POSTPARTUM COUNSELING

A Quick Reference Guide for Clinicians®

Association of
Reproductive
Health
Professionals
Contents

Using This Guide 1

Postpartum Counseling Checklist 2
Diet, Nutrition, and Exercise 3
Postpartum Mental Health 13
Sexuality and Contraception 20
C LINICAL A DVISORY C OMMITTEE
Kelly Boyd, PsyD John Sunyecz, MD, FACOG
Clinical Psychologist President
Center for Counseling and MenopauseRx.com
Reproductive Psychology Uniontown, PA
Austin, TX Michael A. Thomas, MD,
Beth Cheney, RN, MSN, CFNP Committee Chair
Women’s Health Coordinator Professor, Obstetrics and
Windham Hospital Gynecology
Willimantic, CT Director, Division of Reproductive
Endocrinology and Infertility
Anne Davis, MD
Director, REI Fellowship Program
Assistant Professor, Clinical
University of Cincinnati
Obstetrics and Gynecology
Medical Center
New York Presbyterian Hospital,
Cincinnati, OH
Columbia University
New York, NY
Margaret Plumbo, RN, MS, CNM
Instructor, Nurse Midwife and
Women’s Health Program
University of Minnesota School
of Nursing
Minneapolis, MN

ARHP S TAFF
Shama Alam, MScPH
Education Associate
Elizabeth S. Callihan
Designer
Beth Jordan, MD
Medical Director
Nancy Monson
Writer/Editor
Wayne Shields
President & CEO
Amy M. Swann
Director of Education

This publication has been made possible by an unrestricted educational

grant from GlaxoSmithKline Consumer Healthcare.

 POSTPARTUM COUNSELING
A Quick Reference Guide for Clinicians

U SING T HIS G UIDE

This Quick Reference Guide for Clinicians is designed to assist health
care providers in counseling women in the postpartum period. It
addresses three important areas of concern to these patients:
• Diet, nutrition, and exercise
• Postpartum mental health
• Sexuality and contraception
Each section includes a list of counseling points that providers can
use as a guide when talking with patients, as well as a review of
related health issues.
Comprehensive screening and assessment should be performed first.
This evaluation identifies individual patients’ needs and concerns
and informs appropriate counseling. Key elements in postpartum
screening and assessment appear in the box on page 2.
This guide focuses on the postpartum follow-up visit—typically
scheduled four to six weeks after delivery—for women who have had
an uncomplicated pregnancy and a vaginal delivery. Much of this
information is relevant to other women in the postpartum period as
well, including those who have had cesarean deliveries. Women who
experienced obstetrical complications or other health problems will
need counseling on topics that are not covered here.
Health care providers have an important role in counseling their
postpartum patients on the issues presented in this guide, but time
and opportunity are often limited. The Association of Reproductive
Health Professionals (ARHP) hopes this guide provides a brief, easy­
to-use resource to facilitate addressing these issues during an
important period of change and adjustment.

1
 POSTPARTUM COUNSELING CHECKLIST
ASSESSMENT AND SCREENING
Physical exam
• Weight
• Height
• Body mass index (BMI; compare with pre - p regnancy)
• Lab work
• Pelvic exam (perineal healing/vaginal discharge/

pelvic support)

• Breast exam
• Abdominal exam (diastasis recti)
Diet, nutrition, and exercise
• Eating patterns, nutrition review
• Use of calcium supplement
• Continuing use/non-use of prenatal vitamin and

iron supplements

• Cultural conditions surrounding diet

• Status of breastfeeding
• Weight loss concerns and expectations
• Alcohol consumption
• Substance abuse
• Constipation
• Exercise level (current, pre - p regnancy)
• Exercises for pelvic and abdominal muscles
• Readiness to return to work
Postpartum Mental Health
• Postpartum Depression Screening Scale (PDSS)
• Edinburgh Postnatal Depression Scale (EPDS)
• Postpartum Depression Predictors Inventory (PDPI)
• Sleeping pattern; level of fatigue
• Resources and support
• Relationship with spouse/partner
• Sibling adjustment
Sexuality and contraception
• Sexual relations
• Incontinence
• Contraceptive options
You may photocopy this checklist or visit
www.arhp.org/Postpar
www.arhp.org/Postpar tumQRG for a printable version.
.arhp.org/PostpartumQRG

2
D IET , N UTRITION , AND E XERCISE
The Dietary Guidelines published by the US Department of
Agriculture and endorsed by the American Dietetic Association form
the basis for nutrition counseling for postpartum women.1
Counseling can be tailored to the individual woman based on risk
factors for poor nutrition such as extremes of maternal age,
restrictive dietary practices (e.g., vegan), excessive weight gain during
pregnancy, deviations from ideal body weight, multiple gestation,
history of eating disorders, and a close interconceptional period. An
additional 500 Kcal/day is recommended for women who breastfeed
(e.g., 2,300–2,500 Kcal/day versus 1,800–2,000 for a moderately
active non-pregnant, non-lactating women).1 Even higher intake may
be recommended for lactating women who are underweight, women
who exercise vigorously, or women who are breastfeeding more than
one infant.2
Many women consume less than the recommended amounts of
calcium, magnesium, zinc, vitamin B6, and folate.2 New mothers are
likely to have stopped taking a prenatal vitamin. If a nutritional
deficit is suspected, reinstitution of prenatal nutritional
supplementation may be appropriate. Prenatal supplements generally
do not include a significant amount of calcium; in addition, during
lactation, 250–350 mg of calcium is transferred daily from the
mother to the neonate through breast milk.3 Patients should be
apprised of the need for additional supplementation to meet the
requirement for this key mineral.
Calcium. The recommended daily allowance of calcium for lactating
women ages 19 to 50, as for pregnant and non-pregnant women, is
1,000 mg/day.1 Adolescents may require 1,300 mg/day.1 Some
postpartum women restrict caloric intake for weight loss, and there is
some evidence that diet-induced weight loss results in generalized
bone loss in all women.4 Calcium has many functions in the body—
aiding in muscle relaxation, blood coagulation, transmission of nerve
impulses, and enzyme reactions, as well as promoting tooth and
bone health and preventing osteoporosis. The postpartum period is a

3
 POSTPARTUM COUNSELING CHECKLIST

DIET, NUTRITION, AND EXERCISE

• Nutrition, caloric requirements

• Weight loss
• Supplements
– Calcium
– Iron
– Prenatal vitamins
– DHA, omega-3 fatty acids
• If patient is anemic
– Iron
ƒ Food sources
ƒ Supplements
• Constipation
• Fluid consumption
• For breastfeeding mothers
– Support and encouragement
– Refer to local breastfeeding support groups, such as
La Leche League, as needed
– Additional caloric requirements
– Alcohol and caffeine consumption
• Exercise
– Pelvic and abdominal muscle conditioning
You may photocopy this checklist or visit
www.arhp.org/Postpar
www.arhp.org/Postpar tumQRG for a printable version.
.arhp.org/PostpartumQRG

time when women tend to be receptive to health counseling, and this

provides an excellent opportunity to promote lifelong habits to
ensure adequate calcium intake.
Numerous studies reveal transient bone loss during lactation, which
is rapidly regained after weaning.3 The rate and extent of recovery are
influenced by the duration of lactation and postpartum amenorrhea
and differ by skeletal site. However, studies have not revealed that
pregnancy and lactation are associated with an increased risk of
osteoporotic fracture.3

