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

Copper T IUD Insertion: Step-by-Step Procedure

The insertion of a copper T IUD follows a systematic approach beginning with pre-procedure preparation, followed by bimanual examination, cervical cleansing and stabilization, uterine sounding, device insertion with high fundal placement, and post-insertion monitoring to prevent vasovagal reactions. 1

Pre-Procedure Preparation

Patient Counseling and Consent

• Explain the three key moments when discomfort occurs: cervical stabilization, uterine measurement, and device placement 1
• Use trauma-informed language such as "gentle placement" instead of "insertion" to minimize anxiety 1
• Obtain informed consent after discussing the procedure, anticipated pain, and all pain relief options 1

Pain Management

• Administer naproxen 500-550 mg or ketorolac 20 mg orally 1-2 hours before the procedure, always with food 2, 1
• Advise the patient to eat a light meal and be well-hydrated to prevent vasovagal reactions 3
• For patients with significant anxiety, consider anxiolytics (noting that patients will need someone to drive them home if benzodiazepines are used) 3

Equipment Preparation

• Check and prepare all equipment including speculums of appropriate sizes (consider Pederson for nulliparous patients) 2, 3
• Warm lubricating gel to body temperature 2
• Have available: atraumatic vulsellum or Littlewood forceps (or single-tooth tenaculum), uterine sound (plastic or metal, maximum 3 mm diameter), and cervical dilators if needed 2
• Dilation to 5 mm is typically needed for copper IUD insertion 2

Insertion Procedure

Step 1: Bimanual Examination

• Perform bimanual examination to determine uterine size, position, and direction before insertion 1
• Position the patient in lithotomy position with the exam table elevated so the patient can see the clinician 3

Step 2: Cervical Preparation

• Insert an appropriately sized speculum 3
• Cleanse the cervix with betadine or another antiseptic solution 3
• Consider applying topical anesthetic to the cervix (5 mL EMLA cream or 10% lidocaine spray) 3
• For patients with higher risk of pain, consider a paracervical or intracervical block 3

Step 3: Cervical Stabilization

• Grasp the anterior lip of the cervix with ring forceps or single-tooth tenaculum 3
• Apply gentle traction to straighten the cervico-uterine angle 3
• Communicate with the patient during this step as it causes discomfort 1

Step 4: Uterine Sounding

• Gently insert the uterine sound to determine the depth and direction of the uterine cavity 3
• If dilation is needed, use the smallest possible dilator 3
• Consider ultrasound guidance if cervical dilation is required, as it has demonstrated reduced pain compared to non-guided placement 2

Step 5: Device Loading and Insertion

• Remove the copper T IUD from its sterile packaging 3
• Load the device into the insertion tube according to manufacturer instructions 3
• Set the flange to the measured uterine depth 3
• Insert the loaded device through the cervix until the flange is at the external os 3
• Release the IUD arms by pulling back on the slider 3
• Advance the inserter to ensure fundal placement 3
• Release the IUD by pushing the slider forward 3
• Remove the inserter while holding the threads 3

Step 6: Ensuring High Fundal Placement

• High fundal placement of the copper T IUD is critical to reduce expulsion rates 1
• When properly placed by an experienced clinician, expulsion rates of approximately 7-15 per 100 users at six months can be expected 4

Post-Insertion Care

Immediate Post-Procedure

• Keep the patient lying flat for 5 minutes with legs out of stirrups after insertion 1
• Gradually raise the head of the table in increments to prevent vasovagal reactions 1, 3
• Provide a heat pad for cramping if needed 3

Patient Instructions

• Inform the patient that the copper IUD is immediately effective for contraception, with no backup method 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) 3
• Instruct the patient on how to detect expulsions and to return for reinsertion or another method 4
• Advise that increased menstrual bleeding is the main side effect and may continue even with long-term use 5

Special Populations and Timing Considerations

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
• Pain on insertion is significantly greater in nulliparous patients (VAS 6.5±2.4 versus 3.9±2.2 for multiparous) 6
• The 6-month continuation rate is comparable between nulliparous (83.4%) and parous (92.8%) patients 6
• Nulliparous patients experience more dysmenorrhea requiring analgesics (72% versus 47% in parous patients) 6

Timing of Insertion

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

Postpartum Insertion

• For immediate postpartum insertion after vaginal delivery (10 minutes to 48 hours), use ring forceps and cut strings to 10-12 cm 3, 4
• For insertion after cesarean delivery, place the IUD in the uterine fundus manually or with ring forceps after initiating hysterotomy closure 3
• Place the strings into the cervix before completing closure 3
• Note that expulsion rates are higher with immediate postpartum insertion compared to delayed insertion 5

Common Pitfalls and How to Avoid Them

Failure to Achieve Fundal Placement

• Ensure proper uterine sounding and use of appropriate insertion technique 3
• High fundal placement decreases expulsion rates significantly 1, 4

Vasovagal Reactions

• Have the patient eat before the procedure 3
• Use gentle technique throughout 3
• Keep the patient supine after insertion with gradual elevation 1

Expulsion

• Ensure fundal placement during insertion 3
• Expulsion rates are higher in nulliparous patients (12.2% versus 3.5% in parous patients) 6
• Instruct patients on detection and follow-up 4

Perforation

• Use gentle technique and be aware of uterine position 3
• The risk is not increased with proper technique 3