IUD Insertion
Consent Form
Mirena IUD Insertion Consent Form
Paragard IUD Insertion Consent Form
Patient Information
IUD Post Insertion Patient Take Home Instructions
Ensure Woman is Not Pregnant
How to Be Reasonably Certain a Woman is Not Pregnant
Equipment List
IUD device
Sterile gloves (2 pair)
Chux Pads (3)
Exam-room sheet (1 sheet)
Sanitary Pad (1)
Pipelle (1)
Os Finder (1)
Speculum (1 each size)
Speculum Light (1)
Sponge Forceps (1)
Curved Scissors (1)
Tenaculum (1)
Iodine swabs (5)
Foxtail Swabs (10)
Surgical Lubricant (2)
Procedure Note
IUD INSERTION
Before the procedure the risks and benefits were discussed, including the risk of bleeding, expulsion or migration of IUD, uterine perforation or embedding in the uterine wall, and infection. Patient voiced understanding and desire to proceed. Timeout performed (time documented on paper timeout form).
The speculum was inserted and the cervix was identified. Betadine was applied to the cervix and cervical os. Tenaculum was applied to anterior/superior cervix. Os Finder was inserted to gently dilate the cervix, and pipelle was used to sound the depth of the uterus. Depth measured at _ centimeters. The intrauterine device was inserted and deployed per manufacturer instructions. The string was cut to 3 centimeters length and a sample of the remaining string was given to the patient for later comparison. The patient tolerated the procedure well, without significant signs or symptoms of vasovagal responses. EBL less than _ ml. Standby present throughout the procedure including any pre-procedure examinations: _.
The patient was given the patient handout and card for the specific device and lot number of inserted device. The patient agrees to return for fever, severe lower abdominal cramping, heavy bleeding, or purulent discharge. The patient was counseled on how to check the strings herself to ensure the IUD has not been displaced, and instructed to return for a post-placement exam if desired.