4
 FOODS HIGH IN CALCIUM
There is controversial and DAIRY PRODUCTS
DAIRY PRODUCTS

conflicting evidence that, in Plain, low-fat yogurt, 1 cup –

comparison with a low-calcium 415 mg

diet, a high-calcium diet may Skim milk, 1 cup – 306 mg
increase weight loss slightly.5-7 Buttermilk, 1 cup – 284 mg
This statement may be an
Part-skim mozzarella cheese,
incentive for some women to 1½ oz – 311 mg
boost their calcium intake.
Cheddar cheese, 1½ oz – 307 mg
Most women do not obtain
enough calcium from dietary FISH
sources and will benefit from Sardines, 3 oz – 325 mg
calcium supplementation. Salmon in can, 3 oz – 181 mg
Calcium carbonate (found in Ocean perch, Atlantic, cooked,
Calcium Soft Chews, Caltrate®, 3 oz – 116 mg
Os-Cal®, Tums®, Viactiv®, and Clams, canned, 3 oz – 78 mg
other supplements) is readily
absorbed by most people and is GREENS
the least costly form of calcium Collard greens, ½ cup – 178 mg
supplement.8,9 Calcium citrate Spinach, ½ cup – 146 mg
products (such as Citracal®) may Turnip greens, ½ cup –124 mg
also be recommended but may be Kale, ½ cup – 90 mg
more expensive and require
Beets, ½ cup – 82 mg
patients to take more tablets to
achieve the optimal dosage. To OTHER
improve absorption, calcium Tofu, firm, prepared with nigan,
supplements can be divided into ½ cup – 253 mg
two or three doses and taken with Waffle/pancake with milk and
meals. Vitamin D facilitates egg –179 mg
absorption of calcium, so Molasses, blackstrap, 1 tbsp –
whenever possible, recommend a 172 mg
calcium supplement that contains English muffin – 96 mg
400 to 800 IU of this vitamin.

5
 Iron. Dietary requirements for iron return to pre-pregnancy levels in
the postpartum period—15mg/day.10 Postpartum iron
supplementation may be indicated when blood loss is higher than
usual during vaginal delivery or the interval between pregnancies is
less than two years. In the presence of a low hemoglobin or
hematocrit, and if other causes of anemia such as thalassemia are
ruled out, oral supplementation of 60 to 120 mg of iron can be
recommended. Many fortified cereals provide 100 percent (18 mg)
of a woman’s daily requirement for iron. Oysters, beef liver, and lean
beef are excellent sources of iron. Other good, non-meat food
sources include tofu and, to a lesser extent, potatoes with skin,
watermelon, figs, spinach, chard, and dried fruits such as apricots,
raisins, and prunes. Foods that inhibit iron absorption, such as
whole-grain cereals, unleavened whole-grain breads, legumes, tea,
and coffee, should be consumed separately from iron-fortified foods
and iron supplements.10
Fluid intake. Adequate fluid intake is an important element of good
nutrition. Women, especially those who are lactating, should be
encouraged to drink enough to satisfy thirst and prevent
constipation.11 However, controlled studies provide no evidence that
increased fluid intake will result in weight loss, improved lactation,
or diuresis.12
Weight loss. Returning to their pre-pregnancy weight is a common
interest among postpartum women. Many women feel societal
pressure—enforced by images of postpartum celebrities who appear
to return to their former figures effortlessly—to lose weight and get
back into shape quickly after giving birth. With a healthy diet and
exercise, much of the weight that women gain during pregnancy will
be shed naturally during the first year postpartum. The goal should
be gradual weight loss. For all but those women with high or very
high pre-pregnancy weights, the recommended weight loss after the
first month postpartum is a maximum of 4.5 lbs/month.13

6
Caloric intake should not fall below 1,800 Kcal/day, and this figure
may need to be revised upward on the basis of such considerations as
breastfeeding, nutritional status, and level of activity.1,4 Inadequate
caloric intake may increase postpartum fatigue and have a negative
impact on mood, especially if the mother is breastfeeding. Post-
pregnancy dieting may be accompanied by a significant decrease in
bone mineral density.3
Weight loss should not be promoted as a benefit of breastfeeding,
because some studies suggest that lactation may actually impede
weight loss.14 Often, instructing lactating women to focus on
nutritional foods and exercise, and to eat to satisfy their hunger, will
result in the desired slow pattern of weight loss.
Women who are overweight or obese before, during, or after
pregnancy should be counseled and, if appropriate, referred to
weight-loss programs led by specialists. Recent research suggests that
excess weight gain that persists after pregnancy is an indicator of
obesity in midlife.15
Alcohol and caffeine. Occasional consumption of small amounts of
alcohol and moderate ingestion of caffeine-containing products are
not contraindicated during breastfeeding, according to guidelines of
the Institute of Medicine (IOM).16 The American Academy of
Pediatrics (AAP), while noting that excessive maternal consumption
of caffeine may adversely affect the infant who is breastfeeding, also
considers moderate consumption of caffeine (e.g., a morning cup of
coffee) to be acceptable during breastfeeding.17 AAP advises women
who choose to drink alcohol to do so after nursing, rather than
before. Women also can be advised to delay breastfeeding until
alcohol is cleared from their milk—e.g., to express milk and store it
before they drink alcohol. Some experts note that although an
occasional alcoholic drink causes no problem, alcohol can interfere
with the letdown reflex and reduce milk production by 23 percent
for a few hours after consumption.18

7
 Women should be cautioned that consuming large amounts of
alcohol may interfere with their ability to breastfeed effectively and
may adversely affect their infant in other ways (e.g., impaired motor
development, altered sleep patterns, decreased milk intake).19
Alcohol consumption may also impair a mother’s ability to nurture
and care for her infant.
Fish consumption. The health benefits of fish and seafood have been
well documented and widely promoted in recent years. Fish is low in
saturated fat and is a healthy alternative to red meat. It provides the
body with essential vitamins and minerals, including iron; zinc (from
shellfish); vitamins A, B, and D; and, of course, protein. Omega-3
fatty acids found in fish are also beneficial, particularly for
cardiovascular health.
At the same time, women of reproductive age are particularly
vulnerable to the industrial pollutants—mercury and
polychlorinated biphenyls (PCBs)—that accumulate in fish flesh.
Multiple studies have documented prenatal exposure to mercury and
its effects on fetal development, and breastfeeding mothers are

