STANDARD UNIVERSAL PRECAUTIONS OF: Infection prevention: 1. Hand washing: Wash hands with soap and water or an appropriate alcohol-based hand rub before performing immediate PPIUCD insertions and after the procedure.
Hands should be dried with a clean personal towel or air-dried. Towel should not be shared.
2. Self-protection such as wearing gloves and physical barrier: Wear gloves on both hands before touching anything such as lower genital tract skin and mucous membranes, blood or other body fluids such as urine or faeces, soiled instruments, and contaminated waste materials or while performing invasive procedures.
Use protective goggles, face masks and aprons if splashes and spills of blood or other body fluids are possible (e.g. during the procedure itself or when cleaning instruments and other items).
3. Safe work practices and maintaining asepsis: Before IUCD insertion, apply a water-based antiseptic to the cervix and vagina two or more times.
Use aseptic/no-touch technique during every immediate PPIUCD insertion.
Use only sterile IUCDs that are in intact and undamaged sterile packages and are not beyond expiry date.
Sterile/HLD (High Level Disinfection) gloves or instruments should be used throughout the procedure.
The IUCD should not touch the perineum, the vaginal walls or any other non-sterile surface that may contaminate it before placement in the uterus.
Ideally the IUCD should not be passed through the cervical os more than once.
Specific Infection Prevention Steps for the Immediate PPIUCD Procedure: Before insertion: Ensure that HLD/sterilized instruments and supplies are available and ready for use. Open all required HLD/sterile instruments and supplies onto a dry, HLD/sterile surface. IUCD should be placed close by in its sterile unopened packet.
Ensure that the IUCD package is unopened and undamaged and check the expiry date.
For immediate postpartum insertion within 48 hours of delivery, wash or have the woman wash the perineal area with water before preparing the vagina and cervix. If immediately after delivery, in the absence of frank fecal contamination, cleaning the perineal area gently with a sterile gauze or towel is sufficient.
Hand washing and wearing of gloves should be done appropriately.
Using sterile cotton swab and a sterile sponge/ring forceps ensure that the cervix is cleaned with a water based antiseptic solution two times.
During insertion (as applicable): Sterile or HLD gloves are used to stabilize the IUCD in its packet.
Throughout the procedure, use "no-touch" technique to reduce the risk of infection.
STEPS FOR INSERTION OF IUCD USING INSERTER: Steps of Postplacental/Morning After Delivery (MAD): Insertion by using PPIUCD Inserter: The steps described succeedingly follow the Clinical Skills Checklist for Postplacental/MAD Insertion of the IUCD using Inserter:
1. 1st assessment-Check woman's record to ensure that the woman is an appropriate client for IUCD and was given written consent. Note time of injection Oxytocine given to client.
2nd assessment Using the Job-aid for PPIUCD preinsertion screening of client, rule out conditions which prevent insertion (exclusion criteria) of IUCD like: Rupture of membranes for more than 18 hours; Chorioamnionitis; Unresolved postpartum hemorrhage.
2. Confirm that HLD/sterile instruments, PPIUD inserter, supplies and light source are available in the labor room for immediate postplacental/MAD insertion.
Talk to the woman with kindness and respect. Confirm with the woman whether IUCD is still wanted.
Explain that the IUCD will be inserted following delivery of the placenta. Answer any questions the woman might have.
3. Perform hand hygiene and put on HLD or sterile gloves.
4. Arrange instruments and supplies on sterile tray or draped area.
5. Inspect perineum, labia and vaginal walls for lacerations. If lacerations are not bleeding heavily, insert the IUCD and repair if needed.
6. Gently visualize cervix by inserting a Sims speculum in the vagina and depressing the posterior wall of the vagina.
7. Gently clean cervix with antiseptic solution two times using two separate cotton swabs with Povidone Iodine or Chlorhexidine. Wait for two minutes to allow the antiseptic to work.
8. Gently grasp the anterior lip of the cervix with the ring forceps up to the first lock.
(The same ring forceps that was used to clean the cervix can be used).
9. Open the inserter pack from lower end. Grasp the Insertion tube at the lower end of the tube.
10. Apply gentle traction on the anterior lip of the cervix using the ring forceps and insert IUCD into lower uterine cavity. Avoid touching the walls of vagina. The provider passes the PPIUCD inserter carefully into the lower uterine cavity.
11. Once the PPIUCD inserter is in the lower uterine cavity, lower the ring forceps that is holding the anterior lip of the cervix. Move the left hand to the woman's abdomen and push the entire uterus superiorly (upward). This is to straighten out the angle between the vagina and the uterus, so that the inserter can easily move upward toward the uterine fundus.
12. Gently move PPIUCD inserter upward towards the fundus following the curve of the uterine cavity. The provider should take care not to apply excessive force. If the uterus is not pushed upward, the angle between the cervix and the uterus may not allow the inserter to advance smoothly.
13. Confirm that the IUCD has reached the fundus and when it reaches the uterine fundus, the provider will feel resistance and will also feel the thrust of the inserter at the fundus of the uterus with her left hand which is placed on the abdomen.
14. Move blue flange/depth gauge upward and release thread of IUCD. Release the IUCD at the fundus. Stabilize the uterus until the inserter is completely out of the uterus. Partially withdraw the insertion tube from the cervical canal until the string can be seen extending from the cervical os.
