If there’s one pelvic care procedure people seem to universally dread, it’s an IUD insertion. The most common words I hear when describing an IUD insertion are excruciating and traumatic. It does not need to be this way! With careful and respectful handling of the body, and knowledge of the natural mechanisms of the cervix, an IUD insertion can be as gentle as possible.
The IUD itself will likely feel foreign and tender in its early moments in the uterus as the uterus adjusts, but we have SO. MUCH. POWER to make the insertion gentle!
Respectful Pelvic Handling
When working with someone’s body, a gentle IUD insertion starts with a gentle and respectful pelvic exam. When handling someone’s pelvis, cervix, uterus, vagina, and vulva, have reverence for the power and vulnerability of these parts of someone’s body. Treat their self and body with respect. This starts with lots of discussion before the pelvic exam, including inquiring about past experiences with pelvic exams, if there’s anything you should know about their body to be most sensitive and respectful, an acknowledgement of the frequency of obstetric and sexual abuse in society, and a deference of power in the room to the person having the exam. Attention to emotional and physical comfort is paramount, as a nervous body will only clench and resist any attempts at entry. The clenching and resisting is a normal healthy response when a body is not being treated carefully.
Inserting an IUD requires a centralized view of someone’s cervix. Visualizing someone’s cervix involves placing a speculum in the vagina. How we handle a speculum will set the tone for the rest of the insertion, and show someone’s body whether we can be trusted to be responsive and gentle, or not. Speculums should be inserted at an angle and gently rotated up or down. Abundant lubrication should be used along with a warm speculum and gentle pressure. Talk the person through what you are doing at each step (ask if they want this narration). When the speculum is inserted, gently open its bills to visualize the cervix. If the cervix is not in central view, slow and careful adjustments can be made to the angle of the pelvis and/or to the angle of the speculum. Demonstrating care with the speculum will help build trust with the cervix as we prepare for IUD insertion.
Tools Used
When inserting an IUD, we typically use a standard set of tools, some of which can be used harmfully. It’s important to take great care and consideration with your tools.
Different options for tenaculums (click image to enlarge to view differences)
Speculum: make sure you choose the right size of speculum, and work with its insertion gently (as described above). Both plastic and metal speculums work equally well for IUD insertion.
Dilators: most people won’t need the help of dilators to open up the cervical canal to permit the IUD + cannula through. In some cases when a cervix may need this (very small or tight os), plastic or metal dilators will work equally well. Try inserting an IUD right at the time of ovulation, or while someone is menstruating to ensure a cervical os is open as much as possible without the need for dilators. You could also consider natural cervical softeners in advance of IUD insertion to assist with a soft/open cervix.
Tenaculum: whenever possible, I try to avoid tenaculum use. In many instances, especially with a cervix that has birthed a baby before, tenaculum use may be unnecessary altogether. When needed, you can brace the cervix with the ends of the bills of the speculum. With gentle pressure with the IUD cannula/catheter, that respects the cervix, insertion without a tenaculum can be commonplace. When a tenaculum is needed, consider using an “atruamatic” tenaculum (pictured here), with textured grip (rather than the standard pointed clamp). If you must grip with a tenaculum, consider holding it closed with gentle tension rather than locking the instrument (works best when you have a helper to hand you the other needed things!)
Uterine Sound: these are typically used to “measure” the uterus and place the IUD correctly in the body. Sometimes these are a part of the insertion tool itself, or are their own instrument. Often plastic is more appreciated than metal, as the metal is cold through the cervix. You can also use a cannula or other rounded/gentle tool carefully inserted into the uterus through the cervix. Due to body heat, on withdrawal you’ll be able to clearly see how much was inside the uterus, and measure appropriately. *When passing anything through the cervix, see the section below on being gentle with a cervix, and patience in waiting for the body to spontaneously let you in.
IUD insertion tool: the mechanism for inserting the IUD itself may vary slightly depending on the IUD manufacturing. Typically, the IUD is collapsed inside a catheter/cannula with some rigidity to it. *When passing anything through the cervix, see the section below on being gentle with a cervix, and patience in waiting for the body to spontaneously let you in.
