KB PASCA PERSALINAN

Isi
Setiap kehamilan selayaknya memang direncanakan dan diharapkan keberlangsungannya. Namun, banyak orang yang nyatanya tak mampu mencapai kondisi ideal tersebut. Alhasil, mereka menerima karunia luar biasa itu dengan terpaksa. Oleh karena itu, agar tidak timbul keterpaksaan tersebut, hendaknya dilakukan antisipasi terlebih dahulu, antara lain dengan penggunaan kontrasepsi. Kontrasepsi merupakan upaya untuk mencegah terjadinya kehamilan. Upaya itu dapat bersifat sementara, dapat pula bersifat permanen. Penggunaan kontarsepsi merupakan salah satu variabel yang mempengaruhi fertilitas. Pada umumnya klien pasca persalinan ingin menunda kehamilan berikutnya paling sedikit 2 tahun lagi, atau tidak ingin tambahan anak lagi. Konseling tentang keluarga berencana atau metode kontrasepsi sebaiknya diberikan sewaktu asuhan antenatal maupun pasca persalinan. Konseling tentang KB dimulai pada saat kunjungan asuhan antenatal (perawatan kehamilan) ke fasilitas pelayanan kesehatan oleh tenaga kesehatan (dokter / bidan). Dimana pada saat melakukan asuhan antenatal tersebut ibu akan mendapatkan konseling selain konseling KB, juga tentang gizi dan ASI eksklusif, serta konseling tentang persiapan persalinan oleh tenaga kesehatan. KB pasca persalinan merupakan suatu program yang dimaksudkan untuk mengatur kelahiran, menjaga jarak kehamilan dan menghindari kehamilan yang tidak diinginkan, agar dapat mengatur kehamilan melalui penggunaan alat / obat kontrasepsi setelah melahirkan. Pasca persalinan / masa nifas adalah suatu masa yang dimulai sejak bayi lahir diikuti dengan ke luarnya plasenta (ari-ari). Berakhir sampai rahim pulih kembali seperti keadaan sebelum hamil, biasanya 40 hari. Berikut adalah kontrasepsi bagi ibu pasca persalinan yang menyusui : Kontrasepsi yang tidak mengandung hormonal merupakan pilihan utama. - Segera setelah plasenta lahir : MAL, IUD, MOW - Sebelum 2 X 24 jam : MOW - 6 minggu : IUD, MOW, Kontrasepsi progestin ( Pil, Suntik, Implant ) - 3 bulan : IUD, MOW, Kontrasepsi progestin ( Pil, Suntik, Implant ) - 6 bulan : semua jenis kontrasepsi baik hormonal maupun non hormonal sesuai dengan pilihan dan kondisi ibu. Kontrasepsi bagi ibu pasca persalinan yang tidak menyusui Jenis alat kontrasepsi yang dapat diberikan sama dengan jenis alat kontrasepsi untuk ibu menyusui, kecuali MAL. Pil kombinasi estrogen-progesteron dapat diberikan lebih awal, tidak diberikan sebelum minggu ke-3 pasca persalinan, implant dan suntikan KB 3 bulanan diberikan segera setelah melahirkan. A. Metode amenorea laktasi ( MAL ) MAL adalah suatu cara yang mengandalkan pemberian ASI secara eksklusif, artinya hanya diberikan ASI tanpa tambahan makanan atau minuman apa pun lainnya. MAL dapat dipakai sebagai kontrasepsi bila menyusui secara penuh dan lebih efektif bila pemberian 8x sehari sampai 6 bulan, belum haid, umur bayi kurang dari 6 bulan dan harus dilanjutkan dengan pemakaian metode kontrasepsi lainnya. Cara kerja : penundaan/penekanan ovulasi Keuntungan MAL : Efektivitas tinggi (keberhasilan 98% pada enam bulan pascapersalinan) / Segera efektif Tidak mengganggu senggama Tidak ada efek samping secara sistemik Tidak perlu pengawasan medis Tidak perlu obat atau alat Tanpa biaya Keuntungan lain : Untuk bayi : Mendapat kekebalan pasif (mendapatkan antibodi perlindungan lewat ASI) Sumber asupan gizi yang terbaik dan sempurna untuk tumbuh kembang bayi yang optimal Terhindar dari keterpaparan terhadap kontaminasi dari air, susu lain atau formula, atau alat minum yang dipakai. Untuk ibu : Mengurangi pendarahan pasca persalinan Mengurangi risiko anemia Meningkatkan hubungan psikologi ibu dan bayi Keterbatasan Perlu

