Fptraining.org



Copper-Bearing Intrauterine Devices (IUDs): Session Plan

Notes to Facilitator:

The slides and session plan provide presentation support for conveying technical information and for conducting the interactive learning activities.

This module focuses on copper-bearing IUDs and more specifically, the Copper T IUD (TCu380A), which is the most commonly used copper IUD worldwide.

To use this presentation most effectively, please:

• Read the IUDs Facilitator’s Guide, on the Using the Training Resource Package tab, for guidance on selecting and adapting TRP materials for the learning needs of your audience.

• Next read this session plan, which includes detailed learning objectives for this module and describes how to use this presentation and other materials required to prepare for and conduct the learning activities.

|Training Process |Resources |

|Session I: Characteristics of IUDs |

|Session I Objective: Describe the characteristics of copper-bearing IUD in a manner that clients can understand. |

|Welcome and Introduction (10 min.) |Basic Slide Set #1 Slide 2: Copper |

|Greet participants and introduce yourself. |IUDs: Objectives |

|See conducting training tool for ice breaker options. | |

|Objectives |Conducting training tool: Ice |

|Discussion (5 min.) |Breaker Options |

|The session is designed to address the IUD-related objectives listed in the session plan. | |

|Review objectives with participants. | |

|Explain that the learning objectives will be assessed through knowledge assessments, role plays, the | |

|use of skills checklists, and during clinical practicum. | |

|Explain that during this training, participants will learn, practice and demonstrate skills during | |

|role plays and other activities. Participants will also be encouraged to think about what it will be | |

|like to perform these tasks on the job. | |

|Solicit input about whether the planned objectives match participant’s expectations of the training. | |

|Distribute the pre-test. | |

|Pre-Test Questionnaire |Evaluation Tool: The Copper |

|(30 min.) |Intrauterine Devices (IUDs) |

| |Pre-Test |

|What are IUDs? Key Points for Providers and Clients |Basic Slide Set #1 Slides 3 and 4: |

|Discussion (10 min.) |IUDs: Key Points for Providers and |

|Ask the participants: |Clients |

|What are IUDs? . | |

|What are some qualities of IUDs that are unique to this method? . | |

|Explain: | |

|IUDs are small plastic devices inserted through the vagina and cervix into the uterus. | |

|The key points to remember about IUDs include: | |

|They are small devices that fit inside the womb | |

|Are very effective (more than 99 percent effective) in preventing pregnancy | |

|Are long acting and easily reversible. IUDs can work up to 12 years (depending on type) and can be | |

|easily removed by a provider whenever the woman wants. Return to fertility occurs very soon after an | |

|IUD is removed. It has also been shown that the IUD can be used by women who have never had a baby | |

|without having any negative effect on their future fertility. | |

|Are very safe; they might increase menstrual bleeding or cramps; and they do not provide protection | |

|against STIs or HIV and AIDS. | |

|Copper IUDs |Basic Slide Set #1 Slides 5 and 6: |

|Discussion (10 min.) |Copper IUDs and Other Types of IUDs|

|Ask the participants: | |

|What are the types of IUDs in use today? . | |

|How do they differ? | |

|Explain: | |

|Today, the most commonly inserted IUDs are copper-bearing IUDs. The most commonly used copper-bearing| |

|IUD is a small, T-shaped plastic frame with copper sleeves or wire around it. | |

|In the late 1960s, researchers found that adding copper to the plastic frames made IUDs more | |

|effective than earlier devices. The copper released into the uterine cavity increases the | |

|contraceptive efficacy of the IUD. | |

|They are safe, highly effective and long-acting contraceptive methods. IUDs remain effective for up | |

|to 12 years, depending on the type of the device. | |

|The TCu-380A, or “Copper T,” is the most widely used copper IUD in the world. | |

|The Multiload 375 is another copper-bearing IUD that is commonly available in some countries. | |

|Hormonal IUDs are another type of IUD currently in use. However, in most countries, the availability | |

|of hormonal IUDs is very limited because of their much higher cost compared to copper IUDs. | |

|Hormonal IUDs and copper IUDs have very different mechanisms of action and medical eligibility | |

|criteria. | |

|This session does not cover hormonal IUDs. Instead, the remainder of this module will focus on the | |

|Copper T IUD. | |

|Note to facilitator: Introduce the types of copper IUDs available in the country. The Copper T 380A | |

|and the Multiload 375 (if this is available) will most likely be registered under different names in | |

|different countries. | |

|Effectiveness |Basic Slide Set #1 Slide 7: |

|Discussion (10 min.) |Effectiveness of IUDs |

|Ask the participants: | |

|Where would you put IUDs on this list? |2: IUDs: Effectiveness |

|Inform: | |

|The list on this slide categorizes contraceptive methods from most effective to least effective as | |

|commonly used. In this list, spermicides are the least effective method and the most effective | |

|methods are contraceptive implants, sterilization and IUDs. | |

|Conclude by emphasizing that IUDs would be in the top tier of methods, as they are a very effective | |

|method of contraception. Only implants and male and female sterilization are more effective than | |

|IUDs. | |

|Relative Effectiveness |Basic Slide Set #1 Slide 8: |

|Lecturette (5 min.) |Relative Effectiveness of Family |

|Explain: |Planning Methods |

|There is another way to look at effectiveness. In this slide we look at how effective family planning| |

|(FP) methods are as they are commonly used. | |

|The slide shows the number of women who would get pregnant if 1,000 women used a method for one year.| |

|So, if 1,000 fertile women who were having sex, but not using any protection from pregnancy, 850 of | |

|them would become pregnant. | |

|But, if the same 1,000 women were using a Copper T IUD, 8 would become pregnant. | |

|As part of good counseling, it is important to inform clients about how effective each method is. | |

|Ask the participants: | |

|What if these same women were using a female condom? How many would become pregnant? | |

|Method Effectiveness |Handout #1: Comparing Effectiveness|

|Role Play (20 min.) |of Family Planning Methods |

|The purpose of this activity is to give participants an opportunity to practice explaining the |Handout #2: If 100 Women Use a |

|effectiveness of IUDs using two job aids: Comparing Effectiveness of Family Planning Methods and If |Method for One Year, How Many will |

|100 Women Use a Method for One Year, How Many Will Become Pregnant? |Become Pregnant? |

|Distribute copies of these job aids for participants to use. | |

|Remind participants that clients consider method effectiveness a key factor when making a decision | |

|about which method to use. | |

|Explain that the information on the previous slides on effectiveness may not necessarily be easy for | |

|clients to understand. These two job aids present the information in a more understandable format. | |

|Explain that: If 100 women use IUDs for 1 year, less than 1 woman will become pregnant if she uses | |

|IUDs consistently and correctly (perfect use). Less than 1 woman will become pregnant of IUDs are | |

|occasionally used incorrectly or not used (typical use). | |

|Before practicing with the tools, ask participants to answer following questions: | |

|How might you use these tools to help explain how effective IUDs are compared to other contraceptive | |

|methods? | |

|How do these job aids compare with other ways you have explained method effectiveness to clients? | |

|Allow time for participant discussion. | |

|Role play Instructions: | |

|Instruct participants to pair off with a person sitting next to them. | |

|One person should play the role of the provider, while the other pretends to be a client. | |

|Providers should use one of the job aids to explain IUD effectiveness as if they were interacting | |

|with an actual client. Encourage “clients” to ask questions. | |

|Give partners several minutes to practice. | |

|To conclude the activity, ask participants to gather as a large group and talk about the experience. | |

|Find out how well they thought the tools worked, whether they were helpful to the clients, and what | |

|they learned from this experience. | |

|Remind participants that they will have various opportunities to practice client-provider interaction| |

|and counseling, rotating client and provider roles, throughout the session. | |

|Explaining How IUDs Work |Basic Slide Set #1 Slide 9: |

|Brainstorming (10 min.) |IUDs: Mechanism of Action |

|The purpose of this activity is to keep participants focused on how they translate technical | |

|information into concepts that their clients can understand. | |

|For women who are interested in this method, how will you explain how IUDs work? | |

|Brainstorming instructions: | |

|Ask participants to brainstorm ideas about how to explain how IUDs work to prevent pregnancy, using | |

|simple language the client will understand. | |

|For example, “The IUD works mainly from stopping the sperm and egg from meeting.” | |

|Characteristics of IUDs |Basic Slide Set #1 Slide 10: Copper|

|Work Group Activity (20 min.) |IUDs: Characteristics |

|The purpose of this activity is to give participants an opportunity to think about some additional | |

|characteristics of copper IUDs that their clients may find to be positive or negative. | |

