In order to optimally initiate contraception and properly evaluate postpartum bleeding and pain when should women be appointed back for their postpartum exam?
A very clear answer!
Women should return at 3 weeks or even 2 weeks, but definitely NOT 6, which may stretch out to 7 or 8 weeks for postpartum checkups!
Doctors Leon Speroff and Dan Mishell wrote the lead article in Contraception in August, 2008. They suggest that “the 6-week postpartum visit is an anachronism.” It simply does not make sense. Many women resume sexual activity, they point out BEFORE 6 weeks and ovulation frequently occurs before 6 weeks. They suggest that “A 3-week visit would be more effective at preventing postpartum conception by initiating effective contraception at this time, instead of after the 6-week visit.”
This earlier date has been suggested for the past 2 decades by clinicians wanting to diagnose harmful bleeding due to a partially retained placenta. Obviously it is desirable to detect this earlier than the 6-week visit, perhaps at 3 weeks.
An IUD may be placed at 21 days (if not placed immediately after delivery).
Speroff and Mishell point out that “total contraceptive protection is achieved by the exclusively breastfeeding woman for a duration of only 10 weeks” [Visness, Kennedy, Gross et al 1997]. “Supplemental feeding increases the chance of ovulation (and pregnancy) even in amenorrheic women [Diaz S, Aravena R, Cardenas H. 1991 43-335-52]. Speroff and Mishell further point out that “Half of women who are not fully breastfeeding ovulate before the sixth week. Lactation, therefore, provides a contraceptive effect, but it is variable and not reliable for every woman.”
RAH COMMENT: When a physician, nurse midwife or nurse practitioner cares for a woman in the immediate postpartum period, neither the woman nor her clinician knows with certainty whether she will continue to be exclusively breastfeeding for the entire 6 weeks suggesting that for breastfeeding women as well as women not breastfeeding the routine postpartum visit be scheduled for 3 weeks postpartum.
Handing an immediately postpartum woman her birth control pills in the hospital and instructing her to take her first pill when her baby is 3 weeks old (if it is her plan to use combined pills), avoids some of the confusion and loss of effectiveness of delaying starting her pills until her 6-week postpartum visit.
Similarly, handing an immediately postpartum woman her progestin-only pills in the hospital and instructing her to take her first pill on discharge from the hospital (if it is her plan to use POPs), avoids some of the confusion of delaying starting her pills until her 6-week postpartum visit.
To learn more about the advantages and disadvantages of all available contraceptives, go to our website: www.managingcontraception.com and click on Choices 2014 edition. You can also order this wonderful new educational book from our website or by calling 404-875-5001. Do you have your copy yet? This book is now available in English and Spanish.
Key Words: postpartum, checkup, return, Dr. Leon Speroff, Dr. Dan Mishell, Contraception, anachronism, sexual activity, ovulation, conception, contraceptive, bleeding, retained placenta, protection, breastfeeding, combined pills, progestin-only pills
Speroff L, Mishell DR. The postpartum visit: it’s time for a change in order to optimally initiate contraception. Contraception 78 (2008) 90-98.
Posted 3-8-2012, updated 3-12-2012, Updated 2-5-2013, Updated 3-30-2014, Updated 7-12-2015
Contraceptive Technology 20th Edition
Managing Contraception 2015-2016
The authors advise consultation of a primary-care provider or a specialist before making decisions about, managing, or treating any problem discussed in these questions and answers. Under no circumstances should the information provided on this website be used instead of, or to override the judgment of the treating provider.