Mirena Insertion Guidelines

Pre-Insertion Preparation

The American College of Obstetricians and Gynecologists recommends administering pre-procedure NSAIDs such as naproxen 500-550 mg or ibuprofen 800 mg 1-2 hours before the procedure to reduce pain and cramping 3, 4
Patients should be advised to eat a light meal and be well-hydrated to prevent vasovagal reactions 4
Consider offering anxiolytics for patients with significant anxiety, noting that patients will need someone to drive them home if benzodiazepines are used 3
Discuss the procedure steps with the patient, explaining that there are three points when discomfort may be experienced: cervical stabilization, uterine sounding, and IUD placement 4, 5
Use person-centered counseling and trauma-informed care approaches to reduce anxiety 5

Position the patient in lithotomy position with the exam table elevated so the patient can see the clinician 5
Perform a bimanual examination to determine uterine size and position 3
Insert an appropriately sized speculum (consider Pederson for nulliparous patients) 3
Cleanse the cervix with betadine or another antiseptic solution 1, 2
Consider applying topical anesthetic to the cervix (options include 5 mL EMLA cream or 10% lidocaine spray) 3
For patients with higher risk of pain, consider a paracervical or intracervical block 3
Grasp the anterior lip of the cervix with a ring forceps or single-tooth tenaculum 1, 2
Apply gentle traction to straighten the cervico-uterine angle 1
Gently insert the uterine sound to determine the depth and direction of the uterine cavity 1
If dilation is needed, use the smallest possible dilator 3
Communicate with the patient during this step as it may cause cramping 4
Remove the Mirena IUD from its sterile packaging 1
Load the Mirena into the insertion tube according to manufacturer instructions 1
Set the flange to the measured uterine depth 4
Insert the loaded device through the cervix until the flange is at the external os 6
Release the IUD arms by pulling back on the slider 1
Advance the inserter to ensure fundal placement 6
Release the IUD by pushing the slider forward 1
Remove the inserter while holding the threads 3

Keep the patient lying flat for 5 minutes with legs out of stirrups 3
Gradually raise the head of the table in increments to prevent vasovagal reactions 3
Provide a heat pad for cramping if needed 3
Advise continued NSAID use for 24 hours post-procedure (naproxen 440-550 mg every 12 hours or ibuprofen 600-800 mg every 6-8 hours) 3
Instruct the patient on expected side effects, including cramping and irregular bleeding 4

For nulliparous patients, anticipate potentially higher pain scores (6.6-8.1/10 compared to 3.7/10 for multiparous patients) and consider additional pain management 3
For immediate postpartum insertion after vaginal delivery, cut strings to 10-12 cm 1, 2, 6
For insertion after cesarean delivery, place the IUD in the uterine fundus manually or with ring forceps after initiating hysterotomy closure 1
Place the strings into the cervix before completing closure 1, 2

Failure to achieve fundal placement: Ensure proper uterine sounding and use of appropriate insertion technique; high fundal placement decreases expulsion rates 1, 2
Vasovagal reactions: Have the patient eat before the procedure, use gentle technique, and keep the patient supine after insertion 3, 4
Perforation: Use gentle technique and be aware of uterine position; the risk is not increased with proper technique 1, 2
Expulsion: Ensure fundal placement and consider ultrasound confirmation when available 1, 6