copper t presentation - insertion and removal.pptx

For MBBS and nursing students

1. Cu-IUD and PP-IUD -Dr Shwetha -Dr Alankrita Moderator- Dr Pooja

2. INTRODUCTION Intrauterine contraception (IUC) is a long acting reversible contraceptive(LARC), highly effective, reversible method of contraception. Cost effective Fertility returns immediately after removal. Safe for women who are breastfeeding. Two categories - Copper intrauterine devices (Cu-IUDs) Levonorgestrel intrauterine devices (LNG-IUDs).

3. CU-T Small, flexible plastic frame containing copper impregnated with barium sulphate. Currently there are 2 types of Cu IUCDs available under the national programme . CU-T 375 CU-T 380 A Effective for 5 years Effective for 10 years

4. CuT 380 A CuT 375

5. Copper IUCD 380 A

6. Copper IUCD 375

7. Forms biological foam in cavity- contains strands of fibrin, phagocytic cells and proteolytic enzymes. Forms prostaglandins in cavity -causes smooth muscle contraction and inflammation. Cu ion - greater inflammatory response Change the surface morphology of cells , especially of microvilli of ciliated cells. Changes the intrauterine environment Decrease sperm motility and function by altering the uterine and tubal fluid environment, thus preventing sperm from reaching the fallopian tubes and fertilizing the egg – prevents fertilization . The device stimulates foreign body reaction in the endometrium that releases macrophages and prevents implantation MECHANISM OF ACTION

8. EFFECTIVENESS- Contraceptive effectiveness of IUDs is high and is not affected by enzyme-inducing drugs or weight/body mass index (BMI). Contraceptive failure rates -0.6%–0.8% in the first year of use for the Cu-IUDs. Highly effective emergency contraception (EC) that can be retained to provide ongoing contraception.

9. DURATION OF USE- Used for contraception for 5 or 10 years (device dependent). If ≥40 years old, can be used for contraception until menopause. Fertility returns promptly after an IUCD is removed.

10. TIMING OF INSERTION Can be inserted anytime- Interval IUCD Emergency contraception Postpartum Post Abortion -not pregnant -anytime preferably post menstrually if inserted within 5 days after the first episode of unprotected sexual intercourse (UPSI) that cycle, or within 5 days of the earliest expected date of ovulation. Post Placental Immediate post partum Trans caesarean Delayed /Interval post partum After Surgical Abortion: Immediately or within 12 days of an abortion procedure After Medical Method of Abortion: Around day 15 of MMA (follow up/ 3rd scheduled visit for medical method of abortion)

11. Absolute Contraindications Pregnancy Puerperal sepsis Immediate placement post septic abortion Unexplained vaginal bleeding Uterine anomalies that distort the anatomy Uterine fibroids that distort the shape of the uterus Current PID or history of PID in past 3 months Current purulent cervicitis or infection with gonorrhea or chlamydia Known pelvic tuberculosis Cervical cancer awaiting treatment Wilson’s disease

12. RELATIVE CONTRAINDICATIONS Excessively heavy periods or marked dysmenorrhea Small uterine cavity

13. Side Effects Menstrual changes: There may be increase in the duration/amount of menstrual bleeding or spotting or light bleeding during the first few days or months after insertion. These usually subside with symptomatic treatment Discomfort or cramps during insertion and for the next few days which subsides in due course

14. Principles of FP Counselling Privacy and confidentiality Respectful, non-judgmental, accepting and caring attitude Simple, culturally appropriate and in easy language for patient to understand Good verbal and non-verbal interpersonal communication skills Brief, simple and specific information Patient should be able to ask questions and express any concerns Voluntary informed decision making by the patient

15. Benefits of Family Planning Counselling • Increases acceptance of the methods • Enhances continuation of methods • Dispels misconceptions/ rumors • Increases patient satisfaction Counselling helps the patient to make voluntary decisions and increases compliance.

16. Timing of Counselling IUCD in Interval Period:- • During visit to the health facility • During home visits by ASHA

17. IUCD in Post Partum period :- Postpartum period - During antenatal visits At the time of admission/ early labour Within 48 hours of delivery Post Abortion Period- On confirmation of pregnancy, if the woman wants MTP Before initiating the abortion procedure After completion of abortion for the woman

18. COUNSELLING General FP Counselling- to choose what , why , when and how. Method specific counselling- Effectiveness ,Health benefits and advantages ,Side effects, health risks and complications and when to return for follow up. Follow up Counselling- satisfaction ,any problems or concerns

19. Post Insertion Counselling Follow-up visits - after 6 weeks or first menstruation. Any time if any warning sign or if the IUCD is expelled Warning signs - P: Period related problems or pregnancy symptoms A: Abdominal pain or pain during intercourse I: Infections or unusual vaginal discharge N: Not feeling well, fever, chills S: String problems

20. ASSESSMENT FOR ELIGIBILITY 1. Clinical assessment – Clinical history, physical examination( general, systemic and pelvic). 2. Assessment for PPIUCD- First Assessment Second Assessment Insertion • Any distorted uterine cavity (uterine septum, fibroid uterus, etc.) • Acute purulent discharge • High risk of exposure to STIs like Gonorrhoea or Chlamydia • Malignant or benign trophoblastic disease • AIDS and neither clinically well nor on antiretroviral therapy Rule out • Chorioamnionitis • Postpartum endometritis or puerperal sepsis • More than 18 hours from rupture of membranes to delivery of the baby • Unresolved postpartum hemorrhage • Extensive genital trauma If patient is eligible

21. INSERTION TECHNIQUES

22. PRE INSERTION PREPARATION Patient Preparation Provider preparation Visualization of the cervix Cleaning of the cervix and vagina Grasping the anterior lip of cervix Grasping the anterior lip of cervix with vulsellum

23. Loading of IUCD 380 A ‘No Touch Technique’ – for Interval IUCD or PAIUCD IUCD 375 is pre-loaded Check the contents of the packet Partially open the packet Place the white plunger rod in the clear insertion tube Placing plunger rod in insertion tube.