persiapan sejak perawatan kehamilan agar segera menyusui dalam 30 menit pasca persalinan Mungkin sulit dilaksanankan karena kondisi sosial Efektivitas tinggi hanya sampai kembalinya haid atau sampai dengan 6 bulan Tidak melindungi terhadap infeksi menular seksual (IMS) termasuk virus hepatitis B/HBV dan HIV/AIDS Yang dapat menggunakan MAL adalah ibu yang menyusui secara eksklusif, bayinya berumur kurang dari 6 bulan dan belum mendapat haid setelah melahirkan. Sebaliknya yang seharusnya tidak menggunakan MAL adalah ibu yang sudah mendapat haid setelah bersalin, tidak menyusui secara eksklusif, bayinya sudah berumur lebih dari 6 bulan, ibu yang bekerja dan terpisah dari bayi lebih lama dari 6 jam. B. Kontrasepsi kombinasi (hormon estrogen dan progesteron) Bentuk pemberian kontrasepsi kombinasi dapat berbentuk tablet atau injeksi. Kontrasepsi oral biasanya dikemas dalam satu kotak yang berisis 21 atau 22 tablet, dan sebagian kecil berisi 28 tablet. Minipil digunakan tanpa masa istrahat yang terdiri dari 35 tablet. Sediaan depo injeksi dapat berupa injeksi mikro kristalin (depoprovera) atau cairan minyak dari asam lemak sterioid ester. Sediaan estrogen gestagen dibagi menjadi kombinasi monofasik, bertingkat, dan sekuensial bifasik. C. Pil kombinasi Adalah pil kontrasepsi yang berisi estrogen maupun progesteron. Dosis estrogen ada yang 0,05; 0,08 dan 0,1 mg per tablet. Sedangkan dosis dan jenis progesteronnya bervariasi dari masingmasing pabrik pembuatnya. Cara kerja : Menekan sekresi gonadotropin dari hipofise secara terus menerus, sehingga tidak terjadi ovulasi. Merubah konsistensi lendir serviks menjadi tebal dan kental, sehingga penetrasi dan transportasi sperma akan terhalang, sulit, atau tidak mungkin sama sekali. Merubah peristaltik tuba dan rahim, sehingga mengganggu motilitas tuba untuk ovum dan transportasi sperma. Menimbulkan perubahan pada endometrium, sehingga tidak memungkinkan terjadinya nidasi. Merubah kepekaan indung telur terhadap rangsangan-rangsangan gonadotropin. Manfaat : Memiliki efektivitas yang tinggi, dapat dipercaya jika dimakan sesuai aturan pakainya Pemakai pil dapat hamil lagi, bilamana dikehendaki kesuburan kembali dengan cepat Tidak mengganggu hubungan seksual Resiko terhadap kesehatan sangat kecil Siklus haid menjadi teratur, banyaknya darah haid berkurang, tidak terjadi nyeri haid Dapat digunakan jangka panjang selama perempuan masih ingin menggunakannya untuk mencegah kehamilan Dapat digunakan sejak usia remaja hingga menopause Mudah dihentikan setiap saat Dapat digunakan sebagai kontrasepsi darurat Dikatakan dapat mengurangi angka kejadian kanker ovarium Kekurangan : Pil harus dimakan setiap hari, kurang cocok bagi wanita yang pelupa Mual, terutama pada 3 bulan pertama Perdarahan bercak atau perdarahan sela, terutama 3 bulan pertama Pusing, nyeri payudara, berat badan naik sedikit Tidak boleh diberikan pada perempuan menyusui (mengurangi ASI) Meningkatkan tekanan darah, retensi cairan, sehingga resiko stroke, dan gangguan pembekuan darah pada vena dalam sedikit meningkat Tidak mencegah IMS Yang dapat menggunakan pil kombinasi : Usia reproduksi, telah memiliki anak ataupun belum memiliki anak Gemuk atau kurus Setelah melahirkan dan tidak menyusui Setelah melahirkan 6 bulan yang tidak memberikan ASI eksklusif, sedangkan semua cara kontrasepsi yang dianjurkan tidak cocok bagi ibu tersebut Pascakeguguran, anemia, nyeri haid hebat, siklus haid tidak teratur Riwayat kehamilan ektopik, kelainan payudara jinak, DM tanpa komplikasi, penyakit tiroid, penyakit radang panggul dll Varises vena Yang tidak boleh menggunakan pil kombinasi : Hamil atau dicurigai hamil, menyusui eksklusif Perdarahan pervaginam yang belum diketahui Penyakit hati akut Perokok usia > 35 tahun Riwayat penyakit jantung, stroke, tekanan darah > 180/110 mmhg, riwayat gangguan pembekuan darah atau DM > 20 tahun, kanker payudara, migrain dan gejala neurologi fokal Tidak dapat

