Eduovisual
Pregnancy, Childbirth & Puerperium
Contraception: postpartum and lactation-compatible options
— Short interpregnancy interval (<18 months) is associated with preterm birth, low birth weight, placental abruption, and maternal anemia; <6 months carries the highest risk.
— Ovulation can resume as early as 25 days postpartum in non-lactating women; first ovulation often precedes first menses, so unprotected intercourse before contraception is initiated risks unintended pregnancy.
— ~50% of postpartum pregnancies in the US are unintended; ACOG recommends contraceptive counseling during prenatal care, not just at the 6-week visit.
— Patient declined a plan antenatally, missed the postpartum visit, or is breastfeeding and assumes "lactation = contraception."
— Adolescents, patients with limited follow-up access, those with prior unintended pregnancy, and patients with medical comorbidities (cardiac disease, diabetes, hypertension) where another pregnancy carries elevated risk.
— Ask about reproductive goals (One Key Question: "Would you like to become pregnant in the next year?").
— Assess lactation status and intentions.
— Screen for VTE risk factors, hypertension, migraine with aura, smoking, and breast cancer history.
— Apply CDC US Medical Eligibility Criteria (US MEC) categories 1–4.
Board pearl: The lactational amenorrhea method (LAM) is only ~98% effective when all three criteria are met: exclusive breastfeeding, amenorrhea, and infant <6 months old—miss any one and efficacy drops sharply.
— A 28-year-old G2P2 at her 6-week postpartum visit, exclusively breastfeeding, asking about birth control.
— A 32-year-old 2 days postpartum after uncomplicated vaginal delivery requesting an IUD before discharge.
— A 35-year-old with chronic hypertension or migraine with aura, formula-feeding, asking about "the pill."
— A patient with history of DVT in pregnancy now 3 weeks postpartum.
— An adolescent who delivered, lives far from clinic, and wants a "set-and-forget" option.
— Delivery details: mode (vaginal vs cesarean), date, complications (hemorrhage, preeclampsia, infection, retained products).
— Lactation: exclusive vs partial vs formula; plans for duration; milk supply concerns.
— VTE risk factors: prior VTE, thrombophilia, obesity, smoking, age ≥35, immobility, cesarean.
— Cardiovascular: hypertension (chronic or gestational), preeclampsia, peripartum cardiomyopathy.
— Neurologic: migraine with aura (absolute contraindication to combined hormonal contraception).
— Reproductive goals and partner involvement.
— Prior contraceptive experience, side effects, adherence patterns.
— Medications: anticoagulants, antiepileptics (enzyme inducers reduce efficacy of pills, patch, ring, implant).
— STI risk: dual protection counseling.
— Postpartum hemorrhage with anemia → avoid copper IUD initially if heavy menses anticipated.
— Active sepsis, chorioamnionitis, or endometritis → defer IUD insertion.
— Hypertension uncontrolled → avoid estrogen-containing methods (US MEC 3–4).
Key distinction: Breastfeeding status alone does not contraindicate progestin-only methods (pills, implant, DMPA, LNG-IUD)—these are US MEC 1–2 in lactation. It is combined hormonal contraception (estrogen-containing) that is restricted, primarily due to VTE risk in the first 21–42 days and theoretical effects on milk supply.
Step 3 management: Always pair the history with the US MEC chart—the exam rewards recognition that a single condition (e.g., migraine with aura) can shift a method from "preferred" to "absolutely avoid."
— Blood pressure: essential before prescribing any estrogen-containing method. BP ≥160/100 is US MEC 4 for combined methods.
— BMI: obesity (BMI ≥30) is US MEC 2 for combined hormonal contraception in the postpartum period due to additive VTE risk.
— Signs of VTE: unilateral calf swelling, tenderness, erythema, pleuritic chest pain, dyspnea—must be ruled out before estrogen.
— Assess for engorgement, mastitis, nipple trauma if breastfeeding.
— Palpable mass → defer hormonal contraception pending workup; current breast cancer is US MEC 4 for all hormonal methods.
— Assess uterine involution; subinvolution or tenderness suggests endometritis or retained products → defer IUD.
— For immediate postpartum IUD (within 10 minutes of placental delivery) or early postpartum IUD (10 min to 4 weeks), uterine size and position guide insertion technique.
