IUD Clinical Pearls

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

Instead of admonishing your patient to “just relax” consider saying:
- “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 choose to refer to a tenaculum, rather than "grasp" or "clamp," consider "placing a holder" or "holding"
When describing potential pain with sounding and passage of the IUD into the uterus consider referring to it as “like a strong menstrual cramp”

Visualization

Position the patient far down on the exam table
Ensure adequate lighting (a lamp or plastic lighted speculum)
Use the right sized 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 person with obesity, consider:
- a stronger wider metal speculum
- have the patient put their fists beneath their sacrum or hold their knees in a knee to chest position

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
Move slowly to help prevent momentum and pain
Pause once you have passed through the internal os and then slowly, carefully proceed to the fundus
Touch the fundus once. Repeated tapping is uncomfortable for the patient
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.
- Use os finders

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 or with a simulator just prior to actual placement
Use no-touch technique or non-contaminated sterile gloves to load the device

Note these are not placement instructions they are suggestions to avoid common pitfalls

Copper T IUD

Make sure the white rod stays in contact with the bottom of the IUD at all times “Kissing the butt”
Pause for a second after passing through the internal os before slowly advancing the inserter to the fundus
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

Bayer LNG IUCs

Hold the thumb or index finger on the slider during the entire procedure
You can not re-load the Bayer IUDs
Stop when the flange is 1.5-2cm from the external os
Wait a full 10 seconds after releasing the arms
Keep your thumb or forefinger firmly on the slider as you proceed slowly and carefully to the fundus
Check each position visually to be sure the slider lines up correctly
Once you either meet fundal resistance or once the flange is at the external os: stop

Liletta with the single-handed inserter

Align the arms horizontally prior to pulling the arms of the IUD into the insertion tube—the arms are not stabilized within the insertion tube so you must hold them against the inside the sterile packaging to keep them in the horizontal position
Firmly hold the blue slider in the forward-most position when you pull the strings towards you to load the arms into the insertion tube
You can reload if necessary
Once the IUD is loaded into the inserter maintain pressure on the sliders with your thumb or index finger during the entire placement procedure
Stop when the flange is 1.5-2cm from the external os
Gently bring the blue slider down towards the green slider for the first step. This releases the arms
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

Cutting strings (all IUDs)

You can use the insertion tube as a guide to cut the strings once the tube is withdrawn from the uterus but while still in the vagina
Cut the strings approximately 3-4 cm from the external os; leave a string length that is adequate to cover the distance from the external 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 accidentally 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