Contraception after pregnancy and abortion

01Role and principlesWho benefits and the main preventive aims.

Fertility return is faster than many people expect. After abortion, ovulation may occur within weeks. After birth, pregnancy risk is very low during the first 21 days but then rises, and ovulation can precede menstruation. A six-week check is therefore too late to be the first contraception conversation for many patients.

Breastfeeding is not a single contraceptive state. LAM is effective only while all three conditions remain: under six months postpartum, no menses and fully or nearly fully breastfeeding with no long gaps. Formula supplementation, reduced frequency or return of bleeding ends reliable reliance. Contraceptive safety also differs from contraceptive effect on lactation and from VTE risk.

Immediate provision reduces access barriers. Implant, POP and DMPA can start after birth with exact UKMEC distinctions. IUC can be placed post-placentally or within 48 hours, but expulsion counselling matters; if not inserted then, the routine next window begins at four weeks. After abortion, most methods can start immediately and do not impair future fertility.

Key points

Discuss contraception during pregnancy or abortion care and provide the chosen method before discharge whenever clinically possible; fertility can return before the next period.
After childbirth, contraception is needed from day 21 unless the patient is less than six months postpartum, remains amenorrhoeic and is fully or nearly fully breastfeeding at effective frequency.
Insert an IUD immediately to 48 hours postpartum or from four weeks; the 48-hour to under-four-week interval is UKMEC 3, and postpartum sepsis is category 4.
POP and implant can start immediately postpartum. While breastfeeding before six weeks, each is UKMEC 1, whereas DMPA is category 2.
For breastfeeding CHC, use UKMEC 4 before six weeks, category 2 from six weeks to under six months and category 1 from six months, then add any other VTE or medical risk.
For non-breastfeeding CHC before three weeks, category is 4 with another VTE risk and 3 without; from three to under six weeks it is 3 with risk and 2 without; from six weeks it is 1 on timing alone.
After first- or second-trimester abortion, offer immediate implant, injection, POP or CHC if otherwise eligible; an IUD can be inserted immediately unless sepsis is present, with higher expulsion after later gestation discussed.

02Assessment and patient selectionRisk features, eligibility and important cautions.

Day-21 transitionRed flag

Unprotected sex from day 21 postpartum can create pregnancy risk unless every LAM criterion remains satisfied.

Effective LAM

Less than six months postpartum, amenorrhoea and fully or nearly fully breastfeeding must all coexist.

IUD timing gap

From 48 hours to under four weeks postpartum is category 3 rather than a routine insertion window.

Postpartum sepsisRed flag

Endometritis or puerperal sepsis makes immediate intrauterine insertion category 4 and needs treatment.

Post-abortion fertility

Ovulation can return before the next expected menses, making same-day provision particularly useful.

Red flags requiring action

Contraception is required from day 21 after childbirth unless all lactational amenorrhoea criteria are met: under six months, amenorrhoeic and fully or nearly fully breastfeeding.
Postpartum IUD insertion is UKMEC 1 at 0–48 hours, category 3 from 48 hours to under four weeks, category 1 from four weeks and category 4 with postpartum sepsis.
Breastfeeding CHC is UKMEC 4 before six weeks, category 2 from six weeks to under six months and category 1 from six months on feeding status alone.
Implant and POP are UKMEC 1 while breastfeeding in the first six weeks; DMPA is category 2, so each progestogen method retains its own classification.
After abortion, immediate contraception is usually possible; IUD insertion is category 1 after first-trimester abortion, category 2 after second-trimester abortion and category 4 with post-abortion sepsis.