— After 4 weeks, interval IUD insertion follows standard technique; expulsion rates are lowest with interval placement and highest with immediate placement (~10–27%) but absolute attendance and continuation favor immediate.
— Incision healing assessment if considering tubal procedures or delayed IUD.
— Postpartum tubal ligation is often performed at the time of cesarean or via mini-laparotomy within 48 hours of vaginal delivery.
— Latch, milk transfer, infant weight gain inform whether progestin timing might matter (most evidence shows no clinically significant impact on supply).
Board pearl: Document a baseline BP at every postpartum contraception visit; a normotensive antenatal patient may have persistent postpartum hypertension (peaks days 3–6), which reclassifies estrogen-containing methods from MEC 1 to MEC 3–4.
Step 3 management: If exam reveals endometritis (fever, uterine tenderness, foul lochia), treat with IV clindamycin + gentamicin and defer IUD insertion until infection resolves—IUD in active pelvic infection is US MEC 4.
— Blood pressure measurement for all hormonal methods (mandatory before combined hormonal contraception).
— Pregnancy assessment: confirm not pregnant using the CDC "reasonably certain not pregnant" criteria (no intercourse since last menses, correct/consistent contraception use, within 7 days of menses, within 4 weeks postpartum, fully breastfeeding/amenorrheic/<6 months postpartum, or within 7 days of abortion).
— Pelvic exam is not required for pills, patch, ring, implant, or DMPA.
— Pap smear, STI testing, breast exam, glucose, lipids, LFTs, thrombophilia panel are not routine prerequisites.
— Pelvic/bimanual exam is required before IUD insertion (to assess uterine size, position, and rule out infection).
— STI screening (GC/CT NAAT) at the time of IUD insertion if patient is at risk (age <25, new/multiple partners); can insert IUD same-day and treat if positive.
— Hemoglobin/hematocrit if heavy postpartum bleeding or anemia symptoms—influences method (avoid copper IUD if severe menorrhagia anticipated).
— Lipid panel and HbA1c in patients with diabetes or cardiovascular risk before estrogen-containing methods.
— Confirm timing since delivery—drives US MEC category for combined methods (CHC):
– <21 days postpartum: MEC 4 (avoid) regardless of breastfeeding.
– 21–42 days postpartum with VTE risk factors (age ≥35, smoking, BMI ≥30, prior VTE, preeclampsia, cesarean, transfusion): MEC 3.
– ≥42 days postpartum, no breastfeeding, no risks: MEC 1.
Key distinction: Pregnancy testing is not required if any of the CDC "reasonably certain not pregnant" criteria are met—do not delay initiation waiting for menses. This is the "Quick Start" approach and is heavily tested.
Step 3 management: When in doubt, start the method today and use backup contraception for 7 days; recheck pregnancy in 2–4 weeks if uncertainty persists. Delays drive unintended pregnancy more than false starts.
— Immediate postplacental: within 10 minutes of placental delivery (vaginal or cesarean). Highest expulsion rate (~10–27%) but highest uptake and continuation. Endorsed by ACOG.
— Early postpartum: 10 minutes to 4 weeks. Higher expulsion than interval but still beneficial.
— Interval: ≥4 weeks postpartum. Standard expulsion rate (~3–5%).
— Avoid insertion between 48 hours and 4 weeks in non-immediate scenarios due to elevated perforation/expulsion risk.
— Puerperal sepsis, postseptic abortion, current PID, current cervical cancer, current breast cancer (LNG-IUD), distorted uterine cavity, unexplained vaginal bleeding pre-evaluation.
— Active pelvic TB, gestational trophoblastic disease with persistent elevated β-hCG.
— Can be placed any time postpartum, including immediately after delivery before hospital discharge—MEC 1 regardless of breastfeeding.
— MEC 2 if breastfeeding and <1 month postpartum (theoretical concern about neonatal exposure, no clinical evidence of harm).
— MEC 1 if ≥1 month postpartum or not breastfeeding.
— Breastfeeding: MEC 4 (<21 days), MEC 3 (21–30 days), MEC 2–3 (30–42 days depending on risks), MEC 2 (>42 days).
