RCOG GTG
Guidance on the provision of contraception by maternity services after childbirth during the COVID-19 pandemic
Provides clinical recommendations on offering and initiating effective contraception, including long-acting reversible contraception (LARC) and progestogen-only pills, prior to discharge from maternity services during the COVID-19 pandemic.
1Importance and Timing of Postpartum Contraception Counselling
Postpartum contraception is critical due to the rapid return of fertility. Antenatal discussion and pre-discharge provision help prevent short inter-pregnancy intervals and reduce health inequalities.
- Rapid return of fertility: Fertility returns quickly after childbirth; the Faculty of Sexual and Reproductive Healthcare (FSRH) recommends starting contraception as soon as possible for both breastfeeding and non-breastfeeding mothers.
- Prevents short inter-pregnancy intervals, which are clinically associated with poorer pregnancy outcomes.
- Reduces health inequalities by capturing women who may not otherwise engage with sexual health services.
- RECInformation about contraception after childbirth should be offered in the antenatal period to support informed decision-making and facilitate provision by maternity services.
- Discussions during pregnancy about elective caesarean birth are a particularly useful time to plan contraception.
- Antenatal planning allows women more time to consider options without the immediate distractions and recovery demands of caring for a newborn.
- RECAfter childbirth, effective contraception should be discussed and offered prior to discharge from maternity services.
- Maternity services are ideally placed to provide postpartum contraception, especially when access to primary care and sexual health clinics is reduced (e.g., during pandemic restrictions).
2Postpartum Contraceptive Initiation Rules & Suitability
Guidelines on the safe timing, eligibility, and administration of combined hormonal contraception, lactational amenorrhoea, and female sterilisation in the immediate postpartum period.
- General suitability: Most contraceptive methods (except combined hormonal contraception) can be started safely by both breastfeeding and non-breastfeeding women immediately after birth.
- UK Medical Eligibility Criteria (UKMEC) 2016 should be used to assess individual suitability.
- CHCCombined Hormonal Contraception (CHC) timing is strictly dependent on breastfeeding status and venous thromboembolism (VTE) risk factors:
- Breastfeeding women: Do not start CHC until at least 6 weeks postpartum.
- Non-breastfeeding women WITH additional VTE risk factors: Do not start CHC until at least 6 weeks postpartum.
- Non-breastfeeding women WITHOUT additional VTE risk factors: May consider starting CHC from 3 weeks postpartum.
- CHCMandatory clinical assessments prior to CHC provision to mitigate immediate postnatal health risks:
- Careful medical eligibility assessment (UK MEC).
- Blood pressure (BP) and Body Mass Index (BMI) measurement.
- Counseling regarding CHC-associated health risks (e.g., VTE).
- Provision during COVID-19: If other methods are unsuitable or unavailable, a 6-month supply of CHC can be provided prior to discharge with clear start instructions and interim contraception advice.
- LAMLactational Amenorrhoea Method (LAM) criteria and limitations:
- Can only be relied upon for the first 6 months postpartum.
- Requires the woman to remain fully amenorrhoeic AND continue to breastfeed fully.
- Caution: Breastfeeding frequency may reduce or menses may return unexpectedly, causing immediate loss of contraceptive effect.
- Recommendation: Breastfeeding women should commence additional contraception as soon as possible after birth to avoid unintended pregnancy, especially when service access is restricted.
- FSRHFemale Sterilisation during elective Caesarean Section:
- Written consent must be obtained at least 2 weeks prior to the birth due to the high risk of potential regret.
- GPPDischarge and Bridging Contraception:
- If the preferred contraceptive method cannot be provided prior to discharge, offer effective bridging contraception and local service access details.
- Contraceptive administration and dispensing must not delay discharge; protocols should be established to prevent discharge delays (e.g., utilizing community pharmacies).
3Postpartum Intrauterine Contraception (Cu-IUD & LNG-IUS)
Clinical guidance, timing, and contraindications for the safe insertion of the copper intrauterine device (Cu-IUD) and the 52mg levonorgestrel intrauterine system (LNG-IUS) within the immediate postpartum period.
- TimingBoth Cu-IUD and 52mg LNG-IUS can be inserted at the time of caesarean section, immediately after vaginal birth, or at any time up to 48 hours postpartum.
- Must be performed by maternity staff trained in the specific postpartum insertion technique.
