What are the guidelines for intrauterine device (IUD) placement?

Guidelines for Intrauterine Device (IUD) Placement

Intrauterine device placement should follow a trauma-informed, person-centered approach that prioritizes patient comfort, with pre-procedural NSAIDs and paracervical blocks offered for pain management. 1

Pre-Procedure Preparation

Patient Selection and Timing

• IUDs can be inserted at any time during the menstrual cycle if pregnancy can be reasonably excluded 1
• No best time in menstrual cycle exists for IUD placement 1
• Ideal candidates are women in stable, monogamous relationships, though IUDs are appropriate for most women 2

Pre-Procedure Medication

• Recommended pain management:
  • Naproxen 500-550 mg PO or ketorolac 20 mg PO 1 hour before procedure (with food) 1, 3
  • Alternative: Ibuprofen 600-800 mg PO 1 hour before procedure 1

Patient Instructions

• Eat a light meal and stay hydrated before the procedure 1
• Wear comfortable clothing (separate top and bottom) 1
• Consider bringing a support person 1

Procedure Technique

Pain Management Options

1. Non-pharmacological approaches:

   • Therapeutic language (avoid triggering terms)
   • Slow, gentle breathing techniques
   • Music therapy
   • Warm environment

2. Pharmacological options:

   • Topical/local anesthetics:

     • EMLA cream (2.5% lidocaine/2.5% prilocaine) to cervix and canal - wait 5-7 minutes 1
     • 10% lidocaine spray to cervix and canal - wait 3 minutes 1

   • Paracervical block (PCB):

     • 18-20 mL of 1% lidocaine with 2 mL sodium bicarbonate buffer 1
     • Particularly helpful for nulliparous patients or those with prior difficult IUD placements 1

Insertion Technique

1. Use appropriate size speculum (Pederson for nulliparous patients) 1
2. Apply single tooth tenaculum or Allis forceps gently 1
3. If dilation needed, use topical anesthetic and start with smallest possible dilator 1
4. Use gentle, slow movements during insertion 1
5. Verbally check in with patient throughout procedure 1

Post-Procedure Care

1. Keep patient lying flat for 5 minutes with legs out of stirrups 1
2. Gradually raise head of table to prevent vasovagal reaction 1
3. Offer beverage/snack and heat pad 1
4. Consider acupressure on LI4 or SP6 points 1, 3
5. Advise patient to take scheduled NSAIDs for 24-72 hours post-procedure:
   • Naproxen 440-550 mg every 12 hours with food, OR
   • Ibuprofen 600-800 mg every 6-8 hours with food 1, 3

Special Considerations

Failed First Attempt

• Consider misoprostol 400 mcg buccally/vaginally 3-4 hours before next attempt 1
• Consider ultrasound-guided placement 1
• Consider paracervical block if not used in first attempt 1

Pregnancy with IUD in Place

• Evaluate for possible ectopic pregnancy 1
• If strings are visible, remove IUD as soon as possible 1
• If strings are not visible, consider ultrasound to locate IUD 1
• Advise patient about increased risks of spontaneous abortion and preterm delivery if IUD remains in place 1

Pain Management Based on Patient Factors

• Nulliparous women and those with previous cesarean deliveries report higher pain scores and may benefit from more aggressive pain management 4
• LNG-IUS 52 mg placement may be associated with more pain than copper IUD placement 4

Common Pitfalls to Avoid

1. Inadequate pain management: Failing to offer appropriate analgesia, especially for nulliparous women
2. Rushing the procedure: Moving too quickly can increase patient anxiety and pain
3. Neglecting trauma-informed care: Using triggering language or failing to obtain ongoing consent
4. Improper patient positioning: Not elevating the exam table so patient can see clinician
5. Inadequate post-procedure instructions: Not advising on scheduled NSAID use for 24-72 hours

IUDs are highly effective contraceptives with Pearl indices of 0.06 for LNG-IUS and 0.52 for copper IUDs 5, making proper placement technique essential for ensuring optimal effectiveness and patient satisfaction.