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Postpartum contraception — DFSRH MCQ

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EasyMaternal HealthPostpartum contraceptionDFSRH

A 31-year-old woman attends 18 days after an uncomplicated vaginal birth. A planned postplacental 52 mg levonorgestrel intrauterine device was not inserted because no trained clinician was available. She remains amenorrhoeic but is mixed feeding, with several formula feeds each day. She has had no sexual intercourse since delivery and intends to resume intercourse from day 21. There was no prolonged rupture of membranes, postpartum haemorrhage or sepsis. She still wants the levonorgestrel intrauterine device, accepts desogestrel as a temporary method and strongly prefers not to use condoms. Which is the most appropriate contraceptive plan?

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Correct answer: D — Start desogestrel today and insert the levonorgestrel intrauterine device on or after day 28

Postpartum intrauterine contraception may be inserted within 48 hours of birth or from 28 days postpartum. Between 48 hours and 4 weeks, initiation is UKMEC 3 and is not usually recommended because of concern about perforation during uterine involution. The requested device should therefore be deferred until day 28, not inserted today or routinely delayed until 6 weeks. Contraception is required from day 21 postpartum. Mixed feeding does not satisfy the criteria for the lactational amenorrhoea method, which requires amenorrhoea, age under 6 months postpartum and full or nearly full breastfeeding. Desogestrel can be started now; when any progestogen-only pill is initiated by day 21 postpartum, it is effective immediately without additional precautions. If desogestrel has been taken correctly, an LNG-IUD can subsequently be inserted without additional contraceptive precautions, so the pill may be stopped at insertion. A is inappropriate within the UKMEC 3 interval. B incorrectly treats mixed feeding as effective lactational contraception. C adds unnecessary barrier precautions contrary to her preference. D provides effective bridging but delays her chosen long-acting method beyond the point at which interval insertion is acceptable.

Reference: FSRH Guideline: Intrauterine Contraception (March 2023, amended January 2025) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-clinical-guideline-intrauterine-contraception-mar-23-amended.pdf FSRH Guideline: Progestogen-only Pills (August 2022, amended April 2026) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-ceu-clinical-guideline-progestogen-only-pills-aug22-amended-11july-2023-.pdf FSRH Guideline: Contraception After Pregnancy (January 2017, amended October 2020) — https://fsrh.org/Common/Uploaded%20files/documents/contraception-after-pregnancy-guideline-oct2020.pdf