A Pilot Study of a CuIUD (Nova-T 380®) insertion technique (PPIUD) at Caesarean Section

C. Apollos 1,2  & J. Kluge 1,3

1. Stellenbosch University 2. Tygerberg Hospital, Cape Town, South Africa 3. Paarl Hospital, South Africa

Introduction

 Around 218 million women in low- and middle-income countries (LMICs) require modern contraception. In South Africa, 59% of sexually active women use modern methods, but only 1% use intrauterine devices (IUD) which maybe increased with Post Partum IUD (PPIUD) insertion during CS.

However, concerns include higher expulsion rates (0-15%) and non-visible/ “missing” strings (30-60%) at follow up, which often necessitate further ultrasound/ X-ray/ specialist referral which create a barrier to it’s consistent use.

Insertion Techniques and Guidelines:

Many training manuals focus on PPIUD following vaginal delivery a but those that include intra-CS PPIUD insertion recommend against guiding IUD strings through the cervix to avoid infection or displacement. However, several studies have included manual insertion or the use of the inserter tube to guide strings through the cervix at the time of CS with especially lengthened IUD strings with Vicryl suture, facilitating removal if complications arise. These studies had small sample sizes and did not verify IUD fundal placement prior to hospital discharge.

 Challenges and Barriers:

Non-visible strings at follow-up may result from expulsion, coiling in situ, malposition, or perforation. LMICs face additional challenges due to limited access to specialists and imaging tools.

Need for Further Research:

There are no randomized controlled trials comparing outcomes of passing strings through the cervix versus leaving them in the lower uterine segment during CS

Aim: To evaluate the accuracy &  feasibility of a novel IUD insertion technique during CS. 

Hypothesis: This technique may reduce the need for ultrasound to locate IUDs when strings are missing, while still ensuring accurate fundal placement

Method

Prospective observational pilot study at two hospitals in Cape Town, South Africa (August 2021 – May 2022)

Inclusion Criteria

Exclusion criteria

Signed consent obtained by the two investigators

The two investigators performed the CS &  inserted the Nova-T 380® (Bayer OY, Finland)

Method of Insertion at time of CS

Perform speculum examination to ascertain visibility of strings at cervical os. Trim strings to 2cm from external 

Method continued…

Day2-3 Post CS

 Follow up 4-8 weeks post partum

Key Findings and Recommendations

•  Simple Technique:

Using the standard IUD inserter tube during Caesarean section is feasible and practical — instruments are already available in the operating room.

•  Important Caution:

When removing the inserter tube through the vagina, care must be taken to avoid traction that could dislodge the IUD from the fundus.

•  Addressing Missing Strings:

This technique may help reduce the problem of missing strings by allowing the strings to pass through the cervix into the vagina.

•  Call for Further Research:

Larger studies are needed, with multiple clinicians involved to reflect real-world conditions.

Randomized controlled trials (RCTs) are essential to determine the optimal IUD insertion technique at CS.

Ethics

The Human Research Ethics Committee of Stellenbosch University, South Africa approved the study. (HREC reference nr: S20/11/327)

Conflicts of Interest

JK sits on the Adcock Ingram Women’s Advisory board in South Africa. In the past she has received remuneration from Bayer, MSD and Organon. No renumeration or industry funded sponsorship was received for this study.

References

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