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IUD POSTPLACENTA IUDPOSTPLACENTA

Biran Affandi Biran Affandi


Kli ik R d S l h Klinik Raden Saleh
DepartmentofObstetrics&Gynecology
F lt f M di i U i it f I d i / FacultyofMedicine,UniversityofIndonesia/
Cipto Mangunkusumo GeneralHospital
k Jakarta
Affandi B.IUDPostplacenta .Rapat Persiapan TOT IUDPascapersalinan .BKKBNPusat ,Jakarta,28Desember 2010
Objectives: Objectives:
1 T d t t t 1.Toupdatepostpartum
contraception contraception
2 To review IUD 2.ToreviewIUD
POSTPLACENTA POSTPLACENTA
3.To discuss medical barriers 3.Todiscussmedicalbarriers
Affandi B.IUDPostplacenta .Rapat Persiapan TOT IUDPascapersalinan .BKKBNPusat ,Jakarta,28Desember 2010
MillenniumDevelopmentGoals
1 E di d h 1.Eradicateextremepovertyandhunger
2.Achieveuniversalprimaryeducation
3.Promotegenderequality&empowerwomen
4.Reducechildmortality
5.Improvematernalhealth
6.CombatHIV/AIDS,malaria&otherdiseases
7.Ensureenvironmentalsustainability
8.Develop a global partnership for development 8.Developaglobalpartnershipfordevelopment
MDGs challenges are not new MDGs challenges are not new; what is new is that they involve ; what is new is that they involve MDGs challenges are not new MDGs challenges are not new; what is new is that they involve ; what is new is that they involve
concrete, time concrete, time--bound & quantitative bound & quantitative targets targets 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
Maternalmortalityisan
indicatorofgrossinequality,
human rights abuse and humanrightsabuseand
developmentfailure.
Allmaternalhealthproblems
bl l h arepreventableaslongasthe
government pays attention and governmentpaysattentionand
prioritizesmaternalhealth.
Dr.S.T.Mathai,UNFPA,TheJakartaPost,13Jan.,2010
AffandiB.KesehatanReproduksidanUpayaKesehatanMaternaldiIndonesia,QuoVadis?OrasipadaPITXVIIIPOGI,Jakarta,7Juli2010
Ofthe11countriesthatcontributeto65
l b l l d h fi i percenttoglobalmaternaldeath,fivearein
AsiancountriesincludingIndonesia,
Bangladesh,Pakistan,IndiaandAfghanistan.
Ahighmaternalmortalityrateisan g y
indicatorofthestatusofpoorfunctioningof
a countrys health system including lack of acountry shealthsystemincludinglackof
supportiveandprotectivelegalandpolicy
environment environment.
Dr.S.T.Mathai,UNFPA,TheJakartaPost,13Jan.,2010
Affandi B.Kesehatan Reproduksi dan Upaya Kesehatan Maternaldi Indonesia,QuoVadis?Orasi pada PITXVIIIPOGI,Jakarta,7Juli 2010
GOAL5ImproveMaternalHealth p
Target6:Reducebythreequarters,between
1990and2015,thematernalmortalityratio
Indicators:
Maternalmortalityratio
Percentageofbirthsattendedbyskilled g y
healthpersonnel
Contraceptiveprevalencerate
AffandiB.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta,22Sept.2010
Threeprongedstrategy
toreducingmaternalmortality
Family planning to ensure that every birth is Familyplanningtoensurethateverybirthis
wanted
Skilled care by a health professional with Skilledcarebyahealthprofessionalwith
midwiferyskillsforeverypregnantwoman
d i d hildbi th duringpregnancyandchildbirth
EmergencyObstetricCare(EmOC)toensure
timelyaccesstocareforwomenexperiencing
complications.
UNFPA,2009
p
AffandiB.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta,22Sept.2010
PERENCANAANKELUARGA
1. Seorangwanitatelahdapatmelahirkan,segera
setelahiamendapathaidyangpertama
( h ) (menarche)
2. Kesuburanseorangwanitaakanterusberlangsung,
sampai mati haid (menopause) sampaimatihaid(menopause)
3. Kehamilandankelahiranyangterbaik,artinya
risikopalingrendahuntukibudananak,adalah p g ,
antara2035tahun
4. Persalinanpertamadankeduapalingrendah
i ik risikonya
5. Jarakantaraduakelahiransebaiknya24tahun
Affandi, 1984
Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010
POLA PERENCANAAN KELUARGA POLAPERENCANAANKELUARGA
Fase Fase
Fase Fase Fase Fase
M d M d M j k M j k Menunda Menunda
Kehamilan Kehamilan
Menjarangkan Menjarangkan
Kehamilan Kehamilan
Tidak Tidak Hamil Hamil
lagi lagi
2 2 44
20 20 35 35
Affandi, 1984
Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010
PEMILIHANKONTRASEPSIRASIONAL
Fase Fase Fase Fase
Fas Fasee
menunda menunda
Kehamilan Kehamilan
Menjarangkan Menjarangkan
Kehamilan Kehamilan
Tidak Tidak hamil hamil
lagi lagi
2 2 44
Pil Pil
IUD IUD
IUD IUD
Suntikan Suntikan
IUD IUD
Suntikan Suntikan
Steril Steril
IUD IUD
20 20
35 35
Sederhana Sederhana
Suntikan Suntikan
Implant Implant
Suntikan Suntikan
MiniPil MiniPil
Pil Pil
Implant Implant
Sederhana Sederhana
Suntikan Suntikan
MiniPil MiniPil
Pil Pil
Implant Implant
Sederhana Sederhana
Implant Implant
Suntikan Suntikan
Sederhana Sederhana
Pil Pil
Sederhana Sederhana
Sederhana Sederhana
Steril Steril
Affandi, 1984
Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010
CONTRACEPTIVEPREVALENCE
INDONESIA 19702007 INDONESIA,1970 2007
70
80
61 4 %
60
70
48 %
57 %
60 %
61.4 %
40
50
20
30
26 %
10
20
5 % (?)
