Apply your prior experience along with what you have ...



Contraceptive Implants (Implants): Method-Specific Facilitator’s GuideTable of ContentsDiagram of the TRP Module: Contraceptive Implants2Overview of the Contraceptive Implants Facilitator’s Guide3Purpose of the Contraceptive Implants Module3Using the Implants Module to Develop and Deliver Training3Overview of the Design of the Technical Resource Package Module on Implants4The Learning Objectives4Method Specific Facilitator’s Guide4Illustrative Module Session Plan with Training Schedule5Presentation Materials (PowerPoint slides)6Handouts7Evaluation Tools8Conducting Clinical Practice9References10Appendices12Appendix A: Role Plays’ Instructions Observation Checklist and Scenarios13Appendix B: Answer Key for the Implant Case Studies20Appendix C: Game Show Answer Key27Appendix D: Competency-based Skills Checklist for Contraceptive Implants Counseling and Clinical Skills31Appendix E: Answer Keys for Contraceptive Implants Pre- and Post-Test55Appendix F: Applied Learning Case Studies Answer Key…………………………………59Contraceptive Implants (Implants):Facilitator’s Guide to the Training Resource PackageOverview of the Contraceptive Implants Facilitator’s GuideThis method-specific facilitator’s guide is designed to complement the General Facilitator’s Guide to the Training Resource Package. The general guide provides an overview of the TRP materials and how they are intended to be used as well as overall guidance on how to conduct effective training in different types of settings and with different audiences. There are additional resources to assist you with adapting training and training materials to the specific needs of your audience in the Conducting Training section of the TRP website. There is also guidance on how to use each of the training techniques, such as case studies and role plays that are incorporated into the TRP session plans.In this method-specific facilitator’s guide you will find additional information on how to use the training materials and techniques specific to contraceptive implants that are available in the contraceptive implants module of the TRP. Most importantly, you will also find method-specific tools and answer keys that support delivery of training. Purpose of the Contraceptive Implants ModuleThis training module is designed to support health care workers in developing the knowledge, skills and attitudes needed to provide accurate information and counseling on contraceptive implants to clients and promote voluntary and informed choice. In addition, it can also be used to train physicians, nurses, midwives and other health care providers to insert and remove implants, if this is appropriate to their scope of practice and job description. It is designed to actively involve the trainees in the learning process. Training sessions include the use of PowerPoint presentations, skills practice in the form of role plays, case studies and discussions, as well as clinical practice, with anatomic models and clients, using objective competency-based skills checklists. At the end of this module, the trainee will be able to describe implants as an effective FP method, counsel and screen clients seeking implants, respond to rumors and misconceptions about implants, provide services for clients desiring to use implants, recognize and manage common side effects and complications, and provide follow up care for implant acceptors, as appropriate to their scope of practice and job description. Using the Implants Module to Develop and Deliver TrainingAll of the materials needed to develop a curriculum for implants training are included in the TRP module on implants. The diagram following the Table of Contents shows how the different components of the module fit together. As described in the General Facilitator’s Guide and other resources in the Conducting Training section of the TRP, each component of the implant module may be adapted to fit the circumstances in the country where they will be used, the trainers who will be conducting training, and the level of expertise and skills of the trainees. The module can be adapted to fit any style of training, for example, face-to-face or self-study combined with clinical practicum and on-the-job training. It can also be adapted to meet the purpose for training: refresher training; training new providers; pre-service education. It can be used as a stand-alone course on a single method or as part of a comprehensive course in FP. Whenever possible, the module and its materials should be translated into the local language. Overview of the Design of the Technical Resource Package Module on ImplantsIn order to understand the design of the module, it is helpful to see the diagram on page two. The basic design includes the following:The Learning Objectives By the end of the training, as appropriate to their scope of practice and job description, trainees will be able to:Describe the characteristics of implants in a manner that clients can understand:What implants are and how they work (mechanism and onset of action)EffectivenessSide effectsNon-contraceptive health benefitsPossible health risks (complications)Other characteristics (STI/HIV protection, ease of use, return to fertility, when to initiate and discontinue)Demonstrate the ability to:Screen clients for medical eligibility for implantsExplain to clients the insertion, removal, and follow-up proceduresExplain when to return to the clinicAddress common concerns, misconceptions, and mythsConduct follow-up for implant clients in a way that enhances continuing safety, satisfaction, and acceptanceDescribe when to initiate use of implants (postpartum, switching from another method).Explain how to manage side effects.Identify conditions that require switching to another method.Identify clients in need of referral for implant-related complications.Demonstrate on anatomical models how to insert and remove implants.Method Specific Facilitator’s Guide This Facilitator’s Guide – which you reading right now - contains information on the module design, a description of the materials, learning objectives, instructions and answer keys for role plays, case studies, games and pre- and post-tests, as well as a sample course evaluation form. It also includes a detailed competency-based checklist for insertion and removal of contraceptive implants. However, it does not contain the illustrative session plan and training schedule for training in contraceptive implants, described in the next section. It has its own tab in the module – Illustrative Module Session Plan. The Training Resource Package General Facilitator’s Guide provides overall guidance on how to conduct effective training in different types of settings and with different audiences which may be helpful to you. There are still more resources to assist you with adapting training and training materials to the specific needs of your audience in the Conducting Training section of the TRP website. Illustrative Module Session Plan with Training ScheduleThe session plan and training schedule are found in the Illustrative Module Session Plan tab within the module. The session plan summarizes how the resources and documents in the module should be used to achieve the learning objectives. Each section of the session plan addresses a module topic, such as characteristics of the method or medical eligibility. The slides to be shown with each section and appropriate handouts are identified. The implants module is divided into six sessions:Session I is on the characteristics of implants and includes key points for providers and clients, effectiveness, mechanism of action, health benefits of implants, side effects, and complications. Session II contains information on who can and who cannot use implants, medical eligibility for the use of implants, information on screening for contraceptive use and when a woman can start using implants (e.g. first 7 days of menstrual cycle, post abortion, switching from a hormonal method, etc).Session III is on providing implants. It includes a review of when to start implants, key counseling topics for implant users, correcting rumors and misunderstandings, counseling about side effects, helping continuing users, and problems that may require switching to another method. Session IV A shows the steps in one-rod implant insertion.Session IV B shows the steps in one rod implant removal.Session V A shows the steps in two-rod implant insertion.Session V B shows the steps in two-rod removal.Session VI is on infection prevention procedures related to the insertion or removal of implants.The Training Schedule provides a snapshot of the breakdown of the module by day, time, and topic covered. For example:DAY 1TimeTopicMethodResources8:00-8:15Welcome and IntroductionLearning ObjectivesDiscussionBasic Slide Set: Session I, Slide 28:15-8:45Pre-testTestEvaluation Tool: The Contraceptive Implants Pre-TestDAY 2TimeTopicMethodResources8:00-9:30Session III, continuedImplant Insertion and RemovalDiscussion/Role PlayBasic Slide Set: Session III, Slide 7What Clients Need to Remember After InsertionLecturetteBasic Slide Set: Session III, Slide 8Presentation Materials (PowerPoint slides)The PowerPoint presentations include technical information on implants. Text and information for these slides is included in the slides’ speakers notes, as well as in the session plans where each slide is used. There are three types of slides:Slides conveying most of the technical information are pale blue/green:The pale green slides with a pink header are Basic Slides that include basic information needed by most, if not all, providers and simple illustrations The pale blue advanced slides present research that supports the recommendations in the Global Handbook and the Training Resource Package and can be included or excluded by the facilitator as appropriate. They are especially appropriate for physicians who may desire additional information from supporting research studies. The text for these slides can be found in the speaker’s notes, rather than in the session guide.HandoutsRole plays The implant module includes a set of role play scenarios that enable trainees to practice using the knowledge and skills they are learning. Each role play describes a typical client scenario and the tasks specific to that scenario. The role plays scenarios along with the observation guide, are included in both the facilitator’s guide and in the Handouts tab of the module. In addition, Facilitating Role Plays in the Conducting Training section of the TRP includes, role play observation checklists, and general instructions for the observer, provider, and client roles. Case studiesThe module also includes case studies with progressive case descriptions and questions that enable trainees to analyze a situation and think through how to apply their newly learned technical information. The answer keys for the case studies