Postpartum Tubal Sterilization

Procedure background

Postpartum tubal sterilization is an effective permanent contraceptive option for women whether it is performed by partial salpingectomy, electrocoagulation, or the use of rings or clips. ^[1] This procedure can be performed at the time of cesarean delivery or shortly after a vaginal delivery. It should not prolong a patient’s hospital stay. According to the American College of Obstetricians and Gynecologists, the immediate postpartum period may be the optimal time to perform sterilization because of technical ease for the physician and convenience for the patient. ^[2] Some background information is provided below.

Tubal sterilization remains the most common contraceptive method for women older than age 35 years, although oral contraceptive use superseded tubal sterilization as the leading method of contraception in the United States in 2002. Overall, nearly 19% of US women aged 15-49 years rely on female sterilization for contraception. ^[2]

The number of tubal sterilization procedures performed in the United States has remained relatively stable since the early 1980s at approximately 650,000 procedures annually. About 50% of these are performed in the postpartum setting following 8-9% of all live births. ^[3]  In a 2015 report, data from the National Hospital Discharge Survey between 2000-2008 noted that postpartum tubal sterilizations after cesarean sections were more common in those with Medicaid coverage and in black women, older women, and nonsingle women. ^[4] In addition, the South, small hospitals, and proprietary and government hospitals had a higher proportion of postpartum tubal sterilizations after cesarean section. ^[4]  A retrospective cohort study that included data from 10,741 tubal sterilization procedures reported an increase in salpingectomies performed from 0.4% to 35.5% from 2011-2016. ^[5]

Worldwide and in the United States, the most common surgical approach for postpartum tubal sterilization is by infraumbilical minilaparotomy. With the fundus at the level of the umbilicus immediately postpartum, the fallopian tubes are usually easily accessed from this entry point. Bilateral tubal ligation may also be performed after hysterotomy closure at the time of cesarean, but this article will focus on the postpartum approach within 48 hours following a vaginal delivery.

Indications and contraindications

Postpartum tubal sterilization is indicated in any patient who is medically stable after a vaginal delivery (usually within 48 hours) and desires permanent contraception. The patient should have been properly counseled about the procedure (see Patient Education and Informed Consent). Consideration must also be given to regulations regarding timing of consent ^[6] and adequacy of staff to perform an elective procedure.

Contraindications to postpartum tubal sterilization include the following:

• There is an unstable medical condition postpartum (eg, hemorrhage, infection, uncontrolled hypertension, HELLP [hemolysis, elevated liver enzymes, and low platelets] syndrome)

• The patient is ambivalent regarding the procedure

• The patient has known or suspected significant abnormalities of the uterus, fallopian tubes, or intra-abdominal cavity

• The patient consent is not mature according to state/local regulations

• The status of the newborn is unclear

Technical considerations

Procedure planning and complication prevention are briefly discussed below.

Procedure planning

It is critical to correctly identify the fallopian tube before ligation or clip application.

In situations in which visualization is difficult, Trendelenburg and lateral tilt positions may help as well as the use of small laparotomy sponges.

When performing a postpartum modified Pomeroy tubal ligation, holding one suture long before excision of the tubal portion prevents retraction of the tube back into the abdomen before hemostasis can be assessed and the tubal ostia visualized.

The Filshie clip system is an alternative to partial salpingectomy in the postpartum setting, particularly useful in difficult surgical cases (eg, obesity, intra-abdominal adhesions). ^{[7, 8]} A randomized controlled trial published in 2012 showed, however, that the titanium clip was not as effective as partial salpingectomy in the postpartum setting. ^[9] Through 2 years of observation, the pregnancy probability for the clip group was 0.017 compared with 0.004 for the partial salpingectomy group (P = 0.04). However, this study was limited by a high loss–to–follow-up rate (just over 50% for both groups) and a limited follow-up period (24 mo). ^[9] Increased edema and hypertrophy of the fallopian tubes in pregnancy are thought to be responsible for this difference in effectiveness.

Complication prevention

Complications of minilaparotomy are typically minor, including wound infection and incisional hernia formation. To avoid the minor wound infection that may occur following surgery, a thorough preoperative skin preparation with an antiseptic solution must be performed. There is no indication for preoperative antibiotic prophylaxis for the procedure.

To decrease the risks associated with difficulty in locating abdominopelvic structures, the surgeon must assess the level of the fundus before the start of the procedure to ensure the adnexa is adequately accessible.