— Non-breastfeeding: MEC 4 (<21 days), MEC 3 (21–42 days with VTE risk), MEC 2 (21–42 days no risk), MEC 1 (>42 days no risk).
— Postpartum bilateral tubal ligation (BTL) requires informed consent, ideally obtained antenatally; Medicaid requires signed consent ≥30 days before procedure (and not >180 days).
Board pearl: The 21-day mark is the universal cutoff—before 21 days postpartum, never start estrogen-containing contraception regardless of breastfeeding, because peripartum hypercoagulability persists.
CCS pearl: Order "Contraception counseling" and "Postpartum visit" at appropriate intervals; the CCS clock rewards early antenatal documentation of method choice.
— Tier 1 (most effective, <1% failure with typical use): copper IUD, LNG-IUDs, etonogestrel implant, sterilization.
— Tier 2 (6–12% typical-use failure): DMPA injection, pills, patch, ring.
— Tier 3 (18–28% failure): condoms, diaphragm, withdrawal, fertility awareness.
— Step 1: Elicit patient preferences (frequency of use, hormone tolerance, bleeding pattern, future fertility timing).
— Step 2: Apply medical eligibility via US MEC—identify any MEC 3 or 4 conditions that exclude estrogen.
— Step 3: Layer lactation status onto the framework.
— Step 4: Discuss reversibility, side-effect profile, and STI protection (dual method counseling).
— LARC: LNG-IUD, copper IUD, etonogestrel implant.
— Progestin-only pill (POP), DMPA, LAM (if criteria met).
— Barrier methods, sterilization.
— Migraine with aura (any age).
— Hypertension, especially uncontrolled.
— Smoking + age ≥35.
— History of VTE, known thrombophilia.
— Active or recent breast cancer (avoid all hormonal: choose copper IUD or barrier).
— Peripartum cardiomyopathy, complicated valvular disease.
— Lupus with antiphospholipid antibodies.
— Estrogen contraindicated AND patient wants to avoid hormones, or wants emergency contraception (most effective EC within 5 days).
Key distinction: Breast cancer (current or past) is MEC 4 for all hormonal contraception including progestin-only methods—copper IUD is the only first-line hormonal-free LARC.
Step 3 management: Use a shared decision-making aid; document method, counseling, and backup plan. Avoid "method bias"—do not push LARC on adolescents or marginalized patients without explicit preference (reproductive justice consideration).
— Dose: 1 tablet daily at the same time (within a 3-hour window); if late, use backup for 48 hours.
— Ideal for breastfeeding, VTE risk, or estrogen-intolerant patients.
— Newer drospirenone 4 mg POP has a 24-hour window—more forgiving.
— Initiate any time postpartum, including immediately.
— 150 mg IM or 104 mg SC every 11–13 weeks.
— Breastfeeding: MEC 2 if <1 month, MEC 1 thereafter; many providers give first dose before hospital discharge for high-risk patients.
— Side effects: irregular bleeding (most common reason for discontinuation), weight gain, reversible bone density loss (BBW—reassess after 2 years, but ACOG advises not limiting duration based on BMD alone).
— Return to fertility delayed up to 10 months after last dose—counsel patients planning pregnancy soon.
— Single rod, 3 years of efficacy (FDA-approved; evidence supports up to 5 years).
— Insert subdermally in non-dominant upper arm; can be placed immediately postpartum.
— Most effective reversible method (failure ~0.05%).
— Main side effect: unpredictable bleeding—counsel extensively to improve continuation.
— Mirena/Liletta: 52 mg, 8 years (Mirena), 8 years (Liletta).
— Kyleena: 19.5 mg, 5 years; Skyla: 13.5 mg, 3 years.
— Reduce menstrual blood loss; ~20% amenorrhea at 1 year (52 mg).
— Non-hormonal, 10–12 years of efficacy.
— Increases menstrual blood loss and cramping; avoid in anemic or dysmenorrhea-prone patients.
Board pearl: Etonogestrel implant + LNG-IUD are the two most effective reversible methods, both safe immediately postpartum, both lactation-compatible (MEC 1–2). When the stem says "wants most effective, breastfeeding, immediate"—pick one of these.
— Includes combined oral contraceptive pills (COCs), transdermal patch (norelgestromin/EE), vaginal ring (etonogestrel/EE or segesterone/EE annual ring).
