Trust PPIUD Caution For Usage

Infection Prevention: Infection prevention practices are integral part of PPIUCD insertion procedure. The following basic infection prevention processes are to be ensured: Consistent implementation of Standard Universal Precautions (SUP).
Use of aseptic/no-touch technique during every insertion procedure.
Use of High Level Disinfection (HLD)/sterilized equipment for every procedure with appropriate disposal of waste.
Standard Universal Precautions of Infection Prevention: Handwashing: Wash hands with soap and water or an appropriate alcohol-based hand rub before performing PPIUCD insertions and after the procedure.
Hands should be dried with a clean personal towel or air-dried. Towel should not be shared.
Self-protection such as wearing gloves and physical barrier: Wear gloves on both hands before touching anything such as lower genital tract skin and mucous membranes, blood or other body fluids while performing procedures.
Use protective goggles, face masks and aprons if splashes and spills of blood or other body fluids are possible (e.g. during the procedure itself or when cleaning instruments and other items).
Safe work practices and maintaining asepsis: Before PPIUCD insertion, apply a water-based antiseptic to the cervix and vagina two or more times.
Use aseptic/no-touch technique during every PPIUCD insertion.
Use only sterile PPIUCDs that are in intact and undamaged sterile packages and are not beyond expiry date.
Sterile/HLD gloves or instruments should be used throughout the procedure.
The IUCD should not touch the perineum, the vaginal walls or any other non-sterile surface that may contaminate it before placement in the uterus.
Ideally the IUCD should not be passed through the cervical os more than once.
The sterile Copper T and Inserter is for single use only and should not be reused.
Specific Infection Prevention Steps for the PPIUCD Procedure: Before insertion: Ensure that HLD/sterilized instruments and supplies are available and ready for use. Open all required HLD/sterile instruments and supplies onto a dry, HLD/sterile surface. PPIUCD should be placed close by in its sterile unopened packet.
Ensure that the PPIUCD package is unopened and undamaged and check the expiry date.
Do not pour the content of pouch in the instrument tray.
For postpartum insertion within 48 hours of delivery, wash or have the woman wash her perineal area with water before preparing the vagina and cervix. If immediately after delivery, in the absence of frank fecal contamination, cleaning the perineal area gently with a sterile gauze or towel is sufficient.
Hand washing and wearing of gloves should be done appropriately.
Using sterile cotton swab and a sterile sponge/ring forceps ensure that the cervix is cleaned with a water based antiseptic solution two times.
During insertion: Check black indicator strip on the inserter tube below the guard which indicates the horizontal position of the IUCD and guide correct placement of IUCD during insertion.
Throughout the procedure, use "no-touch" technique to reduce the risk of infection.
Steps for Insertion of IUCD Using PPIUCD Inserter: Steps of Postplacental/Postpartum within 48 hours Insertion by using PPIUCD Inserter: The steps described in the following text follow the 'Clinical Skills Checklist for Postplacental/Postpartum' within 48 hours Insertion of the IUCD using Inserter: 1. 1st assessment: Check woman's record to ensure that she is an appropriate client for IUCD and she has given her written consent.
2nd assessment: Using the Job-aid for PPIUCD pre-insertion screening of client (Annexure 1), rule out conditions which prevent insertion (exclusion criteria) of PPIUCD like: Rupture of membranes for more than 18 hours; Chorioamnionitis; Unresolved postpartum hemorrhage.
2. Confirm that HLD (High Level Disinfection)/sterile instruments, PPIUD inserter, supplies and light source are available in the labor room tor postplacental/Postpartum within 48 hours insertion.
Talk to the woman with kindness and respect.
Confirm with the woman whether she still wants IUCD.
Explain that the IUCD will be inserted following delivery of the placenta. Answer any questions she might have.
3. Perform hand hygiene and put on HLD or sterile gloves.
4. Arrange instruments and supplies on sterile tray or draped area.
5. Inspect perineum, labia and vaginal walls for lacerations. If lacerations are not bleeding heavily, insert the IUCD and repair if needed.
