Chapter 4:Contraception

CHAPTER 4
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CONTENTS

Appendix 7: Steps for inserting intrauterine devices andspecific job aids
1.

Gather equipment:

6.

Load the IUD into the inserter in a sterile fashion.
See job aids: Instructions for loading the Copper T
380A in a sterile package; Instructions for loading
and inserting the one-handed LNG-IUD; andInstructions for loading and inserting the twohanded LNG-IUD).

7.

Place the sound next to the IUD and set the depth
gauge at the measured depth of the uterus.

8.

Holding the cervix and uterus steady with thetenaculum, gently insert the IUD in its inserter
through the cervical os into the uterus. See job
aids: Instructions for inserting the loaded Copper T
380A intrauterine device; Instructions for loading
and inserting the one-handed LNG-IUD; andInstructions for loading and inserting the twohanded LNG-IUD for instructions on how to release
the IUD into the uterus. The goal is to place the IUD
at the uterine fundus. Remove the inserter after
successful placement.

9.

Cut the IUD strings to approximately 3 cm from thecervical os. The strings can be cut shorter, including
flush with the cervix, at the request of the client.

• Speculum• Ring forceps• Metal cup• Tenaculum• Uterine sound• Scissors• Sterile gauze
2.

Perform bimanual examination and speculum
visualization of the cervix to assess uterine sizeand position and to detect any cervical or uterine
abnormalities.

3.

Wipe cervix with antiseptic solution.

4.

Gently place the tenaculum on the cervix.

5.

Holding the cervix and uterus steady with thetenaculum, gently insert the uterine sound throughthe cervical os until it reaches the uterine fundus.
Be sure to avoid touching the tip of the soundon the speculum or vagina (see Box 1: No touchtechnique). It may be necessary to gently pull thetenaculum to straighten the cervical canal andallow passage of the sound. Remove the soundand, using the markings, note the depth of theuterus. Usually, the sound will be wet or darker
from the antiseptic solution where it was in theuterus. Typically, the uterus will measure 6–9 cm.
Most IUDs cannot be inserted if the uterine depth
is less than 6 cm; providers should refer to themanufacturer’s instructions for guidance for specific
IUDs. If the depth is more than 10 cm, the soundmay have perforated the uterus.

10. Remove the speculum, reassure the client thatprocedure was completed successfully and withoutcomplication.
11. Allow the client to rest on the examination table
until they feel ready to get dressed.

BOX 1: No touch technique• Do not let the loaded IUD or uterine sound touch
any unsterile surface, such as hands, speculum,
vagina, or tabletop• Load the IUD into the inserter in a sterile package;
do not touch the IUD directly• Pass the uterine sound and the loaded IUD throughthe cervical canal only once

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Job aid: Instructions for loading the Copper T 380A intrauterine
device in a sterile package

Copper Intra-Uterine Device (Cu-T)*Do not start this loading procedure more than 10 minutes before inserting into the uterus. The
arms of Cu-T will not straighten out easily if they are left within inserter tube too long.

1

2

Adjust the contents of the package throughthe clear plastic cover. Confirm the verticalstem of Cu-T is fully inside inserter tube.

Horizontal arms
Verticalstem

Open the package from the bottom(end farthest from Cu-T) one-thirdof the way. Pick up the packagewith the open end up. Bend clear
plastic cover and white backing
away from each other tomaintain sterility.

Rod

Place the white rod
inside insertion tube
from the bottom,
along side of threads.
Gently push it up
until it just touches
the bottom of Cu-T.

Depth guage(flange)

Measurement
card
Inserter
tube

Use free hand to pushmeasurement card soit slides underneath
Cu-T.

Place the package
on a clean, flat
surface.

34Through the plastic
cover, stabilize Cu-T
in place by putting
thumb and index
finger over ends of
its horizontal arms.

Fold arms enough to touchsides of inserter tube, thenpull tube out slightly fromunder tips of arms.
This action will
create resistancefor the arms of
Cu-T to bend
down towards
its stem.

With the otherhand, pushinserter tube
towards Cu-T.

