Immediate Postpartum Long-Term Reversible Contraception (LARC) Bethany Berry, CNM, MSN and Alyssa Givens, MSN, RN

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1 Immediate Postpartum Long-Term Reversible Contraception (LARC) Bethany Berry, CNM, MSN and Alyssa Givens, MSN, RN

2 Disclosures O Bethany Berry CNM is a Nexplanon trainer with Merck O Alyssa Givens, RN has no financial disclosures

3 O Captive audience Why Postpartum Contraception? O Rapid repeat pregnancy is common O 35% of adolescent mothers become pregnant again within 2 years O Most unintended O ½ continue, ½ abortion O Up to 40% no show for postpartum visit Baldwin, Journal of Adolescent Health, 2012

4 Publicly Funded Postpartum Contraception Visits 41% of publicly funded women who had given birth had a contraceptive claim within 3 months 59% Had no funded contraception method postpartum within 3 months of birth.

5 Barriers in Alaska O Distance from remote villages to clinics or hospitals O Weather effecting travel O Untrained providers in villages O No access to providers in villages O Limited travel dates/times O High cost of travel

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7 Definitions Postpartum: Insertion after delivery, but within 48 hours Postplacental: within 10 minutes after expulsion of the placenta after vaginal delivery Delayed Postpartum Insertion: after the post-placental period, but within 48 hours of delivery and before the client leaves the hospital Transcesarean: following a cesarean delivery, before the uterus is sutured

8 IUD Insertion Postpartum O 15 studies O Copper IUD compared to different time periods O Immediate (within 10 minutes) lower expulsion rates than later in the postpartum period O No increase in complications = SAFE O Bleeding, infection, perforation O Expulsion lower with trans-cesarean than vaginal delivery (not necessarily )

9 Expulsion O 2-8% in the first year of use with interval insertion. O Expulsion rates <10% if post-partum IUD inserted within 10 minutes of placental delivery O Expulsion rates 2-37% if placed 2-72 hours after delivery. O Provider experience has a major influence on expulsion rates Grimes DA, Lopez LM, Schulz KF, Van Vliet HA, Stanwood NL. Immediate post-partum insertion of intrauterine devices. Cochrane Database of Systematic Reviews 2010, Issue 5.

10 IUD: Why 10 minutes? Adjusted cumulative expulsion rates <= 10 min 2-23 hr hr hr P<0.001 Chi Contraception 1985

11 Expulsion Women generally recognize an expulsion IUD can be reinserted before 48 hours or after 4 weeks if there is an expulsion Counsel women about breastfeeding as contraception, and provide condoms/ecp as backup

12 Postpartum IUD Insertion Advantages Women are motivated to contraception Not pregnant Insertion is simple (Sort of ) Disadvantages Higher expulsion rate May be offset by higher proportion of patients actually getting an IUD inserted

13 Contraindications O Chorioamnionitis O Prolonged rupture of membranes O Prolonged labor O Endometritis/sepsis O Hemorrhage O Severe perineal laceration

14 Learning PP IUD Insertion

15 Uterus: Immediately Postpartum

16 Post-placental Manual Insertion O Within 10 minutes of placental delivery if possible O The cervix is open and limp O Allows for the passage of the hand O Placement of the IUD high in the fundus O String length

17 Manual Insertion

18 Manual Insertion

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21 Insertion with Ring Forceps

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24 Trans-Cesarean Insertion Place the IUD with the inserter

25 Implant: Nexplanon Off Label Use

26 Postpartum Nexplanon O Can be placed immediately postpartum or just prior to discharge home O Little research on effects of etonorgestrel on breast milk or breastfeeding O Reimbursement Issues

27 What About Breastfeeding?

28 Impact on Breastfeeding According to the Academy of Breastfeeding Medicine there is a theoretical impact on breastmilk production with progestin methods (LNG IUD and Etonorgestrel Implant).

29 ANMC Satisfaction Data 73 women who received postpartum LARCs (IUCs and implants) over a 3 month period. A phone survey was conducted to evaluate satisfaction and continuation 12 months after insertion/delivery.

30 Immediate PP IUD Satisfaction/Continuation Urban Rural 83% 66% 80% 75%

31 Immediate PP Implant Satisfaction/Continuation Urban Rural 42% 69% 50% 69%

32 Conclusions of Study O The satisfaction and continuation rates of the IUD were high among both urban and rural women. O The satisfaction and continuation rates of the implant were lower for both urban and rural women, but still substantial.

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34 Questions?

35 Qaĝaasakung Aleut Quyanaq Inupiaq Chin an Dena ina Athabascan Thank You!!!