— Non-breastfeeding, no VTE risk: start at ≥21 days postpartum.
— Non-breastfeeding, with VTE risk: wait until ≥42 days.
— Breastfeeding: generally avoid until ≥30 days (MEC 3) and prefer waiting until ≥6 weeks if any risk; many clinicians defer until well-established lactation.
— Estrogen + progestin → suppress LH/FSH → inhibit ovulation; progestin thickens cervical mucus and thins endometrium.
— Estrogen reduces breakthrough bleeding and stabilizes cycle but increases VTE risk 3–4×.
— Enzyme inducers: rifampin, rifabutin, phenytoin, carbamazepine, oxcarbazepine, topiramate (>200 mg/day), barbiturates, primidone, St. John's wort.
— Some HIV antiretrovirals (efavirenz, ritonavir-boosted regimens).
— DMPA and IUDs are not affected by enzyme inducers—preferred in patients on antiepileptics.
— Copper IUD within 5 days—most effective (>99%).
— Ulipristal acetate 30 mg PO once within 120 hours—may transiently suppress lactation, advise pumping and discarding milk for 24 hours per some guidelines.
— Levonorgestrel 1.5 mg PO within 72 hours—lactation-compatible.
— From CHC to LARC: insert any time; if active pills taken in past 7 days, no backup needed.
— From DMPA to IUD/implant: insert at the time of next scheduled injection.
Step 3 management: If a patient on lamotrigine wants contraception, choose a non-estrogen method—estrogen induces lamotrigine glucuronidation and reduces serum levels, risking seizure breakthrough; cyclic pill changes can cause toxicity during pill-free week.
Key distinction: Progestin-only methods do NOT increase VTE risk—they are safe in patients with prior VTE, thrombophilia, or on anticoagulation.
— Adequately controlled: CHC is MEC 3 (avoid if possible).
— BP 140–159/90–99: MEC 3 for CHC.
— BP ≥160/100 or vascular disease: MEC 4 for CHC.
— All progestin-only methods and copper IUD: MEC 1–2.
— Uncomplicated DM: all methods MEC 1–2.
— DM with nephropathy, retinopathy, neuropathy, or >20 years duration: CHC is MEC 3–4; progestin-only and IUDs are MEC 2.
— CHC: MEC 4.
— On anticoagulation: all progestin methods safe; LNG-IUD reduces heavy menstrual bleeding common on anticoagulants.
— With aura, any age: CHC is MEC 4 (stroke risk).
— Without aura, age <35: CHC MEC 2; age ≥35: MEC 3.
— Peripartum cardiomyopathy with normal function >6 months: CHC MEC 3; with reduced function: MEC 4.
— Ischemic heart disease, stroke history: CHC MEC 4; progestin-only MEC 2–3.
— Acute hepatitis, severe cirrhosis, hepatocellular adenoma/carcinoma: CHC MEC 4; progestin-only MEC 3.
— Copper IUD is unaffected.
— All methods MEC 1–2; patch may be less effective at BMI >90 kg; implant and IUDs maintain efficacy.
— All methods compatible; some patients report mood effects with progestin—monitor and switch if needed.
— All methods generally safe; check ART interactions; DMPA and IUDs preferred with enzyme-inducing ART.
Board pearl: A breastfeeding patient with gestational hypertension that persisted past 6 weeks + age 36 + BMI 32 → CHC is MEC 3–4; choose LNG-IUD or implant.
Step 3 management: When MEC ≥3 for a desired method, document risk-benefit discussion and offer alternatives; "MEC 3" means risk usually outweighs benefit but is permissible if no alternative—on Step 3, pick the safer alternative.
— LARC is first-line per ACOG and AAP due to efficacy and continuation.
— Confidentiality: most states allow minors to consent to contraception without parental involvement—know your state law.
— DMPA: BMD concern less critical given typically short duration of use; benefits outweigh risks.
— Counsel on dual method (condoms + hormonal) for STI prevention.
— Performed at cesarean or within 48 hours of vaginal delivery via mini-laparotomy.
— Medicaid consent rules: Form must be signed 30–180 days before delivery, patient must be ≥21 years old, must be of sound mind (not in active labor, not under anesthesia influence at signing).
