GUIDELINES FOR IUD INSERTION FOR MEDICAL OFFICERS
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GUIDELINES
FOR
IUD INSERTION
FOR
MEDICAL OFFICERS - extracted text
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GUIDELINES
FOR
IUD INSERTION
FOR
MEDICAL OFFICERS
Issued by
Technical Operations Division
Ministry of Health & Family Welfare
(Department of Family Welfare)
Government of India
Nirman Bhavan, New Delhi-11.
PREFACE
This booklet on ‘Guidelines for IUD insertion for the Medical Officers’ will serve as a
basic document for the trainers as well as reference material for trainees.
It has been well illustrated. It includes guidelines for sterilisation of equipment, follow
up, treatment of complications etc.
I hope this booklet will be of use to the trainers as well as the trainees.
Sd./-
USHA VOHRA
Secretary(FW)
New Delhi-110011
Dated: 31st March, 1994
ACKNOWLEDGEMENT
The ‘Guidelines for IUD insertion’ have been framed to assist in training the medical
officers, female health assistants and health workers in IUD insertion and in their day to day
work.
I thank the gynaecologists and obstetricians who have participated and helped in the
formulation of these guidelines.
My thanks are also due to Dr. K.N. Srivastava, Dr. V.K. Behal and Dr. S. Sarkar,
Assistant Commissioners of this Ministry and to Shri B.L. Manocha, my Private Secretary, who
have rendered all help and assistance in formulating these guidelines.
I am also thankful to Prof. S.K. Guha, Director and Dr. G.L. Jain, Principal Scientific
Officer of the Bio-Medical Engineering Unit, IIT and Shri Rajiv Gupta of Computer Section of
IIT for assistance in this regard.
Sd./Dr.(Mrs.) K. Kehar
Deputy Commissioner (TO)
New Delhi-110011
Dated:
1.
OBJECTIVE
The objective of this module is to enable you to have necessary knowledge and technical
skills in IUD (Cu T 200 B) insertion.
2.
INTRODUCTION - WHAT IS COPPER T
Copper T 200 B is a “T” shaped plastic device made of polyethylene and impregnated
with Barium Sulphate to make it visible in an X Ray. It is 3.6 cm in length and 3.2 cm
in width. Copper is wound round its vertical stem. The surface area of copper wire is
200 Sq. Mm and a nylon thread is attached to the lower end of the vertical stem. Figure
1 shows Cu T 200 B with insertion tube, flange and plunger.
Cu-T
Plun ger
flange
Insertion tube
Fig. 1. Copper T 200 B with insertion tube, Flange and plunger.
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It is a safe and reliable method of contraception and it offers several advantages,
namely i)
One time insertion procedure
ii)
It is readily reversible
iii)
It is coitus independent
iv)
Effective for 3 years
v)
It is cost effective
Despite all this, it is disappointing to note that the continuation rate of less than 30% at
the end of one year has not improved over the years. This may be due to improper
selection of cases who may develop side effects and demand its removal. It may also be
due to poor counselling and motivation by the medical and paramedical staff.
In view of this and the above mentioned advantages it is necessary to increase the
acceptability and continuation rates of this method especially for spacing of children.
3.
COUNSELLING
The client should be counselled in a simple language which she understands and
following information should be provided to her:i)
It is one of the most effective and reversible methods for family planning.
ii)
It is ideal for spacing of children as it does not affect the quality of milk in
lactating mothers. Spacing is important for health of the mother.and children.
iii)
It can be easily removed when desired.
iv)
It provides continuous protection for 3 years.
v)
Its insertion is a simple procedure and the optimal time of insertion is during the
last two days of the menstrual period and immediately following MTP but can be
inserted within seven to ten days after last menstrual period.
vi)
It does not affect sexual pleasure, performance nor hurt the husband.
vii)
IUD does not affect a women’s chance of becoming pregnant after its removal.
viii)
IUD does not cause cancer.
ix)
It has 1-3% chance of failure.
