JHPIEGO IUD Guidelines for Family Planning Service Programs- Course Handbook for Participants

Publication date: 2006

JHPIEGO, an affiliate of The Johns Hopkins University, builds global and local partnerships to enhance the quality of health care services for women and families around the world. JHPIEGO is a global leader in the creation of innovative and effective approaches to developing human resources for health. Copyright © 2006 by JHPIEGO. All rights reserved. Published by: JHPIEGO Brown’s Wharf 1615 Thames Street Baltimore, Maryland 21231-3492, USA http://www.jhpiego.org The Capacity Project is an innovative global initiative funded by the United States Agency for International Development (USAID). The Capacity Project applies proven and promising approaches to improve the quality and use of priority health care services in developing countries by: • Improving workforce planning and policy making; • Developing better education and training systems for the workforce; and • Strengthening systems to support workforce performance. Led by IntraHealth International, the Capacity Project partnership includes: Emerging Markets Group, Ltd. (EMG); Interchurch Medical Assistance, Inc. (IMA); JHPIEGO; Liverpool Associates in Tropical Health (LATH); Management Sciences for Health (MSH); Program for Appropriate Technology in Health (PATH); and Training Resources Group, Inc. (TRG). http://www.capacityproject.org Editors: Julia Bluestone Rebecca Chase Enriquito R. Lu Editorial Assistance: Dana Lewison Melissa McCormick Graphic Assistance and Layout: Youngae Kim Deborah Raynor TRADEMARKS: All brand and product names are trademarks or registered trademarks of their respective companies. This publication was completed for the Capacity Project through support provided by the United States Agency for International Development, under the terms of Award No. GPO-A-00-04-00026-00; and would not have been possible without initial support provided by Constella Futures (formerly Futures Group)/Key Social Marketing Pakistan Program, also through support provided by the U.S. Agency for International Development, under the terms of Award No. 391-A-00-0301017-00. The views expressed in this publication are those of JHPIEGO and do not necessarily reflect the views of the U.S. Agency for International Development or the United States Government. June 2006 IUD Guidelines for Family Planning Service Programs i IUD COURSE HANDBOOK FOR PARTICIPANTS OVERVIEW Before Starting This Training Course .1 Training Approach .1 Key Features of Mastery Learning .2 Competency-Based Training .3 Components of the IUD Training Package .5 Using the IUD Training Package .5 INTRODUCTION Course Design.7 Evaluation.8 Course Syllabus .9 Model IUD Course Schedule .13 INSTRUCTIONS FOR USING ZOE® GYNECOLOGIC SIMULATORS Contents of the Original ZOE Model.15 Assembly of the Original ZOE Model .16 Procedures with All ZOE Models.18 Care and Maintenance of All ZOE Models .19 PRECOURSE QUESTIONNAIRE How the Results Will Be Used.20 Precourse Questionnaire/Answer Sheet .21 Individual and Group Assessment Matrix .23 EXERCISE: HOW PEOPLE LEARN .25 EXERCISE 1: WHO ELIGIBILITY CRITERIA.29 EXERCISE 2: COUNSELING IUD USERS.31 EXERCISE 3: INFECTION PREVENTION .32 EXERCISE 4: CLIENT ASSESSMENT .33 EXERCISE 5: IUD INSERTION AND REMOVAL.34 EXERCISE 6: QUIZ .35 LEARNING GUIDES AND PRACTICE CHECKLIST Using the Learning Guides .37 Using the Practice Checklist.38 Learning Guide for IUD Counseling Skills .39 Learning Guide for IUD Clinical Skills (Adapted for the Regular Copper T 380A) .43 Learning Guide for IUD Clinical Skills (Adapted for the Safe Load Copper T 380A) .49 Learning Guide for IUD Clinical Skills (Adapted for the Multiload Cu375) .56 ii IUD Guidelines for Family Planning Service Programs Practice Checklist for IUD Counseling and Clinical Skills (Adapted for the Regular Copper T 380A) .62 Practice Checklist for IUD Counseling and Clinical Skills (Adapted for the Safe Load Copper T 380A) .65 Practice Checklist for IUD Counseling and Clinical Skills (Adapted for the Multiload Cu375) .68 COURSE EVALUATION.71 (Completed by participant) PRESENTATION GRAPHICS HANDOUTS Intrauterine Contraceptive Devices (IUDs): Introduction Intrauterine Contraceptive Devices (IUDs): Education and Counseling Intrauterine Contraceptive Devices (IUDs): Infection Prevention Intrauterine Contraceptive Devices (IUDs): Client Assessment Intrauterine Contraceptive Devices (IUDs): Insertion and Removal Intrauterine Contraceptive Devices (IUDs): Follow-up Care and Management of Potential Problems IUD Guidelines for Family Planning Service Programs 1 OVERVIEW BEFORE STARTING THIS TRAINING COURSE This training course will be conducted in a way that is very different from traditional training courses. First of all, it is based on the assumption that people participate in training courses because they: „ Are interested in the topic „ Wish to improve their knowledge or skills, and thus their job performance „ Desire to be actively involved in course activities The training approach used in this course stresses the importance of the cost-effective use of resources and application of relevant educational technologies including use of humane training techniques. The latter encompasses the use of anatomic models, such as the ZOE 7 , to minimize client risk and facilitate learning. TRAINING APPROACH The mastery learning approach to clinical training assumes that all participants can master (learn) the required knowledge, attitudes, or skills provided sufficient time is allowed and appropriate training methods are used. The goal of mastery learning is that 100 percent of those being trained will “master” the knowledge and skills on which the training is based. While some participants are able to acquire new knowledge or a new skill immediately, others may require additional time or alternative learning methods before they are able to demonstrate mastery. Not only do people vary in their abilities to absorb new material, but individuals learn best in different ways—through written, spoken, or visual means. Mastery learning takes these differences into account and uses a variety of teaching and training methods. The mastery learning approach also enables the participant to have a self-directed learning experience. This is achieved by having the clinical trainer serve as facilitator and by changing the concept of testing and how test results are used. In courses that use traditional testing methods, the trainer administers pre- and post-tests to document an increase in the participants= knowledge, often without regard for how this change affects job performance. 2 IUD Guidelines for Family Planning Service Programs By contrast, the philosophy underlying the mastery learning approach is one of a continual assessment of participant learning. With this approach, it is essential that the clinical trainer regularly inform participants of their progress in learning new information and skills, and not allow this to remain the trainer=s secret. With the mastery learning approach, assessment of learning is: „ Competency-based, which means assessment is keyed to the course objectives and emphasizes acquiring the essential knowledge, attitudinal concepts, and skills needed to perform a job, not simply acquiring new knowledge. „ Dynamic, because it enables clinical trainers to provide participants with continual feedback on how successful they are in meeting the course objectives and, when appropriate, to adapt the course to meet learning needs. „ Less stressful, because from the outset participants, both individually and as a group, know what they are expected to learn and where to find the information, and have ample opportunity for discussion with the clinical trainer. KEY FEATURES OF MASTERY LEARNING Effective clinical training is designed and conducted according to adult learning principles—learning is participatory, relevant, and practical—and: „ Uses behavior modeling „ Is competency-based „ Incorporates humanistic training techniques Behavior Modeling Social learning theory states that when conditions are ideal, a person learns most rapidly and effectively from watching someone perform (model) a skill or activity. For modeling to be successful, the trainer must clearly demonstrate the skill or activity so that participants have a clear picture of the performance expected of them. Learning to perform a skill takes place in three stages. In the first stage, skill acquisition, the participant sees others perform the procedure and acquires a mental picture of the required steps. Once the mental image is acquired, the participant attempts to perform the procedure, usually with supervision. Next, the participant practices until skill competency is achieved and the individual feels confident performing the procedure. The final stage, skill proficiency, occurs only with repeated practice over time. IUD Guidelines for Family Planning Service Programs 3 Skill Acquisition Knows the steps and their sequence (if necessary) to perform the required skill or activity but needs assistance Skill Competency Knows the steps and their sequence (if necessary) and can perform the required skill or activity Skill Proficiency Knows the steps and their sequence (if necessary) and efficiently performs the required skill or activity COMPETENCY-BASED TRAINING Competency-based training (CBT) is distinctly different from traditional educational processes. Competency-based training is learning by doing. It focuses on the specific knowledge, attitudes, and skills needed to carry out a procedure or activity. How the participant performs (i.e., a combination of knowledge, attitudes, and, most important, skills) is emphasized rather than just what information the participant has acquired. Moreover, CBT requires that the clinical trainer facilitate and encourage learning rather than serve in the more traditional role of instructor or lecturer. Competency in the new skill or activity is assessed objectively by evaluating overall performance. For CBT to occur, the clinical skill or activity to be taught first must be broken down into its essential steps. Each step is then analyzed to determine the most efficient and safe way to perform and learn it. This process is called standardization. Once a procedure, such as intrauterine contraceptive device (IUD) insertion, has been standardized, competency-based skill development (learning guides) and assessment (checklists) instruments can be designed. These instruments make learning the necessary steps or tasks easier and evaluating the participant's performance more objective. An essential component of CBT is coaching, which uses positive feedback, active listening, questioning, and problem-solving skills to encourage a positive learning climate. To use coaching, the clinical trainer should first explain the skill or activity and then demonstrate it using an anatomic model or other training aid such as a video. Once the procedure has been demonstrated and discussed, the trainer/coach then observes and interacts with the participant to provide guidance in learning the skill or activity, monitors progress and helps the participant overcome problems. 4 IUD Guidelines for Family Planning Service Programs The coaching process ensures that the participant receives feedback regarding performance: „ Before practice—The clinical trainer and participant should meet briefly before each practice session to review the skill/activity, including the steps/tasks that will be emphasized during the session. „ During practice—The clinical trainer observes, coaches, and provides feedback as the participant performs the steps/tasks outlined in the learning guide. „ After practice—This feedback session should take place immediately after practice. Using the learning guide, the clinical trainer discusses the strengths of the participant’s performance and also offers specific suggestions for improvement. Humanistic Training Techniques The use of more humane (humanistic) techniques also contributes to better clinical training. A major component of humanistic training is the use of anatomic models, which closely simulate the human body, and other learning aids such as videos. The effective use of models facilitates learning, shortens training time, and minimizes risks to clients. For example, by using anatomic models initially, participants more easily reach the performance levels of skill competency and beginning skill proficiency before they begin working in the clinic setting with clients. Before a participant attempts a clinical procedure with a client, two learning activities should occur: „ The clinical trainer should demonstrate the required skills and client interactions several times using an anatomic model and appropriate audiovisual aids (e.g., video). „ While being supervised, the participant should practice the required skills and client interactions using the model and actual instruments in a simulated setting that is as similar as possible to the real situation. Only when skill competency and some degree of skill proficiency have been demonstrated with models, however, should participants have their first contacts with clients. When mastery learning, which is based on adult learning principles and behavior modeling, is integrated with CBT, the result is a powerful and extremely effective method for providing clinical training. And when humanistic training techniques, such as using anatomic models and other learning aids, are incorporated, training time and costs can be reduced significantly. IUD Guidelines for Family Planning Service Programs 5 COMPONENTS OF THE IUD TRAINING PACKAGE This course is built around use of the following components: „ Need-to-know information contained in a reference manual „ A course handbook containing validated questionnaires and learning guides, which break down the skill or activity (e.g., classroom presentation or clinical demonstration) into its essential steps „ A trainer’s notebook, which includes questionnaire answer keys and detailed information for conducting the course „ Well-designed teaching aids and audiovisual materials, such as videos, anatomic models, and other training aids „ Competency-based performance evaluation The reference manual recommended for use in this course is IUD Guidelines for Family Planning Service Programs: A Problem- Solving Reference Manual, Third Edition, which contains practical “how-to” information and techniques to help the clinical trainer conduct participatory, humanistic IUD skills training courses. USING THE IUD TRAINING PACKAGE In designing the training materials for this course, particular attention has been paid to making them user-friendly and to permit the course participants and clinical trainer to easily adapt the training to the participants’ (group and individual) learning needs. For example, at the beginning of each course, an assessment is made of each participant’s knowledge. The results of this precourse assessment are then used jointly by the participants and the advanced or master trainer to adapt the course content as needed so that the training focuses on acquisition of new information and skills. A second feature relates to the use of the reference manual and course handbook. The reference manual is designed to provide all of the essential information needed to conduct the course in a logical manner. Because it serves as the “text” for the participants and the “reference source” for the trainer, special handouts or supplemental materials are not needed. In addition, because the manual contains only information that is consistent with the course goals and objectives, it becomes an integral part of all classroom exercises, such as giving an illustrated lecture or providing problem-solving information. 6 IUD Guidelines for Family Planning Service Programs The course handbook, on the other hand, serves a dual function. First, and foremost, it is the road map that guides the participant through each phase of the course. It contains the course syllabus and course schedule, as well as all supplemental printed materials (precourse questionnaire, individual and group assessment matrix, learning guides and course evaluation) needed during the course. The trainer’s notebook contains the same material as the course handbook for participants as well as material for the trainer. This includes the course outline, precourse questionnaire answer key, midcourse questionnaire and answer key, and competency-based qualification checklists. In keeping with the training philosophy on which this course is based, all training activities will be conducted in an interactive, participatory manner. To accomplish this requires that the role of the trainer continually change throughout the course. For example, the trainer is an instructor when presenting a classroom demonstration; a facilitator when conducting small group discussions or using role plays; and shifts to the role of coach when helping participants practice a procedure. Finally, when objectively assessing performance, the trainer serves as an evaluator. In summary, the CBT approach used in this course incorporates a number of key features. First, it is based on adult learning principles, which means that it is interactive, relevant, and practical. Moreover, it requires that the trainer facilitate the learning experience rather than serve in the more traditional role of an instructor or lecturer. Second, it involves use of behavior modeling to facilitate learning a standardized way of performing a skill or activity. Third, it is competency-based. This means that evaluation is based on how well the participant performs the procedure or activity, not just on how much has been learned. Fourth, where possible, it relies heavily on the use of anatomic models and other training aids (i.e., it is humanistic) to enable participants to practice repeatedly the standardized way of performing the skill or activity before working with clients. Thus, by the time the trainer evaluates each participant=s performance using the checklist, every participant should be able to perform every skill or activity competently. This is the ultimate measure of training. IUD Guidelines for Family Planning Service Programs 7 INTRODUCTION COURSE DESIGN This clinical training course is designed for service providers (physicians, nurses, and midwives). The course builds on each participant’s past knowledge and experience and takes advantage of the individual’s high motivation to accomplish the learning tasks in the minimum time. Training emphasizes doing, not just knowing, and uses competency-based evaluation of performance. This training course differs from traditional courses in several ways: „ During the morning of the first day of the course, participants are introduced to the key features of mastery learning and then are briefly tested (Precourse Questionnaire) to determine their individual and group knowledge of the management of IUD services. „ Classroom and clinic sessions focus on key aspects of service delivery (e.g., counseling of clients, how to provide services, and manage side effects and other potential problems). „ Progress in knowledge-based learning is measured during the course using a standardized written assessment (Midcourse Questionnaire). „ Clinical skills training builds on the participant’s previously mastered skills. Participants first practice on the anatomic models using learning guides that list the key steps in insertion and removal of IUDs. In this way, they learn more quickly the skills needed to insert and remove IUDs with clients in a standardized way. „ Progress in learning new skills is documented using the counseling and clinical skills learning guides. „ Evaluation of each participant’s performance is conducted by a clinical trainer using competency-based skills checklists. Successful completion of the course is based on mastery of both the content and skills components, as well as satisfactory overall performance in providing IUD services to clients. IUD service delivery is a team effort, requiring the knowledge and skills of trained clinicians (physicians, nurses, or midwives) and other types of health professionals, such as counselors. Although this course is designed for a single health professional, it is easily adapted for training teams of two people (a clinician and a non-clinician, such as a counselor or health assistant) in all aspects of IUD service provision. 