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Society of Family Planning Guidelines: Postplacental insertion of intrauterine devices

      Abstract

      Postplacental intrauterine device (IUD) placement, defined as IUD placement within 10 min after delivery of the placenta, is an appealing strategy for increasing access to postpartum IUDs because it does not require a separate postpartum visit. These guidelines present an evidence-based assessment of postplacental IUD placement after vaginal and cesarean delivery. Postplacental IUD insertion is safe and does not have higher risks of complications than interval insertion. Most studies find that the risk of IUD expulsion is higher after postplacental insertion than after interval insertion for both vaginal and cesarean deliveries. Most studies find higher rates of expulsion after vaginal delivery than after cesarean delivery. However, expulsion rates vary widely across studies, without clear evidence about the factors that may influence expulsion. In settings where replacement of expelled IUDs is available, patient populations with low rates of return for the postpartum visit are most likely to benefit from provision of postplacental IUD placement with appropriate counseling about risks and benefits.

      Keywords

      1. Background

      Intrauterine device (IUD) placement within 10 min after delivery of the placenta is an appealing strategy for increasing access to postpartum IUDs because it does not require a separate postpartum visit. The American College of Obstetricians and Gynecologists (ACOG) strongly encourages the practice of immediate postpartum provision of long-acting reversible contraception (LARC) [
      ]. To increase access to postpartum LARC, 27 states and the District of Columbia have published proposed or final guidelines for Medicaid reimbursement for in-hospital provision of postpartum LARC, including IUDs [
      • American Congress of Obstetricians and Gynecologists
      ]. In the United States, the rate of postpartum IUD insertion prior to hospital discharge has been increasing, from 0.10 per 10,000 deliveries in 2001–2002 to 0.55 per 10,000 deliveries in 2007–2008 [
      • Whiteman M.K.
      • Cox S.
      • Tepper N.K.
      • Curtis K.M.
      • Jamieson D.J.
      • Penman-Aguilar A.
      • et al.
      Postpartum intrauterine device insertion and postpartum tubal sterilization in the United States.
      ]. An updated analysis found an overall LARC insertion rate of 13.5 per 10,000 deliveries in 2012–2013 with significant increases in both IUDs and implants [
      • Moniz M.H.
      • Chang T.
      • Heisler M.
      • Admon L.
      • Gebremariam A.
      • Dalton V.K.
      • et al.
      Inpatient postpartum long-acting reversible contraception and sterilization in the United States, 2008–2013.
      ].
      In these guidelines, we use a modified version of the 1983 World Health Organization (WHO) definitions for insertion after delivery [
      • World Health Organization
      Intrauterine devices: their role in family planning care.
      ]:
      • 1.
        postplacental (or immediate postpartum): IUD insertion within 10 min of delivery of the placenta;
      • 2.
        early postpartum: IUD insertion>10 min to 1 week postpartum;
      • 3.
        delayed postpartum: IUD insertion 1 week through 6–8 weeks after delivery;
      • 4.
        interval: IUD insertion unrelated to timing of delivery, usually after 6–8 weeks.

      2. Short-interval pregnancies

      Contraceptive options should be discussed during antenatal care and if desired should be initiated as soon as possible postpartum [
      • American Academy of Pediatrics and the American College of Obstetricians and Gynecologists
      Guidelines for Perinatal Care.
      ] because repeat pregnancy within the first year postpartum can be as high as 10–44%, with higher rates in high-risk adolescents [
      • Templeman C.L.
      • Cook V.
      • Goldsmith L.J.
      • Powell J.
      • Hertweck S.P.
      Postpartum contraceptive use among adolescent mothers.
      ,
      • Jacoby M.
      • Gorenflo D.
      • Black E.
      • Wunderlich C.
      • Eyler A.E.
      Rapid repeat pregnancy and experiences of interpersonal violence among low-income adolescents.
      ,
      • White K.
      • Teal S.B.
      • Potter J.E.
      Contraception after delivery and short interpregnancy intervals among women in the United States.
      ,
      • Damle L.F.
      • Gohari A.C.
      • McEvoy A.K.
      • Desale S.Y.
      • Gomez-Lobo V.
      Early initiation of postpartum contraception: does it decrease rapid repeat pregnancy in adolescents?.
      ]. Women who have consecutive pregnancies with less than 12 months between delivery and conception are more likely to experience adverse health outcomes, including uteroplacental bleeding, preterm premature rupture of membranes, and uterine rupture among women attempting a trial of labor after cesarean delivery [
      • Conde-Agudelo A.
      • Rosas-Bermudez A.
      • Kafury-Goeta A.C.
      Effects of birth spacing on maternal health: a systematic review.
      ]. Infants born from short-interval pregnancies are at higher risk for preterm delivery, low birth weight, and small for gestational age [
      • Conde-Agudelo A.
      • Rosas-Bermudez A.
      • Kafury-Goeta A.C.
      Birth spacing and risk of adverse perinatal outcomes: a meta-analysis.
      ]. Use of a highly effective contraceptive method has been found to lead to more healthy interpregnancy intervals [
      • Damle L.F.
      • Gohari A.C.
      • McEvoy A.K.
      • Desale S.Y.
      • Gomez-Lobo V.
      Early initiation of postpartum contraception: does it decrease rapid repeat pregnancy in adolescents?.
      ,
      • Baldwin M.K.
      • Edelman A.B.
      The effect of long-acting reversible contraception on rapid repeat pregnancy in adolescents: a review.
      ,
      • Stevens-Simon C.
      • Kelly L.
      • Kulick R.
      A village would be nice but...It takes a long-acting contraceptive to prevent repeat adolescent pregnancies.
      ,
      • Tocce K.M.
      • Sheeder J.L.
      • Teal S.B.
      Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference?.
      ,
      • Cohen R.
      • Sheeder J.
      • Arango N.
      • Teal S.B.
      • Tocce K.
      Twelve-month contraceptive continuation and repeat pregnancy among young mothers choosing postdelivery contraceptive implants or postplacental intrauterine devices.
      ,
      • Thiel de Bocanegra H.
      • Chang R.
      • Howell M.
      • Darney P.
      Interpregnancy intervals: impact of postpartum contraceptive effectiveness and coverage.
      ].

      3. Advantages of immediate IUD placement

      IUDs are recommended as first-line contraceptives by ACOG [
      ] and the American Academy of Pediatricians (AAP) [
      • American Academy of Pediatrics
      Contraception for adolescents.
      ]. The Centers for Disease Control and Prevention U.S. Medical Eligibility Criteria for Contraceptive Use (USMEC) places no restrictions on use, and states advantages generally outweigh the risks for immediate postpartum use of IUDs [
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • Berry-Bibee E.
      • Horton L.G.
      • Zapata L.B.
      • et al.
      U.S. medical eligibility criteria for contraceptive use, 2016.
      ].
      Postplacental IUD insertion offers convenience, assurance that the patient is not pregnant, and insurance coverage that may last only through the pregnancy and postpartum period. In a survey of postpartum women, 23% stated that they would have chosen a postplacental IUD if it had been available [
      • Glazer A.B.
      • Wolf A.
      • Gorby N.
      Postpartum contraception: needs vs. reality.
      ]. Studies that have investigated return for IUD insertion after delivery have consistently found low rates of insertion for women who desired an IUD (27–60%) [
      • Ogburn J.A.
      • Espey E.
      • Stonehocker J.
      Barriers to intrauterine device insertion in postpartum women.
      ,
      • Echeverry G.
      Family planning in the immediate postpartum period.
      ,
      • Bergin A.
      • Tristan S.
      • Terplan M.
      • Gilliam M.L.
      • Whitaker A.K.
      A missed opportunity for care: two-visit IUD insertion protocols inhibit placement.
      ,
      • Chen B.A.
      • Reeves M.F.
      • Hayes J.L.
      • Hohmann H.L.
      • Perriera L.K.
      • Creinin M.D.
      Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial.
      ].
      The objective of this guideline is to provide evidence-based recommendations for clinicians, programs, and institutions that would like to offer postplacental IUD insertion, with a focus on modern IUDs available in the United States.

