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Simulation

Intrauterine Device (IUD) Insertion

Simulation

Preparation

Simulators to be Used

There are many varieties of IUD trainers for insertion. Many of the representatives for IUDs will have task trainers that can be used
A papaya can be used to simulate a uterus for IUD insertion

Room Setup

The room should be set up as similarly as an office patient room or procedure room if you are going to run through the entire scenario of speaking/counseling the patient and then performing the task. If only the task is going to be done, then the set up would not be as significant.

On a tray table, the following items should be set up:

  • Single-toothed tenaculum
    • Betadine swabs
    • Speculum
    • Uterine Sound
    • Scissors
    • Silver nitrate sticks
  • Chair or rolling stool for learner to sit on
  • Chair for standardized patient (SP) to sit (if using a SP for counseling)

If using a papaya:

  • Papaya on a table lined with paper or chux
  • Papaya sitting in a large paper/plastic cup (optional)
  • Papaya sitting in a hemipelvis (optional)

Figures

Papaya
Papaya diagram for the first trimester uterine aspiration manual vacuum simulation.

Equipment Needed

  • Tenaculum
  • Uterine sound
  • Scissors

Personnel needed for Simulation Exercise

  • Standardized patient (SP) if so desired

Approximate Expected Duration of Exercise

  • Set up: 15 minutes
  • Full Scenario: 20 minutes
  • Task only: 10-15 minutes

Basic Scenario Tips

Answers to common questions that come up:

  • Remember that this is a simulation, nothing can be as exact as real-life, but this is a close approximation
  • Reiterate that what is important is the learner going through the steps of the procedure from start to finish, so they are more familiar with them when they actually do the procedure in the office

Common pitfalls to monitor for:

  • Getting a green papaya may make the IUD insertion more difficult. Try to make sure that the papayas are ripe
  • May need to develop relationship with industry representative to obtain task trainers
  • There may be financial constraints to purchasing simulators

Lab Sequence

  1. Assemble all of the equipment as described above
  2. Begin counseling the patient on all of the risks, benefits, and alternatives to procedure (if using a SP, if not proceed to step 4)
  3. Conduct a timeout
  4. Bimanual exam for size/position of uterus (if using a hemipelvis with papaya)
  5. Insert speculum and clean cervix with betadine (if using hemipelvis with papaya)
  6. Place tenaculum on anterior lip
    1. Close ratchets slowly to lessen pain
    2. Exert traction on cervix for dilation
  7. Sound the uterus to fundus
  8. Make a note of the sounding length
  9. For copper IUD insertion:
    1. Partially open plastic wrapper
    2. Without touching the IUD, flex the tips of the horizontal arms and tuck them into inserter tube
    3. Alternately sterile gloves may be used to load the IUD
    4. Insert solid rod into distal end of inserter tube, until rod tip abuts vertical arm of IUD
    5. Adjust flange to measurement determined by sounding
    6. Using inserter, place IUD through os, advance to uterine fundus
    7. Stabilize IUD with the solid rod
    8. Slide insertion tube back towards you until inserter meets ring of rod
    9. Remove the rod completely and then the insertion tube
    10. Using scissors, trim strings to a length of approximately 3 cm
  10. For Levonorgesterel (LNG) IUD insertion:
    1. While holding inserter, lay IUD flat on internal packaging surface
    2. Pull strings firmly while holding slider all the way forward
    3. Fix the threads in the cleft of the handle to hold IUD in place
    4. Place inserter through os
    5. Advance to 2 cm below fundus
    6. Hold inserter steady
    7. Move slider back to indicator mark on handle
    8. Allow time of arms to open in uterus
    9. Advance inserter to fundus
    10. Retract slider fully until "click" is heard
    11. Remove insertion tube
    12. Using scissors, trim string to a length of approximately 3 cm
  11. Remove tenaculum, and ensure hemostasis
  12. Remove speculum

Competency Assessment

Resident conducts a "time out." Resident performs bimanual exam, properly inserts speculum and visualizes cervix, cleans cervix, places tenaculum, and sounds uterus. Resident properly inserts both the copper IUD and LNG IUD. Resident trims strings to 3-4 cm, removes tenaculum and applies hemostatic treatment if needed, and removes the speculum.