Inserting the immediate postpartum IUD after vaginal or cesarean birth step by step
Technique for placing an IUD immediately after vaginal birth
1. Bring supplies for intrauterine device (IUD) insertion: the IUD, posterior blade of a speculum or retractor for posterior vagina, ring forceps, curved Kelly placenta forceps, and scissors.
2. Determine that the patient still wants the IUD and is still medically eligible for the IUD. Place the IUD as soon as possible following placenta delivery; in most studies IUD placement occurred within 10 minutes of the placenta. Any perineal lacerations should be repaired after IUD placement.
3. Break down the bed to facilitate placement. If the perineum or vagina is soiled with stool or meconium then consider povodine-iodine prep.
4. Place the posterior blade of the speculum into the vagina and grasp the anterior cervix with the ring forceps.
5. Set up the IUD for insertion: Change into new sterile gloves. Remove the IUD from the inserter. For levonorgestrel IUDs, cut the strings so that the length of the IUD and strings together is approximately 10 to 12 cm; copper IUDs do not need strings trimmed. Hold one arm of the IUD with the long Kelly placenta forceps so that the stem of the IUD is approximately parallel to the shaft of the forceps.
6. Insert the IUD: Guide the IUD into the lower uterine segment with the left hand on the cervix ring forceps and the right hand on the IUD forceps. After passing the IUD through the cervix, move the left hand to the abdomen and press the fundus posterior and caudad to straighten the endometrial canal and to feel the IUD at the fundus. With the right hand, guide the IUD to the fundus; this often entails dropping the hand significantly and guiding the IUD much more anteriorly than first expected.
7. Release the IUD with forceps wide open, sweeping the forceps to one side to avoid pulling the IUD out with the forceps. 8. Consider use of ultrasound guidance and ultrasound verification of fundal location, especially when first performing postplacental IUD placements.
8. Consider use of ultrasound guidance and ultrasound verification of fundal location, especially when first performing postplacental IUD placements.
Troubleshooting tips:
- If you are unable to visualize the anterior cervix, try to place the ring forceps by palpation.
- If you are unable to grasp the cervix with ring forceps by palpation, you may try to place the IUD manually. Hold the IUD between the first and second fingers of the right hand and place the IUD at the fundus. Release the IUD with the fingers wide open and remove the hand without removing the IUD.
Technique for placing an IUD immediately after cesarean birth
1. Determine that the patient still wants the IUD and is still medically eligible for the IUD. Place the IUD as soon as possible following placenta delivery; in most studies IUD placement occurred within 10 minutes of the placenta.
2. For levonorgestrel IUDs: Remove the IUD from the inserter. Cut the strings so that the length of the IUD and strings together is approximately 10 to 12 cm. Place the IUD at the fundus with a ring forceps and tuck the strings toward the cervix. It is not necessary to open the cervix or to place the strings through the cervix.
3. For copper IUDs: String trimming is not necessary. Place the IUD at the fundus with the IUD inserter or a ring forceps and tuck the strings toward the cervix. It is not necessary to open the cervix or to place the strings through the cervix.
4. Repair the hysterotomy as usual.