Nexplanon Insertion

• Verify

  • No history of

    • Ischemic heart disease, liver tumors/cirrhosis, systemic lupus erythematosus, cerebrovascular disease

    • Breast cancer within the previous 5 years

  • No active AUB, cervical/endometrial cancer

  • Pregnancy test negative

  • Arm desired for insertion (generally non-dominant)

• Obtain consent

  • Procedure: Pain, bleeding, infection, injury at insertion site

  • Contraceptive method: Irregular uterine bleeding, potential for Nexplanon to dislodge, failure of contraceptive method

• Site preparation

  • Position patient with shoulder and elbow at 90 degrees

  • Mark insertion site located

    • 8 cm medial to medial epicondyle of humeral head

    • 4 cm inferior to bicep/tricep sulcus

  • Mark a second (terminal) point 4 cm proximal to insertion site to act as a guide

  • Place sterile drape over insertion site

  • Clean insertion site with betadine and let dry

  • Do NOT insert any needles through ink mark to avoid tattooing skin

• Local anesthetic

  • Wipe injection site with alcohol pad

  • Using a 5 mL syringe with 1.5 inch, 25 gauge needle, inject 2 cc of 1% lidocaine without epinephrine just distal to first mark

  • Advance the syringe along the planned insertion path and raise a wheel

• Nexplanon insertion

  • Remove plastic cover from Nexplanon injector

  • Place Nexplanon injector needle just distal to first mark and aim toward second

  • Advance along full length of the needle

  • Apply downward pressure to slider and retract fully backward

  • Lift Nexplanon away from skin

• Post-procedure

  • Stop any local bleeding with gauze

  • Palpate Nexplanon to ensure appropriate insertion

  • Remove sterile drape and place under patient's arm

  • Place adhesive bandage over insertion site

  • Have patient palpate Nexplanon

  • Wrap insertion site with elastic pressure bandage

IUD

• IUD protocols (UCSF)

• Mirena insertion and removal

• Paraguard insertion and insertion/removal

• Retrieval hook

IUD insertion -Contraindications for copper IUD -Additional contraindications for levonorgestrel IUD

• Instruments IUD

  • Sterile cup with betadine

  • Syringe with lidocaine

  • Speculum

  • Ring forceps

  • Tenaculum

  • Sound

  • String scissors

• Procedure

  • Insert speculum

  • Visualize the cervix

  • Betadine solution on exterior cervix

  • Consider lidocaine with tenaculum

  • Sound the uterus to depth of at least 6 cm

  • Mirena - up, advance, center, back, remove

  • Cut the string (don't pull string when cutting)

• Post-procedure

  • Give pad to patient

  • Discuss follow-up pregnancy testing

• Billing

  • Insertion procedure 58300

  • Device

    • Skyla J7301

    • Paraguard J7300

    • Mirena J7302