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Missing strings following immediate postpartum IUD placement
  1. Andrea Henkel,
  2. Paul D Blumenthal
  1. Department of Obstetrics & Gynecology, Division of Family Planning Services & Research, Stanford University, Stanford, California, USA
  1. Correspondence to Dr Andrea Henkel, Obstetrics & Gynecology, Stanford University School of Medicine, Palo Alto, CA 94304, USA; ahenkel{at}

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Key messages

  • Non-visibility of IUD strings is more common following postplacental insertion after caesarean birth than vaginal birth.

  • Since unrecognised expulsion or perforation is rare, missing IUD strings following postplacental insertion most likely indicates an intrauterine device.

  • Where readily available, pelvic ultrasonography should be the first-line imaging modality to confirm intrauterine retention of IUD.

  • In settings with limited ultrasound or radiography capacity, it is reasonable to recommend a trial of expectant management awaiting string descent with consideration of a secondary form of contraception. If strings are still not visualised after return of menses, consider an in-office removal, with concomitant insertion of a new IUD if desired.


A 31-year-old gravida 3 para 3 presents for a scheduled postpartum follow-up 4 weeks following an uncomplicated spontaneous vaginal birth. Immediately following delivery, a postplacental copper intrauterine device (IUD) was placed for contraception.

On pelvic examination, IUD strings are not palpable, nor are they visible at the external cervical os on speculum examination. The patient reports exclusive breastfeeding without return of menses after lochia cessation. No sexual intercourse since delivery.


IUD placement immediately following birth is an effective and safe contraceptive strategy in the postpartum period.1–3 As historically defined in guidelines and research protocols, postplacental or immediate postpartum insertion occurs within 10 min of the third stage of labour.1 Contemporary definitions now include any placement in the delivery room, rejecting the artificially strict timeline.4 Fundal placement can be achieved with manual insertion, ring or Kelly placental forceps, or with a dedicated postplacental IUD inserter.1–3

Postplacental IUD placement decreases barriers to contraceptive access at a time many are highly motivated to avoid another pregnancy. Continuation rates after postplacental insertion—a reflection of contraceptive initiation and thus an important metric in the context of a public health programme—are higher than planned interval (>6 weeks postpartum, office …

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  • Editor's note The details of this case are fictitious. Any resemblance to actual persons, living or dead, or actual events is coincidental.

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  • Contributors AH and PDB shared equally in the review and manuscript preparation.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Commissioned; externally peer reviewed.