Fitter resources

• Obtain informed consent and arrange for chaperone.
• An appropriately trained assistant should be present (to monitor & support the patient and assist in an emergency).
• Basic risk assessment includes gathering information about previous intrauterine procedures. Patients who have had previous adverse events during insertion are more likely to have them again.
• Pulse rate and blood pressure should be documented.
• The need for pain relief during insertion should be discussed with the patient.
• Routine antibiotic prophylaxis is not recommended pre-insertion. Women who have symptoms suggestive of STI should usually delay insertion of IUC for routine contraception. However, if immediate insertion of an IUD (for emergency contraception) is required, antibiotic cover could be considered.

Mirena^® (levonorgestrel 52mg) is contraindicated in those with current genital infection and current or recurrent pelvic inflammatory disease.^*

Kyleena^® (levonorgestrel 19.5mg) and Jaydess^®▼ (levonorgestrel 13.5mg) are contraindicated in acute or recurrent pelvic inflammatory disease or conditions associated with increased risk for pelvic infection.^*

^{* For a full list of contraindications, please refer to the Summary of Product Characteristic.}

• For women with symptomatic pelvic infection, postpone fitting and treat infection. Treatment should be complete before another attempt at insertion.
• A pelvic examination should be performed prior to inserting the device, to assess the size, shape, position and mobility of the uterus. It should also be done in order to detect any signs of acute genital infections or other contraindications for the insertion and to exclude pregnancy.
• Assessment of uterine size by sound measure.
• Forceps (tenaculum) are used to stabilise the cervix during insertion and reduce risk of perforation.
• Some fitters offer para-cervical block for the procedure.
• Many fitters use local anaesthetic gel on the cervix.
• Documentation should be made in the case notes of pre- and post-insertion counselling, the procedure, the type of device inserted, and any adverse events.

Mirena^® (levonorgestrel 52mg) is contraindicated in those with current genital infection and current or recurrent pelvic inflammatory disease.

Kyleena^® (levonorgestrel 19.5mg) and Jaydess^®▼ (levonorgestrel 13.5mg) are contraindicated in acute or recurrent pelvic inflammatory disease or conditions associated with increased risk for pelvic infection.

• Stop the procedure, lower the head and/or raise the legs. The IUD/IUS may need to be removed. An assistant should monitor observations. Ensure a clear airway. ‘ABC approach’ in basic resuscitation.
• Oxygen and suction as required. Consider use of atropine IV/IM for persistent bradycardia. Consider use of adrenaline IM 1:1000 for management of anaphylaxis.
• Automated external defibrillator (AED) should be available. Arrange ambulance transfer if there is no improvement.

• Syncope may be experienced at insertion secondary to vagal stimulation from the cervix. Bradycardia is more common in nulliparous women.

• If perforation is suspected the system should be removed as soon as possible; surgery may be required.

Information, advice and counselling

• Contraceptive choices discussed/preparation chosen
• Risks/benefits/uncertainties discussed
• How it works and efficacy
• Potential side effects
• Choice of device and duration of use
• Effects on bleeding pattern
• Risk of spontaneous expulsion and perforation and advisability of thread check and teaching
• Risk of post-insertion pelvic infection and record of any swabs taken, if applicable
• Bleeding pattern
• Explanation of insertion and removal procedure
• Consent obtained
• Leaflets given including manufacturer’s PIL
• Advice given on practising safe sex

Details of insertion procedure

• Name of clinician/assistant
• Any tests undertaken
• Bimanual/speculum examination findings
• Analgesia/local anaesthesia if used, including batch number and expiry date
• Tenaculum/Allis application used
• Uterine sounding/utero-cervical length
• Type of device inserted including batch number and expiry date
• Use of no-touch technique
• Problems encountered, if any, and action taken

Post-insertion advice and follow-up advice given

• Other treatment, if any e.g. antibiotics
• Special instructions, if any e.g. additional contraception for 7 days
• Follow up date if arranged; “see if any problems” acceptable