Failure rates at 12 months poststerilization and major morbidity are rare. ^[1] A common reason for sterilization failure is ligation of the wrong structure, typically the round ligament. Therefore, careful identification and isolation of the fallopian tube before ligation is necessary. Furthermore, if a tubal segment is excised, pathologic confirmation is an important step, when available.

Poststerilization regret is very age-dependent, with 20% of women aged 30 years or younger regretting their decision, whereas only 6% of those older than 30 years express regret. ^[10] Any ambivalence displayed by a patient in the peripartum period should be considered an indication to delay the sterilization procedure. However, a retrospective study by Thurman and Janecek reported that women who requested postpartum tubal sterilization but did not receive it were more likely to become pregnant again within 1 year than women who did not request sterilization. ^[11]

Approach considerations

The patient is placed supine on the operating table. The bladder should be drained before the procedure to ensure that the fundus is not displaced too far above the umbilicus by a distended bladder.

Abdominal entry

After the patient has been surgically prepped and draped and adequate anesthesia has been confirmed, a 2-3 cm infraumbilical semilunar or vertical incision is made. Elevating the skin with Allis clamps may help accomplish this (see the following image).

Further dissection through the subcutaneous tissue may be done with a Kelly clamp or hemostat down to the level of the fascia. Once visualized, the fascia is grasped and elevated with 2 Kelly or Kocher clamps and incised with Mayo scissors. The opening in the fascia should be approximately the same size as the skin incision. The underlying parietal peritoneum is then grasped with 2 hemostats, elevated and cut with Metzenbaum scissors.

Fundus and tube visualization

Two small retractors are then placed in the incision and the fundus identified. Army-Navy retractors (see the image below) are firmer and easier to manipulate, but in some instances, such as when the subcutaneous layer is thicker, small S-shaped retractors may be more effective.

Using the 2 retractors, one operator then pulls the surgical opening in the direction of the adnexa, whereas the second operator is prepared to grasp the fallopian tube once visualized with a Babcock clamp. If visualization is difficult, lateral tilting the patient toward the opposite side may help. If omentum or bowel is obscuring visualization, small, moistened laparotomy packs (see the following image) may be placed through the incision with Singley forceps using a sweeping motion over the fundus to displace bowel and omentum cephalad. These packs should be tagged.

Once the fallopian tube is visualized, it is carefully grasped with the Babcock clamp and gently elevated through the incision, as shown in the image below. The tube should then be followed to its fimbriated end in a stepwise fashion with either another Babcock clamp or the Singley forceps to ensure that the correct structure has been identified.

Tubal occlusion

Tubal occlusion may be performed using the modified Pomeroy method, the Parkland method, or, in limited cases, the Filshie clip device.

Modified Pomeroy method

The fallopian tube is then followed back to the mid-isthmic portion, and a loop of tube is elevated with the Babcock clamp. The base of the loop is ligated with 2 ties of 2-0 plain gut suture, holding one suture long with a hemostat to avoid retraction of the tube back into the abdomen after transection (see the image below).

Next, a window is created bluntly in the mesosalpinx within the loop using the tips of the Metzenbaum scissors (see the first image below). Each limb of the tube is then individually cut, leaving an adequate tubal stump proximally and distally to ensure that the cut ends do not slip through the suture (see the second image below).

The tubal segment is routinely sent to surgical pathology for confirmation. While holding onto the hemostat, the cut ends are inspected for the presence of tubal ostia both proximately and distally as well as hemostasis (see the following image). Tension on the suture should be released when observing for hemostasis. The tube is then released back into the abdomen. This procedure is then repeated on the remaining side.

Parkland method

In some circumstances, tubal occlusion by the Parkland method may be appropriate, usually when there is excessive tension on the loop of tube that makes it more likely that the cut ends would slip out of the suture once excised.

The fallopian tube is identified and grasped in the mid-isthmic portion as above. An incision is made in an avascular window of the mesosalpinx below the tube with Bovie cautery or Metzenbaum scissors. A 1-2 cm portion of tube is then ligated proximately and distally with chromic suture, and the tubal portion is excised with Metzenbaum scissors. Again, one suture should be held long until hemostasis is assured and the tubal ostia identified.

