Contraceptive Implants Session V B: Two-Rod Implant Removal Use the illustrations and the information on each slide to describe each step in the removal procedure.

Two-Rod Implant Removal: Required Equipment An examination table Sterile surgical drapes and gloves Antiseptic solution Local anesthetic, needles, and syringe Sterile #11 scalpel, forceps (straight and curved mosquito) Skin closure, sterile gauze and compresses Instructions for facilitator: Use the illustration and the information on the slide to describe the equipment required for the removal 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 Removal: Types of Forceps Instructions for facilitator: Use the illustration and the information on the slide to describe the types of forceps. A combination of mosquito and Crile (or Kelly) forceps is preferred because recent evidence has shown reduced risk of breakage of the implant during removal with this combination of forceps. The Jadelle manufacturer (Bayer HealthCare) recommends using Mosquito forceps to stabilize Jadelle rods at the site of the incision during removal and using Crile forceps to remove the rods. The manufacturer of Sino-implant (II)/Levoplant (Dahua) advises that Mosquito forceps can be used if Crile/Kelly forceps are not available. 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 Removal Step 1 Have the client lie on her back with her arm flexed at the elbow. Palpate the area to locate both implants. Clean the patient’s upper arm with an antiseptic solution Use the slide illustration to describe this step in the procedure Advise providers that: If the implants cannot be felt, they may be located by ultrasound or X-ray. Surgery without knowledge of the exact localization of the implant is strictly discouraged. Removal of deeply inserted implants should be conducted with caution in order to prevent damage to deeper neural or vascular structures in the arm.

Two-Rod Implant Removal Step 2 Apply a small amount of local anesthetic, such as lidocaine (1%) to the skin and under the ends of the implants (below the bottom of the “V”). This will raise the ends of the implants. Use the slide illustration to describe this step in the procedure Advise providers that: Anesthetic injected over the implants will obscure them and make removal more difficult. Additional small amounts of the anesthetic can be used for removal of the second implant, if required.

Do not make a large incision. Two-Rod Implant Removal Step 3 Make a 4 mm incision with the scalpel close to the ends of the implants (below the bottom of the “V”). Do not make a large incision. Use the slide illustration to describe this step in the procedure

Push each implant gently toward the incision with your fingers. Two-Rod Implant Removal Step 4 Push each implant gently toward the incision with your fingers. When the tip is visible or near to the incision, grasp it with mosquito forceps. Use the slide illustration to describe this step in the procedure.

Two-Rod Implant Removal Step 5 Use the scalpel, the other forceps, or gauze to very gently open the tissue sheath that has formed around the implant. Use the slide illustration to describe this step in the procedure

Repeat the procedure for the second implant. Two-Rod Implant Removal Step 6 Grasp the end of the implant with the Crile or Kelly forceps and gently remove it. Repeat the procedure for the second implant. Measure the length of the removed implants to confirm type of implant removed Use the slide illustration to describe this step in the procedure

Close the incision with a skin closure. Two-Rod Implant Removal Step 7 Close the incision with a skin closure. 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. Review post-removal instructions and other key messages. Clean or dispose of the instruments properly. Use the slide illustration to describe this step in the procedure

Post-removal Options If the woman decided to keep using this method and is still eligible, insert a new set of implants through the same incision, or if the client prefers, use the other arm. If the woman decided to discontinue using implants and does not want to become pregnant, counsel her about other contraceptive options. Use the slide to describe this step in the procedure Remind providers to inform their clients that following removal, the contraceptive effects reverse quickly and a woman can become pregnant at a rate similar to women who have not used the method.