9 Postpartum Tubal Ligation

POSTPARTUM TUBAL LIGATION
By Laston Kastom,BscBMS(RH),Dip.Clin.Med
INTRODUCTION
This is a permanent contraceptive method where by the both fallopian tubes are ligated. It is the best
choice for those who do not want to have any more children. It is the commonest permanent
contraceptive method done in Malawi.
INDICATIONS
MEDICAL INDICATIONS
 Repaired uterus following rupture

 Classical caesarean section
 Repeated caesarean sections, this depends on the findings during operation
 Serious maternal heart conditions
 Severe maternal hypertension
 Maternal mental disability
VOLUNTARY INDICATIONS
 This is when the couple have completed their family and prefer sterilization to other forms of
contraceptive
CONTRA-INDICATIONS
 Presence of any signs of endometritis

 If the labour was complicated by a serious postpartum haemorrhage
 If the patient has changed her mind
COUNSELLING
This is very important to every couple so that they have knowledge of the contraceptives and make a
conformed choice. Counseling needs to start during pregnancy until during labour. You need to discuss
issues like;
 The irreversibility of tubal ligation

 Alternative forms of contraceptives
 Discuss about the operation itself like timing, anaesthesia, incision and hospitalization
Permission is very important before you do tubal ligation except in emergencies such as in operation of
the ruptured uterus
ACTUAL PROCEDURE
 Shave the area where the incision will be made

 Catheterization is not necessary but I.V line may be necessary in some clients
 Apply antiseptics and then drape the abdomen
 You may give pethidine 25-50mg and diazepam 10-20mg I.V depending on the patient’s size and
state of nervousness
 You should prepare 80mls of 0.5% lignocaine with adrenaline 1:200000.
 Inject 10 mls in 10cm long subcutaneous tract, lateral of each rectus muscle, starting about 4 cm
above the level of the umbilicus
 Inject 10-15 mls in a skin and subcutis in the area of the planned sub-umbilical incision. Also
infiltrate the area just above the umbilicus.
 Inject three 5 ml depots of local anaesthestic in each rectus muscle above, at the level of and
bellow the planned incision.
 Then make a 2-5 cm long transverse incision in the skin under the umbilicus
 Retract the skin with two toothed retractors or Allis’ forceps.
 Then inject 10 mls under the fascia to anaesthetize the peritoneum
 Lift the fascia with two Allis’ forceps and make a vertical incision through the fascia and
peritoneum about 2-5 cm long
 Clamp all bleeders
 Then inject little anaesthesia in the mesosalpinx of the tubes, and if convenient, sprinkle some
on them.
 Next is the most difficult part of identifying the fallopian tubes and bringing it out through this
small incision
 With the blunt retractor pull the opening in the abdominal wall to the area where you expect to
find the right adnexa
 Put a finger behind the uterus and then slide it to the right until you are behind the adnexa. The
ovary is posterior to the fallopian tube and the fallopian tube is posterior to the round ligament
 Rotate with your finger the adnexa forward and pick up the fallopian tube with an artery forceps.
 You can also use a swab on your holder to identify the tube and then pick it up with a forceps.
 If you find it difficult by either method you can enlarge the incision.
LIGATION OF THE TUBE
 The commonest method used is the pomeroy’s method

 Identify a nicely mobile part of the tube (usually this is found at the junction of the isthmus and
the ampulla) and lift this with an artery forceps.
 Pass a chromic 0 suture on a needle through the mesosalpinx about 2 cm away from the tube;
be careful not to puncture a blood vessel
 Tie the suture round the tube on both sides of the artery forceps and about 1-2 cm away from it.
 Remove a small segment of tube with scissors; make sure to leave the remaining stumps 0.5-1
cm long.
 Then repeat the same procedure on the left
 And close the abdominal wall in layers, fascia and peritoneum together with continuous chromic
0 and the skin should be closed with a few interrupted sutures of the catgut or mersilene ( silk)
POSTOPERATIVE ORDERS
 Stop I.V infusion

 Full diet immediately
 Pain relief should be considered, give analgesics i.e. paracetamol for five days, and pethidine
may be necessary in first evening
 Antibiotics are not necessary, unless you have doubts on your sterility
 Discharge is done after one to two days
 Review the patient after one week, and also remove the sutures if necessary

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POSTPARTUM TUBAL LIGATION

 Repaired uterus following rupture

 Presence of any signs of endometritis

 The irreversibility of tubal ligation

 Shave the area where the incision will be made

LIGATION OF THE TUBE

 The commonest method used is the pomeroy’s method

 Stop I.V infusion

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