10 · Insertion Procedure, Post-Care & Infection Control

The full skills-certificate sequence: consent → preparation → insertion → follow-up, with aseptic technique throughout.

Objectives (Skills Certificate): obtain informed consent · prepare and assemble equipment and site · perform insertion with appropriate technique · provide post-procedure instructions · adhere to infection control and safety throughout.

1 · Informed consent

Explain the procedure's purpose, expected benefits, potential risks (pain, bleeding, vasovagal reaction, perforation, expulsion, infection, ectopic risk), and post-procedure care. Confirm the patient understands and answer questions. Obtain a complete medical and social history and exclude contraindications; if indicated, screen for genital/STIs and exclude endometrial pathology in patients with persistent atypical bleeding.

2 · Preparation

Bimanual exam in lithotomy position to establish uterine size, shape, and position; exclude pregnancy and other contraindications.
Insert the speculum to visualize the cervix; cleanse the cervix and vagina thoroughly with antiseptic.
Tenaculum on the appropriate lip (upper if anteverted, lower if retroverted); apply gentle traction to align the canal. Perform a paracervical block if needed. Maintain traction throughout.
Sound the uterus to measure depth (6–10 cm for the 52 mg device) and confirm direction. If stenosis is met, dilate — do not force. Consider analgesics before insertion.

3 · Insertion steps

Step	Action
1	Open the sterile package with sterile gloves; lift the inserter handle out.
2	Load the arms by pushing the slider fully forward; do not move the slider down yet (premature release cannot be reloaded).
3	Set the flange to the sounded depth in centimeters.
4	Advance through the cervix until the flange is ~1.5–2 cm from the cervix, then pause. Do not force.
5	Hold the inserter steady; move the slider to the mark to release the arms; wait ~10 seconds for them to open.
6	Advance gently to the fundus until the flange touches the cervix; stop at fundal resistance (fundal position prevents expulsion).
7	Holding the inserter in place, move the slider all the way down to release the device; withdraw the inserter while holding the slider down.
Cut	Cut the threads perpendicular, leaving ~3 cm visible; do not pull the threads. Record the lot number; give analgesics if indicated.

⭐ If malposition is suspected during or after insertion (exceptional pain, bleeding, or symptoms not resolving in ~30 min), evaluate with exam and transvaginal ultrasound. Remove if not completely within the uterus — and never reinsert a removed device.

4 · Post-procedure care & follow-up

Re-examine and evaluate the patient at 4–6 weeks, then yearly (or sooner if indicated).
Teach the patient to check the threads monthly and to report warning signs: lower abdominal/pelvic pain, odorous discharge, unexplained bleeding, fever, or genital lesions (possible PID), and signs of ectopic pregnancy.
Counsel on expected bleeding changes and pain management.

5 · Infection control & safety

Aseptic technique is essential — the strongest defense against serious infection (including Group A strep sepsis).
Sterile gloves and instruments; cleanse the cervix/vagina before instrumentation; use sterile single-use devices.
Monitor for vasovagal reaction during and after; position safely and observe before discharge.