Post partum iud insertion

POSTPARTUM IUD INSERTION ,PRINCIPLES ,METHODS ,ADVANTAGES AND DISADVANTAGES

1. DEPARTEMENT OF FAMILY MEDICINE AKTH KANO POST- PARTUM IUD INSERTION DR OGECHUKWU MBANU

2. POST PARTUM INTRA-UTERINE DEVICES

3. OUTLINE Introduction /definition IUDs ,uses , classification ,mechanisms of action and advantages classification of PPIUDs Why PPIUD Non pregnant versus immediate post partum uteru and cervix An overview of the process of PPIUD Contraindications /misconceptions IUDs and STIs Reasons for non use of IUDs Warning symptoms Conclusion References

4. introduction As of 2013 250 million pregnancies occurred globally Majority in less developed nations with high fertility rate, hence, need for fertility regulation 33.3% unintended; As of 2013 Unmet need for family planning in Nigeria is currently 16% among married women IUD is the most commonly used reversible method of contraception worldwide with about 127 million current users Postpartum insertion of IUD is safe, effective and convenient for women

5. Unmet Need for Modern Contraception

6. Introduction cont’d , world map showing IUD use

7. DEFINITIONS Post-partum : This is the period beginning immediately after the birth of a child and extending for about four to six weeks IUD OR IUCD: Is a small usually T – shaped plastic device that is wrapped in copper or contains hormones , inserted into the uterine cavity mostly for the purpose of contraception Post – partum IUD(PPIUD) :The insertion of an IUD into the uterine cavity during post- partum period Trans – caesarean: Procedure done within the period of the cs

8. Definitions cont’d ; Stages of postpartum period 4 stages : The post - placental period—within the first 10 minutes after expulsion of the placenta The immediate postpartum period—includes the first 48 hours postpartum The early postpartum period—extends until the first week postpartum The remote postpartum period—which includes the period of time required for the complete involution of the uterus and has traditionally extended through the fourth week postpartum

9. Intrauterine Contraception Devices: Most commonly used reversible method of Contraception worldwide effective > 97% The newer devices have failure rate of < 0.5%

10. Clinical uses Long-term contraception Emergency contraceptive ( 1:1000 ) Menorrhagia Endometriosis Chronic pelvic pain Dysmenorrhea Endometrial hyperplasia Contraindication to COC such as in ischemic heart disease , focal migraine, liver disease,and breast CA

11. CLASSIFICATION

12. First generation IUD They are inert or Nonmedicated devices made up of polyethylene Different shapes and sizes LIPPE’S LOOP: Double ‘S’ shaped device Made up polyethylene material Non toxic, non tissue reactive & extremely durable Small amount of Barium Sulphate is also added for radiological examination Available in 4 sizes A,B,C &D Failure rate: 3-5 / HWY(hundred women years) 12

13. Second generation Iud Wrapped with copper. EARLIER DEVICES Copper – 7( Gravigard ) Copper - T 200 1 st year failure rate of 0.1- 2.2% NEWER DEVICES Variants of T device T copper 220C T copper 380A( paragard ) Nova T Multi load devices ML-Cu250 ML-Cu375 (u- shaped) 13

14. Third generation iud Hormone releasing IUD Progestastert Most commonly used T shaped device filled with 38mg of progesteron Releasing rate 65µg/day . Effective for 1 yr Failure rate: 0.2 / HWY LNG-20 ( Minera ) Releases 20µg of levonorgesterol . Effective for 5 yrs Effective rate 99%

15. Other types IUD Silver IUD ( silverlily ): a silver copper combination Gold containing IUD such as Goldring medusa, Eurogine gold T IUD, Gold lily :these contain gold and copper Frameless IUD such as Gynefix which consists of hollow copper tubes on a polypropylene thread. It is anchored about 1 cm into the myometrium at the fundus.

16. Mechanism of Action: All IUCD cause a foreign body reaction in the endometrium with increased prostaglandin production and Leucocyte infiltration thus inhibiting sperm transport. Alteration of uterine and tubal fluid which impaired the viability of the gametes. The progesterone IUCD (LNG.IUD) cause endometrial suppression and thinning, also changes in the cervical mucus and utero- tubal fluid which impair sperm migration.

