Immediate postpartum intrauterine device insertion is the right default in most services, and it is also the setting in which the device is five times more likely to be expelled after a vaginal birth. Those two facts have to be delivered together, in the same conversation, or the programme quietly converts a proportion of women from protected to unprotected without either party noticing.
Expulsion after postpartum insertion is often silent. A woman discharged within a day or two, told she now has five years of contraception, has no reason to check anything. So the counselling has to include what expulsion is, that it is more likely with this timing, how to feel for the threads, and specifically what to do and where to go if she cannot find them.
The corollary is a follow-up check at around six weeks that is actually arranged rather than merely advised, because the whole reason immediate insertion works is that women who leave without a device often do not come back.
- Say plainly that expulsion is several times more likely with immediate insertion
- Teach thread-checking before discharge, not at a later visit
- Give a specific route back if the threads cannot be felt
- Arrange the six-week check rather than advising it
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