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February 21, 2019

Immediate Postpartum ContraceptionMinnie Yordon, MD — R3, Family Medicine Residency of Idaho

Disclosures

✤ None

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Goals and Objectives

✤ Identify myths and facts regarding immediate

postpartum hormonal contraceptives

✤ Identify pros and cons of immediate postpartum

LARCs

Current/Traditional Practices

✤ Most frequently, contraception initiated at 6 week

postpartum visit

✤ Contraception ideally discussed at antepartum visits,

but decisions often not totally undertaken until

postpartum

✤ Tubal ligation generally offered immediately

postpartum

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Why start contraception immediately?

✤ 10 - 40% of women don’t come to any postpartum visit

✤ 40 - 75% of women who plan for a 6 week postpartum IUD do not get one

✤ Timing is convenient

✤ They’re already in your care

✤ You know they aren’t pregnant

✤ They are still covered by their insurance

✤ Recently postpartum women are highly motivated

✤ From a systems effective, quite cost effective

✤ ACOG cites it as a best practice

What options are there in the

postpartum period?

✤ Sterilization: BTL or vasectomy

✤ Lactational amenorrhea

✤ IUDs: Copper or hormonal

✤ Implant

✤ Depot medroxyprogesterone

✤ OCPs: COC or POP/ Contraceptive Ring and Patch

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What counts as “Immediate

Postpartum?”

✤ Immediate Postplacental

✤ In the delivery room, less than 10 min after delivery of placenta

✤ Immediate Postpartum

✤ Prior to discharge from hospital

✤ Postpartum

✤ Within 6 weeks after delivery

✤ Interval

✤ 6 weeks or greater after delivery

Does hormonal contraception

interfere with breastfeeding?

✤ Basically, we’re not sure

✤ Progesterone doesn’t seem to

✤ Estrogen has conflicting data

✤ Worth counseling on theoretical risk but letting women

know that evidence so far doesn’t look like

progesterone, at least, affects milk production

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IUDs

Quick Copper IUD Facts

✤ Prevents pregnancy by disrupting sperm motility

✤ 1 year failure rate 0.8/100 women

✤ Approved for up to 10 years

✤ Many women experience increased cramping or

heavier periods

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Quick Levonorgestrel IUD Facts

✤ Prevent fertilization by increasing quantity and viscosity of

cervical mucous, rendering it impermeable to sperm. Also

thins endometrium. Most women still ovulate.

✤ 1 year failure rate of 0.31/100 women

✤ Approved for up to 5 years

✤ Side effects can include headaches, nausea, breast

tenderness, mood changes, and ovarian cysts

Immediate Postpartum IUDs

✤ Contraindicated if uterine infection or ongoing postpartum hemorrhage

✤ Expulsion rates may be as high as 10-27%

✤ IUD continuation at 6 months postpartum still higher in immediate IUD at cesarean

delivery than delayed insertion (83% vs 64%)

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Placement of Immediate Postpartum

IUD

✤ After vaginal delivery:

✤ Remove device from inserter & cut strings to 10cm

✤ Grasp stem of IUD with ring forceps, pass it through the cervix, and place it at the fundus

✤ Confirmation with ultrasound can be done

✤ After cesarean delivery:

✤ Initiate closure of uterus

✤ Place the IUD at the fundus

✤ Place the strings through the cervix

✤ Finish closing the uterus

Video Illustration

✤ https://player.vimeo.com/video/260827389

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Implants

Quick Implant Facts

✤ Prevent pregnancy by inhibiting ovulation. May also

thicken cervical mucous

✤ Typical failure rate 0.05%

✤ Side effects include irregular bleeding, GI upset,

headaches, breast pain, vaginitis, weight gain, and

acne. Can also have pain at insertion site.