|Work group activity instructions: | |

|Ask participants to work in teams to create a list of the positive characteristics (advantages) of | |

|IUDs and the characteristics of IUDs that clients may perceive as negative (limitations) on separate | |

|sheets of flip chart paper. Encourage participants to consider not only the characteristics that have| |

|already been discussed, but to also think about their own professional experience with clients who | |

|have used copper IUDs. | |

|Tell the teams they will have exactly two minutes to create their lists. Signal the teams at the | |

|start and stop times, give a 30-second warning notice before the stop time, and ensure that teams put| |

|down their markers at the stop time. | |

|After the stop signal, ask teams to present their lists to the larger group. After all the groups | |

|have presented, ask participants to examine the lists and compare whether all the groups agreed about| |

|whether particular characteristics were positive or negative. Ask the participants to consider | |

|whether there may be clients who would perceive certain “beneficial” characteristics to be | |

|undesirable, and vice versa. | |

|Use Slide 9 to present the characteristics of IUDs (including advantages and limitations). | |

|Remind participants that women with similar characteristics in similar situations may have very | |

|different reasons for making method choices. When counseling women, it is important to help clients | |

|consider how these method characteristics fit into their lifestyles and reproductive health goals and| |

|desires. | |

|Award a token prize to the team with the most thorough lists. | |

|As you review the next few slides in the presentation, refer to the lists that the participants | |

|developed. | |

|Copper IUDs: Health Benefits |Basic Slide Set #1 Slide 11: Copper|

|Discussion (10 min.) |IUDs: Health Benefits |

|Inform: | |

|In addition to the benefit of preventing unwanted pregnancy and therefore preventing the risks |Optional Advanced Slide Set Slide |

|associated with pregnancy, IUD-use has some significant non-contraceptive health benefits. IUDs are |3: IUDs Reduce Risk of Ectopic |

|known to reduce risk of ectopic pregnancy. The ectopic pregnancy rate in IUD users is only 12 in |Pregnancy |

|10,000 (2 in 10,000 for the Copper T), compared to 65 in 10,000 for women using no contraception. | |

|However on a very rare occasion when an IUD fails, 6-8 out of 100 pregnancies resulting from a failed| |

|IUD are ectopic. | |

|IUDs have also been shown to help protect against endometrial cancer. | |

|Copper IUDs: Side Effects |Basic Slide Set #1 Slide 12: |

|Lecturette (10 min.) |Possible Side-Effects |

|Remind participants that as with many contraceptive methods, there are some side effects associated | |

|with IUDs that are not harmful but may be unpleasant. | |

|Women’s preferences for certain methods are often related to side effects. Ask the participants: What| |

|side effects of IUDs, have you heard about? | |

|As we have acknowledged, some women who take IUDs experience certain side effects. IUD users commonly| |

|experience the following side effects: | |

|Heavier and/or prolonged menstrual bleeding | |

|Increased menstrual cramping | |

|Spotting between periods. Spotting or irregular bleeding is more common immediately following IUD | |

|insertion. | |

|Typically, these side effects will become less pronounced within the first 3–6 months of use. | |

|Providers need to reassure the woman that these side effects do not indicate a serious medical | |

|problem. Increased cramping can be alleviated by taking ibuprofen, paracetamol, or other pain | |

|reliever—except aspirin—as needed. (Aspirin should not be taken because it slows clotting). | |

|Because these side effects may have an important impact on users’ experience with an IUD, they should| |

|be addressed during counseling and follow-up visits. | |

|Copper IUDs: Counseling about Side Effects |Basic Slide Set #1 Slide 13: |

|Lecturette (10 min.) |Copper IUDs: Counseling about Side |

|Thorough counseling is the best way to help women manage the side effects associated with IUDs. |Effects |

|When women know what to expect, there is less change that they will want to discontinue use. | |

|Before insertion, describe common side effects. | |

|Explain side effects: | |

|A woman who is considering using an IUD should be counseled that she may experience these side | |

|effects, and that they are not signs of disease or health problems. | |

|Providers need to reassure the woman that cramping can be alleviated by taking ibuprofen, | |

|paracetamol, or other pain reliever–except aspiring–as needed. | |

|For the majority of women, these side effects will become less pronounced within the first 3-6 months| |

|of use. | |

|Encourage to come back with questions or concerns: | |

|After IUD insertion, the practitioner should tell a client to come back if she has any questions or | |

|concerns. | |

|Ongoing counseling and reassurance should be provided if needed. | |

|If the user continues to be concerned or if she finds the side effects unacceptable, it may be | |

|necessary to remove the IUD. | |

|IUDs Fact Sheet |Handout #3: Fact Sheet: Copper IUDs|

|Brainstorming (10 min.) | |

|The purpose of this activity is to give participants an opportunity to review the characteristics of | |

|copper IUDs and explore the contents of the fact sheet. | |

|Brainstorming instructions: | |

|Introduce the fact sheet and ask participants to review copper IUD characteristics on the first page.| |

|Ask participants if there are any additional comments or questions about the characteristics of IUDs.| |

|Discuss and clarify as needed. | |

|Ask participants to consider how they might be able to use the fact sheet in their work. Remind | |

|participants that although it might be useful for helping providers to remember important information| |

|to share with clients, the fact sheet is not intended to be used as a brochure to be distributed to | |

|clients. | |

|Ask participants to review the rest of the information on the first page (about medical eligibility | |

|for IUD insertion) and the second page of the fact sheet. Inform the participants that the next | |

|segment of the training will address these issues. | |

|Training Process |Resources |

|Session II: Who Can and Cannot Use IUDs |

|Session II: Demonstrate how to screen clients for eligibility for IUD use. |

|Copper IUD is Safe for Most Women |Basic Slide Set #2 Slide 2: Copper |

|Lecturette (10 min.) |IUD Is Safe for Most Women |

|Most women can use copper-bearing IUDs safely and effectively, including women who: | |

|Have or have not had children | |

|Are not married | |

|Are of any age | |

|Have just had an abortion or miscarriage (no infection) | |

|Are breastfeeding | |

|Have had pelvic inflammatory disease (PID) – an infection of a woman’s upper genital tract. (More | |

|information on PID is provided in Complications of IUDs, Slide 9). | |

|Have vaginal infections | |

|Are infected with HIV and have mild or no clinical disease, whether or not they are on antiretroviral| |

|therapy | |

|Most health conditions do not affect safe and effective use of copper-bearing IUDs. | |

|Who Can and Cannot Use the IUD |Basic Slide Set #2 Slide 3: Who Can|

|Lecturette (15 min) |and Cannot Use the IUD |

|Use slide to explain that most women can safely use the IUD as mentioned in the previous slide. | |

|Medical Eligibility Criteria |Basic Slide Set #2 Slide 4: Medical|

|Brainstorming (10 min.) |Eligibility Criteria |

|This activity has two purposes: |Basic Slide Set #2 Slides 5 and 6: |

|To give participants an opportunity to share what they know about the eligibility criteria used in |WHO’s Medical Eligibility Criteria,|

|their national family planning guidelines or the WHO medical eligibility criteria (WHO MEC) so that |Categories for IUDs, Hormonal and |

|the facilitator can determine whether the participants understand the criteria and how they are used |Barrier Methods |

|or whether they need additional background information before proceeding. |Basic Slide Set #2 Slide 7: |

|To introduce job aids that help participants understand eligibility criteria (and that they may also |Category 1 and 2 Examples (not |

|use at their worksites), such as the WHO Medical Eligibility Criteria Wheel for Contraceptive Use, or|inclusive): |

|the Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use. |Who Can Use Copper IUDs |

|Brainstorming instructions: |Basic Slide Set #2 Slide 8: |

|Use slide 5 to introduce the concept of medical eligibility and determine whether participants have |Category 3 and 4 Examples (not |

|an adequate foundation. Explain the 4 categories: |inclusive): |

|Category 1: For women with these conditions or characteristics, the method presents no risk and can |Who Should Not Use Copper IUDs |

|be used without restrictions. | |

|Category 2: For women with these conditions or characteristics, the benefits of using the method |Handout #4: WHO Medical Eligibility|

|generally outweigh the theoretical or proven risks. Women with Category 2 conditions generally can |Criteria Wheel for Contraceptive |

|use the method, but careful follow-up may be required. |Use |

|Category 3: For women with these conditions or characteristics, the theoretical or proven risks of |Handout #5: The Quick Reference |

|using the method usually outweigh the benefits. Women with Category 3 conditions generally should not|Chart for the WHO Medical |

|use the method. However, if no better options for contraception are available or acceptable, the |Eligibility Criteria for |

|provider may judge that the method is appropriate, depending on the severity of the condition. In |Contraceptive Use |

