Elsevier

Contraception

Volume 86, Issue 2, August 2012, Pages 102-105
Contraception

Original research article
Immediate postplacental IUD insertion at cesarean delivery: a prospective cohort study

https://doi.org/10.1016/j.contraception.2011.11.019Get rights and content

Abstract

Background

Immediate postplacental insertion of intrauterine devices (IUDs) during cesarean delivery could reduce a substantial barrier to access to long-term effective contraception. Initiating IUD use prior to discharge from the hospital postpartum eliminates a 6-week postpartum waiting period and an additional office visit.

Study Design

This was a prospective cohort study of 90 patients undergoing cesarean delivery. After delivery of the placenta, a copper T380A IUD was inserted into the endometrial cavity through the incision. The study participants were followed up at 6 weeks and 6 months postpartum. This study was conducted at the Weiler Division of the Montefiore Medical Center and at the Jacobi Medical Center in the Bronx, NY.

Results

Forty-three (48%) women returned for their 6-week follow-up visits, and among those, no expulsions were recorded. Forty-two (47%) women were reached for phone follow-up at 6 months postpartum, and 80% reported being “happy” or “very happy” with their IUD.

Conclusions

Immediate postplacental IUD insertion at the time of cesarean delivery is safe and acceptable.

Introduction

Traditionally, postpartum birth control initiation has been delayed until the 6-week postpartum visit, and women are discharged from the hospital with instructions to avoid sexual activity until 6 weeks postpartum. Waiting until the 6-week postpartum visit to initiate a method of birth control puts women at risk for unintended pregnancy in this immediate postpartum period. Most women are sexually active by 6 weeks postpartum [1], and women who deliver by cesarean may be more likely to resume sexual activity earlier than women who had vaginal deliveries [2], [3]. Additionally, nonbreastfeeding women will begin to ovulate by the fourth postpartum week, putting them at risk for an unintended pregnancy by the time they return for their 6-week postpartum visit [1].

The intrauterine device (IUD) is an effective, long-lasting and reversible method of birth control, with a cumulative pregnancy rate of less than 1 per 100 women within the first year of use [4], [5].

Immediate postpartum IUD insertion has been established as a safe alternative to interval insertion [6]. Specifically, the use of a copper T380A IUD in the immediate postpartum period, including after cesarean delivery, has a category 1 rating in the World Health Organization's medical eligibility for contraceptive use [7]. There are no restrictions on its use in this time period among breastfeeding and nonbreastfeeding women. Reported expulsion rates of IUDs placed immediately postpartum after vaginal delivery are higher than for interval placement; however, few data exist regarding IUDs placed at the time of cesarean delivery [6], [8], [9], [10], [11]. Theoretically, when IUDs are placed at the time of cesarean delivery, the cervix is frequently not fully dilated, making it more difficult for the IUD to be expelled through the cervical canal. Additionally, it is technically easier to achieve appropriate fundal placement of the IUD during cesarean delivery because the entire uterus can be visualized, palpated and manually explored within the surgical field.

We conducted a study to examine the feasibility of a larger study that could determine the expulsion rates of copper T380A IUDs placed at the time of cesarean delivery. Study objectives were to determine the feasibility of enrolling and following women who chose to use the IUD after cesarean delivery, to collect data on IUD expulsion rates within this cohort and to demonstrate that immediate postplacental IUD at the time of cesarean delivery is acceptable to women.

Section snippets

Methods and materials

This study was conducted at the Weiler Division of the Montefiore Medical Center and at the Jacobi Medical Center with the approval from the Institutional Review Board of the Albert Einstein College of Medicine. Women undergoing cesarean delivery at 35 weeks of gestation or greater, who desired a copper T380A IUD for postpartum contraception, were eligible for enrollment. Women were excluded from the study if they met any of the following criteria: (1) less than 35 weeks of gestation, (2)

Results

Ninety women were enrolled from October 2008 until November 2009. The median age of the women was 30 years. Participants were evenly distributed among the two enrollment sites. Eighty-five percent of the women were either Black/African American or Hispanic. Only four (4%) of the women underwent cesarean delivery after the onset of labor. Most women were multiparous, with only four (4%) of the women being nulliparous (Table 1). Although we did not specifically collect data regarding the presence

Discussion

In this feasibility study, we were able to successfully enroll 90 women in approximately 1 year. The copper T380A IUD was an acceptable method of contraception for all of the women contacted at 6 months postpartum. No reported IUD expulsions occurred during our study. A larger study of IUD placement at the time of cesarean delivery is feasible and is needed to further ascertain the expulsion rates and continuation rates associated with IUDs placed at the time of cesarean delivery. Specifically,

Acknowledgments

ParaGard® Copper T380A IUDs were donated by Teva Pharmaceuticals (5 Basel St., Petach Tikva 49131, Israel). There were no other funding sources for this study.

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  • Ultrasound location of intrauterine devices placed at cesarean section over the first year postpartum

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    However, follow-up and symptom management may differ for women receiving IUDs at the time of delivery compared to routine interval placement. When IUDs are placed during cesarean section, 21–54% of strings are visible at the external os at the 6-week follow-up [1,7,8]. Patients without visualized strings require ultrasound to locate the IUD; ultrasound findings may differ for IUDs placed during cesarean section compared to interval placement.

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