menggunakan pil secara teratur. Waktu mulai menggunakan pil kombinasi : Setiap saat selagi haid, untuk meyakinkan kalau perempuan tersebut tidak hamil. Hari pertama sampai hari ke-7 siklus haid Boleh menggunakan pada hari ke-8, tetapi perlu menggunakan metode kontrasepsi yang lain mulai hari ke-8 sampai hari ke-14 atau tidak melakukan hubungan seksual sampai paket pil tersebut habis. Setelah melahirkan : Setelah 6 bulan pemberian ASI eksklusif Setelah 3 bulan dan tidak menyusui Pasca keguguran (segera atau dalam waktu 7 hari) Bila berhenti menggunakan kontrasepsi injeksi, dan ingin menggantikan dengan pil kombinasi, pil dapat segera diberikan tanpa perlu menunggu Sangat efektifhaid. D. IMPLANT Keuntungan Kontrasepsi Implan : (0.0511 kehamilan per 100 wanita dalam tahun pertama pemakaian) Segera bekerja efektif (< Metode jangka panjang24 jam) Pemeriksaan panggul tidak diperlukan(perlindungan s/d 5 tahun) Tidak berpengaruh Tidak mengganggu proses sanggama sebelum pemakaian Efek Kesuburan segera pulih setelah dilepaskan pada produksi ASI Tidak perlu Klien hanya kembali apabila ada masalah samping minimal Dapat dipasang oleh petugas kesehatanpemeriksaan tambahan untuk klien Tidak mengandung estrogen Waktuterlatih (dokter, bidan atau perawat) Setiap waktu wanita tersebut dinyatakan tidak hamil Penggunaan : sesudah 6 bulan Pascapersalinan: Dalam 7 hari pertama menstruasi setelah 6 minggu jikajika memakai metode laktasi amenorea (MLA) Segera setelah 6 minggu jikamemberikan ASI tetapi tidak memakai MLA Dalam 11 hari pertama pascakeguguran E. IUD Jenistidak memberikan ASI IUD di Indonesia ada beberapa macam, diantaranya : Lippes Loop CuT 380A --------- jenis ini yang digunakan oleh BKKBN Nova T Cara kerja CuT-380A mencegah fertilisasi ion tembaga menurunkan motilitasIUD : dan fungsi sperma, mengganggu cairan tuba dan uterus, mencegah sperma IUD tembaga menyebabkan traumamencapai tuba dan membuahi sel telur. lokal di endometrium karena respon tubuh terhadap benda asing perubahan biokimiawi sehingga dihasilkan lingkungan dalam uterus yang toksik dan letal terhadap sperma dan embrio. Keuntungan penggunaan IUD : Efektivitas tinggi, perlindungan jangka panjang dari kehamilan (10-12 Tidak ada efek Fertilitas cepat kembali setelah pengangkatan. th). Secara ekonomis tidak mahal dibandingkan jangkasamping hormonal. Nyaman, tidak membutuhkan tindakan setiap hari danwaktu pemakaian. Tidak mempengaruhi kualitastidak ada kunjungan ulang untuk kontrol. dan volume ASI. Rumor dalam masyarakat : * Ngeri ada benda asing dalam badan. * Dapat geser2 sampai keluar dari kandungan. * Harus dilepas 5 tahun lagi. * Ada yang keluar sendiri. * Ada yang masih bisa hamil. Waktu pemasangan IUD : 1. Dalam 48 jam pasca persalinan (termasuk segera setelah plasenta lahir) 2. Bila 4 minggu/lebih pasca persalinan belum haid langsung dipasang IUD (tidak perlu kontrasepsi perlindungan). 3. Bila 4 minggu/lebih pasca persalinan sudah haid dipasang dalam 7 hari haid, atau jika dipasang >7 hari haid perlu menunda hubungan seks atau kontrasepsi perlindungan selama 7 hari. 4. Persalinan bedah cesar IUD dipasang setelah plasenta lahir, sebelum menjahit dinding rahim. WHO (Medical Eligibility Criteria for Contraceptive Use, 2008) Daftar Pustaka 1. Biran Affandi, Prof, dr, SpOG(k) ; Hasil Workshop Peningkatan KB di RS, Bandung, 2009. 2. dr. Hartanto Hanafi 2002. Keluarga Berencana dan KB. Pustaka Sinar Harapan Jakarta. 3. Prawirohardjo S. 2003. Buku Pelayanan Kesehatan Maternal dan Neonatal, EGC. Jakarta. 4. Grimes DA, Lopez LM, Schulz KF, Van Vliet HAAM, Stanwood NL up-to-date : 31 March 2010. 5. Selected Practice Recommendations For Contraceptive Use ; 2 ed, 2004

