Counseling Outline

Highly effective for up to 6 months if fully breastfeeding and no menstrual bleeding (amenorrheic).

Gives time to choose and arrange for surgical or other contraceptive methods.

Effectiveness declines as weaning takes place or breastfeeding is supplemented.

• should not be used during the first 6–8 weeks postpartum. (WHO class 4)
• should be avoided from 6 weeks to 6 months postpartum unless other more appropriate methods are not available or acceptable. (WHO class 3)

If using LAM, delay for 6 months. Start COCs or CICs when weaning begins. (WHO class 2)

If not breastfeeding, COCs or CICs can be started after 3 weeks postpartum.

During the first 3 weeks postpartum, the estrogen in COCs and CICs slightly increases the risk of blood clotting problems.

If client has resumed menses and sexual activity, start COCs or CICs only if reasonably sure she is not pregnant.

COCs and CICs may be given for women who were pre-eclamptic or had hypertension during pregnancy as long as BP is in normal range when starting COCs or CICs.

There is no increased risk of blood clotting beyond the 3rd week postpartum.

If using LAM, POCs may be delayed until 6 months postpartum. (WHO class 1)

If not breastfeeding, can be started immediately.

If not breastfeeding and more than 6 weeks postpartum or already menstruating, start POCs only if reasonably sure the woman is not pregnant. (WHO class 1)

No effect on quantity or quality of breastmilk or health of infant.  

If not inserted postplacentally or within 48 hours postpartum, insertion should be delayed until 4–6 weeks postpartum. (WHO class 3)

If breastfeeding and menses have resumed, insert only if reasonably sure the client is not pregnant.

Fewer postinsertion side effects (bleeding, pain) when IUD inserted in breastfeeding women.

Clients should be screened and counseled during prenatal period for postplacental insertion.

First year IUD removal rates are lower among breastfeeding women.

Spontaneous expulsion rate higher (6–10%) than for interval insertion (lowest rates if inserted high in fundus within 10 minutes after placenta delivered).

After 4–6 weeks postpartum, the provider does not have to be trained in postpartum IUD insertion (technique same as for interval client).

Useful as interim methods if initiation of another chosen method must be postponed.

Use of spermicides helps overcome vaginal dryness during intercourse (common problem in breastfeeding women).

Basal body temperature fluctuates when mother awakens at night to breastfeed. Thus, measuring "early morning" basal body temperature elevation after ovulation may not be reliable.

Acceptable in cultures in which postpartum abstinence is traditional.

Counsel the couple about the need for a backup method if they decide to resume intercourse.

If not performed within 48 hours, should be delayed until 6 weeks postpartum.

Ideal timing: After recovery from delivery and once the health of the infant is more certain.

Postpartum minilaparotomy is easiest to perform within first 48 hours of delivery because the position of the uterus makes the fallopian tubes easier to find and see.

Ideally, counseling and informed consent should take place prior to labor and delivery (during prenatal period).

Ideal timing: Once the health of the infant is more certain.