8 IUD Guidelines for Family Planning Service Programs The person who actually performs the counseling or inserts the IUD may vary from country to country, depending on national and programmatic policies. Thus, opportunities are provided for learning and practicing IUD insertion and removal, as well as counseling techniques, infection prevention, record keeping and follow-up of clients. Even if a participant will not carry out a specific task, s/he needs to be familiar with it in order to ensure high-quality service delivery. Therefore, all course participants should be provided the opportunity to observe or perform all of the skills/activities associated with the safe delivery of IUD services. EVALUATION This clinical training course is designed to produce qualified IUD service providers. Qualification is a statement by the training organization that the participant has met the requirements of the course in knowledge, skills, and practice. Qualification does not imply certification. Personnel can be certified only by an authorized organization or agency. Qualification is based on the participant=s achievement in three areas: „ Knowledge: A score of at least 85% on the Midcourse Questionnaire „ Skills: Satisfactory performance of IUD counseling and clinical skills „ Practice: Demonstrated ability to provide IUD services in the clinical setting Responsibility for the participant’s becoming qualified is shared by the participant and the trainer. The evaluation methods used in the course are described briefly below: „ Midcourse Questionnaire. This knowledge assessment will be given at the time in the course when all subject areas have been presented. A score of 85% or more correct indicates knowledge- based mastery of the material presented in the reference manual. For those scoring less than 85% on their first attempt, the clinical trainer should review the results with the participant individually and provide guidance on using the reference manual to learn the required information. Participants scoring less than 85% can take the Midcourse Questionnaire again at any time during the remainder of the course. „ Provision of Services (Practice). During the course, it is the clinical trainer’s responsibility to observe each participant’s overall performance in providing IUD services. This provides a key opportunity to observe the impact on clients of the participant’s IUD Guidelines for Family Planning Service Programs 9 attitude, a critical component of high-quality service delivery. Only by doing this can the clinical trainer assess the way the participant uses what s/he has learned. „ Counseling and Clinical Skills Checklists. The clinical trainer will use these checklists to evaluate each participant as s/he counsels clients and inserts or removes IUDs with clients. Evaluation of the counseling skills of each participant may be done with clients; however, it may be accomplished at any time during the course through observation during role plays using participants or volunteers. Evaluation of the clinical skills usually will be done during the last 2 days of the course (depending on class size and client caseload). In determining whether the participant is qualified, the clinical trainer(s) will observe and rate the participant’s performance for each step of the skill or activity. The participant must be rated satisfactory in each skill or activity to be evaluated as qualified. It is recommended that, within 3 to 6 months of qualification, graduates be observed and evaluated working in their institution by a course trainer using the same counseling and clinical skills checklist. (At the very least, the graduate should be observed by a skilled provider soon after completing training.) This postcourse evaluation is important for several reasons. First, it not only gives the graduate direct feedback on her/his performance, but also provides the opportunity to discuss any startup problems or constraints to service delivery (e.g., lack of instruments, supplies or support staff). Second, and equally important, it provides the training center, via the clinical trainer, key information on the adequacy of the training and its appropriateness to local conditions. Without this type of feedback, training easily can become routine, stagnant and irrelevant to service delivery needs. COURSE SYLLABUS Course Description. This 6-day clinical training course is designed to prepare the participant to counsel individuals concerning the use of IUDs as a contraceptive method and to become competent in inserting and removing the Copper T 380A IUD (regular and/or with Safe Load) and in managing side effects and other potential problems associated with the use of IUDs. Course Goals „ To influence in a positive way the attitudes of the participant toward the benefits and appropriate use of IUDs „ To provide the latest technical information on IUDs, including the most up-to-date WHO medical eligibility criteria (MEC) 10 IUD Guidelines for Family Planning Service Programs „ To provide the participant with information on general family planning counseling, as well as training in method-specific counseling for IUDs „ To provide the participant with the knowledge and skills necessary to use the appropriate infection prevention practices when providing IUD services „ To provide the participant with the knowledge and skills necessary to conduct an assessment of potential IUD users „ To provide the participant with the knowledge and skills needed for IUD insertion and removal „ To provide the participant with the knowledge and skills needed to provide routine follow-up care, and manage side effects and potential problems related to IUD use „ To provide the participant with the knowledge and skills needed to organize and manage quality IUD services Participant Learning Objectives By the end of the training course, the participant will be able to: 1. Explain how copper-bearing IUDs prevent pregnancy, their basic attributes, and their health benefits and risks, as well as most common side effects. 2. Address common misconceptions about the IUD. 3. Explain the WHO MEC for copper-bearing IUDs, as well as precautions and contraindications to IUD use. 4. Counsel a client interested in using a copper-bearing IUD. 5. Use recommended infection prevention practices to minimize the risk of postinsertion/postremoval infections and transmission of serious diseases (e.g., hepatitis B, HIV) to patients, clients, and health care staff. 6. Perform an assessment for potential IUD users, including a targeted history and physical examination (including a complete pelvic examination). 7. Load the Copper T (regular or with Safe Load) in its sterile package without using high-level disinfected (or sterile) gloves. 8. Insert the IUD gently and safely, using the “no-touch” technique. 9. Provide appropriate client education/counseling following IUD insertion (e.g., about when the IUD should be removed/replaced, side effects, the use of condoms to protect against sexually transmitted infections, warning signs, when to return to the clinic). 10. Explain the indications for IUD removal. IUD Guidelines for Family Planning Service Programs 11 11. Remove an IUD gently and safely, using the using the “no-touch” technique. 12. Provide routine follow-up support to IUD users, as well as appropriate management of side effects and other potential problems. Training/Learning Methods „ Illustrated lectures and group discussions „ Individual and group exercises „ Role plays „ Simulated practice with anatomic (pelvic) models „ Guided clinical activities (counseling and IUD insertion and removal) Learning Materials. This course handbook is designed to be used with the following materials: „ Reference manual: IUD Guidelines for Family Planning Service Programs: A Problem-Solving Reference Manual (JHPIEGO) „ Infection prevention videos: Infection Prevention Guidelines for Healthcare Facilities with Limited Resources: Overview and Practical Training Demonstration Segments and Safe Practices in the Operating Room „ IUD insertion and removal kits, and Copper T IUDs in sterile packages „ Pelvic and hand-held uterine models for both types of IUDs Participant Selection Criteria Participants for this course should be clinicians (physicians, nurses, or midwives) working in a health care facility (clinic or hospital) that provides women’s health services. Methods of Evaluation Participant „ Pre- and Midcourse Questionnaires „ Learning Guides and Practice Checklist for IUD Counseling and Clinical Skills „ Checklist for IUD Counseling and Clinical Skills (to be completed by clinical trainer) 12 IUD Guidelines for Family Planning Service Programs Course „ Course Evaluation (to be completed by each participant) Course Duration „ 6 days Suggested Course Composition „ 10 health professionals (clinicians) or 5 teams1 „ 2 clinical trainers 1 The course size will be limited by the available space (classroom and demonstration areas/rooms) at the training facility and the number of potential IUD clients per session at the clinical training site(s). 13 IUD Guidelines for Family Planning Service Programs MODEL IUD COURSE SCHEDULE (STANDARD COURSE: 6 DAYS, 12 SESSIONS) DAY 1 DAY 2 DAY 3 0830–1200 OPENING z Welcome z Participant expectations Overview of course z Goals and objectives z Review of course materials and schedule Precourse Questionnaire—Identify individual and group learning needs. Lecture/Discussion—Introduction to copper-bearing IUDs Lecture/Demonstration—Family planning education and counseling 0830–1200 Overview of day’s scheduled activities and warmup exercise Tour of Clinic Facilities and Observation Presentation—Infection prevention (IP) Discussion—Counseling, IP practices and method provision observed Demonstration—From abdominal exam through IUD insertion and removal 0830–1200 Overview of day’s scheduled activities and warmup exercise Discussion and Presentation—Client assessment Clinic Practice—Provide counseling, IP, or IUD services in the clinic with supervision or in classroom practice. LUNCH LUNCH LUNCH 1330–1630 Assessment—Assess current skills in stations Discussion—Use and care of anatomical models Review of the day’s activities 1330–1630 Demonstration and Practice—Loading the IUD in its sterile package Activity and Discussion—Review IP practices and discuss Classroom Practice—Divide into two groups to practice: z Counseling a client z Pelvic exam and insertion/removal of the IUD using pelvic models Review of the day’s activities 1330–1630 Clinical Conference Exercise/Discussion—Client assessment and screening Exercise and discussion—Insertion of the IUD Discussion—Assessing individual risk of STIs Review progress so far Reading Assignment: Chapters 1–5 and FHI’s “Quick Reference” Chart (at end of the manual) Reading Assignment: Chapter 6 and Appendices A–D Reading Assignment: As needed 14 IUD Guidelines for Family Planning Service Programs MODEL IUD COURSE SCHEDULE (STANDARD COURSE: 6 DAYS, 12 SESSIONS) DAY 4 DAY 5 DAY 6 0830–1200 Overview of day’s scheduled activities and warmup exercise Clinic Practice—Provide counseling, IP, or IUD services in the clinic with supervision or in classroom practice. (Note: Participants assess each other’s performance using learning guides or practice checklist. Over the next few days, those who wish to be assessed in certain skills should let the trainer know, and trainers will assess their performance using the checklist.) 0830–1200 Overview of day’s scheduled activities and warmup exercise Clinic Practice/Assessment—Provide counseling, IP, or IUD services in the clinic with supervision or in classroom practice. 0830-1200 Overview of day’s scheduled activities and warmup exercise Clinic Practice/Assessment—Provide counseling, IP, or IUD services in the clinic with supervision or in classroom practice. LUNCH LUNCH LUNCH 1330–1630 Clinical Conference Demonstration/Discussion: Review IP guidelines Demonstration and Practice—In a simulated clinical area, demonstrate and practice insertion of IUD. Review of the day’s activities 1330–1630 Midcourse Questionnaire Classroom Practice— In a simulated clinical area, demonstrate and practice pelvic exam and insertion of IUD. Discussion/Activity—Quality assurance for IUD services Review of the day’s activities 1330-1630 Clinical Conference Classroom Assessment—In a simulated clinical area, the trainer will evaluate insertion of IUD. Demonstration/Discussion—Managing lost strings COURSE EVALUATION CLOSING Reading Assignment: As needed to prepare for the Midcourse Questionnaire Reading Assignment: As needed IUD Guidelines for Family Planning Service Programs 15 INSTRUCTIONS FOR USING ZOE7 GYNECOLOGIC SIMULATORS A ZOE Gynecologic Simulator is a model of a full-sized, adult female lower torso (abdomen and pelvis). It is a versatile training tool developed to assist health professionals to teach the processes and skills needed to perform many gynecologic procedures. ZOE models are ideal for demonstrating and practicing the following procedures: „ Bimanual pelvic examination including palpation of normal and pregnant uteri „ Vaginal speculum examination „ Visual recognition of normal cervices and abnormal cervices „ Uterine sounding „ IUD insertion and removal „ Diaphragm sizing and fitting „ Laparoscopic inspection and occlusion of fallopian tubes (Falope rings or other clips) „ Minilaparotomy (both interval and postpartum tubal occlusion) „ Treatment of incomplete abortion using manual vacuum aspiration (MVA) CONTENTS OF THE ORIGINAL ZOE MODEL There are several models of ZOE Gynecologic Simulators now available, including an interval model and postpartum kit, so specific parts and accessories will vary. The original ZOE Gynecological Simulator kit includes the following: ITEM QUANTITY Normal ante- and retroverted uteri with clear tops, attachments for round and ovarian ligaments as well as fallopian tubes and normal patent cervical os for pelvic examination and IUD insertion 2 6–8 week uterus with dilated (open) cervical os, which allows passage of a 5 or 6 mm flexible cannula 1 10–12 week uterus with dilated (open) cervical os, which allows passage of a 10 or 12 mm flexible cannula 1 Postpartum uterus (20 week size) with attached fallopian tubes for practicing postpartum tubal occlusion by minilaparotomy 1 Cervices (not open) for use in visual recognition: z Normal cervix 1 z Cervix with proliferation of columnar epithelium (ectropion) 1 z Cervix with inclusion (nabothian) cyst and endocervical polyp 1 z Cervix with lesion (cancer) 1 16 IUD Guidelines for Family Planning Service Programs ITEM QUANTITY Normal cervices with open os for IUD insertion/removal 5 Cervices for 6–8 week and 10–12 week uteri (2 of each size) 4 Normal tubal fimbriae and ovaries (2 of each) 4 Fallopian tubes for tubal occlusion 8 Simulated round and ovarian ligaments (set of 2 each) 4 Extra thin cervical locking rings 3 Flashlight with batteries 1 Soft nylon carrying bag 1 Outer Skin The outer skin of the model is foam-backed in order to simulate the feel of the anterior pelvic wall. The entire outer skin is removable to allow the model to be used for demonstration purposes (e.g., performing IUD insertion). The 3 cm incision (reinforced at each end) located just below the umbilicus can be used to insert a laparoscope to look at the uterus, round ligaments, ovaries and fallopian tubes and practice laparoscopic tubal occlusion. This incision also can be used for practicing postpartum tubal ligation by minilaparotomy. The 3 cm incision located a few centimeters above the symphysis pubis is used for practicing interval minilaparotomy. This incision also is reinforced, which allows the skin to be retracted to facilitate demonstration of the minilaparotomy technique. Cervices The normal cervices have a centrally located, oval-shaped os, which permits insertion of a uterine sound, uterine elevator or IUD. The abnormal cervices are not open and can be used for demonstration only. Each of the cervices for treatment of incomplete abortion has a centrally located, oval-shaped os, which is dilated to allow passage of a 5 or 6 mm or 10 or 12 mm flexible cannula, respectively. The normal cervices and interchangeable uteri feature the patented “screw” design for fast and easy changing. ASSEMBLY OF THE ORIGINAL ZOE MODEL To use the original ZOE pelvic model for demonstrations or initially to learn how to change the parts (e.g., cervices and uteri), you need to know how to remove the skin. IUD Guidelines for Family Planning Service Programs 17 Removing and Replacing the Detachable Skin and Foam Backing 1. First, carefully remove the outer skin and its foam lining away from the rigid base at the “top” end of the model. (“Top” refers to the portion of ZOE nearest to the metal carrying handle located above the umbilicus.) 2. Lift the skin and foam up and over the legs, one leg at a time. 3. Be as gentle as possible. The detachable skin is made of material that approximates skin texture and it can tear. 4. If you wish to change the anteverted uterus and normal cervix that are shipped attached to ZOE, first you must remove the uterus. 5. Start by pulling the round ligaments away from the wall. 6. Then grasp the uterus while turning the wide grey ring counterclockwise until the cervix and uterine body are separated. 7. To remove the cervix, turn the thin grey ring counterclockwise until it comes off. 8. You then can push the cervix out through the vagina. 9. To reassemble, simply reverse this process. 10. To replace the skin and foam lining, start by pulling them down over the legs. 11. Then make sure the rectal opening is aligned with the opening in the rigid base. 12. Pull the skin and foam over the top of the model. 13. Finally, make sure both are pulled firmly down around the rigid base, and the skin is smoothly fitted over the foam. Once you understand how ZOE=s anatomic parts fit together, we suggest you change them through the opening at the top of the model. This helps to preserve ZOE=s outer shell as you will only have to remove it for demonstrations or to change the postpartum (20 week size) uterus. The anteverted and retroverted uteri have transparent top halves and opaque lower halves for use in demonstrating IUD insertion. These uteri are supported by round ligaments attached to the pelvic wall. The round ligaments, ovaries and fallopian tubes are removable. To remove the uterus: „ Unscrew the wide locking ring attached to the uterus using a counterclockwise rotation. 18 IUD Guidelines for Family Planning Service Programs To remove the cervix: „ Unscrew the thin locking ring immediately outside the apex of the vagina. „ The cervix should be pushed through the vagina and removed from the introitus. To reassemble, proceed in reverse order. PROCEDURES WITH ALL ZOE MODELS Speculum examination: „ Use a medium bivalve speculum. „ Prior to inserting the speculum, dip it into clean water containing a small amount of soap. (This makes inserting the speculum easier.) „ To see the cervix, fully insert the speculum, angle it posteriorly (as in the human, the vagina in the ZOE model is angled posteriorly), then open the blades fully. „ To increase the diameter of the opening, use the speculum thumb screw (Pederson or Graves specula). Passing instruments (uterine sound, uterine elevator, dilator or cannula) through the cervical os: „ Apply a small amount of clean water containing a drop or two of soap solution to the cervix (just as you would apply it with antiseptic solution in a client). This will make passing the instrument through the cervical os easier. Sounding the uterus, inserting an IUD and interval minilaparotomy or laparoscopy: „ Use either the normal (nonpregnant) anteverted or retroverted uterus with a cervix having a patent os. Postpartum minilaparotomy (tubal occlusion): „ Use the postpartum uterus (20 week size) with a cervix having a patent os. Treatment of incomplete abortion using MVA: „ Use either the 6 to 8 or 10 to 12 week uteri (incomplete abortion) with the appropriate size cervix. IUD Guidelines for Family Planning Service Programs 19 CARE AND MAINTENANCE OF ALL ZOE MODELS The specific model of ZOE Gynecological Simulator will vary, depending on the location of the training site and the procedures being performed, but the care and maintenance of these models are the same for all. „ ZOE is constructed of material that approximates skin texture. Therefore, in handling the model, use the same gentle techniques as you would in working with a client. „ To avoid tearing ZOE’s skin when performing a pelvic exam, use a dilute soap solution to lubricate the instruments and your gloved fingers. „ Clean ZOE after every training session using a mild detergent solution; rinse with clean water. „ DO NOT write on ZOE with any type of marker or pen, as these marks may not wash off. „ DO NOT use alcohol, acetone or Betadine7 or any other antiseptic that contains iodine on ZOE. They will damage or stain the skin. „ Store ZOE in the carrying case and plastic bag provided with your kit. „ DO NOT wrap ZOE in other plastic bags, newspaper, plastic wrap or any other kinds of material, as these may discolor the skin. 20 IUD Guidelines for Family Planning Service Programs PRECOURSE QUESTIONNAIRE HOW THE RESULTS WILL BE USED The main objective of the Precourse Questionnaire is to assist both the clinical trainer and the participant as they begin their work together in the course by assessing what the participants, individually and as a group, know about the course topic. Providing the results of the precourse assessment to the participants enables them to focus on their individual learning needs. In addition, the questions alert participants to the content that will be presented in the course. The questions are presented in the true-false format. For the clinical trainer, the questionnaire results will identify particular topics that may need additional emphasis during the learning sessions. Conversely, for those categories in which 85% or more of participants answer the questions correctly, the clinical trainer may elect to use some of the allotted time for other purposes. For example, if the participants as a group did well (85% or more of the questions correct) in answering the questions in the category “Counseling” (Questions 4 through 8), the clinical trainer may elect to assign that section as homework rather than discussing these topics in class. For the participants, the learning objective(s) related to each question and the corresponding section(s) in the reference manual are noted beside the answer column. To make the best use of limited course time, participants are encouraged to address their individual learning needs by studying the designated section(s). IUD Guidelines for Family Planning Service Programs 21 PRECOURSE QUESTIONNAIRE Instructions: In the spaced provided, print a capital T if the statement is true or a capital F if the statement is false. OVERVIEW 1. A good candidate for using an IUD is a woman who wants at least several years of contraception. ______ Participant Objective 1 (Chapter 1) 2. The risk of pelvic inflammatory disease in IUD users is related to sexually transmitted infections, not the IUD itself. ______ Participant Objective 2 (Chapter 1) 3. Women who have had an ectopic pregnancy in the past can use the IUD. ______ Participant Objective 3 (Chapter 1) COUNSELING 4. The service provider is the person best qualified to choose a contraceptive method for a woman in good health. ______ Participant Objective 4 (Chapter 2) 5. Women who are not in a mutually faithful relationship (i.e., either partner has more than one sexual partner) are at increased risk for STIs and should be urged use condoms, in addition to the IUD, for protection. ______ Participant Objective 4 (Chapter 2) 6. Counseling about possible side effects and how to manage them increases continued contraceptive use. ______ Participant Objective 4 (Chapter 2) 7. The provider should avoid discussing “rumors” the woman may have heard about the method. ______ Participant Objective 4 (Chapter 2) 8. Clients should be counseled that after IUD insertion, heavy vaginal discharge often occurs, which requires frequent douching. ______ Participant Objective 4 (Chapter 2) INFECTION PREVENTION 9. Surgical (metal) instruments that have been decontaminated and thoroughly cleaned can be sterilized by boiling them in water for 20 minutes. ______ Participant Objective 5 (Chapter 3) 10. High-level disinfection of gloves can be done by steaming them for 20 minutes. ______ Participant Objective 5 (Chapter 3) 11. Tarnished (discolored) IUDs still inside the undamaged, sealed package should be discarded because they are no longer