Safety and Success of immediate post-placental intrauterine device insertion at the time of Cesarean Section

a Senior Lecturer, Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Colombo bActing Consultant Obstetrician and Gynaecoogist, Base Hospital, Maha-Oya cAdditional Medical officer of Health, Medical Officer of Health office Biyagama, Ministry of Health d Registrar in Community Medicine, National Cancer Control Programe, Ministry of Health. eProfessor of Obstetrics and Gynecology, Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Peradeniya


INTRODUCTION
Intra Uterine Device (IUD) insertion is a safe and reversible method of contraception which has a cumulative pregnancy rate of less than 1 in 1000 in the first year of use 1 . Immediate postplacental IUD (PPIUD) insertion is defined as placement of the IUD within 10 minutes of delivery of the placenta 2 . This method is an attractive option due to many reasons, such as women being more amenable to the procedure at the time of delivery because of increased motivation for contraception, minimal discomfort related to insertion, lack of interference with breast feeding 1,2,3, plus safety and efficacy of the procedure 1,5. PPIUD insertion therefore ensures that the women leave the hospital with a proper contraceptive method 3 . This can also have a positive impact on reducing maternal morbidity and mortality in countries where the implications of unwanted pregnancies, such as criminal abortions, are high 1 . PPIUD insertion at the time of Cesarean Section (CS) is also a safe and an acceptable method 1,4. However, scientific evidence on safety and efficacy of this practice is scarce globally as well as locally. Despite the facts that, cervix is not fully dilated and fundal placement of IUD is easier and safer at the time of CS, PPIUD insertion at the time of CS is not performed commonly around the world. This could be due to many reasons, including lack of awareness among practitioners and lack of evidence to assess benefits. Applicability of evidence is higher when it is generated from local setting. Therefore we conducted a study to assess the safety and effectiveness of PPIUD insertion following CS and Vaginal Deliveries (VD) at a Teaching Hospital in Sri Lanka.

METHODS We conducted a cross
sectional study with an analytical component at the Teaching Hospital, Kandy. Women who underwent PPIUD http://orcid.org/0000-0002-0739-5661 iD insertion following VD and CS were considered as the study population. Women who had a diagnosis of a mental disorder were excluded. Study units were recruited to the study during the three months' period from 1 st of January 2013 to 31 st of March 2013 until the calculated sample size of 485 was achieved. All the study participants were invited for a follow up interview and examination at six weeks and six months after insertion of PPIUD. Initial data were collected by an interviewer-administered questionnaire by trained data collectors at postnatal wards.
Women were re-assessed clinically and ultrasonically at 6 weeks and 6 months following insertion of the PPIUD. Expulsion of IUD was defined as ultrasonic confirmation of absence of the IUD within the uterine cavity with or without a history of expulsion from the woman. Associations with selected variables were assessed using the Chi Square test and a p value less than 0.05 was considered as significant.
RESULTS Mean age of the study population was 27.1 (SD=0.4). There were 261 (53.7%) primiparous women. Multigravid women with more than three deliveries were 26(5.5%) The study population was dichotomized into those who underwent PPIUD insertion following VD 364 (75.1%) and those who underwent the same following CS 121 (24.9%). Out of 121 CSs, 99 (81.8%) were emergency CSs. With regard to the morbidities, the commonest complaint in the CS group was abdominal pain (8; 6.6%), followed by abnormal vaginal bleeding (5; 4.1%). In the VD group, 3(0.8%) complained of abdominal pain and 7 (1.9%) complained of abnormal vaginal bleeding. There was no difference in morbidity rates between the two groups (p=0.2). Six (4.9%) IUDs had been expelled before six months in the CS group. However, all six expulsions in the CS group were from women who did not have any complaints. These expulsions were recorded from both elective (1; 4.5%) and emergency (4; 5.5%) CSs and did not show any association with the type of CS (p=0.5). Among the women who experienced PPIUD insertion following VD, 64 (17.7%) IUDs had been expelled before 6 months in this group of women, which was significantly higher than the group of women who underwent PPIUD following CS (p<0.001).

DISCUSSION:
The expulsion rate in women after vaginal delivery was found to be 17.7%, which was significantly higher than that of post CS PPIUD insertions (5%) (p<0.001). There was no difference in the proportion of morbidities following insertion of PPIUD in the two groups as well. Therefore PPIUD insertion at the time of CS appears to be a safe and effective option for women opting for a long acting, reversible contraceptive method. Even though the failure rates are low, confirming the presence of IUD in the uterine cavity ultrasonically at the end of 6 months would improve patient acceptance of the method in the long term. This practice of contraception could be more useful in countries like Sri Lanka where unsafe criminal abortions are high 9 . This method ensures that the patient leaves the hospital with a long acting and user independent method of contraception. Considering the poor compliance to other family planning methods and the rate of CS at hospitals, application of this intervention seems feasible. Authors strongly recommend conduction of further studies to evaluate long-term outcomes to build up the evidence.