are in this method specific facilitator’s guide, while the case studies themselves are in the Handouts tab of the module. See Using Case Studies in the Conducting Training section of the TRP website.Job aids/Skills checklists/Technical resourcesThe implants module includes job aids and checklists that describe how and when to perform important provider tasks—for example, screening checklists and job aids for explaining method effectiveness, steps of insertion and standard removal of one and two rod implants, clinical skills checklist for Insertion and removal of one and two rod Implants. Learning activities in the modules give trainees opportunities to practice using these job aids and checklists so they can more easily incorporate use of these tools at the workplace. Counseling toolsThe implants module activities can be used with a variety of counseling approaches and job aids. The term counseling tool in TRP materials refers to the counseling tool or job aid that trainees will be using. Examples include WHO’s Balanced Counseling Strategy counseling cards or other approaches and tools. Facilitators should incorporate activities that enable trainees to use the counseling tool or job aids that they use at work (or will use after the learning intervention). Games and activitiesThis module contains a review game that provides a fun way for trainees to review module content. Instructions for the game are provided in the session plan, and the answer key is provided in this implants facilitator’s guide. Evaluation ToolsThe implants module contains several options for evaluating trainees including pre- and post-tests which contain objective questions, with instructions for scoring the tests. The module also contains competency-based skills checklists and an optional review games and instructions for evaluating role plays and case studies.Pre- and Post-testsThe pre-test knowledge evaluation should be given at the beginning of the course and again at the end of the course (post-test). The trainee’s pre- and post-test scores should be compared to measure changes in knowledge. The pre-test contains the same test items as the post-test. The pre- and post-tests are objective and comprised of true/false and multiple choice questions. Instructions are given on how to score the tests. There are also two case studies included with the post-test. Grade the case studies separately. The case studies are a good way to determine whether trainees are able to apply the knowledge they have gained. Competency-based Skills ChecklistsTrainers may observe trainees practicing and applying skills, tools, and techniques during the session. This can be done through direct observation of clinical skills, role plays, simulations, or case studies. A competency-based checklist is developed by breaking down the clinical skill or activity to be taught into its essential steps. Each step is then analyzed to determine the most efficient and safe way to perform and learn it. These checklists make learning the necessary steps or tasks easier and evaluating the learner’s performance more objective. The checklists contain enough detail to permit the trainer to evaluate and record the overall performance of the skill or activity.Using checklists in competency-based clinical training:Ensures that trainees are confident and competent in the counselling and clinical skills through role plays and simulated practice with anatomical models, before performing the procedure on clients. Ensures that all trainees will have their skills measured according to the same standard; andForms the basis for follow-up observations and evaluations. Used by the trainees in guiding them during skill practice on models and clinical practice.Criteria for satisfactory performance by the trainees are based on the knowledge, attitudes, and skills demonstrated and practiced during training. In preparing for formal evaluation by the trainer, trainees can familiarize themselves with the content of the checklist by critiquing each other’s skills. When evaluating the performance of a trainee, the trainer will judge each step of the skill to be:NI= Needs Improvement. Step or task not performed correctly or out of sequence CP= Competently Performed. Step or task performed correctly in proper sequence but participant does not progress from step to step efficiently.PP= Proficiently Performed. Step or task efficiently and precisely performed in the proper sequence N/O=Not observed: Step or task not performed by the trainee during evaluation’ The Illustrative Competency-based Skills Checklists for Implants Counselling, Screening and Clinical skills can be found in Appendix D.Course EvaluationsThe course evaluation is an important first step in determining the success of a training programTrainees reactions help determine the effectiveness of a program and how it can be improved. The Course Evaluation can’t measure the ability to apply the learning, changes in attitudes or beliefs, organizational impact, or the trainer’s technical knowledge. A Sample Course Evaluation can be found in the Conducting Training/Facilitator’s Materials section of the TRP.Rapid evaluations can be done quickly determine trainee’s reactions to the day’s session. Ask the following:How valuable was today’s session for you using a 5-point scale?What are the most important things you learned today? How do you plan to apply those ideas to your job?If you choose not to use the course evaluation form, a quick alternative at the end of training (or during) is to put up two flip charts. On one flip chart write, “Here are some things we found especially useful in the training.” On the other write, “Here are some suggestions for how the training could be even better.” Make sure the trainer leaves the room while the trainees are writing. Review Exercises and GamesAn interesting way to measure what trainees have learned is through the use of review exercises and games. One of these can be found under the evaluation tools section of the website.Conducting Clinical PracticeEnsuring an effective and safe clinical practice experience is both essential and challenging. The following are key points to consider when designing the clinical practicum. For more information on each of these areas please refer to “General Resources on Training”; there are several documents listed there that will provide additional guidance. The clinical practice site must expose trainees to adequate numbers of cases as well as a supportive environment that reinforces the standards taught in the classroom. Clear criteria for site selection are needed. Clinical sites may need to be prepared for this role and that can take time and resources. Expert clinical trainers are needed at the site, in order to ensure adequate supervision of trainees. Not only must they be expert clinicians, they also need mentoring skills. These individuals may need to be developed as well. Standards for certification of learners – the level of skill they must demonstrate in order to independently, without supervision, perform a procedure - needs to be determined in advance. Case load, the number of trainers, the number of trainees, the complexity of the skill and time available are all factors to be taken into consideration. The time available for clinical training, as well as the ratio of trainers to trainees are additional important planning considerations. Further information on conducting clinical practice is available in the Conducting Training section of the TRP. ReferencesThe main references for the implants module as well as for other modules of the TRP are the World Health Organization’s four cornerstones of family planning guidance:Family Planning: A Global Handbook for Providers (2018 update). This book serves as a quick-reference resource for all level of health care workers. It provides practical guidance on delivering family planning methods appropriately and effectively. The Medical Eligibility Criteria for Contraceptive Use (5th edition 2015). This resource provides guidance on whether people with certain medical conditions can safely and effectively use specific contraceptive methods. Selected Practice Recommendations for Contraceptive Use (3rd Edition 2016). This resource provides guidance on how to use contraceptive methods safely and effectively, once they are deemed to be medically appropriate. WHO Medical Eligibility Criteria Wheel for Contraceptive Use (2015) is a tool that makes it easy to identify medical eligibility for use of family planning methods. New app for WHO’s medical eligibility criteria for contraceptive use-2019 is a digital tool to facilitate the task of family planning providers in recommending safe, effective and acceptable contraceptive methods for women with medical conditions or medically relevant characteristics.New app for WHO's Medical eligibility criteria for contraceptive useWHO updated guidance statement: Contraceptive eligibility for women at high risk of HIV-August 2019Other resources related to implants:Jhpiego: Skills Demonstration Video of Localization and Removal of Deeply Placed Contraceptive Implants (2017) Jhpiego: Providing Contraceptive Implants Learning Resource Package (2014) learning resource package provides health workers with a consolidated source for essential information on safe use of contraceptive implants, specifically on Jadelle, Sinoimplant (II), Implanon, and Implanon NXT (also known as Nexplanon). Includes a reference manual, trainer notebook, learner handbook, presentation graphics and webinar slidesKnowledge for Health, Implants Toolkit for Health, Jadelle Insertion and Removal Video HealthCare, Jadelle: Contraceptive Implants. 