Postpartum Contraception in Breastfeeding

Explanation

Two considerations govern contraception in the early puerperium: the postpartum hypercoagulable state and the effect of exogenous oestrogen on milk production. Oestrogen-containing methods, whether pill, patch or vaginal ring, raise venous thromboembolism risk exactly when it peaks, so all combined hormonal contraception is category 4 in breastfeeding women less than 21 days postpartum and category 3 from 21 to 30 days. Progestogen-only methods carry no thrombotic penalty and do not reduce milk supply, so the progestogen-only pill is category 2 at 2 weeks and can be started today without delay. It is also fully reversible, which suits a woman who has not yet chosen a long-term method. A diaphragm cannot be fitted at 2 weeks because uterine involution and the return of normal vaginal anatomy are incomplete, and fitting is deferred until about 6 weeks postpartum. Intrauterine devices are best inserted within 10 minutes of placental delivery or from 4 weeks onward, since insertion in between carries higher expulsion rates. Depot medroxyprogesterone acetate and the etonogestrel implant are also acceptable while breastfeeding, so the true discriminators here are oestrogen exposure and correct timing rather than the progestogen itself. Lactational amenorrhoea protects only while a woman is fully breastfeeding, amenorrhoeic and less than 6 months postpartum, and it fails as soon as any of those conditions lapses. Combined methods can be introduced later, generally after 6 weeks in a breastfeeding woman, once lactation is established and thrombotic risk has fallen.

Why each option

A.

Combined pills are category 4 before 21 days postpartum in a breastfeeding woman because of venous thromboembolism risk and reduced milk supply.

B.

The vaginal ring delivers the same oestrogen and carries the identical thrombotic and lactation objections as the combined pill.

C.

A diaphragm cannot be fitted until about 6 weeks postpartum, when uterine involution is complete and the fit is reliable.

D.

Correct. The progestogen-only pill is safe in breastfeeding at any time postpartum, has no thrombotic contraindication, and can be started today.

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