Nexplanon trainer module 2017

SUB-DERMAL CONTRACEPTIVE IMPLANT
TECHNOLOGY AND INSERTION SKILLS
Training Module
First Edition, 2018
Sultanate of Oman
Ministry of Health
Department of Women & Child Health
Directorate General of Primary Health Care
(ML- 105)

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SUB-DERMAL CONTRACEPTIVE IMPLANT
TECHNOLOGY AND INSERTION SKILLS
Training Module
First Edition 2018

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Preface
The birth spacing program was initiated in Oman on 1st
October 1994 as an
integral part of maternal and child health services.The program has started
with theprovision of four contraceptive methods. In 1996 intrauterine
contraceptive device has been added as a fifth method. One of the strategies
of the Ministry of Health in the current five- year plan (2011-2015) for
woman’s healthis to expand thebirth spacing program throughintroducing
anew contraceptive method to currently provide birth spacing methods which
aresub-dermal contraceptive implants and to encourage women to use long-
acting methods.
Subdermal contraceptive implant research and development began at the
Population Council laboratories in New York in 1966.Nowadays this method is
being used in many countries around the world.
This new training module has been prepared in the line with the new national
guidelines for this new method (ML-104).Both, the guidelines and the training
module have been developed by the department of Woman and Child Health
with the technical supportof UNFPA,Sub-Regional Office for the GCC
countries.
The main purpose of this training module is to standardize the training on sub-
dermal Implant in all governorates. The module will be used by master
trainers whom they were trained and certified to cascade the training in their
respective governorates.
Dr. Fatima Ibrahim Al-Hanai
Director of Woman& Child Health Department

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Acknowledgment
Contributors
Dr. Salwa Jabbar Alshahabi, Specialist, Community Medicine, Department of
Woman and Child Health
Dr. Bahaa Shawkat, Reproductive Health Freelance Consulnat
Dr. Faiza Al Fadhil, Senior Consultant, Directorate General of Health
Services, Muscat Governorate
Reviewers
Dr. Hanan Al Mahroqi, Senior Consultant, Azaiba Health Center
Dr. Ahdab Abdul Hafiz, Specialist, Muscat Health Center
Dr. Naama Al Rawahi, Senior Specialist. Seeb Health Center
Dr. Nishani Thilakarathene, Medical officer
SS.N Fatima AL Ajmi, Midwife, Department of Woman and Child Health

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Module Overview
This training module is a complete package of training resources needed to address the
learning objectives of the sub-dermal implant clinical training course, including asession
plan, PowerPoint presentations, and accompanying activities andresources. The module is
designed for birth spacing service providers working in the ministry of health – Sultanate of
Oman. The implant module materials could be tailored and adapted according to the
training background and learning needs of the targeted trainees.
This 3 days competency-based clinical training course has been developed to prepare
physicians working in health facilities providing birth spacing services to counsel clients
regarding the use of IMPLANON NXTcontraception and to become skilled at inserting and
removing IMPLANON NXTmanaging side effects and other health problems associated
with the use of IMPLANON NXT, and providing high-quality IMPLANON NXTservices.
The Learning Objectives
By the end of the training, trainees should be able to:
1. Describe the characteristics of implants in a manner that clients can understand:
a. What are the implants? And how they work? (mechanism and onset of action)
b. Effectiveness
c. Side effects
d. Non-contraceptive health benefits
e. Possible health risks (complications)
f. Other characteristics (STI/HIV protection, ease of use, return to fertility, when to
initiate and discontinue)
2. Demonstrate the ability to:
a. Screen clients for medical eligibility for implants
b. Explain to clients the insertion, removal, and follow-up procedures
c. Explain when to return to the clinic
d. Address common concerns, misconceptions, and myths

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e. Conduct follow-up for implant clients in a way that enhances continuing safety,
satisfaction, and acceptance
3. Describe when to initiate theuse of implants (postpartum, switching from another
method).
4. Explain how to manage side effects.
5. Identify conditions that require switching to another method.
6. Identify clients in need of areferral for implant-related complications.
7. Demonstrate on anatomical models how to insert and remove implants.
8. Demonstrate competency in assessing clients and inserting IMPLANON NXTin real
patients of birth spacing clinic

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Table of Contents
CONTENTS Page No
PREFACE 2
ACKNOWLEDGMENT 3
MODULE OVERVIEW 4
TABLE OF CONTENTS 6
DAY (1) 7
SESSION 1 Welcome and module Introduction
- Pre- test
- Characteristics of implants (What are implants?)
- Annex 1 (Implants pre-test)
- Annex 2 (Pre-test answer)
- Annex 3 (Implants fact sheet)
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SESSION 2 Who Can and Cannot Use Implants?
- Medical Eligibility Criteria
- Understanding the Implant Checklist
- When to start?
- Annex 4 (MEC wheel)
- Annex 5 (MEC Quick reference chart)
- Annex 6 (Checklist for Screening Clients)
- Annex 7 (Using implant checklist
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SESSION 3 Providing Implants
- When to start? Exercise
- Key Counseling Topics for Implant Users
- Counseling About Side Effects and complications
- Annex 8 (Correcting Rumors and Misconceptions
about implants)
55
DAY (2) 61
SESSION 4 Implanon NXTinsertion and removal
- Annex 9 (Where we are)
- Annex 10 (Infection prevention checklist)
63
SESSION 5 Implanon NXTinsertion and removal practice
- Annex 11 (Basic Learning Guide insertion and
removal)
- Annex 12 (Insertion and removal supervision
checklist)
75
SESSION 6 Management of side effects and complications
- Annex 13 (Implanon NXTcase study 1)
88
DAY (3) 97
SESSION 7 Implanon NXTremoval problems
- Annex 14 (Role play scenario)
99
SESSION 8 Implanon NXTinsertion and removal practice 107
SESSION 9 Module review and evaluation
- Annex 15 (Post-test)
- Annex 16 (Final course evaluation)
109
References 119

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DAY (1)
• Welcome and module Introduction
• Pre- test
• What are implants
• IMPLANON NXTclinical profile
• Who can and cannot use implants
• When to start using the method
• Key Counseling Topics for Implant
Users

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PROGRAM
DAY (1)
Time Topic
7:30 – 8:00 Registration
8:00 – 8: 15 Welcome and Introduction
8:15 – 8: 45 Pre-test
8:45 – 10:00 Session 1: Characteristics of Implants
What are implants
Effectiveness
How Implanon NXTworks
Health benefits and side effects
10:00 – 10:30 Coffee Break
10:30 – 12:15 Session 2: Who Can and Cannot Use Implants?
Medical Eligibility Criteria
Understanding the Implant Checklist
When to start
12:15 – 12:30 Prayer Break
12:30 – 02:00 Session 3: Providing Implants
When to start exercise
Key Counseling Topics for Implant Users
Counseling About Side Effects and complications

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Session1
(Characteristics of Implants)
Session Outline

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Illustrative Schedule
SESSION 1 (Characteristics of Implants)
Time Topic Method Resources
8:00-8:15am
Welcome and Introduction
Learning Objectives
Discussion Session(1): Slide 3
8:15-8:45 Pre-test Test
Evaluation Tool: The Implant Pre-
TestAnnex 1
8:45-10:00
Session I: Characteristics of Implants
What Are Implants? Discussion
Session (1):Slide 4
Key Points for Providers and
Clients
Mini-lecture Session (1):Slide 5
Key Points for Clients Discussion Session (1): Slide 6
Effectiveness Discussion Session (1):Slide 7
Relative Effectiveness Mini-lecture Session (1):Slide7
Explaining How Implants Work Mini-lecture Session (1):Slide 8
Characteristics of Implants Brainstorming Session (1):Slide 9
Health Benefits of Implants Mini-lecture Session (1):Slide 10
Side Effects of Implants Mini-lecture Session (1):Slide 11-12
Implants Fact Sheet Brainstorming
Session (1):Slide 13
Annex3

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Session Outline
SESSION 1: Characteristics of Implants
TIME: 75 Minutes
Training Process Resources
Session I: Characteristics of Implants
Session Objective: Describe the characteristics of implants.
Welcome and Introduction
• Greet participants and introduce you to participants and then ask
them to introduce themselves.
Session Objectives
Discussion
Explain:
• Contraceptive implants are a safe and highly effective family
planning (FP) option for most women.
• This presentation provides an overview of the characteristics of
this method. It also provides training on how to counsel, screen,
and provide follow-up to clients who are interested in using
implants as a way to regulate their fertility.
• During this training, you will learn and demonstrate these skills
during role plays and other activities. You will also be
encouraged to think about what it will be like to perform these
tasks on-the-job.
• Review objectives with participants.
• Solicit input about whether the planned objectives match
participant’s expectations of the training.
Slide 2-3: Objectives
Pre-Test Questionnaire
(30 min.) Distribute the pre-test. (Annex 1)
Evaluation Tool: The
Contraceptive Implants
Pre-Test
What are Implants?
Discussion
Explain:
• Implants are hormone-filled rods (sometimes referred to as
capsules) that are inserted under the skin of a woman’s upper arm.
• Jadelle®, Sino-implant (II) ®, Implanon NXT®, and Norplant®
are types of implants.
• Implanon NXTis a single-rod system that continually releases a
low, steady dose of the progestin etonogestrel for up to three
years.
• Norplant was the first progestin-only implant system developed.
Slide 4: What are
Implants?

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It consisted of six thin, flexible capsules made of silicone.
Norplant is no longer being manufactured
• The newer implant systems—Jadelle, Sino-implant (II), and
Implanon NXT—have fewer rods than Norplant, making insertion
and removal much easier. The newer implants are also more
comfortable for the user.
• Introduce theImplanon NXTwhich isavailable in the country.
• Provide copies of the reference manual that providers will be
using at their workplace. Throughout this presentation, encourage
providers to look at the sections that they can use to support
efforts to counsel and provide information on implants.
Key Points for Providers and Clients
Mini-lecture
• Give an overview of the key points about implants (What are
they, how do they work, What to expect, important points about
implants).
Slide 5: Key Points for
Providers and Clients
Key Points for Clients
Discussion
Ask the participants:“What do you think are the most important
messages to give clients about implants.” Allow participants to answer
and add to the participants’ responses as needed.
Slide 6: Key Points for
Clients
Effectiveness
Discussion
• The purpose of this activity is to emphasize the effectiveness of
implants.
• The list of this slide categories contraceptive methods from most
effective to least effective as commonly used. In this list,
spermicides are the least effective method and the most effective
methods are sterilization and IUDs.
• Ask participants:Where would you put progestin-only implantson
this list?<after participants respond, click the mouse to reveal the
answer>
• Conclude by emphasizing that implants would be in atop tier of
methods as they are one of the most effective reversible methods
available. As commonly used, implants are more effective than
sterilization and IUDs.
Slide 7: Effectiveness of
Implants
Relative Effectiveness
Mini-lecture
• Explain that there is another way to look at effectiveness. In this
slide, we look at how effective FP methods are as they are
commonly used.
Slide 7: Relative
Effectiveness of FP
Methods

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• The slide shows the number of women who would get pregnant if
1,000 women used a method for one year. So, if 1,000 fertile
women who were having sex, but not using any protection from
pregnancy, 850 of them would become pregnant.
• But, if the same 1,000 women were using an implant, less than
one would become pregnant.
• As a part of good counseling, it is important to inform clients
about how effective each method is.
Ask participants:
• What if these same women were using an injectable? How many
would become pregnant?
Explaining How Implants Work
Mini-Lecture
• Explain that implants prevent pregnancy in two ways:
1. They prevent the release of eggs from the ovaries by
suppressing the hormones that cause ovulation. When there is
no egg, there is nothing for sperm to fertilize.
2. Implants also cause the cervical mucus to thicken. The thicker
mucus acts as a barrier, making it more difficult for sperm to
enter the uterine cavity. In the unlikely event that a woman
does ovulate, this barrier of mucus greatly reduces the chance
that the egg will be fertilized.
• Implants do not disrupt an existing pregnancy and have no
adverse effect on a woman or a fetus if accidentally inserted in the
arm of a woman who is already pregnant.
• However, in the rare event that a woman is found to be pregnant
with an implant in place, the device should be removed.
Slide 8: Implants:
Mechanism of Action
Characteristics of Implants
Brainstorming
The purpose of this activity is to keep participants focused on how they
translate technical information into concepts that their clients can
understand.
Brainstorming instructions:
• Ask trainees to brainstorm first a list of positive characteristics
(advantages) and then negative characteristics of implants.
• Write these suggested characteristics on a flip chart. Then show
the slide of implant characteristics and compare them to the list
generated through brainstorming.
Slide 9: Implants:
Characteristics

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Health Benefits of Implants
Mini-Lecture
• In addition to being an effective way to prevent pregnancy,
implants offer other health benefits.
o Physicians have observed that women who use implants tend
to have fewer cases of thesymptomatic pelvic inflammatory
disease, or PID. It is not clear if this is due to actual
prevention of PID or whether using implants makes PID
symptoms less severe.
o Because most implant users experience an overall reduction in
the amount of menstrual blood loss, implant use can reduce
the likelihood of iron-deficiency anemia.
o Because implants are so effective at preventing pregnancy,
they dramatically lower a woman’s chances of having an
ectopic pregnancy, which is a potentially life-threatening
condition.
 The risk of ectopic pregnancy is reduced by a factor of
more than 100; the rate of ectopic pregnancy among
women using implants is 6 per 100,000 women per year
compared with 650 per 100,000 women per year among
women using no contraceptive method.
 In the rare event that implants fail and pregnancy occurs,
providers must be aware that an ectopic pregnancy is
possible and be prepared to treat this life-threatening
condition.
Slide 10: Implants:
Health Benefits
Side Effects of Implants
Mini-Lecture
• Remind participants that as with many contraceptive methods,
there are some side effects associated with implants that are not
harmful but may be unpleasant.
• Women’s preferences for certain methods are often related to side
effects.
• Ask the participants:What side effects of implants, have you
heard about?
• Show slides 12 and 13 on side effects. Explain that many women
who use implants experience side effects.
• The most commonly reported side effects are menstrual changes.
Light bleeding or spotting, irregular bleeding that occurs
frequently, prolonged bleeding that lasts more than eight days,
infrequent bleeding, and amenorrhea are the types of menstrual
irregularities that women report. In the first year of implant use,
the majority of women experience menstrual changes that deviate
from their normal bleeding pattern.
Slide 11:
Possible Side Effects of
Implants (part 1)
Slide 12: Possible Side
Effects of Implants (part
2)

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• Typically, the frequency of these menstrual changes—especially
prolonged bleeding—decreases with time and is less of a problem
by the end of the first year of use. These menstrual irregularities
are not usually medically harmful, but they may be unacceptable
for some women.
• The type of implant can also have an impact on the bleeding
pattern that users experience. For example, Implanon NXTusers
are more likely to experience infrequent or no menstrual bleeding
than prolonged bleeding.
Implants Fact Sheet
Brainstorming
The purpose of this activity is to give participants an
opportunity to review the characteristics of implants and explore the
contents of the fact sheet.
• Introduce the fact sheet and ask participants to review the first
page.
• Ask participants if there are any additional comments or questions
about the characteristics of implants.
• Discuss and clarify as needed.
• Ask participants to consider how they might be able to use the
fact sheet in their work. Remind participants that although it
might be useful for helping providers to remember important
information to share with clients, the fact sheet is not intended to
be used as a brochure to be distributed to clients.
• Ask participants to review the page two of the fact sheet. Inform
the participants that the next segment of the training will address
the issues outlined on page two of the fact sheet.
Slide 13: Group
Activity: Implants Fact
Sheet
Handout Annex3:
Fact Sheet: Implants