2017., Sino-implant (II)/Levoplant Overview aid on when to use Pregnancy Tests vs. Pregnancy Checklist: information and resources for use by facilitators and trainers is available in the References section of the module. AppendicesAppendix A: Role Plays’ Instructions Observation Checklist and ScenariosProvider Instructions for Role PlaysPretend that you are meeting the client for the first time. Ask the client for his or her name, gender (male or female) and age. Pretend that there is a health center nearby to which you can refer the client, if needed. Remember to:Assess the client’s reproductive health (RH) goals, concerns, and fertility intentions.Address the primary and secondary reasons for the client’s visit.Facilitate the client’s decision-making process.Integrate information and services related to other RH issues as appropriate.Help the client act on her or his decision(s).Apply your prior experience along with what you have learned from the training and use job aids and tools as appropriate to address the client’s concerns. Observer Instructions for Role PlaysPrior to the start of the interaction: Review the Role Play Observation Checklist so that you are familiar with the behaviors that you are observing and where they appear on the checklist. Review the case-specific issues on the observer information sheet for the role play.While observing the interaction between the provider and client, remember to:Use the observation checklist to take notes on what happens during the interaction. Record how well the provider addresses the case-specific issues in the space provided.Be prepared to give feedback to the provider regarding how well he or she addressed the client’s needs.Pay particular attention to whether the provider:Helped the client deal with anxietyFacilitated communication with a partnerAllowed the client to make an informed decisionEnsured that the client met the medical eligibility criteria for the method she choseHelped the client carry out her decisionClient Instructions for Role PlaysPrior to the start of the interaction: Read the client information sheet and make sure you understand your character’s situation. Pick a name for your character. Tell the provider your name, age, and whether you are male or female.During the interaction, offer information only when the provider asks relevant questions. Use the information given in your client information sheet to respond to the provider’s questions. Feel free to ask questions of the provider.Role Play Observation Checklist Case: ____________________________ Provider: _______________________________ Client: _______________________________ Observer: _______________________________ Date: ___________________________Overall: Communicate Effectively and Maintain Rapport Shows respect and avoids judging client Maintains relaxed, friendly and attentive body postures and eye contact Uses simple, clear language Uses open-ended and probing questions correctlyListens carefully to client (paraphrases and reflects)Asks client about feelings (and shows empathy)Encourages client participation Explains what will occur during visit and procedures Ensures client understanding and corrects misunderstandings Uses job aids appropriately Offers to involve client’s partnerRecords data according to protocolsEstablish Rapport and Assess Client’s Needs and ConcernsGreets client appropriately Ensures confidentiality and privacy and that client is comfortableAsks about reason for visit Asks about client’s partner(s), children, family, sexual behavior, healthAsks about plans to have children, desire for FP (e.g., spacing, limiting)Explores STI risk and what client does to avoid STIsIdentifies areas to evaluate during physical exam (if indicated) Provide Information and Options Related to Client’s ConcernsAdvises on preventing STIs (i.e., abstain, fewer partners, use condoms) Advises on achieving desired pregnancy as safely as possibleExplains benefits of FP and healthy spacingHelps client identify FP methods suited to her or his needsGives information on FP methods of interestResponds to other client questions or concerns YesNoN/AHelp Client Make an Informed Decision or Address a ProblemAsks client if he or she has any questions about methods of interestAsks client to choose a methodUses screening checklist to determine if client can use the methodAgrees on decision or plan in partnership with client Provide Assistance to Support Client’s DecisionGives contraceptive method and condoms for dual-method use, if needed Explains and/or demonstrates correct use Asks client to explain or demonstrate correct use, and reinforces client’s understanding and/or corrects client’s demonstration Reminds client about side effects and reasons for returningGives treatment, supplies, medications (as indicated) Role plays or rehearses negotiation skills and helps client plan approachArranges follow-up, resupply, and referral to other services, as needed Case-Specific Observations or Questions: YesNoN/ARole Play Scenario 1—Client with HIV is interested in and is eligible for implantsImplants Scenario 1—Client Information SheetImplants Scenario 1—Observer Information SheetClient DescriptionYou are a 29-year-old married woman with HIV. You are monogamous and have three children. You have met previously with a provider at the PMTCT clinic, have learned about different methods of contraception, and are very interested in implants.Offer this information only when the provider asks relevant questions:You and your spouse are both HIV-positive.Your youngest child is two years old.You do not want to become pregnant again for now.You have been using condoms consistently and correctly.You worry about a condom slipping or breaking and desire a more effective method that is easy to use.You feel healthy, have regular menstrual cycles every four weeks, and have no other health problems.Make note of whether the provider addresses these case-specific issues:Assesses the client’s reproductive health goals, fertility intentions, and life plansEnsures that the client understood the contraceptive options described by the PMTCT provider and has made an informed choice to use implantsMakes certain that the client understands and is willing to tolerate the potential side effects caused by use of implantsDetermines the client’s medical eligibility using the implants screening checklistDescribes implant insertion and follow-up proceduresExplains the benefits of continuing to use condoms even though both partners are HIV-positiveOffers couples counselingMethods for which the client is eligible:ImplantsCOCsDMPA or NET-ENIUDMale or female condoms Standard Days MethodRole Play Scenario 2—Client without children is interested in but is not eligible for implants Implants Scenario 2—Client Information SheetImplants Scenario 2—Observer Information SheetClient DescriptionYou are a 28-year-old married woman with a busy professional career. You do not want to have children. You have been married and monogamous for over eight years. You have recently seen a promotion for progestin-only implants and have come to the family planning site to learn more about them.Offer this information only when the provider asks relevant questions:You are interested in implants, but your husband is concerned that they will make you infertile.You are currently using COCs but are tired of the daily pill-taking routine.You do not want to have children, but your husband has recently said that he might want children some day.You have recently had unexplained bleeding after intercourse.You feel healthy and have no other health problems.Your last period started four days ago.You smoke cigarettes, about 10 to 15 per day.Make note of whether the provider addresses these case-specific issues:Assesses the client’s reproductive health goals, fertility intentions, and life plansEnsures that the client understands the possible side effects of implants, especially the likelihood of irregular bleeding (which is very different from the regular bleeding pattern of COCs)Describes implant insertion and follow-up proceduresDetermines the client’s medical eligibility using the implants screening checklistExplains that the client is not eligible at this time due to unexplained bleeding and must be evaluated to determine the cause before implants are initiatedOffers couples counseling to address the husband’s concern about infertility and to correct misunderstandings about implantsMethods for which the client is eligible:*COCsMale or female condoms*After the cause of the unexplained bleeding is determined, the client may be eligible for implants, DMPA, NET-EN, or an IUD. Role Play Scenario 3—Postpartum, breastfeeding client is interested in but is not currently eligible for implantsImplants Scenario 3—Client Information SheetImplants Scenario 3—Observer Information SheetClient DescriptionYou are a 20-year-old woman who gave birth to your first child four weeks ago. You are unmarried and are not in a serious relationship. You read about progestin-only implants in a family planning brochure, and you have come to the family planning site to learn more.Offer this information only when the provider asks relevant questions:You love your infant, but your pregnancy was unintentional. You use condoms pretty consistently.You are in school, want to finish, and cannot afford to have another child anytime soon.You have not had a menstrual period since your baby was born.You are fully breastfeeding, but you intend to start weaning the baby soon because of the demands of school.You feel healthy and have no health problems.You have not had sex since the baby was born, but you do have a casual boyfriend.Make note of whether the provider addresses these case-specific issues:Assesses the client’s reproductive health goals, fertility intentions, and life plansEnsures that the client has made a fully informed decision to use implants and understands the possible side effects, especially the likelihood of irregular bleedingDescribes implant insertion and follow-up proceduresDetermines the client’s medical eligibility using the implants screening checklistMethods for which the client is eligible:*ImplantsLAMPOPsIUDMale or female condoms*At six weeks postpartum, the client will be eligible for DMPA or NET-EN. She will also become eligible for COCs after she stops breastfeeding.Role Play Scenario 4—Client requires management of implants side effects and an understanding of management instructionsImplants Scenario 4—Client Information SheetImplants Scenario 4—Observer Information SheetClient DescriptionYou 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.Make note of whether the provider addresses these case-specific issues:Reassesses the client’s reproductive health goals, fertility intentions, and life plansAttends to the mother-in-law’s concern about infertility and corrects misunderstandings about implantsReassures the client that heavy, irregular bleeding is frequently a side effect among implant users and tends to go away after a few monthsDiscusses potential options for management of the bleeding side effectsDecides 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 unacceptableMethods for which the client is eligible:ImplantsCOCsDMPA or NET-ENIUDMale or female condoms Female sterilization or vasectomy for her husband Role Play Scenario 5—Client with HIV is using implants but needs to discontinue due to new health condition Implants Scenario 5—Client Information SheetImplants Scenario 5—Observer Information SheetClient DescriptionYou are a 28-year-old single woman with HIV. You started implants about four months ago. Initially you experienced mild side effects which recently escalated. You have returned to the clinic to express your concern.Offer this information only when the provider asks relevant questions:You have been experiencing bleeding patterns that are irregular and somewhat heavier and more prolonged than what is typical for you.You began getting headaches soon after the implants were inserted, but recently you have been experiencing migraine headaches with an aura.About two months ago, you were prescribed a new antiretroviral drug regimen.You have no other health conditions and have been feeling well since starting the new ARV regimen.You are in a relationship with a partner who is also HIV-positive, and you do not want to become pregnant at this time.Make note of whether the provider addresses these case-specific issues:Reassesses the client’s reproductive health goals, fertility intentions, and life plansConfirms migraines with aura and advises the client that women who experience migraine headaches with an aura are not eligible for hormonal methods of contraceptionCounsels the client about nonhormonal methods that she is medically eligible to useDescribes removal procedure and removes implants or refers the client for immediate removalMethods for which the client is eligible:IUDMale or female condoms Appendix B: Answer Key for the Implant Case StudiesCase Study 1—Answer KeyAnswers to Question Set AHow do implants prevent pregnancy?Progestin-only implants prevent pregnancy in two ways. They prevent the release of eggs from the ovaries (suppress ovulation). When no egg is released, there is nothing for the sperm to fertilize.Progestin-only implants also cause the cervical mucus to thicken. 