Neobook — clinical reference

Z30.0/Z30.4/Z30.8

Dual protection with barrier methods is recommended to reduce the risk of STIs, including HIV.

The subdermal implant is an effective, safe, reversible, and convenient long-term contraceptive method that does not require daily adherence or frequent follow-up.

Progestin-only subdermal implant contraceptive, e.g.:
- Etonogestrel, subdermal, 68 mg, single-rod implant.

The progestin-only subdermal implant can be inserted at any time during the menstrual cycle, once pregnancy has been excluded. If the implant is inserted within day 1 to day 5 of the onset of the menstrual cycle, the contraceptive effect is achieved within 24 hours of placement.

The main reason for discontinuation of the implant is irregular bleeding. This requires good counselling before the implant is inserted to inform women that this side effect can occur and can be treated. See Breakthrough bleeding with contraceptive use.

The progestin-only subdermal implant is contraindicated in certain conditions, e.g. unexplained vaginal bleeding, active liver disease. Consult the package insert in this regard.

CAUTION
Medicines that induce the metabolism of progestins could reduce contraceptive efficacy.
These medicines include efavirenz, rifampicin, phenytoin, carbamazepine, and phenobarbital.
Women receiving any of the above listed hepatic enzyme-inducing medicines should be advised that the efficacy of the subdermal implant may be reduced. If it is decided to continue using the subdermal implant, women should be advised to also use a nonhormonal contraceptive method during the time of concomitant use (the subdermal implant is not contra-indicated when using the above medicines). Dolutegravir, however, can be effectively used in combination with subdermal implants.
LoE:IIIb⁸

Insertion and removal procedures

Training on the techniques for insertion and removal of the sub-dermal implant is strongly recommended.
Only healthcare professionals familiar with these procedures should insert and remove subdermal implants, under aseptic conditions.
Insert the implant subdermally just under the skin of the upper non-dominant arm.
Important: Refer to the specific professional information for detailed guidance on the product available on the National contract.

Insertion of etonogestrel 68 mg implant

Insertion should only be performed with the preloaded applicator
Ask the woman to lie on her back on the examination table with her non-dominant arm flexed at the elbow and externally rotated, so that her hand is underneath her head (or as close as possible)
Identify the insertion site, which is on the inner side of the non-dominant upper arm. The insertion site overlies the triceps muscles about 8 to 10 cm from the medial epicondyle of the humerus and 3 to 5 cm posterior to the sulcus (groove between the biceps and triceps muscles). This location is intended to avoid large blood vessels and nerves lying within and surrounding the sulcus. If it is not possible to insert the implant in this location (e.g. in women with thin arms), it should be inserted as far posterior from the sulcus as possible
Make two marks with a surgical marker: First, mark the spot where the implant will be inserted, and second, mark a spot at 5 cm proximal (toward the shoulder) to the first mark. This second mark (guiding mark) will later serve as a direction guide during insertion
Clean the insertion site with an antiseptic solution
Anaesthetise the insertion area
Insert the implant subdermally:
- Hold the applicator just above the needle at the textured surface area. Remove the transparent protection cap by sliding it horizontally in the direction of the arrow away from the needle
- Puncture the skin with the tip of the needle slightly angled less than 30° relative to the skin surface. If you insert the needle past the bevel, withdraw it until only the bevel is beneath the skin
- Lower the applicator to a horizontal position. To facilitate subdermal placement, lift the skin with the needle, while sliding the needle to its full length. You should be able to see the applicator just below the skin. In a seated position, look at the applicator from the side and NOT from above to clearly see the insertion and positioning of the needle just under the skin
- While keeping the applicator in the same position and the needle inserted to its full length, the purple slider should be unlocked by pushing it slightly down. The slider should be moved fully back until it stops
- The implant is now in its final subdermal position. Remove the applicator
Always verify the presence of the implant in the woman’s arm immediately after insertion by palpation, and allow her to feel the implant as well
Apply sterile gauze with a pressure bandage to minimise bruising. The woman may remove the pressure bandage in 24 hours, and the small bandage over the insertion site after 3-5 days

LoE:IVb⁹

Insertion of levonorgestrel 2 x 75 mg implants

Clean the woman's upper arm with an antiseptic solution
The optimal insertion area is on the medial aspect of the upper arm about 6-8 cm above the fold of the elbow
The implants will be inserted subdermally, in the shape of a narrow V, opening towards the armpit
Anesthetise two areas about 4.5 cm long, to mimic the V shape of the implantation site
Mark the insertion site with a marker
Use the scalpel to make a small incision (about 2 mm) just through the dermis of the skin. Alternatively, the trocar may be inserted directly through the skin without making an incision
Open the implant pouch by pulling apart the film of the pouch and let the two implants drop on a sterile cloth

Note:
Always use sterile gloves or forceps when handling the implants. If an implant is contaminated, (e.g. falls on the floor), leave it for later disposal, open a new package and continue with the procedure.

