Intrauterine Device (IUD): Indication, Insertion Procedure, Complications by NJE

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Intrauterine Device (IUD) is a small plastic device that is inserted through the cervix and is retained in the uterus to prevent pregnancy. A string or strings hang from the IUD through the cervix and into the vagina to ensure the presence of the IUD and for removal. The IUD is a reversible form of contraception that does not offer protection against and may increase the risk of sexually transmitted diseases.

Types of IUDs include ParaGard Copper T (wrapped with copper wire and hormone-free) and Mirena. The Mirena IUD has a levonorgestrel-releasing system that thickens cervical mucus and alters the endometrial lining and decreases the ability of sperm to enter the uterus and implant.

Use a medical checklist to determine eligibility for IUD placement

Medical Eligibility Checklist for IUDs

Ask the client the following questions, before inserting an IUD:

• Do you think you are pregnant or have you had a recent pregnancy? 

• When was your last menstrual period, and was it normal? 

• Are your periods unusually heavy, or do you experience severe cramping? 

• Do you have any abnormalities of the uterus? 

• What contraception have you been using? 

• Are you having any unusual bleeding between periods? 

• Do you have multiple sexual partners, or does your partner have multiple partners? 

• Have you ever had a sexually transmitted disease? If yes, which ones? 

• Do you think you have HIV? 

• Have you ever had the pelvic inflammatory disease? 

• Have you ever had cancer of the reproductive organs? 

• Do you have any other medical conditions (i.e., bleeding disorders, anemia, steroid therapy, heart disease or murmur, hepatitis

OVERVIEW OF INTRAUTERINE DEVICE (IUD)

• Perform the following laboratory tests before insertion.

• Urine pregnancy test. 

• Chlamydia and gonorrhea culture. 

• Offer HIV screening.

• Pap smear.

POTENTIAL COMPLICATIONS  OVERVIEW OF INTRAUTERINE DEVICE (IUD)

• Increased risk of pelvic inflammatory disease. 

• Increased risk of infertility. 

• Increased risk of menorrhagia and dysmenorrhea with Copper-T-380/ParaGard. 

RATIONAL OF INTRAUTERINE DEVICE (IUD)

• To provide a reliable and reversible form of contraception. 

• To treat menorrhagia (Mirena) due to progesterone effect.

INDICATIONS OF INTRAUTERINE DEVICE (IUD)

• Contraception.

• Patient choice .

• Menorrhagia (Mirena).

• Contraindications to other forms of contraception. 

• Emergency contraception (ParaGard Copper T insertion within 5 days of unprotected intercourse).

CONTRAINDICATIONS OF INTRAUTERINE DEVICE (IUD)

• Pelvic inflammatory disease within the past 12 months or recurrent pelvic inflammatory disease (more than one episode in the past 2 years).

• Postabortal or postpartum endometritis or septic abortion in the past 3 months.

• Known or suspected untreated endocervical gonorrhea, chlamydia, or mucopurulent cervicitis.

• Undiagnosed abnormal vaginal bleeding.

• Pregnancy or suspicion of established pregnancy.

• Small uterine cavity with sounding less than 6.5 cm.

A sound is a long, narrow plastic disposable or metal calibrated rod that measures the internal length of the uterine cavity, including the length of the cervix.

• Suspected or known uterine perforation occurring with the placement of a uterine sound during the current insertion procedure.

• History of ectopic pregnancy.

• HIV/AIDS.

• History of symptomatic pelvic actinomycosis confirmed by culture (not asymptomatic colonization).

• Known or suspected allergy to copper or history of Wilson’s disease (for copper IUD only).

• Acute liver disease or tumor—benign or malignant (levonorgestrel IUD only).

• Known or suspected breast cancer (levonorgestrel IUD only).

• Known or suspected cervical and uterine cancer.

◗ Informed consent required

PROCEDURE OF INTRAUTERINE DEVICE (IUD)

Equipment FOR INTRAUTERINE DEVICE (IUD)

• IUD 

• Stabilizing rod (Mirena only) 

• Insertion tube 

• Gloves—nonsterile 

• Gloves—sterile 

• Speculum—sterile 

• Uterine sound 

• Light source 

• K-Y jelly 

• Povidone-iodine swabs 

• Large cotton-tipped applicator 

• Tenaculum 

• 1% lidocaine—optional 

• Silver nitrate—optional 

Procedure—Both ParaGard Copper T and Mirena

• Screen client for copper sensitivity, if using the ParaGard Copper T IUD. 

• Determine if the client is menstruating or in the follicular phase of the cycle. 

• Advise client to take 400 to 800 mg of ibuprofen 1 to 2 hours before appointment. 

• Have client read the medical checklist and sign consent form. 

• Put on nonsterile gloves. 

• Apply K-Y jelly to second and third digits. 

• Place client in the lithotomy position with feet in stirrups, and perform a bimanual examination to determine the size and position of the cervix and uterus. 

• Change into sterile gloves. 

• Using a sterile speculum, visualize the cervix. 

• Wash the cervix three times with povidone-iodine swabs. 

• Consider using a paracervical block (see Chapter 55 ) if the patient has never had a full-term pregnancy, has cervical stenosis, or has a history of vasovagal reactions. 

Intrauterine Device (IUD)
IMAGE CREDIT ADVANCED NURSING PRACTISE Colyar
Intrauterine Device (IUD)

Sound the uterus prior to insertion of the IUD.

• Insert a speculum into the vagina. 

• Cleanse the cervix and vagina with an antiseptic (povidone-iodine or chlorhexidine). 

• Place a tenaculum at the 2:00 and 10:00 positions.