WOMEN OF REPRODUCTIVE AGE:

RECOMMENDATIONS FOR CONSUMPTION OF FISH

Low levels of mer cur

mercur
curyy and low in fat
• 12 oz per week (two servings)—e.g., cod, haddock, pollock,
shrimp, tilapia, and chunk light tuna

Moderate levels of mer cur

mercur
curyy

• No more than 6 oz of fish per week (one serving)—e.g.,

bluefish, grouper, orange roughy, marlin, and fresh tuna

High levels of mer cur

mercur
curyy

• Do not consume—e.g., swordfish, shark, king mackerel,

and tilefish

High levels of PCBs, high in fat and low levels of mer cur
mercur
curyy

• No more than one to two times per month—e.g., farm-raised

salmon, herring, and sardines

8
advised to minimize fish consumption because mercury passes
through breast milk.20-23 Early life exposure to PCBs can cause
harmful neurological effects, leading to learning deficits, poor
memory, and behavioral problems. PCBs are highly toxic, and
infants may be particularly vulnerable to the adverse effects of these
chemicals.24 Women of child-bearing age can minimize their blood
mercury levels by eating fish with care, but PCBs accumulate over
time, and lifelong vigilance is required to minimize maternal body
burden of these chemicals.
Constipation. Constipation is common during pregnancy and the
postpartum period. Contributing factors include relaxed muscle tone
following delivery, inadequate fluid intake, a diet low in fiber, iron or
calcium supplementation, painful hemorrhoids, or fear of damaging
perineal repair during a bowel movement. Suggestions for preventing
constipation include eating foods high in fiber, drinking eight to 10
large glasses of liquid daily (water, juice—including prune juice—or
milk), and getting regular exercise. The use of ice packs or sitz baths
can be encouraged to alleviate persistent hemorrhoidal or perineal
pain that interferes with bowel movements.
Exercise. Published studies confirm the importance of regular
exercise in the postpartum period, as in other times of life, although
its effect on weight loss may not be significant without specific
calorie restriction.25 Women can be reassured that exercise will
promote healing, support emotional well-being, and not adversely
affect their ability to breastfeed successfully. Even strenuous exercise
minimally increases lactic acid levels in breast milk and has no effect
on an infant’s acceptance of breast milk one hour after exercise.26,27
One study found that women who consume adequate amounts of
long-chain polyunsaturated fatty acids (LC-PUFA), which are
essential for infants’ growth and development, can exercise
moderately without decreasing the LC-PUFA in their breast milk.27
Breastfeeding before exercise may reduce the discomfort of
engorged breasts.

9
 Evaluating the integrity and function of the pelvic floor and assessing
the diastasis recti are integral components of the postpartum visit.
Kegel exercises have been shown to be effective in reducing the
incidence of stress incontinence.28 Proper technique is important.
Patients should be instructed to contract the pelvic muscles for 10
seconds and then relax them for 10 seconds for 15 minutes four
times per day. Women may need help from a qualified provider in
locating the right muscles antepartum.
Providers can offer information on postpartum exercise programs
available at the YMCA, fitness centers, or hospitals in the
community to all new mothers in the birth center, hospital, or at the
four- to six-week visit. Postpartum exercise programs are good
resources that offer opportunities for physical activity, mutual
support, short-term daycare, and a way to meet other women with
infants. New mothers also may find it convenient to use postpartum
DVDs or videos to supplement their exercise regimen. Fast walking
with a baby jogger-type stroller, either outdoors or in a local indoor
mall, also can be recommended. Many pregnancy magazines are an
excellent resource for women of all fitness levels, both during
pregnancy and postpartum. They offer step-by-step exercise
programs, which are particularly useful for women who were not
very physically fit before they became pregnant.
The appropriate exercise level will depend on each woman’s medical
history, obstetrical course, level of fitness, and postpartum recovery.
Some women may be able to engage in an exercise routine within
days of delivery; others may need to wait four to six weeks.29 Gradual
resumption of exercise is recommended to gauge effect and identify
appropriate level of intensity.
As with vaginal birth, recommendations for exercise after cesarean
birth depend upon obstetric and medical history and rate of physical
recovery. In most cases, exercises to restore abdominal muscle tone in
the cesarean mother can begin as soon as abdominal soreness

10
diminishes.30 According to some experts, women can safely start
doing straight and diagonal curl-ups within the first few days after a
cesarean birth. These exercises can help in bringing the rectus
muscles back together.31

R EFERENCES
1. US Department of Agriculture Dietary Guidelines. Available from:
http://www.health.gov/DietaryGuidelines/ [Accessed July 14, 2006].
2. Institute of Medicine. Nutrition Services in Perinatal Care. 2nd ed. Washington,
DC. 1992
3. Oliveri B, Parisi MS, Zeni S, Mautalen C. Mineral and bone mass changes during
pregnancy and lactation. Nutrition 2004;20(2):235-40.
4. Jensen LB, Kollerup G, Quaade F, Sorensen OH. Bone mineral changes in obese
women during a moderate weight loss with and without calcium supplementation.
J Bone Miner Res 2001;16(1):141-7.
5. Heaney RP, Davies KM, Barger-Lux MJ. Calcium and weight: clinical studies.
J Am Coll Nutr 2002;21(2):152S-5S.
6. Zemel MB. The role of dairy foods in weight management. J Am Coll Nutr
2005;24(6 Suppl):537S-46S.
7. Teegarden D. The influence of dairy product consumption on body composition.
J Nutr 2005;135(12):2749-52.
8. Heaney RP, Recker RR, Weaver CM. Absorbability of calcium sources: the limited
role of solubility. Calcif Tissue Int 1990;46(5):300-4.
9. Heaney RP, Dowell MS, Bierman J, Hale CA, Bendich A. Absorbability and cost
effectiveness in calcium supplementation. J Am Coll Nutr 2001;20(3):239-46.
10. American Dietetic Association. Medical Nutrition Therapy. Chicago, Illinois.
2006. Available from: http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/
advocacy_382_ENU_HTML.htm.
11. American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists. Guidelines for Perinatal Care. 5th ed. Elk Grove Village, IL:
American Academy of Pediatrics; 2002.
12. Keirse MJ, Enkin M, Crowther C, Nelison J, Hodnett E, Hofmeyr J, Duley L.
A Guide to Effective Care in Pregnancy and Childbirth. London: Oxford University
Press; 2000.
13. Institute of Medicine. Nutrition During Pregnancy and Lactation.
Washington, DC. 1992.
14. Reece EA, Hobbins JC. Medicine of the Fetus and Mother. 2nd ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 1999.