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 mucus barrier greatly reduces the chance that the egg will be fertilized.Progestin-only 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 pregnant.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 year following implant removal are comparable to those for women of similar age not using contraception.They contain no estrogen, so they can be used by women who are breastfeeding or have health conditions that might restrict their use of contraceptives containing estrogen.They may provide non-contraceptive health benefits, including preventing iron-deficiency anemia and reducing the risk of acquiring symptomatic pelvic inflammatory disease (PID).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 trained provider’s help because a minor procedure is required for both insertion and removal.Like other hormonal methods, implants provide no protection against STIs, including HIV.Answers to Question Set BWhat 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 Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use identify clients who have conditions or characteristics that prevent safe use of implants, conditions classified as category 3 and 4 in the Medical Eligibility Criteria for Contraceptive Use (WHO, 2015).Does Sasha’s current infection with chlamydia affect her eligibility for implants? Will the antibiotics she is taking interfere with the effectiveness of the implants? Sasha’s medical condition, infection with chlamydia, does not affect her eligibility for progestin-only implants. The antibiotics Sasha is taking to treat chlamydia will not interfere with the effectiveness of the implants.What additional information would you provide to Sasha, given her particular situation?You should emphasize that implants do not protect her against STIs, including HIV.How soon can Sasha start using implants?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. Since Sasha’s period started four days ago, she could start using implants immediately without the need for a backup method.Answers to Question Set CWhat tool(s) would you use to conduct this counseling session?Comparing Effectiveness of Family Planning Methods (WHO)Fact Sheet: Progestin-Only ImplantsInserting Implants (from Family Planning: A Global Handbook for Providers)Family planning counseling tool, an illustrated client brochure, or a poster on implantsHow can you help Sasha anticipate and manage possible side effects?Counseling about what to expect is the best way to help Sasha manage the side effects associated with progestin-only implants. Explain the possible side effects and ensure that Sasha understands that they are not signs of disease or health problems. While some women may not have any side effects, the majority of women experience menstrual changes in the first year of implant use. Light bleeding or spotting, irregular bleeding that occurs frequently, prolonged bleeding that lasts more than eight days, infrequent bleeding, and no bleeding at all (amenorrhea) are menstrual irregularities that women report. 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. Non-menstrual side effects include headaches, abdominal pain, acne that can worsen or improve, weight change, breast tenderness, dizziness, mood changes, and nausea. Tell Sasha that if she experiences side effects that are unacceptable, there are ways to alleviate discomfort.What type of medical examination does Sasha require before initiating implants?You must be reasonably sure that Sasha is not pregnant and is medically eligible for implants. Use the Checklist for Screening Clients Who Want to Initiate Contraceptive Implants. No pelvic examination or blood tests are required to start using this method.What should you tell Sasha about the insertion procedure and what to expect afterwards?You should tell Sasha that:An injection of local anesthetic to prevent pain will be given under the skin of her 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 or tugging.After insertion, the incision is closed with an adhesive bandage. Stitches are not needed. The incision is covered with a dry cloth and her arm will be wrapped with gauze.Sasha’s arm may be sore for a few days after insertion. Some swelling and bruising 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 adhesive bandage after five days.Encourage Sasha to return anytime she has questions, problems, or concerns; suspects that she is pregnant; or has a major change in health status. If she has any pain, heat, pus, or redness at the insertion site, or sees an implant coming out, she should return for treatment.Give Sasha a reminder card so that she knows what type of implant she has and when she will need to have it replaced. Tell her to inform other health care providers that she is using implants.Answers to Question Set DHow would you address Sasha’s concern about the irregular bleeding?Ask Sasha probing questions so that you have a complete understanding of her concerns and the pattern of her bleeding. Reassure Sasha that irregular bleeding sometimes happens with progestin-only implants. Explain that the implant makes the uterine lining thinner, so shedding can sometimes start early. This does not mean that anything is wrong, and in many cases the bleeding diminishes with time.In the meantime, recommend that Sasha begin a five-day course of ibuprofen, up to 800 mg, three times per day. If that does not provide adequate relief, you can recommend a low-dose oral contraceptive pill for 21 days to help reduce the bleeding. If bleeding is very heavy, you may also give Sasha iron tablets to prevent anemia.Assure Sasha that if these solutions do not work, or if she continues to be uncomfortable with the method, she can choose another method.How would you address Sasha’s concern about the headaches?Ask Sasha probing questions so that you have a complete understanding of her concerns and the severity and type of headaches she is having. Reassure Sasha that headaches are a side effect commonly associated with implants. Suggest that she use a standard dose of painkiller to manage the headache pain. If Sasha describes symptoms of migraines or is having headaches that worsened since the implants were inserted, evaluate to determine if discontinuation is appropriate. If her headaches persist and are unacceptable to her, remove the implants and counsel Sasha about nonhormonal methods.How would you address Sasha’s concern about implants causing infertility?Assure Sasha that the bleeding irregularities caused by the implants will not cause infertility. When she chooses to become pregnant, the implants can be removed and she can become pregnant as quickly as women using nonhormonal contraceptive methods. Implants do not cause a delay in the return of a woman’s fertility after they are removed. The bleeding pattern that she had prior to implants generally returns soon after implants are removed. However, some women wait several months for their usual bleeding pattern to return.Note: The recommendations provided in the Answer Key are from Family Planning: A Global Handbook for Providers. If national guidelines are available and provide guidance on these topics, participants should be encouraged to follow recommendations from the national guidelines.Case Study 2—Answer KeyAnswers to Question Set AHow effective are implants compared with other methods?Using the Comparing Effectiveness of Family Planning Methods chart from WHO, show Maria how implants compare with other contraceptive methods; implants are one of the most effective methods of contraception available. How do the implants keep her from becoming pregnant?Progestin-only implants prevent pregnancy in two ways. They prevent the release of eggs from the ovaries (suppress ovulation). When no egg is released, there is nothing for the sperm to fertilize.Progestin-only implants also cause the cervical mucus to thicken. Thicker mucus acts as a barrier, making it more difficult for sperm to enter the uterine cavity. In the unlikely event that Maria does ovulate, this mucus barrier greatly reduces the chance that the egg will be fertilized.Will the medicine in the implants get into her breast milk?A very small amount of the hormone from the implants does make its way into the breast milk. However, studies have shown that there is no effect on the quantity or quality of the breast milk or on the development of her infant. What are the limitations of implants?They have side effects, especially changes in the menstrual bleeding pattern.They cannot be initiated or discontinued without a trained provider’s help because a 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 BWhat 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 Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use identify clients who have conditions or characteristics that prevent safe use of implants, conditions classified as category 3 and 4 in the Medical Eligibility Criteria for Contraceptive Use (WHO, 2010).Does Maria’s history of hypertension during pregnancy affect her eligibility for implants?Maria’s prior history of hypertension during pregnancy does not affect her eligibility for progestin-only implants.How soon can Maria start using implants?Progestin-only implants can be initiated anytime as long as the provider can be reasonably sure the woman is not pregnant. Since Maria has been fully breastfeeding her infant for three months and her periods have not returned, you can be reasonably sure that she is not pregnant. She can start using implants immediately without the need for a backup method.Answers to Question Set CWhat tool(s) would you use to help conduct this counseling session?Fact Sheet: Progestin-Only ImplantsInserting Implants (from Family Planning: A Global Handbook for Providers)FP counseling tool, an illustrated client brochure or poster on implantsHow can you help Maria anticipate and manage possible side effects?Counseling about what to expect is the best way to help Maria manage the side effects associated with progestin-only implants. Explain the possible side effects and ensure that Maria understands that they are not signs of disease or health problems. While some women may not have any side effects, the majority of women experience menstrual changes in the first year of implant use. Light bleeding or spotting, irregular bleeding that occurs frequently, prolonged bleeding that lasts more than eight days, infrequent bleeding, and no bleeding at all (amenorrhea) are menstrual irregularities that women report. 