - 4.15pm, except public holidays)

3.3 Provision of contraception

  • All appropriate methods of contraception should be available to women before they are discharged from the service
  • Sufficient numbers of staff should be trained to provide IMP to ensure that women who are medically eligible can initiate these immediately after pregnancy. Up to date records of staff trained in implant are available from all charge midwives.
  • Effective contraception should be initiated in breastfeeding and non-breastfeeding women as soon as possible as sexual activity and ovulation may resume soon after delivery. It is estimated that approximately 50% of women are sexually active 6 weeks following delivery.8
  • In non-exclusively breast feeding women this need is present after 21 days following delivery over 24 weeks.
  • Women should be advised that although contraception is not required in the first 21 days after delivery, most methods are safe to initiate immediately, with the exception of combined hormonal contraception (CHC).
  • Contraceptive need is present within 5 days following miscarriage, ectopic pregnancy and abortion.

If methotrexate is required for management of ectopic pregnancy or pregnancy of unknown location, women are recommended not to conceive within 3 months following the first dose.

3.4 Effectiveness of contraceptive method

  • During pregnancy women should be informed about the efficacy of different methods of contraception, including the superior efficacy of LARC methods.

Rates of unintended pregnancy are higher for methods for user depend methods of contraception (barrier, oral contraceptive pills). Table 2 compares the typical and perfect use percentage of women who experience an unintended pregnancy during the first year of contraceptive use.

Table 3: Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use10

Method

Typical Use (%)

Perfect use (%)

No method

85

85

Fertility awareness-based methods

24

0.4-5

Female diaphragm

12

6

Male condoms

18

2

Combined hormonal contraception*

9

0.3

Progestogen-only pills

9

0.3

Progestogen-only injectables

6

0.2

Copper intrauterine device (IUD)

0.8

0.6

Levonorgesterl-releasing intrauterine system (IUS)

0.2

0.2

Progestogen-only implant

0.05

0.05

Female sterilisation

0.5

0.5

Vasectomy

0.15

0.1

Includes combined oral contraception, transdermal patch and vaginal rings. Long-acting reversible contraceptive methods are in bold.

3.5 Information giving and counselling

3.5.1 When should contraception be discussed?

  • Contraception counselling should be ideally be initiated at any time after the booking appointment. The contraception guidance leaflet should be provided by 32 weeks and a decision should be documented by 36 weeks on Badgernet.
  • Care should be taken to ensure that women are informed of all available methods and that she is not pressured to choose a method.

    https://www.sandyford.scot/professionals/clinical-guidance/postpartum-contraception-information/ 
    Women should be informed about the efficacy of different methods of contraception, including the superior efficacy of long-acting reversible contraception (LARC).

3.5.2 Who should provide contraception to women after childbirth

  • All staff involved in the care of pregnant women should offer the opportunity to discuss contraception. This information should be up-to-date and accurate.
  • Maternity services within GGC are able to provide all progestogen-only methods including implants, injectable and progestogen only pills before women are discharged from the service.
  • Please contact your area charge midwife for an up to date list of all staff trained in implant insertion.

3.5.3 Record keeping and obtaining valid consent

  • Staff should clearly document the discussion and provision of contraception.
  • The contraception plan should be clearly documented in BadgerNet under “Contraception”. Once a method has been selected, an alert should be added to her notes to ensure that this is provided prior to discharge.

4. Choosing a method of contraception

4.1 Which methods of contraception are safe to use after childbirth?

  • Women can be advised that although contraception is not required until day 21 postnatal, most methods (with the exception of combined hormonal contraception) can be safely initiated immediately.

Method

Timing of Insertion

Intrauterine Contraception (IUC)
Cu- IUD and LNG-IUS

 

 ✓ Can be safely inserted immediately after birth (within 10 minutes of delivery of placenta) or within the first 48hours after an uncomplicated caesarean section or vaginal birth. UKMEC 1

 ✓ After 48 hours, insertion should be delayed until day 28 post-natal UKMEC 1

 x Contra-indicated in the presence of postpartum sepsis UKMEC 4

Progestogen-only implants (IMP)

 ✓ Safe to initiate any time after childbirth, including immediately after delivery (breastfeeding and non-breastfeeding) UKMEC 1

Progestogen-only injectable (POI)

 ✓ Safe to initiate any time after childbirth, including immediately after delivery UKMEC 2

Progestogen-only pills (POP)

 ✓ Safe to start any time after childbirth, including immediately after delivery UKMEC 1

