IUD POSTPLACENTA

IUD POSTPLACENTAIUDPOSTPLACENTA

Biran AffandiBiran Affandi

Kli ik R d S l hKlinik Raden SalehDepartmentofObstetrics&Gynecology

F lt f M di i U i it f I d i /FacultyofMedicine,UniversityofIndonesia/Cipto Mangunkusumo GeneralHospital

kJakarta

Affandi B.IUDPostplacenta .Rapat Persiapan TOT IUDPascapersalinan .BKKBNPusat ,Jakarta,28Desember 2010

Objectives:Objectives:1 T d t t t1.Toupdatepostpartumcontraceptioncontraception

2 To review IUD2.ToreviewIUDPOSTPLACENTAPOSTPLACENTA

3.To discuss medical barriers3.TodiscussmedicalbarriersAffandi B.IUDPostplacenta .Rapat Persiapan TOT IUDPascapersalinan .BKKBNPusat ,Jakarta,28Desember 2010

MillenniumDevelopmentGoals1 E di d h1.Eradicateextremepovertyandhunger2.Achieveuniversalprimaryeducation3.Promotegenderequality&empowerwomen4.Reducechildmortality5.Improvematernalhealth6.CombatHIV/AIDS,malaria&otherdiseases7.Ensureenvironmentalsustainability8.Develop a global partnership for development8.Developaglobalpartnershipfordevelopment

MDGs challenges are not newMDGs challenges are not new; what is new is that they involve; what is new is that they involveMDGs challenges are not newMDGs challenges are not new; what is new is that they involve ; what is new is that they involve concrete, timeconcrete, time--bound & quantitative bound & quantitative targetstargets for action by 2015.for action by 2015.Affandi B.Kesehatan Reproduksi dan Upaya Kesehatan Maternaldi Indonesia,QuoVadis?Orasi pada PITXVIIIPOGI,Jakarta,7Juli 2010

GOAL5ImproveMaternalHealth

TARGET6

Reducebythreequarters,between1990and

2015,thematernalmortalityratio

Affandi B.Kesehatan Reproduksi dan Upaya Kesehatan Maternaldi Indonesia,QuoVadis?Orasi pada PITXVIIIPOGI,Jakarta,7Juli 2010

Maternalmortalityisanindicatorofgrossinequality,human rights abuse andhumanrightsabuseanddevelopmentfailure. Allmaternalhealthproblems

bl l harepreventableaslongasthegovernment pays attention andgovernmentpaysattentionandprioritizesmaternalhealth.

Dr.S.T.Mathai,UNFPA,TheJakartaPost,13Jan.,2010

AffandiB.KesehatanReproduksidanUpayaKesehatanMaternaldiIndonesia,QuoVadis?OrasipadaPITXVIIIPOGI,Jakarta,7Juli2010

Ofthe11countriesthatcontributeto65l b l l d h fi ipercenttoglobalmaternaldeath,fivearein

AsiancountriesincludingIndonesia,Bangladesh,Pakistan,IndiaandAfghanistan.Ahighmaternalmortalityrateisang yindicatorofthestatusofpoorfunctioningofa countrys health system including lack ofacountry shealthsystemincludinglackofsupportiveandprotectivelegalandpolicyenvironmentenvironment.

Dr.S.T.Mathai,UNFPA,TheJakartaPost,13Jan.,2010

Affandi B.Kesehatan Reproduksi dan Upaya Kesehatan Maternaldi Indonesia,QuoVadis?Orasi pada PITXVIIIPOGI,Jakarta,7Juli 2010

GOAL5ImproveMaternalHealthp Target6:Reducebythreequarters,between

1990and2015,thematernalmortalityratio

Indicators:MaternalmortalityratioPercentageofbirthsattendedbyskilledg yhealthpersonnelContraceptiveprevalencerate

AffandiB.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta,22Sept.2010

Threeprongedstrategytoreducingmaternalmortality

Family planning to ensure that every birth is Familyplanningtoensurethateverybirthiswanted

