UNITED NATIONS POPULATION INFORMATION NETWORK (POPIN)
UN Population Division, Department of Economic and Social Affairs,
with support from the UN Population Fund (UNFPA)

IUD Insertion Timing Vital in Postpartum Use

NETWORK

Intrauterine Devices

Family Health International, Vol. 16, No. 2, Winter 1996



Copyright 1996, Family Health International





IUD Insertion Timing Vital in Postpartum Use



Because of expulsion risks, insertion ideally should take place

soon after delivery, or delayed for weeks.



As a contraceptive used during the postpartum period, the IUD has

a distinct advantage: It does not affect breastfeeding, as do many

systemic contraceptive methods. The postpartum period may also be

a convenient time during a woman's life to have an IUD inserted,

since it may be one of the few times she is in contact with medical

services.



In addition, IUDs do not require regular user compliance.

Coital-dependent methods may be used inconsistently during the

postpartum period by couples who think conception is less likely

during this period. Also, if a woman says she wants no more

children but has not had time to consider sterilization carefully,

an IUD offers a reversible alternative.



Timing of insertion, counseling, provider training and programmatic

support are critical factors for IUD use during the postpartum

period.



The timing of insertion is important primarily because it

influences the risk of expulsion. Expulsion can leave a woman

unprotected from pregnancy without her realizing it. Ideally,

postpartum insertion should take place within 10 minutes of

placental delivery (immediate postplacental) or at about six weeks

after birth, when a woman returns for a routine postpartum care

visit.



Postpartum insertion can be done before hospital discharge (up to

72 hours after delivery), but it should not be done between 72

hours and about six weeks postpartum because of an increased risk

of expulsion and perforation. Special training is required for

immediate postplacental insertions and for insertion within the

first  2 hours. Copper T IUDs may be safely inserted as early as

four weeks postpartum, but for other IUDs, one should wait until

six weeks postpartum. This is because the so-called "push insertion

technique," used for some types of noncopper IUDs, might result in

higher perforation rates.1/



Immediate postplacental insertion should only be done if there is

adequate prenatal counseling. Ideally, choices of methods should be

discussed during routine prenatal visits, allowing women to choose

the most appropriate method at that point. In some cases, a woman

in the early stages of labor could receive enough information after

arriving at the clinic to decide to have a postplacental insertion.

Likewise, a woman could decide after delivery to have an IUD

inserted before leaving the hospital. A woman should never receive

an IUD immediately after delivery without having received adequate

counseling and giving her informed consent. Counseling should be

done once the emotional and physical stresses of labor have ended.





Good postpartum IUD programs in hospitals need national and

regional support. Clinicians need specialized insertion training,

and prenatal clinics must give priority to contraceptive

counseling. A variety of methods should be available to potential

users. Also, the obstetric unit of the health-care center must work

in close coordination with the family planning or maternal and

child health unit. Only a few countries, including Mexico and

Colombia, have committed major resources and programmatic attention

to postpartum IUD programs.



Safe and effective



Studies have shown that postpartum IUD insertions, including those

done immediately after placental delivery or cesarean section, are

generally safe and effective. Compared with interval insertions,

postpartum insertions do not increase the risk of infection,

bleeding, uterine perforation or endometritis, nor do they affect

the return of the uterus to its normal size.2/  ("Interval

insertions" are those that are done after the postpartum period of

six weeks following delivery.)



Research shows that with the Copper T 380A IUD, breastfeeding women

have less pain at insertion, and have lower removal rates due to

bleeding or pain than nonbreastfeeding women.3/



An IUD can also be safely inserted immediately after a spontaneous

or induced abortion except when the uterus is infected or at risk

of infection, there is serious injury to the genital tract, or

there is hemorrhage or severe anemia. If the abortion occurs after

16 weeks of pregnancy, IUD insertion should only be done by someone

specially trained in correct fundal placement. Otherwise, the

insertion should be delayed for six weeks after abortion because

the uterine cavity is too enlarged for using routine insertion

techniques.



The main problem with postpartum insertions is that they generally

result in higher expulsion rates than interval insertions. Risk of

expulsion is lower for insertions done within 10 minutes of

delivery than for those done between 10 minutes and hospital

discharge.@4 One multisite study found that after six months, the

cumulative expulsion rate was 9 percent for immediate postplacental

insertion, or nine of every 100 women, compared with 37 percent for

insertions done between 24 and 48 hours after delivery, or about

one out of three women.5/  The risk of expulsion can be reduced

substantially with appropriate training in postpartum insertion

techniques.