Combined hormonal contraception (CHC)

 x If risk factors for VTE then should not be used within 6 weeks of childbirth

 ✓ If low risk for VTE and not breastfeeding, can be commenced after day 21 of childbirth UKMEC 2

 ✓ If breastfeeding can be commenced after 6 weeks UKMEC 2

* Adapted from UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) categories applicable to women after childbirth

4.2 Emergency Contraception after childbirth

  • EC is indicated if a woman has had unprotected sexual intercourse from day 21 after childbirth. It is not required prior to this.
  • Oral EC Levonorgesterel 1.5mg (LNG-EC) and Ulipristal acetate 30mg (UPA-EC) are safe to use from 21 days after childbirth. The copper intrauterine device (Cu-IUD) can be safely inserted for EC from 28 days after childbirth.
  • If a woman is breastfeeding she should be informed that the limited available evidence indicates that LNG-EC has no adverse effect on breastfeeding.
  • If a woman is breastfeeding she should be advised to express and discard milk for one week after taking UPA-EC.

4.3 Additional Contraception

  • If contraception is started immediately or within 21 days of childbirth additional contraceptive precautions (Eg: barrier method/abstinence) are not required

Methods of contraception

Initiation <21 days after childbirth

Initiation >21 days after childbirth

 

Number of days of additional contraceptive precautions required (days)

Copper Intrauterine device

 

None if inserted 0 to <48 hours

Insertion between 48 hours and
<4 weeks may not be appropriate (UKMEC 3)

None

Levonorgestrel-releasing intrauterine system

7

Progestogen-only pill

None

2

Progestogen-only implant or injectable

None

7

Combined hormonal contraception

Use not recommended

7

 

4.4 Breastfeeding and contraception

  • Women should be informed that the available evidence indicates that progestogen-only methods of contraception have no adverse effects on lactation or infants.
  • If a woman is breastfeeding, she should wait until 6 weeks postnatal before initiating a CHC method.
  • There is limited evidence about the effect of CHC on breastfeeding. Studies looking at early initiation of CHC found no adverse effects on either breastfeeding performance or infant outcomes.

4.4.1 Lactation amenorrhoea method (LAM) as contraception

  • LAM is a highly effective method of contraception (less than 2% failure rate) if all of the following three criteria are fulfilled
    • Less than 6 months postpartum
    • Amenorrhoeic
    • Fully breastfeeding
  • Efficacy is reduced if the frequency of breastfeeding reduces (eg: increasing intervals between breastfeeding of >4 hours during the day and >6 hours at night, use of a dummy, increasing supplementary feeding or expressing milk), when menstruation returns or if over 6 months since childbirth

5. Method specific considerations

See Section 4.1 for information about timing of initiation

5.1 Intrauterine Contraception

  • Clinicians should clearly document the type of device inserted (e.g. hormonal: LevosertTM, MirenaTM or non-hormonal: T-safe Cu 380A QL or TT380). Please see Standard Operating Procedure for “Insertion of Intrauterine Contraception at Caesarean Section” for further information about documentation and referral to Sandyford for follow up.
  • There is no evidence of increased risk of uterine perforation if IUC is inserted immediately after delivery of the placenta or within 48hours of delivery, compared with delayed insertion (after 4 weeks).
  • There is no increased risk of infection.
  • The insertion of IUC immediately after childbirth is associated with higher rates of expulsion but also higher continuation rates 6-12 months postpartum for all types of IUC and mode of delivery. Expulsion is more likely to occur within the first 3 months after insertion. Within the pilot there was a 13.5% expulsion rate. Sandyford have agreed to provide follow up. The Sandyford Team will initially phone the patients and if they are willing and able to feel their own threads, Sandyford will advise the woman that she can rely on the IUCD for contraception. If the woman can not feel the threads or feels the tip of the coil, they will advise the woman to use additional contraception until a routine appointment at Sandyford can be facilitated. If patients are experiencing symptoms, Sandyford will provide an urgent review.
  • All patients should be provided with a written patient information leaflet after insertion of their IUC. This is available in all post natal ward areas or can be accessed via link in resources

5.2 Progestogen only implant

 5.3 Progestogen only injectable

  • There are two available preparations of injection
    • Depo-ProveraTM – administered intramuscularly
    • Sayana PressTM – administered subcutaneously
  • There is theoretical concern that the use of DMPA may be associated with an increased risk of VTE compared to other progestogen-only methods. The progestogen only injection is therefore classified as UKMEC 2 for use by women in the first 6 weeks after childbirth.

