Hello, I’m Patty Cason and I’m a Family Nurse Practitioner.

This instructional video for healthcare professionals will walk you through the steps required for the placement of Paragard intrauterine copper contraceptive. These steps include preparation, loading and placement.

Let’s get started. After establishing the patient has no known contraindications to placement of Paragard, perform a bimanual exam to assess the orientation, size, and position of the uterus and to ensure no palpable uterine abnormalities or signs of infection.

Next, place the shortest speculum that is appropriate and cleanse the vagina and cervix with an antiseptic solution.

Use of an analgesic before placement is at the discretion of the patient and the clinician.

Apply a tenaculum to the cervix and use gentle traction to align the cervical canal and uterine cavity.

Then, while applying steady traction with the tenaculum, gently pass a sterile uterine sound through the internal os. If you encounter difficulty passing through the internal os do not use force and consider use of a small dilator or os finders.

Once you have successfully passed the uterine sound through the internal os, pause for a moment, and then gently advance the sound until it touches the uterine fundus. Once the tip of the sound is at the fundus, note the measurement of the distance between the external os and the fundus. This measurement should be between 6 and 9 centimeters, unless you are placing Paragard immediately postabortion or postpartum.

At this point you can gently rest the tenaculum on the speculum as you prepare Paragard for placement. Loading Paragard can be done with the use of sterile gloves or within the sterile packaging. Please note that Paragard must not be loaded earlier than 5 minutes before it’s to be placed in the uterus. Note the lot number on the packaging so that you can record it in the patient’s medical record.

To load Paragard outside of the package, open the package containing Paragard, taking care that the white stabilizing rod or other contents do not fall out. Hold the package at the end furthest from the device and open the package where you see the “open” arrow.

Next, don sterile gloves and pick up the insertion tube containing Paragard with your non-dominant hand. With the index finger and thumb of your dominant hand fold the arms of Paragard down and slip the ends of the arms into the insertion tube. Note that the tips of the arms will be tucked down into the tube with the copper collars remaining outside of the tube. The tube will hold Paragard in its folded position for placement.

The next step in loading is to pick up the white stabilizing rod and insert it into the tube. Advance the rod in the tube until the tip of the rod is touching the bottom of Paragard. This stabilizing rod must be in contact with Paragard because later, during placement, the rod will hold the device in place as the arms are released.

The final step in loading is to set the blue flange to match the patient’s uterine depth measurement. You can do this by using the centimeter markings seen on the sterile white card found in the packaging. Also, ensure that the flange is in the same horizontal plane as the arms of the device.

To load Paragard within the sterile packaging without sterile gloves:

Lay the package on a flat surface. Hold the package at the end furthest from the device and open the package where you see the “open” arrow. Open the package halfway. Take care not to allow the white stabilizing rod or other contents to fall out.

Tap the white card down until it touches the bottom of the package at the end of the package that contains the device. Note the picture of Paragard on the white card. Position Paragard so that it’s laying over the picture.

Grasp the insertion tube with your dominant hand. Hold the tube like you would hold a pencil or a dart. With your other hand, hold the arms of the device in place by positioning the tip of your thumb on one copper collar and the tip of the index finger on the other copper collar. While holding the arms steady with your thumb and index finger, push the insertion tube towards your other hand. As you push against the device with the insertion tube the arms will fold down alongside the tube. Once the arms are folded down, pull back the tube and squeeze the arms together until they are touching. With the dominant hand scoop with the insertion tube so that you can slip the tube over the tips of the arms.

Note that the tips of the arms will be tucked down into the tube with the copper collars remaining outside of the tube. The tube will hold Paragard in its folded position for placement.

The next step in loading is to pick up the white stabilizing rod and insert it into the tube. Advance the rod within the tube until the tip of the rod is touching the bottom of Paragard. This stabilizing rod must be in contact with Paragard because later, during placement, the rod will hold the device in place as the arms are released.

Take care not to contaminate the tip of the white rod that will be in contact with the bottom of the device.

The final step in loading is to set the flange to the same distance that you measured during sounding. You can do this using the centimeter markings seen on the white card that is beneath the device. Ensure that the flange is in the same horizontal plane as the arms of Paragard.

Once it's properly loaded, you're ready to place Paragard. Remember not to keep it loaded more than 5 minutes prior to placement. Apply steady traction with the tenaculum. Hold the insertion tube like a pencil or a dart between the thumb and first two fingers of your dominant hand.

Gently pass the loaded insertion tube through the internal os. Once through the os, pause for a moment and check that the flange is in the horizontal position.

Gently advance the insertion tube until it touches the fundus.

Once at the fundus, you may let the tenaculum rest on the speculum or on the back of your hand as you use the thumb and index finger of your non-dominant hand to hold the solid white rod completely motionless. While holding the rod steady, pull the insertion tube towards you until you can see the bottom edge of the insertion tube touching the ring of the rod. Pulling the tube back without moving the rod allows the arms of the device to be released from the tube. You may feel a slight pop as the arms are released from the tube. Don’t use the solid white rod to push or “plunge” the device. Note: You are not yet done with the placement!

To ensure fundal placement, gently re-advance just the tube until you feel slight resistance at the fundus or until the flange is again flush with the cervix. You may feel a sensation as the edge of the tube passes over the copper wires. This tells you that you have correctly re-advanced the tube to the fundus. This step secures Paragard at the fundus. It’s very important at this point not to remove the insertion tube and the stabilizing rod at the same time as this can cause malpositioning of Paragard.

While holding the tube in place, remove the white rod.

Then, after removing the rod, remove the tube from the uterus. Before the tube is completely out of the vagina, while the threads are still inside the tube, you may use the tube as a guide to cut the threads. Use long, curved, sharp scissors to trim the threads so there’s 3 to 4 centimeters visible outside of the cervix. As you cut, take care to hold the scissors perpendicular to the threads to cut straight across rather than at an angle. Note the length of the threads in the patient’s record.

Lastly, remove the tenaculum and speculum from the vagina.

I hope you found this training useful for your clinical practice. For more information or to order Paragard, please visit hcp.paragard.com.

To remove Paragard, first locate the exposed threads and grasp them with forceps then gently pull. The arms of Paragard will fold upwards as it is withdrawn from the uterus.

You may immediately place a new Paragard if the patient requests it and has no contraindications.

Embedment or breakage of Paragard in the myometrium can make removal difficult. Analgesia, paracervical anesthesia, and cervical dilation may assist in removing an embedded Paragard. An alligator forceps or other grasping instrument may be helpful. Hysteroscopy may also be helpful.

I hope you found this training useful for your clinical practice. For more information or to order Paragard, please visit hcp.paragard.com.