      4. Clinical questions and recommendations

      • 1.
        What risks are associated with postplacental IUD insertion?
        Postplacental IUD insertion has risks similar to insertion at other time points [
        • Sonalkar S.
        • Kapp N.
        Intrauterine device insertion in the postpartum period: a systematic review.
        ,
        • Lopez L.M.
        • Bernholc A.
        • Hubacher D.
        • Stuart G.
        • Van Vliet H.A.
        Immediate postpartum insertion of intrauterine device for contraception.
        ]. Theoretical risks have been assessed in a number of trials and observational studies.
        • Perforation
          Small trials and observational studies of postplacental insertion suggest that perforation is rare, and large systematic reviews have not found higher rates of perforation [
          • Sonalkar S.
          • Kapp N.
          Intrauterine device insertion in the postpartum period: a systematic review.
          ,
          • Lopez L.M.
          • Bernholc A.
          • Hubacher D.
          • Stuart G.
          • Van Vliet H.A.
          Immediate postpartum insertion of intrauterine device for contraception.
          ]. In a prospective study of 8343 women receiving a Copper T 380A (CuT380A) at different postpartum timings, there was only one documented case of perforation after 460 postplacental insertions (0.2%). This risk was not greater than the risk of insertion more than 6 months after delivery [
          • Caliskan E.
          • Ozturk N.
          • Dilbaz B.O.
          • Dilbaz S.
          Analysis of risk factors associated with uterine perforation by intrauterine devices.
          ].
        • Infection
          Risk of infection after postplacental insertion is low, and randomized trials have not demonstrated a difference in infection based on insertion timing [
          • Chen B.A.
          • Reeves M.F.
          • Hayes J.L.
          • Hohmann H.L.
          • Perriera L.K.
          • Creinin M.D.
          Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial.
          ,
          • Whitaker A.K.
          • Endres L.K.
          • Mistretta S.Q.
          • Gilliam M.L.
          Postplacental insertion of the levonorgestrel intrauterine device after cesarean delivery vs. delayed insertion: a randomized controlled trial.
          ,
          • Lester F.
          • Kakaire O.
          • Byamugisha J.
          • Averbach S.
          • Fortin J.
          • Maurer R.
          • et al.
          Intracesarean insertion of the copper T380A versus 6 weeks postcesarean: a randomized clinical trial.
          ,
          • Levi E.E.
          • Stuart G.S.
          • Zerden M.L.
          • Garrett J.M.
          • Bryant A.G.
          Intrauterine device placement during cesarean delivery and continued use 6 months postpartum: a randomized controlled trial.
          ]. Welkovic et al. assessed infection at 10 days postpartum in 145 women who chose a postplacental CuT380A after vaginal delivery and 157 who did not choose an IUD. They found no difference in clinical signs of endometritis between IUD acceptors and non-acceptors (3% vs. 5%, p=.65) or in leukocyte ratio with a left shift (16% in both groups, p=.99) [
          • Welkovic S.
          • Costa L.O.
          • Faundes A.
          • de Alencar Ximenes R.
          • Costa C.F.
          Post-partum bleeding and infection after post-placental IUD insertion.
          ].
        • Vaginal bleeding
          Vaginal bleeding does not appear to be increased after postplacental IUD insertion. Elsedeek et al. examined postplacental IUD insertion at the time of cesarean delivery in 191 women. They compared bleeding patterns among women receiving no IUD (control) to those of women receiving the copper-containing Nova-T IUD and the IUD containing 52 mg of levonorgestrel (LNG-IUD). The mean duration of bleeding was similar for the control group and the Nova-T group, but shorter for the LNG-IUD group (27 days vs. 33 days vs. 20 days, respectively, p<.0001). The same was true of mean pads per day (4.9 vs. 5.0 vs. 3.1, p=.012). [
          • Elsedeek M.S.
          Puerperal and menstrual bleeding patterns with different types of contraceptive device fitted during elective cesarean delivery.
          ]. Welkovic et al. also compared heavy vaginal bleeding between women who had a postplacental CuT380A inserted after vaginal delivery and women who did not. They found no significant difference in the proportion of either women or their nurses reporting heavy vaginal bleeding. Women in both groups had similar hemoglobin concentrations at 10 days postpartum (11.9 g/dL in both groups) [
          • Welkovic S.
          • Costa L.O.
          • Faundes A.
          • de Alencar Ximenes R.
          • Costa C.F.
          Post-partum bleeding and infection after post-placental IUD insertion.
          ].
      • 2.
        What is the rate of expulsion after postplacental IUD placement?
        Most recent studies agree that IUD expulsion after postplacental insertion is higher than after interval insertion (Table 1). There is wide variability in reported expulsion rates, ranging from 2% to 27% after vaginal delivery and 0% to 20% after cesarean [
        • Chen B.A.
        • Reeves M.F.
        • Hayes J.L.
        • Hohmann H.L.
        • Perriera L.K.
        • Creinin M.D.
        Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial.
        ,
        • Whitaker A.K.
        • Endres L.K.
        • Mistretta S.Q.
        • Gilliam M.L.
        Postplacental insertion of the levonorgestrel intrauterine device after cesarean delivery vs. delayed insertion: a randomized controlled trial.
        ,
        • Lester F.
        • Kakaire O.
        • Byamugisha J.
        • Averbach S.
        • Fortin J.
        • Maurer R.
        • et al.
        Intracesarean insertion of the copper T380A versus 6 weeks postcesarean: a randomized clinical trial.
        ,
        • Levi E.E.
        • Stuart G.S.
        • Zerden M.L.
        • Garrett J.M.
        • Bryant A.G.
        Intrauterine device placement during cesarean delivery and continued use 6 months postpartum: a randomized controlled trial.
        ,
        • Dahlke J.D.
        • Terpstra E.R.
        • Ramseyer A.M.
        • Busch J.M.
        • Rieg T.
        • Magann E.F.
        Postpartum insertion of levonorgestrel – intrauterine system at three time periods: a prospective randomized pilot study.
        ,
        • Jatlaoui T.C.
        • Marcus M.
        • Jamieson D.J.
        • Goedken P.
        • Cwiak C.
        Postplacental intrauterine device insertion at a teaching hospital.
        ,
        • El-Shafei M.
        • Mashali A.
        • Hassan E.
        • El-Boghdadi L.
        • El-Lakkany N.
        Postpartum and postabortion intrauterine device insertion unmet needs of safe reproductive health: three years experience of Mansoura University hospital.
        ,
        • Singal S.
        • Bharti R.
        • Dewan R.
        • Divya
        • Dabral A.
        • Batra A.
        • et al.
        Clinical outcome of postplacental copper T 380A insertion in women delivering by caesarean section.
        ,
        • Levi E.
        • Cantillo E.
        • Ades V.
        • Banks E.
        • Murthy A.
        Immediate postplacental IUD insertion at cesarean delivery: a prospective cohort study.
        ,
        • Çelen Ş.
        • Sucak A.
        • Yildiz Y.
        • Danişman N.
        Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section.
        ,
        • Çelen Ş.
        • Mőrőy P.
        • Sucak A.
        • Aktulay A.
        • Danişman N.
        Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices.
        ]. Uncontrolled studies in the 1980s often reported expulsion rates of less than 10% [
        • Chi I.C.
        • Wilkens L.
        • Rogers S.
        Expulsions in immediate postpartum insertions of Lippes loop D and copper T IUDs and their counterpart Delta devices – an epidemiological analysis.
        ,
        • Thiery M.
        • van Kets H.
        • van der Pas H.
        • van Os W.
        • Dombrowicz N.
        The ML Cu250; clinical experience in Belgium and The Netherlands.
        ,
        • Thiery M.
        • Van der Pas H.
        • Delbeke L.
        • Van Dets H.
        Comparative performance of two copper-wired IUDs (ML cu 250 and T cu 200): immediate postpartum and interval insertion.
        ,
        • Van Kets H.
        • Thiery M.
        • Van der Pas H.
        IUD insertion during cesarean section.
        ,
        • Van Kets H.
        • Thiery M.
        • van der Pas H.
        • Parewijck W.
        Immediate postpartum insertion: performance of the Nova-T-PP and randomized comparison with the Nova-T.
        ]. However, these findings have not been replicated in more recent studies using modern IUDs.
        Table 1Expulsion of the intrauterine device after postplacental insertion, from studies that included devices currently available in the United States.
        StudySample sizeIUD typeDelivery typeFollow-up (months)Expulsion
        Expulsion is in n/N (%) unless otherwise noted.
        p value
        Significance is for comparison of expulsion only, not utilization.
        CopperHormonalPostplacentalEarly postpartumDelayed or interval
        A. Comparative – RCTs with randomization of insertion timing
        Levi 2015
        • Levi E.E.
        • Stuart G.S.
        • Zerden M.L.
        • Garrett J.M.
        • Bryant A.G.
        Intrauterine device placement during cesarean delivery and continued use 6 months postpartum: a randomized controlled trial.
        112CuT380A52 mg LNG-IUDC64/48 (8%)(≥6 wk) 1/50 (2%)
        Denominator includes all women with follow-up at 6 months, even those who did not have an IUD placed. (Only 34 women in the delayed group had IUD placed.)
        p=.20
        P value not reported; calculated based on data within paper.
        Lester 2015
        • Lester F.
        • Kakaire O.
        • Byamugisha J.
        • Averbach S.
        • Fortin J.
        • Maurer R.
        • et al.
        Intracesarean insertion of the copper T380A versus 6 weeks postcesarean: a randomized clinical trial.
        68CuT380AC61/34 (3%)(6 wk) 1/18 (6%)p=1.0
        Whitaker 2014
        • Whitaker A.K.
        • Endres L.K.
        • Mistretta S.Q.
        • Gilliam M.L.
        Postplacental insertion of the levonorgestrel intrauterine device after cesarean delivery vs. delayed insertion: a randomized controlled trial.
        4252 mg LNG-IUDC124/20 (20%)(4–8 wk) 0/22 (0%)p=.04
        Dahlke 2011
        • Dahlke J.D.
        • Terpstra E.R.
        • Ramseyer A.M.
        • Busch J.M.
        • Rieg T.
        • Magann E.F.
        Postpartum insertion of levonorgestrel – intrauterine system at three time periods: a prospective randomized pilot study.
        4652 mg LNG-IUDV64/15 (27%)(>10 m-48 h) 4/15 (27%)(≥6 wk) 0/16 (0%)p=.026
        Chen 2010
        • Chen B.A.
        • Reeves M.F.
        • Hayes J.L.
        • Hohmann H.L.
        • Perriera L.K.
        • Creinin M.D.
        Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial.
        10252 mg LNG-IUDV612/50 (24%)(6–8 wk) 2/46 (4%)p=.008
        B. Comparative – cohort studies and RCTs with randomization based on factor other than insertion timing
        Sucak 2015
        • Sucak A.
        • Ozcan S.
        • Çelen Ş.
        • Çağlar T.
        • Gőksu G.
        • Danişman N.
        Immediate postplacental insertion of a copper intrauterine device: a pilot study to evaluate expulsion rate by mode of delivery.
        160CuT380AC (no labor), C (during active labor), V12C (no labor): 4/51 (8.7%)p>.05 in all pairwise comparisons
        C (active labor): 4/47 (8.9%)
        V: 7/62 (11.3%)
        Elsedeek 2012
        • Elsedeek M.S.
        Puerperal and menstrual bleeding patterns with different types of contraceptive device fitted during elective cesarean delivery.
        140
        Does not include 40 women who had no IUD placed.
        Nova-T IUD52 mg LNG-IUDC24LNG-IUD: 0/65 (0%)p=.06
        P value not reported; calculated based on data within paper.
        Nova-T:
        5/75 (7%)
        Eroğlu 2006
        • Eroğlu K.
        • Akkuzu G.
        • Vural G.
        • Dilbaz B.
        • Akin A.
        • Taşkin L.
        • et al.
        Comparison of efficacy and complications of IUD insertion in immediate postplacental/early postpartum period with interval period: 1 year follow-up.
        268CuT380AV & C, results combined12Complete: 12/84 (14%)(>10 m-72 h)