Skilled care by a health professional with Skilledcarebyahealthprofessionalwithmidwiferyskillsforeverypregnantwomand i d hildbi thduringpregnancyandchildbirth

EmergencyObstetricCare(EmOC)toensuretimelyaccesstocareforwomenexperiencingcomplications. UNFPA,2009p

AffandiB.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta,22Sept.2010

PERENCANAANKELUARGA

1. Seorangwanitatelahdapatmelahirkan,segerasetelahiamendapathaidyangpertama( h )(menarche)

2. Kesuburanseorangwanitaakanterusberlangsung,sampai mati haid (menopause)sampaimatihaid(menopause)

3. Kehamilandankelahiranyangterbaik,artinyarisikopalingrendahuntukibudananak,adalahp g ,antara2035tahun

4. Persalinanpertamadankeduapalingrendahi ikrisikonya

5. Jarakantaraduakelahiransebaiknya24tahun

Affandi, 1984

Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010

POLA PERENCANAAN KELUARGAPOLAPERENCANAANKELUARGA

FaseFase FaseFase FaseFase

M dM d M j kM j kMenundaMenundaKehamilanKehamilan

MenjarangkanMenjarangkanKehamilanKehamilan

TidakTidak HamilHamillagilagi

22 44

2020 3535

Affandi, 1984


PEMILIHANKONTRASEPSIRASIONAL

FaseFase FaseFase FasFaseemenundamenundaKehamilanKehamilan

MenjarangkanMenjarangkanKehamilanKehamilan

TidakTidak hamilhamillagilagi

22 44

PilPil IUDIUD

IUDIUD SuntikanSuntikan

IUDIUD SuntikanSuntikan

SterilSteril IUDIUD

2020 3535 SederhanaSederhana SuntikanSuntikan ImplantImplant

SuntikanSuntikan MiniPilMiniPil PilPil ImplantImplant SederhanaSederhana

SuntikanSuntikan MiniPilMiniPil PilPil ImplantImplant SederhanaSederhana

ImplantImplant SuntikanSuntikan SederhanaSederhana PilPilSederhanaSederhana SederhanaSederhana

SterilSterilAffandi, 1984


CONTRACEPTIVEPREVALENCEINDONESIA 19702007INDONESIA,1970 2007

70

80

61 4 %

60

70

48 %

57 %60 % 61.4 %

40

50

20

3026 %

10

205 % (?)

01970 1980 1987 1997 2002 2007

Affandi B.UnsafeAbortion:IndonesianExperience.1stInternationalCongressonWomenHealth&UnsafeAbortion,Bangkok,Thailand,2023January2010

CurrentContraceptiveUsersIndonesia March 2006Indonesia,March2006

METHODS USERS %METHODS USERS %

INJECTABLES 9 743 550 35 2INJECTABLES 9,743,550 35.2

PILLs 7,796,474 28.1

IUDs 5 218 196 18 8IUDs 5,218,196 18.8

IMPLANTABLES 3,156,705 11.4

STERILIZATION 1 515 406 5 5STERILIZATION 1,515,406 5.5

OTHERS 278,473 1.0

TOTAL 27 708 804 100 0TOTAL 27,708,804 100.0BKKBN, 2007

Affandi B.UnsafeAbortion:IndonesianExperience.1stInternationalCongressonWomenHealth&UnsafeAbortion,Bangkok,Thailand ,2023January2010

BIRTHRATEBIRTHRATE

STILL HIGH ! ! !STILL HIGH ! ! !

