Family Health Intl - Checklist for Screening Clients who want to initiate use of the Copper IUD

Publication date: 2008

Determining Current Pregnancy Questions 1–6 are intended to help a provider determine, with reasonable certainty, whether a client is not pregnant. If a client answers “yes” to any of these questions and there are no signs or symptoms of pregnancy, it is highly likely that she is not pregnant. An IUD should never be inserted in a woman who is pregnant as it may result in a septic miscarriage. However, if a client answers “yes” to question 1, IUD insertion should be delayed until four weeks postpartum. There is an increased risk of perforating the uterus when IUDs are inserted after 48 hours and up to four weeks postpartum. However, IUDs can be inserted by a trained professional within the fi rst 48 hours after the client has given birth. Assessing Medical Eligibility for the IUD 7. Do you have bleeding between menstrual periods that is unusual for you, or bleeding after intercourse (sex)? Unexplained vaginal bleeding may be a sign of an underly- ing pathological condition, such as genital malignancy (can- cer), or a pregnancy-related problem. All these possibilities must be ruled out before an IUD can be inserted. If neces- sary, refer the client to a higher-level provider or specialist for evaluation and diagnosis. Counsel the client about other contraceptive options available and provide condoms to use in the meantime. 8. Have you been told that you have any type of cancer in your genital organs, trophoblastic disease, or pelvic tuberculosis? There is a concern about the increased risk of infection, perforation, and bleeding at insertion in clients with genital cancer. Clients with trophoblastic disease may require multiple uterine curettages, and an IUD is unwise in this situation. There is also an increased risk of perforation. Clients with known pelvic tuberculosis may have a higher risk of secondary infection and bleeding if an IUD is inserted. If a woman has any one of these three conditions, she should not have an IUD inserted. Counsel her about other contraceptive options available and provide condoms to use in the meantime. Note: Questions 9–12 are intended to identify clients at high individual risk of sexually transmitted infections (STIs), be- cause there is a possibility that they may currently have chla- mydia and/or gonorrhea infection. Unless these STIs can be reliably ruled out, clients at high risk are not good candidates for IUD insertion. IUD insertion may increase risk of pelvic infl ammatory disease (PID) in these clients. They should be counseled about other contraceptive options and provided with condoms for STI protection. However, if other contracep- tive methods are not available or acceptable and there are no signs of STI, an IUD still can be inserted. Careful follow-up is required in such cases. Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD Research fi ndings over the past 20 years have established that intrauterine devices (IUDs) are safe and eff ective for use by most women, including those who have not given birth, who want to space births, and those living with or at risk of HIV infection. For some women, IUDs are not recommended because of the presence of certain medical conditions, such as genital cancer and current cervical infection. For these reasons, women who desire to use an IUD must be screened for certain medical conditions to determine if they are appropriate candidates for the IUD. Family Health International (FHI), with support from the U.S. Agency for International Development (USAID), has developed a simple checklist (see center spread) to help health care providers screen clients who were counseled about contraceptive options and made an informed decision to use an IUD. The checklist is based on the guidance included in the Medical Eligibility Criteria for Contraceptive Use (WHO, 2004). It consists of a list of 20 questions designed to identify medical conditions and high-risk behaviors that would prevent safe IUD use or require further screening, as well as provide further guidance and directions based on clients’ responses. A health care provider should complete the checklist before inserting an IUD. In some settings the responsibility for completing the checklist may be shared – with a counselor completing questions 1–13 and an appropriately trained health care provider, including a physician, midwife, clinical offi cer, nurse, or auxiliary nurse, determining the answers to the remaining questions during the pelvic exam. Clients who are ruled out because of their response to some of the medical eligibility questions may still be good candidates for an IUD after the suspected condition is excluded through appropriate evaluation. This checklist is part of a series of provider checklists for reproductive health services. The other checklists include the Checklist for Screening Clients Who Want to Initiate Combined Oral Contraceptives, the Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN), and the Checklist on How to be Reasonably Sure a Client is Not Pregnant. For more information about the provider checklists, please visit www.fhi.org. 9. Within the last 3 months, have you had more than one sexual partner? Clients who have multiple sexual partners are at high risk of contracting STIs. Unless chlamydia and/or gonorrhea infection can be reliably ruled out, these clients are not good candidates for IUD insertion. (See note regarding questions 9–12.) 10. Within the last 3 months, do you think your partner has had another sexual partner? Clients whose partners have more than one sexual partner are at high risk of contracting STIs. Unless chlamydia and/or gonorrhea infection can be reliably ruled out, these clients are not good candidates for IUD insertion. In situations where polygamy is common, the provider should ask about sexual partners outside of the union. (See note regarding questions 9–12.) 11. Within the last 3 months, have you been told you have an STI? There is a possibility that these clients currently have chla- mydia and/or gonorrhea infection. Unless these STIs can be reliably ruled out, these clients are not good candidates for IUD insertion. (See note regarding questions 9–12.) 12. Within the last 3 months, has your partner been told that he has an STI or do you know if he has had any symptoms – for example, penile discharge? (Note: There are two parts to this question. Answering “yes” to either part or both parts of the question restricts IUD insertion.) Clients whose partners have STIs may have these infections as well. Unless chlamydia and/or gonorrhea infection can be reliably ruled out, these clients are not good candidates for IUD insertion. (See note regarding questions 9–12.) 