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. Non-menstrual side effects include headaches, abdominal pain, acne that can worsen or improve, weight change, breast tenderness, dizziness, mood changes, and nausea. Tell Maria that if she experiences side effects that are unacceptable, there are some ways to alleviate discomfort.What type of medical examination does Maria require before initiating implants?No pelvic examination or blood tests are required to start using this method. What should you tell Maria about the insertion procedure and what to expect afterwards?You should tell Maria that:An injection of local anesthetic to prevent pain will be given under the skin of her 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 or tugging.After insertion, the incision is closed with an adhesive bandage. Stitches are not needed. The incision is covered with a dry cloth and her arm will be wrapped with gauze.Maria’s arm may be sore for a few days after insertion. Some swelling and bruising 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 adhesive bandage after five days.Encourage Maria to return anytime she has questions, problems, or concerns; suspects that she is pregnant; or has a major change in health status. If she has any pain, heat, pus, or redness at the insertion site, or sees an implant coming out, she should return for treatment. Give Maria a reminder card so that she knows what type of implant she has and when she will need to have it replaced. Tell her to inform other health care providers that she is using implants.Answers to Question Set DAre Maria’s symptoms a cause for concern; what health problem might she have? Maria’s symptoms—complaints of chest discomfort or chest pain beginning during exertion and subsiding during rest—could be symptoms of ischemic heart disease. Tests must be conducted to know for sure. How will you proceed?Ask Maria probing questions so that you have a complete understanding of her concerns and the severity and type of symptoms that she is having. Explain to Maria that it is good that she has come to see you as the symptoms that she is experiencing are possible signs of a serious health problem—a disease of the arteries that supply blood to the heart. Tell Maria that some tests must be conducted as soon as possible (refer as needed). If Maria’s condition requires removal of the implants, is there another long-acting method for which she would be eligible?Inform Maria that should she be diagnosed with ischemic heart disease, it will be necessary to remove the implants. Assure Maria that there are other nonhormonal contraceptive methods that she can use. For instance, the copper IUD is very effective and provides the long-acting protection that she found to be a desirable feature of implants.Note: The recommendations provided in the Answer Key are from Family Planning: A Global Handbook for Providers. If national guidelines are available and provide guidance on these topics, participants should be encouraged to follow recommendations from the national guidelines.Appendix C: Game Show Answer KeyValueQuestionCorrect AnswerCharacteristics$100What are progestin-only implants?Progestin-only implants are thin flexible rods or capsules, each about the size of a matchstick, that release the hormone progestin, which is similar to the natural progesterone in a woman’s body.$200How effective are progestin-only implants?Progestin-only implants are one of the most effective and long-lasting methods, resulting in less than 1 pregnancy per 100 women using implants over the first year. This means that 999 of every 1,000 women using implants will not become pregnant during one year of use.$300Name 3 advantages of progestin-only implant use.They do not require the user to do anything once they are inserted.They prevent pregnancy very effectively.They are long lasting.They do not interfere with sexual intercourse.$400Name 3 limitations or disadvantages of progestin-only implants.Most women have some side effects—especially changes in menstrual bleeding patterns.Insertion and removal require minor surgery.Progestin-only implants provide no protection against sexually transmitted infections, including HIV. $500How do progestin-only implants prevent pregnancy (mechanism of action)?Thickening cervical mucus (blocking sperm from meeting an egg)Preventing the release of eggs from the ovaries (ovulation).ValueQuestionCorrect AnswerSide Effects and Complications$100Name 4 non-menstrualside effects associated with progestin-only implants.HeadacheAbdominal painBreast tendernessAcne (can improve or worsen)Weight changeDizzinessMood changesNausea$200What menstrual changes can a new progestin-only implant user expect?Changes in bleeding patterns in the first several months include:Light bleeding/spottingIrregular bleeding Prolonged bleeding Infrequent bleeding Amenorrhea (no monthly bleeding) $300What menstrual changes can a progestin-only implant user expect after one year of use?Changes in bleeding patterns after the first year of use:Lighter bleeding and fewer days of bleedingIrregular bleedingInfrequent bleeding$400Name two possible complications associated with progestin-only implants.Infection at insertion siteDifficult removalExpulsion of implant$500What is the procedure if one or more implantsbegins to come out of awoman’s arm?This rare occurrence; it usually happens within a few months of insertion or with an infection. If no infection is present, replace the expelled implant with a new rod or capsule through a new incision near the original insertion site. If there is an infection, treat prior to reinsertion if using the original insertion site.ValueQuestionCorrect AnswerMEC and Initiation$100Are heavy smokers good candidates for progestin-only implants? Yes, smokers are medically eligible to use progestin-only implants. Smoking is considered a category 1 condition in the medical eligibility criteria. $200Is a women who is five weeks postpartum and breastfeeding eligible to initiate progestin-only implants?Yes. Women who are breastfeeding and less than six weeks postpartum are eligible to initiate implants (MEC Category 2). There is no need for a backup method. $300To which MEC category does unexplained vaginal bleeding (prior to evaluation) belong?Unexplained vaginal bleeding prior to evaluation is a category 3 condition, “usually not recommended.” $400According to the MEC, is a client who is HIV positive and on an ARV regimen eligible for progestin-only implants?Yes, according to the MEC, HIV-positive women who are on antiretroviral (ARV) therapy can generally use progestin-only implants, but follow-up may be required in some cases. The ARV efavirenz may reduce the effectiveness of implants. Women taking the ARV efavirenz should be encouraged to use condoms along with implants to provide better protection from pregnancy.$500If a woman meets the criteria for medical eligibility, when can she start using contractive implants?Anytime a provider is reasonably certain the woman is not pregnant:First seven days of the menstrual cycle, no backup method neededAfter the seventh day, rule out pregnancy and use a backup method for seven daysPostpartum:Can be given immediately whether breast feeding or not.Post abortion or miscarriage: immediately or within 7 days, without backup. Switching from a hormonal method: immediately if that method was used consistently and correctly.After taking progestin-only or combined emergency contraceptive pills: immediately, use a backup method for seven daysAfter taking ulipristal acetate ECPs (UPA-ECPs): On 6th day after taking UPA-ECPs, no need to wait for her next monthly bleeding, use a backup method from the time she takes UPA-ECPs until 7 days after implant is insertedWild Card$100Name 2 different brands of progestin-only implants.Jadelle—two rods, five yearsLevoplant/Sino-implant (II)—two rods, three yearsImplanon NXT—one rod, three years (maybe up to 5)$200What are three key counseling messages to discuss with clients before inserting progestin-only implants?Reproductive health goalsAdvantages and limitations of implant usePossible side effectsInsertion and removal proceduresFollow-up procedures and when to return$300What should a provider recommend to a client who returns because of irregular bleeding?Reassure the client that this is a common and expected side effect. It is not harmful and usually lessens or stops after the first year of use.Recommend a five-day course of ibuprofen (up to 800 mg three times per day).If ibuprofen does not help, she can use combined oral contraceptives for 21 days to address irregular bleeding.If bleeding is heavy, iron tablets may prevent anemia.If irregular or heavy bleeding continues to bother the client, or starts after several months of normal monthly bleeding or amenorrhea, rule out a possible underlying condition unrelated to method use, such as uterine fibroids, a sexually transmitted infection, genital cancer, or pregnancy.