— If consent invalid (e.g., preterm delivery before 30 days elapsed), procedure cannot be performed under Medicaid—offer interval sterilization or LARC.
— Salpingectomy (vs ligation) reduces ovarian cancer risk and is increasingly preferred.
— Counsel on regret risk: highest in patients <30, recently postpartum, after relationship change—~20% express regret long-term.
— Safer, less expensive, more effective than female sterilization; takes effect after ~3 months and post-vasectomy semen analysis.
— Decision-making capacity assessment; involve patient maximally; surrogate consent for permanent sterilization has strict legal protections (court approval often required).
— Use professional medical interpreters; avoid coercion; provide written materials in preferred language.
— Federal law restricts contraceptive coercion; consent must be free and uninfluenced.
Key distinction: ACOG endorses LARC as first-line for adolescents postpartum, but the choice must remain patient-driven—provider should not steer based on age, race, or socioeconomic status (reproductive justice).
Step 3 management: If a 19-year-old Medicaid patient wants postpartum BTL but did not sign consent 30 days prior, offer LARC now and interval BTL later—do not perform the procedure.
— Expulsion: 2–10% interval, up to 10–27% immediate postpartum; check strings at 4–6 weeks.
— Perforation: ~1/1000; higher with breastfeeding and <6 weeks postpartum (uterus softer, smaller).
— Pelvic infection: elevated only in first 20 days post-insertion; screen for GC/CT at insertion in high-risk patients.
— Pregnancy with IUD in place: higher risk of ectopic pregnancy (though absolute ectopic rate is lower than no contraception). Remove IUD if strings visible.
— Lost strings: ultrasound to confirm intrauterine position; if not seen, plain film or CT to rule out perforation.
— Insertion site infection, hematoma, deep insertion (avoid placing too deep—palpate before discharge from procedure).
— Removal difficulty if migrated; imaging-guided removal may be needed.
— Persistent irregular bleeding, weight gain (~5 lb/year average), delayed fertility return, decreased BMD (reversible).
— VTE: 3–4× baseline; postpartum risk is additive.
— MI/stroke: rare but increased in smokers ≥35, hypertension, migraine with aura.
— Cholestasis, gallbladder disease, hepatic adenoma (rare).
— Hypertension induction—recheck BP at 3 months.
— Early CHC may reduce milk supply; switching to progestin-only or delaying CHC mitigates risk.
— Counsel on EC access; teratogenicity of hormonal contraception is not increased—reassure patients who conceive on hormones.
Board pearl: A patient pregnant with an IUD in place has a higher proportion of ectopics than the general population—always rule out ectopic with TVUS and β-hCG before assuming intrauterine.
Step 3 management: Suspected uterine perforation → pelvic ultrasound first; if not seen, abdominal X-ray or CT; refer for laparoscopic retrieval if intraperitoneal.
— Suspected ectopic pregnancy with IUD in place.
— Acute severe abdominal pain after IUD insertion (perforation, expulsion with bleeding).
— Signs of DVT/PE in a patient on CHC: unilateral leg swelling, pleuritic chest pain, dyspnea, hypoxia.
— Acute stroke symptoms in CHC user with migraine with aura.
— Failed IUD insertion (cervical stenosis, anatomic distortion).
— Lost IUD strings with non-visualization on ultrasound.
— Difficult implant removal or deep/migrated implant.
— Patient requesting permanent sterilization—coordinate consent and OR scheduling.
— Persistent abnormal bleeding unresponsive to method change.
— Patients with cardiac disease, prior VTE, thrombophilia, or complex medical conditions for preconception planning and contraception coordination.
— Thrombophilia evaluation in patients with VTE on CHC, or those planning future contraception.
— Co-management of diabetes, thyroid, or pituitary disease affecting contraceptive choice.
— Patients with barriers to follow-up (housing, transportation, insurance).
— Adolescent confidentiality and minor consent navigation.
— Intimate partner violence screening—reproductive coercion is a recognized form of IPV; LARC and injectable methods may be discreet options.
— Postpartum endometritis with hemodynamic instability → admit.
— Suspected septic abortion or pelvic abscess with IUD → admit, IV antibiotics, IUD removal.