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SPACING OF CHILDREN ENSURES HEALTH OF THE MOTHER,
ENABLES HER TO CARE AND BREAST FEED HER CHILD AND
PREVENTS LOW BIRTH WEIGHT OF THE NEXT INFANT
4.
MECHANISM OF ACTION
Cu T 200 B exerts multiple anti-fertility effects on the reproductive tract i)
It inhibits sperm migration in the upper genital tract.
ii)
It stimulates foreign body reaction in the endometrium and releases macrophages
which prevent implantation.
iii)
Copper also causes changes in the endometrial cells which prevents implantation
of fertilized eggs.
5.
GUIDELINES FOR IUD INSERTION
5.1
Selection of cases for IUD
Indications
i)
Any women, in the reproductive age group, who would want to space or avoid
pregnancy;
ii)
It should be promoted in couples having two children when the age of the
younger child is less than five years.
5.1.1
CONTRA INDICATIONS
a)
Absolute
IUD should not be inserted in the following conditions:i)
Pregnancy;
ii)
Anaemia with haemoglobin less than 8 gm%
iii)
Excessive or irregular menstrual bleeding;
iv)
Active genital tract infection e.g. Vaginitis, Cervicitis, Pelvic inflammatory
diseases, Septic abortion, Cervical erosion.
v)
Enlarged uterus;
vi)
Previous history of ectopic pregnancy;
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b)
Relative
i)
Previous history of caesarean section;
ii)
Medical disorders like heart disease, diabetes, etc. In both these conditions refer to
specialists.
5.2
Timing of insertion
i)
The safest and optimum time for insertion is the last two days of the menstruation
but can be inserted within 7-10 days of the LMP.
5.3
ii)
Immediately after MTP is performed.
iii)
After the first period following spontaneous abortion.
iv)
In lactating mothers after excluding pregnancy.
Venue of insertion
IUD should be inserted only at the sub-centre, primary health centre, community health
centre or hospital.
IUD MUST NOT BE INSERTED AT RESIDENCE OF THE WOMAN
5.4
Equipment and Supplies required for IUD insertion.
Copper T insertion kit containing the following instruments
i)
Copper T with inserter and plunger in a presterilised packet.
ii)
Sim’s/Cusco’s speculum
iii)
Anterior vaginal wall retractor
iv)
Allis forceps/volsellum (small toothed)
v)
Sponge holding forceps
vi)
Uterine Sound
vii)
Scissors
viii)
Toothed forceps
ix)
Cheatle’s Forceps in jar containing an antiseptic solution.
x)
Gloves
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5.5
xi)
Sterilised cotton swabs and swab stick in ajar with lid.
xii)
Kidney tray for keeping used instruments
xiii)
Bowl for antiseptic solution
xiv)
Antiseptic solution (any one of the following):a)
Savlon
1%
b)
Cetavlon
2%
Sterilisation of instruments
Cu T is available in a pre-sterilised pack.
Instruments and gloves.
The Medical Officer must instruct the LHV/ANM to ensure that all instruments/gloves
are preferably autoclaved. In case autoclaving is not possible she must see that the
instruments are fully immersed in water and boil for at least 20 minutes.
IN ORDER TO PREVENT ANY INFECTION IT IS ESSENTIAL, THAT
INSTRUMENTS ARE AUTOCLAVED OR SHOULD BE FULLY IMMERSED
IN WATER AND BOIL FOR ATLEAST 20 MINUTES AFTER THE WATER
STARTS BOILING
6.
EXAMINATION OF CLIENT
6.1
History taking
History should be taken very carefully and should include age of the client, medical,
surgical and gynaecological history. Last menstrual period must invariably be noted.
6.2
Menstrual and obstetric history need to be carefully taken.
Periods - regular or irregular, flow excessive or normal.
Date of last menstrual period.
No. of deliveries and abortions, MTP/ previous history of caesarian
section/ectopic pregnancy.
Recent history of Post Partum/Post Abortal infections.
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6.3
General Examination
Particular attention has to be paid to detect whether the client has severe anaemia.
diabetes or heart disease.
