It is the responsibility of the person performing the procedure to ensure they have received the appropriate training and supervision to proceed.

It is the final responsibility of the inserter to confirm that the woman is eligible for intrauterine contraception, and has had sufficient time to consider appropriate written and verbal information prior to insertion.

Women should have had all of the available options for postnatal contraception discussed with them during the antenatal period, including provision of the Patient Information Leaflet – “Starting Contraception After Having a Baby”.

The person performing the procedure should confirm consent and the type of intrauterine contraception to be placed prior to its insertion.

Finally it is the responsibility of inserter to ensure accurate documentation of the procedure including the details of the intrauterine contraceptive inserted and refer the woman to the Sandyford for follow-up.

1. Assessment and Eligibility

An assessment should be carried out prior to insertion to ensure suitability for the method and procedure.

2. Timing

An intrauterine contraceptive can be inserted at any suitable time within the first 48 hours following a vaginal birth. Ideally, this should occur as soon as possible after the delivery of the placenta.

If it is not possible to insert an intrauterine contraceptive within the first 48 hours then this should be delayed, an interval insertion, until after 4 weeks, in accordance with The Faculty of Sexual & Reproductive Healthcare (FSRH) guidance.

3. Consent

Verbal consent is adequate to proceed. The person undertaking the procedure should be satisfied that the woman understands the procedure and risks involved, and has appropriate capacity to give consent on a voluntary basis.

Advantages:

• Long acting: 5 - 10 years depending on contraceptive choice.
• Fit and forget.
• Easy to remove.
• Quick return of fertility when removed.

Disadvantages:

• Perforation: 1-2:1000. Risk lower in immediate postpartum insertion vs interval insertion.
• Expulsion: 1:7 immediate postpartum vs 1:20 interval insertion.
• Infection: 1:100.
• Failure: < 1:1000.
• Bleeding patterns: LNG-IUD – 1:4 amenorrhoeic, other women can experience irregular bleeding but this tends to be light. Cu-IUD - periods likely to be heavier, more painful and last longer.

4. Equipment

The procedure may be performed in a labour ward room, maternity theatres or another suitable clinical setting provided the necessary equipment is available. 

The basic equipment list is as follows:

• Adequate light source.
• Sterile gloves.
• Sims’ speculum.
• Cleaning solution.
• Detectable swabs (counted).
• Sponge holding forceps (Rampleys) x 1-2.
• Intrauterine contraceptive (LNG-IUD or Cu-IUD) x 1.
• Long placental forceps (Kelly’s) x 1.

The intrauterine contraception should not be inserted using the standard inserter as it may be associated with a higher risk of expulsion (due to inadequate fundal placement) or uterine perforation in the immediate post-partum setting.

5. Preparation for Procedure

The type of intrauterine contraceptive to be inserted should be confirmed with the woman when she is transferred to labour ward. A supply of both the hormonal and non-hormonal methods can be found in the obstetric theatre suite. The correct contraceptive should be taken to the labour ward room prior to the 2^nd stage.

The woman should be positioned in lithotomy for the duration of the procedure. A suitable chaperone/assistant should be present.

If the woman has vaginal or perineal lacerations these should be repaired after the contraceptive is inserted unless in the presence of significant bleeding. However, clinical judgement should be employed as there may be a risk of dislodging the contraceptive during a repair.

6. Analgesia

Routine analgesia is not recommended specifically for the procedure.

If a regional block is already in situ then this can be maintained. Inhalation nitrous oxide (Entonox) may be provided if the woman wishes.

Cervical infiltration with local anaesthetic is not recommended as the cervix is already dilated, and injection may precipitate bleeding. 

7. Insertion Technique

Insertion should be carried out utilising the Royal College of Obstetricians & Gynaecologists (RCOG) approved technique and in accordance with the local training programme.

The technique is detailed in Appendix 2, this includes a link to an RCOG video of immediate vaginal postpartum intrauterine contraceptive insertion on a model.

