Copper IUD Insertion

Copper IUD insertion places a T-shaped copper device in the uterine cavity. It provides highly effective contraception with immediate protection and does not alter hormones. The copper T 380A is effective for up to 12 years; some other copper devices last 3 to 8 years. It is also the most effective emergency contraceptive.

Indications.

• Contraception for any patient who wants a long-acting, hormone-free reversible method, including nulliparous patients and adolescents.

• Emergency contraception within 5 days of unprotected sex.

• Contraception when hormones are contraindicated.

Contraindications (category 4 at initiation). Pregnancy; puerperal sepsis; immediately after septic abortion; current pelvic inflammatory disease, purulent cervicitis, chlamydia or gonorrhoea; unexplained vaginal bleeding before evaluation; cervical or endometrial cancer awaiting treatment; gestational trophoblastic disease with persistently raised hCG; uterine distortion; pelvic tuberculosis. Also avoid with copper allergy or Wilson disease.

Timing.

• Interval: within the first 12 days after the start of menses, or at any other time when reasonably certain the patient is not pregnant. No backup is needed.

• Post-placental: within 10 minutes after delivery of the placenta.

• Trans-caesarean: after delivery and before the uterus is closed.

• Immediate postpartum: after the post-placental window but within 48 hours of birth; if not done within 48 hours, wait until 4 weeks after delivery.

• Postabortion: immediately or within 12 days when there is no infection or significant genital tract injury.

• Do not insert after prolonged rupture of membranes, prolonged labour or puerperal infection.

Preparation. Consent and pregnancy exclusion; bimanual examination for uterine size, position and tenderness; ibuprofen 400 to 800 mg 30 to 60 minutes before; local anaesthetic if needed.

Equipment. Sterile gloves; speculum; antiseptic (chlorhexidine or povidone-iodine) and swabs; tenaculum or atraumatic cervical forceps; uterine sound; sterile scissors; the device in its sterile package; a container for waste; emergency drugs.

Interval insertion, no-touch technique.

• Place the patient in the lithotomy position; perform a bimanual examination to establish the position and size of the uterus.

• Insert the speculum, visualise the cervix and clean the cervix and vagina with antiseptic.

• Apply the tenaculum to the anterior cervical lip at 12 o'clock, taking time to place it gently, and apply gentle traction to straighten the cervical canal.

• Pass the sound slowly through the cervix until it meets the fundus; the depth is usually 6 to 9 cm. Seek expert help if it is outside this range or the sound will not pass.

• With the device still in its package, load the T so that the arms fold into the inserter without touching the device, and set the flange at the sounded depth.

• Remove the tenaculum traction slightly, introduce the loaded inserter through the cervix to the flange mark, withdraw the tube about 1 cm to release the arms, and gently push the inserter up so that the arms rest at the fundus.

• Withdraw the inserter fully and cut the strings about 3 to 4 cm from the cervix.

• Remove the tenaculum, check for bleeding at the site, remove the speculum and check the patient's condition.

Post-placental insertion. Use long forceps to place the device at the fundus within 10 minutes of the placenta, with the strings left toward the cervix. At caesarean section place the device at the fundus by hand and pass the strings through the cervix before closing the uterus.

After the procedure. Allow the patient to rest for 15 to 30 minutes, check vital signs, and confirm she can walk without dizziness before discharge. Decontaminate instruments.

Problems at the time of insertion.

• Pain, cramping or vasovagal reaction: pause, reassure, lay flat with legs raised, monitor pulse and blood pressure.

• Difficult insertion or cervical stenosis: stop and reassess; do not force.

• Cervical laceration: apply pressure; repair if large or bleeding persists.

• Suspected uterine perforation (sudden pain, sound or inserter passing without resistance past the expected depth, bleeding): stop immediately, remove the device and instruments if possible, keep the patient at rest, monitor vital signs and abdominal tenderness, start an intravenous line, give a prophylactic antibiotic, and refer urgently for surgical review if there is severe pain, changing vital signs or peritoneal signs.

Delayed problems.

• Expulsion: in about 2 to 10 in 100 in the first year, and more often after immediate postpartum insertion; reinsert after excluding pregnancy.

• Pelvic infection, mostly in the first 20 days after insertion and usually linked to infection present at insertion.

• Heavier or longer periods in the first 3 to 6 months: ibuprofen 400 mg orally three times daily for 5 days, or tranexamic acid 1 g orally three times daily for 4 days.

• Pregnancy with the device in place: exclude ectopic pregnancy.

Instructions. Cramping and spotting are common for a few days. Check for the strings after each period in the first months. Use condoms for STI protection.

Return urgently for fever, chills, increasing or severe lower abdominal pain, pain during sex, unusual vaginal discharge (especially in the first 20 days), a missed period or suspected pregnancy, or if the strings cannot be felt or the device is felt or has come out.

Follow up. Review at 3 to 6 weeks to check the strings and ask about symptoms. If the strings cannot be felt on bimanual examination, give backup contraception and arrange ultrasound to confirm the device is in the uterus.

Card. Give a card with the device type, date of insertion and the date for removal or replacement.

Special groups. Postpartum insertion carries a higher expulsion risk and needs follow up. Breastfeeding patients have a higher perforation risk; use extra care.

Referral and escalation. Refer for suspected perforation, device not found in the uterus, failed or difficult insertion after one attempt, and pregnancy with the device in place.