Oregon AWHONN

Promoting the Health of Women and Newborns

June 2017 Vol. 4 No. 6

In This Issue

Keep Calm and LARC On: What You Need to Know

by Kara Johnson, DNP, RNC-OB, CNS


Introduction

It is estimated that long-acting reversible contraceptives (LARC), including intrauterine devices (IUD), are the most effective forms of contraception with a less than 1% failure rate annually, yet it is estimated that only 11.6% of American women use this form of contraception (Kavanaugh, Jerman, Finer, 2015). One barrier to women choosing LARC for contraception is the associated costs with IUD placement. Now that the Patient Protection and Affordable Care Act (ACA) requires health insurance to cover all Food and Drug Administration-approved contraceptives at no cost to patients, including highly effective LARC (Durante & Woodhams, 2016), more women have LARC available as an option for family planning.


Immediate Postpartum Placement

An IUD may be placed immediately following a vaginal or cesarean delivery after the placenta is delivered. Insertion of the copper 380A IUD, also known as Paraguard, has been extensively studied and is supported by the package label. Paraguard is approved for continuous use for up to 10 years. Insertion of the levonorgestrel-releasing IUDs have not been studied as extensively. The levonorgestrel-releasing IUDs are manufactured with four different doses of the hormone known as Mirena, Skyla, Liletta, and Kyleena. The Mirena and Kyleena are approved for up to 5 years continuous use and Skyla and Liletta are approved for 3 years. The Centers for Disease Control (CDC) support the use of either type of IUD, copper or levonorgestrel-releasing, whether or not the woman is breastfeeding (Curtis et. al., 2016). Breastfeeding does not appear to increase the risk of IUD expulsion.


An IUD may be placed immediately following

a vaginal or cesarean delivery

after the placenta is delivered.


Postpartum insertion should take place within 10 minutes after the placenta is delivered. The patient should have adequate anesthesia prior to procedure. Before IUD insertion the provider should verify that the delivery was uncomplicated, bleeding is normal and the uterus is firm, and there is no evidence of infection. The IUD should not be placed in cases of postpartum hemorrhage, suspected retained placenta, infection, or disruption of uterine scar. Insertion by hand or with an instrument does not seem to make a difference in risk of expulsion. Correct fundal placement minimizes the risk of expulsion. A recent study demonstrated a lower rate of expulsion of 4% with the copper IUD compared to 17% with the levornegestrel-releasing IUD (Eggebroten, Sanders, & Turok, 2017).


Benefits, Side Effects, and Considerations

The major advantage of LARC compared to other reversible contraceptive methods is the effort of the user for long-term and effective use. The return of fertility after removal is also rapid. In an economic analysis both types of IUDs were among the three least expensive methods of contraception over a 5-year period (ACOG, 2015). IUD insertion immediately following delivery can be convenient for both the patient and the provider. Women that have just given birth are highly motivated to prevent unintended pregnancy. It reduces the need for a return clinic visit for contraception and patients often delay or do not return for contraception.


Postpartum women are at risk for unintended pregnancy. Women also have increased health risks if there is a short interval between pregnancies. Ovulation can return three weeks postpartum if not fully breastfeeding and within three months for women breastfeeding only. Although women were counseled after delivery to abstain from intercourse for six weeks, a study showed that 45% of women reported having unprotected intercourse prior to six weeks after delivery (ACOG, 2015). Complications of IUD placement are expulsion, method failure, and perforation. The expulsion rate the first year is between 2-10%. Perforations occur 1 in 1000 or less (ACOG, 2015). Signs of perforation include severe, unrelenting pain, and IUD string short or not visible (in IUDs with strings). Bleeding is another symptom, but obviously is difficult to diagnose post-delivery. If perforation is suspected the patient must be monitored for tachycardia, hypotension, syncope, or an acute abdomen. Antibiotics should also be administered if perforation occurs.


Although women were counseled after delivery

to abstain from intercourse for six weeks,

a study showed that 45% of women reported

having unprotected intercourse

prior to six weeks after delivery.


Adverse side effects for the copper IUD are abnormal bleeding and pain. Patients should be aware that bleeding and cramping may increase with initial use of the copper IUD, but patients report this decreases over time. Patients that have the levonorgestrel-releasing IUD have a decrease in the amount and duration of bleeding and bleeding becomes progressively less due to the hormonal effects on the endometrium. Hormonal side effects may occur such as headaches, breast tenderness, depression, and cyst formation. Both types of IUDs do not protect against STIs or HIV. Occasionally IUD placement causes a vasovagal response which resolves by stopping procedure, placing in recumbent position, and supportive care.


Discharge instructions include to call their provider if they have abdominal pain, unexplained fever, unusual vaginal odor, they cannot feel the strings (if applicable), if they think the IUD has moved or fallen out, suspected STI, or their period is late or unusual.


Barriers

Many women have financial concerns and may be unfamiliar with the Affordable Care Act (ACA) contraception coverage which includes covering IUDs. Stocking IUDs has also been a concern due to cost and reimbursement challenges. It has also been challenging for hospitals in Oregon to bill insurance companies for reimbursement related to coding, which has prevented hospitals from offering this procedure. Nurses and obstetric providers may have a lack of knowledge about immediate postpartum placement. Providers also may have not been trained on postpartum placement and may feel uncomfortable offering to their patients. Competing clinical and documentation priorities immediately after delivery have also been a barrier to immediate IUD placement. Facilities that offer this procedure have the IUD and an “IUD kit” ready in the room prior to delivery. Providers may have personal preferences in supplies, but a kit may include a speculum, ring forceps (2), scissors, and antiseptic solution (povidone-iodine or chlorhexidine).


Summary

Immediate postpartum IUD placement may be a beneficial option for some patients. The procedure can be done immediately following the birth if patients have uncomplicated deliveries and no contraindications. §

References

American College of Obstetricians and Gynecologists. (2015). Long-acting reversible contraception: Implants and intrauterine devices. Obstetrics & Gynecology, 118, 184-196.


Curtis, K.M., Tepper, N.K., Jatlaoui, T.C., Berry-Bibee, E., Horton, L.G., Zapata, L.B,. Simmons, K.B., Pagano, H.P., Jamieson, D.J., & Whiteman, M.K. (2016). U.S. Medical eligibility criteria for contraceptive use. MMWR Recommendations and Reports, 65, 1-103. doi: 10.15585/mmwr.rr6503a1


Durante, J.C. & Woodhams, E.J. (2016). Patient education about the Affordable Care Act contraceptive

coverage requirement increases interest in using long-acting reversible contraception. Women’s Health Issues, 27, 152-157. doi: 10.1016/j.whi.2016.11.006


Eggebroten, J.L., Sanders, J.N., & Turok, D.K. (2017). Immediate postpartum intrauterine device and implant program outcomes: A prospective analysis. American Journal of Obstetrics & Gynecology.

doi: 10.1016/j.ajog.2017.03.015


Kavanaugh, M.L., Jerman, J., & Finer, L.B. (2015). Changes in use of long-acting reversible contraceptive methods among U.S. women, 2009-2012. Obstetrics & Gynecology, 126, 917-927.

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Remain calm, serene, always in command of yourself. You will then find out how easy it is to get along.

Paramahansa Yogananda