What instrument is used for Postpartum Intrauterine Contraceptive Device (PPIUCD) insertion?

Instruments Used for PPIUCD Insertion

For postpartum intrauterine contraceptive device (PPIUCD) insertion, ring forceps or Kelly placental forceps are the primary instruments used, as they provide optimal fundal placement and lower expulsion rates compared to other insertion methods. 1

Instruments for Vaginal Delivery PPIUCD Insertion

• Ring forceps or Kelly placental forceps are the recommended instruments for grasping the IUD wings during insertion after vaginal delivery 1
• Additional ring forceps is used to grasp and stabilize the anterior lip of the cervix during the procedure 1
• Manual insertion using the operator's hand is an alternative technique but may provide less precise placement 1
• Manufacturer's inserter can be used but has shown higher rates of partial expulsion (10.8% vs 5.0%) and lower IUD retention at 6 weeks (72.2% vs 83.7%) compared to forceps 1
• Dedicated PPIUCD inserters are emerging as specialized instruments designed specifically for the postpartum setting 2, 3, 4

Technique for PPIUCD Insertion After Vaginal Delivery

• Change into new sterile gloves before beginning the procedure 1
• Remove the IUD from its original inserter 1
• Cut the IUD strings to approximately 10-12 cm (similar length to ParaGard strings) 1, 5
• Cleanse the cervix with betadine or another antiseptic solution 1, 5
• Use a hand or retractor to visualize the cervix 1
• Grasp the anterior lip of the cervix with ring forceps 1
• Carefully grasp the IUD wings with ring or Kelly placental forceps 1
• With gentle cervical retraction and under full visualization, pass the device through the cervix 1
• Stabilize the ring forceps on the cervix while transferring the other hand to the abdomen 1
• Palpate the uterine fundus abdominally to confirm fundal placement of the device 1
• Release the ring or Kelly placental forceps and move laterally to avoid IUD displacement 1

Instruments for Cesarean Delivery PPIUCD Insertion

• Manual insertion with the operator's hand is commonly used during cesarean delivery 1
• Ring forceps can also be used for placement during cesarean section 1
• The manufacturer's inserter is another option during cesarean delivery 1
• The IUD is placed in the uterine fundus after initiation of hysterotomy closure 1
• The strings are then placed into the cervix prior to completing the hysterotomy closure 1

Advantages of Using Forceps for PPIUCD Insertion

• Higher IUD retention rates at 6 weeks (83.7% with forceps vs. 72.2% with inserter) 1
• Lower rates of partial expulsion (5.0% with forceps vs. 10.8% with inserter) 1
• Better ability to achieve high fundal placement, which decreases expulsion rates 1
• More precise control during insertion compared to manual insertion 1

Additional Considerations

• Transabdominal ultrasound may be useful to guide insertion and ensure fundal placement after vaginal delivery 1
• High fundal placement of the IUD has been shown to decrease expulsion rates 1
• Proper training specific to immediate postpartum IUD placement is recommended for providers 1
• Dedicated PPIUCD inserters have shown promising results in recent studies with high fundal placement achieved in 82% of cases 4
• Expulsion rates with dedicated inserters have been reported as low as 7.5% for complete expulsion 4

Potential Complications and Mitigation

• Expulsion rates are higher with immediate postpartum insertion compared to interval insertion but can be minimized with proper fundal placement using appropriate instruments 1
• Expulsion rates are approximately 10% when the IUD is placed within 10 minutes of placental delivery 1
• Despite higher expulsion rates, the benefits of immediate placement appear to outweigh the drawbacks with higher continuation rates at 6 months (80% vs. 50%) 1
• Perforation and infection risks are not increased with proper technique, regardless of mode of delivery 1