$400Name three known health benefits associated with progestin-only implants.Reduced risk of symptomatic PID Reduced risk of iron-deficiency anemia Reduced risk of ectopic pregnancyRate in implant users: 6 per 100,000Rate in women using no contraception: 650 per 100,000 $500Name two conditions that are MEC category 2 for initiating progestin-only implants and category 3 for continuation.Current or history of ischemic heart diseaseHistory of strokeMigraines with aura, at any ageAppendix D: Competency-based Checklist for Contraceptive Implants Counseling and Clinical Skills (To be completed by the trainer)Date of Assessment ____________ Dates of Training ________________________Place of Assessment: Facility _______________ Classroom ____________________Name of Facility _____________________________________________________Type of Facility: ? MOH/Gov’t ? NGO ? OtherLevel of Facility: ? Primary ? Secondary ? TertiaryName of the Service Provider _____________________________________________Name of the Assessor __________________________________________________This assessment tool contains the detailed steps that a service provider should follow in counselling and providing quality and safe services to women receiving Implants. The tool/checklist may be used:During training, to monitor progress of the trainee as s/he acquires the new skills During the clinical phase of training to determine level of competence of the trainee in performing the skill. By trainer or supervisor during follow-up /monitoring of the learner. As a guide for the learner as he/she continues to practice the sequence of steps to become confident and competent in the new skill. The trainee should always receive a feedback after the assessment and a copy of the assessment/ providing quality insertion and removal checklist for her/him to know what went well and steps /areas for improvement.Instructions for the AssessorWhen performing procedure on a client-always explain to the client what you are doing before beginning the assessment. Ask for the client's permission to observe.Begin the assessment when the trainee greets the client.Use the following rating scale:NI= Needs Improvement. Step or task not performed correctly or out of sequence CP= Competently Performed. Step or task performed correctly in proper sequence but participant does not progress from step to step efficiently.PP= Proficiently Performed. Step or task efficiently and precisely performed in the proper sequence N/O=Not observed: Step or task not performed by the trainee during evaluation’ Observe only and fill in the form using abbreviation of the rating scale. Do not interfere unless the trainee misses a critical step or compromises safety of the client.Continue assessing trainee throughout the time s/he is with the client, using the rating scale.Write specific comments when a task is not performed according to standards.Use the same copy for several observations.When you have completed the observation, review the results with the trainee. Do this in private, away from the client or other traineesTo certify that trainee is ready to perform insertion/removal procedures independently, all steps should be graded as “Competently Performed” (at a minimum) or “Proficiently Performed”. If any of the steps are graded as “Needs Improvement” or “Not Observed”, the trainee should continue practicing insertion/removal procedures under close supervision and guidance of a good performing peer or clinical mentor until the required level of confidence and competence is achieved.Note: There are separate checklists for counselling and screening, insertion and removal of one-rod and two-rod Implants. Choose the appropriate checklist set for your program and for the type of implant available in the implementing area. Competency- Based Checklist for Counseling and Screening for Contraceptive Implants Task/ActivityCasesCommentsGeneral Counseling123Greets the woman respectfully and with kindnessIntroduces herself/himself and develops a rapport with woman.Ensures privacy and confidentialityTalks in a way that the woman understandsAsks the woman, the purpose of her visit? Is she here-For a new FP method? or Has follow up questions about her current method? orDesires to switch to another method. Tailors counselling as per the needs of the woman.Asks the woman about her family size, age of her last child, and her current family planning practices and experience.If her youngest child is less than 2 years old, tells her about healthy spacing and timing of pregnancy and how it benefits both the mother and the baby. Asks the woman about her reproductive goals:Does she want more children in the future? How long do she and her partner want to wait for the next pregnancy?Has she used any FP method in the past? What was her experience with the method?Is she breastfeeding a baby less than 6 months old?Will her partner support her in family planning? Listens attentively and maintains eye contact with the woman.Based on the client’s responses, talks about methods that meet her reproductive goals, beginning with the most effective one.Briefly discusses benefits and limitations of methodsAsks her if she is interested in using any of these methods. Allows her to make her own choice of the method that best suits her needs.If the woman expresses an interest in using Implants, continues with the next stepsMethod specific counselingAsks her what she knows about contraceptive ImplantsDescribes in simple language the key features of Implants. (If available shows the woman a sample or picture of the implant). Can be inserted anytime during the menstrual cycle, after ruling out pregnancy How it works in preventing a pregnancyHow effective it is in preventing pregnancyLength of protection: up to 3-5 years (depending on type). However, the woman can get it removed anytime she wants.Fertility returns without a delay after removal. Contains low doses of hormone and is safe for the vast majority of women, including those who are breastfeeding Explains benefits of Implants, including the non- contraceptive health benefits.Talks upfront about common side-effects and changes in the bleeding patterns to be expected after insertion. Tells her that these are not harmful, often diminish with time, and she can come-back to the provider if it is of concern to her. Common side effects include:Lighter bleeding and fewer days of bleedingProlonged bleedingIrregular and Infrequent bleedingNo monthly bleedingHeadaches, Breast tenderness, Abdominal pain, Acne, Weight changes, Dizziness, Mood changes, Nausea.Describes the screening and insertion process and what she should expect during and after the procedure.Allows her to make a final decision by herself (informed choice) without any coercion Responds respectfully to any questions or concerns she may have.Addresses any myths, rumors or misinformation she may expressScreens client using the Checklist for Screening Clients Who Want to Initiate Contraceptive Implants to rule out pregnancy and identify any existing medical conditions that may interfere with safe use of Implant use. Asks all questions on checklist and records responses. Have you ever been told you have breast cancer?Do you currently have a blood clot in your legs or lungs?Do you have a serious liver disease or jaundice (yellow skin or eyes)?Have you ever been told that you have a rheumatic disease, such as lupus?Do you have bleeding between menstrual periods, which is unusual for you, or bleeding after intercourse?If the client answered NO to all of questions 1–5, she can use implants. Proceed to questions 6–11.If the client answered YES to question 1, she is not a good candidate for implants. Counsel about other available methods or refer.If the client answered YES to any of questions 2–5, implants cannot be initiated without further evaluation. Evaluate or refer as appropriate, and offer other options to use in the meantime.Client Screening, continuedAsk questions 6–11 to be reasonably sure that the client is not pregnant. As soon as the client answers YES to any question, stop, and follow the instructions after question 11.Did your last menstrual period start within the past 7 days ?Have you abstained from sexual intercourse since your last menstrual period or delivery ?Have you been using a reliable contraceptive method consistently and correctly ?Have you had a baby in the last 4 weeks ?Did you have a baby less than 6 months ago, are you fully or nearly-fully breastfeeding, and have you had no menstrual period since then ?Have you had a miscarriage or abortion in the last 7 days?If the client answered YES to at least one of questions 6–11 and she is free of signs or symptoms of pregnancy, you can be reasonably sure that she is not pregnant. The client can have implants inserted now. If the client began her last menstrual period within the past 7 days, she can have implants inserted now. No additional contraceptive protection is needed. If the client began her last menstrual period more than 7 days ago, she can have implants inserted now, but instruct her that she must use condoms or abstain from sex for the next 7 days. Give her condoms to use for the next 7 days.If the client answered NO to all of questions 6–11, pregnancy cannot be ruled out. She must use a pregnancy test or wait until her next menstrual period to have implants inserted. Give her condoms to use in the meantime. Offer emergency contraception if every unprotected sex act since last menses occurred with the last five days.If decision is to NOT insert the Implant at this time, explains reasons to the client and offers other contraceptive options and treatment/referral if necessary.If decision is to proceed with Implants, follows the insertion steps as outlined on the Clinical Skills ments:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Competency-Based Skills Checklist for Insertion and Removal of One Rod Implanon NXT Step/TaskCases1 2 3CommentsOnce the woman has chosen to use the one rod Implanon NXT and her eligibility has been assessed and confirmed, proceeds with the insertion procedure. Insertion Checks that the woman has thoroughly washed her entire arm in which the rod will be inserted with soap and water and dries it well.Ensures that the required sterile or high-level disinfected instruments are?present.?Removes the sterile Implanon NXT applicator with the preloaded implant from the package by allowing it to fall on the sterile tray without touching it.Ensures adequate lighting is availableEnsures audio and visual privacyTells woman what is going to be done and?if she has any questions?Positions the woman’s arm with the elbow flexed and her hand behind her head. Places a clean, dry cloth under her arm.Marks the position on the arm for insertion of rod 8-10 cm proximal to the medial epicondyle and 3-5 cm posterior to the arm sulcus, above the triceps.Washes hands thoroughly with soap and water and dries them Puts on a pair of sterile gloves?on both handsArranges instruments and supplies, so that they are easily accessible.Cleans insertion site with antiseptic, using a tissue forceps to hold a cotton or gauze swab soaked with antiseptic.Covers insertion arm with sterile or HLD drape Injects 1-2 ml of 1% lidocaine just under the skin using a sterile syringe and needle, raising a wheal at the insertion point and advancing up to 5 cm along the insertion track. Gently massages the area of infiltration to spread the anesthesia Gently touches the insertion site with forceps to make sure the anesthetic is working.Holds the Implanon NXT applicator just above the needle at the textured surface area and removes the transparent protection cap by sliding it horizontally away from the needle containing the rod.Visually verifies the presence of the rod inside the metal part of the needle. Positions self to visualize the insertion site and to ensure it is subcutaneous and parallel to the arm.Stretches the skin around the insertion site with thumb and index finger. Using the needle, punctures the skin at a 30° angle and inserts only up to the bevel of the needle.While visualizing the needle, lowers the applicator to the horizontal