6.4
Preparation of client
i)
Ask the woman to empty her bladder and lie down on the table on her back with
knees flexed.
ii)
Protect her privacy.
iii)
Wash and scrub your hands. Wear sterile gloves taking care that the outer side
of gloves does not get contaminated.
iv)
Clean the vulva with antiseptic solution.
v)
Conduct bimanual examination as follows:a)
Introduce two fingers of the gloved hand into the vagina and feel for the
cervix. Place one finger on either side of the cervix. Move the cervix
from side to side with the two fingers. If this produces pain, do not insert
the IUD.
b)
Put both the examining fingers in front of the cervix and gently bring
them towards the public bone. Meanwhile the other hand is placed over
the lower abdomen above the public hone. Gently try to bring together
the finger tips of both the hands. If the uterus is anteverted i.e. lies to the
front, the entire uterus will be felt with both the hands as show in figure
2.
Fig. 2 Anteverted uterus
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c)
Now put the fingers behind the cervix and repeat the procedure as shown
in figure 3. If the uterus is retroverted, that is, lies to the back only the
cervix will be felt between both the hands.
In case the uterus is enlarged or irregular in shape, there may be
pregnancy or tumor; do not insert an IUD and refer the client to specialist
for advice. If the uterus is normal in size change the gloves and proceed
for inserting IUD.
Fig. 3
Retroverted uterus
A speculum should be inserted sideways gently into the vagina to inspect the
cervix. In case of difficulty in inspecting the cervix, use anterious vaginal wall
retractor. Clean the cervix with antiseptic solution and then grasp the anterior lip
of the cervix with a Volsellum/Allis forceps, while telling her that she feel slight
discomfort.
Gentle traction of the cervix with the Volsellum/Allis forceps should be
maintained continuously downward and backward to correct the position of the
uterus. This will help in introduction of the uterine sound and Cu T.
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viii)
Introduce the uterine sound into the uterus gently till a slight resistance is felt
which indicates that the tip of the uterine sound has reached fundus. During the
process gentle traction of the cervix with the volsellum/Allis forceps should be
maintained.
Care should be taken to introduce the sound according to the
position of the uterus and direction of the uterine cavity as detected during the
bimanual pelvic examination.
ix)
The length of the uterus is determined and varies between 6 to 9 cm.
IUD SHOULD NOT BE INTRODUCED INTO A UTERUS WHICH IS LESS THAN
6 CM AND MORE THAN 9 CM IN LENGTH. IF THERE IS DIFFICULTY IN
INTRODUCING THE SOUND IN THE CERVICAL CANAL OR IT CAUSES
PAIN, STOP THE PROCEDURE AND REFER HER TO THE DOCTOR
Copper T is provided in a pre-sterilised package.
To minimise the chances of
contamination, do not remove the contents of the package before beginning the insertion
procedure.
IF ANY OF THE CONTENTS OF THE PACKAGE BECOME CONTAMINATED
PRIOR TO INSERTION, DISCARD THE PACKAGE AND COPPER T
7.
TECHNIQUE OF INSERTION
i)
The package should be opened approximately halfway holding the open end up
towards ceiling, by the helper, so that the contents do not fall out.
ii)
Take sterile inserted with Cu T out of the packet. Be careful not to touch the
outside of the packet after wearing the gloves.
iii)
Grasp the tips of the transverse arms lying out of the insertion tube with the
thumb and index fingers. Bend the tips downwards and push them easily into the
insertion tube, beside the vertical arm. Take care that the tips of the transverse
arms are not more than 6 mm within the tube as shown in figure 4.
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Fig.4 (a: CuT 200 B in the Inserter, b: Pressing tips of the
horizontal arms into the inserter)
iv)
Take out the plunger from the packet and introduce it from the free end of the
inserter tube (opposite Cu T) until it just touches the lower most portion of the
vertical arm of the T.
v)
Adjust the movable blue flange on the inserter tube according to the length of the
uterus so that the Cu T within the tube will just reach the upper end of the uterine
cavity.
vi)
For inserting the IUD grasp the Allis forceps/Volsellum and pull firmly
downwards and backwards to bring the uterine cavity in line.with the cervical
canal.