11
 15. Rooney BL, Schauberger CW, Mathiason MA. Impact of perinatal weight change
on long-term obesity and obesity-related illnesses. Obstet Gynecol
2005;106(6):1349-56.
16. Institute of Medicine. Nutrition During Lactation. Washington, DC 1991.
17. AAP.org [homepage on the Internet]. Elk Grove Village, IL: American Academy of
Pediatrics. [Accessed May 11, 2006.]
18. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. St.
Louis: C.V. Mosby; 2000.
19. American Academy of Pediatrics. Pediatrics. Elk Grove Village, IL: 2001.
20. Grandjean P, Weihe P, White RF, Debes F. Araki S. Murata K, Sørensen N. Dahl
D, Yokoyama K, Jorgensen PJ. Cognitive deficits in 7-year-old children with
prenatal exposure to methylmercury. Neurotoxicol Teratol. 1997;19(6):417–28.
21. National Academy of Sciences, National Research Council. Toxicological Effects
of Methylmercury 2000. Available at: http://books.nap.edu/catalog/9899.html.
[Accessed May 26, 2004.]
22. Steuerwald U, Weihe P, Jorgensen PJ, Bjerve K, Brock J, Heinzow B, Budtz-
Jorgensen E, Grandjean P. Maternal seafood diet, methylmercury exposure, and
neonatal neurologic function. J Pediatr 2000:136(5);599–605.
23. Murata K, Weihe P, Budtz-Jorgensen E, Jorgensen PJ, Grandjean P. Delayed
brainstem auditory evoked potential latencies in 14-year-old children exposed
to methylmercury. J Pediatr 2004:144;177-83.
24. Environmental Protection Agency, Office of Research and Development. Draft
Dioxin Reassessment 2001. Available at: http://cfpub.epa.gov/ncea/cfm/
dioxreass.cfm. [Accessed July 14, 2006.]
25. Larson-Meyer DE. Effect of postpartum exercise on mothers and their offspring:
a review of the literature. Obes Res 2002;10(8):841-53.
26. Wright KS, et al. Quinn TJ, Carey GB. Infant acceptance of breast milk after
maternal exercise. Pediatrics 2002;109(4):585-9.
27. Bopp M, Lovelady C, Hunter C, Kinsella T. Maternal diet and exercise: effects on
long-chain polyunsaturated fatty acid concentrations in breast milk. J Am Diet
Assoc 2005;105(7):1098-103.
28. Elia G, Bergman A. Pelvic muscle exercises: when do they work? Obstet Gynecol
1993;81(2):283-6.
29. ACOG Committee on Obstetric Practice. ACOG Committee opinion.
Washington, DC: American College of Obstetricians and Gynecologists; 2002.
30. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC, Wenstrom KD.
Williams Obstetrics. 22nd ed. Dallas, TX: McGraw-Hill; 2004.
31. Noble E. Essential Exercises for the Childbearing Year. Waltham, MA: New Life
Images; 2003.

12
P OSTPARTUM M ENTAL H EALTH
Postpartum mood disorders pose health risks for mother and infant
and impair family relationships,1 yet mental health assessments often
are not incorporated into postpartum care. Screening and
counseling for disorders such as postpartum depression (PPD),
anxiety, and obsessive-compulsive disorder (OCD) can prevent
potentially serious consequences. Delay in receiving adequate
treatment is associated with an increased duration (and perhaps
severity) of PPD.2 Clinicians must be proactive in identifying women
at risk and providing appropriate counseling, referral, or both.

POSTPARTUM COUNSELING CHECKLIST

MESSAGES FOR NEW MOTHERS ABOUT

EMOTIONAL HEALTH

• “Baby blues” and anxiety are common in the first week

postpartum

• Postpartum mood changes are not the fault of the mother

• Nutritional adjustment, sleep, and exercise may help in

managing mood swings

• Awareness of predisposing risk factors may help mothers

identify symptoms earlier
• Timeframe for postpartum mood disorders
– “Blues” peak approximately three to five days postpartum and
disappear within a couple of weeks after the baby is born
– Postpartum depression usually develops within the first
three months postpartum but may occur later (up to one
year after childbirth)
– Incidence of psychosis peaks within the first few weeks
after childbirth
• Effective strategies exist for preventing and managing

postpartum mood disorders

• Early identification of postpartum mood disorders is important

• Reassurance of support and adequate resources and

appropriate referral will mitigate risk

You may photocopy this checklist or visit

www.arhp.org/Postpar
www.arhp.org/Postpar tumQRG for a printable version.
.arhp.org/PostpartumQRG

13
 Postpartum mood disorders are usually grouped into the
following categories:
• Baby blues
• Postpartum depression (PPD)
• Postpartum psychosis (PPP)3
• Postpartum anxiety (panic disorder, social phobia,

generalized anxiety)4

• Postpartum obsessive-compulsive disorder (OCD)4

Baby blues refers to commonly occurring mood swings or mild
feelings of sadness after childbirth. Also called postpartum reactivity,
these feelings usually peak approximately three to five days
postpartum and disappear within a couple of weeks after the baby is
born.5 Postpartum depression, a far more serious disorder, usually
develops within the first three months postpartum but may develop
any time during the first year and includes symptoms such as low
mood, sleep disturbance, and poor functioning.6 PPD affects up to
20 percent of postpartum women.7,8 Potential for the development
of postpartum psychosis is highest within the first few weeks after
childbirth. Onset is sudden and characterized by hallucinations,
delusions, agitation, and other psychotic symptoms. Incidence is
estimated at one to three per 1,000 postpartum women.9
Postpartum anxiety and OCD are less well-recognized disorders and may
occur on their own or in conjunction with depression. Anxiety affects 5 to
20 percent of new mothers; onset can be sudden or gradual.10 The woman
may worry excessively or feel anxious, have a short temper, feel irritable
and sad, or experience unusual symptoms of anxiety. Roughly 3 to 5
percent of postpartum women experience obsessive symptoms—intrusive,
repetitive, and persistent thoughts or mental pictures (often about harming
their baby), as well as behaviors targeted to reducing anxiety.
Clinicians should maintain a heightened alertness for the range of
possible symptoms that may indicate a mental health problem in a
postpartum woman so that early treatment can be initiated.11

14
Risk factors. Hormonal changes are theorized to be a causative factor
in postpartum mood disorders, and such changes may affect women
predisposed to the development of mood disorders most.12,13 The
stress of dealing with a newborn, lack of sleep, and nutritional
deficiencies may exacerbate the problem.14 Other factors known to
put women at risk for the development of serious postpartum mood
changes should be assessed by the clinician periodically during
pregnancy, after delivery, and at the time of the postpartum follow-
up visit.15 These risk factors include a personal or family history of
depression, anxiety, bipolar disorder, or other mental illness. Stress,
marital conflict, single status,
young age, lack of social
support, low self-esteem, POSTPARTUM

infant temperament, COUNSELING CHECKLIST

unplanned pregnancy, MESSAGES FOR NEW

unplanned cesarean birth, MOTHERS ABOUT

pre-term labor and delivery, EMOTIONAL HEALTH

perinatal complications, REVISED POSTPARTUM

and fatigue also may DEPRESSION PREDICTORS
signal vulnerability. 16-19 INVENTORY (PDPI)15
• Marital status
Some women may experience
• Self-esteem
depressive or anxiety-related
• Prenatal depression
symptoms when they • Prenatal anxiety
breastfeed or encounter • Social support
difficulties with the • Unplanned or unwanted
breastfeeding experience. pregnancy
Similarly, when a woman • Life stress
stops breastfeeding, she may • History of previous

experience these symptoms, depression

likely because of significant • Child-care stress

hormonal shifts. Many • Marital satisfaction
women also may feel sadness • Infant temperament
and a sense of loss after they • Maternity “blues”
stop nursing.

