Tubectomy : Essential Information
Tubectomy or female sterilization is the most popular method of contraception in India. It comprises of about 80% of all contraceptives accepted by a couple. It is a permanent method of contraception performed on the female partner when the couple do not want to have any more children. Occlusion of the fallopian tubes by some form so as to prevent the union of the sperm and the egg is the underlying principle. Tubectomy fulfills most of the criteria of an ideal method of sterilization. It is a technique that can be performed in an out patient setting. It can be done without general anaesthesia. It is simple quick and easily learnt, has minimum side effects and can be reversed. As per the guidelines the woman should be married, should be between the ages of 22 and 45 years and the couple should have at least one child whose age is above one year and is fully vaccinated. The woman or her partner should not have undergone sterilization in the past unless it is a case of sterilization failure. The couple should be in a perfectly normal state of mind so as to understand the full implication of the procedure. Mentally ill patients should be certified by a psychiatrist and in such cases consent should be given by spouse/guardian. Counseling must be thorough before the procedure. The couple must understand that this is a permanent procedure. They must be informed of all the other methods of family planning like condoms, oral pills, IUCD, injections. They must be counseled in a language they understand. They must be made to understand what will happen before, during and after the procedure, the potential side effects and the complications.
The following features of the sterilization procedure must be explained to the client
a. It is safe and simple procedure. b. It is a permanent method of preventing future pregnancies. c. It is a surgical procedure that has a small risk of complications which may require further treatment. d. It does not affect sexual pleasure, ability or performance. e. It does not affect the client’s strength or her ability to perform normal day to day activities. f. It has a small chance of failure, even if performed under optimum circumstances. g. Sterilization does not protect against RTI / STDs or HIV / AIDS. h. Clients must be encouraged to ask questions and to clarify doubts, if any i. Clients must be told that they have the option of deciding against the procedure at any time without sacrificing their right to other reproductive health services. j. The client must be told that a reversal of this surgery is possible, but the reversal involves a major surgery and its success cannot be guaranteed. Consent for sterilization operation should not be obtained under coercion or when the client is under physical or mental stress. Consent should not be obtained when a woman is sedated or when she experiences stress associated with some pregnancy related events / problems. Clients must sign a printed application and consent form for sterilization. There are certain conditions that require doctors to be cautious, delay the surgery, refer the client to a specialty equipped centre, or counsel to opt for alternative contraception. There may be situations when it is better to counsel the female client’s husband to go in for vasectomy. There are no absolute contraindications for tubectomy. Temporary contraindications include anaemia, severe hypertension, diabetes, local skin diseases etc The best timing for performing tubectomy is after delivery also called postpartum sterilization. Tubectomy can also be performed after periods when pregnancy is ruled out. This procedure is called interval tubectomy or tubectomy can be done after the woman undergoes MTP or spontaneous abortion. Female sterilization by minilap tubectomy can be performed by a trained MBBS doctor, whereas laparoscopic sterilization can only be performed either by a gynecologist with DGO/ MD/MS or a surgeon with a MS degree and trained in laparoscopy. Prior to performing sterilization operation, a careful clinical assessment of the clients should be made to ensure their fitness for surgery. Tubectomy is either done by laparotomy which entails opening of the abdomen by a small incision or by laparoscopy. Tubectomy by laparotomy is best done in the postpartum period when the operation is quite simple to perform as the uterus is large and felt per abdomen. This is a very simple and safe procedure. The operation is done at least 24 hours after delivery so that the woman has adequate rest and has sufficient time to make up her mind as this a permanent procedure. Her hemoglobin and urine are checked preoperatively. Consent of the women is enough for this operation. Husband’s consent is not a must for this operation. The operating doctor confirms her physical fitness for this operation before proceeding for the surgery. Tubectomy can be performed under local anaesthesia, spinal anaesthesia or general anaesthesia. Preparation for surgery includes pre-operative assessment and instructions, a review of the surgical procedure and 24 post-operative care. Pre-operative assessment is essential to assess the client’s physical fitness for surgery and also ensure that the consent for surgery is voluntary and well informed. This assessment can also provide an opportunity for overall health screening and treatment of RTI/STDS, if required Demographic information: on age, marital status, occupation, religion, education, number of living children, sex and age of the youngest child is required to be elicited.
Medical history :
1. History of any medical illness 2. Immunization status of client for tetanus and of all the children for tetanus, TB, diphtheria, pertussis, poliomyelitis and measles. 3. Addictions 4. Current medications 5. Last contraceptive used 6. Menstrual history 7. Obstetric history Physical Examination: includes pulse, BP, respiratory rate, temperature, weight, general condition and nutritional status. Auscultation of the heart and lungs, examination of abdomen, pelvic examination and other examinations as indicated by medical history or general physical examination are to be done prior to surgery. Laboratory Examinations: includes hemogram [ Hb< 10 gm%] and urine analysis for albumin and sugar. Other tests can be performed as indicated.
Pre-operative Instructions :
1. The client must bathe and wear clean and loose clothing to the OT. 2. The client must not ingest anything by mouth 4-6 hours prior to surgery. 3. On the morning of surgery she must empty her bowels, and empty her bladder before entering the OT. 4. She should remove nail polish, jewellery or hairpins before entering the OT. 5. She must also remove her glasses, contact lenses and dentures. 6. A responsible adult must be available to accompany the client home after surgery. Small incision is taken on the abdomen through which the abdominal cavity is entered and both the tubes which are present one on either side of the uterus are identified and then clamped, cut and ligated. One or two stitches are taken to close the abdominal wound and these stitches are removed on the seventh day. Patient is given antibiotics and painkillers after the operation. Laparoscopic sterilization is best done six weeks after delivery, after periods or after MTP/abortion. At these times the uterus is of normal size and situated within the pelvis. Tubes are occluded with rings or clips. The patient can be discharged within 24 hours of operation. Laparoscopic sterilization avoids the need for prolonged hospitalization, is associated with minimal postoperative pain, and allows faster recovery and resumption of normal activities.
Benefits of tubectomy :
It is a one time permanent almost irreversible surgical contraception. It is the most cost effective method of family planning. It does not hamper sexual pleasure, in fact it may improve it due to freedom from anxiety of unplanned childbirth. There are no side effects on physical, psychological, menstrual or sexual functions of woman and her husband. Complications are minor like wound infections, scar hernia in properly selected cases. The overall failure rate is about 0.7%.Failure rate is increased when tubectomy is done along with Caesarean section. Failure may be due to fistula formation or due to spontaneous reanastomosis. Occasionally couples regret after the operation and request reversal. To avoid such problems couples should be well counseled before the procedure that this is a permanent method of sterilization. Microsurgical techniques give excellent results for reversal. Reversal of tubectomy with restoration of tubal patency is very good with laparoscopic cases. But pregnancy rate is low(50%).