Pre-service Education on FP and AYSRH

1. Pre-service Education on FP and AYSRH Session II, Topic 8 IUDs Copper T 380A IUDs, Session II Topic 8 Slide 1

2. IUDs: Key Points for Providers and Clients Copper IUD IUDs, Session II Topic 8 Slide 2

3. IUDs: Key Points for Providers and Clients Copper IUD IUDs, Session II Topic 8 Slide 3

4. Copper IUDs Copper IUDs have a small plastic frame with copper sleeves or wire around it TCu-380A, “Copper T” is most widely used copper IUD Multiload 375 is another copper IUD commonly available in some countries Copper T-380A Multiload 375 IUDs, Session II Topic 8 Slide 4

5. Copper IUDs Effectiveness of IUDs In this progression of effectiveness, where would you place copper intrauterine devices (IUDs)? More effective Less effective IUDs, Session II Topic 8 Slide 5

6. IUDs: Mechanism of Action Prevents fertilization by: Impairing the viability of the sperm Interfering with movement of the sperm Source: Ortiz, 1996 IUDs, Session II Topic 8 Slide 6

7. Copper IUDs: Characteristics • Safe and highly effective • Require no user action • Long-acting (up to 12 years) • Rapid return to fertility • No systemic effects • Have health benefits • Trained provider needed to insert and remove • Require pelvic exam • Possible pain or discomfort during insertion • Have potential side effects • Complications are rare, but may occur • Do not protect against STIs/HIV Source: CCP and WHO, 2011. IUDs, Session II Topic 8 Slide 7

8. Copper IUDs: Health Benefits IUDs are known to: Prevent risks of pregnancy Reduce risk of ectopic pregnancy Rate in IUD users is 12 in 10,000 (2 in 10,000 for Copper T380A) Rate in women using no contraception is 65 in 10,000 Help protect against endometrial cancer IUDs, Session II Topic 8 Slide 8

9. Possible Side-Effects Copper IUD If a woman chooses this method, she may have some side-effects. They are not usually signs of illness. After insertion: Other common side-effects: Longer and heavier periods Some cramps for several days Bleeding or spotting between periods Some spotting for a few weeks More cramps or pain during periods May get less after a few months IUDs, Session II Topic 8 Slide 9

10. Copper IUDs:Counseling about Side Effects Before insertion, describe common side effects: Heavier and/or prolonged menstrual bleeding Menstrual cramping Spotting between periods Explain that side effects: Are not signs of illness Usually become less within the first 3–6 months Encourage to come back with questions or concerns If client cannot tolerate side effects, treatment or discontinuation may be necessary IUDs, Session II Topic 8 Slide 10

11. Who Can and Cannot Use the IUD Copper IUD Most women can safely use the IUD But usually cannot use IUD if : Unusual vaginal bleeding recently Gave birth recently (more than 2 days ago) May be pregnant At high risk for STIs Infection or problem in female organs IUDs, Session II Topic 8 Slide 11

12. WHO’s Medical Eligibility Criteria Categories for IUDs, Hormonal and Barrier Methods Source: WHO, 2010. IUDs, Session II Topic 8 Slide 12

13. WHO’s Medical Eligibility Criteria Categories for IUDs, When Only Limited Clinical Judgment is Available Source: WHO, 2010. IUDs, Session II Topic 8 Slide 13

14. Category 1 and 2 Examples (not inclusive): Who Can UseCopper IUDs Source: WHO, 2010. IUDs, Session II Topic 8 Slide 14

15. Category 3 and 4 Examples (not inclusive):Who Should Not UseCopper IUDs Source: WHO, 2010. IUDs, Session II Topic 8 Slide 15

16. IUD Use by Women with HIV and AIDS Women who are at risk of HIV can safely have the IUD inserted. Women who have HIV clinical disease that is mild or with no symptoms can safely have the IUD inserted(WHO stage 1 or 2). This includes women who are doing well on ART. Women who haveHIV clinical disease that is severe or advanced (AIDS) should not have the IUD inserted(WHO stage 3 or 4). Source: WHO, 2010. IUDs, Session II Topic 8 Slide 16

17. IUD Use by Women with HIV and AIDS(Continued) If a woman becomes infected with HIV or her HIV clinical disease becomes severe or advanced while she has an IUD in place, it does not need to be removed. IUD users with HIV clinical disease that is severe or advanced should be monitored for pelvic inflammatory disease. Urge women to use condoms along with the IUD. Used consistently and correctly, condoms help prevent transmission of HIV and other STIs. Source: WHO, 2010. IUDs, Session II Topic 8 Slide 17

18. IUD Use by Postpartum Women Women less than 48 hours postpartum can have copper IUD inserted Women 48 hours to 4 weeks postpartum generally should not initiate IUDs No restrictions starting at 4 weeks postpartum Women with puerperal sepsis should not have IUD inserted Source: WHO, 2010. IUDs, Session II Topic 8 Slide 18