- Cu-IUD ContraindicationsAbsolute contraindications to postpartum Cu-IUD insertion:
- Postpartum sepsis
- History of sexually transmitted infection (STI) during the current pregnancy
- Current pelvic tuberculosis (TB)
- Current gestational trophoblastic disease (GTD)
- Diagnosis of cervical or endometrial cancer in the current pregnancy
- Copper allergy or Wilson disease
- Cu-IUD Potential ContraindicationsConditions requiring clinical caution or representing relative contraindications for Cu-IUD:
- Previous heavy menstrual bleeding or anaemia
- Complications after organ transplant
- Long QT syndrome
- Previous trachelectomy
- Uterine cavity significantly distorted by fibroids or structural abnormalities
- HIV infection with CD4 count < 200 cells/μl
- LNG-IUS ContraindicationsAbsolute contraindications to postpartum 52mg LNG-IUS insertion:
- Allergy to any component of the system
- Postpartum sepsis
- History of STI during the current pregnancy
- Current pelvic TB
- Diagnosis of breast, endometrial, or cervical cancer in the current pregnancy
- Current gestational trophoblastic disease (GTD)
- LNG-IUS Potential ContraindicationsConditions requiring clinical caution or representing relative contraindications for LNG-IUS:
- Previous breast cancer diagnosis
- Previous arterial thromboembolic event during use
- Decompensated cirrhosis, hepatocellular adenoma, or carcinoma
- Complications after organ transplant
- Long QT syndrome
- HIV infection with CD4 count < 200 cells/μl
- Uterine cavity significantly distorted by fibroids or structural abnormalities
- Previous trachelectomy
- Efficacy & InteractionsBoth devices are highly effective immediately upon postpartum insertion, and their efficacy is unaffected by enzyme-inducing drugs.
- Cu-IUD: 0.6–0.8% failure rate in the first year; lasts 5 or 10 years (device-dependent).
- LNG-IUS: 0.2% failure rate in the first year; lasts 5 years.
- Bleeding PatternsBleeding profiles differ significantly between the two devices:
- Cu-IUD: Bleeding is often heavier, longer, and more painful, though the overall pattern usually remains unchanged.
- LNG-IUS: Bleeding is initially erratic, but typically becomes light over the first year of use and may lead to amenorrhoea.
- Follow-upEssential discharge information for intrauterine contraception users:
- How to check for threads and the possibility of encountering long threads.
- How to access clinical review for pain, abnormal bleeding, or very long/missing threads.
- Clear documentation of the replacement date.
Postpartum LARC Comparison Profile
| Feature | Copper IUD (Cu-IUD) | 52 mg Levonorgestrel IUS (LNG-IUS) | Etonogestrel Implant (ENG-IMP) |
|---|---|---|---|
| Insertion Window | At Caesarean section, immediately after vaginal birth, or up to 48 hours postpartum. | At Caesarean section, immediately after vaginal birth, or up to 48 hours postpartum. | Immediately after birth or any time prior to discharge. Effective immediately if inserted by day 21. |
| Absolute Contraindications | Postpartum sepsis, history of STI in current pregnancy, current pelvic TB, current GTD, cervical/endometrial cancer in current pregnancy, copper allergy, Wilson's disease. | Allergy to content, postpartum sepsis, history of STI in current pregnancy, current pelvic TB, current GTD, breast/endometrial/cervical cancer in current pregnancy. | None listed as absolute, but see potential contraindications. |
| Potential Contraindications / Cautions | Heavy menstrual bleeding, anaemia, organ transplant complications, long QT syndrome, previous trachelectomy, uterine cavity distorted by fibroids/structural abnormality, HIV with CD4 < 200 cells/µl. | Previous breast cancer, previous arterial thromboembolic event during use, decompensated cirrhosis, hepatocellular adenoma/carcinoma, organ transplant complications, long QT, HIV with CD4 < 200, distorted uterine cavity, previous trachelectomy. | Previous arterial thromboembolic event during use, previous breast cancer, decompensated cirrhosis, hepatic adenoma or adenocarcinoma. |
| Failure Rate (Year 1) | 0.6% - 0.8% | 0.2% | 0.05% |
| Enzyme-Inducing Drug Interactions | No effect on efficacy. | No effect on efficacy. | May reduce contraceptive effectiveness. |
| Duration of Use | 5 or 10 years (device-dependent). | 5 years. | 3 years. |
| Bleeding Profile | Often heavier, longer, and more painful; baseline pattern usually unchanged. | Initially erratic; likely to become light over the first year; may lead to amenorrhoea. | Unpredictable bleeding pattern. |
| Key User Education | How to check threads, risk of long threads, how to access review for pain/bleeding, replacement date. | How to check threads, risk of long threads, how to access review for pain/bleeding, replacement date. | How to feel for implant, how to access review for bleeding/non-palpability, drug interactions, replacement date. |
4Postpartum Progestogen-Only Contraception (Implant, POP, & DMPA)
Fast facts and clinical reference profiles for the safe initiation of the etonogestrel implant (ENG-IMP), desogestrel progestogen-only pill (POP), and depot medroxyprogesterone acetate (DMPA) after childbirth.
