# Paragard Insertion

## Overview

This module describes how to insert a Paragard, a copper-based intrauterine contraceptive device.

## Indications

1. Contraception for up to 10 years

## Contraindications

1. Current pregnancy

2. Any anomaly causing distortion of the uterine cavity

3. Current pelvic inflammatory disease or an increased susceptibility to pelvic infections

4. Postpartum endometritis or infected abortion in the past 3 months

5. Known or suspected malignancies of the uterus or cervix

6. Undiagnosed abnormal uterine bleeding

7. Untreated lower genital tract infections

8. Wilson’s disease

9. A previously inserted unremoved intrauterine device

10. Hypersensitivity to any part of the product

## Patient information and consent

Patients should be fully counseled about their contraceptive options. Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“You have chosen the Paragard intrauterine device for family planning. The Paragard is a very small device which is stored in a thin tube. I will place the tube through your cervix into your womb, where the wings will pop out to keep it in place. I will then remove the tube.”

### What can my patient expect?

“Some patients do not find this painful, but other patients get moderate to severe pain during insertion. Afterwards, you can get cramping and minor spotting for a few days, but bleeding should be minimal. You or your sexual partner will not feel the Paragard device in your womb.”

### What is my patient’s role?

“Tell me if you have any illnesses, symptoms of sexually transmitted infections, or allergies. Tell me if the pain becomes too much, or you need a break before we go ahead. If at any point you feel you do not want to continue with the procedure, tell me and I’ll stop immediately. Let me know if you feel faint.”

## Preparation

Prepare a trolley with equipment. A female chaperone should be present.

### Documentation

1. Patient notes

### Equipment

1. Non-sterile and sterile gloves

2. Alcohol-based hand rub

3. Skin disinfectant
   Skin disinfectant

   Commonly used preparations include 0.5-2% chlorhexidine in 70% alcohol (Steriprep), or 10% povidone iodine. There is no consensus on the superiority of one agent above another.

4. Swabs/cotton balls

5. Sterile pack

6. Sterile tenaculum

7. Sterile uterine sound

8. Sterile speculum & lubricant

9. Sterile curved scissors

10. Ring forceps

11. Paragard in sterile package
    Paragard in sterile package

## Site & Positioning

The patient should be positioned in dorsal lithotomy. A bimanual examination using non-sterile gloves should be performed to determine uterine position and size.

## Procedure

Follow medical asepsis with sterile gloves.

1. Perform hand hygiene.

2. Open a sterile pack and create a sterile field. Open sterile equipment onto the field, leaving the Paragard, open, in its packaging beside the field. Fill the well with cleaning solution and open gauze/cotton wool into the well. Squeeze lubricant onto the blades of the speculum.

3. Perform hand hygiene and don sterile gloves.

4. Insert the lubricated speculum into the vagina.

5. Clean the cervix using soaked cotton balls and the ring forceps.

6. Apply the tenaculum to the

   anterior
   anterior

   Apply to the posterior cervix if retroverted uterus is detected.

   cervix (12 o’clock position) and apply gentle traction to straighten the uterus.

7. Insert the uterine sound carefully, avoiding perforation, and note the

   depth
   depth

   A depth of 6-9 cm is required.

   of the uterus. Remove the sound.

8. Load
   Load

   Grasp the arms of the device and squeeze them backwards. Tuck them backwards into the insertion tube, only as far as necessary to keep them in place. Do not keep the arms bent backwards for more than 5 minutes.

   Insert the rod into the opposite end of the tube until it touches the bottom end of the IUD.

   the Paragard device and rod into the tube.

9. Move the flange to the mark corresponding to the depth of the uterus. Align the flange with the arms.

10. Holding it by the insertion tube, insert the device through the cervix up to the flange, with the arms orientated

    laterally
    laterally

    within the tube. This ensures that the arms will be released in the correct position, preventing them from becoming embedded in the walls of the uterus.

    .

11. Holding the rod in place, withdraw the tube 1cm to

    release
    release

    the arms of the Paragard.

12. Then, gently slide the tube forward until you feel

    resistance
    resistance

    This pushes the Paragard all the way to the fundus.

    .

13. Hold the tube steady and fully

    withdraw
    withdraw

    Note: If you withdraw both at the same time, you risk tugging the Paragard out by the strings.

    the rod from the tube.

14. Cut the threads perpendicularly 3 cm from the cervical os

    without applying tension
    without applying tension

    Applying tension risks moving the Paragard out of position.

    .

15. Withdraw the speculum.

16. Dispose of medical waste safely.

17. Document the procedure, including the IUD serial number.

## Troubleshooting

The cervical os is too tightly closed to pass the Paragard.

You may need a set of graduated cervical dilators to dilate the cervix before insertion.

I want to manage IUD insertion and post-insertion pain.

There is no evidence that using a cervical block, misoprostol, or NSAIDs reduces insertion pain, but a cervical block may reduce tenaculum application pain, and NSAIDs may reduce cramping post-insertion. Procedural sedation may be necessary in patients experiencing severe insertion pain.

## Risks

1. Vasovagal response

2. Tenaculum site & cervical bleeding

3. Pelvic inflammatory disease

4. Group A streptococcal infection

5. Uterine perforation

6. Complications of Paragard use

## References

1. Paragard Prescribing Information. Cooper Surgical. 2019.

2. American College of Obstetricians and Gynecologists. LARC Video Series.