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  • Title: Comparative study of safety and efficacy of IUD insertions by physicians and nursing personnel in Brazil.
    Author: Lassner KJ, Chen CH, Kropsch LA, Oberle MW, Lopes IM, Morris L.
    Journal: Bull Pan Am Health Organ; 1995 Sep; 29(3):206-15. PubMed ID: 8520606.
    Abstract:
    To assess whether trained nursing personnel could provide IUD services as safely and effectively as physicians in Brazil, an experimental study was conducted at the main clinic of the Center for Research on Integrated Maternal and Child Care in Rio de Janeiro. From November 1984 through April 1986, a total of 1,711 women who requested IUD insertion at the clinic were randomly assigned to have a Copper-T 200 IUD inserted by one of the clinic's 11 physicians or 13 nurses. All of the physicians and nursing staff members who provided these services had taken the Center's standard clinical family planning training course. Of 860 insertions attempted by the physicians and nurses, 1.3% and 3.3%, respectively, were unsuccessful. Statistically, this difference was very significant (P < 0.01). Also, mainly because the cervix was small and undilated, nulliparous women had a relatively high insertion failure rate of 8.0%, as compared to 1.5% for primiparas and 1.0% for multiparas. The overall rate of complications at insertion was 1.8%, these complications including diaphoresis, vomiting, syncope, cervical laceration, and one case of perforation of the uterus; no significant difference was found between the complication rates for insertions performed by physicians as compared to nurses. However, 9.0% of the study subjects reported severe pain during IUD insertion, with significantly higher percentages reporting pain if the IUD was inserted by a physician, or if the subject was nulliparous, had preinsertion symptoms, or had a history of pelvic inflammatory disease (PID) or sexually transmitted disease (STD). It was also found that the nurses had a dramatically high insertion failure rate (11.6%) with nulliparous subjects, while the physicians' failure rate with such subjects was a significantly lower 3.4%. No significant difference was found in the groups served by nurses and physicians with regard to postinsertion complaints or termination of use within 12 months of insertion. These findings suggest that future training, besides preparing nursing personnel in IUD insertion, should emphasize preparation in taking the client's medical history and diagnosing existing medical symptoms that could be associated with IUD insertion complications. In addition, if a nulliparous woman requests an insertion, it should be performed by a physician or more experienced nursing staff member with close medical supervision. Because of high rates of reported pain at insertion, such women, as well as those with medical symptoms associated IUD insertion complications and those with a history of PID or STD, should be considered candidates for extra care and counseling.(ABSTRACT TRUNCATED AT 400 WORDS) In the mid-1980s in Brazil, health workers randomly assigned 1711 women aged 15-48 requesting IUD insertion at the Center for Research on Integrated Maternal and Child Care clinic in Rio de Janeiro to have the Copper-T 200 IUD inserted by a physician or by a nurse. The study aimed to determine whether trained nurses could perform as safe and effective IUD insertions as physicians. Insertion failure was more common when performed by nurses than physicians (3.3% vs. 1.3%; p = 0.005). Severe pain at insertion was more common during physician insertions than nurse insertions (10.8% vs. 7.1%; p = 0.008) and in women who had menstrual bleeding, bleeding, dysmenorrhea, or pelvic pain than in women lacking these preinsertion symptoms (14.2% vs. 7.8%; p 0.001). History of pelvic inflammatory disease (PID) or a sexually transmitted disease (STD) increased the likelihood of severe pain at insertion (14.5% vs. 8.5%; p = 0.022). Nulliparous women were more likely to experience insertion failure than parous women regardless of provider, especially for nurse insertions (11.6% vs. 1.6%; p 0.01). The higher failure rate among nurses was probably due to a higher proportion of nulliparous women in the nurse insertion group (17.2% vs. 13.6%; p 0.05). The overall IUD use-effectiveness rate at 12 months was 98.8% (98.6% for physicians and 99% for nurses). The cumulative IUD continuation rate at 12 months was slightly better for nurse insertions than for physician insertions (75.2% vs. 74.4%). There were no significant differences between termination rates regardless of reason (pregnancy, expulsion, or removal) between physicians and nurses. The increases in complaint rates between preinsertion and postinsertion were the same for both physicians and nurses (25.8% and 25.1%, respectively). These results indicate the need to emphasize taking the client's medical history and diagnosing existing medical symptoms that are possibly linked to IUD insertion complications. Physicians or more experienced nurses should insert an IUD in nulliparous women. More counseling and care are needed for women with IUD insertion complications and those with a history of PID or STD.
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