MANDATORY MODULE OF PP-IUCDs

GNM 3RD YEAR

Postpartum intrauterine contraceptive device

Submitted to: ______________________________________

Submitted by: ______________________________________

Submitted on: ______________________________________

Class teacher Certified by Principal Signature of External

 CLASS GNM 3RD YEAR
MANDATPORY MODULE PP-IUCD

NAME OF STUDENTS

SURINDERJIT KAUR

SUSHIL KAUR

TAJINDER KAUR

TIYA

Class coordinator Certified by Principal Subject

Respected Respected Coordinator

Miss. Simran mam Dr. Harbans kaur kang Mrs.Kalpnamam

 INDEX

Sr.no CONTENT PAGE NO.

1. INTRODEUCTION

2. DEFINITION OF PPIUCDs

3. TYPES OF PPIUCDs

4. PURPOSES OF PPIUCDs

5. ADVANTAGES OF PPIUCDS

6. DISADVANTAGES OF PPIUCDs

7. PROCEDURE OF INSERTION IUDs

8. ROLE OF NURSE IN PPIUCDs

9. BIBLIOGRAPHY
 Postpartum intrauterine contraceptive devices (PP-IUCD)

Introduction

The postpartum intrauterine contraceptive device (PPIUCD) is a method of family planning that may be
used during the first few weeks after giving birth, and it is very successful, reliable, affordable, non-
hormonal, immediately reversible, long-acting, and does not interfere with lactation. It is an effective
means of providing contraceptive services to women in countries with high rates of unmet needs for family
planning services.

The Postpartum Intrauterine Contraceptive Device (PPIUCD) is a highly effective, reversible contraceptive
method that can be inserted into the uterus shortly after childbirth. It offers women a reliable option for
long-term contraception during the postpartum period, helping them to space pregnancies and plan their
family size effectively. PPIUCD insertion is typically done within 48 hours after delivery, making it a
convenient and accessible contraceptive choice for women who have just given birth.

PPIUCDs come in different types, including copper intrauterine devices (Cu-IUDs) and hormonal
intrauterine devices (Hormonal IUDs), each with its unique mechanism of action and duration of
effectiveness. The choice of PPIUCD type depends on factors such as a woman's medical history,
preferences, and contraceptive needs.
Definition

IUCD/PPIUCD

It is the insertion of an intrauterine contraceptive device in the endometrial cavity shortly after the
delivery of placenta which is immediate PP-IUCD or post placental PPIUCD

Postpartum Intrauterine Contraceptive Device (PPIUCD): A form of long-acting reversible contraception

(LARC) that is inserted into the uterus shortly after delivery, usually within 48 hours postpartum. PPIUCDs
can be either non-hormonal (copper IUDs) or hormonal (progestin-releasing IUDs), and they work by
creating a hostile environment for sperm or altering cervical mucus to prevent fertilization. These devices
offer women a reliable and effective contraceptive option during the postpartum period, allowing them to
space pregnancies and plan their family size.

TYPES OF PPIUCDs
There are two main types of Postpartum Intrauterine Contraceptive Devices (PPIUCDs) based on their
composition and mechanism of action:

Non-Hormonal (Copper) PPIUCD:

These devices are made of copper and do not contain any hormones. The copper ions released by the device
create an environment within the uterus that is toxic to sperm, preventing fertilization. Non-hormonal
PPIUCDs are effective immediately after insertion and can provide contraception for several years.
 Non-Hormonal (IUDs)

Safe load cut 380A The T-Safe CU 380A QL is a contraceptive device recommended by the WHO that
lasts for up to 10 years. The horizontal arms completely embed the copper sleeves resulting in an extremely
smooth and plane surface. Effortless and quick loading of the IUD because of the new insertion body.

Safe load cut 380A

Silver line Cu 200 Ag provides the user with a long term protection for up to 3 years while the 380 Ag
could last up to 5 years. These products require a 1/3 dilation cervical dilation during insertion compared to
the Copper T 380A.

Silver line Cu 200 Ag

Multiload-cu 250 has a copper wire with a surface of 250 square mm. It works for three years.