6. Gently visualize cervix by inserting a Sims speculum in the vagina and depressing the posterior wall of the vagina. Alternatively, four fingers or one hand can be placed in the vagina, depressing the posterior wall of the vagina and exposing the cervix.
7. Gently clean cervix with antiseptic solution two times using two separate cotton swabs with Povidone Iodine or Chlorhexidine. Wait for two minutes to allow the antiseptic to work.
8. Gently grasp the anterior lip of the cervix with the ring forceps up to the first lock. (The same ring forceps that was used to clean the cervix can be used).
9. Open the inserter pack from lower end. Grasp the Insertion tube at the lower end of the tube based on the provider's assessment of the uterus, the inserter can be bent slightly to better accommodate the angle of the uterus. Ensure that the blue guard is about 1 cm from where the strings end on the sleeve/tube of the inserter.
10. Apply gentle traction on the anterior lip of the cervix using the ring forceps and insert IUCD into lower uterine cavity. Avoid touching the walls of vagina.
The provider passes the PPIUCD inserter carefully into the lower uterine cavity.
11. Once the PPIUCD inserter is in the lower uterine cavity, lower the ring forceps that is holding the anterior lip of the cervix. Move the left (or non-dominant) hand to the woman's abdomen and push the entire uterus superiorly (upward). This is to straighten out the angle between the vagina and the uterus, so that the inserter can easily move upward toward the uterine fundus.
Alternatively, move the left hand to the woman's abdomen and stabilize the uterine fundus by applying gentle pressure at the fundus.
12. Gently move PPIUCD inserter upward towards the fundus following the curve of the uterine cavity.
The provider should take care not to apply excessive force. If the uterus is not pushed upward, the angle between the cervix and the uterus may not allow the inserter to advance smoothly.
13. Confirm that the IUCD has reached the fundus and when it reaches the uterine fundus, the provider will feel resistance and will also feel the thrust of the inserter at the fundus of the uterus with her left (or nondominant) hand which is placed on the abdomen at the level of the fundus.
14. Using the thumb of the hand holding the inserter, slide blue guard upward, releasing the threads of the IUCD. Release the IUCD at the fundus by now withdrawing the plastic sleeve from the fundus. Stabilize the uterus until the inserter is completely out of the uterus. Partially withdraw the insertion tube from the cervical canal until the string can be seen extending from the cervical os.
15. Use HLD or sterile scissors to cut the IUD string/thread close to the cervix/inside the cervix and then remove the insertion tube and place in 0.5% chlorine solution for 10 minutes for decontamination.
16. Examine the cervix to ensure there is no bleeding. It is important to check that the IUCD limb is not visible at the cervical os. If it is visible, then the IUCD has not been adequately placed at the fundus and the chance of spontaneous expulsion is higher.
If it appears that the IUCD is not placed high enough, the provider can remove the same.
17. Remove all instruments & inserter used and place them in 0.5% chlorine solution for 10 minutes for decontamination.
18. Allow the woman to rest for few minutes. Support the initiation of routine postpartum care, including immediate breastfeeding.
The woman should rest on the table for few minutes following the insertion procedure. The provider should reassure her that the insertion was done smoothly and that she now has an effective, safe and reliable long term spacing method of contraception.
19. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out and disposing of them.
Perform hand hygiene.
All infection prevention steps should be followed as per standard infection prevention procedures and facility protocol for waste management.
20. Provide the woman with postinsertion instructions: Provide IUCD card showing type of IUCD and date of insertion.
Inform her about the IUCD side effects and normal postpartum symptoms.
Tell the woman when to return for IUCD follow-up/PNC/newborn checkup.
Emphasize that she should come back any time she has a concern or experiences warning signs.
Inform her about the warning signs regarding IUCD.
Explain how to check for expulsion and what to do in case of expulsion.
