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Pre-service Education on FP and AYSRH

Pre-service Education on FP and AYSRH. Session II, Topic 7 Implants. What Are Implants?. Progestin-filled rods (each about the size of a match stick) that are inserted under the skin Jadelle : 2-rod system, highly effective for 5 years

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Pre-service Education on FP and AYSRH

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  1. Pre-service Education on FP and AYSRH Session II, Topic 7 Implants

  2. What Are Implants? Progestin-filled rods (each about the size of a match stick) that are inserted under the skin • Jadelle: 2-rod system, highly effective for 5 years • Sino-implant (II): 2-rod system, being registered with WHO as effective for 3 years. (Studies are underway to see if it lasts for 4 years.) Will be marketed globally as Levoplant. • Implanon: 1-rod system, a recent study shows it is highly effective for 5 years • Nexplanon: The same as Implanon, but can be seen on an x-ray • Norplant: 6-capsule system, effective for 5 years (possibly 7); no longer manufactured but some women are still using it and may need removal

  3. Key Points for Providers and Clients • Implants are small flexible rods that are placed just under the skin of the upper arm. • Provide long-term pregnancy protection. Very effective for 3 to 5 years, depending on the type of implant. Immediately reversible. • Require specifically trained provider to insert and remove. A woman cannot start or stop implants on her own. • Little required of the client once implants are in place. • Bleeding changes are common but not harmful. Typically, prolonged irregular bleeding over the first year, and then lighter, more regular bleeding or infrequent bleeding.

  4. Effectiveness of Implants More effective Implants Less effective In this progression of effectiveness, where would you place implants? More effective Less effective

  5. Implants: Mechanism of Action Implants work in two ways Changing the menstrual cycle, including preventing ovulation Thickens cervical mucus to block sperm Implants have no effect on an existing pregnancy.

  6. Implants: Characteristics • Have side effects • Require minor surgery to insert and remove • Cannot be initiated and discontinued without provider’s help • Provide no protection from STIs/HIV • Very safe and effective, less than 1 pregnancy per 100 women in over 5 years of use • Both long-lasting and reversible • Do not interrupt sex • Fertility returns without delay when removed • Can be used by breastfeeding women • Offer health benefits Source: Hatcher, 2007; WHO, 2010; CCP and WHO, 2011.

  7. Implants: Health Benefits • Helps protect against pregnancy • Reduced risk of symptomatic pelvic inflammatory disease (PID) • May help reduce the risk of iron-deficiency anemia Source: CCP and WHO, 2011; Task Force for Epidemiological Research on Reproductive Health, 1998.

  8. Some users report changes in bleeding patterns: First several months Lighter bleeding and fewer days of bleeding Irregular bleeding Prolonged bleeding Infrequent bleeding No monthly bleeding After about one year: Lighter bleeding and fewer days of bleeding Irregular bleeding Infrequent bleeding Implanon users are more likely to have infrequent bleeding, prolonged bleeding or no monthly bleeding rather than irregular bleeding Possible Side-Effect of Implants (part 1) How would you feel about these side-effects?

  9. Possible Side-Effect (part 2) • Headaches • Lower abdominal pain • Acne (can improve or worsen) • Weight change • Breast tenderness • Dizziness • Mood changes • Nausea • Other possible physical changes: Enlarged ovarian follicles

  10. Complications from Implants Are Uncommon or Rare Uncommon • Infection at insertion site • If occurs, most likely within the first 2 months • Difficult removal • Uncommon if inserted properly and removed by a trained provider Rare • Expulsions expulsions most often occur within the first 4 months after insertion

  11. Implants Are Safe for Nearly All Women • Almost all women can use implants safely, including women who: • Have just had an abortion, miscarriage or ectopic pregnancy • Have just given birth • Have anemia now or in the past • Have varicose veins • Have or have not had children • Are not married • Are of any age including adolescents and women over 40 years old • Are infected with HIV • Most health conditions do not affect safe and effective use of implants. • Many women who cannot use methods that contain estrogen can safely use implants.