sterile. ______ Participant Objective 5 (Chapter 3) 22 IUD Guidelines for Family Planning Service Programs 12. To minimize the risk of staff contracting hepatitis B or HIV/AIDS during the cleaning process, instruments and gloves first should be soaked for 20 minutes in 8% formaldehyde solution. ______ Participant Objective 5 (Chapter 3) CLIENT ASSESSMENT 13. The physical examination of a potential IUD client must include breast, abdominal, and pelvic (speculum and bimanual) examinations. ______ Participant Objective 6 (Chapter 4) 14. If a woman is found to have a retroverted (posterior) uterus, she cannot have an IUD inserted. ______ Participant Objective 6 (Chapter 4) 15. If a client has current purulent cervicitis, the IUD should not be inserted at this time. ______ Participant Objective 6 (Chapter 4) IUD INSERTION AND REMOVAL 16. To correctly insert the IUD, you must wear high- level disinfected or sterile gloves. ______ Participant Objective 7 (Chapter 5) 17. IUDs can be inserted at any time during the menstrual cycle provided that the client is not pregnant. ______ Participant Objective 8 (Chapter 5) 18. Following insertion of the IUD, the woman should be advised to return to the clinic after her next period (3 to 6 weeks). ______ Participant Objective 9 (Chapter 5) 19. A woman should not have her IUD removed unless she is willing to start another method immediately. ______ Participant Objective 10 (Chapter 5) 20. The Copper T 380A IUD should be removed/replaced in 12 years. ______ Participant Objective 10 (Chapter 5) 21. Prophylactic antibiotics should be given for routine IUD removal. ______ Participant Objective 11 (Chapter 5) FOLLOW-UP CARE/MANAGEMENT OF POTENTIAL PROBLEMS 22. If a woman becomes pregnant with an IUD in place, she is more likely to have increased vaginal discharge. ______ Participant Objective 12 (Chapter 6) 23. When a woman is undergoing evaluation/treatment for a medical condition, the IUD usually does not need to be removed. ______ Participant Objective 12 (Chapter 6) 23 IUD Guidelines for Family Planning Service Programs IUD TRAINING COURSE: INDIVIDUAL AND GROUP ASSESSMENT MATRIX Course:____________________________________ Dates:___________________ Clinical Trainer(s):____________________________________ CORRECT ANSWERS (PARTICIPANTS) QUESTION NUMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 CATEGORIES 1 2 3 OVERVIEW 4 5 6 7 8 COUNSELING 9 10 11 12 INFECTION PREVENTION 13 14 15 CLIENT ASSESSMENT 24 IUD Guidelines for Family Planning Service Programs CORRECT ANSWERS (PARTICIPANTS) QUESTION NUMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 CATEGORIES 16 17 18 19 20 21 IUD INSERTION AND REMOVAL 22 23 FOLLOW-UP CARE/ MANAGEMENT OF POTENTIAL PROBLEMS IUD Guidelines for Family Planning Service Programs 25 HOW PEOPLE LEARN2 After completing this session, the participant will be able to identify how adults learn skills and apply this to attain the session objective. The participant will: „ Compare formal (school) and practical (hands-on) methods of learning „ List the three stages of learning clinical skills „ Identify the principles of learning COMPARISON OF FORMAL (SCHOOL) AND PRACTICAL (HANDS-ON) METHODS OF LEARNING „ Characteristics of formal (school) teaching: „ Structured „ Instructor acts as though s/he is “better” than the students (top down) „ Information is usually theoretical „ Little or no interaction or student involvement „ Few questions by the students „ Characteristics of practical training (e.g., the way a wood carver would teach his children about carving): „ Informal „ Learning is fun (low stress) „ Learn by doing (hands-on) „ Participatory (trainer and student are partners) „ Interactive (questions going both ways) The practical method is more like coaching as opposed to school teaching. An example of where coaching is an appropriate training method is learning a skill such as IUD insertion or removal. HOW PEOPLE LEARN „ Training must be relevant. Learning experiences should relate directly to the job responsibilities of the participants. „ People often bring a high level of motivation to training: „ Desire to improve job performance „ Desire to learn 2 Adapted from: Sullivan R et al. 1995. Clinical Training Skills for Reproductive Health Professionals. JHPIEGO: Baltimore, MD. 26 IUD Guidelines for Family Planning Service Programs „ Desire to improve their life „ People need involvement during training. This can be accomplished by: „ Allowing participants to provide input regarding schedules, activities, and other events „ Using questioning and feedback „ Using brainstorming and discussions „ Providing hands-on work „ Conducting group and individual projects „ Setting up classroom activities or games „ People desire variety. Ways to provide this include: „ Varying the schedule „ Using a variety of audiovisual aids: – Writing boards – Flipcharts – Overhead transparencies – Slides – Videos – Anatomic models or real items (e.g., instruments) „ Using a variety of teaching methods: – Illustrated lectures – Demonstrations – Small group activities – Group discussions – Role plays and case studies – Guest speakers „ People need positive feedback. Positive feedback is letting participants know how they are doing, and providing this information in a positive manner. The clinical trainer provides positive feedback when s/he uses one or more of the following: „ Verbal praise either in front of other participants or individually. „ Recognizing appropriate responses during questioning: – That=s correct! – Good answer! – That was an excellent response! IUD Guidelines for Family Planning Service Programs 27 „ Acknowledging appropriate skills while coaching in a clinical setting: – Very good work! – I would like everyone to notice the incision that was just made. Ilka did an excellent job. All incisions should look like this one. „ Letting the participants know how they are progressing toward achieving the learning objectives. „ The clinical trainer must recognize that participants may come to training with a number of personal concerns such as a fear of: „ Failure or embarrassment „ Fitting in with the other participants „ Getting along with the trainer „ Understanding the content „ Being able to perform the skills being taught The clinical trainer must be aware of these concerns and begin the course with an opening exercise that allows all participants to get to know each other in a safe and positive climate. „ People prefer to be treated as individuals who have unique and particular backgrounds, experiences, and learning needs. The clinical trainer can ensure that participants feel like individuals by using one or more of the following methods: „ Using participant names as often as possible „ Involving all participants as often as possible „ Treating participants with respect „ Allowing participants to share information with others during classroom and clinical instructionParticipants need to maintain high self-esteem to deal with the demands of clinical training. Respect on the part of the clinical trainer, which includes avoiding negative feedback, is essential to maintaining participant confidence while learning. „ The clinical trainer must maintain participants= high expectations by: „ Conducting a training course that adds, rather than subtracts, from the participant’s self-esteem and sense of competence „ Setting high expectations for her/himself and her/his fellow trainers „ Allowing participants to get to know and respect the trainer „ Understanding and recognizing the participant’s career accomplishments 28 IUD Guidelines for Family Planning Service Programs „ All participants have personal needs during training. Timely breaks from instruction, the best possible ventilation, proper lighting, and an environment as free from distraction as possible reduce tension and create a positive atmosphere. STAGES OF LEARNING CLINICAL SKILLS „ Skill acquisition represents the initial phase in learning a new clinical skill or activity. One or more practice sessions are needed for learning how to perform the required steps and the sequence (if necessary) in which they should be performed. Assistance and coaching are necessary to achieve correct performance of the skill or activity. „ Skill competency represents an intermediate phase in learning a new clinical skill or activity. The participant can perform the required steps in the proper sequence (if necessary) but may not progress from step to step efficiently. „ Skill proficiency represents the final phase in learning a new clinical skill or activity. The participant efficiently and precisely performs the steps in the proper sequence (if necessary). PRINCIPLES OF LEARNING (KEYS TO SUCCESS) „ The most productive way of learning is by doing. Repetition is necessary for proficiency. „ The more realistic the content, the more productive the learning. „ Learning is: „ Most productive when the participant is ready to learn (It is up to the clinical trainer to create a climate that will motivate participants.) „ Most productive when it builds on what the participant already has experienced or knows „ Easier when the participant knows what s/he is expected to learn „ More fun when a variety of methods and teaching techniques are used IUD Guidelines for Family Planning Service Programs 29 EXERCISE 1: WHO MEDICAL ELIGIBILITY CATEGORIES 1. Which two eligibility categories mean you may provide the method? 2. Which two eligibility categories mean you generally should not use or can’t use the method? 3. Which WHO category means use of the method is generally not recommended, and you should only use it if no other method is available or acceptable? 4. A woman has diabetes. What is the WHO category of this condition for IUD use? 5. A woman comes to you and would like an IUD. She is HIV- infected, her CD4 count is 400, and she is clinically well. What is the WHO category of this condition? Can you give this woman the IUD? Why or why not? 6. The same woman comes to see you several years later. Now she has AIDS, her CD4 count is 150, and she is not on antiretroviral therapy. What is the WHO category for this woman for continuing the IUD? What would the WHO eligibility category be for the same situation for insertion, not continuation? 7. If a woman has AIDS but is on antiretroviral therapy and receiving clinical care, what is the WHO category for IUD insertion? For continuation? 30 IUD Guidelines for Family Planning Service Programs 8. A woman who wants the IUD has a reddened vagina and complains of some irritation. On pelvic examination, there is no purulent discharge, and STIs have been ruled out by lab tests. You treat her for bacterial vaginosis. Can you insert the IUD on this visit? Why or why not? 9. List six of the WHO category 4 conditions for IUD insertion. 10. A woman has herpes. What is the WHO category of this condition for IUD use? 11. A woman is nulliparous and would like the IUD for several years of protection. What is the WHO category? What additional information/counseling would you give her about nulliparity and the IUD? 12. A woman had PID several months ago, but she and her partner have been treated. Upon reexamination, you find nothing unusual and she currently has no known risk factors for STIs. Can you give this woman the IUD? Why or why not? IUD Guidelines for Family Planning Service Programs 31 EXERCISE 2: COUNSELING IUD USERS Here are some sample scenarios for use in counseling role plays. Participants should use their learning guides as well as any informational/educational brochures or leaflets during practice. 1. A woman comes in who is interested in using an IUD. Counsel her using the GATHER technique. 2. A woman comes in who wants long-term contraceptive protection. As you are counseling her using the GATHER technique, she tells you she is concerned that an IUD can become dislodged and travel into other parts of her body. Address her fears by showing her how the IUD works using a handheld model or picture. 3. A woman comes in who is interested in using an IUD. As you are counseling her using the GATHER technique, she tells you she is concerned about the IUD will affect existing menstrual bleeding problems (heavy, prolonged, painful). Address her fears. 4. A woman comes in seeking contraception. As you are counseling her using the GATHER technique, she tells you that she got gonorrhea from her husband last year and is worried about getting another infection from him. Counsel her as appropriate. 32 IUD Guidelines for Family Planning Service Programs EXERCISE 3: INFECTION PREVENTION 1. Which is the most important of the standard precaution practices? 2. Which is the first step in instrument processing and what is its purpose? 3. What is the key difference between sterilization and high-level disinfection? 4. When inserting an IUD, the client should put on a clean gown— true or false? 5. List the two antiseptics that may be used to cleanse the cervix and vagina prior to IUD insertion or removal. 6. Why is it appropriate to use new/clean examination gloves, rather than high-level disinfected (or sterile) surgical gloves, when inserting an IUD? 7. Define the no-touch technique. 8. A tarnished IUD inside its intact, sterile package is contaminated and should not be used—true or false? IUD Guidelines for Family Planning Service Programs 33 EXERCISE 4: CLIENT ASSESSMENT 1. During the menstrual history, the woman complains of heavy menstrual bleeding and cramping. What would be your concern about the IUD for this woman? 2. When gathering her general medical history, you should ask every potential IUD user about which three medical conditions? 3. During the reproductive history, the woman complains of purulent discharge. What are three possible diagnoses? 4. What are you checking for when palpating the abdomen during the physical examination? 5. What are two reasons that the bimanual examination is so important? 6. During the visual inspection of the cervix using a speculum, list three things you are looking for. 7. In what situation would you perform a rectovaginal examination? 8. A woman has purulent cervical discharge, what should you do? 9. You are preparing to insert an IUD. When you insert the speculum, you notice purulent discharge from the cervix. What do you do? 34 IUD Guidelines for Family Planning Service Programs EXERCISE 5: IUD INSERTION AND REMOVAL 1. List five things you can do to prevent infection when inserting an IUD. 2. List the two antiseptics that are appropriate for cleansing the cervix or vagina. 3. You sound the uterus at 8 cm; to what distance do you set the depth-gauge before IUD insertion? 4. You are explaining common side effects to a woman who just had an IUD inserted. What three points do you want to be sure to address about menstrual changes? IUD Guidelines for Family Planning Service Programs 35 EXERCISE 6 KEY: QUIZ 1. When should a woman return for her first scheduled follow-up visit? 2. When else should she return to the clinic? 3. List three questions to ask clients when they return the first time. 4. The manual lists seven potential problems that may occur with IUD users. Which one is the most common cause of IUD removal? 5. If a woman becomes pregnant with the IUD in place, there are two things that are very important to do as soon as possible. What are they? 6. A woman comes to you and has heavy bleeding and cramping with her periods. She is extremely unhappy. What can you do to help her? 7. What are three possible signs of uterine perforation during uterine sounding or IUD insertion? 8. A woman is concerned about uterine perforation and asks for details about incidence and usual side effects. What can you tell her? 36 IUD Guidelines for Family Planning Service Programs 9. What are some of the signs/symptoms that can indicate expulsion, other than missing strings? 10. A woman with an IUD who has a partner with multiple partners comes in complaining of mild abdominal pain and fever. She has no unusual discharge, but has cervical motion tenderness. What would you do and why? IUD Guidelines for Family Planning Service Programs 37 LEARNING GUIDES AND PRACTICE CHECKLIST FOR IUD COUNSELING AND CLINICAL SKILLS The Learning Guides and Practice Checklist for IUD Counseling and Clinical Skills contain the steps or tasks performed by the counselor and clinician when providing IUD services. These tasks correspond to the information presented in the manual IUD Guidelines for Family Planning Service Programs: A Problem-Solving Reference Manual, 3 rd ed. These tools are designed to help the participant learn the steps or tasks involved in: „ Counseling a potential family planning client „ Counseling a client requesting IUD insertion or removal „ Inserting and removing the Copper T 380A IUD (regular or with Safe Load) There are two learning guides in this handbook: „ Learning Guide for IUD Counseling Skills „ Learning Guide for IUD Clinical Skills—two versions: „ Adapted for the Regular Copper T 380A „ Adapted for the TCu 380A with Safe Load There is one practice checklist in this handbook: „ Practice Checklist for IUD Counseling and Clinical Skills—two versions: „ Adapted for the Regular Copper T 380A „ Adapted for the TCu 380A with Safe Load USING THE LEARNING GUIDES The Learning Guide for IUD Clinical Skills is designed to be used primarily during the early phases of learning (i.e., skill acquisition) when participants are practicing with the anatomic (pelvic) model. Therefore, it does not include the steps involved in pre- and postinsertion counseling of clients. „ The participant is not expected to perform all of the steps or tasks correctly the first time s/he practices them. Instead, the learning guides are intended to: „ Assist the participant in learning the correct steps and sequence in which they should be performed (skill acquisition) „ Measure progressive learning in small steps as the participant gains confidence and skill (skill competency) Note: If IUD insertion/removal training is con- ducted only with clients instead of using pelvic models, the clinical skills learning guide should be sup- plemented with relevant portions of the Learning Guide for IUD Counseling Skills. 38 IUD Guidelines for Family Planning Service Programs „ The Learning Guide for IUD Counseling Skills should be used initially during practice (simulated) counseling sessions with volunteers or with clients in real situations. „ Initially, participants can use the learning guides to follow the steps as the clinical trainer role plays counseling a client or demonstrates IUD insertion or removal using a pelvic model. „ Subsequently, during the classroom practice sessions, they serve as step-by-step guides for the participant as s/he performs the skill using pelvic models, or counsels a volunteer “client.” Because the learning guides are used to assist in developing skills, it is important that the rating (scoring) be done carefully and as objectively as possible. The participant=s performance of each step is rated on a three-point scale as follows: 1 Needs Improvement: Step or task not performed correctly of out of sequence (if necessary) or is omitted 2 Competently Performed: Step or task performed correctly in proper sequence (if necessary) but participant does not progress from step to step efficiently 3 Proficiently Performed: Step or task efficiently and precisely performed in the proper sequence (if necessary) USING THE PRACTICE CHECKLIST The Practice Checklist for IUD Counseling and Clinical Skills combines, and is derived from, both the counseling and clinical skills learning guides, but it focuses only on the key steps in the entire procedure. „ As the participant progresses through the course and gains experience, dependence on the detailed learning guides decreases and the practice checklist may be used in their place. „ The practice checklist can be used by participants, when providing services in a clinical situation, to rate one another=s performance „ The practice checklist is the same as the Checklist for IUD Counseling and Clinical Skills, which the clinical trainer will use to evaluate each participant=s performance at the end of the course. Because the checklist is used to measure skills, it is important that the rating (scoring) be done carefully and as objectively as possible. The participant=s performance of each step is rated on a three-level scale as follows: Satisfactory: Performs the step or task according to the standard procedure or guidelines Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines Not Observed: Step, task or skill not performed by participant during evaluation by trainer Remember: It is the goal of this training that every participant perform every task or activity correctly with clients by the end of the course. IUD Guidelines for Family Planning Service Programs 39 LEARNING GUIDE FOR IUD COUNSELING SKILLS (To be used by Participants) Rate the performance of each step or task observed using the following rating scale: 1 Needs Improvement: Step or task not performed correctly or out of sequence (if necessary) or is omitted 2 Competently Performed: Step or task performed correctly in proper sequence (if necessary) but participant does not progress from step to step efficiently 3 Proficiently Performed: Step or task efficiently and precisely performed in the proper sequence (if necessary) LEARNING GUIDE FOR IUD COUNSELING SKILLS STEP/TASK CASES GENERAL FAMILY PLANNING COUNSELING Greet the Woman 1. Greet the client with warmth and respect, and thank her for coming. 2. Ask why she has come, and what she hopes to get out of the visit. 3. Explain your role: to assist her in choosing a contraceptive method. 4. Encourage her to talk and to answer questions openly. 5. Assure her that the meeting will be confidential. Ask the Woman about Herself 6. Ask about previous experiences with family planning. 7. Assess partner/family attitudes about family planning. 8. Ask about her reproductive goals (how many children she wants, desire for birth spacing, desire for long-term protection, etc.). 9. Ask about her need for protection against STIs (this will be further assessed later). 10. Ask whether she is interested in a particular family planning method. Tell the Woman about Family Planning [Tip: Use support materials such as diagrams, brochures, and actual samples of methods to emphasize and illustrate points.] 