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Immediate Postpartum (Post-Placental) IUD Placement

Contributor: Adam Tyson, MD
Date: December 1, 2016

Immediate postpartum placement of intrauterine contraception in the delivery room or operating room is safe, effective and offers the patient an advantage in immediate protection and convenience, avoiding the necessity of additional visits and possible loss of opportunity for placement. Immediate postpartum placement has as its goal, post-placental insertion of an IUD performed within 10 minutes after delivery of the placenta. Either the Copper T or Levonorgestrel system devices may be used.
Counseling should include the following:

  • Expulsion rates may be higher than interval placement with rates up to 10-24% reported after vaginal delivery an 8% after cesarean (compared to 4-6% for interval placement).
  • Signs and symptoms of expulsion including the need for backup contraception, if expulsion occurs.
  • Replacement cost vary with insurance plan and if possible the device should be brought to the office for refund.
  • A follow-up clinical visit is required in approximately 6 weeks to trim the strings from IUD. This visit can coincide with the 6 weeks postpartum check.

Eligibility

  • The patient must have Medicaid or commercial insurance which covers immediate postpartum IUD placement or must have made prior arrangements to obtain the device by purchase or private support (such as ARCH Foundation).
  • A standard hospital consent form should be signed at admission for immediate post placental placement of IUD.

Contraindications and Exclusions
Antepartum Exclusions:

  • Device- Specific contraindications such as allergy to any component of the IUD or Wilson’s disease
  • Active or suspected cervical malignancy which includes HSIL pap
  • Uterine cavity abnormality
  • Sexually Transmitted Infection during current pregnancy which has not been treated or no test of cure is documented

Intrapartum Exclusions:

  • Placenta accreta
  • Chorioamnionitis either diagnosed or suspected
  • Genital trauma with active severe bleeding requiring urgent repair that would preclude timely IUD placement
  • Postpartum hemorrhage which is actively being treated 10 minutes after delivery of the placenta
  • Purulent cervical discharge
  • Retained placenta requiring manual or curettage removal

Insertion Technique for Ring Forceps or Mirena IUD Applicator after Vaginal Delivery
It is recommended that bedside ultrasound be used during insertion to confirm high fundal placement. Ideally insertion should began within 10 minutes of delivery of the placenta, although if the cervix remains open and high placement is feasible then it may be done at the provider’s discretion. YouTube SPIRES Training video: https://www.youtube.com/watch?v=uMcTsuf8XxQ

Click here for Procedural List for ring IUD

Manual insertion can be accomplished requiring no instruments; however, it may be more painful than insertion with ring forceps or the IUD applicator in the absence of anesthesia. Insertion with forceps or IUD applicator is preferred at this time secondary to less pain and possibly fewer expulsions.
Insertion Technique for Cesarean Delivery
The preoperative timeout should include IUD placement as part of the procedure and the device accounted for as an implant.

Click here for Procedural List for Cesarean IUD

Postpartum Care

  • Anticipate routine postpartum care.
  • Treatment of abnormal bleeding or uterine atony should follow usual clinical practice. If manual exploration of the intrauterine cavity or curettage is required for any reason, this may calls inadvertent is location of the IUD.
  • If the patient subsequently develops postpartum endometritis, it is advisable to remove the IUD device.
  • Strings may not be visible within the vagina. Placement may be confirmed by bedside ultrasound, if this is the case.
  • Instruct the patient not to pull on strings if they are felt within the vagina. Strings may be trimmed as needed at a 6 weeks postpartum follow-up visit.

Documentation

  • Procedure note should be written for each placement. This should be separate from the delivery or operative note for billing purposes.
  • The note should include the type of device and the method of insertion.
  • The patient consent form and documentation of the device number should be scanned into the patient’s electronic medical record.

Additional Resources

References

  • ACOG practice bulletin 121 Long Acting Reversible Contraception: Implants and Intrauterine Devices.  (July, 2011, reaffirmed 2015).
  • ACOG Committee Opinion 670 Immediate Postpartum Long-Acting Reversible Contraception (August 2016)
  •  Intrauterine Device Placement During Cesarean Delivery and Continued Use 6 Months Postpartum: A Randomized Controlled Trial.Levi EE, Stuart GS, Zerden ML, Garrett JM, Bryant AG.Obstet Gynecol. 2015 Jul;126(1):5-11.
  • Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial.Chen BA, Reeves MF, Hayes JL, Hohmann HL, Perriera LK, Creinin MD.Obstet Gynecol. 2010 Nov;116(5):1079-87.
  • Immediate postplacental insertion of a copper intrauterine device: a pilot study to evaluate expulsion rate by mode of delivery. Sucak A, Ozcan S, Çelen Ş, Çağlar T, Göksu G, Danışman N.BMC Pregnancy Childbirth. 2015 Sep 2;15:202.
  • Immediate postpartum insertion of intrauterine device for contraception. Lopez LM, Bernholc A, Hubacher D, Stuart G, Van Vliet HA.  Cochrane Database Syst Rev. 2015 Jun 26
  • Intrauterine device insertion during the postpartum period: a systematic review.  Kapp N, Curtis, KM.
  • Contraception. 2009 Oct;80(4):327-36.

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