Postpartum IUD Placement, with Dr. Sarah Prager

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This week we are joined by Dr. Sarah Prager, a professor at the University of Washington in OB/GYN and Complex Family Planning. She shares with us some particular expertise in an ever-more common procedure - the postpartum IUD placement. There’s definitely a few pearls in the podcast that are worth listening for!

Definitions: 

  • Immediate postplacental insertion: within 10 minutes of placental extraction

  • Immediate postpartum insertion: 10 minutes to 48 hours after delivery

  • Delayed postpartum insertion: 48 hours to 6-8 weeks after delivery

  • Interval placement: IUD placement not related to recent delivery

  • Trans-cesarean insertion: IUD placed through the hysterotomy at the time of cesarean delivery

Exclusion criteria:

  • Chorioamnionitis/uterine infection

  • Prolonged rupture of membranes (18-24 hours)

  • Excessive postpartum bleeding that is unresolved

  • Extensive genital trauma that would be negatively impacted by IUD placement

Expulsion rates: 

  • 10% if placed in the first 10 minutes

  • Up to 25-30% if placed after 48 hours

  • Limited data on 10 minutes to 48 hours

    • Pilot study in Zambia showed 4% expulsion with “morning after delivery” IUD placement

  • Provider experience matters!

    • Study from 1985 showed providers cut their expulsion rates almost in half comparing the beginning to the end of the study

  • Take home message: don’t get discouraged! Your expulsion rate will decrease with experience!

Copper vs. LNG-IUD

  • Most older data is with various copper IUDs (primarily the Copper T 380A – ParaGard)

  • Some limited data with specifically Mirena brand LNG-IUD.

  • Recent data often pooled LNG-IUD, without separating different IUDs

  • Limited comparative data

    • Possibly higher expulsion rates with LNG-IUD than Copper IUD

    • Could be due to method used for insertion – inserter vs. no inserter

    • LNG-IUD inserters are long enough to reach the fundus of a PP uterus, ParaGard IUD inserters are not

    • There is a dedicated PP inserter for Copper IUD (longer, stiffer, but not available in USA at this time); unclear if it changes outcomes

  • Recent study out of Kaiser showed slightly lower expulsion rates for breastfeeding vs. non-breastfeeding people.

    • Largest study to date with mostly LNG-IUD

    • Expulsion rates:

      • 10.7% expulsion by 5 years with placement 0-3 days

      • 3.9% for 3 days to 6 weeks

      • 3.2%for 6-14 weeks postpartum

      • 4.9% for interval placement

Medical Eligibility Criteria:

  • CDC: category 1 or 2 at any time, regardless of type of IUD or breastfeeding status.

    • Of course, category 4 if uterus is infected

  • WHO: category more nuanced depending on type of IUD and timing of placement

Method of placement:

  • With the inserter

    • Need a long enough inserter

    • Often can use the LNG-IUD inserters

    • Also need the inserter to be stiff enough – sometimes doesn’t work with LNG-IUD inserters

    • Dedicated copper IUD inserter both longer and stiffer

  • With an instrument

    • Can use a ring forceps

    • Can use a Kelly placenta forceps (longer)

  • With your hand

    • No difference in expulsion seen compared with instrument

    • Personal bias – WAY more painful! No-one likes a hand in their uterus

      • Not reported in the early studies that compared this to using a ring

Clinical tips and tricks for successful insertion with an instrument:

  • Place a ring on the anterior lip of the cervix

  • Hold the IUD gently in a ring forceps (don’t click down if LNG-IUD – don’t want to disrupt the LNG delivery system!)

  • Know the orientation of the IUD with respect to the orientation of the ring handles to make sure you place IUD with the proper orientation in the uterus!!!

  • Once the IUD is in the lower uterine segment, gently let go of the ring on the cervix and place the non-dominant hand on the uterine fundus

  • Drop your wrist! Drop your shoulder! Aim for the fundal hand

    • Angle different from interval insertions – basically aim for the umiblicus

    • Will not go wrong if you aim for the fundus! Feel it with your fundal hand!

  • Let go of the IUD and gently remove the ring without pulling on the IUD or strings

  • If strings are visible, cut at the os

    • Can also pre-cut the strings of LNG-IUDs so they are about 10 cm

    • Cutting strings can sometimes pull the IUD lower or out

  • Can use ultrasound if you want!

If using an inserter: 

  • Pre-deploy the IUD – you do not need the narrow profile with an open cervix!

  • Personal bias – don’t use the inserter

If using your hand:

  • Change your gloves

  • Precut the strings

  • Hold between the index and middle fingers with the strings laying across your palm

  • Make sure you don’t pull it out when you remove your hand!

If trans-cesarean placement:

  • Close 1/3 – ½ the hysterotomy then place

  • Precut the strings shorter before directing down into the cervix

  • Personal bias again toward instrument placement, but usually hand and inserter also work fine

Follow-up care:

  • See patients at 1-2 weeks postpartum and trim strings as needed.

    • May need to do this again at 6-week visit

  • If strings not visible at follow-up, do an ultrasound to verify presence of IUD in the uterus

    • If IUD there, NO NEED FOR ROUTINE ULTRASOUND TO CHECK CONTINUED PRESENCE OF THE IUD

    • Counsel patient that efficacy unchanged, but removal may be more complicated if strings don’t emerge from the cervix

      • This should have been a counseling point during consent!