The implant is provided with a disposable trocar that is sharp enough to penetrate the skin directly. Thus, the disposable trocar can be used to puncture the skin and insert the rods, without the need for an incision
The trocar has two marks. One mark is close to the handle and one close to the tip. When inserting the implants, the mark closest to the handle indicates how far the trocar should be introduced under the skin before loading each implant. The mark closest to the tip indicates how much of the trocar should be left under the skin after the insertion of the first implant. When inserting the trocar, avoid touching the part of the trocar that will go under the skin
Once the tip of the trocar is beneath the skin it should be directed along the subdermal plane horizontally by pointing it slightly upwards and raising the skin (tenting). Failure to keep the trocar in the subdermal plane may result in deep placement of the implants, causing a more difficult removal. The trocar should be oriented with the bevel up throughout the insertion procedure
Advance the trocar beneath the skin, about 5.5 cm from the incision to the mark closest to the handle of the trocar. Do not force the trocar; if you feel any resistance, try another direction
Remove the plunger when the trocar is advanced to the correct mark
Load the first implant into the trocar with either tweezers or fingers
Push the implant gently with the plunger to the tip of the trocar until you feel resistance. Never force the plunger
Hold the plunger steady and pull the trocar back along it until it touches the handle of the plunger. It is important to keep the plunger steady and not to push the implant into the tissue
Do not completely remove the trocar until both implants have been placed. The trocar is withdrawn only to the mark closest to its tip
When you can see the mark near the tip of the trocar in the incision, the implant has been released and will remain in place beneath the skin. You can check this by palpation
Insert the second implant next to the first one, to form a V shape. Fix the position of the first implant with the left fore-finger and advance the trocar along the side of the finger. This will ensure a suitable distance between implants. To prevent expulsions, leave a distance of about 5 mm between the incision and the ends of the implants. You can check their correct position by cautious palpation of the insertion area
After inserting the second implant, press the edges of the incision together, close with a skin closure and dress the wound
Advise the woman to keep the insertion area dry for 3 days
The gauze and the bandage may be removed as soon as the incision has healed, usually after 3–5 days

For pain after insertion

Ibuprofen, oral, 400 mg 8 hourly with or after a meal as needed for up to 5 days

Removal of progestin-only subdermal implants

Remove etonogestrel implants at the end of 3 years and levonorgestrel implants at the end of 5 years.

Locate the implant/s by palpation. If impalpable, refer for ultrasound-guided removal
Mark the distal end (end closest to the elbow) with a surgical marker
Clean the removal site with an antiseptic solution
Anaesthetise the removal area. Inject the local anaesthetic under the implant to keep the implant close to the skin surface
Push down the proximal end of the implant. A bulge may appear to indicate the distal end of the implant
Make a longitudinal (parallel to the implant) incision of approximately 2 mm towards the elbow
Very gently remove the implant, using a small forceps (preferably curved mosquito forceps). Where an implant is encapsulated, dissect the tissue sheath to remove the implant with the forceps
Confirm that the complete implant has been removed by measuring the length (etonogestrel rod: 40 mm; levonorgestrel rods: 43 mm). Close the incision with a steristrip or plaster and dress
Advise the woman to keep the arm dry for a few days

REFERRAL

Heavy or prolonged bleeding, despite treatment with COCs
Infection at the insertion site, inadequately responding to an initial course of antibiotic treatment. See Cellulitis
Failure to locate an implant (in the arm) by palpation

Click here for the pdf

Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-2024_Version 1.0_ April 2025

Chapter 7: Family Planning_7.2.1 Subdermal Implant

Subdermal Implant (Contraception, Hormonal)

Insertion and removal procedures

REFERRAL

Drugs mentioned

ICD-10 codes