PROCEDURE FOR THE REMOVAL OF: SE XUAL HE ALTH S E R VICE

Transcription

1 PROCEDURE FOR THE REMOVAL OF: 1. COPPER B E AR ING INT R AUT E R INE CONTRACEPTIVE DEVICE (CU-IUD) 2. LEVONORGESTREL RELEASING INTRAUTERINE CONTRACEPTIVE SYST E M (LNG-IUS ) SE XUAL HE ALTH S E R VICE Issue History Issue Version One Purpose of Issue/Description of Change To ensure the safe, effective and efficient removal of Intrauterine Contraceptive Devices (IUD) and Intrauterine Contraceptive Systems (IUS) Planned Review Date 2013 Named Responsible Officer:- Approved by Date Sexual Health Lead Clinical Policy and Procedure Group January 2011 Section: - Sexual Health Services MM 19 Impact Assessment Screening Complete Date: December 2010 Full Impact Assessment Required Y/N UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM PROVIDER SERVICES WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

2 CLINICAL PROCEDURE FOR THE REMOVAL OF COPPER BEARING INTRAUTERINE CONTRACEPTIVE DEVICE (Cu-IUD) AND LEVONORGESTREL RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LNG-IUS) INTRODUCTION The Contraception and Sexual Health Service trains the nursing staff to fit, conduct follow up checks and remove Intrauterine Contraceptive Devices (IUD) and Intrauterine Contraceptive Systems (IUS). PROCEDURE AIM The Sexual Health Service will increase productivity and service provision by supporting nurses to have additional training to ensure the safe, effective and efficient removal of Intrauterine Contraceptive Devices (IUD) and Intrauterine Contraceptive Systems (IUS). PROCEDURE OUTCOME All registered sexual health nurses who are assessed as competent in the removal of IUD/IUS and as outlined in their job description will follow this procedure. TRAINING Formal in-house training is required for the removal of IUD/IUS. Practical training must be undertaken and assessed by a Faculty of Family Planning and Reproductive Health Care (FFPRHC) accredited trainer holding a current Letter of Competence for Intrauterine Techniques (LoC IUT) or an experienced nurse who is trained and accredited by the Royal College of Nursing (RCN) Training will consist of a demonstration of the removal of at least one IUD/IUS by the accredited trainer from a woman who has given valid consent. This will be followed by the accredited trainer observing at least two IUD/IUS being removed by the trainee from women who have given valid consent. If the trainee requires further support, this can be negotiated with their mentor. COMPETENCY STATEMENT A qualified Sexual Health Nurse who has the knowledge and skills to counsel clients appropriately, and has witnessed at least one removal of IUD/IUS successfully carried out at least two removals of IUD/IUS under supervision has been assessed as competent 1/9

3 EQUIPMENT REQUIRED A warm room where privacy can be respected A firm couch at a convenient height Disposable paper couch roll / plastic protective sheeting Appropriate clinical waste bag / bin An adjustable light Small single-use sachet of lubricating jelly Single use speculums various sizes (Small, Medium, Large) Single use spencer Wells Forceps Single use disposable non-sterile gloves Single use disposable apron Galipot Cotton wool Small sachet of sterile water Sanitary towels Emergency equipment: Refer to Faculty of family planning and reproductive healthcare July 2006, to follow service standards for resuscitation in sexual health Oxygen cylinder Detergent wipes CHAPERONE - A chaperone (if required throughout procedure and to assist in the rare event of an emergency / crisis situation) and support the client. ASSESSMENT OF SUITABILITY FOR PROCEDURE ACTION Introduce self as a staff member, and at all times wear identity badge which includes name status and designation. Verify client identity, address and DOB are correct Offer the client a chaperone. If chaperone is declined, ensure that this is documented Document name of chaperone, and any other person present. Ensure verbal consent for the presence of any third party was obtained prior to commencement of the consultation. RATIONALE To offer a welcoming environment and put client at their ease. To ensure procedure is undertaken on correct client To ensure client consents to the presence of third parties and understands why a chaperone is offered. To comply with legal and professional record keeping requirements and comply with NHS Wirral Health Records Policy. 2/9