Multiload-cu 250

The Multiload-cu 250 comes in a standard length; the Multiload-cu 375 comes in a standard and short
length, to suit the size of your womb.
Multiload-cu 375 has a thicker copper wire, with a surface of 375 square mm. It works for five years

Multiload-cu 375

Hormonal PPIUCD (Progestin-Releasing IUD):

These devices release a low dose of progestin hormone directly into the uterus.. Progestin thickens cervical
mucus, making it difficult for sperm to reach the egg, and may also suppress ovulation in some cases.
Hormonal PPIUCDs are also highly effective at preventing pregnancy and can provide contraception for
several years.

Both types of PPIUCDs offer women a reversible and long-acting contraceptive option that can be inserted
shortly after childbirth, typically within 48 hours postpartum. The choice between non-hormonal and
hormonal PPIUCDs depends on factors such as individual preferences, medical history, and any
contraindications to hormonal contraception. It's important for women to discuss their options with
healthcare providers to determine the most suitable type of PPIUCD for their needs.

Hormone-Releasing IUDs
• Progestasert - It is a T shaped IUD made of ethylene and vinyl acetate copolymer containing titanium
dioxide. The vertical stem contains a reservoir of 38 mg progesterone together with barium sulfate dispersed
in silicone fluid. The progesterone is released at the rate of 65 µg per day.

• LNG - 20 (Mirena) - This T shape & device has a collar attached to vertical arm containing 52 mg of
levonorgestrel dispersed in poly dimethyl siloxane. It releases 15µg of levonorgestrel per day in vivo and is
effective for 7-10 years

PURPOSES

The purposes of Postpartum Intrauterine Contraceptive Devices (PPIUCDs) include:

 Effective Contraception: PPIUCDs offer highly effective contraception, with failure rates
comparable to sterilization methods, reducing the risk of unintended pregnancies.

 Immediate Postpartum Protection: By inserting a PPIUCD shortly after childbirth, usually within
48 hours, women can receive immediate protection against pregnancy without the need for additional
visits or procedures.

 Long-Acting Reversible Contraception (LARC): PPIUCDs provide long-term contraception, with

non-hormonal devices lasting up to 10 years and hormonal devices lasting between 3 to 5 years. This
allows women to space pregnancies and plan their family size effectively.

 Convenience: PPIUCDs offer a convenient contraceptive option for women during the postpartum
period, eliminating the need for daily or monthly contraceptive methods and reducing user-
dependent factors.

 Preservation of Fertility: Unlike permanent sterilization methods, such as tubal ligation, PPIUCDs
are reversible, allowing women to regain fertility quickly after device removal when they desire to
become pregnant.

 Safety: PPIUCDs are generally safe for most women, including those who are breastfeeding, and do
not interfere with lactation or breastfeeding practices.

 Reduced Inter-pregnancy Interval: Using PPIUCDs can help reduce the inter-pregnancy interval,
which is the time between one pregnancy and the next. Optimal spacing between pregnancies is
associated with better maternal and infant health outcomes.

 Cost-Effectiveness: PPIUCDs are cost-effective over time compared to other contraceptive methods
due to their long duration of effectiveness and low maintenance requirements.

 Promotion of Reproductive Autonomy: PPIUCDs empower women to make informed decisions

about their reproductive health, giving them control over when and if they want to have children.
  Population Health Benefits: Wide adoption of PPIUCDs can contribute to reducing unintended
pregnancies, maternal mortality, and infant mortality rates, leading to improved population health
outcomes.

ADVANTAGES OF PPIUCDs

There are additional advantages of Postpartum Intrauterine Contraceptive Devices (PPIUCDs):

 Reduced Risk of Expulsion: PPIUCDs inserted immediately postpartum have a lower risk of
expulsion compared to IUDs inserted at other times. The uterus is more receptive to the device
shortly after childbirth, reducing the likelihood of displacement.

 No Interruption in Sexual Activity: once a PPIUCD is inserted, there is any need for interruption in
sexual activity. Couples can engage in sexual intercourse without worrying about contraceptive
effectiveness.

 Privacy and Confidentiality: PPIUCDs provide a discreet form of contraception. There is no visible
external device, and the contraceptive method remains private between the woman and her
healthcare provider.

