Postpartum Tubal Sterilization

Postpartum tubal sterilisation is tubal occlusion done within 7 days of birth, when the uterine fundus is near the umbilicus and the tubes are easily reached through a small infraumbilical incision. It is also done at caesarean section. It is a permanent method with no effect on lactation, milk volume or infant health.

Mechanism. The tubes are divided and tied, usually by partial salpingectomy, so sperm and ovum cannot meet.

Effectiveness. First-year pregnancies are 0.5 per 100 women with typical use and 0.5 per 100 women with perfect use. Partial salpingectomy after birth has among the lowest long-term failure rates of any technique.

Regret. The decision is made around childbirth, which is the period of greatest regret, particularly in women under 30, with few children, or after a poor neonatal outcome.

Return to fertility. None is expected. Reversal is not assured.

Window. After 7 days the oedematous, vascular tubes and high fundus make surgery unsafe. Delay interval sterilisation until at least 42 days after birth.

Ideal candidates. Women who decided in pregnancy, gave written consent before labour, have a healthy newborn, and have an uncomplicated delivery.

Consent timing. Obtain and record consent during antenatal care or well before labour. Consent obtained in active labour, under pain or under pressure is not valid. Confirm the decision again before surgery.

History and examination. Obstetric course, haemorrhage, hypertension, infection, anaesthesia given in labour, vital signs, uterine tone and involution, lochia, abdominal wall.

Investigations. Haemoglobin. Blood pressure. Confirmation that the infant is stable and feeding.

Accept. Postpartum under 7 days, breastfeeding, mild pre-eclampsia, previous pre-eclampsia with normal current blood pressure, sterilisation with caesarean section, HIV clinical stage 1 or 2.

Delay beyond 7 days to 42 days or more. Prolonged rupture of membranes, puerperal sepsis, severe antepartum or postpartum haemorrhage, severe genital tract trauma including uterine perforation, severe pre-eclampsia or eclampsia, peritonitis, haemoglobin under 7 g/dL, fever, uncertain neonatal outcome.

Caution. Obesity, controlled hypertension, anaemia, uncomplicated diabetes, epilepsy, depressive disorders, kidney disease.

Special. Blood pressure 160/100 or higher, hypertension with vascular disease, complicated valvular disease, coagulation disorders, anticoagulant use, umbilical hernia, chronic respiratory disease, AIDS, allergy to local anaesthetics.

Special groups. Adolescents under 18 years give assent and need consent in line with the law, and young age with no living children calls for particular care. Women with HIV on antiretroviral therapy may proceed when stable. Lactating women may take usual analgesics and antibiotics.

Regimen line. Procedure: infraumbilical minilaparotomy with partial salpingectomy, done within 7 days of birth. Anaesthesia: lidocaine 1% (10 mg/mL) infiltrated about 5 minutes before incision, up to 4.5 mg/kg without adrenaline (maximum 300 mg, 30 mL) or 7 mg/kg with adrenaline (maximum 500 mg), reduced in liver disease, with light sedation as needed, or spinal anaesthesia when an epidural or spinal is already in place. Protection immediate and lifelong. Backup none.

Pregnancy exclusion. Not needed in a woman who has delivered within the last 4 weeks.

Timing.

• Best within 48 hours of birth, when the fundus is highest and the abdominal wall is lax.
• Acceptable up to 7 days.
• After 7 days, delay until at least 42 days and then do an interval procedure.

Switching. A woman on pills finishes the pack, and one on an injectable has the procedure before the next injection is due. An implant may stay until it is not needed. An intrauterine device placed postpartum can be removed at the procedure or at follow up.

Technique steps.

1. Confirm consent, fasting status, empty bladder, firm contracted uterus.
2. Infiltrate and make a 2 to 3 cm infraumbilical incision, then open the fascia and peritoneum.
3. Grasp the tube and follow it to the fimbria to identify it.
4. Lift a loop of the mid isthmus and tie its base with absorbable suture, excise the loop beyond the tie and check haemostasis.
5. Repeat on the other side, close in layers.

Choice of material. Use plain absorbable suture so the cut ends separate and are not held by non-absorbable material. Clips and rings are less suitable on the thick postpartum tube.

Follow up. Observe in the postnatal ward, discharge with the newborn. Wound review within 2 weeks. Return for fever, wound discharge, heavy bleeding, severe abdominal pain or a missed period.

Complications. Postpartum haemorrhage from uterine atony or tubal vessel bleeding, wound infection, haematoma, anaesthetic reaction, bladder injury, thromboembolism, later failure and ectopic pregnancy.

Wound infection regimen. Cefalexin 500 mg orally every 6 hours for 5 to 7 days, maximum 4 g daily, reduced to 250 mg every 8 to 12 hours when creatinine clearance is 15 to 29 mL/min and to 250 mg every 24 hours under 15 mL/min. For serious penicillin allergy, clindamycin 300 mg orally every 6 hours for 5 to 7 days, maximum 1.8 g daily, watching the infant for diarrhoea. Both are compatible with breastfeeding.

Analgesia. Paracetamol 1 g orally every 6 hours, maximum 4 g daily (3 g in liver disease or under 50 kg), with ibuprofen 400 mg every 8 hours with food for up to 3 days, maximum 1.2 g daily, avoiding it in creatinine clearance under 30 mL/min, in peptic ulcer disease and in anticoagulation. Both are compatible with breastfeeding.

Haemorrhage. Check uterine tone first. Rub up the uterus and give oxytocin 10 IU intramuscularly or 20 to 40 IU in 1 litre of crystalloid at 60 to 120 mL/hour intravenously. Look for bleeding from the mesosalpinx and secure by ligation.

Regret. Counsel without judgement and refer for reversal or assisted reproduction assessment.

Referral and escalation. Refer haemodynamic instability, suspected visceral injury, uncontrolled bleeding, abscess unresponsive to drainage and antibiotics, and any ectopic pregnancy after failure.