The association of insertion methods on immediate postpartum intrauterine device expulsion rates: A retrospective cohort study.

Objective: To evaluate the method of immediate postpartum IUD (ppIUD) insertion (manual versus ring forceps) and expulsion rate within 6-week postpartum.

Study design: We performed a retrospective cohort study of patients who had a singleton vaginal delivery and an immediate ppIUD inserted at Rush University from January 2014 to September 2023. The primary outcome was rate of expulsion within 6-week postpartum. We compared the rate of expulsion by method of insertion, either using a manual technique versus using ring forceps. We performed univariable analysis for the association between baseline maternal characteristics and the primary outcome and we performed multivariable logistic regression to determine the independent association of the method of insertion and the primary outcome.

Results: Two hundred nineteen patients met eligibility with 117 immediate ppIUDs inserted manually and 102 inserted with ring forceps. Baseline maternal demographics were similar across study groups. After adjusting for factors selected a priori (estimated blood loss, body mass index, gestational age at delivery, nulliparity, type of IUD), use of ring forceps was more likely to result in expulsion compared to manual insertion (30.4% vs 16.2% respectively; adjusted OR 2.49, 95% confidence interval 1.28-4.90).

Conclusion: In this retrospective analysis, insertion of immediate ppIUD with ring forceps was independently associated with an increased rate of expulsion within 6 weeks postpartum when compared to manual insertion.

Implications: In this setting, ring forceps was associated with high rates of immediate postpartum IUD expulsion compared to manual technique. Studies disagree, suggesting need for additional work.