0
1970 1980 1987 1997 2002 2007
Affandi B.UnsafeAbortion:IndonesianExperience.1stInternationalCongressonWomenHealth&UnsafeAbortion,Bangkok,Thailand,2023January2010
CurrentContraceptiveUsers
Indonesia March 2006 Indonesia,March2006
METHODS USERS % METHODS USERS %
INJECTABLES 9 743 550 35 2 INJECTABLES 9,743,550 35.2
PILLs 7,796,474 28.1
IUDs 5 218 196 18 8 IUDs 5,218,196 18.8
IMPLANTABLES 3,156,705 11.4
STERILIZATION 1 515 406 5 5 STERILIZATION 1,515,406 5.5
OTHERS 278,473 1.0
TOTAL 27 708 804 100 0 TOTAL 27,708,804 100.0
BKKBN, 2007
Affandi B.UnsafeAbortion:IndonesianExperience.1stInternationalCongressonWomenHealth&UnsafeAbortion,Bangkok,Thailand ,2023January2010
BIRTHRATE BIRTHRATE
STILL HIGH ! ! ! STILL HIGH ! ! !
4 5 5 Million/year 4.5 5 Million/year
Affandi B.UnsafeAbortion:IndonesianExperience.1stInternationalCongressonWomenHealth&UnsafeAbortion,Bangkok,Thailand ,2023January2010
FAKTA FAKTA
1.PascasalinOVULASIdapat p
terjadidalamwaktu21hari
2.PascakeguguranOVULASI
dapatTERJADIdalamwaktu
11hari
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.Theuseofprogestogenonlymethodsinthefirst6
weekspostpartumdoesnotappeartohaveanadverse p p pp
effectonbreastmilkvolume(GradeB).
13.Theuseofprogestogenonlymethodswhen
b f di id 99% ffi (G d ) breastfeedingprovidesover99%efficacy(GradeB).
14.Theproblematicbleedingassociatedwithprogestogen
only methods appears to be more acceptable than that onlymethodsappearstobemoreacceptablethanthat
experiencedbywomenwhoarenotbreastfeeding
(GradeB).
Aftercounselling,breastfeedingwomenmaychooseto
useaprogestogenonlymethodofcontraceptionbefore
6 weeks postpartum if other contraceptive methods are 6weekspostpartumifothercontraceptivemethodsare
unacceptable.
Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30:181189
Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010
17.DMPAusebefore6weekspostpartumis
not usually recommended (Grade C) notusuallyrecommended(GradeC).
18.TroublesomebleedingcanoccurwithDMPA
useintheearlypostpartumperiod(GradeC).
DMPAwillnotrequiretheinjectionuntilDay
21postpartum,butiftheriskofimmediate
subsequentpregnancyishighitmaybegiven
beforethistime.
Contraceptive choices for breastfeeding women. Journal of Family Planning and Reproductive Health Care 2004; 30: 181189 Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30:181 189
Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010
Breastfeedingwomenmaychooseto
useaprogestogenonlyimplantbefore
Day 28 without the need for Day28withouttheneedfor
additionalcontraceptiveprotection.
IMPLANTwillnotberequireduntil
Day 28 postpartum, but if the risk of Day28postpartum,butiftheriskof
immediatesubsequentpregnancyis
high it ma be gi en before this time highitmaybegivenbeforethistime.
C i h i f b f di J l f il l i d d i H l h C 2004 30 181 189 Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30:181189
Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010
Statement,WHOGeneva,22Oct.2008:
Progestinonlycontraceptiveuseduringlactation
1. Useofprogestinonlymethods,withtheexceptionofthe
l l b ll d d f levonorgestrel bearingIUD,isnotusuallyrecommendedfor
womenwhoarelessthan6weekspostpartumandbreastfeeding,
unlessothermoreappropriatemethodsareunavailableor
unacceptable.
2. Beyond6weekspostpartum,thereisnorestrictionfortheuseof
progestin only contraceptive methods among breastfeeding progestinonlycontraceptivemethodsamongbreastfeeding
women.