24. Bend the “arms” of the “T” downward Positioning IUCD and bending arms of T

25. Pull the insertion tube away from folded arms of the T Push the folded arms of the T into the insertion tube Inserting folded IUCD arms in insertion tube

26. Set the cervical guard/ blue length-gauge to the appropriate measurement Align the cervical guard/blue length-gauge and folded arms of the T so that they are both in a “horizontal” position Remove the loaded IUCD from the package IUCD fully loaded in insertion tube

27. Insertion of IUCD Insert the sterile uterine sound Advance the sound into uterine cavity, and STOP when slight resistance is felt Determine the angle/ direction and length of the uterine cavity Hold the loaded IUCD with one hand Insert the loaded IUCD Gently advance loaded IUCD into the uterine cavity

28. IUCD-While holding vulsellum and plunger rod stationary Withdraw the insertion tube downwards Release of IUCD arms -‘ Withdrawal technique’ Remove the white plunger rod To ensure that arms of ‘T’ are high in fundus of the uterus, gently push the insertion tube upwards again Use sharp curved scissors to cut the strings at 3 to 4 cm from the cervical opening and remove the insertion tube from the cervical canal

29. PPIUCD insertion (post placental: within 10 min of delivery) The anterior lip of the cervix to be held with ring forceps or sponge holding forceps Grasp the IUCD

30. Insert PPIUCD in lower uterine cavity Advance IUCD in uterine cavity High fundal placement of IUCD release the IUCD at the fundus. Slowly remove PPIUCD insertion forceps Examine the Cervix

31. Postpartum IUCD Insertion within 48 Hours of Delivery Ask to empty her bladder. Abdominal examination- for level and tone Insert IUCD using PPIUCD insertion forceps Examine the cervix following insertion Between 48 hours and6 weeks after birth:IUCD insertion is not recommended during this period because the uterus is softer and more vascular than in its non-pregnant state and is susceptible to an increase in perforation and overall complication rate.

32. Intra-caesarean Insertion of IUCD Counsell for PPIUCD before the caesarean procedure After delivery of the baby and placenta and evaluation for PPH but prior to closure of uterine incision. Either manually or using sponge holding forceps Hold IUCD between the middle and index fingers of the hand and pass it through the uterine incision IUCD strings can be pointed towards lower uterine segment but should NOT be pushed through the cervical canal. Holding the IUCD between middle and index finger

33. Post-insertion counselling There may be increase in duration/ amount of menstrual bleeding or spotting Discomfort or cramps Spontaneous expulsion IUCD does not protect against STIs/ HIV Can be removed anytime (Except for PPIUCD insertion, when IUCD removal should be delayed till at least 6 weeks after insertion

34. INSERTION TECHNIQUES If the insertion is correct, strings will not be seen at the cervix at postpartum. Even in cesarean section, there is no need to push the strings into the cervix. The strings follow the lochia and can be seen at the cervix by about 6 weeks. In about 50 % of the patients, strings will not be seen at the cervix. Hence, one follow-up at 6 weeks with the provider is mandatory. If at 6 weeks the strings are long, or the partner can feel strings, it can be trimmed. If the strings cannot be seen, ultrasonography can be done to reassure the patient about the placement of IUCD

35. COMPLICATIONS

36. Follow up Visits First follow up visit is mandatory and has to be done at 6 weeks or after next menstrual periods Subsequent visits should be after 3 months and 6 months Anytime if she is experiencing problems Follow up home visits can be done by ANM supported by ASHA or AWW Follow-up Care - Assessing for menstrual changes ,infection and expulsion

37. IUCD removal Indications for IUCD removal - Woman wants another child IUCD needs to be replaced Medical reasons (e.g. pregnancy, heavy menstrual bleeding) Woman wants to switch to another method Menopause Evidence of IUCD displacement Personal reasons

38. IUCD should not be removed if- Infection is present Between 48 hours and 6 weeks post-delivery Procedure- Clean the cervix and vagina at least two times Hold the anterior lip of cervix with a vulsellum Grasp the strings of the IUCD with an artery forceps and apply traction, gently pulling the strings

39. Grasping the IUCD threads

40. Future of IUD ( under investigation)

41. MISSING THREAD Rule out pregnancy Probe the cervical canal using sterile long artery forceps to locate the strings, and gently draw them out so that they can be seen protruding into the vaginal canal. If the strings are not located in the cervical canal refer the woman for an ultrasound (or X ray, if ultrasound is unavailable) to help determine whether the IUCD is still in place, is malpositioned , or has been expelled.

42. PREGNANCY WITH CU T INSITU Possible Symptoms/ Signs :- Missed menstrual period Other symptoms/ signs of pregnancy Missing strings Strings which are shorter or longer than expected

43. Management of pregnancy with IUCD Confirm pregnancy and its duration. Rule out ectopic pregnancy When ectopic pregnancy has been ruled out, and if the pregnancy is in the first trimester Counsel the woman - the benefits and risks of removal ,the risk of abortion. If the woman requests for removal- proceed with immediate removal if the strings are visible and the pregnancy is in the first trimester. If the strings are not visible, do an ultrasound to determine whether the IUCD is still in the uterus or has been expelled. If the IUCD is still in place, do not try to remove it. If the woman declines removal, provide antenatal care

44. References:-

45. References:- Berek & Novak's Gynecology - Wolters Kluwer Gabbe's Obstetrics Essentials: Normal and Problem Pregnancies Reference Manual for IUCD Services - National health Mission.