What are the steps for inserting a copper T (intrauterine device)?

Steps for Copper T IUD Insertion

The copper T IUD should be inserted using a systematic, trauma-informed approach that prioritizes patient comfort through pre-procedural NSAIDs, therapeutic language, gentle technique, and high fundal placement to minimize pain and expulsion risk. 1, 2

Pre-Procedure Preparation

Patient Counseling and Consent

• Explain the three key moments when discomfort occurs: cervical stabilization, uterine measurement, and device placement 1, 2
• Use trauma-informed language: say "gentle placement" not "insertion," "cervix holder" not "tenaculum," and "measuring your uterus" not "sounding" 1
• Emphasize patient control: "You are in control. We can stop at any time" 1
• Obtain informed consent after discussing the procedure, anticipated pain, and all pain relief options 1

Pharmacological Preparation

• Administer naproxen 500-550 mg or ketorolac 20 mg orally 1 hour before the procedure (always with food) 1, 3, 2
• For patients with significant anxiety, consider offering anxiolytics (requires someone to drive them home) 2
• For higher-risk patients, prepare topical anesthetic (5 mL EMLA cream or 10% lidocaine spray) or paracervical/intracervical block 1, 2

Patient Preparation

• Instruct the patient to eat a light meal and drink water beforehand to prevent vasovagal reactions 3, 2
• Have the patient wear comfortable clothing with separate top and bottom 1
• Ensure clinical support staff are trained to recognize vasovagal symptoms (pale skin, sweating, dilated pupils, dizziness, nausea) 1

Insertion Procedure

Positioning and Examination

• Position the patient in lithotomy with the exam table elevated so they can see you 2
• Perform bimanual examination to determine uterine size, position, and direction 2, 4

Speculum Insertion and Cervical Preparation

• Insert an appropriately sized speculum (consider Pederson for nulliparous patients) 2
• Use therapeutic language: "I am going to place the speculum" 1
• Cleanse the cervix with betadine or antiseptic solution 2
• Apply topical anesthetic to the cervix if planned 2

Cervical Stabilization

• Grasp the anterior lip of the cervix with a ring forceps or single-tooth tenaculum 2
• Apply gentle traction to straighten the cervico-uterine angle 2
• Warn the patient: "You may feel a sensation" 1

Uterine Sounding

• Gently insert the uterine sound to determine depth and direction of the uterine cavity 2
• Communicate with the patient during this step as it may cause cramping 2
• If dilation is needed, use the smallest possible dilator 2

Device Insertion

• Remove the copper T IUD from sterile packaging 2
• Load the device into the insertion tube according to manufacturer instructions 2
• Set the flange to the measured uterine depth 2
• Insert the loaded device through the cervix until the flange reaches the external os 2
• Release the IUD arms by pulling back on the slider 2
• Advance the inserter to ensure high fundal placement (critical to reduce expulsion rates) 2, 5
• Release the IUD by pushing the slider forward 2
• Remove the inserter while holding the threads 2

Post-Insertion Care

Immediate Management

• Keep the patient lying flat for 5 minutes with legs out of stirrups 2
• Gradually raise the head of the table in increments to prevent vasovagal reactions 2
• Provide a heat pad for cramping if needed 2
• Monitor for vasovagal symptoms and position supine if they occur 3

Patient Instructions

• Advise continued NSAID use for 24 hours (naproxen 440-550 mg every 12 hours or ibuprofen 600-800 mg every 6-8 hours) 3, 2
• Inform the patient that the copper IUD is immediately effective for contraception with no backup method needed 3
• Explain expected side effects: cramping and increased menstrual bleeding (which may continue with long-term use) 4
• Instruct on how to detect expulsions and when to return 5

Special Populations and Timing

Nulliparous Patients

• Anticipate higher pain scores (6.6-8.1/10 compared to 3.7/10 for multiparous patients) 2
• Consider additional pain management strategies 2
• Be aware of higher insertion failure rates (8.0% vs 1.0% for multiparous) 6

Postpartum Insertion

• Immediate postpartum (vaginal delivery): Insert manually or with ring forceps within 10 minutes to 48 hours after delivery; cut strings to 10-12 cm 2, 5
• Cesarean delivery: Place the IUD in the uterine fundus manually or with ring forceps after initiating hysterotomy closure; place strings into cervix before completing closure 2, 7
• Expulsion rates are higher with immediate postpartum insertion (7-15% at 6 months) compared to delayed insertion 5

Timing Considerations

• The copper T IUD may be placed at any time in the menstrual cycle if pregnancy is reasonably excluded 1, 4
• Can be used as emergency contraception up to 5 days after unprotected intercourse (or up to 5 days after ovulation) 1, 3, 8

Common Pitfalls and Prevention

• Failure to achieve fundal placement: Ensure proper uterine sounding and high fundal placement to decrease expulsion rates 2, 5
• Vasovagal reactions: Have patient eat beforehand, use gentle technique, keep patient supine after insertion 3, 2
• Perforation: Use gentle technique and be aware of uterine position; risk is not increased with proper technique 2
• Infection: Do not insert if purulent cervicitis is present or if patient has current chlamydia or gonorrhea; wait at least 3 months after STI resolution 3, 4