Postpartum LARC Sample Protocols Introduction
An important first step in establishing postpartum LARC (PPLARC) services at your hospital is to develop a protocol to be reviewed and approved by your department administration.
PICCK provides three sample protocols for postpartum LARC insertion and one ambulatory guideline for immediate postpartum LARC counseling, consent, and follow up. These protocols can be adapted for use at your institution and PICCK can support you in making these adaptations.
These sample inpatient protocols have stylistic differences and vary in the depth of supporting information they include. There is no right way to format the protocol or portray the necessary information. PICCK can support you in crafting a protocol that meets your hospital’s requirements.
We would like to call attention to two differences to consider when adapting the protocols.
The sample protocols list the contraindications to postpartum intrauterine device insertion, including duration of ruptured membranes.
- Sample Protocol 1: Rupture of membranes of greater than 24 hours prior to delivery
- Sample Protocol 2: Prolonged rupture of membranes more than 18 hours before the onset of labor
The concern with prolonged rupture of membranes (ROM) is the risk for chorioamnionitis, and the inadvisability of placing an IUD into an infected uterus. There is no evidence to support prolonged membrane rupture as a contraindication to immediate postpartum IUD placement; however, patients with prolonged ROM have been excluded from all studies of PPIUD placement. Therefore, in your hospital’s protocol, we recommend you consider selecting a duration of time of membrane rupture beyond which you do not feel comfortable permitting postpartum IUD placement.
Risk of Expulsion
The sample protocols vary in the percent risk for expulsion of IUD following placement at the time of delivery.
- Sample Protocol 1: “The best data estimate that the risk of IUD expulsion following placement at the time of cesarean delivery is approximately 10% and the risk of IUD expulsion following placement at the time of vaginal delivery is approximately 25-30%.”
- Sample Protocol 2: “higher expulsion rate (possibly as high as 25%)”
- Ambulatory Protocol: “higher expulsion rate (possible as high as 27%, as compared to 5-10% for outpatient placement)”
Hospitals have created their protocols with the best available evidence at the time regarding IUD expulsion rates following postpartum placement. Below are two more recent systematic reviews and meta-analyses that assessed expulsion rates:
- Averbach SH, Ermias Y, Jeng G, Curtis KM, Whiteman MK, Berry-Bibee E, Jamieson DJ, Marchbanks PA, Tepper NK, Jatlaoui TC. Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and IUD type: a systematic review and meta-analysis. Am J Obstet Gynecol. 2020 Mar 3. pii: S0002-9378(20)30236-2. doi: 10.1016/j.ajog.2020.02.045. [Epub ahead of print] Review. PMID: 32142826
- Immediate postplacental: 2% (range 0.0-26.7)
- Early inpatient: 2% (range 3.5-46.7)
- Early outpatient: 0%
- Interval placement: 8% (range 0.0-4.8)
- Vaginal delivery: 8% (range 4.8-43.1)
- Cesarean delivery: 8% (0.0-21.1)
- Jatlaoui TC, Whiteman MK, Jeng G, Tepper NK, Berry-Bibee E, Jamieson DJ, Marchbanks PA, Curtis KM. Intrauterine Device Expulsion After Postpartum Placement: A Systematic Review and Meta-analysis. Obstet Gynecol. 2018 Oct;132(4):895-905. doi: 10.1097/AOG.0000000000002822. PMID: 30204688
- Immediate postplacental: 0% (range 0.0–26.7)
- Early inpatient: 7% (range 0.0–46.7)
- Interval placement: 9% (range 0.0–3.9)
- Vaginal delivery: 9% (range 3.3–46.7)
- Cesarean delivery: 6% (range 0.0–21.1)
Further, it is believed that provider experience/practice and use of ultrasound guidance lowers the risk of postpartum expulsion.
The PICCK team is happy to work with you in adapting one of these protocols for your practice – please Contact Us for assistance.