In 2014/15, slightly more than a third of women using sexual and reproductive

health services for contraception (excluding those who were only seeking

advice) were using some type of long-acting reversible contraceptive or LARC

(Health and Social Care Information Centre, 2015). In general practice, despite

an initiative to encourage prescription of LARCs, the proportion of women

using these methods may well be lower (Arrowsmith et al., 2014). Many of the

women using LARCs will have been fitted with an intrauterine contraceptive

device (IUCD): either a levonorgestrel-releasing intrauterine system or a

copper intrauterine device

Fawcett, Emma

Rogers, Melanie

University of Huddersfield Repository

University of Huddersfield RepositoryRogers, Melanie and Fawcett, EmmaChecking the Threads of an IUCDOriginal CitationRogers, Melanie and Fawcett, Emma (2016) Checking the Threads of an IUCD. ClinicalSkills.net. This version is available at http://eprints.hud.ac.uk/28374/The University Repository is a digital collection of the research output of theUniversity, available on Open Access. Copyright and Moral Rights for the itemson this site are retained by the individual author and/or other copyright owners.Users may access full items free of charge; copies of full text items generallycan be reproduced, displayed or performed and given to third parties in anyformat or medium for personal research or study, educational or not-for-profitpurposes without prior permission or charge, provided:• The authors, title and full bibliographic details is credited in any copy;• A hyperlink and/or URL is included for the original metadata page; and• The content is not changed in any way.For more information, including our policy and submission procedure, pleasecontact the Repository Team at: E.mailbox@hud.ac.uk.http://eprints.hud.ac.uk/When visible and/or palpable, the threads will project 2 to 3 cm from the cervix. CervixVaginaUterusAnatomyProtouchProtouch350AmbidextrousPowder-free non-sterileNitrile examination gloves100PCSRef:Size Large350AmbidextrousPowder-free non-sterileNitrile examination gloves Ref:Size Large100PCSPage 1 of 3ContraceptionAdultsDo not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain his/her consent, in line with the policies of your employer or educational institution.Prepare equipment on a clean trolley or other easily accessible clean surface. Take the patient’s historyChecking the threads of an intrauterine contraceptive device Demonstrated by Melanie Rogers, Senior Lecturer/Advanced Nurse Practitioner (Primary Care), University of Huddersfield  and Emma Fawcett, Cervical Screening Mentor/Coordinator, NHS Kirklees, Calderdale and Wakefield            ©2016 Clinical Skills Limited. All rights reservedIn 2014/15, slightly more than a third of women using sexual and reproductive health services for contraception (excluding those who were only seeking advice) were using some type of long-acting reversible contraceptive or LARC (Health and Social Care Information Centre, 2015). In general practice, despite an initiative to encourage prescription of LARCs, the proportion of women using these methods may well be lower (Arrowsmith et al., 2014). Many of the women using LARCs will have been fitted with an intrauterine contraceptive device (IUCD): either a levonorgestrel-releasing intrauterine system or a copper intrauterine device. The healthcare professional who fits the device will have explained to the woman, at the time of fitting, how to check that she can feel the threads by inserting a finger into the vagina to touch the os. The patient should check for the threads after every period or at regular intervals if she has no periods or periods are irregular. She should seek medical attention if:•  She cannot feel the threads;•  She can feel the IUCD at the cervix;•  She has symptoms such as pain, abnormal bleeding or unusual vaginal    discharge, especially if this is green or yellow.  If the woman cannot feel the threads at the os, this may be because they soften over time and can become curled around the os. However, the device may have been expelled or may have perforated the uterus (FSRH, 2015). Expulsion occurs in around 1 in 20 women fitted with an IUCD, and is most likely to occur within the first 12 months after fitting, with the highest risk during the first 3 months (FSRH, 2015). Perforation of the uterus by the device is rare, at under 2 per 1000 devices inserted (FSRH, 2015). This complication is more likely to happen in women who are breastfeeding or if an inexperienced fitter inserted the IUCD. If your patient cannot feel the threads, she should abstain from sexual intercourse or use a barrier method of contraception until investigations have confirmed the location of the IUCD. If, on checking, you can see the threads, and her menstruation pattern is unchanged, it is likely that the device is in the correct position. If you can see the threads but her normal bleeding pattern has altered (if she has a period when she has been amenorrhoeic or she misses an expected period), she should likewise abstain from sexual intercourse and use an alternative method of contraception until the position of the IUCD is known. If she cannot feel the threads and you cannot see them either, carry out a pregnancy test and refer her for an ultrasound scan (FSRH, 2015); if the pregnancy test is negative, she should abstain from sexual intercourse or use alternative contraception until the position of the IUCD is known. If the pregnancy test is positive, refer the patient for medical advice.  