O&G Forum

OBSTETRICS & GYNAECOLOGY FORUM 2021 | ISSUE 3 | 6 O&G Forum 2021; 31: 06 - 10 ORIGINAL RESEARCH A review of intrauterine device placement during caesarean section at level two facilities in the Metro West, Cape Town M Schutte 1 , G Petro 2 , M Patel 1 1 Department of Obstetrics and Gynaecology, Groote Schuur Tertiary Hospital, Cape Town, South Africa 2 Department of Obstetrics and Gynaecology, New Somerset Hospital, Cape Town, South Africa Introduction e immediate postpartum insertion of long acting reversable contraceptives (LARCs) such as the intrauterine contraceptive device (IUD) is an important strategy to increase interpregnancy intervals. Pregnancy intervals of less than two years signi cantly contributes to increased perinatal and maternal morbidity and mortality, with complications ranging from preterm rupture of membranes, preterm birth and lowbirthweight to uterine scar rupture andmaternal anaemia. 1 e majority of pregnancies occurring a er a short interpregnancy interval are unplanned. 1 Providing reliable contraception in the immediate postpartum period may be the most e ective way of preventing unwanted pregnancy and short interpregnancy intervals. A woman who is not breastfeeding may ovulate by the third week a er delivery. Up to 50% of women have resumed sexual activity by 6 weeks postpartum, putting them at risk of unwanted pregnancy by the time they return for the 6 weeks visit. 2 ose who do not return are o en socially and economically disadvantaged, and face barriers such as lack of transport and stable housing, and di culty communicating with their health care providers. 3 Women who choose the IUD are up to ten times less likely to having it placed at the 6 weeks visit compared to women receiving it at the time of delivery. 3-7 Follow-up rates for the 6-weeks postpartum visit are poor, ranging between 25 and 62%. 1,2 is could in part be explained by di erent follow-up locations and dates for mother and baby - a signi cant barrier to women with new-born babies who just had surgery, and even more so for someone with socio- economic di culties. 6 By not providing LARC at the time of delivery, the most vulnerable women who are most unlikely to return for follow- up are being put at risk of unwanted pregnancy. 2,3 By inserting the IUD at delivery, an important barrier to LARC namely an additional visit for insertion is removed. Intra-caesarean insertion is easier, less time-consuming, less painful and requires less instrumentation than interval insertion. ere is no risk of primary perforation as the insertion is performed under direct vision. 7-10 Few contraindications exist, and timing is ideal since counselling and expertise are available and the patient is motivated for family planning. E cacy of the copper-containing IUD (Pearl index = 0.6) is on par with female sterilization (Pearl index = 0.5), and thus could be o ered as a reversable alternative. 11 Once it is placed its e ect is not dependent on any patient action, and even if the patient does not return for her 6-week visit, she is protected against pregnancy provided that the device stays in place. e hormone-free IUD does not have any e ect on breastmilk production or infant growth, and has no maternal systemic e ects. 12,13 In contrast to some other LARCs, the e cacy of the IUD is not a ected by antiretroviral, antituberculosis or anti-epileptic therapy. In addition, it is immediately e ective, can last for up to 10 years, and requires active discontinuation. Insertion at the time of C/S eliminates a 6-week waiting period for contraception and an additional o ce visit. In a prospective cohort study by Heller et al, more than one in eight women chose this method of contraception when routinely o ered before elective C/S. 14 e study con rmed a low complication rate and an expulsion rate in keeping with that of insertion in women who were not postpartum. Satisfaction and continuation rates remained high at 12 months post-insertion, and it proved to be convenient and cost-e ective for both women and health services. Complications include malpositioning, expulsion, perforation, Abstract Background: In the Western Cape there are many intrauterine contraceptive devices (IUDs) inserted during caesarean section (C/S). Little is known about long-term outcomes in the Metro West region of Cape Town. Objective: To assess placement of IUDs at C/S and describe follow-up, with a view to compile best practice guidelines for insertion and follow-up in our clinic setting. Methods: A retrospective descriptive audit of clinical records was performed of all women who received an IUD at C/S between January and June 2018 at Mowbray Maternity Hospital (MMH) and New Somerset Hospital (NSH) in Cape Town. Results: There were 2310 and 1376 C/Ss performed at MMH and NSH respectively. The IUD insertion rate was 17.4% (n=402) at MMH and 14.3% (n=197) at NSH. Almost two third of insertions were performed during emergency C/S (59.1%; n=276). The majority of women experienced no immediate complications (84.4%). Only 77 women attended follow-up. The continuation rate at follow-up was 71.6%. The overall expulsion rate in hospital and at follow-up was 3%. Strings were visible in 53.2 % of patients. An ultrasound was performed in 67.5 % of patients. The IUD removal rate at follow-up was 24.7%. Conclusion: The immediate postpartum period may be the only opportunity to provide long acting contraception to some women. In our study population follow-up rates are poor and therefore conclusions cannot be accurately gauged. Measures must be taken to improve follow-up. Key words: Contraceptive IUDs, caesarean section, best practices, postpartum and outcome. Correspondence Marcelle Schutte email: marcelleschutte@gmail.com