ACOG now recommends that, ideally, all women have some contact with an obstetrical provider within the first 3 weeks postpartum; the timing of a comprehensive postpartum visit should be individualized and patient centered.3 Assessment of how a patient is doing with her immediate postpartum LARC should be performed. For patients who have had postplacental IUD placement, a speculum exam can be performed to visualize the IUD strings. The strings can be trimmed as they often lengthen. Routine ultrasound surveillance is not recommended.
If incidental displacement of the IUD is diagnosed, removal is not mandated but can be considered after appropriate patient counseling, if desired.28 Patients who receive a postpartum implant should be examined like any other patients with an implant, with verification that the device can be palpated and inspection of insertion site.
Management of lost IUD strings
Inability to visualize IUD strings after postplacental placement ranges from 5% for LNG-IUS placement after vaginal delivery to 44% to 79% for IUD placement during cesarean delivery.25,30,31 If the IUD strings are not visualized or palpated at the external os, it may be necessary to use ultrasound to confirm the intrauterine location. Women who undergo postplacental IUD placement should be counseled that confirmation of the IUD may require ultrasound examination.
Postpartum LARC cost-effectiveness
Several studies have shown that postpartum insertion of LARC typically is more expensive up front but is cost-saving overall because of reductions in future unintended pregnancies. A 2015 cost-effectiveness analysis calculated postpartum IUD placement had an estimated cost savings of approximately $282,540 per 1,000 women over a 2-year period. Higher cost was incurred at time of postplacental IUD placement due to more devices used (in part due to expulsion and replacement), but that was offset by prevention of an additional 88 unintended pregnancies over 2 years per 1,000 women.32 Another model found that immediate insertion of contraceptive implants was associated with a higher cost at insertion ($1,091 per patient for immediate placement vs. $650 per patient for delayed placement, likely due to more implants placed in the immediate group) but was more effective in preventing pregnancies, saving $1,263 per patient.33 This prevented 191 unintended pregnancies per 1,000 women with a total savings of $1,263,000 compared with delayed insertion. One caveat is that savings may depend on payor; a 2009 cost-benefit analysis estimated that a postpartum IUD program for patients with Emergency Medicaid would be costly to individual hospitals with a loss of 70 cents per $1 spent.34 Conversely, the same program funded by the state government would save an estimated $2.94 for every $1 spent. This difference was attributed to the likelihood that the state would cover all costs of future unintended pregnancies but hospitals would not see future profits from same-hospital deliveries.
- Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunc. 2005;16:263-267.
- Jackson E, Glasier A. Return of ovulation and menses in postpartum nonlactating women: a systematic review. Obstet Gynecol. 2011; 117:657-662.
- McKinney J, Keyser L, Clinton S, Pagliano C. ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstet Gynecol. 2018 Sep;132(3):784-785.
- Danilack VA, Brousseau EC, Paulo BA, Matteson KA, Clark MA. Characteristics of women without a postpartum checkup among PRAMS participants, 2009-2011. Matern Child Health J. 2019 Jan 10. doi: 10.1007/s10995-018-02716-x. [Epub ahead of print]
- White K, Teal SB, Potter JE. Contraception after delivery and short interpregnancy intervals among women in the United States. Obstet Gynecol. 2015;125;1471-1477.
- Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA 2006; 295 (15): 1809-23
- U.S. Office of Disease Prevention and Health Promotion. Available at https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health
- Committee on Gynecologic Practice Long-Acting Reversible Contraception Working Group. Committee Opinion No. 642: Increasing Access to Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy. Obstet Gynecol. 2015 Oct;126(4):e44-e48.
- American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice. Committee Opinion No. 670: Immediate Postpartum Long-Acting Reversible Contraception. Obstet Gynecol. 2016 Aug;128(2):e32-e37.
- Wu JP, Pickle S. Extended use of the intrauterine device: a literature review and recommendations for clinical practice. Contraception 2014; 89: 495-503
- Rivera R, Yacobson I, Grimes D. The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices. Am J Obstet Gynecol. 1999;181:1263-1269.
- Ortiz ME, Coxatta HB. Copper T intrauterine device and levonorgestrel intrauterine syste; biological bases of their mechanism of action. Contraception. 2007;75:S16-S30.
- Godfrey EM, Folger SG, Jeng G, Jamieson DJ, Curtis KM. Treatment of bleeding irregularities in women with copper-containing IUDs: a systematic review. Contraception. 2013;87:549-566.
- Natavio MF, Taylor D, Lewis RA, Blumenthal P, Felix JC, Melamed A, et al. Temporal changes in cervical mucus after insertion of the levonorgestrel-releasing intrauterine system. Contraception. 2013;87:426-431.
- Lewis RA, Taylor D, Natavio MF, Melamed A, Feliz J, Mishell D Jr. Effects of the levonorgestrel-releasing intrauterine system on cervical mucus quality and sperm penetrability. Contraception. 2010;82:491-496.
