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Anna Graham on 'Immediate post-partum intrauterine contraception - making the guidelines a reality'
Date: 11 Jul 2018
Author: Anna Graham
As the FSRH guidelines on Contraception After Pregnancy were released in January last year, there was a sharp intake of breath at the statement that maternity services should be able to provide intrauterine contraception (IUC) (amongst other methods of contraception) immediately post-partum. This blog outlines our journey at King’s College Hospital (KCH) to make postpartum IUC insertion a routine practice and the challenges we encountered.
Demonstrating a need for the service
Kings College Hospital has a large tertiary centre maternity service delivering over 6000 babies a year; often the mothers have complex medical and social needs which make future pregnancies, particularly with short pregnancy intervals, high risk. I undertook an audit looking at patients with complex social needs, many with children removed directly into social care, and shockingly only 3% received any form of long acting reversible contraception (LARC) and 15% were pregnant again within the subsequent year. I presented this audit across a variety of forums demonstrating the clear need for postpartum contraception. I then met with key players in maternity, gynaecology and sexual and reproductive health (SRH) to try to tackle the problem. As part of a wider programme implementing postpartum contraception, in collaboration with a senior obstetrician and gynaecologist, I developed a guideline for immediate postpartum IUC insertion at both caesarean section (CS) and vaginal delivery (VD).
This comprehensive guideline included antenatal counselling and consent, the insertion procedure, patient information leaflets and a referral process for a 6 week follow up with ultrasound scanning (to be discontinued if acceptably low complications rates were demonstrated). At KCH we are lucky to have a fantastic early pregnancy and gynaecology scanning department who helpfully agreed to scan these patients at 6 weeks and also to offer an emergency walk –in service for people with any urgent needs.
The guideline was rolled out and included training for the obstetric and gynaecology (O&G) trainees and midwives. The obstetricians in our service were champions for this provision due to the range of complex patients and the need to prevent future pregnancies. They immediately started offering IUC at elective caesarean sections and demonstrating the technique to the registrars. The service quickly picked up and we began to insert a few IUCs a week at CS.
There were however, significant challenges with IUC insertion at VD. The first one planned was cancelled by a nervous registrar due to maternal high blood pressure…not a documented contraindication. The majority of VDs are by midwives who weren’t trained in insertion, and the registrars were reluctant to advise this method antenatally or to insert these postnatally.
Another challenge we faced was when the O&G trainees rotated, and as the new batch arrived there was a significant dip in IUC insertions.
Once we had 53 IUC insertions we analysed the results. The majority of patients had Mirena IUSs inserted (94%), mostly at CS (94%). 89% attended for follow up and on these 92% were correctly situated. The main issues were long threads (9%) and no threads seen (23%). 97% were happy with the insertion and process and 88% would recommend to a friend.
Looking to the future
We felt that the results demonstrated that we no longer needed our 6 week follow up scan appointment and that the follow up could be taken over by our GP colleagues with the option to refer in for a scan for any problems identified.
We have recognised that a lot more work needs to be done in the implementation of immediate post partum IUC insertion at VD and this will be our focus in the future.
Anna won a prize at FSRH's Annual Scientific Meeting for her poster presentation.