15
 Screening. Both provider-administered and patient self-report

assessment tools have been recommended to identify women at risk

for PPD. The Postpartum Depression Predictors Inventory (PDPI-
Revised) provides a guide for interviewing a patient at any point
between the preconception and postpartum periods.15 It includes
questions related to 13 predictors of PPD and assists the clinician in
identifying issues for discussion and possible intervention.
Two well-tested, self-administered screening tools are available. The
Edinburgh Postnatal Depression Scale (EPDS) assesses depressive
mood in the past seven days based on patient responses to 10
questions related to mood, anxiety, guilt, and suicidal ideation.15 The
Postpartum Depression Screening Scale (PDSS) comprises 35 items
that cover seven dimensions: sleeping/eating disturbances, anxiety/
insecurity, emotional lability, mental confusion, loss of self, guilt/
shame, and suicidal thoughts.20 Although the EPDS has fewer items
than the PDSS, either can be completed by the patient within five to
10 minutes. The short-form Depression Anxiety Stress Scales
(DASS-21) also can be used to diagnose depression or anxiety in
postpartum women.21
Caring for the patient at risk. The way a health care provider
manages postpartum mood disorders will depend on that
practitioner’s level of comfort and expertise in dealing with mental
and emotional problems, as well as the perception of the seriousness
of the woman’s problem.
If a patient appears at risk for serious depression or postpartum-
related anxiety, the primary care provider can:
• Acknowledge concern to the patient
• Reassure her that treatment is available, that it is NOT her fault,
and that you—her health care provider—are there for her
• Encourage her to discuss how she is feeling
• Help her identify support systems and, if she consents, enlist
their support

16
 • Offer breastfeeding education and support, behavioral

counseling, and ongoing reinforcement

Even women who exhibit no signs of depression, anxiety, or

maladjustment at the time of the postpartum follow-up visit need to
be educated about the ongoing risk of mood disorders beyond the
initial month or two following childbirth. Hormonal shifts that can
trigger mood swings or depression may occur at any time during the
first year postpartum.12

POSTPARTUM MOOD CHANGES

What to Say to Your Patient Who May Be at Risk
“Many women experience some degree of sadness, anxiety, or
other mood changes after the birth of a baby. Many things may
contribute to these feelings, and they are understandable. However,
I am concerned about the level of sadness and depression that you
expressed in your answers to some of the questions on the
assessment form that I have asked. This sometimes happens, but
not as a result of anything you have done. It is important to talk
about exactly how you are feeling, and what to do about it. You do
not have to deal with this problem alone. Help is available.”

Review some of the steps that the woman can take to help ward off
depression or anxiety and promote general health:
• Get enough rest
• Call on family and friends for help
• Eat a well-balanced diet
• Get regular exercise
• Consider joining a mothers’ or postpartum support group
• Delay going back to work for at least six weeks postpartum23
Treatment options. Treatments for postpartum mood disorders
include psychological and pharmacological therapy. Research
demonstrates that both individual and group counseling as well as

17
 cognitive-behavioral therapy can be effective.8,23 Selective serotonin
reuptake inhibitors and tricyclic antidepressants are effective in
treating postpartum depression and anxiety, and current research
suggests little if any adverse effect on the infants of nursing mothers
who take these drugs.24-26 Carbamazepine, sodium valproate, and
short-acting benzodiazepines also appear to be relatively safe during
breastfeeding.24 Further research is needed to clarify the risks of these
drugs for newborns.
Close follow-up and an interdisciplinary approach are keys in the
care of the woman experiencing mood disorders during the
postpartum period.

R EFERENCES
1. Beck CT. Postpartum Depression: it isn’t just the blues. Am J Nurs
2006;106(5):40-50.
2. Beck CT. Theoretical perspectives of postpartum depression and their treatment
implications. Am J Matern Child Nurs 2002;27(5):282-7.
3. American College of Obstetricians and Gynecologists. News Release: Answers to
common questions about postpartum depression. 2002.
4. Rapkin AJ, Mikacich JA, Moatakef-Imani B, Rasgon N. The clinical nature and
formal diagnosis of premenstrual, postpartum, and perimenopausal affective
disorders. Curr Psychiatry Rep 2002;4(6):419-28.
5. Kennedy HP, Beck CT, Driscoll JW. Postpartum depression. J Midwifery &
Women’s Health 2002 Sep-Oct;47(5):391.
6. Halbreich U, Karkun S. Cross-cultural and society diversity of prevalence of
postpartum depression and depressive symptoms. J Affect Dis 2006;91(2-3):97-111.
7. Flores DL, Hendrick VC. Etiology and treatment of postpartum depression.
Curr Psychiatry Rep 2002;4(6):461-6.
8. Milgrom J, Negri LM, Gemmill AW, McNeil M, Martin PR. A randomized
controlled trial of psychological interventions for postnatal depression. Br J Clin
Psychol 2005;44(Pt 4):529-42.
9. Indiana Perinatal Network. Postpartum depression consensus statement.
Indianapolis, IN. October 2002.
10. Bennett SS, Indman P. Beyond the Blues—A Guide to Understanding and Treating
Prenatal and Postpartum Depression. San Jose, CA: Moodswings Press; 2003.
Available from: http://www.beyondtheblues.com. [Accessed July 14, 2003.]

