Most women do not desire a pregnancy immediately after a delivery but are unclear about contraceptive usage in postpartum period. This results in unplanned and undesired pregnancies, which in turn increases induced abortion rates and consequently maternal morbidity and mortality. In a recent study of postpartum unintended pregnancies 86% resulted from nonuse of contraception and 88% ended in induced abortions [
In India, as in many other countries, postpartum family planning is usually initiated after 6 weeks postpartum. Early resumption of sexual activity coupled with early and unpredictable ovulation leads to many unwanted pregnancies in the first year postpartum. Moreover, in developing countries particularly, women who once go back home after delivery do not return for even a routine postpartum check-up, leave aside contraception. This is may be due to lack of education and awareness, social pressure, and nonaccess to facilities nearby.
Thus, immediate postpartum family planning services need to be emphasized wherein the woman leaves the hospital with an effective contraception in place. Increase in hospital deliveries provides an excellent opportunity to sensitize women and provide effective contraception along with delivery services. An intrauterine contraceptive device (IUCD) has several advantages for use in postpartum period as it is an effective, long term reversible contraception, is coitus independent, and does not interfere with breast feeding.
Cochrane reviews provide evidence of safety and feasibility of postpartum IUCD (PPIUCD) insertions in various settings [
Immediate postpartum IUCD (IPPIUCD) insertions at Pt. B.D. Sharma Post Graduate Institute of Medical Sciences were studied. Follow-up clinic visits of women who reported for examination after 6 weeks of IPPIUCD insertion at our institute were analyzed.
Inclusion criteria for IPPIUCD insertions were women delivering either vaginally or by caesarean section, had received counselling for postpartum contraception, and consented to IPPIUCD insertions. Counselling was done during antenatal visits or during early labour and a written informed consent was taken prior to insertions. Criteria used for exclusion were haemoglobin less than 8 gm%, rupture of membranes more than 18 hours, postpartum haemorrhage, coagulation disorders, fever, or clinical symptoms of infection during labour. The IUCD used was CuT-380 A, which was available free of cost in the Government Program. This was placed in uterine fundus with the help of long and curved forceps without lock (Kelly’s Placental Forceps) for vaginal insertions, within 10 minutes of removal of placenta. During caesarean section ring forceps were used to place the IUCD in fundus of uterus through the lower segment incision which was closed subsequently as routine. The IUCD strings were not trimmed in both types of insertions and left in uterine cavity. Active management of third stage of labour was performed as routine. All IPPIUCD insertions were done by doctors who had been trained for this purpose. Postinsertion counselling was done and women were advised to follow-up for examination at our centre after 6 weeks.
At the follow-up visit, the women were asked for any symptoms of unusual vaginal discharge, irregular bleeding per vaginum, and any expulsions noticed. Pelvic examination was performed to examine the descent of IUCD strings into vagina and to check signs of infection and bleeding. Descended strings were trimmed approximately 2 cm beyond external os. If strings were not visible on per speculum examination, an ultrasound was performed to check for expulsions and confirm presence of intrauterine IUCD. If the women requested removal of IUCD for any medical or personal reason, she was counselled and intrauterine device was removed. Women were offered reinsertion of IUCD or alternative methods of contraception in case of expulsions/removals.
Immediate postpartum IUCD service became a Government of India approved program in 2010. Since then IPPIUCD insertions are a part of routine curriculum at this institute. Written informed consent was obtained from all clients of IPPIUCD.
The primary outcome measures were the clinical outcomes in terms of safety (perforation, unusual vaginal discharge, infection, and irregular bleeding), efficacy (pregnancy, expulsions, and discontinuations), and incidence of undescended IUCD strings. These outcomes were compared for vaginal and caesarean IPPIUCD insertions.
Statistical analysis was carried out using Statistical Package for Social Sciences (SPSS) Version 19.0. Descriptives were calculated for various clinical outcomes, and chi square tests were used for comparison in between categorical variables. For all the tests performed, results were considered statistically significant for
A total of 593 immediate postpartum IUCD insertions were studied. Out of these 346 (58.3%) insertions were intracaesarean and 247 (41.7%) IUCDs were placed after vaginal delivery.
Follow-up clinic visits of IPPIUCD clients recorded were 171 (28.8% of total insertions). Fifty-five percent of the total follow-up visits were of intracaesarean IPPIUCD insertions, but the difference in follow-up visits of vaginal and caesarean IPPIUCDs was not significant (
Outcomes of PPIUCDS at follow-up visits.
Frequency ( |
Percentage (%) | |
---|---|---|
|
||
(i) Perforation | 0 | 0% |
(ii) Unusual vaginal discharge | 21 | 12.3% |
(iii) Infection | 3 | 1.75% |
(a) Vaginitis | 2 | 1.17% |
(b) PID | 1 | 0.58% |
(iv) Irregular bleeding | 18 | 10.5% |
|
||
(i) Pregnancy | 0 | 0% |
(ii) Expulsion | 9 | 5.3% |
(iii) Discontinuation | 7 | 4.1% |
|
65 | 38% |
Symptoms of unusual vaginal discharge were reported by 12.3% women at follow-up and this complaint was significantly higher after caesarean IUCD insertions (
Assessment of safety.
