Title: Equipment and instruments for implanon insertion
Course: Level 3 - Family Planning > Section: Contraceptive implants

The equipment and instruments recommended for Implanon insertion are the following:

- Examining table for the client to rest her arm.
- Marker pen/optional/.
- Soap for washing the arm.
- Gloves.
- One bowl for an antiseptic solution.
- Antiseptic solution (iodine).
- Sterile syringe with a needle.
- 2ml of lidocaine (1% without adrenaline),
- Preloaded sterile Implanon and applicator containing a single rod
- Ordinary band-aid or bandage.
- Gauze/cotton ball.
- Safety box.
- Gloves.

Implanon Insertion Procedure

Implanon Insertion procedure steps of Insertion:

Getting Ready:

Step 1: Greet the client respectfully and with kindness.
Step 2: Review the client screening checklist and further evaluate client,
Step 3: Tell the client what is going to be done and encourage her to ask questions.
Step 4: Ask about any allergies to the antiseptic solution and local anaesthetic agent.
Step 5: Check to be sure that the client has thoroughly washed and dried her entire arm.
Step 6: Help position and allow the client on the table to lie on her back with her non-dominant arm (the arm, which the woman does not use for carrying pitcher or for writing) on the armrest of the table turned outwards and bent at the elbow.
Step 7: Determine the insertion site at the inner side of the upper arm (non-dominant arm) about 6-8 cm above the elbow
Step 8: Mark the insertion site on arm with a marker/pen (optional)
Step 9: Open a sterile Implanon package by pulling apart the sheets of the pouch completely without touching the preloaded applicator and place it on the work table.

Pre-Insertion tasks:

Step 1: Wash your hand and dry with clean towel or air dry.
Step 2: Put a pair of gloves on both hands.
Step 3: Arrange instruments and supplies on the tray.
Step 4: Using iodine or betadine solution on gauze & clean the insertion site two times using a circular motion for 8 to 13 cm from centre to periphery starting at the site of insertion, and allow to air dry.
Step 5: Using a sterile needle and syringe, inject 2 ml of local anaesthetic (1% lidocaine without adrenaline) just under the skin along the "insertion canal" to anaesthetise the insertion site, starting first at the needle entry point to raise a small wheel. During the procedure, one has to make sure that the needle is not in the blood vessels by repeatedly withdrawing on the syringe.
Step 6: Withdraw the needle and dispose it in a safety box to prevent accidental needle sticks.
Step 7: Wait for 2 to 3 minutes for the anaesthesia effect to take place.

Insertion of Implanon:

Step 1: Carefully, remove the disposable sterile applicator carrying Implanon rod from the sterile bliste. Then, remove the needle cap or shield.
Step 2: Always, hold the applicator in the upward position (e.g., with the needle pointed upwards) until the time of insertion. This precaution is done to prevent the implant from dropping out.
Step 3: Visually verify the presence of the implant inside the metal part of the cannula (the needle). The implant can be seen as a white tip inside the needle. If the implant protrudes from the needle, return it to its original position by tapping into the plastic part of the cannula.

(Note: Keep the needle and the implant sterile. Do not touch the needle of the cannula or the implant inside the applicator with anything, including client skin before insertion. If contamination occurs, a new package with a new sterile applicator must be used).

Step 4: Stretch the skin around the insertion site with thumb and index (Figure below) or pulling the skin with thumb towards the elbow joint (Figure below).

Step 5: Insert only the tip of the cannula (needle), slightly angled (~20º) (Figure below).

Step 6: Release the skin.
Step 7: Tent or elevate the skin and lower the applicator to a horizontal position without touching the skin with parts the needle which you are going to insert subdermally (Figure below).

Step 8: Lift the skin with the tip of the needle in the subdermal connective tissue (Figure below).

Step 9: While lifting the skin gently insert the needle to its full length without using force.
Step 10: Keep the applicator parallel to the surface of the skin.

(Note: When the implant is placed too deeply the removal can be difficult).

Step 11: Break the seal of the applicator (Figure below).

Step 12: Turn the obturator 90º (Figure below).

Step 13: Fix the obturator with one hand against the arm and with the other hand slowly retract the cannula (needle out of the arm) (Figure below).

(Note: Never push against the obturator)

Step 14: Check the needle to ensure that the implant is not within the needle. After retraction of the cannula, the grooved tip of the obturator should be visible (Figure below).

(Note: Always verify the presence of the implant by palpation).

Dispose the applicator into the safety box (Figure below).

Step 15: Palpate with the index finger to ensure that the implant is placed/released under the skin

Post-insertion tasks:

Step 1: Press down over the incision with a gauzed finger to stop bleeding (if any).
Step 2: Apply a first aid plaster and a pressure bandage to ensure a good hemostasis and to prevent bruising.
Step 3: Fill-out the user card and hand it over to her for follow-up and to facilitate the removal of the implant later on.
Step 4: Dispose of waste materials by placing them in a leak-proof container or plastic bag.
Step 5: Remove the gloves by turning them inside out and put the gloves in a leak-proof container or plastic bag.
Step 6: Wash your hands thoroughly with soap and water and dry them with a clean towel or air dry.
Step 7: Complete the client record, including a drawing of the position of the capsules.

Post-insertion counselling:

Step 1: Explain the woman how to take care of the wound and make a return visit appointment, if needed.
Step 2: Discuss what to do if the woman experiences any problems following insertion or side effects.

- There may be some bruising and tenderness for the first few days.
- The insertion area should be kept dry for 48 hours, after which the bandage can be removed.
- See if any irritation occurs at the site of insertion.
- Inform about the possible changes in menstrual irregularities which could be no menses or frequent spotting or longer cycle lengthl.
- Tell her to carry the follow-up card during each visit to the clinic.

Step 3: Assure the woman she can return to receive advice or medical attention at any time, and, if desired, to have the capsules removed.
Step 4: Ask the woman to repeat the instructions.
Step 5: Answer all the woman's questions.
Step 6: Observe the woman for at least 5-10 minutes and ask how she feels before sending her home.