Contraceptive Implant Counselling – OSCE Guide

Contraceptive counselling often features in OSCEs and it’s therefore important to be familiar with the various types of contraception available. This article focuses on counselling patients about the contraceptive implant (also referred to as simply “the implant”) including the common questions patients ask, the answers you’ll be expected to articulate and how best to structure the consultation.

Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Check the patient’s understanding of the types of contraception available.

Explore the reasons why the patient wants the contraceptive implant.

Ideas, concerns and expectations

It is important to explore the patient’s ideas, concerns and expectations early in the consultation, as you may need to correct any misconceptions about the implant and address the patient’s concerns. When exploring concerns, it is important to do so in a sensitive and honest manner.

It’s also important to clarify the patient’s expectations of the implant because if these are unrealistic, other forms of contraception may be better able to meet their needs.

Ideas

Explore what the patient currently understands about the implant:

• “Have you heard of the contraceptive implant?”
• “What do you already know about the contraceptive implant?”

Concerns

Ask if the patient has any concerns about the implant:

• “Is there anything that worries you about the contraceptive implant?”

Expectations

Explore the patient’s expectations of the implant:

• “What are you hoping the implant can do for you?”
• “Why do you think the implant is the best choice for you?”

What is the implant?

Using patient-friendly language, explain that the implant is a flexible, plastic rod that is placed subdermally in the upper part of the arm.¹

“The implant is a small plastic rod that sits just under the skin in the upper part of the arm, it is a long-acting reversible method of contraception and can be effective for up to 3 years.”

How does the implant work?

Explain that the implant primarily works by preventing ovulation, however, it also thickens cervical mucus and thins the endometrium.²

 “The implant stops an egg from being released from your ovaries. It also thickens the mucus in the neck of your womb and thins the lining of your womb. This can make it difficult for sperm to reach an egg and make it less likely for your womb to accept a fertilised egg.”

How effective is the implant?

Often patients want to know how effective contraception is, as this can help guide their decision on which contraception to choose. As a result, it’s useful to know some basic statistics on efficacy. However, if you’re unsure, signpost the patient to a reliable source and don’t guess!

“The implant 99% effective. Less than 1 implant user in 100 will get pregnant in one year.”¹

Advantages and disadvantages of the implant

Always give patients as much information as possible so that they can make an informed decision. It is useful to do this by discussing the pros and cons of choosing the implant.

 “If it is okay with you, I’d like to tell you about the benefits and disadvantages of the implant, then hopefully you will have enough information to make a decision.”

Advantages of the implant

Long term contraception

“The implant is a form of long-term contraception. It will remain effective for up to three years from the date of insertion.”

Can be reversed easily

“As soon as the implant is removed, fertility should resume as normal.”

May make periods less heavy and painful

“The implant may help with heavy or painful periods.”

Safe to use when breastfeeding

“The implant is safe to use if you choose to breastfeed your baby.”

Disadvantages of the implant

Unpredictable periods

“Some people experience irregular periods, longer-lasting periods or no periods at all.”

Possible temporary side effects

“You may experience some side effects such as headaches, breast tenderness and mood changes. However, normally these last for no longer than a few months.”¹

Acne

“Some people find that they may develop acne or have worsening of their acne after insertion of the implant.”

Small procedure required

“A simple procedure is required to insert and remove the implant. I will go on to explain this later in the consultation.”

No protection from STIs

“Unfortunately, the implant does not protect you from sexually transmitted infections (STIs). Barrier contraception (e.g. condoms) is the only form of contraception that provides protection from STIs.”

Some risks of the implant

Infection

“There’s a small chance of getting an infection during the first few weeks after an implant is put in. However, the healthcare professional will take the appropriate steps to reduce the chance of an infection developing.”

Bruising and bleeding

“It is common to have a small amount of bleeding during the procedure and pressure will be applied to minimise this.”

“You will most likely develop a bruise, which may be large and extend down your arm as a result of small amounts of blood leaking under your skin. Although this might look concerning, these bruises typically fade over the following week or so.”

Damage to local structures

“We carefully insert the implant in a location that isn’t close to any large blood vessels or nerves. However, there is a very small possibility that some of your blood vessels, nerves or muscles could be damaged during the procedure.”

Breast cancer

“There may be a slightly increased risk of developing breast cancer compared with people who do not use hormonal contraception.”¹

How is the implant fitted?

It is useful to explain the process of inserting an implant using a before, during and after structure. This will also help you remember the key points for each step.

Before

“You can have the implant fitted at any time during your period.”

“Firstly, a trained healthcare professional will use a needle and syringe to administer a small amount of local anaesthetic to numb the relevant area of your arm. This means that the insertion of the implant itself should not hurt.”

“You will experience a stinging sensation when the local anaesthetic is injected, but this should fade quickly.”

During

“The implant is the size of a matchstick. A nurse or doctor will insert the implant into the skin. It should not take more than a few minutes.”

After

“After the procedure, the nurse or doctor will show you how to feel the implant to make sure that it is in place. The area where the implant was inserted may be slightly tender, bruised or swollen for a couple of days following the procedure.”

“It is important to try to keep this area clean for the next few days to help prevent infection.”

“If the implant is inserted during the first five days of your period, you will be protected immediately after. However, if it is inserted at any other time in your cycle, you would need to use condoms for the next seven days.”

Removing the device

“The implant can be kept in for up to three years. If you decide you do not want it, a trained healthcare professional can remove it.”

“Just like with the insertion, you’ll be given a local anaesthetic injection and a small cut will be made in your arm. The implant will be removed through this. This should only take a couple of minutes.”

“Occasionally, there can be some difficulty removing the implant. If this is the case, you will be referred to a specialist centre to remove it with the assistance of an ultrasound scan.”

Closing the consultation

Summarise the key points back to the patient.

Ask the patient if they have any further questions or concerns that haven’t been addressed.

Throughout the consultation you should check the patient’s understanding at regular intervals, using phrases such as “Can you just repeat back to me what we’ve just discussed regarding…”.

It may also be useful to direct the patient to any websites or leaflets with further information.

Offer the patient time to consider their decision.

Encourage the patient to use condoms if they are not currently using contraception.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

Common patient questions

Can medication impact the effectiveness of the implant?

The implant is effected by enzyme-inducing drugs such as:

• Barbiturates
• Carbamazepine
• Phenytoin
• Rifampicin

The patient’s medication history should be checked prior to being commenced on the implant. The patient should also be told to make other clinicians aware of their implant, before starting a new medication.

Will the implant still work if I have diarrhoea or vomiting?

The implant is not affected by vomiting or diarrhoea.

How will the implant affect my periods?

It is likely that the patient will experience changes to their menstrual cycle. Some people experience irregular unpredictable periods or longer-lasting periods, whilst others find that their periods stop completely.

References

1. FPA.org.uk. (2018). The Contraceptive Implant – Your Guide. [online]. Available from: [LINK].
2. FSRH Clinical Effectiveness Unit. (2014). FSRH Clinical Guidance: Progestogen-only Implants [online]. Available from: [LINK].