Vaginal |
Caesarean |
Total |
|
Odds ratio | ||
---|---|---|---|---|---|---|
Perforation | No | 77 | 94 | 171 | — | — |
Yes | 0 | 0 | 0 | |||
|
||||||
Unusual vaginal discharge (self-reported) | No | 72 | 78 | 150 |
|
2.621 |
Yes | 05 | 16 | 21 | |||
|
||||||
Infection | No | 76 | 92 | 168 | 0.681 | 1.638 |
Yes | 01 | 02 | 03 | |||
|
||||||
Irregular bleeding per vaginum | No | 67 | 86 | 153 | 0.343 | 0.6553 |
Yes | 10 | 08 | 18 |
Change in bleeding pattern, which was mainly increased blood loss (menorrhagia), was observed in 10.5% women. There was no significant statistical difference in rates of infection or irregular bleeding between the two insertion groups (Table
Spontaneous expulsion of IUCD occurred in 9 (5.3%) cases at follow-up. One IUCD which was partially expelled into cervical canal was also included in expulsions. Women who had IUCD inserted after vaginal delivery had significantly higher expulsion rates (9.1%) than intracaesarean IUCDs (2.1%) with
Comparison of efficacy.
Vaginal |
Caesarean |
Total |
|
Odds ratio | ||
---|---|---|---|---|---|---|
Pregnancy | No | 77 | 94 | 171 | — | — |
Yes | 0 | 0 | 0 | |||
|
||||||
Expulsion | No | 70 | 92 | 162 |
|
4.273 |
Yes | 07 |
02 | 09 | |||
|
||||||
Discontinuation |
No | 72 | 92 | 164 | 0.152 | 3.052 |
Yes | 05 | 02 | 07 |
IUCD removal was done on request of the women for medical/personal reasons leading to discontinuation in 7 cases (4.1%).
IUCD strings had not descended into vagina in 38% cases at clinical examination done at follow-up visits (the cases of spontaneous expulsions were excluded). All women with undescended strings underwent ultrasonographic confirmation of intrauterine placement of the device. Half of the intracaesarean insertions (55.1%) presented with undescended strings at follow-up as compared to 22.1% insertions after vaginal delivery. This difference was highly significant statistically (
The revival of postpartum IUCD by Ministry of Health and Family Welfare, Government of India, with technical assistance from Jhpiego in 2010 leads to conscious efforts to provide the benefits of this long term reversible postpartum contraception in the delivery setting of our institute [
Women undergoing caesarean section seem to have greater probability of accepting postpartum IUCD possibly due to postcaesarean conception fear. Further, the number of women following up after intracaesarean insertions was also higher than postplacental vaginal insertions, although this difference was not statistically significant. It appears that women undergoing caesarean delivery are more compliant with follow-up visits probably for fear of complications.
Although all the women who underwent immediate postpartum IUCD insertions (vaginal or caesarean) were counselled and advised to come for a follow-up examination at our institute, only a few women actually reported for a follow-up clinic visit. The possible explanation could be that even though a large number of rural women from all over our state and neighbouring districts come to our tertiary centre for purpose of delivery, for follow-up examination they prefer visiting their local health centres due to large distances and transportation problems.
In a recent prospective study of follow-up of PPIUCD from a peripheral health centre of India, scheduled follow-up was observed in 65.2% cases. Around 22% cases had to be contacted telephonically and transportation incentives were provided for coming for follow-up [
Amongst the women studied at follow-up, there was no case of uterine perforation. None of the studies, as per literature search, have reported uterine perforation after PPIUCD insertion.
In women reporting symptoms of unusual vaginal discharge, actual infection was present in only 1.75% cases on clinical examination. It is known that some women report increased vaginal discharge with the IUCD, which is usually normal leucorrhoea and not a sign of infection [
The symptom of irregular bleeding per vaginum was not influenced by route of insertion. The women mainly complained of excessive bleeding and were treated adequately with Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and haematinics. Shukla et al. indicated a higher incidence of menorrhagia (27.2%) with use of CuT 200 in postpartum women [
In the present study, a lesser number of spontaneous IUCD expulsions were observed as compared to other studies. Çelen et al. reported 1-year cumulative expulsion rates of 12.6% and 17.6% in two different studies of PPIUCD insertions [
The expulsions were significantly higher in postplacental IUCD insertions after vaginal deliveries as compared to caesarean insertions. This difference was also observed in a recent systematic review of PPIUCD insertions [
In the present study, even if we combine the discontinuations (removal of IUCD for different medical or personal reasons) and spontaneous expulsions we still have a commendable IUCD continuation rate of 90.6%. In the absence of IPPIUCD insertions, these women would have left the hospital premises without effective postpartum contraception. Similar rates of removal of PPIUCD have been reported in recent studies, ranging 3–8% [
One of the main observations at follow-up was that of undescended IUCD strings. The practice of leaving the full length of IUCD string in uterine cavity during caesarean section and not passing it through the cervix, unlike study by Çelen et al., may have had a role in the significant difference in the incidence of undescended strings in intracaesarean insertions. Our technique might also be the reason for lower expulsion rates as compared to study by Çelen et al. (5.3%) for intracaesarean IUCD insertions at 6 weeks of follow-up [
Insertion of IUCD in immediate postpartum period is an effective, safe, and convenient contraceptive intervention in both cesarean and vaginal deliveries. Although there is a relatively higher incidence of expulsions after vaginal IPPIUCD insertions, they should be encouraged considering the advantages that come along. PPIUCD insertions by trained clinicians, principles of fundal placement using long placental forceps, and timing of insertion are instrumental in reducing complications and expulsions. Early follow-up examinations are important to identify spontaneous expulsions and provide alternative contraceptives or IUCD reinsertions.
Intrauterine contraceptive device
Immediate postpartum IUCD
Copper-T.
The authors declare no competing interests.
The authors acknowledge Jhpiego and Ministry of Health and Family Welfare, Government of India, for technical support and training in PPIUCD. The work of PPIUCD counsellor Ms. Sarita is also acknowledged for counselling women for postpartum contraception.