        Complete: 8/43 (19%)

        Partial:

        22/43 (51%)
        (>6–8 wk)

        Complete: 5/130 (4%)

        Partial: 4/130 (3%)
        p<.001
        Partial: 19/84 (23%)
        Lara-Ricalde 2006
        • Lara Ricalde R.
        • Menocal Tobias G.
        • Ramos Perez C.
        • Velazquez Ramirez N.
        Random comparative study between intrauterine device multiload Cu375 and TCu 380a inserted in the postpartum period.
        157CuT380A & ML Cu375V & C12V: 4/32 (13%)

        C: 3/32 (9%)
        (>10 m-48 h)

        V: 5/41 (12%)

        C: 2/52 (4%)
        V: p=1.0
        P value not reported; calculated based on data within paper.


        C: p=.36
        P value not reported; calculated based on data within paper.
        El-Shafei 2000
        • El-Shafei M.
        • Mashali A.
        • Hassan E.
        • El-Boghdadi L.
        • El-Lakkany N.
        Postpartum and postabortion intrauterine device insertion unmet needs of safe reproductive health: three years experience of Mansoura University hospital.
        1378
        Does not include 56 participants who had IUD placed post-abortion.
        CuT380AV & C12V: 2.4
        Expulsion per 100 woman-years.


        C: 2.4
        Expulsion per 100 woman-years.
        (>10 m-48 h)

        Total: 2.6
        Expulsion per 100 woman-years.
        p>.05
        Morrison 1996
        • Morrison C.
        • Waszak C.
        • Katz K.
        • Diabate F.
        • Mate E.M.
        Clinical outcomes of two early postpartum IUD insertion programs in Africa.
        Kenya: n=224

        Mali: n=110
        CuT380AV & C, results combined6Kenya: 0.01
        Life table expulsion rates at 6 months.


        Mali: 0.15
        Life table expulsion rates at 6 months.
        (>10 m-72 h)

        Kenya: 0.05
        Life table expulsion rates at 6 months.


        Mali: 0.27
        Life table expulsion rates at 6 months.
        Kenya: p=.05

        Mali: p=.20
        C. Non-comparative studies
        StudySample sizeIUD TypeDelivery TypeFollow up (mo)Expulsion
        CopperHormonalPostplacental
        Eggebroten 2017
        • Eggebroten J.L.
        • Sanders J.N.
        • Turok D.K.
        Immediate postpartum intrauterine device and implant program outcomes: a prospective analysis.
        211CuT380A52 mg LNG-IUDV & C6CuT380A: 3/78 (4%)