— Stable expulsion → outpatient replacement.
CCS pearl: On a CCS case where a postpartum patient on CHC develops calf pain, order Doppler ultrasound STAT, discontinue CHC immediately, and initiate anticoagulation if positive—do not wait for the 6-week visit.
Step 3 management: Document the specific reason for consult, expected timing, and bridge plan (e.g., barrier method while awaiting LARC insertion).
— Normal lochia: rubra (days 1–4), serosa (days 4–10), alba (up to 6 weeks).
— Resumption of menses: ~6–8 weeks in non-breastfeeding; 6+ months with exclusive breastfeeding.
— Breakthrough bleeding on POP/implant/DMPA: common in first 3–6 months; reassure and trial NSAIDs or short estrogen course if persistent (and not contraindicated).
— Heavy bleeding with copper IUD: expected increase in flow ~50%; LNG-IUD or removal if intolerable.
— Retained products of conception: persistent heavy bleeding beyond 2 weeks postpartum—evaluate with TVUS.
— Endometritis: fever, foul lochia, uterine tenderness—rule out before attributing bleeding to contraception.
— Always rule out before attributing irregular bleeding to method side effect.
Key distinction: New-onset heavy or prolonged bleeding on a previously well-tolerated method should prompt evaluation for pregnancy, infection, or structural pathology—not automatic attribution to the method.
Step 3 management: Postpartum bleeding workup tier: (1) pregnancy test, (2) pelvic exam, (3) TVUS for retained products or endometritis findings, (4) consider endometrial sampling if >6 weeks postpartum with persistent abnormal bleeding.
— Postpartum VTE: baseline risk elevated 4–5× through 6 weeks, regardless of contraception; do not blame CHC alone.
— Preeclampsia/HELLP beyond delivery can present with headache, abdominal pain, elevated LFTs—not a CHC side effect.
— Peripartum cardiomyopathy: dyspnea, edema, fatigue—evaluate with echocardiogram, not attributed to method.
— Postdural puncture headache (positional, post-epidural).
— Cerebral venous sinus thrombosis (postpartum + CHC = elevated risk).
— Pituitary apoplexy (Sheehan syndrome after PPH)—amenorrhea, lactation failure, hypotension.
— Postpartum depression vs progestin-induced mood effects: PPD is far more common; screen with EPDS at every postpartum visit.
— Postpartum thyroiditis (transient hyper- then hypothyroidism).
— DMPA-associated weight gain vs lifestyle/postpartum physiologic changes vs hypothyroidism.
— Hyperprolactinemia, hypothyroidism, Sheehan, Asherman (after instrumentation)—evaluate independently.
— Ovarian cyst (from POP/implant) vs ectopic vs appendicitis vs cholelithiasis (elevated postpartum).
— May worsen on progestin-only methods; PCOS unmasked postpartum.
Board pearl: A breastfeeding postpartum patient develops severe headache + visual changes at 3 weeks—do not assume migraine; rule out cerebral venous sinus thrombosis (postpartum hypercoagulability) with MR venography before initiating estrogen.
Step 3 management: Always reassess symptoms with a fresh differential—blaming contraception delays diagnosis of serious mimics like CVST, postpartum preeclampsia, or PPCM.
— Document chosen contraceptive method on discharge summary.
— If LARC desired but not placed inpatient, schedule 2-week postpartum visit (rather than 6-week) for placement.
— Provide bridging method (condoms, POP starter pack) until LARC insertion.
— Provide written method instructions and emergency contraception access info.
— Recommend ≥18 months between delivery and next conception.
— Discuss optimal preconception care before stopping contraception: folic acid 400–800 mcg, vaccine update, glycemic and BP optimization, weight, mental health.
— Address side effects proactively—most discontinuation occurs in first 3 months from unmanaged irregular bleeding.
— Set realistic expectations: "Bleeding may be unpredictable for 3–6 months."
— Easy access to method removal—do not require multiple visits to discontinue.
— Annual GC/CT for women <25 or with risk factors regardless of contraception.
— HIV screening at least once for adults 15–65.
— Pap/cervical cancer screening per USPSTF (every 3 years cytology or every 5 years co-testing starting at 21).
— Check BP at 3 months after starting CHC.