 Suitable for Women with Health Conditions: PPIUCDs are suitable for women with various health
conditions, such as hypertension or diabetes, who may have contraindications to other contraceptive
methods.

 User Independence: Once inserted, PPIUCDs do not require daily attention or user compliance. This
reduces the risk of human error often associated with other contraceptive methods.

 Immediate Return to Fertility: Upon removal of the PPIUCD, fertility returns promptly. This allows
women to plan pregnancies according to their desired timeline.
  Compatibility with Breastfeeding: Both non-hormonal and hormonal PPIUCDs are compatible with
breastfeeding, making them a suitable choice for postpartum women who are nursing their infants.

 Flexible Timing for Insertion: While immediate postpartum insertion is optimal, PPIUCDs can also
be inserted up to 4 to 6 weeks postpartum. This flexibility allows women who missed the immediate
insertion window to still benefit from long-acting contraception.

 Minimal Discomfort: Insertion of PPIUCDs is generally well-tolerated by most women and causes
minimal discomfort. Local anesthesia or pain management techniques can be used to further reduce
any discomfort during insertion.

 Continuity of Care: For women who desire long-term contraception, PPIUCDs provide continuity of
care without the need for frequent changes or replacements, enhancing convenience and satisfaction
with the chosen contraceptive methods.

DIS-ADVANTAGES OF PPIUCDs

While Postpartum Intrauterine Contraceptive Devices (PPIUCDs) offer many advantages, they also have
certain disadvantages and considerations that should be taken into account. Here are some of the
disadvantages of PPIUCDs:

 Risk of Expulsion: There is a small risk that the PPIUCD may be expelled from the uterus, especially
if it is inserted shortly after childbirth. Expulsion rates vary but are generally higher in the immediate
postpartum period compared to later insertions.

 Risk of Perforation: In rare cases, there is a risk of uterine perforation during insertion, where the
device may puncture the uterine wall. This risk is higher in women with uterine abnormalities or
during difficult insertions.
  Increased Menstrual Bleeding: Non-hormonal PPIUCDs, such as copper IUDs, may lead to heavier
menstrual bleeding, longer periods, or increased cramping for some women. This can be a significant
drawback for those who already experience heavy menstrual bleeding.

 Risk of Infection: While uncommon, there is a risk of infection associated with PPIUCD insertion.
Proper sterile technique during insertion and post-insertion care can help minimize this risk.

 Hormonal Side Effects (for Hormonal IUDs): Hormonal PPIUCDs, such as those releasing progestin,
may cause hormonal side effects such as irregular bleeding, spotting between periods, breast
tenderness, or mood changes. These side effects may diminish over time but can be bothersome for
some women.

 Not Suitable for some women: PPIUCDs may not be suitable for women with certain medical
conditions, such as pelvic inflammatory disease (PID), current or recent history of certain cancers, or
abnormalities of the uterus that could interfere with device placement.

 Cost Considerations: While cost-effective over time, there may be initial costs associated with
PPIUCD insertion, including the cost of the device itself, healthcare provider fees, and any additional
tests or procedures required during insertion.

 Delay in Return to Fertility: While PPIUCDs are reversible; it may take some women a few months
to resume ovulation and fertility after device removal, which could delay pregnancy if desired.

 Healthcare providers need to be aware of the device's presence when planning such procedures.

It's essential for women to discuss these potential disadvantages, along with the benefits and suitability of
PPIUCDs, with their healthcare provider to make an informed decision about whether this contraceptive
method is appropriate for them.
PROCEDURE OF PPIUCDs

The procedure for inserting a Postpartum Intrauterine Contraceptive Device (PPIUCD) involves several
steps and should be performed by trained healthcare providers. Here is an overview of the general
procedure:

 Patient Counseling and Informed Consent:

Before the insertion procedure, healthcare providers should counsel the patient about PPIUCDs, including
their benefits, risks, potential side effects, and alternative contraceptive options.

Obtain informed consent from the patient after ensuring she understands the information provided.

 Patient Evaluation: Conduct a thorough medical history review, including any previous
pregnancies, deliveries, contraceptive use, allergies, and current health status.

Perform a pelvic examination to assess the size, position, and condition of the uterus and cervix.