13. Are you HIV-positive and have you developed AIDS? This is a two part question, and both parts must be asked together. If the woman answers “yes” to both parts, ask whether she is taking ARVs and make sure she is doing clinically well. If she is, she may be a candidate for the IUD. If she is not, an IUD is usually not recommended unless other more appropriate methods are not available or not acceptable. There is concern that HIV-positive clients who have developed AIDS and are not taking ARVs may be at increased risk of STIs and PID because of a suppressed immune system. IUD use may further increase that risk. If the woman is HIV-positive but has not developed AIDS, the IUD may generally be used. Pelvic Examination 14. Is there any type of ulcer on the vulva, vagina, or cervix? Genital ulcers or lesions may indicate a current STI. While an ulcerative STI is not a contraindication for IUD insertion, it indicates that the woman is at high individual risk of STIs, in which case IUDs are not generally recommended. Diagnosis should be established and treatment provided as needed. An IUD can still be inserted if co-infection with gonorrhea and chlamydia are reliably ruled out. 15. Does the client feel pain in her lower abdomen when you move the cervix? Cervical motion tenderness is a sign of PID. Clients with current PID should not use an IUD. Treatment should be provided as appropriate. If necessary, referral should be made to a higher-level provider or specialist. Counsel the client about condom use and other contraceptives. 16. Is there adnexa tenderness? Adnexa tenderness or/and adnexa mass is a sign of a malig- nancy or PID. Clients with genital cancer or PID should not use an IUD. Diagnosis and treatment should be provided as appropriate. If necessary, referral should be made to a higher-level provider or specialist. 17. Is there purulent cervical discharge? Purulent cervical discharge is a sign of cervicitis and pos- sibly PID. Clients with current cervicitis or PID should not use an IUD. Treatment should be provided as appropriate. If necessary, referral should be made to a higher-level provider or specialist. Counsel the client about condom use. 18. Does the cervix bleed easily when touched? If the cervix bleeds easily at contact, it may indicate that the client has cervicitis or cervical cancer. Clients with cur- rent cervicitis or cervical cancer should not have an IUD inserted. Treatment should be provided as appropriate. If necessary, referral should be made to a higher-level provider or specialist. If, through appropriate additional evaluation beyond the checklist, these conditions may be excluded, then the woman can receive the IUD. 19. Is there an anatomical abnormality of the uterine cavity that will not allow appropriate IUD insertion? If there is an anatomical abnormality that distorts the uterine cavity, proper IUD placement may not be possible. Cervical stenosis also may preclude an IUD insertion. 20. Were you unable to determine the size and/or position of the uterus? Determining size and position of the uterus is essential before IUD insertion to ensure high fundal placement of the IUD and to minimize the risk of perforation. © Family Health International, 2007• P.O. Box 13950, Research Triangle Park, NC 27709 USA • Fax: (919) 544-7261 • http://www.fhi.org Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD NO 14. Is there any type of ulcer on the vulva, vagina, or cervix? YES NO 15. Does the client feel pain in her lower abdomen when you move the cervix? YES NO 16. Is there adnexa tenderness? YES NO 17. Is there purulent cervical discharge? YES NO 18. Does the cervix bleed easily when touched? YES NO 19. Is there an anatomical abnormality of the uterine cavity that will not allow appropriate IUD insertion? YES NO 20. Were you unable to determine the size and/or position of the uterus? YES If the answer to all of questions 14–20 is NO, you may insert the IUD. If the answer to any of questions 14–20 is YES, the IUD cannot be inserted without further evaluation. See explanations for more instructions. © 2007 If the client answered NO to all of questions 1–6, pregnancy cannot be ruled out. The client should await menses or use a pregnancy test. If the client answered YES to any one of questions 1–6 and she is free of signs or symptoms of pregnancy, you can be reasonably sure that she is not pregnant. Proceed to questions 7–13. However, if she answers YES to question 1, the insertion should be delayed until 4 weeks after delivery. Ask her to come back at that time. First, be reasonably sure that the client is not pregnant. If she is not menstruating at the time of her visit, ask the client questions 1–6. As soon as the client answers YES to any question, stop, and follow instructions below. To determine if the client is medically eligible to use an IUD, ask questions 7–13. As soon as the client answers YES to any question, stop, and follow instructions below. If the client answered NO to all of questions 7–13, proceed with the PELVIC EXAM. If the client answered YES to question 7 or 8, an IUD cannot be inserted. Further evaluation of the condition is required. If the client answered YES to any of questions 9–12, she is not a good candidate for an IUD unless chlamydia and/or gonorrhea infection can be reliably ruled out. If she answered YES to the second part of question 13 and is not currently taking ARV drugs, IUD insertion is not usually recommended. If she is doing clinically well on ARVs, the IUD may generally be inserted. HIV-positive women without AIDS also generally can initiate IUD use. During the pelvic exam, the provider should determine the answers to questions 14–20. NO 7. Do you have bleeding between menstrual periods that is unusual for you, or bleeding after intercourse (sex)? YES NO 8. Have you been told that you have any type of cancer in your genital organs, trophoblastic disease, or pelvic tuberculosis? YES NO 9. Within the last 3 months, have you had more than one sexual partner? YES NO 10. Within the last 3 months, do you think your partner has had another sexual partner? YES NO 11. Within the last 3 months, have you been told you have an STI? YES NO 12. Within the last 3 months, has your partner been told that he has an STI or do you know if he has had any symptoms – for example, penile discharge? YES NO 13. Are you HIV-positive and have you developed AIDS? YES YES 1. Have you had a baby in the last 4 weeks? NO YES 2. Did you have a baby less than 6 months ago, are you fully or nearly-fully breastfeeding, and have you had no menstrual period since then? NO YES 3. Have you abstained from sexual intercourse since your last menstrual period or delivery? NO YES 4. Did your last menstrual period start within the past 12 days? NO YES 5. Have you had a miscarriage or abortion in the last 12 days? NO YES 6. Have you been using a reliable contraceptive method consistently and correctly? NO

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