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Annex 1
Session 1(Characteristics of Implants)
Pre-Test

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Contraceptive Implants (Implanon NXT) Pre-test
Name:__________________________________ Date:___________________
Instructions:Circle the letter(s) for all that apply. (Some questions may have more than one
correct answer.) Follow specific directions for each section. There is a total of 30 points.
Scoring:Score each correct answer by 1. It is recommended that a passing score is 80% and above.
Multiple Choice
For each of the following questions, circle the letter(s) of the correct answer(s).
1. Which of the following contraceptive methods are less effective than progestin-only implants?
A. Oral contraceptives
B. DMPA
C. Spermicides
D. Condoms
2. How do progestin-only implants prevent pregnancy? You may choose more than one answer.
A. Preventing a fertilized egg from embedding in the uterine lining
B. Thickening of cervical mucus
C. Suppressing ovulation
D. Damaging sperm
3. Implants are safe for breastfeeding women because they do not contain
A. Estrogen
B. Progestin
C. Both estrogen and progestin
D. None of the above
4. Which of the following are possible side effects of implants?
A. Irregular bleeding
B. No monthly bleeding
C. Breast tenderness
D. Heavy or prolonged bleeding
5. Implants are NOT suitable for women who-
A. Have a serious liver condition
B. Have ever had breast cancer
C. Have pelvic inflammatory disease
D. Have a sexually transmitted infection (STI)
6. Which infection prevention practices are essential after implant insertion?
A. Clean around the insertion site with an antiseptic
B. Dispose of the applicator, syringe, and needle in a sharps container
C. Cover the insertion site with a bandage and then cover with gauze
D. Decontaminate non-disposable instruments in 0.5% chlorine for 10 minutes

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7. Complications from implants are rare. Which of the following are possible complications?
A. The decrease in breast milk.
B. Infection at the insertion site.
C. Difficulty in removing the implant
D. Expulsion of the implant.
True or False
Circle true or false for each statement.
8. Implanon NXTprovides protection against STIs True False
9. For women weighing 80kg or more, Implanon NXTbecomes
less effective after two years of use.
True False
10. Implanon NXTis more than 99 percent effective. True False
11. Implanon NXTcan be used by breastfeeding women.
(after six weeks postpartum).
True False
12. Fertility returns without delay when Implanon NXTis removed. True False
13. Implanon NXTrequires minor surgery to initiate and remove. True False
14. Infection at the insertion site may cause Implanon NXTto
come out.
True False
15. Using Implanon NXTdoes NOT make a woman infertile. True False
16. Hormones remain in the body once the implant is removed. True False
17. Women infected with AIDS who are on antiretroviral therapy
can safely use Implanon NXT.
True False
18. Women can only have an implant inserted while they are
menstruating.
True False
19. Women can have an implant inserted within 7 days following
a miscarriage or abortion
True False
True or False, continued
20. Women who are not breastfeeding must wait 6 weeks after
birth before using an implant.
True False
21. Implanon NXTlasts for 5 years. True False

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22. Implanon NXTis a good method for breastfeeding women. True False
23. Women can use Implanon NXTregardless of how many
cigarettes they smoke.
True False
24. Dizziness is a common side effect of implants. True False
25. In women using implants, acne can either get better or worse. True False
26. No routine visit is required until it is time to remove an
implant.
True False
27. A client who knows about side effects is more likely to keep
using it, even if she experiences side effects.
True False
Fill in the Blank
Complete the following sentences with one of these words.
headaches blood clots nausea dysmenorrhea hypertension
anemia irregular bleeding menstrual cramps expulsion heavy bleeding
28. While very rare, _____________ is a complication associated with progestin-only implants that
most often occurs within the first four months of use.
29. Non-menstrual side effects of progestin-only implants include _____________ and
_____________.
30. Women who have a current problem with _____________ in their legs or lungs should not use
implants.

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Annex 2
(Pre-Test – Answers)

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Contraceptive Implants: Answer Keys for
Pre- and Post-Test
Name: ______________________________ Date:_________________
Instructions:Circle the letter(s) for all that apply. (Some questions may have more than one correct
answer.) Follow specific directions for each section. There is a total of 30 points.
Scoring:Score each correct answer by 1 point. It is recommended that a passing score is 80% and
above.(For this test, the passing score is 25 correct point out of 30)
Multiple Choice
For each of the following questions, circle the letter(s) of the correct answer(s).
Tip for trainer: The correct answers are printed in bold letters
1. Which of the following contraceptive methods are less effective than progestin-only implants?
A. Oral contraceptives
B. DMPA
C. Spermicides
D. Condoms
2. How do progestin-only implants prevent pregnancy? You may choose more than one answer.
A. Preventing a fertilized egg from embedding in the uterine lining
B. Thickening of cervical mucus
C. Suppressing ovulation
D. Damaging sperm
3. Implants are safe for breastfeeding women because they do not contain
A. Estrogen
B. Progestin
C. Both estrogen and progestin
D. None of the above
4. Which of the following are possible side effects of implants?
A. Irregular bleeding
B. No monthly bleeding
C. Breast tenderness
D. Heavy or prolonged bleeding
5. Implants are NOT suitable for women who-
A. Have a serious liver condition
B. Have ever had breast cancer
C. Have pelvic inflammatory disease
D. Have a sexually transmitted infection (STI)
6. Which infection prevention practices are essential after implant insertion?
A. Clean around the insertion site with an antiseptic

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B. Dispose of the applicator, syringe, and needle in a sharps container
C. Cover the insertion site with a bandage and then cover with gauze
D. Decontaminatenon-disposable instruments in 0.5% chlorine for 10 minutes
7. Complications from implants are rare. Which of the following are possible complications?
A. The decrease in breast milk.
B. Infection at the insertion site.
C. Difficulty in removing the implant
D. Expulsion of the implant.
True or False
8. Implants provide protection against STIs True False
9. For women weighing 80kg,Implanon NXTbecomes less effective
after two years of use.
True False
10. Implanon NXTis more than 99 percent effective. True False
11. Implanon NXTcan be used by breastfeeding women.
(after six weeks postpartum).
True False
12. Fertility returns without delay whenImplanon NXTisremoved True False
13. Implanon NXTrequires minor surgery to initiate and remove.
Implants require minor surgery to initiate and remove.
True False
14. Infection at the insertion site may cause Implanon NXTtocome out. True False
15. Using Implanon NXTdoes NOT make a woman infertile. True False
16. Hormones remain in the body once the Implanon NXTis removed. True False
17. Women infected with AIDS who are on antiretroviral therapy can safely
use Implanon NXT.
True False
18. Women can only have an implant inserted while they are menstruating. True False
19. Women can have an implant inserted within 7 days following a
miscarriage or abortion
True False

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True or False, continued
20. Women who are not breastfeeding must wait 6 weeks after
birth before using Implanon NXT.
True False
21. Implanon NXTlasts for 5 years. True False
22. Implanon NXTis a good method for breastfeeding women. True False
23. Women can use Implanon NXTregardless of how many
cigarettes they smoke.
True False
24. Dizziness is a common side effect of Implanon NXT. True False
25. In women using Implanon NXT, acne can either get better or
worse.
True False
26. No routine visit is required until it is time to remove
theImplanon NXT.
True False
27. A client who knows about side effects is more likely to keep
using it, even if she experiences side effects.
True False
Fill in the Blank
Complete the following sentences with one of these words.
headaches blood clots nausea dysmenorrhea hypertension
infertility amenorrhea
anemia irregular bleeding menstrual cramps expulsion heavy bleeding
28. While very rare, expulsion is a complication associated with progestin-only implants that most
often occurs within the first four months of use.
29. Non-menstrual side effects of progestin-only implants include headaches and nausea.
30. Women who have a current problem with blood clots in their legs or lungs should not use
implants.
Note: (For this test, the passing score in post-test is 25 correct point out of 30).
*Each answer should be correct in all parts of the question to be scored as one point.

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Annex 3
(Implants Fact Sheet)

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Fact Sheet: Contraceptive Implants
Progestin-only implants consist of hormone-filled capsules or rods that are inserted under the skin of a
woman’s upper arm. Current systems consist of one or two rods.
Jadelle is a two-rod system designed to deliver a steady daily dose of levonorgestrel over a period of five
years. Sino-implant (II) is identical to Jadelle but is approved for use over a period of four years.
Implanon NXT—a single-rod system—continually releases a low, steady dose of the progestin
etonogestrel for a period of up to three years.
Norplant, which is effective for five years, is an older implant system with six rods that is nolonger
manufactured. Women who are still relying on Norplant will need to consider a newer implant system or
another contraceptive method when their existing implants are no longer effective.
Primary mechanisms of action
Thicken cervical mucus (make it difficult for sperm to penetrate)
Prevent ovulation partially (in about half of menstrual cycles)
Characteristics of progestin-only implants
Highly effective
-acting pregnancy protection but easily reversible
, private
-contraceptive health benefits (help prevent ectopic pregnancy and iron-deficiency anemia)
tions including HIV
Side effects (generally not signs of a health problem; may diminish or change over time)
combined oral contraceptives)

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Who can use progestin-only implants
Women of any parity or reproductive age, married or unmarried, who:
Who should not initiate progestin-only implants (for a complete list, see WHO eligibility
criteria)
Women who have the following known conditions:
leeding (before evaluation)
hyperplasia (which is a tumor that consists of scar tissue and normal liver cells)
Use of progestin-only implants by women with HIV and AIDS
Women with HIV and AIDS who do not take antiretroviral drugs (ARVs) can use progestin-only
implants without restrictions. Women with AIDS who take antiretroviral drugs (ARVs) can generally
use progestin-only implants since the effectiveness of implants seems not to be significantly affected by
ARVs.
Provide follow-up and counseling for
Any client concerns or questions
the following symptoms develop:
Infection at the insertion site
Very bad headaches that start or become worse after initiation
Unusually heavy or prolonged bleeding
Severe pain in the lower abdomen (symptom of ectopic pregnancy)
Unusually yellow skin or eyes
Explain to the client that implants can be removed any time for any reason.
Dispelling myths regarding progestin-only implants
Progestin-only implants do not:

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Session 2
(Who Can and Cannot Use Implants?)
Session Outline

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SESSION 2 (Who Can and Cannot Use Implants?)
10:30 – 12:15 Characteristics of Implants Discussion Session (2): Slide 2
Implants Are Safe for Nearly
All Women
Mini-lecture Session (2): Slide 3
Who Can and Cannot Use
Implants
Discussion Session (2): Slides 4-5
Medical Eligibility Criteria Brainstorming
Session (2): Slides 6-10
Annex 4-5
Implant Use By Women With
HIV
Discussion Session (2): Slide 11
Implant Use by Postpartum
Women
Understanding the Implant
Checklist
Learning
Exercise
Session (2): Slide 13
Annex 6
Implant Eligibility Checklist Brainstorming Annex 7
When to Start Implants part (1) Discussion Session(2): Slide 14
When to Start Implants part ( 2) Mini-lecture Session(2): Slide 15
When to Start Implants part (3) Mini-lecture Session(2): Slide 16

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SessionOutline
SESSION 2: Who Can and Cannot Use Implants?
TIME: 105 Minutes
Session II: Who Can and Cannot Use Implants
Session II Objective: Demonstrate how to screen women for medical eligibility to use implants.
Characteristics of Implants
Discussion
• The purpose of this activity is to ensure that participants
understand how the characteristics of implants might affect a
client’s choice of or eligibility for implants.
• Ask participants for reasons why women listed in the slide might
prefer or avoid implants. Click the mouse to reveal the next
example. Move through each case quickly and mention the
following points.
• Breastfeeding mother:
o Because implants do not reduce the quantity of breast milk or
decrease the duration of lactation, they can be used by
breastfeeding mothers.
o After insertion, a woman has three years of highly effective
protection from unintended pregnancy, which is an ideal
child-spacing interval for the health of the mother and the
child.
o Note to Facilitator: Slides 2 and 3 represent the international
consensus on the initiation of implants and breastfeeding as
reflected in the WHO MEC. For further information on the
initiation of implants and breastfeeding, see slide 10. This
consideration will be more fully discussed at that time.
• Adolescent:
o Young women may be especially interested in implants
because there is nothing to do or remember after insertion.
o Also, fertility returns quickly after implants are removed, so
women who wish to plan a pregnancy can do so easily.
o Young women can use implants to delay the first pregnancy
or to space subsequent pregnancies.
o Studies show that adolescent mothers who choose implants
over pills have higher rates of continued use and lower rates
of new pregnancy.
• Infected with HIV:
o Implants are one of the most effective methods available and
are an excellent choice for women with HIV who wish to
avoid unintended pregnancy.
Slide 2: Characteristics
of Implants

31
o Women with AIDS who are on antiretroviral therapy can use
implants effectively because they do not interact with ARV
drugs.
• Little to no access to a health care facility:
o Implants may be a good choice for women with limited access
to health care because routine periodic visits are not necessary
and implants provide long-term protection from pregnancy. A
minor surgical procedure is necessary for both insertion and
removal.
• Desires no more children:
o Implants are an excellent alternative to sterilization for
women who want to stop childbearing.
Implants are Safe for Nearly All Women
Mini-lecture
• Nearly all women can use implants safely and effectively,
including women who:
o Have or have not had children
o Are of any age, including adolescents and women over 40
years old
o Have just had an abortion, miscarriage or ectopic pregnancy
o Are cigarettes smokers, regardless of age or number of
cigarettes smoked
o Are breastfeeding (after 6 weeks postpartum)
o Have anemia now or in the past
o Have varicose veins
o Are infected with an HIV, whether or not on antiretroviral
therapy
o Most health conditions do not affect thesafe and effective use
of implants and only a few conditions or situations may affect
a woman’s eligibility to use progestin-only implants.
• In addition, many women who cannot use contraceptive methods
that contain estrogen can safely use implants.
• WHO medical eligibility criteria were developed to reassure
providers about some conditions that do not interfere with thesafe
use of contraceptives and highlight all conditions that might affect
women’s eligibility to use any given contraceptive method.
Slide 3: Implants are
Safe for Nearly All
Women
Who Can and Cannot Use Implants
Discussion
• Explain that most women can safely use implants as mentioned
in the previous slide. Show the slides and discuss which women
should not use implants.
• Ask several participants to share one thing that they know about
Slide 4: Who Can and
Cannot Use Implants
(Part 1)
Slide 5: Who Can and
Cannot Use Implants
(Part 2)

