Intrauterine Device Training Presenter: LaBetta Wallenmeyer, MSN, APRN Leanna Harkess, APRN, CNP, CNM Oklahoma State Department of Health

Disclosure Statement I have no relevant financial or affiliations with commercial interests to disclose

Objectives Upon completion of this presentation, participants will be able to: List the steps in preparation and insertion of the IUDs presented Describe complications that can occur with IUD insertions/removal Demonstrate insertion and removal of the Paragard, Mirena and Liletta IUDs

Preparation Timing: Ensure the patient is not pregnant and screen for STIs if high risk Tools: Assemble items required for inseertion Technique: Perform steps of insertion

Timing Anytime during the menstrual cycle is acceptable as long as the provider can be reasonably certain that a woman is not pregnant! In 2013 the CDC came out with a MMWR entitled: U.S. Selected Practice Recommendations for Contraceptive Use, 2013 In this report they gave 6 criteria by which if any one is met, the provider can be reasonably certain the woman seeking contraception is not pregnant

Six criteria : Is < 7 days after start of a normal menses Has not had sexual intercourse since the start of last normal menses Has been correctly and consistently using a reliable method of contraception Is < days after spontaneous or induced abortion Is within 4 weeks postpartum Is fully or nearly fully breastfeeding, amenorrheic, and < 6 months postpartum

STI screening Women should be routinely screened for chlamydia and gonorrhea according to national screening guidelines (see CDC Sexually Transmitted Diseases Treatment Guidelines) Results not necessary for placement, however if having clinical S&S such as purulent cervicitis or known chlamydia/gonorrhea infection or exposure, IUD placement should be delayed.

Tools

Technique: Prior to insertion Perform a bimanual exam to assess uterine size and position Insert a speculum to visualize the cervix Cleanse the cervix with an antiseptic solution (betadine or hibiclens) Sound the Uterus

Uterine positions

Technique: Applying Tenaculum Grasp the cervix with tenaculum forceps Upper lip of cervix if anteverted or antiflexed Lower lip of cervix if retroverted or retroflexed Apply traction to stabilize and align cervical canal with uterine cavity Maintain traction throughout entire insertion procedure Sound the uterus

Technique: Sounding the Uterus

Technique: Sounding the Uterus If you encounter any difficulty or encounter cervical stenosis Use dilation to overcome resistance Allow time for spasm to pass Uterus should sound to a depth of 6 to 10 cm. Insertion of IUD into a cavity below 6 cm may increase incidence of expulsion, bleeding, pain, perforation or pregnancy

Insertion of IUD

Bayer manufactured IUDs Types of IUDs Bayer manufactured IUDs Mirena (Approved for 5 years, Levonorgestrel 52 mg) Kyleena (Approved for 5 years, Levonorgestrel 19.5 mg) Skyla (Approved for 3 years, Levonorgestrel 13.5 mg)

Allergan manufactured IUD Types of IUDs (Cont.) Allergan manufactured IUD Liletta IUD (Approved for 3 years, Levonorgestrel 52mg) Teva Manufactured IUD Paragard (Non-hormonal, Copper)

Insertion of Mirena, Kyleena and Skyla

Insertion of Liletta

Liletta IUD

Loading the Liletta Inserter

Loading the Liletta Inserter (Cont.)

Loading the Liletta Inserter (Cont.)

Inserting Liletta into Uterus

Inserting Liletta into Uterus (cont.)

Releasing the Liletta

Releasing the Liletta (cont.)

Cutting the Threads

Insertion of Paragard

Insertion of Paragard

Insertion of Paragard Do not bend the arms of the Paragard earlier than 5 minutes before it is to be placed in the uterus. Remember to use aseptic technique when handling the Paragard and the part of the insertion tube that will enter the uterus. My personal preference is to prepare the Paragard with sterile gloves opposed to trying to manage within the package.

Loading Paragard into Inserter

Inserting Paragard

Inserting Paragard

Inserting Paragard

Inserting Paragard

Removing Paragard Inserter

Paragard Insertion Tips

Complications and Considerations

Rotation of the IUD It is important to check the rotation of the IUD prior to inserting. Make sure the IUD arms are parallel to the uterus and have no tilt when inserting into insertion applicator

Uterine Perforation Always maintain gentle traction on the tenaculum when inserting sound or IUD into the uterine cavity Traction will straighten the uterus and remove flexion Be careful when inserting sound not to push too fast or hard (stop when you feel resistance)

Pain with Insertion Normal for client to experience severe cramping during both the sounding of uterus and insertion of IUD Consider having client take an NSAID prior to procedure Vasovagal Reaction including Syncope can occur Have the client remain supine until she stops having syncopal symptoms Have the client sit up gradually and continue to sit upright for a while before attempting to stand

Potential for incorrect insertion Always palpate the cervix following IUD insertion to check strings and feel for plastic Check placement with transvaginal ultrasound if incorrect insertion is suspected Consult a Gynecologist if perforation or other issues are a clinical concern following placement (examples would be exceptional pain or bleeding during or after insertion)

IUD Follow UP 4-6 weeks after insertion IF client is unable to feel strings OR is having discomfort or other problems with IUD Once a year Anytime client is having problems/pain with her IUD or is not able to feel her strings

IUD Removal IUDs are all removed the same way Items you need for removal include Speculum Gloves Ring forceps

Removal Insert speculum to visualize the cervix Strings should be visible If strings are not visible, try using a endocervical brush to disengage the strings from the cervical canal Grasp the strings with the ring forceps Use gentle, steady traction on the IUD strings After removal, ensure that the IUD is intact

Use of Endocervial Brush

Complications of Removal If IUD threads are not visible and can not be disengaged with the endocervical brush, refer to Gynecologist If unable to remove the IUD with steady firm traction, could indicate IUD is imbedded in uterine wall, refer to Gynecologist IUD not removed intact, refer to Gynecologist

References Centers for Disease Control and Prevention (2016). U.S. selected practice recommendations for contraceptive use, 2016: MMWR 2016:65. Retrieved from http://www.cdc.gov/mmwr/volumes/65/rr/rr6504a1.htm Centers for Disease Control and Prevention (2016). U.S. medical eligibility criteria for contraceptive use, 2016. MMWR 2016:59. Retrieved from http://www.cdc.gov/mmwr/volumes/65/rr/rr6503a1.htm https://hcp.mirena-us.com/index.php https://hcp.kyleena-us.com/

References Cont. http://hcp.skyla-us.com/index.php https://www.lilettahcp.com/ http://hcp.paragard.com/

Pictures https://www.netterimages.com/uterus-variations-in-position-unlabeled-gynecology-frank-h-netter-3060.html •https://healthmanagement.org/products/view/plastic-cervical-dilator-g91-445-stingray-surgical-products •http://www.viviennebalonwu.com/2010/11/safe-sex-iud-doesnt-increase-infection.html •https://www.publichealthwatchdog.com/iuds-pushed-for-teens-despite-risk-of-uterine-wall-perforation-other-serious-complications/ •https://safesymptoms.com/anteverted-uterus/