8. Post-procedure Care

Following completion of the procedure, the woman can receive routine postnatal care and breastfeed normally.

Additional written and verbal advice should be provided, including when and how to seek help following discharge from hospital. This should specifically include: the type of contraceptive fitted, the duration of the contraception, signs of possible expulsion and management of ‘long threads’.

Self-checking of threads should not be routinely advised in this setting due to the risk of accidentally removing the contraceptive.

Women should be provided with a copy of the Patient Information Leaflet – “Advice Following Intra-uterine Contraception (“coil”) Fitting at the Time of Birth”. The card / patient leaflet from the intrauterine contraceptive pack should be completed and attached to the front of this patient information leaflet.

All women are referred to the Sandyford Specialist Sexual Health Services, Glasgow for clinical review, at which time placement will be confirmed. Alternative contraception is recommended until this has taken place.

9. Documentation

The procedure should be clearly documented in the woman’s BadgerNet record as a “Surgical Intervention” note.

Documentation should include confirmation of eligibility and obtainment of verbal consent. In addition the insertion technique used, analgesia (if required) and the exact type of intrauterine contraceptive inserted should be documented.

It is important to document the specific intrauterine contraceptive, e.g. hormonal: Levosert^TM/ Mirena^TM or non-hormonal: Nova T 380/ TT 380 Slimline, as they differ in their duration of contraceptive license.

All women who have had an intrauterine contraceptive inserted after a vaginal birth must be referred to the Sandyford Specialist Sexual Health Services for confirmation of coil placement.

Referrals to the Sandyford are made by email. An email should be sent to Sandyford.Postpartum@ggc.scot.nhs.uk.

The following details should be included in the referral:

1. Patient name / DOB / CHI number.
2. Address / Postcode.
3. Current contact number for patient.
4. Date of delivery / insertion of IUC.
5. Type of IUC inserted e.g. Levosert^TM/ Mirena^TM/ Nova T 380/ TT 380 Slimline.
6. Any need for interpreter.

Insertion of intrauterine contraception must be documented on the woman’s discharge letter. It is the responsibility of the person writing the immediate discharge letter to ensure that the exact method of contraception is accurately recorded.

Vaginal Postpartum Intrauterine Contraception Insertion Training Record (pdf)

1. Confirm woman’s eligibility and consent.
2. Check required equipment available, including intrauterine contraceptive.
3. Position woman in to lithotomy and inspect for signs of bleeding.
4. Insert a Sims’ speculum to visualise the cervix and gently clean with antiseptic solution.
5. Gently apply sponge forceps to anterior lip of the cervix.
6. Remove IUC from standard inserter grasping it in the sterile package with long placental forceps (Kelly’s) using a no-touch technique.
7. Apply gentle traction to cervix using sponge forceps and insert IUC into lower uterine cavity.
8. Remove the sponge forceps from the cervix and using the left hand on the woman’s abdomen, gently push the uterus superiorly.
9. At the same time, move the placental forceps upwards towards the fundus following the curve of the uterine cavity.
10. Confirm that the placental forceps have reached the fundus and open them to release the IUC.
11. Sweep the forceps towards the right side wall of the uterus (maternal left) to remove them, taking care not to dislodge the IUC.
12. Once device in place check for signs of bleeding.
13. Provide woman with written information. The card/ patient leaflet from the IUC pack should be attached to the patient information leaflet – “Advice Following Intra-uterine Contraception (“coil”) fitting at the Time of Birth”, and given to the patient.
14. Insertion should be recorded appropriately. Insertion should be documented in BadgerNet under “Surgical Intervention”, documentation must include the exact name of the contraceptive inserted.
15. Referral for follow-up. An email must be sent to the Sandyford to ensure post-procedure placement confirmation.

Royal College of Obstetricians and Gynaecologists. Video of Immediate Vaginal Postpartum Intrauterine Contraceptive Insertion on Model. Available from: https://vimeo.com/840392469