31
the Medical Eligibility Criteria (MEC) in their national FP/RH
guidelines (if they exist) or the WHO MEC.
• Introduce job aids that help participants understand eligibility
criteria (and that they may also use at their worksites), such as the
WHO Medical Eligibility Criteria Wheelfor Contraceptive Use or
the Quick Reference Chart for the WHO Medical Eligibility
Criteria for Contraceptive Use.
Medical Eligibility Criteria
Brainstorming
This activity has two purposes:
1. To give participants an opportunity to share what they know
about the eligibility criteria used in their national FP guidelines or
the WHO medical eligibility criteria (WHO MEC) so that the
facilitator can determine whether the participants understand the
criteria and how they are used or whether they need additional
background information before proceeding.
2. To introduce job aids that help participants understand eligibility
criteria (and that they may also use at their worksites), such as the
WHO Medical Eligibility Criteria Wheelfor Contraceptive Use or
the Quick Reference Chart for the WHO Medical Eligibility
Criteria for Contraceptive Use.
• Use slides 7 and 8 to introduce the concept of medical eligibility
and determines whether participants have an adequate
foundation.Explain the 4 categories.
• List 10-15 medical criteria on a flip chart. Ask participants to find
the appropriate category on the WHO MEC Wheel or the Quick
Reference Chart. If time allows, this exercise can be made into a
game using teams to determine the correct answers. Ask several
participants to share one thing that they know about the eligibility
criteria in their national FP/RH guidelines (if they exist) or the
WHO MEC.
 Category 1: For women with these conditions or
characteristics, the method presents no risk and can be used
without restrictions. According to the MEC, implants can be
used without any restrictions by women with category 1
conditions. For example, progestin-only implants can be used
freely by women of any age, including those who are less than
18 years old; women who are breastfeeding a baby older than
six weeks (to be discussed later); women who are heavy
smokers; or women who have complicated valvular heart
disease, endometriosis, endometrial or ovarian cancer, or
thyroid disease.
Slide 6: Medical
Eligibility Criteria
Slides 7 and 8: WHO’s
Medical Eligibility
Criteria, Categories for
IUDs, Hormonal, and
Barrier Methods
Slide 9: Who Can Start
Implants
Slide 10: Who Cannot
Start Implants
Annex 4: WHO Medical
Eligibility Criteria
Wheelfor Contraceptive
Use
Annex 5: The Quick
Reference Chart for the
WHO Medical
Eligibility Criteria for
Contraceptive Use

32
characteristics, the benefits of using the method generally
outweigh the theoretical or proven risks. Women with
Category 2 conditions generally can use the method, but
careful follow-up may be required. For women with category
2 conditions, the advantages of using this method outweigh
the theoretical or proven risks. Progestin-only implants can
generally be used by women with category 2 conditions, but
careful follow-up may be required in some cases. Examples of
such conditions include blood pressure above 160/100 mm
Hg, a history of deep venous thrombosis/pulmonary embolism
(DVT/PE), diabetes with vascular complications, heavy or
prolonged vaginal bleeding patterns, or multiple risk factors
for cardiovascular disease.
characteristics, the theoretical or proven risks of using the
method usually outweigh the benefits. Women with Category
3 conditions generally should not use the method. However, if
no better options for contraception are available or acceptable,
the provider may judge that the method is appropriate,
depending on the severity of the condition. In such cases,
ongoing access to clinical services and careful follow-up will
be required.
characteristics, the method presents an unacceptable health
risk and should not be used.
• In some cases, a particular condition or characteristic is assigned
to one category for initiation and another for thecontinuation of
the method. In other words, the category may depend on whether
a woman with the condition wishes to initiate the contraceptive
method or was already using that method when she developed the
condition.
• Demonstrate how to use the WHO MEC Wheel or the Quick
Reference Chart. Explain that implants are safe for the
overwhelming majority of women. Use slides 9-10 to provide an
overview of the medical eligibility criteria for implants.
• Although progestin-only implants are safe for most women, there
are some exceptions.
o According to the MEC, progestin-only implants are not
generally recommended for women with category 3
conditions. In these situations, the risks of using this method
usually outweigh the advantages. Category 3 conditions
include:
 An acute blood clot in deep veins of legs or lungs,
unexplained vaginal bleeding, history of breast cancer,
severe liver disease and most liver tumors, certain cases of

33
systemic lupus and breastfeeding before 6 weeks
postpartum.
 The condition of breastfeeding before 6 weeks postpartum
is a special case that merits further consideration. Based
on theoretical (i.e. not proven) reasons having to do with
the concern that progestogens may negatively affect the
neonatal liver or brain, the WHO MEC has classified
breastfeeding before 6 weeks postpartum as a category 3.
WHO also notes that “in many settings pregnancy
morbidity and mortality are high, and access to services is
limited. Progestin-only contraceptives may be one of the
few types of methods widely available and accessible to
breastfeeding women immediately postpartum.”
Reflecting this consideration, after careful evaluation of
the evidence and their own health systems and settings,
some countries have made different classifications. The
United States Center for Disease control (CDC) gives the
condition of breastfeeding at 0-4 weeks a Category 2 and
from 4-6 weeks a Category 1. The United Kingdom’s
Royal College of Obstetricians and Gynecologists:
Faculty of Sexual and Reproductive Health Care give it a
Category 1 from birth onward. The materials in this
training package reflect the WHO classification.
 Women who develop ischemic heart disease, have a stroke
or develop migraine headaches with an aura while using
implants should generally not continue using progestin-
only implants.
o Women with category 4 conditions should not use implants.
Current breast cancer is the only category 4 condition.
o WHO also notes that, in settings where clinical judgment is
limited, category 2 conditions should be treated in the same
manner as category 1 conditions. This means that women with
category 1 and category 2 conditions should be able to obtain
and use progestin-only implants without restrictions.
Implant Use by Women with HIV
Discussion (10 min.)
• Ask participants: Let us take a closer look at the conditions and
categories pertaining to clients with HIV or AIDS.
• Use slide to present the following:
o According to the MEC, progestin-only implants can be used
without restrictions by women with HIV who may or may not
have AIDS. These are considered category 1 conditions. This
table shows the specific WHO recommendations.
o HIV-positive women who are on antiretroviral (ARV) therapy
Slide 11: Implant Use
by Women with HIV

34
can generally use progestin-only implants, but follow-up may
be required in some cases. This is because progestin blood
levels are slightly reduced by some ARVs. However, these
reductions are probably not enough to affect contraceptive
efficacy because implants provide a consistent dose of
hormone over time.
o As with other hormonal methods, progestin-only implants do
not provide protection from STIs.
• Ask participants: What advice should you give to clients with
HIV who choose implants? <accept responses from several
participants; click the mouse to reveal the next bullet>
o Women with HIV who choose to use implants should be
counseled about dual method use and should consider using
condoms in addition to hormonal methods. Condoms provide
additional protection from pregnancy in the event that the
effectiveness of progestin-only implants is reduced. Condoms
also provide protection against STI/HIV transmission.
o WHO classifies nucleoside reverse transcriptase inhibitors
(NRTIs) as category 1 and non-nucleoside reverse
transcriptase inhibitors (NNRTIs) and ritonavir and ritonavir-
boosted protease inhibitors as category 2 conditions for
progestin-only implants. Because ARV therapy is a multidrug
regimen that always contains a category 2 drug, ARV therapy
is a category 2 condition. This means that women on ARV
therapy can generally use progestin-only implants although
follow-up may be required in some cases.
Implant Use by Postpartum Women
Mini-lecture
Ask participants: Let us take a closer look at the conditions and
categories pertaining to postpartum clients.
o Non-breastfeeding women can initiate implants immediately
postpartum.
o We have also discussed the differ
o rent recommendations adopted by WHO and countries such as
the US and the UK regarding the use of implants earlier than 6
weeks postpartum based on theoretical concerns about
possible negative effects of progestins on the fetal liver and
brain. WHO has classified use at 0-6 weeks postpartum a
classification of 3, while others have given it a lower
classification (1 or 2). Unlike Combined Oral Contraceptives
(COCs), implants do not have an effect on breast milk
production.
• Ask participants about what they encounter with postpartum
Slide 12: Implant Use
by Postpartum Women

35
women. Is it easy or difficult for them to come back for insertion
at 6 weeks postpartum?
Understanding the Implant Checklist
Experiential Learning Exercise (15 min.)
The purpose of this activity is to introduce participants to the Checklist
for Screening Clients Who Want to Initiate Contraceptive Implants, to
provide an overview of its purpose, and to show how to use it.
• Distribute an implant checklist to each participant.
• When introducing the checklist, mention that it should be used by
providers to determine whether a client is medically eligible to
use the method that she selected during an informed decision-
making process.
• The questions on the checklist identify women who have health
conditions—WHO category 3 or 4—that make it unsafe for them
to use progestin-only implants. The checklist also incorporates
questions that allow a provider to determine with reasonable
certainty that a client is not pregnant.
• To use the checklist, providers ask the questions on the checklist
and follow the instructions based on the client’s responses.
Explain that the medical eligibility questions, questions 1–6, are
at the top of the checklist.
• Ask participants to pair themselves with the person sitting next to
them and take turns reading questions 1–6 on the checklist and
finding the condition on the Quick Reference Chart for the WHO
Medical Eligibility Criteria for Contraceptive Use. Ask the pairs
to verify that all the category 3 and 4 conditions for implants on
the MEC chart are represented in the questions on the checklist.
Allow participants about three to four minutes to examine the
checklist questions and compare them with the MEC chart.
• Ask participants:
o After examining the checklist and the MEC chart, are you
confident that the checklist questions address the conditions
that prohibit thesafe use of progestin-only implants? Explain
why.
o How have you determined a client’s medical eligibility for
implants in the past and how might the checklist facilitate that
process?
• Accept responses from several participants and discuss any
concerns that participants may raise.
• Draw attention to questions 7–12 and emphasize that providers
should follow the instructions for this set of questions to identify
women who are not pregnant or those who might be pregnant and
Slide 13: Understanding
the Implant Checklist
Annex 5:
Quick Reference Chart
for the WHO Medical
Contraceptive Use
Annex 6: Checklist for
Screening Clients Who
Want to Initiate

36
require a pregnancy test to rule out pregnancy.
• Tell providers that the final set of instructions provides details
about initiating the method, especially whether the client will
need to use a backup method initially.
Implant Eligibility Checklist (1)
Brainstorming
The purpose of this exercise is to give participants a
chance to use Handout #8, the Contraceptive Implant Checklist.
• Describe the following scenario (1): Your client is a healthy 24-
year-old woman who gave birth to her first child five months ago.
She has been fully breastfeeding and has not had a menstrual
period since giving birth. She is returning to work in two weeks
and will begin supplementing with formula.
• Ask participants to consider the client description when
answering these questions:
1. Which question(s) on the checklist address this client’s
conditionor situation?
Encourage participants to review the checklist and locate the
question(s) relevant to this client’s situation. Ask them to read
the explanation for questions #6 and #8. Although the client is
breastfeeding, in this situation she would reply “NO” to
question 6 because she is more than six weeks postpartum.
2. Considering the client’s condition and the explanation
provided on the checklist, is this client a good candidate for
progestin-only implants?
Review with the participants why the client is medically
eligible for implants. Because the client is healthy and her
infant is older, she would answer “NO” to questions #1–6.
She would also answer “YES” to question #8, so the provider
can be reasonably sure that she is not pregnant because she is
still protected from pregnancy by the lactation amenorrhea
method (LAM).
3. What would be your course of action for this client?
Discuss with participants why the correct course of action is
to counsel the client about using progestin-only implants. If
everything is acceptable to the client, the provider may
proceed with implant insertion.
Annex 5:
for the WHO Medical
Contraceptive Use
Annex 6:
Checklist for Screening
Clients Who Want to
Initiate Contraceptive
Implants
Annex 7:
Using the Implant
Eligibility Checklist
Brainstorming
The purpose of this exercise is to give participants
a chance to use Handout #7, the Contraceptive Implant Checklist.
Annex 5:
for the WHO Medical
Contraceptive Use

37
• Describe the following scenario (2): Your client is a 30-year-old
woman who is married, with single partener, and has three
children. She has HIV but has no symptoms and has no other
health problems. She has been using condoms consistently and
correctly but is still concerned that she might become pregnant.
 Ask participants to consider the client description when
1. Which question(s) on the checklist address this client’s
condition or situation?
the explanation for question #12.
progestin-only implants?
eligible for implants. Although the client has HIV, HIV and
AIDS are not conditions that limit theuse of implants.
Because the client is otherwise healthy, she would answer
“NO” to questions #1–6. She would also answer “YES” to
question #12, so the provider can be reasonably sure that she
is not pregnant because she has been using condoms
consistently and correctly.
3. What would be your course of action for this client? Discuss
with participants why the correct course of action is to counsel
the client about using progestin-only implants. The client
should also be encouraged to continue using condoms to
prevent sexually transmitted infections. If everything is
acceptable to the client, the provider may proceed with
implant insertion.
Handout Annex6:
Clients Who Want to
Initiate Implants
Handout Annex7: Using
the Implant Eligibility
Checklist
Brainstorming
The purpose of this exercise is to give participants a
chance to use Handout #7, the Contraceptive Implant Checklist.
• Describe the following scenario (3): Your client is a 42-year-old
woman with five children. Six months ago, she was admitted to
the hospital with severe chest pain and shortness of breath. She
was diagnosed with a blood clot in her lung. She is now on
anticoagulant therapy (blood thinners). She has no other health
problems. She has not had sex since her last menses.
 Ask participants to consider the client description when
1. Which question on the checklist addresses this client’s
condition or situation?
Handout Annex 5:
for the WHO Medical
Contraceptive Use
Handout Annex 6:
Clients Who Want to
Initiate Implants
Handout Annex7: Using
the Implant Eligibility
Checklist

38
the explanation for questions #2 and #9.
implants?
eligible for implants. She should answer NO to question #2
because she does not currently have blood clots in her legs or
lungs and she is on anticoagulant therapy. However, because
of her history with blood clots, she may answer YES to the
question. If so, the provider has the opportunity to probe
further and confirm that she does not currently have clots in
her legs or lungs as she has been on anticoagulant therapy for
six months. The provider can be reasonably sure the client is
not pregnant because she has not had intercourse since her last
menses.
3. What would be your course of action for this client? Discuss
with participants why the correct course of action is to counsel
the client about using progestin-only implants. The client
should also be encouraged to continue with her anticoagulant
therapy and inform other health care providers whom she sees
that she is using implants and taking blood thinners. If
everything is acceptable to the client, the provider may
proceed with implant insertion. If her menses started more
than seven days ago (five days for Implanon NXT), tell her to
use condoms or abstain for the next seven days.
When to Start Implants (part 1)
Discussion
Remind participants that questions #7–12 in the Checklist for Screening
Clients Who Want to Initiate Contraceptive Implants are used to rule out
pregnancy as part of the screening process for initiating implants.
• Ask participants: If a woman is medically eligible and wants to
use implants, when can she initiate them?<participants
brainstorm; accept responses from several participants>
• Let us compare your responses with the information on the next
several slides. <click the mouse to reveal each bullet on the
slide>
• Progestin-only implants can be initiated anytime during the
menstrual cycle as long as the provider can be reasonably sure the
woman is not pregnant.
• A provider can be reasonably certain that a woman is not
pregnant if any of these situations apply:
o The woman is fully breastfeeding, has no menses, and her
Slide 14: When to Start
Implants (part1)

39
baby is less than six months old.
o She has abstained from intercourse since her last menses
or since delivery.
o She has given birth in the past four weeks.
o Her monthly bleeding started within the past seven days.
o She had a miscarriage or an abortion in the past seven
days.
o She has been using a reliable contraceptive method
consistently and correctly.
• If none of these situations apply, a provider can use a urine
pregnancy test or conduct a bimanual pelvic exam to determine if
the woman is pregnant.If no other means to rule out pregnancy
are available, a provider can ask a woman to come back at a time
of her next menses and use a backup contraceptive method in a
meantime.
Mini-lecture
• Remind participants that the instruction boxes below the
questions on the Checklist for Screening Clients Who Want to
Initiate Contraceptive Implants also provide guidance about when
to initiate implants for women who are eligible.
• With Implanon NXT, no backup method is needed if it is initiated
within the first five days of the menstrual cycle.
• If progestin-only implants are initiated more than five days after
the start of woman’s monthly bleeding, she should be counseled
to use a backup contraceptive method such as condoms for the
first seven days following insertion.
• A woman who is not breastfeeding may have implants inserted
immediately after delivery. If a woman who is not breastfeeding
wants to start using implants more than four weeks after she has
given birth, it is necessary to rule out pregnancy before they can
be inserted.
• Ideally, women who are breastfeeding should not start using
implants until six weeks postpartum because of theoretical
concern that hormones in breast milk may have an adverse effect
on a newborn during the first six weeks after birth.
Implants (part 2)
Discussion
• Implants can be initiated immediately following an abortion or
miscarriage without theneed for a backup method.
• If a woman is switching to implants from a hormonal method, she
Implants (part 3)

41
can have the implants inserted immediately provided that she has
been using the hormonal method consistently and correctly or if it
is otherwise reasonably certain that she is not pregnant. There is
no need for her to wait for her next monthly bleeding. There is no
need for her to use a backup method.
• If she is switching from indictable, she can have implants inserted
anytime during the reinjection window. There is no need for a
backup method.
• If a woman has taken emergency contraceptive pills, it is
recommended that she delay implant insertion until her menses
return to ensure that emergency contraception was effective.
Implants can be inserted within the first seven days after the start
of her menstrual period (within five days for Implanon NXT) or
any other time it is reasonably certain that she is not pregnant.
Give her a backup method such as condoms, or oral
contraceptives to start the day after she finishes taking the
emergency contraceptive pills until the implants can be inserted.