|such cases, ongoing access to clinical services and careful follow-up will be required. | |

|Category 4: For women with these conditions or characteristics, the method presents an unacceptable | |

|health risk and should not be used. | |

|In some cases, a particular condition or characteristic is assigned to one category for initiation | |

|and another for continuation of the method. In other words, the category may depend on whether a | |

|woman with the condition wishes to initiate the contraceptive method or was already using that method| |

|when she developed the condition. | |

|Show slide 6. Explain that in situations where clinical judgment is limited, the four-category | |

|classification framework can be simplified into two categories. When simplified for these situations,| |

|categories 1 and 2 indicate that the method can be used, while categories 3 and 4 indicate that the | |

|woman is not medically eligible to use the method. | |

|Demonstrate how to use the WHO MEC Wheel or the Quick Reference Chart. Explain that IUDs are safe for| |

|the overwhelming majority of women. Use slides 7-8 to provide an overview of the medical eligibility | |

|criteria for IUDs. | |

|List 10-15 medical criteria on a flip chart. Ask participants to find the appropriate category on the| |

|WHO MEC Wheel or the Quick Reference Chart. If time allows, this exercise can be made into a game | |

|using teams to determine the correct answers. Ask several participants to share one thing that they| |

|know about the eligibility criteria in their national family planning/reproductive health guidelines | |

|(if they exist) or the WHO MEC. | |

|Answer any questions that participants have about general medical eligibility issues or how to use | |

|the Quick Reference Chart or MEC Wheel before moving on to medical eligibility for IUDs. | |

|IUD Use by Women with HIV Infection |Basic Slide Set #2 Slide #9: IUD |

|Discussion (10 min.) |Use by Women with HIV Infection |

|Ask participants: Let us take a closer look at the conditions and categories pertaining to clients | |

|with HIV or AIDs. |Optional Advanced Slide Set Slide |

|Use slide to present the following: |4: IUDs: Safe for Women with HIV |

|The medical eligibility criteria state that women with HIV can generally initiate and continue to use| |

|an IUD. HIV is classified as a Category 2 condition. This chart shows the specific WHO |Optional Advanced Slide Set Slide |

|recommendations. |5: IUD Use Does Not Increase HIV |

|An IUD can be provided to a woman with HIV if she has no or mild clinical disease whether or not she |Transmission |

|is on ARVs (Category 2) | |

|A woman who develops advanced or severe clinical disease while using an IUD can continue to use the | |

|device but should be monitored closely for pelvic inflammatory disease (Category 2) | |

|While IUD users who develop advanced or severe clinical disease can continue using the method, IUD | |

|initiation is generally not recommended in women who already have advanced or severe clinical | |

|disease. The WHO determined that IUD initiation in such women should be classified as a Category 3 | |

|conditions because of the theoretical risk that advanced immunosuppression could increase the risk of| |

|IUD-related complications. | |

|While the IUD offers highly effective protection from pregnancy, it does not guard against STI and | |

|HIV transmission. As with other methods, providers who counsel sexually active HIV-infected clients | |

|about their contraceptive options should always encourage condom use in addition to the IUD. | |

|IUD Use by Postpartum Women |Basic Slide Set #2 Slide 10: IUD |

|Lecturette (5 min.) |Use by Postpartum Women |

|Ask participants: Let us take a closer look at the conditions and categories pertaining to postpartum| |

|clients. | |

|Use slide to present the following: | |

|Women who are less than 48 hours postpartum may generally initiate the copper IUD. | |

|Women who are more than 48 hours but less than 4 weeks postpartum generally should not have an IUD | |

|inserted because of the increased risk of expulsion. | |

|Women who are 4 or more weeks postpartum may start using an IUD without restrictions. | |

|Postpartum women who have puerperal sepsis should not initiate IUD use until they are infection free.| |

|Note to facilitator: Consider using this slide if the participants will be offering services to | |

|postpartum clients. It provides a concise overview of medical eligibility issues related to IUD use | |

|by these clients. | |

|Understanding the Checklist for IUD Screening |Basic Slide Set #2 Slide 11: |

|Experiential Learning Exercise (15 min.) |Understanding the Copper IUD |

|The purpose of this activity is to introduce participants to the Checklist for Screening Clients Who |Checklist |

|Want to Initiate Use of the Copper IUD, to provide an overview of its purpose, and to show how to use| |

|it. |Handout #6: Checklist for Screening|

|Distribute an IUD checklist to each participant. |Clients Who Want to Initiate Use of|

|When introducing the checklist, note that it should be used by providers to determine whether a |the Copper IUD |

|client is medically eligible to use the method that she selected during an informed decision-making | |

|process. |Handout #5: |

|The questions on the checklist identify women how have health conditions–WHO category 3 or 4–that |Quick Reference Chart for the WHO |

|make it unsafe for them to use a copper IUD. The checklist also incorporates questions that allow a |Medical Eligibility Criteria for |

|provider to determine with reasonable certainty that a client is not pregnant. |Contraceptive Use |

|To use the checklist, providers ask the questions on the checklist and follow the instructions based | |

|on the client’s responses. Explain that the medical eligibility questions, questions 7-14, are in the| |

|middle of the checklist. | |

|Ask participants: to pair up with the person sitting next to them and take turns reading questions | |

|7-14 on the checklist as if they were asking a client each question. | |

|How have you determined a client’s medical eligibility for IUDs in the past? If so, how might the | |

|checklist facilitate that process? | |

|Accept responses from several participants and discuss any concerns that participants may raise. | |

|Ask participants to read questions 15-21. Emphasize that providers should follow the instructions for| |

|this set of questions to identify gynecological conditions during the pelvic exam that would make it | |

|unsafe to insert an IUD or that require further evaluation. | |

|Tell participants that the final set of instructions provides details about when to initiate the | |

|method. | |

|IUD Eligibility Checklist |Handout #6: Checklist for Screening|

|Brainstorming (10 min.) |Clients Who Want to Initiate Use of|

|Describe the following scenario: your client is a 32-year-old woman who wants no more children. She |the Copper IUD |

|and her husband are mutually monogamous. She reports having recently had unexplained bleeding after | |

|intercourse with her husband. Her last menstrual period started four days ago. |Handout #5: |

|Ask participants to consider the client description when answering the following question: |Quick Reference Chart for the WHO |

|Which question on the checklist addresses this client’s condition? |Medical Eligibility Criteria for |

|Encourage participants to review the checklist and locate the question(s) relevant to this client’s |Contraceptive Use |

|situation. Ask them to read the explanation for question #7. | |

|Considering the client’s condition and the explanation provided in the checklist, is this client a | |

|good candidate for an IUD? | |

|Review with the participants the reason the client is not medically eligible. She is not eligible | |

|because she would answer YES to question #7; that the unexplained vaginal bleeding could be the sign | |

|of an underlying condition, such as cancer or an infection. | |

|What would be your course of action for this client? Discuss with participants why the correct course| |

|of action is to not insert the IUD until the client’s condition has been further evaluated. | |

|Underlying conditions (e.g., pregnancy, malignancy, or infection) that preclude IUD insertion should | |

|be ruled out. If the provider does not have the capacity to rule out cancer of an infection, the | |

|client should be referred to a higher-level provider or specialist for evaluation and diagnosis. In | |

|either case, the woman should be counseled about other suitable contraceptive methods, and be | |

|provided with a method (such as condoms), until the provider can determine whether she is medically | |

|eligible to use an IUD. | |

|IUD Eligibility Checklist (2) |Handout #6: Checklist for Screening|

|Brainstorming (10 min.) |Clients Who Want to Initiate Use of|

|Facilitator: |the Copper IUD |

|Describe the following scenario: your client is a 30-year old woman who is married, monogamous, and | |

|has three children. She is living with HIV but has no symptoms and feels healthy. She has been using |Handout #5: |

|condoms consistently and correctly, but worries about condom breakage. She does not wish to become |Quick Reference Chart for the WHO |

|pregnant. |Medical Eligibility Criteria for |

|Ask participants to consider the client description when answering these questions: |Contraceptive Use |

|Which question on the checklist addresses this client’s condition? | |

|Encourage participants to review the checklist and locate the question(s) relevant to this client’s | |

|situation. Ask them to read the explanation for questions #6 and #14. | |

|Considering the client’s condition and the explanation provided in the checklist, is this client a | |

|good candidate for IUD? | |

|Review with the participants the reason the client is medically eligible. She is eligible for an IUD | |

|(the scenario assumes she has no other conditions which may preclude IUD initiation). HIV infection | |

|is not a contraindication for IUD insertion or continuing use. As the explanation for question #14 | |