11. Provide general information about family planning, focusing on the method(s) in which she is interested and any other appropriate methods. Tailoring information to fit her individual needs and situation, explain the following attributes of the method(s): z Effectiveness and effective life z Mechanism of action z Side effects z Health benefits and potential risks z Protection against HIV and other STIs z Cost and convenience z Accessibility/availability of supplies needed [Note: Keep in mind that many women may not be aware of the IUD or know anything about it.] 12. Correct any misconceptions the woman may have about the method(s) she is considering. Ask whether she has any concerns about the method. Ask what she has heard about it. [Note: This may be especially important for potential IUD users, as misinformation about the IUD is prevalent in many parts of the world.] 40 IUD Guidelines for Family Planning Service Programs LEARNING GUIDE FOR IUD COUNSELING SKILLS STEP/TASK CASES Help the Woman Select a Method 13. Once the woman has selected a method, assess her knowledge about it by asking her questions about it, and having her repeat key information back to you. 13a. Ensure that the potential IUD user understands that menstrual changes (increase in amount and duration of bleeding and pain/cramping) are a common side effect among IUD users, and: z Are the main reason women choose to discontinue the method z Are not usually harmful z Often lessen or go away within a few months z Can be reduced by use of NSAIDs. 13b. Ensure that the potential IUD user understands that the IUD does not protect against STIs, including HIV, and: z The IUD is not a good choice for women who have a very high individual risk of gonorrhea and chlamydia (this will be further assessed later). z Women who may be at risk for STIs should use a condom, in addition to the IUD, for protection every time they have sex. 14. Encourage her to ask questions and state any remaining concerns about the method selected. Provide additional information and reassurance as needed. 15. Ensure that the woman understands any examinations or procedures required for provision of the method selected. [Potential IUD users should understand that a medical assessment including a pelvic examination is required to confirm a woman’s eligibility for IUD use, and that IUD insertion and removal require minor procedures that must be performed by a skilled provider.] 16. Once the appropriate assessment is completed to confirm that the woman is medically eligible to start the method, provide the method. [Potential IUD users should be provided an overview of the procedure before the IUD is inserted; this is expanded upon below in “Preinsertion Education/ Counseling.”] METHOD-SPECIFIC COUNSELING Explain How to Use the Method [Expanded upon below in “Postinsertion Education/Counseling”] 1. Explain to the client how to use the method, as well as what to do if she experiences side effects, and provide any other basic information needed. 2. Provide information on warning signs that indicate a need to return to the clinic immediately. 3. Provide specific instructions on when to return to the clinic for follow-up. 4. Have the woman repeat key messages for safe and effective use of the method. 5. Encourage her to ask questions and state any remaining concerns about the method selected. Provide additional information and reassurance as needed. Return Visit/Refer 6. Assess the woman’s satisfaction with the method. 7. Check for problems or concerns. [For IUD users during the first routine check- up, emphasis is on menstrual problems, use of condoms for protection against STIs as needed, PAINS, and checking for IUD expulsion.] 8. Reinforce key messages for safe and effective use of the method. [For new IUD users during the first routine check-up, emphasis is on providing reassurance for menstrual problems, and reminding the woman about use of condoms for protection against STIs as needed, PAINS, and checking for IUD expulsion.] 9. Refer the woman if needed. IUD Guidelines for Family Planning Service Programs 41 LEARNING GUIDE FOR IUD COUNSELING SKILLS STEP/TASK CASES IUD INSERTION (COUNSELING) Preinsertion Education/Counseling 1. Provide an overview of the procedure, explaining what it involves, how long it will take, etc. 2. Explain that it is very safe. 3. Tell her that she may experience some discomfort, but that you will try to make it as comfortable as possible; advise her to let you know if/when she feels pain. 4. Ask if she has questions or concerns; provide additional information or reassurance as needed. [Note: Continue informing the woman of what you are doing throughout the procedure; alert her to possible discomfort before performing the step that may cause it. Immediately following the procedure, ask the client how she feels. (She should stay in clinic for the next 15 to 30 minutes.)] Postinsertion Education/Counseling (before the woman leaves the clinic) 5. Reinforce basic facts about her IUD: z Type of IUD [Copper T 380A] z Course of protection [immediately effective; lasts for 12 years] z Removal [any time for any reason, as long as performed by a skilled provider] 6. Remind client of need to use condoms in addition to the IUD if she is at risk for STIs. 7. Review common side effects (menstrual changes) and what to do if they occur. 8. Review warning signs that indicate a need to return to the clinic immediately: PAINS (Period late or heavy, Abdominal pain, Infection symptoms, Not feeling well, String changes or problems). 9. Tell the woman how and when to check for IUD expulsion. z Check for IUD strings after first few menses z Check for IUD on pad, in latrine, etc., during first few menses 10. Inform the client when to return for the follow-up visit: z After first postinsertion menses (3 to 6 weeks) for routine check-up z If side effects become bothersome z If PAINS occur (immediately) z To have IUD removed z Any other time for any reason 11. Have the woman repeat key messages for safe and effective use of the method. 12. Encourage her to ask questions and state any remaining concerns about the method selected. Provide additional information and reassurance as needed. IUD REMOVAL (COUNSELING) 1. Greet the woman with warmth and respect and thank her for coming. 2. Establish the purpose of the visit. 3. Ask the woman her reason for having the IUD removed. [Note: Appropriate counseling, assessment, and other aspects of care will depend in part on the reason for IUD removal.] 4. Determine whether she will have another IUD inserted immediately, start a different method, or neither. 42 IUD Guidelines for Family Planning Service Programs LEARNING GUIDE FOR IUD COUNSELING SKILLS STEP/TASK CASES 5. Provide basic family planning counseling as needed: z Ensure that she understands that there is immediate return to fertility upon IUD removal. z Ask client about her reproductive goals (Does she want to continue spacing or limiting births?). z Ask about her need for protection against STIs. z Help her choose another contraceptive method if needed. 6. Before removing the IUD, provide a brief overview of the procedure, and: z Advise her to let you know if/when she feels pain. z Ask if she has any questions or concerns. z Provide additional information or reassurance as needed. [Note: Continue informing the woman of what you are doing throughout the procedure; alert her to possible discomfort before performing the step that may cause it. Immediately following the procedure, ask the client how she feels. (She should stay in clinic for the next 15 to 30 minutes.)] 7. If the woman has had a new IUD inserted, review key messages for IUD users. [If the woman is starting a different method, provide the information she needs to use it safely and effectively (and a back-up method, if needed).] 8. Have the woman repeat key messages for safe and effective use of the method she is using. 9. Encourage her to ask questions and state any remaining concerns about the method selected. Provide additional information and reassurance as needed. IUD Guidelines for Family Planning Service Programs 43 LEARNING GUIDE FOR IUD CLINICAL SKILLS (ADAPTED FOR THE REGULAR COPPER T 380A) (To be used by Participants) Rate the performance of each step or task observing the following rating scale: 1 Needs Improvement: Step or task not performed correctly or out of sequence (if necessary) or is omitted 2 Competently Performed: Step or task performed correctly in proper sequence (if necessary) but participant does not progress from step to step efficiently 3 Proficiently Performed: Step or task efficiently and precisely performed in the proper sequence (if necessary) LEARNING GUIDE FOR IUD CLINICAL SKILLS (REGULAR COPPER T 380A) STEP/TASK CASES IUD INSERTION Client Assessment 1. Greet the client with kindness and respect. 2. Determine that the client has been counseled about the IUD in general, as well about the insertion procedure. History 3. Review the client’s contraceptive, menstrual, and obstetric history to confirm that the IUD is an appropriate choice for the client, focusing especially on ensuring that the client is not pregnant. Ask about: z Heavy, prolonged, or menstrual painful periods z Parity/gravida z Childbirth or abortion within the last 4 weeks; signs/symptoms of infection with either z Possibility of pregnancy (delayed or missing period, unprotected sex since last menstrual period [LMP]) (Note: If needed, use checklist provided in Appendix B to be reasonably sure the client is not pregnant.) 4. Review the client’s pertinent (general and reproductive) medical history to confirm that the IUD is an appropriate choice for the client, focusing especially on ensuring that the client is not at high individual risk of sexually transmitted infections (STIs). Ask about: z Severe anemia z HIV/AIDS z Complicated valvular heart disease z Cancer of the reproductive organs z Trophoblastic disease z Pelvic tuberculosis z Unexplained vaginal bleeding z High individual risk of STIs – STI within last 3 months (self or partner) – Multiple partners (self or partner) – Partner with symptoms of STI (e.g., penile discharge) z Diagnosis of pelvic inflammatory disease (PID), gonorrhea, chlamydia, or other STIs (within last 3 months) z Symptoms of PID, gonorrhea, chlamydia, or other STIs – Lower abdominal pain – Current unusual or purulent vaginal discharge Physical Examination 5. Ensure that a high-level disinfected (HLD) instrument pan (or sterile pack), supplies, and light source are available. 44 IUD Guidelines for Family Planning Service Programs LEARNING GUIDE FOR IUD CLINICAL SKILLS (REGULAR COPPER T 380A) STEP/TASK CASES 6. Have the client empty her bladder and wash and rinse her perineal area if possible. 7. Help the client onto the examination table. 8. Tell the client what is going to be done, and ask her if she has any questions. 9. Wash your hands thoroughly with soap and water; and dry them with clean, dry cloth or allow them to air dry. 10. Check for signs of anemia/severe anemia. 11. Palpate the abdomen: z Check for suprapubic tenderness. z Check for swellings, bulges, masses, or other gross abnormalities. 12. Drape the client appropriately for pelvic exam. 13. Wash your hands again thoroughly with soap and water; and dry them with clean, dry cloth or allow them to air dry. 14. Open the HLD instrument pan (or sterile pack) without touching instruments. 15. Using an HLD (or sterile) pick-up forcep, arrange the instruments and supplies on an HLD pan (or sterile tray), being very careful not to touch parts of the instruments that will go into the vagina or uterus. 16. Put new/clean examination or HLD (or sterile) surgical gloves on both hands. 17. Inspect the external genitalia and urethral opening: z Check for ulcers, lesions, and sores. z Check for buboes (enlarged groin nodes). z Palpate Skene’s and Bartholin’s glands, checking for tenderness or discharge. Note: z If findings are normal (findings that do not suggest possible infection or other pelvic problems), perform the bimanual exam first and the speculum exam second. This allows you to sound the uterus and insert the IUD without having to insert the speculum twice. z If there are potential problems (findings that suggest possible infection or other pelvic problems), perform the speculum exam first and a bimanual exam second. 18a. Perform a bimanual exam (see Note above): z Determine the size, shape, and position of uterus. z Check for enlargement or tenderness of the adnexa and for cervical motion tenderness. z Check for uterine abnormalities that may interfere with proper placement of the IUD. 18b. Perform rectovaginal exam only if: z Position or size of uterus is unclear. z There is a possible mass behind the uterus. 18c. If rectovaginal exam is performed, do the following before continuing: z Immerse both gloved hands in 0.5% solution. z Remove gloves by turning inside out and dispose of them z Put on new/clean examination or HLD (or sterile) gloves. 19. Perform a speculum exam (see Note above) of the vagina and cervix (by gently spreading the labia with two fingers and then inserting the HLD [or sterile] speculum, starting obliquely and then rotating it to the horizontal position): z Check for purulent vaginal discharge. z Check for ulcers, lesions, and sores. z Check cervix for purulent cervicitis, bleeding, erosions, or narrowing of the cervical canal (stenosis). (Note: If laboratory testing is indicated and available, refer to steps at the end of learning guide.) IUD Guidelines for Family Planning Service Programs 45 LEARNING GUIDE FOR IUD CLINICAL SKILLS (REGULAR COPPER T 380A) STEP/TASK CASES Preinsertion and Insertion Steps 1. If both bimanual and speculum exams are normal, give the client a brief overview of the insertion procedure, encourage her to ask questions, and provide reassurance if needed. Remind her to let you know if she feels any pain. Sounding the Uterus 2. Gently insert the HLD (or sterile) speculum (if not already done; visualize cervix), and cleanse the cervical os and vaginal wall with an appropriate antiseptic two or more times. 3. Gently grasp the cervix with an HLD (or sterile) tenaculum and apply gentle traction. Do not lock the tenaculum beyond the first notch, unless necessary. 4. While gently pulling on the tenaculum, and without allowing the tip of the sound to touch the vaginal walls or the speculum blades, carefully insert the sound into the cervical os. 5a. Gently advance the sound at the appropriate angle (based on bimanual exam). 5b. STOP advancing the sound when a slight resistance is felt, and confirm the position of the uterus (anterior or posterior) for the IUD insertion. Do not use force at any stage of this procedure. 6. Remove the sound. (Do not pass the sound into the uterus more than once.) 7. Determine the depth of the uterus by noting the level of mucus or wetness on the sound. 8. Place the sound in 0.5% chlorine solution for 10 minutes for decontamination. Loading the IUD in Its Sterile Package (Important: Do not load the IUD until the final decision to insert the IUD has been made.) 9. Adjust the contents of the package (through the package) so that the “T” is fully inside insertion tube. 10. Peel the clear plastic cover half-way to blue depth-gauge. 11. Place the white plunger rod in the clear insertion tube. 12. Bend the “arms” of the T downward: z Place the package on a flat surface. z Stabilize the arms of the T with one hand. z Slide the measurement insert under the T with the other hand. z Still holding the arms of the T, push the insertion tube toward the IUD to push the arms downward. (Important: Do not fold the arms of the T into the insertion tube more than 5 minutes before the IUD is inserted into the uterus.) 13. When the arms of the T touch the sides of the insertion tube, pull the tube away from the folded arms of the IUD. 14. Slightly elevate the insertion tube, and push and rotate it back over the tips of the arms of the IUD, so that both tips are caught inside the tube. 15. Push the folded arms of the IUD into the tube only as far as needed to keep them fixed in the tube. 16. With the loaded IUD still in the package, set the blue depth-gauge to the corresponding measurement obtained from sounding the uterus. z Press down on the gauge with one hand to keep it stable. z At the same time, slide the insertion tube with your other hand until the tip of the IUD aligns with the tip in the diagram on the measurement insert. 17. Align the blue depth-gauge and the folded arms of the T so that they are both in horizontal position (flat against the package on the table). 46 IUD Guidelines for Family Planning Service Programs LEARNING GUIDE FOR IUD CLINICAL SKILLS (REGULAR COPPER T 380A) STEP/TASK CASES 18. Finish peeling back the cover in one brisk, continuous movement with one hand, while holding the loaded IUD through the open end of the package against the white backing (on the table) with the other hand. 19. Lift the loaded IUD from the package, without allowing it to touch anything that is not sterile. Keep it level so that the IUD does not fall out, and be careful not to push the white rod toward the IUD. Inserting the IUD 20. Put new/clean examination or HLD (or sterile) surgical gloves on both hands (if taken off to load the IUD). 21. Give the client a brief overview of the procedure, encourage her to ask questions, and provide reassurance if needed. Remind her to let you know if she feels any pain. 22. Hold the IUD so that blue depth-gauge is in horizontal position. Gently grasp the tenaculum with the other hand and gently pull outward and downward. 23a. Carefully insert the loaded IUD into the vaginal canal and gently push it through the cervical os and into uterine cavity at the appropriate angle (based on sounding). 23b. Gently advance the loaded IUD into the uterine cavity until the blue depth- gauge comes into contact with the cervix or slight resistance is felt. (Important: Be careful not to touch the wall of vagina or the speculum blades with the tip of the loaded IUD. Do not use force at any stage of this procedure.) 24. Hold the tenaculum and white rod stationary with one hand, and release the arms of the T from the insertion tube using the withdrawal technique: z Gently pull the insertion tube away from the IUD (while holding the white rod stable) until it touches the circular thumb grip of the white plunger rod. z Remove the white plunger rod, while holding the insertion tube stationary. 25. Gently push insertion tube upward again, toward the fundus of the uterus, until you feel a slight resistance. 26. Partially withdraw the insertion tube from the cervical canal until the string can be seen extending from the cervical os. 27. Use HLD (or sterile) sharp Mayo scissors to cut the IUD strings to 3–4 cm length. 28. Gently remove the tenaculum and place in 0.5% chlorine solution for 10 minutes for decontamination. 29. Examine the cervix. If there is bleeding where the tenaculum was attached to the cervix, use HLD (or sterile) forceps to place cotton (or gauze) swab on the affected tissue, and apply gentle pressure for 30–60 seconds. 30. Gently remove speculum and place in 0.5% chlorine solution for 10 minutes for decontamination. 31. Ask the client if she is experiencing nausea, mild to moderate lower abdominal pain/cramping, and dizziness or fainting. If she is experiencing any of these symptoms, provide reassurance and allow her remain on the examination table until she feels better (she should stay in clinic for at least 15 to 30 minutes). Begin performing the postinsertion steps. Postinsertion Steps 1. Before removing the gloves, place all used instruments in 0.5% chlorine solution for 10 minutes for decontamination. (After the client has left, wipe the examination table with 0.5% chlorine solution.) 2. Dispose of waste materials (e.g., cotton balls) by placing in a leak-proof container (with a tight-fitting lid) or plastic bag. IUD Guidelines for Family Planning Service Programs 47 LEARNING GUIDE FOR IUD CLINICAL SKILLS (REGULAR COPPER T 380A) STEP/TASK CASES 3. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning inside out: z If disposing of gloves, place in the leak-proof container or plastic bag. z If reusing surgical gloves (not recommended), submerge them in 0.5% chlorine solution for 10 minutes for decontamination. 4. Wash hands thoroughly with soap and water; and dry them with a clean, dry cloth or air dry. 5. Provide postinsertion instructions (key messages for IUD users): z Basic facts about her IUD (e.g., type, how long effective, when to replace/remove) z No protection against STIs; need for condoms if at risk z Possible side effects z Warning signs (PAINS) z Checking for possible IUD expulsion z When to return to clinic IUD REMOVAL Preremoval Steps 1. Greet the woman with kindness and respect, and establish purpose of visit. 2. Ask the woman her reason for having the IUD removed. 3. Determine whether she will have another IUD inserted immediately, start a different method, or neither. 4. Counsel as appropriate: z Ensure that she understands that there is immediate return to fertility after IUD removal. z Review the client’s reproductive goals and need for STI protection z Discuss other contraceptive methods if desired. 5. Ensure that a high-level disinfected (HLD) instrument pan (or sterile pack), supplies, and light source are available. 6. Open the HLD instrument pan (or sterile pack) without touching instruments. Using an HLD (or sterile) pick-up forcep, arrange the instruments and supplies on an HLD pan (or sterile tray), being very careful not to touch parts of the instruments that will go into the vagina or uterus. 7. Have the client empty her bladder and wash and rinse her perineal area if possible. 8. Help the client onto the examination table. 9. Wash your hands thoroughly with soap and water; and dry them with clean, dry cloth or allow them to air dry. 10. Put new/clean examination or HLD (or sterile) surgical gloves on both hands. 11. Give the client a brief overview of the procedure, encourage her to ask questions, and provide reassurance as needed. Remind her to let you know if she feels any pain. Removing the IUD 1. Insert an HLD (or sterile) speculum to visualize the IUD strings. 2. Cleanse the cervix (especially the os) and vagina with an appropriate antiseptic two or more times. 3. Alert the client immediately before you remove the IUD. Ask her to take slow, deep breaths and inform her that she may feel some discomfort and cramping, which is normal. 4. Grasp the IUD strings close to the cervix with an HLD (or sterile) hemostat or other narrow forceps. 48 IUD Guidelines for Family Planning Service Programs LEARNING GUIDE FOR IUD CLINICAL SKILLS (REGULAR COPPER T 380A) STEP/TASK CASES 5. Apply steady but gentle traction, pulling the strings toward you, to remove the IUD. Do not use excessive force. 