41
Annex 4
Session 2 (Who Can and Cannot UseImplants)
MEC Wheel (Samples are Available at MOH)

42
Cover’s Picture of the Medical Eligibility Criteria
Wheel for Contraceptive Use

43
Annex 5
Session 2 ((Who can and cannot use
implants)
Quick Reference Chart for the WHO Medical
Eligibility Criteria for Contraceptive Use

44
MEDICAL ELIGIBILITY CRITERIA FOR IMPLANT (Adopted from WHO MEC 2015)
Condition Sub-condition Implant
I C
Age
Menarche to >45
1
Anemias
a) Thalassemia 1
b) Sickle cell disease‡ 1
c) Iron-deficiency anemia 1
Benign ovarian tumors
(including cysts) 1
Breast disease
a) Undiagnosed mass 2*
b) Benign breast disease 1
c) Family history of cancer 1
d) Breast cancer‡
i) current 4
ii) past and no evidence of current
disease for 5 years
3
Breastfeeding
(Postpartum)
a) < 1 month postpartum 2*
b) 1 month or more postpartum 1*
Cervical cancer
Awaiting treatment 2
Cervical ectropion
1
Cervical intraepithelial
neoplasia
2
Cirrhosis
a) Mild (compensated) 1
b) Severe‡ (decompensated) 3
Deep venous thrombosis
(DVT) / Pulmonary embolism
(PE)
a) History of DVT/PE, not on
anticoagulant therapy
i) higher risk for recurrent DVT/PE 2
ii) lower risk for recurrent DVT/PE 2
b) Acute DVT/PE 3
c) DVT/PE and established on
anticoagulant therapy for at least 3
months

45
i) higher risk for recurrent DVT/PE 2
ii) lower risk for recurrent DVT/PE 2
d) Family history (first-degree
relatives)
1
e) Major surgery
(i) with prolonged immobilization 2
(ii) without prolonged
immobilization
1
f) Minor surgery without
immobilization
1
Depressive disorders
1*
Diabetes mellitus (DM)
a) History of gestational DM only 1
b) Non-vascular disease
(i) non-insulin dependent 2
(ii) insulin dependent‡ 2
c) Nephropathy/ retinopathy/
neuropathy‡
2
d) Other vascular disease or diabetes
of >20 years' duration‡
2
Endometrial cancer‡
1
Endometrial hyperplasia
1
Endometriosis
1
Epilepsy‡
(see also Drug Interactions) 1*
Gallbladder disease
a) Symptomatic
(i) treated by cholecystectomy 2
(ii) medically treated 2
(iii) current 2
b) Asymptomatic 2
Gestational trophoblastic
disease
a) Decreasing or undetectable ß-hCG
levels
1
b) Persistently elevated ß-hCG levels
or
malignant disease‡
1
Headaches
a) Non-migrainous 1* 1*
b) Migraine
i) without aura, age <35 2* 2*
ii) without aura, age >35 2* 2*
iii) with aura, any age 2* 3*
History of bariatric surgery‡
a) Restrictive procedures 1
b) Malabsorptive procedures 1
History of cholestasis
a) Pregnancy-related 1
b) Past COC-related 2

46
History of high blood
pressure
during pregnancy
1
History of pelvic surgery
1
HIV
High risk 1
HIV infected (see also Drug
Interactions)‡
1*
AIDS (see also Drug Interactions)‡ 1*
Hyperlipidemias
Clinically well on therapy 2*
Hypertension
a) Adequately controlled
hypertension
1*
b) Elevated blood pressure levels
(properly taken measurements)
(i) systolic 140-159 or diastolic 90-99 1
(ii) systolic ≥161 or diastolic ≥111‡ 2
c) Vascular disease 2

47
Inflammatory bowel disease
(Ulcerative colitis, Crohn’s disease) 1
Ischemic heart disease‡
Current and history of 2 3
Liver tumors
a) Benign
i) Focal nodular hyperplasia 2
ii) Hepatocellular adenoma‡ 3
b) Malignant‡ 3
Malaria
1
Multiple risk factors for
arterial cardiovascular
disease
(such as older age, smoking, diabetes
and hypertension)
2*
Obesity
a) >30 kg/m2
body mass index (BMI) 1
b) Menarche to < 18 years and > 30
kg/m2
BMI
1
Ovarian cancer‡
1
Parity
a) Nulliparous 1
b) Parous 1
Past ectopic pregnancy
1
Pelvic inflammatory
disease
a) Past, (assuming no current risk
factors of STIs)
(i) with subsequent pregnancy 1

48
(ii) without subsequent pregnancy 1
b) Current 1
Peripartumcardiomyopathy‡
a) Normal or mildly impaired cardiac
function
(i) < 6 months 1
(ii) > 6 months 1
b) Moderately or severely impaired
cardiac function
2
Postabortion
a) First trimester 1*
b) Second trimester 1*
c) Immediately post-septic abortion 1*
Postpartum
(see also Breastfeeding)
a) < 21 days 1
b) 21 days to 42 days
(i) with other risk factors for VTE 1
(ii) without other risk factors for VTE 1
c) > 42 days 1
Pregnancy
NA*
Rheumatoid arthritis
a) On immunosuppressive therapy 1
b) Not on immunosuppressive
therapy
1
Schistosomiasis
a) Uncomplicated 1
b) Fibrosis of the liver‡ 1
Severe dysmenorrhea
1
Sexually transmitted infections (STIs)
Sexually transmitted
infections
(cont.)
a) Current purulent cervicitis or
chlamydial infection or gonorrhea
1
b) Other STIs (excluding HIV and
hepatitis)
1
c) Vaginitis (including
trichomonasvaginalis and bacterial
vaginosis)
1
d) Increased risk of STIs 1

49
Smoking
a) Age < 35 1
b) Age > 35, < 15 cigarettes/day 1
c) Age > 35, >15 cigarettes/day 1
Solid organ
transplantation‡
a) Complicated 2
b) Uncomplicated 2
Stroke‡
History of cerebro-vascular accident 2 3
Superficial venous
thrombosis
a) Varicose veins 1
b) Superficial thrombophlebitis 1
Systemic lupus
erythematosus‡
a) Positive (or unknown)
antiphospho-lipid antibodies
3
b) Severe thrombocytopenia 2
c) Immunosuppressive treatment 2
d) None of the above 2
Thrombogenic mutations‡
2*
Thyroid disorders
Simple goiter/hyperthyroid/
hypothyroid
1
Tuberculosis‡
(see also Drug Interactions)
a) Non-pelvic 1*
b) Pelvic 1*
Unexplained vaginal
bleeding
(suspicious for serious condition)
before evaluation
3*
Uterine fibroids
1
Valvular heart disease
a) Uncomplicated 1
b) Complicated‡ 1
Vaginal bleeding patterns
a) Irregular pattern without heavy
bleeding
2
b) Heavy or prolonged bleeding 2*

51
Viral hepatitis
a) Acute or flare( with normal LFT) 1
b) Carrier/Chronic 1
Antiretroviral therapy
a) Nucleoside reverse transcriptase
inhibitors
1
b) Non-nucleoside reverse
transcriptase inhibitors
2*
c) Ritonavir-boosted protease
inhibitors
2*
Anticonvulsant therapy
a)Certain anticonvulsants
(phenytoin, carbamazepine,
barbiturates, primidone,
topiramate, oxcarbazepine)
2*
b) Lamotrigine 1
Antimicrobial
therapy
a) Broad spectrum antibiotics 1
b) Antifungals 1
c) Antiparasitics 1
d) Rifampicin or rifabutin therapy 2*
I = initiation of contraceptive method;
C = continuation of contraceptive method;
NA = Not applicable
* Please see the complete guidance for a clarification to this classification
‡ Condition that exposes a woman to increased risk as a result of unintendedpregnancy.

51
Annex 6
Session 2(Who can and cannot use implants)
Checklist for Screening Clients Who Wants to
Initiate Implants

53
Annex 7
Session 2(Who can and cannot use implants)
Using the Implant Eligibility Checklist

55
Session 3
(Providing Implants)
Session Outline

56
SESSION 3 (Providing Implants)
12:30 – 02:00 Session (3): Providing Implants
When to Start Implants:
A Review
Group
discussion
Session (3): Slide 2 Annex 6 (from
theprevious session)
Key Counseling Topics for
Implant Users
Discussion/
Role Play
Correcting Rumors and
Misunderstandings
Brainstorming Session (3): Slide 9(Annex 8)
Additional Key Counseling
Topics
Brainstorming/
Discussion
Counseling About Side Effects Mini-lecture Session (3): Slide 4
Implant Insertion and Removal
Discussion/
Role Play
What Clients Need to
Remember After Insertion
Supporting Method
Continuation
Brainstorming
Helping Continuing Users Discussion Session (3): Slide 8

57
Session Outline
SESSION 3: Providing Implants
TIME: 90 Minutes
Session (3) Providing Implants
Session (3) Objective: Demonstrate how to provide implants.
When to Start Implants (A Review)
Group Work
The purpose of this activity is to allow participants to think about how
they would apply what they have learned about when to initiate implants.
The activity can be conducted in a large group or small groups as long as
participant responses are monitored by afacilitator. Encourage
participants to use the job aid, Checklist for Screening Clients Who Want
to Initiate Contraceptive Implants, to help them determine what to do in
each case.
• Ask participants to explain what they would do in each case. The
correct approaches for each case are outlined below.
o In day 4 of menstrual cycle—can have implants inserted
immediately, no need to rule out pregnancy or use a
backup method (regardless of type of implant being
inserted)
o Condom user in day 8 of menstrual cycle—ensure client
has used condoms consistently and correctly, can have
implants inserted immediately, instruct her to continue
using condoms for 7 more days
o 2½ weeks postpartum, not breastfeeding—can have
implants inserted immediately, no need to use a backup
method
o 2½ weeks postpartum, currently breastfeeding and wishes
to continue—must be at least six weeks postpartum before
initiating implant use because of the theoretical concern
that progestin from the implant that gets into the breast
milk may have an adverse effect on a newborn during the
first six weeks after birth.
o The injectable user, amenorrhea, within reinjection
window—can have implants inserted immediately, no
need to rule out pregnancy or use a backup method.
o IUD user, mid-cycle, has had sex since her last menses—
can have implants inserted immediately, remove IUD
during the next menstrual cycle (this is because ovulation
may have already occurred and viable sperm may be
present in her fallopian tubes so implants even in
Implants (A Review)
Annex 6: Checklist for
Screening Clients Who
Want to Initiate

58
combination with a backup method would not be
effective).
o After taking emergency contraceptive pills (ECPs)—can
be inserted within five days after the start of her next
monthly bleeding or any other time it is reasonably certain
she is not pregnant; give her a backup method, or oral
contraceptives to start the day after she finishes taking the
ECPs, to use until the implants are inserted.
Key Counseling Topics for Implant Users
Discussion/Role Play
• Ask participants: What are the key counseling
topics for new Implant users?<allow participants to respond,
affirm correct responses and click mouse to reveal the list>
o After a client makes an informed choice to use implants, and
you determine that she has no known conditions that would
prohibit theuse, you and the client should discuss in greater
detail how to use implants and address any additional
questions or misconceptions that the client may have about
the characteristics of implants.
o Specifically, you should discuss how safe and effective
implants are, how efficacy is affected by a woman’s ability to
take pills on time, how implants work, health benefits, and
possible side effects
o You should also discuss the fact that implants do not protect
against STIs/HIV.
o During counseling, help the client to assess her risk of
acquiring or transmitting infection and discuss the benefits
and feasibility of condom use to reduce that risk. Explain how
to use condoms correctly and consistently and, if needed, help
women develop and practice strategies to negotiate condom
use with their partners.
o Tell the client that if she is diagnosed with any serious new
health problem she should inform her health care provider she
has a contraceptive implant in place.
o Finally, discuss when to return, and tell the client about the
warning signs of possible complications. We will discuss the
warning signs in a few moments.
• Role play instructions:
o Divide participants into groups of three. Ask the members of each
group to choose who will play the role of client, provider, or
observer.
Slide 2: Key Counseling
Topics for Implant
Users

59
o The observer will observe the roleplay and then make suggestions
for improvement.
o Explain that each participant will play each role during the
activity.
o The “provider” will explain about what implants are,
effectiveness, how they work, advantages and disadvantages,
client instructions, and when to return to the provider. The
“provider” may use local counseling material if available.
Correcting Rumors and Misunderstandings about
ImplantsBrainstorming
• Explain that rumors are unconfirmed stories that
are transferred from one person to another by word of mouth.
In general, rumors arise when:
o An issue or information is important to people, but it has not
been clearly explained.
o There is nobody available who can clarify or correct the
incorrect information.
o The original source is perceived to be credible.
o Clients have not been given enough options for contraceptive
methods.
o People are motivated to spread them for political reasons.
• A misconception or misunderstanding is a mistaken
interpretation of ideas or information. If a misconception is
imbued with elaborate details and becomes a fanciful story, then it
acquires the characteristics of a rumor.
• Ask participants:What are some common misconceptions about
implants?<participants brainstorm; write the answers on a flip
chart>
1. Discuss methods for counteracting rumors and misinformation
2. When a client mentions with a rumor, always listen politely.
Don't laugh.
3. Define what a rumor or misconception is.
4. Find out where the rumor came from and talk with the
people who started it or repeated it. Check whether there is
some basis for the rumor.
5. Explain the facts.
6. Use strong scientific facts about FP methods to counteract
misinformation.
7. Always tell the truth. Never try to hide side effects or
problems that might occur with various methods.
Slide 9: Correcting
Rumors and
Misunderstandings
Annex 8:
Correcting Rumors and
Misconceptions about
implants