        LNG-IUD: 18/108 (17%)
        Jatlaoui 2014
        • Jatlaoui T.C.
        • Marcus M.
        • Jamieson D.J.
        • Goedken P.
        • Cwiak C.
        Postplacental intrauterine device insertion at a teaching hospital.
        99CuT380A52 mg LNG-IUDV617/88 (19%)
        Singal 2014
        • Singal S.
        • Bharti R.
        • Dewan R.
        • Divya
        • Dabral A.
        • Batra A.
        • et al.
        Clinical outcome of postplacental copper T 380A insertion in women delivering by caesarean section.
        300CuT380AC1216/300 (5%)
        Levi 2012
        • Levi E.
        • Cantillo E.
        • Ades V.
        • Banks E.
        • Murthy A.
        Immediate postplacental IUD insertion at cesarean delivery: a prospective cohort study.
        90CuT380AC60/43 (0%)
        Çelen 2011
        • Çelen Ş.
        • Sucak A.
        • Yildiz Y.
        • Danişman N.
        Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section.
        245CuT380AC1243/245 (18%)
        Çelen 2004
        • Çelen Ş.
        • Mőrőy P.
        • Sucak A.
        • Aktulay A.
        • Danişman N.
        Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices.
        235CuT380AV & C, results combined1212.3
        Gross cumulative event rate per 100 women.
        (12-month follow-up data available for 183 women)
        RCT, randomized controlled trial; CuT380A, Copper T380A; LNG-IUD, levonorgestrel intrauterine device; V, vaginal delivery; C, Cesarean delivery; ML Cu375, Multiload Copper 375 intrauterine device.
        Denominators may not match sample size due to loss to follow-up or failed insertions. Denominator is the number of women who had follow-up information available.
        i Expulsion is in n/N (%) unless otherwise noted.
        ii Significance is for comparison of expulsion only, not utilization.
        iii Denominator includes all women with follow-up at 6 months, even those who did not have an IUD placed. (Only 34 women in the delayed group had IUD placed.)
        iv P value not reported; calculated based on data within paper.
        v Does not include 40 women who had no IUD placed.
        vi Does not include 56 participants who had IUD placed post-abortion.
        vii Expulsion per 100 woman-years.
        viii Life table expulsion rates at 6 months.
        ix Gross cumulative event rate per 100 women.
        In a large randomized controlled trial (RCT) of postplacental IUD insertion, Chen et al. randomized 102 women to postplacental insertion of the 52-mg LNG-IUD or delayed insertion 6–8 weeks later. Expulsion was higher in the postplacental group than in the delayed group (24% vs. 4%; p=.008). However, 10 out of the 12 women who experienced expulsion after postplacental insertion had a new LNG-IUD inserted, and both groups had similar rates of IUD use at 6 months (84% vs. 77%, p=.32) [
        • Chen B.A.
        • Reeves M.F.
        • Hayes J.L.
        • Hohmann H.L.
        • Perriera L.K.
        • Creinin M.D.
        Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial.
        ].
        A 46-person 3-arm pilot RCT by Dahlke et al. that compared postplacental to early postpartum (>10 min to 48 h) and delayed insertion (≥6 weeks) of the 52-mg LNG-IUD after vaginal delivery reported expulsion rates of 27% (4/15) in both the postplacental and early postpartum groups, compared with none in the delayed group. Most women who experienced expulsion had a second IUD placed, and use at 3 and 6 months was similar across groups [
        • Dahlke J.D.
        • Terpstra E.R.
        • Ramseyer A.M.
        • Busch J.M.
        • Rieg T.
        • Magann E.F.
        Postpartum insertion of levonorgestrel – intrauterine system at three time periods: a prospective randomized pilot study.
        ]. In an observational study comparing postplacental placement of the 52-mg LNG-IUD and the CuT380A after vaginal delivery, 19% (17/88) of women who had at least one follow-up contact experienced an expulsion [
        • Jatlaoui T.C.
        • Marcus M.
        • Jamieson D.J.
        • Goedken P.
        • Cwiak C.
        Postplacental intrauterine device insertion at a teaching hospital.
        ]. In another observational study of 84 women who had a postplacental insertion of the CuT380A, complete and partial expulsion at 12 months was 37% (14% complete expulsion; 23% partial expulsion) compared to 7% in the delayed group. However, this study included both vaginal and cesarean deliveries and did not report results stratified by delivery type [
        • Eroğlu K.
        • Akkuzu G.
        • Vural G.
        • Dilbaz B.
        • Akin A.
        • Taşkin L.
        • et al.
        Comparison of efficacy and complications of IUD insertion in immediate postplacental/early postpartum period with interval period: 1 year follow-up.
        ]. Similarly, Cohen et al. found a 25% expulsion rate (17/67) after postplacental IUD insertion, of which 15 of the expulsions were recognized, but results were also not stratified by delivery type [
        • Cohen R.
        • Sheeder J.
        • Arango N.
        • Teal S.B.
        • Tocce K.
        Twelve-month contraceptive continuation and repeat pregnancy among young mothers choosing postdelivery contraceptive implants or postplacental intrauterine devices.
        ].
        Expulsion after postplacental insertion at the time of cesarean delivery appears to be lower than after vaginal delivery, but there is also wide variability [
        • Whitaker A.K.
        • Endres L.K.
        • Mistretta S.Q.
        • Gilliam M.L.
        Postplacental insertion of the levonorgestrel intrauterine device after cesarean delivery vs. delayed insertion: a randomized controlled trial.
        ,
        • Lester F.
        • Kakaire O.
        • Byamugisha J.
        • Averbach S.
        • Fortin J.
        • Maurer R.
        • et al.
        Intracesarean insertion of the copper T380A versus 6 weeks postcesarean: a randomized clinical trial.
        ,
        • Levi E.E.
        • Stuart G.S.
        • Zerden M.L.
        • Garrett J.M.
        • Bryant A.G.
        Intrauterine device placement during cesarean delivery and continued use 6 months postpartum: a randomized controlled trial.
        ,
        • Levi E.
        • Cantillo E.
        • Ades V.
        • Banks E.
        • Murthy A.
        Immediate postplacental IUD insertion at cesarean delivery: a prospective cohort study.
        ,
        • Çelen Ş.
        • Sucak A.
        • Yildiz Y.
        • Danişman N.
        Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section.
        ]. Several RCTs have directly compared postplacental IUD insertion after cesarean delivery to delayed insertion. Levi et al. randomized 112 women to intracesarean insertion of either a CuT380A or 52-mg LNG-IUD versus insertion 6 or more weeks postpartum. Expulsion after intracesarean insertion was 8% compared with 2% in the delayed-insertion group, but the difference did not reach statistical significance. The intracesarean group had higher IUD use at 6 months postpartum compared to the delayed group (83% vs. 64%; RR 1.3, 95% CI 1.02–1.66), primarily because fewer women in the delayed group received an IUD [
        • Levi E.E.
        • Stuart G.S.
        • Zerden M.L.
        • Garrett J.M.
        • Bryant A.G.
        Intrauterine device placement during cesarean delivery and continued use 6 months postpartum: a randomized controlled trial.
        ].
        In a small (n=42) RCT of postplacental insertion of the 52-mg LNG-IUD at the time of cesarean section versus delayed insertion 4–8 weeks postpartum, the expulsion rates were 20% (4/20) and 0% (0/22), respectively (p=.04). This trial was stopped early because of difficulties with recruitment and follow-up. Confirmed use of the LNG-IUD at 12 months postpartum was 60% in the postplacental group and 41% in the delayed group (p=.35) [
        • Whitaker A.K.
        • Endres L.K.
        • Mistretta S.Q.
        • Gilliam M.L.
        Postplacental insertion of the levonorgestrel intrauterine device after cesarean delivery vs. delayed insertion: a randomized controlled trial.
        ]. Another small (n=68) RCT conducted in Uganda found no difference in the number of expulsions between intracesarean and delayed CuT380A insertions (one expulsion in each group). In this RCT, the intracesarean group also had higher IUD utilization at six months (93% vs. 50%, p<.0001) [
        • Lester F.
        • Kakaire O.
        • Byamugisha J.
        • Averbach S.
        • Fortin J.
        • Maurer R.
        • et al.
        Intracesarean insertion of the copper T380A versus 6 weeks postcesarean: a randomized clinical trial.
        ].
        Two descriptive studies of the CuT380A at the time of cesarean delivery showed markedly different results. Çelen et al. reported a 12-month expulsion rate of 18% after postplacental insertion of the CuT380A at the time of cesarean in 245 women. Removal rates for pain and bleeding and for medical reasons were 8% and 2%, respectively, and use at 12 months was 62%. The authors reported no loss to follow-up [
        • Çelen Ş.
        • Sucak A.
        • Yildiz Y.
        • Danişman N.
        Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section.
        ]. Levi et al. followed 90 patients who had the CuT380A inserted at the time of cesarean. Although they had no reported cases of expulsion, loss to follow-up was 53% at 6 months, which makes definitive conclusions about expulsion in this study less reliable [
        • Levi E.
        • Cantillo E.
        • Ades V.
        • Banks E.
        • Murthy A.
        Immediate postplacental IUD insertion at cesarean delivery: a prospective cohort study.
        ].
        Prior studies on postplacental IUD placement at time of cesarean delivery have generally included both laboring and nonlaboring patients, or have not specified the patient population. In a prospective cohort pilot study of women receiving a postplacental CuT380A IUD, Sucak et al. followed women who underwent planned cesarean delivery (n=51), cesarean delivery during active labor (n=47), and vaginal delivery (n=62). They found 12-month cumulative expulsion rates of 8.7%, 8.9%, and 11.3%, respectively. This study was designed as a pilot study and was not expected to be large enough to detect a statistically significant difference between groups [
        • Sucak A.
        • Ozcan S.
        • Çelen Ş.
        • Çağlar T.
        • Gőksu G.
        • Danişman N.
        Immediate postplacental insertion of a copper intrauterine device: a pilot study to evaluate expulsion rate by mode of delivery.
        ].
      • 3.
        How does the rate of expulsion after postplacental insertion compare to the rate after insertions at other postpartum intervals?
        Data are conflicting when comparing expulsion after postplacental insertion to early postpartum insertion [
        • Dahlke J.D.
        • Terpstra E.R.
        • Ramseyer A.M.
        • Busch J.M.
        • Rieg T.
        • Magann E.F.
        Postpartum insertion of levonorgestrel – intrauterine system at three time periods: a prospective randomized pilot study.
        ,
        • Eroğlu K.
        • Akkuzu G.
        • Vural G.
        • Dilbaz B.
        • Akin A.
        • Taşkin L.
        • et al.
        Comparison of efficacy and complications of IUD insertion in immediate postplacental/early postpartum period with interval period: 1 year follow-up.
        ,
        • Lara Ricalde R.
        • Menocal Tobias G.
        • Ramos Perez C.
        • Velazquez Ramirez N.
        Random comparative study between intrauterine device multiload Cu375 and TCu 380a inserted in the postpartum period.
        ,
        • Morrison C.
        • Waszak C.
        • Katz K.
        • Diabate F.
        • Mate E.M.
        Clinical outcomes of two early postpartum IUD insertion programs in Africa.
        ]. In the Dahlke et al. pilot RCT of the 52-mg LNG-IUD after vaginal delivery, expulsion at 6 months was the same (27%) for postplacental as for early postpartum (>10 min to 48 h) insertion. However, 14 of the 15 women who had early postpartum insertions underwent insertion within 30 min after placental delivery, and only 15 women in each group received an IUD per protocol [
        • Dahlke J.D.
        • Terpstra E.R.
        • Ramseyer A.M.
        • Busch J.M.
