By Rebecca Bowers
EXECUTIVE SUMMARY
The American College of Obstetricians and Gynecologists now recognizes immediate postpartum placement of either the intrauterine device or the contraceptive implant as a best practice because of the long-acting reversible contraceptive methods’ role in preventing rapid repeat and unintended pregnancy.
- Results of a just-released study of women who received a postplacental copper T-380A IUD within 10 minutes after vaginal or cesarean delivery suggest that women are more likely to retain the device after cesarean delivery.
- The best practice for immediate postpartum IUD insertion is to place the device in the delivery room within 10 minutes of placental delivery in vaginal and cesarean births when possible. The contraceptive implant may be inserted in the delivery room or at any other time before hospital discharge.
It is estimated that at least 70% of pregnancies in the first year postpartum are unintended.
1 What can family planning clinicians do to help decrease this number?
Both of the intrauterine devices (IUDs) and the contraceptive implant can provide safe, effective birth control. Postpartum use of such long-acting reversible contraceptive (LARC) methods now is recognized by the American College of Obstetricians and Gynecologists as a best practice because of their role in preventing rapid repeat and unintended pregnancy.2 (Contraceptive Technology Update reported on the move; see the January 2018 article, “Time to Update Your Knowledge of Long-acting Reversible Contraceptives,” available at https://bit.ly/2rw9xCO.) Postpartum insertion of the copper T380A IUD is supported by the package label, notes Anita Nelson, MD, professor and chair of the obstetrics and gynecology department at Western University of Health Sciences in Pomona, CA.
By receiving LARC insertions in the immediate postpartum period, women are assured of contraceptive protection following their hospitalization. Research indicates that many women, including those at highest risk of short interpregnancy intervals, have low rates of postpartum visit follow-up. It is estimated that 10-40% of women do not attend the postpartum visit, and 40-75% of women who plan to use an IUD postpartum do not obtain it.3,4 Research indicates that typical-use pregnancy rates for LARC methods are lower when compared with those for oral contraceptives.5
New Data Offer IUD Insight
Results of a just-released study of women who received a postplacental copper T-380A IUD within 10 minutes after vaginal or cesarean delivery suggest that women are more likely to retain the device after cesarean delivery.6 However, the data indicate that women who have an IUD placed after cesarean delivery are more likely to have nonvisible strings with a pelvic exam and to undergo pelvic ultrasound evaluation compared to those women with a device placed at the time of a vaginal delivery. The retrospective cohort study conducted by University of Pennsylvania researchers included 210 women; 169 were available for follow-up.
Expulsion rates for immediate postpartum IUD insertions are higher than for interval or postabortion insertions, with research suggesting percentages as high as 10-27%.7-10 Despite the higher expulsion rate, evidence from clinical trials and cost-benefit analyses indicates that immediate placement is beneficial in lowering unintended pregnancy rates, especially for those at greatest risk of not receiving recommended postpartum follow-up.2
In another recent study, researchers examined pain scores self-reported by women before and during immediate postpartum placement of a copper or levonorgestrel IUD after vaginal delivery.11 A total of 38 women received epidural analgesia, while 30 had no epidural. Data indicate that those who received epidurals had minimal pain before and during IUD placement, with about 50% of those who did not receive epidurals noting some pain during both vaginal delivery and IUD placement.
Consider the Timing
According to published guidance, the best practice for immediate postpartum IUD insertion is to place the device in the delivery room within 10 minutes of placental delivery in vaginal and cesarean births when possible.2 The procedure for immediate postpartum IUD placement differs from the interval insertion technique, so hands-on didactic instruction is required.
Clinicians may place the contraceptive implant in the delivery room or at any other time during the woman’s stay in the postpartum unit before hospital discharge. The technique for placing the implant in the immediate postpartum period does not differ from the technique for interval insertion.
There are no contraindications or risks for implants specific to the postpartum period with the exception of theoretical issues related to breastfeeding, according to American College of Obstetricians and Gynecologists guidance.2
Since progesterone withdrawal after delivery of the placenta is believed to trigger lactogenesis, theoretical concerns have been raised that exogenous progesterone, such as the progestin in hormonal IUDs or implants, could hinder the start of milk production. A review of observational studies of progestin-only contraceptives, including progestogen-only pills, injectables, implants, and hormonal intrauterine devices, indicates that they have no effect on the successful start and continuation of breastfeeding or on infant growth and development.12
The U.S. Medical Eligibility Criteria for Contraceptive Use, 2016 classifies immediate postpartum provision of the levonorgestrel IUD and implant as Category 2 for women who are breastfeeding, with the advantages generally outweighing theoretical or proven risks.13 The copper T380A IUD has no restrictions (Category 1) when it is inserted less than 10 minutes after delivery of the placenta, with a Category 2 rating for insertion 10 minutes after delivery of the placenta and less than four weeks after delivery.
Practice Is Supported
The LARC Program of the American College of Obstetricians and Gynecologists has established the Postpartum Contraceptive Access Initiative (PCAI) to provide clinical and operational support training for immediate postpartum LARC implementation. The initiative’s website, https://pcainitiative.org, contains details about the initiative, information about immediate postpartum LARC, and an application to become a participating hospital site.
- White K, Teal SB, Potter JE. Contraception after delivery and short interpregnancy intervals among women in the United States. Obstet Gynecol 2015;125:1471-1477.
- American College of Obstetricians and Gynecologists. Committee Opinion No. 670: Immediate postpartum long-acting reversible contraception. Obstet Gynecol 2016;128:e32-37.
- Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397-404.
- Gurtcheff SE, Turok DK, Stoddard G, et al. Lactogenesis after early postpartum use of the contraceptive implant: A randomized controlled trial. Obstet Gynecol 2011;117:1114-1121.
- Simmons KB, Edelman AB, Li H, et al. Personalized contraceptive assistance and uptake of long-acting, reversible contraceptives by postpartum women: A randomized, controlled trial. Contraception 2013;88:45-51.
- Colwill AC, Schreiber CA, Sammel MD, Sonalkar S. Six-week retention after postplacental copper intrauterine device placement. Contraception 2018;97:215-218.
- Dahlke JD, Terpstra ER, Ramseyer AM, et al. Postpartum insertion of levonorgestrel intrauterine system at three time periods: A prospective randomized pilot study. Contraception 2011;84:244-248.
- Chen BA, Reeves MF, Hayes JL, et al. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: A randomized controlled trial. Obstet Gynecol 2010;116:1079-1087.
- Hayes JL, Cwiak C, Goedken P, Zieman M. A pilot clinical trial of ultrasound-guided postplacental insertion of a levonorgestrel intrauterine device. Contraception 2007;76:292-296.
- Celen S, Sucak A, Yildiz Y, Danisman N. Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section. Contraception 2011;84:240-243.
- Carr SL, Singh RH, Sussman AL, et al. Women’s experiences with immediate postpartum intrauterine device insertion: A mixed-methods study. Contraception 2018;97:219-226.
- Kapp N, Curtis K, Nanda K. Progestogen-only contraceptive use among breastfeeding women: A systematic review. Contraception 2010;82:17-37.
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep 2016;65:1-103.