Jampersal-IUD Pascasalin Disandingkan

Pontianak | Rabu, 25 Jul 2012 PUSAT Kesehatan Masyarakat (Puskesmas) Alianyang Pontianak menerapkan sebuah Metode Kontrasepsi Jangka Panjang (MKJP) dengan menyandingkan antara Jaminan Persalinan (Jampersal) dengan salah satu alat kontrasepsi Intra Uterine Device (IUD) atau spiral. Skema ini kemudian mengantarnya sebagai Puskesmas terbaik ketiga dalam ajang Lomba Pencapaian KB Kategori Klinik KB Pemerintah Tingkat Nasional Wilayah Luar Jawa-Bali 2012. Kepala Badan Pemberdayaan Masyarakat, Perempuan, Anak dan KB (BPMPAKB) Kota Pontianak, Dharmanelly mengatakan Puskesmas Alianyang paling banyak melayani MKJP. "Sekitar 30 persen di antaranya menggunakan IUD atau spiral," katanya di Pontianak, Selasa (24/7). Dia mengakui akseptor KB di Kota Pontianak masih didominasi pil dan suntik. Namun, untuk meningkatkan MKJP IUD, pemerintah menerapkan pemasangan IUD post partum melalui Jaminan Persalinan (Jampersal). "Jadi begitu selesai bersalin, langsung kami pasangkan IUD. Kalau kami masih terapkan metode lama, berarti harus menunggu sampai 40 hari pascamelahirkan baru dipasang. Kami khawatir askeptor akan berubah pikiran dan tidak mau memasang IUD," kata Dharmanelly. Post partum adalah kondisi di mana seorang ibu pascamelahirkan atau lebih dikenal dengan nifas. Pada masa ini adalah saat pemulihan kembali, mulai dari persalinan kembali sampai alat-alat kandungan kembali seperti sebelum hamil. "Melalui MKJP post partum kami harapkan peserta KB IUD semakin meningkat," katanya.

Knowledge summary 1 - Understand the burden

Women and children are essential to socio-economic progress around the world. Yet they also suffer from some of the greatest inequities and vulnerabilities in terms of the burden of preventable ill-health. Pregnancy and childbirth can be unique and joyous experiences. However, they are also times of stress, as health risks and economic and social issues combine to make a woman and her newborn susceptible to illness and death. From adolescence, through pregnancy, childbirth and motherhood, all these factors impact on a woman and her childs health. The choices she can make for herself and her child to promote well-being and to access healthcare as and when needed, make a fundamental difference to current and future generations across the developing world. Numbers alone do not tell the entire story. But the estimates are overwhelming. In 2008 alone:

358,000 maternal deaths1 8.1 million deaths among newborns and children under five2,3 22 million unsafe abortions4,5

And another stark fact: the vast majority of the burden borne by women, adolescent girls, newborns and children occurs among the poorest and most vulnerable individuals and is concentrated in sub-Saharan Africa and South Asia. However, concerted global efforts are now being made to change this.With renewed pledges and financial commitments, between 2011 and 2015, the world aims to:

prevent 740,000 women dying from pregnancy-related causes, including unsafe abortion prevent 15 million deaths among newborns and children under five protect 88 million children under five from stunting and 120 million from pneumonia prevent 33 million unintended pregnancies.

Where do we stand now?

The UN Millennium Development Goals (MDGs) 4 and 5 gave impetus to efforts to address many of the inequities that have been entrenched in countries and their health systems. Concerted efforts globally have helped to advance reproductive, maternal, newborn and child health. However, there is a long way to go before the goals are reached. Inequities persist, despite progress (see Knowledge Summary 9).
Reproductive health: slowdown in progress over the last ten years

About 200 million women would like to delay or stop childbearing, but are not using contraception.There is clearly an unmet need, and addressing this through family planning would, together with maternal and newborn services, reduce unintended pregnancies by two-thirds, maternal deaths by 70% and newborn deaths by 44%.6

Enlarge image

Fig 1 - The unequal world of family planning

Progress in uptake of contraceptives has slowed since 2000, largely due to inadequate funding for supplies and lack of access, while differences in contraceptive prevalence have widened. Sub-Saharan Africa has the lowest prevalence and highest unmet need: one in four women of reproductive age who would like to use a contraceptive cannot obtain one (see Figure 1). Teenage pregnancy rates continue to be high, with sub- Saharan Africa recording the highest birth rates in this age group (15 to 19), followed by Latin America.The poorest families, and those with little education, account for the lowest use of contraception and highest number of teenage pregnancies.7 In sub-Saharan Africa, a poor teenager is three times more likely to get pregnant and give birth than a teenager from a rich family (see Figure 2a).

