Contraceptive Implant Placement Periprocedural Care

Patients who desire a contraceptive implant should be counseled on other birth control methods before choosing this device. The practitioner should show the patient the implant palpation simulator that Merck provides to clinicians so her expectation of how the implant feels after insertion is realistic.

Elements of informed consent

Informed consent should be obtained. The practitioner should explain the implant’s efficacy, complications of insertion, likely changes in bleeding pattern, and why other women have chosen to stop using this form of birth control.

Pregnancy should always be ruled out with a urine pregnancy test prior to contraceptive implant placement. Optimal timing of insertion of the implant to minimize chance of pregnancy is as follows: ^[16]

• If no previous method of contraception is being used, insert between days 1 and 5 of menstrual cycle

• If using oral combined hormonal pills, insert during the hormone-free week

• If using a progestin-only pills, insert at any time

• If using injectable contraception (Depo Provera), insert when next injection is due

• If inserting after a first- or second-trimester abortion, including septic abortion, insert within 5 days

• If inserting after use of a contraceptive implant, remove old implant and immediately insert new implant during the same procedure ^[17]

• If inserting after use of the transdermal patch or vaginal ring, insert on same day as those methods are removed

• If inserting after childbirth in a breastfeeding mother, insertion at any time is acceptable, either within 24-48 hours of delivery or at the 6-week postpartum visit; studies have not found differences in milk production or content, continuation of breastfeeding, or infant growth based on these different time windows of insertion ^{[14, 15]}

• If the implant is not inserted as directed, the patient should use a barrier method for 7 days

The practitioner should have the following available for the office procedure:

• Sterile gloves

• Disposable sterile implant applicator

• Local injectable anesthetic, such as 1% lidocaine with or without epinephrine

• 2-mL syringe

• Needle (18 gauge) for drawing up the anesthetic

• Needle (25 gauge, 1.5 cm) for injecting the anesthetic

• Antiseptic solution such as povidone iodine or chlorhexidine

• A sterile marking pen, if desired

• Adhesive dressing, such as Steri-Strips

• Pressure dressing, like Kerlix

Nexplanon is manufactured by Merck and had been distributed since about 2012. Its first-generation model, the Implanon, became available in the United States in 2006. ^[4] The implant is a single-rod nonbiodegradable device that measures 4 cm in length and 2 mm in diameter. It contains a core of 68-mg etonogestrel (3-ketodesogestrel), which is the biologically active metabolite of desogestrel. The rod is made of the plastic ethylene vinyl acetate (EVA) copolymer covered by a thin EVA membrane that slowly releases hormone over 3 years.

Anesthesia

After cleaning the insertion site with antiseptic, sterile gloves should be worn by the practitioner. In preparation for local anesthesia, 1-2 mL of 1% lidocaine with or without epinephrine should be drawn into a syringe with an 18-gauge needle. Then, a smaller 25-gauge needle should be applied to the syringe. The lidocaine should be injected along the planned subdermal insertion site of the implant to both hydrodistend and anesthetize the space where the implant is to be inserted (see image below).

The insertion site, which is at the inner side of the nondominant upper arm about 8cm above the medial epicondyle of the humerus.

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Positioning

The medial side of the upper nondominant arm should be exposed to the practitioner. This is best accomplished by having the patient lie on her back on an examination table with her arm flexed at her side so her hand lies near her head, palm facing the ceiling (see image below).

Patient's wrist is parallel to her ear or her hand is positioned next to her head.

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The implant should be inserted 8 -10 cm (3-4 inches) above the medial epicondyle of the humerus. It should be inserted subdermally, avoiding the sulcus between the biceps and triceps muscles, which contains a neurovascular bundle. Some practitioners like to mark the approximate insertion site, as well as a few centimeters proximal to that as a guiding mark. When actually inserting the needle, do not place the needle directly through this marking to avoid tattooing of the skin.

After insertion and confirmation of proper placement of the implant by practitioner and patient palpation, no further monitoring is necessary. Acetaminophen or ibuprofen is an acceptable option for postprocedural pain. A patient user card provided in the device packaging should be filled out, indicating the 3-year removal date, and given to the patient.

The Nexplanon contains barium sulfate and is radiopaque. If nonpalpable, it can be identified with radiography or CT scanning.

If the first-generation Merck contraceptive implant, Implanon, cannot be palpated after insertion or at the time of removal, it can be localized with high-resolution ultrasonography (>10 MHz) or MRI. ^[4]

Near-infrared light has also been used to locate nonpalpable etonogestrel implants. ^[18]