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True versus false expulsion rate of PPIUCD

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PPIUCD  is an effective method of family planning .It is reversible , convenient and safe.

It is applied postplacental (within 10 minutes of normal vaginal delivery ) , immediate (within 48 hrs of normal delivery ) , intracaesarean or post abortal.

Chances of perforation are less within 48 hrs of delivery as the wall of uterus is thick.

It can be applied in systemic diseases like hypertension , epilepsy , tuberculosis and diabetes etc where pills, injectables and ligation has its limitations.

In Govt sectors OPDs are overloaded , running short of manpower so it reduces certain amount of burden by avoiding doing urine test for pregnancy and boiling the instruments again and again so saving the time.

The only disadvantage being the high expulsion rate , the study of the expulsion rate was done for 4 consecutive months.

Study was done to see the actual expulsion rate by inserting the IUCD by untranied staff and trained staff. Comparison was also done between manually placed  IUCD and placed by kelly's forceps.

Intracaesarean cases were also studied for the expulsion rate

Training for its insertion was given under NRHM and service provider was given a fixed amount per case.

The comparison of the expulsion rate was done before and after the training

Kelly’s forceps were provided and all the LMO’s and GNM.s of the Government hospital and from CHCs PHCs were trained theoretically as well as practically by the Gynecologist for three months.

In intracaesarean IUCD the expulsion rate was nil .The follow up was done for 6-8 weeks but not even a single case reported missing thread or heavy bleeding or any other side effect.

 

When it was inserted manually before training the expulsion rate was high and when applied by the trained staff with proper use of kelly's forceps , expulsion rate was less.

Manually placed IUCD showed higher expulsion rate as compared to IUCD placed by kelly’s frceps.

Three consecutive months were studied for the expulsion rate .

 There was marked difference between the expulsion rate before and after training

 Comparison between manually placed and using kellys forceps was also done . Expulsion was higher in the IUCD placed manually and by untrained staff 

The IUCD  did not reach the fundus when applied manually by untrained staff . It was already lying in the cervix or vagina causing false datas for the expulsion rate.

.The expulsion rate was less when applied using kellys forcep and under doctor's supervision by trained staff and it was true expulsion rate.

In LSCS it was directly put on fundus by gynaecologist , expulsion rate was nil.

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Tagged as being relevant to: 
In-Service Training
, Global
, India
, Allied Health Workers
, Nurses
, Physicians
, Community Health Workers
, Nurses' Assistants
, Nursing/Midwifery Students
, Midwives

Comments

For the 1st item on PPIUD expulsion:

 

Thank you for sharing with the community your work documenting PPIUCD in India. It is truly remarkable to note the effort to expand access to LARC at birthing facilities across India. Equally remarkable is the opportunity to document the results of using the right technique for ensuring that complications including expulsion, long been the bane of PPIUCD services are brought down to a level well below the 10-15 % reported in older literature.  Indeed Capp et al. in a review  in Contraception 2009, noted that majority of PPIUCD expulsions occur in the 1st 3 months which can be as high as 1-2 for every 10 insertions.  However, the technique championed by the  PPIUD Provider Service Delivery Manual (2010) using uterine elevation to maneuver the long placental Kelly forceps to reach the fundus and releasing the Copper IUD have generally resulted to a substantially cutting down the expulsion rate to 4-5 %.  In fact a 2014 article by Somesh et al. in  Reproductive Health reported a 3.6 % expulsion rate at 6th weeks.  The other remarkable findings reported by the article on “Women’s experience with postpartum intrauterine contraceptive device use in India” was the high satisfaction rate with the decision to use PPIUCD at the time of insertion and 6 weeks later, 99.6 % and 92%, respectively.

 

 

For the second item on Postabortal IUCD and Tubal Ligation

 

Providing choice and accessible contraception among women who have had spontaneous or elective early pregnancy termination are critical services at the point of care. In fact  the High Impact Practices web site  https://www.fphighimpactpractices.org/resources/postabortion-family-planning-strengthening-family-planning-component-postabortion-care considers that “providing family planning counseling and services at the same time and location where women receive treatment for complications related to spontaneous or induced abortion improves maternal and child health and contributes to national family planning programs”.   Whether elective or spontaneous abortion, timing of when to engage in education and counseling a woman and her partner is important particularly when it concerns a major decision such as tubal ligation.  The provider need to ensure that the woman have had the opportunity to fully consider her options, and voluntarily and with full knowledge made the decision to go for tubal ligation.   The use of IUCD in the immediate non-septic postabortion is generally a category 1 and a category 4 when the condition is a post-septic abortion according to the WHO MEC.  However, there are providers who feel that the immediate postabortion period may not be a good time to place an IUCD because of the mistaken notion that the uterus may not be ready yet.  To round this remarkable discussion on options for long acting and permanent methods in the PA period, one method that ought to be considered is discussing vasectomy. Perhaps the presence of the partner at the facility would be a great opportunity to have this discussion with the couple of using vasectomy.  To round up this remarkable discussion, the use of prophylactic antibiotics when providing PA FP such as IUCDs and Tubal Ligation is worth contemplating.  Review of literature indicates that there is insufficient evidence to support the use of routine prophylactic antibiotics are not generally recommended. What is critical is the client selection (especially for those who are high risk for STI ) and complying with infection prevention practices and control appropriate for these methods.

Thanks for replying.It is encouraging to hear from you.In rural India females do not come for IUCD after a gap post abortally.They will again conceive so I apply IUCD just after the procedure under antibiotic cover in non septic cases.NSV is out of Question in India just after delivery or abortion.
Thanks once again