18
11. Beck CT, Indman P. The many faces of postpartum depression. J Obstet Gynecol
Neonatal Nurs 2005;34(5):569-76.
12. Parry BL, Newton RP. Chronobiological basis of female-specific mood disorders.
Neuropsychopharmacology 2001;25(5 Suppl):S102-8.
13. Bloch M, Schmidt PJ, Danaceau M, Murphy J, Nieman L, Rubinow DR. Effects
of gonadal steroids in women with a history of postpartum depression. Am J
Psychiatry 2000;157(6):924-30.
14. Blenning CE, Paladine H. An approach to the postpartum office visit. Am Fam
Physician 200515;72(12):2443-4.
15. Beck CT. Revision of the Postpartum Depression Predictors Inventory. J Obstet
Gynecol Neonatal Nurs 2002;31(4):394-402.
16. Cutrona C, Troutman BR. Social support, infant temperament, and parenting
selfefficacy: a mediational model of postpartum depression. Child Dev
1986;57(6):1507-18.
17. Bozoky I, Corwin EJ. Fatigue as a predictor of postpartum depression. J Obstet
Gynecol Neonatal Nurs 2002;31(4):436-43.
18. Britton JR. Pre-discharge anxiety among mothers of well newborns: prevalence
and correlates. Acta Paediatr 2005;94:1771-76.
19. Zelkowitz P, Papageorgiou A. Maternal anxiety: an emerging prognostic factor in
neonatology. Acta Paediatr 2005;94:1704-5.
20. Beck CT, Gable RK. Postpartum Depression Screening Scale: development and
psychometric testing. Nurs Res 2000;49(5):272-82.
21. Miller RL, Pallant JF, Negri LM. Anxiety and stress in the postpartum: is there
more to postnatal distress than depression? BMC Psychiatry 200612;6:28.
22. McGovern P, Dowd B, Gjerdingen D, Gross CR, Kenney S, Ukestad L, et al.
Postpartum health of employed mothers 5 weeks after childbirth. Ann Fam Med
2006;4(2):159-67.
23. Dennis CL. Psychosocial and psychological interventions for prevention and
postnatal depression: systematic review. BMJ 20052;331(7507):15.
24. Austin MP, Mitchell PB. Use of psychotropic medications in breast-feeding women:
acute and prophylactic treatment. Aust NZ J Psychiatry 1998;32(6):778-84.
25. Gupta S, Masand PS, Rangwani, S. Selective serotonin reuptake inhibitors in
pregnancy and lactation. Obstet Gynecol Surv 1998;53(12):733-6.
26. Epperson CN, Jatlow PI, Czarkowski K, Anderson GM. Maternal fluoxetine
treatment in the postpartum period: effects on platelet serotonin and plasma drug
levels in breastfeeding mother-infant pairs. Pediatrics 2003;112(5):e425.

19
 S EXUALITY AND C ONTRACEPTION
Sexuality in the postpartum period is strongly influenced by a
woman’s culture, her experience before pregnancy, her physiology,
and her emotional and psychological make-up. Postpartum sexual
changes and adjustment may not be easy to discuss, for the patient
or the provider. Yet sexual concerns are common, and the majority
of patients will welcome help from their primary care provider,
especially one who is prepared to elicit patient concerns and respond
to them.1,2
Patient attitudes about sexuality in the postpartum period. Perineal
healing is normally sufficient to allow resumption of sexual

POSTPARTUM COUNSELING CHECKLIST

SEXUALITY AND CONTRACEPTION

• Status of perineal healing

• Resumption of intimacy and sexual intercourse
• Alternatives to intercourse
• Reassurance that lack of sexual desire is common and
normal among women in the postpartum period
• Comfort during sexual relations (e.g., healing and vaginal
dryness)
• Incontinence
• Importance of pelvic floor muscle exercises (e.g., Kegels)
and how to perform them
• Contraceptive options
• For the woman who is breastfeeding
– Effect of lactation on vagina and lubrication
– Effect of sexual activity on letdown reflex
– Hormonal effects on sexual desire
– Efficacy of Lactational Amenorrhea Method for contraception
– Effect of estrogen-containing contraceptives
– Alternative contraceptive choices

You may photocopy this checklist or visit

www.arhp.org/Postpar
www.arhp.org/Postpar tumQRG for a printable version.
.arhp.org/PostpartumQRG

20
intercourse somewhere between four and six weeks postpartum, and
sometimes earlier.3 Women who undergo episiotomy or laceration
and repair may be less comfortable resuming intercourse earlier than
those who have not.
Short-term changes in sexual functioning have been noted among 22
to 86 percent of postpartum women, particularly those who have
had assisted vaginal deliveries as opposed to spontaneous vaginal
deliveries or cesarean birth.4 Several studies link episiotomy or
perineal laceration and operative vaginal delivery to dyspareunia,
which can persist for more than six months in a minority of
women.5-7 Women who have experienced cesarean birth also may
encounter discomfort with intercourse, and cesarean birth does not
appear to have protective effects on women’s sexual functioning.4,8
Factors other than physical recovery from labor and delivery affect
women’s decisions about resuming sexual relations. Providers should
be sensitive to the possibility of religious or cultural beliefs, fatigue,
or other influences on
women’s attitudes toward COMMON FACTORS IN

sexual intercourse in the early POSTPARTUM SEXUAL

postpartum period. In some ADJUSTMENT11

instances, providers may want

• Episiotomy discomfort
to suggest that other forms of • Fatigue
sexual expression, such as • Lack of sexual desire
touching, kissing, and mutual • Vaginal bleeding
pleasuring techniques, can or discharge
help to re-establish physical • Dyspareunia
closeness with a partner. • Insufficient lubrication
• Fears of awakening or
Diminished sexual desire.
failing to hear the infant
Low or absent sexual desire is • Fear of injury
a very common experience in • Decreased sense of
the postpartum period; a attractiveness, poor
reduction in sexual interest body image
and activity, compared with

21
 pre-pregnancy levels, is the norm during the first few months after
childbirth.9,10 One study found that 57 percent of women had
resumed intercourse at six weeks after delivery; 82 and 90 percent
reported sexual relations by 12 and 24 weeks postpartum,
respectively.7 The majority of the women reported experiencing
orgasm by 12 weeks postpartum. Most researchers report gradual
return to pre-pregnancy levels of sexual desire, enjoyment, and coital
frequency within a year.11
Effects of breastfeeding. Breastfeeding may negatively affect sexual
desire.12 The effect of lactation on hormone levels offers one
explanation, because estrogen levels decline during breastfeeding.13
Decreased estrogen may indirectly affect sexual interest by decreasing
vaginal lubrication, which can lead to pain with intercourse.12 The
use of water-based vaginal lubricants can reduce discomfort during
intercourse. (Petroleum-based products may cause irritation and can
cause condom breakage.) Vaginal moisturizers also can relieve vaginal
dryness and pain.
Incontinence. Women may hesitate to raise the subject of
incontinence, which can lead to sexual inhibition. Childbirth-related
incontinence is usually temporary and nearly always diminishes over
time. Kegel exercises strengthen the muscles of the pelvic floor and
have been shown to improve urine control, especially in women with
mild (rather than severe) stress incontinence.14
Choosing a contraceptive. Return to fertility is unpredictable and
may occur before the onset of regular menstrual cycles, even in
breastfeeding women. The first ovulation in non-lactating women
typically occurs 45 days postpartum but may occur earlier.15
Use of birth control should begin before sexual activity is resumed.
Ideally, choice of postpartum contraception should take place in the
prenatal period. In general, most women should start contraception
at the six-week visit or earlier, depending on when they resume
intercourse. All women should be offered emergency contraception.

