More and more women in the developing world are having their babies in hospitals. After the birth of a child, most couples welcome the opportunity either to delay their next pregnancy or, if they have reached their desired family size, to terminate childbearing altogether.
The postpartum insertion of IUDs has a number of advantages, including ease of insertion, availability of skilled personnel and appropriate facilities, and convenience for the woman. Practitioners have been concerned about the possibility of higher expulsion, infection and perforation rates. Postpartum women who choose to breastfeed their infants have an additional concern about the effect of the IUD on breastfeeding and the effect of breastfeeding on the expulsion of the IUD.
Expulsion
After birth, as the uterus returns to normal size (involution), uterine contractions expel retained placental and blood clots and may have a similar effect on any foreign body introduced into the uterus. IUDs inserted within 10 minutes of placenta expulsion have a much lower expulsion risk than those inserted later in the postpartum period, although the expulsion is still higher than for interval insertions (about 42 days after childbirth).
New IUDs have been designed and existing IUDs modified in an attempt to reduce the expulsion rate for postpartum insertions. None of these efforts has been universally successful. A multicenter trial of more than 6000 postpartum insertions of standard and modified Lippes Loop D's and TCu 220C's, conducted by Family Health International (FHI), produced the following conclusions:
Immediate postpartum insertion. The timing of postpartum IUD insertion is important. FHI studies show that for best results devices should be inserted within 10 minutes of placenta expulsion rather than at any other time before discharge from the hospital.
Fundal placement.The way the IUD is inserted is more important than the design of the device. Differences in IUD expulsion rates between centers participating in the trials were generally greater than expulsion rates for different IUDs; the expulsion rates at different study sites ranged from 6 to 37 per 100 women at six months. FHI data show that emphasis needs to be given to the fundal placement of the device. The provider should be able to feel the device through the abdominal and uterine walls at the time of insertion. Retraining is necessary for those individuals who report high expulsion rates.
Type of IUD. The TCu 220C did as well as any other device tested with respect to expulsion rates. The cumulative expulsion rate was 11% at six months post insertion. FHI modification of the TCu 220C by adding biodegradable sutures to the device did not reduce expulsions. The arms of the T device may normally embed in the endometrium and submucosal layer for a few millimeters, thus enhancing the retention of the device. It is expected that the TCu 380 will do equally well; it was not available at the time of these studies. Modification of the Lippes Loop D with sutures had a greater effect; 6-month expulsion rates were 21.5% for the Lippes Loop D and 15.7% for the postpartum modification.
Because uterine contractions are stronger and more frequent in breastfeeding women, uterine involution after delivery is believed to be faster. This could possibly produce either higher expulsion rates (if IUDs were pushed out) or lower expulsion rates (if IUDs were held in). However, results from an FHI pooled dataset of 1800 immediate postpartum insertions indicate that breastfeeding does not increase the risk of expulsion.
Infection
The risks of pelvic infection appear to be no greater with postpartum insertion than with insertion six weeks or longer post delivery. For immediate postpartum insertions the cumulative six-month pelvic inflammatory disease (PID) rate was 3 per 100 women. This rate was inflated because of high reports from one investigator; other investigators reported rates ranging from 1.4 to 2 per 100 women. Most cases of PID occurred within three months of insertion, and some were undoubtedly the result of endometritis associated with delivery rather than with the IUD.
Perforation
The enlarged postpartum uterus may contribute to the displacement of the IUD. This has caused concern over possibile increased risk of uterine perforation as uterine involution occurs. FHI has reported that the perforation risk at one month for immediate postpartum insertions was no greater than that associated with interval insertion, about 1 per 2000 insertions.
Effect on Breastfeeding
IUDs do not have any effect on breastfeeding. Studies have shown that interval insertions of IUDs did not affect length of breastfeeding, infant growth, quantity of milk or milk composition. Thus, they can be used as safely by breastfeeding women as by other women.
Conclusions
In summary:
The risk of IUD expulsion is greater with postpartum insertions, but the risk can be reduced significantly by properly inserting the IUD. The IUD should be inserted at the fundus within ten minutes of placenta expulsion.
No increased risk of pelvic infection occurs with postpartum IUD insertion.
The risk of uterine perforation for postpartum IUD insertion is low.
There is no effect on breastmilk quantity or quality.
The turmoil of delivery can be a difficult time for a woman to make a decision about contraception. Future contraception should be discussed as a part of antenatal care, and women should be counseled and informed about postpartum IUD insertion as an option. Caution must be exercised to ensure that enthusiastic health personnel do not exert any explicit or implicit coercion on these women regarding use of the IUD or any other contraceptives.
