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1. 1 Voluntary Surgical Contraception for WomenTubal Occlusion
2. 2 Tubal Occlusion: Most Popular Contraceptive Method Globally
3. 3 Types of Tubal Occlusion Postpartum
Minilaparotomy (Infraumbilical)
Interval
Minilaparotomy
Laparoscopy
4. 4 Tubal Occlusion: Client Issues The client should make the decision for sterilization voluntarily.
The client has the right to change her mind anytime prior to the procedure.
The client should understand that voluntary sterilization (VS) is a permanent (not easily reversible) method.
No incentives should be given to clients to accept VS.
A standard consent form must be signed by the client before the VS procedure.
Spousal consent is not required.
5. 5 Tubal Occlusion: Mechanism of Action
6. 6 Tubal Occlusion: Contraceptive Benefits Highly effective (0.51 pregnancies per 100 women during first year of use)
Effective immediately
Permanent
Does not interfere with intercourse
Good for client if pregnancy would pose a serious health risk
Simple surgery, usually done under local anesthesia
No long-term side effects
No change in sexual function (no effect on hormone production by ovaries)
7. 7 Tubal Occlusion: Noncontraceptive Benefits Does not interfere with breastfeeding
Decreased risk of ovarian cancer
8. 8 Tubal Occlusion: Decreased Risk of Ovarian Cancer 39% decrease in risk compared to clients without tubal occlusion
Decrease in risk does not depend upon method of sterilization
Risk remains low 25 years after surgery
9. 9 Tubal Occlusion: Limitations Must be considered permanent (success of reversal cannot be guaranteed)
Client may regret later (age < 35)
Small risk of complications
Short-term discomfort and pain following procedure
Requires trained physician (gynecologist or surgeon for laparoscopy)
Slightly decreased long-term effectiveness
Increased risk of ectopic pregnancy
Does not protect against STDs (e.g., HBV, HIV/AIDS)
10. 10 Tubal Occlusion: Long-Term Effectiveness by Age Group
11. 11 Tubal Occlusion: Long-Term Effectiveness by Method
12. 12 How Effective Is Tubal Occlusion?
13. 13 CREST Study: Summary of Results1 Risk of pregnancy:
higher than previously found in year 1
less than 2% over 10 years of use (18.5/1000 procedures)
highest in women under 30
lowest for postpartum partial salpingectomy (8 per 100 procedures)
highest for spring clip (37 per 100 procedures)
14. 14 CREST Study: Summary of Results1 continued Ectopic pregnancy:
1 in 3 pregnancies following VS is ectopic
10 year cumulative risk = 7.3/1000 procedures
Risk in women under 30 is twice as high
Rate of ectopic pregnancy in years 4–10 is three times as high as in years 1–3
15. 15 Who Can Use Tubal Occlusion Women:
Who are age > 22 and < 45
Who want highly effective, permanent protection against pregnancy
For whom pregnancy would pose a serious health risk
Who are postpartum
Who are postabortion
Who are breastfeeding (within 48 hours or after 6 weeks)
Who are certain they have achieved their desired family size
Who understand and voluntarily consent to procedure
16. 16 Tubal Occlusion: Who May Require Additional Counseling Women:
Who cannot withstand surgery
Who are uncertain of their desire for future fertility
Who do not give voluntary, informed consent
17. 17 Tubal Occlusion: Conditions Requiring Precautions (WHO Class 3) Unexplained vaginal bleeding (until evaluated)
Acute pelvic infection
Acute systemic infection (e.g., cold, flu, gastroenteritis, viral hepatitis)
Anemia (Hb < 7 g/dl)
Abdominal skin infection
Cancer of the genital tract
Deep venous thrombosis
18. 18 Tubal Occlusion: Conditions Requiring an Experienced Clinician with Full Backup Diabetes
Symptomatic heart disease
High blood pressure (> 160/100 or with vascular disease)
Coagulation (clotting) disorders
Overweight (> 80 kg/176 lb if H/W ratio not normal)
Abdominal or umbilical hernia
Multiple lower abdominal incisions/scars
19. 19 Complications of Laparoscopic Sterilization Short-term
Occur in less than 1% of all procedures
Directly related to surgical expertise
Long-term
Decreased long-term effectiveness
20. 20 Tubal Occlusion: Intra-operative Complications Minilaparotomy and Laparoscopy:
Uterine perforation
Bleeding from mesoslpinx
Convulsion and toxic reactions to local anesthesia
Injury to urinary bladder
Respiratory depression or arrest
Injury to intra-abdominal viscera
Laparoscopy (primarily):
Gas or air embolism
Vasovagal attack
21. 21 Tubal Occlusion: Immediate Postoperative Complications Pain at infection site
Superficial bleeding (skin edges or subcutaneously)
Postoperative fever
Wound infection
Gas embolism with laparoscopy (very rare)
Hematoma (subcutaneous)
22. 22 When to Perform Tubal Occlusion Procedure Anytime during the menstrual cycle you can be reasonably sure the client is not pregnant
Days 6–13 of menstrual cycle (proliferative phase preferred)
Postpartum: Within 2 days or after 6 weeks
If delivered at home and immunized (tetanus toxoid), can be performed under antibiotic cover (if no sepsis).
Postabortion: immediately or within 7 days, provided no evidence of pelvic infection
23. 23 Tubal Occlusion: Anesthesia Local anesthesia of choice
General–only in select cases
obese
associated (documented) pelvic pathology
allergy to local anesthesia
medical problems
24. 24 Tubal Occlusion: Client Instructions Keep operative site dry for 2 days. Resume normal activities gradually.
Avoid sexual intercourse for 1 week or until comfortable.
Avoid heavy lifting and hard work for 1 week.
For pain take 1 or 2 analgesic tablets every 4 to 6 hours.
Schedule a routine followup visit between 7–14 days.
Return after 1 week if nonabsorbable stitches used.
25. 25 Tubal Occlusion: General Information Shoulder pain during 12–24 hours after laparoscopy is common due to gas (CO2 or air) under diaphragm.
Tubal occlusion is effective from time operation is complete.
Menstrual periods will resume as usual.
Use a condom if at risk for STDs (e.g., HBV, HIV/AIDS).
26. 26 Warning Signs for Tubal Occlusion Clients Return to clinic if following problems occur:
Fever (greater than 38°C or 100.4°F)
Dizziness with fainting
Persistent or increased abdominal pain
Bleeding or fluid coming from the incision
Signs or symptoms of pregnancy
27. 27 Tubal Occlusion:Mobile Programs (Camps) Counseling and followup should be the same as at fixed sites.
All recommended infection prevention practices should be followed.
Followup for short-term and long-term complications must be available.
28. 28 Tubal Occlusion:Common Medical Barriers Age restrictions (young and old)
Provider bias
Who can provide:
Specialists only
Physicians only