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Difficult insertions

Difficult insertions. Obese patient ++ retroverted or anteverted uterus Known or suspected fibroids Nullip with tight os Abnormal uterus (mild bicornuate ) Anxiety/pain * *most common reason for insertion failure. Obesity (or multi-gravid). Speculum choices

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Difficult insertions

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  1. Difficult insertions • Obese patient • ++ retroverted or anteverted uterus • Known or suspected fibroids • Nullip with tight os • Abnormal uterus (mild bicornuate) • Anxiety/pain* • *most common reason for insertion failure

  2. Obesity (or multi-gravid) • Speculum choices • Patient positioning (knees to chest) • Side wall retraction/ assistant • Lighting

  3. ++ retro- or ante- verted • Tenaculum positioning • Bending the IUD inserter • Checking first (os finder) • Using a short speculum (pull don’t push)

  4. Os finders Os finders (re-useable)

  5. Short speculum

  6. Known Fibroids/mild bicornuate uterus/other abnormalities • Use os finder • Ultrasound guidance

  7. Tight Os • Freezing • Timing of insertion (intra-menstrual) • ?Misoprostol • Os finders

  8. Remember: the internal os has ridges and is often curved. Curving and twisting the instruments helps negotiate the curves.

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