For interval insertions, the rate of expulsion after 12 months is

about 6 percent, or six out of 100 women.6/ Expulsion rates for

insertions following cesarean deliveries are about the same as for

interval insertions, according to studies conducted in Mexico,

Belgium and China. Expulsion rates can vary extensively, depending

on the timing of insertion, the technique used, skill of the person

doing the insertion, and the type of IUD used. These factors are

especially important in postpartum insertions.  A study of

immediate postplacental insertions reported three-year cumulative

expulsion rates of 28 percent for the Lippes Loop compared to 11

percent for copper T's.7/



High fundal placement by hand or with forceps during the postpartum

period reduces the risk of expulsion. The provider should feel the

IUD against the fundus both internally and through the abdominal

wall. An inexperienced person might tend to place the IUD too low

in the uterus.8/



A recent FHI study in Africa showed the importance of training and

experience. The study evaluated postpartum IUD programs at the

Provincial General Hospital of Nyeri, Kenya and the Maternite

Hamdallaye of Bamako, Mali. All women who received an IUD during a

seven-month period were interviewed. In Kenya, 224 IUD acceptors

were interviewed at six weeks, three months and six months after

insertion along with 185 nonacceptors. In Mali, a similar approach

involved 110 acceptors and 273 nonacceptors.9/



The six-month cumulative expulsion rates in Kenya were 1 percent

for immediate insertions and 5 percent for insertions done before

hospital discharge, rates comparable to or even lower than interval

insertions. These low rates might be attributable to the extensive

training and experience of the Kenyan providers.



In Mali, the six-month expulsion rates of 15 percent (immediate

postplacental) and 27 percent (before leaving the hospital) were

skewed by the high rates for one of the three providers, who had

far less training and experience than the other two. All of the

providers were midwives. Removals for medical reasons and pelvic

infections were rare in both countries, and no uterine perforations

were reported.



Counseling critical



In the Kenya and Mali programs, women who had received counseling

in the prenatal period or during the first stage of labor at the

hospital were eligible for an immediate insertion. Women who were

counseled about IUD insertion after delivery could choose to have

an IUD inserted before hospital discharge, generally within 72

hours of delivery. "Prenatal counseling is important because it

allows for immediate postplacental placement, which is associated

with lower expulsion rates," says Dr. Charles Morrison of FHI,

study coordinator.



Few studies have examined counseling issues and other service

delivery questions regarding postpartum IUD use. Often, providers

discuss the method choice only with the woman. But later, a husband

or other family member such as a mother-in-law may object to the

choice. Ideally, a couple would receive thorough prenatal

counseling together about contraceptive choices, including IUDs.

Such a counseling approach would better prepare the family for the

method and encourage longer continuation rates. In the Africa

postpartum study, for example, husbands' desires for IUD removals

was a significant reason for removal, emphasizing the importance of

involving the husband in prenatal counseling.



Because most expulsions occur in the early months, it is

particularly important to give clear instructions about recognizing

expulsion through the string length. The copper T device has a

string 12 cm long that can easily move into the enlarged postpartum

uterus and therefore can no longer be felt by the woman.



"A number of relevant questions with regard to missing strings need

to be answered," says Dr. I-cheng Chi of FHI, an IUD specialist.

"Do the missing threads indicate expulsions or retraction of the

strings into the uterus? Should the IUDs be removed when the

strings are missing, and is this removal difficult? Should

follow-up visits for immediate postpartum insertion be scheduled

earlier than for interval insertions so as to discover the missing

threads in time?"



Characteristics of successful postpartum contraceptive programs

were identified at a 1990 worldwide meeting sponsored by FHI, the

Mexican Ministry of Health and the Instituto Mexicano del Seguro

Social (IMSS). Among the important characteristics was good

training in counseling, quality of care, and clinical issues for

personnel at all levels.



                                             -- William R. Finger



Footnotes



1. Curtis KM, Bright PL, eds. Recommendations for Updating Selected

Practices in Contraceptive Use: Results of a Technical Meeting,

Volume I. (Chapel Hill: Technical Guidance Working Group, U.S.

Agency for International Development, 1994) 74.



2. Chi I-c. Postpartum IUD insertion: Timing, route, lactation and

uterine perforation. Proceedings from the Fourth International

Conference on IUDs. Ed. Bardin CW, Mishell DR. (Newton, MA:

Butterworth-Heinemann, 1994) 219-27.



3. Farr G, Rivera R. Interactions between intrauterine

contraceptive device use and breastfeeding status at time of

intrauterine contraceptive device insertion: Analysis of TCu-380A

acceptors in developing countries. Am J Obstet Gynecol 1992;167(1):

144-51.



4. Chi I-c, Farr G. Review article: Postpartum IUD contraception --

a review of an international experience. Adv Contracept

1989;5(3):127-46.



5. Chi I-c, Wilkens LR, Rogers S. Expulsions in immediate

postpartum insertions of Lippes Loop D and Copper T IUDs and their

counterpart Delta devices -- an epidemiological analysis.

Contraception 1985;32(2):119-34.



6. Sivin I, Greenslade F, Schmidt F, et al. The Copper T 380

Intrauterine Device: A Summary of Scientific Data. (New York: The

Population Council, 1992) 15.



7. Thiery M, Van Kets H, Van Der Pas H. Immediate postplacental IUD

insertion: The expulsion problem. Contraception 1985;31(4):331-49.



8. O'Hanley K, Huber DH. Postpartum IUDs: keys for success.

Contraception 1992;45(4):351-61.



9. Morrison C, Waszak C, Katz K, et al. Clinical outcomes of two

postpartum IUD insertion programs in Africa. Contraception, in

press.


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