Expulsion
ACOG supports immediate postpartum LARC insertion as a best practice, recognizing its role in preventing unintended and short-interval pregnancy.
Despite the higher expulsion rate of immediate postpartum IUD placement over interval placement, evidence from clinical trials and from cost-benefit analyses strongly suggests the superiority of immediate placement in reduction of unintended pregnancy, especially for those at greatest risk of not having the recommended postpartum follow-up visit or those who may face barriers to obtaining an intended LARC device.
Expulsion rates for immediate postpartum IUD insertions are higher than for interval or postabortion insertions, vary by study, and may be as high as 10–27% (73-90% of women retain the device).
Differences in expulsion rates are similar with manual insertion versus use of ring forceps, but may differ depending on the experience of the inserter.
Optimally, patients should be counseled prenatally about the option of immediate postpartum LARC. Using a shared medical decision-making approach, counseling should include advantages, risk of IUD expulsion, contraindications, and alternatives to allow for informed decision making.
Many patients experience barriers to interval LARC placement, such that the advantages of immediate placement may outweigh the disadvantages.
As many as 40% of women are unable to return for a postpartum visit due to:
- Childcare obligations
- Inability to take time off at work
- Unstable housing
- Lack of transportation
- Communication or language barrier
- Lack of insurance coverage or potential expiration of Medicaid eligibility
Anyone who experiences or suspects expulsion should contact their health care provider and use a back-up contraceptive method. Replacement cost may vary by insurance plan.