What are the steps for inserting Nexplanon (etonogestrel implant)

From the Guidelines

Nexplanon insertion should be performed by a trained healthcare provider, ideally during the first five days of the menstrual cycle, to ensure the patient is not pregnant, and the procedure involves placing a small, rod-shaped hormonal contraceptive implant under the skin of the upper arm. The insertion process begins with determining the correct timing, and according to the U.S. selected practice recommendations for contraceptive use, 2013, the implant can be inserted immediately if it is reasonably certain that the woman is not pregnant 1. The provider first identifies the proper insertion site on the inner side of the non-dominant upper arm, about 8-10 cm above the medial epicondyle of the humerus. After cleaning the area with antiseptic, local anesthetic is injected to numb the insertion site. The provider then uses a preloaded applicator, holding it at a shallow angle while tenting the skin. The needle is inserted subdermally to its full length, and the seal of the applicator is broken by retracting the slider. The applicator is rotated 180 degrees, and the slider is pulled back to deploy the implant. Before removing the applicator, the provider should verify the implant's presence by palpation. The insertion site is then closed with Steri-Strips or a bandage, and a pressure bandage is applied to reduce bruising.

Some key considerations for the insertion process include:

• The need for back-up contraception if it has been more than 5 days since menstrual bleeding started, as the woman needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days after insertion 1
• The importance of proper insertion technique to avoid complications like deep insertion or neurovascular injury, which is why only providers with specific training should perform this procedure
• The potential for rare complications, such as transient nerve injury and the need for removal under general anesthesia, as noted in a study on contraception for adolescents 1
• The ideal candidate for Nexplanon, including adolescents who prefer a method that does not require regularly scheduled adherence and who desire an extended length of protection, as identified in a study on progestin implants 1

The entire procedure typically takes less than five minutes, and the implant provides contraception for up to three years. Proper insertion technique is crucial to avoid complications, which is why only providers with specific training should perform this procedure. Additionally, it is essential to consider the potential effects on bleeding patterns, as experience in the first 3 months may help predict future bleeding patterns, but individual experience is highly variable 1.

From the Research

Insertion Instructions for Nexplanon

To insert Nexplanon, healthcare providers must be trained on the procedure before performing insertions or removals of the implant 2. The following steps are general guidelines for the insertion of Nexplanon:

• The implant should be inserted subdermally in the upper arm, typically within 5 days of the start of menstruation or after an abortion 3.
• The insertion procedure should be performed in a clinical setting, with the patient in a comfortable position and the arm exposed 4.
• The skin should be cleaned and disinfected before insertion, and a local anesthetic may be used to minimize discomfort 3.
• The implant should be inserted at a depth of about 5-6 mm, with the tip of the needle bevel facing up 3.
• After insertion, the implant should be palpable, and the patient should be instructed on how to check for the implant's presence 4.

Potential Complications and Considerations

While the insertion of Nexplanon is generally a safe procedure, there are potential complications to consider:

• Incorrect insertion, including non-insertion, partial insertion, or deep insertion, can occur in about 12.6 per 1000 insertions 4.
• Migration of the implant to other areas, such as the axilla, is a rare but possible complication 5.
• Other potential adverse reactions include change in menstrual bleeding patterns, pins and needles/numbness in the arm/hand/fingers, and encasement of the implant within fibrotic tissue 2, 4.

Importance of Training and Experience

The importance of healthcare providers being trained on the insertion and removal of Nexplanon cannot be overstated. Studies have shown that complications associated with insertion and removal of Nexplanon are rare when performed by trained clinicians 4. Therefore, it is essential that healthcare providers receive proper training and have experience with the procedure to minimize the risk of complications.