Fig. 2a - Teenage pregnancy; Fig 2b - Contraceptive use Enlarge image

Unsafe abortions rates have declined in some regions, but continue to be high in parts of Africa and South America.8
Maternal health: slow progress towards MDG 5

Estimates show that the maternal mortality ratio (MMR) for 2008 was 260 deaths per 100,000 live births.9 Nearly 99% of the estimated 358,000 maternal deaths were in developing countries, and most of these deaths (65%) were concentrated in 11 countries. Forty-five countries had a fairly high MMR (300 or more deaths per 100,000 live births) and Afghanistan, Chad, Guinea-Bissau and Somalia had extremely high MMRs (1,000 or more deaths per 100,000 live births). The adult lifetime risk of maternal death was the highest in sub-Saharan Africa (1 in 31). Globally, the number of maternal deaths has declined, with a 34% decrease between 1990 and 2008. Reductions have happened across all world regions, with the largest changes happening in East Asia (63% reduction). However, this reduction masks the high risks that many women face within the poorest countries. Moreover, the progress

is insufficient to achieve MDG 5.The average annual decline in MMR was 2.3% between 1990 and 2008, instead of the required rate of 5.5% per year.
Enlarge image

Fig 3 - Maternal mortality ratio across countries

More than half the maternal deaths in developing countries are due to heavy bleeding after childbirth, and hypertension. Obstructed labor and other complications at childbirth are responsible for 11% of the deaths, while indirect causes such as malaria and HIV/AIDS cause 18% of the deaths overall, although in some countries this proportion is much higher. Most of these deaths can be prevented if the woman receives the appropriate interventions from a skilled health worker, and with adequate equipment, drugs and medicines (see Knowledge Summaries 5 and 6).
Newborn and child health: progress, but not enough to meet MDG 4

Mortality rates for under-fives dropped by 28% between 1990 and 2008. Some poor countries such as Bangladesh, Bolivia, Malawi and others have been able to reduce mortality for under-fives. 67 countries continue to have rates of 40 or more under-five deaths per 1000 live births, and only 10 countries are on track to achieve MDG 4. Despite progress, most of these deaths continue to happen in sub-Saharan Africa (see Figure 4).

Fig 4 - Under-five mortality rates Enlarge image

Newborn mortality accounts for a large proportion of child deaths: more than 40% of the under-five deaths in 2008 were among newborns. Newborn mortality is high in the same regions where maternal mortality is high (see Figure 5), which highlights the

potential to improve outcomes for both women and children particularly through timely and effective care at childbirth. Stillbirths are not part of the MDGs and hence have received less attention. An estimated 3.3 million stillbirths globally were reported for 2000, with 99% occurring in developing countries. A third of these happened during childbirth, mainly due to maternal conditions such as hypertension, obstructed labor, etc. but also partly reflecting poor quality of care in the management of these problems (see Knowledge Summary 7). However, better data and research are still needed to develop effective policies.10
Enlarge image

Fig 5 - Newborn mortality rate

Pneumonia, diarrhea and malaria were the lead killers, accounting for 43% of underfive deaths in 2008 (see Figure 6). On the other hand, vaccine-preventable diseases have declined owing to improvements in routine immunization coverage in the last ten years. For example, measles-related deaths reduced by 78% between 1990 and 2008, as coverage of measles immunization increased (81% in 2008).11

Enlarge image

Undernutrition contributes to one-third of the under-fives deaths. Children under two are most vulnerable, and stunted growth is largely irreversible after that age. In adult life, poor nourishment and short stature in mothers can increase the risk of low birth weight in babies, which in turn raises the risk of death in newborns. Although the global prevalence of underweight children has reduced between 1990 (31% prevalence) and 2008 (26% prevalence), sub-Saharan Africa and South Asia have not made much progress. Children from poorer and rural families are more likely to be underweight. Figures show that even in countries that have a low prevalence of underweight children, stunting is still a problem. For example, Peru has an underweight prevalence of just 6% but a stunting prevalence of 30%.12