6
Cu-T is now ready to beplaced in the woman’s uterus.
Carefully peel clear plastic
cover of package away fromthe white backing.

USE NO-TOUCHTECHNIQUETHROUGHOUT
LOADING

Push and rotate tube over tips ofthe arms only enough to retain arms
inside tube next to the stem.

5
Adjust blue flange
to the depth ofuterus, measured
with uterine sound.
Ensure the longest
side of the flange isparallel with arms of
the Cu-T.

UterinedepthThe sterile cardin package may
also be used to set
flange according to
the premeasured
uterine depth.
FlangeLift the loaded inserter, keeping it
horizontal to ensure the Cu-T or
white rod does not fall out.

Source: Reproduced with permission from USAID Maternal and Child Survival Program. Long-Acting Reversible Contraceptives Learning
Package. May 2017.

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Job aid: Instructions for inserting the loaded
Copper T 380A intrauterine device
Step 1

Step 4• Grasp the tenaculum (whichis still in place on the cervix
after sounding the uterus) andpull firmly to pull the uterine
cavity and cervical canal in linewith the vaginal canal. Gently
place the loaded inserter tube
through the cervical canal.
Keep the blue depth gauge ina horizontal position.

• Gently and slowly withdraw
the inserter tube from thecervical canal. The strings
should be visible protrudingfrom the uterus. Cut thestrings so that they protrude
only three to four centimeters
into the vagina.

• Advance the loaded IUD until
the blue depth gauge touches
the cervix or resistance of theuterine fundus is felt. Keep
the blue depth gauge in ahorizontal position.
Step 2• Hold the tenaculum and thewhite rod in place in one hand.
With your other hand, withdraw(pull toward you) the inserter
tube until it touches the thumbgrip of the white rod. This will
release the arms of the TCu
380A high in the uterine fundus.
Step 3• Once the arms have beenreleased, again very gently andcarefully, push the inserter tube
upward, toward the top of theuterus, until you feel a slightresistance.
This step ensures the arms of
the T are as high as possible inthe uterus.

• Remove the tenaculum. If thecervix is bleeding from thetenaculum site, press a swab
to the site, using clean forceps,
until the bleeding stops.
Step 5• Gently remove the speculum,and put all of the instruments
used in 0.5% chlorine
solution for 10 minutes fordecontamination.

DON’TMOVEROD

Step 6• Help the client get up from thetable very slowly. Watch her incase she becomes dizzy or feels
faint. Teach her how and whento check the strings. Ask her tocheck the strings now. Ask her
if she has any questions andanswer them in simple words
she can understand. Tell her toreturn in three to six weeks. If
she can read, give her written
instructions or tell her thewarning signs of problems andhow to get help if she needs.

WITH
TUBE

This step ensures
the top of the T is
as high as possible
in the uturus

DON’T
MOVE
ROD

PUSH
TUBE
UP• Hold the inserter tube still
while removing the white rod.
Source: Diagrams redrawn with the permission of the Population Council from: Population Council and The Program for Appropriate Technology in Health(PATH). Copper T380A IUD: A Manual for Clinicians. Second edition. Seattle, Washington: PATH, 1989.

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Job aid: Instructions for loading and inserting the one-handedlevonorgestrel intrauterine device
STEP 1: Open the sterile package

STEP 3: Set the flange to uterine depth• Open the sterile LNG-IUD package.

While maintaining forward pressure on the slider, set theupper edge of the flange to correspond to the uterine
depth (in centimeters) measured during sounding.

• Lift the handle of the sterile inserter from the sterilepackage.

soundmeasure

STEP 2: Move slider all the way to forward position

STEP 4: Advancing insertion tube

• Move slider all the way to forward position to loadLNG-IUD.

• Apply gentle traction on the tenaculum to straighten
the alignment of the cervical canal and uterine cavity.

• The tips of the LNG-IUD arms will meet to form arounded dome that extends slightly beyond theinsertion tube.

• Maintaining the slider in forward position, advancethe loaded insertion tube through the cervical canal
until the upper edge of the flange is 1.5-2.0 cm fromthe cervical os.