 Preparation: Gather all necessary equipment, including the PPIUCD device, sterile gloves,
speculum, antiseptic solution, tenaculum (for some insertions), and uterine sound or probe, and
insertion instruments. Ensure a clean and sterile environment for the procedure

Requirements
Clinics/centers will need to have the following facilities, equipment and supplies for IUCD service:
♦ Place/furniture:
- Space to maintain privacy
- Table for IUCD insertion
- Linen/cloth to cover the woman’s pelvic area
- Adequate light source
- Water for washing
♦ Equipment & supplies:
- Copper IUCD insertion kit, which includes the following:
1. Stainless steel tray with cover (12”×8”×2”)
2. Small bowl for antiseptic solution
3. Kidney tray
4. Sim’s or Cusco’s vaginal speculum-large, medium, small
5. Anterior vaginal wall retractor (If Sim’s speculum is used)
6. Sponge holding forceps
7. Volsellum forceps curved/tenaculum
8. Uterine sound
9. Mayo scissors
10. Long artery straight forceps (for IUCD removal)
11. Gloves (high-level disinfected/sterile surgical gloves or examination gloves)
12. Dry cotton swabs
- Cheatle’s forceps
-Antiseptic solution (chlorhexidine or povidone iodine)
- Torch
- IUCD (in an unopened, undamaged, sterile package and the date of expiry is not over)

♦ I.P. equipment:
- Plastic bucket/tub for decontamination
- Bleaching powder
- Utility gloves
- Autoclave/boiler/container with lid for boiling
- Soap
- Leak proof colour coded covered container for disposables
Basic Minimum Instruments for IUCD insertion
Steps of Post placental Insertion
Steps for insertion using PPIUCD insertion forceps
1. Check woman’s record to ensure that she is an appropriate client for IUCD and she has given her consent.
# To screen for PPIUCD pre-insertion, rule out conditions which prevent insertion of IUCD like:
 Rupture of membranes for more than 18 hours
 Chorioamnionitis
 Unresolved postpartum hemorrhage
2. Confirm that sterile instruments, supplies and light source are available in the labor room.
Talk to the woman with kindness and respect.
Confirm with the woman whether she still wants IUCD.
Explain that you will insert the IUCD following delivery of the placenta.
Answer any questions she might have.

3. Perform hand hygiene and put on HLD or sterile gloves.

4. Arrange instruments and supplies on sterile tray or draped area.

5. Inspect perineum, labia and vaginal walls for lacerations. If lacerations are not bleeding heavily, insert the
IUCD and repair if needed.
6. Gently visualize cervix by inserting a Sim’s speculum in the vagina and depressing the posterior wall of
the vagina.
7. Gently clean cervix with antiseptic solution two times using two separate cotton swabs with Povidone
Iodine or Chlorhexidine. Wait for two minutes to allow the antiseptic to work.

8. Gently grasp the anterior lip of the cervix with the ring (or sponge holding) forceps up to the first lock.
(The same ring (or sponge holding) forceps that was used to clean the cervix can be used).

9. Grasp IUCD with PPIUCD insertion forceps in the sterile package using a no-touch technique as noted It
should be held just on the edge of the PPIUCD insertion forceps so that it can be easily released from the
instrument when opened.

10. Apply gentle traction on the anterior lip of the cervix using the ring (sponge holding) forceps and insert
IUCD into lower uterine cavity. Avoid touching the walls of vagina. The provider passes the PPIUCD
insertion forceps with the IUCD carefully into the lower uterine cavity.

11. Once the PPIUCD insertion forceps is in the lower uterine cavity, remove the ring (or sponge holding)
forceps that is holding the anterior lip of the cervix. Move the left hand to the woman’s abdomen and push
the entire uterus superiorly (upward). This is to straighten out the angle between the vagina and the uterus,
so that the instrument can easily move upward toward the uterine fundus.

12. Gently move PPIUCD insertion forceps upward towards the fundus following the curve of the uterine
cavity. The provider should take care not to apply excessive force. If the uterus is not pushed upward, the
angle between the cervix and the uterus may not allow the instrument to advance smoothly. The provider
should always keep the instrument closed so that the IUCD is not dropped accidentally in the mid-portion of
the uterine cavity.