Fig 7 - Proportion of children under 5 years who are underweight Enlarge image

Early initiation of breastfeeding reduces newborn deaths by 20%. However, less than 50% of newborns in developing countries are breastfed within one hour of birth. Many countries have improved rates of exclusive breastfeeding until six months, but the average rate is still less than 35%.13

Conclusion
Women, newborns and children in many parts of sub-Saharan Africa and South Asia continue to be the most vulnerable in the world. Some poor countries have, however, made progress toward achieving MDG 4 and 5, as can be seen in Figure 8, and provide a stimulus for accelerated action. Lessons from their successes can offer pointers to how progress can be achieved elsewhere. Improved health and survival can be extended to all women and children.
Enlarge image

Fig 8 - Progress on the MDGs 4 and 5

References

1 WHO (2010). Trends in maternal mortality 1990 2008. (PDF). http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf 2 WHO (2010). Global Health Indicators Part 2. (PDF). www.who.int/entity/whosis/whostat/EN_WHS10_Part2.pdf 3 UN (2010). Millennium Development Goals Report 2010. (PDF). www.un.org/en/mdg/summit2010/pdf/MDG%20Report%202010%20En%20r15%20low%20res%2020100615%20-.pdf 4 UNFPA (2010). How universal is access to reproductive health? A review of

evidence. (PDF). www.unfpa.org/webdav/site/global/shared/documents/publications/2010/universal_rh. pdf 5 WHO (2010). Unsafe abortion in 2008. www.who.int/reproductivehealth/topics/unsafe_abortion/poster_unsafe_abortion.pdf 6 UNFPA and Guttamacher Institute (2010). Adding it up:The Benefits of Investing in Sexual and Reproductive Health Care. (PDF). www.unfpa.org/upload/lib_pub_file/240_filename_addingitup.pdf 7 UN (2010). Millennium Development Goals Report 2010. (PDF). www.un.org/en/mdg/summit2010/pdf/MDG%20Report%202010%20En%20r15%20low%20res%2020100615%20-.pdf 8 WHO (2010). Unsafe abortion in 2008. www.who.int/reproductivehealth/topics/unsafe_abortion/poster_unsafe_abortion.pdf 9 WHO (2010). Trends in maternal mortality 1990 2008. (PDF). http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf 10 Lawn JE, et al (2010). Global report on preterm birth and stillbirth (1 of 7): definitions, description of the burden and opportunities to improve data. BMC Pregnancy and Childbirth 2010, 10(Suppl 1):S1 www.biomedcentral.com/content/pdf/1471-2393-10-S1-S1.pdf 11 Millennium Development Goals Report 2010. (PDF). www.un.org/en/mdg/summit2010/pdf/MDG%20Report%202010%20En%20r15%20low%20res%2020100615%20-.pdf 12 UNICEF (2010). Progress for Children: Achieving the MDGs with Equity. www.unicef.org/publications/index_55740.html 13 Countdown to 2015 Decade Report (2000-2010):Taking stock of maternal, newborn and child survival. www.Countdown2015mnch.org/documents/2010report/CountdownReportAndProfile s.pdf

Intrauterine Device (IUD) for Birth Control

An IUD is a small, T-shaped plastic device that is wrapped in copper or contains hormones. The IUD is inserted into your uterus by your doctor. A plastic string tied to the end of the IUD hangs down through the cervix into the vagina. You can check that the IUD is in place by feeling for this string. The string is also used by your doctor to remove the IUD.
Types of IUDs

Hormonal IUD. The hormonal IUD, such as Mirena, releases levonorgestrel, which is a form of the hormone progestin. The hormonal IUD appears to be slightly more effective at preventing pregnancy than the copper IUD. The hormonal IUD is effective for at least 5 years. Copper IUD. The most commonly used IUD is the copper IUD (such as Paragard). Copper wire is wound around the stem of the T-shaped IUD. The copper IUD can stay in place for at least 10 years and is a highly effective form of contraception.