• Maintain forward pressure with your thumb or
forefinger on the slider to avoid releasing strings
prematurely.

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Chapter 4:
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CHAPTER 4
CONTENTSSTEP 5: Release the arms of the LNG-IUD

STEP 7: Release LNG-IUD and withdraw inserter• While holding the inserter steady, move the slider
down to the mark to release the arms of the LNGIUD.

• Holding the inserter firmly in place, release LNG-IUD
by moving the slider all the way down.

• Wait 10 seconds for the horizontal arms to open
completely.

STEP 6: Place IUD in fundal position• Advance the inserter gently towards the fundus ofthe uterus until the flange touches the cervix.
• LNG-IUD is now in the fundal position.

• Keep holding the slider down while gently
withdrawing the inserter from the uterus.

STEP 8: Cut the threads
Use blunt-tipped sharp scissors to cut the LNG-IUDthreads perpendicular to the thread length leaving
about 3 cm outside of the cervix while strings ends arestill in the inserter tube.

Source: Training Resource Package for Family Planning [website]. https://www.fptraining.org/training

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Chapter 4:Contraception

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MAIN
CONTENTSJOB AID: LNG-IUD loading wi
STEP 1: Open the package• PlacethJob aid: Instructions for loading and inserting the two-handed
JOB AID: LNG-IUD loadingwith twlevonorgestrel intrauterine device
surface.

LNG-IUD loading with two-handed inserter

STEP 1: Open the package

STEP 1: Open the package• Place the LNG-IUD package on a flat, cleansurface.
•Open from the bottom by pulling on the clear
plastic cover from the end farthest from theLNG-IUD until package is 1/3 open.

Open froplastic co
IUD until••

Place the LN
surface.

Open from thplastic cover fr
STEP 2: Release threads from theflangeandIUD
until pack•Pick-up treleasethSTEP 2: Release threads from the flangeand inse•

STEP 2: Release threads from the flange and insert the rod• Pick up threads with dominant hand andrelease them from flange.
• While holding inserter tube and threads,
remove rod and insert it into the inserter tube
until the tip of the rod is at 5 cm mark.

Arms of T-frame areparallel to the Flange

While ho•Flange•Pick-upthreadremover
releasethemuntil the tf•While holding
remove rod anuntil the tip ofSTEP 3: Load the LNG IUD into the InserterSTEP 3: Load the LNG-IUD into the inserter• Hold inserter tube and rod firmly with thethumb and index finger of dominant hand.
• With the other hand grasp threads and gently
pull the IUD down slowly and steadily into theinsertion tube until the knobs of the lateralarms form a hemispherical dome at the topof the tube and the tip of the rod is touching
the bottom of the LNG-IUD. The hemisphericaldome facilitates safe passage through thecervical os.
STEP 4: Adjust the flange to the uterine depth• Adjust the upper end of the flange tocorrespond with the uterine depth asmeasured by the uterine sound.

161

Hold inseand index•

STEP 3: Load the LNG IUD into the Inserter•

Hold inserter t• Withandindexthefing

pull the IU

Withinsertion
the otherpull form
the IUDdoa heinsertiontube
tube andformbottom
a hemisp
otube
andtheti
STEP 4: Adjust the flange to the uterine
depth
dome
fac
bottom of the L
cervicalodomefacilitate
cervical os•

Uterine depth•

Adjust the ucorrespondthe uterine

STEP 5: Check final IUD positioning•Chapter 4:Contraception

CHAPTER 4
CONTENTS

Adjust thcorrespo
MAINtheuteri
CONTENTSSTEP 5: Check final IUD positioning
STEP 5: Check final IUD positioning• LNG-IUD should be positioned in the tube
so that the knobs of the lateral arms form ahemispherical dome.
• The top of the rod is touching the bottom ofthe IUD.
• The threads are hanging through the end ofthe insertion tube.
• The flange is marking the depth of the uterus.
• The proximal end of the insertion tube will beapproximately at the top of the first indent onthe rod.