        • Rieg T.
        • Magann E.F.
        Postpartum insertion of levonorgestrel – intrauterine system at three time periods: a prospective randomized pilot study.
        ]. A small trial by Lara Ricalde et al. used two types of copper IUDs, the CuT380A and the Multiload 375, and found no difference in 12-month expulsions (p=.3) when comparing postplacental to early postpartum (>10 min to 48 h) insertion after either vaginal delivery (13% postplacental, 12% early postpartum, n=73) or cesarean section (9% postplacental, 4% early postpartum, n=84) [
        • Lara Ricalde R.
        • Menocal Tobias G.
        • Ramos Perez C.
        • Velazquez Ramirez N.
        Random comparative study between intrauterine device multiload Cu375 and TCu 380a inserted in the postpartum period.
        ]. In the Eroğlu et al. cohort study of the CuT380A, cumulative complete expulsion within 1 year was similar for postplacental and early postpartum (>10 min to 72 h) insertion (14% vs. 19%, respectively). However, partial expulsion was much lower in the postplacental group (23% vs. 51%, respectively) [
        • Eroğlu K.
        • Akkuzu G.
        • Vural G.
        • Dilbaz B.
        • Akin A.
        • Taşkin L.
        • et al.
        Comparison of efficacy and complications of IUD insertion in immediate postplacental/early postpartum period with interval period: 1 year follow-up.
        ].
        A systematic review of 18 comparative studies of IUD insertion at varying points in the postpartum period determined that both postplacental and early postpartum insertion result in higher expulsion rates than delayed or interval insertion, but that expulsion after postplacental insertion and early postpartum insertion at >10 min to 48 h are generally similar [
        • Sonalkar S.
        • Kapp N.
        Intrauterine device insertion in the postpartum period: a systematic review.
        ]. However, this review did not contain results from two studies conducted by Stuart et al. that found expulsion rates of 38–41% in the early postpartum period (6–48 h after vaginal delivery) [
        • Stuart G.S.
        • Bryant A.G.
        • O'Neill E.
        • Doherty I.A.
        Feasibility of postpartum placement of the levonorgestrel intrauterine system more than 6 h after vaginal birth.
        ,
        • Stuart G.S.
        • Lesko C.R.
        • Stuebe A.M.
        • Bryant A.G.
        • Levi E.E.
        • Danvers A.I.
        A randomized trial of levonorgestrel intrauterine system insertion 6 to 48h compared to 6 weeks after vaginal delivery; lessons learned.
        ]. A planned RCT comparing postplacental and early postpartum insertion was terminated early because in the early postpartum arm, the combined rate of expulsion (7/17) and early removal (3/17) was over 50% [
        • Stuart G.S.
        • Lesko C.R.
        • Stuebe A.M.
        • Bryant A.G.
        • Levi E.E.
        • Danvers A.I.
        A randomized trial of levonorgestrel intrauterine system insertion 6 to 48h compared to 6 weeks after vaginal delivery; lessons learned.
        ].
      • 4.
        What are the risk factors for expulsion after postplacental IUD insertion?
        No studies have been designed specifically to assess what factors influence risk of expulsion after postplacental insertion.
        • Type of delivery
          Several studies compared postplacental IUD insertion after cesarean versus vaginal delivery [
          • El-Shafei M.
          • Mashali A.
          • Hassan E.
          • El-Boghdadi L.
          • El-Lakkany N.
          Postpartum and postabortion intrauterine device insertion unmet needs of safe reproductive health: three years experience of Mansoura University hospital.
          ,
          • Lara Ricalde R.
          • Menocal Tobias G.
          • Ramos Perez C.
          • Velazquez Ramirez N.
          Random comparative study between intrauterine device multiload Cu375 and TCu 380a inserted in the postpartum period.
          ,
          • Letti Muller A.L.
          • Lopes Ramos J.G.
          • Martins-Costa S.H.
          • Palma Dias R.S.
          • Valerio E.G.
          • Hammes L.S.
          • et al.
          Transvaginal ultrasonographic assessment of the expulsion rate of intrauterine devices inserted in the immediate postpartum period: a pilot study.
          ,
          • Fernandes J.H.A.
          • Lippi U.G.
          A clinical and ultrasound study on the use of postplacental intrauterine device.
          ,
          • Zhou S.W.
          • Chi I.C.
          Immediate postpartum IUD insertions in a Chinese hospital – a two year follow-up.
          ,
          • Lara R.
          • Sanchez R.A.
          • Aznar R.
          Application of intrauterine device through the incision of the cesarean section.
          ]. Although most studies had limited power, expulsion was higher in the vaginal group in all except one study [
          • El-Shafei M.
          • Mashali A.
          • Hassan E.
          • El-Boghdadi L.
          • El-Lakkany N.
          Postpartum and postabortion intrauterine device insertion unmet needs of safe reproductive health: three years experience of Mansoura University hospital.
          ].
        • Provider experience
          Provider experience may play a role in expulsion. In a multinational study of postplacental insertion after vaginal delivery, pooled data from all sites showed that insertions performed in the first half of the trial, when investigators had little prior experience, were associated with higher expulsion rates than insertions in the second half (12% vs. 7%, p<.001). [
          • Chi I.C.
          • Wilkens L.
          • Rogers S.
          Expulsions in immediate postpartum insertions of Lippes loop D and copper T IUDs and their counterpart Delta devices – an epidemiological analysis.
          ]. In one RCT of postplacental insertion of the 52-mg LNG-IUD after cesarean delivery, two sites were involved. At the secondary site, providers had less experience with IUD insertion, and four of six (67%) participants experienced expulsion after intracesarean placement compared with none of 14 (0%) expulsions at the primary site (p<.01). No providers at either site had prior experience with intracesarean insertion [
          • Whitaker A.K.
          • Endres L.K.
          • Mistretta S.Q.
          • Gilliam M.L.
          Postplacental insertion of the levonorgestrel intrauterine device after cesarean delivery vs. delayed insertion: a randomized controlled trial.
          ]. However, a study of postplacental insertion after vaginal delivery did not find a difference in expulsion rates by training level of provider (first- or second-year resident physician vs. third-year resident physician or above), although the study did not have adequate power to examine this outcome [
          • Jatlaoui T.C.
          • Marcus M.
          • Jamieson D.J.
          • Goedken P.
          • Cwiak C.
          Postplacental intrauterine device insertion at a teaching hospital.
          ].
        • Parity
          Data are conflicting regarding the relationship between parity and expulsion after postplacental IUD insertion. Two studies found that the risk of expulsion increased with higher parity [
          • Sucak A.
          • Ozcan S.
          • Çelen Ş.
          • Çağlar T.
          • Gőksu G.
          • Danişman N.
          Immediate postplacental insertion of a copper intrauterine device: a pilot study to evaluate expulsion rate by mode of delivery.
          ,
          • Bonilla Rosales F.
          • Aguilar Zamudio M.E.
          • Cazares Montero Mde L.
          • Hernandez Ortiz M.E.
          • Luna Ruiz M.A.
          Factors for expulsion of intrauterine device Tcu380A applied immediately postpartum and after a delayed period.
          ], but one study found the opposite [
          • Jatlaoui T.C.
          • Marcus M.
          • Jamieson D.J.
          • Goedken P.
          • Cwiak C.
          Postplacental intrauterine device insertion at a teaching hospital.
          ]. However, none of these studies were designed specifically to look at parity, and further research is required to resolve their conflicting results.
          The wide variability of expulsion across studies suggests that there are modifiable factors that could reduce the occurrence of expulsion. Further research will be required to identify these variables.
      • 5.
        Are there any techniques, device modifications, or device types that can reduce expulsion after postplacental IUD insertion?
        A systematic review found little or no evidence suggesting that expulsion rates vary with insertion technique, design modifications, or IUD type [
        • Lopez L.M.
        • Bernholc A.
        • Hubacher D.
        • Stuart G.
        • Van Vliet H.A.
        Immediate postpartum insertion of intrauterine device for contraception.
        ]. However, most published data on this topic are sparse and date from the 1980s and 1990s.
        • Insertion technique
          Older studies examining postplacental insertion technique, such as hand insertion, forceps insertion, or use of an IUD inserter, showed mixed results, with most finding no difference [
          • Cole L.P.
          • Edelman D.A.
          • Potts D.M.
          • Wheeler R.G.
          • Laufe L.E.
          Postpartum insertion of modified intrauterine devices.
          ,
          • Apelo R.A.
          • Waszak C.S.
          Postpartum IUD insertions in Manila, Philippines.
          ,
          • Lavin P.
          • Bravo C.
          • Waszak C.
          Comparison of T cu 200 and Progestasert IUDs.
          ]. In an RCT using currently available IUDs, Xu et al. randomized 910 women to postplacental insertion of the CuT380A using a ring forceps or manual insertion after vaginal delivery. Expulsion at 6 months was 13% in each group. They also found no difference in removal for pain and bleeding or for nonmedical indications [
          • Xu J.X.
          • Rivera R.
          • Dunson T.R.
          • Zhuang L.Q.
          • Yang X.L.
          • Ma G.T.
          • et al.
          A comparative study of two techniques used in immediate postplacental insertion (IPPI) of the copper T-380A IUD in shanghai, People's Republic of China.
          ]. A recent pilot proof-of-concept study examined a dedicated device inserter for IUD insertion up to 48 h after a vaginal delivery. The inserter was similar to the standard CuT380A inserter but had a longer insertion sleeve and longer IUD strings. By 6–8 months postpartum, 5 of 80 women (7.5%) experienced a complete expulsion and 8 of 80 women (10%) experienced an asymptomatic partial expulsion. Ongoing research on the dedicated inserter is under way [
          • Singh S.
          • Das V.
          • Agarwal A.
          • Dewan R.
          • Mittal P.
          • Bhamrah R.
          • et al.
          A dedicated postpartum intrauterine device inserter: pilot experience and proof of concept.
          ].
        • Device modifications
          Several IUDs were designed specifically for use in the postpartum period. A modification of the GYNE-T 380 (a copper IUD almost identical to the CuT380A), the GYNE-T 380 Postpartum, included a chromic suture on the top of the vertical arm. In a quasi-randomized trial of 592 women, expulsion at 1 year in the GYNE-T 380 arm was 13.2 per 100 cases versus 16.2 per 100 cases in the GYNE-T 380 Postpartum arm. No perforations or significant pelvic infections occurred in either group [
          • Tatum H.J.
          • Beltran R.S.
          • Ramos R.
          • Van Kets H.
          • Sivin I.
          • Schmidt F.H.
          Immediate postplacental insertion of GYNE-T 380 and GYNE-T 380 postpartum intrauterine contraceptive devices: randomized study.
          ]. Other studies involving modifications of older IUDs specifically for postpartum insertion also showed no benefit [
          • Van Kets H.
          • Thiery M.
          • van der Pas H.
          • Parewijck W.
          Immediate postpartum insertion: performance of the Nova-T-PP and randomized comparison with the Nova-T.
          ,
          • Cole L.P.
          • Edelman D.A.
          • Potts D.M.
          • Wheeler R.G.
          • Laufe L.E.
          Postpartum insertion of modified intrauterine devices.
          ,
          • Apelo R.A.