03Baseline assessmentMeasurements that guide the plan and track progress.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Pregnancy and abortion chronologyFirst step
Why
Establish delivery or abortion date, gestation, complications and current pregnancy risk.
Interpretation and limitations
Use exact elapsed days and recent sex, because day 21 and the 48-hour or four-week IUD boundaries are categorical.
02
Feeding and amenorrhoea assessment
Why
Determine whether all LAM criteria are present and whether breastfeeding alters CHC classification.
Interpretation and limitations
Any return of menses, age at least six months or reduced feeding frequency ends reliable LAM use.
03
VTE and medical eligibility review
Why
Classify postpartum CHC and identify safe non-oestrogen alternatives.
Interpretation and limitations
Breastfeeding and postpartum timing are only some factors; thrombosis, smoking, migraine, hypertension and medicines add separate categories.
04
Sepsis and uterine assessment
Why
Identify infection that contraindicates immediate IUD placement.
Interpretation and limitations
Postpartum or post-abortion sepsis is category 4; treat first and provide another method while planning later insertion.

04InterventionsLifestyle, treatment and escalation options.

01Antenatal pathwayChoose and document before birthFirst stepA pregnant person wants to avoid or space another pregnancy.

1Discuss reproductive goals, breastfeeding plans, effectiveness, bleeding, reversibility and procedure preferences antenatally.
2Arrange post-placental IUD, immediate implant, POP or DMPA access and document who will provide it.
3Provide a backup plan if birth circumstances prevent the intended method, avoiding reliance on a distant routine visit.

02Postpartum pathwayUse exact timing and feeding rulesA patient requests contraception at any time after childbirth.

1At 0–48 hours offer eligible immediate methods, including trained post-placental IUC, and explain expulsion.
2From 48 hours to under four weeks use an interim method rather than routine IUD insertion; from four weeks reassess IUC eligibility.
3From day 21 ensure contraception or valid LAM, applying breastfeeding and VTE categories before any CHC.

03Post-abortion pathwayStart before fertility returnsMedical or surgical abortion has been completed and the patient wants contraception.

1Offer immediate POP, implant, injection or CHC when medically eligible and coordinate timing with the abortion medicine regimen.
2Insert IUC immediately after surgical abortion or after confirmed completion of medical abortion when suitable; do not insert with sepsis.
3Explain bleeding, expulsion, follow-up pregnancy testing and how to access removal or switching without delay.

05Medicines and treatment safetyRegimens, contraindications and review points.

Prevents pregnancy before ovulation returns and avoids oestrogen-related early postpartum VTE risk.

Immediate postpartum progestogen-only contraception

Start the chosen POP daily, insert the implant once or give DMPA at the product dose after birth; apply formulation-specific backup and UKMEC rules.

During breastfeeding under six weeks, implant and POP are category 1 while DMPA is category 2; review bleeding, interactions and future fertility plans.

Provides reversible contraception and cycle-related benefits later postpartum for suitable users.

Postpartum combined hormonal contraception

Begin pill, patch or ring only after the exact breastfeeding, postpartum interval and VTE-risk category makes CHC eligible, then use product-specific initiation instructions.

Breastfeeding before six weeks is category 4; non-breastfeeding timing and additional VTE factors create separate categories before six weeks.

06Targets, monitoring and follow-upResponse, safety and longer-term review.

Confirm that an immediate method was actually administered or inserted rather than merely selected on an antenatal form.
After post-placental IUC, counsel about higher expulsion risk, thread changes and pregnancy symptoms, and arrange local follow-up.
Reassess LAM whenever feeding frequency changes, menses returns or six months postpartum is reached.
After quick start following recent sex, arrange a pregnancy test 21 days after the latest exposure and provide ectopic safety-net advice.

07Special situationsVariants, exceptions and circumstances that change the usual approach.

Amenorrhoea alone is insufficient

LAM fails as a rule if feeding is not full or near-full, or once six months have elapsed.

Immediate and early differ

IUD placement inside 48 hours is category 1, while the next weeks until four are category 3.

Progestogens remain distinct

Implant and POP are category 1 in early breastfeeding, whereas DMPA is category 2.

Abortion does not delay fertility

Same-day provision prevents an access gap without harming the ability to conceive after method cessation.

08Common pitfallsFrequent interpretation and management errors.

01
Waiting for the six-week check before first discussing contraception.
02
Calling any breastfeeding pattern reliable contraception.
03
Inserting an IUD routinely at two weeks postpartum.
04
Using CHC before six breastfeeding weeks.
05
Failing to provide the method documented in the discharge plan.

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