It is common for women to be offered a follow-up appointment 3 to 6 weeks after having an IUCD fitted, but many women fail to attend for this check-up (FSRH, 2015). The pages below show the procedure for checking whether an IUCD is still in place, for a patient who can no longer feel the threads, or where she or her partner have noticed an unusual sensation during sexual intercourse. Always take a full history (see below; BASHH, 2013). If you decide that it is necessary to perform a vaginal examination, explain the reasons for this to the patient and obtain her consent. Offer the presence of a chaperone. Ensure that you give her an opportunity to ask questions, and answer these fully. If you are concerned that she may have an infection, you may need to obtain swabs for microbiological analysis: refer to the clinicalskills.net procedure on “Taking female genital swabs”.water soluble for general lubricating needslubricating jellyAppropriately sized speculumNon-sterile glovesGood light sourceLubricating jelly (if required)ContraceptionAdultsChecking the threads of an intrauterine contraceptive device Page 2Take the patient’s history Ask the patient if she would like to go to the toiletOffer the patient a chaperone Patient position; decontaminate your handsReassure the patient Preparing the speculumAsk the patient: When was her last period? When was her last cervical screening test? What were the results? Has she ever had any abnormal results? Has she had any unusual discharge? Does she experience any pain during intercourse? Does she have any abnormal bleeding between periods or after/during sexual intercourse? If the patient has a full bladder, then passing a speculum can be more uncomfortable for her. You should therefore ask her if she would like to go to the toilet. Ask the patient if she would like a chaperone. If she confirms that she is comfortable being alone in the room with you, ask her if she is happy for you to lock the door. Draw the blinds on any windows.  Provide the patient with privacy while undressing, with a curtain or screen if available. Ask her to disrobe from the waist down and lie down on the couch. Offer her a disposable paper towel to protect modesty. Wash your hands and dry them thoroughly or decontaminate with an alcohol-based hand rub. Put on an apron and gloves. Raise the bed to a suitable height. Explain to the patient that she is in charge of the procedure: if she is in discomfort, you can pause to allow her to relax down onto the speculum, or she can ask you to stop at any time. Ask her to open her legs.  Page 2 of 3Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain his/her consent, in line with the policies of your employer or educational institution.Warm the speculum if required by holding it under a warm running tap. Alternatively, open the lubricating gel, if using. Smooth the gel over the front and back of the speculum, taking care not to put gel on the tip of the speculum (see inset). Patient Notes ? XOK CancelGeneral NotesPatient reported unable to feel IUCDthreads. Threads visible on examination. Allergy NotesContraception AdultsChecking the threads of an intrauterine contraceptive device Page 3Introduce the speculum: (a) (b)Remove the speculum as soon as possibleVisualise the threadsMaintain the patient’s dignity DocumentationAdjust the light source to illuminate the vulva. Separate the labia and insert the speculum sideways into the vagina.Aiming for the small of the back, gently push the speculum into the vagina until you meet some resistance, rotating it as you go until the handles are vertical. Avoid touching the clitoris with the handles. Visualise the threads. Is there any discharge or any change to the cervix? If there are any problems then go on to take swabs and/or, if trained to do so, perform a full bimanual examination. If the threads are present and all looks normal, gently and slowly remove the speculum from the patient, taking care not to trap the vaginal wall between the blades as you close the speculum. Reassure the patient.Lower the bed and assist the patient to stand if necessary. Allow the patient to dress, ideally in private. Maintain the patient’s dignity. Allow the patient to wipe herself with the paper towel if required and show her how to dispose of it.Wash your hands and dispose of equipment in the appropriately coloured bags and/or sharps bins: follow local policy. Document the date, the care given and your findings. Page 3 of 3Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain his/her consent, in line with the policies of your employer or educational institution.

Checking the Threads of an IUCD

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