Why LARCs?  Why immediately postpartum?

The Contraceptive CHOICE project found a 20 times higher unintended pregnancy rate among those women with user dependent hormonal contraceptives compared to LARCs.  At twelve month followup, 86% of LARC users were still using, vs 55% of those who initiated short term methods.

The Colorado Family Planning Initiative increased the utilization of LARCs from 5 to 19% in young women across the state, and saw a decrease in unintended pregnancies by 29%, and a decrease in abortions by 34% in the teenage population.

Levi study showed a higher continuation rate with immediate postpartum insertion than planned interval placement after 6 months (83% vs 64%), despite 24% expulsion rate for IUDs.

About half of women report having unprotected intercourse before the 6 week postpartum visit.  Ovulation occurs on average after 39 days in non lactating women (can occur as early as 25 days).  70% of short-interval pregnancies (within one year) are unintended. 

10-40% of women do not attend the postpartum visit, 40-75% of women who plan to use an IUD postpartum do not obtain it (barriers such as inability to pay, clinic not offering LARC, need for repeat visit for placement)

How to implement immediate postpartum LARCs - Sample Hospital Protocol:

  1. Identify interested patients early in the prenatal care or labor process, place order for device so that it is available at the time of delivery.
  2. Patient to sign consent form.
  3. If vaginal delivery, may use ring forceps or insertion device to place IUD at fundus within 10 minutes of placental delivery.  Do not cut strings.  May use sono visualization if desired. 
  4. If CS, begin closure of hysterotomy incision, and then remove IUD from applicator.  Place manually or with ring forceps at fundus, place strings through cervix (do not cut), and complete incision closure.
  5. If Nexplanon, should place closer to discharge (especially if she is breastfeeding), for theoretical concerns about progesterone withdrawal and lactation initiation.
  6. Contraindications to IUD: infection or hemorrhage.
  7. Hospital will bill for device.
  8. Your office will submit bill for insertion. (ICD10 surgical codes: 0UH97HZ or 0UHC7HZ via opening; 0UH98HZ or 0UHC8HZ via SVD.  ICD10 diagnosis codes: Z30.014 IUD, Z30.019 Nexplanon; CPT 58300 insert IUD, 11981 insert Nexplanon)
  9. When should a provider discuss immediate postpartum LARCs with their patients?  This discussion can be initiated early during prenatal care.  However, if a patient presents in labor without prenatal care, or on transfer from another hospital, it can be discussed with them during labor (for IUD), or even postpartum (for implant).