Synopsis
Provide contraception across rapid fertility transitions after birth, abortion or pregnancy loss and through perimenopause, using correct start windows, thrombosis assessment and stopping rules.
- Discuss postpartum contraception antenatally and provide the chosen method before discharge where possible; fertility intention and consent must be revisited after birth rather than assumed.
- The implant and POP can start immediately after childbirth. DMPA can also be provided postpartum when medically eligible, with bleeding, bone and fertility-return counselling.
- Insert a copper or levonorgestrel IUD within 48 hours of birth, including at caesarean, or wait until at least four weeks postpartum if that immediate window is missed.
- Before three weeks postpartum, CHC is UKMEC 4 with additional VTE factors and 3 without them; breastfeeding makes CHC category 4 until six weeks. From three to six weeks, apply the current category rather than a calendar rule alone.
- All contraceptive methods can generally be started immediately after abortion or pregnancy loss when clinically appropriate; immediate provision prevents loss to follow-up and does not impair future fertility.
- Emergency contraception is considered from day 21 after birth unless strict lactational-amenorrhoea criteria apply, and from day 5 after abortion, miscarriage, ectopic treatment or uterine evacuation.
- In perimenopause, HRT is not contraception. Eligible nonsmokers may use CHC until age 50; POP, implant and suitable intrauterine methods can continue longer under method-specific rules.
- Without hormonal contraception, stop after two years of amenorrhoea if under 50, one year if 50 or older, or at age 55 when spontaneous conception is exceptionally rare.
Key red flags
Heavy bleeding, fever, offensive discharge, severe pelvic pain or systemic illness after birth or abortion may indicate haemorrhage, retained tissue, endometritis or sepsis and needs urgent assessment before routine contraceptive care.
Unilateral leg swelling, chest pain or sudden breathlessness postpartum may represent venous thromboembolism; do not start oestrogen and arrange emergency assessment.
A positive pregnancy test with pain or bleeding after abortion or miscarriage may represent persisting pregnancy, retained tissue, ectopic pregnancy or a new conception and requires prompt location assessment.
New postcoital, persistent intermenstrual or postmenopausal bleeding in perimenopause requires diagnostic assessment rather than being labelled a normal hormonal transition.
Investigation priorities
Determine immediate initiation, emergency contraception and repeat-testing requirements after pregnancy.
Management branches
Contraception is requested antenatally or after childbirth.
- Reconfirm reproductive intention and medical eligibility after birth, including breastfeeding, VTE factors, bleeding and whether the patient still wants the antenatal choice.
- Offer immediate POP, implant or eligible DMPA, or intrauterine placement within 48 hours; if that IUD window is missed, arrange insertion from four weeks.
- Delay CHC for at least 21 days and longer when breastfeeding or thrombosis factors require it, using an effective bridge and exact start precautions.
An abortion, miscarriage or ectopic pregnancy has been managed and contraception is wanted.
- Offer all suitable methods before discharge and verify completion when intrauterine insertion follows a medical process.
- Start pills, implant or injection immediately and insert an IUD at surgical treatment or after completion according to the service pathway.
- If initiation occurs more than five days after pregnancy ends, apply method-specific backup and assess intercourse from day 5 for emergency contraception.