Fitting coils: developing a safe and supportive service

Summary

In this blog, Sexual and Reproductive Health Consultant, Neda Taghinejadi tells us about the coil fitting service she is part of in Oxfordshire. Neda explains how the service has integrated a number of tools, including a triage system to identify more complex cases, to help support a safe and quality service. 

Content

Within our service, we are commissioned to fit coils, also known as IUDs (intra uterine devices) for contraception. However, there are many other reasons why someone might want to have a coil fitted. These include using the hormonal coil for heavy menstrual bleeding, for menstrual pain, and as part of HRT (hormone replacement therapy).

There are currently 18 coils fitters in our service, working together to offer appointments in a range of locations across Oxfordshire. This team includes four nurses and fourteen doctors from a variety of backgrounds including obstetrics and gynaecology, community sexual and reproductive health, genitourinary medicine and primary care. The service fits approximately 2000 coils in Oxfordshire each year.

Sharing information and supporting decision-making

Our ethos centres on providing a safe and high-quality service in which we listen to and respond to our patients. As a team, we are committed to sharing learning and being open and reflective about ways we can improve our service.

All patients requesting a coil are offered an initial assessment, usually by telephone, with a clinician in our service. One of the main aims of this consultation is to share information about the coil with the patient, to support them in making decisions and to ensure they are adequately prepared for the coil insertion appointment.

This involves making sure that we can safely fit a coil, for example, offering a sexually transmitted infection (STI) screen to minimise the risk of infection, and offering them contraception whilst they are waiting for their fitting appointment. We also have a discussion about coil-related side effects and what to expect during the fitting appointment. This is an opportunity to discuss pain and options for pain relief during the fitting.

Identifying and responding to more “complex” needs

Another important aim of this initial consultation is for the clinician to identify certain things in the patient's history, or related to the patient's concerns, that may make the fitting more "complex" than "routine".

For example, if the patient has a history of surgical procedures on their cervix or uterus, this can make insertion of a coil more challenging, and so the patient would be triaged into a complex appointment. Another example is where a patient has experienced a difficult or painful coil fitting in the past, which would again mean the patient would be triaged into a complex appointment.

You might be wondering what the difference is between a routine and a complex appointment. Complex appointments are generally run by clinicians who may have specific additional skills such as ability to scanning with ultrasound or administer a cervical anaesthetic injection. It's important to say that all our clinicians in both settings are highly skilled, and that if someone in a routine appointment unexpectedly requires additional services, like an ultrasound scan for example, their clinician can ask one of their colleagues to offer this. 

Coil insertions can be unpredictable, and we don't always know when a fitting will be routine or complex. Our triaging system is just a way of trying to be prepared when we anticipate that a fitting might be more complex and ensuring the best experience possible for our patients.

Flexibility is key

Another benefit of this triage system is that it is very flexible. We offer clinicians a list of suggestions to help them identify when someone might require a complex appointment.

This list includes:

• a history of a cervical or surgical procedure, for example LLETZ (Loop excision of the transformation zone) or surgery for urinary incontinence
• a history of three or more Caesarean sections
• a previous painful or unsuccessful fit
• a history of vulvodynia.

However, it is really important to note that this list is not exhaustive. Clinicians have the autonomy to triage patients into a complex appointment based on the discussion they have had with their patient, for any reason, if they or the patient feel they would benefit from it.

Talking about pain relief options

Pain experiences during coil insertions vary hugely from person to person. Some people feel no pain, some people feel severe pain, and there is a whole spectrum of experiences in between. We feel that is important to discuss with patients that there is a range of experiences, and we always offer pain relief.

Pain relief options include:

• taking pain killers like ibuprofen before the appointment
• anaesthetic lidocaine gel that is inserted into the uterus and in the vagina
• cervical anaesthetic injection.

Decisions about anaesthetic are individual, as there is no one, single best option.[1] For example, some people find the anaesthetic injection really helpful, whilst others find it painful and would rather not have an injection. An important part of our role is to share information about the pros and cons of each anaesthetic option, to support our patients to make the choice that is right for them.

Supporting and listening to patients during the appointment

In every fitting appointment, a clinician works with an assistant. Their role is to offer support to the patient throughout the procedure, and importantly, talk to them about their pain level throughout. We discuss with patients that if any aspect of the procedure is too uncomfortable or painful for them, then we can stop, and have a discussion about whether and how to best continue.

Patient feedback

We always ask patients how they are feeling after a coil fitting. But beyond this, we do not currently have a formal method of seeking patient feedback about their experience. This is something we are discussing and planning to implement, particularly in light of evidence that coil fitters may underestimate the level of pain that patients experience.[2]

Safety and quality

Patients occasionally contact the service with feedback on their experience. Often comments are very positive but sometimes the patient makes a complaint or reports issues with their experience. There may also be clinical complications following a procedure. The service has a formal clinical governance structure which looks at the compliments, complaints or clinical incidents in order that we might learn from these and make changes that improve safety and quality.

Peer support and keeping practice up-to-date

Examples of strategies we use to enhance the skill and expertise of fitters include peer  review, whereby two fitters share a list or work together. This provides opportunities for fitters to observe one another’s’ practice and share learning. Also, fitters are scheduled to provide a regular IUD clinic which helps to maintain their expertise.

We also have "coil fitters’ " meetings which we use to discuss and share learning from specific cases, from recent publications, or from changes in guidance. As an example, I have been leading a research project analysing what people tweet about their experiences of coil fittings. I shared the results with the rest of the team. Feedback from colleagues is that they have changed how they counsel people about pain as a result of reading these patient testimonials. I feel grateful to work in a team where we acknowledge the things we can improve and are responsive to patient experiences.

It is such a privilege to be trusted by patients to fit their coils, a procedure that can feel incredibly vulnerable. In order to maintain the professional trust that patients put in us, it is important that as a community we regularly discuss and reflect on our own practice and what we can do to improve it, and implement strategies to actively listen to and respond to patient experiences.

Final reflections

Coil appointments are honestly one of the best parts of my job. I feel so privileged to have the opportunity to talk to people about their contraception and related healthcare, and to try and support them in making choices and decisions that work for them.

To sum up I’d like to recap some of the tools we use to help us provide a safe and quality coil fitting service:

• flexible triage system
• detailed consultation process
• regular coil fitters’ meetings
• clinical governance meetings
• sharing practice/shadowing each other.

If you would like to get in touch with questions about this service please contact me at neda.taghinejadi@ouh.nhs.uk.

References

1. The Faculty of Sexual and Reproductive Health, July 2021. FSRH press release: women should always be offered pain relief in IUD. Accessed 8/01/24.
2. Akintomide H, Brima N, Sewell RD et al. Patients' experiences and providers' observations on pain during intrauterine device insertion. Eur J Contracept Reprod Health Care. 2015;20(4).

Related reading

• We must validate the painful experiences of many women using intrauterine devices (BMJ, 29 June 2023)

• Coil procedures: Exploring negative experiences through qualitative research (an interview with Sabrina Pilav)

• BMJ Deep Breath In podcast: Fitting IUDs with Rebekah Fenton

• Why aren't doctors managing pain during gynecologic procedures? 

Join the conversation

Have you ever had a coil fitted? What was your experience like? What options for pain management did the clinician discuss with you? If you'd like to share your thoughts, please visit the community forum post on IUD procedures. 

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