Postpartum IUD

Immediate postpartum intrauterine contraception is the placement of a copper or levonorgestrel device within 48 hours of birth: post-placental within 10 minutes of placental delivery after vaginal birth, during caesarean section before uterine closure, or later within 48 hours. It provides highly effective contraception before the patient leaves the facility, at a time of high unmet need and high risk of short birth intervals.

Timing categories.

Mechanism and effectiveness. Unchanged from interval insertion once the device stays in place. Expulsion is the main limitation.

Return to fertility. Immediate on removal.

Counselling. Counsel during antenatal care and early labour, not in advanced labour or under distress. Obtain informed consent before delivery and reconfirm it after birth. The patient may decline at any point.

Ideal candidates. Patients who want long-acting contraception, have limited access to later postnatal care, or are planning caesarean section.

Do not insert (infection risk).

• Rupture of membranes for more than 18 hours.
• Prolonged labour.
• Chorioamnionitis, intrapartum fever or puerperal sepsis.
• Unresolved postpartum haemorrhage.
• Extensive genital tract trauma whose repair would be disrupted.
• Fibroids or anomalies distorting the cavity, and malignant gestational trophoblastic disease.

Conditions that do not prevent insertion. HIV on antiretroviral therapy, pre-eclampsia, anaemia once bleeding is controlled, diabetes, and adolescence.

Copper regimen line. Copper T 380A, 380 mm² copper; post-placental within 10 minutes of placental delivery, at caesarean before closure, or up to 48 hours after birth; no backup; effective up to 12 years; compatible with breastfeeding; if not placed by 48 hours, delay to 4 weeks.

Levonorgestrel regimen line. Levonorgestrel 52 mg device; same timing; no backup when placed within 48 hours; replace at 5 years; category 2 in breastfeeding patients within 48 hours.

Post-placental vaginal insertion.

• Confirm complete placenta and a well-contracted uterus; give oxytocin as part of active management of the third stage.
• Visualise the cervix, grasp the anterior lip with ring forceps, and carry the device to the fundus with long placental forceps (about 30 cm) or a dedicated postpartum inserter.
• Stabilise the fundus with the abdominal hand, release the device at the fundus, sweep the forceps laterally and withdraw.
• Do not cut the threads at insertion.

Intracaesarean insertion. After placental delivery, place the device at the fundus through the hysterotomy by hand or forceps, direct the threads towards the lower segment without pushing them through the cervix, and close the uterus avoiding the threads.

Follow up. Review at 3 to 6 weeks with postnatal care. Trim long threads to 3 cm. If threads are not seen, especially after caesarean, use a thread retriever or ultrasound before assuming expulsion.

Return advice. Fever, foul discharge, increasing pain, heavy bleeding, a felt or expelled device, or a missed period after menses return.

Expulsion. More frequent than after interval insertion, and higher after vaginal post-placental insertion than after caesarean insertion. Expulsion is often unnoticed; teach the patient to check pads and to feel for threads. Confirm by ultrasound and offer reinsertion from 4 weeks or another method.

Displacement at insertion. Remove with sterile forceps and reinsert. Discard a contaminated device and use a new one.

Cervical laceration. Repair cervical tears, with the technique chosen by tear size and bleeding.

Perforation. Rare at post-placental insertion. If suspected, stop, remove the device and instruments, start intravenous fluids, give prophylactic antibiotics, and monitor vital signs and peritoneal signs. Refer for emergency surgery for severe pain, haemodynamic change or peritonism.

Infection. Danger signs include fever, rigors, foul discharge, pain and shock. Assess for endometritis and sepsis, give broad-spectrum antibiotics, and refer urgently.

Referral and escalation. Refer urgently for sepsis, haemorrhage, suspected perforation or shock. Refer for specialist review if the device cannot be located.