What are the steps for postpartum tubal ligation (sterilization)?

Postpartum Tubal Ligation: Procedural Steps

Postpartum tubal ligation should be performed using neuraxial anesthesia (spinal or epidural) rather than general anesthesia, with the procedure ideally completed within 24-48 hours after delivery to minimize technical difficulty and maximize safety. 1

Pre-Procedure Requirements

Timing and NPO Status

• Ensure the patient has had no oral intake of solid foods for 6-8 hours before surgery, with the specific duration depending on fat content of foods consumed 1
• Schedule the procedure as soon as feasible after delivery, recognizing that epidural catheters placed for labor become less reliable with longer postdelivery intervals 1
• Treat postpartum sterilization as an urgent surgical procedure given the limited time window and high rates (approaching 50%) of repeat pregnancy within one year if the procedure is missed 2

Patient Assessment

• Verify hemodynamic stability and assess for excessive blood loss before proceeding 1
• Confirm informed consent was obtained during prenatal care, not during active labor, to prevent potential regret 3, 2, 4
• Document that the patient understands the permanent, irreversible nature of sterilization 5, 6

Aspiration Prophylaxis

• Administer nonparticulate antacids to reduce maternal complications from aspiration 1
• Consider additional aspiration prophylaxis measures, particularly in patients who received opioids during labor (which delays gastric emptying) 1

Anesthetic Management

Preferred Technique

• Select neuraxial anesthesia (spinal or epidural) over general anesthesia for most postpartum tubal ligations 1
• If an epidural catheter is already in place from labor and the patient is hemodynamically stable, use epidural anesthesia 1
• Use pencil-point spinal needles instead of cutting-bevel needles if performing spinal anesthesia to minimize post-dural puncture headache risk 1

Individualization Factors

• Base the final anesthetic choice on: anesthetic risk factors (airway assessment, aspiration risk), obstetric risk factors (blood loss, hemodynamic status), and patient preferences 1
• Be aware that patients who received opioids during labor have delayed gastric emptying, increasing aspiration risk 1

Surgical Approach

Access and Technique

• Perform the procedure through a small infraumbilical incision, taking advantage of the enlarged postpartum uterus that brings the fallopian tubes closer to the abdominal wall 4, 7
• The optimal timing is within the first 24-48 hours postpartum when the uterine fundus remains at or near the umbilicus, making tube identification easier 4, 7

Tubal Occlusion Method

• Use the Pomeroy technique, Parkland method, or mechanical devices (Filshie clips or Falope rings) for tubal occlusion 4, 7
• The choice of occlusion technique should balance effectiveness with potential for future reversal, though patients must understand sterilization is intended to be permanent 6, 4

Post-Procedure Considerations

Immediate Postoperative Care

• Monitor for standard postoperative complications including bleeding, infection, and anesthetic complications 4, 7
• Postpartum sterilization does not adversely affect lactation establishment when performed immediately after delivery 3, 4

Contraceptive Efficacy

• Inform patients that postpartum tubal ligation provides immediate contraceptive protection with a first-year failure rate of 0.5% 6, 2
• Counsel that the procedure does not protect against sexually transmitted infections 6

Critical Pitfalls to Avoid

• Do not delay the procedure unnecessarily, as this increases technical difficulty and the risk of missed sterilization with subsequent unintended pregnancy 2, 4
• Never obtain consent during active labor or immediately postpartum—informed consent must be documented during prenatal care to ensure voluntary decision-making and reduce regret 3, 2, 4
• Do not require spousal consent, as this violates patient autonomy and may be illegal in many jurisdictions 5
• Avoid general anesthesia unless specifically indicated by maternal factors (e.g., contraindication to neuraxial anesthesia, patient refusal), as neuraxial techniques have superior safety profiles 1