  12. Who Can and Cannot Use Implants (part 1) Most women can safely use implants But usually cannot use implants if: Some other serious health conditions May be pregnant

  13. Who Can and Cannot Use Implants (part 2) Most women can safely use implants.But usually cannot use implants if: “We can find out if implants are safe for you. Usually, women with any of these conditions should use another method.” • May be pregnant • If in doubt, use pregnancy checklist or perform pregnancy test. • Has blood clot in lungs or deep in legs. Women with superficial clots (including varicose veins) CAN use implants. • Ever had breast cancer. • Unexplained vaginal bleeding: if the bleeding suggests a serious condition, help her choose a method without hormones to use until unusual bleeding is assessed. • Serious liver disease or jaundice (yellow skin or eyes). • Systemic lupus erythematosus • Some other serious health conditions Usually cannot use with any of these serious health conditions (if in doubt, check handbook or refer)

  14. Category 1 and 2 Examples (not inclusive):Who Can Start Implants Implants are safe for nearly all women. WHO Category Conditions Category 1 adolescents, nulliparity, heavy smokers, breastfeeding 6 weeks to < 6 months, endometriosis, endometrial or ovarian cancer, thyroid disorders, uterine fibroids, hepatitis, hypertension 140-150/90-99,HIV, PID blood pressure ≥160/100, postpartum and breast feeding < 6 weeks, cervical cancer, history of DVT/PE, diabetes with vascular complications, heavy or prolonged vaginal bleeding patterns, multiple risk factors for CVD, heart disease, hypertension >160->100, migraine with aura Category 2 Source: WHO, 2015.

  15. Category 3 and 4Who Should Not Start Implants A small number of women may not be able to use implants. WHO Category Conditions Category 3 acute DVT/PE, unexplained vaginal bleeding, history of breast cancer, serious liver disease, infection or tumor, certain cases of systemic lupus Continuation only: ischemic heart disease, stroke, migraine with aura Category 4 current breast cancer Source: WHO, 2010.

  16. Implant Use by Women with HIV • Women with HIV or AIDS can use without restrictions • Some ARV drugs reduce blood progestin level • Efficacy is not affected because implants provide consistent dose of hormone over time • Dual method use should be encouraged Source: WHO, 2010; Mildvan, 2002.

  17. When to Start Implants (part 1) • Anytime a provider is reasonably certain a woman is not pregnant • Pregnancy can be ruled out if any of these situations apply: • Is fully breastfeeding, has no menses, and baby is less than 6 months • Abstained from intercourse since last menses or delivery • Had a baby in the past 4 weeks • Started monthly bleeding within the past 7 days (5 days for Implanon) • Had a miscarriage or abortion in the past 7 days (5 days for Implanon) • Is using a reliable contraceptive method consistently and correctly • If none of the above apply, pregnancy can be ruled out by pregnancy test, pelvic exam, or by waiting till next menses Source: WHO, 2004 (updated 2008).

  18. When to Start Implants (part 2) • First 7 days of menstrual cycle (5 days for Implanon), no backup method needed • After 7th day of menstrual cycle (5thfor Implanon), rule out pregnancy and use backup method for 7 days • Postpartum • Not breastfeeding: immediately (no need to rule out pregnancy until 4 weeks postpartum) • Breastfeeding: delay 6 weeks Source: WHO, 2004 (updated 2008).

  19. When to Start Implants (part 3) (continued) • Postabortion or miscarriage: immediately; without backup • Switching from a hormonal method: immediately if it was used consistently and correctly • Injectable users can have implants inserted within the reinjection window; without backup • After using emergency contraceptive pills: • Insert within 7 days after start of next menstrual period (5 days for Implanon); provide with backup method during interim Source: WHO, 2004 (updated 2008).