- Gemzell-Danielsson K, Schellschmidt I, Apter D. A randomized phase II study describing the efficacy, bleeding profile and safety of two low-dose levonorgestrel releasing intrauterine contraceptive systems and Mirena. Fertil Steril. 2012;97:616-622. E1-E3
- Graesslin O, Korver T. The contraceptive efficacy of Implanon: A review of clinical trials and marketing experience. Eur J Contracept Reprod Health Care. 2008;13 Suppl 1 4-12.
- Davies GC, Feng LX, Newton JR, Van Beek A, Coeling-Bennink HJ. Release characteristic, ovarian activity and menstrual bleeding pattern with a single contraceptive implant releasing 3-ketodesestril. Contraception. 1993;47:251-261.
- Croxatto HB. Mechanisms that explain the contraceptive action of progestin implants for women. Contraception. 2002;65:21-27.
- Update to CDCs U.S. Medical Eligibility Criteria for Contraceptive Use 2010: revised recommendations for the use of contraceptive methods during the postpartum period. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2011;60:878-883.
- Caliskan E. Ozurk N, Dilbaz S. Analysis of risk factors associated with uterine perforation by intrauterine devices. Eur J Contracept Reprod Health Care. 2003;8(3):150-155.
- Dahlke JD, Terpstra ER, Ramseyer AM, Busch JM, Rieg T, Magann EF. Postpartum insertion of levonorgestrel-intratuerine system at three time periods: a prospective randomized pilot study. Contraception. 2011;84;244-248.
- Celen S, Sucak A, Yildiz Y, Danisman N. Immediate postplacental insertion of intrauterine contraceptive device during cesarean section. Contraception. 2011;84:240-243.
- Chen BA, Reeves MF, Hayes JL, Hohmann HL, Perriera LK, Creinin MD. Postplacetnal or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2010;116:1079-1087.
- Levi EE. Stuart GS, Zerden ML, Garrett JM, Bryant AG. Intrauterine device placement during cesarean delivery and continued use 6 months postpartum: a randomized controlled trial. Obstet Gynecol. 2015;126:5-11.
- Sothornwit J, Werawatakul Y, Kaewrudee S, Lumbiganon P, Laopaiboon M. Immediate versus delayed postpartum insertion of contraptive implant for contraption. Cochrane Database Sys Rev. 2017 Apr 22;4.
- Chen BA, Reeves MF, Creinin MD, Schwarz EB. Postplacental or delayed levonorgestrel intrauterine devices insertion and breastfeeding duration. Contraception. 2011;84(5):499-504.
- Whitaker A, Chen BA. Society of Family Planning Guidelines: Postplacental insertion of intrauterine devices. Contraception. 2018;97:2-13.
- American College of Obstetrics and Gynecology. Video on Immediate Postplacental LARC Insertion. Available at https://cfweb.acog.org/district_ii/larc/section4.html
- Glazer AB, Wolf A, Gorby N. Postpartum contraception: needs vs. reality. Contraception. 2011;83(3):238-241.
- Lester F, Kakaire O, Byanugish J, Averbach S, Fortin J, Maurer R, et al. Intracesarean insertion of the copper T380A versus 6 weeks postcesarean: a randomized clinical trial. Contraception. 2015;91(3):198-203.
- Washington CI, Jamshidi R, Thung SF, Naveri UA, Caughey AB, Werner EF. Timing of postpartum intrauterine device placement: a cost-effectiveness analysis. Fertil Steril. 2015;103(1):131-137.
- Gariepy AM, Duffy JY, Xu X. Cost-Effectiveness of Immediate Compared With Delayed Postpartum Etonogestrel Implant Insertion. Obstet Gynecol. 2015 Jul;126(1):47–55.
- Rodriguez MI, Caugher AB, Edelman A, Darney PD, Foster DG. Cost-benefit analysis of state and hospital funded postpartum intrauterine contraception at a university hospital for recent immigrants to the United States. Contraception. 2010; 81(4):304-308.
- Ongoing barriers to immediate postpartum long-acting reversible contraception: a physician survey. Holden EC, Lai E, Morelli SS, Alderson D, Schulkin J, Castleberry NM, McGovern PG. Contracept Reprod Med. 2018 Nov 8;3:23.
- Moniz MH, Dalton VK, Davis MM, et al. Characterization of Medicaid policy for immediate postpartum contraception. Contraception. 2015 Dec;92(6):523-531.
- Hofler LG, Cordes S, Cwiak CA, Goedken P, Jamieson DJ, Kottke M. Implementing immediate postpartum long-acting reversible contraception programs. Obstet Gynecol. 2017 Jan;129(1):3-9.
- ACOG Postpartum Contraceptive Access Initiative. Available at https://pcainitiative.acog.org