61
8. Clarify information with the use of demonstrations and
visual aids.
9. Give examples of people who are satisfied users of the
method (only if they are willing to have their names used).
This kind of personal testimonial is most convincing.
10. Reassure the client by examining her and telling her your
findings.
11. Counsel the client about all available FP methods.
• Refer back to the flipchart and ask participants how they could
counteract each rumor or misconception.
Additional Key Counseling Topics
Brainstorming and Discussion
• Ask participants: in addition to providing
information on the characteristics of implants—including side
effects, assessing the client’s eligibility, and addressing client
misconceptions or questions—what are some other key
counseling topics related to implants? <participants brainstorm;
accept responses from several participants>
• Let us compare your responses with the slide. <click the mouse to
reveal the list>
• In addition to the topics we have already discussed, it is
imperative that during counseling about implants providers also:
• Explain the procedure used to insert and remove the implants.
Use illustrations if possible. Include the length of time it takes to
complete the procedure, who will perform it, and that it may be
somewhat uncomfortable but not painful. We will review a job
aid that can be used for this purpose.
• Provide post-insertion instructions so that a client knows how to
care for the incision and when to return to the clinic if something
does not seem right. We will also review these instructions in
more detail.
• Explain how long the implants protect against pregnancy. Help
women remember when they should come back to have the
implants removed or replaced. All clients should be provided with
the following information:
o Type of implant
o Date of insertion
o Month and year when implants will need to be
removed
o Where to go in case of questions or problems
• A reminder card like the one shown on the slide can be useful for
Slide 3: Additional Key
Counseling Topics

61
this purpose.
• Finally, the provider should advise a client about circumstances
that require her to return, which are described in more detail on
the next slide.
Counseling About Side Effects
Mini-lecture
• Use the slide to present the following important points:
o Counseling—both prior to insertion and for women already
using implants—is the best way to help women manage the
side effects associated with progestin-only implants.
o The most common side effects of implants are irregular
bleeding, prolonged bleeding, infrequent bleeding, or no
bleeding at all. Headaches, mild abdominal pain, and breast
tenderness are examples of less common side effects.
o Women who are considering using implants should be
counseled that menstrual changes are expected and that they
are not signs of disease or health problems. For the majority
of women, side effects will become less pronounced or will
stop within the first year. Some women may not have any side
effects.
o After an implant is inserted, the practitioner should tell the
client to come back with any questions or concerns. Ongoing
counseling and reassurance should be provided if needed.
o If the user continues to be concerned or finds the side effects
unacceptable, it may be necessary to manage the side effects
or remove the implants.
Slide 4: Counseling
About Side Effects
Implant Insertion and Removal
Discussion and Role Play
• A client who has chosen an implant needs to
know what will happen during insertion. Clients will want to
know the following:
o Implants usually only take a few minutes to insert, but can
sometimes take longer.
o Complications related to the insertion are rare.
o The provider will carefully clean the area on the arm and will
use sterile gloves and equipment.
o The client will receive a small injection under the skin so that
she will not feel the implant being inserted. The injection may
sting a bit.
o The client will be awake during the procedure.
o The provider will make a small incision on the inside of the
Slide 5: Implant
Insertion and Removal
Slide 8: What to
remember

62
upper arm.
o The provider will insert the implant.
o After the implant has been inserted the provider will put on a
small bandage and then gauze will be wrapped around the arm
to keep the area clean.
• Role plays instructions: ask for 2 volunteers to do a short role
play on explaining implant insertion to a client.
Supporting Method Continuation: Question to
Consider
Brainstorming
 Ask participants to share any strategies that they have developed
to support method continuation among their clients.
 Assure clients that they are welcome to come back anytime for
any reason. Although there is no need for a routine follow-up
visit, there are some reasons that an implant user might want to or
should return.
 Clients should be advised to come back for the following reasons:
o If she has problems or questions related to side effects or
other issues or if she wants to try another method.
o If she experiences pain, heat, pus, or redness at the insertion
site that becomes worse or does not go away—this may
indicate an infection.
o If she notices a rod is coming out—since the implant should
be replaced after ensuring there is no infection or treating the
infection if present.
o If she is concerned that she may be pregnant—since the
implant should be removed if she plans to carry the pregnancy
to term. But, it would be very rare to get pregnant with the
implant in place, unless it is left in too long.
o If she has gained a lot of weight. This may decrease the length
of time the rod is effective.
o If she suddenly feels that something is seriously wrong with
her health; although, it is unlikely that the implant is the cause
of the condition.
Helping Continuing Users
Discussion
• Explain that no routine visit required for implants, but if she
returns, ask:
o Whether satisfied with themethod or has questions.
o If she is concerned about bleeding changes.
Slide 8: Helping
Continuing Implant
Users

63
o About new health problems or major life changes (plans for
more children, change in STI/HIV risk).
o If she wants to continue using theimplant and has no new
medical condition, remind her how much longer her implant
will protect her.

64
Annex 8
Correcting Rumors and Misunderstandings
Session 3 (Providing Implants)

65
Rumors and Misconceptions about Implants
Technical Resource Package for Family Planning Page 1 of 3 Contraceptive Implants Module
Rumors are unconfirmed stories that are transferred from one person to another by word of mouth.
In general, rumors arise when:
• An issue or information is important to people, but it has not been clearly explained.
• There is nobody available who can clarify or correct the incorrect information.
• The original source is perceived to be credible.
• Clients have not been given enough options for contraceptive methods.
• People are motivated to spread them for political reasons.
A misconception is a mistaken interpretation of ideas or information. If a misconception is imbued
with elaborate details and becomes a fanciful story, then it acquires the characteristics of a rumor.
Unfortunately, rumors or misconceptions are sometimes spread by health workers who may be
misinformed about certain methods or who have religious or cultural beliefs pertaining to birth spacing
which they allow impacting on their professional conduct.
The underlying causes of rumors have to do with people's knowledge and understanding of their
bodies, health, medicine, and the world around them. Often, rumors and misconceptions about birth
spacing make rational sense to clients and potential clients. People usually believeagiven rumor or piece
of misinformation due to immediate causes (e.g., confusion about anatomy and physiology).
Methods for Counteracting Rumors and Misinformation
1. When a client mentions with a rumor, always listen politely. Don't laugh.
2. Define what a rumor or misconception is.
3. Find out where the rumor came from and talk with the people who started it or repeated it. Check
whether there is some basis for the rumor.
4. Explain the facts.
5. Use strong scientific facts about birth spacing methods to counteract misinformation.
6. Always tell the truth. Never try to hide side effects or problems that might occur with various
methods.
7. Clarify information with the use of demonstrations and visual aids.
8. Give examples of people who are satisfied users of the method (only if they are willing to have their
names used). This kind of personal testimonial is most convincing.
9. Reassure the client by examining her and telling her your findings.
10. Counsel the client about all available birth spacing methods.
11. Reassure and let the client know that you care by conducting home visits.

67
DAY (2)
 IMPLANON NXTinsertion and removal
 Insertion and removal demonstration
 Insertion and removal practice on arm
model
 Insertion and removal practice in
clinical setting
 Infection prevention precautions
 Management of side effects and
complications

68
PROGRAM
DAY (2)
Time Topic
8:00 – 8: 15 Welcome and where we are activity
8:15 – 10:00 Session4:IMPLANON NXTinsertion and removal
Insertion demonstration
Post insertion instructions
Removal demonstration
Infection prevention
10:00 –10:30 Coffee Break
10:30 – 12:15 Session 5:Insertion and removal practice
Practice on arm model
Practice in clinical setting
Clinical setting practice feedback
12:30 – 02:00 Session 6: Management of side effects and
complications
Case study and problem-solving exercise

69
Session 4
(Implanon NXTinsertion & removal)
Session Outline

71
SESSION 4 (IMPLANON NXT Insertion and Removal)
8:00– 8:15 Where are we? And
reflections
Group
discussion
Annex 9
8:15 – 10:00 Session (4): Practicing Insertion Implanon NXT
Implanon NXT Insertion:
Required Equipment
Video
demonstration
Mini-lecture
Video tape or CD
Session (4) A: Slides 2-3
Steps in Implanon NXT
Insertion
Mini-lecture Session (4) A: Slides 4-13
Steps in Implanon NXT
Removal
Mini-lecture Session (4) B:Slides 2-10
Session (4): Infection Prevention
Infection Prevention Steps Mini-lecture Session (4) C:Slide 2-4
Demonstration/Return
Demonstration: Implant
Insertion/Removal and
Infection Prevention
Demonstration
Removal
Instructions in Trainer’s Guide
Competency Based Checklist for Implanon
NXT Insertion/Removal
Trainees Practice on
Anatomical Models
Group Work
Annex 10 Basic learning guidelines for
insertion and removal of Implanon NXT
*Note to Facilitator: Classroom training may end here and participants proceed on to
clinical practice. However, if you feel that participants need more practice on anatomical
models, continue in the classroom before proceeding to clinical practicum.

71
Session Outline
SESSION 4: IMPLANON NXT Insertion and Removal
TIME: 105 Minutes
Practicing Insertion and Removal Single-Rod Implant
Session Objective: To demonstrate insertion and removal procedures
for single-rod implants.
This presentation is focused solely on the mechanics of the clinical
procedure; refer to the basic presentation slide sets for guidance about
counseling users and other implant-related issues.
Slide Set:
Session
One-Rod Implant Insertion: Required Equipment
Mini-lecture
• Implanon NXT is the only one-rod system currently on the market.
Similar to two-rod implants, Implanon NXT is inserted
subdermally.
• The basis for the successful use and subsequent removal of a one-
rod implant is a correct and carefully performed subdermal insertion.
The provider should give special attention to aseptic technique and
careful surgical technique to minimize tissue trauma and to keep the
implant from being inserted too deeply, thus becoming more
difficult to remove.
• Providers with little experience in subdermal insertion should
acquire the correct technique under the supervision of an
experienced colleague.
• Use the illustration and the information on Slide 2 to describe the
equipment required for the insertion procedure.
• Use the illustration on Slide 3 and the information below to describe
individual components of the applicator and clarify their specific
functions.
• Explain that insertion of Implanon NXT is performed with the
specially designed applicator (see Slide 3)
• Remove the sterile preloaded disposableImplanon NXT
applicator carrying the implant from its blister. The applicator
should not be used if sterility is in question
Slide 2: One-Rod
Implant Insertion:
Required Equipment
Slide 3: Implanon
NXTApplicator
Steps in Implanon NXT Insertion Implanon NXT
Mini-lecture
• Use the illustrations and the information on the slides to
describe each step in the insertion procedure.
Slides 4-13:
Implanon NXT
Insertion Steps 1-10

72
• Use Slide 5 to:
• Explain the implant should be inserted subdermally just under the
skin to avoid the large blood vessels and nerves that lie deeper in
the subcutaneous tissue in the sulcus between the triceps and bicep
muscle
• Use Slide 8 to:
• Remind providers that the implant can fall out of the needle
prior to insertion. Instruct them to always hold the applicator
with the needle pointed upwards, until the time of insertion.
This will prevent the implant from dropping out. The needle
and the implant must be kept sterile. If contamination occurs,
a new package with a new sterile applicator must be used.
• Use Slide 12 to:
• Instruct providers to make sure that they do not insert the
implant too deeply. Remind them that if the implant is placed
too deeply, paresthesia (due to neural damage) and migration
of the implant (due to insertion of the fascia or in the muscle)
may occur. Improper insertions have been associated with
rare cases of intravascular insertion. Moreover, the implant
may not be palpable, and localization or removal can be
difficult later.
• Use Slide 13 to instruct providers how to:
• Make sure that they always verify the presence of the implant
by palpation and also have the woman palpate it herself.
• Apply a sterile gauze with a pressure bandage to prevent
bruising.
• Complete the user card and give it to the client. Explain that
the user card records the batch number of the implant, the
date of insertion, the arm of insertion, and the intended day
of removal.
• Review the post-insertion instructions and key messages for
implant users, and address any final questions that the client
may have. (See basic presentation slide sets for details).
• Dispose of the applicator and syringe properly. The
applicator is for single use only and must be disposed of in a
sharps container in accordance with local regulations for the
handling of biohazardous waste.
*Note to trainer:Because Implanon NXTis the only one-rod system
currently on the market, these instructions are specific to Implanon NXT.
This presentation is focused solely on the mechanics of the clinical
procedure; refer to the basic presentation slide sets for guidance about

73
counseling users and other implant-related issues.
Steps in Implanon NXT Removal
Mini-Lecture
• Slide 2:
o Use the illustration and the information on the slide to describe
the equipment required for the removal procedure.
o The removal of Implanon NXT should only be performed by a
provider who is trained to perform the removal procedure.
o There have been occasional reports of displacement of the
implant, usually involving minor movement from the original
position. This may complicate localization of the implant and
may require a somewhat larger incision and more time. The
precise location of the implant is specified on the birth spacing
card given to the woman.
o In the rare cases where Implanon NXThas not been inserted
correctly, the implant might not be palpable. If this occurs, there
are other localization techniques that may be performed. If the
implant is not palpable, it may be appropriate to seek
consultation or provide a referral. Ifa woman wishes to avoid
pregnancy, she may have another implant inserted―if she is
eligible―or choose another method of contraception.
• Use Slide 3 to advise providers that:
o If they cannot feel the implant, it should be localized by x-ray,
ultrasound, or magnetic resonance imaging (MRI) if needed.
o If there is asuspicion that the implant was expelled without client
noticing, the presence of Implanon NXTcan be verified by
measuring the etonogestrel level in a blood sample from the
woman.
o 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.
• Slide 10:
o Use the information on the slide to clarify options for clients
who decide to continue or discontinue the method.
o Remind providers to inform their clients thatfollowingthe
removal, the contraceptive effects reverse quickly and a woman
can become pregnant at a rate similar to women who have not
used the method.
Slide Set:
Session (4) B
Slides 2-10:
Implanon NXT
Removal Steps 1-7

74
Infection Prevention
Discussion
• Inserting and removing progestin-only implants are minor surgical
procedures, and it is important that providers follow careful infection
prevention procedures with every client.
o Use slide 2 to describe infection prevention procedures prior to
implant insertion or removal.
o Use slide 3 to describe infection prevention procedures after
implant insertion or removal.
• Ask participants to brainstorm: “What steps should you take to
prevent infection prior to, during, and after the insertion or removal
procedure?” <participants brainstorm; accept responses from
several participants; click the mouse to reveal the information on the
slide>
• Distribute to each participant a copy of the Handout #12: Checklist:
Providing Implants with Appropriate Infection Prevention Practices;
review each step on page 5 of the checklist.
Slide Set:
Session (4)C:
Slide 2: Infection
Prevention: Prior to
Implant Insertion or
Removal
Slide 3: Infection
Prevention: After
Implant Insertion or
Removal
Handout # (Annex
10):Checklist:
Providing Implants,
With Appropriate
Infection
Prevention Practices
Implants: Summary
Mini-lecture Summarize the important points about implants.
Slide 4: Implants:
Summary

75
Annex 9
Session 4(IMPLANON NXTinsertion and
removal)
(Where are we?)

76
"Where Are We?" and "Reflections"
Where Are We?
Activity: Daily review of key concepts Materials:
Flipchart, stand, and markers Time: 10-15
minutes each day
Purpose:
1. To give people the opportunity to review what they learned the previous day.
2. To provide a transition from one day to the next.
3. To indicate to the trainers how muchparticipantshave retained.
4. To clarify any misconceptions or misunderstandings.
Procedure:
Each morning (with theexception of the first day) before the session begins,a designated
trainer should come to the front of the group to discuss the key concepts of the day before.
1. Ask theparticipant to state the main or key points from the day before.
2. Write down their comments on the flipchart.
3. If someone gives you a one-word answer, ask that person to expand on the point. If
s/he has difficulty verbalizing the concept, ask another participantto help.
4. Do not spend too long on this; remember you are looking only for the most important
themes, not a summary of the previous day's session.
5. Save the flipcharts to review at the last session. This helps participants see what they
consider the main points learned throughout the workshop. The information may also
help the trainers in their evaluation of the workshop and its activities.
Alternative procedure:
1. Has the trainer read the previous day’s key concepts from a flipchart? (This ensures
that the correct concepts are presented, rather than assuming that every participant is
capable of identifying and clearly stating them.)
2. Either review the flipcharts at the last session or present eachparticipant with a Key
Concept handout for them to use as a permanent reminder of their most important
workshop learning's.
Reflections
After a full day of activities, we need to take thetime to look at what we have done and
examine what it means to us individually. This is a method to explore how what we have
learned can be applied in a broader setting.
The "Reflections" activity will be our opportunity to make these analyzes. It is also an
opportunity for the trainers and participants to share feedback on the training activities and
to identify areas that need reinforcement or further discussion. Therefore, at the end of
each day, we will use various methods of conducting this activity to reflect on the day's
work.