How it works

Both types of IUD prevent fertilization of the egg by damaging or killing sperm. The IUD also affects the uterine lining (where a fertilized egg would implant and grow).
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Hormonal IUD. This IUD prevents fertilization by damaging or killing sperm and making the mucus in the cervix thick and sticky, so sperm can't get through to the uterus. It also keeps the lining of the uterus (endometrium) from growing very thick.1 This makes the lining a poor place for a fertilized egg to implant and grow. The hormones in this IUD also reduce menstrual bleeding and cramping. Copper IUD. Copper is toxic to sperm. It makes the uterus and fallopian tubes produce fluid that kills sperm. This fluid contains white blood cells, copper ions, enzymes, and prostaglandins.1

Insertion

You can have an IUD inserted at any time, as long as you are not pregnant. An IUD is inserted into your uterus by your doctor. The insertion procedure takes only a few

minutes and can be done in a doctor's office. Sometimes a local anesthetic is injected into the area around the cervix, but this is not always needed. IUD insertion is easiest in women who have had a vaginal childbirth in the past. Your doctor may have you feel for the IUD string right after insertion, to be sure you know what it feels like. You may be given antibiotics to prevent infection.

What To Expect After Treatment

You may want to have someone drive you home after the insertion procedure. You may experience some mild cramping and light bleeding (spotting) for 1 or 2 days.
Follow-up

Your doctor may want to see you 4 to 6 weeks after the IUD insertion, to make sure it is in place. Be sure to check the string of your IUD after every period. To do this, insert a finger into your vagina and feel for the cervix, which is at the top of the vagina and feels harder than the rest of your vagina (some women say it feels like the tip of your nose). You should be able to feel the thin, plastic string coming out of the opening of your cervix. It may coil around the cervix, which can make it difficult to find. Call your doctor if you cannot feel the string or the rigid end of the IUD. If you cannot feel the string, it doesn't necessarily mean that the IUD has been expelled. Sometimes the string is just difficult to feel or has been pulled up into the cervical canal (which will not harm you). An exam and sometimes an ultrasound will show whether the IUD is still in place. Use another form of birth control until your doctor makes sure that the IUD is still in place. If you have no problems, check the string after each period and return to your doctor once a year for a checkup.

The copper IUD is approved for use for up to 10 years. The hormonal IUD is approved for use for up to 5 years.

Why It Is Done
You may be a good candidate for an IUD if you:

Do not have a pelvic infection at the time of IUD insertion. Have only one sex partner who does not have other sex partners and who is infection-free. This means you are not at high risk for sexually transmitted infections (STIs) or pelvic inflammatory disease (PID), or you and your partner are willing to also use condoms. Want an effective, long-acting method of birth control that requires little effort and is easily reversible. Cannot or do not want to use birth control pills or other hormonal birth control methods.

Are breast-feeding.

The copper IUD is recommended for emergency contraception if you have had unprotected sex in the past few days and need to avoid pregnancy and you plan to continue using the IUD for birth control. As a short-term type of emergency contraception, the copper IUD is more expensive than emergency contraception with hormone pills.

How Well It Works

The IUD is a highly effective method of birth control.1

When using the hormonal IUD, about 2 out of 1,000 women become pregnant in the first year.2 When using the copper IUD, about 6 out of 1,000 women become pregnant in the first year. 2 Most pregnancies that occur with IUD use happen because the IUD is pushed out of (expelled from) the uterus unnoticed. IUDs are most likely to come out in the first few months of IUD use, after being inserted just after childbirth, or in women who have not had a baby.

Advantages of IUDs include cost-effectiveness over time, ease of use, lower risk of ectopic pregnancy, and no interruption of foreplay or intercourse.1
Other advantages of the hormonal IUD

Also, the hormonal IUD:

Reduces heavy menstrual bleeding by an average of 90% after the first few months of use.1 Reduces menstrual bleeding and cramps and, in many women, eventually causes menstrual periods to stop altogether. In this case, not menstruating is not harmful. May prevent endometrial hyperplasia or endometrial cancer. May effectively relieve endometriosis and is less likely to cause side effects than high-dose progestin.3 Reduces the risk of ectopic pregnancy. Does not cause weight gain.

Risks
Risks of using an intrauterine device (IUD) include:

Menstrual problems. The copper IUD may increase menstrual bleeding or cramps. Women may also experience spotting between periods. The hormonal IUD may reduce menstrual cramps and bleeding.1 Perforation. In 1 out of 1,000 women, the IUD will get stuck in or puncture (perforate) the uterus.1 Although perforation is rare, it almost always occurs during insertion. The IUD should be removed if the uterus has been perforated. Expulsion. About 2 to 10 out of 100 IUDs are pushed out (expelled) from the uterus into the vagina during the first year. This usually happens in the first few months of

use. Expulsion is more likely when the IUD is inserted right after childbirth or in a woman who has not carried a pregnancy.1 When an IUD has been expelled, you are no longer protected against pregnancy.