13. Confirm that the end of PPIUCD insertion forceps has reached the fundus and tilt the forceps slightly
inwards. When it reaches the uterine fundus, the provider will feel resistance and will also feel the thrust of
the instrument at the fundus of the uterus with her left hand which is placed on the abdomen.

14. Open PPIUCD insertion forceps and release the IUCD at the fundus. Sweep PPIUCD insertion forceps
to side wall of the uterus. Stabilize uterus (using base of hand against lower part of body of uterus). Slowly
remove PPIUCD insertion forceps from uterine cavity, keeping it slightly open. Take particular care not to
dislodge the IUCD as PPIUCD insertion forceps are removed Stabilize the uterus until the PPIUCD
insertion forceps are completely out of the uterus. To help prevent the IUCD being drawn downward in the
uterus, the instrument is swept to the right to ensure that the instrument is away from the IUCD. Then the
instrument is slowly withdrawn, keeping it slightly open at all times. If the instrument closes and catches the
strings of the IUCD, it can accidentally pull the IUCD down from its fundal position, increasing the risk of
expulsion. Counter traction is applied to stabilize the uterus while the instrument is being withdrawn and
until it is completely out of the uterus.

15. Examine the cervix to ensure there is no bleeding. If IUCD is seen protruding from cervix, remove
and reinsert. It is important to check that the IUCD is not visible at the cervical os. If it is visible, or if
the strings appear to be very long, then the IUCD has not been adequately placed at the fundus and the
chance of spontaneous expulsion is higher. If it appears that the IUCD is not placed high enough, the
 provider can use the same forceps to remove the IUCD and repeat steps of insertion using aseptic
procedures.
16. Remove all instruments used and place them in 0.5% chlorine solution for 10 minutes for
decontamination.
17. Allow the woman to rest for few minutes. Support the initiation of routine postpartum care, including
immediate breastfeeding. The woman should rest on the table for few minutes following the insertion
procedure. The provider should reassure her that the insertion was done smoothly and that she now has
an effective, safe and reliable long term spacing method of contraception.
18. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out
and disposing of them. Perform hand hygiene. All infection prevention steps should be followed as per
standard infection prevention procedures and facility protocol for waste management.
19. Provide the woman with post insertion instructions.
 Provide IUCD client card showing type of IUCD and date of insertion.
 Inform her about the IUCD side effects and normal postpartum symptoms.
 Tell the woman when to return for IUCD follow-up/PNC/ newborn checkup.
 Emphasize that she should come back any time she has a concern or experiences warning signs.
 Inform her about the warning signs regarding IUCD.
 Explain how to check for expulsion and what to do in case of expulsion.
 Assure the woman that the IUCD will not affect breastfeeding and breast milk.
 Ensure that the woman understands the post-insertion instructions.
 Give written post-insertion instructions.
These instructions should be reinforced again by the staff of the postpartum unit and repeated to the
woman, and if possible with her family.
20. Record information regarding the PPIUCD insertion in the woman’s chart or record and in the
PPIUCD register kept at the facility.

A,. Non-Hormonal (Copper) PPIUCD:

i. Insert the speculum into the vagina to visualize the cervix.

ii. Cleanse the cervix and vagina with an antiseptic solution.

iii. Use a tenaculum to stabilize the cervix if needed.

iv. Measure the depth of the uterus with a uterine sound or probe to determine the appropriate size of the
PPIUCD.
v. Insert the PPIUCD device into the uterine cavity through the cervical os using the insertion tube provided
with the device.

vi. Release the arms of the device inside the uterus, allowing it to open and position itself securely.

B, Hormonal PPIUCD (Progestin-Releasing IUD):

i. Follow the same initial steps as for non-hormonal PPIUCDs.

ii. Insert the hormonal PPIUCD device into the uterine cavity through the cervical os using the insertion tube
provided.

iii. Release the device inside the uterus, allowing it to open and position itself securely.

 Confirmation and Trimming:

Confirm the correct placement of the PPIUCD by gently pulling on the device to ensure it is anchored within
the uterine cavity.

Trim the device strings to an appropriate length, leaving them long enough for future checks but not
protruding from the cervix.

