# Nexplanon Insertion

## Overview

This module describes how to insert the Nexplanon contraceptive implant.

## Indications

1. Contraception for up to 3 years

## Contraindications

1. Current pregnancy

2. Current/past thrombosis or thromboembolism

3. Liver tumours or active liver disease

4. Undiagnosed abnormal vaginal bleeding

5. Current/former breast cancer or other progestin-sensitive tumours

6. Allergy to any component of Nexplanon

## Patient information and consent

Patients should be fully counselled about their contraceptive options. Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“You have chosen the Nexplanon implant for family planning. I will insert the implant under the skin of your upper arm.”

### What can my patient expect?

“I will give you an injection for pain first. The Nexplanon is a very small device which is stored in a needle. I will use the needle to inject the Nexplanon under your skin. After insertion, it should not be painful and there may be a small scar where I inserted the needle. The Nexplanon should not migrate to other sites in your body. You will be able to feel it as a flexible rod under your skin.”

### What is my patient’s role?

“Tell me if you think you might be pregnant, or have any illnesses or allergies. Fearing blood or needles is normal, but tell me if you have fainted from it. If at any point you feel you do not want to continue with the procedure, tell me and I’ll stop immediately. Let me know if you feel faint or have any pain. Keep the dressing on for a day.”

## Preparation

Insertion may be

timed with previous contraceptive use

timed with previous contraceptive use

COC: on the day after taking the last active tablet in the packet

Injectable: on the day the next injection is due

Minipill: within 24 hours of taking a tablet

Intrauterine device: on the day of removal

Post-partum: directly after delivery

or occur on days 1-5 of the menstrual cycle for immediate effectiveness. If deviating from these recommendations, barrier protection should be used for the first week after insertion.

###

### Documentation

1. Patient notes

### Equipment

1. Sterile gloves

2. Alcohol-based hand rub

3. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

4. Skin disinfectant
   Skin disinfectant

   Commonly used preparations include 0.5-2% chlorhexidine in 70% alcohol (Steriprep), or 10% povidone iodine. There is no consensus on the superiority of one agent above another.

5. Swabs/cotton balls

6. Sterile pack

7. 3 ml syringe

8. Blunt fill needle & 20-22 G needle

9. Lignocaine

10. Alcohol swab

11. Transparent film dressing and gauze

12. Nexplanon in sterile package

## Site & Positioning

Position the patient with the non-dominant arm flexed, the hand behind their head. The insertion site is 8-10 cm proximal to the medial epicondyle and 3-5 cm inferior, overlying the triceps and

avoiding the sulcus

avoiding the sulcus

Following reports of intravascular insertion and migration, the recommended insertion site is now inferior to the sulcus, overlying the triceps.

between the biceps and triceps. Insert the implant from this point subdermally towards the axilla, parallel to the triceps.

## Procedure

Follow medical asepsis with sterile gloves.

1. Perform hand hygiene.

2. Draw up 2 ml lignocaine and inject it into the insertion site and along the insertion tract.

3. Open the sterile pack and create a sterile field on a clean, dry surface. Pour disinfectant into the well containing cotton balls. Open the Nexplanon onto the sterile field.

4. Perform hand hygiene and don sterile gloves.

5. Clean
   Clean

   Use circular motions from the centre outwards.

   and drape the site.

6. Remove the plastic shield from the Nexplanon applicator needle.

7. Stretch the skin towards the elbow with your non-dominant hand.

8. Insert the needle until the bevel is just under the skin surface

   at a 30° angle
   at a 30° angle

   .

9. Angle the applicator parallel to the skin and advance to the hub, with the needle tip tracking just below the skin surface.

   Lift the skin
   Lift the skin

   with the applicator and needle to ensure superficial insertion.

10. Holding the applicator steady and without retracting,

    slide the slider
    slide the slider

    all the way down.

11. Remove the applicator.

12. Apply a gauze pad and transparent film dressing.

13. Palpate the implant and request the patient to do the same to confirm placement.

14. Dispose of medical waste safely.

15. Document the completion of the procedure. Complete the user card for the patient to keep. Attach the chart label to the patient’s notes.

## Troubleshooting

I inserted the needle too deeply into the subcutaneous tissues.

Withdraw until just under the skin surface and reangle it. Try to lift the skin slightly with the needle tip as you advance.

I didn’t advance all the way before I retracted the slider AND/OR the implant is sticking out of the puncture site.

Remove and discard the implant and try again with a new applicator.

I broke the skin with the needle while I was advancing because I was trying to stay superficial.

Withdraw a little, reangle the needle slightly deeper and try again. As long as this wound does not gape open and the implant does not stick out of the skin, it should heal without consequence.

## Risks

1. Deep insertion: difficult or impossible removal

2. Bruising, minor bleeding, local pain and irritation

3. Scarring

4. Abscess formation or local infection

5. Sharps injury to healthcare personnel

6. Implant expulsion

7. Implant migration

8. Risk of adverse events related to the Nexplanon implant

## References

1. Nexplanon Prescribing Information. Organon USA LLC. 2021.