          • Waszak C.S.
          Postpartum IUD insertions in Manila, Philippines.
          ,
          • World Health Organization
          Comparative multicentre trial of three IUDs inserted immediately following delivery of the placenta.
          ].
        • Device type
          Hormonal IUDs may have a higher rate of expulsion compared to copper IUDs though data are not consistent. Older trials comparing the progesterone-releasing Progestasert IUD to the CuT200 IUD provide limited evidence that progestin-containing IUDs may have higher expulsion rates [
          • Apelo R.A.
          • Waszak C.S.
          Postpartum IUD insertions in Manila, Philippines.
          ,
          • Lavin P.
          • Bravo C.
          • Waszak C.
          Comparison of T cu 200 and Progestasert IUDs.
          ]. A more recent cohort study found a 7% expulsion for the Nova-T copper IUD and 0% for the 52-mg LNG-IUD after postplacental insertion at the time of cesarean [
          • Elsedeek M.S.
          Puerperal and menstrual bleeding patterns with different types of contraceptive device fitted during elective cesarean delivery.
          ]. In Levi et al.’s RCT, 10% (4/40) of the 52-mg LNG-IUDs placed at time of cesarean section were expelled, compared with 0% (0/15) of the CuT380A IUDs, but the study did not have adequate power to look at a difference in expulsions by IUD type [
          • Levi E.E.
          • Stuart G.S.
          • Zerden M.L.
          • Garrett J.M.
          • Bryant A.G.
          Intrauterine device placement during cesarean delivery and continued use 6 months postpartum: a randomized controlled trial.
          ].
          Eggenbroten et al. also found a difference in expulsion by IUD type in their prospective observational study of women requesting a postpartum IUD or implant. Of 186 women who received an immediate postpartum IUD and were successfully contacted at 6 months postpartum, 17% (18/108) of LNG-IUD users and 4% (3/78) of CuT380A IUD users reported expulsions (adjusted hazards ratio 5.9 (CI 1.3–26.4) [
          • Eggebroten J.L.
          • Sanders J.N.
          • Turok D.K.
          Immediate postpartum intrauterine device and implant program outcomes: a prospective analysis.
          ]. The question of whether IUD type (CuT380A IUD or LNG-IUD) is associated with increased risk of expulsion warrants further study.
      • 6.
        What is the role of ultrasound in postplacental IUD provision?
        • Use of ultrasound during insertion
          Recent studies that reported use of ultrasound during postplacental insertion after vaginal delivery showed expulsion rates of 19–24% [
          • Chen B.A.
          • Reeves M.F.
          • Hayes J.L.
          • Hohmann H.L.
          • Perriera L.K.
          • Creinin M.D.
          Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial.
          ,
          • Jatlaoui T.C.
          • Marcus M.
          • Jamieson D.J.
          • Goedken P.
          • Cwiak C.
          Postplacental intrauterine device insertion at a teaching hospital.
          ], whereas studies that do not report ultrasound use showed expulsion rates of 27–37% [
          • Dahlke J.D.
          • Terpstra E.R.
          • Ramseyer A.M.
          • Busch J.M.
          • Rieg T.
          • Magann E.F.
          Postpartum insertion of levonorgestrel – intrauterine system at three time periods: a prospective randomized pilot study.
          ,
          • Eroğlu K.
          • Akkuzu G.
          • Vural G.
          • Dilbaz B.
          • Akin A.
          • Taşkin L.
          • et al.
          Comparison of efficacy and complications of IUD insertion in immediate postplacental/early postpartum period with interval period: 1 year follow-up.
          ]. However, there are no studies directly investigating whether use of ultrasound during postplacental insertion reduces expulsion rates, and there is not sufficient evidence to support routine use of ultrasound. Therefore, it is reasonable to perform insertions with or without ultrasound guidance. If there is concern about fundal placement of the IUD, clinical judgment may be used to employ ultrasound at the time of insertion when it is available. Lack of ultrasound guidance should not prohibit provision of postplacental insertion after vaginal delivery.
        • Use of ultrasound for follow-up and surveillance
          Published data about malpositioned IUDs after postplacental IUD insertions are limited. One observational study of 100 women who underwent CuT380A insertion after vaginal delivery or cesarean section found that 44% had malpositioned IUDs. Women with malpositioned IUDs were more likely to have had the IUD placed after vaginal delivery than after cesarean delivery and were more likely to report complications by 6 months postpartum, including expulsion, irregular bleeding, and lower abdominal pain [
          • Gupta S.
          • Malik S.
          • Sinha R.
          • Shyamsunder S.
          • Mittal M.K.
          Association of the position of the copper T 380A as determined by the ultrasonography following its insertion in the immediate postpartum period with the subsequent complications: an observational study.
          ].
          It is uncertain whether asymptomatic partial expulsions or malpositioned IUDs, found after IUD placement in any time frame, are clinically significant. While many studies examining IUD failures, i.e. pregnancies with IUDs in utero, have noted malpositioned IUDs, it is unclear if IUD failure occurred due to the malpositioned IUD or if the IUD became displaced due to the enlarging gestational sac [
          • Golightly E.
          • Gebbie A.E.
          Low-lying or malpositioned intrauterine devices and systems.
          ]. The importance of malpositioned IUDs has not been studied specifically for postplacental IUD insertions. However, a case–control study of 364 women found no association between IUD malpositioning and placement at 6–9 weeks postpartum. No pregnancies occurred among women with malpositioned copper or LNG-IUDs left in situ, but there was an increased risk of pregnancy among women who underwent removal of malpositioned IUDs without initiation of another highly effective contraceptive, which highlights the importance of avoiding unnecessary removals [
          • Braaten K.P.
          • Benson C.B.
          • Maurer R.
          • Goldberg A.B.
          Malpositioned intrauterine contraceptive devices: risk factors, outcomes, and future pregnancies.
          ]. One study randomizing women to intracervical or intrauterine placement of an investigational LNG-IUD found similar low pregnancy rates for both groups over 5 years [
          • Pakarinen P.
          • Luukkainen T.
          Five years' experience with a small intracervical/intrauterine levonorgestrel-releasing device.
          ]. This supports the hypothesis that position is not likely to adversely affect LNG-IUD efficacy due to the effect of progestin on cervical mucus. While there is concern that copper IUDs may be less effective if not located at the uterine fundus, no well-designed study has confirmed this theory [
          • Anteby E.
          • Revel A.
          • Ben-Chetrit A.
          • Rosen B.
          • Tadmor O.
          • Yagel S.
          Intrauterine device failure: relation to its location within the uterine cavity.
          ].
          Studies have attempted to correlate IUD distance from the fundus or internal os after postplacental insertion with risk of expulsion [
          • Fernandes J.H.A.
          • Lippi U.G.
          A clinical and ultrasound study on the use of postplacental intrauterine device.
          ,
          • Singh S.
          • Das V.
          • Agarwal A.
          • Dewan R.
          • Mittal P.
          • Bhamrah R.
          • et al.
          A dedicated postpartum intrauterine device inserter: pilot experience and proof of concept.
          ,
          • Dias T.
          • Abeykoon S.
          • Kumarasiri S.
          • Gunawardena C.
          • Padeniya T.
          • D'Antonio F.
          Use of ultrasound in predicting success of intrauterine contraceptive device insertion immediately after delivery.
          ]. However, since multiple studies document movement of an IUD within the uterine cavity without expulsion [
          • Shimoni N.
          • Davis A.
          • Westhoff C.
          Can ultrasound predict IUD expulsion after medical abortion?.
          ,
          • Faundes D.
          • Perdigao A.
          • Faundes A.
          • Bahamondes L.
          • Petta C.A.
          T-shaped IUDs accommodate in their position during the first 3 months after insertion.
          ,
          • Morales-Rosello J.
          Spontaneous upward movement of lowly placed T-shaped IUDs.
          ], these measurements are not a useful clinical measure. Based on this evidence, we do not recommend routine ultrasound for surveillance after postplacental IUD insertion. If incidental displacement of an IUD is diagnosed on ultrasound, removal is not mandated but may be considered after appropriate patient counseling if immediate IUD replacement or initiation of alternate highly effective contraceptive is feasible and desired.
        • Missing strings
          Use of ultrasound to confirm intrauterine location of an IUD may be necessary if the IUD strings are not visible or palpable at the external cervical os. Inability to visualize the IUD strings during speculum exam occurs more frequently after postplacental IUD insertion than after interval insertion, especially after placement during cesarean delivery. Inability to visualize IUD strings after postplacental insertion ranges from 5% for LNG-IUD placement after vaginal delivery [
          • Chen B.A.
          • Reeves M.F.
          • Hayes J.L.
          • Hohmann H.L.
          • Perriera L.K.
          • Creinin M.D.
          Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial.
          ] to 44–79% for IUD placement during cesarean delivery [
          • Lester F.
          • Kakaire O.
          • Byamugisha J.
          • Averbach S.
          • Fortin J.
          • Maurer R.
          • et al.
          Intracesarean insertion of the copper T380A versus 6 weeks postcesarean: a randomized clinical trial.
          ,
          • Levi E.E.
          • Stuart G.S.
          • Zerden M.L.
          • Garrett J.M.
          • Bryant A.G.
          Intrauterine device placement during cesarean delivery and continued use 6 months postpartum: a randomized controlled trial.
          ,
          • Levi E.
          • Cantillo E.
          • Ades V.
          • Banks E.
          • Murthy A.
          Immediate postplacental IUD insertion at cesarean delivery: a prospective cohort study.
          ,
          • Dewan R.
          • Dewan A.
          • Singal S.
          • Bharti R.
          • Kaim M.
          Non-visualisation of strings after postplacental insertion of copper-T 380A intrauterine device.
          ]. This finding may be due to the technique of IUD placement during cesarean delivery in which the IUD strings may not be traversing through the cervix into the vagina at time of placement [
          • O'Hanley K.
          • Huber D.H.
          Postpartum IUDS: keys for success.
          ].
          Women undergoing postplacental IUD insertion should be counseled that confirmation of the intrauterine location of an IUD may require use of ultrasound. After postplacental insertion at the time of cesarean delivery, IUD strings may be more likely to be visualized for LNG-IUDs than for CuT380A IUDs [
          • Levi E.E.
          • Stuart G.S.
          • Zerden M.L.
          • Garrett J.M.
          • Bryant A.G.
          Intrauterine device placement during cesarean delivery and continued use 6 months postpartum: a randomized controlled trial.
          ], likely because of the LNG-IUD's longer strings. In addition, strings may descend into the vagina with further involution of the postpartum uterus and thus may become visible over time after postplacental insertion [
          • Dewan R.
          • Dewan A.
          • Singal S.
          • Bharti R.
          • Kaim M.
          Non-visualisation of strings after postplacental insertion of copper-T 380A intrauterine device.
          ,
          • Hayes J.L.
          • Cwiak C.