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vii)
The loaded inserted with the plunger is than gently introduced through the
cervical canal upwards till the blue flange comes in contact with the cervix and
resistance of the uterine fundus is felt. Be sure that the flange is in horizontal
plane as show in the figure 5.
Fig. 5 Introducing the inserter into the uterus
viii)
When the loaded inserter reaches the upper end of the uterine cavity hold the
plunger in a fixed position and withdraw the inserter tube downwards till it
touches the base of the plunger. This will release the arms of the Cu T in the
uterine cavity at the fundus. This is the pull out method to minimise perforation
as shown in figure 6.
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Fig. 6 Pull out method
ix)
Hold the inserter tube firmly, while removing the plunger. The plunger should
be removed before the inserter tube is pulled out, otherwise the threads may be
caught between the tube and plunger resulting in downward displacement of Cu
T or expulsion of Cu T from uterine cavity.
x)
Gently and slowly pull the inserter tube from the cervical canal. The strings may
be cut so that they may protrude only 2-3 cm into the vagina. At the completion
of the procedure the CuT remains within the uterine cavity. The horizontal
(transverse) arms will have slight downwards curve due.to their flexibility as
shown in figure 7.
xi)
Remove the Allis forceps/Volsellum and see if there is excessive bleeding from
the Allis forceps/Volsellum site. This can be controlled by pressing on the
bleeding point with a cotton swab using a clean sponge holding forceps until the
xii)
The client should be kept lying on the table for 5-10 minutes after insertion since
occasionally a fainting attack may occur on getting down from the table
immediately after the insertion.
Fig. 7 Cu T in uterus
8.
CARE OF INSTRUMENTS AFTER COMPLETING THE INSERTION
PROCEDURE
Health assistant (female)/health worker (female) should be instructed to take proper care
of the instruments after insertion of IUD as follows:-
i)
Instruments
With the gloves on wash all the instruments in water to remove the blood.
scrub with brush in hot soapy water to clean the joints and screws of the
instruments.
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A&ain rinse in clear water. The instruments are now ready to be sterilized
again.
ii)
Rubber Gloves
Fold the cuff of the gloves, straighten the fingers, wash, dry and apply
dusting powder.
Gloves now be reboiled/sterilised/autoclaved before being used again.
9.
POST INSERTION ADVICE TO THE CLIENT
i)
There may be slight bleeding for a week but if the bleeding is not more than
spotting or normal period she should not worry. If the bleeding is profuse or
prolonged she should come to the PHC.
ii)
If there is any pain or cramping in the abdomen for the first few days, advice
paracetamol.
iii)
She should periodically check the presence of the thread by feeling it but should
not pull the string as it might dislodge the IUD.
iv)
If the device is expelled, or thread cannot be felt or she misses her period, she
must report immediately to the PHC.
v)
There may be spotting or increased bleeding during menstrual period for tire first
3-4 months or so but they tend to become normal thereafter.
vi)
10.
In case of any problem she must report to the Medical Officer/ANM.
FOLLOW UP SCHEDULE
The under-mentioned follow-up schedule is proposed:
First Visit
Immediately after the first menstrual period
Second Visit
After one year
The medical officer should instruct the ANM that during her routine field visits she
should advice her client to come for follow-up.
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11.
SIDE EFFECTS AND COMPLICATIONS AFTER IUD INSERTION AND THEIR
MANAGEMENT
11.1
Bleeding
The most common and important side-effect of IUD insertion is bleeding per vagina :i)
Spotting in few cases.
ii)
In case of bleeding, do a PV examination to ascertain the cause which may be
a)
Infection - Treat the infection,
b)
Displacement of Copper T - remove the IUD and call for reinsertion
during the next period.
iii)
11.2
11.3
11.4
In case no cause is found, reassure the client and prescribe haematinics.