6. Show the IUD to client. 7. Place the IUD in 0.5% chlorine solution for 10 minutes for decontamination. 8. If the woman is having a new IUD inserted, insert it now if appropriate. If she is not having a new IUD inserted, gently remove the speculum and place it in 0.5% chlorine solution for 10 minutes for decontamination. 9. Ask the client if she is experiencing nausea, mild to moderate lower abdominal pain/cramping, and dizziness or fainting. If she is experiencing any of these symptoms, provide reassurance and allow her remain on the examination table until she feels better (she should stay in clinic for at least 15 to 30 minutes). Postremoval Steps 1. Before removing the gloves, place all used instruments in 0.5% chlorine solution for 10 minutes for decontamination. (After the client has left, wipe the examination table with 0.5% chlorine solution.) 2. Dispose of waste materials (e.g., cotton balls) by placing in a leak-proof container (with a tight-fitting lid) or plastic bag. 3. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning inside out: z If disposing of gloves, place in the leak-proof container or plastic bag. z If reusing surgical gloves (not recommended), submerge them in 0.5% chlorine solution for 10 minutes for decontamination. 4. Wash hands thoroughly with soap and water; and dry them with a clean, dry cloth or air dry. 5. If the woman has had a new IUD inserted, review key messages for IUD users. [If the woman is starting a different method, provide the information she needs to use it safely and effectively (and a back-up method, if needed).] *Laboratory Testing (if available and if indicated based on assessment) 1. Remove speculum after taking samples of vaginal and cervical discharge. 2. Immerse both gloved hands in 0.5% solution. Remove gloves by turning inside out. z If disposing of gloves, place in leakproof container or plastic bag. z If reusing surgical gloves (not recommended), submerge in 0.5% chlorine solution for 10 minutes for decontamination. 3. Prepare for saline and KOH wet mounts and Gram staining. 4. Identify on the wet mounts: z Vaginal epithelial cells z Trichomoniasis (if present) z Monilia (if present) z Clue cells (if present) 5. Identify on the Gram stain: z WBC (polymorphonuclear white cells) (if present) z Gram-negative intracellular diplococci (GNID) (if present) z Clue cells (if present) 6. When testing is done, wash hands thoroughly with soap and water; and dry them with clean, dry cloth or air-dry. 7. Treat any conditions identified according to national guidelines/local protocols (refer, if needed). IUD Guidelines for Family Planning Service Programs 49 LEARNING GUIDE FOR IUD CLINICAL SKILLS (ADAPTED FOR THE TCU 380A WITH SAFE LOAD) (To be used by Participants) Rate the performance of each step or task observing the following rating scale: 1 Needs Improvement: Step or task not performed correctly or out of sequence (if necessary) or is omitted 2 Competently Performed: Step or task performed correctly in proper sequence (if necessary) but participant does not progress from step to step efficiently 3 Proficiently Performed: Step or task efficiently and precisely performed in the proper sequence (if necessary) LEARNING GUIDE FOR IUD CLINICAL SKILLS (TCU 380A WITH SAFE LOAD) STEP/TASK CASES IUD INSERTION Client Assessment 1. Greet the client with kindness and respect. 2. Determine that the client has been counseled about the IUD in general, as well about the insertion procedure. History 3. Review the client’s contraceptive, menstrual, and obstetric history to confirm that the IUD is an appropriate choice for the client, focusing especially on ensuring that the client is not pregnant. Ask about: z Heavy, prolonged, or menstrual painful periods z Parity/gravida z Childbirth or abortion within the last 4 weeks; signs/symptoms of infection with either z Possibility of pregnancy (delayed or missing period, unprotected sex since last menstrual period [LMP]) (Note: If needed, use checklist provided in Appendix B to be reasonably sure the client is not pregnant.) 4. Review the client’s pertinent (general and reproductive) medical history to confirm that the IUD is an appropriate choice for the client, focusing especially on ensuring that the client is not at high individual risk of sexually transmitted infections (STIs). Ask about: z Severe anemia z HIV/AIDS z Complicated valvular heart disease z Cancer of the reproductive organs z Trophoblastic disease z Pelvic tuberculosis z Unexplained vaginal bleeding z High individual risk of STIs – STI within last 3 months (self or partner) – Multiple partners (self or partner) – Partner with symptoms of STI (e.g., penile discharge) z Diagnosis of pelvic inflammatory disease (PID), gonorrhea, chlamydia, or other STIs (within last 3 months) z Symptoms of PID, gonorrhea, chlamydia, or other STIs – Lower abdominal pain – Current unusual or purulent vaginal discharge Physical Examination 5. Ensure that a high-level disinfected (HLD) instrument pan (or sterile pack), supplies, and light source are available. 50 IUD Guidelines for Family Planning Service Programs LEARNING GUIDE FOR IUD CLINICAL SKILLS (TCU 380A WITH SAFE LOAD) STEP/TASK CASES 6. Have the client empty her bladder and wash and rinse her perineal area if possible. 7. Help the client onto the examination table. 8. Tell the client what is going to be done, and ask her if she has any questions. 9. Wash your hands thoroughly with soap and water; and dry them with clean, dry cloth or allow them to air dry. 10. Check for signs of anemia/severe anemia. 11. Palpate the abdomen: z Check for suprapubic tenderness. z Check for swellings, bulges, masses, or other gross abnormalities. 12. Drape the client appropriately for pelvic exam. 13. Wash your hands again thoroughly with soap and water; and dry them with clean, dry cloth or allow them to air dry. 14. Open the HLD instrument pan (or sterile pack) without touching instruments. 15. Using an HLD (or sterile) pick-up forcep, arrange the instruments and supplies on an HLD pan (or sterile tray), being very careful not to touch parts of the instruments that will go into the vagina or uterus. 16. Put new/clean examination or HLD (or sterile) surgical gloves on both hands. 17. Inspect the external genitalia and urethral opening: z Check for ulcers, lesions, and sores. z Check for buboes (enlarged groin nodes). z Palpate Skene’s and Bartholin’s glands, checking for tenderness or discharge. Note: z If findings are normal (findings that do not suggest possible infection or other pelvic problems), perform the bimanual exam first and the speculum exam second. This allows you to sound the uterus and insert the IUD without having to insert the speculum twice. z If there are potential problems (findings that suggest possible infection or other pelvic problems), perform the speculum exam first and a bimanual exam second. 18a. Perform a bimanual exam (see Note above): z Determine the size, shape, and position of uterus. z Check for enlargement or tenderness of the adnexa and for cervical motion tenderness. z Check for uterine abnormalities that may interfere with proper placement of the IUD. 18b. Perform rectovaginal exam only if: z Position or size of uterus is unclear. z There is a possible mass behind the uterus. 18c. If rectovaginal exam is performed, do the following before continuing: z Immerse both gloved hands in 0.5% solution. z Remove gloves by turning inside out and dispose of them z Put on new/clean examination or HLD (or sterile) gloves. 19. Perform a speculum exam (see Note above) of the vagina and cervix (by gently spreading the labia with two fingers and then inserting the HLD [or sterile] speculum, starting obliquely and then rotating it to the horizontal position): z Check for purulent vaginal discharge. z Check for ulcers, lesions, and sores. z Check cervix for purulent cervicitis, bleeding, erosions, or narrowing of the cervical canal (stenosis). (Note: If laboratory testing is indicated and available, refer to steps at the end of learning guide.) IUD Guidelines for Family Planning Service Programs 51 LEARNING GUIDE FOR IUD CLINICAL SKILLS (TCU 380A WITH SAFE LOAD) STEP/TASK CASES Preinsertion and Insertion Steps 1. If both bimanual and speculum exams are normal, give the client a brief overview of the insertion procedure, encourage her to ask questions, and provide reassurance if needed. Remind her to let you know if she feels any pain. Sounding the Uterus 2. Gently insert the HLD (or sterile) speculum (if not already done; visualize cervix), and cleanse the cervical os and vaginal wall with an appropriate antiseptic two or more times. 3. Gently grasp the cervix with an HLD (or sterile) tenaculum and apply gentle traction. Do not lock the tenaculum beyond the first notch, unless necessary. 4. While gently pulling on the tenaculum, and without allowing the tip of the sound to touch the vaginal walls or the speculum blades, carefully insert the sound into the cervical os. 5a. Gently advance the sound at the appropriate angle (based on bimanual exam). 5b. STOP advancing the sound when a slight resistance is felt, and confirm the position of the uterus (anterior or posterior) for the IUD insertion. Do not use force at any stage of this procedure. 6. Remove the sound. (Do not pass the sound into the uterus more than once.) 7. Determine the depth of the uterus by noting the level of mucus or wetness on the sound. 8. Place the sound in 0.5% chlorine solution for 10 minutes for decontamination. Loading the IUD in Its Sterile Package (Important: Do not load the IUD until the final decision to insert the IUD has been made.) 9. Adjust the contents of the package (through the package) so that the “T” is fully inside insertion tube. 10. Peel the clear plastic cover half-way to blue depth-gauge. 11. Place the white plunger rod in the clear insertion tube. 12. Push the insertion tube into the Safe Load device: z Place the package back on the clean, hard, flat surface. z Stabilize the Safe Load device with one hand. z Slide measurement insert toward sealed end of the package. z Still holding the Safe Load device, push the insertion tube toward the Safe Load device. z Continue pushing until the arms of the T are inside the “profile” of the Safe Load device. (Important: Do not fold the arms of the T into the Safe Load device or insertion tube more than 5 minutes before the IUD is to be inserted into the uterus.) 13. When the arms of the T are touching the sides of the insertion tube, slowly pull the insertion tube away from the folded arms of the IUD until it comes out of the Safe Load device. 14. While keeping the Safe Load device flat on the table, gently push and rotate the insertion tube back over the tips of the folded arms of the T, so that both tips are caught inside the insertion tube. Push the folded arms of the IUD into the insertion tube only as far as necessary to keep them fixed in the tube. 15. Turn the insertion tube by 90 degrees (in either direction), and gently withdraw the insertion tube along with the loaded IUD from the device, but do not remove the loaded IUD from the package. 52 IUD Guidelines for Family Planning Service Programs LEARNING GUIDE FOR IUD CLINICAL SKILLS (TCU 380A WITH SAFE LOAD) STEP/TASK CASES 16. With the loaded IUD still in the package, set the blue depth-gauge to the corresponding measurement obtained from sounding the uterus. z Press down on the gauge with one hand to keep it stable. z At the same time, slide the insertion tube with your other hand until the tip of the IUD aligns with the tip in the diagram on the measurement insert. 17. Align the blue depth-gauge and the folded arms of the T so that they are both in horizontal position (flat against the package on the table). 18. Finish peeling back the cover in one brisk, continuous movement with one hand, while holding the loaded IUD through the open end of the package against the white backing (on the table) with the other hand. 19. Lift the loaded IUD from the package, without allowing it to touch anything that is not sterile. Keep it level so that the IUD does not fall out, and be careful not to push the white rod toward the IUD. Inserting the IUD 20. Put new/clean examination or HLD (or sterile) surgical gloves on both hands (if taken off to load the IUD). 21. Give the client a brief overview of the procedure, encourage her to ask questions, and provide reassurance if needed. Remind her to let you know if she feels any pain. 22. Hold the IUD so that blue depth-gauge is in horizontal position. Gently grasp the tenaculum with the other hand and gently pull outward and downward. 23a. Carefully insert the loaded IUD into the vaginal canal and gently push it through the cervical os and into uterine cavity at the appropriate angle (based on sounding). 23b. Gently advance the loaded IUD into the uterine cavity until the blue depth- gauge comes into contact with the cervix or slight resistance is felt. (Important: Be careful not to touch the wall of vagina or the speculum blades with the tip of the loaded IUD. Do not use force at any stage of this procedure.) 24. Hold the tenaculum and white rod stationary with one hand, and release the arms of the T from the insertion tube using the withdrawal technique: z Gently pull the insertion tube away from the IUD (while holding the white rod stable) until it touches the circular thumb grip of the white plunger rod. z Remove the white plunger rod, while holding the insertion tube stationary. 25. Gently push insertion tube upward again, toward the fundus of the uterus, until you feel a slight resistance. 26. Partially withdraw the insertion tube from the cervical canal until the string can be seen extending from the cervical os. 27. Use HLD (or sterile) sharp Mayo scissors to cut the IUD strings to 3–4 cm length. 28. Gently remove the tenaculum and place in 0.5% chlorine solution for 10 minutes for decontamination. 29. Examine the cervix. If there is bleeding where the tenaculum was attached to the cervix, use HLD (or sterile) forceps to place cotton (or gauze) swab on the affected tissue, and apply gentle pressure for 30–60 seconds. 30. Gently remove speculum and place in 0.5% chlorine solution for 10 minutes for decontamination. 31. Ask the client if she is experiencing nausea, mild to moderate lower abdominal pain/cramping, and dizziness or fainting. If she is experiencing any of these symptoms, provide reassurance and allow her remain on the examination table until she feels better (she should stay in clinic for at least 15 to 30 minutes). Begin performing the postinsertion steps. IUD Guidelines for Family Planning Service Programs 53 LEARNING GUIDE FOR IUD CLINICAL SKILLS (TCU 380A WITH SAFE LOAD) STEP/TASK CASES Postinsertion Steps 1. Before removing the gloves, place all used instruments in 0.5% chlorine solution for 10 minutes for decontamination. (After the client has left, wipe the examination table with 0.5% chlorine solution.) 2. Dispose of waste materials (e.g., cotton balls) by placing in a leak-proof container (with a tight-fitting lid) or plastic bag. 3. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning inside out: z If disposing of gloves, place in the leak-proof container or plastic bag. z If reusing surgical gloves (not recommended), submerge them in 0.5% chlorine solution for 10 minutes for decontamination. 4. Wash hands thoroughly with soap and water; and dry them with a clean, dry cloth or air dry. 5. Provide postinsertion instructions (key messages for IUD users): z Basic facts about her IUD (e.g., type, how long effective, when to replace/remove) z No protection against STIs; need for condoms if at risk z Possible side effects z Warning signs (PAINS) z Checking for possible IUD expulsion z When to return to clinic IUD REMOVAL Preremoval Steps 1. Greet the woman with kindness and respect, and establish purpose of visit. 2. Ask the woman her reason for having the IUD removed. 3. Determine whether she will have another IUD inserted immediately, start a different method, or neither. 4. Counsel as appropriate: z Ensure that she understands that there is immediate return to fertility after IUD removal. z Review the client’s reproductive goals and need for STI protection z Discuss other contraceptive methods if desired. 5. Ensure that a high-level disinfected (HLD) instrument pan (or sterile pack), supplies, and light source are available. 6. Open the HLD instrument pan (or sterile pack) without touching instruments. Using an HLD (or sterile) pick-up forcep, arrange the instruments and supplies on an HLD pan (or sterile tray), being very careful not to touch parts of the instruments that will go into the vagina or uterus. 7. Have the client empty her bladder and wash and rinse her perineal area if possible. 8. Help the client onto the examination table. 9. Wash your hands thoroughly with soap and water; and dry them with clean, dry cloth or allow them to air dry. 10. Put new/clean examination or HLD (or sterile) surgical gloves on both hands. 11. Give the client a brief overview of the procedure, encourage her to ask questions, and provide reassurance as needed. Remind her to let you know if she feels any pain. 54 IUD Guidelines for Family Planning Service Programs LEARNING GUIDE FOR IUD CLINICAL SKILLS (TCU 380A WITH SAFE LOAD) STEP/TASK CASES Removing the IUD 1. Insert an HLD (or sterile) speculum to visualize the IUD strings. 2. Cleanse the cervix (especially the os) and vagina with an appropriate antiseptic two or more times. 3. Alert the client immediately before you remove the IUD. Ask her to take slow, deep breaths and inform her that she may feel some discomfort and cramping, which is normal. 4. Grasp the IUD strings close to the cervix with an HLD (or sterile) hemostat or other narrow forceps. 5. Apply steady but gentle traction, pulling the strings toward you, to remove the IUD. Do not use excessive force. 6. Show the IUD to client. 7. Place the IUD in 0.5% chlorine solution for 10 minutes for decontamination. 8. If the woman is having a new IUD inserted, insert it now if appropriate. If she is not having a new IUD inserted, gently remove the speculum and place it in 0.5% chlorine solution for 10 minutes for decontamination. 9. Ask the client if she is experiencing nausea, mild to moderate lower abdominal pain/cramping, and dizziness or fainting. If she is experiencing any of these symptoms, provide reassurance and allow her remain on the examination table until she feels better (she should stay in clinic for at least 15 to 30 minutes). Postremoval Steps 1. Before removing the gloves, place all used instruments in 0.5% chlorine solution for 10 minutes for decontamination. (After the client has left, wipe the examination table with 0.5% chlorine solution.) 2. Dispose of waste materials (e.g., cotton balls) by placing in a leak-proof container (with a tight-fitting lid) or plastic bag. 3. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning inside out: z If disposing of gloves, place in the leak-proof container or plastic bag. z If reusing surgical gloves (not recommended), submerge them in 0.5% chlorine solution for 10 minutes for decontamination. 4. Wash hands thoroughly with soap and water; and dry them with a clean, dry cloth or air dry. 5. If the woman has had a new IUD inserted, review key messages for IUD users. [If the woman is starting a different method, provide the information she needs to use it safely and effectively (and a back-up method, if needed).] *Laboratory Testing (if available and if indicated based on assessment) 1. Remove speculum after taking samples of vaginal and cervical discharge. 2. Immerse both gloved hands in 0.5% solution. Remove gloves by turning inside out. z If disposing of gloves, place in leakproof container or plastic bag. z If reusing surgical gloves (not recommended), submerge in 0.5% chlorine solution for 10 minutes for decontamination. 3. Prepare for saline and KOH wet mounts and Gram staining. 4. Identify on the wet mounts: z Vaginal epithelial cells z Trichomoniasis (if present) z Monilia (if present) z Clue cells (if present) IUD Guidelines for Family Planning Service Programs 55 LEARNING GUIDE FOR IUD CLINICAL SKILLS (TCU 380A WITH SAFE LOAD) STEP/TASK CASES 5. Identify on the Gram stain: z WBC (polymorphonuclear white cells) (if present) z Gram-negative intracellular diplococci (GNID) (if present) z Clue cells (if present) 6. When testing is done, wash hands thoroughly with soap and water; and dry them with clean, dry cloth or air-dry. 7. Treat any conditions identified according to national guidelines/local protocols (refer, if needed). 56 IUD Guidelines for Family Planning Service Programs LEARNING GUIDE FOR IUD CLINICAL SKILLS (ADAPTED FOR THE MULTILOAD CU375) (To be used by Participants) Rate the performance of each step or task observing the following rating scale: 1 Needs Improvement: Step or task not performed correctly or out of sequence (if necessary) or is omitted 2 Competently Performed: Step or task performed correctly in proper sequence (if necessary) but participant does not progress from step to step efficiently 3 Proficiently Performed: Step or task efficiently and precisely performed in the proper sequence (if necessary) LEARNING GUIDE FOR IUD CLINICAL SKILLS (MULTILOAD CU375) STEP/TASK CASES IUD INSERTION Client Assessment 1. Greet the client with kindness and respect. 2. Determine that the client has been counseled about the IUD in general, as well about the insertion procedure. History 3. Review the client’s contraceptive, menstrual, and obstetric history to confirm that the IUD is an appropriate choice for the client, focusing especially on ensuring that the client is not pregnant. Ask about: z Heavy, prolonged, or menstrual painful periods z Parity/gravida z Childbirth or abortion within the last 4 weeks; signs/symptoms of infection with either z Possibility of pregnancy (delayed or missing period, unprotected sex since last menstrual period [LMP]) (Note: If needed, use checklist provided in Appendix B to be reasonably sure the client is not pregnant.) 