What are the key considerations for proper Nexplanon (etonogrel) placement?

Key Considerations for Proper Nexplanon Placement

The most effective Nexplanon placement involves insertion into the inside of the nondominant upper arm, 6 to 8 cm above the elbow, following adequate local anesthesia and an 8 mm incision to prevent pressure-related skin lesions. 1

Preparation and Patient Selection

• Ensure proper training before attempting Nexplanon insertion

  • Clinicians must complete requisite training specific to the insertion technique 1
  • Familiarity with the clinical profile of etonogestrel is essential before counseling patients

• Patient counseling should include:

  • High efficacy rate (>99% with typical use) 1
  • Duration of action (3 years) 1
  • Common side effects, particularly unpredictable bleeding patterns 1
  • Need for backup contraception for 7 days if not inserted within first 5 days of menstrual cycle 1

Insertion Technique

Anatomical Considerations

• Insert into the inside of the nondominant upper arm
• Place 6 to 8 cm above the elbow 1
• Position in the subdermal tissue (not too deep)
• Avoid major blood vessels and nerves

Procedural Steps

1. Mark the insertion site with the patient's arm bent at the elbow
2. Provide adequate local anesthesia (consider needle-free jet injector if patient has needle phobia) 2
3. Make an appropriate initial incision (8 mm) to prevent pressure-related skin lesions 1
4. Insert the applicator at a shallow angle (< 30 degrees)
5. Advance the applicator parallel to the skin surface
6. Follow the manufacturer's instructions for releasing the implant
7. Verify placement by palpation immediately after insertion

Critical Safety Measures

• Ensure the implant is palpable after insertion
• Nexplanon contains barium sulfate, making it visible on radiography if non-palpable 1, 3
• Document the location of insertion in the patient's chart
• Instruct the patient on proper wound care

Timing of Insertion

• Can be inserted at any time if reasonably certain the woman is not pregnant 1
• If inserted within first 5 days of menstrual cycle, no backup contraception needed 1
• If inserted >5 days since menstrual bleeding started, use backup contraception for 7 days 1
• Can be inserted immediately postpartum in non-breastfeeding women 1
• For breastfeeding women, can be inserted at any time (U.S. MEC 2 if <1 month postpartum, U.S. MEC 1 if ≥1 month postpartum) 1
• Can be inserted within 7 days post-abortion, including immediately after the procedure 1

Common Pitfalls and Complications

• Insertion too deep: Can cause nerve injury and difficult removal 1
• Improper incision size: Too small an incision can cause pressure-related skin lesions 1
• Failure to verify placement: Always palpate after insertion to confirm proper placement
• Inadequate anesthesia: Ensure complete anesthesia before proceeding
• Poor patient selection: Consider drug interactions, particularly with hepatic enzyme-inducing medications like efavirenz that may reduce efficacy 1

Post-Insertion Care

• Apply a Y-compress under the external fixation plate to avoid formation of a moist cavity 1
• Ensure the external fixation does not exert tension on the stoma canal 1
• Allow free movement of at least 5 mm 1
• First dressing change should be performed the morning after placement 1
• Provide sterile dressing daily with local disinfection until granulation occurs (usually day 1-7) 1

By following these guidelines, clinicians can ensure proper Nexplanon placement, minimize complications, and provide patients with a highly effective contraceptive option that requires minimal ongoing adherence.