4 5 5 Million/year4.5 5 Million/year

Affandi B.UnsafeAbortion:IndonesianExperience.1stInternationalCongressonWomenHealth&UnsafeAbortion,Bangkok,Thailand ,2023January2010

FAKTAFAKTA1.PascasalinOVULASIdapatpterjadidalamwaktu21hari

2.PascakeguguranOVULASIdapatTERJADIdalamwaktu11hari

Affandi B.Kontrasepsi Terkini dan IUDPascaplasenta .Pertemuan Koordinasi Peningkatan KBPascapersalinan di Rumah Sakit ,Makassar31Agustus 2010

Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30(3):181189

SimplifiedClassificationofEligibility( )Criteria(WHO)

AffandiB.PerkembanganKontrasepsi,TeknikPenapisandanKBPostpartum,BPMPPKB,Balikpapan,24Juni2010

12.Theuseofprogestogenonlymethodsinthefirst6weekspostpartumdoesnotappeartohaveanadversep p ppeffectonbreastmilkvolume(GradeB).

13.Theuseofprogestogenonlymethodswhenb f di id 99% ffi (G d )breastfeedingprovidesover99%efficacy(GradeB).

14.Theproblematicbleedingassociatedwithprogestogenonly methods appears to be more acceptable than thatonlymethodsappearstobemoreacceptablethanthatexperiencedbywomenwhoarenotbreastfeeding(GradeB).Aftercounselling,breastfeedingwomenmaychoosetouseaprogestogenonlymethodofcontraceptionbefore6 weeks postpartum if other contraceptive methods are6weekspostpartumifothercontraceptivemethodsareunacceptable.

Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30:181189

Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010

17.DMPAusebefore6weekspostpartumisnot usually recommended (Grade C)notusuallyrecommended(GradeC).

18.TroublesomebleedingcanoccurwithDMPAuseintheearlypostpartumperiod(GradeC).

DMPAwillnotrequiretheinjectionuntilDay21postpartum,butiftheriskofimmediatesubsequentpregnancyishighitmaybegivenbeforethistime.

Contraceptive choices for breastfeeding women. Journal of Family Planning and Reproductive Health Care 2004; 30: 181189Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30:181 189


BreastfeedingwomenmaychoosetouseaprogestogenonlyimplantbeforeDay 28 without the need forDay28withouttheneedforadditionalcontraceptiveprotection.

IMPLANTwillnotberequireduntilDay 28 postpartum, but if the risk ofDay28postpartum,butiftheriskofimmediatesubsequentpregnancyishigh it ma be gi en before this timehighitmaybegivenbeforethistime.

C i h i f b f di J l f il l i d d i H l h C 2004 30 181 189Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30:181189


Statement,WHOGeneva,22Oct.2008:Progestinonlycontraceptiveuseduringlactation

1. Useofprogestinonlymethods,withtheexceptionofthel l b ll d d flevonorgestrel bearingIUD,isnotusuallyrecommendedforwomenwhoarelessthan6weekspostpartumandbreastfeeding,unlessothermoreappropriatemethodsareunavailableorunacceptable.

2. Beyond6weekspostpartum,thereisnorestrictionfortheuseofprogestin only contraceptive methods among breastfeedingprogestinonlycontraceptivemethodsamongbreastfeedingwomen.

3. ThelevonorgestrelbearingIUDisnotusuallyrecommendedforth fi t 4 t t k l th i tthefirst4postpartumweeks,unlessothermoreappropriatemethodsareunavailableorunacceptable.Beyond4weekspostpartum,thereisnorestrictiononitsuse.


IUDCuAffandiB.PerkembanganKontrasepsi,TeknikPenapisandanKBPostpartum,BPMPPKB,Balikpapan,24Juni2010

ThepostpartuminsertionofIUDshasb f d l danumberofadvantages,including

ease of insertion, availability of skilledeaseofinsertion,availabilityofskilledpersonnelandappropriatef ili i d i f hfacilities,andconvenienceforthewoman.

Practitionershavebeenconcernedaboutthepossibilityofhigherexpulsion, infection and perforationwww.fhi.org/en/rh/pubs/factsheets/iud_pp.htmexpulsion,infectionandperforationrates.Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010

Postplacental (preferably within Postplacental (preferablywithin10minutesafterexpulsionoftheplacenta)andimmediatepostpartum insertion during thepostpartuminsertionduringthefirstweekafterdelivery(butpreferablywithin48hours)areconvenient effective and safeconvenienteffectiveandsafetimestoinsertcopperIUDs.

Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010

{ManagingContraception20052007,page92}

Teknik Pemasangan AKDR


Fundal placement ThewaytheIUDisinsertedismoreimportantthanthedesignofthedevice.Diff i IUD l i b DifferencesinIUDexpulsionratesbetweencentersparticipatinginthetrialsweregenerallygreaterthanexpulsion rates for different IUDs;expulsionratesfordifferentIUDs;

FHIdatashowthatemphasisneedstobegiventothefundal placement of the device.fundal placementofthedevice.

Theprovidershouldbeabletofeelthedevicethroughtheabdominalanduterinewallsatthetimeofinsertion.

Retrainingisnecessaryforthoseindividualswhoreporthighexpulsionrates www.fhi.org/en/rh/pubs/factsheets/iud_pp.htmAffandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010

Teknik Pemasangan AKDR


Allowthewomantorest.Besureshegetscomplete

t tpostpartumcare.

P id i iProvidepostinsertioninstructionsinstructions.

ExpulsionExpulsion Afterbirth,astheuterusreturnstonormalsize(involution),uterinecontractionsexpelretainedplacentalandbloodclotsandmayp yhaveasimilareffectonanyforeignbodyintroduced into the uterus.introducedintotheuterus.

IUDsinsertedwithin10minutesofplacental i h h l l i i kexpulsionhaveamuchlowerexpulsionrisk

thanthoseinsertedlaterinthepostpartumperiod. www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm


BarrierThatPreventContraceptiveSSuccess

Barriertoeffectivefamilyplanning services

Outcomewhenbarrierplanningservices areovercome

Accesstoservice

Contraceptivefpreference

Quality services Qualityservices

MAQExchangecurriculum(Online)MaximizingAccessandQualityinitiative,WashingtonDC,2001


Medical barriersMedicalbarriersweredefinedas "practices,derivedatp ,leastpartlyfromamedicalrationale,thatresultinascientifically unjustifiablescientificallyunjustifiableimpedimentto,ordenialof,p , ,contraception" SheltonJD,etal.Lancet,1992;340:13341335


MedicalBarriersthatrestrictfaccesstofamilyplanningservices

1 Provider bias When the provider is1.Providerbias Whentheproviderisfororagainstaspecificmethod

2 O l t i ti li ibilit it i2.Overlyrestrictiveeligibilitycriteria Whocangetwhatcontraceptive

3.Unnecessaryprocesshurdles Requirementsthat,fromtheuser'spointofview,makeitdifficulttoobtainacontraceptive SheltonJD,etal.Lancet,1992;340:13341335


4.Inappropriatecontraindications Medical conditions that restrict theMedicalconditionsthatrestricttheuseofsomecontraceptives

5 Overly restrictive regulations 5.Overlyrestrictiveregulations Nationallawsandclinicorhospitalregulationsregulations

6.Providerlimitation Whocanprovide what methodprovidewhatmethod

7.Inappropriatemanagementofsideeffects Actions taken by theeffects Actionstakenbytheprovidertohelptheusertolerateacontraceptive method Shelton JD et al Lancet 1992;340:13341335contraceptivemethod


SheltonJD,etal.Lancet,1992;340:1334 1335

ChecklistsReduceMedicalBarriers

Medicalbarriersoftenpreventclientsfromusingtheirdesiredmethodoffamilyplanning.

Thepregnancy,COC,DMPA,andIUDchecklistscaneffectivelyincreaseaccesstofamilyplanningwhilehelping ensure client safetyhelpingensureclientsafety.

Introductionofchecklistsintoservicedeliverysettingsshouldincludecarefultrainingonhowtousethegchecklistsaswellasthemedicaleligibilitycriteriaonwhichtheyarebased.


Knowingisnotenough,wemustapplyWillingisnotenough,we

t dmustdoG hGoethe


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IUD POSTPLACENTA