What are the steps for Mirena (levonorgestrel-releasing intrauterine system) insertion?

Mirena (Levonorgestrel-Releasing Intrauterine System) Insertion Steps

The proper insertion of Mirena requires a specific technique to ensure correct fundal placement, which is critical for both contraceptive efficacy and reducing the risk of expulsion. 1

Pre-Insertion Preparation

• Administer pre-procedure NSAIDs such as naproxen 500-550 mg or ibuprofen 800 mg 1-2 hours before the procedure to reduce pain and cramping 1
• Ensure the patient has eaten a light meal and is well-hydrated to prevent vasovagal reactions 1
• Consider offering anxiolytics for patients with significant anxiety, noting that patients will need someone to drive them home if benzodiazepines are used 1
• Discuss the procedure steps with the patient, explaining that there are three points when discomfort may be experienced: cervical stabilization, uterine sounding, and IUD placement 1
• Use person-centered counseling and trauma-informed care approaches to reduce anxiety 1

Equipment Preparation

• Sterile gloves
• Antiseptic solution (betadine or equivalent)
• Speculum
• Ring forceps or single-tooth tenaculum
• Uterine sound
• Mirena IUD with its inserter
• Scissors for trimming strings 1

Insertion Procedure

Step 1: Patient Positioning and Initial Examination

• Position the patient in lithotomy position with the exam table elevated so the patient can see the clinician 1
• Perform a bimanual examination to determine uterine size and position 1
• Insert an appropriately sized speculum (consider Pederson for nulliparous patients) 1

Step 2: Cervical Preparation

• Cleanse the cervix with betadine or another antiseptic solution 1
• Consider applying topical anesthetic to the cervix (options include 5 mL EMLA cream or 10% lidocaine spray) 1
• For patients with higher risk of pain, consider a paracervical or intracervical block 1

Step 3: Cervical Stabilization

• Grasp the anterior lip of the cervix with a ring forceps or single-tooth tenaculum 1
• Apply gentle traction to straighten the cervico-uterine angle 1
• If using a tenaculum, close it only one notch and time the closure with the patient's exhalation 1

Step 4: Uterine Sounding

• Gently insert the uterine sound to determine the depth and direction of the uterine cavity 1
• If dilation is needed, use the smallest possible dilator 1
• Communicate with the patient during this step as it may cause cramping 1

Step 5: IUD Preparation and Insertion

• Remove the Mirena IUD from its sterile packaging
• For standard interval insertion:
  • Load the Mirena into the insertion tube according to manufacturer instructions
  • Set the flange to the measured uterine depth
  • Insert the loaded device through the cervix until the flange is at the external os
  • Release the IUD arms by pulling back on the slider
  • Advance the inserter to ensure fundal placement
  • Release the IUD by pushing the slider forward
  • Remove the inserter while holding the threads 1, 2

Step 6: String Trimming

• Trim the strings to approximately 3 cm from the external cervical os for standard interval insertion 2
• For immediate postpartum insertion, trim strings to 10-12 cm 1

Step 7: Confirmation of Placement

• Confirm proper fundal placement by one of the following methods:
  • Feeling the strings retract into the cervix when the inserter is removed
  • Visualizing the strings protruding from the cervix
  • Using transabdominal ultrasound if available, especially for difficult insertions 1

Post-Insertion Care

• Keep the patient lying flat for 5 minutes with legs out of stirrups 1
• Gradually raise the head of the table in increments to prevent vasovagal reactions 1
• Provide a heat pad for cramping if needed 1
• Advise continued NSAID use for 24 hours post-procedure (naproxen 440-550 mg every 12 hours or ibuprofen 600-800 mg every 6-8 hours) 1
• Instruct the patient on expected side effects, including cramping and irregular bleeding 1

Special Considerations

• For nulliparous patients, anticipate potentially higher pain scores (6.6-8.1/10 compared to 3.7/10 for multiparous patients) and consider additional pain management 1
• For immediate postpartum insertion after vaginal delivery:
  • Change into new sterile gloves
  • Remove the IUD from the inserter
  • Cut strings to 10-12 cm
  • Grasp the IUD wings with ring or Kelly placental forceps
  • Pass the device through the cervix under visualization
  • Confirm fundal placement by abdominal palpation or ultrasound 1
• For insertion after cesarean delivery:
  • Place the IUD in the uterine fundus manually or with ring forceps after initiating hysterotomy closure
  • Place the strings into the cervix before completing closure 1

Common Pitfalls and How to Avoid Them

• Failure to achieve fundal placement: Ensure proper uterine sounding and use of appropriate insertion technique; high fundal placement decreases expulsion rates 1
• Vasovagal reactions: Have the patient eat before the procedure, use gentle technique, and keep the patient supine after insertion 1
• Perforation: Use gentle technique and be aware of uterine position; the risk is not increased with proper technique 1
• Infection: While antibiotic prophylaxis is generally not required, ensure proper aseptic technique 3
• Expulsion: Ensure fundal placement and consider ultrasound confirmation when available 1