Prepared by: Mrs Raheegeh Awni 10/13/2014 Procedures for Insertion

1. Prepared by: Mrs Raheegeh Awni 10/13/2014 Procedures for Insertion

2. IUD insertion • The FDA requires that before an IUD is inserted, the woman must be given a brochure detailing the side effects and apparent risks associated with its use. • Most devices have a special inserter, usually a sterile graduated plastic tube into which the device is drawn just before insertion.

3. Timing of insertion influences the ease of placement as well as the pregnancy and expulsion rates. • Insertion near the end of normal menstruation, when the cervix is usually softer and the canal somewhat more dilated, may facilitate insertion and at the same time exclude early pregnancy.

4. Insertion, however, need not be limited to this time. • For the woman who is sure she is not pregnant and does not want to be pregnant, insertion may be carried out at any time. • Insertion immediately or very soon after delivery is followed by an unsatisfactorily high expulsion rate.

5. The recommendation has been made, therefore, to withhold insertion for at least 8 weeks to reduce expulsion as well as to minimize the risk of perforation. • In the absence of infection, the device may be inserted immediately after early abortion.

7. technique ParaGard device is as follows: • Determine whether there are contraindications, counsel the woman regarding various problems associated with device use, and obtain written consent. • Administer a nonsteroidal anti-inflammatory agent with or without codeine to allay cramps.

8. 3. Perform a pelvic examination to identify the position and size of the uterus and adnexa. If abnormalities are found, they should be evaluated, because the IUD may be contraindicated. Mucopurulent discharge and significant vaginitis should be appropriately treated and resolved before insertion.

10. 4. Make sure that the device is not loaded into its inserter tube more than 5 minutes before insertion. • The malleable arms tend to retain the "memory" of the inserter. 5.Wipe the cervix and the vaginal walls with an antiseptic solution. 6. Then grasp the cervix with a vertically oriented single-tooth tenaculum—one tooth in the canal and one atop the cervix.

11. 6. Use sterile instruments and a sterile device. The cervical canal and uterine cavity are first straightened by applying gentle traction on the tenaculum, and the uterus is sounded to identify the direction and depth of the uterine cavity.

13. 8.Adjust the device on the barrel of the inserter to the sounded depth, from external cervical os to fundus. 9. gently inserted to the fundus. After rotating the inserter so that the device is positioned high in the transverse plane of the uterus, the inserter is removed while the device is held in the fundus by the plastic rod within the inserter.

14. 10. Cut the marker tail 2 cm from the external os, remove the tenaculum, observe for bleeding from the tenaculum puncture sites, and if there is no bleeding, remove the speculum. • Advise the woman to report any adverse effects

16. Expulsion • Loss of the IUD from the uterus is most common during the first month. • The woman should be instructed to palpate the strings protruding from the cervix by either sitting on the edge of a chair or squatting down and then advancing the middle finger into the vagina until the cervix is reached.

17. The woman should be examined again in about a month, usually after menses, for appropriate placement by identifying the tail protruding from the cervix. • Barrier contraception may be desirable during this time, especially if a device has been expelled previously.

18. Lost Device • When the tail of an IUD cannot be visualized, the device may have been expelled, or it may have perforated the uterus. • In either event, pregnancy is possible. Conversely, the tail simply may be in the uterine cavity along with a normally positioned device. • Never assume that the device has been expelled unless it was seen.

19. check • When the tail is not visible and the device is not felt by gentle probing of the uterine cavity, sonography can be used to ascertain if the device is within the uterine cavity. • If these findings are negative or inconclusive, then a radiograph of the abdomen and pelvis is taken with a sound inserted into the uterine cavity.

20. Instillation of radiocontrast for hysterography may be done. • Hysteroscopy is yet another alternative. Obviously none of these maneuvers except sonography should be performed during early pregnancy.

21. An open device of inert material, such as the Lippes Loop, located outside the uterus may or may not do harm. Perforations of large and small bowel and bowel fistulas, with attendant morbidity, have been reported remote from insertion.

22. An extrauterine copper-bearing device induces an intense local inflammatory reaction and adhesions. • Chemically inert devices usually are removed easily from the peritoneal cavity by laparoscopy or colpotomy. • Copper-bearing devices are more firmly adherent, and laparotomy may be necessary.

23. device may penetrate the uterine wall to varying degrees. • Part of the device may extend into the peritoneal cavity, or part may remain firmly fixed in the myometrium. • A device also may penetrate into the cervix and actually protrude into the vagina.

24. Replacement • The ParaGard device is approved for 10 years of continuous use and the Mirena device for 5 years.

25. Thank you