77
For the first session of "Reflections," each trainer and participant should answer the
following questions and share responses with the group:
• What did I like about today?
• What did I not like about today?
• What did I learn and experience today that I will be able to use?

78
Annex 10
Session 4(IMPLANON NXTInsertion and
Removal)
(Infection Prevention Checklist)

79
Providing Implanon NXT, With Appropriate Infection Prevention Practices
Although insertion and removal of implants are minor surgical procedures, careful infection prevention
procedures must be followed with every client. Infection prevention during insertion and removal
involves aseptic technique (performing the procedures under sterile conditions). Proper infection
prevention procedures minimize the chances of blood-borne infections such as HIV and hepatitis B and
of infections at the insertion site. Infection at the insertion site may require early removal or cause
spontaneous expulsion of implants. Generally, sterilization is required for instruments such as scalpels
and needles that touch tissue beneath the skin. If sterilization is not possible or practical, instruments
must be high-level disinfected.
Family planning providers can use this checklist to help ensure that the procedure is done safely:
Getting Ready
 Have the client wash her entire arm and hand (the one she uses less often) with soap and water,
and dry with clean towel or air-dry.
 Cover the procedure table and arm support with a clean cloth.
 Ask the client to lie on her back on the table so that the arm in which the implants will be placed is
turned outwards and bent at the elbow and is well supported.
 Prepare a clean instrument tray and open the sterile instrument pack without touching the
instruments or other items.
 For Implanon NXT, remove the sterile applicator with the preloaded implant from the package by
allowing it to fall on the sterile tray without touching it.
Before Insertion
 Wash hands thoroughly with antiseptic soap and water and dry with clean towel or air-dry.
 Put sterile or high-level disinfected gloves on both hands before each procedure.(If using gloves
with powder, rinse them in sterile or boiled water before starting the procedure because the
powder may fall into the insertion site and cause scarring.)
 Clean the insertion site with a cotton or gauze swab soaked in theantiseptic solution and held in a
sterile or high-level disinfected forceps.
 Use sterile surgical drape with a hole in it to cover the arm. The hole should be large enough to
expose the entire area where the implants will lie once they are inserted
 When giving local anesthetic, use a new disposable syringe and needle, from a sealed package.
 During Insertion
 Hold the applicator just above the needle at the textured surface area. Remove the transparent
protection capby sliding it horizontally in the direction of the arrow away from the needle. If the
cap does not come off easily, theapplicator should not be used. You can see the white colored
implant by looking into the tip of the needle. Do not touch the purple slider until you have fully
inserted the needle subdermally, as it will retract the needle and prematurely release the implant
from the applicator.
After Insertion
 Press down on the incision with gauze for a minute or so to stop any bleeding, and then clean the
area around the insertion site with antiseptic solution on a swab.

81
 Use an adhesive bandage or surgical tape with sterile cotton to cover the insertion site. Check for
any bleeding. Cover with a dry compress and wrap gauze around arm tight enough to provide some
compression to minimize bleeding under the skin (hematoma), but not so tight that it will cause
pain and paleness in the arm.
 Dispose of the single-use applicator (for Implanon NXT) and used disposable syringes and needles
in a puncture-resistant container.
 Immediately after inserting or removing the implants, decontaminate non-disposable instruments
by soaking them in a 0.5% chlorine solution for 10 minutes. Decontamination makes them safer for
final processing of the instruments (described below).
 Dispose of contaminated objects (gauze, cotton, and other waste items) in a properly marked leak-
proof container with a tight-fitting lid or in a plastic bag.
 Wash instruments with a brush, using water and either liquid soap or detergent. Avoid bar soap or
powdered soap, which can stay on the equipment. Rinse and dry the equipment.
 Sterilize instruments
 in a high-pressure steam autoclave or a dry-heat oven or with chemicals. If sterilization is not
possible or practical, high-level disinfect them by boiling, by steaming, or with chemicals.
 Decontaminate all surfaces that could have been contaminated by blood, such as the procedure
table or instrument stand, by wiping them down with 0.5% chlorine solution.
 Wash hands with soap and water and dry with clean towel or air-dry.
Sources: McIntosh 1993 (8), Organon 1999 (9), Organon 2005 (10), EngenderHealth 2001 (4), World Health
Organization2004 (16), and World Health Organization and Johns Hopkins Bloomberg School of Public
Health 2007 (17)

81
Session 5
(IMPLANON NXTInsertion and Removal
Practice)
Session Outline

82
SESSION 5 (IMPLANON NXTInsertion and Removal Practice)
Time Objective Content &
Activities
Resources
10:30-11:15 By the end of
this session the
participants should
be able to:
Demonstrate
competency on
inserting Implanon
NXTrod on arm
model
Trainees practice in
pairs by using BLG
and exchanging
roles as performer
and observer
- Implanon
NXTapplicator
- Arm model
- BLG for insertion
and removal
(Annex 11)
11:15-11:30 Demonstrate
competency in
performing infection
prevention
procedures in
simulated situation
Trainees practice in
pairs by using
infection prevention
checklist and
exchanging roles as
performer and
observer
- Simulated
setting using
infection control
materials
- IP checklist
(Annex 10)
11:30-12:15 Demonstrate
competency on
inserting Implanon
NXTrod on real client
(optional for those
who become
competent on arms
model)
Providing service at
clinical setting under
close supervision of
master trainer/coach
- Implanon
NXTinsertion
supervisor
checklist (Annex
12)

83
Session outline
SESSION 5: IMPLANON NXTinsertion and removal practice
TIME: 90 Minutes
Clinical Procedure Skills Training
Competency-based training (CBT) is very different from the traditional education most of us
received. Competency-based training is learning by doing. It focuses on the specific knowledge,
attitude and skills (KAS) that are needed to carry out a procedure, task or activity. All clinical
training should be competency-based. In CBT, clinical skills are developed in the classroom, in a
simulated setting, using role plays or an anatomical model, before the trainee comes in contact with
an actual patient in a clinical setting. During the learning process, the clinical trainer determines
whether and when the learner is competent to practice the relevant procedures on clients in a
supervised clinical setting.
Clinical trainers should determine competency in the provision of methods by assessing a
learner’s KAS throughout the learning intervention against a set of criteria captured on a
validated knowledge assessment tool and skills checklist. As a general rule, trainees should:
 Be introduced to the procedure
 Observe demonstrations in role plays, on models, and with clients
 Have opportunities to practice the required procedures in role plays or on anatomical models
in a simulated setting
 Be coached and receive constructive feedback
In the CBT approach, actions required to complete each clinical task are detailed in BLG(Basic
Learning Guide) that then serve as guides for both instructors and trainees. The checklists of tasks
for each skill are derived from evidence-based internationally accepted standards. They are very
specific and even include the communication and recording activities required.
The BLG and checklists are used in a variety of ways in training. On arrival, the trainer should
assess the participant’s learning needs by assessing his/her performance with a checklist. The
checklist should be filled out and given to the trainee to use as a learning guide for the training.
Trainees can verify the validity of the items on the checklist as they observe the trainer performing
the skill. Later each participant uses the checklist to guide development, integration and proper
sequence of each task within the skill as he/she develops clinical competency. Periodically during
the CBT course, the participant is observed by the trainer to assess progress. Trainees may also
observe and critique each other using the checklist. When the trainee can demonstrate the ability to
perform all of the actions on the checklist with 100% accuracy, the trainee can advance to actual
clinical practice with clients.
During the practicum, the clinical trainer must again determine whether the learner can safely,
effectively, and independently perform the procedures. Only then can a learner be considered
qualified to provide the method(s) at their workplace. Newly qualified trainees should be
instructed to refer complicated cases to more experienced providers unless they can perform
those under supervision. Trainees should not be left alone in clinical practice until they are
considered to be competent and have support in their clinics.

84
A skilled trainer’s judgment is the most important factor in determining a trainee’s
competence. Competence carries more weight than the number of procedures performed.
Trainers must enable every participant to achieve competency and provide additional practice of
skills if necessary. Using competency-based checklists ensures that trainees have mastered
clinical and counseling skills and activities, first with role plays and models and then with
clients. Checklists also ensure that all trainees will have their skills measured according to the
same standard and forms the basis for follow-up observations and evaluations. After a trainee
demonstrates competency, they can work with clients, and checklists can be used again to assess
their performance.
Certification of a trainee's competency means that a trainee is competent to perform a procedure
independently, without supervision.
Steps for Guiding a Clinic-Based Practicum
1. Orient the trainee to the space where they will be seeing clients for visits. Ensure that they
know where to access the supplies that they need during their interactions with clients.
2. Pre-screen clients to ensure that their reason for visiting the clinic is to receive FP services.
Ideally, it would be most efficient to identify those who express an interest in the
contraceptive method(s) that the provider has learned to provide (e.g., clients interested in an
implant if the provider is learning to offer implants).
3. Before initiating any interaction with a client, inform the client that this is a learning activity
for the trainee that will occur under the close observation of an experienced
provider/supervisor who is prepared to intervene as needed. Ask the client’s permission for
the trainee to conduct the session and request that she/he initial the observation checklist to
indicate her/his approval. The supervisor should also initial the observation form to verify
that the client’s permission was obtained.
4. Use a competency-based skills checklist to document the trainer’s observations of the
interactions that the trainees have with clients. Adapt the checklist as needed to include
specific tasks and sub-tasks related to implants. Duringthe course of each trainee’s
interaction with a client, check YES, NO, or NA (not applicable) next to the item described
in the checklist. Use the space on the second page of the checklist to make detailed notes
about your observations.
5. If at any time during the trainee’s interaction with the client it appears that the client’s care is
being compromised, intervene in the interaction or the procedure to ensure the client’s safety
is maintained at all times. Decide whether the trainee should receive a passing score (if she
demonstrated overall competence) for this interaction and note that on the last page of the
checklist.
6. Immediately after the conclusion of the client interaction, meet with the trainee to discuss
your observations. Provide reinforcement for the items or tasks that the trainee completed
correctly and offer constructive feedback for items or tasks that the trainee needs to improve.
As indicated, instruct the trainee to read pages from the counseling tool or job aids booklet
to review key information or tasks that need improvement. Share your overall score of the
interaction with the trainee, indicate passed/failed in the space provided and ask the trainee
to sign the checklist.

85
Annex 11
Session 5 (IMPLANON NXTInsertion and
Removal Practice)
(Basic learning Guide for insertion and
removal of IMPLANON NXT)

86
A. BASICLEARNING GUIDE FOR IMPLANON NXTINSERTION CLINICAL
SKILLS
(To be used by Participants)
Check whether the required task/activity has been done or not by writing (√) for
Yes and (×) for No in the box in front of each case.
Name of Participant:------------------------------------------------------------------------------------------Course Dates-------------------------------
LEARNING GUIDE FOR IMPLANON NXTINSERTION CLINICAL SKILLS
TASK/ACTIVITY CASES
Getting Ready
1. Ensure that client was counseled for Implanon NXTuse.
2. Review “Client Assessment Checklist” and further evaluate client if
indicated.
3. Assure client she will not feel Pain.
4. Ask client about allergy to anesthetics.
5. Help client get on the table and correct positioning of the non-dominating
arm.
6. Ensure that all instruments needed for insertion and Implanon NXTset are
present.
Pre-Insertion Tasks
7. Wash hands thoroughly with soap and water, and dry with asterile cloth.
8. Put sterile or HLD gloves on both hands.
9. Arrange instruments and supplies.
10. Prepare insertion site by swabbing area with antiseptic.

87
LEARNING GUIDE FOR IMPLANON NXTINSERTION CLINICAL SKILLS
TASK/ACTIVITY CASES
Insertion of Implanon NXT
1. Correctly choose insertion site on themedial side of arm 6-8 cm above the
elbow between biceps and triceps muscles.
2. Anesthetize the insertion site with anesthetic spray or injecting 2 ml
Lidocaine solution.
3. Remove the sterile preloaded disposable Implanon NXTapplicator carrying
the implant from its blister.
4. Hold applicator just above the needle at the textured surface area and
remove the transparent protection cap by sliding it horizontally,away from
the needle
5. The applicator should not use if it doesn’t come off easily.
6. Do not touch the purple slider until you have fully inserted the needle
subdermally.
7. Stretch the skin at insertion site before inserting the needle.
8. Puncture the skin with the tip of the needle angled about 30 degrees.
9. Lower the applicator to a horizontal position and slide the needle to its full
length while lifting the skin with the tip of the needle.
10. Unlock the purple slider by pushing it slightly down and move fully back until
it stops.
11. Remove the applicator now.
12. Palpate the skin to ensure that the implant is in place.
Post-Insertion Tasks
13. Apply sterile gauze and apressure bandage.
14. Instruct client as regards care of the insertion site, removal of thebandage,
washing, and symptoms that necessitate reporting to theclinic.
15. Proper decontamination and disposal of waste materials according to
guidelines.

88
USING THE BASIC LEARNING GUIDES (BLG)
- BLG do not include the steps involved in counseling clients.
- BLG are designed to be used primarily during the early phases of learning (i.e. skill
acquisition) when trainees are practicing on models.
- Before using the BLG, the clinical trainer will review the entire insertion/removal
activity with the trainees using slides, videotapes, and arm models. The trainees can
use the BLG to follow the steps as the clinical trainer is demonstrating the
insertion/removal procedures.
- Subsequently, BLG serves as step-by-step guides for trainees as he/she performs
the skill in arms model.
The clinical trainer circulates to each trainee to observe how his learning is
progressing and check to see that he/she is following the steps outlined in the BLG.
- As the trainee progress through the course and gain experience, dependence on the
detailed BLG decreases.
- Once theskill is acquired, trainees can use the BLG to rate each other’s performance.
This exercise can be used as a basis for discussion during a small group discussion
before the trainees provide service to clients.