5.4 Progestogen only pill
(Desogestrel 75 microgram tablets)

  • POP can be started at any time after childbirth, including immediately after delivery
  • If started before day 21 post natal, no additional contraception is required. If started after day 21, then additional precautions are required for 2 days.

5.5 Combined hormonal contraception (CHC)

  • All women routinely have a postnatal VTE risk assessment. CHC should not be used for women who have risk factors for VTE until 6 weeks postnatal. This applies to both women who are breastfeeding and not breastfeeding (UKMEC 4).
  • Women who are not breastfeeding without any additional risk factors for VTE should wait until 21 days after childbirth. In women who are breast feeding it is recommended that it should be delayed until 6 weeks postpartum to allow breastfeeding to establish.
  • Combined hormonal contraception should not be supplied on discharge, however, if desired a bridging method of contraception should be considered.
  • Many women may have previously used the CHC very successfully. It’s popular due to its predictable bleeding pattern. If no new risk factors have developed during the pregnancy, women may wish to resume this option when appropriate.

5.6 Female sterilisation

  • Female sterilisation is a safe and permanent option for contraception after childbirth.
  • Both FilshieTM clips and modified PomeroyTM technique are effective
  • Women should be made aware that some LARC methods are as, or more effective than female sterilisation and may also offer non-contraceptive benefits.
  • Women who opt for tubal occlusion should be made aware that they need to seek medical advice in the event of a pregnancy. They will be more likely to have an ectopic pregnancy.
  • Women requesting sterilisation at the time of delivery should be advised of the possible increased risk of regret.
  • Written consent for sterilisation at Caesarean section should be obtained and documented at least 2 weeks prior to planned date for elective caesarean section.

5.7 Male Sterilisation

  • Vasectomy should be discussed with all people requesting sterilisation. Individuals should be informed that some LARC methods are as effective as sterilisation (Table 3) and may offer some non-contraceptive benefits.
  • They should be advised that vasectomy is associated with a lower failure rate, is quicker and associated with less morbidity than laparoscopic sterilisation.11
  • A negative ejaculate specimen is required to confirm that a vasectomy is effective. This can take up to 12 months and it is important that women are counselled about their on-going need for contraception during this time.
  • An appointment to discuss a vasectomy can be made at Sandyford Central and does not require GP referral.

5.8 Barrier methods

  • Male and female condoms can be safely used by women after childbirth.
  • If using a diaphragm, women should be advised to wait at least 6 weeks after childbirth before fitting as the size required may change as the uterus involutes.

5.9 Fertility Awareness Methods (FAM)

  • Can be used after childbirth. Women should be advised that as FAM relies of the detection of signs and symptoms of ovulation its use may be inaccurate after childbirth and when breastfeeding.
References
  1. Faculty of Sexual and Reproductive Health. Contraception after Pregnancy. 2017 
  2. Bexhell H, Guthrie K, Cleland K, et al. Unplanned pregnancy and contraceptive use in Hull and East Yorkshire. Contraception Published Online First: 28 October 2015.
  3. Lakha F, Glasier A. Unintended pregnancy and use of emergency contraception among a large cohort of women attending for antenatal care or abortion in Scotland. Lancet 2006;368:1782–1787.
  4. Young H. Short interval pregnancies Glasgow. 2018 (unpublished)
  5. Heller R, Cameron S, Briggs R, et al. Postpartum contraception: a missed opportunity to prevent unintended pregnancy and short inter-pregnancy intervals. J Fam Plann Reprod Health Care 2016;42:93–98
  6. Smith GCS, Pell JP, Dobbie R. Interpregnancy interval and risk of preterm birth and neonatal death: retrospective cohort study. Br Med J 2003;327:313.
  7. World Health Organization (WHO). Report of a WHO Technical Consultation on Birth Spacing. 2007. 
  8. McDonal E, Brown S. Does method of birth make a difference to when women resume sex after childbirth. BJOG 2013; 120.
  9. Faculty of Sexual & Reproductive Healthcare (FSRH). UK Medical Eligibility Criteria for Contraceptive Use (UKMEC). 2016. 
  10. Trussell J. Contraceptive efficacy. In: Hatcher R, Trussell J, Nelson A, et al. (eds), Contraceptive Technology. New York, NY: Ardent Media, 2011.
  11. Faculty of Sexual and Reproductive Health. Male and Female Sterilisation. 2014. 

Last reviewed: 15 September 2021

Next review: 21 September 2022

Author(s): Helena Young / Catrina Bain

Version: 4

Approved By: Jane Richmond /Ros Jamieson