Pain
i)
In case of cramps in lower abdomen / low backache give tablet paracetamol.
ii)
In case of severe pain - Remove the IUD immediately.
Infection
i)
In case of vaginal discharge, pain and fever; give a course of antibiotics.
ii)
If there is no relief - remove the IUD.
Perforation
This is rare following Cu T insertion and is likely in the post abortive/postpartum uteri.
Cu T should not be inserted if the uterine size measures less than 6 cm. When string are
not seen and Cu T not felt on uterine sounding, perforation of uterus and intraperitoneal
migration of IUD should be suspected. The client should referred to a specialist at the
earliest.
11.5
Pregnancy
It'is a rare occurrence. In case the client becomes pregnant with Cu T in situ, she may
be offered MTP if so desired. In case she wants to continue pregnancy there is no need
to remove copper T.
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11.6
Expulsion
This occurs mostly if the Cu T is inserted in the immediate post partum period and soon
after spontaneous abortion. Avoid inserting IUD at this time. Expulsion occurs mostly
in the first year of use (6%) but the incidence decreases to 2% in the subsequent years.
11.7
Missing IUD String
When the threat can't be felt by the client and cannot be visualised by a doctor, further
investigation is necessary and the client should be referred to a specialist.
11.8
Ectopic pregnancy
Ectopic pregnancy is rare and if suspected the client should be referred to the specialist.
12.
REMOVAL OF IUD
The general steps are to be followed as at the time of insertion.
12.1
12.2
Indication for removal
i)
Moderate to severe bleeding if no relief with treatment.
ii)
Moderate to severe pain
iii)
Foul smelling vaginal discharge
iv)
Pelvic infection not responding to treatment
v)
The client's desire to have another child
vi)
Menopause
Techniques for removal of IUDs
i)
Client is positioned as for the insertion of IUD
ii)
Wear sterile gloves;
iii)
Clean the vulva and vagina with antiseptic solution (savlon 1%)
iv)
Put the sterile speculum into the vagina, locate the thread; grasp the thread close
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to the cervix with the sponge holding forceps and pull it out by steady gentle
traction.
v)
Show the IUD to the client and discard it.
vi)
If the thread is not seen, refer the client for specialist's attention.
vii)
If the removal requires more than a gentle traction, do not try to remove it but
refer her to the specialist.
13.
DO’S AND DON’TS ABOUT Cu T INSERTION
13.1
DO’s
I)
Explain the safety of the Cu T.
ii)
Explain the reversibility of Cu T.
iii)
Insert the Cu T preferably during the last two days of the menstrual period but
can be inserted within 7-10 days of L.M.P.
iv)
Use aseptic technique when inserting the Cu T.
v)
Uterine sound should be used to measure the length of the cavity of the uterus and
the blue flange must be adjusted accordingly.
vi)
Pull the plunger completely out of the inserter tube before removing the tube
from the uterus.
vii)
Tell the client what to expect and what to do in case of bleeding, pain or
expulsion of the Cu T.
viii)
Reassure the client about mild side effects.
ix)
Schedule the return visit as per point 10.
x)
Attend sympathetically to every complaint.
xi)
Maintain complete records.
xii)
Remove the Cu T after 3 years of continuous use and reinsert a new one.
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13.2
Don’ts
i)
Do not insert the Cu T if:-
a)
there is a suspicion of pregnancy.
b)
menstrual periods are excessive or very irregular.
c)
there is any sign of pelvic infection.
d)
history of septic abortion in the last 3 months.
e)
there is suspicion of tumour.
f)
the uterus is less than 6 cm and more than 9 cms.
g)
Any of the contents of the package become contaminated prior to
insertion, discard the package and use a new Copper T.
ii)
Do not keep the Cu T in the inserter for more than five minutes before insertion.
iii)
Do not push the plunger to insert the Cu T.
iv)
Do not remove the plunger and inserter tube together.
v)
Counteract false rumours.
vi)
Do not insist on retention of IUD if it is unacceptable to the client.
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