|indicates, a woman with HIV who has not developed advanced or severe clinical disease may be an | |

|appropriate candidate for IUD insertion. You can also be reasonably sure she is not pregnant, since | |

|she would answer YES to question #6. | |

|What would be your course of action for this client? | |

|Discuss with participants why the correct course of action is to remind the client to come back to | |

|the clinic approximately one month after her IUD insertion for a follow-up visit. At that time, you | |

|should check for signs of infection and make sure that she has adapted well to the method. | |

|Note to facilitator: You may choose to ask a follow-up question, such as “What would you do if this | |

|client returns in a few years having developed advanced clinical disease?” The answer is that the | |

|client can continue IUD use regardless of level of clinical disease or antiretroviral use, and | |

|therefore no action would need to be taken. | |

|IUD Eligibility Checklist (3) |Handout #6: Checklist for Screening|

|Brainstorming (10 min.) |Clients Who Want to Initiate Use of|

|Describe the following scenario: your client is a 30-year-old woman with five children. She had a |the Copper IUD |

|miscarriage four days ago. She is married and faithful to her husband. However, her husband often | |

|travels for work and she suspects that he is with other women when he is away. She is interested in |Handout #5: |

|an IUD. |Quick Reference Chart for the WHO |

|Ask participants to consider the client description when answering these questions: |Medical Eligibility Criteria for |

|Which question on the checklist addresses this client’s condition? |Contraceptive Use |

|Encourage participants to review the checklist and locate the question(s) relevant to this client’s | |

|situation. Ask them to read the explanation for question #11. | |

|Considering the client’s condition and the explanation provided in the checklist, is this client a | |

|good candidate for an IUD? | |

|Review with the participants the reason the client is not medically eligible for an IUD. The answer | |

|to question #11 indicates that a woman whose partner has more than one sexual partner is at high | |

|individual risks of sexually transmitted infections (STIs). Unless an STI can be reliably ruled out | |

|prior to insertion, this client is not a good candidate for an IUD, as she may be at higher risk of | |

|pelvic inflammatory disease (PID) following IUD insertion. | |

| | |

|What would be your course of action for this client? | |

|Suggest that providers should counsel this client about other contraceptive options. If, after | |

|counseling, the client still wishes to have an IUD inserted and laboratory tests are available, the | |

|provider could do a test to determine if she has gonorrhea or chlamydia. If she has either of these | |

|infections, the provider could prescribe antibiotics. After treatment is completed, she could be | |

|provided with an IUD. The provider should counsel this client to use condoms during the period of | |

|testing and treatment to be sure she does not become re-infected by her husband. She also should be | |

|counseled to refer her husband for treatment. If there is no other acceptable contraceptive method | |

|available for the client, and it is not possible to test for STIs, an IUD may still be inserted if | |

|the provider is able to follow the client closely to make sure she does not develop PID. | |

|Training Process |Resources |

|Session III: Providing IUDs |

|Session III Objective: Demonstrate how to provide an IUD. |

|Timing of IUD Insertion |Basic Slide Set #3 Slides 2 and 3: |

|Lecturette (15 min.) |You May be Able to Get Your IUD Now|

|Discuss the timing of IUD insertion: | |

|Postpartum insertion: | |

|The client should be counseled appropriately prior to delivery. | |

|An IUD can be inserted postpartum if the provider has received adequate training in the procedure and| |

|there is no infection or bleeding complications. | |

|Any time within 48 hours after giving birth are considered safe, including immediately after a | |

|caesarean section delivery. | |

|An IUD insertion following a vaginal delivery can be done during the first 10 minutes after delivery | |

|of the placenta. | |

|If it is more than 48 hours after giving birth, delay until 4 weeks or more after giving birth when | |

|the uterus returns to its normal size. | |

|Although the expulsion rate for postpartum insertions is higher, postpartum IUD insertion may be | |

|advantageous when compared to the generally low rate of women who return later for IUD insertion. | |

|Clients choosing to have the IUD inserted immediately postpartum should be counseled that the risk of| |

|expulsion is greater if the IUD is inserted during this period. | |

|Interval insertion (having menstrual cycles): | |

|An interval insertion can be performed within the first 12 days after the start of menstrual bleeding| |

|or anytime during the menstrual cycle, as long as the woman is not pregnant. There is no need for a | |

|backup method. | |

|Some providers prefer to insert an IUD during the last few days of menstruation when the cervical | |

|opening is a little larger than usual and pregnancy can be ruled out based on the fact the woman is | |

|currently menstruating. | |

|However, it is easier to examine for signs of reproductive tract infections when a woman is not | |

|menstruating. Therefore, it is recommended that IUDs can be inserted at the client’s convenience if | |

|the provider can be reasonably sure the client is not pregnant. | |

|Fully or nearly fully breastfeeding less than 6 months after giving birth: | |

|An IUD can be inserted anytime from 4 weeks to 6 months after giving birth and menstruation has not | |

|returned. | |

|Miscarriage or postabortion insertion: | |

|An IUD can be inserted immediately or within 12 days after a first- or second-trimester abortion or | |

|miscarriage and if no infection is present. No need for a backup method. | |

|IUD insertion after second-trimester abortion or miscarriage requires specific training. If not | |

|specifically trained, delay insertion until at least 4 weeks after miscarriage or abortion. | |

|If infection is present, an IUD can be inserted after infection is fully treated and cured. Offer | |

|condoms or another method to use in the meantime. | |

|If switching from another method: | |

|An IUD can be inserted immediately, if she has been using the method consistently and correctly | |

|(including LAM) or if it is otherwise reasonably certain she is not pregnant. There is no need to | |

|wait for her next monthly bleeding and there is no need for a backup method. | |

|No monthly bleeding (not related to childbirth or breastfeeding) | |

|An IUD can be inserted any time if it can be determined that she is not pregnant. No need for a | |

|backup method. | |

|Correcting Rumors and Misconceptions |Basic Slide Set #3 Slide 4: |

|Brainstorm (20 min.) |Correcting Rumors and |

|Explain that rumors are unconfirmed stories that are transferred from one person to another by word |Misconceptions |

|of mouth. In general, rumors arise when: | |

|An issue or information is important to people, but it has not been clearly explained. |Handout #7: Rumors and |

|There is nobody available who can clarify or correct the incorrect information. |Misconceptions about IUDs |

|The original source is perceived to be credible. | |

|Clients have not been given enough options for contraceptive methods. | |

|People are motivated to spread them for political reasons. | |

|A misconception is a mistaken interpretation of ideas or information. If a misconception is filled | |

|with elaborate details and becomes a fanciful story, then it acquires the characteristics of a rumor.| |

| | |

|Ask participants: what are some common misconceptions about IUDs? | |

|Discuss methods for counteracting rumors and misinformation: | |

|When a client mentions a rumor, always listen politely. Don’t laugh. | |

|Define what a rumor or misconception is. | |

|Find out where the rumor came from and talk with the people who started it or repeated it. Check | |

|whether there is some basis for the rumor. | |

|Explain the facts. | |

|Use strong scientific facts about family planning methods to counteract misinformation. | |

|Always tell the truth. Never try to hide side effects or problems that might occur with various | |

|methods. | |

|Clarify information with the use of demonstrations and visual aids. | |

|Give examples of people who are satisfied users of the methods (only if they are willing to have | |

|their names used). This kind of personal testimonial is most convincing. | |

|Reassure the client by examining her and telling her your findings. | |

|Counsel the client about all available family planning methods. | |

|What Will Happen When You Get Your IUD |Basic Slide Set #3 Slide 5: What |

|Brainstorming (20 min.) |Will Happen When You Get Your IUD |

|In addition to providing information on the characteristics of IUDs, including side effects; | |

|accessing the client’s eligibility; and addressing misconceptions or questions that a client may have| |

|about IUDs, what are some other key counseling topics related to IUDs? | |

|In addition to the topics we have already discussed, it is imperative that during counseling about | |

|IUDs providers: | |

|Explain the procedure used to insert (or remove) the IUD, using illustrations if possible, including | |

|the length of time it takes to complete the procedure, who will perform it, and that the woman may | |

|experience some pain and cramping, briefly. (We will discuss how to explain the procedure on the next| |

|slide). | |

|Provide post-insertion instructions so that a client knows what to expect in the first few days (some| |

|cramping and spotting) and when to return to the clinic if something does not seem right. We will | |

|review these instructions in more detail later. | |

|Explain how long the IUDs protect against pregnancy and help women remember when they should come | |

|back to have IUD removed or replaced. All clients should be given the following information: | |

|The type of IUD (such as Copper T) | |

|Date of insertion | |

|Month and year when the IUD will need to be removed/replaced | |

|Where to go in case of questions or problems (a reminder card can be useful for this purpose) | |