LNG-IUDthat thehemisph• The topthe IUD• The threthe inse• The flan
• The proxapproxim
the rod.
STEP 6: Remove the insertion tube from the packet• Remove the loaded IUD insertion tube from the package while
holding
lower end oftheInsertion
tube firmly between
STEP
6:theRemove
thetube from the•your fingers and thumb.
• If not using sterile gloves, do not touch the flange and any part of the insertion tube above the flange during this• Remove the loaded IUD insertion tube fromstep and through the IUD insertion procedure.

end of the tube firmly between your fingers

LNG-IUD insertion with two-handed inserter
STEP 1: Insert loaded LNG-IUD into the uterus• Apply gentle traction on the tenaculum tostraighten the alignment of the cervical canaland uterine cavity.
• Slide the loaded LNG-IUD insertion tube
through the cervical canal until the upper edgeof the flange is approximately 1.5–2.0 cm fromthe cervix.
• DO NOT advance flange to the cervix at thisstep.

•JOB AID:LNG-IUDInsertion
withtwIf not using sterile
gloves,do nottouchthetubeabove
theloadedflangeLNG
duringthisthestep
andSTEP1: Insert
IUD intoUterus

Applyto strcervi• Slidetubepinch
FirmFirm
pinch
the uontube
andon tube androd prevents
approrodprevents
the rod fromcervi
the fallingrod from
outof thefalling
outtubeof• DO N
the tubeat thi
STEP 2: Release arms of LNG IUD in the uterus•

Stop
Stop 1.5-2.0
1.5-2.0 cm
cm from
fromthethecervix cervix

STEP 2: Release arms of LNG-IUD in the uterus• Release hold on tenaculum.
• Hold insertion tube with the fingers of one
hand (Hand A) and the rod with the fingers ofother hand (Hand B).
• Relax the firmness of the pinch on the tube,
AND PULL THE INSERTION TUBE BACK withHand A to the edge of the second (bottom)
indent on the rod.
• Wait 10-15 seconds for the arms of the IUD tofully open.

••STOP••

Relea
Holdone hthe fi
Relax
tube,
TUBEof therod
Wait
the IU

Hand A
Hand B

STEP 3: Advance LNG IUD to fundus••
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ApplyWithend otubeuterinChapter 4:
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CHAPTER 4CONTENTS

MAIN
CONTENTSSTEP 3: Advance LNG-IUD to fundus• Apply gentle traction with tenaculum.
• With Hand A still holding the proximal end ofthe tube, advance the insertion tube (with therod still inside) up to the uterine fundus.
• You will feel slight resistance when theLNG‑IUD is at the fundus.
• The flange should be touching the cervix whenthe LNG-IUD reaches the uterine fundus.

STEP 4: Release the LNG IUD and withdraw the Insert
Hand A•
STEP 4: Release the LNG-IUD and withdraw the inserter• Hold rod still with Hand B while pulling theinsertion tube back with Hand A to the ring ofthe rod.
• While holding the inserter tube with Hand A,withdraw the rod from the insertion tube allthe way out.
• Withdraw the insertion tube until the tube is
3-4 cm away from the cervical os, but the endsof the strings are still inside the tube.
Removing the rod first and then the tube
prevents the LNG-IUD from being pulled out ofthe uterus.
STEP 5: Cut the threads• Use blunt-tipped sharp scissors to cut the LNGIUD threads perpendicular to the thread lengthleaving about 3 cm outside of the cervix while
strings ends are still in the inserter tube
(cutting threads at an angle may leave sharpends).
• Do not apply tension or pull on the threads
when cutting to prevent displacing the LNGIUD.

••STOP!

Hand A

Removing t
tube prevenpulled out oHand B

STEP 5: Cut the threads

Source: Training Resource Package for Family Planning [website]. https://www.fptraining.org/training

163

Hold rodthe inser
the ring oWhile ho
Hand A,insertion
Withdraw
tube is 3os, but thinside th••3 cm

Use blunthe LNGthe threa
outside oends are(cutting t
sharp en
Do not athreads w
displacin