— Reassess VTE/CV risk factors annually.
— Lipid and glucose monitoring per general guidelines, not method-driven.
— IUD strings check at 4–6 weeks; thereafter self-checks or annual visits.
— Implant: track 3-year expiration date; pre-schedule removal/replacement.
Step 3 management: Switch the postpartum visit paradigm—ACOG now recommends an initial postpartum contact within 3 weeks and comprehensive visit by 12 weeks, not a single 6-week visit; contraception is a centerpiece of this "fourth trimester" care.
Board pearl: A short interpregnancy interval <6 months is the strongest modifiable risk factor for preterm birth in the subsequent pregnancy—LARC is the most reliable way to extend interval.
— Antenatal (3rd trimester): initial counseling, method preference documented.
— Delivery admission: confirm plan; offer immediate postpartum LARC or BTL if elected and consented.
— Hospital discharge: ensure bridging method, prescription, and follow-up appointment.
— 2–3 weeks postpartum: phone or in-person check; assess mood, breastfeeding, bleeding, contraception adherence.
— 6–12 weeks postpartum: comprehensive visit—physical exam, BP, mood screen (EPDS), pelvic exam if indicated, LARC insertion if not yet done.
— 3 months after CHC initiation: BP check, side effect review.
— Annually: STI screen if indicated, method satisfaction, switch if desired.
— IUD: string check at 4–6 weeks; then patient self-checks monthly or annual provider visits.
— Implant: palpate insertion site at follow-up; track expiration.
— DMPA: every 11–13 weeks; reassess BMD risk in adolescents and those on >2 years.
— CHC: BP at 3 months, annually; reassess MEC category with each new comorbidity.
— Side effect expectations and timelines (bleeding patterns normalize by 6 months for most).
— When to seek care: severe abdominal pain, lost IUD strings, signs of VTE/stroke (ACHES mnemonic: Abdominal pain, Chest pain, Headache, Eye changes, Severe leg pain).
— Drug interaction awareness (new antibiotics—rifampin only is significant; not standard antibiotics).
— Dual method (condoms) for STI prevention.
— Postpartum depression screening at every visit through 6 months.
— Address impact of method side effects on mood.
CCS pearl: Order "Postpartum visit at 6 weeks" AND "Contraception counseling" as separate items; on Step 3 CCS, document the method initiated and the planned follow-up to avoid loss of credit.
Step 3 management: Use the fourth trimester framework—contraception is one of five pillars (mood, breastfeeding, chronic disease, contraception, transition of care) and is best addressed in continuity.
— Discuss method efficacy, risks, alternatives, and reversibility.
— Avoid coercive language ("you should get an IUD"); use neutral, patient-centered framing.
— Reproductive justice principles: protect patient autonomy regardless of age, race, income, or disability.
— Patient must be ≥21 years old, mentally competent, not in labor, not under sedation.
— Sterilization consent form signed ≥30 days and ≤180 days before procedure.
— Emergency exceptions (premature delivery, emergency abdominal surgery): consent must have been signed ≥72 hours before; otherwise sterilization cannot be performed.
— Common Step 3 trap: patient delivers preterm at 32 weeks but signed consent only 14 days earlier—cannot perform BTL at this delivery; offer interval procedure or LARC.
— Most states allow minors to consent to contraception; know state-specific rules.
— Do not document confidential services in shared family records.
— Screen privately at every visit; offer discreet methods (DMPA, implant, IUD with trimmed strings).
— Document concerns and provide resource referrals; mandatory reporting only when statutorily required.
— Patients with cognitive impairment require careful capacity assessment; involve ethics committee for permanent sterilization decisions.
— Failure to communicate contraceptive plan between OB, primary care, and pharmacy is a major safety gap—use closed-loop referrals.
— Document method, start date, expiration, and follow-up explicitly in discharge summary and primary care handoff.
— Extended IUD use (e.g., copper IUD beyond 10 years per FDA, evidence supports 12 years) requires patient disclosure.
Step 3 management: When a patient with intellectual disability desires contraception, involve her, her guardian, and an interdisciplinary team; choose the least restrictive effective method (often LARC) rather than sterilization; sterilization in this population may require court approval.