|Finally, the provider should advise a client about circumstances that require her to return (which | |

|are described in more detail later in the presentation). | |

|Explaining the IUD Insertion Procedure |Basic Slide Set #3 Slide 6: |

|Discussion (10 min.) |Explaining the IUD Insertion |

|A client who has chosen to use an IUD needs to know what will happen during insertion. |Procedure |

|A provider should describe the procedure simply and with just enough detail so the client will know | |

|what to expect. For example, the provider could describe the procedure in this way: | |

|“The IUD is placed in the uterus through the vagina and the opening of the uterus, using a small | |

|applicator. It has two thin strings attached, which hang down into the vagina. These strings make it | |

|easy for provider to remove an IUD. If you want, you may also touch the strings to check each month | |

|after your menstrual period that the IUD is still in place and that you are still protected from | |

|getting pregnant.” | |

|“Inserting the IUD is simple. You may feel uncomfortable for a few minutes. Most women, however, say | |

|that it is not too painful and compare the feeling to having heavy menstrual cramps. Before I insert | |

|the IUD, I will need to ask you some questions about your medical history, and perform a pelvic | |

|examination to make sure the IUD is right for you.” | |

|The provider could add more details to describe the procedure, such as: | |

|“Before inserting the IUD, I will clean the cervix and vagina with an antiseptic. Next, I will insert| |

|a small rod into the uterus to measure the length of your uterus. Then I will use a thin inserter | |

|tube to insert the IUD through the cervix, or opening of the uterus, and place it into the uterus. I | |

|will cut the strings on the IUD so they hang just a little ways into the vagina. After the insertion,| |

|you will rest.” | |

|“Removing the IUD takes only a few minutes and is usually not painful. When you want the IUD removed,| |

|it must be done by a doctor or trained health worker.” | |

|Post-Insertion Instructions |Basic Slide Set #3 Slide 7: |

|Discussion (10 min.) |Post-Insertion Instructions |

|Ask participants: Providing post-insertion instructions is an important element of counseling for IUD| |

|use. What information or instructions should you give clients after IUD insertion? | |

|Tell the client to expect cramping and spotting or light bleeding for a few days, in addition to | |

|common side effect. | |

|If a client wants to be able to check the strings, teach her how. | |

|Make sure that she knows to wash her hands thoroughly before inserting her fingers into her vagina. | |

|If she is unwilling or unable to check with her hand, she can inspect the pads she uses during menses| |

|for possibly expulsion of the IUD. | |

|A woman may want to check for strings after each menses, especially during the first six months, | |

|since this is when the chance of the IUD being expelled is higher. | |

|If the strings are missing the client should start using a backup method and visit her provider as | |

|soon as possible. | |

|If it is convenient for the client, schedule a return visit with the client 3-6 weeks after insertion| |

|to check for presence and length of the IUD strings and to check for signs of infection. This visit | |

|is not mandatory. She does not need to return to the clinic again, unless she experiences problems or| |

|has concerns. | |

|A client should return to the clinic immediately if she experiences any signs of possible | |

|complications. | |

|Complications of IUDs |Basic Slide Set #3 Slide 8: |

|Discussion (10 min.) |Complications of IUDs |

|Ask participants: Among your colleagues, what concerns do you hear about serious complications of IUD| |

|use? | |

|Most concerns about the safety of IUDs are rooted in earlier IUD experiences and research. | |

|Several biases in early research overstated risks of PID. | |

|Most research since the 1980s demonstrates that serious complications are area with modern IUDs. | |

|Potential complications of IUDs include: | |

|Perforations | |

|PID | |

|Expulsions | |

|Complications of IUDs, continued |Basic Slide Set #3 Slide 9: |

|Lecturette (10 min.) |Complications of IUDs, continued |

|Perforations are associated almost exclusively with the insertion procedure. The woman’s uterus or | |

|cervix can be perforated when an IUD is inserted. |Optional Advanced Slide Set Slide |

|Although perforations are rare, it is a potentially serious event if it does occur. According to the |6: Risk of PID Greatest in the |

|WHO, rates of perforation at the time of insertion are about 1 in 1,000. |First Few Weeks after IUD Insertion|

|The risk of perforation is directly linked to the skill and experience of the provider. Carefully | |

|following the instructions for IUD insertion reduces the risk of perforation the uterus. |Optional Advanced Slide Set Slide |

|The risk of perforation does not vary by timing of insertion. |7: Infertility is Linked to STIs, |

| |Not to IUDs |

| | |

| |Optional Advanced Slide Set Slide |

| |8: Expulsion Rates are Higher for |

| |Postpartum Insertion |

|Signs of Possible IUD Complications |Basic Slide Set #3 Slide 10: Signs |

|Lecturette (10 min.) |of Possible IUD Complications |

|During counseling, providers need to discuss the signs of possible IUD complications and advise the | |

|client to return immediately if any of the following signs or symptoms appear: | |

|Bleeding or severe abdominal cramping during the first few days after insertion–this could indicate | |

|that the uterus or cervix may have been perforated when the IUD was inserted. | |

|Irregular bleeding or pain in every cycle–this could indicate an IUD dislocation, partial expulsion, | |

|or perforation. | |

|Fever and chills, unusual vaginal discharge, or lower abdominal pain – this could indicate an | |

|infection, which is a concern especially during the first month after the IUD is inserted. This is | |

|when PID, although rare, is most likely to develop. | |

|Missing IUD strings or a missed menstrual period – these could indicate IUD expulsion and pregnancy, | |

|either uterine or ectopic. | |

|Explain Removal Procedure to Client |Basic Slide Set #3 Slide 11: |

|Discussion (10 min.) |Explain Removal Procedure to Client|

|Prior to removal, a provider should describe to the lcient what will happen during the removal | |

|procedure. Providers hould explain that IUD removal is quick, and usually quite painless. | |

|The simplified description is: | |

|The provider inserts a speculum to see the cervix and IUD strings. | |

|The provider carefully cleans the cervix and vagina with an antiseptic solution. | |

|The provider asks the woman to take slow, deep breaths and to relax. The woman should say if she | |

|feels pain during the procedure. | |

|Using narrow forceps, the provider pulls the IUD strings slowly and gently until the IUD is | |

|completely out of the uterus. | |

|Another IUD may be inserted immediately, if desired. | |

|Providers must not refuse or delay when a woman asks to have her IUD removed, whatever her reason, | |

|whether it is personal or medical. All staff must understand and agree that she must not be pressured| |

|or forced to continue using the IUD. | |

|If a woman is finding side effects difficult to tolerate, first discuss the problems she is having. | |

|See if she would rather try to manage the problem or to have the IUD removed immediately. | |

|Removing an IUD is usually simple. It can be done any time of the month. Removal may be easier during| |

|monthly bleeding, when the cervix is naturally softened. In cases of uterine perforation or if | |

|removal is not easy, refer the woman to an experienced clinical who can use an appropriate removal | |

|technique. | |

|Managing IUD Side Effects or Complications: Heavy, Prolonged or Irregular Bleeding |Basic Slide Set #3 Slide 12: |

|Brainstorming (20 min.) |Managing IUD Side Effects or |

|Ask participants: What is the most important thing that you can do for women who experience side |Complications: Heavy, Prolonged or |

|effects? |Irregular Bleeding |

|Let us compare your responses with the slide. | |

|As we have discussed, the best way to reduce the anxiety some women feel when they experience side | |

|effects is to provide detailed information about possible side effects during counseling, before the | |

|client makes a decision to use the IUD. If side effects occur, the first step is to address the | |

|client’s concerns through a follow-up counseling. | |

|Recommended management for heavy or prolonged menstrual bleeding are as follows: | |

|Reassure the client that some women using IUDs experience heavy or prolonged bleeding. It is | |

|generally not harmful and usually becomes less or stops after the first several months of use. | |

|For modest, short-term relief she can try (one at a time): Tranexamic acid (1500 mg three times daily| |

|for three days, then 1000 mg once a day for two days beginning when bleeding starts; ibuprofen (400 | |

|mg) or indomethacin (25 mg) two times daily after meals for five days. | |

|Other NSAIDs may be prescribed. Do not prescribe aspirin. | |

|Provide iron tablets and recommend a diet high in iron when high iron-content foods are available. | |

|Give examples of locally available food with high-iron content. | |

|Recommended management for irregular bleeding are as follows: | |

|Reassure the client. | |

|For short-term relief, she can try ibuprofen (400 mg) or indomethacin (25 mg) two times daily after | |