position so that it is parallel to the surface of the skin while continuing to tent or lift the skin with the needle tip to ensure superficial placement.While lifting the skin with the tip of the needle, slides the needle to its full length toward the guide mark, continuing to tent the skin as the trocar is advanced. Makes sure that the entire length of the needle is inserted under the skin.While keeping the applicator in the same position and the needle inserted to its full length with one hand, unlocks the purple slider by pushing it slightly down.Moves the slider fully back until it stops, leaving the rod now in its final subdermal position and locking the needle inside the body of the applicator. Removes the applicator.Palpates to check that the rod is in place, subdermal and over the triceps. Has the woman palpate the rod for confirmation of its presenceRemoves the drape and wipes?the woman’s skin with antiseptic?Brings the?edges of the incision together?and closes it?with a band aid or sterile gauze and surgical adhesive tape and applies the pressure dressing snugly?Before removing gloves:?Disposes the used needle (without capping), syringe and the trocar in a?sharp’s?container, Wipes the non-disposable instruments with a wet cloth or soak in water at point of use to remove any tissue or blood before further cleaning and processing. Disposes the waste materials like cotton, gauze in leakproof container or plastic bag?Decontaminate surfaces that could have been contaminated by blood, such as the procedure table or instrument stand, by wiping them down with 0.5% chlorine solutionRemoves gloves by turning them inside out and places them in a leakproof container or plastic bag?Washes hands thoroughly with soap and water and dries them.Post-Insertion CounselingProvides Post Insertion Counselling?:Instructs woman to keep the insertion area dry for 4-5 days and that she can take off the pressure bandage after 2 days and the surgical adhesive tape after 5 days.Explains that her arm may be sore for a few days and that she may have some swelling or bruising at the insertion site.Assures her that she can comeback any time she has concerns and she can have the implant removed any time she desires Gives woman a card with details of the type of implant and the month and year when the implant should be removed, including drawing position of the rod.Reassures that complications are very rare but may occur. Emphasizes she should return immediately if :Infection at the insertion (red with increased heat and tenderness or pus)Heavy menstrual bleeding, twice as long or twice as much as normalSevere lower abdominal pain Repeated very severe headaches or blurred visionImplant begins to come out of the arm Discusses what to do if woman experiences any side effects/ problems. Asks woman a few questions to ensure that she understands and remembers key instructions.Observe the woman for 15-20 minutes before sending her homeDocuments the procedure.Removal Note : there may still be women coming in for Implanon removalsGreets the woman?respectfully and with kindness. Ensures privacyDescribes the removal procedure and what to expect. Ensures that sterile instruments and other required materials for removal are available. Makes sure new implants?are?available if reinserting.?Ensures adequate light is available Ensures audio and visual privacyChecks that the woman has thoroughly?washed her arm?with soap and water and dries it well.??Positions the woman’s arm with her elbow flexed and places a clean, dry cloth under her arm. If removing an Implanon NXT rod which was inserted into the new location above the triceps, place the woman’s hand behind her head.???Palpates the rod to determine?the?point for removal?and marks with a waterproof marker, where the tip of the rod is palpated?Notes that it may be necessary to palpate both possible insertion sites (the prior site over the sulcus and the new site 3-5 cm posterior, over the triceps) to locate the rod.??Washes hands thoroughly with soap and water and dries them.??Puts sterile/HLD gloves on both hands???Preps removal site?with antiseptic solution twice?and drapes the arm with a sterile sheet having a hole.??Injects?a?small amount of local?anesthetic?(1% without epinephrine) at the incision site and?under?the end of the rod.?Massages lightly to spread the anesthetic.??Checks for?anesthetic?effect before making skin incision???Pushes down the proximal end of the implant to stabilize it; a bulge may appear indicating the distal end of the implant???Makes a small (2mm) incision below?the?end of?the?rod???Gently pushes?the?end of?the?rod toward the incision with fingertip until the tip of the implant is visible.???Grasps?the?end of?the?rod with?curved mosquito or Crile forceps???Uses sterile gauze (or blunt side of scalpel) to clean off?the?fibrous tissue sheath that covers?the?tip of?the?rod???Grasps?the?exposed end of?the?rod with?second forceps and gently removes the rod. ??Ensures that?the?rod is intact and completely?removed; shows?it?to the woman.???Wipes?the woman’s skin with an antiseptic???Brings?the?edges of?the?incision together and close it using sterile gauze and surgical tape or band aid and applies?a pressure dressing snugly???Before removing gloves:Disposes the removed implant rod as per local guidelinesWipes the non-disposable instruments with a wet cloth or soak in water at point of use to remove any tissue or blood before further cleaning and processing. Disposes the syringe and needle in a sharp’s containerDisposes of contaminated items like gauze, cotton, etc. in a leak-proof container or plastic bagDecontaminates all surfaces that may have been contaminated by blood, such as the procedure table or instrument stand, by wiping them down with 0.5% chlorine solution.??Removes gloves by turning?them?inside out and?places?them?in?a?leakproof?container or plastic bag???Washes hands thoroughly and dries them completely???Instructs the woman about wound care and to make?a?return?visit appointment, if needed???Discusses what to do if any problems?occur and answers any questions???If woman does not want an implant re-inserted and does not want to get pregnant soon, counsels her on other contraceptive options and helps her get one if desired.???Observes the woman for at least 15–20 minutes before sending?her home?Completes?the record???Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Competency- Based Skills Checklist for Insertion and Removal of Two Rod ImplantsStep/TaskCases1 2 3 CommentsOnce the woman has chosen to use the Two Rod Implant and has been assessed and confirmed that she is eligible for it, proceeds with the Insertion procedure.Insertion Checks that the woman has thoroughly washed her entire arm in which the rod will be inserted with soap and water and dries it well. Ensures that the required sterile or high-level disinfected instruments and the two rods implant are?present.?Carefully opens the pouch containing the sterile rods by pulling apart, without touching the rods and allowing them to fall into a sterile bowl or sterile drape.Removes the sterile trocar from the package by allowing it to fall on the sterile tray/drape Ensures adequate lighting is availableEnsures audio and visual privacyTells the woman what is going to be done and?and?if she has any questions? ?Positions the woman’s arm with the elbow flexed and places a?clean, dry cloth under her arm?Marks the position on the woman’s arm for insertion of rods 6cm to 8cm above the elbow fold (this should form a “V” pattern)?Washes hands thoroughly with soap and water and dries them Puts on a pair of sterile gloves?on both handsArranges instruments and supplies in the sterile field so that they are easily accessible.Cleans insertion site with antiseptic using a tissue forceps to hold a cotton or gauze swab soaked with the antiseptic.Covers insertion arm with sterile or HLD drape Fills a sterile syringe with 2 ml of 1% lidocaine. Injects a very small amount of the anesthetic to raise a small wheal at the puncture site. Advances the needle under the skin for 5 cm (2 inches) between where the two rods will be inserted. As withdraws the needle, slowly injects 1 ml of anesthetic in a trackGently massages the area of infiltration to spread the anestheticGently touch the insertion site with forceps to make sure the anesthetic is working.Inserts the trocar directly (subdermal?and superficially)?with the beveled tip of the trocar facing up.While tenting the skin, advances the trocar and plunger to mark (1) nearest the hub of the trocar?Removes the plunger and loads the first rod into the trocar with the gloved hand or forcepsReinserts the plunger and advances it until resistance is felt Holds the plunger firmly in place with one hand and slides the trocar out of the incision until it reaches the plunger handleWithdraws the trocar and plunger together until mark (2) nearest the trocar tip, just clear of incision (does not remove the trocar from the skin)Moves the tip of the trocar away from the end of the rod, and hold the rod out of the path of the trocarRedirects the trocar about 15°, and advance the trocar and plunger to mark (1) Inserts the second rod using the same techniquePalpates the rods to check that the two rods have been inserted in a V-distribution and that both rods are 5mm clear of the incisionRemoves the trocar only after insertion of the second rod and presses down on the incision with a gauzed finger for a minute or so to stop any bleeding. Asks the woman to palpate?the two rods prior to dressing? Removes the drape and wipes?the woman’s skin with antiseptic?Brings the?edges of the incision together?and closes with a Band-Aid?or tape on a sterile?gauze and applies the pressure dressing snugly?Before removing gloves,?Disposes the used needle (without capping) and the single use trocar in a?sharp’s?container, ?Wipes the non-disposable instruments with a wet cloth or soak in water at point of use to remove any tissue or blood before further cleaning and processing. Disposes the waste materials like cotton, gauze in leakproof container or plastic bag?Decontaminates surfaces that may have been contaminated by blood, such as the procedure table or instrument stand, by wiping them down with 0.5% chlorine solution.Removes gloves by turning them inside out and disposing them in a leakproof container or plastic bag?Washes hands with soap and water and dries them.?Post-Insertion Counseling34. Provides Post Insertion Counselling?:Instructs woman to keep the insertion area dry for 4 days and that she can take off the pressure bandage after 2 days and the band aid/ surgical tape after 5 days.Explains that her arm may be sore for a few days and that she may have some swelling or bruising at the insertion site.Assures her that she can comeback any time she has concerns and she can have the implant removed any time she desiresGives a woman card with details of the type of implant and the month and year when the implant should be removed including drawing the position of the rods?Reassures that complications are very rare but may occur. Emphasizes she should return immediately if :Infection at the insertion (red with increased heat and tenderness or pus)Heavy menstrual bleeding, twice as long or twice as much as normalSevere lower abdominal pain Repeated very painful headache or blurred visionRod/s begins to come out of the armDiscusses what to do if the she experiences any side effects or problems.Asks woman a few questions to ensure that she understands and remembers key instructions.Observes the woman for 15-20 minutes before sending her homeDocuments the procedureRemovalGreets woman?respectfully and with kindness?and ensures privacy.Describes the removal procedure and what to expect. Ensures that sterile instruments and other required materials for removal are available. Makes sure new implants?are?available if reinserting new implants.???Ensures adequate light is availableEnsures privacyChecks that the woman has thoroughly?washed her arm?with soap and water and dries her arm.??Positions the woman’s arm and places a?clean, dry cloth under her arm???Palpates the rods to determine?the?point for removal and marks the woman’s arm where the tip of the rods is palpated?with a marker.??Washes hands thoroughly with soap and water and dries them???Preps removal site?with antiseptic solution twice?using cotton/gauze held with a tissue forceps??Injects?a?small amount of local?anesthetic?