  • If you have not used a paracervical block, alert the patient that she will feel a sharp cramp with the placement of the tenaculum. The cramping subsides within 1 minute.

• With gentle traction on the tenaculum, pull the uterus to align the uterus, cervical opening, and vaginal canal. 

• Insert the sound into the vagina and through the cervical opening. 

• Advance the sound into the uterine cavity until a slight resistance is felt.

  • Alert the client she will feel another cramp when the sound reaches the uterine fundus. 

• Remove the sound and assess the level of mucus/blood to determine the depth of the uterus.

 • Most uteri sound between 7 and 9 cm. Do not insert the IUD if the uterus sounds only to 6.5 cm or less, owing to increased expulsion rates.

Procedure PARAGARD COPPER T 

 Using sterile technique, load the IUD into insertion tube by bending the T arms of the device downward. The positioning rod is pushed back into the insertion tube when the IUD is loaded. The device has an approximate 5-minute memory to spring back into the T shape. 

• Adjust the flange on the insertion tube to the depth measured by the sound. The flange is oval-shaped, and the flattest part of the flange should be lined up with the T arms of the IUD to ensure proper positioning inside the uterus. 

• With gentle traction on the tenaculum, alert the client she will feel another uterine cramp as the IUD is being placed. Insert the IUD and insertion device into the cervix to the level of the flange, making sure the flange is in a horizontal orientation to the cervix. 

• Holding the stabilizing rod in one hand and the insertion tube in the other, withdraw the insertion tube toward you.

• Never push the stabilizing rod deeper into the uterus; this would increase the possibility of uterine perforation. 

• Withdraw the stabilizing rod with the insertion tube. 

• Cut the string of the IUD to approximately 3 cm from the cervical os. 

• Remove the tenaculum, and observe for bleeding at the tenaculum site on the cervix. 

• Apply pressure to the site with a large cotton swab. If bleeding does not cease within 1 to 2 minutes, dab the site gently with silver nitrate or Monsel ’ s solution. 

• Give a piece of the IUD string to the client for her to feel and have her check her own cervix to feel the protruding IUD string. 

Client Instructions—ParaGard Copper T 

• Give client the card to have ParaGard Copper T removed after 10 years. 

• Take 400 to 800 mg of ibuprofen for several days if needed for cramping. 

• Your menstrual periods may be heavier, or you may experience severe cramping. 

• Return to the clinic in 6 weeks for a follow-up visit to check string length and side effects. 

• Check strings after each menstrual period and call immediately if unable to locate the strings. 

• If you miss a menstrual period, perform a pregnancy test and come into the clinic immediately for removal of the IUD if you are pregnant. 

LEVONORGESTREL-RELEASING IUD (MIRENA) 

• Carefully release the threads from behind the slider so that they hang freely. 

• The slider should be in the farthest position away from you (positioned at the top of the handle nearest the IUD). 

• The arms of the system must be horizontal, before loading the system. 

• Without touching the IUD arms, load the IUD by pulling on both strings. This draws the IUD into the insertion tube, with the arms in an upward extended position. 

• When the IUD is fully loaded, the end of the rounded knobs of the arms protrude from the end of the insertion tube. 

• Fix the strings tightly in the cleft at the end of the handle. 

• Set the flange to the depth measured by the sound. 

• Advise the client she will feel a cramping sensation with the insertion of the IUD. 

• Insert the IUD by using gentle traction on the tenaculum. Stop advancing the IUD insertion tube when the flange is within 1.5 to 2 cm of the cervix.

• While holding the inserter steady, release the arms of the IUD by pulling the slider back until it reaches the horizontal line on the handle. You will feel a popping sensation as the IUD is released. 

• Push the inserter gently into the uterine cavity until the flange touches the cervix. The IUD now should be in the fundal position of the uterus. 

• Holding the inserter firmly in position, release the IUD by pulling the slider down all the way. The strings release automatically. 

• Remove the inserter from the uterus. 

• Remove the tenaculum from the cervix.

• Observe for bleeding and apply pressure at the tenaculum site with a large cotton swab. 

• If the bleeding does not cease within 1 to 2 minutes, dab the site with silver nitrate. 

• Cut the string to approximately 3 cm from the cervical os. 

• Give a piece of the IUD string to the client for her to feel, and have her check her own cervix to feel the protruding IUD string. 

Client Instructions—Levonorgestrel-Releasing IUD (Mirena) 

• Give client the card to have Mirena IUD removed after 5 years. 

• Return to the clinic in 6 weeks for a follow-up visit to check string length and side effects. 

• Check strings after each menstrual period and call immediately if you are unable to locate the strings.

 • You may have some irregular menstrual bleeding for the first 3 to 6 months after insertion.

• These symptoms decrease over time; 90% of women have lighter periods in the future, and 20% will stop menstruating altogether. 

• If you do become pregnant on the IUD, you need to have it removed as soon as possible. 

Removal of an Intrauterine Device (IUD)

Equipment 

• Gloves—nonsterile 

• Speculum 

• Light source 

• K-Y jelly 

• Pelvic ultrasound—optional 

Procedure Removal of an Intrauterine Device (IUD)

• Put on gloves. 

• With the patient in the lithotomy position, insert a speculum into the vagina. 

• Grasp the IUD strings with ring forceps, and with gentle traction withdraw the IUD from the uterus. 

• If the strings are not present, obtain a pelvic ultrasound to determine the location of the IUD.

 Client Instructions Removal of an Intrauterine Device (IUD)

• Client will feel slight cramping when the IUD is pulled. This should quickly abate.

• Only minimal bleeding should be experienced. 

• If bleeding does not stop, contact healthcare provider immediately.

 • Fertility status returns immediately on removal of the IUD. 

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