89
B. BASIC LEARNING GUIDE FOR IMPLANON NXTREMOVAL CLINICAL
SKILLS
(To be used by Participants)
Check whether the required task/activity has been done or not by writing
(√) for Yes and (×) for No in the box in front of each case.
Name of Participant:-----------------------------------------------------------------------------------Course Dates-------------------------------------
LEARNING GUIDE FOR IMPLANON NXTREMOVAL CLINICAL SKILLS
TASK/ACTIVITY CASES
Getting Ready
1. Ask client the reason for removal (if less than three years after insertion).
2. Assure client she will not feel Pain.
3. Ask client about allergy to anesthetics.
4. Ensure that client had washed her arm with soap and water and rinsed it to
remove all soap.
5. Help client gets on the table and position the arm and place a clean dry cloth
under the arm.
6. Palpate the capsule to locate thepoint of removal.
Pre-Removal Tasks
7. Wash hands thoroughly with soap and water, and dry with asterile cloth.
8. Put sterile or HLD gloves on both hands.
9. Arrange the instruments and supplies.
10. Prepare removal site by swabbing area with antiseptic beginning at the
incision site and moving outward in a circular manner, then allow to dry.

91
Removal of Implanon NXT
1. Locate the Implanon NXTcapsule and anesthetize the area below the distal
tip by injecting 0.5 – 1 ml of theanesthetic solution under the implant.
2. Check for anesthetic effect before making the incision.
3. Make a longitudinal incision 2 mm long at thedistal end of Implanon NXT.
4. Push implant down until the tip become visible in the wound.
5. Grasp the implant with a mosquito forceps and pull it out.
6. If it does not come out, incise tissues with a scalpel and push the implant.
7. Show the implant to the client.
Post-removal Tasks
1. Close the incision with an aid-band.
2. Apply sterile gauze and apressure bandage.
3. Instructs client about thecare of the site, removal of thebandage, washing,
and symptoms that necessitate reporting to the clinic.
4. Observe client for at least five minutes before sending home.

91
Annex 12
Session 5 (IMPLANON NXTInsertion and
Removal Practice)
Implanon NXTInsertion Supervisor Checklist

93
Session 6
(Management of side effects and
complications)
Session Outline

94
SESSION 6:Management of side effects and complications
12:30 – 02:00 Management of Side
Effects: Bleeding
Changes
Mini-lecture Session (6) : Slide 4
Management of Side
Effects: Non-Menstrual
Problems
Mini-lecture Session (6) :Slide 5
Management of Side
Effects: Problems
Related to Insertion
Brainstorming/
Discussion
Session (6) :Slide 6
Managing Problems
Reported As Side Effects
Group Work Annex 13

95
Session Outline
SESSION 6: Management of side effects and complications
TIME: 90 Minutes
Training process Resources
Management of Implant Side Effects: Bleeding Changes
Mini-lecture
• Ask participants: What is the most important thing that you can
do for women who experience side effects? Participants
brainstorm; accept responses from several participants,Compare
responses with the slide.
• As we have discussed, the best way to reduce the anxiety some
women feel when they experience side effects is to provide
detailed information about possible side effects before implant
insertion. If side effects occur, the first step is to address the
client’s concerns through follow-up counseling.
• If a client complains about irregular or breakthrough bleeding, the
provider should explain that implants make the uterine lining
thinner, sometimes causing it to shed earlier than usual, resulting
in this type of bleeding. It is also important to reassure the woman
that this bleeding does not mean that anything is wrong and
remind her that it will likely diminish with time.
• If the irregular bleeding is unacceptable to the client, the provider
may recommend up to 800 mg of ibuprofen, or an equivalent
amount of another non-steroidal anti-inflammatory drug (NSAID)
other than aspirin, three times per day for five days. Women who
are experiencing irregular bleeding should not take aspirin since it
may increase bleeding, not decrease it.
• If an NSAID does not provide relief, the provider can give a low-
dose combined oral contraceptive (COC)containing the progestin
levonorgestrel for 21 days. An alternative to COCs is to give 50
µg ethinylestradiol daily for 21 days. If bleeding is prolonged or
heavy—twice as long or twice as much as usual—the provider
can suggest that the woman takes iron tablets to help prevent
anemia. If irregular or heavy bleeding continues to bother the
client or starts after several months of normal monthly bleeding or
amenorrhea, the provider should rule out a possible underlying
condition unrelated to method use, such as uterine fibroids, an
STI, genital cancer, or pregnancy.
• Amenorrhea is another common side effect of implants. Providers
can reassure their clients that it does not indicate a health problem
and no medical treatment is necessary. This side effect is similar
to not having monthly bleeding during pregnancy.
Slide 4: Management of
Implant Side Effects:
Bleeding Changes

96
• If side effects persist and are unacceptable to the client, the
provider should help her choose another contraceptive method.
Management of Implant Side Effects: Non-Menstrual Problems
Mini-lecture
• There are several non-menstrual side effects that clients who are
using implants may experience.
o If a client experiences frequent headaches that are not
migraines, reassure her that ordinary headaches do not
indicate dangerous conditions and usually diminish over time.
Standard doses of painkillers such as ibuprofen, paracetamol,
or other pain relievers may be used to alleviate symptoms.
However, if headaches get worse or occur more often after
insertion of implants, they should be evaluated.
o Mild abdominal pain may be caused by many conditions,
including enlarged ovarian follicles or cysts. Reassure the
client that ovarian follicles or cysts usually disappear on their
own and standard doses of painkillers or other local remedies
will usually alleviate discomfort. To be sure the problem is
resolving, see the client again in six weeks. There is no need
to treat enlarged ovarian follicles or cysts unless they grow
abnormally large, twist, or burst. However, if abdominal pain
becomes severe, refer at once for immediate diagnosis and
care. This is especially true if the severe abdominal pain
occurs with other signs or symptoms of ectopic pregnancy
such as abnormal vaginal bleeding or no monthly bleeding
(especially if this is a change from her usual bleeding pattern),
light-headedness, dizziness, or fainting. Ectopic pregnancy is
rare but can be life-threatening.
o Clients who experience breast tenderness may try wearing a
supportive bra and can apply hot or cold compresses. They
can also take standard doses of painkillers such as aspirin,
ibuprofen, or paracetamol.
o In thecase of weight gain, review the client’s diet and counsel
her about healthy eating habits and exercise as a way to better
control her weight.
o If side effects persist and the client wants to stop using
implants, health care providers should counsel about non-
hormonal options and help the woman choose another
method.
Non-Menstrual
Problems
Management of Implant Side Effects: Problems
Related to Insertion
Brainstorming/Discussion
• Clients may sometimes experience problems related to the
insertion of implants.
Problems Related to
Insertion

97
• Ask participants to brainstorm what side effects may occur as a
result of insertion and what advice would they give to the client.
These problems can usually be addressed easily.
• For pain after insertion, check that the bandage on the client’s arm
is not too tight. Put a new bandage on the arm and advice the
client to avoid pressing on the site for a few days. Standard doses
o, ibuprofen, paracetamol, or another pain reliever may also be
helpful.
• If the woman experiences redness, heat, pain, or pus at the
insertion site, this may indicate an infection. In this case, do not
remove the implants. Clean the infected area with soap and water
or antiseptic. Give oral antibiotics for 7 to 10 days. Instruct the
client to take all the antibiotics. If the infection has not cleared
after completing the course of antibiotics, ask the client to return
for removal of the implants.
• In some cases, the client may develop an abscess—a pocket of
pus under the skin caused by an infection. If this happens, clean
the area with antiseptic. Cut open and drain the abscess, and treat
the wound. Give the woman oral antibiotics for 7 to 10 days.
Instruct the client to take all the antibiotics. If she still has signs of
infection—such as heat, redness, pain, or drainage from the
wound—after completing the antibiotics, ask the client to return
for removal of the implants.
• Expulsion or partial expulsion of the implants often follows an
infection. Ask the client to return for follow-up care if she notices
an implant coming out.
Managing Problems Reported as Side Effects
Group Work
• Note that the national FP guidelines provide specific
recommendations for management of implants side effects,
photocopy, distribute, and refer to the guidelines.
• Divide participants into several groups. Divide the side effects
among the groups. Ask the groups to develop plans for managing
each side effect. Allow 30 minutes for the groups to develop their
plans and 15 minutes to report back.

98
Annex 13
Session 6 (Management of side effects and
complications)
(Case study 1, Answer Key)

99
Implanon NXT: Case Study 1
Salma is a 20-year-old woman who just married and wants to delay pregnancy until shegraduates.
She and her husband both feel healthy. On the advice of a family doctor, theydecided to get tested
for sexually transmitted infections (STIs), including HIV, and tobegin using contraception. Salma
thinks that she would like to use progestin-onlyimplants. She heard about it from one of her
colleagues.
Question Set A
During the initial meeting, Salma wants to learn more about implants and asks thefollowing
questions:
1. How do implants prevent pregnancy?
2. What are some advantages of using implants?
3. What are some limitations of implants?
Question Set B
After one week, Salma and her husband return for their STI test results, and sheaffirm her decision
to have implants inserted that day if possible. She and herhusband both tested positive for
chlamydia, for which they will need to takeantibiotics. Salma started her period four days ago.
1. What tool(s) would you select to screen for medical eligibility of implants?
2. Does Salma’s current infection with chlamydia affect her eligibility for implants?
Will the antibiotics she is taking interfere with the effectiveness of the implants?
3. What additional information would you provide to Salma, given her particularsituation?
4. How soon can Salma start using implants?
Question Set C
Salma has carefully considered her options and has decided to use implants, for which
you determined she is medically eligible. Before inserting the implants, you provide
Pre-insertion counseling.
1. What tool(s) would you use to conduct this counseling session?
2. How can you help Salma anticipate and manage possible side effects?
3. What type of medical examination does Salma require before initiating implants?
4. What should you tell Salma about the insertion procedure and what to expectafterward?
Question Set D
Salma has been using progestin-only implants for the past three months. She returns
to the clinic with complaints of irregular bleeding and non-migraine headaches. Sheis also
concerned that the irregular bleeding may indicate infertility. Salma wonders ifshe should have the
implants removed.
1. How would you address Salma’s concern about the irregular bleeding?
2. How would you address Salma’s concern about the headaches?
3. How would you address Salma’s concern about implants causing infertility?

111
Case Study 1—Answer Key
Answers to Question Set A
1. How do implants prevent pregnancy?
Progestin-only implants prevent pregnancy in two ways. They prevent the releaseof eggs from the
ovaries (suppress ovulation). When no egg is released, there isnothing for the sperm to fertilize.
Progestin-only implants also cause the cervical mucus to thicken. Thicker mucusacts asa barrier,
making it more difficult for sperm to enter the uterine cavity. Inthe unlikely event that a woman
does ovulate, this mucus barrier greatly reducesthe chance that the egg will be fertilized.
Progestin-only implants do not disrupt an existing pregnancy and have no adverseeffect on a woman
or a fetus if accidentally inserted in the arm of a woman who ispregnant.
2. What are some advantages of using implants?
They are very safe.
They are more than 99 percent effective in preventing pregnancy.
They are easy to use.
They do not affect long-term fertility. If a woman wants to become pregnant,she can have the
implants removed. Pregnancy rates for women in the yearfollowing implant removal are comparable
to those for women of similar agenot using contraception.
They contain no estrogen, so they can be used by women who arebreastfeeding or have health
conditions that might restrict their use ofcontraceptives containing estrogen.
They may provide non-contraceptive health benefits, including preventingiron-deficiency anemia
and reducing the risk of acquiring symptomatic pelvicinflammatory disease (PID).
3. What are some limitations of implants?
They have side effects, especially changes in the menstrual bleeding pattern.
They cannot be initiated or discontinued without a provider’s help becausea minor surgical
procedure is required for both insertion and removal.
Like other hormonal methods, implants provide no protection against STIs,including HIV.
Answers to Question Set B
1. What tool(s) would you select to screen for medical eligibility of implants?
The Checklist for Screening Clients Who Want to Initiate Contraceptive Implants,the WHO Medical
Eligibility Criteria Wheel for Contraceptive Use, or the QuickReference Chart for the WHO
Medical Eligibility Criteria for Contraceptive Useidentify clients who have conditions or
characteristics that prevent safe use of implants,conditions classified as category 3 and 4 in the
Medical Eligibility Criteria forContraceptive Use (WHO, 2010).
2. Does Salma’s current infection with Chlamydia affect her eligibility forimplants? Will the
antibiotics she is taking interfere with the effectiveness ofthe implants?
Salma’s medical condition, infection with Chlamydia, does not affect hereligibility for progestin-
only implants. The antibiotics Sasha is taking to treatChlamydia will not interfere with the
effectiveness of the implants.
3. What additional information would you provide to Salma, given herparticular situation?
You should emphasize that implants do not protect her against STIs, includingHIV.
4. How soon can Salma start using implants?
Progestin-only implants can be initiated anytime during the menstrual cycle aslong as the provider
can be reasonably sure the woman is not pregnant. SinceSalma’s period started four days ago, she
could start using implants immediatelywithout the need for a backup method.

111
Answers to Question Set C
1. What tool(s) would you use to conduct this counseling session?
Comparing Effectiveness of Family Planning Methods (WHO)
Fact Sheet: Progestin-Only Implants
Inserting Implants (from Family Planning: A Global Handbook for Providers)
Family planning counseling tool, an illustrated client brochure, or a poster onimplants
2. How can you help Salma anticipate and manage possible side effects?
Counseling about what to expect is the best way to help Salma manage the sideeffects associated
with progestin-only implants. Explain the possible side effectsand ensure that Sasha understands
that they are not signs of disease or healthproblems. While some women may not have any side
effects, the majority ofwomen experience menstrual changes in the first year of implant use.
Lightbleeding or spotting, irregular bleeding that occurs frequently, prolonged bleedingthat lasts
more than eight days, infrequent bleeding, and no bleeding at all
(Amenorrhea) are menstrual irregularities that women report. Typically, thefrequency of these
menstrual changes—especially prolonged bleeding—decreaseswith time and is less of a problem by
the end of the first year of use. Non-menstrualside effects include headaches, abdominal pain, acne
that can worsen orimprove, weight change, breast tenderness, dizziness, mood changes, and nausea.
Tell Salma that if she experiences side effects that are unacceptable, there areways to alleviate
discomfort.
3. What type of medical examination does Salma require before initiatingimplants?
You must be reasonably sure that Salma is not pregnant and is medically eligiblefor implants. Use
the Checklist for Screening Clients Who Want to InitiateContraceptive Implants. No pelvic
examination or blood tests are required to startusing this method.
4. What should you tell Salma about the insertion procedure and what to expectafterward?
You should tell Salma that:
An injection of local anesthetic to prevent pain will be given under the skin ofher arm. It may sting
a little.
A small puncture is made in the skin of the upper arm.
Implants are inserted just under the skin, and she may feel some pressure ortugging.
After insertion, the incision is closed with an adhesive bandage. Stitches arenot needed. The
incision is covered with a dry cloth and her arm will bewrapped with gauze.
Salma’s arm may be sore for a few days after insertion. Some swelling andbruising are common
and do not require treatment.
Emphasize that she needs to keep the insertion area dry for four days.
The outer bandage or gauze can be removed after two days; the adhesivebandage after five days.
Encourage Salma to return anytime she has questions, problems, or concerns;suspects that she is
pregnant; or has a major change in health status. If she hasany pain, heat, pus, orredness at the
insertion site, or sees an implant comingout, she should return for treatment.
Give Salma a reminder card so that she knows what type of implant she hasand when she will
need to have it replaced. Tell her to inform other health careproviders that she is using implants.
Answers to Question Set D
1. How would you address Salma’s concern about the irregular bleeding?
Ask Salma probing questions so that you have a complete understanding of herconcerns and the
pattern of her bleeding. Reassure Salma that irregular bleedingsometimes happens with progestin-
only implants. Explain that the implant makesthe uterine lining thinner, so shedding can sometimes
start early. This does notmean that anything is wrong, and in many cases, the bleeding diminishes
withtime.