17. General advantages of IUD Long acting and reversible No excessive weight gain Very effective – at least 99%. Can be easily removed Does not affect breastfeeding. Does not interfere with sexual intercourse No-one else needs to know you are using it. No evidence of an increased risk of cancer.. Copper IUDs can also be used for emergency contraception Hormone IUDs release a very small dose of hormone thus side effects are minimal Mirena reduces period bleeding and pain so most women will have light bleeding or no periods at all.

18. Classification of PPIUD Based on Postpartum IUD timing Post - placental : Inserted within 10 minutes the placenta is expelled in a vaginal delivery Immediate postpartum : Insertion within 48 hours of delivery , before the client leaves the hospital. Trans - ceasarean : Insertion following a cesarean delivery, before the uterine incision is sutured. Post - abortion : The IUD is inserted following an abortion. Note: An interval IUD inserted at any time between pregnancies after 4 weeks post-partum or completely unrelated to pregnancy

19. Why postpartum IUD ? It is readily accessible for women who deliver at health care facilities Postpartum amenorrhea and Return to fertility Breastfeeding status: has no effect on amount or quality of breast milk Postpartum abstinence and return to having sex Limited mobility and access to services in postpartum period Decision- making: influence of other parties like mother in laws

20. Why postpartum IUD cont’d inertia in seeking postpartum services Does not require any daily action on the part of the user Preventing lost opportunities . Cost-effectiveness

21. Non pregnant versus immediate post partum uterus and cervix Anatomic Structure Nonpregnant Immediate Postpartum Uterus Weighs approximately 100g or less weighs as much as 1 kg Is situated in the pelvis is just below the umbilicus; gradually moves lower, until back in non pregnant position Usually contracts only during menses Experiences regular, strong, contractions that decrease slowly after the first postpartum days Has walls that are together, creating a “virtual” uterine cavity Has distended, separated walls at first ,comes together at involution Cervix Is a narrow canal communicating between the uterine cavity and vagina Is collapsed ,along with the lower uterine segment after third stage of labor, then slowly contracts

22. Non pregnant versus immediate post partum uterus cont,d Non – pregnant uterus The uterus , immediately post partum

23. Immediate postpartum versus non pregnant uterus and cervix The anatomical changes in immediate postpartum uterus and cervix Makes it possible to safely insert IUD immediately after delivery This Insertion can be immediate, pre discharge ,or at caesarean section This will reduce the un-met need of our women for contraception

24. An overview of the process of PPIUD Key Components of Care Related to PPIUD Service Delivery Rights of Clients Information Access to services Informed choice Safe services Privacy and confidentiality Dignity, comfort, and expression of opinion Continuity of care

25. An overview of the process of PPIUD cont’d Key Components of IUD service cont’d Needs of Providers Facilitative supervision and management Information update training, and development Supplies, equipment, and infrastructure

26. Process cont’d PPIUD counseling This should be integrated into the antenatal programme Encourage healthy spacing of pregnancies Discuss the different types of family planning and encourage to consider PPIUD Encouraged to discuss and choose a family planning method with husband before she is at risk of getting pregnant The right family planning method must suit the patients brestfeeding need and other family needs

27. Counseling for those who have accepted PPIUD She can have it inserted within 48 hours of delivery before leaving the facility, or she can have it inserted four weeks after delivery. Postpartum IUD does not affect breast milk and breast feeding. Post-placental , immediate , Trans - caesarean and interval IUD insertion are safe procedures. The expulsion rate is higher for IUDs inserted within 48 hours of delivery . The client needs to be on the lookout for an expulsion

28. COUNSELING CONT’D In the case of expulsion she can usually have another IUD inserted after four weeks she will need another method of contraception in the mean time possibility of “missing strings” The importance of a follow-up visit Be sure to discuss any possible difficulties related to her returning for a follow-up visit

