Performing tubal sterilizations during women's postpartum hospitalization: a review of the United States and international experiences

Abstract

A considerable number of tubal sterilizations have been performed while women are still in hospital after delivery in the United States as well as in other countries. There are few review papers exclusively on this sterilization modality. This paper provides a comprehensive review of results reported from recent studies of this approach, and answers the pertinent medical and related questions such as: To achieve maximum safety, what is the best time to perform the procedure during the women's postpartum hospitalization? Specifically, is it advisable for the procedure to be performed while the woman is still on the delivery table? What surgical approach and tubal occlusion technique are preferred? What are the risks that the women undergoing sterilization immediately or soon after delivery may incur the short- and long-term medical sequelae, and to conceive accidental pregnancy? What effect does sterilization have on lactation? And how should the women be screened and counseled to prevent poststerilization regret, generally thought to be more likely to occur in women after postpartum sterilization? Newly-developed mechanical tubal occlusion techniques have been included for consideration. Practical guidelines are given in this paper to help service providers achieve maximum safety and satisfaction for their patients with this convenient and low-cost method of postpartum sterilization.

PIP: Postpartum tubal sterilization (PPTS), referring to sterilization before day 42, usually within 48 hours, and often immediate sterilization while the woman is still on the delivery table, is reviewed from reports from developed and developing countries. PPTS is convenient and cost-effective both for the woman and for the provider. Factors arguing for greater safety of PPTS are the natural hemostatic and anti-infective state of the puerperium, umbilical location of the fundus, use of the same anesthesia, and same operative site in case of cesarean delivery. Some have argued that the adnexa are more vascular and enlarged at this time. Yet PPTS done up to 7 days after delivery does not bear any increased burden of complications, surgical drawbacks, or complaints than interval sterilization. Minilaparotomy is recommended over laparoscopic sterilization, unless the surgeon is extremely experienced, since laparoscopy at this time is risky and difficult. The Pomeroy method is most often used, the Irving method is most reliable, while tubal clips may offer an improved chance of reversal. Anesthetic deaths are rarely reported from developed countries with PPTS. Developing countries usually use local anesthesia, and have fewer obese women and fewer anesthesia-related complications. Somewhat higher pregnancy rates have been reported with PPTS, although small case series, and non-random selection of cases may flaw this interpretation. There has been more PPTS sterilization regret after cesarean deliveries than after vaginal deliveries. It is important to counsel women, especially those at risk of regret, who are young, of low parity, or at risk of life changes, that sterilization is irreversible. Only patients with no labor and delivery complications and with a health infant should be considered candidates for PPTS.