Filshie clip method

After proper identification of the fallopian tube as above, the tube is followed back to approximately 1-2 cm from the cornua. Using the Filshie applicator designed for laparotomy, the clip is placed in the applicator and the jaws of the clip are opened and advanced around the tube at an angle perpendicular to the tube until the lower jaw of the clip is seen through the mesosalpinx, assuring the entire tube is within the clip. The clip is then slowly applied to the tube using gentle but firm pressure on the finger bar until the stop is reached. Pressure is then slowly released, leaving the clip in place on the fallopian tube. Caution must be taken to avoid lacerating the tube or tearing the mesosalpinx. Next, attention is turned to the remaining side, and the above steps are repeated. Of note, especially edematous tubes are not appropriate for this method.

Closing

Once the fallopian tubes on both sides have been successfully occluded, all laparotomy sponges are removed, and all instruments must be accounted for. The fascia is closed with a delayed-absorbable suture, and the skin is closed, usually in a subcuticular fashion. ^{[12, 13]}

Procedure complications

The risk of complication with postpartum minilaparotomy and tubal ligation is low. As with all surgery, there is some risk associated with anesthesia. These risks are generally low, but they depend on the method and route of anesthesia used.

Some of the most serious complications occur during entry into the abdomen. A patient with a history of abdominal surgery or pelvic infection may be at greater risk of complication upon abdominal entry and result overall in a more difficult surgery. Additionally, care must be taken with the tube during the procedure, as excessive traction on the fallopian tube can lead to mesosalpingeal tearing or tubal laceration leading to intra-abdominal hemorrhage. ^[13] Before the start of the procedure the surgeon must assess the level of the fundus, ensuring the adnexa is adequately accessible. This will aid in decreasing risks associated with difficulty in locating structures.

Failure rates should be discussed with any patient considering postpartum tubal sterilization. One third of tubal failures will be ectopic pregnancies. Of all female sterilization procedures, postpartum partial salpingectomy has the lowest cumulative pregnancy rates: 6.3 per 1000 procedures at 5 years and 7.5 per 1000 at 10 years. ^{[14, 15]}

Despite early reports of increased menstrual abnormalities in women after tubal ligation, later analysis failed to show a significant difference in menstrual patterns in sterilized women relative to nonsterilized women. ^[16]

Patient education and informed consent

Counseling for postpartum tubal sterilization is critical and should occur before the intrapartum period. Patients should be made aware that tubal sterilization is more effective than user-dependent methods but comparable to intrauterine devices and vasectomy. ACOG recommends emphasizing the permanent nature of the procedure to patients during counseling. ^[2] Postpartum tubal sterilization is associated with higher regret in women younger than 30 years.

Other contraceptive options, both permanent and nonpermanent methods, should be reviewed with the patient, and consideration should be given to other comorbidities (eg, obesity, previous abdominal surgeries, history of pelvic inflammatory disease [PID]) which could complicate the procedure.

Operative equipment

A basic laparotomy tray includes hemostats; Kelly, Kocher and Allis clamps; Metzenbaum and Mayo scissors; a needle driver and small tissue forceps; and a scalpel. See the following image.

Other equipment that are needed include the following:

• Babcock clamps

• Singley forceps

• Plain gut suture or Filshie clips and applicator

• Small laparotomy sponges

• Small retractors (Army-Navy or S-shaped)

• Delayed absorbable suture for the fascia and skin

• Skin prep, sterile drapes, and appropriate personal protective equipment

Patient preparation

Anesthesia considerations and patient positioning are included in patient preparation for the procedure.

Anesthesia

The American Society of Anesthesiologists Task Force on Obstetric Anesthesia published recommendations for anesthetic choice for postpartum sterilization in their Practice Guidelines for Obstetric Anesthesia. ^[17] In most patients, tubal sterilization can be performed safely within 48 hours of delivery, either by epidural, spinal, or general anesthesia.

Overall, the timing of the procedure and the choice of anesthetic route is influenced by the presence of a functioning epidural, recent food ingestion, and opioid administration, among other factors. ^[18]

Positioning

Patients should be placed on the operating room table in the supine position with their arms extended out to the side. Trendelenburg positioning may help with displacement of the bowel superiorly for enhanced exposure. Additionally, to aid in visualization, the patient can be placed in slight right lateral tilt when attempting to identify and ligate the left fallopian tube; when the surgeon is operating on the right fallopian tube, the patient can be placed in a left lateral tilt.