          • Goedken P.
          • Zieman M.
          A pilot clinical trial of ultrasound-guided postplacental insertion of a levonorgestrel intrauterine device.
          ,
          • Agarwal K.
          • Dewan R.
          • Mittal P.
          • Aggarwal A.
          Visibility of strings after postplacental intracesarean insertion of CuT380A and Cu375 intrauterine contraceptive device: a randomized comparative study.
          ]. One prospective cohort study of 348 women who received a CuT380A IUD after vaginal or cesarean delivery found an increase in IUD string visibility over time, with 90% and 32% of strings visible at 6 weeks after vaginal and cesarean deliveries, respectively, compared with 98% and 72% at 12 months [
          • Dewan R.
          • Dewan A.
          • Singal S.
          • Bharti R.
          • Kaim M.
          Non-visualisation of strings after postplacental insertion of copper-T 380A intrauterine device.
          ]. A prospective randomized study evaluating string visibility after intracesarean placement of a Cu375 IUD (19.4 cm string length) to a CuT380A IUD (11.5 cm string length) found higher rates of string visibility in women receiving the Cu375 IUD (100% vs 47.9% at 3 months, respectively, p<.001) [
          • Agarwal K.
          • Dewan R.
          • Mittal P.
          • Aggarwal A.
          Visibility of strings after postplacental intracesarean insertion of CuT380A and Cu375 intrauterine contraceptive device: a randomized comparative study.
          ]. A CuT380A IUD designed for postpartum use with longer strings may help increase identification of IUD strings after insertion [
          • Singh S.
          • Das V.
          • Agarwal A.
          • Dewan R.
          • Mittal P.
          • Bhamrah R.
          • et al.
          A dedicated postpartum intrauterine device inserter: pilot experience and proof of concept.
          ].
      • 7.
        Which patients are not candidates for postplacental IUD insertion?
        There are few restrictions on postpartum insertion of IUDs. The USMEC gives only one absolute contraindication to postplacental or other postpartum insertion: puerperal sepsis. Both copper IUDs and LNG-IUDs have no restrictions (Category 1), or the advantages outweigh the risks (Category 2), for use in any postpartum time frame, regardless of breastfeeding status and mode of delivery [
        • Curtis K.M.
        • Tepper N.K.
        • Jatlaoui T.C.
        • Berry-Bibee E.
        • Horton L.G.
        • Zapata L.B.
        • et al.
        U.S. medical eligibility criteria for contraceptive use, 2016.
        ].
        Almost all research involving postplacental IUD insertion excluded women with risk factors for postpartum infection, including rupture of membranes more than 18–24 h before delivery or chorioamnionitis prior to delivery, so safety of placement in these situations has not been demonstrated. Clinical judgment should be used to assess risk of postpartum endometritis. In addition, many studies have excluded women with uterine anomalies or fibroids. Presumably the greatest risk for these women would be IUD expulsion, therefore informed counseling should be performed to advise women about the increased risk of expulsion. Unresolved postpartum hemorrhage or other intrapartum events may prevent IUD insertion within 10 min of delivery of the placenta, which by definition precludes postplacental insertion but may permit early postpartum placement.
      • 8.
        Does postplacental IUD insertion have any effect on breastfeeding?
        There is no evidence that copper IUDs have any effect on breastfeeding. A large body of research provides evidence that progestin-only contraception in the postpartum period is safe for mother and infant, and does not adversely affect lactation [
        • Kapp N.
        • Curtis K.
        • Nanda K.
        Progestogen-only contraceptive use among breastfeeding women: a systematic review.
        ,
        • Gurtcheff S.E.
        • Turok D.K.
        • Stoddard G.
        • Murphy P.A.
        • Gibson M.
        • Jones K.P.
        Lactogenesis after early postpartum use of the contraceptive implant: a randomized controlled trial.
        ]. Early studies of postplacental insertion of the LNG-IUD showed mixed results, with one pilot RCT finding similar breastfeeding continuation among users of the 52 mg LNG-IUD regardless of timing of postpartum insertion [
        • Dahlke J.D.
        • Terpstra E.R.
        • Ramseyer A.M.
        • Busch J.M.
        • Rieg T.
        • Magann E.F.
        Postpartum insertion of levonorgestrel – intrauterine system at three time periods: a prospective randomized pilot study.
        ] and another cohort study finding no difference in mean duration of breastfeeding between women choosing no IUD, immediate copper IUD and immediate 52-mg LNG-IUD [
        • Elsedeek M.S.
        Puerperal and menstrual bleeding patterns with different types of contraceptive device fitted during elective cesarean delivery.
        ]. However, a subanalysis of the Chen et al. RCT found a significantly lower median duration of breastfeeding among women receiving a postplacental 52-mg LNG-IUD compared to delayed insertion [
        • Chen B.A.
        • Reeves M.F.
        • Creinin M.D.
        • Schwarz E.B.
        Postplacental or delayed levonorgestrel intrauterine device insertion and breast-feeding duration.
        ].
        A large noninferiority randomized trial was specifically designed to compare breastfeeding outcomes between postplacental and delayed insertion of the 52-mg LNG-IUD. For the primary outcome of any breastfeeding at 8 weeks postpartum, postplacental insertion was noninferior to delayed insertion (79% vs. 84%, respectively, p=.28). Time to lactogenesis was also noninferior in the postplacental compared to delayed insertion groups (65.3 vs. 63.6 h, p=.61) [
        • Turok D.K.
        • Leeman L.
        • Sanders J.N.
        • Thaxton L.
        • Eggebroten J.L.
        • Yonke N.
        • et al.
        Immediate postpartum levonorgestrel intrauterine device insertion and breast-feeding outcomes: a noninferiority randomized controlled trial.
        ]. Based on the results of this definitive study, we do not recommend withholding the option of postplacental LNG-IUD for breastfeeding women.
      • 9.
        What is the risk–benefit ratio of postplacental IUD insertion?
        Postplacental insertion of copper IUDs and LNG-IUDs is as safe as insertion at other time frames and may offer advantages over delayed insertion. However, expulsion rates are higher after postplacental insertion. In determining if postplacental IUD insertion is a reasonable approach in any individual situation, various factors must be considered, including availability of replacement IUDs after expulsion and the patient population return rate for the postpartum visit. Randomized trials of postplacental versus delayed insertion have shown either no difference in usage or improved usage of postplacental IUDs at 6 and 12 months postpartum [
        • Chen B.A.
        • Reeves M.F.
        • Hayes J.L.
        • Hohmann H.L.
        • Perriera L.K.
        • Creinin M.D.
        Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial.
        ,
        • Whitaker A.K.
        • Endres L.K.
        • Mistretta S.Q.
        • Gilliam M.L.
        Postplacental insertion of the levonorgestrel intrauterine device after cesarean delivery vs. delayed insertion: a randomized controlled trial.
        ,
        • Lester F.
        • Kakaire O.
        • Byamugisha J.
        • Averbach S.
        • Fortin J.
        • Maurer R.
        • et al.
        Intracesarean insertion of the copper T380A versus 6 weeks postcesarean: a randomized clinical trial.
        ,
        • Levi E.E.
        • Stuart G.S.
        • Zerden M.L.
        • Garrett J.M.
        • Bryant A.G.
        Intrauterine device placement during cesarean delivery and continued use 6 months postpartum: a randomized controlled trial.
        ,
        • Dahlke J.D.
        • Terpstra E.R.
        • Ramseyer A.M.
        • Busch J.M.
        • Rieg T.
        • Magann E.F.
        Postpartum insertion of levonorgestrel – intrauterine system at three time periods: a prospective randomized pilot study.
        ]. In these studies, participants were able to receive a new IUD after expulsion. Thus, in a clinical environment where replacement of expelled IUDs is feasible, increased expulsion rates after postplacental insertion may be less clinically relevant. Given the multiple barriers that exist for IUD insertion in routine practice [
        • Ogburn J.A.
        • Espey E.
        • Stonehocker J.
        Barriers to intrauterine device insertion in postpartum women.
        ,
        • Bergin A.
        • Tristan S.
        • Terplan M.
        • Gilliam M.L.
        • Whitaker A.K.
        A missed opportunity for care: two-visit IUD insertion protocols inhibit placement.
        ,
        • Chen B.A.
        • Reeves M.F.
        • Hayes J.L.
        • Hohmann H.L.
        • Perriera L.K.
        • Creinin M.D.
        Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial.
        ], a patient population with low return rates for the postpartum visit is more likely to benefit from the option of postplacental IUD insertion.
        Two studies have looked at cost implications of postplacental IUD placement. A retrospective cost–benefit analysis focusing on underinsured immigrant women concluded that although individual hospitals may lose money if they initiate an in-hospital postpartum IUD program, the state would save $2.94 for each dollar spent on a state-financed program [
        • Rodriguez M.I.
        • Caughey A.B.
        • Edelman A.
        • Darney P.D.
        • Foster D.G.
        Cost-benefit analysis of state- and hospital-funded postpartum intrauterine contraception at a university hospital for recent immigrants to the United States.
        ]. A decision-analysis model evaluated the cost-effectiveness of postplacental IUD insertion. That analysis overwhelmingly supports the potential for financial savings with postplacental IUD insertion, predicting a cost savings of $282,540 over 2 years for every 1000 women who desired a postpartum IUD [
        • Washington C.I.
        • Jamshidi R.
        • Thung S.F.
        • Nayeri U.A.
        • Caughey A.B.
        • Werner E.F.
        Timing of postpartum intrauterine device placement: a cost-effectiveness analysis.
        ].
        For programs that offer postplacental IUD insertion, comprehensive counseling regarding risks and benefits is essential. It is especially important to avoid contraceptive coercion or perception of coercion in this setting. LARC methods may be particularly susceptible to potential coercion due to dependence on a health care provider to insert and remove the device [
        • Moskowitz E.
        • Jennings B.
        Directive counseling on long-acting contraception.
        ]. Given the history of forced sterilization in the United States and patient perceptions about directive counseling and coercion by health care providers [
        • Yee L.M.
        • Simon M.A.
        Perceptions of coercion, discrimination and other negative experiences in postpartum contraceptive counseling for low-income minority women.
        ], providers must ensure that women receive nonjudgmental patient-centered counseling and maintain autonomy in their contraceptive decision-making. The health care team must make sure that women have the information and time necessary to make informed decisions without coercion based on their personal preferences and reproductive goals [
        • Yee L.
        • Simon M.
        Urban minority women's perceptions of and preferences for postpartum contraceptive counseling.
        ,
        • Callegari L.S.
        • Aiken A.R.
        • Dehlendorf C.
        • Cason P.
        • Borrero S.
        Addressing potential pitfalls of reproductive life planning with patient-centered counseling.
        ,
        • Dehlendorf C.
        • Kimport K.
        • Levy K.
        • Steinauer J.
        A qualitative analysis of approaches to contraceptive counseling.
        ]. To this end, a patient-centered, shared decision-making approach to contraceptive counseling should be utilized throughout the antepartum and early postpartum periods.