22
LAM. The Lactational Amenorrhea Method (LAM) has a
contraceptive effect in the first six months postpartum if the
woman is fully breastfeeding (i.e., the woman is amenorrheic, is
breastfeeding every three to four hours, and is not supplementing
infant suckling with bottle feedings or expressed breast milk).16
Separation from the infant for many hours may increase the risk of
pregnancy in lactating women.17 The need for skilled counseling and
support, the lack of protection from sexually transmitted infections,
and the intensive demands on a woman’s time associated with LAM
limit its suitability as a contraceptive choice. For some women,
it can be an attractive, cost-effective, and temporary form of
birth control.18
Hormonal contraception and breastfeeding. Estrogen may decrease
the quantity and quality of breast milk.19 The standard of care for
lactating women has been to avoid contraceptives containing
estrogen, including oral contraceptives (OCs), the combination
patch, and the combination vaginal ring. Estrogen-containing
contraceptives should not be used until three to four weeks
postpartum in non-breastfeeding women, to reduce the risk of
venous thromboembolism.19 At that time, women can be offered the
option of hormonal regimens that allow them to suppress
menstruation if they desire to do so.
Recommended methods for women who are breastfeeding include
the progesterone-only pill, copper-T intrauterine device (IUD;
ParaGard®), levonorgestrel intrauterine system (IUS; Mirena®),
depot medroxyprogesterone acetate injectable (DMPA; Depo-
Provera® and Depo-subQ provera 104®) and the single-rod implant
(Implanon®). DMPA has a black box on its labeling that warns it
may be appropriate to restrict use to 21 months; a woman should
use DMPA as long-term method of birth control (e.g., for longer
than two years) only if other birth control methods are inadequate
for her.20 At issue is concern that prolonged use may result in
significant loss of bone density. The loss is greater the longer the

23
 drug is administered. However, recent research shows complete
recovery of bone mineral density after DMPA use, and the World
Health Organization does not recommend changes in prescribing
practices because of concerns about bone loss in adult users. For
adolescents, an increased risk of fracture with long-term use remains
theoretical. Until more data are available, providers should reconsider
the overall risks and benefits of long-term DMPA use in adolescents
over time.
Diaphragm, cervical cap, sponge, spermicides, and condoms.
Because pregnancy and childbirth influence vaginal tone and may
alter the size of the cervix and vagina, women choosing the
diaphragm or cervical cap will need to be refitted for their
contraceptive. Fitting should occur no earlier than six weeks
postpartum to ensure that the cervix is no longer dilated and that
maximum healing has occurred.15 Use of the contraceptive sponge
(Today®) should also be delayed until six weeks postpartum because
of the risk of toxic shock syndrome.15 Spermicides and condoms may
be initiated in the immediate postpartum period.
IUD and IUS. The copper-T IUD and the levonorgestrel (LNG)
IUS are long-acting, highly effective contraceptive options for both
lactating and non-lactating women. The copper-T IUD (ParaGard®)
is effective for 10 years. Expulsion rates are slightly higher when the
IUD is inserted immediately postpartum,21 and many clinicians
recommend delaying insertion for four to six weeks following
delivery after complete uterine involution. The LNG IUS (Mirena®)
is effective for five years; the mechanism of action is similar to that of
LNG implants or LNG-containing mini-pills. Menstrual bleeding
may be substantially reduced, and women need to be counseled
about the possibility of oligomenorrhea or amenorrhea with the
LNG IUS.22
Sterilization. The vast majority of women who undergo sterilization
(or whose partners have a vasectomy) are satisfied with this

24
method.23 An exception to this finding is young age, which is the
strongest predictor of regret.24 Risk factors such as an unstable
marriage, recent divorce, or other life changes should be taken into
account when counseling women on this permanent contraceptive
option. Immediately postpartum is the ideal time to perform surgical
sterilization. This represents a convenient time if the woman delivers
in a hospital setting, and the procedure may be covered by the
patient’s medical insurance. Postpartum sterilization is also associated
with a lower failure rate than procedures performed later. If surgical
sterilization is requested later, the most common method is
laparoscopy performed as ambulatory surgery with rings, clips, or
cautery to the fallopian tubes.25
A transcervical sterilization method (Essure™) provides another
option for delayed postpartum sterilization. With this method,
microinserts, placed into the fallopian tubes via the uterus, promote
formation of scar tissue that blocks the tubes. By three months, both
tubes are closed in 96 percent of women, and by six months, 100
percent of women experience tubal occlusion. Reliable contraception
is required until a hysterosalpingogram demonstrates that the inserts
have been correctly placed and the tubes are occluded.26

R EFERENCES
1. Nusbaum MR, Gamble G, Skinner B, Heiman J. The high prevalence of sexual
concerns among women seeking routine gynecological care. J Fam Pract
2000;49(3):229-32.
2. Basson R, Leiblum S, Brotto L, Derogatis L, Fourcroy J, Fugl-Meyer K, et al.
Definitions of women’s sexual dysfunction reconsidered: advocating expansion and
revision. J Psychosom Obstet Gynecol 2003;24(4):221-9.
3. Richardson AC, Lyon JB, Graham EE, Williams NL. Decreasing postpartum
sexual abstinence time. Am J Obstet Gynecol 1976;126(4):416-7.
4. Hicks TL, Goodall SF, Quattrone EM, Lydon-Rochelle MT. Postpartum sexual
functioning and method of delivery: summary of the evidence. J Midwifery Womens
Health 2004;49(5):430.
5. Buhling KJ, Schmidt S, Robinson JN, Klapp C, Siebert G, Dudenhausen JW. Rate
of dyspareunia after delivery in primiparae according to mode of delivery. Eur J
Obstet Gynecol Reprod Biol 2006;124(1):42-6.