29. An overview of the process of PPIUD cont’d NOTE 1. Prior to inserting the postpartum IUD: Confirm that the client has made an informed, voluntary decision ,consent form signed. 2. Before and during postpartum insertion of the IUD: Put the client at ease by talking with her 3. After the insertion: A client card with the name of the IUD and the date of insertion should be given to her Written post-insertion instructions should be given too Assure her that IUD does not affect breast milk or breastfeeding Give appointment for follow up

30. Client Assessment for Postpartum IUD Use Components of a Client Assessment 1. Taking and assessing the client’s medical history, including a. General medical, obstetric, and gynecologic history b. STI risk assessment 2. Performing a physical examination 3.There is no laboratory test required for postpartum IUD insertions 4. Providers should check in the antenatal and obstetric record for any laboratory test done at that moment as a good practice

31. Technique Immediate postpartum IUD can be inserted using a kellys or ringed forceps Post-placental IUD can be done with kellys forceps or by manual insertion For trans-caesarean IUD ,as the uterus is open, the IUD can be placed with the fingers or with any grasping instrument in the uterine fundus

32. General contraindications to IUDs Post partum puerperal sepsis Suspected gynecological malignancy ( Cervical cancer, Endometrial cancer) Current STDs Current PID Anatomical abnormalities of the uterus or cervix Allergy to copper History of abnormal uterine bleeding Wilsons disease in the case of copper T 380A Endometritis Pregnancy History of ectopic pregnancies

33. Complications of IUD(PPIUD) infection (about 1%) this can lead to PID perforation of the womb (about 1 in 1,000). pregnancy can occur with an IUD in place but this is rare. ectopic pregnancy ;Higher rate with progestasert copper IUD may cause more bleeding and cramping during periods. copper IUD can very rarely cause an allergic reaction Hormone IUDs may initially cause irregular, light bleeding for more days than usual. Expulsion (about 5%) Spontaneous abortion Increase risk of preterm labour (if left in place)

34. missconceptions .There is no evidence that IUDs cause acne, headaches, breast Tenderness nausea, mood changes, loss of libido or weight gain

35. The IUD and sexually transmitted infections According to WHO 2004 medical eligibility criteria , the following women with STIs and with HIV-related conditions generally can start using IUD: Women who have had pelvic inflammatory disease (PID) in the past, as long as they have no known current risk factors for STIs. (If they have had a subsequent pregnancy, they can use the IUD—) Women who have HIV but who do not have AIDS. Women who have AIDS and who are doing clinically well on antiretroviral therapy

36. Reasons for nonuse of IUD can be grouped into a few broad categories Opposition to family planning Lack of knowledge Access and cost Health concerns and side effects of methods Misconceptions about pregnancy risk

37. Warning symptoms Cannot feel string Missed period Unusual vaginal fluid or odour Severe abdominal pain, cramps ,or bleeding Bleeding occuring with sex Unexplained fever ,chills Severe pain during sex

38. Conclusion In Nigeria risk of pregnancy increases over time during post partum period . Over half (54%) of all non- first births in Nigeria are spaced at less than the recommended 24 month interval This puts women and their infants at increased risk of poor maternal and perinatal outcomes Greater awareness and use of PPIUD can help reduce this risk

39. THANK YOU FOR LISTENING

40. REFERENCE Nelson A. Intrauterine contraceptives vol.6. Philadelphia .Lippincott Williams and Wilkins ; 2004 .Gynaecology and obstetrics WHO and gutmacher institute; facts on induced abortion worldwide .2007 THE POSTPARTUM INTRAUTERINE DEVICE participant handbook . A training course for service providers 2008 USAID , the ACQUIRE project The postpartum intrauterine device(PPIUD) services- A reference manual for providers 2010 ,USAID , access Family planning needs during the 1 st two years post partum in nigeria - 2013 – USAID, CHIP. Iud – A quick review , Kamlesh Giri Intrauterine contraceptive devices ppt presentation by Lavina Balavutham Intrauterine devices knowledge , attitude and use among women seeking termination of pregnancy in Gauteng South Africa A giude to developing family planning messages for women in the first year post partum