IUD Replacement

Consent Form

IUD Removal Consent Form

IUD Insertion Consent Form

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)

Cytobrush (1)

Curved scissors (1)

Tenaculum  (1)

Iodine swabs (5)

Foxtail swabs (10)

Surgical lubricant (2)

Procedure Note


Before the procedure began the risks and benefits were discussed, including the risk of bleeding, device failure or expulsion, device migration, uterine perforation or insertion 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.  The IUD strings were visualized and grasped with sponge forceps.  The IUD was removed without difficulty.  

IUD inspected by myself and patient, complete IUD and attached strings present.  IUD disposed of appropriately.

Betadine was used to clean the cervix.  After cleansing, 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.