 Post-Insertion Counseling:

Provide post-insertion counseling to the patient, explaining any potential side effects, follow-up visits, and
what to do in case of complications or concerns.

Advise the patient to check the PPIUCD strings regularly to ensure the device remains in place.

 Follow-Up Visits:

Schedule follow-up visits as recommended by guidelines or healthcare provider protocols to monitor the
placement, position, and effectiveness of the PPIUCD.

Encourage the patient to seek medical attention if they experience unusual symptoms or have concerns about
the device.

It's important to note that the specific steps and techniques for PPIUCD insertion may vary slightly
depending on the type of device used, institutional protocols, and healthcare provider preferences.
Healthcare providers should be trained and experienced in PPIUCD insertion procedures to ensure safety
and efficacy for the patient.
ROLE OF NURSE IN PPIUCD PROCEDURE

The role of a nurse in the procedure of inserting a Postpartum Intrauterine Contraceptive Device (PPIUCD)
is crucial in providing comprehensive care to women during the postpartum period. Here are the key
responsibilities and contributions of a nurse in this procedure:

Patient Education and Counseling:

- Explain the benefits, risks, and potential side effects of PPIUCDs to the patient.
- Provide information about alternative contraceptive options and answer any questions or concerns
the patient may have.
- Obtain informed consent from the patient after ensuring she understands the procedure and its
implications.

Preparation and Support:

- Assist in preparing the necessary equipment and supplies for the insertion procedure.
- Ensure a clean and sterile environment in the procedure room.
- Offer emotional support and reassurance to the patient throughout the process, addressing any
anxieties or apprehensions she may have.

Patient Assessment:

- Conduct a thorough assessment of the patient's medical history, including previous pregnancies,
deliveries, contraceptive use, allergies, and current health status.
- Perform a pelvic examination to assess the size, position, and condition of the uterus and cervix,
providing valuable information for device selection and insertion.

Assist During Insertion:

- Assist the healthcare provider during the insertion procedure by handing instruments, maintaining a
sterile field, and providing support to the patient.
- Position the patient comfortably on the examination table and assist with positioning aids, such as a
leg rest or lithotomy stirrups.
- Offer comfort measures, such as holding the patient's hand or providing distractions, to help alleviate
discomfort during the procedure.

Post-Insertion Care:

- Monitor the patient's vital signs and overall condition after the insertion procedure.
- Educate the patient about post-insertion care instructions, including checking the device strings,
recognizing signs of complications, and when to seek medical assistance.
- Provide information about follow-up visits and ensure the patient understands the importance of
regular monitoring and evaluation of the PPIUCD.
Documentation and Reporting:

- Accurately document all aspects of the insertion procedure, including patient education, consent,
assessment findings, insertion details, post-procedure care, and any complications encountered.
- Report any adverse events, complications, or concerns related to the PPIUCD insertion promptly to
the healthcare provider for further evaluation and management.

Follow-Up and Support:

- Schedule follow-up appointments as recommended by guidelines or healthcare provider protocols to

monitor the placement and effectiveness of the PPIUCD.
- Provide ongoing support and guidance to the patient, addressing any questions or issues that may
arise during the post-insertion period.

Overall, the role of a nurse in the PPIUCD insertion procedure encompasses education, assessment,
assistance, monitoring, documentation, and ongoing support, all aimed at ensuring the safety, efficacy, and
satisfaction of the patient with this contraceptive method
 BIBLIOGRAPHY

- www.google.com
- ChatGPT
- https://youly.com.au/wp-content/uploads/Non-hormonal-vs-hormonal.png
- World Health Organization. Medical Eligibility Criteria for Contraceptive Use. 5th ed.
Geneva, Switzerland: World Health Organization; 2015.
- https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.allcareobgyn.com%2Fblog
%2Fiud-intrauterine-
device&psig=AOvVaw1h4iAFZZOI9ymlZGCH_yTB&ust=1712065390669000&source=images
&cd=vfe&opi=89978449&ved=0CBAQjRxqFwoTCOinnemSoYUDFQAAAAAdAAAAABAIS.
- Textbook of Midwifery and Obstetrics by Dr.shally MagoSS
- Community textbook 4th Edition by K.PARK