(1% without epinephrine) at the incision site and?under?the end of the rods (Below the bottom of V)??Checks for?anesthetic?effect before making skin incision???Pushes down the proximal end of the rod to stabilize it; a bulge may appear indicating the distal end of the implant???Makes a 4 mm incision with the scalpel below?the?ends of?the?rods???Gently pushes?the?rods toward the incision with fingers till it is visible.??Grasps?the?end of?the?rod with?curved mosquito or Crile forceps???Uses sterile gauze (or blunt side of the scalpel) to clean off?the?fibrous tissue sheath that covers?the?tip of?the?rod???Grasps?the?exposed end of?the?rod with?second forceps;?gently remove and inspect to ensure that the rod is intact.???Ensures that?the?rod is intact and complete?and shows?it?to the woman.???Repeat steps 14-18?for the second rod??Wipes?the woman’s skin with an antiseptic???Brings?the?edges of?the?incision together and closes it with a band aid?or tape on a sterile gauze (2x2) and applies?pressure dressing snugly???Before removing gloves:Disposes the removed rods as per local guidelinesWipes the non-disposable instruments with a wet cloth or soak in water at point of use to remove any tissue or blood before further cleaning and processing. Disposes the syringe and needle in a sharp’s containerDispose of contaminated items like gauze, cotton, etc. in a leak-proof container or plastic bag.?Decontaminates all surfaces that may have been contaminated by blood, such as the procedure table or instrument stand, by wiping them down with 0.5% chlorine solution.??Removes gloves by turning?them?inside out and?places?them?in?a?leakproof?container or plastic bag???Washes hands thoroughly and dry them completely???Instructs the woman about wound care and make?a?return?visit appointment, if needed???Discusses what to do if any problems?occur and answer any questions???If the woman does not want to an implant and does not want a pregnancy soon, counsels her about?other contraceptive options and helps her get it, if desired???Observe the woman for at least 15–20 minutes before sending?her home?Completes?the record?Comments: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Appendix E: Answer Keys for Contraceptive Implants Pre- and Post-Test Name: Date:Instructions: Circle the letter(s) for all that apply. Follow specific directions for each section. There is a total of 50 points.Scoring: Score each correct answer by 1. Multiply total correct answers by 2 to get total percentage. It is recommended that a passing score is 80% and above.Multiple ChoiceFor each of the following questions, circle the letter(s) of the correct answer(s).Which of the following contraceptive methods are less effective than progestin-only implants? You may choose more than one answer (each correct answer worth 1 point).Oral contraceptivesDMPASpermicidesFemale sterilizationCondomsHow do progestin-only implants prevent pregnancy? You may choose more than one answer (each correct answer worth 1 point).Preventing a fertilized egg from embedding in the uterine liningThickening of cervical mucusSuppressing ovulationDamaging spermImplants are safe for breastfeeding women because they do not containEstrogenProgestinBoth estrogen and progestinNone of the aboveWhich of the following are possible side effect of implants? You may choose more than one answer (each correct answer worth 1 point).Irregular bleedingSevere abdominal painNo monthly bleedingBreast tendernessHeavy or prolonged bleedingImplants are NOT suitable for women who-Are breastfeedingHave ever had breast cancerHave pelvic inflammatory diseaseHave a sexually transmitted infection (STI)Which infection prevention practices are essential after implant insertion? You may choose more than one answer (each correct answer worth 1 point).Clean around the insertion site with an antisepticDispose of the applicator, syringe and needle in a sharps containerCover the insertion site with a sterile gauze and then bandage Clean used instruments with a wet cloth or soak in water before further plications from implants are rare. Which of the following are possible complications? You may choose more than one answer (each correct answer worth 1 point).Decrease in breast milk.Infection at the insertion site.Difficulty in removing the implantExpulsion of the implant.True or FalseCircle true or false for each statement.Implants provide protection against STIsTrueFalseThere is some evidence that implants remain very effective beyond their labeled use.TrueFalseImplants are more than 99 percent effective.TrueFalseImplants can be used by breastfeeding women.(after six weeks postpartum).TrueFalseFertility returns without delay when implants are removed.TrueFalseImplants require minor surgery to initiate and remove.TrueFalseInfection at the insertion site may cause implants to come out.TrueFalseUsing implants does NOT make a woman infertile.TrueFalseHormones remain in the body once the implant is removed.TrueFalseWomen infected with HIV who are on antiretroviral therapy can safely use implants.TrueFalseWomen can only have an implant inserted while they are menstruating.TrueFalseWomen can have an implant inserted within 7 days following a miscarriage or abortionTrueFalseWomen must wait 6 weeks after birth before using an implant, whether they are breastfeeding or not.TrueFalseIf a woman develops an infection at the implant site, the implant should immediately be removed.TrueFalseImplants are a good method for breastfeeding women.TrueFalseWomen can use implants regardless of how many cigarettes they smoke.TrueFalseFor heavier women, the effectiveness of Jadelle and Sino-Implant (II) /Levoplant may decrease near the end of the duration of use stated on the label.TrueFalseIn women using implants, acne can either get better or worse.TrueFalseNo routine visit is required until it is time to remove an implant.TrueFalseA client who knows about side effects is more likely to keep using it, even if she experiences side effects.TrueFalseFill in the BlankComplete the following sentences with one of these words. Each blank is worth 1 point.headachesblood clotsnauseadysmenorrheahypertensiondiarrheaSTIsHIVCrileamenorrheaanemiairregular bleedingmenstrual crampsexpulsionheavy bleedingmosquitoinfertilityWhile very rare, expulsion is a complication associated with progestin-only implants that most often occurs within the first four months of use.Non-menstrual side effects of progestin-only implants include headaches and nausea. Changes in bleeding patterns could include irregular bleeding and amenorrhea.One possible health benefit of progestin-only implants is the reduced risk of anemia.Women who have a current problem with blood clots in their legs or lungs should not use implants.Implants do not provide protecting against STIs or HIV.When removing implants, mosquito forceps should be used to grasp the implant and Crile forceps should be used to remove it from the arm.Appendix F: Applied Learning Case Studies Answer Key*Note to the Facilitator: This section should not be graded as part of the post-test. It is an extra section, which will give you an indication of whether the trainee is able to apply what he/she has learned.Case 1Read the case and answer the questions.Mariam is a 30-year-old mother of two. She has been married for five years and wants no more children at the moment. Mariam recently was tested for sexually transmitted infections and was diagnosed with chlamydia. She is otherwise healthy and having regular menstrual cycles. She started her period four days ago. Her husband’s test for chlamydia also came back positive. Mariam has come to the clinic somewhat informed about implants and expresses interest in using this contraceptive method.1a)Is Mariam medically eligible to initiate implants? Why or why not?Mariam is eligible. According to the medical eligibility criteria, chlamydia infection is not a contraindication for use of progestin-only implants. Pregnancy can be ruled out by the fact that Mariam’s menses started four days ago.1b)What are the three key counseling messages to share with Mariam? (Any three of the following):Review method characteristics (effectiveness, how implants work, length of protection, health benefits, return of fertility, requires a trained provider to insert and remove, possible complications).Explain possible side effects (especially bleeding).Review the insertion procedure.Explain that she can return any time she has questions or concerns, or wants the implant removed for any reason.Counsel that implants provide no protection from STIs and clients at risk of STIs should use condoms in addition to implants. (Note: Although not the focus of this case study, the provider should also refer or treat chlamydia.)Case 2Mariam has been using implants for six months. She has returned to the clinic and reports having very bad headaches that are making her eyes sensitive to light and affecting her vision.2a)Is Mariam still a good candidate for continued use of implants? Why or why not?Because Miriam is now having headaches with aura, she is no longer eligible to use progestin-only implants.2b)Describe your course of action.Discuss why she is no longer eligible, remove the implants, and if she wishes to continue avoiding pregnancy, help her choose a contraceptive method that does not contain hormones. ................
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