The Norplant System of subdermally-implanted levonorgestrel-containing capsules is the most effective reversible contraceptive option available to women today. Patients' acceptance of the System is high and crosses cultural, social, and economic boundaries. As more women become aware of the Norplant System it is increasingly important for all primary health care providers to be knowledgeable and proficient in the procedures for insertion and removal. Both procedures are short, in-office procedures that are straight-forward and easy to master. This article examines the Norplant System, with emphasis on the removal procedure, and offers tips and techniques for nurse practitioners planning to add Norplant-related skills to their repertoire. Topics covered include a brief review of the history and methods of action of Norplant, the importance of patient counseling, the insertion procedure, the removal procedure, and tips for handling nonstandard removal situations.
PIP: The most effective reversible contraceptive method currently available to women is Norplant, which contains 6 subdermally inserted levonorgestrel-containing capsules. It protects against pregnancy for up to 5 years and does not depend on user compliance. It can be removed at any time to restore fertility. Extensive patient education and counseling before its insertion increases patient acceptance of side effects and satisfaction. The main side effect is irregular menstrual patterns. Levonorgestrel thickens the cervical mucus and, in most cycles, inhibits ovulation. Providers should use a specially-marked trocar to insert all 6 capsules at a uniform depth and a uniform distance from the 2 mm incision. Insertion lasts 10-15 minutes. Less than 1% of patients experience infection at the insertion site. When a patient requests removal, providers should conduct preremoval counseling to address possible misperceptions. Removal takes 15-30 minutes to complete. About 2-4 cc of 2% lidocaine injected under the capsule tips nearest to the original insertion site should reduce discomfort during removal. This also lifts the capsule tips, making it easier to remove them. The removal incision should be made close to these tips and a few millimeters higher up on the arm than the insertion incision. A curved mosquito clamp is used to gain access to and to grasp the capsules. The provider can use a scalpel or an open gauze sponge to gently release the fibrous tissue sheath around each capsule. Another clamp is used to remove the capsule. A new set of capsules can be inserted at the same site after removal of all the old capsules. Removal difficulties occur in about 13% of cases. They may include nonpalpable capsules, poorly positioned or misshapen capsules, and heavy fibrous sheath encasing the capsules. The first 2 difficulties can be a result of poor insertion. Providers can well manage unusual removals.