Nearing the end of pregnancy? Time to talk birth control

Do you know which birth control method you’re going to use after giving birth?

Many of my pregnant patients are surprised when I bring this up early in the third trimester. They say, “I’m still super pregnant. Why do I need to think about birth control already?”

Women begin ovulating, on average, about six weeks after giving birth. But some women start as early as three weeks. And, contrary to the old wives’ tale, breastfeeding alone may not prevent pregnancy. If you wait until your six-week postpartum visit to discuss birth control, you might give your new baby a sibling sooner than you planned!

About 70 percent of pregnancies that occur less than a year after a previous birth were unplanned. These are known as short-interval pregnancies and can carry risks such as low birth weight and higher rates of preterm birth and postpartum depression.

The American Congress of Gynecologists and Obstetricians (ACOG) in August 2016 stressed the importance of counseling still-pregnant women about their birth control options. In particular, they said women should be offered placement of long-acting reversible contraception (LARC), such as IUDs, immediately after delivery.

Let’s take a look at your birth control options, including birth control methods that are long-acting and reversible, short-acting and reversible, and permanent, as well as breastfeeding as contraception.

Long-acting, reversible methods: IUDs, implant

ACOG’s recommendation that women consider using IUDs after childbirth aligns with national birth control trends. According to the Centers for Disease Control and the National Center for Health Statistics, the use of LARCs has increased dramatically. In 2002, 2.4 percent of women using contraception chose a LARC. That number rose to 11.6 percent in 2013.

The IUD is the most common LARC. It is a small T-shaped device with strings that your doctor inserts into your uterus. This only takes a few minutes. There are two types:

• Hormonal IUD: This IUD lasts five years. It releases progesterone, which prevents pregnancy by thickening the cervical mucus so sperm can’t get into the uterus and alters the uterine lining to prevent implantation. Most women will have spotting in the first few months after insertion, but will stop menstruating after six to 12 months.
  
• Copper IUD: This IUD, which lasts 10 years, has a copper wire coiled around the stem. The copper is toxic to sperm and makes the uterus and fallopian tubes produce fluid that kills sperm. You will continue to have a monthly period with a copper IUD.

The second option is the birth control implant. This is a matchstick-size rod we insert under the skin in your upper arm. Like a hormonal IUD, it releases progesterone. Implants last up to three years, and you likely will have light to no menstrual periods.

Both of these methods are safe for moms who plan to breastfeed. When you decide you’re ready to have another baby, your doctor will remove the IUD or implant. You will be able to get pregnant immediately after your LARC is removed.

If you have an IUD inserted right after giving birth, it’s done and you don’t need to think about it. This is nice because as simple as placing an IUD is, up to 75 percent of women who said they planned to get an IUD didn’t. This could be because they had a problem with their insurance or because they are one of the nearly 40 percent of women who don’t come back for their postpartum visit.

Your uterus shrinks dramatically in the weeks after pregnancy, so there is an increased risk the IUD can be expelled from the uterus if it’s implanted right after childbirth (10 to 27 percent) than if it’s implanted any other time (3 to 5 percent).

If you are worried about the higher expulsion rate, talk to your doctor about their experience with IUD placement. Doctors with more experience placing IUDs tend to have lower expulsion rates.

If you have an infection or a lot of postpartum bleeding, we recommend against placing an IUD immediately after childbirth.

Short-acting, reversible methods: ‘The pill,’ vaginal ring, condoms

The birth control pill remains the most popular form of contraception for women. There are two main types of “the pill”:

• Combination birth control pill: Contains estrogen and progesterone.
• Minipill: Includes only progesterone.

If you plan to breastfeed, avoid the combination pill because estrogen can decrease your milk supply.

If you want to start taking birth control pills immediately after giving birth, and are breastfeeding, then the progesterone only pill is an option. Remember though, these pills need to be taken at the same time every day. If you’re off even an hour, you should use a back-up birth control method. This can be difficult for anyone, but especially new moms whose schedules are suddenly at the mercy of an infant.

• Vaginal ring: Another option is the birth control ring, which is a soft, flexible ring you insert into your vagina at the beginning of your menstrual cycle. The ring stays in the vagina for three weeks. Like the combination birth control pill, the vaginal ring releases estrogen and progesterone and shouldn’t be used if you plan to breastfeed.
• Condoms: They tend to be the least effective form of birth control. Their high failure rate can be attributed to the fact that people aren’t perfect. They forget to use them, use expired products, or do not use them correctly.

Permanent birth control options

If you are certain you want this to be your last pregnancy, you have a few permanent birth control options.

• Tubal ligation – known as having your “tubes tied” – is a procedure in which we clamp or sever the fallopian tubes so your eggs can’t reach the sperm for fertilization. We can tie your tubes immediately after birth. If you have a C-section, we’ll do it before we close you up. If you deliver vaginally, we can make a small incision in your belly button, pull the fallopian tubes out, and tie them.
• The Essure system is another permanent birth control method that can be done outside of pregnancy or the postpartum period. You should speak to your doctor more about this option.

Remember, these options are not reversible. You must be sure that you do not want to become pregnant again. If your partner plans to get a vasectomy, use another form of birth control until the procedure has been performed and is fully effective. Otherwise, you may find your last pregnancy wasn’t your last!

Can I get pregnant while breastfeeding?

Many women have heard the old wives’ tale that you can’t get pregnant while breastfeeding. It’s true that milk production interferes with the release of hormones needed to trigger ovulation, but some women will ovulate despite diligent breastfeeding.

The contraceptive technique known as the lactation amenorrhea method (LAM) requires you to exclusively breastfeed. This means breastfeeding every two to three hours. One missed feeding makes it less effective.

This can be very difficult to keep up. Babies are notorious for not always doing what you want them to do when you want them to do it. If you return to work and are separated from your baby, it may become impossible. LAM is also no longer effective after six months.

How soon can I have sex after childbirth?

Many women tell me, “There’s no way I’ll want to have sex right after giving birth.” But you may be surprised by how soon you feel ready to reconnect with your partner. More than 40 percent of women report having unprotected sex before their six-week postpartum appointment.

We recommend you wait to have sex until after your six-week visit for a number of reasons.

The biggest reason is your reproductive tract is still healing and “getting back to normal.” By six weeks, your uterus and cervix likely have returned to normal size and are less prone to infection. We recommend waiting a year after childbirth before trying to become pregnant again. Childbirth is a traumatic – yet miraculous – event. You need time to heal physically and emotionally.

And if you didn’t have your tubes tied or an IUD placed after delivery, you will need to get some birth control at this visit!

Awareness surrounding birth control has grown in the last few years as access has increased, insurance coverage improves, and women become savvier about their options. If your doctor doesn’t bring up birth control by your third trimester, initiate the conversation yourself. This gives you time to think about your options, discuss them with your partner, and know what you want to do by your due date.

If you have a pregnancy, labor, and delivery topic you’d like to learn more about, connect with us through the blog comments section or through email.