Session V: Giving the Injection with Sayana Press Progestin-Only Injectable Contraceptives Session V: Giving the Injection with Sayana Press This session describes the steps for injecting and re-injecting Sayana Press and for preventing infection during injection. Sayana Press is a new form of the progestin-only injectable contraceptive DMPA. It has been approved by the United States Food and Drug Administration (FDA) and the European Medicines Agency (EMA). Sayana Press consists of a low dose of DMPA in Uniject (a single-use, prefilled injection system). Sayana Press is injected into the fatty tissue directly under the skin (subcutaneous or SC injection) with a short needle (3/8 inches or 9.5 mm) instead of a deep intramuscular (IM) injection of Depo- Provera® or other brands of DMPA. Even though the dose of DMPA is smaller in Sayana Press, it is just as effective. Just like the DMPA given intramuscularly, it is given every 3 months. Sayana Press comes in a single dose, prefilled device that is small, easy to use and disposable. The Medical Eligibility Criteria for Sayana Press is just the same as for DMPA IM. The side effects are similar, except that there may be some mild skin irritation with Sayana Press.

Objectives At the end of this session, participants will be able to: Demonstrate how to administer the injection of Sayana Press Steps to prepare for the injection Steps to administer the injection Steps to safely dispose of the Sayana Press injection device How to support the user in self-injection using Sayana Press

Step 1: Getting together the supplies Supplies include: Injection device at room temperature Soap Cotton swabs or cotton balls Safe container for sharps disposal • Present the steps used in giving the injection with Sayana Press. the steps include: Getting the supplies together. Supplies include: Injection device at room temperature Soap Cotton swabs or cotton balls Safe container for sharps disposal

Step 2: Wash hands 1. Wash your hands well with soap and water. 2. Let your hands dry in the air. Step 2 Wash hands—if possible, with soap—after you have set out your supplies and before you give the injection. • Let your hands dry in the air. • If the injection site is dirty, wash it with water on a cotton swab or ball. • No need to wipe the site with antiseptic. Note to facilitator: Demonstrate each of the steps as you review them. Inform the participants to pay close attention as they will be expected to demonstrate these steps during practice. Ensure that participants can see the demonstration and encourage them to ask questions. Illustration credit: Ambrose Hoona-Kab

Step 3: Ask where the client wants the injection You can give the injection in the back of the upper arm in the abdomen (but not at the navel) on the front of the thigh. If your client is very thin and it is difficult to pinch enough fat at the site she prefers, ask her if you can try the other sites to get a better pinch. Remember that Sayana Press should NOT be injected in the buttocks, hip, or deltoid muscle like with depo-IM. 3. Ask where the client wants the injection. You can give the injection In the back of the upper arm In the abdomen (but not in the navel) On the front of the thigh *Note: If your client is very thin and it is difficult to pinch enough fat at the site she prefers, ask her if you can try the other sites to get a better pinch. Remember that Sayana Press should NOT be injected in the buttocks, hip, or deltoid muscle like with depo-IM.

Step 4: Open the pouch Check that the expiration date on the pouch has not passed. Open the foil pouch by tearing the small notch and remove the Sayana Press 4. Open the pouch Check that the expiration date on the pouch has not passed Open the pouch by tearing the small notch and remove the Sayana Press

Step 5: Mix the solution Hold the device by the port (see drawing) Shake it hard for 30 seconds Check that the solution is mixed and there is no damage or leaking Do not flick or bend the device. This can damage the device. 5. Mix the solution Hold the device by the port (see illustration on slide) Shake it hard for 30 seconds Check that the solution is mixed and there is no damage or leaking. Do not flick or bend the device. This can damage the Device.

Step 6: Activate the device Hold the device by the port. Keep the device with the needle pointed upward to avoid spilling the drug. Push the needle shield into the port. Continue to push firmly until the gap between the needle shield and port is closed (see drawing 2). Take off the needle shield. 6. Activate the device Hold the device by the port Keep the device with the needle pointed upward to avoid spilling the drug Push the needle shield into the port Continue to push firmly until the gap between the needle shield and port is closed (see drawing 2). Take off the needle shield.

Closing the gap and taking off the needle shield Explain that there is a gap between the port and the reservoir where the DMPA is held. It is very important to close that gap be cause: This pushes the needle through the barrier that holds the DMPA. The DMPA goes into the needle and to the client Explain that there is a gap between the port and the reservoir where the DMPA is held. It is very important to close that gap because: This pushes the needle through the barrier that holds the DMPA. The DMPA goes into the needle and to the client Why is it important to close the gap? • This pushes the needle through a barrier that holds the DMPA-SC. • The DMPA goes into the needle and then to the client