  20. When to Start Implants(A Review) • What if this client, who has no medical conditions that would preclude implants use, wants to initiate implants? • Client situation: • In day 4 of menstrual cycle • Condom user in day 8 of menstrual cycle • 2½ weeks postpartum, not breastfeeding • 2½ weeks postpartum, breastfeeding • Injectable user, amenorrheic, within reinjection window • IUD user, mid-cycle, had sex since last menses • After taking emergency contraceptive pills (ECPs)

  21. Key Counseling Topics for Implant Users • Safety and efficacy • How Implants work • Health benefits • Possible side effects • No protection from STIs/HIV • Inform provider she has an implant in case of serious new health problem • Reasons to return: questions, concerns or experiencing any warning signs

  22. Counseling about Implants:Additional Key Counseling Topics • Explain the insertion and removal procedure • Provide post-insertion instructions • Explain the length of protection and when to return for removal or replacement • Describe reasons to return for follow-up

  23. Counseling About Side Effects • Before insertion, describe possible side effects: • Changes in bleeding pattern (most common) • Headaches, breast tenderness, mild abdominal pain (less common) • Explain that side effects: • Are not signs of illness • Often subside within the first year • Encourage the client to come back with questions or concerns • If the client cannot tolerate side effects, management or discontinuation may be necessary

  24. Implant Insertion and Removal • Insertion and removal should be quick and easy. • Injection prevents pain. • Provider puts 1 or 2 rods just under the skin of inside upper arm. • Provider bandages opening in skin and wraps the arm—no stitches. • Need to be removed after 3 to 5 years, depending on the type of implant and your weight.

  25. What to Remember • Keep the insertion area dry for 4 days. • Expect a bit of soreness and bruising. • Come back when it is time to have the implants removed. • Side effects are common but rarely harmful Come back if they bother you. • Come back any time if you have problems or want implants removed. See a nurse or doctor if: • A bright spot in your vision before bad headaches • Yellow skin or eyes • Infection or continued pain in the insertion site or sees rod coming out • May be pregnant, especially if pain or soreness in belly • Unusually heavy or long bleeding

  26. Helping Continuing Implant Users • No routine visit required, but if she returns, ask: • Whether satisfied with method or has questions. • If she is concerned about bleeding changes. • About new health problems or major life changes (plans for more children, change in STI/HIV risk). • Significant weight changes. • If she wants to continue using implant and has no new medical condition, remind her how much longer her implant will protect her.

  27. Management of Implant Side Effects:Bleeding Changes Counseling and reassurance are key Source: CCP and WHO, 2011.

  28. Management of Implant Side Effects:Non-Menstrual Problems Source: CCP and WHO, 2011.

  29. Management of Implant Side Effects:Problems Related to Insertion Source: CCP and WHO, 2011.

  30. Problems That May Require Switching from Implants to Another Method (Part 1) Source: CCP and WHO, 2011.

  31. Problems That May Require Switching from Implants to Another Method (Part 2) Source: CCP and WHO, 2011.

  32. Complications from Implants Are Uncommon or Rare • Infection at insertion site • If occurs, most likely within the first 2 months • Difficult removal • Rare if inserted properly and removed by a trained provider • Expulsions • Rare; most occur within the first 4 months Source: CCP and WHO, 2011.

  33. Counseling about Implants:Explain Removal Procedure to Client Prior to removal, the provider should tell the client that: • An injection of local painkiller is given. The client stays awake. • A small cut is made near the implant. • A special instrument is used to pull out each implant. The client may feel tugging or slight pain. • The site may be sore for a few days. • The cut is closed with an adhesive bandage; no stitches. • The cut is covered and wrapped with gauze. Source: CCP and WHO, 2011; Bayer.

  34. Infection Prevention:Prior to Implant Insertion or Removal Getting ready • Have the client wash her arm • Cover the procedure table • Prepare a clean instrument tray • Open the sterile instrument pack Before insertion/removal • Wash hands thoroughly and put on gloves • Clean the insertion/removal site • Use a sterile drape with a hole over the site • Use a new disposable syringe and needle Source: INFO Reports, 2007.

  35. Infection Prevention:After Implant Insertion or Removal • Stop any bleeding with gauze and clean the insertion/removal site • Apply a sterile adhesive bandage • Place sharps in a safety container • Decontaminate instruments • Dispose of contaminated objects • Sterilize instruments and gloves • Decontaminate all surfaces • Wash hands with soap Source: INFO Reports, 2007.

  36. Implants: Summary • Implants are a new option that fulfills an unmet need for many women • Provides long-term protection • Safe and easy to use • Highly effective and readily reversible • Appropriate for most women, including young and nulliparous • Little is required of the client once the implant is in place • Irregular bleeding patterns may be a problem for some women • Thorough counseling is essential

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