|meals for five days. | |

|Managing IUD Side Effects or Complications: Cramping and Mild Pain |Basic Slide Set #3 Slide 13: |

|Lecturette (10 min.) |Managing IUD Side Effects or |

|When a client reports cramping and pain: |Complications: Cramping and Mild |

|Inform her she can expect some cramping and pain for the first day or two after insertion. |Pain |

|Reassure her that cramping is also common in the first three to six months after insertion, | |

|particularly during menses. Generally this is not harmful and decreases over time. | |

|Suggest ibuprofen (200-400 mg) or other pain reliever. If there is heavy bleeding, aspirin should not| |

|be prescribed because it inhibits clotting and thus can increase bleeding. | |

|If cramping continues and occurs outside of monthly bleeding, evaluate for underlying health | |

|conditions, treat, and refer. If no underlying conditions are found but cramping continues and client| |

|finds it unacceptable, discuss removing the IUD. | |

|Managing IUD Side Effects or Complications: Severe Pain in Lower Abdomen (Rare) |Basic Slide Set #3 Slide 14: |

|Lecturette (10 min.) |Managing IUD Side Effects or |

|When a client reports severe pain in her lower abdomen: |Complications: Severe Pain in Lower|

|Do abdominal and pelvic examinations to rule out PID, ectopic pregnancy, or perforation. |Abdomen (Rare) |

|If a pelvic exam is not possible, suspect PID if she has a combination of the following signs and | |

|symptoms in additional to abdominal pain: | |

|Unusual vaginal discharge | |

|Fever or chills | |

|Pain during sex or urination | |

|Bleeding after sex or between monthly bleeding | |

|Nausea and vomiting | |

|A tender pelvic mass | |

|Pain when the abdomen is gently pressed or when gently pressed and then suddenly released | |

|If PID is suspected, treat with appropriate antibiotics for gonorrhea, chlamydia, and anaerobic | |

|bacterial infection or refer for treatment. There is no need to remove the IUD. | |

|Suspect ectopic pregnancy if she has a combination of these signs or symptoms: | |

|Unusual abdominal pain or tenderness | |

|Abnormal vaginal bleeding or not monthly bleeding–especially if this is a change from her usual | |

|bleeding pattern | |

|Light-headedness or dizziness | |

|Fainting | |

|If ectopic pregnancy or other serious health condition is suspected, refer at once. | |

|Managing IUD Side Effects or Complications: Suspected Perforation |Basic Slide Set #3 Slide 15: |

|Lecturette (10 min.) |Managing IUD Side Effects or |

|If you suspect the IUD has perforated the uterus, stop the insertion procedure immediately and remove|Complications: Suspected |

|the IUD. Observe the client carefully as follows: |Perforation |

|Provide bed rest and check vital signs every five to 10 minutes for the first hour. | |

|If client remains stable after an hour, check for signs of intra-abdominal bleeding and observe for | |

|several more hours. If she shows no signs or symptoms, she can be sent home, but should avoid sex for| |

|two weeks. Help her choose another contraceptive method. | |

|If she has a rapid pulse and falling blood pressure, or new or increasing pain around the uterus, | |

|refer her for high level care. | |

|If uterine perforation is suspected after insertion and is causing symptoms, refer the client for | |

|evaluation by a clinic an experienced at removing such IUDs. | |

|Managing IUD Side Effects or Complications: Missing Strings |Basic Slide Set #3 Slide 16: |

|Lecturette (10 min.) |Managing IUD Side Effects or |

|In the case of missing IUD strings, the provider should ask the following questions: |Complications: Missing Strings |

|Did the client see the IUD come out? If yes, when? | |

|When did the client last feel the strings? | |

|When did she have her last monthly period? | |

|Does she have symptoms of pregnancy? | |

|Has she used a backup method since she noticed the strings were missing? | |

|Always start with minor and safe procedures. | |

|Check for the strings in the folds of the cervical canal with forceps. About half of missing IUD | |

|strings can be found in the cervical canal. If the strings cannot be located in the cervical canal, | |

|either they have gone up into the uterus of the IUD has been expelled. | |

|Rule out pregnancy before attempting more invasive procedures, including x-ray. Refer for evaluation | |

|and give the client a backup method to use, in case the IUD did not come out. | |

|If expulsion is confirmed and the woman is not pregnant, insert another IUD if she still wants to use| |

|an IUD. | |

|Managing IUD Side Effects or Complications: Suspected Pregnancy |Basic Slide Set #3 Slide 17: |

|Lecturette (10 min.) |Managing IUD Side Effects or |

|In the case of suspected pregnancy, the provider should asses for pregnancy, including ectopic |Complications: |

|pregnancy. |Suspected Pregnancy |

|An IUD in the uterus during pregnancy increases the risk of preterm delivery or miscarriage, | |

|including infected (septic) miscarriage during the first or second trimesters, which can be | |

|life-threatening. | |

|If the client does wish to continue the pregnancy, advise her that it is best to remove the IUD. | |

|Explain the risks of pregnancy with the IUD in place. Early removal reduces risk although the removal| |

|procedure itself involves a small risk of miscarriage. | |

|If the client agrees, gently remove the IUD or refer for removal. Explain that she should return if | |

|there are any signs of miscarriage. If she chooses to keep the IUD, her pregnancy should be followed | |

|closely by a healthcare provider and she should seek their attention if any signs of miscarriage | |

|develop. | |

|If the IUD strings cannot be found in the cervical canal and the IUD cannot be safely retrieved, | |

|refer her for an ultra sound to determine whether the IUD is still in the uterus. If it is, or if | |

|ultrasound is not available, her pregnancy should be followed closely. She should seek care at once | |

|if she develops any signs of septic miscarriages. | |

|Role Plays (30 min.) |Handout #8: |

|Follow the step-by-step instructions in the IUDs Facilitator’s Guide section on facilitating role |Role Play Scenarios |

|plays to prepare for and conduct this activity. | |

|Review the instructions for the client, provider, and observer roles and the other learning resources|Conducting Training Tool: |

|developed for the activity. |Facilitating Role Plays |

|View a demonstration role play and clarify any questions. | |

|Conduct role plays in small groups based on the scenarios provided and discuss reactions. |Conducting Training Tool: |

|Discuss the activity as a large group. |Role Play Observation Checklist |

|Review Handouts #8 and #9 with participants. These include: | |

|Six different role play scenarios, each with a client information sheet and observer information | |

|sheet (Handout #8). | |

|The instruction sheet that describes the roles of providers, clients, and observers (in Handout #9). | |

|The Role Play Observation Checklist for Clinicians (in Handout #9). | |

|Role play scenario/information sheets for clients and observers for the role plays you have selected | |

|or adapted from Handout #8. | |

|Use the following questions to help the small groups structure the feedback that they provide to each| |

|other after each role play. | |

|What was going on between the provider and client? | |

|What did the provider do that was effective in this situation? | |

|What might the provider consider doing differently if this situation were to happen again? | |

|How did the provider attend to the items on the counseling observation checklist and the | |

|case-specific observations included in the role-play description? | |

|After the small groups conduct each role play, encourage the groups to talk about what happened | |

|during the role play from the perspective of the provider (self-assessment), the client (personal | |

|satisfaction with the interaction), and the observer (objective assessment using the Role Play | |

|Observation Checklist, including the case-specific observations included in the role-play | |

|description) | |

|Prepare a flip chart to display these discussion questions where the questions can easily be seen by | |

|all the participants in the small groups. | |

|Case Studies (45 min.) |Handout #9: Copper Intrauterine |

|Divide Participants into 4 groups. |Devices |

|Give 2 groups case study. Ask each group to review the case study and answer the questions. |Case Study |

|Allow each group 25 minutes to prepare their answers and 5 minutes to present their answers to the | |

|rest of the group. | |

|Copper IUDs: Summary |Basic Slide Set #3 Slide 18: Copper|

|Lecturette (5 min.) |IUDs: Summary |

|IUDs are a safe, effective, and convenient method of reversible contraception. | |

|They are long lasting, cost-effective, easy to use, and appropriate for the majority of women. | |

|Health care provides play an important role in making sure that IUDs are used safely. | |

|Providing education and counseling, careful screening of potential users, appropriate infection | |

|prevention techniques, and proper follow-up care can help prevent possible complications associated | |

|with IUD use. | |

|Counseling is especially important to help women be alert to potential problems. | |

|Counseling can also improve client satisfaction with the device. | |

|Post-Test, Applied Learning Case Studies, and Course Evaluation (40 min.) |Evaluation Tools: |

| |Post-test, Applied Learning Case |

| |Studies, and Course Evaluation |

|Session IV: Practicing IUD Insertion and Removal |

|Session IV Objective: Demonstrate how to insert and remove the IUD on an anatomical model. |