25
 6. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning
and its relationship to perineal trauma: a retrospective cohort study of primiparous
women. Am J Obstet Gynecol 2001;184(5):881-8; discussion 888-90.
7. Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum
sexual function: a longitudinal prospective study. Int Urogynecol J Pelvic Floor
Dysfunct 2005 16(4):263-7.
8. Barrett G, Peacock J, Victor CR, Mayonda . Cesarean section and postnatal sexual
health. Birth 2005;32(4):306-11.
9. Von Sydow K, Ulmeyer M, Happ N. Sexual activity during pregnancy and after
childbirth:results from the Sexual Preferences Questionnaire. J Psychosom Obstet
Gynaecol 2001;22(1):29-40.
10. Von Sydow K. Sexuality during pregnancy and after childbirth: a metacontent
analysis of 59 studies. J Psychosom Res 1999;47(1):27-49.
11. Reamy KJ, White SE. Sexuality in the puerperium: a review. Arch Sex Behav
1987;16(2):165-86.
12. Kayner CE, Zagar JA. Breast-feeding and sexual response. J Fam Pract
1983;17(1):69-73.
13. Alder EM, Cook A, Davidson D, West C, Bancroft J. Hormones, mood and
sexuality in lactating women. Br J Psychiatry 1986;148:74-9.
14. Elia G, Bergman A. Pelvic muscle exercises: when do they work? Obstet Gynecol
1993;81(2):283-6.
15. Kennedy KI, Trussell J. Postpartum contraception and lactation. In: Hatcher RA,
et al. Contraceptive Technology. 18th revised ed. New York, NY: Ardent Media;
2004, pp 575-600.
16. Kennedy KI. Efficacy and effectiveness of LAM. Adv Exp Med Biol 2002;
503:207-16.
17. Valdes V, Labbok MH, Pugin E, Perez A. The efficacy of the lactational
amenorrhea method (LAM) among working women. Contraception
2000;62(5):217-9.
18. Kennedy KI, Kotelchuck M, Visness CM, Kazi A, Ramos R. Users’ understanding
of the lactational amenorrhea method and the occurrence of pregnancy. J Hum
Lact 1998;14(3):209-18.
19. Hatcher RA, Nelson A. Combined hormonal contraceptive methods. In: Hatcher
RA, et al. Contraceptive Technology. 18th revised ed. New York, NY: Ardent Media;
2004, pp 391-460.
20. Depo-Provera Physician Information. Pfizer, Inc. Available from: http://
www.pfizer.com/pfizer/download/uspi_depo_provera_contraceptive.pdf. [Revised
November 2004.]

26
21. Grimes D, Schulz K, Van Vliet H, Stanwood N. Immediate post-partum insertion
of intrauterine devices. Cochrane Database Syst Rev 2003;(1):CD003036.
22. Cox M, Tripp J, Blacksell S. Clinical performance of the levonorgestrel
intrauterine system in routine use by the UK Family Planning and Reproductive
Health Research Network: 5-year report. J Fam Plann Reprod Health Care
2002;28(2):73-7.
23. Jamieson DJ, Kaufman SC, Costello C, Hillis SD, Marchbanks PA, Peterson HB,
et al. A comparison of women’s regret after vasectomy versus tubal sterilization.
Obstet Gynecol 2002;99(6):1073-9.
24. Wilcox LS, Chu SY, Eaker ED, Zeger SL, Peterson HB. Risk factors for regret after
tubal sterilization: 5 years of follow-up in a prospective study. Fertil Steril
1991;55(5):927-33.
25. Westhoff C, Davis A. Tubal sterilization: focus on the U.S. experience. Fertil Steril
2000;73(5):913-22.
26. Association of Reproductive Health Professionals. An update on transcervical
sterilization. Clin Proc 2002.

27
28
Contraceptive Options for U.S. Women in the Postpar tum Perioodd
METHOD ADVANTAGES CONSIDER
Most effective (99% or more effective)
Transcervical sterilization (EssureTM) Permanent. May be placed in an office setting. Delayed efficacy. Follow-up procedure
(hysterosalpingogram) required to confirm
efficacy. Non-reversible.
Tubal ligation Permanently eliminates concerns about birth Non-reversible in most cases. Can be done
control. Surgical procedure. laparoscopically.
Intrauterine contraception (Copper T IUD Copper T IUD lasts 10 -12 years; LNG IUS lasts Lower risk of expulsion if insertion delayed until 6
[ParaGard®] or LNG IUS [Mirena®]) up to 5 years. Can be used by nursing women. weeks postpartum.
Not recommended for women currently at risk of
STIs or pelvic inflammatory disease.

Very effecti ve (91% ­ 99% effective)

Oral contraceptives (OCs): combination Does not interfere with sexual activity. Helps Estrogen-containing OCs are not generally
ease menstrual cramps and regulate menstrual recommended for women who are breastfeeding.
periods; may be used continuously to suppress If not nursing, women can begin using 3-4 weeks
periods. Reduces risk of ovarian and postpartum.
endometrial cancer.
Oral contraceptives: progestin-only Suitable for breastfeeding women. Does not Breastfeeding women can initiate 6 weeks
interfere with sexual activity. May cause irregular postpartum.
menstrual bleeding.

Injection (DMPA) Contains synthetic progesterone. Suitable for Injections 4 times/year. Irregular menstrual cycles
nursing mothers. and weight gain possible. Fertility may take up to
1 year to return.

Patch Provides 1 week of protection. Contains estrogen and therefore

Easy to apply. not recommended for breastfeeding women.
 Vaginal ring Once-a­month vaginal insertion. Can be used Small percentage of users report discomfort;
continuously to suppress menstruation. some women are uncomfortable with vaginal
method.
Effecti ve (81% ­ 90% effective)
Condom Lubricated condoms can ease pain with sex if Condoms may tear during intercourse. Some
vaginal dryness is a problem. Provide STI people are allergic to latex, in which case
protection. Female condom allows woman to polyurethane condoms are recommended.
control use of barrier method.

Diaphragm (with spermicide) Good option for women who prefer a barrier Refitting after childbirth required but should be
method to hormones. delayed for 6 weeks postpartum. Not suitable for
women allergic to latex. May increase risk of
bladder infection. Should be refitted/replaced at
least every 2 years.
Moderately effective (80% effective)
Cervical cap (with spermicide) An option for women who prefer a barrier method Refitting after childbirth required but should be
to hormones. delayed for 6 weeks postpartum. Not suitable for
women who are allergic to latex. Should be
refitted/replaced every 2 years.
Spermicides Non-hormonal contraception that is highly Includes foam, creams, gels, vaginal
portable and discreet. Protection against some suppositories, and film. Use with a condom
STIs. boosts effectiveness. Spermicides do not protect
against HIV.
Sponge Non- hormonal contraception that provides a Delay use until 6 weeks postpartum to reduce
barrier to sperm and contains spermicide. risk of toxic shock syndrome. Does not protect
against HIV.

Many couples rely on vasectomy, an option for men, as a method of permanently eliminating concerns about birth control.
29

Vasectomy is an office procedure that is non-reversible in most cases. Vasectomy is 99% or more effective.
Association of Reproductive Health Professionals (ARHP)
2401 Pennsylvania Avenue, NW, Suite 350
Washington, DC 20037
Telephone: (202) 466-3825
Fax: (202) 466-3826
E-Mail: [email protected]
Web: www.arhp.org
ARHP is a non-profit 501(c)(3) educational organization that has been
educating front-line health care providers and their patients since 1963. The
organization fosters research and advocacy to improve reproductive health.
Additional copies of this guide can be ordered by calling (202) 466-3825 or
visiting www.arhp.org. The guide also can be downloaded in PDF format at
www.arhp.org/guide.

©ARHP 2006