IUD

IUD Insertion

IUD Insertion Consent Form

Mirena IUD Insertion Consent Form

Paragard IUD Insertion Consent Form


IUD Insertion Patient Information

IUD Post Insertion Patient Take Home Instructions

IUD Self Removal


Ensure Woman is Not Pregnant

How to Be Reasonably Certain a Woman is Not Pregnant


IUD Insertion Equipment List


IUD Insertion 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.

IUD Removal

IUD Removal Consent

IUD Removal Consent Form


IUD Removal Equipment List

Chux pads (3)

Exam-room sheet (1 sheet)

Sanitary pad (1)

Speculum (1 each size)

Speculum light (1)

Sponge forceps (1)

Cytobrush (1)

Foxtail swabs (10)

Surgical lubricant (2)


IUD Removal Procedure Note

IUD REMOVAL


Pre-procedure counseling and consent completed, all questions answered.  A timeout was performed and time documented on paper consent form.


The speculum was inserted and the cervix was identified.  The IUD strings were identified and grasped with sponge forceps and the IUD was removed without difficulty.  The patient tolerated the procedure well.  No complications.  IUD inspected by myself and patient, complete IUD and attached strings present.  IUD disposed of appropriately.  Standby present throughout procedure: _.

IUD Replacement

IUD Replacement Consent Form

IUD Removal Consent Form

IUD Insertion Consent Form


IUD Replacement Equipment List


IUD Replacement Procedure Note

IUD REMOVAL AND INSERTION


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.