15. Use HLD or sterile scissors to cut the IUD string/thread to <1 cm length and then remove the insertion tube and place in 0.5% chlorine solution for 10 mins for decontamination.
16. Examine the cervix to ensure there is no bleeding. It is important to check that the IUCD limb is not visible at the cervical os. If it is visible, then the IUCD has not been adequately placed at the fundus and the chance of spontaneous expulsion is higher. If it appears that the IUCD is not placed high enough, the provider can remove the same. Note-Fundal placement should be rechecked by doing USG immediately after insertion to ensure horizontal limb is not below 2.5 cm.
17. Remove all instruments used and place them in 0.5% chlorine solution for 10 minutes for decontamination.
18. Allow the woman to rest for few minutes. Support the initiation of routine postpartum care, including immediate breastfeeding. The woman should rest on the table for few minutes following the insertion procedure. The provider should reassure the woman that the insertion was done smoothly and that there is now an effective, safe and reliable long term spacing method of contraception.
19. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out and disposing of them. Perform hand hygiene. All infection prevention steps should be followed as per standard infection prevention procedures and facility protocol for waste management.
20. Provide the woman with post insertion instructions. Provide IUCD card showing type of IUCD and date of insertion. Inform the woman about the IUCD side effects and normal postpartum symptoms. Tell the woman when to return for IUCD follow-up/PNC (Postnatal care)/newborn checkup. Emphasize that the woman should come back any time there is a concern or experience of warning signs. Inform the woman about the warning signs regarding IUCD. Explain how to check for expulsion and what to do in case of expulsion. Assure the woman that the IUCD will not affect breastfeeding and breast milk. Ensure that the woman understands the post-insertion instructions. Give written post-insertion instructions. Inform the woman that follow up is scheduled 4-6 weeks. These instructions should be reinforced again by the staff of the postpartum unit and repeated to the woman, and if possible with the family.
21. Record information regarding the PPIUCD insertion in the woman's chart or record and proforma and in the Immediate PPIUCD register kept at the facility.
Tips for Reducing Spontaneous Expulsion: Right technique: Elevate the uterus. Place IUCD at the fundus. Sweep instrument to the side of the uterine cavity. Stabilize the uterus until the inserter is completely out of the uterus.
Right instrument: Use an insertion instrument (inserter) that is long enough to reach the fundus.
Right time: Postplacental and intracesarean insertions have lowest expulsion rates.
Post-Insertion Care for Immediate PPIUCD Immediate post-insertion care at the health facility: The client should be advised to report any increase in more than expected vaginal bleeding or uterine cramping.
Vaginal hemorrhage related to uterine atony should be managed as per standard procedure with uterine massage and uterotonics as necessary (Note, the immediate PPIUCD does not increase the risk of uterine atony).
If severe uterine cramping occurs and persists after immediate PPIUCD insertion, a speculum or bimanual exam should be performed to check for partial or complete expulsion.
If the woman complains of fever, a full clinical evaluation needs to be done and in the presence of endometritis, an accepted antibiotic regimen should be used for treatment.
See the following for management of infection in association with the immediate PPIUCD.
Post-insertion Instructions to the woman: There may be vaginal bleeding or spotting or cramping for initial few days/weeks after insertion. These symptoms are normally experienced by the woman in the postpartum period. Take Ibuprofen, Paracetamol or other pain reliever as needed.
Spontaneous expulsion can happen in some cases, and is most likely to occur during the first three months postpartum. Be observant whether the IUCD comes out. If it does, come to the health facility immediately for reinsertion or another contraceptive.
At six weeks postpartum, the IUCD strings can be felt by some women. It is not necessary to check the strings. The woman may come to the health facility if there is any concern about the strings.
Remember IUCD does not protect against STls and HIV. Resume intercourse at any time the woman feels ready.
Return for removal of the IUCD at any time the woman wants a pregnancy and will have almost immediate return of fertility.
BEFORE DISCHARGE, THE FOLLOWING WARNING SIGNS SHOULD BE HIGHLIGHTED AND THE CLIENT SHOULD BE ENCOURAGED TO CALL OR COME TO THE FACILITY IMMEDIATELY FOR ASSESSMENT: Heavy vaginal bleeding. Severe lower abdominal discomfort. Fever and not feeling well. Unusual vaginal discharge. Suspected expulsion: can either feel IUCD in the vagina or has seen it expelled from the vagina.
Any other problems or questions the woman has related to IUCD.
INDICATIONS FOR REMOVAL OF AN IUD: The major reason for IUD removal is desire for pregnancy. Medical reasons for removal are partial expulsion, usually occurring in the first few months of use; persistent cramping, bleeding, or anemia, accounting for about 20% of removals during the first 3 months; acute salpingitis or Actinomyces infection on Pap smear; pregnancy (for the reasons previously cited); intra-abdominal placement/perforation; and significant post-insertion pain, which may indicate improper placement or partial perforation.
REMOVAL: Woman must come to the health facility to have it removed whenever the woman wants to get pregnant, otherwise, at the end of the recommended period.
Woman will be able to get pregnant soon after IUCD is removed. The woman can get the IUCD removed any time the woman desires for a pregnancy or to change to another method. If the woman wants to continue to use the IUCD for a longer time, can use it for 10 years and then have it replaced with another one.
WASTE DISPOSAL: After completing a procedure (e.g., IUCD insertion), on completion of shelf life or on removal after use, dispose the items as per local regulations governing disposal of non-recyclable waste/medical waste.