Pocket ObGyn – Intrauterine Device Insertion (IUD) / Subdermal Device Insertion
See Abbreviations

Intrauterine Device Insertion (IUD)

Levonorgestrel Intrauterine System (LNG-IUS) (Adapted from Bayer HealthCare Pharmaceuticals Inc., physician insert, 2009)

Timing: Insert after Preg ruled out or after 1st trimester abortion or postpartum

• Preparation:

Informed consent, bimanual exam

Obtain cervical cx, cleanse cervix w/ an antiseptic solution Consider paracervical block

Sound uterine cavity

• Procedure (sterile):

See http://www.mirena-us.com/hcp/placement-&-removal/precise-placement.jsp Ensure slider on inserter is advanced all the way toward the device. Pull threads

to draw device into insertion tube. Ensure arms are parallel to slider. Fix threads in the cleft at end of handle. Set flange to depth measured by uterine sound.

Hold the slider firmly. Apply gentle countertraction w/ tenaculum. Gently advance the insertion tube into the uterus until flange is 1.5–2 cm from external cervical os. While holding inserter, release device by pulling slider back until top of slider reaches mark. Advance inserter until flange touches cervix.

Release LNG-IUS by pulling the slider down all the way Cut threads to 2–3 cm visible outside cervix

Consider US to verify position. Remove if not positioned appropriately. Do not reinsert same device.

String check ~4 w after placement of IUD

ParaGard (Copper T 380A IUD) (Adapted from Teva Women’s Health, Inc., physician insert, 2010)

Timing: Same as LNG-IUS. Can be used as emergency contraception w/i 5 d of unprotected intercourse.
Preparation: Same as LNG-IUS

• Procedure:

See http://www.paragard.com/Pdf/ParaGard-PI.pdf

Load IUD into insertion tube by folding the 2 horizontal arms against the stem, & push tips of the arms securely into the inserter tube (<5 min from insertion)

Introduce white rod into the insertion tube until it touches the end of the IUD Adjust the blue flange to the uterus cavity length. Advance insertion tube to uter-

ine fundus (blue flange should be at external os).

Hold white rod steady & withdraw the insertion tube 1 cm to release IUD Advance insertion tube to fundus

Hold the tube steady & withdrew rod

Withdraw tube completely. Trim threads to 3–4 cm.

Consider US to verify position. Remove if not positioned appropriately. Do not reinsert same device.

String check ~4 w after placement of IUD

Go to Top

Subdermal Device Insertion

Etonogestrel implant (Implanon) insertion (Adapted from Merck & Co Inc., physician insert, 2012)

Timing: Same as LNG-IUS
Preparation: Informed consent

• Procedure (sterile):

Position arm flexed at the elbow & externally rotated so that wrist is parallel to ear or her hand is positioned next to her head

Identify insertion site at the inner side of the nondominant upper arm about 8–10 cm (3–4 in) above the medial epicondyle of the humerus

Insert just under skin to avoid large bld vessels & nerves deeper in the subcutaneous tissue btw triceps & biceps muscles

Mark the spot where implant will be inserted. Mark a spot a few centimeters prox to the 1st mark as a direction guide.

Clean insertion site w/ an antiseptic solution; anesthetize area along insertion path. Remove implant applicator from package. Ensure implant needle & rod are sterile.

Look for the etonogestrel implant rod, (white cylinder inside the needle tip) Lower the IMPLANON rod back into the needle by tapping it back into the nee-

dle tip. Remove the needle shield while holding the applicator upright.

Stretch the skin around the insertion site w/ thumb & index finger At <20-degree angle, insert tip of the needle w/ bevel up

Lower applicator to a horizontal position. Lift the skin up w/ the tip of the needle. While “tenting” the skin, insert the needle to its full length parallel to skin surface Press the obturator support, turn obturator 90 degrees

Hold obturator fixed & fully retract cannula. Confirm that the implant has been inserted by palpation. Grooved tip of the obturator should be visible.

Consider pres dressing to minimize bruising

If not palpable, implant can be located w/ high-frequency US or MRI