19. When to Insert an IUD Copper IUD IUDs, Session II Topic 8 Slide 19

20. When to insert an IUD (continued) Copper IUD Copper IUD IUDs, Session II Topic 8 Slide 20

21. What Will Happen When You Get Your IUD Steps: Pelvic examination Cleaning the vagina and cervix Placing IUD in the womb through the cervix    • May hurt at insertion • Please tell us if it hurts • Rest as long as you like afterwards • May have cramps for several days after insertion Afterwards: you can check your IUD from time to time if you want. IUDs, Session II Topic 8 Slide 21

22. Explaining the IUD Insertion Procedure Cleans the cervix and vagina with an antiseptic Inserts a small rod into the uterus to measure the depth of the uterus Inserts the IUD through the vagina and into the uterus using a small applicator You may feel discomfort, like heavy menstrual cramps. The provider: • Performs a pelvic examination After the insertion, you will rest. IUDs, Session II Topic 8 Slide 22

23. Post-Insertion Instructions Tell client to expect cramping and spotting for a few days If client wants to check strings, teach her how: Use clean hands Check after menses If convenient for client, schedule follow-up visit for 3–6 weeks Counsel to return immediately if there are any signs of complications. IUDs, Session II Topic 8 Slide 23 Source: CCP and WHO, 2011; WHO, 2004, updated 2008.

24. Complications of IUDs Potential complications of IUDs include perforations, pelvic inflammatory disease (PID), and expulsions. Biases in early research overstated risks of PID. Most research since the 1980s has concluded that serious complications are rare with modern IUDs. IUDs, Session II Topic 8 Slide 24

25. Complications of IUDs, continued IUDs, Session II Topic 8 Slide 25

26. Signs of Possible IUD Complications Advise client to return immediately in case of: • Bleeding and severe abdominal cramping within a few days post-insertion perforation • Irregular bleeding or pain every cyclepartial expulsion, perforation • Fever, unusual vaginal discharge, low abdominal pain infection • Missing IUD strings, missed period expulsion,pregnancy Source: CCP and WHO, 2011. IUDs, Session II Topic 8 Slide 26

27. Explain Removal Procedure to Client The provider: Inserts a speculum to see the cervix and IUD strings. Cleans the cervix and vagina with an antiseptic. Asks the woman to take slow, deep breaths, and tell the provider if she feels pain during the procedure. Using forceps, pulls the IUD strings slowly and gently until the IUD is completely out of uterus. IUD removal is quick and usually quite painless. IUDs, Session II Topic 8 Slide 27 Source: CCP and WHO, 2011.

28. Managing IUD Side Effects or Complications:Heavy, Prolonged or Irregular Bleeding Counseling and reassurance are key Source: CCP and WHO, 2011. IUDs, Session II Topic 8 Slide 28

29. Managing IUD Side Effects or Complications: Cramping and Mild Pain Counseling and reassurance are key Source: CCP and WHO, 2011. IUDs, Session II Topic 8 Slide 29

30. Managing IUD Side Effects or Complications: Severe Pain in Lower Abdomen (Rare) Rule out PID, ectopic pregnancy or perforation. If PID is suspected, treat with appropriate antibiotics for gonorrhea, chlamydia and anaerobic bacterial infection. There is no need to remove the IUD. If ectopic pregnancy is suspected, refer immediately. Source: CCP and WHO, 2011. IUDs, Session II Topic 8 Slide 30

31. Managing IUD Side Effects or Complications: Suspected Perforation Stop procedure immediately, remove IUD Observe vital signs for an hour; check for signs of bleeding If rapid pulse, falling blood pressure, or increased pain: refer Provide alternative contraception Advise avoid sex for 2 weeks Follow-up in a week or as needed Source: CCP and WHO, 2011. IUDs, Session II Topic 8 Slide 31

32. Managing IUD Side Effects or Complications: Missing Strings Determine risk of pregnancy Perform pelvic exam, probe for strings in cervical canal If cannot locate strings, consider X-ray or ultrasound, or refer Give choice of another contraceptive method Insert another IUD if expulsion is confirmed and Woman is not pregnant She still wants to use an IUD Source: CCP and WHO, 2011. IUDs, Session II Topic 8 Slide 32

33. Managing IUD Side Effects or Complications: Suspected Pregnancy Assess for pregnancy, including ectopic pregnancy If the client is pregnant and wishes to continue the pregnancy: Explain that using an IUD during pregnancy increases the risk of preterm delivery or miscarriage If possible, remove the IUD If not possible to remove, advise close follow-up for signs of septic miscarriage Source: CCP and WHO, 2011. IUDs, Session II Topic 8 Slide 33

34. Copper IUDs: Summary Copper IUDs are: Safe, highly effective, convenient, reversible, long lasting, cost-effective, easy to use, and appropriate for the majority of women. Providers can ensure safety by: Informative counseling Careful screening Appropriate infection prevention practices Proper follow-up IUDs, Session II Topic 8 Slide 34