Discussion
uterine colics, bleeding
BLEEDING, STILL, COMPLICATIONS, CAVITY, VAGINA, UTERUS
The ideal time to place an IUD following a cesarean birth is still up for discussion. Recent studies have reported inserting the IUD as soon as possible after birth (within 10 min of placental delivery) to maximize the usage of trustworthy, efficient, and long-lasting contraceptive techniques, especially in countries with high populations and at a time when women are highly motivated for contraception [Till now, there is no standardized technique for IUD insertion during cesarean section. The conventional technique of IUD insertion during cesarean section, as described in previous studies, is based on the manual placement of the IUD in the uterine fundus and manual guide of the IUD threads through the cervix [Our study compared the conventional manual technique to a new technique (intra-cesarean post-placental introducer withdrawal IUD insertion technique). This is the first study that describes and outlines this technique in detail and its advantage compared to the conventional post-placental manual IUD insertion technique.The rationale of our technique is to use the introducer to ensure placing the IUD in the uterine fundus and ensuring that its threads pass through the cervix to the vagina. The conventional manual insertion technique of grasping the IUD from the stem does not ensure that the arms of the IUD are firmly in contact with the uterine fundus, while pushing the IUD unfolded arms with introducer up to the fundus ensures that. Additionally, we must note that pushing the IUD differs from grasping and releasing it. Putting a grasped IUD in the uterine fundus may be followed by some degree of pulling the IUD downward during the withdrawal of the grasping hand (or even a grasping instrument) due to the narrowness of the available cavity that creates some negative pressure and due to some inability to completely ungrasp the IUD. In contrast, withdrawal of the introducer will not be followed by pulling forces to the IUD downwards as the introducer now has no attachment to the IUD, as usually happens in routine IUD insertion withdrawal techniques used in gynecology.In another study, they used the introducer during the insertion technique, but they did not trim it or trim the threads and they put the IUD first in the fundus before passing it through the cervix. We can expect that they have faced difficulty in passing the introducer through the cervix as in this way as the length of the uterine cavity may not allow easily for the entry of the whole introducer before pushing it through the cervix, and that they faced resistance by the posterior vaginal wall in case the cervix is directed posterior. Furthermore, in this study, they compared intra-cesarean insertion with interval insertion [IUD displacement is the major problem of IUD usage, leading to other problems such as unwanted pregnancy, expulsion, bleeding, and uterine colics [Fixation of the IUD after placement of it in the uterine fundus will lead to less liability for displacement [However, we aimed to standardize a technique that can be used in developing countries with limited resources using the commonly available types of IUDs and the regular tools for IUD insertion provided with each package. Moreover, suturing and fixing the IUD to the uterus may increase the risk of bleeding, prolongation of operative time, and undue surgical difficulty. Still, there will be a need for studying the additive value of fixing the IUD to this new technique as previous studies applied fixation of the IUD with conventional manual technique.Thread visibility may be a problem with post-placental IUD placement. Non-visibility of IUD threads makes the dilemma of missed IUD difficult to extract. In our research, the new method group had a proportion of missing IUDs threads (after 6 months) of 3.6%, which was statistically significantly lower than the conventional technique (9.6%). The FIGO project reported the rates of absent threads in around one-third of women (visible in two-thirds), although this was for both vaginal and cesarean births [In our study, we took the continuation of the IUD usage after 6 months as a marker for acceptance, side effects, and complications. The continuation of IUD usage was higher in the new technique group than in the conventional technique group (88.1% versus 79.9%, with a highly significant statistical difference). In another study in which they used the introducer to put the IUDs in the fundus and ring forceps to guide the threads in the cervical canal, the continuity after 6 months was 83%, considering that they used different types of IUDs [Finally, we studied the duration of surgery between the two groups to know if our new technique added more significant time for the surgical procedure, and there was no significant statistical difference between the two groups as regards the duration of surgery. However, more trials of the technique with different types of IUDs and different levels of obstetricians’ training are needed.