4. Review the client’s pertinent (general and reproductive) medical history to confirm that the IUD is an appropriate choice for the client, focusing especially on ensuring that the client is not at high individual risk of sexually transmitted infections (STIs). Ask about: z Severe anemia z HIV/AIDS z Complicated valvular heart disease z Cancer of the reproductive organs z Trophoblastic disease z Pelvic tuberculosis z Unexplained vaginal bleeding z High individual risk of STIs – STI within last 3 months (self or partner) – Multiple partners (self or partner) – Partner with symptoms of STI (e.g., penile discharge) z Diagnosis of pelvic inflammatory disease (PID), gonorrhea, chlamydia, or other STIs (within last 3 months) z Symptoms of PID, gonorrhea, chlamydia, or other STIs – Lower abdominal pain – Current unusual or purulent vaginal discharge Physical Examination 5. Ensure that a high-level disinfected (HLD) instrument pan (or sterile pack), supplies, and light source are available. IUD Guidelines for Family Planning Service Programs 57 LEARNING GUIDE FOR IUD CLINICAL SKILLS (MULTILOAD CU375) STEP/TASK CASES 6. Have the client empty her bladder and wash and rinse her perineal area if possible. 7. Help the client onto the examination table. 8. Tell the client what is going to be done, and ask her if she has any questions. 9. Wash your hands thoroughly with soap and water; and dry them with clean, dry cloth or allow them to air dry. 10. Check for signs of anemia/severe anemia. 11. Palpate the abdomen: z Check for suprapubic tenderness. z Check for swellings, bulges, masses, or other gross abnormalities. 12. Drape the client appropriately for pelvic exam. 13. Wash your hands again thoroughly with soap and water; and dry them with clean, dry cloth or allow them to air dry. 14. Open the HLD instrument pan (or sterile pack) without touching instruments. 15. Using an HLD (or sterile) pick-up forcep, arrange the instruments and supplies on an HLD pan (or sterile tray), being very careful not to touch parts of the instruments that will go into the vagina or uterus. 16. Put new/clean examination or HLD (or sterile) surgical gloves on both hands. 17. Inspect the external genitalia and urethral opening: z Check for ulcers, lesions, and sores. z Check for buboes (enlarged groin nodes). z Palpate Skene’s and Bartholin’s glands, checking for tenderness or discharge. Note: z If findings are normal (findings that do not suggest possible infection or other pelvic problems), perform the bimanual exam first and the speculum exam second. This allows you to sound the uterus and insert the IUD without having to insert the speculum twice. z If there are potential problems (findings that suggest possible infection or other pelvic problems), perform the speculum exam first and a bimanual exam second. 18a. Perform a bimanual exam (see Note above): z Determine the size, shape, and position of uterus. z Check for enlargement or tenderness of the adnexa and for cervical motion tenderness. z Check for uterine abnormalities that may interfere with proper placement of the IUD. 18b. Perform rectovaginal exam only if: z Position or size of uterus is unclear. z There is a possible mass behind the uterus. 18c. If rectovaginal exam is performed, do the following before continuing: z Immerse both gloved hands in 0.5% solution. z Remove gloves by turning inside out and dispose of them z Put on new/clean examination or HLD (or sterile) gloves. 19. Perform a speculum exam (see Note above) of the vagina and cervix (by gently spreading the labia with two fingers and then inserting the HLD [or sterile] speculum, starting obliquely and then rotating it to the horizontal position): z Check for purulent vaginal discharge. z Check for ulcers, lesions, and sores. z Check cervix for purulent cervicitis, bleeding, erosions, or narrowing of the cervical canal (stenosis). (Note: If laboratory testing is indicated and available, refer to steps at the end of learning guide.) 58 IUD Guidelines for Family Planning Service Programs LEARNING GUIDE FOR IUD CLINICAL SKILLS (MULTILOAD CU375) STEP/TASK CASES Preinsertion and Insertion Steps 1. If both bimanual and speculum exams are normal, give the client a brief overview of the insertion procedure, encourage her to ask questions, and provide reassurance if needed. Remind her to let you know if she feels any pain. Sounding the Uterus 2. Gently insert the HLD (or sterile) speculum (if not already done; visualize cervix), and cleanse the cervical os and vaginal wall with an appropriate antiseptic two or more times. 3. Gently grasp the cervix with an HLD (or sterile) tenaculum and apply gentle traction. Do not lock the tenaculum beyond the first notch, unless necessary. 4. While gently pulling on the tenaculum, and without allowing the tip of the sound to touch the vaginal walls or the speculum blades, carefully insert the sound into the cervical os. 5a. Gently advance the sound at the appropriate angle (based on bimanual exam). 5b. STOP advancing the sound when a slight resistance is felt, and confirm the position of the uterus (anterior or posterior) for the IUD insertion. Do not use force at any stage of this procedure. 6. Remove the sound. (Do not pass the sound into the uterus more than once.) 7. Determine the depth of the uterus by noting the level of mucus or wetness on the sound. 8. Place the sound in 0.5% chlorine solution for 10 minutes for decontamination. Removing Multiload from its Sterile Package (Note: The Multiload does not require loading because its vertical stem is “preloaded” in the inserter tube, and its arms are flexible enough to adapt to the shape of the cervical canal.) 9. Prepare to remove Multiload from its sterile package: z Place package on flat surface. z Remove wrapping 1/3 of the way by lifting the transparent front sheet from the bottom end of the package 10. Grasp the insertion tube and the IUD string together at the lower end of the tube. 11. Move the cervical guard to the number corresponding to the measurement obtained from sounding the uterus, using the no-touch technique. 12. Remove loaded insertion tube from the package without touching anything that is not sterile. Make sure to hold the tube level so that the IUD does not fall out. Inserting Multiload 13. Put new/clean examination or HLD (or sterile) surgical gloves on both hands (if not already done). 14. Give the client a brief overview of the procedure, encourage her to ask questions, and provide reassurance if needed. Remind her to let you know if she feels any pain. (Note: Women who are having the Multiload Cu375 inserted may feel more discomfort [than those having a Copper T inserted] as the arms of the IUD pass through the cervical os, especially if they are nulliparous.) 15. Hold the IUD so that cervical guard is in horizontal position. Gently grasp the tenaculum with the other hand and gently pull outward and downward. 16a. Carefully insert the loaded IUD into the vaginal canal and gently push it through the cervical os and into uterine cavity at the appropriate angle (based on sounding). IUD Guidelines for Family Planning Service Programs 59 LEARNING GUIDE FOR IUD CLINICAL SKILLS (MULTILOAD CU375) STEP/TASK CASES 16b. Gently advance the loaded IUD into the uterine cavity until the cervical guard comes into contact with the cervix or slight resistance is felt. (Important: Be careful not to touch the wall of vagina or the speculum blades with the tip of the loaded IUD. Do not use force at any stage of this procedure.) 17. Continuing to apply gentle downward traction to the tenaculum, remove the inserter tube from the cervical canal. 18. Partially withdraw the insertion tube from the cervical canal until the string can be seen extending from the cervical os. 19. Use HLD (or sterile) sharp Mayo scissors to cut the IUD strings to 3–4 cm length. 20. Gently remove the tenaculum and place in 0.5% chlorine solution for 10 minutes for decontamination. 21. Examine the cervix. If there is bleeding where the tenaculum was attached to the cervix, use HLD (or sterile) forceps to place cotton (or gauze) swab on the affected tissue, and apply gentle pressure for 30–60 seconds. 22. Gently remove speculum and place in 0.5% chlorine solution for 10 minutes for decontamination. 23. Ask the client if she is experiencing nausea, mild to moderate lower abdominal pain/cramping, and dizziness or fainting. If she is experiencing any of these symptoms, provide reassurance and allow her remain on the examination table until she feels better (she should stay in clinic for at least 15 to 30 minutes). Begin performing the postinsertion steps. Postinsertion Steps 1. Before removing the gloves, place all used instruments in 0.5% chlorine solution for 10 minutes for decontamination. (After the client has left, wipe the examination table with 0.5% chlorine solution.) 2. Dispose of waste materials (e.g., cotton balls) by placing in a leak-proof container (with a tight-fitting lid) or plastic bag. 3. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning inside out: z If disposing of gloves, place in the leak-proof container or plastic bag. z If reusing surgical gloves (not recommended), submerge them in 0.5% chlorine solution for 10 minutes for decontamination. 4. Wash hands thoroughly with soap and water; and dry them with a clean, dry cloth or air dry. 5. Provide postinsertion instructions (key messages for IUD users): z Basic facts about her IUD (e.g., type, how long effective, when to replace/remove) z No protection against STIs; need for condoms if at risk z Possible side effects z Warning signs (PAINS) z Checking for possible IUD expulsion z When to return to clinic IUD REMOVAL Preremoval Steps 1. Greet the woman with kindness and respect, and establish purpose of visit. 2. Ask the woman her reason for having the IUD removed. 3. Determine whether she will have another IUD inserted immediately, start a different method, or neither. 60 IUD Guidelines for Family Planning Service Programs LEARNING GUIDE FOR IUD CLINICAL SKILLS (MULTILOAD CU375) STEP/TASK CASES 4. Counsel as appropriate: z Ensure that she understands that there is immediate return to fertility after IUD removal. z Review the client’s reproductive goals and need for STI protection z Discuss other contraceptive methods if desired. 5. Ensure that a high-level disinfected (HLD) instrument pan (or sterile pack), supplies, and light source are available. 6. Open the HLD instrument pan (or sterile pack) without touching instruments. Using an HLD (or sterile) pick-up forcep, arrange the instruments and supplies on an HLD pan (or sterile tray), being very careful not to touch parts of the instruments that will go into the vagina or uterus. 7. Have the client empty her bladder and wash and rinse her perineal area if possible. 8. Help the client onto the examination table. 9. Wash your hands thoroughly with soap and water; and dry them with clean, dry cloth or allow them to air dry. 10. Put new/clean examination or HLD (or sterile) surgical gloves on both hands. 11. Give the client a brief overview of the procedure, encourage her to ask questions, and provide reassurance as needed. Remind her to let you know if she feels any pain. (Note: Women who are having the Multiload Cu375 removed may feel more discomfort [than those having a Copper T removed] as the arms of the IUD pass through the cervical os, especially if they are nulliparous.) Removing Multiload 1. Insert an HLD (or sterile) speculum to visualize the IUD strings. 2. Cleanse the cervix (especially the os) and vagina with an appropriate antiseptic two or more times. 3. Apply a HLD (or sterile) tenaculum to the cervix to straighten out the uterine axis. This will help prevent the IUD arms from breaking as they pass through the os. 4. Alert the client immediately before you remove the IUD. Ask her to take slow, deep breaths and inform her that she may feel some discomfort and cramping, which is normal. 5. Grasp the IUD strings close to the cervix with an HLD (or sterile) hemostat or other narrow forceps. With the Multiload, it is important to grasp the strings as close to the cervical os as possible. 6. Apply steady but gentle traction, pulling the strings toward you, to remove the IUD. Do not use excessive force. 7. Show the IUD to client. 8. Place the IUD in 0.5% chlorine solution for 10 minutes for decontamination. 9. If the woman is having a new IUD inserted, insert it now if appropriate. If she is not having a new IUD inserted, gently remove the speculum and place it in 0.5% chlorine solution for 10 minutes for decontamination. 10. Ask the client if she is experiencing nausea, mild to moderate lower abdominal pain/cramping, and dizziness or fainting. If she is experiencing any of these symptoms, provide reassurance and allow her remain on the examination table until she feels better (she should stay in clinic for at least 15 to 30 minutes). IUD Guidelines for Family Planning Service Programs 61 LEARNING GUIDE FOR IUD CLINICAL SKILLS (MULTILOAD CU375) STEP/TASK CASES Postremoval Steps 1. Before removing the gloves, place all used instruments in 0.5% chlorine solution for 10 minutes for decontamination. (After the client has left, wipe the examination table with 0.5% chlorine solution.) 2. Dispose of waste materials (e.g., cotton balls) by placing in a leak-proof container (with a tight-fitting lid) or plastic bag. 3. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning inside out: z If disposing of gloves, place in the leak-proof container or plastic bag. z If reusing surgical gloves (not recommended), submerge them in 0.5% chlorine solution for 10 minutes for decontamination. 4. Wash hands thoroughly with soap and water; and dry them with a clean, dry cloth or air dry. 5. If the woman has had a new IUD inserted, review key messages for IUD users. [If the woman is starting a different method, provide the information she needs to use it safely and effectively (and a back-up method, if needed).] *Laboratory Testing (if available and if indicated based on assessment) 1. Remove speculum after taking samples of vaginal and cervical discharge. 2. Immerse both gloved hands in 0.5% solution. Remove gloves by turning inside out. z If disposing of gloves, place in leakproof container or plastic bag. z If reusing surgical gloves (not recommended), submerge in 0.5% chlorine solution for 10 minutes for decontamination. 3. Prepare for saline and KOH wet mounts and Gram staining. 4. Identify on the wet mounts: z Vaginal epithelial cells z Trichomoniasis (if present) z Monilia (if present) z Clue cells (if present) 5. Identify on the Gram stain: z WBC (polymorphonuclear white cells) (if present) z Gram-negative intracellular diplococci (GNID) (if present) z Clue cells (if present) 6. When testing is done, wash hands thoroughly with soap and water; and dry them with clean, dry cloth or air-dry. 7. Treat any conditions identified according to national guidelines/local protocols (refer, if needed). 62 IUD Guidelines for Family Planning Service Programs PRACTICE CHECKLIST FOR IUD COUNSELING AND CLINICAL SKILLS (ADAPTED FOR THE REGULAR COPPER T 380A) (To be used by Participants for practice) Place a “✓ ” in case box of step/task is performed satisfactorily, an “✗ ” if it is not performed satisfactorily, or N/O if not observed. Satisfactory: Performs the step or task according to the standard procedure or guidelines Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines Not Observed: Step, task or skill not performed by participant during evaluation by trainer Participant _________________________________________ Course Dates ______________ CHECKLIST FOR IUD COUNSELING AND CLINICAL SKILLS (REGULAR COPPER T 380A) STEP/TASK CASES METHOD-SPECIFIC COUNSELING 1. Once the woman has chosen to use the IUD, assess her knowledge of the method. 2. Ensure that she knows that menstrual changes are a common side effect among IUD users, and that the IUD does not protect against STIs. 3. Describe the medical assessment required before IUD insertion, as well as the procedures for IUD insertion and removal. 4. Encourage her to ask questions. Provide additional information and reassurance as needed. IUD INSERTION Client Assessment (Use Appendix B to confirm that the woman is eligible for IUD use.) 1. Review the client’s medical and reproductive history. 2. Ensure that equipment and supplies are available and ready to use. 3. Have the client empty her bladder and wash her perineal area. 4. Help the client onto the examination table. 5. Tell the client what is going to be done, and ask her if she has any questions. 6. Wash hands thoroughly and dry them. 7. Palpate the abdomen. 8. Wash hands thoroughly and dry them again. 9. Put clean or HLD gloves on both hands. 10. Inspect the external genitalia. Note: z If findings are normal, perform the bimanual exam first and the speculum exam second. z If there are potential problems, perform the speculum exam first and a bimanual exam second. 11a. Perform a bimanual exam (see Note above) 11b. Perform rectovaginal exam only if indicated. 11c. If rectovaginal exam is performed, change gloves before continuing. 12. Perform a speculum exam (see Note above). (Note: If laboratory testing is indicated and available, take samples now.) IUD Guidelines for Family Planning Service Programs 63 CHECKLIST FOR IUD COUNSELING AND CLINICAL SKILLS (REGULAR COPPER T 380A) STEP/TASK CASES Preinsertion and Insertion Steps (Using aseptic, “no touch” technique throughout) 1. Provide an overview of the insertion procedure. Remind her to let you know if she feels any pain. 2. Gently insert the HLD (or sterile) speculum to visualize the cervix (if not already done), and cleanse the cervical os and vaginal wall with antiseptic. 3. Gently grasp the cervix with an HLD (or sterile) tenaculum and apply gentle traction. 4. Insert the HLD (or sterile) sound using the “no touch” technique. 5. Load the IUD in its sterile package. 6. Set the blue depth-gauge to the measurement of the uterus. 7. Carefully insert the loaded IUD, and release it into the uterus using the “withdrawal” technique. 8. Gently push the insertion tube upward again until you feel a slight resistance. 9. Withdraw the rod, and partially withdraw the insertion tube until the IUD strings can be seen. 10. Use HLD (or sterile) sharp Mayo scissors to cut the IUD strings to 3–4 cm length. 11. Gently remove the tenaculum and speculum and place in 0.5% chlorine solution for 10 minutes for decontamination. 12. Examine the cervix for bleeding. 13. Ask how the client is feeling and begin performing the postinsertion steps. Postinsertion Steps 1. Before removing the gloves, place all used instruments in 0.5% chlorine solution for 10 minutes for decontamination. 2. Properly dispose of waste materials. 3. Process gloves according to recommended IP practices. 4. Wash hands thoroughly and dry them. 5. Provide postinsertion instructions (key messages for IUD users): z Basic facts about her IUD (e.g., type, how long effective, when to replace/remove) z No protection against STIs; need for condoms if at risk z Possible side effects z Warning signs (PAINS) z Checking for possible IUD expulsion z When to return to clinic IUD REMOVAL Preremoval Steps 1. Ask the woman her reason for having the IUD removed. 2. Determine whether she will have another IUD inserted immediately, start a different method, or neither. 3. Review the client’s reproductive goals and need for STI protection, and counsel as appropriate. 4. Ensure that equipment and supplies are available and ready to use. 5. Have the client empty her bladder and wash her perineal area. 6. Help the client onto the examination table. 7. Wash hands thoroughly and dry them. 8. Put new or HLD gloves on both hands. 64 IUD Guidelines for Family Planning Service Programs CHECKLIST FOR IUD COUNSELING AND CLINICAL SKILLS (REGULAR COPPER T 380A) STEP/TASK CASES Removing the IUD 1. Provide an overview of the insertion procedure. Remind her to let you know if she feels any pain. 2. Gently insert the HLD (or sterile) speculum to visualize the strings, and cleanse the cervical os and vaginal wall with antiseptic. 3. Alert the client immediately before you remove the IUD. 4. Grasp the IUD strings close to the cervix with an HLD (or sterile) hemostat or other narrow forceps. 5. Apply steady but gentle traction, pulling the strings toward you, to remove the IUD. Do not use excessive force. 6. Show the IUD to client. 7. Place the IUD in 0.5% chlorine solution for 10 minutes for decontamination. 8. If the woman is having a new IUD inserted, insert it now if appropriate. [If she is not having a new IUD inserted, gently remove the speculum and place it in 0.5% chlorine solution for 10 minutes for decontamination.] 9. Ask how the client is feeling and begin performing the postremoval steps. Postremoval Steps 1. Before removing the gloves, place all used instruments and the IUD in 0.5% chlorine solution for 10 minutes for decontamination. 2. Properly dispose of waste materials. 3. Process gloves according to recommended IP practices. 4. Wash hands thoroughly and dry them. 5. If the woman has had a new IUD inserted, review key messages for IUD users. [If the woman is starting a different method, provide the information she needs to use it safely and effectively (and a back-up method, if needed).] IUD Guidelines for Family Planning Service Programs 65 PRACTICE CHECKLIST FOR IUD COUNSELING AND CLINICAL SKILLS (ADAPTED FOR THE TCU 380A WITH SAFE LOAD) (To be used by Participants for practice) Place a “✓ ” in case box of step/task is performed satisfactorily, an “✗ ” if it is not performed satisfactorily, or N/O if not observed. Satisfactory: Performs the step or task according to the standard procedure or guidelines Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines Not Observed: Step, task or skill not performed by participant during evaluation by trainer Participant _________________________________________ Course Dates ______________ CHECKLIST FOR IUD COUNSELING AND CLINICAL SKILLS (TCU 380A WITH SAFE LOAD) STEP/TASK CASES METHOD-SPECIFIC COUNSELING 1. Once the woman has chosen to use the IUD, assess her knowledge of the method. 2. Ensure that she knows that menstrual changes are a common side effect among IUD users, and that the IUD does not protect against STIs. 3. Describe the medical assessment required before IUD insertion, as well as the procedures for IUD insertion and removal. 4. Encourage her to ask questions. Provide additional information and reassurance as needed. IUD INSERTION Client Assessment (Use Appendix B to confirm that the woman is eligible for IUD use.) 1. Review the client’s medical and reproductive history. 2. Ensure that equipment and supplies are available and ready to use. 3. Have the client empty her bladder and wash her perineal area. 4. Help the client onto the examination table. 5. Tell the client what is going to be done, and ask her if she has any questions. 6. Wash hands thoroughly and dry them. 7. Palpate the abdomen. 8. Wash hands thoroughly and dry them again. 