3. ThelevonorgestrelbearingIUDisnotusuallyrecommendedfor
th fi t 4 t t k l th i t thefirst4postpartumweeks,unlessothermoreappropriate
methodsareunavailableorunacceptable.Beyond4weeks
postpartum,thereisnorestrictiononitsuse.
Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010
IUDCu
AffandiB.PerkembanganKontrasepsi,TeknikPenapisandanKBPostpartum,BPMPPKB,Balikpapan,24Juni2010
ThepostpartuminsertionofIUDshas
b f d l d anumberofadvantages,including
ease of insertion, availability of skilled easeofinsertion,availabilityofskilled
personnelandappropriate
f ili i d i f h facilities,andconvenienceforthe
woman.
Practitionershavebeenconcerned
aboutthepossibilityofhigher
expulsion, infection and perforation
www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm
expulsion,infectionandperforation
rates. Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010
Postplacental (preferably within Postplacental (preferablywithin
10minutesafterexpulsionofthe
placenta)andimmediate
postpartum insertion during the postpartuminsertionduringthe
firstweekafterdelivery(but
preferablywithin48hours)are
convenient effective and safe convenienteffectiveandsafe
timestoinsertcopperIUDs.
Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010
{ManagingContraception20052007,page92}
Teknik Pemasangan AKDR
Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010
Fundal placement
ThewaytheIUDisinsertedismoreimportantthan
thedesignofthedevice.
Diff i IUD l i b DifferencesinIUDexpulsionratesbetweencenters
participatinginthetrialsweregenerallygreaterthan
expulsion rates for different IUDs; expulsionratesfordifferentIUDs;
FHIdatashowthatemphasisneedstobegiventothe
fundal placement of the device. fundal placementofthedevice.
Theprovidershouldbeabletofeelthedevicethrough
theabdominalanduterinewallsatthetimeof
insertion.
Retrainingisnecessaryforthoseindividualswho
reporthighexpulsionrates
www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm
Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010
Teknik Pemasangan AKDR
Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010
Allowthewomantorest.
Besureshegetscomplete
t t postpartumcare.
P id i i Providepostinsertion
instructions instructions.
Expulsion Expulsion
Afterbirth,astheuterusreturnstonormal
size(involution),uterinecontractionsexpel
retainedplacentalandbloodclotsandmay p y
haveasimilareffectonanyforeignbody
introduced into the uterus. introducedintotheuterus.
IUDsinsertedwithin10minutesofplacenta
l i h h l l i i k expulsionhaveamuchlowerexpulsionrisk
thanthoseinsertedlaterinthepostpartum
period.
www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm
Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010
BarrierThatPreventContraceptive
SSuccess
Barriertoeffectivefamily
planning services
Outcomewhenbarrier
planningservices
areovercome
Accesstoservice
Contraceptive
f preference
Quality services Qualityservices
MAQExchangecurriculum(Online)MaximizingAccessandQualityinitiative,WashingtonDC,2001
Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010
Medical barriers Medicalbarriers
weredefinedas "practices,derivedat p ,
leastpartlyfromamedical
rationale,thatresultina
scientifically unjustifiable scientificallyunjustifiable
impedimentto,ordenialof, p , ,
contraception"
SheltonJD,etal.Lancet,1992;340:13341335
Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010
MedicalBarriersthatrestrict
f accesstofamilyplanningservices
1 Provider bias When the provider is 1. Providerbias Whentheprovideris
fororagainstaspecificmethod
2 O l t i ti li ibilit it i 2. Overlyrestrictiveeligibilitycriteria
Whocangetwhatcontraceptive
3. Unnecessaryprocesshurdles
Requirementsthat,fromtheuser's
pointofview,makeitdifficultto
obtainacontraceptive
SheltonJD,etal.Lancet,1992;340:13341335
Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010
4.Inappropriatecontraindications
Medical conditions that restrict the Medicalconditionsthatrestrictthe
useofsomecontraceptives
5 Overly restrictive regulations 5.Overlyrestrictiveregulations
Nationallawsandclinicorhospital
regulations regulations
6.Providerlimitation Whocan
provide what method providewhatmethod
7.Inappropriatemanagementofside
effects Actions taken by the effects Actionstakenbythe
providertohelptheusertoleratea
contraceptive method
Shelton JD et al Lancet 1992;340:13341335
contraceptivemethod
Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010
SheltonJD,etal.Lancet,1992;340:1334 1335
Checklists
ReduceMedicalBarriers
Medicalbarriersoftenpreventclientsfromusingtheir
desiredmethodoffamilyplanning.
Thepregnancy,COC,DMPA,andIUDchecklistscan
effectivelyincreaseaccesstofamilyplanningwhile
helping ensure client safety helpingensureclientsafety.
Introductionofchecklistsintoservicedeliverysettings
shouldincludecarefultrainingonhowtousethe g
checklistsaswellasthemedicaleligibilitycriteriaon
whichtheyarebased.
Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010
Knowingisnot
enough,wemustapply
Willingisnotenough,we
t d mustdo
G h Goethe
Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010

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