Step 7: Give the injection Gently pinch the skin at the injection site. (This helps to make sure that the drug is injected into fat and not into muscle.) Hold the port. Gently push the needle straight into the skin at a downward angle (never upward) until the port touches the skin. Squeeze the reservoir slowly. Take 5 to 7 seconds. Pull out the needle. Do not clean or massage the site after injecting Gently pinch the skin at the injection site. (This helps to make sure that the drug is injected into fat and not into muscle.) Hold the port. Gently push the needle straight into the skin at a downward angle (never upward) until the port touches the skin. Squeeze the reservoir slowly. Take 5 to 7 seconds. Pull out the needle. Do not clean or massage the site after injecting

Step 8: Discard the used device Do not replace the needle shield Place the device in a safety box Wash hands again with soap and water. Place the used syringe in a puncture-proof container. Use great care to avoid a needle- stick injury to yourself or others Wash hands again with soap and water. Note to facilitator: Ask participants if they have questions about any of the steps for giving an injection. Illustration credit: Ambrose Hoona-Kab

Practice Safe Handling of Needles Do not overfill the sharps container. Do not leave the needle inside the vial. Do not dispose of used needles in anything other than a sharps container. Do not re-cap the needle. Do not touch the needle. Ask participants: There are very specific rules for how to handle needles. In particular there are five DON’Ts for handling needles. What do you think are the five things that you should not do when handling needles? [Ask for participant responses to the question before clicking the mouse to reveal the correct information.] Answer: Safe handling and disposal of needles, is an important CHW responsibility so before practicing with needles, it is important to learn how to handle them safely. To avoid accidental needle-stick injuries, do not re-cap the needle after use. Immediately after use, place the used syringe in the sharps container. Do not touch a needle. If you accidentally touch a needle or stick yourself with a needle, do not use the needle on a client. Simply discard the needle and use a fresh one. Do not leave a needle inside the vial to avoid contaminating both the needle and the contents of the vial. Needles are also known as sharps. Sharps are objects that need to be placed in hard-walled container before disposal to protect garbage handlers and others from injury. The box where used needles are placed for disposal is called a sharps container. Do not overfill the sharps container. When the sharps container is 2/3 to 3/4 full, return the container to your supervisor and get a new one. Replacing a sharps’ container before it gets too full prevents needle sticks that occur when a provider stuffs a needle and syringe into the container and pricks him/herself on a dirty needle that is already in the container. Always place used needles and syringes in the sharps container. Do not put anything into the sharps container other than needles and syringes. When the sharps container is 2/3 to 3/4 full return it to your supervisor or the health care facility and get a new sharps container. Local regulations on disposal of sharps containers should be followed to ensure the health and safety of all the members of the community. Note to facilitator: Demonstrate for participants how to assemble a sharps container and show how full it should get before the CHWs return the box for a new one. Program administrators must consider what type and size puncture-proof container is appropriate for CHWs to use when disposing of used syringes. If CHWs are moving from place-to-place to provide services they must be issued portable sharps containers. Home-made portable sharps containers can be crafted from sturdy plastic bottles with wide mouths covered by tight-fitting caps or sturdy cardboard boxes. It is essential that home-made containers share the same safety features as the commercial grade containers (e.g., the container walls are sturdy to prevent needles from poking through, the syringes can be deposited in the container without forcing them, the needles/syringes cannot fall out after they are in the container, the entire container can be disposed of when it is 2/3 to 3/4 full ). Illustration credit: World Health Organization (WHO). Ensuring safe injections. In WHO, Immunization in Practice: A practical resource guide, 2004 update. Geneva: WHO, 2004. Destroy full sharps container by burning or burying.

Supporting the user Teaching the clients to self-inject. Some clients will want to give themselves the injection. Teach them the following steps: Discuss plan for storage and disposal Explain and show them how to self-inject. Teaching clients to self-inject Some clients will want to give themselves the injections. You can teach them how to do this. The following steps apply to self-injection with Sayana Press injection device. 1. Discuss plan for storage and disposal Storage. Discuss where the client can store the devices for at least 3 months that is out of the reach of children and animals and in moderate temperatures (not in direct sunlight or in a refrigerator). Disposal. Discuss how the client can dispose of the device in a container that has a lid and cannot be punctured and can be kept away from children. 2. Explain and show how to self-inject. Explain the important steps. Also explain and show the client how to do each of these steps. You can give the client a copy of these instructions and the pictures on the next page or a booklet of more detailed instructions. Explain how to read the instructions. Source: CDC, 2001.

How to use the Sayana Press injectable contraceptive device Important steps Choose a correct injection site Mix the solution Push the needle cap and the base of the stem together How to do it Choose either the belly or the front of the thigh After washing hands, open pouch, take out device. Hold the device at the base of the stem and shake hard for about 30 seconds. Point needle upward. Hold needle cap with one hand and the base of the cap with the other. Press the cap firmly down until the cap is closed

How to use Sayana Press (cont) 4. Pinch your skin to make a “tent” 5. Put the needle into the skin, and squeeze the bulb slowly. 4. Take the cap off the needle. Hold the device by its base. With the other hand pinch about 4 cm (11/2 inches) of skin with one hand. 5. Press the needle straight into the skin with the needle facing downward.