4 Discuss and document the client s reason for requesting removal. To ensure the client is given appropriate advice and support and any potential complications can be identified. If the device is past the expiry date, a pregnancy test may be indicated. Prior to removal of the IUD / IUS carefully check the client s history to ascertain the date of her last menstrual period (LMP) and the date of her last sexual intercourse (SI). Removal is usually undertaken during a menstrual period. It may also be removed if the client has used another alternative, effective method of contraception or has abstained from sexual intercourse for the preceding 7 days. If an IUS is replacing an IUD, the client must ensure they abstain from sexual intercourse or use condoms for the following 7 days in addition to the preceding 7 days. If the client is post menopausal, the IUD / IUS should only be removed if their LMP occurred 2 years before the age of 50 years OR 1 year after the age of 50 years. To ensure that the client is not left at risk of an unintended pregnancy and it is appropriate to remove the device. To ensure the client is not left at risk of an unintended pregnancy See Appendix 1 If the client is requesting removal in order to conceive then the IUD / IUS can be removed at any time during the menstrual cycle. Client s history may indicate that it would not be appropriate or in the client s best interest to remove device at that consultation Client may need to return for removal at more appropriate time. Discuss and document sexual history as appropriate Ensure the client is aware of Sexually Transmitted Infection (STI) screening, if she is under 25 years. Discussion of Chlamydia Trachomatis (CT) screening must be evidenced, if CT test declined, this must be documented. 3/9

5 If the client has had SI, relying only on the IUD / IUS within the last 7 days, removal should be deferred until it is safe to do so unless client is prepared to accept the risk of a potential pregnancy. This must be documented appropriately and the client offered Progestogen only emergency contraception (Levonelle). It is good practice to record and document the client s pulse and blood pressure prior to removal of the IUD/IUS. Discuss on-going contraception requirements (if attempting to conceive ensure client has postpartum contraceptive advice, as appropriate) If the client would like to become pregnant, discuss pre-conceptual care, healthy lifestyle, and signpost to appropriate relevant agencies as required. Ensure all information is documented, including valid consent to procedure. To ensure that the client is not left at risk of an unintended pregnancy See Appendix 1 To provide a baseline observation prior to procedure To ensure that the client has appropriate contraception and/or knowledge of which methods are available and where these can be obtained (CaSH clinics, own GP) To help promote a healthy pregnancy To comply with legal and professional record keeping requirements and comply with NHS Wirral Health Records Policy. PROCEDURE ACTION Ensure patient is positioned comfortably on the prepared couch. RATIONALE To maintain client comfort, privacy and dignity throughout procedure Ensure privacy curtain is drawn around the area. Ensure all equipment which may be needed is available and to hand on a clean prepared field e.g. dressing trolley. To ensure a clean area, minimise the risk of infection, and ensure all equipment is available to prevent delaying the procedure. Adhere to NHS Wirral s Infection Prevention & Control Policies Decontaminate hands prior to procedure Apply single use disposable apron To reduce the risk of transfer of transient microorganisms on the healthcare workers hands To protect clothing or uniform from contamination and potential transfer of micro-organisms 4/9

6 Apply single use disposable non-sterile gloves Using a non-touch clean technique, insert speculum, open and manoeuvre until the whole of the cervix can be visualised clearly To enable a clearer view of the area, the cervix can be cleaned with sterile water and sterile cotton wool balls as required (dispose of used cotton wool balls in the appropriate clinical waste bag) If threads are not easily visible, spencer wells forceps may be used at the os OR a thread retriever to gently attempt to locate threads. If unsuccessful please refer to an IUD / IUS inserter on site (Dr. or Nurse), or refer client to the next available specialist clinic. Advice should be given to the client to use an additional barrier method of contraception until it is certain the device remains in situ, if client does not want to become pregnant. Discuss need for emergency contraception When threads are visualised, clamp the threads with Spencer wells forceps and pull using gentle downward traction (it may be helpful to ask the client to do a cough at this point, or use a similar method of distraction) The device must be shown to the client after removal (document that this has occurred in the client s record) and then dispose of in appropriate clinical waste bag Remove speculum and dispose of all equipment safely in clinical waste On completion of procedure remove and dispose of personal protective equipment (PPE) to comply with waste management policy Decontaminate hands following removal of PPE To protect hands from contamination with organic matter and transfer of micro-organisms To visualise cervix and minimise the risk of trauma To clean any mucous / blood from the cervix to allow clear visualisation and avoid area contamination. To minimise the risk of complications, trauma and prevent an unintended pregnancy To remove IUD/IUS without trauma to the client and unnecessary anxiety To ensure client is aware that the IUD/IUS has been removed and minimise risk of cross infection To prevent cross-infection and environmental contamination To prevent cross-infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE 5/9

7 Ensure client is feeling well following the procedure before asking her to get dressed and be seated. Remove blue roll and clean treatment couch with detergent wipes Decontaminate hands Document procedure fully, including the instruments used, and any concerns or issues encountered and actions taken. The completed record must include: date of consultation, time in 24hr format; printed name of remover, signature and designation, chaperone and any third parties; advice given and any follow up information provided to the client. Follow-up to be arranged with client, depending on continuing method of contraception / care. Written information provided as appropriate. Assist client for whom English is not the first language to receive information in an appropriate and understandable form. Ensure that the client knows how to contact the service should she need any further advice. To ensure client has not experienced a (vasovagal reaction) or other possible complications To prevent cross infection and environmental contamination To remove cleaning products from hands and prevent transfer of micro-organisms To comply with legal and professional requirements and comply with NHS Wirral s record keeping policy To ensure contraception cover is maintained Ensure Equality & Diversity in Service delivery Sexual Health Service continuation of client care ABBREVIATIONS Cu-IUD LNG-IUS C.a.S.H C.T. G.P. S.I. S.T.I. L.M.P. Copper bearing Intrauterine Device Levonorgestrel-releasing Intrauterine System Contraception and Sexual Health Chlamydia Trachomatis General Practitioner Sexual Intercourse Sexually Transmitted Infection Last Menstrual Period 6/9