|Session Overview |Slide Set #4 Slide 2: Session |

|Lecturette (5 min.) |Overview |

|This session describes the steps for inserting and removing a copper-bearing IUD and for preventing | |

|infection during insertion and removal. | |

|Complications such as perforation of the uterus or expulsion are associated mainly with provider | |

|skill. | |

|Extensive practice on models, observations of master clinicians and supervised practice are necessary| |

|for the provider to be skillful in the IUD insertion and removal procedures. | |

|During this session, we will first review the steps of IUD insertion and removal, using the slides. | |

|This will be followed by a demonstration and return demonstration and practice by participants on | |

|anatomical models, using competency based checklists to monitor progress. | |

|Note to Facilitator: this session is focused solely on the mechanics of the clinical procedures | |

|involved in IUD insertion and removal. Refer to Session III for guidance about counseling users and | |

|other IUD-related issues. | |

|IUD Insertion Procedure: Instruments and Supplies |Slide Set #4 Slide 3: IUD Insertion|

|Lecturette (5 min.) |Procedure: Instruments and Supplies|

|Note to Facilitator: review the list of recommended supplies and equipment for IUD insertion | |

|procedures on Slides 3 and 4. Adapt this list as needed to be consistent with national guidelines. | |

|The recommended supplies and equipment include: | |

|IUD in an unopened, undamaged, sterile package that is not beyond its expiration date. | |

|Bivalve speculum | |

|Tenaculum | |

|Uterine sound | |

|Ring forceps | |

|Sharp scissors for trimming IUD strings | |

|Narrow forceps (uterine dressing or sponge) | |

|IUD Insertion Procedure: Instruments and Supplies (2) |Slide Set #4 Slide 4: IUD Insertion|

|Lecturette (5 min.) |Procedure: Instruments and Supplies|

|(continued from previous slide) Additional required items include: |(2) |

|Light source to visualize cervix | |

|Gloves (single use disposable, or HDL, or sterile) | |

|Bowl with antiseptic solution | |

|Chlorine solution, 0.5% | |

|Sterile gauze/cotton balls | |

|Drape/cloth to cover table and woman’s pelvic area | |

|IUD Insertion Procedure: Preventing Infection during IUD Insertion |Slide Set #4 Slide 5: IUD Insertion|

|Lecturette (10 min.) |Procedure: Preventing Infection |

|To minimize the risk of infection at the time of IUD insertion it is important to comply with these |During IUD Insertion |

|infection prevention practices: | |

|Wash hands before and after procedure and wear examination gloves. Providers should wash hands using |Handout #10: Instructions for |

|soap and clean, running water for at least 15 seconds and then air dry or use a clean personal towel.|Loading the TCu380A in the Sterile |

|Alternately, an alcohol-glycerin solution is an acceptable step for a water-free hygiene technique. |Package |

|Wear gloves during procedures and while handling waste and cleaning. Gloves do not need to be | |

|sterilized if performing the no-touch IUD insertion technique. | |

|Use high-level disinfected (or sterile) instruments. High-level disinfect (HLD) or sterilize | |

|instruments such as the speculum, tenaculum, uterine sound, and scissors before insertion and | |

|removal. | |

|Load the IUD within the sterile package without touching the IUD. The no-touch loading technique is | |

|simple but extremely important step and helps prevent the IUD from being contaminated before it is | |

|inserted. | |

|Clean the cervix with antispetic. Clean the cervix with antiseptic for both IUD insertion and | |

|removal. Antiseptic preparation of the cervix and vagina minimizes the number of microorganisms on | |

|the client’s cervix. After the speculum is inserted, thoroughly apply antiseptic solutions such as | |

|povidone iodine two or more times to the cervix (especially the os) beginning at the center of the os| |

|and moving outward on the cervix and into the surrounding vaginal canal. | |

|IUD Insertion Procedure: Preventing Infection during IUD Insertion (2) |Slide Set #4 Slide 6: IUD Insertion|

|Lecturette (5 min.) |Procedure: Preventing Infection |

|(continued from previous slide) Other infection prevention steps during insertion include: |During IUD Insertion (2) |

|Insert the IUD without touching the speculum blades or vaginal wall. Insert the IUD using the | |

|no-touch insertion technique to reduce contamination of the uterine cavity. Providers should not let |Handout #11: Inserting the Loaded |

|the uterine sound or loaded IUD touch the speculum or vaginal canal. |TCu380A IUD |

|Pass sound and loaded IUD only once through cervical canal. Be careful not to pass the uterine sound | |

|or loaded IUD through the cervical os more than once. This step minimizes the introduction of | |

|microorganisms into the uterine cavity. | |

|Decontaminate instruments after the procedure. | |

|Dispose of contaminated waste properly. After completing an IUD insertion or removal, and while still| |

|wearing gloves, dispose of contaminated objects, such as the IUD inserter tube and rod, the cut ends | |

|of the IUD threads, gauze, cotton, and other waste items, in a properly marked, leak-proof container | |

|with a tight-fitting lid or in a plastic bag. | |

|IUD Insertion Procedure: Procedure Overview |Slide Set #4 Slide 7: IUD Insertion|

|Lecturette (5 min.) |Procedure: Procedure Overview |

|This is an overview of the major steps of the IUD insertion procedure. These steps begin after family| |

|planning counseling (both general and method-specific) and screening for medical eligibility based on| |

|medical history. | |

|The next series of slides will review these steps in more detail. | |

|IUD Insertion Procedure: Step 1: Perform Pelvic Exam |Slide Set #4 Slide 8: Insertion |

|Lecturette (5 min.) |Procedure: |

|The first step of the IUD insertion procedure is the pelvic examination, to screen for medical |Step 1: Perform Pelvic Exam |

|eligibility and assess the size and position of the uterus. | |

|If no signs of infection are found during the pelvic exam (no ulcers, cervical tenderness, adnexia |Handout #12: Pelvic Bimanual and |

|tenderness, purulent cervical discharge, and cervix does not bleed easily when touched), the provider|Speculum Examination Checklist |

|should proceed with the remaining steps of IUD insertion. | |

|If any of the infection signs or symptoms are present, diagnose and treat as appropriate. Reassess | |

|the woman’s eligibility for insertion afterwards. | |

|The provider also determines the position of the uterus so he/she knows in which direction to point | |

|the uterine sound and IUD inserter (uterus could be tilted up or down). | |

|The next step is sounding the uterus. | |

|Note to facilitator: Distribute the Pelvic Bimanual and Speculum Examination Checklist handout. Ask | |

|participants to review it as you discuss the steps involved in a pelvic exam. | |

|IUD Insertion Procedure: Step 2: Sound the Uterus |Slide Set #4 Slide 9: Insertion |

|Lecturette (5 min.) |Procedure: |

|Sounding the uterus is required for all IUD insertions to ensure placement of the IUD high in the |Step 2: Sound the Uterus |

|uterus. Sounding the uterus enables the provider to: | |

|Check for obstructions in the cervical canal. |Handout #13: Passing a Uterine |

|Assess the depth from external cervical os to the uterine fundus, so that the blue depth-gauge on the|Sound |

|insertion tube can be set at the same distance, ensuring that the IUD will be placed as high in the | |

|uterus as possible, without perforating the uterus. | |

|Insert the curved sound instrument according to the position of the uterus as determined during the | |

|pelvic examination: | |

|If the uterus is retroverted (tilted down/back), insert the sound with its tip pointing down | |

|If the uterus is anteverted (tilted forward/up), insert the sound with its tip pointing up. | |

|Always hold the sound very lightly, so that the slightest resistance will make it slide backwards | |

|through the fingers that are holding it, which minimizes the risk of perforation. | |

|It is important to note that the position of the uterus is determined during the pelvic examination, | |

|not during sounding. If uterine position is not correctly determined before sounding, the sound may | |

|be inserted incorrectly and cause uterine perforation. | |

|IUD Insertion Procedure: Step 3: Load the Copper IUD (Copper T 380A) |Slide Set #4 Slides 10-20: Steps |

|Lecturette (15 min.) |3-3.10: Load the Copper IUD |

|Remind participants that loading should be done no more than 5 minutes before introducing the IUD | |

|into the uterus. |Handout #10: Instructions for |

|When the arms of the IUD stay folded for too long, they may not return to their original shape when |Loading the TCu 380A in the Sterile|

|the IUD is released from the inserting tube inside the uterine cavity. |Package |

|Providers should begin the loading procedure after performing the pelvic exam, after they have | |

|determined that the woman is eligible for the IUD and after sounding the uterus. | |