Numbing: injecting lidocaine into a cervix can numb too much, causing swelling and spasm. It does not make the cervix more receptive, nor does it relax the person having the IUD inserted. It just allows a practitioner to feel they can clamp a painful tenaculum wherever they like, and force an IUD through when a cervix isn’t quite ready. When working with cervical softeners, or inserting when someone is at peak ovulation or peak menstruation, or using gentle cervical technique (described below), or working with a cervix that has birthed many babies, numbing should not be universally necessary!
Respect the Cervix!
Cervices aren’t made to have things enter them from the outside (except for some fluids like sperm). Rather, things pass from inside out. Therefore it’s NATURAL for them to resist pressure from a foreign instrument trying to insert something through them from the outside. This is a healthy protective response in the body! Respect this response, and learn to work with it.
In a clinical setting, the answer to this is often the grab hold with a tenaculum and force the IUD insertion through, often with some numbing to the cervix. This is often super painful and can trigger a strong vaso-vagal response as the body tries to protect itself. Don’t do this!
Rather, we have to respect the natural mechanisms of the cervix and its normal physiology. If you’re inserting an instrument through the cervix and meet resistance at the outer or inner OS, respect that. Honour that. Give gentle pressure against the cervix and gently twist your device back and forth while soothing and talking to the person you’re working with. When the person is able to relax the cervix will often eventually “give” and the instrument will slide through. Wait for this spontaneous release. If it doesn’t come, don’t force it. The cervix is communicating a clear NO to you.
When working with cervical softeners, and a respectful approach to a cervix and its normal physiology (especially if you have also eliminated the tenaculum), a cervix should not need numbing to get through the procedure.
Seek Feedback
When you feel comfortable offering this skill to others, it can be critical to ask for feedback so you can improve your practice and be more and more intuitive and responsive to people’s needs while working with some of the most intimate parts of their body.
After an insertion is finished, make sure you give time and space for the person to clean up and get dressed privately before trying to talk or debrief the exam. When you return to the space with them, start by asking
How are you feeling? How’s your body?
In a professional setting (in a clinic with a gyne table for example) clients may not want to offer their time and space to debrief the experience. If you’re in what they perceive as a safe or comfortable setting and they do not feel rushed (in their own home, for example), they may be more keen to open up about the experience. Offer if they would like to debrief the experience:
Would you like to debrief that exam (or procedure) at all? Are there any pieces of feedback you’d like to share with me? I’m always working to be better and gentler with people’s bodies, and if there’s any questions or reflections you have for me, I can keep improving.
If they’re open to talking but don’t really know what to say, you could consider asking some open-ended questions:
How did the exam feel overall? How was the insertion itself?
Were you able to connect with what I was doing and understand what to expect?
Did you ever feel scared or tense?
How was your level of comfort?
Did I accidentally scrape or pull anywhere that I could be more careful with next time?
I find people usually know their own bodies the best. Next time, would you have any interest in inserting your own speculum? What if I showed you how?
Was there anything that went well?
What was most awkward?
How did that exam compare to others you’ve had in your life?
Ensure that it doesn’t come across as if you’re fishing for compliments, rather genuinely looking to improve your practice for them and for others in the future.
Genuinely thank them for any feedback, even and especially if the feedback makes you feel embarrassed that you did something '“wrong”, or frustrated with yourself that you weren’t as gentle as you’d have liked. They are trusting you with their truth and feelings about their body and the ways you interacted with it: that’s a major gift! Don’t get defensive, just thank them for the feedback and reflect later. Asking for more information on some pieces of reflection may be appropriate.
Some people will not want to share feedback: respect this choice as well! Others may be open to sharing feedback, but not immediately, or not verbally directly to you. You could offer a few other ways of providing feedback to increase interaction:
ask about their comfort and reflections the next time you see them (at another appointment, for example, but not in a public or social setting)
offer an anonymous way to provide feedback to your professional practice (feedback box made available in the office, phone number or email of a colleague or administrator they can provide feedback to, anonymous feedback forms on your website, etc.)
Remind them they can always contact you in the future with feedback if it comes to them later, and provide direct and indirect methods of communication (phone call, email, etc.)