9. Put clean or HLD gloves on both hands. 10. Inspect the external genitalia. Note: z If findings are normal, perform the bimanual exam first and the speculum exam second. z If there are potential problems, perform the speculum exam first and a bimanual exam second. 11a. Perform a bimanual exam (see Note above) 11b. Perform rectovaginal exam only if indicated. 11c. If rectovaginal exam is performed, change gloves before continuing. 12. Perform a speculum exam (see Note above). (Note: If laboratory testing is indicated and available, take samples now.) 66 IUD Guidelines for Family Planning Service Programs CHECKLIST FOR IUD COUNSELING AND CLINICAL SKILLS (TCU 380A WITH SAFE LOAD) STEP/TASK CASES Preinsertion and Insertion Steps (Using aseptic, “no touch” technique throughout) 1. Provide an overview of the insertion procedure. Remind her to let you know if she feels any pain. 2. Gently insert the HLD (or sterile) speculum to visualize the cervix (if not already done), and cleanse the cervical os and vaginal wall with antiseptic. 3. Gently grasp the cervix with an HLD (or sterile) tenaculum and apply gentle traction. 4. Insert the HLD (or sterile) sound using the “no touch” technique. 5. Load the IUD in its sterile package. 6. Set the blue depth-gauge to the measurement of the uterus. 7. Carefully insert the loaded IUD, and release it into the uterus using the “withdrawal” technique. 8. Gently push the insertion tube upward again until you feel a slight resistance. 9. Withdraw the rod, and partially withdraw the insertion tube until the IUD strings can be seen. 10. Use HLD (or sterile) sharp Mayo scissors to cut the IUD strings to 3–4 cm length. 11. Gently remove the tenaculum and speculum and place in 0.5% chlorine solution for 10 minutes for decontamination. 12. Examine the cervix for bleeding. 13. Ask how the client is feeling and begin performing the postinsertion steps. Postinsertion Steps 1. Before removing the gloves, place all used instruments in 0.5% chlorine solution for 10 minutes for decontamination. 2. Properly dispose of waste materials. 3. Process gloves according to recommended IP practices. 4. Wash hands thoroughly and dry them. 5. Provide postinsertion instructions (key messages for IUD users): z Basic facts about her IUD (e.g., type, how long effective, when to replace/remove) z No protection against STIs; need for condoms if at risk z Possible side effects z Warning signs (PAINS) z Checking for possible IUD expulsion z When to return to clinic IUD REMOVAL Preremoval Steps 1. Ask the woman her reason for having the IUD removed. 2. Determine whether she will have another IUD inserted immediately, start a different method, or neither. 3. Review the client’s reproductive goals and need for STI protection, and counsel as appropriate. 4. Ensure that equipment and supplies are available and ready to use. 5. Have the client empty her bladder and wash her perineal area. 6. Help the client onto the examination table. 7. Wash hands thoroughly and dry them. 8. Put new or HLD gloves on both hands. IUD Guidelines for Family Planning Service Programs 67 CHECKLIST FOR IUD COUNSELING AND CLINICAL SKILLS (TCU 380A WITH SAFE LOAD) STEP/TASK CASES Removing the IUD 1. Provide an overview of the insertion procedure. Remind her to let you know if she feels any pain. 2. Gently insert the HLD (or sterile) speculum to visualize the strings, and cleanse the cervical os and vaginal wall with antiseptic. 3. Alert the client immediately before you remove the IUD. 4. Grasp the IUD strings close to the cervix with an HLD (or sterile) hemostat or other narrow forceps. 5. Apply steady but gentle traction, pulling the strings toward you, to remove the IUD. Do not use excessive force. 6. Show the IUD to client. 7. Place the IUD in 0.5% chlorine solution for 10 minutes for decontamination. 8. If the woman is having a new IUD inserted, insert it now if appropriate. [If she is not having a new IUD inserted, gently remove the speculum and place it in 0.5% chlorine solution for 10 minutes for decontamination.] 9. Ask how the client is feeling and begin performing the postremoval steps. Postremoval Steps 1. Before removing the gloves, place all used instruments and the IUD in 0.5% chlorine solution for 10 minutes for decontamination. 2. Properly dispose of waste materials. 3. Process gloves according to recommended IP practices. 4. Wash hands thoroughly and dry them. 5. If the woman has had a new IUD inserted, review key messages for IUD users. [If the woman is starting a different method, provide the information she needs to use it safely and effectively (and a back-up method, if needed).] 68 IUD Guidelines for Family Planning Service Programs PRACTICE CHECKLIST FOR IUD COUNSELING AND CLINICAL SKILLS (ADAPTED FOR THE MULTILOAD CU375) (To be used by Participants for practice) Place a “✓ ” in case box of step/task is performed satisfactorily, an “✗ ” if it is not performed satisfactorily, or N/O if not observed. Satisfactory: Performs the step or task according to the standard procedure or guidelines Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines Not Observed: Step, task or skill not performed by participant during evaluation by trainer Participant _________________________________________ Course Dates ______________ CHECKLIST FOR IUD COUNSELING AND CLINICAL SKILLS (MULTILOAD CU375) STEP/TASK CASES METHOD-SPECIFIC COUNSELING 1. Once the woman has chosen to use the IUD, assess her knowledge of the method. 2. Ensure that she knows that menstrual changes are a common side effect among IUD users, and that the IUD does not protect against STIs. 3. Describe the medical assessment required before IUD insertion, as well as the procedures for IUD insertion and removal. 4. Encourage her to ask questions. Provide additional information and reassurance as needed. IUD INSERTION Client Assessment (Use Appendix B to confirm that the woman is eligible for IUD use.) 1. Review the client’s medical and reproductive history. 2. Ensure that equipment and supplies are available and ready to use. 3. Have the client empty her bladder and wash her perineal area. 4. Help the client onto the examination table. 5. Tell the client what is going to be done, and ask her if she has any questions. 6. Wash hands thoroughly and dry them. 7. Palpate the abdomen. 8. Wash hands thoroughly and dry them again. 9. Put clean or HLD gloves on both hands. 10. Inspect the external genitalia. Note: z If findings are normal, perform the bimanual exam first and the speculum exam second. z If there are potential problems, perform the speculum exam first and a bimanual exam second. 11a. Perform a bimanual exam (see Note above) 11b. Perform rectovaginal exam only if indicated. 11c. If rectovaginal exam is performed, change gloves before continuing. 12. Perform a speculum exam (see Note above). (Note: If laboratory testing is indicated and available, take samples now.) IUD Guidelines for Family Planning Service Programs 69 CHECKLIST FOR IUD COUNSELING AND CLINICAL SKILLS (MULTILOAD CU375) STEP/TASK CASES Preinsertion and Insertion Steps (Using aseptic, “no touch” technique throughout) 1. Provide an overview of the insertion procedure. Remind her to let you know if she feels any pain. 2. Gently insert the HLD (or sterile) speculum to visualize the cervix (if not already done), and cleanse the cervical os and vaginal wall with antiseptic. 3. Gently grasp the cervix with an HLD (or sterile) tenaculum and apply gentle traction. 4. Insert the HLD (or sterile) sound using the “no touch” technique. 5. Grasp the insertion tube and the IUD string together at the lower end of the tube. 6. Move the cervical guard to the measurement of the uterus. 7. Gently advance the loaded IUD into the uterine cavity until the cervical guard touches cervix or a slight resistance is felt 8. Continuing to apply gentle downward traction to the tenaculum, remove the inserter tube from the cervical canal. 9. Partially withdraw the insertion tube from the cervical canal until the string can be seen extending from the cervical os. 10. Use HLD (or sterile) sharp Mayo scissors to cut the IUD strings to 3–4 cm length. 11. Gently remove the tenaculum and speculum and place in 0.5% chlorine solution for 10 minutes for decontamination. 12. Examine the cervix for bleeding. 13. Ask how the client is feeling and begin performing the postinsertion steps. Postinsertion Steps 1. Before removing the gloves, place all used instruments in 0.5% chlorine solution for 10 minutes for decontamination. 2. Properly dispose of waste materials. 3. Process gloves according to recommended IP practices. 4. Wash hands thoroughly and dry them. 5. Provide postinsertion instructions (key messages for IUD users): z Basic facts about her IUD (e.g., type, how long effective, when to replace/remove) z No protection against STIs; need for condoms if at risk z Possible side effects z Warning signs (PAINS) z Checking for possible IUD expulsion z When to return to clinic IUD REMOVAL Preremoval Steps 1. Ask the woman her reason for having the IUD removed. 2. Determine whether she will have another IUD inserted immediately, start a different method, or neither. 3. Review the client’s reproductive goals and need for STI protection, and counsel as appropriate. 4. Ensure that equipment and supplies are available and ready to use. 5. Have the client empty her bladder and wash her perineal area. 6. Help the client onto the examination table. 70 IUD Guidelines for Family Planning Service Programs CHECKLIST FOR IUD COUNSELING AND CLINICAL SKILLS (MULTILOAD CU375) STEP/TASK CASES 7. Wash hands thoroughly and dry them. 8. Put new or HLD gloves on both hands. Removing the IUD 1. Provide an overview of the insertion procedure. Remind her to let you know if she feels any pain. 2. Gently insert the HLD (or sterile) speculum to visualize the strings, and cleanse the cervical os and vaginal wall with antiseptic. 3. Apply an HLD (or sterile) tenaculum to the cervix to straighten out the uterine axis. 4. Alert the client immediately before you remove the IUD. 5. Grasp the IUD strings close to the cervix with an HLD (or sterile) hemostat or other narrow forceps. With the Multiload, it is important to grasp the strings as close to the cervical os as possible. 6. Show the IUD to client. 7. Place the IUD in 0.5% chlorine solution for 10 minutes for decontamination. 8. If the woman is having a new IUD inserted, insert it now if appropriate. [If she is not having a new IUD inserted, gently remove the speculum and place it in 0.5% chlorine solution for 10 minutes for decontamination.] 9. Ask how the client is feeling and begin performing the postremoval steps. Postremoval Steps 1. Before removing the gloves, place all used instruments and the IUD in 0.5% chlorine solution for 10 minutes for decontamination. 2. Properly dispose of waste materials. 3. Process gloves according to recommended IP practices. 4. Wash hands thoroughly and dry them. 5. If the woman has had a new IUD inserted, review key messages for IUD users. [If the woman is starting a different method, provide the information she needs to use it safely and effectively (and a back-up method, if needed).] IUD Guidelines for Family Planning Service Programs 71 IUD COURSE EVALUATION (To be completed by Participants) Please indicate your opinion of the course components using the following rate scale: 5-Strongly Agree 4-Agree 3-No Opinion 2-Disagree 1-Strongly Disagree COURSE COMPONENT RATING 1. The Precourse Questionnaire helped me to study more effectively. 2. The role play sessions on counseling skills were helpful. 3. There was sufficient time scheduled for practicing counseling through role play and with clients and volunteers. 4. The demonstration helped me get a better understanding of how to insert and remove IUDs prior to practicing with the pelvic model. 5. The practice sessions with the pelvic model made it easier for me to perform IUD insertion and removal when working with actual clients. 6. There was sufficient time scheduled for practicing IUD insertion and removal with clients. 7. The interactive training approach used in this course made it easier for me to learn how to provide IUD services. 8. The time allotted for this course was sufficient for learning how to provide IUD services. 9. I feel confident in IUD insertion and removal. 10. I feel confident in using the infection prevention practices recommended for IUD services. ADDITIONAL COMMENTS (use reverse side if needed) 1. What topics (if any) should be added (and why) to improve the course? 2. What topics (if any) should be deleted (and why) to improve the course? IUD Guidelines for Family Planning Service Programs Presentation Graphics - 1 INTRAUTERINE CONTRACEPTIVE DEVICES (IUDs): INTRODUCTION Slide 1 Intrauterine Contraceptive Intrauterine Contraceptive Devices (IUDs): IntroductionDevices (IUDs): Introduction ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 2 2 Introduction to IUDsIntroduction to IUDs Objectives: • Explain how copper-bearing IUDs prevent pregnancy • Correct misconceptions about the IUD regarding pelvic inflammatory disease (PID), ectopic pregnancy, HIV • Explain WHO medical eligibility criteria (MEC) for copper-bearing IUDs • Explain contraindications and precautions based on WHO MEC ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 3 3 IUDs Around the WorldIUDs Around the World 153 million users worldwide ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 2 IUD Guidelines for Family Planning Service Programs Slide 4 4 IUD Use in DifferentIUD Use in Different Parts of the WorldParts of the World • 60% (92 million) of world’s married IUD users live in China • 12% in other Asian countries • 11% in Eastern Europe and Central Asia • 7% in Near East and North Africa • 5% in Latin America and the Caribbean • 5% in developed countries • <1% in Sub-Saharan Africa ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 5 5 Resurgence of Interest in the IUDResurgence of Interest in the IUD • Despite persistent misconceptions, IUD users have higher satisfaction rates (99% versus 91% for pill users) and continuation rates than users of many other methods • Recent research has lead to important changes in WHO MEC • Risk of PID in IUD users is negligible • The IUD is appropriate for most women, including… ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 6 6 Resurgence of Interest in the IUD Resurgence of Interest in the IUD ((contcont.).) • Women with the following characteristics/ conditions: • Under 20 years of age and/or nulliparous • HIV-infected and clinically well • AIDS and on antiretroviral therapy (ARV) therapy and clinically well • History of ectopic pregnancy • History of PID (assuming no known risk factors for sexually transmitted infections [STIs]) • Living in area with high STI prevalence (assuming no known risk factors for STIs) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ IUD Guidelines for Family Planning Service Programs Presentation Graphics - 3 Slide 7 7 Types of Medicated IUDsTypes of Medicated IUDs Copper-bearing: • Copper T 380A* • TCu 200C • Multiload Cu250 and Cu375 • Nova-T * This learning package focuses on the Copper T 380A Levonorgestrel-releasing: • Mirena7 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 8 8 Copper T 380ACopper T 380A • Comes in regular and Safe Load varieties • Effective for at least 12 years ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 9 9 CopperCopper--Bearing IUDs: Bearing IUDs: Mechanisms of Action Mechanisms of Action Decreases sperm motility and function Thickens cervical mucus Interferes with ability of sperm to pass through uterine cavity Alters the uterine and tubal environment ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 4 IUD Guidelines for Family Planning Service Programs Slide 10 10 IUDs: Basic AttributesIUDs: Basic Attributes • Highly effective (failure rate less than 1% in first year of use) • Long-term protection (at least 12 years) • Effective immediately • Immediate return to fertility upon removal ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 11 11 IUDs: Other Reasons Women IUDs: Other Reasons Women Like ThemLike Them In addition to reasons listed on previous slide: • No hormonal side effects • Inexpensive over time • Convenient: • No day-to-day action needed • After first routine check-up, no need to return to clinic unless experiencing problems • No additional supplies needed ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 12 12 IUDs: ConsiderationsIUDs: Considerations • Pelvic examination required before IUD insertion • IUD insertion and removal require provider trained in these procedures • Client can not stop use whenever she wants (provider-dependent) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ IUD Guidelines for Family Planning Service Programs Presentation Graphics - 5 Slide 13 13 IUDs: Side Effects IUDs: Side Effects Menstrual problems: • Increase in menstrual bleeding (up to 50%) and associated cramping/pain • Worse during first few months • Most common reason for removal • Cramping may occur during insertion and for several days afterward • Spotting/light bleeding may occur for first few days or months after insertion ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 14 14 IUDs: Health Benefits IUDs: Health Benefits • May help protect against endometrial and cervical cancers ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 15 15 IUDs: Health Risks IUDs: Health Risks Expulsion (uncommon): • May be spontaneously expelled (2–8%) • More common in first 3 months and during menstrual period • Factors that increase risk: • Nulliparity • Heavy menstrual flow • Insertion immediately postpartum or after second-trimester abortion ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 6 IUD Guidelines for Family Planning Service Programs Slide 16 16 IUDs: Health Risks IUDs: Health Risks ((contcont.).) Uterine perforation (rare): • Rarely occurs (<1.5/1000 cases) • Usually occurs during insertion • Serious complications from perforation are rare • Surgical intervention is rarely required ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 17 17 IUDs: Health Risks IUDs: Health Risks ((contcont.).) Infection (rare): • Minimal risk (less than 1%) • Increase in risk only in 20 days after insertion • Due not to IUD itself, but to nonsterile insertion technique • After first 20 days weeks, risk returns to normal ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 18 18 Ready for an Activity?Ready for an Activity? • Refer to the section in this chapter on “Addressing Common Misconceptions about the IUD” • Take some time to review the information • How would you respond to the following questions or comments from clients (next slide)? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ IUD Guidelines for Family Planning Service Programs Presentation Graphics - 7 Slide 19 19 Ready for an Activity?Ready for an Activity? • “I heard the IUD can cause an ectopic pregnancy. Is this true?” • “Doesn’t the IUD cause PID?” • “Can’t the IUD make you sterile?” • “I thought women who are HIV-infected couldn’t use the IUD.” • “I’ve never been pregnant before. Shouldn’t I use another method?” ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 20 20 WHO Medical Eligibility CriteriaWHO Medical Eligibility Criteria • Category 1: Use the method in any circumstances (no restrictions) • Category 2: Generally use the method (advantages generally outweigh risks) • Category 3: Use of the method not usually recommended (risks generally outweigh advantages) • Category 4: Method not to be used (too risky) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 21 21 IUDs: Who Should Not Use IUDs: Who Should Not Use (WHO Category 4)(WHO Category 4) IUD should not be inserted if a woman: • Is pregnant • Has puerperal sepsis or post-septic abortion • Has a distorted uterine cavity • Has current PID, gonorrhea, or chlamydia* • Has current purulent cervical discharge* * Category 2 for continuation while undergoing evaluation and treatment ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 8 IUD Guidelines for Family Planning Service Programs Slide 22 22 IUDs: Who Should Not Use IUDs: Who Should Not Use (WHO Category 4) (WHO Category 4) ((contcont.).) IUDs should not be inserted if a woman has: • Malignant trophoblast disease • Known pelvic tuberculosis • Unexplained vaginal bleeding (until the cause is determined and any serious problems are treated)* • Cervical or endometrial cancer* * Category 2 for continuation while undergoing evaluation ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 23 23 IUDs: Who Should GenerallyIUDs: Who Should Generally Not Use (WHO Category 3)Not Use (WHO Category 3) IUD insertion is not recommended—unless other methods are not available or acceptable— if a woman has: • AIDS, but is not on antiretroviral (ARV) therapy* • A “very high individual risk” of gonorrhea or chlamydia (e.g., recent STI, multiple partners, partner with symptoms of STI)* * Category 2 for continuation ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 24 24 IUDs: Who Can Generally UseIUDs: Who Can Generally Use (WHO Category 2)(WHO Category 2) Women with the following conditions can generally use the IUD but may require additional care/follow-up: • Anemia • Heavy, prolonged, or painful menstrual periods • Simple vaginal infection (candidiasis or bacterial vaginosis) without purulent discharge; certain STIs (other than gonorrhea or chlamydia) • Risk of certain STIs (other than gonorrhea or chlamydia), including HIV (but should also use condoms for protection) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ IUD Guidelines for Family Planning Service Programs Presentation Graphics - 9 Slide 25 25 SummarySummary • The IUD is a safe, very effective method for most women. • Menstrual problems are the most common side effect and frequent cause for discontinuation. • Few conditions are contraindications for IUD use. • Some conditions present a problem for IUD initiation (insertion), but not continuation. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 10 IUD Guidelines for Family Planning Service Programs IUD Guidelines for Family Planning Service Programs Presentation Graphics - 11 INTRAUTERINE CONTRACEPTIVE DEVICES (IUDs): EDUCATION AND COUNSELING Slide 1 Intrauterine Contraceptive Intrauterine Contraceptive Devices (IUDs): Devices (IUDs): Education and CounselingEducation and Counseling ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 2 2 ObjectivesObjectives • Explain client rights • Explain the difference between education and counseling • Discuss strategies for effective education • Describe ways to enhance client understanding and retention of information • Describe characteristics of good counseling • List some key factors in family planning decisions • Demonstrate the GATHER technique for family planning counseling, highlighting important points for potential IUD users ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 3 3 Education and CounselingEducation and Counseling…… • Provide information clients need to make informed decisions about family planning • Help them select a method that is well suited to their situation • Provide information they need to use the chosen method safely and effectively ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 12 IUD Guidelines for Family Planning Service Programs Slide 4 4 Client RightsClient Rights • Right to unbiased information about family planning, and to a wide range of contraceptive options • Right to use method selected if available and medically eligible • Right to switch/start/stop method as desired • Right to kindness and respect, and to discuss concerns openly ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 5 5 Client Rights Client Rights ((contcont.).) • Right to confidentiality and privacy (bodily) • Right to safe and comfortable environment • Right to refuse examination, procedure, or treatment • Right to appropriate referral and follow-up • Right to continuity of services • Right to express views about services provided ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 6 6 Education versus CounselingEducation versus Counseling • How are education and counseling different? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ IUD Guidelines for Family Planning Service Programs Presentation Graphics - 13 Slide 7 7 Tips for Client EducationTips for Client Education • Engage learners in an activity • Focus/limit key messages • Ensure appropriate timing • Assess client understanding and retention • Provide printed materials • What might be some strategies for helping clients understand and retain information? • What might be some ways to conduct a “group education” session? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 8 8 Effective CounselingEffective Counseling • What might be some characteristics of an effective counselor? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 9 9 Some Key FactorsSome Key Factors in Family Planning Decisionsin Family Planning Decisions • Reproductive goals • Effectiveness • Reversibility of method • Side effects • Health benefits/risks • Need for protection against STIs • Cost • Availability • Convenience ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 14 IUD Guidelines for Family Planning Service Programs Slide 10 10 The Counseling ProcessThe Counseling Process • General family planning counseling: focus on assisting client in choosing a method • Method-specific counseling: focus on ensuring client’s safe and effective use of method chosen • Follow-up counseling: focus on assessing client’s satisfaction or problems with method chosen ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 11 11 Important Points for Important Points for PotentialPotential IUD UsersIUD Users • Providing correct information: • Long-term, highly effective, reversible contraceptive protection • Safe and appropriate for use by most women • Addressing rumors and myths: • What have you heard about the IUD? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 12 12 Important Points for Important Points for PotentialPotential IUD Users IUD Users ((contcont.).) Informing of important considerations: • No protection against STIs; women at risk should use condoms (in addition to IUD) • Menstrual changes are a common side effect • A complete medical assessment (including a pelvic examination) is needed to confirm that a woman can use the IUD • Starting and stopping the IUD requires a procedure performed by a skilled provider ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ IUD Guidelines for Family Planning Service Programs Presentation Graphics - 15 Slide 13 13 GATHER Technique in CounselingGATHER Technique in Counseling • Greet • Ask • Tell • Help • Explain • Return/Refer Ready for a demonstration? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 14 14 SummarySummary • It is important to aid, not persuade, the client in choosing a contraceptive. • A client needs both education and counseling to select an appropriate method; and to help ensure safe, effective, continued use of the method chosen. • Education and counseling should be integrated throughout the visit. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 16 IUD Guidelines for Family Planning Service Programs IUD Guidelines for Family Planning Service Programs Presentation Graphics - 17 INTRAUTERINE CONTRACEPTIVE DEVICES (IUDs): INFECTION PREVENTION Slide 1 Intrauterine Contraceptive Intrauterine Contraceptive Devices (IUDs): Devices (IUDs): Infection PreventionInfection Prevention ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 2 2 Purpose of Infection PreventionPurpose of Infection Prevention • To reduce the risk of disease transmission to health care clients, patients and communities • To protect health care workers at all levels—from physicians and nurses to cleaning, housekeeping and laboratory staff— from disease • And, for IUD clients, to reduce the risk of infection following IUD insertion/removal ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 3 3 Important ConceptsImportant Concepts • Microorganisms are the causative agents of infection: • Bacteria (vegetative, mycobacteria, and endospores) • Viruses • Fungi • Parasites • Colonization means that disease-causing microorganisms are present in a person but not causing symptoms (clinical changes) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 18 IUD Guidelines for Family Planning Service Programs Slide 4 4 Important Concepts Important Concepts ((cont.cont.)) • Infection means that the colonizing microorganisms are now causing symptoms (clinical changes) or disease • Infection prevention involves placing protective barriers (physical, chemical or mechanical) between an individual and microorganisms ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 5 5 Understanding the Disease Understanding the Disease Transmission CycleTransmission Cycle • All microorganisms can cause infection • All humans are susceptible to most infectious agents unless immune (naturally or by vaccination) • Risk of infection is related to the number and virulence of organisms • Number of organisms needed to cause infection varies with location (blood stream—least; intact skin— greatest) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 6 6 Standard PrecautionsStandard Precautions • Are guidelines designed to create barriers between microorganisms and an individual to prevent the spread of infection (i.e., the barrier serves to break the disease transmission cycle) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ IUD Guidelines for Family Planning Service Programs Presentation Graphics - 19 Slide 7 7 Standard Precautions Standard Precautions ((contcont.).) • Apply to care of all clients and patients attending health care facilities Reason: Many people with HIV or other life-threatening bloodborne diseases do not have symptoms or appear ill ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 8 8 Standard Precautions Standard Precautions ((contcont.).) • Apply to all blood, body fluids, secretions, excretions (except sweat), non-intact skin and mucous membranes Reason: Increased risk of exposure by touching, accidental injury (needlestick) or contact (splashing or spraying of potentially contaminated blood or body fluids) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 9 9 Standard Precautions: Standard Precautions: Key ComponentsKey Components • Consider every person (patient, client, or staff) as potentially infectious and susceptible to infection • Wash hands (or use an antiseptic handrub) before and after touching blood or body fluids, after removing gloves and between patient contacts—the single most important IP measure! ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 20 IUD Guidelines for Family Planning Service Programs Slide 10 10 Standard Precautions: Standard Precautions: Key Components Key Components ((contcont.).) • Wear gloves (both hands) before touching anything wet—broken skin, mucous membranes, blood or body fluids, soiled instruments or contaminated waste materials— and before performing invasive procedures • Use physical barriers (protective goggles, face masks and aprons) if splashes and spills of blood or body fluids (secretions and excretions) are likely ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 11 11 Standard Precautions: Standard Precautions: Key Components Key Components ((contcont.).) • Use antiseptic agents for cleansing the skin or mucous membrane prior to surgery, cleaning wounds or doing handrubs or surgical handscrubs with an alcohol-based antiseptic product • Use safe work practices such as not recapping or bending needles, safely passing sharp instruments and suturing, when appropriate, with blunt needles ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 12 12 Standard Precautions: Standard Precautions: Key Components Key Components ((contcont.).) • Safely dispose of infectious waste materials to protect those who handle them and prevent injury or spread of infection to the community • Process instruments, gloves, and other items after use by first decontaminating them, then thoroughly cleaning them, and then either high-level disinfecting or sterilizing them using recommended procedures ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ IUD Guidelines for Family Planning Service Programs Presentation Graphics - 21 Slide 13 13 Decontaminate Clean Key Infection Prevention ProcessesKey Infection Prevention Processes Sterilize Chemical High-pressure steam Dry heat Dry/Cool and Store High-Level Disinfect Boil Steam Chemical ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 14 14 Processing Instruments, Gloves Processing Instruments, Gloves and Other Itemsand Other Items • Decontamination (first step) makes inanimate objects safer to be handled by staff before cleaning ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 15 15 Processing Instruments, Gloves Processing Instruments, Gloves and Other Items and Other Items ((contcont.).) • Cleaning (second step) physically removes all visible dust, soil, blood or other body fluids from inanimate objects and skin ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 22 IUD Guidelines for Family Planning Service Programs Slide 16 16 Processing Instruments, Gloves Processing Instruments, Gloves and Other Items and Other Items ((cont.cont.)) • Final-processing by high-level disinfection (HLD) or sterilization is the third step • HLD eliminates all organisms (bacteria, viruses, fungi, and parasites) except some endospores Note: HLD is the recommended method of final- processing for IUD services. (It is sufficient because mucus membranes are left intact during IUD insertion.) • Sterilization eliminates all organisms including all endospores ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 17 17 IUDs: Infection PreventionIUDs: Infection Prevention • Infection in IUD users is rare but is most often due to nonsterile insertion technique, not to the IUD itself. • Prophylactic antibiotics are not recommended for IUD insertion or removal. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 18 18 IUDs: Infection Prevention IUDs: Infection Prevention RecommendationsRecommendations Preinsertion: • Have client wash her perineal area with soap and water. • Wash hands with soap and water; dry with clean, dry cloth or allow to air-dry. • Put new/clean examination or high-level disinfected (or sterile) gloves on both hands. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ IUD Guidelines for Family Planning Service Programs Presentation Graphics - 23 Slide 19 19 IUDs: Infection Prevention IUDs: Infection Prevention Recommendations Recommendations ((contcont.).) Preinsertion (cont.): • Ensure that IUD package is unopened/ undamaged. • Cleanse the woman’s cervix and vagina thoroughly two times with antiseptic. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 20 20 IUDs: Infection Prevention IUDs: Infection Prevention Recommendations Recommendations ((contcont.).) Insertion: Use aseptic, “no touch” technique (next slide) and high-level disinfected or sterile instruments in: • Sounding the uterus • Loading the IUD in the sterile package • Inserting the IUD ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 21 21 IUDs: Infection Prevention IUDs: Infection Prevention Recommendations Recommendations ((contcont.).) Using the “no touch technique” means that you do not allow the sound or IUD insertion tube to: • Touch the vaginal walls or blades of the speculum, or • Pass through the cervical os more than once. This helps reduce the risk of contaminating the uterine cavity. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 24 IUD Guidelines for Family Planning Service Programs Slide 22 22 IUDs: Infection Prevention IUDs: Infection Prevention Recommendations Recommendations ((cont.cont.)) Postinsertion: • Before removing your gloves: • Place all used instruments in 0.5% chlorine solution for 10 minutes for decontamination, if not already done. • Dispose of waste materials (e.g., cotton balls) by placing them in a leak-proof container (with tight- fitting lid) or plastic bag. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 23 23 IUDs: Infection Prevention IUDs: Infection Prevention Recommendations Recommendations ((cont.cont.)) Postinsertion (cont.): • Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out. • If disposing of the gloves, place them in the leak- proof container or plastic bag. • If reusing the gloves (not recommended), submerge them in 0.5% chlorine solution for 10 minutes for decontamination. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 24 24 IUDs: Infection Prevention IUDs: Infection Prevention Recommendations Recommendations ((cont.cont.)) Postinsertion (cont.): • Wash your hands thoroughly with soap and water; dry them with a clean, dry cloth or allow them to air dry. • After the client has left, wipe the examination table with 0.5% chlorine solution to decontaminate. • Ensure that all instruments, gloves, and other reusable items are further-processed according to recommended infection prevention practices. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ IUD Guidelines for Family Planning Service Programs Presentation Graphics - 25 Slide 25 25 SummarySummary • Risk of infection can be minimized or prevented by using standard precautions consistently. • HLD is the recommended method of final-processing for IUD services. • Infection in IUD users is rare but is most often due to nonsterile IUD insertion technique. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 26 26 Summary Summary ((contcont.).) • Some critical measures for preventing infection during IUD insertion are: • Cleansing the cervix and vagina with an antiseptic beforehand • Loading the IUD in the sterile package • Using the “no-touch” technique during sounding and insertion ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 26 IUD Guidelines for Family Planning Service Programs IUD Guidelines for Family Planning Service Programs Presentation Graphics - 27 INTRAUTERINE CONTRACEPTIVE DEVICES (IUDs): CLIENT ASSESSMENT Slide 1 Intrauterine ContraceptiveIntrauterine Contraceptive Devices (IUDs):Devices (IUDs): Client AssessmentClient Assessment ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 2 2 ObjectivesObjectives Perform a client assessment, including the following components: • Targeted history • Targeted physical examination, including a complete pelvic examination • Laboratory testing (if indicated and available) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 3 3 Client Assessment for Potential Client Assessment for Potential IUD Users Helps to:IUD Users Helps to: • Ensure that the woman is not pregnant • Ensure that she does not have gonorrhea or chlamydia, and is not at “very high individual risk” of these STIs • Determine the depth and direction of her uterus (for IUD insertion) • Identify other characteristics or conditions that may affect her eligibility for IUD use • Identify any other problems that may require further assessment or treatment ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 28 IUD Guidelines for Family Planning Service Programs Slide 4 4 HistoryHistory Contraceptive history/reproductive goals: • Past experience/methods used • Desire for children/more children or birth spacing • Desire for long-term contraceptive protection ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 5 5 History History ((contcont.).) Menstrual history: • Possibility of pregnancy/last menstrual period (LMP) (if not currently menstruating) • Menstrual patterns (e.g., duration, amount, cramping/pain) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 6 6 History History ((contcont.).) Obstetric history: • Parity, gravida • Past pregnancies and childbirths • Birth within last 4 weeks • Past abortions (spontaneous and induced) • Abortion within last 4 weeks • Signs/symptoms of infection (puerperal sepsis, post-septic abortion) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ IUD Guidelines for Family Planning Service Programs Presentation Graphics - 29 Slide 7 7 History History ((contcont.).) Medical (general): • Anemia or severe anemia (or symptoms) • Known complicated valvular disease (e.g., artificial valve, rheumatic heart disease) • HIV-infected • Clinically well? • Diagnosed with AIDS • On ARV therapy and clinically well? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 8 8 History History ((cont.cont.)) Medical (reproductive): • Recent diagnosis of PID, gonorrhea or chlamydia, cervicitis, or other STIs • Known cancer of genital tract, trophoblastic disease, or pelvic tuberculosis • Unexplained bleeding • Symptoms of current pelvic infection (e.g., purulent discharge, lower abdominal pain, pain with sexual intercourse) • High individual risk of gonorrhea or chlamydia, or other STIs ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 9 9 Physical ExaminationPhysical Examination • General • Signs of anemia or severe anemia • Abdominal examination • Suprapubic tenderness • Masses ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 30 IUD Guidelines for Family Planning Service Programs Slide 10 10 Physical Examination Physical Examination ((contcont.).) • Pelvic examination (bimanual and speculum; rectovaginal, if indicated): • Ulcers, purulent discharge, other signs of current STI • Uterine size, shape and position; anatomical abnormalities • Enlargement/tenderness of adnexa • Cervical motion tenderness • Purulent cervicitis; cervix that bleeds easily • Cul-de-sac mass or tenderness ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 11 11 Laboratory TestsLaboratory Tests (if indicated and available)(if indicated and available) • To rule out/diagnose gonorrhea or chlamydia • To diagnose anemia/severe anemia • To rule out pregnancy (in cases in which the pregnancy checklist does not apply) Note: Although laboratory testing would be ideal in certain situations, it is not always available. Therefore, guidelines for providing the IUD generally do not depend on laboratory tests. The provider must weigh the advantages and disadvantages of providing the IUD on a case-by-case basis. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 12 12 STI Testing/TreatmentSTI Testing/Treatment If a woman might have gonorrhea or chlamydia, these STIs must be ruled out or treated before an IUD can be inserted. • If STI testing is available, test the woman and her partner, and proceed accordingly. • If STI testing is not available, consider presumptive treatment of the woman and her partner, or counsel on more appropriate methods. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ IUD Guidelines for Family Planning Service Programs Presentation Graphics - 31 Slide 13 13 Determining Whether the IUD Determining Whether the IUD Should Be InsertedShould Be Inserted • Pregnant or can not be reasonably certain she is not pregnant—IUD should not be inserted • Never been pregnant—can generally use IUD, but slightly increased risk of expulsion ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 14 14 Determining Whether the IUD Determining Whether the IUD Should Be Inserted Should Be Inserted ((contcont.).) • Heavy, prolonged or painful periods—can generally use IUD, but symptoms may increase (a common side effect) • Inform the woman of these side effects • Provide careful counseling/reassurance • Discuss other contraceptive methods, if appropriate Note: A hormone-releasing IUD, such as the Mirena, is an excellent option for women with heavy bleeding ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 15 15 Determining Whether the IUD Determining Whether the IUD Should Be Inserted Should Be Inserted ((contcont.).) • Birth within last 4 weeks—IUD should not be inserted • Birth within last 48 hours—can generally use IUD (provided no infection) but insertion requires specially trained provider • Immediately following first-trimester abortion— can use the IUD (provided no infection) (insertion after second-trimester abortion requires specially trained provider) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Presentation Graphics - 32 IUD Guidelines for Family Planning Service Programs Slide 16 16 Determining Whether the IUD Determining Whether the IUD Should Be Inserted Should Be Inserted ((contcont.).) • Anemia—can generally use IUD • Complicated valvular heart disease—can generally use IUD, but prophylactic antibiotics should be given • HIV and clinically well—can generally use IUD • AIDS and on ARV therapy and clinically well— can generally use IUD • AIDS and not on ARV therapy—IUD should not be inserted ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 17 17 Determining Whether the IUD Determining Whether the IUD Should Be Inserted Should Be Inserted ((contcont.).) • Conditions that distort the shape of the uterine cavity—IUD should not be used • Current PID, gonorrhea, chlamydia, or purulent cervicitis—IUD should not be inserted until STI ruled out or treated (partner also) • Cancer of genital tract, trophoblastic disease or pelvic tuberculosis—IUD should not be used ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ______________

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