112
In the meantime, recommend that Salma begins a five-day course of ibuprofen, up to800 mg, three
times per day. If that does not provide adequate relief, you canrecommend a low-dose oral
contraceptive pill for 21 days to help reduce thebleeding. If bleeding is very heavy, you may also
give Sasha iron tablets to preventanemia.
Assure Salma that if these solutions do not work, or if she continues to beuncomfortable with the
method, she can choose another method.
2. How would you address Salma’s concern about the headaches?
Ask Salma probing questions so that you have a complete understanding of herconcerns and the
severity and type of headaches she is having. Reassure Salmathat headaches are a side effect
commonly associated with implants. Suggest thatshe use a standard dose of painkiller to manage the
headache pain. If Salmadescribes symptoms of migraines or is having headaches that worsened
since theimplants were inserted, evaluate to determine ifdiscontinuation is appropriate. Ifher
headaches persist and are unacceptable to her, remove the implants andcounsel Sasha about non-
hormonal methods.
3. How would you address Salma’s concern about implants causing infertility?
Assure Salma that the bleeding irregularities caused by the implants will not causeinfertility. When
she chooses to become pregnant, the implants can be removedand she can become pregnant as
quickly as women using non-hormonalcontraceptive methods. Implants do not cause a delay in the
return of a woman’sfertility after they are removed. The bleeding pattern that she had prior to
implantsgenerally returns soon after implants are removed. However, some women waitseveral
months for their usual bleeding pattern to return.

113
DAY (3)
 When to remove IMPLANON NXT
 Rare complications and difficult removals
 Insertion and removal practice on arm
model
 Insertion and removal practice in
clinical setting
 Participants evaluation
 Module review

114
PROGRAM
DAY (3)
Time Topic
8:00 – 8: 15 Welcome and where we are activity
8:15 – 10:00 Session 7: IMPLANON NXTremovalproblems
When to remove
Rare complications
Difficult removal demonstration
Role play (Annex 14)
10:00 –10:30 Coffee Break
10:30 – 12:15 Session 8:Insertion and removal practice
Practice on arm model
Practice in clinical setting
Clinical setting practice feedback
12:30 – 02:00 Session 9: Module review and evaluation
Post-test
Module reviews and course wrapping
Course evaluation
Closing ceremony

115
Session 7
(IMPLANON NXTRemoval Problems)
Session Outline

116
SESSION 7 (IMPLANON NXTRemoval Problems)
Time TOPIC Content & Activities Resources
8:15-10:00 Problems That May Require
Stopping or Switching to
Another Method
- Brainstorming
/Discussion
- Mini-lecture
Session (7):
Slide 7-8 from
session (6)
Complications From
Implants Are Rare
- Discussion
- Mini-lecture
Session (7):
Slides 9 from
session(6)
Explaining Implant Removal
to the Client
Mini-lecture Session (7):
Slide 6 from session
(3)
Review some cases of
difficult removal
Video clips on Media
CD
Demonstrate competency in
clinical decision making
regarding some Implanon
NXTside effects
Annex 14: Implanon
NXTside effects, role
play scenario

117
Session Outline
SESSION 7:Implanon NXTRemoval Problems
TIME: 105 Minutes
Problems that May Require Switching from Implants to
Another Method
Brainstorming/Discussion
• As a review exercise, write 2 columns on a flip chart. Label one
column side effect and the other management. Brainstorm the
different side effects and their management.
• Explain that there are some serious health conditions that may
require a client to stop using implants.This include:
o If a client experiences unexplained vaginal bleeding or heavy
or prolonged bleeding that is suggestive of a medical
condition not related to the method, she might need to
discontinue use of implants.
 Refer the client or evaluate by taking her medical history
and doing a pelvic examination. Diagnose and treat as
appropriate.
 If no cause of bleeding can be found, consider stopping
implants to make the diagnosis easier. Provide the client
with another contraceptive method of her choice until the
condition is evaluated and treated. The alternative method
should be something other than progestin-only injectable
or a copper-bearing or hormonal IUD.
 If the bleeding is caused by an STI or PID, the client can
continue using implants during treatment.
o Although women who have migraine headaches with an aura
can initiate implants, implants should be removed if a woman
develops migraines with aura after implants are inserted. The
provider should help her choose a non-hormonal method.
o If a woman develops health conditions such as blood clots in
the deep veins of the legs or lungs, heart disease due to
blocked or narrowed arteries, severe liver disease, or breast
cancer, the implants must be removed.
o Although women with ischemic heart disease and women who
have had a stroke can initiate theuse of implants, use of
implants should be discontinued if these conditions develop or
get worse while using implants.
 Remove the implants or refer for removal and give the
woman a backup method to use until her condition is
evaluated. Refer her for diagnosis and care if she is not
already receiving treatment.
o Finally, if a woman is pregnant, the implants should be
removed. However, there are no known risks to a fetus
Slide 7 from session (6):
Problems that May
Require Switching from
Implants to Another
Method (Part 1)
Problems that May
Require Switching from
Implants to Another
Method (Part 2)

118
conceived while a woman has the implants in place.
Complications from Implants are Rare
Mini-lecture
• Whereas side effects—especially those related to menstruation
are relatively common with progestin-only implants,
complications are uncommon or rare. They may include:
o Infection at the insertion site is an uncommon complication. If
an infection occurs, it will most likely be within the first two
months.
o The difficulty with removal may occur if insertion was done
improperly or if removal is attempted by an untrained
provider. However, if implants are properly inserted and
removed by a trained provider, difficulty in removing
implants is rare.
o Expulsion of an implant is a rare complication. If this occurs,
it is most likely to happen in the first four months. If no
infection is present, a fresh implant may be inserted through a
new incision near the other rods or capsules to replace the one
that was expelled.
Complications from
Implants are
Uncommon or Rare
Explaining Implant Removal to the Client
Discussion
• Prior to removal, a provider should describe for the client that
removing implants usually takes somewhat longer than insertion.
Providers should also reassure clients that complications related
to implant removal are rare.
o The provider uses proper infection prevention procedures.
o The woman receives an injection of local anesthetic under the
skin of her arm to prevent pain during implant removal. This
injection may sting. She stays fully awake throughout the
procedure.
o The health care provider makes a small incision in the skin on
the inside of the upper arm, near the site of insertion.
o The provider uses an instrument to pull out each implant. A
woman may feel tugging, slight pain, or soreness during the
procedure and for a few days after.
o The provider closes the incision with an adhesive bandage.
Stitches are not needed. An elastic bandage may be placed
over the adhesive bandage to apply gentle pressure for two or
three days and reduce swelling.
o If a woman wants to continue using implants, a new set of
implants may be inserted through the same incision, either in
the same or in the opposite direction.
o Providers must not refuse or delay when a woman asks to
have her implants removed, regardless of the reason.
o All staff must understand and agree that clients must not be
pressured or forced to continue using implants.
Counseling about
Implants: Explain
Removal Procedure to
Client

119
Review some cases of difficult removal Video clips on Media
CD
Role Plays
(30 min.)
• Follow the step-by-step instructions in the
Facilitator’s Guide section on facilitating role plays to prepare for
and conduct this activity.
1. Discuss the learning objective of the role play activity.
2. Review the instructions for the client, provider, and observer
roles and the other learning resources developed for the
activity.
3. View a demonstration role play and clarify any questions.
4. Conduct role plays in small groups based on the scenarios
provided and discuss reactions.
5. Discuss the activity as a large group.
• Review Handouts # and # with participants. This include:
1. Five different role play scenarios, each with a client
information sheet and observer information sheet.
2. The instruction sheet that describes the roles of providers,
clients, and observers.
3. The Role Play Observation Checklist for Clinicians.
4. Role plays scenario/information sheets for clients and
observers for the role plays you have selected or adapted from
Handout #14: Role Play Scenarios.
• Use the following questions to help the small groups structure the
feedback that they provide to each other after each role play.
o What was going on between the provider and client?
o What did the provider do that was effective in this situation?
o What might the provider consider doing differently if this
situation were to happen again?
o How did the provider attend to the items on the counseling
observation checklist and the case-specific observations
included in the role-play description?
• After the small groups conduct each role play, encourage the
groups to talk about what happened during the role play from the
perspective of the provider (self-assessment), the client (personal
satisfaction with the interaction), and the observer (objective
assessment using the Role Play Observation Checklist included in
Handout #14, including the case-specific observations included in
the role-play description).
Handout
Facilitating Role Plays
Handout ( Annex 14):
Role Play Scenarios

111
• Prepare a flip chart to display these discussion questions where
the questions can easily be seen by all the participants in the small
groups.

111
Annex 14
Session 7(Implanon NXTRemoval Problems)
Role play

112
Role Play Scenario Client requires management of implants side effects and an understanding of
management instructions
Client information sheet
Client Description
You are a 39-year-old woman with three adolescent children. You and your husband are
relatively sure you do not want any more children, but your mother-in-law does not think that
sterilization would be a good idea. Six weeks ago, you had progestin-only implants inserted.
Since then, you have experienced a number of side effects and are very concerned. You are
returning to the family planning site because you think you would like to try another method.
Offer this information only when the provider asks relevant questions:
• You have been experiencing heavy, irregular bleeding, whereas you had regular cycles
with no heavy bleeding before.
• The bleeding concerns you, and you will not be comfortable or satisfied if it continues.
• Your mother-in-law heard from a friend that using implants could result in infertility.
• You feel that your decision to use implants was made too quickly, and you are now
having second thoughts.
• You last had sex five days ago.
You are otherwise healthy
Observerinformation sheet
Make note of whether the provider addresses these case-specific issues:
• Reassesses the client’s reproductive health goals, fertility intentions, and life plans
• Attends to the mother-in-law’s concern about infertility and corrects misunderstandings
about implants
• Reassures the client that heavy, irregular bleeding is frequently a side effect among
implant users and tends to go away after a few months
• Discusses potential options for management of the bleeding side effects
• Decides which option(s), if any, the client would like to try to manage the side effect
(e.g., ibuprofen, COCs for 21 days, an iron supplement)
• Reviews the possible side effects as well as the benefits and limitations of implants and
other contraceptive options for which the client may be eligible if she decides that
implants are unacceptable
Methods for which the client is eligible:
 Implants
 COCs
 DMPA or NET-EN
 IUD
 Male or female condoms
Female sterilization or vasectomy for her husband

113
Session 8
(Implanon NXTInsertion and Removal
Practice)

114
To the Trainer:
Session number (8) and (5) are the same. It is repeated in this module to ensure that
all participants have participated in the practical training.
This session should take around (100) minutes.

115
Session 9
(Module Review and Training Evaluation)
Session Outline

116
Session Outline
SESSION 9: (ModuleReview&Training Evaluation)
TIME: 60 Minutes
Time Training process Resources
12:30 - 1: 00 Post-Test Questionnaire
(30 min.) Distribute the post-test. (Annex 15)
Evaluation
Tool: The
Contraceptive
Implants Post-
Test
1:00 -1:15 Module reviews and course wrapping
Review module objectives on slide 2-3, Session (1) and
ask participants whether thoseobjectives were achieved
during the course or not and let them summarize the
content.
Slides 2-3 from
session 1 or
objectives
written on a flip
chart
1:15 -1:45 Course evaluation
Distribute the final evaluation form and give participants
a chance to express their feeling and provide feedback
about the value of this training and its impact on
performance and quality of services.
Annex 15: Final
course
evaluation
1:45 - 2:00 Closing ceremony: Distribute certificates of completing
the course on Implanon NXTinsertion and removal;
celebrate.

117
Annex 15
Session 9 (Module Review & Evaluation)
Post-test

118
Contraceptive Implants (Implanon NXT) Post-test

121
Annex 16
Session 9 (Module review & Evaluation)
Final Course Evaluation Form

122
Training Course Final Evaluation
Please, Tick (√) the answer you feel is most appropriate.
We appreciate very much if you would take the time to give us feedback
about this course.
Excellent or always Good or usually Poor or rarely
  
Course content & Teaching methods:
1 Presentations were well organized.

2 The technical information/ skills presented in
the course were clear. 
3 Clinical training was relevant to my practice.

4 At the beginning of the course, the instructor
identified the main topics, objectives, and
evaluation techniques utilized in the course.

5 Teaching methods varied and were interesting.

6 Each training session had told, show, and do
parts. 
7 Session objectives were clearly identified by
instructors. 
8 Enough class time was spent on explaining
ideas, terms and skills. 
9 Participants were given opportunities to ask
and interact with the core teaching staff. 
10. At the end of each session, the instructor
summarized the main points presented. 
11. The course schedule reflected a reasonable
balance between didactic and practice teaching
hours.


123
12. Both the didactic topics and the practice skills
were relevant to the delivery of family planning
services.

13. Tests and quizzes were objectively handled by
the teaching staff. 
14. Course sessions were appropriate in length.

15. Classes consistently started and ended at the
assigned time. 
16. Printed materials were helpful and well-
designed. 
17. Printed materials were handled in a timely
fashion. 
18. Assignments were clearly identified in the class
syllabus or by the staff. 
19. Trainers were pleasant and respected my
feelings and opinions. 
20. Audio-visual materials were well-integrated in
the course. 
Course Logistics:
21. The course announcement clearly stated dates,
location, and duration of the course. 
22 The course announcement clearly stated the
address of the Training site. 
22 Adequate time was allowed to plan for
attending this course. 
24. Training site accommodations were adequate.

25. Breaks arrangements were adequate.

26. The timing of the coffee breaks was
appropriate. 

124
27. The training facilities were comfortable.

28. Financial arrangements were well-handled by
the Adm. & Fin. Unit. 
29 The overall experience of attending this course
is a positive one. 
30 The training center facilitates field visits,
tours,and extra services when requested 
Recommendations& suggestions
______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

126
References
 Global Handbook of family planning 2011- WHO and others
 Copyright © 2011 Merck Sharp & Dohme B.V., a subsidiary of Merck & Co.,
Inc.Revised: 07/2014 www.merck.com/product/patent/home.html
 RCTImplanon Training Curriculum. Egypt 2007
 RCT Sub-dermal implants Training Curriculum. Egypt 2000
 Sub-derma Implants Course Handbook and Notebook for Nurse-Midwives in Uganda
Ministry of Health, Regional Centre for Quality of Health Care and the JHPIEGO
Corporation.
 Contraceptive Implants- Facilitator’s Guide to the Training Resource Package 2013
– K4HEALTH Website 2014

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