This protocol provides basic requirements for implementing IUD services at a family medicine teaching site. This interactive version also includes pop-up citations and practice tips. A print-ready/PDF version of the protocol is also available.

IUD Protocol

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Scheduling

Patients who request appointments for IUD insertion or removal should be scheduled as soon as possible—but no later than 7 days after appointment request.

  • Priority should be given to patients requesting removal due to symptomsIn settings where this information is not possible to obtain during the appointment request, consider getting a patient call-back number so a qualified staff member can contact the patient to clarify details ahead of the appointment.
  • Try to obtain prior authorization for devices as quickly as possible (per clinic protocol)
  • If no appointments are available, a provider should be consulted

Patient Eligibility

There are very few contraindications to using an IUD. However, the provider must be reasonably certain the patient is not pregnant before initiating contraception.

Further eligibility considerations can be addressed using these resources:

Staffing/Clinic Coverage

A medical provider needs to be credentialed prior to performing IUD procedures. Residents may perform IUD insertions only if a credentialed physician is present during the procedure.

In addition to the credentialed medical provider performing the IUD insertion, an additional person, such as a medical support person (LPN, PCT, MA, etc.) must be available in the room during the procedure. A family member may be present but does not replace the need for one of the above personnel.

The medical support person can have the role(s) of:

  • Witnessing the consent form
  • Retrieving instruments or supplies as needed during the procedure
  • Helping to keep the patient stable during a vasovagal or vomiting episode
  • Providing additional emotional support for the patient

A learner (resident, medical/nursing student, etc.) may be in the room and/or involved in the procedure only if the patient agrees to their participation. If a learner is present, an additional LPN/PCT/MA support person may not be needed. Recommended roles for learners include:

  • Medical students/NP students: observation only
  • Medical residents: observation and hands-on training. The IUD insertion and removal assessment tools may be used to evaluate the resident’s competence.

Storage Space

An instrument cart can be used for storage of both instruments and devicesIn many institutions, devices must be kept locked with medications. Refer to your institution’s policies and practices.. The cart can also serve as a surface for instruments during the procedure. The cart should remain locked when not in use. Sterilized instruments can be pre-packed and kept in the instrument cart along with devices and other necessary supplies.

No-Touch Technique

Preventing infection is an important goal during uterine instrumentation. During the procedure, the provider and staff will use a “no-touch” technique For more information on the technique, see this chapter from TEACH’s Early Abortion Training Workbook.to handle the instruments. This means having supplies on a sterile tray, keeping sterile and non-sterile instruments separate, and handling instruments in a way that avoids contact with the tips that enter the uterus.

List of Supplies

Single-use Items
Re-usable items
Medications
Chux for patient table
Specula in multiple sizes
IUD devices
GC/C, pap if needed
Single-tooth tenaculumAtraumatic or multi-tooth tenaculum should also be available.
ibuprofen
Gloves / Sterile gloves (optional)
Serrated ring forceps
Vaginal antisepticThere are ongoing studies evaluating the necessity of routine vaginal antiseptics before office-based vaginal procedures. At present, there is no evidence to demonstrate change in infection risk when using antiseptic cervicovaginal preparation. See for example:
                           
Achilles, Sharon L. et al. Prevention of infection after induced abortion. Contraception, Volume 83, Issue 4, 295-309
and applicatorThere are different ways to apply the antiseptics (individual pre-packaged swabs vs. pouring antiseptic onto 4X4 gauze or into basin)..
Sterile drape for tray
Disposable uterine sound
Sterile lubricating gel
Scissors
Sterile 4×4 gauze
13/15 Pratt dilator (optional)
Sanitary pad
Hot pack
Light source

 

Sample Tray Setup for IUD

Useful Documents

On the day of the IUD insertion:

  • Collect urine
    1. for pregnancy test
    2. for GC/CT screen
  • Document blood pressure
  • Print and have patient sign consent form and have it witnessedTypically, the witness only needs to observe the patient signing the document.
  • Offer pain medicationsDepending on your practice, you may choose to offer other forms of pain management. (ibuprofen 800mg)
  • Review Information for Patients after IUD Insertion
  • Confirm that patient knows how to contact the medical team if needed
  • Make a follow-upMost patients do not require an in-person follow-up visit after an IUD insertion. Offer a follow-up based on patient preferences and other medical needs. plan with the patient

On the day of the IUD removal:

  • Document blood pressure
  • Print and have patient sign consent form and have it witnessedTypically, the witness only needs to observe the patient signing the document.
  • Confirm that patient knows how to contact the medical team if needed
  • Determine if the patient prefers to start a new contraceptive today or notIt is important to recognize that patients may prefer not to discuss other contraceptive methods during this visit, or may wish to return to using condoms or no method at all.. Offer follow up appointment based on patient’s preferences and health needs.

“Time Out” Protocol

Consult with your institution to determine whether you must follow Joint Commission regulations regarding “time out”See:
                           
Barsuk JH et al. Process Changes to Increase Compliance With the Universal Protocol for Bedside Procedures. Arch Intern Med. 2011;171(10):941–954. doi:10.1001/archinternmed.2011.202
                           
Pellegrini CA. Time-outs and their role in improving safety and quality in surgery. Bull Am Coll Surg. 2017 Jun;102(6):54-6. PMID: 28885812
                           
The Joint Commission, National Time Out Day increases awareness on supporting safety culture, safe practices in OR. Accessed 2/26/2019.
prior to a LARC insertion. Obtaining the consent in the presence of the involved staff may serve as an appropriate substitute. Otherwise, “time out” may include verifying the patient’s name and DOB prior to the procedure.

Document the patient encounter per clinic protocol.

Before the patient leaves:

  • Take post-procedural VS
  • Ensure patient has a way to reach the clinic
  • Make sure patient has received the post-procedure information

Clean-up per clinic protocol.

Preparedness for Fainting/Vomiting

If fainting does occur, the following are appropriate interventions:

  • Observation (most patients recover without any intervention)
  • Administer ammonia inhalant
  • Apply cool towel to forehead
  • If patient vomits, this will most likely resolve with observation (no intervention)

Management of IUD Instruments

LPN/PCT should soak dirty instruments in enzymatic cleaner, scrub any visually bloody areas, then rinse the instruments and let them air-dry. All used, dirty medical instruments must be kept in a “dirty” area of a room. Once dry, the instruments should then be packaged into bags to be autoclaved.

Autoclaving on-site:

  • Document training and certification in sterilization/infection control procedures.
  • Maintain a log for machine runs, cleaning schedule; attest results.

Sterile instruments can then be stored in the instrument cart.