Contraceptive Implants Session V A: Two-Rod Implant Insertion Use the illustration and the information on each slide to describe each step.

Two-Rod Implant Insertion: Required Equipment An examination table Sterile surgical drapes and gloves Antiseptic solution Local anesthetic, needles, and syringe #10 trocar, forceps, #11 scalpel (optional) Skin closure, sterile gauze, and compresses Use the illustration and the information on each slide to describe each step. Use the illustration and the information on this slide to describe the equipment required for the insertion procedure. Illustrations on this slide and following adapted from: Prescribing Information: Norplant® II Levonorgestrel Implants (Jadelle®), NDA 20-544, Supplement 003/Population Council.

Two-Rod Implant Insertion: Trocar The trocar usually has two or three marks: The mark closest to the hub indicates how far the trocar should be introduced under the skin to place the implants. If included, a middle mark (small arrow) should be ignored for two- rod implant insertions. The mark closest to the tip indicates how much of the trocar should remain under the skin following placement of the first implant. Use the illustration and the information on each slide to describe each step. In 2010 USAID released an announcement1 that Jadelle, which is a commodity offered through USAID’s procurement system, is now provided with a sterile, single-use, disposable trocar.

Two-Rod Implant Insertion: Step 1 Have the client lie on her back with her nondominant arm flexed at the elbow and externally rotated. The implants will be inserted subdermally and positioned in a “V” shape. Use the illustration and the information on this slide to describe this step. Highlight that the optimal insertion area is in the inner surface of the upper arm about 8 to 10 cm above the elbow joint groove.

Clean the client's upper arm with an antiseptic solution. Two-Rod Implant Insertion: Step 2 Clean the client's upper arm with an antiseptic solution. Frame the insertion area with a drape that has an opening. Use the illustration and the information on this slide to describe this step.

Two-Rod Implant Insertion: Step 3 Open the package carefully by pulling apart the sheets of the pouch. Allow the two implants to fall onto a sterile drape. Use the illustration and the information on this slide to describe this step.

Two-Rod Implant Insertion: Step 4 Fill a 5-ml syringe with a local anesthetic, such as lidocaine (1%). Insert the needle under the skin and inject a small amount of anesthetic. Anesthetize two areas about 4.5 cm long, to mimic the V shape of the implantation site. Use the illustration and the information on this slide to describe this step. Use the insertion card, pictured on the slide, to explain how the anesthetized areas map to the final placement of the implants. (Slide 7) Insertion card illustration adapted from: Bayer Schering Pharma AG. Available from: http://www.k4health.org/sites/default/files/InsertionCard_105x85mm%20qxp_Layout%201.pdf

Two-Rod Implant Insertion: Step 5 Use a scalpel to make a small skin incision (about 2 mm); many providers prefer to use the implant trocar to puncture the skin. Use the illustration and the information on this slide to describe this step. Mention that many providers prefer to insert the trocar directly through the skin without making an incision with the scalpel. The bevel of the trocar should always face up during the insertion.

Two-Rod Implant Insertion: Step 6 Insert the tip of the trocar beneath the skin at a shallow angle. Gently insert the trocar while lifting the skin; failure to do so may result in deep placement of the implants and could make removal more difficult. Advance the trocar to the mark nearest the hub of the trocar. Use the illustration and the information on this slide to describe this step. Remind providers that the trocar should not be forced. If they encounter resistance, they should try another direction.

Two-Rod Implant Insertion: Step 7 When the trocar has been inserted the appropriate distance, remove the obturator and load the first implant into the trocar using the thumb and forefinger. Use the illustration and the information on this slide to describe this step.

Two-Rod Implant Insertion: Step 8 Gently advance the implant with the obturator toward the tip of the trocar until you feel resistance. Never force the obturator. Use the illustration and the information on this slide to describe this step.

Two-Rod Implant Insertion: Step 9 Holding the obturator stationary, withdraw the trocar to the mark closest to the trocar tip. Keep the obturator stationary and do not push the implant into the tissue. Do not completely remove the trocar until both implants have been placed (withdraw only to the mark closest to its tip). Use the illustration and the information on this slide to describe this step.

Two-Rod Implant Insertion: Step 10 The implant should have been released under the skin when the mark closest to the tip of the trocar is visible at the insertion point. Release of the implant can be checked by palpation. Use the illustration and the information on this slide to describe this step.

Two-Rod Implant Insertion: Step 11 To place the second implant, align the trocar so that the second implant will be positioned at about a 30-degree angle relative to the first. Fix the position of the previous implant with the forefinger and middle finger of the free hand, and advance the trocar along the tips of the fingers. This will ensure a suitable distance of about 30 degrees between implants and keep the trocar from puncturing the previously inserted implant. Use the illustration and the information on this slide to describe this step.

Two-Rod Implant Insertion: Step 12 Leave a distance of about 5 mm between the incision (puncture) and the tips of the implants. This will avoid spontaneous expulsions. Use the illustration and the information on this slide to describe this step.

Two-Rod Implant Insertion: Step 13 After placement of the second implant, a sterile gauze may be used to apply pressure briefly to the insertion site and ensure there is no bleeding. Palpate the other ends of the implants to make sure that both have been properly placed. Use the illustration and the information on this slide to describe this step.

Two-Rod Implant Insertion: Step 14 Press the edges of the incision together, and close the incision with a skin closure. Use the illustration and the information on this slide to describe this step. Remind providers that suturing the incision is not necessary.

Two-Rod Implant Insertion: Step 15 Apply a sterile gauze and wrap the arm with a pressure bandage. Before the client is discharged, observe her for a few minutes for signs of bleeding from the insertion site. Fill out the user card and give it to the client. Review post-insertion instructions and other key messages. Clean or dispose of the instruments properly. Use the illustration and the information on this slide to describe this step. Instruct providers how to: Apply a sterile gauze with a pressure bandage to prevent bruising. Complete the user card and explain to the client the information that is included on the card (e.g., batch number of the implant, the date of insertion, the arm of insertion, and the intended day of removal). Review the post-insertion instructions and key messages for implant users, and address any final questions that the client may have. (See basic presentation slide sets for details). Dispose of the trocar and syringe properly. The trocar is for single use only and must be disposed of in a sharps container in accordance with local regulations for the handling of biohazardous waste.