|IUD Insertion Procedure: Steps 4–8 |Slide Set #4 Slides 21–24 |

|Lecturette (15 min.) | |

|Note to facilitator: Use the information on the slides to describe Steps 4–8 in the IUD insertion | |

|procedure: | |

|Step 4: Insert IUD into Vagina (Slide 21) | |

|Step 5: Advance IUD into Uterus (Slide 22) | |

|Step 6: Release Arms of Copper T (Slide 23) | |

|Step 7: Gently Push Insertion Tube (Slide 24) | |

|IUD Insertion Procedure: Step 8: Remove Plunger Rod |Slide Set #4 Slide 25: Step 8: |

|Lecturette (5 min.) |Remove Plunger Rod |

|Use information on Slide 16 to describe Step 9 in the IUD insertion procedure. | |

|Inform participants that the white plunger rod should be completely removed from the insertion tube | |

|at this step. | |

|IUD Insertion Procedure: Steps 9–13 |Slide Set #4 Slides 26–29 |

|Lecturette (15 min.) | |

|Note to facilitator: Use the information on the slides to describe Steps 10–13 in the IUD insertion | |

|procedure: | |

|Step 9: Partially Withdraw Inserter (Slide 26) | |

|Step 10: Cut IUD Strings (Slide 27) | |

|Step 11: Remove Tenaculum Uterus (Slide 28) | |

|Step 12: Remove Speculum and Decontaminate Instruments (Slide 29) | |

|IUD Insertion Procedure: Step 14: Allow Woman to Rest |Slide Set #4 Slide 30: |

|Lecturette (5 min.) |Step 13: Allow Woman to Rest |

|Allow the woman to rest, and begin the post-insertion tasks: | |

|Properly dispose of waste materials. | |

|Process gloves according to recommended infection prevention practices. | |

|Wash hands thoroughly and dry them. | |

|After the woman has rested and dressed: | |

|Complete the IUD reminder card and give it to the client. Explain that the user card shows the name | |

|of the IUD, the date of insertion, the clinic name, and the intended date of removal. | |

|Review the post-insertion instructions and key messages for IUD users and address any final questions| |

|that the client may have. | |

|Encourage her to return if she has concerns or questions. | |

|Complete the client record. | |

|Note to facilitator: See Session III for details about post-insertion counseling messages. | |

|Removing an IUD |Slide Set #4 Slides 31-32: IUD |

|Lecturette (5 min.) |Removal Procedure |

|IUD removal is usually routine and uncomplicated. | |

|The IUD can be removed at any time, although removal during menses may make the procedure easier for | |

|the provider. Any trained health care provider, including a nurse or midwife, can remove the IUD. | |

|As with IUD insertion, the provider should follow standard infection prevention guidelines to | |

|minimize the risk of infection. Apply slow, gentle traction to avoid breaking the strings. Let the | |

|woman know that some cramping and/or bleeding is normal during removal. Refer the client to a | |

|specially trained or experienced clinician for difficult removals. | |

|A woman returning to the clinic to have an old IUD replaced can have a new IUD inserted at the same | |

|time. | |

|It is common practice to remove an IUD in menopausal women after one year without menses. In cases | |

|where an IUD is not removed after menopause, ill effects have not been reported, but there have been | |

|no scientific studies on this topic. | |

|Note to facilitator: Use the information on the slide to describe steps in the IUD removal procedure.| |

|If available, show a video demonstrating IUD insertion and removal procedures. | |

|Pelvic Examination | |

|Demonstration/ Return Demonstration (2 hours or more, depending on the number of participants and | |

|availability of anatomical models) | |

|Before beginning the demonstration, the trainer should: | |

|Get a sense of the knowledge and participant’s skill levels from the pretest and other means. Some | |

|participants will have no experience in performing a pelvic exam, others may have a lot. Some | |

|participants may have learned habits which must be unlearned. | |

|Before participants practice on the life-size pelvic model, the trainer should demonstrate on the | |

|model, pointing out its parts and how to use them. | |

|After demonstrating a pelvic exam on the model, the trainer will allow each participant to do the | |

|same, while being coached by the trainer at first and then by a fellow participant who will use the | |

|competency based skills checklist. | |

|The trainer will then assess the skills of the participants in distinguishing an anteverted from a | |

|retroverted uterus, a non-pregnant from a pregnant uterus, and an abnormal from a normal cervix (done| |

|by trainer changing optional organs in the pelvic model without participants observing). | |

|Throughout the simulated practice, the trainer and participants should practice her or his role as | |

|clinician by talking to the “client” while performing the exam, explaining what is taking place and | |

|why, what sensations the client might be feeling, and what the findings are. | |

|Loading the Copper T 380A in the Sterile Package | |

|Demonstration and Return Demonstration (continued) | |

|Discuss the reasons for loading the Copper T 380A in the sterile package. | |

|Have sample IUDs on hand, some out of the package and some still inside of the sterile package. | |

|Distribute 1 or 2 Copper T 380As in sealed packages to each participant (expired IUDs may be used). | |

|Ask the participants to point to the following parts in the packages they are holding and name them: | |

|arms, stem, inserter tube, blue depth gauge, ID card, white rod, thumb grip. | |

|Name the 2parts of the IUD package—the clear plastic and the white backing flap. | |

|Demonstrate the steps needed to load the Copper T 380A in the sterile package. | |

|Observe participant as she or he follows the steps in order. | |

|Allow the participants to practice until competent; alternatively, she or he may choose to practice | |

|at home or work and then demonstrate the skill, once acquired, to the trainer. | |

|Insertion and Removal | |

|Demonstration/Return Demonstration | |

|Demonstrate insertion and removal both on the hand-held and life-size pelvic models, if available. | |

|During this demonstration, role-play a provider, speaking to the “client.” | |

|Demonstrate insertion and removal exactly, and in the same order, as in the competency based | |

|checklist | |

|Have one participant use the checklist to coach the other participant, step-by-step, in the insertion| |

|technique. | |

|Each participant will have a chance both to coach a colleague and to insert and remove the IUD on the| |

|model under observation by the trainer. | |

|The rest of the participants may spend this time working with hand-held models, The rest of the | |

|participants may spend this time working with hand-held models, practicing loading the Copper T 380A | |

|inside the package, or viewing slides or video, etc. | |

|Be available after this activity, as participants will need access to the life-size pelvic model to | |

|practice until they feel ready for competency-based evaluation by trainer. | |

|Meet with each participant and correct any misinformation or steps not performed correctly, etc. | |

|The time required per participant will vary and is defined only by the time necessary for trainer and| |

|participant to be satisfied with skill competency (i.e., the participant will perform all key steps | |

|of IUD insertion and removal in correct manner and in correct order, as determined by the trainer). | |

|Note: This competency-based checklist also includes counseling skills. Although these do not have to | |

|be demonstrated for the purpose of this session, the complete checklist will be used during the | |

|clinic practicum. | |

|At the skills acquisition stage, participants may also spend time observing IUD insertions and | |

|removals in clients by the trainer or training-center staff and obtaining more experience in pelvic | |

|examination. | |

|Infection Prevention Procedures in IUD Insertion and Removal |Handout #14: Infection Prevention |

|Demonstration/Return Demonstration (1 hour) |for IUDs |

|Pass out 4-5 index cards to each participant. | |

|Ask participants to think of possible ways that infection may be spread in connection with IUD |Evaluation Tool: Copper-Bearing |

|insertion or removal procedures. |Intrauterine Devices (IUDs): |

|Collect all of the index cards. |Competency-Based Skills Checklist |

|Organize them according to various phases in the IUD insertion and removal process. Use this exercise|for Infection Prevention |

|as a way to introduce the topic. |Related to IUD Insertion or Removal|

|Review infection prevention guidelines for IUD insertion or removal and infection prevention tips for| |

|both IUD insertion and removal as seen in the content column. | |

|Set up a demonstration area with the following supplies: | |

|Leak-proof container or plastic bag | |

|Plastic bucket | |

|Chlorine | |

|Gloves—either single-use or reusable | |

|Detergent | |

|Soft brush | |

|HLD container | |

|Cooker pot, dry heat oven or sterilizer (depending on which one is more commonly used in clinics) | |

|Forceps | |

|Demonstrate all of the steps of infection prevention before, during, and after IUD insertion and | |

|removal following the checklist. | |

|Ask participants to work in pairs or triads, depending on the amount of equipment you have available | |

|and demonstrate the steps in instrument processing, using the participant handouts. | |

|Discuss with participants how to best manage specifics of infection prevention in their individual | |

|clinics. Who will do cleaning, rinsing, HLD, or sterilization? If not the provider, how will the | |

|provider train other staff? | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download