      5. Conclusions and recommendations

      The following recommendations are based on good and consistent scientific evidence (Level A):
      • The rate of expulsion is higher after postplacental insertion than after delayed insertion.
      • Usage of the IUD is similar or greater after postplacental insertion than after delayed insertion in settings where replacement of expelled IUDs is readily available.
      • Postplacental insertion is safe and does not have higher risks of perforation or infection than insertion at other time frames.
      The following recommendations are based on limited or inconsistent scientific evidence (Level B):
      • The rate of expulsion is lower after cesarean delivery than after vaginal delivery.
      • The rate of expulsion after early postpartum insertion is similar to or possibly higher than the rate of expulsion after postplacental insertion.
      • Provider experience may play a role in expulsion rates.
      • IUD insertion techniques and modifications do not influence expulsion rates.
      • Inability to visualize IUD strings at the external cervical os may be more common after postplacental insertion than after interval insertion, and is higher after insertion at the time of cesarean delivery compared to insertion immediately after vaginal delivery
      The following recommendations are based primarily on consensus and expert opinion (Level C):
      • Lack of ultrasound guidance should not prohibit provision of postplacental insertion.
      • Contraceptive coercion or perceived coercion may be more likely with LARC methods. Comprehensive patient-centered counseling on contraception with full disclosure of risks and benefits of postplacental IUD insertion must be undertaken for all women who are considering this option.

      6. Important questions to be answered

      Expulsion rates after postplacental insertion vary widely across studies. Research to isolate the modifiable factors that contribute to this variability—e.g., provider experience or IUD type—may serve to reduce expulsion in clinical practice. Other areas of future research include comparisons of intervals for postpartum insertion (e.g., postplacental vs. early postpartum). Furthermore, research is needed on the utility of ultrasound in placement, as well as investigation of potential interventions to decrease the incidence of missing strings on follow-up exams (which can necessitate ultrasound use). Further research is also needed on the incidence and management of malpositioned IUDs after postplacental placement. Studies on antepartum and postpartum contraceptive counseling and decision making, particularly to ensure reproductive autonomy and to avoid coercion, is necessary. Finally, policy research is needed to address barriers to IUD insertion, including cost and insurance barriers as well as institutional barriers at the hospital and state level.

      Sources

      Authors used the following search terms in the Ovid MEDLINE databases to identify relevant references published from 1946 to 2017: postplacental, postpartum period, intrauterine devices, intrauterine devices + medicated, intrauterine devices + copper, cesarean, obstetric delivery. Search terms were used singly and in combination with each other to optimize the search. English- and Spanish-language abstracts were reviewed and relevant articles obtained. Authors used similar search terms in PubMed to identify articles in press. Authors used the citations within those references to supply additional sources for review.

      Authorship

      These guidelines were prepared by Amy K. Whitaker, MD, MS, and Beatrice A. Chen, MD, MPH, and were reviewed and approved by the Board of the Society of Family Planning.

      Conflict of interest

      Dr. Whitaker has no conflicts of interest to report.
      Dr. Chen receives research support from Medicines 360, Bayer Pharmaceuticals, and Merck, managed through Magee-Womens Research Institute & Foundation. Dr. Chen also serves on a Merck & Co. advisory board.
      The Society of Family Planning receives no direct support from pharmaceutical companies or other industries.

      Intended audience

      This guideline is for members of the Society of Family Planning and other health care professionals who are involved in the provision of antepartum, postpartum, or contraceptive care. It may also be useful for policy makers, health care institutions, and insurance companies in determining policies regarding postplacental IUD insertion. The purpose of this document is to review the medical literature evaluating postplacental insertion of intrauterine devices. Although this evidence-based review can be used to guide health care professionals, it is not intended to dictate care.

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