Clinical Pearls and Common Pitfalls 1) Use care with language: give anticipatory statements to patient as you go, − “soften your muscles, take a deep breath, allow your head and shoulders to fall into the pillow” rather than to just “relax” − “you will feel me swabbing here” rather than “I am cleaning” 2) Visualization: − Position the patient far down on the exam table − Ensure adequate lighting (a gooseneck lamp or plastic lighted speculum) − Use the right size and shaped speculum: o if too narrow or too short the speculum will not allow good visualization o go up a size or increase width if needed o it may help to open the speculum blades at the base as well as the tip For the obese patient consider: o a stronger or longer metal speculum o have her hold her knees or legs up if necessary to lift her buttocks o lower the head of the table if necessary o if redundant vaginal tissue obstructs the cervix, consider placing the speculum in a condom then cut a hole at the end of the condom 3) Tenaculum: Always use a tenaculum for IUC placement; traction on the tenaculum straightens the sharp angle between the cervix and uterine body − Hold the tenaculum with your palm up so you can see above it − Take a bite that is about the size of a nickel. A bite that is too small can lead to tearing, too large a bite is unnecessarily painful − Place the bite about halfway between the external os and the edge of the cervix (1.5-3 cm away from the external os.) Any closer may clamp down or obscure the opening so that the sound will not pass through − Only clamp to first or second ratchet, and clamp slowly to minimize pain − If the tenaculum obstructs your view, rather than moving it out of the way, remember to use it. Check your hand placement: you may need to flip your hand over, or move your palm away from the handle. − During IUC placement, hold the tenaculum between thumb and fingers without hooking your fingers through the rings; this may cause inadvertent movements which can be painful for the patient 4) Sound: Always use a sound (metal, plastic disposable or endometrial sampler) to measure the uterine length and gauge the curvature of the uterus and cervical canal prior to placement of an IUC − Hold the sound like a pencil or a dart between the thumb and first two fingers. This gives a natural limit to how far the sound will travel which helps reduce risk of perforation − Initiate movement from the wrist rather than the shoulder or elbow. − If you encounter difficulty passing through the internal os, try a small dilator or a plastic os- finder to open or gently dilate the internal os before sounding. Also, just wait to see if the internal os will relax and open. Maintain sterility of the tip (the working end) of the sound. Do not allow it to touch the vaginal wall. − Bend it as needed to reflect uterine flexion in the first 4-8cm rather than >9cm. Metal sounds may come out of a sterile package bent at >9cm. − Advance with steady gentle pressure. o If the sound does not pass with gentle pressure, it is probably not oriented correctly. o Feel the smooth wall of the cervix as you advance the sound, if it gets to a gritty feeling, you may be in a cervical gland or making a false passage o Do not apply more pressure: gently change the angle of the sound, trying to advance more anteriorly or posteriorly, or change the direction or amount of traction on the tenaculum slightly. − Touch the fundus once. Repeated tapping is uncomfortable for the patient − Move slowly. Moving too quickly increases the risk of perforation 5) Loading and preparing the IUC: Remember: different devices have different loading & deployment instructions. − Review the instructions for the particular device you are about to place: Read or go over each step and watch a placement video and/or or practice with a sample of the device and a model just prior to actual placement. − Use no-touch technique or non-contaminated sterile powderless gloves to load the device. 5a) Copper T IUC: − Make sure the white rod stays in contact with the bottom of the IUC at all times. “Kissing the butt” − Do not use the white rod as a plunger as this increases risk of perforation--pull back the insertion tube to release the arms of the IUC − Re-advance the insertion tube after deployment to ensure correct fundal positioning. − After deployment take out the white rod first and the insertion tube second 5b) LNG IUCs − Align the arms horizontally prior to pulling the IUC into the insertion tube − Hold the thumb or index finger on the slider during the entire procedure. − Bring the slider exactly to the first mark when the inserter is 1.5-2cm from the external os − Wait 10 seconds at the first mark 6) Cutting strings: − Cut the strings approximately 3-4 cm from the external os; adequate to cover the distance from the os to the bottom of the posterior cervical lip. o Cutting the strings < 3 cm can cause discomfort for a partner o Cutting the strings too long may cause discomfort for the patient or nadvertent pulling of the IUD out when checking for it − Use sharp scissors and be sure that both strings are cut completely. If the scissors are dull or the strings are merely bent and not cut through completely, the strings may be lying within the scissor blades, and you may accidently pull out the IUC as you pull out the scissors. − Long curved scissors are best − Cut strings straight across (perpendicular) rather than at an angle, this creates a less sharp tip to prevent discomfort for a male partner .