8 REFERENCES Department of Health (2001) Good Practice in consent, implementation guide: Consent to examination for treatment. London: HMSO. Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. FFPRHC Guidance (November 2007) Intrauterine Contraception. London. Faculty of Sexual and Reproductive Health Care (June 2007). Service standards on obtaining consent in services. London. Faculty of Sexual and Reproductive Healthcare (January 2009) Service standards on confidentiality. London. Faculty of Family Planning and Reproductive Health Care (July 2006) Service Standards for Resuscitation in Sexual Health Services. London Guillebaud. J. (2009) Contraception Your Questions Answered (5 th Churchill Livingstone. Edition). London: Nursing and Midwifery Council the Code Standards of conduct, performance and ethics for nurses and midwives. London: NMC Nursing and Midwifery Council (2002) Guidelines for records and record keeping. London. Nursing and Midwifery Council (2008) Guidelines for the Administration of Medicines (Revised Edition) London. NHS Wirral Chaperone & Intimate Care Policy NHS Wirral Infection Prevention & Control Policies NHS Wirral Health Records Policy 7/9

9 Appendix 1 Timing the removal of intrauterine contraception (Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. FFPRHC Guidance (November 2007) Intrauterine Contraception. London: Faculty of Sexual and Reproductive Healthcare). Advice regarding the removal of intrauterine contraception varies depending on the reason for removal and if there is a wish to continue to avoid pregnancy. Most women using intrauterine contraception will continue to ovulate and this is relevant when considering the timing of removal without risking implantation of a fertilised ovum. If pregnancy is to be avoided, women should be advised to attend in the first few days after the onset of menstruation, or use condoms or abstain from sexual intercourse, for 7 days before removal of intrauterine contraception, even when reinsertion is planned. When intercourse has occurred in the preceding 7 days, the need for removal and use of emergency hormonal contraception should be discussed. Recommendations for removal of intrauterine contraception Reason for removal For a planned pregnancy When removal and replacement is at the end of the licensed duration of use When removal and replacement is outside the licensed duration of use Recommendations for removal Remove at any time in the menstrual cycle (offer pre-pregnancy advice regarding folic acid, rubella immunity) Remove at any time in the menstrual cycle. If pregnancy is to be avoided remove in the first few days after the onset of menstruation or advise condoms or abstinence from sexual intercourse for at least 7 days before the procedure in case re-insertion is not possible. Postmenopausal removal A Cu-IUD inserted at or after the age of 40 years can be retained until 1 year after the LMP, if this occurs when the women is over the age of 50 years. A Cu-IUD inserted at or after the age of 40 years, can be retained until after the LMP but if this occurs under the age of 50 years the device should be retained for a further 2 years. The LNG-IUS can continue to be used as contraception for 7 years if inserted at or after the age of 45 years. Use beyond this time can discussed with individual clients.

10 For Nurses within Contraception and Sexual Health Services to feel competent and confident in the removal of IUD / IUS as service requires. Subject matter: Competency Client accessing the service requesting removal of IUD / IUS Level 1 Level 2 Date Assessor s signature Knowledge Taking an appropriate detailed sexual/menstrual / contraceptive history form client Provide advice regarding pre conceptual care as appropriate Provide information regarding alternative contraceptive choices Awareness of recommendations for post menopausal removal Awareness of vaso-vagal attack management (rare after removal of IUCD / IUS) Awareness of NHS Wirral Sexual Health Service Procedure for the removal of IUCD / IUS Skills To explain procedure thoroughly to client to obtain informed consent Confident at inserting speculum and using Spencer Wells forceps Confident in identifying the cervix and device threads, and action to take if unable to view. Awareness of own limitations / referral process to experienced colleague / Doctor if necessary Confident in identifying and documenting type of device removed Attitude Awareness of patient privacy and dignity and availability of chaperone if requested Active listening throughout consultation Allow client time to ask questions, clarify information given. Reassure client before and after procedure. Depending on the role of the health care professional within the service they may wish to work at level 1 or level 2 competency in any objective. Level 1: carry out the whole activity under direct supervision of a senior colleague (i.e. senior colleague is present throughout) and/or Level 2: independent competence, no need for supervision. This is the expected competency for a practitioner responsible for delivery of a more specialised sexual health service. 9/9