Postpartum Sterilization
Efua B. Leke
Susan P. Raine
GENERAL PRINCIPLES
Definition
Female sterilization is the most common method of contraception in the United States (used by ˜36% of fertile contracepted women) and can be performed in the immediate postpartum period shortly after giving birth or at an interval time unrelated to pregnancy (1).
Postpartum sterilization is performed either concomitantly with cesarean delivery or in the immediate postpartum period following a vaginal delivery by occluding or removing the fallopian tubes.
Postpartum sterilization is a popular contraceptive method owing to its efficacy and convenience as well as the lack of additional recovery time when performed immediately postpartum.
Physical Examination
A review of the patient’s obstetric and gynecologic history should be undertaken before the procedure noting any history of pelvic or abdominal surgery. Patients with an extensive surgical history raising concern for adhesive disease may not be appropriate candidates for a postpartum approach. Ideally, these concerns are noted and addressed early in prenatal care when discussing contraceptive options.
Intrapartum and postpartum events should be reviewed to ensure the patient is a suitable candidate for sterilization. If the patient is already undergoing cesarean delivery, the additional time required for tubal sterilization is unlikely to raise any concerns; however, in patients who delivered vaginally with complications, it may be advisable to delay a sterilization procedure until a future date.
Patients with postpartum hemorrhage should be assessed for hemodynamic stability before proceeding. If minimal blood loss occurred at delivery in a patient without baseline anemia, laboratory examination may be deferred.
Patients with complications related to hypertensive disorders or peripartum infection may not be ideal surgical candidates immediately following vaginal delivery.
In a patient undergoing an infraumbilical minilaparotomy approach, the uterine fundus should be palpable at or just below the umbilicus so that the fallopian tubes are accessible via a periumbilical incision. Issues that may preclude an infraumbilical approach include significant central obesity precluding palpation of the uterus, preterm delivery, and rapid involution of the uterus.
Nonoperative Management
There are a number of nonoperative contraceptive methods available to patients who wish to avoid a postpartum minilaparotomy.
The most efficacious forms of contraception in those who decline tubal ligation include long-acting reversible contraception (LARC) methods such as injectables, intrauterine devices, or subdermal implants.
IMAGING AND OTHER DIAGNOSTICS
Imaging is not typically necessary or helpful in preparation for this procedure.
If the procedure is performed >24 hours postpartum or there are any concerns regarding significant anemia, it may be advisable to have a current assessment of the patient’s hemoglobin and hematocrit.
PREOPERATIVE PLANNING
Given the permanence of sterilization procedures, patients should be appropriately counseled to ensure consent is well informed. Discussion is ideally initiated early in prenatal care to afford the patient and her family ample time to consider the permanence of the procedure and other available alternatives.
Discussion of the risks, benefits, and alternatives to sterilization should also accompany a review of efficacy rates as well as the risk of future complications including ectopic pregnancy. The risks accompanying the need for additional anesthetic and surgical procedures should be discussed.
Male sterilization in the form of vasectomy should also be reviewed as a safe and reliable alternative to female sterilization.
Women at any age can give consent for sterilization; however, those whose care is covered by military insurance or federal funding (i.e., Medicaid or the Indian Health Service) must be 21 years or older to meet eligibility requirements for the procedure.
There is a two-fold increased risk of regret in women who undergo sterilization at <30 years of age when compared to older women (with a baseline of 5.9% risk of regret for women older than 30 years, according to the U.S. CREST) (2). Targeted counseling should be employed with these patients. The efficacy of LARC in relation to that of sterilization should be particularly reviewed with younger patients.
Antibiotic prophylaxis is not recommended for routine postpartum sterilization procedures but should be individualized with consideration given to any potential obstetric indications.
Need for venous thromboembolism (VTE) prophylaxis should be assessed for each patient.
SURGICAL MANAGEMENT
Postpartum sterilization within the first 24 hours following vaginal delivery is recommended owing to the location of the uterine fundus near the umbilicus. In addition, there is no additional need for the patient to abstain from food or drink if the procedure can be performed immediately.
In patients who received regional anesthesia for pain control in labor, it is recommended to proceed immediately with postpartum sterilization when possible to avoid the need for a second anesthetic.
In circumstances where the uterine fundus is not palpable, it may be appropriate to consider interval tubal sterilization or an alternate form of contraception.
Positioning
After appropriate preparation, the patient is taken to the surgical suite and placed in dorsal lithotomy position.
If the patient has an epidural in place, the adequacy of anesthesia is verified.
If the patient has no current anesthetic, regional or general anesthesia may be used for completion of the procedure, though in certain cases, tubal sterilization may be performed with a combination of intravenous (IV) sedation and infiltration of local anesthetic.
Approach
Mode of delivery will dictate the optimal technique to be used for permanent sterilization.
With an open abdomen and fully exposed adnexa following cesarean delivery, the surgeon has more surgical sterilization options available than with an infraumbilical minilaparotomy approach.
The success of sterilization relies on correctly identifying the fallopian tube.
The excised fallopian tubes or tubal segments should be labeled and sent separately to pathology to ensure successful sterilization. Resection of a minimum of a 2-cm tubal segment is recommended.
Procedures and Techniques
For patients undergoing sterilization following vaginal delivery, a 2- to 3-cm infraumbilical minilaparotomy incision is performed at the level of the uterine fundus.
Upon entry into the peritoneal cavity, the surgeon palpates the uterine fundus and sweeps the index finger laterally toward the adnexa, hooking the fallopian tube and gently pulling the tube toward the incision. Tilting the operative table or using external abdominal manipulation of the uterus may help make the fallopian tube more accessible. It is also possible to use small retractors to expose the fallopian tube visually.
Once the fallopian tube is brought to the midline, a Babcock clamp is used to grasp the tube and elevate it through the incision. A second Babcock clamp is then used to help trace the tube to the fimbriated end. This step is critical to avoid incidental ligation of the round or broad ligaments.
At this point, several techniques are available to the surgeon to complete the sterilization. The Pomeroy and Parkland methods are the most commonly utilized, but choice of surgical technique should be based on the surgeon’s experience and preference.
Pomeroy Technique
This method, dating back to 1930, is the most commonly used for postpartum sterilization through a minilaparotomy incision (see Tech Figure 5.5.1).
A 2-cm mid-isthmic portion of the fallopian tube with a relatively avascular underlying mesosalpinx is grasped with a Babcock clamp and elevated through the incision. Upon elevation, the
tube doubles over on itself and the distal and proximal ends ligated using absorbable suture, usually plain gut as it is more rapidly absorbed. (The original Pomeroy method uses chromic suture, whereas the “modified” Pomeroy method uses plain gut.) Either one or two sutures may be used to ligate the tube.
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