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Immediate Postpartum Implants

✤ No specific postpartum contraindications

✤ MEC 1 if not breastfeeding, MEC 2 if breastfeeding and placed <30

days postpartum

✤ Insertion doesn’t differ in postpartum period from standard insertion

✤ Initiation rate higher with immediate postpartum insertion than with

delayed insertion, and continuation is the same at 6 months

✤ Similar side effects over first 12 months, though immediate postpartum

insertion may have more irregular bleeding in first 6 weeks

How to Make It Happen

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Team members

✤ Clinicians

✤ Pharmacists

✤ Finance/billing specialists

✤ IT/EHR gurus

Step 1: Exploration

✤ Identifying clinicians, pharmacists, and billers to be

“champions”

✤ Educate administrators, ensure their awareness

✤ Clarify insurance participation, and verify

reimbursement/payment

✤ Assemble a team/taskforce!

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Reimbursement

✤ Medicaid has specifically clarified reimbursement for

immediate postpartum LARC placement separately

from global OB fee

✤ “Reimbursement for an IUD insertion includes any fees for the office visit. A

separate office exam may only be billed for treatment of an unrelated

diagnosis. Attach modifier 25 to the evaluation and management code.

Insertion is covered following a delivery including in an inpatient setting

when billed by the physician or non-physician practitioner with the ICD-10-

CM diagnosis Z30.430 and FP modifier.”

✤ They don’t specify about implants

Step 2: Installation

✤ Ensure clinician and nursing training (L&D AND

postpartuum!)

✤ Develop protocols for device and insertion kit content,

storage and availability, and patient consents and education

✤ P&T committee approval, vendor sourcing and distribution

✤ Clarify specific coding, charting, and inventory maintenance

systems

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Step 3: Implementation and

Sustainability

✤ Start small- trial/pilot period with frequent assessments

✤ Do insertion kits have correct items?

✤ Are supplies stored in right places?

✤ Is reimbursement happening?

✤ Continue assessing needs: Retraining? New hire

orientation?

Other Hormonal Methods

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Depot medroxyprogesterone

✤ Similar risks/benefits as implant above

✤ Higher risk of delayed return to fertility

✤ Longterm use in adolescents may contribute to

decreased bone density, but this concern should not

be used to limit duration of therapy

OCPs

✤ COCs

✤ Risks

✤ Increased risk of VTE with estrogen; wait at least 3 weeks PP

✤ Breastfeeding effects??- MECs recommend waiting until 30 days due to this

✤ Benefits

✤ Higher efficacy than POPs

✤ POPs

✤ Risks

✤ Narrow time window to take them

✤ Benefits

✤ No increased clotting risk, seems to not affect breastfeeding

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Where to Learn More

✤ Postpartum Access to Contraception Initiative

✤ Sponsored by ACOG and the LARC project

✤ ACOG Resource page for Immediate Postpartum

LARC

Final Thoughts

✤ Immediate postpartum LARCs are safe and effective,

with few contraindications

✤ Immediate postpartum LARC insertion is a best

practice per ACOG, and it should be discussed during

the antepartum period to facilitate use

✤ Evidence thus far does not indicate that progesterone

negatively impacts breastfeeding

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Resources

✤ ACOG Committee Opinion #670 (2016): Immediate Postpartum Long-Acting Reversible

Contraception

✤ ACOG Practice Bulletin #186 (2017): Long-Acting Reversible Contraception: Implants and

Intrauterine Devices

✤ Immediate Postpartum IUD Expulsion Fact Sheet, ACOG

✤ Lopez LM, Bernholc A, Hubacher D, Stuart G, Van vliet HA. Immediate postpartum insertion of

intrauterine device for contraception. Cochrane Database Syst Rev. 2015;(6):CD003036.

✤ Sothornwit J, Werawatakul Y, Kaewrudee S, Lumbiganon P, Laopaiboon M. Immediate versus

delayed postpartum insertion of contraceptive implant for contraception. Cochrane Database

Syst Rev. 2017;4:CD011913.

✤ Wachino, Vikki. CMCS Informational Bulltein. Subject: State Medicaid Payment Approaches to

Improve Access to Long-Acting Reversible Contraception