Board pearl: Reproductive coercion is a recognized form of IPV; offer methods that cannot be detected by a partner (DMPA, deep implant, IUD with cut strings).
— 21 days postpartum: earliest CHC start if no risk factors and not breastfeeding.
— 42 days postpartum: safe CHC start with VTE risk factors.
— 6 months: maximum duration of effective LAM.
— 30 days / 180 days: Medicaid sterilization consent window.
— 18 months: recommended minimum interpregnancy interval.
— Copper IUD, LNG-IUD, implant, POP, DMPA (MEC 2 if <1 month), LAM, barrier, sterilization.
— All combined hormonal contraception (pill, patch, ring).
— Implant (0.05% failure), LNG-IUD (0.1–0.4%), copper IUD (0.8%).
— Abdominal pain (liver/gallbladder), Chest pain (PE/MI), Headache (stroke), Eye changes (TIA/clot), Severe leg pain (DVT).
— Rifampin, antiepileptics (phenytoin, carbamazepine, topiramate >200, oxcarbazepine, phenobarbital), St. John's wort → reduce CHC, POP, implant.
— DMPA and IUDs unaffected.
— Lamotrigine: estrogen lowers its level—use non-estrogen method.
— Current breast cancer (all hormonal).
— Active VTE, severe hypertension, migraine with aura, ischemic heart/stroke, decompensated cirrhosis, hepatic adenoma → CHC.
— Active pelvic infection, distorted cavity, GTD with persistent β-hCG, cervical cancer → IUD.
— Copper IUD > ulipristal acetate > levonorgestrel.
— As early as 25 days in non-lactating; precedes first menses.
— Immediate: IUDs, implant, pills.
— Delayed up to 10 months: DMPA.
Board pearl: When the vignette says "immediate, breastfeeding, most effective, reversible"—the answer is etonogestrel implant or immediate postpartum LNG-IUD.
— Stem: "28-year-old G1P1, 6 weeks postpartum, exclusively breastfeeding, BP 118/76, requests effective contraception. Most appropriate?"
— Answer: LNG-IUD, copper IUD, implant, or POP. Avoid CHC if any risk factor; many stems pick implant or IUD.
— Stem: BP 150/95, smoker, not breastfeeding, requests pills.
— Answer: Not CHC (MEC 3–4); choose progestin-only or copper IUD.
— Stem: patient signed sterilization consent 20 days ago; now delivering at term.
— Answer: Cannot perform BTL; offer LARC or interval sterilization (need 30 days).
— Stem: postpartum, has migraine with visual aura, wants pills.
— Answer: Avoid CHC (MEC 4); offer progestin-only or copper IUD.
— Stem: history of ER+ breast cancer 2 years ago.
— Answer: Copper IUD (all hormonal methods MEC 4).
— Stem: on carbamazepine, requests OCP.
— Answer: enzyme inducer—reduces CHC, POP, implant; use DMPA or IUD.
— Stem: rural patient, low follow-up likelihood, wants long-acting method.
— Answer: Immediate postplacental IUD or implant before discharge.
— Stem: 3 months post-insertion, cannot feel strings.
— Answer: pregnancy test → ultrasound → if not seen, X-ray/CT for perforation.
— Stem: meets CDC "reasonably certain not pregnant" criteria.
— Answer: Start method today; no test needed.
— Answer: All progestin methods safe; avoid CHC.
Step 3 management: When the stem combines lactation, time-since-delivery, and a comorbidity, work through US MEC systematically—elimination of MEC 3–4 options usually narrows to one or two correct answers.
The single highest-yield teaching point: Postpartum contraception should be discussed antenatally, initiated as early as the patient desires (immediately postpartum for LARC), and matched to lactation status, time since delivery, and US MEC category—avoiding combined hormonal contraception in the first 21 days for everyone and in the first 6 weeks for any patient with VTE risk or active breastfeeding.
Board pearl: When in doubt on a stem, default to LARC—it satisfies "most effective," is lactation-compatible, has minimal contraindications outside active pelvic infection or current breast cancer (LNG only), and is the answer to the majority of postpartum contraception questions on Step 3.
Step 3 management: Document the chosen method, follow-up plan, and bridging contraception in the discharge summary—closing the loop on contraception is a core patient safety and value-based care metric in the fourth trimester.