Alternatively, immediately ater miscarriage, surgical abortion, or delivery, an IUD may be inserted in the absence of overt infection (Lopez, 2015a; Okusanya, 2014). Also, "immediate" insertion 1 week ater mifepristone and completed medical abortion has been described (Saav, 2012; Shimoni, 2011). The risk ofIUD expulsion is slightly higher if it is placed immediately following any of these recent pregnancies (Whitaker, 2017). However, in studies, the number of women in immediate-placement groups who ultimately receive and retain an IUD is greater than in groups scheduled for traditionally timed placement, some of whose members do not return for insertion (Bednarek, 2011; Chen, 2010).
With immediate insertion, techniques depend on uterine size. After irst-trimester evacuation, the IUD can be placed using the manufacturer's standard instructions. If the uterine cavity is larger, the IUD can be placed using ring forceps with sonographic guidance (Drey, 2009; Fox, 2011).
Immediately following vaginal or cesarean delivery, an IUD can be placed by a hand, by its inserter tube, or by ring forceps (Levi, 2015; Xu, 1996). With any of these methods, the arms of the IUD need not be folded into the inserter tube prior to insertion. During cesarean delivery placement, the hand or inserter travels through the unsutured open hysterotomy to deposit the device at the fundus. A second hand cupping the outer fundus can provide back pressure and stabilize the uterus during insertion. Strings are then gently directed toward the cervix. For instrumented insertion following vaginal delivery, the clinician resterilizes the vulva and changes gloves after placental delivery but before perineal repairs. he anterior lip of the loppy cervix is held with ring forceps. A second ring forceps grasp the IUD stem and guides it through the uterine cavity to the fundus. For manual insertion following vaginal delivery, the provider secures the IUD between the index and middle fingers to deposit the device. In either case, back pressure against the fundus by an abdominal hand can guide positioning (Stuart, 2017; The ACQUIE Project, 2008).
For placement not related to pregnancy, insertion near the end of normal menstruation, when the cervix is usually softer and somewhat more dilated, may be easier and also helps exclude early pregnancy. But, insertion is not limited to this time. For the woman who is sure she is not pregnant and does not want to be pregnant, insertion is done at any time.
Before insertion, contraindications are sought. Candidates are counseled, and written consent obtained. n oral NSAID, with or without codeine, can be used to allay cramps ater insertion (Ngo, 2015). But NSAIDs, misoprostol, or even paracervical during device placement (Bednarek, 2015; Hubacher, 2006;
Mody, 2012; Pergialiotis, 2014). Of topical lidocaine products, 2-percent gel is inefective, but a newer gel and a spray both show promise (Aksoy, 2016; Lopez, 2015b; Tornblom-Paulander, 2015). Bimanual pelvic examination delineates uterine position and size. Abnormalities are evaluated, as they may contraindi cate insertion. Mucopurulent cervicitis or signiicant vaginitis is appropriately treated and resolved before IUD insertion.