- Timing & EfficacyAll three progestogen-only methods can be started immediately after birth.
- If initiated by day 21 postpartum, no additional contraceptive precautions are required, and they are effective immediately.
- ENG-IMP: Can be inserted immediately after birth or at any time prior to discharge by trained staff. First-year failure rate is 0.05%.
- Desogestrel POP: Taken daily at the same time. First-year failure rate is 0.3% with perfect use and 9% with typical use. A National Reproductive Health PGD template is available for supply.
- DMPA (IM or SC): Administered immediately after birth and repeated every 13 weeks. First-year failure rate is 0.2% with perfect use and 6% with typical use.
- Drug InteractionsEfficacy susceptibility to enzyme-inducing medications varies by method:
- ENG-IMP: Efficacy may be affected by enzyme-inducing drugs.
- Desogestrel POP: Efficacy may be affected by enzyme-inducing drugs and conditions impairing gastrointestinal absorption.
- DMPA: Efficacy is NOT affected by enzyme-inducing drugs.
- POP Missed Pill RulesDesogestrel POP has a 12-hour missed-pill window.
- The pill can be taken up to 12 hours late without loss of contraceptive efficacy.
- Subsequent pills should be taken at the regular scheduled time.
- DMPA Self-AdministrationSubcutaneous DMPA (SC-DMPA) supports remote care pathways:
- Users can be taught to self-administer SC-DMPA at home to avoid additional in-person healthcare contact.
- Injection training can be conducted virtually via video link.
- ContraindicationsContraindications and potential contraindications for progestogen-only methods:
- Current breast cancer is an absolute contraindication for POP and DMPA, and a potential contraindication for ENG-IMP (or previous breast cancer for all three).
- Potential contraindications common to ENG-IMP, POP, and DMPA: Previous arterial thromboembolic event during use, decompensated cirrhosis, and hepatic adenoma or adenocarcinoma.
- DMPA-specific potential contraindications: Multiple cardiovascular disease (CVD) risk factors or established cardiovascular/cerebrovascular disease.
Comparison of Postpartum Progestogen-Only Contraception
| Parameter | Etonogestrel Implant (ENG-IMP) | Desogestrel POP | Depot MPA (DMPA) |
|---|---|---|---|
| First-Year Failure Rate | 0.05% | 0.3% (perfect) / 9% (typical) | 0.2% (perfect) / 6% (typical) |
| Duration of Action | 3 years | Daily (12-hour late window) | 13 weeks (can self-administer SC) |
| Enzyme-Inducer Interaction | May affect effectiveness | May affect effectiveness | No effect on effectiveness |
| Bleeding Pattern | Unpredictable | Unpredictable | Erratic initially, then light or amenorrhoeic |
| Key Follow-up Info | How to feel for implant; what to do if non-palpable | Missed pill rules (including vomiting instructions) | Date of next injection; self-administration support |
5Follow-up and Complication Pathways
While implants and POPs require no routine follow-up, intrauterine devices require clear pathways for managing potential complications such as lost threads, long threads, or expulsion.
- ENG-IMP / POPNo routine follow-up is required after postpartum initiation of the etonogestrel implant (ENG-IMP) or desogestrel progestogen-only pill (POP).
- IUCIntrauterine Contraception (IUC) requires active safety netting for pain, bleeding, or expulsion.
- Clear local pathways must be established to manage common post-insertion problems, and women must be advised on how to access them.
- RECWomen should receive clear information about how to use their contraception and when to seek medical advice.
- RECProtocols for timely offer and provision of contraception should be put in place to prevent delay in discharge from maternity services.
- Administering and dispensing contraception must not disrupt discharge; community pharmacies and other options should be explored if delays are anticipated.
IUC Troubleshooting Pathways (COVID-19 Model)
| Problem | Immediate Advice to User | Clinical Pathway / Action |
|---|---|---|
| Unable to feel threads | Use condoms immediately. | Contact local contraceptive provider for a supply of POP; contact local Sexual and Reproductive Healthcare (SRH) service or GP to arrange an ultrasound scan. |
| Very long threads | Do not pull threads. Trim threads to the vaginal entrance and use condoms. | Contact local contraceptive provider for POP; contact local SRH service to arrange review and further trimming (may be deferred depending on circumstances). |
| Expulsion | Use condoms immediately. | Contact local contraceptive provider for a supply of POP; if local services cannot offer immediate re-insertion due to restrictions, obtain a bridging supply of POP. |