Assure the woman that the IUCD will not affect breastfeeding and breast milk.
Ensure that the woman understands the postinsertion instructions.
Give written post-insertion instructions. Inform her that follow up is scheduled at 2 weeks and at 6 weeks. These instructions should be reinforced again by the staff of the postpartum unit and repeated to the woman, and if possible with her family.
21. Record information regarding the PPIUCD insertion in the woman's chart or record and proforma and in the Immediate PPIUCD register kept at the facility Tips for Reducing Spontaneous Expulsion.
Right technique: Elevate the uterus.
Place IUCD at the fundus.
Stabilize the uterus until the inserter is completely out of the uterus.
Right instrument: Use an insertion instrument (inserter) that is long enough to reach the fundus.
Right time: Postplacental insertions have lowest expulsion rates.
Post-Insertion Care for Immediate PPIUCD: Immediate post-insertion care at the health facility: The client should be advised to report any increase in more than expected vaginal bleeding or uterine cramping.
Vaginal hemorrhage related to uterine atony should be managed as per standard procedure with uterine massage and uterotonics as necessary (Note, the immediate PPIUCD does not increase the risk of uterine atony.)
If severe uterine cramping occurs and persists after PPIUCD insertion, a speculum or bimanual exam should be performed to check for partial or complete expulsion.
If the woman complains of fever, a full clinical evaluation needs to be done and in the presence of endometritis, an accepted antibiotic regimen should be used for treatment.
Post-insertion Instructions to the woman: There may be vaginal bleeding or spotting or cramping for initial few days/weeks after insertion. These symptoms are normally experienced by the woman in the postpartum period.
Spontaneous expulsion can happen in some cases, and is most likely to occur during the first three months postpartum. Be observant whether the IUCD comes out. If it does, come to the health facility immediately for reinsertion or another contraceptive.
The IUCD strings can be felt by some women. It is not necessary for her to check the strings. She may come to the health facility if she has any concern about the strings.
Remember IUCD does not protect against STIs and HIV. Resume intercourse at any time she feels ready.
Return for removal of the IUCD at any time she wants a pregnancy and she will have almost immediate return of fertility.
Before discharge, the following warnings signs should be highlighted and the client should been encouraged to call or come to the facility immediately for assessment: Heavy vaginal bleeding; Severe lower abdominal discomfort; Fever and not feeling well; Unusual vaginal discharge; Suspected expulsion: can either feel IUCD in the vagina or has seen it expelled from the vagina; Any other problems or questions she has related to IUCD.
Indications for Removal of an IUD: Wants another child.
IUCD to be replaced [i.e., at the end of its effective life of 10 yrs. (Cu IUCD 380 A) or before if she desires]. Ensure that she has undergone appropriate assessment to determine whether she is eligible for IUCD reinsertion at this time.
Medical reasons (e.g., pregnancy, heavy menstrual bleeding): Ensure that she has undergone the appropriate assessment to determine whether routine IUCD removal is safe for her at this time. Refer if needed.
Starting a different method Ask when her LMP began. This will help her choose an appropriate backup method.
Menopause.
Evidence of IUCD displacement.
Personal reasons (offers no reason at all): The woman has a right to discontinue the method at any time, regardless of the reason.
Ensure that she understands the following key points about having her IUCD removed, as appropriate: Woman must come to the health facility to have it removed whenever she wants to get pregnant, otherwise, at the end of the recommended period.
If she wants to continue to use the IUCD for a longer time, she can use it for 10 years and then have it replaced with another one.
Woman will be able to get pregnant soon after IUCD is removed.
If she does not want to become pregnant, she should immediately have another IUCD inserted or start another contraceptive method.
No rest period is needed between IUCDs.
Waste disposal: After completing a procedure (e.g., PPIUCD insertion), on completion of shelf life or on removal after use, dispose the items as per local regulations governing disposal of non-recyclable waste/medical waste.