Clinical Pearls and Common Pitfalls for IUD Placement

 

1. Use care with language: give anticipatory statements to patient as you go

  • Instead of admonishing your patient to “just relax” consider saying:

    • “Soften your muscles”

    • “Allow your head and shoulders to fall into the pillow”

    • “allow your buttocks to drop onto the table"

  • Rather than “I am cleaning” consider "you will feel me swabbing here”

  • If you refer to a tenaculum, rather than "grasp" or "clamp" consider "placing a holder" or "holding"

2. Visualization

  • Position the patient far down on the exam table

  • Ensure adequate lighting (a lamp or plastic lighted speculum)

  • Use the right size and shaped speculum:

    • if too narrow the speculum will not allow good visualization

    • increase width if needed but not length

    • open the speculum blades at the base as well as the thumb screw

  • For the obese patient consider:

    • a stronger wider metal speculum

    • have the patient hold their knees in a knee to chest position

    • lower the head of the table if necessary

    • if redundant vaginal tissue obstructs the cervix, consider placing the speculum in a condom then cut a hole at the end of the condom

3. Sound

  • Hold the sound like a pencil or a dart between the thumb and first two fingers. This gives a natural limit to how far the sound will travel which helps reduce risk of perforation

  • Initiate movement from the fingers or wrist rather than the shoulder or elbow

  • Consider use of plastic rather than metal to prevent perforation.

  • If you encounter difficulty passing through the internal os, try a small dilator or a plastic os finder to open or gently dilate the internal os before sounding

  • Maintain sterility of the tip of the sound. Do not allow it to touch the vaginal wall.

  • Bend metal sound as needed to reflect uterine flexion in the first 4-8cm rather than >9cm. Metal sounds may come out of a sterile package bent at >9cm

  • Advance with steady gentle pressure.

    • If the sound does not pass with gentle pressure, it is probably not oriented correctly.

    • Feel the smooth wall of the cervix as you advance the sound, if it gets to a gritty feeling, you may be in a cervical gland or making a false passage

    • Do not apply more pressure: gently change the angle of the sound, trying to advance more anteriorly or posteriorly, or change the direction or amount of traction on the tenaculum slightly.

  • Move slowly to help prevent momentum and pain

  • Pause once you have passed through the internal os and then intentionally proceed to the fundus

  • Touch the fundus once. Repeated tapping is uncomfortable for the patient

4. Loading and preparing the IUD:

  • Remember: different devices have different loading and deployment instructions

    • Review the instructions for the particular device you are about to place: Read or go over each step and watch a placement video and/or practice with a sample of the device in a plastic model just prior to actual placement

    • Use no-touch technique or non-contaminated sterile gloves to load the device

5A. Copper T IUD:

  • Make sure the white rod stays in contact with the bottom of the IUD at all times “Kissing the butt”

  • Do not use the white rod as a plunger as this increases risk of perforation--pull back the insertion tube to release the arms of the IUD

  • Re-advance the insertion tube after deployment to ensure correct fundal positioning.

  • Take out the white rod first and the insertion tube second

 

 5 B. Bayer LNG IUCs

  • Hold the thumb or index finger on the slider during the entire procedure

  • Bring the slider exactly to the first mark when the inserter is 1.5-2cm from the external os

  • Wait 10 seconds at the first mark

5C. Liletta with the single handed inserter

  • Align the arms horizontally prior to pulling the IUD into the insertion tube

  • Hold the thumb or index finger on the sliders during the entire procedure.

  • Firmly hold the blue slider in the forward-most position after loading

  • Reload if necessary

  • Gently bring the blue slider down towards the green slider for the first step

  • Feel the soft scooped thumb groove when the sliders meet

  • Wait 10 seconds after deploying the arms

  • Firmly bring both sliders all the way down to the bottom of the inserter and be sure you feel 2 clicks - one for each slider

  • Check the green indicator after deploying the IUD

6. Cutting strings

  • Cut the strings approximately 3-4 cm from the external os; adequate to cover the distance from the os to the bottom of the posterior cervical lip.

    • Cutting the strings < 3 cm can cause discomfort for a partner

    • Cutting the strings too long may cause discomfort for the patient

  • Use sharp scissors and be sure that both strings are cut completely. If the scissors are dull or the strings are merely bent and not cut through completely, you may accidently pull out the IUD as you pull out the scissors.

  • Long curved scissors are best

  • Cut strings straight across (perpendicular) rather than at an angle, to prevent creating a sharp tip at the end of the string which can cause discomfort for a partner

For a PDF version of this Job Tool, click here.

Los Angeles, CA
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