Disadvantages of IUDs include the high cost of insertion, no protection against STDs, and the need to be removed by a doctor.
Disadvantages of the hormonal IUD

The hormonal IUD may cause noncancerous (benign) growths called ovarian cysts, which usually go away on their own. The hormonal IUD can cause hormonal side effects similar to those caused by oral contraceptives, such as breast tenderness, mood swings, headaches, and acne. This is rare. When side effects do happen, they usually go away after the first few months. Pregnancy with an IUD If you become pregnant with an IUD in place, your doctor will recommend that the IUD be removed. This is because the IUD can cause miscarriage or preterm birth (the IUD will not cause birth defects).
When to call your doctor

When using an IUD, be aware of warning signs of a more serious problem related to the IUD. Call your doctor now or seek immediate medical care if:

You have severe pain in your belly or pelvis. You have severe vaginal bleeding. You are passing clots of blood and soaking through your usual pads or tampons each hour for 2 or more hours. You have vaginal discharge that smells bad. You have a fever and chills. You think you might be pregnant.

Watch closely for changes in your health, and be sure to contact your doctor if:

You cannot find the string of your IUD, or the string is shorter or longer than normal. You have any problems with your birth control method. You think you may have been exposed to or have a sexually transmitted infection.

What To Think About

The IUD is most likely to work well for women who have been pregnant before. Women who have never been pregnant are more likely to have pain and cramping after the IUD is inserted. They are also more likely to expel the IUD. But they can still use the IUD.

Pelvic inflammatory disease (PID) concerns have been linked to the IUD for years. But it is now known that the IUD itself does not cause PID. Instead, if you have a genital infection when an IUD is inserted, the infection can be carried into your uterus and fallopian tubes. If you are at risk for a sexually transmitted infection (STI), your doctor will test you and treat you if necessary, before you get an IUD. Intrauterine devices reduce the risk of all pregnancies, including ectopic (tubal) pregnancy. But if a pregnancy does occur while an IUD is in place, it is a little more likely that the pregnancy will be ectopic. Ectopic pregnancies require medicine or surgery to remove the pregnancy. Sometimes the fallopian tube on that side must be removed as well.
IUD use and medical conditions

An IUD can be a safe birth control choice for women who:4

Have a history of ectopic pregnancy. Both the copper IUD and hormonal IUD are appropriate. Have a history of irregular menstrual bleeding and pain. The hormonal IUD may be appropriate for these women and for women who have a bleeding disorder or those who take blood thinners (anticoagulants). At risk for bacterial endocarditis. Antibiotics would be used at the time of insertion and removal to prevent infection. Have diabetes. Are breast-feeding. Have a history of endometriosis. The hormonal IUD is a good choice for women who have endometriosis.

Considerations

IUDs may not be a good choice if you:

Have a sexually transmitted infection (STI) currently or had one within the past 3 months. Are not willing to use condoms to protect yourself from sexually transmitted infections. Have an active infection of your vagina or cervix. Have pelvic inflammatory disease (PID) or have a recent history of PID. Have a bleeding disorder or take blood-thinners (anticoagulants). Your doctor may not recommend a copper IUD, but you may be able to use a hormonal IUD. Have a history of problems with IUDs. Have never been pregnant (you are more likely to have pain with an IUD and are more likely to have the IUD come out after it is inserted). Have abnormalities of your uterus. Have a uterine infection after childbirth or a septic abortion. Have uterine bleeding of unknown origin. Have an allergy to copper, so the copper IUD would not be an option.

If you have one of the older, all-plastic IUDs, such as the Lippes Loop, ask your doctor at your next checkup about replacing this IUD with a more effective copper or hormonal one. Complete the special treatment information form (PDF) document?) to help you understand this treatment. (What is a PDF

Citations
1. Grimes DA (2007). Intrauterine devices (IUDs). In RA Hatcher et al., eds., Contraceptive Technology, 19th ed., pp. 117-143. New York: Ardent Media. 2. Trussell J (2007). Choosing a contraceptive: Efficacy, safety, and personal considerations. In RA Hatcher et al., eds., Contraceptive Technology, 19th ed., pp. 19-47. New York: Ardent Media. 3. Fritz MA, Speroff L (2011). Endometriosis. In Clinical Gynecologic Endocrinology and Infertility, 8th ed., pp. 1221-1248. Philadelphia: Lippincott Williams and Wilkins. 4. Speroff L, Darney PD (2005). Intrauterine contraception. In Clinical Guide for Contraception, pp. 221-257. Philadelphia: Lippincott Williams and Wilkins.